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NHS KIRKLEES

QUALITY REPORT

(April – June 2010)

1. Background

1.1 NHS Kirklees is committed to raising standards and monitoring performance, not only by focusing on targets, but also by monitoring the quality of services and improvement in patient related outcomes.

1.2 Nationally, there is a focus on quality improvement and the responsibility of commissioners is to assure the public that the services they receive are of the highest quality and standards are consistent with evidence based effective practice. Lord Darzi, in his report High Quality Care For All (DH 2008), named the three domains of quality as “patient experience”, “patient safety” and “clinical effectiveness”. This has been reinforced in the white paper Equity and Excellence; Liberating The NHS (DH 2010). The paper commits the present Government to quality improvement in the NHS reassuring the public that failure to deliver high quality services will not be acceptable. The principle is that the NHS should be a world leader in delivering high quality services.

1.3 Leverage to improve quality further is in the system through the payment for Quality Improvement and Innovation (CQUINS). The introduction of quality performance indicators into contracts and the monitoring of those indicators through Clinical Quality Boards, has introduced robust processes into the system that are clinically led across the health economy.

1.4 We have already seen an improvement in health care acquired infections; delivered on single sex accommodation (DSSA) and improved care for people with stroke, long term conditions; seen reductions in hospital standardised mortality rates (HSMR) and improvement in patient experience.

2. Setting the Standards

2.1 The importance of the quality agenda is embedded across the whole system. We recognise the need to monitor quality improvement and challenge any failure to reach the highest standards. This is best achieved through joint working and aligning of strategic goals. The

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Clinical Quality Boards (CQB) have a key role in driving forward the quality agenda, seeking assurances and reviewing the standards.

The focus is on the following areas:

• Clinical outcomes where performance is not at the required standard.

• Significant clinical incidents. • Patient experience and patient reported outcome measures. • Setting and monitoring Clinical Quality Indicators (CQUINS). • Responses to national enquiries. • Review of quality indicators DSSA, HSMR.

2.2 All providers have consistently attended the Clinical Quality Boards with nursing and medical directors taking the lead for their organisations. The commitment to a joint approach to quality improvement is demonstrated by this high level attendance.

2.3 Following the introduction in 2009 of CQUINs, initially set at regional level, the process has been extended to include national and local indicators. Local indicators have been developed that not only set standards for improvement in quality, but also, if achieved, will have an impact on costs, eg reduction in pressure ulcers will have a significant cost benefit as well as improving the quality of care.

2.4 We have deliberately set the local CQUINs not only to improve the quality of care in individual providers, but also to bring together providers across the whole system, working together to achieve joint outcomes, eg end of life care - reduction in admissions in the last 48 hour of life in acute trusts is dependent on good primary care services and a joint approach to advanced care planning.

3. Quality and Risk Profiles (QRPs)

3.1 Monitoring risk in provider organisations is one element in the improving quality agenda. This is being facilitated by the work of the Care Quality Commission (CQC).

3.2 The information collated and presented by CQC in the QRPs is organised using essential outcomes of quality and safety. CQC have analysed a range of data, both qualitative and quantitive, to build each QRP.

3.3 The first wave of QRPs is related to NHS Trusts as they were the first providers to be registered under the new system. Trusts were able to view their updated profile from September and can access the password-protected part of the CQC website.

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3.4 Lead commissioning primary care trusts as well as strategic health authorities and Monitor will also have access to QRPs from October 2010. Commissioners will be able to use the QRPs to monitor risk profiles and hold providers to account. Providers will be expected to use the QRPs to support their internal monitoring of quality.

3.5 QRPs will be monitored through the Clinical Quality Board and variances reported to the Board in the Clinical Quality Board report.

4. First Quarter Report.

This interim report will focus on the three foundation stones of high quality services - patient experience, patient safety and clinical effectiveness.

The focus will be on the main providers, Calderdale and Huddersfield NHS Foundation Trust (CHFT), Mid Yorkshire Hospitals NHS Trust (MYHT), South West Yorkshire Partnership NHS Foundation Trust (SWYPFT), and Kirklees Community Health Services (KCHS).

5. Patient Experience

5.1 Calderdale and Huddersfield NHS Foundation Trust: Patient Experience Survey.

The Trust’s performance in all categories was rated about the same as other Trusts:

• The overall score for views and experiences - 6.3. • CHFT scored highly for patients being treated with respect and

dignity - 8.9/10. • For not wanting to complain about the quality of care - 9.1/10. • The lowest score was for patients being asked for their comment on

the quality of care they received during their stay - 0.9/10 and information on complaints - 3.9/10.

5.1.1 Action

Patient experience is an element of national and local CQUINS. CHFT have engaged the Picker Institute to conduct real time patient surveys and have an action plan in place to monitor progress which is reported through the Clinical Quality Board. This will enable us to see progress without waiting for the annual patient survey results which is an element of the national CQUINs

5.2 Mid Yorkshire Hospitals NHS Trust: Patient Experience Survey

The Trust’s performance in the majority of categories was rated about the same as other Trusts. However, in the category Leaving Hospital,

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it was rated worse than other Trusts. Particularly concerning were the scores for privacy.

• The overall score for views and experience - 6.1. • Information given on discharge - 4.3/10 • A named contact - 6.5/10 • Being informed of danger signs to watch for - 3.5/10 • Lack of privacy for discussions was worse than other hospitals -

7.4/10 • Lack of privacy for examination - 9/10

5.2.1 Action

Improvement in patient experience is an indicator of the quality of services and this has been recognised with MYHT incentivised through the local CQUINs scheme, to improve on the areas highlighted as poor practice against the national benchmark of the patient survey. An improvement plan is in place that has been agreed with the SHA and is monitored through the CQB.

One of the areas of concern was the copy letters to patients and this has now been resolved with all patients receiving copies of letters sent between MYHT and GPs. Many of the issues re privacy will be improved with the move to the new hospitals .

MYHT hold an annual patient experience summit to gather views of patents in person. It is generally well received and a rich source of information.

5.3 South West Yorkshire Partnership NHS Foundation Trust Survey of people who use community mental health services:

The overall rating for the care received in the last twelve months was ranked in the top 20% nationally. In total, SWYPFT had 10 out of 38 elements in the top 20%; 18 out of 38 in the middle range and 10 out of 38 in bottom 20%

The overall score for the Trust was 6.6/10 which was in the same range as other Trusts:

• Finding and keeping work - top 20%. • Treated with respect and dignity - top 20%. • Ease of contacting care coordinator - top 20%. • Discussion re the need to continue using mental health service -

top 20%.

Lowest ranking scores were for:

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• Provision of talking therapies. • Support with care responsibilities. • Contact for crisis care.

5.3.1 Action

Reported through September CQB, SWYPFT assured the Board that they had work in progress to improve the scores. Progress will continue to be monitored through the CQB. Care planning is a particular focus for the organisation going forward. Care plans are regularly monitored and all teams are performing well against the target but there is an organisational focus to improve the quality of the plan.

6. Patient Experience: Delivering Single Sex Accommodation

Over the last two years significant progress has been made to deliver single sex accommodation (DSSA). The impetus is now to maintain that level of delivery and to monitor any breeches.

In 2011, we will be expected to monitor and report all breeches as part of performance management and there will be a defined set of criteria against which we will performance manage our acute providers.

6.1 MYHT

MYHT have an excellent system for monitoring and tracking any breeches and have been identified by the SHA as an exemplar of good practice. They have invested in an IT bed flow system, have a robust action plan in place and report all breeches to the CQB.

In Q2, there were 56 breeches (they count a breech as 5 if a female is put into a bay with 4 men). This, however, is still a significant number and we will be monitoring this closely through Q3.

6.2 CHFT

CHFT reported 19 breeches in Q2, but this related to only the initial incident not the impact on other patients. The SHA visit acknowledged there had been significant improvements to enhance the privacy and dignity of patients in CHFT, particularly noting the real time patient survey monitoring. However, whilst recognising the commitment and priority given to this, by both commissioners and providers, there needed to be greater rigor in agreeing and monitoring breeches .

6.3 There are no breeches to report for SWYPFT and KCHS.

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7. Patient Safety

7.1 We report as part of the regular performance report, the number of health care acquired infections (HCAI) across the health economy. We have seen a significant reduction in the numbers of hospital acquired infections but we still have increasing numbers in care homes.

7.2 As an organisation, we need to work with independent providers to improve these rates and understand the root causes. The infection control team, under the leadership of Jane O’Donnell, are working with care homes to raise the standards of infection control. It is recognised that some of the most frail and elderly patients are in care homes and, therefore, particularly vulnerable.

7.3 Prevention of pressure ulcers is a regional and local CQUINs indicator. A reduction in numbers not only improves patient safety but impacts significantly on costs.

The Q1 returns will form the baseline for a trajectory setting a target for a significant reduction in incidence. Any pressure ulcer at level 3-4 will be reported as a Serious Untoward Incident (SUI) and should be regarded as a never event.

7.3 Falls are another area where early assessment and intervention can prevent serious injury. Falls prevention requires a multidisciplinary approach across the whole system which ranges from risk assessment and safety issues, to understanding the impact of medication as a risk factor. Local CQUINS have been agreed with all providers that include risk assessment for high risk groups and a target to reduce overall numbers and particularly, repeat falls.

7.4 National enquiries: This year has seen the release of the reports from three national enquiries resulting from extreme SUIs.

The Norris report, the Frances report and the Airedale report, all highlight the need for organisations to be vigilant, listen to patients, understand and monitor complaints and to have good HR policies in place.

In all three reports there was evidence of avoidable deaths and in two, unlawful killing. As commissioners, we have to be sure that the providers from whom we commission are delivering high quality, safe services and that staff are appropriately trained and managed.

We are monitoring the action plans of all our providers against the recommendations coming out of these enquiries and a number of

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improvements have been made in incident reporting, management of complaints and investigations into unexplained deaths.

7.5 Monitoring of SUIs was highlighted in the Frances report as a key role for Commissioning organisations and Trust Boards. In the first 2 quarters of this year, we have had 4 clinical SUIs. This suggests a degree of under reporting which is being taken through the CQB to review criteria. All SUIs are reported through the Governance Committee and action plans monitored.

8. Clinical Effectiveness:

8.1 National, regional and local CQUINS form an incentive scheme for providers that are based on continuous quality improvement. CQUINs are based on indicators that are evidence based and clinically effective.

8.2 National and regional Q1 data has now been validated and published and gives us a regional benchmark against which we can monitor the standards in provider services.

8.3 Whilst there are concerns over the consistency of reporting across the region, through the Quality Boards we have challenged providers on areas where we are not meeting a consistently high standard.

8.4 The following areas are for the Board to note and will be monitored over the next 3 quarters.

8.5 For the VTE, the number of patients risk assessed in Q1 was 35% in CHFT and a nil return from MYHT.

8.6 Figure 1 shows the variation across the region, with some providers reporting very high uptake and others not submitting any data. At CQB, it was agreed to challenge the consistency across the region but it was also acknowledged that in Q2, a considerable improvement was required. The medical director of the SHA has asked for a regional and local focus on understanding the incidence and appropriate care in terms of prophylaxis. The action and care that is delivered in response to the risk assessment is of paramount importance for patient safety. There is a need to strengthen the regional/local CQUINS. This will be discussed at the next regional Quality Forum on 12 November 2010.

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Figure 1 - VTE Risk assessment

8.7 For the Acute Myocardial Infarction indicator, there were a high number of exclusions for those receiving coronary angiography in the first 96 hours of admission and those having smoking cessation advice. To deliver significant improvement in patient outcomes, the evidence from the USA, and following implementation in the North West, shows that the bundle of interventions all have to be delivered as part of each patient’s treatment plan if there is to be a significant impact on patient outcomes. Figures 2/3 show that there is still considerable progress needed to deliver against all indicators.

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Figure 2 - Acute Myocardial Infarction Bundle

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Figure 3 - Acute Myocardial Infarction Bundle

8.8 Across all the other indicators there is some progress, but end of life care remains an area where advanced care planning for patients at the end of life need to improve. There has been an improvement in the

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number of wards that have undertaken Liverpool Care Planning (LPC) training, but numbers with plans in place remain low across the health economy.

A significant piece of work is being done at CHFT and with the Collaborative in developing advanced care planning and working across a number of non cancer specialties.

This is an action for the End of Life Care HIT and is a priority across the health economy.

9. Community Services: CQUINS

9.1 KCHS have not reported on all indicators and, therefore, it is difficult to benchmark their progress in all areas regionally. They have assured the CQB that Q2 data will be up-to-date.

9.2 However, on those indicators that have been reported on, in some areas we are seeing a significant improvement in the standard of care. This is seen in the percentage of people with a long term condition cared for by a community matron or case manager is 100%.

9.3 An area of significant improvement is the number of patients over 65 undergoing nutritional screening on admission is 100%, one of the highest in the region.

9.3 An area we are monitoring is the number of people having regular child protection supervision. Whilst numbers are rising, we are below the SHA average. This is been closely monitored by Karen Hemsworth as Designated Nurse.

9.4 The number of people with a long term condition with a personalised care plan is one of the lowest in the region (see figure 4) but we expect significant improvement by Q2. We have implemented care planning that is more focused on goal setting and is patient led which means we are only reporting on implementation of these high level care plans .

Action - to roll out personalised care planning to all services .

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Figure 4 – Indicator 1: Long Term Conditions

9.5 There are a significant number of people on LCP with preferred place of choice who died in their preferred place (figure 5). This also has a financial impact, as many emergency admissions for palliative care patients occur in the 24/48 hours prior to death.

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Figure 5 – Indicator 2: End of Life

9.6 There is a marked improvement following the initiation of the common assessment framework for children and young people, but regionally we are significantly below the regional average (figure 6) .

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Figure 6 – Indicator 3: Common Assessment Framework

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10. South West Yorkshire Partnership NHS Foundation Trust: CQUINS

10.1 Regional Indicators for SWYPFT focus on access and improving outcomes for BME patients. Nutritional assessment is the third indicator, as many people with mental health problems, especially the vulnerable elderly, are nutritionally compromised.

10.2 Q1 data shows that access for adults within 4 hours is one of the highest in the region (figure 7).

Figure 7 – Indicator 1: Access for Adult Acute Mental Health

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10.2 The percentage of patients admitted who have had a nutritional screen is, however, one of the lowest (figure 8).

Figure 8 – Indicator 4: Nutrition

11. Summary

Quality monitoring and setting standards are core to the delivery of high quality services.

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We are seeing significant improvements across the system driven by the Clinical Quality Boards.

We note the areas where improvements need to made and continue to monitor the progress made in these areas.

CQUINs incentives are making an impact on quality and innovation.

This interim report highlights the systems and processes we have in place to provide assurance to the Board.

Q1 CQUIN data provides a benchmark for the monitoring of future performance which will be reported to the Board in the Annual Quality Report.

12. Recommendations

The Board RECEIVES this report and NOTES the content.

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