QUALITY ACCOUNT PART 1, CHAPTER

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QUALITY ACCOUNT PART 1, CHAPTER 1 – INTRODUCTION

Welcome to our 2019/20 Quality Account, which describes how we performed against our main patient

safety, outcome and experience standards during the year. Our Annual Report and Accounts is a separate

document which provides detailed information about how we performed across the full spectrum of

standards, including financial performance and waiting times.

Over the last year, despite the challenges of the global pandemic, we have maintained our focus on

strengthening the quality and safety of care that we are privileged to provide to our patients. We have made

excellent progress against our quality priorities, achieving 10 so far.

We’ve used digital advances to improve the care we offer, Nervecentre assists us in screening all adult

inpatients for sepsis, and we’ve successfully implemented our electronic assessment tool, NEWS2, to support

the identification and care of acutely unwell patients.

We’ve listened to our patients and, in response to their feedback, we’ve developed sleep guides to support

them. Four of our teams were also finalists at the 2019 National Patient Experience Awards (PENNA).

We are committed to ensuring our patients receive consistently high quality, safe care, with outstanding

outcomes and experience. A Medical Examiner Team was implemented to support the review and learning

from deaths. And we’ve maintained our mortality position (SHMI) in line with the expected national position.

We consistently achieved the national CQUIN (quality improvement) targets for the first three quarters –

with the fourth quarter being disrupted by the Covid-19 pandemic. We have also continued to perform well

with national audit outcomes, including benchmarking against peers.

We continue to prioritise the areas highlighted in our Care Quality Commission (CQC) inspection of

2018/2019 with our ambition to be outstanding at the next inspection. In particular we have focused on the

improvement of Do Not Attempt Resuscitation (DNACPR) documentation and end of life care. End of life care

has been further improved in our organisation, with the ongoing implementation of the SWAN initiative and

our work across the care community.

We also vaccinated 80% of staff against flu over the winter.

One of our continued challenges is providing timely emergency care. Our clinical teams appreciated the

opportunity, from May 2019, to take part in the national field testing programme for new clinical standards

in urgent and emergency care. This enabled them to both test and challenge assumptions around this area.

Our focus during this process remained the delivery of safe, timely care, as well as providing a positive overall

experience for our emergency patients. This was, however, challenged during the winter with increased

numbers of patients needing our services. We were pleased to receive funding to redesign our acute urgent

and emergency care services, enabling us to increase the number of beds, particularly in our admission areas.

In mid-January we were delighted to open our brand new Acute Medical Unit at the Queen’s Medical Centre.

This unit has a very large assessment and treatment area for patients with medical problems that require a

stay in hospital of less than 48 hours. It is a mixture of new and old estate and provides us with 91 acute

https://www.nuh.nhs.uk/download.cfm?doc=docm93jijm4n8221.pdf&ver=18034

https://www.nuh.nhs.uk/latest-news/nuh-finalists-in-national-patient-experience-awards-4875

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beds. It also helps us care for our older patients with dementia and we incorporated some dementia friendly

designs into the new build. Whilst this important work has delivered what it set out to, we still struggle to

admit patients in a timely way due to a shortage of beds, particularly in our medical wards at the Queen’s

Medical Centre. This therefore remains a key priority during 2020/21.

We recognise other challenges in our furtherance of improving the quality and safety of care we provide, not

least responding to the current pandemic and seeking to restore activity as far as possible.

Our 2020/2021 quality priorities, described in this report, set out our programme of work for the year to

come, showing our commitment to further improve the safety and quality of care we provide for our patients

and their families. These are summarised below:

Priority 1 - Improve Patient Experience

WHAT HOW ASSOCIATED MEASURES

Improve patient, family and carer experience of loved ones with dementia

Implement the Trust’s Dementia Strategy

Implement year one objectives.

Improve the quality of complaint investigations and responses

Implement the Complaints Quality Improvement Plan

Reopened complaints (% of total closed complaints) will be ≥15%.

By the end of 2020/21, 100% of all nominated complaint investigators will be trained.

By the end of 2020/21, 25 complaint case Peer Reviews will have been completed.

A pilot will be evaluated to achieve ≥10% improvement in meeting agreed complain response timescales within 30 working days.

Provide timely and useful patient information

Information leaflets will be accessible and in a format that meets patient, carer and family needs

By the end of 2020/21, 100% of all patient leaflets will be updated within review dates.

A review of the Patient Information Service will have been undertaken and a Trust-wide Strategy and Policy developed.

Priority 2 - Improve Patient Safety


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Escalate and respond to deteriorating patients in a timely manner

The national NEWS2 CQUIN will be used as a lever to support improvements in care of the acutely unwell patient (with an ambition to reduce unplanned ward transfers to Critical Care)

By the end of 2020/21, 70% of patients who have triggered for medical review will be seen within agreed (NEWS2 policy) timescales.

Escalate and respond to deteriorating patients in a timely manner (continued)

A focus on A-E patient assessment (and standardised management planning) will form part of high quality reviews of acutely unwell patients

A Trust, Division and Speciality QLik app will be developed to make visible key measures of care of the acutely unwell patient to measure and monitor for improvement

Investment in the City Hospital campus medical specialities through SPR level twilight cover will be implemented

NUH will scope the feasibility of implementing an electronic fluid balance system via Nervecentre

A-E patient assessment will form part of mandatory training for all Registered Nurses.

Fluid balance electronic monitoring for all adult inpatient areas with the exception of critical care/ theatres.

Reduce the incidence of grade 3 and 4 pressure ulcers

The Trust’s pressure ulcer prevention strategy will be reviewed, updated and implemented to positively impact the care of patients who are at risk of developing pressure ulcers.

Establish baseline and set target reduction at the end of Q1.

Optimise information flow by implementing a standardised handover process

A standardised handover process will be defined and implemented to improve transfer of critical information within and across teams.

Initial work will focus on a daily clinical handover at the end of the day on city based medical admission areas.

Standardised process (such as SBAR) to be implemented for use in adult emergency admission areas and at internal transfer of patients.

Priority 3 - Improve Clinical Effectiveness


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Improve the way we plan and respond at the end of life with patients and families

Focus on improving conversations and documentation of Do Not Attempt Resuscitation (DNACPR) decisions

100% of patient demographics will be completed fully on the DNACPR forms by June 2020.

A date to review the decision will be documented on 100% of forms by December 2020.

100% of forms will have a valid clinical reason for DNACPR decision documented by June 2020.

Improve the way we plan and respond at the end of life with patients and families (continued)

100% of patients requiring a Mental Capacity Assessment (MCA) will have this completed by September 2020.

Conversations will occur with the patient and family and these conversations will be documented in 100% of instances by June 2020 (the achievement date for this measure will be extended due work stream delays during the COVID-19 pandemic).

90% of patients and/or their family will receive a DNACPR leaflet by December 2020.

Improved Local Surveys Programme

Develop and enhance our Local Surveys Programme to identify actions for improvement

Establish a tool and benchmark to define improvement target during Q1.

Identification of a defined number of projects (≤5).

Implementation of agreed improvement goals in line with Trust objectives during Q2-Q4.

Align improvement resources to support delivery of Trust objectives

Develop a programme of Trust-wide Quality Improvement projects aligned to Trust objectives

Scope current projects and map to objectives in Q1.

Identify priority projects and implementation plan during Q2.

Implementation of agreed priority projects during Q3 to Q4.

DECLARATION OF ACCURACY

I confirm, on behalf of all Executive Directors at NUH, that to the best of my knowledge the information

provided in our Quality Account is accurate.

Tracy Taylor

Chief Executive

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QUALITY ACCOUNT PART 2:

2.1 Priorities for Improvement - a review of 2019/20 achievements

Ensuring our patients receive consistently high quality, safe care, with outstanding health outcomes and

experience, is at the centre of all we do. NUH has six strategic objectives (called our 6 Promises - or 6 ‘Ps’ for

short). These are:

Our patients: We will ensure our patients receive consistently high quality, safe care, with outstanding

outcomes and experience

Our people: We will build on our position as an employer of choice; with an engaged, developed and

empowered team that puts patient care at the heart of everything it does

Our places: We will invest in our estate, equipment and digital infrastructure, to support the delivery of

high quality patient care

Our performance: We will consistently achieve our performance standards and make the best use of

resources that contribute to an affordable healthcare system

Our partners: We will support the improvement of the health of the communities we serve through

strong system leadership and innovative partnerships to deliver integrated models of care

Our potential: We will deliver world-class research and education and transform health through

innovation

Under the promise to our patients we identified a number of quality priorities for 2019/20, outlined below

along with an overview of achievements against delivery.

Quality Aim Priority How will we know that we

have done it? Progress

Improve Patient Experience

Make it easier for patients to stay in touch with relatives and friends.

Introduce charging points in all admission and discharge areas and across ED and outpatient areas.

Mobile charging point in place in the ED. Plans for patient areas and main entrances awaiting approval.

Keeping patients active to aid their recovery.

Developing staff and patient/carer information. Get patients up, dressed and moving as early as possible.

Patient Participation Group led Placemat Project and the first draft of placemat produced.

Improve the night time experience of patients by reducing unnecessary light sources and the level of noise from staff.

Develop and implement a Trust-wide ‘better sleep’ strategy. 85% of patients will respond negatively to the question ‘were you bothered by noise at night from staff’.

Produced Sleep Guide for staff and made information available to patients. Continuing to review feedback and to identify areas for further improvement.

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Enhance Patient Safety

Focus on timely escalation and response to the deteriorating patient.

Integrate NEWS 2 into practice. Evaluate the NEWS2 programme including impact on number of escalations. Reduce avoidable harm and death associated with missed opportunities to detect and manage the deteriorating patient. Rate of unplanned in-patient transfers to Critical Care (baseline by Q2 followed by identification of improvement interventions).

NEWS2 was successfully implemented electronically using Nervecentre across NUH and evaluated. Whilst escalations increased, the model is more sensitive and supports earlier identification of the acutely unwell patient. Incident data, including serious incidents, does not support a significant reduction in avoidable harm associated with the acutely unwell patient (risk remains 20). During 2019/20, our rate of unplanned ward transfers to Critical Care remained with expected levels of variation.

Increased involvement of families when something goes wrong.

Implement and evaluate revised Duty of Candour process. Involve patients in incident investigation through co-design. Implement Patient and Family Liaison Officer role. Roll out the Complaints with Compassion programme.

Duty of Candour processes revised and published, including Trust Policy (see page 29 for detail). Patient and Family Liaison Officer role introduced. Review of complaints processes completed locally. Quality assurance checks introduced. Letter Writing workshops delivered, which focus on compassionate complaints handling.

Improve support for patients and staff involved in incidents.

Establish a rapid incident support team to respond to serious incidents.

Trialled and work continues to resource ability to establish team.

Develop an evaluation tool for families and staff involved in incidents.

Evaluation tool drafted and clinical academic recruited to support formal evaluation.

Increase the rate of incident reporting.

Rate of incident reporting increased from 38.2 incidents per 1,000 occupied bed days in 2018/19 to 48.6 incidents per occupied bed days in 2019/20.

Improve Clinical Effectiveness

Increase our learning from deaths to improve outcomes.

Implement Medical Examiner Role by September 2019.

Medical Examiner Team implemented.

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Maintain SHMI within confidence intervals.

SHMI remains within national mean and confidence intervals (see page 57).

Improve outcomes for patients using audit and benchmarking.

Take part in all relevant National audits and quality standard reviews. Benchmark against peer organisations. Screen for sepsis within one hour of admission for all patients.

NUH participated in all but one eligible national audits (see page 31). NUH has established a clinical audit outcomes bi-annual report to compare outcomes against peers. All adult and paediatric patients admitted to NUH are screened for sepsis. In 2019/20 100% of adult (non-maternity) and paediatric patients admitted to NUH were screened for sepsis on every set of observations taken and entered electronically. 84.4% of obstetric patients unwell with infection were screened for sepsis during 2019/20.

Increase improvement capability across the organisation to enable greater learning from incidents and feedback.

Roll out QSIR1 programme across teams and services. Develop data base of Quality Improvement projects and outcomes.

QSIR has been rolled out across NUH. QSIR Practitioner training delivered to staff across the Integrated Care System (101 were NUH staff). QSIR Fundamentals training delivered to 286 NUH staff.

NUH has made good progress across the quality priorities with 10 achieved and two partially achieved. An

update on the work underway to achieve outstanding priorities is described in the quality account along with

a summary of work NUH has implemented to improve the quality of care through 2019/20.

1 Quality, Service Improvement and Redesign (QSIR) programmes are delivered using improvement tools to increase

quality improvement capability within organisations and across the healthcare system.

https://improvement.nhs.uk/resources/qsir-programme/

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Patient Safety - making care safer

Safety thermometer

The safety thermometer is a national measurement tool for improvement that focuses on commonly

occurring harms in healthcare: Pressure ulcers, falls, urinary tract infection (UTI) in-patients with a catheter

and venous-thromboembolism (VTE, or blood clots). Data is collected through a point of care survey on a

single day each month on 100% of adult and neonatal inpatients on that date. This enables wards, teams and

the organisation to understand the burden of particular harms, measure improvement over time and

connect frontline teams to the issues of harm, enabling immediate improvements to patient care.

NUH has consistently performed well against the safety thermometer, with a consistent harm-free care rate

of greater than 97% since April 2017.

The proportion of patients with harm free care (new harms only) April 2018 to March 2020

Pressure Ulcers

NUH achieved its aim of reducing pressure ulcers by 50% over three years from the 2012/14 baseline.

Subsequently, NUH aimed to further reduce avoidable pressure ulcers by 10% year-on-year concluding in

2019/20. This is however unlikely to be achieved and following recent NHSI guidance, we no longer record

avoidable harm.

Category 2 pressure ulcers

Between 01 April 2019 and 29 February 2020, there was an increase in category 2 pressure ulcer incidents of

33% from 491 (during 2018/19) to 655. This increase may be due to a change in process where Tissue

Viability Nurses no longer validate all the pressure ulcer incidents reported.

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Category 2 hospital acquired pressure ulcers per 1,000 occupied bed days (April 2018 - March 2020)


The rate of hospital acquired category 3 and 4 pressure ulcers during 2019/20 remained within normal

variation. However, there were 40 category 3 incidents whose investigation remained ongoing at the time of

reporting. This may impact on the ability to complete a comparison against 2018/19’s performance in terms

of the number of moderate (previously termed avoidable) harm incidents. Concluding the investigation

process is a priority and there is a plan in place to achieve this.


Five hospital acquired category 4 pressure ulcers were reported during 2019/20 (1st April 2019 to 29th

February 2020). Outcomes of investigations concluded:

One hospital acquired, moderate harm case

One case with no significant lapses in the quality of care provided (no Trust apportioned harm)

Three cases with outcome to be determined.

Category 3/4 hospital acquired pressure ulcers per 1,000 occupied bed days (April 2018 - March 2020)

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Themes/learning from investigations:

Delayed and ineffective repositioning

Inaccurate skin assessments

Lack of effective continence care

Substandard management of non-compliance

Lack of individualised care

Omissions in documentation

Inpatient Falls

The Trust continued to apply a consistent, challenging and appropriate ambition, to work to see a reduction

of harm arising from falls amongst inpatients. In 2019/20 there was a 19% increase in the rate of all falls and

a 28% increase in falls associated with harm.

Falls per 1,000 occupied bed days April 2018 - March 2020

Over the last seven months the rate of falls has been above the mean rate, indicating that there has been a

shift in the rate of reported falls. The rate of falls has also increased over this period. However, the rate of

falls remained low historically.

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Harmful Falls per 1,000 occupied bed days April 2018 - March 2020

Over the last seven months the rate of harmful falls has been above the mean rate indicating that there has

been a shift in the rate of reported harmful falls. There was also an aberration in October 2019 where the

rate was above expected levels. This was linked to staffing issues and performance immediately returned

within the control limits.

The Falls Learning Group recognises the increase in falls and harmful falls and continues to work with

frontline clinicians to further understand the drivers and apply appropriate safety control measures.

Ratio of falls to fallers April 2018 - March 2020

There were no concerns as the rate remains within the control limits.

Learning from inpatient fall investigations

Inadequate patient supervision due to:

o No change to the planned care despite a change in the patient’s condition

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o Staffing levels

o Inappropriate patient placement to a clinical area

Lack of effective patient continence assessment and individualised care; urinary and faecal urgency a

particular issue

Missed opportunities to assess patient for orthostatic hypotension. Inconsistent assessment of lying and

standing blood pressure

Catheter-acquired and new urinary tract infection (CAUTI)

Training in the basics of effective continence promotion, urinary catheter and basic bowel care has been

available since September 2019 and up to the end of February 2020, 22 sessions had been delivered.

Gillies Ward had been piloting the use of the PureWick external female catheter device since February 2020.

The aim is to reduce the duration of post-operative urinary catheters. This is due for evaluation by 30th April

2020.

Mar

-19

Ap

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9

May

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Jun

-19

Jul-

19

Au

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9

Sep

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9

Oct

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No

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9

De

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9

Jan

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Feb

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Mar

-20

% of Catheter

and New UTI

Harm

0.00% 0.22% 0.00% 0.00% 0.36% 0.15% 0.22% 0.08% 0.14% 0.00% 0.22% 0.00% 0.00%

Number of actual

patients 0 3 0 0 5 2 3 1 2 0 3 0 0

Venous thrombo-embolism (VTE)

Our VTE programme aims to reduce preventable harm to our patients, by promoting timely and accurate VTE

risk assessment and ensuring thromboprophylaxis is prescribed accurately and administered effectively when

required.

NUH’s overall VTE risk assessment compliance for 2019/20 was 94.7% (against a target of 95%).

VTE Risk Assessment Compliance April 2018-March 2020

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NUH recognises that its compliance level is below target in 2019/20 but has shown improvement since

2018/19. In-depth analysis of performance within the Divisions has been undertaken to identify areas where

focussed action is needed and strategy developed. Advanced Nurse Practitioners and prescribing pharmacists

are now trained to complete the VTE Risk Assessments to provide support to the medical teams. A new IT

system is prepared for rollout in 2020/21 which will improve usability of the assessment tool, making it more

accessible to medical teams. Hospital Associated Thrombosis (HAT) route cause analysis compliance is 100%

and the rate of preventable HAT remains low. The Trust is committed to investigating and sharing knowledge

in cases where an element of preventability has been found to drive improvement and has a clear

governance structure to facilitate this.

VTE risk assessment by provider (peer group) April to December 2019

Harms associated with infection, prevention and control

C. Difficile & MRSA

There were 152 cases of C. difficile at NUH against a control total of no more than 120 cases.

We had two cases of hospital acquired MRSA bacteraemia against a zero tolerance target. We continue to

do all we can to prevent and reduce healthcare-associated infections and remain committed to improving

and sustaining high levels of environmental cleanliness and total room decontamination by the investment in

developed hydrogen peroxide technology against C. difficile spores.

NUH has well developed and effective programmes of surveillance and audit and continues to effectively

investigate manage sometimes complex outbreaks of infection. NUH promotes the optimum use of

antibiotics as a patient safety priority to prevent and reduce the risk from multi-resistant organisms, e.g. CRE.

In 2019/20 emphasis has been placed on the continued development of a safe and sustainable organisation

wide approach in order to embed:

• Getting the diagnosis of infection right first time and every time

• Ensuring appropriate antibiotic use and review.

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Rate of C. Difficile infections per 100,000 occupied bed days for April 2019 - December 2019, compared

with peer group

19

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Cases Healthcare Assoc. Control total

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NUH acquired C. difficile cases

Cumulative NUH acquired C. difficile cases (2019/20)

Reducing the impact of serious infections (Antimicrobial Stewardship and Sepsis)

Antimicrobial Stewardship (AMS)

AMS is a programme of ensuring appropriate antibiotics are prescribed and administered to our patients.

This programme of work will improve the safety and quality of patient care and reduce the development and

spread of antibiotic resistance. The following initiatives have been undertaken by the AMS team:

Trust-wide roll-out of diagnostic stewardship quality improvements:

o ‘Skip the dip’, to reduce the over diagnosis and inappropriate treatment of urinary tract infections

(UTI)

o Launch of an interprofessional staff training resource ‘getting infection right first time.’

Creation of a diagnostic stewardship group, bringing together hospital and community teams

Creation of an antifungal dashboard to improve the accessibility of antifungal consumption data to all

staff

Joint pharmacy and microbiology led AMS ward rounds, enabling timely interventions

0

20

40

60

80

100

120

140

160

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

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Total 19/20 Control total

UCL

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0

50

100

150

200

250

300

350

400

450

14

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/14

06

/09

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19

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21

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07

/07

/15

13

/07

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/15

28

/10

/15

29

/10

/15

18

/12

/15

02

/05

/16

11

/05

/16

23

/05

/16

02

/12

/16

29

/01

/17

26

/06

/17

03

/02

/18

19

/04

/18

07

/02

/19

20

/04

/19

05

/11

/19

31

/03

/20

Day

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MRSA Case

Days between MRSA cases Days since last MRSA case

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Revision of the AMS work plan to reflect the Department of Health five year plan

Response to the COVID-19 pandemic with team emphasis on Infection Prevention and Control

o Contribution to NICE COVID -19 guidance consultations, alongside the development of local

guidance

o Staff mask fit testing, Personal Protective Equipment (PPE) advice and training, diagnostic testing

and front line staff support.

2019/20 achievements

CQUINs

Q1 Q2 Q3 Q4

Lower Urinary Tract Infections in Older People

Diagnosis based on signs

and symptoms

Baseline 9/19

(47%) 38/52 (73%)

Q2 and Q3

73/102 (71.5%)

Q2, Q3 and Q4

108/153 (71%)

Dipstick not used to justify

diagnosis 14/19 (74%) 39/52 (75%)

Q2 and Q3

75/102 (73.5%)

Q2, Q3 and Q4

119/153 (78%)

Antibiotics in-line with

guidance 12/19 (63%) 42/52 (81%)

Q2, Q3 and Q4

81/102 (79%)

Q2, Q3 and Q4

123/153 (80%)

Urine sent for culture 11/19 (58%) 41/52 (79%) Q2, Q3 and Q4

82/102 (80%)

Q2, Q3 and Q4

120/153 (78%)

Antibiotic prophylaxis in

Colorectal Surgery 91.6% 92.4% 97.6% 99.0%

Anti-Fungal Stewardship Achieved Achieved Achieved Achieved

Antibiotic consumption

The current target is to reduce our total antibiotic consumption by 1% from 2018 calendar year baseline. Our

performance was 5.5% higher than baseline.

Data has continued to be produced during the COVID -19 pandemic with March 2020 seeing the highest

antibiotic consumption levels across the Trust in the last five years.

Due to the lack of an e-prescribing system, there is no real-time measure of antibiotic consumption and

figures are based on stock issues. Therefore this data does not take into account whether it is appropriate

antibiotic use.

The impact of the UTI quality improvement work

NUH has greatly improved the way it diagnoses and treats UTIs in older people. This reflects the large

amount of quality improvement work that has been done in this area and the uptake of the ‘skip the dip’

training by Trust staff.

High level priorities and ambitions for 2020/21

To engage the public on antimicrobial resistance, with attendance at the NUH Patient Partnership Group

to discuss this

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To continue the great progress being made to including AMS within Trust mandatory training for all staff

groups

In the absence of e-prescribing, to review patient level antibiotic consumption data from high

consumption areas

To continue to embed diagnostic stewardship principles within the Trust to improve the way we

diagnose and manage infection.

Recognise and Rescue (R&R) the Deteriorating Patient

R&R aims to improve the care of the deteriorating patient by reducing and preventing avoidable harm from

clinical deterioration. This is achieved through early recognition and reducing avoidable delays in escalation

of unwell patients, reducing critical care admissions and reducing cardiac arrest. NUH has employed a

Matron from September 2019 to lead the R&R programme of work with oversight from the Associate

Medical Director for Patient Safety. The R&R education committee was reinstated January 2020. The R&R

committee has agreed priorities for 2020/21, which include delivery of improved outcomes associated with

Community Acquired Pneumonia, implementation of the NEWS2 deteriorating patient CQUIN, maintaining

our excellent Sepsis care and introducing standardised handovers in clinical practice.

2019/20 Safety Priorities and deliverables:

Timely escalation and response to deteriorating patients

Roll-out of the new National Early Warning Score (NEWS) 2 system

NEWS2 was successfully rolled out across the Trust on 25th June 2019 following mandate from NHS England

and Royal College Physicians. NEWS2 has been found to be more sensitive than the historic scoring system

and a review of our electronic observations system data (Nervecentre) indicates that there has been a 4%

increase in the total number of e-Observations taken and a 31% increase in the total number of escalations.

NUH has shown the achievement of over 72% of all clinical observations performed on-time across the Trust

during 2019/20, which has fallen slightly since introduction of NEWS2. Consistently NUH’s principle acute

admission areas continue to show over 80% of clinical observations were taken on-time during 2019/20.

In-depth clinical evaluation has been carried out to ascertain compliance with NEWS2 policy with varying

results. National compliance targets with escalation in response to NEWS2 do not exist due to insufficient

data nationally, leading to a challenge with benchmarking. However, the compliance rate at NUH is similar

and in several instances is higher than one other comparable trust that has completed similar in-depth

evaluation. The NEWS2 evaluation reported that 83% (n=256/309) of patients were rated as receiving good

or excellent care, 13% as adequate, 3.6% poor care and 0.3% (n=1) as very poor care (the latter was

confirmed as already under investigation). We will work on setting interim local targets for improving timely

response to acute deterioration and implement the deteriorating patient CQUIN for 2020/21.

Reducing avoidable harm and death associated with missed opportunities to identify and respond to

deteriorating patients

The risk associated with failure to rescue remains high (20), which is in keeping with trends across other NHS

Trusts and is recognised nationally as a safety priority. NUH rate of cardiac arrests is lower than the national

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median and comparing the same three month period pre and post roll-out of NEWS2, cardiac arrest rates

suggest a slight downward trend.

Improved outcomes for patients

All patients screened for sepsis within 1 hour of admission

92% of all patients diagnosed with high risk sepsis receive antibiotics within 1 hour of confirmed

diagnosis

During 2019/20, NUH continued to maintain good management of patients with High Risk Sepsis as outlined

in the NHS Standard Contract. Introduction of a “Sepsis screening and bundle toolkit” in Midwifery services in

May 2019 further strengthened the already high rate of screening.

Antibiotic compliance <1hour as per Standard Contract requirement 2019/20

NUH has consistently achieved greater than 90% of patients being screened for high risk Sepsis electronically,

and on average 91.5% of patients audited receive antibiotics within one hour of diagnosis with High Risk

Sepsis (see graph above for Antibiotic compliance <1hour as per Standard Contract requirement 2019/20).

Adherence with general Sepsis management as per the Quality Standard (NICE QS161) continues to be

monitored and well adhered to (see average times for each key stage of the sepsis bundle).

In addition, 92% of patients had timely blood cultures taken in Q4 which provides valuable opportunity for

good antimicrobial stewardship, with timely diagnostics to enable targeted antibiotic therapy.

Ensuring that NUH identifies and manages Septic patients appropriately is key to reducing mortality and

morbidity. The key actions undertaken during 2019/20 to support this have been:

Maintenance audit as outlined in the NHS Standard Contract

Bimonthly delivery of Sepsis Survivor Support groups sponsored by the UK Sepsis Trust

70%

75%

80%

85%

90%

95%

100%

Apr 19 May 19 Jun 19 Jul 19 Aug 19 Sep 19 Oct 19 Nov 19 Dec 19 Jan 20 Feb 20 Mar 20

Compliance with IVAb <1hr as per NHS Standard Contract and CQUIN Definition Target

Page 19

Strengthening of Sepsis Link Staff across all clinical areas

Continued Sepsis education to all clinical staff

Intensive work focussed on the Emergency Department in support of prompt identification of Sepsis.

This included sending two sets of blood cultures [which is gold standard] in a timely manner. The

national requirement is one set (between 60-80% of NUH ED patients have 2 sets sent) and

administration of antibiotics, with encouraging results (see graph below)

An electronic Sepsis bundle has been designed and tested and is due to be rolled out in April 2020.

Do Not Attempt CPR (DNACPR)

NUH’s DNACPR Quality Improvement project is a response to the CQC ‘must do’ action that “the Trust must

ensure that DNACPR forms are fully completed and conversations with patients and relatives are

documented in the patient’s medical records”.

Progress to date includes collaborative working across all Divisions through the DNACPR Steering group,

which aims to enhance the experience of patients and their families in relation to the DNACPR decision and

support implementation of the actions required to meet the CQC recommendations for the Trust.

Key interventions in 2019/20:

Identification of improvements to the DNACPR form and dissemination of a new form throughout NUH

Identification and definition of trajectories to work towards attainment of required standards

Attending ward rounds on an acute medical admissions ward, reviewing current DNACPR decisions and

engaging with medical and nursing teams

Flow mapping the DNACPR process to identify barriers

Engagement with Patient Partnership representation in identifying required improvements from the

patient’s perspective

Identification of clinical areas in which to focus improvements.

Initial improvements have been identified in small sample areas following key interventions.

Focus for 2020/21:

Roll out of ward-round clinician review of the DNACPR decision, to ensure all elements are completed

and that the decision is supported by the patients’ consultant

Observation of the DNACPR pathway in the Emergency Department to guide future improvement

programmes

Review current educational strategies and develop platforms for further support in ‘having difficult

conversations’, Mental Capacity Assessments’ and ‘DNACPR decision making’

Introduce a standardised audit process to measure the impact of improvement strategies and allow

comparison of results through Qliksense

Commencement of individual clinician feedback reports

Implement an electronic fluid management system

A standardised handover process will be defined and implemented to improve transfer of critical

information within and across teams.

https://www.resus.org.uk/dnacpr/do-not-attempt-cpr-model-forms/

Page 20

Medication optimisation

There has been a Trust-wide focus on Medication Optimisation in 2019/20 including:

The review and update of the Trust’s vitamin K antagonist prescription chart with the supporting policy

and quick reference guide to support all staff with the safe prescribing, supply and administration of all

vitamin K antagonists

Trust-wide audit of omitted doses of critical medication resulting in:

o Further improvement and audit work around the documentation of omitted critical medicines

o Launch of the critical medicines poster on the Trust clinical guidelines intranet and app

Successful implementation of an electronic referral mechanism to community Pharmacy at the point of

discharge to reduce medication related harm across interfaces of care

Implementing further actions to ensure safe storage, supply and administration of potassium

permanganate to reduce the risk of severe harm or death from ingesting potassium permanganate

Review of the resources, procedures required for the safe prescribing, administration and monitoring of

gentamicin for in-patients

Resources to support the safe prescribing and administration of insulin doses (short and long acting)

The introduction of regular five minute medicines safety messages for all junior medical staff

Progression of quality improvement projects to support the management of key medicines priorities

Successes include:

o The introduction of an acute pain guideline for adults to support better pain management and

strong opioid prescribing

o Collaborative working with primary care to reduce risk of readmission with harm events due to

interactions with anticoagulants

o Pilot of a Pharmacist led medication review targeting patients identified as high risk for falls.

Digital solutions are being designed to support the scalability of the intervention

o Development of a digital tool, supported by an enhanced clinical pharmacy model in ED to target

medicines reconciliation at the point of entry to NUH

We have fully implemented the recommendations of national alerts including:

Risk of death and severe harm from ingesting supra-absorbent polymer gel granules.

The medicines optimisation priorities for 2020/21 include:

Improving the safety and quality of prescribing and administration of anticoagulants, opioids and

insulins

Reducing unintentional missed doses of medication

Further digitalisation of medicines systems within the Trust

Patient Experience

NUH is committed to providing services to patients which value people and act in their best interests.

Patients and their families will be treated with respect, compassion and understanding. We have measured

this through our real-time local patient survey with the following results (on average, 1,000 inpatients per

month complete this survey):

During the year 97.3% of our patients reported that they were treated with dignity and respect whilst in

hospital

92.4% of our patients reported that they were involved in decisions about care and treatment

87.1% of our patients were aware of who the nurse looking after them was on any given day

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80% of our patients were given information on how to provide feedback on the quality of their care.

In 2019/20 there has been a significant focus on Dementia Carers and their feedback about our services:

97.4% of Carers of Dementia patients recommended the support the ward gave them

75.8% of Carers of Dementia patients had been asked before if they were a carers

86.9% of Carers of Dementia patients have been involved in care and worked with patients as a carer

76.3% of Carers of Dementia patients have been given information about the support they could get as a

carer

Development of SWAN occasion boxes to facilitate weddings or for example an early Christmas. These

have been funded by the Nottingham Hospitals Charity

Development of cultural, spiritual and religious resources for a range of faiths that wards can access

through the Chaplaincy to meet these needs at end of life

We have seen a number of ward developments and an increase in staff resourcefulness to meet patients

and family’s needs, which is the very essence of SWAN, which offers compassionate support to patients

in their last days of life and to their families into bereavement.

Patient Priorities for 2020/21 include:

Implementing the year two milestones of the Trust-wide Dementia Strategy 2019-22

Improving the identificationand support of carers

Improving and standardising customer care across the organisation.

Reduce patient waiting times in the Emergency Department

Our ambition to reduce unnecessary delays in the Urgent and Emergency Care pathway remains a significant

challenge for NUH.We have worked relentlessly to improve systems and processes within our Emergency

Department, across the hospital and wider system to improve flow and reduce discharge delays during

2019/20. The transformation of urgent and emergency care at NUH is a highly ambitious project to ensure

that our patients receive high quality, timely care, in the right environment. We are disappointed that too

many of our patients waited too long in ED and we continue efforts to improve this situation.

Last summer the Prime Minister asked the NHS to undertake a clinical review of current emergency access

targets. NUH was selected as one of the field testing sites (one of 14 Trusts across the country) and has been

reporting against new standards since May 2019. Due to our participation in the national pilot, we are not

able to publically share performance information. Our duty to our patients and focus remains unchanged

whereby we aim to improve the timeliness of emergency patient care and overall patient experience.

The first phase of testing focussed on the total time in the Emergency Department (ED) with indicators

relating to mean time in the department and number of 12-hour waits from time of arrival. Following the

first phase of testing, an initial ‘target’ mean time in the department was set as 200 minutes or less. The

second phase of testing commenced at the end of July 2019 and included additional measures, including

mean time to initial assessment and mental health metrics. This includes the time it takes to get a

psychological assessment and how long it takes for patients to be transferred to mental health beds.

Page 22

From October we have also been asked to measure the time that patients spend in ED from the time that

they are fit to transfer to an inpatient ward (which we call the “fit for ward time”).

From the start of October we have also been reporting on measures associated with “Critical Hour Standards

(CHORUS)”. These are submitted monthly and include measures of our response to abnormal patient

observations within ED, as well as our hospital’s response to heart attacks and strokes.

The Emergency Pathway Transformation Programme has helped us throughout this period to focus on

several areas that were designed to help to reduce delays and improve patient care in the inpatient journey.

This included four workstreams:

Work stream 1 - Front door and assessment

Improvements and rightsizing ED Medical workforce capacity

Improvements in internal operational processes

Maximising the use of our Clinical decision Unit

To improve the amount of patients receiving same day emergency care.

Work stream 2 - Internal Flow Reducing delays associated with patient movement.

Work stream 3 - Specialty Flow Reducing delays associated with assessment areas.

Work stream 4 - Integrated discharge Reducing the volume of long stay patients and the

amount of time patients wait after being made medically safe for discharge.

The Emergency Care Transformation Programme has highlighted that we do not have consistent flow

through the hospital and out into the community and that is a significant contributing factor to the on-going

challenges in ED. The programme of work is continuing to develop, with a focus on developing the actions to

address the contributing factors of the variation in flow of patients during 2020/2021.

Patient-Led Assessments of the Care Environment (PLACE) assessment

Our PLACE inspections enables our patients and hospital staff to share their views on standards of

cleanliness, food and hydration, privacy and dignity and whether the premises are equipped to meet the

needs of people with dementia or with a disability.

The results were published at the end of January 2019 and are an important measure of the non-clinical

experience of patients, from the public who will experience our services and from staff who work in these

environments.

Services are reviewed against standards patients deem to be important and we use the results from these

inspections alongside other feedback through the year.

Actions are taken on the day through the Estates and Facilities Management Helpdesk and plans are

developed to further improve services.

We appreciate the feedback and involvement from our 18 patient assessors who undertook 49 inspections

over six days that enabled us to improve our facilities and services.

Please note the 2019 results are not comparable with those in previous collections due to a large scale

national review and question set changes.

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The Estates and Facilities Management Team review the results alongside the feedback received throughout

the year, much of which gives more real-time feedback about what patients think of the environment and

related standards at our hospitals. This includes monthly cleaning audits, results from the annual patient

surveys, friends and family test results, as well as online and social media feedback e.g. NHS Website, Care

Opinion, Twitter and Facebook.

2019 NUH % scores: QMC campus City Hospital

campus Ropewalk

House Treatment

Centre

Cleanliness 96.56 98.76 100 97.92

Food 90.52 91.69 N/A N/A

Food organisational 100 100 N/A N/A

Ward food 89.18 90.61 N/A N/A

Privacy, dignity and well being 81.82 82.89 85.19 83.87

Condition and appearance and maintenance

93.37 96.44 94.37 93.04

Dementia 62.76 70.39 69.57 57.97

Disability 69.46 74.16 64.29 62.26

QUALITY ACCOUNT PART 2:

2.2 Statements of Assurance from the Board

During 19/20, NUH provided 157 NHS services as identified in Schedule 2A of the contract between the Trust

and its principal Commissioners and NHS England. NUH has reviewed all the data available to them on the

quality of care in all of these relevant health services.

The income generated by the relevant health services reviewed in 2019/20 represents 100% of the total

income generated from the provision of NHS services by NUH for 2019/20. The Trust’s review of quality of

care data for all contracted services is carried out via coding audit, a monthly confirm and challenge process

with commissioners, reviews by Divisions for accuracy and improvements in manual data processes.

The table below provides a summary of the income generated through the commissioned health services for

2019/20:

NHS England services: Total contract income £385,013,337

Acute Services £280,089,052

Cancer Services £90,127,734

Diagnostic screening and/or Pathology £4,223,585

Radiotherapy Services £10,572,966

Clinical Commissioning Groups: Total Contract Income £508,032,502

Accident & Emergency (A&E) £31,549,827

Acute Services £386,157,768

Cancer Services £74,782,528

Diagnostic, Screening and/or Pathology £15,542,379

Page 24

Cancer Drugs Fund, NHS England (national) £7,841,911

Review of Clinical Strategies/Trust Strategy

Ensuring our patients receive consistently high quality, safe care, with outstanding health outcomes and

experience is at the centre of all we do. Following the launch of our revised Trust strategy (2018-2028), we

have defined clear ambitions for our patients in order to think differently about how we deliver safe, high

quality and effective care.

We have six strategic objectives (called our 6 Promises, or 6 ‘Ps’ for short). These are:

Our patients: We will ensure our patients receive consistently high quality, safe care with outstanding

outcomes and experience

Our people: We will build on our position as an employer of choice; with an engaged, developed and

empowered team that puts patient care at the heart of everything it does

Our places: We will invest in our estate, equipment and digital infrastructure to support the delivery of

high quality patient care

Our performance: We will consistently achieve our performance standards and make the best use of

resources that contribute to an affordable healthcare system

Our partners: We will support the improvement of the health of the communities we serve through

strong system leadership and innovative partnerships to deliver integrated models of care

Our potential: We will deliver world-class research and education and education and transform health

through innovation

Underpinning each promise, we have described key milestones for years one, two and three so that we can

closely monitor our progress, which we publish quarterly. Each year, detailed actions are created for the

current year milestones which form the basis of the Trust’s Annual Plan. This ensures specific plans are in

place for each area and service, which enables appropriate resources to be directed, to ensure achievement

of the vision and our promises. We are developing our priorities and milestones for 2020/21 as we respond

to Covid-19 and will publish these later in the year.

Our NUH Clinical Service Strategy provides a foundation to achieve our vision of being “outstanding in health

outcomes and patient and staff experience”. The underpinning drive is a paradigm shift towards focusing on

population health outcomes and holistic patient-centred care (Our Patients promise). We are not able to

deliver the required paradigm shift in isolation of our partners (Our Partners promise). As an organisation we

will also need to change the way we work and focus on new priorities that will have the biggest positive

impact on our population.

To respond to our population health challenges, we have established five planning principles for our services

to adopt as they transform over the next 5-10 years in order to support the Trust’s vision.

• Planning principle one: Person-centred care and how we manage multiple health conditions

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• Planning principle two: Focussed clinical priority conditions on the most pressing areas of health need

to improve our overall population health outcomes (Clinical areas include: Cardiovascular diseases

(CVD), Diabetes (Endocrine), Cancer, Respiratory diseases, Musculoskeletal disease, Healthcare of Older

People (including Frailty/Dementia) and Gastroenterology. We also know that we will continue to

deliver core services that our population will need such as: Accident and emergency, major trauma,

maternity and neonatal services and diagnostic services

• Planning principle three: Embedding Health promotion, prevention and holistic care

• Planning principle four: Developing Partnerships to deliver high-quality specialised services

• Planning principle five: Driving clinical innovation and emerging technologies.

We are embedding our five planning principles at all levels in the organisation to influence how we do

business and create the right focus to improve population health outcomes. We use our five planning

principles to:

1. Inform our clinical approach: The principles provide a reference point to ask ‘does what we’re doing

support the Clinical Service Strategy?’ (For example we will now ask this question as part of our annual

planning process)

2. Agree priorities: The principles provide clear criteria to inform our future investment e.g. infrastructure,

staffing and transformation projects

3. Transform our clinical decision-making: The principles and priorities provide a strong steer and underpin

our future approach to planning and decision-making, organisational structures and support

mechanisms at all levels including service/specialty level.

Our enablers to making it happen

Our staff engagement highlighted a number of barriers to delivering our Clinical Service Strategy ambitions

that span all five principles. From this we have identified five enablers that provide the building blocks to

making this happen, and suggest how we will take this forward.

• The ICS Long-term plan will promote better integration of care and sharing of information and will

identify key priorities for delivery in both the short and long-term

• Aligning our planning process to our Clinical Service Strategy (e.g. investment, capacity planning, and

infrastructure). We will review our processes and develop new ‘quick’ approaches to facilitate rapid

investment and focus on areas of transformation, aligned to agreed priorities e.g. create a health

promotion and prevention fund

• Getting the basics right with our ICT systems. Review of systems to streamline, prioritisation of areas for

investment. Common systems across the ICS to share information; all electronic patient records,

including prescribing. Standardisation of data to improve transferability

• Involving patients in developing our plans for services to gain their perspectives and insights,

understanding the wider non-health issues (e.g. accommodation, access to ICT). Improved links with key

patient groups to gain feedback and perspectives to inform decision-making

• Leadership and leadership development will promote a culture change to embed our five planning

principles. Through leadership we will transform our approach to focus on our population heath needs

and ‘system’ ways of working within the ICS.

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Divisional performance management

NUH has six clinical Divisions: Medicine, Surgery, Cancer and Associated Specialties, Ambulatory Care, Family

Health and Clinical Support.

Each Division is led by a Divisional Leadership Team comprising a Divisional Director, Divisional General

Manager and Divisional Nurse/Midwife.

Each month our Divisional Leadership Teams are held to account for their performance against the Trust’s

agreed quality and performance targets, and with compliance against expected standards in each of their

clinical services. This accountability has been enhanced with the establishment of an Operational Quality,

Risk and Safety Committee, chaired by either the Medical Director or Chief Nurse. Through the scheduled

reporting to this committee, Divisions are held to account for performance in the domains of safety,

effectiveness, patient experience and risk management. Additionally, during 19/20 Divisions have provided a

quality account to the Board committee, the Quality Assurance Committee, twice a year against the same

domains.

In 2020/21 a sixth Division will be formed incorporating a number of specialities with a focus on ambulatory

care. The Treatment Centre will form part of this Division.

Developing our quality priorities with patients, families and carers

Our quality improvement priorities are based on feedback from our patients, carers and staff, and on

national standards and developments. We have engaged and worked with our patients, public and carers

from the communities we serve and with staff through a range of meetings and events, including:

NUH Patient Partnership Group

NUH Patient and Public Involvement Steering Group (PPISG)

NUH Divisional Patient and Carer Groups

Healthwatch (Nottingham City and Nottinghamshire)

NUH Public Members

Page 27

Health Scrutiny Committees (County and City)

External Visits, Audits and Peer Reviews

Patient safety conversations between Board members and ward/department teams

We also collect regular feedback through the year from: National and local surveys, the ‘Friends and Family’

Test, complaints, concerns, comments and compliments, social media and online feedback. This helps us to

identify areas where patients say they wish to see improvements.

In 2019/20, we held 479 patient and public involvement events with 10,195 participants. PPI Events included

the Daisy Awards, Bowel Cancer Awareness Events, Memory Menu Tasting, BAME Networks, Patient Safety

Leaflet Review, Local Community Engagement Events, Team NUH Awards and Carers Drop in Sessions. PPI

Groups also supported our Neonatal Unit achieving the Bliss Baby Charter Accreditation Award which

recognises high quality family-centred care delivered against seven core principles.

Our quality priorities for 2020/21 have been developed from PPI and Engagement Events, consultation and

feedback with our local communities. The priorities reflect the things that our people and patients have told

us are important to them. They will be monitored through our Quality Governance Committees with regular

updates from the priority leads.

Our quality priorities for 2020/21

Priority 1 - Improve Patient Experience


Improve patient, family and carer experience of loved ones with dementia

Implement the Trust’s Dementia Strategy

Implement year one objectives.

Improve the quality of complaint investigations and responses

Implement the Complaints Quality Improvement Plan

Reopened complaints (% of total closed complaints) will be ≥15%.

By the end of 2020/21, 100% of all nominated complaint investigators will be trained.

By the end of 2020/21, 25 complaint case Peer Reviews will have been completed.

A pilot will be evaluated to achieve ≥10% improvement in meeting agreed complain response timescales within 30 working days.

Provide timely and useful patient information

Information leaflets will be accessible and in a format that meets patient, carer and family needs

By the end of 2020/21, 100% of all patient leaflets will be updated within review dates.

A review of the Patient Information Service will have been undertaken and a Trust-wide Strategy and Policy developed.

Page 28

Priority 2 - Improve Patient Safety














Optimise information flow by

implementing a standardised

handover process

A standardised handover

process will be defined and

implemented to improve

transfer of critical

information within and across

teams.

Initial work will focus on a

daily clinical handover at the

end of the day on City

Hospital campus based

medical admission areas.

Standardised process (such as

SBAR) to be implemented for

use in adult emergency

admission areas and at internal

transfer of patients.

Page 29

Priority 3 - Improve Clinical Effectiveness


Improve the way we plan and respond at the end of life with patients and families

Focus on improving conversations and documentation of Do Not Attempt Resuscitation (DNACPR) decisions

100% of patient demographics will be completed fully on the DNACPR forms by June 2020.

A date to review the decision will be documented on 100% of forms by December 2020.

100% of forms will have a valid clinical reason for DNACPR decision documented by June 2020.

100% of patients requiring a Mental Capacity Assessment (MCA) will have this completed by September 2020.

Conversations will occur with the patient and family and these conversations will be documented in 100% of instances by June 2020 (the achievement date for this measure will be extended due work stream delays during the COVID-19 pandemic).

90% of patients and/or their family will receive a DNACPR leaflet by December 2020.

Improved Local Surveys Programme

Develop and enhance our Local Surveys Programme to identify actions for improvement

Establish a tool and benchmark to define improvement target during Q1.

Identification of a defined number of projects (≤5).

Implementation of agreed improvement goals in line with Trust objectives during Q2-Q4.

Align improvement resources to support delivery of Trust objectives

Develop a programme of Trust-wide Quality Improvement projects aligned to Trust objectives

Scope current projects and map to objectives in Q1.

Identify priority projects and implementation plan during Q2.

Implementation of agreed priority projects during Q3 to Q4.

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Commissioning for Quality and Innovation (CQUIN) goals agreed with commissioners for 2019/20

A proportion of NUH’s income in 2019/20 was conditional on achieving quality improvement and innovation

goals agreed between the local Clinical Commissioning Group (CCG) and NHS England Specialist

Commissioners. For the period 2019/20 the base line value for national and specialised CQUIN was £10.5

million.

Due to COVID-9, we have not been able to progress end of year achievement assessments with our Clinical

Commissioning Partnership, PHE or NHSE leads. The below achievement statement is therefore based on an

internal review by all scheme leads, commissioned by the NUH CQUIN Steering Group. Our achievement

assessment will be updated should this change following Clinical Commissioning Partnership, PHE and NHSE

sign-off.

2019/20 CQUIN Scheme Title: 2019/20 CQUIN Scheme Description Scheme

achievement

Achieving 80% uptake in flu vaccinations for front-line staff (TC-CCG2)

Achieving an uptake of flu vaccinations by frontline clinical staff of 80%. Improving the uptake of flu vaccinations for front line staff within Providers.

Achieved

Alcohol & Tobacco screening and brief advice (TC-CCG3)

Percentage of unique Treatment Centre inpatient cohort screened for both smoking and alcohol risk status, and results recorded in patient's record. Percentage of identified eligible patients (recorded as drinking above low risk levels or identified smokers) have been given brief advice as outlined in the alcohol and tobacco brief interventions E-Learning programme, or offered a specialist referral.

Partly achieved

Offering advice and guidance (TC-CCG12)

Providers to report on which Treatment Centre specialties are covered by Advice and Guidance (A&G) services, which will be linked to data to quantify performance. Demand on elective specialties covered by A&G should be tracked locally to provide insight on the impact of the service.

Achieved

Antimicrobial resistance - lower UTI in Older People (CCG1a)

Percentage of antibiotic prescriptions for lower UTI in older people (65 years +) meeting NICE guidance for lower UTI (NG109) and PHE Diagnosis of UTI guidance in terms of diagnosis and treatment. Recurrent UTI is excluded, where management is antibiotic prophylaxis, pyelonephritis and catheter associated UTI.

Achieved

Antimicrobial resistance - antibiotic prophylaxis in Colorectal surgery (CCG1b)

Percentage of antibiotic surgical prophylaxis prescriptions for elective colorectal surgery patients (18 years +), being a single dose and prescribed in accordance to local antibiotic guidelines.

Achieved

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Efforts for Reducing Smoking at the Time of Delivery (CCG3)

To localise the National CQUIN for reducing smoking at the time of delivery (SaToD), and work collaboratively with all partners across the local health system with providers being challenged to be the system leaders, be innovative with service improvements, provide services, skill staff and educate and support future mothers to quit smoking.

Achieved

2019/20 CQUIN Scheme Title: 2019/20 CQUIN Scheme Description Scheme

achievement

Same day Emergency care (CCG11)

Percentage of patients with confirmed pulmonary embolism (PE), atrial fibrillation (AF) and community-acquired pneumonia (CAP) being managed in a same day setting where clinically appropriate (total number of patients attending ED, aged 18 years + who are discharged to usual place of residence on the same day as attendance/admission). Clinical exclusion criteria applied.

Partly achieved

Medicines Optimisation and Stewardship (PSS1)

To support the procedural and cultural changes required to optimise use of medicines commissioned by specialised services through a series of procedural and cultural changes.

Achieved

Supporting Hepatitis C Virus (HCV) Elimination (PSS2)

To respond to the WHO strategy for elimination by 2030 and NHS England’s ambition to accelerate this to 2025, with increased focus on improving treatment of diagnosed patients and increasing rates of testing and diagnosis. Whilst the wider health and social care system has a role to play, ODNs, as expressed in the service specification, have a leadership role to play in supporting these actions.

Achieved

Cystic fibrosis; supporting self-care (PSS3)

To support changes in clinician and patient behaviour that will transform Cystic Fibrosis (CF) care from an emphasis on clinician led reactive hospital based rescue, to patient led community based prevention.

Achieved

Severe asthma specialised care review (PSS8)

To promote a networked model of care as a vehicle for delivering an optimal pathway and maximising patient outcomes and experience.

Achieved

Cirrhosis Care bundle (PSS14)

Improve patient care and reduced care costs through a network model to ensure adoption of nationally developed clinical guidelines and policies regarding management of patients with decompensated cirrhosis. The network should be rolled out and developed over three years. First stage implementation to be rolled out.

Achieved

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Neonatal Outreach (PSS Local)

To improve community support and to take other steps to expedite discharge, pre-empt re-admissions, and otherwise improve capacity within the neonatal unit for those babies requiring a higher level of care and reducing out of Network transfers due to a lack of capacity.

Achieved

Identify and reduce local inequalities in Abdominal Aortic Aneurysm Screening (PHE1)

Continue to implement, monitor and evaluate a health inequalities action plan for the Abdominal Aortic Aneurysm screening programme (2-year CQUIN with two stages).

Achieved

Identify and reduce local inequalities in Breast Cancer Screening Programme (PHE2)

Develop, implement and evaluate a health inequalities action plan for the Breast Screening service (2-year CQUIN with two stages).

Achieved

Identify and reduce local inequalities in Diabetic Eye Screening Programme (PHE3)

Develop, implement and evaluate a health inequalities action plan for the Diabetic Eye Screening programme (2-year CQUIN with two stages).

Achieved

Care Quality Commission (CQC)

NUH has been registered with the CQC since its inception in 2010 and has maintained its registration without

conditions or enforcement action ever since, including 2019/20.

The Trust is registered by the CQC to provide the following regulated activities:

Assessment of medical treatment for persons detained under the Mental Health Act 1983

Diagnostic and screening procedures

Surgical procedures

Treatment of disease, disorder or injury

Maternity and midwifery

Termination of pregnancy

Family planning

The last comprehensive inspection of NUH (QMC and City Hospital campuses) took place between

20thNovember 2018 and 10th January 2019, when a total of seven core services provided by the Trust across

two locations were inspected. NUH was rated ‘good’ overall with the following individual ratings:

Page 33

In November 2019 the CQC undertook a standalone inspection of the children’s Sexual Assault Referral

Centre (SARC) and issued its inspection report in February 2020. These inspection findings do not impact on

the Trust’s ratings. The outcome of the inspection was as follows:

SAFE

CQC found that the service was providing safe care in accordance with the relevant regulations

EFFECTIVE

CQC found that the service was providing effective care in accordance with the relevant regulations

CARING

CQC found that the service was providing care in accordance with the relevant regulations

RESPONSIVE

CQC found that the service was providing responsive care in accordance with the relevant regulations

WELL LED

CQC found that this service was not providing well-led care in accordance with the relevant regulations,

specifically that “governance arrangements and board assurance on the safe and effective operation of the

SARC were underdeveloped”. The CQC issued four compliance actions in relation to this finding, all of which

are being actioned and monitored as part of the established CQC oversight arrangements.

It should be noted that the CQC explicitly stated that the impact of their concerns, in terms of the safety of

clinical care, were regarded as minor and that once the shortcomings had been put right the likelihood of

them occurring in the future was low.

Progress with the action plan from both inspections continues to be closely monitored by the Quality and

Safety Committee, with quarterly reports to both Management Board and the Trust Board’s Quality

Assurance Committee, augmented by regular quality visits by commissioners and NHS Improvement.

The action plan oversight arrangements were reviewed by internal audit who awarded a significant

assurance opinion in November 2019.

Page 34

As part of its engagement strategy, the CQC meets regularly with the Trust, undertakes visits to clinical areas,

holds focus groups with staff, and attends Trust Board meetings a minimum of twice a year.

Duty of Candour

Duty of Candour (DoC), Regulation 20 of the Health and Social Care Act 2008, is a statutory requirement for

all providers registered with the CQC. It covers any patient safety incident that appears to have caused, or

has the potential to cause, significant harm and requires the provider to undertake:

Initial disclosure of the incident

Provision of a written account

Completion of an investigation and sharing of investigation findings to include a formal apology.

At NUH, the Being Open Policy clearly outlines the requirements for the Trust to comply with Regulation 20

and the key responsibilities for staff are regularly shared and updated through mandatory training and

newsletters. Divisions are responsible for ensuring Duty of Candour occurs in those incidents that meet the

threshold and the Corporate Patient Safety Team ensures Duty of Candour occurs for any Serious Incidents

that occur.

During 2019/20, NUH undertook an audit of its compliance with Regulation 20 for all incidents of moderate

or above avoidable harm. The audit showed:

90% compliance with initial disclosure

73% compliance with written notification

61% compliance with follow-up.

NUH has explored its compliance and these results are influenced by the availability of information

evidencing Duty of Candour. NUH has an open and transparent culture which has been recognised.

Improvements during 2019/20:

NUH continues to be open and honest after patient safety incidents

Being Open and Duty of Candour have been truly embedded in Serious Incident processes

In August 2019 the Corporate Patient Safety Team employed a Patient and Family Liaison Officer. This

role is new to the Trust and has evidenced early benefits in supporting patients, families and SI

investigation panel members

In May 2019- the Trust having undertaken significant engagement and re-design work- launched its

revised Duty of Candour guidance in the Trust, including bespoke patient/family letters co-designed with

patient involvement.

Areas for future improvement 2020/21:

Utilise local audit results and independent 360 assurance review findings to strengthen sharing of local

investigations where statutory candour is indicated

Formally evaluate the impact of the Patient and Family Liaison Officer role in conjunction with a Patient

Safety Academic.

Safeguarding Patients

Page 35

Safeguarding the health and wellbeing of all our patients remains a high priority for the Trust. The Trust is

committed to safeguarding all children, young people and adults at risk of abuse. We believe that everyone

has an equal right to protection from abuse, regardless of their age, race, religion, gender, ability,

background or sexual identity.

NUH continues to work to enhance safeguarding practice and standards across the whole organisation to

safeguard our most vulnerable patients and to continue to develop and embed a culture that puts

safeguarding at the centre of care delivery.

The Safeguarding Team continues to raise the profile of safeguarding across the Trust, the aim being for the

Safeguarding Team and the process to be integrated into the work of NUH. The team are visible and staff feel

informed and confident in accessing safeguarding advice.

NUH is recognised as a key multi-agency partner on, and a valuable contributor to, local adult safeguarding

boards and children’s partnerships.

Key achievements in 2019/20:

The safeguarding team has been strengthened to meet the increasing demand

During 2019/20, the mandatory training theme for training was ‘Back To Basics’ which was delivered as

part of our three year cycle of training with a different area of focus in each of the three years

Launch of a new IT system for the safeguarding team, enabling better information sharing with the

clinical teams and improving the collection of data

Representation by the Safeguarding Team on a number of serious case reviews, rapid reviews,

safeguarding adult reviews and domestic homicide reviews. The Trust continues to play a full part in

safeguarding across the region. Partnerships with our multi-agency partners continue to be

strengthened year on year.

Priorities for 2020/21:

Implementation of the Liberty Protection Safeguards.

Participation in National Clinical Audits 2019/20

The NUH 2019/20 Clinical Audit Programme consisted of 356 registered projects, 183 (51%) of which were

registered on the database as “National Clinical Audits”.

A total of 116 (63%) of these ‘registered’ National Clinical Audits were described in the NHS

England/Healthcare Quality Improvement Partnership (HQIP) Quality Account Schedule for 2019/20 (as

either National Clinical Audits or National Confidential Enquiries).

There were seven National Clinical Audits/Audit programmes which were deemed as not applicable to NUH

(i.e. we do not provide that particular type of service or participation was not required by the organising

bodies) and so were excluded from the 2019/20 Clinical Audit programme. These are as follows:

2019/20:

Specialty Audits that NUH has not participated in:

Respiratory Medicine National Audit of Pulmonary Hypertension

Upper GI Surgery National Bariatric Surgery Registry (NBSR)

Page 36

Rheumatology National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis

(NCAREIA)

Trust-wide National Clinical Audit of Psychosis

Surgery Prescribing Observatory for Mental Health (POMH-UK).

Trust-wide National Clinical Audit of Anxiety and Depression (re-confirmed with Royal

College of Psychiatrists 01/03/19).

Children & Young People National Child Mortality Database (NCMD)

Of the 116 National Clinical Audits and National Confidential Enquiries registered on the Trust Clinical Audit

Database that NUH were expected to participate in from the NHS England/HQIP Quality Account schedule,

we participated in 115 (99%).

The National Audit that was registered on the Trust Database that NUH is understood to provide the service

for but for 2019/20 did not participate in were:

“Society of Acute Medicine Benchmarking Audit” (SAMBA) - it was felt that there was little return in

terms of learning for the specialty, due to the very small sample size after the specialty underwent

operational redesign. The National Lead was made aware and agreed for 19/20 exemption.

In addition to the 116 National Audits ‘registered’ on the Audit Database, there was one National Audit, that

NUH did not participate in, this was the National Audit of Seizure Management in Hospitals (NASH3)

2019/20.

The table below shows the number and percentage of cases submitted into each of the National

Audits/Confidential Enquiries: (Please note some audits may ‘appear’ to be duplicates, but they were either

carried over from the previous year’s audit plan (awaiting publication of the National Report) or, if the audit is

“continual data collection”, then a new audit ID will have been generated in order to enable NUH to comment

on that reports recommendations.

Specialty Audit Title Expected

Sample Size

Number

Submitted

Percentage of

participation

compliance

Audit

completed or

action plan

received National Audits carried over from 2018/19 and completed with action plan

Ophthalmology National Ophthalmology Database (NOD) Audit 2018 report

1198 1198 100% Yes

Renal Medicine Renal replacement therapy (Renal Registry)

1238 1238 100% Yes

Urology National Prostate Cancer Audit (2018/19)

655 655 100% Yes

Urology BAUS Urology Audit - Female Stress Urinary Incontinence (2018/19)

104 104 100% Yes

Neonatal Unit National Neonatal Audit Programme (NNAP) 2017 Report

1741 1741 100% Yes

PICU Paediatric Intensive Care Audit (PICAnet) (2017)

1723 1723 100% Yes

Page 37


Sample Size

Number

Submitted

Percentage of

participation

compliance

Audit

completed or

action plan

received

ED Adult RCEM Vital Signs in Adults (care in emergency departments) (2018/19)

262 262 100% Yes

Health care for Older people

National Dementia Audit Round 3 (2016)

100 69 69% Yes

Respiratory Medicine

National Lung Cancer Audit (NLCA) (2018/19)

492 492 100% Yes


UK Cystic Fibrosis Registry (2017/18) national report

215 215 100% Yes

Trust-wide NCEPOD Long Term Ventilation (patients 0-25 years old)

29 17 59% Yes

Colorectal Surgery

National Bowel Cancer audit (NBOCA) (2017/18) report

644 442 69% Yes

Gastroenterology IBD Registry Biologics audit 2018/19

1632 1632 100% Yes

Emergency General Surgery

National Emergency Laparotomy Audit (NELA) 2019-20 report

2263 2263 100% Yes

National Audits in the HQIP Quality Account list in 2018/19 and being repeated in 2019/20, but not as HQIP Quality Account Audits Oncology & Radiotherapy

National Small Cell Bladder Cancer Audit (2019/20)

27 27 100% Yes

Trust-wide National Mortality Case Record Review Programme (NMCRR) (2019/20)

Continuous data

collection

Continuous data

collection

Continuous data

collection

Continuous data

collection

National Audits in the HQIP Quality Account 2019/20 with action plans

Breast Services National Audit of Breast Cancer in Older Patients (NABCOP) (2018/19)

700 700 100% Yes

Urology BAUS Urology Audit - Female Stress Urinary Incontinence (2019/20)

98 98 100% Yes

Cardiology

National Audit of Percutaneous Coronary Interventions (PCI) (BCIS) 2019 National Report

4796 4796 100% Yes

Ophthalmology

National Ophthalmology Database (NOD) 2019 Audit Report (2017-2018 Audit Data)

3138 3138 100% Yes


UK Cystic Fibrosis Registry (2018 report)

215 215 100% Yes

National Audits in the HQIP Quality Account 2019/20 and ongoing

Palliative Care National Audit of Care at the End of Life (NACEL) Round 2

40 40 100% -

Page 38


Sample Size

Number

Submitted

Percentage of

participation

compliance

Audit

completed or

action plan

received Palliative Care

National Audit of Care at the End of Life (NACEL)

81 81 100% -

Urology BAUS Urology Audit - Cystectomy

64 8 12% -

Urology BAUS Urology Audit - Nephrectomy

332 133 40% -

Urology BAUS Urology Audit - Percutaneous Nephrolithotomy (PCNL) (2019/20)

189 187 90% -

Urology BAUS Urology Audit - Radical Prostatectomy

316 221 70% -

Urology National Prostate Cancer Audit (2019/20)

595 595 100% -

Critical Care Case Mix Programme (CMP) - ICNARC

897 897 100% -

Children & Young People

National Clinical Audit of Seizures and Epilepsies in Children and Young People (Organisation Report 2018).

1 1 100% -


Paediatric Intensive Care Audit (PICANET)

3451 3451 100% -


National Paediatric Diabetes Audit (NPDA) 2019/20

376 376 100% -


Child Health Clinical Outcome Review Programme 2019/20 (NCEPOD)

29 17 58.6% -

Maternity

Maternal, Newborn and Infant Clinical Outcome Review Programme - MBRRACE - UK

See individual studies in

this document

See individual studies in

this document

100%

See individual

studies in this document

Maternity

National Maternity and Perinatal Audit (NMPA) UK Perinatal Deaths for Births from January to December 2017

8407 8407 100% -

Neonatal Unit

Intensive and special care: Neonatal (inc. National Neonatal Audit programme - NNAP) (2019/20)

1504 1504 100% -

Acute Medicine Society for Acute Medicine's Benchmarking Audit (SAMBA)

NUH did not participate



Divisional Governance

aware

Cardiology National Audit of Cardiac Rehabilitation

685 685 100% -

Page 39


Sample Size

Number

Submitted

Percentage of

participation

compliance

Audit

completed or

action plan

received

Diabetes & Endocrinology

National Diabetes Inpatient Audit 2019

Figures not expected until May

2020


2020


2020

ED Adult RCEM Mental Health - Care in Emergency Departments 2019

42 42 100% -

ED Adult

RCEM Assessing Cognitive Impairment in Older People /Care in Emergency Departments

132 132 100% -

ED Paediatrics RCEM Care of Children in Emergency Departments

292 292 100% -


National Asthma Audit (NACAP) Adults

273 273 100% -


BTS National Smoking Cessation Audit

216 216 100% -


Cancer: Lung (NLCA) 2019/20

Continuous data

collection, awaiting

collation of report

Continuous data


collation of report

Continuous data


collation of report

Data still being

collected

Stroke National Audit of Dementia Round 4 (2018)

148 148 100% -

Stroke Stroke: Sentinel stroke national audit programme (SSNAP) (2018/19 report)

1213 1213 100% -

Trust-wide UK Parkinson’s National Audit

40 40 100% -

Elective Orthopaedics

Elective Surgery (National PROMs Programme) 2019/20

1798 1798 100% -


Elective Surgery (National PROMS programme) (2018/19)

1715 1715 100% -


Joint replacement surgery: the National Joint Registry (NJR) 2019/20

1798 1798 100% -


National Emergency Laparotomy Audit (NELA) 2018/19 REPORT

363 363 100% -

Endocrine Surgery

Endocrine and Thyroid National Audit 2019/20

218 218 100% -

ENT Cancer: Head and neck cancer audit (HANA) 2019/20

GT reports Rishi

Srivastava to report back

asap

Awaiting

data

Gastroenterology National Gastro-intestinal Cancer Programme

GT reports Lindsay

Stevens is getting info

asap

Awaiting

data

Page 40


Sample Size

Number

Submitted

Percentage of

participation

compliance

Audit

completed or

action plan

received Gastroenterology

IBD: Inflammatory bowel disease 2019/20

2324 2324 100% -

Major Trauma Major Trauma Audit 676 676 100% -

Neurosurgery National Neurosurgical Audit programme (NNAP)

2200 2200 100% -

Orthopaedic Trauma

Falls and fragility fractures programme (FFFAP) (includes the Hip Fracture Database) 2019/20

834 834 100% -

Vascular Surgery National Vascular registry (NVR) (2018/19 report)

325 325 100% -

Pharmacy

Reducing the impact of serious infections (Antimicrobial Resistance and Sepsis) - Antibiotic Consumption (2018/19)

120 30 25% (Q3) Awaiting

data

Trust-wide National Cardiac Arrest Audit (NCAA) (2018/19)

541 541 100% -

Trust-wide

Mental Health Clinical Outcome Review Programme (NCISH) (2019/20)

N/A N/A N/A -

Trust-wide Mandatory Surveillance of bloodstream infections and clostridium difficile infection

Awaiting

data

Trauma and Orthopaedics

PHE Surgical Site Infection Surveillance Service 2019/20

2598 (JN) 2598(JN) 100% -

National Audits in the HQIP Quality Account list in 2018/19 and continuous data collection


National Paediatric Asthma Audit (NACAP) (Children)

78 78 100% - National Audits carried over from 2018/19 and awaiting completion


National Paediatric Diabetes Audit (NPDA) (2018 report) (2016/17 data)

351 351 100% -


National Paediatric Diabetes Audit (NPDA) (2017/18 data)

271 271 100% -

Urology BAUS Urology Audit - Percutaneous Nephro-lithotomy (PCNL) (2018/19)

74 74 100% -

Renal Medicine Renal replacement therapy (Renal Registry) (not on QA for 2019/20)

All cases at NUH from

our renal IT system direct

to the UK registry

All cases at NUH from

our renal IT system direct

to the UK registry

100% -

Page 41


Sample Size

Number

Submitted

Percentage of

participation

compliance

Audit

completed or

action plan

received Children & Young People

National Audit of Seizures and Epilepsies in Children and Young People

84 (1

Organisational) 84 (1

Organisational) 100% -

Neonatal Unit

MBRRACE Child Death Review (Perinatal Mortality Surveillance) January - December 2017 (Published October 2019)

77 77 100% -

Cardiac Surgery Adult cardiac surgery audit (ACS)

619 619 100% -

Cardiac Surgery GIRFT Programme National Specialty Report (Cardiothoracic Surgery)

1 1 100% -

Cardiology Myocardial ischaemia National Audit Project (MINAP)

1637 1586 97% -

Cardiology

NCEPOD Hospital Management of Out of Hospital Cardiac Arrest (OHCA)

18 18 100% -

Cardiology NCEPOD Acute Heart Failure Study

12 1 8% -

Cardiology National Heart Failure Audit (NICOR) 2019/20

1464 1351 92% -

Cardiology National Heart Failure Audit (NICOR) (2018 National report)

1464 1351 92% -

Cardiology National Audit of Percutaneous Coronary Interventions (PCI) (BCIS)

4796 4769 999%9 -


National Diabetes Inpatient Audit 2018

184 184 100% -

ED Adult

RCEM VTE risk in lower limb immobilisation (care in emergency departments) (2018/19)

127 127 100% -

ED Paediatrics RCEM Feverish Children (care in emergency departments) (2018/19)

136 136 100% -

ED Paediatrics NCEPOD Young Persons Mental Health Audit (YPMH)

8 7 88% -

Health care for Older people

NCEPOD Dysphagia in people with Parkinson’s Disease study

8 8 100% -


BTS Non-Invasive Ventilation - Adults

24 24 100% -

Page 42


Sample Size

Number

Submitted

Percentage of

participation

compliance

Audit

completed or

action plan

received Respiratory Medicine

BTS Adult Community Acquired Pneumonia (2018/19)

152 152 100% -


National Asthma and Chronic Obstructive Pulmonary Disease Audit Programme (NACAP) COPD clinical audit (for patients from 2017/18)

273 273 100% -


UK Cystic Fibrosis Registry 208 208 100% -

Trust-wide NCEPOD Non-Invasive Ventilation Study

5 11 45% -

Trust-wide NCEPOD Pulmonary Embolism

10 8 80% -

Colorectal Surgery

National Bowel Cancer audit (NBOCA) (2018/19)

189 189 100% -


NCEPOD acute bowel obstruction study

17 11 65% -

Major Trauma Trauma and Audit Network (TARN) (2018/19)

1942 1942 100% -

Neurosurgery GIRFT Programme National Specialty Report (Cranial Neurosurgery)

1 1 100% -

Ophthalmology GIRFT Ophthalmology - Surgical Site Infection 2019

N/A Awaiting

data

Ophthalmology National Audit for Cataract Surgery

1198 1198 100% -

Orthopaedic Trauma

Falls and Fragility Fracture audit programme (FFFAP) (Annual Report 2018)

806 806 100% -

Upper GI Surgery

National Oesophago-Gastric Cancer Audit report 2018 (NOGC) (version 2, March 2019)

273 273 100% -

Upper GI Surgery National Oesophago-gastric cancer audit (NOGCA) (2017 report)

334 334 100% -

Vascular Surgery National Vascular Registry (2016/17)

75 75 100% -


National Asthma and COPD Audit Programme (2017/18 National Report)

190 190 100% -

Trust-wide Learning Disability Mortality Review Programme (LeDeR) 2019/20

27 27 100% -

Audits that have been registered as “National Audits”, but not part of the HQIP Quality Account list

Page 43


Sample Size Number

Submitted Percentage

Blood Transfusion

National Comparative Audit of The Use of Fresh Frozen Plasma, Cryoprecipitate and other Blood Components in Neonates and Children

20 15 75%

Blood Transfusion National Comparative Audit 2018 Massive Haemorrhage Audit

10 6 60%

Blood Transfusion 2019 National Comparative re-audit of the medical use of red cells

80 0 0%

Breast Services Mastitis And Mammary Abscess Management Audit (MAMMA STUDY)

80 Not yet started

Not yet started

Breast Services Breast Angiosarcoma Surveillance Study 15 15 100%

Breast Services Neoadjuvant systemic therapy in breast cancer (previously under ID 17-316C)

13 13 100%

Breast Services GIRFT Breast Surgery N/A 22 100%

Breast Services

The iBRA-2 Study - A National prospective multi-centre audit of the impact of immediate breast reconstruction on the delivery of adjuvant therapy (see project ID 16-938C)

86 86 100%


NCEPOD Chronic Neurodisability Study 8 6 75%


Sample Size Number



National Audit of Paediatric Stoma patient outcomes

25 25 100%


NCEPOD Cancer in Children, Teens and Young Adults

12 10 83%


Phototherapy Service Audit 20 20 100%

Clinical Pathology GIRFT Thrombosis Survey 2019 120 120 100%

Colorectal Surgery

Postoperative ileus and provision of management after colorectal surgery (IMAGINE)

32 32 100%

Colorectal Surgery

International, prospective snapshot collaborative audit of acute diverticulitis (DAMASCUS)

4000 Postponed


NCEPOD Peri-operative management of surgical patients with diabetes

18 8 44%


GIRFT Programme National Specialty Report (Orthopaedic Trauma)

1 1 100%


GIRFT Orthopaedic Surgery - Surgical Site Infection 2019

N/A 860 100%

ENT GIRFT Programme National Specialty Report (ENT)

1 1 100%

ENT Head and Neck Cancer Surveillance Audit 2018 (BAHNO)

190 190 100%

ENT National Epistaxis Audit 1826 1826 100%

Page 44

ENT GIRFT ENT Surgery - Surgical Site Infection 2019

N/A Awaiting data

Gastroenterology RICOCHET audit 56 56 100%

General Surgery GIRFT General Surgery - Surgical Site Infection 2019

N/A Awaiting data

General Surgery Trauma Emergency Laparotomy Audit (TELA)

26 26 100%

General Surgery GIRFT Programme National Specialty Report (General surgery)

1 1 100%

Genetics National Von Hippel-Lindau Syndrome (VHL) screening audit: Genetics - 2018

48 48 100%

Major Trauma Liver and Pancreatic Trauma Audit (LiPTA) 100 0 0%

Maxillofacial Surgery

GIRFT Dentistry - Oral and Maxillofacial Surgery - Surgical Site Infection 2019

N/A Awaiting data

Neurosurgery GIRFT Neurosurgery, Surgical Site Infection 2019

1 1 100%

Neurosurgery Multi-disciplinary team management of cerebral metastases in the UK

101 101 100%

Obstetrics Antenatal Screening Programmes 2017-2018

200 201 100%

Obstetrics National Comparative Audit of the Management of Maternal Anaemia (2018)

10 10 100%

Obstetrics GIRFT Obstetrics and Gynaecology - Surgical Site Infection 2019

N/A Awaiting data


Sample Size Number


Obstetrics Each Baby Counts (2018/19) 27 27 100%

Oncology & Radiotherapy

UK National Radium-223 audit project 19 19 100%

Ophthalmology GIRFT Programme National Specialty Report (Ophthalmology)

1 1 100%

Paediatric Surgery Audit of Outcomes in Major Burns (> 25% TBSA)

N/A 10 100%

Paediatric Surgery GIRFT Paediatric General Surgery - Surgical Site Infection 2019

N/A Awaiting data

Pain Management

National audit of inpatient complex and chronic pain (CHIPS)

41 41 100%

Pharmacy Antimicrobial NHS Improvement / CQUIN - Colorectal

400 95 24%

Pharmacy Antimicrobial NHS Improvement / CQUIN - Urinary Tract Infection

400 0 0%

Pharmacy Antimicrobial NHS Improvement / CQUIN - Antifungal

20 20 100%

Physiotherapy The EU-PARK-PICU Study: European Prevalence of Acute Rehab for Kids in the PICU

16 16 100%

Plastic Surgery & Burns

National Quality Outcome Measures: Quality dashboard for specialised burn care

63 63 100%

Page 45

Radiology RCR National Audit Evaluating Radiological Reporting of Fragility Fractures

50 50 100%

Radiology RCR National Audit of Seven Day Care Radiology.

1 1 100%

Sexual Health BHIVA national clinical audit 2018: monitoring of adults with HIV aged 50 or over

39 39 100%

Spinal A Multi-centre Retrospective Audit of Native Vertebral Osteomyelitis Cases (NITCAR)

11 8 73%

Spinal GIRFT Spinal Surgery - Surgical Site Infection 2019

N/A Awaiting data

Stroke National Audit of Dementia / Delirium (NAD) - Spotlight Audit

20 20 100%

Thoracic Surgery GIRFT Cardiothoracic Surgery - Surgical Site Infection 2019

N/A 2 100%

Trust-wide (GIRFT) Surgical Site Infection audit "Umbrella" Registration

2512 2512 100%

Trust-wide Community Acquired Pneumonia CQUIN 2019

600 600 100%

Trust-wide NCEPOD Provision of Mental Health Care in Acute Hospitals

9 8 89%

Trust-wide Pulmonary Embolus CQUIN 2019 600 600 100%

Trust-wide Tachycardia with Atrial Fibrillations CQUIN 2019

400 200

(data collection ongoing)

50% (data collection

ongoing)


Sample Size Number


Trust-wide GlobalSurg: Quality and outcomes in global cancer surgery: a prospective, international cohort study

120 120 100%

Upper GI Surgery Oesophago-gastric Anastomosis Audit (OGAA)

21 21 100%

Urology GIRFT Urology - Surgical Site Infection 2019 No expected sample size

Awaiting data

Vascular Surgery GIRFT Programme National Specialty Report (Vascular Surgery)

1 1 100%

Vascular Surgery GIRFT Vascular Surgery - Surgical Site Infection 2019

No expected sample size

Awaiting data

Vascular Surgery Groin wound Infection after Vascular Exposure Audit (VERN)

NUH not participated.

NUH not participated.

Awaiting response

*Denotes audits where data collection is either still underway or there was no actual minimum expected sample size

specified (hence the figure represents the number of submissions to date)

Participation in National Confidential Enquiries 2019/20

During 2019/20 NUH participated in all relevant enquiries set by the National Confidential Enquiry into

Patient Outcome and Death (NCEPOD) and by the Maternal Infant and Newborn Programme (MBRRACE-UK).

NCEPOD projects improve standards by identifying common poor practice. NUH participated in the NCEPOD

studies outlined below.

Page 46

Title of study Return rate*

(% of eligible cases

submitted by NUH)

MBRRACE Child Death Review (Perinatal Mortality Surveillance) January - December 2017 (published October 2019)

100%

MBRRACE-UK Saving Lives, Improving Mothers’ Care - Term, singleton, intrapartum stillbirth and intrapartum-related neonatal death

100%

NCEPOD Cancer in Children, Teens and Young Adults 83%

NCEPOD Chronic Neurodisability Study 75%

NCEPOD Acute Heart Failure Study 8%

NCEPOD Dysphagia in people with Parkinson’s Disease study 100%

NCEPOD Hospital Management of Out of Hospital Cardiac Arrest (OHCA) 100%

NCEPOD Long Term Ventilation (patients 0-25 years old) 59%

NCEPOD Non-Invasive Ventilation Study 45%

NCEPOD Peri-operative management of surgical patients with diabetes 44%

NCEPOD Pulmonary Embolism 80%

NCEPOD Young Persons Mental Health Audit (YPMH) 88%

NCEPOD Provision of Mental Health Care in Acute Hospitals 89%

*Relates to case notes and questionnaires requested and returned

In 2019/20 there were no NUH patients eligible for the National Confidential Enquiries (NCI) into Suicide and

Homicide by People with Mental Illnesses (NCI/NCISH). It was previously confirmed with NCISH via a

Consultant Liaison Psychiatrist that NUH do not need to contribute to this study (Trusts are however

encouraged to review findings as an acute Trust once published).

Response to National Confidential Enquiries 2019/20:

In 2019/20 there were four National Confidential Enquiries published which were relevant to services

provided by NUH:

Long Term Ventilation (February 2020): Action Plan Received

Acute Bowel Obstruction (January 2020): Awaiting Action plan from Specialties

Pulmonary Embolism (October 2019): Awaiting Action plan from Specialties

Mental Health Care in Young People, and Young Adults (September 2019): Awaiting Action plan from

Specialties

Learning from Clinical Audits 2019/20:

One of the Trust’s 2019/20 quality priorities was to increase improvement capability across the organisation

to enable greater learning from incidents and feedback. Two of the suggested methodologies to achieve this

priority included:

Page 47

Rolling out the Quality, Service, Improvement and Redesign (QSIR) Fundamentals Programme across

teams and services

Developing a database of Quality Improvement (QI) projects and outcomes

Four of the five members of the Trust-wide Clinical Effectiveness team are QSIR trained. A robust audit

database including QI projects are captured regularly and a live report of this database is now available to

NUH staff through the Clinical Effectiveness Qlik App.

In addition, a bi-annual National Clinical Audits benchmarking report is generated to describe NUH’s

outcomes in national clinical audits against other Trusts and peers across the country. Each NUH Division,

and the Quality and Safety Committee, receives reports on a quarterly basis from the Clinical Effectiveness

team which include national and local audit outcomes.

The Clinical Audit Programme/database comprised of 356 ‘registered’ audits

Some of these were new additions to the plan, whilst others were audits that were carried over from

the previous year’s plan because they were still at data collection/analysis stage or were awaiting the

return of a completed audit review/action plan

183 (51%) of these 356 were “national audits” (Either NHSE / HQIP QA or any other “national”)

116 (63%) of these 183 registered on the Trust database were national audits on the NHSE / HQIP

Quality Account list for 2019/20. The remaining 67 (37%) were non-HQIP national audits.

Partially Supported Audit Registrations

A total of 579 Partially Supported Audits were registered in 2019/20, which is similar to the previous year

(589 for 2018/19). A breakdown of these partially supported audits is in the table below:

Examples of improvements in, or assurance of the quality of care for NUH patients as a result of National

or local Clinical Audit

The reports of 26 National Clinical Audits were reviewed by the provider in 2019/20 and NUH intends to take

the following actions to improve the quality of healthcare provided/can celebrate the following excellence in

care provided.

National Audit / Quality Improvement Programmes

The National Audit of Percutaneous Coronary Interventions (PCI) (BCIS) 2019 (Cardiology):

Page 48

Service is compiling a list of re-interventions at one year and pneumothorax/haemothorax post

procedure (by cross-referencing ICD code from discharge letters obtained from coding and pacing

procedures)

Most current operators are (at least for complex devices) compliant with data completeness

Lead Clinician has provided more reinforcement regarding this to operators following March 2019

NICOR validation exercise.

Respiratory Medicine National Lung Cancer Audit (NLCA) (2018/19):

Overall 91.6% of patients had performance status recorded which is an improvement on 2018/19 (84%).

This is higher than the England average (81.6%) and higher than the East Midlands (84.1%)

97.9% had a stage recorded which again is an improvement from the 2018/19 report (94.7%). This is

higher than the England figure of 96.1%

Pathological confirmation rate in stage I/II was 89.3% which is in line with the England average of 88.9%

Chemotherapy in SCLC is 81.8% which is good practice

Recruitment to a lung cancer administrative staff is currently underway to enhance and improve the

data collection

A business case for a sixththoracic surgeon is underway which will increase capacity. Robotic thoracic

surgery has also commenced which allows more extensive surgery in borderline patients.

The National Ophthalmology Database (NOD) 2019 Audit Report: (2017-2018 Audit Data):

PCR rate is better than the national average

A cataract pathway day has been arranged to facilitate maximising the recording of both pre-operative

and post-operative data for every operation as per national recommendations

Medisoft has the facility and is being completed to enhance Patient Reported Outcome Measures

(PROMs) before and after surgery to quantify and validate patient benefit from surgery, as advised in

the NOD recommendations and 2019 NICE Quality Standard for serious eye disorders (QS180).

BHIVA Sexual Health National Clinical Audit: monitoring of adults with HIV aged 50 or over:

National recommendation is to use proformas where feasible as prompts and to set up electronic

reminder systems with appointments for annual review, which for older patients should focus especially

on:

o CVD and bone risk assessment

o Review of mood, memory and cognition

o Poly-pharmacy and potential for drug-drug interactions

Use of a new electronic system has enabled staff to see parameters and timescales more easily. Pop-up

reminders are also set up.

Local Audit/Quality Improvement Programmes

The Trust intends to take the following actions to improve patient care and experience and/or notes the

following improvements and excellence in outcomes as a result of local Clinical Audit:

Obesity Prevention in Children and Young People (NICE QS 94):

Obesity Guideline updated and available through intranet. URL links to patient leaflets are part of the

guideline. Updated guideline submitted for peer review

Leaflet printed and offered in Childrens Outpatient clinics.

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Reviewing Sodium levels in postnatal women (Maternity):

30 sets of maternal notes were reviewed during the course of this audit. Of these 30 sets, two babies

had low sodium levels. The two babies had their sodium levels escalated appropriately and received

appropriate intervention as per NUH guidelines.

A Cellular Pathology audit of biopsy reporting for NSCLC:

100% compliance with the standards (1. Biopsy classified according to recommended terminology 100.

2. Percentage of non-resected cases classified as NSCLC-NOS100)

100% compliance with RCPath recommended terminology

100% compliance with acceptable percentage of non-resected cases classified as NSCLC-NOS.

Antimicrobial use in ENT:

100% of patients had a clear documented decision to start all antibiotics in the medical notes

100% had antibiotics prescribed in-line with guidelines/microbiology

Consultant reviews increased to 80%.

PATIENT FEEDBACK

4Cs (Compliments, Complaints, Concerns and Comments)

2019/2020 is the ninth year that NUH has been using the 4C (complaints, concerns, compliments and

comments) approach to capture feedback from patients, carers and families. Patient Experience Quarterly

Reports on complaint themes and examples of learning are received by the Quality Assurance Committee.

The charts below describe the number of complaints received, the number referred to the Parliamentary

Health Service Ombudsman (PHSO), the number of compliments and the five most common complaint

themes for each year 2016/17 to 2019/20.

Number of local complaints and PHSO referrals:

2016/17 2017/18 2018/19 2019/20

Complaints 656 637 683 735

Complaints Upheld 122 fully 177 partially

87 fully 129 partially



PHSO Contacts 76 75 70 53*

Investigations taken up by the PHSO

16 15 6 6*

Upheld PHSO referrals (in year)


0 fully 3 partially

0 fully 5 partially

0 fully* 1 partially*

*National PHSO annual data only available up to 30/11/2019.

Most frequent complaint themes:

2016/17 2017/18 2018/19 2019/20

Standards of care (treatment)


Standards of care (diagnosis)


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Standards of care (assessment)



Complications during/after surgery


Verbal Communication Complications

during/after surgery

Lack of communications regarding discharge





Verbal Communication Lack of communication

regarding discharge Verbal communication

Total Compliments:

2016/17 2017/18 2018/19 2019/20

5892 6415 5703 5463

Reopened Complaints:

Reopened complaints are reported monthly in the Integrated Performance Report.

Divisions are informed of all reopened complaints on a monthly basis so they can review these and identify

whether the complaint could have been handled differently in order to resolve this at the first response.

Q1 2019/20 Q2 2019/20

Q3 2019/20 Q4 2019/20

Total complaints 159

237 193 146

Reopened 17

23 26 14

% resolved at first response

90% 91% 87% 91%

Examples of learning from complaints taken from most frequent complaint themes:

Reason for

Complaint Quality Objective Action taken


Improve clinical effectiveness

Clinical Educator changed practice to work directly with staff involved as a result of a complaint.

Patient experience shared with staff for reflection and learning.

All learning points from complaints are collated into a learning document. This is shared with the staff involved and wider team for continuous learning and improved good practice.

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A review of capacity and demand work was completed in the outpatient specialty. This resulted in a workforce change that led to virtual clinics.

New equipment purchased to aid in the identification of cleft palate.

Process implemented to improve timeliness of triage and to ensure that patients have a wristband issued within one hour of attendance.



Audit findings have shown that surgical team have improved their compliance of the use of the internal transfer document. The actions and recommendations from the audit have also been implemented.

Ward Sister has discussed with staff the use of anti-embolism stockings. Further checks have been implemented to ensure this is reviewed on handover. A full review of the nursing handover has also been completed.



A complaint regarding standards of assessment was shared at the specialty governance forum for reflection and learning by the wider team.

Staff have been updated on the Traffic Light Assessment Process and Resource Box to assist in providing care.

Verbal communication

Improve patient experience

Patient and relatives experience anonymously shared with staff and added to induction program for awareness.

Surgical ward have reviewed their processes on how they communicate discharge plans with their patients and relatives. This includes implementing afternoon leadership rounds to ensure that the discharge coordinator or nurse in charge makes contact with relatives and carers early on in the process.

HCOP Liaison Service reviewed their DNAR systems and conversations. The service has liaised with surgical colleagues to agree who will undertake these discussions to improve standards of communication.

Improving complaint handling:

In 2019/20:

NUH has continued to participate in the Peer Review process on a bi-monthly basis. This involves

reviewing the complaint process and peer assessment of complaints handling. This year we have met

our annual goal of reviewing 25 complaint files. Recommendations and learning from the Peer Review

process have been implemented by the Complaints Team to improve local systems and processes.

Patient stories, taken from complaints which have demonstrated learning within the organisation are

presented monthly at Trust Board. Patients and relatives have attended Trust Board this year in person

to share their story.

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The Complaints Team is actively engaged with the weekly Incident Review Meetings, led by the Patient

Safety Team, to identify cases for escalation or joint investigation. The meetings also provide an

opportunity for information sharing and triangulation of intelligence relating to complaints, incidents

and claims

We have introduced new quality standards for checking all complaints letters before they are approved

within the current signing off process

An internal review of complaints handling systems and processes has been undertaken resulting in the

development of the Complaints Quality Improvement Plan 2020/21. The plan outlines quality initiatives

aimed at improving the overall quality of complaint investigations, timeliness of responses as well as

improving shared learning

In partnership with our Patient Participation Group and Clinical Psychology Team, we have developed

and delivered a Letter Writing Workshop which focusses on compassionate complaints handling.

Patient Surveys

During 2019, the results of the National Urgent and Emergency Care Survey 2018 and Children & Young

People’s Survey 2018 were published by the Care Quality Commission (CQC). A summary of our results is

given below.

Urgent and Emergency Care 2018 Survey, published by the CQC in October 2019

Our response rate to the survey improved from the previous year. Overall, our patients felt listened to and

confident in their care. We did significantly better than most Trusts in providing privacy and dignity to

patients when discussing their conditions. The Medicine Division participated in a shared learning workshop

and developed a plan for improving patient experiences in response to the survey feedback.

Children and Young People’s 2018 Survey, published by the CQC in November 2019

Children and young people feel they are well looked after in our services. We have seen a number of

improvements since the last survey in 2016. The survey feedback identified the following areas where we are

doing well:

• Speaking to children about their worries

• Children liking the hospital food

• Parent being able to prepare food and hot drinks using the available facilities

• Parents feeling there are enough activities for their child to do during their stay in hospital

• Children feeling wards are suitable for their age group

• Staff communicating information clearly about a child’s condition or treatment.

We also participated in the following national patient surveys during the year:

Maternity Services Survey 2019, published by the CQC in January 2020

The CQC results show our performance compared to 125 other acute Trusts. All sections scores in the

antenatal, labour and birth and postnatal reports were in the expected range compared to other Trusts. We

have seen an improvement in a total of nine questions when compared to the previous survey. The survey

feedback identified the following areas where we are doing well:

• Partners being supported to stay as long as they wanted

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• Women being given enough information about their physical recovery and information about changes

to mental health

• Midwives giving active support and encouragement about feeding

• Women being able to see their midwife as much as they wanted

• Midwives being aware of a woman’s medical history

• Women being offered a choice of where they have their baby

• Women feeling their concerns are taken seriously.

The Family Health Division participated in a shared learning workshop and developed a plan for improving

patient experiences in response to the survey feedback.

Adult In-patient Survey 2019

The Trust is awaiting the publication of the national results of this survey by the CQC.

Patient Friends and family test (FFT)

Patients are invited to give feedback on their care and experience by answering one simple question – ‘How

likely is it that you would recommend this service to friends and family if they needed similar treatment?’ A

total of 44,044 inpatient and day case patient FFT responses were received in 19/20 with an overall

recommend rate of 96.7%. We also received 14,588 emergency department FFT responses with an overall

recommend rate of 89.4%.

FFT Survey Total Responses % Recommended

Emergency Department 14,588 89.4%

Inpatient & Daycase 44,044 96.7%

Outpatients 61,385 96.2%

Maternity (Antenatal) 1,070 99.3%

Maternity (Labour Ward/ Birthing Unit) 607 96.4%

Maternity (Postnatal Ward) 1,526 96.1%

Maternity (Postnatal Community Service) 1,948 99.6%

Learning from real-time feedback:

Here are some of the actions we have taken to improve patient experience in direct response to the FFT

survey as well as our local surveys.

Communication

The #hellomynameis campaign is being promoted and is now included on all new ID badges

We have developed a new information video for patients Preparing For Surgery - Live Brief - YouTube

Patients and carers continue to be involved and contribute to our culture and values work across the

Trust and offer advice on a range of projects and leaflets.

Food

We have improved our food including special diet menus and the availability of drinks and snacks. Our

Memory Menu has been developed, implemented and promoted

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We have focussed our efforts on improving nutrition. Our Critical Care team have menus on display for

easy access and to help promote better patient choice

In response to feedback around requirements to have more assistance for patients at mealtimes, we

have developed training through the Teams Helping Teams staff volunteering initiative. Support for

mealtime assistance is available for wards who have requested this.

Sleep

We have focussed on identifying what helps patients sleep well at home and replicating this in hospital

where possible e.g. music, drinks, pillow, blankets etc

In response to feedback about noise at night and patients experiencing difficulties in sleeping we have

produced ‘Top Tips for Patients and Staff’: https://www.nuh.nhs.uk/sleep-guidance-for-patients

Pain

A number of education and support sessions for staff have been held and the development of a pain

application is underway to enable staff to review, monitor and action pain care more easily.

Carers

We have improved support for carers through working in partnership with the Carers Trust. We have

set up new monthly carers support sessions at both QMC and City sites

We have introduced an Excellence in Dementia Discharge information ID Wallet Card for staff.

Other

In response to patient feedback around inactivity and having limited things to do during their

hospital stay, we have introduced fitness fiends and boredom busters

Pet Therapy visits help us reduce stress, anxiety, isolation, boredom and improve the patient and

staff experience.

% recommended provider Trust (peer group) comparison April 2018-December 2019

STAFF FEEDBACK

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https://www.nuh.nhs.uk/sleep-guidance-for-patients

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Staff ‘Friends and Family’ Test (FFT)

Staff are invited to provide feedback on the quality of care and the likelihood of recommending NUH as a

place to work through the Staff Friends and Family Test (FFT) , the results of which are shown below.

Factor Q1 Q2* Q4

% of respondents would be extremely likely or likely to recommend NUH services to friends and family if they needed care or treatment

83% 83%* 87%

% of respondents would be extremely likely or likely to recommend NUH as a place to work.

54% 80%* 62%

*These values reflect only new starters within the organisation as a sample group was chosen in Q2 to

undertake the Staff FFT.

National Staff Survey 2019

A total of 38% (5,899) of staff responded to the national staff survey. The median national response rate was

47%.

Highlights from our national survey results across 11 themes include:

• The Trust is above average for four themes of which two (Safe Environment - Bullying and Harassment

and Safe Environment – Violence) are within the best 20% of benchmarked Trusts in the country)

• The Trust is average for three themes (Immediate managers, Morale and Staff engagement)

The Trust is below average for four themes of which three (Quality of Appraisals, Quality of Care and Team

Working) are in the lowest 20% of benchmarked Trusts.

The focus for improvements in 2020/21 will be:

• Review of car parking provision and transport to work

• Looking after staff health and well-being at work, including working flexibly and making reasonable

adjustments for staff who need them

• Making sure everyone has the same opportunity to progress their career

• Making sure that everyone is treated fairly

• Making sure staff have the resources to do their job

• Making sure staff feel they can influence decisions and make improvements in their role

• Improving the skill set of managers, including communication and visibility and ensuring that staff are

supported in challenging times and recognised for their efforts.

Social media and online feedback

During the 2019/20 period, we gained 2,421 new followers to our main Twitter account, taking our total

followers to 18,748. Nearly six million people have seen our Tweets over the past year.

NUH received on average, 1,500 Twitter mentions per month during the 2019/20 period. Of these mentions

over the year, 514 related directly to patient feedback; 316 (62%) were positive, 155 were negative (30%)

and 43 were neutral (8%).

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The most common themes were care standards (52%), staff attitudes and behaviours (43%), the Emergency

Department (10%), parking (6%) and phone communication (6%). The vast majority of these particular

Tweets were positive with the exception of Tweets about parking and phone communication.

94% of parking Tweets were concerns. The majority of the parking concern Tweets were received Q1 and

Q2, and amounted to 21 tweets. This is a reduction of 39 from Q3 and Q4 of 2018/19 but is a carry-over of

the announcement in the third quarter 2018/19 that the Trust would no longer be offering free parking to

drivers who held blue disabled parking badges, and the implementation of this policy in Q4. Parking is still an

area of concern for many people due to the lack of available spaces and the cost of parking for certain

groups.

97% of all Tweets relating to phone communication were negative, however, there is no emerging theme for

why this is other than known operational pressures within services.

NUH received 233 pieces of feedback from patients/relatives on the Care Opinion and NHS (formerly NHS

Choices) websites. Of these, 58% were compliments and 36% were concerns, with 6% neutral. Consistent

with social media subject of concerns, the comments received related to care standards (67%), and staff

attitudes and behaviours (66%). Feedback posted online has reduced slightly overall since 2018/19 when we

received 288 comments.

We have continued to share feedback from Care Opinion and the NHS website on Twitter. A selection of

patient and relative comments (including compliments and concerns and complaints) are shared weekly with

all staff as part of the Trust Briefing sent by the Communications Team. NUH continues to receive praise

nationally for our commitment to openness and transparency, including regularly sharing both positive and

negative feedback and our learning from such feedback.

Improving patient information

We continually build on our commitment to providing high quality patient information. We provide all

necessary guidance, templates and other information for authors of patient information leaflets, to enable

them to produce good quality information in line with the Trust Patient Information Policy and national best

practice guidance.

Overall, we have a total of 745 leaflets in use across the Trust. A total of 63 new leaflets were produced in

2019/20.

Our 2020/21 Quality Priority is to undertake a full review of our current Patient Information Policy and

Processes and to improve information leaflets to be more accessible and in a format that meets patient,

carer and family needs. We will also be considering quality improvements within the wider aspects of Patient

Information.

Data quality management and assurance

The Trust submitted records during 2019/20 to the Secondary Uses Service (SUS) for inclusion in the Hospital

Episode Statistics (HES), which are included in the latest published data.

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The percentage of records in the published data which included the patient’s valid NHS number was:

99.8% for admitted patient care

99.9% for outpatient care

99.1% for accident and emergency care.

The percentage of records in the published data which included the patient’s valid General Medical Practice

Code was:

99.9.0% for admitted patient care

99.8.0% for outpatient care

99.9.0% for accident and emergency care.

Improving data quality

The Data Quality Team continues to work with wards and outpatient clinic areas across the Trust providing

updated guideline documents, outlining and explaining patient administration processes and data input

requirements and investigating and advising on areas of concern. This is underpinned by a bi-annual ward

audit which monitors the quality of data input to the Trust PAS system, with the results reported to the Data

Quality and Reporting Assurance (DQRA) Group.

Data quality awareness sessions are undertaken across the Trust to highlight to colleagues the importance of

data quality and highlight the areas where they have specific responsibility. These include relevant ward,

outpatient clinic and administration staff.

Information has been distributed across the Trust to highlight to patients the importance of ensuring their

details are up-to-date and changes have been made to current Trust documentation to improve the data

quality across the Trust.

The Data Quality Team has responsibility for maintaining the Healthcare Professional, GP and Consultant

reference files along with daily NHS Number tracing via the ‘Demographic Batch Tracing Service’ (DBS). This

work, together with the training of relevant staff in the use of the Summary Care Record, ensures that the

Trusts patient administration system (Medway) maintains a high level of data completeness and validity.

NHS number and general practice code validity

Category % NHS number completeness % Inclusion of General Medical

Practice Code

Inpatient/admissions 99.8 99.9

Outpatients 99.9 99.8

ED attendances 99.1 99.9

Clinical coding and error rate

Clinical coding is the translation of medical terminology (written by clinicians to describe a patient’s diagnosis

and treatment) into nationally-recognised standard codes. The Trust was not subject to an external clinical

coding audit during 2019/20.

Information Governance

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Information Governance (IG) provides a framework for effective handling of information, particularly the

personal and sensitive information of patients and employees, to ensure that information is processed

legally, securely and confidentially. The Data Security and Protection Toolkit mandates NHS organisations to

self-assess their compliance with current legislation and national guidance. The Trust has yet to submit its

final submission for 2019/20 as NHSD postponed the final submission to the end of September 2020 due to

the Covid-19 pandemic.

The Trust is continuing to undertake work in preparation for the submission of the Data Security and

Protection Toolkit, looking to: Make improvements wherever it can do so, work to deliver national initiatives

such as the National Data Opt Out, alongside ensuring Information Governance and Security practices

remains robust during the current Covid-19 pandemic and the new and changing ways of working this has

resulted in.

Information Commissioner’s Office Reported Incidents

Seven IG incidents were reported to the Information Commissioner’s Office (ICO) and/or Department of

Health and Social Care (DHSC) in 2019/20.

All reported IG incidents are assessed for severity according to national guidance. Where it is considered the

incident needs to be reported to the ICO, they are escalated to the Trust’s Caldicott Guardian and Data

Protection Officer who confirm the scoring, ensure appropriate action has been taken and authorise

reporting to the ICO or DHSC, via the Data Security and Protection Toolkit.

The Trust has recently made changes to its incident management process to ensure that all reported

incidents receive a level of follow-up relevant to the nature of the incident, regardless of severity. The Trust

believes this is important to ensure there is a strong culture of IG awareness in the organisation.

Quality Impact Assessments (QIA)

The Trust has a Quality Impact Assessment process which is described in the QIA policy. All projects that sit

within the Trusts Quality and Efficiency programme have to be assessed to evaluate whether there is a

possibility of a negative impact of an financial saving on Patient Safety, Clinical Outcomes or Patient

Experience.

Performance against national quality standards and targets

Emergency access standard

In 2019/20 there has been a Trust-wide focus and determination to improve the experience of our

emergency patients and flow in and through our Emergency Department (ED) and out of our hospitals. In

May 2019 we started reporting against new clinical standards for Urgent and Emergency Care as part of the

national field testing programme. Reporting against the four-hour standard paused for 2019/20 for the pilot

Trusts to avoid contaminating the study design.

Cancelled operations

There were 67 instances where NUH breached the 28-day readmission guarantee in 2019/20 but no urgent

operations were cancelled more than once.

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Number of breaches of the 28-day cancelled operations guarantee by provider (peer Trusts) April 2019-

December 2019 (due to COVID-19, this data publication was paused nationally and therefore data is

only available to December 2019).

Referral to treatment (RTT) - 18-week wait

The 18-week RTT performance was 86.5% (against >92% national target) at end of March 2020 with 13

specialties reporting under performance. For full details of our broader performance, including waiting times,

please see our Annual Report.

Waiting lists have grown and for the first time since June 2012 we under-performed against the 18-week RTT

standard in October 2019, with performance remaining below standard for the remainder of the year. Our

ability to recover elective activity has been compromised by the national pension’s issue that has resulted in

a reduction in the number of clinicians undertaking additional sessions. The decision in mid-March by NHS

England to cease all routine elective work to create capacity for Covid-19 patients has and will continue to

impact heavily on the Trust’s RTT performance and associated elective pathway metrics.

Performance over time against the RTT is outlined below:

Performance over time (RTT)

2011/12 90.5%

2012/13 95.6%

2013/14 96.6%

2014/15 98.2%

2015/16 97.5%

2016/17 96.1%

2017/18 92.9%

2018/19 93.2%

2019/Feb20 93.2%

2.3 Reporting against Core Indicators

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We aim to deliver safe, caring and person centred care for our patients throughout Nottingham and the East

Midlands. Our patients will have health outcomes that achieve or exceed those required in the NHS

Outcomes Framework and by NICE Quality Standards. We aim to do this in a way which is recognisable,

measurable and meaningful to everyone in the community we serve.

We seek assurance that we are delivering on these expectations through regularly monitoring the quality and

outcome of our services by a number of Board Committees. In particular:

The monthly Quality Assurance Committee (of the Trust Board) monitors the quality of our services and

the risks associated with the delivery of care

The Audit Committee of the Board monitors the quality of our risk management systems and assurance

processes

Management Board is responsible for leading ensuring delivery of the required quality of care and for

driving forward sustainable improvement to the quality of the services we provide.

These committees are supported by a Trust Quality Management structure as shown below.

Organogram to be inserted

PERFORMANCE AGAINST NHS OUTCOMES DOMAINS (HEADING)

In this section we report our performance in the five domains/areas of the NHS national outcomes

framework and compare it with last year and with other hospitals.

Domains 1 and 2 - preventing people from dying prematurely

Mortality indices

The Summary Hospital-level Mortality Indicator (SHMI) reports on mortality at Trust level across the NHS in

England. The SHMI is the ratio between the actual number of patients who die following hospitalisation at

the Trust and the number that would be expected to die on the basis of average England figures, given the

characteristics of the patients treated there. It covers patients admitted to hospitals in England who died

either while in hospital or within 30 days of discharge.

SHMI values for each Trust are published along with bandings indicating whether a Trust's SHMI is '1 - higher

than expected', '2 - as expected' or '3 - lower than expected'. For any given number of expected deaths, a

range of observed deaths is considered to be 'as expected'. If the observed number of deaths falls outside of

this range, the Trust in question is considered to have a higher or lower SHMI than expected.

The SHMI for NUH is 1.05 with a banding of 'as expected' for the period November 2018 - October 2019

(source: NHS Digital; published 12 March 2020). The England average SHMI is 1.0 by definition, and this

corresponds to a SHMI banding of 'as expected'. For the SHMI, a comparison should not be made with the

highest and lowest Trust level SHMIs because the SHMI cannot be used to directly compare mortality

outcomes between Trusts and, in particular, it is inappropriate to rank Trusts according to their SHMI.

The SHMI methodology does not make any adjustment for patients who are recorded as receiving palliative

care. This is because there is considerable variation between Trusts in the coding of palliative care. However,

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in order to support the interpretation of the SHMI, various contextual indicators are published alongside it,

including indicators on the topic of palliative care coding.

Palliative care coding

The percentage of deaths with palliative care coded at either diagnosis or specialty level for NUH is 39

percent for the period November 2018 – October 2019. The England average for the same time period is 36

percent (source: NHS Digital; published 12 March 2020).

Table 5: Figures for four previous reporting periods are shown below:

(Source: NHS Digital)

Hospital Standardised Mortality Ratio (HSMR)

The Hospital Standardised Mortality Ratio (HSMR) is another method used to monitor death rates in a Trust.

The HSMR is based on the routinely collected administrative data often known as Hospital Episode Statistics

(HES). The HSMR is similar in concept to SHM,I in that the expected number of deaths is calculated from a

risk-adjusted model. For any given number of expected deaths, a range of observed deaths is considered to

be ‘as expected’. If the observed number of deaths falls outside of this range, the Trust in question is

considered to have a higher or lower HSMR than expected.

There are however differences between the SHMI and HSMR methods. For example, the SHMI includes

deaths that occur within 30 days of discharge, including those outside of hospital, whereas the HSMR is

based on a subset of diagnoses which give rise to around 80% of in-hospital deaths. The HSMR model also

adjusts for patients in receipt of palliative care.

Both the SHMI and HSMR indices require careful interpretation and should be used in conjunction with other

indicators and information from other sources (e.g. patient feedback, staff surveys and other similar

material) that together form a holistic view of Trust outcomes.

Indicator - SHMI (Domain 1)

NUH National

(a) The value and banding of the Summary Hospital-

level Mortality Indicator (‘SHMI’) for the trust for the

reporting period and

1.05 'as expected' 1.00 'as expected'

(b) the percentage of patient deaths with palliative

care coded at either diagnosis or specialty level for

the trust for the reporting period.

39 36

Current period (November 2018 -

October 2019)

Reporting Period SHMI Banding

NUH England average

October 2018 - September 2019 1.06 as expected 38 36

July 2018 - June 2019 1.07 as expected 37 36

April 2018 - March 2019 1.08 as expected 36 35

January 2018 - December 2018 1.08 as expected 33 34

Percentage of deaths with

palliative care coding

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The HSMR for NUH is ‘higher than expected’ [HSMR 111.7, 95% confidence interval: 107.6 to 115.9]. The

England average for the HSMR is 100, which corresponds to a banding of 'as expected'. (Source: Hospital

Evaluation Data [HED] portal; HSMR discharges in the period December 2018 - November 2019; as published

on 26 February 2020.)

LEARNING FROM DEATHS

NUH considers that this data is as described for the following reasons. NUH is fully engaged in the national

mortality surveillance programme. NUH has built and implemented an e-coroner and mortality screening

tool which supports an initial high-level screening of all adult inpatient deaths and provides clinical teams

with intelligence of cases that may warrant a more in-depth review. The Trusts Mortality and End of Life

Care Group, Quality Assurance Committee and Board receives a quarterly Learning from Deaths report.

These are available on our public web site at: Board Papers

Total number of deaths (2019/20

In 2019/20:

90% (3,081) of adult inpatient deaths were verified using Nervecentre

99% (3,397) of adult inpatient deaths were screened in Nervecentre (mortality and coroner screening)

54% (1,849) of adult inpatient deaths were referred to HM Coroner of which 18% [339] of the cases

were taken by HM coroner for review.

The total number of deaths per quarter based on age groups are outlined in the table below.

Quarterly (and total) deaths 2019/20 (as at 6 April 2020)

https://www.nuh.nhs.uk/board-papers

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Number of deaths subject to a Structured Judgement Case Review (SJCR)

As of 19th March 2020, 218 colleagues have been trained to undertake SJCRs at Nottingham University

Hospitals.

A total of 135 (with a further 32 in progress as at 6 April 2020) Structured Judgement Case Reviews (SJCR)

and 15 Serious Incident investigations have been commissioned in relation to 3,527 patients that died while

an inpatient during 2019/20 (excluding Still Births). In one case a death was subjected to both a SJCR and a

Serious Incident investigation (converted from SJCR to SI).

During 2019/20 there were three Serious Incidents commissioned where the outcome was death where the

investigation was completed during 2019/20 (excluding Still Births). The outcome of death does not mean

that the death was avoidable.

The number of deaths in each quarter during 2019/20 for which a SJCR or a Serious Incident investigation

was commissioned are outlined in table 1.

Table 1: SJCRS and Serious Incidents undertaken per quarter in relation to deaths in 19/20 (as at 6 April

2020).

2019/20 Q1 Q2 Q3 Q4 Total

SJCR completed 52 48 29 6 135

Serious Incident Commissioned 1 0 3 2 6

Page 64

where outcome was death

Serious Incident investigation

completed where outcome was

death associated with above cases

1 0 2

(1 in

progress)

0

(2 in

progress)

3

(3 in

progress)

All infant, children and young people and neonatal inpatient deaths are reviewed under the Child Death

Review Process (CDRP). All still births in 2019/20 were reviewed under the perinatal mortality review

process. Of the total still births in 2019/20, four were investigated under the national Serious Incident

framework.

Deaths in patients with a Learning Disability

All learning disability (LD) deaths should be reviewed using the Learning Disabilities Mortality (LeDeR)

methodology. In 2019/20 50 adult patients who died while an inpatient, were assessed following initial

screening as having a learning disability. These cases are reviewed by the Learning Disability Team along with

the Trust’s LFD lead. A total of 32 deaths have been considered for SJCR to date and a SJCR was undertaken

in 21 cases, with a further two in progress. Two of the reviews identified potentially poor care and both have

had a second stage review.

Thematically, there were frequent examples of excellent communication between clinicians, patients and

families alongside good interdisciplinary working. End of Life Care and communication in general in those

cases reviewed were positive with greater involvement of Learning Disabilities Specialist Nurses over the last

12 months in particular. Issues of capacity and consent noted previously have become less evident but

inaccuracies and errors in the completion of DNACPR forms remains problematic, on occasion. The results of

SJCR in these cases are fed back directly to the Specialty M&M meeting. All NUH learning disability deaths

are reported to the LeDeR Programme by the Adult LD Nurse Specialists.

Judgement and Care Quality Scores (refer to Serious Incident section)

Of the 135 SJCR cases completed in 2019/20 a judgement score was made in three cases as to a death being

“more likely than not” associated with problems in care/service delivery (table 3). Of the total (135)

completed SJCRs three deaths were deemed more likely than not to be due to care of service deficiencies.

Table 3: SJCR judgement of care/service delivery contributing to death (as at 6 April 2020).

2019 Q1 Q2 Q3 Q4 Total

Total deaths 825 820 924 958 3,527

SJCR completed 52 48 29 6 135

Number of cases where it is thought ‘more likely than not’ that problems in care/service delivery contributed to the death.

1 2 0 0 3

Overall care judgements of the 135 SJCRs completed for 2019/20 deaths were assessed as poor in 1 (1%)

case, adequate in 32 (24%) cases and as good or excellent in the remaining 102 (75%) of cases, table 4.

Table 4: Overall quality of care ratings for 135 SJCR cases completed in 19/20.

http://www.bristol.ac.uk/sps/leder/

Page 65

Themes, issues and learning identified through review and investigation (including examples of good

practice)

The purpose of the SJCR process is to identify areas for improvement in care/services and to highlight

good/excellent practice. A summary is provided in table below.

Table 4: Thematic analysis of learning from SJCRs (2018/19 and 2019/20).

Page 66

In addition to reviewing SJCR themes, consideration has been given to learning from review of Serious

Incidents and a sample of speciality based Morbidity and Mortality meeting minutes. This learning is

summarised below:

1. Clinically urgent amendments to results and reports (such as radiology/laboratory results) should be

rung through to the relevant team, rather than relying on electronic solutions alone

2. Internal capacity and flow can impact on tertiary transfer times significantly. Processes must be in place

to escalate tertiary referrals or waits based on clinical need to reduce the clinical risk associated with

delays to treatment

3. Appropriate communication of Fast Track discharge plans to receiving “home” and primary care is

required to prevent inappropriate re-admission/ED attendance

4. There is evidence from SJCRs of exemplary documentation of family discussions by medical staff

associated with end of life care

5. Changes to end of life care management were highlighted as having been managed sensitively by teams,

with excellent examples of good multi-professional care demonstrated in many palliative care cases.

NUH considers that the data is as described for the following reason: The data is reviewed and discussed at

the NUH Mortality and End of Life Care Group and interrogated in line with the Key lines of enquiry identified

by that group.

Page 67

NUH is taking the following actions to improve this indicator and so the quality of its services by:

1. The establishment of the Medical Examiner Team, which comprises of eight Medical Examiners to date.

The service has reviewed over 400 deaths with the vast majority of families very appreciative of the care

at NUH (following telephone consultations)

2. A newly appointed Patient and Family Liaison Officer commenced in post in August 2019. This post

supports patients, families and carers in relation to their involvement and support in investigations (SI

and SJCR). The post holder has engaged early on with multiple internal and external stakeholders to help

identify priorities. They have met with families either involved in historical SI and inquest cases or in

support of current investigations. A family member and PPI representative are supporting the co-design

of this important role

3. The SJCR process has led to increased cross speciality case reviews and learning. A number of specialities

are starting to align their Morbidity & Mortality reviews through utilising the SJCR format

4. The function of the Mortality Surveillance Group (MSG) has been reviewed, along with the terms of

reference. The group from January 2020 is chaired by the Medical Director and is focusing further on

end of life care and DNACPR improvement work

5. The ReSPECT tool designed to support the healthcare system to understand an individual patient’s

wishes and preferences around end of life, DNACPR and ceilings of treatment is being trialled in

Hayward House. This will support learning and conversations around possible wider adoption

6. A prevention of future deaths SOP and log has been developed. Learning from inquests is being shared

via the legal services team at the Learning and Review Group (LRG) and with the Mortality and End of

Life Care Group.

7. Audit and clinical observation of the pneumonia pathway across both campuses in response to our

mortality position has commenced

8. Work developing a shared understanding across the ME service and Patient Safety Team in regard to the

review and investigation of deaths continues with HM Coroner and assistants. Two learning events have

been held

9. QLik Sense LFD portal has been modified to track completion of SJCRs aligned to the national SI

timescale of 60 working days (no mandated timescales have been set nationally, rather this is an

internal process measure).

Priorities 2019/20:

1. Establish weekend and out of hours cover via the Medical Examiner Team

2. Ongoing delivery of the DNACPR project to further support improvements in the management and

documentation of DNACPR decisions

3. Evaluate the Patient and Family Liaison Officer role in support of helping patients and families following

an incident or a loved one’s death

4. Formalise links within the context of the Integrated Care System in support of cross boundary learning

5. Finalise analysis of pneumonia work, identifying recommendations to be shared with relevant fora,

aligning the national Community Acquired Pneumonia (CAP) CQUIN requirements to this work.

Page 68

Domain 3 - Helping people to recover from episodes of ill-health or following injury

Indicator 1 - Patient Reported Outcome Measures (PROMS)

PROMS describe the health gains after four operations using pre and post-operative surveys. NUH

undertakes two2 of these four operations and the date is provided below. NUH is one of the largest

providers of hip and knee replacement surgery in the country and performs a large proportion of complex

cases. The functional outcome of the operation is measures independently and nationally for all providers.

The results are expressed in terms of an improvement in function expressed by the patient as a result of the

surgery and labelled as patient reported outcome measures (PROMS). The improvement for hip function is

expressed as the improvement in the Oxford hip score and for the knee function, the Oxford knee score.

An adjustment is made to the figures to account for any co-existing conditions that may influence the

outcome.

The table shows the mean (average) improvement for patient who had orthopaedic surgery at NUH during

2018/19 (finalised) and April to September 2019 (the latest provisional data available), and the national

average.

2018/19 April 2019 to September 2019 (Provisional)

Indicator detail

NUH National Lowest/Highest NUH National Lowest/Highest

Hip replacement surgery

22.7 22.3 18.6 - 24.4 21.9 22.5 18.7 – 25.5

Knee replacement surgery

17.8 17.2 13.5 –19.9 18 17.6 14.4 – 21.3

NUH considers that this data is as described for the following reasons. NUH continues to perform in line with

expectations. The data is reviewed regularly by the service management team. NUH intends to take the

following actions to improve this indicator and so the quality of its services by ensuring that the results are

regularly reviewed by the Divisional Governance Forum in order to inform and support multi-professional

team working.

Indicator 2 – Emergency Readmissions within 30 days

Our readmission rate for the 12 months to November 2019 was 14.5%. This is a rise from the previous 12

month period of 14.0%. Table below shows the NUH monthly readmit rate – December 2017- November

2019.

2 NUH does not provide routine hernia and varicose vein surgery [provided by external provider to the Trust]

Page 69

NUH considers the data to be as described, which is regularly reviewed as part of the Trust internal

performance management process. NUH continues to take action to improve this indicator and the quality of

its services by monitoring the readmit rate with monthly Trust Board oversight through defined Performance

management reporting.

Domain 4 - ensuring people have a positive experience of care

Indicator 1 - The Trust’s responsiveness to the personal needs of its patients during the reporting period

(most current data at the time of writing, May 2020).

Indicator 4.2 Responsiveness to inpatients' personal needs (most current data at the time of writing, May

2020).

69.4

65.5

66.6

65.3 65.9

66.4

67.4

69

67.7

70.8

69.2

67.1 67.4

62

63

64

65

66

67

68

69

70

71

72

20

06

-07

20

07

-08

20

08

-09

20

09

-10

20

10

-11

20

11

-12

20

12

-13

20

13

-14

20

14

-15

20

15

-16

20

16

-17

20

17

-18

20

18

-19

Page 70

NUH considers that this data is as described, having participated fully in the National Patient Survey

Programme. NUH is taking the following action to improve this composite score and so the quality of its

services:

A detailed action plan is in development to respond to the findings and drive improvement in patient

experience.

Indicator 2 - Staff ‘Friends and Family’ test (FFT)

The percentage of staff employed by, or under contract to the Trust during the reporting period who would

recommend the Trust as a provider of care to their family or friends, is shown in the table below. We use our

staff Friends and Family Test (FFT) results as another method of monitoring the experience of our staff and

the results for 19/20 are shown below (the Quarter 3 FFT is replaced by the national survey)

Factor Q1 Q2 Q4

% of respondents would be extremely likely or likely to recommend

NUH services to friends and family if they needed care or treatment

83 83* 87%

% of respondents would be extremely likely or likely to recommend

NUH as a place to work.

54 80* 62%

*These values reflect only New Starters within the organisation as a sample group was chosen in Q2 to undertake the

Staff FFT

NUH considers that the data is as described for the following reasons. Within the National Staff Survey

Results (Quarter 3) NUH is above the NHS average for Acute Trusts in recommend for care and average for

recommend to work and is comparable to other large university teaching hospitals.

Page 71

Trust I would recommend my

organisation as a place to work

If a friend or relative needed treatment I would be happy

with the standard if care provided by this organisation

NUH 62.5% 75.3%

Leeds Teaching Hospitals 69.9% 79.3%

Oxford University Hospitals NHS Foundation Trust

64.2% 78.1%

University Hospitals Birmingham NHS Foundation Trust

58.9% 69.2%

University Hospitals of Coventry and Warwickshire NHS Trust

65.3% 73.7%

University Hospitals of Derby & Burton NHS Foundation Trust

67.5% 78.7%

University Hospital of Leicester NHS Trust

62.5% 67.0%

University Hospitals of North Midlands 60.4% 73.9%

Acute Trust Average 62.5% 70.5%

NUH is taking the following action to improve the overall survey scores and so the quality of its services by:

Launch of Culture and Leadership Strategy April 2020

Implementation of Improvement programme

Embedding values and behaviours

Review of the Health and Wellbeing Policy

Work around Just Culture and Civility Saves Lives

Support to existing/launch of specific task and finish groups to address specific areas of need identified

through NSS focus groups (February/March 2020).

Indicator 3 - Patient ‘Friends and Family’ test (FFT)

The Trust considers both in-patient and emergency department Friends and Family Test scores are an

authentic representation of our performance during 2019/20.

96

.92

%

0%10%20%30%40%50%60%70%80%90%

100%

Page 72

FFT Inpatients would recommend the Trust to their family or friends by provider (peer group) April 2019-

December 2019

FFT ED Attendances would recommend the Trust to their family or friends by provider (peer group) April

2019-December 2019.

NUH considers that this data is as described because it is regularly reviewed and discussed by Divisional and

Trust-wide patient experience forum.

NUH is taking action to improve these scores, and so the quality of its services. The scores, including analysis

and actions to improve are discussed by: Specialties and Divisions as part of their quality governance

arrangements and also at the quality, risk and safety and Board quality assurance committees. NUH’s

recommend rates are among the best in the country.

Domain 5 - Treating and caring for people in a safe environment and protecting them from avoidable harm

Indicator 1 - Venous Thromboembolism (VTE)

Venous Thromboembolism (VTE) is a significant risk to hospitalised patients. Our VTE programme aims to

reduce preventable harm to our patients by promoting timely and accurate VTE risk assessment and ensuring

thromboprophylaxis is prescribed accurately and administered effectively when required.

NUH’s overall VTE risk assessment compliance for 2019/20 was 94.4% (against a target of 95%).

NUH recognises that its compliance level is below target in 2019/20 but has shown improvement since

2018/19. In-depth analysis of performance within the Divisions has been undertaken to identify areas where

focussed action is needed and strategy developed. Advanced Nurse Practitioners and prescribing pharmacists

are now trained to complete the VTE Risk Assessments to provide support to the medical teams.

The graph below shows our performance against peers and the national average for England; this gives us an

accurate representation of NUH data.

96

.92

%

0%10%20%30%40%50%60%70%80%90%

100%

Page 73

VTE risk assessment by provider (peer group) April - December 2019

NUH is taking the following action to further improve this indicator and so the quality of its services:

Rollout of new IT system which will improve usability of the assessment tool, making it more accessible

to medical teams

Maintain Hospital Associated Thrombosis (HAT) route cause analysis compliance at 100%, where current

rate of preventable HAT remains low. The Trust is committed to investigating and sharing knowledge in

cases where an element of preventability has been found to drive improvement and has a clear

governance structure to facilitate this.

Indicator 2 - C. Difficile and MRSA infections

Rate per 100,000 bed days of cases of C. Difficile infection in the Trust amongst patients aged two or over

during the reporting period are described in table 1 (appendicies). Please see table 1 (appendices) for how

we do compared with our peers for C. Difficile and MRSA. We publish our infection rates for C. Difficile and

MRSA monthly on our website and on TV screens inside our hospitals.

NUH considers this to be an accurate representation of the data and is taking the following actions to

improve this indicator and so the quality of its services:

Continued strong emphasis on environmental cleaning and high level disinfection against C. Difficile

spores using our hydrogen peroxide systems

Regularly reviewing antibiotic prescribing and monitoring and feeding back on cases where

inappropriate prescribing is a possible contributory factor

Publication of outcome data

NUH supports the publication of outcomes of operations by our surgeons. This information enables patients

to make decisions and helps us provide better services. Clinical outcome data at Trust and consultant level in

the following specialties are available publically via online national audit registries including:

Cardiac surgery

Vascular

Bariatric

Interventional cardiology

Orthopaedics

94

.4%

71

.8%

10

0.0

%

England ave.

0%

20%

40%

60%

80%

100%

Bri

sto

l

Sou

tham

pto

n

Live

rpo

ol

No

ttin

gham

Leed

s

Shef

fie

ld

Man

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ter

Cam

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ire

Ne

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Leic

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and

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t

Page 74

Endocrine and thyroid

Urology

Head and neck

Bowel cancer

Upper gastro-intestinal (mouth and stomach)

TRUST-WIDE PATIENT SAFETY IMPROVEMENT PROGRAMME

Patient safety is central to the Trust’s aim of delivering high-quality care to patients. In 2018, NUH published

its Patient Safety Improvement Strategy describing key priorities for patient safety across the Trust over the

next five years. This has continued to inform the patient safety programme of work during 2019/20.

2020/21 Patient Safety priorities

The Patient Safety Programme, as described in the strategy, is focussed on creating an open and just culture

across NUH through a sustainable, high-quality programme based on best evidence to support the delivery of

safe care for patients, and a supportive work environment for volunteers and staff.

The 2020/21 priorities are outlined below. In support to realising these improvements in safer care in

2020/21 we intend to appoint to a patient safety clinical fellowship programme and to a clinical academic

role. In summary core safety priorities for 2020/21 include:











Page 75




Optimise information flow by implementing a standardised handover process

A standardised handover process will be defined and implemented to improve transfer of critical information within and across teams.

Initial work will focus on a daily clinical handover at the end of the day on city based medical admission areas.

Standardised process (such as SBAR) to be implemented for use in adult emergency admission areas and at internal transfer of patients.

Further details of the safety priorities are outlined below.

Recognise and Rescue (R&R) the Deteriorating Patient

The plans for 2020/21 are:

Roll out of ward-round clinician review of the DNACPR decision, to ensure all elements are completed

and that the decision is supported by the patients’ consultant

Observation of the DNACPR pathway in the Emergency Department to guide future improvement

programmes

Review current educational strategies and develop platforms for further support in ‘having difficult

conversations’, Mental Capacity Assessments’ and ‘DNACPR decision making’

Introduce a standardised audit process to measure the impact of improvement strategies and allow

comparison of results through Qliksense

Commencement of individual clinician feedback reports.

Implement an electronic fluid management system

A standardised handover process will be defined and implemented to improve transfer of critical

information within and across teams.

Medicines Optimisation

The Medicines Optimisation priorities for 2020/21 include:

Improving the safety and quality of prescribing and administration of anticoagulants, opioids and

insulins

Reducing unintentional missed doses of medication

Further digitalisation of medicines systems within the Trust.

Supporting our Staff

Supporting our Staff (SoS), a tiered programme to support staff after patient safety incidents and other

traumatic events, was officially launched in May 2018. It is well known that incidents can also negatively

Page 76

affect staff involved and this work stream has focussed on supporting staff to normalise their reactions and

look after themselves. This also creates support to maintain effective working. Work in 2019/20 has included:

Supporting our Staff (SoS) peer support network has now 60 trained members of staff to independently

assist where needed. This has resulted in 15 peer support conversations held across the Trust during

2019/20. This does not include those held locally by Specialties/Divisions

Whilst formal evaluation is planned, both managers and individuals accessing SoS have expressed how

much they value the support through the tiered programme.

During 2020/21, the SoS work stream will continue to be developed with plans to develop staff with expert

debriefing skills after major traumatic events.

Safety Spaces

Safety Spaces were developed by the Patient Safety Team as an opportunity for staff members to talk with

members of the safety team. Similar to those launched by the national Sign up to Safety team where they

encourage ‘kitchen table conversations’. Four Safety Spaces were held during 2019/20 and themes

highlighted included: Staffing, equipment and environmental challenges. Two of these conversations formed

part of a wider quality review.

Whilst we acknowledge the multiple competing demands, NUH must continue to prioritise these

conversations as they are a valuable opportunity for frontline staff to have an open and honest dialogue with

the Patient Safety Team and to develop a supportive focused culture at NUH.

Safety Spaces will continue into 2020/21 with plans to re-launch Patient Safety Conversations. These

conversations take place across the Trust within clinical workplaces and are usually attended by an Executive

and Non-Executive Director, with a member of the Patient Safety Team.

Freedom to Speak Up

Freedom to Speak Up (FTSU) guardians were introduced following Sir Robert Francis’s Freedom to Speak Up

Review in 2015. Their role is to work with leadership teams to create a culture where people can speak-up to

protect patient safety.

NUH is committed to creating a culture where staff feel able to speak up about any concerns they may have.

NUH appointed its first Freedom to Speak Up Guardian in 2016 as a stand-alone role to provide independent

and impartial advice and support to colleagues.

Handling of cases

The Trust’s Speak Up policy makes it clear that all cases will be handled with the strictest of confidence and

outlines the types of concerns the Guardian can support staff with.

The total number of cases reported to the Freedom to Speak up Guardian in 2019/20 was 51, an 8% increase

from the previous year. Key themes emerging within the 51 cases raised with the Guardian include culture,

leadership and quality of care.

Page 77

Nursing staff remain the group reporting the highest number of concerns, followed by doctors, midwives and

administrative staff.

The Freedom to Speak up Guardian works closely with NUH senior leaders to make improvements to policy

and practice, with the aim of improving the experience of NUH staff and the quality of care provided.

Culture

The Trust has a publicly visible dedicated internet site with key contacts and information on speaking up,

including frequently asked questions and speak up guidance and escalation processes. Various actions taken

to contribute to a more open and supportive culture during the year include:

Increasing Visibility: The Guardian has open door access to the Chair, Chief Executive, Executive Lead

and Freedom to Speak Up Non-Executive Director, supported by regular quarterly meetings

Supporting Vulnerable groups: We know from our staff survey results there are some groups of people

who are less likely to speak up. The Guardian has fostered strong links with the BAME Staff Network to

increase confidence in speaking up

Communication and engagement: There is regular use of the Trust Briefing to raise awareness of FTSU

and point staff to the NUH Speak Up web page that contains information and guidance. NUH uses a

variety of means to promote the Guardian role, including posters, induction, social media and

attendance by the Guardian at key staff meetings.

The Guardian conducted a number of walk around sessions during Speak Up Month in October 2019, and in

early 2020 presented to matrons and middle management teams, along with trainee health care assistants,

to generate awareness of Freedom to Speak Up.

Measures to support good practice

The Guardian is supported by a network of Speak Up Champions who promote the various channels through

which concerns and other important information on quality, safety and improvement can be reported. Based

on feedback, the role of Speak Up Champions has been refreshed, a robust training programme introduced,

including line management agreement for protected time to carry out the role.

Feedback

Comments on support provided by the Guardian has been overwhelmingly positive. However, it is recognised

that there is more work to do on consistency of approach to understanding, investigating and feeding back

on the types of concerns raised with line managers prior to contact with the Guardian and this will be a focus

of attention in the 2020/21 Freedom to Speak Up delivery plan.

Serious Incidents

NUH continues to encourage staff to report all incidents and to immediately escalate any that may require

consideration as a Serious Incident, including Never Events. This is to support prompt review, investigation

and learning. Whilst all reported incidents are investigated to enable organisational learning and

implementation of mitigating actions, Serious Incidents are subject to particularly comprehensive

investigation in line with the National Serious Incident Framework.

Page 78

Patients, relatives or carers are invited to meet with Serious Incident investigation panels in order to

contribute their experiences and questions as part of the investigation process. The Trust Learning and

Review Group ensures wide dissemination of the learning from Serious Incidents across the organisation, and

monitors implementation of recommendations to completion. Patient safety incident data is uploaded

regularly to NHS England via the National Reporting and Learning System (NRLS).

In 2019/20, NUH reported 38 Serious Incidents (excluding Level 1 harm free care serious incidents). Two of

these incidents were Never Events.

SERIOUS INCIDENTS 2019/20

(Excluding Harm Free care Level 1 SIs) NEVER EVENT TOTAL

Failure to rescue (Clinical Deterioration) 11

Delay / failure to treatment or procedure 11

Maternity triggers 1 7

Communication failure 2

Medication 2

Diagnosis, Scans and Tests 2

Other (Patient-Safety) 1 1

Nutrition 1

Contact with / Exposure to Harmful Agent, Substance or Object 1

Total 2 38

LEVEL 1 SERIOUS INCIDENTS (SI) CLASSIFICATIONS 2016/17 2017/18 2018/19 2019/20

Patient Fall 3 7 4 2

Infection Prevention and Control 20 10 10 6

Pressure Ulcer (stage 3)* 52 42 54 38

Total 75 59 68 46

*Pressure ulcer data is subject to validation. A lag of 45 days means incidents reported in March 20 could be

subject to removal or amendment.

Never Events

Never Events are a subset of Serious Incidents and are defined as ‘Serious Incidents that are wholly

preventable because guidance or safety recommendations that provide strong systemic protective barriers

are available at a national level and should have been implemented by all healthcare providers’ (NHS

Improvement January 18). They are infrequent events as outlined below (days between never events).

Page 79

NUH reported two Never Events during 2019/20:

1) A patient was found to have a retained vaginal swab post-delivery

2) A patient had the wrong strength lens implanted post cataract surgery.

Incident Reporting (via Datix)

Incident reporting is essential for NUH to learn about unintended or unanticipated occurrences in patient

care. NUH staff appreciate the importance of incident reporting and this is regularly updated through

mandatory training. Recognising and reporting an incident (or near-miss), no matter the level of harm, is the

first step in learning to reduce the risk of future occurrence.

Crude data from Datix (incident reporting system) shows that the majority of our patient safety incidents

continue to cause no harm (74.11%) or low harm (24.80%) (see table), with a total of 28,604 patient safety

incidents with an incident date in 2019/20 (25,851 incidents in 2018/19).

The number and rate of patient safety incidents reported within the Trust during the reporting period, and

the number and percentage of such patient safety incidents that resulted in severe harm or death are shown

in the table below.

Table: degree of harm for patient safety incidents reported in 2019/20 based on crude Datix reports.

CL

UCL

0

50

100

150

200

250

300

350

400

450

16

/03

/11

28

/03

/11

18

/04

/11

09

/05

/11

25

/05

/11

26

/09

/11

27

/09

/11

30

/04

/12

09

/11

/12

21

/12

/12

17

/01

/13

22

/12

/13

17

/06

/14

21

/08

/14

09

/12

/14

19

/08

/15

08

/09

/15

04

/11

/15

09

/11

/15

06

/02

/16

12

/03

/16

29

/04

/16

20

/06

/16

16

/07

/16

16

/09

/16

24

/09

/16

07

/02

/17

08

/02

/17

28

/12

/17

15

/02

/19

25

/02

/19

30

/05

/19

01

/08

/19

31

/03

/20

Day

s b

etw

ee

n c

ase

s

Degree of Harm n %

None 21197 74.11

Low 7095 24.80

Moderate 260 0.91

Severe 44 0.15

Catastrophic (e.g. death caused by the incident) 8 0.03

Total 28604 100

Days between Never Events Days since last Never Event

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Figure xx: patient safety incidents per 1000 bed days from April 2018 to the end of March 2020.

Examples of learning from Serious Incidents

NUH is committed to learning from its Serious Incident investigations. During 2019/20 we have continued to

code Serious Incidents against a human factors analysis framework to extract the learning. These emerging

themes over time can be compared with organisations known risks and shortfalls escalated. The learning

from these incidents are shared via “Safety Snippets”; short communications to be read out at all handovers

and ward rounds for seven days after release. They are duplicated in the Patient Safety Newsletter.

Examples of learning from Serious Incidents:

Communication:

o Ensure that patients/families and colleagues are fully appraised and updated regarding the

management of care and treatment plans; use all available sources

o Contemporaneous documentation must be easily accessible to all staff involved to include

conversations with patient/family

o Regular communication across specialties should be considered good clinical practice.

o Ensure instructions are clear, with designated roles and responsibilities. Ensure what has been

said has been heard and understood.

Process:

o Processes must be clear, written-down and communicated to those who use it; avoid ambiguity

o Ensure staff are aware of the guidelines that are relevant to the care they deliver

o Ensure all necessary staff can access emergency equipment and facilities when they need it

o Staff must be fully aware of whose responsibility it is to request further investigations

o New staff, either on a substantive or temporary basis must be clear of local process for arranging

follow up tests and investigations.

Checking and distractions:

o Let checking become a habit. We should trust colleagues, but also recognise that humans make

errors. Independent checks allow us to safely work as a team

o Avoid distracting colleagues when undertaking critical tasks. Remove distractors from areas of

critical work processes

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o Be familiar with equipment before using it. Ensure equipment is included in in local induction and

that support is always available.

Wider learning:

o Vitamin K Antagonist Prescription Chart revised to minimise the risk of further errors, positively

identify the patient and ensure that an identification band is applied as soon as possible on

admission

o Complex contact and referral processes. Specialties should review their availability to the clinical

areas they cover and other clinical teams. Any rota changes should be communicated clearly to

both switchboard and relevant clinical areas.

Serious Incident Learning Events

Serious Incident Learning Events were developed by the Patient Safety Team during 2019. The aim of these

events are through a shared learning and development workshop, develop an aspirational improvement plan

with agreed priorities and approaches to achieve it. A number of appreciative inquiry methods are used to

support conversations around learning themes.

During 2019/20 the Patient Safety Team have facilitated five learning events in a variety of specialties.

Serious Incident Investigation Faculty

NUH launched its Serious Incident Investigation Faculty. This group of medical and non-medical staff are

responsible for undertaking high-quality Serious Incident investigations in line with the Trust’s and external

expectations. These investigators ensure in-depth analysis is undertaken, staff support is provided and the

patient/family is involved. Training is delivered in line with national expectations. Significant improvements

have been made internally to the quality of SI training, investigation and reports.

2020/21 priorities

The Patient Safety Team has the following priorities for improvement:

Developing the Serious Incident Investigation Faculty so that investigators have protected time to

ensure high-quality reports completed, with clear learning identified as a result of changes in

response to investigation

Ensure Duty of Candour processes are strengthened to meet the expectations of Regulation 20

Evaluate the impact of the Patient and Family Liaison Officer role to support patients and families

through investigations

Implement a rapid incident response team to support patients, families and staff early on following

adverse events

Respond to the new national Patient Safety Incident Response Framework as guided by NHS E/I.

PEOPLE METRICS

Mandatory training attendance

A total of 77% of staff attended their mandatory training refresher in 2019/20 (against a target of 90%).

There have been some challenges around access and recording of staff as the Trust moved on to bookings via

Employee Self-Serve (ESS) accessed through the 'NHS ESR Login' application. Improvements in compliance

have been noted within the last quarter as new systems and processes become embedded, to include

changes to the content and delivery of Mandatory Training.

https://improvement.nhs.uk/documents/6516/200312_Introductory_version_of_Patient_Safety_Incident_Response_Framework_FINAL.pdf

https://improvement.nhs.uk/resources/patient-safety-incident-response-framework/

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Appraisal rate (medical and non-medical)

84% of non-medical and dental staff had an annual appraisal during 2019/20 (against a target of 90%). A

simplified new appraisal process was introduced Trust-wide in November 2018 and is supported by using

quality conversation between appraiser and appraisee. It has been well received, with operational pressures

noted as the main challenge to achieving target.

Medical and dental appraisal consistently performs well with 98.3% of medical and dental staff (excluding

Junior Doctors) having had an appraisal within the last 12 months. Appraisal of medical and dental

practitioners is linked to revalidation.

Turnover

The Trust performance for turnover is currently 11.27%, (against a target of 10.8%) improvements have

continued in 2019/20 for Registered Nursing (RN) staff and Healthcare Assistants as part of the work with

NHS Improvement.

It should be noted that a level of turnover should be expected and encouraged within the Trust. The leavers

survey (launched in 2018), which continues to provide additional detail as to why people leave the

organisation, is shared with recruitment and retention groups across the Trust to enable the Trust to respond

accordingly.

Sickness absence

Rolling sickness absence rate of 4.33% for 2019/2020 (against a target of 3.8%) and whilst an increase on last

year is still one of the lowest in the East Midlands. The continued operational pressures of the Trust have

impacted on the absence of staff on occasions.

Job Planning

85% of our consultants have job plans which have either been submitted for approval, or have been

approved-an increase of 6% on the previous year.

Time to Hire

Our time to hire is at 47 days against the 45 day target for 2019/2020.

STAFF ENGAGEMENT

Staff Friends and Family Test (FFT)

The last Staff FFT was undertaken in March 2020. The Staff FFT is a quarterly measure of the satisfaction rate

of the staff within the Trust. It asks two key questions:

Would you recommend NUH as a place to receive care or treatment?

Would you recommend NUH as a place to work?

Factor Quarter 1 Quarter 2 Quarter 4

% of respondents would be extremely likely or likely to recommend NUH services to friends and family if they needed care or treatment

83% 83%* 87%

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% of respondents would be extremely likely or likely to recommend NUH as a place to work.

54% 80%* 62%

*These values reflect only New Starters within the organisation as a sample group was chosen in Q2 to undertake the

Staff FFT

For Quarter 3, the National Staff Survey is utilised as the measure for Staff FFT. This is not an exact

comparison with Staff FFT, as the questions are asked slightly differently and are weighted to allow

comparisons with other Acute NHS Trusts. We compare to other teaching hospitals as follows:

Trust

I would recommend my

organisation as a place to

work

If a friend or relative needed

treatment I would be happy

with the standard if care

provided by this organisation

NUH 62.5% 75.3%

Leeds Teaching Hospitals 69.9% 79.3%

Oxford University Hospitals NHS Foundation Trust

64.2% 78.1%


58.9% 69.2%

University Hospitals of Coventry and Warwickshire NHS Trust

65.3% 73.7%

University Hospitals of Derby & Burton NHS Foundation Trust

67.5% 78.7%

University Hospital of Leicester NHS Trust 62.5% 67.0%

University Hospitals of North Midlands 60.4% 73.9%

Acute Trust Average 62.5% 70.5%

National Staff Survey (NSS) 2019

38% (5,899) members of staff responded to the NSS 2019. The Staff Engagement ‘theme score’ is 7.0/10 the

same as in 2017 and 2018 and is in-line with the Acute Trust average. This score is seen as a key indicator in

measuring staff satisfaction and motivation, with the score derived from nine questions around motivation,

involvement and advocacy.

Themes were newly introduced summary indicators for 2018, (previously key findings were reported on)

providing an overview of staff experience. All themes are scored on a 0-10pt scale and reported as mean

scores. A higher theme score always indicates a more favourable result. Each theme is comprised of between

three and nine questions, with Team Working a new theme introduced in 2019.

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Of the 11 reported themes:

Four themes are better than average: Equality, diversity & inclusion, Safe environment – Bullying &

harassment, Safe environment – Violence and Safety culture, (of which 2 are within the best 20% of

benchmarked Trusts)

Three themes are average:Immediate managers, Morale and Staff engagement

Four themes are worse than average: Health and Wellbeing, Quality of appraisals, Quality of care and

Team working (of which 3 are in the lowest 20% of benchmarked Trusts).

When comparing with NSS 2018 results, a statistical significant change (decrease) for Trust results is

suggested for two themes, as detailed in the table below.

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N.B. Theme score remains at 7.0 for Staff Engagement in both 2018/2019. On checking with SCC the score

was 7.03 in 2018 and 6.96 in 2019, so the figure in 2018 has rounded down to 7.0 and the figure in 2019 has

rounded up to 7.0. Rounding is one factor that will impact why results that look different to one decimal

point aren’t significantly different, yet those that look similar to one decimal point can be significantly

different. Other factors can affect determination of statistical significance, such as differences in the sample

sizes at different questions (for instance due to non-response data).

The Trust has analysed the quantitative results and qualitative comments, sharing with divisions and

corporate departments to enable development of Trust-wide and local actions which will be delivered and

monitored through Divisional People Committees and People Experience Group.

Seven day services

The seven day service standards were founded on published evidence and on the position of the Academy of

Medical Royal Colleges (AoMRC) on Consultant-delivered acute care. Ten standards were agreed. With the

support of the AoMRC, four were identified as priority clinical standards on the basis of their potential to

positively affect patient outcomes. NUH has a seven day service project group and has undertaken and a

number of self-assessments adopting the NHS Improvement Board Assurance Framework tool. The self-

assessments along with operational plans have been reviewed by Trust Board and submitted to NHS

England/Improvement. Key outcomes are summarised below:

An audit of emergency patients’ admissions from 1st to 7th September 2019 was used to inform our self-

assessment against delivery of the priority standards, detailed below.

Standard 2 - 54% (weekday 55%, weekend 53%) - non compliant

Standard 5 - compliant

https://improvement.nhs.uk/resources/seven-day-services/

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NUH has self-assessed as compliant against nine of the ten 2019 standards, the exception being:

Priority standard 2 (All emergency admissions must be seen and have a thorough clinical assessment by

a suitable consultant as soon as possible but at the latest within 14 hours from the time of admission to

hospital).

Priorities 2020/21

Develop business cases to support increased consultant cover in key admission areas

Review current risk rating/assessment.

Research and Innovation

The Research and Innovation department at NUH is responsible for leading, managing and developing clinical

research in every part of our hospitals.

In 2019/20 NUH continued to be at the forefront of clinical research development in the country based on

National Institute for Health Research (NIHR) data. We carried out a total of 472 clinical trials involving

14,415 adults and children. NUH is now the third most active research hospital in England.

Clinical research is part of everything we do as a teaching hospital, bringing the skills of front-line NHS staff in

every profession together with scientists, academics, data analysts and industry partners to ensure that NUH

patients can benefit from the latest advances in clinical care.

In 2019/20 we were particularly pleased to see the contributions of nurses in our research workforce

recognised with three national awards.

NUH was one of the most successful hospital Trusts in the country in the National Institute for Health

Research (NIHR) 70@70 programme which was set up to mark the 70th anniversary of the NHS. The

programme selected 70 nurses and midwives from across the country with the aim of enabling more

professionals to get involved in clinical research.

Currently over 400 nurses, midwives, doctors and health professionals are directly involved in helping to

deliver research trials at NUH each year. The 70@70 programme is designed to open up new opportunities to

support the world-class research taking place in Nottingham.

One of those selected for the programme, Dr Sarah Brand, Senior Research Nurse for the NUH Renal and

Transplant Unit, is using her 70@70 role to explore how clinical research can be more integrated within

frontline nursing practice, sharing research skills with all nursing staff and making research part of “business

as usual”. Sarah, who is based at Nottingham City Hospital, said: “I am delighted to have been awarded a

prestigious NIHR 70@70 Nurse Research Leader role. This gives me the chance to influence the development

and embedding of a culture of research within nursing at NUH - a culture which is the foundation of

evidence-based nursing practice and excellent patient care.”

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Awards were also given to Aquiline Chivinge, Ambulatory Care Pathway Matron, and chair of the NUH BAME

(Black, Asian and Minority Ethnic) Shared Governance Council, and Dr Louise Bramley, Clinical Lead for

Research and Innovation at the NUH Institute of Nursing and Midwifery Care Excellence.

In 2019/20 our key performance achievements were:

2019/20

Target Actual

Minimum % of patients offered the opportunity to participate in research 20% 30%

Number of patients recruited in NIHR studies 14,000 14,115

Total Research and Innovation Income £26m £25.9M

Research Following Patient Need

Our research portfolio and activity prioritises diseases which have a high prevalence in our region. A total of

2,685 cancer patients helped deliver 106 different research studies. The NIHR Nottingham Biomedical

Research Centre is strategically aligned to the clinical needs of the Nottingham and Nottinghamshire

population. More than 15,000 patients suffering from respiratory, gastrointestinal, hearing loss and

musculoskeletal disorders benefited from access to innovative therapies.

NIHR Nottingham Biomedical Research Centre (BRC)

The Nottingham Biomedical Research Centre is our centre of excellence which was set up in 2017 to fast-

track scientific developments from the research laboratory to patient care.

In the last 12 months our research has produced breakthrough results for understanding why some patients

develop a fatal respiratory illness, Idiopathic Pulmonary Fibrosis (IPF); in our understanding of Tinnitus, a

hearing condition for which there is no cure; a genetic link between the health of our guts and hardening of

the arteries which can lead to heart disease; and the impact of some cancer drugs on hearing loss.

During 2019/20 the Nottingham BRC carried out 406 translational research projects, supported 197 early

researchers in their careers and published 437 research articles available to all researchers which will help to

develop new treatments for patients.

NIHR Nottingham Clinical Research Facility (CRF)

Our Clinical Research Facility provides the equipment, skilled staff and dedicated facilities to enable us to

carry out experimental medicine research.

It is part of a network of facilities across the country who have been selected by the National Institute for

Health Research (NIHR) to increase our capabilities in complex research into new drugs and therapies.

Nottingham hosted the national conference for all Clinical Research Facilities across the UK and Ireland. The

conference heard from scientists and researchers at the cutting edge of new medicine and from Nottingham,

the 400 delegates learned about our work with young people in developing a new treatment for childhood

constipation. The volunteer group swallowed harmless mini-capsules that show up on MRI scans to track

their digestion. One in ten children and young people suffers from constipation at some point and the

problem becomes chronic in a third of them, with 27,500 per year needing hospital treatment in England

alone.

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Up to now, there has been no completely safe and efficient way of tracking the movement of food through

the gut, so possible reasons for constipation have been hard to diagnose.

The ‘MAGIC’ (MAGnetic resonance Imaging in paediatric Constipation) programme has been designed by

experts at the birthplace of MRI in Nottingham. The study involved gastroenterology experts from NUH, the

University of Nottingham and the Nottingham BRC.

The ‘Magic Bean’ mini-capsules are made of a medical-grade plastic shell and are smaller than Tic Tacs to

make them easy for children and young people to swallow. They do not dissolve in the gut, and are filled

with a MRI-visible liquid that stands out clearly in the scan pictures of the gut.

In 2019/20, the Nottingham CRF delivered 503 projects, a 22% year on year increase in Nottingham’s

experimental medicine activity with the largest growth in therapeutic areas outside the BRC such as cancer,

neurology and renal diseases.

Links with the Life Sciences Industry

NUH recruited 316 patients in 76 contract commercial studies in 2019/20. The new business development

team made significant progress in leveraging strategic partnerships at local, national and international level

to drive innovation and financial growth.

Priorities for 2020/21

NUH is a research hospital, with clinical research taking place in each of the Clinical Divisions as well as in our

centres of research excellence.

In 2019/20 we set out four key priorities to ensure that local patients continue to benefit from better

healthcare, treatments and technology which our research provides. These included aligning clinical research

with the needs of the wider health system in Nottingham.

For 2020/21 our ambitions include supporting the development and delivery of novel Covid-19 treatments,

launching the Nottingham Health Science Partners as a vehicle for greater joint working and alignment with

our local partners in research, increasing our partnerships with industry to ensure that we provide new

treatments and better evidence to improve the health of our local communities and increasing the number

of members of Team NUH who are research active through our Research Futures School, which supports

research careers for all professional groups.

Highlights

Hat-trick of national research awards for NUH doctors

Consultant neurologists Doctors Akram Hosseini and Radu Tanasescu, and Consultant Respiratory physician

Dr Sherif Gonem, are among a select group of doctors who have been awarded grants by the Medical

Research Council (MRC). The Clinical Academic Research Partnerships (CARP) is a new initiative which aims to

support more NHS clinicians to take part in clinical research.

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For her research project, Dr Akram Hosseini, Consultant Neurologist, will be harnessing powerful Magnetic

Resonance Imaging (MRI) – an area in which Nottingham leads the world – to study the build-up of iron in

patients’ brains, a factor which contributes to the development of Alzheimer’s disease.

There are 850,000 people in the UK living with dementia – many of whom have Alzheimer’s disease – a

devastating condition that causes gradual decline in memory, thinking and reasoning skills and therefore

disruption to their daily lives.

Dr Hosseini said: “It is a golden opportunity to draw on the physics expertise at the Nottingham Sir Peter

Mansfield Imaging Centre, for clinical studies and biomedical sciences. Professor Richard Bowtell and I will be

working together to apply new MRI sequences to investigate dementia.

“I’m grateful to work at a leading medical centre and be able to conduct clinical research using high

resolution MRI in a study that is meaningful to patients.”

Dr Radu Tanasescu and his study team will be using MRI and clinical data routinely collected from people

with Multiple Sclerosis (MS) and apply AI (Artificial Intelligence) techniques to identify models that predict

MS outcomes. AI will be used to extract hidden-information from MRI scans.

Where patients have given consent for their data to be used, the researchers will analyse information about

the patients' clinical condition, their demographics and MRI scans, using AI.

The study team’s IT specialists will train a computer to use mathematical models to predict whether a

person's MS will mean greater disability or cognitive impairment over the long-term.

The AIMS study will take advantage of a collaborative environment which includes the Nottingham MS clinic

and research programme and its international exposure and networking, the NIHR Nottingham Biomedical

Research Centre and the University of Nottingham.

Dr Tanasescu said: “I feel very honoured to be the recipient of this award. The CARP award involves

collaborative high-quality research partnerships with established leading biomedical researchers.

“We intend to harness more valuable information from routine MRI scans and existing NHS clinical data with

our study, which makes the research cost-efficient. I am aware of the complexity and challenge the clinical

application of AI entails, but through collaboration and support from AI experts and a robust plan of external

validation, we aim to make a breakthrough. This can provide a tool for informed decision-making and

personalised treatment in MS.”

Dr Tanasescu added: “We hope this study will have in the end a direct benefit for patients – it is not science

for the sake of it. And we aim to expand our knowledge of Multiple Sclerosis using real-world clinical data.”

Respiratory Consultant Dr Sherif Gonem is based at Nottingham City Hospital.

The CARP award is enabling him to work with respiratory medicine Professor Dominick Shaw on a

retrospective study to improve the early warning system used to monitor patients on respiratory (lung

disease) wards.

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Drawing on five years of existing patient data to predict potentially life-threatening events occurring during a

hospital stay, the study also aims to reduce the rate of false alarms. As a result, doctors and nurses should be

able to better manage their workloads.

Sherif’s study will draw on the expertise of computer scientists and use AI and machine learning - where

computer programmes access data and use it learn for themselves - to analyse anonymised data generated

by the existing NUH Nerve Centre clinical system.

He said: “I’m very pleased to be one of the three recipients of CARP at NUH. It’s a great opportunity and I

hope my research project will have a positive impact on patients with lung disease both in Nottingham and

further afield.”

Professor Stephen Ryder, Clinical Director of Research & Innovation said: “It is a fantastic achievement for

our colleagues at NUH to have been successful in this new area of research funding. NUH is already one of

the most research-active hospitals in the country, and the quality of our research is recognised nationally and

internationally.

“We know the importance of supporting clinicians at every stage of their careers to take part in research, and

the CARP funding is an excellent opportunity for front-line staff to bring their skills and knowledge to clinical

research.”

Nottingham joins national research programme for asthma and COPD

Patients in Nottingham and across the East Midlands with respiratory illnesses including asthma and COPD

are benefitting from a pioneering new research programme.

Researchers in Leicester and Nottingham are part of the UK’s first dedicated data hub for respiratory illnesses

that is enabling cutting-edge research for health discoveries to give patients across the UK faster access to

pioneering new treatments.

The BREATHE Health Data Research Hub for Respiratory Health is one of seven data hubs set up to improve

the lives of people with debilitating conditions by linking up different types of health data to make it more

easily accessible and user-friendly for research. Researchers from centres of excellence based at NUH and in

Leicester are joining with partners from across the UK, including the NHS, academia and charities to develop

the new Hub.

Professor Ian Hall, COPD lead for the BREATHE Hub and Director of the NIHR Nottingham Biomedical

Research Centre said: “I am delighted that researchers in Leicester and Nottingham will be playing a major

role in helping the national Hub deliver its objectives. This builds on a decade of close collaboration between

the NIHR Nottingham and Leicester Biomedical Research Centres, and on the extensive links we have already

put in place across the UK. Ultimately our aim is to accelerate access to relevant health data to facilitate

research into lung diseases and to improve patient care.”

Patients, researchers and clinicians are working together to explore the safe and ethical use of health data

for research into specific diseases including cancer, Crohn's disease and asthma. They will also enable access

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to data for trialling new treatments and support improvements in clinical care. Patients will be involved in

decisions about how their data is used to ensure the benefits are returned to the NHS and the wider UK

community, and existing rules for accessing data safely and securely will continue to apply.

The Health Data Research Hubs are part of a four-year £37million investment from the UK Government

Industrial Strategy Challenge Fund (ISCF) announced in November 2017 led by UK Research and Innovation,

to create a UK-wide system for the safe and responsible use of health-related data on a large scale. The hubs

will also stimulate further economic growth through greater research activity.

Each hub was selected following an open competition by an independent panel involving patient and public

representatives. They were assessed against criteria that included the potential for impact, the innovative

uses of data, plans for involving patients and the public, and the value for public funding.

We took our research to the zoo this year

Our orthopaedic surgeons swapped their operating theatres and clinics for a day out at the zoo in the hope

of encouraging young people and their families from across the East Midlands to take part in the

international CORE-Kids research trial.

Their research is funded by the National Institute for Health Research (NIHR) and involves children from

around the world, looking at how broken bones (fractures) are treated in children aged 5-15. Overall,

researchers are hoping to speak to over 300 children and families over the next year.

Ben Marson, Orthopaedic Surgery registrar at Nottingham Children’s Hospital and NIHR Doctoral Fellow

explains: “Children and young people who suffer a fracture may be living in pain and may miss out on doing

activities they enjoy such as playing sports and generally being active.

“These kinds of injuries may mean that children experience disrupted sleep, they may need to take time off

school, and their general happiness can be affected. And 10 per cent of children who suffer from a fracture

won’t make a full recovery a year after their injury.”

Ben added: “With CORE-Kids, which is an international study, we will be finding out which outcomes - or

results - are the most important ones to measure.

“This will mean that we will shape all future research trials on children’s fractures. This should lead to better

care and management of these children through better evidence-based medicine.”

The CORE-Kids trial will also help to provide more consistent standards of treatment and follow-up after a

fracture.

Twycross Zoo was chosen as a popular location to help raise awareness of this research trial among parents

and children affected by fractures.

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QUALITY ACCOUNT PART 3

The tables below show the Trust’s latest performance for 2019/20 and the last three financial years against a

range of indicators for patient safety, clinical effectiveness and patient experience. The Board of Directors

have chosen to include the same set of indicators included in the 2017/19 Quality Account to enable patients

and the public to understand performance over time. The latest data available for 19/20 is shown below and

has been subject to data quality checks by the NUH Informatics team in line with NUH processes.

Table 1. Overview of Quality of Care Indicators provided over 2019/20

201920 QA Appendices.xlsx

Table 2. Performance against indicators in the Standard Operating Framework

Table 3 Performance against core indicators

201920 Quality Accounts Prescribed Content.xlsx

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Appendix A - Peer hospitals

University Hospitals of Leicester NHS Trust

Leeds Teaching Hospitals NHS Trust

Sheffield Teaching Hospitals NHS Foundation Trust

University of Southampton NHS Foundation Trust

Newcastle Hospitals NHS Foundation Trust

Cambridge University Hospitals NHS Foundation Trust


Manchester University NHS Foundation Trust

University Hospitals Bristol NHS Foundation Trust.

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Appendix B - Statistical Process Control Charts

Statistical Process Control (SPC) is an analytical technique that plots data over time. It helps us understand

variation and in so, doing guides us to take the most appropriate action. SPC is widely used in the NHS to

understand whether change results in improvement. We have used the NHS Improvement SPC tool to

produce the SPC charts in this report. Below is a key to the icons used in these charts.

https://improvement.nhs.uk/resources/statistical-process-control-tool/

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Annex 1 - Statements of assurance from:

Nottingham University Hospitals NHS Trust - Statement of Assurance from NHS Nottingham

and Nottinghamshire Clinical Commissioning Group

NHS Nottingham and Nottinghamshire Clinical Commissioning Groups (NNCCG) (formally consisting of

Greater Nottingham Clinical Commissioning Partnership, Mansfield and Ashfield CCG and Newark and

Sherwood CCG) collaboratively commission services from Nottingham University Hospital NHS Trust (NUH).

Since July 2019 NUH has held the contract to deliver services in the Nottingham Treatment Centre. There

was a period of mobilisation and transformation followed by a short number of months of ‘normal’ delivery,

followed by the impact of Covid-19. The months of normal delivery showed significant transformation of the

delivery of services however, performance reporting was impacted by mobilisation and therefore it is

difficult to comment on the national performance indicators. NNCCG acts as the co-ordinating commissioner

and leads on the contract on behalf of the other CCGs in gaining assurance on patient safety and quality of

care delivered by NUH.

The quality assurance framework that Commissioners use consists of reviewing information on safety,

patient experience, outcomes and performance, in-line with the quality schedule and national and local

contractual requirements. Intelligence is gained in various formats, including local and national reported

data, this is complemented by quality visits to clinical areas, which enables commissioners to experience the

clinical environment and gain first hand experiences from patients and front-line staff, including the clinical

environment.

NUH has continued to provide the CCG with high level reporting in line with their 2019/20 contract. The CCG

has measured and reviewed reporting via Quality and Performance Scrutiny Group meetings. The CCG has

also undertaken quality and insight visits to various wards and departments with the Trust, to gain additional

assurance around: Safety, effectiveness of services and patient experience. The Quality Account provides

information which is consistent with the information received by the CCG during the year.

In 2019/20, NUH has continued to ensure that patients receive consistent high quality, safe care, with good

health outcomes and experience. The Trust has performed well against the safety thermometer, with a

consistent harm-free care rate. NUH has achieved its aim of reducing pressure ulcers by 50% over three

years. It is noted that there was an increase in the rate of all falls, and falls associated with harm, but the

rate of falls remained low historically. The Falls Learning Group continues to work with frontline clinicians to

understand the drivers and apply appropriate safety control measures. Commissioners are part of the core

membership to the Falls Learning Group and Pressure Ulcer Learning Group.

NUH reported 38 Serious Incidents (SI) in 2019/20 (excluding level 1 harm free care serious incidents).

Serious incidents are events in health care where the potential for learning is so great, or the consequences

to patients, families and carers, staff or organisations are so significant, that they warrant using additional

resources to mount a comprehensive response. Serious incidents can extend beyond incidents which affect

patients directly and include incidents which may indirectly impact patient safety or an organisation’s ability

to deliver on-going healthcare. There is not an exhaustive list which details what events would be included.

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Two of the incidents were Never Events. Never Events are defined as Serious Incidents that are wholly

preventable because guidance or safety recommendations that provide strong systemic protective barriers

are available at a national level and should have been implemented by all healthcare providers.

The Trust encourages staff to report all incidents and to immediately escalate any that may require

consideration as a SI, including Never Events. NUH has internal processes in place for reporting SIs on the

Strategic Executive Information System (StEIS) and to Commissioners. Commissioners review all SIs regularly

and work closely with NUH on obtaining further assurance when needed and then final closure of incidents.

NUH confirms in the Quality Account that the Trust is committed to learning from its SI investigations.

The Quality Account demonstrates examples of good work and achievement undertaken by NUH over the

past year around: Do Not Attempt CPR and medication optimisation, antibiotic consumption, impact of UTI

quality improvement, recognise and rescue the deteriorating patient, roll-out of the new NEWS 2 system,

reducing avoidable harm and death associated with missed opportunities to identify. and respond to

deteriorating patients.

Commissioners note that the CQC undertook a standalone inspection of the children’s sexual assault referral

centre in November 2019 and the only area for concern was within the ‘Well Led’ domain. The CQC is

monitoring actions and has oversight arrangements in place. However, it is to be noted that the inspection

findings do not impact on the Trust’s ratings.

NUH has achieved a majority of the Commissioning for Quality and Innovation (CQUIN) goals in 2019/20.

Commissioners recognise that NUH has been working relentlessly to improve systems and processes within

the Emergency Department. NUH was selected as one of the field testing sites for new metrics and has been

reporting against these since May 2019. Patients waited too long in ED which is a significant issue for NUH

and there is need for urgent improvements. . The number of patients waiting on a trolley in ED for 12 hours

or more continues to be monitored by Commissioners.

NUH participated in 99% of National Clinical Audits with learning and actions identified, from which the Trust

intends to improve the quality of healthcare provided. Results from the most of the Patient Surveys

published by CQC highlighted that patients felt listened to, confident in the provision of care and well looked

after. To strengthen this, plans and actions have been taken to improve patient experience in response to

the Maternity Services and Patient Friends and Family Test (FFT) Surveys. Improvement plans are also in

place for 2020/21 in response to the National Staff Survey.

NUH has demonstrated good progress around safety and quality in 2019/20 but some challenges still remain

for the Trust. For the first time since June 2012, NUH underperformed against the 18 week RTT standard.

This is largely due to increase in waiting lists and reduction in number of clinicians undertaking additional

sessions as a result of issues relating to the NHS Pension Scheme. The decision to cease all routine elective

work to create capacity for COVID-19 patients will continue to impact on the Trust’s RTT performance.

NUH’s overall VTE risk assessment compliance was still below target in 2019/20 but has seen an

improvement over 2018/19. Training on completing VTE Risk Assessments and a new IT system in 2020/21

will improve usability of the assessment tool. C.Difficile and MRSA at NUH were above trajectory for 2019/20

but the Trust has developed effective programmes of surveillance and remains committed to improving and

sustaining high levels of environmental cleanliness.

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The Quality Account highlights that NUH had challenges achieving its target for mandatory training

attendance due to access issues and recording while staff were moved on to different systems. Appraisal

rates for non-medical and dental staff were below target but a new simplified appraisal process has been

introduced. Medical and dental appraisal consistently performs well at NUH.

Commissioners acknowledge the commendable work by the Research and Innovation Department at NUH

and extend their praise to the doctors on their national research awards. Commissioners also recognise

NUH’s journey to MAGNET® to be nationally and internationally recognised for excellence in care. Magnet

recognition will build upon the 'Outstanding for Caring' rating from the Care Quality Commission providing a

roadmap to nursing excellence, which benefits the whole of an organisation.

Commissioners recognise that NUH is working actively with system partners as a member of the

Nottinghamshire Integrated Care System, to transform the Trust’s approach to focus on population health

needs and ‘system’ ways of working.

The Trust-wide patient safety improvement programmes for 2020/21 explained in detail in the Quality

Account are innovative and ambitious which Commissioners are supportive of.

As Commissioners we have worked closely and built close relationships with NUH over the course of 2019/20

to review the Trust’s progress. We hope to continue to build good relationships as we move into 2020/21.

Commissioners support the quality priorities set by NUH for 2020/21 and look forward to working with NUH

over the coming year as they continue to look for opportunities to make improvements to safer care and to

the quality of care provided to patients and families.

Nottingham County Council Health Scrutiny Committee

The Health Scrutiny Committee for Nottinghamshire welcomes this opportunity to comment on Nottingham

University Hospital’s draft Quality Account.

The committee is pleased to see a strong focus on reducing the incidence of Grade 3 & 4 pressure sores

within the Trust’s quality priorities. It is, however, unfortunate that the 10% year on year improvement

target is unlikely to be met.

The move to improve the quality of patients’ sleep by reducing unnecessary light sources and noise from

staff is to be particularly welcomed.

The development of the Trust’s Duty of Candour processes, and the involvement of families when things go

wrong, is something that the committee would like to hear about in more detail in due course.

It is unfortunate that cases of C.Difficile remain stubbornly high. It would be interesting to know what further

innovative measures could be deployed by the Trust to reduce the number of cases.

The committee commends the crucial work undertaken by the Trust in the appropriate management of

sepsis patients, particularly, the delivery of the bi-monthly sepsis survivors support group.

The Trust is to be congratulated on the high uptake of flu vaccination amongst frontline staff (80%) as well as

the generally high level of achievement of CQUIN targets.

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The Committee also congratulates the Trust on achieving a rating of ‘Good’ overall at its last CQC inspection.

We hope that the Trust will make all possible efforts to make the improvements necessary to achieve a

higher rating in the safety domain next time.

The Health Scrutiny Committee would also like to take this opportunity to thank the staff of NUH for all of

the work they have undertaken during the particularly challenging time of the COVID-19 pandemic.

Councillor Keith Girling

Chairman of the Health Scrutiny Committee

Nottinghamshire County Council

July 2020

In the context of COVID-19 statements of assurance were not recived from Healthwatch Nottingham and

Nottinghamshire and Nottingham City Health Scrutiny Committee.

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Annex 2 - Statement of Directors responsibilities in respect to the quality account

The directors are required under the Health Act 2009, National Health Service (Quality Accounts) Regulations

2010 and National Health Service (Quality Account) Amendment Regulation 2011 to prepare Quality

Accounts for each financial year. The Department of Health and Social Care has issued guidance on the form

and content of annual Quality Accounts which incorporate these legal requirements.

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 subject to

appropriate scrutiny and review; and

The Quality Account has been prepared in accordance with Department of Health and Social Care

guidance.

The directors confirm to the best of their knowledge and belief that they have complied with the above

requirements in preparing the Quality Account.

Eric Morton Tracy Taylor

Chair Chief Executive

Insert date Insert date

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QUALITY ACCOUNT PART 1, CHAPTER

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