2015 - 2016 Quality Account Reports... · 2017-09-12 · UHCW 2015 - 2016 Quality Account Page 4...

2015 - 2016 Quality Account

University HospitalsCoventry and Warwickshire

NHS Trust

Content


NHS Trust

UHCW 2015 - 2016 Quality Account

Section

1 AWelcomefromourChiefExecutiveOfficer Page3

2 IntroductiontoQuality Page4

2.1 QualityHighlights2015-2016 Page4-7

2.2 QualityImprovementPrioritiesfor2015-2016ProgressUpdate Page7-9

2.3 QualityImprovementPrioritiesfor2016-2017 Page10-14

2.4 StatementsbytheTrustBoard Page15-34

2.5 PerformanceagainsttheNHSOutcomesFramework Page35-42

3 OverviewofOrganisationalQuality Page43-77

4 Invitationtocommentandofferfeedback Page78

Annexes

StatementsfromPartnerAgencies Page79-80 CommentaryfromJointQualityAccountTaskGroup Page80-82 Director’sStatementofResponsibility Page83 ExternalAuditor’sLimitedAssuranceStatement Page84-86

Appendices CQUIN2015-2016 Page87

Glossary Page88-99

Section 1A Welcome from our Chief Executive Officer

Welcome to our Quality Account for 2015-2016. This report provides you with an overview of the quality of the services we provided to our patients during 2015-2016, and an outline of our priorities for the forthcoming year.

UniversityHospitalsCoventryandWarwickshire(UHCW)NHSTrusthassomeofthemostskilledandprofessionalstaffworkingintheNHS.Our9,600staffworkincrediblyhardtoprovideexcellentcareforourpatients,whocometoourhospitalsfromacrossCoventryandWar-wickshireandbeyond.AsChiefExecutiveOfficer,Iamproudtocelebratetheirachievementsoverthelastyear,aswellaslookingaheadtowherewehopetobeinMarch2017.

Thelastyearhasseenanumberofimportantdevelopmentstoimprovethequalityofcareweprovide.FollowingourinspectionbytheCareQualityCommission’s(CQC)ChiefInspectorofHospitalsTeaminMarch2015,wehaveimplementeda‘GettingtheBasicsRight’assuranceprogrammeacrosstheTrust.

InJuly2015,UHCWwasannouncedasoneofjustfiveTrustsinEnglandtoworkwiththeprestigiousVirginiaMasonInstitute,tofurtherimprovethequality,safetyandefficiencyofthecareweprovidetoourpatients.

Lastyear,ourtopthreeprioritieswerePatient Safety;ensuringeffectivehandoversbetweenstaff(continuingtheprogressmadein2014-15), Clinical Effectiveness;ensuringeffectiveEndofLifeCare,and Patient Experience;implementing‘AlwaysEvents’,i.e.thoseelementsofgoodcarethatallourpatientsshouldreceive.

Throughoutthisreportyouwillfindexamplesofourachievementsintheaboveareas.

Lookingforwardtoouryearahead,ourprioritiesfor2016-2017focuson:

• Patient Safety:Reducingandimprovingmedicationerrors;• Clinical Effectiveness:ImprovingcompliancewithCareBundles;packagesofinterventionsto befollowedforeverypatienttoimproveoutcomes,and;• Patient Experience:ImplementingtheCareContactTimeprojectacrosstheTrusttoincrease theamountoftimethatstaffspendwithpatients.

Overthenextyear,wewillcontinuetolistentotheviewsofourpatientsandstafftomakefurtherimprovementsaspartofourobjectivetodeliverexcellentpatientcareandexperience.ThroughourworkwiththeVirginiaMasonInstitute,wearealsolookingathowwecanidentify,celebrateandreplicateareasofoutstandingpracticeacrosstheTrust.

Theinformationanddatacontainedwithinthisreporthasbeensubjecttointernalreviewand,whereappropriate,externalverification.Therefore,tothebestofmyknowledge,theinformationcontainedwithinthisdocumentreflectsatrueandaccuratepictureoftheperformanceoftheTrust.

Iwouldliketothankallourstaff,volunteersandpatientsupportgroupsfortheirinputandsupportinhelpingustoprogressagainstourobjectivesduringtheyear.

Professor Andrew Hardy ChiefExecutiveOfficer


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Section 2Introduction to Quality

2.1 Introduction to the annual Quality Account

UHCWisonajourneytobecomeanationalandinternationalleaderinhealthcare.Thereareanumberofbuildingblocksthatsupportthisambition;thesearearticulatedwithinthevision,mission,values,aimsandobjectiveswhichareillustratedwithinthestrategicframeworkforQualitybelow:

AspartofthisUHCWhasqualityastheorganisingprincipleacrossallourservices,meaningthatpatientsafetyandharm-freecare,excellentclinicaloutcomesandhighqualitypatientexperienceiscentraltoallwedo.OurannualQualityAccountprovidesanopportunityforustotakestockofachievementsandprogresstodateandtolookforwardtotheyearahead.

2015-2016 Quality Highlights

OurPerfectWeekforPatients–BreakingFree

TheEmergencyCarePathwayatUHCWhasbeenchallengedformanyyears.TheEmergencyCareIntensiveSupportTeam,recommendatechniqueknownasthe‘PerfectWeek’to“resetthesystem”instrugglingorganisationsandhealtheconomies.Essentiallythisrequiresthewholehospitaltopauseandfocusonthekeyissuesimpactinguponpoorperformanceandtospendaweekfixingtheseissues.

TheEmergencyCareIntensiveSupportTeamsuggestedthatcommunicationisakeyissuefororganisationsattemptingtorun‘PerfectWeek’.TheTrustagreedacommunicationplanwhichbriefedtheorganisationaboutthe‘PerfectWeek’fromthepointofplanning.

TheCommunicationsPlanbeganwithemailandwrittenbriefings,butitquicklybecameap-parentthatthiswasnotsufficient.Projectleadsfoundface-to-facecommunicationthebestmethodtoengagestaffaboutthe‘PerfectWeek’andsoformalbriefingsessionswereorgan-isedaswellassocialevents(teaandcoffee/curry)and1:1meetings.Everyconversationwehadduringtheplanningperiodincludedreferencetothe‘PerfectWeek’.

Keyachievementsfollowingthe‘PerfectWeek’include:

• 120morepatientsweredischarged duringthePerfectWeek.• 20morepatientsweredischargedbefore 12noon each day compared to a poor performingweek.• 313 patientshadbeeninhospitalmore than14dayscomparedto430 for the weeksbefore.• 60patientswaitedmorethanfourhours intheEmergencyDepartmentduring PerfectWeekcomparedto584sixweeks previously.• Therewere16medicaloutliersi.e.dueto thelackofbedsinmedicalwards,many patientsareplacedinotherdepartments’ wards(usuallyinsurgicalwards).These patientsarecalled“medicaloutliers”.On abadweek,thisfigurestoodat160.

Thefollowingkeywork-streamsalsoderivedoutof‘PerfectWeek’andarebeingimplementedanddevelopedattheTrust:

• Reviewandintroduceweekendand eveningcoverforPhysiotherapy, OccupationalTherapy,Speechand LanguageTherapyandIntegrated Discharge.


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• Reviewandintroduceimproved administrativesupporttowardsat weekends.

• Reviewandstrengtheneveningand weekendcoverfrompartneragenciesin healthandsocialcare.

• Resolvetheoutlierissueonceandfor all,ensuringrobustmedicalcareforall patientsinthehospital.

• Introduceafocusseddailymulti-agency dischargeconferencecallsevendaysa weekwhichfocussesonproblem-solving aroundspecificpatients.

• ReviewtheHospitalEscalationPlan.• FocusonFREEDeverydayandreview thepublicationofrelevantmetricsto supportpractice.TheFREEDcampaign hasfivekeystepsallstaffareresponsible fortoensurepatientsreceivegoodcare:

Facilitateeffectivedischarge Rightperson,rightplace Earlyspecialistinput Eliminateunnecessarydiagnostics Dailyseniorreview

• Establishanannualprogrammeof themedPerfectWeeksatstrategicpoints acrosstheyear.

Virginia Mason

InJuly2015,UHCWwaschosenfollowingacompetitiveprocesstobenefitfromtheexpertiseoftheVirginiaMasonInstituteaspartofanewinitiativelaunchedbyHealthSecretaryJeremyHuntandtheNHSInstitute.

TheVirginiaMasonInstituteinSeattle,USAisworld-renownedfortransforminghealthcare.Theirmantraisthattheperfectpatientexperiencemeansthepatientcomesfirstaboveeverythingandeveryone.Itisexpertinteachingotherhealthcareorganisationshowtoimplementandmaintainapatient-centeredapproachthatwillhelptoincreasequality,safetyandefficiencyusingthesamemethodsthatmadethemsosuccessful.

ThefirstworkstreamtheTrustisfocusingonis‘OphthalmologyOutpatients:Fromreferraltothepatientintheroomwiththeclinician.’The

OphthalmologyTeaminOutpatientshasalreadytakenpartinaRapidProcessImprovementWorkshopwhichisafive-dayworkshopfocusedonaparticularprocessfromavaluestream,wherethosewhodotheworkareempoweredtoeliminatewaste.Thiswasverysuccessfulandidentifiedanumberofareaswithinthereferralprocesswhichcouldbeimproved.Thisworkshopalsoallowedtheteamtomakethenecessarychangeswhichultimatelywillleadtoimprovementstothepatientexperienceinthisarea.

Accreditation for its Lean Competency System

InSeptember2015,UHCWbecamethefirstNHSorganisationinthecountrytogainaprestigiousaccreditationforitsLeanCompetencySystem(LCS)fromCardiffBusinessSchool.

Leanisabusinessapproachthathelpsimprovement.DevelopedbyToyota,itaimstoimproveproductivitybyeliminatingwaste.Forexample,timecouldbesavedbysituatingequipmentclosertowhereitisneeded,ratherthanstafftravellingfurthertolookforit.

TheaccreditationallowstheTrusttoawardstaffanofficialLCSqualificationuponsuccessfulcompletionoflearningsessionsanddemonstrationofpracticalapplication.

LeantechniquesarealreadybeingusedinmanyareasofUniversityHospital,Coventry,andtheHospitalofSt.Cross,Rugby,toimprovecareforpatients.Theyincludeapre-operativeassessmentserviceatbothhospitalstocheckthatpatientsarefitforsurgery,andreorganisingthepharmacyworkspaceinUniversityHospitalsothatpatientsreadytoleavehospitalcangettheirprescriptionssooner.

Sign Up to Safety

ThisyeartheTrustwonfundingaspartofanationalsafetycampaign‘SignUptoSafety.’Itisathreeyearcampaignaimedatreducingavoidableharmtopatientsbyhalfandsaving6,000lives.TheTrustisinvestinginHumanFactorseducationforstaffwhoworkinTheatres,TraumaandOrthopaedicsandtheEmergencyDepartment.


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Humanfactorscanbedefinedasthosefactorsthatcaninfluencepeopleandtheirbehaviour;suchasenvironmental,organisationalandjobfactorsandindividualcharacteristicswhichinfluencebehaviouratwork.

TheTrustanticipatestheoutcomesfollowingfundingwillbethatitimprovespatientcare,re-ducesharmtopatientsandthelikelihoodofNeverEventsandtheywillprovideadditional‘humanfactors’traininganddevelopmentforstaff.

TheTrustwasoneofonly67successfulbidsoutof243bidsreceivedbytheNHSLitigationAuthority.MoredetailsaboutthiscampaignareoutlinedinPartThreeinthePatientSafetysection.

Our Brilliant Staff

2016

• TheTrust’sHospitalRadioteamhasbeen shortlistedforfourcategoriesinthe NationalHospitalRadioAwards.

• TimRobbinshasbeenawardeda WinstonChurchillMemorialFellowship whichwillentailsixweeksoftravelinthe USAtolearnfromtheirhealthcare systems(particularlythedigitalelements) andbringthatlearningbacktotheUK.

• HealthcareAssistantPharbinderAthwal wonaBritishJournalofMidwifery PracticeawardforMidwifeorPeer SupporterinImprovingBreastfeeding.

• MidwifeLyndseyPruewasshortlistedfor aTommy’sHealthcareHeroAward. Thesearegiventoamidwifewhohas providedexceptionalphysicalcareor emotionalsupporttoparentsindifficult times.

• ShortlistedforNHSEngland’sBest FriendsandFamilyTestInitiativeinany otherNHS-fundedservice–Maternity Services.

• ShortlistedforNHSEngland’sFriends andFamilyTestChampion(s)oftheYear- thePatientExperienceTeam.

• TwoteamsintheResearch,Development and Innovation Department have reached

thefinalsofthePharmaTimesNHS ClinicalResearchSiteoftheYear2016.

• InApriltheTommy’sCharityopenedthe UK’sfirstnationalresearchcentre dedicatedtoearlymiscarriage,UHCW isoneofthethreeNHSTrustsinvolved intheCentre,whichisthebiggestin Europe(inpartnershipwithImperial CollegeHealthcareTrust,Birmingham Women’sHospitalFoundationTrustand Birmingham,ImperialandWarwick Universities).

• TheDementiaTeamwerefinalistsfor theServiceInnovationTeamofthe YearAwardattheDementiaServices DevelopmentCentreUniversityofStirling InternationalDementiaAwards2015.

2015

• TheUHCWLungNursingTeamwonthe RoyCastleLungCancerTeamof theYear.

• MacmillanGynae-OncologyAdvanced NursePractitionerVikkiJoneswas awardedtheMacmillanHenryGarnett Award.

• MidwivesElizabethBaileyandAlison SearlewereshortlistedforaRoyal CollegeofMidwivesAwardinthe categoryofJohnson’sAwardforEvidence intoPracticefor“MindyourPsandQs: Protectedquiettimeinthehourafter birth.”

• ChiefNursingOfficerMarkRadfordwas recognisedasoneofthetopleadersin nursingintheNursingTimesInspirational Leaderslist2015whichrecognisedtop leadersinthenursingprofession.

• TherapistSueCrewe-Smithwasawarded aWinstonChurchillMemorialFellowship.

• CardiologyResearchRegistrarDoctor ChrisMcAloonwasawardedtheRoyal CollegeofPhysicians(RCP)andNational InstituteofHealthResearch(NIHR) ClinicalResearchNetworkClinical TraineesAwardinrecognitionofhis outstandingcontributiontoresearchinthe NHS.


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TheAwardacknowledgestheessential workofNHSphysiciansandtraineesin sustainingandbuildingclinicalresearch intheNHShealthservice,despite competingdemandsoncliniciantimeand resources.

• TheTogetherTowardsWorldClass organisationaldevelopmentprogamme wasshortlistedforanHealthService JournalAward2015intheStaff Engagementcategory.

• The2015PharmaTimesClinical Researchsiteoftheyearawardwaswon byUHCW’sResearch,Developmentand InnovationTeamforthesecondyearina row.

2.2 Quality Account Improvement Priorities 2015-16 A progress update

ThebelowdetailsprogressandachievementsagainsttheQualityImprovementPrioritiesfor2015-2016whichwereoriginallyoutlinedinthe2014-2015QualityAccount.

Priority 1 - Patient Safety: Ensuring effective handover between healthcare professionals

Rationale for Inclusion:

Accurate and timely handover of information aboutapatient,particularlywhenadmittedandtransferredbetweenteams,iskeyinensuringcareandtreatmentisefficient,safeandappropriate.

Achievements:

• AllJuniorDoctorshavebeengiven extensiveexposuretothehandovertool andprinciplesunderpinningitsuse, throughpresentationsand demonstrations.Additionally, presentationshavebeengivenatGrand Rounds,SpecialtyQualityandPatient Safetymeetings,ClinicalDirectors meetingsandattheChiefOfficer Groupmeeting.Emailcommunications havebeencirculated.

• WehavestartedworkonanewJunior DoctorInductionprocessforthesummer of2016,toensureallstaffhavethe

appropriateskillsettousecurrent informationtechnologysystems appropriatelyandeffectively,particularly e-handover.Thisworkcommencedin December2015andwearecurrently deliveringonetotwoweeklyclassroom teachingsessionsfor10JuniorDoctors for an hour at a time in the Clinical SciencesBuildingTrainingSuite,with themallloggedintoacomputer.Theaim istotrainall400JuniorDoctorsbefore progressingtootherstaffgroups.

• Ward22HospitalatNight(H@N)room hascontinuedtobethehubforoutof hoursfacetofacehandover,supported bytheuseofe-handoverandiPads.With newchangestoe-handover,thepatient bannerinClinicalResultsReporting System(CRRS)ande-discharge summary,afurtherupdatedlaunchtook placeinMarch2015.Thisintroduceda formalfacetofacehandovermeeting everymorningat8:30amintheseminar roomoffWard2.ThisinvolvesaJunior Doctorrepresentativefromallmedical wards,specialtiesandoutlierwardswho takeaformalhandoverreportfromthe H@Nteam.

• Rolloutofelectronichandoverofficially launchedwithiPadsforusebyoncall staffbetween5pmand9am.

• E-learningtrainingmaterialfor e-handover developed and implemented withrevisionofoperationalpolicy.

• Themobiledevicedeployment (WorkstationsonWheelsorWoWs) supportsembeddingusageofCRRS functionalityincludinge-handover.Over thelast6months,131(87%)ofWoWs havebeeninstalled.


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Priority 2 - Clinical Effectiveness: Ensuring effective End of Life Care Practices


AsystemwideapproachtoEndofLifeCareisrequiredtohelpstreamlineandco-ordinatelocalservicesforthebenefitofpatientsandtheirfamiliesandtoimprovecommunicationandefficiencyoflocalcaringprofessionals.

Achievements so far:

• Re-configurationoftheSupportiveand SpecialistPalliativeCareTeamsto theunifiedPalliativeCareTeamhas ledtobetterPalliativeMedicineand Nursingleadership.

• LeadershipfromtheChiefNursingOfficer astheChairmanfortheEndofLifeCare Committee(EOLC)hasledtowork disseminatingTrust-widebysubgroups workingonimprovingpatientexperience, bereavementservices,educationand training.

• VOICES(ViewsOfInformalCarers EvaluationSurvey)beingdevised electronicallybyLepidusandin-houseas hard copy.

• DeathCafétosupportbereavedstaff.A DeathCaféisanationalinitiativeand theyareforpeopletocometogether informallyanddiscussdeath.The objectiveis‘toincreaseawarenessof deathwithaviewtohelpingpeople makethemostoftheir(finite)lives.’

• Trainingneedsanalysisisbeingexplored onaTrustwideeducationprogramme forendoflifecarelookingate-learning optionsandworkingwiththeMedical EducationTeamtoestablisharobust formaleducationprogrammeforallstaff.

• TheDoveCampaignlaunchedin November2015toidentifydyingpatients ensuringrespectanddignityinthelast daysandhoursoflife.

• Sixcarerbedsarenowavailableand wereobtainedthroughcharitablefundsto supportrelativesofpatientswhoarein thelastdaysoflife.

• VolunteerCompanionServicehasbeen introducedwhichoffersacompanion tothedyingwithnosignificantotherto supportthepatientinthedyingphase.

• Collaborativeworkingwithpartnership organisations.Phase3QualityEndofLife CareforAll(QELCA)isfacilitatedby thePalliativeCareTeamstaffandhospice staffatCoventryandWarwickMyton Hospicesfacilitatingeducationaland practicallearning.

• QELCAtrainingdeliveredthisyearat CoventryandWarwickMytonHospiceto seniorwardnursesandTransform ProgrammeChampionsonWards 52,11,42and43.

• Qualityandgovernancereportingbeing achievedthroughtheEndofLife CommitteeandthePalliativeCareTeam monthlyQIPSmeetings.

• NationalEndofLifeCareClinicaland OrganisationalAuditcompletedbetween JulyandSeptember2015retrospective forMay2015.


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Priority 3 – Patient Experience Always Events: Implementing ‘Hello My Name Is’


The‘Hellomynameis’campaignwascreatedbyDrKateGranger,ayounghospitalconsultantfromYorkshirewhoworkedinelderlycare,toimprovethepatientexperiencenotonlyhereintheUK,butacrosstheworld.Katebecamefrustratedwiththenumberofstaffwhofailedtointroducethemselvestoherwhenshewasapatientin.Hercampaign,startedonthesocialmediaplatformTwitterandhasinspirednurses,doctors,therapists,receptionists,porters,domesticsandstaffinallroles.

Thecampaignissimple–remindingstafftogobacktobasicsandintroducethemselvestopatientsproperly.Katetalksaboutthisas“thefirstrungontheladdertoprovidingcompassionatecare”andseesitasthestartofmakingavitalhumanconnection,helpingpatientstorelax,andbuildingtrust.Feedbackfrompatientsacrossthecountryshowshowvitalthisistothem,sayingthatthesmallestthingsmakethebiggestdifference.

The#hellomynameiscampaignissomethingmanyareasoftheTrusthaveadopted.However,wehavenowexpandeditacrossbothourhospitalsitestoensurethatnomatterwhatdepartmentapatientgoesto,theywillgetafriendlyandattentiveservicefromallofourstaff.UHCWwantstaffintroducingthemselvestobean‘AlwaysEvent’somethingthatshouldhappenateveryinteractionapersonhaswithstaff.

Achievements so far:

• Asuccessfullaunchofthe #hellomynameiscampaignwithinthe TrustduringPatientExperience WeekinFebruary.Thislaunchsawover 85,000peopleinteractwiththecampaign overFacebookandTwitteraswellas over1000staffacrossbothsitesengage inpledgingsupport.

• Ashortvideohasbeenmadetousewith stafftohighlighttheimportanceof introductions.Thiscanbeviewedat www.uhcw.nhs.uk.

• Thecampaignteampresentedata UHCWGrandRoundwhichisamonthly meetingwherebyallstaffhavethe opportunitytoshareandlearnfromothers intheTrustonavarietyoftopics.The teamalsopresentedtoTrustBoardto overwhelmingsupportandpositivefeed back.

• TheTrusthasamendeditsonlineversion ofitsfeedbacksurveytogather informationastowhetherstaffintroduced themselves.

• Amulti-disciplinaryworkinggrouphas beenstartedtomaintainmomentumwith thecampaign.


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2.3 Quality Improvement Priorities for 2016-2017

Quality Priority 1 - Patient SafetyIncreasing the reporting of medication errors and learning from reports.

Why is it a priority?

RecommendationsbySirRobertFrancisQCandProfessorDonBerwickonpatientsafetyrecommendedtakingstepstomaximisethequalityandquantityofadverseincidentreportsfromhealthcareorganisations.

TheNationalPatientSafetyAgencyreportSafetyinDoses[2007]definedmedicationerroras“anyincidentwheretherehasbeenanerrorintheprocessofprescribing,dispensing,preparing,administering,monitoringorprovidingmedicinesadvice,regardlessofwhetheranyharmoccurredorwaspossible.”

Increasingreportingofmedicationerrorsenablestheorganisationtoanalyse,learnandthenreduceriskofpatientharm.Researchindicatesthatorganisationswithahighreportingratehaveagoodsafetycultureandbetterriskmanagementstrategies.ThePharmacyDepartment,workingwiththeQualityDepartment,willleadonaprojecttoincreaseoverallincidentreport-ingwhilstreducingthenumberofmoderateandseriousmedicationincidents.

Thekeydriversare:

• Reducingerrorsandharmtoourpatients.

• Understandingharmtoourpatients.

• Belowaveragereportingofmedication incidentslocally.

• Limitedcapabilitytomaximise organisationallearningfromthese incidents.

• MandatefromtheMedicinesand HealthcareproductsRegulatoryAgency. LookingatdataUHCWwerebelowtheaveragerateforreportingmedicinesrelatedincidents(per100admissions)whenrankedwithotherteachingtrusts.InUHCW0.68medicationincidentsarereportedper100admissions,

comparedtoarangefromNationalReportingandLearningSystemDataof0.46-1.75incidentsper100admissions.

Our Goal

PromotetheUHCWvalueofopennessinordertoincreasereportingandincreasethevalueofreportsbylearningwhereweneedtoimproveandmakingstepstoimprovepatientcare.Initiallywewillfocusonreducingharmfromomitteddosesofmedicinesasthisisourmostcommonlyreportedincident.

Our Starting Point – baseline

MedicationerrorsarethethirdmostcommonlyreportedClinicalAdverseEventwithintheTrust,withanincreaseofreportinginexcessof55%overthelast5years.Inorganisationswithagoodsafetyculturethepercentageofnoorlowharmincidentsreportedisexpectedtobehigh.AtUHCW,lowornoharmincidentshaveaccountedfor98%ofreportedmedicationerrorsforthelastfouryears(seetablepage11).

How will we achieve our goals?

• Promotereportingofmedicationerrorsto allstaffgroupsinvolvedinpatientcare.

• Co-ordinateeducationandtraining supporttoimprovethenumberand qualityofmedi-cationerrorincident reportsandsafemedicationpractices.

• Analyseincidentsreportedtoidentify trendsandthemesinordertoprioritise andaddressmedicationrisks.

• Communicaterisksidentifiedthroughthe Trustintranet,newslettersandposters.

• Auditomitteddosesofmedicines,looking atreasonsforomissionandthetypesof medicationsthatareomitted.

• Commencequalityimprovementprojects toreducethenumberofomitteddoses fromcriticalmedicines.

• Safetymessagessenttostafffromthe ChiefMedicalandQualityOfficer


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YearNumber of

medication errors reported

Increase on previous year - number (%)

Percentage No or low harm

2010 794 141(21.5%) 83%

2011 852 58(7.3%) 96%

2012 857 5(0.6%) 98%

2013 1089 232(27%) 98%

2014 1149 60(6%) 99%

2015 1789 640(55%) 98%

How will we monitor and report progress?

Monitorthenumberofmedicationincidentsreported,aimingtoseeamonthonmonthincrease,withatotalincreaseofatleast20%overthe year.

Monitorharmtopatients,bymonitoringthepercentageofNo/Lowharmincidentsaimingforthistobemaintainedatgreaterthan98%bytheend of the year.

Auditthefrequencyandnatureofomitteddosesinordertounderstandcontributingfactors.

Presentsuccessfulqualityimprovementprojectstoreduceomitteddoses.

ProgressagainstthesemeasureswillbemonitoredbytheMedicinesSafetyCommitteeeachquarterandreportedtothePatientSafetyCommittee.

Leads

TheprojectisbeingcollaborativelyledbyRebeccaMills(MedicinesSafetyOfficer)JanetteKnight(PharmacyGovernanceManager),MarkEaster(DirectorofPharmacy),andSharonFarthing(NursePracticeFacilitator).


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Quality Priority 2 - Clinical Effectiveness Improving Care Bundle Compliance


ImprovedcompliancewithCareBundleswillleadtomoreeffectiveandsaferpatientcare.

ACareBundleisastructuredwayofimprovingtheprocessesofcareandpatientoutcomes:asmall,straightforwardsetofevidence-basedpractices—generallythreetofive—that,whenperformedcollectivelyandreliably,havebeenproventoimprovepatientoutcomes.TheInstituteofHealthImprovement(IHI)developedtheconceptof“Bundles”tohelphealthcareprovidersdeliverthebestpossiblecareforpatientsundergoingparticulartreatmentswithinherentrisks.

ThepowerofaCareBundlecomesfromthebodyofsciencebehinditandthemethodofexecution:withcompleteconsistency.It’snotthatthechangesinabundlearenew;they’rewellestablishedbestpractices,butthey’reoftennotperformeduniformly,makingtreatmentunreliable,attimesuniquetoanindividual.

ACareBundletiesthechangestogetherintoapackageofinterventionsthatpeopleknowmustbefollowedforeverypatient,everysingletime.

Our Goal

TheTrust’sgoalistoprovideimprovementsinpatientcarebyminimisingunwarrantedvariationinclinicalcareofacutelyillpatientsthroughincreasedcompliancewithclinicalCareBundles.In2016-2017wewillensurethatCareBundlesareimplementedforthehighriskgroupsandhighvolumeclinicalpathwaysincludingpneumonia,myocardialinfarction,heartfailure,acuterenalfailure,sepsisandstroke.

Our starting point – baseline

AnumberofspecialtygroupshaveusedCareBundlessincetheywereintroducedintoclinicalpracticeintheNHS.TheseincludeBundlesforcentralvenouslineinsertion,peripheralcannulacare,theventilatorCareBundleonGeneralCriticalCareUnitandtheSavingBabiesLivesCareBundleinNeonatology.TheSepsisSixBundleandtheAcuteKidneyInjuryPathwayare

thesubjectofCQUINS(CommissioningforQualityandInnovation)forallacuteadmissions.TherespiratoryandcardiologyservicesarecurrentlydevelopingCareBundlesforpneumoniaand heart failure.


WewillestablishtheAcutelyIllPatientManagementCommittee(AIPMC)whichwillprovideleadershipanddirectiontobringtogethertheclinicalleadsofthemultipleworkstreamsandfacilitate development of further clinical Care Bundlesaswellasprovidingaforumtodevelopstrategiestoreduceepisodesof“failuretorescue.”ItisessentialtoensurethatallclinicianshaveanunderstandingofthebenefitsofCareBundlesandtheirbenefitforpatientsafety.ThecommitteewillalsolinktogethertheCQUINprojectsandworkbeingdoneinconjunctionwiththeSignuptoSafetyprogramme.

TherespectiveworkstreamswillbeexpectedtoreportprogresstotheAIPMConamonthlybasis.GrandRoundpresentations,multidisciplinaryundergraduateandpostgraduateteachingandwardbasedtrainingwillsupportthedisseminationoftheCareBundlesandpromotetheuptakeandcompletionofthespecificcarebundlecomponent.


OnceeachCareBundleisagreedbytherespectiveclinicalgrouptheCareBundleproformawillbeintroducedintoclinicalpractice.Theywillbeavailableinallclinicalareasandwillbecompletedandincludedinthepatient’smedicalrecord.TheprogressofeachCareBundlewillbemonitored.EachoftheCareBundleworkstreamswillbeexpectedtoreporttheirprogresstotheAIPMConamonthlybasis.TheAIPMCwillreporttothePatientSafetyCommitteeeverythreemonths.TheperformancewillalsobetrackedbytheSignuptoSafetyinitiative.

Leads

ChairsoftheAcutelyIllPatientManagementCommitteeandleadcliniciansforeachclinicalCareBundle.


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Quality Priority 3 - Patient ExperienceThe measurement of direct care using a multi-professional team approach (Care Contact Time)


Theaimofmeasuringthedirectcaretimespentwithpatientsbyclinicalteamsistoachieveefficientandeffectivehighqualitycarethataddsvaluebybeingdeliveredatthepatientbedside.Deliveringcareatthebedsideplaysapivotalroleinpromotingpersoncentredcarefocusedonimprovingpatientexperienceandoutcomes.TheCareContacttoolisanationalinitiativewhichisbasedonLeanprinciplesandpartoftheSaferNursingCareTool.

UHCWisthefirstacuteTrusttohaveimplementedane-carecontacttoolwhichprovidesinstantreportingonthetimeeachclinicalandmulti-professionalgroupspendsdirectlywithpatientsandprovidesdatathatcanbeutilisedtoreduceandeliminatetimeandtasksthataddlittlevaluetotheprovisionofcare.

TheinitialworkundertakenwiththeNursingTeamsin2015,usingtheManchesterCareContactTimeModelgeneratedanumberoflocalwardbasedprojectstoimprovedirectcaretime.Thisincludesmedicinesmanagement,bedsidedocumentation,nurseperbayandhasinfluencedTrustwideinitiativessuchasvitalsignsobservationsandnighttimecaremanagement.However,therewasasubstantiallossofdatabecausetheTrustfollowednationalguidancewhichencouragedthatstaffrecorddataonpaper-basedclocks.Alsoonlydirectcaretimefornursingwascalculatedanddatadidnottakeintoaccountdirectcaretimebymedicalprofessionals.

TheelectronicclockandreportingsystemhasbeendevelopedincollaborationwiththeLeadNursesforPatientExperience,QualityandSafety,InformationTechnologyandarangeofmulti-professionalstaffincluding,nurses,midwives,doctorsandtherapists.

NationallytheManchesterCareContactTimeModelhasbeenadvocatedbyNHSEnglandasthepreferredmeasurementsystem,whichispaperbasedandrequiresadministrativesupporttocollect,collateandinputdata.

Thedevelopmentoftheelectronictoolsupportsaccuracyindatacollection,islesslabourintensive,enablestimetobemeasuredacrossclinicalteamsandgeneratestimelyreportsthatcanbeutilisedtoimproveefficiency,patientsafetyandexperienceoutcomes.TheimplementationteamhasundertakenapilotacrosstheTraumaandOrthopaedicClinicalGroupasphaseoneoftheTrustwiderollout.Toprogresstophase2(Trust-widedatacollection)thefollowingwillberequired:

• Adequateinformationtechnologysupport andresource

• E-Trainingpackage

• SystemsGatekeeper

• Supportofclinicalgroupleaders

• Timetodiscussreportfindingsand sharedlearningacrossgroupsand professions

• TimetoestablishPlanDoStudyAct (PDSA)cyclestoimprovedirectcaretime

Our Goal

Themaingoalistoimprovethetimespentwithpatientsbyutilisingmulti-professionalcarecontacttimefindingsforallclinicalgroupsandservices.Theelectronicsystemwillprovideaprocessbywhichinformationcanbeobtainedconsistentlyandaccurately,providingastandardisedtoolforthemeasurementofserviceimprovementacrosstheTrust.


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Task/Action By When

Firstnursingcarecontacttimerecordedacrossallinpatientadult,paediatricandmidwiferywards

April-September2015

DevelopmentofelectronicandApplication(App)reportingsystem September2015-January 2016

PilotconductedacrossTraumaandOrthopaedicwardstotestdatacollectionandreportingsystems

February2016

Evaluationofpilottobepresentedatrelevantcommittee April 2016

RolloutplanbyclinicalgrouptobedevelopedforTrustwiderollout May2016-September2016

ClinicalGroupstoestablishPlan,Do,Study,Act(PDSA)serviceimprovementprojectstoenhancemulti-professionaldirectpatientcare time

September2016-February2017


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• Educateandraiseawarenessregarding thevalueandhowcarecontacttime multi-professionaltoolkitcanbeutilised toaddvaluetopatientoutcomes,safety and experience.

• Sufficientinformationtechnologyresource -correctnumberofhandhelddevices enablingallstafftohaveaccessto the app.

• Developauniversal,simple,online trainingmoduleaccessibletoallgroups.

• ShareprogressinregardtolocalPDSA projectsandevaluateoutcomes.


Evaluatethroughthelocalimprovementindirectcaretimewhichwillbemonitoredtwiceayear.

Leads: TheprojectisbeingcollaborativelyledbyJudithSmith-LeadNurseforQualityandSafety;DianeEltringham–LeadNurseProfessionalStandardsandPatientExperienceandKarlO’SullivanSmith-SeniorInformationTechnologyManager.

2.4 Statements of Assurance from the Board

2.4.1 Review of Services

During2015-2016UHCWprovidedand/orsubcontracted66relevanthealthservices*.UHCWhasreviewedallthedataavailableonthequalityofcarein66oftheserelevanthealthservices.Theincomegeneratedbytherelevanthealthservicesreviewedin2015-2016represents88%ofthetotalincomegeneratedfromtheprovisionofrelevanthealthservicesbyUHCWfor2015-2016.

*thisnumberrepresentsthenumberofservicesasdetailedintheTrust’sAcuteContract2015-2016.

2.4.2 Participation in Clinical Audits

During2015-201647nationalclinicalauditsand7nationalconfidentialenquiriescoveredrelevanthealthservicesthatUHCWprovides.DuringthatperiodUHCWparticipatedin100%ofnationalclinicalauditsand100%ofnationalconfidentialenquirieswhichtheTrustwaseligibletoparticipate in.

ThenationalclinicalauditsandnationalconfidentialenquiriesthatUHCWwaseligibletoparticipateinduring2015-2016arelistedinthetablebelow.ThenationalclinicalauditsandnationalconfidentialenquiriesthatUHCWparticipatedin,andforwhichdatacollectionwascompletedduring2015-2016areindicatedwithagreentick,alongsidethenumberofcasessubmittedtoeachauditorenquiryasapercentageofthenumberofregisteredcasesrequiredbythetermsofthatauditorenquiry.UHCWhasinvestigatedwhyparticipationwaslowerthanexpectedinsomeaudits,identifiedwithanasterisk(*).

Thereportsof37nationalclinicalauditsand93localauditswerereviewedbyUHCWin2015-2016andUHCWistakingthefollowingactionstoimprovethequalityofhealthcareprovided:

• Shareclinicalauditoutcomeswith relevantclinicalareas

• Undertakefollow-upauditstomeasure progress

• Providetrainingandsupportwhere requiredtoimprovecarestandardsor compliancewithbestpractice.

FurtherinformationontheactionstheTrusthasalreadytakeninresponsetonationalandlocalauditscanbefoundonpage20onwards.

For more information on National or Local Clinical Audit please contact Effectiveness and Compliance on 02476 968282.


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Eligible audits applicable to UHCW as published in the Department of

Health’s Quality Account List

Did UHCW Participate in 2015-2016?

Participation 2015-2016

AcuteMyocardialInfarctionandotherACS(MINAP) 100%

AdultCardiacSurgeryAudit(CABGandValvularSurgery) 100%

NationalBowelCancerAuditProgramme(NBOCAP) 100%

Cardiac Arrhythmia (CardiacRhythmManagementAudit) 100%

Adultcriticalcare(CaseMixProgramme)100%

NCEPODChildHealthClinicalOutcomeReviewProgramme-ChronicNeurodisability

Awaitingstartofdata collection

NCEPODChildHealthClinicalOutcomeReviewProgramme-YoungPeople’sMentalHealth

Awaitingstartofdata collection

CoronaryAngioplasty(AdultCardiacInterventionsAudit) 100%

NationalPaediatricDiabetesAudit(NDPA)100%

BTSEmergencyUseofOxygen100%

FallsandFragilityFracturesAuditProgramme-NationalHipFractureDatabase(NHFD)

100%

FallsandFragilityFracturesAuditProgramme-InpatientFalls

100%


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Did UHCW articipate in 2015-2016?


InflammatoryBowelDisease(IBD)Programme 100%

TraumaAudit&ResearchNetwork(TARN)(MajorTraumaAudit)

100%

Maternal,NewbornandInfantClinicalOutcomeRe-viewProgramme(MBRRACE-UK)(previouslyCEMACH)

100%

NCEPODAcutePancreatitisStudy100%

NCEPODPhysicalandMentalHealthCareofMentalHealthPatientsinAcuteHospitals 100%

NCEPODSepsisStudy100%

NCEPODGastrointestinalHaemorrhageStudy100%

NCEPODNon-invasiveVentilationStudyData collection

not yet due

NationalCardiacArrestAudit(NCAA)100%

NationalComparativeAuditofBloodTransfusionProgramme-UseofBloodinHaematology

100%

NationalComparativeAuditofBloodTransfusionProgramme-AuditofPatientBloodManagementinScheduledSurgery

100%

NationalComparativeAuditofBloodTransfusionProgramme-AuditoftheuseofBloodinLowerGIBleeding

100%


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NationalComplicatedDiverticulitisAudit(CAD) 100%

NationalDiabetesFootcareAudit(NDFA) 100%

NationalInpatientDiabetesAudit100%

NationalPregnancyinDiabetesAudit(NPID) 100%

NationalDiabetesAudit(NDA) 100%

NationalEmergencyLaparotomyAudit(NELA) 100%

NationalHeartFailureAudit100%

NationalJointRegistry(NJR) 100%

NationalLungCancerAudit(NLCA) 100%

NationalOphthalmologyAudit100%

NationalProstateCancerAudit100%

NationalVascularRegistry(NVR) 100%


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NationalNeonatalAuditProgramme(NNAP) 100%

NationalOesophago-gastric(NAOGC)CancerAudit 100%

BTSPaediatricAsthma100%

RCEMProceduralSedationinAdults(careinemergencydepartments) 19%*

(Estimated)

SentinelStrokeNationalAuditProgramme(SSNAP) 100%

UKCysticFibrosisRegistry(Paediatriconly) 100%

NationalUKParkinson’sAudit100%

RCEMVitalSignsinChildren(careinemergencydepartments) 100%

RCEMVTERiskinLowerLimbImmobilisation(careinemergencydepartments)

100%


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Therewasonenationalclinicalauditthathadalowerthanexpectedparticipationrate,identifiedwithanasterisk(*)inthetableabove.UHCWhasinvestigatedthereasonswhythisoccurredasdescribedbelow:


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Audit Title Participation Rate Rationale for Low Participation Rate

NationalClinicalAuditofRheumatoidandEarlyInflammatoryArthritis

19% LowparticipationhasbeenacknowledgedandtheTrusthasrespondedtotheBritishSocietyofRheumatologytooutlineplanstoimproveparticipation.Discussionsaroundthefeasibilityofimplementingadedicatedearlyarthritiscliniccontinue.AnewclinicalnursespecialistisnowinpostandtheTrusthasagreedtofund2middlegradedoctorswhichwouldhelptoreducepatientwaitingtimes.Itishopedthatthiswillsubsequentlyimproveparticipationintheaudit.AposterhasbeencreatedinordertoremindRheumatologystafftorecruitallapplicablepatientsattheirfirstvisit,whichshouldhelptoincreaseourbaselineparticipation.ThereisaplantostartputtingthepostersupintheTrust’sRheumatologyOutpatientsclinicwhenthenextphaseoftheauditbegins.

Theparticipationrateof19%isonlyanestimateandisbasedupontheclinicalteamsanticipatingtheywouldseeapproximately2patientsperweek.Unfortunately,duetotheauditmethodology,itisdifficulttoidentifytheexactnumberofpatientsviaclinicalcodingforinclusionintheaudit.

Allofthe15patientssubmittedatbaselinealsohadatleastonefollow-upformcompleted,showingafollow-upcompletionrateof100%.


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Eligible audits applicable to UHCW as published in the Department of Health’s

Quality Account List

Reason for non-participation during 2015-2016

BTSAdultAsthma Auditdidnottakeplacein2015-2016.DuetocommenceSeptember2016

ChronicObstructivePulmonaryDisease(COPD) Auditdidnottakeplacein2015-2016.Duetocommenceearly2017

BTSNon-InvasiveVentilation-Adults Auditdidnottakeplacein2015-2016.Notcollectingdataduring2016-2017

BTSPaediatricPneumonia Auditdidnottakeplacein2015-2016.DuetocommenceinNovember2016

ThefollowingtabledetailsthenineauditsincludedintheQualityAccountlistpublishedbytheDepartmentofHealthinwhichUHCWdidnotparticipateduetoeligibility.

Ofthesenineaudits,infourUHCWdoesnotprovidetherelevantservice,intwotheTrustdoesnotperformtheprocedureandtheotherthreearenotapplicabletoAcuteTrusts.

ThefollowingnationalclinicalauditsareincludedontheQualityAccountlistfor2015-2016;howevertheTrustdidnotparticipateforthereasonsoutlinedbelow:

Audit Title Rationale for Non-participation

ChronicKidneyDiseaseinPrimaryCare Noteligible–notapplicabletoAcuteTrusts

CongenitalHeartDiseaseAudit(PaediatricCardiacSurgeryCHD)

Noteligible–procedurenotperformedatUHCW

Electivesurgery(NationalPROMSProgramme)

Noteligible–servicenotprovidedatUHCW

NationalAuditofInter-mediateCare Noteligible–servicenotprovidedatUHCW

NationalChronicObstructivePulmonaryRehabilitationWorkstream

Noteligible–servicenotprovidedatUHCW

NationalConfidentialInquiryintoSuicideandHomicideforPeoplewithMentalIllness(NCISH)

Noteligible–notapplicabletoAcuteTrusts

PulmonaryHypertensionAudit Noteligible–servicenotprovidedatUHCW

PaediatricIntensiveCareAuditNetwork(PICANet)

Noteligible–procedurenotperformed

PrescribingObservatoryforMentalHealth(POMH)

Noteligible–notapplicabletoAcuteTrusts


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ThefollowingtableoutlinesparticipationintheNationalClinicalAuditandPatientOutcomesProgramme(NCAPOP)from2010-2011topresentday.

Participation in the National Audit and Patient Outcomes Programme

2010 - 2011 100%

2011 - 2012 95%(non-participationin1audit)

2012-2013 98%(non-participationin1audit)



2015 - 2016 100%

Commentsonperformance UHCWisnowparticipatingintheNationalCardiacArrestAudit


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National Clinical Audits – Key Actions Taken in 2015-2016

ThefollowingarebriefsummariesofsomeofthekeyactionstheTrusthastakentoimprovethequalityofhealthcareasaresultofthereviewofnationalclinicalauditreports:

Audit Title Key Actions

RoyalCollegeofEmergencyMedicine(RCEM)ParacetamolOverdose

TheassessmentofmentalstateisnowpartofTrust’sEmergencyDepartmentdocumentation,allowingsimplerrecordingofcapacitytoconsent.

TheParacetamolOverdosetreatmentpathwaysummaryisnowreadilyavailableontheTrust’swebsite,toensurethesafeandtimelytreatmentofpatients,inlinewithnationalrecommendations.

TheTrust’sEmergencyDepartmentprovideseducationatstaffinductionandregularteachingsessionsforallnursingandmedicalstaffonthecorrecttreatmentofParacetamolOverdose,toensurethatpatientsreceivetheappropriatecareandtreatment.

BritishThoracicSociety(BTS)PaediatricAsthma

TheTrusthasupdatedthelocalasthmaguideline,whichcontainsasummaryondiagnosingasthmaandsignpoststothemostrecentBritishThoracicSociety(BTS)guidelineforin-depthguidance.Thisensuresthattreatmentisinlinewithnationalrecommendations.Allpatientsnowreceiveapersonalisedsymptom-basedwheezeactionplanaspartofthesalbutamolreducingregimeondischarge.

AdditionalAsthmaUKactionplansareprovidedtoasthmaticpatientsseenbythePaediatricRespiratoryClinicalNurseSpecialist(PRCNS)andtheseareavailabletoprintintheappendixofthenewasthmaguidelineforConsultants/otherhealthcareprofessionalstouse.Theplansclearlystipulateconcerningsymptomsandhowtorespond.Locallythegenericactionplanisidentifiedasa‘wheeze’actionplantocoverpatientswithbothasthmaandviralinducedwheeze.ThePRCNSidentifiespatientsathigherriskofrelapse/whohaveuncontrolledasthmaandtargetsthechildandfamilywithpersonalisedasthmaeducation.PatientscanalsobereferredtothePRCNSon‘inpatientinternalreferral’,andConsultantshaveaccesstothePRCNSforadvice.Thisensuresthateachpatientistreatedusinganindividualisedcareplan.

AllpatientsareassessedoninhalertechniqueusingaMeteredDoseInhalerandlargevolumespacer.Itistheresponsibilityoftheprescribertoteachinhalertechniqueifusinganyotherinhalerdevices,butthisisusuallyreservedforexceptionalcases.

ThereisanobjectivepathwaywithintheTrust’snewasthmaguidelineclearlystipulatingtreatmentaccordingtoseverity.LargepostershavebeencreatedfordisplayintheTrust’sPaediatricResuscitationDepartmentandtheChildren’sEmergencyDepartmentexhibitingthepathway.


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BritishThoracicSociety(BTS)PaediatricAsthma

Thisensuresthatpatientsreceiveanaccuratemeasurementofseverityatthetimeofpresentationwhentheyattendwithanexacerbationoftheirsymptoms.

TheTrusthasimplementedadischargechecklistusedonthePaediatricwards.

Thechecklistaddressesdocumentationof:checkinginhalertechnique,supplyingadviceleaflets,supplyingthewheezeplanorasthmaactionplan,informingchild/parentof‘redflag’signs,andfollow-uparrangements.TheTrustisalsoworkingonaversionofthechecklisttouseintheChildren’sEmergencyDepartment.Thiswillensureconsistent,effectivetreatmentofpaediatricpatientswithasthma.

NationalPaediatricDiabetesAudit(NPDA)

Astructurededucationprogrammeforstaffandpatientsisinplaceandwillbereviewedanddevelopedoverthenext2years(itispartofthediabetesserviceworkprogrammefor2016-2018).

Apsychologyscreeningtoolhasbeenimplementedandisnowinusewhichhelpstoensurepatientsreceivetheappropriatecareand treatment.

SentinelStrokeNationalAuditProgramme(SSNAP)

Tworing-fencedbedsarenowavailableontheStrokeUnittoensurethatthereisspacetomeetpatientdemand.ThishasresultedinpatientsbeingadmittedmorequicklytotheStrokeUnitfromtheEmergencyDepartment.

TheStrokeSpecialistNurseandtheWardManagernowhaveaccesstotheTrust’sonlineEmergencyDepartmentsystem(ExtraMed),inordertosuccessfullyidentifypotentialStrokepatientsintheEmergencyDepartment.TheStroketeamarenowabletoensurethatallsuspectedStrokepatientsreceiveaswallowscreenwithin4hoursandaswallowassessmentwithin72hours.

AllseniorstrokenurseshavereceivedtrainingtorequestCTscansfornewpatientadmissions.Thishashelpedtoensurethatmorepatientsarescannedwithin1hourofarrivalathospital.

FollowingasuccessfulpilotofanEarlySupportedDischargeTeam(ESD),whichsupportspatientsinbeingdischargedfromhospitalearlier,theTrusthasnowimplementedthisonanongoingbasis.

TheTrusthasemployedanewPsychologyAssistant,whoisnowregularlyassessingandtreatingpatientsontheward,toensurethatStrokepatientsrequiringpsychologyinputarereceivingthis.


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NationalJointRegistry(NJR) TheTrusthasputmeasuresinplaceforOrthopaedicSurgeonstouseasingletypeofprosthesisinpartialkneereplacementsurgerytoensureabetteroutcomeforpatients.

BritishThoracicSociety(BTS)AdultCommunityAcquirePneumonia

PneumoniapatientsingeneralwardsareidentifiedatwardroundsandtransferredtotheRespiratorywardswheretheycanreceiveappropriate care.

SingleantibioticpolicydevelopedforCommunityAcquiredPneumoniapatients,ensurestheappropriatecareandtreatmentisprovided.

TheTrusthasincreasedthenumberofrespiratorynurses,withfurtherplanstointroduceanAdvanceNursePractitionertoincreasethelevelofcareandsupportprovidedtopatients.

CapacityisbeingincreasedatRugbyStCrossforpost-dischargepulmonaryrehabilitationservicestoreducewaitingtimesforpatients.

Resultsofspirometrytests,measuringlungfunction,arenowavailableontheClinicalResultsReportingSystem(CRRS),makingthedataavailabletoallclinicalstaff.Thishelpstoassessandidentifyanumberofrespiratorycondi-tions,includingasthma,cysticfibrosisandChronicObstructivePulmonaryDisease.

NationalDiabetesAudit(NDA) InconjunctionwiththeClinicalCommissioningGroup(CCG),theTrust’sDiabetesEducationServicehasbeenrestructuredtoincludeinformationregardingType2DiabetesCare(excludingcomplexcases)whichwillbepredominantlyprovidedtopatientsinIntermediateClinics.ThisensurespatientsreceivetheappropriatecareandtreatmentasrecommendedbytheNationalInstituteofHealthandCareExcellence(NICE).

TheTrusthasimplementedadedicated‘youngadultclinic’,thepurposebeingtoensureyoungadultsdiagnosedwithdiabetesarefullysupportedandreceivevitalinformation,careandtreatmentfortheir condition.

Arevisedinpatientfootcarepathwayhasbeenimplemented;aimingtoimprovefootsurveillanceforinpatientswithDiabetes.


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NationalDiabetesInpatientAudit

TheTrusthasworkedwithSouthWarwickshireNHSFoundationTrustandRugbySt.CrossHospitaltoimprovepatients’footcarebydevelopingapathwaychart,whichassessesfootcareduringandafteranyhospitalcare.

InorderforpatientswithDiabetestobeidentifiedearlier,consultant/specialistregistrarwardroundsaredoneeverymorning,MondaytoFriday.Thisaimstofacilitateearlyreviewandsafedischargeaswellasreviewthediabeticemergenciesearly.Inadditiontothis,aninpatientdiabetessteeringgrouphasbeenformedtomeetonceamonthtoencourageserviceimprovementsandencouragemultidisciplinaryteamworkingwithinthespecialty.

TheTrusthasincreasedspecialistinputintoinpatientdiabeteswhichwillincreasethelevelofcareandsupportprovidedtopatients.

AnInpatientfootpathwayhasbeenagreedwiththevascularteamandtissueviabilityteamwhichwasimplementedin2015.Thisenablesearlyidentificationofdiabeticfootproblemsallowingearlytreatmentandsafedischargeandavoidanceofamputations.

EducationwithintheTrusthasincreasedfortrainedstaffwherebyastudydayondiabetesisheldonceamonth.Thisallowsstafftocompleteonlinetrainingmodulessuchas‘SafeUseofInsulin’and‘Hypoglycaemia’whichresultsinimprovedcareforpatientswithdiabetesinthehospital,whichmakesupmorethan15%ofallpatients;overallimprovingoutcomes,reducinglengthofstayandimprovingpatientsatisfaction.


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Local Clinical Audits – Key Actions Taken in 2015-2016

ThefollowingarebriefsummariesofsomeofthekeyactionstheTrusthastakentoimprovethequalityofhealthcareasaresultofthereviewoflocalclinicalauditreports:


Re-AuditofPretermCare LocalguidelinesforpretermcarehavebeenupdatedtoincludethenationalguidelinesforRetinopathyofPrematurity(ROP)screening,aneyeexaminationoftheretina,followingdiscussionwiththePaediatricOphthalmologists.ThisensuresthattheTrustisfollowingnationalrecommendationsforpretermcare.

AnAntenatalNeonatalCounsellingClinicisnowinplacetoensurethatmothersofpretermbabiesreceivedantenatalcounselling.

Audittomeasurecurrentpractice and diurnal variation in practiceagainstthrombolysisguidelines

AnInternationalNormalisedRatio(INR)bedsidemachinehasbeenacquiredinordertoreducelaboratorywaitingtimeforINRinwarfarinisedpatients.Staffhavebeentrainedontheuseofthemachine.Thisensuresthatthrombolysedpatientsonwarfarincanbemonitoredsooner.

Nursingstaffhavebeentrainedincannulationandvenepuncture,sotheycannowtakeamoreactiveroleintheassessmentofthrombolysedpatients.

AuditofMentalHealthActdocumentationinEmergencyDepartment

InformationonholdingpowershasbeenincorporatedintotheTrustinductionforjuniordoctors,toensurethatthereisaclearunderstanding.Thiswillensurethecorrectproceduresarefollowed.

MentalCapacityActdocumentationisnowbeingrecordedontheTrust’selectronicClinicalResultsReportingSystem(CRRS)intheEmergencyDepartment/ObservationsArea,andthisfunctionalityisbeingrolledouttothewiderTrust.ThiswillensureinformationregardingMentalCapacityforpatientsisdocumentedcorrectlyandthatpatientsaretreatedaccordingly.

ManagementofSuspectedNonAccidentalInjury(NAI)

Reportshavebeencompletedforanypaediatriccasesinwhichtherewassuspicionofnon-accidentalinjuryorharm,andthesereportshavebeendisseminatedamongstprofessionals.Thisensuresthatconcernsaroundchildsafeguardingarehandledappropriately.

UHCW 2015 - 2016 Quality AccountUHCW 2015 - 2016 Quality Account


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Audit of the Outpatient ManagementofConstipation

Legandbackexaminationshavebeenroutinelyincorporatedintoclinicexamination,toensurethatpatientswithsuspectedconstipationreceiveeffectivetreatment,inlinewithnationalrecommendations.

LaminatedcopiesoftheBristolStoolCharthavebeenplacedinObservationfoldersonthewardsandpapercopiesofthecharthavebeenmadeavailableintheOut-patientsdepartment,toensurethatthisinformationisavailableforpatientstoview/takeaway.

Re-auditofPalliativeCareinParkinson’sPatients

‘Planningforyourfuture’leafletsarenowavailableintheTrust’sParkinson’sDisorderclinics.ThishashelpedtoinitiatediscussionsofAdvancedCarePlanningwithpatientsinclinic.

AsecondParkinson’sDiseaseNurseSpecialisthasbeenemployedbytheTrust,todevelopafollow-upclinicforpatientswithComplex/AdvancedCare.ThishashelpedtoensurethatAdvancedCarePlanningisdiscussedearlier.IthasalsoensuredthatpatientswithParkinson’sdiseaseareabletoavoidunwantedadmissionstohospitalatalaterstageofthedisease.

PaediatricdiabetesBestPracticeTariffaudit

AnewPointofCareTesting(POCT)deviceisnowinuse,facilitatingHbA1Cmeasurementinclinic.Thishelpswithmonitoringchildren’sbloodglucoselevelstoensurethecorrecttreatmentisprovided.

Apsychologyscreeningtoolhasbeenimplementedinordertoimprovepsychologyservicesforchildrenwithdiabetes.

AuditofSoffbanPlus ForallpatientswhorequiredcontinuousbloodpressuremonitoringwhilstinTheatre,OperatingDepartmentPractitioners/AnaesthetistsnowapplyathinlayerofSoffbanPlusbetweenthebloodpressurecuffandpatientsskintopreventtissuedamage.Thishasimprovedlevelsofsafetyandenhancesthepatientexperience.

Audit of the Dementia Care Bundle

Introductionofanewchecklisttoensurethattheneedsofpatientswithdementiaaremoreeasilyidentifiedandobserved.

Specialiseddementiaawarenesstrainingprovidedtoportersandsupportstafftoimprovepatientexperience.



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AuditofTotalKneeReplacementalignmentinobesepatients

Raisingawarenesstopatientsoftheriskandfrequencyofproblemswiththealignmentofthebonesintheknee.

Recommendingfixingsupportstructuresontheinsideoftheboneasopposedtotheoutside,thereforeimprovingtheexperienceandoutcomesoftotalkneereplacementsonpatientswithaBMIofover35.

AuditofImplantcheckingduringorthopaedic procedure (Jointreplacement)

NewguidelinesdevelopedanddistributedtotheatrestaffacrosstheTrusttoreinforcetheimportanceofcheckingimplantlabelsbeforewoundclosureinsimpleandcomplexcases,andtoensurethattheleadorassistingsurgeonrecordstheimplantdetailsonthetheatrewhiteboard,inviewofallpresentinthetheatre.Thismulti-checkingapproachensurespatientsarefittedwiththecorrectimplantandensurespatientsafety.

Re-auditofdocumentationandreviewoffluidbalancechartsonrespiratorywards

ImportanceofaccuratedocumentationreinforcedwithnightnursingstaffandHealthCareAssistants,avoidingtheuseofambiguousterminologyinpatientnotes.

Desiredbalanceandfluidmanagementplansreviewedbybothseniorandjuniordoctorstoensurepatientsreceivetheappropriateamount.

Doweneedtoprovidecross-matchedbloodatRugbyforPrimaryHipReplacements?

Patientsarenowreviewedaheadofplannedoperationstochecktheymeetthecriteriaforcross-matchbloodtestingthusreducingthenumberoftestsrequiredandpotentialdelaystosurgery.

AuditofAcutePainManagementinPaediatricOrthopaedicPatients-Howareweperforming?

Increasededucationandawarenessprovidedtojuniordoctorsoninductiontoemphasisetheimportanceofpromptandaccurateanalgesicprescribingforallpaediatricpatientsadmittedwithafracturetoensureeffectivepainmanagement.

AuditofAcuteKidneyInjury AnAcuteKidneyInjury(AKI)alertsystemhasbeenimplementedintheTrust’selectronicClinicalResultsReportingSystem(CRRS).CRRScreatesanAKIflagwhichisanalertindicatingthatapatienthasabnormallevelsofcreatinine.ItadvisesclinicianstocontacttheRenalteamifappropriate.

TheRenalSpecialistRegistrarwillusetheinformationreportedonCRRStocreateadatabaseofinpatientswhohavereceivedanAKIalertandwillmonitorthis.ThealertisanextralevelofsafetytomakesureeverypatientwithpotentialAKIisidentifiedandensuringtheappropriatecareandtreatmentisprovided.



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Compliancewiththestandardsforthediagnosisandmanagementoftherarebleedingdisorders(RBD)

TheTrusthasimplementedaprocesswherebypatientswhoreceivefactorreplacementtherapy,willhavetheirclinicalindicatedfactorlevelscheckedpriortoreceivingtreatment.Thisensuresaquickerdiagnosisandcommencementoftreatment.

Inpatientswherethereisnospecificcontraindication,tranexamicacidisofferedtoreducetheriskofbleedinginpatients.

Re-auditofcardiacarresttrolleyequipment

TheTrustensuredthatare-auditofadultandpaediatrictrolleysandgrabbagsandtheresuscitairesintheneonataldepartmentwasconductedtocomplywithUHCWstandards.Beforethiswasconducted,checklistswereamendedasaresultofthisauditwhichallowedbetterauditingofequipmentandcapturedthecorrectdata.Forthenon-compliantequipment,theResuscitationTeamreturnedtore-auditandensureallstockwasreplenished.

Re-auditofPhotodynamicTherapy(PDT)

PatientsaregiveninformationleafletspriortothemattendingforPhotodynamicTherapy(PDT);advisingthemofthediscomfortthetreatmentcancauseandprovidingadviceonwhatprecautionstotakepriortotreatmentincludingtheuseofanalgesia.

Re-AuditofSurgicalSafetyChecklist

TheSurgicalSafetyChecklisthasnowbeenincorporatedintotheTrust’selectronicTheatresystemwhichensurestherelevantsafetychecksforpatientsareundertakenbytheatrestaffduringandaftersurgicalprocedures.

AuditofComplianceagainstcommunication,educationandmonitoringofRheumatoidArthritispatientsfromatherapyperspective

Allpatientsnewlyreferredfortherapyarenowtriagedwithin24hoursandseenbyanOccupationalTherapistwithinonemonth.

TheOccupationalTherapistensuresthatpatientsareprovidedwitheducationalandself-managementadviceduringtheirfirstappointment after referral and are offered a place in the early arthritisgroupwhichprovidesongoingsupporttopatients.


2.4.3 Participation in Clinical Research

Researchisanintegralcomponentofprovidingworld-leadingexcellenceinclinicalcareandhasbeenlinkedtoimprovedpatientoutcomes.ItenablesUHCWtoleadinnovationanddevelopmentwhichenablesustoprovidethehighestqualitypatientcare.Itensuresthatwearealeaderratherthanafollowerinhealthcareprovisionandallowsustoattract,developandmaintainhighlyskilledandmotivatedstaff.WearecommittedtoestablishingourTrustasaninternationallyrecognisedcentreofexcellencethroughsupportingourstaff,workinginworldclassfacilitiesandconductingcutting-edgeresearchfocusedontheneedsofourpatients.

Thenumberofpatientsreceivingrelevanthealthservicesprovidedorsub-contractedbyUHCWin2015-2016thatwererecruitedduringthatperiodtoparticipateinresearchapprovedbyaresearchethicscommitteewas3885(proratatoJanuary2016asdatareportedtwomonthsinarrears,estimated4,500inyear).Whilethiswilllikelyrepresentareductionofrecruitmentonthepreviousyear(5146recruitedin2014-2015)ourcurrentportfolioconsistsofagreaterproportionofinterventionalandmorecomplextrials.Weaimtoexceed4,500patientsrecruitedtoNationalInstituteforHealthResearchPortfoliotrialsin2016-2017andincreasethenumberofpatientsrecruitedintocommercialtrials.

WeareoneoftheleadingresearchcentreswithintheWestMidlands,withaproventrackrecordofdeliveringhighqualityresearch.Wehavedevelopedourresearchbaseinrecentyears,movingfromapositionoflittleresearchactivitytobecomingahighlyresearchactiveuniversityhospital.Ourambitiouscommercialresearchstrategyhasresultedincontinualgrowthinincometoover£930kin2015-2016.

Ourexternalcollaborationwithacademicandindustrypartnerscontinuestoattractsignificantresearchincome.Thevalueofresearchgrantsawardedin2014-15was£6.3million(£8.4millionin2013-14).In2015-16,130researchgrantapplicationsweresubmittedtoexternalfunders.Currently,22%ofthesehavebeenfunded(totalvalue£3.9million)butthiswillriseastheoutcomeofapplicationsbecomesknown.Wehaveactivelyincreasedourcapacityandcapabilityinthesupportofhome-grownresearcherswithadedicatedstaffofferingcompre-hensiveguidanceandadviceoneverystepoftheresearch

pathway;fromdevelopingresearchideas,protocoldevelopment,grantapplication,trialmanagementanddeliverythroughtodataanalysisanddissemination.

Withmorethan350ongoingresearchprojectsledbystaffacrossawiderangeofspecialities,ourpatientsaregivenmanyopportunitiestotakepartinresearch.Patientinvolvementandrepresentationisdemonstratedthroughoutourresearchinfrastructure.Regulareventssuchasopendays,workexperienceopportunities,multi-mediacommunicationsandsocialmediaenableustoengagewithstaff,patientsandthepublic.OurResearch,DevelopmentandInnovationTeamwereawardedthePharmaTimesNHSClinicalResearchSiteoftheYearin2014and2015throughacompetitiveprocessjudgedbytheNationalInstituteforHealthResearch(NIHR)andAssociationofBritishPharmaceuticalIndustries.

InJuly2015weheldourinauguralResearch,DevelopmentandInnovationSummitwhichprovidedanopportunityforresearchactivestaffacrosstheTrustandourwiderpartnerstonetwork,collaborateandsharelearningandbestpractice.Buildingonthesuccessofthiseventweplan to hold a full-day event in July 2016 to coincidewiththelaunchoftheInnovationHubwhichisdetailedfurtherinSection3.

Ourcurrentmajorresearchthemesarereproductivehealth,traumaandorthopaedics,gastro-enterologyandcancer.Thesearecomplementedbyadditionalareasofclinicalresearchactivityandresearchactivitycontinuestoincrease.Thereareover100researchnurses,midwivesandalliedhealthprofessionalsassistingwithresearchprojectsandincreasingnumbersofstaffareundertakingresearch,clinicalacademicinternships,higherdegreesandPhDs.ThisyearhasseentheintroductionoftheInterdisciplinary(NonMedic)ClinicalAcademic(INCA)programmeincollaborationwithCoventryUniversitytofacilitateandsupportnurses,midwivesandalliedhealthprofessionalsdevelopessentialresearchskillsandtoencourageandnurturetheresearchersofthe future.

TheTrustprovidesfreeresearchtrainingforallstaffandoffersacomprehensivecompetencyframeworktoensurethatstaffarefullyequippedtodeliverhighquality,patientcentredcareandcontributetowardstorobustresearchoutcomes.


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ThisincreasinglevelofparticipationinclinicalresearchdemonstratesUHCW’scommitmenttoimprovingthequalityofcareweofferandtomakingourcontributiontowiderhealthimprovement.

Inthelastthreeyears,morethan500publicationshaveresultedfromourinvolvementinresearch,helpingtoimprovepatientoutcomesandexperienceacrosstheNHS.TheTrust’smission,Care-Achieve-Innovate,isexplicitinthatwewilldeliverthebestcareforourpatients,achieveexcellenceineducationandteachingandinnovatethroughresearchandlearning.Assuch,wehaveaclearstrategytodevelopresearchandinnovation.Thekeyareasfordeliveryareto‘instilandembedacultureofresearchandinnovation’and‘growinvestmentin,andrevenuefrom,researchandinnovation’.Bydeliveringonourresearchandinnovationstrategy,wealsocontributetothedeliveryoftheotherTruststrategicpriorities.InSection3.8ofthisQualityAccountyouwillfindmoredetailsofthewaysthatresearchcanbeusedtocreateimmediatebenefitsinpatientcare.

ForregularupdatesandinformationyoucanfollowUHCWresearchonTwitter:twitter.com/UHCWRDandI.

2.4.4 Goals agreed with Commissioners

Aproportionofourincomein2015-2016wasconditionaluponachievingqualityimprovementandinnovationgoalsagreedbetweenusandanypersonorbodiesthatweenteredintoacontract,agreementorarrangementwith,fortheprovisionofrelevanthealthservicesthroughthe

CommissioningforQualityandInnovationpayment(CQUIN)framework.Furtherdetailsoftheagreedgoalsfor2015-2016canbefoundinAppendix1ofthisQualityAccount.

2.4.5 Care Quality Commission

UniversityHospitalsCoventryandWarwickshireNHSTrust(UHCW)isgovernedbyaregulatoryframeworkthatrequireshealthcareproviderstoberegisteredwiththeCareQualityCommission(CQC)andthereforelicensedtoprovidehealthcareservices.TheTrust’scurrentregistrationstatusis‘registeredwithnoconditions’andtheCQChasnottakenenforcementactionagainstUHCWduring2015-2016.

TheCQChasastatutorydutytoassesstheperformanceofhealthcareorganisations,providingassurancetothepublicaboutthequalityofcarethroughasystemofmonitoring.CQCassessorsandinspectorsfrequentlyreviewallavailableinformationandintelligencetheyholdabouttrusts. FollowingtheCQCcomprehensiveinspectionwhichtookplaceintheTrustfrom10to13March2015,anactionplanwasdevelopedtoaddressthehighlevelspecificareasofimprovementidentifiedintheCQCreportthatwaspublishedinAugust2015.TheprogressagainsttheactionplanhasbeenmonitoredbytheChiefInspectorsofHospitalProgrammeBoardandhasbeenreportedtotheTrustDevelopmentAuthority(TDA)andtheTrustBoardonaregularbasis.Alloftheactionsintheactionplanarenowcomplete. Theoutcomeratingoftheoverallreviewresultedasfollows:


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Individualsiteratingsofeacharearesultedasfollows:

University Hospital

Onreview,theCQCdeemedOutpatientsandDiagnosticImaging‘inadequate’fortheSafedomain.ThiswasspecificallyinrelationtoservicesprovidedbyImagingservices.InresponsetheImagingDepartmentdevelopedaspecificactionplantoaddresstheissueshighlightedbytheinspectionprocess.ProgressagainstthisactionplanwasmonitoredbytheChiefInspectorofHospitalsProgrammeBoardandisnowreportedascomplete.

Hospital of St Cross, Rugby


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During2015-2016theCQCmadeoneinspectionvisitandonethematicreviewtoUHCW.

TheCQCundertookamulti-agencyinspectionoftheCoventryhealtheconomyon11May2015,aspartofanationalreviewofhealthservicesforchildrenlookedafterandsafeguarding.TheTrusthasreceivedthereportwithnoratinginDecember2015andajointactionplan,ledbytheCoventryandRugbyClinicalCommissioningGrouphasbeensubmittedtotheCQC.

Inaddition,apilotUrgentandEmergencyThematicReviewtookplaceattheHospitalofStCrossintheRugbyUrgentCareCentreon23February2016.ThisreviewcoveredthegeographicalareaoftheSouthWarwickshireSystemResilienceGroupandareportwillbeissuedinduecoursebutwithnorating.

2.4.6 Data Quality

ThelastyearhasseenprominentdevelopmentsinDataQualityattheTrust;aDataQualityModelwasdevelopedthatconsistedoftheDataQualityStrategy,DataQualityPolicy,DataQualityStandards,andaDataQualityself-assessmenttool.ThishasbeenrolledouttothemajorsystemsintheTrust,wheretheobjectivehasbeentoengagewithInformationAssetOwners.ThisworkwillcontinuewithothersystemsandwillbereportedandmonitoredthroughtheInformationGovernanceCommittee.

ThePatientAdministrationSystemcontinuestobeapriorityfortheTrust,asanumberoftherequirementsintheInformationGovernanceToolkitencompassdataquality.Toensurethatwemeettherequiredattainmentlevels,specifictrainingandadvicetousersofthePatientAdministrationSystemwillbefocusedsothatinformationcapturedtosupporttheprovisionofpatientcareandnationaldatasubmissionsremainsaccurateandreliable.

TheTrustsubmittedrecordsduring2015-2016totheSecondaryUsesServiceforinclusionintheHospitalEpisodeStatisticswhichareincludedinthelatestpublisheddata.

Thepercentageofrecordsinthepublisheddata:

• whichincludedthepatient’s valid NHS numberwas:

- 99.4%foradmittedpatientcare; - 99.7%foroutpatientcare;and - 97.7%foraccident&emergency care:97.7%.

• whichincludedthepatient’s valid General Medical Practice codewas: - 100%overallinAdmittedpatient care,Outpatientcare,and Accident&Emergencycare.

2.4.7 Information Governance Toolkit

Version13oftheInformationGovernanceToolkithadanumberofchangesspecificallyaroundtheintegrationofCaldicott2intotheToolkit.UHCW’sInformationGovernanceToolkitassessmentfor2015-16wasanoverallscoreof81%andwasgradedgreenandsatisfactory.TheTrustimproveditsperformancefromthepreviousyearof78%andachievedLevelTwooraboveinallrequirements.Mandatoryinformationgovernancetrainingforallstaffstillremainsachallenge,buttheInformationGovernanceUnitcontinuestochampioninformationgovernanceacrosstheorganisation.

2.4.8 Clinical Coding Error Rate

UHCWwasnotsubjecttoaPaymentbyResultsclinicalcodingauditinthereportingperiod.TheTrustdidcommissionanexternalauditofarandomsampleofdiagnosisandtreatmentcodingandtheresultswere:

• PrimaryDiagnosesincorrect2.5%

• SecondaryDiagnosisincorrect4.9%

• PrimaryProceduresincorrect4.7%

• SecondaryProceduresincorrect3.8%


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2.5 Performance against NHS Outcomes Framework 2015-2016

At UHCW:

• TheTrustmonitorsmortalityratesusingthenationalHospitalStandardisedMortalityRatio (HSMR;providedbyDrFosterIntelligence)andSummaryLevelHospitalMortalityIndicator (SHMI;providedbytheHealthandSocialCareInformationCentre),whichmeasuremortality astowhetheritishigherorlowerthanthatwhichwouldhavebeenexpected.

• BoththeSHMIandHSMRarenotdefinitivemeasuresofqualityofcare.Theyactasawarning systemfordeviancefromthe‘norm’andcanprovideindicationforareastoinvestigate.They providetheTrustwith‘alerts’whentherehasbeensignificantlymoredeathsthanexpected. AllalertsreceivedfrombothmonitoringreportsarereviewedanddiscussedattheMortality ReviewCommittee.

• TheSHMIusesabenchmarkof1tomonitorperformance.Ifthevalueishigherthan1,thenit impliesthattherehavebeenmoredeathsthanexpected.Ifthevalueisbelow1thenthere havebeenfewerdeathsthanexpected.Analertwillonlybegeneratediftherehavebeen significantlymoreorfewerdeathsthanexpected.TheSHMIvalueforthemostrecentthree publicationsiswithinthe‘expected’mortalityrange.

• TheHSMRusesabenchmarkof100tomonitorperformance.Ifthevalueishigherthan100 thentherehavebeenmoredeathsthanexpected.IftheHSMRisbelow100,itmeansthat therearefewerdeathsthanexpected.Iftherearesignificantlymoredeathsorfewerdeaths thanexpected,amortalityalert(eithernegativeorpositive)willbecreated.

• ForJanuary2015toDecember2015theHSMRis103.26whichiswithinthe‘expected’ mortalityrange(thisisthelatestavailabledata).TheHSMRforDecember2015is79.95which isalowrelativeriskformortality(therehavebeensignificantlyfewerdeathsthanexpected). ThechartbelowshowstheTrust’smortalityperformancetrendover12months.Ithighlightsan improvementinmortalitydatafromSeptember2015.


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Related NHS Outcomes Domains 1 and 2

Indicator: Mortality Rates [source: HSCIC]

January 2014 –

December 2014

April 2014 – March 2015

July 2014 – June 2015

National Average

(July 2014 – June)

Lowest and Highest reported Trust (July 2014

– June 2015)

a) thevalueandbandingofthesummaryhospital-level mortalityindicator(“SHMI”)forthetrustforthereporting

period

1.038(within

expected)

1.039(within

expected)

1.054(within

expected)

1.00

0.661(lowerthan

expected)

1.209(higherthanexpected)

b) thepercentageofpatientdeathswithpalliativecare

coded for thereportingperiod 11.6% 12.5% 14% 26.1%

0.0%

52.9%

• UHCWhasbeenworkingtoimproveitsHSMRvalue.Investigationwasundertakenintothe diagnosisgroupswiththelargestnumberofdeathstoidentifyareasforimprovementacross allaspects–clinical,organisational,andcoding.Asaresultoftheseinvestigations,the followingareinprogress:

- EvidencebasedCareBundlesarebeingcreatedbyspecialtiesfordiagnosisgroups withalargemortalityrate.Acarebundleisasetofinterventionsthat,whenused together,significantlyimprovepatientoutcomes.Theyaimtoconsistentlydeliverthe bestpossiblecareforpatientsandhavebeenproventoimprovepatientoutcomes

- Pre-admissionpathwayswerealsoreviewedduringtheseinvestigationsandworkwith theCoventryandRugbyClinicalCommissioningGroupisinprogresstopromote adequatecommunitycaretoreduceavoidablehospitaladmissions.

- PalliativecareisimportantwithintheTrustasitfocusesonprovidingpatientswithrelief fromthesymptoms,pain,physicalstress,andmentalstressofaseriousillness. UHCWhasbeenoneofthelowestTrustsforrecordingpalliativecareforseveral years.Workhasbeenongoingduringtheyeartoincreasethenumberofpatients receivingpalliativecarebyourSpecialistPalliativeCareTeambyaccurately recordingtheiractivities.Thisincludestwicedailywardvisitstoprovideadditional supporttopatientsandnurses.Thishasresultedinanincreaseintherecordingof palliativecare.BetweenJanuary2014andDecember2014,thepalliativecarerate fordeceasedpatientsatUHCWwas8.78%.However,followingtheimprovements incapturingactivitywithintheSpecialistPalliativeCareTeamthisyear,thepalliative codingrateofdeceasedpatientshasincreasedto23.81%(January2015-December 2015).Thenationalaverageforpalliativecodingdur-ingthistimeis24.77% indicatingthatUHCWisnowreportingsimilarlytootherTrusts.Thishashadapositive impactontheTrust’sHSMR.


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• Additionally,allinpatientdeathsatUHCW(patientsaged18andabove)receiveamortality reviewcompletedbythespecialtyinchargeoftheircare.Thisistoprovideassurancethat patientsreceivedagoodqualityofcare–andinsituationswherecarecouldbeimproved, actionsandlearningaresharedacrosstheTrust.Currently,91%ofpatientshavereceiveda NationalConfidentialEnquiryintoPatientOutcomeandDeath(NCEPOD).Agradeatprimary review–thismeansthattherehasbeenagoodqualityofcare.Thisisanimprovementon previousper-formance.UHCWtakesprideinensuringthatallpotentialareasforlearningare highlightedandsharedamongsttheteamstopromotebettercareandreducepatientharm.

*PROMS Adjusted Health Gain Scores. Items marked with an asterisk are due to low numbers of patient records being submitted and therefore this information is suppressed on HSCIC. Full year 2015/16 information was not available from HSCIC when this account went to publication.

TheTrustconsidersthatthisdataisasdescribedforthefollowingreasons:Patientsareaskedtocompleteafeedbackformpost-operativelyfollowinganationallyagreedprotocol.

TheTrustintendstotakethefollowingactionstoimprovethisscoreandsothequalityofitsservices,bysharingfeedbackandliaisingwiththerelevantclinicalareastoensureinformationaboutthequestionnaireisgiventopatientsandpatientsareencouragedtoparticipate.


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Related NHS Outcomes Domain 3

Indicator :Patient reported outcome measures scores

(PROMS)[source: HSCIC]

2013/2014 2014/2015 Apr-Sep 2015Provisional

NationalAverage(Apr-Sep

2015Provisional)

Lowestand Highest

Reported TrustApril-September 2015 provisional

GroinHerniasurgery * 0.077 * 0.088 0.008– 0.135

VaricoseVeinsurgery * * * 0.104 0.037– 0.130

Hip replacementsurgery 0.449 0.454 0.520 0.454 0.359– 0.520

Knee Replacementsurgery

0.326 * 0.312 0.334 0.207– 0.412

**Indicates the information is not yet available on the HSCIC portal, it is due to be released in August 2016 + Indicates data is UHCW Data

TheTrustconsidersthatthisdataisasdescribedforthefollowingreasons:TheconsistencyandaccuracyofthedatacollectionhasbeenevaluatedbyinternalauditandismonitoredbytheTrustPerformanceManagementOffice.

TheTrustintendstotakethefollowingactionstoimprovethispercentage,andsothequalityofitsservices:bycontinuingtoimplementactionsaroundimprovingeffectiveandsafedischarge.


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Indicator: emergency readmissions to hospital [source: HSCIC, UHCW]

Year UHCW NHS England Average

lowest reported

Trust highest reported

Trust

Thepercentageofpatientsaged0to15readmittedtoahospitalwhichformspartoftheTrustwithin28daysofbeingdischargedfromahospitalwhichformspartofthetrustduringthereportingperiod

2013/14 7.87+ *

Not available

* Not

available

* Not

available

2014/15 7.33+ *

Not available

* Not

available

* Not

available

2015/16 7.54+ *

Not available

* Not

available

* Not

available thepercentageofpatientsaged16 or over readmitted to a hospitalwhichformspartoftheTrustwithin28daysofbeingdischargedfromahospitalwhichformspartofthetrustduringthereportingperiod

2013/14 7.76+ *

Not available

* Not

available

* Not

available

2014/15 7.76+ *

Not available

* Not

available

* Not

available

2015/16 8.09+ *

Not available

* Not

available

* Not

available

*The Trust’s responsiveness to the personal needs of its patients during 2015-2016 is not yet available on the HSCIC website.

Thepercentageofstaffemployedby,orundercontractto,thetrustduringthereportingperiodwhowouldrecommendthetrustasaproviderofcaretotheirfamilyorfriends:

**Thepercentageofstaffemployedby,orundercontractto,theTrustduringthereportingperiodwhowouldrecommendtheTrustasaproviderofcaretotheirfamilyorfriends:ThesefiguresarebasedontheresultsforUHCWfromtheNationalStaffSurvey.Eachyear850randomlyselectedstaffareabletotakepartinthesurvey.InApril2014theNationalStaffFriendsandFamilyTestwaslaunched,whichseesstaffbeingaskedwhethertheywouldrecommendtheTrustasaplacefortheirfriendsandfamilytoworkoraplaceforthemtobetreated.Wearerequiredtoaskallstaffeachyearthefriendsandfamilyquestions,howeveraspartofourcommitmenttolistenandrespondtostafffeedbackwehaveaskedallstaffineachquarterof2015-2016.InformationandtheresultsfromthissurveycanbefoundinSection3.11ofthisaccount.


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Indicator: A positive experience of care [source HSCIC] 2013/14 2014/15 2015/16

National Average 2015/16

Lowest and Highest

Reported Trust 2015/16

TheTrust’sresponsivenesstothepersonal needsof itspatientsduring thereportingperiod.

74.2% 75.5% * * *

Thepercentageofstaffemployedby,orundercontractto,theTrustduringthereportingperiod whowouldrecommend theTrustasa provider of care to their family orfriends.**

62% 70% 76% 69% HIGHEST 100% LOWEST44%

TheTrustconsidersthatthisdataisasdescribedforthefollowingreasons:theconsistencyandaccuracyofthedatacollectionhasbeenevaluatedbyinternalandexternalauditandismonitoredbytheTrustPerformancemanagementoffice.ThenationalVTEriskassessmenttooloriginatesfromNICEguidanceandstatesthatallpatientsshouldberiskassessedonadmissiontohospital.Patientsshouldbereassessedwithin24hoursofadmissionandwhenevertheclinicalsituationchanges.UHCW’saveragecomplianceacrosstheyearis96.2%ofpatientsreceivingaVTEriskassessmentonadmission.TheTrusthasincorporatedanumberofsystemcontrolswithinitsClinicalReportingandResultsSystem(CRRS)toenhancethequalityofcaretopatientsandthispromotescompletionoftheriskassessmentwithin12hours.Whilst,theTrustisconsciousthatitisnotclinicallyappropriatetocompleteaVTEassessmentwithinadefinedperiodoftimeforallpatients,whentakingintoconsiderationthenumberofpatientswhoseVTEassessmentwascompleted24hoursormoreafteradmission,theindicatorwouldchangeslightlyto92.6%.


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Indicator: avoiding harm [source HSCIC]

Year by quarters

UHCW National average

Trust with highest/lowest

score

The percentage ofpatientswho wereadmitted tohospitalandwhowere riskassessedforVenousThromboembolism(VTE) during thereporting period The indicator is expressed as a percentage of all adult in-patients that have received a VTE risk assessment upon admission to the Trust using the clinical criteria of the national VTE tool

2013/14 Q1 95.8%

95.5%

100%

78.8% Q2 95.9% 95.6% 100%

81.7% Q3 96.1% 95.8% 100%

74.1% Q4 96.2% 96.0% 100%

78.9% 2014/15

Q1 96.1%

96.1%

100% 87.2%

Q2 96.4% 96.1% 100% 86.4%

Q3 96.5% 95.9% 100% 81.2%

Q4 96.6% 96.0% 100% 79.2%

2015/16 Q1 96.6%

96.0%

100%

86.1% Q2

95.8% 95.9% 100% 75.0%

Q3 96.2% 95.5%

100% 61.5%

Q4 96.4% 95.5%

100% 78.1%

*National averages are not available from HSCIC until mid-July. It will then be available on the HSCIC website.

Pleasenotethatthe2015-16ratehasbeencalculatedusingCDifficilereportedcasesavailableontheHSCICandKH03beddaydata(38/382,843x100,000).

TheTrustconsidersthatthisdataisasdescribedforthefollowingreasons:ReportingofdataonC.difficileinfectionismandatory;dataqualityismonitoredthroughinfectioncontrolandsubjecttoauditandreportingtocommissioners.UHCWhassubmitteditsmandatoryreturnbutthishasnotyetbeenpublishednationally.

TheTrustintendstotakethefollowingactionstoimprovethispercentage:bycontinuingtoimplementitsinfectioncontrolandpreventionstrategy.


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Indicator: Reducing Infection [source HSCIC]

2013/14 2014/15 2015/16 National Average

Lowest to Highest Reported Trust

Therateper100,000beddaysofcasesofC.difficileinfection reportedwithintheTrustamongstpatientsaged2oroverduringthereportingperiod. The Trust is deemed responsible for a case where the sample was taken on the fourth day or later of an admission to that trust (where the day of admission is day one)

12.7 10.7 9.9 * *

**The patient safety indicator is expressed as a percentage of patient safety incidents reported to the National Reporting and Learning Service (NRLS) that have resulted in severe harm or death.

Apatientsafetyincidentisdefinedas‘anyunintendedorunexpectedincident(s)thatcouldordidleadtoharmforoneofmoreperson(s)receivingNHSfundedhealthcare’.

The‘degreeofharm’forpatientsafetyincidentsisdefinedasfollows:

• ‘severe’–thepatienthasbeenpermanentlyharmedasaresultoftheincident;

• ‘death’–theincidenthasdirectlyresultedinthedeathofthepatient.

TheTrustconsidersthatthisdataisasdescribedforthefollowingreasons:UHCWassessesdataqualitybeforesubmissiontoNHSEngland’sNationalReportingandLearningSystem(NRLS).TheNRLSmonitorsthedataandinformsUHCWofanyanomaliesorerrors.

TheTrustintendstotakethefollowingactionstoimprovethispercentage. • ContinuetoincreaseawarenessofincidentreportingthroughTrustinductionandad-hoc spot-checksonwardsanddepartments• Continuetoprovideimmediatefeedbacktoreporters• Improvefeedbacktostaffthroughavarietyofmedia,e.g.email,posters,newsletters,Grand Roundpresentations,webpages.• Ensurethatactionplanstoaddressincidentsarerealisticandachievableandhencecompleted withintheirdeadlines.


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Indicator: Incident reporting [source NRLS]

Apr 1

4 –

Sep

14

O

ct 1

4 –

Mar

15

Apr 1

5 –

Sep

15 National Median

(Acute non-specialist Trusts)

April 15-Sep 15

Lowest and Highest reported Trusts

April 15-Sep 15

The number of PatientSafety Incidents reportedwithin the Trust in thereportingperiod

5532 6141 6,047 4.125 Lowest- 1,559

Highest- 12,080

Rate of Patient SafetyIncidents reported withinthe Trust in the reportingperiod(per1000 beddays)

28.74 31.67 32.18 38.25 Lowest - 31.65

Highest- 61.32

The number of suchincidents that resulted insevereharmordeath

19 14 37 17 Lowest- 2

Highest- 89 **Percentage of suchPatient Safety Incidentsthat resulted in severeharm or death

0.3% 0.2% 0.6% 0.4% Lowest:- 0.1%

Highest- 2.9%

Section 3Overview of Organisational Quality

3.1 Patient Safety

Theaimofincidentreportingistocapturethemesandtrendsfromthenumerouslowlevelincidentsandresolvethem,toavoidthepotentialforaggregatedfailuresthatcancausepatientsahigherdegreeofharm.Ouronlineincidentreportingsystem(Datix)facilitatesearlydetectionofthesetrendsandalertsthecentralSafetyTeamtoanyseriousincidents,enablingescalationandswiftinvestigation.

ThelasttwelvemonthshaveseenanincreaseinthereportingofpatientsafetyincidentswithintheTrust.Thereportingofallincidentswhichimpactonapatient’scareissomethingwhichisencouraged,howeverminortheoutcome.Allreportedincidentsareinvestigatedaccordingtothetypeofincidentandtheirpotentialforharm.Seriousincidentsareinvestigatedusingrootcauseanalysismethodology.

Allofourstaffcanreportincidentsknowingthattheywillbesupportedthroughouttheprocessofinvestigationandinvolvedinmakingrecommendationsanddevelopingactionplans.TheprocessforincidentreportingistaughtatTrustinduction,whichisa3-daycoursewhichintroducesallstafftotheTrust’scorevaluesaspartofthewiderTogetherTowardsWorldClassprogramme.

Themajorityofpatientsinvolvedinasafetyincidentincurminorornoharm,whichisanindicationofanopenandlearningculture(refertobelowchart).Wesharetheoutcomesofinvestigationsandtrendanalysisacrosstheorganisationaswellaswithourcommissioners,otherlocalprovidersandwithNHSEngland.


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Serious Incidents

Seriousincidentsaredefinedasincidentswheretheconsequencesorpotentialforlearningissogreatthattheuseofadditionalresourcestocompileaninvestigationisappropriate.

Wereported182seriousincidentsin2015-2016.

AseriousincidentrequiringinvestigationisdefinedasanincidentthatoccurredinrelationtoNHS-fundedservicesandcareresultinginoneofthefollowing:

• Unexpectedoravoidabledeathofoneor morepatients,staff,visitorsormembers ofthepublic.

• Seriousharmtooneormorepatients, staff,visitorsormembersofthepublic orwheretheoutcomerequireslife- savingintervention,majorsurgical/ medicalintervention,permanentharmor willshortenlifeexpectancyorresultin prolongedpainorpsychologicalharm (thisincludesincidentsgradedunderthe NPSAdefinitionofsevereharm).

• Ascenariothatpreventsorthreatensto preventaproviderorganisation’s abilitytocontinuetodeliverhealthcare services,forexample,actualorpotential lossofpersonalandorganisational information,damagetoproperty, reputationortheenvironment,orIT failure.

• Allegationsofabuse.

• Adversemediacoverageorpublic concernabouttheorganisationorthe widerNHS.

ForAcuteTrusts2015-2016theNeverEventlistwas:

- WrongSiteSurgery

- WrongImplant/prosthesis

- Retainedforeignobjectpost-procedure

- Mis-selectionofastrongpotassium containingsolution

- Wrongrouteadministrationofmedication

- Intravenousadministrationofepidural medication

- OverdoseofInsulinduetoabbreviations or incorrect device

- Overdoseofmidazolamduringconscious sedation

- Overdoseofmethotrexatefornon-cancer treatment

- Fallsfromunrestrictedwindows

- Chestorneckentrapmentinbedrails

- TransfusionofABO-incompatibleblood componentsororgans

- Misplacednaso-ororo-gastrictubes

- Scaldingofpatients

ThisguidanceissetoutintheSeriousIncidentFrameworksetbyNHSEngland.

Over70%ofthesearemadeupofspecifictypesofincidentthatareautomaticallyreportedasSeriousIncidents,forexampleInfectionControlincidents(e.g.MRSAbacteraemia,CDifficile-associateddeathsandinfectionoutbreakssuchasNorovirus),pressureulcersandallNeverEvents.


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Chart illustrating serious incidents by type 2015-2016

WehaveaweeklySignificantIncidentGroupmeeting,whichisattendedbyseniorclinicalandnon-clinicalstaffaswellasacommissioningrepresentative,whoensurethatourprocessconformstothenationalSeriousIncidentFramework2015.Thegroupoverseestheinvestigationsandresultingactionplans,allofwhicharemonitoreduntilcompletion.

Asaresultofseriousincidentswehaveintroducedmanysafetyimprovements,examplesofwhichare:

• ReviewoftheTrust’sPatientTransferPolicy.

• Improvingthesafetyofcentrallineuseonthegeneralcriticalcareunit.

• Patient“callbells”nolongerusedonquieternight-timesettings.

• Introductionofanenhancedcareteamtoprovideonetoonecareforpatientswhorequire additionalinputduringtheirhospitaladmission.

• Anaide-memoirewasputinthemulti-birthroomtoremindstaffaboutspecific intrapartumcarerequirementsforwomenwithtwinpregnancy.

• WeeklysafetymessagesarecirculatedbytheChiefMedicalandChiefNursingOfficers.


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FurtherdetailsoftheworkundertakenareoutlinedintheQualityDepartmentAnnualReport2015-2016.

AleaguetableproducedbyMonitorandtheNHSTrustDevelopmentAuthorityinFebruary2016identifiedlevelsofopennessandtransparencywithinNHSTrustsandFoundationTrusts.TherankingsthatTrustsweremeasureonwere:

1– outstanding levelsofopennessand transparency

2– goodlevelsofopennessand transparency

3– significant concernsaboutopenness andtransparency

4– poor reporting culture

UHCWreceivedaratingas“good.”Theleaguetablewasdrawntogetherbyscoringprovidersbasedonthefairnessandeffectivenessofproceduresforreportingerrors;nearmissesandincidents;staffconfidenceandsecurityinreportingunsafeclinicalpractice;andthepercentageofstaffwhofeelabletocontributetowardsimprovementsattheirTrust.

Never Events

During2015-2016regrettablywereportedthree“NeverEvents”.Wehaverespondedtotheseincidentswithrobustinvestigationsandscrutinyofourprocessesandprocedures.

Allthreecasesweredeclaredas“wrongsitesurgery”,whichisdefinedbyNHSEnglandas:“asurgicalinterventionperformedonthewrongpatientorwrongsite(forexamplewrongknee,wrongeye,wronglimb,wrongtoothorwrongorgan);theincidentisdetectedatanytimeafterthestartoftheprocedure.”

Twocasesrelatedtoincorrectspinallevels(oneofwhichoccurredin2013butwasdetectedin2016followingimagingforfurthersurgery)andonecaserelatedtohandsurgery.

AllcasesoccurreddespiteuseoftheWorldHealthOrganisation’s(WHO)SaferSurgerychecklist.

Oneachoccasionwehavediscussedtheerrorwiththepatientinvolvedand/ortheirnextofkin

andofferedtosharetheresultsofourinvestigations.TheinvestigationswereeachledbyaseniorclinicianusingRootCauseAnalysis(RCA)methodology.RCAreportsarescrutinisedbyourSignificantIncidentGroup,whichhasarepresentativefromourcommissioners,toensurethatallaspectsareconsideredandthattheassociatedactionplansarerobust.Allactionsaremonitored until completion.

StaffinvolvedinaNeverEventarerequiredtodiscusstheincidentandactionstakenatameetingwiththeChiefExecutiveOfficerandtheRCAreportsaresharedwiththeTrustBoard.DetailsaboutNeverEventsarealsopublishedinthepublicTrustBoardpapersavailableontheTrustwebsiteatwww.uhcw.nhs.uk/about-us/trust-board.

WecontinuetotakeactivestepstotrytoeradicatetheoccurrenceofNeverEventsintheorganisation.Examplesofactionswehavetakenare:

• Conductedagapanalysisagainstthe 2015/16NeverEventslistandsupporting information.

• CommencedHumanFactorseducation withstaffwhoworkinoperatingtheatres.

• Setupamulti-disciplinaryTheatresafety team.

• RaisedawarenessofNeverEventsand sharedthelearningwithourstaff.

• Takenactionasrequiredbysafetyalerts andrecommendationsfromtheNational ReportingandLearningSystem(NRLS).

• MonitoredtheuseofWorldHealth Organisation(WHO)surgicalsafety checklistsandaddressedany shortcomingsimmediately.

• Reviewedandrevisedclinicalguidelines toimprovepatientsafety,basedon learningfromtheincidents.


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Duty of Candour

FollowingtheFrancisReportoftheMidStaffordshireNHSFoundationTrustPublicInquiryandaseriesofotherreviews,theDutyofCandourbecamepartofaregulatoryregistrationpackagewhichwasimplementedinOctober2014.

ClinicianshaveanethicalDutyofCandourtoinformpatientsaboutmistakesthatcauseseriousharmtotheirpatients.TheCareQualityCommission’s(CQC)Regulation20istoensurethatprovidersareopenandtransparentwithpeoplewhouseservicesandother‘relevantpersons’(peopleactinglawfullyontheirbehalf)ingeneralinrelationtocareandtreatment.Itsetsoutspecificrequirementsthatprovidersmustfollowwhenthingsgowrongwithcareandtreatment,includinginformingpeopleabouttheincident,providingreasonablesupport,providingtruthfulinformationandanapologywhenthingsgowrong.

InresponsetotheDutyofCandourthePatientSafetyTeamhasledontheproductionandpilotingofanewTrustpolicywhichisbasedonnational and international evidence.

Thepolicyincludesclearinformationforstaffonwhattheyshoulddowhentheyareinvolvedinaseriousincidentandthesupportavailabletothemtodealwiththeconsequencesofwhathappenedandhowtocommunicatewiththepatientsorserviceusers,theirfamiliesandcarers.

FollowinganincidenttowhichtheDutyofCandourapplies,thepatientinvolvedwillreceiveaverbalapologyandawritteninformationleafletwithacontactnameandnumberanddetailsofwhatwillhappennext.Followingtheinvestigationtheywillbegivenanopportunitytodiscussthefindingswithamemberoftheclinicalteam.

Sign up to Safety

UHCWjoinedthenationalSignuptoSafetyCampaignin2014,whichhastheambitionofmakingtheNHSthesafesthealthcaresystemintheworld.SignuptoSafety’sthreeyearobjectiveistoreduceavoidableharmby50%andsave6,000lives.

UHCWhassigneduptothecampaign’sfivepledges:

1. Wewillput‘Safety First’bycommittingto reduceavoidableharmbyhalf.2. Wewilllookto‘Continually Learn’ throughmakingourorganisationmore resilienttorisks,andactingonfeedback fromourpatientstomonitorhowsafeour servicesare.3. Wewillensure‘Honesty’ and transparencywithpeopleonourprogress intacklingpatientsafetyissues.4. Wewill‘Collaborate’withourpatient groupsandotherlocalpartnerson improvingpatientcare.5. Wewill‘Support’peopletounderstand whythingsgowrongandhowtoputthem right.

Aspartofthecampaign,in2015webidforaone-offdiscretionarypaymentbytheNHSLitigationAuthority.Ourbidwasoneofthe67successfulbidsoutofatotalof243,earningus£245,329whichisearmarkedfortheintroductionofHumanFactorsandforthedevelopmentofaninnovativeaudiosurgicalsafetychecklistforourTheatres.

Todatewehaveimplementedhumanfactorseducationandinnovationinanumberofways:

• Wehavecommencedselectionofthose staffwhowillbecomeourHumanFactors trainers.

• Wehavestartedtolookatstafftostaff “interactivity”,thatis,howstaff communicatewithoneanotherandhow thismightrelatetosafety.

• Theaudiosafetychecklisthasbeen pilotedintheatresoveroneweekandthe evaluationiscurrentlyinprogress.We willpossiblyneedtorepeatitforalonger period of time.

• WehavestartedtoaddHumanFactors educationintoouractionplansforserious incidents

• Weareworkingwithanationalcompany tolookathowtomakepatientbathrooms saferaswefoundoneofthereasonsthat patientswerefallingoverinbathrooms wasbecausethetoiletpaperdispensers werenoteasytoreach.


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3.2 Claims

TheTrustinthefinancialyear2015-2016reported101clinicalnegligenceclaimstotheNationalHealthServiceLitigationAgency(NHSLA),adecreaseof10claimsonthelastfinancialyear.In2015-16theNHSLA,onbehalfoftheTrust,settled46claims.FurtherdetailsontheTrust’sclaimshistorycanbeobtainedviatheNHSLA’swebsite:www.nhsla.com.

WecanconfirmthattheTrust’sclinicalnegligenceclaimshistoryiswithinthenationalaverageforAcuteTrustsprovidingamaternityservice.

TheTrustiscommittedtominimisingtheopportunityforhumanerrorinmedicineandwiththisaimhascommittedsubstantialresourcesinimplementingitsclinicalgovernanceframework.Clinicaladverseeventsareactivelyreportedandasappropriatelyinvestigated;withactionplansimplementedseekingtoavoidsimilarincidentsagain.

3.3 Dementia

AccordingtotheAlzheimer’sSociety,thereareover800,000peopleintheUKlivingwithdementiaandatanyonetimethisgroupoccupiesapproximately25%ofgeneralhospitalbeds.Itisestimatedthatifcurrenttrendscontinueandnoactionistaken,thenumberofpeoplewithdementiaintheUKisforecasttoincreaseto1,142,677by2025,anincreaseof40%overthenext12years.

Weaimtoensurethatweprovidehighquality,personalized,compassionatecareforthisvulnerablegroupofpatients,makingsuretheyareproperlysupportedandreassuredwhilsttheyareinhospitalandafterdischargewhentheyareinthecommunity.Wealsorecognisethatcarefulplanningforthefutureisrequiredtoensurethattherightcareandsupportisavailableforpatientswithdementiabothinhospitalandwithinthecommunity.

TherecentCareQualityCommissioninspectionfoundthattheTrusthaddemonstratedimprovementsindementiacareandoverallagoodexperienceforpatients.


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Graph of patients admitted to UHCW over the past 3 years with a diagnosis of dementia showing a steady increase in trend.


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What we set out to do

Promptly identify patients with dementia

TheTrustwantstomakesurepatientswhohaveormayhavedementiaareappropriatelyidentifiedonadmissiontohospitalsotheyreceivetherighttypeofcareandtreatment.Weknowthatitisimportantthatearlywarningsignsofdementiaareidentifiedtherefore;weaimtopromptlyscreen,assess,investigateandifnecessary,referpatientsovertheageof75ontoaspecialistwhentheyareadmittedtohospitalinanemergency.ThisformspartofthedementiaCQUINschemeandwehavecontinuallyachievedourtarget.Thegraphbelowshowsthatover90%ofpatientsarescreenedandreceivingsuitableinterventions:


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TheTrusthastakenactionstoimprovethisrateandtherebyincreasethequalityofourservice.Adashboardapplicationhelpstheteamtracktheirprogress.TheTrustcontinuestomeetthenationalstandardfordementiascreeningtoensureourpatientsreceivetheappropriatecare.

UHCWwanttoensurethatallstaffhavetheknowledge,confidenceandskillsrequired,andaccesstospecialistknowledgeandadvicesothatweareabletoprovidethemosteffectivecarepossibletoourpatientslivingwithdementia.DementiatrainingispartofthedementiaCommissioningforQualityandInnovation(CQUIN)paymentframeworkandwehaveconsistentlyachievedourtargetfortheCQUINsetbythelocalClinicalCommissioningGroup.

TheTrustiscommittedtocontinuallyembeddinggoodpracticewithregardstodementiacareandallstaff,whetherclinicalornon-clinical,areoffereddementiaawarenesstrainingtorecognizethesignsofdementiaandtogenerallyraiseawarenessoftheissuesaffectingpeoplewithdementiaandtheirfamiliestohelpthemprovidethemostappropriatecareforthisgroupofpatients.

During2015-2016(betweenApril2015andMarch2016),697UHCWstaffweretrainedondementia.Trainingisdeliveredthroughclassroomsessions;wardbasedonetooneexperientiallearningandane-learningmodule.Moreindepthdementiatrainingiscarriedoutinstand-alonesessionssuchastherecentworkshopon‘DealingwithChallengingBehaviour’organisedbytheDementiaTeam.

Staffarealsotrainedinvarioustechniquesformanagingpatientswithdementiasuchasthe‘M’Technique.The‘M’techniqueisasimplemethodofstructuredtouch.Eachmovementandsequenceisdoneinasetpatternatasetpressureandsetspeed,whichneverchange.TheMtechniqueisdifferentfrommassageandissuitablefortheveryfragile;thecriticallyill,activelydying,orwhenthegiverisnottrainedinmassage.The‘M’techniqueworksonskinreceptorswhichsendsignalstothebrainandhasbeendescribedas‘physicalhypnotherapy’anda‘spiritualdance’.StaffarealsotaughtthetheVERAtechnique.TheVERAtechniqueisahelpfulapproachandanaidtomemoryforstaffwhenworkingwithpatientsdiagnosedwithdementia.

VERAstandsfor:

V= Validate,acceptingthatthebehaviour exhibitedhasavaluetothepersonand isn’tjustasymptomofdementia.

E= Emotion,payingattentiontothe emotionalcontentofwhattheperson’s saying.

R= Reassure,canbeassimpleassaying‘it’ll beokay’andsmiling,holdingtheirhand.

A= Activity,peoplewithdementianeedtofeel occupied,active,seeifyoucanengage theminsomerelatedactivity.

Staffarealsoencouragedtoparticipateinanationallyrecognizedqualificationindementiaorganizedbythetrainingdepartment.WehaveinvestedintwoClinicalEducationLeadswhoworkcloselywithourstafftosupportwiththeirtraining.

Thetrainingmethodshavebeenimprovedtoallowmoreinteractionwithtraineesandprovidemorepracticallearningexperiencethroughwardbasedtraining.Wewillcontinuetofurtherdevelopoureducationalprogramwithafocusondevelopingstaffawarenessandunderstandingofeffectivecareindementiaandhopetoincreasethepercentageofstafftrainedinthecomingyear.

Promote dementia awareness across the Trust

Aswellasraisingawarenessofdementiathrougheducation,wehaveundertakensignificantworktowardsembeddingtheForgetMeNotCareBundleacrosstheorganization.ThisCareBundleprovidespromptsforstafftoensurethatcareisfocusedonfourkeydomains:communication,nutritionandhydration,asafeenvironmentandpersonalinformation.TherationaleforimplementingtheCareBundleistoprovidepersonalandindividualizedcaretodementiapatients.ArecentauditoftheCareBundleidentifiedareasofimprovementforstandardisationagainstfundamentalstandardsinthecareofpatientswithdementia.AfurtherauditofthecarebundleisongoingonsevenwardsinthehospitalwhichisduetocompleteinApril2016.

AllwardsanddepartmentshaveidentifiedDementiaChampionswhoreceiveadditionalregulartrainingandsupport.


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Theirroleistosupportpatientswithdementiaandstaffbypromotinggoodpracticeinthisareaandtheyalsoprovidefeedbacktothedementiateam.Weholdregulardementiachampionsforums.Workhastakenplacetoincreasethenumberofattendees,tomaintainmomentumandeffectchangeatwardlevel.

The‘GettingtoKnowMe’form,whichisakeyelementoftheforgetmenotcarebundleisadocumentwhereinformationrelevanttoeachpersonandtheirlikes/dislikesiswrittenbythepersonwithdementiaortheirrelativestohelpstaffprovidepersoncenteredcarerightfromtheonsetoftheircare.AllpatientswithdementiaaregivenaformfortheircarerstocompleteonadmissiontotheTrust.

Support Carers of patients with dementia

Werecognisethatcarersplayavitalroleinthecareofpatientswithdementiaandarecommittedtoimprovinghowweworkwithandsupportcarersofourpatientsandreducingtheriskofcarerbreakdown.

WehavesetupaCarersSupportGrouptoexplorebetterwaysofcommunicatingwithandsupportingcarers.Carersalsoreceivesignpostingtorelevantserviceswithinthetrustandinthecommunity.ViewsofcarersarefedbacktotheDementiaSteeringGrouptofacilitateanynecessaryimprovementstoservice.

Followingdiscussionwithwardstaffpatientnearestrelativeorprimarycarerareofferedflexiblevisitinghourstoenablethemvisitoutsidenormalvisitinghoursinordertoprovidesupportwithpersonalcare,provideassistanceatmealtimesifdesiredandbeactivelyinvolvedindiscussionsabouttheirlovedone’scare,ongoingtreatmentanddischarge.

AspartofthedementiaCQUINscheme,weestablishedaCarers’Surveywhichhasprovidedmuchwelcomedfeedbackonhowtoimproveservicesforourpatientswithdementia.Wehavetakenonboardfeedbackfromthesurveyandworkisongoingtoaddresssomeofthepointsraised.Wehaveimprovedinformationsharingwithcarersandnowprovidethemwithcarerinformationpacks.Wealsodisplayrelevantinformationoncarerinformationboardsprovidedonthewards.

BelowarekeyfindingsfromtheCarers’Survey(December2015toMarch2016):

- 90%ofcarerssaidtheywereprovided withtheGettingToKnowMeform.

- 90%ofcarerssaidtheyaskedhowmuch involvementtheywouldlikewiththeir relative’scare.

- 100%ofcarersfeltthattheenvironment meetstheneedsoftheirrelativesand wereofferedflexiblevisitingtimes.

- 100%ofcarersfeltthatstaffwere approachableandthattheywereableto askforinformationabouttheirrelative.

- 65%saidtheyhadsufficientinformation abouttheirrelative’sdischargeplans.

- 65%ofcarerswereofferedaninformation leafletfromtheirrelative’sward

- Overall,onascaleof1-10,anaverage scoreof9.0wasgivenforthecare receivedbypatientsandtheircarers.

What we hope to achieve this year

- Consistentcompliancewiththedementia CQUINtargets.

- Anincreaseinpercentageofstaff particularlynursingstaffandjunior doctorsindicatethattheyhavehad dementiatrainingandcanaccess dementiaspecialistknowledgeand advice.

- Continued evidence of dementia friendly environmentsthroughouttheTrust.

- ImprovedattendanceattheCarers’ SupportGroupsessions.

- Continuedpositivefeedbackfromcarers throughtheCarersSurvey.

- Establishedlinkswiththecarers associationtoimproveengagementwith carerswithinthecommunity.

- Furtherdevelopedlinkswithstakeholders todevelopamulti-agencyintegratedcare pathwayforpatientswithdementia.


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- Continually monitor the amount of time apatientspendsinhospitali.e.lengthof stay,readmissionsanddischarge destinationsinvolvingthosewith dementiatoensurepatientsare appropriatelyreferredontospecialist services.

- EvidencethattheCareBundleisused consistentlyacrosstheTrust.

- ConducttheNationalDementiaAuditin 2016.

How we will monitor progress

WewillmonitorprogressofourplannedimprovementsandmeasuresofsuccessthroughthemonthlyDementiaSteeringGroupwhichreportsprogresstotheTrustQualityGovernanceCommittee.Thiswillbeusedasaforumtosharelatestguidelinesandreviewfeedbackfromsurveysandauditsinordertodevelopactionplansforcontinuedimprovement.


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3.4 Infection Control

End of year performance against Department of Health (DH) Targets.

Clostridium difficile (C.diff)

UHCWendedtheyear2015-16*belowboththenationalandinternalstretchtargetssetforClostridiumdifficile.

ChartshowingreductioninC.diffnumbers

DHTarget InternalTarget Total cases Trustapportioned

42 40 38


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Methicillin-sensitive Staphylococcus aureus (MSSA)

TheTrustcontinuestoperformwellagainstnationaltargets.OurMSSAnumbersremainconsistentlylowandareinthebestperformingquartilenationally.

MRSA

UHCWdeclaredzeroMRSABacteraemiaattributedfor2015-2016.TheInfectionPreventionandControlTeamcontinuetoworkfurtheronaspectsofpracticetomaintainthis.


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Influenza and Norovirus

InfluenzalevelswerehighthisyearandstaffatUHCWmanagedthiswell,reducingpotentialharmtootherpatients.

Noroviruswasexperiencedatverylowlevels.UHCWhadnowardclosuresthisyearasagainstaffmanagedextremelywellandwesawonlyareaspartiallyclosedandverylimiteddisruptiontoservicedelivery.

WhenbenchmarkedagainstotherlargeacuteteachingTrustsUHCWperformswell,thetablebelowshowsTeachingHospitalComparisons–April-2015toMarch-2016:

TakenfromNationalMESSdatabase

Team innovation and research

UHCWInfectionPreventionandControlTeamhadfivepostersacceptedfortheInfectionPreventionSocietynationalconference.Onewasoverallwinnerandtwowererequestedtobesubmittedasarticlestoleadinghealthcarejournals.Oneotherposterwaschosentobeanoralpresentationattheconference.

DoctorCarolynDawson,PostDoctoralResearcherwasinvitedtoBraziltoattendtheprestigiousnovicehealthcareresearcherinternationalworkshop.Wecontinuetoworkwithotheragenciestoseeknovelsolutionstohealthcarerelatedissues.WehavebegunworkontheUrrghfactorresearchandtheWHOfivemomentsbehaviouralandeducationstudy.

The@uhcw_Inf_Contwitteraccountremainspopularwith2664followers.TheteamareinvolvedinteachingatBirminghamCity,andCoventryUniversities.


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3.5 Safeguarding Vulnerable Adults and Child Protection

TheSafeguardingTeamconsistsofaNamedNurseforChildProtection,aNamedNurseforSafeguardingVulnerableAdults,aSupportMidwifeandaSafeguardingAdministrator.Theteamisco-locatedandthisallowsforseamlesssafeguardingadviceandsupporttobeavailable.InMarch2016theSafeguardingTeamadvertisedaposttoincreasethecapacitytosupporttheAdultSafeguardingAgenda.Aposttoincreasetheteamcapacityinrelationtothechildren’sagendacommencedinMarch2016.

AdultSafeguardingTrainingatLevel1continuestobedeliveredviatheTrustinductionpackagethatallnewstaffarerequiredtoattend,withstaffrequiredtotakearefreshercourseeverythreeyears.Updatesareaccessedonline,orareavailableasbespokefacetofacesessionsuponrequest.Thereisnowane-LearningpackageforAdultSafeguardingTrainingatLevel2whichcanbeaccessedonlineviatheElectronicStaffRecord.

TheteamprovidesafulldayofSafeguardingTrainingonceamonthwhichhasevaluatedverypositively,andcoversthefollowingareas:

• Mentalhealthawareness• Mentalcapacity• DeprivationofLibertySafeguards(DoLS)• Theuseofrestraint• ThePREVENTAgenda• Domesticviolence

ThisparticularsessionisdeliveredatLevel3(childprotection).ThistraininghasbeenavailablesinceJanuary2015,andthereisamonthlyrollingprogrammeinplace.

TrainingcomplianceforLevel1(adults)hasrisenfrom85.29%inApril2015to90.22%inFebruary2016.TrainingcomplianceforLevel2(adults)hasrisenfrom86.14%inApril2015to92.94%inFebruary2016.Thismeetsthe90%compliancetargetsetforLevel1and2trainingwhichwassetbytheCoventryandRugbyClinicalCommissioningGroupthisyear.

PREVENT Training

PREVENTtrainingformspartoftheGovernment’sagendatopreventvulnerablepeoplebeingdrawnintoterrorism.The

GovernmenthasoutlinedadutythatallhealthworkerswillreceivePREVENTtraining.ThistrainingisbeingdeliveredbytheNamedNurseforSafeguardingAdults,whoisalsoaTraintheTrainerinPREVENT.ThereareplanstocreateaninternalpooloftrainersthatcanalsosupportwiththedeliveryofPREVENT.Atpresent42.56%ofstaffhavereceivedthistrainingandthenumberisincreasingsteadilymonthbymonth.ThetrainingisincludedintheSafeguardingTrainingDayandthereareplansforittobeincludedinthemandatorytrainingsuite.

RaisingawarenessofthehealthsectorcontributiontothePREVENTstrategyamongsthealthcareworkersiscrucial.TheNHSisoneofthebestplacedsectorstoidentifyindividualswhomaybegroomedinterroristactivity,with1.3millionpeopleemployedbytheNHSandafurther700,000privateandcharitablestaffdeliveringservicestoNHSpatients,wehave315,000patientcontactsperdayinEnglandalone.Staffmustbeabletorecognisesignsofradicalisationandbeconfidentinreferringindividualswhocanthenreceivesupport.

Child Protection

Level2ChildProtectiontrainingisalsodeliveredatTrustInduction.Updatesareavailableonline,orasbespokesessions,uponrequest.CompliancewithLevel2trainingattendancehasrisenfrom79.43%inFebruary2014to92.16%inJanuary2016.ThecohortofstaffrequiringLevel3childprotectioncompetenceshasbeenincreased.Thishasresultedinadecreaseinthecompliancefigures;however,atrainingstrategyisinplace,whichwilladdressthis.Priortothecohortbeingincreased,Level3compliancewasat94.42%.WorkingTogethertoSafeguardChildren(2015)andtheIntercollegiateDocument(2014)havebothbeenincor-poratedintorelevanttraining.

ForthosestaffthatrequireLevel3training,theyareencouragedandsupportedtoattendtrainingsessionsprovidedbytheCoventrySafeguardingChildrenBoard.Inaddition,UHCWdeliversLevel3trainingeventstowhichbothmulti-agencyandmulti-disciplinarydelegatesareinvited.

UHCWaverages47referralstochildren’ssocialcareeachmonth.Ofthesemorethanhalfresultinsomesocialcareactivityi.e.meetingsorassessment.Mostreferralstosocialcarearesubmittedbycommunitymidwives.


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Thisisinlinewithnationaldata.Regularauditsareundertakentoensurethatpracticeisinlinewithpolicy.ArecentSafeSleepAuditdemonstrat-edthereis100%compliance.Forthcomingauditsincludebothsingleagencyandmulti-agencyactivity.AUHCWFemaleGenitalMutilationAuditisdueinApril2016andaDomesticViolenceAuditisdueinMay2016.

BothNamedNursessupporttheirrespectiveSafeguardingBoardsubgroupsandremaincommittedtostrengtheningtheworkwithintheorganisation.Support,adviceandguidancearerequiredbystaffonadailybasisandparticipationinprofessionaldevelopmentwithstudentsisalsooffered.Learningeventsareorganisedfollowingseriouscasereviewsandsafeguardingincidentsandthisissharedwiththerelevantteamsanddepartments.Lessonslearntaredisseminatedtoallrelevantstaffandappropriatechangestopractice are introduced.

TherehasbeensignificantresourcecommittedtothecreationandsupportofthelocalMultiAgencySafeguardingHub(MASH)andtheChildSexualExploitation(CSE)agendaandmulti-agencyresponse.

3.6 Medical Revalidation

MedicalRevalidationisastatutoryrequirementbywhichlicenseddoctorsmustdemonstratetheyareup-to-dateandfittopractiseprovidinggreaterassurancetopatients,thepublic,employersandotherhealthcareprofessionals.

Itisbasedprimarilyontheoutcomeofannualappraisalthroughadoctor’sformallink(prescribedconnection)withanorganisation,knownasadesignatedbody.EachdesignatedbodyhasaResponsibleOfficer(RO)whoisresponsibleforensuringprocessesareinplacetosupportmedicalappraisalandrevalidationalongwithsubmittingrecommendationstotheGeneralMedicalCouncil(GMC).ForUHCWthisisChiefMedicalOfficer,ProfessorMeghanaPandit.Todateshehasmaderecommendationstorevalidate464oftheTrusts589prescribedconnections.

InApril2014NHSEngland(NHSE)introducedtheFrameworkforQualityAssurance(FQA)toprovideguidancewithregardstoqualityassessingtherevalidationandappraisalprocess.WiththistheTrustisobligatedtoprovideQuar-terlyAppraisalRates(QAR)toNHSE.TheTrust

mustprovideNHSEnglandwithassuranceofitsappraisalratesonaquarterlybasis.Percentagesreportedbelowfortheappraisalyear1stApril2015-31stMarch2016reflectsthosewhohavesuccessfullycompletedandthosewheretheROacceptsthatappraisalpostponementwasreasonable:

• Quarter1–86%• Quarter2–75%• Quarter3–81%• Quarter4–90%

Forthelastquarter(1stJanuary–31stMarch2016)217appraisalsdue,119doctorsdidnotholdanappraisalmeetinginthisperiod.14haveavalidreasonforpostponement(e.g.sickleave,maternity,etc.)53werestillwithinthe15monthwindowand8havesincelefttheTrust.Overall423appraisalswerecompletedthisyearmeaningcompliancewasat83%.

Achievementstostrengthenandstandardisetherevalidationandappraisalprocessmadeduringthisyearinclude:

• TheuseofMedicalPracticeInformation Transfer(MPIT)formwentliveinHuman Resources(HR)inAugust2015tomeet requirement1.1.5oftheCoreStandards laidoutintheFQA.

• Deliveryoffivein-houseappraiser top-uptrainingsessionstoretrain44 appraiserswhofirstcompletedacourse in2012,sincethereisaneedfor trainingtobeupdatedona3yearly basis.Thisalongwiththedeliveryof twonewmedicalappraiser trainingsessionshasmaintainedthe Trustsappraisertoappraiseratio. Therearecurrently96trainedappraisers intheTrust.

• NHSEIndependentVerificationVisit– RepresentativesfromNHSERegional MedicalDirectorate(Midlands&East) visitedtheTruston4thMarch2016to undertakeareviewofprocesses thatsupportMedicalRevalidation. Initialfeedbackwaspositivehoweverwe arestillawaitingformalfeedbackinthe formofareportandactionplan,which willbeimplementedintotheactionplanto TrustBoard.


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InadditiontoanythinghighlightedbytheNHSEVisitandtofurthercontinueprogresstheTrustsobjectivesfor2016/2017inrelationtomedicalappraisalandrevalidationareto:

• Ensureeducationalappraisalshavebeen undertakenbyallnamedEducationaland ClinicalSupervisorstofacilitateformal approvalwiththeGMC.

• Increaseappraisalrateswithbetter utilisationofRMSreportfunctions andsharingofinformationwithGroupsto ensuretimelycaptureofbreached appraisals.UHCWwillcontinuetowork toembedrevalidationacrossthe Trusttoensureitisviewedasatool bywhichdoctorscanreflectonand developtheirpractice,andthusdeliver ahigherqualityofcaretopatients. Goingforward,wewillcontinuetoassess ourselvesagainsttheFQAinorderto strengthenourprocessesfurther.

3.7 Equality, Diversity and Human Rights

Equality,DiversityandHumanRightsisvitaltoensuringthatourpatientsreceivethemostappropriateandrelevantservicesandtreatmenttomatchtheirneeds.Itisalsokeytoaworkforcethatisreflectiveofthecommunitiesthatitservesandabletorespondtothoseneeds.

AspertherequirementsoftheEqualityAct2010,allrelevantequalitydataispublishedannuallyontheTrust’swebsite,aswellasallpolicies,businesscasesandsignificantchangesintheTrustareassessedforimpactonprotectedcharacteristicgroups.

WenowhaveinplaceanumberofactivitiesandnewinitiativesthatnotonlyprogresstheEquality,DiversityandHumanRightsagendabutalsodemonstratesourabilitytobeexemplarsofbestpracticeandemployersofchoice.

Independent Advisory Group for Equality and Diversity (IAG)

TheIAGwassetupin2013andwearebothpleasedandencouragedbythecommitmentshowntothegroupbyitsmembers.Membershipofthegroupincludesrepresentationfrom:

• Healthwatch

• Coventry City Council

• HeartofEnglandCoventryCarer’sCentre

• TamarindCentre-BlackMentalHealth

• CoventryRefugeeandMigrantCentre

• Communityindividual(gay/lesbian community)

• Communityindividual(olderpeople)

• Grapevine(peoplewithphysical/sensory/ learningdisabilities)

• Patientrepresentative

• UHCWrepresentativesfrom: - PALS(PatientAdviceandLiaison Service) - Communications - Health Information Centre - ModernMatrons - WardManagers - Staffside - VolunteerServices - PatientExperience - FaithCentre

TheIAGhasfurtherstrengtheneditsinfluenceindevelopingpracticeandpoliciesthatpromoteEquality,DiversityandHumanRightsissuesforbothpatientsandstaff.


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Supporting Staff and Patients

TheEqualityandDiversityTeamandtheIAGhaveimplementedanddeliveredanumberoftrainingprogrammesandactivitiestodevelopknowledge,skillsandunderstanding.TheTeamhasworkedinpartnershipwithinternaldepartmentsandexternalagenciessupportingstafftobetterunderstandtheneedsofourpatientsandworkforce,makingrespectanddignitykeyelementsinallthattheydo.

Toachievethiswehave:

• Producedatrainingvideoinpartnership withtheVoluntaryServicesDepartment andPatientExperienceTeamtosupport staffwhenworkingwithblind/visually impairedanddeaf/hearingimpaired patients.

• Securedfundingtoprovideallwards witha‘Toolbox’containingresources thatwillenableblind/visuallyimpairedand deaf/hearingimpairedpatientstobe moreindependentandaccessimportant informationwhilststayinginhospital.

• DeliveredDignityatWorkTrainingtoover 300staff,furtherdevelopingtheir understandingofissuesthatcan negativelyimpactontheworking environment.

• Supportedseveraldepartmentsin developingtheirown‘StaffCharter’ settingouthowtheywillbehaveandtreat eachotherinlinewiththeTrust’svalues.

• ProvidedEqualityandDiversitytraining aspartoftheTrust’smandatorytraining programmeaswellotherbespoketraining programmes,suchasthementalhealth, mentalcapacityandrestraintday.

• Providedfeedbackregardingcultural menusforpatients.

• ConsultedwithCoventryRefugeeand MigrantCentretoidentifyspecificneeds/ issuesforrefugees,migrantsandasylum seekers.

• Organisedaseriesofactivitiesand eventsforNHSEquality,Diversity andHumanRightsWeekinMay2015.

ThisyearUHCWhasbeeninvolvedinthreekeyinitiativeswhichexemplifiesourcommitmenttomakingmeaningfulchangestoourpracticetoensuretrueengagementandaccessibilityformembersofourcommunityfromProtectedCharacteristicgroups.Theseinitiativesnotonlysupportourlocalagendabutalsoalignwithnationalaimstoaddressgapsandissuesastheyrelatetospecificgroups.

British Sign Language (BSL) Charter

OnThursday7May2015UHCWsigneduptotheBritishSignLanguageCharterataneventheldattheHenryFryCommunityCentre(CoventryDeafClub).Over100peopleattended,notonlyfromCoventryandthesurroundingareasbutfromotherpartsofthecountryincludingSheffieldandBristol.TheTrustwasthefirstpublicsectororganisationintheWestMidlandstocommittothecharterpledgingto:

• Ensureaccessfordeafpeopleto informationandservices.

• Consultwithourlocaldeafcommunityon aregularbasis.

AndtosupporttheBSLCharter,theE&DteaminconsultationwithCoventryDeafCommunityhasdeveloped a draft action plan.

(Fromlefttoright)MonicaMabbett(EqualityandDiversityAssistant),BarbaraHay(HeadofDiversity),AndyHardy(ChiefExecutiveOfficer),AndrewBlincow

(Coventry&WarwickshireAssociationfortheDeaf)LindaDay(Vice-ChairofBritishDeafAssociation),RobinAsh(BritishDeafAssociation)

TheChiefExecutiveOfficerandHeadofDiversitysignedonbehalfoftheTrust,theVice-ChairfortheBDAandarepresentativefromCoventryandWarwickshireAssociationoftheDeafsignedonbehalfoftheDeafcommunity.

TheChiefExecutiveOfficeralsotooktheopportunitytoengagewiththeDeafcommunitylisteningtotheirexperiencesandconsideringthepossiblesolutionsthatweresuggested.


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Changing Futures Together – Supported Internship Programme

UHCWhasworkedinpartnershipwithTheEmploymentSupportService(TESS),whichispartofCoventryCityCouncil’sEmploymentTeamtodevelopaSupportedInternshipProgrammeforyoungdisabledpeoplefromHerewardCollege.

ThisinitiativehasprovidedeightyoungpeoplewithlearningdisabilitiestheopportunitytocompleteworkplacementsinavarietyofdepartmentsandsettingsatUHCWduringtheninemonthprogramme.

TheInternsworkalongsidestaffandaresupportedbydedicatedJobCoaches/experiencedEmploymentAdvisors.Allinternsaretreatedinthesamewayasemployees,receivingafullinduction,occupationalhealthchecksandriskassessments.TheaimofSupportedInternshipistoenableInternstogainworkexperiencethroughon-the-jobtrainingandprovidethemwiththeskillsandknowledgerequiredforpaidemployment.Theyarealsoworkingtowardsanationallyrecognisedqualification.

TheInternstakeonvariousrolestosupportpatientcareeitheronthewards,administrationorfacilities.InstrivinginlinewiththeTogetherTowardsWorldClassorganisationaldevelopmentprogramme,thisprogrammestrengthensthesocialresponsibilitywehaveasoneofthelargestemployersinCoventryandWarwickshire.WorkforceRaceEqualityStandard(WRES)InApril2015theNHSEqualityandDiversityCouncil(EDC)introducedtheWREStoensureemployeesfromBMEbackgroundshaveequalaccesstocareeropportunitiesandreceivefairtreatmentintheworkplace.

UHCW’sWRESreportofSeptember2015identifiedanumberofareaswhereactionisre-quiredinordertoensurethatthesystemswe

haveinplacearerobustenoughtogatherthedatarequiredfortheWRESreportingtemplate.

AsmallworkinggrouphasworkedtogethertoensureajoinedupapproachandtodevelopaplanthatisbothachievableandprovidesrelevantandappropriateoutcomestomeettheneedsofourBMEstaff.

TheactionsidentifiedaredirectlyrelatedtotheWRESreportingtemplatebutalsosupporttheTrust’sTTWCprogrammeandtheTrust’sobjectivestobeanEmployerofChoiceandtoDeliverExcellentPatientCareandExperience.

3.8 Innovation to Improve Patient Care

Therearemanywaystotackleachallenge.TheUHCWInnovationTeamwascreatedtosupportstaffwiththeirideasforhowsomethingcanbedonedifferentlyandbetter.In2015-2016wecontinuedtoreceiveasteadyflowofstaffideaswith58ideasformallydisclosed.ApproximatelyhalfofthosehadIntellectualPropertywhichcouldpotentiallybeprotectedand/or exploited.

Examples of staff ideas:

Experience Innovation: Ideas for the way in which we interact, communicate and engage relevant audiences to enhance the delivery of our services.

TheTissueViabilityNurseswantedtodosomethingdifferentfor‘GlobalStopThePressureUlcerDay’inNovember2015.Wehelpedthemcreatea‘livinginstallation’usinglife-sizemock-upscenariosinthemainOutpatientswaitingarea.Thisformatwasfarmoreengagingthanjusthandingoutleaflets.

Product Innovation: Ideas for how new or existing devices and equipment could function and perform better to fill a clinical need.

Ashouldersurgeonhasdevelopedanideaforamodificationofthereverseshoulderimplantinanattempttoovercometheproblemofrestrictioninmotion.Havingfiledforapatent,wearenowincommercialisationnegotiationswiththemarketleaderinmusculoskeletalhealthcare.

Configuration Innovation: Ideas about creating superior processes, systems or networks by considering how they are best arranged or combined.


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Working with Radiology WorkingwithmembersoftheRadiologyDepartmenthelpedidentifyareasofhighestriskaswellaswhichactionswouldhavethehighestimpact,themajorityofwhichwereinformationtechnologyrelated.

Intellectual Property

Staffprovideanimportantsourceofideas,particularlyforsmall-scale,easy-to-implementinnovations.TheresponsibilitytoexploitIntellectualPropertywhichderivesfromstaffideaslieswiththeResearch,Development and Innovation Department.

During2015-16,wehaverevisedthe‘divisionofproceeds’elementoftheIntellectualPropertypolicytobemoreattractivetostaffintermsoftherevenuesharetheycouldreceiveiftheirideasturnintocommercialisedinnovation.

Innovation Hub

TheInnovationTeamhascreatedanaspirationalvisionofwhatanInnovationHubwithinUHCWwouldlooklike,includingwhowoulduseitandwhy,andwhatpartnershipsandout-comesitwouldaimtodeliver.WithcontinuedsupportfromChiefExecutiveOfficer,AndrewHardyasExecutiveSponsor,TrustBoardandChiefOfficers,implementationworkhasalreadybegunonmakingtheInnovationHubareality.AsoftlaunchisscheduledforJuly12016.

3.9 Patient Experience

TheTrust’srealtimefeedbacksystem,Impressions,hascontinuedtocapturefeedbackaboutitsservicefrompatients,relatives,carersandvisitors.Amongstthevarietyofquestions,thesurveyasksrespondentswhethertheyhadamainlygoodormainlybadimpressionoftheTrustanditsservices.Theresultsforthisquestionfor2015-2016areshownhere:


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TheTrustispleasedtonotethatthescoreswereconsistentlyinthe90%+range.Impressionsalsoasksrespondentstofeedbackintheirownwordsabouttheirexperiencesandsuggestionsforimprovements.Thesecomments/suggestionsaresenttorelevantmembersofstaffonadailybasisand,wherepossible/appropriate,actedupontodevelopservicesinlinewithwhatourpatientswant.

Friends and Family Test (FFT)

TheTrusthasimplementedtheFriendsandFamilyTest(FFT)inlinewithnationalguidanceandassuch,2015-2016hasbeenthefirstfullyeartoseeitusedthroughoutallitsservices.

PatientsrespondingtotheFriendsandFamilyTest,indicatedthehighestandlowestlevelsofsatisfactioninthefollowingelementsoftheTrust’sservices:

Highest:

• Staffrespecting[thepatient’s]privacyanddignity

• Stafftreating[thepatient]withkindnessandcompassion

• Feelingsafeinourcare

Lowest:

• Parking

• Thestandardoffoodanddrink

• Doingthingsontime

Inpatient and A&E National Comparison

ThefollowingtablesshowhowtheTrusthascomparednationallywithbothitsFFTrecommenderandresponseratesforbothInpatientsandA&E.Severalmeasureshavebeentakentoimproveresponseratesincluding:

• ThereinstatementoftheFFTImplementationGroupwithexpandedmembershiptoinclude broaderrepresentationfromstaffgroups.Itsprimaryremitistoensureresponseratesare maintained and improved.

• TheintroductionofFFTChampionsatawardanddepartmentallevelisbeingexplored.


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FFT Inpatient Experience Response Rate % by Month:

Month UHCW Figures National Figures ComparisonApr-15 25% 26% 1%↓May-15 24% 26% 2%↓Jun-15 29% 27% 2%↑Jul-15 26% 27% 1%↓Aug-15 24% 25% 1%↓Sep-15 26% 25% 1%↑Oct-15 25% 24% 1%↑Nov-15 27% 24% 3%↑Dec-15 23% 23% 0%↔Jan-16 26% 24% 2%↑Feb-16 28% 24% 4%↑Mar-16 24% 23% 1%↓


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FFT Inpatient Experience Recommender % by Month:

76%

78%

80%

82%

84%

86%

88%

90%

Rec

omm

ende

r %FFT A&E Experience Recommender % by Month

UHCWFigures NationalFigures

Month UHCW Figures National Figures ComparisonApr-15 91% 95% 4%↓May-15 90% 95% 5%↓Jun-15 90% 96% 6%↓Jul-15 91% 96% 5%↓Aug-15 91% 96% 5%↓Sep-15 92% 95% 3%↓Oct-15 91% 95% 4%↓Nov-15 90% 95% 5%↓Dec-15 90% 95% 5%↓Jan-16 89% 95% 6%↓Feb-16 92% 95% 3%↓Mar-16 89% 95% 6%↓


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FFT A&E Experience Response Rate % by Month:

0%2%4%6%8%10%12%14%16%

Res

pons

e R

ate

%FFT A&E Experience Response Rate % by Month


Month UHCW Figures National Figures ComparisonApr-15 13% 15% 2%↓May-15 13% 14% 1%↓Jun-15 14% 15% 1%↓Jul-15 15% 15% 0%↔Aug-15 14% 14% 0%↔Sep-15 13% 14% 1%↓Oct-15 14% 14% 0%↔Nov-15 13% 13% 0%↔Dec-15 14% 13% 1%↑Jan-16 14% 13% 1%↑Feb-16 14% 13% 1%↑Mar-16 13% 12% 1%↑


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FFT A&E Experience Response Rate % by Month:

76%

78%

80%

82%

84%

86%

88%

90%

Rec

omm

ende

r %FFT A&E Experience Recommender % by Month


Month UHCW Figures National Figures ComparisonApr-15 81% 88% 7%↓May-15 83% 88% 5%↓Jun-15 83% 88% 5%↓Jul-15 87% 88% 1%↓Aug-15 86% 88% 2%↓Sep-15 84% 88% 4%↓Oct-15 86% 87% 1%↓Nov-15 85% 87% 2%↓Dec-15 84% 87% 3%↓Jan-16 83% 86% 3%↓Feb-16 83% 85% 2%↓Mar-16 83% 84% 1%↓


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Maternity Friends and Family Test

Antenatal question:theTrustispleasedtonotethatfor10monthsitsrecommenderratewashigherthanthenationalaverage.

Birth question:theTrustispleasedtonotethatfor11monthsitsrecommenderratewashigherthanthenationalaverage.However,withtheexceptionofJune,JulyandAugust,itsresponseratewasbelowthisaverage.

Postnatal in hospital question:theTrustispleasedtonotethatfor10monthsitsrecommenderratewashigherthanthenationalaverage.

Postnatal in community question:theTrustispleasedtonotethatfor9monthsitsrecommenderratewashigherthanthenationalaverage.

Surveys undertaken as part of the national NHS Patient Survey Programme

Duringthe2015-2016,theresultsofthreenationalpatientsurveyswereundertaken/receivedaspartoftheCareQualityCommission’sNHSPatientSurveyProgramme:theannualInpatientSurvey,MaternityServicesSurveyandthefirstChildrenandYoungPeople’sSurvey.

WhilsttheTrustispleasedtonoteasignificantimprovementinthescoresinalargenumberofquestionsintheMaternityServicesSurvey,theresultsofitsInpatientSurveyremainmixed.TheTrustisalsodisappointedtonotethat,consistentwiththenationalpicture,theresponserateforwithitsfirstnationalChildrenandYoungPeople’sSurveyislow.

Analysisofallthesurveysundertakenduring2015-2016allowstheTrusttoconclude:

Patient,relativeandcarersatisfactionlevelsremaininghighparticularlywithstaffrespectingpatients’privacyanddignity,treatingpatientswithkindness,compassion,politenessandrespect.

Therecontinuestobehighlevelsofdissatisfactionwithparking,timeliness(e.g.waitingfortestresultsorTTOs–ToTakeOuts)andfoodanddrink.

You said we did in 2015-2016

InlinewiththeTrust’svisiontobecomeanationaland international leader in healthcare and our organisationaldevelopmentprogrammetoprovideaworldclassexperienceforourpatients,during2015-2016,theTrusthascontinuedtolistenandactupontheviewsofitspatients,relativesandcarers.Baseddirectlyonthisfeedback,areasanddepartmentshavecarriedoutthefollowinginthepast12months:

Hello My Name Is Campaign:ThenationalandinternationalHelloMyNameIscampaignwaslaunchedasaTrustwideAlwaysEventremindingallstafftoalwaysintroducethemselvestopatients.

Parking:AtUniversityHospital,onandoffsitedevelopmentshavecontinuedwiththecompletionoftheredesignoftheoff-sitepinchpointsincludingtheroundaboutatthejunctionattheAnstyRoad/HinckleyRoad/CliffordBridgeRoad,theredesignofonsiteroadsalongwiththere-routingoftraffic.

Food and Drink:WorkhascontinuedwithISS,ourPFIpartner,toimprovethemenuandthewayinwhichfoodorderingiscarriedoutacrosstheTrust.AmenureviewresultedinnewmenusbeingintroducedinApril2015withagreatermeal/snackchoiceandtheimplementationofasevenday menu cycle.

Increase in Birthing Partners:Inresponsetorequestsfromwomen,twobirthingpartnersarenowallowed.

WiFi access:WiFiaccessisnowavailableforpatientsattheHospitalofSt.Cross.


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Complaints

During2015-2016wereceived574formalcomplaints.

83%ofthe574complaintswererespondedtowithin25workingdaysofreceiptofthecomplaint.

40%ofthecomplaintsrespondedtoatthetimeofreportingwereupheld.Therearestillthree complaintsreceivedin2015-2016thatareyettobeanswered.

Parliamentary and Health Service Ombudsman (PHSO)

• Newrequestsreceivedin2015-2016–25

• ThePHSOdecided15complaintsin2015-2016–sevenpartiallyupheldandeightnotupheld.

Thetop5subjectsofcomplaint

ForfurtherinformationaboutcomplaintspleaseaccesstheComplaintsandPALSAnnualReportontheTrust’swebsite:www.uchw.nhs.uk.

Totalnumberofcomplaints

2011/12 2012/13 2013/14 2014/15 2015/16

UniversityHospitalCoventry

450 431 459 457 537

HospitalofSt.Cross,Rugby

44 42 26 21 36

Other 3 10 5 0 1 TOTALS 497 483 490 479 574 ReferredtothePHSO 25 23 16 14 25 Ratioofcomplaintstoactivity

911,206 914,700 966,763 900,392 997,149 0.05% 0.05% 0.05% 0.05% 0.06%

Allaspectsofclinicaltreatment 331

Communication/informationtopatients(writtenandoral) 107

Attitudeofstaff 58

Failuretofollowagreedprocedure 4

Admissions,dischargeandtransferarrangements 40


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3.10 PLACE (Patient Led Assessment of the Care Environment)

TheTrusthasagainachievedsatisfactoryresultscomparedtoother(PrivateFinanceInitiative)PFIhospitalsofsimilarsize:

Site Year Cleanliness Food - Overall

Food – Ward

Food- Organisation

Privacy Dignity and Wellbeing

Condition, Appearance and Maintenance

UniversityHospital

2014 98.17% 88.13% 89.96% 77.37% 97.74% 93.07%

2015 100.00% 95.24% N/A* N/A* 94.58% 97.45%

HospitalofStCross

2014 99.47% 86.19% 92.51% 76.53% 91.15% 96.12%

2015 100.00% 88.97% N/A* N/A* 92.75% 96.15%

NationalAverageAcute/Specialist

2014 97.26% 88.79% 89.1% 85.9% 87.73% 91.97%

NationalAverageAcute/Specialist

2015 97.57% 88.48% N/A* N/A* 86.02% 90.11%

*Duetochangesinscoringfor2015ascomparedto2014acomparisoncannotbedefined.TherearealsochangestothewaythePLACEauditswillbescoredin2016.

Thetableaboveshowsimprovementsinallareasacrossbothsiteswiththeexceptionofa3.16%reductionintheprivacyanddignityscoreattheUniversityHospital.Furtherworkwillbeundertakentobetterunderstandthedriversbehindtheseandappropriateactionundertakentoimprove.AcomparisonisalsoincludedtoshowthenationalaverageforAcute/SpecialistTrustsfor 2015

Althoughimprovementsweremadein2015-2016,aseriesofinitiativeswillbeadoptedacrosstheorganisationtoimprovePLACEauditscores,theseinclude:

• Cateringservices–theon-goingreview ofbothpatientandvisitorserviceswill continue.

• Regularfoodtastingsessionsare programmedforstaffandvisitorstotaste the patient menu food.

• Workcontinuestodevelopadecoration/ enhancedmaintenanceprogramto address:

- Publicspacesonatwiceyearlybasis- someareasfourtimesperyear,i.e.main entrancesandpublictoiletsdueto footfall. - EmergencyDepartmentbi-annually.- GeneralCriticalCareannually.- Ward50andtheRenalunitannually.- AshRenalunitannually.- OffsiteRenalUnitsannually.

UHCWworkedwithHealthwatchCoventrytoconsiderhowtostrengthenlayinvolvementinthePLACEassessmentprocessandensurethatmorelayassessorswereavailableforthenextroundtobalancetheassessmentteams.AworkshopwasrunbyLincolnDawkin,DirectorofEstatesandattendedbyHealthwatchvolunteers.ThisenabledvolunteerstobebriefedonthePLACEmethodology,howtorecordfindingsanddiscussionofhowbesttoorganisetheassessments.TheinputofVolunteerAssessorsisimperativewhencontributingtoimprovementstotheNHS.FollowingthissuccessfulworkshopthenumberofvolunteerPLACEAssessorsincreasedandnotificationhasbeenissuedforthe2016PLACEaudits.


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Site Access and Car Parking

Workhasbeenprogressingduring2015-2016withtheplannedon-siteimprovementstoaddressongoingcarparkingandcongestionissues.

PlanningpermissionwasgrantedinMay2013foraseriesofon-siteworks.Thefollowinghavebeencompleted:

• Anewtaxirank.

• Anewlargermainentrancepatientdrop offzone.

• Anupgradedbusinterchangefacilitythat willincreasecapacity.

• Modifiedroadandcarparkaccess layoutstoenablebettertrafficflow.

• Automatedcarparksignageindicating locationofavailablespaces.

Thereareafurthertwoelementswhicharebeingplannedtoincreasebothstaffandvisitorparkingandaredueforcompletionbytheendof2016.

Theseare:

• AnextensiontotheA&Edeckedcarpark.

• Anewraiseddecktoasectionofthecar parkbytheFacilitiesManagement(FM) Building.

Inconjunctionwiththeon-siteworks,asuccessfulapplicationwassubmittedtotheDepartmentofTransportwithCoventryCityCouncilfor£3.9moffundingtoaddressthepinchpointissuestojunctionsonroadsapproachingUniversityHospital.Theseworksarenowcompletedandconsistof:

• MajorenhancementstotheAnstyRoad/ CliffordBridgeRoadgyratoryjunction includingthemainhospitalsiteaccess.

• AdditionallanesattheAnstyRoad/Hall Lanecrossroadstoincreasevehicular capacityandrelievedelays,particularlyin WoodwayLane.

• Newpedestriancrossingfacilitiesatthe HinckleyRoad/BradeDriveroundabout.

3.11 Staff Experience

TheNHSStaffSurveyisundertakennationallybyallTrustsonanannualbasisandtakesplacebetweenthemonthsofOctoberandDecember.ThesurveyisusedtogaugethedegreeofstaffengagementandidentifytheeffectsofthefourstaffpledgeswithintheNHSConstitution.

Staff Pledges

ThefourstaffpledgescontainedintheNHSconstitutionare:

Staff Pledge 1:Toprovideallstaffwithclearrolesandresponsibilitiesandrewardingjobsforteamsandindividualsthatmakeadifferencetopatients,theirfamiliesandcarersandcommunities.

Staff Pledge 2:Toprovideallstaffwithpersonaldevelopment,accesstoappropriatetrainingfortheirjobsandlinemanagementsupporttoenablethemtofulfiltheirpotential.

Staff Pledge 3:Toprovidesupportandopportunitiesforstafftomaintaintheirhealth,well-beingandsafety.

Staff Pledge 4:Toengagestaffindecisionsthataffectthemandtheservicestheyprovide,individually,throughrepresentativeorganisationsandthroughlocalpartnershipworkingarrangements.Allstaffwillbeempoweredtoputforwardwaystodeliverbetterandsaferservicesforpatientsandtheirfamilies.


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2015 National Staff Survey

The2015NHSStaffSurveyinvolved297NHSorganisationsinEngland,withover741,000NHSstaffbeinginvitedtoparticipateusingaself-completionpostalquestionnairesurveyorelectronicallyviaemail.

Allfull-timeandpart-timestaffdirectlyemployedbyUHCWonSeptember1st2015wereeligibletoparticipateinthesurveythatwascarriedoutbetweenmid-Septemberand30thNovember2015.2015sawtheTrustutilisethenewlyintroducedoptionofelectronicsurveys,sodependingontheirstaffgroup,850randomlyselectedstaffweresenteitherapapercopyofthesurveyoralinktotheonlinesurveyviaemail.QualityHealth,ournationalstaffsurveyadministrator,sentthesurveysandemailsalongsidealetterfromourChiefExecutiveOfficerandremindercopiesofthesurveyandemails,forthosewhohadnotreturnedtheirsurveywithinafourweekperiod.

Response rate

TheTrust’sresponseratehasimprovedslightlythisyearto39%(332staff),anincreaseof2%from2014,althoughbelowthenationalaverageforAcuteTrust’swhichwas41%.ThenationalaverageforAcuteTrustshasslightlyfallenfrom42%in2014.

Engagement Score

Overallourengagementscore,measuredonascaleof1(poorlyengaged)to5(highlyengaged)calculatedusingtheresponsetoseveralofthesurveyquestions,standsat3.91.

Thisisanincreasefrom3.78in2014andisabovethenationalaverageforAcuteTrustswhichstandsat3.79.Onanationalscale,theoverallstaffengagementindicatorhasincreasedslightlyfrom3.70(2014)to3.79(2015).

Acute Sector Comparisons

Aswellasreceivingourresponsedirectly,ourresponsesarecomparedtootherAcuteTrustsinEngland.Fromthiswecanidentifytheareaswhereweperformmostandleastfavorably.

TheNationalStaffSurveyprovidesuswithabaselinesetofdataandanindicationofwhereactionsshouldbefocused.However,theresultsshouldalsobetreatedwithcaution,giventhesmallnumberofrespondentsincomparisontoourstaffbody.


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Top Five Ranking Areas

Thedriversforthisimprovementonthismetricincludeimprovementsinstafffeelingtheyhavetheabilitytocontributetowardsimprovementatwork,thenumbersofstaffrecommendingtheTrustasaplacetoworkorforfriendsandfamilytobetreated,andtheextenttowhichstafflookforwardtogoingtoworkandareenthusiasticabouttheirroles.

Key

Positivefinding,increaseinscoredcomparedto2014

Negativefinding,decreasedinscorecomparedto2014

Becauseof changes to the format of the survey questions this year, comparisonswith the2014scorearenotpossible

Area 2015 UHCW Percentage Score or Scale Summary Score

2015 Acute Average Score

Percentageofstaffagreeingthattheirrolemakes a difference to patients / serviceusers

93% 90%

Recognition and value of staff bymanagersandtheorganisation

3.60

3.42

Staff satisfaction with resourcing andsupport

3.51 3.30

Percentage of staff appraised in last 12months 93%

86%

Percentage of staff reporting errors, nearmisses or incidents witnessed in the lastmonth

94% 90%


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Bottom Four Ranking Scores

Where Staff Experience Has Improved

Thetablebelowhighlightsthefivekeyfindingswherestaffexperienceshaveimprovedattheorganisationsincethe2014survey.

Area 2015 UHCW Percentage Score


Percentageofstaff /colleaguesreportingmostrecent experience of violence 41%

53%

Percentage of staff experiencing physicalviolencefrompatients,relativesorthepublicinthelast12months

16% 14%

Percentage of staff witnessing potentiallyharmful errors, nearmissesor incidents in thelastmonth

31% 31%

Percentage of staff experiencing harassment,bullyingorabusefrompatients,relativesorthepublicinthelast12months

28% 28%

Area 2015 UHCW Percentage Score or Scale Summary Score


Staffmotivationatwork 4.03

3.89

Effectiveuseofpatient/serviceuserfeedback 3.76

3.51

Supportfromimmediatemanagers 3.82

3.66

Percentageof staff experiencingdiscriminationatworkinthelast12months 10%

15%

Staff recommendation of the organizationas aplacetoworkorreceivetreatment 3.90

3.76


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Where Staff Experience Has Deteriorated

ThetablebelowhighlightstheoneKeyFindingthathasdeterioratedattheTrustsincethe2014survey.

StafffeedbackalreadyformsthebasisofactionsbeingundertakenundertheTogetherTowardsWorldClassprogramme.Therefore,adecisionhasbeentakennottocompleteseparateactionsplansfromtheNationalStaffSurveyresults.

However,ourresultshaveidentifiedthatfocusneedstobegiventotheTrust’sresponsetonotonlythepercentageofstaff/colleaguesreportingviolence,butalsotostaffexperiencingphysicalviolenceandaggression.Todate,therearenospecificactionsundertheTogetherTowardsWorldClassprogrammethatwouldaddressthisareathereforeseparateactionswillbeledintheareabytheTrust’sSecurityManager,withareportbeingprovidedtoQualityGovernanceCommitteeinMarch2016.

Staff Friends and Family Test

Background

Undertakeneverythreemonths,theStaffFriendsandFamilyTestasksstafftogivetheirfeedbackonhowlikelytheyaretorecommendtheTrusttofriendsandfamilyforcareortreatmentandhowlikelytheyaretorecommendtheTrustasaplacetowork.

TheTrustisobligedtoaskallstafftheStaffFriendsandFamilyTestquestionsonanannualbasis,withtheopportunitytoundertakewithidentifiedsamplesintheremainingperiods.

Furthermoreaspartofourcommitmenttomovetowardsgainingcontinuousstafffeedbackwehaveprovidedallstaffwiththeopportunitytocompletethequestionsonaquarterlybasis,withtheexceptionofQuarter3(September–November2015)whereresultsweregatheredthroughtheNationalStaffSurvey.

Staff Friends and Family – Service/ Treatment Provider

2015-2016 Results - “How likely are you to recommend our Trust to friends and family if they needed care or treatment?”

Area 2015 UHCW Percentage Score


Percentageofstaff /colleaguesreportingmostrecent experience of violence 41%

65%

Period Recommender Non-recommender Unsure

2015Qtr4(1371) 87% 4% 9%

2015 Qtr3(332) 76% 5% 18%

2015Qtr2(1655) 89% 3% 7%

2015Qtr1(288) 81% 7% 13%


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InQuarter3(throughtheNationalStaffSurvey)76%ofrespondentssaidtheywouldrecommendtheTrustasaplacetoreceivetreatment.WhilstthisisadecreasefromQuarter2(89%)weremainabovethenationalaverageof69%recommendingtheirTrust.

Staff Friends and Family – Workplace

2015-2016 Results – “How likely are you to recommend our Trust to friends and family as a place to work?”

InQuarter3(throughtheNationalStaffSurvey)68%ofsurveyrespondentssaidtheywouldrecommendtheTrustasaplacetoworkcomparedtoanationalaverage59%.

WhilstitisdisappointingtoseeareductioninthepercentageofrecommendersinQuarter3,itisimportanttonotethatthedifferentsurveymethodologiesusedacrossthequarters.Insummary,theNationalStaffSurveyisonlyreceivedbyarandomsampleof850staff,thereforerestrictingthoseinvolvedinrespondingtotheStaffFFTinQuarter3whilstinQuarter1andQuarter2allstaffhavehadtheopportunitytoparticipateprovidingawiderrepresentationofviews.TheresultsgainedinQuarter4throughStaffImpressionswillprovideanopportunitytofurtherreviewpatternsofrecommenders.

3.12 Performance against National Priorities 2015-2016

QualityandPatientSafetyIndicatorsgiveTrusts,Commissionersandthegeneralpublic,comparabledataonhowweareperforming.Becausetheindicatorsarestandardised,andhavetobemeasuredinspecificways,theyprovideanopportunityforperformancetobecomparedovertimeandacrosstheNHS.ThelocalindicatorsareagreedbytheTrustBoardandwhereappropriateagreedwithourCommissioners.ThebelowtableofindicatorsareoneswhereUHCWisrequiredtosubmitinformationnationally.

Period Recommender Non-recommender Unsure

2015Qtr4(1371) 71% 12% 16%

2015Qtr3(332) 68% 8% 24%

2015Qtr2(1655) 80% 8% 11%

2015Qtr1(288) 65% 17% 18%


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Indicators Target 2015/16

2015/16 2014/15 2013/14 Rating

CQCFundamentalStandards n/a Licensedwithout

conditions

Licensedwithout

conditions

Licensedwithout

conditionsMaximumtimeof18weeksfrom point of referral to treatmentinaggregate-patientsonaincompletepathway

92% 89.67% 88.10% 94.01%

Maximumtimeof18weeksfrom point of referral to treatmentinaggregate-admitted

90% 72.09% 75.13 91.84

Maximumtimeof18weeksfrom point of referral to treatmentinaggregate-non-admitted

95% 88.36% 94.41% 97.55%

A&E:maximumwaitingtimeoffourhoursfromarrivaltoadmission/transfer/discharge

95% 89.17% 90.37% 93.93%

Cancer:twoweekwaitfromreferraltodatefirstseen,comprising:allurgentreferrals(cancersuspected)

93% 96% 97.3% 94.41%

-forsymptomaticbreastpatients(cancernotinitiallysuspected)

93% 93% 98.8% 94.57%

Allcancers:31-daywaitfromdiagnosistofirsttreatment

96% 99.1% 99.3% 99.49%

Allcancers:31-daywaitforsecondorsubsequenttreatment,comprising:-surgery

94% 97% 98% 99.08%

-anticancerdrugtreatments 98% 100% 100% 100%

- radiotherapy 94% 96% 95.5% 95.80

Allcancers:62daywaitforfirsttreatmentfrom:-urgentGPreferralforsuspectedcancer

85% 82.7% 84.6% 85.01

-fromNHSCancerScreeningServicereferral

90% 93.7% 95.4% 95.92%

Performance against locally agreed priorities

*TheHSMRfigurefor2015/16isnotpublishedtotheTrustuntilJuly2016.


2015/16 2014/15 2013/14 Rating

NumbersofacquiredavoidablePressureUlcersIncidentreporting

Grade3:0Grade4:0

Grade3:21Grade4:0

Grade3:21Grade4:1

Grade3:16Grade4:0

Incidenceof‘NeverEvents’ 0 3 3 4

Hospitalstandardisedmortalityratio(HSMR)

100 * 109.18 104.84 Notyetrated

Delayedtransfersofcare 3.5% 6.67% 5.67% 4.37%

Breachesofthe28dayreadmissionguarantee

0 112 119 118

FriendsandFamilyTestinpatientrecommenders

89% 89.23% 90.82% n/a

FriendsandFamilyTestA&Erecommenders

85% 83.17% 81.9% n/a


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2015/16 2014/15 2013/14 Rating

ClostridiumDifficile-meetingtheClostridiumDifficileobjective

42 L38 41 47

Methicillin-resistantStaphylococcusAureus(MRSA)bacteraemia-meetingtheMRSAobjective

0 80 9 2

Certificationagainstcompliancewithrequiredaccesstohealthcareforpeoplewithlearningdisability

Green Green Green Green

Section 4An Invitation to comment and offer feedback

Your Views - Your Involvement

ThankyoufortakingthetimetoreadourannualQualityAccount.Wehopeyouhavefounditaninterestingandenjoyableread.IfyouwouldliketocommentonanyaspectofthisAccountorgiveusfeedbackonanyaspectofourservices,pleasewriteto:

Quality Department

UniversityHospitalsCoventryandWarwickshireNHSTrustCliffordBridgeRoadCoventryCV2 2DX

Youcanalsoshareyourviews:

• [email protected]

• byvisitingourwebsitewww.uhcw.nhs.ukandcompletingtheImpressionsSurveyor

• byvisitingNHSChoiceswebsiteatwww.nhs.uk

Welookforwardtohearingyourcommentsandsuggestions.


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ANNEXES

Statements from Partners

NHS Coventry and Rugby Clinical Commissioning Group Commentary

NHSCoventryandRugbyClinicalCommissioningGroup(CCG)welcometheopportunitytocommentonUniversityHospitalsCoventryandWarwickshireNHSTrust’s2015/16QualityAccount.TheCCGbelievethattheQualityAccountfor2015/16meetstherequiredcontentassetoutinnationalguidanceandisagoodreflectionofthequalityofservicesprovidedbytheTrust.Whilstnotalldatafieldswerecompleteinthedraftaccount,theCCGhasreviewedtheinformationpresentedagainstdatasourcesavailabletotheCCGaspartofcontractingandperformanceandcanconfirmthemasaccurate.

TheTrusthasexperiencedanumberofchallengesthisyear,thefirstbeinginrelationtotheachievementofAccidentandEmergencyfourhourwaitstargetwhichisalsorecognisedasachallengeforthemajorityofacutetrustsnationally.ThiswillcontinuetobeoneofthebiggestchallengestheTrustwillhaveoverthenextyear.ItwillrequireeffectivepartnershipworkingwithcommunityprovidersandsocialcarethroughtheSystemTransformationPlantosupportachievementofthistarget.AsaCCG,wewillensurepatientsremainsafethroughcontinuedassurancevisitstotheTrust.

Nationally,achievementof62DayCancerwaitsisalsoachallenge.Locally,theTrusthasundertakensignificantworktostreamlinecancerpathwaysandreduceunnecessarydelays.Thishasbeguntoshowimprovementsandweareoptimisticthatthiswillhaveapositiveimpactonachievementofthistargetinthecomingyear.Nationally,achievementof62DayCancerwaitsisalsoachallenge.Locally,theTrusthasundertakensignificantworktostreamlinecancerpathwaysandreduceunnecessarydelays.Thishasbeguntoshowimprovementsandweareoptimisticthatthiswillhaveapositiveimpactonachievementofthistargetinthecomingyear. Patientfeedbackisanimportantpartofmonitoringandserviceimprovement.WearepleasedwithhowtheTrusthasmadesignificantprogresshandlingandrespondingtocomplaints.TheTrust’sstrengtheningoftheirPALSServicehasmadeasignificantdifference.However,theTrusthasfurtherworktodoinordertoensurelearningandfeedbackfromcomplaintsistranslatedintopractice.ThiswillbeapriorityfortheTrustin2016/17.

During2015/16theTruststrengthenedtheirSafeguardingTeamandisplanningtoincreasecapacityfurtherin2016/17.Thisisextremelypositiveandweareconfidentthiswillenablethemtoachievetheirtrainingtargets.However,wearedisappointedthatthePREVENTAgendahasnotprogressedaswewouldhavehoped,asthisisakeynationalpriority.

Whilsttheendofyearpositionisnotavailableattimeofwriting,evidencetodateindicatestheTrusthasprogressedwellagainsttheirnationalCQUINsforDementia,DeliriumandAcuteKidneyInjury(AKI)for2015/16.However,wearedisappointedthattheTrusthasnotprogressedalocalCQUINinrelationtocommunicatingwithpatientsandGeneralPractitionerspostdischarge.WeseethisasakeyimprovementareaandwillworkwiththeTrustthisyear,withtheaimofexploringimprovementstrategies.

TheTrusthasexcellentMaternityServices,whohavelistenedtofeedbackfrompatientsandrespondedbyimplementinginnovativepractices.TheyhavealsosharedagapanalysiscompletedagainsttherecommendationswithinthenationalBetterBirthsReport.Theirfocusfor2016/17willbetofurtherstrengthenMaternityServicesthrougheffectivemulti-professionalpartnershipworking. PatientSafetyremainsapriorityfortheCCG.WearedelightedthattheTrustwassuccessfulsecuringaplaceonanationalprojectbeingpilotedbytheDepartmentofHealthtoworkalongsidetheVirginiaMasonInstitute.TheCCGfullysupportstheinitialworkstreamsthathavebeenidentifiedbytheTrust.TheseincludeOphthalmology,TheatresandSeriousIncidentreporting.


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WebelievethiscomplimentstheTrust’sparticipationinthenationalSignuptoSafetycampaign.ThisshouldhaveasignificantpositiveimpactintermsofpatientsafetyandwewillfollowtheTrust’sprogresswithgreatinterest.Inconclusion,werecognisethattheTrusthasmadegoodprogressinanumberofareasandcanconfirmthatwefullysupporttheprioritiesidentifiedbytheTrustfor2016/17.

UHCW Comment:

UHCWwouldliketothankourCommissionersfortheirresponsetothe2015-16QualityAccount.WearecommittedtoworkingeffectivelywithourpartnersinthecommunityandsocialcaretostrivetoachievetheAccidentandEmergencyfourhourwaittarget.TheTrustisinagreementthatfurtherenhancementsneedtotakeplaceinrelationtohowlearningfromcomplaintsandconcernsleadstoimprovementsinpatientexperience.WecontinuetolookforwardtoworkingwiththeCCGonanumberofprojectsin2016-17andwelcometheircontinuedsupportinhelpingtorealiseourvisionofbecomingWorldClass.

Joint Quality Account Task Group Commentary

TheQualityAccountTaskGroupismadeupofHealthwatchCoventry,HealthwatchWarwickshire,CoventryCityCouncilScrutinyandWarwickshireCountyCouncilScrutiny.TheGroupmetwiththeTrustanddiscussprogressonlastyear’sprioritiesandtodiscusswhatshouldbeincludedasprioritiesthisyear.OverallthisdocumentisclearandeasytoreadwithintheconstraintsforthetemplateinformationTrusts’mustusewhenwritingaqualityaccount.

Theversionwereceivedtoprovideourcommentarywasnotcomplete–withnationaldatarelatedtoNHSoutcomesandotherdatawasnotavailable.Thisyearmoredatawasunavailabletousthanhaspreviouslybeenthecaseandthiswasproblematic.

However,weknowfromourongoingworkthatthisyearamajorchallengeforUHCWandthewiderhealthandsocialcaresystemhasbeentheflowthroughthehospitalfromA&E,toadmissionandthroughtodischarge.Thehospitalisoperatingataveryfulllevelofbedoccupancy.ThishasbeenimpactingonA&EwaitingtimesandtheTrust’sabilitytoachievethe4hourtargetwhichhasbeenmissedforanumberofconsecutivemonths.Therehavealsobeenissuesregardingmeetingcancerreferralwaitingtimetargetsandotheroutpatientreferraltargetsduringthecourseoftheyear,whichimpactsonpatientsnegatively.

EffectivejointworkandplansacrossNHSandsocialcareorganisationsareneededinordertoaddressissueswithpatientflow.

Thestatedproposaltointroduceweekendandeveningphysiotherapyiswelcome.Itshouldaidrecoveryandthedischargeprocess,althoughthereisnoindicationthatoutcomesaretobemeasured.

ItispleasingthatUHCWhavereversedpreviousincreasesincasesofMRSAandthefocusonOphthalmologyoutpatientsthroughtheTrust’sVirginiaMasonworkiswelcomeasthisreflectsfeedbackreceivedbyHealthwatch.

ThesectionoutliningresponsestotheCQCinspectionreportof2015wouldbenefitfrommoredetailaboutwhatactionstheTrusthastakentoaddressthepointshighlightedbytheCQCforexampleintheimagingdepartment.

Last year’s priorities

Priority1:Handover–ThisseemstobeworkinprogressacrosswhatisalargeTrust,whereconsistencyofuseofthetoolsdevelopedisimportant.

Priority2:EndofLifecare-FromtheinformationprovideditseemsthatalotofgoodworkhasbeendoneregardingEndofLifeCare.


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Priority3:Alwaysevents-DuringtheyeartherehasbeenachangeandfocusingoftheoriginalgoalsetlastyearofimplementingAlwaysEvents.TheHellomyNameIsinitiativeispositiveandchimeswithpatientfeedbackbutitisunclearhowextensivetheadoptionhasbeenacrosstheTrust.

Thereisanopportunitytoworkwithpatientsandrelativestoestablishabroadersetofpatientfocusedalwaysevents.

2016/17 Priorities

TheQualityAccountTaskGroupprovidedfeedbackonalonglistofpotentialqualityprioritiesandprovidedchallengeaboutsettingprioritieswhicharesufficientlychallenginganddonotreplicateexistingworkplansforexamplerelatedtotheTrust’sCQCinspectionin2015.Wefeelwehavebeenpartlysuccessfulinthis.

Priority1:IncreasingthereportingofmedicationerrorsTheinformationprovidedaboutthisgoalisclearandwellevidencedwithaclearmeasurementinplace.

Priority2:ImprovingcarebundlecomplianceThereismuchevidencetosupporttheimplementationofcarebundlesandanexpectationthatTrustswilldoso(hencetheCQUINtargetsalreadyinplace).Thereforeisseemsthatthispriorityistoacertainextentbusinessasusual.

Priority3:CareContactTimeTherecordingsystemdescribedise-basedandtheredoesnotseemtobeanelementofpatientfeedback.Thismakesthispriorityseemtobeabouttimeuseefficiencyratherthanpatientcontact.Whilstefficientandeffectivecareisimportantthisisapatientexperiencepriorityandthereforeshouldcapture an element of patient experience.

Other issues

Pressureulcersarethe1stand3rdhighestseriousincidentseventhoughtherehasbeenawidespreadpressureulcerpreventioncampaignoverlastcoupleofyears.Slipstripsandfallsrepresentthe2ndlargestnumberofseriousincidentsandthereforewouldbenefitfromdetailabouthowtheTrustwillworkonthis.

ItisgoodtoreaddetailsofworkrelatedtodementiaawarenessandthecommitmentfromtheTrusttoaddressingcareforpatientswhohavedementia.Thetrustissizeableandthereforethereisalargeongoingtaskoftrainingstaffwhichrequiresresourcing.

Carer’sofDementiapatientshaveasupportgroupaswellascompletingacarerssurvey.Thisideacouldbeextendedtothecarersofpatientsmoregenerally.

Communicationissueswithdeafpatients,peoplewithlearningdisabilityandpeoplewithEnglishasasecondlanguagehavebeenflaggedtoHealthwatch.Theworktodevelopresources,supportforstaffandsignuptotheBSLCharterarewelcomeandshouldbebuiltuponfurther.ThereisabigemphasisinthedocumentonFriendsandFamilyTestdataandlessinformationaboutotherTrustinitiativestogatherpatientexperienceortocarryoutdifferentlevelsofpatientengagementactivity.WewouldhavelikedtoseeacommitmenttodevelopingtheTrust’spatientengagementstrategywithinthisdocument.

TheTrustisclearlycarryingoutsignificantworkrelatedtoquality,howevermuchofthisisdrivenfrommanagementorotherinitiativesandthereisscopefordevelopingpatientinvolvementandengagementtodrivechangesandquality.ThiswillenabletheTrusttobeinabetterpositiontoinvolvepatientsandthepublicinthequalityaccountandsettingprioritiesforquality.


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Thecomplaintsdatawasnotavailabletousatthetimeofwriting.Fornextyearwewouldliketoseetheemphasisshifttoafocusonlearningfromcomplaints.

WelookforwardtocontinuingtoworkwiththeTrustinthecomingyear.

UHCW comment:

WewelcometheresponsefromtheJointQualityAccountTaskGroup.TheTrustagreesthateffectivejointworkingandplansacrossNHSandsocialcareorganisationsisrequiredtomeetthechallengesaroundpatientflowthroughthehospitalandUHCWarecommittedtothis.TheTrustwouldliketoworkfurtherwithHealthwatchinfurtherdevelopingourpatientinvolvementandengagementstrategyandwelookforwardtoworkingwiththeJointTaskGroupagainin2016-17.


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Statement of Directors’ Responsibilities in respect of the Quality Account

The directors are required under the Health Act 2009 to prepare a Quality Account each financial year. The Department of Health has issued guidance on the form and content of the Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the National Health Service (Quality Accounts) Regulations (as amended by the National Health Service (Quality Accounts) Amendment Regulations 2011 and the National Health Service (Quality accounts) Amendment Regulations)

InpreparingtheQualityAccount,directorsarerequiredtotakestepstosatisfythemselvesthat:

• theQualityAccountpresentsabalancedpictureoftheTrust’sperformanceovertheperiod covered;• theperformanceinformationreportedintheQualityAccountisreliableandaccurate;• thereareproperinternalcontrolsoverthecollectionandreportingofthemeasuresof performanceincludedintheQualityAccount,andthesecontrolsaresubjecttoreviewto confirmthattheyareworkingeffectivelyinpractice;• thedataunderpinningthemeasuresofperformancereportedintheQualityAccountisrobust andreliable,conformstospecifieddataqualitystandardsandprescribeddefinitions,andis subjecttoappropriatescrutinyandreview;and• theQualityAccounthasbeenpreparedinaccordancewithDepartmentofHealthguidance.

ThedirectorsconfirmtothebestoftheirknowledgeandbelieftheyhavecompliedwiththeaboverequirementsinpreparingtheQualityAccount.

ByorderoftheBoardNB: sign and date in any colour ink except black


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External Auditors

Independent Auditors’ Limited Assurance Report to the directors of University Hospitals Coventry and Warwickshire NHS Trust on the Annual Quality Account

WearerequiredtoperformanindependentassuranceengagementinrespectofUniversityHospitalsCoventryandWarwickshireNHSTrust’sQualityAccountfortheyearended31March2016(“TheQualityAccount”)andcertainperformanceindicatorscontainedthereinaspartofourwork.NHStrustsarerequiredbysection8oftheHealthAct2009topublishaQualityAccountwhichmustincludeprescribedinformationsetoutinTheNationalHealthService(QualityAccount)Regulations2010,theNationalHealthService(QualityAccount)AmendmentRegulations2011andtheNationalHealthService(QualityAccount)AmendmentRegulations2012(“theRegulations”).

Scope and subject matter

Theindicatorsfortheyearended31March2016subjecttolimitedassuranceconsistofthefollowingindicators:

• FriendsandFamilyPatientElementScore;and• Percentageofpatientsriskassessedforvenousthromboembolism.

Werefertothesetwoindicatorscollectivelyas“theindicators”.

Respective responsibilities of the Directors and the auditor

TheDirectorsarerequiredundertheHealthAct2009toprepareaQualityAccountforeachfinancialyear.TheDepartmentofHealthhasissuedguidanceontheformandcontentofannualQualityAccounts(whichincorporatesthelegalrequirementsintheHealthAct2009andtheRegulations).

InpreparingtheQualityAccount,theDirectorsarerequiredtotakestepstosatisfythemselvesthat: • theQualityAccountpresentsabalancedpictureofthetrust’sperformanceovertheperiod covered; • theperformanceinformationreportedintheQualityAccountisreliableandaccurate;• thereareproperinternalcontrolsoverthecollectionandreportingofthemeasuresof performanceincludedintheQualityAccount,andthesecontrolsaresubjecttoreviewto confirmthattheyareworkingeffectivelyinpractice;• thedataunderpinningthemeasuresofperformancereportedintheQualityAccountisrobust andreliable,conformstospecifieddataqualitystandardsandprescribeddefinitions,andis subjecttoappropriatescrutinyandreview;and• theQualityAccounthasbeenpreparedinaccordancewithDepartmentofHealthguidance.

TheDirectorsarerequiredtoconfirmcompliancewiththeserequirementsinastatementofdirectors’responsibilitieswithintheQualityAccount.

Ourresponsibilityistoformaconclusion,basedonlimitedassuranceprocedures,onwhetheranythinghascometoourattentionthatcausesustobelievethat:

• theQualityAccountisnotpreparedinallmaterialrespectsinlinewiththecriteriasetoutinthe Regulations;• theQualityAccountisnotconsistentinallmaterialrespectswiththesourcesspecifiedinthe NHSQualityAccountsAuditorGuidance(“theGuidance”);and• theindicatorsintheQualityAccountidentifiedashavingbeenthesubjectoflimitedassurance intheQualityAccountarenotreasonablystatedinallmaterialrespectsinaccordancewiththe RegulationsandthesixdimensionsofdataqualitysetoutintheGuidance.


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WereadtheQualityAccountandconcludewhetheritisconsistentwiththerequirementsoftheRegulationsandtoconsidertheimplicationsforourreportifwebecomeawareofanymaterialomissions. WereadtheotherinformationcontainedintheQualityAccountandconsiderwhetheritismateriallyinconsistentwith: • BoardminutesfortheperiodApril2015toJune2016;• papersrelatingtoqualityreportedtotheBoardovertheperiodApril2015toJune2016;• feedbackfromtheCommissionersdated25/05/2016;• feedbackfromLocalHealthwatchdated07/06/2016;• theTrust’scomplaintsreportpublishedunderregulation18oftheLocalAuthority,Social ServicesandNHSComplaints(England)Regulations2009,dated30/06/2016• feedbackfromothernamedstakeholder(s)involvedinthesignoffoftheQualityAccount;• thelatestnationalpatientsurveydatedFebruary2016;• thelatestnationalstaffsurveydatedFebruary2016;• theannualgovernancestatementdated01/06/2016;• theCareQualityCommission’sIntelligentMonitoringReportdatedMay2015.

Weconsidertheimplicationsforourreportifwebecomeawareofanyapparentmisstatementsormaterialinconsistencieswiththesedocuments(collectivelythe“documents”).Ourresponsibilitiesdonot extend to any other information.

Thisreport,includingtheconclusion,ismadesolelytotheBoardofDirectorsofUniversityHospitalsCoventryandWarwickshireNHSTrust. WepermitthedisclosureofthisreporttoenabletheBoardofDirectorstodemonstratethattheyhavedischargedtheirgovernanceresponsibilitiesbycommissioninganindependentassurancereportinconnectionwiththeindicators.Tothefullestextentpermissiblebylaw,wedonotacceptorassumeresponsibilitytoanyoneotherthantheBoardofDirectorsasabodyandUniversityHospitalsCoventryandWarwickshireNHSTrustforourworkorthisreportsavewheretermsareexpresslyagreedandwithourpriorconsentinwriting.

Assurance work performed

WeconductedthislimitedassuranceengagementunderthetermsoftheGuidance.Ourlimitedassuranceproceduresincluded:

• evaluatingthedesignandimplementationofthekeyprocessesandcontrolsformanagingand reportingtheindicators;• makingenquiriesofmanagement;• testingkeymanagementcontrols;• limitedtesting,onaselectivebasis,ofthedatausedtocalculatetheindicatorbackto supportingdocumentation;• comparingthecontentoftheQualityAccounttotherequirementsoftheRegulations;and• readingthedocuments.

Alimitedassuranceengagementisnarrowerinscopethanareasonableassuranceengagement.Thenature,timingandextentofproceduresforgatheringsufficientappropriateevidencearedeliberatelylimitedrelativetoareasonableassuranceengagement.


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Limitations

Non-financialperformanceinformationissubjecttomoreinherentlimitationsthanfinancialinformation,giventhecharacteristicsofthesubjectmatterandthemethodsusedfordeterminingsuchinformation.

Theabsenceofasignificantbodyofestablishedpracticeonwhichtodrawallowsfortheselectionofdifferentbutacceptablemeasurementtechniqueswhichcanresultinmateriallydifferentmeasurementsandcanimpactcomparability.Theprecisionofdifferentmeasurementtechniquesmayalsovary.Furthermore,thenatureandmethodsusedtodeterminesuchinformation,aswellasthemeasurementcriteriaandtheprecisionthereof,maychangeovertime.ItisimportanttoreadtheQualityAccountinthecontextofthecriteriasetoutintheRegulations. Thenature,formandcontentrequiredofQualityAccountsaredeterminedbytheDepartmentofHealth.Thismayresultintheomissionofinformationrelevanttootherusers,forexampleforthepurposeofcomparingtheresultsofdifferentNHSorganisations.

Inaddition,thescopeofourassuranceworkhasnotincludedgovernanceoverqualityornon-mandatedindicatorswhichhavebeendeterminedlocallybyUniversityHospitalsCoventryandWarwickshireNHSTrust.

Conclusion

Basedontheresultsofourprocedures,nothinghascometoourattentionthatcausesustobelievethat,fortheyearended31March2016:

• theQualityAccountisnotpreparedinallmaterialrespectsinlinewiththecriteriasetoutinthe Regulations;• theQualityAccountisnotconsistentinallmaterialrespectswiththesourcesspecifiedinthe Guidance;and• theindicatorsintheQualityAccountsubjecttolimitedassurancehavenotbeenreasonably statedinallmaterialrespectsinaccordancewiththeRegulationsandthesixdimensionsof dataqualitysetoutintheGuidance.

KPMGLLPOneSnowhillSnowHillQueenswayBirminghamB46GH 30June2016


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Appendices Appendix 1

CQUIN Schemes 2015-2016

TheCQUINframeworkwasintroducedinApril2009asaNationalFrameworkforlocallyagreedqualityimprovementschemes.Itenablescommissionerstorewardexcellencebylinkingaproportionofhealthcareprovider’sincometotheachievementoflocalqualityimprovementgoals.TheFrameworkaimstoembedqualitywithincommissioner-providerdiscussionsandtocreateacultureofcontinuousqualityimprovement,withstretchinggoalsagreedincontractsonanannualbasis.ForfurtherinformationonCQUINSchemesfor2016-17pleasecontactamemberoftheUHCWContractingTeamon02476968471.


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National/Local Theme Focus

National AcuteKidneyInjury Acute Kidney Injury diagnosis and treatment inhospital and planofcare tomonitorkidney failureafterpatientdischarge.

National SepsisScreening (a) All appropriate patients arriving via emergencydepartmentordirect emergency admissions tobescreenedforSepsis.

National

SepsisAntibioticAdministration(b)

Administration of intravenous antibiotics within 1hourforpatientsscreenedwhohaveseveresepsisorsepticshock.

National Dementia and Delirium – Find,Assess,Investigate,ReferandInform(FAIRI) (a)

Assess patients aged 75 years and over for DementiaorDeliriumwherethereisanepisodeofemergencyorunplannedcare.

National

Dementia and Delirium - StaffTraining (b) Ensure appropriate dementia training is available

toallstaff.

National

Dementia and Delirium - SupportingCarers (c)

Biannual survey to assess whether the carers ofpeople with dementia or delirium feel adequatelysupported.

Local

Reducing proportion of avoidableemergency admissions: Developing anintegratedGeneral Practitioner AssessmentUnitandEmergencyAmbulatoryCareclinic

Toensurepatientswithambulatorycareconditionsthat do notnormally requireadmission tohospitalreceivehighlyresponsiveurgentcareservices.

Local DevelopinganAcuteFrailtyUnittoimprovethemanagementoffrailelderlypatient

DevelopmentofanAcuteFrailtyUnittoensurefrail andelderlypatientsareassessedandcaredforinthemostclinicalappropriatesetting.

Local Improvingpsychologicalsupporttopatientswithcancer.

Increase psychological input into acute cancerservices with the appointment of a dedicatedpsychologist to improve psychological care in linewithnationalcancerstandards.

Local Improvingtheeffectiveness ofrehabilitationaftercriticalillness

Undertakeareviewofpatientsadmittedtocriticalcare who receive a rehabilitation assessment a)within 24 hours and b) at discharge from criticalcare and c) number of patients who have arehabilitation prescription on discharge. Actionplantoimprovetheeffectivenessofrehabilitation.

Local Facilitatingeffectivedischarge Toimprovethetimelinessofinpatientdischargeprocess.

Local CommunicatingwithpatientsandGPsafterdischarge

Toreviewthespecific type of clinical information to besharedwithpatientsandtheirGPpostdischarge,foranumberofclinicalpathways.

Appendix 2

Glossary

Acute Trust

ATrustisanNHSorganisationresponsibleforprovidingagroupofhealthcareservices.AnAcuteTrustprovideshospitalservices(butnotmentalhealthhospitalservices,whichareprovidedbyaMentalHealthTrust).

Advocacy

IndependentAdvocacyisavailabletopeoplewhowantsupportinmakingacomplaintaboutNHSservices.ContactdetailsareavailablefromyourlocalHealthwatch

Algorithm

Aspecificsetofinstructionsforfollowingaprocedureorsolvingaparticularproblem.

Appraisal

Theprocessbywhichamanagerorconsultantexaminesandevaluatesanemployee’sworkbehaviourbycomparingitwithpresetstandards,documentstheresultsofthecomparison,andusestheresultstoprovidefeedbacktotheemployeetoshowwhereimprovementsareneededandwhy.

Always Events

AlwaysEventsrefertoaspectsofthepatientexperiencethataresoimportanttopatientsandfamiliesthathealthcareprovidersmustperformthemconsistentlyforeverypatient,everytime.ThePickerInstituteleadsonthisnationalprogramme.

Audit Commission

TheAuditCommissionregulatesthepropercontrolofpublicfinancesbyLocalAuthoritiesandtheNHSinEnglandandWales.TheCommissionauditsNHSorganisationstoreviewthequalityoftheirfinancialsystems.Italsopublishesindependentreportswhichhighlightrisksandgoodpracticetoimprovethequalityoffinancialmanagementinthehealthservice.ItworkswiththeCareQualityCommissiontoproducenationalvalue-for-moneystudies.

BDA (British Deaf Association)

TheBDAisahighprofilenational“DeafPeople’sOrganisation”withastrongpresencethroughoutEngland,Scotland,WalesandNorthernIreland.

Benchmark

Astandardorsetofstandardsusedasapointofreferenceforevaluatingperformanceorlevelofquality.Benchmarkingisusedtocompareoneorganisationwithothers.

Board (of Trust)

TheroleoftheTrust’sBoardistotakecorporateresponsibilityfortheorganisation’sstrategiesandactions.TheChairandnon-executivedirectorsarelaypeopledrawnfromthelocalcommunityandareaccountabletotheSecretaryofState.TheChiefExecutiveOfficerisresponsibleforensuringthattheboardisproperlysupportedtogoverntheorganisationandtodeliveritsclinical,qualityandfinancialobjectives.

Board Round

Asimpleandeffectiveprocessuseddailyinwardstosupportthesafeandtimelydischargeofpatients,helpingtoaddresstherisksinherentinprolongedadmissions.

Breaking Free

TheBreakingFreecampaignwasintroducedtointroducetheperfectWeekinitiativetoimprovehospitalflow.Theperfectweekmethodologyisawayofresettingabrokensystemrelyingonamixtureofsocialmovementtheory,multiplerapidimprovementmethodologyandstrongleadershipandsupportmechanisms.Ithasbeendevelopedtohelpsolvepoorflowinhospitalsresultinginovercrowdinginemergencydepartments.Oneweekofintenseimprovementactivitycanimproveflowacrossthewholehospitalresultinginsafer,higherqualitycareanditcanthenbesustained.

British Sign Language

BritishSignLanguage(BSL)isthesignlanguageusedintheUnitedKingdom(UK),andisthefirstorpreferredlanguageofsomedeafpeopleintheUK.


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Care Act 2014

TheCareAct2014wascreatedtomakeprovisiontoreformthelawrelatingtocareandsup-portforadultsandthelawrelatingtosupportforcarers;tomakeprovisionaboutsafeguardingadultsfromabuseorneglect;tomakeprovisionaboutcarestandards;toestablishandmakeprovisionaboutHealthEducationEngland;toestablishandmakeprovisionabouttheHealthResearchAuthority;tomakeprovisionaboutintegratingcareandsupportwithhealthservices;andforconnectedpurposes.

Care Quality Commission

TheCareQualityCommission(CQC)istheindependentregulatorofhealthandsocialcareinEngland.Itregulateshealthandadultsocialcareservices,whetherprovidedbytheNHS,localauthorities,privatecompaniesorvoluntaryorganisations.Itmakesavailablereportsandinformationonallhealthcareproviders,andanyonecanusetheirwebsitetocommentonservices.Visitwww.cqc.org.uk

FromAugust2013theCQCbegantochangethewaythatitassessesthequalityofhospitalservices.Longerinspectionswithlargerteams(includingprofessionalsandpatients)evaluatequalityandcontributetothe‘Rating’;ultimatelyeveryhealthandsocialcareservicewillhavesucharating.

Care Quality Review Group

AmeetingheldmonthlybetweenUHCWandourCommissionerstodiscussclinicalqualityissuesatthehospital.

CiH (Chief Inspector of Hospitals)

CQCappointedProfessorSirMikeRichardsasthefirstChiefInspectorofHospitals,taskedwithimplementingtheCQC’snewwayofinspectinghospitals.Heisresponsibleforleadingtheinspectionserviceandassessingtheextenttowhichhospitalsaredeliveringqualitycare.

Clinical Audit

Clinicalauditmeasuresthequalityofcareandofservicesagainstagreedstandardsandsuggestsormakesimprovementswherenecessary.Ittellsuswhetherwearedoingwhatweshouldbedoing.InadditiontoinformationintheQualityAccount,theTrustpublishesmore

informationonclinicalauditwithintheQualityDepartment’sAnnualReportandontheTrust’swebsite:www.uhcw.nhs.uk

Clinical Coding

Clinicalcodingtranslatesthemedicalterminologywrittenbyclinicianstodescribeapatient’sdiagnosisandtreatmentintostandard,recognisedcodes.Theaccuracyofcodingisanindicatoroftheaccuracyofthepatienthealthrecords.Incorrectcodingcanhavepotentiallyseriousconsequencesforthecommissioningofhealthservices,aswellasmisleadingmanagersandcliniciansbyfalselyrepresentingtheprevalenceofparticularhealthproblems.TheTrustisassessedannuallyontheaccuracyofitscodingsystem.

CCG (Clinical Commissioning Group)

Since1April2013CCGshavebeenresponsibleforensuringadequatecareisavailablefortheirlocalpopulationbyassessingneedandpurchasingservices.Theycommissionservices(includingacutecare,primarycareandmentalhealthcare)forthewholeoftheirlocalpopulation,withaviewtoimprovinghealthandwell-being.CCGscommissionemergencyandurgentcare,includingambulanceandout-of-hoursservices.SeealsoCommissioning

C.diff (Clostridium Difficile)

AspeciesofGram-positivebacteriathatcausesseverediarrhoeaandotherintestinaldiseasewhencompetingbacteriainthegutflorahavebeenwipedoutbyantibiotics.

Commissioning

Commissioningistheprocessofensuringthathealthservicesmeettheneedsofthepopulation.Itisacomplexprocessthatincludesassessingtheneedsofthepopulation,procuringhealthcareservicesandensuringthatservicesaresafe,effective,patient-centredandofhighquality.NHSSpecialisedServicesisanationalorganisationresponsibleforthecommissioningofspecialisedservicesthathelptoimprovethelivesofchildrenandadultswithveryrareconditions.SeealsoClinical Commissioning Group.


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CQUIN (Commissioning for Quality and Innovation)

High Quality Care for All included a commitment tomakeaproportionofproviders’incomeconditionalonqualityandinnovation,throughtheCommissioningforQualityandInnovation(CQUIN)paymentframework.TheTrusthastomeetagreednationalandlocalperformancetargets;aproportionofourbudgetisonlyreleasedbyCommissionersiftheTrustcanshowthatithasmetthetargets.

CRRS (Clinical Results and Reporting System)

CRRSisanelectronicpatientrecordwherebypatients’clinicalresultsareuploadedandheld.

Dashboard

Avisualtoolthatgivescliniciansrelevantandtimelyinformationtheyneedtoinformthosedailydecisionsthatimprovequalityofpatientcare.Thetoolgivesclinicianseasyaccesstoawealthofdatathatiscapturedlocally,whenevertheyneedit.Italsoprovidesstraightforwardcomparisonsbetweenlocalandnationalperformanceforsomeactivities

Discharge

• Complexdischargeconcernspatients’ whohavecontinuinghealthcareneeds afterleavinghospitalandwhomayhave socialcareneedsrequiringspecialist equipmenttosupportthemina community environment.

• Simpledischargeconcernspatientsgoing homeortoresidentialcarewhoneed intermediatecareservices,renewedshort termpackagesofcareandaccessto rehabilitationfacilitatesinthecommunity.

DNA CPR (Do Not Attempt Cardio Pulmonary Resuscitation)

IfcardiacorrespiratoryarrestisanexpectedpartofthedyingprocessandCPRwillnotbesuccessful,makingandrecordinganadvancedecisionnottoattemptCPRwillhelptoensurethatthepatientdiesinadignifiedandpeacefulmanner.Itmayalsohelptoensurethatthepatient’slasthoursordaysarespentintheirpreferredplaceofcareby,forexample,avoidingemergencyadmissionfromacommunitysetting

tohospital.ThesemanagementplansarecalledDoNotAttemptCPR(DNACPR)orders,orDoNotAttemptResuscitationorAllowNaturalDeathdecisions.

Dr Foster

An independent provider of healthcare information intheUnitedKingdom;itmonitorsNHSperformanceandprovidesinformationonbehalfofthepublic.DrFosterIntelligenceisajoint-venturewiththeDepartmentofHealthandwaslaunchedinFebruary2006.Visitwww.drfoster-health.co.ukformoreinformation

Electronic Staff Record (ESR)

AstheworkforcesolutionfortheNHS,ESRsupportsthedeliveryofnationalworkforcepolicyandstrategybyprovidingHumanResourcesDirectorsandtheirteamswitharangeoftoolsthatfacilitateeffectiveworkforcemanagementandplanning;therebyenablingimprovedquality,efficiencyandassuranceofcomplianceagainstessentialworkforcestandards.

End of Life care

Itexplainswhatyoucanexpectfromendoflifecare,includingpalliativecaretocontrolpainandothersymptomsandtoofferpsychological,socialandspiritualsupport.

Equality Act 2010

Theactreplacedmanyseparatepiecesoflegislationconcernedwithdiscrimination.ItrequiresNHSTruststomeetvariousobligations,mostimportantlytoactinwaysthatdonotdiscriminateagainstanypatientoremployeeonthegroundsofninedefined‘specialcharacteristics’.Theninegroupsare:

• Age:Wherethisisreferredto,itrefers toapersonbelongingtoaparticularage (e.g.32yearolds)orrangeofages(e.g. 18-30yearolds).


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• Disability:Apersonhasadisabilityif s/hehasaphysicalormentalimpairment whichhasasubstantialandlong-term adverseeffectonthatperson’sabilityto carryoutnormalday-to-dayactivities.

• Gender reassignment:Theprocessof transitioningfromonegendertoanother.

• Marriage and civil partnership:The legallyorformallyrecognizedunionofa manorawoman(or,insome jurisdictions,twopeopleofthesamesex) aspartnersinarelationship

• Pregnancy and maternity:Pregnancy istheconditionofbeingpregnantor expectingababy.Maternityrefersto theperiodafterthebirth,andislinkedto maternity leave in the employment context.Inthenon-workcontext, protectionagainstmaternity discriminationisfor26weeksaftergiving birth,andthisincludestreatingawoman unfavourablybecausesheis breastfeeding.

• Race:Referstotheprotected characteristicofrace.Itreferstoagroup ofpeopledefinedbytheirrace,colour, andnationality(includingcitizenship) ethnicornationalorigins.

• Religion and belief:Religionhasthe meaningusuallygiventoitbutbelief includesreligiousandphilosophical beliefsincludinglackofbelief(e.g. Atheism).Generally,abeliefshouldaffect yourlifechoicesorthewayyouliveforit tobeincludedinthedefinition.

• Sex:thegenderofaperson(e.g.manor awoman)

• Sexual Orientation:Whetheraperson’s sexualattractionistowardstheirownsex, theoppositesexortobothsexes.

FFT (The Friends and Family Test)

Launchedon1April2012,theFFTispartofanationalinitiativerequiringthatpatientsareaskedwhethertheywouldrecommendthewardordepartmenttotheirfriendsandfamily.TheTrustalreadyhasanestablishedpatientexperience

feedbackprocess,butthisnationalrequirementasksthekeynationalquestiononwhichwewillbecomparedwithotherhospitalsacrosstheUK.

TheFriendsandFamilyTestquestionis:How likely are you to recommend our ward/Minor Injury Unit to friends and family if they needed similar care or treatment?Answersarechosenfromthefollowingoptions:Extremelylikely;Likely;Neitherlikelynorunlikely;Unlikely,ExtremelyUnlikelyorDon’tknow.

TheFriendsandFamilyTestgivespatientstheopportunitysharetheirviewsofthecareortreatmenttheyhavereceivedprovidinguswithvaluablefeedback.Weusethefeedback,alongsideotherinformation,toidentifyandtackleconcernsatanearlystage,improvethequalityofcareweprovide,andcelebrateoursuccesses.FormoreinformationontheFriendsandFamilyTest,pleasevisitwww.nhs.uk/friendsandfamily.FromApril2014,NHSEnglandintroducedtheStaffFriendsandFamilyTest(FFT)inallNHStrustsprovidingacute,community,ambulanceandmentalhealthservicesinEngland.NHSEngland’svisionforStaffFFTisthatallstaffshouldhavetheopportunitytofeedbacktheirviewsontheirorganisationatleastonceperyear.

General Medical Council

IndependentregulatorfordoctorsintheUK.Thepurposeistoprotect,promoteandmaintainthehealthandsafetyofthepublicbymakingsurethatdoctorsmeetourstandardsforgoodmedicalpractice.www.gmc-uk.org.

Getting Emergency Care Right

ThisprogrammewasdesignedbyUHCWtoimprovepatientflowacrossthehospitalandim-provethecareandqualityinourEmergencyDepartment.TohelpimplementthiscampaigntheFREEDmetricwasdeveloped;

• Facilitateeffectivedischarge.• Rightperson,rightplace.• Earlyspecialistinput.• Eliminateunnecessarydiagnostics.• Dailyseniorreview.


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Health Act

TheHealthAct2009receivedRoyalAssenton12November2009.ItisthelegislationthatunderpinsorganisationalarrangementsandresponsibilitieswithintheNHSinEngland

The Health and Social Care Information Centre

HSCICisadata,informationandtechnologyresourceforthehealthandsocialcaresystem.Itprovidessupporttoeveryonestrivingforbettercare,improvingservicesandthebestoutcomesforpatients.ItsupportsthedeliveryofITinfrastructure,informationsystemsandstandardshelpingtoensurethatclinicalandorganisationalinformationflowsefficientlyandsecurelythroughhealthandsocialcaresystems.Visitwww.hscic.gov.uk

Healthcare

Healthcareincludesallformsofhealthcareprovidedforindividuals,whetherrelatingtophysicalormentalhealth,andincludesotherproceduresthatarenotnecessarilyprovidedasaresultofamedicalconditionsuchascosmeticsurgery.

Health Education England

HealthEducationEnglandisresponsiblefortheeducation,trainingandpersonaldevelopmentofeverymemberofstaff,andrecruitingforvalues.

HRA (Health Research Authority)

TheHRApromotesandprotectstheinterestsofpatientsinhealthresearchandstreamlinestheregulationofresearch.

Healthwatch

HealthwatchistheconsumerchampionfortheNHSandsocialcareservices.LocalHealthwatchenableslocalpeopleandvoluntarygroupstoworkfortheimprovementofNHSandsocialcareservicesbycollectingtheexperiencesofthelocalcommunityandmakerecommendationstoserviceproviders.

High Quality Care for All

High Quality Care for All,publishedinJune2008,wasthefinalreportoftheNHSNextStageReview,ayear-longprocessledbyLordDarzi,arespectedandrenownedsurgeon,andaround2000frontlinestaff,whichinvolved60,000NHSstaff,patients,stakeholdersandmembersofthepublic.Itwasthisreportthatdescribedqualityashavingthreecomponents:PatientSafety,ClinicalEffectivenessandPatientExperience.

HSMR (Hospital Standardised Mortality Ratio)

TheHospitalStandardisedMortalityRatioistheratioofobserveddeathstoexpecteddeathsforagroupof56diagnosisgroupswhichrepresentapproximately80%ofinhospitaldeaths.Itisasubsetofallandrepresentsabout35%ofadmittedpatientactivity.HSMRisquotedasapercentageandisequalto100;thismeansthenumberofobserveddeathsequalsthatofexpected.Ifhigherthan100,thenthereisahigherreportedmortalityratio.

HSCIC (Health and Social Care Information Centre)

TheHSCICintheUKisanexecutivenon-departmentalpublicbodyoftheDepartmentofHealth.PreviouslyknownastheNHSInformationCentre,itproducesnationalcomparativedataforsecondaryuses,developedfromthelong-runningHospitalEpisodeStatisticswhichcanhelplocaldecisionmakerstoimprovethequalityandefficiencyoffrontlinecare.Itsprimaryaimistodrivetheuseofinformationtoimprovedecisionmakinganddeliverbettercarebyprovidingaccessible,highqualityandtimelyinformationtohelpfrontlinehealthandsocialcarestaffdeliverbettercare.

Human Factors

Humanfactorsencompassallthosefactorsthatcaninfluencepeopleandtheirbehaviour.Inaworkcontext,humanfactorsaretheenvironmental,organisationalandjobfactors,andindividualcharacteristicswhichinfluencebehaviouratwork.


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IAG (Independent Advisory Group)

TheIAGwassetupin2013andhasinfluencedthedevelopmentofpracticesandpoliciesthatpromoteEquality,DiversityandHumanRightsissuesforbothpatientsandstaff.

Information Governance Toolkit

TheIGToolkitisanonlinesystemwhichallowsNHSorganisationsandpartnerstoassessthemselvesagainstDepartmentofHealthInformationGovernancepoliciesandstandards.

Intellectual Property

Broaddescriptionforthesetofintangiblesownedandlegallyprotectedbyacompanyfromoutsideuseorimplementationwithoutconsent.Intellectualpropertycanconsistofpatents,tradesecrets,copyrightsandtrademarks,orsimplyideas.

Theconceptofintellectualpropertyrelatestothefactthatcertainproductsofhumanintel-lectshouldbeaffordedthesameprotectiverightsthatapplytophysicalproperty.

Intentional Rounding

Thisinvolvesreviewingallpatientsatsetintervalsforkeysafetyissuese.g.repositioning,toileting,food,fluidandpainmanagement;itsusehascontributedtothecontinuinglowlevelofavoidableharmsforpatientssuchaspressureulcersanddehydration.

ISS

ISSFacilityServicesmanagetherecruitmentofcleaning,patienthospitality,security,porteringandcateringstaffandprovidetheseservicesatUHCW.

IV (Intravenous)

Aprocedureinwhichahypodermicneedleinsertedintoaveinprovidesacontinuoussupplyofbloodplasma,nutrients,ormedicinedirectlytothebloodstream.

Key Performance Indicator (KPI)

Atypeofperformancemeasurement,KPIsarecommonlyusedbyanorganisationtoevaluateitssuccessorthesuccessofaparticularactivityinwhichitisengaged.

Lean

Simply“lean”,isasystematicmethodfortheeliminationofwaste.Leanalsotakesintoaccountwastecreatedthroughoverburdenandwastecreatedthroughunevennessinworkloads.

Major Trauma

Definedasmultiple,seriousinjuriesthatcouldresultindeathorseriousdisability,thesemightincludeseriousheadinjuries,severegunshotwoundsorroadtrafficaccidents.

Medical Revalidation

MedicalRevalidationisamechanismfordoctorspracticingintheUKtoprovetheirskillsareup-to-dateandtheyremainfittopracticemedicine.Itisintendedtoreassurepatients,employersandotherprofessionals,andtocontributetoimprovingpatientcareandsafety.

MEWS (Modified Early Warning System)

UtilisationoftheMEWSscoringsystemisnowtherecommendedassessmentofvitalsigns.Theaimofthesesystemsistoidentifypatientsatrisk/deterioratingstatuswhichtriggersanimmediateresponsethroughscoringpointsforabnormalphysiologicalvalues.


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MRSA and MSSA Bacteraemia

Staphylococcus aureusisabacteriumfoundontheskinandaproportion(upto30%)ofthehealthy population carry Staph. aureus in their noseorinothermoistpartsofthebody.

Commonly Staphylococcus aureuscausesinfectionssuchasboilsandinfectedskinwounds.Itcancausepneumonia,urinarytractinfectionsandbacteraemiabothinthecommunityandinhospitalpractice.

SometypesofStaph. aureushavebecomeresistanttovariousantibiotics.TheseareknownasmethicillinresistantStaph.aureusorMRSA.ThosetypesthatarenotresistanttocertainantibioticsareknownasmethicillinsensitiveStaph. aureusorMSSA.

‘M’ Technique

The‘M’techniqueisasimplemethodofstructuredtouch.Eachmovementandsequenceisdoneinasetpatternatasetpressureandsetspeed,whichneverchange.TheMtechniqueisdifferentfrommassageandissuitablefortheveryfragile;thecriticallyill,activelydying,orwhenthegiverisnottrainedinmassage.The‘M’techniqueworksonskinreceptorswhichsendsignalstothebrainandhasbeendescribedas‘physicalhypnotherapy’anda‘spiritualdance’.

NPSA (National Patient Safety Agency)

TheNationalPatientSafetyAgencywasanarm’s-lengthbodyoftheDepartmentofHealth,responsibleforpromotingpatientsafetywherevertheNHSprovidescare.ItsrolehasbeentransferredtotheNHSCommissioningBoardSpecialHealthAuthority.ThisensuresthatpatientsafetyisattheheartoftheNHSandbuildsonthelearningandexperiencedevelopedbytheNPSA,drivingpatientsafetyimprovement.

National Patient Surveys

TheNationalPatientSurveyProgramme,coordinatedbytheCareQualityCommission,gathersfeedbackfrompatientsondifferentaspectsoftheirexperienceofrecentlyreceivedcare,acrossavarietyofservices/settings.

National Research Ethics Service

TheNationalResearchEthicsServiceispartoftheNationalPatientSafetyAgency.Itprovidesarobustethicalreviewofclinicaltrialstoprotectthesafety,dignityandwellbeingofresearchparticipantsaswellasensurethroughthedeliveryofaprofessionalservicethatitisalsoabletopromoteandfacilitateethicalresearchwithintheNHS.

NCEPOD (National Confidential Enquiry into Patient Outcome and Death)

Confidentialenquirieshelpmaintainandimprovestandardsofmedicalandsurgicalcareforthebenefitofthepublic.Usinganonymiseddatafromconfidentialsurveysandresearch,theyreviewtheclinicalmanagementofpatients,publishingreportsandmakingrecommendationsforimprovement.Byrespectingconfidentiality,theymaximisethecomplianceofmedicalandsurgicalstaffinsharinginformationonclinicaloutcomes.

Never Event

NeverEventsareserious,oftenpreventablepatientsafetyincidentsthatshouldnotoccurifavailablepreventativemeasureshavebeenimplemented.NHSEnglandpublishesafulllistofNeverEventseachquarter.

NHS Choices

AwebsiteforthepubliccontainingextensiveinformationabouttheNHSanditsservices;gotowww.nhs.uk.

NHS England

NHSEnglandisanexecutivenon-departmentalpublicbodyoftheDepartmentofHealth.NHSEnglandoverseesthebudget,planning,deliveryandday-to-dayoperationofthecommissioningsideoftheNHSinEnglandassetoutintheHealthandSocialCareAct2012.


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NHS Next Stage Review

AreviewledbyLordDarzi.Thiswasprimarilyalocallyledprocess,withclinicalvisionspublishedbyeachregionoftheNHSinMay2008andanationalenablingreport,High Quality Care for All,publishedinJune2008.

NICE - National Institute for Health and Care Excellence

NICEisanindependentorganisationresponsibleforprovidingnationalguidanceonpromotinggoodhealthandpreventingandtreatingillhealth.Cliniciansaregenerallyexpectedtofollowguidanceunlesstheyhavegoodcause.

Parliamentary and Health Service Ombudsman (PHSO)

TheroleofPHSOistoinvestigatecomplaintsofindividualsthathavebeentreatedunfairlyorhavereceivedpoorservicefromgovernmentdepartmentsandotherpublicorganisationsandtheNHSinEngland.

Patient and Advice Liaison Service (PALS)

ThePatientAdviceandLiaisonService(PALS)offersconfidentialadvice,supportandinformationonhealth-relatedmatters.Theyprovideapointofcontactforpatients,theirfamiliesandtheircarers.

Pathway

Atoolusedbyallhealthcareprofessionalsintreatingpatients,inwhichthedifferenttasksinvolvedinthepatient’scarearedefined.Apathwaywillclarifystaffrolesandresponsibilities,andwhatfactorsshouldbeconsideredindeterminingwhenandhowpatientsmovetothenextstageofcareandtreatment.Healthcarecanbemoreeffectiveandefficientwhenwell-designedandpatient-centredpathwaysareused.

Patient flow

Atermusedtodescribehowefficientlyhospitalsuseresources.Ideallypatientsareadmitted,treatedanddischargedintheshortestpossibletimeconsistentwithsafepracticeandbestavailabletreatment.Disruptiontopatientflowmayresultindelayatanypoint,fromarrivalatA+Etodischarge,causingconcernordistresstopatientsandcarers.Delayincreasestheriskofharmtopatients.

Patient-led assessments of the care environ-ment (PLACE)

Anewsystemforassessingthequalityofthepatientenvironment,replacingtheoldPatientEnvironmentActionTeam(PEAT)inspections.Theassessmentswillapplytohospitals,hospicesanddaytreatmentcentresprovidingNHSfundedcare.Theywilllookathowtheenvironmentsupportspatientprivacyanddignity,themeetingofdietaryneeds,cleanlinessandgeneralbuildingmaintenance.

ResultsfromtheAnnualassessmentsarereportedpubliclytohelpdriveimprovementsinthecareenvironment;theywillshowhowwearedoinglocallyandbycomparisonwithotherTrustsacrossEngland.Formoreinformationvisitwww.england.nhs.uk/ourwork/qual-clin-lead/place

Periodic reviews

PeriodicandthematicreviewsarereviewsofhealthservicescarriedoutbytheCareQualityCommission(CQC).Theterm‘review’referstoanassessmentofthequalityofaserviceortheimpactofarangeofcommissionedservices,usingtheinformationthattheCQCholdsaboutthem,includingtheviewsofpeoplewhousethoseservices.

PDSA (Plan, Do, Study, Act)

ThePDSACycleisasystematicseriesofstepsforgainingvaluablelearningandknowledgeforthe continual improvement of a product or process.ThecyclebeginswiththePlanstep.Thisinvolvesidentifyingagoalorpurpose,formulatingatheory,definingsuccessmetricsandputtingaplanintoaction.TheseactivitiesarefollowedbytheDostep,inwhichthecomponentsoftheplanareimplemented,suchasmakingaproduct.NextcomestheStudystep,whereoutcomesaremonitoredtotestthevalidityoftheplanforsignsofprogressandsuccess,orproblemsandareasforimprovement.TheActstepclosesthecycle,integratingthelearninggeneratedbytheentireprocess,whichcanbeusedtoadjustthegoal,changemethodsorevenreformulateatheoryaltogether.


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Thesefourstepsarerepeatedoverandoveraspartofanever-endingcycleofcontinualimprovement.

Pressure Ulcer

Alsosometimesknownasbedsoresorpressuresores,theyareatypeofinjurythataffectsareasoftheskinandunderlyingtissue.Theyarecausedwhentheaffectedareaofskinisplacedundertoomuchpressure.Pressureulcerscanrangeinseverityfrompatchesofdiscolouredskintoopenwoundsthatexposetheunderlyingboneormuscle.

Avoidable pressure ulcer:Thepersonreceivingcaredevelopedapressureulcerandtheproviderofcaredidnotdooneofthefollowing:evaluatetheperson’sclinicalconditionandpressureulcerriskfactors;planandimplementinterventionsthatareconsistentwiththeperson’sneedsandgoals,andrecognisedstandardsofpractice;monitorandevaluatetheimpactoftheinterventions;orrevisetheinterventionsasappropriate.

Unavoidable pressure ulcer:meansthattheindividualdevelopedapressureulcereventhoughtheindividual’sconditionandpressureulcerriskhadbeenevaluated;goalsandrecognisedstandardsofpracticethatareconsistentwithindividualneedshasbeenimplemented.Theimpactoftheseinterventionshadbeenmonitored,evaluatedandrecorded;andtheapproacheshadrevisedasappropriate.

Inherited pressure ulcer:ApatientisadmittedtotheTrustwithpressuredamageandthisisidentifiedorbecomesapparentwithin72hoursofadmission

Acquired pressure ulcer:thepatientdevelopsapressureulcerwhilstahospitalinpatientafterthefirst72hoursofadmission.

Grade 1 pressure ulcer:Theskinatthispointisredandontheapplicationoffingertippressuretheskinremainsred.

Grade 2 pressure ulcer:thesuperficiallayeroftheskinisdamaged.Itpresentsasablister,abrasionorshallowcraterandanyofthesecanhaveblue/purple/blackdiscoloration.

Grade 3 pressure ulcer:fullthicknessskinlossinvolvingdamageornecrosistosubcutaneous

tissue.

Grade 4 pressure ulcer:fullthicknessskinlosswithextensivedestructionextendingtounderlyingstructures;i.e.bone,muscle,tendon,orjointcapsule.

Prescribed Connection

Alicenseddoctorwithaformalconnection(e.g.contractofemployment)totheorganisationforthepurposesofregularappraisalandsupportingthemintheprocessofrevalidation.

Primary Care TrustswerereplacedbyClinical Commissioning Groups (CCGs) from 1 April 2013(seeCCGentry).

Protected Characteristics Groups:seeEquality Act

QIPS (Quality Improvement Patient Safety) meetings

TheQualityImprovementPatientSafetymeetingsarewherepatientsafety,clinicalauditandpatientexperienceissues,includingcomplaintsaresharedanddiscussedwithspecialties,sothatlessonscanbelearned.

RAG Rate

Trafficlightsystemisusedasacodingsystemforgoodorbadperformance-usuallyknownasa‘RAGrating’.Forexampleinrelationtotheworkloadperformance,redwouldmeaninadequate,amberwouldmeanreasonable,andgreenwouldmeanideal.ThelettersR,AandGareusedinadditiontoswatchesofcolour.

Registration – licence to provide health services

FromApril2009,everyNHSTrustthatprovideshealthcaredirectlytopatientsmustberegisteredwiththeCareQualityCommission(CQC).UHCWislicensedtoprovidehealthcareserviceswithoutconditions


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Research

ClinicalresearchandclinicaltrialsareaneverydaypartoftheNHS.Thepeoplewhodoresearcharemostlythesamedoctorsandotherhealthprofessionalswhotreatpeople.Aclinicaltrialisaparticulartypeofresearchthattestsonetreatmentagainstanother.Itmayinvolvepeopleingoodhealthaswellasthoseundergoingtreatment.ResearchandTrialshelpclinicalstafflearnthebestwaysoftreatingpatients,butcanalsobeusefulinshowingwhatworkslesswell,ornot at all.

RCA (Root Cause Analysis)

EverydayamillionpeoplearetreatedsafelyandsuccessfullyintheNHS.However,whenincidentsthatresultinharmtopatients(orthatare‘nearmisses’)dohappen,itisimportantthatlessonsarelearnedtopreventthesameincidentoccurringagain.RootCauseAnalysisinvestigationisanestablishedwayofdoingthis.

RootCauseAnalysisidentifieshowandwhyincidentshappen.Ateamapproachisusuallytakenandinvolvesteammemberswiththerelevantknowledgeand/orexpertiseaswellasmembersofstaffwhowereinvolvedintheincident.TheaimofanyinvestigationistolearnfromtheeventandtomakerecommendationstotheTrust.

Safeguarding

Toprotectanadultorchildfromharmordamagewithanappropriatemeasure.

Safer Nursing Care Tool

IsatoolkitwhichhasbeendesignedbytheChiefNursesofUniversityCollegeLondonHospitalsandSheffieldTeachingHospitalstohelphospitalssetappropriatenursestaffinglevelsandthishasbeenendorsedbytheNationalInstituteforHealthandCareExcellence(NICE).

Secondary Uses Service

TheSecondaryUsesServiceisdesignedtoprovideanonymouspatient-baseddataforpurposesotherthandirectclinicalcaresuchashealthcareplanning,commissioning,publichealth,clinicalauditandgovernance,benchmarking,performanceimprovement,medicalresearchandnationalpolicy

development.TheTrustcanusethisinformationtocompareperformancewithothersimilarTrusts.

SIRI (Serious Incident Requiring Investigation)

AseriousincidentrequiringinvestigationisdefinedasanincidentthatoccurredinrelationtoNHS-fundedservicesandcareresultinginoneofthefollowing:

• Unexpectedoravoidabledeathofoneor morepatients,staff,visitorsormembers ofthepublic;

• Seriousharmtooneormorepatients, staff,visitorsormembersofthepublic orwheretheoutcomerequireslife- savingintervention,majorsurgical/ medicalintervention,per-manentharmor willshortenlifeexpectancyorresultin prolongedpainorpsychologicalharm (thisincludesincidentsgradedunderthe NPSAdefinitionofsevereharm);

• Ascenariothatpreventsorthreatensto preventaproviderorganisation’sabilityto continuetodeliverhealthcareservices, forexample,actualorpotentiallossof person-al/organisationalinformation, damagetoproperty,reputationorthe environment,orITfailure;

• Allegationsofabuse;

• Adversemediacoverageorpublic concernabouttheorganisationorthe widerNHS;

• ForAcuteTrusts2015-2016theNever Eventlistwas:

- WrongSiteSurgery- WrongImplant/prosthesis- Retainedforeignobjectpost-procedure- Mis-selectionofastrongpotassium containingsolution- Wrongrouteadministrationofmedication- Intravenousadministrationofepidural medication- OverdoseofInsulinduetoabbreviations or incorrect device


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- Overdoseofmethotrexatefornon-cancer treatment - Fallsfromunrestrictedwindows- Chestorneckentrapmentinbedrails- TransfusionofABO-incompatibleblood componentsororgans- Misplacednaso-ororo-gastrictubes- Scaldingofpatients

ThisguidanceissetoutintheSeriousIncidentFrameworksetbyNHSEngland.

Sign Up to Safety Campaign

SignuptoSafetyisanationalinitiativetohelpNHSorganisationsandtheirstaffachievetheirpatientsafetyaspirationsandcarefortheirpatientsinthesafestwaypossible.AttheheartofSignuptoSafetyisthephilosophyoflocallyled,self-directedsafetyimprovement.

Special Review

AspecialreviewisconductedbytheCareQualityCommission(CQC).Specialreviewsandstudiesareprojectsthatlookatthemesinhealthandsocialcare.Theyfocusonservices,pathwaysofcareorgroupsofpeople.AreviewwillusuallyresultinassessmentsbytheCQCoflocalhealthandsocialcareorganisations.Astudywillusuallyresultinnational-levelfindingsbasedontheCQC’sresearch.

Summary Hospital Mortality Indicators (SHMI)

TheSHMI,liketheHSMR,isaratiooftheobservednumberofdeathstotheexpectednumberofdeaths.However,thisisonlyappliedtonon-specialistacuteproviders.Thecalculationisthetotalnumberofpatientadmissionstothehospitalwhichresultedinadeatheitherinhospitalorwithin30dayspostdischarge.Likeallmortalityindicators,theSHMIshowswhetherthenumberofdeathslinkedtoaparticularhospitalismoreorlessthanexpected,andwhetherthatdifferenceisstatisticallysignificant.

Trauma Audit and Research Network (TARN)

TheTARNmainaimistocollectandanalyseclinicalandepidemiological(thesciencethatstudiesthepatterns,causes,andeffectsofhealthanddiseaseconditionsindefinedpopulations)dataandtherebytoprovideastatisticalbasetosupportclinicalaudittoaidthedevelopment

oftraumaservicesandtoinformtheresearchagenda.

Teaching Trusts

Ahospitalthatisaffiliatedtoamedicalschoolandprovidesthestudentswithteachingandsupervisedpracticalexperience;UHCWhasclosetieswiththeUniversityofWarwickMedicalSchool.

Tissue Viability

TheTissueViabilityServiceatUHCWprovidesaspecialistservicetopatientswithawidevarietyofcomplexwoundsincludingpressureulcerpreventionandmanagement,managementoflegulceration,managementoftraumaticinjuriesandcomplexnon-healingwounds.

Transform Programme

“Transformingendoflifecareinacutehospitals:RoutetoSuccess.”

Thisistheimplementationofkeyenablers:AdvancecareplanningAMBERcarebundle,rapiddischargeforpatientsintheterminalstagesoftheirdisease,careinthelastdaysoflifeEPaCCS(ElectronicPalliativeCareCo-ordinationSystem),supportingthecollaborativede-velopmentandimplementationofaclinicalelectronicregisterofpatientsapproachingtheendoflifeacrossdifferentcaresettings.

VERA approachA helpful approach and an aid to memory for staffwhenworkingwithpatientsdiagnosedwithdementiaisVERA(mustbeassociatedwithVeraLynnandthe1940’s)–thisstandsfor:

V=Validate,acceptingthatthebehaviourexhibitedhasavaluetothepersonandisn’tjustasymptomofdementia.E=Emotion,payingattentiontotheemotionalcontentofwhattheperson’ssaying.R=Reassure,canbeassimpleassaying‘it’llbeokay’andsmiling,holdingtheirhand.A=Activity,peoplewithdementianeedtofeeloccupied,active,seeifyoucanengagetheminsomerelatedactivity.


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Virginia Mason Institute

TheVirginiaMasonInstituteinSeattleisworld-renownfortransforminghealthcare.Theirmantraisthattheperfectpatientexperiencemeansthepatientcomesfirst-aboveeverythingandeveryone.Theyareexpertsinteachingotherhealthcareorganisationshowtoimplementandmaintainapatient-centredapproachthatwillhelptoincreasequality,safetyandefficiencyusingthesamemethodsthatmadethemsosuccessful.A“valuestream”isaspecificprojecti.e.theOphthalmologyOutpatientsprojectwhichfollowstheVirginiaMasonInstituteimprovementprocess.ARapidProcessImprovementWorkshop(RPIW)ranbyVirginiaMasonInstituteandtheTrustisafive-dayworkshopfocusedonaparticularprocessfromavaluestream(i.e.patientreferraltotheOphthalmologyOutpatientclinic)wherethosewhodotheworkareempoweredtoeliminatewastei.e.inefficienciesintheservice.

WHO (World Health Organisation)

TheWorldHealthOrganisation(WHO)isaspecialisedagencyoftheUnitedNations(UN)thatisconcernedwithinternationalpublichealth.


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UniversityHospitalCliffordBridgeRoad

Coventry CV2 2DX

HospitalofStCrossBarbyRoad

RugbyCV225PX

www.uhcw.nhs.uk

02476964000

June 2016


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2015 - 2016 Quality Account Reports... · 2017-09-12 · UHCW 2015 - 2016 Quality Account Page 4...

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