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Quality Account for Nottingham University Hospitals NHS Trust 2009/10


Contents

Contents Section One - Chairman’s introduction

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Section Two - Chief Executive’s summary and declaration of accuracy

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Section Three - Priorities for improvement and Board statements of assurance

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• • • • • •

2010/11 priorities for improvement Services in 2009/10 Clinical audits National confidential enquiries Clinical research Commissioning for Quality and Innovation (CQUIN) framework 2009/10 - CQUIN framework 2010/11

• What others say about NUH • Data quality Section Four - Review of 2009/10 quality performance • • • • •

A selection of quality indicators

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Safety strategy and programme Quality framework: ward to Board Quality of the environment in which care is delivered (and access) Public involvement in our Quality Account

Appendix - Commentary from NHS Nottinghamshire County and NHS Nottingham City

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Glossary

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Section One - Chairman’s introduction

Chairman’s introduction Welcome to the first Nottingham University Hospitals NHS Trust (NUH) Quality Account.

We recognise that we are here to deliver safe, life-enhancing care. We are determined to demonstrate that we do so across NUH from each ward to our Board, and that patients and their families will be ever-more confident in the excellence and safety of our services. This Quality Account sets out our evidence that we are moving steadily towards our aim of being the best acute teaching Trust in England by 2016, that we have systems and processes to sustain our progress, and that we recognise the importance of working with our staff and patients to achieve this goal. We have established a whole hospitals change programme, called ‘Better for you’, that has improving quality at its heart, and which recognises that it must deliver its improvements alongside the Trust’s (and the NHS’s) financial and waiting time challenges. This innovative programme will help us to look at every part of our complex organisation to develop new and better ways to deliver caring, safe and thoughtful services, and to work even more closely with our partners in the wider health and social care community. We have consulted widely about what should be in this Account; with our patients and families, with prospective Foundation Trust members, with our staff, and with the people of Nottingham and beyond (see Section 4.6). Our thanks to those who took the time to give us their views and feedback. We have tried to capture the wishes of all of our community, and to reflect in particular the views of those in our community who may be most in need of our services, but least able to influence them by traditional, established routes. By addressing these patients’ needs we will make our services better and safer for all. Our Account does not avoid those areas where we know we need to improve. For each such area we are implementing changes, many far-reaching, and we are confident that by our next Account

we will be able to describe real, meaningful improvements.

NUH is a large and complex organisation. Our Account describes the systems we are developing to measure and report our safety record, and to drive the necessary changes in the way we work and communicate with our patients and their families (Section Four). It describes how we are working with the organisations who commission health services to ensure that we use our partnerships to improve the quality of our services, in general and in targeted, identified areas each year. We recognise that we must all engage more effectively with our patients if we are to improve our services. Over the last year we have worked with both patients and staff to develop new service standards, which set out very clearly how we will behave and treat our patients to ensure that their experience is the best it can be, all day, every day. When in our care patients should always feel safe, looked after, and confident. Embedding our ‘we are here for you’ programme across our organisation is one of our priorities for the coming year. This Account describes some of our many achievements in 2009/10, and the positive impact this has had on our patients’ outcomes and experience. We are determined to build on the very solid foundations now in place at NUH to deliver everimproving services.

Dr Peter Barrett, Chairman

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Section Two - Chief Executive’s summary

From the Chief Executive - summary and declaration of accuracy We are here to improve the health and wellbeing of our patients, and, of course to keep them safe from harm.

In 2009/10 we achieved notable improvements in the quality of our services. Patients and visitors tell us that one of their main concerns about coming into hospital is getting an infection. In 2009/10 we built on our previous progress to reduce healthcare associated infections. Fewer patients acquired Clostridium difficile infections in NUH than in previous years and fewer in NUH than in most similar hospitals. The number of cases of all bloodstream infections was our lowest on record last year (this group of infections includes Methicillin-Resistant Staphylococcus Aureus (MRSA)). Our rate of bloodstream infections was significantly lower in 2009/10 than in 2008/09. We are determined to avoid MRSA bloodstream infections, by taking all necessary preventive actions, all the time, for all our patients. We check we are doing so every week at a meeting that I chair. We recognise that there are other areas where we can reduce the harm we cause patients. We have an effective and wide-ranging patient safety programme, driving down the risks associated with (for example) medicines and operations. Our ward teams have undertaken innovative work to reduce the number of patient falls. In 2010 the Trust registered without conditions with the Care Quality Commission (CQC), (the CQC regulates the quality of health and adult social care). The CQC carried out an unannounced visit in May 2009 to inspect

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our infection control practice and compliance with regulations to protect patients, staff and others from the risk of acquiring a healthcare associated infection. CQC inspectors were assured we protected patients, staff and visitors from infection. The four hour emergency access target has always been a big challenge for us. Our Emergency Department is one of Europe’s busiest. Patients deserve to be seen promptly, and rapid expert diagnosis and management maximises the chances of a harm-free encounter with our hospital. We recognised that seeing, treating and admitting or discharging only 96.5% of patients within four hours in the first nine months of the year was not good enough. Furthermore, in August 2009 we became aware that some patients may have been in the department for longer than we had originally reported. An independent report commissioned by NHS East Midlands described that last year 524 patients (3.74% of 14,254 seen) had been given shorter times than appropriate because of unclear understanding of the rules which should have been applied to the timings. This independent report concluded that staff always put the care of patients first, and no patients had been harmed or disadvantaged. However, we changed many established working practices, making them more responsive, more expert, and more patient-centred. We strengthened the way in which we monitor and record our performance, as recommended by the external report. Between January and the end of March 2010, 98.9% of patients were managed within the four hour target. Maintaining high levels of performance is a key focus for 2010/11. Other priorities for 2010/11 include:

Establishing ‘Better for you’, our exciting whole hospitals change programme. Alongside our other safety and quality programmes, we are introducing innovative and improved ways of working to keep patients safer, to make their


Section Two - Chief Executive’s summary experience better, and to improve patient outcomes. We will measure each of these improvements • We aim to reduce harm events by 10% • We aim to reduce our Hospital Standardised Mortality Rate by 2.5% this year from its current high-performing level of 92% (NUH patients survive serious illness more often than those in the average English hospital). We will further reduce the number of bloodstream MRSA infections and patient falls • We will use our patient survey to measure how much better we make our patients’ experience. We intend to improve by 3% year on year Our Quality Account is presented in two main sections:

In the following Section Three we describe our priorities for improvement, why we have chosen them, and how we will deliver and measure the ways in which we are making our services better for patients. This section contains some specific measures of NUH quality (as required by law, and enabling comparison with other NHS Trusts, and hence patient choice) • Section Four includes detailed information on the safety and experience of patients in the range of services we provided through 2009/10. It sets out who has helped us determine the priorities and content of our Quality Account (in line with current equality legislation and the Health Act 2009). The statements about our Account by commissioning Primary Care Trusts (PCTs) are included in the Appendix. They did not require any changes to the final version of our Account. We expect commentaries from Local Involvement Networks (LINks) and relevant Overview and Scrutiny Committees (OSC) in future years I can confirm that to the best of my knowledge the information presented in our Quality Account is accurate.

Peter Homa, Chief Executive

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Section Three - Priorities for improvement

Priorities for improvement and Board statements of assurance 3.1 2010/11 Priorities for improvement We have developed plans to achieve each of the quality improvements included in the Commissioning for Quality and Innovation (CQUIN) scheme agreed with our commissioners.

These include two national, six regional and 10 local targets. After consulting with our patients and community about the things they most want to see improved, and with our clinicians, our priorities in 2010/11 are listed below. Progress against each of these priorities will be monitored, measured and reported regularly to the Board. Together they cover each of the safety, experience and outcome domains of quality and innovative practice.

Priority One -

To reduce NUH-associated avoidable harm Patients tell us that they want to know there will be no mistakes in their care. We will: 1 Reduce our hospital standardised mortality rate (HSMR) by 2.5% 2 Reduce the number of patient harm events by 10% 3 Reduce the number of patients who fall by 5% 4 Achieve the national CQUIN target for venous thromboembolism (VTE) risk assessment

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Priority Two -

To reduce NUH-associated infections Patients tell us that among their greatest concerns about coming into hospital is the fear that they will contract an avoidable infection. We will: 1 Have fewer than 16 patients acquire MRSA bloodstream infections caused by our care (compared to 21 in 2009/10) 2 Screen at least 98% of patients for carriage of MRSA when or before they are admitted 3 Have fewer than 186 cases of Clostridium difficile caused by our care (compared to 201 in 2009/10) 4 Reduce catheter-related infections by 10%


Section Three - Priorities for improvement

Priority Three To improve staff training

We know that well-trained and engaged staff are essential for excellent care quality and patient experience. We will: 1 Increase the number of staff trained in quality improvement techniques by 20% 2 Increase the number of staff engaged in clinical audit by 20%, and incorporate this (or equivalent) in at least two clinical specialty dashboards 3 Improve staff responsiveness to patient needs (shown by five key questions in the patient survey)

3.2 Services in 2009/10 During 2009/10 NUH provided and/or subcontracted 81 NHS services (as described in the service level agreement (SLA) with our principal commissioners). NUH has reviewed data available to it on the quality of care in each of the nine directorates into which these services are grouped.

Priority Four -

To improve application of NUH research in clinical practice Research is a vital part of what we do. The NHS is ambitious and aims for 20% of all patients to be involved in clinical trials and to express recruitment per head of population. We share that ambition. We will: 1 Increase by 20% the number of eligible patients recruited into high quality clinical trials 2 Establish robust systems for identifying the number of eligible patients and whether they are offered participation

The income generated by the NHS services reviewed in 2009/10 represents more than 95% of the total income generated from the provision of NHS services by NUH for 2009/10.

3.3 Participation in clinical audits 2009/10 The Department of Health describes a number of national clinical audits which Trusts should consider in their 2009/10 Quality Account. During 2009/10 there were 50 national clinical audits that examined NHS services provided by NUH. NUH participated in 44 (88%) of the national clinical audits for which it was eligible. The table overleaf shows NUH participation (or non-participation with a commentary), and percentage coverage of eligible patients (where this is known with reasonable confidence).

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Section Three - Priorities for improvement

Title of Audit

NUH

Continuous audits: all patients Adult Cardiac Interventions Adult Cardiac Surgery Audit (CABG and valvular surgery)

Yes 100%

Centre for Maternal and Child Enquiries (CEMACE) Perinatal mortality

Yes

Heart Failure Audit

Yes

Intensive Care National Audit & Research Centre (ICNARC ITU, Minimum data set and Apache II)

Yes1

National Bowel Cancer Audit Programme

Yes

National Diabetes Audit (NDA)

No2

National Elective Surgery Patient Outcome Programme (PROMS)

Yes

National Head and Neck Cancer Audit (DAHNO)

Yes

National Hip Fracture Database (NHFD)

100%

National Joint Registry (NJR) Hip and Knee replacements

100%

National Lung Cancer Audit (NLCA)

Yes

National Neonatal Audit Programme (NNAP)

Yes

National Vascular Database (NVD)

Yes

NHS Blood and Transplant: intra-thoracic, liver and renal transplants

Yes

NHS Blood and Transplant: potential donor audit

Yes

Paediatric Intensive Care Audit Network (PICANet)

95%

Renal Registry: renal replacement therapy

Yes

The Myocardial Ischemia National Audit Project (MINAP)

Yes3

Trauma Audit & Research Network (TARN)

Yes

Intermittent samples of patients British Thoracic Society: respiratory diseases

(NIV, Paediatric Pneumonia, Adult Asthma, Emergency Oxygen, Paediatric Asthma)

College of Emergency Medicine National Audit Programme

(pain in children audit, fractured neck of femur audit, severe and moderate asthma audit)

National Audit of Dementia: dementia care (from April 2010) National Audit of Falls and Bone Health in Older People National Kidney Care Audit

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Partial4

Yes N/a 100% 40-70%


Section Three - Priorities for improvement National Sentinel Stroke Audit

Yes

One-off: all patients National Audit of Continence Care

Yes

National Mastectomy and Breast Reconstruction Audit

Yes

National Oesophago-gastric Cancer Audit

Yes

Additional National Audit Activity relevant to NUH British Cardiovascular Intervention Society (BCIS) Angioplasty Audit

100%

Cardiac Rehabilitation Audit (partial)

Yes

Cardiac Rhythm Management

Yes

Congenital Heart Disease (adults)

Yes

Corneal Transplantation Audit

No

Heavy Menstrual Bleeding Audit (audit over four years)

No

Inflammatory Bowel Disease

100%

National Audit of the Management of Familial Hypercholesterolaemia

Yes

National Audit on Pectus Repairs

Yes

National Carotid Interventions (partial)

Yes

National Hepatobilary (HPB) Cancer Resection Audit

Yes

National Infarct Angioplasty Project (NIAP) v1

Yes

National Lung Cancer Data Audit (LUCADA)

Yes

National Thoracic Surgery Activity and Outcomes

Yes

Pain Database

No

Renal – Vascular Access (currently registered to take part)

Yes

Society for Cardiothoracic Surgeons (CCAD database)

Yes

Surgical Site Infection Surveillance

Yes

The Sudden Arrhythmic Death Syndrome Audit (SADS)

No

Transcatheter Aortic Valve Implantation (TAVI) DDAD Database

Yes

UK Renal Transplant Audit

Yes

(Elective hip / knee replacements and fractured neck of femur)

1 2 3 4

ITU mortality rates are significantly below the national average NUH will implement the National Diabetes Audit from April 2010 Participation in MINAP was partial in 2009/10, but will be complete in 2010/11 Participation in Paediatric Pneumonia and Paediatric Asthma

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Section Three - Priorities for improvement National audits in which we would not expect to participate (because of patient and service mix).

Title of Audit Congenital Heart Disease: paediatric cardiac surgery POMH: prescribing topics in mental health services National Audit of Psychological Therapies for Anxiety and Depression (NAPTAD) Pulmonary Hypertension Audit

The reports of these national clinical audits were reviewed by NUH directorates or departments in 2009/10. The Clinical Effectiveness Committee receives reports from each directorate of their compliance against relevant national audits and associated standards, and their plans for improvement. National clinical audit reports (published in 2009/10) were not systematically reviewed by the Trust Board, though several formed part of relevant annual reports. As part of an improvement programme for audit and effectiveness, the relevant committee structure has been strengthened, and the Board will receive an annual audit report (initially in the first quarter of 2010) which will include details of NUH participation in, and performance as described by, national audits, as well as local audit activity. There is a comprehensive 2010/11 clinical audit plan for all speciality and directorate levels, agreed by the clinical directorates. 608 projects were registered on the NUH Clinical Audit Database in 2009/10. 487 of these were registered as clinical audit, 45 as patient surveys and 58 as service evaluation (and the rest as a mixture of these). 290 were classified as highest priority audits (eg. for national audit programmes, or NHS Litigation Authority or CQC registration, or to assure compliance with National Institute for Clinical Excellence). 160 projects were classified as high priority local, and 158 as lower priority local. Of the 329 audits registered in the six months up to 30 September 2009, 114 have been fully completed and 37 have reported.

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Examples of audits and resultant changes this year include:

audit of the management of nasal cancer which described improved results with NUH combination of surgery and radiotherapy • audit of antibiotic use in acute appendicitis in children and recommendations for improvements • the redesign of our observations chart with improved regular recording • re-audit of compliance of recording pain • sedation and nausea scores on observation charts in the 24 hours post operative period on surgical wards • regular audits of antibiotic use on all wards (with improved compliance with best practice and reduced unnecessary use) • improvements in management of urinary catheters with regular audit cycles • re-audit and further improvements in the management of children after operations for pyloric stenosis (narrowing of the stomach outlet) The national confidential enquiries in which NUH participated in 2009/10 for which data collection was completed, are listed below. The number of cases submitted to each audit or enquiry (as a percentage of the number of registered cases required by the terms of that audit or enquiry) is also shown.

3.4 Response to national confidential enquiries 2009/10 In 2009/10 two national confidential enquiries relevant to services provided by NUH were published; ‘Acute Kidney Injury’ (AKI) and ‘Caring to the end’. Acute Kidney Injury (National Confidential Enquiry into Patient Outcome and Death (NCEPOD)) NUH convened an AKI working group to consider the Report, and to make recommendations (via the Clinical Effectiveness Committee). An NUH guideline for management of AKI will be available from the first quarter of 2010/11. This will include management of emergency admissions and those


Section Three - Priorities for improvement for elective surgery. The guidelines will describe criteria for referral for specialist renal advice and will be made widely available in NUH (including on the intranet). The AKI working group are interrogating the NUH AKI database to identify high risk areas on the Queen’s Medical Centre campus where patients may benefit from an on-site nephrologist. Caring to the end (NCEPOD) One key recommendation of ‘Caring to the end’ is that nurses and doctors are appropriately trained in the basic skills of monitoring vital functions, recognising deterioration, and acting appropriately. At NUH the tool used by nursing and medical staff to monitor patients’ observations, and to assess their risk of deterioration, has been audited and

redesigned. The team providing expert help to patients who may deteriorate (nurse specialists) has been expanded to provide cover each day between 8am and 10pm. Our patient safety programme lead (Deputy Medical Director) heads a specific workstream which aims to improve identification of (and response to) patient deterioration.

3.5 Participation in national confidential enquiries 2009/10 During 2009/10 NUH participated in all ten (100%) relevant enquiries undertaken by the NCEPOD and by the Centre for Maternal and Child Enquiries (CMACE).

Return Rate (‘coverage’)

Title of Study

(% eligible cases submitted by NUH)

Parenteral nutrition

56

Elective and emergency surgery in the elderly

74

Cosmetic surgery

50

Perioperative care

Study ongoing

Surgery in children

Study ongoing

Obesity in pregnancy

Study ongoing

Intrapartum care

Study ongoing

Maternal and perinatal mortality

Awaiting data

Child Death Review

100

Head injury in children

Study ongoing

In 2009/10 there was no National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness (NCI/NCISH) for which NUH was eligible.

3.6 Participation in clinical research 2009/10 NUH is committed to research and innovation as drivers for improving the quality of care (including outcomes) and patient experience. This is demonstrated by our three Biomedical Research

Units in gastroenterology, respiratory medicine and hearing, although our research effort (often in partnership with the University of Nottingham) spans a wide range of specialties. Our increasing level of participation in clinical research is evidence of our contribution to wider health improvement.

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Section Three - Priorities for improvement 5,784 patients receiving NHS services provided or subcontracted by NUH in the calendar year 2009 were recruited to participate in research approved by a research ethics committee and in portfolio studies. In future years we plan to capture patients in non-portfolio studies. In contrast, we do not plan to capture those who agreed to participate but do not complete the study. There would be no way of assuring accuracy. During 2009/10 NUH was involved in 960 clinical research studies. In future years we will publish here the number of studies completed in the relevant time period within the agreed time and to the agreed recruitment target. NUH used national systems to manage the studies in proportion to risk. Of the 353 studies given permission to start, 100% were given permission by an authorised person less than 30 days from receipt of a valid complete application. 80% of the studies were established and managed under national model agreements, and 100% of the 37 eligible research projects involved used a Research Passport. In 2009/10 the National Institute for Health Research (NIHR) supported 197 of these studies through its research networks. In the last three years, more than 250 publications have resulted from our involvement in NIHR research (a measure of its high quality), helping to improve patient outcomes and experience across the NHS.

3.7 Goals agreed with commissioners 3.7.1 CQUIN framework 2009/10 A proportion of NUH’s income in 2009/10 was conditional on achieving quality improvement and innovation goals agreed between NUH and persons and bodies with which we entered into a contract, agreement or arrangement for the provision of NHS services, through the Commissioning for Quality and Innovation (CQUIN) payment framework. We agreed six CQUIN measures with our commissioning PCTs for 2009/10. These are listed below, with a commentary on their achievement by NUH. They were chosen because of the strength of their alignment with local and regional health community strategies. It was anticipated that, particularly in this inaugural developmental year, and although the targets were stretching, NUH

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would receive the conditional monies provided substantial progress was made. 1. Smoking cessation We trained 90% (as planned) of our specialist nurses in cardiovascular and respiratory disease, diabetes and midwives to deliver brief interventions for smoking cessation, and to make appropriate referrals to smoking cessation services within primary care. Smoking is a major cause of premature death in England. Nottingham has higher than average smoking rates. Brief interventions by health professionals are known to be effective in helping smokers quit, especially if delivered at a time when patients are considering their health. In the first quarter of 2010/11 we will re-measure the impact of the training on patient experience and quitting rates. The 2009/10 CQUIN target was that 90% of eligible patients should receive an intervention.


Section Three - Priorities for improvement 2. Alcohol misuse identification and response

Alcohol misuse causes very significant morbidity and mortality, much of it preventable by earlier identification and interventions to reduce intake and harm. A significant proportion of attendances at the Emergency Department are related to acute or chronic alcohol misuse. Patients identified as having a problem with alcohol use or addiction are referred to relevant specialist services (including the NUH alcohol liaison service provided by specialist nurses).

considerable progress has been made. A minimum data set has been developed (based on Royal College of General Practitioners’ definitions). Associated work has very significantly reduced the number of outstanding misdirected (to wrong GP) letters from NUH. Pilot schemes are running with a substantial proportion of letters being generated for electronic transmission from the Emergency Department, Medical Admissions areas, Healthcare of Older People, Urology and Oncology. 33% of GP practices regularly receive same-day discharge information by this route, and a greater and growing proportion can do. We are working internally, and closely with primary care organisations, to deliver same-day electronic information for 95% of discharges by the end of 2010/11.

In the first quarter of 2010/11 we will re-measure the impact of the training on patient experience and referral rates to specialist services. The 2009/10 CQUIN target was that 90% of eligible patients should receive a referral.

The timely and accurate transfer of information as patients’ care is transferred from NUH to another provider reduces the likelihood of readmission, and increases the chances of patients continuing to receive the recommended treatments.

3. Development of specialty quality dashboards

5. Implementation of (and compliance with) National Institute for Clinical excellence (NICE) guidelines

We have trained over 90% (as planned) of Emergency Department staff to apply in all patients a screening tool for alcohol misuse via our Emergency Department Information System (EDIS).

In line with the CQUIN, we have developed dashboards in four specialties (heart services, stroke, urology and maternity). These allow clinical teams to track, in near-real-time, important aspects of their patients’ journey (eg. waiting times, delays in theatre start times and use of medications according to protocols). The impact of variations in practice and improvement changes can be readily examined. NUH has extended dashboard development to diabetes, the Emergency Department and renal services, and in April 2010 introduced one for monitoring our performance and actions against healthcare associated infections across the whole of the Trust. In 2010/11 the development programme will continue and we will review the impact of dashboards on clinical outcomes, and on patient experience. 4. Electronic discharge summaries The CQUIN target was the electronic delivery of discharge information on 75% of discharged patients on the day of discharge. This has presented several significant challenges, but

CQUIN described development of an enhanced audit system to ensure that NICE guidance is identified, implemented, and monitored. NUH has a well-established NICE Committee, and an updated NICE guidance policy was implemented during 2009. A clear process is in place for technical appraisals/interventional procedures and clinical guidelines. This is supported by the Trust’s Clinical Effectiveness Committee, which was further strengthened during 2009. 6. Real-time patient experience data A real-time patient experience data collection system has been developed and piloted in the Emergency Department. The system was also used to collect data as part of the same-sex accommodation project during 2009.

3.7.2 CQUIN framework 2010/11 In 2010/11 circa 1.5% of NUH income will be contingent on achieving an agreed portfolio of 18 improvements in quality and innovation.

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Section Three - Priorities for improvement 4

Trust to be in the top quartile for reduction in 28 day emergency readmissions for long-term conditions 5 Improvements in post stroke death and dependency rate. By year end 95% of patients will have their dependency score assessed within 24 hours of admission 6 The proportion of vaginal births to be in the top quartile of peer comparator trusts Local CQUIN indicators Ten local indicators are allocated a total of 0.8%: 1

National CQUIN indicators 0.3% is allocated to two national CQUIN indicators: 1

Improve risk assessment for venous thromboembolism (0.2%)

(90% of all adult inpatients will have a risk assessment on admission)

2

Improve responsiveness to personal needs of patients (0.1%) (measured by five key questions in patient survey)

Regional CQUIN indicators Six SHA (regional) standards are allocated a total of 0.4%. 1 2

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Increase day surgery rate by 5% (incrementally over the year) Reduce the number of very short admissions in children. (Conversion rate in patients aged under 17 with zero Length of Stay (LoS) (reduced to 22% and proportion of admission reduced to 13%)) 5% reduction in mean LoS of emergency patients by the end of 2010/11

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95% of all inpatient prescribing in line with Better Care Better Value (BCBV) recommendations 2 a) 95% of smokers offered brief intervention before operation ‘Stop Before the Operation’ scheme and offered referral to smoking cessation services b) 95% smokers in highest risk specialties offered brief intervention and referral to smoking cessation services 3 95% ED or Admissions Unit patients identified via screening tool offered appropriate alcohol reduction intervention 4 95% relevant women to receive Vaginal Birth after Caesarean Section (VBAC) information 5 95% compliance with ‘Saving Lives’ catheter care guidance 6 Stroke care is in line with national best practice 7 No more than 15% of ambulance handover times will exceed 15 minutes 8 Improvements in Cancer Services (measures to be agreed) 9 Improve patient experience (as per the East Midlands Patient Experience project) 10 Reduce the number of patients aged 17-65 attending ED who have very short admissions (zero days LoS)


Section Three - Priorities for improvement Specialist CQUIN indicators 1

To ensure Spinal Cord Stimulation is used effectively to modify perception of pain in patients experiencing chronic pain for at least six months 2 a) To ensure parents of babies who are transferred into the Neonatal Unit have the opportunity to discuss the care of their baby with a senior member of the medical team within 24 hours of admission b) To ensure babies admitted to the Neonatal Unit have their temperature recorded within the first hour of admission 3 To improve the prevention, detection, and management of cases of acute kidney injury by appropriate screening and monitoring checks, reported through local audit and use of NCEPOD self assessment tool to benchmark and improve current practice 4 Assessment and referral of adults and children with acute burns to specialist burns services to ensure that 80% of patients who have sustained a burn injury are cared for in the right place at the right time, as per referral criteria 5 To ensure that 90% of children who have sustained a burn injury are assessed by a paediatrician within 24 hours of their admission to the Burns Unit, and 100% will be reviewed before discharge 6 To review the 100 day mortality of adult patients undergoing bone marrow transplant 7 To assess the proportion of admitted patients receiving cardiac surgery within seven days of the decision by the cardiothoracic surgeon to accept the patient for urgent surgery. Following baseline assessment, agree targets for improvement 8 Access to Sunitinib for the first line treatment of advanced and/or metastatic renal cell carcinoma 9 Outcome data for use of Omalizumab for severe persistent allergic asthma in adults and children aged six years and over 10 Outcome data for Cetuximab for the first line treatment of metastatic colorectal cancer

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Section Three - Priorities for improvement

3.8 What others say about NUH 3.8.1 Care Quality Commission (CQC) NUH is required to register with the CQC. Our current registration status is unconditional. The CQC has not taken enforcement action against NUH during 2009/10, as of 31 March 2010. NUH has not participated in any special reviews or investigations by the CQC during the reporting period. Annual ‘Health Check’ The CQC scored NUH ‘fair’ for Quality of Services in 2008/09. We performed relatively poorly against the standards listed below. We acknowledged these weaknesses, just as we do our strengths. Through 2009/10 we made very considerable progress in each of these areas (as reported regularly to our Board). We declared non-compliance for the whole of 2009/10 against three core standards. C4b (safe use and acquisition of medical devices), C8b (appraisals/Personal Development Reviews), and C11b (mandatory training). For each of these standards compliance by the year end (i.e. 31 March 2010) was predicted. We declared non-compliance for part of 2009/10, but compliance by the year end, against C9 (records management) (after misreported Emergency Department breaches) and with C20b (environment which supports privacy and dignity) (after the challenges of same-sex accommodation). The CQC predecessor, the Healthcare Commission, published comparative indicators for safety, and clinical and cost effectiveness in 2009. NUH was ‘about the same’ as other hospitals in each of four composite measures of patient experience (of hospital and ward, doctors, nurses and leaving hospital). Of the 29 indicators across incidents, infections, cardiovascular, orthopaedics, violence and other, NUH was ‘as expected’ in 27, ‘better than expected’ in two, and ‘below expected’ in none.

3.8.2 Dr Foster Good Hospital Guide (www.drfosterhealth.co.uk) The independent Dr Foster organisation analyses the data collected by all NHS Trusts. This year

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Dr Foster awarded a quality (safety, effectiveness and patient experience) ‘score’ to each English NHS trust. NUH scored well on our commitment to patient safety. Our overall score reflected some weaknesses in the selfassessments we had made to Dr Foster, notably that we had not fully implemented all aspects of all National Patient Safety Agency alerts, but we have action plans to achieve this and have strengthened our monitoring and management and saw significant progress through 2009/10. The Dr Foster ‘safety score’ also reflected a relatively low rate of incident reporting. We successfully improved this to rates comparable with other hospitals in 2009/10. For the great majority of clinical effectiveness indicators described by Dr Foster our performance is ‘in line with expected’ (eg. the mortality rates for patients after stroke, heart attack or fractured hip, the speed of CT scanning for suspected stroke patients, and the number of unplanned readmission after a range of operations, or the rates of keyhole surgery). In the very few areas where we performed less well than expected we have developed and implemented strengthened arrangements and monitoring and where necessary invested resources, and have seen improvements (eg. reductions in the interval to operation after hip fracture). We are reassured that our considerable strengths counterbalanced these areas of weakness and that, most notably, our overall mortality rate, and our mortality rate in intensive care, remain lower


Section Three - Priorities for improvement than expected (patients are more likely to survive serious illness in our hospitals than in the majority of English hospitals). Our ambition to reduce our HSMR by 2.5% in 2009/10 resulted in 76 lives being saved.

Relative Risk

HSMR rates

Trend (recent 12 months)

We have developed a performance summary (dashboard) of clinical indicators around patient safety, effectiveness and quality which is scrutinised to detect areas where there is deterioration or concern, and to benchmark our performance against other hospitals. Examination of the indicators drives improvements for patients. An example is that in early 2009 we recognised an increase in the readmission rate after prostate biopsy. Investigation revealed that this had coincided with the implementation of a new antibiotic regime for prostatic biopsy, in line with published evidence. Reversion to the previous regimen reversed the trend of increased readmissions.

3.8.3 Complaints Our Board received monthly reports (which are publically available) on complaints, the reasons for them (grouped into circa 20 themes), the age and ethnicity of complainants, and the timeliness and contents of our responses to them. Complaints, concerns, comments and compliments are an important source of information in our efforts to improve our services. A consistently important theme is that we must improve communication with patients and between team members.

Our Situation, Background, Assessment, Recommendation (SBAR) communication tool helps the latter, and the former is one focus of our ‘we are here for you’ programme.

3.8.4 Patient surveys Our outpatients were asked for their observations on services in a national survey for the CQC in the first quarter 2009/10. 365 of 850 NUH patients contacted replied. We were in the top 20% of trusts for patients having a doctor they could trust and have confidence in, for not changing appointment dates, for providing sufficient information on conditions/treatment, and for sideeffects of medication. The vast majority of patients were highly appreciative of the care we provided. We were worse than average in providing patients with information about what would happen to them during an appointment. Improvements in standardised outpatient information will be supported by a newly-appointed patient information officer. In a separate survey for the CQC in August 2009 NUH inpatients were asked about admission to hospital, the hospital and ward, doctors, nurses, care and treatment, operations and procedures, leaving hospital, and overall views and experiences. NUH scores were very similar to those of other large hospitals in each category. Our scores were higher than those of other hospitals in availability of same-sex accommodation and perceptions of our infection prevention and control measures. But we have work to do to reduce noise at night on our wards, and to provide information for inpatients. Where patients gave us lower than expected scores we have incorporated these issues into our own regular patient surveys. From April 2010 we will routinely capture patients’ opinions and observations using hand-held electronic devices. This will help us to get more immediate information about how we are doing, and allow more timely response to areas of patient concern.

3.9 Data quality Good quality information, including notably the quality of ethnicity and other equality data, underpins the effective delivery of patient care and is essential for improvements in care quality.

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Section Three - Priorities for improvement

3.9.1 NHS Number and General Medical Practice Code Validity NUH submitted records during 2009/10 to the Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics which are included in the latest published data (April 2009-December 2009 SUS data). The percentage of records in the published data which included the patient’s valid NHS number was 99.6% for admissions 99.8% for outpatients, and 95.6% for Emergency Department care. 100% of records in the published data included the patient’s valid General Medical Practice Code for admissions and outpatients (99.7% for Emergency Department). These figures are better than the national average. NUH submitted records during 2009/10 to the SUS for 131,995 Emergency Department attendances.

3.9.2 Information Governance Toolkit attainment levels NUH keeps person-identifiable information confidential and secure. The NHS Information Governance Toolkit provides a national standard assessment of information security and confidentiality. 62 standards cover six areas. 25 of the 62 standards are classed as the ‘core’ information governance standards and are required to be at a level two or above. In the audited submission against the Toolkit

in March 2010, all of the core standards in the Information Governance Toolkit scored a level two or above. NUH scored 86%, 83%, 78%, 75%,75% and 58% respectively in the six core standards (an overall score of 79%). With the exception of the developmental standards in the Corporate Use Assurance Initiative (which scored amber). All areas were classified as ‘green’ in the national Toolkit. NUH achieved an acceptable level of performance.

3.9.3 Clinical coding error rate Clinical coding is using information from clinical notes (and other documents) to categorise patients’ diagnosis and treatment into a limited number of codes. This understanding of our patients’ conditions and treatments allows us to better manage and plan our services. NUH clinical coding is of high quality. Audit Commission Payment by Results clinical coding audit during the reporting period described the following error rates for diagnoses and treatment coding (‘clinical coding’). Primary diagnoses incorrect

16.3%

Secondary diagnoses incorrect

13.0%

Primary procedures incorrect

5.9%

Secondary procedures incorrect

7.7%

These error rates are in line with those reported for NHS hospitals of similar case complexity. Overall areas audited were: Paediatrics, Vascular Surgery, Eyes and Periorbital Procedures and Disorders (subchapter BZ), and Minor Bladder Procedure 19 years and over (HRG LB15B).

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Section Four - Review of 2009/10

4. Review of 2009/10 Quality Performance 4.1 A selection of quality indicators The table below sets out NUH performance against a range of quality measures. This describes satisfactory performance for most of the measures, but also areas where we appreciate we have to improve.

Quality Measure (% unless shown)

Key more than less than

> < Year

National Target

Cases of Clostridium difficile

201

<240

MRSA bacteraemia cases (target <50% of 2003/04 number)

40

<45

Patients waiting <31 days from diagnosis to first treatment for all cancers

97

>96

Patients waiting <31 days for subsequent treatments for all cancers - Surgery

96

>94

Patients waiting <31 days for subsequent treatments for all cancers - Drug treatment

98

>98

Patients waiting <2 months from referral to treatment for all cancers

81*

>85

Patients waiting <2 months from referral to treatment for all cancers - referrals from national screening programmes

94

>90

Patients waiting <2 weeks from urgent GP referral to date first seen for all urgent suspect cancer referrals

94

>93

Patients waiting <18 weeks from referral to admitted treatment

93

>90

Patients waiting <18 weeks from referral to non-admitted treatment

98

>95

Patients waiting <four hours in Emergency Department from arrival to admission, transfer or discharge

97

>98

Heart attack patients who receive thrombolysis within 60 minutes of call (but this is no longer the preferred local treatment for heart attack)

62

>68

94**

100

87

<85

Elective inpatients screened for MRSA Bed occupancy

* Performance in the last two months of 2009/10 was above the target. This performance has been sustained into 2010/11 and current year to date performance is over 94% (as at May 2010) ** We are steadily improving the proportion of elective patients who are screened for MRSA and expect to reach near-100% by the second quarter of 2010/11

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Section Four - Review of 2009/10 NUH provides a wide range of services. This Account does not attempt to offer a quality measure for each and every service, but Section 3.8 includes measures across a range of our services to illustrate areas of both strength and some relative weakness, across each of outcome, effectiveness and experience.

4.2 Safety Strategy and Programme Our strategy for improving safety is set out in our Risk Management Policy. We are ambitious that all our staff understand their opportunities to identify hazards, and have the confidence and skills to exploit them. We appreciate that patients and their families and carers are valuable partners in this endeavour, and seek to involve them, through complaints, concerns and comments, and through patient feedback surveys. Our plans to measure and improve patient safety are set out in our patient safety programme. Many hundreds of staff are already directly involved. Our aim is that every single member of staff will be able to make their contribution, and to recognise the harm they help avoid. We paid particular attention this year to establishing effective leadership for safety, and to improving ways of working to reduce harm from medicines and in critical care. We are already seeing the benefits. Examples of our improvement in 2009/10:

• •

The World Health Organisation (WHO) surgical safety checklist has been introduced in all our theatres In our Children’s Service the number of medication incidents fell from 86 in the first six months to 20 in the second after an awareness and education programme for nurses and doctors Hand hygiene compliance improved from 90% at the start of the year to 95%. Our ‘Clean your Hands’ campaign aims to convince staff, patients and visitors that hand cleaning is everyone’s responsibility. Cleaning your hands is the most effective way of preventing and controlling infections in hospital The proportion of patients starting dialysis via a fistula increased from 75% to 84% (this dramatically reduces the chance of infection). The number of peritoneal dialysis infections reduced from 117 to 74

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We will describe how we did against these targets, and many more measures, in our Quality Account of 2010/11. Board patient safety conversations Board directors receive information on a wide range of quality indicators, many described in this Account. In addition they receive regular reports in person from our matrons, and January 2010 saw the first NUH patient safety conversations. This programme of visits to clinical areas by Board members and senior leaders gives frontline staff the opportunity to share their experience of patient and staff safety in NUH. We are confident that these conversations will promote our safety culture, incident reporting, and Board to ward understanding of the important issues and priorities. Staff surveys on patient safety We are creating a culture in which staff talk openly about incidents, errors or harm to patients. Patient safety culture surveys are anonymous questionnaires completed by hospital staff in different areas of the hospital. They tell us how confident and expert staff are about what to do when they encounter poor practices, and help us target work to support all our staff to challenge each other, wherever we work and whatever our role. High 5s in NUH We are one of only 12 hospitals in England chosen to work with the WHO and the National Patient Safety Agency on an international patient safety project called High 5s. This three year project is designed to reduce harm to patients from three injectable medicines: morphine, heparin and potassium. Only designated areas will be allowed to stock these medicines, and where they are stocked they will be stored more safely segregated from other medicines and with a prominent warning label attached. The project also promotes ready-to-use, less concentrated alternative preparations of the medicines.


Section Four - Review of 2009/10 Reducing harm from falls Falls are the most frequently reported clinical safety incident in UK hospitals. Falls occur at a frequency of 5-5.5 per 1,000 bed days in acute hospitals, and are estimated to cost the NHS ÂŁ15 million a year. Here at NUH, falls are one of the most commonly reported incidents for inpatients and, in common with falls outside the hospital environment, these incidents cause significant physical and psychosocial harm. We are committed to reducing the harm from falls, by reducing both the number of falls and the severity of injuries sustained as a result of falls. The Trust has an established Inpatient Falls Group

which provides advice and support to departments across the hospital. Over the last year an updated adult inpatient falls management policy has been rolled out which includes guidelines for the medical management of patients who have fallen. A revised patient and carer information leaflet is being developed and will be completed in 2010. The Trust is also involved in innovative research to test the effectiveness of chair and bed alarms in the reduction of falls. We have devoted considerable time to improving the way in which we record and count falls. Increased awareness, encouragement to record, and easier reporting make interpretation of the numbers less difficult. No significant trend can be seen (2007/08: 3,283, 2008/09: 2,860, and 2009/10: 3,365), but we are confident that the work we are doing will have demonstrable benefits for patients in 2010/11 (and in future years).

Checklist for theatres The WHO surgical safety checklist was launched in December across the Trust. This is a global initiative, designed to improve communication and patient safety during and after surgery. The process mirrors the checklist processes which have been used successfully for many years in highly safety-conscious industries such as aviation and nuclear power. NUH has a very extensive suite of operating theatres across two campuses, and a wide range of surgical specialties. Prior to the checklist there had been a strong drive to ensure that wrong site surgery did not occur. The checklist goes further, addressing wider issues of patient safety such as team communication, prevention of surgical site infection, and avoidance of deep venous thrombosis. The process for NUH has been piloted very successfully across theatres, and modified to make it fit with how our theatres work. Participation of the whole multi-professional team is crucial, and theatre, surgical and anaesthetic staff now recognise that they can transform patient safety by working together with this tool. A process of continual feedback has started to determine whether the checklist is helping staff to identify issues which could lead to patient harm. Regular data is collected from staff about how the checklist is working in practice, to highlight areas where the checklist works well and where the process could be improved. Learning from highly safety-aware healthcare organisations from around the world, information about how well the checklist is working will be displayed prominently, including in theatres. Looking ahead to 2010/11, we will apply the checklist principles to other areas such as endoscopy and radiology.

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Section Four - Review of 2009/10 Situation, Background, Assessment, Recommendation (SBAR) In August 2009, as part of our commitment to improve patient safety, the Trust adopted the SBAR communication tool for use in all clinical areas. This tool has been shown by the Institute for Health Improvement to reduce medical errors related to poor communication. SBAR provides a framework for the standardisation of communication and transfer of clinical information between members of the healthcare team. It can be used to frame any conversation, handover, telephone call or referral to ensure that vital information is not missed. It provides an easy and focused way to set expectations for what will be communicated. The SBAR tool has been piloted and rolled out on both the Queenâ&#x20AC;&#x2122;s Medical Centre and City Hospital campuses, and will be further embedded across the Trust in 2010/11. Incidents We earlier mentioned improvements through 2009/10 in the number of reported untoward incidents and near misses. Safer organisations are generally those with high reporting (because more serious incidents are avoided by actions taken after less serious ones). Each incident is considered by the manager for the area in which it happened. When incidents have serious consequences we undertake a detailed investigation and implement changes. In 2009/10 we had 23 serious untoward incidents (although not all caused serious harm to patients). Among the actions we took were to strengthen our surgical checklist procedures (to prevent wrong site surgery), changed our procedures for intravenous infusions in children (to ensure that correct doses are given), and tighten up our processes for following up the results of investigations. In July 2009 there was an outbreak of very serious infections after heart valve surgery in our Trent Cardiac Centre. Five patients died. As soon as we knew there was this problem we introduced control measures. We have continued to do heart

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valve operations. There have been no cases of this infection since we took the control measures. Our very detailed investigation, advised by outside experts, has uncovered areas where we can improve, but no major deficiencies in our standard practices and procedures. Medicines Safety Group In 2009/10 we established a new multiprofessional Medicines Safety Group to review medication incidents, identify trends, make recommendations for improvement, and monitor action taken.

4.3 Quality Framework: Ward to Board Patient safety is only one domain of quality. We recognise that the improvements which are most important for patients are achieved through integrating our efforts to improve safety, clinical effectiveness, outcomes and patient experience and engagement. We know that our systems of clinical governance, which drive improvement in (and provide internal assurance of) quality, need to evolve. 2010/11 will see significant changes to the committees and groups which examine risks and effectiveness. Clinical audit will be reinvigorated and a new Committee for Quality and Safety chaired by a non-executive director will scrutinise the measures of quality, and monitor the action plans for improvement. The tasks and membership of the Clinical Risk and Clinical Effectiveness Committees have been revised to ensure better exchange of information between clinical teams and the Board. These Committees oversee the work of specialties and directorates to develop and use risk assessment, clinical audit and morbidity and mortality review to improve quality and assurance. Workforce This Account has several times emphasised the importance we place on our staff. We recognise that we will become the best acute teaching Trust by 2016 only if we harness the talent and commitment, and realise the potential, of all our employees. The quality of the working


Section Four - Review of 2009/10 environment and the effectiveness of our ways of working, have, we believe, a direct bearing on the quality of outcomes and experience for our patients. In 2009 we undertook an extensive consultation exercise in which over 7,000 staff (of 12,000) described the changes they wanted to see in NUH. The results shaped a cultural change programme ‘we are here for you’, which aims to create a workforce which values improvements in patient experience and in which openness and challenge in the promotion of safety is encouraged and expected. The impact of the programme will be measured (including through the staff survey) and reported in our 2010/11 Account. The 2009 national staff survey highlighted strengths and weaknesses (all figures are percentages). NUH compared favourably against other acute trusts in England in; staff using flexible working (75 compared to 70), staff appraised with personal development plan in last 12 months (67 compared to 59), staff saying hand washing materials are always available (73 compared to 69), and staff able to contribute towards improvements at work (64 compared to 61). NUH compares least favourably with other acute trusts in England in staff feeling satisfied with the quality of work and patient care they are able to deliver (65 compared to 74), staff suffering from work-related injury in last 12 months (21 compared to 17), and in staff suffering from work related stress in last 12 months (33 compared to 28). In the overall impact of health and wellbeing on staff ability to perform work or daily activities NUH scored 1.66 compared to the acute trust average of 1.57. Our 2010/11 Annual Plan describes commitments to improve staff experience in the low ranking areas, including renewal of the NUH health and wellbeing strategy. Specific actions will include: increasing support for staff with mental health problems, roll-out of our Dignity at Work campaign, and growing the Q-Active campaign including recruiting additional workplace champions for both campaigns.

4.4 Quality of the environment in which care is delivered (and access) Patient Environment Action Team (PEAT) The environment is assessed on specific key areas within the ward and the surrounding areas including décor, lighting, tidiness, waste management, odour control, furnishings, maintenance, linen and floors. Food is assessed on the menu document, the choice, availability, quality and quantity, temperature, presentation, service and support, and beverages. Privacy and dignity is assessed on the sleeping accommodation, privacy and toilet and washing facilities for patients.

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Section Four - Review of 2009/10 The Patient Environment Action Team (PEAT) undertook their inspections on 2 February 2010 and gave the NUH the following scores (the 2009 scores are also included):

Year 2010

2009

PEAT Criteria

City Hospital

QMC

Environment

Acceptable

Acceptable

Food

Good

Good

Privacy & Dignity

Good

Good

Environment

Acceptable

Acceptable

Food

Excellent

Good

Privacy & Dignity

Acceptable

Good

Six-Facet Survey of the Estate The physical condition of the estate was systematically assessed in this 2008/09 survey. The survey described many areas that require considerable early work and investment, notwithstanding the PEAT assessments. The results are being used to prioritise our backlog maintenance and capital (buildings) programme. All capital projects, including refurbishment, are designed to be at least 10% more efficient than typical performance for new constructions. Our new-build Nottingham Radiotherapy Centre (under construction) received a Building Research Establishment’s Environmental Assessment Method for Healthcare (BREEAM) score of excellent (the building is designed to run with lower costs and improved sustainability). NUH aims to be a non-smoking trust. In 2010/11 we will review arrangements for management of smoking and provision of smoking cessation help on each of our sites to promote this ambition.

4.5 Aligning quality, the use of resources and our wider business strategy NUH acknowledges the interrelationship between quality and productivity improvements, which is at the centre of the national Quality, Innovation, Productivity and Prevention (QIPP) programme. Our very extensive ‘Better for you’ whole hospitals change programme is an innovative approach to realising improvements in patient experience, safety and efficiency by investing in providing front-line staff with change techniques and skills (exemplified by ‘lean’ approaches), and engaging

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them in change as never before. Building on our pilot whole hospital adoption of the Productive Ward programme, ‘Better for you’ pilots had a significant impact in 2009/10. We are in the midst of an exponential roll-out of the programme. We are committed to the Productive Nottinghamshire programme, a partnership with


Section Four - Review of 2009/10 our health community partners which aims to improve efficiency, effectiveness and safety.

4.6 Public Involvement in our Quality Account The national patient survey, our analysis of complaints, concerns and comments, and our interactions with the Overview and Scrutiny Commitee affords some insight into the issues our community considers most important in their interaction with us. But we sought assurance that the content of this, our first, Quality Account would indeed reflect the concerns our community had about our services and organisation. A sample of 318 of 10,000 members, recruited in anticipation that we will become an NHS Foundation Trust, responded to a bespoke survey. Our Local Involvement Networks (LINks) helped promote the survey among the groups they represent. A matched group of 318 staff responded (we recorded demographic details to make sure we included people from a wide range of backgrounds). Nearly all the people surveyed wanted us to

include information about how clean our hospitals are. A similar number wanted to see information about privacy and dignity (this meant things like having a curtain around your bed, how we look after your medical notes and whether you have to share sleeping areas with people of the opposite sex). Quality of food, waiting times, and complaints handling were also considered important. For patient safety, nearly everyone said that their main concern was rates of healthcare associated infections. They were also interested in information about mistakes, such as medication errors and avoidable death rates. For quality of patient care, people said that they were particularly interested in waiting times for and during treatment. They asked how often we cancel appointments and operations. They also wanted to receive information about Patient Reported Outcome Measures (PROMs) and about the outcomes of Care Quality Commission assessments of our hospitals. As much as possible we have included information about each of these areas in this Quality Account.

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Appendix

Appendix

Commentary from NHS Nottinghamshire County & NHS Nottingham City.

â&#x20AC;&#x153;The commissioning PCTs recognise the areas of strength described in the Quality Account. Priority areas for quality improvement are also supported. The commissioning PCTs monitor quality and performance at NUH throughout the year. There are monthly quality and performance review meetings and there is frequent ongoing dialogue as issues arise. The information contained within this Quality Account is consistent with information supplied to commissioners throughout the year. NUH works constructively with commissioners and other partners. For instance, quality goals were jointly agreed in order to improve the health of local residents. When significant incidents occur, the Trust conducts robust investigations. Independent and expert reviews are commissioned readily, so that lessons are learned and improvements can be made. Examples of this include the Emergency Department four-hour wait recording errors and infections following heart valve replacements. Both of these incidents were widely reported in the media and the Trust was open about key causes. Commissioners have participated in some significant incident investigations. The complaints process at the Trust appears to be fair and robust. Joint PCT and NUH investigations have been conducted when complaints transcend organisational boundaries or when complainants approach the commissioners about care at NUH. Complaints are treated seriously and genuine efforts are made to improve services in the light of patient feedback.â&#x20AC;?

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Glossary

Glossary

Acute - describes a disease of rapid onset or deterioration. Annual ‘Health Check’ - the Annual Health Check is the Care Quality Commission’s (formerly Healthcare Commission) method for assessing the performance of NHS organisations. The process is designed to assess, on behalf of patients and the public, whether NHS organisations are meeting the Government’s standards such as those on safety and the quality of clinical care. There are two key performance measures: Quality of Services and Quality of Financial Management and each of these measures is awarded one of the following ratings: Excellent, Good, Fair, Weak. Arrhythmia - abnormal heart beat (often irregular). Audit Commission - an independent watchdog, driving economy, efficiency and effectiveness in local public services, including the National Health Service, to deliver better outcomes for everyone. Better Care Better Value (BCBV) - the NHS Better Care, Better Value indicators are published each quarter for all primary care, acute hospital and foundation trusts by the NHS Institute for Innovation and Improvement. The indicators are primarily intended to help NHS organisations see where to improve their effectiveness and efficiency and offer an insight into the operational performance of the system as a whole. ‘Better for you’ - NUH’s whole hospitals change programme. Launched in 2009, the programme will enable NUH to deliver caring, safe and thoughtful care to patients. It is an opportunity, through acting on ideas from our staff and patients, to improve our systems and processes and make sure they help us deliver high quality, efficient patient care. Biomedical Research Units (BRUs) - the National Institute for Health Research (NIHR) has established sixteen BRUs to undertake translational clinical research in priority areas of high disease burden and clinical need that are currently under-represented in the existing

Biomedical Research Centres. Each NIHR Biomedical Research Unit is a partnership between an NHS Trust and a university, which will enable some of our best health researchers and clinicians to work together. Funding for the Biomedical Research Units commenced on 1 April 2008. Each Unit will receive £750k for the first year (to allow for start-up) and £1m per year for the following three years (£3.75m over four years). Awards will be made to the NHS partner, and can only be used to support the recurrent costs of patient focused research. Nottingham was the only centre in the country to be awarded three BRUs; for research into respiratory diseases, digestive diseases and hearing problems. CABG - coronary artery bypass graft (CABG) surgery. An operation in which a section of vein or artery is used to bypass a blockage in a coronary artery allowing enough blood to flow to deliver oxygen and nutrients to the heart muscles. CABG is performed to prevent heart attacks and to relieve chest pain. Care Quality Commission (CQC) - is the independent regulator of health and social care in England. The CQC regulates care provided by the NHS, local authorities, private companies and voluntary organisations. ‘Clean you Hands’ campaign - is a national awareness campaign to encourage more patients, visitors and staff to carry out effective hand washing. Clinical Effectiveness Committee - provides assurance that all NUH clinical services and treatment programmes meet best-practice standards for assessing and maintaining their clinical effectiveness. Clostridium difficile - an intestinal infection commonly associated with healthcare. Commissioning for Quality & Innovation (CQUIN) - The CQUIN payment framework is a national framework for locally agreed quality improvement schemes. It makes a proportion of provider income conditional on the achievement

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Glossary of ambitious quality improvement goals and innovations agreed between Commissioner and Provider, with active clinical engagement. The CQUIN framework is intended to reward genuine ambition and stretch, encouraging a culture of continuous quality improvement in all providers. In order to earn CQUIN money, providers of acute, ambulance, community, mental health & learning disability services using national contracts must agree a full CQUIN scheme with their commissioners. CQUIN schemes are required to include goals in the three domains of quality: safety, effectiveness and patient experience; and to reflect innovation. Congenital - present at birth. Day surgery - surgery which can be performed in a single day, without the need to admit the patient for an overnight stay in hospital. Dr Foster Good Hospital Guide - Dr Foster is an independent organisation dedicated to making information about the performance of hospitals and medical staff as accessible as possible. Elective - elective care is planned. A patient will be aware of the required treatment and have been given a date to be admitted to hospital. Nonelective care is provided in critical or emergency situations when a medical professional deems specific treatments or hospital admission cannot be delayed for more than 24 hours. Emergency Department Information System (EDIS) - an electronic patient tracking system Femur - the thigh (upper leg) bone. Four hour standard - relates to the emergency access standard set by the Department of Health. The target states that at least 98% of patients attending Emergency Departments must be seen, treated, admitted or discharged within four hours. Hospital Episode Statistics (HES) - is the national data for England on the care provided by NHS hospitals and for NHS hospital patients treated elsewhere. HES is the data source for a wide range of healthcare analysis for the NHS, government and many other individuals and organisations.

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Hospital Standardised Mortality Rate (HSMR) is an indicator of healthcare quality that measures whether the death rate at a hospital is higher or lower than you would expect. The HSMR compares the expected rate of death in a hospital with the actual rate of death. Factors such as age and severity of illness are taken into account. Information Governance - is the way by which the NHS handles all information, in particular the personal and sensitive information of patients and employees. It allows organisations and individuals to ensure that personal information is dealt with legally, securely, efficiently and effectively in order to deliver the best possible care. Institute for Health Improvement (IHI) - an independent not-for-profit organisation helping to lead the improvement of healthcare throughout the world. Intrapartum care - management and delivery of care to women in labour. Intra-thoracic - within the cavity of the chest. Length of stay - the duration of a single episode of hospitalisation. Local Involvement Networks (LINks) - are made up of individuals and community groups, such as faith groups and residentsâ&#x20AC;&#x2122; associations, working together to improve health and social care services. In Nottingham there are two LINks groups - one for Nottingham City and another for Nottinghamshire. MRSA - Methicillin-Resistant Staphylococcus Aureus - bacteria that can cause infection in a range of tissues such as wounds, ulcers, abscesses or bloodstream. National Patient Survey - The NHS national patient survey programme was established as a result of the Governmentâ&#x20AC;&#x2122;s commitment to ensuring that patients and the public have a real say in how NHS services are planned and developed. Getting feedback from patients and listening to their views and priorities is vital for improving services. All NHS trusts in England are legally required to carry out local surveys asking patients their views on their recent health care experiences.


Glossary One main purpose of these surveys is to provide organisations with detailed patient feedback on standards of service and care in order to help set priorities for delivering a better service for patients. There are inpatient and outpatient surveys. National Patient Safety Agency (NPSA) - an Armâ&#x20AC;&#x2122;s Length Body of the Department of Health which leads and contributes to improved, safe patient care by informing, supporting and influencing the health sector. National Institute for Clinical Excellence (NICE) - an independent organisation responsible for providing national guidance on promoting good health and treating ill health. National Institute for Health Research (NIHR) - is the body responsible for creating a health research system in which the NHS supports outstanding individuals, working in world class facilities, conducting leading edge research focused on the needs of patients and the public. Nephrologist - a doctor who specialises in kidney (renal) disease. NHS East Midlands - is the strategic health authority for the region providing leadership of the NHS across Derbyshire, Leicestershire and Rutland, Lincolnshire, Northamptonshire and Nottinghamshire. The role of NHS East Midlands is to relay and explain national policy, set direction and support and develop all NHS Trust bodies (Primary Care Trusts and NHS Trusts providing acute, mental health and ambulance services). NHS Foundation Trust - NHS Foundation Trusts have been created to devolve decisionmaking from central Government control to local organisations and communities so they are more responsive to the needs and wishes of their local people. NHS Number - is the only National Unique Patient Identifier, used to help healthcare staff and service providers match you to your health records. Overview and Scrutiny Committees (OSCs) - since January 2003, every local authority with social services responsibilities have had the power to scrutinise local health services. OSCs take on the role of scrutiny of the NHS â&#x20AC;&#x201C; not just major changes but the ongoing operation and planning of services. They bring democratic accountability

into healthcare decisions and make the NHS more publicly accountable and responsive to local communities. Patient Environment Action Teams (PEAT) an annual assessment of inpatient healthcare sites in England. It is a benchmarking tool to ensure improvements are made in the non-clinical aspects of patient care, such as cleanliness, food and infection control. Patient Reported Outcome Measures (PROMS) - all patients who are having hip replacements, varicose vein surgery or groin surgery are being invited to fill in PROM questionnaires. The NHS is asking patients about their health and quality of life before and after they have an operation. This will help the NHS to measure and improve the quality of care. Payment by Results (PbR) - was introduced to improve efficiency, increase value for money, facilitate choice, enable service innovation and improvements in quality, and reduce waiting times. PbR uses a national tariff of fixed prices that reflect national average prices for hospital procedures. Patient treatments within a cluster of diagnosis and procedure that consume the same level of resources are assigned to a Healthcare Resource Group. The price for a particular procedure is called the reference cost and is standardised across the NHS with adjustments made for market forces. Perinatal - the period shortly before or after birth. Perioperative - the care that is given before, during and after surgery. PCTs - have the responsibility for improving the health of the community, developing primary and community health services and commissioning secondary care services. POMH - the national Prescribing Observatory for Mental Health (POMH-UK) was launched in 2005 and its aim is to help specialist mental health services improve prescribing practice. Productive Nottinghamshire programme - is the response from all NHS organisations in Nottinghamshire to meet the Quality, Innovation and Productivity and Prevention (QIPP) agenda. All healthcare organisations in Nottinghamshire are working together to

28


Glossary make quality improvements to services whilst maintaining high levels of patient and staff satisfaction. Productive Ward: Releasing Time to Care programme - organise wards so that they work more efficiently, releasing time for nurses to provide direct care for patients. Pulmonary Hypertension - is a condition in which blood pressure in the arteries of the lungs (the pulmonary arteries) is abnormally high. Quality dashboards - a clinical dashboard is a toolset of visual displays developed to provide clinicians with the relevant and timely information they need to inform daily decisions that improve quality of patient care. Quality, Innovation, Productivity & Prevention (QIPP) programme - QIPP focuses on the NHS working in different ways to ensure that the highest quality care is delivered. It encourages efficiency and focuses on a ‘joined up’ approach to delivering healthcare. Research Passport - is the mechanism for obtaining an honorary research contract from the NHS for researchers who will have a direct impact on patient care, have direct access to identifiable patient information, have indirect contact with patients/service users whose research has a direct bearing on the quality of their care or wish to access “with consent” identifiable patient data, tissues or organs with likely direct bearing on the quality of their care (with likely impact on prevention, diagnosis or treatment). Same-sex accommodation - In January 2009, the Department of Health announced a package of measures designed to eliminate mixed-sex accommodation. These plans include funding for hospitals to improve patient privacy and dignity, specialised advice and support to help hospitals make the most of their resources, introducing rigorous and transparent performance measures through the standard contract from April 2010 monitoring patients’ experience of hospital accommodation. Service level agreement (SLA) - a formal agreement between two organisations that sets out the detail of the way in which one organisation will provide services to the other organisation in return for an agreed amount of money.

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Situation, Background, Assessment Recommendation (SBAR) - is an easy to remember framework that can be used for conversations which require a clinician’s attention and action. It enables people to clarify what information should be communicated between members of the team, and how. It can also help to develop teamwork and foster a culture of patient safety. The tool consists of standardised prompt questions within four sections, to ensure that staff are sharing concise and focused information. It allows staff to communicate assertively and effectively, reducing the need for repetition. Smoking cessation - giving up smoking. Staff survey - the annual national survey of NHS staff in England is co-ordinated by the Care Quality Commission and provides the most reliable source of national and local data on how staff feel about working in the NHS. The principal aim of this survey is to gather information that will help individual NHS organisations to improve the working lives of their staff and so help to provide better care for patients. Strategic Health Authority - see NHS East Midlands. Surgical safety checklist - a tool for the relevant clinical teams to improve the safety of surgery. In June 2008, WHO launched a second Global Patient Safety Challenge, ‘Safe Surgery Saves Lives’, to reduce the number of surgical deaths across the world. The checklist is part of this initiative. Transcatheter Aortic Valve Implantation - an alternative to open heart surgery in patients with narrowing of the aortic valve. Venous thromboembolism (VTE) - a condition in which a blood clot (thrombus) forms in a vein. World Health Organisation (WHO) - is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends.


This document is available in other languages and formats upon request from the Communications Team at Nottingham University Hospitals NHS Trust on 0115 924 9924 ext 63562 or by e-mail at nuhcommunications@nuh.nhs.uk


Nottingham University Hospitals NHS trust Quality Account 2009/10  

Nottingham University Hospitals NHS trust Quality Account 2009/10

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