Quality Account 2020/21 Contents Page Section 1: Introduction 3 Statement on Quality from the Chief Executive 3 About Our Trust 4 Section 2: 5 Review of Quality Performance 2020/21 6 Theme 1 – Providing Safe and Effective Care and Improving Outcomes 8 Theme 2 – Ensuring Services are Caring and Responsive 17 Theme 3 – Building a Quality Culture 28 CQC Inspection 35 Priority 9: Improving our infrastructure 36 Quality Performance Indicators 37 Our Quality and Improvement Priorities for 2021/22 38 A Review of Our Services 41 CQC Registration 41 Inclusion and Diversity 42 Freedom to Speak Up 43 Participation in Clinical Audits and National Confidential Enquiries 44 Research 45 CQUIN Performance 45 Data Quality 45 NHS Number and General Medical Practice Code Validity 46 Information Governance 46 Clinical Coding Error Rate 46 Section 3: Appendix 1: Quality Performance Indicators 49 Appendix 2: Our 2020/21 Quality Objectives 51 Appendix 3: Participation in Clinical Audits and National Confidential Enquiries 52 Appendix 4: National Confidential Enquiries for 2020/21 60 Appendix 5: National Clinical Audits Reviewed During 2020/21 61 Appendix 6: Local Clinical Audits Completed During 2020/21 69 Appendix 7: Participant Recruitment to Research 71 Appendix 8: Glossary 76 Section 4: Annex 1: Statement of Directors’ Responsibilities in respect of the Quality Account 78 Annex 2: Statement from Healthwatch Hertfordshire 79 Annex 3: Herts Valley Clinical Commissioning Group’s response to the Quality Account of West Hertfordshire Hospitals NHS Trust for 2020/21 80 Annex 4: Hertfordshire Health Scrutiny Committee 82 2 Section 1. Introduction The Quality Account is an annual report which reviews the quality of services provided by an NHS healthcare organisation. Quality Accounts aim to increase public accountability and drive quality improvements in the NHS. Our Quality Account looks back on how well we have done in the past year at achieving the goals which we set ourselves. It also looks to the year ahead and defines what our priorities for quality improvements will be and how we expect to achieve and monitor them. The quality of the services is measured by looking at patient safety, the effectiveness of treatments patients receive and patient feedback about the care provided. Statement on quality from the Chief Executive Our 2020/21 Quality Account looks back at a year where we faced our greatest challenge from the COVID-19 pandemic. Through our skilled and dedicated workforce, we responded to the pandemic’s challenges and strived to provide safe and effective care to our patients. We remain immensely proud of our response to the first and second wave of the pandemic. Our teams have shown incredible resilience and ingenuity and the support that we have received from our community has been overwhelming. Inevitably, the pandemic has impacted our staff wellbeing and we have put in place many sources of pastoral and psychological support to assist with stress, anxiety and improve staff health and well-being. As you would expect, our ability to deliver services and meet performance targets continued to be adversely affected by the pandemic and is not reflective of our mission to provide the very best care possible. Attendances at all our Urgent and Emergency Departments (ED) were lower in 2020/21 compared to 2019/20 because of the pandemic. We experienced the second highest ambulance conveyance rate in the region, and we were the only organisation to experience over a 5% increase in conveyances. In 2020/21, 81% of our patients were seen within 4 hours in our ED, which was a similar position to 2019/20, but below the national target of 95%. Our planned care performance was severely affected because of the national suspension of elective care during the first and second wave of the pandemic. Against the Referral to Treatment (RTT) standard, our 52-week breaches were 1702 as of March 2021. Similarly, we were unable to sustain our previously consistent achievement in meeting diagnostic waiting time standards and our performance fell below the 99% standard throughout the year. Treatment for the most urgent, time critical patients including cancer continued during the pandemic with, just under 4000 patients being treated by Trust teams at independent sector (ISP) facilities. This enabled us to improve and maintain performance against the 62-day GP referral to treatment cancer waiting time standard. During 2020/21, we implemented shadow reporting for the new 28-day faster diagnosis standard of 75% which we consistently achieved throughout the year. This puts us in a good position for 2021/22 when this target goes live. The Trust’s overall performance against the 62-day referral to first definitive treatment standard was 82.2% in 2020/21, in comparison to 82% in 2019/20 and 82.6% in 2018/19. The target is 85%. We were delighted to receive two Healthcare Financial Management Association (HFMA) Awards in 2020. We received the Excellence in Organisational Development category which acknowledged the senior medics’ assessment and review trial (SMART) initiative. We also received HFMA’s HR Team of the Year award. In addition, our Chief Nurse Tracey Carter and respiratory consultant Dr Matthew Knight were appointed MBEs (Member of the Order of the British Empire) for services to the NHS in the Queen’s Birthday 2020 Honours List. Our partnership with the Royal Free London NHS Foundation Trust continued in 2020/21 which supports the Trust’s central quality improvement (QI) hub. The hub uses a consistent QI methodology developed by the institute of Healthcare Improvement (IHI) to facilitate service improvements and drive quality commitment throughout every area of 3 the Trust. During the pandemic, work focused on harm free care reviews to keep our patients safe with the programme widening its scope again at the end of the year as services restarted. In February 2020, the Care Quality Commission (CQC) inspected urgent and emergency care, medical care (including older people), and surgery at Watford General Hospital. The minor injuries unit at St Albans City Hospital and the urgent treatment centre at Hemel Hempstead Hospital were also inspected. We achieved marked improvements in urgent and emergency care across our hospital sites. There was a review of our leadership under the CQC’s ‘well led’ regime where we improved our rating to ‘good’. Before the outbreak of COVID-19 , our integrated care partnership (ICP) work was well underway with good engagement. It responded well to the test of the pandemic and worked together in the best interests of patients on changes to support people in care homes, facilitate rapid discharges from hospital and manage people safely at home through our virtual hospital model. Locally, we are working with other health and care organisations to change the way we care for children, people with diabetes, and frail people, to help them stay as healthy as possible and reduce their need to spend time in hospital. Our new clinical strategy for the next 5 years will focus on collaboration with our strategic partners to improve clinical outcomes for our patients. Although the pandemic limited our services in many ways – we stopped accepting referrals except for urgent and cancer cases – it also accelerated new ways of digital working. We introduced a ‘virtual hospital’ where patients were remotely monitored from home which prevented unnecessary admissions while keeping patient safe. This enabled us to monitor and manage over 4000 patients by the end of the year. It is estimated that at least 1000 “bed days” have been saved since the pilot started. We have continued to implement changes to improve the experience of patients such as the opening of the new acute respiratory care unit, new secure rooms in the children’s emergency department, a new CT scanner in St Albans, which came into use in October 2020, a new outpatient digital call centre, new orthopaedic centre in St Albans and a new Urgent Treatment Centre in Watford. We remain well prepared as a Trust for managing any further waves of COVID-19. We have learned new ways of working including testing and vaccinating our staff to manage the impact of the virus. We have developed different ways to treat the disease leading to better clinical outcomes for patients. Our continued innovation has also ensured the continuation of non-urgent appointments which is great news for our patients. In closing, we would like to acknowledge the support from our community which has been overwhelming. We would like to thank and pay tribute to our staff, volunteers and our health and social care partners who have worked so incredibly hard to provide the very best care for our patients in the most challenging of years. Christine Allen Chief Executive About Our Trust West Hertfordshire Hospitals NHS Trust provides acute healthcare services to a core catchment population of approximately half a million people living in West Hertfordshire and the surrounding area. The Trust also provides a range of more specialist services to a wider population, serving residents of North London, Bedfordshire, Buckinghamshire, and East Hertfordshire. Overall, the population served by the Trust is relatively affluent, but there are some areas of deprivation. With approximately 5,400 staff and 593 volunteers working across our three hospital sites in Watford, St Albans, and Hemel Hempstead we are one of the largest employers locally. There are 674 inpatient beds (including surge capacity) throughout the Trust, the majority being at Watford General Hospital. 4 Watford General Hospital • Inpatient emergency and intensive care • Elective care for higher risk patients • Outpatients and diagnostics services • 613 beds and nine theatres • Women's and children's services Hemel Hempstead Hospital • UTC open seven days a week, 8am to 10pm • Diagnostic services, including MRI and pathology • Outpatient services • Endoscopy and bowel cancer screening St Albans City Hospital • Elective care • Outpatient and diagnostic services • 40 beds and six theatres • Minor injuries unit (closed April 2020).