Page 1 of 113 Quality Account 2014/15 Final
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1 of 113
Quality Account
2014/15
Final
Page 2 of 113
Contents
Achievements in Quality ................................................................................................................ 5
Achievements in 2014/15 .............................................................................................................. 6
1. Statement on Quality from the Chair and Chief Executive ............................................... 9
2. Our Trust ................................................................................................................................ 12
2014/15 in numbers: .................................................................................................................... 13
3. Our Quality Achievements 2014/15 ................................................................................... 16
3.1. Achievements against our Quality Objectives 14/15 ................................................. 17
3.2. Where we have been working to improve quality in 2014/15 ................................ 19
Reducing Mortality ................................................................................................................... 19
Reducing harm ......................................................................................................................... 20
Put safety first by reducing avoidable harm from falls .................................................... 20
Dementia ............................................................................................................................... 21
Medicines management ...................................................................................................... 21
Safer surgery ........................................................................................................................ 22
Safe nurse staffing ............................................................................................................... 23
Maternity ................................................................................................................................ 24
Family Nurse Partnership ................................................................................................... 25
Patient Experience ................................................................................................................... 26
Outpatients ............................................................................................................................ 26
End of life care ...................................................................................................................... 26
Buckinghamshire Integrated Respiratory Service (BIRS) .............................................. 28
Urgent care ............................................................................................................................ 29
Culture for Quality improvement ........................................................................................ 35
Clinical leadership ................................................................................................................ 36
Quality and safety peer reviews ......................................................................................... 37
Safeguarding Adults and Children ..................................................................................... 37
Page 3 of 113
Speaking Out ........................................................................................................................ 38
Feedback from patients ....................................................................................................... 39
Part 2 - Information required by regulation ............................................................................... 48
4. Our Plans for the Future ...................................................................................................... 48
4.1. Clinical Strategy ............................................................................................................ 48
4.2. Quality strategy ............................................................................................................. 50
Quality Objectives 2015/16 ................................................................................................. 51
4.2.1. Priority 1 Reducing mortality ............................................................................... 51
4.2.2. Priority 2 - Reducing harm .................................................................................. 53
4.2.3. Priority 3 Great patient experience .................................................................... 56
4.3. Corporate Objectives 15/16 ........................................................................................ 58
5. Service Provision .................................................................................................................... 62
6. Clinical Audit...................................................................................................................... 63
7. Research ............................................................................................................................... 64
8. Goals agreed with commissioners ........................................................................................ 65
9. What the Care Quality Commission say about Buckinghamshire Healthcare Trust . 66
10. Data Quality ........................................................................................................................... 70
Part 3 Review of quality performance ....................................................................................... 72
11. Patient Safety ........................................................................................................................ 72
11.1. Incident Reporting .......................................................................................................... 72
11.2. Infection Prevention and Control .................................................................................. 75
Clostridium difficile and MRSA Bacteraemia Trajectories 2014/15 .............................. 75
12. Patient Experience ................................................................................................................ 77
12.1. Care Quality Commission National Annual Inpatient Survey 2013 ........................ 77
12.2. Care Quality Commission National Maternity Survey 2014 ..................................... 77
12.3. Care Quality Commission National A&E Survey 2014 ....................................... 77
12.4. Complaints ....................................................................................................................... 79
Page 4 of 113
12.5. Principles for remedy ...................................................................................................... 80
12.6. Friends and Family Test ................................................................................................ 80
13. Performance against National Targets 2014/15 ........................................................... 81
14. Health and Social Care Information Centre Indicators 2014/15 ................................ 83
Statement from Clinical Commissioning Groups ..................................................................... 87
Statement from Healthwatch ...................................................................................................... 89
Statement from Health and Adult Social Care Select Committee ......................................... 90
Statement by Directors ................................................................................................................ 91
Appendix 1 Audit ................................................................................................................... 92
Appendix 2 CQUIN ................................................................................................................ 96
Appendix 3 Glossary of Terms ............................................................................................. 98
Appendix 4 Auditors Limited Assurance Report .................................................................. 106
Appendix 5 Examples of improvement resulting from national clinical audits: .................. 110
Page 5 of 113
Achievements in Quality
We have a track record in making our care
safer.
In 2014/15
94% of our patients would be
extremely likely or likely to
recommend our A&E services based
on their experience (Friends and
Family Test March 2015)
We have undertaken two pivotal
breakthrough collaborative to devise
ways to improve the early recognition
of deteriorating patients and to reduce
numbers of falls and harm from falls
The surgical outcomes published for
our individual surgeons shows
excellent results
We have invested £5m in additional
nurses to improve safe staffing levels
We have recruited 356 registered
nurses
Page 6 of 113
Achievements in 2014/15
Bucks County Council Dignity and Respect Awards
Health category
Winner: Salma Hussein, Healthcare Assistant on ward 12a at Wycombe Hospital
Shortlisted: Mr Hiten Sheth, Consultant Ophthalmologist
Recognised: Amersham Adult Community Healthcare Team and Jo Birrell, Matron, Medicine for Older People
UKActive Flame awards
Spirit of Flame category
Shortlisted: Andrew Jackson-Shaw, Volunteer in the National Spinal Injuries Centre
Ceremony not until 24 June
Journal of Wound Care (JMC) awards
Chronic oedema and compression category
Second place: Sue Lawrance, Lymphoedema Specialist Nurse at Florence Nightingale Hospice and Ruth Peachment, occupational therapy clinical specialist in
National Spinal Injuries Centre
Patient Experience Network (PEN) awards
Partnership working to improve patient experience category
Winner: Care4Today cardiac rehabilitation programme at Wycombe Hospital
Page 7 of 113
Wesleyan Royal Society of Medicine awards
Young trainee of the year 2013/14
Winner: Dr Sam de Silva, Clinical Training Fellow in Opthalmology Announced January 2015
Association of Healthcare Communications and Marketing (AHCM) awards
Best use of social media category
Highly commended: ‘Be the Future’ recruitment campaign
Health Service Journal
Top 50 innovators in health
Named: Dr Piers Clifford, Cardiology Consultant and clinical lead for cardiology, Wycombe Hospital
University of Bedfordshire and Buckinghamshire Healthcare NHS Trust
Placement of the Year
Winner: Marlow Community Hospital team Based on feedback from students, audits and visits
Association of Optometrists awards
Contact lens practitioner of the year
Shortlisted: Daniel Goh, Optometrist, Wycombe Hospital
British Dietetic Association (BDA) awards
Rose Simmonds category
Winner: Samford Wong, Lead Dietitian at the National Spinal Injuries Centre
Page 8 of 113
Spinal Injuries Association (SIA) Rebuilding Lives awards
Shortlisted finalists: Staff
Outstanding Consultant: Dr Allison Graham
Outstanding Occupational Therapist Ruth Peachment
Outstanding Nurse Debbie Green
Outstanding Healthcare Support/Care worker Lorraine Hedgecock
Winners: Staff
Outstanding team St Francis Young Persons Unit
Outstanding Occupational Therapist Michelle Clarke
Outstanding Psychologist Paul Kennedy
Page 9 of 113
1. Statement on Quality from the Chair and Chief
Executive
This year has been a year of change and development as we work to deliver ‘safe and compassionate care, every time’. There have been both highlights and challenges and these are reflected in this report. At the end of the year we sadly said goodbye to Anne Eden who led the organisation as Chief Executive for the last nine years and has now moved on to work with the NHS Trust Development Authority (TDA). She has remained constantly committed to delivering the best for patients in Buckinghamshire and we thank her for the significant difference she has made in her time here. A number of other Board appointments were made during the year and with a new leadership team in place we are in a strong position to go even further in our development. It was a great step forward for us when the Care Quality Commission recommended to the TDA that we were removed from special measures in June 2014. This was an acknowledgement of the improvements they had seen to the quality of care and patient experience when they had inspected the services we provide from our main hospital sites in March 2014. We were proud that many services were rated either good or outstanding, but recognise that the overall rating of ‘requires improvement’ shows that we still have much work to do achieve the ‘outstanding’ performance that we aspire to. Other highlights of this year include:
Our specialist hyper-acute stroke unit was ranked in the top three in the country for the treatment of stroke-related blood clots
The cancer care and haematology unit retained its’ Macmillan ‘quality environment mark’ for another three years
We continued to develop services offered within the community with an additional adult community healthcare team put in place to support patients overnight and the launch of new technologies to support mobile working and the delivery of care in patients’ own homes
The National Spinal Injuries Centre retained its international CARF accreditation for another three years recognising the world-class rehabilitation programme we offer to patients
The fracture liaison service at Stoke Mandeville Hospital became one of only six in the country to be awarded the International Osteoporosis Foundation’s ‘capture the fracture’ silver rating
Marlow Hospital was named placement of the year by University of Bedfordshire
Pharmacy was praised nationally at the NHS Improving Quality Conference for its move to a seven-day service
We ranked 30th in the National Institute of Health Research’s top 100 performing trusts across the UK for recruitment to research studies
Our surgeons achieved some of the best outcomes in the country.
Page 10 of 113
Developing services that are best meet patient needs has continued to be a focus for us during the year and we have extensively involved and listened to patient views to inform our improvement work. Over the past year we:
have developed our emergency services to ensure patients are seen and treated by the most appropriate staff as quickly as possible. This includes, where relevant, patients being sent by their GP directly to our medical or surgical teams without needing to go through A&E. Plus the creation of a new same day assessment unit, next door to A&E, allows us to provide treatments like blood transfusions without the need for patients to be admitted to a ward.
invested in our staff, technology and estates to support quality improvements – spending over £5m recruiting an additional 360 nurses; £1m in mobile technology; £500k on diagnostic imaging machines; and over £18.5m capital investment.
have been innovative – we are one of the first UK trusts to offer pioneering swallowing therapy; we have launched a unique cardiac rehabilitation programme, which has seen participation increase whilst waiting times fall; and our project to improve hydration was praised by the Chief Inspector of Hospitals.
April 2015 marked our fifth birthday as an integrated community and hospital provider. Since our creation in 2010, we have:
Supported 2.5 million children and adult contacts in the community
Cared for 400,000 inpatients
Seen and treated over 1.5 million outpatients
Been part of 27,000 babies first days and weeks in the world. Our staff have continued to be ambassadors for our services, with a number gaining national recognition through awards - such as burns care advisor Suzie Whiting winning
the prestigious Mӧlnlycke Health Care Wound Academy Scholarship Award for
Innovations in Care; NSIC dietician Samford Wong winning the British Dietetic Association’s Rose Simmond Prize; cardiac consultant Dr Piers Clifford being named as one of the HSJ’s top 50 innovators in health. Our NSIC staff took away a heap of gongs at the Spinal Injury Association’s Rebuilding Lives Awards. And hundreds of staff have been nominated by their peers and patients through our monthly Going the Extra Mile awards and annual staff awards. But we are not complacent. Nationally, there have been increasing demands on A&E and inpatient wards over the winter, which we have not been immune from. We did meet our national cancer standards, have continued reporting some of the best day case rates for surgery, and have seen improvements in our referral to treatment time for planned care. For all the improvements we have made, there is more we need to do to continue improving how patients move through and between our services and making the best use of the unique relationships we can build and develop between our hospital and community services – alongside developing our relationships with GPs and social care colleagues to improve how patients are cared for across different organisations.
Page 11 of 113
The Board has invested considerable time and effort into developing our five year strategy, which is aligned with local partners and NHS England’s own five year forward view. With a national financial challenge, growing elderly population living with long term conditions, and increased expectations from the communities we serve, we know continuous change is inevitable. From visiting our sites across the county and listening to staff, patients and local partners we see that the opportunities for us to go further lie in:
Providing care in the right setting
Truly making the most of integration and building partnerships with primary and social care
Preventing illness and supporting people to manage their own health and wellbeing
Helping children to have the best start in life
Continuing to offer great specialist and life-saving care when it’s needed most
Developing staff and investing in leadership. We recognise that we have more to do but also that we have some fantastic services. It is our unique position as an integrated provider that puts us at the leading edge of NHS England’s future vision for the health service. We have a clear strategy to help us get there – putting patients at the centre of our care. We are committed to regularly engaging with patients, the public and our staff as we continue on our quality improvement journey.
Hattie Llewelyn-Davies Chairman Neil Dardis, CEO
Page 12 of 113
2. Our Trust
Buckinghamshire Healthcare NHS Trust is a major provider of community and hospital
services for people living in Buckinghamshire and surrounding counties, providing care
to over half a million patients every year.
Over 5,700 members of staff provide integrated services to approximately half a
million people, including the population of Buckinghamshire and the surrounding areas of
Thame (Oxfordshire), Tring (Hertfordshire) and Leighton Buzzard (Bedfordshire).
As well as being a major provider of community and acute hospital care, we are well
known for our specialist services. The internationally renowned National Spinal Injuries
Centre is one of only a few such centres of expertise in the UK. We are recognised
nationally for our urology and skin cancer services. Similarly at a regional level; we are a
specialist centre for burns care, plastic surgery and dermatology.
Our aim is to provide safe and compassionate care, every time to our patients. Our
highly trained doctors, nurses, midwives, health visitors, therapists, healthcare scientists
and other support staff deliver this care.
We are working hard to develop clinical teams which provide integrated pathways of care,
with patients at the centre of our services. For example our Integrated Respiratory Team
care for people in their own homes; liaise with the patients during any in-patient admission
and work with ward staff to ensure that they go home as soon as clinically possible.
Patients receive better outcomes and improved satisfaction.
Page 13 of 113
2014/15 in numbers:
Attendances
Procedures and Admissions
0 50,000 100,000 150,000 200,000 250,000
Follow-up outpatient attendances
New outpatient attendances at our hospitals
Attending A&E at Stoke Mandeville Hospital
214,670
145,691
79,480
0 10,000 20,000 30,000 40,000 50,000 60,000 70,000
Outpatient procedures
Elective day case admissions
Emergency admissions
Elective inpatient admissions
Non face to face contacts
62,495
42,003
40,235
5,539
4,600
Page 14 of 113
0 200,000 400,000 600,000
598,659
Numbers of contacts with patients being supported in their own home
Page 15 of 113
Where we are based
Where possible we provide care in people’s own homes and from over 20 other settings
such as health and leisure centres and GP practices. When an admission to hospital is
necessary we have a range of in-patient facilities including two acute hospitals and five
community hospitals in Buckinghamshire.
Our community health services aim to promote the health and well-being agenda,
support patients to stay at home, being treated in the right place at the right time. We
support the goal of ensuring that every child has the best start in life. This is delivered
through adult community healthcare teams (district nursing, occupational therapy and
physiotherapy), specialist services for people with long term conditions, services for children
and families, health visitors and palliative care.
Our main community facilities
• Amersham Hospital, Whielden Street, Amersham HP7 0JD
• Buckingham Hospital, High Street, Buckingham MK18 1NU
• Chalfont & Gerrards Cross Hospital, Hampden Road, Chalfont St Peter SL9 9SX
• Marlow Hospital, Victoria Road, Marlow SL8 5SX
• Thame Community Hospital, East Street, Thame OX9 3JT
• Rayners Hedge Rehabilitation Unit, Croft Road, Aylesbury, Buckinghamshire
HP21 7RD.
The acute hospitals
• Stoke Mandeville Hospital, Mandeville Road, Aylesbury HP21 8AL
• Wycombe Hospital, Queen Alexandra Road, High Wycombe, HP11 2TT.
Our headquarters are at Amersham Hospital.
Visit our website for more details on our services
www.buckshealthcare.nhs.uk
Page 16 of 113
3. Our Quality Achievements 2014/15
Our mission is to provide safe and compassionate care, every time. This is at the heart of the
goals and objectives for Buckinghamshire Healthcare NHS Trust. The diagram below
summarises our current Quality Improvement Strategy.
The Strategy describes how we intend to reduce mortality, reduce harm and improve our
patients’ experience of care. We aim to reduce variation across our services and ensure that
patients receive safe and compassionate care, every time. We aspire to match the best in the
country in terms of quality.
This mission will only be realised if we are constantly ambitious and continue to stretch
ourselves to achieve excellence.
Through 2014/15 we have had a quality improvement plan in place and the following section
describes some of our achievements through the year.
Page 17 of 113
3.1. Achievements against our Quality Objectives 14/15
We set ourselves some clear objectives at the beginning of the year and the tables below
show a brief summary of our progress against these objectives.
Reduce mortality Progress in 14/15
Establish and run the breakthrough collaborative on care of the deteriorating patient
We successfully ran the first breakthrough collaborative on recognising and managing the acutely unwell patient. With the pilot work complete a working group is now taking forward the various work streams. For example 10 wards are piloting two changes from the change package, manual observations and visual prompts to aid communication of high National Early Warning scores. The earlier we recognise when a patient is deteriorating, the earlier we can take action and do everything we can to stop them getting any worse.
Review every death at Service Delivery Unit level
We have a programme in place to review every death. When we review every death it means that it helps us to learn where in some cases we can do things better. If we find that something has gone seriously wrong in a patient’s care and treatment we report this as a Serious Incident and we make sure that the family knows what has happened. We investigate and put actions in place to try and stop the same thing happening again.
Reduce harm Progress in 14/15
Roll out falls management pathway
We have started a second breakthrough collaborative which is focusing
on reducing numbers of patient falls and the level of harm from falls.
Patient falls are our highest reported incident category and some falls
can lead to serious harm such as a fracture. Sadly it occasionally
happens that a fall can ultimately lead to a death.
A grant has been awarded by the National Health Service Litigation
Authority to provide a fund which will support the collaborative in
implementing tests that identify which practical environmental changes
reduce falls.
Reduce harm Progress in 14/15
Page 18 of 113
Regular audit of care bundle pathways e.g. Sepsis
We have rolled out care bundles for sepsis and community acquired pneumonia. This means that any patient who comes to us with these conditions should follow the same pathway of care. This has been shown nationally to improve outcomes for patients. We are monitoring how well we follow these pathways. In March 2015 we found that for severe sepsis we achieved 86% compliance with the sepsis bundle for the patients audited.
Reduce harm Progress in 14/15
Develop Medication Safety Steering Group to reduce harm from medication errors
Incident reporting data shows an increase in numbers of medication related incidents with a drop in level of harm from these incidents (April 2012- March 2015)
Great patient experience
Progress in 14/15
Implement You said, we did
Each ward now displays a ‘You said, we did’ Board in their entrance which shows responsiveness to feedback from patients and visitors. For example, on one of the wards patients asked for window covering to be changed to enable them to see out without anyone being able to see in. This change has been put in place.
Deliver published patient centred equality objectives
Improved Equality Delivery Scheme 2 scores in February 2015.
Page 19 of 113
3.2. Where we have been working to improve quality in 2014/15
Reducing Mortality
Our aim was to reduce the Hospital Standardised Mortality Ratio (HSMR) by five points in
2014/15 and by a further five points in 2015/16.
We do not yet know the full year HSMR for 2014/15. We do know that the HSMR from April to
December 2014 was 110 and therefore we have continued to focus on delivering the actions
described below.
What we did
Mortality reviews
During 2014 we have set up a process to review every death within three months of the death.
The process is two stage. The first stage asks the question “was the death expected” if it was
the process need go no further. The second stage is a clinical review of all deaths which were
not expected looking for any care which was sub-optimal.
Any lessons learnt are identified and shared across the Service Delivery Unit. The next step
will be to ensure that learning is shared with other clinicians across the organisation.
Care bundles
Care bundles are a way of ensuring that each element of best practice is delivered to each
patient on time.
We reviewed our mortality data and found that we had higher than expected deaths from
sepsis and community acquired pneumonia in 2013/14. To reduce this, we introduced a care
bundle for each diagnosis. In addition we developed standardised documentation to support
the recognition and treatment of acute kidney injury.
In April 75% of patient coming in
with community acquired
pneumonia received their
antibiotics within 4 hours by
December this had risen to 87%
In December all A&E
patients suspected of
having sepsis received
their antibiotics within an
hour.
Page 20 of 113
Crude Mortality
We have continued to monitor our crude mortality on a month by month basis through the
year. It is not unusual to see a rise in this number over the winter period and we did see a rise
in December and January before the figure returned back to the usual level by the end of
March. Our programme of mortality reviews helps us to find out if there is any additional
learning from these winter months.
Reducing harm
Sign up to safety
Buckinghamshire Healthcare NHS Trust has committed to make its contribution to Sign Up to
Safety (SU2S), a national campaign to reduce avoidable harm by half and save 6000 lives
over the next three years.
Put safety first by reducing avoidable harm from falls
Why are around 250,000 patients falling in acute and community hospitals across the country
every year? The team on Wards 1&2 (a 42 bedded Trauma and Orthopaedic ward at
Buckinghamshire Healthcare NHS Trust) set out to discover why and to take action.
What we did
The ward team reviewed how many falls had been recorded in the last year. The data revealed
that most patients admitted were frail elderly and between 17 and 20 patients per month were
falling on the ward. These did not all result in injury however there was an increase in
psychological and mobility problems as a result of the fall contributing to an increased length
of stay.
The causes of falls are many so a multidisciplinary team was assembled to make the
improvements. These included
Staff training
Observation of the ward at night
Trial of sensor mats
Cohort bays of highest risk patients
Falls awareness Notice board
Improve supply of walking aids
Medication reviews
Recording of sitting and standing blood pressure
There has been a 20% reduction in the number of falls over ten months post implementation.
This work is now being shared across the Trust through the collaborative model.
Community falls service
Page 21 of 113
During the year the community falls service has been commissioned to focus on empowering
patients to be partners in their own safety, in their own homes and elsewhere.
Dementia
We wanted to improve the care we give patients with dementia. We have for the last three
years been screening patients who are over 75 to check if they have dementia. In 2014/15 we
wanted to make sure all such patients were screened and those who are at risk of having
dementia are referred for diagnosis and treatment.
What we did
The first step was to improve the clinical leadership around dementia care. We appointed a
second specialist nurse and in March appointed a Consultant Nurse, affiliated with
Bedfordshire University.
All our wards have information available to support people with dementia.
The team have worked closely with A&E and our wards to encourage screening but also
supporting staff in managing patients with dementia, especially assisting with those who have
challenging behaviour. This improves the experience for the patient and for their families and
carers.
Medicines management
A challenge for all trusts is to ensure that a pharmacist carries out ‘medication reconciliation’
for all patients within 24 hours of admission. Medicines reconciliation means that we make
sure that the drugs patients are prescribed in hospital match the drugs they were taking at
home.
What we did
Our pharmacy team realised that patients who were admitted at weekends did not have
access to medication reconciliation and also that patients who are assessed in A&E and then
discharged home might have medication needs that are not being met.
We now have a seven day a week clinical pharmacy service. We also have pharmacists
working in the urgent care hub to support the nursing and medical staff and to ensure patients
90% of patients over 75 are
screened for dementia and
100% who need it are referred
on to memory clinics.
Page 22 of 113
get a medication review where appropriate. This means that they are also available in the hub
to facilitate discharges so that patients can return to their own homes as soon as possible.
For total medicines reconciliations completed we have achieved a 10% increase in 14/15
compared to 13/14.
For the number of medicines reconciliations started within 24 hours of a patient's admission we
have achieved a 12% increase in 14/15 compared to 13/14.
The number of discharge medicines validated at ward level has increased by 28% in 14/15
compared to 13/14.
Medication errors rarely cause harm however there are a group of drugs where an error is
more likely to be harmful – insulin, anticoagulants, and opiates. For this reason we have
decided to focus on these medicines to reduce errors.
Insulin was the first medicine reviewed. The actions we have agreed are:
To develop a flashcard to help junior doctors identify the brand of insulin
To appoint a clinical educator for diabetes to support ward staff
To encourage patients to take responsibility for their own safety by
encouraging use of the insulin passport.
Safer surgery
We have worked hard to improve the quality of
our surgical care. This is the second year that
the NHS has published on-line outcomes of
operations carried out by around 5,000
consultant surgeons across 16 specialities. The
results take into account the complexity of the
cases and the patients’ risk factors.
The publication is a response to an initiative of
NHS England (Everyone Counts: Planning for
Patients 2013/14) to create greater transparency
and more choice for patients and commissioners.
“Care on 16B was
unbelievably great,
functions completed with
soul, care and feelings.”
“I was on 12c for four days
and I could not have got
better care, attention and
levels of comfort.
Page 23 of 113
A summary of our achievement for the 2014 publication is shown below:
Aortic aneurysm surgery – all mortality within the expected range
Carotid endarterectomy – outcomes are good and adverse outcomes within the
expected range
Nephrectomy surgery – mortality below national average
Upper limb surgery – joint replacement surgery – all mortality within expected range
Colorectal cancer surgery – mortality rate one of the lowest in England
Endocrine surgery – zero mortality. Buckinghamshire Healthcare Trust is the only UK
hospital to offer day case thyroid surgery as a routine to suitable patients and there
have been no readmissions following day case surgery in the period under review.
Our theatre team have worked closely with the Tissue Viability Team to try to ensure that
patients do not get pressure ulcers when they are immobile during surgery. We are working to
ensure that all elements of the Five Steps to Safer Surgery are carried out every time. This
makes sure that all the appropriate checks are carried out before surgery begins and that all
important information is shared between all the clinicians caring for the patient. At the last audit
100% of notes contained a WHO checklist. By adhering closely to internationally accept
standards we are seeing a fall in the numbers of these painful and often avoidable ulcers.
Our surgical floor at Stoke Mandeville cares for patients with a range of specialities including
plastics, gynaecology and ophthalmology. The specialist outpatient nurses in-reach onto the
ward to support the ward staff.
Safe nurse staffing
We are committed to ensure that our nurse staffing levels are safe. We have recruited 398
registered nurses, midwives and health visitors in 14/15. All our wards are staffed with at least
one qualified nurse to eight patients. Many of our wards exceed this number. We undertake a
bi-annual audit of staffing using a validated acuity and dependency tool to inform review of our
staffing numbers.
Evidence shows that where there is one nurse looking after more than eight patients care can
become unsafe. We plan our nursing rosters six weeks in advance and therefore can take
action to address any staffing problems in advance. As an extra check we monitor the staffing
on our wards three times a day. In these reviews we consider not only the number of nurses
on the wards but the needs of the patients. For example if there are a number of acutely sick
patients or a particularly vulnerable patient we would increase the number of staff on the ward.
Page 24 of 113
The staffing levels are displayed at the entrance to every ward and are updated on every shift.
These boards also tell visitors and patients who is in charge of the ward that day. The name of
the nurse and consultant responsible for each patient is displayed at the head of each bed.
Our community teams also review their capacity regularly and escalate any concerns.
In 2015/16 we will be working with our Adult Community Healthcare Teams to develop a model
which will make this more systematic, taking into account the complexity of the patients but
also the geography of the locality.
A monthly report on safe staffing is published on our website with a link to NHS Choices.
Maternity
We have developed our maternity strategy for 2015-18. Key priorities have been identified to
ensure that we have a shared multi-disciplinary vision for maternity services with our partner
organisations. We aim to provide integrated care pathways that support women and their
families to give their children the best possible start in life.
In 2014/15 the maternity unit delivered 5402 deliveries – nearly 100 extra babies compared
with the previous year.
A Department of Health grant in 2014 was used to improve the environment on the
antenatal/postnatal ward. This included the provision of an en-suite bathroom for each bay.
The perinatal mortality rate decreased for the period 2014/15 and is now below the national
average. The caesarean section rate at BHT saw a rise of 2% during this period. The
response from the maternity unit has been to produce a normal birth strategy. The aim is to
bring the c-section rate down to 25% by March 2016.
A midwife for perinatal mental health has been appointed and this role will need to be
evaluated over the next 18 months to ensure its effectiveness.
We had a cluster of serious incidents in early 2014 and we wanted to check that we had
picked up any learning from these incidents. We asked another organisation to review these
incidents to ensure that our governance processes were robust. We received positive
feedback.
We pride ourselves on being a responsive service and we listened and responded to themes
identified from our patient feedback mechanisms and complaints. We responded in the
following ways:
Tongue tie specialist midwife post created to improve patient experience. Historically
women have had to access private tongue tie division or await referral to another
healthcare organization. This service is now provided by the maternity department.
More flexible visiting times were introduced on Rothschild ward in response to women’s
views
Page 25 of 113
Access to Wi-Fi for inpatient mothers – how to do guides developed in response to
women’s requests
Birthrate Plus is an evidence-based manpower tool which enables the midwifery team to
assess patient activity, acuity and dependency. We are in the process of using the tool to
review the staffing levels and take any necessary action.
Family Nurse Partnership
Our Family Nurse Partnership is offered to first time parents aged 19 or under. The
programme begins in early pregnancy and continues until the child is two years old. The aim of
the programme is to help young people develop good parenting skills. More details can be
found on the Family Nurse Partnership national web-site (http://www.fnp.nhs.uk/ ).
In 14/15 we are particularly proud of the level of client engagement and we are one of the high
performing organisations delivering this programme.
Page 26 of 113
Patient Experience
Outpatients
In 2013/14 we held listening events with patients and the public called ‘A Big Conversation’. At
these events patients told us many good things about our services but also where they wanted
to see improvement. People told us that our outpatients’ service needed to be brought up to
date for the 21st century.
What we did
We started by asking our patients what they
thought of the service. We had 342 responses
to our survey. In most cases the clinical care
that was delivered was reported to be excellent.
However patients felt that sometimes our
supporting processes and administration had a
negative effect on their experience.
To reduce the appointments cancelled at short
notice (six weeks) we put in a process where
this can only be authorised by a senior
manager. By March 2015 25% fewer
appointments were cancelled than in October
2014.
We have started a refurbishment of the clinic rooms at Stoke Mandeville. They have been re-
floored and painted and the seating is currently being replaced.
End of life care
We know that recognising and responding to the fact
that a patient is in their final days is very important to
their loved ones. We only have one chance to get it
right.
In July 2013 the findings from a national independent
review, led by Baroness Neuberger, into the Liverpool
Care Pathway (LCP) were published. The report
highlighted failings in the implementation of the LCP
and recommended that the Government replace it with
individual care plans by 14 July 2014. On 26 June
2014, a new approach to care of the dying in England
based on the needs and wishes of the person and
those close to them was published. The approach,
which is outlined in One Chance to Get it Right, is
There are no adequate words to
describe how grateful my
daughter and I are for the care
you gave my husband in his last
weeks. You were all so efficient
and caring you made those last
difficult weeks bearable.
Thank you
What patients told us
94% of people want to make
an appointment as they leave
the hospital.
13% said we cancelled their
appointments frequently.
32% waited more than 30
minutes for their appointment.
15% said that the outpatient
environment was poor.
Page 27 of 113
based on five Priorities for Care which replace the
Liverpool Care Pathway as the new basis for caring for
someone at the end of their life.
The five Priorities for Care are:
When it is thought that a person may die within the next few days or hours...
1. This possibility is recognised and communicated clearly, decisions made and actions
taken in accordance with the person's needs and wishes, and these are regularly
reviewed and decisions revised accordingly.
2. Sensitive communication takes place between staff and the dying person, and those
identified as important to them.
3. The dying person, and those identified as important to them, are involved in decisions
about treatment and care to the extent that the dying person wants.
4. The needs of families and others identified as important to the dying person are
actively explored, respected and met as far as possible.
5. An individual plan of care, which includes food and drink, symptom control and
psychological, social and spiritual support, is agreed, co-ordinated and delivered with
compassion.
We want to ensure that these priorities are consistently delivered for patients at the end of life
wherever they are being looked after in our services. During the Care Quality Commission’s
inspection of the Trust in 2014 they found that the care in our hospice was of a very high
standard but that this was not always so on the acute wards. Some patients were noted to be
waiting too long to receive adequate pain control.
What we did
Our pharmacy team led the work to ensure that all wards could access a defined list of End of
Life drugs all day every day. The Palliative Care Matron developed ‘micro teaching‘ sessions
which she delivered on wards to increase nurses understanding of end of life and facilitate
discussion of practical problems on the wards.
All our work on improving care at the end of life has been informed by patients and carer views
on what good end of life care looks like for them. To help patients and carers share their views,
we have held a number of events including one in December 2014 – called “One chance to get
it right” – on what matters most to people in the county and their loved ones with regards care
at the end of life. Guests were invited from the public and from bereaved families who had
either complained or complimented the Trust on its care at the end of life.
Volunteers from those events have also agreed to help us with our improvement journey for the
next 12 months. A patient reference panel is already helping us re-write patient information
Page 28 of 113
leaflets and website content to improve the quality of information we provide to people and
their families. The same group will be contributing to our new strategy for end of life care which
we hope to launch in October 2015.
Since the beginning of 2015 a multi-disciplinary
team has overseen the production of a new
person centred care plan for people at the end
of life which will aid communication, help deliver
consistent care and become the patient’s own
record of their needs and wishes. Once piloting
and testing is complete, the new care plan will
be rolled out across the Trust. Improvements in
the quality of end of life care will be monitored
using audits and by reviewing complaints from
bereaved friends and family. We are also
reviewing our bereavement care and how we
can best support the recently bereaved.
To reduce the number of people admitted to hospital at the end of their life we are developing
Treatment Escalation Plans where we discuss patient’s wishes with them and agree a plan to
manage any deterioration in their condition during the last year of life. These plans will be
shared with all agencies working with the patient to reduce the number of times the patient has
to tell their story. Our aim is to increase the number of people dying in their place of choice.
Buckinghamshire Integrated Respiratory Service (BIRS)
As a Trust which provides both community services and inpatient care we wish to improve
patient experience and clinical outcomes by developing clinical teams which can work across
the whole pathway. This reduces the number of times patients have to tell their story and
allows us to deliver more complex care in the patient’s home, reducing the need for hospital
admissions.
What we did
The BIRS service is a nurse led service which provides self- management support to patients
with respiratory disease. By increasing the patient’s understanding of their disease e.g.
through pulmonary rehabilitation programmes for COPD, we are seeing a reduction in the
length of time our patients are in hospital. With support from the respiratory consultants all
members of the team can deliver the full service including home oxygen assessments.
Enhanced care during an exacerbation, support with smoking cessation. When patients are
admitted to hospital the BIRS nurses visit them on the ward the ward and facilitate early
discharge.
To empower patients in managing their own disease the team helps patients devise their own
self management plan and ensures stand by medication is in place and that the patient knows
how to use it.
The care and attention you were
able to provide for mum and our
family enabled us to carry out her
wish to spend her last days at home
, surrounded by her family and
those she loved.
Page 29 of 113
Urgent care
In 2013/14 patients and staff were telling us that their experience in A&E was not what they
wanted it to be.
What we did
We have redesigned our Urgent Care Hub
so that patients who have been assessed
and referred to us by a GP go straight to
the Surgical Assessment Unit or the
medical Assessment and Observation Unit
to see a specialist rather than through A&E.
We have opened an Ambulatory
Emergency Care Unit where patients can
receive treatments, for example blood
transfusions, and then return home, without
being admitted to a ward.
We have developed our REACT (Rapid
Emergency Assessment and Care Team)
teams which works to ensure that patients,
particularly older people or those with
complex needs, receive early
comprehensive assessments to quickly put
packages of care in place to enable safe
discharge home from the Urgent Care Hub.
On our wards we have reduced the number of wards each consultant covers so that the
medical team can work more closely with the ward nursing team to deliver co-ordinated care
that is focussed on meeting the patient’s clinical needs and ensuring they can go home as
soon as possible.
In March 2014 94% of patients discharged from A&E said that they were likely or extremely
likely to recommend our services.
One patient said -
94 years young. Quick in
attendance. Doctor and
nurse very friendly and
explained clearly.
Discharged same day.
Thank you.
Page 30 of 113
School Nurses
Our school nursing service is available to all school age children and young people who attend
a Buckinghamshire school. The challenge they faced was how to make sure they were
addressing the diverse needs of the children and young people across the county.
What we did
We developed a website which describes our service and how to access it, and provides links
to other services and advice that parents might find useful
http://www.buckshealthcare.nhs.uk/School-nursing/
Example of innovation
To make sure that the services we offer in each school reflect the needs of the pupils we are
pioneers of a web based needs assessment tool on which we record the assessments of each
child at three fixed contact points – school entry, year six and year nine. The health reviews
are completed by the parent or carer of each school entry child and then by the children and
young people themselves at yr 6 and 9. The data is analysed by the HAPI portal and is sent
back to the school nursing teams as a series of alerts requiring attention and in the form of a
health profile for each of the 183 primary schools and 34 secondary schools in the area we
serve. This will enable us to deliver a bespoke service addressing the exact needs of the
health communities within each specific area.
Every school in Buckinghamshire has a named school nurse and team.
All secondary schools have been offered a “Drop in” session which allows young people to
access health and well being advice on a regular basis during school time.
We have worked with our colleagues in the mental health and voluntary services (Connexions)
to develop a 1-2-1 tool which school nurses use to deliver first line, tier 1/2 mental health
support. This means a faster response to a child or young person in need and ensures that all
referrals to CAMHS (Community Adult Mental Health Service) are appropriate therefore
reducing the waiting time for specialist care.
Page 31 of 113
Community Nurses Team for Children with a Learning Disability
The Community Nurses Team for Children with a Learning Disability specialises in working
with children and young people who have an identified learning disability. This was set up as a
county wide service in 2008.
The team works in partnership with the children, their families and carers to provide a Health
Needs Assessment and where appropriate therapeutic interventions are planned which will
meet individual health needs. These interventions are based upon current Learning Disability
philosophies of care. The team also aims to consult and work in partnership with the Multi
Agency Team around the child.
We mainly work with families who require interventions such as; Behaviour management
which may include issues around bereavement and loss, sleep problems, continence
promotion/products, health promotion; growing up, puberty and keep safe. The team have an
Away Day annually to help focus on areas where we can make improvements, these are
currently the following:
Initial Health Needs Assessments
We have always provided the families with an extensive initial assessment however, this
proves to be a time consuming exercise, in order to still obtain the information but save time,
we have split the assessment in half, the first part is sent to the parent/carer to complete along
with their initial appointment letter, they then have it with them for their first appointment/ home
visit, this gives us more time to focus on the specific need and provide them with appropriate
information. We are also currently working on a set of leaflets for them about the interventions;
behaviour, continence promotion, etc. We have also created our own behaviour, continence
and sleep assessments based on current evidence based practice.
Groups
In the past year or so we have received a number of referrals for young people in some of the
special schools who need help around puberty and growing up. We have negotiated with these
schools to go in and target these young people in groups and this has proved to be very
successful.
Pilot Sexual Health Roadshow
We organised a Pilot Sexual Health Roadshow at a local special school this year, this was
prompted by some students in a group asking a lot of questions around relationships. We felt
that the aim of the Road Show would be to ensure that young people with learning disabilities
are able to enjoy safe, happy, sexual lives and healthy relationships. We feel that they need to
Page 32 of 113
understand what is happening to their maturing bodies and their changing emotions and to be
accepted as sexual people in the same way as the general population, in line with advice from
the Ofsted Report “not yet good enough” 2014.
We approached professionals from the Sexual Health Services and asked them to help us to
facilitate the day. Joint working on this pilot went really well and we had some very positive
feedback from the students. We have since been approached by the County Council and
Brook Sexual Health Services to facilitate some further Road Shows later this year.
Parent Consultations
We have set up Parent Consultations in Aylesbury at Rayners Hedge and Amersham Health
Centre, this involves parents/carers coming to us for an appointment so that we can initially
assess their child's needs and then allocate them a named nurse, it is also an opportunity for
us to refer/sign post them on to other services and provide them with information. We had
predicted that this would help us reduce waiting times for the team and also cut down on our
time on the road/mileage and this has indeed been the case. We are currently planning parent
consultations in the Wycombe area.
Care Pathways
We have reviewed all of our care pathways including referral, allocation, discharge and
continence. This has enabled us to ensure that all children receive an equitable service and
that all team members are clear about what to do and when.
School Consultations
We have received a number of referrals from one particular primary school and we have
noticed that most of them are referred for toileting support. We are currently in consultation
with them to use their premises for assessing these families and providing them with advice
and support. It is hoped that this will tie in with an existing coffee morning that the school has
set up to encourage parents to come in and discuss their children's needs. Our long term goal
will then be to target school starters who are still in nappies and require toilet training and in
turn promote independence and good continence and also reduce the amount of children who
are reliant on continence pads from the continence service at considerable financial cost.
Annual Clinical Skills Update
Every year we have a Clinical Skills Update where each nurse has the opportunity to share
clinical excellence, skills and experiences, everyone is expected to take part in the day. This
gives everyone the opportunity to update their skills and network with each other. This year we
have organised for outside speakers to come in and speak about Female Genital Mutilation
and Sensory Communication.
Page 33 of 113
Parent/Carer Feedback
In line with the NHS Constitution we want to listen to our families and so we have created our
own questionnaire about user experience. Other teams within the directorate have also
adapted this for their services. All information given is anonymous and confidential. Once
completed, it is returned to the Audit Team in a pre-paid envelope. It is hoped that this will give
us feed back about how we are doing and how we can improve our performance in the future.
Sexual health
Our Specialist Nurse for Contraception was concerned that
some women experienced significant anxiety or pain when
having a coil fitted. Evidence showed that for these women
taking pain killers beforehand made little difference.
What we did
The Sexual Health Team piloted offering Entonox (gas and
air) to women during coil insertion. Women who had had
pain during a previous coil fitting reported they were
extremely anxious. Some had gone privately for a general
anaesthetic.
After being offered Entonox patients had reduced pain and
it significantly reduced the anxiety patients felt allowing
them to `relax. Not all patients choose to use the Entonox
but it gives them confidence to know that it is there.
Therapies
This year in Speech and Language Therapy (SLT) we have hosted an international training
course in pioneering swallowing therapy and had some excellent results for patients who have
gone on to eat and drink rather than requiring tube feeding. The SLT department has also
been developing the use of technology particularly IPADs for communication aids and for
remote computer therapy. We are working with the Community Neuro Rehabilitation Team,
Community Head Injury Service and a company called Vitrucare to develop smart technology
in providing neuro-rehabilitation services e.g. patient secure messaging their care team and
arranging Skype rather than face to face contacts.
The acute and community dietetic teams integrated during 2014 to become one trust-wide
nutrition and dietetic service. Clinical specialist teams have been formed to ensure that clinical
areas are developed across the patient pathway, to improve services for patients. One
example of this is the development of milk free education groups for children with cow’s milk
protein intolerance, these sessions can be accessed via GP’s and hospital teams and they
have been piloted, evaluated and rolled out across Bucks.
Gas & air helped enormously to relax me and allow coil to be fitted. I was completely spaced out and could only hear. Helped when I could hold a hand and was comforted when I was tearful (not through pain but emotion). Helped to be told what was happening. A truly wonderful experience with professional service.
Page 34 of 113
Radiology
Radiology installed a second CT scanner within the A&E department at Stoke Mandeville; this
has facilitated improved access to CT for all emergency access patients and especially those
with life threatening conditions.
The relocation of the breast service into a purpose built unit with all the imaging going fully
digital in April 2014.
o The digital equipment enables the identifications of small lesions that were
sometimes difficult to visualise with analogue equipment.
o The unit itself has been designed so that symptomatic patients can be seen by
Breast surgeons and have imaging performed at one appointment. In addition
the design is such that breast screening patients and symptomatic patient’s
pathways do not cross with separate changing and waiting areas.
Occupational Therapy
Patients who had lower limb amputations were waiting many weeks for a suitable wheelchair
to enable them to mobilise and be discharged home.
Now for elective surgery patients by contacting the relevant community service the
community Occupational Therapists are able to undertake a pre op home visit and
identify information and actions that need to be taken e.g. widths of doorways for a
wheelchair, steps, pre op functional ability and order the wheelchair before the
operation.
Now there is the possibility of gaining a wheelchair immediately after their surgery
either by ensuring this process is followed or by use of a small stock provided by the
Wheelchair service.
Hand Therapy clinics have become overwhelming for Therapists with many patients returning
for medical follow-ups they don’t require
There is a determination to have a Therapy led Hand clinic and this is being developed
at this time providing a focused appropriate treatment session for referred patients
The therapists in the Hand team are ensuring that they are involved in the rotational
doctors’ induction to clarify roles and treatment protocols they must follow for the
patients.
Page 35 of 113
Culture for Quality improvement
Breakthrough Collaborative
Buckinghamshire Healthcare NHS Trust has adopted the Institute for Healthcare
Improvement’s methodology for quality improvement. This system helps our front line staff
think about what would make things better for our patients and then to make changes in a
systematic way. The methodology has been shown both nationally and internationally to
dramatically improve care.
A Quality Improvement Collaborative involves groups of professionals coming together to
identify what they are trying to accomplish; how they will know change is an improvement;
what changes will they make to deliver improvement. The teams then go through small cycles
of change, measuring the outcomes until the goal is reached.
Collaborative Number 1 – the recognition and management of the acutely unwell patient
Our first collaborative set an aim to reduce the number of cardiac arrests by addressing the
recognition and management of the deteriorating patient.
Eight wards across the Trust worked together for six months to develop a Change Package to
roll out across the Trust
Change 1: Reliable manual observations
Change 2 Red/yellow card –visual prompts
Change 3: Raising public awareness
Change 4: Initiating DNACPR discussion
Change 5: Weekend care planning
The Change Package is in the process of being piloted in the 8 wards that tested changes with
further wards volunteering to participate. Evaluation of the pilot wards will identify any changes
required prior to the roll out of the change package across the Trust and will be used as an
opportunity to raise awareness generally around the Trust policies and protocols for managing
acutely unwell patients.
Page 36 of 113
Collaborative Number 2 – reducing the number and harm cause by falls
The second collaborative to reduce the number and harm from falls was launched in January
2015 with 12 teams taking part.
Improvement Methodology training
The Collaborative Model for Improvement methodology is being disseminated across the Trust
with the development of a training programme delivered to preceptor nurses and junior
doctors. Participating staff are taught the skills required to apply their ideas for small changes
in the clinical areas they work in, using PDSA (Plan, Do, Study, Act) methodology. 475 staff
were trained during 2014/15. This is important as evidence shows that continuous quality
improvement requires both the capacity and capability to change.
Clinical leadership
We recognise that to consistently improve the quality of our services we need to develop
strong clinical leaders across the Trust.
The Service Delivery Units are the cornerstone of our organisation, bringing together clinicians
working in specialities to discuss best practice; review mortality, audits, incidents and
complaints; and ensure that patients are getting optimum care.
For this reason we are working with the national Leadership Academy to deliver a bespoke
development programme for our SDU leads.
When I was first asked to participate in the collaborative… I accepted with
cynicism. How great to be proved wrong! ALL areas in the trust had very
similar issues in caring for the deteriorating patient. It’s too easy to become
isolated in your ward bubble and think you are the only ones ‘struggling’.
The other main thing… how easily we can implement changes so quickly – only
small changes, nothing to alter the course of history – but changes that could
have a big impact on patient safety.
We are also finding that one idea/change ‘sparks’ another so that can only
means more improvements.”
Page 37 of 113
Quality and safety peer reviews
A Quality and Safety Peer Review is a small number of clinicians (doctors, nurses, AHPs,
midwives), patient representatives, administrative staff and managers who visit a service or
ward and directly observe the care given to patients, the environment and talk to staff about
the quality of care. These reviews help to provide assurance that the plans and improvements
we are working hard to deliver are providing these results direct to the patients we care for.
A range of wards and community services has been visited during the year. In general they
show that staff are proud of the care they give their patients. However we need to improve the
quality of our care planning and record keeping in some areas. Patients interviewed fed back
that the care they had received was compassionate and caring with many of our staff being
praised for going the extra mile.
Safeguarding Adults and Children
We recognise the importance of safeguarding
children and adults who are possibly at risk of
being harmed in some way. We are committed
to having robust, effective systems in place to
detect risk early and to take any required actions.
We carry out this work in partnership with others.
We are an active member of the
Buckinghamshire Safeguarding Boards for both
adults and children.
During the year the Multi-Agency Safeguarding
Hub (MASH) was launched to enable good
communication and a prompt, integrated
response to safeguarding alerts. We provide
members of staff to attend the MASH to make
sure that we are well informed and are playing
our part in safeguarding.
A Domestic Violence pathway has been agreed by all partner agencies and is now in place to
protect women and their dependents.
364 children on a child protection
plan in Bucks
40 safeguarding champions
identified across the organisation.
88 Deprivation of Liberty
Safeguards applications made
83% of staff trained in
safeguarding adults and children
Page 38 of 113
Training has been delivered across the Trust to increase awareness of Female Genital
Mutilation and a Task and Finish group will be set up to implement the National FGM
guidance.
Speaking Out
In October 2012 allegations relating to the late Jimmy Savile started to emerge through the
media. In response to this the Trust immediately initiated an independent investigation into
Savile’s association with Stoke Mandeville Hospital. This investigation along with a number of
other NHS investigations, was carried out under the oversight of Kate Lampard who was
appointed by the Secretary of State for Health into this oversight role.
The investigation was carried out by Dr Androulla Johnstone Chief Executive of the Health and
Social Care Advisory Service. Dr Johnstone and her team carried out a comprehensive
document review and interviewed over 250 witnesses. Among these witnesses were a
number of victims dating back to a period of time from 1968 to 1992. All victims and witnesses
were offered support throughout the process.
After the main investigation ceased gathering evidence a small number of people came
forward with new accounts. These were investigated by independent investigators from
Oxford Health and published as a Legacy report. This was one of 15 legacy investigations
conducted nationwide.
The Speaking Out Independent Investigation report was published on the 25th February 2015
at a national launch. The Legacy report was also published on the same day.
The investigation made a number of recommendations which are incorporated into our
Safeguarding Workplan. The investigation found that the trust has a safeguarding team of
experienced and qualified staff members who are fully aware of the importance of
safeguarding and it has not found any safeguarding related situation where either children or
vulnerable adults have been at risk.
Page 39 of 113
Feedback from patients
Our patients help to shape the way we design our services. We have received much feedback
from our patients this year. Some of this is shared as a patient story at our Trust Board, and
some is shared with all our staff through our staff bulletin.
One of these accounts is shown below:
If you sometimes need reminding of the great work you do, take a couple of moments to read
an extract from this thank you letter published in the Bucks Examiner newspaper last Thursday
(16 April):
"I am writing to offer my great thanks for the excellent service I am receiving from
Buckinghamshire Healthcare NHS Trust.
Recently I woke up as I was very short of breath and had a tight pain in my chest. It happened
a couple of times during the night and in the morning I contacted my GP at Little Chalfont
surgery.
My GP referred me for a cardiovascular screening at Wycombe Hospital. Within five minutes of
showing my referral letter to the receptionist at the hospital a bed was available and I was
attended by a nurse and an ECG.
The nurse was very kind and quickly connected all the wires and at the same time took blood
tests, sugar level tests and some other measurements. I was also visited by two consultants
who had a very detailed conversation with me about my condition. I was discharged from the
hospital later that day and within two days I had received a very detailed report on the
investigations carried out.
I was recommended for further tests. Later in the week I received another appointment letter
as well as an SMS notification via my mobile phone.
If there were a care Olympics, then I have no doubt the splendid nurses at Wycombe Hospital
would have won several gold medals. My only wish is that the public could experience and
recognise the excellent level of care and services available in today's NHS. Thanks once again
to Buckinghamshire Healthcare NHS Trust.
Page 40 of 113
Over the past year we have received the views of more than 650 patients, carers and
members of the public. Feedback has been collated as a result of a range of engagement and
involvement activities. Some are ongoing or have a fixed period and others are single events
or workshops.
How have we listened?
What When Key messages Action taken
“Learning From You”
Two patient sessions
On clinical information for
patients in orthopaedics,
urology and colorectal
pathways.
Random sample of patients who had been through one of these pathways <12 months previously
Report cascaded widely
Action plan in place
Repeat sessions planned for April 2015
June
July
-More information for the
rehabilitation phase.
-Past patients to be invited
to the education class
-More information on
preparation to be fit for
operation at GP referral
stage.
-A point of contact on
discharge from within the
ward.
-More information about
medication and pain relief
when at home
-3 designated nurses now
have an enhanced
recovery remit
- Participants volunteered
to share their patient
experience at future
classes.
- Colorectal patient
information leaflet trialled
- Discharge checklists
implemented
-Follow up telephone calls
made from ward to
patients 7 -10 days after
discharge
Improving our Heart Health
Programme
Feedback from patients who
have experience of the
Cardiac for Care Programme
(CRP).
4 patient events countywide
Over 450 patients and carers, relatives were invited
August -Great team,
-Individualised care
approach works
-A unanimous response as
to why patients had not
been using the important
self monitoring website, i.e.
registration info and
process
-The specific model of
pedometer used received
praise and has significant
positive impact on patient
exercise behaviours
-10 point staged action
plan developed
-Review some of the
processes and
information for patients
- Looking into how
patients can purchase
pedometers directly from
us
Page 41 of 113
What When Key messages Action taken
- Don’t give patients too
much information at once
- Would like more visual
aids to explain what has
happened to their heart
- Ensure we address
patient’s anxiety before
attending exercise classes
-Review referral processes
and raise awareness on
wards and with GPs.
-Involve carers
Seeking your views – Your
outpatient experience.
Survey – People were asked
to respond if they had
attended our outpatients
departments at any time within
the last 6 months. We
received a good response with
three hundred and fifty people
participating.
Improving the outpatient
experience is a key work
stream reporting into the
Reforming Elective Care
Programme Board.
May – Aug
- >90% patients said they
want to be able to make
their follow up appointment
before they leave.
-Only 4% of patients had
received their appointment
by choose and book
- 13% of patients
experienced cancellations
- Only answering calls
within 90 seconds for 50%
of patients.
- 53% said their usual
experience of waits in
clinics was within 30
minutes of their
appointment whilst 32%
said they usually wait more
than 30 minutes
Action plan in place being
monitored through the
Reforming Elective Care
Programme Board.
-Work to minimise clinic
cancellations,
-Implementation of pagers
for patients as a pilot,
-Environment and signage
has been reviewed
-Focus on start times of
clinics
-Bid for new texting
service being developed
Page 42 of 113
What When Key messages Action taken
This was identified as a key
area of work as a result of our
“Big Conversation” listening
events that took place
countywide.
Report cascaded widely
internally.
Improving Urgent Care
Aim was to :
a) inform the launch of our
new Ambulatory Care Unit –
b) Inform the development of a
patient information leaflet
One face to face session.
A random sample of patients
who had previously attended
the A&E department within
the last 6 months
October - “Please rename it”
Patients suggested “Same
Day Service”
Patients strongly supported
the concept
-See a consultant straight
away
-Less waiting
-Therapy assessments at
front door
-Access to diagnostics and
can return another day
-No overnight stay in
hospital
-Main concern was that
they could still be admitted
if necessary plus clear
explanatory information
about what the Unit does.
-Service is launched
- “Same day service” is
being designed into
signage.
- All comments
incorporated into patient
information leaflet
- A short patient
satisfaction survey put
into place.
-Positive tweets from
patients reporting positive
experiences were seen in
the first week.
-Friends and Family Test
results positive
-Follow up event planned
Page 43 of 113
What When Key messages Action taken
“One Chance to Get it right”
End of life Care Event
One session face to face.
Participants included patients,
carers, public and
representatives of other
stakeholder organisations
December -Patients and relatives
praised the Trust for
holding such an event.
-Participants welcome early
conversations and good
end of life care planning.
Very supportive.
-Some asked why is it not
treated like a birth plan for
each individual – why do
we treat it any differently?
Embed this approach in
primary care
- Needs an individualised
approach, one size doesn’t
fit all
- More information about
what to do as a relative or
carer in event of a death
- Clear communication and
information throughout
- Clarity on the do not
resuscitate is needed what
it really means.
- Showing compassion is
essential
- Negative impact on loved
ones when not done well,
can be long lasting and
damaging.
- Report of event
developed. Includes
record of feedback.
- Quick reference key
point slides developed for
leads to share at team
meetings
- January - The Trust EOL
steering group received
the report
- 13 participants signed
up to form a patient
reference panel
- Feedback continues to
inform actions monitored
by Steering group.
Page 44 of 113
What When Key messages Action taken
End of Life patient reference
panel
As a result of the EOL event
“One Chance to get it right”,
we wanted to create a patient
/carer reference panel, to help
shape and advise on our
improvement work as we
progress
March
Inaugural meeting 9th
March.
- Agreed terms of reference
- Agreed programme of
work
With focus on input around
- Care Plan - Strategy - Facilities - Reviewing
e.g. developing
patient information
As a first task, the panel
were asked to review five
patient /carer leaflets about
what to do as a relative or
carer in event of a death.
One good example of
helpful feedback was that
the leaflets had missed an
important opportunity to
remind people about the
opportunity for organ
donation.
- Panel members have
reviewed early drafts of
information leaflets for
patients and carers.
- The panel have agreed
to provide input to the
development of our new
EOL care plan
- Matters around facilities
will also be brought to the
panel for their views, e.g.
better privacy and dignity
for patients and family
members
Heart Failure – Introducing
new service IV diuretics at
home.
Face to face session to inform
IV diuretics at home service.
One Face to face session
Participants were patients with
heart failure currently under
our care.
Inform development of a
patient information leaflet if
service launched.
November Patients fed back that they
welcomed the idea and
would support the service.
- They know their nurses
well.
--Liked the idea of not
coming into hospital
- Received very positively
because they would be
able to get on with their life
by receiving care at home.
- Trust keeps beds free for
others in need.
-Nurses progressing with
plan to implement
-Leaflet finished and
progressing to PEG
- Nurses gained a lot of
useful information from
patients at this session
- Implementation will
result in reduction of bed
days.
Page 45 of 113
What When Key messages Action taken
Equality Delivery System 2
(EDS2) -Patient grading
panel.
A panel of patients who share
a protected characteristic were
invited to participate to grade
our Trust against the EDS2
national framework.
Results of grades are
published and combine with
staff feedback to inform and
shape our equality objectives.
March - Key overall message
Sensory impairment –
feedback reflected that
those with a sensory
impairment did not feel our
environments reflect their
needs well. This can have
an impact on access to
information and in some
cases treatment. Possible
cost efficiency savings
highlighted by the panel, if
issues addressed.
- Use of BSL interpreters is
not felt to be as proactively
offered as needs to be.
- EDS2 patient panel
results report to Trust
Board
- Combine with staff
feedback
- Agree staff side union
representatives
- Both inform and shape
equality objectives – to
Trust Board
- Publish overall grades
by April 6th in public
domain.
- Action plan to address
matters raised across
patient and staff goals.
Patient Experience Group
(PEG)
An ongoing well established
group of patients that also
have outreach to other local
groups. Meets every two
months
Service user approval of all
new patient information
leaflets.
This year have focussed
on:-
- our supporting processes
and administration
- experience of both good
and not so good care
- easy and close drop off
points for access to A&E –
better signage
-more designated spaces
for disabled car parking and
the wider issue of car
parking capacity
- communication
- Individual service related
issues
The PEG has a system of
follow up for each action
raised which is reported
back at the following
meeting or if urgent
before. If action or
explanation is not
satisfactory for the group
senior leads are invited to
explain further the actions
we are taking.
PEG was successful in
recruiting several new
members in 2014 either to
broaden representation or
to replace those who are
unable to continue in their
role.
Page 46 of 113
What When Key messages Action taken
Activities listed below are for information and more detail can be provided if required.
NEW - Chairing Consultant
appointment panels.
Four patients are now trained
to chair our consultant
appointment panels
August Relevant training given – now implemented and has
commenced.
PLACE
More patients have been
trained for PLACE
Assessments helpfully
expanding our pool.
On-going Recruitment for this process is ongoing. Current pool
35 - 40 patients.
NEW - Nurse training
Patients are now telling stories
and sharing experiences to
inform nurse development and
learning. Preceptorship and
student nurse courses.
On-going Feedback to date has been positive.
Following one patient story a student nurse said:
“ I went back to the ward with different eyes in”
Interviews
Patient representative sat on
the panel for the Deputy Chief
Nurse interviews and Deputy
Medical Director post. HR
looking to build on this positive
experience
November
February
Patient representative identified with appropriate
experience and background.
Page 47 of 113
What When Key messages Action taken
NEW patient representation
on committees
- Infection Prevention Control
- Resuscitation New Clinical procedures
&Mortality Reduction
Group
April
Patients have been requested by Chairs or clinical
leads on the committees.
Evaluations and equality monitoring analysis is undertaken. Whilst helping us to identify
outreach and representation of views which is important, it also feeds into our collation at end
of year for our Public Sector Equality Duty annual publication on our website.
Page 48 of 113
Part 2 - Information required by regulation
4. Our Plans for the Future
4.1. Clinical Strategy
Our clinical strategy – by 2020 working together with our partners we will develop:
Integration of hospital, community and primary care services which are shaped around the needs of every adult and child;
Emergency and urgent care services for the local population which maximise the chances of survival and good recovery;
Planned services which are seen as some of the best in the country for patient outcomes, access and efficiency; and
Specialist services which are renowned regionally and nationally as centres of excellence.
In order to achieve our ambitions, we will need our supporting strategies:
An estates programme to ensure we make the best use of our hospitals, estates and facilities;
An IT programme which will help us use technology and innovation to drive improvement;
A people strategy to ensure we have skilled and committed teams who live our vision, values and behaviours; and
A strong financial foundation to ensure we deliver outstanding quality of care and meet our financial duties.
Strategic priorities have been agreed that drive the work of the trust to improve care and services we provide through integration, collaboration and partnership:-
Page 49 of 113
Figure 1 Our Mission and Strategy 2015-2020
Whilst many of these relate to delivering services effectively today a number signal major
transformational change programmes over the next five years that will require oversight,
programme management, investment and focus to deliver our aspirations.
In order to be successful the organisation needs to focus on a few key programmes that drive innovation and transformation of services. In 2015/16 these programmes are proposed as follows:- Urgent Care – the redesign and co-production of a new model for urgent care across the county Health and Well-Being – ensuring that health and well being programmes and prevention matters programme is implemented throughout the Trust’s services Integrated Community Services - the integration and redesign of the community services Musculo-Skeletal- the redesign and implementation of a new model of care for Musculo-Skeletal Services Estates- the implementation of year one of the agreed estates strategy
Page 50 of 113
Information technology - the development of IT interoperability solutions across the health and social care economy. This will enable closer collaboration. Workforce – a specific programme assessing the challenges of transforming our workforce to meet the changing needs of patients. This includes introducing new roles, training and equipping staff for the roles of the future, developing workforce planning in conjunction with HEPV and other agencies to meet both our financial and quality commitments. Foundation Trust Development - on behalf of the Board ensuring that the Trust meets the requirements in terms of governance and process for a future application for foundation Trust status linked to TDA guidelines.
4.2. Quality strategy
The Five Year Forward View sets out the five year ambitions for quality for the NHS in England with the Secretary of State’s mission being to deliver the safest and highest quality healthcare system in the world. Achieving safe, effective care with a good patient experience occurs when a caring culture, professional commitment and strong leadership are combined to serve patients.
Across the NHS we strive to consistently achieve these standards and it is a priority for Buckinghamshire Healthcare NHS Trust to reduce variation across our services and ensure that patients receive safe, compassionate care, every time.
Our Quality Strategy demonstrates our ambition to have a culture that promotes quality and continuously improving the care for our patients is at the heart of everything we do. The strategy also describes the specific quality goals for the organisation, how they will be monitored and reported so that our patients and their families and carers can have confidence in the quality of care we provide.
We aspire to be the best in the country in terms of quality. We want our patients to choose to come to us to receive their healthcare because they have confidence in our reputation for providing high quality services.
This vision will only be realised if we are constantly ambitious and continue to stretch ourselves to achieve excellence.
Page 51 of 113
Quality Objectives 2015/16
The Trust Board has agreed three strategic priorities in relation to quality These were first described in the 2013-2015 Quality Strategy and remain priorities for the Trust.
4.2.1. Priority 1 Reducing mortality
In 2013 Buckinghamshire Healthcare Trust was identified as one of the trusts which had a higher than expected mortality, as measured by the HSMR, for three consecutive years.
A challenging Quality Improvement Plan was put in place and delivered and as a result the HSMR has been within the expected range. Despite this assurance the Board are committed to reducing mortality further as a measure of the quality of care for our patients using a proactive approach where we seek understanding of any variation and continually strive for improvement.
Care Bundles
Developing Care bundles are a means of ensuring that every patient gets the same standard of care every time. The principle is to define the evidence based pathway of care as a series of steps, preferably with time scales attached.
In 2014/15 we introduced three care bundles along the urgent care pathway – sepsis, acute kidney injury and community acquired pneumonia.
In 2015/16 Sepsis and Acute Kidney Injury are part of the national CQUINs.
Acute Kidney Injury (AKI)
This CQUIN aims to improve the follow up and recovery of individuals who have sustained AKI, reducing the risk of readmission, re-establishing medication for other long term conditions and improving follow up of episodes of AKI to reduce the long term cardiovascular risk.
Sepsis
The Sepsis CQUIN required all appropriate patients to be screened for sepsis and ensure antibiotics are administered within an hour for all those who have suspected severe sepsis, red Flag Sepsis or septic shock.
During 2015/16 we will be working to improve our performance against these measures.
Priority 1
Reducing mortality
Priority 2
Reducing harm
Priority 3
Great patient
experience
Page 52 of 113
Deteriorating patient
In addition to the interventions aimed at improving the level of Harm Free Care as measured on the Safety Thermometer, the Trust is committed to achieving the elimination of all avoidable cardiac arrests (i.e. excluding those occurring in critical care areas). The Deteriorating Patient Collaborative focuses on the identification of deteriorating patients, appropriate referral and timely management in order to prevent cardiac arrests. This project will also oversee the introduction of treatment escalation plans to identify patients who would not benefit from resuscitation attempts, so that ceilings of care can be established in order to, where suitable, provide compassion and safeguard patient dignity.
The Trust’s performance against each of the Deteriorating Patient KPIs are reviewed at the Mortality Reduction Group and reported to the Quality and Safety Group on a monthly basis.
Mortality reviews
One of the ways of reducing mortality is to screen each death for whether it was expected or not and then for each unexpected death do a clinical review to identify any sub-optimal care. Actions can them be identified to ensure such care does not recur.
In 2014/15 we have been carrying out mortality reviews. However our goal is to reach a state where all deaths are reviewed within three months of the death occurring. More importantly learning from the reviews will inform the mortality reduction strategy.
In addition we will work to link the process of sharing learning with our Serious Incident process to ensure the lessons are linked and shared widely.
Proactively analysing information
The quality of information on mortality in hospitals is improving with access to rolling 12 month HSMRs, monthly HSMRs, CUSUM charts etc.
We are committed to monitoring our mortality monthly, identifying areas where we could do better and carrying out clinical reviews of these areas.
Improving the recording of our patients risk factors
Key to identification of patients who may have had sub-optimal care is the accurate recording of co-morbidities and expectations of care. In addition the transfer of this information to primary care makes the ongoing treatment of the patient safer and reduces the risk of readmission.
We are committed to improving the recording of co-morbidities; identifying all patients at the end of life within 24 hours of admission; fully implementing electronic discharge to communicate this information to GPs.
Page 53 of 113
4.2.2. Priority 2 - Reducing harm
Hospital care in the UK is associated with approximately 10% incidence of avoidable harm resulting in requiring further monitoring, treatment or care and very occasionally, even patient deaths.
The Safety Thermometer is used nationally to benchmark harm caused to patients in terms of healthcare acquired pressure ulcers, venous thrombo-embolism (VTE), catheter associated urinary tract infections and falls. The metric that is used to benchmark quality performance is the percentage of patients who do not suffer any of these harm events and thereby receive ‘harm free care’. National performance is currently approximately 93%. Buckinghamshire Healthcare Trust is committed to achieving a harm free care rate of at least 95% from the end of 2015/16 onwards.
It is unacceptable that any patient who chooses to receive care from Buckinghamshire Healthcare Trust should be harmed in any way. One of our quality priorities therefore is to aspire to eliminate incidence of avoidable harm and injury to our patients and to ensure there is a continual reduction in harm suffered by our patients.
As part of our commitment to Sign Up to Safety the Trust has published a Safety Improvement Plan.
Hospital Acquired Pressure Ulcers
In 2014/15 the Trust launched a 2 year Pressure Ulcer Reduction programme to reduce the number of grade 3 and grade 4 healthcare acquired pressure ulcers by 50%. We have a zero tolerance approach to avoidable healthcare acquired pressure ulcers supported by a skin care bundle (SSKIN), training and competency assessments. All pressure ulcer incidents will continue to be reported to the Patient safety Group (PSG) so that Trust wide performance against the trajectory can be monitored. All healthcare acquired grade 3 and grade 4 pressure ulcers will continue to be routinely subject to root cause analysis investigations in order to learn from them and to determine whether they meet the European Pressure Ulcer Advisory Panel’s definition of a preventable pressure ulcer.
Venous Thrombo-embolism (VTE)
The Trust is committed to eliminating preventable hospital acquired VTEs (Deep Vein Thrombosis and Pulmonary Embolism). In order to support the achievement of this ambition;
1. A minimum of 95% of all admitted patients will undergo a VTE risk assessment and where necessary receive the appropriate prophylaxis. 2. 100% of patients who develop a new VTE will undergo a root cause analysis.
The Trust currently monitors compliance with the assessment of VTE, this is achieved through the use of the Safety Thermometer on a monthly basis, with the information from this is used to develop corrective actions where there is a reduction in performance.
During 2014/15 Ernst and Young LLP completed testing of mandated performance indicators, one of them being VTE. The findings of the testing for VTE identified from the walkthrough of the system for this indicator was suitably designed.
Page 54 of 113
Furthermore during sample testing of cases they identified that for 3 of the 20 cases these had been ticked but not signed by Doctors, this is an area for development of which the Trust is aware and has a program in place to improve this activity. Additional testing of 5 further cases has also highlighted for 3 of those cases they were incorrectly excluded from the indicator, this identifies that there is a risk that patients may not have had a VTE assessment when required. The Trust is currently completing a full review of the processes surrounding management of VTE as part of our focussed programme of work on harm reduction. The review focus will include the need to ensure that all VTE assessments are appropriately evidenced, and ensuring adequate review of all excluded cases takes place on a routine basis.
Patient Falls
In addition to the Trust’s efforts to reduce the level of harm caused by falls as measured by the Safety Thermometer, the Trust has launched a falls collaborative with the focus of reducing harm from falls in hospital. The Falls Steering Group will continue working on reducing the harm from falls, building on our past improvements, most notably on the implementation of the Fall Safe care bundle on wards 1&2. Our ambition is to reduce falls per 1000 bed days by 25% from the 2014/15 baseline.
In 2015 we were awarded £526,000 from the NHSLA as part of the Sign up to Safety Campaign to support us in making environmental changes which would reduce the incidence of falls.
In the community we will build on the launch of a new community Falls and Bone Health service which aims to empower patients to reduce their risk of harm through falls by providing assessment, treatment, exercise programmes and activities of daily living advice.
The Trust is a member of the Oxford Academic Health Sciences Network on falls.
Medication errors Medications are the most common intervention in healthcare but are also most commonly associated with adverse events in hospitalised patients. At least 20% of all harm is associated with medication errors. High alert medications are more likely to be associated with harm than other medications as they cause harm more commonly, the harm they produce is likely to be more serious and they have the highest risk of causing injury even when used correctly.
The aim in 2015/16 is to increase reporting of medication errors. There is evidence nationally that not all medication errors are reported to Trust safety teams, however without the recording of errors we will not have a full picture of the risks and the improvements we need to make.
The second aim is to decrease harm by focussing on high risk medicines. These include insulin, warfarin, low molecular weight heparins, narcotics and sedatives
The US Department of Health and Human Services1 published a guide to reducing harm from high-alert medications. They identified the following harm reduction issues:
Awareness and education
1 Implementation guide to reducing harm from high-alert medications www.hret-hen.org
Page 55 of 113
Standardised care processes
Errors at transition of care
Decision support
Smart use of technology
The Medication Error Reduction Group will review each high risk medication and devise an appropriate action plan. The Trust is a member of the Oxford Academic Health Sciences Network on medication errors.
Safeguarding children and adults We will continue to ensure that we protect children and adults from harm working in partnership with other healthcare providers, social services and the police. The assurance framework will monitor our effectiveness and external peer reviews of our safeguarding practice and processes will identify best practice and areas for improvement.
Children’s health and well being Support in the early years will be a key focus working with our health visitors and children’s community services. National key performance indicators will monitor our improvement journey and drive best practice.
Monitoring quality performance
The implementation of the Quality Strategy to reduce harm caused by VTE, medication errors, falls and pressure ulcers will be monitored by the Patient Safety Group which meets monthly and reports to the Quality Committee.
The performance and effectiveness of the VTE, medication errors, falls and pressure ulcer work streams at increasing the percentage of patients who receive harm free care will be measured by way of the Trust’s Safety Thermometer performance and the agreed KPIs incorporated into the Quality Dashboard. Safety Thermometer data is collected monthly and is reported to the Trust Board through the Quality Report. The Trust’s Safety Thermometer performance is benchmarked nationally on the NTDA Quality Dashboard and will be reported to the Quality Committee for triangulation with the monthly Patient Safety Group reports for more detailed scrutiny.
Incident Reporting and learning
Central to the Trust achieving the aspiration to continually reduce harm is its ability to analyse and learn from its mistakes so that the risk of harm can be reduced in the future. In order to do this it is essential the Trust has a strong incident reporting and learning culture. Therefore, the Trust aspires to exceed the national median for incidents reported per 100 admissions by March 2014, and subsequently aspires to remain at the top quartile of medium sized acute trusts.
In order to achieve this, the Trust Board will promote a culture that encourages incident reporting and does not blame or pursue reprisals against members of staff who report incidents.
We are committed to delivering a continual reduction in patient harm. The Trust aspires to deliver a continual reduction in the proportion of patient safety incidents that result in death,
Page 56 of 113
permanent severe or moderate harm, in comparison to the proportion of incidents that are near misses, result in no or minor harm. In order to ensure that a high incident reporting rate is indicative of a strong incident reporting culture, rather than a deterioration in the quality of our services, the level of harm caused by our incidents will be reviewed against national benchmarks. Where the Trust appears as an outlier and we are reporting a higher percentage of incidents that result in moderate, severe or catastrophic harm, this will be investigated by the Quality Committee and remedial action plans implemented and monitored.
The timeliness of incident investigations is crucial to being able to take meaningful action to reduce the risk of harm to future patients. Furthermore when managers act swiftly in response to incident reports, it demonstrates to staff that incident reports are important and taken seriously as opportunities to learn and improve. By the end of 2015/16 the Trust aspires to meet the national median for average length of time taken to investigate incidents and upload them to the NRLS.
We will also promote feedback from investigations to incident reporters by integrating this process into the performance management framework and increasing attention and scrutiny of this process. The Trust will continue to develop effective mechanisms for communicating lessons learnt from incident investigations to frontline staff.
Performance against these incident reporting objectives will be monitored at the Quality Committee when the bi-annual NRLS Feedback Report is reviewed
Patients participating in their own safety A key element of safety coming out of the Francis Report is that organisations should work to empower patients to be partners in their own safety. We are committed to this principle. Each of our Reducing Harm work streams will have clearly identified actions to support patients in managing their own safety. In addition we will work closely with the Sign Up to Safety campaign work stream to ensure best practice is implemented.
4.2.3. Priority 3 Great patient experience
In order to improve the patient experience, we aim to enhance the culture of the organisation by re-focusing attention on identifying and responding to our patient’s needs and desires. To support this ambition, we will also endeavour to improve communication between us and our patients, their carers and their families so that we are better able to tailor the care we provide to the individual needs of our patients.
The executive lead for patient experience is the Chief Nurse. The NHS Mandate sets out an ambition for the NHS in England that the experiences people have of our health and care services become amongst the best in the world. In 2015/16 we will develop a patient experience strategy that will communicate to our staff and patients how we will deliver our contribution to this ambition. Improving our experiences of care: Our Shared Understanding and Ambition was published by the National Quality Board in 2015 and describes how patient experience can be understood in two ways
What the person experiences when they receive treatment or care
How that made them feel It begins at the first contact with a service and carries through to the last.
Page 57 of 113
We believe that a great patient experience is important for the way it makes people feel but also because evidence shows it improves outcomes and ensures we are delivering value for money. A focus on patient experience encourages staff to engage with patients, making them active partners in their care. The implementation of the Trust’s 2015/16 Patient Experience Strategy will be overseen by the Deputy Director of Nursing and reported to the Quality Committee for monitoring on behalf of the Trust Board.
Our corporate performance with regards to responding to complaints will be reported quarterly to the Trust’s Quality Committee. Furthermore individual Division formal complaint response performance will be monitored on a monthly basis at the Division Performance Meetings.
The principal metrics for measuring the impact and effectiveness of these improvements on the patient experience will be the Friends and Family Test. We expect that the combined impact of the 2013/14 Patient Experience Strategy will increase participation in the Friends and Family Test as well as increase the proportion of patients who say they are ‘extremely likely’ to recommend either our wards or A&E department to a friend or family member if they needed similar care or treatment. This figure will be routinely reported to the Trust Board so they can be assured that the 2015/16 Patient Experience Strategy is actually translating into genuine improvements as felt by our patients across the Trust.
We will also review the findings of the 2015/16 national inpatient, outpatient and cancer surveys in order to assure the Trust of the efficacy of the Patient Experience Strategy. Where survey results can be triangulated to identify specific problems with the patient experience, further action will be taken in response to address any disappointing patient survey results.
Page 58 of 113
4.3. Corporate Objectives 15/16
The Quality Priorities have been summarised down into quality related corporate objectives for 15/16 as follows:
Key Actions Target Exec
Lead
Milestones
Reduce mortality
Roll out Electronic
Discharge
Summaries
Improve coding to
capture all co-
morbidities
The number of
patients with
triggering scores are
recognised.
Patients recognised
are escalated
appropriately.
Increase the number
of mortality reviews
completed within 3
months of death.
By end
August
2015
95% (no
2014/15
baseline)
95% (no
2014/15
baseline)
95%
(2014/15 baseline
– 78%)
Medical
Director
HSMR is at or
below 98.8 by
March 2016
Reduce Harm
Reduce falls
Reduce avoidable grade
3&4 pressure ulcers
Reduce medication errors
Reduce falls by
25%
Reduce grade 3&4
pressure ulcers by
25%
Reduce medication
errors by 5%, and
increase
medication error
reporting by 10%.
(from
Chief
Nurse
By March 2016,
Reduce falls from 1748
to 1311
Reduce grade 3&4
pressure ulcers from 35
to 26
Reduce medication
errors from 393 to 373
Increase reporting of
medication errors from
Page 59 of 113
Key Actions Target Exec
Lead
Milestones
Annual establishment
reviews following acuity and
dependency surveys.
Work with HR on
strategies to improve
retention and recruitment.
Improve compliance with
staffing portal to reflect
real time information and
dynamic actions.
Safeguard vulnerable adults
across Buckinghamshire
Healthcare NHS Trust
Improved partnership
working with BCC to
improve the quality of adult
safeguarding reviews and
lessons learnt.
Safeguarding vulnerable
children across
Buckinghamshire
Healthcare NHS Trust.
Improved partnership
working with BCC to
improve the quality of
serious case reviews and
lessons learnt.
2014/15
baseline)
90 % fill rate
monthly on
registered nurses
and HCAs.
95% compliance
with Safeguarding
vulnerable adults
training
10% reduction in
safeguarding SIs
(baseline to be
established)
Improved
compliance with
Children’s
Safeguarding
Training
1143 to 1257
Monthly staffing fill rates
reflect 90% or above on
Unify return
By March 2016: 95 % of all staff identified as needing adults safeguarding training will be trained. 95% of all staff receive MCA (Mental Capacity Act) and DOLS (Deprivation of Liberty Standards) training.
By March 2016:
95% of staff identified as requiring training will receive the correct level of Children’s safeguarding training
Great patient experience
Implement the patient
experience strategy
Outpatients &
community by
Chief
Nurse
Net promoter
score of 95 or
Page 60 of 113
Key Actions Target Exec
Lead
Milestones
Expand the F&FT to include
Outpatients and the
community.
Develop and implement a
person centred care plan for
patients (owned by the
patient/carer) identified as
being in the last month of
life to help communicate
people’s wants and wishes,
wherever they are being
cared for.
Demonstrate more evidence
based symptom control for
patients at the end of life
through the training of
relevant staff and ensure
improved access to
appropriate medicines.
Increase the number of
people discharged to their
preferred place of care
September 2015
Full
implementation of
care plans across
the organisation.
All relevant staff
trained in symptom
control.
Pilot an electronic
notification of
death system.
above by March
2016
Pilot April 2015
Roll out from May 2015
onwards
Pilot April 2015
Roll out from May 2015
onwards
50% of care plans in
use by November 2015
95 % wards will have
embedded the use of
the EoL care plans with
regular audits to
achieve > 95%
compliance by March
2016
Map training and define
curriculum
Audit wards for all EoL
meds by June 2015
Design content July
2015
50% of staff trained by
March 2016
100% all in –patient
areas to have or be
able to identify access
to appropriate EoLC
symptom management
drugs by September
2015.
March 2016- 85%
patients at EoL to have
documented
conversations around
Page 61 of 113
Key Actions Target Exec
Lead
Milestones
Develop use of electronic
notification of death to
general practices
specifically in relation to
inpatient deaths.
their preferred place of
care
Map death notification
requirements against
current e-discharge
plans and pilot by
September 2015.
Establish base line
measure through audit
by September 2015.
Pilot an electronic
discharge system by
March 2016
Page 62 of 113
5. Service Provision
The Trust organisational structure is key to the ongoing integration of our hospital and
community services. Each division has a Clinical Divisional Chair supported by an
Assistant Chief Operating Officer and an Associate Chief Nurse. This tripartite manner of
working is reflected in each of the Service Delivery Units grouped within each division. All
services are managed on a Trust Wide basis rather than by hospital site.
Division of Integrated medicine
Division of Surgery
Specialist services Division
Adult integrated health care teams
Community specialist palliative care
Health promotion Acute and
general medicine Emergency medicine
Medicine for older people/rehab/neurology
Neuro-rehabilitation
services Cardiology Respiratory
medicine Gastroenterology
Diabetes and endocrinology
Rheumatology Podiatry
Community specialist nursing
Dermatology
Anaesthetics/critical care
General surgery Trauma and
orthopaedics Plastics and burns Ophthalmology Urology Ears, Nose and
Throat (ENT) Oral surgery and
orthodontics Outpatients
Paediatrics/children and young people
Obstetrics and gynaecology
Sexual health services
National spinal injuries centre (NSIC)
Pathology Imaging Cancer services Haematology Infection control Pharmacy Therapies
Page 63 of 113
The Trust has reviewed all the data available to us in 2014/15 on the quality of care in each
of the division’s delivering these NHS services.
The income generated by the NHS services in 2014/15 represents 91% of the total income
generated from the provision of NHS services by the Buckinghamshire Healthcare NHS
Trust.
6. Clinical Audit
Clinical audit is an evaluation of the quality of care provided against agreed standards and
is a key component of quality improvement. Its aim is to provide assurance and to identify
improvement opportunities. The Trust has an annual programme of clinical audits which
includes both national and local clinical audits and national confidential enquiries.
During 2014/15, 33 National Clinical Audits (NCA) and three National Confidential
Enquiries (NCE) applied to NHS services that BHT provides. During this period we
participated in 32 (97%) of NCAs and three (100%) of NCEs. The reasons for not
participating are identified against each specific audit and decisions not to participate are
under review at the time of writing this account. The Trust reviewed 179 local audits in
2014/15. Further information about the delivery of the audit programme may be found in
Appendix 1
National Survey Projects Participation
We participated in the following national surveys:
National Care Quality Commission A&E survey 2014
Neonatal National parents Experience Survey 2014
National inpatient survey
National Paediatric Inpatient Survey 2014
National Maternity Survey 2015
Review of national and local clinical audits reports
The reports of 11 national clinical audits were reviewed by us in 2014/15. Examples of action the Trust intends to take to improve the quality of healthcare provided can be found in Appendix 5.
Page 64 of 113
7. Research
In September 2014, the National Institute of Health Research (NIHR) published Trust’s
performance data in delivering research for 2013/14, we were extremely pleased to be ranked
30th in the top 100 performing trusts.
We are part of the Thames Valley & South
Midlands Local Research Network and they
continue to provide us with the funding required to
facilitate research within the trust. In 2014/15 our
allocation was £930k. This funds the Research &
Innovation Office, research nurses, clinical trials
officers, study administrators, clinical trials
pharmacist and technician as well as radiology
and pathology support costs to deliver research
The Cardiology research team have received recognition both nationally and locally through
awards for their research into improving cardiac rehabilitation to prevent readmission of
patients following cardiac events. The study has been very successful and the team continue
to attract a good number of new studies which are commercial and non-commercial as their
profile is increasing among cardiac research groups.
We have several new areas setting a portfolio of research during this year which includes
Ophthalmology, Ear Nose & Throat and Anaesthetics. We are excited to recruit a paediatric
research nurse who is due to start in May. He will be working closely with the Oxford team to
enable us to build a portfolio of research around child health.
Other clinical areas such as Stroke, Diabetes, Rheumatology, Gastroenterology & Hepatology,
Obstetrics & Gynaecology and Neurology continue with their research portfolio with continued
successful in securing new studies, which is credit to the reputation our research teams are
building within the research community.
This year the Research & Innovation team worked on promoting research. We had our first
research day within the trust for staff which had good representation, we were very fortunate to
have two patients attend to speak about their experience in being involved in research. We
also launched our research video which promotes the trust as being research active and the
importance of research for the health of us all. The research video is on the trust’s website on
the research page and is also on YouTube, we have had great feedback on the video so far.
Another promotional tool was an animation for the screens in the waiting areas, this describes
the different ways patients can be involved in research and encourages them to ask their
healthcare team about research.
We recruited 6,773 patients to trials
(approved by a research ethics
committee within the National
Research Ethics Service).
97% of out studied were approved
within 15 days
92% of our studies recruited their
first patient within 70 days
61% of our studies fully recruited to
Page 65 of 113
The team has also been working on better engagement with the community and service users.
One of the outcomes is a promotional event in a local shopping centre on 20 May 2015 which
is International Clinical Trials Day. We hope to highlight that we are a research active trust and
encourage people to ‘ask about research’ which is the slogan for the day.
We have also started work on creating Trust Patient Research Ambassadors, this is in the
early stages but we hope to have them in place by September 2015. We hope to recruit
volunteers interested in research or who may have been involved with a study, to promote
involvement in research, help us to better communicate research and also advise us on study
literature, areas important to service users for specific diseases and representation on
research groups.
Another tool created which will be launched in 2015/16 is a Consent for Contact database.
People can register to be contacted should a suitable study be available to them, and one trust
which set up a similar tool had a positive response rate of 74% which we hope we can
achieve.
The year has been very successful and we are looking ahead to build collaborative
relationships with higher education institutes, increase our commercial profile and increase
patient representation and involvement in the facilitation of research.
8. Goals agreed with commissioners
In order to incentivise quality improvement 2.5% of all NHS trusts’ contract value is
conditional on achieving quality improvement and innovation goals agreed with the local
Clinical Commissioning Groups through the Commissioning for Quality and Innovation
(CQUIN) payment framework. Of the 2.5% payment, 0.5% was set against achievement of
the national CQUINs and 2% against local priorities. If the milestones are not achieved
within the agreed timescales then a proportion of the CQUIN monies are withheld.
The Trust achieved 88% of its goals and received a CQUIN income of £4,471,288.
Full details of achievement can be found in Appendix 2.
Information about the CQUIN goals for 15/16 can be obtained from the Finance Department
at Amersham Hospital.
Page 66 of 113
9. What the Care Quality Commission say about
Buckinghamshire Healthcare Trust
Buckinghamshire Healthcare NHS Trust is required to register with the Care Quality
Commission and its current registration status is registration without conditions effective
from April 2010.
The acute services provided by the Trust were inspected, as part of the new Care Quality
commission inspection regime in March 2014, the report being published in July 2014. A
community focussed inspection was carried out in March 2015. At the time of writing this
report, the findings have not been published.
The following tables show the Care Quality Commission assessment of the Trust’s acute
services at 31 March 2015. The care quality commission rate each service inspected
against five criteria – safe, effective, caring, responsive and well led. The scores are then
collated to give an overall rating for the service and for the Trust.
Page 67 of 113
Stoke Mandeville Hospital Site Overall Rating
Inadequate
Requires Improvement
Good
Outstanding
Safe Effective Caring Responsiv
e Well led Overall
National spinal injuries centre
Good
Outstanding
Outstanding
Good
Good
Good
Urgent and emergency services (A&E)
Requires Improvement
Outstanding Requires improvement
Inadequate
Requires Improvement
Requires Improvement
Medical care including older people
Requires Improvement
Good
Good
Requires Improvement
Requires Improvement
Requires Improvement
Surgery
Requires Improvement
Requires Improvement
Requires Improvement
Requires improvement
Requires improvement
Requires Improvement
Intensive/ critical care
Good
Good
Outstanding Good
Good
Good
Maternity and gynaecology
Good
Good
Good
Good
Good
Good
Services for children and young people
Good
Good
Good
Good
Good
Good
End of life care
Requires Improvement
Inadequate
Requires Improvement
Requires Improvement
Requires Improvement
Requires Improvement
Outpatients
Good
Not rated Good
Requires Improvement
Requires Improvement
Requires Improvement
Amersham Hospital Site Overall Rating
Inadequate
Requires Improvement
Good
Outstanding
Safe Effective Caring Responsive Well led Overall Medical care including older people
Requires Improvement
Requires improvement
Good Requires improvement
Good
Requires improvement
Outpatients
Good Not rated Good
Requires Improvement
Requires Improvement
Requires Improvement
Page 68 of 113
Wycombe Hospital site Overall Rating
Inadequate
Requires Improvement
Good
Outstanding
Safe Effective Caring Responsiv
e Well led Overall
Medical care including older people
Requires Improvement
Good Good Requires improvement
Requires improvement
Requires improvement
Surgery
Requires Improvement
Good Good
Requires Improvement
Good Requires Improvement
Intensive/critical care
Good Good Good Good Good Good
Maternity/ gynaecology
Good Good Good Good Good Good
Services for children and young people
Good Good Good Good Good Good
End of life care Requires improvement
Inadequate
Requires improvement
Requires improvement
Requires improvement
Requires improvement
Outpatients
Good Not rated Good Requires Improvement
Requires Improvement
Requires Improvement
During 2014/15 the Trust delivered an ambitious action plan to address the concerns
raised.
Following the lifting of special measures in July 2014 the trust was issued with a
compliance action against five of the CQC standards. At the time of writing the Trust
has been re-inspected and we await the outcome of that inspection.
While in special measures the CQC has a policy that regulatory warning notices or
compliance notices are not issued. Now that the Trust has exited special measures the
CQC has issued the Trust with compliance actions relating to all the ‘must do’ actions in the
report arising from the Chief Inspector of Hospitals’ inspection of the Trust in March 2014.
These compliance actions are not based on new information but solely on the information
arising from that inspection. Compliance actions are not enforcement action but inform the
registered body that they are not compliant with the relevant legislation. They are in effect
the first stage of regulatory response to issues of compliance.
The compliance actions relate to the following essential standards of quality and safety:
Outcome 4, Regulation 9, Care and Welfare of Service Users
Page 69 of 113
Timely assessment of patients in A&E by appropriate specialists
Care plans for all patients
End of life care
Outcome 16, Regulation 10, Assessing and monitoring the quality of service provision
Monitoring length of time patients are waiting in A&E
Outcome 11, Regulation 16 Safety, availability and suitability of equipment
Equipment in A&E
Outcome 9, Regulation 13, Management of Medicines
Treatment room on Ward 16B
Storage of medicines in fridges
Availability of medicines for end of life care
Outcome 21, Regulation 20, Records
Do not attempt cardio-pulmonary resuscitation forms The CQC received our response to these actions in the inspection action plan submitted and they do not require any additional action. There have been no inspections under Section 48 of the Health and Social Care Act 2008 in the reporting period.
Page 70 of 113
10. Data Quality
The Trust submitted records during 2014/15 to the Secondary Uses service for inclusion in
the Hospital Episode Statistics which are included in the latest published data.
The percentage of records in the published data which included the patient’s valid NHS
number for April 2014 to February 2015 was:
• 99.4% for admitted patient care;
• 99.9% for outpatient care; and
• 99.2% for accident and emergency care
The percentage of records in the published data which included the patient’s valid General
Medical Practice Code was:
• 100% for admitted patient care
• 100% for outpatient care
• 100% for accident and emergency care
The trust’s Information Governance self-assessment score for 2014/15 using the
Information Governance Toolkit version 12 was 80% (Satisfactory / Green). This includes
assessments on information quality and records management.
The Trust has an established data quality group that address data quality issues
throughout the year. This includes improving the accuracy of data recording through
training and education; improving the quality of our clinical coding with a regular audit
and training programme; and improving compliance with the use of the NHS number.
The Clinical Coding department have a rolling training program and all staff are up to
date with mandatory Clinical coding refresher training, all new staff have undergone
mandatory Standards training. The department also has a rolling audit plan for the year
this year it includes doing staff audits, obstetrics, general medicine, trauma &
orthopaedics and general surgery.
Page 71 of 113
The Trust Information Governance audit 2014/15 showed:
• Primary diagnosis was 93% accurate.
• Secondary diagnoses were 92.84 % accurate.
• Primary Procedure was 97.44% accurate.
• Secondary Procedure was 97.39% accurate.
The Trusts External Payment and Tariff audit 2014/15 showed:
• Primary Diagnosis 96.5% accurate • Secondary Diagnosis 95.5% accurate • Primary Procedure 98.9% accurate • Secondary Procedure 83.9% accurate
Page 72 of 113
Part 3 Review of quality performance
11. Patient Safety
11.1. Incident Reporting
In 2014/15 we continued to report patient safety related incidents to the National Reporting
and Learning System (NRLS). The numbers so far reported for 14/15 are shown on the
graph below. Incidents are only submitted to the NRLS when they have been investigated
and signed off by a senior manager. This means that there may be more incidents reported
in due course to the NRLS for the 14/15 year.
We are currently working with an out-of-date version of Datix. This can cause some small
discrepancies between the numbers we report and those reported by the NRLS. We aim to
upgrade our Datix software in 15/16 and along with other benefits this will resolve this issue.
Our goal is to sustain a high level of incident reporting but with a reduction in level of harm from patient safety incidents. High reporting organisations tend to be learning organisations. The trend in levels of actual harm are shown in the graph below and indicate a gradual reduction in levels of actual harm.
10/11 11/12 12/13 13/14 14/15
6295 7227 7750 8180 7707
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
Incidents reported to the National Reporting and Learning System April 2010 to March 2015
Page 73 of 113
The National Reporting and Learning System reported on the period 1 April 2014 to 30 September 2014. This information indicates that 0.7% of patient safety incidents reported resulted in severe harm or death. This is set in the context of a national average of 0.5%, with 10 Trusts reporting 0% and the worst performer reporting 3.1%.
The top 10 types of incident are shown on the table below. Of the ‘Accident that may result in personal injury’ category over 90% of the incidents are categorised as slips, trips or falls.
Accident that may result in personal injury 1817
Implementation of care or ongoing monitoring/review 1610
Medication 932
Access, Appointment, Admission, Transfer, Discharge 778
Treatment, procedure 602
Infrastructure or resources (staffing, facilities, environment) 525
Clinical assessment (investigations, images and lab tests) 328
Labour or Delivery 316
Medical device/equipment 253
Patient Information (records, documents, test results, scans) 240
10/11 11/12 12/13 13/14 14/15
DEATH 43 23 14 10 2
SEVERE 87 80 39 43 23
MOD 1166 1025 969 577 232
LOW 1929 2383 2988 3354 2569
NONE 3069 3714 3740 4196 4885
0
1000
2000
3000
4000
5000
6000
Actual Harm from Incidents reported to the National Reporting and Learning System April
2010 to March 2015
DEATH
SEVERE
MOD
LOW
NONE
Page 74 of 113
We have a comprehensive system in place for identifying, reporting, investigating and learning from serious incidents. We are committed to being open with patients and relatives when things go wrong and endeavour to provide information about why things have happened and what we have done to reduce the risk that something similar could go wrong again. In 15/16 we are working to improve on timeliness in following the process; and to continuously improve the quality of our investigation reports and action plans. The numbers and types of serious incidents are shown on the graph below according to the number reported each month. There have been no VTE serious incidents in the time period.
Never Events reported 2014/15
By definition a ‘Never Event’ should never happen and we take it extremely seriously. In
2014/15 we reported 2 ‘Never Events’ both of which related to a wrong tooth extraction. We
have conducted rigorous investigations into how this happened and action plans are in place
and being delivered to minimise the risk of this ever happening again.
0 2 4 6 8 10 12
SIs
Pressure ulcer
VTE
Falls Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Page 75 of 113
11.2. Infection Prevention and Control
We continue to minimise the risk of our patients acquiring Healthcare-associated Infections.
We reported 3 MRSA bacteraemias this year, one of which was considered to be a
contaminant in that the patient’s condition was not adversely affected by the MRSA.
Regarding Clostridium difficile infections, although we reported 37 cases, against a limit of
33, only one of these was due to a lapse in the care of the patient while in the care of the
Trust.
Clostridium difficile and MRSA Bacteraemia Trajectories 2014/15
0
10
20
30
40
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
BHT Clostridium difficile Trajectory 2014/2015
Cumulative Trajectory Limit
Cumulative BHT cases reported on PHE database
Cumulative cases where lapse in care identified
0
1
2
3
4
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Preventable MRSA Bacteraemia Trajectory 2014/2015
BHT cases reported to PHE
Cumulative Trajectory Limit
Cumulative BHT cases reported on PHE database
Page 76 of 113
Page 77 of 113
12. Patient Experience
Overall the Care Quality Commission surveys rated the experience people had in our care
as similar to that of other Trusts. There has not been an outpatient survey since publication
of the last Quality Account. The following describes some of the areas where we need to
improve if we wish to achieve our ambition of excellence.
12.1. Care Quality Commission National Annual Inpatient Survey
2013
The survey was sent to a sample of patients who had been admitted as inpatients to the
Trust in the summer of 2013. The results were published in April 2014.
Most of the scores were about the same as other Trusts but in some areas we achieved
poorer scores than other Trusts.
We did not do as well at discussing any further services which were needed when leaving
hospital. We have worked closely with our social care colleagues to improve access to a
social worker and to improve our internal discharge planning.
Two out of ten people felt that the copies of letters they received between the hospital
doctors and their GP were not written so they could understand them.
About half our patients reported that the hospital was noisy at night. Although this was
similar to other organisations we carried out a campaign to reduce this by making staff more
aware of the effect noise has on patients who are trying to sleep.
Too many of our patients felt they needed more emotional support and a faster response
when they needed help. We have ensured that all wards staffing levels are checked three
times a day and that intentional rounding is in place, where a nurse speaks to each patient
hourly to check their needs, both physical and emotional, are being met.
12.2. Care Quality Commission National Maternity Survey 2014
The survey was sent to all women who gave birth in February 2013.
Areas where we need to improve are responding to call bells- two out of ten women felt
there was not a quick enough response; and giving clear information and explanations after
the birth where three out of ten women felt this had not been achieved.
12.3. Care Quality Commission National A&E Survey 2014
The survey was sent to a sample of patients who attended A&E during January, February
and March 2014.
Page 78 of 113
Overall the survey said that patients found the quality of our services to be similar to other
A&Es with 7.3 patients out of ten feeling their experience had been good. However it is our
ambition to be among the best.
The detail shows that that patients feel that there is not enough privacy at reception. We
recognise this and are developing a short term mitigation. The long term solution will be
delivered through the redesign of the department.
Two out of ten patients felt they were not listened to and five out of ten said they were not
reassured when distressed. Four out of ten patients said that they had to wait too long for
pain relief.
We have invested in more nursing staff for A&E to give staff time to care for their patients
and by March 2015 all our nursing posts were recruited to. In addition we introduced
intentional rounding where a senior nurse speaks to every patient every hour to make sure
their needs are being met.
Page 79 of 113
12.4. Complaints
Complaints and compliments
685 formal complaints were received in 2014/15, an 11% increase; and our PALs service
helped 3,566 people. 73% of our complaints were responded to within 25 working days.
Our goal as an organisation is to respond to 85% of formal complaints within 25 working
days. We recognise that we have more work to do to achieve this. The complexity of some
complaints means that we need to take longer to make sure we provide the best response
and we aim to provide this within 40 days. It is important that at the start of the process
each complainant receives contact either through a phone call or a letter to let them know
what they might expect in terms of response. Some complainants prefer to talk through the
issues at a meeting and we try to accommodate this as far as possible. Others prefer to
receive a response in writing. We also recognise the need to make contact with a
complainant if the process of investigation and response is taking longer than the time
anticipated at the beginning.
The main subjects of the complaints were:
Page 80 of 113
We also receive thousands of compliments every year which are sent through to the
corporate office and to wards and departments. In the past year we have received
approximately 9,000 compliments.
12.5. Principles for remedy
The Ombudsman’s “Principles for Remedy” states that an attempt to resolve a complaint
should be based on:
Getting it right
Being customer focused
Being open and accountable
Acting fairly and proportionately
Putting things right
Seeking continuous improvement
We have reviewed our complaints process and are working hard to make sure we uphold
these standards.
Of 13 complaints referred to the Parliamentary and Health Service Ombudsman one has
been up held in full and five are still being investigated.
12.6. Friends and Family Test
We are pleased that our Friends and Family scores show that 95% of our in-patients in both
our main wards and maternity would be likely or extremely likely to recommend our services.
In out-patients 85% of people would recommend our service.
We have seen a significant improvement in the number of people who would recommend
our A&E and are particularly pleased that this continued through the winter when the
department was attended by unprecedented numbers of people.
During 2015/16 we need to focus on rolling out the Friends and Family test across our
services and on ensuring that a high proportion of our patients respond to give us an
accurate reflection of the experience in our services.
Page 81 of 113
13. Performance against National Targets 2014/15
Below are a list of national quality targets and the Trusts performance against these. March (and therefore YTD) cancer figures are provisional.
KPI Target RAG 14/15 13/14 12/13 11/12
Time in A&E: Percentage of patients seen
within four hours
95% 92.9% 94.9% 93.6% 95.8%
Delayed transfer of care <3.5% 2.4% 2.1% 2.3% 2.9%
Mixed Sex Accommodation breaches 0 0 0 0
VTE Risk assessment 90% 95.7% 95.5% 94.2%
Maintain two week cancer waits >93% 93.8% 98.5% 99.4% 99.3%
Max 2 week wait for non symptomatic
breast referrals
>93%
95.6%
97.0%
98.2%
99.1 %
31 days diagnosis to treatment for all
cancer
>96%
99.8%
99.5%
99.6%
98.4%
31 day second or subsequent treatment -
surgery
>94%
100%
99.8%
99.6%
96.9%
31 day second or subsequent treatment -
drug
>98%
100%
100%
100%
99.8%
62 day referral to treatment from screening >90% 97.3%
97.2% 96.8% 93.2%
62 days urgent referral to treatment for
cancer
>85%
88.3%
90.7%
91.0%
89.0%
%age within 18 weeks admitted pathway 90% 88.2% 86.9% 93.5% 92.3%
%age within 18 weeks non-admitted
pathway
95%
95.4%
95.8%
98.4%
97.1%
%age within 18 weeks incomplete
pathways
92%
92.7% 88.0%
92.9%
Diagnostic test waits < 6 weeks <1% 0.2% 0.8% 0.7%
MRSA Bacteraemia 0 3 2 0 2
Clostridium Difficile positive results 33 37 35 31 64
The Trust has a robust performance monitoring framework in place, routinely measuring our business against a range of key performance indicators (KPIs). The framework allows the
Page 82 of 113
Board to monitor performance in key areas and supports our efforts to drive up quality, enhance patient experience, improve waiting times and deliver better, safer services. Accident and Emergency – four hour standard
Our performance against this standard was affected by a number of issues affecting patient flow, both internal and external. For example, our length of stay was affected by long delays for patients waiting to be found a place in Adult Social Care assessment and onward care to be sourced. At some points of the year we had a high patient acuity. A number of transformational changes have been taking place under the leadership of the Reforming Urgent Care Programme Board. These changes include expanding the Ambulatory Emergency Care unit and Multi-disciplinary Assessment Service to 7 days a week; opening up additional capacity at Stoke Mandeville hospital; providing senior management support to eradicate delays in obtaining longer term social care for patients; increasing medical staffing; launching ward based working, basing speciality teams on wards; and implementing a daily review panel particularly focused on discharge delays and facilitating rapid access to diagnostics or onward care. Percentage within 18 weeks admitted pathway
The Trust was compliant with this aggregated standard from October 2014 after a significant period of backlog reduction. In late January 2015 the Trust was requested to reduce its total waiting list size (patients over 18 weeks) from 1,800 down to 1,611 (across all pathways, admitted and non admitted) by the end of February 2015. Since we were dealing with backlog cases, current cases received less attention. This was agreed in advance with commissioners and the Trust Development Authority and was therefore a ‘planned’ breach of the standard, with no contractual penalties or performance fines applicable. The Trust achieved the required backlog reduction target, reducing its overall waiting list size (patients > 18 weeks) down to 1,447.
Page 83 of 113
14. Health and Social Care Information Centre Indicators 2014/15
The NHS Outcomes Framework 2014/15 sets out high level national indicators which the NHS is focussing on to improve. The Framework provides indicators which have been chosen to measure these outcomes. An overview of the indicators in provided in the table. It is important to note that whilst these indicators must be included in the Quality Account the most recent national data available for the reporting period is not always for the most recent financial year. Where this is the case the time period used is noted underneath the indicator description.
Domai
n
Indicator 2014/
15
Nati
onal
Aver
age
Best
Perfo
rmer
Worst
Perfor
mer
Trust Statement 13/14 12/13 11/12
Preven
ting
people
from
dying
premat
urely
Enhan
cing
quality
of life
for
people
with
long
term
conditi
ons
SHIMI
value
and
banding
106
Oct
13 –
Sept
14
Band
2 (as
expe
cted)
1.00
0.597
Band
3
(better
than
expec
ted)
Whitti
ngton
NHS
Trust
1.198
Band 1
(worse
than
expect
ed)
Medwa
y NHS
Found
ation
Trust
Buckinghamshire Healthcare NHS
Trust considers that this data is as
described because mortality reduction
has been a consistent focus for the
Trust over the last three years.
Buckinghamshire Healthcare has taken
actions including introduction of the
care bundle approach for sepsis, AKI
and community acquired pneumonia,
the redesign of the Urgent Care Hub
and the focus on care of the
deteriorating patient. Buckinghamshire
Healthcare will continue to improve the
timeliness of senior level review of
every death and through this learning
improve the quality of care and so
improve this rate.
107
Oct
12
Sep
13
115
Oct
11 –
Sep
12
% of
patients
admitted
whose
treatment
included
palliative
care
Apr 14 –
Feb 15
(taken
from Dr
Foster
mortality
Compara
tor)
3.74
Not
applic
able
Not
applica
ble
Buckinghamshire Healthcare NHS
Trust considers that this data is as
described because Buckinghamshire
Healthcare Trust is an integrated
hospital and community Trust which
includes an integrated palliative care
team covering all areas of practice.
Actions we have taken include our
palliative care team working with A&E
to identify all patients admitted at the
end of their life within 24 hours of
admission to ensure that they get the
best care possible. Buckinghamshire
Healthcare NHS Trust will improve the
quality of end of life care by rolling out
the care plan based on the five
priorities.
34.9
Oct
12 –
sep
13
30.7
Oct
11 –
Sep
12
Helpin
g
people
recove
r from
episod
es of ill
health
or
followi
ng
injury
PROM
groin
hernia
surgery
(Apr –
Dec
2014)
0.151 0.15
9
Not
applic
able
Not
applica
ble
Buckinghamshire Healthcare NHS
Trust considers that this data is as
described because any operation has
risks as well as benefits. We want to
ensure that our patients have the best
chance of having health gains after
their procedure.
Actions we have taken include we have
worked hard with our commissioners
and the public to put in place thresholds
which will ensure we are operating on
the right people and people treating
unnecessarily.
0.140 0.103 0.117
PROM
varicose
vein
surgery
(Apr –
Sep
2014)
Not
avail
able
Not
avail
able
Not
applic
able
Not
applica
ble
0.420 0.051
PROM 0.206 0.21 Not Not 0.312 0.398
Page 84 of 113
Domai
n
Indicator 2014/
15
Nati
onal
Aver
age
Best
Perfo
rmer
Worst
Perfor
mer
Trust Statement 13/14 12/13 11/12
Hip
replacem
ent
surgery
(Apr –
Sep
2014)
7 applic
able
applica
ble
The individual policies can be accessed
at
http://www.fundingrequests.cscsu.nhs.u
k/buckinghamshire/cosmetic-other-
surgeries-devices-screening-
diagnostics-and-other-therapies-policy-
statements PROM
knee
replacem
ent
surgery
(Apr –
Sep
2014)
0.218 0.22
6
Not
applic
able
Not
applica
ble
No
rating
samp
le too
small
0.226
28 day
readmiss
ion rate
for
patients
aged 0-
15
Data not available
Data beyond 11/12 is not yet available. 11.12
%
2011/
12
11.45
%
2010/
11
28 day
readmiss
ion rate
for
patients
aged 16
and over
Data not available
Data beyond 11/12 is not yet available. 9.37
2011/
12
11.56
%
2010/
11
Ensuri
ng that
people
have a
positiv
e
experi
ence
of care
Responsi
veness
to
inpatient
s
personal
needs
CQC
national
inpatient
survey
This
indic
ator
is no
longe
r
provi
ded
by
HSCI
C
Not
applic
able
Not
applica
ble
Data is not available. 64.8 64.5
Percenta
ge of
staff who
would
recomme
nd the
provider
to friends
and
family
needing
care
53%
65%
89%
Frimle
y Park
Hospit
al
NHS
FT
38%
Royal
Cornw
all
NHS
Trust
Buckinghamshire Healthcare NHS
Trust considers that this data is as
described and recognises that we need
to work hard to improve this score.
The actions Buckinghamshire
Healthcare Trust have taken include
our work on clinical leadership,
described in the main report.
We have also invested significantly in
the working environment for our staff
and in resolving the car parking issues
which have been a major concern.
Buckinghamshire Healthcare is focused
on staff engagement to improve this
score.
47%
2013
52%
2012
Inpatient
s Friends
and
Family
99%
Mar1
5 95%
9
Trusts
report
100%
78%
Northa
mpton
Genera
Buckinghamshire Healthcare NHS
Trust considers that this data is as
described.
We are delighted that such high
80
Apr –
Oct
13
Not
applic
able
Not
applic
able
Page 85 of 113
Domai
n
Indicator 2014/
15
Nati
onal
Aver
age
Best
Perfo
rmer
Worst
Perfor
mer
Trust Statement 13/14 12/13 11/12
Test l NHS
Found
ation
Trust
numbers of our patients would
recommend our services.
Buckinghamshire Healthcare Trust
have taken include the redesign of the
Urgent Care Hub, our work on hospital
noise at night and developing our
clinical leaders
Our aim is to provide safe,
compassionate care every time so
during 2015/16 we will be working to
improve the consistency of our care.
Accident
and
Emergen
cy
Friends
and
Family
Test
94%
Mar1
5
87%
99%
Wirral
Univer
sity
Teach
ing
Hospit
al
NHS
FT
58%
Milton
Keynes
NHS
FT
38 Not
applic
able
Not
applic
able
Maternity
Friends
and
Family
Test
(Antenat
al)
94%
Mar
15
95%
34
Trusts
report
100%
68%
Imperia
l
Colleg
e
Health
care
NHS
Trust
Not
applic
able
Not
applic
able
Treatin
g and
caring
for
people
in a
safe
enviro
nment
and
protect
ing
them
from
avoida
ble
harm
% of
admitted
patients
risk
assessed
for
Venous
thrombo
embolis
m
95%
Oct –
Dec
14
96%
8
Trusts
achiev
ing
100%
89%
North
Cumbri
a
Univer
sity
NHS
Trust
Buckinghamshire Healthcare NHS
Trust considers that this data is as
described.
Buckinghamshire Healthcare Trust
continues to take the following actions
including embedding systems to record
VTE risk assessment, monthly Matrons
rounds to ensure compliance.
96.8
%
Rate of C
difficile
per
100,000
bed days
15.14
(see
note
*)
*The C difficile numerator has a value of 15.14. The denominator is based on NHS England estimate in the absence of KH03 official figures.
14.4
Apr1
3-
mar
14
12.4
Apr
12-
Mar
13
Rate of
patient
safety
incidents
per 1000
bed days
32
Apr
13 –
Sept
14
(total
no of
incid
ents
=
3967
)
Not
avail
able
74.96
North
ern
Devon
Health
care
NHS
Trust
0.86
Dorset
County
Hospit
al NHS
Trust
Buckinghamshire Healthcare NHS
Trust considers that this data is as
described.
Buckinghamshire Healthcare Trust
continues to increase our reporting of
low harm incidents and near misses to
ensure we are constantly learning and
improving our care while reducing the
numbers of incidents that result in
severe harm or death.
32.4
Oct –
Mar
13
Not
availa
ble
Not
availa
ble
% of
patient
safety
incidents
reported
that
resulted
in severe
0.7
Apr1
3-
Sep1
4
(total
no of
sever
0.5
10
Trusts
report
0
3.1
Isle of
Wight
NHS
Trust
0.3
Apr1
3 –
Sep
13
0.6
Oct
12 –
Mar
13
Page 86 of 113
Domai
n
Indicator 2014/
15
Nati
onal
Aver
age
Best
Perfo
rmer
Worst
Perfor
mer
Trust Statement 13/14 12/13 11/12
harm or
death
e
harm
= 28
Total
no of
death
= 0)
The list of indicators to be included was mandated in 2009. Where the data is no longer collected nationally we have stated data not available.
Page 87 of 113
Statement from Clinical Commissioning Groups
NHS Aylesbury Vale CCG and NHS Chiltern CCG response to Buckinghamshire
Healthcare NHS Trust Quality Account 2014/2015
The Trust has made tremendous gains on improving the quality of care for patients in the last year. This is evident not only in the report outlined but the growing numbers of positive patient and carer feedback on care and improvement in targeted quality indicators. We will outline some specific areas of note within the Trust stated objectives. Quality objective 1 - Reduce mortality It is notable that the Trust has continued to make good progress on their significant quality improvement plans and as we know this kind of sustainable transformation does takes time. The progress made on the care of the deteriorating patient through the breakthrough collaborative in recognising and managing the acutely unwell has shown some significant impact In addition to the implementation of a process to review every death within three months of death and the two- stage process that follow. This includes the sharing of lessons learned across the organisation. It’s great to see that the Trust has extended the success of the collaborative model to other clinical areas of the Trust. It would be helpful to have comparative data to support the progress made regarding mortality ratios. Quality Objective 2 - Reduce harm Significant progress has been made by the Trust to engage and strengthen multi-disciplinary teams to address the issue of Falls. The evidence clearly tells us that one of the biggest impacts on patient safety is the effectiveness of multidisciplinary team working. A reduction in the number of Falls by 20% within one year is a significant achievement and we look forward to seeing a continued focus on strengthening multidisciplinary team effectiveness. The introduction of care bundles to ensure best practice was delivered to each patient on time and is improving dementia care by enabling the clinical leadership team around dementia to work closely with the A & E and wards. This has led to 90% of patients who are over 75 years old to be screened for dementia and 100% of these were referred on to memory clinic, a commendable feat and very appreciated. The seven-day a week pharmacy service is a welcome introduction and having pharmacists working in the Urgent Care hub to support the nursing and medical staff and ensure patients get prescribed medication in timely way. Staffing is always a challenge and we recognise the efforts of the Trust toward safer surgery including working closely with other specialist teams such as tissue viability, plastics, gynaecology and ophthalmology. We welcome the achievement of having 100% of notes containing a WHO checklist. This has contributed greatly to the reduction in clinical indications such as ulcer. There has also been progress in safe nurse staffing and we join the Trust in celebrating being one of the high performing organisations delivering the Family Nurse Partnership programme. We are satisfied that the Trust has demonstrated gradual reduction in the total number of incidents in 2014/2015 compared with 2013/2014. There has been a significant decrease in the number of actual and severe harm from 53 to 25 in years 2013/2014 to 2014/2015 respectively. We welcome this information as it indicates that a low proportion of patient
Page 88 of 113
safety incidents reported resulted in severe harm or death. When looked at from the perspective of national average, the Trust ranks very well amongst the Top-performing Trusts nationally.
Quality Objective 3 - Patient Experience
The Trust has actively been practicing “you said, we did" initiative to demonstrate impact on the areas of care which patients have told them they would like improving. We note the improvements made in Out-patients; End of life care; Buckingham Integrated Respiratory Service; Urgent Care; and School Nurses. We recognise measures taken by the Trust in bringing about the progress it has achieved regarding Patient Experience and similar activities it has undertaken within this realm. Conclusion We appreciate that the Trust acknowledges areas of continued focus for improvement highlighted in the report. We are grateful to the Trust for their collaborative approach to working with us. The Trust is very open and transparent, which we know is essential to delivering safe and compassionate care. We are very pleased to already see a strong alignment between our commissioning quality promises to our population and the priority areas of focus for the Trust. Our Commissioning for Quality Promises being:
1. Involve patients, public and carers in our monitoring and assurance processes and developments in quality improvement
2. Improve the quality monitoring and assurance of our Primary Care and Out of Hospital Services
3. Delivering quality improvements for:
Children and young people
People with mental health issues
People living in care homes 4. Work with our providers to drive the right culture for patient care through
Ensuring regular systematized feedback processes are in place
Embedding the 6C’s
Monitoring the implementation of Equality and Diversity Framework
Collaboration on workforce development 5. Work with providers on making improvements to patient safety.
We look forward to seeing an even greater connection between the Trusts organisational and workforce development and quality improvements. The incontestable evidence that an organisation with a combined approach of ‘One Team’ which embraces individual difference and diversity at every level of the organisation is widely accepted as one which is successful, a nice and healthy place to work for staff and a safer more compassionate place for patients. Alison Foster, RMN, MA Director of Quality Aylesbury Vale Clinical Commissioning Group Address: First Floor, The Gatehouse, Gatehouse road, Aylesbury, Buckinghamshire, HP198FF
Page 89 of 113
Statement from Healthwatch
Page 90 of 113
Statement from Health and Adult Social Care Select
Committee
29th June 2015, no feedback provided for the Quality account.
Page 91 of 113
Statement by Directors
Statement of directors’ responsibilities in respect of the Quality Account The directors are required under the Health Act 2009 to prepare a Quality Account for
each financial year. The Department of Health has issued guidance on the form and
content of annual Quality Accounts (which incorporates the legal requirements in the
Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010
(as amended by the National Health Service (Quality Accounts) Amendment Regulations
2011).
In preparing the Quality Account, directors are required to take steps to satisfy themselves
that:
the Quality Account presents a balanced picture of the trust’s performance over
the period covered;
the performance information reported in the Quality Account is reliable and accurate;
there are proper internal controls over the collection and reporting of the measures
of performance included in the Quality Account, and these controls are subject to
review to confirm that they are working effectively in practice;
the data underpinning the measures of performance reported in the Quality
Account is robust and reliable, conforms to specified data quality standards and
prescribed definitions, and is subject to appropriate scrutiny and review; and the
Quality Account has been prepared in accordance with Department of Health
guidance.
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
NB: sign and date in any colour ink except black
29th June 2015 Chair
29th June 2015 Chief Executive
Page 92 of 113
Appendix 1 Audit
Table 1: National Clinical Audit Projects Participants: The national clinical audits and national confidential enquires listed on the national programme and quality accounts list for 2014/2015 and BHT eligibility and participation is detailed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.
Title Eligible Participated % Submitted Acute Care Adult Critical Care Case Mix Programme (ICNARC CMP)
Yes Yes 100%
Adult Community Acquired Pneumonia (BTS)
Yes Yes 100%
National Emergency Laparotomy Audit (NELA)
Yes Yes Ongoing
National Joint Registry (NJR) Yes Yes 2014 report shows 95% for 2013
Pleural Procedures Audit (BTS) Yes Yes 100%
Severe trauma (Trauma Audit & Research Network, TARN)
Yes Yes 100%
Blood and Transplant National Comparative Audit of Blood Transfusion programme
Yes Yes 100%
Cancer Bowel cancer (NBOCAP) Yes Yes Latest report
published 2013 shows 101% for 2011/12
Head and neck oncology (DAHNO) Yes Yes Data submitted by Oxford
Lung cancer (NLCA) Yes Yes 2013 report – 85.6%
National Prostate Cancer Audit Yes Yes 5 year audit to be completed in 2017
Page 93 of 113
Title Eligible Participated % Submitted Oesophago-gastric cancer (NAOGC) Yes Yes Data
submitted by BHT and Oxford Hospitals
Heart Acute coronary syndrome or Acute myocardial infarction (MINAP)
Yes Yes MINAP report 2013 states unable to publish participation rates
Cardiac Rhythm Management (CRM) Yes Yes Ongoing Congenital heart disease (Paediatric cardiac surgery) (CHD)
No Not applicable to Buckinghamshire Healthcare NHS Trust
N/A
Adult Cardiac Interventions Audit (Coronary angioplasty)
Yes Yes Ongoing
National Adult Cardiac Surgery Audit No Not applicable to Buckinghamshire Healthcare NHS Trust
N/A
National Cardiac Arrest Audit (NCAA) Yes Did not participate - National Heart Failure Audit Yes Yes Ongoing National Vascular Registry* Yes Yes 100% Pulmonary Hypertension (Pulmonary Hypertension Audit)
No Not applicable to Buckinghamshire Healthcare NHS Trust
-
Long term conditions Diabetes (Adult) ND(A), includes National Diabetes Inpatient Audit (NADIA)*
Yes Yes Trust level participation rates are not reported
Diabetes (Paediatric) (NPDA) Yes Yes 100% Inflammatory bowel disease (IBD)* Yes Yes Ongoing National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme*
Yes Yes 100%
Renal replacement therapy (Renal Registry)
No Not applicable to Buckinghamshire Healthcare NHS Trust
-
Rheumatoid and early inflammatory arthritis*
Yes Yes Ongoing until 2017
Page 94 of 113
Mental Health Mental health clinical outcome review programme: National Confidential Inquiry into Suicide and Homicide for people with Mental Illness (NCISH)
No Not applicable to Buckinghamshire Healthcare NHS Trust
-
CEM Mental Health (care in emergency departments)
Yes Yes 100%
Prescribing Observatory for Mental Health (POMH)
No Not applicable to Buckinghamshire Healthcare NHS Trust
-
Older People Falls and Fragility Fractures Audit Programme (FFFAP)
Yes Yes 100%
CEM Older People (care in emergency departments)
Yes Yes 100%
Sentinel Stroke National Audit Programme (SSNAP)*
Yes Yes Ongoing
Other Elective surgery (National PROMs Programme)
Yes Yes See section 3.2.7
National Audit of Intermediate Care Yes Yes 100%
Women & Children Epilepsy 12 audit (Childhood Epilepsy) Yes Yes 2013 report
shows 83%
CEM Fitting Children (care in the emergency department)
Yes Yes 100%
Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK)
Yes Yes 100%
Neonatal intensive and special care (NNAP)
Yes Yes 100%
Paediatric intensive care (PICANet) No Not applicable to Buckinghamshire Healthcare NHS Trust
-
Table 2: NCEPOD Projects Participation
Page 95 of 113
Title Eligible Participated % Submitted Study of Gastrointestinal Haemorrhage Yes Yes 100%
Sepsis Study Yes Yes 100% Acute Pancreatitis Study Yes Yes study not yet
completed
Page 96 of 113
Appendix 2 CQUIN
Clinical Commissioning Group CQUINs Available CQUIN Value
Year-End Achievement
National
1.1
Friends and Family Test Implementation
0.03%
£60,972 Achieved 100%
National
1.2
Friends and Family Test Early implementation
0.04%
£81,296 Awarded 100% as not
selected as early implementer
National
National
1.3
1.3
Friends and Family Test Phased Expansion (response rates)
0.04%
0.04%
£81,296 0%
National 1.4 Friends and Family Test
Response rate 0.05% £101620 Achieved 87%
National
2.1
NHS Safety thermometer improvement
0.17%
£338,734 0
National
3.1
Dementia Find, assess, investigate, refer
0.10%
£338,734
Achieved – 100%
National
3.2 Dementia
Clinical leadership
0.02% £40,648 Achieved – 100%
National
3.3
Dementia Supporting carers
0.05%
£60,972
Achieved – 100% Local
A3.2
Pneumonia care bundle
0.35%
£711,341 Achieved – 100%
Local A3.3 Sepsis care bundle 0.35% £711,341 69% achieved against a target of 75%
Local
A4
NHS Services – seven days a week
0.50% £1,016,202 Achieved – 100%
Local
A5
Real time information for GPs
0.30% £60,972 Achieved – 100%
Local
CI
Redesign reablement pathway
0.30%
£609,721 Achieved – 100%
Local C2 Developing community geriatrician
service 0.20% £406,481 Achieved – 100%
Total CQUIN 2.50% £5,081,010
Page 97 of 113
NHS England Wessex CQUINs Value Year end achievement
Specialist CB2 HIV:GP registration and communication
0.38% £138,174
100%
Specialist
CB10 Investment in HIV IT
0.38% £138,174
Specialist QD Quality Dashboards template 0.38% £138,174
Specialist TR1 Acute spinal cord injury centre outreach
0.38% £138,174
Specialist WC6 Improved access to maternal milk preterm babies
0.38% £138,174
Total CQUIN (including national CQUINs)
2.50% £872,616
NHS England Thames Valley CQUINs
Health visiting
HV Health Child programme 0.67% £84,749
100%
Screening Cervical screening quality
improvement
0.67% £84,749
ANNB Infectious diseases in pregnancy screening
0.57% £72,642
Total CQUIN (including national CQUIN
2.50%
£305,861
Page 98 of 113
Appendix 3 Glossary of Terms
Acute hospital services
Medical and surgical interventions provided in hospitals.
Annual governance statement
The chief executive as the accounting officer is required to make an annual statement
alongside the accounts of the Trust, which provides a high-level summary of the ways
in which risks are identified and the control systems in place.
Assurance framework (and Board Assurance Framework)
The assurance framework provides organisations with a simple but comprehensive
method for the effective and focused management of the principal risks to meeting
their objectives. It also provides a structure for the evidence to support the statement
on internal control.
Audit commission
They are an independent public body responsible for ensuring that public money is
spent economically, efficiently, and effectively in the areas of local government,
housing, health, criminal justice and fire and rescue services. They appoint the
external auditors.
Care Bundle
A bundle is a structured way of improving the processes of care and patient
outcomes: a small straightforward set of evidence based practices – generally three
to five – that, when performed collectively and reliably, have been proven to improve
patient outcomes.
Care pathway
This is the route and interactions with healthcare services that a patient will take from
their initial meeting with a GP to completion of their treatment.
Care Quality Commission(CQC)
The Care Quality Commission provides an independent assessment of the standards
of healthcare services, whether provided by the NHS, the private sector or voluntary
organisations. The CQC replaces the Healthcare Commission.
Choose and book
It is the government's aim to allow patients to choose the hospital they are treated in.
Page 99 of 113
Patients needing elective treatment are offered a choice of four or five hospitals once
their GP has decided that a referral is required. These could be NHS trusts,
Foundation Trusts, treatment centres, private hospitals or practitioners with a special
interest operating within primary care. Choose and book is a national service that, for
the first time, combines electronic booking and a choice of place, date and time for
first outpatient appointments.
Clinical commissioning group
Clinical commissioning groups (CCGs) are NHS organisations set up by the Health
and Social Care Act 2012 to organise the delivery of NHS services in England. They
are clinically led groups that include all of the GPs in their geographical area. The aim
of this is to give GPs and other clinicians the power to influence commissioning
decisions for their patients.
Clinical division
The Trust’s organisation management structure is based on three clinical divisions,
each led by a divisional clinical chair who is a medical consultant supported by an
associate chief nurse and associate chief operating officer. The three divisions are:-
integrated medicine
surgery and critical care
specialist services.
Clostridium difficile (C. difficile)
Clostridium difficile is a bacterium that can cause an infection of the gut and is the
major infectious cause of diarrhoea that is acquired in hospitals in the UK.
Commissioning
A continuous cycle of activities that underpins and delivers on the overall strategic
plan for healthcare provision and health improvement of the population. These
activities include stakeholders agreeing and specifying services to be delivered over
the long term through partnership working, as well as contract negotiation, target
setting, providing incentives and monitoring.
Community care
Healthcare care provided in a community setting such as at home or from a
community hospital.
CQUIN (Commissioning for Quality and Innovation) payment targets
These new payment targets are aimed at driving up quality in certain areas. They
have been developed to support implementation of High Quality Care for All.
Disability equality scheme
The Disability Discrimination Act amended in 2005 gives the Trust ‘general’ and
Page 100 of 113
‘specific’ duties to promote disability equality.
Eighteen week and cancer waits
The NHS improvement plan gave a commitment that by December 2008 no one will
have to wait longer than 18 weeks from GP referral to hospital treatment. However,
many patients will be seen much more quickly. For example by December 2005,
cancer patients were guaranteed a maximum two month wait from urgent GP referral
to first treatment and a maximum one month wait from diagnosis to first treatment for
all cancers.
Elective inpatient activity
Elective activity is where the decision to admit to hospital could be separated in time
from the actual admission, i.e. planned. This covers waiting list, booked and planned
admissions.
Emergency inpatient activity
Emergency activity is where admission is unpredictable and at short notice because
of clinical need.
Equality delivery system (EDS)
The EDS was designed in 2011 as a tool to support NHS commissioners and
providers to deliver better outcomes for patients and communities and better working
environments for staff, which are personal, fair and diverse. The EDS is about making
positive differences to healthy living and working lives.
Evolve
Evolve, is a new electronic document and records management system (EDRM)
which has been rolled out from Autumn 2013.
Executive directors
The executive directors are senior employees of the NHS Trust who sit on the Board
of Directors and will include the chief executive and finance director. Executive
directors have decision-making powers and a defined set of responsibilities thus
playing a key role in the day to day running of the organisation.
Francis report
The Francis Report 2013 is the final report of the Mid Staffordshire NHS Foundation
Trust Public Inquiry by Robert Francis QC. It was published on Wednesday 6
February 2013 and makes recommendations to the Secretary of State based on the
lessons learnt from Mid Staffordshire. http://www.midstaffspublicinquiry.com/
Page 101 of 113
Governance
Governance arrangements are the 'rules' that govern the internal conduct of an
organisation by defining the roles and responsibilities of key officers/groups and the
relationship between them, as well as the process for due decision making and the
internal accountability arrangements.
Health and Adult Social Care Select committees (HASC)
HASCs have the power to scrutinise health services. This contributes to their wider
role in health improvement and reducing health inequalities for their area and its
inhabitants.
Health and Social Care Act 2012
The Health and Social Care Act 2012 is an Act of the Parliament of the UK. It is the
most extensive reorganisation of the structure of the NHS in England. It abolished
NHS primary care trusts and strategic health authorities from April 2013, with clinical
commissioning groups made up of GPs now responsible for buying health services
for their population.
Health Education Thames Valley
Health Education Thames Valley is the local education and training board covering
Buckinghamshire and responsible for NHS workforce planning, education and training
in the area. It is a committee of Health Education England, the organisation
established as part of the Health and Social Care Act 2012 to lead on workforce
issues nationally.
HSMR
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare
quality used by the NHS that measures whether the death rate at a hospital is higher
or lower than you would expect.
ICT
Information and communications technology.
Integrated business plan
The Trust’s Integrated Business Plan (IBP) describes services provided by
Buckinghamshire Healthcare. It outlines plans for the Trust to operate as a legally-
constituted, financially viable and well- governed NHS Foundation Trust over a five-
year period and will form part of our Foundation Trust application to the Trust
Development Authority.
Integrated care
Integrated care – also known as coordinated care, comprehensive care, seamless
Page 102 of 113
care – is a worldwide trend in health care reforms and new organisational
arrangements that focuses on more coordinated services across acute, community
and primary care sectors.
Key performance indicators (KPIs)
KPIs are the nationally recognised method for calculating performance in NHS acute
trusts and are defined by the NHS Information Authority. In 2009/10 the KPIs covered
existing commitments and national targets set out by the Department of Health (DH)
and Care Quality Commission (CQC); clinical quality, outcome and clinical efficiency
indicators and activity levels, workforce and health & safety indicators.
Local health economy
The NHS organisations including GP practices, and voluntary and independent sector
bodies involved in the commissioning, development and provision of health services
for particular population groups.
Meticillin resistant staphylococcus aureus (MSRA)
This is a strain of a common bacterium which is resistant to an antibiotic called
Meticillin.
NHS foundation trust(FT)
NHS foundation trusts have been created to devolve decision-making from central
government control to local organisations and communities so they are more
responsive to the needs and wishes of their local people.
NHS trusts
NHS Trusts are hospitals, community health services, mental health services and
ambulance services which are managed by their own boards of directors. NHS trusts
are part of the NHS and provide services based on the requirements of patients as
commissioned by PCTs.
Non-executive directors
Non-executive directors, including the chair, are Trust Board members but they are
not full time NHS employees. They have a majority on the Board and their role is to
bring a range of varied perspectives and experiences to strategy development and
decision-making, ensure effective management arrangements and an effective
management team is in place and hold the executive directors to account
for organisational performance.
Outpatient attendance
An outpatient attendance is when a patient visits a consultant or other medical
outpatient clinic. The attendance can be a ‘first’ or ‘follow up’.
Page 103 of 113
Patient administration system (PAS)
A computer system used to record information about the care provided to service
users. The data can only be accessed by authorised users.
Patient Advice and Liaison Service (PALS)
All NHS trusts are required to have a Patient Advice and Liaison Service. The service
offers patients information, advice, and quick solution of problems or access to the
complaints procedure. PALS are designed to offer on the spot help and information,
practical advice and support for patients and carers.
Payment by results (PbR)
Payment by results (PbR) aims to be a fair and transparent, rules-based system for
paying NHS Trusts. It uses a national price list (tariff) linked to activity and adjusted
for case complexity.
Private finance initiative (PFI)
The private finance initiative (PFI) provides a way of funding major capital
investments, without immediate recourse to the public purse. Private consortia,
usually involving large construction firms, are contracted to design, build, and in some
cases manage new projects
Primary care
Family health services provided by family doctors, dentists, pharmacists,
optometrists, and ophthalmic medical practitioners.
Protected characteristics
The Equality Act 2010 makes it unlawful to discriminate against people with a
‘protected characteristic’ (previously known as equality strands / grounds). The
protected characteristics are Age, Disability, Gender Reassignment, Pregnancy and
Maternity, Marriage and Civil Partnership, Race, Religion or belief, Sex and Sexual
Orientation.
Public Sector Equality Duty (PSED)
The Equality and Human Rights Commission published new guidance in January
2013 on the public sector equality duty (PSED) under the Equality Act, to help public
authorities encourage good relations, promote equality and eliminate discrimination in
the workplace and in delivering public services.
Quality account
From 2009/10 onwards all NHS trusts have to publish quality accounts to give
information about the quality of the services being delivered.
Page 104 of 113
Revenue
Expenditure other than capital. For example, staff salaries and drug budgets. Also
known as current expenditure.
Ring-fenced
Funding specifically designated for a purpose and which can only be used for that
purpose.
RiO
An electronic patient records system for community health organisations.
Risk register
A register of all the risks identified by the organisation, each of which is assessed to
determine the likelihood of the risk occurring and the impact on the organisation if it
does occur.
Safety Thermometer
National indicator based on a monthly prevalence audit. The Safety Thermometer
measures harm from falls, pressure ulcers, Venous-Thrombo-embolism (VTE), and
catheter associated urinary tract infection.
Secondary care
Care provided in hospitals.
Service standards
The Trust’s service standards focus on themes around communication, courtesy,
compassion and commentary. For the first time they set out the standards of
behaviour we expect all of our staff to deliver, with every interaction, every day, with
every patient or colleague.
Tariff / national tariff
The national tariff underpins the implementation of the payment by results policy by
providing a national price schedule for commissioning services for patients in
England. The tariff is a schedule of prices for healthcare resource groups (HRGs).
These HRG’s cover a range of clinical procedures, treatments and diagnoses that
cover a large proportion of hospital services in England.
Trust Board
The Trust Board comprises the chair, executive and non-executive directors and is
the body responsible for the operational management and conduct of a particular
Page 105 of 113
NHS Trust.
Trust Development Authority
The NHS Trust Development Authority (NHS TDA) is a national body established
through the Health and Social Care Act 2012 to support the performance
management of NHS trusts and manage foundation trust applications. It has special
health authority status and also looks at clinical quality, governance and risk in NHS
trusts and oversees the non-executive appointments of chairs, non-executive
directors and trustees for NHS charities.
Whole system reform
In relation to our agenda this involves looking at the whole system of NHS care in
Buckinghamshire, for example the organisations and professions involved, and
improving it collaboratively.
Page 106 of 113
Appendix 4 Auditors Limited Assurance Report
INDEPENDENT AUDITORS’ LIMITED ASSURANCE REPORT TO THE DIRECTORS OF BUCKINGHAMSHIRE HEALTHCARE NHS TRUST ON THE ANNUAL QUALITY ACCOUNT
We are required to perform an independent assurance engagement in respect of Buckinghamshire Healthcare NHS Trust’s Quality Account for the year ended 31 March 2015 (“the Quality Account”) and certain performance indicators contained therein as part of our work. NHS trusts are required by section 8 of the Health Act 2009 to publish a quality account which must include prescribed information set out in The National Health Service (Quality Account) Regulations 2010, the National Health Service (Quality Account) Amendment Regulations 2011 and the National Health Service (Quality Account) Amendment Regulations 2012 (“the Regulations”).
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the following indicators:
► Percentage of patients risk-assessed for VTE; and
► Rate of clostridium difficile infections.
We refer to these two indicators collectively as “the indicators”.
Respective responsibilities of Directors and auditors
The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the Regulations).
In preparing the Quality Account, the Directors are required to take steps to satisfy themselves that:
► the Quality Account presents a balanced picture of the trust’s performance over the period covered;
► the performance information reported in the Quality Account is reliable and accurate;
► there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice;
► the data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review; and
► the Quality Account has been prepared in accordance with Department of Health guidance.
The Directors are required to confirm compliance with these requirements in a statement of directors’ responsibilities within the Quality Account.
Page 107 of 113
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that:
► the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations;
► the Quality Account is not consistent in all material respects with the sources specified in the NHS Quality Accounts Auditor Guidance 2014-15 published on the NHS Choices website in March 2015 (the Guidance); and
► the indicators in the Quality Account identified as having been the subject of limited assurance in the Quality Account are not reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of the Regulations and to consider the implications for our report if we become aware of any material omissions.
We read the other information contained in the Quality Account and consider whether it is materially inconsistent with:
► Board minutes for the period April 2014 to June 2015;
► papers relating to quality reported to the Board over the period April 2014 to June 2015;
► feedback from the Commissioners dated 25/06/2015;
► feedback from Local Healthwatch dated 19/06/2015;
► the Trust’s complaints report published under regulation 18 of the Local Authority, Social Services and NHS Complaints (England) Regulations 2009, dated 15/05/2015;
► feedback from other named stakeholder(s) involved in the sign off of the Quality Account;
► the latest national patient survey dated 21/05/2015;
► the latest national staff survey dated 2014;
► the Head of Internal Audit’s annual opinion over the trust’s control environment dated 14/05/2015;
► the annual governance statement dated 04/06/2015;
► the Care Quality Commission’s quality and risk profiles dated March 2014. July 2014, December 2014 and May 2015; and
► the results of the Payment by Results coding review dated 13/05/2015.
We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with these documents (collectively the “documents”). Our responsibilities do not extend to any other information.
This report, including the conclusion, is made solely to the Board of Directors of Buckinghamshire Healthcare NHS Trust.
Page 108 of 113
We permit the disclosure of this report to enable the Board of Directors to demonstrate that they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permissible by law, we do not accept or assume responsibility to anyone other than the Board of Directors as a body and Buckinghamshire NHS Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement under the terms of our appointment under Guidance. Our limited assurance procedures included:
► evaluating the design and implementation of the key processes and controls for managing and reporting the indicators;
► making enquiries of management;
► testing key management controls;
► limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation;
► comparing the content of the Quality Account to the requirements of the Regulations; and
► reading the documents.
A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Account in the context of the criteria set out in the Regulations.
The nature, form and content required of Quality Accounts are determined by the Department of Health. This may result in the omission of information relevant to other users, for example for the purpose of comparing the results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or non-mandated indicators which have been determined locally by Buckinghamshire Healthcare NHS Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2015:
► the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations;
Page 109 of 113
► the Quality Account is not consistent in all material respects with the sources specified in the Guidance; and
► the indicators in the Quality Account subject to limited assurance testing have not been reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Guidance.
Ernst & Young LLP
Apex Plaza, Forbury Road, Reading, RG1 1YE
29 June 2015
Page 110 of 113
Appendix 5 Examples of improvement resulting from national
clinical audits:
British Thoracic Society Audit of Emergency Oxygen Prescription 2013
Boxes have been added to the Acute General Medical and General Surgical drug charts for the prescription of oxygen. Plans are in place to add these to the Trauma drug chart.
Education sessions for doctors and nurses have been completed. CEM Audit of Decreased Conscious Level in Children
Enquire about and document details of medicines available to the child in the household.
Include testing for ammonia in the core investigations, especially in pre-school children.
Save serum and freeze urine.
Actively document differential diagnoses based on the 18 bundles.
Re-audit after 2 years. National Paediatric Diabetes Audit 2012/13
A Diabetes Specialist Nurse has been recruited.
The THINK glucose campaign has been re-launched together with the ward Diabetes Link Nurse Programme. The lead diabetes specialist nurse for the wards and a consultant now attend the insulin errors group with the pharmacists. These measures will improve care on the wards for patients with diabetes and reduce insulin errors.
A business case has been put forward for permanent staff to carry out foot examinations for all patients on the wards with diabetes.
National Care of the Dying Audit 2013
Trustwide education as per CQC report re recognition of dying.
Symptom guidelines for dyspnoea to be added to EOL Guidelines.
Spiritual care plans and chaplaincy details to be documented in patient notes.
Symptom guidelines for dyspnoea to be added to EOL Guidelines and mandatory Trustwide EOL education (as per CQC Report).
Deliver Trustwide DNACPR awareness sessions. Re-audit DNACPR at SMH; WH & AH sites and consideration to be given to the most appropriate way to document details of DNACPR in clinical notes.
Nutritional and hydration assessments to be made and documented in the medical notes and shared with family.
Improve Trustwide nursing documentation in patients’ notes regarding care of the body after death.
British Thoracic Society National Paediatric Asthma Audit 2013
The trust guidelines have been updated in line with the new information leaflet / traffic light protocol produced by the Aylesbury Vale and Chiltern CCGs.
An Asthma Discharge Checklist has been created which is put into each child’s notes and completed on discharge.
Page 111 of 113
CEM National Audit of Paracetamol Overdose 2013/14
Improve documentation of capacity in patients who decline treatment.
Review the wide variation in the provision of N-acetylcysteine for patients with toxic levels.
Provide education / training regarding the MHRA guidelines. CEM Audit of Severe Sepsis and Septic Shock 2013/14
Vital signs and capillary blood glucose measures are recorded within 15 minutes of arrival in the Emergency Department for all patients presenting with sepsis.
Oxygen prescribed and stats recorded for all patients with sepsis unless contraindicated.
Blood culture samples to be taken from the patients and documented in their notes before administration of antibiotics.
All septic patients who are having their blood pressure monitored to also have urine output measured.
CEM National Audit of Moderate or Severe Asthma in Children (care provided in Emergency Departments)
Improve recording of vital signs and the processes for repeating these, particularly after an intervention which may have a significant effect on them.
Review practice regarding the measurement and recording of peak flow.
Review practices regarding administration of beta agonists and make changes as appropriate. Also review practice in relation to giving beta agonists to patients within 10 minutes of arrival.
Make improvements regarding the administration of IV hydrocortisone or oral prednisone.
Introduce a standard discharge proforma including advice / discharge medications and follow up advice for patients.
Improve the detail and accuracy of data in patients’ records. Management of Paediatric Psoriasis
Many of the treatments used to treat psoriasis in children are largely based on the experience derived from managing psoriasis in adults. The national proposal is to conduct well designed clinical trials in order to obtain reliable long-term safety data regarding the use of systemic and biological therapies in children which will guide optimal management.
National Audit of Intermediate Care 2014
Care planning and goal setting will be discussed with patients by clinicians. These discussions to be clearly documented in patients’ notes by nurses, therapists and doctors.
Families and carers to be involved in care planning and therapy goal setting for patients.
Improved communication with families and carers including early family meetings to ensure partnership working with carers and shared care planning and goal setting.
Ensure carers are fully engaged in the discharge planning process. This will include the completion of a template with meetings documented and outcomes identified and dated.
Page 112 of 113
National Oesophago-Gastric Cancer Audit (NOGCA) 2014
The results of this audit were reviewed but as most patients with oesophago-gastric cancer are referred to the John Radcliffe Hospital at Oxford for treatment and the John Radcliffe submits the majority of data for this audit no local action plan was formulated.
Examples of improvements from local audits: Pain management
Introduction of study days for pain management. These are aimed at nurses and advertised on the trust intranet.
Pain management is discussed during Health Care Assistant study days and is also included in the induction programme for nurses. Staff are encouraged to complete the elearning module.
Management of Infection in Diabetic Patients with Burns
A regional guideline has been developed to improve management , this was presented at the National Plastic Surgery Conference (December 2014)
Surgical Record Keeping of Operation notes in Plastic Surgery
An educational presentation designed to raise staff awareness of correct record keeping procedures has been given.
A poster and a checklist have been introduced for use in patients’ admission packs.
A subsequent re-audit has shown an improvement in total data recorded. Audit of Outcomes in Pregnancy with High BMI
The Trust guideline has been amended to comply with the NPEU birth place study secondary analysis recommendations and NICE antenatal quality standards.
As part of their mandatory training all community midwives received training on obesity including the importance of recording BMI.
Audit of NICE Clinical Guideline for post Stroke Rehabilitation on Buckinghamshire Neuro- rehabilitation Unit.
A working party has been set up to improve the reception area in the Stroke Unit.
Manual handling requirements, patient mouth care and continence management have been added to the care plan.
Copies of the Stroke Association aphasia information leaflet are now available for patients.
Communication training has been given to all Multi Disciplinary Team Members.
Information leaflets about community exercise programmes and benefits entitlement are now available for patients.
Page 113 of 113
Processing of Cerebrospinal Fluid Specimens for Suspected bacterial or Viral Meningitis or Encephalitis
The laboratory handbook has been updated to include a specific section on the collection, storage, transport and processing of CSF samples. This includes a table on normal CSF values.
Clinicians have been reminded to keep CSF samples at room temperature.
Following recommendations from the microbiologists a second CSF sample is collected to allow repeat testing if required.
Related Documents
![Donati - CIP-def [modalità compatibilità] · 28 Luglio 1948 primi Giochi di Stoke Mandeville donatella donati 22/10/13 10 Salute diritto umano & interesse di tutti Preambolo della](https://static.cupdf.com/doc/110x72/5c69d75b09d3f2e4178bb091/donati-cip-def-modalita-compatibilita-28-luglio-1948-primi-giochi-di-stoke.jpg)
