Nuh Qa Full Web

2012/13
Quality Account
How we are continuously improving quality, safety and patient experience
Contents
1 Introduction from the Chairman & Chief Executive......................................................................2 2 Declaration of Accuracy...................................................................................................................4 3 Quality Review of 2012/13..............................................................................................................5 4 Priorities for improvement and Board statements of assurance................................................ 15
Public involvement and consultation for our Quality Account......................................................................................... 16 Quality priorities for 2013/14......................................................................................................................................... 17
5 Service quality in 2012/13 and its assurance................................................................................ 21 6 Incidents......................................................................................................................................... 47 7 Quality framework: Ward to Board.............................................................................................. 51 8 Workforce and quality...................................................................................................................55 9 Quality, Innovation, Productivity and Prevention.......................................................................57 10 Research and quality at NUH........................................................................................................59 11 Appendices.....................................................................................................................................63
Appendix 1 Summary of performance against all objectives 2012/13........................................................................... 64 Appendix 2 Statements of assurance........................................................................................................................... 66 Appendix 3 Themes from public consultation for our 2013/14 Quality Account priorities ............................................. 68 Appendix 4 Statement of Directors responsibilities in respect of the Quality Account ................................................. 69 Appendix 5 Standards inspected by Care Quality Commission, September 2012.......................................................... 70 Appendix 6 National audits in which NUH participates................................................................................................ 71 Appendix 7 Independent auditors limited assurance report........................................................................................ 73 Appendix 8 Peer hospitals........................................................................................................................................... 77 Appendix 9 Index & glossary of terms......................................................................................................................... 78
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Introduction from our Chairman & Chief Executive
Welcome to Nottingham University Hospitals NHS Trusts (NUH) 2012/13 Quality Account, our fourth. It is designed to be read alongside our Annual Report (to be published in September 2013). Our Quality Account focuses on quality and safety standards and our Annual Report describes the Trusts 2012/13 broader performance and achievements, and its finances.
Our Quality Account priorities have been informed by the views of our patients and their carers, our members, staff, and our partner organisations. We engaged patients in the Accounts development to ensure it is meaningful and accessible. We include details of our performance over a number of years, and how we compare with similar hospitals.
We can point to improvements in the safety of our services and the experience of our patients in 2012/13. The outcomes for some patients were better than in previous years. The Account also describes those areas in which we made insufficient progress, detailing the reasons for underachievement and the work underway to deliver lasting improvements. When the Care Quality Commission (CQC) inspected us in autumn 2011 they had moderate concerns about the consistency of elements of our care, notably record keeping and security, assessment and documentation of mental capacity and consent, and some aspects of privacy, dignity and nutrition. We have applied great energy into improving our care in these domains. The CQC reported very considerable improvement at reinspection in September 2012, when we met all but one of the CQC essential standards (minor concerns remained about the completeness of records in some areas). To improve consistency of safety and experience for our patients we launched Caring around the Clock in 2012. This programme, our version of hourly rounding, is now established in all wards and is already making a difference (as you will read later in the Account). We had far fewer avoidable pressure ulcers and deaths from severe sepsis in 2012/13 than in previous years. We consistently assessed 95% of patients for risk of blood clots. We improved nutrition and hydration for patients (see page 53 more information on each of these areas and our extensive safety programme). In early 2012 the Trust Board, and our patients and staff, were understandably concerned about the high number of cancelled operations. We committed to reducing the number of cancelled operations, and we have done so. We now publish on-the-day and priorto-the-day cancellations, to present a full picture. We believe we were the first (and still only) trust in England to do so. The Trust Board reviews the rate of cancellation at each meeting (see page 37 for full details). The publication of the Francis Report in February 2013 is significant for all of us in the NHS, and for NUH. At the heart of the Francis recommendations is the duty to place the needs of patients at the forefront of everything that the NHS does. Organisational culture and behavioural standards are critical. Our established values and behaviours programme, we are here for you, was further embedded in our hospitals in 2012/13. By the end of 2013 we will have trained 14,000 staff in our values. The Board fully appreciates that it must be ever more attentive to the views of our patients, their loved ones, and our staff, who have first-hand experience of receiving and providing care. In the last year we have strengthened patient input into service improvements and changes. One of the ways we are doing this is through Better for You, our established quality improvement programme (launched in 2009). Each project involves patients and staff developing and implementing ideas for improvement. In 2012/13 we started 75 new projects and completed 100. You can read more about how Better for You is improving patient and staff experience on page 39 and in the Better for You 2012 Annual Report available on our website (www.nuh.nhs.uk). Another immensely powerful way in which our Board seeks to understand the views of patients and staff is via the 15 steps challenge. These are ward or department visits by Board members and senior managers who walk in the shoes of patients and staff to experience our hospitals through their eyes and ears. In 2012 NUH became the first hospital in the country to introduce 15 steps across all its wards. We are also giving careful thought to our existing systems and processes for quality assurance in light of the Francis Report and its recommendations. In April 2012 we introduced the new friends and family test, asking patients if they would recommend our hospitals. Used as part of our repetoire of patient experience measures, the test is enriching the feedback we receive from patients on the quality of our care. We faced challenges in a number of areas this year. While we achieved an 8% reduction in our rate of falls, this was short of the 10% target we set ourselves. However, we did reduce falls causing the most serious harm (such as hip fractures) by 35%. Our trust-wide Stop Falls campaign continues to highlight to staff
the main reasons why patients fall (poor footwear, poor vision, confusion, multiple drugs, and continence) and how they can prevent falls (read more on pages 11 and 12). Despite a huge effort by colleagues across the Trust, and significant investment to increase resources (beds and staffing), we did not achieve the four-hour emergency access standard in 2012/13. This means some emergency patients are not getting the timely care they deserve. Much work is underway to improve performance and to sustain it month-onmonth through 2013/14. We are working closely with primary and social care colleagues to improve emergency patient care and access to pre and post-hospital services in Nottingham city and county. Our 2013/14 priorities are:
through 2012/13. It then sets out who has helped us determine the priorities and content of this Quality Account (in line with current legislation and national requirements). Our Account includes statements from our partners at Nottingham West Clinical Commissioning Group. On behalf of the Trust Board we would like to take this opportunity to thank our patients, carers, members, stakeholder groups and partners for helping us on our journey of continuous improvement. Our patients are safer and more confident in our care this year than last. We also thank our 14,000-strong workforce and our valued volunteers who demonstrated such commitment to NUH, to the NHS and to improving our care.
Better communication (with patients,

between staff and to other agencies) (values and behaviours)
Continued focus on staff attitude Improved patient environment Fewer cancelled operations Reducing harm from falls and
infection
Dr Peter Barrett, Chairman
Achieve specific quality targets for Improve services for vulnerable

adults, including patients with dementia and their carers
MRSA, Clostridium difficile, inpatient falls, VTE, sepsis and pressure ulcers Peter Homa, Chief Executive
Integrate the Trusts quality reporting

framework with the new national quality dashboard of the Francis Report (inquiry into Mid Staffordshire Hospital NHS Foundation Trust)
Respond to the recommendations
Our Quality Account has five sections. Section 3 summarises our performance against the priorities we set ourselves for 2012/13. In Section 4 we set out our priorities for 2013/14 and describe (1) why we have chosen them and (2) how we will deliver and measure the improvement. Section 5 includes detailed information on the safety and experience of patients in the range of services we provided
Nottingham University Hospitals NHS Trust Quality Account 2012/13 Chapter 1: Introduction
Declaration of Accuracy
I confirm, on behalf of all Executive Directors at NUH, that to the best of my knowledge the information presented in this Quality Account is accurate.
Peter Homa, Chief Executive
Quality review of 2012/13
We have made good progress against the priorities and key targets we set ourselves for 2012/13 (as described in our 2011/12 Quality Account). Some of our main achievements include:
Improving clinical outcomes
Standardised Hospital-Level Mortality Indicator (SHMI) A trusts SHMI compares its death rate with the rate in the average hospital (100). SHMIs much higher than 100 suggest poor care (the highest was 125) and those much lower then 100 good care (the lowest was 71). Our latest (October 2011 to September 2012) SHMI is 93. This is within the normal range for all hospitals and for our peer hospitals (Figure 1). Over the past three years our trend is of modest improvement though this has not yet achieved statistical significance (Figure 2). The Trust Board and Clinical Effectiveness Committee regularly monitor the SHMI, which provides an important independent confirmation for our patients and community that the care provided by our many thousands of staff is safe and of a high standard. NUH considers this data (calculated and provided by an external agency) is an authentic description of our mortality rate, but we are seeking to improve the quality of the data still further to allow greater analysis of variation in standardised mortality rates across our services and days of the week. NUH has a programme of patient safety improvements to reduce complication and mortality rates. Several important elements of the programme (notably improved recognise and rescue of deteriorating patients, improved sepsis care, falls reduction and improved medication safety) are described later in this Report.
Figure 1. SHMI against peers (hospitals of similar size and complexity) (latest data) SHMI by provider (peer group) for all admissions October 2011September 2012 (with confidence intervals)
Relative risk
Leeds
Newcastle
Southampton
Cambridge
Birmingham (UHB)
Lancashire
Leicester
Oxford
Nottingham
Bristol
Royal Liverpool
Sheffield
Provider The SHMI makes no direct adjustment for the proportion of patients who are admitted for end-oflife (palliative) care. If this proportion is inappropriately high, the SHMI will be inappropriately low (because more patients deaths will be counted as expected). For October 2011September 2012, 0.97% of NUH inpatient admissions included palliative care and 15.45% of NUH deaths included palliative care code(s). These figures are in line with other hospitals (including our peer hospitals).
Central Manchester
Figure 2. NUH SHMI 20092012 SHMI trend for all activity across the last available 3 years of data
Financial quarter Major trauma patients saving lives NUH took on the important responsibility of our regions major trauma centre last year. In 2012/13 around 2 patients each month survived devastating injuries that were predicted to be fatal. Immediate management is by specialist consultants, and most patients who require a CT scan have it within our 30 minute target. We are consistently in the top 10% of trauma centres. We were highly commended by a recent external review, which praised the patient benefits of our multi-professional and collaborative working.
Improving patient safety

In 2012 we introduced the Safety Thermometer - monthly audits on our adult wards of pressure ulcers, falls, treatment for new blood clots (venous thrombo-embolism VTE), and catheter-associated urinary tract infections. We reduced the number of pressure ulcers (see page 12), improved our risk assessment and prevention of VTE (Figure 3) and reduced the number of serious injuries from falls (see pages 11 and 12).
Figure 3. VTE risk assessment Admitted patients risk-assessed for VTE
Nottingham University Hospitals NHS Trust
Quality Account 2012/13
Chapter 3: Quality review 2012/13
Crude mortality rate (%)
Relative risk
Improving patient experience

Examples of 2012/13 successes:
Caring around the Clock (our unique
approach to hourly rounding) was introduced in all wards by the end of March 2013. This programme re-establishes systematic anticipatory and individualised care, and patients feel more confident that their needs will be met our hospital to their family and friends (friends and family test scores) see page 13 patient stories every month
More patients are recommending
Our public Trust Board now hears Board members undertake In Your
Shoes sessions with patients (oneto-one conversations) and patient safety conversations with ward staff
Improving staff experience

In the 2012 staff survey NUH was among the best 20% of trusts for the second consecutive year for job satisfaction, staff motivation, and colleagues feeling empowered to make improvements for the benefit of patients.
Figure 4. Patient Environment Action Team (PEAT) scores 20092012
Year 2012
PEAT Criteria
Environment Food Privacy and dignity Environment
City Hospital
Good Excellent Good Good Good Good Acceptable Good Good Acceptable Excellent Acceptable
QMC
Good Good Good Acceptable Good Good Acceptable Good Good Acceptable Good Good
Delivering environmental improvements

Our Patient Environment Action Team (PEAT) assessment of nonclinical aspects of patient care (includingenvironment, food, and privacy and dignity) is improving year-on-year (Figure 4). In 2012 we scored excellent or good for each domain at both our hospitals. Our 15 steps challenge ward visits look at care through the eyes of patients and service users, to help us focus on what is important for them (including cleanliness and tidiness). Our monthly cleaning audits for ward areas show year-on-year improvement (Figure 5).
2011
Food Privacy and dignity Environment
2010
Food Privacy and dignity Environment
2009
Food Privacy and dignity
Smoke-free Kick the Butt campaign

In October 2012 we had our third week of action to tackle patients and visitors who smoke on-site, outside our hospital buildings. Staff, Community Protection Officers and volunteers asked smokers to stop smoking or to move off hospital property. New Leaf and Nottingham City Smokefree Homes were on hand to promote ways to stop smoking. 21 on-the-spot fines were issued to staff and the public for littering (mainly for the discard of cigarette butts). Nottingham City Council has committed to weekly cleaning of the council-owned areas at the QMC entrance.
Figure 5. Ward cleanliness assessment scores 20092012
Performance Baseline standard
press regarding hospitals but I couldnt have asked for anything better than the treatment I received on Berman and Newell (Stroke) Wards, from the doctors down to the cleaners and all in between. I was treated with dignity and respect. Everyone worked so hard to enable me to return home. The food was excellent, and for the patients who couldnt feed themselves there was always someone to feed them. So a very big thank you to all at the Nottingham City Hospital.
Patient feedback Source: compliment via email Autumn 2012
You hear a lot of bad
How we did against our priorities for 2012/13 (from our 2011/12 Quality Account)
Priority 1 for 2012/13 Improve outcomes of treatment for patients

TARGET Reduction in avoidable deaths from severe sepsis
We exceeded our target for the proportion of our patients who received all four elements of the sepsis care bundle. This set of interventions (including prompt antibiotics, intravenous fluids and blood tests) reduces mortality from severe infections. Our target translated to 305 patients, we achieved the bundle in more than twice as many (785).
TARGET Fewer than 5 MRSA bacteraemias

NUH has a zero tolerance of healthcare-associated infections. In 2012/13 we had 5 cases of MRSA bacteraemia. We have a robust and strengthened action plan to prevent MRSA bacteraemia infections. This includes assessment and management of MRSA positive patients, and roll-out of a new patient cleansing product to eradicate MRSA from the skin. The trend of reducing MRSA bacteraemias by rate is shown in Figure 6. Figure 6. MRSA bacteraemia rate 2007-2012
MRSA bacteraemia cases per 100,000 bed days
16 14 12 10 8 6 4 2 0 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13
NUH Peers
TARGET Fewer than 133 cases of Clostridium difficile

In 2012/13 we had 138 cases of Clostridium difficile (C diff). The rate of 25 cases per 100,000 bed days has not significantly changed from 2011/12, and is in the range experienced by our peer hospitals (Figure 7). The national rate is 17.37 per 100,000 bed days (based on available data March 2012 December 2012). Only a small proportion of C diff cases were severe, and the majority (92%) were unlinked (sporadic). NUH commissioned an external review in November 2012, which found no significant shortcomings in our management and practices
Figure 7. Clostridium difficile rate 2007-2012

Cases of Clostridium dicile per 100,000 bed days
120 100 80 60 40 20 0 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13
NUH Peers
in relation to this infection. Nonetheless recommendations from the review (notably about
antibiotic stewardship) have been incorporated into our Clostridium difficile Action Plan.
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TARGET 10% reduction in number of patient falls

Inpatient falls are a very important cause of harm at NUH. Each fall has a cost in terms of lost confidence, fear of further falls and physical injuries. All of these factors add to the length of time people spend in hospital and reduce the chances
of these patients retaining their independence. Many falls are not inevitable and can be prevented. We set ourselves a challenging target of a 10% reduction in falls in 2013/13. We achieved an 8%
reduction (from 7.05 to 6.47 falls per 1,000 bed days). There was a 35% reduction in falls resulting in serious patient harm (hip fractures).
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Key actions in 2012/13 to reduce falls included:
Recruitment of over 60 falls
champions to work with each ward area to highlight best practice and support staff in identifying patients at increased risk of falls by risk assessment toolkit across all inpatient wards, including best practice examples and guidance on actions to reduce the likelihood and severity of falls (e.g. ensuring satisfactory footwear, reducing multiple medication and making sure patients are helped to and from the toilet). This was supported by a high profile communications campaign patients
Launch of a revised falls prevention
The falls committee has been undertaking a number of falls environmental visits, checking that ward environments adhere to best practice in relation to falls prevention, which they use to inform change. Recent focus groups with shop floor staff have identified key topics for action to improve consistency with best practice.
Purchase of 40 low beds for high risk Development of a Special Falls Team
in Acute Medicine to provide ad hoc, prompt extra support to wards on which there are patients at high risk
Eliminate avoidable stage 2, 3 and 4 pressure ulcers

We significantly reduced, but did not eliminate, pressure ulcers. To ensure we count pressure ulcers accurately we collect two sets of data: (1) the Safety Thermometer (i.e. data collected on a single day of the month, providing a moment in time picture (point prevalence) and (2) incidence (the proportion of patients who develop a pressure ulcer when in our care). Key actions:
Figure 8. Pressure ulcers 2012/13
JanMar 2012
AprJun 2012
JulSep 2012
OctDec 2012
JanMar 2013
Our point prevalence fell from 2.8% (45 patients) in March 2012 to 1.1% (16 patients) in February 2013 (Figure 8).
Improvements in documentation to
record prevention (SsKIN Bundle: surface, skin assessment, keep moving, incontinence, nutrition) and more helpful risk assessment their position changed every two hours
The tissue viability service was
High risk patients more reliably had We appointed two pressure ulcer
brought in-house in April 2012. Ward visits have since increased by 100%, with many more patients being seen by the team. As a result, more ward staff are educated and trained about pressure ulcers viability link nurse who receives additional training in pressure ulcer prevention and acts as a resource for information and advice to inform best practice in their clinical area
Fewer avoidable emergency readmissions caused by poor NUH care or discharge

Through this year we have been working to better understand and record the reasons for readmission (and to agree those which are avoidable). We commenced work in early 2013 targeting alcohol-related readmissions and readmissions caused by poor communication with patients and their carers. Several specialties have local readmission reduction schemes.
Every inpatient ward has a tissue
champions in January 2013. The champions visit all patients with Stage 2 pressure ulcers, investigate the causes and identify common themes
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Priority 2 for 2012/13 Improve our patients experience

Significantly reduce the likelihood that a patients planned operation will be cancelled compared to 2011/12
We achieved this target, sustaining a reduction in on-the-day and priorto-the-day cancellations through the year. Our total cancellation rate January to March 2013 (winter) was 2.77% compared to 10% for the same period a year before. We achieved the national standard for on-the-day cancellations (0.8%) see page 37 for full details.
Improve the quality of communication with patients and their families

We achieved the Information Standard quality kite mark in 2011, and maintained it in 2012. This kitemark offers assurance that our patient information is of a satisfactory standard. The review team reported progress since 2011 including:
A 10 percentage point increase in patients who would recommend our services to their friends and family
We achieved this objective. In April 2012 we started asking our patients: how likely is it that you would recommend this service to a friend or family? using a scale from extremely likely to not at all likely. We asked approximately 1,000 inpatients (10%) each month around the time of their discharge. From January to March 2013, we scored 64, compared to 54 from April to June 2012. We are reporting the friends and family test results (obtained by standard trust-wide methodology) at ward and directorate level, and to the Board. The friends and family test will be asked in all NHS acute hospitals of all inpatients using what is hoped will be a standard methodology from April 2013. The standard methodology may allow cautious comparisons between organisations (to date this test has not been designed for that purpose). From that date we will also ask a follow-up question to help us focus on necessary changes and improvements.
Our Readers Panel of patients, carers
and members recruited more than 30 new members to ensure they were meeting the standards set out by the Information Standard
Significantly reduce unnecessary waits in a patients journey, notably for discharge arrangements (including medications) to be completed
The national Emergency Care Intensive Support Team described (winter 2012) that we needed to give closer attention to improving the quality and timeliness of discharge processes. Key actions in 2012/13:
The Readers Panel audited 20 leaflets
We developed an online library for
accessing patient information via the NUH website information which includes essential VTE and medication details
We have introduced new e-discharge We introduced consent and capacity
Our 5 daily actions programme
encouraged early use of the Discharge Lounge (pre-noon), a focus on timely availability of take home medication (TTOs), and morning safety and flow Board rounds on every ward attended by senior clinical decision-makers QMC
cards for staff to raise awareness and understanding in recognising when a vulnerable patient may not be able to make informed decisions and how to ensure we always act in a patients best interests if they lack capacity to make a decision themselves
Increase the proportion of patients who feel listened to and involved in their care
We have collected feedback throughout the year about how involved patients feel in decisions about their treatment and care. We have seen the number of positive responses to this question increase from 81% in April 2012 to 90% by March 2013. We also monitor patient feedback through our complaints and compliments process, Essence of Care benchmarks, Caring around the Clock leadership rounds, and Peer Reviews. We consider that we met this objective.
Opened a new Discharge Lounge at A focus on predicted discharge date

for every patient
Roll-out individualised information prescriptions to all patients receiving cancer care in our hospitals, and evaluate whether these can be used for patients with other long-term conditions
We have introduced individualised information prescriptions for all cancer patients.
New discharge information for
patients and carers to better involve them in discharge planning for patients in use across NUH
New standardised discharge leaflet Through our home for lunch

campaign, we are better involving patients and their carers in their discharge from our care
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Update our infection control leaflets for the public, and roll-out bedside information to all wards
We have updated all our infection control leaflets, and we are working with our patients and members to update our safety information (work commenced January 2013). We have new bedside information folders on all inpatient wards.
We launched a new Trust website in summer 2012, with direct access to patient safety information and our latest performance against key safety and quality standards.
Priority 3 for 2012/13 Align research and clinical service priorities and build capacity for future research
Increase research income by 10% compared with 2011/12
We maintained our research income compared to 2011/12. NUH received 15million of research income from various National Institute for Health Research (NIHR) and research council funding streams in addition to collaborations with the pharmaceutical and medical technology industries.
20% increase in samples in the Biobank

We achieved this target. The Nottingham Health Science Biobank (NHSB) collected more than 15,000 biosamples and attracted 420,000 external funding.
Established a successful and
sustainable infrastructure for nursing and midwifery research and innovation that informs and directs improvements in the quality of patient care manuscripts from 1,073 active research projects
Published 943 peer reviewed
Other achievements in Research & Innovation
14 new NIHR research grants
Enrol 20% more patients in clinical trials compared with 2011/12

We did not meet this target. 7,483 patients (83% of target) were recruited in 287 NIHR adopted studies, ranking NUH eleventh in the NIHR league table. In addition, 531 patients were recruited to 210 commercial studies.
were awarded to NUH (total value 7.8million) range of research support services based in the NIHR-funded Nottingham Health Science Partners (NHSP) Centre at QMC was established, bringing together all the research design and support services in Nottingham
A comprehensive and innovative
See appendix 1 for an at a glance summary of NUH performance against all 2012/13 objectives.
Review of Services in 2012/13

During 2012/13 NUH provided 105 NHS services as identified in Schedule 2, part 4 of the contract between the trust and our principle commissioners NHS Nottingham West Clinical Commissioning Groups. The income generated represented more than 90% of the total income generated from the provision of NHS services by NUH for 2012/13. Review of clinical strategies During 2012/13 36 clinical service strategies were reviewed for how each met current and future care quality standards. Services were analysed against national benchmarks (on mortality, length of stay, readmission rates, waiting times, patient and staff experience scores, staff vacancy and sickness rates). Directorate Performance Management Each month our directorates are held to account for their performance against the Trusts agreed quality targets and compliance with expected standards for each of our clinical services.
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Priorities for improvement and Board statements of assurance

19 members attended our quality priorities focus group
which was attended by Trust Board members and clinical leaders. We shared our draft annual plan for 2013/14 and asked our members which three areas from our draft objectives they felt would make the greatest improvement on their experience as a patient or carer for views on our draft objectives
Public involvement and consultation for our Quality Account

Each year NUH sets out its priorities for improvement in the forthcoming 12 months. Central to this work is listening to our patients and their carers, understanding what matters most to them, and establishing the areas to which they wish us to give greatest attention. The publication of the Francis Report reinforces the importance of listening to the patient voice. We start from a position of strength. We know that listening to our patients and acting on their feedback brings improvements. This year we have developed our priorities for 2013/14 following a range of consultation exercises with our patients (including patient groups), members, staff and the public, to ensure we focus our efforts in the right places over the coming year. We have consulted our patients, carers and the public on what our priorities should be through our Directorate patient (and carer) groups, a quality priorities event for members, and online and postal surveys. Through Community in Unity, a partnership involving all local NHS organisations, we have sought the views of patients with learning disabilities, young patients, visually-impaired patients and patients from minority ethnic groups. Figure 9. Patient priorities How we compare to other hospitals Waiting times Whether our patientswould recommend us to family and friends
26 members contributed to our electronic survey asking 80 patients responded to our online survey which asked
patients and carers for their views on what our quality and safety priorities should be in 2013/14. This survey included detailed narrative feedback, adding depth to our wider feedback from patients Local Involvement Networks (LINks), carers and trust members) participated in a focus group to identify what was good public involvement with the development of quality priorities, and what was important to publish in this Account
9 of our Patient Partnership Group members (representing
Cleanliness of our wards and clinics
Privacy and dignity
Complaints, comments, compliments and concerns
Incidents and learning from mistakes How involved patients felt in their care Cancelled operations How caring and compassionate we are
Patient safety
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Following our four-month consultation process, we have a rich source of information which tells us what is important to our local population. This information has been considered alongside the feedback we receive from our patients, their carers and their families via other routes. These include feedback from our patient surveys, friends and family test scores, nursing dashboard,
4Cs (compliments, complaints, comments and concerns) and online feedback via websites such as NHS Choices and Patient Opinion as well as social media sites such as Twitter. In addition to this important direction from our patients, our priorities are also influenced by national, regional and local priorities, standards and reports, including the Francis Report.
The most frequent and powerful observations and requests are detailed in Appendix 3.
Quality priorities for 2013/14

We have distilled the observations and requests of our patients, relatives, members, staff and partners into 5 priority action areas for next year.
Priority 1 Better communicate at all levels (between patients, staff, professionals and NUH and other agencies)
Improve care of frail, older patients
During 2013/14 we will undertake Comprehensive Geriatric Assessment on all frail older people admitted as an emergency. This will help ensure our patients are cared for in the right place, with an appropriate management plan. We will monitor the quality of admissions and discharges and the rate of avoidable readmissions. This programme of work reports to the Clinical Contract Board of the Clinical Commissioning Group.
Better involvement and engagement
with patients when service changes are planned and on a more individual level where patients want to have more say in how their individual care is provided
Our Patient and Public Involvement (PPI) policy is clear on patients and public involvement when
service changes are planned. This activity will be included in each Directorate PPI plan for 2013/14. All involvement activity is logged onto our Datix system. This is monitored at the PPI Steering Group. Involvement in care will be part of internal inpatient surveys throughout the year and improvement will be monitored at the Trusts Quality Assurance Committee, a committee of our Trust Board.
Priority 2 Continue to focus on values, staff attitudes and listening to patients

All staff (14,000) to be trained in
NUH values and behaviours by the end of 2013 increased focus on the recruitment and appraisal processes
Embed values and behaviours with
Trust-wide core activity (training, education and policy change) and local bespoke activity dependent on identified need.
Embed Caring around the Clock
The focus of our values and behaviours work in 2013/14 will be
across all inpatient wards, supported by senior nurse leadership and delivered through training and monitoring
Phase 2 of Caring around the Clock will involve evaluating the rollout of the programme to shape the next steps of this important work. The measures of success will be agreed at each phase. Both priorities will be monitored via the Better for You programmes governance structure.
Priority 3 Improve patient environment

Through Think Clean Days, patientled inspection programme and monthly cleaning service auditing, we will work with patients and staff to further improve cleanliness and the environment of our hospitals
Our monthly cleaning figures, data from quarterly Think Clean days, and the annual inspections programme will be monitored monthly by our Infection Control Operational Group, chaired by our Chief Executive. Our progress is reported quarterly to the Trust Board.
Nottingham University Hospitals NHS Trust Quality Account 2012/13 Chapter 4: Priorities for improvement
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Priority 4 Cancel fewer operations

We will further reduce cancelled
operations by focusing on individual surgeon list level, improved scheduling, booking processes and sterile services provision This will be monitored weekly at the General Managers Operational Group meeting and monthly at directorate performance management meetings. We will continue to report performance on a monthly basis via our website at www.nuh.nhs.uk.
Priority 5 Reduce harm from falls and infection

We will achieve a 5% reduction in
inpatient falls, a 10% reduction in falls resulting in harm, and have 15% fewer repeat fallers
We have a zero tolerance to MRSA

bacteraemia (our target is zero)
We will develop a set of measures
The development of a falls dashboard at ward/directorate level will support the monitoring of our progress at the Falls Operational Group, chaired by our Chief Executive.
to monitor our performance in preventing and managing Clostridium difficile infections. We have been set a target by our commissioners of no more than 74 cases of Clostridium difficile in 2013/14
Both healthcare-acquired infection targets and implementation of associated action plans will be monitored bi-monthly by the Infection Control Operational Group (and by our commissioners), and reported monthly to the Trust Board.
Priority 6 Improve services for vulnerable adults, notably patients with dementia and their carers
We will survey the carers of patients
with dementia to see what we can do to support them more effectively
This will be reported to the monthly Quality Assurance Committee.
Chapter 4: Priorities for improvement
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Commissioning for Quality and Innovation (CQUIN) goals agreed with commissioners for 2013/14 Total value 15.4million
General CQUINS (nationally determined) i Improving patient experience friends and family test to include Emergency Department patients and maternity patients from October 2013 ii NHS Safety Thermometer (improve data collection in relation to falls, VTE, pressure ulcers and catheter-related infections) iii Dementia improving patient experience and safety by introducing a comprehensive screening, assessment and referral process and surveying carers of dementia patients monthly General CQUINS (locally agreed) iv Theatre safety reducing the incidence of never events through improvement in the safety culture of theatres and ensuring that the pre-theatre briefing is completed v Improving patients perceptions of feeling safe in hospital. This will be measured by patient surveys vi Reducing length of stay for diabetic patients and insulin medication errors vii Improving the application of the resuscitation sepsis care bundle for patients with a diagnosis of sepsis viii Improve timeliness of GPs receiving x-ray results ix Reducing harm in patients at risk of deterioration (cardiac arrest) x Reducing ambulance handovers no waits over 45 minutes Specialised CQUIN indicators (national) 2013/14 i Development of clinical dashboards in a range of specialist services ii Adult neurosurgery to ensure patients receive optimal outcomes from neurological surgical shunt surgery iii Bone marrow transplants donor acquisition measures iv Cardiac surgery ensure no inpatient waits longer than 7 days for surgery v Fetal medicine rapidity of obtaining tertiary level fetal medicine opinion vi Neonatal intensive care improved access to breast milk in pre-term infants vii Paediatric intensive care monitoring and minimising the number of children transferred out of region viii Renal transplant maximum time between donation to transplant.
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Service quality in 2012/13 and its assurance
Care Quality Commission (CQC) inspections in 2012/13

The Care Quality Commission is the independent regulator of health and adult social care services in England. It carries out inspections to ensure the care provided meets national standards of quality and safety. NUH was registered with the CQC in April 2010 and we have continued to maintain our registration without conditions during 2012/13. The CQC has not taken enforcement action against NUH during 2012/13. The CQC inspected QMC and Nottingham City Hospital in September 2012 against ten essential standards of quality and safety (Appendix 5). This was an unannounced inspection. Inspectors observed patient care, interviewed patients, visitors and staff, checked patient records and spoke to partner organisations. Compliance was confirmed against all but one of the standards (record keeping, where CQC considered the non-compliance had minor impact on patients). The Commission also undertook a themed dignity and nutrition (DANI) inspection at the City Hospital in August 2012. The Trust was compliant. The Trust is working to address the area of noncompliance described by the CQC, and to maintain compliance with all 16 essential standards of quality and safety. Each month Peer Reviews are carried out across the Trust to assess compliance against the essential standards by visual inspection and by talking to patients, carers and staff. The CQC found that:
Patients felt safe and knew who to speak to if they had

any concerns
Participation in national clinical audits 2012/13

The Department of Health describes 50 national clinical audits which Trusts should consider in their 2012/13 Quality Account. NUH participated in 45 of the national clinical audits (NUH is not eligible for 5 audits) (Appendix 6).
The Trust had taken steps to ensure that the care
environment was suitably designed and adequately maintained (and had invested in new and additional bathroom facilities on a number of wards)
Patient confidentiality was respected Patient privacy and dignity was respected Staff obtained consent before carrying out treatment and
provided explanations to patients about their care and treatment each other
Patient Reported Outcome Measures (PROMS)

PROMs describe thehealth gains after 4 operations using pre-and post-operative surveys. NUHs participation rates are good for both hip and knee replacements. We undertake relatively few groin hernia repairs and no varicose vein operations. NUH patients report very similar health gains as patients in peer hospitals, and there was no change 2011/122012/13 (Figure 10). In depth analysis is being undertaken by our orthopaedic surgeons to identify and focus on any areas for improvement. This will be discussed and monitored by the Clinical Effectiveness Committee.
Staff were respectful in their interactions with patients and Care plans for patients catered for their individual needs There had been improvements in discharge planning Staff were attentive to patients nutritional needs and
gave support and encouragement to patients who had been assessed as being at risk in relation to nutrition and weight loss.
Full reports are available on our website www.nuh.nhs.uk.
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Figure 10. NUH PROMS data compared to national and peer data 2009-2011
0.6
0.5
0.4 Average Health Gain
0.3
0.2
0.1
-0.1
1/4/2009 to 31/3/2010
1/4/2010 to 31/3/2011
1/4/2009 to 31/3/2010
1/4/2010 to 31/3/2011
1/4/2009 to 31/3/2010
1/4/2010 to 31/3/2011
PROMS Groin Hernia Min Max
PROMS Hip Replacement NaBonal Mean Peer Mean NUH
PROMS Knee Replacement
Participation in national confidential enquiries 2012/13

During 2012/13 we participated in all relevant enquiries undertaken by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and by the Maternal, Infant and newborn programme (MBRRACE-UK) (Figure 11). NCEPOD helps improve standards by identifying common poor practice. For the relevant published reports, NUH has identified a consultant who leads our consideration of the report and makes recommendations to the Clinical Effectiveness Committee.
Figure 11. NCEPOD and MBRRACE enquiries
Title of Study Alcoholic Liver Disease Study Bariatric surgery Maternal and perinatal mortality surveillance Child death data collection Tracheostomy study Head injury in children
In 2012/13 there were no NUH patients eligible for the National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness (NCI/NCISH).
Return Rate (coverage) (% eligible cases submitted by NUH)

100 100 100 100 Study ongoing Study ongoing
Response to national confidential enquiries 2012/13

In 2012/13 one national confidential enquiry was published relevant to services provided by NUH: Cardiac arrest procedures: time
to intervene? A consultant anaesthetist led a Trust-wide review of the Reports recommendations. As recommended, NUH has audited pre-arrest care for antecedent (and warning) factors and actions. Each cardiac arrest will be subject to a root-cause-analysis using NCEPOD
Chapter 5: Service quality in 2012/13
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methodology. A summary report of root cause analyses has been made available to relevant internal groups and to individual departments with the aim of reducing avoidable cardiac arrests. The Trust is submitting data to NCEPOD and to the National Cardiac Arrest Audit (NCAA) database. NCEPOD recommended the use of ceilings of care documentation to facilitate decision-making. At NUH ceilings of care documentation is already in place in paediatrics. Similar documents are being prepared for a trial in adult medicine.
3 In October 2011, the National Institute for Health and Clinical Excellence (NICE) published a clinical guideline for the management of hyperglycaemia in people with Acute Coronary Syndrome (ACS). NUH practice was audited against this guideline. A local guideline will be introduced on the cardiology ward and acute medical units in 2013 4 In 2010 the renal specialty undertook a baseline audit of young people (18-25) with Chronic Kidney Disease (CKD), specifically those under Adult Renal Care or on Renal Replacement Therapy. A support service and support worker was put in place with the intention of improving health and social care for this group of patients. In 2012 re-audit showed the positive impact of the service: overall urgent clinic attendance rates have fallen from 21.2% to 15.6% and hospital admissions from 73 (329 bed days) to 34 (159 bed days) 5 The Digestive Diseases and Thoracics Directorate undertook an audit in general surgery following the National GIFTASUP Guidelines. There was poor compliance in the initial audit (18%) and poor knowledge of fluids (37%). Interventions such as fluid cards, learning and posters on wards have resulted in significant improvements; to 61% compliance and 83% knowledge of fluids 6 A re-audit was undertaken to assess whether the Trust was meeting the Neurosurgical Care Bundle in Traumatic Brain Injured (TBI) patients in Intensive Care. Interventions after an earlier audit included improved education, development and circulation of TBI guidance, poster publications, bedside teaching, a TBI notice board and the launch of TBI week. There was 100% compliance at the re-audit. 7 Trauma and Orthopaedics, using the National Hip Fracture Database and the local Hip Fracture Audit have made system-wide changes to meet best practice clinical standards. These changes have resulted in a significant reduction in 30-day mortality from 12% (2008) to 6.9% (2012). In addition, the percentage of patients receiving best practice in this area increased from 40% (2010) to 80% (2012)
8 The vascular surgery specialty undertook an audit in respect of the Secondary Prevention of Peripheral Vascular Disease in angioplasty patients. The initial audit showed that the Trust was only 66% compliant with NICE guidance in prescribing anti-platelet and lipid lowering drugs to patients attending for angioplasty. As a result a prechecking reminder system in clinic was put in place: at re-audit the compliance rate had increased to 85% The Quality Assurance Committee received the following internal reports (and where necessary action plans) prompted by external alerts or reports during 2012/13:
Response to national and local clinical audits 2012/13

The Clinical Effectiveness Committee receives reports and updates from across the Trust against relevant national audits and improvement plans. We considered 42 national and 123 local clinical audits in 2012/13. Some examples of NUH improvement actions after these audits are described below: 1 The Acute Medicine Directorate audited the appropriateness of prescribing in acutely ill elderly patients (as determined by STOPP/ START criteria). The following interventions were put in place: teaching sessions at the beginning of doctor rotations, daily drug chart checks on ward rounds and thorough completion of documentation when drugs have been stopped/started. This activity has resulted in better prescribing awareness amongst junior members of the Health Care of Older People team and implementation of daily drug chart checks 2 The Digestive Diseases and Thoracics Directorate undertook a medical records audit in general surgery. Whilst overall notes were completed well, improvement areas were identified, including detailing the location of the ward and reducing loose documentation. As a result staff received updates on NHSLA audit capture requirements, and guidelines on case note completion were disseminated and reinforced
Thematic review of deaths occurring

out-of-hours in Acute Medicine Directorate
Report on the progress
implementing recommendations from an internal audit review of compliance with five CQC essential standards in the Specialist Support Directorate on peri-operative care in the higher risk surgical patient Mortality Ratio
Trust response to the national report Report on Hospital Standardised Reports on endoscopic biliary tract
intervention and on craniotomy after trauma following Dr Foster alerts
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2012/13 Performance against CQUIN 2012/13

CQUIN framework 2012/13 2.5% of the NUHs contract income 2012/13 was dependent on reaching quality goals we set with persons and bodies with whom we entered a contract, agreement or arrangement to provide services. These goals are known as CQUINs (Commissioning for Quality Improvement and Innovation payment framework). We had 4 national, 8 local and 7 specialised CQUINs in 2012/13, with a total value of 14.98million. Further information on last years and this years CQUINs can be found at www.nuh.nhs.uk. National CQUIN indicators (four) in 2012/13 i NHS Safety Thermometer monthly prevalence audits on all inpatient wards are undertaken for pressure ulcers, falls in care, urinary infection in patients with a urinary catheters, and treatment for new VTE Achieved (95.7% of our patients received harm-free care) ii Patient experience to improve responsiveness to personal needs (measured by five key questions in the National Inpatient Survey). Achieved iii Dementia care to ensure that all patients aged 75 and over admitted as an emergency are screened, risk assessed and if appropriate referred for specialist diagnosis. We did not meet this objective An electronic screening tool has been developed which doctors will use to risk-assess patients over 75, and to inform the patients GPs if they are identified as being at risk of having dementia, so that further investigations or treatment or support can be organised. This tool has been launched and will be rolled-out across the Trust, but the target will not be achieved in the required time-frame.
iv Improved assessment and treatment of patients at risk of developing blood clots VTE (venous thromboembolic events) targets riskassessing 95% patients and 99% compliance with prophylactic treatment (where indicated). We achieved the risk assessment for VTE objective (94.8%) Across England compliance averaged 95.7%, with the lowest level of 80%, highest of 100%. We will continue to work with those clinical specialties that are not consistently achieving 95% compliance to ensure that outof-hours practice mirrors practice in-hours. We averaged 94% compliance with VTE prophylaxis Local CQUIN Indicators (eight) in 2012/13 i Increase the friends and family test score by 10 percentage points from baseline. Achieved Score increased from 50% in April 12 to 63% in March 2013 ii Smoking status to be recorded in 90% of patients, 90% of smokers are offered brief intervention advice, and 50% are referred to local stop smoking services. By the end of the year we had improved our compliance with recording smoking to 89%, 73.5% offered brief intervention and 73% referred to New Leaf services. iii Embed use of a cultural safety survey into theatres and develop a programme of work based on the findings. Achieved (please refer to page 42) iv Increase in proportion of patients with severe sepsis admitted to critical care who receive the surviving sepsis resuscitation bundle. Achieved 78% patients now receive all four elements of the sepsis care bundle (from starting point of 28%). 70% patients received antibiotics within 1 hour (versus target 50%).
v Improve ambulance turnaround time: reduction in time to initial assessment 95% of ambulance clinical handovers will be completed in 15 minutes. Achieved vi Reduce medication administration errors (antibiotics and thromboprophylaxis). Achieved vii Reduce harm by better recognition of (and rescue from) deterioration (adults) to better understand the reason for and prevention of cardiac arrest by implementing a root cause analysis tool and comparison with other hospitals by joining the National Cardiac Arrest Audit. Achieved viii Reduce the difference in length of stay for patients with and without diabetes, and a reduction in diabetic medication errors. Carry out in-depth audit to identify issues and implement action plan for improvement. This is a 2 year CQUIN (to March 2014). We have reduced the difference in length of stay of patients with diabetes. We will re-audit our practice in September 2013 to identify whether the improvements we have made following the results of the first audit have helped to reduce diabetic medication errors. Specialised CQUIN Indicators (seven) in 2012/13 i Implement the routine use of specialised services clinical dashboards in the following areas: radiotherapy, Cystic Fibrosis and paediatric neurosurgery. Achieved ii Maximise the choice of dialysis modality and location available for patients by increasing access for patients to home therapies. Achieved iii Increase access to Intensity Modulated Radiotherapy Therapy (IMRT) supported by the cancer network. Achieved
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iv Intravenous chemotherapy performance status recorded and monitored with appropriate action taken for oncology patients receiving intravenous chemotherapy. Achieved v Increase compliance with treatment/ improved patient outcomes for patients with Hepatitis C. Achieved vi Reduction in percentage of catheter-related coagulase negative staphylococcus blood stream infections in low birth weight babies (less than 1500 grams). Despite a robust action plan being in place to achieve the reduction in infections, we narrowly missed this target of 15% (at 15.1% by end of March 2013). vii To minimise the number of children in paediatric intensive care who have unplanned extubations. Achieved Community Public Health CQUINS i To increase the take up of Chlamydia screening in 15-25-year olds. Achieved ii To increase by 1% the number of Community and Sexual Health (CASH) core service contacts prescribed long acting contraceptives. Achieved
iii Smoking cessation in pregnancyincrease brief intervention advice and referral to new Leaf services. Achieved iv To increase by 100% the initiation of Common Assessment frameworks for young vulnerable families. This was not achieved We initiated the Common Assessment Framework for one third (37%) of families who met the criteria. Last year we focused our efforts on ensuring all our community staff were trained in the use of the framework and to ensure our specialist midwifery team who undertake most of this work were back to full capacity following a period of reduced staffing. v To increase the number of women (who meet the criteria for) referred to specialist weight management services. Achieved CQUIN Delivery: Assurance There are regular CQUIN performance meetings with commissioners to assess progress. The Trusts Quality Assurance Committee receives quarterly reports.
What others say about NUH

The Dr Foster Good Hospital Guide is an independent assessment of standards of care and clinical outcomes. The 2012 Guide, available at www.drfosterhealth.co.uk was published in November 2012. It includes 13 measures of efficiency for every trust. NUH performed particularly well on new (first time to see a specialist doctor) to followup ratios (ensuring patients only return if their condition requires them to continue with specialist oversight) and undertaking few procedures of limited clinical effectiveness. NUH performed less well compared to peer trusts in a number of areas, including day case rates and length of stay for orthopaedic surgery, though this probably reflects the impact of the local Nottingham NHS Treatment Centre on NUH case-mix.
Day case rates

We were disappointed that Dr Foster chose toignore the impact of theNottingham NHS Treatment Centre, where our surgeons also operate. Far from being a poor performer our true day case rate for the last 12 months was 91%, slightly better than the national average of 90%. In gallbladder keyhole surgery our day case rate is in the top 25% of peer hospitals.
Case study: SCOPES (Systematic Care for Older People in Elective Surgery)
The incidence of adverse post-operative outcomes increase with age as does the length of stay in hospital (often a consequence of complications). Older patients may be denied access to effective elective (planned) procedures on the grounds that surgery would be too risky. But much can be done to reduce these risks. Multi-professional, multi dimensional Comprehensive Geriatric Assessment (CGA) can optimise a patients physiological state (especially heart, lung and kidney function) and general fitness, and can plan support at home after the operation (which is often temporary).
Our SCOPES (Systematic Care for Older People in Elective Surgery) project has brought this approach to older patients who need heart, hip and knee operations. It relies on close working between the hospital, community care providers, GPs and the local city and county councils We are encouraged that SCOPES has reduced the average length of stay in hospital by 2.1 days for patients receiving hip operations and by 2.35 days for knee operations.
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Length of stay (orthopaedic)

Aslightlylongerstay in hospitalafter planned hip and knee operations does not necessarily equate topoor care quality.Our readmission rates are lower than similar hospitals. Ourrevision rates for knee replacements are in line with the national average.We monitor outcomes after these operations most carefully and are confident that in the long run our patientsreceive safe, effectiveand lasting joint replacements.
NHS Litigation Authority (NHSLA) Risk Management Assessment

The NHSLA aims to raise safety standards and reduce the number of negligent or preventable incidents through its risk management scheme, in which NUH participates. We have continued to strengthen our systems and processes to comply with higher levels of NHSLA standards. We have named NHSLA champions in each of our Directorates who
co-ordinate activities and provide support and expertise. Robust monitoring tools have been developed to assess the quality of our health records. Clinical staff visit wards and check adherence to Trust policy in real-time. We will be reassessed in March 2014.
4Cs (complaints, concerns, comments and compliments)

For the fourth consecutive year, the Trust has utilised the 4Cs approach to capture feedback from patients and families. Quarterly reports demonstrating examples of learning are received by the Quality Assurance Committee. Figures 12 and 13 describe the number of complaints received and referred to the health service ombudsman, and the 5 most common complaint themes for each year 2009/10 2012/13. Figure 14 gives examples of learning from complaints.
Figure 12. Number of local complaints and Ombudsman referrals
2009/10 Complaints No. of contacts to Ombudsman Ombudsman referrals upheld against the Trust
649 87
2010/11
737 67
2011/12
876 51
2012/13
819 23* During this year 1 complaint that was originally referred in 2011/12 was partially upheld and 1 complaint that was originally referred in 2010/11 was fully upheld
2 fully (both 2009/10 investigations)
2 fully (both 2009/10 investigations)
* The number of contacts NUH is aware of at the time of goint to print. The final figure is due to be published Autumn 2013
Figure 13. Most frequent complaint themes 20092013
2009/2010 1 2 3 4 5
Standards of care (Medical) Standards of care (Nursing & Midwifery) Manner and attitude Communication Complications
2010/2011
Standards of care (Medical) Standards of care (Nursing & Midwifery) Manner and attitude Complications Communication
2011/2012
Standards of care (Medical) Standards of care (Nursing & Midwifery) Manner and attitude Complications Communication Patient safety
2012/2013
Standards of care (Medical) Manner & Attitude Complications Communication Discharge
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Table 14. Examples of learning and actions from complaints (including case study)
Complaint
Area of concern
Action taken
Improved awareness among pharmacists of newly-prescribed

Waits for medication Discharge delay Side effects of medication not fully explained
medications so that they can advise the patient about their medication and possible side effects
Computers on wheels allow take out medications counselling on

discharge from the pharmacist to take place at the bedside preparation of medications to take home
5 a day checks on wards to track progress against timely Improved information about taking control of your medicines
information is printed out for patients pre-discharge
Staff attitude and behaviour
Lack of compassion and help for patient getting out of bed/call bell left out of reach Poor communication at pre-operative appointment resulted in delayed treatment
Weekly monitoring of Pharmacy dispensing times A professional reflective session with the individual nurse around
values and behaviours
Launch of Caring around the Clock (hourly rounding) to ensure each

and every patients individual needs are reviewed every hour
Leadership rounds introduced as part of Caring around the Clock
to allow patients to give real time feedback about the care they are receiving Leaflet now includes an instruction not to wear contact lenses for 2 weeks before the pre-operative assessment if they wear contact lenses
The Trusts Cataract Patient Pre-operation Assessment and Operation A poster in the Eye Clinic asks patients to tell their doctor and nurse Waiting list co-ordinators enquire about contact lenses when
patients telephones to change their appointment
Poor communication
Case study: Unsatisfactory consultations

Background: A relative attended the Trust Board to give his account of our failings and where he felt we had let him and his family down. The Board felt it important that lessons were learnt by the Trust and the Nottingham NHS Treatment Centre in the interest of future patients. Area of concern An improvement programme which included three multidisciplinary staff timeouts identified three main areas of failings:
Poor continuity and co-ordination of care in the Hepatobiliary (HPB)

multi-disciplinary team
Lack of administrative pathway processes for ensuring agreed

management plans are actioned accordingly
Poor and inconsistent communication with patients and carers

Action taken
Unavailable tests and notes, delayed diagnosis of cancer, poor symptom control
A programme to strengthen the role, responsibility and decisionmaking function of the multi-disciplinary team
A programme for reviewing the clinical and administrative steps
in the cancer journey to ensure that these are as timely, safe and patient-centred positive impact on the HPB 2-week wait pathway
Ongoing work in the emergency surgical pathway which will have a
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Working with the Patient Association to improve complaints handling

This year the Trust engaged in three Patient Association complaint projects. 1 In the Complainant Benchmarking Survey complainants were given the opportunity to complete a survey about complaint handling. These are returned directly to the Patient Association. NUH was one of 10 Trusts taking part in this project. NUH benchmarked well against other hospitals. Our strengths included helpfulness of staff when concerns were raised, explanation about what action would be taken to prevent the same thing happening again, complainant feeling they had been told the truth, timeliness of complaint handling and the complainant feeling they had been kept up-to-date during the complaint process. 2 In July 2012, the Trust submitted five anonymised complaint files for Peer Review by the Patient Association. The assessments ranged from excellent to poor. The weakest area of our practice was our investigation process and documentation. A new complaint investigation record has since been introduced to support documentation and decision-making. 3 We were excited to begin the Hear to Care project in January 2013. The project aims to develop new ways to involve and listen to seldom/unheard voices, so that all patients and carers can influence how we deliver care. The project looks to help staff at all levels better understand the concepts of co-production of, and shared decision-making about care.
Social media: Twitter feedback

In 2012/13, NUH had 517 mentions on Twitter, of which 15 were complaints. Most of these complaints were about smoking.
Patient surveys
The Trust measures patient experience and satisfaction in a variety of ways including local and national surveys, complaints and compliments, online patient feedback and the friends and family test.
National Inpatient Survey 2012: general

The National Inpatient Survey asked 776 people who had been an NUH inpatient during 2012 about
their experience of our care and treatment. 417 people replied in 10 domains where a score out of ten is calculated, and the trust judged better, worse or about the same as other hospitals. NUH was about the same in each of the ten domains. Our domain scores had changed little from the previous years. In one specific question (Did you receive copies of letters sent between hospital doctors and your family doctor? (GP)) our score had improved (6.4 to 7.6), and in two questions (Were you ever bothered by noise at night from other patients? and After you used the call button, how long did it usually take before you got help?) our score had deteriorated (down from 6.2 to 5.5 and from 6.4 to 5.8 respectively).
Figure 15. National Inpatient Survey 2012: responsiveness to inpatients personal needs Q32 Q34 Q36 Q56 Q62 Were you as involved as you wanted to be in decisions about your care and treatment? Did you find someone on the hospital staff to talk to about worries and fears? Were you given enough privacy when discussing your condition or treatment? Did a member of staff tell you about medication side effects to watch for when you went home? Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital? 69.4 58.3 83.4 47.9 78.1
Responsiveness to inpatients personal needs score is derived from five survey questions. For 2012/13 NUH scored 67.4. This is
unchanged from previous years, and is within 1% of the national and regional mean scores.
Feedback received through the NHS Choices and Patient Opinion websites
The Trust routinely monitors two external patient feedback websites NHS Choices and Patient Opinion. Feedback is forwarded to the relevant service/department manager for information and action. A response to every comment is posted. There was a year-on-year increase in comments posted on social media sites such as Twitter.
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Figure 16. NUH scores comparison (national, local, historical)
NUH Regional National
2009
65.3 66.6 66.7
2010
65.9 67.2 67.3
2011
66.4 67.5 67.4
2012
67.4 67.7 68.1
In response to the National Inpatient Survey we will: 1 Reduce discharge delays through our 5 daily actions campaign and new discharge documentation for patients 2 Improve standards of cleanliness through targeted interventions based on continuous monitoring against enhanced standards
3 Involve patients more in their care and provide increased emotional support, notably through our Caring around the Clock and Hear to Care projects, Directorate Patient and Public Involvement (PPI) work programmes 2013/14 and values and behaviours training 4 Roll out our SSSH campaign to reduce noise at night which was
successfully piloted this year. This included providing patients with soft ear plugs and eye pads, turning off lights by 11pm and reminding staff to lower their voices
The staff were very very busy, however they made no attempt at communication whatsoever. Then my relative had to spend another 2 days on the assessment bay and was moved to an outlying ward late at night without informing her relatives.
Feedback from relative March 2013 Source: Patient Opinion website
My elderly relative was admitted to hospital and was kept waiting in A&E for 6 hours.
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directions to the MRI department. The lady on the desk was lovely and even walked me all the way to the MRI department. During my walk to the MRI, I just felt like the whole environment hadnt been updated in decades, which created a poor atmosphere and made it seem like the hospital wasnt clean. Although, I didnt physically see anything that was dirty, just the floors and walls were scuffed from all the usual wear and tear when things arent updated for long periods of time. I think the staff that I have met today have been brilliant and if the place could be modernised with extra car parking with good access to the hospital, it would be a much more pleasant place to visit.
Patient feedback March 2013 Source: Patient Opinion website
I entered the hospital through the ear, nose and throat department and asked for
National Accident and Emergency (A&E) Department Survey

The National Accident and Emergency Department survey asked 850 people who had attended the Trusts Accident and Emergency Department about their experience of our care and treatment. 225 people (28%) replied. In 8 domains (see Figure 17) a score out of ten is calculated, and the trust judged better, worse or about the same as other hospitals. NUH was worse than other hospitals in one domain (Leaving the A&E Department (answered only by those who were not admitted to hospital or to a nursing home)). In the other seven domains NUH was about the same as other hospitals. We improved in one question compared to the 2008 survey (On your arrival, was the receptionist courteous?). We performed well compared to other trusts in areas relating to privacy and dignity when discussing condition with the receptionist on arrival and waiting less than four hours for tests to be carried out. We had lower scores availability of printed information about condition and treatment before leaving the department, patients not being fully told about danger signals to look out for before leaving hospital, patients not finding a place to sit when waiting, feeling threatened by other patients and doctors and nurses appearing not to work well together. In response to the Accident and Emergency Department Survey we will:
Provide better oral and printed
information for patients (especially about what to look out for after they leave the department) areas (number of seats and presence of staff and security)
Explore ways to improve our waiting Improve discharge
Figure 17. NUH scores for National Accident and Emergency (A&E) Department Survey
Score/10 Travel by ambulance (answered by those who travelled by ambulance only) Reception and waiting Doctors and nurses (answered by those who saw a doctor or nurse Care and treatment Tests (answered only by those who had tests) Hospital environment and facilities Leaving the A&E Department (answered only by those who were not admitted to hospital or to a nursing home) Overall views on experience
Nottingham University Hospitals NHS Trust Quality Account 2012/13 Chapter 5: Service quality in 2012/13
9.2 6.1 7.8 8.0 8.3 7.9 5.3 6.7
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Friends and Family Test

The Trust introduced the friends and family test in 2012. Patients are asked How likely is it that you would recommend this service to friends and family? In 2012/13, the Trust asked over 20,000 patients and achieved its 10 point improvement target.
Electronic inpatient survey (local survey)

11,657 patients completed an electronic survey, providing a wealth of information about their
experience and allowing us to track month-on-month changes. Over the year there were improvements in the proportion of patients who reported being asked to give their views about the quality of their care, having someone on the staff to talk to about their worries and fears, a member of staff telling them about medication side-effects to watch for when they went home, and staff telling them who to contact if they were worried about their condition or treatment after they left hospital.
Walking in patients shoes the 15 steps challenge

The challenge takes its name from a mothers comment in a patients consultation workshop: I can tell what kind of care my daughter is going to get within 15 steps of walking on to a ward. Developed by the NHS Institute for Innovation and Improvement, the challenge asks staff to visit wards and clinical areas and to view them through the eyes of a patient or visitor. In 2012 NUH became the first trust in the country to introduce the 15 steps
Staff comment: the 15 steps challenge

Suzanne Hawkins, Ward Manager, Berman 1 Ward, City Hospital
Suzanne explained how she welcomed the walkabout on her ward and the opportunity to visit other clinical areas in the Trust.
It was good to see how others perceive the ward. When you work somewhere every day you dont see it as others see it. The feedback was very positive and we welcomed suggestions such as perhaps providing a whos who board of the team on the ward. What I found particularly useful was the chance to visit other areas of the Trust. Ive worked at City for the past 12 years and never at the QMC. Being somewhere unfamiliar meant I was able to look at a ward with fresh eyes and really learn how others see us. I also visited the wards in the evening during busy times such as handover, so it really gave me an opportunity to experience the ward as a visitor, not a nurse.
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challenge across all its wards. The NHS Institute said: NUH holds the unique and trailblazing position of being the only Trust in the country to have done the 15 steps challenge across every ward, on two campuses and across three shifts, in 12 hours. The challenge walkabout teams include a Board member or senior trust leader, a matron, a ward sister and a patient or public volunteer. 14 prospective Foundation Trust members took part. Although the wards were made aware of the challenge they were not told when they would be visited. Visit our website at www.nuh.nhs.uk for a video showing the 15 steps challenge in action.
Supporting carers
We did considerable work in 2012/13 to better involve carers in patient pathways by securing their expert knowledge and by emphasising that patient documentation should include details of carer involvement in care (and discharge), and its planning. Specific measures include:
Updated Carers Policy launched April

2012
New carers cards were launched

and distributed to all wards and departments
Carers awareness stand at QMC in
June 2012 visited by patients, visitors and staff providing information and support for patients, carers and visitors in February and March 2013 launched on all wards to improve involvement of carers of patients with dementia
Carers Federation: 2 drop in sessions
A new About Me document was
experience and those they care for. The introduction of Caring for Carers cards is proving to be a useful way of providing information and signposting carers to further support and help within the community.
Carer quote 2012 Source: Event
It is good to see how the Trust has worked with carers at all levels to improve the carer
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Data Quality Management and Assurance

Data is fundamental to delivering high quality care. The national Information Strategy, published recently, emphasises the significant role that health and social care information has in providing effective patient-led care, and the need for improvements in the quality of information recorded in care records. Poor data quality undermines confidence in the information used to plan and commission services, assess quality, facilitate patient choice and ensure effective use of resources. NUH scored 99.7% in the National Data Quality Report. The national trust mean is 98.3% and our peer hospitals average 99.4%. In early 2013 we commissioned an external review of Trust-wide information, to reassess the information, analysis and reporting needs of all levels of staff from ward to Board to support decision-making. This report will be available mid-2013. In 2012/13 we inaugurated a new approach (and team) of proactive data validation at source (rather than subsequent reactive correction), and we undertook an extensive data cleansing programme in preparation for our new Patient Administration System (PAS) due to go live in autumn 2013. We have incorporated the new (2013) National Quality Dashboard metrics into our Board Reports. These include:
Helping people to recover Positive experience of care Timely care Safe environment
Data Validation Falls & Safety Thermometer In February 2013 while validating the data we found that we had doublecounted some falls and some other elements of the safety thermometer. We had reported more falls (and other events) than had actually occurred. This has been corrected (as agreed with the relevant national agency) and we have commissioned an independent audit of the relevant data collection. NHS Number and General Practice Code Validity The Trust submits records to the Secondary Uses Services (SUS) for inclusion in the Hospital Episodes Statistics. Between April and November 2012 the NHS number was included in 99.6% admissions, 99.7% outpatients and 98.2% accident and emergency care attenders. This is a slight improvement on 2011 figures. A valid General Medical Practice Code was included in 100% submissions (as in 2011/12). Clinical coding error rate Clinical coding translates the medical terminology written by clinicians to describe a patients diagnosis and treatment into standard, recognised codes. In September 2012 NUH was subject to the Payment by Results clinical coding audit undertaken by the Audit Commission. The error
rates for that period for diagnoses and treatment codes were as follows:
Primary diagnosis Secondary diagnosis Primary procedures Secondary procedures HRG errors
Incorrect Incorrect Incorrect Incorrect Incorrect
11.7% 8.2% 0% 4.9% 0%
These error rates place NUH in the best performing 25% of trusts. Outpatient data items had an error rate of 0%, except for Healthcare Resource Group (HRG) change which had an error rate of 6.7% (similar to other trusts). Information Governance Information Governance (IG) guides organisations in handling all information, in particular the personal and sensitive information of patients and employees, legally, securely, and confidentially. The IG toolkit allows NHS organisations to self-assess their compliance with current legislation and national guidance. Although we have improved on 2011/12 we still have work to do (Figure 18). The Trusts overall IG assessment score for 2012/13 was 80% and graded as not satisfactory (red). The only area of the toolkit in which we failed to achieve the necessary compliance level was in staff training.
Preventing premature deaths Quality of life for people with longterm conditions
Figure 18. Information Governance toolkit self-assessment 2011/12 and 2012/13
Information Governance Toolkit Performance Information Governance Management Confidentiality and Data Protection Assurance Information Security Assurance Clinical Information Assurance Secondary Use Assurance Corporate Information Assurance Overall percentage Overall assessment
Nottingham University Hospitals NHS Trust Quality Account 2012/13
2011/12
66% 66% 80% 80% 79% 66% 74% Not satisfactory
2012/13
73% 74% 84% 86% 83% 66% 80% Not satisfactory
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Information Governance (IG) Training 78% of staff have completed IG training at 31 January 2013 (vs 69% at 31 March 2012). This is a similar level to that reported by peer hospitals, but it does fall short of our 95% target. An action plan is being prepared to achieve the standard by the end of March 2014.
NUH performance in 2012/13 against national quality standards/targets

The table below sets out NUH performance against a range of quality metrics for which there is a national standard or target, and provides a comparison with peer hospitals.
Table 19. NUH performance compared to our peer hospitals on a range of quality measures 2009-2012
Quality measure (%unless shown) Patients waiting less than 62 days from urgent referral to treatment for all cancers Patients waiting < 31 days from diagnosis to first treatment for all cancers Patients waiting < 31 days for subsequent treatments for all cancers surgery Patients waiting < 31 days for subsequent treatments for all cancers drug treatment Patients waiting < 2 months from referral to treatment for all cancers referrals from national screening programmes Patients waiting < 2 weeks from urgent GP referral to date first seen for all urgent suspected cancer referrals 36
2009/10
2010/11
2011/12
2012/13
Peer average 2012/13
National target 2013/14
81.8
86.8
84.9
82.4
86.6
>85
97
97
96.5
96.3
97.8
>96
96
95
94.9
94.5
96.4
>94
98
99
99.7
99.4
99.8
>98
94
91
91.5
94.2
95.8
>90
94
94
94.8
93.6
95
>93
Quality measure (%unless shown) Patients waiting < 18 weeks from referral to admitted treatment Patients waiting < 18 weeks from referral to nonadmitted treatment Patients waiting longer than 4 hours from arrival to admission, transfer, discharge Breaches of the 28 day readmission guarantee as % of cancelled operations Bed occupancy
2009/10
2010/11
2011/12
2012/13
Peer average 2012/13
National target 2013/14
93
93
91
90.5
91.4
>90
98
98
98.7
98.5
97.1
>95
97
97
93.9
93.9
94.3
>95
7.68
7.92
10.15
13.31
4.18
<5
87
86
83.4
85.1
N/A
Cancelled operations
Our cancellation of so many operations in the early part of 2012 caused significant distress to many of our patients and their families. An external review, published in September 2012, concluded that there was no single reason for the cancellations. Rather the increase was caused by the unforeseen and complex interaction of interrelated organisational and service changes. The report supported our safety and quality reasons for making these changes to the configuration of services across our campuses. It also described that, notwithstanding the significant number of cancellations and the pressure experienced by our hospitals and staff, our clinical outcomes remained among the finest in the country. The full report and related action plan are available on our website at www.nuh.nhs.uk. The report described that we made changes to patient flow in a system which was already
Figure 20. NUH Rate of Cancelled Operations 2011/12

Total and On the Day Cancelled Operations (as % of all operations)
12.0% 10.0% 8.0% 6.0% 4.0% 2.0%
Dec-11 Nov-11 Nov-12 Dec-12 Jun-11 Oct-11 Jun-12
0.0%
Apr-11 Feb-11 Mar-11 Jan-11 May-11
Apr-12
Oct-12
Jul-11
Jul-12
Sep-11
Feb-12
Sep-12
Mar-12
Feb-13
% of Operations cancelled (Total)
% of Operations cancelled (on the day)
stressed. Although bed numbers remained the same at QMC in the run up to winter 2011/12, the types of bed changed. Fewer elective beds (for planned operations and procedures) were readily available for emergency use when there were peaks in demand. The overall impact was that our system was less able to cope with extreme dayto-day variations in demand, and we took much longer to recover from very busy days, than in previous years. In the first weeks of January, QMC became overfull with emergency patients and we had no
reasonable alternative other than to cancel many operations at short notice. To improve performance we undertook a series of improvement actions, notably created additional bed capacity, reduced our elective activity (planned operations) from December 2012-March 2013 and implemented a new escalation policy to ensure senior managerial and clinical input before any operation is cancelled. We made significant progress in reducing the number of cancelled
May-12
Mar-13
Aug-11
Aug-12
Apr-13
Jan-12
Jan-13
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operations during this year, both on-the-day and prior-to-the-day. In JanuaryMarch we cancelled 10% of operations. By October December we had reduced this to 2.77%. In JanuaryMarch 2013 we achieved the national 0.8% standard for on-the-day cancellations. We are determined to achieve the national standard month-onmonth and to continue to reduce cancellations for all reasons. We will do further internal work, notably on improved scheduling and insession utilisation rate at individual consultant level, protecting elective work from cancellation because of emergency clinical priority, and improving the reliable availability of instruments and equipment.
Emergency access standard

In 2012/13 we did not achieve the national standard (95%) for patients waiting less than four hours in our Emergency Department (Figure 21). This was despite energetic actions to improve performance including:
Transferred elective orthopaedics
from QMC to City (completed August 2012) to provide greater resilience for elective (planned) patient care over winter to meet demand on our services beds
Opened over 100 extra medical beds Recruited 120 nurses to these new Introduced our 5 daily actions
Figure 21. Performance vs 4-hour access target 2012/13 campaign to improve early decision making and flow this includes a focus on the early use of the Discharge lounge at QMC, timely to take out medication, early safety and flow Board rounds, escalating and resolving internal and external waits, and wards pulling patients from admissions areas. Performance against the five daily actions and length of stay is published weekly at ward and consultant level management system to help release beds earlier in the day by giving staff real time information about bed occupancy and patient activity ward at City Hospital, which helped ease the pressure on our Emergency Department during the busiest months of the year (see case study on page 39)
A&E 4-hour performance 2012/13

100% 99% 98% 97% 96% 95% 94% 93% 92% 91% 90%
Implemented a new electronic bed
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Commissioned an external review by
Opened a new specialist respiratory
the national Emergency Care Intensive Support Team (November 2012) and implemented their recommendations for NUH
Our challenge is to sustain improved performance into and through 2013/14. We remain absolutely committed to improving the safety and timeliness of our emergency services, and to improving the experience of our emergency patients.
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Readmissions within 28 days (National Outcomes Framework) Our adult readmission rate is higher than other hospitals and amongst the highest in our peer hospitals (Figure 22). An audit in early 2012 identified a range of possible improvement actions including better discharge processes and information for patients and improved coding of scheduled ward or clinic reattendances. We will continue the work commenced during 2011/12 to:
Figure 22. Case-mix adjusted 28 day readmission rate

1.3
1.25
1.2
1.15
Casemix Adjusted Readmisison Rate
1.1
1.05
0.95
0.9
0.85
0.8 Standardised 28 Day Readmissions 0-14 Standardised 28 Day Readmissions 15+ Peer Max Nottingham University Hospitals NHS Trust Peer Min Mean
Expand our Enhanced Recovery Focus on high-volume service
after Surgery (ERAS) programme (improves discharge outcomes) user alcohol-related admissions, with a key link to primary care, East Midlands Ambulance Service,
Emergency Department and specialist services including substance misuse
Improve communications with GPs

via discharge summaries, improve
patient information post operatively on what to expect at home, and provide an enhanced GP telephone link for consultant advice
Better for You: Case study

Respiratory Assessment Unit, City Hospital
Patients with chronic lung conditions told us how frustrating it is for them to go through general admissions units when they know they need specialist lung care. Their stay in hospital is often longer and there may be a delay until their treatment is optimised.
Our new Respiratory Assessment Unit (RAU) takes patients directly. They do not need to go via ED. They are seen by a specialist lung team straight away. Not only is this better for these patients, but by directing them to the RAU at City Hospital, we can improve flow through our emergency department at QMC. Patient Kate Aitken said: I felt very safe and confident in the care of specialist staff that were always there for me when I needed them. It was a very calm environment which is exactly what you need if you are struggling with respiratory difficulties. As staff were able to pre-empt what I needed I didnt have to ask for anything. The ward also offered more privacy and so it was like being treated at home. Because of this I got a good nights sleep.
Referral to treatment 18 weeks

The NHS Constitution describes an 18 week maximum waiting time from referral to consultantled treatment for non-urgent conditions. We did not meet this standard in several specialties in early 2012/13 as we worked to clear a backlog of elective surgery caused by the high number of cancelled operations over winter 2011/12. Most specialties have achieved the standard since August 2012. In a small number of specialties,
notably spinal surgery and elective orthopaedic surgery, we have not yet fully recovered the standard. However, we are working closely with our commissioners and other providers, both private and NHS, to offer patients a choice of provider to enable their treatment to take place as soon as possible. We report monthly on our performance against all of the national standards. This is available on our website at www.nuh.nhs.uk (integrated performance report).
Quality Management
Our aim is to deliver excellent, caring, safe and thoughtful healthcare for patients in Nottinghamshire and the East Midlands. Our ambition is to be the best acute teaching trust in England by 2016 (by when each of our services will be in the top three peer hospitals). Our patients will have healthcare outcomes which achieve or exceed those described in the NHS Outcomes Framework and NICE quality standards. We want to achieve this in a way which
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is recognisable, measurable and meaningful to everybody in our community. We are committed to delivering a compassionate, caring, communicative and collaborative experience for our patients and their carers. Two committees meet regularly to ensure we deliver this strategy. The Quality Assurance Committee
(of the Trust Board) monitors the quality of services we provide and the quality of our risk management and assurance processes. The Directors Group (Quality), which superseded the Quality Operational Group in November 2012, meets monthly. Members are the executive directors, corporate advisors to the Board,
and our senior clinical leadership team. The group is responsible for leading and delivering the required quality standards and for driving continuous and sustainable improvement in the quality of our services. Members are responsible for sharing local best practice to enable Trust-wide learning and adoption of best practice.
Figure 23. Trust Quality Management Structure
Trust Board
Chief Executive Officer Board Committees
Quality Assurance Committee 8 other Committees Four meetings a month, one with focus on Quality
Chief Executives Team
Directors Group
Investment Governance Committee Operational Performance Group Patient and Public Involvement Steering Group Theatres Strategy Group Procurement Steering Group Equality and Diversity Steering Group Learning and Education Committee Sustainable Development group Clinical Risk Committee
Clinical Effectiveness Committee Trust Health and Safety committee Organisational Risk Committee Pressure Ulcers Operational Infection Control Operational Group Falls Operational Group Venous thrombo-embolic (VTE) Operational Group
Trust-wide patient safety programme

This programme is central to our ambition to deliver care which is free of avoidable harm. It has several workstreams. Recognise and Rescue the deteriorating patient There is strong evidence that hospitals can improve (1) how they identify that a patient is deteriorating and (2) the effectiveness and speed of their response to the deterioration. In 2012/13 our revitalised Recognise and Rescue of the Deteriorating Patient Committee worked to: 1 Bring together relevant groups under one umbrella to consider specific patient safety issues, share learning and work together to improve safety 2 Engage key areas of the hospital (including the Emergency Department, Acute Medicine, Critical Care, Obstetrics and Gynaecology and Paediatrics) in a more integrated work programme 3 Started to collect data to identify priority areas or systems for improvement. An overview of specific work undertaken by the groups that feed into the Recognise and Rescue Committee is described below. Improving outcome for patients with severe sepsis Every year in the United Kingdom approximately 160,000 people are affected by sepsis. Sepsis is the change in physiology in response to severe infection, and patients with sepsis can deteriorate rapidly. Mortality (death rate) in sepsis can be as high as 40%. Rapid treatment, including timely administration of antibiotics, can prevent many deaths. It is important to recognise the signs of severe sepsis and deterioration quickly. We treated 400 patients with severe sepsis last year. We recorded fewer sepsis deaths at our hospitals in 2012/13 than in previous years. This remains one of our key safety priorities (see CQUIN section on page 25). Following a successful pilot we implemented a new tool to identify sepsis in adult areas in 2012. We have a lead consultant for our sepsis campaign Dr Mark Simmonds, and in 2012 we employed a Sepsis Nurse to help educate staff about sepsis and to support our improvement work. We have introduced a systematic review system which includes feedback to clinical teams who managed the sepsis patient
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before their admission to critical care. After a successful pilot, all our adult wards now have Sepsis Boxes (which contain all that is needed to start treatment immediately). We launched our think, treat, stop sepsis campaign in 2012 to raise awareness of sepsis as a medical emergency (like heart attacks and strokes). Taking blood cultures, checking a blood sample for lactate levels and starting intravenous fluid resuscitation should be completed within six hours of onset. Members of the Trusts Sepsis Action Group led the Trusts support of World Sepsis Day. The NUH Sepsis Action group is a finalist in the 2013 National Patient Safety Awards. These initiatives have had an impact. 1 80% sepsis patients get antibiotics within one hour (vs 40% before the campaign) 2 Compliance with early treatment care bundle is now consistently greater than 70% (vs 25% in 2011/12) Our focus for 2013/14:
Figure 24. Compliance with 4 elements of the sepsis early treatment care bundle 20112013
Compliance with CQUIN 4
100 90 80 70
Percent
60 50 40 30 20 10
20 06 20 1 N 0 ov -1 D 1 ec -1 Ja 1 n1 Fe 2 b1 M 2 ar -1 Ap 2 r1 M 2 ay -1 Ju 2 n12 Ju l-1 Au 2 g1 Se 2 p1 O 2 ct -1 N 2 ov -1 D 2 ec -1 Ja 2 n1 Fe 3 b1 M 3 ar -1 3
C ompliance 201 2/1 3 T arget 201 3/1 4 T arget
Resuscitation There are circa five cardiac arrests per week in our hospitals, but surprisingly little good evidence on how to improve outcomes in patients who undergo cardio pulmonary resuscitation (CPR). Our resuscitation team have begun to review each cardiac arrest looking to understand not only whether the arrest might have been prevented, but also which treatments reduce longer-term complications and improve survival. We agreed with our Commissioners to review 80% of cardiac arrests in 2012/13 through a Root Cause Analysis (RCA) process. We met this target (see CQUIN section on page 25). In 2013 we will launch a new app for mobile devices which will enable clinical colleagues to record their learning from cardiac arrests. Early Warning Score (EWS) We are committed to ensuring that patient observations are undertaken reliably, and that when they are abnormal or deteriorate staff take appropriate action. This has proved very difficult for us to achieve (as for most hospitals). We can however point to significant progress shown in an audit of Early Warning Score (observations) in adult wards in July 2012:
By April 2014, we aim to achieve
1 96% of patients had observations taken at least 12 hourly, compared to 32% in 2010 2 90% of early warning scores were correctly scored and added up in the 2012 audit compared to 14% in 2010 3 30% of audited cases had observation frequency increased correctly based on the EWS score 4 12% of audited cases had nursing escalation interventions completed if required 5 31% of audited had medical escalation interventions completed if required This confirmed that whilst we have made improvements with the introduction of the new charts (2010) in recording of observations, there is still on occasion poor and limited response to deteriorating patients by nursing and medical staff. These figures for response after EWS are similar to those reported by other hospitals. In response to these results we have agreed a specific CQUIN in 2013/14 to focus attention and resource on this issue.
60% compliance with all six sepsis interventions an automated electronic feedback mechanism to increase learning about improving sepsis care and we aim to introduce this by July 2013
Funding has been secured to develop
Improve outcome in Acute kidney injury (AKI) When the heart or the lungs begin to fail it is typically evident quickly, but failing kidneys may go unnoticed. If acute kidney injury (AKI) is recognised early it may be more readily reversible, complications can be reduced and recovery can be quicker (with shorter hospital stays). At NUH we developed an electronic AKI alert system, which has been in place since 2011. It helps detect AKI and alerts clinicians to the diagnosis. This system links clinicians to the Trusts clinical guidelines for AKI, which advise on AKI management and referral to kidney specialists. The NUH AKI alert system has been nationally recognised for improving detection rates and clinical outcomes and copied elsewhere.
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Safer Surgery In 2012/13 there were five Never Events at NUH. Two had occurred in the year before (but only came to light during 2012). We had reported seven Never Events in 2011/12. Four of the 2012/13 Never Events were related directly to surgery. Our aim is to have no such events. All such events are considered by the Board. We have built on the recommendations of an expert review of Never Events and serious incidents that had occurred in NUH theatres (2011/12). In 2012/13 we worked to embed the uniform application of the Five Steps checklist in practice. In January 2012, we introduced mandatory pre-list briefings for all our surgical lists in addition to use of the safer surgical checklist for each patient. Pre-list briefings bring the operating team together before the surgical list starts to discuss any potential patient safety issues that might arise. At NUH, the Five Steps checklist therefore involves theatre teams being briefed before and after surgery, a sign-in stage before anaesthesia, a time-out moment before the actual surgery starts, and a sign-out before the patient leaves theatre. These actions
complement the other aspects of best practice that make up high quality care in our theatres: well trained staff, resources, preoperative assessment and planning. Our second Surgical Safety Conference, supported by charitable funds from Nottingham Hospitals Charity, featured lectures and seminars from national and local experts in human factors and patient safety to over 500 staff. Venous thrombo-embolism (VTE) Blood clots in the leg (deep vein thrombosis/DVT) or the lungs (pulmonary embolism) can cause significant harm, and may be fatal.
Many clots can be prevented by simple treatment. The mainstay of prevention is identification of patients at highest risk. We have developed an electronic risk assessment tool to improve the timeliness and accuracy of risk assessments. We now risk asses around 95% of patients. Our Thrombosis Committee was runnerup in the Lifeblood VTE Awards 2012 in the Most Improved Trust 2011/12 category. The judges felt our submission demonstrated an exceptional level of leadership and innovation, and that our strategys wider adoption throughout the NHS could lead to significant improvements in VTE prevention nationwide.
Staff comment: Patient safety conversations

Kathryn Whittaker, Deputy Sister, Ward C52, QMC
It was nice for the Board to see the grass roots of the ward and for them to speak to the ward staff they can see the ward warts and all.
As a result of our patient safety conversation, we have been able to turn our double side room into a dayroom for our patients. The room was entirely unsuitable for two patients, and as such we have been able to create a bright space for our patients to relax away from their bedside. We felt that we were truly listened to and that our concerns were fully taken on board. Its nice that they took the trouble to listen and feedback both the negatives and positives about our ward. It was great for staff morale to see the board really taking note of our feedback. Comment from Peter Homa, Chief Executive (pictured above) We have an active programme to encourage our staff to raise concerns. At our regular patient safety walkabouts involving Trust Board members, we talk with front line staff and provide a forum in which staff can share concerns directly with senior colleagues.
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Around 95% of those patients identified as being at high risk receive the appropriate blood thinning treatment (to prevent clots) within 24 hours of admission. All clinicians receive VTE education as part of their mandatory training programme. Patient safety conversations We have had regular patient safety conversations for executive and non-executive directors since 2009. This programme of visits gives frontline staff the opportunity to share their experience of patient safety for their ward or department in an informal and open environment. In 2012/13 we completed 31 conversations. Staff feedback that they feel listened to and that rapid action is taken by senior colleagues where improvements are needed. Staff report that they feel more able and supported to introduce local solutions for identified problems. Concerns are also fed back into existing working groups such as falls and pressure ulcers. Staff survey on patient safety We continue to foster a culture in which staff can talk openly about incidents, errors or harm to patients. In the 2012 National Staff Survey (a lower proportion of our staff reported witnessing potentially harmful errors, near misses or incidents in the preceding month than the general or peer average, but a higher proportion described that they had reported such an event). We were in the best 20% of trusts for (a) the percentage of staff reporting errors, near misses or incidents witnessed in the last month (b) fairness and effectiveness of incident reporting and (c) staff recommending NUH as a place to work or receive treatment. In addition, NUH remained better than average for the percentage of staff reporting good communication between senior managers and staff. We undertook an internal online staff survey, which complemented the national survey. Of the 1,166 respondents, 91% felt confident in reporting errors, near misses or incidents.
Figure 25. % staff witnessing safety incidents (NUH, peers and England)
% sta witnessing poten.ally harmful errors, near misses or incidents in last month
36 35 34 33 32 31 30 29 England Acute Trusts Peer Trusts NUH
Figure 26. % staff reporting safety incidents (NUH, peers and England)
% sta repor+ng errors, near misses or incidents witnessed in the last month
94 93 92 91 90 89 88 England Acute Trusts Peer Trusts NUH
Figure 27. % staff reporting fair and effective incident reporting (NUH, peers and England)
Fairness and eec,veness of procedures for repor,ng errors, near misses and incidents
3.58 3.56 3.54 3.52 3.5 3.48 3.46 England Acute Trusts Peer Trusts NUH
NUH patient safety newsletter In 2012/13 we continued to issue a monthly newsletter from the Chief Executive, Medical Director and Director of Nursing to communicate key patient safety messages to staff
across the Trust. Bi-monthly we share learning from serious incidents and Never Events.
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Patient safety information leaflets and bedside folders In 2012 we updated our patient safety information leaflets for staff and patients. The patient version now includes a patient/relatives check-list of important things that should have happened in the first 24 hours of admission to hospital, such as have we talked to you about
falls? and have we given you information about VTE prevention? We launched a new bedside folder across our inpatient wards in 2012. Developed by and for patients, the new folders include vital patient safety information for patients and their families.
Improving safety communication with Junior Doctors In 2012, we developed a mobile app for Junior Doctors in response to feedback on how they wish us to communicate with them and keep them informed. We have piloted this new tool, which gives improved access to safety information, including clinical guidelines, patient safety alerts and educational materials.
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National recognition for Hospital @ Night Our Hospital @ Night (H@N) project was fully rolled out across City Hospital and QMC in 2012/13, improving out-of-hours care and patient safety. H@N uses an IT system, called Nervecentre, to coordinate our care at night, weekends and bank holidays (ie 75% of the time). A wireless communication system connects the H@N coordinator to mobile phones and tablets carried by doctors, reducing response times for dealing with emergencies (and more standard tasks) out-of-hours. Research has shown that when multidisciplinary clinical teams work in this systematic and recorded way mortality is reduced and outcomes are improved. Implemented in conjunction with researchers from the University of Nottingham our H@N won a British Medical Journal (BMJ) Improving Health Award in May 2012 and was Highly Commended in the Health Service Journal Awards in November 2012. Improving medicines safety Our Medicine Management Committee regularly reviews relevant policies on how the Trust procures, handles, stores, prescribes, dispenses, administers and monitors medication to ensure that this is done as safely as possible. The prescription chart has been redesigned. Antibiotics are now prescribed on a dedicated section of the chart to facilitate adherence to best practice. The Drugs and Therapeutics Committee (DTC) ensures that drugs available for prescription within NUH are appropriately safe, efficacious and cost-effective. The DTC works closely with the Area Prescribing Committee when making decisions about drugs which are also prescribed from primary care. Alongside this, the Medicines Safety Group works to raise awareness around medicine safety, identifies medicines safety risks, and implements actions to reduce medicine-related harm. Trustwide medication incident data are reviewed quarterly to look for trends and develop actions. The group works closely with
the Directorates, which regularly review their medicine-related incidents and analyse them for patterns and trends according to a structured algorithm. Fifteen reports were received during 2012. The number of incidents reported and investigated, and the detail of the reports demonstrate an improving medication safety culture. They have informed the workplan for 2013/14 when NUH will focus on further improving medicines reconciliation when patients are admitted, the safe use of insulin, and reducing the number of omitted drug doses. Health Foundation Safer Clinical Systems project The Safer Clinical Systems programme is a new, structured approach to improve patient safety. NUH was chosen by the Health Foundation as one of four hospitals nationally to test this new methodology to improve prescribing safety. Systems thinking is used to build safe and reliable patient care through proactively identifying and managing hazards (rather than just reacting to harm events), and ensuring feedback to create continuous learning, engagement and sustainable solutions. The work at NUH is focused on one of our busy acute admission wards where we have incorporated patient experience into the diagnostic phase of the programme. As a result we are now concentrating on better communication across care interfaces, making sure patients receive their medicines more quickly, and improving the culture around medication safety. Working with other organisations on medicines safety In addition to medication-related risks that have been identified in the Trust, NUH also implements safety solutions in response to medicine-related alerts from external organisations, including legacy alerts from the NPSA. During 2012 NUH successfully completed the NPSA Alert on Insulin Passport and the alert of Safer Spinal Part A within the national timescale. NUH representatives are part of the Regional Medicine Safety Pharmacists Network which discusses risks and is a forum for
sharing good practice. During 2012 twenty-one medication risks identified in other Trusts within the region have been assessed and (where necessary) actioned at NUH. Medication-related Never Events Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Ten of the Department of Healths list of Never Events concern medication. NUH has developed an assurance framework which is updated every quarter to allow regular review of the risks around medication Never Events. This framework has been adopted by other trusts within the region to allow benchmarking of medication Never Events and shared learning to manage the risks. During 2012/13 NUH has declared one medication Never Event. A patient was administered a drug called Bortezomib subcutaneously instead of intravenously. The drug is licensed for administration by either route and the patient was not harmed. However because the drug was administered by a different route to that prescribed, this was declared a wrong route chemotherapy Never Event. There has been a full investigation and an action plan has been implemented. Drug safety teaching and learning Teaching and further education on medicine-related topics are included in induction and ongoing education for nurses, doctors and pharmacists. A newly-convened Medicines Education Group is working to make this more relevant and accessible, and is creating a responsive multi-professional education plan. New online learning and assessment modules are being developed to provide the flexibility needed. During 2012 our Medicines Information Unit answered 1,171 patient-centred enquiries for NUH and 92 enquiries for primary care/ members. The information for patients on what to do and where to turn to with queries about medication has been updated on their copy of the discharge letter.
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Harm-free care On a single day each month the NHS Safety Thermometer establishes the proportion of inpatients who have had pressure ulcers, harms from falls, catheterrelated urine infections and venous thrombo-embolic events. Care is said to be harm-free when a patient has endured none of these four harms. NUH has submitted data every month April 2012March 2013. In 2012/13, 95.73% of our patients were considered harm-free only.
Figure 28. % of harm-free care delivered in 2012/13
% of care which was "harm free"

96 95 94 93 92 91 90 89 88
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Incidents
Incident reporting is a key element of our patient safety programme. Our staff appreciate that when we learn from errors or mishaps we can prevent future harm to our patients. Recognising and reporting an incident (or near-miss) is the first step in that learning.
High levels of incident reporting are generally a feature of hospitals which have a strong safety culture. Our rate of incident reporting is 8.9 per 100 admissions (NHS Commissioning Board, September 2012). This was increased from 7.3 in March 2012, and NUH is now in the best 25% of acute teaching hospitals for rate of incident reporting.
Incidents are classified for the degree of harm they cause. In the first 6 months of 2012/13 NUH reported externally to the NHS Commissioning Board via the National Reporting and Learning System (NRLS) 6,011 no harm incidents, 2,166 low harm, 651 moderate harm, 23 severe harm, and 22 deaths in patients affected by an incident. This distribution of harms is similar to that reported by peer hospitals although the NHS Commissioning Board identifies that organisations apply degree of harm inconsistently, making comparison difficult (Figure 29). NUH has a robust process in place to review the degree of harm assigned at time of incident reporting. This may result in re-grading the incident to a higher or lower level following clinical review.
Figure 29. Incidents reported by degree of harm for acute teaching trusts compared with NUH, 1 April30 September 2012 (reported in March 2013)
Incidents reported by degree of harm for acute teaching organisations March 2013
All acute teaching organisations NUH
The 37 most severe incidents (death or severe harm) were each thoroughly investigated (23 by full root cause analysis/14 by speciality clinical team review). Action plans are tracked to completion by our Clinical Risk Committee, which also oversees discussion with patients and relatives and dissemination of the learning. Incidents resulting in no/low or moderate harm are investigated locally.
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Serious incidents
Incidents can also be classified by their seriousness (not only the actual harm, but the potential for harm even if it was avoided this time). Never Events are examples of such serious incidents, and the Department of Health has now (2012/13) classified incidents in specific categories as serious incidents (see Figure 30). In 2012/13 there was some overlap between the previous classification and these new serious categories. We reported 16 Serious Incidents in 2012/13 according to the old classification. Five of these were Never Events.
Table 30. Serious incidents (old criteria) 2012/13
Serious Incidents (SI) 2012/13 Inadvertently retained foreign object following procedure Wrong site surgery Medication Patient Falls Information governance Infection prevention and control Intrauterine fetal death Failure to follow up test results Unexpected death following surgery Total
We reported 229 Serious Incidents in 2012/13 according to the new criteria (Table 31). Table 31. Serious incidents (new criteria) 2012/13
Never Event
2 2 1
Other SI
Total
2 2
3 2 1 2 1 1 1
4 2 1 2 1 1 1
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16
Patient fall resulting in fracture or significant head injury Pressure ulcers (stages 3 & 4) Infection Prevention and Control includes all outbreaks, MRSA bacteraemias and severe Clostridium difficile morbidity) Maternity-related matters
(for example unexpected admission of the baby or mother to intensive care) Each serious incident is subject to robust investigation and careful monitoring of the associated action plan. Robust scrutiny is applied by the Trusts Governance Team to ensure that investigations identify the underlying (root causes) of serious incidents and proportionate recommendations are made. Learning from the outcome of these incidents informs a number of our patient safety work streams described in other areas of this report. Our Commissioners receive copies of all serious incident investigation
48 86 avoidable 25 unavoidable 39 31 patient safety leads from the hospitals across the region come together with commissioners to exchange best practice, discuss implementation of new initiatives and present their patient safety programmes. Examples of learning from incidents:
reports in order to provide assurance of our systems and processes. We have implemented all of the recommendations resulting from a thematic review of Never Events in 2011/12. It is important that the learning and key messages are shared widely, not only in our hospital but externally. In October 2012, NUH hosted the first meeting of the East Midlands Safety Collaborative. This is a regional shared learning event where senior clinicians and
The process by which clinicians are

alerted to abnormal x-ray results (RADalert) has been extended to include inpatients, which once fully embedded, will serve as an additional safety net
Chapter 6: Incidents
49
The production of the NUH Safer
Surgery DVD and booklet focusing on a uniform approach to the Five Key Steps to Safer Surgery supports new staff during their induction period retention of a guide wire in one of our patients, stickers have been developed for individual patient case notes where removal of the guide wire must be confirmed in writing by two people. This is supported by a Trust-wide written procedure considering the role of human factors in patient safety incidents and looking at ways of minimising their impact. Human factors relate to the issues that Influence people and their behaviour for example the environment in which they work. Teams have (e.g.) considered how to reduce noise and unnecessary interruptions during high risk procedures and introduced standardised safety checklists
Following the inadvertent
Clinical teams are increasingly
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Quality framework: Ward to Board
Caring and Accountability around the Clock
Case study: Caring around the Clock (CATC)

In January 2012 the Prime Minister announced his desire to see hourly rounding introduced in all NHS trusts. CATC is our innovative interpretation of hourly rounding which we implemented in 2012/13. Between 8am and 11pm, nurses check on the essential care needs of patients every hour (two hourly between 12 midnight and 8am). This includes checking what we call the Ps & QS pain, position, personal care, prevention, plan of care, questions and supplies. Clocks by the patients bedside are used to indicate to patients when their nurse is due back, helping to increase confidence in our care, and the visibility of nurses.
Louise Challans, Ward sister, Loxley Ward, City Hospital: CATC has been a catalyst for so many positive changes on the ward. Quality and safety has improved. It has helped us to go back to basics. The single biggest difference for me as a ward manager is that I now have more contact with patients and their families, Im more visible on the ward and can get and act on feedback from patients immediately. Rhonda Christian, Ward Manager, Ward E14 at QMC: CATC is setting out how we do nursing at NUH and what patients can expect when in our care. All nurses are involved, including student nurses, helping us to train the future generation.
Case study: Embedding Caring around the Clock

Ward C4, QMC
Ward C4 was a pilot ward for CATC. The new way of working anticipates patients needs rather than just responding to patients requests for help. Feedback has been very positive from staff, patients and relatives. There have been no formal complaints from patients since CATC was introduced. Ward Sister leadership rounds, when patients are asked how they feel about the nursing care given to them, have helped ensure that patients are receiving safer care and a better experience. Staff are encouraged to hold each other to account for the effectiveness of their rounding, and for the completeness of documentation and communication/handover of care. A staff recognition board has been set up to incentivise good performance.
A C4 patient said: The clock by the bed tells you when the nurses are coming next. As a patient you lose all track of time while lying in bed or sitting in a chair. Day and night blur into one. The clock reassures you that you are guaranteed some time with a nurse.
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Essence of Care
Essence of Care benchmarks assess how well a ward delivers the essentials of good care. Our Trust-wide performance against all Essence of Care benchmarks improved in 2012/13. The food and drink benchmark improved from 51% areas green or gold in February 12 to 77% in August 12, reflecting the impact of our Mealtimes Matter campaign. The pressure ulcer benchmark similarly improved from 29% to 52%. Any area scoring red against a benchmark is required to take effective remedial action within 2 months. Performance is monitored by the Essence of Care Steering Committee.
Improving nutrition and hydration

Our Mealtimes Matter campaign (launched in 2012) has remained a priority in 2013. The campaign (and its mealtime standards) was developed to:
Other improvements in 2012/13 include:
Safeguarding vulnerable adults

The number of safeguarding referrals increased this year. The most common reasons for concern (and alert) were neglect and financial abuse. No patient for whom a safeguarding investigation had been initiated was discharged until we were assured that they would be safe after discharge. Social care received 19 safeguarding alerts about care in NUH from other agencies, most frequently care homes. Each of these alerts was investigated by the Safeguarding and Consent Matron. No cases of abuse were substantiated - the concerns were most commonly about discharge planning and communication. Important aspects of safeguarding including consent, mental capacity and safeguarding from abuse, were reviewed during the September 12 CQC unannounced inspection at City Hospital and QMC. Both hospitals were compliant with these essential standards. The CQC commented: All staff demonstrated a good understanding of the MCA and how and when they would need to use this in their everyday practice to ensure patients rights and choices were maintained. During our tour of the wards, we saw that safeguarding procedures and telephone numbers were clearly displayed on the noticeboards of each ward. Each care record contained safeguarding information as a further reminder for staff. Staff also carried safeguarding information on a credit card-sized reminder card. All patients told us they felt safe and they knew who to speak to if they had any concerns.
Communicate the importance of
food and drink in patients care and recovery everyones responsibility
Promote nutrition and hydration as Ensure that patients have mealtimes

protected from unnecessary interruptions - all non-urgent activity should stop and staff who are not helping with meals should leave the ward activity at mealtimes on meals (eg helping those who need help and monitoring intakes) carers to participate in meals where appropriate professional, who is allocated 6 hours of protected time. Recruitment of 94 volunteer mealtime assistants (they are present on over 20 wards across NUH) information leaflets about why mealtimes matter
Nursing dashboard
We have continued to develop our nursing and midwifery dashboard, introduced in 2011. This supplements the essence of care benchmarks. Each month compliance against care and documentation standards in 9 domains is assessed in a substantial sample of patients (around 650 patients in 81 patient areas). There have been improvements in the dashboard domains for falls and pain control. There has been little change in the other domains (bowel and bladder, infection prevention and control, medication safety, nutrition, patient observations, pressure ulcers and respect and dignity), but the detailed information in the dashboard allows targeted local and Trustwide improvement actions. In September 2012 an external audit provided significant assurance that the dashboard measures are providing reliable information on compliance with Trust policy and CQC requirements regarding nursing documentation. To enable ward staff to have a greater understanding of the measures used, and to support improvements to practice, a new intranet site was developed and the dashboard is being viewed alongside other information such as patient experience feedback and the Essence of Care benchmarks.
Encourage nurses to focus their
Encourage and enable relatives/ Each ward has a nutrition link
Development of patient and staff Revised and adapted documentation
about enteral and parenteral nutrition is ensuring consistent practice across adult services on both campuses dietetic support to be put in place for patients receiving renal transplants plus more regular support for patients attending renal dialysis outreach units including the new unit at Lings Bar
Additional funding has allowed
One of our practice development matrons, Tracey Warren, won the British Journal of Nursing Award for her work to improve patient nutrition and hydration. Tracey has worked on our Mealtimes Matter campaign to ensure patients have protected time to eat their food, supported by nurses, healthcare assistants and volunteers.
Chapter 7: Quality framework: ward to board
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Dementia
The number of people with dementia will double in the next 20 years. There is an urgent need for hospital staff to increase their knowledge and skills to care for people with dementia. During the year we re-launched the dementia champions network and held our first dementia champions day in October 2013. This was attended by 45 staff across the Trust. We now have 88 dementia champions working across our wards. All of our staff have training in dementia in 2012/13 2,780 staff received this training either at induction or as ongoing mandatory training. Additionally over 400 nurses, support workers and allied health professionals have received detailed (level 2 and 3) dementia training and awareness in 2012/13
(supported by the Alzheimers Society) focused on our wards which have the most contact with elderly patients. Working first-hand with researchers from the University of Nottingham on the award-winning Medical and Mental Health Unit has provided us with a unique insight into the way we care for this growing group of patients in our hospitals. It has introduced a person-centred approach to care and new roles for staff for example activity coordinators who help to reduce patients distress and anxiety using organised activities such as games and painting. We have produced an About Me document, which collects information from patients, carers and families to tell us about the patient so that care plans can be truly individualised.
One of our nurses won a Nightingale Scholarship to explore how the New York University NICHE programme (Nurses Improving Care for Healthsystem Elders) is equipping nurses to deliver high quality geriatric care. She brought new ideas, such as the Healthcare of Older People Nurse Consultant, which we have implemented. Specialist geriatricians now have a greater presence in our emergency admissions wards to ensure early appropriate care of patients with dementia.
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Workforce and quality
Staff engagement
We undertook an online 9-question survey of staff engagement in July 2012. 4,066 staff replied. Our aggregate score of 73% was typical of scores for acute trusts. In the Picker staff survey in September 2012, 70% of staff would recommend our Trust as a place to work, and we scored in the top 20% of trusts for job satisfaction, staff feeling able to contribute towards improvements at work, motivation at work, staff recommending NUH as a place to work or receive treatment, low numbers of staff experiencing harassment, bullying or abuse from patients, relatives or the public in the last 12 months, and low numbers of staff experiencing physical violence from staff in the last 12 months. The survey described deterioration and/ or below average scores in staff reporting that they were working longer hours and suffering work-related stress, the percentage of staff having equality and diversity training, the proportion of staff unhappy with the standard of care at the Trust, and the proportion of staff who were enthusiastic about their job and looked forward to coming to work. We will address each of these areas of weaker performance in 2013/14. Our action plan includes strengthening Better for You, implementing a new shared governance model, and the re-launch of our Dignity at Work Champions Scheme.
Nursing skill-mix
Our skill-mix at March 2013 was 70% registered/30% unregistered nurses.
Leader and manager development

We have trained 485 senior nurses on the leadership elements of our Caring around the Clock programme. In 2012/13, 160 senior managers received a bespoke training programme. Nearly 700 managers have been through our externally-accredited Building Essential Leadership programme since its launch in 2009/10. 312 staff received change management Better for You training this year. 315 healthcare assistants (non-registered staff) have attended our Skills Academy since its launch in 2012. This skills programme increases healthcare assistants theoretical knowledge, understanding and practical skills and competency to underpin their daily work caring for patients and their families.
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Quality, Innovation, Productivity and Prevention (QIPP)
Through the QIPP process we are working closely with colleagues in primary care to redesign services to ensure that patients are seen at the right time in the right place. This includes a review of Cardiology and Diabetes pathways in conjunction with local GPs, and a variety of schemes aimed at providing additional post-discharge support for patients to avoid unnecessary readmissions.
One relevant quality improvement initiative this year was training our staff to provide patients who smoke with brief intervention advice and referral to stop smoking services for those patients who would like to be supported to stop smoking. We have trained 373 staff, who have evaluated the training sessions very positively. We will continue the training during 2013/14. We currently provide brief intervention advice to 73.5% of smokers. 2013/14 will see the evolution of our Make Every Contact Count (MECC) initiative, which will expand early intervention advice to include alcohol and lifestyle factors.
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10
10
Research and quality at NUH
Hospitals which engage in research generally provide higher standards of treatment. During 2012/13 NUH maintained excellence in research in a changing and challenging environment. Our distinguished portfolio expanded to include a new Arthritis Research UK Centre of Excellence for Sports Injury and Osteoarthritis in which NUH is leading a consortium of research partners, including the Universities of Nottingham, Oxford, Southampton, Bristol and University College London. Our NIHR Biomedical Research Units (BRUs) in Digestive Diseases and Hearing continue to deliver high-impact translational research.
The Digestive Diseases liver group has designed and piloted a novel community pathway to improve the detection and assessment of liver disease. The pathway translates previous research into biomarkers of liver fibrosis into clinical care.
Our Hearing BRU has worked with several research partners (including the University of Nottinghams School of Clinical Sciences Biomaterials-related Infection Group and its School of Pharmacy) to develop a revolutionary award-winning, controlled-release antibiotic pellet, which can be implanted in the middle ear during surgery to fit grommets. The pellets slowly release antibiotics, reducing the risk of infection and repeat operations, thereby improving the lives of thousands of children who have glue ear.
Naomi Russell, senior audiologist
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Our close partnership with the local Collaboration for Leadership in Applied Health Research and Care (CLAHRC) has enabled wider involvement in research and practice improvement. 10 colleagues from nursing, midwifery and physiotherapy have been supported in a Masters in Research Methods course. We are working closely with the University of Nottingham to develop a harmonised strategy aimed at increasing patient and staff participation in impactful research. NUH is committed to making research easier and faster. 7,483 patients were recruited to 287 NIHR-adopted studies last year, making NUH the sixth most research-active university hospital.
A comprehensive and sustainable research infrastructure of more than 160 staff has been established to improve patient access to clinical research. The Trust now participates in 210 commercial studies supported by a team of dedicated research nurses. Commercial clinical research is important to the NHS as it provides patients with access to innovative medicines and services. We have developed an effective service to support staff in the identification, protection and exploitation of Intellectual Property arising from 19 research projects. We made significant progress in developing and implementing an infrastructure for public involvement in research. The NUH
Research Advisory Group consists of patients and carers who get involved in NUH-led research as lay reviewers for specific research studies and research related activities. A total of 118 patients, carers and members of the public have joined the NUH Research Advisory Group which undertakes multiple and varied researchrelated activities, including the development of websites with information about NUH research, supporting and promoting research through different channels such as patient forums, videos of patient stories and television interviews. The Nottingham Health Sciences Biobank (NHSB) has grown within a year from a small collection of 1,000 samples to a bank of over 15,000 stored and categorised samples.
Chapter 10: Research and quality
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The NHSB will work in tandem with the ORCHID system which is a system for the transformation of anonymised clinical data gathered during routine patient visits to create a research database which fully captures and aligns Trust clinical activity with research. This comprehensive system of tissue and data will provide a powerful and innovative translational research platform. Participation in clinical research 2012/13. 7,483 patients receiving NHS services provided or subcontracted by NUH in 2012/13 were recruited to participate in research approved by a research ethics committee (NUH hosts 287 active NIHR-adopted studies). Our involvement in research has resulted in 943 publications. The 160 of our clinical staff who have substantial dedicated time for research, champion this activity across the Trust. We do however recognise that 2012/13 recruitment did not achieve the improvements seen in previous years. We have undertaken a review of our research processes, and implemented changes to regain our very strong earlier performance.
Quality Account: Feedback

We welcome feedback on our Quality Account
We welcome feedback on our Quality Account so that we can continue to make improvements to our publications year-on-year. Your can feedback by email at nuhcommunications@nuh.nhs.uk, by phone 0115 9249924 ext 70411 or via our website at www.nuh.nhs.uk. Copies of our full, summary and easy read versions of our 2012/13 Account are available on our website at www.nuh.nhs.uk. Hard copies of each of these versions, including large print and Braille copies, are available upon request by contacting 0115 9249924 ext 70411 or by emailing nuhcommunications@nuh.nhs.uk. If you would like our Quality Account in a different language or format please contact 0115 9249924 ext 70411 and we will arrange this. NUH received commentaries in 2013 from NHS Nottingham West Clinical Commissioning Group and Nottingham City and Nottinghamshire County Joint Health Scrutiny Committee see Appendix 2.
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Performance against all NUH 2012/13 objectives Review of 2012/13 annual objectives Strategic aim
Above all, ensure that patients would recommend our services to their friends and family
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Appendices: Appendix 1
Key Performance Indicators

Capture net promoter score (NPS)for 10% of discharged patients NPS improvement from 50.1 to 60.1 Meet all CQC requirements Achieve NHSLA level 2 No Never Events Fewer than 5 NUH-acquired MRSA bacteraemias
Met?
Further improve outcome of treatment for patients
133 Clostridium difficile cases 10% reduction in patient falls Eliminate avoidable stage 2,3 and 4 pressure ulcers 15% reduction in avoidable emergency readmissions
Increase staff satisfaction at work so that patients value their efforts
Improvement in 4 key areas in the 2012 national staff survey compared with 2011 results Deliver a financial surplus of 0.7% for reinvestment by delivering a Cost Improvement Programme of 4.9% Procurement savings. Target saving of 4.4million Pharmacy improvement including outpatients pharmacy and clinical trials. Target saving of 2.7million Length of stay reductions target saving of 1.6million
Work with commissioners to maintain the range and quality of our services, whilst reducing our cost base
Theatre efficiency programme and right-sizing of elective activity. Target saving of 2.4million Improved efficiency in back office functions and estates. Target saving of 3.8million Increase clinical income through growth in specialist and elective activity. Target efficiencies of 5.1million Medical pay savings through reduction in waiting list payments, PA reductions and banding payments. Target savings of 1million Reduction in staffing costs through workforce productivity totalling 7.4million
Work with commissioners to maintain the range and quality of our services, whilst reducing our cost base
Achieve at least Level 3 overall Monitor Financial Risk Rating (FRR) Increase research income by 10% compared with 2011/12
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Review of 2012/13 annual objectives Strategic aim

Align research and clinical service priorities and build capacity for future research
Key Performance Indicators

Enrol 20% more patients in clinical trials compared with 2011/12 20% increase in samples in the Biobank Achieve Foundation Trust status Increase critical care capacity in line with plans agreed with commissioners
Met?
Improve emergency and elective pathways to achieve national performance targets particularly: Deliver the strategic developments required to support the 2016 vision 4-hour access target 18 weeks Referral-To-Treatment Cancelled operations Cancer waits of 31 and 62 days
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Appendix 2: Statements of assurance

NUH received commentaries in May 2013 from NHS Nottingham West Clinical Commissioning Group and the Joint Nottingham and Nottinghamshire Health and Scrutiny Committee. The Trust has taken all comments on board and where appropriate, further strengthened our priority areas for 2013/14 in light of this feedback.
1 NHS Nottingham West Clinical Commissioning Group response to 2012/13 Quality Account for NUH.
Clinical Commissioning Groups have in place a collaborative commissioning arrangement for which Nottingham West CCG is the co-ordinating commissioner for NUH on behalf of a number of clinical commissioning groups. We have shared the Quality Account with a number of the CCGs and this narrative is a collective response. The commissioners have in place a number of measures for monitoring the quality of services we commission. This includes a schedule of regular visits to all areas of the hospital. These can be in response to patient safety incidents or patient feedback. These visits in conjunction with our regular contract reviews provide commissioners with real-time data from which we can form a judgement about the quality of services NUH offer. It is pleasing to see a number of successful quality initiatives have improved patient safety and patient experience. Through CQUIN we have been able to see a real improvement in patient safety through increasing the number of patients who receive the sepsis care bundle and understand why cardiac arrests occur and what needs to done next to further improve patient safety. NUH has exceeded the requirements for some CQUIN measures, such as sepsis, but unfortunately were unable to complete the CQUIN for dementia. We are pleased to see this is a priority for the coming year. We were concerned that there were a number of never events reported by the Trust this year. However we have worked closely with NUH to understand why these have happened and what measures need to be in place to prevent them happening again. NUH have a good reporting culture and should be commended for this however work continues to reduce the number of never events through their work on culture. NUH have shown an improvement in the number of falls and harm from falls however far too many people suffer avoidable harm and we are pleased to see a continued focus in this area. The MRSA and C diff limits are challenging for the Trust. We are working together to drive the number of healthcare acquired infections down. We are pleased to see this as a priority this year and wish to see an ambition to improve further. We are seeing a number of poor patient experiences involving discharge or transfers of care. We have noted inconsistencies in the quality of transfers and would wish to see further emphasis on improving arrangements in order to eliminate poor patient experiences. We are therefore pleased to see that better communication is a priority next year. We would encourage the Trust to extend this to improve the communication with commissioners; in particular General Practitioners. Improvements here would improve the patient journey over all. We do see a number of excellent examples of care and quality services however we also hear from patients whose experience is less than good and therefore we would like to see greater emphasis on achieving and maintaining consistency across all services. Reducing cancelled operations was a priority last year and we are pleased to see an improvement. Commissioners, supported by the Trust, also want to see a zero tolerance to waits over the national target of 18 weeks for all operations. No patient should have to wait longer than necessary for an operation. However we appreciate the challenges for the Trust in meeting this standard in some speciality areas. The Trust has improved significantly in relation to the CQC standards. Clearly this needs to be sustained and commissioners welcome the Trusts plan for delivering this. There is evidence of the Trust engaging with patients and staff in developing of the quality priority areas, however commissioners feel this can be further improved. We will work with the Trust to develop a mechanism for commissioners to be more actively involved in priority setting in the future. Dr Guy Mansford Chief Clinical Officer NHS Nottingham West Clinical Commissioning Group Dr Cheryl Crocker Director Quality and patient Safety/Nursing On behalf of NHS Nottingham West Clinical Commissioning Group
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2 Joint Nottingham and Nottinghamshire Health Scrutiny Committee response to the 2012/13 Quality Account for NUH.
The Joint Health Scrutiny Committee welcomes the opportunity to comment on the Nottingham University Hospitals NHS Trust Quality Account 2012/13. Our comment focuses on the areas in which we have engaged with the Trust during 2012/13. The Committee was pleased that the Trust responded to public concern about the high level of cancelled operations in early 2012 and placed significant focus on reducing the number of cancelled operations during 2012/13. The Trust regularly reported performance in both prior-to-the-day and on-the-day cancellations to the Committee and we had opportunity to scrutinise action being taken to improve and then maintain performance. The Committee welcomes the Trusts recognition that it needs to maintain a focus on work to minimise cancelled operations during 2013/14 and the Committee will continue to review progress, including how the Trust improves its performance in comparison to its peers. During 2012/13 the Trust has continued to share with the Committee its ongoing work to improve the care it provides to people with dementia in hospital. The expansion of basic dementia training to all staff, improvements to the patient environment through use of colour, signposting and increase in personal items, improving activity programmes and introduction of About Me documentation has been reported to the Committee during 2012/13. The Committee will review how the Trust responds to findings of the second National Dementia Audit during 2013/14. The Committee is supportive of the work taking place between the Trust and local authorities to improve care processes between hospital and community settings and achieve greater costeffectiveness in service delivery. In 2012/13 the Trust shared its work on the Integrated Health and Social Care Discharge Pilot which, amongst other things, intends to introduce new ways of working to ensure delays in discharge are minimised which the Committee is aware is an important issue for patients and their carers.
3 Healthwatch Nottingham and Healthwatch Nottinghamshire response to Quality Account for NUH.
Healthwatch Nottingham and Healthwatch Nottinghamshire came into being on April 2013. Both organisations welcome the opportunity to work closely with the Trust over the next 12 months to identify where they can contribute to the continuous improvement of services for the benefit of patients, relatives and carers. Healthwatch are grateful for the opportunity to be asked to comment on the NUH Trusts Quality Account, and will provide a considered view for inclusion in the Trusts 2013/14 Quality Account.
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Appendix 3: themes from public consultation for 2013/14 Quality Account priorities
Patient experience Discharge
Recognise patient expertise in management of long-term

conditions
First impressions count Keep patients well-informed about the consequences
Reduce discharge delays Improve communication between the hospital and GPs,
hospitals and community
of patient complaints , the main themes and informing patients what happens to complaints after their investigation and keeping the public informed of the main themes from complaints staff
Communication
Check the right information is sent out (is request needed

and are we sending to correct address/right patient?)
Continue to reinforce values and behaviours amongst Make patients feel like an individual Display compassionate care Privacy and dignity important
Nursing care
Improve communication between different staff disciplines

Environment
Ensure patients receive help with feeding when they need

it. This includes monitoring that our vulnerable patients receive the right nutrition and hydration responsibility for answering call bells on our wards
First impressions are important some wards look tired Improve disabled car parking provision Take action to tackle smoking outside the hospital Lifts at QMC often broken Improve signage (internal) Expand meeters and greeters to all entrances of the City
Hospital so patients and relatives are welcomed on arrival
Know how long patients have to wait and who has the Information about pressure ulcers and blood clots
Medical care
Parking at QMC
Patient safety
Need Clinical outcomes (Trust-level and individual surgeon

level)
Details of ongoing medical training for Doctors post

qualification
Carers
Cleanliness and hospital-acquired infections Mortality (death) rates for NUH Hand washing compliance Numbers of patient safety incidents reported How we learn from mistakes
Information about the experience of carers and support

given to carers
Organisation
Details of how we decide nursing ratios on wards

including the ratio of qualified staff to patients
Use of agency staff Improve continuity of care Improve staff morale and engagement Reduce waiting times and cancelled operations
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Appendix 4: Statement of Directors responsibilities in respect of the Quality Account

The directors are required under the Health Act 2009, National Health Service (Quality Accounts) Regulations 2010 and National Health Service (Quality Account) Amendment Regulation 2011 to prepare Quality Accounts for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporate the above legal requirements).
In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
The Quality Accounts presents a balanced picture of the

Trusts performance over the period covered; Account is reliable and accurate;
The performance information reported in the Quality There are proper internal controls over the collection and
reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice; reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Account has been prepared in accordance with Department of Health guidance.
The data underpinning the measures of performance
The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Account. By order of the Board
Dr Peter Barrett, Chairman
20/06/2013
Peter Homa, Chief Executive
20/06/2013
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Appendix 5: Standards inspected by CQC September 2012

Respecting and involving people who use services Consent to care and treatment Care and welfare of people who use services Meeting nutritional needs Co-operating with other providers Safeguarding people who use services from abuse Safety and suitability of premises Supporting staff Assessing and monitoring the quality of service provision Records
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Appendix 6: National audits in which NUH participates

National Audit
National Lung Cancer Data Audit (LUCADA)
Participation
Yes
Number of cases eligible/ requested for submission

414 2012 participated in organisational part (did not require individual cases) 507/50 315/50 See NCEPOD section 983 Ongoing data entry until end May 2013 40 Snapshot
% of cases submitted (or no cases)

100%
National Sentinel Audit of Stroke
Yes
100%
College of Emergency Medicine: Renal Colic National Audit of Paediatric Fever NCEPOD TARN (severe trauma) Adult community-acquired pneumonia (British Thoracic Society) National Review of Asthma Deaths (NRAD) National Audit of Dementia (NAD) British Thoracic Society: emergency use of oxygen British Thoracic Society: adult asthma National comparative audit of blood transfusion: bedside transfusion National comparative audit of blood transfusion: medical use of blood National Bowel (Colorectal) Cancer Audit (NBOCAP) National inflammatory bowel disease: ulcerative colitis and Crohns disease Adult cardiac surgery: CCAD SCTS (CABG and valvular surgery) Heart failure (BSHF) Myocardial Ischemia National Audit project (MINAP) (includes ambulance outcomes) Congenital heart disease BCIS Angioplasty Audit NICOR Diabetes Audit (NDA) Carotid interventions (Carotid Intervention Audit)
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
100% 100% 100% 100% 100%
92.5%
40
100%
Yes
62
62/100%
Yes Yes Yes Yes Yes Yes Yes Yes Yes Ongoing data collection 640 patients, 1,303 procedures 220 685 28 1284 116 89
398 On target 100% 100% 67.5% 100% 99.9% 100% 91%
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National Audit
Renal Registry: renal replacement therapy Renal transplantation (NHSBT UK Transplant Registry) NUH data submission to ODT database at NHSBT Peripheral vascular surgery National Vascular Database: (VSGBI) Dialysis Patients NHS Blood and Transplant Registry potential donor audit National Cardiac Arrest Audit (NCAA) Paediatric Intensive Care: PICA net Childhood epilepsy Neonatal intensive and special care (NNAP) Maternal, infant and newborn programme (MBRRACE-UK) British Thoracic Society: paediatric asthma DAHNO National Hip Fracture Database National joint Registry (NJR) Hip and Knee replacements Patient Reported Outcome Measures (PROMS): Knee replacement, hip replacement, hernia Adult Intensive Care: case mix programme ICNARC National Pain Database Audit: chronic pain services Bronchiectasis (British Thoracic Society) Non invasive ventilation (NIV) adults (British Thoracic Society) Parkinsons UK: National Parkinsons Audit Diabetes (RCPH National Paediatric Diabetes Audit) British Thoracic Society: paediatric pneumonia
Participation
Yes
Number of cases eligible/ requested for submission
% of cases submitted (or no cases)

100%
Yes
684
100%
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 50 160 791 1372 840 2548 80 10 minimum/31 entered 26 347 100% 100% 100% 100% 100% 100% 100% 364 Ongoing data collection 98%
Yes
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100%
Cardiac Rhythm Management Audit Oesophago gastric cancer audit
Yes Yes
1,119 215
100% 100%
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Appendix 7: Independent auditors limited assurance report to the directors of Nottingham University Hospitals NHS Trust on the annual Quality Account
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Appendix 8: Peer hospitals

Cambridge University Hospitals NHS Foundation Trust Central Manchester University Hospitals NHS Foundation Trust Lancashire Teaching Hospitals NHS Foundation Trust Leeds Teaching Hospitals NHS Trust Oxford Radcliffe Hospitals NHS Trust Royal Liverpool and Broadgreen University Hospitals NHS Trust Sheffield Teaching Hospitals NHS Foundation Trust Southampton University Hospitals NHS Trust The Newcastle Upon Tyne Hospitals NHS Foundation Trust University Hospital Birmingham NHS Foundation Trust University Hospitals Bristol NHS Foundation Trust University Hospitals Of Leicester NHS Trust
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Appendix 9: Index and glossary of terms

15 steps challenge ward or department visits in which board members and senior managers walk in the shoes of patients and staff to experience our hospitals through their eyes and ears. 2, 33, 34. Acute describes a disease of rapid onset, severe symptoms and brief duration. The majority of hospital services provided by QMC and Nottingham City Hospital are for acute illnesses. 13, 24, 39, 41, 45, 48,56. Audit Commission an independent watchdog, driving economy, efficiency and effectiveness in local public services, including the National Health Service, to deliver better outcomes for everyone. 35, 73. Better for You NUHs continuous improvement programme. Launched in 2009, the programme is enabling NUH to deliver caring, safe and thoughtful care to patients. It is an opportunity, through acting on ideas from our staff and patients, to improve our systems and processes and make sure they help us deliver high quality, efficient patient care. 2, 17, 39, 56. Biomedical Research Units (BRUs) The National Institute for Health Research (NIHR) has established sixteen BRUs to undertake translational clinical research in priority areas of high disease burden and clinical need that are currently under-represented in the existing Biomedical Research Centres. Each NIHR Biomedical Research Unit is a partnership between an NHS Trust and a university, which will enable some of our best health researchers and clinicians to work together. Funding for the Biomedical Research Units commenced on 1 April 2008. Each Unit will receive 750k for the first year (to allow for start-up) and 1million per year for the following three years (3.75million over four years). Awards will be made to the NHS partner, and can only be used to support the recurrent costs of patient focused research. Nottingham was the only city in the country to be awarded three BRUs for research into respiratory diseases, digestive diseases and hearing problems. 60. Board (of the Trust) The Trust Board is accountable for setting the strategic direction of the Trust, monitoring performance against objectives, ensuring high standards of corporate governance and helping to promote links between the Trust and the community. 2, 3, 6, 8, 13, 16, 17, 19, 28, 34, 35, 40, 42, 48, 53, 69. 4Cs refers to complaints, concerns, comments and compliments received by NUH. 17, 27. CABG coronary artery bypass graft (CABG) surgery. An operation in which a section of vein or artery is used to bypass a blockage in a coronary artery allowing enough blood to flow to deliver oxygen and nutrients to the heart muscles. CABG is performed to prevent heart attacks and to relieve chest pain. 71. Care Quality Commission (CQC) is the independent regulator of health and social care in England. The CQC regulates care provided by the NHS, local authorities, private companies and voluntary organisations. 2, 22, 53, 64, 66, 70. Caring around the Clock (CATC) our version of hourly rounding. Between 8am and 11pm, nurses check on the essential care needs of patients every hour (two hourly between 12 midnight and 8am). 2, 8, 52. Centre for Maternal and Child Enquiries (CMACE) independent charity dedicated to improving the health of mothers, babies and children.They carry out confidential enquiries and other related audit and research work across the UK. Clinical audit Clinical audit measures the quality of care and services against agreed standards and suggests or makes improvements where necessary. 22, 24 Clinical coding Clinical coding officers are responsible for assigning a code for every inpatient stay and day case visit (or episode). The coding process enables patient information to be easily sorted for statistical analysis. 35. Clinical Commissioning Group (CCGs) replaced Primary Care Trusts with effect from April 1 2013. These groups will comprise of GPs and other clinicians who will have a greater influence on how the NHS budget is spent. There will also be a new national NHS Commissioning Board to oversee the process. 3, 14, 66. Clinical Effectiveness Committee provides assurance that all NUH clinical services and treatment programmes meet best-practice standards for assessing and maintaining their clinical effectiveness. Clostridium difficile (C difficile) A healthcare associated intestinal infection that mostly affects elderly patients with other underlying diseases. 3, 10, 19, 49, 64, 66.
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Commissioners of services These are organisations that buy services on behalf of people living in a defined geographical area. They may purchase services for the population as a whole, or for individuals who need specific care, treatment and support. Healthcare services are commissioned by the local authorities. 14, 19, 20, 26, 39, 49, 64, 65, 66. Commissioning for Quality & Innovation (CQUIN) The CQUIN payment framework is a national framework for locally agreed quality improvement schemes. It makes a proportion of provider income conditional on the achievement of ambitious quality improvement goals and innovations agreed between Commissioner and Provider, with active clinical engagement. The CQUIN framework is intended to reward genuine ambition and stretch, encouraging a culture of continuous quality improvement in all providers. In order to earn CQUIN money, providers of acute, ambulance, community, mental health & learning disability services using national contracts must agree a full CQUIN scheme with their commissioners. CQUIN schemes are required to include goals in the three domains of quality: safety, effectiveness and patient experience; and to reflect innovation. 20, 25, 26, 40, 41, 66. Community Programme set up to establish greater coordination and cooperation between health and social care in the hospital setting and out in the community. The first workstream focuses on frail, elderly people. Complaint This is an expression of dissatisfaction that can relate to any aspect of a persons care, treatment or support. It can be expressed orally, through gestures or in writing. 13, 17, 27, 28, 29, 68.
Chronic Obstructive Pulmonary Disease (COPD) a term used for a number of conditions; including chronic bronchitis and emphysema. COPD leads to damaged airways in the lungs, causing them to become narrower and making it harder for air to get in and out of the lungs. Day surgery surgery which can be performed in a single day, without the need to admit the patient for an overnight stay in hospital. Dementia a syndrome (a group of related symptoms) associated with an ongoing decline of the brain and its abilities. One in three elderly patients in our hospital has some form of dementia. 3, 19, 20, 25, 34, 54. Department of Health The Department of Health is the department of the UK government responsible for policies on health, social care and the NHS (in England only). Discharge The point at which a patient leaves hospital to return home; or is transferred to another service; or the provision of a service is formally concluded. 12, 13, 28, 31, 34, 37, 39, 46, 53, 58, 66, 69. Discharge Lounge an area where patients can wait in comfort ahead of discharge, freeing up hospital beds for new patients to be admitted. 38. Dr Foster Good Hospital Guide Dr Foster is an independent organisation dedicated to making information about the performance of hospitals and medical staff as accessible as possible. 26. Elective elective care is planned. A patient will be aware of the required treatment and has been given a date to be admitted to hospital. Non-elective care is provided in critical or emergency situations when a medical professional deems specific treatments or hospital admission cannot be delayed for more than 24 hours. 64, 65.
Emergency access standard the treatment of patients within fourhours of arrival in the Emergency Department. The national target is set at 95% of patients within this time. 38. Essence of Care aims to support localised quality improvement on wards, by providing a set of established and refreshed benchmarks supporting front line care across care settings at a local level. It aims to improve the quality of fundamental aspects of nursing care. 53. Friends and family test a nationally-implemented survey that asks patients if they would recommend our hospitals to their friends or family. 2, 8, 13, 17, 29, 33. Four hour standard relates to the emergency access standard set by the Department of Health. The target states that at least 98% of patients attending Emergency Departments must be seen, treated, admitted or discharged within four hours. 3, 31, 38. Francis Report report into the care provided by Mid Staffordshire NHS Foundation Trust by Robert Francis QC. It concluded that patients were routinely neglected by a Trust that was preoccupied with cost cutting, targets and processes and which lost sight of its fundamental responsibility to provide safe care. 2, 3, 16, 17. Healthcare associated infection This is an avoidable infection that occurs as a result of the healthcare that a person receives. 10, 11. Hospital Episode Statistics (HES) is the national data for England of the care provided by NHS hospitals and for the NHS hospital patients treated elsewhere. HES is the data source for a wide range of healthcare analysis for the NHS, government and many other individuals and organisations.
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Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures if the death rate at a hospital is higher or lower than you would expect. The HSMR compares the expected rate of death in a hospital with the actual rate of death. Factors such as age and severity of illness are taken into account. 6, 7. Information Governance is the way by which the NHS handles all information, in particular the personal and sensitive information of patients and employees. It allows organisations and individuals to ensure that personal information is dealt with legally, securely, efficiently and effectively in order to deliver the best possible care. 35, 36, 49. Intensive Care National Audit & Research Centre (ICNARC) aim is to foster improvements in the organisation and practice of critical care (intensive and high dependency care) in the UK. 72. Intrapartum care management and delivery of care to women in labour. Joint Health Scrutiny Committee (known as Overview and Scrutiny Committees (OSCs) Since January 2003, every local authority with social services responsibilities have had the power to scrutinise local health services. OSCs take on the role of scrutiny of the NHS not just major changes but the ongoing operation and planning of services. They bring democratic accountability into healthcare decisions and make the NHS more publicly accountable and responsive to local communities. Just Do It part of the Better for You programme, staff are encouraged to come up with ideas to improve patient care or working practices and then be given the freedom to implement their ideas. 28. Length of stay a term used to measure the duration of a single episode of hospitalisation. 14, 20, 25, 26, 27, 38, 64.
Liverpool Care Pathway an integrated care pathway that is used at the bedside to drive up sustained quality of the dying in the last hours and days of life. Local Involvement Networks (LINks) are made up of individuals and community groups, such as faith groups and residents associations, working together to improve health and social care services. In Nottingham there are two LINks groups one for Nottingham city and another for Nottinghamshire. 16. Mealtimes Matter protected mealtimes for patients, where visitors and other distractions are kept to a minimum to allow nurses and healthcare assistants to focus on patient nutrition and hydration. 53. Myocardial Ischaemia National Audit Project (MINAP) established in 1999, in response to the national service framework (NSF) for coronary heart disease, to examine the quality of management of heart attacks (myocardial infarction) in hospitals in England and Wales. 71. MRSA methicillin-resistant Staphylococcus aureus bacteria that can cause infection in a range of tissues such as wounds, ulcers, abscesses or bloodstream. 3, 10, 19, 49, 64, 66. National Institute for Clinical Excellence (NICE) an independent organisation responsible for providing national guidance on promoting good health and treating ill health. 24, 39. National Institute for Health Research (NIHR) is the body responsible for creating a health research system in which the NHS supports outstanding individuals, working in world class facilities, conducting leading edge research focused on the needs of patients and the public. 14, 60, 61, 62. National Patient Safety Agency (NPSA) an arms-length body of the Department of Health that leads and contribute to improved, safe patientcare by informing, supporting and influencing
organisations and people working in the health sector. 45. National Patient Survey The NHS national patient survey programme was established as a result of the Governments commitment to ensuring that patients and the public have a real say in how NHS services are planned and developed. Getting feedback from patients and listening to their views and priorities is vital for improving services. All NHS trusts in England are legally required to carry out local surveys asking patients their views on their recent health care experiences. One main purpose of these surveys is to provide organisations with detailed patient feedback on standards of service and care in order to help set priorities for delivering a better service for patients. There are inpatient and outpatient surveys. 29, 30. Never Event related to surgery, where incidents occur that should never happen, such as retained medical instruments, swabs or wrong-site surgery. Never events are reported to the Board. 42, 43, 45, 49, 64. NHS Blood & Transplant (NHSBT) provides a reliable, efficient supply of blood, organs and associated services to the NHS. 72. NHS Choices See also Patient Opinion National website for patients to leave feedback on opinions on NHS services. 17, 29. NHS East Midlands is the strategic health authority for the region providing leadership of the NHS acrossDerbyshire, Leicestershire and Rutland, Lincolnshire, Northamptonshire and Nottinghamshire. The role of NHS East Midlands is to relay and explain national policy, set direction and support and develop all NHS Trust bodies (Primary Care Trusts and NHS Trusts providing acute, mental health and ambulance services).
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NHS Foundation Trust NHS foundation trusts are a new type of NHS trust in England and have been created to devolve decisionmaking from central Government control to local organisations and communities so they are more responsive to the needs and wishes of their local people. 3, 34, 65, 74. NHS Litigation Authority (NHSLA) The NHSLA is a special health authority responsible for handling negligence claims made against NHS bodies. It also aims to raise safety standards and reduce the number of negligent or preventable incidents through its risk management programme. This incorporates organisational, clinical and health and safety risks. Most healthcare providers, including NUH, are assessed against their standards. NHS Number is the only National Unique Patient Identifier, used to help healthcare staff and service providers match you to your health records. 35. Overview and Scrutiny Committees (OSCs) see Joint Health Scrutiny Committee. Paediatric medical care of children. Patient This is a person who receives health or social care through a regulated activity. Patients are defined as service users in the Health and Social Care Act 2008. Patient Environmental Action Team (PEAT) an annual assessment of inpatient healthcare sites in England that have more than 10 beds. It is a benchmarking tool to ensure improvements are made in the non-clinical aspects of patient careincludingenvironment, food, privacy and dignity. The assessment results help to highlight areas for improvement and share best practice across healthcare organisations in England. 8. Patient Opinion (see also NHS Choices) - an independent nonprofit feedback website for health services. 17, 29, 30, 31.
Perinatal the period shortly before or after birth. Peri-operative the care that is given before, during and after surgery. PCTs succeeded primary care groups (PCGs) with responsibilities for improving the health of the community, developing primary and community health services and commissioning secondary care services. Whereas PCGs were sub-committees of the health authority, PCTs are freestanding bodies. Nottinghams PCTs took over functions from the PCGs, Nottingham Community Health NHS Trust, most of the functions of Nottingham Health Authority and some services from Nottingham Healthcare NHS Trust. The PCTs have the same boundaries as local authorities. Picker Institute a not-for-profit organisation that works with patients, professionals and policy makers to promote a patientcentred approach to care. The Institute uses surveys, focus groups and other methods to gain a greater understanding of patients needs. 56. Pressure Ulcers a type of injury that break down the skin and underlying tissue. They are caused when an area of skin is placed under pressure. They are also sometimes known as bedsores or pressure sores. 2, 3, 7, 12, 20, 25, 43, 46, 49, 53, 64, 68. Providers providers are the organisations that provide NHS services, for example, NHS trusts, and their private or voluntary sector equivalents. Quality dashboards a clinical dashboard is a toolset of visual displays developed to provide clinicians with the relevant and timely information they need to inform daily decisions that improve quality of patient care. 3, 17, 19, 20, 25, 53. Quality, Innovation, Productivity & Prevention (QIPP) programme is an opportunity to prepare the NHS to defend and promote high quality care in a tighter economic climate.
QIPP focuses on the NHS working in different ways to ensure that the highest quality care is delivered. It encourages efficiency and focuses on a joined up approach to delivering healthcare. 58. Pulmonary Hypertension is a condition in which high blood pressure in the arteries of the lungs (the pulmonary arteries) is abnormally high. Research Clinical research and clinical trials are an everyday part of the NHS, and often conducted by medical professionals who also see patients. A clinical trial is a particular type of research that tests one treatment against another. It may involve either patients, or people in good health, or both. 14, 60, 61, 62, 65. Safeguarding Safeguarding means putting measures in place to enable people to live free from harm, abuse and neglect. The measures protect their health, wellbeing and human rights. Children, and adults in vulnerable situations, need to be safeguarded. 53, 70. Safer Surgery Checklist a tool for the relevant clinical teams to improve the safety of surgery by reducing deaths and complications. In June 2008, World Health Organisation (see WHO) launched a second Global Patient Safety Challenge, Safe Surgery Saves Lives, to reduce the number of surgical deaths across the world. The checklist is part of this initiative. 42. Safety Thermometer data collected on a single day of the month providing a moment in time picture. 25, 35, 46. Secondary User Services (SUS) single source of comprehensive data to enable a range of reporting and analysis. 35. Sepsis Sepsis is a life-threatening illness caused by the body overreacting to an infection. The bodys immune system goes into overdrive, setting off a series
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of reactions that can lead to widespread inflammation (swelling) and blood clotting. 2, 3, 6, 10, 20, 25, 40, 41. Stroke Improvement National Audit Programme (SINAP) a national audit is funded by the Department of Health and run by the Stroke Programme at the Royal College of Physicians (RCP). The aims of the audit are to:
We are here for you our values, known as we are here for you, developed after consultation with patients and staff, describe the NUH way of doing things. 2.
describe the pathway followed by

patients with acute stroke (in the first three days) in hospital
assess the quality of care provided to

acute stroke patients during the first three days of care services need to be improved for acute stroke patients
identify the major areas where
Smoking cessation is the process of discontinuing the practice of inhaling a smoked substance. 26. Staff survey the annual national survey of NHS staff in England is co-ordinated by the Care Quality Commission and provides the most reliable source of national and local data on how staff feel about working in the NHS. The principal aim of this survey is to gather information that will help individual NHS organisations to improve the working lives of their staff and so help to provide better care for patients. 8, 43, 56, 64. Strategic Health Authority see NHS East Midlands. Think Glucose campaign is a major programme from the NHSInstitute, designed to improve the management of people with diabetes when they are admitted to hospital. Venous thrombo-embolism (VTE) a condition in which a blood clot (thrombus) forms in the vein. 3, 7, 13, 20, 25, 40, 42, 43, 44. Vascular Society of Great Britain and Ireland (VSGBI) a registered charity founded to relieve sickness and to preserve, promote & protect the health of the public by advancing excellence & innovation in vascular health, through education, audit & research.
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Designed by NUH Communications Team. Photographs by Nottingham University Hospitals NHS Trust. 2013 Nottingham University Hospitals NHS Trust. All rights reserved.

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2012/13

How we are continuously improving quality, safety and patient experience

Introduction from our Chairman & Chief Executive

Better communication (with patients,

Dr Peter Barrett, Chairman

Achieve specific quality targets for Improve services for vulnerable

Integrate the Trusts quality reporting

Respond to the recommendations

Peter Homa, Chief Executive

Quality review of 2012/13

Improving patient safety

Figure 3. VTE risk assessment Admitted patients risk-assessed for VTE

Nottingham University Hospitals NHS Trust

Quality Account 2012/13

Chapter 3: Quality review 2012/13

Crude mortality rate (%)

Improving patient experience

Caring around the Clock (our unique

More patients are recommending

Improving staff experience

Figure 4. Patient Environment Action Team (PEAT) scores 20092012

Delivering environmental improvements

Food Privacy and dignity Environment

Food Privacy and dignity Environment

Food Privacy and dignity

Smoke-free Kick the Butt campaign

Figure 5. Ward cleanliness assessment scores 20092012

Performance Baseline standard

You hear a lot of bad

Nottingham University Hospitals NHS Trust

Quality Account 2012/13

Chapter 3: Quality review 2012/13

Priority 1 for 2012/13 Improve outcomes of treatment for patients

TARGET Fewer than 5 MRSA bacteraemias

TARGET Fewer than 133 cases of Clostridium difficile

Figure 7. Clostridium difficile rate 2007-2012

TARGET 10% reduction in number of patient falls

Chapter 3: Quality review 2012/13

Key actions in 2012/13 to reduce falls included:

Recruitment of over 60 falls

Launch of a revised falls prevention

Eliminate avoidable stage 2, 3 and 4 pressure ulcers

Figure 8. Pressure ulcers 2012/13

The tissue viability service was

Fewer avoidable emergency readmissions caused by poor NUH care or discharge

Every inpatient ward has a tissue

Priority 2 for 2012/13 Improve our patients experience

Improve the quality of communication with patients and their families

Our Readers Panel of patients, carers

The Readers Panel audited 20 leaflets

We developed an online library for

We have introduced new e-discharge We introduced consent and capacity

Our 5 daily actions programme

Opened a new Discharge Lounge at A focus on predicted discharge date

New discharge information for

New standardised discharge leaflet Through our home for lunch

Nottingham University Hospitals NHS Trust

Quality Account 2012/13

Chapter 3: Quality review 2012/13

20% increase in samples in the Biobank

Established a successful and

Published 943 peer reviewed

Other achievements in Research & Innovation