Quality Account 2013/14

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1 1 Quality Account 2013/14

2 What is a quality account? Part 1: Statement from the Chief Executive 5 Part 2: Our priorities and statements of assurance Our priorities 2.1.1: How well have we done in 2013/14? 10 Safety 12 Clinical Effectiveness 22 Patient Experience : What are our priorities for 2014/15? 40 Safety 42 3 Clinical Effectiveness 46 Patient Experience : Statements of assurance 56 Information on the review of services 57 Information on participation in clinical audit 57 A Quality Account is an annual report about 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 our goals. It also looks forward to the year ahead and defines what our priorities for quality improvements will be and how we expect to achieve and monitor them. Glossary Symbol This symbol indicates a term's inclusion in the glossary on page 92 Information on participation in clinical research 58 Information on the use of the CQUIN framework 59 The Care Quality Commission 64 Quality of data 64 Information Governance 69 Clinical coding : Reporting against core indicators 70 Part 3: Other information 76 Annex 1: Statement from stakeholder organisations 80 Annex 2: Statement of directors' responsibilities 90 Glossary 92

3 4 1 Statement from the Chief Executive 1 Statement from the Chief Executive 5 Statement from the Chief Executive 1 Statement from the Chief Executive Our vision is to provide safe, effective and personalised care every patient, every time. This means achieving excellent clinical outcomes for our patients in a caring, compassionate and safe environment, valuing each patient as a unique individual. The environment and context in which we provide our services is ever changing and we need to ensure that we are not only resilient but also continue to be highly successful in providing quality clinical care to our patients, remain at the forefront of research and innovation and continue to be a good employer. Gloucestershire s rich history is reflected in the diversity of the population of 800,000 that we are proud to serve. Equality and diversity in our hospitals is about valuing every patient as a unique individual. It means recognising that some people will need different treatment to achieve a fair outcome. This is why we're committed to designing our services around the needs of individual patients and those around them. This report is an overview of our performance in relation to the three dimensions of quality as described by Lord Darzi's Next Stage Review (2008): Safety Clinical effectiveness Patient experience While the Francis Report into the care provided at Mid Staffordshire Hospital was a watershed moment for the NHS, locally it has presented us with an opportunity to enact change and to actively demonstrate to patients that we will provide the best levels of compassionate care. Our response to the report and subsequent government findings has been a considered one as we look to the areas where we can make continued progress and can deliver further long-term, sustainable change. We have already started work, establishing a project team to look at how we can improve the culture of our organisation, investing significantly in our nurse recruitment programme and implementing new ways to ensure senior nursing staff have time to lead, supervise and monitor the standard of care on their wards. You can read more about this on p52. This year we have seen some significant changes to the structure of the NHS as a result of the Health and Social Care Act Despite the inevitable challenges that such changes bring, we have continued to work well with our partners and have made progress in establishing community support and advice for patients to help us manage the increasing demand on our services and provide care for the patients who need our help the most. This year we are pleased to see a number of key improvements in the quality of care we provide to patients across our services.

4 6 1 Statement from the Chief Executive 1 Statement from the Chief Executive 7 Following the changes we made to our emergency care pathway last summer, which were proposed, designed and delivered by our clinical teams, we have seen an improvement in our performance against the national fourhour wait target in A&E. Now six months on since the changes were introduced, patients treated in our A&Es benefit from an increased availability of senior decision makers and greater supervision of junior doctors, meaning that patients can be assured they will receive a competent and well-supervised medical review. We acknowledge that we still have some work to do in improving the way patients flow through our hospital to ensure that we are able to cope with the ever-increasing pressure on our services. This will involve further consideration on how best to manage our emergency patients, as well as how to ensure patients who no longer need acute hospital care can return to their homes or other community settings as soon as possible. Our care for patients with life-threatening sepsis continues to improve, particularly in our Emergency Departments. Work will continue in the year ahead to create the same awareness of the sepsis care bundle in our inpatient areas. See p14 for more information. Understanding our patients' experience of our services is key to improving the quality of care in our hospitals. We really value patient feedback, whether good or bad, and in the year ahead we are keen to provide more opportunities for patients and their families to give us more feedback and to translate this into improvements in services. This year saw the introduction of the national Friends and Family Test and we have been encouraged by our scores to date. You can read about this in more detail on p33. While we are pleased to report that we have met, and in many cases exceeded our targets for our quality priorities, we always want to do better for every patient and are not complacent just because a target has been met. We know that our discharge arrangements still need to be improved, in particular the way in which we discuss leaving hospital with patients, relatives and carers. I hope that this document is accessible and informative and I would like to thank everyone who contributed to its development, including members of the public, our own Trust Governors, Healthwatch Gloucestershire, Gloucestershire Health and Care Overview and Scrutiny Committee (HCOSC) members and commissioner colleagues. Most importantly, I would like to thank all members of our dedicated team of staff who have worked so hard to achieve the highest standards of care for our patients. We recognise that there is still much work to be done but I know that across all areas of our organisation there is a real commitment towards our aspiration for excellence. It is important to us that our quality accounts are accurate and accessible. I can confirm that to the best of my knowledge the information included in this document has been subject to all the appropriate scrutiny and validation checks to ensure the data is accurate. Dr Frank Harsent Next section: Our priorities and statements of assurance

5 8 2 Our Priorities and statements of assurance 2 Our Priorities and statements of assurance 9 Helping us improve the quality of care 2 Our priorities and statements of assurance Each year our Quality Committee agrees a set of priorities which help us improve the quality of care we provide for our patients. Some of these priorities are identified because they are important to our regulators and/or commissioners. However most are decided following discussions with our Council of Governors, the Gloucestershire Health and Care Overview and Scrutiny Committee (HCOSC) and the newly-formed Healthwatch Gloucestershire. The following section is divided into four parts: How well have we done in 2013/14: looks at what our priorities were during 2013/14 and whether we achieved the goals we set ourselves. Where performance was below what we expected we explain what went wrong and what we are doing to improve What are our priorities for 2014/15: explains why these priorities have been identified and how we intend to meet our targets for these during the year ahead. See p11 and 37. The Quality Committee is a sub-committee of the Board and has clinical and managerial representation from across our Trust. It includes non-executive directors, executive directors, governors, representation from Gloucestershire Clinical Commissioning Group and during 2013/14 was chaired by Helen Munro, Non-Executive Director. statements of assurance from the Board reporting against core indicators The second two parts give an overview of the range of services we provide and give some context to the data we provide in section three. The Quality Committee is responsible for monitoring the progress of the organisation against our quality improvement priorities. The Committee meets eight times a year and reviews a series of measures which give us a picture of how well we are doing.

6 How well have we done in 2013/14? How well have we done in 2013/14? 11 Priorities for improving quality in 2013/14 Previous section: Our priorities and statements of assurance introduction Below is an overview of our priorities for 2013/14. The table gives you an at-a-glance view of the work undertaken in the past year and which of our stakeholder groups highlighted it as an issue to be addressed. Priorities Incomplete from last year National priority for 2013/14 Issue for commissioners / CQUIN Issue for HCCOSC Issue for LINk Issue identified internally 1. Safety Emergency care pathway NHS Safety Thermometer VTE assessment Sepsis six Medicines management How well have we done in 2013/14? 2. Clinical Effectiveness Readmission rates Dementia Acute Kidney Injury COPD admissions bundle 3 Million Lives (telehealth) (PQ) Digital First Exploitation of IP Supporting clinical programmes (PQ) (PQ) 3. Patient Experience Friends and Family test Information for carers of people with dementia (PQ) Personal care Privacy and dignity Involvement in decisions Improving the discharge process Patient experience escalator PQ = pre-qualification requirement for CQUINs

7 How well have we done in 2013/14?: Safety How well have we done in 2013/14?: Safety How well have we done in 2013/14? Safety Improve the emergency care pathway Following a public consultation in the early part of 2013, we made changes to the way we provide emergency care at night, to ensure that the sickest patients are treated by skilled, specialist staff and all patients receive safe, high quality care. Since July 29, 2013, between 8pm and 8am seriously ill patients being brought to us by ambulance have been taken to Gloucestershire Royal Hospital (GRH) rather than Cheltenham General Hospital (CGH). Ambulance crews are however encouraged to bring a selected group of patients directly to the acute medical ward in Cheltenham. These are stable patients who fulfil strict clinical criteria or patients who have already been referred by their GP. During the planning stages for this change, our projections were that this change would affect around 16 patients per night. This assumption has proved accurate. During these night-time hours, patients who walk-in to A&E at CGH requiring care are treated by a specialist team of Emergency Nurse Practitioners (ENPs). The ENPs can treat a wide range of conditions and minor injuries including minor fractures, burns, cuts and illnesses. After 8am the A&E at CGH receives all emergency patients as usual, whether walk-in patients, GP referrals or patients brought to us by ambulance. Our performance against our target to see, treat and discharge or admit 95% of emergency patients within four hours of their arrival, has improved since we introduced the above changes to the emergency care pathway (see Figure 1 below). The target is measured monthly, across both hospitals. One of the key drivers for the changes to the way we provide emergency care was to ensure that our A&Es were better staffed. Patients are now treated in an environment where junior doctors have better access to advice from more senior staff. When we have had a breach of the fourhour target, this has largely been because of a shortage of beds. So our challenge for the year ahead is to improve the flow of patients through our hospitals to ensure we can admit patients through our A&Es when required. In order to tackle this issue we have worked with our community partners to focus efforts on both reducing the number of patients attending our A&Es and eliminating delays in discharging patients when they are ready to leave. You can read more about our work on improving the discharge process on p35. In order to reduce the number of patients attending A&E: Figure 1: Emergency Department 4-hour wait performance Apr 2013 May 2013 Jun 2013 Jul 2013 Aug 2013 Sep 2013 Oct 2013 Nov 2013 Dec 2013 Jan 2014 Feb 2014 Mar 2014 CGH 89.92% 92.54% 95.41% 93.40% 97.24% 97.90% 98.22% 97.31% 97.57% 95.86% 94.37% 95.74% GRH 91.33% 90.83% 93.66% 95.45% 93.71% 94.44% 94.43% 93.26% 93.81% 93.18% 90.65% 89.60% Total 90.75% 91.52% 94.35% 94.65% 95.05% 95.73% 95.77% 94.70% 95.11% 94.15% 92.00% 91.85%

8 How well have we done in 2013/14?: Safety How well have we done in 2013/14?: Safety 15 we opened Ambulatory Emergency Care (AEC) units: these units provide same day emergency care to patients at our hospitals. This means that patients are assessed, diagnosed and treated and are able to go home the same day, without being admitted overnight. There are AECs at both CGH and GRH and GPs are able to refer patients directly to the AEC at GRH we created an Older People Advice & Liaison (OPAL) service: around half of the people who are admitted to our hospitals are over the age of 65. Consultants in General Old Age Medicine are now involved in the early assessment of older patients' care needs in A&E so that any issues other than the primary cause for attendance, can be addressed as early as possible Gloucestershire Care Services has created virtual wards: these are integrated community teams which consist of community nurses, social workers, occupational therapists and physiotherapists and have an enhanced rapid response service available 24-hours-a-day, seven days-a-week. These developments have been in collaboration with health and social care partner organisations and will mean that community-based services can care and treat more people at home, rather than in hospital. From January 2014, GPs in the Gloucester city area can refer their patients directly to this service and from here, the rapid response will be rolled out across Gloucestershire over the coming months You can see our overall performance against the four hour waiting target in Figure 1 on p13. In comparison, at the end of 2012/13, 94.7% of patients were admitted, treated and discharged within the target timeframe of four hours. It is also worth noting that of those patients that attend A&E but are not admitted, over 97% are seen, treated and discharged in under four hours, across both hospitals. Improve the management of patients with sepsis Worldwide sepsis kills more than 1,400 people every single day. In the UK alone it is estimated that more than 37,000 people die every year. This means that more people die each year from sepsis than from lung cancer and from breast and bowel cancer combined. Sepsis is a life-threatening condition that arises when the body's response to an infection injures its own tissues and organs. Sepsis can lead to shock, multiple organ failure and death, especially if not recognised early and treated quickly. Each month our hospitals' Emergency Department treats between 40 and 50 patients with severe sepsis. Since the management of patients with sepsis was first identified as a national quality priority in 2010, we have had increasing success in improving the care and outcomes for these patients. Our target last year was to ensure 90% of patients with severe sepsis in the Emergency Department are given what is known as the Sepsis Six care bundle. The Sepsis Six is a set of six simple tasks delivered by doctors or nurses within one hour of diagnosis. By August 2013 we were meeting this target consistently and have maintained this performance throughout the year (see Figure 2: Achievement of Sepsis 6 in our Emergency Department RATIO PER 1000 BED DAYS APR-13 MAY-13 JUN-13 JUL-13 AUG-13 SEP-13 OCT-13 NOV-13 DEC-13 JAN-14 FEB-14 Data Target Figure 3: Achievement of Sepsis 6 on our wards RATIO PER 1000 BED DAYS APR-13 MAY-13 JUN-13 MAR-14 JUL-13 AUG-13 SEP-13 OCT-13 NOV-13 DEC-13 JAN-14 FEB-14 MAR-14 Data Target

9 How well have we done in 2013/14?: Safety How well have we done in 2013/14?: Safety 17 Figure 2). This success is a real credit to the staff in this department who remain fully engaged and committed to this life-saving treatment pathway. In order to maintain this high standard this year we focussed on identifying simple adjustments which ensure that patients who display the early signs of sepsis, such as a high temperature, are identified and treated as soon as possible. You can see how we have performed in Figure 3 on p15. We are pleased to report that following a campaign to improve early recognition of severe sepsis in inpatient areas we were able to meet our target in the final quarter of the year. We have run a number of targeted awarenessraising campaigns to highlight the importance of early recognition and treatment, as well as education campaigns for ward staff this year. We hope we can replicate the excellent performance of the Emergency Department across the whole trust in the coming year. Our sepsis six project team won the 'Excellence in Safety' award at our annual Celebrating Success Staff Awards in 2013 and have shared their achievements in exceeding the Emergency Department target at conferences both at home and abroad. Implement the Safety Thermometer The NHS Safety Thermometer was developed as a survey tool that allows hospitals to measure the proportion of patients that are 'harm free' during their stay. It is based around four key nationallyrecognised indicators of harm to patients: pressure sores falls venous thromboembolism (VTE) urinary tract infections in patients with a catheter These conditions affect more than 200,000 people each year in England alone, leading to avoidable suffering and additional treatment for patients. The 'harm free' care programme aims to eliminate these four avoidable conditions through one plan. Every acute trust is required to measure the percentage of its patients who receive harm free care on a monthly basis. In 2013/14 the percentage of patients who received harm free care in our hospitals was an average of 94% each month (cumulative mean since we started collecting data in June 2012). Nationally this figure was 92.3% at the end of March 2013 (cumulative mean since all trusts started collecting data from as early as January 2012). This year there has been a particular focus on reducing the incidence of pressure ulcers. We have carried out a monthly audit of every single inpatient to assess the level of pressure ulcers (both new and old), falls, new venous thromboembolism (VTE) and urinary tract infections. Our target this year was to reduce the number of recorded new pressure ulcers by 10% based on the totals (70 ulcers) at the end of 2012/13. As a Trust historically we have done much to reduce the incidence of pressure ulcers, therefore this small reduction has been challenging. At the end of March 2014 the full number of pressure ulcers recorded for the year was 70. While we did not achieve the 10% reduction target, it was reassuring that there was not a further deterioration in the number of ulcers developed by patients. In order to reduce the incidence of pressure ulcers we will be developing a number of new initiatives in the year ahead. You can see our performance this year in Figure 4 below. Our Tissue Viability Steering Group has overseen the development of an action plan which has targeted two areas for reducing the incidence of pressure ulcers. changing clinical pathways for lower limb fractures Figure 4: New pressure ulcers recorded NO. OF NEW PRESSURE ULCERS JUL-13 AUG-13 SEP-13 OCT-13 identifying and adjusting clinical practices in critical care which help reduce the incidence of pressure ulcers We have invested in the latest technologies available to help prevent pressure sores, including air-based and supported mattresses to encourage air flow around a patient, and we use the Waterlow scoring system to identify as soon as possible which inpatients are most at risk of developing a pressure sore. We are committed to further reducing the incidence of pressure sores in the year ahead. You can read more about how we plan to do this on p43. NOV-13 DEC / /14 JAN-14 FEB-14 MAR-14

10 How well have we done in 2013/14?: Safety How well have we done in 2013/14?: Safety 19 Increase the number of those assessed for venous thromboembolism (VTE) Venous thromboembolism (or VTE) is the collective term for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). DVT is a blood clot in one of the deep veins in the body. It can cause pain and swelling and may lead to complications such as PE. This is when a piece of blood clot breaks off into the bloodstream and blocks one of the blood vessels in the lungs. Each year more than 25,000 people in England die from VTE contracted in hospitals. This is more than the combined total of deaths from breast cancer, AIDS and traffic accidents and more than 25 times the number who die from MRSA. During 2013/14 our quarterly target was to risk assess 95% of all patients with a clinical condition which may lead to a VTE, which accounts for almost every patient admission. We met this target during the first quarter of the year and in the second and third and final quarter we reached around 94%. We are confident that this assessment is being carried out on almost every occasion but it is of course disappointing that we have been unable to fully achieve the target this year. Although all ward areas are over 90% most of the time, in the year ahead we will be focussing our efforts on individual wards which are not yet achieving the target to help them improve performance. Improve the management of medicines Medicines management is the term used to describe a system of processes and behaviours that determines how medicines are used by patients and the NHS. Good medicines management means that patients receive better, safer and more convenient care. It leads to better use of time and enables practitioners to use their skills where they are needed most. Nationally the NHS spends billions on medicines every year so effective management of their use also means these funds can be better utilised by providing the most appropriate and effective treatments. Our hospital pharmacists, as experts in medicine, provide advice and support to ensure the safe, evidence-based use of medicines. Working alongside senior clinicians both in our hospitals and in partner NHS organisations, our pharmacists have produced guidance to aid the correct choice and dose of medication - a formulary. To improve the access to and implementation of its recommendations, the formulary migrated to a new publicly accessible web platform in 2013 ( uk/). This demonstrates compliance with NICE technology appraisals (recommendations on the use of new and existing medicines and treatments) and assures patients that they have access to clinically and cost effective technologies and medicines. This year we had a CQUIN target to ensure that 70% of all medicines dispensed within our hospital pharmacies are compliant with the county-wide formulary. See Figure 6 on p19 to see how we performed against this target. Figure 5: Percentage of patients risk assessed for VTE % PATIENTS RISK ASSESSED FOR VTE % COMPLIANCE WITH FORMULARY APR-13 MAY-13 JUN-13 JUL-13 AUG-13 SEP-13 OCT-13 NOV-13 DEC-13 JAN-14 FEB-14 Data Target Figure 6: Management of medicines compliance with formulary MAR-14 Two other measures were linked to 0 APR-13 MAY-13 JUN-13 JUL-13 AUG-13 SEP-13 OCT-13 NOV-13 DEC-13 JAN-14 FEB-14 MAR-14 Data Target

11 How well have we done in 2013/14?: Safety How well have we done in 2013/14?: Safety 21 ensuring further improvements in the use of antibiotics through an Antimicrobial Stewardship Programme to reduce healthcare associated infections (HCAI) and minimise antimicrobial resistance, which demonstrated adherence to newly-published national requirements. The fourth was to ensure that patients were receiving the appropriate medication at the time of admission through a medicine reconciliation process. Next section: How well we have we done in 2013/14?: Clinical Effectiveness

12 How well have we done in 2013/14?: Clinical Effectiveness How well have we done in 2013/14?: Clinical Effectiveness Previous section: How well have we done in 2013/14?: Safety How well have we done in 2013/2014? Clinical Effectiveness Reduce readmission rates Reducing unnecessary readmissions to hospital is better for patients and better for the NHS. If a hospital has a high readmission rate, it is an indication that patients are being discharged from hospital too early, before they are medically ready or before they have the proper support in place to care for them while at home. It is not always possible for us to prevent an emergency admission as the patient's clinical circumstances may have changed or their readmission may be unrelated to their original condition. Our target during 2013/14 was to reduce the percentage of patients readmitted to the Emergency Department within 30 days of discharge, from 5.9% at the end of 2012/13. During 2013/14 we have expanded a phone service aimed at reducing the number of patients who are readmitted to our hospitals for care. A six-month pilot which tested the effectiveness of this service in the Acute Care Unit (ACU) at GRH in 2013 showed that the readmission rate for these patients was reduced from 37.33% to just 8.36% over the period. Patients who were discharged from ACU between July and December 2013 were phoned at home by a member of the pilot team (made up of nurses and other clinical staff) and asked how they were doing and whether they needed any help, support or advice. The significant reduction in admissions as a result of this pilot has meant that we have now rolled out the service to our General Old Age Medicine wards. See Figure 7 below to see how well we have performed against our target to reduce the rate of readmissions in 2013/14. Figure 7: Percentage of patients readmitted as an emergency within 30 days READMISSION BEDDAYS APR-13 MAY-13 JUN-13 JUL-13 AUG-13 READMISSION RATE (%) SEP-13 OCT-13 NOV-13 DEC-13 JAN-14 FEB-14 MAR Beddays Rate

13 How well have we done in 2013/14?: Clinical Effectiveness How well have we done in 2013/14?: Clinical Effectiveness 25 Improve diagnosis and care for patients with dementia In England today there are an estimated 670,000 people living with dementia. This is expected to double in the next 30 years. In our hospitals, one in four patients may experience cognitive impairment (problems with memory and processing thoughts) and around 180 patients with a diagnosis of dementia are discharged every month. Early diagnosis is important for a person with dementia and their carers as it enables them to understand the condition, access support and the appropriate treatment to help manage symptoms and gives the person time to plan for the future. Building on the work undertaken in previous years, in 2013/14 we have taken further steps to improve the care we provide for our patients with dementia. Our revised Dementia Training Strategy was agreed in April 2013, with a renewed emphasis on promoting an understanding of person-centered care and skills to support communication with patients and carers. So far 5,774 members of staff have completed our Level 1 Dementia Care e-learning package and 2,641 clinical staff have completed Level 2. All new Band 2 clinical staff must now attend a one-day Dementia Care Study Day as part of their development programme, with more than 100 staff trained since April 2013 and from December 2013 all new band 5 registered nurses complete dementia care training. Our ward-based dementia champions continue to play an essential role in educating and supporting colleagues in their areas. The dementia champions are committed, enthusiastic and take pride in their role and in the difference they make for their patients and their families. The dementia champions are members of the care team who, in addition to their staff role, act as a resource for their clinical team and as a source of information for families and carers. The dementia champions have held a number of awareness sessions throughout the year and take a leading role in improving dementia care in their area During 2013/14 we have developed resources to support staff to assess the nutrition needs of all our patients and have introduced a new range of initiatives to support patients with dementia. These include the use of coloured crockery to help patients with dementia to be able to see and recognise food and drink more easily. We are exploring the use of finger food for patients with dementia. It is considered best practice for patients who are used to eating in this way, to further support their nutritional care while in hospital. It maximises the opportunities for a patient to eat and ensures they stay well nourished while in hospital. For people who have symptoms which may be suggestive of dementia, it is vital that a diagnosis is made as early as possible. Where treatment is an option, this ensures it can be started early, support can be provided for the patient and their family and planning can begin to allow the person to live well with their dementia. Diagnosis is a key objective as part of the Department of Health's National Dementia Strategy In our hospitals, one of our key objectives and a CQUIN goal, is to support dementia case finding (identification of patients who may have symptoms suggestive of dementia). Objective 1 was to ensure that 90% of patients over the age of 75, admitted as an emergency are clinically assessed to identify if they have symptoms which indicate a loss of memory or some degree of confusion. Objective 2 was to ensure that 90% of these patients are assessed and investigated further. Objective 3 was to ensure that 90% of these patients are referred as appropriate. This year our dementia leads have worked with doctors to improve the admission assessment and the clinical pathway (way in which the patient is assessed and treated) to make sure that all patients receive the best possible care. % OF ED PATIENTS OVER 75 IDENTIFIED FOR DEMENTIA ASSESSMENT MAR-13 APR-13 MAY-13 JUN-13 JUL-13 AUG-13 During 2013/14 we have demonstrated good progress against the dementia 'case finding' target and have doubled achievement against objective 1. At the end of March 2014, 82.2% was achieved. For objective 2 (investigation) and 3 (specialist referral) we are achieving 100%. We have also met the objectives relating to staff training and have met all the objectives relating to our Carers Survey. Our performance against objective 1 can be seen in Figure 8 below. Figure 8: Percentage of ED patients over 75 identified for dementia assessment Data SEP-13 OCT-13 NOV-13 Target DEC-13 JAN-14 FEB-14 MAR-14

14 How well have we done in 2013/14?: Clinical Effectiveness How well have we done in 2013/14?: Clinical Effectiveness 27 Increase the use of cardiac output monitoring during surgical procedures any drugs prescribed do not adversely affect the kidneys Figure 9: Compliance with AKI bundle Cardiac output monitoring is one of the tools which can be used by anaesthetists to check that patients are stable and comfortable. This kind of monitoring gives information on the blood volume circulating each time the heart beats and allows anaesthetists to give fluids accurately throughout surgery. Having the right level of fluids can help speed up recovery and reduce post-operative complications. This priority was one of several areas identified by our commissioners as potential CQUIN options in 2013/14. However in discussions with Gloucestershire Clinical Commissioning Group during the early stages of the year it was agreed that this pre-qualifying CQUIN priority would be replaced by one of the other options. a repeat creatinine test (a blood test which measures how well the kidneys are working). This target, which increased from 60% at the end of 2012/13, has proved challenging for us. In April and May we achieved the target, but between June and August the results were disappointing, though performanced improved significantly in the final quarter and we exceeded our target by more than 10%. The reasons behind this are still unclear, although the summer change over of new and more experienced junior doctors is likely to have had some impact. It will remain a priority to ensure we sustain this performance during the year ahead. PERCENTAGE COMPLIANCE APR-13 MAY-13 JUN-13 JUL-13 AUG-13 SEP-13 OCT-13 NOV-13 DEC-13 JAN-14 FEB-14 MAR-14 Reduce the incidence of avoidable renal failure (Acute Kidney Injury) The challenge for next year will be to further embed the process and work more closely with colleagues in primary care. Data Target Acute Kidney Injury (AKI) is a sudden loss of kidney function and is strongly associated with mortality and increased lengths of stay. In a hospital environment there are a number of reasons why a patient may develop an AKI, for example through infection or as a result of dehydration. This year we had a target of treating 75% of all patients highlighted by our pathology team as at risk of AKI based on test results, with a care bundle within 24 hours. This bundle prescribes: Improve care for patients with Chronic Obstructive Pulmonary Disease (COPD) Chronic Obstructive Pulmonary Disease (or COPD) is the name for a collection of lung disease including chronic bronchitis, emphysema and chronic obstructive airways disease. COPD is one of the most common respiratory diseases in the UK, affecting more than 3 million people nationwide. People with COPD have difficulties breathing, primarily due to the narrowing of their airways. Figure 10: Compliance with COPD bundle % COMPLIANCE a review by a senior clinician a fluid balance assessment for the patient a review of medication to ensure Patients with COPD often attend hospital regularly, so we know that standardising and improving the way that these patients are treated will benefit both the patient's experience and reduce pressure on our APR-13 MAY-13 JUN-13 JUL-13 AUG-13 SEP-13 OCT-13 NOV-13 DEC-13 JAN-14 FEB-14 MAR-14 Trustwide Data Target

15 How well have we done in 2013/14?: Clinical Effectiveness How well have we done in 2013/14?: Clinical Effectiveness 29 services. Each month around 100 patients with COPD are admitted to our hospitals. The team has introduced a care bundle with the support of the emergency consultants, junior doctors, specialist nurses and physiotherapists. The care bundle improves the reliability of key clinical interventions occurring at the right time for every patient. The CQUIN target during 2013/14 was to ensure that 30% of the patients audited, both at individual hospitals and as a Trust, received the COPD care bundle. During 2013/14 patients were audited to assess whether they were receiving key treatments as developed by the British Thoracic Society. These treatments are as follows: oxygen should be administered within one hour of admission (if required) and a target oxygen saturation range prescribed during that admission if oxygen levels are less than or equal to 94%, Arterial Blood Gas (ABG) tests should be performed. These measure the levels of oxygen and carbon dioxide in the blood and indicate how well a patient's lungs are functioning nebulisers, steroids and antibiotics should be administered within four hours of admission (if indicated as appropriate by a doctor) In the first year of a two year project the admission pathway for our patients has been reviewed and documentation to support the clinical treatment has been developed and tested. Following some improvement of the patient pathway on admission with clinical staff in ED and our respiratory department, we were able to far exceed our target for 2013/14. Supporting Clinical Programmes In 2013/14 our commissioner, Gloucestershire Clinical Commissioning Group, intended to adopt the clinical programme group approach to commissioning. This means our clinicians in the Trust play a full part in ensuring patient care is as seamless as possible, by designing and agreeing clinical pathways with clinicians from all local health organisations. This CQUIN relates to clinicians within the hospitals trust playing a full part in these clinical programme groups, and in response we have implemented an agreed set of consultant roles for key areas: cancer children's health cardiovascular disease dermatology diabetes diabetes footcare gastroenterology genito-urinary and renal medicine mental health musculo-skeletal neurology older people ophthalmology respiratory home oxygen women's health Across these areas we have 22 consultants actively participating in clinical programme groups. The 'clinical programme approach' refers to a goal to provide a consistent, coordinated clinically-integrated approach to the development of our services, balancing the provision of high quality care for individual patients with the longer term needs of our services and the wider population. It also aims to achieve the best possible outcomes and value for the population and patients given the resources we have available. This year we have established a Clinical Programme Group (CPG) which will be responsible for the oversight of our whole clinical programme, providing assurance of innovative, evidence-based best practice, with good clinical outcomes, setting priorities for investment and ensuring that all services commissioned are within the programme budget. It is anticipated that each CPG will meet three to four times per year, with the majority of programme work taking place by group members outside this formal meeting. The groups' work is based on five key principles: population planning: taking into consideration all relevant patients and not just those that attend our hospitals or are referred to us Clinical Programme budget: focussing on commissioning high value services within a given (indicative) budget commissioning pathways: reinforcing prevention at all stages creating sustainable clinical systems: and reducing unwarranted variation shared decision making: making sure the experience of patients can help shape our services for the future. Implement Digital First initiatives and 3 Million Lives Digital First is a term for a Department of Health initiative which aims to reduce unnecessary face-to-face contact between patients and healthcare professionals by incorporating technology, for example phone or , into these interactions. One initiative which is helping us improve quality through the use of digital technology is SmartCare a major project which will improve the use of clinical information across our hospitals. SmartCare is a collaborative project with Northern Devon Healthcare NHS Trust and Yeovil District Hospital NHS Foundation Trust, which will provide us with an integrated clinical system this means that the same information about an individual patient will be available across every department in our hospitals, reducing barriers to consistent care and improving the patient s experience at every step. It will also help us to reduce our reliance on paper records, improving speed of access and quality. It is a significant investment that will bring benefits to our whole infrastructure, our staff and, most importantly, to our patients. Secure and accurate patient information is the foundation of providing safe, consistent and effective care, and it will provide us with further detailed information on which we can base our planning and service developments. Our aspiration in last year s Quality Account was to start deployment of SmartCare by early This timescale was unavoidably delayed for a short period while we waited for Treasury approval of our plans. We have now almost completed a very robust and diligent selection process, and will be able to announce our selected system in early Summer 2014, with deployment taking up to two years. Establish clear process to enable the exploitation of Intellectual Property Innovation is about converting knowledge and ideas into a benefit - delivering value by

16 How well have we done in 2013/14?: Clinical Effectiveness How well have we done in 2013/14?: Clinical Effectiveness 31 implementing new ideas and doing things differently. Innovation can transform patient outcomes, improve quality and productivity as well as contribute to the wider economic growth of the country. When we talk about being innovative in healthcare this can be in relation to services, processes or products. We encourage our staff to bring forward ideas for new products. Each idea is assessed carefully to identify any potentially valuable intellectual property (IP) and opportunities for commercial exploitation. Projects with potential are supported by our innovation leads and specialist advisors. Our Innovation Panel oversees the management of our IP portfolio. The panel is chaired by Non- Executive Director, Clive Lewis. The Intellectual Property policy offers staff the opportunity to share the benefits of any revenue from commercialisation. This year we successfully achieved the requirements of an important 'gateway' CQUIN, without which we would not have been eligible to access other CQUIN payments. The criteria for the CQUIN was to demonstrate that we had clear plans in place to exploit the value of commercial intellectual property. We have also increased our capacity to support innovators in our Trust and are building a small team of Trust Innovation Leaders. Two more members of staff have now completed their training. We have progressed key projects in collaboration with academic partners and have also involved industry and commercial partners. One of our clinicians, Prof Hugh Barr, and his team were highly commended in two categories of this year's national Innovation Challenge Prize initiative for their work in enabling earlier diagnosis of cancer and improving diagnostic investigations. This year we also contributed to the successful application to create the West of England Academic Health Science Network (AHSN) and our Chief Executive represents acute hospital providers on their Board. We continue to implement the High Impact Innovations, as outlined in the national strategy 'Innovation, Health and Wealth', such as 3 Million Lives and Digital First (see page 27), and always try to adopt leading edge, innovative technologies to improve the quality of care for our patients. This year our Board approved funding for a new urological surgery robot. This technology is considered to be one of the most significant developments in the world of surgery for 30 years, allowing the surgeon to operate with far greater precision than ever before. We will be showcasing this, and other innovations at the 2014 Cheltenham Science Festival, enabling members of the public, our staff and the wider health community to see how our use of healthcare technology is improving care for our patients. Next section: How well we have we done in 2013/14?: Patient Experience

17 How well have we done in 2013/14?: Patient Experience How well have we done in 2013/14?: Patient Experience Previous section: How well have we done in 2013/14?: Clinical Effectiveness How well have we done in 2013/2014? Patient Experience Friends & Family Test The Friends and Family Test is one of the many ways in which our patients provide us with their views on the quality of our services. It is a national initiative, launched in April 2013, which aims to capture patient feedback by asking one simple question: would you recommend us to your friends and family if they needed similar care or treatment? This year we started using the Friends and Family Test on our wards and the Emergency Departments (A&E) and the percentage of all patients who have responded to date is displayed in Figure 10. The CQUIN target this year was to both extend the test from the Emergency Departments and also to increase the response rate to 15% by the end of Figure 11: Friends and Family test /14. We met this target see Fig 11 below. On our wards, patients are asked to fill out a card which asks them the Friends and Family Test question, as well as follow up questions which ask them why they responded in the way they did. The completed card can then be posted into a box by the exit on each ward. Patients are also given the option of using the QR code (similar to a barcode which can be read by a mobile device, such as a smartphone) on the card to visit an online version of the survey or to complete it over the phone. In the Emergency Departments the survey is now carried out by issuing all patients with a pink token which they can then insert into one of six sections of a large token box, depending on their views of our services and staff. This method has proved 30 % OF PATIENTS WHO RESPONDED APR-13 MAY-13 JUN-13 JUL-13 AUG-13 SEP-13 OCT-13 NOV-13 DEC-13 JAN-14 FEB-14 MAR Inpatients Trust total Emergency Departments

18 How well have we done in 2013/14?: Patient Experience How well have we done in 2013/14?: Patient Experience 35 successful and will be considered again when we roll out the Friends and Family test to outpatient areas later in The results of the test are presented as a score using a nationally-prescribed calculation. A positive score of +50 or above is considered to be an indicator of good practice. At the end of quarter 3 our score was +71. This is similar to the scores of other trusts in the South West region. Each quarter the results of the Friends and Family test are analysed and each ward is provided with a summary of their performance to display in public areas. Each ward is also given a list of issues where they need to improve and is also told what they have done well. A 'tag cloud' (a graphic illustration of themes) showing common themes or comments is also produced by the patient experience team so that each ward can share it with patients and staff. privacy and dignity are upheld. You can read more about this initiative on p52. We encourage patients, carers and relatives to share their views on our services with us so that we can identify areas to improve for future patients. Following a complaint from the relatives of a patient about having to take home soiled clothing in a standard plastic bag, which then had to be removed for washing, we have introduced new 'Dissolvo bags'. These bags can be placed directly into the washing machine, therefore reducing any infection risks associated with removing soiled clothes from unwashable bags. This year we have also enhanced the elements of Care and Compassion in our Health Care Assistants training programme. The training was devised by senior nurses and our Education, Learning and Development team. She shared an experience relating to the identification of severe sepsis, so it was informative for managers to hear about her views on an issue which has since become a quality priority. Dr Neil said: In the past because of my experience both as a doctor and as a patient, I didn't feel able to talk about my experiences because I didn t think that they would be taken seriously. Now the Trust is actively seeking views. None of us are perfect but we can improve the quality of our care by listening to comments both positive and negative and by learning from our mistakes. It was good to have the opportunity to talk about some experiences of poor quality care and to feel that staff were ready to listen and to learn. Figure 12: Discharges Improve the discharge process We have continued our focus this year on improving the discharge process, making it easier for patients to go home when they are medically fit to do so. Starting in 2013, we began an joint initiative with our partners called Getting Mrs Foster Home. Centred around a fictional patient called Mrs Foster, the programme is aimed at improving discharge and transfer processes from our hospitals and is led by the Chief Executives from our Trust, Gloucestershire Care Services NHS Trust, NHS Gloucestershire Clinical Commissioning Group, Gloucestershire County Council and 2Gether NHS Foundation Trust. Personal Care: Privacy and dignity, involvement in decisions Staff story: Dr Dilys Neil We recognise that dignity in care is one of the most important issues for patients who come to us for care and treatment. We are committed to maintaining patient privacy and dignity and to ensuring that patients are only treated in single sex wards unless clinically necessary. From April 2013 to January 2014 there were a total of nine breaches of this policy, most occuring in acute wards. These rare occasions generally arise only when we have a long list of patients waiting for discharge and an increase in demand for beds. This year we provided funding to ensure our senior (Band 7) nurses spend more time supervising and managing their staff and ensuring that standards of care and In 2013 we invited members of staff to share with us any experiences they had as users of our service. After sharing her experiences at this event, Paediatric Oncologist, Dr Dilys Neil, spoke again at our Board meeting and a meeting for senior leaders. NO. OF PATIENTS DISCHARGED APR-13 MAY-13 JUN-13 JUL-13 AUG-13 SEP-13 OCT-13 NOV-13 DEC / /13 JAN-14 FEB-14 MAR-14

19 How well have we done in 2013/14?: Patient Experience How well have we done in 2013/14?: Patient Experience 37 In the fictional, but true-to-life scenario common to many of our patients, Mrs Foster has been identified as having four key needs as a patient: timely and responsive services staff who communicate effectively only telling her story once a single point of contact who can deal with all her enquiries. The idea is to trial new ways of working during the 'Mrs Foster Weeks' so that they become part of the normal way of working in the future. Many of these new actions are small adjustments to the discharge process, but can make a big difference to our ability to get patients back into their own homes or on to a place where they can get the nursing or care support they need. Some examples of these changes include setting a realistic Expected Date of Discharge (or EDD) early on in the patient's inpatient stay and creating a clear management plan for that patient so that they meet this date. Setting an EDD enables staff to plan effectively and to work with relatives, carers and colleagues in community settings, such as care homes, to ensure that everything is in place to continue their care once they have left our services. Providing the best possible experience for these patients is of paramount importance to us, and staff are encouraged to discharge patients early in the day and to comply with all the relevant professional standards. So far we have run Mrs Foster Weeks in November 2013, and in January, February and March A positive impact of this initiative on the availability of beds has not yet been realised, but the aim is that preparing and planning ahead for a patient's discharge becomes part of the day-today operations of staff on our wards. Patient experience escalator The patient experience escalator was a CQUIN goal for us this year and is about demonstrating that we listen and respond to concerns raised by patients and carers about their experiences, and celebrating staff whose attitude and approach embody our organisational values and standards of behaviour. This year we worked in partnership with Carers Gloucestershire to develop a service to offer support, advice and information on our hospital sites for carers. The Hospital Liaison Officer from Carers Gloucestershire visits our stroke wards and general and old age medicine wards. Over the year a total of 248 carers have been in contact with the liaison officer and a total of six wards have been visited. Carer story: Pat Eagle Mrs Pat Eagle first contacted our complaints team to make a complaint about a lack of communication and missed opportunities for diagnosis when her partner was admitted with abdominal pain. He was later diagnosed with Clostridium difficile. Her partner had been seen by a number of agencies, including us, and a number of missed opportunities meant a delay in diagnosis and treatment. Our infection control team was really keen to learn from Pat s experience and she was invited to speak at a study day last Autumn. Pat spoke very eloquently and movingly about the impact of such an infection on both her and her partner, both in the acute phase of illness and during recovery. Pat said: My complaint was dealt with promptly and efficiently. I also had a meeting and felt that the staff listened to what I had to say and as a result I am aware changes have been made and implemented. When I met with the Infection Control Team it gave me the opportunity to have a discussion with them and I felt that by their reaction to me, they had taken on board my feedback from a couple of issues missed. The Trust has acted positively and I feel has learnt from the concerns I raised. We continue to celebrate staff achievement and recognise those members of staff who regularly display exemplary behaviour through our Kindness and Respect Awards. Members of staff are able to nominate their colleagues for an award on a monthly basis. Each year at our Celebrating Success Staff Awards we honour one member of staff from those who have been nominated for the monthly Kindness and Respect award, and invite them to attend our awards ceremony where they are presented with a certificate by the Chair of our Trust. Information for carers of people with dementia This year we have been working with our volunteer team to develop and carry out a survey of carers of people with dementia to establish what we do well and what we need to improve. Every month our specialist volunteers speak to ten carers of patients with dementia in our General Old Age Medicine wards. The findings of these faceto-face interviews are then compiled into a quarterly report which is presented to our local Clinical Commissioning Group and our own Dementia Steering Group. The report always looks to highlight three aspects of care and support that we do well and three areas which need to be improved. Things we are doing well: communication involving family and carers nutrition support dignity and respect for our patients access to information being able to visit outside of normal visiting hours when supporting relatives who are vulnerable. Things we are taking action to improve upon in light of feedback received: controlled entry systems at wards: some relatives reported having to wait at times before being allowed to enter social activities when in hospital: a pilot

20 How well have we done in 2013/14?: Patient Experience How well have we done in 2013/14?: Patient Experience 39 project was introduced this year on Ward 9b at GRH to run lunchtime activities with patients who suffer from dementia. This has been well received and other wards are now considering similar events more staff training on importance of liaising with carers: we are using carer feedback as part of our staff training getting things right each and every time: we are working to achieve this. In April 2013 we launched a new Carers Information Leaflet specifically for carers or relatives of patients with dementia, following consultation with a number of charities and partner groups. The leaflet explains to readers what advice and support is available within our hospitals as well as in the wider community. It is now displayed within the leaflet racks of all adult inpatient wards and on our website to allow it to be easily accessed by relatives and carers. Next section: What are our priorities for 2014/15? This year we have also been working closely with Carers Gloucestershire who are now on our hospital sites to provide face-to-face expert advice and support to carers. This year we have also re-launched our Carer's Badge, making it easier for carers to access support, such as free parking and discounted meals, while visiting patients in our hospitals.

21 What are our priorities for 2014/15? What are our priorities for 2014/15? 41 Priorities for improving quality in 2014/15 Previous section: How well have we done in 2013/14?: Patient Experience Below is an overview of our priorities for 2014/15. The table gives you an at-a-glance view of the work to be undertaken in the year ahead and which of our stakeholder groups highlighted it as an issue to be addressed. Priorities Incomplete from last year National priority for 2014/15 Issue for commissioners / CQUIN Issue for HCOSC Issue for Healthwatch Issue identified internally by Governors 1. Safety NHS Safety Thermometer Management of Sepsis Never events Improving patient flow Seven day working What are our priorities for 2014/15? Reducing violence and aggression 2. Clinical Effectiveness Dementia and delirium Acute Kidney Injury Chronic Obstructure Pulmonary Disease Reducing variation 3. Patient Experience Friends & Family Test Learning from feedback (patients, carers and staff) Involving patients in service improvement Delivering compassionate care Cancer wait times

22 What are our priorities for 2014/15?: Safety What are our priorities for 2014/15?: Safety Previous section: Introduction to 2014/15 priorities What are our priorities for 2014/15? Safety NHS Safety Thermometer Following the approach used by the Safety Thermometer we will be examining a new tool that helps monitor the safety of medicines. The tool looks at the amount of missed drug doses which can cause delays in treatments, drug allergies, as well as what drugs a patient is taking when admitted and whether they are compatible with those they are prescribed while in hospital. Preventing the development of pressure sores among our inpatients will continue to be a priority for us during 2014/15. In particular we will be focussing efforts on our General and Old Age Medicine wards where the nature of the patients cared for means they are more susceptible to pressure sores. In April 2014 we will be launching an awareness campaign among staff throughout the health community called Stop the Pressure, holding study events and safety cafe-style events. These events will not only focus on the prevention of pressure sores but also the social, legal and financial consequences of failing to prevent the development of these harmful and distressing ulcers. We will also be conducting Serious Untoward Incident reviews on all grade 3 and 4 pressure ulcers indentified so that we fully understand the root causes and to help prevent future incidents. Management of Sepsis As outlined on p14 we are meeting and often exceeding our targets for treating patients with sepsis using the 'sepsis six' care bundle within an hour of diagnosis in our Emergency Department. However, meeting our target of treating 80% of these patients in the same way on our inpatient wards has proved challenging in 2013/14 (read more on p14). For this reason, our focus will continue to be on achieving our target on ward areas in 2014/15 (to be agreed) although this will not be a CQUIN for 2014/15. We will also be reviewing our approach to the management of severe sepsis in our paediatric patients (children and younger people), and emphasising the importance of giving the first dose of antibiotics to adult patients as early as possible after diagnosis. Never Events Never events are very serious, largely preventable patient safety incidents or errors that should not occur if the relevant preventative measures have been put in place. There are currently 25 types of incident which the Department of Health has identified as never events. During 2013/14 we had three never events at our Trust. These were: wrong implant two retained foreign objects post operation When a never event has been identified, a thorough investigation process is triggered immediately and the senior clinician and executive Board members informed. The aim of this investigation is to identify both the organisational and human factors that led to the error. From this work we identify what improvements are needed and then monitor this action plan until it has been fully implemented.

23 What are our priorities for 2014/15?: Safety What are our priorities for 2014/15?: Safety 45 Details of all investigations, their outcomes and subsequent actions are always shared with the patient involved in the original incident and, depending on their preference, can include a face-to-face meeting and explanation of what went wrong, and/or a letter and copy of the investigation report. In response to one of the retained foreign object incidents, the system of using a white board in each theatre to record the instruments used on each patient, such as a surgical swab, was adapted to ensure that any foreign object inserted into a patient is recorded. Localised training sessions are also taking place for nursing staff on the use of foreign objects and their removal. In October 2013 the Care Quality Commission published an Intelligent Monitoring Report which highlighted never events as a risk for us. This was in response to the increase in the number of never events from two in 2012/13 to three in 2013/14. In response to this a 'high level review' is now underway to further improve the safety of our patients. This review will look back at previous never events and other incidents to identify any common themes which can then be targeted for improvement in the year ahead. Supporting Patient Flow The term 'patient flow' refers to the way in which patients move through a hospital, from admission through to eventual discharge. Designing services with effective patient flow is a core part of our ambitions to provide safe, patient-centered, high quality care. Patients whose care or return home is delayed are less likely to have a good experience of our services. In addition, evidence links poor patient flow to increased mortality, increased risk of adverse incidents, readmissions and poor financial performance. As outlined on p35, we have been working with our partners in the wider health community to look at ways to improve the discharge process. This CQUIN will focus on audit and questionnaires to develop a baseline understanding of the position in relation to discharge arrangements and the impact on the flow of patients through our hospitals. This includes when and if the assessment of a patient's capacity for discharge planning took place and how many times the patient's pathway (journey through hospital care) was changed. We will also conduct an audit to capture the experience of patients who are dying to establish, among other things, whether they received care from the right teams of staff to enable them to be supported at home in their last days of life. Seven day working Patients need the NHS every day. Evidence shows that nationally, the limited availability of some hospital services at weekends can have a detrimental impact on outcomes (the result of their treatment and care) for patients. In December 2013, Sir Bruce Keogh, National Medical Director for NHS England, published a paper outlining ten key standards that describe the quality of urgent and emergency care that all patients should expect seven days a week. They describe, for example, how quickly people admitted to hospital should be assessed by a consultant, the diagnostic and scientific services that should always be available and the process for handovers between clinical teams. This will be a significant and challenging piece of work for us locally and is likely to require fundamental changes to the way we organise our consultants work and how we organise our services. During 2014/15 we will be developing an action plan to enable us to work towards the achievements of these standards. Violence and aggression Within the Trust we do a variety of things to protect NHS staff from violence and aggression. We have dedicated security professionals whose role is to ensure the best use of valuable NHS resources and develop a safer more secure environment for NHS care. We also have extensive training on conflict resolution and if a role requires it, extensive safer handling training for staff dealing with patients who display challenging behaviour. Additionally we have a range of support services that can be accessed by staff if they have been physically assaulted. Despite this, the current staff survey revealed there has been a 3% increase in the number of staff who say they have been physically assaulted. The number of reported assults that have been recorded by our reporting systems and sent to NHS Protect for the annual National Violence Against Staff (VAS) return, shows that during 2012/13 our staff had suffered 152 physical assaults of which 140 related to clinically confused patients rather than malicious behaviour. This is a ratio of 21 per 1000 staff and an increase from the previous year. This data was taken from the number of staff declared by the Health and Social Care Information Centre. As part of last year's health and safety objectives we conducted a detailed audit of the current violence and aggression policy. This indicated that there was room to improve our existing system for managing violence and aggression. Our aim this year is to improve the management and prevention of violence and aggression particularly with patients who are confused which requires considerable understanding of the clinical condition and a real empathy for the patients and family involved. Our work will include an evaluation of the best preventative methods available, how we respond to a emergency situation and how we best support the staff involved. To do this we will be establishing an expert group involving staff members and other relevant representatives to identity and test new approaches and enhance current practice to reduce the amount of patient-related incidents and to improve the support for staff. As a consequence of the attention paid to this area we expect to see an increase in awareness and therefore an increase in reported incidents in the coming year so we will establish of a range of indicators to measure any improvement in our approach to complement the incident reporting system.

24 What are our priorities for 2014/15?: Clinical Effectiveness What are our priorities for 2014/15?: Clinical Effectiveness Previous section: Safety What are our priorities for 2014/15? Clinical Effectiveness Dementia and delirium As we have demonstrated on p24 and p37 we have taken a number of actions this year to improve the care we provide for our patients with dementia and their carers. Improving care for this group of vulnerable patients will continue to be a national priority in 2014/15 and has also been highlighted as a key issue for our commissioners and our local Health, Community and Care Overview and Scrutiny Committee. Our dementia CQUIN objectives now also include targets in support of our patients experiencing symptoms of delirium. Our present admission assessment and our clinical pathway includes guidance on recognising delirium. In the year ahead we will review how we assess and manage the care and treatment of patients with delirium, as part of the delirium pathway, and take action to further improve the experience of patients and their carers. Building on our success in 2013/14, we will continue to work closely with our dementia champions to implement their objectives for 2014/15. These are: to promote person-centred care to promote care and compassion in action to promote best practice standards for nutrition support to promote best practice standards for pain assessment and to champion the use of the Adapted Abbey Pain Score for patients who are not able to tell us that they may have pain support and promote involvement of families and carers. Reducing the incidence of avoidable renal failure (Acute Kidney Injury) During 2013/14 we had a target of treating 75% of all patients highlighted by our pathology team as at risk of AKI based on test results, with a 'care bundle' within 24 hours. As outlined on p24 we did not achieve this target as hoped. For this reason the Acute Kidney Injury will continue to be a priority for us in 2014/15. Improve the care for patients with Chronic Obstructive Pulmonary Disease (COPD) In 2014/15 our new target is to ensure that by March % of all patients receive the COPD care bundle on both hospital sites. You can read more about the work we have done in 2013/14 to improve care for COPD patients on p26. Reducing variation Variation in the way we are treated by healthcare professionals is not always considered to be a bad thing. We are all individuals with individual needs and there are many legitimate reasons why our treatment will need to be different from another patient with a similar condition. These are considered to be 'natural variations', and are an inevitable feature of healthcare systems. However some variations in the way we work are less desirable and can affect our ability to run services efficiently and the safety and quality of care we provide to our patients. Some examples of these might be: the way we schedule services

25 What are our priorities for 2014/15?: Clinical Effectiveness What are our priorities for 2014/15?: Clinical Effectiveness 49 the working hours of staff and how leave is planned the order in which we see or treat patients the way patients are managed and drugs are prescribed eg. not using evidencebased agreed pathways or protocols. A lot of work has been done to help NHS organisations understand and reduce these kinds of 'artificial' variations. For our organisation, the move from paper notes towards an electronic health record for every patient will significantly reduce variation in their care. Our SmartCare project (see p29 for more information) will bring mobile digital technology to our wards, enabling doctors to make decisions and access information about patients at their bedside. Next section: What are our priorities for 2014/15? Patient Experience By using these devices, clinicians will be able to make their decisions within the parameters of agreed pathways and protocols, while still providing enough flexibility in the system to make independent clinical judgements where appropriate. These devices have the added benefit of providing us with a clear audit trail for the treatment of each individual patient. If there are significant or concerning variations in the clinical outcomes (results of treatment and care) of a particular group of patients then these can be quickly and easily investigated via the data gathered by the new SmartCare system. Once a clinical system has been identified during the procurement process in the early part of 2014, the SmartCare project team will be looking at the design and configuration of the system, training of staff and planning, before going live in 2015/16.

26 What are our priorities for 2014/15?: Patient Experience What are our priorities for 2014/15?: Patient Experience Previous section: What are our priorities for 2014/15?: Safety What are our priorities for 2014/15? Patient Experience Friends & Family Test Finding out whether our patients would recommend us to their friends and family is an important indication of how highly they rate our services, and gathering this feedback will continue to be an important focus for us during the year ahead. Our efforts will be concentrated on increasing our target response rates for the Friends & Family test in adult inpatient areas, from 15% at the end of 2013/14 to 30% by the end of 2014/15, in order to achieve our CQUIN funding. In increasing the response rates we will also have greater insight into the experience of patients in our hospitals. In the Emergency Department we must also increase our target response rate from 15% at the end of 2013/14 to 20% by the end of 2014/15. This year we have started the Friends & Family test in our maternity departments and this work will continue although no target has been set for response rates. In addition we will be expanding the test to our outpatient areas by the end of the second quarter of the year. There is no target for response rates, but this will be a considerable piece of work for us as our outpatients, due to the nature of their treatment, spend less time with staff and there is therefore less opportunity to promote the feedback options. Significantly, this year will also see the introduction of the staff Friends & Family Test. Starting at the beginning of 2014, each member of staff will be asked two questions on a quarterly basis: would you recommend this as a place of work to your friends and family? would you recommend our services to your friends and family? It is also important that we not only increase the numbers and breadth of patients and staff asked these questions, but also that we demonstrate what we have learned from the feedback we have received. This is a priority for us and is part of a broader approach to transparency and openness that will continue to be a theme for us this year. Learning from feedback As mentioned above, we know that it is not only important to receive feedback from patients, but also to hear what our patients, carers, visitors and staff are telling us and to respond positively to those comments, making improvements where they are needed. We also believe that it is important that we share the lessons we have learned with the public so that patients can see the value in sharing their feedback with us and understand that their comments can and do lead to demonstrable improvements in our services. We work closely with Healthwatch Gloucestershire who aim to give both citizens and local communities a stronger voice to influence and challenge how our services are provided. They are in regular contact with our Chief Executive and Chair to share patient experiences with us. Our PALS and complaints teams receive around 2,812 comments, concerns, complaints and 7,010 compliments each year and each of these is passed on to the departments concerned so they can act on them where appropriate. In 2014/15 we will focus on creating systems which enable staff and other patients to see what patients have been saying about us and what we've done in response. We will also aim to create more opportunities for

27 What are our priorities for 2014/15?: Patient Experience What are our priorities for 2014/15?: Patient Experience 53 patients to provide feedback in areas such as neonatal intensive care and outpatient departments, which in the past have not received as much feedback as in others. Involving patients in service improvement We believe that it is often those closest to the process of providing healthcare who are best placed to give useful feedback on the way services work and on how they can be improved in the future. Our patients experience our services first hand; they have a unique, highly relevant perspective on what works and what doesn't. Their input into designing services can therefore be invaluable. Sometimes, seeing services from the patients point of view opens up real opportunities for improvement that may not have been considered before. This may include changes that make life easier for staff and patients, whilst reducing delays or other inefficiencies at the same time. We are continually looking at how we can better design our services so they meet the needs of our population within the resources available. Making sure that our patients play a vital role in this shaping of future services has been identified as a priority by our commissioners and our local Healthwatch. Our CQUINs include a target to demonstrate that we have learned from the results of the Friends and Family Test data, to show how we have used that information to inform practice, spread good practice or trigger an improvement to a service. Delivering compassionate care We know that it is the commitment, professionalism and dedication of our staff that can make the greatest difference in providing high quality services and care for patients and their families. In April 2013 NHS England set out a 'Compassion in Practice' strategy to transform care in all support settings. Part of this strategy is to ensure that hospital staff demonstrate the 6Cs in their practice and daily working lives. The 6Cs are: care: defines us and our work. People receiving care expect it to be right for them consistently throughout every stage of their life compassion: is how care is given on empathy, respect and dignity competence: means all those in caring roles must have the ability to understand an individual's health and social needs and the expertise, clinical and technical knowledge to deliver effective care and treatments based on research and evidence communication: is central to successful caring relationships and to effective team working. Listening is as important as what we say and do and essential for 'no decision without me.' courage: enables us to do the right thing for the people we care for, to speak up when we have concerns and to have the personal strength and vision to innovate and to embrace new ways of working commitment: to our patients and population is a cornerstone of what we do. We need to build on our commitment and improve the care and experience of our patients to take action to make this vision and strategy a reality for all and meet the health and social care challenges ahead. In response to the above and as part of our action plan following the publication of the Francis Report recommendations, we have already taken several key steps to improving the delivery of compassionate care. We are committed to investing in clinical leadership and our specialty directors (senior consultants with leadership time built into their working week) are at the heart of this initiative. We have invested 700k in releasing time for ward sisters to lead, supervise and monitor the care on their wards and be a key point of contact for patients. For the past five years we have been using a nationally-recognised benchmarking tool - the Keith Hurst Database - to ensure we have the right number of nurses on our wards. Our latest assessment has led us to invest 900k in additional nursing staff. We have invested jointly with the University of Gloucestershire in five clinical nurse tutors to lead on each of the following five education pathways: care of the frail elderly dementia and mental health unscheduled care surgical pathways developing newly-qualified nurses. All of these actions are also supported by our new Nursing and Midwifery Strategy which was launched in September Cancer wait times More than one person in three will develop cancer at some time in their lives and one in four will die of cancer. More than 250,000 people in England are diagnosed with cancer every year and around 130,000 die from it. Early detection and treatment are crucial if patients are to have the best possible outcomes and the growing public awareness and screening programmes mean that survival rates and patients' experience of care are improving at a national level. The impact of increasing public awareness of the importance of early detection has also been felt locally in our hospitals. Our oncology service receives around 1,200 referrals a month, yet only 10% of these patients are likely to be diagnosed with cancer. Referrals of patients with suspected cancer continue to increase month on month. Currently all patients referred with suspected cancer by their GP have a maximum wait of two weeks to see a specialist consultant. Cancer patients should also wait no more than 31 days from the decision to treat to the start of their first treatment. Both of these two targets are consistently met across our Trust. However, patients should also wait a maximum of 62 days from their urgent GP referral to the start of their treatment. This national standard also includes all patients referred from NHS cancer screening programmes (breast, cervical and bowel) and all patients

28 What are our priorities for 2014/15?: Patient Experience What are our priorities for 2014/15?: Patient Experience 55 whose consultants suspect they may have cancer. This 62-day target has proved difficult for us to meet for a variety of reasons. This is primarily the result of internal delays in three areas: histopathology: this department processes tests and analyses results radiology have now all been filled. Efforts have also been focussed on reducing the waiting time for consulant clinic appointments. We are confident that an increase in the number of consultants and a new acute oncology service which aims to identify and treat cancer patients when they are admitted via A&E, will improve performance in this area in the year ahead. theatre capacity. Monitoring performance during 2014/15 We have developed an action plan to help address the delays, shortages of staff and/ or equipment that has been identified to help us meet this important standard. Healthwatch Gloucestershire have raised concerns about the delays experienced by cancer patients in our waiting areas for appointments and treatment. As a result of a few key initiatives, we are pleased to report that waiting times for chemotherapy treatment have been significantly reduced since January The steps we have taken to achieve this include: making better use of the Mobile Chemotherapy Unit. We will be expanding the use of this further to treat patients in Tewkesbury in May 2014 improved working arrangements with the pharmacy to ensure that chemotherapy treatment can be provided throughout the day All the initiatives that we will be taking forward during the year ahead will have a lead sponsor and a project group. Progress on these initiatives will be monitored through regular project update reports and progress on the desired outcomes monitored through the metrics included in the quarterly Quality Report presented to the Quality Committee. Next section: Statements of assurance review of patient information so that nurses can spend more time providing chemotherapy treatment and less time explaining the process chemotherapy nurse vacancies

29 Statements of assurance 2.2 Statements of assurance Statements of assurance The following section includes responses to a nationally defined set of statements which will be common across all Quality Accounts. The statements serve to offer assurance that our organisation is: performing to essential standards, such as securing Care Quality Commission registration measuring our clinical processes and performance, for example through participation in national audits involved in national projects and initiatives aimed at improving quality such as recruitment to clinical trials Information on the review of services The purpose of this statement is to ensure we have considered quality of care across all our services. The information reviewed by our Quality Committee is from all clinical areas. Information at individual service level is considered within our divisional structure and any issues escalated to the Quality Committee. During 2013/14 Gloucestershire Hospitals NHS Foundation Trust provided and/or subcontracted 42 NHS services. The Trust has reviewed the data available to us on the quality of care in all of these NHS services. The income generated by the NHS services reviewed in 2013/14 represents 100% of the total income generated from the provision of NHS services by Gloucestershire Hospitals NHS Foundation Trust for 2013/14. Information on participation in Clinical Audit The purpose of this statement is to demonstrate that we monitor quality in an ongoing, systematic manner. From 1 April 2013 to 31 March 2014, 33 national clinical audits and 4 national confidential enquiries covered NHS services that Gloucestershire Hospitals NHS Foundation Trust provides. During that period Gloucestershire Hospitals NHS Foundation Trust participated, or is currently participating in 32 (97%) of national clinical audits and 4 (100%) national confidential enquiries of the national clinical audits and national confidential enquiries in which it was eligible to participate. The one audit where the Trust did not participate there were justifiable reasons for non participation (please see Table 1 on p60) The national clinical audits and national confidential enquires in which Gloucestershire Hospitals NHS Foundation Trust participated, and for which data collection was completed during 1 April March 2014 are listed in Table 1 on p60, alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry or a straight percentage of cases submitted. The reports of 19 (60%) national clinical audits/confidential enquiries participated in were reviewed by the provider in 2013/14. Eight reports are still awaited. Five are currently in the data collection phase of the audit. The actions Gloucestershire Hospitals NHS Foundation Trust intends to take to improve the quality of healthcare provided are summarised in Table 1 on p60.

30 Statements of assurance 2.2 Statements of assurance 59 The reports of over 200 local clinical audits were reviewed in 2013/14 and Gloucestershire Hospitals NHS Foundation Trust either has or intends to take the following actions to improve the quality of healthcare provided: the provision of the availability of speciality specific patient information leaflets has improved following a rolling programme of audit to improve communication at a ward level as a result of the Paediatric Early Warning Score (PEWS) audit, new age related charts were introduced alongside an education programme for nursing staff to improve documentation of PEWS Participation in clinical research The inclusion of this statement demonstrates the link between our participation in research and our drive to continuously improve the quality of services. The number of patients receiving NHS services provided or subcontracted by Gloucestershire Hospitals NHS Foundation Trust in 2013/14, which were recruited during that period to participate in research approved by an NHS research ethics committee, and included on the National Institute for Health Research (NIHR) Portfolio is currently This figure includes recruitment recorded on the NIHR Internet Portal up to 17 February NHS Foundation acted as host to 62 new studies approved from 1st April Of these studies 44 were adopted to the NIHR Portfolio. Although a decrease on the total number of approved studies from 2012/13, the proportion of NIHR Portfolio studies has increased from 61% to 71% in 2013/14. In total the Trust was recruiting to around 142 Portfolio Studies over the 12 month period. This is a reduction from 2012/13, but an illustration of how the portfolio can affect recruitment. Although the number of studies reduced, the number of recruits is up which shows how one or two high-recruiting studies can greatly influence the overall picture. which was conditional upon the quality and innovation goals was 8,669,940 out of a total planned income of 350,306,510. In line with national rules this represented about 2.5% of income (with 0.125% removed from Specialised Income to support a national development fund). Current indications show that 8,436,047 has been secured. The main area of loss was the missed improvement target for new pressure ulcers, 156,057, which formed part of the Safety Thermometer. All local CQUINs have been achieved and it is expected that all specialised CQUINs will also meet requirements with only Quality Dashboards left to report in Quarter 4. interventions by the urology department have shown an increase in compliance with the prescribing of low molecular weight heparin on discharge, and completion of the course following major urological surgery in accordance with NICE guidelines. Clinical Audit has been an integral part of the Trust s CQUIN programme for the years 2013/2014 providing evidence information for eg. VTE, Sepsis, Acute Kidney Injury, Safety Thermometer. Additionally clinical audit has also provided information for other national projects eg. Saving Lives campaign This high level of participation demonstrates that quality is taken seriously by our organisation and that participation is a requirement for clinical teams and individual clinicians as a means of monitoring and improving their practice. This figure is likely to increase over the next couple of months as participants recruited to research studies in the final six weeks of the financial year continue to be reported. If recruitment continues at a similar rate, we can expect a final total for 2013/14 to be around 1,700 participants although it is always difficult to plan for seasonal variations in recruitment and closure of high recruiting studies. This would be a substantial increase on 2012/13 and closer to our peak recruitment year of 2010/11. This also means that we have already achieved our yearly recruitment target of 1,100 as set by the Western Comprehensive Local Research Network. As the Gloucestershire R&D Consortium Delivery Budget is dictated by activity, the increased activity in 2013/14 may have a positive effect on budgets going into 2014/15. During 2013/14, Gloucestershire Hospitals There was a wide range of clinical staff participating in research approved by an NHS Research Ethics Committee during 2013/14. These staff participated in research covering the majority of medical specialties across all four divisions in Gloucestershire Hospitals NHS Foundation Trust. Information on the use of the Commissioning for Quality & Innovation (CQUIN) framework The CQUIN payment framework continues to support the cultural shift towards making quality the organising principle of NHS services by embedding quality at the heart of commissioner-provider discussions. The agreed national, local and specialised CQUIN schemes, the rationale behind them and the associated payments for 2013/14 can be seen in Table 2 on p66. The level of the Trust s income in 2013/14 The CQUIN schemes agreed for 2014/15 can be seen in Table 3 on p68. These include three nationally mandated, five local schemes and four schemes from specialised commissioning. There is a high level of overlap between these goals and the priorities in our Quality Account for 2014/15. This demonstrates the high level of active engagement with our commissioners in quality improvement. It has been confirmed from national guidance that the value of CQUIN schemes in 2014/15 has again been set at 2.5% of total patient care income value. A key change for 2014/15 is that there are no pre qualification goals.

31 Statements of assurance 2.2 Statements of assurance 61 Table 1: Participation in National Audits Audit title Did the Trust Participate? Number of case submitted / number required Was the report reviewed? Actions taken as a result of audit / use of the database Peri and Neonatal Neonatal Intensive and Special Care Audit Programme (NNAP) Yes Yes Paediatric Governance The Trust participates via the Badger system. This is the database used to record all the NICU activity. The data is used internally for benchmarking against similar units Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRACE-UK) Yes Data entered for all maternal deaths and still births All maternal deaths and stillbirths reviewed at Governance meetings Children Paediatric Bronchiectasis No Not applicable Not applicable Decision made to undertake paediatric asthma audit National Diabetes Audit (PNDA) paediatric Yes 296 patients submitted Epilepsy 12 (Childhood epilepsy) Yes Ongoing data entry and data collection Moderate or severe asthma in children (care provided in emergency departments) Yes Currently in data collection phase of this audit 50 cases from GRH, 33 cases from CGH to date Reports not yet published but will be reviewed at specialty meetings Paediatric Asthma Yes Currently in data collection phase of this audit Reports will be reviewed at speciality meetings Child health clinical outcome review programme (CHR-UK) Yes Acute Care Paracetamol overdose (care provided in ED) Yes Currently in data collection phase 13 cases from CGH, 45 cases entered from GRH to date Reports not yet published but will be reviewed at specialty meetings Severe sepsis and septic shock Yes Currently in data collection phase 44 cases from CGH, 50 cases entered from GRH to date Reports not yet published but will be reviewed at specialty meetings National Cardiac Arrest Audit Yes 100% submission cases from GRH 100% submission cases from CGH Yes Resuscitation committee Risk Adjusted Comparative Analyses has allowed benchmarking against the national picture. Results and points for discussion are taken to the Resuscitation Committee, and from there points of interest are then disseminated. Reassured that the Trust is performing above the national level for survival to discharge. Current actions include the monitoring of futile events with an aim to a reduction of these futile events occurring, as a marker of quality. National Audit of Seizures in Hospitals (NASH) Yes 30 cases submitted to the second round of the NASH audit Yes at specialist and divisional meetings Audit highlighted issues with referral from ED new system put in place which is improving the situation however again this highlighted the need for a dedicated 1st fit clinic which is being worked towards as due to limited capacity it takes too long presently. Case Mix Programme Yes 100% of patients admitted to critical care areas. 556 CGH & 619 GRH cases submitted 1/4/13 to 31/1/14 Yes at quarterly business and mortality meetings The reports provide information on mortality rates, length of stay, etc and provide the Trust with an indication of our performance relation to other ICUs. Where trends are identified then these allow us to make recommendations about changes to practice. Standards are reviewed against those proposed as quality indicators by the Intensive Care Society Long term conditions National Chronic Obstructive Pulmonary Disease (COPD) audit Programme Yes All patients admitted with COPD during data collection period of 1st February 30th April Report will be reviewed at speciality and divisional level Following on from participation the COPD care bundle programme a Respiratory Admission Care Bundle has been introduced in the Trust, in line with recommendations from the BTS aiming to improve the quality of care for patients admitted with COPD there has been an improvement in the number of patients receiving the required elements of the care bundle since its introduction. Also incorporated with a local CQUIN Renal replacement therapy (Renal Registry) Yes 100% of renal dialysis and transplant patients registered Yes Renal Team Audit meetings. Latest report is 16th annual Report Trust is generally compliant. Area for action is to develop an annual review programme for patients >70 years of age with renal physician and surgeon from regional transplant centre. Trust now also participates in the Acute Kidney Injury section of the Renal Registry National Diabetes Audit (NDA) ADULT, includes National Diabetes Inpatient Adult (NADIA) Yes 100% of patients on the snapshot day submitted - 96 patients in total Report reviewed by countywide Diabetes Group and within medical division Actions include continuing education with ward staff, daily ward round by diabetes team and assessment of e referrals. To improve discharge planning with use of discharge stickers and TTO stickers in notes/drug chart Inflammatory bowel disease (IBD) Yes 30 patients submitted for the clinical phase of data entry. Organisational component of data entry ongoing Results will be reviewed at Gastroenterology Speciality meetings once available Results not available until June 2014 Bowel Cancer (NBOCAP) Yes 2013 report - 376/487 cases submitted Reports discussed at the annual business meeting for the MDT & at the Cancer Management Board 178 (51.7%) cases having major surgery 77% case ascertainment 88% data completeness 100% of cases reviewed at MDT Head and neck oncology (DAHNO) Yes 8th Annual report 205 cases submitted Reports discussed at the annual business meeting for the MDT & at the Cancer Management Board 99.5% cases discussed at MDT meetings Lung cancer (NLCA) Yes 298 cases submitted Reports discussed at the annual business meeting for the MDT & at the Cancer Management Board 95% cases reviewed at MDT (98.3% data completeness) 76.2% seen by specialist nurse (98.7% data completeness) Oesophago-gastric cancer (NAOGC) Yes 136 cases submitted Reports discussed at the annual business meeting for the MDT & at the Cancer Management Board

32 Statements of assurance 2.2 Statements of assurance 63 Cardiovascular Disease Coronary angioplasty Yes CGH cases of PCI performed Yes at departmental meetings and monthly mortality and morbidity meetings Myocardial Infarction National Audit Project (MINAP) Yes 100% for patients with ST elevation Yes Shared with regional, network and local colleagues National Heart Failure Audit Yes Yes 117/643 cases submitted Reports reviewed at speciality meetings National Vascular Registry Yes 183/198 HES cases submitted Yes at specialty and divisional meetings Surgery Severe Trauma (Trauma Audit and Research Network, TARN) Yes 55 cases submitted Report reviewed jointly at ED and T&O morbidity and mortality meeting Patient Reported Outcome Measures (PROMs) measure quality of a procedure from the patient perspective. PROMs calculate the health gain after surgical treatment using pre and post operative surveys. Elective surgery (National PROMs Programme) Yes Patients are invited to participate, it is not mandatory. Currently there are four procedures being measured groin hernias, varicose veins, total knee and total hip. Participation Rate: Æ Æ All procedures 69% Æ Æ Groin hernia 56.8% Æ Æ Hip replacement 75.7% Æ Æ Knee replacement 81.7% Æ Æ Varicose vein 53.3% Æ Æ Post-operative questionnaire response rate for the Trust is 41.4% (36.7% in England) Falls and Fragility Audit Programme (FFAP) Yes National Hip Fracture Database CGH 299 cases submitted (300 estimated) GRH 418 cases submitted (400 estimated) Participating in the Pilot of Inpatient Falls currently in data collection phase aiming for 40 patients to be submitted at both sites Reports reviewed at Trust falls group and in the GOAM speciality Sentinel Stroke National Audit Programme (SSNAP) Yes All patients admitted with stroke or TIA entered 600 entered to date Yes Reviewed at departmental meetings, also at divisional and board level National Emergency Laparotomy Audit Yes Organisational phase completed Currently in 1st year of patient data collection phase. 2 nd year of patient data collection phase due to commence Dec st report (organisational report) due May st patient audit report expected July 2015 National Joint Registry Yes Trust continues to submit data 10th nati and onal report 1064 patients data submitted (62%) Annual report is reviewed at Governance meetings Medical and Surgical clinical outcome review programme: National confidential enquiry into patient outcome and death Yes Tracheostomy Study: 8/10 patients entered Lower limb Amputation Study: 8/10 patients entered (study still open so final figures not available Will be reviewed when reports available at specialty and divisional meetings - report due June 2014 Will be reviewed when reports available at specialty and divisional meetings Subarachniod haemorraghe: 2/3 patients entered Report disseminated to divisions Alcohol Related Liver Disease: 4/6 patients entered Report disseminated to divisions for information only National Comparative Audit of Blood Transfusion programme: 2 audits participated in: 2013 National Comparative Audit of the Use of Anti-D 2014 National Comparative Audit of Patient Information and Consent for Blood Transfusion Yes 93 cases submitted Data being collected currently Yes will be discussed at Hospital Transfusion committee once available Rated as excellent for data completeness Emphasis on improving timings of response and analysis of patients with timings outside of standard Partial participation 18.2% submissions further funding being sought to ensure minimum requirement of 70% submissions achieved 92% case ascertainment Plans include to review current ED Trauma documentation and to increase number of cases submitted to TARN to ensure data completeness and accreditation. Funding approved for a full-time TARN coordinator 43.9% of groin hernia respondents, 83.6% of hip replacement patients and 66.7% of knee replacement patients recorded an increase in their EQ-5D index score. Actions taken with the division: Æ Æ Monthly monitoring of patient participation and forms returns from wards. Æ Æ Weekly volunteer who visits wards to collect forms. Æ Æ Regular reports by Consultant lead to surgical division Trust performing well in relation to national average for falls assessment, admission to orthopaedic care within 4 hours, surgery within 48 hrs and pre-operative assessment by geriatrician. Actions include ongoing work to improve access to radiology to improve times to CT scan, extra training in performing swallow assessment for nurses. Also planning for introduction of DVT prevention prophylaxis in form of Intermittent Pneumatic Compression. Reports when available will be reviewed by anaesthetic and surgical divisions and actions developed as required Data is entered retrospectively. Action is taken as necessary No actions required Report expected June 2014 changes will be made as necessary after presentation to HTT and HTC

33 Statements of assurance 2.2 Statements of assurance 65 The Care Quality Commission The Care Quality Commission (CQC) is the independent regulator of health and adult social care services in England. From April 2010, all NHS Trusts have been legally obligated to register with the CQC. Registration is the licence to operate and to be registered, providers must, by law, demonstrate compliance with the regulatory requirements of the CQC (Registration) Regulations Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) is registered with the CQC without conditions. This means that our Trust has continued to demonstrate compliance with the regulations. The Care Quality Commission has reviewed our Trust once in the past year. We are aware that Healthwatch Gloucestershire also meet separately with the CQC, providing further opportunity for public and patient concerns to be shared with the regulator. The review was a responsive review, as requested by the Coroner, of paediatric and neonatal services on both hospital sites on the May The CQC concluded that the neonatal and paediatric services at Gloucestershire Royal and Cheltenham General Hospitals provided good care. They found no evidence to suggest that babies born in any of the units across both hospitals were being put at risk. The full report is available on the CQC website Our Trust now receives the Intelligent Monitoring Reports from the CQC. Any issues raised as risks in this report are reviewed as part of our governance arrangements. In the latest report published in March, we were allocated to Band 6 on the CQC's new banding scale. Band 1 represents the highest risk and Band 6 the lowest. Quality of Data Good quality data underpins the effective delivery of patient care and is essential if improvements in quality of care are to be made. The patient NHS number is the key identifier for patient records. Accurate recording of the patient s General Medical Practice Code is essential to enable the transfer of clinical information about a patient from a trust to the patient s GP. During 2013/14, Gloucestershire Hospitals NHS Foundation Trust has taken the following actions to improve data quality (DQ): all existing reports have been reviewed and revised the majority of routine DQ reports have now been automated and are routinely available to all staff on the Trust intranet via the Business Intelligence portal Analyzer (more details below) in parallel, a series of road shows has been held with operational staff to review the new-style reports and to explain actions required to complete records, rectify errors and improve DQ. An external data validation company has been engaged to advise the Trust on optimising the recording of clinical information and the capture of clinical coding data. This work is expected to improve significantly the Trust s income position for the inpatient activity it undertakes. Gloucestershire Hospitals NHS Foundation Trust submitted records during 2013/14 to the Secondary Users Service (SUS) for inclusion in the Hospital Episode Statistics which are included in the latest published data. In data published for the period April 2013 to February 2014 (the most recent currently available), the percentage of records which included a valid patient NHS number was: 99.8% for admitted patient care (national average: 99.1%) 99.9% for outpatient care (national average: 99.3%) 98.4% for accident and emergency care (national average: 95.8%) The percentage of published data which included the patient s valid GP practice code was: 100.0% for admitted patient care (national average: 99.9%) 99.9% for outpatient care (national average: 99.9%) 100% for accident and emergency care (national average: 99.1%) A comprehensive suite of data quality reports covering the Trust s main operational system (PAS) is available and acted upon. These are run on a daily, weekly and monthly basis and most are now available through the Trust s Business Intelligence system, Analyzer. These include areas such as:- outpatients including attendances, outcomes, invalid procedures inpatients including missing data such as NHS numbers, theatre episodes critical care including missing data, invalid Healthcare Resource Groups A&E including missing NHS numbers, invalid GP practice codes waiting list including duplicate entries, same day admission On a weekly basis any missing/incorrect data is highlighted to staff and added or rectified. Our Trust Data Quality Policy is published on the intranet setting out responsibilities for data quality. All Trust systems have an identified system manager with data quality as a specified duty for this role. System managers are required under the Clinical and Non- Clinical Systems Management Policy to identify data quality issues, produce data quality reports, escalate data quality issues and monitor that data quality reports are acted upon.

34 Statements of assurance 2.2 Statements of assurance 67 Table 2: 2013/14 CQUIN goals Table 2: 2013/14 CQUIN goals (cont.) Goal No. Measure Description Weighting as % of contract value Actual value of goal Quality domain Goal No. Measure Description Weighting as % of contract value Actual value of goal Quality domain Compliance with 3 Million Lives The national programme to roll out telehealth and telecare. Gateway Access to CQUIN monies Clinical Effectiveness 12 Neonatal Improvement in monitoring of screening for retinopathy of prematurity and total parental nutrition (TPN) 0.31% 416,670 Safety Intellectual property and commercialisation Clear processes in place to exploit commercial intellectual property Gateway Dementia Signposting of carers with dementia to relevant services Gateway Access to CQUIN monies Access to CQUIN monies Business development Safety 13 Access and impact of CNS support on Patient Experience To assess the impact of CNS support on the patients experience of their cancer journey & agree action plan to improve experience. 0.19% 250, Renal Avoidance, detection and management of AKI 0.19% 250,000 Patient Experience Patient Experience National CQUIN goals (including specialised element) 1 VTE 1. Risk assessment 95% 2. RCA on hospital acquired thrombosis ,800 Safety 15 Improving the proportion of IMRT with level 2 Imaging This CQUIN aims to improve the proportion of radical intensity modulated radiotherapy (IMRT) (excluding breast and brain) with level 2 imaging image guided radiotherapy (IGRT) 0.19% 250,000 Clinical Effectiveness 2 Friends and family test 3 Dementia Adult inpatient services and ED from Apr 13. Maternity from Oct 13. Improvement in staff recommendation All patients aged >75 admitted as emergency: 1. Case finding, assessment & specialist 2. Dementia clinical leadership plus staff training (new for 13/14) 3. Supporting Carers (new for 13/14) ,500 Patient Experience ,050 Safety TOTAL 8,436,047 4 Safety Thermometer Monthly surveying of all patients to collect data on 3 outcomes:1. Pressure Ulcers 2. Falls 3. UTI in patients with catheters. Indicators for GHT will be:1. Data collection plus 2. Reduction targets ,440 Safety Local CQUIN goals 5 COPD Admission Care Bundle Care bundle approach using BTS best practice guidelines for admission COPD patients ,260 Clinical Effectiveness 6 Patient experience escalator Multi - level goal on organisational responsiveness to patient experience ,260 Patient Experience 7 Sepsis management Implementation of the Sepsis 6 care bundle ,260 Safety 8 Acute kidney injury Avoidance, detection and management of AKI ,260 Safety 9 Medicines Management Related to antimicrobial stewardship and joint formulary ,200 Clinical Effectiveness 10 Supporting Clinical Change Programmes Promotion of clinical engagement and system change to deliver the QIPP programme ,801,300 Clinical Effectiveness Specialised CQUIN goals 11 Quality dashboards Completion and return of data to support national registries of clinical information 0.12% 125,010 (pending Q4 submission) Clinical Effectiveness

35 Statements of assurance 2.2 Statements of assurance 69 Table 3: 2014/15 CQUIN goals Goal No. Measure Description National CQUIN goals (including specialised element) Weighting as % of contract value Potential value of goal,000 Quality domain Information Governance The Trust s Information Governance Assessment Report score for 2013/14 remains 77% for the third consecutive year and is graded green. trauma and orthpoaedics: trauma procedures. The results should not be extrapolated further than the actual sample audited. 1 NHS Safety Thermometer Pressure ulcers management including reduction in incidence ,630 Safety 2 Friends and family test Subject to negotiation ,630 3 Dementia Local CQUIN goals COPD Admission Care Bundle Patient and staff experience Improving patient flow and discharge Specialised CQUIN goals 11 Quality dashboards All patients aged >75 admitted as emergency: 1. Case finding, assessment & specialist 2. Dementia clinical leadership plus staff training (new for 13/14) 3. Supporting Carers Care bundle approach using BTS best practice guidelines for admission COPD patients Multi - level goal on organisational responsiveness to patient and staff experience Range of initiatives predominantly addressing the emergency care pathway, including: audit of compliance with the implementation of choice policy, and caring for patients in their last days of life Continue from 12/13. Completion and return of data to support national registries of clinical information Patient Experience ,630 Safety , , , Hepatitis To ensure use of MDTs is optimised for best patient care Cancer patient experience 14 Neonatal 15 Specialised Orthopaedics (Adults) Network Development: regional audit and governance, regional MDT for complex cases To improve experience of patients in response to real-time surveys Timely administration of total parenteral nutrition (TPN) for preterm infants To ensure that complex orthopaedic cases are reviewed and included as part of an orthopaedic network Clinical Effectiveness Patient Experience Patient Experience & Safety Clinical Effectiveness Clinical Effectiveness Clinical Effectiveness Clinical Effectiveness Clinical Effectiveness The Information Governance Toolkit is available on the Health and Social Care Information Centre website igt.hscic.gov.uk. The information quality and records management attainment levels assessed within the Information Governance Toolkit provide an overall measure of the quality of data systems, standards and processes within an organisation. The effectiveness and capacity of these systems is routinely monitored by our Trust's Information Governance and Health Records Committee. A performance summary is presented to our Trust Board annually in March. Clinical Coding Error Rate Clinical coding translates the medical terminology written by clinicians to describe a patient s diagnosis and treatment into standard, recognised codes. The accuracy of this coding is a fundamental indicator of the accuracy of the patient records. Our Trust was subject to an audit of clinical coding accuracy during the reporting period in October 2013 under the auspices of the Audit Commission s Payment by Results Data Assurance Framework. This was based on a sample audit of 200 inpatient episodes: The error rates for diagnosis and treatment coding for 2013/14 were (2012/13 figures in brackets): primary diagnosis incorrect 11.3% (11.8%) secondary diagnosis incorrect 11.5% (25.5%) primary procedures incorrect 17.3% (12.5%) secondary procedures incorrect 30.6% (22.8%) These errors meant that 6.4% of the spells audited attracted an incorrect HRG which affected the income received by our Trust and paid by its commissioners. The net impact was that we over-charged commissioners by 4,900 on a total bill of more than 100million (compared to a net over-charge of 2,900 in 2012/13). The Audit Commission made two recommendations which our Trust will have fully actioned by Summer paediatric medicine: complications and co-morbidities

36 Statements of assurance 2.2 Statements of assurance 71 A review of our quality performance Since 2012/13 NHS foundation trusts have been required to report performance against a core set of indicators using data made available to the trust by the Health and Social Care Information Centre (HSCIC). 2.3 Reporting against core indicators Monitor, the Foundation Trust regulator, produces guidance each year for the Quality Account, outlining which performance indicators should be published in the annual document. This year we have been required to publish data from the HSCIC only for at least two reporting periods. Please note that the information shared is restricted to data available in the HSCIC. For this reason some of the data for 2013/14 is either incomplete or unavailable. You can see our performance against these mandated indicators in Table 4 on p72.

37 Statements of assurance 2.2 Statements of assurance 73 Table 4: Reporting against core indicators Indicator (required by NHS England) Year GHNHSFT National average Highest trust figure Lowest trust figure Explanation of why GHNHSFT considers that this data from the HSCIC is as described (a) SHMI for the trust for the reporting period; and 2011/ / /14 (Oct12-Sep13) This indicator cannot be calculated locally due to the requirement for standardisation at national level. GHNHSFT monitors crude mortality using its own data. The banding for all years is 'as expected'. (b) The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period. 2013/14 (Oct12-Sep13) 19.6% 20.9% 44.9% 0.0% 2011/12 17% 17.9% 44.2% 0.0% This indicator cannot be calculated locally as it uses the same national dataset 2012/ % 19.9% 44.0% 0.1% as SHMI which includes ONS data on post-hospital deaths. A proxy using inhospital data only can be calculated but this is not currently routinely reported Rate of patient safety incidents per 100 admissions 2011/ / /14 (Apr13-Sep13) National, highest and lowest rates are drawn from large acute trusts group only for trusts with a full year of data in that cluster (source: NPSA website) Rate per 100 admissions of patient safety incidents resulting in severe harm or death 2011/ / /14 (Apr13-Sep13) Rates derived from locally collated and submitted data. Source: NPSA website. National indicator values may differ slightly from locally-calculated values due to small variations in assumptions for denominator Rate of C diff (per 100,000 bed days) among patients aged over two 2011/ / /14 N/A N/A N/A N/A We do not routinely calculate this rate indicator, however the number of cases for the year is consistent with the figures we report internally. Bed day numbers in both years are approx 2% higher than our own internal figures but this does not affect the rate value calculated Percentage of patients risk assessed for VTE 2011/ % 89.0% 100% 40.5% 2012/ % 93.8% 100% 86.9% 2013/14 (Apr13-Feb14) 94.6% 95.4% 100% 81.6% Source: NHS England VTE Risk Assessment Statistical Work Area. National dataset compiled from monthly local data submissions. National indicator values may differ slightly from locally calculated values due to small variations in assumptions for denominator The percentage of patients aged 0-15 readmitted to hospital within 28 days of being discharged 2011/ % 9.88% 14.94% 6.4% 2012/13 N/A N/A N/A N/A 2013/14 N/A N/A N/A N/A Figure for GHNHSFT is unstandardised. No standardised figure calculated for the national total. Other figures are standardised. This indicator is no longer reported locally. The preferred national and local indicator is now readmissions within 30 days which is broadly consistent with this indicator Readmissions within 28 days: age 16 or over 2011/ % 10.52% 13.80% 9.34% 2012/13 N/A N/A N/A N/A 2013/14 N/A N/A N/A N/A No national data has been published since 2011/12. This indicator is no longer reported locally. The preferred national and local indicator is now readmissions within 30 days which is broadly consistent with this indicator 2011/ % 75.6% 87.8% 67.4% Responsiveness to inpatients' personal needs 2012/ % 76.5% 88.2% 68.0% 2013/ % 76.9% 87.0% 67.1% Data is taken from NHS England's Statistical Work Areas - Patient Experience. This is a national dataset collated from local patient surveys Friends & Family Test Q12d (If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation) 2011/12 N/A N/A N/A N/A 2012/13 N/A N/A N/A N/A 2013/ % 66.2% 93.9% 39.6% Data is taken from the National Staff Survey 2013 which is administered and analysed by a third party. Friends & Family Test - Patient (inpatients and those discharged from ED)Net Promoter Score 2011/12 N/A N/A N/A N/A 2012/13 N/A N/A N/A N/A 2013/ Source: NHS England Statistical Wrok Areas. This data is consistent with local data produced from collated Friends & Family Test returns Actions GHNHSFT intends to take to improve the indicator and quality of services This data is as expected range compared with other trusts. We have established a Trust Mortality Review Group, chaired by the Medical Director, which reviews this indicator and another of other more granular parameters in relation to motality. We also use the Dr Foster Intelligence System to monitor mortality indicators. This places us close to the national average and we do not regard ourselves to be significantly different from it. This data is within the expected range compared with other trusts. The Trust will continue to encourage reporting of patient safety incidents and carry out root cause analysis investigations for significant patient safety incidents. This data is within the expected range compared with other trusts. The Trust will continue to encourage reporting of patient safety incidents and carry out root cause analysis investigations for significant patient safety incidents We will continue to monitor key processes and target areas that requirement improvement GHNHSFT intends to take the following actions to improve this percentage and so the quality of its services, by targeting individual areas where performance isn't meeting the required standard. See p18 for more information We have be working on a range of initiatives to improve our performance against this indicator and see p21 We have be working on a range of initiatives to improve our performance against this indicator and see p21 We were pleased to note that our score against 'Were you given enough privacy when discussing your condition or treatment?' was in the top 20% of trusts. Scores were lower this year in two questions relating to communications ('Did a member of staff tell you about medication side effects to watch for when you went home?' and 'Did hospital staff tell you who to contact if you were worried about your condition after you left hospital?'). These are being addressed in a wider action plan in response to the wider National Inpatient Survey. In 2014/15 we will be giving staff the opportunity to answer this question on a quarterly basis. An action plan is being developed as part of the wider response to the Staff Survey. GHNHSFT intends to take the following actions to improve this score and so the quality of its services, by: this is considered to be a high score so we will be focussing on maintaining this and increasing response rates during 2014/15

38 Statements of assurance 2.2 Statements of assurance 75 Table 5: Patient Reported Outcome Measures April 2011 March 2012 (final, published October ) EQ-5D EQ VAS Condition-specific Measure Procedure Trust % England % Trust % England % Trust % England % Groin Hip Knee Varicose Veins April 2012 March 2013 (provisional, February 2014 release) EQ-5D EQ VAS Condition-specific Measure Procedure Trust % England % Trust % England % Trust % England % Next section: Other information Groin Hip Knee Varicose Veins April September 2013 (provisional, published February ) EQ-5D EQ VAS Condition-specific Measure Procedure Trust % England % Trust % England % Trust % England % Groin Hip Knee Varicose Veins Too Few 52.2 Too Few 39.9 Too Few 85.3 No condition-specific measure for groin surgery Where numbers of cases are small, data is not published at Trust level to preserve patient confidentiality. These are shown as 'Too few'

39 76 3 Other information 3 Other information 77 Other information on the quality of our services The following section presents more information relating to the quality of the services we provide. In Table 6 on p78 are a number of performance indicators which we have chosen to publish which are all reported to our Quality Committee. 3 Other information The majority of these have been reported in previous Quality Account documents. These measures have been chosen because we believe the data from which they are sourced is reliable and they represent the key indicators of safety, clinical effectiveness and patient experience within our organisation.

40 78 3 Other information 3 Other information 79 Table 6: Other indicators we've chosen to report Indicators 2012/ /14 National target for 13/14 Indicators 2012/ /14 National target for 13/14 Safety Patient Experience Clostridium difficile year on year reduction: post 48 hrs 67 60* 52 MRSA bacteraemia at less than half the 2003/4 level: post 48 hrs 2 1* 6 MSSA* 25 17* N/A Implementation of sepsis 6 bundle 90% of patients in ED with severe sepsis receive 100% of the sepsis six bundle 83.3% 96.6%** N/A Implementation of sepsis 6 bundle 80% of patients in the hospital will receive 100% of the sepsis six bundle 70%*** 83%** N/A Rate of Inpatient Falls per 1000 bed days 5.4 5* N/A Rate of Medication Incidents per 1000 bed days * N/A COPD care bundle compliance N/A 59%** N/A Never events 2 3* 0 Hand washing compliance 98% 97%* N/A Number of RIDDOR 39 30* N/A Rate of Staff Falls per 1000 head count * N/A Rate of Incidents arising from Clinical sharps per 1000 staff * N/A Rate of physically violent and aggressive incidents occurring per 1000 staff * N/A Number of written complaints * N/A Rate of written complaints per 1000 episodes of care * N/A Number of comments on NHS Choices: Positive / Negative N/A 60 / 27 # N/A Number of comments Patient Opinion: Positive / Negative N/A 17 / 5 # N/A Max 2 week wait for patients urgently referred by GP 92% 93.9%* 93% Max 2 week wait for patients referred with non cancer breast symptoms 96.2% 88.7%* 93% Max wait 31 days decision to treat to treatment 99.7% 99.7%* 96% Max wait 31 days decision to treat to subsequent treatment : surgery 99.8% 100%* 94% Max wait 31 days decision to treat to subsequent treatment: drugs 100% 100%* 98% Max wait 31 days decision to treat to subsequent treatment: Radiotherapy 99.9% 99.9%* 94% Max wait 62 days from urgent GP referral to 1 st treatment (exl. rare cancers) 84.9% 81.0%* 85% Max wait 62 days from national screening programme to 1 st treatment 96.1% 96%* 90% Max wait 62 days from consultant upgrade to 1 st treatment 90% 88.9%* 90% Effectiveness Dementia 1a: Case Finding 90% of eligible patients aged 75 years and over, as emergency admissions, asked the case finding question 26.6% 80.7%* 90% 18 week maximum wait from point of referral to treatment (admitted patients adjusted) 92.4% 92.3%* 90% 18 week maximum wait from point of referral to treatment (non-admitted patients unadjusted) 97.8% 97.3%* 95% Dementia 1b: Clinical Assessment 90% of eligible patients aged 75 years and over, as emergency admissions will receive clinical assessment of their reported memory loss Dementia 1c: Referral for Management 90% of eligible patients aged 75 years and over, as emergency admissions, who score positively on the Abbreviated Mental Test (a test used to assess dementia), and where concerns over memory function remain will be referred onwards 96.2% 100%* 90% 58.6% 86.3%* 90% % patients spending 4 hours or less in ED 94.7% 93.8%* 95% Number of ambulance handovers delayed over 30 minutes * Reduction on 12/13 * April 2013 March 2014 data ** Quarter 4 average *** March 2013 data Data to February Figures are updated on a rolling two month basis # August 2013 March 2014 The methodology for reporting this indicator was amended at the end of December 2013 in line with recommendations from the NHS Intensive Support Team. This indicator has been selected by governors for review as part of the external assurance of our report. Number of ambulance handovers delayed over 60 minutes * Emergency readmissions within 30 days elective & emergency 5.9% 6.0%* Reduction on 12/13 Reduction on 12/13 Research Accruals * 1100 Comparison of median time (months) to complete local governance checks % stroke patients spending 90% of time on stroke ward 78.8% 82.8%* 80% % women seen by midwife by 12 weeks 85.7% 88.7%* 90%

41 80 Annex 1 Statements from stakeholder organisations Annex 1 Statements from stakeholder organisations 81 Statement from Gloucestershire Clinical Commissioning Group Annex 1 Statements from stakeholder organisations Gloucestershire Clinical Commissioning Group (CCG) has taken the opportunity to review the Quality Account prepared by Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) for 2013/14. We are very pleased that GHNSHFT have worked alongside the CCG during 2013/14 to maintain and further improve the quality of commissioned services. As the 2013/14 Quality Account clearly demonstrates GHNHSFT has been open and transparent regarding challenges and concerns and the CCG would like to acknowledge this transparency. GHNHSFT have been supportive of and engaged with the joint development of the Clinical Programme Groups with the CCG which aims to achieve the best possible outcomes and value for the population and patients given the resources we have available. They have demonstrated further improvement of the safety, effectiveness and patient experience of services across a wide range of specialties, with particular progress made in the assessment and care of patients with Chronic Obstructive Pulmonary Disease (COPD), and building on previous years progress in acute kidney injury (AKI) and sepsis. GHNHSFT are also to be congratulated on their performance in the early diagnosis of patients with dementia and the achievement of 100% follow up investigation and specialist referral. The CCG very much welcome GHNHSFT's strong focus on patient experience and quality of care, which demonstrates a joint commitment to delivering high quality compassionate care. The CCG welcome the use of staff and patient stories to promote and inform learning and the emphasis on care and compassion in practice. There are robust arrangements in place with GHNHSFT to agree, monitor and review the quality of its services. The Clinical Quality Review Group meets on a quarterly basis and brings together GPs, senior clinicians and managers from both GHNHSFT and Gloucestershire CCG. We have received assurance throughout the year from GHNHSFT in relation to key quality issues, both where quality and safety has improved and where it occasionally fell below expectations with remedial plans put in place and learning shared wherever possible. The CCG note that the ED (Emergency Department) 4-hour target has been challenging during 2013/14 and has not been consistently achieved over the year. The CCG will work with GHNHSFT to address the challenge for the year ahead to improve the flow of patients through the hospitals to support the 4-hour target and this is reflected in the 2014/15 CQUIN (Commissioning for Quality and Innovation) schedule. Another challenging area has been the achievement of the cancer target of maximum weight of 62 days from urgent GP referral to 1st treatment (excluding rare cancers), with a year-end performance of 80.7% against a threshold of 85%. The CCG have worked with GHNHSFT to ensure actions have been taken to address capacity issues within certain specialties and work has also been undertaken to review patient pathways. This work will remain a priority during 2014/15. The priorities for 2014/15 have been developed in partnership, and the quality priorities identified demonstrate a high level of engagement between the CCG and GHNHSFT. Gloucestershire CCG is very pleased with

42 82 Annex 1 Statements from stakeholder organisations Annex 1 Statements from stakeholder organisations 83 the approach taken by GHNHSFT, which is reflected in the Quality Account, to persist with and reinforce the values of honesty, transparency and effective engagement with stakeholders. Upholding these values ensures that the population of Gloucestershire will maintain trust and confidence in these core NHS services. GHNHSFT are in a strong position to manage both present and future challenges, and to work with Gloucestershire CCG to deliver best value effective care for the people of Gloucestershire. Gloucestershire CCG fully endorse the proposals set out in the Quality Account. Gloucestershire CCG can confirm to the best of our knowledge that we consider that the Quality Account contains accurate information in relation to the quality of services that Gloucestershire Hospitals NHS Foundation Trust provides. During 2014/15 the CCG would like to work with GHNHSFT, GPs and the population of Gloucestershire to further develop ways of receiving the most comprehensive reassurance we can regarding the quality of the system provided to the residents of Gloucestershire and beyond. Marion Andrews-Evans Executive Nurse & Quality Lead, Gloucestershire CCG Statement from Healthwatch Gloucestershire (HWG) HWG is pleased to have had the opportunity to comment on this Quality Account and can confirm that early, comprehensive drafts have been shared with us, so that there has been a meaningful opportunity to make a contribution to the document. The Trust has received detailed comments about the content and presentation of a draft account and made several drafting changes to accommodate comments from us. We would like to make comments across three headings: general and contextual; priorities and performance in 2012/13; and priorities for 2013/14. General comments Healthwatch Gloucestershire is a new organisation, which has worked since April 2013 to gather and represent the views of people who live in Gloucestershire about their health and social care, and then to communicate them to those organisations that provide services, in this case the Hospitals Trust. Our contribution to this Quality Account is one of several ways in which we work with the Trust to provide independent, regular and continuous feedback from the public. We have been encouraged during 2013/14 by the ways in which the Trust has worked with HWG, and the willingness it has shown to encourage visits to the Trust; to receive comments from the public; and to involve us in the development of its clinical, quality and patient experience strategies. We look forward to deepening those connections during 2014/15 and beyond so that the Trust s performance continues to be genuinely informed by real patient experience. The Quality Account includes information in a variety of styles and from various perspectives. We welcome efforts to make what is complex information as readable as possible. The inclusion of patient and staff stories and reflection is interesting and makes the Account more readable. We would urge the Trust to be aware of readers who may not be familiar with the complex language that is used, or of how the wider health system is currently structured. Perhaps it would be possible to derive some core messages from the Account for various audiences? Priorities and Performance in 2013/14 Emergency Care Pathway There has been considerable public interest in this area in 2013/14. There is evidence of much work to strengthen the system and improve efficiency where feasible. The 4-hour wait aggregated position and the differential rates of performance between the two hospital sites, in particular, are of concern for their impacts upon patients. We welcomed the opportunity to participate in the review of emergency services that was conducted in the year and to contribute patients feedback to the process. There is much evidence here of crosssystem working to improve performance (eg

43 84 Annex 1 Statements from stakeholder organisations Annex 1 Statements from stakeholder organisations 85 virtual wards). From the public s perspective it would be good to show performance expectations as to how each of these initiatives is planned to have an impact on the ED performance and, hence, upon the patients experience of the emergency pathway. Management of patient with sepsis The evident progress on this complex project with far-reaching implications is welcome. Safety Thermometer In areas where performance appears to not yet be meeting the targets that have been set, it would be helpful if the Trust could be explicit as to its expectations as to when it plans to do so, or where it is may not be feasible to do so. Pressure ulcers VTE assessments Diagnosis and care for patients with dementia This area continues to be of particular interest to the public and to HWG. We welcome the priority that is attached to the involvement of families and other carers in the development of these services and in the value placed upon the contribution of Dementia champions. While performance does seem to be improving in some aspects, it is disappointing that all the performance targets do not yet seem to be within reach. It is important that an indication is provided of when the current level of investment and organisation development will translate into achievement of the assessment target. Supporting Clinical Programmes HWG welcomes the evidence that pathways are being actively considered in a comprehensive way that provides opportunities for patient and public involvement. We would reiterate the value and importance of ensuring that patient experience of current pathways is reflected in the work of these groups and the formulation of improvement plans. Friends and Family Test We understand that there is a high priority attached to the test becoming more widely used and embedded and that is has considerable value as a source of information. It should be acknowledged that it provides one source and type of feedback, but has risks where it is perceived by patients as being an end in itself. We know that the Trust has a variety of mechanisms available to it for obtaining information about how patients feel about the care that they have received. Often, feedback can include both compliments and criticism. It will be important for the Trust to continue to develop a wide range of mechanisms that are sensitive to the variety of ways in which people want to describe their experience. Priorities for 2014/15 We were asked by the Trust to identify those specific priorities that have emerged from the various contacts that we have had throughout the year with people who use the hospitals, their carers, and with voluntary and community organisations. These conversations provide really valuable information about what is working well and what needs to be improved. We have highlighted four areas, which the Trust has included in its priorities for 2014/15. Improving Patient Flow We receive much feedback from people who experience problems when they leave hospital when they are discharged home or to another setting eg a community hospital or care home. We know that this has been brought to the Trust s attention before and it will continue to be a challenge that is not entirely within its control. (Our predecessor organisation, LINk, produced an independent report about the processes for discharging people from hospitals.) We welcome the fact that the Trust will examine all aspects of a patient s experience as they move into, through, and out of its care. HWG will undertake an independent piece of research this year to examine various discharge processes and looks forward to using this work to inform the Trust s improvements. Delivering Compassionate Care We recognise that this is a cornerstone of safe and effective care and we welcome the range of initiatives that the Trust is taking to strengthen its performance in terms of communication, culture and staff training and development in this area. Communication whether it be face-to-face or written - continues to feature prominently in patient feedback to HWG. We look forward to seeing how these projects impact upon patient and staff surveys and upon the comments that we gather independently. Patient stories about their experience are a valuable source of learning in this area. We welcome the way in which this Quality Account includes some personal accounts, which is evidence of a willingness to learn from critical patient feedback as well as celebrating achievements. Cancer Wait Times This was an area that was the subject of a significant number of our comments from the public in 2013/14 to which the Trust has responded positively. Patients have described being frustrated by the length of time they have to wait once they arrive for their appointments, and when appointments are rescheduled. There has also been criticism about the environment in which care takes place. Set alongside such feedback we have also received comments about the excellence of the care that has been received and the dedication and compassion shown by nursing staff. Our feedback has been accepted by the Trust and we welcome the prominence that the project to improve the timeliness of appointments is being given in 2014/15. We will continue to ensure that the Trust is made aware of all feedback that we receive about this subject. Involving Patients in Service Improvements We welcome the Trust and Clinical Commissioning Group s public confirmations of the value they attach to patients being involved in service improvement. This can happen in several ways. We know of lay patient involvement in the Clinical Programme Groups that are examining pathways of care at the strategic level and there is patient and public participation in a number of the Trust s more operational groups about patient experience and safety. We would also like the Trust to continue to develop innovative ways to include patients in some of its administrative processes eg how it communicates with patients in its letters and by telephone and in its various leaflets. Patients are clearly best-placed to describe how some of these systems feel and when they do not work well, especially when people cross between one system and another eg from the Hospital Trust to GP and community services. Claire Feehily Chair of Healthwatch Gloucestershire

44 86 Annex 1 Statements from stakeholder organisations Annex 1 Statements from stakeholder organisations 87 Statement from Gloucestershire Health and Care Overview and Scrutiny Committee On behalf of the Health and Care Overview and Scrutiny Committee I welcome the opportunity to comment on the Gloucestershire Hospitals NHS Foundation Trust Quality Account 2013/14. As a newly elected county councillor and newly appointed Chairman of the (new) Health and Care Overview and Scrutiny Committee (HCOSC) I have valued the attendance of the Trust at committee meetings to contribute to debate and respond to members questions. During the course of this year the committee has developed a constructive and robust working relationship with the Trust and I hope that this will continue. I would particularly like to thank Professor Clair Chilvers, Dr Frank Harsent and Dr Sally Pearson for attending meetings and responding to members many questions. The HCOSC commenced work by considering the proposed service changes relating to emergency and urgent medical care; medical specialties Gastroenterology & Hepatology, cardiology and respiratory (or thoracic medicine); and paediatric day cases. The committee supported these proposals, although it is important to note that the emergency and urgent care service change was not supported by all committee members. The committee has been closely monitoring the impact of this service change and received a six month review at its meeting on 4 March 2014; and is due to receive the twelve month review in September I would like to thank Dr Tom Llewellyn for attending the committee to discuss and respond to members many questions on this issue. I would also like to thank Dr Llewellyn, and the Hospitals Trust, for hosting member visits to the Emergency Departments at the Acute Hospitals to enable members to see the emergency care pathway first hand. Feedback from patients is a valuable way of understanding how services can be improved. I therefore welcome the Trust s work to implement the Family and Friend Test (FFT), and the innovative approaches taken in wards and the Emergency Department to encourage patients to engage with this matter. However I do have to question whether the FFT gives sufficient information on how patients feel about the actual service they received. I am aware that the FFT is a national requirement, but I would ask that the Trust consider how it can add to the FFT in order to gain more information on how people feel about the services it delivers, as a driver for service improvement. I am disappointed to see that there has been an increase in the number of physical assaults on staff and welcome the initiatives which aim to reduce these assaults on staff. It is important that the Hospitals are safe environments for both staff and patients. For the committee the important aspect is the patient journey which is why we asked for all aspects of the patient experience to be marked as a priority. I particularly welcome the commitment to delivering compassionate care; but would also welcome information on how the Trust will measure whether it is achieving this aim. Cllr Steve Lydon Chairman Independent Auditor s Limited Assurance Report to the Council of Governors of Gloucestershire Hospitals NHS Foundation Trust on the Quality Report We have been engaged by the Council of Governors of Gloucestershire Hospital NHS Foundation Trust to perform an independent limited assurance engagement in respect of Gloucestershire Hospitals NHS Foundation Trust s Quality Report for the year ended 31 March 2014 (the Quality Report ) and certain performance indicators contained therein. Scope and subject matter The indicators for the year ended 31 March 2014 subject to limited assurance consist of those national priority indicators mandated by Monitor: Number of Clostridium difficile (C.difficile) infections for patients aged two or over on the date the specimen was taken (page 78 of the Quality Report) Percentage of patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer (page 79 of the Quality Report) We refer to these national priority indicators collectively as the indicators. Respective responsibilities of the Directors and Auditors The Directors are responsible for the content and the preparation of the Quality Report in accordance with the criteria set out in the NHS Foundation Trust Annual Reporting Manual issued by Monitor. Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: The Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual; The Quality Report is not consistent in all material aspects with the sources specified in Monitor s 2013/14 Detailed Guidance for External Assurance on Quality Reports; and The indicators in the Quality Report identified as having been the subject of limited assurance in the Quality Report are not reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and the six dimensions of data quality set out in the Detailed Guidance for External Assurance on Quality Reports. We read the Quality Report and consider whether it addresses the content requirements of the NHS Foundation Trust Reporting Manual, and consider the implications for our report if we become aware of any material omissions. We read the other information contained in the Quality Report and consider whether it is materially inconsistent with: Board minutes for the period April 2013 to April 2014; Papers relating to quality reported to the Board over the period April 2013 to April 2014

45 88 Annex 1 Statements from stakeholder organisations Annex 1 Statements from stakeholder organisations 89 Feedback from Gloucestershire CCG dated 13 May 2014; Feedback from local Healthwatch organisations dated 12 May 2014; The Trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009 dated May 2014; The national patient survey dated March 2014 The national staff survey dated March 2014 The Head of Internal Audit s annual opinion over the trust s control environment dated May 2014 and Care Quality Commission Intelligent Monitoring Report dated 17 March We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively the documents ). Our responsibilities do not extend to any other information. We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts. Council of Governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body and Gloucestershire Hospitals NHS Foundation Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing. Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (revised) Assurance Engagements other than Audits or Reviews of Historical Financial Information issued by the International Auditing and Assurance Standards Board ( ISAE 3000 ). Our limited assurance procedures included: Evaluating the design and implementation of the key processes and controls for managing and reporting the indicators Making enquiries of management Testing key management controls Limited testing, on a selective basis, of the data used to calculate the indicators back to supporting documentation engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Report in the context of the criteria set out in the NHS Foundation Trust Annual Reporting Manual. The scope of our assurance work has not included governance over quality or nonmandated indicators which have been determined locally by Gloucestershire Hospitals NHS Foundation Trust. criteria set out in the NHS Foundation Trust Annual Reporting Manual; The Quality Report is not consistent in all material respects with the sources specified above, and The indicators in the Quality Report subject to limited assurance have not been reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual Grant Thornton UK LLP Victoria Street, Bristol, BS1 6FT 23 May 2014 This report, including the conclusion, has been prepared solely for the Council of Governors of Gloucestershire Hospitals NHS Foundation Trust as a body, to assist the Council of Governors in reporting Gloucestershire Hospitals NHS Foundation Trust s quality agenda, performance and activities. We permit the disclosure of this report within the Trust s Annual Report to the year ended 31 March 2014, to enable the Comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to the categories reported in the Quality Report Reading the documents A limited assurance engagement is smaller in scope than a reasonable assurance Conclusion Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2014: The Quality Report is not prepared in all material respects in line with the

46 90 Annex 2 Statement of Directors' responsibilities Annex 2 Statement of Directors' responsibilities 91 Statement of directors' responsibilities for the Quality Account Annex 2 Statements of Directors' responsibilities The directors are required under the Health Act 2009 and the National Health Service Quality Accounts Regulations to prepare quality accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support data quality for the preparation of the quality report. In preparing the quality report, directors are required to take steps to satisfy themselves that: the content of the quality report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2013/14 the content of the quality report is not inconsistent with internal and external sources of information including: board minutes and papers for the period April 2013 to April 2014 papers relating to quality reported to the Board over the period April 2013 to April 2014 feedback from commissioners dated 13/05/14 feedback from governors dated 17/01/14 feedback from local Healthwatch organisations dated 12/05/14 the trust's complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated May Patient Survey March National Staff Survey March 2014 the head of internal audit's annual opinion over the trust's control environment dated May 2014 CQC Intelligent Monitoring Report 17/03/14 the quality report presents a balanced picture of the NHS foundation trust's performance over the period covered the performance information in the quality report is reliable and accurate there are proper internal controls over the collection and reporting of the measures of performance included in the quality report, and these controls are subject to review to confirm that they are working effectively in practice the data underpinning the measures of performance in the quality report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review and; the quality report has been prepared in accordance with Monitor's annual reporting guidance (which incorporates the Quality Accounts Regulations) as well as the standards to support data quality for the preparation of the quality report. The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the quality report. By order of the Board: Dr Frank Harsent Chief Executive Gloucestershire Hospitals NHS Foundation Trust May 2014 Clair Chilvers Chair Gloucestershire Hospitals NHS Foundation Trust May 2014

47 92 Glossary Glossary 93 Abbey Pain Score Academic Health Science Networks The Pain Scale is an instrument designed to assist in the assessment of pain in patients who are unable to clearly articulate their needs Academic Health Science Networks are new partnerships responsible for driving improvements in patient care by sharing innovations across the NHS. Their creation was announced in December 2011 in the Government s Innovation, Health and Wealth report as a way to align education, clinical research, informatics, innovation, training, education and healthcare delivery at a local level. C. Difficile Clostridium difficile, also known as CDF/cdf, or C. diff, is a species of Gram-positive sporeforming bacteria that is best known for causing antibiotic-associated diarrhea Care bundle A care bundle is a set of clinical interventions that, when used together, significantly improve patient care. CGH Cheltenham General Hospital Commissioners From April 1, 2013, our commissioners became the Gloucestershire Clinical Commissioning Group. Commissioning is the process of assessing the needs of a local population and putting in place services to meet those needs. Commissioners are those who do this and who agree service level agreements with service providers for a range of services. COPD Chronic obstructive pulmonary disease is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. CQUIN This stands for the Commissioning for Quality and Innovation payment framework. The motivation behind CQUINs is to reward excellent performance by linking a proportion of providers' income to the achievement of local quality improvement goals. Glossary of abbreviations and terms DVT Emergency Department GHNHSFT Healthwatch Gloucestershire Governors Deep Vein Thrombosis. This is the formation of a blood clot (thrombus) in a deep vein, predominantly in the legs Otherwise known as A&E Gloucestershire Hospitals NHS Foundation Trust Healthwatch was established in April 2013 and is the new consumer champion of the health and social care in England, giving children, young people and adults a powerful voice Members can become more involved by standing for election as a governor and representing their fellow members views on the Council of Governors. Governors play an important role in the governance of the Trust. They represent the views of patients, carers and patients. GRH Gloucestershire Royal Hospital HCAI Health Care Associated Inefections - such as Clostridium difficile or MRSA HCOSC Gloucestershire Health and Care Overview and Scrutiny Committee. This is a body which scrutinises the decisions of local health organisations HRG Health Resource Groups. These are derived by a complex algorithm from diagnosis and procedure codes assigned to a patient's stay in hospital plus some simple demographic data (age, sex) to produce a large set of codes which group together treatments with similar resource consumption IP Intellectual Property. This refers to something you create that is unique and includes copyright, patents, designs and trade marks and can be something you invent, a product's design or appearance, a brand or logo, written work, artistic work, film recordings or musical compositions or computer software. Members As an NHS Foundation Trust we are accountable to our local community. This means we give greater say in how we re run to local people, staff and all those who use our services including patients, their families and carers. Each foundation trust must recruit members to reflect these groups and help us ensure that we are providing the best service we can. MRSA Methicillin-Resistant Staphylococcus Aureus. This is a type of bacterial infection that is resistant to a number of widely used antibiotics. This means it can be more difficult to treat than other bacterial infections.

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