QUALITY ACCOUNTOUR

SUMMARY 2018/19

04 Chiefexecutive’sstatement

06 Ourperformance

10 Qualityimprovement

14 Safetyculture

15 Continuousimprovement

16 Listeningtopatientsandstaff

18 Highqualityinformation

19 Listeningtostakeholders

23 Clinicalresearch

24 Futurefocus

CONTENTS

...we have much to be

positive about and I look

forward to seeing many

more improvements

over the next year.

It has been another very busy year with periods of intense pressures on our services, however, we used the lessons we learnt from the harsh winter of 2017/18 to good effect. The changes we made, often on the back of direct feedback from frontline staff, have made a tangible difference to our patients.

This is exactly what our trust is about - taking fantastic performance not as a ceiling but as a new benchmark, learning new lessons and innovating to overcome problems. We have more to do but I could not be more proud of our record to date.

This year we decided to focus on a smaller number of quality improvement (QI) programmes due to a desire to develop and embed a culture of QI across the trust - encouraging new thinking at every level. We have made great strides and now have a proven formula to help structure these changes.

Staff are encouraged to undertake training and, above all, suggest a change that could have a positive impact. After all, good ideas come from everywhere and anywhere.

Our progress on our five priorities for 2018/19 - falls, staff experience, surviving sepsis, flow and frailty - is set out in detail later on. However, I want to highlight one of them - the new ambulatory care unit at The Northumbria hospital, a key part of our work to improve the flow of patients through our system.

The ground-breaking unit, which will accommodate medical, surgical, gynaecology and orthopaedic services will result in a much improved journey and experience for patients, and also be more efficient, helping staff adapt to changing demands.

This doesn’t detract from the excellent work taking place to make improvements in other

areas, including a significant reduction in the number of falls, thanks in part to the introduction of innovative new observation tools.

This progress wouldn’t have been possible without the hard work and unfaltering dedication of our staff who continually focus their efforts on making the care we provide for our patients the very best it can possibly be. I’d like to thank each and every one of them for their service and enthusiasm over the last year.

We have a clear set of priorities for 2019/20 which aim to build on what we have achieved so far. However, we are also determined to branch out into entirely new areas. Among the most prominent is how we approach bereavement and as part of ‘realistic medicine’, we are committed to changing the shape of the conversations we have with our patients. There will be a greater emphasis on

tailoring care to the priorities people tell us they have, rather than what we think they are.

Another important initiative is ‘every contact counts’, about making the most of each interaction with patients. Moreover, to make sure the care we deliver is linked to wider issues around public health and taking every opportunity to improve the health and wellbeing of the populations of Northumberland and North Tyneside we serve.

As we look to the year ahead we have much to be positive about and I look forward to seeing many more improvements over the next year.

Sir James Mackey

CHIEF EXECUTIVE’S STATEMENT

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Core safety outcomes Progress against prioritiesIn 2018/19 we focussed on a smaller number of programmes to develop and embed a culture of quality improvement (QI) across the organisation and to include services and teams in the priorities. These were:

FallsSignificant improvements have been made in the number of falls that take place in hospital - we are now in line with the national average and our previous risk rating on the Board Assurance Framework was modified to a moderate risk.

Three key initiatives have taken place this year:

• roll out of falls safe bundle

• attendance at the NHS Improvement falls collaborative

• launch of AFLOAT (avoiding falls level of observation tool) and Bay Watch, enabling staff to identify and support those patients most at risk of falls

StaffexperienceOur staff experience programme has made excellent progress, beginning with a review being undertaken to understand more about the aspects of staff experience that mattered most and how these were linked to improving patient experience.

After piloting a survey with eight teams, we launched the programme to get a baseline understanding of how staff across the organisation were feeling. We were delighted with the response from over 2,700 staff and more than 200 teams.

For the first time, we were able to have a far more detailed picture of staff experience and achieve this feedback in a timely way.

OUR PERFORMANCE

SUMMARY HOSPITAL-LEVEL MORTALITY INDICATOR

AS EXPECTED

PATIENT REPORTED OUTCOME MEASURES

ABOVE THE NATIONAL AVERAGE FOR HIP

RESPONSIVENESS TO NEEDS OF PATIENTS TOP 20% NATIONALLY

STAFF WHO WOULD RECOMMEND TRUST TO FAMILY OR FRIENDS

83%

VENOUS THROMBOEMBOLISMRISK ASSESSMENT

AS EXPECTED

C.DIFFICILEBETTER THAN

EXPECTED

PATIENT SAFETY INCIDENTS

AS EXPECTED

EMERGENCY READMISSIONS0-15 YEARS AS EXPECTED

16 + YEARS WORSE THAN EXPECTED* - ACTIONS FOR IMPROVEMENT INCLUDE DISCHARGE LOUNGES AND FOLLOW-UP CALLS FOR ELECTIVE CARE PATIENTS

AND KNEE REPLACEMENT (POSITIVE OUTLIER)

*same day emergency care activity recorded as admitted patients which impacts on the reported measures

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SurvivingsepsisScreening is important in managing sepsis to ensure we identify those at risk as early as possible. It relies on the recording of a Northumbria Early Warning Score - NEWS (clinical observations), and a question regarding the possibility of infection.

We introduced Nervecentre, a digital system, to the emergency department which incorporates NEWS observations as part of triage, and a prompt in relation to sepsis is incorporated into the tool. We have now been able to ensure that sepsis screening continues to exceed our 95% threshold.

The sepsis screening tool is designed to support staff to deliver the care bundle to those suspected of having sepsis. As we have become more digital within the emergency setting, it has become apparent that its use has declined due to its written format and our target for the screening tool has not been achieved.

We have continued to see improvements in the time taken to deliver the bundle and this

continues to sit below one hour. Our focus is now on consistent and sustainable delivery to increase the number of people receiving the full bundle, and moving forward we aim to introduce a digital version of the screening tool.

FlowGood flow through our hospitals is key and all of our safety and quality priorities are, in one way or another, related to it.

Introducing Nervecentre into the emergency department has allowed us to identify our sickest patients and ensure they are seen in a timely way and also identify those who could be seen in ambulatory care.

We have achieved our target of 120 attendances a day within the ambulatory care unit - an increase from 70 a day previously. Throughout the year we started the build of a new purpose-built ambulatory care unit which will accommodate medical, surgical, emergency gynaecology and orthopaedic services.

We have also been focussing on improving bed availability, with initiatives taking place to reduce the number of extended stay patients - those who are in hospital more than 21 days.

This includes a new HomeSafe service which ensures patients who need further therapy and assessment but don’t require hospital care, are discharged to complete their recovery at home where possible. Our extended stay programme has also introduced a co-ordinated approach to discharge planning involving both community and ward-based staff.

We have reduced the number of patients who stay more than 21 days in hospital by 18%.

FrailtyFrailty is a priority for us as the majority of our hospital population are older. The frailty assessment unit provides access to a geriatrician and multi-disciplinary team along with a comprehensive geriatric assessment.

Unfortunately, we have been unable to meet

our target this year of 30 patients a day due to operational difficulties.

However, we have continued to develop the geriatric assessment through a multi-disciplinary team document and work has now moved into scoping the transfer of care between hospital sites, with the potential to introduce this in a digital format.

We are also developing a strategy that has an understanding of Getting It Right First Time (GIRFT) and wider regional initiatives to inform good practice.

Other areas we have focussed on are:• incorporating The Rockwood Score

into Nervecentre to identify the level of support required - now 100% of patients attending the emergency department have a frailty score recorded

• initiatives to prevent and manage falls and pressure care including a physiotherapy exercise programme in our elderly care environments

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QUALITY IMPROVEMENT

As we work towards embedding a culture of QI across our trust, there are many examples of initiatives that have been successfully delivered throughout the year resulting in improved quality of care for the people who use our services. Here are just some examples:

TraineenursingassociatesOver the past two years, we have supported the training and development of trainee nursing associates - a programme of education providing an opportunity to upskill some of our talented nursing assistants. We are now preparing to welcome the first-ever cohort of registered nursing associates in the North East into the trust.

The programme is run in partnership with Teesside University with practice experiences provided across the three areas of home, close to home and hospital. We have implemented various initiatives to enhance the experience and development of this group of staff. This includes employing a dedicated clinical

educator - whilst supporting the trainee they also provide guidance for mentors. The role has been well received and we have facilitated a further two cohorts of trainees.

EndoscopicfullthicknessresectionWe have recently started full thickness endoscopic resection for colon cancer, only the second trust in the UK to offer this minimally-invasive technique. Whilst it has been carefully introduced and is only suitable for early colonic cancers, the initial procedures have been carried out successfully both in terms of cancer outcomes and patient outcomes.

Patients treated so far have had overnight stays and returned to normal activity the next day, compared to an average hospital stay of five to seven days and potential complications associated with the major resections they would otherwise have undergone.

UsingAFLOATtoreducefallsAFLOAT was developed as part of our improvement work with NHS England’s National Falls Collaborative. It identifies seven characteristics that increase a patient’s risk of falling and assigns a score to each, when added up a safe level of observation is advised. The nurse then uses their clinical judgement to set the level of observation for the patient.

During engagement, our nurses had said they would feel better supported in their decision making with such a tool, and since we devised and launched it this year, staff feedback has been very positive. It has enabled more robust, evidence-based decisions relating to the required level of observation. We’re delighted it has been shortlisted for the 2019 HSJ Patient Safety Awards in the category of ‘improving care for older people award’.

HIPQIPcollaborative-ourambitiontosave100livesEnsuring safe, effective and equal care

of patients with hip fractures remains a major public health issue. Our hip fracture improvement programme (HIP QIP), running for a number of years, had already been extremely successful and our ambition was to see if these improvements could be adopted in other NHS organisations.

Our collaborative began in 2016 and we identified a group of hospitals where we could make an impact. With our primary outcome focussed on reducing mortality, our overarching programme goal was to save 100 additional lives by the end of the two-year collaborative.

At the start, 30 day mortality for the collaborative was 10.3%, by December 2018 their mortality rates had reduced to 5.7% - well below the national average. Evaluation by the Royal College of Physicians not only reported benefits in terms of lives saved but also wider gains including patients having their operation within 36 hours and returning to their own home.

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DementialeadnurseinpostA new dementia lead nurse started with us this year, beginning by visiting departments, wards and areas across the trust to understand what we are currently doing well and where further work is needed to support our patients with dementia and their carers. She has also been visiting our third and voluntary sector colleagues to look at working more collaboratively.

We are working towards the goal of being a dementia-friendly trust and also being able to say that we provide the gold standard of care to our patients with dementia and their carers. Areas we are currently working on include patient and carer experiences, dementia training, our ward environments and our delirium pathway.

JubileeDayHospital The Jubilee Day Hospital at North Tyneside General Hospital provides outpatient

appointments for a variety of clinics including falls, Parkinson’s disease, stroke and general care of the elderly. Historically referral has been made through various sources such as GPs, consultants and community services.A QI project aims to create a single referral route that is accessible and efficient, and that will reduce waiting times and improve patient experience.

Members of the multi-disciplinary team will triage the referral into either a new generic clinic or a standard clinic. Patients triaged into the new generic clinic will attend for a single appointment and receive a comprehensive assessment. During the development of the project, it has demonstrated reduced waiting times to access the clinic and positive patient experience data.

QISTprogramme-QualityImprovementinSurgicalTeamsWe have implemented two interventions, namely reducing MSSA infection and proactive detection and treatment of anemia. Our

ambition is to support spread and adoption across more than 30 NHS sites. If the benefits seen by us are replicated, patients will:

• have fewer serious complications post surgery

• have a reduced length of stay in hospital• be less likely to be readmitted to hospital• be less likely to need critical care

The results of the QIST programme are being formally evaluated by researchers in the York Trials Unit and we await the final outcomes with interest. Meanwhile, the team were very pleased to see their early work acknowledged as ‘highly commended’ in the 2018 HSJ Awards innovation of the year category.

Award-winningbirthreflectionprogramme (HSJ compassionate care award 2018)A team from our obstetrics, patient experience and health psychology services came together to develop a pathway to try to reduce the negative impact a difficult birth can have for some mothers. The birth reflection service

allows women to work back through a difficult delivery, receiving support to address any trauma and getting answers to any questions they may have.

To create the service, more than 100 members of staff were trained in a psychological model of birth trauma - one grounded in compassion.

Birth reflection clinics have now been running for a year at the trust and patient feedback is extremely positive.

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SAFETY CULTURE

As an open and transparent organisation, we want our staff to feel empowered to raise any concerns or issues they may have come across.

We encourage this in a number of ways:

ReportingincidentsThe National Reporting and Learning Service recognises that organisations, like ours, that report more incidents usually have a better and more effective safety culture.

Our staff reported 17,381 incidents during 2018/19. Once reported, each incident is investigated and remedial action is taken where necessary. To further encourage reporting, staff receive feedback on incidents electronically through our incident reporting system.

We will continue to work with all staff to emphasise and publicise the importance of reporting incidents whenever they are witnessed.

DutyofcandourAs with all trusts, we are required to comply with the duty of candour after becoming aware of any notifiable safety incident. This is an unintended incident that may have resulted in death or severe harm to a patient or service user.

We have made our staff aware of their responsibilities around duty of candour through internal communication briefings, amendments to trust policies and procedures and also through our induction process.

FreedomtoSpeakUpStaff can speak to our Freedom To Speak Up Guardian about any concern they have through text, email or phone. They will receive confidential support and advice on how to escalate or manage their concerns.

They are encouraged to speak to their line manager, or the guardian can escalate the issue through an appropriate route.

CONTINUOUS IMPROVEMENT

To help us ensure that our services continue to provide the best possible care we have once again carried out our rolling programme of reviews of our specialties using our quality panels. They analyse individual services with clinical directors and management leads, both in terms of clinical outcomes and also measures such as patient experience. This allows us to identify areas of good practice and those in need of improvement along with any gaps in knowledge.

The reviews examine if services are safe, effective, caring, responsive, and well-led. During 2018/19 we reviewed the following specialties and services:

• acute medicine • care management• community learning disability team • district nursing• haematology and blood transfusion• infection control• integrated health and wellbeing • maternity• palliative care

• physiotherapy• POAS mental health services for older

people • radiology• rheumatology• safeguarding• tissue viability• trauma and orthopaedics

Every year we also take part in national and regional audits of our specialties. These measure the quality of their clinical practice against agreed best practice standards and criteria.

In 2018/19 we took part in 51 national clinical audits and 309 local clinical audits, contributing to patient care in a number of ways. This includes improving the information provided to patients and their families about their care and treatment; and delivering safer care through enhanced assessment, timeliness of treatment, more effective communication, better use of technology and improved documentation.

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LISTENING TO PATIENTS AND STAFF

We are widely recognised as having one of the best patient experience programmes in the NHS and use a range of approaches to actively engage with the people who use our services. This allows us to understand where we may need to improve care, and also design and deliver services that people really need.

We remain focussed on obtaining detailed feedback at all points along the patient journey.

OF PATIENTS RATED THEIR CARE ON OUR WARDS AS EXCELLENT, VERY GOOD OR GOOD98% PATIENTS RECEIVING CARE AS AN OUTPATIENT RATED US AS EXCELLENT, VERY GOOD OR GOOD99%

OF TRUSTS FOR PATIENTS USING EMERGENCY CARE TOP 20%

Our staff are key to providing safe, effective and respectful care.

The NHS staff survey provides us with good information about how our staff feel about their work and how well they are equipped to deliver high quality patient care. Our response rate was 72% - once again one of the highest in the country.

ONE OF THE TOP TRUSTS FOR STAFF HEALTH AND WELLBEING

TOP TRUST FOR STAFF MORALE

TOP TRUST FOR EQUALITY, DIVERSITY AND INCLUSION

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LISTENING TO STAKEHOLDERSHIGH QUALITY INFORMATION

We know how important good quality information is to the effective delivery of patient care and that it is essential if improvements in the quality of that care are to be made.

AccuratedataOur continued emphasis on high quality data to ensure information held about an individual patient and used in their care is accurate has been demonstrated in a number of ways over the past year:

• a patient’s NHS number is a key identifier for patient records - our work to ensure the completeness of this data means our performance is above the national average

• with 100% of our records for outpatients, admitted, and emergency care patients including the patient’s GP practice code, we are above the national average

• clinical coding translates the medical terminology used to describe a patient’s diagnosis and treatment into standard recognised codes and is a key identifier of the patient record. We carried out an internal audit covering 200 episodes from

breast surgery, colorectal surgery, upper gastrointestinal and plastic surgery. The overall accuracy scores achieved Data and Security Protection Toolkit ‘advisory’ requirement level.

• we have met and completed all 100 of the evidence items for the Data Security and Prevention Toolkit, indicating a ‘standards met’ status. We await formal publication by NHS Digital.

We will continue to further improve data quality over the coming year.

ComplaintsWe value the contributions patients and their carers have made to our feedback channels, and listening to concerns allows us to make the necessary improvements in our care.

The number of new complaints received in 2018/19 was 334, which represents a decrease of 15% from the previous year. We encourage concerns to be raised immediately with the person in charge of a patient’s care as we recognise that in the majority of instances it is best to resolve issues as soon as possible.

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CLINICAL RESEARCH

Clinical research plays a vital role in improving healthcare for everyone. We continually engage in high quality research to enable every patient, family member and member of staff to have the opportunity to participate in the work we do.

In 2018/19, 3,547 patients participated in 84 studies, a 21% increase in recruitment from the previous year.

During the year our research and development department restructured to provide dedicated support to the major areas of clinical research we support across the trust, with teams participating in research in:

• cardiology• care of the elderly• community• dementia• gastroenterology• haematology• obstetrics and gynaecology

• oncology• orthopaedics• palliative care• parkinson’s disease• respiratory• rheumatology• stroke

We already participate in a number of commercial studies across several specialties, with our rheumatology team often featured by our commercial sponsors as being one of the top recruiters nationally.

In addition, we sponsor many academic projects, resulting in high quality journal publications and conference presentations. In 2018 there were 75 journal publications from the academic work performed by our employees.

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FUTURE FOCUS

FRAILTY FLOW

CANCER BEREAVEMENT

DETERIORATING PATIENT STAFF EXPERIENCE

MATERNITY EVERY CONTACT COUNTS

Continuing to provide the best healthcare for those with complex needs, with particular focus on our frail elderly patients. We will do this through increased geriatric assessments, reduced hospital transfers and reduced readmissions.

Ensuring appropriate care / enhanced care plans are in place for people who are frequent users of emergency care and are admitted to hospital frequently.

Looking in detail at specific cancer pathways, starting with colorectal, to map the patient journey so we can improve both outcomes and experience.

Learning and improving the care that we provide at end of life, which includes introducing our own medical examiners.

Increasing screening rates for sepsis and acute kidney injury to support the early identification of patients who are at risk of serious illness and deterioration.

Carrying out a comprehensive measurement programme for staff experience that will match the deep understanding we have about patient care.

Improving the care and experience of service users, especially in light of increased birth rates.

Working to improve self-care among the population through initiatives such as social prescribing, care and support planning and connecting people to social networks.

Our safety and quality priorities 2019/20

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