Board of Directors (Public) 26.07.18
MEETING 26 July 2018 11:00
PUBLISHED 25 July 2018 1. Part One -
Agenda
Location Date Owner Time 2.
Meeting Room 1, Main Entrance 26/07/18 Frank Collins 11:00 Strategy &
1. Part One - Public Meeting
1.1. Matters Arising All 11:00 3.
1.2. Minutes of the previous meeting (24.05.18) All 11:05 Performance & 1.3. Declarations of Interest All 11:10 1.4. Staff/Patient Story (Verbal) Olivia Evans 11:15
2. Strategy & Policy Updates
2.1. Chief Executive Update (verbal) Chief Executive 11:25 4.
2.1.1. CQC Update Chief Quality & Executive/Chai rman 2.1.2. Information Governance Briefing Chief Executive 2.2. IM&T Strategy Associate 11:35 Director of IM&T 5. Annual
3. Performance & Governance 3.1. Integrated Performance Report (M3) Associate 11:45 Director of Performance 3.2. Research Update Director of 12:05 6. Strategy and Planning Items to note 3.3. Chair Report: Finance Planning and Investment Commitee Non Executive 12:15 Diretor 3.4. Chair Report: Risk Management Committee Non Executive 12:20 Director 3.5. Board Assurance Framework Trust Secretary 12:25 7. Any Other 8. Date and Time
Continued on the next page... 2 1. Part One -
Agenda
Location Date Owner Time 2.
Meeting Room 1, Main Entrance 26/07/18 Frank Collins 11:00 Strategy &
4. Quality & Safety
4.1. Chair Report: Quality and Safety Committee (verbal) Non Executive 12:30 3. Director Performance & 4.2. Infection Control (Q1) Deputy 12:35 Director of Nursing 4.3. Inpatient Survey (Presentation) Medical 12:40 Director
4.4. Learning from Deaths Medical 12:50 4. Director Quality & 4.5. Guardian of Safe Working Hours Medical 12:55 Director
5. Annual Reports 5.1. Safeguarding Annual Report Deputy 13:00
Director of 5.
Nursing Annual 5.2. Infection Control Annual Report Deputy 13:10 Director of Nursing
6. Items to note 6. 6.1. Governor's Update (Verbal) Trust Secretary 13:20 Items to note
7. Any Other Business 7.1. Questions from the Public 13:25
8. Date and Time of next meeting 7.
8.1. 27.09.2018 in Meeting Room 1 Any Other 8. Date and Time
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Frank Collins 4358 2. Chairman Strategy & BOARD OF DIRECTORS – PUBLIC SESSION 24 MAY 2018 MINUTES OF MEETING
Present: Frank Collins Chairman FC Mark Brandreth Chief Executive MB 3.
Alastair Findlay Non-Executive Director AF Performance & Bev Tabernacle Director of Nursing BT Craig Macbeth Director of Finance CM Chris Beacock Non-Executive Director CB Harry Turner Non-Executive Director HT Nia Jones Director of Operations NJ David Gilburt Non-Executive Director DG Hilary Pepler Non-Executive Director HP 4. Quality & In Attendance: Kerry Robinson Director of Strategy and Planning KR Shelley Ramtuhul Trust Secretary SR Sarah Sheppard Director of People SS Laura Peill Associate Director of Performance LP 5. FC welcomed all Board members to the Public Board. Annual
MINUTE NO TITLE 24/05/1.0 APOLOGIES Steve White, Medical Director 24/05/2.0 MINUTES OF THE MEETING 30 APRIL 2018 The minutes of the meeting held on the 30 April 2018 were agreed as an accurate
representation of the meeting. 6. 24/05/3.0 MATTERS ARISING Items to note FC went through the actions which were noted to be either completed or progress updates were provided. 24/05/4.0 DECLARATIONS OF INTEREST David Gilburt advised that he has been invited to become a member of the HFMA Audit Committee. 24/05/5.0 PATIENT STORY (LIZ FISHER)
BT introduced Liz Fisher who had undergone surgery at the Trust six months ago and 7.
she highlighted the following aspects of her experience: Any Other
Good information was provided in advance of the procedure and lots of opportunity to ask questions. There were numerous interactions during her pre-op visit resulting in her almost missing her x-ray The Joint School was a great help and provided information and answers to 8. questions that she had not thought of Date and Time Her admission time was 7.15am along with everyone else being admitted that day which made the waiting area very congested
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It was not clear what to do with her belongings and she felt something could be done to address this She was taken to Theatre at 2pm having not eaten since the night before and she thought staggered admissions may help with this After her procedure she was taken to a different ward to the one she had been in prior to the procedure, she had not been warned of this 2. She was nervous about having a spinal anaesthetic but the staff helped to relax Strategy & her. The anaesthetist was willing to stay and talk through the operation and as somebody who likes to know what is going on this helped her greatly and she extended her thanks to him for this. The procedure itself was very quick and she was back in recovery within the hour and the cups of tea and warm blankets were very relaxing
The physio team were supportive of what she felt she could and could not do in 3. the immediate post-operative period Performance & Being in the ward rather than a single room meant that she could chat to the other patients but it did cause her difficulty sleeping. There was an apology on her discharge for this The discharge process was clear and staff apologised for moving her out of her bed on the day of discharge to make way for another patient but she did not feel they needed to apologise She sought and obtained reassurance following her discharge 4. Quality & Overall Liz felt her experience had been positive experience and that the staff had been fantastic.
FC thanked Liz for attending and for her positive feedback but also for highlighting the areas that the Trust can pick up on and take forward. 5. HP commented that the issue of admission times has previously been picked up and is Annual being looked at as the issues this can recognised this can cause issues.
HT asked if there was overlap in the various assessments undertaken during the pre- operative clinic or whether these could be consolidated. Liz advised that she felt there were some areas of overlap and HT asked BT if this could be looked at.
ACTION: BT to look at potential overlaps in the pre-operative assessments and whether 6.
these can be consolidated. Items to note
HT also commented on her experience with the anaesthetist and asked whether this was personalised to her. She felt it was personal to her and he had gauged her desire for information.
MB agreed with her comments around the Joint School and commented that this should be extended beyond joints. He also commented on the opportunity this creates to 7. involve the families as they are the carers once patients leave the hospital. Any Other
MB advised that the Trust can look at the checking in of belongings and also the disturbance at night, which has already been worked on, but can be looked at again.
ACTION: BT to look at the checking in of patient belongings and the disturbances at night. 8.
FC thanked the Liz for coming and sharing her story. Date and Time
The Board noted the Patient Story
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24/05/6.0 PATIENT STORY (OWEN PATERSON MP) FC introduced the next patient story which related to the positive comments of Owen Paterson MP during Prime Minister’s Questions who registered his thanks to staff at the Midlands Centre of Spinal Injuries for the care and treatment he had received. The Prime Minister had supported these comments. 2. Strategy & Owen Paterson MP was also complimentary about the Trust and in particular the care he received from the Midlands Centre of Spinal Injuries during an interview on the Jeremy Vine Show. He specifically highlighted the Trust’s record of getting patients back to walking following significant and life changing spinal injuries.
The team from MCSI were in attendance and FC extended his thanks to the team on 3. behalf of the Board. Performance &
The Board noted the Patient Story
24/05/7.0 THEATRE UTILISATION LP introduced Amanda Peet, Divisional Manager for Theatres and Mr Simon Hill, Orthopaedic Surgeon to present the work they have undertaken on Theatre Utilisation. 4.
Details of the presentation can be found via the following: Theatre Utilisation Update Quality & 24.05.18
The presentation provided context around the complexity of the Trust’s cases before looking at the work that has been done on the culture in Theatres and the recent initiative of the ‘Perfect List’.
The presentation outlined the benefits realisation both in terms of productivity but also 5.
with regard to staff retention. Amanda outlined there has been learning from the perfect Annual list and the next perfect list will be refined to take these into account. There was also the benefit of staff feeling less rushed which cannot be captured in any data extracts.
Mr Hill gave an account of his experience of the perfect list and the benefit this had on the staff. He felt that the predictability of the time taken to get the patient into the Theatre would give him confidence to add an additional patient to the list. 6.
FC picked up on the comment around increased confidence and the opportunities this Items to note presents with embedding these improved processes going forward.
MB commented on the opportunity for improved safety through these refined processes.
CB asked about the potential for rolling this out to every list. Amanda advised that there
is already interest from other specialties and the plan is therefore to look at how this 7.
would work for other areas. Any Other
NJ advised that each list runs differently and the key will be testing what works for each list taking into account the types of cases.
HT asked if there is a dashboard of KPIs and where this gets discussed and scrutinised for Board Assurance. LP confirmed that there is a theatre utilisation dashboard and whilst this is not presented at Finance Planning and Investment Committee there is in- 8.
depth discussion and oversight. Date and Time
HT asked about the seasonal fluctuations and if there is anything that can be done,
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using the information and data available, to address these in terms of managing costs. Amanda confirmed that seasonal planning work has been undertaken and this will ensure that the staffing costs are closely aligned to the activity and will take into account the known seasonal variations.
MB advised that the seasonal plan has been presented to the Clinical Management 2.
Board. Strategy &
AF asked about the changing case mix and increasing complexity and whether there is anything the Board should be mindful of. NJ commented on the loss of small cases to infill between the larger cases and the work is therefore focussed on maximising the time at the end of the list to accommodate a larger case. 3. FC thanked Amanda and Mr Hill for attending. Performance &
The Board noted the presentation and the next steps. 24/05/8.0 VETERAN’S SERVICE Col Carl Meyer, Consultant Orthopaedic Surgeon and Becky Warren, MCSI Ward Manager attended to provide an overview of the Veteran’s Service. Details of the presentation can be found via the following: Veterans Service Presentation 4.
The presentation highlighted how the service has developed and grown and the services Quality & it currently provides as well as the areas it is hoping to move into. Col.Meyer recognised the Trust’s support for this service.
Becky Warren presented to the Board the learning that has been taken from a recent visit to the Walter Reed National Military Medical Centre.
The presentation focussed on the areas the Medical Centre did well and how these 5.
would translate into improvement opportunities at the Trust. Annual
KR advised the Board of the soft launch of the fundraising that has taken place with the formal launch taking place at the Houses of Parliament. The aim is to raise £1m for a dedicated Veteran’s Outpatient Department with the fundraising being hosted by the Orthopaedic Institute with support from the League of Friends. 6. FC highlighted that this is a service that will operate within the NHS. Items to note
HP asked about how the learning for the Veteran’s Service will transfer into the wider NHS services. Col Meyer advised that this is already happening through his working with outpatients and radiology.
DG commented on the interest from the Walter Reid Medical Centre and Col. Meyer
advised that there was lots of learning for them too as the Trust carries out a significant 7. number more surgeries than they do. Any Other
FC thanked Col Meyer and Becky Warren for attending and presenting to the Board.
The Board noted the presentation. STRATEGY AND POLICY UPDATES 24/05/9.0 CHIEF EXECUTIVE UPDATE MB provided the following update: 8.
A statement on the IG Breach that the Trust has been investigating relating to a Date and Time breach identified with regard to a post market surveillance study. MB emphasised that the Trust was taking this very seriously and was in the process
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of contacting all affected patients. MB highlighted that it had been a month of celebration and recognition from Nurses Day and ODP Day to Equality and Diversity Week. MB thanked the Library Team for their work on the poster displays to support this. Developments with the Veteran’s service with the trip to Washington highlighted previously and the launch of the Veteran’s Service. 2.
Veteran’s Launch Strategy & MB and KR, with the Trust’s Associate Director of IM&T, had visited the Deep Mind Team at Google to look at how electronic intelligence can be utilised in the NHS. The Trust has been recognised with the Youth Friendly Gold Award. MB thanked Allen Edwards, Training Advisor and SS for their work on this
Health Hero for the month was Kristine Griffiths a member of the Estates Team 3.
Details have been published to staff on the £100k pot. This is a fund that has Performance & been set up for staff to put forward ideas of improvement that they can bid for funding.
FC thanked MB for his update.
The Board noted the update. 24/05.10.0 ELECTRONIC PATIENT RECORDS STRATEGIC OUTLINE CASE 4.
KR presented the paper which outlined the options that have been explored regarding Quality & an EPR. The paper has been redacted to take out the financial figures due to the commercial sensitivities around procurement.
Simon Adams, Associate Director of IM&T attended and highlighted the potential benefits of an EPR solution. He emphasised that this is not an IT project, it is a transformational change programme that needs to be clinically led. The solution would 5. be an integrated EPR which will integrate all current systems into one. The Trust has already invited potential suppliers to site so that staff can gain an insight into the way the Annual systems will potentially work.
The paper presented the preferred option of a partnership model and the Board was asked to approve progressing this to the next stage of a full business case.
The Board approved the progress to a full business case. 6. Items to note PERFORMANCE AND GOVERNANCE 24/05.11.0 AUDIT COMMITTEE CHAIR’S REPORT DB presented an overview of the Audit Committee Meeting which took place on 23 May 2018 and highlighted the following: The paper presented provided an overview of the discussion during the meeting The Head of Internal Audit Opinion was one of ‘significant assurance with minor improvement’ 7. The Committee reviewed at length the Annual Report, Quality Account and Any Other Annual Accounts Gus Miah, Head of External Audit was complimentary about the Trust’s financial performance and there was a clear opinion on our Annual Accounts and limited opinion on the Quality Account as that is all they are required to provide.
The Board noted the update and assurances provided 8. 24/05/12.0 CHAIRS REPORT - RISK MANAGEMENT COMMITTEE Date and Time CB presented an overview of the Risk Management Committee which took place on 9 May 2018 and highlighted the following: There had been a focus on the Corporate Risk Register which is going to be
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reviewed and brought back to the next meeting The Board Assurance Framework had been received and considered The final version of the Annual Governance Statement had been received and approved.
The Board noted the update and assurances provided 2. 24/05/13.0 INTEGRATED PERFORMANCE REPORT – M1 LP thanked the information team for the turnaround of this report in its new format. LP Strategy & highlighted the reading guide and additional SPC charts. For Month 1 there were some exceptions in quality indicators but the majority remained within or exceeding target. The activity levels had been low but in line with plan and the financial performance was ahead of plan.
Caring for Patients 3.
BT highlighted the following: Performance & There had been one serious incident reported, the IG breach previously highlighted during the Chief Executive’s Update. There had been three Category 2 Pressure Ulcers which were being taken through an RCA process Delayed discharge rates had improved with those delays being seen often associated with issues external to the Trust There had been one E.coli bacteraemia 4. One unexpected death had occurred following a cardiac arrest. This had been Quality & assessed against the Trust’s serious incident criteria and is going through the learning from deaths process and will report back through the Quality and Safety Committee 28 day readmissions have seen a spike in relation to spinal patients and a Matron and Clinician have reviewed all of these cases to identify any themes or
trends with nothing found to link the cases together. 5. Annual CB asked about the new metric regarding urinary tract infections associated with catheters. BT confirmed this is in response to the Safety Thermometer definitions.
HT asked about the WHO checklist KPI that is now included in the report. He thought the Trust was fully compliant prior to the CQC inspection. BT confirmed the Trust has always audited this but the CQC inspection highlighted the qualitative aspects of this
audit and the team are therefore strengthening these areas. 6. Items to note NJ highlighted the following: Patients waiting over 52 weeks - On 17 May a patient was identified who had not previously been picked up, this patient has since had their surgery but it took the total number of breaches for the month to two RTT 18 weeks – the Trust sustained the total number of patients on the waiting list and an RTT rate of 90% within 18 weeks 7. Inpatient activity – the theatre activity plan was met. There was a complex case Any Other mix in month and this is reflected in a number of KPIs i.e the average length of stay, day case mix and the average number of cases per session. Notwithstanding this, performance was within a normal variation.
Caring for Finances CM highlighted the following:
The Trust was £186k ahead of plan in month although in a deficit position which 8.
was planned for. Date and Time The case mix was strong and that contributed to additional income along with increased private activity
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A £3.6m programme of cost improvements has been identified and this is ahead of plan for April, with £369k of efficiencies.
Caring for Staff SS highlighted that all the KPIs are green for Month 1 and she extended her thanks to the team and sider staff for their efforts. 2. Strategy & HT commented that there must be recognition for the great improvement in the staffing KPIs
The Board noted the update and the noted the assurances provided. 24/05/14.0 ANNUAL REPORT (INC QUALITY ACCOUNT AND ANNUAL ACCOUNTS) SR presented the Annual Report and advised that there had been oversight of the 3. various drafts of this from the Audit Committee, Risk Management Committee and Quality and Safety Committee. Performance &
The Board approved the Annual Report. 24/05/15.0 BOARD GOVERNANCE PACK SR presented the Board Governance Pack and advised that this had been updated to reflect changes to the Terms of Reference of the Assurance Committees over the
previous 12 months. In particular, SR highlighted the change in membership / 4.
attendance requirements to the Risk Management Committee where the Executive Quality & Directors have been buddied up.
The Board approved the Board Governance Pack 24/05/16.0 PROVIDER LICENCE DECLARATIONS SR presented the Provider Licence Declarations that are required to be made by the Board on an annual basis. SR confirmed that these had been circulated to the Council of Governors for comment but that all were content that the statements made were 5.
accurate. Annual
The Board approved the Provider Licence Declarations and noted that these would be uploaded to the Trust’s website. QUALITY AND SAFETY 24/05/17.0 SAFER STAFFING UPDATE
BT presented the Safer Staffing Update and advised that the Trust is still seeing low 6. percentages of registered nurse fill rates in MCSI Wrekin, Gladstone, Powys and Clwyd. Items to note There are plans in place to upskill the newly qualified nurses in order that the percentages can be balanced across nights and days.
BT advised that the Trust is still looking at the solution for IPAMs to ensure that acuity can be adequately monitored. The current IPAM system is still being utilised but alternative solutions are being looked at. 7.
BT confirmed that the Trust continues to triangulate its incident reporting and harms with Any Other its staffing levels. All staffing incidents are recorded as red flags and reviewed by the Ward Managers and there had been no harms for the reporting period.
BT highlighted the work being done with Alice Ward in relation to actions from the CQC feedback. A business case has been formulated to uplift the B5s to B6s and this is being presented to the Executive Team next week. 8.
BT confirmed that the next steps are around the continued e-rostering roll out and the Date and Time ongoing review of the IPAM solutions.
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FC asked about timescales regarding the e-rostering roll out and BT confirmed that good progress has been made. This was originally a two year project but there are opportunities to widen the scope, particularly with regard to medical staff. NJ added that the Operational Excellence work stream is looking at this.
HT asked about the decision taken last year to change the mix of staff on nights. BT 2.
advised the issue is vacancies and so the focus is on getting the vacancies filled and Strategy & staff to the level of competency required to work nights. BT confirmed the Trust is not currently compliant with the 1:8 requirement on nights but there are mitigations in place to address this.
DG commented that an internal audit report picked up on staff monitoring and that there is currently inflexibility in the way the numbers are reported but staff are used flexibly. 3. The Trust is therefore not taking into account the wider staff available to support and therefore in some instances the staffing levels are underreported. Performance &
The Board noted the report 24/05/18.0 CQC UPDATE BT confirmed that the Trust is still awaiting the final report and the paper presented is the updated report which is overseen by the Quality and Safety Committee. 4.
The Board noted the update. Quality & 24/05/19.0 CONSULTANT APPRAISAL REPORT SS presented the Consultant Appraisal Report on behalf of SW. The Trust is fully compliant with all requirements and 100% compliant with the appraisal rates for medical staff. SS commented that this is an excellent position to be in but there is no complacency and a lot of effort is still going into how the appraisal process can be improved. 5.
Ruth Longfellow, Consultant Lead and Jo Bayliss, Training Manager were thanked for Annual their preparation for individuals and for ensuring that appraisers are given full support and development.
The Board noted the report. 24/05/19.0 STP UPDATE MB advised that the consultation on Future Fit is opening on 30 May, this remains the 6. focus of the STP. KR will be pulling the Trust’s response together. Items to note MB confirmed that clarification around the leadership of the STP in the form of an independent Chair is still awaited.
The Board noted the update.
ITEMS TO NOTE 24/05/20.0 AOB 7.
BT highlighted PJs for Paralysis campaign and thanked staff for their support with this Any Other DATE OF NEXT MEETING: Thursday 26 July 2018 at 11 a.m. in the Meeting Room 1. CHAIRMAN’S CLOSING REMARKS FC thanked everyone for their contribution and closed the meeting. 8. Date and Time
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BOARD OF DIRECTORS MEETING 24 MAY 2018
SUMMARY OF KEY ACTIONS 2. Outstanding Actions from Previous Meetings Lead Progress Responsibility Strategy &
Actions from Last Meeting Lead Progress Responsibility
24/05.05 PATIENT STORY 3.
BT to look at the following: Director of Performance & potential overlaps in the pre-operative Nursing assessments and whether these can be consolidated. the checking in of belongings the issue of disturbances at night 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
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IM&T Digital Strategy 2018-2023
0. Reference Information 2.
Simon Adams, Strategy & Author: Associate Director of Paper date: 26th July 2018 IM&T Kerry Robinson, Executive Sponsor: Director of Strategy and Paper Category: Governance Planning
Paper Reviewed by: IM&T Steering Group Paper Ref: N/A 3.
Forum submitted to: Board of Directors Paper FOIA Status: Confidential Performance &
1. Purpose of Paper
1.1 Why is this paper going to Trust Board and what input is required? The Trust Board are receiving the IM&T Digital Strategy 2018 – 2023 for approval. 4.
2. Executive Summary Quality &
2.1 Context Information Management, Governance and Technology (IM&T) plays a pivotal role in supporting the achievement of strategic change in the way health and social care services are delivered. It is essential that informatics investments are driven by service plans in order
that information and technology is successfully exploited. 5.
This document outlines the IM&T Strategy for the Robert Jones and Agnes Hunt Annual Orthopaedic Foundation Trust (the Trust) 2018 – 2023. It provides an overview of the Trust’s position with a local and national focus, highlighting the organisations IM&T work programme which will facilitate delivery against national and local targets. The strategy describes the range and complexity of the Trust’s IM&T work agenda for the next five years and beyond. This IM&T strategy has been developed in response to local and national policy initiatives and is fully aligned with the Trust Organisational Strategy. 6.
This strategy supports and underpins the organisational strategy. These are prioritised into Items to note four key areas: Operational Excellence. Local Musculoskeletal Services. Specialist Services. Culture and Leadership. 7. The Trust is committed to harnessing information and new technologies to achieve higher quality care and improve outcomes for patients and service users alike. Any Other
2.2 Summary
The strategy sets out a roadmap for the delivery of key elements that are required in order to meet local and national need, ensuring that the Trust have safe and secure systems which enable the patient to be in control. 8.
The IM&T Digital Strategy has been through internal review with clinicians and has been Date and Time approved at the May IM&T Steering Group.
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IM&T Digital Strategy 2018-2023
2.2 Conclusion The Trust Board are asked to review and approve the IM&T Digital Strategy 2. Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
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14 1. Public Meeting Part One - 2. Policy Strategy & 3. Governance Performance & 4. Safety Quality & 5. Reports Annual 6. Items to note 7. Business Any Other 8. of next Date and Time
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IM&T Project Management...... 15 2. Policy Strategy & Contents Finance ...... 15 Strategic Context...... 3 Benefits ...... 16 Summary ...... 3 Core Principals...... 16 3.
Introduction ...... 4 Governance Performance & Risks...... 16 Baseline, Current position...... 5 Governance & Monitoring Progress...... 17 Drivers for IT...... 5 Timetable ...... 18
IT Strategic Objectives...... 6 4. Conclusion...... 20 Safety Quality & Consuming Data ...... 7 Securing the Data: Empowering the Patient, Enabling the Clinician...... 7 Shared Working across organisational boundaries...... 9 5.
Systems and Applications...... 9 Reports Annual Access to data - Using Business Intelligence (BI)...... 11 Good Analytics ...... 11
Empowering the Users ...... 11 6. Items to note Dashboards ...... 12 Approach to Design...... 12 Digital Citizens and Patients...... 12 7.
Artificial Intelligence...... 13 Business Any Other Digital Champions – Staff at the Centre...... 13 Wearable Technology...... 14
Local Infrastructure ...... 14 8. of next Date and Time
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Strategic Context Summary Policy Strategy & Information Management, Governance and Technology (IM&T) plays a At RJAH the Trust vision is aspiring to deliver World Class Patient Care. pivotal role in supporting the achievement of strategic change in the way The Trust recognise the need to provide the best systems and processes health and social care services are delivered. It is essential that to enable their staff to excel, and for patients to receive the best possible
informatics investments are driven by service plans in order that outcomes. 3. information and technology is successfully exploited. This document Governance Performance & outlines the IM&T Strategy for the Robert Jones and Agnes Hunt Our IT systems and applications support the Trust and patients together Orthopaedic Foundation Trust (the Trust) 2018 – 2023. It provides an with the wider health economy in driving better healthcare and outcomes overview of the Trust’s position with a local and national focus, for all and must continue to do so. highlighting the organisations IM&T work programme which will facilitate 4. This strategy focuses on the delivery of optimum services within our Safety Quality & delivery against national and local targets. The strategy describes the hospital and community settings, supporting the development of an range and complexity of the Trust’s IM&T work agenda for the next five integrated musculoskeletal pathway and as such recognises the years and beyond. important role that IM&T will play in driving better care. This IM&T strategy has been developed in response to local and national 5. It is recognised that there are many challenges in the provisioning of Reports Annual policy initiatives and is fully aligned with the Trust Corporate Strategy services. We must ensure that data is kept secure, enabling standard This strategy supports and underpins the organisational strategy. These driven pathways and integrated systems which are accessible to both are prioritised into 4 key areas: clinicians and the public in whichever care setting they choose. 6.
RJAH will ensure that investment is used wisely; developing partnerships Items to note Operational Excellence. with other organisations, procuring systems and technology that will Local Musculoskeletal Services. improve and enhance us as a specialist provider of integrated Specialist Services. orthopaedic services.
Culture and Leadership. 7.
This will enable RJAH to drive safe capture of data, enabling good decision Business Any Other The Trust is committed to harnessing information and new technologies making through the use of business intelligence, improving outcomes for to achieve higher quality care and improve outcomes for patients and our patients and driving operational efficiencies that ultimately lead to an service users alike. excellent service. 8. of next Date and Time
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g. High quality Information Governance owned by the staff 2.
Introduction Policy Strategy & The Trust is committed to the development of robust and sustainable operating within the Trust. IM&T to support the delivery of the best possible care for patients. This will take a timescale beyond the life of this strategy to achieve, This strategy supports the long-term goal of developing and however the steps taken in this strategy will move the Trust significantly nearer this state. 3. implementing integrated care pathways and informatics enabled decision Governance Performance & support. Acknowledging that this is best approached incrementally, the This strategy commits to supporting the Trust, its staff and patients by: medium and short-term goals are to improve information systems functionality along with the underlying infrastructure access, Developing and maintaining solid, robust and reliable systems performance and reliability. Fundamental to the success of this strategy is infrastructure. 4. Safety Quality & maximum participation by our staff to overcome any barriers that might Placing greater emphasis on information systems improving patient prevent us from using technology to the full. The strategy will help to care and supporting clinical processes. establish a modern performance focused environment keeping the Trust Facilitating the enhancement of an electronic patient record. at the forefront of the provision of clinical care, education and training. Providing clinicians with on-line and mobile access to patient records 5.
and results, online booking, ordering and administrative services. Reports Annual Our overall IM&T enabled healthcare vision encompasses: Enhancing management information to facilitate the most effective a. Radically improved informatics solutions to support clinicians and use of NHS resources. clinical practice including the procurement of a new Patient Aligning and integrating clinical and business information systems to
Administration System and enhanced electronic patients enable informed organisational decisions to be made. 6. Items to note recorded solution. Migrating the Trust towards an electronic communications b. Provision of a reporting solution to enable real time, cost and environment to reduce reliance on paper records and documents. activity analysis across a wide spectrum. Ensuring that there is a robust workforce plan which addresses any c. Paper-light working across the Trust and community settings with potential skill mix issues ensuring IM&T staff resources are fit for 7.
wide scale electronic access to personal records. purpose. Business Any Other d. Seamless patient care supported by exchange of electronic Establishing operational and security policies enabling staff to work patient centred information between the Trust and other effectively and confidently with person identifiable data including providers/ partners across the health sector as a whole. anonymisation and pseudonymisation.
e. Improved handover arrangements for medical and nursing staff. Providing customer focused service for all aspects of IM&T. 8. f. Effective knowledge management. of next Date and Time
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It is recognised that technology changes and expands at a significant rate, Adoption of electronic pre-op techniques has begun, with the next stage 2. Policy Strategy & resources, over and above those committed at present will be required to seeking to manage low risk patients at home prior to surgery negating the deliver this strategy. need to attend a site visit and carrying out much of the consultation and data gathering remotely.
The Trust have a large number of end user devices available which 3. Baseline, Current position Governance Performance & The Robert Jones and Agnes Hunt (RJAH) has progressed towards an compare favourably with its peers, and is a sign of the investment that integrated digital record. It has been possible since the late 1990’s to the Trust has committed to over the last 3 years. record information electronically and to view the record within the Over the next five years the Trust will continue to invest in staff, systems, hospital environment. As time has moved on the record has developed, 4. application and infrastructure with the main focus dealing with migrating however the technology used to develop the record has altered over Safety Quality & to a new electronic patient record, incorporating improved structure time, and the need to look at a “whole system approach” needs to be clinical noting, introduction of a full order and reporting communications adopted, not just with Trust systems, but wider. system with electronic workflow with access and integration to wider
Traditionally the Trust has used a number of differing systems, with health systems for both staff and patients. 5. partial levels of integration, which whilst this permits a view of the Reports Annual patient record it is not always effective from a user perspective due to the additional complexities of identifying all the relevant information Drivers for IT when viewing the patient record in context. The NHS has had ambitions for many years to create an electronic record, allowing patients to access key information, and for other clinicians, 6. The Trust has commenced removing the traditional paper record ensuring regardless of care setting to also be able to access relevant information to Items to note that the historical note has been scanned and available through secure enable them to treat the patient safely and in a timely fashion improving electronic medium. Electronic observation systems have been patient outcomes. A change in culture and mind-set will be required, in implemented and now automatically file within the electronic patient which our health and care professionals, partners and systems recognise 7.
record upon discharge of the patient. that information in care records is fundamentally about the patient so it Business Any Other becomes normal for patients to access their own records easily. Theatre resource and stock management are managed electronically, allowing the utilisation of individual stock items to be recorded and assist RJAH have recognised that it needs to enhance and replace some of its in the process of reordering. systems if it is to continue to flourish and share information safely and 8. of next Date and Time
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19 1. Public Meeting Part One -
securely across the community as it works with its partners to develop The “Five Year Forward View” gives insight into new models of 2. Policy Strategy & new models of care. care, and starts to close the circle on Health and Social Care so it acts as one united entity. Data must be made available to relevant parties, including citizens and Lord Carter of Coles report “Operation Productivity and patients enabling them to make informed choices over their care. By
Performance in English NHS acute hospitals: Unwarranted 3. publishing and making relevant information available in easily understood variations” looks at efficiencies and how organisations can Governance Performance & formats will maximise benefit to all. improve. Dame Fiona Caldicott published the report “Review of data security, consent and opt-outs“ which addresses concerns patients and citizens may have with how their data is handled 4. Safety Quality & Secure & and used and ensure protocols are in place to enable providers to Integrated give the best possible care and ensure patients confidentiality is maintained. Professor Wachter and the National Information Board published 5.
a report, “Using information technology to improve the NHS” Reports Annual Capture IT which analysed how the NHS can improve their use of technology Information Enables Supports at Point of Change Care Transformation and to look at how investment is used to maximise benefit.
RJAH are already working closely with our neighbouring Trusts and GP’s in 6.
how we deliver care through the delivery of the Sustainable Items to note Transformation Partnerships and the development of a local digital Delivers Safety & roadmap, ensuring that it is safe and delivers an excellent outcome to the Quality patient. 7.
The IT Digital Strategy supports the Trust aims and vision. Business Any Other There are a numerous reports that have been published that share a vision for how the NHS needs to change and adapt for the future. IT Strategic Objectives
The Trust requires consistent and quality digitised health records that can 8. of next Date and Time
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20 1. Public Meeting Part One -
be made visible to all involved in the delivery of patient care without the It is now expected that all organisations will have a website - email is 2. Policy Strategy & need for duplication. already considered “old” by the under thirties who will use social media to contact friends and organisations. Websites can no longer just be static The high level objectives and aims are to support the Trust information; they need to provide a portal to the organisation. Social
media routes need to enhance and enable safer two way interaction 1. Remove the need for the citizen, patient or staff member to 3. duplicate information. between RJAH and patients if desired. Governance Performance &
2. Provide a single source of information, for both clinical records Organisations have had to adapt and the NHS is no different. RJAH will and performance information, for them to fulfil their role ensure that patients and citizens have the opportunity to interact with
effectively; the Trust via a safe and secure channel of their choosing. 4. Safety Quality & 3. Ensure data is available in real or very near real time in order to RJAH will enable enhanced communication routes, with video take effective and proactive decisions prior to “crisis” points conferencing and messaging facilities made available to enable patients being reached. to interact with professional and clinical staff where safe to do so. 5.
4. Provide access to that information securely and quickly at the Reports Annual point of care for both clinicians and citizens. Securing the Data: Empowering the Patient, It is essential that the systems we use are secure, enabling citizens, Enabling the Clinician patients and staff to know that information stored is only available to Data must be protected ensuring that it is safe and secure from malicious parties that may wish to intercept the data for their own ends. 6. those that are authorised to view. It should be possible to enter data into Items to note the systems in a structured format the enables audit and workflow to RJAH recognise the importance of ensuring that data remains protected take place seamlessly. and puts this at the heart of its strategy - the need to ensure that personal information remains that, personal. 7.
Consuming Data Cyber criminals continue to pose a risk and increased awareness shows Business Any Other The way that IT and data is consumed by citizens has altered dramatically that attacks on bodies such as the NHS may become increasingly over the past 20 years. Google had barely been heard of, people would common. The fact that networks are under threat and need to be use a phone to contact companies and had only just began to use email protected is clear, what the NHS and RJAH seek is to be one step ahead to contact organisations. Very few people had considered ordering their and ensure that vulnerabilities are managed and data remains safe. 8. grocery shop online let alone set up repeat orders. of next Date and Time
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21 1. Public Meeting Part One -
RJAH will continue to invest, ensuring that staff are trained in both the 2. Policy Strategy & technical ability to protect information, and that all staff understand the Unlocking the Data need for confidentiality and that they must be trained to be able to interpret human vectors, such as phishing emails, and to respond Other NHS appropriately. Bodies 3. Governance Performance & Dame Fiona Caldicott in her latest report stresses the need to ensure that Secure data is protected and that only authorised staff can access the GP Trust information. Data
RJAH are committed to ensuring data remains secure and will ensure it 4. Safety Quality & Other services meet the CyberCERT standards as set out by Dame Fiona Care Providers Caldicott.
As part of any system replacement RJAH will embed the principals of 5. rd
Caldicott within the terms of the contract with 3 parties ensuring that Reports Annual Secure Hosting of Applications: There are a number of accredited data consent where required can flow from system to system and is fully centre suppliers which have the ability to provide or host systems on auditable. Patients will be in control of who can access their record when behalf of RJAH. Some of these service agreements are commonly called it crosses organisational boundaries. When they consent, the consent will “hardware as”, “software as” service contracts. They can be taken out for flow through the system, reducing the need to repeat information 6. short durations or longer terms and enables the Trust to migrate from gathering and enabling clinicians to make informed decisions based on Items to note existing hardware on site to a secure facility should the need arise. good quality data and ultimately lead to better outcomes. There is clear benefit in terms of security in relation to this type of facility. The service providers are dedicated and invest time and money in their facility and staff ensuring that it meets the highest standards. It will be 7. Business Any Other audited on a regular basis ensuring it meets ISO accreditation or other appropriate security standards. It removes single point of failures and can provide access to data securely from multiple locations without the need
to reinvest in additional infrastructure. 8. of next Date and Time
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22 1. Public Meeting Part One -
The facilities are architected to ensure that should elements of the to the end user device being critical to the successful delivery of clinical 2. Policy Strategy & system fail due to the design architecture the system and applications will data. continue to function, essential when delivering healthcare with further reliance being places on IT for the delivery of services. Data will need to be stored in such a format that allows systems to easily access but remain secure. Vendor neutral archives will be considered in RJAH intend to migrate services to secure cloud based technology where the future so that data can be stored in standardised formats without the 3. Governance Performance & the business case supports the change. need to migrate to different storage formats when systems are replaced.
Single points of failure within the current infrastructure must be Shared Working across organisational boundaries. analysed, risk assessed and where appropriate provide alternate methods of connectivity as we migrate to electronic delivery of information for 4. Traditionally data tends to reside within the organisation, but as systems Safety Quality & need replacing it is appropriate to review location and also who should patient care. manage the data. Systems and Applications Collaboration with other organisations in the future will be key and Currently RJAH have over 200 applications and systems in use. Some of 5.
working with other NHS organisations is essential. Sharing how systems these may range from having over 500 users, to just one. As we migrate Reports Annual are developed and implemented enables efficiencies at all sites ensuring to electronic delivery of information from paper based, we need to good models of care and effective use of resources. ensure that systems and applications are fit for purpose and can be supported and are appropriately managed. Utilising the same systems across organisational boundaries and sharing 6. the infrastructure makes sense from all perspectives; patient, employee, RJAH will work to rationalise the list of applications, ensuring that a Items to note quality, and financial. standard list of supported applications exists for users, enabling a standardised set of support measures to be defined. Infrastructure must be capable of delivering data to the end user device
with speed. Traditional hardwired devices are already transitioning to Investment in technology enables new models for delivery of care. It 7. wireless connectivity methods placing an increased demand upon the enable new models of care to be developed, standardising pathways and Business Any Other wireless network which will need to be considered for future facilitating more “remote” access to services, be it the clinical member of infrastructure. staff attending a remote clinic, having full access to the hospital systems, or a patient having access to the hospital via different interfaces, such as
Fibre backbones, the roads on which the data travels, must not be a 8. video consultation for follow up. bottleneck with speed between the server and application environments of next Date and Time
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23 1. Public Meeting Part One -
Over the next five years the Trust are seeking to acquire a new fit for available (such as Child Protection Information Services) and accessible to 2. Policy Strategy & purpose integrated Electronic Patient Record, enabling greater cross support frontline care, individual self-management, planning and boundary working to deliver the sustainability and transformation research. programme within the area, a move to a digital platform is required to allow improved patient flow and access to information. It is essential that the systems we use are secure, enabling citizens, patients and staff to know that information stored is only available to 3. Governance Performance & The Trust requires consistent and accurate digitised health records visible those that are authorised to view. It should be possible to enter data into to those involved in the delivery of patient care. This will include the the systems in a structured format the enables audit and workflow to ability to digitally add (and not just scan information) to the clinical take place seamlessly.
record using digital assessments, forms and clinic notes, stopping the 4. In order to enable greater cross working within the STP a move to a paper management life cycle. Safety Quality & digital platform is required to facilitate the capture of information to 1. Provide colleagues with a single “digital” source of information, enable both improved patient flows and enable clinicians at the point of for both clinical records and performance information, for them care to have a view of the citizen / patient.
to fulfil their role effectively; 5.
2. Ensure digital data is available in real or very near real-time in The overarching aim of the will be to provide as solution that enables: Reports Annual order to take effective and proactive decisions prior to “crisis” Single patient record. points being reached. Improved quality and safety within the Trust through enhanced 3. Provide access to that information securely and quickly at the decision support and secure systems. point of care for both clinicians and citizens. 6. Improve the workflow management to speed up the patient Items to note 4. Remove the need for the citizen, patient or staff member to pathway, resulting in improved efficiencies in staff time, allowing duplicate information. a single context patient view. 5. Improve workflow within the organisation, enhancing the Improve recording of outcomes and subsequent monitoring in pathway and experience for the staff and patient. order to demonstrate clinical benefits. 7. Business Any Other The aim is to allow other service delivery partners to interact with, and Interoperability with other providers of care to allow a real-time share, information within a patient’s journey, where the patient has view of the citizen in different settings in a secure manner. permitted with more emphasis on access and update to shared care Improve the Trusts and the local health economy ability to plan for future demand and growth. records. Giving a prominent role to the implementation of the shared 8. care record will provide a vehicle to make information more widely of next Date and Time
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24 1. Public Meeting Part One -
Data from patient monitoring equipment should be enabled to allow the 2.
Good Analytics Policy Strategy & data to feed the patient record without the need to duplicate and re- The most effective way to deliver BI is to surround the data warehouse enter that data, be it from blood pressure to data from anaesthetic (DW) with tools that allow analysis of the data directly, these tools can monitors. range from a simple excel spreadsheet linked to a data source to a fully
integrated online analytical processing (OLAP) linked through dashboards. 3. Secure and adequate bandwidth to provide appropriate speed to cloud Governance Performance & based application is essential ensuring that data is readily accessible for A reporting solution, is currently in the process of being implemented and clinicians and patients. is scheduled to complete over the next 12 - 24 months to help improve the reporting throughout the Trust. This will provide one place to view Investment in technology enables new models for delivery of care. It
reports and consistency for users. It will also help to highlight data quality 4. enable new models of care to be developed, standardising pathways and issues throughout the systems to enable quick resolutions. Safety Quality & facilitating more “remote” access to services, be it the clinical member of staff attending a remote clinic, having full access to the hospital systems, Empowering the Users or a patient having access to the hospital via different interfaces, such as BI will empower discovery, operational reporting, ad-hoc queries, video consultation for follow up. visualisations (Dashboards), data-mining, and true analytics such as 5. predictive model. The need to understand the requirements from service Reports Annual The end user devices already deployed can be reviewed at the users will be paramount in the design of the model, enabling users to appropriate point in the lifecycle and are already capable of working with carry out extensive analysis of data. the integrated systems. Improved interfaces to devices enable new ways of working, such as voice activation / dictation etc. The Trust will consider new and emerging trends in the how data is 6. Items to note managed, for example data lake as it continues to develop.
Access to data - Using Business Intelligence (BI) The Trust will need to develop properly designed data models for the The implementation of a new data warehouse and the replacement of end-users. We would also want to provide data dictionaries, metadata, legacy systems is key to providing a platform for delivering good quality, and common business definitions. Data will be derived from a variety of 7. Business Any Other timely and relevant information to managers and clinicians. The Trusts sources, including but not limited to systems such as the electronic staff data warehouse has been designed to support Business Intelligence (BI). record (ESR), outcome information, pharmacy etc. In additional to internal sources of data information from external sources will need to be reflected without our management data ( e.g. . GIRFT) 8. of next Date and Time
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25 1. Public Meeting Part One -
The development of the data warehouse will enable the trust to define 2. Policy Strategy & complex data models which enable the trust to run simulations of different case scenarios.
The data schema to support this requirement is already in place within the DW for some services/teams and will be further developed to support 3. Governance Performance & other Trust services.
The Trust are standardising approach to dashboard design based on Microsoft SQL Server Reporting Services (SSRS) . 4. Approach to Design Safety Quality & In order to encourage dashboard usability by staff and patients, we need to start with the basics: what they have now, what they would need to shift to a new system, and what they ultimately want. Staff and patients 5.
should also participate in the development, testing, deployment and Reports Annual Training programs will be created to enable staff to perform and execute training phases of dashboards. reports enabling them to analyse the data and extract meaning. The dashboard development will require an iterative design approach Self-service users will need to have confidence in the data quality and will that involves getting the requirements, prototyping the design (with the 6. need be informed when new data sets/ uploads are available. data), getting user feedback, refining the design and then possibly doing Items to note it all over again. This process will take time but the longer term benefits Dashboards have become the default performance management will include reduced demands on the Information team. applications and are increasingly used to report information to users
without the need to request. Developing a dashboard that doesn't have the data which the user is 7.
looking for is worthless. While the dashboard is being developed it’s Business Any Other Integrated dashboard design that provides discovery, operational important to make sure resource is identified to focus on getting the data reporting, ad-hoc queries, visualisations (dashboards), data-mining, and and data quality issues resolved. true analytics are key. There is opportunity to gain greater business
insight through the analysis of information provided in a consumable It’s important that the Trust define the relevant key performance 8. fashion. indicators (KPIs). We must ensure that we get the level of detail needed of next Date and Time
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26 1. Public Meeting Part One -
to define the KPIs and ensure that those metrics are validated. If the Remote check in for clinics at RJAH can be improved allowing check in via 2. Policy Strategy & Trusts dashboard is to be relevant, it will need to be a consistent, single smart phones. version of the truth. Access to coded discharge information readily available in the future so Users will often want to drill into the details beyond the data to that patients know their GP’s have received them without the need to determine what action is called for. A report or graph displaying trends visit. 3. Governance Performance & should be the focal point within the dashboard supported with drill into the detail functions. Artificial Intelligence The dashboard will need to help users take action. The dashboard will Artificial Intelligence (AI ) is a term used to define machine learning. It is only be an information source, the action that produces the results that is 4. recognised that the power of AI within the NHS can offer immense Safety Quality & most important. benefits to patients, potentially assisting in the early identification and diagnosis of ailments.
Digital Citizens and Patients Whilst the NHS is not at the stage of being able to realise the full benefits 5.
As we move to an integrated system patients will be able to get greater at this time and RJAH understands the need to capture the initial data is Reports Annual access to their record, either via the GP or through a portal that enables a crucial if we are to leverage the power from this technology. “wider” view, for example, reducing the need to review medication lists when arriving at hospital. In order for the NHS to benefit from such progressive use of data it must ensure that it captures data consistently so that when the data is 6.
In the future the patient will be able to grant who has access to the analysed it can be mapped and understood. Items to note record, keeping them in control and at the same time ensuring that they can get the best possible care and outcome from the system. There is a high level of scrutiny in this area from both the public and media, and the Trust will ensure it maintains the highest standards.
Citizens will be able to view data from the Trust that enables them to 7. Whenever RJAH undertakes any sharing of data with 3rd parties it will be make informed choices over their care, from viewing a video of what a Business Any Other procedure may encompass, to completing outcome forms that enable a conducted in a transparent fashion, abiding by the standards set out by clinician to inform a treatment plan. the Information Commissioners Office. Consent for the sharing of any personal information must be obtained before sharing can commence,
Future appointments will be able to be booked or rearranged via a simple and where data is being shared anonymously be aware of what data is 8. to use interface, either via text or from a website. being shared and why, ensuring that trust is maintained. of next Date and Time
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27 1. Public Meeting Part One -
The true power of AI is in the future but we must start now if we are to RJAH are committed to investing in staff and ensuring that they are fully 2. Policy Strategy & realise it benefits. trained on the applications they use. Whilst we train our staff in the use of the applications, we will also keep them up to date to ensure that they know how to keep the data safe. Digital Champions – Staff at the Centre As we develop and migrate to an integrated system approach, staff will 3.
If staff are not effectively engaged in systems and applications the Trust Governance Performance & will struggle to implement and get any system to work effectively. The be able to access the data and manage patients without the need to Trust will ensure that we engage and get staff to lead technological consult back to paper records – with all relevant data being available developments, with IT assistance, and ensure that technology is not seen through the one interface.
as the answer but as the enabler for change. 4. The types of devices made available to staff must be appropriate; it is Safety Quality & The Trust has introduced the role of a Chief Clinical Information Officer to recognised that “one size” will not fit all and it will be necessary to work alongside IT. Whilst this is currently fulfilled by one individual, the provide a variety of devices depending upon the setting – laptop, tablet, Trust recognises the need that this position will need to grow and adapt desktop smartphone. In the future it could be glasses – whilst this and may require to have more than one and from different disciplines. technology is new today in five years it could be common place in the 5.
future. Reports Annual A programme will be established to engage with users and encourage their development in order to create “digital champions” within the Key to the use of all of the systems is the need to keep the data “real workforce. time” wherever possible. Staff involvement in the implementation and
management of systems is actively encouraged as we move forward to 6.
Through participation in events staff will be encouraged to assist in IT ensure that the best possible workflows for systems can be incorporated. Items to note style projects to actively help develop and foster new ways of working across the organisation, encouraging their colleagues to develop and Wearable Technology adopt new processes to maximise use of systems and applications. Ensure The use of technology will lead to different care models and this includes that staff help design the workflows maximises the opportunity of success patients using technology to either monitor their own conditions, or to 7. with new systems and ensures we don’t just replicate what happened on assist the clinician in monitoring the effectiveness of a treatment. Business Any Other paper. Technology already exists to monitor orthotic wearable “supports”, the At RJAH we realise to get the best from applications users need to data can be analysed to ensuring that the patient is getting the best use understand and want to use the system. from the device. 8. of next Date and Time
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Technology in this area is moving at pace and RJAH seek to be at the 2.
IM&T Project Management Policy Strategy & forefront and working with patients and suppliers to ensure that data is The procurement and implementation of computerised informatics captured safely and securely and available to the clinician to improve the systems and technology is often complex involving not just the resolution outcomes for the patient. of technical matters but also fundamental changes to business processes
and working practises in the departments concerned. It is essential that 3. Secure follow up video consultations will be available to those patients such projects are properly controlled and that roles and responsibilities Governance Performance & which may benefit, reducing the need to travel to site, having any tests within them are appropriately defined in order that implementation is locally and reviewed by a consultant at RJAH prior to the follow up. effective and that the expected benefits are achieved. Local Infrastructure Key features include: 4.
Network Safety Quality & As equipment reaches end of life, provision of new infrastructure needs Effective change management through integrated planning and to be planned. Priority areas for investment will be the replacement of implementation. the network with a resilient core and edge network including digital voice A focus on the business change objectives rather than system
(voice over internet protocol – VOIP), with a manged service wrapper to implementation, with a clear path to move from current to future 5. ensure the equipment is maintained to the highest standard. business operations. Reports Annual Effective method of controlling a complex range of activities by Security and Malware Protection clearly defining roles and responsibilities for managing the These will be reviewed annually and a report submitted to the Audit project portfolio and realising the benefits expected from the Committee giving an overview of the current threat to the organisation. 6. project. Items to note This will be in a restricted session to maintain security of patient data. Achievement of business benefits through a formal process of benefit identification, management, realisation and Email measurement.
Migration to cloud based services will occur in 2018. This will enable the 7. sending of secure personal data to patients where required and the Before a project can be started a project proposal must be submitted to Business Any Other introduction of video conferencing for both internal and external use as the IM&T steering group for review. Projects are only considered if they standard. have clear senior stakeholder ownership and are able to demonstrate both criticality and viability as part of a project eligibility and prioritisation
assessment in order to deliver the organisational strategy. 8. of next Date and Time
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29 1. Public Meeting Part One - 2.
Finance Policy Strategy & Typically RJAH have invested around 1.5% of its overall budget on IT Risk 2: Change Management – The Trust need to ensure clinical through revenue and capital models. ownership of projects and then accept the ongoing business change following implementation and help adapt the systems as we move Running the IT services within a small hospital does not necessarily
forward and requirements change. 3. equate to the same ratio as a large hospital as the same backbone o Mitigation – Introduction of the role of Chief Clinical Governance Performance & infrastructure is still required along with similar systems and therefore Information Officer/Digital Champions and adopting a 1.5% of £100m will not necessarily equate to being able to deliver a standard approach to projects and acknowledging that some similar proportion. In the future it is essential that investment is targeted projects should be stopped to enable others to succeed. and prioritised to ensure that infrastructure is capable of delivering the 4. Safety Quality & data to clinicians and patients wherever they need to access it. Risk 3: System Flexibility – Ensuring that systems we procure are capable of flex as future requirements and needs are identified we Collaborating with partner organisations on infrastructure and systems need to ensure that systems can be modified to reflect changes in a enables not only economy of scale, but opens up new methods of timely and cost effective manner. delivering care. 5.
o Mitigation – Ensuring that supplier contracts enable change Reports Annual The Trust are already active within the Sustainable Transformation and that timelines are relevant. Partnership for Shropshire and are also linking in with neighbouring NHS organisations in how we deliver care in the future, looking for economies Risk 4: Security – one of the top risks for any organisation and of scale and reducing the need for duplicate purchases of software. patient. It is essential that the Trust invest and ensure that security 6. meets approved standards. Items to note Risks o Mitigation – Ensure RJAH has CyberCERT accreditation and all The current top 5 risks in the delivery of this strategy have been identified 3rd parties hold appropriate security accreditation. and must be revisited on a regular basis. 7.
Risk 5: Resources and Prioritisation – Manged conflicts on resources Business Any Other Risk 1: Financial – Whilst the Trust has invested in IT the amounts o Mitigation – standardised approach to projects and effective required to move to an integrated system and ensure a successful programme management. implementation will be large approx. £1m per year for systems is required, with additional resources required during any transition. o 8.
Mitigation – Review access to funding via national schemes. of next Date and Time
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30 1. Public Meeting Part One - 2.
Governance & Monitoring Progress Timetable Policy Strategy & It is essential that as the Trust and the NHS migrate into a true digital age To support the introduction of new application and enhancement of whereby data is held securely at all times, and that adequate risk existing infrastructure it is necessary to develop business cases that assessments are carried out and reviewed, and where necessary verified support the investment; clearly defining the benefits that will be rd by 3 party audit. provided, broken into direct cash releasing benefit, efficiency benefits, 3. quality, safety, wider health economy efficiencies and patient benefits. Governance Performance & Without patients and staff having confidence that their data remains secure it will be impossible to deliver a useful digital record. During the first 12 months various cases will need to be established - work will concentrate on preparation of both outline and detailed models RJAH will build on the current governance model, incorporating the IM&T of an integrated approach to the provision of clinical systems, comparing 4. Steering Group and Information Governance Group that reports and the as is model with different variants. Safety Quality & monitors progress which enables the Trust Board to be fully aware and assured of the progress towards a digital record and ensuring that the Alongside this work will continue with our STP and other interested data remains secure so patients and staff can be assured. parties, as to how we collaborate in delivering systems and provide
benefits across the whole economy. 5.
RJAH will continue to invest in staff and ensure that the board receive Reports Annual reports from both the Chief Clinical Information Officer (CCIO) and Chief Detailed planning will need to be undertaken in which system to Information Officer on a regular basis. The two roles will work side by side transition and when, however one possible scenario will be to look at to ensure that systems are implemented and then managed effectively, replacing system which give greatest benefit, either from a cash or maximising the benefits and ensuring that data is manged safely and quality/efficiency perspective. 6. Items to note securely. Typically it would be expected to replace the Patient Administration Clinical ownership of the delivery is key in successful project System initially, and bring online and order communications systems at implementation and by introducing the role of CCIO this facilitate. the early phase of implementation, and would envisage this being complete within the first two years. 7. Business Any Other
As plans develop in month 6 of the year a more detailed plan for the next 18 month will be updated and presented. 8. of next Date and Time
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31 1. Public Meeting Part One - 2.
IT Digital Strategy: 2018 - 2023 Policy Strategy & Year 1 Year 2 Year 3 Year 4 Year 5
External Website Enhancement
Enhance Social Media
Communication 3. Video Conference and Messaging Governance Performance &
Digital Chanpions
Remote Access
Local Area Network Upgrade 4. Technologies Continuous Standardised Applications Safety Quality &
Cyber Cerificaiton
Secure Cloud Services Security 5. Reports Annual
Clinical Outcome Recording
Electronic EPR 6. EPR
Continuous Items to note Wearable Technology Integrated Monitoring of Patient Data
Business Intelligence Dashboard/ 7.
Reporting BI Self Service Business Any Other BI Dashboards 8. of next Date and Time
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32 1. Public Meeting Part One -
improve the efficiency and quality of the services it delivers to patients 2.
Conclusion Policy Strategy & The strategy concentrates on the need to deliver an effective IM&T and enhance the working environment for staff. service that meets the needs of the Trust. The Trust regards IM&T as a key enabler of change, it should be exploited to deliver and perpetuate
efficiency initiatives through re-investment of resources. This will serve 3. both the immediate future and longer-term processes redesign required Governance Performance & for the changing health and social care models.
The changes to the National Programme for Information Technology offerings has brought the Trust to a position where open market solutions 4. need to be considered, this will have a bearing on both functionality and Safety Quality & cost perspectives. Whilst the Trust works actively to highlight an appropriate solution set, it is essential to ensure that the existing solutions and infrastructures are as robust as they possibly can be in order to form a solid foundation on which to build. 5. Reports Annual
Given the ambitions, new systems must be implemented during the lifetime of this strategy. We will take an incremental approach towards implementing an enhanced integrated electronic patient record. This will 6.
include the deployment of a modern PAS with full clinical noting. The Items to note clinical systems interfacing will be re-engineered in order to make systems more tightly coupled with seamless integration. The Trust will become much more ‘paper light’ and the vast majority of clinical
information will start to be available electronically. The services that are 7. to be established and run in community settings will have far superior Business Any Other access to informatics systems making for far greater service potential.
The delivery of these key systems and the improvements they will enable, are important factors in ensuring that the Trust is able to continuingly 8. of next Date and Time
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33 1. Part One -
Month 3 Integrated Performance Report 2.
0. Reference Information Strategy &
Claire Jones, Senior Author: Paper date: 26th July 2018 Information Analyst Laura Peill, Associate Executive Sponsor: Paper Category: Performance Director of Performance Paper Reviewed by: Executive Team Paper Ref: N/A 3. Full Performanc Forum submitted to: Board of Directors Paper FOIA Status:
1. Purpose of Paper
1.1. Why is this paper going to Trust Board and what input is required? 4. This Trust Board is asked to discuss and note the Month 3 (June) Integrated Performance Quality & Report.
2. Executive Summary
2.1. Context The paper incorporates the monthly integrated performance report with associated narrative and descriptions of key actions. 5. Annual
2.2. Summary
In line with the Trust’s Performance Management Strategy and Accountability Framework, Board-level Key Performance Indicators (KPIs) which are considered to drive the overall performance of the Trust have been agreed by committees of the Board and included in this
report. 6. Items to note There were no unexpected deaths, never events, serious incidents, cases of E.coli, C. Difficile or MRSA in June.
No English patients waited over 52 weeks in June and performance against the 18 week RTT open pathways target increased to 89.98%. A control total surplus of £235k was delivered in month which was £46k better than plan. Agency expenditure has exceeded the
NHS Improvement control total by £102k in month and £138k year to date. 7.
The presentation of the Statistical Process Control (SPC) graphs has been amended to Any Other more clearly reflect the control range and arrows comparing performance to the previous month have been removed to reduce focus on month on month comparisons.
2.3. Conclusion The Trust Board is asked to discuss and note the report. 8. Date and Time .
1
34 1. Meeting Part One - Public 2. Updates Strategy & Policy 3.
Integrated Performance Report Governance Performance & June 2018 – Month 3 4. Quality & Safety 5. Annual Reports 6. Items to note 7. Any Other Business 8. meeting Date and Time of next
35 1. Integrated Performance Report Meeting Part One - Public June – Month 3 2. Updates Strategy & Policy Contents
3. Reading guide Page 3 Governance Performance &
Trust Performance SummaryPage 4 Balanced scorecard
• Caring for PatientsPage 5 4.
• Caring for FinancesPage 6 Quality & Safety • Caring for StaffPage 7
Narrative 5.
• Caring for PatientsPage 8 Annual Reports • Caring for FinancesPage 27 • Caring for StaffPage 39
Heatmaps 6. • Caring for PatientsPage 42 Items to note • Caring for FinancesPage 45 • Caring for StaffPage 47 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 2
36 1. Integrated Performance Report Meeting Part One - Public June – Month 3 2. Updates Strategy & Policy Reading guide
The Integrated Performance Report (IPR) is designed to provide the Board with a monthly balanced summary of the Trust’s performance across the three areas of the Trust’s mission: caring for patients, caring for staff and caring for finances. To achieve this, the Trust has identified the Board-level Key Performance Indicators (KPIs), which are considered to drive the overall performance of the Trust. The report highlights key areas of improvement or concern enabling the Board to identify those areas that require the most consideration. As such, this report is not designed to replace the need for more 3.
detailed reporting on key areas of performance, and therefore detailed reporting will be provided to the Board and its committees to accompany the IPR where requested by the Board, its committees Governance Performance & or the Executive Team. Contents of the report include:
Trust Performance Summary This provides a balanced scorecard and summary of improving and deteriorating KPIs within each of the three areas of the Trust’s mission. Year-to-date and forecast performance red, amber and green (RAG) ratings are also provided in this section. 4. Narrative Quality & Safety Supporting narrative and trend graphs (with statistical process control where appropriate) are provided for each KPI including mitigating actions for red or amber rated indicators. Heatmaps ,QPRQWK\HDUWRGDWHDQGIRUHFDVWSHUIRUPDQFHDJDLQVWWDUJHWIRUHDFK.3,DQGUROOLQJPRQWKSHUIRUPDQFHLQIRUPDWLRQ£$GDWDTXDOLW\ indicator for each KPI is also included where available.
Key 5. Annual Reports Key Performance Indicator RAG Ratings Data Quality Indicator YTD: Performance meets or exceeds target The data quality rating for each KPI is included within the 'heatmap' section of this Green report. The indicator score is based on audits undertaken by the Data Quality Forecast: Little risk of missing target at year end Team and will be further validated as part of the audit assurance programme.
YTD: Performance behind target but within tolerance Green No improvement required to comply with the dimensions of data quality 6. Amber Items to note Forecast: Risk of missing target at year end Blue Satisfactory – minor issues only YTD: Performance behind target and outside tolerance Amber Requires improvement Red Red Significant improvement required Forecast: High risk of missing target at year end Trend graphs 7.
KPIs reported in arrears Any Other Business Within the narrative section of this report, each KPIs reported in arrears, for which no current-month values are available, are KPI has a trend graph (Statistical Process marked with an asterisk (*) next to their name. Control (SPC) where appropriate), which summarises performance over a rolling thirteen- The latest values for these KPIs are from the previous reporting month. month period. 8. meeting Date and Time of next
Integrated Performance Report 3
37 1. Integrated Performance Report Meeting Part One - Public June – Month 3 2. Updates Strategy & Policy Trust performance summary 3. Governance Performance &
Caring for Patients Improved – Serious Incidents – % Non-Reportable Cancellations
– Patient Falls (With Moderate or Severe Harm) 4. – RJAH Acquired E. Coli Bacteraemia Quality & Safety Decreased –% Delayed Discharge Rate – 28 days Emergency Readmissions – % Reportable Cancellations 5.
Caring for Finances Annual Reports Improved – Touchtime Utilisation – % Sessions Used Against Plan – Theatre Cases Per Session Decreased –Average Length of Stay 6.
– Agency Control Total Items to note
Caring for Staff Improved – Mandatory training
Decreased 7.
– Voluntary Staff Turnover Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 4
38 1. Integrated Performance Report Meeting Part One - Public June – Month 3 2. Updates Strategy & Policy Caring for Patients Plan Current month Previous month YTD actual Year-end forecast Plan Current month Previous month YTD actual Year-end forecast Plan Current month Previous month YTD actual Year-end forecast 3.
Cancer Plan 62 Days Standard Governance Performance & Serious Incidents 0 0 2 3 A RJAH Acquired C.Difficile 0 0 0 1 G (Tumour)* 85% 100% 0% 66.67% G
Cancer 62 Days Consultant Never Events 0 0 0 0 G RJAH Acquired MRSA Bacteraemia 0 0 0 0 G Upgrade* 85% 100% 100% 100% G
Patient Falls (With Moderate or Severe Harm) 1 0 2 2 G Medication Errors with Harm 2 2 2 5 G 18 Weeks RTT Open Pathways 92% 89.98% 89.49% 89.83% G 4.
Inpatient Ward Falls Per 1,000 Bed Patients Waiting Over 52 Weeks – Quality & Safety Days 3 2.12 2.18 2.42 G Unexpected Deaths 0 0 0 1 R English 0 0 1 G
Patients Waiting Over 52 Weeks – UTIs Associated with Catheters 5 2 0 4 G RJAH Acquired VTE (DVT or PE) 4 2 1 4 G Welsh 0 2 2 G
Patients Waiting Over 52 Weeks – Pressure Ulcer Assessments 99% 99.9% 99.9% 99.93% G VTE Assessments Undertaken 95% 99.92% 100% 99.89% G Welsh (BCU Transfers) 128 126 G 5.
RJAH Acquired Pressure Ulcers - Annual Reports Grade 2 1 2 2 7 G 28 days Emergency Readmissions* 1% 1.45% 1.13% 1.3% A English List Size 6,369 6,367 5,972 G
RJAH Acquired Pressure Ulcers - 6 Week Wait for Diagnostics - Grades 3 or 4 0 0 0 0 G WHO Compliance 100% 100% 100% 100% G English Patients 99% 99.37% 99.53% 99.21% G Patient Friends & Family - % Would Recommend (Inpatients & 8 Week Wait for Diagnostics - Welsh % Reportable Cancellations 0.7% 0.88% 0.18% Patients 100% 99.76% 100% Outpatients) 95% 99.49% 99.08% G 0.47% G 99.91% G 6.
New to Follow Up Ratio (Consultant Items to note % Non-Reportable Cancellations 2% 1.33% 2.56% Led Activity) 2.5 1.96 2.12 Number of Complaints 8 11 9 27 G 2.03% G 2.12 G Cancellations Not Rebooked within 28 Days 0 0 0 Safe Staffing 90% 96.6% 96.2% G 0 G
% Delayed Discharge Rate 2.5% 4.99% 3.92% Cancer Two Week Wait* 93% 100% 96.15% 97.96% G G 7. Any Other Business 31 Days First Treatment (Tumour)* 96% 100% 100% Mixed Sex Accommodation 0 0 0 0 G 100% G 31 Days Subsequent Treatment (Tumour)* 94% 100% 100% RJAH Acquired E. Coli Bacteraemia 0 0 1 2 R 100% G 8. meeting Date and Time of next
Integrated Performance Report 5
39 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Caring for Finances 2. Updates Strategy & Policy Plan Current month Previous month YTD actual Year-end forecast Plan Current month Previous month YTD actual Year-end forecast
Referrals Received for Consultant Led Services* 3,063 2,828 2,411 5,239 G Other Income 579 520 562 1,625 A 3.
Overall Daycase Rate 46% 46.81% 47.77% 46.68% G Pay 5,043 5,016 4,980 14,938 G Governance Performance &
101.27 % Sessions Used Against Plan 100% % 100.1% 100% G Non Pay 3,140 3,260 3,108 9,238 A
Touchtime Utilisation 82% 83.14% 81.95% 82.47% G Financing 425 426 426 1,278 G 4.
Theatre Cases Per Session 2.08 1.98 2.07 G CIP Delivery 308 357 282 1,008 G Quality & Safety
Total Theatre Activity 1,055 1,024 1,004 2,849 G Agency Control Total 305 407 374 1,015 R
Average Length of Stay 3.5 4.13 3.62 3.89 G Cash Balance 4,250 4,200 4,773 4,200 G
Bed Occupancy – Adult Orthopaedic 5. Wards – 2pm 87% 86.75% 82.95% 82.7% G Capital Expenditure 720 346 264 703 G Annual Reports
Bed Occupancy – All Wards – 2pm 83% 85.73% 82.52% 83.06% G Use of Resources (UOR) 3 3 3 3 G
8,654.2 Consultant Led Outpatient Activity 2 9,074 8,850 25,054 G 6.
Outpatient DNA Rate 5% 5.75% 5.72% 5.61% G Items to note
Financial Control Total 189 235 7 -525 G
Clinical Income from Activity 7,818 7,884 7,455 21,693 G 7.
Private Patients Income 346 478 450 1,445 G Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 6
40 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Caring for Staff 2. Updates Strategy & Policy Plan Current month Previous month YTD actual Year-end forecast
Sickness Absence 3.25% 3.4% 3.41% 3.25% A 3.
Vacancy Rate 8% 7.63% 7.6% G Governance Performance &
Voluntary Staff Turnover 8% 8.56% 8.37% G
Staff Appraisal 92% 94.3% 94.4% G 4.
Mandatory Training 92% 91.2% 90.9% A Quality & Safety 5. Annual Reports 6. Items to note 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 7
41 1. Integrated Performance Report Meeting Part One - Public June – Month 3 2. Updates Strategy & Policy Description Number of Serious Incidents Comment reported in month There were no serious incidents reported in June.
Target 0 serious incidents in month 3. Governance Performance & (Internal Monitoring)
Executive Lead Director of Nursing 4. Quality & Safety 5. Annual Reports Description Number of Never Events Comment Reported in Month There were no never events reported in June.
Target
0 never events in month 6. (Internal Monitoring) Items to note
Executive Lead Director of Nursing 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 8
42 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Comment
Number of patient falls split by There were 10 falls in June, 8 relating to Inpatients and 2 2. level of harm. Outpatients. A full breakdown is provided here: Updates Strategy & Policy - No harm (1) 10% - Low harm (9) 90%, made up of: Target - No obvious injury but unwitnessed fall (6) 60% 1 or fewer falls with moderate or - Bruising/graze (3) 30% severe harm (Internal Monitoring) 3. Governance Performance &
Executive Lead Director of Nursing 4. Quality & Safety
Description Number of Inpatient Ward Falls Comment per 1,000 Bed Days There were 2.12 falls per 1000 bed days reported in June, 5. consistent with previous months. Annual Reports
Target 3 or fewer falls per 1,000 bed days (Internal Monitoring) 6.
Executive Lead Items to note Director of Nursing 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 9
43 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Total number of UTIs associated Comment 2.
with catheters There were two cases of catheter associated urine infections Updates Strategy & Policy during June.
Target 5 in month (Internal Monitoring)
Executive Lead 3. Director of Nursing Governance Performance & 4. Quality & Safety
Description % of adult admissions in the Comment month who have been risk The percentage of admissions risk assessed remains 5. assessed for pressure ulcers consistent and is reported at 99.90% in June. Annual Reports
Target 99% in month (Internal Monitoring) 6. Items to note Executive Lead Director of Nursing 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 10
44 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Total number of category 2 Comment 2.
pressure ulcers acquired at There were two category two pressure ulcers acquired in Updates Strategy & Policy RJAH June, both rehabilitation patients.
Target 1 in month (Internal Monitoring) 3.
Executive Lead Governance Performance & Director of Nursing 4. Quality & Safety
Description Total number of category 3 & 4 Comment pressure ulcers acquired at There were no category three or four pressure ulcers in June. 5. RJAH Annual Reports
Target 0 in month (Internal Monitoring) 6.
Executive Lead Items to note Director of Nursing 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 11
45 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description % of patients who would Comment 2.
recommend the trust (inpatients There were 974 responses collected with a breakdown as Updates Strategy & Policy and outpatients) follows: - 969 positive - giving a rate of 99.49% would recommend the Trust to friends and family Target - 5 responses as "neither likely or unlikely" or "don't know" 90% in month (External Measure, Internal Target) There were no negative responses collected in June giving a
0% rate against the would not recommend measure. 3. Governance Performance & Executive Lead The number of compliments received in June was 450. Director of Nursing 4. Quality & Safety
Description Number of complaints received Comment in month There were eleven complaints received in June. Five of these 5. related to the quality of care with reasons associated with care Annual Reports given by staff in both wards and therapies settings. There Target were six further operational complaints that related to 8 or fewer in month (Internal cancelled surgery (1), cancelled appointments (2), staffing Monitoring) levels on a ward (1), waiting times for surgery (1) and delays obtaining x-ray results (1). 6.
Executive Lead Items to note Director of Nursing
Action We have seen an upward trend in relation to complaints. A deep dive into both Care related complaints and Operational complaints will be undertaken to ensure any emerging themes
can be identified and actioned quickly. 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 12
46 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description % Shift Fill Rate. Comment 2.
The overall shift rate for June was 96.60% against the 90% Updates Strategy & Policy target. Supporting data is collected on a daily basis to monitor Target this metric. There were times throughout the month where 90% in month (External average fill rates fell below target on some wards but they Measure, Internal Target) remained safely staffed at these times.
Executive Lead 3. Director of Nursing Governance Performance & 4. Quality & Safety
Description The total number of delayed Comment days against the total available The delayed discharge rate is red rated this month with a total 5. bed days for the month in % of 228 delayed days and a rate of 4.99%. This equates to 5 Annual Reports surgical patients amounting to 13 days and 21 rehabilitation patients totalling 215 delayed days. The patients fall under Target the responsibility of Shropshire (12), Wales (3), Stoke on 2.5% in month (External Trent (3), Dudley (2) and six others with 1 patient each. Measure, External Target)
Action 6.
This information also triangulates with the increase seen in the Items to note Executive Lead average length of stay. All escalation processes have been Director of Nursing followed in relation to further pushing discharge for those patients in MCSI, however a further piece of work is underway within in Surgery in relation to adherence with the Estimated Date of Discharge set on admission and this will be delivered to the Senior Nursing Meeting in July. 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 13
47 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Number of breaches to the Comment 2.
mixed sex accommodation There were no breaches of the mixed sex accommodation Updates Strategy & Policy standard for non clinical reasons standard in June.
Target 0 breaches in Month (External Monitoring) 3. Governance Performance & Executive Lead Director of Nursing 4. Quality & Safety
Description Number of cases of E. Coli Comment Bacteraemia in Month. There were no incidents reported in June. 5. Annual Reports
Target 0 cases in Month (Internal Monitoring) 6.
Executive Lead Items to note Director of Nursing 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 14
48 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Number of cases of C.Difficile in Comment 2.
Month There were no incidents reported in June. Updates Strategy & Policy
Target 0 cases in Month, Annual tolerance 1 per Year (External Measure, External Target) 3. Governance Performance & Executive Lead Director of Nursing 4. Quality & Safety
Description Number of cases of MRSA Comment bacteraemia in month There were no incidents reported in June. 5. Annual Reports
Target 0 cases in Month (Internal Monitoring) 6.
Executive Lead Items to note Director of Nursing 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 15
49 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Comment
Total number of medication There were seventeen medication errors reported in June. 2. errors, and those with harm These are categorised as prescribing (4), administration (4), Updates Strategy & Policy supply (7), storage (1) and incorrect method of supply (1). Two patients were deemed to sustain low level harm as a Target result of the errors. One occurred in the prescription process 2 or fewer errors with harm and the second involved incorrect formulation. (Internal Monitoring) 3. Governance Performance & Executive Lead Medical Director 4. Quality & Safety
Description Number of Unexpected Deaths Comment in Month There were no patient deaths in the Trust throughout June. 5. Annual Reports
Target 0 Unexpected deaths in month (Internal Monitoring) 6.
Executive Lead Items to note Medical Director 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 16
50 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Number of RJAH acquired DVT Comment 2.
or PE within 90 days of surgery Two surgical patients acquired a pulmonary embolism post Updates Strategy & Policy operatively. The patients had been risk assessed in an outpatient clinic and correctly validated on admission. They Target had received the appropriate anticoagulation. The incidents 4 or fewer in month (Internal will be reviewed by the Venous Thromboembolism Clinical Monitoring) Lead and reported through the Quality and Safety Committee 3.
Executive Lead Governance Performance & Medical Director 4. Quality & Safety
Description % of adult admissions in the Comment month who have been risk The percentage of admissions risk assessed is reported at 5. assessed for VTE 99.92% in June and remains above the 95% target. Annual Reports
Target 95% in month (External Measure, External Target) 6. Items to note Executive Lead Medical Director 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 17
51 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description % of patients readmitted to Comment 2.
RJAH as an emergency Nine patients were readmitted as an emergency within 28 Updates Strategy & Policy following an overnight stay days of initial discharge in May 2018, giving a readmission (*Reported one month in rate of 1.45% against the 1% tolerance. The reasons for arrears) readmission were associated with wound issues (3), pain (2), query DVT (1), query infection (2) and revision lumbar procedure (1). Target
Less than 1% in month (Internal Action 3. Monitoring) The readmissions are being reviewed each month by both the Governance Performance & Matron and one of the Clinical Directors for Surgery, with no particular themes identified, only a statistical clustering. Executive Lead Medical Director 4. Quality & Safety
Description % Compliance against Comment completion of WHO Surgical We continue to monitor compliance by ensuring there have 5. Safety Checklist in Theatre been no datix raised to report any failures in completing the Annual Reports Department WHO Surgical Safety Checklist. The compliance is reported at 100% in June.
Target 100% in month (Internal
Monitoring) 6. Items to note
Executive Lead Medical Director 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 18
52 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description % of procedures which were Comment 2.
reportable cancellations on the There were ten reportable cancellations in June with reasons Updates Strategy & Policy day i.e. within Trust's Control associated with emergency case took priority (3), lack of kit (1) and lack of time (6). Based on the activity levels carried out in June, reportable cancellations amounted to 0.88%. Target 0.7% in month (External Action Measure, Internal Target) Root cause analysis is undertaken for all cancellations with
key themes identified as following 3. - Emergency cases have led to elective cancellations this Governance Performance & Executive Lead month Director of Operations - Case complexity led to cancellations, this information is being fed back to assist improved planning of lists 4. Quality & Safety
Description % of procedures which were Comment non-reportable cancellations on There were fifteen non-reportable cancellations in June with 5. the day reasons associated with DNAs (3), further investigations Annual Reports required (1) and medically unfit (11). Non-reportable cancellations are reported at 1.33% of activity in June. Target 2% in month (Internal Monitoring) 6. Items to note Executive Lead Director of Operations 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 19
53 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Number of theatre cancellations Comment 2.
(reportable) not rebooked within All reportable cancellations were rebooked within 28 days of Updates Strategy & Policy 28 days cancellation.
Target 0 in month (External Measure, External Target) 3. Governance Performance & Executive Lead Director of Operations 4. Quality & Safety
Description % of urgent cancer referrals Comment seen within 2 weeks (*Reported The Cancer 2 week wait standard was achieved in May and 5. one month in arrears) indicative data for June shows achievement of the standard Annual Reports will continue.
Target 93% in month (External Measure, External Target) 6. Items to note Executive Lead Director of Operations 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 20
54 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description % of cancer patients treated Comment 2.
within 31 days of decision to The Cancer 31 day first treatment standard was achieved in Updates Strategy & Policy treat (*Reported one month in May and indicative data for June shows achievement of the arrears) standard will continue.
Target 96% in month (External
Measure, External Target) 3. Governance Performance &
Executive Lead Director of Operations 4. Quality & Safety
Description % of cancer patients Comment subsequent treatment within 31 The Cancer 31 day subsequent treatment standard was 5. days of decision to treat achieved in May and indicative data for June shows Annual Reports (*Reported one month in achievement of the standard will continue. arrears)
Target
94% in month (External 6.
Measure, External Target) Items to note
Executive Lead Director of Operations 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 21
55 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description % of cancer patients treated Comment 2.
within 62 days of referral The Cancer 62 day standard was achieved in May and Updates Strategy & Policy (*Reported one month in indicative data for June shows achievement of the standard arrears) will continue.
Target 85% in month (External
Measure, External Target) 3. Governance Performance &
Executive Lead Director of Operations 4. Quality & Safety
Description % of cancer patients treated Comment within 62 days of date of The Cancer 62 day consultant upgrade standard was 5. upgrade (*Reported one month achieved in May and indicative data for June shows Annual Reports in arrears) achievement of the standard will continue.
Target 85% in month (External
Measure, External Target) 6. Items to note
Executive Lead Director of Operations 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 22
56 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description % of English patients on waiting Comment 2.
list waiting 18 weeks or less Our June performance was 89.98% against the 92% open Updates Strategy & Policy pathway performance for patients waiting 18 weeks or less to start their treatment. The total number of breaches increased Target from 622 in May to 638 in June. 92% at month end (External Measure, External Target) Action This is a positive over performance of our planned trajectory
for RTT performance in 2018/19 and aligned to our theatre 3. Executive Lead activity plan. Governance Performance & Director of Operations 4. Quality & Safety
Description Number of English RTT patients Comment currently waiting 52 weeks or At the end of June there were no English patients waiting over 5. more 52 weeks. Annual Reports
Target 0 at month end (External Measure, External Target) 6. Items to note Executive Lead Director of Operations 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 23
57 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Number of RJAH Welsh RTT Comment 2.
patients currently waiting 52 There were two patients waiting over 52 weeks at the end of Updates Strategy & Policy weeks or more June 2018.
Action Target Both of these patients are complex upper limb cases. 0 at month end (External Measure, External Target) 3. Governance Performance & Executive Lead Director of Operations 4. Quality & Safety
Description Number of BCU transfer Welsh Comment RTT patients currently waiting At the end of June there were 128 Welsh patients waiting over 5. 52 weeks or more. 52 weeks who were all transfers of care from BCU. Annual Reports
Target No target (External Measure, External Target) 6. Items to note Executive Lead Director of Operations 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 24
58 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Number of English patients Comment 2.
currently waiting The number of English patients waiting at the end of June is Updates Strategy & Policy reported at 6367, in line with our trajectory.
Target 6369 in June (Internal Monitoring) 3.
Executive Lead Governance Performance & Director of Operations 4. Quality & Safety
Description % of English patients currently Comment waiting less than 6 weeks for The 6 week standard for diagnostics was achieved this month 5. diagnostics and is reported at 99.37%. Annual Reports
Target 99% at month end (External Measure, External Target) 6. Items to note Executive Lead Director of Operations 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 25
59 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description % of Welsh patients currently Comment 2.
waiting less than 8 weeks for The 8 week standard for diagnostics was not achieved this Updates Strategy & Policy diagnostics month and is reported at 99.76%. Two patients failed to meet the eight week standard due to capacity issues.
Target Action 100% at month end (External The Division is working with their teams to provide additional Measure, External Target) capacity within our ultrasound services. 3. Governance Performance & Executive Lead Director of Operations 4. Quality & Safety
Description Outpatient new to follow up ratio Comment (Consultant Led Activity) The new to follow up ratio remains within anticipated levels 5. and is green rated at 1.96 in June. Annual Reports
Target 2.5 follow up for each new in month 6.
Executive Lead Items to note Director of Operations 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 26
60 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Total number of referrals Comment 2.
received in month (*Reported The number of referrals received for consultant led services is Updates Strategy & Policy one month in arrears) green rated this month with 2828 received against a plan of 3063.
Target 3063 in May (Internal Monitoring) 3. Governance Performance & Executive Lead Director of Operations 4. Quality & Safety
Description % of procedures performed as a Comment daycase The Daycase rate is green rated this month at 46.81% against 5. the 46% target. Annual Reports
Target 46% in March
Executive Lead 6.
Director of Operations Items to note 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 27
61 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description % of sessions used against plan Comment 2.
Performance against this measure is green rated in June with Updates Strategy & Policy 101.27% sessions used against plan. Target 100% in month (Internal Monitoring)
Executive Lead 3. Director of Operations Governance Performance & 4. Quality & Safety
Description % of Minutes Utilised replicating Comment Touch Time methodology Performance in June is above the 82% target at 83.14%. 5. Annual Reports
Target 82% in month (Internal Monitoring) 6.
Executive Lead Items to note Director of Operations 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 28
62 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Average number of cases per Comment 2.
theatre session Theatre cases per session remains amber rated in June at Updates Strategy & Policy 1.98 against the 2.08 target.
Target Action 2.08 in June (Internal The complexity of cases carried out in June has impacted on Monitoring) our cases per session this month, however, has led to better utilisation of our theatre times, as seen against the previous
indicator. 3. Executive Lead Governance Performance & Director of Operations 4. Quality & Safety
Description Activity in theatres in month Comment A breakdown of Total Theatre Activity against plan is: 5. - T&O - 928 against plan of 973 (-45 cases) Annual Reports Target - MCSI - 32 against plan of 34 (-2 cases) 1055 in June (Internal - Private Patients - 64 against plan of 48 (+16 cases) Monitoring) Action The complexity of cases carried out in June has impacted on
Executive Lead the number of cases undertaken this month, however, has led 6.
Director of Operations to better utilisation of our theatre times, as seen against the Items to note utilisation indicator. 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 29
63 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Elective patients length of stay Comment 2.
(excluding daycase) The average length of stay is red rated this month at 4.13 Updates Strategy & Policy days against a target of 3.5 days. We continue to monitor the number of patients who require an extended stay as part of Target their treatment plan. In June eight patients required a length 3.5 in month (Internal of stay over 20 days, without these patients our average Monitoring) length of stay would be at 3.23 days and below the target of 3.5 days. 3.
Executive Lead Action Governance Performance & Director of Operations The average length of stay has particularly increased in the Medicine Division. We are currently undertaking a review of our length of stay on our care of the elderly ward. 4. Quality & Safety
Description % Bed occupancy at 2pm Comment The occupancy rate for adult orthopaedic beds is green rated 5. this month at 86.75%. Annual Reports Target 87% in month (Internal Monitoring)
Executive Lead 6.
Director of Operations Items to note 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 30
64 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description % Bed occupancy at 2pm Comment 2.
The occupancy rate for all wards is amber rated this month at Updates Strategy & Policy 85.73%. Target 83% in month (Internal Monitoring)
Executive Lead 3. Director of Operations Governance Performance & 4. Quality & Safety
Description Number of attendances seen in Comment Consultant Led Clinics The number of attendances seen in Consultant Led clinics is 5. ahead of plan with 9074 seen against a plan of 8654. Annual Reports
Target Action 9680 in June (Internal Overall capacity for outpatient appointments remain under Monitoring) review as part of the Follow Up transformation project and the MSK transformation project. The focus for these work
streams remains on triaging our patients to the appropriate 6.
Executive Lead service, securing additional capacity and developing Items to note Director of Nursing alternative pathways for patients by increasing utilisation of Allied Health Professionals, virtual clinics and patient questionnaires as an alternative to review appointments. A stakeholder meeting was held in June 2018 with key actions identified to take forward. 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 31
65 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description % of outpatient appointments Comment 2.
not attended The DNA rate remains red rated in June with 502 missed Updates Strategy & Policy appointments, resulting in a DNA rate of 5.75%.
Target Action 5% in month We continue to review the data within both the Surgical and Medicine Divisions at a sub-specialty level to identify any themes. The Surgical Division has identified some sub-
Executive Lead specialties with particularly high DNA rates so is reviewing the 3. Director of Operations booking process to try alternative methods of booking that Governance Performance & could reduce the number of missed appointments. The Medicine Division have an action plan in place including text reminders roll out and other service improvement initiatives. Progress will be monitored through the Divisional Performance Review Meetings. 4. Quality & Safety
Description Surplus/deficit adjusted for Comment donations and excluding STF - Overall in month surplus of k 5. Annual Reports funding - k ahead of plan in month ( k ahead of plan YTD)
Target m 6.
Executive Lead Items to note Director of Finance 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 32
66 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Income associated with clinical Comment 2.
activities (excludes pass through - k ahead of plan in month Updates Strategy & Policy drugs) - Theatres favourable driven by Spinal Disorders case mix - Medicine adverse driven by reduced outpatients activity
Target m 3.
Executive Lead Governance Performance & Director of Finance 4. Quality & Safety
Description Income generated by private Comment patient activity - k ahead of plan overall in month - predominantly driven 5. by Surgery Annual Reports
Target m
Executive Lead 6.
Director of Finance Items to note 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 33
67 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Non-clinical income e.g. Comment 2.
research, education and NHS - k behind plan overall in month driven by Updates Strategy & Policy Injury Cost Recovery (ICR) - Reduction in education and training income linked to nursing placement numbers - Research shortfall Target m Action Review of forecasted trainees and methodology for remaining
periods to ensure quarterly income is clear. 3. Executive Lead Review of trial forecast trial income and opportunities to Governance Performance & Director of Finance increase. 4. Quality & Safety
Description Expenditure on workforce Comment - Pay costs k underspent overall, driven by vacancies to 5. funded posts Annual Reports Target - Non LLP OJP below plan m
Executive Lead
Director of Finance 6. Items to note 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 34
68 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Non-workforce expenditure e.g. Comment 2.
consumables, implants and - Non Pay costs k overspent overall Updates Strategy & Policy drugs (excludes pass through - LLP OJP ahead of plan drugs) - Estates utilities pressures - Private Patient Implants ahead of plan (offset by income over performance) Target m 3.
Action Governance Performance & Executive Lead Continue to track LLP OJP allocation against activity plan with Director of Finance appropriate sign off processes. Review of utilities spend and savings projected from CHP plant. 4. Quality & Safety
Description Costs associated with financing Comment the Trust i.e. depreciation, PDC - On plan in month 5. and interest charges Annual Reports
Target m 6.
Executive Lead Items to note Director of Finance 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 35
69 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Cost Improvement Programme Comment 2.
requirement - CIPs over achieved by k in month, driven by private Updates Strategy & Policy patients, YTD k ahead of plan
Target m
Executive Lead 3. Director of Finance Governance Performance &
4. Quality & Safety
Description Annual ceiling for total agency Comment spend introduced by NHS - Overall agency spend k in month (including LLP), k 5. Annual Reports Improvement ahead of the agency ceiling in month - k driven by LLP - YTD k ahead of ceiling (ceiling set at m for 18/19)
Target m Action Deep dive to be carried out with divisions to assess the
current drivers for agency and future plans to alleviate. 6.
Executive Lead Items to note Director of Finance 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 36
70 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Cash in bank Comment 2.
- Cash balances of m, decrease of m in month driven Updates Strategy & Policy by settlement of 17/18 underperformance Target - On plan in month m (at March 2019)
Executive Lead
Director of Finance 3. Governance Performance & 4. Quality & Safety
Description Expenditure against Trust Comment capital programme - Capital spend of k in month 5. Annual Reports - k below plan in month driven by phasing of plan
Target m
Executive Lead 6.
Director of Finance Items to note 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 37
71 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Overall Use of Resources Comment 2.
indicator UOR on plan at level 3 Updates Strategy & Policy
Target 1 (at March 19)
Executive Lead 3. Director of Finance Governance Performance & 4. Quality & Safety 5. Annual Reports 6. Items to note 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 38
72 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description WTE lost due to Staff Absence Comment 2.
There has been a slight reduction in absence overall but we Updates Strategy & Policy have seen an increase particularly in long term absence. Target 3.25% in month (Internal Action Monitoring) Ensuring appropriate management and pro-active approach that includes occupational health support for long term sickness cases.
Executive Lead 3. Director of People Governance Performance & 4. Quality & Safety
Description % of posts vacant at month end Comment Vacancy rate has slightly increased in month but remains 5. below (positive) the target. Annual Reports Target 8% in month (Internal Monitoring)
Executive Lead 6.
Director of People Items to note 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 39
73 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description Total numbers of voluntary Comment 2.
leavers in the last 12 months as Turnover has increased this month. Updates Strategy & Policy a percentage of the total employed Action Deep dive analysis report into reasons and hotspots has been commissioned. Findings to be discussed at next WDG Target (August 9th) which is a sub committee of Q&S therefore 8% in month (Internal allowing for further discussion and agreed action plan which
Monitoring) will then be presented to the Q&S committee in September. 3. Governance Performance &
Executive Lead Director of People 4. Quality & Safety
Description % of staff who have had an Comment appraisal within the last 13 Slight reduction in the number of staff who have been 5. months appraised in in the last 13 months, but remains above Annual Reports (positive) the target.
Target 92% at month end (Internal Monitoring) 6. Items to note Executive Lead Director of People 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 40
74 1. Integrated Performance Report Meeting Part One - Public June – Month 3
Description % of staff completed mandatory Comment 2.
training in latest 12 month Increase in the completion rate for mandatory training, but Updates Strategy & Policy period remains below (negative) the target.
Action Target Divisions to focus on ensuring out of date training is 92% in month (Internal scheduled. Monitoring) 3. Governance Performance & Executive Lead Director of People 4. Quality & Safety 5. Annual Reports 6. Items to note 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 41
75 1. Integrated Performance Report Meeting Part One - Public June – Month 3 2. Updates Strategy & Policy Jul 2017 Oct 2017 Apr 2018 Jun 2017 Jan 2018 Jun 2018 Feb 2018 Mar 2018 Nov 2017 Dec 2017 Aug 2017 Sep 2017 Caring for Patients May 2018 Latest target YTD plan YTD actual Year-end forecast DQ rating
1 0 2 1 1 0 0 0 0 0 1 2 0 0 0 3 A Apr-18 3.
Serious Incidents Governance Performance &
Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 G Apr-18
Patient Falls (With Moderate or Severe Harm) 1 0 3 0 0 0 0 0 0 0 0 2 0 1 3 2 G 4. Quality & Safety Inpatient Ward Falls Per 1,000 Bed Days 3.15 3.71 4.31 4.08 2.75 2.01 2.87 2.17 3.37 1.49 1.94 2.18 2.12 3 3 2.42 G May-18
UTIs Associated with Catheters 2 0 2 5 15 4 G
100% 100% 99.9% 100% 100% 100% 99.89% 100% 100% 100% 100% 99.9% 99.9% 99% 99 99.93% G Apr-18 Pressure Ulcer Assessments 5. Annual Reports
RJAH Acquired Pressure Ulcers - Grade 2 1 2 2 0 3 0 1 0 2 3 3 2 2 1 3 7 G Apr-18
RJAH Acquired Pressure Ulcers - Grades 3 or 4 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 G Apr-18
Patient Friends & Family - % Would 6.
Recommend (Inpatients & Outpatients) 98.39% 99.27% 98.92% 98.86% 98.96% 99.47% 98.99% 99.7% 98.92% 99.17% 99.35% 99.08% 99.49% 95% G Items to note
Number of Complaints 9 1 7 4 8 7 6 4 6 9 7 9 11 8 24 27 G May-18
Safe Staffing 96.2% 94.3% 94.5% 96.2% 96.5% 96.9% 98.6% 97.7% 95.9% 95.5% 95.2% 96.2% 96.6% 90% G May-18 7. Any Other Business % Delayed Discharge Rate 3.29% 3.29% 2.56% 1.82% 0.43% 2.54% 5.41% 5.02% 7.28% 7.47% 5.83% 3.92% 4.99% 2.5% G
Mixed Sex Accommodation 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 G
RJAH Acquired E. Coli Bacteraemia 1 0 0 0 1 0 3 1 0 0 1 1 0 0 0 2 R 8. meeting Date and Time of next
Integrated Performance Report 42
76 June 3 – June Month Integrated Performance Report Cancer 62DaysConsultant Upgrade* Cancer Plan62DaysStandard(Tumour)* 31 DaysSubsequentTreatment(Tumour)* 31 DaysFirstTreatment(Tumour)* Cancer TwoWeekWait* Days Cancellations NotRebookedwithin28 % Non-ReportableCancellations % ReportableCancellations WHO Compliance 28 daysEmergencyReadmissions* VTE AssessmentsUndertaken RJAH AcquiredVTE(DVTorPE) Unexpected Deaths Medication ErrorswithHarm RJAH AcquiredMRSABacteraemia RJAH AcquiredC.Difficile 2.09% 0.64% 1.11% 100% 100% 100% 100% 100% 40% 4 1 1 0 0 0 Jun 2017 99.92% 1.95% 0.56% 1.21% 100% 100% 100% 100% 100%
0 1 0 1 0 0 Jul 2017 99.92% 2.07% 0.54% 0.16% 100% 100% 100% 100% 80%
0 1 0 3 0 0 Aug 2017 2.02% 0.65% 0.66% 100% 100% 100% 100% 100% 0%
0 3 0 3 0 0 Sep 2017 99.85% 2.04% 0.73% 0.43% 100% 100% 100% 100% 60% 0 0 0 0 0 0 Oct 2017 2.09% 0.81% 0.89% 100% 100% 100% 100% 100% 100%
0 2 0 1 0 0 Nov 2017 99.62% 2.16% 0.91% 1.01% 100% 100% 100% 100% 100%
0 2 0 0 0 0 Dec 2017 99.92% 2.26% 0.98% 100% 100% 100% 100% 100% 0.6%
0 1 0 2 0 0 Jan 2018 0.91% 100% 100% 100% 100% 100% 100% 2.3% 0.9%
0 4 0 0 0 0 Feb 2018 99.92% 2.29% 0.88% 1.38% 100% 100% 100% 50% 96%
0 2 0 1 0 0 Mar 2018 96.15% 99.71% 2.25% 0.32% 1.13% 100% 100% 100% 100% 0%
0 1 1 1 0 1 Apr 2018 2.56% 0.18% 1.45% 100% 100% 100% 100% 100% 100% 100%
0 1 0 2 0 0 May 2018 99.92% 1.33% 0.88% 100%
0 2 0 2 0 0 Jun 2018 100% 0.7% 95%
2% Latest
0 4 0 2 0 0 target
YTD plan 100 0.7 85 85 94 96 93 95 12 0 2 1 0 6 0 1 66.67% 97.96% 99.89% 2.03% 0.47% 100% 100% 100% 100%
Integrated Performance Report YTD actual 1.3% 0 4 1 5 0 1 G G G G G G G G G G G G G G R A Year-end forecast
Apr-18 Apr-18 Apr-18 Apr-18 Apr-18 DQ rating 43
77 Updates Meeting Governance meeting
Items to note to Items 6. Any Other Business Other Any 7. Reports Annual 5. Safety & Quality 4. Policy & Strategy 2. Public - One Part 1. Performance & Performance 3. Date and Time of next of Time and Date 8. June 3 – June Month Integrated Performance Report Activity) New toFollowUpRatio(ConsultantLed Patients 8 WeekWaitforDiagnostics-Welsh Patients 6 WeekWaitforDiagnostics-English English ListSize (BCU Transfers) Patients WaitingOver52Weeks–Welsh Patients WaitingOver52Weeks–Welsh Patients WaitingOver52Weeks–English 18 WeeksRTTOpenPathways 99.84% 99.67% 90.17% 1.9 13 5 1 Jun 2017 99.63% 89.28% 99.76% 2.03 10 4 2 Jul 2017 99.62% 88.74% 100% 1.86 14 6 4 Aug 2017 99.34% 88.21% 100% 2.03 91 7 0 Sep 2017 99.82% 88.86% 100% 2.12 127
4 1 Oct 2017 99.46% 88.95% 100% 2.18 167
4 0 Nov 2017 99.65% 98.58% 88.84% 1.83 165
4 0 Dec 2017 99.41% 88.99% 100% 2.16 103
2 1 Jan 2018 99.82% 99.77% 89.37% 2.1 43 5 1 Feb 2018 99.42% 90.05% 99.6% 2.34
0 6 1 Mar 2018 98.73% 100% 5,918 90% 2.31 43 2 2 Apr 2018 99.53% 89.49% 100% 5,972 2.12 126
2 1 May 2018 99.76% 99.37% 89.98% 6,367 1.96 128
2 0 Jun 2018 100% 6,369 99% 92%
2.5 Latest
0 0 target
YTD plan 100 2.2 99 92 0 0 99.91% 99.21% 89.83%
Integrated Performance Report YTD actual 2.12
G G G G G G G G Year-end forecast
DQ rating 44
78 Updates Meeting Governance meeting
Items to note to Items 6. Any Other Business Other Any 7. Reports Annual 5. Safety & Quality 4. Policy & Strategy 2. Public - One Part 1. Performance & Performance 3. Date and Time of next of Time and Date 8. 1. Integrated Performance Report Meeting Part One - Public June – Month 3 2. Updates Strategy & Policy Jul 2017 Oct 2017 Apr 2018 Jun 2017 Jan 2018 Jun 2018 Feb 2018 Mar 2018 Nov 2017 Dec 2017 Aug 2017 Sep 2017 Caring for Finances May 2018 Latest target YTD plan YTD actual Year-end forecast DQ rating
Referrals Received for Consultant Led Services* 3,243 3,015 2,947 3,256 3,624 3,418 2,414 3,112 2,867 2,804 2,411 2,828 5642 5,239 G
Overall Daycase Rate 44.06% 45.58% 44.19% 49.05% 48.24% 47.25% 47.2% 46.67% 45.93% 45.26% 45.18% 47.77% 46.81% 46% 46 46.68% G 3. Governance Performance & 101.27 % Sessions Used Against Plan 99.53% 100.1% % 100% 100 100% G
Touchtime Utilisation 80.84% 79.7% 81.9% 81.36% 81.81% 84.93% 80.89% 82.67% 83.26% 86.46% 82.19% 81.95% 83.14% 82% 82 82.47% G 4.
Theatre Cases Per Session 2 1.98 2.07 2.05 2.05 2.09 2.17 2.05 2.07 2.13 1.95 2.07 1.98 2.08 G Quality & Safety
Total Theatre Activity 984 1,005 1,005 1,042 1,123 1,126 904 1,133 1,043 1,125 821 1,004 1,024 1,055 2870 2,849 G
Average Length of Stay 4.77 3.49 3.64 4.07 3.47 3.96 3.54 3.25 3.74 3.37 3.89 3.62 4.13 3.5 3.5 3.89 G 5.
Bed Occupancy – Adult Orthopaedic Wards Annual Reports – 2pm 84.89% 86.33% 88.7% 86.69% 92.55% 91.3% 84.52% 90.33% 92.41% 88.62% 78.07% 82.95% 86.75% 87% 87 82.7% G
Bed Occupancy – All Wards – 2pm 78.44% 78.52% 80.59% 83.3% 88.3% 87.92% 85.33% 89.16% 90.7% 86.3% 80.91% 82.52% 85.73% 83% 83 83.06% G
8,654.2 Consultant Led Outpatient Activity 7,976 8,850 9,074 2 29452 25,054 G 6. Items to note
Outpatient DNA Rate 5.09% 4.89% 5.1% 5.11% 5.01% 5.06% 6.83% 5.73% 5.65% 5.64% 5.33% 5.72% 5.75% 5% 5 5.61% G
Financial Control Total 118 58 -199 133 371 544 -804 639 208 337 -768 7 235 189 -892 -525 G 7. Any Other Business Clinical Income from Activity 7,297 7,170 6,953 7,266 7,787 7,890 6,447 7,952 7,673 8,439 6,356 7,455 7,884 7,818 21355 21,693 G
Private Patients Income 310 444 534 454 541 654 370 530 349 492 516 450 478 346 1169 1,445 G
Other Income 543 845 493 527 447 618 584 440 729 839 545 562 520 579 1724 1,625 A 8. meeting Date and Time of next
Pay 4,749 4,723 4,819 4,685 4,808 4,901 4,823 4,911 4,927 4,903 4,944 4,980 5,016 5,043 15108 14,938 G Integrated Performance Report 45
79 June 3 – June Month Integrated Performance Report Use ofResources(UOR) Capital Expenditure Cash Balance Agency ControlTotal CIP Delivery Financing Non Pay 3,890 3,044 562 171 389 355
3 Jun 2017 4,916 3,357 127 143 413 369
3 Jul 2017 4,480 3,021 119 434 370 31 3 Aug 2017 3,032 3,125 250 357 349 81 3 Sep 2017 3,593 3,265 125 322 381 64 3 Oct 2017 3,272 3,358 103 167 362 409
3 Nov 2017 3,184 3,470 199 135 303 400
3 Dec 2017 4,163 3,443 187 371 399 65 2 Jan 2018 4,277 3,661 119 164 207 443
2 Feb 2018 4,249 4,632 828 180 250 393
2 Mar 2018 3,863 2,869 232 369 426 93 3 Apr 2018 4,773 3,108 264 374 282 426
3 May 2018 4,200 3,260 346 407 357 426
3 Jun 2018 4,250 3,140
720 305 308 425 Latest
3 target
YTD plan 4250 1279 8918 915 877 942 3 4,200 1,015 1,008 1,278 9,238 Integrated Performance Report YTD actual 703 3 G G G G G R A Year-end forecast
DQ rating 46
80
Updates Meeting Governance meeting
Items to note to Items 6. Any Other Business Other Any 7. Reports Annual 5. Safety & Quality 4. Policy & Strategy 2. Public - One Part 1. Performance & Performance 3. Date and Time of next of Time and Date 8. 1. Integrated Performance Report Meeting Part One - Public June – Month 3 2. Updates Strategy & Policy Jul 2017 Oct 2017 Apr 2018 Jun 2017 Jan 2018 Jun 2018 Feb 2018 Mar 2018 Nov 2017 Dec 2017 Aug 2017 Sep 2017 Caring for Staff May 2018 Latest target YTD plan YTD actual Year-end forecast DQ rating
Sickness Absence 3.63% 3.6% 3.06% 3.26% 3.07% 3.73% 3.64% 4.03% 4.06% 3.47% 2.93% 3.41% 3.4% 3.25% 3.25 3.25% A
Vacancy Rate 7.94% 7.6% 7.63% 8% G 3. Governance Performance &
Voluntary Staff Turnover 7.36% 7.28% 7.83% 7.38% 7.23% 7.12% 7.14% 7.49% 7.33% 7.57% 7.88% 8.37% 8.56% 8% G
Staff Appraisal 89.81% 85.51% 83.73% 84.11% 82.09% 85.61% 84.74% 87.79% 88.78% 94.53% 95.02% 94.4% 94.3% 92% G 4.
Mandatory Training 94.6% 93.7% 93.3% 76.3% 78% 81.2% 84.7% 86.4% 89.5% 91.4% 92.7% 90.9% 91.2% 92% A Quality & Safety 5. Annual Reports 6. Items to note 7. Any Other Business 8. meeting Date and Time of next
Integrated Performance Report 47
81 1. Public Meeting Part One -
Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Finance Dashboard 30th June 2018 2.
Income and Expenditure £'000s Statement of Financial Position £'000s Policy Updates Strategy & In Month Position Year To Date Position Category May-18 Jun-18 Movement Drivers Annual Category Fixed Assets 74,468 74,548 80 Additions less depreciation Plan Plan Actual Variance Plan Actual Variance Non current receivables 951 825 (126) Clinical Income 96,940 8,271 8,312 41 22,714 23,014 300 Total Non Current Assets 75,419 75,373 (46) STF 833 42 42 0 126 126 0 Inventories (Stocks) 945 855 (90) Theatre stocks usage Private Patient income 5,831 346 478 132 1,169 1,445 276
Other income 6,529 583 523 (60) 1,739 1,638 (101) Receivables (Debtors) 6,736 7,777 1,041 Accrued income over performance 3. Pay (60,670) (5,043) (5,016) 27 (15,108) (14,938) 171 Non-pay (42,937) (3,594) (3,686) (93) (10,277) (10,556) (279) Cash at Bank and in hand 4,773 4,204 (569) Capital spend on CT Scanner & Performance
EBITDA 6,527 606 653 47 363 729 366 Total Current Assets 12,454 12,836 382
Finance Costs (5,197) (425) (426) (1) (1,279) (1,278) 1 Payables (Creditors) (10,121) (10,207) (86) Capital Donations 200 100 23 (77) 40 23 (17) Borrowings (1,176) (1,176) 0 Operational Surplus 1,530 281 250 (31) (876) (526) 349 Current Provisions (90) (90) 0 Remove Capital Donations (200) (100) (23) 77 (40) (23) 17 Total Current Liabilities (< 1 year) (11,387) (11,473) (86) Add Back Donated Dep'n 607 50 50 (0) 150 150 (0) 4. Total Assets less Current Liabilities 76,486 76,736 250
Remove STF Funding (833) (42) (42) 0 (126) (126) 0 Safety Quality & Non Current Borrowings (7,060) (7,060) 0 Control Total exl STF 1,104 189 235 46 (892) (525) 367 Non Current Provisions (186) (186) 0 STF Earnt 833 42 42 0 126 126 0 Non Current Liabilities (> 1 year) (7,246) (7,246) 0 Total Assets Employed 69,240 69,490 250 Control Total 1,937 231 277 46 (766) (399) 367 d th EBITDA margin 6.0% 6.6% 7.0% 0.4% 1.4% 2.8% 1.4% Public Dividend Capital (33,260) (33,260) 0 Revenue Position (11,847) (11,847) 0 Before control total adjustment 5. Capital service 3 I&E Margin 4 Retained Earnings 776 526 (250) Current period surplus
Jun-18 YTD Revaluation Reserve (24,909) (24,909) 0 Reports Annual Liquidity (days) 1 Variance in I&E Margin 1 Debtor Days 28 25 Total Taxpayers Equity (69,240) (69,490) (250)
Agency 2 Creditor Days 35 34 Overall UOR 3 Cash Flow Monthly Surplus/Deficit £2,000 8.0 6.
7.0 Items to note £1,500
C6.0 S £1,000 a ( s u 5.0 D h r e £500 p £4.0 f Plan M 7. l
i Business Any Other i 3.0 c £0 u i s Actual 2.0
) t (£500) / 1.0 (£1,000) 0.0 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 8.
(£1,500) Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 of next Date and Time Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Plan £M 3.6 3.7 4.3 4.2 5.1 4.0 4.1 4.2 4.3 4.6 5.0 5.2 Actual £M 3.8 4.8 4.2 Period Forecast £M 3.8 4.8 4.2 5.8 5.2 4.0 4.2 4.3 4.3 4.5 4.9 5.2
82 1. Public Meeting Part One -
Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Finance Dashboard 30th June 2018 2. Policy Updates Strategy & Cost Improvement Programme
In Month CIP Achievement £000's Year To Date CIP Achievement £000's Trust YTD Achievement Against YTD Plan £000's
1,200 National Strategic National Strategic 1,000 3. Local Strategic Local Strategic 800 & Performance
600 FYE 17/18 FYE 17/18 400
CIP CIP by Theme Divisional Divisional 200
0 50 100 150 200 250 0 100 200 300 400 500 600 700 0 4. Jun Plan Jun Actual YTD Plan YTD Actual YTD Plan YTD Actual Safety Quality &
In Month CIP Achievement £000's Year To Date CIP Achievement £000's
RAG of Total Schemes Being Tracked Theatres Theatres 709 19% b Research 1,285 34% g Research 5. Corporate 1,062 28% a Corporate 706 19% r Reports Annual Estates & Facilities Estates & Facilities 3,762 100.0% Diagnostics Diagnostics Medicine
CIP CIP by Division Medicine
Surgery Surgery
0 50 100 150 0 50 100 150 200 250 300 350 400 6.
Jun Plan Jun Actual YTD Plan YTD Actual Items to note
Year to date capital programme £000's Year To Date Commissioner Income against Plan £m Position as at 1819-03 Capital Programme 2018-19
In Month In Month In Month YTD Forecast Annual Plan YTD Plan YTD Variance Project Plan Completed Variance Completed Outturn £000s £000s £000s £000s £000s £000s £000s £000s Shropshire
CT Scanner replacement infrastructure works 650 400 301 99 500 529 -29 650 BCU 7. TSSU solution 600 0 -1 1 0 7 -7 600 New IT network 200 0 0 0 0 0 0 200 Specialist Business Any Other Bed capacity solution 350 0 2 -2 0 2 -2 350 Project management / implementation support 150 10 9 1 30 26 4 150 Other English Contracted Estates backlog 400 50 8 42 75 87 -12 400 IT investment / replacement 300 30 1 29 30 1 29 300 Powys Equipment and minor works investment / Capital Telford replacement 500 50 2 48 80 27 53 500 Fire safety work 200 50 0 50 50 0 50 200 Other Kenyon toilet block 100 0 3 -3 0 3 -3 100 Operational Control Centre 100 0 0 0 0 0 0 100 CQC / Site Improvements 100 30 0 30 30 0 30 100 Commissioner Commissioner Performance 8. EPR development 100 0 0 0 0 0 0 100 - 2.00 4.00 6.00 8.00 10.00 300 0 0 0 0 0 0 300 Contingency of next Date and Time NHS Capital Funding 4,050 620 323 297 795 680 115 4,050 Donated Equipment 200 100 23 77 120 23 97 200 YTD actual YTD plan Total Capital Funding (NHS & Donated) 4,250 720 346 374 915 703 212 4,250
83 1. Part One -
Research Update July 2018
0. Reference Information 2. Strategy &
Teresa Jones, Author: Paper date: 26th July 2018 Research Manager
Steve White, Medical Director Executive Sponsor: Kerry Robinson, Paper Category: Strategy Director of Strategy and 3.
Planning Performanc
Paper Reviewed by: N/A Paper Ref: N/A
Forum submitted to: Trust Board Paper FOIA Status: Full
1. Purpose of Paper 4.
1.1. Why is this paper going to Trust Board and what input is required? Quality &
The Board are asked to note the update on research progress within the Trust.
2. Executive Summary
2.2. Summary 5. In summary the research department continues to support the delivery of clinical research Annual within the Trust, supporting hosted and sponsored studies. Against the National Institute for Health Research (NIHR) West Midlands Clinical Research Network (WM CRN) recruitment target at 30th June 2018, the Trust was at 106% participant recruitment and 138% against Activity Based Funding (ABF). Although ahead of target for recruitment, this report demonstrates how our research activity is non-linear.
The core funding from the WM CRN has reduced compared to 2017/18, however the Trust 6. have been awarded additional strategic funding for two study support officer posts. Items to note 2.3. Conclusion In conclusion, the research department continues to add value to the Trust, contributing to the aspiration of being a world class provider and leader in MSK services. 7. Any Other 8. Date and Time
1
84 1. Part One -
Research Update July 2018
3. The Main Report 2.
3.1. Introduction Strategy & This report will highlight the research performance of the Trust from a patient recruitment, financial and NIHR perspective.
3.2. Research update July 2018
3.2.1. Participant Recruitment 3.
At 30th June 2018, recruitment to NIHR studies was 206 against a pro-rata target of 195 Performanc (106%). The annual target has been increased by the CRN to 781, compared to a target of 599 for 2017/18. This increase is in line with the West Midlands increased annual target of 65,000 participants, of which RJAH’s percentage contribution remains constant at 1.2% (1.1% last yr.). This is comparable with The Royal Orthopaedic Hospital and Shrewsbury and Telford Hospitals at 1.0% and 2.8% respectively.
During 2018/19 the research department will continue to increase patient, carers and visitors 4. awareness that RJAH is a research active Trust working in partnership with our communication experts within the Trust. Quality & 3.2.2. Active Studies The total number of Health Research Authority approved (including ethical approval) studies currently active at RJAH is as follows: 5.
Study Type Current Status No. No. of which are Research Dept. Annual NIHR Portfolio supporting Laboratory Based no pt. recruitment 14 2 Staff / No pt. Organisation recruitment 7 3 Questionnaire Clinical Study Pts in follow-up 21 16 21 6. Items to note Clinical Study Active 50 31 48 Recruitment Total 92 52 69 The growth in the number of active studies is attributable to further departments within the Trust becoming research active, thus increasing the number of studies within these departments. e.g. Tumour Unit, Anaesthetics. 7.
There are currently 38 studies including six commercial studies in various stages of Any Other development. Start dates of studies will be subject to available capacity within the research department, commercially funded studies are given priority due to provision of funding to provide resources for support. 3.2.3. Finance The WM CRN core funding for 2018/19 has decreased by c. £50k from 2017/18, a decrease 8. of 20%. However, approval of a strategic funding application has resulted in this decrease being recovered which is to fund two study support officer roles to support the delivery of Date and Time research in the upper limb service and the daily management of all our research studies.
2
85 1. Part One -
Research Update July 2018
3.2.4. Development of ACI Service 2.
The ACI project continues to move forward with one of our research project managers Strategy & assigned to project lead the development, having worked closely with the team on the initial research studies that resulted in the approval of the strategic outline case. Additionally the WM AHSN has provided some initial funding to support this development through a grant.
3.3. Associated Risks The success of research within RJAH creates a potential risk in managing the level of growth, ensuring that our resources to support and open new studies is aligned with further 3. developments, recognising that the funding and activity of research is not linear, further work Performanc within the department is being developed to ensure our financial resourcing model aligns to the practice of research in action. As our services continue to grow, with greater coverage of services operating throughout the weekends, the research department are flexing to match such changes to ensure patient recruitment continues to grow. As this develops and sustains there will be a requirement to review working patterns in the future to support our ambitions. 4. Quality & 3.4. Conclusion In conclusion, RJAH continues to enhance its reputation as a leader in orthopaedic and MSK research. Through participation in research, the Trust is able to evidence change and improve the patient experience and treatment, leading to achievement of its aspiration to be a world class provider and a leader in MSK care. 5. Annual 6. Items to note 7. Any Other 8. Date and Time
3
86 1. Part One -
Research Update July 2018
Appendix 1: Acronyms 2. Strategy &
WM CRN West Midlands Clinical Research Network NIHR National Institute for Health Research ABF Activity Based Funding FPI Finance, Planning and Investment Committee 3. ACI Autologous Chondrocyte Implantation Performanc FDA Food and Drug Administration ROH Royal Orthopaedic Hospital NHS FT NICE National Institute for Health and Care Excellence SOP Standard Operating Procedures
WM AHSN West Midlands Academic Health Science Network 4. MSK Musculoskeletal Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
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87 1. Part One -
Chair’s Assurance Report Finance Planning and Investment Committee – 26 June 2018 2. Strategy & 0. Reference Information
Shelley Ramtuhul, Author: Paper date: 26th July 2018 Trust Secretary
Alastair Findlay, Executive Sponsor: Paper Category: Governance and Quality 3. Non-Executive Director Performanc Paper Reviewed by: N/A Paper Ref: N/A
Forum submitted to: Board of Directors Paper FOIA Status: Full
1. Purpose of Paper
1.1. Why is this paper going to the Board of Directors and what input is 4.
required? Quality & This paper presents an overview of the Finance Planning and Investment Committee Meeting which was held on 26th June 2018 and is provided for assurance purposes.
2. Executive Summary
2.1 Context 5.
The Board of Directors has delegated responsibility for the oversight of the Trust’s system of Annual internal control to the Finance Planning and Investment Committee. This Committee is responsible for seeking assurance on that the Trust is operating within its financial constraints and that the delivery of its services represents value for money. Further it is responsible for seeking insurance that any investments again represent value for money and delivery the expected benefits. It seeks these assurances in order that, in turn, it may provide appropriate assurance to the Board. 6. Items to note 2.2 Summary The meeting was well attended There was good progress of actions from the previous meeting with all actions completed The work plan was reviewed and agreed 2 Business Cases were received and considered 7. Consideration was given to the Trust’s financial position and performance. Any Other Assurance was obtained from the Capital Management Group
2.3. Conclusion The Board is asked to note the meeting that took place and the assurances obtained. 8. Date and Time
1
88 1. Part One -
Chair’s Assurance Report Finance Planning and Investment Committee – 26 June 2018 2. Strategy &
3. Main Report 3.1 Introduction This report has been prepared to provide assurance to the Board from the Finance Planning th and Investment Committee which met on 26 June. The meeting was quorate with two Non- 3.
Executive Directors present. A full list of the attendance is outlined below: Performanc
Chair/ Attendance:
Members Alastair Findlay, Non-Executive Director (Chair) 4.
David Gilburt, Non-Executive Director Quality & Mark Brandreth, Chief Executive Craig Macbeth, Director of Finance Nia Jones, Director of Operations Laura Peill, Associate Director of Performance
In Attendance 5. Annual Bev Tabernacle, Director of Nursing/Deputy CEO Mark Salisbury, Deputy Director of Finance Imran Hanif, Chief Pharmacist Simon Adams, Associate Director of IM&T
Lee Osborne, Transformational Lead 6.
Mary Bardsley, PA to Director of Finance (Minutes) Items to note
Apologies:
Shelley Ramtuhul, Trust Secretary Kerry Robinson, Director of Strategy and Planning 7.
3.2 Actions from the Previous Meeting Any Other The Committee noted the actions of the previous meeting and receive an updated on the progress of each. All actions were noted to be completed. 3.3 Key Agenda
The Committee received all items required on the work plan with an outline provided below 8. for each: Date and Time
2
89 1. Part One -
Chair’s Assurance Report Finance Planning and Investment Committee – 26 June 2018 2. Strategy &
Agenda Item / Discussion Assured Assurance Sought (Y/N) Declaration of Interest
There were no announcements regarding declarations 3. N/A of interest. Performanc
Finance and Performance Report The committee received the finance and performance report for month 2 and held a discussion on the following: RTT trajectory
Theatre activity 4.
Forecast for June/July Quality & 52 week waiters Y On the day cancellations Current financial position
The committee noted the Finance and Performance Report. 5.
Service Line Reporting (Q4) Annual The committee discussed the service line reporting (SLR) data for quarter 4 2017/18 and focussed particularly on those areas not performing as expected. To be kept under Partial review by the The committee noted the Service Line Reporting Data Executive Team and that overall positive contributions were made in 6.
Quarter 4 Items to note
Revised 2018/19 Operational Plan The paper updated the committee with the correspondence received from NHSi regarding the 2018/19 operational plan submission along with the Trusts response. A formal resubmission was submitted on 20th June Y 7. The committee approved the revised 2018/19 Any Other operational plan.
Veterans Update The committee reviewed the suggested development which aligns with the Trust estates strategy. It was
explained that the funding need had increased and 8. further detail was given regarding the phrase 1 and 2 N of the development. The committee asked Date and Time for the original bid to The committee expressed concerns, noting there has
3
90 1. Part One -
Chair’s Assurance Report Finance Planning and Investment Committee – 26 June 2018 2. Strategy & been no agreement through the Charitable Funds be revisited. Committee or extra footprint if the development was to grow to phrase 2. The committee noted the phrase 1 appeal for 1.5million with the possibility of expansion in the future which will include planning through phrase 2. 3. Performanc TSSU Business Case The committee reviewed the TSSU Buinsess Case and approved the favoured option 1b - Improvement of Existing Facilities (staged approach) Y The Executive Team will continue to lead on the post
implementation of the project 4.
EPMA Business Case Quality & The Trust presented the Electronic Prescribing and Medicines Administration System Business Case to the committee to ask for support and approval to apply for national funding for the system in coming months.
The key objective of the system is to improve patient 5.
safety within the Trust by improving the quality of Annual Y prescribing and the medicines administration process. Along with reducing the risk of error and the incidence of adverse events associated with process.
The committee approved and supported the EPMA Business Case and encouraged the Trust to pursue
national funding 6. Items to note Business Case and Investment Making Policy The committee approved the updated policy. Y Committee Self-Assessment and Annual Report The committee approved the committee self- assessment and annual report. 7.
It was noted the further narrative was to be included to Any Other reflect that the committee continues to have oversight Y on the Trusts RTT and trajectories targets throughout the regular performance and finance report framework.
Review of the work plan 8. The work plan was reviewed by the committee a suggested some amendments were to be Date and Time Y incorporated to ensure timely updates of TSSU, Veterans, Pain Service and ACI projects were 4
91 1. Part One -
Chair’s Assurance Report Finance Planning and Investment Committee – 26 June 2018 2. Strategy & reviewed by the committee
The committee approved the work plan.
Minutes: Capital Management Group The minutes from the recent Capital Management
Group was presented with no issues identified. 3.
Y Performanc The committee noted the minutes.
Attendance Matrix The committee noted the paper. N/A 3.4 Approvals 4.
Approval Sought Outcome Quality &
Revised Operational Plan 2018/19 Approved
TSSU Business Case Approved
EPMA Business Case Approved 5.
Business Case and Investment Decisions Making Policy Approved Annual
Committee Self-Assessment and Annual Report Approved
Review of Work Plan Approved 6.
3.6 Risks to be Escalated Items to note
In the course of its business the Committee identified no risks for escalation.
3.5 Conclusion The Board of Directors is asked to note the meeting that took place and the assurances
obtained. 7. Any Other 8. Date and Time
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92 1. Part One -
Chair’s Assurance Report Risk Management Committee 4th July 2018 2. 0. Reference Information Strategy &
Shelley Ramtuhul, Author: Paper date: 26 July 2018 Trust Secretary Chris Beacock, Executive Sponsor: Paper Category: Governance and Quality Non Executive Director
Paper Reviewed by: N/A Paper Ref: N/A 3. Performanc Forum submitted to: Board of Directors Paper FOIA Status: Full
1. Purpose of Paper 1.1. Why is this paper going to the Board of Directors and what input is required? 4. Quality & This paper presents an overview of the Risk Management Committee Meeting held on 4 July 2018 and is provided for assurance purposes.
2. Executive Summary 2.1 Context
The Board of Directors has delegated responsibility for the implementation of the Trust’s risk 5.
management systems and controls to the Risk Management Committee. This Committee is Annual responsible for seeking assurance on the Trust’s risk management in order that it may provide appropriate assurance to the Board.
2.2 Summary The meeting was well attended There was good progress of actions from the previous meeting with the majority of 6. actions completed prior to the meeting The Board Assurance Framework and Risk Register were reviewed Items to note The work plan was reviewed and agreed A deep dive was received from the Medicine and Diagnostics divisions A deep dive into the Finance risks (recorded on the BAF) was presented
2.3. Conclusion 7.
The Board is asked to note the meeting that took place and the assurances obtained. Any Other 8. Date and Time
1
93 1. Part One -
Chair’s Assurance Report Risk Management Committee 4th July 2018 2. 3. Main Report Strategy & 3.1 Introduction This report has been prepared to provide assurance to the Board from the Audit Committee which met on 4 July 2018. A full list of the attendance is outlined below:
Chair/ Attendance: 3.
Chris Beacock, Non-Executive Director (Chair) Performanc Harry Turner, Non-Executive Director Bev Tabernacle, Director of Nursing / Deputy CEO Nia Jones, Director of Operations Shelley Ramtuhul, Trust Secretary 4. Nicki Bellinger , Deputy Director of Nursing Quality & Julie Roberts, Assistant Director of Nursing Judith Sansom, Clinical Governance Lead Sara Ellis Anderson, Matron Mandy Bride, Medicine and Rehab Matron
Amanda Peet, Divisional Manager for Theatres 5.
Paula Jeffreson, Divisional Manager for Medicine and Rehab Annual Eric Hughes, Divisional Manager for Diagnostics Mark Salisbury, Deputy Director of Finance Phil Davies, Head of Estates and Facilities Maryse Mackenzie, Medicines Management Co-Ordinator Tracy Knight, Switchboard (shadowing) 6. Items to note Mary Bardsley , PA to Director of Nursing
Apologies:
Mark Brandreth, Chief executive Office
Craig Macbeth, Director of Finance 7.
Sue Pryce, Head of People Services Any Other Sarah Sheppard, Director of People Kerry Robinson, Director of Strategy and Planning Lindsey Leach, Governance Lead 8. Date and Time
2
94 1. Part One -
Chair’s Assurance Report Risk Management Committee 4th July 2018 2. 3.2 Actions from the Previous Meeting Strategy & The Committee noted that the majority of actions had either been completed or were on the agenda for discussion. The remaining actions were ongoing but with plans in place and a progress update provided. 3.3 Key Agenda
Agenda Item / Discussion Assured Assurance Sought 3.
(Y/N) Performanc Declaration of Interest N/A Nothing to note. Committee Self-Assessment The committee reviewed the self-assessment report and discussed the next steps which were suggested. 4.
A gap in the work plan process had been identified, Quality & the committee agreed work plans will be submitted for approval along with the terms of reference not just for Risk Management but all sub board committees. Y Feedback from the survey was positive but it highlighted the need to strengthen the divisional input further. 5. Annual The committee approved the self-assessment.
Committee Annual Report (Draft) The Committee received the draft annual report. The committee noted the measurement of success with
the Risk Management Committee is through internal 6. audit review. Y Items to note The committee agreed to some minor amendments to be incorporated into the report. The committee approved the Risk Management Committee Annual Report. Board Assurance Framework (BAF)
The Committee discussed the Board Assurance 7.
Framework which had been reviewed with the Any Other Executive Team. The Committee noted the updates that had been made to the controls, assurances and actions. Y The Committee discussed finance risks recorded in detail after receiving a deep dive presentation. 8. The Committee agreed further information was to be included to link the risk assurance and control which Date and Time will be reviewed before the next meeting.
3
95 1. Part One -
Chair’s Assurance Report Risk Management Committee 4th July 2018 2. Risk Register (15+) Strategy & The Committee received a copy of the risk register which identified those risks recorded with a score of over 15+. The Committee felt that a number of risks were no Small working group to longer relevant and also discussed the issue of how Partial undertake a full review Trust-wide risks could be captured. The risk register
of the risk register. 3. is to be reviewed again in full before the next meeting. Performanc The Committee was not assured that all risks were accurately captured but was satisfied with the proposed action to address this however it was noted the journey of the risk recorded had improved greatly in 12 months. Risk Management Report 4. The Committee received the Risk Management Report which outlined the following: Quality & Overall reporting levels for the Trust have Y remained stable over the past 12 months Backlog on Datix incidents – noted to be continuing to reduce Themes and trends of incidents 5. The Committee discussed the importance of the Annual transfer data to bit split into categories for further understanding and learning, this will be reported going forward. The Committee was assured that the Trust had appropriate systems in place for managing its risks and incidents. Major Incidcent Desk Top Exercise 6. Items to note The Committee received a copy Major Incident Desk Y Top Exercise and the feedback from the learning session. It was noted the exercise was well attended and positive feedback has been received.
The major incident annual plan is due to be presented 7. later on this year. Diagnostics Deep Dive Any Other The Committee received the Diagnostics Deep Dive and noted that this risk register is well management and maintained. Y The Committee noted the Diagnostics deep dive and
was assured that appropriate mitigating actions were 8. being taken. Date and Time Medicines Deep Dive The Committee received the Diagnostics Deep Dive
4
96 1. Part One -
Chair’s Assurance Report Risk Management Committee 4th July 2018 2. and noted risk 1914 has been escalated to the executive team. SOOS are currently unable to track Strategy & images unlike other services within the Trust. It was suggested the SOOS department replicate the surgical service process.
The Committee noted the Diagnostics deep dive and was assured that appropriate mitigating actions were 3. being taken. Review of the Work plan Performanc The Committee reviewed and approved the work N/A plan. Committee Attendance The Committee received and reviewed the Committee Attendance Matrix. Y 4. Any Other Business Quality & The committee received a copy of the recently To present a paper published Gosport Report. The committee discussed and action log to the current processes and the Pharmacy department Quality and Safety were invited to Quality and Safety Committee to Committee in Partial present an assurance paper. September in order to provide further
assurance to the 5. Board. Annual
3.5 Committee Approvals
During the meeting the Committee approved the following:
Committee Self-Assessment
Committee Annual Report 6.
Work Plan 2018/19 Items to note
3.6 Risks
During the meeting, one risk which required action following the discussion of the Gosport Report. An assurance paper will be presented to the Quality and Safety Committee in September. 7.
3.7 Conclusion Any Other The Board of Directors is asked to note the meeting that took place and the assurances obtained. 8. Date and Time
5
97 1. Part One -
Board Assurance Framework
0. Reference Information 2. Shelley Ramtuhul,
Author: Paper date: 26 July 2018 Strategy & Trust Secretary Mark Brandreth, Executive Sponsor: Paper Category: Governance Chief Executive Risk Management Paper Reviewed by: Paper Ref: N/A Committee Forum submitted to: Board of Directors Paper FOIA Status: Full 3. 1. Purpose of Paper Performanc
1.1. Why is this paper going to the Board and what input is required? The Board is asked to approve the suggested amendments to the BAF (highlighted in blue).
2. Executive Summary 4. 2.1. Context Quality & The Board of Directors uses the BAF as tool to ensure effective management of any risks which have potential to impact on delivery of the Trust strategy. The Trust has defined its three key strategic aims:
Operational Excellence Specialist Orthopaedic 5. MSK Annual
All underpinned by a fourth aim relating to Culture and Leadership.
2.2 Summary
This paper presents an update of the BAF which has been reviewed by the Risk
Management Committee each month ince it’s last presentation to the Board in April 2018. 6.
The Risk Management Committee have overseen the alignment of all target risks to the Items to note agreed risk tolerances and where this has resulted in a change this is highlighted in blue.
Further at the last Risk Management Committee meeting there was discussion regarding the need to link gaps in controls to gaps in assurances and during the next cycle of review with the Executive Team this will be addressed. 7.
2.3. Conclusion Any Other The Board is asked to: Note the content of the BAF Consider and agree the proposed changes Consider and agree any additional changes required Approve the BAF as a true reflection of the Trust’s strategic risks 8. Date and Time
1
98 1. Part One -
Board Assurance Framework
3. Main Report
3.1. Board Assurance Framework 2. The Board of Directors utilises the BAF to identify and track the management of risks to the Strategy & delivery of the organisations corporate objectives and ultimately the strategy. It documents the controls and assurances in place for each risk and identifies any gaps which require action to be taken.
Attached at Appendix 1 is a copy of the BAF which has been reviewed and updated with the 3. Executive Team since its last presentation to the Committee on 6 June. Performanc
There have been no changes to the risks cited on the BAF but updates have been made to the actions to address identified gaps in controls and assurances.
The Risk Management Committee have overseen the alignment of all target risks to the agreed risk tolerances and where this has resulted in a change this is highlighted in blue. 4.
Further at the last Risk Management Committee meeting there was discussion regarding the Quality & need to link gaps in controls to gaps in assurances and during the next cycle of review with the Executive Team this will be addressed.
3.2. Conclusion
The Board is asked to: Note the content of the BAF 5. Consider and agree the proposed changes Annual Consider and agree any additional changes required Approve the BAF as a true reflection of the Trust’s strategic risks 6. Items to note 7. Any Other 8. Date and Time
2
99 1. Public Meeting Part One -
1.1 2.
Operational Excellence Policy Updates Strategy & Achieving Outstanding Patient Safety Principal Risk: Inadequate or unsuccessful implementation of learning from incidents Missed opportunities to prevent further incidents, risk of increased incidents. Reputational damage and poor patient experience. Lack of output from investigations reduces reporting Risk Rating: Risk Details 3.
Inherent Risk Residual Risk Target Risk Opened: May 2017 & Performance (tolerance) Reviewed Date: June 2018 Consequence 5 4 2 Source of Risk: Incident data Likelihood 5 2 1 Corporate Risk Register? (DX TBC) Total 25 8 3 4. Controls: Assurance: Source of Assurance 3 Safety Quality & Incident and Serious Incident Policy in place and updated NRLS benchmarking Learning triangles introduced CQC Monitoring Robust Quality and Governance Structure Oversight and assurance by Quality and Safety Committee Real time data and feedback via Datix with daily reporting of incidents to executive team Monitoring by CCG with regular Quality Surveillance Meetings Safety Summit (July 2017) Internal audit report on incident management Reporting to Risk Management Committee of ongoing risks linked to incidents Internal audit on WHO process 5. RCA training rolled out to wider organisation Reports Annual Automated feedback to staff who report incidents via Datix Quarterly safety bulletin WHO process revised following Never Event Gaps in Controls: Gaps in Assurance: o Manual patient feedback capture does not provide real time data o Lack of specialty benchmarking 6. o Not all staff use RJAH or NHS.net email accounts and therefore Datix cannot send o Staff survey results on incident reporting feedback Items to note feedback Action Plan to Address Gaps Action Lead Due By Progress Update Completed Roll out of electronic solution for patient Director of Nursing Sept 2018 Project team in place with meeting with supplier taken place feedback capture 7. Monitoring of failed feedback emails with Trust Secretary Ongoing Monitoring in place with no significant issues identified YTD – 98.8% of Business Any Other actions to be identified to address issues reporters have received feedback via Datix. Survey being devised for staff identified to understand further their expectation re: feedback Risk Owner: Lead Committee Director of Nursing
Quality and Safety Committee 8. of next Date and Time
100 1. Public Meeting Part One -
1.2 2.
Operational Excellence Policy Updates Strategy &
Delivering outstanding outcomes and experience Principal Risk: Limitations as a result of IT capabilities Inability to progress innovative ways of working due to limited IT infrastructure and resource, fragmented systems resulting in continuing inefficiencies, efficiency payback of new systems not full realised or optimised 3.
Risk Rating: Risk Details & Performance Inherent Risk Residual Risk Target Risk Opened: March 2018 (tolerance) Reviewed Date: June18 Consequence 4 4 3 Source of Risk: Risk Assessment Likelihood 4 3 2 Corporate Risk Register? (DX TBC) Total 16 12 6 4. Safety Quality & Controls: Assurance: Source of Assurance 3 IMT steering group oversight and action Oversight and assurance by Audit committee Actions in response to internal audit report on cyber security Oversight and assurance by FPI committee Actions in response to internal audit on IT general controls IG committee oversight and assurance Annual penetration test with actions in response as required NHS digital benchmarking 5. Incident policy in place NHS model hospital Reports Annual Training in place NHS Digital oversight KPI’s monitored via IMT steering group STP Digital stream committee Help desk review completed Internal audit report on cyber security Chief Clinical Information Officer role in place Internal audit on IT general controls Capital Management Group Specialty benchmarking in place via model hospital 6. OLA’s for service Items to note Gaps in Controls: Gaps in Assurance: Financial viability to be tested Shared governance arrangements of STP not defined Ability to implement digital strategy Clinical process standardisation 7.
Lack of clinical standards and innovation committee Business Any Other Work required on future IT requirements Board approved IM&T strategy Board level Cyber Training 8. of next Date and Time
101 1. Public Meeting Part One -
Action Plan to Address Gaps 2. Policy Updates Strategy & Action Lead Due By Progress Update Completed EPR procurement and development of EPR Associate Director of IM&T Nov 18 Business Case to include stakeholder engagement. 3.
Development of EPR Business Case to include Associate Director of IM&T Apr 2018 & Performance stakeholder engagement.
Stakeholder engagement. Associate Director of IM&T Sep 2018
Board approved IM&T strategy Associate Director of IM&T May 2018 On the Agenda for Board in July 4. Safety Quality & Cyber training to be arranged Associate Director of IM&T Jul 2018 Scheduled for 5 July
Risk Owner: Lead Committee Director of Strategy and Planning Finance Planning and Investment Committee 5. Reports Annual 6. Items to note 7. Business Any Other 8. of next Date and Time
102 1. Public Meeting Part One - 2.
Operational Excellence 1.3 Policy Updates Strategy &
Spending our money wisely Principal Risk: Failure to achieve activity and income target within planned cost base Potential impact on Trust’s financial stability, inability to grow and invest as required, impact on cash balances, single oversight framework ratings adversely affected Risk Rating: Risk Details 3.
Inherent Risk Residual Risk Target Risk Opened: March 2018 & Performance (tolerance) Reviewed Date: June 2018 Consequence 5 4 2↑ Source of Risk: Financial management Likelihood 5 3 2 Corporate Risk Register? (DX TBC) Total 25 12 2
Controls: Assurance: Source of Assurance 3 4.
Cost improvement schemes identified to required level for 2018/19 with 20% contingency Monitoring of CIP delivery via Divisional Performance Meetings Safety Quality & QIPP schemes identified to required level Oversight by Operational Board and Finance, Planning and Investment Carter recommendations embedded in savings scheme discussions Committee Access to good quality benchmark information as per model hospital QIPP monitored by RJAH and CCG at contract meetings Daily tracking of theatre bookings NHS I oversight Focus on theatre productivity KPIs monitored via Board 5. Forward view of availability of LLP sessions and cost of this factored in to financial plan QIA process in place to ensure quality not impacted Reports Annual Risks reviewed on a monthly basis and addressed through performance reviews Planned Care Working Group oversight Lessons learned when setting the 2018/19 plan for theatre activity Gaps in Controls: Gaps in Assurance: o Further work required on future savings programmes o N/A o Demand and capacity modelling to be completed o Review of bookings process required 6. o Uncertainty around compliance with consultant job plans Items to note o Reliance on OJP some of which is not based in contract Action Plan to Address Gaps Action Lead Due By Progress Update Completed Divisions to identify further mitigating schemes Director of Finance Ongoing Ongoing discussions via Performance Meetings Demand and capacity modelling to be Assoc. Director of Sept 2018 Reconfigured plan developed with new milestones 7. completed Performance Business Any Other Bookings process to be reviewed Director of Operations Sept 2018 Enhanced external support put in place Audit of job plan compliance to be completed Director of People / October 2018 Incorporated into Internal Auditor Work Plan Director of Operations Risk Owner: Lead Committee 8.
Director of Finance Finance Planning and Investment Committee of next Date and Time
103 1. Public Meeting Part One - 2.
Operational Excellence 1.4 Policy Updates Strategy &
Meeting the requirements of our regulators Principal Risk: Failure to improve performance in relation to the CQC core standards Potential for reputational damage and impact on business growth. Inability to attract quality staff. Poor patient perception Risk Rating: Risk Details 3.
Inherent Risk Residual Risk Target Risk Opened: May 2017 & Performance (tolerance) Reviewed Date: June 18 Consequence 5 5 1 Source of Risk: CQC regulation Likelihood 5 2 2 Corporate Risk Register? (DX TBC) Total 25 10 2
Controls: Assurance: Source of Assurance 3 4.
Implementation of ‘Clutter Busters’ on each ward Regular meetings with CQC Officer Safety Quality & CQC Action Plan and Mock CQC Action Plan Internal audit review of CQC action plan Review and revision to Quality and Governance structure Board oversight and assurance Removal of breach of licence CQC Mock Inspection held Well Led Self-Assessment completed and action plan compiled External reviews of both Theatres and Paediatrics Completed PIR to CQC 5. Learning from recent CQC inspection with debriefs held with staff Initial feedback from the CQC inspection team Reports Annual
Gaps in Controls: Gaps in Assurance: o Latest inspection report awaited o Not all specialities are included in the data collection
Action Plan to Address Gaps 6. Items to note Action Lead Due By Progress Update Completed Await inspection report and Exec Team to Director of Nursing TBC Factual accuracy exercise completed on draft report, final report decide actions required awaited. Interim action plan drafted and circulated to the Board
Risk Owner: Lead Committee 7.
Director of Nursing Quality and Safety Committee Business Any Other 8. of next Date and Time
104 1. Public Meeting Part One - 2.
Operational Excellence 1.5 Policy Updates Strategy &
Spending our money wisely Principal Risk: Instability arising from fluctuations in the annual tariff from 2019/20 onwards Year on year fluctuations create a risk of instability, single oversight framework rating and segmentation adversely affected Risk Rating: Risk Details 3.
Inherent Risk Residual Risk Target Risk Opened: November 2016 & Performance (tolerance) Reviewed Date: June 2018 Consequence 4 4 3 Source of Risk: Commissioning contract Likelihood 5 4 2 Corporate Risk Register? (DX1490, DX1533, DX1602) Total 25 16 6
Controls: Assurance: Source of Assurance 3 4.
Feedback through NHS I consultation process Local pricing agreements to offset losses based on local PLICS Safety Quality & Lobbying to support adverse losses via the NOA NHS I engagement and recognition by pricing team Trust actively participating in the development of future orthopaedic tariff as part of NOA benchmarking costing transformation programme (CTP) pilot scheme CTP Report NOA and Expert Working Group Strong costing systems locally 5. Reports Annual
Gaps in Controls: Gaps in Assurance: o 2019/20 national tariff will be based on national reference costs – historically this causes o N/A shortfalls in specialist activity prices Action Plan to Address Gaps 6.
Action Lead Due By Progress Update Completed Items to note Trust working with NHSI as part of pre- Finance Director June 2018 Draft tariff currently being sense checked and assessed for impact consultation early impact assessment Lobbying through NOA on tariff losses Chief Executive / Finance Ongoing Await release of 2019/20 draft tariff under CTP Director
Risk Owner: Lead Committee 7.
Director of Finance Finance, Planning and Investment Committee Business Any Other 8. of next Date and Time
105 1. Public Meeting Part One -
1.6 2.
Operational Excellence Policy Updates Strategy &
Delivering outstanding outcomes and experience Principal Risk: Inadequate operational processes Inability to reduce the number of rescheduled episodes, missed opportunities to prevent rescheduled appointments, reputational damage and poor patient experience, inability to backfill short notice cancellations, lack of an operational transparency model to support improvements in operations processes leading to missed opportunities to increase efficiency. 3. & Performance Risk Rating: Risk Details Inherent Risk Residual Risk Target Risk Opened: March 2018 (tolerance) Reviewed Date: June 2018 Consequence 5 4 2 Source of Risk: National and local health landscape
Likelihood 5 3 1 Corporate Risk Register? (DX TBC) 4. Total 25 12 3 Safety Quality & Controls: Assurance: Source of Assurance 2 Access Policy in place Daily Comms Cell Pre-operative Assessment Transformation workstream Weekly Operational Board oversight Daily scheduling / theatre comm cell Oversight and assurance via the Finance Planning and Investment Admin review completed, full implementation 2018/19 Committee 5. Monitoring of efficiency KPIs Inpatient Survey Performance Reports Annual Operational Excellence transformation programme working groups Operational Excellence Programme Board Oversight from Strategy Board
Gaps in Controls: Gaps in Assurance:
o Booking pathway timeline compliance o N/A 6.
o Financial viability of transparency model to be assessed Items to note Action Plan to Address Gaps Action Lead Due By Progress Update Completed Implementation of Admin Review Director of Operations Sept 2018 Enhanced external support put in place Operational Excellence Programme Board to Director of Operations / Ongoing Programme Board held 11 June and proposed programme plan
develop programme plan Assoc. Dir of Performance discussed. PIDs to go to monthly meetings going forward. 7.
Options appraisal of existing technologies for Director of Operations / Sept 2018 Project lead identified and workshop with external software provided Business Any Other control room model Assoc. Dir of Performance taking place in July Risk Owner: Lead Committee Director of Operations / Assoc. Director of Performance Finance Planning and Investment Committee 8. of next Date and Time
106 1. Public Meeting Part One -
1.7 2.
Operational Excellence Policy Updates Strategy &
Delivering timely access to patient care Principal Risk: Inability to sustain the delivery of our access and waiting times Lack of capacity in sub specialties together with a failure to follow polices and embed RTT management processes. Pressure on sub specialties where demand exceeds capacity. Potential to result in breach of contracts and key targets, potential for increased costs if OJP or external capacity used. Risk of patient safety issues due to long waits. Overall reputational damage. 3.
Risk Rating: Risk Details & Performance Inherent Risk Residual Risk Target Risk Opened: November 2016 (tolerance) Review Date: June 2018 Consequence 4 4 2 Source of Risk: National Targets Likelihood 5 4 1 Corporate Risk Register? (DX885, DX1573, DX1601) Total 20 16 3 4. Safety Quality & Controls: Assurance: Source of Assurance 3 Fast track recruitment days for Theatre staff NHSi agreed recovery trajectories and monitoring and breach of licence New Access Policy in place removed Close monitoring of shortfall in theatre sessions through daily Comm Cell Finance Planning and Investment Committee monitoring Transformation work streams identified Planned Care Working Group monitoring Additional consultants recruited in Spinal Disorders, Knee and Sports Injuries and Weekly exec comm cell 5. Paediatric Orthopaedics Weekly activity and assurance meeting Reports Annual Bed modelling completed with Kenyon opened as required to support activity Mandated returns approved by Exec Team CCG PLCV /VBC authorisation process placing controls on demand to RJAH Data quality assessment of all KPIs Referrals being monitored as part of monthly planned care working group and monthly Daily theatre activity comm cell contract meeting with CCG (Service Performance Forum) Twice weekly theatre scheduling meeting
Menzies M12 opened on 1 October Operational Board established with oversight of work to deliver access targets 6.
Theatre recovery plan in place focussing on theatre efficiency – minutes utilised and cases Items to note per session with remodelling completed
Gaps in Controls: Gaps in Assurance: o Transformation work ongoing o N/A o Roll out of training to consultants on patient choice based on patient management plan 7.
expectations to be completed Business Any Other o Demand and capacity work ongoing o Case mix of RTT backlog continues. Reduction in backlog requires deliver of efficiency of theatres for inpatient activity o Spinal Disorders capacity o Control of the impact of CCG PLCV/VBC on SOOS demand and case mix imbalance 8. o Follow up backlog project behind plan of next Date and Time
107 1. Public Meeting Part One -
Action Plan to Address Gaps 2. Policy Updates Strategy & Action Lead Due By Progress Update Completed Recruitment of required consultants Medical Director Mar 18 Spinal Disorders appointment has been made, Arthroplasty appointment was delayed pending further discussion regarding the role requirements but now out to advert. Foot and Ankle appointment under review. Business case for additional spinal capacity has been discussed and progressed via Executive Team 3. & Performance Completion of capacity and demand work Associate Director of Sept 18 Reconfigured plan developed with new milestones Performance Implementation of Administration Review Director of Operations Sept 18 Enhanced external support put in place recommendations to improve booking process Progress follow up back log project Director of Operations Sept 18 Recovery plan in place, stakeholder workshop with CCG held in June, refreshed membership of the project group 4. Safety Quality & Risk Owner: Lead Committee Director of Operations Finance Planning and Investment Committee 5. Reports Annual 6. Items to note 7. Business Any Other 8. of next Date and Time
108 1. Public Meeting Part One -
2.1 2.
Specialist Orthopaedic Policy Updates Strategy &
Delivering outstanding outcomes and experience Principal Risk: Lack of clear national strategy for the commissioning of our specialist services Risk of fragmentation and risk to sustainability of specialist services, centres of excellence diminished impacting on the quality of patient care for complex cases
Risk Rating: Risk Details 3.
Inherent Risk Residual Risk Target Risk Opened: March 2018 & Performance (tolerance) Review Date: June 2018 Consequence 4 4 3 Source of Risk: National and local health landscape Likelihood 4 3 2 Corporate Risk Register? (DX TBC) Total 16 12 6 4. Controls: Assurance: Source of Assurance 3 Safety Quality & NOA collaboration Previous national strategy for specialised commissioning Engagement with specialist commissioners and NHS England NHS I and NHS E oversight Internal definition and understanding of specialist services with a wider view beyond Trust strategy specialist commissioning STP collaboration Specialist Orthopaedic programme 5. Reports Annual
Gaps in Controls: Gaps in Assurance: o Further definition of specialist orthopaedic programme o N/A 6. Items to note
Action Plan to Address Gaps Action Lead Due By Progress Update Completed Strategy development Director of Nursing Ongoing – Forward view underdevelopment, working with the NOA. Update 7. next report to provided to Board in June Business Any Other Strategy Board Risk Owner: Lead Committee Director of Nursing
Board of Directors 8. of next Date and Time
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2.2 2.
Specialist Orthopaedic Policy Updates Strategy &
Delivering outstanding outcomes and experience Principal Risk: Local health partners do not see the benefit of specialist orthopaedic services within the system Ability to lead the MSK pathways compromised, difficulties integrating into the local system work with weak voice Risk Rating: Risk Details 3.
Inherent Risk Residual Risk Target Risk Opened: March 2018 & Performance (tolerance) Review Date: June 2018 Consequence 4 4 3 Source of Risk: National and local health landscape Likelihood 4 3 2 Corporate Risk Register? (DX TBC) Total 16 12 6 4. Controls: Assurance: Source of Assurance 3 Safety Quality & Trust representation within the STP workstreams STP updates to Board CEO and Chair Network for the STP NHS I and NHS E input Engagement with key partners in the local health system Kings Fund led workshops Trust strategy Horizon scanning 5. Reports Annual
Gaps in Controls: Gaps in Assurance: o N/A o N/A 6. Items to note
Action Plan to Address Gaps Action Lead Due By Progress Update Completed 7. Business Any Other Risk Owner: Lead Committee Director of Nursing Board of Directors 8. of next Date and Time
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3.1 2.
MSK Policy Updates Strategy &
Delivering timely access to patient care Principal Risk: MSK service integration fails to deliver expected benefits due to lack of understanding of the self-management and non-surgical pathways Potential reduction in activity at the Trust with loss of contracted work, impact on stability and availability of specialist work, potential for duplicate visits for patients, inability to respond to external factors. Host commissioner in financial recovery and requires material reduction in orthopaedic spend, impact for the Trust still to be determined. 3.
Risk Rating: Risk Details & Performance Inherent Risk Residual Risk Target Risk Opened: May 2017 (tolerance) Review Date: June 2018 Consequence 4 4 4↑ Source of Risk: External drivers Likelihood 4 3 1 Corporate Risk Register? (DX1490, DX1533, DX1602) Total 16 12 4 4. Safety Quality & Controls: Assurance: Source of Assurance 3 Monitoring of GP referrals Strategy Oversight Group overseeing delivery Horizon scanning in place Board reporting programme in place Regular dialogue through contract meetings Clinical Cabinet established Monthly 1:1 between the Directors of Finance and Chief Executives Local MSK Programme Board in place Participation in MSK service developments and SOOS Finance, Planning and Investment Committee Oversight (Previously BRIC) 5. Delivery of QIPP prior approval requirements Monthly performance report Reports Annual STP Directors Monthly Report NHS I monitoring Strategy deployment linked to objective setting Shropshire CCG MSK Programme Board Programme plan in place SOOS project board in place STP governance arrangements defined Contract in place with contractual review meetings
SOOS KPIs in place Monthly MSK meeting with the CCG 6.
1st phase complexity modelling completed Items to note Gaps in Controls: Gaps in Assurance: o Ability to implement strategy N/A o Stakeholder communication void Action Plan to Address Gaps Action Lead Due By Progress Update Completed 7. Business Any Other Staff engagement on MSK Director of Strategy and Oct 2018 Staff survey to be distributed in July Planning Tactical communications plan to be taken Director of Strategy and Jul 2018 Steer provided by the Board, to be followed up through the through the Executive Team Meeting Planning Executive Team Risk Owner: Lead Committee 8. Director of Strategy and Planning Finance, Planning and Investment Committee of next Date and Time
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Culture and Leadership 4.1 Policy Updates Strategy &
Being an extraordinary place to work Principal Risk: Failure to improve staff engagement linked to communication between managers and the workforce Inability to improve the culture and behaviour of the workforce, difficulties attracting staff to the organisation, poor patient experience Risk Rating: Risk Details 3.
Inherent Risk Residual Risk Target Risk Opened: Apr 17 & Performance (tolerance) Review Date: June 2018 Consequence 4 4 2 Source of Risk: Staff survey results Likelihood 5 3 2 Corporate Risk Register? (DX TBC) Total 20 12 4
Controls: Assurance: Source of Assurance 3 4.
Monthly Barometer Group Regular updates to the Quality and Safety Committee and Board Safety Quality & 6 weekly pulse checks to measure delivery NHS I PRM Ward buddying with escalation of issues to exec team Staff Survey Communications and engagement strategy Pulse Checks Six monthly big conversations NHS I Oversight Framework Leadership training and bite-sized modules for wider organisation Oversight from Workforce Development Group Workforce Development Group in place 5. Established Performance Review Programme Reports Annual Additional resource in place to assist with the delivery of the engagement programme Performance framework in place Gaps in Controls: Gaps in Assurance: o Effectiveness of information cascade as a result of having no formal cascade process o Service improvement expertise o Establishing / re-enforcing management code of conduct 6. Action Plan to Address Gaps Items to note Action Lead Due By Progress Update Completed Review of how communications cascade works Assoc. Dir of Performance Sept 2018 Survey of staff regarding communication has been issued with results to be undertaken now in the process of being reviewed and to feed into the Communications Strategy Business case to be developed for service Director of Strategy and Sept 2018 7. improvement expertise Planning Business Any Other Risk Owner: Lead Committee Director of Strategy and Planning Workforce Development Group 8. of next Date and Time
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Culture and Leadership 4.2 Policy Updates Strategy &
Being an extraordinary place to work Principal Risk: Potential inability to have the right workforce in the right place at the right time Inadequate succession planning and talent management resulting in gaps in levels of expertise. Risk to staff morale resulting in increased turnover. Inability to increase activity safety to meet RTT targets resulting in further regulatory scrutiny. Poor patient experience and potential patient safety risks 3. Risk Rating: Risk Details & Performance Inherent Risk Residual Risk Target Risk Opened: March 2018 (tolerance) Review Date: June 2018 Consequence 4 3 2 Source of Risk: Workforce Likelihood 4 3 2 Corporate Risk Register? (DX TBC) Total 16 9 4 4.
Controls: Assurance: Source of Assurance 3 Safety Quality & Recruitment plan in place with targeted recruitment to staff bank to increase resilience Performance report Sickness absence management Safe staffing audits Staff turnover monitoring Turnover and sickness absence rates Leadership training to support effective management and engagement of staff Quality and Safety Committee and Board oversight Line of sight of the detail of theatre usage Agency usage monitoring (within the cap) 5 year people plan in place Workforce development oversight and deep dives into hotspots 5. 50% of areas within target for vacancy percentages Reports Annual Gaps in Controls: Gaps in Assurance: o Development of new roles o N/A o Manager engagement, responsibility and accountability o Efficiency and timeliness of recruitment process o Role specific recruitment plan 6. Items to note Action Plan to Address Gaps Action Lead Due By Progress Update Completed Development of new roles to be looked at Deputy Director of HR Mar 2019 New roles currently being looked at are the expansion of within the Divisions apprenticeships, associate nurse roles and physician associates through 5 year people plan Review of recruitment processes Deputy Director of HR Oct 2018 Looking at introducing the system TRAC (subject to budget increase) to 7. enable more transparency re delays. Business Any Other Manager workshops Deputy Director of HR Oct 2018 Workshops commenced – values based recruitment training launched Role specific recruitment plans to be devised Deputy Director of HR Oct 2018 Nursing specific recruitment plan being looked with potential also for radiology. Risk Owner: Lead Committee Director of People Workforce Group 8. of next Date and Time
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Appendix One: Assessment of Trust’s Risk Appetite Against the ‘Risk Appetite for NHS Organisations Matrix 2. Policy Updates Strategy &
Risk Levels 0 1 2 3 4 5 Key Avoid Minimal Cautious Open Seek Mature Avoidance of risk and As little risk as possible. Preference for safe Willing to consider all Eager to be innovative Confident in setting high
Elements 3. uncertainty is a key Preference for ultra-safe delivery options that have potential delivery options and to choose options levels of risk appetite
↓ organisational objective delivery options with low a low degree of inherent and choose while also offering potentially higher because controls, forward & Performance degree of risk and only for risk and may only have providing an acceptable business rewards (despite scanning and response limited reward potential limited potential for reward level of reward greater inherent risk) systems are robust Financial / Avoidance of financial loss Only prepared to accept Prepared to accept Prepared to invest for Investing in best possible Consistently focussed on Value for is a key objective. We are the possibility of very possibility of limited return and minimise the return and accept the the best possible return only willing to accept the limited financial loss if financial loss. VfM still the possibility of financial loss possibility of financial loss for stakeholders.
Money (VfM) low cost option as VfM is essential. VfM is the primary concern but will by managing risks to a (with controls in place). Resources allocated in 4.
the primary concern primary concern. consider other benefits of tolerable level. Value and Resources allocated ‘social capital’ with Safety Quality & constraints. Resources benefits considered. without guarantee of confidence that process is generally restricted to Resources allocated to return – ‘investment a return in itself existing commitments. capitalise opportunities. capital’ type approach Compliance / Play safe, avoid anything Want to be very sure we Limited tolerance for Challenge would be Chances of losing any Consistently pushing back Regulatory which could be would win any challenge. sticking neck out. Want to problematic but we are challenge are real and on regulatory burden. challenged, even Similar situations be reasonably sure we likely to win it and the gain consequences would be Front foot approach unsuccessfully elsewhere have not would win any challenge will outweigh the adverse significant. A win would informs better regulation 5. breached compliances consequences be a great coup Reports Annual Innovation / Defensive approach to Innovations always Tendency to stick to the Innovation supported, with Innovation pursued – Innovation the priority – Quality / objectives – aim to avoided unless essential status quo, innovations in demonstration of desire to ‘break the mould’ consistently ‘breaking the maintain/protect, rather or commonplace practice avoided unless commensurate and challenge current mould’ / challenging Outcomes** than create or innovate. elsewhere. Decision necessary. Decision management control working practices. New current working practices. Tight management making authority is held making authority held by improvements. Systems / technologies viewed as a Investment in new
controls and oversight / by senior management. senior management. technology developments key enabler of operational technologies as catalyst 6. limited devolved decision Only essential systems / Systems / technology used to enable operational delivery. High levels of for operational delivery. Items to note taking authority. General technology developments developments limited to delivery. Responsibility devolved authority – Devolved authority – avoidance of systems / to protect current protection of current for non-critical decisions management by trust management by trust not technology developments operations operations. may be devolved rather than tight control tight control is standard. Reputation No tolerance for any Tolerance for risk taking Tolerance for risk taking Appetite to take decisions Willingness to take Track record / investment decisions that could lead limited to events where limited to events where with potential to expose decisions likely to bring in communications has to scrutiny of, or indeed there is no chance of there is no chance of the Trust to additional scrutiny but where built public, press and
attention to, the significant repercussions. significant repercussions. scrutiny/interest. potential benefits politician confidence that 7.
organisation. External Senior management Should there be failure. Prospective management outweigh risks. New difficult decisions will be Business Any Other interest in the organisation distant from chance of Mitigations in place for of organisations reputation ideas seen as potentially taken following benefits / is viewed as a concern exposure to attention undue interest enhancing reputation risk analysis ** Where pursuit of the Trust’s strategic objectives results in quality and outcome risks the Trust will adopt a cautious approach but will adopt a seeking approach for innovation risks. 8. of next Date and Time
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0. Reference Information 2.
Strategy &
Sue Sayles th Author: Paper date: 26 July 2018 Phil Davies- Cleanliness Executive Sponsor: Bev Tabernacle Paper Category: Governance and Quality Quality& Safety Paper Reviewed by: Infection Control Paper Ref: N/A Committee 3.
Performance & Forum submitted to: Trust Board Paper FOIA Status: Full
1. Purpose of Paper
1.1. Why is this paper going to Trust Board and what input is required? 4.
The Board of Directors are asked to note the progress report against the annual plan for: Quality & Infection Prevention and Control and Cleanliness Report
2. Executive Summary
2.1. Context
Through the monthly Board performance report, the Board are briefed on the mandatory 5.
bacteraemia and any key issues emerging from those results. Over and above the Annual mandatory reporting, the Board receive a report at least four times per year from the Director of Infection Prevention and Control (Director of Nursing). This report includes a high level summary of the key issues in Infection Prevention and Control as well as cleanliness.
2.2. Summary MRSA MSSA E .coli 6. Bacteraemia Bacteraemia Bacteraemia
C. difficile Items to note RJAH Acquired RJAH Acquired RJAH Acquired Month No. of Cases No. of Cases No. of Cases No. of Cases April 0 0 1 1 May 0 0 1 0
June 0 1 0 0 7. Any Other Quarter 0 1 2 1
2.3. Conclusion The Board of Directors will have seen through the Board performance papers that there have been no cases of reportable MRSA bacteraemia since 2006.
Summary in the main report shows current performance in cleanliness and infection control 8.
against the work plan. Date and Time
1
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3. The Main Report Strategy &
3.1. Introduction This report provides an update on progress made within quarter 1, 2018/19 to the Board of Directors, to ensure that the Board are briefed at a high level on any trends or issues that identify best practice or any gaps in assurance from which further work or actions are required. 3.
3.1.2 Infection Control Committee Performance & The Board agreed the Infection Prevention and Control programme of work for 2015 – 18, which has been developed in line with the Shropshire and Telford Health and Social care Strategy. The Trust has achieved full compliance on all standards with the exception of having a fit for purpose IT system to support surveillance activity.
4. The IPC Programme of Work 2018 20 will be shared at the Infection Control Committee in – Quality & July 2018.
3.2. Cleanliness Measured cleanliness has been maintained above the National calculated target (85.0%)
and Trust target (94.0%) over the most recent quarter, achieving an overall average for the 5. quarter of 98.2% which is consistent with recent reporting periods. The below chart Annual demonstrates the position for the last 2 quarters. Cleaning Score 100
95 6.
90 RJAH Score Score Items to note
85 National Target % Clean Trust Target 80
75
Jan Feb Mar Apr May Jun 7.
Any Other
8.
Date and Time
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2. 3.2.1. Cleanliness – High Risk Areas Strategy & Measured standards in the Very High Risk areas including Theatre areas, HDU and TSSU are displayed below: • 98.45% Theatres 1-6 • 98.39% Menzies
• 97.30% TSSU - Main Theatre 3.
• 99.92% HDU Performance & • 98.25% Theatres 7-10 • 98.09% TSSU B
The graph below demonstrates scores in very high risk areas across the quarter. Failings are picked up through specific action plans, with supervisors performing regular spot checks 4.
to compliment a robust audit schedule. Quality & Very High Risk Area Cleaning Scores 100.0% 99.5%
99.0% 5.
98.5% Annual 98.0% 97.5%
% Clean 97.0% 96.5% 96.0% 6. Items to note 95.5% 95.0% April May June
Theatres 1-6 Menzies TSSU HDU Theatres 7-10 TSSU B National Target 7. Any Other TSSU A continues to be a challenging environment. When auditing, the area is broken down into three rooms, which magnifies any one individual fail. Audits of 520 items identified 14 items failing to meet the required standard. Audits highlighted various issues, including cleanliness of hand gel dispensers, the need to scrub the floor and a requirement to buff and polish surfaces. Each individual issue is raised with the domestic who takes ownership of the area, and resolutions are followed up. 8.
Because of the persistent breach of threshold, cleaning in theatres is being escalated with Date and Time members of the management team in attendance over the night shift to observe and formalise improvement actions. 3
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2. Strategy & 3.2.2. Cleanliness – Staff Training has a very high compliance for the rolling 12 month period, demonstrating our commitment to the highest level of staff competency. The rolling year position is: demonstrated below: 3. Performance & 4.
Less than 70%-89% 90% or Less than 70%-89% 90% or Quality & 70% greater 70% greater To bolster the infection control e learning all housekeepers now undertake practical infection control learning, led on each occasion by the infection control specialist nurse, this will roll on an annual basis. Estates have been providing the domestic team with enhanced water infection training to address issues including pseudomonas and legionella through good practice and flushing 5. regimes Annual 3.2.3. Cleanliness – Spend on Cleanliness Cleaning is currently overspent, the majority of the overspend is in staffing, where bank staff are being used to cover vacancies. The department is following the HR process to bring new staff in as quickly as possible onto contract to provide a consistent service. 6.
Budget Variation Items to note £25,000.00 £20,000.00 £15,000.00 £10,000.00
£5,000.00 7.
£- Any Other £(5,000.00) Apr-18 May-18 £(10,000.00) £(15,000.00) £(20,000.00) Overspend Underspend 8. £(25,000.00) Date and Time Budget Gap
4
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3.2.4. Cleanliness – Patient Satisfaction Strategy & Patient satisfaction is sustaining its very high level, reflecting the feedback from the CQC inpatient survey and the net promoter score.
Did you feel the Ward environment was clean?
Month Always Mostly Sometimes Never N/A 3.
April 356 6 3 0 2 Performance & May 385 24 0 0 1 June 482 25 1 0 2 99.7% of those asked found the ward environment to be always or mostly
clean; 4. 24 compliments relating to cleanliness were recorded in the written comments; Quality & One written comment that provided feedback of “Always” however they queried staffing levels for cleaning staff on Powys ward. This comment appears in isolation. Ward receives assistance during periods of low annual leave and sickness; this is known as the buddy process. On occasions when the buddy is not available the ward is sufficiently staffed but there may be a perception that staffing has been reduced.
Positive compliments are regularly fed back to housekeeping staff. 5.
The CQC adult inpatient survey 2017 results were published in June 2018. The survey of Annual 728 patients revealed a Trust score of 9.6/10 for cleanliness of rooms/wards; reflecting the continued positive feedback received in patient satisfaction surveys.
3.2.5. Cleaning Developments As the department replaces failing equipment, it is investing in new technology. The new device, which was initially trialled and subsequently purchased incorporates high frequency 6. oscillation to achieve a deep floor clean. The results of which are apparent in the below Items to note picture: 7. Any Other 8. Date and Time
5
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3.2.6. PLACE 2. Strategy & The Trust undertook its annual PLACE assessment in May 2018. Results will be verified and publish in August 2018 to enable benchmarking; however initial finding indicate some key themes: Roll out of ‘Dementia Friendly’ environment across surgical wards, including toilet seats, signage & matt flooring Clutter – particularly in terms of signage/posters on walls and noticeboards. 3. Paint chipping and scuffs on walls. Non complaint waste bins (i.e. not solid sided and soft closing) Performance & A risk rated action plan is being created and will be presented back to infection control committee and monitored through the infection control working group.
3.3. Infection Prevention & Control 4.
3.3.1. Training Quality &
The Infection Control Training expires every 3 years, the data below shows the number of staff who are compliant and the number who’s training has expired.
Total number of eligible staff: 1231 Total number of staff compliant: 964 5. Total number of staff who’s training is due in Qtr1: 267 Annual Total number of staff who completed their training in Qtr1: 148 Total number of staff still to complete their training: 119
RJAH % Infection Control Training Completed/Outstanding -
Qtr 1 18/19 6. Items to note 148 staff complete Q1 2018-19, 12.02%
119 staff still to complete, 9.67% Percentage Complete Jul-15 -
Mar-18 7.
964 staff complete Any Other Percentage Still to Complete prior to Q1 2018-19, 78.31% Percentage Completed Q1 2018- 19 8. Date and Time
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2. Ward/departmental managers are responsible for ensuring that staff are up to date with infection control training as part of the appraisal process. Interactive infection control training Strategy & is delivered to all staff on induction including volunteers and work experience to the trust. Practical ward training is delivered on request.
3.3.2. Infection Control Link Meetings 3. •Health Care Associated Infections/PIR Documentation •Catheter Associated Urinary Tract Infections (CAUTI) Datix Reporting Performance & April •Theatres Inspection Update •Catheter Passport •Clinimatic/Macerator Cleaning Checklist
• Importance of hyration to prevent urinary tract infections
• Hydration leaflet 4. May E -update •Hydrating fruits Quality & • Signs and symptoms of a catheter associated urinary tract infection
•Environmental Audit Changes •Hand Hygiene Competency Assessment Tool June •Reported E.coli /pseudomonas and klebsiella bacteramia •Audit update 5.
Annual
3.3.3. Audit In Quarter 1, the identified planned clinical audits have been undertaken. These include audit tools from: A purpose designed environmental audit covering cleanliness, waste, linen, sharps, personal protective equipment, kitchens, hand hygiene facilities and isolation 6. facilities. Items to note High Impact Interventions
Hand hygiene/ Bare below the elbow audits These audit results are displayed on ward STAR Boards.
7.
Any Other
8. Date and Time
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3.3.3.1. Hand Hygiene 2. Strategy & RJAH IPC Hand Hygiene Compliance Q1 2018/19 (Target 95%) 100.00%
90.00% 3. 80.00% 70.00% Performance & 60.00% 50.00% 40.00% Apr-18 30.00% 20.00% May-18 10.00% Jun-18 0.00% 4. Quality & DXA OPD HDU TSSU POAU Clwyd Powys ORLAU Wrekin Ludlow Oswald Kenyon Sheldon Menzies Theatres Recovery Orthotics Therapies Radiology MCSI OPD Gladstone Baschurch Alice/COPD Anaesthetic Montgomery
RJAH IPC Bare Below Elbow Compliance 5.
Q1 2018/19 (Target 95%) Annual 100.00% 90.00% 80.00% 70.00% 60.00%
50.00% 6. Apr-18 40.00% Items to note 30.00% May-18 20.00% Jun-18 10.00% 0.00% DXA OPD HDU TSSU POAU Clwyd Powys ORLAU 7. Ludlow Wrekin Oswald Kenyon Sheldon Menzies Theatres Recovery Orthotics Therapies Radiology MCSI OPD Gladstone Baschurch Any Other Alice/COPD Anaesthetic Montgomery
The overall hand hygiene and bare below the elbow audit compliance remains above 95%. 1326 hand hygiene audits were undertaken over quarter 1 with an overall Trust score of 96.98% compliance, and bare below the elbow element of the audit resulted in 98.87% compliance with 1329 audits completed. Staff are encouraged to challenge poor practice at 8. the point of care and action plans are devised for any areas scoring less than 95%. Date and Time
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3.3.3.2. Environment 2. Strategy & RJAH IPC Environmental Compliance Q1 2018/19 (Target 95%) 100.00% 3. 90.00% Performance & 80.00%
70.00%
60.00%
50.00%
Apr-18 4. 40.00% May-18 Quality & 30.00% Jun-18 20.00%
10.00%
0.00% 5. DXA OPD HDU Annual TSSU POAU Clwyd Powys ORLAU Ludlow Wrekin Oswald Kenyon Sheldon Menzies Theatres Recovery Orthotics Therapies Radiology MCSI OPD Gladstone Baschurch Alice/COPD Anaesthetic Montgomery The above graph demonstrates the monthly environmental audit results. The most common areas of non-compliance are:
Environment: Floors clean & in good state of repair 6.
Environment: Bins are enclosed, foot operated & soft closing Items to note Hand wash sink clean & in good state of repair
Estates have reviewed the hand hygiene sinks across the Trust; high risk areas have been agreed and immediately funded so works to replace the sinks (sensor taps etc.) can be programmed in. The long term strategy is that all other remaining areas will be incorporated into the backlog maintenance and be carried out on a rolling programme yearly. 7. Any Other A bin replacement programme is in place across the Trust to ensure that they are solid sided and soft closing. Any floors identified as being unclean are flagged to the domestics at the time of the audit; a floor replacement programme is in place.
8. Date and Time
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3.3.3.3. Saving Lives: High Impact Interventions 2. Strategy &
RJAH IPC High Impact Interventions Compliance Q1 2018/19
100.00% 3. Performance & 90.00%
80.00%
70.00%
60.00% 4. 50.00%
Apr-18 Quality & 40.00% May-18 30.00% Jun-18
20.00%
10.00% 5. 0.00% Annual
6.
7238 High Impact Intervention audits were undertaken over quarter 1 with a score of 97.83% Items to note compliance, which is consistently above the Trust target of 95%. These include insertion and care of peripheral, central and PICC lines; insertion and care of urinary catheters; prevention of surgical site infection and cleaning and decontamination. The lower results for Ludlow Ward are due to the inconsistency of completing the audit tool; this has been shared with the Ward Manager to raise awareness and encourage consistency
going forward. 7.
Any Other
8.
Date and Time
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2. 3.3.4. Surgical Site Surveillance Strategy & Providing data to the national SSI process enables the Trust to benchmark on a national basis with other Trusts and promote the low infection rates within the Trust. The process uses nationally agreed criteria from which the definition of a Surgical Site Infection is formed. Understanding surgical site infection rates enables the Trust to estimate the size of SSI risk in patients undergoing specific operations.
The Trust submits the maximum of all data, which is above the national requirement for one 3. quarter of surveillance in one category of surgery per year. Year round surveillance is performed in total hip, total knee and spinal surgeries. Performance & The Trust submits surgical site infection data to the PHE database on a quarterly basis; these reports are always one quarter in arrears to allow a window of time for any infections to present. The data below shows the SSI rates for Jan – Mar 2018. 4. Quality & TKR THR Spines 3 infections 2 infections 1 infection from 520 from 448 from 249 procedures procedures procedures 5. 0.6% 0.4% 0.4% Annual
National National National Average Average Average 0.9% 0.9% 1.4%
. 6.
The Infection Control Nurse/ Surgical Site Surveillance Nurse liaise with Consultants Items to note concerning wound infections. The data for Jan-March has been verified and the results have been submitted to PHE and published on their web site. All of these infections were discussed and agreed at the infection Multi-Disciplinary Team meeting (MDT). Infection rates across the three specialities during quarter 4 show a marked improvement since the previous quarter, with the Trust performing well below the national average.
7.
Any Other
8.
Date and Time
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Graph showing trend in SSIs: 2. Strategy & RJAH No. of SSIs Reported on the Surgical Site Infection Surveillance Service per Qtr by Speciality Apr 2016 - Apr 2018 10 9 8
7 3.
6 Performance & 5 4 No. of SSIs 3 2 1 0 Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan - 4.
16 16 16 17 17 17 17 Mar 18 Quality & THR 2 0 1 0 0 1 3 2 TKR 3 3 6 0 0 2 5 3 Spinal Surgery 1 2 4 2 3 4 4 1
We continue to review all potentially infected cases at the weekly infection MDT including other orthopaedic specialities such as foot and ankle, hand/upper limb and paediatric; these 5. are not submitted to PHE but are recorded on our local database. Annual
3.3.5. MRSA Swabbing & New Isolates
MRSA swabbing for all admissions continues and is monitored internally to ensure that the Trust remains compliant to the national requirement for reducing preventable Hospital 6. Acquired Infections. Items to note
April 18 May 18 June 18 Eligible patients 835 1032 1049
Screened for MRSA 835 1030 1046
% achieved 100% 99.81% 99.71% 7. Target 95% 95% 95% Any Other
MRSA screening compliance remains well above the target of 95%.
8. Date and Time
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3.3.6. Alert Organisms 2. Strategy & 3.3.6.1. C..difficle
There has been one case of C.difficle infection reported to the PHE HCAI database in Q1 During April a patient on Powys ward tested positive for C.difficle following requiring intravenous antibiotics for a post- operative chest infection. 3. Performance & A post infection review meeting identified that there had been no lapse in patient care and the antibiotic prescribed to treat the chest infection was within the Shropshire Antibiotic Guidelines. The Trust has followed the appeals process for consideration by the Commissioners for removal from the actual number of cases for the purpose of calculations of financial sanctions. The trust identified there had not been a lapse in care, however, the lessons learned from this case resulted in an action plan being implemented focusing on the following:- 4. Quality & Timeliness of obtaining a stool specimen Poor communication of loose bowel history on transfer from HDU to Ward Timeliness of isolation
5. Annual
6.
3.3.6.2 MSSA bacteraemia Items to note There have been no reported cases of MSSA bacteraemia during quarter 1 3.3.6.3 E.coli bacteraemia. During quarter 1 RJAH reported two E.coli blood stream infections to the HCAI surveillance database.
7. Any Other One case of E. coli bacteraemia was on Sheldon ward in April. The patient had recently been treated for urosepsis and was transferred to RJAH for rehabilitation. The patient became acutely unwell with pyrexia, blood cultures grew E.coli. A urine infection was the most likely source of the blood stream infection. The second case of E. coli bacteraemia on Powys ward in May. The patient had previously been treated for a presumed urinary tract infection (UTI) and septicaemia prior to transfer to RJAH. The patient became acutely unwell with pyrexia, vomiting and abdominal pain, a 8. blood culture obtained grew E.coli. The patient was transferred to the Royal Shrewsbury Date and Time Hospital for a surgical team assessment for possible gall bladder pathology.
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3.4 Outbreaks 2. Strategy & There have been no outbreaks recorded during Quarter 1. 3.5 Serious Incidents
There have been no serious incidents recorded during Quarter 1.
3.6 Conclusion 3.
The Trust reports positive outcomes against national set targets for HCAI: Performance & o The Trust continues to have no cases of MRSA bacteraemia. o The Trust has had one case of C.difficle against a target set at one for 2018/19. The surgical site infection data for January – March 18 shows there were 6 surgical site infections across hips, knees and spines, performing well below the national average. All orthopaedic speciality surgery is being monitored closely and all cases of 4.
suspected/confirmed infections are discussed at the Consultant Led Weekly Infection Quality & MDT meetings.
5. Annual
6.
Items to note
Sue Sayles: Infection prevention and Control Nurse Bev Tabernacle: Director of Infection Prevention & Control July 2018 7. Any Other
8.
Date and Time
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2.
Appendix 1: Acronyms Strategy &
MRSA Methicillin Resistant Staphylococcus Aureus MSSA Methicillin Sensitive Staphylococcus Aureus MDT Multi-Disciplinary Team 3. E.coli Escherichia. Coli Performance & C.diff Clostridium difficile KPI Key Performance Indicators PHE Public Health England STAR Sustaining Through Assessment and Review SSI Surgical Site Infection 4. Quality & TKR Total Knee Replacement THR Total Hip Replacement HCAI Healthcare Associated Infection UTI Urinary Tract Infection
5.
Annual
6.
Items to note
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Any Other
8.
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Infection Prevention & Control & Cleanliness Quarter 1 Report 2018/19
Glossary 2. Strategy & Bacteraemia: The presence of bacteria in the blood without clinical signs or symptoms of infection C. difficile: or C. diff is short for Clostridium difficile. It is a type of bacteria (germ) which less than 5% of the population carry in their gut without becoming ill. It is normally kept under control by the ‘good’ bacteria in the gut. However, when the good bacteria are reduced, e.g. by taking antibiotics, C. difficile can multiply and produce toxins (poisons) which can cause diarrhoea. The C. difficile bacteria form spores (germs that have a protective coating). These 3. spores are shed in the diarrhoea of an infected person and can survive for a long time in the Performance & environment. C. difficile is highly infectious and can be spread from patient to patient unless strict hygiene measures are followed. E coli: is an organism we all carry in our gut, and most of the time it is completely harmless. It is part of the coliform group of bacteria – often known as Gram Negative bacteria. Most strains do not cause any symptoms while being carried in the gut. Instead E coli forms part of our “friendly” colonising gut bacteria. However when it escapes the gut it can be 4. dangerous. E coli is the commonest cause of blood stream infections (bacteraemia) in the Quality & community. The most frequent problem it causes is a urinary tract infection, but it can also cause infections in the abdomen such as gallbladder infections or following perforations of the bowel. HCAI: Health Care Associated Infection. An infection acquired as a result of receiving treatment in a health care setting.
Legionella: Legionellosis is a collective term for diseases caused by legionella bacteria 5. including the most serious Legionnaires’ disease. Legionnaires’ disease is a potentially fatal Annual form of pneumonia and everyone is susceptible to infection especially the elderly. The bacterium Legionella pneumophila and related bacteria are common in natural water sources such as rivers, lakes and reservoirs, but usually in low numbers. They may also be found in purpose-built water systems such as cooling towers, evaporative condensers, hot and cold water systems and spa pools. MRSA: or Methicillin Resistant Staph aureus, is a highly resistant strain of the common bacteria,Staph aureus. Bloodstream infections (bacteraemia) cases are the most serious 6. form of infection where bacteria, in this case MRSA, escape from the local site of infection, Items to note such as an abscess or wound infection, and spread throughout the body via the bloodstream. All cases of MRSA detectedin the blood are reported by the trust. MSSA: or Methicillin Sensitive Staph aureus, is the more common sensitive strain of Staph aureus. Up to 25% of us are colonised with this organism. Mostly it causes us no problem but it is a frequent cause of skin, soft tissue and bone infections. As with its more resistant
cousin, MRSA, sometimes the infection can escape into the bloodstream producing a 7. “bacteraemia” i.e. bacteria in the blood. Unlike MRSA, the majority of the infections will be acquired in the community, and are not associated with health care. However, some may Any Other arise as a consequence of health care, and like MRSA, it can arise from infected peripheral and central intravenous lines and other health care interventions. We were asked by the Department of Health in 2011 to report all MSSA bacteraemia cases, whether acquired in the community or in hospital, so that we can review the sources and identify potentially avoidable cases. So far no targets have been set. However, we can compare ourselves with
other trusts and put in interventions to further reduce infections. 8.
Date and Time
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130 1. Part One -
PICKER REPORT
0. Reference Information 2. Strategy &
Author: Paper date: 26 July 2018
Strategy / Governance Executive Sponsor: Stephen White Paper Category: and Quality / Performance Inpatient Survey Paper Reviewed by: Paper Ref: 3. Full PICKER Report Full / Partial / Non Performance & Forum submitted to: Board of Directors Paper FOIA Status: disclosure
1. Purpose of Paper
1.1. Why is this paper going to Trust Board and what input is required? 4.
For information Quality &
2. Executive Summary
2.1. Context This full report is now available from Picker where we are joint second in NHS England Trusts performing at this very high level for two years running (Top place last year). 5. Annual 2.2 Summary This is much to celebrate but also lessons for us to learn. We need to support patients on their discharge from hospital especially involving patients in decisions about them and considering their family or home situation.
6. Items to note
2.3. Conclusion
Continue to prioritise patients needs
7.
Any Other 8. Date and Time
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Inpatient Survey 2017 6. Items to note
The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
7. Final Report Any Other
January 2018
8.
www.picker.org Date and Time
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Picker 2.
Strategy & Picker is an international charity dedicated to ensuring the highest quality health and social care for all, always. We are here to:
Influence policy and practice so that health and social care systems are always centred around people’s needs and preferences. 3. Inspire the delivery of the highest quality care, developing tools and services which enable all experiences to be better understood. Performance &
Empower those working in health and social care to improve experiences by effectively measuring, and acting upon, people’s feedback.
© Picker 2018
4.
Published by and available from: Quality &
Picker Institute Europe Buxton Court 3 West Way Oxford OX2 0JB 5.
Annual Tel: 01865 208 100 Fax: 01865 208 101
Email: [email protected] Website: www.picker.org
6. Registered Charity in England and Wales: 1081688 Items to note Registered Charity in Scotland: SC045048 Company Limited by Registered Guarantee No 3908160
Picker Institute Europe has UKAS accredited certification for ISO20252: 2012 (GB08/74322) and ISO27001:2013 (GB10/80275). Picker is registered under the Data Protection Act 1998 (Z4942556).
This research conforms to the Market Research Society’s Code of Practice. 7.
Any Other 8. Date and Time
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Contents 2.
Strategy & Contents ...... 3 Introduction: Inpatient Survey 2017 ...... 5 The report ...... 6 Problem scores ...... 10 Understanding this report ...... 11 3. Survey responses ...... 15 Problem score summary ...... 17 Performance & Ranked problem scores ...... 21 Historical Comparisons ...... 25 External benchmarks ...... 29 Appendix 1: Frequency tables ...... 38 Appendix 2: Questionnaire ...... 93 4.
Quality &
5. Annual 6. Items to note 7. Any Other 8. Date and Time
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Strategy &
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Performance &
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SECTION 1 5.
Introduction Annual
6. Items to note 7. Any Other 8. Date and Time
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Introduction: Inpatient Survey 2017 2.
The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Strategy & Trust
Background to the survey
The Inpatient Survey 2017 is an annual survey required by the Care Quality Commission (CQC) for 3. all NHS Acute trusts in England. Performance & Picker was commissioned by 81 UK trusts to undertake the Inpatient Survey 2017, which is 55% of all eligible trusts in England. The survey is based on a sample of consecutively discharged patients who had an overnight inpatient stay in July 2017.
4.
Survey methodology Quality &
The questionnaire used for the Inpatient Survey 2017 was developed by the NHS Patient Survey Coordination Centre. Further information on its development can be found on the NHS Surveys website http://www.nhssurveys.org.
Patients were eligible if they were 16 years old or over and had stayed overnight. Maternity and psychiatric patients were ineligible, as were patients treated privately. For the purposes of the survey, 5. day case patients who arrived and left on the same day were ruled as ineligible. Annual
The survey was sent by post. Patients were sent a questionnaire, a covering letter from the Trust, a multiple language sheet offering help with the survey and a CQC flyer. A Freepost envelope was also supplied in which those who wished could return their completed questionnaire. Non-responders were sent a reminder letter after 2-3 weeks and a further reminder with another copy of the questionnaire after a further 2-3 weeks. 6. Picker ran a Freephone helpline for patients who had queries or concerns about the survey. Access to Items to note LanguageLine was also available with interpreters in over 100 languages.
A copy of the questionnaire is provided in Appendix 2 of this report and more details on the survey methodology are published here: http://www.nhssurveys.org/surveys/1078.
7. Any Other 8. Date and Time
5 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 136 1. Part One -
The report 2.
We aim to help you to identify areas for improvement from the perspective of the patients. We have Strategy & presented the results in a number of ways to help you address important issues around the survey results. How to use this report
When deciding which areas to act upon, we suggest you address each section of the questionnaire: 3.
Performance & Problem score summary Helps identify areas of success and weakness The problem score summary is the first step to pick out any questions where the results are significantly better/worse than the ‘Picker Average’.
Ranked problem scores Demonstrates where the Trust is performing well and highlights areas where there is the most room 4.
for improvement Quality &
Historical comparisons Helps pinpoint areas where experience has changed over time The historical comparison looks back over the survey’s life cycle and identifies whether experience has fluctuated over the years.
5. External benchmarks Annual Considers scope for improvement Indicates range of scores amongst all trusts that work with Picker for each question. Provides additional detail about your position in relation to other trusts.
Internal benchmarks Compares differing performance at sites within the Trust This helps establish which areas at your Trust have the best practice that others can learn from and 6.
which are in need of support. Items to note
7. Any Other 8. Date and Time
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Reports also available: 2.
To help your trust gain more from your Inpatient Survey 2017, the following reports are included as part Strategy & of the Picker standard survey package:
Picker Improvement Maps™
What are the issues of higher importance to patients?
Which issues are of high, medium or low importance to your 3. patients? Performance & These easy to use maps help you prioritise areas for improvement by analysing the result for each question alongside how important they are to patients.
Dartboard reports 4.
Easy visual summary of survey results Quality & Similar questions are grouped together Comparison against the Picker Average Historical comparison against previous year’s results
Free text comments 5. Annual Available in Excel format Breakdowns available by specialty and site on request dependent on respondent base size
Site and specialty reports 6. Summary reports comparing internal results Items to note Identifies areas of best practice and where improvement could be best targeted
To gain a deeper understanding of your Trust’s result, please contact the Patient Feedback Team ([email protected]) to discuss commissioning the following additional extras.
Free text reports 7.
What are your patient saying about their experiences? Any Other Our free text reports provide a detailed analysis of common themes and requests
Experience reviews 8.
In-depth review of all recent patient and staff experience surveys Date and Time Aggregate insight of historical, external and internal benchmarking Helps shapes action plans for sustainable improvement
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CQC Report 2.
For each national survey your Trust is provided with two final reports: one from Picker and one from the Strategy & CQC. Purpose
The Picker and CQC reports have different purposes, which require that the survey data is
presented in different ways. 3.
The Picker report is designed for use in action planning by individual trusts, to improve performance. Performance & The CQC benchmarking report is a national overview, comparing trusts to one another and identifying the trusts that are performing out of the ‘expected range’.
Scoring
The Picker report uses problem scores to help trusts identify areas for improvement historically and 4. Problem Scores against the Trust average (see p11). Quality & In the CQC report individual responses are converted into scores on a scale from 0-10, with 10 representing the best possible score and 0 the worst. To find a significant difference between problem scores, the Picker report uses the Z-test (see Significant Differences on p14). The CQC report uses an analysis technique called the ‘expected range’ to determine whether the
Trust is performing the ‘same’, ‘better’ or ‘worse’ than other trusts. 5. Annual Weighting
Your Picker report simply presents the responses of patients. In contrast, the CQC report is based on data that has been standardised by age, gender and route of admission. Standardisation is used to avoid penalising trusts simply because of their demographic make-up so
underrepresented groups have more weight added to their responses to even it out. 6. This may mean that results appear more positive or more negative when this standardisation has Items to note been applied. If great change is seen in results, it may be useful to examine sample demographics. Please contact [email protected] if you wish to see if these proportions have changed at your Trust.
Picker Report CQC Report 7. A national overview that identifies To assist individual trusts in improving Any Other Purpose trusts that are performing outside of the experience of their patients the 'expected range'
Publication January 2018 Summer 2018
Scoring Problem scores Points based system
Standardised by age, route of 8.
Weighting None Date and Time admission and gender Sample Size Boosted samples available 1250 only
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Strategy &
3.
Performance &
4.
Quality &
SECTION 2 5. Reading the report Annual
6. Items to note 7. Any Other 8. Date and Time
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Problem scores 2.
Problem scores are used by Picker as a summary measure to monitor the Trust’s results over time and Strategy & to compare your scores with all 'Picker' trusts. This is the cornerstone of all of our reporting with all benchmarking and historical comparison based on the Trust’s calculated problem scores. This information is not supplied to the CQC.
We hope that you will find problem scores a helpful way of targeting areas in need of attention within your Trust – this in turn can help you to bring about real quality improvement for your patients. 3.
How are problem scores calculated? Performance &
The problem score shows the percentage of patients for each question whose response indicated that an aspect of their care could have been improved.
The problem score is calculated by combining responses which indicate a problem. 4. For example, for the following question ‘Did you have confidence and trust in the doctors treating you?’ Quality & we have combined the responses ‘Yes, sometimes’ and ‘No’, to create a single problem score. Asterisks indicate which responses have been combined to create the problem score.
5. Annual 6.
Items to note
For a full list of frequency tables please see Appendix 1. How should problem scores be used?
Lower scores reflect better performance. 7.
Any Other Where there are high problem scores, or high in comparison with other trusts, this area should be highlighted as a potential area for further investigation.
As the name suggests, problem scores indicate where there may be an area of poorer experience. 8. Date and Time
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Understanding this report 2.
Routed questions Strategy &
Routed questions are designed to make sure that patients respond only to questions which are relevant to their experience.
For example, Q12 Did you change wards at night? routes patients who did so to Q13 to ask further 3. questions about those experiences and those who did not change wards are directed to Q14. Performance & Targeted questions
Certain questions within the survey are not applicable to all patients but are not preceded by a routed question.
The purpose of the report is to produce precise indicators to identify problems within the Trust so 4. more meaningful scores are needed. Quality &
Picker has recalculated the scores for questions of this nature, excluding patients to whom the question does not apply.
Example: Question 17 has the response option ‘I did not need help to wash or keep myself clean’, which indicates 5. that this question did not apply to these patients. These 333 patients are therefore excluded to Annual calculate the targeted question. Targeted questions are identifiable by their original question number followed by a + sign to indicate that their base size has reduced. They are displayed as additional questions within the Trust’s frequency tables (see Appendix 1) and examples are included below.
6. Items to note 7. Any Other 8. Date and Time
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Low numbers of respondents 2.
The questionnaire included some routed questions, whereby only relevant questions are asked of Strategy & patients.
For example, patients who reported that they did not undergo an operation or procedure would not be asked subsequent questions about operations or procedures.
This means that certain questions will have fewer responses than others. 3.
Performance & Where fewer than 50 patients have answered a particular question, the problem score is shown in square brackets.
Example: 4. Quality &
5.
Questions 4 and Question 7 here have square brackets round their results, indicating a low number Annual of respondents
If this is the case, the result should be treated with caution, as the problem score may not be representative of the wider patient population.
Where fewer than 30 patients (29 and below) have answered a particular question, the results have 6. been supressed and are shown with an asterisk. The reason for this is two-fold: Items to note
The result would not be reliable enough for comparison purposes.
The Coordination Centre require contractors to suppress any results where fewer than 30 patients have responded to a particular question.
7.
Example: Any Other
Question 47 has been asterisked, indicating that fewer than 30 people responded to this question. 8.
Date and Time
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Significant differences 2.
The report identifies questions where there are significant differences between your Trust and the Strategy & ‘Picker Average’ or between your Trust’s result this year and the previous survey.
The term ‘significant difference’ indicates that the finding is statistically reliable.
We can be confident that the result reflects a real difference
3.
The calculation to test the statistical significance of scores was the Z-test. Performance &
p1 = Sample 1 problem score p2 = Sample 2 problem score n1 = Sample 1 base size n2 = Sample 2 base size
4.
Confidence intervals Quality &
The survey undertaken was with a sample of patients. As the survey was not of all patients, the results may not be totally accurate.
We can calculate a margin of error around the results. The table below shows the maximum margin of error for various numbers of respondents. 5. Annual Number of respondents Confidence Interval (+/-) 30 17.9% 50 13.9% 100 9.8% 200 6.9% 300 5.7% 6. 400 4.9% 500 4.4% Items to note 600 4.0% 800 3.5% 1000 3.1%
The smaller the margin of error, the greater confidence you can have that the score accurately
reflects the result that would be recorded if all patients were surveyed. 7.
Any Other Example: For a particular question, 400 patients responded, of whom 50% answered ‘yes’.
From the table above, we can see that for 400 respondents the margin of error is ± 4.9%.
We can be confident that the true result is likely to be between 45.1% and 54.9%. 8.
However, if only 50 patients responded, we would be confident that the true result could be between Date and Time 36.1% and 63.9%
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Quality &
SECTION 3
Survey responses 5. Annual
6. Items to note 7. Any Other 8. Date and Time
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Survey responses 2.
Strategy &
Dates of fieldwork: Initial mailing 14 September 2017 Close of Fieldwork 05 January 2018
Response rate: Initial mailing 1248
Returned completed 729 3.
Ineligible - returned undelivered 0 Performance & Ineligible - deceased 2 Too ill/Opt out 9 Ineligible - other 0 Ineligible - deceased before mailing 1 2
Total eligible 1246 4.
Quality & Returned completed 729
Overall response rate 58.5% (total returned as a percentage of total eligible) Average Picker response rate 38.3%
5. Hospitals / sites: ROBERT JONES & AGNES HUNT Annual ORTHOPAEDIC HOSPITAL
About your respondents
Key facts about the 729 inpatients who responded to the survey: 6.
Items to note 93% of patients were on a waiting list/planned in advance and 6% came as an emergency or urgent case 94% had an operation or procedure during their stay 44% were male; 56% were female 4% were aged 16-39; 19% were aged 40-59; 27% were aged 60-69 and 50% were aged 70+
7.
Picker runs a Freephone Helpline for patients. The lines are open from 8am-8pm Monday to Friday and Any Other Saturdays from 9am to midday. Your Trust received a total of 24 calls to the Freephone helpline, which included 0 LanguageLine calls.
8. Date and Time
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2.
Strategy &
3.
Performance &
4.
Quality &
SECTION 4
Problem score summary 5. Annual Overview of results by section
6. Items to note 7. Any Other 8. Date and Time
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Problem score summary 2.
This section shows your problem score for each question and a comparison against the average Strategy & score for all Picker trusts. The ‘Picker Average’ is designed to help the Trust focus on areas where its performance is poor compared to others and to identify areas where improvement can be targeted.
Significant differences between your Trust and the average are indicated as follows:
3. scores significantly better than average Trust The problem score for your Trust Performance & scores significantly worse than average Average Average score for all 'Picker' trusts
For help reading your understanding your report, please see Reading your report, Problem scores (p11) and Significant differences (p14) for details on how these are calculated.
Note that lower scores indicate better performance.
4.
Quality & ADMISSION TO HOSPITAL Trust Average 3 A&E Department: not enough/too much information about treatment or condition * % 21 % 4 A&E Department: not given enough privacy when being examined or treated * % 21 % 6 Planned admission: should have been admitted sooner 20 % 25 % + 7 Planned admission: admission date changed by hospital 27 % 20 % - 5. 8 Planned admission: specialist not given all the necessary information 2 % 2 % Annual 9 Admission: had to wait long time to get to bed on ward 14 % 34 % +
THE HOSPITAL AND WARD Trust Average 11+ Hospital: shared sleeping area with opposite sex 2 % 8 % + 6. 13 Hospital: staff did not completely explain reasons for changing wards at night * % 46 % Items to note 14 Hospital: bothered by noise at night from other patients 14 % 38 % + 15 Hospital: bothered by noise at night from staff 8 % 19 % + 16 Hospital: room or ward not very or not at all clean 0 % 3 % + 17+ Hospital: did not always get enough help from staff to wash or keep clean 13 % 29 % + 18+ Hospital: not always able to take own medication when needed to 22 % 34 % +
19+ Hospital: food was fair or poor 12 % 39 % + 7. 20 Hospital: not always offered a choice of food 5 % 20 % + Any Other 21+ Hospital: did not always get enough help from staff to eat meals 11 % 37 % + 22 Hospital: did not get enough to drink 1 % 6 % +
8. Date and Time
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DOCTORS Trust Average 2.
23+ Doctors: did not always get clear answers to questions 11 % 30 % + Strategy & 24 Doctors: did not always have confidence and trust 3 % 17 % + 25 Doctors: talked in front of patients as if they were not there 7 % 22 % +
NURSES
Trust Average 3.
26+ Nurses: did not always get clear answers to questions 13 % 29 % + Performance & 27 Nurses: did not always have confidence and trust 8 % 20 % + 28 Nurses: talked in front of patients as if they weren't there 7 % 17 % + 29 Nurses: sometimes, rarely or never enough on duty 19 % 40 % + 30 Nurses: did not always know which nurse was in charge of care 38 % 49 % +
4.
YOUR CARE AND TREATMENT Quality & Trust Average 31+ Other clinical staff: did not always have confidence and trust 17 % 22 % + 32 Care: staff did not always work well together 10 % 21 % + 33 Care: staff contradicted each other 16 % 30 % + 34 Care: wanted to be more involved in decisions 21 % 43 % +
35 Care: did not always have confidence in the decisions made 12 % 27 % + 5.
36 Care: not enough or too much information given on condition or treatment 6 % 19 % + Annual 37+ Care: could not always find staff member to discuss concerns with 36 % 61 % + 38+ Care: not always enough emotional support from hospital staff 22 % 43 % + 39 Care: not always enough privacy when discussing condition or treatment 9 % 23 % + 40 Care: not always enough privacy when being examined or treated 3 % 9 % + 42 Care: staff did not do everything to help control pain 14 % 29 % + 43+ Care: staff did not help within reasonable time when needed attention 16 % 37 % + 6. Items to note
OPERATIONS & PROCEDURES Trust Average 45+ Procedure: questions beforehand not fully answered 6 % 18 % + 46 Procedure: not told how to expect to feel after operation or procedure 21 % 36 % + 47 Procedure: did not explain how it had gone in an understandable way 17 % 30 % + 7.
Any Other
8. Date and Time
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LEAVING HOSPITAL Trust Average 2.
48+ Discharge: did not feel involved in decisions about discharge from hospital 29 % 45 % + Strategy & 49 Discharge: not given notice about when discharge would be 26 % 43 % + 50 Discharge: was delayed 20 % 40 % + 52 Discharge: delayed by 1 hour or more 77 % 88 % + 54+ Discharge: did always get enough support from health or social care professionals 44 % 45 % Discharge: did not definitely know what would happen next with care after leaving 55+ 31 % 47 % +
hospital 3. Discharge: not given any written/printed information about what they should or
56 15 % 36 % Performance & should not do after leaving hospital + 57+ Discharge: not fully told purpose of medications 9 % 25 % + 58+ Discharge: not fully told side-effects of medications 35 % 61 % + 59+ Discharge: not told how to take medication in an understandable way 9 % 24 % + 60+ Discharge: not given completely clear written/printed information about medicines 12 % 27 % + 61+ Discharge: not fully told of danger signals to look for 34 % 56 % + 62+ Discharge: family or home situation not considered 21 % 37 % + 4. 63+ Discharge: family not given enough information to help care 35 % 49 % + Quality & 64 Discharge: not told who to contact if worried 5 % 20 % + 65+ Discharge: staff did not discuss need for additional equipment or home adaptation 5 % 19 % + 66+ Discharge: staff did not discuss need for further health or social care services 10 % 18 % +
OVERALL 5. Trust Average 67 Overall: not always treated with respect or dignity 6 % 16 % + Annual 68 Overall: rated as less than 7/10 3 % 14 % + 69 Overall: not asked to give views on quality of care 55 % 69 % + 70 Overall: did not receive any information explaining how to complain 37 % 57 % + 71+ Overall: not always well looked after by non-clinical hospital staff 6 % 15 % +
6. Items to note 7. Any Other 8. Date and Time
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2.
Strategy &
3.
Performance &
4.
Quality &
SECTION 5
Ranked problem scores 5. Annual Where most patients report room for improvement
6. Items to note 7. Any Other 8. Date and Time
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Ranked problem scores 2.
This section ranks the scores from the highest problem score (most patients reporting room for Strategy & improvement) to lowest problem score (fewest patients reporting room for improvement). Focusing on areas with high problem scores could potentially improve the patient experience for a large proportion of your population.
Significant differences between your Trust and the average are indicated as follows:
3. scores significantly better than average Trust The problem score for your Trust Performance & scores significantly worse than average Average Average score for all Picker trusts
For help reading your understanding your report, please see Reading your report, Problem scores (p11) and Significant differences (p14) for details on how these are calculated.
Note that lower scores indicate better performance.
4.
Quality &
Problem scores 50%+ Trust Average 52 Discharge: delayed by 1 hour or more 77 % 88 % + 69 Overall: not asked to give views on quality of care 55 % 69 % +
5.
Annual Problem scores 40% - 49% Trust Average 54+ Discharge: did always get enough support from health or social care professionals 44 % 45 %
Problem scores 30% - 39%
Trust Average 6.
30 Nurses: did not always know which nurse was in charge of care 38 % 49 % + Items to note 70 Overall: did not receive any information explaining how to complain 37 % 57 % + 37+ Care: could not always find staff member to discuss concerns with 36 % 61 % + 58+ Discharge: not fully told side-effects of medications 35 % 61 % + 63+ Discharge: family not given enough information to help care 35 % 49 % + 61+ Discharge: not fully told of danger signals to look for 34 % 56 % + 55+ Discharge: did not definitely know what would happen next with care after leaving hospital 31 % 47 % + 7.
Any Other
8. Date and Time
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Problem scores 20% - 29%
Trust Average 2.
48+ Discharge: did not feel involved in decisions about discharge from hospital 29 % 45 % + Strategy & 7 Planned admission: admission date changed by hospital 27 % 20 % - 49 Discharge: not given notice about when discharge would be 26 % 43 % + 18+ Hospital: not always able to take own medication when needed to 22 % 34 % + 38+ Care: not always enough emotional support from hospital staff 22 % 43 % + 34 Care: wanted to be more involved in decisions 21 % 43 % + 46 Procedure: not told how to expect to feel after operation or procedure 21 % 36 % + 3.
62+ Discharge: family or home situation not considered 21 % 37 % + Performance & 6 Planned admission: should have been admitted sooner 20 % 25 % + 50 Discharge: was delayed 20 % 40 % +
Problem scores 10% - 19%
Trust Average 4. 29 Nurses: sometimes, rarely or never enough on duty 19 % 40 %
+ Quality & 31+ Other clinical staff: did not always have confidence and trust 17 % 22 % + 47 Procedure: did not explain how it had gone in an understandable way 17 % 30 % + 33 Care: staff contradicted each other 16 % 30 % + 43+ Care: staff did not help within reasonable time when needed attention 16 % 37 % + Discharge: not given any written/printed information about what they should or should not do 56 15 % 36 % after leaving hospital + 9 Admission: had to wait long time to get to bed on ward 14 % 34 % + 5. 14 Hospital: bothered by noise at night from other patients 14 % 38 % + Annual 42 Care: staff did not do everything to help control pain 14 % 29 % + 17+ Hospital: did not always get enough help from staff to wash or keep clean 13 % 29 % + 26+ Nurses: did not always get clear answers to questions 13 % 29 % + 19+ Hospital: food was fair or poor 12 % 39 % + 35 Care: did not always have confidence in the decisions made 12 % 27 %
+ 6. 60+ Discharge: not given completely clear written/printed information about medicines 12 % 27 % + Items to note 21+ Hospital: did not always get enough help from staff to eat meals 11 % 37 % + 23+ Doctors: did not always get clear answers to questions 11 % 30 % + 32 Care: staff did not always work well together 10 % 21 % + 66+ Discharge: staff did not discuss need for further health or social care services 10 % 18 % +
7. Any Other 8. Date and Time
22 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 153 1. Part One -
Problem scores 0% - 9%
Trust Average 2.
39 Care: not always enough privacy when discussing condition or treatment 9 % 23 % + Strategy & 57+ Discharge: not fully told purpose of medications 9 % 25 % + 59+ Discharge: not told how to take medication in an understandable way 9 % 24 % + 15 Hospital: bothered by noise at night from staff 8 % 19 % + 27 Nurses: did not always have confidence and trust 8 % 20 % + 25 Doctors: talked in front of patients as if they were not there 7 % 22 % + 28 Nurses: talked in front of patients as if they weren't there 7 % 17 % + 3.
36 Care: not enough or too much information given on condition or treatment 6 % 19 % + Performance & 45+ Procedure: questions beforehand not fully answered 6 % 18 % + 67 Overall: not always treated with respect or dignity 6 % 16 % + 71+ Overall: not always well looked after by non-clinical hospital staff 6 % 15 % + 20 Hospital: not always offered a choice of food 5 % 20 % + 64 Discharge: not told who to contact if worried 5 % 20 % + 4. 65+ Discharge: staff did not discuss need for additional equipment or home adaptation 5 % 19 % + 24 Doctors: did not always have confidence and trust 3 % 17 % + Quality & 40 Care: not always enough privacy when being examined or treated 3 % 9 % + 68 Overall: rated as less than 7/10 3 % 14 % + 8 Planned admission: specialist not given all the necessary information 2 % 2 % 11+ Hospital: shared sleeping area with opposite sex 2 % 8 % + 22 Hospital: did not get enough to drink 1 % 6 %
+ 5. 16 Hospital: room or ward not very or not at all clean 0 % 3 % + Annual
6. Items to note 7. Any Other 8. Date and Time
23 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 154 1. Part One -
2.
Strategy &
3.
Performance &
4.
Quality &
SECTION 6 5. Annual Historical comparisons
Comparing results with previous years
6. Items to note 7. Any Other 8. Date and Time
24 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 155 1. Part One -
Historical Comparisons 2.
This section shows the problem scores for this year’s survey in comparison to previous years. Strategy & By looking at changes in results over time it is possible to focus on those areas where performance might be slipping. Examining areas where performance has improved will help you to measure the effects of any service improvements that have been put in place.
Significant differences from the previous year's survey are indicated as follows: 3.
Performance & scores significantly better than previous survey scores significantly worse than previous survey
For help reading your understanding your report, please see Reading your report, Problem scores (p11) and Significant differences (p14) for details on how these are calculated.
Note that lower scores indicate better performance. 4.
Quality & ADMISSION TO HOSPITAL 2012 2013 2014 2015 2016 2017 A&E Department: not enough/too much 3 * % * % * % * % * % * % information about treatment or condition A&E Department: not given enough privacy when 4 * % * % * % * % [10] % * % being examined or treated Planned admission: should have been admitted
6 30 % 21 % 23 % 26 % 27 % 20 % 5. sooner +
Planned admission: admission date changed by Annual 7 33 % 26 % 25 % 27 % 30 % 27 % hospital Planned admission: specialist not given all the 8 1 % 1 % 1 % 2 % 1 % 2 % necessary information Admission: had to wait long time to get to bed on 9 14 % 17 % 15 % 14 % 12 % 14 % ward
THE HOSPITAL AND WARD 6.
2012 2013 2014 2015 2016 2017 Items to note 11+ Hospital: shared sleeping area with opposite sex - % - % - % - % - % 2 % Hospital: staff did not completely explain reasons 13 - % - % - % - % - % * % for changing wards at night Hospital: bothered by noise at night from other 14 29 % 23 % 26 % 21 % 21 % 14 % patients + 15 Hospital: bothered by noise at night from staff 11 % 10 % 14 % 10 % 11 % 8 % + 16 Hospital: room or ward not very or not at all clean 0 % 0 % 1 % 1 % 0 % 0 %
Hospital: did not always get enough help from staff 7. 17+ - % - % - % - % 13 % 13 % to wash or keep clean Any Other Hospital: not always able to take own medication 18+ - % - % - % - % 25 % 22 % when needed to 19+ Hospital: food was fair or poor 11 % 11 % 15 % 14 % 18 % 12 % + 20 Hospital: not always offered a choice of food 7 % 7 % 7 % 8 % 10 % 5 % + Hospital: did not always get enough help from staff 21+ 20 % 18 % 12 % 13 % 11 % 11 % to eat meals 22 Hospital: did not get enough to drink - % - % - % - % - % 1 %
8.
Date and Time
25 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 156 1. Part One -
DOCTORS
2012 2013 2014 2015 2016 2017 2. Doctors: did not always get clear answers to 23+ 13 % 11 % 13 % 12 % 11 % 11 % Strategy & questions 24 Doctors: did not always have confidence and trust 5 % 4 % 6 % 4 % 3 % 3 % Doctors: talked in front of patients as if they were 25 10 % 9 % 9 % 7 % 7 % 7 % not there
NURSES 2012 2013 2014 2015 2016 2017 3.
Nurses: did not always get clear answers to Performance & 26+ 17 % 14 % 16 % 15 % 11 % 13 % questions 27 Nurses: did not always have confidence and trust 10 % 10 % 11 % 12 % 9 % 8 % Nurses: talked in front of patients as if they weren't 28 10 % 10 % 9 % 10 % 8 % 7 % there Nurses: sometimes, rarely or never enough on 29 26 % 24 % 29 % 23 % 21 % 19 % duty Nurses: did not always know which nurse was in 30 - % - % - % - % 39 % 38 %
charge of care 4.
Quality & YOUR CARE AND TREATMENT 2012 2013 2014 2015 2016 2017 Other clinical staff: did not always have confidence 31+ - % - % - % - % - % 17 % and trust 32 Care: staff did not always work well together - % - % - % 10 % 10 % 10 % 33 Care: staff contradicted each other 19 % 16 % 18 % 17 % 17 % 16 %
34 Care: wanted to be more involved in decisions 24 % 24 % 26 % 18 % 22 % 21 % 5. Care: did not always have confidence in the 35 - % - % 13 % 11 % 11 % 12 % Annual decisions made Care: not enough or too much information given 36 7 % 9 % 7 % 9 % 6 % 6 % on condition or treatment Care: could not always find staff member to 37+ 38 % 37 % 47 % 36 % 40 % 36 % discuss concerns with Care: not always enough emotional support from 38+ 28 % 20 % 27 % 20 % 23 % 22 % hospital staff Care: not always enough privacy when discussing 39 19 % 16 % 18 % 12 % 15 % 9 % 6. condition or treatment +
Care: not always enough privacy when being Items to note 40 4 % 4 % 6 % 4 % 5 % 3 % examined or treated Care: staff did not do everything to help control 42 17 % 15 % 19 % 18 % 16 % 14 % pain Care: staff did not help within reasonable time 43+ - % - % - % - % - % 16 % when needed attention
OPERATIONS & PROCEDURES 7.
2012 2013 2014 2015 2016 2017 Any Other Procedure: questions beforehand not fully 45+ 12 % 10 % 13 % 11 % 8 % 6 % answered Procedure: not told how to expect to feel after 46 34 % 30 % 29 % 28 % 25 % 21 % operation or procedure Procedure: did not explain how it had gone in an 47 26 % 19 % 20 % 18 % 16 % 17 % understandable way
8.
Date and Time
26 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 157 1. Part One -
LEAVING HOSPITAL
2012 2013 2014 2015 2016 2017 2. Discharge: did not feel involved in decisions about 48+ 32 % 30 % 29 % 25 % 26 % 29 % Strategy & discharge from hospital Discharge: not given notice about when discharge 49 32 % 29 % 29 % 26 % 26 % 26 % would be 50 Discharge: was delayed 24 % 25 % 28 % 26 % 23 % 20 % 52 Discharge: delayed by 1 hour or more 75 % 77 % 82 % 72 % 72 % 77 % Discharge: did always get enough support from 54+ - % - % - % 38 % 45 % 44 % health or social care professionals Discharge: did not definitely know what would 55+ - % - % - % 76 % 30 % 31 % 3. happen next with care after leaving hospital
Discharge: not given any written/printed Performance & 56 information about what they should or should not 16 % 15 % 16 % 14 % 14 % 15 % do after leaving hospital 57+ Discharge: not fully told purpose of medications 12 % 10 % 10 % 10 % 9 % 9 % Discharge: not fully told side-effects of 58+ 45 % 39 % 39 % 39 % 40 % 35 % medications Discharge: not told how to take medication in an 59+ 13 % 11 % 10 % 10 % 10 % 9 % understandable way
Discharge: not given completely clear 4. 60+ 15 % 12 % 12 % 14 % 12 % 12 % written/printed information about medicines Discharge: not fully told of danger signals to look Quality & 61+ 40 % 36 % 34 % 37 % 33 % 34 % for 62+ Discharge: family or home situation not considered 23 % 19 % 19 % 23 % 18 % 21 % Discharge: family not given enough information to 63+ 42 % 31 % 38 % 38 % 37 % 35 % help care 64 Discharge: not told who to contact if worried 8 % 8 % 7 % 6 % 6 % 5 % Discharge: staff did not discuss need for additional 65+ 4 % 6 % 7 % 8 % 8 % 5 % equipment or home adaptation Discharge: staff did not discuss need for further 5. 66+ 10 % 11 % 10 % 11 % 11 % 10 %
health or social care services Annual
OVERALL 2012 2013 2014 2015 2016 2017 67 Overall: not always treated with respect or dignity 7 % 5 % 7 % 5 % 5 % 6 % 68 Overall: rated as less than 7/10 6 % 4 % 5 % 5 % 3 % 3 %
69 Overall: not asked to give views on quality of care 67 % 64 % 64 % 65 % 64 % 55 % + 6. Overall: did not receive any information explaining 70 48 % 43 % 44 % 45 % 44 % 37 % Items to note how to complain + Overall: not always well looked after by non- 71+ - % - % - % - % - % 6 % clinical hospital staff
7. Any Other 8. Date and Time
27 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 158 1. Part One -
2.
Strategy &
3.
Performance &
4.
Quality &
SECTION 7
External benchmarks 5. Annual Comparing results with other trusts
6. Items to note 7. Any Other 8. Date and Time
28 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 159 1. Part One -
External benchmarks 2.
This section shows how your Trust compared to all trusts who commissioned Picker for this survey. Strategy & Examining the range of performance across the country will help to determine where there is scope for improvement. The range of scores are shown as a blue bar from the best score (to left), to the worst (to right). The average is the black line and your Trust is shown as the yellow triangle.
For help reading your understanding your report, please see Reading your report, Problem scores (p11) 3. and Significant differences (p14) for details on how these are calculated. Performance &
Note that lower scores indicate better performance.
ADMISSION TO HOSPITAL
4. Better Score Worse Score Quality & 3. A&E Department: not enough/too much information about treatment or condition 4. A&E Department: not given enough privacy when being examined or treated 5. 6. Planned admission: should have been admitted sooner Annual
7. Planned admission: admission date changed by hospital
8. Planned admission: specialist not given all the necessary information 6.
9. Admission: had to wait long time to get Items to note to bed on ward
Better Score Worse Score
UK Picker Average 7. The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust Any Other
8. Date and Time
29 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 160 1. Part One -
THE HOSPITAL AND WARD
2.
Strategy & Better Score Worse Score
11+. Hospital: shared sleeping area with opposite sex
13. Hospital: staff did not completely explain reasons for changing wards at night 3. Performance & 14. Hospital: bothered by noise at night from other patients
15. Hospital: bothered by noise at night from staff
16. Hospital: room or ward not very or 4. not at all clean Quality &
17+. Hospital: did not always get enough help from staff to wash or keep clean
18+. Hospital: not always able to take own medication when needed to 5. 19+ Hospital: food was fair or poor Annual
20. Hospital: not always offered a choice of food
21+. Hospital: did not always get enough help from staff to eat meals 6.
22. Hospital: did not get enough to drink Items to note
Better Score Worse Score
7. Any Other 8. Date and Time
30 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 161 1. Part One -
DOCTORS
2.
Strategy & Better Score Worse Score
23+. Doctors: did not always get clear answers to questions
24. Doctors: did not always have
confidence and trust 3. Performance & 25. Doctors: talked in front of patients as if they were not there
Better Score Worse Score
4.
Quality &
NURSES
Better Score Worse Score 5.
Annual 26+. Nurses: did not always get clear answers to questions
27. Nurses: did not always have confidence and trust
28. Nurses: talked in front of patients as 6. if they weren't there Items to note
29. Nurses: sometimes, rarely or never enough on duty
30. Nurses: did not always know which nurse was in charge of care 7. Better Score Worse Score Any Other
8. Date and Time
31 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 162 1. Part One -
YOUR CARE AND TREATMENT
2.
Strategy & Better Score Worse Score
31+. Other clinical staff: did not always have confidence and trust
32. Care: staff did not always work well
together 3. Performance & 33. Care: staff contradicted each other
34. Care: wanted to be more involved in decisions
35. Care: did not always have confidence 4. in the decisions made Quality & 36. Care: not enough or too much information given on condition or treatment
37+. Care: could not always find staff member to discuss concerns with
38+. Care: not always enough emotional 5.
support from hospital staff Annual
39. Care: not always enough privacy when discussing condition or treatment
40. Care: not always enough privacy when being examined or treated 6. 42. Care: staff did not do everything to Items to note help control pain
43+. Care: staff did not help within reasonable time when needed attention
Better Score Worse Score
7.
Any Other
8. Date and Time
32 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 163 1. Part One -
OPERATIONS & PROCEDURES
2.
Strategy &
Better Score Worse Score
45+. Procedure: questions beforehand not fully answered
46. Procedure: not told how to expect to 3. feel after operation or procedure Performance &
47. Procedure: did not explain how it had gone in an understandable way
Better Score Worse Score
4.
Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
33 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 164 1. Part One -
LEAVING HOSPITAL - 1
2.
Strategy &
Better Score Worse Score
48+. Discharge: did not feel involved in decisions about discharge from hospital
49. Discharge: not given notice about 3. when discharge would be Performance &
50. Discharge: was delayed
52. Discharge: delayed by 1 hour or more
54+. Discharge: did always get enough 4. support from health or social care Quality & professionals 55+. Discharge: did not definitely know what would happen next with care after leaving hospital 56. Discharge: not given any written/printed information about what they should or should not do after leaving hospital 5. Annual 57+. Discharge: not fully told purpose of medications
58+. Discharge: not fully told side-effects of medications
59+. Discharge: not told how to take medication in an understandable way 6. Items to note
Better Score Worse Score
7. Any Other 8. Date and Time
34 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 165 1. Part One -
LEAVING HOSPITAL - 2 2. Strategy & Better Score Worse Score
60+. Discharge: not given completely clear written/printed information about medicines
61+. Discharge: not fully told of danger signals to look for 3. Performance & 62+. Discharge: family or home situation not considered
63+. Discharge: family not given enough information to help care
64. Discharge: not told who to contact if 4. worried Quality & 65+. Discharge: staff did not discuss need for additional equipment or home adaptation 66+. Discharge: staff did not discuss need for further health or social care services 5. Better Score Worse Score
Annual
6. Items to note 7. Any Other 8. Date and Time
35 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 166 1. Part One -
OVERALL
2.
Strategy & Better Score Worse Score
67. Overall: not always treated with respect or dignity
68+. Overall: rated as less than 7/10 3. Performance & 69. Overall: not asked to give views on quality of care
70. Overall: did not receive any information explaining how to complain
71+. Overall: not always well looked after 4. by non-clinical hospital staff Quality &
Better Score Worse Score
5.
Annual 6. Items to note 7. Any Other 8. Date and Time
36 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 167 1. Part One -
2.
Strategy &
3.
Performance &
4.
Quality &
Appendix 1
Frequency tables 5. Annual A detailed breakdown of your results
6. Items to note 7. Any Other 8. Date and Time
37 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 168 1. Part One -
Appendix 1: Frequency tables 2.
Strategy & This section shows a breakdown of responses for each question. It also shows which groups of patients responded to each question and how the problem score was calculated. The response categories that have been combined to calculate the problem score are indicated with an asterisk. 3.
ADMISSION TO HOSPITAL Performance &
Q1. Was your most recent hospital stay planned in advance or an emergency?
This Trust All Trusts 4.
693 37799 Quality & All Patients 100.0% 100.0% 39 22534 Emergency or urgent 5.6% 59.6% 644 14040 Waiting list or planned in advance 92.9% 37.1% 5. 10 1225 Something else Annual 1.4% 3.2%
Q2. When you arrived at the hospital, did you go to the A&E Department (the Emergency Department / Casualty / Medical or Surgical Admissions unit)?
6. This Trust All Trusts Items to note 47 24411 Patients admitted via A&E department 100.0% 100.0% 22 21249 Yes 46.8% 87.0% 25 3162 No 7. 53.2% 13.0% Any Other
8. Date and Time
38 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 169 1. Part One -
Q3. While you were in the A&E Department, how much information about your condition or
treatment was given to you? 2.
Strategy & This Trust All Trusts
21 21169 Patients admitted via A&E department 100.0% 100.0% 3 2799 *Not enough 14.3% 13.2% 3.
15 14186 Performance & Right amount 71.4% 67.0% 0 99 *Too much 0.0% 0.5% *I was not given any information about my treatment or 1 1649 condition 4.8%
7.8% 4. 2
2436 Quality & Don’t know / can’t remember 9.5% 11.5%
Q4. Were you given enough privacy when being examined or treated in the A&E Department?
This Trust All Trusts 5. Annual 20 21351 Patients admitted via A&E department 100.0% 100.0% 16 15843 Yes, definitely 80.0% 74.2% 1 4050 *Yes, to some extent 6. 5.0% 19.0% Items to note 2 429 *No 10.0% 2.0% 1 1029 Don’t know / can’t remember 5.0% 4.8%
7. Any Other 8. Date and Time
39 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 170 1. Part One -
Q5. When you were referred to see a specialist, were you offered a choice of hospital for your 2. first hospital appointment? Strategy &
This Trust All Trusts
683 16782 Waiting list or planned admissions 100.0% 100.0% 291 4528 3. Yes 42.6% 27.0% Performance & 40 1546 No, but I would have liked a choice 5.9% 9.2% 329 9984 No, but I did not mind 48.2% 59.5% 23 724
Don’t know / can’t remember 4. 3.4% 4.3% Quality &
Q6. How do you feel about the length of time you were on the waiting list before your admission to hospital?
This Trust All Trusts 5. Annual 678 16349 Waiting list or planned admissions 100.0% 100.0% 540 12327 I was admitted as soon as I thought was necessary 79.6% 75.4% 86 2550 *I should have been admitted a bit sooner 12.7% 15.6% 6.
52 1472 Items to note *I should have been admitted a lot sooner 7.7% 9.0%
7. Any Other 8. Date and Time
40 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 171 1. Part One -
Q7. Was your admission date changed by the hospital?
2. Strategy & This Trust All Trusts
690 16578 Waiting list or planned admissions 100.0% 100.0% 507 13213 No 73.5% 79.7% 3. 160 2707 Performance & *Yes, once 23.2% 16.3% 22 595 *Yes, 2 or 3 times 3.2% 3.6% 1 63 *Yes, 4 times or more 0.1% 0.4% 4.
Quality & Q8. In your opinion, had the specialist you saw in hospital been given all of the necessary information about your condition or illness from the person who referred you?
This Trust All Trusts
689 16837 5. Waiting list or planned admissions
100.0% 100.0% Annual 606 13776 Yes, definitely 88.0% 81.8% 62 2194 Yes, to some extent 9.0% 13.0% 15 415 *No 6. 2.2% 2.5% Items to note 6 452 Don't know / can't remember 0.9% 2.7%
7. Any Other 8. Date and Time
41 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 172 1. Part One -
Q9. From the time you arrived at the hospital, did you feel that you had to wait a long time to
get to a bed on a ward? 2.
Strategy & This Trust All Trusts
722 38941 All Patients 100.0% 100.0% 29 5305 *Yes, definitely 4.0% 13.6% 3.
69 7862 Performance & *Yes, to some extent 9.6% 20.2% 624 25774 No 86.4% 66.2%
4.
Quality &
5. Annual 6. Items to note 7. Any Other 8. Date and Time
42 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 173 1. Part One -
THE HOSPITAL AND WARD
2.
Strategy &
Q10. While in hospital, did you ever stay in a critical care area (Intensive Care Unit, High Dependency Unit or Coronary Care Unit)?
This Trust All Trusts
723 39094 3.
All Patients Performance & 100.0% 100.0% 105 8992 Yes 14.5% 23.0% 601 27832 No 83.1% 71.2%
17 2270 4. Don't know / can't remember
2.4% 5.8% Quality &
Q11. When you were first admitted to a bed on a ward, did you share a sleeping area, for example a room or bay, with patients of the opposite sex?
5. This Trust All Trusts Annual 726 39274 All Patients 100.0% 100.0% 17 3177 Yes 2.3% 8.1% 709 36097 No 6. 97.7% 91.9% Items to note
Q11+. When you were first admitted to a bed on a ward, did you share a sleeping area, for example a room or bay, with patients of the opposite sex?
This Trust All Trusts 7. Any Other 622 30346 Patients who did not stay in critical care area 100.0% 100.0% 11 1717 Yes 1.8% 5.7% 611 28629
No 8. 98.2% 94.3% Date and Time
43 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 174 1. Part One -
Q12. Did you change wards at night?
2. Strategy & This Trust All Trusts
726 38892 All patients 100.0% 100.0% 0 2663 Yes, but I would have preferred not to 0.0% 6.8% 3. 13 5322 Performance & Yes, but I did not mind 1.8% 13.7% 713 30907 No 98.2% 79.5%
4. Q13. Did the hospital staff explain the reasons for being moved in a way you could understand? Quality &
This Trust All Trusts
13 7901 Patients who changed ward at night 100.0% 100.0% 5. 10 4235 Yes, completely Annual 76.9% 53.6% 2 2173 *Yes, to some extent 15.4% 27.5% 1 1493 *No 7.7% 18.9%
6.
Items to note
Q14. Were you ever bothered by noise at night from other patients?
This Trust All Trusts
726 38998 7. All Patients 100.0% 100.0% Any Other 102 14763 *Yes 14.0% 37.9% 624 24235 No 86.0% 62.1%
8. Date and Time
44 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 175 1. Part One -
Q15. Were you ever bothered by noise at night from hospital staff? 2.
Strategy &
This Trust All Trusts
727 39008 All Patients 100.0% 100.0% 56 7461 *Yes 3. 7.7% 19.1% Performance & 671 31547 No 92.3% 80.9%
Q16. In your opinion, how clean was the hospital room or ward that you were in? 4. Quality & This Trust All Trusts
728 39338 All Patients 100.0% 100.0% 680 28192 Very clean 93.4% 71.7% 5.
48 10090 Annual Fairly clean 6.6% 25.6% 0 857 *Not very clean 0.0% 2.2% 0 199 *Not at all clean 0.0% 0.5% 6.
Items to note Q17. Did you get enough help from staff to wash or keep yourself clean?
This Trust All Trusts
719 38894 7. All Patients
100.0% 100.0% Any Other 471 16667 Yes, always 65.5% 42.9% 58 4877 Yes, sometimes 8.1% 12.5% 10 2036
No 8. 1.4% 5.2% Date and Time 180 15314 I did not need help to wash or keep myself clean 25.0% 39.4%
45 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 176 1. Part One -
Q17+. Did you get enough help from staff to wash or keep yourself clean? 2.
Strategy &
This Trust All Trusts
539 23580 Patients who needed help 100.0% 100.0% 471 16667 Yes, always 3. 87.4% 70.7% Performance & 58 4877 *Yes, sometimes 10.8% 20.7% 10 2036 *No 1.9% 8.6%
4.
Quality & Q18. If you brought your own medication with you to hospital, were you able to take it when you needed to?
This Trust All Trusts
719 38347 5. All Patients
100.0% 100.0% Annual 403 14783 Yes, always 56.1% 38.6% 38 3057 Yes, sometimes 5.3% 8.0% 74 4677 No 6. 10.3% 12.2% Items to note I had to stop taking my own medication as part of my 77 3772 treatment 10.7% 9.8% 127 12058 I did not bring my own medication with me to hospital 17.7% 31.4%
7.
Any Other 8. Date and Time
46 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 177 1. Part One -
Q18+. If you brought your own medication with you to hospital, were you able to take it when
you needed to? 2.
Strategy & This Trust All Trusts
515 22517 Patients who needed own medication 100.0% 100.0% 403 14783 Yes, always 78.3% 65.7% 3.
38 3057 Performance & *Yes, sometimes 7.4% 13.6% 74 4677 *No 14.4% 20.8%
4.
Quality & Q19. How would you rate the hospital food?
This Trust All Trusts
726 39141
All Patients 5. 100.0% 100.0% 410 9205 Annual Very good 56.5% 23.5% 227 13768 Good 31.3% 35.2% 80 10176 Fair
11.0% 26.0% 6.
9 4378 Items to note Poor 1.2% 11.2% 0 1614 I did not have any hospital food 0.0% 4.1%
7. Any Other 8. Date and Time
47 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 178 1. Part One -
Q19+. How would you rate the hospital food? 2.
Strategy &
This Trust All Trusts
726 37527 Patients who had food 100.0% 100.0% 410 9205 Very good 3. 56.5% 24.5% Performance & 227 13768 Good 31.3% 36.7% 80 10176 *Fair 11.0% 27.1% 9 4378 *Poor 1.2% 11.7% 4.
Quality &
Q20. Were you offered a choice of food?
This Trust All Trusts 5. Annual 724 38621 All Patients 100.0% 100.0% 689 30846 Yes, always 95.2% 79.9% 28 5353
*Yes, sometimes 6. 3.9% 13.9% Items to note 7 2422 *No 1.0% 6.3%
7. Any Other 8. Date and Time
48 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 179 1. Part One -
Q21. Did you get enough help from staff to eat your meals? 2.
Strategy &
This Trust All Trusts
723 38679 All Patients 100.0% 100.0% 145 5378 Yes, always 3. 20.1% 13.9% Performance & 14 1726 Yes, sometimes 1.9% 4.5% 4 1432 No 0.6% 3.7% 560 30143 I did not need help to eat meals 77.5% 77.9% 4.
Quality &
Q21+. Did you get enough help from staff to eat your meals?
This Trust All Trusts 5.
163 8536 Annual Patients who needed help 100.0% 100.0% 145 5378 Yes, always 89.0% 63.0% 14 1726 *Yes, sometimes 8.6% 20.2% 6. 4 1432 *No Items to note 2.5% 16.8%
7. Any Other 8. Date and Time
49 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 180 1. Part One -
Q22. During your time in hospital, did you get enough to drink? 2.
Strategy &
This Trust All Trusts
720 39059 All Patients 100.0% 100.0% 710 35818 Yes 3. 98.6% 91.7% Performance & 0 475 *No, because I did not get enough help to drink 0.0% 1.2% 8 1759 *No, because I was not offered enough drinks 1.1% 4.5% 2 1007 No, for another reason 0.3% 2.6% 4.
Quality &
5. Annual 6. Items to note 7. Any Other 8. Date and Time
50 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 181 1. Part One -
DOCTORS 2.
Strategy &
Q23. When you had important questions to ask a doctor, did you get answers that you could understand?
This Trust All Trusts 3. 723 39090 All Patients Performance & 100.0% 100.0% 570 24615 Yes, always 78.8% 63.0% 63 8703 Yes, sometimes 8.7% 22.3%
8 1832 4. No 1.1% 4.7% Quality & 82 3940 I had no need to ask 11.3% 10.1%
Q23+. When you had important questions to ask a doctor, did you get answers that you could 5. understand? Annual
This Trust All Trusts
641 35150 Patients who had questions 100.0% 100.0%
570 24615 6. Yes, always
88.9% 70.0% Items to note 63 8703 *Yes, sometimes 9.8% 24.8% 8 1832 *No 1.2% 5.2%
7. Any Other 8. Date and Time
51 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 182 1. Part One -
2.
Q24. Did you have confidence and trust in the doctors treating you? Strategy &
This Trust All Trusts
724 39124 All Patients 100.0% 100.0% 700 32441 3.
Yes, always Performance & 96.7% 82.9% 22 5531 *Yes, sometimes 3.0% 14.1% 2 1152 *No 0.3% 2.9%
4.
Quality & Q25. Did doctors talk in front of you as if you weren’t there?
This Trust All Trusts
722 39018 All Patients 5. 100.0% 100.0% Annual 11 1920 *Yes, often 1.5% 4.9% 40 6724 *Yes, sometimes 5.5% 17.2% 671 30374
No 6. 92.9% 77.8% Items to note
7. Any Other 8. Date and Time
52 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 183 1. Part One -
NURSES
2.
Strategy &
Q26. When you had important questions to ask a nurse, did you get answers that you could understand?
This Trust All Trusts
724 39157 3.
All Patients Performance & 100.0% 100.0% 546 24184 Yes, always 75.4% 61.8% 73 8600 Yes, sometimes 10.1% 22.0%
7 1401 4. No
1.0% 3.6% Quality & 98 4972 I had no need to ask 13.5% 12.7%
Q26+. When you had important questions to ask a nurse, did you get answers that you could 5. understand? Annual
This Trust All Trusts
626 34185 Patients who had questions 100.0% 100.0% 546 24184 Yes, always 6. 87.2% 70.7% Items to note 73 8600 *Yes, sometimes 11.7% 25.2% 7 1401 *No 1.1% 4.1%
7.
Any Other 8. Date and Time
53 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 184 1. Part One -
Q27. Did you have confidence and trust in the nurses treating you? 2.
Strategy &
This Trust All Trusts
724 39189 All Patients 100.0% 100.0% 669 31329 Yes, always 3. 92.4% 79.9% Performance & 53 6890 *Yes, sometimes 7.3% 17.6% 2 970 *No 0.3% 2.5%
4.
Quality & Q28. Did nurses talk in front of you as if you weren’t there?
This Trust All Trusts
725 39110 All Patients 100.0% 100.0% 5.
8 1467 Annual *Yes, often 1.1% 3.8% 46 5078 *Yes, sometimes 6.3% 13.0% 671 32565 No 92.6% 83.3% 6.
Items to note
Q29. In your opinion, were there enough nurses on duty to care for you in hospital?
This Trust All Trusts 7. 721 39091
All Patients Any Other 100.0% 100.0% 582 23527 There were always or nearly always enough nurses 80.7% 60.2% 116 11331 *There were sometimes enough nurses 16.1% 29.0%
23 4233 8. *There were rarely or never enough nurses 3.2% 10.8% Date and Time
54 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 185 1. Part One -
Q30. Did you know which nurse was in charge of looking after you? (this would have been a 2. different person after each shift change) Strategy &
This Trust All Trusts
723 39054 All Patients 100.0% 100.0% 449 19898 3. Yes, always 62.1% 50.9% Performance & 195 11897 *Yes, sometimes 27.0% 30.5% 79 7259 *No 10.9% 18.6%
4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
55 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 186 1. Part One -
YOUR CARE AND TREATMENT
2.
Strategy & Q31. Did you have confidence and trust in any other clinical staff treating you (e.g. physiotherapists, speech therapists, psychologists)?
This Trust All Trusts
722 38869 3. All Patients 100.0% 100.0% Performance & 555 18991 Yes, always 76.9% 48.9% 93 4415 Yes, sometimes 12.9% 11.4% 18
994 4. No 2.5%
2.6% Quality & 56 14469 I was not seen by any other clinical staff 7.8% 37.2%
Q31+. Did you have confidence and trust in any other clinical staff treating you (e.g. physiotherapists, speech therapists, psychologists)? 5.
Annual
This Trust All Trusts
666 24400 Patients seen by other clinical staff 100.0% 100.0% 555 18991 Yes, always 6. 83.3% 77.8% Items to note 93 4415 *Yes, sometimes 14.0% 18.1% 18 994 *No 2.7% 4.1%
7.
Any Other 8. Date and Time
56 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 187 1. Part One -
Q32. In your opinion, did the members of staff caring for you work well together? 2.
Strategy &
This Trust All Trusts
722 39159 All Patients 100.0% 100.0% 635 28953 Yes, always 3. 88.0% 73.9% Performance & 67 7033 *Yes, sometimes 9.3% 18.0% 6 1326 *No 0.8% 3.4% 14 1847 Don't know / can't remember 1.9% 4.7% 4.
Quality &
Q33. Sometimes in a hospital, a member of staff will say one thing and another will say something quite different. Did this happen to you?
This Trust All Trusts 5.
724 39062 Annual All Patients 100.0% 100.0% 15 2561 *Yes, often 2.1% 6.6% 101 9304 *Yes, sometimes
14.0% 23.8% 6.
608 27197 Items to note No 84.0% 69.6%
7. Any Other 8. Date and Time
57 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 188 1. Part One -
Q34. Were you involved as much as you wanted to be in decisions about your care and
treatment? 2.
Strategy & This Trust All Trusts
718 38749 All Patients 100.0% 100.0% 568 22111 Yes, definitely 79.1% 57.1% 3.
127 12930 Performance & *Yes, to some extent 17.7% 33.4% 23 3708 *No 3.2% 9.6%
4.
Q35. Did you have confidence in the decisions made about your condition or treatment? Quality &
This Trust All Trusts
722 38822 All Patients 100.0% 100.0% 5. 638 28343 Yes, always Annual 88.4% 73.0% 76 8313 *Yes, sometimes 10.5% 21.4% 8 2166 *No 1.1% 5.6%
6.
Items to note
7. Any Other 8. Date and Time
58 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 189 1. Part One -
Q36. How much information about your condition or treatment was given to you?
2. Strategy & This Trust All Trusts
724 38937 All Patients 100.0% 100.0% 31 5921 *Not enough 4.3% 15.2% 3. 671 30231 Performance & Right amount 92.7% 77.6% 1 249 *Too much 0.1% 0.6% *I was not given any information about my treatment or 8 1078 condition 1.1% 2.8% 4. 13 1458
Don't know / can't remember Quality & 1.8% 3.7%
Q37. Did you find someone on the hospital staff to talk to about your worries and fears?
5.
This Trust All Trusts Annual
724 38869 All Patients 100.0% 100.0% 222 8776 Yes, definitely 30.7% 22.6%
91 7990 6. Yes, to some extent
12.6% 20.6% Items to note 32 5941 No 4.4% 15.3% 379 16162 I had no worries or fears 52.3% 41.6%
7.
Any Other
8. Date and Time
59 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 190 1. Part One -
Q37+. Did you find someone on the hospital staff to talk to about your worries and fears?
2. Strategy & This Trust All Trusts
345 22707 Patients who had worries or fears 100.0% 100.0% 222 8776 Yes, definitely 64.3% 38.6% 3. 91 7990 Performance & *Yes, to some extent 26.4% 35.2% 32 5941 *No 9.3% 26.2%
4.
Q38. Do you feel you got enough emotional support from hospital staff during your stay? Quality &
This Trust All Trusts
719 38862 All Patients 100.0% 100.0% 317 13267 5.
Yes, always Annual 44.1% 34.1% 75 6502 Yes, sometimes 10.4% 16.7% 17 3367 No 2.4% 8.7%
310 15726 6. I did not need any emotional support
43.1% 40.5% Items to note
Q38+. Do you feel you got enough emotional support from hospital staff during your stay?
This Trust All Trusts 7. Any Other 409 23136 Patients who needed emotional support 100.0% 100.0% 317 13267 Yes, always 77.5% 57.3% 75 6502
*Yes, sometimes 8. 18.3% 28.1% Date and Time 17 3367 *No 4.2% 14.6%
60 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 191 1. Part One -
Q39. Were you given enough privacy when discussing your condition or treatment? 2.
Strategy &
This Trust All Trusts
710 38606 All Patients 100.0% 100.0% 643 29727 Yes, always 3. 90.6% 77.0% Performance & 52 6605 *Yes, sometimes 7.3% 17.1% 15 2274 *No 2.1% 5.9%
4.
Quality & Q40. Were you given enough privacy when being examined or treated?
This Trust All Trusts
722 38895 All Patients 100.0% 100.0% 5.
700 35434 Annual Yes, always 97.0% 91.1% 18 2953 *Yes, sometimes 2.5% 7.6% 4 508 *No 0.6% 1.3% 6.
Items to note
Q41. Were you ever in any pain?
This Trust All Trusts 7. 719 38629
All Patients Any Other 100.0% 100.0% 537 24038 Yes 74.7% 62.2% 182 14591 No 25.3% 37.8%
8.
Date and Time
61 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 192 1. Part One -
Q42. Do you think the hospital staff did everything they could to help control your pain?
2. Strategy & This Trust All Trusts
533 24061 Patients who experienced pain 100.0% 100.0% 458 17171 Yes, definitely 85.9% 71.4% 3. 66 5443 Performance & *Yes, to some extent 12.4% 22.6% 9 1447 *No 1.7% 6.0%
4. Q43. If you needed attention, were you able to get a member of staff to help with within a reasonable time? Quality &
This Trust All Trusts
719 38731 All Patients 100.0% 100.0% 5. 582 22132 Yes, always Annual 80.9% 57.1% 96 10729 Yes, sometimes 13.4% 27.7% 11 2257 No 1.5% 5.8%
30 3613 6. I did not want/need this 4.2% 9.3% Items to note
7. Any Other 8. Date and Time
62 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 193 1. Part One -
Q43+. If you needed attention, were you able to get a member of staff to help you within a
reasonable time? 2.
Strategy & This Trust All Trusts
689 35118 Patients who needed attention 100.0% 100.0% 582 22132 Yes, always 84.5% 63.0% 3.
96 10729 Performance & *Yes, sometimes 13.9% 30.6% 11 2257 *No 1.6% 6.4%
4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
63 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 194 1. Part One -
OPERATIONS & PROCEDURES
2.
Strategy & Q44. During your stay in hospital, did you have an operation or procedure?
This Trust All Trusts
717 38421 3. All Patients
100.0% 100.0% Performance & 672 24013 Yes 93.7% 62.5% 45 14408 No 6.3% 37.5%
4.
Quality & Q45. Beforehand, did a member of staff answer your questions about the operation or procedure in a way you could understand?
This Trust All Trusts
671 24038 Patients who had an operation/procedure 5. 100.0% 100.0% Annual 610 18673 Yes, completely 90.9% 77.7% 40 3426 Yes, to some extent 6.0% 14.3% 2 559
No 6. 0.3% 2.3% 19 1380 Items to note I did not have any questions 2.8% 5.7%
7. Any Other 8. Date and Time
64 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 195 1. Part One -
Q45+. Beforehand, did a member of staff answer your questions about the operation or
procedure in a way you could understand? 2.
Strategy & This Trust All Trusts
Patients who had questions before their 652 22658 operation/procedure 100.0% 100.0% 610 18673 Yes, completely 93.6% 82.4% 3.
40 3426 Performance & *Yes, to some extent 6.1% 15.1% 2 559 *No 0.3% 2.5%
4.
Q46. Beforehand, were you told how you could expect to feel after you had the operation or Quality & procedure?
This Trust All Trusts
672 23941 Patients who had an operation/procedure
100.0% 100.0% 5. 529 15206 Annual Yes, completely 78.7% 63.5% 126 6026 *Yes, to some extent 18.8% 25.2% 17 2709 *No 2.5% 11.3% 6.
Items to note
Q47. After the operation or procedure, did a member of staff explain how the operation or procedure had gone in a way you could understand?
This Trust All Trusts 7. 672 23967 Patients who had an operation/procedure Any Other 100.0% 100.0% 557 16723 Yes, completely 82.9% 69.8% 99 5205 *Yes, to some extent 14.7% 21.7%
16 2039 8. *No 2.4% 8.5% Date and Time
65 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 196 1. Part One -
LEAVING HOSPITAL
2.
Strategy &
Q48. Did you feel you were involved in decisions about your discharge from hospital?
This Trust All Trusts
724 38848 3. All Patients
100.0% 100.0% Performance & 503 20693 Yes, definitely 69.5% 53.3% 158 11078 Yes, to some extent 21.8% 28.5% 45 5677 No 4. 6.2% 14.6% Quality & 18 1400 I did not want to be involved 2.5% 3.6%
Q48+. Did you feel you were involved in decisions about your discharge from hospital? 5. Annual This Trust All Trusts
706 37448 Patients who wanted to be involved 100.0% 100.0% 503 20693 Yes, definitely 71.2% 55.3% 6.
158 11078 Items to note *Yes, to some extent 22.4% 29.6% 45 5677 *No 6.4% 15.2%
7. Any Other 8. Date and Time
66 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 197 1. Part One -
Q49. Were you given enough notice about when you were going to be discharged?
2. Strategy & This Trust All Trusts
723 38942 All Patients 100.0% 100.0% 534 22121 Yes, definitely 73.9% 56.8% 3. 142 11957 Performance & *Yes, to some extent 19.6% 30.7% 47 4864 *No 6.5% 12.5%
4.
Q50. On the day you left hospital, was your discharge delayed for any reason? Quality &
This Trust All Trusts
716 38692 All Patients 100.0% 100.0% 140 15415 5.
*Yes Annual 19.6% 39.8% 576 23277 No 80.4% 60.2%
Q51. What was the MAIN reason for the delay? (Cross ONE box only) 6.
Items to note
This Trust All Trusts
144 14911 Patients whose discharge was delayed 100.0% 100.0% 75
9389 7. I had to wait for medicines 52.1%
63.0% Any Other 14 1830 I had to wait to see the doctor 9.7% 12.3% 22 1674 I had to wait for an ambulance 15.3% 11.2% 33 2018
Something else 8. 22.9% 13.5% Date and Time
67 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 198 1. Part One -
Q52. How long was the delay?
2. Strategy & This Trust All Trusts
146 15507 Patients whose discharge was delayed 100.0% 100.0% 34 1847 Up to 1 hour 23.3% 11.9% 3. 47 4570 Performance & *Longer than 1 hour but no longer than 2 hours 32.2% 29.5% 40 5412 *Longer than 2 hours but no longer than 4 hours 27.4% 34.9% 25 3678 *Longer than 4 hours 17.1% 23.7% 4.
Quality & Q53. Where did you go after leaving hospital?
This Trust All Trusts
724 38985 All Patients 5. 100.0% 100.0% Annual 687 35322 I went home 94.9% 90.6% 24 1466 I went to stay with family or friends 3.3% 3.8% 5 930
I was transferred to another hospital 6. 0.7% 2.4%
6 876 Items to note I went to a residential nursing home 0.8% 2.2% 2 391 I went somewhere else 0.3% 1.0%
7.
Any Other 8. Date and Time
68 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 199 1. Part One -
Q54. After leaving hospital, did you get enough support from health or social care
professionals to help you recover and manage your condition? 2.
Strategy & This Trust All Trusts
709 36658 Patients who went home or to stay with family or friends 100.0% 100.0% 233 11547 Yes, definitely 32.9% 31.5% 3.
105 5223 Performance & Yes, to some extent 14.8% 14.2% 75 4414 No, but support would have been useful 10.6% 12.0% 296 15474 No, but I did not need any support 41.7%
42.2% 4.
Quality & Q54+. After leaving hospital, did you get enough support from health or social care professionals to help you recover and manage your condition?
This Trust All Trusts
Patients who went home or to stay with family or friends and 413 21184 5.
needed support 100.0% 100.0% Annual 233 11547 Yes, definitely 56.4% 54.5% 105 5223 *Yes, to some extent 25.4% 24.7% 75
4414 6. *No, but some support would have been useful 18.2%
20.8% Items to note
7. Any Other 8. Date and Time
69 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 200 1. Part One -
Q55. When you left hospital, did you know what would happen next with your care?
2. Strategy & This Trust All Trusts
723 38860 All Patients 100.0% 100.0% 453 17868 Yes, definitely 62.7% 46.0% 3. 159 10736 Performance & Yes, to some extent 22.0% 27.6% 42 5083 No 5.8% 13.1% 69 5173 It was not necessary 9.5% 13.3% 4.
Quality &
Q55+. When you left hospital, did you know what would happen next with your care?
This Trust All Trusts
654 33687 5.
Patients who needed to know what would happen next Annual 100.0% 100.0% 453 17868 Yes, definitely 69.3% 53.0% 159 10736 *Yes, to some extent 24.3% 31.9%
42 5083 6. *No
6.4% 15.1% Items to note
Q56. Before you left hospital, were you given any written or printed information about what you should or should not do after leaving hospital?
This Trust All Trusts 7. 716 38368 All Patients Any Other 100.0% 100.0% 611 24699 Yes 85.3% 64.4% 105 13669 *No 14.7% 35.6%
8.
Date and Time
70 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 201 1. Part One -
Q57. Did a member of staff explain the purpose of the medicines you were to take at home in
a way you could understand? 2.
Strategy & This Trust All Trusts
723 38649 All Patients 100.0% 100.0% 520 20589 Yes, completely 71.9% 53.3% 3.
39 4522 Performance & Yes, to some extent 5.4% 11.7% 11 2394 No 1.5% 6.2% 104 5870 I did not need an explanation 14.4%
15.2% 4. 49
5274 Quality & I had no medicines 6.8% 13.6%
Q57+. Did a member of staff explain the purpose of the medicines you were to take at home in a way you could understand?
5. This Trust All Trusts Annual
570 27505 Patients who needed an explanation 100.0% 100.0% 520 20589 Yes, completely 91.2% 74.9% 39
4522 6. *Yes, to some extent 6.8%
16.4% Items to note 11 2394 *No 1.9% 8.7%
7. Any Other 8. Date and Time
71 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 202 1. Part One -
Q58. Did a member of staff tell you about medication side effects to watch for when you went
home? 2.
Strategy & This Trust All Trusts
666 33338 Patients who were given medicines to take home 100.0% 100.0% 297 9210 Yes, completely 44.6% 27.6% 3.
77 4443 Performance & Yes, to some extent 11.6% 13.3% 84 9757 No 12.6% 29.3% 208 9928 I did not need an explanation 31.2%
29.8% 4.
Quality & Q58+. Did a member of staff tell you about medication side effects to watch for when you went home?
This Trust All Trusts
458 23410 5. Patients with medicines who needed an explanation 100.0% 100.0% Annual 297 9210 Yes, completely 64.8% 39.3% 77 4443 *Yes, to some extent 16.8% 19.0% 84
9757 6. *No 18.3%
41.7% Items to note
7. Any Other 8. Date and Time
72 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 203 1. Part One -
Q59. Were you told how to take your medication in a way you could understand?
2. Strategy & This Trust All Trusts
671 33416 Patients who were given medicines to take home 100.0% 100.0% 475 18693 Yes, definitely 70.8% 55.9% 3. 37 3521 Performance & Yes, to some extent 5.5% 10.5% 10 2247 No 1.5% 6.7% 149 8955 I did not need to be told how to take my medication 22.2% 26.8% 4.
Quality & Q59+. Were you told how to take your medication in a way you could understand?
This Trust All Trusts
522 24461 Patients with medicines who needed to be told 5. 100.0% 100.0% Annual 475 18693 Yes, definitely 91.0% 76.4% 37 3521 *Yes, to some extent 7.1% 14.4% 10 2247
*No 6. 1.9% 9.2%
Items to note
7. Any Other 8. Date and Time
73 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 204 1. Part One -
Q60. Were you given clear written or printed information about your medicines?
2. Strategy & This Trust All Trusts
671 33426 Patients who were given medicines to take home 100.0% 100.0% 452 18103 Yes, completely 67.4% 54.2% 3. 36 4013 Performance & Yes, to some extent 5.4% 12.0% 29 3074 No 4.3% 9.2% 138 7214 I did not need this 20.6% 21.6% 4. 16 1022
Don't know / can't remember Quality & 2.4% 3.1%
Q60+. Were you given clear written or printed information about your medicines?
This Trust All Trusts 5. Annual Patients who needed written or printed information about 533 26212 medicines 100.0% 100.0% 452 18103 Yes, completely 84.8% 69.1% 36 4013
*Yes, to some extent 6. 6.8% 15.3%
29 3074 Items to note *No 5.4% 11.7% 16 1022 Don't know / can't remember 3.0% 3.9%
7.
Any Other 8. Date and Time
74 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 205 1. Part One -
Q61. Did a member of staff tell you about any danger signals you should watch for after you
went home? 2.
Strategy & This Trust All Trusts
720 38718 All Patients 100.0% 100.0% 377 12509 Yes, completely 52.4% 32.3% 3.
107 6005 Performance & Yes, to some extent 14.9% 15.5% 87 9741 No 12.1% 25.2% 149 10463 It was not necessary 20.7%
27.0% 4.
Quality & Q61+. Did a member of staff tell you about any danger signals you should watch for after you went home?
This Trust All Trusts
571 28255 5. Patients who needed to know about danger signals 100.0% 100.0% Annual 377 12509 Yes, completely 66.0% 44.3% 107 6005 *Yes, to some extent 18.7% 21.3% 87
9741 6. *No 15.2%
34.5% Items to note
7. Any Other 8. Date and Time
75 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 206 1. Part One -
Q62. Did hospital staff take your family or home situation into account when planning your
discharge? 2.
Strategy & This Trust All Trusts
722 38826 All Patients 100.0% 100.0% 442 15174 Yes, completely 61.2% 39.1% 3.
91 5334 Performance & Yes, to some extent 12.6% 13.7% 30 4376 No 4.2% 11.3% 151 12615 It was not necessary 20.9%
32.5% 4. 8
1327 Quality & Don't know / can't remember 1.1% 3.4%
Q62+. Did hospital staff take your family or home situation into account when planning your discharge?
5. This Trust All Trusts Annual
Patients whose family or home situation needed to be taken 571 26211 into account 100.0% 100.0% 442 15174 Yes, completely 77.4% 57.9% 91
5334 6. *Yes, to some extent 15.9%
20.4% Items to note 30 4376 *No 5.3% 16.7% 8 1327 Don't know / can't remember 1.4% 5.1%
7.
Any Other
8. Date and Time
76 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 207 1. Part One -
Q63. Did the doctors or nurses give your family or someone close to you all the information
they needed to help care for you? 2.
Strategy & This Trust All Trusts
718 38456 All Patients 100.0% 100.0% 327 12807 Yes, definitely 45.5% 33.3% 3.
101 6362 Performance & Yes, to some extent 14.1% 16.5% 73 6015 No 10.2% 15.6% 76 5507 No family, friends or carers were involved 10.6%
14.3% 4. 130
7180 Quality & My family, friends or carers did not want or need information 18.1% 18.7% 11 585 I did not want my family, friends or carers to get information 1.5% 1.5%
Q63+. Did the doctors or nurses give your family or someone close to you all the information 5. they needed to help care for you? Annual
This Trust All Trusts
Patients whose family or friends needed information on how 501 25184 to care for them 100.0% 100.0% 327
12807 6. Yes, definitely 65.3%
50.9% Items to note 101 6362 *Yes, to some extent 20.2% 25.3% 73 6015 *No 14.6% 23.9%
7.
Any Other
8. Date and Time
77 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 208 1. Part One -
Q64. Did hospital staff tell you who to contact if you were worried about your condition or
treatment after you left hospital? 2.
Strategy & This Trust All Trusts
721 38667 All Patients 100.0% 100.0% 665 27379 Yes 92.2% 70.8% 3.
36 7806 Performance & *No 5.0% 20.2% 20 3482 Don't know / can't remember 2.8% 9.0%
Q65. Did hospital staff discuss with you whether you would need any additional equipment in 4.
your home, or any adaptations made to your home, after leaving hospital? Quality &
This Trust All Trusts
718 38660 All Patients 100.0% 100.0%
444 9694 5. Yes 61.8% 25.1% Annual 22 2213 No, but I would have liked them to 3.1% 5.7% 252 26753 No, it was not necessary to discuss it 35.1% 69.2%
6. Q65+. Did hospital staff discuss with you whether you would need any additional equipment Items to note in your home, or any adaptations made to your home, after leaving hospital?
This Trust All Trusts
Patients who needed to discuss equipment or home 466 11907
adaptations 100.0% 100.0% 7.
444 9694 Any Other Yes 95.3% 81.4% 22 2213 *No, but I would have liked them to 4.7% 18.6%
8.
Date and Time
78 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 209 1. Part One -
Q66. Did hospital staff discuss with you whether you may need any further health or social
care services after leaving hospital? (e.g. services from a GP, physiotherapist or community 2. nurse, or assistance from social services or the voluntary sector) Strategy &
This Trust All Trusts
720 38613 All Patients 100.0% 100.0% 451 17334 3. Yes 62.6% 44.9% Performance & 52 3703 No, but I would have liked them to 7.2% 9.6% 217 17576 No, it was not necessary to discuss it 30.1% 45.5%
4.
Quality & Q66+. Did hospital staff discuss with you whether you may need any further health or social care services after leaving hospital? (e.g. services from a GP, physiotherapist or community nurse, or assistance from social services or the voluntary sector)
This Trust All Trusts 5. Patients who needed to discuss their health or social care 503 21037 further 100.0% 100.0% Annual 451 17334 Yes 89.7% 82.4% 52 3703 *No, but I would have liked them to 10.3% 17.6%
6.
Items to note 7. Any Other 8. Date and Time
79 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 210 1. Part One -
OVERALL
2.
Strategy & Q67. Overall, did you feel you were treated with respect and dignity while you were in the hospital?
This Trust All Trusts
724 39108
All Patients 3. 100.0% 100.0% Performance & 684 32695 Yes, always 94.5% 83.6% 39 5484 *Yes, sometimes 5.4% 14.0% 1 929 *No 0.1% 2.4% 4.
Quality &
5. Annual 6. Items to note 7. Any Other 8. Date and Time
80 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 211 1. Part One -
Q68. Overall, how would you rate the care you received?
2. Strategy & This Trust All Trusts
717 38165 All Patients 100.0% 100.0% 0 290 *0 0.0% 0.8% 3. 1 280 Performance & *1 0.1% 0.7% 0 381 *2 0.0% 1.0% 0 580 *3 0.0% 1.5% 4. 5 680
*4 Quality & 0.7% 1.8% 8 1541 *5 1.1% 4.0% 9 1592 *6 1.3% 4.2%
28 3999 5. 7 3.9% 10.5% Annual 90 8822 8 12.6% 23.1% 153 8481 9 21.3% 22.2% 423
11519 6. 10 59.0%
30.2% Items to note
Q69. During your hospital stay, were you ever asked to give your views on the quality of your care?
This Trust All Trusts 7. Any Other 724 38967 All Patients 100.0% 100.0% 190 6744 Yes 26.2% 17.3% 401 26875 *No 8. 55.4% 69.0% Date and Time 133 5348 Don't know / can't remember 18.4% 13.7%
81 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 212 1. Part One -
2. Q70. Did you see, or were you given, any information explaining how to complain to the hospital about the care you received? Strategy &
This Trust All Trusts
705 38069 All Patients 100.0% 100.0% 3. 249 7811 Yes Performance & 35.3% 20.5% 261 21756 *No 37.0% 57.1% 195 8502 Not sure / don't know 27.7% 22.3%
4.
Quality &
Q71. Did you feel well looked after by the non-clinical hospital staff (e.g. cleaners, porters, catering staff)?
This Trust All Trusts
717 38448 5.
All Patients Annual 100.0% 100.0% 653 30213 Yes, always 91.1% 78.6% 36 4691 Yes, sometimes 5.0% 12.2%
5 732 6. No
0.7% 1.9% Items to note 23 2812 I did not have contact with any non-clinical staff 3.2% 7.3%
7. Any Other 8. Date and Time
82 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 213 1. Part One -
Q71+. Did you feel well looked after by the non-clinical hospital staff (e.g. cleaners, porters,
catering staff)? 2.
Strategy & This Trust All Trusts
694 35636 Patients who had contact with non-clinical staff 100.0% 100.0% 653 30213 Yes, always 94.1% 84.8% 3.
36 4691 Performance & *Yes, sometimes 5.2% 13.2% 5 732 *No 0.7% 2.1%
4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
83 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 214 1. Part One -
ABOUT YOU
2.
Strategy &
Q72. Who was the main person or people that filled in this questionnaire?
This Trust All Trusts 3. 712 38473 All Patients Performance & 100.0% 100.0% 657 32647 The patient (named on the front of the envelope) 92.3% 84.9% 14 2379 A friend or relative of the patient 2.0% 6.2% 39 3286 4. Both patient and friend/relative together 5.5% 8.5% Quality & 2 161 The patient with the help of a health professional 0.3% 0.4%
Q73. Do you have any physical or mental health conditions, disabilities or illnesses that have 5. lasted or are expected to last for 12 months or more? Include problems related to old age. Annual
This Trust All Trusts
689 37140 All Patients 100.0% 100.0%
394 21905 6. Yes
57.2% 59.0% Items to note 295 15235 No 42.8% 41.0%
7. Any Other 8. Date and Time
84 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 215 1. Part One -
Q74. Do you have any of the following? Select ALL conditions that you have that have lasted
or are expected to last for 12 months or more. 2.
Strategy & This Trust All Trusts
391 21673 Patients with long-standing conditions 100.0% 100.0% 74 6663 Breathing problem, such as asthma 18.9% 30.7% 3.
18 1562 Performance & Blindness or partial sight 4.6% 7.2% 32 4594 Cancer in the last 5 years 8.2% 21.2% 5 1015 Dementia or Alzheimer's disease 1.3%
4.7% 4. 58
4782 Quality & Deafness or hearing loss 14.8% 22.1% 53 4780 Diabetes 13.6% 22.1% 46 6087 Heart problem, such as angina 11.8% 28.1% 5. 287 10315
Joint problem, such as arthritis Annual 73.4% 47.6% 11 2362 Kidney or liver disease 2.8% 10.9% 2 422 Learning disability 0.5% 1.9%
30 2065 6. Mental health condition 7.7% 9.5% Items to note 42 2485 Neurological condition 10.7% 11.5% 120 6267 Another long-term condition 30.7% 28.9%
7.
Any Other
8. Date and Time
85 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 216 1. Part One -
Q75. Do any of these reduce your ability to carry out day-to-day activities?
2. Strategy & This Trust All Trusts
393 21633 Patients with long-standing conditions 100.0% 100.0% 195 9895 Yes, a lot 49.6% 45.7% 3. 164 8744 Performance & Yes, a little 41.7% 40.4% 34 2994 No, not at all 8.7% 13.8%
4.
Q76. Are you male or female? Quality &
This Trust All Trusts
715 38491 All Patients 100.0% 100.0% 314 18091 5.
Male Annual 43.9% 47.0% 401 20400 Female 56.1% 53.0%
Q77. What was your year of birth? e.g.1934 6.
Items to note
This Trust All Trusts
708 38228 All Patients 100.0% 100.0% 29
2490 7. 16 - 39 4.1%
6.5% Any Other 135 6916 40 - 59 19.1% 18.1% 191 7783 60 - 69 27.0% 20.4% 240 10767
70 - 79 8. 33.9% 28.2% Date and Time 113 10272 80 or over 16.0% 26.9%
86 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 217 1. Part One -
Q78. What is your religion? 2.
Strategy &
This Trust All Trusts
715 38356 All Patients 100.0% 100.0% 106 6286 No religion 3. 14.8% 16.4% Performance & 2 155 Buddhist 0.3% 0.4% Christian (including Church of England, Catholic, Protestant, 576 28944 and other Christian denominations 80.6% 75.5% 0 401 Hindu 0.0% 1.0% 4.
1 260 Quality & Jewish 0.1% 0.7% 1 837 Muslim 0.1% 2.2% 2 203 Sikh 0.3% 0.5% 5. 7 442 Annual Other 1.0% 1.2% 20 828 I would prefer not to say 2.8% 2.2%
6. Items to note 7. Any Other 8. Date and Time
87 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 218 1. Part One -
Q79. Which of the following best describes how you think of yourself?
2. Strategy & This Trust All Trusts
692 37190 All Patients 100.0% 100.0% 656 34694 Heterosexual/straight 94.8% 93.3% 3. 2 335 Performance & Gay/Lesbian 0.3% 0.9% 2 171 Bisexual 0.3% 0.5% 5 319 Other 0.7% 0.9% 4. 27 1671
I would prefer not to say Quality & 3.9% 4.5%
5. Annual 6. Items to note 7. Any Other 8. Date and Time
88 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 219 1. Part One -
Q80. What is your ethnic group?
2. Strategy & This Trust All Trusts
711 37931 All Patients 100.0% 100.0% 688 33959 English/Welsh/Scottish/Northern Irish/British 96.8% 89.5% 3. 7 405 Performance & Irish 1.0% 1.1% 0 18 Gypsy or Irish Traveller 0.0% 0.0% 6 917 Any other white background 0.8% 2.4% 4. 5 99
White and Black Caribbean Quality & 0.7% 0.3% 1 47 White and Black African 0.1% 0.1% 1 103 White and Asian 0.1% 0.3%
0 47 5. Any other Mixed / multiple ethnic background 0.0% 0.1% Annual 2 682 Indian 0.3% 1.8% 1 324 Pakistani 0.1% 0.9% 0
108 6. Bangladeshi 0.0%
0.3% Items to note 0 114 Chinese 0.0% 0.3% 0 216 Any other Asian background 0.0% 0.6% 0 381
African 7. 0.0% 1.0% Any Other 0 338 Caribbean 0.0% 0.9% 0 36 Any other black / African / Caribbean background 0.0% 0.1% 0 69 Arab 0.0% 0.2% 8.
0 68 Date and Time Other Ethnic Group 0.0% 0.2%
89 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 220 1. Part One -
2. Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
90 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 221 1. Part One -
2.
Strategy &
3.
Performance &
4.
Quality &
Appendix 2 5.
Questionnaire Annual
6. Items to note 7. Any Other 8. Date and Time
91 Inpatient Survey 2017 | The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 222 1. Part One - 2. Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time 223 1. Part One -
Appendix 2: Questionnaire 2.
Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
224 1. Part One -
2. Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
225 1. Part One -
2. Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
226 1. Part One -
2. Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
227 1. Part One -
2. Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
228 1. Part One -
2. Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
229 1. Part One -
2. Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
230 1. Part One -
2. Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
231 1. Part One -
2. Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
232 1. Part One -
2. Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
233 1. Part One -
2. Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
234 1. Part One -
2. Strategy & 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
235 1. Part One -
2. Strategy & 3. Performance & 4. Quality &
Picker Institute Europe Buxton Court 5.
3 West Way Annual Oxford, OX2 0JB England
Tel: 01865 208100 Fax: 01865 208101
[email protected] 6. www.picker.org Items to note
Registered Charity in England and Wales: 1081688 Registered Charity in Scotland: SC045048 Company Limited by Registered Guarantee No 3908160
7. Any Other 8. Date and Time
236 1. Part One -
Learning From Deaths
2.
0. Reference Information Strategy &
Dr James Neil, Author: Mortality Lead for the Paper date: 19th July 2018 Trust Mr Steve White, Executive Sponsor: Paper Category: Governance and Quality Medical Director 3.
Mortality Steering Group Performance & & Paper Reviewed by: Paper Ref: N/A Quality and Safety Committee Forum submitted to: Board of Director Paper FOIA Status: Full
1. Purpose of Paper 4. Quality & 1.1. Why is this paper going to the Trust Board and what input is required?
Learning from Deaths summary report to Board.
Review of numbers.
2. Executive Summary 5.
2.1. Context Annual To report the current numbers in 2018 for Learning from Deaths (LFD).
2.2. Summary See Numbers Below. 6. 2.3. Conclusion No concerns identified. One death still under review and likely to generate learning around Items to note the process of death investigation. Dr Neil will include this learning in a report to board once it is complete. 7. Any Other 8. Date and Time
1
237 1. Part One -
Learning From Deaths
2. 3. The Main Report Strategy &
3.1. Introduction NHSI asks that we have an update for the board on the current state of LFD investigations/numbers/actions and themes identified.
3.2. Learning From Deaths Summary. 3.
Performance & Date Total Number SI Death Themes Actions/Learning Deaths for case likely due Identified record to (SJR) problems review with care
Jan. 2018 0 0 0 0 None None 4. Quality & Feb. 2018 1 1 0 0 None None Mar. 2018 1 1 0 0 None None Apr. 2018 One death still under review by MSG, with 2 2 0 0 None 5. learning points likely to arise Annual from it. May 2018 0 0 0 0 None None Jun. 2018 0 0 0 0 None None
3.3. Associated Risks 6.
None identified. Items to note
3.4. Next Steps Expand pool of SJR reviewers to allow broader learning to be drawn. The Board is asked to: Note the summary numbers.
3.5. Conclusion 7.
No issues identified. Any Other
8. Date and Time
2
238 1. Part One -
Learning From Deaths
2. Appendix 1: Acronyms Strategy &
LFD Learning From Deaths SJR Structured Judgment Review MSG Mortality Steering Group 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
3
239 1. Part One -
Guardian of Safe Working Hours: Doctors in Training
0. Reference Information 2. Strategy &
Chris Marquis, Guardian Author: Paper date: 19th July 2018 of Safe Working Steve White, Executive Sponsor: Paper Category: Governance and Quality Medical Director Paper Reviewed by: N/A Paper Ref: N/A Quality and Safety 3. Forum submitted to: Paper FOIA Status: Full
Committee Performance &
1. Purpose of Paper
1.1. Why is this paper going to Board and what input is required?
The Board of Directors is asked to consider and note the Trust’s position in relation to safe working hours for doctors in training. 4. Quality & 2. Executive Summary
2.1. Context As part of the 2016 Terms and Conditions for Junior Doctors it was agreed that additional safeguards would be put in place to protect the working hours of doctors in training. This
included a Guarding of Safe Working to champion safe working hours and provide 5. assurance to the Board in this regard. Annual
2.2 Summary The Trust has in place a Guardian of Safe Working and this paper presents the July 2018 report from the Guardian. It outlines the work that has been undertaken to date and highlights some of the issues being faced as the new system of monitoring and exception reporting embeds. The report provides the data currently available in relation to rota 6. vacancies and agency and locum usage. Items to note 2.3. Conclusion The Board is asked to consider and note this report from the Guardian of Safe Working. 7. Any Other 8. Date and Time
1
240 1. Part One -
Guardian of Safe Working Hours: Doctors in Training 3. The Main Report 2.
3.1. Introduction Strategy & This paper sets outs the background and context around the introduction of the Guardian of Safe Working as part of the 2016 Terms and Conditions for Junior Doctors and implementation of that role in the Trust. The 2016 national contract for junior doctors encourages stronger safeguards to prevent doctors working excessive hours. During negotiations on the junior doctor contract, 3. agreement was reached on the introduction of a 'guardian of safe working hours' in organisations that employ or host NHS trainee doctors to oversee the process of ensuring Performance & safe working hours for junior doctors. The Guardian role was introduced with the responsibility of ensuring doctors are properly paid for all their work and by making sure doctors aren’t working unsafe hours. The role sits independently from the management structure, with a primary aim to represent and resolve issues related to working hours for the junior doctors employed by it. The work of the guardian will be subject to external scrutiny of doctors’ working hours by the Care 4.
Quality Commission (CQC) and by the continued scrutiny of the quality of training by Health Quality & Education England (HEE). These measures should ensure the safety of doctors and therefore of patients. The Guardian will:
Champion safe working hours.
Oversee safety related exception reports and monitor compliance. 5.
Escalate issues for action where not addressed locally. Annual Require work schedule reviews to be undertaken where necessary Intervene to mitigate safety risks. Intervene where issues are not being resolved satisfactorily. Distribute monies received as a result of fines for safety breaches. Give assurance to the board that doctors are rostered and working safe hours. Identify to the board any areas where there are current difficulties maintaining safe
working hours. 6.
Outline to the board any plans already in place to address these Items to note Highlight to the board any areas of persistent concern which may require a wider, system solution.
The Board will receive a quarterly report from the Guardian, which will include:
Aggregated data on exception reports (including outcomes), broken down by 7.
categories such as specialty, department and grade. Any Other Details of fines levied against departments with safety issues. Data on Rota gaps / staff vacancies/locum usage A qualitative narrative highlighting areas of good practice and / or persistent concern. Other new features of the 2016 contract include: Work scheduling – junior doctors and employers will be required to complete work schedules for the doctors in training. This will begin as a generic schedule setting out the hours of work, 8. the working pattern, the service commitments and the training opportunities available during Date and Time the post or placement.
2
241 1. Part One -
Guardian of Safe Working Hours: Doctors in Training Exception reporting – enabling doctors to raise exception reports where their work schedules do not reflect their work, and to ensure that a work schedule remains fit for purpose, This is 2.
beneficial to employers as it will give real-time information and be able to identify key issues Strategy & as they arise. It also benefits doctors, as issues over safe working or missed educational opportunities can be raised and addressed early on in a placement, resulting in safer working and a better educational experience. Requirement for junior doctor forums to be set up - principally these forums will advise the Guardian of Safe Working who will oversee the processes in the new contract designed to protect junior doctors from being overworked. The Guardian and Director of Medical Education in each Trust and relevant organisation shall jointly enable a nomination/election 3. process to establish a Junior Doctors Forum (or fora) to advise them and make appropriate Performance & arrangements to enable the elected representatives time off for their activities & duties in connection with their role. Election onto the forum will be for the period of rotation and replacements must be sought for any vacancies.
3.2 Guardian of Safe Working Report 4. Quality & 3.2.1 High level data
For the period Oct-Dec 2017 To end June 2018 5. Annual Orthopaedics Training posts 15 Of which Doctors in training on 2016 contract 0 Doctors on trust grade contracts 7 Spinal Injuries Training posts 1
Of which Doctors in training on 2016 contract 1 6. Items to note
Expected/Predicted August 2018 (too early to advise number of 2016 contracts)
Orthopaedics Training posts 17
Doctors in training on 2016 contract (all Schedule 7. 14) Any Other Doctors on trust grade contracts 3 McH Fellow 3 Not on payroll (MCH lead employer) Spinal Injuries Training posts 1 Doctors in training on 2016 contract 8. Date and Time
3
242 1. Part One -
Guardian of Safe Working Hours: Doctors in Training 3.2.2 Exception reports (with regard to working hours) 2. The exception reporting system is designed to allow employers to address issues and Strategy & concerns as they arise, in real time, and to keep doctors’ working hours, both rostered and actual, within safe working limits. If the system of work scheduling and exception reporting is working correctly, in anything other than truly exceptional circumstances, the levying of a fine indicates that the system has failed or that someone – the supervisor, Guardian or the individual doctor concerned – has failed to discharge his or her responsibilities appropriately. Any levying of a fine should therefore be followed by an investigation in to why it was necessary and remedial action to ensure that it does not happen again. The most important 3. thing to remember is that fines should rarely, if ever be applied at all. Performance & Currently there have been no exceptions reported to the Trust. The trust continues to engage with the junior doctors regarding rotas and via the Junior Doctor Forum. At all stages care is taken to ensure hour’s compliance is achieved without compromise to patient safety and our training responsibilities.
As it stands the Trust can be reassured we are compliant with the demands placed upon us. 4. Quality &
3.2.3 Work schedule reviews
None – please see above. Work schedule reviews are triggered by repeat exception reporting highlighting an issue with a position or rota. With no exception reports, no work
schedule reviews should be expected. 5. Annual 3.2.4 Junior Doctor Agency and Locum usage and Rota Vacancy Report
Trauma and Orthopaedics April – 1 trainee left early as moved to Stanmore, 1 not on on call rota and 2 part time trainees 6. May – Same position Items to note June – Same position Currently the Trust avoids the use of agency for on call rota shifts due to the rate associated with this and try and use internal locums instead. Vacant shifts – April 6, May 15, and June 6 Total spend has been £ 10530 7. Any Other Medicine April, May and June - Single GP trainee vacancy Vacant shifts – April13, May 5 and June 8 Total spend has been £ 7328 8. Date and Time
4
243 1. Part One -
Guardian of Safe Working Hours: Doctors in Training MCSI April, May and June – 2, speciality doctor vacancy due to career break and SPR 2. Strategy & Vacant shifts – April18, May 16 and June 14 Total spend has been £ 14300
3.2.5 Fines 3.
None – please see exceptions report section 3.2.2 Performance &
3.3 Challenges 3.3.1 Engagement
Engagement with the junior doctor workforce has continued to improve and the JDF provides 4. an open forum for discussion. Attendance has fluctuated and I continue to try and achieve a Quality & broader representation and numbers at the meetings. As Guardian I attended the induction in August 2108. The last meeting took place on the 18th May 2018. The next meeting is on the 17th August 2018.
3.3.2 Software System 5.
The Trust has yet to invest in a system for exception reporting. Neither, available system Annual (Allocate or DRS) is reported as fit for purpose as discussed at regional and national level. Continued engagement at regional meetings has shown this position has not changed. This has been raised as an issue by the BMA and I have discussed this with them. At a minimum level an e-mail system is acceptable and is the current approach of the Trust. The Trust currently uses Allocate for rota organisation and this may prove to be the easiest option to explore if required in the future. 6. Items to note
Associated Risks None identified at the time of this report.
Next Steps 7.
The Board is asked to consider and note this report from the Guardian of Safe Working. Any Other 8. Date and Time
5
244 1. Part One -
Guardian of Safe Working Hours: Doctors in Training 3.4. Conclusion 2. The Trust continues to see no exception reports or fines. This is strongly suggestive of a high level of satisfaction in the training and experience offered by the Trust to the Junior Strategy & Doctors. I am grateful to my colleagues for their timely help in returning data this quarter to allow completion of this report. The trust continues to work hard to fulfil its responsibilities under the terms of the new junior doctors’ contract and based on available information and assessments appear to be 3. compliant. Performance &
Christopher Marquis Guardian of Safe Working 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
6
245 1. Part One -
Annual Report for Safeguarding
2. 0. Reference Information Strategy & Sara Ellis-Anderson Named Nurse Safeguarding Adults/ Author: Paper date: 26th July 2018 Suzanne Marsden Named Nurse 3. Safeguarding Children Performance & Bev Tabernacle Paper Governance and Executive Sponsor: Director of Category: Quality Nursing/Deputy CEO Quality and Safety Paper Reviewed by: Paper Ref: N/A Committee
4. Paper FOIA
Forum submitted to: Board of Directors Full Quality & Status:
1. Purpose of Paper
1.1 Why is this paper going to Trust Board and what input is required?
5.
This paper presents an annual review of Safeguarding across adults and children within Annual the Trust for 2017/18. The Trust Board is asked to approve the paper.
The annual safeguarding reports provide an overview of the work which has been undertaken and the performance during 2017/18 in relation to safeguarding and outlines key priorities for 2018/19. A link to this document will be available on the Safeguarding
web page. 6.
Items to note 2. Executive Summary
2.1 Context
Annual report provided each year for assurance purposes.
7.
2.2. Summary Any Other
The annual safeguarding reports provide an overview of the work which has been undertaken and the performance during 2017/18 in relation to adult safeguarding, working in conjunction with the local adult/ Children safeguarding board and local health economy.
8.
2.3 Conclusion Date and Time
1
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2. The Trust Board are asked to review the content of the report and recommendations and approve as appropriate. Strategy &
3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
2
247 1. Part One -
Annual Report for Safeguarding
2. 3. The Main Report Strategy &
3.1 Introduction
The Robert Jones & Agnes Hunt Orthopaedic (RJAH) NHS Foundation Trust is an
organisation which has a culture that prioritises quality of care having strong leadership 3.
and focus, and good partnership working to promote the well-being, security and safety Performance & of vulnerable adults (adults at risk) who are under our care.
Part of the organisations commitment is to work alongside Keeping Adults Safe in Shropshire Board (KASiSB), and other partner agencies, to ensure there are effective 4.
systems in place to safeguard ‘adults with care and support needs‘. Quality &
The RJAH is committed to the Safeguarding Vulnerable people in the NHS – Accountability and Assurance Framework (July 2015) which provides evidence on how the organisation meets the requirements. 5.
Annual The Trust is required to meet the Care Quality Commission fundamental standards (CQC) which is the independent regulator to ensure health and social care services are safe, effective, compassionate, and of high quality care.
CQC Regulation 13: Safeguarding service users from abuse and improper treatment is 6.
to safeguard people who use services from suffering any form of abuse or improper Items to note treatment while receiving care and treatment. Improper treatment includes discrimination or unlawful restraint, which includes inappropriate deprivation of liberty under the terms of the Mental Capacity Act 2005.
7.
3.2 What is Safeguarding? Any Other
The Care Act Statutory Guidance (section 14.7) describes adult safeguarding as;
“protecting an adult’s right to live in safety, free from abuse and neglect. It is about people and organisations working together to prevent and stop both the risks and 8. Date and Time experience of abuse or neglect, while at the same time making sure that the adult’s wellbeing is promoted including, where appropriate, having regard to their views, wishes, 3
248 1. Part One -
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2. feelings and beliefs in deciding on any action. This must recognise that adults Strategy & sometimes have complex interpersonal relationships and may be ambivalent, unclear or unrealistic about their personal circumstances”.
3.3 Our Vision
3.
Robert Jones and Agnes Hunt NHS Foundation Trust is committed to safeguarding Performance & adults with care and support needs ensuring that promoting the welfare of adults is embedded across every aspect of the Trust, making Safeguarding everybody’s responsibility.
4.
The Trust is compliant with statutory responsibilities, national and local guidance, Quality & Care Quality Commission registration and standards. Evidence of compliance is reported quarterly and annually. The Trust provides evidence on how the organisation meets the requirements of the Safeguarding Vulnerable people in the NHS – Accountability and Assurance 5. Framework (July 2015). Annual The Trust has in place clear lines of accountability, which are accessible and promoted to staff. Staff are trained to the level appropriate to their role and responsibilities. Safeguarding Adult policies and procedures are in place in line with national and
local guidance, and reviewed regularly, including safe recruitment policies and 6. Items to note procedures. Processes are in place for the management of allegations against staff. Staff are encouraged to raise concerns. Incidents and complaints' will be reviewed and monitored to identify trends or
patterns. 7.
The Trust has a Quality and Safety performance framework called STAR Any Other (Sustaining Quality through Assessment and Review) which incorporates a standard whereby staff knowledge and awareness of Safeguarding and how to raise a concern is assessed.
8.
4. Actions undertaken during 2017/18 Date and Time
4
249 1. Part One -
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2. 4.1 Making Safeguarding Personal Strategy &
During 2017/18 there has been continued focus on Making Safeguarding Personal which is aligned to one of the strategic priorities set out by Keeping Adults Safe in Shropshire Board Strategic Plan (2015-18). Making Safeguarding personal is now highlighted within
the level 1 and level 2 training. There needs to be continued focus on this going in to 3.
2018/19. Performance &
4.2 Trust Safeguarding Committee Meeting
The joint adult and child safeguarding committee meetings frequency have changed 4.
from monthly to bi-monthly. The meetings are chaired by the Director of Nursing and Quality & attended by the Trust and Clinical Commissioning Group Safeguarding leads, named doctors and members of the senior nursing team.
Key responsibilities of the committee include: 5.
Annual Dissemination of information from reports at local and national level. Review of incidents and sharing of information through case presentations including lessons learnt. Delivery of assurance to the Trust board that key guidelines and standards in
relation to Adult Safeguarding are being met. 6. Receive assurance through audit and training compliance reports. Items to note To advise on, review and approve Safeguarding related policies and procedures
The 2018 work plan for the committee is outlined below:
7.
Dates- 2018 Any Other
1st 5th 7th 2nd 4th 6th Feb Apr June Aug Oct Dec Incidents of Safeguarding X X X X X X Referrals DOLs Referrals X X X X X X Annual Safeguarding Reports X
Safeguarding NHS- 8. accountability and assurance X X framework action plan Date and Time Training Report X X X Prevent Update X X X X X X 5
250 1. Part One -
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2. Dementia Update X X X Policies for review (When Strategy &
required)
Audit Plan TBC TBC TBC TBC TBC TBC
Safeguarding Dashboard X X X X
3.
4.3 Sustaining Quality through Assessment and Review STAR Performance &
STAR is a performance assessment framework to measure and monitor standards of patient care within the clinical environment. The framework is based on the essence of care standards, and links in with national performance standards set by the Care Quality 4.
Commission (CQC) five Key Lines of Enquiry (KLOE’S). Quality &
Standard two of the STAR assessment directly relates to Safeguarding and assesses staff knowledge. During the last set of assessments conducted seven out of eight ward areas were rag rated as green for this standard providing assurance that staff awareness and knowledge of safeguarding was evident. In addition to the ward areas 5. Annual STAR assessments have been rolled out to outpatient areas; both pre-operative assessment and main outpatients were also rag rated as green against the safeguarding standard.
4.4 Information dissemination and link nurse meetings 6.
Items to note Departments and wards within the Trust have link nurse roles for Safeguarding. The link nurses are encouraged to attend link nurse meetings scheduled bi-monthly. The last link nurse meeting held was July 2017; these meetings are due to be re-instated from June 2018. This was due to a gap from the Lead Safeguarding Nurse retiring to a new Lead 7. Safeguarding Nurse being appointed. Any Other
The NHS have produced a new mobile app, as a resource for healthcare professionals to increase their awareness and understanding of safeguarding requirements by providing an overview of necessary legislation and guidance covering both adult and children’s safeguarding. A link to this app is available on the Trust Applications webpage 8. Date and Time for all staff to access.
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2. Modern Slavery was a hot topic throughout the Adult and Children Safeguarding Strategy & Committee in 2017 due to increased frequency of national incidences. Awareness of the national campaign has been promoted by including links to the Modern Slavery fact sheet and briefing being included on the Trust Safeguarding intranet page.
5.0 Adult Safeguarding Referrals (2017/18) 3.
Performance & There were a total of six formal safeguarding referrals raised during 2017/18. Further detail outlined below:
Patient (1) Resident from a care facility known to have a diagnosis of dementia 4.
attended outpatient DXA scan showing signs of neglect. Concern raised by staff to Quality & Shropshire Safeguarding Team. Patient (2) Patient with known Learning Difficulties and behavioural issues attended hospital for ultrasound scan. Patient has carers to assist with activities of daily living 5. and resides with parents. Staff noticed finger mark bruising to both arms. Key worker Annual contacted and Safeguarding concern raised. (Local Authority – Staffordshire).
Patient (3) Patient admitted from home with two grade 4 pressure sores. Patient having contact with District Nurses but no formal package of care in place. Safeguarding
concern raised with Gwynedd Safeguarding team. Investigation by Gwynedd 6. Safeguarding team revealed patient was non-concordant with advice and use of Items to note pressure relieving equipment. Patient was discharged to cottage hospital where care needs were assessed further.
Patient (4) Patient declared her ex-partner was being abusive to their 18 year old 7.
daughter. Concern raised with local Safeguarding team and police contact made. Any Other
Patient (5) Patient attended outpatients with Grade 3 sore and bruising. Recent discharge from Shrewsbury and Telford NHS Trust (SATH) to nursing home. Safeguarding referral raised with local authority (Shropshire). 8.
Date and Time Patient (6) Allegations against HDU staff. Datix E25012 – Restricted access.
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2.
Strategy & In addition to the referrals made above there were another seven incidents reported where advice had been sought from the lead safeguarding nurse. Themes from these incidents are patients requiring support from mental health crisis teams and signposting to domestic abuse helplines and information.
3.
5.1 DoLS Referrals (2017/18) Performance &
There were a total of 17 DoLS referrals during 2017/18 with the majority of the referrals being made from Sheldon, the elderly care rehab ward.
4.
5.2 Prevent Referrals (2017/18) Quality &
There was one Prevent referral made in 2017/18. Following surgery a patient started speaking about terrorists and ISIS. The Trust Prevent policy and flow chart were followed, raising awareness with CCG, Consultants, Executives and the Police. An investigation has 5. been completed; the Trust received assurance that all documentation was sufficiently Annual completed.
6.0 Adult Safeguarding and related Training (2017/18)
The Trust provides comprehensive training to staff on a regular basis to raise awareness 6.
and enable staff to proactively keep adults safe whilst in the care of the Trust. The detail of Items to note the training provided in 2017-18 is detailed below:
6.1 Adult Safeguarding Training Awareness training Level 1
7.
Level 1 Adult Safeguarding training continues to be provided in the format of an Any Other information leaflet. The leaflet is distributed to new staff on the Corporate Induction Programme and sent to existing staff via the internal mail system every 3 years. As at 31st March 2018, 100% of Trust staff have received this information leaflet.
6.2 Adult Safeguarding training at Induction 8. Date and Time
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2. In 2017-18, the Trust continued to provide a Safeguarding presentation on Day 1 of the Strategy & Corporate Induction Programme which all staff (excluding Medical Staff) must attend within 2 months of their employment start date. The monthly session is delivered by the lead nurses for Adult and Children’s Safeguarding. It includes an overview of the Safeguarding accountability structure within the Trust, signposting to relevant policies and interactive
group work to highlight signs of abuse and how to raise a concern. All medical staff receive 3.
Adult Safeguarding training as an e-learning module during their induction. Performance &
6.3 Adult Safeguarding training Level 2
As of 31st March 2018, 86.7% of staff had completed their Adult Safeguarding training 4.
Level 2. This training is delivered by an internally produced e-learning module which Quality & requires staff to undertake an assessment at the end of the module and should be completed every 3 years.
% Completed Vulnerable Adults Level 2 Training 5. 94.00% Annual 92.00% 90.00% % Completed 88.00% Vulnerable Adults Level 86.00% 2 Training 84.00% 6. Items to note 82.00% 80.00%
7.
There was a slight decline in compliance with this training during the winter months and Any Other this is thought to be related to staff not being released to complete training due to service demand.
6.4 Mental Capacity (MCA) Training and Deprivation of Liberty Safeguarding (DoLS) 8. Training Date and Time
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2. In 2017/18 64.7% of staff were compliant with MCA training and 68.2% of staff were Strategy & compliant with DoLS training. This is a decline from 2016/17 figures of 79.4% and 77.6% respectively. The training is delivered via facilitated workshops on a monthly basis and staff are required to complete this every three years. Lower compliance figures may be related to staff not being released due to service demand. 3. % Completed Mental Capacity Act Training Performance & 100.00% 90.00% 80.00% 70.00% 60.00% % 50.00% Completed 4. 40.00% Mental 30.00% Capacity Quality & Act Training 20.00% 10.00% 0.00%
5.
Annual
% Completed DOLS Training 90.00% 80.00% 70.00% 6. 60.00% % Items to note 50.00% Completed 40.00% DOLS 30.00% Training 20.00% 10.00%
0.00% 7. Any Other
Medical staff compliance remains low at 33.3% for MCA and 33.4% for DoLS during 2017/18. In 2017/18 a bespoke combined training session for medical staff was devised 8. however this appears to have limited impact on training figures overall. Date and Time
6.5 Learning Disability, Mental Health and Dementia Awareness Training 10
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2.
Strategy & The Trust continued to provide an eLearning module to provide staff with information and awareness about Learning Disabilities, Mental Health and Dementia Awareness. As of 31st March 2018 92.8% of staff had completed this training, 88.6% of staff had completed this training, which was an increase on the previous year, this is a continued year on year
increase. 3.
6.6 Prevent Training Performance &
Prevent: Counter Terrorism Training remains a statutory training requirement for all staff to complete every 3 years. As of 31st March 2018, 88.2% of staff are compliant with this training, an increase from 80.8% in the previous year. Staff are now required to complete 4.
the facilitated learning once and can have refresher training in the form of an information Quality & leaflet every three years.
% Completed Prevent Training 100.00% 5. 80.00% Annual 60.00%
40.00% % Completed Prevent Training 20.00%
0.00% 6. Items to note
6.7 Dementia Training (Facilitated)
The Trust continued to provide Dementia Awareness Training for clinical staff and 7. Dementia Friends Information sessions for non-clinical staff. In 2017/18 80.5% had Any Other completed Dementia awareness training and 87.5% had attended Dementia Friends information sessions. Both areas have shown steady and sustained increases in compliance.
8. Date and Time
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2.
% Completed Dementia Awareness Training Strategy & 90.00% 80.00% 70.00% 60.00% 50.00% % Completed 40.00% Dementia 3. 30.00% Workshops 20.00% Performance & 10.00% 0.00%
4. Quality & % Completed Dementia Friends Training 100.00%
80.00%
60.00% 5. 40.00% % Completed Dementia Friends Annual 20.00% Training
0.00%
6.
Items to note 7.0 Associated Risks
No associated risks identified
8.0 Next Steps 7.
Any Other 8.1 Key priorities for 2018/2019
Continue to assess standards against NHS Accountability and Assurance framework
bi-annually and develop subsequent action plan. 8.
Continue to monitor training compliance monthly with particular focus on increasing Date and Time compliance for MCA and DoLS training.
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2. With the support of the CCG conduct an audit on the use of the Mental Capacity Act Strategy & (MCA) and feedback audit results and any remedial actions required. Continue to promote and raise awareness of Making Safeguarding Personnel reinstate safeguarding and dementia link nurse meetings and promote link nurses within other disciplines to ensure multi-disciplinary approach.
3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
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2.
Strategy &
Annual Report for Safeguarding Children and
Young People 3. Performance & 1st April 2017 – 31st March 2018
4.
Quality &
5. Annual 6. Items to note
7.
Any Other
8.
Introduction Date and Time
Welcome to the 2018 Robert Jones and Agnes Hunt (RJAH) Orthopaedic Hospital NHS
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2. Foundation Trust’s annual safeguarding children report, detailing our progress in relation to safeguarding children and our future plans. This report provides a concise summary of the work Strategy & undertaken between 1st April 2017 to 31st March 2018 and our vision for the future
This report should be read in conjunction with the Shropshire Safeguarding Children Board (SSCB) Annual Report on arrangements for Safeguarding Children and Young People county wide, this document will be published in Autumn 2018 and will be available on the safeguarding web page. 3.
For the purpose of this document we define children and young people as those who have not yet Performance & reached their 18th Birthday.
Our Vision
As always we recognise that some children and young people will require specific help to be kept 4. safe from harm and the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust is committed to ensuring that: Quality &
“ We all work together to keep our children and young people safe”
This is underpinned by the Working Together document (DOH 2015) which clearly states that “Safeguarding children is everyone’s responsibility”.
5. Safeguarding children and young people remains high on the national agenda and the RJAH takes this responsibility seriously. Our commitment to children and young people, their families Annual and carers is to provide them with the support they need, to enable them to achieve their aspirations and true potential. Ensuring our staff remain vigilant and follow the robust systems that have been put in place, which will ensure that the safety of the child remains paramount throughout their journey within the Trust.
Shropshire Safeguarding Children Board Objectives 6. In striving to achieve our vision we are also committed to supporting the Shropshire Childrens’ Board Work Programme 2016-2018 includes the following :- Items to note
1. Childhood Neglect Promotion and use of the ‘Graded Care Profile’ to identify concerns of childhood neglect.
2. Child Sexual Exploitation and children who go missing Revised strategy in place and working well, children at risk of CSE are identified, helped and protected. 7. Any Other 3. Domestic abuse Agencies are able to identify children who are exposed to domestic abuse and services are provided to victims.
In addition to the priority areas outlined above the SSCB will seek assurance regarding the following areas of activity in relation to safeguarding children in Shropshire, that should be scheduled into our reporting cycle: 8. Recognition and response to private fostering Date and Time Awareness and systems in place to recognise and respond to FGM, Forced Marriage, Honour based Violence (HBV) 15
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2. ‘Prevent’ strategy and process in place and working effectively Strategy & What does this mean in day to day practice? In practical terms this means that we will work together to improve our arrangements for keeping children safe by: -
Ensuring staff keep the wellbeing of children at the centre of all that they do.
3. Listening to children and providing them with the help and support at the right times and in the right ways. Performance &
Sharing information and taking action to protect children when necessary
Ensuring our work force is trained and competent to deal with safeguarding issues appropriately, targeting neglect training courses where possible.
4. Recognising and escalating concerns around compromised parenting, domestic abuse, Quality & FGM, HBV, Forced Marriage, Private Fostering and ‘Prevent’
Ensuring staff are aware of the possible signs of sexual exploitation and are able to consider this as a possibility when dealing with a ‘troubled’ child.
Embracing children’s views and incorporating them into our practice.
5.
Safeguarding children accountability structure across the Trust Annual
Bev Tabernacle Director of Nursing/ Deputy Chief Executive Board level accountability for 6. Safeguarding Items to note
Suzanne Marsden Named Richa Kulshrestha Named Nurse Safeguarding Children Doctor Safeguarding Children 7. Any Other
The lead roles for safeguarding children in the trust are as follows.
Executive Lead – Bev Tabernacle, Director of Nursing.
8.
Non-executive lead – Hilary Pepler. Date and Time
Named Doctor - Dr Richa Kulshrestha, Consultant Paediatrician allocated 1PA per week
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2. protected time, to undertake this role. The Named Doctor provides expert advice and support regarding safeguarding children issues to all staff groups across the Trust. She is supported and Strategy & supervised as necessary from the County wide Designated Doctor – Dr Ganesh.
Named Nurse - Suzanne Marsden - The Named Nurse is the Children’s Unit Manager and has 7.5 hrs per week allocated time to undertake this role as a band 8a. Protected time for this post can be a challenge during periods of recruitment on the unit, but is managed well when the unit is fully established. The Named Nurse works closely with the Named Doctor to ensure that the Trust 3. meets its statutory responsibilities in safeguarding children as defined in Working Together to Safeguard Children document (2015) and the Children Act (2004). Performance &
Child Protection Information Sharing (CP-IS) The national Child Protection Information Sharing service is now fully functional within the Trust and has been a welcomed by staff, as we are now able to highlight quickly if a child is on a Child Protection Plan or is “Looked After” (i.e. in care). However staff still need to be mindful that not all counties in England have yet signed up to this service, so there are pockets of the country where 4. there will be no data available. Therefore the CP-IS service cannot be used as the sole arbiter of risk and the information gained should be placed in the context of the child’s clinical presentation Quality & and a professional assessment. Access to the system is currently via the via the child’s Summary Care Record, however it is anticipated that as IT systems progress this information may be migrated through into our EPR system which will be the most efficient way of using this tool.
ECINS - Empowering Communities Inclusion and Neighborhood Management System 5. To further support communication channels for our vulnerable children in the county ECINS was introduced in Shropshire last year to enable practitioners working with children, young people and Annual families to create an environment where everyone knows what everyone else is doing. It enables practitioners to choose who they share information with securely, across multiple agencies and even across county borders. It provides a central hub where practitioners can task and inform one another. It brings together assessments and action plans in one place and shares information in real time. It dramatically speeds up processes, enabling support to be quickly and effectively offered. 6. ECINS helps to improve working relationships so that children and their families receive joined up Items to note support and intervention that will provide better outcomes for all. As a Trust it would be beneficial for us to sign up to ECINS. Unfortunately the Trust has not yet signed up to this system to date and executive sign up required. ECINS uses web-based technology and the license has been purchased by Shropshire Strengthening Families, so there would be no cost in introducing ECINS into our organisation.
Safeguarding Training 7. The Named Nurse coordinates and delivers level-one training for staff working in the Trust and Any Other provides all staff groups across the Trust with expert advice and support regarding safeguarding children issues. Clinical staff, undertake level-two training as an e-learning module and the vast majority of level three training is accessed via the Shropshire Safeguarding Children Board (SSCB) training pool and is delivered as multi agency training, however to improve training figures in the short term level 3 single agency training has been delivered by the Named Doctor this year. 8. The Named Professionals maintain their own professional development and aim to attend at least Date and Time one safeguarding training session each year. This year the Named Doctor and Nurse attended
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2. the Staffordshire Voices 4 Victims – breaking the silence of Domestic abuse, which proved to be an extremely powerful training day. The Named Nurse has also attended the following training - Strategy & Early help and capturing the voice of the child - SSCB; Introduction to the LADO – Ellie Jones Shropshire LADO: Prevent – Regional update – NHS England and during SSCB training pool updates has completed Protecting Children and Managing the Challenge; Raising awareness update & Domestic Abuse briefing 2018 and Working Together update + GDPR + Self harm and suicide prevention care pathway updates. 3. The Named Nurse for Safeguarding Children and the Lead for Adult Protection are due to deliver Trust Board training in in March 2019. Performance & Training compliance continues to be monitored against the CCG training target of 98% - level 1, 85% - level 2 and 98% - level 3. Training figures for March 2017 were:
Level 1 – 100% - Green Level 2 – 87.9% - Green
Level 3 – 93.6% - Amber (one staff member) 4. Level 4 100% - Green – Quality &
Due to one safeguarding incident this year, it has been highlighted that we need to review the current staff groups requiring level 3 training to ensure accuracy. If numbers of staff requiring training increases, this will reduce our level 3 training compliance in the short term.
One of last year’s actions was to invite the local LADO (local Area Designated Officer) to speak to
our Human Resource (HR) staff, Named Professionals and Executive Leads. This training 5. session was completed and further updates can be arranged and delivered by the Named Nurse Annual for safeguarding children and young people if required.
Interagency Meetings attendance: Quarterly Shropshire Safeguarding Children Board – attended by the Director/Deputy Director of Nursing. Quarterly Shropshire County & Telford & Wrekin Health Governance Safeguarding
Committee in Shropshire - a subgroup of the Safeguarding Children Board – this meeting 6.
is attended regularly by either the Named Nurse / Named Doctor or Assistant Director of Items to note Nursing. Bi-monthly Trust Adult and Child Safeguarding Committee. This meeting is chaired by the Director/ Deputy Director of Nursing. The Named and County Designated Professionals, Matrons and HR training manager attend this meeting. County Named Nurse meeting – this is held twice a year and has training incorporated into the afternoon session of the meeting.
7.
Information from the county meetings are cascaded through the Paediatric Forum and Children’s Any Other meetings and the Trust Safeguarding committee.
Supervision The Named Nurse receives regular quarterly supervision sessions from the Designated Nurse for Telford and Wrekin. Currently supervision for other staff involved in safeguarding incidents is ad hock, but we would like to make this process more formal in the future. To enable us to do this would like to train more staff within the Paediatric team, to be safeguarding supervisors and this 8.
will enable us to increase the number of supervision sessions that we can offer. Date and Time
Policies & procedures
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2. The Trust has policies and procedures in place to protect both Children and Staff working within the Trust. The following Trust documents are available on the Trust intranet. Strategy & Safeguarding Children and Young People Policy Holding Children for Medical Interventions – Clinical Holding training sessions have been arranged for paediatric staff between April & July 2018 Managing Children who Fail to Attend Appointments (DNA) Missing Adult and Child Policy
Employment Checks Policy- incorporating employment checks procedures 3.
Recruitment and Selection Policy Performance & Managing Allegations Policy Domestic Abuse Policy (for staff) Child Death and Bereavement policy
Safeguarding Activity
4.
This year four safeguarding referrals have been made by the Trust. Quality &
1. August 2017 Referral made as a result of frequent non-attendance to clinic and concerns about the child’s hip development. Concerns were raised by the consultant, contact with the family was unsuccessful and following a discussion with the child’s Health Visitor, a decision was made to refer to Newtown Social Services in Powys. Following this referral the family engaged with the hospital and the child has undergone further investigations. 5.
Annual
2. October 2017 Referral made with family agreement with concerns under the category of neglect. Referral made to Flint Social services. Discharge planning meeting held in the family home with ward physio and Named Nurse in attendance. Community support team arranged to work with family by social care.
6.
Items to note 3. January 2018 Referral made to Newtown Powys Social Services in relation a child seen in Orlau and concerns under the category of neglect. The child was living in Foster Care in Cheshire. Powys Social care lead the investigation and a member of the Orlau team has recently been invited to a strategy meeting relating to this case. Following aDatix review of this case, a learning triangle has been developed to share with staff.
7.
4. January 2018 Any Other Referral made to Wrexham Social Services. Several staff members raised concerns about their colleagues who had left work early the previous day and was uncontactable. Staff reported a history of the staff member having suicide thoughts and concerns about her ability to care of her very challenging children whilst she was feeling so low. HR attempted to contact the staff member with no success, and a decision was made to refer to social care. Staff member given special leave from work and social care worked with family. This case was discussed with the
Shropshire Lado, no referral required as staff member did not work with children. 8.
Date and Time 5. April 2018 Referral made to Staffordshire Social services due to concerns raised under the category of
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2. Fabricated illness. Staff have attended two strategy meetings in Stafford and the case is on-going and will be reported in next year’s annual report. Strategy &
The Trust is managing one Managing Allegation Case with the support of the Staffordshire Lado. Risk assessments are in place and the staff members work plan has been adjusted. This case has been difficult to manage due to a delay of the Shrewsbury Police protection Unit. Outcome June 2018, the police are taking no further action, therefore we are expecting this case to be closed and restrictions lifted. 3.
The Domestic abuse policy has been instigated once this year to offer support and guidance to a Performance & member of Trust staff suffering from domestic abuse. Staff involved in this case had provided excellent support for their colleagues as per Trust Policy.
The muscle team are supporting a family where the children are on a Child protection plan under the category of neglect and the team regularly attend Team around the child Meetings ((TAC) and strategy meeting for children with complex needs. 4.
Safeguarding complaints Quality & The Trust has received two informal complaints directly related to safeguarding intervention. One was received by the foster parents (referral number 3 above) and the other related to a complaint made against a Paediatric physio who had been liaising with a child’s school regarding long term school absence and was they trying to offer support for the TAC process. Both complaints were managed within the PALS service and were not taken any further. Learning from these cases were that staff must not allow complaints to stop a safeguarding 5. investigation. The welfare of the child should always remain paramount and the response to the complaint should include that concerns were raised as indicated in the trust Safeguarding Policy Annual and should run parallel to the safeguarding investigation.
Engaging with Young People Due to funding cuts in the county unfortunately our work with the Shropshire Young Health Champions has been difficult and only one 15 Step Challenge Audit was completed this year. We are now looking for other options to address this requirement and we are hopeful our 15 Step 6. Challenge Audit will recommence in the near future. Items to note
Quality assurance Assuring the quality of both professional practice and organisational processes and structures, depends on robust internal and cross agency audit systems. The Trust’s safeguarding web page is fully functional. This web site allows staff to access policies, procedures, contact numbers and up to date safeguarding information. ‐ 7. Any Other The following audits have been undertaken during 2017/18:
Monthly Female Genital Mutilation (FGM) Information Standard (1610 FGM prevalence data set collection) prevalence is checked monthly and should be uploaded onto their website. This Standard commenced in April 2014. This information will be critical for the future development for the prevention and support of girls and women affected by FGM. To date we have not highlighted any children who have been subjected to this practice. 8. Date and Time Monthly documentation Audit - The aim of the audit to provide assurance that we are highlighting on admission those children who may be high risk. Currently we have no flagging system in place 20
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2. and this and this is a risk for us. Some aspects of the audit includes ensuring that we know if the child is on a protection plan; who the child’s legal guardian is; that we are liaising with their social Strategy & care workers and consent is gained to share information.
Performance Monitoring Safeguarding Children Dashboard – this dashboard is populated quarterly and is shared with CCG for them to monitor the Trust’s safeguarding compliance
3.
Performance &
Priorities for 2018/ 2019
Safeguarding children is clearly everyone’s responsibility and as a Trust it is crucial that we continue to work together to improve the service we provide. Safeguarding children is no easy task and health professionals who are faced with children who present with unclear concerns, 4. should always consider child abuse as part of a holistic assessment of the child. Quality & Priorities for next year are: To continue to improve training compliance and review staff group requiring level 3 training. Improvements have been made this year.
Ensure Named professionals are supported to undertake essential training. This has been achieved this year. 5.
Where possible, training should continue to be targeted at Neglect, Sexual Exploitation Annual and Domestic abuse. This has been successful for 2017/18.
To continue to work with partner agencies in achieving the Shropshire Safeguarding Children Board Key targets.
Trust board Safeguarding training March 2019 6. To develop an alternative process to enable young people to assist in auditing services on Items to note the children’s unit – 15 Step Challenge.
Sign up to ECINS – Outstanding
One to two staff to undertake safeguarding supervision training, this will improve availability of supervision available to staff involved in safeguarding children cases. 7. Any Other Conclusion
This annual report provides an overview of activity for 2017 / 2018. Training continues to remain high on our agenda, ensuring are staff are confident to access the right service at the right time to ensure we play our part in keeping children safe from harm.
8. Suzanne Marsden Date and Time Named Nurse Children’s Safeguarding and young People June 2018 21
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2.
Strategy &
3.
Performance &
Appendix 1: Acronyms
Acronym Full text 4.
Acronym Full text Quality & Acronym Full text
5. Annual 6. Items to note 7. Any Other 8. Date and Time
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0. Reference Information 2. Strategy & Sue Sayles, Infection Control Nurse Author: Paper date: 26th July 2018 Phil Davies, Head of Estates and Facilities Bev Tabernacle, Director Executive Sponsor: Paper Category: Governance and Quality of Nursing
Quality & Safety 3. Paper Reviewed by: Committee Paper Ref: N/A Infection Control Comittee Performance &
Forum submitted to: Trust Board Paper FOIA Status: Full
1. Purpose of Paper 4.
1.1. Why is this paper going to Trust Board and what input is required? Quality &
For approval from Executive Committee.
2. Executive Summary
2.1. Context The Annual Report provides assurance in terms of compliance with the Code of Practice on 5. the prevention and control of infections and related guidance (The Health and Social Care Annual Act 2008).
2.2. Summary Surveillance There were no cases of MRSA bacteraemia against a target set at zero The Trust remains on trajectory and has had one case of C.difficle against a target 6.
set at two for 2017/18 Items to note There were 6 cases of E.coli blood stream infections(BSI), all cases were related to urinary tract infections. No targets have been set, an improvement plan has been developed that describes how Shropshire and Telford and Wrekin local health economy will achieve a 10% or greater reduction of E.coli BSIs in 2017/18 There was one case of MSSA bacteraemia attributable to RJAH. No targets have been set but we act on any obvious preventable cause to reduce health care acquired cases. 7.
There was an outbreak of Norovirus on Sheldon ward Any Other
2.3. Conclusion The Board is asked to: (a) To note the report
(b) To discuss and determine actions as appropriate 8. Date and Time
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Infection Prevention & Control & Cleanliness Annual Report 2017/18 3. The Main Report 2.
3.1. Introduction Strategy & The Director of Infection Prevention and Control (DIPC) is required to produce an Annual Report on the state of Healthcare Associated Infection (HCAI) in the organisation for which she is responsible and release it publicly according to the Code of Practice on the prevention and control of infections and related guidance (The Health and Social Care Act 2008). The Annual Report is produced for the Chief Executive and Trust Board of Directors and
describes the activity of the Infection Prevention and Control Team (IPCT) during the year, 3. including progress made against the work plan and targets identified in the Infection Performance & Prevention and Control Annual Programme. It also includes Divisional performance against key areas in Infection Prevention & Control. Ward specific audits are reported on a monthly basis through Trust wide key performance indicators (KPI’s) and are displayed on public STAR boards.
3.2. Health & Social Care Act Code of Practice
The Robert Jones & Agnes Hunt Orthopaedic Hospital has registered with the Care Quality 4.
Commission and have acknowledged full compliance with the Health and Social Care Act Quality & (2008) Code of Practice (commonly known as the Hygiene Code). 5. Annual 6. Items to note 7. Any Other 8. Date and Time
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Infection Prevention & Control & Cleanliness Annual Report 2017/18 3.2.1. Criterion 1 a): Systems to manage and monitor the prevention and control of infection. 2. Strategy & IPC Structure The Chief Executive Officer has overall accountability for the control of infection at RJAH. The Director of Infection Prevention & Control is the Executive Lead for the IPC service, and oversees the implementation of the IPC programme of work through her role as Chair of the Trust Infection Prevention and Control and Cleanliness Committee (IPCC). The DIPC
approves the Annual IPC report and releases it publicly. She reports directly to the Chief 3. Executive and the board on IPC matters. The DIPC has the authority to challenge inappropriate practice. Performance & The Infection Control Doctor (ICD) is the Clinical Lead for the IPC service and is contracted for 3 sessions a week to include the microbiology ward round and microbiological reporting. The role includes: Advising and supporting the DIPC
Oversees local IPC policies and their implementation by ensuring that adequate 4. laboratory support is in place Attends the Water Safety Group and Decontamination Group Quality & Chairs the Trust Antimicrobial Stewardship Committee Provides expert clinical advice on infection management Attends the Infection multidisciplinary team meetings providing expert advice on complex/infected cases Has the authority to challenge inappropriate practice including inappropriate antibiotic
prescribing decisions 5.
The ICD reports to the DIPC on IPC matters. Annual The Infection Prevention and Control Team (IPCT) The Infection Prevention and Control Team (IPCT) are the medical and nursing infection prevention and control specialists responsible for carrying out the work described in the infection control programme of work. RJAH Orthopaedic Hospital NHS Foundation Trust (RJAH) IPCT currently consists of: 6. Consultant Microbiologist: 24h infection control advice is available from the on-call consultant microbiologist Items to note Infection Prevention and Control (IP&C) Clinical Nurse: (1 WTE) Band 7 Surgical Site Surveillance Nurse (0.4 WTE): Band 5 – A post of (0.66 WTE) is vacant Infection Control Analyst (0.8 WTE): Band 4
The Antimicrobial Pharmacist: The Trust employs 0.5 WTE Antimicrobial Pharmacist who works closely with the ICD and other members of the IPC team. There is robust 7.
management of antimicrobial stewardship throughout the Trust. The role of the antimicrobial Any Other pharmacist includes:
Attending and contributing to the Trust Infection Prevention & Control Committee meetings and the Antimicrobial Stewardship Committee meetings Supporting antimicrobial stewardship initiatives
Participating in and contributing to the ward rounds with the ICD 8. Carrying out audits in line with national guidance Date and Time Providing training regarding antimicrobial stewardship to clinical staff within the Trust
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Infection Prevention Control Committee 2. Strategy & The RJAH Infection Prevention & Control Committee (IPCC) is a multidisciplinary Trust committee with outside representation from Public Health England and the CCG. The IPCC oversees the activity of the IPCT and supervises the implementation of the infection control programme of work. The IPCC met every 3 months during 2017/18. Attendance at IPCC
April Sept Oct January 3.
DIPC apol apol apol Performance & ICD IPCN apol apol Ass. DON
SSSN apol apol apol 4.
CCDC (PHE Rep) apol apol apol apol Quality & Antimicrobial Pharmacist apol Facilities Manager (Estates & Facilities Representation) Matron (Quality & Safety) apol 5. Matron (Medicine) apol Annual Matron (Surgery) apol Matron (Theatre & OPD) Theatre Manager apol apol H&S Officer
Head of IPC SCCG & TWCCG 6. Items to note Clinician Rep apol TSSU Rep apol apol The IPC Programme of Work The IPC programme of work 2015 - 18 was specifically designed to focus on achieving full compliance with the standards identified in the Code of Practice, and the achievement of National and local infection related targets, using a template set by the Shropshire & Telford 7. & Wrekin IPC Lead – the Trust has achieved full compliance on all the standards with the Any Other exception of having a fit-for-purpose IT system to support surveillance activity. Previously SaTH was looking into purchasing ICNET with RJAH purchasing a license; however this is no longer an option, therefore the identification of a most cost-effective solution utilising internal systems and exploring local solutions to develop with the support of resources at RSH is required. 8. Date and Time
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IPC Link Practitioner System 2. Strategy & The Infection Control Link Practitioner group meets bi-monthly, with ‘e-updates’ being sent out alternately. This has been used as a tool for improving communication to the wider ward/departmental teams. Topics of discussion for 2017-18 have included: Surgical Site Infection
Skin Preparation 3. Hand Hygiene Competency Performance & Sharps Safety Outbreak Reports Winter Virus Preparations Updates on IPC issues E. coli, MSSA Bacteraemia, C.difficle/Post Infection Review and Documentation Audit requirements/Results
Sharps injury poster 4. Saving Lives toolkit revised version & Feedback on current audits Quality & Flu campaign
3.2.2. Criterion 1 b): Monitoring the prevention and control of infection Mandatory Surveillance Blood Stream Infection 5. MRSA There were 0 cases of MRSA bacteraemia at RJAH in 2017-87. The target remains Annual at 0 MRSA bacteraemia, any case attributed to RJAH would be considered a never event for the Trust.
MSSA There was 1 case of MSSA bacteraemia attributed to RJAH in 2017-18. The Patient on Powys Ward underwent reconstruction knee surgery and post operatively became unwell with sepsis. Blood cultures and wound aspiration obtained grew 6. staphylococcus aureus. The root cause analysis identified that the wound infection Items to note was the most likely source of the bacteraemia.
E. coli (or gram negative bacteraemia) In light of the Department of Health’s new ambition to reduce healthcare associated blood stream Infections by 50% by the year 2021, the Local Health Economy felt that it would be prudent to convene a group to look at more joined up ways of working locally to try to prevent blood stream infections in our patients. Infections can occur 7. across the wider health economy (hospital and community settings); therefore, Any Other reductions can only be achieved by working together across the whole health and social care sector.
During 2017/18 the health economy was to focus on E.coli as one of the largest infection groups and this is supported by the Quality Premium for CCG’s. The local health economy Infection prevention and Control (IPC) group has worked together and agreed a reduction plan with a focus to reduce E.coli by 10% or greater. 8. Date and Time
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Infection Prevention & Control & Cleanliness Annual Report 2017/18 There were 6 cases of E.coli bacteraemia in 2017 -18. All cases were reviewed
individually to determine whether there were common themes to help identify priority 2.
areas for action, all cases related to urinary tract infections that were unavoidable. Strategy &
C. difficile There was 1 case of C difficile at RJAH in 2017 -18. The Trust appealed the case as the findings of the RCA identified that there had been no lapse in patient care. The case was considered by the Commissioners and agreed for removal from the Trusts actual number of cases for the purpose of calculations of financial sanctions. The 3. positive outcome of the appeals process is tabled below: Performance &
Robert Jones and Agnes Hunt 2017/18 CDI Post Infection Review Outcome Ward Appeals Appeals Panel Date of / Rationale Quarter CCG ID DOB Panel Additional Specimen Care for Decision 4. Decision Comments/Actions
Group Quality & Q1 Out of 24/05/17 1172536 31/07/61 Wrekin UPHELD 1. No 1. Comprehensive County Ward indication to information within suspect CDI PIR transmission documentation 2. No 2. There were antibiotics missed given within opportunities to 5. RJAH take a faecal Annual specimen in the days prior to sample being obtained Lessons learnt from this case included the need for adaptions to the current admission assessment document for spinal injured patients upon transfer from other trusts. This now 6.
incorporates a more detailed assessment of the patient’s history of infection, alongside Items to note improved detail of any other infections present in the ward environment from the transferring hospital.
7. Any Other 8. Date and Time
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Surgical Site Surveillance (SSI) 2.
Since July 2008, hospitals are required to have systems in place to identify patients who are Strategy & included in the surveillance and later develop a surgical site infection. From January 2017 – December 2017, data on 4039 operations – total hip replacements, total knee replacements and spinal surgery was collected by the RJAH surgical site surveillance team. PHE analyses the submitted data at quarterly intervals to identify hospitals whose SSI incidence falls above the 90th or below the 10th percentiles nationally for a given surgical 3. category, enabling the Trust to benchmark itself against the national rate of infection. Performance & Surgeon specific data allows the surgical site surveillance team to provide analysis of infection rates to individual surgeons as part of their validation and appraisal process.
RJAH Surgical Site Infection Surveillance: Total Hip Replacements January 2016 - December 2017 4.
1.2% 500 Quality & 1.0% 400 0.8% 300 0.6% % Rate of THR Procedures 200 0.4%
% SSI % THR National Average 0.2% 100 No. of THR Procedures 0.0% 0 5. Jan - Apr - Jul - Oct - Jan - Apr - Jul - Oct - Mar Jun Sept Dec Mar Jun Sept Dec Annual 2016 2016 2016 2016 2017 2017 2017 2017
The RJAH rate of SSI for total hip replacements has been consistently below the national average through 2016 and 2017. 6.
RJAH Surgical Site Surveillance: Total Knee Replacements Items to note January 2016 - December 2017
2.5% 500 2.0% 400 1.5% 300
% Rate of TKR Procedures 7. 1.0% 200 Any Other
% SSI % TKR National Average 0.5% 100 No. of TKR Procedures 0.0% 0 Jan - Apr - Jul - Oct - Jan - Apr - Jul - Oct - Mar Jun Sept Dec Mar Jun Sept Dec 2016 2016 2016 2016 2017 2017 2017 2017 8. The RJAH rate of SSI for total knee replacements has been consistently below the national average through 2016 and 2017, with the exceptions being Oct-Dec 2016 and Oct – Dec Date and Time 2017.
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RJAH Surgical Site Surveillance: Spinal Surgery Strategy & January 2016 - December 2017
3.5% 250 3.0% 200 2.5% 150 2.0% 3. 1.5% % Rate of Spines Procedures 100 Performance &
% SSI 1.0% % Spines National Average 50 0.5% No. of Spines Procedures 0.0% 0 Jan - Apr - Jul - Oct - Jan - Apr - Jul - Oct - Mar Jun Sept Dec Mar Jun Sept Dec 2016 2016 2016 2016 2017 2017 2017 2017 4. Quality & The RJAH rate of SSI for spinal surgery has been below the national average four quarters out of the eight during the period Jan 2016 and Dec 2017, with a peak showing in Oct-Dec 2016. The last 3 quarters show the rate as being consistently above the national average. The pie charts below show the infections reported split by Deep/Superficial:
Deep/Superficial Infection: Total Deep/Superficial Infection: Total Hip 5. Replacements 2017
Knee Replacements 2017 Annual
Superfici al Deep 43% 25% Deep
57% 6. Superficial 75% Items to note
Deep/Superficial Infection: Spinal Surgery 2017 7. Any Other
Superfic ial 38% Deep 62% 8. Date and Time
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The tables below show how our Hip and Knee Replacement SSI rates and activity compare 2. with other Orthopaedic Alliance Trusts for 2016/17. Data for 2017/18 has not been Strategy & published at the time of this report. The figures demonstrate that RJAH performs the highest activity levels nationally.
2016/17 - Hip NHS Trust No. operations No. of SSIs % of SSIs The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 1503 2 0.1 3.
Wrightington, Wigan and Leigh NHS Foundation Trust 1305 3 0.2 Performance & The Royal Orthopaedic Hospital NHS Foundation Trust 1223 4 0.3 Royal National Orthopaedic Hospital NHS Trust 421 3 0.7
2016/17 - Knee NHS Trust No. operations No. of SSIs % of SSIs
The Royal Orthopaedic Hospital NHS Foundation Trust 1004 3 0.3 4.
Royal National Orthopaedic Hospital NHS Trust 520 3 0.6 Quality & The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 1432 10 0.7 Wrightington, Wigan and Leigh NHS Foundation Trust 1066 7 0.7
Infection MDT The Infection MDT commenced during October 2017, led by Consultant Surgeons within the Trust to review all patients who have been identified as having a surgical site infection. The 5. purpose of the MDT is to discuss complex infections and to make recommendations for the surgeons’ treatment plan. The Infection MDT is attended by the Consultant Microbiologist, Annual Antimicrobial Pharmacist, the Infection Prevention & Control Team, Radiologist and Histopathologist. It is an opportunity for all surgeons to share learning and peer support.
Since the Infection MDT has been running, there have been 58 patients reviewed, of which 30 were identified as having a surgical site infection which was acquired at RJAH. PHE’s Surgical Site Surveillance System requirements are to report hips, knees and spines; the 6. Infection MDT reviews patients from all orthopaedic specialities, e.g. upper limb, lower limb, sport, spinal injuries. Items to note
The pie chart below shows the split of RJAH and non-RJAH acquired SSIs:
% Patients Reviewed at the Infection MDT Oct 2017 - Mar 2018 7.
Non-RJAH Any Other acquired Surgical Site Infection 48% RJAH acquired Surgical Site Infection
52% 8. Date and Time
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The chart below shows how the RJAH acquired surgical site infections are split by speciality: 2. Strategy &
RJAH Acquired Surgical Site Infections By Speciality Reviewed at the Infection MDT Oct 17 - Mar 18
Arthroplasty Foot & Ankle Spinal Disorders 3.
Spinal Injuries Upper Limb Sports/Knee Service Performance &
10% 13% 50%
10% 4.
7% Quality & 10%
It has become apparent since the implementation of the Infection MDT in October 2017, how 5. much data is being collected Trust-wide that enables the Trust to have visibility of infection Annual rates across all orthopaedic specialities.
As a recognised centre of excellence, additional resource is required to support maximising the value of our quality and performance in this field.
Getting it Right First Time (GIRFT) 6. Items to note During Oct16-Oct 17 The Trust took part of in the National Audit for infection. The ‘Getting It Right First Time’ (GIRFT) audit for surgical site infections in hip, knee, shoulder, elbow and ankle replacements; led by Professor Tim Briggs from the Royal National Orthopaedic Hospital, Stanmore.
This initiative encouraged the scrutiny of SSIs and their causes and was intended to be 7.
introduced without prejudice to and without interfering with the complementary collection and Any Other publication of surveillance data on SSIs undertaken by the Trust for Public Health England.
The audit data was submitted in October 2017, to date the results have not been published.
It is likely that collection of this data will become compulsory for all trusts as part of the solutions being developed from the GIRFT programme, with data inputted into the dashboards for each speciality and hosted by the model hospital. 8. Date and Time
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Infection Prevention & Control Ward/Department Audits Strategy &
Wards and departments complete a robust package of infection prevention and control audits across the year. The toolkit comprises of environmental auditing, which highlights patterns of non-compliance to be addressed, the hand hygiene audit tool includes bare below the elbows and a revised set of High Impact Interventions (Saving Lives) tool was implemented January 2018. 3.
The graph below shows the Trust’s compliance against each of the individual audits. The Performance & results show how the Trust consistently achieves the 95% in all areas each month, with the exception of Hand Hygiene for May 2017 and July 2017, local actions plans for non- compliant wards/departments are implemented and staff encouraged to challenge at the point of care. 4. Quality & RJAH Trust Infection Prevention & Control Ward/Department Audits Compliance - Apr 2017 - Mar 2018
100.00%
90.00% 5. 80.00% Annual 70.00% Hand Hygiene
60.00% Bare Below Elbow 50.00%
% Compliant Environment 40.00% 6. High Impact Interventions (Saving
30.00% Items to note Lives) 20.00% Target
10.00% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 7. Any Other 8. Date and Time
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Hand Hygiene & Bare Below the Elbows 2. Strategy & The image below shows the hand hygiene and bare below the elbow compliance split by designation. The ‘Other’ category captures other members of the multi-disciplinary team, such as therapy support, pharmacists and students. 3. Performance & Doctor Nurse HCA Other Clean Hands: Clean Hands: Clean Hands: Clean Hands: 96.46% 99.67% 99.46% 94.07%
Bare Below Bare Below Bare Below Bare Below the Elbow: the Elbow: the Elbow: the Elbow: 96.51 99.67% 99.55% 99.51% 4. Quality &
Environmental Audits – Common areas of non compliance 5. Annual 6. Items to note
Each matron receives a monthly report to show the results of their areas with a view to 7.
implementing any action plans for areas that have not achieved the 95% target. A copy of Any Other the audit results also goes to the Infection Control Link Nurses and Ward/Department Managers. Improvements that have been made include: Floor replacement programme on the Spinal Injuries Unit Outpatients have been decorated and received new chairs
The Daniels representative has visited departments to provide advice and support on 8.
temporary closure mechanisms on sharps boxes Date and Time
High Impact Interventions (Saving Lives) 13
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Infection Prevention & Control & Cleanliness Annual Report 2017/18 During January 2018, a revised set of High Impact Interventions (Saving Lives) audits were implemented across the Trust. The aspects of care, volume and compliance of audits are 2.
shown in the following table: Strategy &
No. audits High Impact Interventions % Compliance Target completed *Antimicrobial Prescribing 42 96.43% 95% *Antimicrobial Secondary Care 12 75% 95% Central Venous Access Devices - 5 100% 95% 3. Insertion Action Performance & Central Venous Access Devices – 450 99.11% 95% Ongoing Care Chronic Wounds - Wound Care Phase 305 92.46% 95% Peripheral Vascular Access Devices – 500 100% 95% Insertion Action
Peripheral Vascular Access Devices – 3516 96.59% 95% 4. Ongoing Care Quality & Preventing Surgical Site Infections - 56 100% 95% Intra-Operative Phase Preventing Surgical Site Infections - Pre- 16 100% 95% Operative Phase Urinary Catheter - Insertion Phase 1024 99.80% 95% Urinary Catheter - Routine Maintenance 3168 98.80% 95% 5. Cleaning and Decontamination 1614 100% 95% Annual
*To note: the Antimicrobial Prescribing aspects of the audits are new and were completed by ward staff, training for staff will be implemented to support the completion of these audits. 6. Items to note 7. Any Other 8. Date and Time
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Infection Prevention & Control & Cleanliness Annual Report 2017/18 2. Strategy & Validation Auditing The peer review audits are complemented by validation audits undertaken by the infection control team. Areas reviewed in 2017/18 are shown below. All areas received copies of audits completed alongside action plan templates and suggestions for improvements in the clinical environment. Staff are encouraged to use the ‘Planet FM’ system to document 3. environmental issues requiring estates attention. Performance &
Theatres Areas of improvements required include: Clutter along the theatre corridors
No clear responsibilities for cleaning 4.
High levels of dust on the stacking trollies Quality & Inappropriate placement of trollies obstructing the vents Rust on wheels All actions have been completed and are monitored by regular walkabouts.
TSSU 5.
Areas of improvements required include: Annual Trolley wheels rusty Build-up of scale on the washers Floors and walls damaged requiring attention All actions have been completed and are monitored by regular walkabouts. 6.
Hydrotherapy Items to note Pool Areas of improvements required include: Rust observed on: o plinth legs/hydraulics o changing room benches
o shower chairs 7.
o poolside rails Any Other o door brackets Lockers discoloured with rusty locks All actions will be addressed following recipt of funding from the £100 K bid. 8. Date and Time
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Orthotics Strategy & Areas of improvements required include: No privacy curtain for when patients undergoing plaster application Build- up of scale in the plaster sink Cluttered shelves with open stored clinical equipment, recommend cupboard doors to be fitted to prevent collections of plaster dust
Clinical equipment being stored in an office environment 3. Outstanding actions include sourcing additional storage and installation of cupboards. Performance &
Orthotics RSH Areas of improvements required include: 4.
Limited storage for clinical equipment within clinical room Quality & Lack of hand hygiene facilities for office staff receiving soiled footwear Taping to floor mat damaged and unable to be cleaned effectively Poor access to sluice activities Outsanding actions have been raised with Royal Shrewsbury Hospital as part of the service level agreement . 5.
Gladstone Annual Areas of improvements required include: Lack of hand washing posters Macerators visibly soiled and had hairline cracks Extraneous items stored in the sluice
Breakfast trolley in poor state of repair 6.
PPE dispensers dusty and not fully stocked Items to note All actions have been completed and are monitored by regular walkabouts.
Alice Areas of improvements required include: Sinks in both sluices have not got elbow taps 7. Clinimatic has two hairline cracks Any Other Plaster room - COPD lack of storage clutter surfaces New hand washing sink in plaster room in COPD does not meet standards Fridge in COPD office for Occupational health immunisations – regular checks not always completed and fridge should not be located in an office All actions are in progress with installation of new sinks set as high priority. 8. Date and Time
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Infection Prevention & Control & Cleanliness Annual Report 2017/18 2. Strategy & Commodes 22 chairs were audited across the Trust by external company Vernacare Areas of improvements identified include: 2 chairs were found to have soiling on the foot rests
7 chairs required replacing due to poor state of repair 3.
7 new commodes have been purchased and monitored by regular walkabouts. Performance &
Troughs/Foam Leg Supports All troughs/foam leg supports throughout the Trust were audited. Areas of improvements identified include: 4. Quality & When uncovered/unzipped bodily fluids evident The majority of the troughs/leg supports were not waterproof A replacement programme to be implemented All soiled troughs have been replaced. 5. Annual 6. Items to note
3.2.3.Criterion 2: Provide and maintain a clean and appropriate environment
The Trust understands the importance of a clean, appropriate environment and focuses on 7.
providing excellent outcomes. Any Other Cleanliness Cleaning is provided by the Trust’s in-house team of cleaners and deep cleaners; the internal team is supported by external window cleaners and pest control operatives. Cleaning staff are allocated to their own area, giving them ownership of the standard; the number of hours for each area is determined by the Credits for Cleaning information system,
with further input from local stakeholders, on a risk adjusted basis. 8.
Outcomes for cleaning are monitored through several sources including internal monitoring, Date and Time internal patient satisfaction surveys, the PLACE assessment and the CQC inpatient survey.
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Infection Prevention & Control & Cleanliness Annual Report 2017/18 Cleanliness – Deep Cleaning Whilst routine cleaning is completed in all areas on a daily basis, staff in high risk areas are 2. supported with extra staff to complete a deep clean on a weekly basis. In the very high risk Strategy & area of theatres there is a rolling deep clean programme that runs alongside the routine clean; cleaning in these areas is completed over night, when the theatres are not in use, to provide the most effective service. In case of an outbreak, the Trust recognises the potential need to employ the use of technologies such as hydrogen peroxide vapour for the fogging of facilities and equipment.
The Trust now also has a working relationship with Bioquell, whose service can be called 3.
upon as need requires it. Performance & Cleanliness – Internal Monitoring The Housekeeping Department has devised an effective sign-off sheet that allows staff to easily demonstrate the work they have completed and alert the next person on shift to any outstanding requirements. Evidence of cleaning is retained by the department and is validated by supervisor monitoring and managerial spot checks.
Internal monitoring is carried out every day, visiting all areas on a weekly basis. Very high 4. risk areas are monitored by a clinical team to ensure the broadest picture is seen. All Quality & required improvements identified by the audits are acted upon by the internal team and the results, along with the patient survey, go to the Infection Prevention & Control Committee on a quarterly basis. 5. Annual 6. Items to note
The Trust has a risk based national cleanliness target of 85%, internally the Trust has set a 7. 94% target, for the year 2017/18 the Trust achieved an average score of 98.45% Any Other Cleanliness – Patient Satisfaction – Internal Internal monitoring very much aligns to the feedback PALS (Patient Advice and Liaison Service) receive from the patient. On a monthly basis an internal team speaks to patients one to one and also reviews feedback forms that the patient can fill in privately. The results are fed back to the Estates and Facilities team to act upon. Satisfaction for cleanliness in 2017/18 was recorded as 99.4%. 8.
Further to the categorisation of cleanliness standards through the patient surveys, the Date and Time department also reviews every comment as part of its 360° review and learns as a team
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Infection Prevention & Control & Cleanliness Annual Report 2017/18 from negative feedback but also highlights the numerous positive comments associated with the hard work of the cleaning team. 2. Strategy & Were you satisfied with the hygiene of the Ward Month Always Mostly Sometimes Never Don’t know
Apr-17 262 5 1 0 0
May-17 219 6 1 0 5 3.
Jun-17 297 11 1 0 1 Performance & Jul-17 255 11 2 1 0 Aug-17 283 9 2 0 2 Sep-17 261 11 3 0 2
Oct-17 371 14 2 0 13 4.
Nov-17 383 5 2 1 13 Quality & Dec-17 261 10 2 0 5 Jan-18 332 20 1 0 10 Feb-18 405 18 2 0 9 Mar-18 366 19 2 0 21 5. Need to explain the negative comments Annual 90 compliments relating to cleanliness were recorded in the written comments; Positive compliments are regularly fed back to housekeeping staff. The 2 ‘Never’ scores received were from Baschurch and Sheldon and were accompanied by no written comment in relation to cleanliness/hygiene. Of the 21 ‘Sometimes’ scores, only 1 patient recorded any written comment in
relation to cleanliness. This was a specific to standards within the relatives 6. accommodation, which was immediately raised with the domestic team & issues Items to note rectified. Subsequent monitoring in this area has shown a consistent high standard of cleanliness and no further comments have been received.
Cleanliness and Environment - Kitchen 7. The Trust kitchen is 5 Star rated for its food hygiene environment by the area Environment Health Officer. To reinforce standards, the department is calling upon a third party auditor to Any Other independently review standards; this has been a recommendation of the Environmental Health Officer. 8. Date and Time
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Infection Prevention & Control & Cleanliness Annual Report 2017/18 PLACE – Patient Led Assessment of the Care Environment The 2017 PLACE assessment identified many positives for the Trust and also areas to work 2. upon. In relation to cleanliness and the environment; Strategy & 3. Performance & 4. Quality & 5. Annual The Trust has improved across all measures, partly down to actions taken over the last 12 months and partly down to the much improved facilities in the new build. There are still areas for improvement, some easy to achieve and some that will only be achieved through future new builds. Cleanliness maintained its high standard, consistent with previous years and the internal reporting that goes to the Infection Control Committee quarterly. The few issues identified were mostly related to dust; all issues were resolved within days 6. following the report. Items to note 7. Any Other
The Trust has already completed its 2018 assessment; Full results will be published later this year. 8. Date and Time
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Committee; these include elements that fall outside of Criterion 2; cleanliness and the 2.
environment. Strategy & Linen In collaboration with the Shropshire Linen Consortium, the Facilities and Infection Control team undertook an audit of the Mid Cheshire Hospital’s laundry facility. The audit was undertaken to a rigorous standard, and concluded with a risk rated action plan. Whilst the staff were enthusiastic to work with the auditors in recognition of the service they provide, a number of issues relating to process were identified. These included a need for improved 3.
signage around clean/dirty area, locations of hand wash basins and application of PPE. Performance & Owing to the buy in created by the collaborative working, actions have been undertaken to reach a gold standard. The team is due to return after June, the Mid Cheshire staff team are confident that all issues have been addressed. Estates Department Contribution to the Clean and Appropriate Work Environment Estates department activity is essential in delivering the IPC agenda, and is delivered under the principles outlined in two main documents:- 4. Quality & 1. Health Building Note 00-09 (Department of Health, 2013 -which supersedes and replaces all versions of Health Facilities Note 30) and covers the importance of a clean, safe environment for all aspects of Healthcare. 2. Health Technical Memorandum 04 01, The Control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems.”
Part A: Design, installation and testing and 5.
Part B: Operational management. (Department of Health (DOH) 2006). CWP’s ‘control of Annual Legionella’ closely adopts the requirements of the above HTM. Water The control of water is covered by the legal requirements of the Health & Safety at Work Act 1974 concerning risks from exposure to legionella and guidance on compliance with the relevant parts of the Management of Health and Safety at Work Regulations 1999. 6. Water safety is managed and controlled by the estates department to guidance HSG274 and HTM 04. The Estates department continues to employ a third party contractor to provide Items to note technical advice for water services and undertake water risk assessments on Trust properties every two years, or where required following incidents or significant infrastructure changes. There is a written site specific scheme of control for each inpatient premises. Eurofins provide an internet based water testing database storage and reporting for statutory test results. There is also a three monthly review of test results, control measures and procedures at the Water Safety Group to ensure compliance with current legislation and 7. these results are published at the Infection Prevention Control Sub Committee. Any Other Estates Operational Service continually undertake water tests throughout the Trust estate, this water testing is carried out under legislation and guidance set out by The Health & Safety Executive and the Department of Health. Testing is standard practice at RJAH to ensure robust control of waterborne infections such as leginaellosis; it is a method of using quantitative data to measure that our planned maintenance is successfully controlling growth of microorganisms in the potable water supply. During April 17 – March 18 at total of 688 water sample tests were undertaken, this is a greater frequency than required by guidance, 8.
the purpose of which is to identify potential issues sooner so that corrective actions can be Date and Time implemented at the earliest possible time. At time of audit 92% of tests were within specified limits. Those tests which recorded a score outside of the most stringent parameters were
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no concern to patient safety. Strategy &
Water Quality
100 3. 80 Performance &
60
40
20
0 4.
42826 42856 42887 42917 42948 42979 43009 43040 43070 43101 43132 43160 Quality & Pass Requires remedial action
As a further development to the robust approach that Estates and Facilities take to water safety training, the department has developed bespoke video tutorials referencing real areas around the Trust for training purposes. 5.
Decontamination Group Annual Decontamination covers the theatre and sterile services environment under the guidance of HTM 03-01. Decontamination is led and monitored by the estates department supported by their third party accredited Authorising Engineer AE(D) .
Accredited third party contractors revalidates theatres on an annual basis, providing an 6.
inspection and reverification report. These reports are then reviewed by the AE(D) Items to note The RJAH estates team maintain a local testing regime on a monthly basis to proactively manage any issues with compliance. Further, there is a three monthly review of test results, control measures and procedures to ensure compliance with current legislation and these results are published at a sub- committee of the Infection Prevention & Control & Cleanliness Committee. For the year 2017/18, all theatres passed their revalidation based on their install 7. specification. Any Other 8. Date and Time
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3.2.4. Criterion 3: Ensure appropriate antimicrobial use The Antimicrobial Stewardship (AMS) Committee meets quarterly. The committee discusses antibiotic consumption and antimicrobial issues within the trust and has also included 3. discussion of antimicrobial Datix incidents at each meeting and agreed an audit plan for Performance & 2018-19. Monitoring of antibiotic consumption is the responsibility of the Antimicrobial Pharmacist within the trust. Consumption of carbapenems and piperacillin/tazobactam has specifically been monitored. Consumption in DDDs/1000 admissions is calculated and compared to historical data, as per the graph below: 4. Quality & RJAH Total Antibitotics issued in DDDs/1000 - Quarterly Apr 2013 - Mar 2018
3100.00
2900.00 5. Annual 2700.00
2500.00
2300.00 Total Antibiotic consumption Median 2100.00
Lower Control Limit 6. Upper Control Limit 1900.00 Items to note
DDDs/1000 admissionsDDDs/1000 1700.00
1500.00 7. 13-14 Q1 13-14 Q2 13-14 Q3 13-14 Q4 14-15 Q1 14-15 Q2 14-15 Q3 14-15 Q4 15-16 Q1 15-16 Q2 15-16 Q3 15-16 Q4 16-17 Q1 16-17 Q2 16-17 Q3 16-17 Q4 17-18 Q1 17-18 Q2 17-18 Q3 17-18 Q4 Any Other
CQUIN achievements The use of broad spectrum antibiotics, such as piperacillin/tazobactum and carbapenems is recognised to contribute to the increase of antibiotic resistant organisms. Reduction in the use of these antibiotics is part of the antimicrobial stewardship program and one of the themes for the 2017-18 CQUIN . In line with Public Health England’s finger tips data, our data shows we are 8.
achieving a steady but gradual decrease in the four quarter rolling rate of total Date and Time antibiotic prescribing per 1000 admissions and Piperacillin-tazobactum but an increase in carbapenem prescribing. 23
290 1. Part One -
Infection Prevention & Control & Cleanliness Annual Report 2017/18 Antibiotic Review of antibiotic prescriptions by 72 hours for ‘Sepsis’ patients was
another component of this year’s CQUIN and the targets were achieved in all four 2.
quarters. Strategy &
Areas of focus for 2017/18 have been: Audit Introduction of Point prevalence studies 3.
Contribution to Local Health economy infection prevention and control and Performance & antimicrobial prescribing group Introduction of specific vancomycin drug chart Infection MDT
Aspirations for the 2018/19 are: 4.
Review of current Trust drug chart to incorporate a specific section for prescribing of Quality & antimicrobials Trust wide use of the vancomycin chart Training with Rx info on bench marking antibiotic consumption to other Vanguard sites. Introduction of the SaTH gentamicin calculator on RJAH’s intranet Integration of the high impact intervention scheme at ward level and ownership by
nursing staff 5. Annual
6. Items to note 7. Any Other 8. Date and Time
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3.2.5. Criterion 4: Provide suitable accurate information on infections to service users-
All patients with alert organisms are seen by the infection control nurse and information 3. leaflets are provided. The microbiologist will also give advice and support to patients and Performance & their relatives upon request. The Trust promotes best practice in infection prevention and control to its patients, relatives and visitors; highlighting the roles they can play in preventing infection through the website, targeted poster campaigns, and promotional events such as hand hygiene day. The patient comment cards are used as a resource of data – including a specific question
asking “Did the staff practice good hand hygiene”. The results shown below provide 4. encouraging feedback from a patient’s perspective. Quality & Feedback from the data is provided to the ward/departmental managers by the PALS team which is then shared with the patients who have raised their concerns. Overall target is 95%. Hand Hygiene: Patient Perception 2017/18 5. 100.00% Annual 90.00% 80.00% 70.00% 60.00% Always 6. 50.00% Don't Know Items to note 40.00% Mostly Never 30.00% Rarely 20.00% Sometimes 10.00%
0.00% 7. Any Other
Alice Clwyd Other Powys Kenyon Oswald Sheldon Baschurch Ludlow NHSMontgomery 8. Date and Time
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Infection Prevention & Control & Cleanliness Annual Report 2017/18 3.2.6. Criterion 5: Ensure prompt identification of people who have or are at risk of developing an infection 2. Strategy & Patients who are at risk or require extra attention – this includes those unable to maintain high levels of hygiene standards, with poor quality skin or at risk of falls. Stakeholders receive an email with patient summaries and suggestions of actions to be in place in readiness for admission & surgery.
MRSA positive cases and ESBL infections are alerted to the IPCT daily as part of the lab reporting system, which are disseminated to the relevant departments; this ensures that 3. positive cases can be decolonised within a timely framework preventing prolonged Performance & postponements of patient surgery.
The Infection Control Nurse/Surgical Site Surveillance Nurse provides advice and support to patients/relatives in the event of acquiring infection. 4.
MRSA Screening Quality &
100.00% 99.00% 98.00% 5. 97.00% Annual 96.00% 95.00%
% screened 94.00% 93.00%
92.00% 6.
91.00% Items to note 90.00% Jul 17 Jan 18 Jun 17 Oct 17 Apr 17 Apr 18 Sep 17 Feb 18 Dec 17 Aug 17 Nov 17 Mar 18 May 17 % achieved Target 7.
The graph above demonstrates the MRSA screening compliance which is consistently above Any Other 99%, set against a Trust target of 95%. 8. Date and Time
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Infection Prevention & Control & Cleanliness Annual Report 2017/18 2. 3.2.7. Criterion 6: Systems to ensure that all care workers (including contractors and Strategy & volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection. The provision of IPC training is met through provision of a mandatory e-learning package based on Department of Health evidence based infection control guidelines. In total 1101 staff have completed this training with 126 staff still to complete during 2017/18. ??? how we address 3. Performance & 4. Quality & 5. Annual
Additional training sessions provided by the IPCN include: Induction training of 45 minutes for all clinical and non-clinical staff (separate sessions for junior hospital doctors). All new/rotational doctors receive a short induction session provided by the IPCN. All volunteers receive a short training presentation and hand hygiene education. The team is part of the work experience programme run by the Trust on a quarterly 6.
basis. Items to note Provided ‘train the trainer’ education for link practitioners. Engage in the work experience programme based at RJAH Engage in the Trust preceptorship programme Provided workshop training sessions at ward training days Well received face to face training for groups of staff such as: o Catering o Porters 7.
o Domestics Any Other o Estates Maintenance staff 8. Date and Time
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5. Annual
6. Items to note 7. Any Other 8. Date and Time
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3.2.8. Criterion 7: Provide or secure adequate isolation facilities The Trust has always been able to accommodate patient isolation with minimal disruption to the running of the wards. However, during the outbreak of Norovirus on Sheldon Ward, once all side rooms were occupied, other symptomatic patients were cohorted together in the bays with robust infection control precautions in place. 3. Performance & Ideally, it is recommended that there are closable doors on a number of the bays to provide further isolation facilities during an outbreak and taking into consideration the mixed sex accommodation requirements.
3.2.9. Criterion 8: Secure adequate access to laboratory support as appropriate.
The management of prosthetic joint infection is challenging, the microbiology ward round is 4. held once a week with the microbiologist, infection control nurse and the antimicrobial Quality & pharmacist. Each patient is reviewed and requires a tailored approach of antimicrobial prescribing due to the microorganisms grown on culture.
The microbiology lab sends a daily list of all positive samples including sensitivities. This enables all patients to receive the appropriate treatment/antibiotic therapy and prompt isolation if required. 5.
A fit for purpose IT system is required to record and report the positive samples to enable Annual the Trust to respond, have visibility of the impact and be able to undertake full surveillance of infections.
3.2.10. Criterion 9: Have and adhere to policies, designed for the individual’s care and provider organisations that will help to prevent and control infections 6.
Infection Prevention & Control Policies & Standard Operation Procedures (SOP) are Items to note reviewed and agreed at the Infection Prevention & Control Committee. IPC currently operates with 1 Infection Prevention & Control Policy, A framework of Infection Prevention & Control and 30 specific IPC SOP.
Policies Reviewed in 2017- 18
Notifiable Infections Norovirus 7.
IPC Protocol Legionella Any Other IPC Framework Viral Haemorrhagic Fever Outbreaks of Infection Trust Cleaning Policy MRSA Blood Borne Virus and Sharps Injury 8. Date and Time
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Infection Prevention & Control & Cleanliness Annual Report 2017/18 3.2.11. Criterion 10: Providers have a system in place to manage the occupational health needs and obligations of staff in relation to infection. 2. Strategy & Sharps Safety
The annual Trust wide audit of compliance with sharps practice was undertaken by Daniels Healthcare Ltd in February 2018. The object of the site survey was to establish whether or not sharps are disposed of in a safe manner, the survey also provided the opportunity for the auditor to raise sharps awareness, assess practice, discuss problems and advise on compliance to current legislation. 3. Performance & 33 wards/departments were audited 23 wards/departments demonstrated compliance of >95% 6 wards/ departments demonstrated compliance of 85-94.9% 4 wards/departments demonstrated compliance of <85%
The survey report recorded the following criteria: 4.
Number of sharps / speciality containers inspected Quality & Speciality containers with protruding items Speciality containers incorrectly assembled Speciality containers with non-matching lid & label Speciality containers with items above the fill line
Speciality containers sited on the floor or at an unsuitable 5.
height Annual Speciality containers in brackets or in Mobile holders
Speciality containers unlabelled whilst in use
Speciality containers with significant inappropriate contents 6.
Speciality containers with temporary closure not in use Items to note when left unattended or during movement
Are trays available for Point of Use Disposal
Is the sharps container on the Crash Trolley empty 7. Any Other Containers in use for more than 3 months 8. Date and Time
The table below shows the results of the Audit by Ward/Department:
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297 1. Part One -
Infection Prevention & Control & Cleanliness Annual Report 2017/18 ACTUAL PERCENT AREA 2. SCORE COMPLIANT Strategy & 1 Alice Ward 14 87.50% 2 Blood Rooms X 2 32 100.00% 3 Childrens Outpatients 32 100.00% 4 Clwyd Ward 40 100.00% 5 C.T. 23 95.83% 3. 6 Daart 16 100.00% Performance & 7 Gladstone Ward 28 87.50% 8 Hand Unit 6 75.00% 9 H.D.U. 96 100.00% 10 Kenyon Ward 40 83.33%
11 Ludlow Ward + O.P.D. 59 81.94% 4.
12 Maternity Unit 72 100.00% Quality & 13 M.C.S.I. 40 100.00% 14 Menzies Day Surgery 45 93.75% 15 M.R.I. 8 100.00% 16 Occupational Therapy 8 100.00% 5. 17 Outpatients 192 100.00% Annual 18 O.R.L.A.U. 24 100.00% 19 Orthotics 16 100.00%
20 Pain Clinics 23 95.83% 21 Pharmacy 16 100.00% 22 Physiotherapy 24 100.00% 6.
23 Powys Ward 49 87.50% Items to note 24 Pre Op 86 97.73% 25 Sheldon Ward 39 81.25% 26 Theatres X 10 / Recovery 606 95.89% 27 Wrekin Ward 40 100.00%
28 Ultrasound In X - Ray 16 100.00% 7.
29 X - Ray 31 96.88% Any Other 30 Baschurch Day Unit 91 87.50% 31 Labs (Arc) 113 94.17% 32 Montgomary Unit 32 100.00% 33 Oswald Ward 39 97.50% 8.
Audit results and photographic evidence have been shared with the Ward/departmental Date and Time Managers and action plans have been implemented for scores below 95%.
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A training plan, based on the recommendations noted below, with Daniels Healthcare, has 2.
been organised for the Infection Control Link Nurse meeting and the theatre department Strategy & during audit day in June 2018.
Recommendations: Training in the assembly of sharps containers Train staff not to overfill sharps containers Train staff to match Lid and Label correctly
Brackets in areas where appropriate 3.
Keep sharps containers off the floor Performance & Train staff to fill in label following assembly Train staff not to put non sharps in sharps containers Train staff to put the temporary closure in place when unattended or when moved A one-brand system Re-audit within one year 4. Quality &
Occupational Health Team Prevent is committed to the protection of all Trust employees as an essential part of Infection Control.
In line with the Health and Social Care Act 2013 and Department of Health Guidelines, Team 5.
Prevent have arrangements in place for assessing the immunisation status of all Trust Annual employees as well as regularly reviewing the immunisation status of existing healthcare workers and providing vaccinations as necessary and in accordance with the Green Book to reduce the risk and spread of vaccine-preventable disease.
Flu Campaign: Team Prevent support the Trust with their annual Seasonal Flu Immunisation
Programme. 6. Items to note The final submission results to Immform for 2017/18 season resulted in achieving 63% of all frontline healthcare workers having the flu vaccine againt a target set at 75%. This has showed a continued improvement on uptake from 2016/17 season which resulted in achieving 50.8% and 2015/16 season, 43.0%.
Blood Borne Virus Exposure Incidents: 7.
Team Prevent are cognisant that Blood Borne Virus Exposure incidents or injuries Any Other represent a significant risk to staff working in health care environments
Under Health and Safety Legislation, Team Prevent work collaboratively with the Trust to ensure their responsibility for the health and safety of staff in relation to preventing, reducing and controlling the risks of healthcare associated infection and management of occupational exposure to blood-borne viruses and post exposure
prophylaxis. 8. Date and Time
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Virus exposure incidents occurring during departmental opening hours and for the 2.
follow up of those exposure incidents occurring out of hours in Emergency Strategy & Departments.
3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
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3.3. Serious Incidents/ Periods of Increased Incidence Strategy &
There were no Infection Prevention & Control Serious Incidents reported during 2017/18.
Periods of Increased Incidence – Joint infections following joint injections 3.
Three patients were readmitted with streptococcal infections following joint injections. One Performance & patient was infected with a streptococcus sanguinis and two had streptococcus oralis – both under the same consultant’s care. These were performed two weeks apart; one in clinic and the other in a theatre setting.
A full root cause analysis was undertaken for these cases; investigation identified no correlating factors to link these cases. 4. Quality & Lessons learned identified through the RCA process has led to a
A change in skin preparation prior to injection Increased documentation of the injection procedure An SOP for joint injection procedures being drafted with the Upper Limb Team and is awaiting approval at the Quality and Governance Quarterly Meeting. 5. Annual
Periods of Increased Incidence – Spinal Surgical Site Infections
As the Trust had identified a gradual increase of spinal surgical site infections during the first two quarters of 17/18, this continued into quarter 3 which prompted concerns to be raised around a specific operating theatre; following analysis of the cases, there was no correlation with the infections and the specific theatre. An improvement plan was developed and the 6.
Theatre Complex underwent a full environmental deep clean, declutter of the corridors and Items to note deep clean of clinical equipment over the Christmas period 2017. A more robust cleaning regime is now in place with clearer cleaning responsibilities and an enhanced monitoring programme, which forms part of the Infection Prevention & Control & Cleanliness Committee agenda. During January to March 2018, to date, there have been no spinal surgical site infections
reported. 7. Any Other 8. Date and Time
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3.4. Conclusion Strategy &
The year 2017/18 was another successful period in meeting the targets set by Public Health England and the Clinical Commissioning Group at RJAH Orthopaedic Hospital NHS foundation Trust. 3.
The Infection prevention and control team have continued to provide an essential service to Performance & the Trust encompassing the Infection Prevention and Control service and surgical site surveillance service, microbiology ward rounds, post infection review/root cause analysis meetings and audit.
A highlight of 17/18 was the introduction of the weekly infection multi-disciplinary team meetings that have been implemented where complex patients are discussed to achieve a 4.
collaborative decision, amongst other decisions, for the most effective treatment plan which Quality & includes surgical options and antibiotic therapy for patients with complex/resistant infection cases. Given the volume of patients reviewed, further investment is required to facilitate full surgical site surveillance across all orthopaedic specialities in line with other Orthopaedic Alliance Trusts. 5. Annual 6. Items to note Bev Tabernacle: Director of Infection Prevention and Control Sue Sayles: Infection Prevention and Control Nurse June 2018 7. Any Other 8. Date and Time
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Key Areas of Focus for 18/19 3.
PIR of all patients IT Solution for Performance & Achieving PHE reported with Infection National & CCG positive blood Prevention & Infection targets cultures Control
Recruitment of 4. Research software
Improve website Surgical Site Quality & for recording VIP and intranet Surveillance Nurse Score to 1 WTE
Members of the Additional surgical Introduce annual 'Joint Infection' site surveillance 5. competencies for Multi Disciplinary for all Orthopaedic Annual ANTT. Team. Specialities 6. Items to note 7. Any Other 8. Date and Time
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Appendix 1: Acronyms Strategy &
AE (D) Authorised Engineer (D) AMS Antimicrobial Stewardship Committee ANTT Aseptic Not Touch Technique 3.
CCDC Consultant in Communicable Disease Control Performance & CQC Care Quality Commission CQUIN Commissioning for Quality and Innovation DIPC Director of Infection Prevention & Control E.Coli Escherichia coli EPR Electronic Patient Record 4. Quality & ESBL Extended Spectrum Beta Lactamase GIRFT Getting It Right First Time HCAI Healthcare Associated Infection HEE Health Education England
IPC Infection Prevention & Control 5.
IPCC Infection Prevention & Control Committee Annual IPCT Infection Prevention & Control Team ICD Infection Control Doctor IV Intravenous JAC JAC – Electronic Pharmacy System 6.
KPI’s Key Performance Indicators Items to note MDT Multi Disciplinary Team MRSA Methicillin-resistant Staphylococcus aureus MSSA Methicillin-sensitive Staphylococcus aureus PHE Public Health England 7. PIR Post Infection Review Any Other RCA Root Cause Analysis RSH Royal Shrewsbury Hospital SATH Shrewsbury and Telford Hospitals SCCG Shropshire Clinical Commissioning Group
SSI Surgical Site Surveillance 8. SNAHP Senior Nurse and Allied Health Professionals Date and Time SOP Standard Operating Procedure
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TSSU Theatre Sterile Services Unit Strategy & VIP Visual Infusion Phlebitis WTE Whole Time Equivalent 3. Performance & 4. Quality & 5. Annual 6. Items to note 7. Any Other 8. Date and Time
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Glossary 2. Strategy & Bacteraemia: The presence of bacteria in the blood without clinical signs or symptoms of infection C. difficile: or C. diff is short for Clostridium difficile. It is a type of bacteria (germ) which less than 5% of the population carry in their gut without becoming ill. It is normally kept under control by the ‘good’ bacteria in the gut. However, when the good bacteria are reduced, e.g. by taking antibiotics, C. difficile can multiply and produce toxins (poisons) which can cause diarrhoea. The C. difficile bacteria form spores (germs that have a protective coating). These 3. spores are shed in the diarrhoea of an infected person and can survive for a long time in the Performance & environment. C. difficile is highly infectious and can be spread from patient to patient unless strict hygiene measures are followed. E coli: is an organism we all carry in our gut, and most of the time it is completely harmless. It is part of the coliform group of bacteria – often known as Gram Negative bacteria. Most strains do not cause any symptoms while being carried in the gut. Instead E coli forms part
of our “friendly” colonising gut bacteria. However when it escapes the gut it can be 4. dangerous. E coli is the commonest cause of blood stream infections (bacteraemia) in the Quality & community. The most frequent problem it causes is a urinary tract infection, but it can also cause infections in the abdomen such as gallbladder infections or following perforations of the bowel. HCAI: Health Care Associated Infection. An infection acquired as a result of receiving treatment in a health care setting.
Legionella: Legionellosis is a collective term for diseases caused by legionella bacteria 5. including the most serious Legionnaires’ disease. Legionnaires’ disease is a potentially fatal Annual form of pneumonia and everyone is susceptible to infection especially the elderly. The bacterium Legionella pneumophila and related bacteria are common in natural water sources such as rivers, lakes and reservoirs, but usually in low numbers. They may also be found in purpose-built water systems such as cooling towers, evaporative condensers, hot and cold water systems and spa pools. MRSA: or Methicillin Resistant Staph aureus, is a highly resistant strain of the common bacteria, Staph aureus. Bloodstream infections (bacteraemia) cases are the most serious 6. form of infection where bacteria, in this case MRSA, escape from the local site of infection, Items to note such as an abscess or wound infection, and spread throughout the body via the bloodstream. MSSA: or Methicillin Sensitive Staph aureus, is the more common sensitive strain of Staph aureus. Up to 25% of us are colonised with this organism. Mostly it causes us no problem but it is a frequent cause of skin, soft tissue and bone infections. As with its more resistant
cousin, MRSA, sometimes the infection can escape into the bloodstream producing a 7. “bacteraemia” i.e. bacteria in the blood. Unlike MRSA, the majority of the infections will be acquired in the community, and are not associated with health care. However, some may Any Other arise as a consequence of health care, and like MRSA, it can arise from infected peripheral and central intravenous lines and other health care interventions. We were asked by the Department of Health in 2011 to report all MSSA bacteraemia cases, whether acquired in the community or in hospital, so that we can review the sources and identify potentially avoidable cases. So far no targets have been set. However, we can compare ourselves with
other trusts and put in interventions to further reduce infections. 8. Date and Time
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