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Quality Account: Final Draft 2 0 11 – 2 0 12


What is a Quality Account?

NHS hospitals or trusts have always had to publish their annual financial accounts. Since April 1 2010 as part of a movement across the NHS to be open and transparent about the quality of services provided to the public, all NHS foundation hospitals must also publish a Quality Account.

Table of contents Part 1

Statement from the Chief Executive

05

Part 2

Our Priorities

09

Part 2A

Safety

12

Part 2B

Clinical Effectiveness

18

Part 2C

Patient Experience

24

Statements of Assurance

33

Information on the Review of Services

34

Information on Participation in Clinical Audits

34

Participation in Clinical Research

40

Information on the use of the Commissioning for Quality and Innovation (CQUIN) framework

40

The Care Quality Commission

42

Quality of Data

42

Information Governance

44

Clinical Coding

44

Review of Quality Performance

47

Overview of quality of care provided during 2011/12 (including performance against national priorities and core standards, performance against patient experience, safety and clinical effectiveness measures)

47

Annexes

51

Annex 1: Statements from Stakeholders

52

Annex 2: Limited Assurance Statement from External Auditors

55

Annex 3: Statement of Directors Responsibilities

56

Glossary of Terms

59

Part 3

Patients, members of the public and our own staff can use each year’s Quality Account to assess the level of care we provide. You can also review the quality of services provided by all other NHS organisations by viewing their Quality Accounts on the NHS Choices website: www.nhs.uk

Part 4

Part 5

Part 6


GHNHSFTQuality Quality Account 2011-2012 GHNHSFT Account 2011-2012

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PART ONE

PART ONE

At Gloucestershire Hospitals NHS Foundation Trust we are committed to providing the best care for all our patients and to continually improving the quality of the services we offer.

This is our fourth Quality Account which allows us to clearly demonstrate the progress we have made in recent years. It also gives us an opportunity to clearly and openly set out our commitment to improving quality and to monitor the standards of care we provide to the communities we serve.

Some of the priorities, for example reducing the number of hospital-acquired infections, are set nationally by the Department of Health and others are agreed with our local Primary Care Trust. We have also set our own priorities to drive up quality across the organisation based on the views of our patients and the public.

Our staff have made good progress this year in relation to our priorities for 2011/12, against a backdrop of considerable financial pressure. This is a testament to their dedication and commitment.

The scrutiny and challenge of our stakeholders has continued to be invaluable in driving improvements in the quality of our services this year through productive engagement with the Trust Council of Governors, LINks and Gloucestershire County Council’s Health, Community and Care Overview and Scrutiny Committee, for example.

The Quality Account for 2011/12 will: ÆÆ demonstrate how well we are doing against targets set by the Department of Health, our local NHS and those we set ourselves as an organisation PA RT ONE

Statement from the Chief Executive

ÆÆ highlight areas where we need to improve ÆÆ set out our priorities for the year ahead ÆÆ allow the public and local stakeholders to scrutinise our performance

Quality has always been at the heart of our organisation. We want people to have complete confidence that our hospitals will provide the best care for all patients. It is what patients expect and what our staff seek to deliver.


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PART ONE

PART ONE

This commitment is reflected in our Vision of ‘safe, effective and personalised care: every patient, every time, all the time.’ It is also clearly embedded in our strategic objectives, which are: ÆÆ to improve year on year the safety of our organisation for patients, visitors and staff and the outcomes for our patients ÆÆ to improve year on year the experience of our patients ÆÆ to further develop a highly skilled, motivated and engaged workforce which continually strives to improve patient care and the Trust’s performance ÆÆ to ensure our organisation is stable and viable with resources to deliver its vision. Our quality framework is based on the three dimensions of quality as defined by Lord Darzi’s NHS Next Stage Review (2008): ÆÆ safety ÆÆ clinical effectiveness ÆÆ patient experience This report is structured to reflect our focus on these three core dimensions and you will find them referred to consistently throughout. The quality and safety culture has clear leadership from all the Executive and Non Executive Directors of the Trust, all of whom are committed to supporting this process and are focussed on the Trust’s duty of service to patients. We have provided comparative data throughout this report to allow you to see at a glance whether we have improved performance in our priority areas. Although these percentages and rates are useful in creating a sense of how well we are doing

and to help us describe our priority areas, we recognise that behind each statistic are many individuals who are affected by our ability to achieve our goals.

Highlights of the year Our work around the implementation of the UTOPIA project earned staff an HSJ Efficiency Award in the category of Efficiency in Acute Service Redesign this year. The twoyear UTOPIA project aimed to improve the emergency care pathway and has delivered significant benefits for patients. In addition, the Trust received a Flu Fighters Award from NHS Employers this year in recognition of our work to promote the NHS flu vaccination campaign, helping protect staff and patients from the virus. Building on the success of last year, staff have continued to make excellent progress in our drive to reduce the incidence of Venous Thromboembolism (VTE) by introducing a new risk assessment for all adult patients admitted to our hospitals. This work has dramatically improved the safety of patients with preventable blood clots and has meant we achieved the Department of Health target of assessing the risk of thrombosis in more than 90% of patients since March 2011.

delivered real benefits for patients with diabetes. You can read more about this on p20.

The year ahead There is no doubt that there are challenging times ahead for the NHS and our Trust is not immune to the need to reduce costs and become more efficient in the way we provide our services. A focus on continuing to deliver high quality care will be vital during the next year and beyond as we adapt to the changing nature of healthcare provision. This account cannot cover all of the work of such a large organisation in detail but I hope that it provides an informative overview of the work carried out by the Trust over the last year to improve quality as well as an indication of our aims for 2012/13. I can confirm that to the best of my knowledge the information contained in this report is accurate. Much of the format of the Quality Account is prescribed by Monitor’s Annual Reporting Guidance. However, I hope it gives you a useful insight into the quality of care we provide for our patients and our commitment to build on our achievements in the next 12 months.

This is a good example of how change can be successfully introduced throughout a large organisation and the impact a simple risk assessment can have on patient safety. Another significant achievement for us has been the marked improvement in the quality of care for diabetic patients. By developing an extensive action plan aimed at promoting the Think Glucose campaign among our staff and improving the clinical pathway, we have

Dr Frank Harsent Chief Executive Gloucestershire Hospitals NHS Foundation Trust May 2012


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PART TWO

PART TWO

Our commitment to outstanding quality of care for our patients and placing patient safety and experience at the heart of all we do continues to be our central priority.

PA RT T WO

Our priorities

Our priorities for improving the quality of the services we offer are identified each year by the Trust’s Quality Committee. This is a subcommittee of the Board and has clinical and managerial representation from across the Trust. It includes non-executive directors, directors, governors, representation from NHS Gloucestershire and during 2011/12 was chaired by Mr Gordon Mitchell, Non-Executive Director.

This regular review of information available to us has enabled the Quality Committee to identify progress against last year’s priorities, determine whether they should remain priorities for the year ahead and highlight new areas for attention.

Each division within the organisation has an established quality reporting structure which feeds into the Quality Committee. The committee meets quarterly to consider progress against our priorities for improvement based on a series of measures which give us a picture of how well we are doing. In addition, the committee meets on a further four occasions during the year to explore in more detail the approach to securing quality care in each of the clinical divisions. This ensures we have a clear route through which any concerns about the quality of care we are providing can be addressed.

ÆÆ patient experience

Our priorities for improving quality throughout our services fall within three core dimensions: ÆÆ safety ÆÆ clinical effectiveness

The priorities for 2012/13 have also been influenced by issues raised with us during the year by key stakeholders both within and outside our organisation, including our Council of Governors, NHS Gloucestershire, Gloucestershire Health, Community and Care Overview and Scrutiny Committee (HCCOSC) and Gloucestershire LINk.


GHNHSFT Quality Account 2011-2012

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PART TWO

PART TWO

Priorities for improving quality in 2011 / 12 Priorities

Incomplete from last year

National priority for 2011/12

Issue for

commissioners

/ CQUIN

Priorities for improving quality in 2012 / 13

Issue for HCCOSC

Issue for LINk

Issue for Governors

Issue for Quality Committee

1. Safety Reduce harm from falls

Improve care of patients with septicaemia Reduce pressure sores

Reduce readmissions

Improve care for patients with dementia

Improve care for people with stroke

Implement NICE quality standards

/ CQUIN

Issue for HCCOSC

Issue for LINk

Issue for Governors

Poor performance

Management of sepsis

ÆÆCatheter induced UTI

ÆÆVTE

ÆÆFalls

3. Patient Experience 

Improve the experience of carers (learning disabilities and dementia)

Readmission rates

Avoidable renal failure

3. Patient Experience Discharge experience

Responsiveness with emphasis on:

ÆÆCommunication about treatment options

ÆÆHydration and nutrition Patient experience escalator

ÆÆPeople with visual and hearing impairment

Implement all NICE Quality standards

Cardiac output monitoring during surgical procedures

2. Clinical Effectiveness

Dementia

Improve privacy and dignity for patients

Improve hydration / nutrition of elderly patients

Improve discharge process

commissioners

ÆÆPressure sores

Improve hospital mortality rates

Improve opportunities for patients to be involved in decisions about their care

Issue for

Emergency care pathway

NHS Safety Thermometer including;

2. Clinical Effectiveness

Improve effectiveness of communication and information

National priority for 2012/13

Reduce ambulance handover delays

Improve care for people with diabetes

Incomplete from last year

1. Safety

Reduce medication errors Reduce venous thromboembolisms

Priorities


GHNHSFT Quality Account 2011-2012

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PART TWO

PART TWO

Target 2011

Ratio per 1000 bedday

0.5

Dec-11

Nov-11

Oct-11

Sep-11

Aug-11

Jul-11

Jun-11

May-11

Apr-11

Mar-11

Feb-11

Jan-11

Dec-10

Nov-10

Oct-10

0

Period

Graph 2. Medication incidents per 1000 bed days 5 4.5 4 3.5 3 2.5 2 Data

1.5

Average

1

Target 2011

0.5

Period

Dec-11

Nov-11

Oct-11

Sep-11

Aug-11

Jul-11

Jun-11

May-11

Apr-11

Mar-11

0 Feb-11

To improve the safety of medicines management the Trust has run several

Data

Jan-11

Reduce errors in medication

1

Dec-10

The Trust is committed to reducing the number of falls that occur in hospital and reducing any harm that occurs should someone fall.

1.5

Average

This year there has been a focus on ensuring that the rails on the side of beds are used appropriately as these can increase the harm to a patient if they are at risk of falling. This has been achieved by introducing a new care plan for patients which includes a risk assessment for the use of bed rails. Health and safety inspections of every ward have also taken place this year by internal teams, looking for and removing slip and trip hazards. This has helped staff identify and prioritise where improvements need to be made and has resulted in a number of small improvements being made to patient areas. So far we have not seen a reduction in the number of falls as a result of the campaign (see Graph 1, p13). However, the best practice guidance suggests that improvements usually take up to two years to produce results so this work will continue during the coming year.

2

Nov-10

Reduce harm from falls Falls prevention is about reducing the number of accidental falls by patients while they are in hospital. A fall in hospital could cause a fracture, head injury or even lead to death in the most serious circumstances. However, even ‘minor’ injuries can create a significant fear of falling which can lead to reduced mobility and social isolation. We also know that patients who have fallen in the past are more likely to fall again.

2.5

Sep-10

During 2011/2012 we set out six key priorities within the domain of safety. Overall we have done well in achieving many of the priorities but there are still some areas where we need to improve. To help judge the quality of care provided, we have set out our performance in relation to each individual priority in the past year.

3

Oct-10

How well have we done this year?

Graph 1. Rate of patient falls resulting in harm per 1000 bed days

Ratio per 1000 bed days

Safety

Throughout 2011/12 a project and supporting awareness campaign took place introducing a ‘falls warning triangle’ which is placed by the bedside of patients considered to be at high risk of falling. The project also generated a new Falls Prevention Care Plan focussing on enabling staff to adopt the national best practice. The medication of patients considered to be at risk of falling is reviewed by a doctor to establish whether it may be contributing to the risk. Patients are also assessed by physiotherapists and occupational therapists to ensure, for example, that their footwear is correctly fitted and would not increase their likelihood of falling.


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PART TWO

PART TWO

40

Data Target

30 20 10 0 -10

Period

*Not including Trauma and Orthopaedics

Dec-11

Oct-11

Nov-11

Sep-11

Jul-11

Aug-11

Jun-11

May-11

Apr-11

Feb-11

Mar-11

Jan-11

Dec-10

Nov-10

Oct-10

Sep-10

Aug-10

Jul-10

Jun-10

May-10

Apr-10

Feb-10

Mar-10

Jan-10

Dec-09

Nov-09

-20 Oct-09

Pressure ulcers, or pressure sores, are a type of injury that affects areas of the skin and underlying tissue. They are caused when the affected area of skin is placed under too much pressure, for example by lying in the same position for too long. Our target was to reduce the incidence of pressure sores in our hospitals by 20% during 2011/2012. In 2010/2011 there were 101 cases making

We still have some work to do in reducing ambulance handover delays. Since the implementation of a revised ambulance handover process in December 2011 and the introduction of the Ambulance Liaison Nurse (mid-January 2012) there has been a significant reduction in the number of ambulance handover delays reported by the Great Western Ambulance Service at both sites. There was a 48% reduction in the number of delays reported at CGH between 28 November 2011 and 8 February 2012 when compared with the same period

50

Sep-09

Reduce pressure sores

Ambulance handover delays

Graph 3. DVT\PE per 1000 surgical discharges*

Aug-09

During 2011/12 we made excellent progress in this area, reducing the incidence of this severe and potentially life-threatening condition. In surgical specialties there has been a reduction approximately half the previous rate from 14 per 1000 bed days to six. This reduction has been achieved

In the past year the Trust has developed a new pathway for patients who are admitted with a condition known as severe sepsis (you can read more about this on p16). The treatment involves six elements of care, known as the ‘Sepsis Six’, every time to every patient. This year’s project has been focussed on establishing a written pathway, developing an e-learning package and launching the new approach. The new system was launched successfully in February 2012 and is currently being evaluated before the system is spread further across the organisation.

Jul-09

Reduce Venous Thromboembolism (VTE)

ÆÆ further roll out of the Intentional Care Rounding project. The project aims to ensure that each patient is visited by a nurse on an hourly basis to check

Jun-09

The Trust target for this year was to reduce serious harm from medication incidents by 10% and this is currently on target (see Graph 2 on p13).

Improve care of patients with septicaemia

levels of pain, hydration and nutrition and to turn the patient to prevent the development of pressure sores.

ÆÆ a revision of the assessment process for patients, including the creation of more effective documentation to promote best practice

Apr-09

During 2011/12 we made excellent progress in our drive to tackle VTE, reducing the incidence of this severe and potentially life-threatening condition.

the target for 2011/2012 84. At the end of 2011/12 the number of pressure sores found in the quarterly audits was 99. While this figure is largely made up of lower grade ulcers, this performance is disappointing for us. We will continue to tackle this priority as part of the actions taken during 2012/13 using the NHS Safety Thermometer tool (see p16). The steps planned to reduce pressure sores in the coming year are:

May-09

We have become more effective at managing patients who need the blood thinning drug Warfarin. In addition, two half-day safety briefings for staff took place during the year to improve knowledge and awareness of the importance of safely storing high risk medicines.

through the use of a risk assessment tool which has been incorporated into the patients’ drug chart. Clinical practice in relation to treatment and assessment of risk has also been standardised across the Trust with clinical champions and teams taking ownership of the issue in their areas. Our successes in reducing VTE have been shared with the Department of Health as an example of excellent service improvement. Staff from the Trust have been asked to present our results at an International Safety Conference in Melbourne. See Graph 3 on p15 for more details on our performance.

Individual Value

programmes of improvement this year. A medicines reconciliation programme, which aims to make sure that patients who are admitted to our hospitals are taking the right medication, continued during 2011/12 and consistently delivered benefits for our patients.


GHNHSFT Quality Account 2011-2012

PART TWO

17 PART TWO

last year and a reduction of 32% at GRH. However we have still got a long way to go to meet our target of having no ambulances waiting to handover emergency patients to clinical staff in our A&E departments. This will therefore continue to be a priority in the context of our work to improve the emergency care pathway.

Priorities for the year ahead During 2012/13 the safety team will focus on achieving the following priorities: Emergency Care Pathway Improving the care of patients who access our services as an emergency is our highest priority for the coming year. Our current performance against the target for no-one to wait more than four hours in our Accident and Emergency departments is below where it should be. During this year there will be a major programme of work to address issues throughout the emergency care pathway. Components of this programme will include: ÆÆ addressing the staffing levels of professionals delivering emergency care to ensure they are aligned with periods of greatest demand ÆÆ improving our systems and processes to eliminate all unnecessary delays in the pathway ÆÆ working with colleagues in the health community to ensure appropriate alternatives to admission in an emergency are in place and utilised. Management of sepsis Sepsis is a life-threatening condition that arises when the body’s response to an

infection injures its own tissues and organs. Sepsis can lead to shock, multiple organ failure and death especially if not recognised early and treated promptly and remains the primary cause of death from infection despite advances in modern medicine. Millions of people die of sepsis every year worldwide. For this reason the Trust has decided that tackling sepsis and reducing its incidence in our hospitals should be a priority for the coming year. It is also a CQUIN target for 2012/13. We have already launched a ‘Sepsis Six’ campaign which targets patients who are admitted to hospital via the emergency department and assessment units. This introduces six simple actions that must be performed within one hour of a patient being diagnosed with severe sepsis and aims to improve the consistency of care provided throughout the hospital. The next stage of the project is to introduce this care into wards so that patients who suffer from severe sepsis while they are an inpatient also receive the same level of care. NHS Safety Thermometer The NHS Safety Thermometer is a national improvement tool for measuring, monitoring and analysing patient care. The Safety Thermometer measures four clinical conditions - venous thromboembolism, urinary tract infection, pressure ulcers and patient falls. The Trust will implement the national measurement system and aim to meet the 90% compliance required by the end of the financial year. The clinical conditions will all feature as priorities for improvement.


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PART TWO

PART TWO

Reduce readmissions

HSMR

Jan-12

Dec-11

Oct-11

Nov-11

Sep-11

Jul-11

Aug-11

Jun-11

Apr-11

May-11

Mar-11

Jan-11

Feb-11

Dec-10

Oct-10

Nov-10

Sep-10

Jul-10

Aug-10

Jun-10

Apr-10

May-10

Mar-10

Jan-10

Feb-10

Dec-09

Oct-09

Nov-09

Sep-09

Jul-09

Aug-09

Jun-09

0

Month

Graph 2. Emergency readmissions following emergency discharge

% Re-admissions

Average 2011/2012

12.00

3,500

10.00

3,000 2,500

8.00

2,000

6.00

1,500

4.00

1,000

Mar-12

Feb-12

Jan-12

Dec-12

Nov-11

Oct-11

0

Sep-11

0.00 Aug-11

500

Jul-11

2.00

*Provided by NHS South West from Dr Foster system, run three months in arrears - values based on 2009/10 standardised baseline. An HSMR of 100 represents that we have had the same number of deaths as would be expected for the type of inpatients that we see. A value below 100 means fewer deaths than expected (‘good’) and a value above 100 means more deaths than expected (‘bad’). However, normal variation can lead to values above 100 which would not cause concern unless very high or sustained over an extended period of time.

Occupied bed days (re-admissions)

% Target

Jun-11

Further developments for this role are planned for the coming year. Dementia training for clinical staff is being rolled out across the Trust with 599 staff trained by January 2012. In addition, a new ‘purple butterfly’ sign has been developed for use on the patient’s bed head to help clinicians easily identify a patient who requires extra support or who may have altered cognition. The ‘This is Me’ document which aids communication between a dementia patient and clinicians is being adapted and

National average HSMR

May-11

We are pleased to report that there appears to be a long-term improvement in average crude hospital mortality from more than 1.5% in 2006 to around 1% in 2011. The Trust is now moving towards the gathering of mortality information at the level of individual specialties and services to help us learn more about our services and identify trends where possible. A new mortality indicator group was formed in January 2012. This group is likely to establish and encourage a common approach to reviewing mortality and deaths in hospital, and possibly within 30 days of discharge, for all specialties, services and clinical conditions. This will ensure we pick up trends early and modify practices and procedures to improve patient outcomes.

Trust HSMR

60

Improve care for people with dementia An extensive dementia strategy and action plan created by the Trust to improve the care and support provided for patients with dementia and their carers continues to be implemented throughout the organisation. Key developments this year include the identification of staff as Dementia Champions in wards and other clinical areas as well as portering and allied health professionals e.g. physiotherapists.

80

Apr-11

Improve hospital mortality ratios

100

Apr-09

To help judge the quality of care provided, we have set out our performance in relation to each individual priority in the past year.

120

May-09

How well have we done this year?

Graph 1. Hospital Standardised Mortality Ratio (HSMR)*

Re-admission rate %

Clinical Effectiveness

A national priority for the year, we are required to ensure that patients admitted as an emergency are not readmitted within 30 days after discharge. This could be a readmission for the same or a different condition to that treated during their previous admission. NHS Gloucestershire, in line with national guidance, required us to reduce emergency readmissions following a previous admission by 25%, giving the Trust a target rate of 7% in 2011/12. Our end of year position was 9.89%. A project group has now been established to look more closely at the reasons for readmission to help address this issue. To find out what we are doing in 2012/2013, see p22.


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PART TWO

PART TWO

4

2

Dec-11

Nov-11

Oct-11

Sep-11

Aug-11

Jul-11

Jun-11

May-11

Period

Graph 4. P  roportion of eligible stroke patients who spent more than 90% of their inpatient spell on a stroke ward

90% 80% 70% 60% 50% 40% 30%

Data

20%

Target

10%

Mar-12

Feb-12

Jan-12

Dec-11

Nov-11

Sep-11

Oct-11

0%

Period

*D r Foster is an independent provider of comparative information on health and social care services.

Apr-11

Mar-11

Feb-11

Jan-11

Dec-10

Nov-10

Oct-10

Sep-10

Aug-10

Jul-10

0

Aug-11

NICE Quality Standards are different from other NICE guidance as they are written as a health community pathway and have specific

There has been a wide range of activity this year aimed at improving hydration and nutrition. A new system of signage above each patient’s bed has been introduced, allowing nursing and other clinical staff to view at a glance the nutritional and hydration requirements of each individual. Tests to explore the use of crockery that is easily recognised by patients with some levels of cognitive impairment has been carried out.

6

Jul-11

Implement NICE quality standards

Improve hydration/ nutrition of elderly patients

8

Jun-11

there has been an increase in the number of patients staying on the stroke unit for 90% of their stay. When the stroke service is centralised at Gloucestershire Royal Hospital this summer, further improvements are expected and we will be able to develop a seven-day-a-week service for patients who suffer from Transient Ischaemic Attacks (TIAs), or mini-strokes. Our improvements in the quality of care provided for stroke patients was recognised this year by Dr Foster*, with our mortality rate for these patients being highlighted as among the lowest in the country.

We also introduced a new discharge checklist for diabetic patients to ensure they are properly prepared before they go home. To reduce the rate of readmissions, any patient who was repeatedly admitted was reviewed by a multidisciplinary team and a new care plan agreed. This project has contributed to shortening the length of stay in hospital for these patients and has significantly improved the quality of their experience.

Target

May-11

Our mortality rates for stroke patients have been highlighted as among the lowest in the country

Data

10

Jun-10

The number of patients with diabetes is steadily increasing nationally and improving the care we provide for these patients is a priority for the Trust. In the past year we have focused on promoting a national Think Glucose campaign internally, setting a new standard of assessment by our diabetes team within 24 hours of a diabetic patient’s referral and introducing new ‘hypo boxes’. These boxes contain all the equipment and drugs a nurse requires to treat patients with an unexpected hypoglycaemic episode.

May-10

Considerable improvements to the care we provide for stroke patients have been made this year. As a direct result of actions taken to encourage better co-ordination between the A&E Departments and the Stroke Unit,

12

Apr-11

Improve care for people with diabetes

Apr-10

Improve care for people with stroke

Graph 3. Length of stay for inpatient diabetic patients

Individual Value

outcome measures. We are working with our partners in the community to introduce a new process which will improve the current approach for implementation.

Proportion of Patients Who Met Target

developed to encourage more patients and their carers to use it. The success of this and other initiatives will be evaluated in the year ahead.


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PART TWO

The assessment of nutrition has also been improved following a review of the Gloucestershire Patient Profile and further work is underway revising the Malnutrition Universal Screening Tool (MUST). The Trust’s Nutrition and Hydration Group contributes to the dementia and learning disability work within the Trust, supporting activities such as the use of the ‘Red Tray’ system, which identifies patients who require help with feeding and the observance of protected meal times for patients.

Avoidable renal failure To prevent avoidable renal failure sometimes known as Acute Kidney Injury (AKI) four main areas need to be addressed. Firstly there has to be early recognition of patients at risk then there has to be an early review of the fluid balance of the patient, review of their medication and consideration of the cause such as sepsis. A programme of improvement will be developed over two years to improve care for these patients. Dementia

Reducing unnecessary readmissions is better for patients and better for the NHS. Reasons for readmission as an emergency soon after a patient’s original discharge are complex. Priorities for the year ahead Implement all NICE quality standards NICE quality standards are a set of specific, concise statements that act as markers of high-quality, cost-effective patient care, covering the treatment and prevention of different diseases and conditions. The new standards will be assessed and monitored and progress reported to the Quality Committee throughout the coming year.

Improving the care of patients with dementia is a priority set out in the National Operating Framework for 2012/13. A significant proportion of our hospital patients also suffer from dementia and we know that this figure continues to grow. Our Dementia Champions will continue to implement the Dementia Strategy and Action Plan to enable us to meet eight standards required by NHS South of England. These standards are about understanding and meeting people’s individual needs, better assessment and discharge, making the hospital environment ‘dementia friendly’, education and training for staff, nutrition and hydration, working with carers, families and volunteers and care towards the end of life. We have already made good progress in meeting these standards this year and will continue to build on these developments in the next 12 months. Readmission rates Reducing unnecessary readmissions is better for patients and better for the NHS. Reasons for readmission as an emergency soon after a patient’s original discharge are complex. There is no single cause but a combination

of different factors, including availability of community services, changing patient expectations, changes in clinical practice and the level of coordination between our hospital, community services and social services. A project group will be working over the next six months to understand the root causes of our readmissions, identify clinical groups where admissions may be avoidable and the actions required to avoid readmissions. This work will start with a clinical review to determine which readmissions are truly avoidable. This review will help to identify any poor quality care in our hospitals and any actions in the community which could have prevented readmission. We will be working closely with our commissioners to improve the integration of acute and community care. We will also continue to monitor readmission rates to measure our success. Cardiac output monitoring Monitoring the flow of blood from the heart during major surgery has been shown to improve how fast, and how well, patients recover. The Department of Health has identified this as a ‘high impact innovation’ that should be implemented by all hospitals. NHS South of England has also recognised its importance and included it in our 2012/13 contract as a CQUIN measure. It is a high priority for the Trust. To date the Trust has used the technique in a limited way. A project is now underway that will assess the current position, determine the patients that will benefit and produce a plan to implement the technique in a standard way.


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PART TWO

At Gloucestershire Hospitals NHS Foundation Trust we place great value in knowing and understanding the experiences of our patients and their carers and relatives. It is those experiences that continue to help us plan and deliver high quality healthcare. To ensure we provide a consistently excellent service the Trust has Inpatient and Outpatient Experience Groups that drive and support clinical teams to improve. The groups are chaired by the Trust’s Head of Patient Experience and have a diverse membership including patient/carer representation and Governors. These groups have responsibility for identifying key areas for improvement arising from all patient and carer feedback, assisting with the development of improvement plans and monitoring their implementation. Both groups report to the Quality Committee, ensuring that issues and developments relating to the experience of our patients remains at the forefront of the

staff and developed with them as part of our drive to improve the experience of patients and staff across the Trust. We already know that the majority of our staff behave in an exemplary and professional manner. The 10 new standards clearly set out what is expected of all staff and enable managers to take action where necessary to address poor behaviour. Members of staff whose kind and considerate behaviour exemplifies the standards will also be recognised via our new monthly Kindness and Respect Awards which are made on a monthly basis.

Overall we performed well against other Trusts in the Outpatient Survey in 2011/12. A total of 850 outpatients were invited to take part and we had very good response rate of 58%. In total 83% said they had an excellent or very good experience of care. You can read more about the Outpatient Survey in this year’s Annual Report which will be published on our website.

Real-time surveys Real time surveys carried out by trained volunteers using hand-held devices continue to provide invaluable feedback on the experiences of inpatients on our wards. Up to 50 patients on each ward are surveyed every six months. They are also a useful tool in evaluating the success of any measures we have taken to make improvements.

The results of the surveys are displayed in the relevant clinical areas and action plans are developed in response to any requirements. ` The questions asked by the survey are based on those asked by the National Inpatient Survey. These fall within the following categories: Information: ÆÆ information on ward routines (i.e. what happens when?) ÆÆ information on condition and treatment ÆÆ whether patients are made to feel welcome on the ward. Communication: ÆÆ opportunity to talk with staff about worries and fears ÆÆ answers are provided in a language the patient can understand.

How well have we done this year? Over the past year we have made good progress against many of the priorities set during 2011/12. To help judge the quality of care provided, we have set out our performance in relation to each individual priority in the past year. Improve effectiveness of communication and information. Improve involvement in decisions about their care. Improve privacy and dignity In January 2012 the Chief Executive launched the Kindness and Respect Behaviour Standards which clearly define the quality of behaviour and communication our patients, visitors and colleagues should expect from all staff. These standards were requested by

Graph 1. Real-time Patient Experience survey results April 2010 – March 2011 & April 2011 – March 2012

2011 / 2012

2010 / 2011

% level of patient satisfaction

Patient Experience

committee’s agenda. Our Foundation Trust Members and Governors as service users continue to play a vital role in improving the experiences of patients and carers. The Members Involvement Forum contributes significantly helping to ensure that the views and experiences of our patients and carers influence our work. This year for example, they have contributed to the ongoing development of the Trust website and the Access and Egress Group, looking at ways to make sure patients, visitors and staff move safely through our hospital grounds.

100 82

80 60

83 69

86

73

93 81

95

84

86

93

40 20 0 Information

Communication

Involvement

Respect and dignity

Overall


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PART TWO

PART TWO

ÆÆ control of pain ÆÆ is the patient treated with dignity and respect? ÆÆ is the privacy of the patient respected?

“Being able to help with my husband’s feeding, shaving and mouth care was helpful to staff and to me as I have cared for him for eight years so I felt part of his care. Staff were so willing and although so busy, nothing was too much trouble.” Patient Information Leaflets This year more than 800 information leaflets have been reviewed, with the removal of all of those that were obsolete. All remaining leaflets are being reviewed with relevant teams. Core leaflets are now in use on the wards, including the Information for Carers When Coming to Our Hospitals leaflet, Information on MRSA and a PALS leaflet. A review of clinical specialty leaflets will be

Improve the experience of carers (learning disabilities and dementia) The Trust’s Carers’ Policy was rewritten and launched this year after extensive consultation with carers and staff. It describes:

Graph 2. Carers of patients with learning disability Results of carers survey carried out between October 2011 — March 2012 100 % of carer satisfaction

Respect and dignity: ÆÆ help eating meals

complete by the end of April, ensuring that they are up to date. All leaflets are developed with patients from the relevant specialist areas and are reviewed and approved by the Patient Information Advisory Group, which includes four service users. In 2011/12, group members received training in how to communicate in plain English.

ÆÆ how carers will be supported to help them get involved in the planning and delivery of care

2010 / 2011

2011 / 2012

80 82

60 40

68 60

53

58

20

25

0 Feeling involved in decisions relating to care and treatment

ÆÆ how we can address the needs of carers and patients, taking this into account when discharge planning

Rating of care as excellent or very good

Information and support prior to discharge

ÆÆ how to address the needs of carers as employees of the Trust. This year’s carers survey was carried out between October 2011 and March 2012. Questionnaires were given to carers of patients with either dementia or with learning disabilities. Graphs 2 and 3 on p27 provide responses to three key questions reflective of the wider experience of carers as captured in the survey. One carer of a patient with learning disabilities said: “Being able to help with my husband’s feeding, shaving and mouth care was helpful to staff and to me as I have cared for him for eight years so I felt part of his care. Staff were so willing and although so busy, nothing was too much trouble.”

Graph 3. C  arers of patients with dementia Results of carers survey carried out between October 2011 — March 2012 2010 / 2011

2011 / 2012

100 100

% of carer satisfaction

Involvement in decisions about care: ÆÆ involvement of patients in decisions about care and treatment (as much as they want to be).

80

89 78

60

73

62

40 20 20

0 Feeling involved in decisions relating to care and treatment

Rating of care as excellent or very good

Information and support prior to discharge

Please note it is vital to interpret this data with caution as the number of respondents is small. Therefore the data provides a snapshot of the experience of carers. The same methods of recruitment were applied with consistent review by the patient experience team. Number of carer respondents to surveys: 2010/11 – LD = 33 / Dementia = 11. 2011/12 – LD = 16 / Dementia = 9


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PART TWO

Volunteers enhancing the experience of patients Volunteers play a key role in the experience of patients and their carers. This year a volunteer role has been specifically developed to support patients with dementia by spending time talking and reminiscing with them while in our care, helping to reduce their anxiety. Dementia volunteer roles are currently being piloted on two wards caring for older patients and those with general medical conditions. Volunteers are also involved in supporting patients while they eat their meals, sitting with those who need help cutting up their food and encouraging them to eat and drink. Improve the experience of those with visual impairment A report from Gloucestershire LINk (October 2011) following their work on access to health and social care services by the visually impaired gave us valuable feedback and identified further actions for improvement in the coming year. These actions are described on p29 in ‘Priorities for the year ahead.’ We have continued to work with Gloucestershire County Association for the Blind (GCAB) this year, developing a pilot project to evaluate the role of an Eye Clinic Liaison Officer. Information from this project will support a Big Lottery application for funding by GCAB for a post, the role of which would be partly

based in an outpatient department. A telephone-based information system has also been piloted for those attending a ‘low vision clinic’ to help address some of the problems faced by people with severe visual impairment when receiving written material. Results identified that patients require a choice of how they are contacted - either by large print letters or by telephone. This is recorded and the preferred method of communication used when contacting a patient. Improve discharge processes Work has continued to help improve the way we communicate with patients when they are discharged from hospital, for example the information they are given about medication to take home. The effectiveness of that work is reflected in the National Inpatient survey results in Graph 4 on p29. The data is collected annually from inpatients during of August. The response rates are above 50% for each year and are above the national average. Please note this is raw data from the survey as opposed to the modified data supplied by the Survey Coordination Centre - Picker Institute Ltd for the National Benchmarking report. While there has been some improvement in all but one of the results further improvement is still required. In the year ahead we will focus on improving the information provided to patients and families when they leave hospital and the way we communicate with them. Work will continue to ensure patients receive copies of letters sent between hospital doctors and their GP.

patients about their condition and treatment, such as their medication. We will be looking at how staff can improve a patient’s experience by communicating with them effectively about their treatment and condition and by encouraging them to ask questions.

Priorities for the year ahead Discharge experience of patients and carers Safe and effective discharge of patients from hospital is a key priority for the Trust. We believe that good communication and the involvement of patients and carers is vital if we are to improve the discharge process in the future. We will continue to help patients and their families understand the process for leaving hospital and to make sure they have the information they need to continue their recovery once they go home. This information will include what to look out for at home, who to call if they have concerns and information on any medications they may have been prescribed.

Improving the experience of those with hearing impairment Following on from the work started in 2011/12 and as a result of the Gloucestershire LINk report mentioned above, we will be working with patients with visual impairment to improve access to our services via: ÆÆ signage ÆÆ labelling of medicines ÆÆ availability of letters in a larger font size Stronger links will be built with Gloucestershire Deaf Association and Gloucester County Association for the Blind. We will develop a clear process to help this client group share their views and

Communication about treatment options This is a priority area of ongoing work which aims to improve the information provided to

Graph 4. D  ischarge experience of patients As reported in National Inpatient Survey 2010 and 2011

100

2010 / 2011

2011 / 2012

80 72

60 61

%

Work continues through the Carers Strategy Group, the Learning Disability Steering Group and the Dementia Strategy Group to improve the experience of carers. Working with support organisations such as Carers Gloucestershire and the Alzheimer’s Society will continue to be integral to that process.

40

46

50

54

61

65

49 33

20

39 16

0 % of patients who said they definitely felt involved in decisions about discharge from hospital

% of patients who said they were given written/printed information about what they should or not do after leaving hospital

% of patients who said they were fully told the purposed of medication in a way they could understand

% of patients who were told who to contact if worried

% of patients who said that those close to them definitely received enough information to help them to care at home

20

% of patients receiving copies of letters sent between hospital doctors and their family GP


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31 PART TWO

experiences as well as make complaints, raise concerns and give compliments. This work will be taken forward by the Inpatient and Outpatient Experience Committees. Hydration and nutrition In addition to the actions highlighted in the Clinical Effectiveness section of this report (see p20), the patient experience team will further develop the role of volunteers in supporting vulnerable patients with their eating and drinking. Patient Experience Escalator This priority is about making sure that we have processes in place to ensure the experience of our patients are actively sought and inform and shape the delivery of our services and the care we provide. This is divided into four key areas: Responding to patient and carer feedback This year we will focus on creating more opportunities for our patients and carers to share their views. In 2012/13 we plan to: ÆÆdevelop web pages to encourage patient/carer feedback and provide updates on actions taken in response ÆÆ work in partnership with carer and patient support organisations to encourage feedback via the web and to raise awareness of how to raise concerns or make complaints ÆÆ develop a process of helping those with visual impairment to share their views on their experiences in hospital. Promoting shared decision making The goal is to enable patients to be involved in decisions about their care and discharge. We will do this by establishing clear

processes to improve information sharing between staff, patients and their families / carers, helping them to be more involved in decisions about their care. Attitudes of staff We know that the attitude of our staff influences the experiences of patients, carers and colleagues. As outlined on p24 in 2011/12 we launched our Kindness and Respect Standards of Behaviour. During 2012/13 we will work to further embed these within the organisation by including the standards in appraisals, providing training and support to managers and continuing to provide awards to recognise examples of exemplary behaviour. Leadership The attitude of our leaders also influences the experiences of patients, carers and colleagues. We will demonstrate our commitment to improving these attitudes by: ÆÆ carrying out observations/audits to demonstrate evidence of the change of behaviour in practice ÆÆ sharing patient/carers’ personal stories with the Trust Board ÆÆ ensuring patient experience matters are always discussed in Executive Director visits to wards and departments.


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PART THREE

PART THREE

The following section includes responses to a nationally defined set of statements which will be common across all Quality Accounts. PA RT THREE

Statements of assurance

The statements serve to offer assurance to the public that our organisation is: ÆÆ performing to essential standards, such as securing Care Quality Commission registration ÆÆ measuring our clinical processes and performance, for example through participation in national audits ÆÆ involved in national projects and initiatives aimed at improving quality such as recruitment to clinical trials.


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PART THREE

Information on the Review of Services The purpose of this statement is to ensure we have considered quality of care across all our services. The information reviewed by our Quality Committee is from across all clinical areas. Information at individual service level is considered within our divisional structure and any issues emerging escalated to the Quality Committee. During 2011/12 Gloucestershire Hospitals NHS Foundation Trust provided and/or subcontracted 42 NHS services. Please see Table 1 for more detail. The Trust has reviewed the data available to us on the quality of care in all of these NHS services. The income generated by the NHS services reviewed in 2011/12 represents 100% of the total income generated from the provision of NHS services by Gloucestershire Hospitals NHS Foundation Trust for 2011/12.

Information on participation in Clinical Audit From 1 April 2011 to 31 March 2012 35 national clinical audits and one national confidential enquiry covered the NHS services that Gloucestershire Hospitals NHS Foundation Trust provides. The national clinical audits and national confidential enquiries that Gloucestershire Hospitals NHS Foundation Trust was eligible to participate in from 1 April 2011 to 31 March 2012 are listed in the tables on p3639. During that period Gloucestershire Hospitals NHS Foundation Trust participated in 32 (91%) of national clinical audits and one (100%) national confidential enquiry of the national clinical audits and national confidential enquiries in which it was eligible to participate. Of the three audits where the Trust did not participate there were justifiable reasons for non participation in two (please see p36-39).

Table 1: Subcontracted services for 2011/12 Accident and emergency

Orthodontics

Adult critical care

Paediatric cardiology

Anaesthetics

Paediatric dermatology

Breast surgery

Paediatric endocrinology

Cardiology

Paediatric ENT

Clinical haematology

Paediatric ophthalmology

Clinical immunology and allergy

Paediatric surgery

Clinical oncology

Paediatric T&O

Colorectal surgery

Paediatric urology

Dermatology

Pain management

Gastroenterology

Palliative medicine

General medicine

Rehabilitation

General surgery

Rheumatology

Gynaecology

Thoracic medicine

Medical oncology

Trauma & Orthopaedics (T&O)

Neonatal critical care

Upper Gastrointestinal surgery

Nephrology

Urology

Nuclear Medicine

Vascular surgery

Obstetrics

Obstetrics

Ophthalmology

Paediatric T&O

Oral surgery

Palliative medicine

Alongside the audits, the number of cases submitted to each audit or enquiry can be seen as a percentage of the number of registered cases required by the terms of that audit or enquiry or a straight percentage of cases submitted. The reports of 18 national clinical audits/ confidential enquiries participated in were reviewed by the Trust in 2011–2012. Fourteen reports are still awaited. The actions Gloucestershire Hospitals NHS Foundation Trust intends to take to improve the quality of healthcare provided are summarised in the tables on p36–39. The reports of over 150 local clinical audits were reviewed in 2011–2012. Examples of the actions Gloucestershire Hospitals NHS Foundation Trust either has or intends to take as a consequence of those audits include: ÆÆ additional nurse training in the care of chest drains ÆÆ training of all maternity staff to improve awareness of health records guidelines and filing instructions ÆÆ improved use of the red allergy wrist band identifier. This high level of participation demonstrates that quality is taken seriously by our organisation and that participation is a requirement for clinical teams and individual clinicians as a means of monitoring and improving their practice. Additionally, in January 2011, an external review of clinical audit was undertaken. As a consequence an action plan was developed that is monitored via the Quality Committee.

The clinical audit activity has been incorporated into the Service Improvement Portal Project which provides a single place to access all planned, current and completed audits.


Yes

Confidential Enquiry: Maternal and Child Health (MBRACE)

Yes

Yes

Childhood epilepsy Pain Management (College of Emergency Medicine)

Yes

Yes

Yes No

ICNARC CMPD Acute critical care units NHS Blood and Transplant potential donor audit

National Participation in Seizure Audit BTS (suite) audit

Yes

Yes

Yes

Parkinson Disease Audit

Ulcerative Colitis and Crohn’s disease (UK IBD audit) Adult asthma

Yes

Yes

National Joint Register (NJR) Hip and knee replacements National Elective Surgery Patient Related Outcome Measures (PROMS): Hip replacement, Knee replacement, Hernia, Varicose Veins

Elective Procedures

Yes

No, but

National Pain Audit

Heavy Menstrual Bleeding (HMB)

National Diabetes Audit (NDA) ADULT

Yes

Yes

Severe sepsis and septic shock (College of Emergency Medicine)

Long term conditions

Yes

National Cardiac Arrest Audit

Acute Care

Yes

National Diabetes Audit (NDA) paediatric

Children

Yes

Yes

Yes

Not yet available

Not yet available

Please see p49 for more details on the PROMS data.

There was concern about certain prostheses. Because of the NJR these patients could be identified and an appropriate follow up in clinic ensured.

Not yet available.

PART THREE

Compliance rates All procedures: 78.6% Groin Hernia: 74% Hip replacement: 66.3% Knee replacement: 85.9% Varicose veins: 135.6%

Yes. Trust continues to submit

Data collection in progress

The Trust submitted 20 Crohn’s and seven cases of UC which was 100% of the minimum requirement

Changes since last audit would include – new chart for patients with acute colitis, increasing capture of C. diff stool cultures, closer working with the surgeons for acute UC patients. The Trust is also involved in the national IBD-QIP, another self improvement project based on the national IBD standards. www.ibdqip.co.uk

Formal report not yet available however preliminary report has been reviewed by the PD group as a result there is to be a review of documentation for consistency and guidance.

Formal report not yet available however preliminary report has been reviewed by the PD group 30/30 – 100% submission

Preliminary report just available

Preliminary report just available

A three-year audit and the Trust continues to submit

National Requirements Trust achieved 75% Overall satisfaction rate 83% 30% Amenorrhoea rates 54% 75% Reduction in Menstrual blood flow 81% Less than 2% immediate complication rates 0% In all instances the Trust exceeded the national standard requirements, therefore comparison with the national standards demonstrated that no changes were needed.

The results obtained were as follows:

Await report for 2011/2012 As a result of the last report the following were introduced: ÆÆ Review of service & priorities for future development highlighted ÆÆ Following Think Glucose; more proactive review of IPs (both admitted because of diabetes & those who happened to be diabetic) ÆÆ Additional teaching input to wards & staff ÆÆ Additional teaching around insulin prescriptions ÆÆ Hypo management & introduction of eLearning package ÆÆ Linkage with surgical pre-assessment clinics

Await report - no date yet published.

Information is input into our Organ Donation Annual Business Plan, written by the clinical lead on behalf of the organ donation committee. This is then disseminated up to the Trust Board. NHSBT also send six monthly reports directly to Chief Executive of the Trust vs. national data.

All admissions are recorded on the ICNARC database. Much data is recorded including reason for admission, illness severity, length of stay. There is a quarterly morbidity and mortality meeting where outcome data is reviewed and each death is reviewed. Generally we perform well with a low SIR, low numbers of readmissions and out-of-hours discharges and a short length of stay.

At the ED Clinical Governance meetings. Actions taken as a result of previous adult BAEM audits include: Abnormal vital signs repeated at 60 mins, production of Clinical Governance newsletter and Local ED pain management policy developed for renal colic.

Await report.

N/A

Await report for 2011/12

N/A

Await report - no date yet published

Yes

Yes

Await report due mid 2012

Await report due mid 2012

Not yet available - due April 12

This was discussed at Gynaecology governance and the Trust decided not to participate as it has already undertaken two significant audits (involving patient participation) in HMB. This audit would be repeating work already undertaken

All in patients on the snapshot day submitted – 100% submitted

50 cases -100%

Since April 2011, 322 deaths in the departments of critical care and accident and emergency have been audited

100%. Between 600–700 admissions

25/25 – 100% Trust participated. Report not yet available

60/60 – 100% cases at CGH and GRH

40/40 – 100% submitted

Not yet applicable.

Not yet applicable. Site reports due in June 2012 and final report in Sep 2012

The childhood epilepsy audit entered 63/63 100% submission

Previous audits are presented at the ED Clinical Governance meetings. Actions taken as a result of previous paediatric BAEM audits include: ÆÆ Advice sheet for patient/carers for feverish children being investigated ÆÆ NICE guidance for feverish children now included in junior doctors induction

Await report for 2011/2012. 2010/2011 report reviewed and as a result actions implemented to achieve improved HbA1c control.

All neonatal deaths are reviewed internally as part of the risk management process and a number of changes to working practices in light of findings from these reviews. An example is that category 1 caesarean sections now go out as a ‘neonatal emergency’ call to ensure senior paediatric presence at these high risk deliveries.

Discussed at Clinical Governance meetings. Linked to CNST Level 3. Part of the Serious Clinical Incident review process. The most recent was 2009, when Gloucestershire had a neonatal mortality rate well below average. The post mortem examination rate was low and it was reviewed why this might have been and how we might improve it.

The Trust participates via the ‘Badger’ system. This is the database used to record all the NICU activity. The data is on a remotely-held database, and as such is accessed by the NNAP team and the local neonatal network.

Actions taken as a result of audit / use of the database

Await report. 2010 report reviewed

Yes

Yes

Was the report reviewed

100% patients submitted

100% maternal 100% neonatal

100% compliance in data submission

Did the Trust Number of case submitted / number Participate? required

Neonatal Care Audit Programme

Peri and Neonatal

Audit title

National Audits as stated by National Clinical Audit Advisory Group (NCAAG)

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PART THREE


No, but

Yes

Acute Stroke SINAP National sentinel stroke audit

Yes

Yes Yes

National Bowel Cancer Audit Programme (NBOCAP) DAHNO: Head and Neck cancer National oesophagogastric cancer

Yes

National falls and bone health

Risk factors – NHS Health Promotion in Hospital

Miscellanous

National comparative audit of blood transfusions: Suite of changing topics

Yes

Yes

Yes

TARN: Severe Trauma

Blood transfusion

Yes

National Hip Fracture Database (NHFD)

Trauma

Yes

National Lung Cancer Audit (NLCA)

Cancer

Renal registry: Renal replacement therapy Yes

Yes

Heart Failure Audit

Renal Disease

Yes

Yes

N/A

Trust maintains a stroke register and contributes to the South West Network stroke registration programme

100/100 – 100% Submission

30/30 – Bedside transfusion: 100% 30/30 – Medical use of blood: 100%

60/60 – 100% submission

Trust is in process of entering backlog data

Await report

Await report

Yes

N/A

Yes

Yes by 3CCN

2010 annual report 271 cases submitted

100%

Yes by 3CCN

Yes by 3CCN

2011 Annual report, 225 cases submitted 51.5% case ascertainment 50.8% data completeness for patients who had major surgery 2011 annual report not yet published 2010 annual report 101 cases submitted

Yes by 3CCN

Yes

2011 Annual report 117% of patients submitted

100%

Yes

Yes

A minimum of 20 patient per month; trust compliant with audit requirements

60/60 – 100%

Yes

Yes

Was the report reviewed?

67/67 – 100% for patients with ST elevation MI

661/661 – 100% interventions

Did the Trust Number of case submitted / number Participate? required

Myocardial Infarction National Audit Project (MINAP)

Cardiovascular Disease

Adult cardiac interventions coronary angioplasty

Audit title

Previous audit has lead to a clarification and change in documentation

Reports are presented to transfusion committee. Previous audits have led to review of blood transfusion policy with information being provided in a newsletter.

This has resulted in improvement in numbers being assessed for postural BP, vision and in written information being given out. A countywide patient satisfaction questionnaire for the falls clinics is currently being undertaken. All the work on the falls CQUIN will have also had an impact on the care of inpatients.

Not yet applicable

Reported monthly to orthopaedics board. As a result of review orthogeriatricians are more involved with reports to improve the number of patients seen within 72hours.

Results are reviewed at the appropriate 3 Counties Cancer Network (3CCN) meetings

Results are reviewed at the appropriate 3 Counties Cancer Network (3CCN) meetings

Results are reviewed at the appropriate 3 Counties Cancer Network (3CCN) meetings

Additional audit work has been undertaken relating to small cell lung cancer and presented at the 3CCN educational meeting

13th Annual Report reviewed. Continue as present

In the past the audit has led to a review of time spent in a stroke unit and of the availability of therapy resources and a stroke co-coordinator. It has been a considerable driver for change within the Trust

N/A

The results are reviewed at Cardiology meetings. One action taken has been the increased use of community Heart Failure Nurses

Emphasis on improving timings of response. Shared with regional, network and local colleagues.

Information from this database is: ÆÆDownloaded to the Central Cardiac Audit Database (CCAD) where it contributes to national data collection ÆÆReviewed at quarterly County Cardiac Audit meetings ÆÆIncluded in Cardiology M+M meetings where appropriate ÆÆUsed to generate unit and operator specific procedural mortality curves using a nationally approved risk adjustment model

Actions taken as a result of audit / use of the database GHNHSFT Quality Account 2011-2012

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PART THREE PART THREE


GHNHSFT Quality Account 2011-2012

41

PART THREE

PART THREE

Participation in Clinical Research The inclusion of this statement demonstrates the link between our participation in research and our drive to continuously improve the quality of services. The number of patients receiving NHS services provided or subcontracted by Gloucestershire Hospitals NHS Foundation Trust in 2011/12, that were recruited during that period to participate in research approved by an NHS research ethics committee, and included on the National Institute for Health Research (NIHR) Portfolio is currently 697 (as of 27 February 2011). This figure is likely to increase over the following months as participants recruited to research studies in the second half of the financial year continue to be reported. In 2010/11 the figures increased by just under 40% before a final figure was achieved in the summer of 2011. If recruitment continues at a similar rate, we can expect a final total for 2011/12 at around 1000 participants. Although this is lower than the final total for 2010/11, we have lost a number of high recruiting studies in 2011/12. Three of these studies recruited 1133 participants between them, accounting for 53% of the total recruitment in 2010/11. Taking this into account, there is an expectation that the final recruitment figures for 2011/12 will be similar to those for 2010/11 after adjusting for these three studies. As the Gloucestershire R&D Consortium Delivery Budget is dictated by activity, the reduction in recruited participants will result in a lower allocation of Delivery Funding in 2012/13. However, it is not expected that this will be detrimental to recruitment in 2012/13 as savings will be made elsewhere.

During 2011/12, the Trust was involved in conducting, hosting and recruiting to over 207 clinical research and other well designed studies. Of these 207 studies, 134 were adopted to the NIHR Portfolio. Although relatively stable in terms of total studies, the number of NIHR Portfolio studies has increased by nearly 11%. Proportionally this is an increase on last year where NIHR portfolio projects accounted for 60% of all active studies as opposed to 65% for 2011/12.

from our host and associate commissioners of £332,723,000. This represented about 1.5% of income. Current indications are that we will be successful in securing between £3,415,893 and £4,464,568. This represents a shortfall of between £441.5k and £1.49m. The final figure will not be

Goal no.

Goal name

Description of goal

There was a wide range of clinical staff participating in research approved by a research ethics committee during 2011/12. These staff participated in research covering the majority of medical specialties across all four Divisions in Gloucestershire Hospitals NHS Foundation Trust.

1

VTE

known until end of year audits have been completed for some schemes. The CQUIN schemes agreed with NHS Gloucestershire for 2011/12 and 2012/13 can be seen below. These include four nationally mandated and five local schemes.

Table 1: 2011/12 CQUIN goals Goal weighting (% of CQUIN scheme available)

Expected financial value of Goal (£)

Quality domain (Safety, Effectiveness, Patient Experience or Innovation)

Reduce avoidable death disability and chronic ill health from venous thromboembolism (VTE)

25.00%

£1,226,530

Safety

2

Patient experience – personal needs

National CQUIN Indicator based on national annual survey. Overall aim was to secure a minimum of six percent improvement on the percentage of patients for each score area.

25.00%

£1,226,530

Patient Experience

3

Improving Inpatient Diabetic Care

National scheme for improvement in inpatient diabetes care

25.00%

£1,226,530

Safety, Effectiveness

Information on the use of the Commissioning for Quality & Innovation (CQUIN) framework

4

Reduction of Harm from Falls

Reduction of harm from inpatient falls across GHNHSFT sites.

25.00%

£1,226,530

Safety

The CQUIN payment framework aims to support the cultural shift towards making quality the organising principle of NHS services by embedding quality at the heart of commissioner-provider discussions.

Table 2: 2012/13 CQUIN goals Goal weighting (% of CQUIN scheme available)

Expected financial value of Goal (£)

Quality domain (Safety, Effectiveness, Patient Experience or Innovation)

The agreed quality incentive goals for 2012/13, the rationale behind them and the associated payments are summarised in Table 2. There is a high level of overlap between these goals and the priorities in our Quality Account for 2012/13. This demonstrates we actively engage with our commissioners in quality improvement. The level of the Trust’s income in 2011/12 dependent on the delivery of these locally agreed quality and innovation goals was £4,906,120 out of a total planned income

Goal no.

Goal name

Description of goal

1

VTE

Continuation of existing nationally mandated goal. Weighting set: Risk assessment 90%, appropriate prophylaxsis 90%

0.125%

£401,250.00

Safety

2

Patient experience – personal needs

National CQUIN Indicator based on national annual survey.

0.125%

£401,250.00

Patient Experience

3

Dementia

Screening, risk assessment and referral to a specialist for all emergency admissions over the age of 75

0.125%

£401,250.00

Safety

4

Safety Thermometer

Data collection for all patients in four harm areas: VTE, pressure ulcers, falls and UTI in patients with catheters

0.125%

£401,250.00

Safety

5

Cardiac output monitoring

Monitoring technology recommended for patients undergoing major or high risk surgery

0.125%

£401,250.00

Clinical Effectiveness

6

Patient experience escalator

Multi-level goal on organisational responsiveness to patient experience

0.375%

£1,203,750.00

Patient experience

7

Sepsis management

Implementation of the Sepsis 6 care bundle

0.250%

£802,500.00

Safety

8

Acute Kidney Injury

Avoidance, detection and management of AKI

0.250%

£802,500.00

Safety

9

Supporting clinical change programme

Promotion of clinical engagement and system change to deliver the QIPP programme

1.000%

£3,210,000.00

Contract performance


GHNHSFT Quality Account 2011-2012

43

PART THREE

PART THREE

The Care Quality Commission The Care Quality Commission (CQC) is the independent regulator of health and adult social care services in England. From April 2010, all NHS Trusts have been legally obligated to register with the CQC. Registration is the licence to operate and to be registered, providers must, by law, demonstrate compliance with the regulatory requirements of the CQC (Registration) Regulations 2009. Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) is registered with the CQC without conditions. This means that the Trust has continued to demonstrate compliance with the regulations. The Care Quality Commission has not taken enforcement action against GHNHSFT during 2011/12. The Trust continues to receive monthly Quality Risk Profiles from the CQC.

Good quality data underpins the effective delivery of patient care and is essential if improvements in quality of care are to be made. The CQC Quality and Risk Profile for February 2012 declares no risks to compliance with any of the 16 essential standards for quality and safety, above a “low amber.” Part of the CQC monitoring of compliance process includes reviews, which can be planned or responsive in nature. On March 2 and 3, 2011, a team of seven

inspectors from the CQC South West Region visited Gloucestershire Royal Hospital for a two day responsive review. The aim of the visit was to add observation, discussion and interview material to the information and intelligence they had previously gathered about the Trust. The review addressed five of the CQC’s 16 essential areas for quality and safety and in addition the essential standard for nutrition. The Review Team found that people using the services at GRH were safe but were not always experiencing the specified outcomes in each of these areas. An action plan to address the highlighted concerns was developed. A team of inspectors also made a visit to CGH on May 15 and 16, 2011 to follow the same themes as the March visit to GRH. The inspectors found that people using the services at CGH were safe but not experiencing some of the specified outcomes in the themes under review; the action plan in place for GRH was further developed and discharged in September 2011, after a further visit to the Trust and discussion with Nursing Director, Maggie Arnold, who took lead responsibility for the action plan implementation. The Trust can expect an annual review of its services by the CQC compliance team at any time in the next twelve months and has in place a Quality Standards Review Group which specifically reviews the evidence against each of the Outcomes to provide assurance to the Board of compliance with the Regulations.

Quality of Data Good quality data underpins the effective delivery of patient care and is essential

if improvements in quality of care are to be made. The patient NHS number is the key identifier for patient records. Accurate recording of the patient’s General Medical Practice Code is essential to enable the transfer of clinical information about a patient from a trust to the patient’s GP. Gloucestershire Hospitals NHS Foundation Trust will be taking the following action to improve data quality: ÆÆ review existing reports structure and access methods ÆÆ review usage within the organisation ÆÆ improve existing monitoring reports which identify areas of concern eg missing income, coverage of NHS numbers and ethnic group. Gloucestershire Hospitals NHS Foundation Trust submitted records during 2011/12 to the Secondary Users Service (SUS) for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of published data which included the patient’s valid NHS number was: ÆÆ 99.8% for admitted patient care (national average: 98.7%) ÆÆ 99.8% for outpatient care (national average: 99.0%) ÆÆ 97.7% for accident and emergency care (national average: 92.9%) The percentage of published data which included the patient’s valid GP practice code was*: ÆÆ 99.9% for admitted patient care (national average: 99.9%) ÆÆ 99.9% for outpatient care (national average: 99.7%)

*Source: SUS data quality dashboard April 2011 to December 2011

ÆÆ 100% for accident and emergency care (national average: 99.4%)

All Trust systems have an identified system manager with data quality as a specified duty for this role A comprehensive suite of data quality reports covering the Trust’s main operational system (PAS) is available and actioned. These are run on a daily, weekly and monthly basis and include areas such as:ÆÆ outpatients including attendances, outcomes, invalid procedures ÆÆ inpatients including missing data such as NHS numbers, theatre episodes ÆÆ critical care including missing data, invalid HRGs ÆÆ A&E including missing NHS numbers, invalid GPs ÆÆ waiting list including duplicate entries, same day admission On a weekly basis this missing/incorrect data is chased and input/rectified. The Trust Data Quality Policy is published on the intranet setting out responsibilities for data quality. All Trust systems have an identified system manager with data quality as a specified duty for this role. System managers are required under the Clinical and Non Clinical Systems Management Policy to identify data quality issues, produce data quality reports, escalate


GHNHSFT Quality Account 2011-2012

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45 PART THREE

data quality issues and monitor that data quality reports are actioned.

Information Governance The Trust’s Information Governance Assessment Report score overall for 2011/12 was 77% and was graded green. This compares with 71% in 2010/11. The Information Governance Toolkit is available on the Connecting for Health website www.igt.connectingforhealth.nhs.uk The information quality and records management attainment levels assessed within the Information Governance Toolkit provide an overall measure of the quality of data systems, standards and processes within an organisation.

Clinical Coding Error Rate Clinical coding translates the medical terminology written by clinicians to describe a patient’s diagnosis and treatment into standard, recognised codes. The accuracy of this coding is a fundamental indicator of the accuracy of the patient records. The error rates for diagnosis and treatment coding for 2011/12 were*: ÆÆ primary diagnosis incorrect 6.0% ÆÆ secondary diagnosis incorrect 14.2% ÆÆ primary procedures incorrect 2.0% ÆÆ secondary procedures incorrect 9.0%

*Source: Payment by Results Data Assurance Framework Audit 2011/12: Audit Commission (GHT Site Audit carried out October 2011)


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PART FOUR

PART FOUR

The following section presents information relating to the quality of the services that we provide.

The information will outline our performance against National Priorities and Core Standards as well as the measures agreed locally as part of our Quality Account last year.

Overview of Performance against the 2011/12 National Priorities and Core Standards National Priority

PA RT FOUR

Review of quality performance

National Target for 2012-13

2008-9

2009-10

2010-11

2011-12

Clostridium difficile year on year reduction2 ÆÆTotal ÆÆPost 48 hrs

363 251

196 126

175 116

160 92

73

MRSA bacteraemia1 at less than half the 2003/4 level ÆÆTotal ÆÆPost 48hrs

26 8

17 6

7 2

7 2

1

18 week maximum wait from point of referral to treatment (admitted patients)

90.1%

91.0%

88.9%

89.6%

90%

18 week maximum wait from point of referral to treatment (non-admitted patients)

95.2%

96.3%

97.2%

98.1%

95%

Maximum waiting time of four hours in A&E from arrival to admission, transfer or discharge (GHNHSFT only)3

97.1%

96.2%

94.97%

92.8%

95%

Maximum waiting time of 31 days from decision to treat to first treatment for all cancers4

99.9%

99%

99.7%

99.4%

96%

Maximum waiting time of 31 days from decision to treat to subsequent treatment: surgery4

N/A

99.4%

99.8%

100%

94%

Maximum waiting time of 31 days from decision to treat to subsequent treatment: drugs4

N/A

99.7%

100%

100%

98%

Maximum waiting time of 31 days from decision to treat to subsequent treatment: radiotherapy4

N/A

N/A

100%

100%

94%

84.1%

85.4%

84.8%

85%

Q1-Q3

Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers2,4

96.3% Q4

77.0%

Maximum waiting time of 62 days from urgent referral from national screening programme to first treatment4

N/A

99.4%

98%

95.8%

90%

Maximum waiting time of 62 days from urgent referral from consultant upgrade suspected cancer referrals 4

N/A

91.7%

92.7%

84.4%

90%

Maximum waiting time of two weeks from urgent GP referral to first outpatient appointment for all urgent suspected cancer referrals 4

100%

93.3%

93.6%

92.1%

93%

Maximum waiting time of two weeks from urgent GP referral to first outpatient appointment for patients referred with non cancer breast symptoms 4

N/A

91.9%

90.6%

88.1%

93%

1. MRSA bacteraemia target: total is for the Health Community, post 48 hours relates to the number of cases for Gloucestershire Hospitals NHS Foundation Trust 2. Shows mandated indicators for external audit. For a definition of the indicators visit www.monitor-nhsft.gov.uk/annualreportingmanual 3. Please note change of measure from countywide to GHNHSFT only, as required by Department of Health 4. For all cancers data is taken from April 2011 — Feb 2012


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PART FOUR

PART FOUR

Performance against selected metrics

are a subset of a broader range of quality measures that are regularly reported to our Quality Committee and to our Board through our performance management framework. We have also included the priorities with measurable outcomes for 2011/12 and will add to this list in the years to come to demonstrate our performance in these key areas. These measures have been chosen because we believe the data from

The following tables show the Trust’s performance for 2011/12 and the last three financial years for a selection of indicators relating to safety, clinical effectiveness and patient experience. We have chosen to include the same indicators as in past years to enable patients and the public to understand performance over time. These

Measure

2008-9

2009-10

2010-11

2011-12

National average 2011-12

Safety Measures

which they are sourced is reliable and they represent the key indicators of safety, clinical effectiveness and patient experience within our organisation.

Dry run of data requested by Department of Health The following indicators have been requested for inclusion by the Department

of Health. Although we do not need to provide this data for 2011/12 we have been encouraged to include results in the following areas as a ‘dry run’ ahead of next year’s Quality Account. We have, however, had considerable difficulty in accessing this data and we are not sure that the data we are presenting here is directly comparable with the national rates.

Measure

2011-12

National average 2011-12

94.2%

89.3%

32.4

59.2

5.6%

N/A

Safety Measures

Adverse event rate

N/A

61

34.19

17.61

N/A

Percentage of patients risk assessed for VTE (Jan 2012) 6

1

2

2

4

N/A

Rate of patient safety incidents based on internal database (per 1000) 6

Reduce harm from falls (per 1000 bed days)

N/A

N/A

1.62 (2010)

1.59 (2011)

N/A

Reduce errors in medication (per 100 bed days, ward areas only)

N/A

N/A

2.26 (2010)

1.94 (2011)

N/A

Reduce pressure sores

N/A

N/A

101

99

N/A

No. of patients discharged with Deep Vein Thrombosis (DVT) or Pulmonary Embolus (PE) per 1000 discharges2

13.6

12.6

14.6

9.0

N/A

1

Never events

ÆÆ percentage resulting in severe harm or death (orange and red graded incidents) Rate of C.difficile (per 10,000 bed days cases aged ≥ 2 years) Summary Hospital-level Mortality Indicator (SHMI)

Q3

3.38

N/A

97.4

100

9.89%

12.97%

ÆÆGroin hernia surgery

47.8%

51.2%

ÆÆVaricose vein surgery

47.4%

51.3%

ÆÆHip replacement surgery

86.8%

86.9%

ÆÆKnee replacement surgery

50.2%

78.3%

51% (2011)

62%

available May ‘12

available May ‘12

Clinical Effectiveness Measures Clinical Effectiveness Measures Hospital Standardised Mortality Ratio

95.6

4

*

102.4

95.3

**

Number of patients on a stroke ward for 90% of their stay*

N/A

N/A

N/A

Readmission rates within 30 days

N/A

N/A

N/A

98.8 Q3

66.7% 9.89%

100 N/A 12.97%

Patient Experience Measures Percentage of complaint responses sent within 25 days

75%

91%

97%

98%

N/A

Percentage rating standard of care as excellent or very good5

78%

78%

75%

74%

available May ‘12

Percentage with medicines to take home who had side effects explained to them 6

34%

25%

26%

33%

available May ‘12

Emergency readmissions to hospital within 28 days of discharge following non-elective admission (currently not measured by Trust. Rate here is for 30 days) 6 Patient Experience Measures Patient reported outcome scores7 for

Percentage of staff who would be happy to recommend the standard of treatment provided by the Trust to friends or family needing care 8 Responsiveness to inpatients’ personal needs

*

Based on 2007/8 data

**

Based on 2008/9 data

Based on 2009/10 data

Based on 2010/11 data

Notes on selected metrics 1. Adverse Event Rate: this is calculated on a monthly basis, auditing a random sample of 20 notes against the Global Trigger Tool. We aim to reduce the rate by 30% over the next 3 years 2. No of patients discharged with deep vein thrombosis (DVT) or pulmonary embolus (PE) per 1000 discharges. This metric is derived from diagnosis on discharge. Some reduction in this years figure due to coding changes 3. Hospital Standardised Mortality Ratio: the Source for this data is Doctor Foster Intelligence. By benchmarking against similar Trusts it measures whether the mortality rate in our Trust is higher or lower than would be expected.

4. Inpatients rating standard of care as good or excellent: this data is taken from the National Patient Survey 5. Patients with medicines to take home who had the side effects explained to them: this data is taken from the National Patient Survey. There are eight questions exploring the patient’s experience around discharge and we have chosen this as a “tracker” indicator 6. National averages for 2011/12 taken from the Acute Trust Quality Dashboard 7. The most recent published outcome data is for the April 2010 – March 2011 period. There is limited data for the April 2011 – June 2011 period for the Trust presently on groin hernia surgery only. This data shows quality of life which patients report as having increased as according to five questions on mobility, self care, usual activities, pain and discomfort and anxiety and depression 8. Data taken from GHNHSFT Staff Survey 2011.


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PART FIVE

PART FIVE

Statements from stakeholder organisations.

In order to ensure the information contained in the Quality Account is accurate, fair and gives a representative and balanced view, our Quality Account has been shared with Gloucestershire Local Involvement Network (LINk), Gloucestershire Health, Community and Care Overview and Scrutiny Committee (HCCOSC) and NHS Gloucestershire, as our lead commissioner. We are grateful for the time and effort they have put in to provide us with their comments which are included on the following pages.

PA RT FI V E

Annexes


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53

PART FIVE

PART FIVE

Gloucestershire Local Involvement Network (LINk) Comments on the GHNHSFT Quality Account 2011/12 SINGLE PAGE IS INDICATIVE ONLY - MORE SPACE CAN BE ADDED

Gloucestershire Health, Community and Care Overview and Scrutiny Committee Comments on the GHNHSFT Quality Account 2011/12 SINGLE PAGE IS INDICATIVE ONLY - MORE SPACE CAN BE ADDED


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PART FIVE

PART FIVE

NHS Gloucestershire Comments on the GHNHSFT Quality Account 2011/12 SINGLE PAGE IS INDICATIVE ONLY - MORE SPACE CAN BE ADDED

Limited Assurance statement from our External Auditors Comments on the GHNHSFT Quality Account 2011/12 SINGLE PAGE IS INDICATIVE ONLY - MORE SPACE CAN BE ADDED


GHNHSFT Quality Account 2011-2012

Statement of Directors’ Responsibilities in respect of the Quality Account The directors are required under the Health Act 2009, National Health Service (Quality Accounts) Regulations 2010 and National Health Service (Quality Account) Amendment Regulation 2011 to prepare Quality Accounts for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporate the above legal requirements). In preparing the Quality Account, directors are required to take steps to satisfy themselves that:

ÆÆ the content of the Quality Account meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual;

ÆÆ the content of the Quality Account is not inconsistent with internal and external sources of information including;

ÆÆ board minutes and papers for the period April 2011 to June 2012; ÆÆ papers relating to Quality reported to the Board over the period April 2011 to June 2012; ÆÆ feedback from the commissioners dated 22/03/2012 ÆÆ feedback from the Governors dated 06/01/2012, 12/03/2012, 16/03/2012, 18/03/2012 ÆÆ feedback from LINks dated 10/04/2012, 05/01/2012 ÆÆ the Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 13/04/2012

ÆÆ the Head of Internal Audit’s annual opinion over the Trust’s control environment dated xx/xx/2012 ÆÆ Care Quality Commission quality and risk profiles dated April 2011, 14/05/2011, 30/06/2011, 31/07/2011, 30/09/2011, 10/11/2011, 31/01/2012, 29/02/2012

ÆÆ the Quality Accounts presents a balanced picture of the Trust’s performance over the period covered; ÆÆ the performance information reported in the Quality Account is reliable and accurate; ÆÆ 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;

ÆÆ 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, is subject to appropriate scrutiny and review; and

ÆÆ the Quality Account has been prepared in accordance with Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations) published at www.monitor-nhsft.gov.uk/ annualreportingmanual, as well as the standards to support data quality for the preparation of the Quality Account. The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Account. By order of the Board

Dr Frank Harsent

Prof Clair Chilvers

Chief Executive

Chair

Gloucestershire Hospitals NHS Foundation Trust May 2012

Gloucestershire Hospitals NHS Foundation Trust May 2012


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59

PART SIX

PA RT SI X

Glossary

PART SIX

Annual Plan

A forward plan detailing the Trust’s future intentions.

Annual Report (and Accounts)

A statutory document produced by the Trust and which is laid before Parliament.

ACU

Acute Care Unit

Adverse Event Rate

This is calculated on a monthly basis, auditing a random sample of 20 notes against the Global Trigger Tool.

Care Quality Commission (CQC)

The Care Quality Commission (CQC) regulates all health and adult social care services in England, including those provided by the NHS, local authorities, private companies or voluntary organisation. It also protects the interests of people detained under the Mental Health Act.

CEMACH

Confidential Enquiry Maternal and Child Health

CGH

Cheltenham General Hospital

Clinical Commissioning Groups

Emerging groups led by GPs which will be responsible for planning and buying of healthcare for the local area. These will replace PCTs in April 2013.

Commissioning/ Commissioners

Commissioning is the process of assessing the needs of a local population and putting in place services to meet those needs. Commissioners may include PCTs or increasingly groups of GP practices.

Co-production and experiencebased design methodologies

Ways of working/activities which involve patients and staff or other stakeholders in re-designing services or improving care, and which draw on their experiences.

CQC

Care Quality Commission

CQUINS

Commissioning for Quality Improvement goals. These are targets for quality improvement agreed between commissioners and providers and included in contracts with financial incentives if they are achieved.

Customer proxies

In this document this term refers to specific groups with a particularly close and informed interest (from a public/patient perspective) in the service provided to patients at the Trust.

DAHNO

Data for Head and Neck Oncology

DCC

Department of Critical Care

DVT

Deep Vein Thrombosis. A blood clot in the veins, usually in the leg. Causes the leg to swell but more significant risk is that bits of the clot can break off (an embolus) and block blood supply to the lungs.

ED

Emergency Department

Foundation Trust

NHS providers who achieve trust status have greater freedoms and are subject to less central control. Foundation Trusts are part of the NHS and have to meet the same national targets and standards.

Foundation Trust Governors

The Board of Governors are elected by Foundation Trust members. Governors advise a Foundation Trust on how it carries out its work so that this is consistent with the needs of members and the wider community.


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PART SIX

PART SIX

GHNHSFT

Gloucestershire Hospitals NHS Foundation Trust

Gloucestershire Patient Profile

Nursing assessment documentation for each inpatient

Global Trigger Tool

This is a case note review tool that enables us to better understand the main causes of harm in our hospitals. It also allows us to calculate an adverse event rate.

Never events

Nationally defined list of serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented

NHS Constitution

A national document which describes the principles and values of the NHS in England, and the rights and responsibilities of patients, the public and staff.

NHSBT

National Health Service Blood and Transplant. Co-ordinates all blood and transplant services nationally

GRH

Gloucestershire Royal Hospital

NICE

National Institute for Health and Clinical Excellence

GWAS

Great Western Ambulance Services. Provides ambulance services for Gloucestershire and the region

PAS

Patient Administration System used with Gloucestershire Hospitals NHS Foundation Trust

Health Community and Care Overview and Scrutiny Committee (HCCOSC)

Overview and Scrutiny Committees are made up of local government councillors and offer a view on local and social care matters. The HCCOSC is responsible for overview and scrutiny of health related issues and the Council’s Community and Adult Care Directorate. It focuses on health issues from a public perspective and works in partnership with other agencies to improve local health services.

Primary Care Trust (PCT)

The NHS body currently responsible for commissioning healthcare services for a local area. NHS Gloucestershire is the PCT for Gloucestershire.

Provider

Organisations which provide services directly to patients, including hospitals, mental health services and ambulances.

HES

Hospital Episode Statistic

HSJ

The Health Service Journal is a health industry magazine published on a monthly basis by Emap.

RCP

The Royal College of Physicians is an independent professional membership organisation and registered charity, representing over 26,000 physicians in the UK and internationally.

HSMR

Hospital Standardised Mortality Ratio

Reference panel

A group of people who can be approached for advice or guidance.

Internal stakeholders

Our staff are the Trust’s internal stakeholders

Regulators

External bodies which regulate and monitor the Trust – these include Monitor, the Care Quality Commission (CQC), Health and Safety Executive (HSE), the Strategic Health Authority, the Department of Health.

Local health community

The local health community includes commissioners and providers of healthcare in the local area.

Representatives

People who are in a position to speak on behalf of other service users. People are representatives when the views they share are the opinions of the people they are representing, which may not be the same as their own.

Local health and social care community

The local health community includes commissioners and providers of healthcare in the local area. The local health and social care community will also include commissioners and providers of social care.

Service users

Those who use services or those who may use them. Service user involvement can be directly or through representatives.

Local Involvement Networks (LINks)

Local organisations in each local authority area, set up to represent the views of local people on health and social care services. These may become local Health Watch in the future.

Strategic Health Authority (SHA)

The public bodies which currently oversee commissioning and provision of NHS services at a regional level.

Local Strategic Partnerships (LSPs)

These bring together representatives of all the different sectors - public, private, voluntary and community. They have responsibility for developing and delivering the local sustainable Community Strategy and the Local Area Agreement.

Stakeholder engagement

A process by which an organisation learns about perceptions, issues and expectations of its stakeholders and uses these views to assist in managing and influencing any planned changes/improvements in service delivery.

LOS

Length of Stay. Refers to the amount of time a patient stays in a hospital bed Stakeholders

Any person or group of people who have a significant interest in services provided, or will be affected by, any planned changes in an organisation or Local Health Community. They may be internal or external to that Local Health Community, and they can comprise staff, patients, trade unions, MPs and members of the public and community groups.

TARN

Trauma Audit and Research Network

Thrombolysis

Administration of drugs to patients with stroke and heart attacks to reduce further blockages in vessels

Monitor

Monitor is the independent regulator of NHS Foundation Trusts. It is independent of central government and directly accountable to Parliament.

MRSA

MRSA is a type of bacterial infection that is resistant to a number of widely used antibiotics. This means it can be more difficult to treat than other bacterial infections. The full name of MRSA is methicillin-resistant staphylococcus aureus

MUST

Malnutrition Universal Screening Tool. MUST is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition), or obese. It also includes management guidelines which can be used to develop a care plan. It is for use in hospitals, community and other care settings and can be used by all care workers.


GHNHSFT Quality Account 2011-2012

PART SIX

TIA

Transient Ischaemic Attack - a mini stroke

T&O

Trauma and Orthopaedics

UTOPIA

An internal Gloucestershire Hospitals NHS Foundation Trust project which took place during 2010/11 to refine and improve the emergency patient pathway

VTE

VTE (venous thromboembolism) is a general term to describe the blocking of a blood vessel by a blood clot. This term includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT occurs when a blood clot blocks a deep vein, usually in the leg. PE is a potentially life-threatening complication and occurs when the blood clot escapes into the circulation and becomes lodged in the lungs.

WHO

World Health Organisation

3CCN

3 Counties Cancer Network. Co-ordinates the provision of cancer care for Gloucestershire, Herefordshire and South Worcestershire

Our Quality Account forms part of a larger range of Trust documents for 2012:

Annual Plan

Annual Report

Equality Compliance Report

2 0 11 – 2 0 12

2 0 11 – 2 0 12

2 0 11

Annual Plan

Annual Report

Equality Compliance Report

Stakeholder engagement

Stakeholder engagement


“Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skilful execution.� William A. Foster

16/04/2012


Quality Account 2011/12