Page 1 of 55 Quality Report Bolton NHS Foundation Trust · Bolton NHS Foundation Trust Statement of...

Page 1 of 55 Quality Report Bolton NHS Foundation Trust


BOLTON NHS FOUNDATION TRUST QUALITY ACCOUNT


Table of Contents

Title Page

Part One

Trust Profile 5

Statement on the Quality of Services from the Chief Executive 6

Statement of Director Responsibilities 8

Part Two

How Quality is prioritised 10

Quality Improvement Strategy 2014 - 2017 10

Patient Experience Strategy 2014 - 2017 11

Achievement on priorities set out in the 2013/14 Quality Account 12

Monitoring Priorities at Bolton NHS Foundation Trust 16

Key Quality Priorities for 2014/15 17

Participation in Clinical Audits and research activity 18

Goals Agreed with the Commissioners (CQUIN) 23

Care Quality Commission Registration/ Reviews 26

Data Quality 27

Clinical Coding 28

Part Three

How we performed on Quality in 2013/14 47

What others say about Bolton NHS Foundation Trust 54


PART ONE


Trust Profile

Bolton NHS Foundation Trust is an integrated care organisation providing care and support in the community at over 20 health centres and clinics, including the prestigious Bolton One complex in the town centre, as well as services such as district and school nursing. We also provide intermediate care in the community and a wide range of services at the Royal Bolton Hospital. Our services are used by the people of Bolton and beyond and as at the end of March 2013 we employed 5300 staff.

At the end of March 2013 the Royal Bolton Hospital RBH had 626 inpatient beds, 32 day case beds and 15 endoscopy (gastrointestinal exploration) beds. Of these 371 were medical beds but included 24 beds which open only for the winter period. It is one of the busiest hospitals in Greater Manchester for urgent care and is also a regional 'supercentre' for maternity services, babies and children. We have an up to the minute delivery suite, a friendly and attractive children's ward, and purpose built neonatal critical care and special care baby units.

Mental health services are provided on the Royal Bolton Hospital site but are managed by Greater Manchester West Mental Health NHS Foundation Trust. Renal dialysis is provided and managed by Salford Royal NHS Foundation Trust at a dedicated unit at the Royal Bolton Hospital.

The Trust has three fundamental aims:-

Best care for better health (for our patients and our community)

Responsible use of resources (for the taxpayer)

Valued, respected and proud (by our staff, patients and public).

We aim to:-

Meet the health needs of our population

Improve the safety and quality of care

Improve patient experience

Make our services more efficient.


Statement of the Quality of Services from the Chief Executive

This Quality Account is an annual review of the quality of healthcare provided by Bolton NHS Foundation Trust in 2013 – 14 and a forward look to outline the key priorities for 2014 – 15.

In part one we provide an overview of the organisation and the responsibilities of the Directors of the Trust are outlined.

In part two of this report we set out our priorities for 2013/14. In our Annual Plan we have set ourselves objectives for improvement, each of which is sub-divided into specific indicators as shown below. We will report back on our progress against each of these in our report next year.

Underpinning our service plans is a strategy for high quality care. Our priorities for the quality of care were identified after consultation with staff across the Trust, building on the improvements seen in the last five years.

To reduce mortality

Aiming to be in the top ten Trusts nationally on measures of hospital mortality and perinatal mortality.

To prevent infection and harm

Aiming for a 50% reduction, year-on-year, in avoidable cases of clostridium difficile and other healthcare acquired infections.

Working to ensure that “never events” don’t occur when patients are in our care.

Aiming to consistently achieve best practice standards for harm free care.

To respond and learn

Improving our complaints process.

Learning from clinical incidents.

Ensuring that we listen to patient voices in planning and delivering our services.

To deliver a better patient experience

Improving our monitoring systems.

Sharing best practice.

Aiming for the best ratings from all our patients, as measured by the national survey of whether patients would recommend our services to friends and family.

Although these objectives are all important to us, the Board has agreed that our main ambition is to be harm free and the first zero harm Trust in the North West. Just one fall or pressure ulcer is one too many. Our aim is to provide services that are safe and that our staff would happily recommend to their family and friends. In part three of this report we look back on performance against the improvement priorities we set ourselves in 2013 -14.


We have worked with our stakeholders to develop this Quality Account – statements from Bolton CCG, Bolton HealthWatch, our Council of Governors and the Overview and Scrutiny Committee are included at appendix one. During 2013/14 we attended a series of meetings with Bolton Healthwatch to provide updates on our progress against the 2013/14 objectives. We will continue with these meetings in 2014/15, and details will be provided on our website and through HealthWatch.

We have been working closely with our commissioners – Bolton CCG to develop the services we deliver to the people of Bolton. An early draft of this report was shared with the CCG. They provided some useful feedback on the issues which matter to them and this has been incorporated into this final report. Our commissioners have been very supportive and we will continue working closely with them to ensure we provide the best possible care to the population we serve.

We aim to be open and transparent with the public we serve and will also provide updates on our progress in our Board meetings and at our Governor meetings. We welcome feedback from our patients and public and will use this to make improvements to the care we provide.

We have tried to use clear and understandable language wherever possible in this report however the inclusion of some medical and healthcare terms is unavoidable. A glossary of terms is provided and further information about health conditions and treatments is available on the NHS Choices website.

Dr Jackie Bene

Chief Executive

29th May 2014

Statement of directors’ responsibilities


The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports (which incorporate the above legal requirements) and on the arrangements that foundation trust boards should put in place to support the data quality for the preparation of the Quality Report.

In preparing the Quality Report, directors are required to take steps to satisfy themselves that:

the content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual;

the content of the Quality Report is not inconsistent with internal and external sources of information including:

o Board minutes and papers for the period April 2013 to April 2014

o Papers relating to Quality reported to the Board over the period April 2013 to April 2014

Feedback from the commissioners dated

Feedback from governors

Feedback from local HealthWatch

The trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, May 2014

The 2013 national patient survey

The 2013 national staff survey

The Head of Internal Audit’s annual opinion over the trust’s control environment

o Care Quality Commission quality and risk profiles

the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered;

the performance information reported in the Quality Report is reliable and accurate;

there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, 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 Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Report has been prepared in accordance with Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations)

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report.

By order of the Board

29th May 2014

Quality Account - part two


PART TWO



How Quality Initiatives are prioritised in the Trust

This Quality account identifies the progress made against the Quality and Safety strategies this year and identifies the Quality Improvement aims for 2014/15.

The Safety and Quality programme will enable the Trust to maintain a focus on the Quality and Safety agenda, whilst delivering our clinical strategy to improve the health and outcomes of our local population based on the values and principles set by the Board and in line with the NHS outcomes framework.

Continuous improvement of clinical quality is further incentivized through the contracting mechanisms that include quality schedules, penalties and CQUIN payments. NHS England frameworks and the recently published Francis Report into Mid Staffordshire Hospitals also highlight the focus on quality, and are now linked to the NHS Mandate and Constitution.

We will work with Commissioners to align our quality aims and to maximize the potential delivery through these mechanisms. The Trusts improvement priorities for 2014/15 built upon those reported in 2013/14 and performance in previous years. They were chosen because the reflected key areas of development for the Trust – reflected Trust Board Priorities and Quality Strategies these assigned from national and local mandated requirements, CQUIN priorities and were informed of those Quality analyses by patient and staff engagement and feedback.

Quality Improvement Strategy 2014 – 2017

Delivery of our strategy will be through programme management of a series of work streams, designed to underpin our fundamental aim - to provide caring, safe and effective services.

The work streams have been identified following wide consultation with clinical and managerial staff and governors. They comprise four quality improvement work streams targeting specific areas of improvement in clinical outcomes, patient safety and patient experience. They are underpinned by three enabling work streams. Each work stream builds on existing work, but adds focus and stronger performance management to ensure delivery.

Each work stream will have a clinical leader, supported by a multidisciplinary team and with a wide range of capability and experience drawn from across the organisation. Key members of each team will be patients and members of the public.

Each work stream will use a systematic approach and proven quality improvement tools, including value stream analysis, strategy and policy deployment, visual management and plan-do-study-adjust (PDSA) cycles, to build continuous improvement. Teams will scope their work at initial workshops, using external experts where necessary; produce a clear description of their purpose and their plans; hold learning sessions and summits; and scale-up and spread their learning. They will identify their priorities, the resources required, set out ambitious annual goals, and define and track the relevant measures of progress.



Patient Experience Strategy 2014 – 2017

This Strategy outlines how Bolton NHS Foundation Trust continues to see the experience of patients as a major priority going forward to 2015 and beyond. It has been developed with the support and collaboration of partner agencies and voluntary organisations and sets out our Patient Experience vision. The priorities and outcomes cross both hospital and community settings

The purpose and aims of this strategy are:

Raise standards and expectations of patient, family and carer experience at Bolton NHS Foundation Trust.

Define the current national drivers and standards for patient experience

Define the action required by staff throughout Bolton NHS Foundation Trust to improve patient, family and carer experience.

Provide a framework of action for the priorities and to clarify responsibility for action for each identified outcome.

This strategy will link into the Bolton NHS foundation Trust Strategic Direction 2013 – 2019 document by implementing actions that will support delivery of the outlined aims in relation to patient experience. These are:

o Improving our monitoring our monitoring systems

o Sharing Best Practice

o Aiming for the best ratings from all our patients as measured by the national measure of

whether patients would recommend our services to friends and family.

Measuring the experience of our patients, families and carers

We have identified seven ‘outcomes’ with underpinning actions that are identified as ‘Always’ Events’. This will underpin the implementation of this strategy and provide a performance framework in order to assess the outcomes of the strategy being delivered and implemented in practice.

Achievement on priorities set out in the 2013/14 Quality Account


PRIORITY ONE: Reduce Infection from Clostridium Difficile

What we did:

Although we achieved a reduction in relation to the number of patients acquiring Clostridium Difficile with 38 patients in 2013/14 compared to 65 patients in 2012/13, this performance was more than the target of 28 cases.

In March 2013 we worked jointly with our many commissioners (Bolton CCG) to commission an external review of Clostridium difficile (C Difficile). We received the results of the review in April 2013 and have developed a plan to address the actions required.

We have agreed a range of actions including:

Investment in new hand wash basins in areas identified as needing these closer to beds and bays.

The provision of doors on bays in some of our older wards.

Hydrogen peroxide “fogging”. This is a procedure where the ward is closed for decontamination.

Mattresses, pillows and commodes will be reviewed and replaced as necessary.

Formal root cause analysis will be held for each and every infection.

Continued close liaison with the commissioners Bolton CCG.

0

2

4

6

8

10

12

14

16

Clostridium Difficile - Hospital Acquired

2012-13 2013-14 2013-14 Target

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

2012-13 4 14 9 1 2 4 2 3 11 6 6 3 65

2013-14 7 5 4 3 4 2 2 2 0 4 3 2 38

2013-14 Target 2 2 2 2 2 2 2 2 2 2 2 2 28

Achieved a 41.54% reduction in patients acquiring Clostridium

Difficile



Although we achieved an overall 13.64% reduction in patients

acquiring pressure ulcers in our care in the hospital and community; unfortunately we recorded an increase in the number

of grade 3 and grade 4 pressure ulcers acquired in our care.

PRIORITY TWO: Reduce Pressure Ulcers

The chart below represents the comparison of category 3 and 4 pressure ulcers for 2012/13 and 2013/14. This equates to a 40% increase in category 3 and 4 pressure ulcers for the year 2013/14. We continue to have a zero tolerance of all category 3 and 4 pressure ulcers through the implementation of the Pressure Ulcer Prevention Strategy. We have improved our reporting processes for category 3 and 4 pressure sores to ensure that all identified sores are reported and receive a full root cause analysis and presented to panel.


2012-13 16 10 28 29 33 28 16 34 20 21 21 8 264

2013-14 19 13 32 27 13 17 22 33 14 14 13 11 228

2013-14 Target 9 9 9 9 9 9 9 9 9 9 9 9 109

0

5

10

15

20

25

30

35

40

Total of Pressure Damage 2+ (Community and Hospital)

2012-13 2013-14 2013-14 Target



What we did:

In the period 2013/14 all category two, three and four pressure ulcers have had a root cause analysis completed and the learning and recommendations shared with the teams concerned. It is recognised that there are different challenges in the community settings when compared to the hospital and that it is important to address these within the context of the diverse settings in which we provide our services.

In addition to this we have implemented the following:

Revised the prevention of pressure ulcer policy to ensure all staff are clear about their responsibilities in preventing pressure ulcers. This policy was launched in November 2013, the incidence of grade 3 and 4 pressure ulcers reduced from December 2013 with zero cases of grade 3 or 4 in March 2014.

Regular on-going education of staff by the Tissue Viability Team, achieving 85% of staff trained.

The replacement of all hospital beds with electric profiling beds and a high quality mattress to make moving and changing of position easier and more comfortable for patients. The Trust also has a rental contract arrangement in place to provide special air mattresses to reduce pressure damage for patients who are at most risk of harm.

Revised and strengthened the harm free care panel in so that all category two, three and four pressure ulcers are presented to a multi professional panel. Any issues identified have been subject to an action plan which is monitored by the Matron and Professional Lead.

Launched the Pressure Ulcer Prevention Strategy across the organisation

This area remains a high priority for the Trust with regular reports to the Board of Directors and Quality Assurance Committee to provide assurance that the required actions have been taken and are having the desired impact.


2012-13 Hospital - Patients acquiring pressure damage (grade 3) 1 0 1 1 3 1 0 2 1 1 1 2 14

Hospital - Patients acquiring pressure damage (grade 4) 2 0 0 1 1 1 0 0 0 0 0 0 5

Community - Patients acquiring pressure damage (grade 3) 1 1 3 0 1 2 4 0 1 3 2 0 18


Total 4 1 5 3 8 5 4 2 2 7 4 2 47

2013-14 Hospital - Patients acquiring pressure damage (grade 3) 2 1 2 4 2 2 3 4 4 3 2 0 29

Hospital - Patients acquiring pressure damage (grade 4) 2 1 0 0 0 1 1 0 0 0 0 0 5



Total 5 5 3 5 3 6 11 12 5 8 3 0 66



Achieved a 15.75% reduction in patient falls

PRIORITY THREE: Reduce falls

What we did:

Although the majority of falls result in no harm there are still significant challenges for the Trust in managing our most vulnerable patients.

The Trust has implemented a number of measures to reduce the levels of harm and needs to keep this as a high priority:

Review of the monthly Harm Free Care Panel where all falls subject to a root cause analysis are presented ensures that all possible improvements are put in place.

In the past year 100% of falls resulting in moderate to severe harm have had a root cause analysis completed and areas where improvement was identified have been communicated back to the staff.

Ensure patients at risk of falls are provided with appropriate footwear if required.

Reviewed and improved the data and reporting systems to ensure information is more robust and accurate.

Ensured the continuity of falls services across the hospital and community.

In September 2013 we launched the Falls Strategy for the organisation.

The figure reported in last year’s quality account was for falls to over 75s and is therefore not comparable.

0

20

40

60

80

100

120

140

All Patient Falls (Safeguard)

2012-13 2013-14 2013-14 Target


2012-13 83 87 73 126 99 90 78 91 103 111 108 100 1149

2013-14 113 97 80 77 73 79 84 77 65 68 62 93 968

2013-14 Target 86 86 86 86 86 86 86 86 86 86 86 86 1034

Statements of assurance from the board


Monitoring Priorities at Bolton NHS Foundation Trust

The constituent strategies relating to quality, safety, risk, governance, human resources and finance come together through our integrated performance report and Heat Map which is provided to the Trust Board and assurance committees. Work is now on-going to adapt this and roll out to our community settings

The Trust uses qualitative and quantative data and information. This includes:

a systematic review of each new publication of the CQC Quality and Risk Profile

benchmarked information from CHKS

A review of the NHS North of England Quality dashboard

Transparency data

Profile of area/local market share/health profile/service review/initial mortality analysis

Outline performance of local providers

Mortality HSMR and SHMI

Patient experience ( annual patient experience surveys)

Safety and Workforce Profile

Clinical and operational effectiveness (National key performance indicators)

Comparison of Trust performance to other National Trusts and targets including PROMS

Collectively these provide assurance regarding the achievement of the key priorities outlined in the 2013 -2014 Quality account.

Rationale for selection of priorities for 2014/15

The 2014/15 priorities have been aligned with the Trust’s Quality strategy. The three main priorities for 2013/14 remain a key part of this strategy and have been revised in line with the achievements and learning from 2013/14.



Key Quality Priorities for Improvement 2014/15

In setting out the key priorities for 2014/15 we have ensured that all of the priorities identified link into the established strategies and strategic aims for the Organisation. The priorities for this year’s quality account are clustered under the following headings;

Quality and Safety

Patient Experience

Workforce

Key priorities and Measures Quality and Safety

Indicator Measure

Mortality Standardised Hospital Mortality Index (SHMI) – Preventing People from dying prematurely.

o Reduce SHIMI to less than 1.0 o Reduce crude mortality by 10%

Infection Control 50% reduction in avoidable cases of C.Diff.

Harm Free Care Zero Tolerance of category 3 and 4 pressure Ulcers

5% reduction in pressure ulcers categorised as avoidable

10% reduction in hospital acquired VTE episodes

5% reduction in falls with severe harm.

Medicines Management 95% harm free reported through the medicines safety thermometer

Patient Experience

Friends and Family Test Expansion of the areas utilising the FFT questions

5% increase in response rates

Real Time Patient Experience

Implementation of ‘real time;’ data collection processes.

Development of 10 patient experience questionnaire processes across hospital and community

Lessons Learnt Development of you said we did processes for FFT comments.

Evidence of lessons learnt being reported throughout the divisions and corporate structures.

Development of Clinical Senate and MAPSAF baseline assessment undertaken.

Dementia 95% compliance with the Dementia Care bundle

10% improvement of the experience of patients with dementia or their carers using services across the hospital and community

Workforce

Friends and Family Test Development of process to measure staff FFT experience

5% decrease in negative comments from Quarter 1 baseline.

Sickness Management reduction in overall sickness rates to 3.75%

Appraisal 80% completion of appraisal information

Mandatory Training 100% of available staff have completed MT



Review of services

During 20013/14 Bolton NHS Foundation Trust provided and/or sub-contracted seven regulated activities (as defined by the CQC) across 38 specialities.

Bolton NHS Foundation Trust has reviewed all the data available to it on the quality of care in these NHS services.

The income generated by the relevant services reviewed in 2013/14 represents 100% of the total income generated from the provision of NHS services by Bolton NHS foundation Trust in 2013/14

Participation in Clinical Audits and Research Activity

National clinical audits and national confidential enquiries are tools that NHS organisations use to assess the quality of services provided, against the best available evidence based guidance and standards.

At Bolton NHS Foundation Trust we undertake many clinical audits. We participate in all the national audits which are applicable to the organisation. This allows us to benchmark against other hospitals in England.

We also have a comprehensive programme of local clinical audits which clinical staff including consultants, junior doctors, nurses and allied health professionals conduct regularly to improve local areas of care.

During 2013/14 29 clinical audits and five national confidential enquiries covered relevant health services that Bolton NHS Foundation Trust provides.

During that period Bolton NHS Foundation Trust participated in 100% national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.

The national clinical audits and national confidential enquires that Bolton NHS FT participated in, and for which data collection was completed during 2013/2014 are listed in the tables below (alongside the number of cases required by the terms of that audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

Audit Specialty Participated

Y/N

Audit Requirements % Cases Submitted

Case Mix Programme (CMP) Acute Y All applicable 100%

Emergency use of oxygen Acute Y All applicable partial

Medical and surgical clinical outcome review programme: National confidential enquiry into patient outcome and death

Acute

National Audit of Seizures in Hospitals (NASH)

Acute Y All applicable 100%

National emergency laparotomy audit (NELA) Acute Y

All applicable Note: Started Jan 2014

partial (22 cases)

National Joint Registry (NJR) Acute Y All applicable 100%

Paracetamol overdose (care provided in emergency departments)*

Acute Y All applicable 100% (50 cases)



Audit Specialty Participated Y/N


Severe sepsis & septic shock* Acute Y All applicable

100% (50 cases)

Severe trauma (Trauma Audit & Research Network, TARN)

Acute Y Submitted 171 cases (Target 65% of 275)

52%

National Comparative Audit of Blood Transfusion programme

Blood and Transplant

All Applicable National Comparative Audit of Consent and Information for Transfusion – in progress, we are aiming for 24 cases National Red Cell Survey -2014 – in progress, number of cases will only be known when data collection is complete National Comparative Audit of the use of Anti-D 2013 – 74 cases, awaiting national report National Comparative Audit of Transfusion sample collection and labelling 327 cases

100% (327 cases)

Bowel cancer (NBOCAP) Cancer Y All applicable 100%

Head and neck oncology (DAHNO) Cancer Y All applicable 100%

Lung cancer (NLCA) Cancer Y All applicable 100%

Oesophago-gastric cancer (NAOGC) Cancer Y All applicable 100%

Acute coronary syndrome or Acute myocardial infarction (MINAP)

Heart Y All applicable 100%

Cardiac Rhythm Management (CRM) Heart Y All applicable 100%

Congenital heart disease (Paediatric cardiac surgery) (CHD)

Heart N N/A -

Coronary angioplasty

Heart N N/A -

National Adult Cardiac Surgery Audit Heart N N/A -

National Cardiac Arrest Audit (NCAA) Heart Y All applicable 100% (n=77 cases)

National Heart Failure Audit Heart Y All applicable 100%

National Vascular Registry* Heart Y All applicable 100%

Pulmonary hypertension (Pulmonary Hypertension Audit)

Heart N N/A -

Diabetes (Adult) ND(A), includes National Diabetes Inpatient Audit (NADIA)*

Long term conditions

Y All applicable 100%

Diabetes (Paediatric) (NPDA) Long term conditions


Inflammatory bowel disease (IBD)* Long term conditions


National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme*


Y All applicable – on-going data collection 100%



Audit Specialty Participated Y/N


Paediatric bronchiectasis* Long term conditions

N

Not applicable to Bolton - joint care of patients with RMCH

-

Renal replacement therapy (Renal Registry) Long term conditions

N N/A -

Rheumatoid and early inflammatory arthritis*


Y

Bolton NHSFT Registered. Delayed due to national Web-based audit tool problems. Audit to start April 2014

partial

Mental health clinical outcome review programme: National Confidential Inquiry into Suicide and Homicide for people with Mental Illness (NCISH)

Mental Health

N N/A

National audit of schizophrenia (NAS) Mental Health

N N/A

Prescribing Observatory for Mental Health (POMH)

Mental Health

N N/A

Falls and Fragility Fractures Audit Programme (FFFAP)

Older People Y All applicable 100%

Sentinel Stroke National Audit Programme (SSNAP)*

Older People Y All applicable partial (182 cases)

Elective surgery (National PROMs Programme)

Other ? TBC

Child health clinical outcome review programme (CHR-UK)*

Women’s & Children’s Health N

Data collection extended into Q1 of 2013/14 for those who had not completed in 12/13 audit year

TBC

Epilepsy 12 audit (Childhood Epilepsy) Women’s & Children’s Health

Y All applicable

100%

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

Women’s & Children’s Health

Y All applicable

100%

Moderate or severe asthma in children (care provided in emergency departments)*

Emergency Care

Y 50 100%

Neonatal intensive and special care (NNAP) Women’s & Children’s Health

Y All admissions to neonatal intensive & special care

100%

Paediatric asthma Women’s & Children’s Health

Y All applicable

100% (n= 65 patients)

Paediatric intensive care (PICANet) Women’s & Children’s Health

N N/A TBC

National Clinical Audits and National Confidential Enquiries 2013/2014

These are “inspections” that are carried out nationally to investigate areas of care where there may have been problems nationally or where the patients may be particularly vulnerable. All hospitals are asked to take part in them so that all care across England can be monitored.



National Confidential Enquiries into Patient Outcome and Death (NCEPOD)

Title Start Date Reporting Progress

Tracheostomy care October 2013 June 2014 Data sent awaiting report

Lower limb amputation May 2013 November 2014 Awaiting 50% clinician data. (n=3 reviews)

Gastro intestinal haemorrhage

November 2013 June 2015 Data collection continuing

The reports of 2 national clinical audits were reviewed by the provider in 2013/14 and Bolton NHS Foundation Trust took the following actions to improve the quality of healthcare provided.

National Cardiac Arrest Audit: Locally audited using Root Cause Analysis

Using data submitted to NCAA and collecting local data on Peri-Arrests. A group was established case review all cardiac arrest and peri arrest within Bolton Hospital. The findings for 2013 re-audit highlighted

1. Effective process of establishing lessons learned.

2. Becoming embedded in clinical governance structure coroner requesting to see them!

3. Effectively addressing DNAR policy

4. Following death, findings of RCAs fed back to families by consultants.

National Audit of seizure management in hospital (NASH2)

This was the second round of the audit, the first round that Royal Bolton Hospital has participated. The results show that Bolton is very good at epilepsy/seizure management in our Emergency department.

Local Audits:

The main purpose of clinical audit is to deliver improvements in clinical practice. A systematic approach to the implementation of clinical audit action plans is therefore strongly advised. Such an approach may include the identification of local barriers to change, and organisational or resource constraints which preclude implementing change.

Not all clinical audits will require an action plan e.g. where an audit shows that standards are met or guidance followed.

National Clinical Audit and Patient Outcomes Programme (NCAPOP)

Title Start Date Reporting Progress

National audit of dementia

2013 Completed



The reports of 84 local clinical audits were reviewed by the provider in 2013/14and Bolton NHSFT has taken the following actions to improve the quality of healthcare provided:

Paediatric re-admission & re-attendance 2013 - Improve availability of written information & advice, increase acute referral rate to Paediatric Community Nurses, address issues raised with making PCN referrals

Acute Kidney Injury Audit - produced guidelines for junior doctors

Sepsis 6 - screen saver introduced, education around sepsis management, care bundle for sepsis introduced

Discussion between clinical effectiveness department and clinical leads as to how to further improve changes in practice

Escalating results to the Quality Assurance Committee (to highlight positive assurance)

Implementation of Quality Improvement work for local audits

Areas of Success

76% increase in registered audits per year at RBH

Increases in audits derived from standards: 68 to 100% (majority national)

Closure of audit loop: 28% to 58%

Information on Clinical Research

A total of 869 patients, receiving NHS services provided by Bolton NHS Foundation Trust, were recruited to NIHR Portfolio Studies in 2013-14. The recruitment target set for this period by GMCLRN of 661 was exceeded by +43%, giving the Trust a Green rating for recruitment.

NHS Permission for Research

A total of 24 NIHR Portfolio Studies were given NHS Permission at Bolton NHS Foundation Trust in 2013-2014. Of the 24 studies submitted to this site, 17 were for full NHS Permission, and 7 for Patient Identification Centre (PIC) approvals.

NHS Permission benchmarking was applied to 15 eligible research studies.

73% of the eligible research studies were approved within the National Benchmark of 30 days from receipt of a valid submission to approval (Amber rating).

From 1st April 2014, the governance review task for Bolton NHS Foundation Trust was outsourced to Greater Manchester Comprehensive Local Research Network (GMCLRN), to streamline NHS Permission processes. During a period of transition in Q1, delays in governance processes were encountered. This improved across the year as communication channels were established. By Q4 100% of Research Studies were approved within the 30 days benchmark.



Goals agreed with Commissioners

A proportion of Bolton NHS Foundation Trust income in 2013/14 was conditional on achieving quality improvement and innovation goals agreed between the Trust and Bolton Clinical Commissioning Group, through the Commissioning for Quality and Innovation payment framework.

In 2013/14 Bolton NHS Foundation Trust achieved £3.9 million in CQUIN payments, against a £4.4 million target. This was an improvement on the performance in 2012/13 when £2.3 million was achieved against a target of 4.6 million.

For further details of the agreed goals for 2013/14 and for the following 12 month period are available electronically on our web site in the Board Report.

Performance against the 2013/14 CQUIN indicators is set out in the chart below;

Name Annual Target Year end

VTE prevention: risk assessment CQUIN >=95% 96.60%

VTE prevention: Quarterly target of RCA's to be completed is met CQUIN 100% 100%

F&F test: Improve responsiveness to personal need of patients-phased expansion

CQUIN To roll out as per national

timetable On plan

F&F test: Improve responsiveness to personal need of patients - increased response rate (A&E)

CQUIN

Q4 response is higher than Q1 and 20 or

more

8.0%

F&F test: Improve responsiveness to personal need of patients - increased response rate (Inpatients)

CQUIN

Q4 response is higher than Q1 and 20 or

more

25.3%

Improved performance or remaining in top quartile on the Staff F&F test (A&E)

CQUIN

Improved performance or remaining

in top quartile on the Staff

F&F test

Annual staff

survey

Improved performance or remaining in top quartile on the Staff F&F test (Inpatients)

CQUIN

Improved performance or remaining

in top quartile on the Staff

F&F test

Annual staff

survey

Dementia - screening CQUIN >=90% 91.3%

Dementia - risk assessment CQUIN >=90% 100%

Dementia - referral for specialist diagnosis CQUIN >=90% 83.7%

Clinical Leadership - named lead clinician for dementia and appropriate training scheme for staff

CQUIN Compliant Named

Supporting Carers of people with Dementia - Monthly audit of carers of people with dementia agreed with commissioners

CQUIN Compliant Compliant

Improve data collection - 3 consecutive quarterly submissions of monthly survey data

CQUIN Compliant compliant




Reduction in the prevalence of pressure ulcer - on a minimum of 6 consecutive monthly data points a max 6.6% prevalence

CQUIN 6.60% 3.0%

Advancing Quality - AMI (Appropriate Care Score) Apr 13-Mar 14 CQUIN >=86.59% 99.5%

Advancing Quality - Heart Failure (Appropriate Care Score) Apr 13-Mar 14

CQUIN >=62.15% 73.1%

Advancing Quality - Hip & Knee (Appropriate Care Score) Apr 13-Mar 14

CQUIN >=82.14% 93.3%

Advancing Quality - Pneumonia (Appropriate Care Score) Apr 13- Mar 14

CQUIN >=66.66% 72.9%

Advancing Quality - Stroke (Appropriate Care score) Apr 13-Mar 14 CQUIN >=57.27% 70.1%

Commissioner assessment of providers achievement of 12 specific actions


Monthly survey of all appropriate patients to collect data on four medications safety issues which can result in harm


Reducing avoidable short stay <24 hour admissions CQUIN TBC

To carry out 2-3 Clinical Peer Reviews on areas of concern in relation to transfers of care identified and agreed with commissioners

CQUIN >=2 Compliant

Local protocol to be developed from Greater Manchester Hospital Discharge (prevention of homelessness) protocol.


Reducing Alcohol Abuse:-Progress with action plan milestone CQUIN Compliant Compliant

Reducing Alcohol Abuse:-Front line staff to undergone training CQUIN >=90%

Reducing Alcohol Abuse:-Patients to be screened CQUIN >=90%

Reducing Alcohol Abuse:-Appropriate patients to receive BIA CQUIN >=90%

Reducing Alcohol Abuse:-Increased number of referrals accepted by the service

CQUIN TBC Compliant

All low weight babies (where appropriate) received timely TPN CQUIN >=95% 100%

Screening rate for retinopathy of prematurity CQUIN 95% 100%

Timely data quality dashboard submission (Quarterly) CQUIN Compliant Compliant

Carers of patients 75+ yrs with a LOS of 7+ days receive friends and family test

CQUIN

Q2 &Q3 implement data implement data collection of carer opinion. Q4 increase in carers receiving questionnaire.

Compliant

Achievement of stage 2 baby friendly accreditation CQUIN Compliant Compliant

Integration: To support the range of activities required to enable the local health and social care economy to begin to fully achieve the benefits of integration.

CQUIN

To participate in the Bolton Health and Social Care Integration work

Evidence submitted




Urgent Care: To support the local health economy to develop a new model of care at the front end of A&E

CQUIN

To reduce in appropriate attendances at A&E

Plan submitted

End of Life Denominator: Number of pts identified as being in the last 12 months of their life, who have died within the month, who were on the GSF register, known to the District Nurse Service.

CQUIN 18 Compliant

End of Life Numerator: Number of pts identified as being in the last 12 months of their life, who have died within the month, who were on the GSF register, known to the District Nurse Service and had an ACP recorded. This information must be documented on the District Nurse Supportive and palliative Care Register with the inclusion of pts who have refused an ACP.

CQUIN 23 Compliant

End of Life - Denominator: Number of pts identified as being in the last 12 months of their life, who have died within the month, who were on the GSF register, known to the District Nurse Service and had an ACP initiated.

CQUIN 23 Compliant

End of Life - Numerator: Number of pts identified as being in the last 12 months of their life, who have died within the month, who were on the GSF register, known to the District Nurse Service and had an ACP initiated, who died within their preferred place of death where this is recorded using the Advanced Care Plan.

CQUIN 5 Compliant

2014/15 CQUIN Goals

CQUIN Indicator Name Indicator

Weighting

Nat

ion

al

Friends and Family Test – Implementation of staff FFT - NHS Trusts Only 1.5%

Friends and Family Test - Early Implementation 1.5%

Friends and Family Test -Phased expansion 1.5%

Friends and Family Test - Increased or maintained Response Rate in Acute Providers

1.0%

Friends and Family Test - Reduction in Negative Responses in Acute Providers 2.0%

Staff Friends and Family Test - Reduction in Negative Responses 1.50%

NHS Safety Thermometer - Improvement Goal Specification 5.00%

Dementia - Find, Assess, Investigate and Refer 3.00%

Dementia - Clinical Leadership 1.50%

Dementia - Supporting Carers of People with Dementia 1.50%

Loca

l

Baby Friendly Accreditation 1.50%

Provision of consultant clinician time to support virtual clinics 25.00%

Patient Experience 5.00%

Gastroscopy 10.00%

Alcohol 3.50%

GM

Lessons Learned Once 5.00%

Ambulatory Care 5.00%

Clinical Effectiveness Community 5.00%

Clinical Effectiveness Acute 5.00%

Improving Learning Disability Patient User Experiences and Support 5.00%



Care Quality Commission Registration

The Care Quality Commission (CQC) is the independent regulator of health and adult social care services in England. This means that as well as checking individual services, they look at how well the two sectors work together. There are many people who need to use both health and social care services and it is important that their care is as ‘joined up’ as possible.

The CQC do this by:

Driving improvement across health and social care.

Putting people first and championing their rights.

Acting swiftly to remedy bad practice.

Gathering and using knowledge and expertise, and working.

The CQC registration system for health and adult social care aims to ensure that people can expect services to meet essential standards of quality and safety that respect their dignity and protect their rights.

If the CQC has concerns that a provider is not meeting essential standards of quality and safety, they aim to act quickly, working closely with commissioners and others, and using their enforcement powers.

The Trust is required to register with the Care Quality Commission and its current registration status is registered without conditions. The Care Quality Commission has not taken enforcement action against the Trust during 2013/14.

There are 16 standards of essential quality and safety and cover the following areas:

Respecting and involving people who use service

Consent to care and treatment

Care and welfare of services users

Meeting nutritional needs

Cooperating with other providers

Safeguarding people from abuse

Cleanliness and infection control

Management of medicines

Safety and suitability of premises

Safety, availability and suitability of equipment

Requirements relating to workers

Staffing

Supporting workers

Assessing and monitoring the quality of service provision

Complaints

Records



In April 2014 the CQC inspected Bolton NHS Foundation Trust in relation to the following essential standards. This was in response to concerns that standards were not being met. The results of the inspection are detailed in the table below:

Following this inspection action plans were submitted to the CQC in relation to the areas highlighted as not meeting the Essential Standards. A follow up inspection in relation the three outstanding areas was conducted in September 2013 and covered the areas identified in the chart below. On reassessment of the standard and the actions put in place the Trust was found compliant in all areas with no remedial actions required.

The CQC Team observed how people were being cared for. They also reviewed records of people who use our services and obtained feedback from people who use our services.

Their overall judgement was that the Trust was meeting all the essential standards of quality and safety inspected.

Data Quality

The Trust submitted records during 2013/14 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data.

The percentage of records in the published data:

Outcome Description CQC Judgement

Care and Welfare of people who use services Compliant

Safeguarding people who use services from abuse

Compliant

Cleanliness and infection control Action Needed

Staffing Action Needed


Action Needed

Outcome Description CQC Judgement

Cleanliness and infection control Compliant

Staffing Compliant


Compliant



— which included the patient’s valid NHS number was:

99.8% for admitted patient care;

99.9% for outpatient care; and

99.1% for accident and emergency care.

— which included the patient’s valid General Medical Practice Code was:

100% for admitted patient care;

100% for outpatient care; and

100% for accident and emergency care

PwC have recently conducted a data quality audit covering 5 main key performance indicators:-

18 week wait for Inpatient Treatments

A&E 4 hour Target

Stroke patients spending 90% of time on a Stroke Unit

Patients waiting over 52 weeks for treatment

Two week wait target for urgent GP cancer referrals.

Whilst we are still awaiting the final reports, it is clear from feedback given that the reporting systems in place are adequate and that the reported performance indicators are assessed as reliable.

The Trust will be taking the following actions to improve data quality

Any errors highlighted will be investigated further and the Trust will determine the reasons for these and where appropriate provide further training for staff.

Information Governance

The Trust Information Governance Assessment Report overall score for 2013/14 was 68% and was graded green

Clinical Coding Audit

The Trust was not subject to the Payment by Results clinical coding audit during 2013/14 by the Audit Commission.

Reporting against core indicators


Since 2012/13 NHS foundation trusts have been required to report performance against a core set of indicators using data made available to the trust by the Health and Social Care Information Centre (HSCIC).

Mortality

The value and banding of the summary hospital-level mortality indicator (“SHMI”) for the trust for the reporting period

Oct 11 - Sept 12

Oct 12 - Sept 13

Bolton 1.006 1.078

National Average 1.000 1.000

Lowest 0.685 0.630

Highest 1.2107 1.186

We consider that this data is as described for the following reasons:

The data has been obtained from the Health & Social Care Information Centre (HSCIC)

The Trust has planned the following actions to improve this indicator and so the quality of its services, by:

Monthly mortality meeting chaired by the Medical Director

Implementation of level one facilities for monitoring patients within ward areas

Increase intensive care consultants within critical care

External critical care outreach.



Palliative care coding

The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period.



The Trust has taken the following actions to improve this indicator and so the quality of its services, by:

Work has commenced to develop an End of Life Care strategy following g the withdrawal of the Liverpool Care Pathway

Regular updates on End of Life Care are provided to the Quality Assurance Committee

% Q2 11/12

Q3 11/12

Q4 11/12

Q1 12/13

Q2 12/13

Q3 12/13

Q4 12/13

Q1 13/14

Q2 13/14

Q3 13/14

Q4 13/14

Bolton 16.5% 16.8% 17.2% 17.4% 18.9% 19.0% 19.7% 20.3% 19.9% 19.9% 21.0%

National Average 16.7% 16.1% 16.6% 17.3% 18.1% 18.6% 19.2% 19.5% 20.4% 20.6% 21.3%

Lowest 0.1% 0.1% 0.0% 0.0% 0.0% 0.3% 0.2% 0.1% 0.1% 0.0% 0.0%

Highest 38.9% 40.1% 41.6% 41.7% 44.2% 46.3% 43.3% 42.7% 44.0% 44.1% 44.9%



Patient reported outcome measures

Groin hernia surgery

Overall Score Apr 11 - March 12 Apr 12 - March 13 Apr 13 - Dec 13

Bolton 46.3% 35.2% 50.0%

National Average 51.0% 50.2% 50.7%

Lowest 14.3% 5.0% 14.3%

Highest 80.0% 84.2% 100.0%

Varicose vein surgery


Bolton 56.4% 30.8% 46.2%


Lowest 13.3% 23.5% 14.3%

Highest 100.0% 85.7% 88.9%




Centralisation of pre-operative services to standardise information received,

In the event of telephone pre-op develop process for identifying and capturing patients on the day of surgery,

Awareness campaign commenced February 2013



Patient reported outcome measures

Hip replacement surgery

Overall Score Apr 11 - March 12

Apr 12 - March 13 Apr 13 - Dec 13

Bolton 81.1% 85.9% 86.2%


Lowest 66.7% 37.6% 70.6%

Highest 100.0% 100.0% 100.0%

Knee replacement surgery


Bolton 72.3% 77.1% 80.0%


Lowest 53.9% 36.4% 35.7%

Highest 100.0% 100.0% 100.0%




Work has commenced with the CCG in relation to thresholds for surgery

Continue to adhere to implant best practice



Readmissions within 28 days

The percentage of patients readmitted to hospital within 28 days of being discharged during the reporting period.

Aged 0 to 15

Readmission %

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Bolton 8.66 10.00 14.29 13.25 14.39 13.29 13.37 14.02 13.78 12.82

National Average

9.54 9.63 9.78 9.64 9.78 9.72 9.44 9.52 9.32 9.50

Lowest 5.87 5.97 6.18 5.92 5.93 4.95 5.10 6.33 5.87 5.10

Highest 13.83 13.58 15.80 18.49 14.99 18.61 17.34 14.20 13.78 13.58

Aged 16 or over

Readmission % 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Bolton 9.42 9.51 10.60 10.39 10.86 10.95 10.24 9.74 10.17 10.04

National Average 8.65 9.11 9.83 10.17 10.36 10.50 10.73 10.97 11.08 11.20

Lowest 6.30 7.14 7.47 8.42 7.82 8.07 7.92 7.34 7.68 8.96

Highest 11.01 11.84 13.74 12.56 12.99 13.32 13.08 13.30 13.00 13.50

0.00

5.00

10.00

15.00

20.00

Re

adm

issi

on

%

Emergency Readmissions to Hospital Within 28 Days of Discharge:, 0-15 Years

Bolton

National Average

Lowest

Highest





The data shows the Trust to have a higher than average readmission rate for the 0 - 15 group, we are reviewing our performance in this area but early indicators are that this reflects our position as a regional neo natal centre and our practice of admitting ward reattenders. Performance against this metric will be reviewed by the QA Committee.


Established a clinically led readmission group

Working collaboratively with the CCG to carry out a follow up audit to determine causes

Further work is on-going around risk stratification of high risk patients with long term conditions.

0

2

4

6

8

10

12

14

16

Re

adm

issi

on

%

Emergency Readmissions to Hospital Within 28 Days of Discharge: 16+ Years

Bolton

National Average

Lowest

Highest



Responsiveness to patients’ personal needs

The trust’s responsiveness to the personal needs of its patients during the reporting period.-as reported in the annual inpatient survey

Overall Score 2010/11 2011/12 2012/13 2013/14

Bolton 74.7 77.6 77.6 79.5

National Average 75.7 75.6 76.5 76.9

Lowest 68.2 67.4 68 67.1

Highest 87.3 87.8 88.2 87


The methodology follows exactly the detailed guidelines determined by the Survey Co-ordination Centre for the overall National Inpatient Survey programme.

The survey required a sample of 850 inpatients to be drawn from those patients being discharged during June, July, or August 2013 who had had a stay of at least one night in hospital. There were a number of categories of patients excluded from the survey e.g. psychiatric patients and maternity patients.

The target response rate for the survey set nationally was to achieve at least 60% from the usable sample, and the number of usable responses should be at least 500.

342 completed questionnaires were returned from the sample of 850 from Bolton NHS Foundation Trust. A group of 37 patients were excluded from the sample for the following reasons:

Moved / not known at this address 18

Deceased 19

The final response rate for the Trust was 42% (342 usable responses from a final sample of 813).

The Trust has planned the following actions to improve this indicator and so the quality of its services, by:

50

55

60

65

70

75

80

85

90

95

100

2010/11 2011/12 2012/13 2013/14

Ove

rall

% S

core

Responsiveness to Personal Needs of Patients - Inpatient Survey

Bolton

National Average

Lowest

Highest



Look at why some patients are saying there are high levels of noise from other patients. If necessary, measure noise levels to ensure that staff are aware of actual levels and can take action where needed.

Review provision and clarity of information that is given to patients about the medication side-effects to watch for and what to do if they are worried.

Review the extent to which clinical staff provide the patient's family with adequate information about caring for the patient.

Ensure that there are robust arrangements in place to provide patients with copies of letters between clinical teams and the patient's GP, if this is what the patient wants.

Look for ways to improve patient feedback, as many patients would like to be asked about their views on the quality of their care.

Ensure that information about how to complain (such as leaflets and posters) are available for patients in hospital; staff are up to date on complaints procedures and able to explain and easily communicate this to patients.

Triangulate the organisation’s staff and patient survey data with that from the CQC in-patient survey, which gives a more accurate method of identifying patient concerns. Data from other surveys including the Friends and Family test can also be used to give a clearer picture of patients’ concerns.



Family and friends

Staff

The percentage of staff employed by, or under contract to, the trust during the reporting period who would recommend the trust as a provider of care to their family or friends.1

Overall Score 2012 2013

Bolton 56 58

National Average 65 67

Lowest 35 40

Highest 86 89

We recognise that our result in this area is below the national average. At the time of the staff survey in October 2014 when this survey was conducted the organisation was in turnaround with a significant impact on staff morale.

Inpatients

The number of patients who having been inpatients would recommend the Trust to their family and friends. The Friends and Family test was formally introduced in April 2014, therefore prior year comparator figures are not available

Overall Score Apr-

13 May

-13 Jun-

13 Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Bolton 78 77 78 73 79 78 76 79 79 80 84 79

National Average 71 72 72 71 72 72 73 73 72 73 72 73

Lowest 35 41 43 39 45 45 41 41 37 27 18 28

Highest 95 100 100 100 97 97 96 97 100 97 94 96

1 In last year’s Quality Account this figure was provided using different metrics, for comparative purposes we would advise

using the prior year figure included in this report.

0

20

40

60

80

100

120

Ove

rall

Sco

re

inpatients who would recommend the trust to friends or family

Bolton

National Average

Lowest

Highest



Accident and Emergency

Overall Score Apr-

13 May-

13 Jun-

13 Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Bolton 74 71 63 57 59 67 62 75 61 59 49 44

National Average 49 55 54 54 56 53 56 56 57 57 55 54

Lowest 0 0 4 0 6 0 12 9 10 0 0 1

Highest 100 94 100 91 85 89 93 92 96 92 90 90

We consider that the friends and family data is as described for the following reasons:



Invested in alternative ways that patients could provide feedback. A text method service has been introduced to increase the response rate.

Inpatient areas now receive monthly feedback of individual performance and comments

Comments are now displayed within ward areas

Development of Exemplar Star Status (ESSA)

Promotion of staff awards and staff recognition schemes to improve staff morale and motivation.

0

20

40

60

80

100

120

Ove

rall

Sco

re

Patients would recommend the trust to friends or family (A&E)

Bolton

National Average

Lowest

Highest



Risk assessment for VTE

The percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.

Overall % Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Bolton 96.5 96.9 96.0 97.2 96.6 95.7 95.3 96.0 96.7 95.9 96.5 96.4

National Average

95.1 95.5 95.7 96.1 95.8 95.6 95.9 95.9 95.6 96.1 96.0

Lowest 79.0 78.6 78.8 80.1 80.1 83.1 80.1 70.5 70.8 74.6 77.0

Highest 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0



We have routinely reported performance in excess of 95% because we have processes in place to risk assess all appropriate patients on admission. We have undertaken an audit of the case notes on discharge of the patient from hospital. The results of the audits are the figures reported monthly to the Trust Board and externally.

The Trust intends to take the following actions to improve this indicator and so the quality of its services, by:

Using real-time capture of the data on admission to and throughout the stay rather than at discharge only in relation to the percentage of patients that are risk assessed which we believe to be routinely in excess of 95%.



Clostridium difficile

The rate per 100,000 bed days of cases of C.difficile infection reported within the trust amongst patients aged 2 or over during the reporting period. (figures for highest and lowest are not available)

Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13 Q1 13/14 Q2 13/14 Q3 13/14 Q4 13/14

Bolton 47.04 7.47 29.62 28.79 26.49 17.67 7.62 17.10

National 18.07 17.68 16.91 17.76 17.14 15.60 15.05 14.41


The data has been obtained from the Health Protection Agency (HPA)


Introduction of a deep cleaning programme

Handwashing basins now outside all ward areas

Weekly strategic meetings to discuss all cases

Improved scrutiny of antibiotic management

Investment in estate

Collaborative working across the health economy

Investment in the infection control and prevention team

Clear guidance and policy

External peer review



Patient safety incidents

The number and, rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death.

Number and rate of Incidents

Number of incidents Oct11-Mar12 Apr12-Sep12 Oct12-Mar13 Apr13 - Sep13

Bolton 1369 2260 2600 2793

National Average 2454 2603 2871 2896

Lowest 745 843 631 1535

Highest 4459 4552 5272 4888

Rate per 100 admissions Oct11-Mar12 Apr12-Sep12 Oct12-Mar13 Apr13 - Sep13

Bolton 3.56 5.49 6.32 6.26


Lowest 2.21 3.11 1.68 3.54

Highest 10.54 14.44 16.73 14.49

0

1000

2000

3000

4000

5000

6000

Oct11-Mar12 Apr12-Sep12 Oct12-Mar13 Apr13 - Sep13

Nu

mb

er

of

inci

de

nts

Medium Acute organisations - Organisational incident data Number of incidents

Bolton

National Average

Lowest

Highest

0.00

5.00

10.00

15.00

20.00


Rat

e p

er

10

0 a

dm

issi

on

s

Medium Acute organisations - Organisational incident data Rate per 100 admissions

Bolton

National Average

Lowest

Highest



Number and rate of incidents resulting in severe harm

Degree of harm - Severe Oct11-Mar12 Apr12-Sep12 Oct12-Mar13 Apr13 - Sep13

Bolton 7 10 5 25


Lowest 1 0 1 0

Highest 80 61 50 69

% Degree of harm - Severe


Bolton 0.50 0.40 0.19 0.90


Lowest 0.00 0.00 0.03 0.00

Highest 3.00 3.10 1.74 2.02

0

20

40

60

80

100


Nu

mb

er

of

inci

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Medium Acute organisations - Organisational incident data Number of incidents - Severe

Bolton

National Average

Lowest

Highest

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50


%

Medium Acute organisations - Organisational incident data % - Severe Harm

Bolton

National Average

Lowest

Highest



Number and rate of incidents resulting in death

Degree of harm - Death Oct11-Mar12 Apr12-Sep12 Oct12-Mar13 Apr13 - Sep13

Bolton 1 0 4 1


Lowest 0 0 0 0

Highest 14 34 32 37

% Degree of harm - Death


Bolton 0.10 0.00 0.20 0.04


Lowest 0.00 0.00 0.00 0.00

Highest 0.60 1.30 3.01 1.08

0

5

10

15

20

25

30

35

40


Nu

mb

er

of

inci

de

nts

Medium Acute organisations - Organisational incident data Number of incidents - Death

Bolton

National Average

Lowest

Highest

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50


%

Medium Acute organisations - Organisational incident data % - Death

Bolton

National Average

Lowest

Highest



Incidents/ SUI/ Never Events We aim to increase the number of reported incidents whilst reducing harm associated with these.

2013-14 Data Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Total / Average

Total number of New SUIs received within the month

3 2 0 1 2 3 2 0 0 0 1 0 14

Total Incidents reported on Safeguard

756 693 662 753 706 727 773 792 712 766 723 786 8849

Total number of patient incidents

668 589 582 614 602 644 672 682 612 636 586 675 7562

Total number of patient incidents reported per 100 admissions

9.4 8.4 8.8 8.6 8.9 9 9 10 9 9 9 8 106.98

Patient incidents that resulted in severe harm or death %

0.9% 0.8% 1.2% 0.2% 0.7% 1.1% 1.1% 0.1% 0.9% 0.1% 0.3% 0.1% 0.6%

Total number of medication incidents

74 75 51 66 66 75 71 78 65 78 71 91 861

Medication incidents that resulted in severe harm or death %

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0%

The figures reported above include one never event, this event which has been investigated on and reported through the appropriate channels was classed as wrong site surgery. In 2012/13 we reported two never events both relating to retained swabs.


The data has been obtained from the National Patient Safety Agency (NPSA)


Introduction of new risk management strategy

Risk management training for clinical risk managers

New risk management committee established

Introduction of “harms” meeting to review incidents and ensure appropriate actions are taken

External training programme for managers to undertake RCA training

Review of the current electronic incident reporting system to ensure investigation conclusion can be logged



Post 48 hour MRSA Bacteraemia

We had reported two cases of post 48 hour MRSA bacteraemia in 2013/14 compared to five in the previous year.

Indicator Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13 Q1 13/14 Q2 13/14 Q3 13/14 Q4 13/14

Bolton 1 2 0 2 0 0 1 1

National 1 1 1 2 1 1 1 1

Lowest 0 0 0 0 0 0 0 0

Highest 16 9 7 7 5 4 5 6

We aim to continue this improvement through our infection control processes including proactive screening of all elective patients for MRSA

0

2

4

6

8

10

12

14

16

18

Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13 Q1 13/14 Q2 13/14 Q3 13/14 Q4 13/14

Nu

mb

er

of

case

s

MRSA - post-48 hour cases per quarter

Bolton

National

Lowest

Highest



PART THREE

Performance in 2013/14


How we performed on Quality and performance in 2013/14

This section indicates how some of the Quality Initiatives were progressed during 2013/14. The indicators included were selected by the Board in consultation with the Council of Governors and other stakeholders. Where these indicators have changed from these selected in 2012/13 this is reflects feedback from our stakeholders however we continue to monitor all previous Quality Account indicators through our integrated performance report.

All of our data is benchmarked nationally using CHKS Methodology, in addition to this we see assurance on the accuracy of our data quality through an annual report on non-financial data from our internal auditors, a review of metrics included in this report performed as part of the audit conducted by our external auditors and other external audit reports as appropriate.

For Patient Safety

o Reduction of pressure ulcers - page 13

o Reduction of clostridium difficile infection page 12

o Reducing patient falls page 15

For Effectiveness

o 62 day cancer waits – page 48

o Implementation of the ESSA framework - page 49

o Readmissions - page 33

For Patient Experience

o Patient experience feedback – the Friends and Family test page 37

o National inpatient survey responsiveness to patient needs page 35

o Complaints and concerns - page 51

Earlier in this report we set out our priorities for the coming year. These were agreed following consultation with stakeholders who were keen to see us continue work on some of the priorities agreed in the previous year.

Where these priorities are discussed elsewhere in the report we will refer to that data to avoid repetition.



62 day cancer performance

The year-end 62 day cancer performance for the Trust is 86.7%. This figure is in line with Greater Manchester and Cheshire Cancer Network agreed policy for the reallocation of breaches to the referring Trust when it fails to refer the patient to the receiving Trust within the agreed time frame. The performance shows that the Trust exceeded the 85% target for patients with a diagnosis of cancer, to be treated within 62 days of their urgent GP referral for suspected cancer.

Notes: The figure for May includes an additional breach identified as a result of the recent audit by KPMG this figure is therefore different from previously reported.

62 Day (Urgent GP Referral to Treatment) waits for first treatment: All Cancers

There are a number of indicators where the Trust is benchmarked against other organisations – this includes:

62 Day wait for first treatment – all cancers (provider data)

62 Day wait for first treatment – by cancer (provider data)

62 Day wait for first treatment from consultant upgrade – all cancers (provider data)

62 Day wait for first treatment from screening service referral – all cancers (provider data)

The data has been used from the following reports

http://transparency.dh.gov.uk/category/statistics/provider-waiting-cancer/

62 Day Reallocated RTT Performance 2013/14

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

% performance

87.7 84.4 95.3 85.3 95.1 86.0 88.6 84.1 81.2 84.4 85.4 85.7

% quarterly 89.0 86.8 84.3 85.2

http://transparency.dh.gov.uk/category/statistics/provider-waiting-cancer/



Implementation of the ESSA performance framework

During the final Quarter of 2014 the Exemplar Star System of Accreditation performance framework was introduced in relation to providing assurance that wards were meeting the expectations in relation to standards of care.

This system builds on the previous work undertaken through Exemplar and builds on this to produce a systematic framework of performance management, which includes:

ESSA

ESSA practice Review Process

Matron and Ward Manager KPI Framework

Weekly KPI Monitoring proforma

SOP Ward Manager Supervisory Role

Exemplar Star System of Accreditation (ESSA)

The ESSA is a set of 13 standards against which a ward/ Department or community service is measured against in relation to Quality and Safety. The standards are assessed by the following methods;

Observation

Conversation with Staff and Patients

Examination of clinical records

Analysis of Complaints, Incidents, Safeguarding, infection control, appraisal, mandatory training.

A star accreditation will be awarded to each area following assessment. Only when standards of Quality and Safety have been maintained may an area apply for Exemplar status. A portfolio of evidence will be presented to an executive panel that will then put the area forward, if agreed by the panel, to the Trust Board to agree the Exemplar accreditation.

ESSA Practice review process

Currently if areas are under performing there is no systematic review process undertaken to ensure improvement is made. The practice review process identifies a framework for reviewing areas identified that need additional support.

It will assist the divisions in having a clear process in place to enable them to report back in a consistent manor on improvements being made in challenging areas.

Matron/ Ward Manger KPI Framework

Clarity in roles and responsibilities is important to ensure clarity in relation to the priorities and expectations of divisional and corporate teams.



This framework is aligned to the Trusts strategic aims and will be utilised to set clear objectives and priorities for both the ward managers and matrons. It refers to both operational priorities and quality and safety priorities ensuring that there is a balance between the two.

This tool will be used to set individual targets through both 1:1 meetings with the Professional Leads or yearly objective setting and appraisal.

Weekly KPI Monitoring

It is proposed that this replaces the current system used in relation to the North West Care Indicators. The monitoring will be undertaken on a Friday of each week and will be completed for each appropriate patient. This will increase the assurance in relation to these KPI being met and enable areas to be identified and actioned quickly should under performance be noted.

Standard Operating Procedure (SOP) Ward Manager Supervisory Role

In June 2013 Trust Board agreed with the decision to ensure the supervisory nature of the Ward Manager role. The SOP identifies the key components of this role, to ensure that ward management, role modelling, support and development occur through the investment in this role.

Together these 5 components working together will provide a robust performance management framework to ensure the delivery of safe and effective care across our wards, departments and community.



Complaints and Concerns

The Trust has a Complaint Policy and Process which includes the management of informal concerns and PALS contacts.

The number of recorded complaints on the annual KO41 Department of Health and reported in the annual complaints report in 2013/14 is represented in the charts below.

By service Area Total number of written complaints received

Total number of written complaints upheld

Hospital Acute Services: Inpatient 212 113

Hospital Acute Services: Outpatient 220 101

Hospital Acute Services: A&E 58 15

Elderly (Geriatric) Services 2 1

Mental Health Services 0 0

Maternity Services 46 19

Ambulance Services 2 2

Community Hospital Services 0 0

NHS Direct 0 0

Walk-In Centres 0 0

Other Community Health Services 12 4

CCG Commissioning 3 1

Other 9 6

TOTAL 564 262

By professional group

Medical and dental(including surgical) 311 117

Allied Health Professionals 17 7

Nursing, Midwifery and Health Visiting 154 95

Scientific, Technical and Professional 9 6

Ambulance crews (including paramedics) 0 0

Maintenance and Ancillary staff 1 1

CCG Administrative staff / members (exc GP admin)

0 0

Trust Administrative staff / members 45 29

Other 18 7

TOTAL 564 262



Complaints by cause Total number of written complaints received

Total number of written complaints upheld

Admissions, discharge and transfer arrangements

31 21

Aids and appliances, equipment, premises (including access)

6 3

Appointments, delay / cancellation (outpatient)

61 39

Appointments, delay / cancellation (inpatient)

3 1

Attitude of staff 88 40

All aspects of clinical treatment 303 121

Communication / information to patients (written and oral)

43 25

Patients privacy and dignity 3 2

Patients property and expenses 2 0

Personal records (including medical and / or complaints)

11 5

Failure to follow agreed procedures 7 4

Patient's status, discrimination 2 0

Transport (ambulances and other) 1 1

Hotel services (including food) 1 0

Other 2 0

TOTAL 564 262

Complaints have increased by 32% from 2012/13. This may be due to the review of complaints procedures that took place in June 2013 leading to changes to our validation process. One of the changes within this review was a change in the categorisation of PALS contacts and complaints.

The Annual Complaints Record published under Regulation 18 of the Local Authority Social Service and NHS Complaints Regulations 2009 provides more detailed analyses of these complaints with a Qualitative and Quantitative analyses. This has been taken into consideration in the preparation of this Quality Account and in setting Quality Priorities going forward.

We believe that by listening and acting on feedback provided we can reduce the number of complaints we receive. This will be achieved by learning from concerns and by getting the patient experience right.



Achievement against the Monitor Risk Assessment Framework 2013/14

Indicator

Year-end position

Target Achieved

Referral to Waiting Times - Admitted 94.8% 90% Yes

Referral to Waiting Times - Non Admitted 96.6% 95% Yes

Referral to Waiting Times - incomplete 96.3% 92% Yes

Maximum waiting time of four hours in A&E from arrival to admission, transfer or discharge

96.5% 95% Yes

Maximum waiting time of 62 days from urgent referral to treatment for all cancers - from urgent GP referral to treatment

86.7% 85% Yes

Maximum waiting time of 62 days from urgent referral to treatment for all cancers - from consultant screening service referral

93.0% 90% Yes

Maximum waiting time of 31 days from diagnosis to treatment of all cancers - surgery

99.3% 94% Yes

Maximum waiting time of 31 days from diagnosis to treatment of all cancers – anti cancer drug treatments

100.0% 98% Yes

All cancers 31-day wait from diagnosis to first treatment 99.0% 96% Yes

Cancer: two week wait from referral to first seen, all cancers

94.9% 93% Yes

Cancer: two week wait from referral to first seen, symptomatic breast patients (cancer not initially suspected)

96.2% 93% Yes

Clostridium difficile - meeting the C. difficile objective

38 28 No

Certification against compliance with requirements regarding access to health care for people with a learning disability

100% 100% Yes

Data completeness community service referral to treatment

99% 50% Yes

Data completeness community services - referral information

100% 50% Yes

Data completeness: community services - treatment activity information

100% 50% Yes

Stakeholder Statements


Foundation Trust Governors

As Foundation Trust Governors we have worked closely with the Directors of the Trust and will continue to do so during 2014/15.

We welcome the publication of the Quality Report and congratulate the Trust on the results achieved particularly with regard to the four hour Accident and Emergency target, the reduction in the number of cases of C Difficile and the implementation of the policies to reduce harm from pressure ulcers and falls which are starting to show results.

We hope that the same effort and determination will continue in 2014/15 and look forward to continuing to support the Trust in the coming year

Bolton NHS Foundation Trust Council of Governors

April 2014

Overview and Scrutiny Committee

On behalf of the Health Overview and Adult Social Care Scrutiny Committee I welcome the opportunity to comment on the quality account for 2013/2014.

The Account is comprehensive in its coverage of the services and aspirations of the Trust. It is good to see that the Trust is listening and learning from the service users and determined to deliver an improved and accessible service.

The Quality Account describes the efforts to ensure that the delivering of high quality, patient-centred care remains central.

The Account provides a quality summary of achievements made and the work required to take the priorities forward in 2014/2015.

Councillor A N Spencer Chairman 2013 /2014

May 2014

Stakeholder Statements


Bolton CCG

We have worked closely with Bolton FT throughout 2013/14 to gain assurances that the services they delivered were safe, effective and personalised to service users. The CCG shares the fundamental aims of the FT and supports their strategy to deliver high quality, harm free care. We also note the development of an integrated performance report which provides accurate quality assurance to the FTs Board.

We acknowledge the significant reduction in patients acquiring CDT and welcome the FT’s contribution to the health economy in reducing infection rates. In spite of this year’s target allowing for more cases, we expect that initiatives implemented to date will enable the FT to both sustain and improve on the progress made last year.

We note the development of strategies for pressure ulcer care and falls and note that improvements in both these areas have been achieved already. We have welcomed the opportunity to join the FTs Harm Free Care Panels and the opportunity this has created to work together to reduce harm across all health and social care sectors.

We have been disappointed with the response rates from the Friends and Family Tests, particularly in A&E and Maternity. Although the scores have been generally positive we would like to see a more ambitious increase in response rates than indicated in this report. We do however note the other initiatives that are taking place to obtain real time patient feedback, in line with the FTs Patient Experience Strategy.

We acknowledge the FTs adherence to the new reporting requirements for this year’s Account and the actions described to improve the quality of services. We are pleased that the information presented is consistent with information provided to the CCG throughout the year.

We are pleased to note the FTs 100% adherence to eligible National Clinical Audits and Confidential Enquiries, providing evidence that the FT is committed to benchmarking its performance against standards. We note the examples provided and would like to see further examples of how these results have been translated in to improved outcomes for patients.

We are pleased to note the improvements made in the number of incidents reported as this indicates an improving safety culture within the FT. We would like to see a further increase in the numbers of ‘no harm’ incidents and ‘near misses’ reported and a sustained reduction in severe harm incidents in line with the FTs new Risk Management Strategy. The CCG expected to see reference to the Never Event that occurred within 13/14 and a focus on the quality improvements that resulted from the investigation.

This Account indicates the FTs commitment to improving the quality of the services it provides. We agree with the key priorities for improvement in 2014/15 but would like to see a greater focus on community services and associated quality indicators reported in next year’s Account. Where planned service changes are to take place the CCG expect stakeholder and patient engagement to occur in the initial stages in order to inform the process and although we acknowledge the challenges ahead for the entire health economy we believe that an open, transparent and collaborative partnership with the FT will enable these challenges to be met.

Michael Robinson

Associate Director of Integrated Governance and Policy

Bolton CCG

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