QUALITY ACCOUNT 2015/16
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STATEMENT FROM OUR CHIEF EXECUTIVE
Welcome to Barking, Havering and Redbridge University Hospitals NHS Trust’s Quality Account.
This document records the enormous amount of work which has taken place in our hospitals over the past year, and sets out our
plans to continue our journey of transformation and improvement.
I am pleased to report that the dedication, hard work and commitment of all our colleagues has led to improvements across the
board during 2015/16.
We have recorded real achievements in crucial areas such as hospital mortality, where our rates remained below expected levels
reflecting our work to review patient care and deliver best practice.
We have continued to achieve a decrease in the number of patient falls on our wards and we are currently below national average
levels for patient falls.
We hope that our commitment to improving the quality and safety of our services is evident throughout this account.
Over the past year, we have trained almost 3,000 colleagues in how to support people with dementia and their carers, improved our services for adults and children
with learning disabilities and launched a series of improvement projects to target specific areas of medicines safety. We have also made improvements to the quality
of patient meals and mealtimes, in direct response to patient feedback.
We provide world-class treatment at our hospitals, and I am pleased that our reputation is beginning to reflect this.
Patient feedback is, of course, the best measure of quality, and I am delighted that the people who use our services are seeing and acknowledging the improvements
we are making for themselves.
We have worked hard over the past 12 months to improve the way we communicate with those we serve. This has included making our Friends and Family surveys
available in different formats, including easy read, ten top languages, child friendly and Braille, and developing our use of Patient Stories to inform care and decisionmaking at all levels of the organisation.
When people using our services don’t feel we have got it right, we are committed to listening, acting and learning to prevent the same things happening again.
We are pleased to report a notable decrease in overall complaints compared to the previous year, and a welcome increase in the number of queries and concerns
which have been successfully dealt with by our early resolution Patient Advice and Liaison Service (PALS). We have also significantly improved our response times to
complaints.
There can be no doubt, however, that the past year has also brought some big challenges.
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There continues to be a considerable demand on our services. We have seen an increase of almost 20 per cent in the number of people coming in to our Emergency
Departments, and we have an on-going challenge to adapt and develop our services to meet that demand.
We are also disappointed that we have significant numbers of people who have been waiting too long for planned care, and we are working hard to deliver our
recovery and improvement plan to ensure we have the capacity to deal with the number of GP referrals we receive.
Our priority for 2016/17 is to continue wholeheartedly on our journey of improvement and to build on what we have achieved so far.
We are delighted to be one of five trusts nationally chosen to form a partnership with the Virginia Mason Institute, a not-for-profit provider of health services in
Seattle, USA, which is widely regarded as running one of the safest hospitals in the world.
The PRIDE way is our locally branded adaptation of the Virginia Mason methodology and will become our change management approach as we seek to achieve
continuous improvement and deliver the highest possible standards of healthcare.
Everything we do at BHRUT will be underpinned by our PRIDE values, as we work with Passion, Responsibility, Innovation, Drive and Empowerment to put in place a
quality improvement culture that will benefit our patients, visitors and colleagues alike.
We know we still have much to do but we are ready for the challenge.
We look forward to working together with all our teams, and with our key stakeholders, over the year ahead, to focus on our outstanding challenges, move forward
and strive towards our goal of putting the patient at the heart of everything we do and delivering excellent care to all.
I confirm that, to the best of my knowledge, the information provided in this document is accurate.
Matthew Hopkins
Chief Executive
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INTRODUCTION FROM OUR MEDICAL DIRECTOR AND CHIEF NURSE
We hope you will find our Quality Account an interesting and informative record of our performance during 2015/16 across a wide range of services and measures,
and our priorities for the next 12 months and beyond.
We believe this document provides a clear picture of the importance we attach to quality and safety, and the way in which these two key principles underpin and
inform everything we do.
We acknowledge the findings of the Care Quality Commission following their visit to our hospitals in March 2015 and are fully committed to providing the safest and
highest quality of care to all our patients. We look forward to the CQC’s review visit, when our colleagues and patients will outline our achievements to date, as well
as our plans for continued improvement through our Delivering our Potential programme.
This report confirms our completion of the majority of the CQC’s ‘must-do’ findings and outlines significant progress on the wider findings in their report of June 2015
Over the past 12 months, we have strengthened our leadership teams and built on our successful devolved leadership structure which puts doctors in key leadership
positions in our divisions, with high levels of management support from dedicated divisional managers and divisional nurses. It is the job of these teams to support
the day-to-day running of our services and to deliver our on-going journey of change and improvement.
Our quality approach is a holistic one and our quality priorities of safe, timely care, a first class patient experience and effective, efficient and equitable services, are
all fundamental to enabling us to deliver outstanding care. With these priorities at the centre of everything we do, our aim is to meet the highest standards possible
and become a Trust that we can all be truly proud of.
We are very grateful indeed to all our colleagues for their hard work during 2015/16, and are justly proud of their passion and commitment to serving our patients.
We look forward to working with all our teams, and with our key stakeholders, as we continue on our improvement journey and strive to deliver first class healthcare
to all over the year ahead.
Dr Nadeem Moghal, Medical Director
Kathryn Halford, Chief Nurse
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OUR PRIORITIES FOR 2015/16 AND OUR PLANS FOR THE FUTURE
Review of our quality priorities in 2015/16
Last year we set out to deliver improvements in the following areas:
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Priority One:
Priority Two:
Priority Three:
Priority Four:
Priority Five:
Priority Six:
Patient Safety – Preventing harm
Improving patient and carer experience
Clinical Effectiveness – ensuring our processes are correct and up to date
Timely care – reducing and preventing delays in care
Efficient Care – Using resources wisely
Equitable Care – Meeting patients’ needs
This section of the Quality Account outlines our specific aims and our progress against each priority.
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PRIORITY ONE: PATIENT SAFETY
Providing safe care is fundamental to delivering high quality care. Preventing avoidable harm requires everyone to understand their responsibility in delivering safe
care and, where errors occur, to work immediately to ensure safe care, extract and share the necessary learning and redesign the pathways of care to prevent a
recurrence, as required. In 2015/16, we aimed to improve on two key systems to help provide increasingly safe care:
REDUCING MORTALITY
We use both the Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital-level Mortality Indicator (SHMI) to measure our mortality levels. Using these
two tools and a measure of actual patient deaths, enables us to understand our areas for improvement and take appropriate action. Ratios of this type identify
whether a trust is at or below the national average level; the use of the SHMI measure includes patient deaths within 30 days of discharge which enables us to
understand both hospital and community care. We review this information on a monthly basis at the Trust’s mortality assurance group, which is chaired the Medical
Director. This group provides monitoring and initiation of improvement actions where needed.
What we said we’d do:
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Develop a mortality review procedure by introducing a mortality checklist to highlight areas of best practice and areas for improvement
Establish an Executive-led, multi-disciplinary Mortality Assurance Group
Reduce our Hospital Standardised Mortality Ratio (HSMR)
What we’ve done:
 Delivered a mortality review process so that all patients that die receive a case review of their care and treatment
 Presented case review information within a mortality scorecard, which is a key agenda item at the Mortality Assurance Group
 Working with our colleagues in Public Health, we have produced specific mortality reports to our divisional teams
 Initiated via our Mortality Assurance Group, quality improvement initiatives to focus on sepsis, pneumonia and respiratory disease, to support improvements in
patient outcomes.
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What the data shows:
The organisation has continued to show mortality below expected levels for both the HSMR & SMHI mortality ratios, which is a positive position and is likely to reflect
the work undertaken to review patient care and deliver improvements.
SHMI data shows detail of place of death. In 2015, 72 per cent (1614) of deaths occurred within hospital. In 2012/13 this figure was 75 per cent.
This reduction may reflect the support received by patients with end of life care needs, to choose their place of death.
Of the 2235 deaths that occurred within 30 days of discharge (April 2015 – Dec 2015), 11 per cent (237) occurred in patients’ own homes and 14 per cent (313)
occurred within a care home setting. Reviewing this information enables us to inform the provision of end of care services and identify areas for potential
development and improvement.
Mortality data comparison
2014/15
2013/14
HSMR Overall
2015/16 (Apr 15-Jan 2016.
Most recently available data)
98.61
94.10
103.66
HSMR Weekday/Weekend Admission
97.15/102.86
91.71/101.21
103.11/105.24
SHMI Overall
96.97
98.84
SHMI Weekday/Weekend Admission
91.65 (Apr 15-Dec 2016. Most
recently available data)
90.23/96.04
94.15/105.99
98.94/98.57
Total deaths and Crude Mortality Rate
(Deaths as a percentage of patient Discharges )
1628 2.4% (Apr 15-Dec 2016.
Most recently available data)
2349 2.93%
2168 2.79%
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Comparing our mortality rates to the rest of England’s acute hospitals
SHMI April 2015 – December 2016
HSMR April 2015 – Jan 2016
Both of the above tables demonstrate the position of our Trust’s SHMI & HSMR ratios with the most recently available data. Both values show a positive position of
below expected mortality.
The green triangle shows the position of BHRUT, and the remaining symbols show the position of all other NHS acute provider organisations. A position above the
upper (red) line demonstrates mortality higher than expected, and a figure below the lower line shows mortality below expected.
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IMPROVING PATIENT SAFETY THROUGH INCIDENT REPORTING - UNDERSTANDING OUR SAFETY AND LEARNING
We carried out a review of our governance process in 2015 and recognised that we needed to improve, particularly by strengthening our ability to both report
incidents promptly and learn lessons from them. To support this, we have increased our quality and safety team and significantly changed the way we work.
What we said we’d do:
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Revise our process for investigating serious incidents and significantly improve our performance against serious incident key performance indicators.

Clear a backlog of serious incidents and ensure zero breaches of the national reporting timescales for incident investigations.
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Meet the national statutory requirements for Duty of Candour, which means being open with our patients when things go wrong.
What we’ve done:
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We have strengthened our quality governance team and put in place strong links with our divisional clinical teams, through the establishment of safety advisors.
This allows divisional leadership teams to own the quality and safety agenda and benefit from dedicated local expertise.

Revised our risk management system to ensure the whole process, from considering risk through to formulating actions, is straightforward. The result is a system
that accurately reflects the risks within the organisation and action being taken.

Re-built the incident management section of the risk management system which has significantly improved our reporting, tracking and ability to interrogate
incidents and incident data. This has resulted in new, very effective incident analysis reports being created and shared at all levels of the organisation, thus
improving our ability to study and learn from incidents.

The backlog of serious incidents for investigation has been cleared and no further breaches of the national reporting timescales have occurred. Our plan to sustain
this position includes the formation of a multi-professional serious incident panel to consider investigations prior to closure. This group will drive both the
timeliness and quality of investigations.

Established a weekly Patient Safety Summit at both our Queen’s and King George sites, which has been a significant success. The group is chaired jointly by the
Medical Director and Chief Nurse and attended by senior clinicians, managers, nurses and trainees from each division. This Trust-wide forum discusses serious
incidents soon after they occur to identify learning. A one-page paper summarises points which have been identified, and actions put in place to prevent a reoccurrence.

Shared key learning from the Patient Safety Summit through a new weekly organisational bulletin, ‘Patient Safety Messages’, and also a monthly Patient Safety
Memo. These help to raise awareness of key safety information and themes quickly.
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Created a comprehensive and integrated Quality & Safety report that enables advanced and combined analysis of key areas of quality, along with a number of
quality dashboards. This ensures that colleagues at all levels, including the Trust board, are fully appraised of how we are performing and developing.
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Redesigned our committees and structures for understanding and acting on the quality of care that we provide.
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Joined the national safety programme Sign up to Safety in 2015 which aims to reduce harm by 50% within 3 years. Using the support from the programme and
our own dedicated plan we have committed to five key pledges around safety and which are to:
1. Put safety first – commit to reduce avoidable harm in the NHS by half and make public our goals and plans locally
2. Continually learn – make our organisation more resilient to risks, by acting on the feedback from patients and by constantly measuring and monitoring how
safe our services are
3. Honesty – be transparent with people about our progress to tackle patient safety issues and support staff to be candid with patients and their families if
something goes wrong
4. Collaborate – take a leading role in supporting collaborative learning, so that improvements are made across all of the local services that patients use
5. Support – help people to understand why things go wrong and how to put them right. Give staff the time and support to improve and celebrate the progress
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DUTY OF CANDOUR
Duty of Candour has been a legal requirement since November 2014. This duty requires openness and transparency with patients, their carers or families when
things go wrong. We have a longstanding commitment to openness across our services. However, the legislation brings with it a clear structure for us to work within.
In addition to the organisation’s duty, our clinical staff have specific responsibilities within individual professional registration.
The legal element of Duty of Candour seeks to ensure that where a patient suffers harm, we provide a timely apology, openness in respect to the specific detail of the
event, transparency regarding the investigation process and information about how we intend to learn from the incident. This process involves an initial and early
conversation with the patient explaining what happened and why it happened, along with an apology and explanation of what action will be taken as part of any
further investigation. A letter is sent to all patients involved in an incident of harm to formally summarise this position. A further letter is sent at the conclusion of the
investigation, offering a copy of the full investigation report and actions to prevent recurrence.
What we’ve done:
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Created an organisational Duty of Candour Policy. This provides an easy-to-understand explanation of Duty of Candour and how colleagues and managers need to
act to adhere to the requirements.
Built a dashboard and reporting process as part of our incident reporting system to monitor compliance and provide a repository of the key evidence
demonstrating our actions.
Delivered a large number of workshops to raise awareness of Duty of Candour and the requirements necessary for full compliance.
Included information on our compliance against this standard within internal and external, publically available, quality reporting.
What the data shows:
The National Reporting and Learning Service (NRLS), which is part of NHS England, monitors incident levels across all English hospitals. Reporting levels are described
in terms of incidents per 1000 bed days. The national average for incident reporting per 1000 bed days is 39. Reporting at this level is referred to as indicative of a
positive patient safety culture as staff report events of actual harm or risks to patient harm in order to highlight risk and make improvement.
“Organisations that report more incidents usually have a better and more effective safety culture. You can't learn and improve if you don't know what the problems
are.”
NRLS 2013
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We have made significant progress with incident reporting rates in 2015. This progress was evident in February 2016 when we reached 32 incidents per 1000 bed
days, which is close to the national average and shows evidence that our plan has delivered results. The total number of incidents in 2015/16 was 10850, which is the
highest level in three years of reporting. Key to this improvement has been the significant improvement to our incident reporting system, better communication
including feedback to colleagues who report incidents, and increased training and empowerment of colleagues to take more ownership of incidents through
divisional business units.
We expect to continue to improve on this area in 2016/17, as we work to further improve our culture and practices.
Over the past three years we have seen a marked decrease in the percentage of incidents reported that cause severe harm or death, which is a significant
improvement. Our aim is to see a high level of zero harm incidents, representing vigilance to safety and a commitment to improvement work to reduce the level of
harm. In 2013, 3.24 per cent of incidents resulted in harm. In 2015/16, this figure had reduced to 1.09 per cent. The national average (as detailed in the NRLS
Reporting Data Set), is below 1.00 per cent. Whilst we are still above this figure, we are on track to decrease our harm levels further in line with the national average
in 2016/17.
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Standards
Metric
National Average
Actual number of Patient Safety Incidents
reported
Patient Safety Incidents
2015/16
2014/15
2013/14
10850
8268
10192
Incident reporting rate per 1000 bed days
38.25
1
29.34
19.16
Percentage of Patient Safety Incidents that
resulted in severe harm or death
>1.00%
1.09%
2.55%
3.24%
PREVENTING PRESSURE ULCERS
A pressure ulcer is damage to the skin and the deeper layer of tissue under the skin. This happens when pressure is applied to the same area of skin for a period of
time and periods of immobility and ill health are significant risk factors. Key to preventing this damage is understanding each patient’s risk and responding
appropriately.
What we said we’d do:
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Investigate the care received by patients who develop grade 2, 3 or 4 pressure ulcers in our care and be open and honest with patients about these wounds.
Continue our ‘PUSH’ - Pressure Ulcers Should be History – campaign, which works to improve risk assessment and preventative action.
Work closely with our community partners to decrease the number of community acquired pressure ulcers.
What we’ve done:
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1
Our wards have developed their own initiatives to tackle avoidable hospital acquired pressure ulcers in their clinical areas, as part of our ‘PUSH’ campaign.
Education is an important part of the Tissue Viability team’s role and we have delivered training on the prevention and treatment of pressure ulcers on both our
mandatory training and induction training programmes. We have also run training sessions at both Queen’s and King George Hospitals to enable colleagues to
further update their knowledge.
Established bi-weekly ‘Pressure Ulcer Review Panels’ for all grades of pressure damage, to assess preventative action and identify learning.
Commenced joint training sessions with our community partners and hosted a Joint Pressure Ulcer Prevention Conference.
NRLS Data Release – April 2016
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What the data shows:
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In the first two quarters of 2015/16, we were pleased to see a decrease in the number of patients who acquired pressure ulcers compared to the previous year.
However, we saw an increase in incidents in the third quarter and investigations are proving helpful to identify why this has occurred. Overall, we are on course to
see a decrease in the number of incidents in 2015/16 compared to the previous year.
The ‘PUSH’ campaign has proved successful with more wards achieving our targets of 100, 200 and 365 days pressure ulcer free.
Medication safety
As part of our commitment to reduce harm we have placed a particular focus on medication safety. Across the NHS, medication incidents most commonly occur in
the areas of incorrect dosage, omission of medication and administration of the wrong medicine. Our work in 2015/16 has centred on these areas and sought to
improve prescribing and administration practice, alongside improving our overall processes for managing and supervising medication practice.
What we said we’d do:
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Improve prescribing guidance and structures across the organisation.
Deliver improved levels of supervision and support from our pharmacy team to frontline clinicians.
Integrate the medicines safety thermometer into our practice to assess our performance and mark areas for improvement.
Launch a series of improvement projects to target specific areas of medicine safety.
Deliver improvement to the process for providing medication to patients on discharge.
What we’ve done:
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Established a multi-professional group to review medicines practice and incidents.
Revised a wide range of policies directing medicines management.
Reviewed ward medication stock lists and developed a critical medicines list. This ensures vital medicines are available within ward areas and prevents omitted
doses.
Provided a dedicated Medicines area within the Trust’s intranet website, ensuring clinical colleagues have access to the latest guidance quickly and in one
location.
Implemented the Medication Safety Cross Tool. This visible tool highlights incidents of missed doses of medication.
Begun use of a national improvement tool called the Medication Safety Thermometer, which assesses a wide range of mediation practices on a monthly basis.
This work will mark out our areas for improvement and track our progress in comparison to other hospitals.
Encouraged reporting of near miss or no harm medication incidents. This helps to identify risks and prompts action and learning to prevent harm.
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Developed and introduced a template for investigating controlled drug discrepancies.
Started work around improving our processes for medicines to take away on discharge.
Introduced a new system for monitoring fridges where drugs are stored.
Implemented a new critical care drug chart across both hospitals’ Intensive Care Units, which has significantly to improved medication safety.
What the data shows:
0.40%
0.30%
Percentage of medicines without a precriber's signature & percentage of medicines given
without a valid prescription (ward areas)
Omitted doses- Medication Safety Cross data
20
0.20%
15
0.10%
10
0.00%
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
% Meds
without
Rxr
Signature
Trust total
5
0
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Having identified missed doses of medication to be a significant issue and addressed the causes, we have seen a welcome decrease in incidents of this type. This
ensures patients are receiving their treatment on time, which makes our care safer and more effective.
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INFECTION PREVENTION CONTROL (IPC)
Infection Prevention and Control (IPC) is an essential component of care and one of the Trust’s key clinical priorities. We have a dedicated infection prevention team
to support our work in this area.
What we said we’d do:
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Decrease the number of avoidable healthcare acquired infections, such as Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C.
difficile).
Increase the amount of MRSA screening we undertake for planned and emergency admissions.
Reduce the number of wards closed by Norovirus (Winter Vomiting Disease).
Improve staff compliance with good hand hygiene.
What we’ve done:
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Introduced a programme of weekly peer to peer auditing of hand hygiene compliance and monthly environmental auditing of all clinical areas.
Purchased specialist equipment to create additional isolation facilities and increase isolation capacity.
Developed additional training for colleagues in Aseptic Non-Touch Techniques.
Established a range of forums to review root cause analysis reports and agree actions to improve patient safety and share lessons learnt.
What the data shows:
We have not met our target for both MRSA bacteraemia and C. difficile infection and we have strengthened our case review process to understand the reasons for
this. Our work in this area continues and we have gained support from a national lead in infection prevention to support the actions of our team. This benchmarking
exercise will help us to ensure we have all possible preventative actions in place. Appropriate use of antibiotics is a key factor in limiting C. difficile infection. We will
continue to work with our GP and wider community colleagues to ensure appropriate antibiotic use is maintained across all services.
MRSA bacteraemia
C. difficile
Norovirus (ward closures)
Target
2015/16
Zero
tolerance
30
0
2015/16
2014/15
5
6
36
1
33
4
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Screening levels for MRSA colonisation prior to surgery are below an expected level. This is an important area and we will target the specific areas not achieving 100
per cent in 2016 to deliver the required improvement.
MRSA Screening
100.0%
90.0%
88.1%
89.6%
80.0%
78.3%
74.5%
70.0%
76.5%
75.9%
75.5%
71.6%
60.0%
50.0%
MRSA Screening Total
40.0%
30.0%
Elective
20.0%
10.0%
Non Elective
0.0%
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
PREVENTING PATIENT FALLS
Falls are a major cause of disability and mortality for older people. As well as the physical effects, falls can have a significant psychological impact on confidence and
independence. It is therefore imperative that we both understand and minimise the risks of patients falling.
What we said we’d do:
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Seek a reduction in the number of falls overall and those that result in harm, as expressed by a rate per 1000 bed days, in comparison to the previous year.
Achieve a reduction in the number of patients experiencing more than two falls per admission.
What we’ve done:
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Identified Falls champions for all our wards and units and held workshops for them every quarter.
Designed new falls documentation and carried out an audit of compliance.
Introduced a series of falls management resources, including making non-slip socks available to all patients and introducing magnetic falls symbols.
Undertaken a detailed review of every patient fall, to understand preventative action and post fall care.
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Carried out joint Falls conferences with the North East London NHS Foundation Trust which provides community and mental health services.
Purchased 30 low beds to be used for high risk falls patients.
Delivered mandatory training on falls prevention.
What the data shows:
The data shows that there continues to be a decrease in falls per thousand bed days compared to last year and that we are below national average levels for the
incidence of patient falls.
The table below shows the total number of patient falls for the last two years. This demonstrates a decrease in the number of patient falls reported in 2015/16
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PRIORITY TWO: PATIENT EXPERIENCE
It is a patient’s right to expect care that is respectful and responsive to their individual needs and values. To understand whether we are making the necessary
improvements, we need to ensure there is uniformity in the way patient feedback data is collected, analysed and displayed. We use a range of methods to collect
positive and negative feedback and this is shared with our divisions in order that learning can take place and actions can be implemented to improve patient
experience.
What we said we’d do:

Reviewed the effectiveness of the Friends and Family test (FFT) methodology to ensure the information we receive is useful and relevant to improve the patient
experience
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Introduce different ways for patients to give us feedback
Make the Friends and Family Test (FFT) available to all patients being discharged
Introduce new ways for patients with communication needs to provide feedback
Maintain patients’ privacy when booking in at reception in our Emergency Department
Improve patient mealtimes, including quality of food and minimising interruptions
Review our CQC Adult Inpatient Survey and Friends and Family Test results to make sure we are acting on our ‘worst’ scoring questions and making improvement.
Improve communication with our patients, including displaying useful information and details of key staff
What we’ve done:
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Included FFT performance at divisional performance reviews and reviewed the effectiveness of the overall friends and family test process
Engaged through a procurement exercise a company to improve both reporting and analysis of patient experience – this work will allow us to harness high
volumes of quantative and qualitative feedback and use it to transform patient experience and outcomes effective from 1st April 2016
We will work towards having multiple data collection methods for example paper survey's, tablets, use of smartphones and websites
In addition we will be gathering via the website individual patient feedback for consultants, specialist nurses and midwives
The surveys will be tailor made for children
Implemented protected mealtimes across both sites
Included named consultant or nurse information on adult in-patient headboards
Introduced identification magnets to alert staff to individual patient needs
Made Friends and Family surveys available in different formats, including easy read, ten top languages, child friendly and Braille.
Continued the Mystery Shopper scheme to allow patients to give anonymous feedback
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Introduced information boards on wards including welcome boards, It’s Good to Talk boards, visitor information, Friends and Family feedback, patient status at a
glance and quality care board
Introduced adaptive cutlery across both sites
Developed and implemented two child-friendly patient surveys for children aged 3 to 12 and 12 to 16
Launched a ‘Monkey visits the Emergency Department’ activity pack for children using our waiting room
Developed a specific name board/comment card so parents can provide feedback or ask questions whilst their baby is in NICU
Installed privacy signs and microphones at Queen’s Hospital Emergency Department so patients don’t have to raise their voices when booking in
Patient stories are now part of our monthly new staff induction programme.
What the data shows:
For positive recommendations and response rate, there is no annual percentage. Therefore, in order to achieve the annual percentage in each area, the monthly
percentages have been averaged. The table below also outlines the agreed internal Trust target set for each area.
Positive Recommendations – the percentage of people completing a survey who would recommend our services.
Area
%
Maternity - Antenatal
Maternity - Birth
Maternity - Postnatal
Maternity - Community Postnatal
Inpatients
Outpatients
ED
97%
98%
92%
99%
95%
90%
82%
Internal
Target
98%
98%
98%
98%
96%
95%
90%
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Response Rate – the percentage of eligible patients who returned a completed survey.
Area
%
Maternity - Antenatal
Maternity - Birth
Maternity - Postnatal
Maternity - Community Postnatal
Inpatients
Outpatients
ED
20%
22%
30%
24%
32%
4%
13%
Internal
Target
22%
22%
22%
22%
28%
9%
14%
Number of surveys returned each month – there is no internal target for the number of surveys returned
Page 21 of 80
What we’re going to do next to continue improvement:
 Improve accessibility to the hospital for deaf patients, including raising deaf awareness among colleagues and achieving the Royal Association for Deaf People
Quality Mark.
 Continue using patient stories as part of the Trust’s corporate induction and at Trust Board meetings.
 Promote the Mystery Shopper scheme for hard to reach patients.
 Recruit new volunteers to help gather FFT survey feedback.
How this benefits patients:



Our initiatives have improved the way we communicate with patients with specific communication needs.
Patient stories are a powerful way of enabling newly-appointed colleagues to hear first-hand about good and bad patient experiences.
Our Mystery Shopper scheme provides a wealth of feedback from patients, visitors and carers, which can be fed back to colleagues so that changes and
improvements can be made.
Page 22 of 80
LISTENING TO CONCERNS AND RESPONDING
Target achievement
When people using our services don’t feel we have got it right, we want to listen, act to put things right and learn to prevent the same thing happening again.
In addition to a formal complaints process, we offer a Patient Advice and Liaison Service known as PALS. This service is available at both Queen’s and King George
Hospitals and via the telephone. The focus of the team is to listen, support and respond to patient queries. During 2015/16, the team received 5,329 queries from
patients, an average of 440 per month. We are very pleased to report that 88 per cent of these queries or concerns were promptly resolved to the patient or carer’s
satisfaction, meaning we acted to clarify an issue or resolve a problem which may have affected the quality of care being provided.
What we’ve done:



Encouraged divisional colleagues to speak directly to patients or carers where possible to resolve concerns at ward level
Regularly reviewed cases to understand themes to be addressed and highlight alternative methods of resolution
Sought the view of the enquirer before a case is closed, to ensure they are happy with the outcome or to provide details of other options.
What the data shows:
In the first half of 2015/16, the number of enquiries being received by PALS steadily increased. However, this position was reversed in Q3 with the number of
enquiries significantly decreasing. In Q4, this position changed again and enquiries began to increase. PALS wants to encourage the use of their early resolution
service and the aim is to continue to increase the number of PALS enquiries per month and to improve and maintain the percentage of enquiries which are
satisfactorily resolved.
Page 23 of 80
600
100%
90%
500
80%
70%
400
60%
300
50%
40%
200
30%
Number of PALS enquiries
received
% of enquiries resolved
20%
100
10%
Mar-16
Feb-16
Jan-16
Dec-15
Nov-15
Oct-15
Sep-15
Aug-15
Jul-15
Jun-15
May-15
0%
Apr-15
0
Month
Number of PALS enquiries
% of enquiries resolved
received
April 2015
454
91%
May 2015
507
93%
June 2015
542
93%
July 2015
487
92%
August 2015
464
90%
September 2015
525
84%
October 2015
392
84%
November 2015
356
79%
December 2015
269
93%
January 2016
380
92%
February 2016
480
84%
March 2016
473
76%
Examples of PALS enquiries during 2015/16 and how we responded:
Page 24 of 80




Patient had procedure cancelled at late notice as the anaesthetist required more tests. Tests were done but the patient was not contacted and didn’t know who
to follow this up with. PALS spoke to the anaesthetist and arranged for the results to be reviewed. Once clinically approved for the procedure, PALS liaised with
the admissions team to ensure the patient was provided with a date.
Patient attended Outpatients for a clinic appointment but was informed she was not on the list. Patient was in significant distress due to pain. PALS liaised with
speciality and arranged for patient to be seen the following day by the Clinical Nurse Specialist.
Patient arrived for a GP-requested blood test but had mislaid the request form. PALS contacted the GP practice and a duplicate form was faxed across ensuring
the patient could have their blood test the same day.
Consultant wrote to patient’s GP advising of a prescription that was required but this was not actioned. Patient was frustrated going backwards and forwards
between the GP and hospital. PALS intervened, spoke to consultant, re-sent clinic letter to the GP practice and the patient received their prescription.
Responding to complaints
Where local resolution of a concern is not possible, a formal process of complaints handling is in place to support patients and co-ordinate detailed investigations. In
line with the national requirements, we aim to achieve a response to each complaint within 25 days in at least 90 per cent of cases. Before an investigation begins, we
are required to acknowledge a complaint within three days and we have achieved this every month in 2015/16.
During 2015/16, a 25 day response rate was achieved in 87 per cent of complaints. This level of response is a significant improvement on the previous year and we
are also pleased to note a 10 per cent reduction in overall complaints compared to the previous year.
The reason for not achieving an expected complaint response time often involves the complexity of the case and availability of clinical staff in order to respond within
the set time frame. Our new quality and safety team is working to support teams to improve in this area. We ensure all patients with an expected delay in response
receive written information about expected completion dates. Our work in this area has delivered improvements in both learning from complaints and our overall
timeliness of response.
How we use complaints to learn
We are committed to learning from all forms of patient feedback, particularly complaints. We strive to use feedback in developing service improvements and
where appropriate, we will help monitor improvement action plans that are put in place following a complaint. Complaints are managed at divisional level,
which means the learning can easily be disseminated to the relevant areas. Where there are corporate themes or issues that affect more than one division,
we ensure that the learning is shared Trust-wide.
We build learning into our processes whether this is from complaints or incidents. We have dedicated patient safety meetings and other governance groups
at which complaints are discussed, focusing on the learning and how to prevent reoccurrence.
Page 25 of 80
We use feedback from our patients to make changes, and when this happens, we are able to highlight this in a “You said, we did” format. We also look at the
themes of complaints which have to be reactivated.
We have made some significant improvements as a direct result of complaints. These have included:




Making adjustments to an Outpatient clinic setting to improve the experience of children with autism.
Providing overnight accommodation for fathers in maternity ward side rooms with their partners.
Making changes to a chemotherapy information leaflet to provide advice on when to call either the 24-hour helpline or 999.
The development and implementation of a new inter-multi-disciplinary team (inter-MDT) referral form, to address communication breakdowns between
specialties and ensure patients are kept appraised of appointments and treatment plans. Total Complaints by Year and Response Rate
Year
Total number of
complaints received
Responses made within
required timescale (%)
2014/15
2015/16
944
843
63.%
87%
Page 26 of 80
Complaints themes for 2015/16
There were 843 Complaints in 2015/16
Theme
Total Number
Attitude
51
Unhappy with treatment
454
Failure/delay with treatment
62
Communication to patient
65
Patient transfer
13
Failure to diagnose
50
Nursing/midwifery Care
25
Waiting for an Outpatient appointment
14
Cases referred to the Parliamentary and Health Service Ombudsman
Where a patient or carer feels we have not responded to a complaint to their satisfaction, they may refer the matter to the Parliamentary and Health Service
Ombudsman to request review and adjudication. Of the 843 complaints received in 2015/16, 18 referrals were made to the Parliamentary and Health Service
Ombudsman. (0.02 per cent of all complaints)
The ombudsman service supported the Trust’s process and response in four cases (upheld organisational finding). Two cases were partially upheld and have received
a formal apology from the Trust and involved a poor complaints process which has been the subject of recent improvement. One case was fully upheld and related to
outcome of a surgical procedure. The remaining 11 referrals are pending an outcome as at May 1st 2016.
Page 27 of 80
DEMENTIA CARE
What we said we’d do:




Improve the patient experience in our Emergency Department and admission areas for people living with dementia and their carers
Improve care for people with dementia and train colleagues to be Dementia Friends
Work in partnership with North East London NHS Foundation Trust
Develop a dementia strategy.
What we’ve done:




Introduced Integrated Care Management (ICM) multi-disciplinary teams, facilitated by the use of teleconferencing. This is where local GPs, community matrons,
social services and geriatricians discuss complex patients with high service use
Created a system where patients who are at risk of emergency admission or who need urgent investigation are referred via the Frail Older People Advisory Liaison
Service (FOPALS) to the day room for urgent assessment and treatment or the Outpatient Hot Clinic, if required
Embedded our Dementia team in the Trust, which has had a positive impact on the Dementia CQUIN and led to improved diagnosis rates in older people
Rolled out dementia friendly modifications on our elderly care wards, including painting colour-coded bays, installing time and date clocks, and using signs on
toilet doors and walls.
What the data shows:



We have so far trained 2,900 colleagues in how to support people with dementia and their carers
All our Executive directors have undergone Dementia Friend awareness training. This will promote consideration of the needs of patients with dementia in the
planning of our services
Over 90 per cent of our patients over the age of 75 have received dementia screening as part of the Dementia National CQUIN.
Page 28 of 80
PRIORITY THREE: CLINICAL EFFECTIVENESS
NICE COMPLIANCE
What we said we’d do:



Develop a process for monitoring and measuring our compliance against NICE guidance.
Develop a process of self-assessment against NICE quality standards.
Ensure a process of dissemination of NICE guidance across the organisation to the relevant departments.
What we’ve done:



Established a NICE Compliance Group which meets on a monthly basis.
Developed and implemented a robust process for how we monitor and measure our compliance against NICE guidance.
Undertaken cycles of testing against the pro forma designed for self-assessment against the quality standards.
What the data shows:

The data demonstrates that there has been improvement, with the latest report showing 87 per cent compliance across the Trust.
What we’re going to do next to continue improvement:


Strengthen our approach to tracking and reporting on our compliance against NICE guidance.
Increase divisional ownership of NICE guidance through our divisional Quality & Safety Advisers and monthly performance reviews.
How this benefits patients:

Through the application of NICE guidance, we ensure that our patients are receiving high standards of care and best practice care.
Page 29 of 80
SEPSIS CARE
What we said we’d do:
Deliver the sepsis bundle which ensures patients receive the right levels of care when attending hospital with a serious condition.
What we’ve done:







Raised awareness of sepsis and implemented an e-learning tool for colleagues.
Implemented a standard sepsis screening tool for adults and paediatrics, including a new adult observation chart.
Commenced an audit in our Emergency Department to assess how we performed against six metrics of sepsis.
Introduced an antibiotic app in order to make it easier for our clinicians to access vital information for the prompt management of sepsis.
Identified a new consultant as the sepsis lead for the Trust.
Identified seven divisional champions to lead and own sepsis quality improvement across all clinical divisions, including maternity and paediatrics.
Fully integrated to the UCLP Sepsis collaborative series in sepsis. This includes 12 NHS Trusts who are sharing knowledge and quality improvement methods to
improve sepsis.
What the data shows:

The data shows that 3916 staff have been trained, which includes 86 per cent of doctors and 97 per cent of nurses in our Emergency department.
Page 30 of 80
PRIORITY FOUR: TIMELY CARE
REFERRAL TO TREATMENT
What we said we’d do:



Conduct a systematic review of potential patient harm arising as a result of long waits for treatment
Validate our patient records to ensure we are working with the most accurate and up to date information
Implement a recovery plan to treat more patients, more quickly.
What we’ve done:



Established a Clinical Harm Review Panel which is chaired by NHS England and attended by a representative from NHS Improvement
Integrated our harm review process within our incident reporting process to understand and act on the effects of potential treatment delays. This process
involves medical and nursing staff reporting harm due to delay as part of the established incident reporting process. In addition to this a number of specific
reviews have been undertaken alongside a review of patients waiting for over one year following referral
A sector-wide recovery plan was agreed with all key stakeholders in September 2015. A recovery programme director was appointed in January 2016 to work with
primary and secondary care participants to take this challenging programme of work forward.
PRIORITY FIVE: EFFICIENT
BUILDING AND DEVELOPING OUR TEAM
What we said we’d do:





Reduce the Trust’s vacancy factor to eight per cent
Reduce time to hire to under to 40 days
Provide a high level of customer/client experience
Reduce sickness levels
Value our team members and support them to develop their skills for the benefit of our patients.
Page 31 of 80
What we’ve done:




Implemented a new recruitment system which has made our recruitment processes more robust and improved our time to hire. Delivered training, advice and
guidance to recruiting managers so they have a better understanding of our recruitment processes
Set up regular meetings with our divisions to discuss their vacancy needs
Launched bi-monthly recruitment campaigns, both in the UK and overseas, with the aim of reducing our vacancy factor
Reduced our colleague sickness rates.
Supporting development
During 2015, a departmental restructure was completed within our Education, Training, Learning and Development service.
This facilitated a fresh leadership approach and focused decision making on the Trust’s Operational Objectives and our
priorities of improving the experience for our trainees, providing conducive learning environments and equipping staff with
the skills to participate, manage and achieve regulated qualifications within their professions.
Medical Student Placements
2%
Queen Mary's
Medical School
University London
6%
10%
University College
London
82%
American
University of
The department has been further strengthened with investment in dedicated skills training posts and a Registered
Caribbean
Workforce Education Manager to complement the Medical Workforce Lead and encourage multi-professional learning. Our
training and access to work portfolio has been streamlined to reflect Health Education England’s Talent for Care Framework
to ‘get in, get on, go further’, and is structured around career pathways, from work experience and apprenticeships to professional registration and beyond.
The Education centres at both Queen’s and King George Hospitals have both been reviewed, resulting in extended opening hours and the provision of dedicated IT
facilities.
During the year, we provided education and training for more than 350 trainees in a range of medical and surgical specialities. We also provided placements for 528
medical students from four medical schools, during the academic year, September 2014 to July 2015.
Our Simulation Centre continues to go from strength to strength and offers a wide range of training opportunities, including:




A dedicated simulation day for undergraduates
A dedicated Intensive Care Nurse programme
A new programme for Paediatric and Anaesthetic trainee nurses and doctors, which focuses on paediatric emergency care
A recovery nurse programme led by Consultant Anaesthetists to review lessons learned from serious incidents in the patient recovery area of theatres.
Page 32 of 80
Our simulation team was nominated in the ‘Innovative Simulation Training’ category at the PGME Awards and has been asked to present a poster at the Trainees in
the Association for the Study of Medical Education (TASME) annual conference in 2016.
Following the appointment of the Director of Medical Education, a new structure has been introduced to support doctors in training and to take forward
improvements suggested in our General Medical Council (GMC) survey and the Health Education North Central and East London (HENCEL) quality plan. We now have
a dedicated Medical Undergraduate Lead and site-based Associate Directors of Medical Education.
The Education department’s ‘Access to work’ team took over responsibility for work experience in September 2015, and from December 2015 to March 2016 we
offered 64 work experience placements to local students. This team has also provided 19 new apprenticeships and supported seven apprenticeship funded diplomas
for our substantive staff. We have also worked with Sodexo to provide an additional ten placements within support services.
In March 2016 we facilitated an introduction to the NHS day for The Prince’s Trust and HENCEL, and 15 local young adults came along to experience a day in the life of
the NHS.
During 2015/16 we focused on increasing staff confidence in the use and understanding of everyday language and culture, and we plan to extend this during the
coming year to meet the needs of trainees from other countries and cultures who will be joining our Trust.
Core skills training has improved considerably during 2015/16. In December 2015, the Trust was awarded a certificate of achievement by the Pan London Streamlining
programme for the greatest improvement in core skills compliance using e-learning.
Our divisions have also been more closely involved in building a Training Needs Analysis and deciding which courses are commissioned and what additional learning
support is required to meet their needs.
Following additional resourcing, our Registered Workforce Education Team, supported by our Divisional Nurses, has increased its focus on mentorship. The number of
‘live’ Stage 2 mentors, those staff who can support learners in practice, improved by 16 per cent between November 2015 and February 2016. We have also further
developed our Preceptorship Programme, which has been extended to cover our Operating Department Practitioners.
We continued to support 200 student nurses from London South Bank University, the University of Hertfordshire and Anglia Ruskin University, and in addition
supported 12 sponsored Health Care Assistants through to Registered Nurse (RN) training.
The Care Certificate was introduced nationally in April 2015 to provide a set of standards for all new care workers, and all Health Care Assistants who have since
started work with the Trust have been issued with a bespoke workbook. The past year also saw the delivery of the first in-house Advance Life Support courses for
several years, and the Education Centre has now been successfully accredited by the Resuscitation Council (UK) to enable the delivery of further programmes in 2016.
Page 33 of 80
During 2016/17, we will be aiming to deliver an education strategy built upon our belief that education opens doors for people, and which underpins our
commitment to recruiting and retaining a workforce that sees high quality patient care as its utmost priority.
DIGITAL BY DESIGN
Technology is critical to delivering safe and effective care.
What we’ve done:







Designed and implemented a faster, more robust computer network.
Provided wireless connectivity enabling more colleagues to access corporate services and the internet from mobile devices.
Changed our current desktop computers and laptops to Windows 7 operating system.
Deployed a single sign-in solution that has the ability to use NHS smart cards to authenticate identity so that users do not need remember countless passwords.
Used technology-based tracking to improve the availability and security of our medical records.
Replaced the network printers across our hospitals.
Expanded wireless provision to enable patients and visitors to use our WiFi.
Page 34 of 80
PRIORITY SIX: EQUITABLE
DIVERSITY OF OUR POPULATION
Our services must be accessible to all people regardless of age, status or specific characteristics. The following actions have been implemented to support our
population’s needs.
LEARNING DISABILITY
What we’ve done:





Advertised the ‘Champion’ role during Safeguarding and Learning Disability training sessions and promoted our quarterly workshops with external speakers
Produced leaflets for colleagues and patients regarding learning disabilities and autism
Implemented a Hospital Passport for children with learning disabilities
Delivered on-going Learning Disability Awareness Training for Outpatient and reception colleagues
Designed and ratified improved Treatment Plan and Transitional documents.
What the data shows:


We increased the number of Safeguarding and Learning Disability Champions from 50 in 2014/15 to a total of 80 in 2015/16
A Hospital Passport belongs to the individual with a learning disability and is a personal record of their health care needs. Our use of the Hospital Passport for
adults has risen from 40 per cent, to an average of 72 per cent between July 2015 and March 2016.
EQUALITY IMPACT ASSESSMENT (EIA) AND EQUALITY AND DIVERSITY
What we said we’d do:


Review our approach to Equality Impact Assessments
Celebrate and promote the diversity of our people through equality, diversity and inclusion initiatives.
What we’ve done:


Issued a new Equality Diversity and Inclusion Policy in October 2015. This states we will undertake Equality Impact Assessments (EIAs) to measure the impact of
policy and service changes and to ensure we understand the needs of our patients, service users, the public and our colleagues
In March 2016 we launched a new approach to EIAs across the Trust, with supporting guidance and pro formas
Page 35 of 80




Secured a London Leadership Academy bursary and used this to co-design bespoke workshops with Capital People on holding open and honest conversations with
our colleagues
Marked NHS Equality Diversity and Human Rights Week in May 2015 with a number of events celebrating the multiculturalism of our people
Worked in partnership with North East London NHS Foundation Trust on our equality goals
We are monitoring the quality and quantity of the Equality Impact Assessments we undertake.
What the data shows:

We have made good use of staff survey and feedback routes to understand our progress and identify areas for further development. The 2015 staff survey shows
we have a more to do in relation to staff reporting harassment from members of the public. The perception of opportunities for career progression and
experience of discrimination are two further areas that will continue to be addressed and reviewed in 2016 via a number of initiatives.
BHRUT 2015
Key finding
% of staff experiencing harassment, bullying or abuse from patients,
relatives or the public in last 12 months
% of staff experiencing harassment, bullying or abuse from staff in last 12
months
% of staff believing that the Trust provides equal opportunities for career
progression or promotion
% of staff who have personally experienced discrimination at work from
manager/team leader or other colleagues
Average Acute
Trusts 2015
BHRUT 2014
White
BME
White
BME
White
BME
33%
32%
28%
28%
29%
34%
31%
31%
25%
28%
30%
32%
82%
64%
89%
75%
84%
68%
9%
18%
6%
13%
7%
15%
Page 36 of 80
How this benefits patients:

Contemporary research clearly demonstrates that diverse and inclusive workplaces increase staff engagement, retention, productivity and service user
satisfaction.
Performance against National Targets and regulatory requirements 2015/16
National Targets
and minimum
standards
Target
Infection Control
Access to Cancer
services
Access to
treatment
Access to A&E
Target
2015/16
2015/16
2014/15
2013/14
2012/13
Number of Clostridium difficile cases
30
36
33
TBC
TBC
Number of MRSA blood stream infection cases
0
5
6
TBC
TBC
97.70%
96.1%
98.0%
96.1%
99.4%
99.60%
99.7%
99.6%
100.0%
100.0%
95.70%
96.1%
98.3%
87.8%
100.0%
97.70%
98.7%
98.7%
95.3%
93.2%
82.50%
74.0%
81.2%
84.2%
83.0%
93.50%
93.7%
94.0%
96.2%
100.0%
94.00%
94.5%
91.3%
90.5%
98.4%
93.00%
93.2%
80.1%
80.4%
96.9%
87.9%
85.3%
88.6%
88.4%
% of cancer patients waiting a maximum of 31 days from diagnosis to
first definitive treatment
% of cancer patients waiting a maximum of 31 days for subsequent
treatment (anti-cancer drugs)
% of cancer patients waiting a maximum of 32 days for subsequent
treatment (surgery)
% of cancer patients waiting a maximum of 31 days for subsequent
treatment (radiotherapy)
% of cancer patients waiting a maximum of 2 months from urgent GP
referral to treatment
% of cancer patients waiting a maximum of 2 months from the
consultant screening service referral to treatment
% of cancer patients waiting a maximum of 2 weeks from urgent GP
referral to date first seen
% of symptomatic breast patients (cancer not initially suspected)
waiting a maximum of 2 weeks from urgent GP referral to date first seen
18 weeks referral to treatment - admitted patients
84.10%
18 weeks referral to treatment - non-admitted patients
94.10%
% of patients waiting a maximum of 4 hours in A&E from arrival to
admission, transfer or discharge
92.00%
Page 37 of 80
Cancelled
Number of in-patients whose operations were cancelled by the hospital
0
524
494
operations
for non-clinical reasons on day of or after admission to hospital
Cancelled
Number of patients whose operations were cancelled by the hospital for
operations not
non-clinical reasons on day of or after admission to hospital, and were
0
38
39
performed within
not treated within 28 days
28 days
Data Source: Trust performance information and Health & Social Care Information Centre, based on National Return dataset
378
400
14
11
The NHS Outcomes Framework 2015/16 indicators
The NHS Outcomes Framework sets out high level national outcomes which the NHS should be aiming to improve. An overview of the organisation’s delivery
against these outcomes is provided in the table below, alongside commentary on our performance against each.
Domain
Indicator
2015/16
National
Average
Trust statement
2014/15
2013/14
2012/13
1: Preventing
People from
dying
prematurely 2:
Enhancing
quality of life for
people with
long-term
conditions
Summary Hospital
Mortality Indicator
(“SHMI”) and
banding
1.0071 Oct
2014-Sept
2015 Latest
available data
1
BHRUT considers that this data is
as described for the following
reasons:
0.9645
0.951
0.9679
July 2014June2015
April
2014March
2015
Jan 2014Dec 2014
Band 2 As
Expected
Band 2 As
Expected
Mortality reduction is a constant
focus for the organisation.
Information related to this area is
considered monthly with
appropriate improvement action
taken where required.
Band 2 As
Expected
Band 2 As
Expected
Band 2 As
Expected
BHRUT continues to work to
reduce mortality rates and harm
through a range of improvement
projects which are detailed within
this account.
Percentage of
admissions with
palliative care coding
1.50%
1.38%
BHRUT considers that this data is
as described for the following
reasons:
1.36%
0.97%
0.92%
Page 38 of 80
The organisation has a wellestablished palliative care team to
support patients across both
hospital sites. We continue to take
action to improve this percentage
which reflects our commitment to
delivering high quality palliative
care to our patients.
3: Helping
people to
recover from
episodes of ill
health or
following injury
3: Helping
people to
recover from
episodes of ill
health or
Patient reported
outcome measures
scores for groin
hernia surgery
0
0.088
BHRUT considers that this data is
as described for the following
Apr 15-Sept reasons: Limited submission of
15
data in the PROMS surveys makes
conclusions on this data difficult.
No Score
due
to
limited
submission
No Score 0.35
due
to
limited
submissio
n
Patient reported
outcome measures
scores for varicose
vein surgery
Procedure not
undertaken
0.523
No Score
due
to
limited
submission
No Score
due
to
limited
submissio
n
No Score
due
to
limited
submissio
n
Patient reported
outcome measures
for hip replacement
surgery
No Score due
to limited
submission
0.404
0.363
0.412
Patient reported
outcome measures
scores knee
replacement surgery
No Score due
to limited
submission
BHRUT intends to take action to
improve this score and the quality
Apr 15-Sept of its services, by relaunching the
15
PROMS programme within the
organisation and participating in a
national study which will require
0.454
>50% participation. This increase
in usage will provide statistically
Apr 15-Sept
significant data with which to
15
consider patient reported
outcomes with existing outcomes
0.334
data.
2.063
0.26
0.25
6.43%
7.61%
8.33%
28 day readmission
rate for patients
aged 0 to 15
6.28%
April 2015-Dec
2015 Most
recently
available data
7.25%
BHRUT considers that this data is
as described for the following
reasons :
Information related to hospital
readmission is reported monthly to
Page 39 of 80
following injury
28 day readmission
rate for patients
aged 16 or over
10.62% April
2015-Dec
2015 Most
recently
available data
7.89%
enable improvement action on
areas outside of expected ranges.
The continued improvement seen
within paediatrics is welcome and
reflects the work undertaken to
ensure the safe discharge of
children to their homes.
10.04%
9.23%
8.28%
BHRUT serves a local population
which has a higher than average
number of elderly people many of
whom live alone both of these
points make readmission more
likely.
BHRUT intends to take action to
improve this score and the quality
of its services by: Undertaking
readmissions audits and working
with partners to identify and
support patients at high risk of
readmission. We also use a system
called health analytics to identify
people at most risk which enables
the community services to better
support patients and carers
4: Ensuring that
people have a
positive
experience of
care
Responsiveness to
the personal needs
of patients
77%
TBC
DATA not yet available as at 17th
May 2016
*
*
*
60%
70%
BHRUT considers that this data is
as described for the following
55%
54%
47%
National Inpatient
Survey
Percentage of staff
who would
recommend the
Page 40 of 80
provider to friends
and family needing
care
reasons:
Although not at national average,
the results show a year on year
improvement and this coincides
with considerable focus to improve
the quality of care through
recruitment and service
development whilst investing in
our team members to ensure
suitable levels of skills and ability.
2015 National NHS
Staff Survey ( 1,925
respondents)
BHRUT continues to focus on this
area through a range of
improvement projects which are
detailed within this account.
5: Treating and
caring for
people in a safe
environment
and protecting
them from
avoidable harm
The percentage of
patients who were
admitted to hospital
and who were risk
assessed for venous
thromboembolism
93.98%
95%
BHRUT considers that this data is
as described for the following
reasons:
96.37%
96.14%
94.79%
8.94
6.38
16.92
Technical issues have prevented
the accurate recording of VTE
assessment It is likely that there is
a considerably higher percentage
of patients assessed than 95%
BHRUT continues to focus on this
area through a range of
improvement projects which are
detailed within this account.
5: Treating and
caring for
people in a safe
environment
and protecting
The rate per 100,000
bed days of cases of
C difficile infection
reported within the
trust amongst
11.77
( 36 appointed
cases)
14.27
BHRUT considers that this data is
as described for the following
reasons:
Achievement of this target has
proved a challenge and work
Page 41 of 80
them from
avoidable harm
patients aged 2 or
over during the
reporting period.
continues to secure further
improvement. Although above the
national average and completing
the year six cases over the
expected level, a wide range of
actions to prevent, detect, isolate
and manage this condition have
been delivered.
BHRUT continues to focus on this
area through a range of
improvement projects which are
detailed within this account.
The number, where
available, and rate of
patient safety
incidents reported
within the Trust
*High reporting in
this area is seen as a
positive sign of a
strong or growing
safety culture
The number and
percentage of
patient safety
incidents that
resulted in severe
harm or death
4,726
Incidents
reported
28.84 Rate per
1,000 bed
days
Apr 15-Sept 15
1.1%
50 incidents
reported
April – Sept
2015 Most
recently
available data
39.29
National
average
rate per
1,000 bed
days
BHRUT considers that this data is
as described for the following
reasons:
24.35
October
2014Improvements in incident reporting march
have been a key action of the
2015
organisation in 2015 and it is
Apr 15-Sept positive to see improved reporting
rates. Improvements to the
15
incident reporting process were
undertaken in 2015 and this
included significant work on the
0.4%
1.3%
categorisation of harm which was
not consistent in 2014.
2,717
57
incidents
incidents
BHRUT continues to focus on this
nationally area through a range of
October
improvement projects which are
April – Sept
2014detailed within this account * see
2015 Most
march
incident reporting and harm
recently
2015
reduction sections.
available
data
Not
available
Not
available
0.4%
0.3%
16
incidents
13
Incidents
April 2014 October
– Sept 14 2013-31st
March
2014
Page 42 of 80
4: Ensuring that
people have a
positive
experience of
care
Inpatient Friends and
Family Test
Friends and Family
Test Accident &
Emergency
BHRUT considers that this data is
as described for the following
reasons:
BHRUT continues to focus on this
area through a range of
improvement projects which are
detailed within this account * see
patient experience.
Data Source: Trust performance information and Health & Social Care Information Centre, based on National Return dataset
Page 43 of 80
COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN) DELIVERY 2015/16
During the reporting period a proportion of BHRUT’s annual income was conditional on achieving quality improvement and innovation goals under the
Commissioning for Quality and Innovation payment framework (CQUIN) agreed between the provider and any person or body they have entered into a contract,
agreement or arrangement with for the provision of NHS services. Schemes under which the organisation participated in CQUIN schemes area as follows
CQUIN SUMMARY 2015/16
Achievement
NATIONAL CQUIN
Item No. CQUIN
RAG
Value
Q1
Q2
Q3
Q4
£890,345
£89,034
£178,069
£178,069
£445,172
£445,172
£89,034
£89,034
£0
£66,775
Sepsis Antibiotic
Administration
The number of patients who present to emergency
departments and other wards/units that directly admit
emergencies with severe sepsis, Red Flag Sepsis or Septic
Shock (as identified retrospectively via case note review of
patients with clinical codes for sepsis) and who received
intravenous antibiotics within 1 hour of presenting.
£445,172
N/A
£89,034
£0
£66,775
3a
Dementia
i. The proportion of patients aged 75 years and over to
whom case finding is applied following an episode of
emergency, unplanned care to either hospital or community
services;
ii. The proportion of those identified as potentially having
dementia or delirium who are appropriately assessed;
iii. The proportion of those identified, assessed and referred
for further diagnostic advice in line with local pathways
agreed with commissioners, who have a written care plan
on discharge which is shared with the patient’s GP.
£534,207
£133,552
£133,552
£133,552
£133,552
3b
Dementia
£89,034
N/A
N/A
£0
£44,517
3c
Dementia
£267,103
N/A
N/A
£0
£133,552
7a
UEC Menu
£1,705,190
N/A
N/A
£852,595
£852,595
£4,376,225
£311,621
Value
Q1
£619,283
N/A
£66,000
£276,641
£276,641
£146,672
N/A
N/A
£73,336
£73,336
£391,126
N/A
£130,375
£130,375
£130,375
1a
Acute Kidney Injury
2a
Sepsis Screening
2b
Scheme Summary
The percentage of patients with AKI treated in an acute
hospital whose discharge summary includes each of four
key items:
1. Stage of AKI (a key aspect of AKI diagnosis);
2. Evidence of medicines review having been undertaken (a
key aspect of AKI treatment)
3. Type of blood tests required on discharge; for monitoring
(a key aspect of post discharge care);
4. Frequency of blood tests required on discharge for
monitoring (a key aspect of post discharge care).
The total number of patients presenting to emergency
departments and other units that directly admit
emergencies who met the criteria of the local protocol and
were screened for sepsis.
To ensure that appropriate dementia training is available to
staff through a locally determined training programme.
To ensure that carers of people with dementia and delirium
feel adequately supported.
Reducing the proportion of avoidable emergency
admissions to hospital.
NATIONAL CQUIN TOTAL
LOCALLY AGREED CQUIN NELC & Essex
Item No. CQUIN
1b
Acute Kidney Injury Early Implementation
of GP Alerts
4a
Integrated Care
Management - End of
Life
4b
Integrated Care
Management -
In line with patient safety alert, communication with
appropriate primary care providers to ensure they seek
advice if test results are received.
Data sharing - accessing, amending care plans for End Of
Life cohort of patients seen by the specialist Pallative Care
team. To develop universal process for sharing EOL DNR
status and EOL plans with the relevant stakeholders.
Secondary care consultants liaising with GP colleagues in
community.
£489,690
£1,164,216
Achievement
Q2
Q3
£1,742,938
RAG
Q4
Page 44 of 80
3c
Dementia
7a
UEC Menu
To ensure that carers of people with dementia and delirium
feel adequately supported.
Reducing the proportion of avoidable emergency
admissions to hospital.
£267,103
N/A
N/A
£0
£133,552
£1,705,190
N/A
N/A
£852,595
£852,595
£4,376,225
£311,621
Value
Q1
£619,283
N/A
£66,000
£276,641
£276,641
£146,672
N/A
N/A
£73,336
£73,336
Secondary care consultants liaising with GP colleagues in
community.
£391,126
N/A
£130,375
£130,375
£130,375
Reduction in LOS, admissions and readmissions.
£684,470
N/A
N/A
£342,235
£342,235
£352,013
N/A
£117,338
£117,338
£117,338
£586,689
N/A
N/A
£293,344
£293,344
NATIONAL CQUIN TOTAL
LOCALLY AGREED CQUIN NELC & Essex
Item No. CQUIN
1b
Acute Kidney Injury Early Implementation
of GP Alerts
4a
Integrated Care
Management - End of
Life
4b
4c
5a
Integrated Care
Management Discharges
Integrated Care
Management Outcomes
Paeds Admission
Avoidance
In line with patient safety alert, communication with
appropriate primary care providers to ensure they seek
advice if test results are received.
Data sharing - accessing, amending care plans for End Of
Life cohort of patients seen by the specialist Pallative Care
team. To develop universal process for sharing EOL DNR
status and EOL plans with the relevant stakeholders.
GP advice and guidance hotline, Training in Primary Care,
Short Stay Paediatric Assessment Unit, Home Care Team.
Reduction in the number of paediatric admissions with
identified conditions.
£489,690
£1,164,216
Achievement
Q2
Q3
£1,742,938
RAG
Q4
5b
Paeds - Outcomes
6
Cancer
Radiology Safety netting and Lung Cancer pathway
£479,129
N/A
£159,710
£159,710
£159,710
Urgent Care
Delivery of the Ambulatory Care pathway to deliver on the
BCF and QIPP targets.
£814,845
N/A
N/A
£325,938
£488,907
£4,074,227
£0
Value
Q1
Q2
Q3
Q4
To ensure 90% of eligible patients have no more than one
CD4 count within 12 months
£145,963
£14,596
£14,596
£14,596
£102,175
To work with the new ODN to develop patient pathways for
treatment of and prescribing Hep C drugs
£145,963
£14,596
£14,596
£58,386
£58,386
7b
LOCAL CQUIN TOTAL
NHSE CommissionLOCAL CQUIN
Item No. CQUIN
1b
4a
HIV: Reducing
unnecessary CD4
monitoring
Improving Pathways
within Hepatitis C
Networks
£473,423
£1,718,918
Achievement
£1,881,887
RAG
4b
Reduce ICU Delays
To reduce ICU Delays to 90% in < 24 hours
£145,964
N/A
£29,193
£43,789
£72,982
4c
Oncotype DX
Gene testing for patients with newly diagnosed breast
cancer
£115,765
N/A
N/A
N/A
£115,765
£553,655
£9,004,107
£29,192
£340,813
£58,385
£1,021,497
£116,771
£2,999,905
£349,308
£3,974,133
LOCAL CQUIN TOTAL
TOTAL
£8,336,348
93%
Key
Not Achieved
Partially Achieved
Achieved
Page 45 of 80
CARE QUALITY COMMISSION REGISTRATION AND COMPLIANCE
Trust is required to register with the Care Quality Commission (“CQC”) under section 10 of the Health and Social Care Act 2008.The CQC is the independent regulator
of health and social care in England. It makes sure health and social care services provide people with safe, effective, caring, well-led and responsive care, and
encourages care services to improve.
The CQC inspects hospitals and other health and social care providers to make sure they meet fundamental standards of quality and safety, and publishes its findings.
BHRUT NHS Trust is required to register with the CQC.
At all of our three sites, our current registration status is ‘ Requires Improvement ‘
CQC registration status as of 02/07/2015.The CQC visited our hospitals between 2-6 March 2015 to carry out a re-inspection of our core services of Urgent and
Emergency Services, Medical Care including older people’s care, Surgery, Critical Care, Maternity and Gynaecology, Children and Young People, End of Life Care and
Outpatients. Each of these areas provided a range of data on topics such as the number of incidents or complaints, its performance data on audit, staffing levels and
training, infection control and environment and plans for the future. The information from the core services was supplemented by a wide range of additional
information about how we are organised and managed.
The CQC published its ratings of the services provided by the organisation on 2 July 2015 and deemed that progress had been made. However, sufficient progress had
not been made to take the Trust out of ‘special measures’.
Under the leadership of the Trust Executive Team, the organisation has delivered an extensive action plan to address areas identified for improvement, which
included a range of ‘must do‘ actions requiring urgent attention. Progress against these actions is as per plan and many are outlined within this quality account.
Monthly updated are provided to the Board on our progress against the Improvements plan, ‘Delivering our Potential’. The updates are published on the Trusts
website and can be accessed at: http://www.bhrhospitals.nhs.uk/improvement-plans?media_search_type=10&media_folder=24&root_folder=Our%20potential%20%20CQC%20improvement%20plans&media_status=archived
Page 46 of 80
OUR FUTURE: QUALITY PRIORITIES AND PROJECTS FOR IMPROVEMENT IN 2016/17
Within this account we have demonstrated progress against five key areas which define quality as a whole.
Considerable improvements have been shown in the culture and practices of our teams and the benefits to patients are clear. We need, however, to go further as
more remains to be done.
During 2016/17, we will continue with increasingly ambitious improvement objectives.
Each of our priorities is led by an Executive Director to ensure that support is provided and progress is made. The Medical Director and Chief Nurse hold responsibility
for delivery of the direct clinical aspects, whilst direct operational priorities rest with the Chief Operating Officer.
Progress in these areas and risks to delivery will be reported monthly through the following groups/committees:
 Trust Board
 Trust Executive Committee
 Quality Assurance Committee
 Audit Committee
 Quality Governance Steering Group
 Clinical Quality Review Meeting with our Commissioners
Trust Priority
Safety
What will we do?
How will we know if this is achieved?
How will we monitor this?
Increase incident reporting whilst
reducing harm from incidents
Achieve an incident reporting of 39 per 1000 bed days
(national average) by April 2017
Percentage of incidents resulting in moderate or
greater level of harm to be less than 1 per cent of all
incidents reported by April 2017
Monthly incident reporting rates and quarterly
national reporting
Monthly incident reporting rates and quarterly
national reporting
Reduce the number of falls
5 per cent reduction in patient falls
Reduce hospital acquired
pressure ulcers
10 per cent reduction in hospital acquired pressure
damage
Monthly falls reporting via the falls prevention group
and integrated quality report
Monthly pressure ulcer reporting via the falls
prevention group and integrated quality report
Reduce healthcare acquired
infections
Achievement of national stretch targets for HCAI (zero
MRSA bacteraemia, 30 cases hospital attributed C.
difficile infection)
Daily review of infection rates and measuring
preventative measures alongside monitoring by the
Infection prevention and control group
Page 47 of 80
Trust Priority
What will we do?
How will we know if this is achieved?
How will we monitor this?
Divisional monitoring and Integrated quality report
Improve diagnostic processes
Reduced clinical incidents related to diagnostic
processes and delivery of an improvement programme
in radiology
Sepsis steering group monitoring and associated
dashboard
Improve management of sepsis
care
Achievement of the national Sepsis CQUIN 2016/17
(90 per cent achievement of patient’s assessment for
sepsis risk, where appropriate and >90 per cent
subsequent delivery of the sepsis six actions, including
antibiotic administration within one hour of arrival in
hospital
Increase discharge rates between 8am and 12 noon,
per ward
Rates of discharge from hospital and reduced incident
rates related to discharge
Reduced delays experienced by families and improved
experience of support and shown in feedback
Bereavement centre reporting
Increased rates of response will improve the reliability
of our measure of patient experience
Monthly patient experience dashboard
Achieve 90 per cent 25 day response rate and 20 per
cent reduction in reopened complaints
Monthly patient experience dashboard
Achievement of the improvement trajectory set
Monthly performance report
Improved patient satisfaction within admission areas
Monthly patient experience dashboard
Reduced clinical incidents resulting in harm from our
admission areas
Integrated Quality Report
Clinical
effectiveness
Improve the hospital discharge
process & overall quality
Patient
experience
Improve the bereavement service
and establish a feedback service
for family members
Increase patient feedback rates in
A&E & Outpatients services
Improve our responsiveness to
complaints and resolution
Timely care
Improve delivery of NHS
constitutional standards (Referral
to treatment standards, cancelled
surgery and Cancer wait) through
delivery of an improvement
programme in 2016
Improve the processes of care
during the first 24 hours of
emergency admission
National CQUIN return
Reduced delays and improved patient flow between
Page 48 of 80
Trust Priority
What will we do?
How will we know if this is achieved?
How will we monitor this?
admission areas and wards
Efficient
Equitable care
Deliver a reduction in agency
usage based on 2015/16 levels
Reduce staff sickness based on
2015/16 levels, towards an
intended 3.2 per cent
Increase critical care capacity for
patients requiring this level of
support in both emergency and
elective ( planned surgery)
settings
Work to recognise the diversity
of the population we serve and
work with partners to understand
access to our services
Delivery of the reporting program and trajectory set
Safe Staffing monthly reporting process
Delivery of the reporting program and trajectory set
Monthly performance report
Increased capacity
Critical care unit reporting & national submissions on
critical care transfers
Profile of the local population and needs reflected in
service design and planning
Audit process and service user feedback
Page 49 of 80
OUR QUALITY IMPROVEMENT STRATEGY
As our 2016/17 quality improvement priorities set out, we are committed to being an outstanding provider of healthcare for our community. It is our duty and
responsibility to protect our patients from unintentional harm and our ultimate goal should be to provide zero defect healthcare.
This ambition won’t be achieved through commitment alone. The safest and most effective healthcare organisations in the world benefit from an improvement
structure and strategy that sets out the principles for delivering high quality harm free care and how to achieve this.
The PRIDE Way
We are one of five English NHS trusts chosen to form a partnership with the Virginia Mason Institute (VMI). Virginia Mason is a not-for-profit provider of health
services in Seattle, USA and is widely regarded as running one of the safest hospitals in the world.
The relationship between BHRUT and VMI offers us an opportunity to implement an evidence-based quality improvement culture and methodology to the benefit of
our patients, visitors and staff. The PRIDE Way is the locally branded adaptation of the Virginia Mason Production System
and will become our change management approach and a fundamental part of our culture.
Our first two value streams (The First 24 Hours of Emergency Admission and Improved Diagnostic Processes) will launch in
2016. This will be the first time the methodology has been applied in its entirety within our organisation and the first step in
its adoption as our change management approach.
The implementation of this method, our approach to quality improvement and change management and our commitment to
a Kaizen approach of continuous, incremental improvement will enable us to meet the requirements of the CQC and be safe,
effective, caring, responsive and well-led.
By linking our vision, values, strategy and operational plan we will put the patient at the heart of everything that we do.
Principles
The PRIDE Way is based on lean principles of improvement. Our focus for all improvement work within our hospitals is the elimination of waste, the standardisation
of work, a focus on mistake proofing and the principle of just-in-time. This means providing our patients and staff with what they need, in the quantity they need it
and at the time they need it.
Our focus is the creation of value added activity as determined by our patients and represented in our strategy below. The Kaizen approach of continuous
incremental improvements will become our method as staff education and training builds up the required knowledge of The PRIDE Way.
Page 50 of 80
Engagement and workforce compatibility
The cornerstone of the success of our strategy is our shared vision for what we want to be in the future. This
vision is captured in our patient triangle (see illustration). We will embark on a series of projects aimed at
fostering a culture of safety, including training and coaching in teamwork and communication.
Improving communications and engagement
In May 2015 our board approved our Communication and Engagement Strategy – PRIDE with a smile. It set out a
change in our approach to communicating with our 6,500 staff and volunteers and our local community of
750,000 people.
Metrics to assure the delivery of our communications approach are formally reported to the quality and
assurance committee, which has four priorities:




Support the organisation to help improve operational performance and patient experience
Improve staff engagement
Improve stakeholder elations
Improve our reputation
Particularly in relation to improving quality, over the last six months we’ve been working hard to have conversations with our teams and the public about safety,
challenging our track record around quality and a fear of being open and honest when we get things wrong.
Our transformation started two years ago after we were put into special measures - hosting staff forums, breakfast sessions, liberating our teams to use social media,
inviting local councillors and MPs to visit our services and speak to our teams.
Following our re-inspection, it was clear we still had more to do, so we designed a safety campaign in partnership with the Good Governance Institute, focussing on
five key themes:





Duty of candour
Patient falls
Medicines management
Raising concerns
Keeping patient records safe
Page 51 of 80
The campaign was built on the premise that patient safety is everyone’s responsibility. We launched monthly patient safety memos and supported these through all
our communication channels. Each week our medical director also chaired, and continues to chair, a patient safety summit with between 50-80 colleagues, following
which we share our ‘patient safety messages’.
To reach our mobile workforce across our hospitals, our quality and safety advisors had ‘corridor conversations’ on the wards, and we used online surveys to capture
frontline views on each of the safety themes.
As a result of this work, we have seen measurable improvements including increased incident reporting rates, improved reporting around falls and small but welcome
changes in our staff survey results.
The next step is to continue with the focus on learning through our partnership with the Virginia Mason Institute, our long-term programme of quality improvement
that we’ve called the PRIDE way.
Working in Partnership
To achieve our objectives and improve the quality of care we provide, we also need to work effectively in partnership with our patients, local community and
stakeholder groups.
This year we are building on our relationships with our stakeholders and our patients to make sure they are at the centre of developments in our hospitals.
We manage a programme of events throughout the year to engage with our community, including public listening events, Twitter chats, meetings of our Local
Representatives’ Panel, and visits to our services. Our GP Liaison Service has also gone from strength to strength, greatly improving links with our local practices to
the benefit of patients.
Page 52 of 80
STATEMENT OF ASSURANCE FROM THE BOARD
Data Quality
Our Data Quality strategy sets out the mechanisms by which we manage and process information and ensure sufficient quality is maintained.
Achieving high levels of data quality assists us directly in the delivery of high quality care and supports us in the following areas:
 Ability to assess our service quality and outcomes and monitor progress. Producing accurate external returns demonstrates our accountability to public
funders and regulators.
 Ensuring there is accurate and comprehensive funding allocation and income for the services we provide.
 Making strategic and service decisions, based on evidence.
 Investigating or diagnosing suspected problems or evaluating service changes.
Our aspiration is that our data is of sufficient quality to be:
 Viewed as important and as everyone’s responsibility.
 Owned by frontline services, and subject to routine monitoring and independent assurance (in line with the Francis recommendations).
 Believed and considered to be reliable.
 Collected the same day.
 Free from omission, duplication or error.
 Codified and structured.
 Entered only once, reducing the burden on frontline teams.
 Analysed directly from source data by appropriately trained information analysts.
What we said we’d do in 2015/16 to enhance data quality:




Create a Data Assurance team.
Create a data quality assurance dashboard.
Establish a Data Quality Group.
Link our Medway Patient Administration System to the national spine service (NHS IT System).
What we’ve done:


We have created a link to a national spine mini service. This allows us to update patients’ forenames, deceased data and GP practice code.
We have developed a suite of reports to cover data quality.
Page 53 of 80
What the data shows:
Information Governance
Information Governance is a combination of legal requirements, policy and best practice designed to ensure information capture, processing and storage are of the
highest standards and protected from inappropriate disclosure.
Information Governance consists of the following:
 Confidentiality and data protection
 Information security
 Data quality
 Records management and access
 Freedom of Information
 Caldicott principles
Our self-assessment in 2015 using version 13 of the IG toolkit demonstrates the following compliance to level 2.
Page 54 of 80
What we’ve done in 2015/16 to improve compliance with the IG toolkit include:



Establishing a dedicated Information Governance Team. This raises the profile of Information Governance and enables compliance with the toolkit.
Implementing an Information Governance training module for our colleagues. This is now linked to our statutory and mandatory electronic training system.
Working closely with our IT team to make sure that our IT systems, processes and procedures are compliant with best practice Information Governance standards
and security.
What the data shows:

The data shows compliance against Information Governance training with a target set at 95%.
Page 55 of 80
Clinical Coding
Clinical Coding is the translation of medical terminology to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into
a coded format which is nationally and internationally recognised. For the Clinical Coding data to accurately reflect our activity, clear, accurate and timely recording of
clinical information in the patient’s notes, clear procedures for collecting and processing the data and appropriate training and accreditation of staff are necessary.
What we said we’d do:




Achieve 100 per cent compliance with coding on monthly submissions
Reach at least Level 2 coding accuracy on Information Governance
Code 35 – 45 finished consultant episode per clinical coder a day
Recruit to 100 per cent to minimise agency spending.
What we’ve done:





Re-organised our service in line with our divisional structure. This means that there is an identified clinical coding lead
linked to each area
Further utilised the electronic clinical record information available within our IT systems
The team now has a dedicated clinical coding auditor and a clinical coding trainer. This means that all queries regarding coding issues are resolved in house within
timescale
Our dedicated clinical coding trainer enables us to provide in-house training, saving time and resources
We have a validation programme with all the clinical specialities to improve the depth of coding which would lead to positive financial results.
What the data shows:

The data shows that we have submitted 100 per cent of coded activity every month for the last 12 months. This means that we have captured 100 per cent of
admitted patients’ clinical activity and accounted for all the resources used for patients.
What’s going to happen next to continue improvement?

We will continue with our data validation programme, audit and training programme.
Submission of records to the Secondary Uses service for inclusion in the Hospital Episode Statistics
BHRUT submitted records during 2015/16 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data.
Page 56 of 80
Percentage of records in the published data that:
Included a valid patient NHS number



Accident & Emergency: 87.2%
Outpatient Services: 98.6%
Inpatients: 98.5%
Included the patient’s valid General Medical Practice Code:



Accident & Emergency: 99.1%
Outpatient Services: 99.8%
Inpatients: 99.8%
Review of services
During 2015/16 the Trust sub-contracted four relevant health services for the provision of : Hip and Knee surgery, Ear Nose and Throat Surgery, Urgent Care Services
and Elective Pain Management services
Trust has reviewed all the data available to them on the quality of care in all of these relevant health services.
The income related to these services has been received via a block contract arrangement with commissioners for 2015/16
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PARTICIPATION IN CLINICAL RESEARCH
The number of patients receiving relevant health services provided or sub-contracted by the Trust in 2015/16 that were recruited during that period to participate in
research approved by a research ethics committee was 6,785 (2853 2014/15)
Throughout the year, the trust has been involved in 200 studies (170 in 2014/15); 200 were funded ([170] in 2014/15) of which 30% were commercial trial
Clinical Audit Activity in 2015/16
Clinical audit is used to constantly evaluate our services, ensuring the Trust is meeting expected quality standards. It provides evidence of when standards are
adhered to and will also highlight when a service is not meeting an agreed standard, providing a framework for suggesting improvements.
The Trust is required to participate in national audits, conducted by third party organisations, which allows us to compare how well we are delivering against a
national standard compared to other organisations.
Local audits are conducted and evaluated in-house and can include issues that have arisen from complaints monitoring, risk management and clinical incident
reporting. Improving patients’ care, outcomes or experiences all contribute to the selection of local audits where more information is needed, or indeed, to allow the
organisation to utilise its resources better.
Please see Appendices for a detailed analysis of clinical audit activity. Below is a summary of that activity.
National Clinical Audit
Non-HQIP National Clinical Audits
National Confidential Enquiries into Patient
Outcome & Death
Local Clinical Audit
Number of audits participated in
35
9
Possible number of audits available for
participation
40
10
%
participation
88%
90%
2
9
2
9
100%
100%
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STATEMENT OF DIRECTORS’ RESPONSIBILITIES FOR THE QUALITY ACCOUNT
Our Directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The Department of Health has issued guidance on the form
and content of annual Quality Accounts, which incorporates the legal requirements in the Health Act 2009, the National Health Service (Quality Accounts) Regulations
2010 and the National Health Service (quality accounts) Amendment Regulations 2011.
In preparing the Quality Account, Directors are required to take steps to satisfy themselves that:
1. The Quality Account has been prepared in accordance with Department of Health guidance and presents a balanced picture of our performance over the
period covered.
2. The content of the Quality Account is not inconsistent with internal and external sources of information including:
 Board minutes and papers for the period April 2015 to March 2016
 Papers relating to quality reported to the Board over the period April 2015 to March 2016
 Feedback from Clinical Commissioning Groups
 Feedback from local scrutinisers, including Healthwatch and local authority overview and scrutiny committees
 The Head of Internal Audit’s Annual Opinion, April 2016
 National Inpatient Survey 2015
 NHS National Staff Survey 2015
 The General Medical Council’s National Training Survey, 2015-16
 Mortality rates provided by external agencies (Health and Social Care Information Centre and Dr Foster)
3. There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and those controls are
subject to review to confirm they are working effectively in practice.
4. The data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and
prescribed definitions, and is subject to appropriate scrutiny and review.
The Directors have reviewed the Quality Account and confirm to the best of their knowledge and belief they have complied with the above requirements in preparing
the Quality Account.
Signatures
Chief Executive
Chair
Page 59 of 80
PART THREE
What others say about us
Or draft Quality Account has been shared with stakeholders both for assurance and to increase understanding
of the value of the report and how we record the data for each of our quality priorities.
By sharing a draft version of our Quality Account with our stakeholders we have given them the opportunity to
provide formal feedback on how we are performing. This Quality Account has been reviewed by the following:
Barking, Havering and Redbridge University Hospitals NHS Trust Commissioners’ Statement for 2015/16
Quality Account
NHS Havering Clinical Commissioning Group welcomes the opportunity to review the Quality Account (the
Account) for Barking, Havering and Redbridge University Hospitals NHS Trust (the Trust) and to provide this
statement. This statement has been prepared in collaboration with Barking and Dagenham and Redbridge
CCGs.
We confirm that we have reviewed the information contained within the Account and checked this against
data sources where these are available to us as part of existing contract assurance and monitoring processes
and can confirm that we believe it is mostly accurate in relation to the services provided by the Trust.
We have noted the number of examples provided within the Account which attest to the Trust’s achievements
in improving the quality of care and patient experience during 2015/16. We also note and agree to the Trust’s
priorities for 2016/17, although we are disappointed that these were not discussed with us prior to publication
of the Account.
Priority One – Patient Safety - Preventing Harm
The Trust focussed on improving two key systems to provide increasingly safe care; reducing mortality and
improving patient safety through increased incident reporting and increased learning from incidents. The
Trust has achieved the task of clearing a backlog of open serious incident investigations and ensuring zero
breaches of the national reporting timescales. The Trust has put a number of important steps in place which
will drive both the timeliness and quality of serious incident investigations, this includes establishing a weekly
Patient Safety Summit at both hospital sites which has been effective.
The Trust has also made significant progress on incident reporting rates, achieving 32 incidents reported per
1,000 bed days which is close to the national standard. Commissioners note that the Trust has included this as
a 2016/17 priority to meet the national average of 39 incidents per 1,000 bed days and also a commitment to
new programmes of work to reduce harmful incidents.
Priority Two – Improving patient and carer experience
The Account notes achievements in the Trust’s Patient Advice and Liaison Service (PALS) in resolving 88% of
patient queries and concerns promptly to patient and carer satisfaction. Commissioners note the Trust’s
commitment to learning from patient experience, through the PALS, complaints and incidents routes and that
new forums have been put in place to focus on the learning. Commissioners are pleased to see that this
remains one of the Trust’s six priorities for 2016-17, with a target to achieve 90% of patient complaints
responded to within 25 days and to reduce the number of re-opened complaints by 20%.
Priority Three – Clinical Effectiveness – ensuring our processes are correct and up to date
The Trust committed to deliver the sepsis bundle in 2015-16 to ensure that patients receive the right levels of
care when attending hospital with a serious condition. The delivery of the bundle focused on raising
awareness of sepsis, implementing a standard sepsis screening tool and new observation chart and
introducing an antibiotic ‘app’ for clinicians to access vital information for the prompt management of sepsis.
The Trust trained 3,916 members of staff on the sepsis care bundle, and now has 86% of doctors and 97% of
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nurses in the Emergency Department trained, which should improve early recognition and treatment of
patients.
Priority Four – Timely care – reducing and preventing delays in care
Efforts to address this major system issue have not yet delivered the impact and improvements that
commissioners need to see. However, Commissioners note that the Trust has an established harm review
process to understand and act on the effects of potential treatment delays. This process involves medical and
nursing staff reporting harm due to delay as part of the established incident reporting process. In addition to
this a number of specific reviews have been undertaken alongside a review of patients waiting for over one
year following referral. Commissioners do acknowledge that the Trust has invested more resource to help
manage the RTT waiting list, and agree that recent efforts around outsourcing of additional appointments are
having some impact. We continue to work together with the Trust and our regulators to develop and deliver
clear, realistic improvement plans that will achieve the necessary benefits to our patients and meet the
national RTT standard.
Priority Five – Using Resources wisely
The Trust aimed to reduce hire time to under 40 days and to reduce staff sickness levels in 2015-16. The
Account does not state that the Trust achieved the reduced hire time to under 40 days, but states that the
Trust has improved the time to hire, by delivering training, advice and guidance to recruiting managers so that
they have a better understanding of their recruitment processes. The Trust’s work to restructure and
strengthen the Education, Training and Learning Development service is showing a number of successes in
taking forward improvements suggested in the General Medical Council (GMC) survey and the Health
Education North Central and East London (HENCEL) quality plan.
The Trust did not achieve their goal of reducing the vacancy rates to 8%. However, Commissioners note that
the Trust’s 2016-17 priorities build on the infrastructure improvements and the Trust has set ambitious targets
to reduce agency staff and reduce staff sickness towards an intended 3.2%.
Commissioners are pleased that the Trust is incorporating the principles of Right Care in 2016-17 to increase
critical care capacity for patients in both emergency and elective (planned) care settings, which is underpinned
and reinforced by the Trust’s Quality Improvement Strategy to become an outstanding provider of healthcare
in the community.
Priority Six – Equitable care – meeting patients’ needs
The Trust recognises the need to ensure that their services are equally accessible to all people regardless of
age, status or specific characteristics, and has focused on improving access for patients with learning
disabilities. The Trust has improved access support for patients with learning disabilities by increasing the
number of Safeguarding and Learning Disability Champions by 60%, and the improved uptake of the Hospital
Passport is commendable.
Priorities not fully met during+ 2015-16
We note the following priorities which were not fully met in 2015/16:
 National Clinical Quality Indicators (CQUINs) were set for sepsis screening and prompt administration
of antibiotics, which the Trust did not meet in Q3. Commissioners note a number of serious incidents
reported where sepsis was not recognised or treated within the advised period, and also a number of
serious incidents related to deteriorating patients. The Trust has recognised that this is a key area for
improvement, and has specifically included as a 2016-17 priority to improve diagnostic processes and
the management of sepsis care in terms of clinical effectiveness. Commissioners are assured that the
Trust has recognised the importance of improving in this area

Infection Prevention and Control is one of the Trust’s key clinical priorities. It is disappointing that the
Trust did not meet its target for both MRSA bacteraemia and C.Difficile infection, and that screening
levels for MRSA colonisation prior to surgery are below an acceptable level. However, Commissioners
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note by the Trust’s intentions to continue to work with GPs and wider community to ensure
appropriate antibiotic use is maintained across all services, and are pleased that the Trust’s priority in
2016-17 is to reduce healthcare-acquired infections

Commissioners have been made aware through the Serious Incidents process of a number of falls
which have caused harm. Although the Trust has reported that there continues to be a decrease in
falls per thousand bed days in comparison with the previous year, and that the Trust is below national
averages for patient falls, the data provided in the report does not break the data down by harm
levels. Commissioners would have liked to have seen more evidence of a downward trajectory of falls
which have caused severe harm, and narrative in that section on how the Trust intends to improve
this. However, Commissioners are assured by the Trust’s continued actions to reduce the number of
falls by 5% in 2016-17 and this will be closely monitored at the monthly Clinical Quality Review
Meetings (CQRMs)

The Account highlights the Trust’s progress against the NHS Outcomes Framework 2015/16 indicators.
The Trust has reported as an outlier against the 28 day readmission rate for patients aged 16 and over;
10.62% of patients readmitted within 28 days against the national average of 7.89%. The Trust has
given mitigation of the local population having a higher than average number of elderly patients living
alone which they state makes re-admissions more likely, and that they are undertaking actions to
perform readmission audits and working with partners to support patients at high risk of readmission.
The Trust notes the use of the Health Analytics system to enable them to easily identify patients most
at risk, and Commissioners note that the Trust has prioritised work on patient acuity profiling in their
2016-17 priorities
We are pleased to note that the Trust confirms completion of the majority of the CQC’s ‘must-do’ findings and
we are in agreement with this.
Commissioners continue to be committed to working collaboratively with the Trust to support delivery of
these improvements, along with the Trust’s 2016-17 priorities and will continue to monitor delivery through
the monthly CQRM.
We believe that the Account represents a fair overview of the quality of care delivered by the Trust and overall
we welcome and support the vision described within the Account and agree on the priority areas. We will
continue to strengthen our good relationship with the Trust to work with and fully support them to continually
improve the quality of services provided to patients.
Yours sincerely
Dr Atul Aggarwal
Conor Burke
Chair
Accountable Officer
Havering Clinical Commissioning Group
Havering Clinical Commissioning Group
Also on behalf of the collaborative commissioning arrangements for Barking, Havering and Redbridge
University Hospitals NHS Trust
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STATEMENTS FROM HEALTHWATCH
BHRUT QUALITY ACCOUNT – response of Healthwatch Havering
The Quality Account demonstrates an organisation which last year recognised the areas which needed to be
addressed and established an ambitious and detailed plan of work. The account sets out clearly a range of
various interventions and measures which supports the Trusts priorities. Within the organisation there has
been a considerable amount of work undertaken by all the staff to develop a new culture and approach to
patients care and this has been particularly demonstrated at the BHRUT’s Improvement Plan Oversight and
Assurance Group which we attend.
There has been progress in a number of ways such as the clearing of the backlog of Serious Incidents and there
now being no further breaches. The training of over 2,900 staff in how to support people with dementia and a
90% assessment for dementia screening has been achieved.
BHRUT has embraced the concerns of families with children with learning disabilities and the concerns of
people with learning disabilities. This is demonstrated by an increase in the number of Safeguarding and
Learning Disability Champions from 50 in 2014/15 to a total of 80 in 2015/16. A Hospital Passport belongs to
the individual with a learning disability and is a personal record of their health care needs. The use of the
Hospital Passport for adults has risen from 40 per cent, to an average of 72 per cent between July 2015 and
March 2016 and produced leaflets for colleagues and patients regarding learning disabilities and autism.
The National Performance statistics indicate that there has been some improvement however overall there is
less success here in achieving the goals set by the Trust. Currently the causes for on-going concern are in
respect of cancer targets, referral treatment delays and cancelled operations. The scores in the Outcome
Framework also reflect a need for further work in developing appropriate recording measures and risk
assessments. However, there were good indicators such as the re-admission rates for children are good
compared with the national average.
The plan for 2016/2017 addresses some new priorities such as improving the bereavement service and
establishing a feedback service for family members and increasing discharge rates between 8am and 12 noon
on each ward. These new priorities are welcomed as people’s feedback to us is that these are areas which can
cause considerable personal distress to patients and families. In the past year, Healthwatch Havering has
carried out a number of Enter & View visits to various wards and departments at Queen's Hospital, making a
number of recommendations for improvements that would benefit patients. It is pleasing to be able to report
that BHRUT has broadly accepted, and in many cases has implemented, the recommended changes. Delayed
Referrals To Treatment are a matter of considerable concern, although it is recognised that the problem arose
prior to 2014 and is being tackled head on by the current management team. Nevertheless, the concern has
prompted Healthwatch Havering to join with Havering Council's Health Overview and Scrutiny Committee
jointly to review the causes and effects of the delays, with a view to ensuring that future risks of repetition are
avoided. It is pleasing to report that BHRUT is co-operating fully in this process.
Anne-Marie Dean, Chairman Healthwatch Havering
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STATEMENT FROM OVERVIEW AND SCRUTINY COMMITTEE
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INDEPENDENT AUDITOR’S LIMITED ASSURANCE REPORT
INDEPENDENT AUDITORS’ LIMITED ASSURANCE REPORT TO THE DIRECTORS OF BARKING,
HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST ON THE ANNUAL QUALITY
ACCOUNT
We are required to perform an independent assurance engagement in respect of Barking, Havering
and Redbridge University Hospitals NHS Trust’s Quality Account for the year ended 31 March 2016
(“the Quality Account”) and certain performance indicators contained therein as part of our work.
NHS trusts are required by section 8 of the Health Act 2009 to publish a Quality Account which must
include prescribed information set out in The National Health Service (Quality Account) Regulations
2010, the National Health Service (Quality Account) Amendment Regulations 2011 and the National
Health Service (Quality Account) Amendment Regulations 2012 (“the Regulations”).
Scope and subject matter
The indicators for the year ended 31 March 2016 subject to limited assurance consist of the following
indicators:
 Percentage of patients risk-assessed for venous thromboembolism (VTE); and
 Rate of clostridium difficile infections.
We refer to these two indicators collectively as “the indicators”.
Respective responsibilities of the Directors and the auditor
The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial
year. The Department of Health has issued guidance on the form and content of annual Quality
Accounts (which incorporates the legal requirements in the Health Act 2009 and the Regulations).
In preparing the Quality Account, the Directors are required to take steps to satisfy themselves that:
 the Quality Account presents a balanced picture of the trust’s performance over the period
covered;
 the performance information reported in the Quality Account is reliable and accurate;
 there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to confirm
that they are working effectively in practice;
 the data underpinning the measures of performance reported in the Quality Account is robust and
reliable, conforms to specified data quality standards and prescribed definitions, and is subject to
appropriate scrutiny and review; and
 the Quality Account has been prepared in accordance with Department of Health guidance.
The Directors are required to confirm compliance with these requirements in a statement of
directors’ responsibilities within the Quality Account.
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether
anything has come to our attention that causes us to believe that:
 the Quality Account is not prepared in all material respects in line with the criteria set out in the
Regulations;
 the Quality Account is not consistent in all material respects with the sources specified in the NHS
Quality Accounts Auditor Guidance (“the Guidance”); and
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 the indicators in the Quality Account identified as having been the subject of limited assurance in
the Quality Account are not reasonably stated in all material respects in accordance with the
Regulations and the six dimensions of data quality set out in the Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of the
Regulations and to consider the implications for our report if we become aware of any material
omissions.
We read the other information contained in the Quality Account and consider whether it is materially
inconsistent with:
 Board minutes for the period April 2015 to June 2016;
 papers relating to quality reported to the Board over the period April 2015 to June 2016;
 the Trust’s complaints report published under regulation 18 of the Local Authority, Social Services
and NHS Complaints (England) Regulations 2009, dated 26 November 2015;
 the CQC Children and Young People Inpatient survey dated July 2015
 the latest national staff survey dated 22 March 2016;
 the Head of Internal Audit’s annual opinion over the trust’s control environment dated 19 May
2016;
 the annual governance statement dated 1 June 2016;
 the Care Quality Commission’s Intelligent Monitoring Report dated May 2015; and
 feedback from Commissions and the Local Healthwatch.
We consider the implications for our report if we become aware of any apparent misstatements or
material inconsistencies with these documents (collectively the “documents”). Our responsibilities do
not extend to any other information.
This report, including the conclusion, is made solely to the Board of Directors of Barking, Havering
and Redbridge University Hospitals NHS Trust.
We permit the disclosure of this report to enable the Board of Directors to demonstrate that they
have discharged their governance responsibilities by commissioning an independent assurance report
in connection with the indicators. To the fullest extent permissible by law, we do not accept or
assume responsibility to anyone other than the Board of Directors as a body and Barking, Havering
and Redbridge University Hospitals for our work or this report save where terms are expressly agreed
and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement under the terms of the Guidance. Our limited
assurance procedures included:
 evaluating the design and implementation of the key processes and controls for managing and
reporting the indicators;
 making enquiries of management;
 testing key management controls;
 limited testing, on a selective basis, of the data used to calculate the indicator back to supporting
documentation;
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 comparing the content of the Quality Account to the requirements of the Regulations; and
 reading the documents.
A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The
nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately
limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for determining
such information.
The absence of a significant body of established practice on which to draw allows for the selection of
different but acceptable measurement techniques which can result in materially different
measurements and can impact comparability. The precision of different measurement techniques
may also vary. Furthermore, the nature and methods used to determine such information, as well as
the measurement criteria and the precision thereof, may change over time. It is important to read
the Quality Account in the context of the criteria set out in the Regulations.
The nature, form and content required of Quality Accounts are determined by the Department of
Health. This may result in the omission of information relevant to other users, for example for the
purpose of comparing the results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or nonmandated indicators which have been determined locally by Barking, Havering and Redbridge
University Hospitals NHS Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe
that, for the year ended 31 March 2016:
 the Quality Account is not prepared in all material respects in line with the criteria set out in the
Regulations;
 the Quality Account is not consistent in all material respects with the sources specified in the
Guidance; and
 the indicators in the Quality Account subject to limited assurance have not been reasonably stated
in all material respects in accordance with the Regulations and the six dimensions of data quality
set out in the Guidance.
Priorities not fully met
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APPENDICES
National and Local Audits Participated in
National Clinical Audit
Target sample size
Cases submitted (%)
Acute coronary syndrome or Acute myocardial infarction (MINAP).
A report highlighted that cardiac patients should be managed on a cardiac ward under cardiac specialists. This
remains an issue due to small bed capacity at Queen’s Hospital, with loss of beds to the High Dependency Unit.
There are plans to increase capacity and to regain our Coronary Care Unit beds.
All cases
Not known
Bowel cancer (NBOCAP)
All cases
100%
Cardiac Rhythm Management (CRM)
All cases
100%
Case Mix Programme (CMP)
All cases
100%
Diabetes (Adult) (NDFA), Diabetes Foot care
Diabetes (Adult) (NPID), Pregnancy in Diabetes
Not Participating
All cases
100%
78 (KGH 42 QH 36)
100%
All cases
100%
330
80%
From the last report published in December 2015, the Trust has increased to three midwives to focus on a
long-term goal of developing a pre-conception service to address preparation for pregnancy.
Diabetes (Adult) (NADIA), National Diabetes Inpatient Audit
Diabetes (Adult) National Audit (NDA)
Diabetes (Paediatric) (NPDA)
From the last report, published in October 2014, there has been an improvement in mean and median HbA1c*,
however, this is still higher than the national median of 69 mmol/mol. The percentage of children with good
control (HbA1C<58 mmol/mol) has also improved (13.7% for King George Hospital and 11.9% for Queen’s) but
we are below the national median of 15.8%. The BHRUT paediatric diabetes team needs to maintain the effort
to improve control to achieve as per the national average.
Action plan:
 Target children with HbA1c >80 mmol/mol so that limited resources cab be utilised effectively.
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National Clinical Audit





Target sample size
Cases submitted (%)
Participation
Confirmed
100%
All cases
100%
30
100%
Increase clinic capacity.
Appoint an additional dietician.
Explore the funding option for 0.5 psychologist.
Increase the number of patients on pump.
Direct communication from diabetes retinopathy screening service to capture the abnormal results.
* HbA1c refers to glycated haemoglobin. It develops when haemoglobin, a protein within red blood cells that
carries oxygen throughout the body, joins with glucose in the blood, becoming 'glycated'. By measuring
glycated haemoglobin (HbA1c), clinicians are able to get an overall picture of what our average blood sugar
levels have been over a period of weeks/months.
For people with diabetes this is important as the higher the HbA1c, the greater the risk of developing diabetesrelated complications.
Elective surgery (National PROMs Programme)
Emergency use of oxygen
Falls and Fragility Fractures Audit Programme (FFFAP): Falls
The following actions were developed following publication of the latest report in October 2015:
• Continue to raise compliance for patients receiving a lying and standing blood pressure assessment. This
monthly audit and practical training pilot began in April 2016 with a target of 100% of appropriate patient
being assessed.
• All patients at a risk of falls are to have their medications reviewed. Stickers were provided for a pilot that
started in January 2016.
• All patients to have access to appropriate walking aids. Guidelines will be developed in conjunction with the
therapy and nursing teams in the summer of 2016.
• To work with the relevant clinical teams to reference falls prevention in the Dementia Strategy during
summer 2016.
• In February 2016, the membership of the Falls Prevention Group was reviewed to include a member of the
Board.
Falls and Fragility Fractures Audit Programme (FFFAP): Fracture Liaison Service Database
Not participating
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National Clinical Audit
Target sample size
Cases submitted (%)
All cases
100%
Inflammatory bowel disease (IBD) – Biologic rolling audit
197
75%
Lung cancer (NLCA)
344
100%
Major trauma (Trauma Audit & Research Network, TARN)
500+
80%
All cases
100%
Falls and Fragility Fractures Audit Programme (FFFAP): National Hip Fracture Database
Following the publication of the latest report, a new member of staff has been employed. The Trauma Network
have acknowledged the hard work of the Trust.
Maternal, New born and Infant Clinical Outcome Review Programme (MBRRACE-UK)
National Cardiac Arrest Audit (NCAA)
National Comparative Audit of Blood Transfusion programme: 2015 Audit of Patient Blood Management in
Scheduled Surgery
Not Participating
44 - 70
90%
National Comparative Audit of Blood Transfusion programme: 2015 Audit of the Use of Blood in Lower GI
Bleeding (Queen’s)
All cases
100%
National Comparative Audit of Blood Transfusion programme: 2016 Audit of the Use of Blood in Haematology
(Submitted for All)
Up to 40
100%
National Complicated Diverticulitis
Not Participating
National Emergency Laparotomy Audit (NELA)
All cases
91% (KGH 94.4%/ QH 87%)
National Heart Failure Audit
All cases
61%
The latest report was published in October 2015 for the 2013/14 data. We have changed the processes of
obtaining information from clinical coding, resulting in improved data submission.
The report highlighted that cardiac patients should be managed on a cardiac ward under cardiac specialists.
This remains an issue due to small bed capacity at Queen’s Hospital with loss of beds to High Dependency Unit.
There are plans to increase capacity and to regain our Coronary Care Unit beds.
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National Clinical Audit
National Joint Registry (NJR)
Target sample size
Cases submitted (%)
489
96%
National Ophthalmology Database Audit
National Prostate Cancer (NPCA)
National Vascular Registry
Neonatal intensive and special care (NNAP)
Oesophago-gastric cancer (NAOGC)
Latest report received 2014.
Not Participating
310
75%
All cases
100%
All Babies admitted
to the NICU
100%
All cases
100%
30
100%
The following recommendations made by the report have long been implemented at BHRUT:
1. Networks should know the proportion of patients admitted as emergencies and develop strategies for
reducing it. This is a significant problem in this Trust and reflects our demographic and the primary care aspects
of care of these patients. Action has been taken to improve this by communication with GPs.
2. All patients being considered for curative treatment should undergo an endoscopic ultrasound (EUS) (if
oesophageal or upper junctional tumour) or a staging laparoscopy (if gastric or lower junctional tumour).
Cancer services should be encouraged to monitor their use.
3. All patients with oesophageal squamous cell carcinoma (SCC) being considered for curative treatment should
be discussed with both a clinical oncologist who specialises in the treatment of upper GI cancers as well as a
surgeon, to discuss the most appropriate treatment approach.
4. Cancer Networks should monitor treatment of patients with early cancers in particular, and consider referral
of such patients to specialist endoscopic centres where endoscopic treatment may be an option.
5. As surgical mortality continues to fall, increased focus should go into optimising efficacy of surgery (lymph
node yield and proportion of patients with positive longitudinal margins) and complication rates. These should
be monitored prospectively by surgeons.
6. Minimally invasive surgery should continue to be introduced cautiously with particular focus on associated
complication rates and length of stay.
A further recommendation - Networks should consider co-ordinating brachytherapy - is not considered a useful
option at this Trust and we have now abandoned this treatment modality having had this for over a decade.
Paediatric asthma
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National Clinical Audit
Target sample size
Cases submitted (%)
Procedural Sedation in Adults (Care in Emergency Departments)
50
24%
Rheumatoid and early inflammatory arthritis
79
36%
Sentinel Stroke National Audit Programme (SSNAP) - Post Acute Organisational Audit
All cases
98%
Sentinel Stroke National Audit Programme (SSNAP) - Clinical Audit
All cases
98%
UK Parkinson's Audit: Patient Management (Elderly Care & Neurology); Physiotherapy; Occupational Therapy;
Speech and Language Therapy
20
100%
Vital signs in Children (Care in Emergency Departments)
100
100%
50
100%
Following the first year of this audit, the Trust has improved screening of referrals for suggestion of
inflammatory arthritis and put a protocol in place for treatment escalation during nurse-led appointments.
We have also made steps to improve our future compliance, including opening up more clinic slots for early
arthritis and employing an administrator.
A Vital Signs observations policy has been introduced for children in the Emergency Department.
VTE Risk in Lower Limb Immobilisation (Care in Emergency Departments)
Non-HQIP National Clinical Audits
Target sample size
Cases submitted (%)
Not Known
National Hepatitis B
All cases
100%
UK Audit of Toxicity & Outcomes of Radical Chemo-radiotherapy for Anal Cancer delivered using
Intensity Modulated Radiotherapy (IMRT)
1
100%
Where do Platelets Go?
38
100%
BAUS Female Sling Surgery
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Non-HQIP National Clinical Audits
Target sample size
Cases submitted (%)
50
98%
All cases
100%
BASHH (British Association of Sexual Health & HIV) 2015 Re-audit of Management of under 16s
attending Sexual Health Services
40
100%
UNICEF UK Baby Friendly Initiative Audit
30
100%
HSCIC National Wisdom Tooth Audit
100
95%
All cases
100%
British HIV Association (BHIVA) National Clinical Audit 2015 - Monitoring Adults with HIV
Use of Insulin Degludec in Clinical Practice
Determining the Worldwide Epidemiology of Surgical Site Infections after Gastro-intestinal
Surgery
National Confidential Enquiries into Patient
Outcome & Death
(NCEPOD)
Cases Included
Clinical Questionnaire
Returned
Case Notes
Returned
Organisational Questionnaire
Returned
Acute Pancreatitis
10
100%
100%
Yes
Mental Health in General Hospitals
3
100%
100%
N/A
Local Clinical Audit
Emergency Department:
Standardising the Rapid Assessment and Treatment (RAT) process at Queen's
Hospital
Actions Taken
Increased staffing and seniority in RAT.
A process change by which patients are received from ambulance off-load.
A clearer distinction of staffing roles within RAT.
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Local Clinical Audit
Actions Taken
Improvement in patient flow.
Improvement in patient safety and care.
Ophthalmology:
Cycloplegia stability in dark irises
Start to use Tropicamide and Cyclopentolate eye drops for cycloplegic refraction
in all children with dark irises.
Further assess the use of Cyclopentolate and Tropicamide mixed together.
Pharmacy:
Ensuring Trust-Wide prescription validity
Trauma and Orthopaedics:
Inpatient clinical notes documentation
Pharmacy:
Are Atrial Fibrillation (AF) patients who are initiated on NOACs (novel oral
anticoagulants) appropriately referred to the Anticoagulant Clinic on discharge
Anaesthetics:
Implementation of the Sepsis Screening Tool and Care Pathway
Respiratory Medicine:
Inhaler technique, satisfaction and appropriateness of prescribing
Elderly Care:
Review of Gold Standard Framework (GSF)
Introduction of a robust escalation process for raising prescription issues.
A new form has been created on yellow paper which is filled out each day for
each patient and inserted into the notes during the ward round. The form is
predominately detailed tick-box items that the doctors have to go through during
their review.
Introduction of a NOAC sticker which is placed in the drug history section of an
inpatient drug chart in a bold colour. The sticker highlights the name of the
NOAC, indication and, where appropriate, duration.
The National Early Warning Score (NEWS) is now part of the sepsis screening tool
and all patients that score 4 or above are put on the sepsis pathway.
Pharmacists now take an active role in checking technique for patients on
inhalers.
A GSF folder introduced to pilot wards was accepted as part of the Gold standard
policy.
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Local Clinical Audit
Actions Taken
Sunrise B ward now have a GSF team which is nurse led and includes ward
doctors and is supported by the palliative team for training and quality
improvement purposes.
Renal:
Medication omission incidents on Mandarin A Ward
Nurses on drug rounds to wear a special apron that notifies others that they are
not to be disturbed.
Nurses to appropriately adjust timings of administering medications for patients
who are due for procedures that day. If in doubt to consult a pharmacist or
doctor.
Ophthalmology:
First 25 age-related macular degeneration (ARMD) patients switched from
Lucentic to Eylea
An earlier switch to Eylea to improve outcomes, especially in antiVEGF highly
dependent cases.
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LIST OF CONTRIBUTORS
Overview
Comments and recommendations for improvement and/or clarification received from our auditors and stakeholders have been incorporated into the final report. We
extend our thanks to them for helping to ensure this report provides clear and understandable information for our readers.
This report will be sent to the Secretary of State as required under the Quality Account Regulations by 30 June 2016 and a copy will be uploaded to our website and
the NHS Choices website.
Any comments from the public can be sent to our Communications and Marketing team at [email protected] or via telephone on 01708 503 624.
Written comments can be sent to the Communications and Marketing team at Trust Headquarters, Queen’s Hospital, Rom Valley Way, Romford, RM7 0AG.
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