Annual Report 2010/11

Transcription

1 Annual Report 2010/11

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3 Papworth Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Presented to Parliament pursuant to Schedule 7, paragraph 25(4) of the National Health Service Act 2006.

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5 Contents Page Annual Report Chairman s Statement 4 Directors Report 6 NHS Foundation Trust Code of Governance 38 Board of Governors 42 Foundation Trust Membership 51 Board of Directors 54 Audit Committee 61 Remuneration Report 64 Other Public Interest Disclosures 70 Staff Survey Report 72 Sustainability Report 76 Equality Reporting 82 Quality Report Part 1 2 Part 2 3 Part 3 16 Annual Accounts Statement of the Chief Executive s responsibilities as the Accounting Officer 1 Statement on internal control 2 Independent Auditor s Report 7 Papworth Hospital NHS Foundation Trust - Annual Report 2010/11 This report is based on guidelines issued by the Independent Regulator of NHS Foundation Trusts and was approved by the Board of Directors on the 2 June

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7 Chairman s Statement The experience that patients have when they are at Papworth Hospital matters, not only to the individual and their family but it is extremely important to everyone who works here, and this year we have built on the work already undertaken by a range of staff to understand better not just the wider patient experience, but also how patients regard the outcomes of their treatment. We have also examined the experience of patients who undergo Coronary Artery Bypass Grafts (CABGs) at Papworth and results show 84% of patients reported that their outcome following surgery was either excellent or good. The Patient Reported Outcome Measures (PROMs), a measurement tool, shows 63% of those asked identified a significant increase in better health, including reduction in patients experiencing chest pain and reduction in breathlessness. I am pleased to report that patients have once again placed Papworth Hospital in the highest scoring 20% of Trusts in England. They rated the hospital in the highest scoring 20% of trusts in 50 out of 61 questions according to the Care Quality Commission s (CQC) comparison with 161 other Trusts. This eighth national survey of adult inpatients showed that for questions about doctors Papworth Hospital scored 9 out of 10 and for questions about nurses scored 8.8 out of 10. You will read in the pages of this report the various clinical developments that have taken place this year, including the development of a new subcutaneous implantable cardioverter defibrillator (S-ICD) for people at risk of sudden cardiac death; an important development in the diagnosis and staging of lung cancer; and the announcement of a new pilot lung cancer screening programme. In addition to this, we reported our best year yet for outcomes of cardiac surgery. The results showed survival after cardiac surgery at Papworth Hospital in 2010 had been the best that the hospital has ever achieved despite treating older and sicker patients than the national average. Survival for all operations, including complex, repeat, multiple and emergency operations, was 97.7% and survival for non-emergency operations was 98.3%. 2010/11 was a year in which great progress was made in relation to the project for relocating Papworth Hospital NHS Foundation Trust to the Cambridge Biomedical Campus. Following an advertisement placed in the Official Journal of the European Union there was substantial market interest in the project and over 120 people attended an event which outlined the project to prospective bidders. From the six consortia which expressed their interest in working with us to develop the new hospital, three were shortlisted. Our project team and a range of staff from across the hospital have worked with the three consortia to develop interim bid submissions. Once these interim bid submissions are received and evaluated two of the consortia will be invited to proceed to the next stage of the process. Papworth Hospital NHS Foundation Trust Annual Report 2010/11-4 -

8 Papworth Hospital was once again shown to be a good place to work; our staff are our greatest asset and I am delighted that the hospital was named as a top healthcare employer in Healthcare 100 Awards supported by the Health Service Journal. Papworth was also the first NHS hospital to receive the joint Investors in People and NHS Health & Wellbeing Award. Papworth staff this year assisted the national effort in relation to H1N1 by providing an Extra-Corporeal Membrane Oxygenation (ECMO) service. As a specialist cardiothoracic hospital and, transplant and pulmonary endarterectomy (PEA) centre, Papworth has a long experience of providing specialist ECMO services. Over the winter months we worked with other hospitals commissioned by the National Specialised Commissioning Team to provide respiratory ECMO services to patients with H1N1. We were delighted to welcome more than 150 members to our Annual Members Meeting and Insight event on 9th September at the Burgess Hall in St Ives. The audience particularly enjoyed the presentations by clinicians who spoke about our Cystic Fibrosis Centre, the success of the Pulmonary Endarterectomy service, the new S-ICD device and developments in our clinical services over the past year. There was also an opportunity to hear about our work to continually improve the experience for our patients and an update on high profile research projects. The event ended with an update on the new Papworth Hospital project. Finally, I need to say a few words in the context of the wider health economy: Papworth has clearly expanded beyond anything envisaged a decade a go. The Annual Report gives the facts and figures of this growth; but they are just part of the story. This hospital is a specialist centre of international significance, and outcomes for patients are increasingly well known. More patients are exercising choice and especially so when facing serious life threatening decisions. Our medical teams are specialists and their outcomes reflect such expertise; Lord Darzi in his assessment as a Health Minister in the last Government suggested that centres of excellence, such as Papworth would play an increasingly important role in the health economy. Indeed it is that specialist role that helps to explain why Papworth is recruiting nurses and consultant teams whilst other sectors are consolidating. It is now urgent that specialist centres expand into 21 st Century facilities and balance the need to further expand with the need to drive increased efficiency. Robert Burgin Chairman Papworth Hospital NHS Foundation Trust - Annual Report 2010/11-5 -

9 Directors Report Papworth s history, activities and purpose About the Hospital Papworth Hospital NHS Foundation Trust (also referred to as Papworth or Papworth Hospital or the Trust) was one of the first foundation trusts to be authorised under the Health and Social Care (Community Health and Standards) Act 2003 and came into existence in July Papworth Hospital is the UK's largest specialist cardiothoracic hospital and the country's main heart and lung transplant centre, treating over 22,800 inpatient and day cases and over 53,400 outpatients each year from across the UK. Its services are internationally recognised and include cardiology, respiratory medicine, and cardiothoracic surgery and transplantation. Papworth Hospital carries out more major heart operations than any other hospital in the UK, currently approximately 2,000 per year. The survival rates and outcomes of these operations are under close and regular scrutiny by robust quality performance monitoring systems. Papworth is the national centre for pulmonary endarterectomy, the largest respiratory support and sleep centre in the UK and a national centre for a range of other specialist services. Since carrying out the UK s first successful heart transplant in 1979, Papworth has an established reputation as a clinical and research centre of excellence. Papworth Hospital is a member of Cambridge University Health Partners (CUHP), an organisation which has been set up to drive forward the partnership between the National Health Service (NHS) and the University of Cambridge. CUHP is one of only five Academic Health Science Centres in England recognised by the Department of Health as internationally competitive centres of excellence in the integrated delivery of health care, health research and the education of health professionals. Our Services Cardiac Services The Cardiac Services Directorate manages one of the biggest cardiac centres in the country, offering dedicated, specialist care. It deals with all aspects of the diagnosis, management and treatment of heart conditions in adults. Papworth Hospital is: one of the UK s leading centres in coronary angiography, angioplasty and stenting a leading centre for intervention in structural heart disease including closure of septal defects and transcatheter treatment of valve disease one of the first centres in Europe to offer transcatheter aortic valve implantation (TAVI) Papworth Hospital NHS Foundation Trust - Annual Report 2010/11-6 -

10 recognised as one of the UK s leading centres for Electrophysiology (EP) a major centre for device implantation including pacemakers, biventricular pacemakers and implantable defibrillators one of the UK s leading and largest specialist providers of cardiac surgery including Coronary Artery Bypass Grafting (CABG) and the UK s largest valve repair/replacement centre Cardiac Services include: Diagnostic and Interventional Cardiology Electrophysiology and Devices Cardiac Surgery Cardiac Technology Thoracic Services Our Thoracic Services Directorate provides care to patients with a wide range of acute and chronic chest conditions. This includes the interstitial lung disease service, the respiratory infection, inflammation and immunology service and surgery and other treatments for lung cancer. Papworth Hospital is: one of the largest services in Europe devoted to the treatment of chronic lung infections home to the Cystic Fibrosis Centre which has gained a national and international reputation for its contribution to research the largest national centre for the provision of ventilator support and sleep medicine the only UK hospital to offer Pulmonary Endarterectomy (PEA) surgery for pulmonary hypertension one of the UK's leading specialist centres for the diagnosis and treatment of pulmonary vascular diseases the largest 'Sleep Clinic' in the UK an internationally recognised specialist centre for the treatment of diseases of the chest a major centre for thoracic surgery using latest research and new techniques Thoracic Services include: Cambridge Centre for Lung Infection o Adult Cystic Fibrosis Centre o Lung Defence Clinic o Immunology Clinic Interstitial Lung Disease Pulmonary Vascular Diseases Respiratory Physiology Respiratory Support and Sleep Centre Thoracic Oncology Thoracic Surgery Papworth Hospital NHS Foundation Trust - Annual Report 2010/11-7 -

11 Transplant Services Papworth is a leading adult heart and lung transplant centre. Performing the UK s first successful heart transplant in 1979, the world s first heart-lung-liver transplant in 1986 and the UK s first beating heart transplant in Papworth Hospital has established a reputation as a clinical and research centre of excellence. Papworth pioneered the use of invasive monitoring and hormone resuscitation for multiorgan donors which has become the gold standard in donor management. Radiology services Papworth s Radiology Service has a key role in the diagnosis of all cardiothoracic conditions. The service uses state-of-the art imaging technology and facilities include two CT and MRI scanner. The Radiology Department images over 50,000 patients each year. Pathology services Papworth s Pathology Service supports all departments of the hospital. Its services include: histopathology, blood sciences, microbiology and a specialist immunology service. Theatres and critical care services The Theatres, Critical Care and Anaesthesia Directorate (TCCA) support all surgical activity across the hospital. Papworth has a theatre suite with five theatres and a recovery unit. Please visit our web site at for more information. Principal activities and achievements 2010/11 Treating More Patients Papworth has achieved a 50% increase in its specialist inpatient and day case work and a threefold increase in out-patient activity in the past decade. Demand for our highly specialised services (e.g. cardiac surgery, pulmonary endarterectomy, electrophysiological services) continues to grow, as patients and their doctors continue to exercise their rights to seek out specialist treatment. Inpatients and day cases 2010/ /10 Cardiology 7,999 7,598 Cardiac Surgery 2,299 2,565 Thoracic Surgery Respiratory Support and Sleep Centre 6,807 6,568 Transplant / Ventricular Assist Devices Thoracic Medicine 4,397 4,329 Total 22,797 22,365 Papworth Hospital NHS Foundation Trust - Annual Report 2010/11-8 -

12 Outpatients 2010/ /10 Cardiology 16,405 14,172 Cardiac Surgery 4,809 4,981 Thoracic Surgery Respiratory Support and Sleep Centre 14,249 12,609 Transplant/ Ventricular Assist Devices 2,784 2,883 Thoracic Medicine 14,669 13,310 Total 53,408 48,422 Control of Infection Papworth retained its excellent record with infection control during the year beating the tough national infection control targets set for the year April 2010 to March The prevention and control of infection is part of Papworth s overall risk management strategy. Evolving clinical practice presents new challenges in infection prevention and control, which need continuous review. Papworth puts infection control and basic hygiene at the heart of good management and clinical practice, and is committed to ensuring that appropriate resources are allocated for effective protection of patients, their relatives, staff and visiting members of the public. In this regard emphasis is given to the prevention of healthcare associated infection, the reduction of antibiotic resistance and the improvement of cleanliness in the hospital. Papworth had a ceiling target of 2 cases of MRSA for the year (3 in 2009/10) and at the end of the year had reported 1 case (2 cases 2009/10). C. difficile cases were also below the ceiling target, at 9 cases, ceiling 13 (13 cases, ceiling 20 for 2009/10). These low rates demonstrate the Trust s continued vigilance in the area of infection control, with measures including: consistent investigation of infectious disease outbreaks; root cause analysis was carried out on all C. difficile and MRSA bacteraemia cases, with feedback to the clinical teams and to the Infection Prevention and Control Committee; on-going planning for pandemic influenza; a designated infection prevention and control page on the hospital intranet and the public-facing website; a rolling programme of procedure development and review for infection prevention and control; infection prevention and control audit programme including weekly hand hygiene audits in the highest risk areas and regular audits in other areas; a rolling programme of infection prevention and control training is in place encompassing all trust staff. Infection prevention and control training is given to all new starters at Papworth as part of the Trust s induction programme. The last unannounced prevention and control of infections inspection visit by the Care Quality Commission (CQC) took place on 5 August The Papworth Hospital NHS Foundation Trust - Annual Report 2010/11-9 -

13 inspection concentrated on how the hospital manages infection prevention and control. Seventeen measures were inspected and analysed, and wards within the hospital were visited. No areas for concern were identified. (See also Quality Report). Patient Reported Outcome Measures (PROMs) Papworth has completed a PROM for Coronary Artery Bypass Graft (CABG). During the period 20 July to 31 October patients attending pre-admission clinic for CABG were identified and asked to complete a questionnaire. A second questionnaire was then sent 12 weeks post procedure. A return rate of 87% compared favourably against the national standard of 66%. The overall report was extremely positive, with high levels of quality and improvement to patient s physical and psychological well-being. Highlights included: 84% of patients reported that their outcome following surgery was either excellent or good; A significant trend can be seen in the patient s health and well-being, with 63% identifying a significant increase in better health, including reduction in patients experiencing chest pain and reduction in breathlessness. In March 2011 the Director of Nursing attended the cardiothoracic national benchmarking group to discuss the development of a national revascularisation PROM. This is a wider piece of work and will include CABG and Percutaneous Coronary Intervention (PCI) as part of the PROM. A working group is being established and it is likely Papworth will convert to the national PROM when it is completed. Matching Michigan Project Papworth Hospital was featured as a case study film to share best practice for the national patient safety project Matching Michigan led by the National Patient Safety Association (NPSA). Papworth was one of the three case studies chosen out of the 97% of acute Trusts in England who are participating in the project. Dr Stephen Webb, Consultant in Anaesthesia and Intensive Care said We have created this simple yet powerful framework for this project to reduce Central Venous Catheter (CVC) blood stream infection which combines a set of daily goals, computerised systems and checklists which are shared and monitored by multidisciplinary teams. Papworth assists with national response to H1N1 Papworth Hospital as a specialist cardiothoracic hospital and a transplant and pulmonary endarterectomy (PEA) centre, has a long experience of providing specialist ECMO services (Extra-Corporeal Membrane Oxygenation). Over the winter months Papworth Hospital worked with other hospitals commissioned by the National Specialised Commissioning Team to provide respiratory ECMO services to patients with H1N1. In addition to patients who routinely require ECMO as part of their specialist treatment at Papworth Hospital NHS Foundation Trust - Annual Report 2010/

14 Papworth, the intensive care unit has provided respiratory ECMO for patients with H1N1. Upgrade to next generation computed radiography system Papworth Hospital became one of the first hospitals in the country to install an updated computed radiography system to ensure that high quality imaging and the radiology department s efficiency are maintained, as patient numbers increase. Carolyn Dyer, Principal Radiographer (General Imaging) at Papworth Hospital, said In the last couple of years we have experienced a rapid expansion in the number of patients we see in the thoracic radiology service and to accommodate that increase and ensure continued high quality imaging, we are pleased to have taken delivery of this upgraded system. The recently installed Agfa DX-G Digitiser and NX software in our Thoracic X-ray room may be small in size, but it really packs a punch in improving radiographic image quality and decreasing patient waiting times. The DX-G Digitiser is able to scan an image in approximately ten to twenty seconds, six times faster than previously possible. This also has the added potential of being able to reduce patient average X-ray dose while still maintaining image quality. National Inpatient Survey Patients have once again placed Papworth Hospital in the highest scoring 20% of Trusts in England. They rated the hospital in the highest scoring 20% of trusts in 50 out of 61 questions according to the Care Quality Commission s (CQC) comparison with 161 other Trusts. This eighth national survey of adult inpatients showed that for questions about doctors Papworth Hospital scored 9 out of 10 and for questions about nurses scored 8.8 out of 10. Questions About Score out of 10 Waiting lists and planned admissions 7.1 Better Waiting to get to a bed on a ward 9.5 Better Hospital and ward 8.6 Better Doctors 9 Better Nurses 8.8 Better Care and treatment 8.3 Better Operations and procedures 8.5 About the same Leaving hospital 7.9 Better Overall views and experiences 7.1 Better How this score compares with other trusts From April 2011 improvement in patient experience scores formed part of the Commissioning for Quality and Innovation (CQUIN) payments to the Trust. At the time of writing this report, preliminary results have been provided by Quality Health which confirm that Papworth has achieved the CQUIN for patient experience with an overall score of 76.9, against our 2009 overall score of Papworth Hospital NHS Foundation Trust - Annual Report 2010/

15 Responses to the specific parts of patient experience that Papworth had to show improvement on are as follows: Were you involved as much as you wanted to be in decisions about your care and treatment? Did you find someone on the hospital staff to talk to about your worries and fears? Were you given enough privacy when discussing your condition and treatment? Did a member of staff tell you about medication side effects to watch for when you went home? Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital? Papworth Percentage 2009 Papworth Percentage 2010 National Comparable Data % 67% 53% 53% 57% 42% 79% 79% 72% 47% 48% 38% 86% 84% 71% Care Quality Commission (CQC) Registration Our current CQC registration status is unconditional. The CQC has not taken any enforcement action against us since our registration in April The most recent periodic review carried out by the CQC in August 2009 on Infection prevention and Control made the following conclusions. On inspection we found no evidence that the Trust had breached the regulation to protect patients, workers and others from the risk of acquiring a healthcare associated infection. Performance of Trust against Selected Metrics Throughout 2010/11 we have continued to measure our quality performance against a number of metrics. Table A sets out our performance against those national targets included within Monitor s compliance framework. Table B sets out our performance against other Department of Health national priorities and a range of local priorities: Papworth Hospital NHS Foundation Trust - Annual Report 2010/

16 Table A Trust performance against Monitor s Compliance Framework Acute Targets national requirements Target Performance Clostridium difficile - year on year reduction 13 9 MRSA meeting the MRSA objective 2 1 Cancer 31 day wait for second and subsequent 94% 100% treatment Cancer 62 day wait for first treatment from GP 79% 87.9% referral* Maximum 18 weeks from referral to treatment for >90% Achieved 94.9% admitted patients Maximum 18 weeks from referral to treatment for nonadmitted >95% Achieved 97.9% patients Acute Targets minimum standards Target Performance MRSA screening all elective inpatients 100% 97% Cancer 31 day wait from diagnosis to first treatment 96% 100% All Trusts Target Performance Compliance with the requirements regarding access compliance Achieved from Q2 for people with learning disability * reduced tolerance levels have been issued by CQC for certain specific single cancer sites. As Papworth only treats lung cancer the revised threshold applies

17 Table B Examples of Trust Performance Against other national and local priorities Domain Metric Target Performance Patient Operations cancelled for non-medical <1.5% 1.4% Experience reasons Percentage readmitted within the 28 5% 14.7% day guarantee 26 week inpatient waits 0% 0% (4 breaches) 13 week outpatient waits 0% 0% (2 breaches) Patient Safety Number of patient related adverse incidents < Number of patients risk assessed for VTE on admission >90% Achieved over 90% from September, over 97% from Patient Experience Effectiveness of Care Domain Rate of harm as assessed using the Global Trigger Tool (GTT) [local priority] Reduce by 50% by 2013 (baseline 7%) % of patients reporting they were >90% >96% treated with privacy and dignity Number of complaints <50 38 Patient Environment Action Team Excellent (PEAT) score. Excellent (100%) Good (90-95%) Acceptable (< 90%) Cardiac surgery in-hospital mortality within statistical limits using 50% of Euroscore (a method of identifying risks to our patients) >95% >97% January 2011 Average rate of harm for 2010/11 is 4.1% (reduction of 41.3%). Range % Excellent/Good Two categories remained good and one increased to excellent

18 Monitor Ratings Monitor (The Independent Regulator of NHS Foundation Trusts) issues a Financial Risk Rating (FRR) to Foundation Trusts based on quarterly financial returns. This rating is based on a formula determined by Monitor which measures financial performance using a composite indicator. The rating ranges from 5 to 1 with 5 the highest rating. Monitor also issues a Red, Amber-Red, Amber-Green, Green (RAG) rating for Governance, where Green indicates low risk and Red indicates high risk (during 2009/10 the rating was Red, Amber and Green). A summary of the planned and actual ratings for 2010/11 and 2009/10 are provided below: Financial Risk Rating Governance Rating Financial Risk Rating Governance Rating Mandatory Services Annual Plan Q1 Q2 Q3 Q4 2010/ / / / / Amber- Green Green Amber- Green Amber- Green Green Annual Plan Q1 Q2 Q3 Q4 2009/ / / / / Green Green Green Amber Amber Green Green Green Green Green During the year, Papworth achieved the second highest available financial rating of four in Q1 to Q3 and the highest rating of five in Q4. In line with Monitor s compliance framework, Papworth was downgraded to Amber-Green in Q2 and Q3 for Governance. The Q2 governance rating was due to a breach of the year to date C.diff trajectory (8 cases vs. 7 cases trajectory). The year end position was within trajectory with a total of 9 cases against a trajectory of 13 (see also Infection Control section). The Q3 governance rating was due to a failure to meet the 62 day cancer wait target for first treatment from urgent GP referral. Papworth as a specialist centre only treats lung cancer. The 62 day wait covers the whole of the patient pathway and can impact on the trust because of the small numbers involved and its position as the last centre of referral on the pathway. In recognition of this the CQC have introduced reduced tolerance levels for certain single cancer sites, of which Papworth is one. Whilst Papworth temporarily breached in Q3, in Q4 and for the whole year the trust was compliant. (see Table B). Patient Environment Action Team (PEAT) Every year all trusts providing inpatient services in England are inspected by a Patient Environment Action Team (PEAT) and assessed against the following standards: organisation policy information; specific cleanliness; toilets and bathrooms cleanliness and environment; infection control; environment; access and external areas; food and hydration and privacy and dignity. Papworth Hospital NHS Foundation Trust Annual Report 2009/

19 This year s PEAT inspection was undertaken on 15 February 2011, the validated outcome of the assessment by the NPSA is as follows: Change Environment and Cleaning Good Good Food and Hydration Services Good Excellent Privacy and Dignity Good Good Feedback from the Team was extremely positive, in particular the significant improvement in all areas including the overall cleanliness of clinical areas together with the tidiness/state of the estate inside and outside since the last inspection. A detailed action plan has been developed to address particular areas of improvement within clinical areas, in particular bathroom areas and visitor rooms requiring refurbishment. The plan will be monitored by the Nursing Advisory Committee. It was noted that whilst the Trust had improved its scores since last year, the age of some of the buildings and access across the site, internally and externally, did impact on the scores especially for people with disabilities. Nutrition In January 2011 a new menu was introduced to improve both the range of options available and the nutritional content appropriate for our patient cohort including special dietary needs and diabetes. All the menus were reviewed by our dieticians prior to introduction and the range of food prepared on site has increased in response to the Trust s requirements to ensure the menu met the specific needs of our patients. Following this a patient satisfaction survey was undertaken; a summary of the results is detailed below. Factor Very Satisfied Satisfied Not Satisfied Don't Know % Very Satisfied or Satisfied Menu Variety Flavour of food Food Temperature Portion Size Appearance/Presentation Quality of Food Understanding of the Menu Staff Friendliness Times when meals are served In addition to the above, patients were asked to comment on dishes they particularly liked and those they did not enjoy so much, together with suggestions or further comments. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

20 The results together with feedback from the Trust s dieticians and housekeepers will inform a further revised menu from April 2011 onwards. The results have also been fed back to the Patient and Public Involvement/Membership (PPIM) Committee of the Board of Governors for comment. Other Highlights of 2010/11 A visit by our Patron HRH The Duchess of Gloucester Papworth Hospital s Patron, HRH The Duchess of Gloucester, made a private visit to Papworth Hospital on 13 April During her visit she was shown around the refurbished cystic fibrosis unit where she met staff, patients and their families. HRH also visited the Critical Care Unit and unveiled a plaque to commemorate the official opening of the extension to the Critical Care Unit. Four transplant patients celebrate 80 years of added life Four people who had their heart transplants at Papworth Hospital on consecutive days, 20 years ago, were all reunited at the hospital in July. Between them they celebrated an extra 80 years of life. This was the first time they had all been together since they were inpatients in June Papworth Hospital patient wins gold at Transplant Games Maggie Gambrill who had her transplant in 2002 returned triumphantly from this year s British Transplant Games held in Bath at the end of August, with a grand total of five medals. Maggie comments "Apart from measles and chicken pox as a child, I had never been ill. I loved sport and thought I was invincible. It therefore came as a terrible shock when in April 1998 I was diagnosed with dilated cardiomyopathy. In 2002 my health began to deteriorate and I was sent to Papworth for assessment. I knew I was very poorly but the shock of being told that I would not survive without a transplant hit me really hard. But I am the proud recipient of a donor heart and I have a quality of life back that I never imagined possible. Transplant sport has become my focus and has taken me down a wonderful path of new challenges, new experiences and new friends. Every medal that I win is dedicated to my donor and family." Mr Steven Tsui, Director of Transplant Services at Papworth Hospital said, "We are really proud of Maggie and the other members of the Papworth Transplant Games team for their sporting successes in the Transplant Games. It is very rewarding for us at Papworth to see our patients making the most of the new lives they have been given and it is an excellent example of how lives can be turned round by signing up to the organ donor register." One of the UK s longest surviving heart-lung transplant recipients celebrated 25 extra years of life on 10/10/10 The UK s second longest surviving heart-lung transplant recipient, 45 year old Julie Bennett from Chepstow, celebrated the 25th anniversary of her heart-lung transplant on 10 October In April 1985, I never dreamt that I would be here 25 years later eating cake with my surgeon John Wallwork. I was extremely ill in hospital and Papworth Hospital NHS Foundation Trust - Annual Report 2010/

21 when the doctors asked to see my mother I thought it was to tell her that I was going to die. Instead I was offered the chance of being assessed for transplantation. Since my transplant I have returned to Papworth Hospital for regular check-ups and it is just like one big happy family. Said Julie. At the time of Julie s transplant in 1985, heart-lung transplantation was in its infancy and Julie was the first person with cystic fibrosis to receive a heartlung transplant at Papworth Hospital, and just the seventh heart-lung transplant recipient, Europe s first successful heart-lung transplant having been carried out by Professor John Wallwork at Papworth Hospital the previous year, in Andrew Lansley shows support for mesothelioma patients Mr Andrew Lansley, CBE MP for South Cambridgeshire and Secretary of State for Health, showed his support for mesothelioma patients by joining their support group at Papworth Hospital on Friday 10 December. Gerry Slade, Group Coordinator and Specialist Nurse at Papworth Hospital said "We were delighted that Mr Lansley made the time to attend our meeting. His depth of knowledge of cancer was evident from the detailed answers he gave, and this was much appreciated by the patients and carers." David Sayce, a mesothelioma patient from Swavesey, Cambridgeshire said "I was diagnosed in January this year with mesothelioma. I had never heard of the illness before that. I must have had an exposure to asbestos, but didn t know it at the time. It is great to have the support of others through the support group and I am delighted that Mr Lansley was able to join our meeting today and show his support. It is important people know about mesothelioma, as not only are there many people suffering from this cancer right now, but people need to be aware of the risks of asbestos to prevent more cases in the future." Mr Lansley had a discussion with the group, during which he said "Papworth Hospital is an exceptional place which we are proud to have in South Cambridgeshire." Papworth Heritage Centre Papworth Heritage Centre opened its doors to celebrate the pioneering achievements of both Papworth village and the hospital since it was originally conceived as a centre for treating tuberculosis patients in Based at House Two, at the top of the hospital site, the new Heritage Centre features a wide variety of objects such as medical equipment, photographs of the first patients and a table commemorating Royal visits, which tell the story of the extraordinary history of the hospital and the village. Patient Experience Patient Safety Focus Groups Patient Safety Focus Groups and walk arounds were introduced as part of our Patient Safety Strategy in June 2009 and have continued during 2010/11. The Focus Groups are led by the Chairman of the Board of Directors and include Non-executive Directors and senior clinical staff. Two unannounced inspections also took place in February Key themes Papworth Hospital NHS Foundation Trust - Annual Report 2010/

22 from these walk arounds are being reviewed by the Director of Nursing and Modern Matrons. Improvements in patient/carer information The Board of Directors is committed to providing patients and carers with good quality information to ensure that patients have greater power, protection and choice enabling them to make decisions in key aspects of their healthcare and treatment. The provision of good quality information is central to the consent process and interpreters are provided as required, either face-to-face or over the telephone, ensuring that those patients whose first language is not English are able to communicate appropriately with healthcare staff. A policy for the development, review and monitoring of all patient information has been in place since August 2007 and has ensured consistency across the Trust. There is a continual cycle of reviewing patient literature. The Patient Experience Reading Panel ensures that patients and the public are involved in the development of all written information produced by the Trust providing a user perspective on the content. They also ensure that the language used in patient information is user-friendly, simple and easy to understand and that a high standard of literature is achieved. During 2010/11 the Reading Panel was expanded to include additional trust members and Governors. Patient and Public Involvement Papworth has a Patient and Public Involvement & Membership Committee (PPIM) which is responsible for monitoring progress on the objectives set under the PPI and Patient Experience Strategy document and is involved in setting the priorities for the Quality Accounts for the year. The Patient Experience Panel (PEP) continued to meet during the year and was involved in agreeing the questions for the patient experience tracker and in the Patient Environment Action Team Inspection (PEAT) which was carried out in February The Trust has a good working relationship with the Local Involvement Network (LINk) for Cambridgeshire and meetings have taken place with the new Papworth Hospital working group. The Trust continues to have strong relationships with The British Cardiac Patients Association (BCPA) and the Norfolk Zipper Club. Other patient support groups include: Pulmonary hypertension; Immunology and lung defence; Mesothelioma; Pulmonary fibrosis. During 2010/11 the Patient Advice and Liaison Service (PALS) received 1,518 enquiries from patients, families and carers. As a direct result of comments from patients, there have been changes made to working Papworth Hospital NHS Foundation Trust - Annual Report 2010/

23 arrangements, in particular in our Radiology department where there is an extended period when the telephones will be manned. Also a complete review of on site signage and maps was carried out, additional relative accommodation has been sourced and the Relatives Hostel on site was completely refurbished. A Hardship Fund was also set up to assist relatives and families who arrived at Papworth in emergency situations and provides assistance to take care of their initial financial needs. Effectiveness of Care Please see our Quality Report, Quality Accounts and Quarterly/Annual Quality & Safety Report published on our website. Information on these reports is used internally to support developments in effectiveness of care. Complaints Handling Listening to the patient experience and taking action following investigation of complaints is an important part of our quality improvement framework. The trend in the number of complaints received by the Trust has fallen year on year. In 2010/11 Papworth Hospital received 39 complaints requiring investigation. 35 were relating to NHS provided services with 1 formal complaint subsequently withdrawn by the complainant prior to investigation and 4 complaints were from patients who accessed the private patient services at Papworth Hospital. The overall numbers of complaints received has reduced from the previous year when 47 complaints were received. Trends and data collected on formal complaints received by the Trust are reported to the Clinical Governance Management Group on a quarterly basis via the quarterly Clinical Governance report. Lessons learnt and actions taken following investigation of formal complaints are detailed in the report, which also includes Patient Advice and Liaison Service (PALS) feedback and patient incidents. The quarterly clinical governance report is presented to the Quality and Risk Committee (acting as a Committee of the Board of Directors), to all clinical management groups, is available on the Trust intranet for staff to access and is on the public website. Complaints trends by subject comparing 2010/11 with previous year Lack of Privacy and Dignity Delay in Diagnosis/ Treatment or Referral Communication / Information Hotel Services Nursing Care Clinical Care Staff Attitude Admission Arrangments Verbal or Physical Abuse Transport Issues Medical Records Medication Environmental Internal Discharge Arrangements 2010/ /10 Papworth Hospital NHS Foundation Trust - Annual Report 2010/

24 All complaints received have been subject to a full investigation, and throughout the year service improvements have been made as a result of analysing and responding to complaints. Details of actions taken following investigation of complaints are available from the Clinical Governance department. Papworth Hospital Charity The Board of Directors of Papworth Hospital NHS Foundation Trust is the Corporate Trustee of Papworth Hospital NHS Foundation Trust Charity. The Charity s registration number is , and its mission statement is as follows: The Papworth Hospital NHS Foundation Trust Charity is a registered charity, which aims to raise significant funding from a variety of charitable sources in order to sustain Papworth Hospital as the UK s leading centre of excellence for the treatment and diagnosis of cardiothoracic diseases. The charity s fundraising activities also support Papworth Hospital s pioneering research activity and vision for the future, as decided by the Corporate Trustee. The Papworth Hospital Charity Office works hard to attract additional funding into the hospital, by supporting those who fundraise in the community and by organising various activities during the year. Among the popular annual events are the World Heart Day Walk, the carol service at Ely Cathedral, and the Grand Summer Draw. The Charity receives wonderful support from members of the public, patients and their families and we are especially grateful to those who make the most personal of gifts by remembering the hospital in their Will. Further information regarding Papworth Hospital Charity may be obtained at Freedom of Information Under current Freedom of Information legislation, the Foundation Trust is required to publish and respond to requests for information about its business and activities. Its public website is registered with the Office of the Information Commissioner as its formal publication scheme. During the period from 1 April 2010 to 31 March 2011 the Trust received 140 requests for information under the Freedom of Information Act 2000 of which 98% were answered within the 20-working-day timeframe. Using Foundation Trust Status to develop services Foundation Trust status has enabled Papworth to invest 4.4 million on improvements to patient care, including the Cystic Fibrosis Ward upgrade, supporting national privacy and dignity initiatives; an Intensive Care Unit extension and; cardiac and medical equipment replacement. As a Foundation Trust, Papworth was able to expedite the decision making process on these developments. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

25 Stakeholder relations / Working with partners Commissioners Relationships with Commissioners have remained good during 2010/11 with regular meetings taking place through the local joint commissioning group. Cambridge University Health Partners (CUHP) In March 2009, the Trust in partnership with the University of Cambridge, Cambridgeshire and Peterborough NHS Foundation Trust, and Cambridge University Hospitals NHS Foundation Trust was designated as an academic health science centre by the Department of Health. This designation followed a national competition in which only five centres in England were successful in demonstrating excellence in clinical care, research and education at a level that places them in the international premier league of academic health organisations. The model of governance for the Cambridge Academic Health Science Centre is through a partnership organisation, Cambridge University Health Partners (CUHP). This was established as a company limited by guarantee in November The objects of CUHP are to improve patient care, patient outcomes and population health through innovation and the integration of service delivery, health research and clinical education. The Chairman and the Chief Executive of Papworth are ex officio directors of CUHP, as are the vice-chancellor of the University of Cambridge, the University Registrary and the Regius Professor of Physic. There are also three further directors with both clinical and academic responsibilities, one linked with each of the NHS trusts. The Chairman of the Board is Professor Sir Keith Peters FRS. The Executive Director is JG Patrick Sissons, Regius Professor of Physic. CUHP employs a small core team and the cost of this is shared equally between the partners. In 2010/11, Papworth s contribution to cost sharing was 93,500 (2009/10 93,500). The constitution of CUHP reserves a range of matters to the members or the board of directors as a means of ensuring that its activities are directed towards its objects at all times and that members are not exposed to any unanticipated risks through participation. CUHP also manages the Cambridgeshire and Peterborough Health Innovation and Education Cluster (HIEC) under contract from NHS East of England. This is a broader partnership, involving NHS organisations, universities and innovation organisations across Greater Cambridge and Peterborough. The HIEC has a budget of 2.4m and is supporting a range of education and innovation projects that are closely aligned to the quality and productivity goals of the Sustainable Health Programme a further partnership programme of the local health economy. Financial Review The following table summarises Papworth s financial performance for 2010/11. Activity levels exceeded those set out in the commissioner contracts and original plans by 3.8m (3%). Other income, mainly workforce Papworth Hospital NHS Foundation Trust - Annual Report 2010/

26 and research and development, exceeded plan by 0.8m. Overall expenditure exceeded plan in line with the additional income. Income exceeded total expenditure during the year, giving a net surplus of 6.0m against the planned surplus of 4.3m. It is a condition of Monitor s agreement to the Trust going to the PFI market for the New Papworth project that the Trust continues to generate in future years revenue surpluses at around the level planned and achieved in 2009/10. Such surpluses will also contribute to a beneficial Financial Risk Rating by Monitor. Summary of Income and Expenditure Position 2010/11 million 2010/11 Plan 2010/11 Actual Variance Fav/(adv) EBITDA * Depreciation (3.53) (3.90) (0.37) Operating Surplus Finance Items (1.67) (1.43) 0.24 Net Surplus * Earnings before Interest, Taxes, Depreciation and Amortisation. The next two tables show total income for the year broken down by commissioner and service. 2010/11 Income by Commissioner - Total 112,641k: (000s) National Commissioning Group 14,731 Cambridgeshire 21,482 Norfolk 14,689 Suffolk 17,880 Bedfordshire 7,207 Peterborough 5,671 Great Yarmouth & Waveney 4,082 Hertfordshire 3,975 Essex 3,325 Luton 443 East Midlands SHA 7,960 Other NHS 6,202 Private Patients 4,994 Total 112,641 Papworth Hospital NHS Foundation Trust - Annual Report 2010/

27 2010/11 Income by Service - Total 112,641k: Admitted patient care ( 000s) 2010/11 Plan Actual (Outturn) Cardiology 27,734 28,673 Cardiac surgery 22,811 21,275 Thoracic surgery 4,255 5,836 Respiratory Support and Sleep Centre 8,058 7,780 Transplant/Ventricular Assist Devices 9,993 10,933 Thoracic Medicine 10,391 9,956 Critical care/other 12,112 13,542 MFF (inpatients and outpatients) 5,102 5,010 Total Admitted Patients 100, ,005 Outpatients ( 000s) 2010/11 Plan Actual (Outturn) Cardiology 3,454 3,766 Cardiac surgery Thoracic surgery Respiratory Support and Sleep Centre 1,654 1,877 Transplant/Ventricular Assist Devices 4 3 Thoracic Medicine 2,409 3,104 Total Outpatients 8,377 9,636 Grand total (Inpatients and Outpatients) 108, ,641 Other operating revenue for the year was 9.851m which included funding to provide education and training, and research and development activities. Other patient related activity was 658k. Key points to note in 2010/11 Clinical income, which comprises both NHS and Private Patients, achieved levels in excess of the 2010/11 plan. Private Patient income was below plan at 4.99m (4.4% of total patient income), and remained within the limit set under the terms of the Foundation Trust s authorisation (6.1% of total patient income). Private Patients Income Total 4.99m: Achieved million Plan million Income Private Patients Income as % of Patient Income Variance million 4.4% 4.5% Max 6.1% Prudential Borrowing Limit The Trust has a Prudential Borrowing Limit set by Monitor (the Independent Regulator of Foundation Trusts), made up of two elements. For 2010/11 Papworth s maximum cumulative long term borrowing limit was 16.8 million Papworth Hospital NHS Foundation Trust - Annual Report 2010/

28 and the Trust did not renew its working capital facility. Papworth borrowed nil in 2010/11 ( nil in 2009/10). Market Value of Fixed Assets A full valuation of the Trust s estate was carried out in 2009/10. The Trust s freehold land, buildings and dwellings were valued by external valuers. In 2010/11 the value of land and buildings have been indexed using indices advised by the Trust s external valuer. Current valuations are shown in Note 9.3 to the accounts. Political and Charitable Donations No political or charitable donations have been made by Papworth Hospital NHS Foundation Trust in the 2010/11 financial year. No political or charitable donations were made in previous years. Financial Instruments The Trust does not have significant exposure to hedge accounting, price risk, credit risk, liquidity risk and cash flow. Further detail is provided in the notes to the accounts. Post Balance Sheet Events There were no significant post balance sheet events affecting Papworth Hospital NHS Foundation Trust in the 2010/11 financial year. Note on Pensions All accounting policies in respect of pensions and other retirement benefits are set out in the notes to the accounts. Details of Director remuneration can be found in the Remuneration Report. Information on additional pension liabilities for individuals who retired early on ill-health grounds can be found in note 5.4 to the accounts. Better Payment Practice Code The Better Payment Practice Code requires the Trust to aim to pay all valid invoices by the due date or within thirty days of receipt of goods or a valid invoice, whichever is later. As a Foundation Trust there is no formal requirement to adhere to the Better Payment Practice Code: nevertheless in the interests of maintaining good supplier relationships, the Trust has complied with the Code during 2010/11. Furthermore, the Trust has made efforts to play its part in assisting small and medium sized enterprises in these more challenging financial times through aiming to make payment within ten days where possible. The Trust endeavours to make payments within the timescales required by the Code. In 2010/11 92% (2009/10 94%) of non-nhs invoices were settled within 30 days of invoice date. The Trust paid 0 (2009/10 0) of interest under the Late Payment of Commercial Debts (Interest) Act 1998 during 2010/11. Details Regarding PFI Schemes No PFI schemes were undertaken by Papworth Hospital NHS Foundation Trust in the 2010/11 financial year. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

29 Management Costs The Trust has chosen not to report management costs incurred during 2010/11 as it feels that the definition used (which has not been updated since 2000/01) does not accurately reflect a definition of NHS management. Relevant Audit Information So far as the Directors are aware, there is no relevant audit information of which the auditors are unaware and each Director has taken all of the steps that they ought to have taken as a Director in order to make themselves aware of any relevant audit information and to establish that the auditors are aware of that information. Accounting Policies The Trust s accounts have been prepared in accordance with directions given by Monitor and are designed to present a true and fair view of the Trust s financial activities. Monitor s guidance draws on HM Treasury s Financial Reporting Manual (FReM), which interprets commercial requirements in the context of the public sector, amended to apply to NHS Foundation Trusts. More financial information can be found in the full set of financial statements for 2010/11. Going Concern After making enquiries, the Directors have a reasonable expectation that Papworth Hospital NHS Foundation Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Future Trends The most significant trends in the external context are the structural changes and current uncertainty arising from the Health & Social Care Bill Of particular relevance to Papworth are: Proposed changes in commissioning arrangements, especially the respective roles of the NHS Commissioning Board (NHSCB) and GP Consortia for regional specialised services; The shift in responsibility for holding the Board of Directors to account from Monitor to the Governors; Removal of the cap on Private Patient income; Replacement of the current FT failure regime by a special administration and insolvency regime (with implications for the PFI funding of new Papworth Hospital); The future role of Monitor as an economic regulator and the Care Quality Commission (CQC) as a quality inspectorate; The respective roles of Monitor and NHSCB in price setting and regulation; Monitor s role in licensing providers of NHS funded care, funded by fees on providers; Papworth Hospital NHS Foundation Trust - Annual Report 2010/

30 The process for designation of protected services for additional regulation. The Health & Social Care Bill 2011 Command Paper acknowledges that achieving greater devolution by 2013/14 requires tighter central control over quality, performance and money during the transition. This theme is picked up in the NHS Operating Framework 2011/12 which is described as the first full year of transition to the new direction of the NHS. It identifies three inter-related themes: transition and reform; transparency and local accountability and service quality. The efficiency challenge of 15-20bn remains (see last year s Annual Report), but is extended (i.e. relaxed) from three to four years (i.e. to 2014/15). Service quality points of particular relevance to Papworth include: Maximum waiting times under the NHS Constitution continue, as does monitoring of maximum, median and 95 th percentile waiting times; Existing cancer waiting time standards continue to apply; Providers must eliminate mixed-sex accommodation unless its in the overall best interest of patients; Monitoring of healthcare associated infections is relaxed, although zero tolerance remains the aim and stretching goals are to be agreed in local contracts. The key financial and business assumptions for 2011/12 are tough, reflecting the national efficiency challenge, and include: Tariff uplift of 0.5% to achieve the national efficiency target of 4% (2.5% for pay and prices; 2% reduction embedded in tariff design); Non-tariff services subject to a 1.5% reduction; Severe limitations on reimbursement for re-admissions within 30 days of discharge; Continuation of the 30% marginal tariff for emergency admissions above a baseline; A new flexibility for prices to be less than mandatory tariff; An extended list of never events i.e. incidents where commissioners can recover costs. These national requirements are reflected in local guidance, the most significant being the East of England SHA s Commissioning Framework for 2011/12 and the East of England Specialist Commissioning Group s (SCG) contract negotiation issues paper. The emphasis of the local guidance is on delivering the Quality, Innovation, Productivity & Prevention (QIPP) programme which aims to drive out 1.4bn of efficiency savings. Much of this is to be achieved through repatriation of care (ensuring pathways closer to home) and demand management schemes. Whilst these measures present a threat to acute provider activity, Papworth is committed to working with commissioners on QIPP programmes. The SCG s position also presents some opportunities for Papworth e.g. it currently spends a significant sum on London providers for cardiac care from parts of West Papworth Hospital NHS Foundation Trust - Annual Report 2010/

31 Essex & Hertfordshire and is committed to ensuring established tertiary centres in the East of England (e.g. Papworth) are the default referral point. Despite the difficult financial climate for 2011/12, negotiations with commissioners have been concluded satisfactorily and will form the basis of the Trust s Forward Plan Strategy Document 2011/12 to be submitted to Monitor by 31 May Principal risks and uncertainties facing the Trust Overall responsibility for the management of risk lies with the Board of Directors. Papworth Hospital is able to demonstrate compliance with the corporate governance principles that the Board of Directors maintains a sound system of internal control to safeguard public and private investment, the NHS Foundation Trust s assets, patient safety and service quality through its Board Assurance Framework (BAF). The BAF was updated in 2010/11 to ensure that it provided an adequate evidence base to support the effective and focused management of the principal risks to meeting our strategic objectives and has been cross referenced to CQC outcomes. This simplified Board reporting and the prioritisation of action plans allows for more effective performance management. Linking with the performance management framework, which demonstrates progress against organisational objectives, the BAF also illustrates the escalation processes to the Board of Directors and its sub-committees when risk, financial, and performance issues arise which require corrective action. The Executive Director with delegated responsibility for managing and monitoring each risk is clearly identified in the BAF. The BAF identifies the key controls in place to manage each of the principal risks and explains how the Board of Directors is assured that those controls are in place and operating effectively. The Board of Directors receives regular reports that detail the financial and performance issues and where required the action being taken to address any identified weakness. These include monthly financial and operational performance reports, quarterly reports on performance against our objectives and disclosure statements relating to governance declarations to Monitor on compliance with our Terms of Authorisation, as well as confirmation of continued compliance with Care Quality Commission (CQC) Registration. The areas of Papworth Hospital NHS Foundation Trust s activities to which the principal risks and uncertainties of the Trust are perceived to be attributable are set out below: failure to stay within ceiling trajectories for MRSA bacteraemia and C. difficile; failure to maintain targets on respecting patients privacy and dignity on the current site; Papworth Hospital NHS Foundation Trust - Annual Report 2010/

32 failure to meet the challenging targets around cancer waiting times; reduced Critical Care capacity due to sub optimal recruitment of trained nursing staff; inability to meet carbon reduction targets due to ageing Estate restraints; under-performance against activity and income plan; inflationary cost pressures in excess of those in plan; service improvement plan targets not achieved; impact of the national financial efficiency challenges on the NHS; failure to progress the new hospital project. To manage these risks the Trust has put in place a range of action plans and monitoring arrangements. Other factors not discussed within this summary could also impact on the Trust and accordingly, this summary should not be considered to represent an exhaustive list of all the potential risks and uncertainties, both positive and negative that may affect the Trust. Future plans New Papworth Hospital growth in services to patients Papworth is facing continued growth in the population of the area, and most specifically the element of the population which is the biggest user of cardiothoracic services. As part of the case for New Papworth, a review was undertaken by the Department of Health predicting significant increases in demand for its services into the future. As a specialist centre, Papworth works at the leading edge of development within its field and endeavours to be a national leader in the implementation of new technologies. At the same time, technologies which were previously regarded as specialist become mainstream and part of the business of general acute providers. In planning its services into the future, both the elements of growth and changes in the services Papworth provides are taken into account. The provision of the New Papworth Hospital in Cambridge will enable the Trust to have sufficient capacity to meet the growing demand for its services. New Papworth Hospital procurement, construction and commissioning Three leading consortia were shortlisted to work with Papworth Hospital to develop plans to relocate the hospital onto the Cambridge Biomedical Campus; Apex Health, The Bouygues Consortium and Skanska. The three shortlisted consortia worked with the Trust to develop interim bid submissions which were submitted on 11 March The interim bids will be evaluated by the Trust to shortlist the number of bidders from 3 to 2. It is anticipated that the procurement will be completed by late 2012, construction and commissioning will take a further 3 years and the new hospital will open in late Workforce Strategies Papworth Hospital NHS Foundation Trust - Annual Report 2010/

33 The Trust s Workforce and Education Strategy is being reviewed to reflect the current financial challenges. The workforce plan is being updated together with educational demands. The key workforce priorities have been identified as follows: Continue the implementation of the Trust s long-term strategic approach to integrated workforce planning to support service re-design through the development of new roles and workforce competence; Develop capacity through working differently and implementing new roles including apprenticeships and associate practitioners to deliver a safe and competent workforce; Implement local pay reform and negotiate local terms and conditions ensuring reward packages are developed to support the retention of staff in mission critical activities; Develop and support future talent and leadership with effective management of performance; Contribute to the development of the HIEC to accelerate whole service redesign and innovation in delivery of healthcare and development of the CUHP Education Centre. The key actions and delivery risks were identified and operational objectives developed together with performance metrics to monitor progress. One of the notable achievements in 2010/11 was Papworth Hospital being successful in obtaining re-accreditation for Investors in People (IiP) and being the first NHS hospital in England to receive the IiP Health and Wellbeing Good Practice Award including the Staying Healthy at Work (SHAW) accreditation. Staff Engagement The previously successful Papworth People campaign has been updated and used to brand Personal Governance and other initiatives including the Service Improvement Programme. Personal Governance is structured within the overall governance framework as follows: Clinical Governance Corporate Governance Personal Governance Papworth Hospital NHS Foundation Trust - Annual Report 2010/

34 Personal Governance enables us to formalise the performance review system that aligns to what we do and how we do it. It is a measurable structured approach around the individual s requirement to take personal responsibility and be accountable for their: Actions Behaviours Competencies Papworth People Working differently Caring for patients Valuing health & wellbeing Achieving excellence Valuing You Your ideas Your talent Your innovation Your input to patient care Your health & wellbeing All staff have been encouraged to get involved in the development of the Papworth Code of Personal Governance incorporating the NHS Constitution and the values of Papworth Hospital. The Performance Management Framework has been reviewed and updated to include simplified appraisals, revised role profiles to ensure expected actions, behaviours and competencies of individuals are clear and understandable for all. A new Individual Performance Review (IPR) form has been developed to include linkages between career and pay progression. The revised process to be implemented from 1 April 2011 has been designed to be simple to implement, paper-light and more robust by focusing on the IPR and identifying future development needs. Therefore, it is simpler to administer and understand by both staff and managers. Revised reporting arrangements have been put in place to simplify the process and all staff receiving pay progression will need to be positively reported in order to be actioned. The IPR process will be developed further over the next year to include performance against objectives and achievement of the Trust s standards of behaviour and attitude. A mandatory training booklet has been developed and given to all staff. A new on-line mandatory training tool has been developed to aid the Trust in compliance with local and national mandatory training requirements. Staff Consultation and Involvement The Trust uses a variety of ways to provide employees with the information which they need about the Trust s activities, including information on clinical, economic and financial performance. Meetings of the Senior Management Forum (SMF) take place regularly in the year. Staff receive information through the Trust s Intranet site, the monthly staff newsletter, a weekly electronic bulletin and communication via line management arrangements. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

35 All clinical guidelines, policies, procedures, protocols and other relevant information can be found on the Trust s intranet. Staff are also involved in contributing to business planning through the Directorate structure. There are seven Staff Governors elected to the Trust s Board of Governors to ensure the staff voice is heard. See other Public Interest Disclosures for the Trust s policy on raising issues of concern. Partnership Working The Joint Staff Consultative Committee (JSC) is the formal management/ staff interface for staff. As in previous years, we have worked with staff side to respond to the results of the annual national and local staff surveys including the development of a staff survey action plan. We are working in partnership to develop a staff engagement strategy to improve the retention and health and well being of our staff. Partnership working remains a key priority for the Trust in the current climate to enable the hospital to accelerate productivity and efficiency gains against a challenging financial situation. Pro-active engagement of staff side to review local pay reforms is on-going. Education and Staff Development A number of key achievements though 2010/11 are indicative of the positive developments and external impact of our staff s learning. Leadership development continues through a number of pathways both local, county and SHA level following recognition of potential talent and targeted development. This has been supported specifically through the development of the Director of Nursing who attended the High Performing Executive Programme and senior clinicians attending the Senior Clinical Leaders programme. The in-house Post-graduate Certificate in Management and Leadership programme has completed with 15 staff gaining the full award and a further 20 staff completed module one Managing a Team, 11 staff completed module 2 Leading Teams and 4 staff completed Leading Services. Recognition and revalidation of the established Clinical Development Programme for staff in bands 2 4 as the first year of the Foundation Degree in Healthcare. This enables Papworth to continue to deliver our successful programme as part of the Assistant Practitioner development; 18 healthcare practitioners are accessing the first intake of the Assistant Practitioner development framework supported with educational funding from the County Workforce Group, this includes15 healthcare support workers and 3 healthcare scientists; Apprentices continue to be supported within the Trust with five currently studying for level 2 & 3 NVQ qualifications; IPR self-assessment tools have been launched to support the Personal Governance Framework and the assessment of individuals actions and behaviours. These are useful tools to assist individuals to focus on an area of their practice and reflect prior to the IPR meeting; Launch of the new Mandatory Training online tool for competencies and complete new Mandatory Training matrix; Papworth Hospital NHS Foundation Trust - Annual Report 2010/

36 Band 6 Nurse rotation programme successfully completed with one substantive appointment and one who has relocated; The Workforce Development team were invited to present at the Society for Cardiothoracic Surgery conference in 2010 on Productive Ward, which won best presentation of conference; Positive assessment visit and feedback on the Foundation Programme for junior doctor trainees in February and March Engagement on the Environment Staff are being encouraged to become more aware of environmental and sustainability issues and become an Environment Awareness Representative (EAR). Papworth launches its Green Campaign - The Sustainability Awareness Campaign was launched in January This included a special issue of the staff newsletter, pages on the intranet and other initiatives aimed at encouraging staff to think of ideas to help the hospital work differently and have a significant impact on how resources could be used more efficiently to support the Government target of reducing energy consumption in all NHS Trusts by 10% by While the Trust plans to re-locate to the Cambridge Biomedical campus, it recognises its responsibility to improve access for patients, improve the health and welfare of staff and support the local community, whilst on the current site. The following projects have already been implemented. CarShare scheme dedicated car parking spaces allocated for staff car sharing; A range of salary sacrifice schemes implemented. Health and Wellbeing Papworth Hospital ensures a working environment which promotes good health and wellbeing for all staff. Through the Personal Governance programme a toolkit has been developed for managers and staff to enable difficult issues to be raised and addressed. In addition, staff have responsibility for maintaining their own health and wellbeing to the best of their ability. Papworth Hospital continues to work with staff to develop the Valuing Health and Wellbeing programme. A working group has been set up to develop and support health and wellbeing activities throughout the Trust. An interactive event which gave advice and support to staff on leading healthy lifestyles was held in January The main focus was on Healthy Lungs and saw the launch of a smoking cessation support programme for staff. The Hospital s intranet has been developed to provide information on current topics and health promotion materials. A working group has been set up to Papworth Hospital NHS Foundation Trust - Annual Report 2010/

37 develop and support health and wellbeing activities throughout the Trust, such as site walks Occupational Health Services Papworth Hospital s Occupational Health Department is accredited with NHS Plus status and continues to generate income through the provision of services to external customers, as well as maintaining the quality of service provided to Papworth s own staff. The Occupational Health Department is integral to the pro-active management of sickness absence. The sickness absence total for the Trust in 2010/11 was 3.35% (4.27% in 2009/10), bettering the Trust target of 3.5%. 2010/11 Quarter 1 Quarter 2 Quarter 3 Quarter 4 % Total 3.13% 3.23% 3.62% 3.42% The reduction of sickness absence remains a key performance target. The joint approach between manager, staff member, Human Resources (HR), Risk Manager and Occupational Health together with return to work interviews and phased returns continues to work well, resulting in an overall reduction in the number of days lost. Musculoskeletal Conditions A key focus has been to reduce musculoskeletal conditions, which is recorded as one of the top three reasons for sickness absence and over the course of the year represented almost one in five episodes of all sickness absence. March 2011 saw the introduction of the Papworth Musculoskeletal Injury Clinic for staff on site. The Clinic is a collaborative venture between the Occupational Health and the Physiotherapy Department and offers staff initial assessments followed by treatment sessions either through a referral by occupational health or through self-referral. Disability Information The number of staff who reported themselves as having a disability at the end of 2010/11 was 23, 1.41% of the workforce. Further information on the Trust s policies in connection with Equality and Diversity can be found in the Equality and Diversity Report. Further information on staff engagement can be found in the Staff Survey Report. Research and Development (R&D) Papworth s longstanding reputation for undertaking leading edge R & D to evaluate rigorously and implement clinically and cost effective interventions for heart & lung disease is maintained by the significant research activity at the Trust throughout 2010/11, which includes: Development for those at risk of Sudden Cardiac Death Papworth Hospital NHS Foundation Trust - Annual Report 2010/

38 Sudden cardiac death is currently responsible for more than 70,000 people losing their lives each year in the UK alone and a new device has been developed, following seven years of world-wide research, published in the New England Journal of Medicine, to help patients who are at risk. This new device, a subcutaneous implantable cardioverter defibrillator (S- ICD) has two main benefits over currently used devices. Firstly, as there are no leads actually placed into the heart, their removal or replacement is much simpler, therefore reducing the potential risk for infection. In addition, the S- ICD, may also have a better capacity than other ICDs to discriminate between normal and abnormal heart rhythms and it is strongly anticipated that patients with this device will receive fewer unnecessary shocks. Dr Andrew Grace, Consultant Cardiologist at Papworth Hospital, who has been working with his Papworth colleague Dr Amo Oduro on this project since its inception said: Having worked on this research for the past seven years it was very exciting to see it published. This new work shows that not only is it possible to develop a device without any leads being inserted into the heart, but it is now clear, based on the substantial body of work completed, that the device has major benefits for the patient. New techniques to improve the diagnosis of lung cancer The way in which patients with lung cancer are diagnosed could change following the publication of important research carried out at Papworth Hospital. The results of the ASTER trial (Assessment of surgical staging versus endoscopic ultrasound in lung cancer: a randomised trial) were published in the Journal of the American Medical Association. Lung cancer is the most common cause of cancer death in the UK killing 95 people every day. An important part of diagnosis is finding out how advanced the cancer is a process called staging. Accurate staging of a cancer is important for deciding upon the best treatment. The ASTER trial compared two methods of staging to see which one was more beneficial for patients. The established technique of surgical staging (where a patient has a surgical procedure under general anaesthetic) to examine the lymph glands in the centre of the chest was compared to the new less invasive technique of endobronchial and endoscopic ultrasound. These new techniques involve passing flexible telescopes through the mouth and into either the airways or the oesophagus (gullet) from where it is possible to take biopsy samples from the lymph glands. This is done under light sedation as a day case. The study has shown that the new techniques are just as effective as the traditional surgical procedures but have fewer complications and are more likely to avoid patients having inappropriate surgical operations to try and remove a lung cancer which has already spread. Papworth Hospital was the only UK centre to take part in the European ASTER trial of 240 patients. The three other centres were in Holland (Leiden) and Belgium (Ghent and Leuven). PulMiCC Trial Papworth Hospital began recruiting for the multi-centre 'PulMiCC' trial. The research, funded by Cancer Research UK, aims to examine the benefits of treatment for patients who, after successful treatment for bowel cancer, go on to develop secondary cancer in their lungs, known as metastases. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

39 Papworth is one of 20 leading UK thoracic surgery centres involved in the trial which is being coordinated by the Royal Brompton and Harefield Clinical Trials Unit. PulMiCC aims to compare the benefits of a type of surgery called metastasectomy against no surgery. Some patients who have been treated for bowel cancer go on to develop pulmonary metastases in their lungs. Patients who are fit enough for surgery may be offered a metastasectomy to remove the growths. However, it is not clear whether patients undergoing metastasectomy live longer and have better quality of life than patients who do not undergo the surgery. Principal investigator for PulMiCC at Papworth Hospital, Thoracic Surgeon, Mr Aman Coonar explains: "We are contacting specialists in colorectal (bowel) cancer and chest physicians around the region to request that patients who fit the criteria are given the opportunity to join the trial to help answer this key question." Papworth Hospital tests potential of a national lung cancer screening programme A new study to test the potential of setting up a national lung cancer screening programme was announced in January Researchers will assess if the expertise and technology at cancer centres, such as Papworth Hospital, could efficiently support a large-scale screening programme, similar to those already in place for breast cancer detection. The pilot UK Lung Screening (UKLS) trial, is funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) programme and builds on a programme of research into the feasibility of lung cancer screening. Dr Robert Rintoul, Lung Cancer Specialist at Papworth Hospital said We are very excited about this trial which will examine whether a national lung cancer screening programme could potentially reduce the number of deaths from lung cancer in the UK. Lung cancer is the leading cause of death from cancer in the UK claiming over lives each year. If we can detect lung cancer at an early stage there is a much better chance that we could cure it. Members of the public who are identified through questionnaires as having one or more of the risk factors for lung cancer will be invited to take part in the pilot UKLS trial. They will receive a CT-Scan and be monitored for early signs of lung cancer. This group will be compared to people with the same risk factors but who have not received specialist scans. All those participants who smoke will be offered smoking cessation advice. Further information on our clinical research can be found in our Quality Accounts. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

40 Register of Interests At the time of their appointment, all Directors are asked to declare any interests on the Register of Directors Interests. There is a standing item on all Board of Directors and Committee meetings to confirm/update declarations of interest. The register is held by the Trust Secretary and updated annually or as required during the year. The register is available to the public on request. Anyone who wishes to see the Register of Directors Interests should make enquiries to the Trust Secretary at the following address: The Trust Secretary, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, CB23 3RE. The Directors Report is presented in the name of the following directors who occupied Board positions during the year 2010/11: Name Robert Burgin Anne Bailey Andrew Bradley John Lodge Nicky Mullany Howard Rolfe Michael Simmonds Stephen Bridge Elizabeth Horne Ann-Marie Ingle Jane Payling Susan Stewart Claire Tripp Title Chairman Non-executive Director Non-executive Director Non-executive Director Non-executive Director Non-executive Director Senior Independent Director and Vice Chairman Chief Executive Officer Director of Human Resources Director of Nursing Director of Finance Medical Director Director of Operations Stephen Bridge Chief Executive for and on behalf of the Board of Directors 2 June 2011 Papworth Hospital NHS Foundation Trust - Annual Report 2010/

41 Compliance with the NHS Foundation Trust Code of Governance Monitor s Code of Governance In March 2010, Monitor published a revised NHS Foundation Trust Code of Governance (the Code). The purpose of the Code is to assist NHS Foundation Trust Boards in improving their governance practices by bringing together the best practice of public and private sector corporate governance. The Code was issued as best practice advice, but imposes some disclosure requirements. The Board of Directors and the Board of Governors of the Trust are committed to the principles of good corporate governance as detailed in the Code. Since publication of the first Code in 2006, work has been undertaken to evaluate compliance with the provisions of the Code. Application of main and supporting principles of the Code: Directors The Board of Directors is responsible for ensuring proper standards of corporate governance are maintained. The Board, as from January 2008, is made up of the Chairman, 6 Executive Directors and 6 independent Non-executive Directors and is collectively responsible for the success of the Trust. The Board of Directors considers all of the current Non-executive Directors (NEDs), including the Chairman, to be independent. The Chairman satisfied the independence criteria of the Code on his appointment and all the Non-executive Directors who have served during the year are considered to be independent according to the principles of the Code. During 2009 the Trust became a partner in one of the first five Academic Health Science Centres designated by the Department of Health. The Chairman, Chief Executive and the Non-executive Director nominated by the University of Cambridge became members of the Board of this separate legal entity. The Board of Directors does not consider this to effect the independence of these Directors and has made Monitor aware of the position. During the year one of the Non-executive Directors, Mr H Rolfe, held the post of Procurement Director at the East of England Collaborative Procurement Hub (EoECPH). The EoECPH is a non-profit making organisation which works on behalf of trusts in the East of England to procure on a collaborative basis. EoECPH covers its operational costs by payments from the trusts it represents. Although the EoECPH is regarded as a related third party of the Trust, the Board of Directors does not consider this to effect the independence of Mr Rolfe. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

42 Independence is kept under review and is based on whether each Director is independent in character, judgement and behaviour. Also considered are factors such as participation and performance on both the Board and Board Committees. Non-executive Directors (NEDs), including the Chairman, are not NHS employees nor are they in receipt of NHS pensions. In the most recent appraisal process Non-executive Directors confirmed their willingness to provide the necessary time for their duties. All NED terms of office are subject to approval by the Board of Governors. The Board is satisfied that no individual or group has unfettered powers or unequal access to information. The Board has received confirmation from all Directors that no conflicts of interest exist with their duties as Directors. The Chairman has regular meetings with the Non-executive Directors without the Executive Directors being present. The Senior Independent Director meets with the other Non-executive Directors without the Chairman being present. The Board considers strategic issues. The New Hospital Project is considered at all Board of Director, Board of Governor and Forward Planning Committee of the Board of Governors meetings. The Board meets regularly and has a formal schedule of matters specifically reserved for its decision. The Board delegates other matters to the Executive Directors and other senior management. The Board has at least ten scheduled meetings each year. The Directors are given accurate, timely and clear information so that they can maintain full and effective control over strategic, financial, operational, compliance and governance issues. The Directors have a range of skills and experience and each brings independent judgement and knowledge to the Board s discussions and determinations. The Trust has arranged appropriate insurance cover in respect of legal proceedings and other claims against its Directors. Independent professional advice is available as required to the Board or its standing committees. Details of the composition of the Board and the experience of the Directors are contained within the Board of Directors section of the Annual Report which also includes information about the standing committees of the Board, the membership of those committees, and attendance. Arrangements have been put in place by which the Trust s employees may in confidence raise concerns about matters of concern to them. These arrangements are covered in the Trust s Policy for Raising Matters of Concern commonly known as a Whistle-blowing Policy. The Chairman of the Trust is Chairman of the Board of Directors and Board of Governors and leads both Boards on strategy and monitoring. The Chief Papworth Hospital NHS Foundation Trust - Annual Report 2010/

43 Executive has responsibility for the implementation of strategy and the day to day operations of the Trust. Governors The Board of Governors is responsible for representing the interests of the Trust s members and stakeholder organisations in the governance of the Trust and exercises certain statutory powers, including the appointment and remuneration of the Chairman and Non-executive Directors and the appointment of the External Auditor. The Board of Governors is responsible for holding the Board of Directors to account for the performance of the Trust. The Board of Governors consists of 18 elected public members, 7 elected staff members and 7 appointed stakeholder representatives. The Board of Governors meets four times a year in plenary session. Details of the composition of the Board of Governors and attendance at meetings are contained within the Board of Governors section of the Annual Report. Board Performance Evaluation An annual appraisal of Non-Executive Directors (NEDs) is carried out by the Trust Chairman for report to the Appointments [NED Nomination and Remuneration] Committee of the Board of Governors. Individual NEDs are briefed on their appraisals by the Trust Chairman. The appraisal of the Trust Chairman is co-ordinated by the Deputy Chair of Governors using input from the Chairs of Governor Committees, the Senior Independent NED and the Chief Executive. The Deputy Chair of Governors is also the Chair of the Appointments Committee of the Board of Governors. During 2010/11 members of the Appointments [NED Nomination and Remuneration] Committee of the Board of Governors and Chairs of Governor Committee were invited by the Board of Directors to attend Board meetings as observers on a rotational basis, to strengthen the link between Governors and to facilitate whole Board and individual member appraisal. Compliance Statement The Board of Directors considers that it complies with the main and supporting principles of the Code of Governance. This includes the issue of whether or not all of the NEDs are independent in accordance with code provision A.3.1. In relation to the more detailed provisions of the Code of Governance, the Trust is either compliant with the provisions or in the process of taking action to ensure compliance, with the following exceptions: A.3.5 The Chairman of the Trust is an advisor to the Board of Governors of Cambridge University Hospitals NHS Foundation Trust (CUH) and the Chairman of CUH is a partner Governor of Papworth. Monitor (the Independent Regulator of Foundation Trusts) has been advised of this arrangement and considers it acceptable due to the proposals for the relocation of Papworth Hospital to the Cambridge Biomedical Campus. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

44 C.2.2 The revised code (March 2010) introduced a change to the number of terms for NEDs, reducing them from three terms of three years to two terms of three years, with annual appointments thereafter in exceptional circumstances. Succession planning arrangements already in place at the time of the publication of the revised code in March 2010 has resulted in the trust having Non-executive Directors who are serving third three year terms. The Appointments [NED Nomination and Remuneration] Committee will keep terms under review but will continue to make decisions based on succession planning priorities. C.2.3 The Trust agrees that the attendance record at formal, plenary meetings of the Board of Governors is relevant and should be made available to voters when elected Governors stand for re-election and this has been provided for elections since The Trust does not believe that attendance at other events is of the same status and should also be so reported. In the interests of recruiting a diverse and representative Board of Governors, the Trust recognises that elected members will come from a wide variety of backgrounds and will be able to devote different amounts of time to the role, in addition to the minimum required to attend formal meetings. The nature of the Trust s Public Constituencies (including Rest of England and Wales, Norfolk, Suffolk and Cambridgeshire) also means that a number of the Trust s Governors travel a considerable distance to attend meetings. E.2.2 The Board has determined that the definition of senior management should be limited to Board members only. E.2.3 The Board of Governors did not appoint external professional advisers to market test the remuneration levels of the Chairman and other Non-executive Directors. The recommendations made to the Board of Governors during 2010/11 and in previous years were based on benchmarking information obtained from the Foundation Trust Network, which provides benchmarked and externally validated guidance relevant to Foundation Trusts at a collective national level. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

45 Board of Governors As an NHS Foundation Trust, Papworth has a Board of Governors as required by legislation. The Board of Governors provides support and advice to the Trust to ensure that it delivers services that best meet the needs of patients and the communities it serves. From September 2007 when constitution changes were approved by the Members, it has comprised 18 public and 7 staff members, all elected from the membership, together with 7 representatives nominated from local organisations. The Board of Governors fulfils a number of formal functions such as the appointment of external auditors and the appointment of the Chairman and other Non-executive Directors. The Board of Governors may, at a general meeting, appoint or remove the Chairman and the other Non-executive Directors of the Trust, although the decision to remove a Non-executive Director would require the support of three quarters of the members of the Board of Governors voting at a meeting. The Board of Governors supports the work of the Trust outside of its formal meetings, advised by the Executive Directors and the Chairman. Board of Governors Committees play an important role, with the skills and experience of individual Governors providing a valuable asset to the Trust. Through the Committees, Governors have the opportunity to concentrate on specific issues in greater detail than is possible at a full meeting of the Board of Governors. The Board of Governors has the following committees: Forward Planning, which reviews forward planning (including the Annual Plan submitted to Monitor) and the New Papworth Hospital project; Appointments [Non-executive Director Nomination and Remuneration], which leads on the appointment; re-appointment and remuneration of NEDs. The Committee is chaired by the Deputy Chair of Governors [Lead Governor]; Patient/Public Involvement and Membership (PPIM), which considers patient and public involvement and membership issues. The remit of this Committee is being extended to include validation of patient outcome information. Composition of the Board of Governors The public and staff members of the Board of Governors are elected from the membership by the members to serve for three years. Details of the membership of the Board of Governors during the year are provided in the following pages. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

46 Members of the Board of Governors during 2010/11 Elected Governors, representing and elected by the membership constituencies Cambridgeshire Julia Fleming from Cambridge Julia worked at Papworth Hospital as Senior Secretary to the East Anglian Regional Cardiac Unit for 23 years from 1961 and has maintained links and a great interest in the hospital s progress ever since. Diana Smith from Huntingdon Diana is a member of the Disability Group and the Equality & Diversity committee of a housing association. Diana is disabled, with spinal muscular atrophy, and has been a patient at Papworth Hospital for the past 14 years. She is a member of a local Baptist church. Daphne Spink MBE from Winslow (formerly Eltisley) Daphne has 26 Years experience as a district councillor, leader for 4 years and chairman for 2 years. Most of the time spent on housing and planning and latterly recycling and refuse. Audrey Stenner from Huntingdon Audrey is a former Chairman of Papworth Hospital and of various national and regional committees. Barry Taylor from Newmarket (elected September 2010) Barry has been with his firm of Solicitors in Newmarket since He commenced his working life as a trainee Legal Executive, qualified as a Legal Executive and then qualified as a Solicitor. He is and has been for some years an Equity Partner of the firm and its current Chairman. Suffolk Eric Flack from Bury St. Edmunds Eric is a retired chemist and food scientist, a former managing director of a food ingredient company, technical author and consultant. Robert Hadley from Colchester (Suffolk Governor until Sept 2010) Robert is a retired chartered accountant with broad experience in both private and public sectors. Robert has been a Papworth patient. Julia Dunnicliffe from Bury St Edmunds Julia is a retired NHS oncology and research nurse and has since been working in local government. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

47 Norfolk John Fiddy MBE from Newton St Faith, Norwich John is the former Chairman of the Norfolk Zipper Club which actively offers help and advice to cardiac patients and their families and continually fundraises for Papworth. John underwent heart surgery at Papworth Hospital in 1984 and again in In 2008 John was awarded an MBE for his services to cardiac patients. Norman Howarth from Old Costessey After National Service in the RAF, Norman joined the Blackburn Borough Police in 1950 and quickly rose to the rank of Det. Ch. Inspector, (Head of CID). On amalgamation with Lancashire Constabulary in 1969 he became Superintendent, and later Ch. Superintendent in that force. In 1974 he was seconded to the Hong Kong Government, and played a leading role in establishing the Independent Commission Against Corruption, formed to deal with rampant corruption within H.K. Government Departments and in particular the Royal Hong Kong Police. He served with distinction for 15 years as Principal Investigator and Asst. Director of the ICAC, returning to the UK in He is an active committee member of the Norfolk Zipper club which raises money to buy equipment for Papworth. He underwent heart surgery at Papworth in Albert Mills from Wymondham Albert is a retired actuary by profession but worked in general management and as a main board director in the insurance industry. Albert was a Papworth patient in David Walker from Old Costessey, Norwich (resigned January 2011) David is retired and a builder by profession. David is a member of the Norfolk Zipper Club. Rest of England and Wales Janet Atkins from Stevenage Janet has been a member of the Patient Experience Panel since 2003 and was joint Chair in She is actively involved in various committees within the hospital concerning patient issues. Janet is a Papworth patient. Mervyn Maclaren from Campton (until September 2010) Mervyn is a retired RAF pilot. He also has 20 years experience in industry at middle management level. He retired in Mervyn is a past patient of Papworth. Robert Hadley from Colchester (elected as Rest of England Governor September 2010) Robert is a retired chartered accountant with broad experience in both private and public sectors. Robert has been a Papworth patient. Richard Maddison from Bedford Richard retired from university teaching of information systems, computing and management; and is Vice-Chairman of The British Cardiac Patients Papworth Hospital NHS Foundation Trust - Annual Report 2010/

48 Association and Editor of their Journal. He is a member of the Patient and Public Involvement and Membership Committee, the Patient Experience Panel, and the Appointments (Non-executive Director Nomination and Remuneration) Committee. Richard has been a Papworth patient for many years. Harvey J Perkins from Manningtree, Essex Harvey is a business consultant and a semi-retired professional engineer with extensive multi-national business experience. Harvey was a Papworth patient in Staff Governors Amo Oduro, Doctors Amo has been a Consultant Anaesthetist at Papworth since December He has represented clinical colleagues at various committees over that period. Michael Moore, Administrative, Clerical & Managers (elected September 2010) Head of Information Technology and Systems, Mike has been in the health service for 13 years and previously was in a similar role for a major international bank. Celia Hyde, Nurses Celia has been a Nurse at Papworth Hospital since 1982 and was promoted to Modern Matron in Transplant Services in August Gillian Stent, Nurses Gillian has worked in the Health Service since 1967 in a variety of posts. She started working at Papworth in 1995 and is currently a Nurse Consultant in Thoracic Malignancy. Arlene Jackson, Scientific & Technical Arlene has worked at Papworth for 25 years, progressing from student to Head of Department for Respiratory Physiology. She has held this post for the last 15 years. Richard Rowlands, Allied Health Professionals Richard has been a qualified Radiographer for 36 years and has been the Radiology Manager at Papworth for the past 19 years. Steve Rackley, Ancillary, Estates & Others Steve has worked within the Estates Department since Sept 2000, working up to his current position as the Operations Manager, in charge of day to day maintenance and man-management. Appointed Governors Graham Allen Academic Secretary, University of Cambridge. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

49 Mary Archer Chairman, Cambridge University Hospitals NHS Foundation Trust. Vacancy Peterborough PCT Linda Oliver Councillor and Chairman, Cambridgeshire County Council. Judy Patrick Chief Contracts Manager, Lincolnshire Primary Care Trust. John Willis (resigned January 2011) Chief Executive, The Varrier-Jones Foundation. A charity giving financial support for the work of The Papworth Trust, providing employment, housing, care and advice for disabled people. Nick Wright District Councillor, South Cambridgeshire District Council (SCDC covers Papworth Everard). Terms of Office of Governors as at 31 March 2011 Elected Public Constituency Name First Elected Re- Elected Second Term Re- Elected Third Term End of Current Term of office Cambridgeshire Julia Fleming Oct 2008 Oct 2011 Diana Smith Oct 2004 Oct 2005 Oct 2008 Oct 2011 Daphne Spink Audrey Stenner Oct 2008 Oct 2011 Oct 2008 Oct 2011 Barry Taylor Oct 2010 Oct 2013 Suffolk Vacancy Julia Dunnicliffe Oct 2009 Oct 2012 Eric Flack Oct 2005 Oct 2008 Oct 2011 Vacancy Rest of England and Wales Harvey Perkins Robert Hadley Oct 2004 Oct 2005 Oct 2008 Oct 2011 Oct 2010 Oct 2013 Janet Atkins Mar 2007 Oct 2010 Oct 2013 Papworth Hospital NHS Foundation Trust - Annual Report 2010/

50 Richard Maddison Oct 2004 Oct 2007 Oct 2010 Oct 2013 Vacancy Norfolk John Fiddy Oct 2004 Oct 2007 Oct 2010 Oct 2013 Albert Mills Oct 2005 Oct 2008 Oct 2011 Vacancy Norman Howarth Oct 2005 Oct 2008 Oct 2011 Elected Staff Constituency Name First Elected Re- Elected Second Term Re- Elected Third Term End of Current Term of office Doctor Amo Oduro Oct 2007 Oct 2010 Oct 2013 Administrative, Clerical & Management Michael Moore Oct 2010 Oct 2013 Nursing Celia Hyde Oct 2004 Oct 2007 Oct 2010 Oct 2013 Gillian Stent Oct 2005 Oct 2007 Oct 2010 Oct 2013 Scientific & Technical Allied Health Professionals Ancillary, Estates and Others Appointed Governor Arlene Jackson Richard Rowlands Steve Rackley Oct 2007 Oct 2010 Oct 2013 Oct 2004 Oct 2007 Oct 2010 Oct 2013 Oct 2007 Oct 2010 Oct 2013 Cambridge University Hospitals NHS FT Chief Executive Varrier Jones Foundation Mary Archer Oct 2004 Vacancy South Cambridgeshire District Council Nick Wright May 2008 Cambridgeshire County Council Linda Oliver Oct 2004 University of Cambridge Peterborough PCT Graham Allen Vacancy Oct 2004 Lincolnshire PCT Judy Patrick Oct 2007 Papworth Hospital NHS Foundation Trust - Annual Report 2010/

51 At the time of writing the Annual Report the election process for 2011 is underway. Register of Interests All Governors are asked to declare any interests at the time of their appointment, annually and on re-election. There is a standing item on all Board of Governors and Committee meetings to confirm/update declarations of interest. The register is held by the Trust Secretary. The register is available to the public on request. Anyone who wishes to see the Register of Governors Interests should make enquiries to the Trust Secretary at the following address: The Trust Secretary, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, CB23 3RE Contacting the Governors Governors can be contacted via Corporate Affairs: Tel: foundation.trust@papworth.nhs.uk Corporate Affairs Office, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge CB23 3RE Governor Election Results Electoral Reform Services Limited (ERS) acted as the returning officer and independent scrutineer for the election process during There were vacancies for Governors in all our Public and Staff constituencies. There was only one candidate for each of the vacancies, hence each candidate was elected unopposed. All Governors were appointed for a period of three years. Table of Attendance at Board of Governors Meetings 2010/2011 Name 22 June 10 9 Sept Nov Mar 11 Allen, Graham Archer, Mary Atkins, Janet Dunnicliffe, Julia Fiddy, John Flack, Eric Fleming, Julia Hadley, Robert Howarth, Norman Hyde, Celia Jackson, Arlene Maclaren, Mervyn (End of term Sept 10) No longer a governor Maddison, Richard Papworth Hospital NHS Foundation Trust - Annual Report 2010/

52 Name 22 June 10 9 Sept Nov Mar 11 Mills, Albert Moore, Mike (Elected Sept 10) Oduro, Amo Oliver, Linda Patrick, Judy Perkins, Harvey Rackley, Steve Rowlands, Richard Smith, Diana Spink, Daphne Stenner, Audrey Stent, Gillian Taylor, Barry Not yet (Elected Sept 10) elected Walker,David (Resigned January 11) No longer a governor Willis, John (Resigned February 11) No longer a governor Wright, Nick Indicates attendance at meeting Involving and Understanding the views of the Governors and Members The Board of Directors welcomes all opportunities to involve and listen to the views of Governors and Members. Listed below are some of the activities that demonstrate this commitment: Members voting (and standing for election) in elections for the Board of Governors; Presentations for Governors on subjects including New Papworth Hospital; Three Governor/Director Committees: Forward Planning, Appointments [Non-executive Director Nomination & Remuneration], and Patient/Public Involvement and Membership (PPIM). Governors chair these Committees; Governors attendance at the Annual Members Meeting; Norfolk Governors chairing and leading Norfolk Zipper Club, which supports patients and their families and actively fundraises for the Trust; Governor membership on the Patient Experience Panel (PEP), Reading Panel, LINkS Charitable Funds Committee and Appeal Committee; Member engagement with the Trust through the PALS (Patient Liaison and Advice Service) & Corporate Affairs Office; Active Volunteer structure; Joint Board of Governors meeting with Cambridge University Hospitals NHS Foundation Trust, to consider Bio-Medical Campus and New Hospital Project. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

53 Table of Attendance of Directors at Board of Governors Meetings 2010/11 Name 22 June Sept Nov Mar 2011 Robert Burgin Anne Bailey Andrew Bradley Stephen Bridge Elizabeth Horne Ann-Marie Ingle John Lodge Nicky Mullany 1 Jane Payling Howard Rolfe 2 3 Michael Simmonds Susan Stewart Claire Tripp indicates attendance at meeting. indicates apologies were received. 1 maternity leave. 2 annual leave 3 advisory attendance before Public Accounts Committee (NHS Procurement) Papworth Hospital is a Trust with a small management team. Executive and Non-executive Directors rationalise attendance at all Trust meetings based on the content of the agenda. However levels of attendance by both Executive Directors and Non-executive Directors at Board of Governor meetings is high. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

54 Foundation Trust Membership Papworth Hospital has always been a patient-centred organisation and as an NHS Foundation Trust strongly believes that greater public participation in the affairs of the hospital combined with the freedoms afforded to Foundation Trusts will help to deliver even better services to patients. In creating a membership the Trust was very clear that it was more important to build an active and engaged membership rather than merely adding numbers. To that end a number of initiatives were undertaken to support greater membership engagement. A new database to allow specific communication with members and an extra category was added to the membership to allow members to indicate that they wish to become more involved with the work of the Trust. A new membership recruitment leaflet was also published, outlining the benefits of membership and promoting the new category of membership. An example of how some members have used this opportunity to become more involved is the hospital's new reading panel. Members were given the opportunity to join a reading panel to give feedback on patient literature and information leaflets before they are published. The new reading panel has more than 30 members and we are extremely grateful to them for taking time to help us in this valuable way. The membership newsletter, Pulse, was redesigned this year to ensure that that it provides value for money as well as the information members wish to learn about the hospital. This year members received three issues of the new-look newsletter. Public constituencies Following changes to its Constitution agreed by Members at our Annual Members Meeting in September 2007, the Trust s public constituencies currently cover the whole of England and Wales allowing anyone over the age of 16 to join. Constituencies have been split to reflect Papworth s regional and national catchment areas. No changes have been made to the constituencies for membership since The Trust has no patient constituency. Public Constituencies are: - Cambridgeshire; Norfolk; Suffolk; and The Rest of England and Wales. Staff constituencies reflect professional groupings using the old Whitley Council classifications: Doctors, Nurses, Allied Health Professionals, Scientific and Technical, Administrative, Clerical and Managers, Ancillary, Estates and Others. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

55 Membership by constituency as at 31 March 2011: Public membership profile Number of members % Cambridgeshire Norfolk Suffolk Rest of England and Wales Sub total 9194 Constituencies - Staff* Number of members Nurses Doctors Allied Health Professionals 88 7 Scientific & Technical 83 7 Ancillary, Estates & Others 64 5 Administrative, Clerical & Managers Sub total 1215 Total Membership *Note: Numbers are of individual members of staff not whole-time equivalents. Annual Members Meeting More than 150 people attended the Papworth Annual Members Meeting and Insight event on 9 September 2010 at the Burgess Hall in St Ives. The audience particularly enjoyed the presentations by clinicians who spoke about our Cystic Fibrosis Centre, the success of the Pulmonary Endarterectomy service, the new S-ICD device and developments in our clinical services over the past year. There was also an opportunity to hear about our work to continually improve the experience for our patients and an update on high profile research projects. The event ended with an update on the new Papworth Hospital project. Membership Plans Plans for future development of membership engagement activity this year include the development of a public and membership involvement strategy. In addition, over the summer, Papworth Hospital will have a presence at key public events in the East of England, namely: the East of England Show, the Royal Norfolk Show, the Cambridgeshire Show and the Suffolk show. Stalls at the events will be run by hospital staff and Governors and will provide an opportunity for members to meet Governors from their area as well as hear about the latest developments at the hospital. The events will provide an opportunity for recruitment of new members, as well as engagement with existing members. The new database will also allow us to survey the membership in 2011/12. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

56 Valuing Volunteers Papworth Hospital continues to be indebted to its 125 volunteers who freely give their time, energy and experience to aid patients and staff and contribute greatly to the patient experience. It has been found that volunteers enrich the lives of patients and their families, contributing significantly to the overall success of patient care. All the staff and patients at Papworth are extremely grateful for the hard work and commitment which its volunteers provide. The areas of the hospital where volunteers help has grown throughout the year and as suitable volunteers are recruited new areas are being considered where their help can be utilised. With the support and guidance of the Voluntary Services Manager, they currently assist in the following areas: Ward visitors; Trolley service around the wards; Meet and greet desk; Gift shop; Chaplaincy visitors; Critical Care Reception Administration; Assisting housekeeping team and help on wards; Help at fundraising events; Assisting in clinics. Heritage Centre The hospital acknowledges the huge contribution that its volunteers make by inviting them to attend an annual Christmas Lunch. In December 2010 over 100 attended this lunch and the Trust s Director of Nursing, Ann-Marie Ingle, formally thanked them on behalf of all the staff for their help and dedication over the past year. Other members of the Executive Team including the Chief Executive attended. Five volunteers were presented with their 10- Year Long Service Awards. Anyone interested in hearing more about the work of the hospital s volunteers should contact the Voluntary Services Manager (via the PALS office, pals@papworth.nhs.uk). Papworth Hospital NHS Foundation Trust - Annual Report 2010/

57 Board of Directors The Board of Directors The Trust Board became the Board of Directors on 1 July 2004, when the Trust formally became an NHS Foundation Trust. The role of the Board of Directors is to manage the Trust by: setting the overall strategic direction of the Trust, within the context of NHS priorities; regularly monitoring the Trust s performance against objectives; providing effective financial stewardship through value for money, financial control and financial planning; ensuring that the Trust provides high quality, effective and patient focused services through clinical governance; ensuring high standards of corporate governance and personal conduct; promoting effective dialogue between the Trust and the communities it serves. Non-executive Directors The Board of Governors has responsibility for appointing the Chairman and Non-executive Directors. One of the Non-executive Directors is a representative nominated by the University of Cambridge. Mr Robert Burgin, Chairman Robert was appointed as Chairman of the Foundation Trust Board in January He was re-appointed from February 2010 for a further term of three years. He is a Member of the Tri-service Armed Forces Review Body appointed in 2004 by the Secretary of State for Defence, completing the maximum allowable remit of six years. He is a Non-executive Director of Circle Anglia Housing Group Management Board and an independent member of the Partners Strategy Board; the group has 64,000 houses under management and is now the second largest in England. Robert was a Director of Invicta Telecare, a company specialising in the provision of 24- hour emergency aid, primarily for the elderly in their own homes or groups in supported housing: the company is now part of Circle Living; as a result Robert ceased to be a Director in January Robert has a wide experience as an executive and Non-executive Director in the private and not-for-profit sectors. Robert was Executive Chairman of the Environment Agency s Anglian Regional Flood Defence Committee until April 2005, responsible for the construction and maintenance of river and sea defences. Prior to May 2000 he was Group Managing Director of Cambridge Water Plc, Gas and Electricity companies and following a long career in the water industry, served as Chairman and Council Member for the East of England with the National Consumer Council for Postal Services prior to his Flood Defence appointment. Robert read Honours in Engineering at Sheffield University and is a Fellow of the Institution of Environmental Papworth Hospital NHS Foundation Trust - Annual Report 2010/

58 Management, a Member of the Institution of Mechanical Engineers and a former member of the Council for Water UK. Robert is a Director of Cambridge University Health Partners (CUHP). Mrs Anne Bailey, Non-executive Director Anne was appointed as a Non-executive Director of the Foundation Trust Board for a term of three years, from October She was re-appointed from November 2010 for a third term of three years. Anne has over 20 years senior management experience in marketing and communications roles in the private, public and third sectors. Previous employers include Reed Elsevier, Suffolk County Council and Safeway. Anne has worked with a diverse range of clients including BT while running her own PR and communications agency. Anne is an Associate Director of Dialogics, a production and training company, as well as DialogueLab, a social enterprise working to improve the communication skills of children and young people. Anne lives in Cambridge and is a graduate of Harvard University. Anne is Chair of the Charitable Funds Committee, member of the Appeal Committee and member of the Quality & Risk Committee. Professor J Andrew Bradley, Non-executive Director Andrew was appointed as a Non-executive Director of the Foundation Trust Board in January 2008 for a term of three years. He was re-appointed from January 2011 for a second term of three years. Andrew qualified in Medicine (MB ChB) from the University of Leeds in 1975, was appointed Lecturer in Surgery at the University of Glasgow in 1978 and became a Fellow of the Royal College of Physicians and Surgeons of Glasgow (FRCS) in In 1984 Andrew was appointed Consultant Surgeon (General Surgery and Transplantation) at the Western Infirmary Glasgow and in 1993 he became Professor at the University of Glasgow. In 1997 he moved to the University of Cambridge to take up the Chair of Surgery and an Honorary Consultant Surgeon position at Addenbrooke's Hospital. Andrew is Head of the Department of Surgery at the University of Cambridge (since 1998), Clinical Director of Transplantation at Addenbrooke's Hospital (since 2001) and one of four Associate Medical Directors at Addenbrooke's Hospital (since 2005). Andrew is currently Chairman of the Kidney Advisory Group at UK Transplant. Andrew is the nominee of the University of Cambridge. Andrew is a member of the Quality & Risk Committee. Andrew is a Director of Cambridge University Health Partners (CUHP). Mr John Lodge, Non-executive Director John was appointed as a Non-executive Director of the Trust Board in November 2002 for a term of four years. He was re-appointed in November 2006 and November 2009 to the Foundation Trust Board for further terms of three years. John worked for IBM from 1974 to 1993, his last position being Chief Operating Officer for IBM s insurance operation. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

59 Since leaving IBM John has been involved in Information Technology in the City of London and held two positions as Chief Executive. He is now Chairman of a medical device company and a property company. John has an MA in Natural Sciences and Economics from Trinity College, Cambridge. John is Chair of the Appeal Committee, Chair of the Research Institute Project Board, a member of the Audit Committee and Charitable Funds Committee. Miss Nicky Mullany, Non-executive Director Nicky was appointed as a Non-executive Director of the Foundation Trust Board in January 2008 for a term of three years and was re-appointed from January 2011 for a second term of three years. Originally a Solicitor, she now runs her own business advising on working with the public. She holds a number of board level appointments in the public, private and not-for profit sectors. Nicky is a member of the Audit Committee and was a member of the Finance and Workforce Committee and the Governance Committee until August Mr Howard Rolfe, Non-executive Director Howard was appointed as a Non-executive Director of the Trust Board in November 2002 for a term of four years. He was re-appointed from November 2006 and November 2009 for further terms of three years. Howard had a career spanning 30 years with Marks and Spencer, including a two year secondment to the Cabinet Office where he led a review of procurement in the NHS and was involved with the first Comprehensive Spending Review. He is now involved with the public sector and community bodies including the East of England NHS Collaborative Procurement Hub and Uttlesford District Council where he is Chair of the Performance Select Committee and the Local Strategic Partnership. He is also a member of the Greater Cambridge Partnership. Howard is Chair of the Audit Committee and is a member of the East of England Audit Chairs group. He takes a particular interest in patient experience and safety, governance, fiscal management, best value and the new hospital. Professor Michael Simmonds, Non-executive Director Michael was first appointed as a Non-executive Director of the Trust Board in August He was re-appointed in 2005 and 2008 for further terms of three years, and is currently the Senior Independent Director. Michael was, prior to his retirement in 2001, Professor of Neuropharmacology and Director of Undergraduate Studies at the School of Pharmacy, University of London. Michael has a lifetime s experience in research, teaching and management. He is also the vice-chair of the Cambridgeshire 1 Research Ethics Committee and a member of the Advisory Group for National Specialised Services. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

60 Michael is Chair of the Quality and Risk Committee and also Chair of the Papworth Organ Donation Committee. Mr Stephen Bridge, Chief Executive Stephen became Unit General Manager of Papworth Hospital in June 1988 and was then appointed Chief Executive in April 1993, when the hospital gained NHS Trust status. He joined the National Health Service in Ipswich in 1976 and held a variety of management positions at regional and district level. Stephen moved into hospital management in 1984, as Director of Operational Services/Deputy Unit General in the acute hospital sector in the West Midlands. Stephen is a Director of CUHP. Miss Elizabeth Horne, Director of Human Resources Elizabeth was appointed as Director of Human Resources in June 2003 with responsibility for all aspects of human resources and has responsibility also for the Hotel Services function. She has worked in a broad spectrum of the service including teaching hospitals and special health authorities. Elizabeth has been actively involved in specific national projects including the specification and evaluation for the electronic staff record system rolled out across the NHS to improve workforce information. Elizabeth has an MA in Law and Employment Relations and is a Fellow of the Chartered Institute of Personnel and Development (FCIPD). Mrs Ann-Marie Ingle, Director of Nursing Ann-Marie was appointed as Director of Nursing in December She first came to Papworth in 1988 to work in Critical Care and subsequently spent a number of years in nurse education at Homerton College in Cambridge, previously Cambridge College of Health Studies. In 1999 Ann- Marie returned to Papworth working as a Practice Development Advisor, followed by involvement in several projects across the hospital. In 2006 she was appointed as Assistant Director of Nursing. Ann-Marie is the professional lead for nursing and is the Director of Infection Prevention and Control. She is also the executive lead for patient safety and the patient experience, patient support services, clinical governance and risk management, and emergency planning. Ms Jane Payling, Director of Finance Jane was appointed as Director of Finance in March 2006 with responsibility for procurement, contracting and performance. Jane joined the NHS in 1992 as a graduate finance trainee with the former East Anglia Regional Health Authority. Jane has worked in a range of organisations spanning provider, commissioner and health authority levels. Her previous role was Director of Finance at Cambridge City and South Cambridgeshire Primary Care Trusts. Jane is an economics graduate and a member of the Chartered Institute of Public Finance and Accountancy (CIPFA). Dr Susan Stewart, Medical Director Susan was appointed as Medical Director at Papworth Hospital in September She has taken up this post after over 20 years experience at Papworth specialising in histopathology, which she still practises. Susan Papworth Hospital NHS Foundation Trust - Annual Report 2010/

61 qualified from Cambridge University and Guy s Hospital, returning to Cambridge in 1979 to train in pathology at Addenbrooke's, Papworth and Peterborough Hospitals. She was appointed as a Consultant Histopathologist at Papworth Hospital in 1986 and developed international expertise in the pathology of heart and lung transplantation alongside lung cancer and other lung diseases. She also has wide experience in clinical governance and quality at Papworth and chairs the Patient Safety Clinical Programme Board at the East of England Strategic Health Authority. Mrs Claire Tripp, Director of Operations Claire was appointed as Director of Operations in October 2008 after previously holding the position of Director of Nursing from November Claire originally started working at Papworth in January 1989 as a Staff Nurse on the Critical Care Unit. She became Thoracic Services Manager in 2000 and in 2003 she was promoted to become the General Manager of Thoracic Services. As Director of Operations, Claire is responsible for the day to day management of the hospital. Claire provides executive lead for IM&T, estate management, medical equipment and the Trust s Service Improvement Planning. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

62 Terms of Office of members of the Board of Directors Appointed Re-appointed From Expiry/End of Term of Office Robert Burgin Chairman Feb 2006 Feb 2010 Feb 2013 Anne Bailey Andrew Bradley John Lodge Nicky Mullany Howard Rolfe Michael Simmonds Stephen Bridge Elizabeth Horne Non-executive Director Non-executive Director Non-executive Director Non-executive Director Non-executive Director Senior Independent Director and Vice Chairman Chief Executive Officer Director of Human Resources Oct 2004 Oct 2010 Oct 2013 Jan 2008 Jan 2011 Dec 2013 Nov 2002 Nov 2009 Nov 2012 Jan 2008 Jan 2011 Dec 2013 Nov 2002 Nov 2009 Nov 2012 Aug 2001 Oct 2008 Oct 2011 April 1993 June 2003 Not Applicable Not Applicable Ann-Marie Ingle Director of Nursing Dec 2008 Not Applicable Jane Payling Director of Finance Mar 2006 Not Applicable Susan Stewart Medical Director Sept 2009 Not Applicable Claire Tripp Director of Operations Oct 2008 Not Applicable Papworth Hospital NHS Foundation Trust - Annual Report 2010/

63 Table of Attendance at Board and Committee Meetings The following table shows the number of Board of Director and Committee meetings held during the year and the attendance of individual Nonexecutive Directors where they were members. Board Audit Quality & Risk Executive Remuneration Number of meetings /11: S Bridge R Burgin A Bailey A Bradley E Horne A-M Ingle J Lodge N Mullany J Payling H Rolfe M Simmonds S Stewart C Tripp Not members of the Committee. However Directors attend meetings of committees of which they are not members either on an annual basis or when required. On maternity leave for part of the year. The dates of the Board of Directors meetings were: 4 May June June July September October November January March March 2011 Contacting the Directors Directors can be contacted via Corporate Affairs: Tel: foundation.trust@papworth.nhs.uk Corporate Affairs Office, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge CB23 3RE Papworth Hospital NHS Foundation Trust - Annual Report 2010/

64 Composition of the Committee Audit Committee As required under Monitor s Code of Governance the membership of this committee is three independent Non-executive Directors. For the purposes of Monitor s Code Howard Rolfe is considered by the Board of Directors to have recent and relevant financial experience. The membership of the Committee during 2010/11 was: Howard Rolfe (Chairman) John Lodge Nicky Mullany Meetings and Attendance Name 28 Apr May Jul Oct Jan 11 Howard Rolfe (Chairman ) John Lodge Nicky Mullany attended meeting apologies were received (maternity leave) To assist the Committee in fulfilling its role the following post holders are in attendance at meetings: The Director of Finance, the Trust Secretary, the Head of Internal Audit, representatives from the External Auditors and the Local Counter Fraud Specialist. The Chairman of the Audit Committee meets both auditors on a more regular basis. The Chairman and Chief Executive are invited to attend the Audit Committee at least once a year. Role of the Committee The Committee s role is to review the adequacy of the Trust s risk and control environment, particularly in relation to: Internal Audit, including reports and audit plans; External Audit, including financial systems and annual financial statements; Counter Fraud Services. The Committee also ensures that the Trust s overall governance and assurance frameworks are robust and active and it reviews the structures, processes and responsibilities for identifying and managing key risks facing the organisation. The Committee is responsible for considering the appointment of the Internal Audit service and reviewing their audit fee. The Committee also reviews Papworth Hospital NHS Foundation Trust - Annual Report 2010/

65 External Audit and makes recommendations to the Board Governors for the re-appointment of the External Auditor. Statement on Internal Control The Trust s draft statement on internal control for 2010/11 was considered by both the Audit Committee and the Quality and Risk Committee. Audit Committee members, together with the Trust s External and Internal Auditors, had the opportunity to comment on the draft statement. The final statement on internal control was endorsed by the Audit Committee on the 26 May 2011 and by the Board of Directors on the 2 June In the opinion of the Audit Committee the Statement on Internal Control is fair and provides assurance to the Accounting Officer that there were no significant risks to the Trust during the year. Specific Audit Committee Issues 2010/11 During 2010/11, the Audit Committee received regular reports from Internal Auditors, External Auditors and Local Counter Fraud Specialist and reviewed their annual workplans and strategies as appropriate. Principal issues considered during 2010/11 were: The Annual Report and Accounts (including Quality Accounts) for 2009/10 (including the External Auditors ISA 260 and letter of representation); The Statement on Internal Control; The Internal Audit Annual Report and Head of Internal Audit Opinion; The External Audit Plan for 2010/11; The Internal Audit Plan for 2011/12; Quarterly submissions to Monitor; Payment by Results Assurance Audit; Service Improvement Assurance; Internal Audit reports were undertaken by the internal auditors for 2010/11 on recruitment, general ledger, creditors, risk management, cash and treasury management, Care Quality Commission registration, Information Governance toolkit, asset management, Governance arrangements (Clinical Governance), medical records, income and debt management, budget setting and budgetary control, payroll, waste collection and disposal, follow up, data quality, ipm PAS, Assurance Framework and business continuity planning; Audit Committee Annual Self Assessment; Follow-up on audit recommendations; Charity Annual Report and Accounts 2009/10. External Auditors - PWC The External Auditors of Papworth Hospital NHS Foundation Trust are: PricewaterhouseCoopers LLP, Abacus House, Castle Park, Cambridge, Papworth Hospital NHS Foundation Trust - Annual Report 2010/

66 CB3 0AN. They report to the Board of Governors through the Audit Committee. Non-audit work may be performed by the Trust s external auditors where the work is clearly audit-related and external auditors are best placed to do that work. For such assignments Audit Committee approval ensures that auditor objectivity and independence is safeguarded. The total cost of audit services for the year was 64,667 (2009/10-60,300), excluding VAT. This was for the statutory audit of accounts for the 12 months ending 31 March 2011, and services carried out in relation to these, plus external assurance on the Quality Report. As part of reviewing the content of the proposed external audit plan for each year, the Audit Committee satisfies itself that the auditors independence has not been compromised. The Foundation Trust is responsible for preparing the Annual Report, the Directors Remuneration Report and the financial statements in accordance with directions issued by the Independent Regulator of Foundation Trusts ( Monitor ) under the National Health Service Act The External Auditors' accompanying opinion on in the financial statements is based on their audit conducted under the National Health Service Act 2006 and in accordance with Monitor's Audit Code for NHS Foundation Trusts and International Standards on Auditing (UK and Ireland), and sets out their reporting responsibilities. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

67 Remuneration Report The Trust has the following Committees contributing to the process of appointment and remuneration of members of the Board of Directors: Nominations Committee of the Board of Directors. The Constitution of the Trust states that the Nominations Committee comprises the Chairman, the Chief Executive and at least one Non-executive Director; Appointments [Non-executive Director Nomination and Remuneration] Committee of the Board of Governors, comprising only Governors; Executive Remuneration Committee of the Board of Directors, comprising all the Non-Executive Directors. Nominations Committee There were no new Executive Director appointments to the Board of Directors during 2010/11. Appointments [Non-executive Director Nomination and Remuneration] Committee The Appointments Committee is responsible for making recommendations on the appointment and re-appointment of the Chairman and Non-executive Directors. One Non-executive Director (NED) was re-appointed for a third term to the foundation trust until the end of October Two NEDs were re-appointed for second terms to the foundation trust until the end of December As required under Section C.2.2 of Monitor s Code of Governance the Trust s Chairman provided the required assurances that following formal performance evaluation, the performance of the NEDs continued to be effective and demonstrated commitment to the role, including commitment of time for Board and Committee meetings and other duties. The Appointments Committee recommended all three reappointments to the Board of Governors and these appointments were supported unanimously. Annual Appraisals Annual appraisal of NEDs was carried out by the Trust Chairman on behalf of the Appointments Committee. Individual NEDs were also briefed on their appraisals by the Trust Chairman. For the appraisal of the Trust Chairman, the Deputy Chair of Governors obtained feedback from the Chairs of Governor Committees, the Senior Independent NED and the Chief Executive, supplemented by feedback from Governor observers at the Board. These views were amalgamated into an overall appraisal, which was considered by the Committee. The Deputy Chair of Governors briefed the Trust Chairman on the contents of his appraisal and action plans were agreed. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

68 During 2010/11 the Board of Directors invited members of the Appointments Committee and Chairs of Governor Committees to attend as observers at Board of Director meetings on a rotational basis, to further enhance Governor involvement. Remuneration/Terms and Conditions of service for Non-Executive Directors (NEDs) The Appointments Committee is also responsible for setting the fees, and terms and conditions of the Trust Chairman and Non-executive Directors. The Chairman and NEDs are not involved in any decision or discussion as to their own remuneration. Non-executive Directors are additionally reimbursed for expenses incurred on Trust business. The Committee recommended to the Board of Governors that the Chairman and NEDs should receive no cost of living increase for 2011/12 as recommended nationally for the National Health Service. The Appointments Committee met twice in 2010/11, on 2 September 2010 and the 8 March Membership and attendance details are provided in the following table. Governor Members Category 2 September 2010 Albert Mills (Chair) Public Celia Hyde Staff 8 March 2011 Richard Maddison Public Audrey Stenner Public Janet Atkins Public Richard Rowlands Staff Attended meeting Apologies received Papworth Hospital NHS Foundation Trust - Annual Report 2010/

69 Executive Remuneration Committee This Committee has delegated authority by the Board of Directors to determine the salary and terms and conditions for Executive Directors. The Chairman and all Non-executive Directors are members of this Committee. Details of Executive and Non-executive remuneration during 2010 /11 can be found in the tables within this section. Table attendance of Non-executive Directors at Executive Remuneration Meetings Name 3 June 2010 Robert Burgin Chairman Anne Bailey Non-executive Director Andrew Bradley Non-executive Director John Lodge Non-executive Director Nicky Mullany Non-executive Director Howard Rolfe Michael Simmonds attended meeting Non-executive Director Senior Independent Director Elements of the Executive Directors Remuneration Executive Directors salaries are reviewed annually, taking into account external market levels and internal comparisons as well as the individual's responsibilities and overall performance against annually agreed objectives. The basic salary is paid as a fixed sum monthly and there is no separate payment or bonus related directly to performance. Pensions Executive Directors are eligible to participate in the NHS Pension Scheme which provides salary-related pension benefits on a defined benefit basis. Employment Contracts The policy of the Executive Remuneration Committee is for the contracts of employment of Executive Directors to contain a maximum notice period of six months. Each contract expires on the pensionable age of the individual which is the normal NHS retirement age, but is subject to earlier termination for cause or if notice is given under the contract. There is no entitlement to any additional remuneration in the event of early termination other than in the case of termination on grounds of redundancy. Remuneration received The remuneration of the Board of Directors appointed or leaving during the year is included in respect of their period of membership only. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

70 Remuneration Details of audited Directors remuneration for 2010/11 and 2009/10 are provided in the following tables: Year ended 31 March 2011 (audited information): Salary 1 Other Remuneration 2 Benefits in kind 3 Name and Title (bands of 5000) (bands of 5000) (Rounded to the nearest 100) Mr R Burgin Chairman Mrs A Bailey Non-executive Director Prof. J Bradley Non-executive Director Mr J Lodge Non-executive Director Miss N Mullany Non-executive Director Mr H Rolfe Non-executive Director Prof. M Simmonds Non-executive Director Mr S Bridge Chief Executive Ms J Payling Director of Finance Miss E Horne Director of Human Resource Mrs A-M Ingle Director of Nursing Dr S Stewart Medical Director Mrs C Tripp Director of Operations Year ended 31 March 2010 (audited information): Salary 1 Other Remuneration 2 Benefits in kind 3 Name and Title (bands of 5000) (bands of 5000) (Rounded to the nearest 100) Mr R Burgin Chairman Mrs A Bailey Non-executive Director Prof. J Bradley Non-executive Director Mr J Lodge Non-executive Director Miss N Mullany Non-executive Director Mr H Rolfe Non-executive Director Prof. M Simmonds Non-executive Director Mr S Bridge Chief Executive Ms J Payling Director of Finance Miss E Horne Director of Human Resource Mrs A-M Ingle Director of Nursing Dr S Stewart Medical Director (ii) Dr D Stone Medical Director (i) Mrs C Tripp Director of Operations Notes: 1. Salary and other remuneration excludes the employer's pension contribution and is gross of pay charges to other NHS Trusts; 2. Other remuneration represents remuneration for clinical duties; 3. Benefits in kind relate to the benefit of a lease car and taxable benefit on mileage; Papworth Hospital NHS Foundation Trust - Annual Report 2010/

71 4. No payments were made in respect of golden hellos or compensation for loss of office; 5. No compensation payments were made to past Executive or Non-executive Directors; 6. No payments were made to a third party for the services of an Executive Director or Non-executive Director; 7. No Executive Director served as a Non-executive Director elsewhere. (i) Dr S Stewart became Medical Director on 1 September 2009; (ii) Dr Stone retired as Medical Director August Pension Benefits 31 March 2011 (audited information): Name and Title Lump Sum at age 60 (bands of 2500) Real Increase in Lump sum at age 60 (bands of 2500) Cash Equivalent Transfer Value Real increase in Cash Equivalent Transfer Value Accrued Pension (bands of 2500) Real Increase in Pension (bands of 2500) Mr S Bridge Chief Executive , Ms J Payling Director of Finance Miss E Horne Director of Human Resource Mrs A-M Ingle Director of Nursing Dr S Stewart Medical Director , Mrs C Tripp Director of Operations Papworth Hospital NHS Foundation Trust - Annual Report 2010/

72 Pension Benefits 31 March 2010 (audited information): Name and Title Lump Sum at age 60 (bands of 2500) Real Increase in Lump sum at age 60 (bands of 2500) Cash Equivalent Transfer Value Real increase in Cash Equivalent Transfer Value Accrued Pension (bands of 2500) Real Increase in Pension (bands of 2500) Mr S Bridge Chief Executive , Ms J Payling Director of Finance Miss E Horne Director of Human Resource Mrs A-M Ingle Director of Nursing Dr S Stewart Medical Director , Mrs C Tripp Director of Operations Notes: 1. Non-executive Directors do not receive pensionable remuneration therefore there are no entries in respect of pensions for Non-executive Directors. 2. Information contained within this note is based on figures provided by the NHS Pension Agency. The CETV is the actuarially assessed capitalised value of the pension scheme benefits accumulated by a member at a particular point in time. 3. The benefits valued are the members accumulated benefits and any contingent spouse s pension payable from the scheme. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries. 4. The current RPI applied to pensions by the NHS Pension Agency is 0%. 5. In calculating the actuarial value of the CETV as at 31 March 2011 the NHS Pensions Agency has used factors which include the indexation of pension benefits in line with the Consumer Price Index (CPI) and not the Retail Price Index (RPI). This follows the Government announcement in July 2010 that pension benefits from 2011 will be indexed in line with CPI and not RPI. The change in inflation assumption can lead to a decrease in the CETV value compared with the CETV as at 31 March S Bridge Accounting Officer 2 June 2011 Papworth Hospital NHS Foundation Trust - Annual Report 2010/

73 Other Public Interest Disclosures Policy to Counter Fraud and Corruption In line with all NHS organisations, Papworth takes a very robust approach to fraud and corruption. A Trust policy is in place which details the points of contact for any members of staff who suspect fraud and corruption is taking place. The Trust has a dedicated counter fraud officer who, amongst other areas of counter fraud work, works on behalf of the Board to create an antifraud culture by raising awareness and undertaking proactive fraud-proofing work. Any concerns reported are investigated at the earliest opportunity by the Local Counter Fraud Specialist (LCFS), in conjunction with the Foundation Trust Management. The LCFS provides reports to the Audit Committee on the concerns raised and the action that has been taken. Consultations There were no consultations in 2010/11 and there are none currently planned for 2011/12. Whistle-blowing The Trust has a Raising Concerns Policy that primarily aims to encourage staff to come forward if they are concerned that the interests of others or of the organisation itself are at risk. Every potential malpractice reported is investigated and appropriate steps taken to deal with it. Whenever possible, feedback is given to the person who raised the issue. Cost allocation and charging During the year 2010/11, the Trust has complied with the cost allocation and charging requirements set out in HM Treasury and Office of Public Sector Information guidance. Data loss or confidentiality breaches The Board annually assesses compliance with the requirements of the Connecting for Health Information Governance Toolkit for the management and control of risks to information. The Trust has nominated the Director of Operations to be its Senior Information Risk Owner (SIRO), the Director of Nursing as the Caldicott Guardian and identified senior managers across the Trust as Information Asset Owners as part of putting in place an Information Governance Management Framework. A regular update on information governance is received by the Quality and Risk (Q&R) Committee of the Board of Directors, which is tasked with providing assurance to the Board. There is an Information Governance Steering Group chaired by the SIRO which reviews / approves policies and procedures / action plans relevant to information governance. The SIRO reports any issues to the Q&R Committee and the Board. The Trust has submitted the NHS Connecting for Health Information Toolkit version 8.0, which includes requirements relating to the Statement of Compliance and achieved a level 2 or above for these key requirements, scoring 68% overall. A serious breach of confidentiality occurred in April 2010 with the loss of paper containing patient data from an offsite location near the hospital. A number of papers were recovered but a number remained lost despite Papworth Hospital NHS Foundation Trust - Annual Report 2010/

74 extensive searches. This incident was reported as a serious untoward incident (SUI) and after a formal investigation identified as an isolated issue where policies had not been followed. Corrective action undertaken includes notices on exits to wards, hospital exits and staff car parks reminding staff not to take patient data home and the provision of secure bags for carrying work on and off the site. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

75 Staff Survey Report Staff Survey Results Response Rate 2009/ /11 Trust Improvement/Deterioration Trust National Trust National Average Average 64% 55% 56% 55% Decrease 8% The 2010 staff survey results were produced by Quality Health. As in previous years, all staff were given the opportunity to complete a survey and a random sample of responses has informed the Care Quality Commission s results. Full results of the National Staff Survey 2010 together with local questions will be made available on the Trust s Intranet. Managers, via the Operational Executive Group (OEG), have been asked to examine the results for their area and feedback to staff as soon as possible. Reporting to staff on the outcomes of the survey and actions taken in response is important in terms of giving information back to staff, in maximising response rates at the next survey and significantly improving the credibility of the process. Specific areas for action are to provide performance metrics for managers to improve their staff engagement and satisfaction scores; implement a staff reward and recognition scheme to recognise the achievements of both individuals and teams; refresh the staff suggestion scheme and increase awareness for staff on raising issues of concerns and eliminating bullying and harassment in the workplace. Each directorate was asked to identify a minimum of three priority actions to inform their performance scorecard and the wider Trust action plan by the end of April This will enable six months implementation prior to the next survey and provide evidence of actions taken. The OEG will monitor implementation. In addition, key working groups such as the Joint Staff Council, Nursing Advisory Committee, Health and Well Being Working Group will contribute to the key priorities for the Trust to further promote staff engagement and improve upon the staff satisfaction results. The Staff Survey results will be used to develop hospital, directorate and team action plans. The Survey questions are structured to enable reports on Health Check and Vital signs ; Health & Safety Executive s Stress Audit; and Improving working Lives. In addition, the Trust is able to use the questions to benchmark its ability to achieve the commitments and pledges stated in the NHS Constitution. The Board of Directors has received the staff survey results and their attention drawn to the areas of improvement and deterioration. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

76 The results are disappointing and reinforce feedback from the Investors in People accreditation process that the Trust is undergoing a period of significant change that raises concern amongst staff together with increased work pressures. In summary, the Trust is above the national average for acute specialist trusts in 2 key areas; average in 14 and worse than average in 22. The four key findings where Papworth compares most favourably with other acute specialist trusts were as follows: 2009/ /11 Trust Improvement/ Deterioration Top 4 Ranking Scores Trust National Average* Trust National Average* Percentage of staff 82% 81% 89% 84% Improvement of 7% receiving health and safety training in last 12 months 2 Percentage of staff 36% 32% 37% 35% Improvement of 1% reporting good communication between senior management and staff 2 Percentage of staff 74% 70% 69% 68% Deterioration of 5% saying hand washing materials are always available 2 Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months 1 12% 15% 9% 9% Improvement of 3% * Compared to other acute specialist trusts. 1 the lower the score the better 2 the higher the score the better Papworth Hospital NHS Foundation Trust - Annual Report 2010/

77 The four key findings where Papworth compares least favourably with other acute specialist Trusts are as follows: 2009/ /11 Trust Improvement/ Deterioration Bottom 4 Ranking Scores Trust National Average* Trust National Average* Staff intention to leave jobs Deterioration of 0.11 Trust commitment to Deterioration of work-life balance Staff job satisfaction Deterioration of 0.7 Papworth scored 2 Support from immediate managers 2 *Compared to other acute specialist trusts. 1 the lower the score the better 2 the higher the score the better Deterioration of 0.15 In relation to patient care, staff were asked if they were satisfied with the quality of care they gave to patients and 90% (of those who felt it was applicable to them) agreed that they were satisfied. 89% said that if a friend or relative needed treatment they would be happy with the standard of care provided by the Trust and 78% of staff thought the Trust made patient or service user care its top priority. The results showed that staff felt positive about work with 68% saying they were enthusiastic about their job and 89% agreed their role made a difference to patients. Health Check and Vital Signs Programme The Operating Framework lists a series of Vital signs indicators with the NHS staff survey job satisfaction scores being a National priority. In order to meet the vital signs targets, there needs to be a year-on-year progress. The score is based on a 5 point scale (with 1 being the lowest and 5 being the highest and the result is published annually. For any year the change in score cannot easily be calculated, although a 0.1 point increase equates to approximately achieving a 2% improvement on every question in the 7 question matrix. The staff survey response for the Trust is shown in the following table: Papworth Hospital NHS Foundation Trust - Annual Report 2010/

78 Subject Questions % change Recognition for good work 51% 53% 48% - 5% Satisfied with support from their immediate manager 63% 66% 61% - 5% Satisfied with the support from their work colleagues 76% 76% 74% - 2% Freedom to choose their own methods of working 71% 61% 61% = Satisfied with the amount of responsibility given 74% 68% 73% + 5% Satisfied with the opportunities to use their abilities 70% 68% 64% - 4% Satisfied with the extent to which the Trust values their work 41% 41% 42% + 1% Overall Staff satisfaction was 3.50 and below average when compared to other acute specialist trusts (3.57). This was a reduction from last year s score of The overall staff engagement score of 3.78 was average when compared with other acute specialist trusts (3.80). The score is based on 3 indicators: Key Findings Staff ability to contribute towards improvement at work Staff recommendation of the Trust as a place to work or receive treatment Staff motivation at work Ranking compared with other acute specialist trusts Below (worse than) average (change from average) Average (change from above average) Average Progress against the action plan will be reviewed by the Quality and Risk Committee, a sub committee of the Board of Directors to assure that ongoing improvements in results is achieved and key areas of concern addressed. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

79 Sustainability Report Introduction Sustainability is defined as Meeting the needs of current generations without compromising the ability of future generations to meet their own needs. It is about energy efficiency, carbon reduction and recycling and also ensuring social justice and equity, and integrating environmental, health, social, political and economic issues into decision making. In January 2009 the Department of Health issued Saving Carbon Improving Health a document aimed at significantly reducing the impact the NHS has on the environment by setting a series of action points. Saving Carbon Improving Health was developed in response to the need to take action on climate change in consultation with the NHS and other organisations. One of the key recommendations in Saving Carbon Improving Health is the development of a Board level Sustainable Development Management Plan, which Papworth Hospital s Board approved in March Success in the sustainable development management plan will allow Papworth Hospital to move towards being an environmentally responsible organisation, as well as contributing to the protection of natural resources and the development and support of sustainable local and global communities. The Sustainable Development Plan documents the initiatives to be actioned by the Trust s Sustainability Steering Group. At a national level the NHS Sustainable Development Unit produced the NHS Carbon Reduction Strategy, launched in January This strategy sets out key commitments and time frames around carbon reduction for NHS organisations. This is a corporate social responsibility issue and fits within the wider sustainability remit of the NHS Sustainable Development Unit as carbon is one of the important measures for examining progress towards a sustainable NHS. The NHS Carbon Reduction Strategy establishes that the NHS should have a target of reducing its 2007 carbon footprint by 10% by In terms of wider targets, the NHS Carbon Reduction Strategy states that meeting the Climate Change Act requirement of a 26% reduction of carbon emissions by 2020 and 80% reduction by 2050 is required. The NHS Carbon Footprint in 2004 was 18.6 MtCO2, which represents 25% of England public sector emissions. Papworth Hospital Baseline Papworth Hospital s baseline year for the Sustainability Management Plan and the Carbon Management Plan is 2007/2008 and uses information from the Trust s annual Estates Return Information Collection [ERIC] (Estate) returns which include full data regarding the use of energy, waste and water. In addition to this annual data collection the Trust engaged NIFES Consulting Group to undertake an assessment of the Trust s electricity consumption in relation to the Carbon Reduction Commitment (CRC) and the requirement to Papworth Hospital NHS Foundation Trust - Annual Report 2010/

80 register the Trust. NIFES also undertook an assessment of Papworth s Carbon footprint and provided proposals to improve the Trust s energy performance. The estimated basic carbon footprint for Papworth Hospital for the 12 months ending 31 March 2011 was 22,109 tco2e. The breakdown of this figure is as follows: Travel 1,932 tco2e (9%) Building 6,824 tco2e (31%) Procurement 13,353 tco2e (Estimated) (60%) (tco2e: 1 tonne of CO2 equivalent) This information is broken down in more detail in Graph 1. The total carbon footprint resulting from procurement has been estimated and is based upon information from the NHS Sustainability Development Unit. The measurement of the carbon emissions due to procurement is more complex, the Sustainability Steering Group will establish appropriate NHS standard metrics as part of the work programme. This procurement related carbon footprint, although an estimate is the largest contributor to carbon emissions related to the Trust. This is currently the least controllable aspect of carbon production, with much of it related to the practices of suppliers. Graph 1. Total Carbon Footprint Procurement 61% Electricity 16% Gas Oil 12% Commuti ng 8% Natural Gas 2% Water 0% Waste 1% LPG 0% Fugitive Emissions 0% Business Mileage 0% Patient Transport 0% Papworth Hospital NHS Foundation Trust - Annual Report 2010/

81 Graph 2. Carbon Footprint(Excluding Procurement) Commuting 21% Patient Tr ansport 0% Business Mileage 1% Fugi ti ve Emissions 0% LPG 1% Gas Oil 31% Water 1% Waste 2% Natural Gas 5% Electricity 38% Graph 2 represents the total carbon footprint excluding procurement. Buildings and energy represent the highest carbon impact (after procurement) at the Trust, the sustainability management plan will need to focus on the issues of energy conservation, water and waste reduction over the next 5 years if the Trust is to achieve the 2015 target reduction in CO2 emissions. Of particular importance is to shift primary fuel sources from high carbon to lower carbon fuels where possible. The Trust will be undertaking three boiler fuel conversion projects during 2011/12 moving from oil to gas fuel. The Carbon Reduction Commitment (CRC) has required the Trust to disclose the electrical energy consumed in a qualification year, 2008, which was just below the 6,000Mwh threshold for full participation in the CRC. Papworth Hospital s consumption at 5,894MWh was such that the Trust was not required to register for the scheme and is not subject to the full reporting requirements or the commitment to purchase CRC allowances. Papworth Hospital has now exceeded the threshold and may well have to enter the scheme at the next milestone year. Performance and Targets The overall energy performance of Papworth Hospital is obtained from the annual ERIC returns and in 2010 was 72GJ (Giga Joules)/100m 3 this compares reasonably to 2007/08 when the performance was 66 GJ/100m 3. Best Practice targets for NHS facilities are as follows: Teaching and Specialist Hospitals < 65GJ/100m 3 General Acute Hospitals < 62 GJ/100m 3 The New Papworth Hospital will be built to a standard of 45 GJ/100m 3. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

82 Graph 3 indicates the actual CO2 emissions up to 2010/11 which are projected to remain at that level to 2015 assuming business as usual and no further expansion of the site or significant increases in activity. The graph also shows the year on year reduction necessary to achieve the 10% reduction in carbon by 2015, a total reduction of 666 tco2. The Sustainability Management Plan sets out the strategy and the actions the Trust plans to take to achieve the target reduction in advance of the move to the New Papworth Hospital Graph 3. Carbon Emissions from Fossil Fuels 6000 Carbon (tonnes) CO2 Emissions Actual (tonnes) CO2 Emissions Target (tonnes) / / / / / / / / / /15 Actions A summary of actions completed in 2010/11 are shown below: Energy and Carbon Management Completion of water usage audit and actions implemented; Completion of Assessment of Energy Saving Opportunities; Improved energy performance monitoring; Roof and cavity wall insulation; Improved lighting efficiency by rolling out a Light Emitting Diode (LED) lighting project; Passive Infra Red Sensors (PIR) sensors installed in theatres to control ventilation plant; Feasibility study into the conversion of oil fired boilers to gas firing; Feasibility study into external LED lighting scheme; Improvements to control systems. Procurement Review of utility tariffs to secure the best value for money; Implementing electronic requisitioning; Increased the volume of goods purchased through NHS Supply Chain thus reducing the number of deliveries; Multi-function devices are required to be more energy efficient; Requirement for all suppliers to minimise waste and packaging. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

83 Transport Introduction of Greencare Travel Plan; Introduction of car share scheme; Introduction of the Papworth People - Valuing Health and Wellbeing programme. Communication Dedicated sustainability page on the Trust s intranet; Environmental Awareness Survey completed; o 166 responses, 13% of staff which is considerably above average for an NHS Trust; o Sustainability Steering Group to develop and implement the resultant action plan; 22 staff have volunteered to become Environmental Awareness Representatives (EARs) and will receive specific environmental awareness training; During Climate Week, rolled out the red dots green hearts initiative, green indicating the item can be switched off when not in use and red indicating the item must not be turned off. Waste Battery recycling introduced; General waste is recycled off-site, 75-80% of the Trust s waste is recycled; Cardboard is recycled; Clinical waste is transported to Ipswich Hospital for incineration, the heat from incineration is used to provide the hospital with heating and hot water; Waste Management Committee re-formed. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

84 Summary Performance to date The Board of Directors received a report on sustainability at its 31 March 2011 meeting and further reports will be received by the Quality and Risk Committee and the Board. Summary of Comparative Data Area Type Non-Financial data Greenhouse Gas Emissions Financial Data expenditure 2008/ / / / / /11 Direct GHG Emissions Electricity (GJ) 22,248 22,929 22, , , ,000 Gas (GJ) 5,744 9,113 9,228 89,000 94,000 45,000 (2) Oil (GJ) 34,194 31,169 36, , , ,000 Waste Minimisation Management Clinical Waste for Incineration (Tonnes) , , ,600 General Waste (Tonnes) (1) 27,769 33,000 36,879 Finite Resources Water (M 3 ) 68,473 64,470 67, , , ,000 (1) 80% of general waste is now recycled % of Waste Electrical Goods are recycled. 100% of cardboard is recycled. (2) Includes rebate due to incorrect billing. (3) GJ is Giga Joules (unit of energy) and M 3 is metres cubed (Volume). Papworth Hospital NHS Foundation Trust - Annual Report 2010/

85 Equality Reporting Papworth Hospital NHS Foundation Trust has a duty to eliminate discrimination and promote equality in all its policies, strategies, functions and services, in order to fulfil our statutory duty and meet the requirements of our diverse service users. Although our public equality duties have previously focused on race, disability and gender, we recognise the importance of all the equality strands (gender, race, age, disability, religious belief and sexual orientation). The Single Equality Scheme brings our equality policies together and is in line with best practice including the Equality Act introduced in October The Scheme sets out our vision and commitment to equality and diversity and was approved by the Board in January The scheme has been widely consulted upon within the Trust including the Equality Taskforce, Operational Executive Group, Senior Managers Forum and Joint Staff Council. The Single Equality Scheme is a working document which contains an action plan to be monitored through the Trust s Equality Taskforce. The Equality and Diversity Taskforce is Chaired by the Medical Director and supported by the Director of Human Resources with representatives from the local community, Board of Governors and PALs. The role of the Taskforce is to monitor performance against the action plan and ensure actions from staff and patient surveys relating to equality and diversity are incorporated within the action plan. The Trust will be working closely with the SHA and PCT Cluster on the regional Equality Delivery System (EDS) implementation plan and milestones and also with the EDS Programme Office to achieve successful implementation during We have demonstrated our on-going commitment to employing disabled people by the Job Centre Plus awarding the Trust the continued use of the - Positive about Disabled People symbol. For staff who become disabled (either temporarily or permanently), we have proactive policies and procedures in place to support them and enable their skills and experience to be retained within the hospital. These include the use of external organisations to undertake detailed workplace assessments and, where appropriate, advise on additional equipment to enable adjustments to working practices. Specific events Equality and Diversity Training In response to the patient and staff survey results, training has been focused on supporting a wide range of equality and diversity issues. Sessions have been delivered to staff over 2010/11 ranging from Religion, Vulnerable People, Dealing with Stress to Violence and Aggression. The latter being a particular issue of concern highlighted in the staff survey results. The session was delivered to a wide audience of staff through an interactive video and question session that received very positive feedback. Papworth Hospital NHS Foundation Trust - Annual Report 2010/

86 Staff Analysis: The table below provides information on the Trust s staff covering age, ethnicity, gender and disability. Age Staff 2009/10 % Staff 2010/11 % Total Ethnicity White Asian or Asian British Black or Black British Mixed-White and Black Chinese Any other ethnic group Not stated Total Gender Male Female Total Disability Disabled Staff Non-Disabled/ not disclosed Total Papworth Hospital NHS Foundation Trust - Annual Report 2010/

87 Foundation Trust Membership Analysis Excludes Staff Members Membership 2009/10 Membership 2010/11 Age ranges (years): & over 7,644 7,297 Not specified 1,702 1,798 Total 9,478 9,194 Ethnicity: White 8,856 8,253 Mixed Asian or Asian British Black or Black British Other Not specified Total 9,478 9,194 Gender: Male 5,165 5,140 Female 4,313 4,054 Not specified - - Total 9,478 9,194 Papworth Hospital NHS Foundation Trust - Annual Report 2010/

88

89 Excellence in heart and lung care Quality Report 2010/11

90

91 Contents Part Quality at the heart of the organisation... 1 Statement from the Chief Executive... 2 Part 2 Quality Improvement priorities... 3 Trust quality assessment... 3 Overview of governance arrangements... 3 Clinical governance & risk management... 3 How we have prioritised our quality improvement initiatives... 3 Summary of performance on 2010/11 priorities... 4 Priority 1: Reducing patient falls... 4 Priority 2: Reducing medication errors... 6 Priority 3: Reducing central venous catheter bloodstream infections (CVC-BSIs)... 7 Priority 4: Prevent delays in discharge following an inpatient stay... 8 Priority 5: To maintain high-quality venous thromboembolism (VTE) prevention thus reducing avoidable death, disability and chronic ill health from VTE How did we review our services (statements of assurance from the board) Continually learning Information on participation in clinical audits and national confidential enquiries The National Clinical Audit and Patient Outcomes Programme 2010/ National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Information on clinical research Information on the use of the CQUIN framework Information relating to registration with the Care Quality Commission (CQC) and periodic/special reviews Information on the quality of data Part Review of quality performance 2010/ Safety domain Patient experience domain Effectiveness of care domain Overall quality performance against Trust selected metrics, national priorities and CQC standards A listening organisation What our patients say about us Patient Reported Outcome Measures (PROMs) Patient support groups What our staff say about us Transparent & open Annexe 1: What others say about us Annexe 2: Statement of directors responsibilities in respect of the Quality Report Annexe 3: Auditors report Annexe 4: Services provided by Papworth Hospital

92 Part Quality at the heart of the organisation Statement from the Chief Executive The principal objectives for the Trust centre around patient safety, patient experience and positive outcomes of care. During 2010/11 the Trust has continued to make significant progress around the key quality measures that impact on patients, their families and visitors experiences through striving to ensure quality care is at the heart of what we do. The principal objectives for the Trust centre around patient safety, patient experience and positive outcomes of care. Performance against national and local quality indicators in these areas are reported to the Board of Directors monthly. These Board-level reports form part of our Patient Safety Strategy, which we developed in 2009 and which has become an integral part of our culture of putting quality first. In addition to this, we recognise that, in order to offer assurance to patients that we provide high quality care, we must demonstrate high levels of reported patient satisfaction and excellent clinical outcomes. These are both demonstrated within these accounts. The commitment to high-quality care will continue through a number of priorities for 2011/12, which have been developed in consultation with clinical staff, other stakeholders, commissioners and the Trust s Governors. These priorities will be addressed later in the quality accounts. Integral to our quality performance is an organisation where staff feel recognised and rewarded and their commitment to the quality agenda is evident in the continued improvement and excellent results I am proud to report in this quality account. The information and data contained within this report has been subject to internal review and, where appropriate, external verification. Therefore, to the best of my knowledge, the information contained within this document reflects a true and accurate picture of the performance of the Trust. Stephen Bridge Chief Executive 2

93 Part 2 Quality improvement priorities Underpinning all of our work at Papworth Hospital is our vision statement to be the leading hospital providing excellence in specialist heart and lung patient care, based on research, education and innovation. We are committed to the highest levels of clinical quality, personalised and effective care, value and growth. Our focus is growth, value and effectiveness, with a commitment to the highest levels of clinical quality and providing the best standards of personalised care possible to our patients. Clinical governance & risk management Comprehensive and robust clinical governance and risk management underpin our quality agenda and the Care Quality Commission Standards of Care. This provides the vehicle for a whole organisation approach to driving forward the quality agenda. How we have prioritised our quality improvement initiatives Trust quality assessment Following cessation of the Standards for Better Health system, the Trust was required to submit the Care Quality Commission s self assessment for registration. A certificate of registration dated 1 April 2010 was issued on the 13 May During 2010/11 Papworth Hospital was not visited for inspection by the Care Quality Commission. A system of mapping against the CQC standards for care has commenced and a series of internal inspections against these standards started in April Overview of governance arrangements Effective governance within the Trust is maintained via robust management processes, which are integrated within committee structures that feed directly to the Board of Directors, providing assurance that safe, effective and quality care is delivered within a risk management framework. To determine our priorities for 2010/11, we reviewed our clinical performance indicators for the year, as well as on-going consultation with our service users on the range and quality of services provided. We used a wide range of methods to gather information, including national patient surveys, real time patient feedback from our Patient Experience Tracker (PET), concerns, compliments and complaints. We also used our patient safety focus groups and Board to Ward walk-arounds to gather issues raised by staff as well as patients. Having identified some priorities, we then spoke to our clinical teams, governors, Patient and Public Involvement Committee and Local Involvement Networks (LINks) before making our final choices. Our Board of Directors has agreed that, whilst there has been excellent progress on last year s priorities, further improvements can be made in some areas. Three of these priorities are, therefore, carried forward to 2011/12. The following table summarises the five quality improvement priorities identified last year along with the outcome. More detailed information in relation to these priorities can be found in parts two and three of this document. 3

94 Summary of performance on 2010/11 priorities Goals 2010/11 Outcomes 1 Reducing patient falls To reduce patient falls by 20% By quarter 4, falls were reduced from 51 to 40, achieving a 20% reduction 2 Increase response to acutely ill deteriorating patients 3 Reduction in medication related errors 4 Reduction in wound infections 5 Reduce avoidable death, disability and chronic ill health from Venous Thromboembolism (VTE) Implementation of a 24 hour, 7 day a week acute pain management service. Commence a continuous positive airway pressure trial Introduce non-medical prescribing within the ALERT Team Launch situation, background, assessment, responses (SBAR) communication tool. To reduce significantly the number of administration related medication errors Increase reporting of medication incidents by 50% To reduce the rate of surgical site infections (SSIs) in coronary artery bypass graft (CABG) patients from 9.69% to 8% in 2010/11 To risk assess all patients admitted as inpatients for VTE, thereby reducing associated harm Achieved Achieved Achieved Achieved Some reduction achieved, but remains the second largest category of incidents reported, therefore carried forward to 2011/12 Reporting of medication incidents increased by 72% Surgical site infection rate reduced to 5.85% by quarter 4 Documented risk assessments increased from 66% to 97% by quarter 4 Our selected priorities for 2011/12 are as follows. Priority 1: Reducing patient falls Rationale Reducing patient falls remains a top priority for the hospital. In June 2010 the National Patient Safety Agency (NPSA) published a reminder to NHS organisations to follow the guidance published by The Patient Safety First Campaign in 2009, which came after 283,438 slips, trips and falls were reported to them between October 2008 and September This was a significant increase on previous years. At Papworth Hospital, falls account for 21% of the total patient safety incidents reported during 2010/2011, making this the highest reported event. Therefore, there continues to be significant work to reduce these incidents and prevent falls whenever possible. The focus has been on increasing assessment of the patients risk of falling and will now also include education of patients at risk as well as our staff to help prevent falls occurring. Baseline Table 1 opposite demonstrates the number of falls reported per quarter. In 2010/11 our target was to reduce the number of falls by 20% from 53 per quarter to 43, which remains our goal and which we measure through our in-house incident management system. As this target remains a challenge, we are carrying forward this priority into 2011/12. Analysis of the falls incidents identifies few common factors, except that most occur when a patient is trying to go the bathroom on their own. Initiatives implemented in 2010/11 1. Review best practice from other Trusts and utilise the National High Impact Actions work 2. Raise fall-prevention awareness 3. Roll out training across the Trust 4. Produce an information leaflet for patients and their carers 5. Roll out across all clinical areas the top ideas from a test site 6. Re-audit compliance with the Falls Prevention procedure These streams of work have resulted in updating of the Falls Prevention procedure and giving regular training sessions, including skills refresher week in October A system is now in place in all clinical areas whereby staff, on a daily basis, identify and display when and if a fall occurs. This is then monitored closely through monthly audit. Through the Releasing Time to Care project, 60% of the ward areas audit the completion of falls risk assessment and implementation of a care plan. In these areas, compliance with completing a risk assessment on admission ranged from 75% to 100% in quarter /11, as demonstrated in Graph 1 opposite. 4

95 Goals for 2011/12 To reduce preventable falls by 20% To increase the use of Falls Risk Assessments To educate patients and carers about preventing falls in hospital To undertake a thorough investigation of all falls to look for the root cause and falls resulting in serious harm will be reported to our commissioners as serious incidents Ensure all inpatient areas audit compliance with falls risk assessment on admission using the Releasing time to care data collator on a monthly basis Plan and deliver falls-prevention awareness week, both for staff and members of the public Display information about preventing falls to reinforce messages given to patients and carers about mobilisation whilst in hospital Monitoring The Falls Prevention Group will monitor (via Datix, the Trust s risk management system) and report on performance to the Risk Management Group which, through the Director of Nursing, feeds directly to the Board of Directors. The focus has been on increasing assessment of the patients risk of falling and will now move to education of patients at risk to help prevent a fall occurring. Table 1 Number of falls per quarter Quarter 1 Quarter 2 Quarter 3 Quarter / / Graph 1 Risk assessment audit on admission Mallard Varrier-Jones Hemingford Higginson Princess Baron and Duchess 20 0 Jan-11 Feb-11 Mar-11 Responsible Officers Executive Lead: Implementation Lead: Programme Lead: Ann-Marie Ingle, Director of Nursing Josie Rudman, Assistant Director of Nursing Pam Fitzgerald, Modern Matron Cardiac Services 5

96 Priority 2: Reducing medication errors Rationale Medication incidents remain the second largest category of incidents reported during 2010/11. The trend continues upwards, although this is not reflected in a proportionate increase in the severity impact nor in incidents resulting in harm to the patient. Baseline 20% of incidents reported related to medication errors in 2010/11. Initiatives Implemented in 2010/11 In addition to the established Trust wide multidisciplinary Medicines Safety Group, we have initiated smaller specialty specific groups in the cardiac and thoracic directorates. These meet quarterly to look at specialty-specific issues relating to medication safety, and focus on the initiatives set out at the beginning of 2010/11. See Table 2. The Trust has also re-launched the guidance for investigating medication incidents during 2010/11, introducing a standardised approach across the hospital using the root cause analysis methods of investigation. We have created a process where evidence of learning from medication incidents is explicit, and thus developed a more robust approach to managing and supporting staff involved in medication incidents. We have also focused on patient involvement through the development of patient information that encourages a true partnership approach to improving medicines safety throughout the hospital. Patient engagement in this safety initiative is a considerable improvement. Positive progress has been made in this area with an overall increase in reported medication incidents. This is the excellent result of our raising of the profile for this safety initiative. There has been a significant increase in openness and transparency regarding incident reporting with our positive safety culture. Although the indicators set for 2010/11 have not all been achieved, we have achieved many improvements, and we are now able to measure the impact of future initiatives to improve medicines safety. Goals for 2011/12 Roll out our patient information on medicines safety to engage the patients in improving medicines safety Roll out ward level monitoring and auditing of omitted medicines not correctly documented to identify trends and take actions for improvement Review and redesign our medicines prescription chart to further improve prescribing practice and reduce prescription errors Focus on reducing checking errors through education, training and support Monitoring Monitoring for achievement against goals will be through the Cardiac and Thoracic Medication Incident review groups, and by exception to the Clinical Governance Management Group. Table 2 Reducing medication errors - achievements 2010/11 Pilot indicators for 2010/11 What: Increase reporting of medication incidents by 50% Measure: Produce run chart of number of incidents reported What: Reduce errors relating to insulin by 75% Measure: Audit of practice utilising the Think Glucose toolkit What: All omitted medicines reported with the clinical reason for omission Measure: Night staff to check all charts and count incidents What: Reduce by 90% number of incidents relating to failure to check Measure: Plot reported incidents then apply contributory factors taxonomy to identify root causes Achieved/update Reported medication incidents increased by 72% (from 133 to 229) The diabetes specialist nurse has redesigned the diabetes observation chart and raised the profile of insulin management across the Trust. The numbers of reported incidents relating to failure to follow Trust Insulin protocol have been too small to draw significant comparisons with the target set The number of medication incidents relating to omissions reported has increased. We have introduced a Trust wide audit procedure to monitor the rate of omitted medicines within each clinical area. We have tried this in two areas This has not been achieved, partly due to the increase in overall reporting of medication incidents Responsible Officers Executive Lead: Programme Lead: Ann-Marie Ingle, Director of Nursing Carole Moderate, Clinical Governance Manager 6

97 Priority 3: Reducing central venous catheter bloodstream infections (CVC-BSIs) Rationale Bloodstream infections associated with central venous catheter insertion are a major cause of morbidity nationally. These infections are caused by contamination of a catheter with bacteria or yeast from another part of a patient s body or from a caregiver. A 2006 prevalence survey found that 42.3% of bloodstream infections in England are central line related. As well as the impact on recovery following treatment and the length of stay in hospital for our patients, in 2000, the National Audit Office (NAO) estimated the additional cost of a bloodstream infection to be 6,209 per patient. Baseline Matching Michigan is a quality improvement project based on a model developed in an intensive care unit in Michigan, USA which saved around 1,500 lives over 18 months. The project consists of technical interventions (evidence based changes in clinical practice) and non-technical interventions (linked to leadership, teamwork and culture change), which have been shown to significantly reduce the incidence of Central Venous Catheter bloodstream infections (CVC-BSIs) to a mean of 1.7 CVC-BSI/1,000 CVC patient days. We have baselined our data and benchmarked with Michigan and other cardiothoracic units nationally. The mean over a 15 month period was 3.6 CVC- BSI/1,000 CVC patient days, the median being 3.4 (range ). Initiatives implemented in 2010/11 Raised the profile of the initiative Established baseline data Established a working group to review data and set actions Introduced the recommended central line insertion checklist Introduced the use of Chloraprep for cleaning of skin prior to line insertion Goals for 2011/12 Our goal is to reduce catheter related bloodstream infections by 25% in 2011/12 and a further 25% in 2012/13 to bring us in line with Michigan. We will achieve this goal by the following actions: Introducing antimicrobial coated central venous catheters (CVC) for selected patient groups Introducing Clinell green 2% chlorhexidine in 70% alcohol wipes for intravenous access port cleansing Adopting aseptic and non-touch technique (ANTT) in critical care, then hospital wide Commencing needle-free connector trials to replace 3-way taps Implementing CVC integrated care pathways for wards Undertaking root cause analysis of CVC BSI Monthly data analysis Trust-wide project dissemination Our goal is to reduce catheter related bloodstream infections by 25%. Monitoring We have established a Matching Michigan Project Group who meet regularly to monitor actions and report to the Infection Prevention and Control Committee on a monthly basis. Responsible Officers Executive Lead: Implementation Lead: Programme Lead: Ann-Marie Ingle, Director of Nursing Stephen Webb, Consultant Anaesthetist Maura Screaton, Modern Matron Critical Care 7

98 Priority 4: Prevent delays in discharge following an inpatient stay Rationale What happens during the discharge process is a key part of a patient s experiences of hospital care (DH 2004). The cost of delayed discharge from acute hospitals can be estimated at approximately 155m per year (DH 2003, Impact Assessment). From the point of view of improving overall bed availability the Department of Health (2004) suggests focusing on patients with simple discharge needs is likely to have the greatest immediate impact because, critically: The numbers of patients you can impact are very large (at least 80% of discharges are simple) The actions needed do not usually require any other agency s involvement to succeed The High Impact Action (NHS Institute for Innovation and Improvement 2010) Ready to go, no delays, tells the story of how acute Trusts have improved discharge processes, including introducing nurse led discharge. Reducing length of stay at Papworth Hospital has been agreed as a key priority throughout all of our services. Baseline Table 3 below demonstrates the number of occasions reported by our staff in relation to delayed discharge or transfer during 2010/11. This equates to 6% of our reported incidents. This year our inpatient survey, although excellent throughout, highlighted that there are some issues relating to discharge. 27% of patients who responded to the survey reported that they had been delayed at discharge. The reasons for this are depicted in Graph 2 below. Goals for 2011/12 The overall goal for this priority is to improve the patient experience when being discharged following an inpatient stay, and reducing our overall length of stay measurements. Within 2011/12 we plan to introduce the following initiatives: Utilise the discharge module of the Productive Ward project across all inpatient areas Introduce predicted date of discharge for all patients and display this on the patient status at-a-glance boards in each ward area Increase Professional Support Services weekend activity in-line with patient needs Explore the current discharge process and improve effectiveness in the areas of medicines wait, the wait to see the doctor and the wait for transportation Identify simple discharges and introduce nurse led discharge where appropriate Introduce IPM PAS update to track delayed discharges Monitoring The improvements in the discharge process will be monitored through the Productive Ward Steering Group and reported to the Nursing Advisory Committee, which feeds directly to the Board of Directors via the Director of Nursing. Table 3 Delayed discharge or transfer during 2010/11 Quarter 1 Quarter 2 Quarter 3 Quarter / Graph 2 Of the patients that reported a delay, 66% stated that they were delayed up to two hours and 11% stated that they were delayed longer than four hours. 20 Percentage 10 0 Wait for medicines Wait to see the doctor Wait for an ambulance Responsible Officers Executive Lead: Implementation Lead: Ann-Marie Ingle, Director of Nursing Josie Rudman, Assistant Director of Nursing 8

99 Priority 5: To maintain high-quality venous thromboembolism (VTE) prevention thus reducing avoidable death, disability and chronic ill health from VTE Rationale VTE prevention is a national priority that has been recognised at the highest level and placed at the top of the health agenda for this year, featuring in the NHS Outcomes Framework for 2011/12. The risk of developing VTE in hospital is a thousand times greater than with long haul travel and a patient is one hundred times more likely to die from VTE in hospital than MRSA (Professor Sir Bruce Keogh, NHS Medical Director, March 2011). VTE is the most common cause of hospital deaths in the UK that can be prevented and last year, NICE placed the prevention of VTE in its list of top ten cost-saving interventions. As the NHS moves towards a period of transition, VTE prevention has a significant role to play in delivering the Quality Innovation Productivity and Prevention (QIPP) agenda and in informing patient choice and it is for these reasons that we are keeping VTE prevention as one of our priorities for improvement for 2011/12. Baseline At the beginning of this initiative, between June and September 2010, our first point of prevalence audits demonstrated an average of 45% compliance. Initiatives implemented in 2010/11 From June 2010 mandatory risk assessment data collection was linked to the Commissioning for Quality and Innovation (CQUIN) payment framework. This framework attaches a financial incentive to the goal of risk assessing 90% of patients for VTE and bleeding on admission. Trusts report this data to the Department of Health through a system called UNIFY. As with the majority of Trusts around the country, Papworth Hospital fell considerably below the 90% target of documented risk assessments in the early stages of this initiative. However, through local campaigns, network events, training and education, we have seen a steady rise in the number of patients who are risk-assessed for VTE on admission to hospital and we have reported over 90% compliance with this CQUIN since October 2010 as illustrated in Table 4. The Department of Health has announced that this nationally mandated goal will remain the same in 2011/12. The Trust VTE Risk Assessment and Prophylaxis document was approved and added to the Trust intranet (DN500) in August 2010 and written information for patients was provided for patients coming in to hospital for surgery. VTE prevention features on the staff induction days and on the annual statutory training day that all staff are required to attend. A mechanism for identifying acute VTE events in hospital has been put in place through the radiology reports which includes VTE notification. This is searched for on a monthly basis by the PACS Manager and a report is sent to the office of the Director of Nursing. A root cause analysis is then initiated by the Trust medical lead for VTE prevention. A mechanism for identifying acute VTE events in hospital has been put in place through the radiology reports which includes VTE notification. Table 4 Percentage of inpatients with documented risk assessment for VTE Month Percentage of inpatients with documented risk assessment for VTE September % October % November % December % January % February % March % 9

100 Goals for 2011/12 To continue to deliver improvements in the standard of VTE prevention ensuring safe and effective care for patients. We plan to achieve this by the following actions: Continue to maintain over 90% compliance in documented VTE risk assessments of patients admitted to Papworth Hospital The risk assessment will be repeated and documented within 24 hours of admission and whenever there is a change in the patient s clinical condition VTE prophylaxis based on national clinical guidance will be audited monthly on a random selection of patients and any shortfalls will be fed back to the clinical areas and directorate managers The Procedure for Suspected VTE document reflecting current best evidence will be approved and added to the Trust intranet site promoting consistency in approach to treatment All patients will receive written and verbal advice on admission and discharge Root cause analysis to be performed on any acute VTE event identified in a patient whilst in hospital or if brought to our attention by another Trust, occurring within 90 days of discharge from Papworth Hospital Root cause analyses and associated actions will be fed back to Clinical Governance Management Group and reported in the quarterly Quality and Safety report. They will be disseminated to the Papworth Medical Advisory Committee via the Medical Director and the Nursing Advisory Committee via the Director of Nursing The Board of Directors will be notified through the monthly update in the Director of Nursing Patient Safety paper which will then inform the commissioners. Sharing of lessons learnt and subsequent action plans will be disseminated to relevant committees and directorates and monitored through the Clinical Governance Management Group for completion Information on VTE prevention is disseminated during the Clinical Skills Refresher week. Raise awareness about the availability and use of foot impulse devices currently in use in theatre New initiatives to be implemented in 2011/12 Amended VTE risk assessment tool introduced to facilitate documentation of the second risk assessment, with a prompt to repeat if there is any change in the patients clinical condition Introduction of the new Papworth Hospital drug chart which incorporates the VTE risk assessment tool. This will link the assessment and treatment in one document Patient advice on VTE prevention described in the new Handbook for inpatients - coming into hospital guide to be launched later this year. In the meantime, copies of the leaflet designed by the East of England NHS are being distributed to all inpatients VTE prevention features in the Patient Safety Focus days taking place in April 2011 Investigate the purchase of intermittent pneumatic compression devices to be used for very high risk patients such as thoracic oncology patients undergoing surgery 15 minute elearning course designed for hospital induction training programmes by the Kings Thrombosis Centre to be completed by all medical and nursing staff within one month of starting work at Papworth Hospital Incorporate VTE advice in the Integrated Care Pathway documentation to include both admission and discharge advice Update the VTE risk assessment and prophylaxis document in accordance with the latest NICE guidance, to include specific recommendations for cardiac and thoracic surgical patients Add an appendix for cohort exemptions as approved by the Medical Director. Currently there is no national, authoritative, clinically defined list of cohorts agreed to be at low risk or no risk Monitoring Root cause analyses are monitored via the Clinical Governance Management Group. Patient Risk Assessment census reported monthly to Department of Health. We will continue to deliver improvements in the standard of VTE prevention ensuring safe and effective care for patients. Responsible Officers Medical Lead: Responsible Officer: Karen Sheares, Consultant Physician (for Medical Director) Helen Munday, Lead Nurse Practice Development (for Director of Nursing) 10

101 2.0 How did we review our services (statements of assurance from the board) The Directors are required under the Health Act 2009 and the National service (Quality Accounts) regulations 2010 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 legal requirements in the NHS Foundation Trust Annual Reporting Manual. Indicators relating to the quality accounts were agreed following a process which included the input of the Quality and Risk Committee (membership three non-executive directors), governors, the Patient and Public Involvement Committee of the Board of Governors and clinical colleagues. Indicators relating to the quality accounts are part of the key performance indicators reported monthly to the Board of Directors and Directorates as part of the monthly monitoring of performance. Scrutiny of the information contained within these indicators and its implications as regards patient safety, clinical effectiveness and patient experience are reported to the Board of Directors, governors and sub-committees as required. During 2010/11 Papworth Hospital provided and/ or sub-contracted six NHS services in the following areas: Cardiology Cardiac surgery Thoracic surgery Respiratory Support and Sleep Centre (RSSC) Transplant and Ventricular Assist Devices (VADs) Thoracic medicine Full details of our services are available on the Trust web site: Papworth Hospital has reviewed all the data available to them on the quality of care in all of these NHS services. The income generated by the NHS services reviewed in 2010/11 represents 100% of the total income generated from the provision of NHS services by Papworth Hospital for 2010/11. 11

102 3.0 Continually learning Information on participation in clinical audits and national confidential enquiries During 2010/11, 12 national clinical audits and three national confidential enquiries covered NHS services that Papworth Hospital provides. During 2010/11, Papworth Hospital participated in 100% national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries in which it was eligible to participate. The National Clinical Audit and Patient Outcomes Programme 2010/11 The national clinical audits and national confidential enquiries that Papworth Hospital was eligible to participate in (and indeed did participate in) during 2010/11 are as follows: Acute care Emergency use of oxygen (British Thoracic Society) Long term conditions Diabetes (National Adult Diabetes Audit) Chronic pain (National Pain Audit) Bronchiectasis (British Thoracic Society) Elective procedures Cardiothoracic transplantation (NHS Blood Transfusion UK Transplant Registry) Coronary angioplasty (National Institute for Clinical Outcome Research Adult Cardiac Interventions Audit) Coronary artery bypass graft and valvular surgery (Adult Cardiac Surgery Audit) Cardiovascular disease Acute myocardial infarction and other acute coronary syndrome (Myocardial Ischaemia National Audit Project) Pulmonary hypertension (Pulmonary Hypertension Audit) Cancer Lung cancer (National Lung Cancer Audit) Blood transfusion O neg blood use (National Comparative Audit of Blood Transfusion) Platelet use (National Comparative Audit of Blood Transfusion) National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Surgery in children Peri-operative care Cardiac arrest The national clinical audits and national confidential enquiries that Papworth Hospital participated in, and for which data collection was completed during 2010/11, are listed below 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. The National Clinical Audit and Patient Outcomes Programme 2010/11-100% Acute care Emergency use of oxygen (British Thoracic Society) - 100% Long-term conditions Diabetes (National Adult Diabetes Audit) - 100% Chronic pain (National Pain Audit) - 100% Bronchiectasis (British Thoracic Society) - 100% Elective procedures Cardiothoracic transplantation (NHSBT UK Transplant Registry) - 100% Coronary angioplasty (NICOR Adult Cardiac Interventions Audit) - 100% CABG and valvular surgery (Adult Cardiac Surgery Audit) - 100% Cardiovascular disease Acute myocardial infarction & other ACS (MINAP) - 100% Pulmonary hypertension (Pulmonary Hypertension Audit) - 100% Cancer Lung cancer (National Lung Cancer Audit) - 100% Blood transfusion O neg blood use (National Comparative Audit of Blood Transfusion) - 100% Platelet use (National Comparative Audit of Blood Transfusion) - 100% 12

103 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) - 100% A breakdown of the data collection requirement for the national confidential enquiries that Papworth Hospital participated in is presented in Table 5 below. The reports of six national clinical audits were reviewed by the provider in 2010/11 and Papworth Hospital intends to take the following actions to improve the quality of healthcare provided. No actions were required by Papworth Hospital as a result of the review of the other four national clinical audits. Elective and emergency surgery in the elderly Provision of an online training package for staff undertaking Malnutrition Universal Screening Tool (MUST) to ensure all elderly surgical admissions should have a formal nutritional assessment as soon as practicable after their admission so that malnutrition can be identified and managed appropriately. Parenteral nutrition (PN)* Changes have been made to the updated version of PN policy advising against starting out-of-hours for non-critical care patients. * Administration of nutrition directly into the bloodstream. Compliance with the local falls policy A training session on falls awareness was included in the skills week held during October 2010 Oxygen prescription and administration in thoracic medicine Integrate current oxygen prescription chart into existing drug chart Specify device and flow-rate independently on the drug chart Discharge service evaluation Concentrate on repatriation and intermediate care delays Audit of compliance with NICE guidance for lung cancer Education for all medical staff and specialist nurses to write which information is being given to patients about their disease in case notes Education for all medical staff and specialist nurses about resources available and appropriate referrals of patients with symptoms of breathlessness Protection of vulnerable adults and young people audit staff survey (re-audit) Poster at skills refresher week in October 2010 to maintain awareness Anaesthetic record keeping To assess feasibility of implementing a reminder prompt for Propofol administration Local clinical audits The reports of 57 local clinical audits were reviewed by the provider in 2010/11 and Papworth Hospital intends to take the following actions to improve the quality of healthcare provided: Table 5 National confidential enquiries that Papworth Hospital participated in Title Spreadsheet received Cases applicable Case notes received Questionnaire received Organisational questionnaire received Surgery in children Yes 0 N/A N/A Yes Peri-operative care Yes 5 100% 100% Yes Cardiac arrest Yes 2 100% 100% N/A 13

104 Information on clinical research Commitment to research as a driver for improving the quality of care and patient experience The number of patients receiving NHS services provided or sub-contracted by Papworth Hospital NHS Foundation Trust in 2010/11 that were recruited during that period to participate in research approved by a research ethics committee was 3,234. See Table 6. The Trust s focus on NIHR* Portfolio research activity is demonstrated by the success of the Papworth Research & Development and Clinical Trials Unit in securing peer-reviewed NIHR research grant funding and a 45% increase in the number of actively recruiting portfolio studies. Papworth Hospital was involved in conducting 30 clinical research studies in heart disease and 51 clinical research studies in respiratory disease during 2010/11. The remaining nine studies were of generic health relevance. There were 35 clinical staff leading, as chief investigator, research projects approved by a research ethics committee at Papworth Hospital during 2010/11. By maintaining a high level of participation in clinical research the Trust demonstrates Papworth Hospital s commitment to improving the quality of healthcare. The Trust s research strengths are applied patientfocused pragmatic trials and health technology assessment of the clinical and cost-effectiveness of new interventions. Evidence from our research helps patients and healthcare professionals make decisions about treatment. It is also used to decide what care is offered in the NHS and worldwide. The Trust remains committed to improving inpatient outcomes by undertaking clinical research that will lead to better treatments for patients undergoing care in the NHS. Information on the use of the CQUIN framework A proportion of Papworth Hospital NHS Foundation Trust s income in 2010/11 was conditional upon achieving quality improvement and innovation goals agreed between Papworth Hospital NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. Papworth Hospital had seven goals as part of the CQUIN payment framework agreed with local commissioners in 2010/11. They were: Venous thromboembolism (VTE) - assessment, prophylaxis and root cause analyses (national) Patient experience - improved overall results on the inpatient survey (national) Increase in the application of the Global Trigger Tool (a tool which helps us identify the rate of adverse events resulting in harm to our patients) Completion of the primary PCI patient data set Reducing the rate of surgical wound infections for coronary artery bypass grafts Increase in surgical resection rates for lung cancer Achievement of target times for primary PCI The amount of income in 2010/11 conditional upon achieving quality improvement and innovation goals was 1,266k and the amount received was 1,190k (94%). Overall there has been excellent progress in our CQUIN goals. An area of non-achievement was in VTE, for which full implementation was slower than that set out in the CQUIN. However, by the end of the financial year Papworth Hospital achieved the highest rate of VTE assessment across the East of England. Further details about the CQUIN scheme are available electronically at ( world_class_commissioning/pct_portal/cquin.html) Table 6 Number of patients recruited for research projects Type of research project No. of patients recruited (No. of actively recruiting studies) per financial year 2009/ /11 NIHR portfolio studies 431 (22) 399 (32) Non-NIHR portfolio studies 866 (73) 684 (58) Tissue bank studies 1,815 (36) 2,151 (44) Total 3,112 (131) 3,234 (134) *NIHR = National Institute for Health Research 14

105 Information relating to registration with the Care Quality Commission (CQC) and periodic/special reviews Papworth Hospital is required to register with the Care Quality Commission and its current registration status is unconditional registration which means we are meeting government regulations on a range of areas of practice. The Care Quality Commission has not taken enforcement action against Papworth Hospital during 2010/11. Papworth Hospital has not participated in any special reviews or investigations by the CQC during the reporting period. Information on the quality of data Quality indicators form an integral part of a comprehensive range of performance indicator s for Papworth Hospital. Indicators are reviewed annually to ensure alignment and comparison with local, regional and national priorities. The delivery of each indicator against its respective target is the responsibility of a range of executive and clinical leads. The indicators are routinely monitored and reviewed on a monthly basis and where performance is adverse, corrective action plans are developed. Performance is ultimately reviewed by the Board of Directors. Papworth Hospital submitted records during 2010/11 to the Secondary Uses Service for inclusion in the hospital episode statistics which are included in the latest published data. For Papworth Hospital the percentage of records in the published data: Which included the patient s valid NHS number was: 99.3% for admitted patient care and 99.7% for outpatient care Which included the patient s valid General Medical Practice Code (code of the GP with which the patient is registered) was: 97.9% for admitted patient care and 98% for outpatient care Overall there has been excellent progress in our CQUIN goals. 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. Papworth Hospital s information governance assessment report overall score for 2010/11 was 68%. The Trust achieved a satisfactory level (level two red ) on all key requirements in the information governance toolkit. Papworth Hospital will be taking the following actions to improve data quality during 2011/12: The further development of the roles of our staff that are responsible for and administer databases Setting out clear maps of how data flows into and out of the organisation Formal refresher training for the clinical coding team Papworth Hospital was not subject to the payments by results clinical coding audit during the reporting period by the Audit Commission. 15

106 Part Review of quality performance 2010/11 The following illustrates a review of our quality performance last year. We have selected examples from the three domains of quality (safety, patient experience and effectiveness of care). This also includes two of our priorities from last year which we have not carried forward (ALERT and pressure ulcers), as we are satisfied that we have embedded these areas into everyday practice. We will continue to monitor our performance as part of our Trust key performance indicators. Safety domain Healthcare associated infections We have continued to demonstrate improvements in our MRSA bacteraemia and C. difficile infection rates across the hospital. See Table 7. Methicillin-resistant Staphylococcus aureus (MRSA) MRSA bloodstream infections are the most serious form of MRSA infection and are associated with significant morbidity and mortality. Hand-hygiene remains an important infection control measure to reduce the risk of spread of MRSA on the hands of healthcare workers. C. difficile Clostridium difficile (C. difficile) is a common pathogen in older people with an asymptomatic carriage rate between 2-20%. The spectrum of C. difficile-associated disease (CDAD) ranges from asymptomatic carrier status through to clinical diarrhoea, to fulminant colitis and toxic megacolon. Antibiotics have commonly been associated with CDAD but are not the only risk factor. Other associations include exposure to antineoplastic agents, gut motility altering drugs, surgery and chronic illnesses. However, it is not only older patients that are affected by C. difficile. In particular, the cystic fibrosis population is known to have a higher carriage rate of C. difficile than the general population, possibly due to the need for repeated courses of broad spectrum antibiotics for chronic lung infection. Due to the underlying cystic fibrosis illness, these patients may not present with classical diarrhoeal symptoms of C. difficile disease but are more likely to present with abdominal symptoms suggestive of severe C. difficile disease. This makes the management and prevention of CDAD in this group of patients challenging. The ability of C. difficile to produce spores enables the organism to survive in the environment. Faecaloral transmission allows colonisation of the gastrointestinal tract. Disruption to the host s normal bowel flora allows C. difficile to multiply in the colon. Toxins are produced which, on binding to target cells in the colon, cause damage to these cells resulting in inflammation and mucosal injury. Prevention relies on reducing exposure to risk factors so as to limit disruption of host bowel flora. Infection control measures are important in limiting spread. CDAD is of great clinical importance as a cause of hospital acquired diarrhoea and has undergone an apparent change in epidemiology and disease patterns. There is now more recognition regarding the ability of different strains to affect morbidity, mortality and ease of spread. For example, there has been increased interest in the 027 strain as one which is associated with a higher morbidity and mortality where strict infection control practices are paramount in limiting spread. We have continued to demonstrate improvements in our MRSA bacteraemia and C. difficile infection rates across the hospital. Table 7 Improvements in our MRSA bacteraemia and C. difficile infection rates Goals for 2009/10 Outcome Goals 2010/11 Outcome No more than 3 MRSA bacteraemias Total for year = 2 No more than 2 MRSA bacteraemias Total for year = 1 No more than 20 C.difficile cases Total for year = 12 No more than 13 C.difficile cases Total for year = 9 Achieve 100% MRSA screening of elective patients Average 96% (commenced December 2010) Achieve 100% MRSA screening of elective patients Average 97% 16

107 MRSA screening MRSA can live harmlessly on the skin and mucosal surfaces (mainly nose, throat and perineum) in about 10% of healthy people (colonisation). The purpose of screening is to identify patients carrying MRSA and offer decolonisation treatment to eradicate MRSA carriage. This not only reduces the risk of cross transmission between patients but also reduces the risk of MRSA infection developing. Infection occurs when the bacteria gain access to usually sterile sites. The east of England Strategic Health Authority required provider Trust organisations to achieve the routine screening of all elective and emergency admissions within the East of England by 1 April This was in line with the Department of Health target of 31 March 2009 for elective admissions but ahead of the Department of Health target of April 2011 for screening all emergency admissions. The early compliance of 1 April 2009 for emergency admissions supported the delivery of the Strategic Health Authority s pledge, and demonstrates Papworth Hospital s commitment to this goal to provide the safest healthcare in England. The definition of screening is microbiological testing of a sample taken from potential carriage sites on or before admission with the purpose of identifying patients colonised with MRSA and to actively de-colonise. ALERT (Acute life threatening events: recognition and treatment) ALERT is a service we now provide 24 hours, 7 days a week delivered by advanced nurse practitioners, which recognises and responds to the deteriorating patient quickly, reducing re-admission to critical care and further deterioration in the patient s condition. The ALERT service has now been running for 17 months. Data is collected on every patient using an electronic data collection tool. This data is collected on every readmission to critical care, first admission to critical care, acute pain management referral and Alert Team referral. Electronic data has been collected since September 2010 and, during this time, the team has seen 1,113 patients who fall into two categories - routine critical care follow-up (89) and ward referrals (1,024). Of these 1,024 referrals, 217 had been discharged from critical care less than 24 hours and 50 were transferred in from another hospital. The team also provides support and advice to all nursing staff in all ward areas and also assists with technical tasks such as cannulation, venepuncture and naso-gastric tube insertion. The team also provides bedside training in areas such as observations, fluid management, pacing, ECG s etc. The team supports the medical team in providing timely intervention with the primary objective being a reduction in patient deterioration and the acquisition of appropriate levels of care being delivered in the right place. Goals 2010/11 Implementation of a 24 hour/7 day a week Acute Pain Management Service Continuous Positive Airways Pressure (CPAP) trial within the Cardiology HDU for patients in acute cardiogenic pulmonary oedema Introduction of non-medical prescribing within the ALERT team. Launch of: SBAR (situation, background, assessment, response) communication tool) Intelligent fluid management bundle Outcome Patients are routinely followed up post cardiac and thoracic surgery and patients with patient controlled analgesia (PCA), epidural or extrapleural analgesia are referred to the Acute Pain Management Service (APMS) for monitoring. This service is supported by the lead consultant anaesthetist for acute pain and the lead consultant anaesthetist for chronic pain. The team has admitted 64 patients to the APMS since January 2011 Achieved: Data is also being collected regarding the CPAP trial Two team members have successfully completed both the advanced skills in clinical assessment module and non-medical prescribing module Achieved New Initiatives for 2011/12 Introduction of a new study day for clinical staff on Recognition and management of the deteriorating patient Launch of The Deteriorating Patient, elearning package Ratification of the Management of the Deteriorating Patient procedure, ensuring we comply with NICE CG 50 guidance Revision of neurological observation charts and escalation criteria to improve recognition of neurological disorders and consequent management Revision of the current fluid balance charts, 17

108 fulfilling recommendations from the intelligent fluid management bundle Sepsis care bundles New documentation on the management of the patient with a tracheostomy, standardised using Intensive Care Society Recommendations and in line with current practice on critical care Advanced nurse practitioner guidelines for the management of the cardiothoracic surgical patient Monitoring The ALERT Service Steering Group will monitor and report on performance to the Patient Safety Steering Group, which feeds directly to the Board of Directors via the Director of Nursing. Pressure ulcers Pressure ulcers have been defined as ulcers of the skin due to the effect of prolonged pressure in combination with a number of other variables, including patient co-morbidities and external factors such as friction and skin moisture. There are four grades of pressure ulcer, ranging from 1 to 4, with 4 being the worst. Throughout 2010/11, we have continued to make excellent progress in the management and monitoring of our pressure ulcers. The table below shows our pressure ulcer prevalence data for the last three years. See Table 8. In 2010 we increased our pressure ulcer prevalence audits to twice yearly. This data is seen as gold standard for interpretation of pressure ulcer rates in a healthcare organisation. Initiatives for 2011/12 include: Pressure ulcer prevalence audit to be carried out quarterly from 2011 Pressure ulcer reporting, investigating and management protocol introduced to facilitate effective and timely reporting of pressure ulcers developed within, and transferred into, the Trust Grade 3 and 4 pressure ulcers transferred into the Trust to have a root cause analysis investigation within 24 hours of the pressure ulcer being identified. Grade 3 and 4 pressure ulcers transferred into the Trust will be reported as serious incidents. This is in addition to the existing practice to undertake root cause analysis investigations of all grade 3 and 4 pressure ulcers that develop at Papworth Hospital, and which are reported as serious incidents Continued education on pressure ulcer prevention, identification, reporting and management in Trust wide mandatory training days Goals 2010/11 Monthly incident reporting to be migrated from a paper system to an electronic risk reporting system (Datix) Root Cause Analysis (RCA) to be introduced for all grade 2 and above pressure ulcers and resultant action plans to be implemented as appropriate Continued education on pressure ulcer prevention, identification, reporting and management in Trust wide mandatory training days Outcome Achieved In year, we refined this to all grade 3 and above pressure ulcers, as per national standard, which has been achieved Pressure ulcer incident and prevalence figures are disseminated to all ward areas, Modern Matrons and the Director and Assistant Director of Nursing. Pressure ulcer incidence/prevalence monitoring forms part of the Trust wide Quality and Safety Measures, which are reported to the Quality and Risk Committee (Committee of the Board of Directors) via the quarterly Quality and Safety Report. It is through continued audit of pressure ulcer prevalence and incidence that staff awareness of prevention and management of pressure ulcers is raised and maintained Table 8 Pressure ulcer prevalence data Year (inpatient numbers audited) Overall n/percentage of pressure ulcers/moisture lesions developed at Papworth Hospital (all grades) 2008 (n=224) n=29/224 (13%) 2009 (n=222) n=10/222 (4.5%) June 2010 (n=289) n=2/289 (0.7%) Dec 2010 (n=266) n=7/266 (2.6%) 18

109 Board to ward focus groups In 2009 Papworth Hospital signed up to the National Patient Safety First campaign, which emerged from the Department of Health s recommendations for improving safety in hospitals. As part of this campaign we developed a patient safety strategy, the aim of which was to build a safety culture where patient safety comes first. As part of this strategy, we introduced patient safety focus groups led by the Chairman of the Board of Directors and a Non-executive Director, with an Executive Director present. Goals 2010/11 To embed quarterly focus groups and report key themes to our Quality and Risk Committee Outcome Our focus groups have become an established medium for patient safety discussions. For 2011/12, we have expanded this to include our nonexecutive directors and chairman on unannounced clinical visits Our staff asked us to Look at nurse staffing levels in ward areas due to increased activity levels and difficulties in recruiting We did A full nursing establishment review was carried out Staffing levels were increased in some areas On-going review throughout the hospital Recruitment trip to Dublin with subsequent appointments made Re-invigorated existing Recruitment & Retention Group Increased involvement at student job fairs Reduce delays in the recruitment process. Introduced a system to fast track post requests Provide low-profile beds, particularly for patients at risk of falling Introduced 100% electric beds throughout the hospital, where required, which can be lowered appropriately Surgical site infections NICE (2008) states in its guidance on the prevention and treatment of surgical site infection that up to 20% of all healthcare acquired infections (HCAIs) are caused by surgical site infections. These affect more than 5% of patients who have had surgery. Goals 2009/10 Outcome Goals 2010/11 Outcome Reduction in infection rates in our patients undergoing coronary artery bypass graft and valve surgery Infection rates reduced from 9.69% to 8% Reduction in infection rates in our patients undergoing coronary artery bypass graft and valve surgery Infection rates reduced from 8% to 5.85% Patient experience domain Delivering same-sex accommodation In early 2009, the Department of Health pledged that men and women should not normally have to share sleeping accommodation or bathroom facilities to respect their privacy and dignity. The gold standard for patients is single-sex wards. However, it was recognised that some hospitals cannot provide this facility and agreed, therefore, that single-sex accommodation can be provided in: Single rooms with en suite or adjacent bathroom facilities, or Wards with male and female bays, but these must have designated male and female bathroom facilities and no mixing of the sexes in bays. The complexity of Papworth Hospital s ageing estate and design has posed a significant challenge. However, on 10 March 2010, we were declared compliant. The on-going challenge of delivering this agenda is a daily part of the role of the nursing staff, as bays are required to flex in line with the gender of our patient mix. Goal 2010/11 100% of patients do not share sleeping or washroom facilities with members of the opposite sex (excluding critical care and high dependency areas) Outcome Declaration of compliance published on website. Committed to a programme of audit throughout 2011/12 to ensure there is no misclassification of reports of compliance. Following the extensive work during 2009/10, and the resulting compliance when inspected in March 2010, there were no reported breaches during 2010/11 19

110 Patient Environment Action Team (PEAT) inspection In view of the ageing estate of Papworth Hospital, it is essential we strive to deliver a positive environment for our patients. Every year all Trusts providing inpatient services in England are inspected by a Patient Environment Action Team (PEAT) and assessed against the following standards: organisation policy information, specific cleanliness, toilets and bathrooms, cleanliness and environment, infection control, environment, access and external areas, food and hydration and privacy and dignity. This serves to provide us with a basis for our improvement and maintenance programmes. See Table 9. A detailed action plan is being developed to address particular areas of improvement within clinical areas in particular bathroom areas and visitor rooms requiring refurbishment. The plan will be monitored by the Nursing Advisory Committee. It was noted that whilst the Trust had improved its scores since last year, the age of some of the buildings and access across the site internally and externally did impact on the scores especially for people with disabilities. Goal 2010/11 Maintain or improve on level of performance year on year Outcome The validated outcome of the assessment by the National Patient Safety Agency is identified below. Feedback from the team was extremely positive and, in particular, the significant improvement in all areas including the overall cleanliness of clinical areas together with the tidiness/state of the estate inside and outside since the last inspection Table 9 Assessment of environment Change Environment and cleaning Good Good Food and hydration services Good Excellent Privacy and dignity Good Good National Inpatient Survey We are delighted that Papworth Hospital has again scored so highly in a national survey of patients. However, we are not complacent and consistently involve our patients in decisions about their care, listen to their views and monitor their feedback, reviewing and revising our practices accordingly. We are delighted that Papworth Hospital has again scored so highly in a national survey of patients. Our staff are really proud of these results and it is thanks to their care, dedication and commitment that the hospital achieves such excellent feedback from our patients. Goal 2010/11 To remain with the top 20% of Trusts reporting maintained or improved patient experience Outcome Our Trust has successfully achieved this goal 20

111 Effectiveness of care domain Primary Percutaneous Coronary Intervention (PPCI) Service The National Service 3 Framework for coronary heart disease in 2000 set out standards for the treatment of heart attack, which commended a technique for unblocking arteries carrying blood to the heart muscle as the main or first treatment for patients suffering a heart attack. This is known as primary angioplasty or primary percutaneous coronary intervention (PPCI). The Primary PCI service opened at Papworth Hospital on 22 September 2008 with a limited catchment area. This was increased in September 2009 and now covers the majority of the East of England which has an anticipated travel time of less than 90 minutes. A pilot study to establish the travel time from the East Suffolk area has been completed and Papworth Hospital are waiting to be informed of the final decision of whether this area will be formally included in the catchment area. the national spine. The percentage figures below represent an actual figure of between 0 and 4 deaths per month, with a total number of deaths within 30 days during 2010 being 18 patients. Papworth Hospital s 30 day mortality rate for PPCI patients was 3.97% in 2010 and therefore much in line with national audit targets at around 4%. See Graph 3. Initiatives for 2011/12 There are a number of planned improvements for the coming year, including further analysis of patient delays with action plans, and improving our information system in reporting major and minor complications. Within the calendar year of 2010 the range of number of activations per month was 46 to 68. Of these activations the range of the number of patients who went onto have a PPCI was 33 to 51 patients. There is little seasonal variation in the number of activations and subsequent treatment. Information relating to mortality up to 30 days post procedure is collected retrospectively from Goal 2010/11 Achieve the standards for door-to-balloon time (90 minutes) and call-to-balloon time (165 minutes) Outcome Four patients exceeded the door-to-balloon time standard. Two of these were due to simultaneous PPCI activations so the catheter lab was not available. The other two were due to patients needing emergency care prior to being able to have a PPCI. 12 patients exceeded the call-to-balloon time standard. All of the 12 patients attended an accident and emergency department at a District General Hospital prior to their transfer to Papworth Hospital. Graph 3 30 day mortality for PPCI % 8.00% 7.00% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Cumulative 21

112 Direct care time (productive series) Papworth Hospital engaged with the productive series through the productive ward in September The main aim of this change project is to release time back into direct care applying lean methodologies. The productive series was developed by the NHS Institute for Innovation and Improvement and offers a systematic way of delivering safe, high quality care to patients across the hospital by applying lean methodology to release time for staff to put back into patient care. Lean methodology, once applied, cuts out wasted time in a process. The productive series is beginning to be truly embedded in the way staff deliver care to the patient. There has been excellent patient engagement in the project, resulting in a patient presenting how they felt the productive ward project impacted positively on their journey whilst an inpatient at Papworth Hospital, at a national level. The priorities for 2011/12 are Work collaboratively through the admission and discharge module Implement patient status-at-a-glance as a whole Trust To ensure data is collected regularly to provide a clear picture of how well the teams are achieving quality targets The project continues to be monitored through the Productive Ward Steering Group, which reports to the Nursing Advisory Committee through to the Board via the Director of Nursing. The main aim of this change project is to release time back into direct care. Goals 2010/11 The main aim of this change project is to release time back into direct care by applying lean methodologies Patient status-at-a-glance Outcome All ward areas have engaged with the productive ward initiative, and are at different stages on this journey. Productive principles are being used across the Trust in areas such as physiotherapy and transplant services. Theatres have undergone a training programme to prepare the team for roll out of productive theatres and have commenced their first modules. All areas that have engaged in the project have managed to release varying amounts of time and have put this back into direct care time. A data collator has been developed to enable all areas to record their audit information and print graphs to display in the clinical areas Order placed for new patient status-at-a-glance boards. Education programme planned for early 2011/12 Emergency planning The many challenges facing NHS organisations, including major incidents, outbreaks of infectious diseases and terrorism threats, mean that robust major incident and business continuity plans are not only in place but are regularly tested and evaluated by the clinical teams. Goals 2009/10 Review and update existing business continuity plans throughout the Trust Outcome Our internal auditors reviewed our business continuity processes in March 2010 and gave us a green rating (* see below) * Provides substantial assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective. 22

113 Overall quality performance against Trust selected metrics, national priorities and CQC standards Performance of Trust against selected metrics Throughout 2010/11 we have continued to measure our quality performance against a number of metrics. Table 10 sets out our performance against those national targets included within Monitor s compliance framework. Table 11 below sets out our performance against other Department of Health national priorities and a range of local priorities. Table 10 Trust performance against Monitor s compliance framework Acute Targets - national requirements Target Performance Clostridium difficile - year on year reduction 13 9 MRSA - meeting the MRSA objective 2 1 Cancer - 31 day wait for second and subsequent treatment 94% 100% Cancer - 62 day wait for first treatment from GP referral* 79% 87.9% Maximum 18 weeks from referral to treatment for admitted patients >90% 94.9% Maximum 18 weeks from referral to treatment for non-admitted patients >95% 97.9% Acute Targets - minimum standards Target Performance MRSA screening all elective inpatients 100% 97% Cancer - 31 day wait from diagnosis to first treatment 96% 100% All Trusts Target Performance Compliance with the requirements regarding access for people with learning disability Compliance Achieved from Q2 * reduced tolerance levels have been issued by CQC for certain specific single cancer sites. As Papworth Hospital only treats lung cancer the revised threshold applies. Table 11 Examples of Trust performance against other national and local priorities Domain Metric Target Performance Patient experience Operations cancelled for non-medical reasons <1.5% 1.4% Percentage readmitted within the 28 day guarantee 5% 14.7% 26 week inpatient waits 0% 0% (four breaches) 13 week outpatient waits 0% 0% (two breaches) Patient safety Number of patient related adverse incidents < Number of patients risk assessed for VTE on admission >90% Achieved over 90% from September, over 97% from January 2011 Rate of harm as assessed using the global trigger tool (GTT) Reduce by 50% by 2013 (baseline 7%) Average rate of harm for 2010/11 is 4.1% (reduction of 41.3%). Range % Patient experience % of patients reporting they were treated with privacy and dignity >90% >96% Number of complaints <50 38 Patient Environment Action Team (PEAT) score. Excellent (100%), good (90-95%), acceptable (< 90%) Excellent Excellent/good Two categories remained good and one increased to excellent Effectiveness of care Cardiac surgery in-hospital mortality within statistical limits using 50% of EuroSCORE (a method of identifying risks to our patients) >95% >97% 23

114 Monitor ratings Monitor (The Independent Regulator of NHS Foundation Trusts) issues a financial risk rating (FRR) to Foundation Trusts based on quarterly financial returns. This rating is based on a formula determined by Monitor which measures financial performance using a composite indicator. The rating ranges from 5 to 1 with 5 the highest rating. Monitor also issues a red, amber-red, ambergreen, green (RAG) rating for governance, where green indicates low risk and red indicates high risk (during 2009/10 the rating was red, amber and green). A summary of the planned and actual ratings for 2010/11 and 2009/10 are provided below. During the year, Papworth Hospital achieved the second highest available financial rating of four in Q1 to Q3 and the highest rating of five in Q4. In line with Monitor s compliance framework, Papworth Hospital was downgraded to ambergreen in Q2 and Q3 for governance. See Table 12 and 13. The Q2 governance rating was due to a breach of the year to date C. difficile trajectory (eight cases vs seven cases trajectory). The year end position was within trajectory with a total of nine cases against a trajectory of 13. During the year, Papworth Hospital achieved the second highest available financial rating of four in Q1 to Q3 and the highest rating of five in Q4. The Q3 governance rating was due to a failure to meet the 62 day cancer wait target for first treatment from urgent GP referral. Papworth Hospital as a specialist centre only treats lung cancer. The 62 day wait covers the whole of the patient pathway and can impact on the Trust because of the small numbers involved and its position as the last centre of referral on the pathway. In recognition of this the CQC have introduced reduced tolerance levels for certain single cancer sites, of which Papworth Hospital is one. Whilst Papworth Hospital temporarily breached in Q3, in Q4 and for the whole year the Trust was compliant. Table 12 Monitor risk ratings 2010/11 Annual plan 2010/11 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11 Financial risk rating Governance risk rating Green Ambergreen Ambergreen Ambergreen Green Table 13 Monitor risk ratings 2009/10 Annual plan 2009/10 Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Financial risk rating Governance risk rating Green Green Green Amber Amber Mandatory services Green Green Green Green Green 24

115 5.0 A listening organisation What our patients say about us 2010 National Audit Inpatient Survey Patients have once again placed Papworth Hospital in the highest scoring 20% of Trusts in England. They rated the hospital in the highest scoring 20% of Trusts in 50 out of 61 questions according to the Care Quality Commission s (CQC) comparison with 161 other Trusts. This eighth national survey of adult inpatients showed that for questions about doctors Papworth Hospital scored 9 out of 10 and for questions about nurses scored 8.8 out of 10. See Table 14. The National Inpatient Survey included responses from 66,000 patients from 161 acute and specialist Trusts. It posed 64 questions of which 61 were applicable to Papworth Hospital. At Papworth Hospital, 577 patients responded and the response rate was 69%, compared to a national average response rate of 50%. Patients were eligible for the survey if they were aged over 16 and had at least one overnight stay during June, July or August Papworth Hospital used Quality Health to undertake the survey. A useful snapshot of the results for the 2010 inpatient survey is the key score comparisons which rates Papworth Hospital scores against the other 49 Trusts which used Quality Health. In Graph 4 below, the Papworth Hospital score is indicated by the diamond and the average score is indicted by the arrow in Graph 4 on the next page. I am a wheelchair user (fulltime). Staff understand my needs and allowed me independence and didn t patronise me. Good understanding of how to treat disabled people. From April 2011 improvement in patient experience scores formed part of the Commissioning for Quality and Innovation (CQUIN) payments to the Trust. At the time of writing this report preliminary results have been provided by Quality Health which confirm that Papworth Hospital has achieved the CQUIN for patient experience with an overall score of 76.9, against our 2009 overall score of Table 14 National survey of adult inpatients Based on patients' responses to the survey, Papworth Hospital scored How this score compares with other Trusts For questions about waiting lists and planned admissions, answered by those referred to hospital 7.1/10 Better For questions about waiting to get to a bed on a ward 9.5/10 Better For questions about the hospital and ward 8.6/10 Better For questions about doctors 9/10 Better For questions about nurses 8.8/10 Better For questions about care and treatment 8.3/10 Better For questions about operations and procedures, answered by patients who had an operation or procedure 8.5/10 About the same For questions about leaving hospital 7.9/10 Better For questions about overall views and experiences 7.1/10 Better 25

116 Graph 4 Key scores comparison 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Admitted as soon as necessary Room or ward very clean Hospital food very good/good Confidence/trust in doctors Confidence/trust in nurses Right amount info on Told about meds side condition/treatment effects Family given all info needed Care excellent/very good Responses to the specific parts of patient experience that Papworth Hospital had to show improvement on are as follows: Papworth Hospital percentage 2009 Papworth Hospital percentage 2010 National comparable data 2010 Were you involved as much as you wanted to be in decisions about your care and treatment? Did you find someone on the hospital staff to talk to about your worries and fears? Were you given enough privacy when discussing your condition and treatment? Did a member of staff tell you about medication side effects to watch for when you went home? Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital? 66% 67% 53% 53% 57% 42% 79% 79% 72% 47% 48% 38% 86% 84% 71% National Cancer Patient Experience Programme National Survey Papworth Hospital NHS Foundation Trust The national cancer patient experience survey was carried out by Quality Health on behalf of the Department of Health and compares results from 158 acute hospitals, and charts feedback from adult inpatients who were discharged between 1 January 2010 and 31 March 2010 on all aspects of their NHS cancer care. 100 postal surveys were sent to Papworth Hospital patients, 71 were returned, giving a response rate of 74% (when patient deaths, and undelivered questionnaires are removed). The survey results were split into two reports, the first gives percentage scores to each question and the second includes the free-text patient comments. In the first report there are 59 questions under 13 headings. Papworth Hospital patients scored us in the top 20% of hospitals for 36 of these questions and in the bottom 20% for five questions. It should be noted that questions relate to the whole patient journey including primary care, not just the Papworth Hospital part of it. 26

117 Of the five questions that Papworth Hospital patients scored in the bottom 20% three related to services provided by General Practitioners. The questions which related to Hospital care and treatment which were scored in the bottom 20% were: Patients never thought they were given conflicting information Doctor had right notes and other documentation with them Our clinical teams are working on actions to improve these areas which we will report back next year. Patients scored Papworth Hospital in the top 20% of hospitals. In 36 of the questions, patients scored Papworth Hospital in the top 20% of hospitals. All these questions related to Papworth Hospital services. A second report included patient comments under three headings: Was there anything particularly good about your NHS Cancer care? Was there anything that could have been improved? Any other comments? This report includes a wide range of positive and small number of negative comments about Papworth Hospital and other NHS centres. Patient Reported Outcome Measures (PROMs) The NHS Next Stage Review, Our NHS Our Future (Darzi 2008), indicated that patient reported information would become an important component of efforts to measure and improve clinical quality. The Patient Reported Outcome Measures (PROMs) programme is a means of collecting information on the effectiveness of care delivered to NHS patients as perceived by the patients themselves. The collection of this data will add to the set of information available on the care delivered to NHS-funded patients and will complement, and be used in conjunction with, existing information on the quality of services. PROMs are being led by the Department of Health and are measures of a patient s health status or health-related quality of life. They are typically short, self-completed questionnaires, which measure the patients health status or health related quality of life at a single point in time. At present there are four types of PROMs questionnaires for different surgery, hip replacement, knee replacement, hernia and varicose veins, but will incorporate all common operations in the near future. Papworth Hospital does not take part in the National PROMs due to the surgical procedures that are not undertaken at this specialist Trust. The PROMs group at Papworth Hospital have therefore designed a series of questionnaires applicable to the type of surgery carried out at Papworth Hospital. We have now completed our first PROM for coronary artery bypass graft (CABG). During the period 20 July to 31 October patients attending pre-admission clinic for CABG were identified and asked to complete a questionnaire. A second questionnaire was then sent 12 weeks post procedure. A return rate of 87% compared favourably against the national standard of 66%. The overall report was extremely positive, with high levels of quality and improvement to patient s physical and psychological well-being. Highlights included: 84% of patients reported that their outcome following surgery was either excellent or good A significant trend can be seen in the patient s health and wellbeing, identifying an increase in better health, including reduction in patients experiencing chest pain and reduction in breathlessness 27

118 Patient support groups Our Trust has several patient support groups in areas such as: Pulmonary hypertension Immunology and lung defence Mesothelioma Pulmonary fibrosis Examples of what our patients have said What have you found helpful? (Mesothelioma Support Group) Just listening and hearing about different issues and being able to talk about mine. The feeling that I am not alone. Talking to people in the same circumstances. I think that over a short period of time friendships will be made as we are all in this together. The mesothelioma support group for patients and carers was one of the best things that has happened, as we got the chance to meet each other and discuss our feelings and hear news on various treatments, and the palliative support that is available to us. Congratulations and thank you Papworth! What our staff have learnt It is possible to make it work even in a disease with very limited life expectancy Hugely satisfying and rewarding Much more insight into patients lives, viewpoints and expectations User group offers great opportunities for feedback on our services Carers really do feel isolated and welcome the opportunity of mutual support England are: Percentage of staff receiving health and safety training in last 12 months Percentage of staff reporting good communication between senior management and staff Percentage of staff saying handwashing materials are always available Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months was a lower score The key findings where our Trust compares least favourably with other acute specialist Trusts in England are: Staff intention to leave jobs Trust commitment to work-life balance Staff job satisfaction Support from immediate managers In relation to patient care, staff were asked if they were satisfied with the quality of care they gave to patients and 90% (of those who felt it was applicable to them) agreed that they were satisfied. 89% said that if a friend or relative needed treatment they would be happy with the standard of care provided by the Trust and 78% of staff thought the Trust made patient or service user care its top priority. The results showed that staff felt positive about work with 68% saying they were enthusiastic about their job and 89% agreed their role made a difference to patients. General comments received I feel I have been treated with respect and dignity throughout by a professional and enthusiastic team congratulate your staff team with the utmost exceptional person-centred skills I have ever come across. What our staff say about us Staff survey All staff were given the opportunity to complete the National Staff Survey 2010 questionnaire and 56% of staff responded. The four key findings for which our Trust compares most favourably with other acute specialist Trusts in 28

119 6.0 Transparent and open Throughout 2010/11 we have continued to be open and transparent in all aspects of the quality of our care. As part of the Trust s monitoring and assurance framework a Quality and Safety Report is produced each quarter detailing the quality and safety activity across the organisation. This information is presented to the Quality and Risk Committee to provide notification of trends, actions and assurance of our continual drive for quality and safety. Learning from incidents, complaints and claims is shared across the organisation and is available on our website. Quality and safety information is presented in the quarterly reports under the following headings: Patient safety The number of reported patient safety incidents has remained constant over the year and there is an upward trend in near miss reports indicating a positive safety culture across the organisation. See Graph 5. The Trust also has a robust mechanism in place for reporting, investigating and managing Serious Incidents (SIs). Learning from such incidents and actions taken contribute to improving safety for our patients. In the last year 2010/11 the Trust has reported six serious incidents. Patient experience Listening to the patient experience and taking action following investigation of complaints is an important part of our quality improvement framework. The trend in the number of complaints received by the Trust has fallen year on year and in the last year 2010/11 the Trust received 39 complaints (4 from patients who accessed the private patient services). See Graph 6. Graph 5 Patient Safety Incidents (actual and near miss) reported in 2010/ Quarter 1 10/11 Quarter 2 10/11 Quarter 3 10/11 Quarter 4 10/11 Actual patient safety incidents Near miss Graph 6 Number of complaints received by year / / / /11 Number of complaints received 29

120 Examples of actions taken following complaints investigated in 2010/11 Reflection on practice by nursing staff Change in administration process when patients transferred into the Grown Up Congenital Heart (GUCH) service Increase in cleaning standards monitoring in area highlighted by complaint Environmental refurbishment in cardiac directorate Protocol for managing complications following angiogram developed Review of documentation on transfer and discharge reviewed by cardiac services Administration systems have been reviewed Review of Primary Percutaneous Coronary Intervention (PPCI) Protocol Patient Advice and Liaison Service (PALS) report The Patient and Public Involvement & Membership Committee (PPIM) met on three occasions during the year and were responsible for monitoring progress on the objectives set under the PPI and Patient Experience Strategy document and were also involved in setting the priorities for the Quality Accounts for the year. The new proposals agreed by the PPIM Committee for the development of a new process for producing patient information reflect current best practice and to further ensure adequate patient engagements, the reading panel has been extended to include governors and members of the Trust. The Patient Experience Panel have continued to meet during the year and have been involved in agreeing the questions for the patient experience tracker and were also involved in the Patient Environment Action Team Inspection (PEAT) which was carried out in February During 2010/11 the PALS service received 1,518 enquiries from patients, families and carers, a slight increase on the figures for last year (1,433). The I could not do justice to staff at Papworth just by ticking boxes. My short stay was a wonderful experience of healing, not only of my body of my mind. fourth quarter of 2010/11 was exceptionally busy with March being the busiest month ever recorded and this can be attributed to an increase in the number of inpatient episodes compared with the same period last year. During the year 24 volunteers were recruited for various wards and departments throughout the Trust, including the gift shop, the greeter desk and ward visitors. The total number of volunteers is currently compliments were received about the PALS service. As a direct result of comments from patients: Our patients said... They encountered problems when telephoning the radiology department Our signs were confusing in places We did... We changed the working arrangements in our radiology department to allow more flexible working within the department and they have extended the period when the telephones will be manned A complete review of on site signage and maps was carried out Our relatives accommodation needed updating Those in financial difficulty struggled when accompanying relatives who were transferred in an emergency situation Additional relative accommodation has been sourced by the Trust and the relatives hostel on site was completely refurbished A hardship fund was also set up to assist relatives and families who arrived at Papworth Hospital in emergency situations and provides assistance to take care of their initial financial needs 30

121 Risk management Health and safety, non-clinical incident reporting and monitoring of the Trust risk register form part of the overall quality improvement programme. During 2010/11 reported non-clinical incidents average out at 47 over the year, which is the same as in 2009/10. The risk management functions have been subject to independent internal audit and the recommendations and actions will form part of the work streams for the risk management team during 2011/12. The risk register is reviewed at all management groups throughout the year and progress on actions required to reduce the risk are monitored through the quality and safety report. Effectiveness of care Clinical effectiveness includes the provision of care in accordance with high-quality evidence-based clinical guidelines. The evaluation of practice through the use of clinical audit or outcome measures can lead to further improvement in the quality of care. The National Institute for Health and Clinical Excellence (NICE) provides patients, health professionals and the public with authoritative, robust and reliable guidance on current best practice. Kindness, efficiency, involvement at all times at all levels. An outstanding example of how it should be done. In 2010/11 NICE published 123 guidance documents on public health, health technologies and clinical practice. All guidance was reviewed by Papworth Hospital and where applicable to the Trust, a clinical lead was appointed to ensure the guidance was actioned through the appropriate clinical management group. Assurance of compliance and follow up of any actions outstanding is reported through the quality and safety report on a quarterly basis. Monitoring mortality The Hospital Standardised Mortality Ratio (HSMR) is a scoring system which works by taking a hospital s crude mortality rate and adjusting it for a wide variety of factors - population size, age profile, level of poverty, range of treatments and operations provided, etc. This establishes the mortality rate that would be expected for NHS hospitals and the observed rate for an individual hospital. This, along with a similar system more recently introduced, the Summary Hospital-level Mortality Indicator (SHMI), are both not applicable to Papworth Hospital as a specialist Trust due to case mix. The reporting of crude mortality is just one of a number of quality measures which can be used to inform the organisation on how well it is performing in relation to patient safety and clinical quality. Graph 7 below illustrates the monthly in-hospital crude mortality rate at Papworth Hospital between for 2010/11. The average for 2010/11 is 0.76%. The data were collected using the in-hospital patient administration system (PAS) and all patient admissions (episodes) were included. Deceased patients were counted as per admission date and not date of death. For more information or detail regarding the Quality and Safety Reports please go to our website at the following link: nhs.uk/content.php?/clinical_quality/healthcare_ professionals/clinical_governance Graph 7 Crude mortality rate % 1.20% 1.00% Admissions 0.80% 0.60% 0.40% 0.20% Crude mortality Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar % Admissions Crude mortality Average 31

122 Annexe 1: What others say about us The following stakeholders have kindly provided us with their comments on this year s Quality Accounts and we appreciate their detailed scrutiny of this document. Some of the comments made have been acted upon. We have particularly tried to ensure we use language accessible by the public, as pointed out by NHS Cambridgeshire, and have clarified our targets for next year. The remaining comments will be taken into consideration when preparing next year s Accounts. Papworth Hospital would like to thank all of the stakeholders below for their input. East of England Specialised Commissioning Group The East of England Specialised Commissioning Group (EoESCG) commissions specialised services from Papworth Hospital on behalf of all Primary Care Trusts in the East of England. The EoESCG has continued to work closely with the Trust who has again delivered demonstrable improvements in quality. The Trust continued its impressive trajectory to reduce both MRSA bacteraemia and C. difficile with just one MRSA and nine C. difficile cases during the year. Root cause analysis is undertaken by the Trust on all cases and reported to the commissioner, alongside agreement of key actions for further improvements, as part of on-going contract monitoring. While the Trust has delivered on the national standards for 18 week waits (95% admitted and 90% non admitted) there continue to be a small cohort of patients waiting in excess of 18 weeks for reasons unrelated to patient choice or clinical complexity. As commissioners of Papworth Hospital s services we continue to work with the Trust on ensuring compliance against what is now a legal right for patients enshrined in the NHS Constitution. Cancer waiting times continue to be met. CQUIN initiatives during 2010/11 were met ensuring continued improvements in the quality of patient care, which are reflected within these quality accounts. Notably the Trust ensured that from October % of patients were risk-assessed for venous thromboembolism. In the last quarter in excess of 97% of patients were being risk-assessed. The National Adult Inpatient Survey demonstrated the high level of patient satisfaction reported by Papworth Hospital patients, showed a year on year increase and remains one of the highest in the region. During the year EoESCG and clinicians from NHS Cambridgeshire met with the Trust Director of Nursing to review general governance issues and the reporting of serious incidents. The Trust was able to evidence a strong commitment to governance and patient safety and demonstrated that a comprehensive system is in place to assess, review and reflect upon incidents and to subsequently ensure changes to practice where appropriate. These quality accounts are a fair reflection of the continual importance the Trust attaches to providing a high quality service and the measurable success they have enjoyed during 2010/11. The 2011/12 contract with the Trust incorporates many of the new quality initiatives for both specialised and non-specialised services. The monthly contract review meetings will provide the forum in which both existing and new quality measures will be monitored and continually developed. In addition quarterly meetings will be held to review the Trust quality and safety report. NHS Cambridgeshire Commissioning Group NHS Cambridgeshire has reviewed the quality account produced by Papworth Hospital NHS Foundation Trust for 2010/11. The quality account is presented in an understandable and consistent format. In most areas a clear explanation of any clinical issues is given and jargon is avoided, although some information is not explained in language accessible to the public. The quality account includes all the nationally mandated sections. A list of services and specialties provided by the Trust is given. The Trust have shown a selection of actions taken as a result of local audit, some linked to priority areas for improvement. There is a balance in the quality account between showing initiatives that have led to improvement and identifying the development areas where further work is needed. The Trust have identified five priority areas for improvement and has set out a range of initiatives for 2011/12. Three of these show significant patient collaboration in the new initiatives. There has also been involvement of service users in the development of the priorities. The results from the National Patient Experience surveys for Papworth Hospital are extremely positive. The Trust has highlighted two areas from the National Cancer Programme where performance was not good. NHSC would like to see the actions plans in place to improve in these areas, particularly for patients feeling that they were receiving conflicting information. Papworth Hospital are focusing on improving patient experience of the discharge process. It would be of interest to understand how the Trust are monitoring patient experience in other areas of the services they provide. The Trust could consider using local surveys in particular areas where any concerns have been raised through incident reporting, PALS queries or complaints. None of the current Patient Reported Outcome Measures (PROMs) relate to procedures carried out by Papworth Hospital. However, the Trust have been proactive in taking forward this patient experience initiative and have developed their own PROMs which have shown positive improvements in patient outcomes. In the review of patient safety initiatives, the Trust summarises its mechanism for risk management, showing examples of actions taking following 32

123 complaints and PALS queries. It would also be useful to show trends and learning from incident reporting. The Trust show mortality rates and it would be useful for further commentary on how these are monitored and analysed. There is a structure of regular meetings in place between NHSC, Papworth Hospital and other appropriate stakeholders to ensure the quality of Papworth Hospital services is reviewed continuously with commissioners throughout the year. Statement from Cambridgeshire Local Involvement Network (LINk) Since April 2010, we have visited the hospital on numerous occasions to canvas the opinion of patients, visitors and staff and have always found the feedback to be favourable. A few of our group members are also members of various hospital focus groups including the Papworth Patient Experience Panel and the Papworth Patient and Public Involvement/ Membership Group (PPIM). We have maintained close links with Papworth Hospital throughout this period and feel that we are, therefore, qualified and pleased to confirm that we are in agreement with the structure of the quality accounts and with the key priorities that have been chosen for the coming year. Statement from Suffolk Local Involvement Network (LINk) It is pleasing to note that comments made in 2009/2010 have been taken into consideration. Especially with regard to the patient being the focus of clinical outcomes. It is appreciated that with the highly specialised services provided at Papworth Hospital, it is not always easy to use the best language for the patients and their carers. However, in the main this is a clear understandable document. The hospital has not been complacent regarding patient falls and has set clear pathways to improve the patient experience having identified specific areas of concern. However, it is not clear if it is a few patients making several falls or many patients making a few falls. How many patients were involved in the 21% of patient safety reported incidents and how has this been addressed? It is pleasing to see a change in culture with the increased reporting of medicine provision incidents coupled with its reported openness and transparency and the attempts to involve the patients in resolving the issues. Suffolk LINk looks forward to seeing the improvements in the 2012 report. Addressing the patient comments around their discharge experience will help reduce stress for both the patients and their carers. Again it is pleasing to see that patients are being asked for their views and actually having a programme to address them over the coming year which will be monitored. The achieving of the seven set goals by CQUIN together with the continued good progress and maintenance of standards was noted. How were these shared with the patients, their families and carers, and staff? The quality data is full of names and numbers. This could be well over the heads of the patients and their families. This has been helped with the full name then initials and some clear graphs etc. Could not the very good outcomes be celebrated more and clearly presented for patients consideration? They are lost in the commentary (eg the gold standard ulcer care). The response to what the staff asked for is well presented and the outcomes clear. However, it would have been useful to see how patients have responded to the new approaches. The patient domain section of the report is clearly presented and does not ignore areas where things need improvement across the estate and its impact on people with disabilities. It would be helpful if details of how patients are helping to shape improvements were identified. Travel time is always a worry for patients. Meeting the travel 90 minute target is often dependent on outside factors. Perhaps how these failed times and the treatment of the patients on arrival could have been mentioned. They have been highlighted and the goal is to achieve them. Suffolk LINk is pleased to note that all the patient experience, acute, and effectiveness of care targets have been met. It was interesting to see what the staff and patients have said and the responses to them. The reaction to the PALS patient comments, especially the hardship fund is very good and much needed. Statement from Adults Wellbeing & Health Scrutiny Committee Cambridgeshire County Council Adults Wellbeing and Health Scrutiny Committee welcomes the achievements of Papworth Hospital NHS Foundation Trust, and supports the proposed priorities for 2011/12. We suggest that the Trust: Set specific targets for improvement in relation to patient falls, reducing medication errors, and preventing delayed discharge Set specific goals in relation to those areas of patient experience, including cancer patient experience, and patient safety where the quality account has identified shortcomings Statement from Patient & Public Involvement/ Membership Committee (PPIM) Chair As a governor and chair of the PPIM, as well as being a current patient, I am in total agreement with the initiatives identified within the quality accounts for the coming year, and praise the progress that was made on initiatives undertaken during the last financial year. I know from first hand experience that the Trust continues to put patients at the centre of all its services and comments made by patients are used to make improvements to our services. 33

124 Annexe 2: Statement of directors responsibilities in respect of the Quality Report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 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 foundation trust boards should put in place to support the 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 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 2010 to May 2011 Papers relating to quality reported to the board over the period April 2010 to May 2011 Feedback from the commissioners dated 16/05/2011 Feedback from governors dated 16/05/2011 Feedback from LINks dated 17/05/2011 The Trust s complaints report under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, draft dated 20/05/2011 The 2010 National Inpatient Survey The 2010 National Staff Survey The Head of Internal Audit s annual opinion over the Trust s control environment dated 26/05/2011 CQC quality and risk profiles dated 6/04/2011 The Quality Report presents a balanced picture of the NHS Foundation Trusts performance over the period covered The performance information reported 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 reported 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) (published at www. monitornhsft.gov.uk/annualreportingmanual) as well as the standards to support data quality for the preparation of the Quality Report (available at annualreportingmanual) 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... 2 June 2011 Date... Chairman... 2 June 2011 Date... Chief Executive 34

125 Annexe 3: Auditors report Independent auditors report to the Board of Governors of Papworth Hospital NHS Foundation Trust on the Annual Quality Report. We have been engaged by the Board of Governors of Papworth Hospital NHS Foundation Trust to perform an independent assurance engagement in respect of the content of Papworth Hospital NHS Foundation Trust s Quality Report for the year ended 31 March 2011 (the Quality Report ). Scope and subject matter We read the Quality Report and considered whether it addresses the content requirements of the NHS Foundation Trust Annual Reporting Manual, and considered the implications for our report if we become aware of any material omissions. Respective responsibilities of the directors and auditors The directors are responsible for the content and preparation of the Quality Report in accordance with the criteria set out in the NHS Foundation Trust Annual Reporting Manual 2010/11 issued by the Independent Regulator of NHS Foundation Trusts ( 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 content of the Quality Report is not in accordance with the NHS Foundation Trust Annual Reporting Manual or is inconsistent with the documents. We read the other information contained in the Quality Report and considered whether it is inconsistent with those documents below: Board minutes for the period April 2010 to May 2011 Papers relating to quality reported to the Board over the period April 2010 to May 2011 Feedback from the commissioners dated 16/05/ 2011 Feedback from governors dated 16/05/2011 Feedback from LINks dated 17/05/2011 The Trust s complaints report under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, draft dated 20/05/2011 The 2010 National Inpatient Survey The 2010 National Staff Survey The Head of Internal Audit s annual opinion over the Trusts control environment dated 26/05/2011 CQC quality and risk profiles dated 6/04/2011 We considered the implications for our report if we became aware of any apparent misstatements or material inconsistencies with those documents (collectively, the documents ). Our responsibilities do not extend to any other information. This report, including the conclusion, has been prepared solely for the Board of Governors of Papworth Hospital NHS Foundation Trust as a body, to assist the Board of Governors in reporting Papworth Hospital NHS Foundation Trust s quality agenda, performance and activities. We permit the disclosure of this report within the annual report for the year ended 31 March 2011, to enable the Board of Governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the Quality Report. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Board of Governors as a body and Papworth Hospital 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: Making enquiries of management; Comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to the categories reported in the Quality Report; and Reading the documents. A limited assurance engagement is less in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations It is important to read the Quality Report in the context of the criteria set out in the NHS Foundation Trust Annual Reporting Manual. 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 2011, the content of the Quality Report is not in accordance with the NHS Foundation Trust Annual Reporting Manual.... PricewaterhouseCoopers LLP Chartered Accountants Cambridge Date... 3 June

126 Annexe 4: Services provided by Papworth Hospital Aims and objectives The aims and objectives of the Trust is the provision of goods and services for the purpose of the health service in England. This does not preclude the provision of cross-border services to other parts of the United Kingdom. Services Papworth Hospital is the UK s largest specialist cardiothoracic hospital. Our services include cardiology, respiratory medicine, and cardiothoracic surgery and we are the country s main heart and lung transplant centre. We serve over three million people in the East of England. However, the specialist nature of much of our work means that patients from all over the UK come to Papworth Hospital for their treatment. Legal status of the Trust Papworth Hospital NHS Foundation Trust was authorised on 1 July 2004 by Monitor, the independent regulator of NHS Foundation Trusts. Trust s business address and location Papworth Hospital NHS Foundation Trust Papworth Everard Cambridge CB23 3RE Tel: Website: Registered person The Trust Chief Executive, Mr Stephen Bridge (telephone number: ). Other authorised services The Trust is also authorised by Monitor to undertake the following authorised services: Research and development - including clinical trials Rent of space on-site to other NHS and Non- NHS organisations Autopsies Clinical training courses The three regulated activities we provide are: 1. Treatment of disease, disorder or injury 2. Surgical procedures 3. Diagnostic screening procedures 36

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129 Papworth Hospital NHS Foundation Trust Accounts for the Year ended 31 March 2011 Presented to Parliament pursuant to Schedule 7, paragraphs 24 and 25 of the National Health Service Act 2006

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131 Papworth Hospital NHS Foundation Trust - Accounts for the year ended 31 March 2011 STATEMENT OF THE CHIEF EXECUTIVE'S RESPONSIBILITIES AS THE ACCOUNTING OFFICER OF PAPWORTH HOSPITAL NHS FOUNDATION TRUST The NHS Act 2006 states that the Chief Executive is the Accounting Officer of the NHS Foundation Trust. The relevant responsibilities of the Accounting Officer, including their responsibility for the propriety and regularity of public finances for which they are answerable and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by the Independent Regulator of NHS Foundation Trusts ("Monitor"). Under the NHS Act 2006, Monitor has directed Papworth Hospital NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of Papworth Hospital NHS Foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial period. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to: - - make judgements and estimates on a reasonable basis; - observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements and apply suitable accounting policies on a consistent basis; state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed and disclose and explain any material departures in the financial statements; and - prepare the financial statements on a going concern basis. The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable him to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor's NHS Foundation Trust Accounting Officer Memorandum. Signed: Chief Executive Date: 2 June 2011 Page 1

132 Papworth Hospital NHS Foundation Trust - Accounts for the year ended 31 March 2011 STATEMENT ON INTERNAL CONTROL FOR THE YEAR ENDED 31 MARCH 2011 Scope of responsibility As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS Foundation Trust s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS Foundation Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum. The purpose of the system of internal control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of Papworth Hospital NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Papworth Hospital NHS Foundation Trust for the year ended 31 March 2011 and up to the date of approval of the annual report and accounts. Capacity to handle risk The Trust has in place a Risk Management Strategy which makes it clear that whilst I have overall responsibility for risk management, responsibility for specific risk management areas has been delegated to the Trust Management Executive. All relevant policies are available on the Trust intranet. Risk management is a core component of the job description of senior managers within the Trust. The system of internal control is underpinned by compliance with the Trust s terms of authorisation and the requirements of regulatory bodies relevant to Foundation Trusts. The Trust learns from good practice through a range of mechanisms including Root Cause Analysis of identified incidents, clinical supervision and reflective practice, individual and peer reviews, performance management, continuing professional development programmes, clinical audit and application of evidenced based practice. Accountability arrangements of the Chief Executive include a requirement to provide regular corporate performance reports to the Board of Directors, Audit Committee, Quality and Risk Committee and the Board of Governors on the Trust s performance against key national targets and on the Trust s financial status. The risk and control framework The Risk Management Strategy sets out the key responsibilities for managing risk within the organisation. Risk assessment information is held in an organisation wide risk register (Datix Risk Management system). All Serious Incidents (SIs) are reported to the Board via the Director of Nursing or Medical Director. All staff are responsible for responding to incidents, hazards, complaints and near misses in accordance with the appropriate policies. As part of the continuous development of the risk management process a risk appetite has been calculated using the consideration of the potential for: injury to patients, staff or the public, breakdown in services, breaches of regulatory and/or legislative compliance, information systems or integrity, financial loss or exposure and reputational damage. The Board has two Committees, the Audit Committee and the Quality and Risk (Q&R) Committee. Membership of the Q&R Committee is three Non-executive Directors (NEDs), one of whom is the Chair. Executive Directors, or deputies, attend as business requires. The Q&R Committee meets six times a year and it reports to the Board through minutes, exception reports and verbal reports from the Chair and Director of Nursing as Executive lead. To support the assessment of the quality of performance information during the year all areas of the Trust have mapped their data flows and assigned information asset managers and information asset administrators. For information on the Audit Committee see the Annual Report. Page 2

133 Papworth Hospital NHS Foundation Trust - Accounts for the year ended 31 March 2011 The Trust is required to be registered with the Care Quality Commission (CQC) and declare compliance with the essential standards of quality and safety. The Trust continues to be registered with no compliance issues. The Trust has a Board Assurance Framework (BAF) which sets out the principal risks to delivery of the organisation's objectives. A traditional risk assessment matrix is used, in accordance with the Risk Management Strategy, to ensure a consistent approach is taken to assessing risk. An Executive Director has been assigned to each principle Trust objective and from 2011 the objectives have been explicitly mapped to the rquirements of the Care Quality Commission (CQC). For each objective the main risks to the achievement of that objective have been fully considered and are recorded in the BAF. The risks are then assessed and rated on the basis of impact and likelihood of occurrence. Existing controls and the sources of assurance on those controls are then mapped to the main risks. Any gaps in the controls or assurances on those controls are identified and addressed through action planning. All Trust policies and procedures are initially assessed to determine if they impact on the following: disability, race, gender, age, sexual orientation, religious & belief and other. Where there is a positive or negative impact an Equality Impact Assessment Form must be completed before the document is approved. Incident reporting is co-ordinated by the Directorate of Clinical Governance and Risk Management using the Datix system. Staff are encouraged to report incidents and there has been a significant increase in openness and transparency regarding incident reporting. Information on incident causes are placed on the Trust s website in the quarterly Quality and Safety Reports. The risk management function is managed by the Directorate of Clinical Governance and Risk Management, which reports to the Director of Nursing. The Directorate is supported by a number of Committees which report through the Clinical Governance & Management Group (CGMG) to the Quality & Risk (Q & R) Committee. There are a range of policies in place to describe the roles and responsibilities of staff in identifying and managing risk and these policies set out clear lines of responsibility and accountability. All relevant policies are available for viewing on the intranet and are regularly updated. Each Directorate has a risk management coordinator, who attends meetings of the Risk Management Group (RMG) to share experience and best practice. The RMG is a committee of the CGMG and reports to the Q&R Committee, through its minutes and reports. Good practice in the control or treatment of risk is regularly shared with other trusts through the various risk and governance forums and benchmarking groups attended by Trust staff. Patients and relatives are involved in reviewing adverse incidents and complaints and in the development of action plans to reduce the risk of recurrence. The Patient Advice and Liaison Service (PALS) is a point of contact for patients and relatives who have queries / concerns. PALS reports to the CGMG and contributes to the quarterly Quality and Safety Report which is available on the Trust s website. The Trust s principal risks are articulated within the Board Assurance Framework (BAF) and comprise both the in-year and future risks to achieving its principal objectives. The strategic risks and the ways in which they will be managed are as follows: Risk Management Control Outcome Measure The uncertain national and local economic position may make it difficult for the Trust to deliver on Monthly scrutiny of financial position and Annual Plan achieved. performance at Board, Board Committees and Executive meetings. agreed long term plans. Sub optimal recruitment of intensive care trained nursing staff, resulting in reduced Critical Care capacity. Proactive recruitment. Ring fenced cardiac recovery beds to optimise elective throughput. Number of critical care beds available for patients. Ability to achieve the service improvement programme (SIP). SIP Project Board. Annual SIP achieved. Failure to respect patient s privacy and dignity on the current site. Modern Matron continuous monitoring of single sex bay usage. No breach reported to Department of Health on monthly return. Patient Survey. Failure to proceed with New Hospital plans. Dialogue with stakeholders. Monthly Board monitoring. Procurement of new Hospital is on track. Page 3

134 Papworth Hospital NHS Foundation Trust - Accounts for the year ended 31 March 2011 The Trust has in place an Information Governance policy which sets out the Trust s commitment to ensuring that information is efficiently and effectively handled, managed and safeguarded. The policy establishes a robust information governance framework which includes up to date policies, procedures and accountabilities. Managers within the Trust are responsible for ensuring that the policy and its supporting standards and guidelines are built into Directorate processes and that there is on-going compliance. The Board annually assesses compliance with the requirements of the Connecting for Health Information Governance Toolkit for the management and control of risks to information. The Trust has nominated the Director of Operations to be its Senior Information Risk Owner (SIRO), the Director of Nursing as the Caldicott Guardian and identified senior managers across the Trust as Information Asset Owners as part of putting in place an Information Governance Management Framework. A regular update on information governance is received by the Quality and Risk (Q&R) Committee of the Board of Directors, which is tasked with providing assurance to the Board. There is an Information Governance Steering Group chaired by the SIRO which reviews / approves policies and procedures / action plans relevant to information governance. The SIRO reports any issues to the Q&R Committee and the Board. The Trust has submitted the NHS Connecting for Health Information Toolkit version 8.0, which includes requirements relating to the Statement of Compliance and achieved a level 2 or above for these key requirements, scoring 68% overall. A serious breach of confidentiality occurred in April 2010 with the loss of paper containing patient data from an offsite location near the hospital. A number of papers were recovered but a number remained lost despite extensive searches. This incident was reported as a serious untoward incident (SUI) and after a formal investigation identified as an isolated issue where policies had not been followed. Corrective action undertaken includes notices on exits to wards, hospital exits and staff car parks reminding staff not to take patient data home and the provision of secure bags for carrying work on and off the site. The overall Executive Lead for CQC compliance is the Director of Nursing, supported by other Executive Directors. The Q&R Committee has been delegated responsibility for monitoring ongoing compliance with CQC registration requirements and CQC compliance is a standing item on all agendas. Through the year the Q&R Committee has considered both the process required to confirm compliance and reviewed evidence for selected outcomes. Going forward the Committee will also receive feedback from the programme of internal inspections started in March 2011 by the Nursing Advisory Committee (NAC), which will focus on specific outcomes. As part of the Quarterly Performance Report to the Board, the Q& R Committee confirms the continuing declaration of CQC compliance. The Director of Nursing is also responsible for highlighting any areas of concern to the Board. The Foundation Trust is fully compliant with CQC essential standards of quality and safety. As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme Regulations are complied with. This includes ensuring that deductions from salary, employer s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. Control measures are in place to ensure that all the organisation s obligations under equality, diversity and human rights legislation are complied with. The Foundation Trust has undertaken risk assessments and Carbon Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisation s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. Page 4

135 Papworth Hospital NHS Foundation Trust - Accounts for the year ended 31 March 2011 Review of economy, efficiency and effectiveness of the use of resources The Trust s Financial Plan for 2010/11 was approved by the Board of Directors. Achievement of the financial plan relied on delivery of cash releasing efficiency savings during the financial year. Progress against delivery of service improvements is monitored throughout the year and updates are presented to the Board of Directors. In addition to the agreed annual service improvement programme (SIP), further efficiency savings are realised during the year through initiatives, such as ongoing tendering and procurement rationalisation. The objectives set out in the Trust s Internal Audit Plan include ensuring the economical, effective and efficient use of resources and this consideration is applied across all audits. The findings of internal audit reports are reported to the Audit Committee and where appropriate considered by the Q&R Committee. The process to ensure that resources are used economically, efficiently and effectively across clinical services include directorate and divisional reviews, the productive ward programme and the regular monitoring of clinical indicators covering quality and safety. Annual Quality Report The Directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 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 in the NHS Foundation Trust Annual Reporting Manual. The Board of Directors has agreed that the Quality Report will be considered and recommended by the Q&R Committee of the Board. This Committee was also responsible for deliberating on and recommending items for inclusion in the Quality Report. Discussions also took place with the Patient and Public Involvement (PPIM) Committee of the Board of Governors and clinical colleagues to ensure the engagement of stakeholders. The Board of Governors and Local Involvement Networks (LINks) endorsed items for inclusion in the report. The Director of Nursing is the Executive lead for Quality reporting. Information to support the quality metrics used in the Quality Report are held in a number of trust systems, including Datix (electronic risk management system), ipm PAS (patient administration database) and Winpath (electronic pathology system) supported by analysis of reporting, national returns and sample testing of medical records. The assessment of quality indicators is integrated into the Trust s performance management system, and hence they are subject to review by operational and managerial staff on a monthly basis in a structured framework of performance review. Review of effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit, and the executive managers and clinical leads within the NHS Foundation Trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the Quality Report attached to this Annual Report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the results of my review of the effectiveness of the system of internal control by the Board of Directors, the Audit Committee, the Q & R Committee, the Internal Auditors and plans to address weaknesses and ensure continuous improvement of the system is in place. My review is informed in a number of ways: - Dialogue with Executive Managers within the organisation who have responsibility for the development and maintenance of the system of internal control, the risk management system and the assurance framework. - Recognition of the dynamic nature of assurance and the work that has been undertaken to further develop the Trust s assurance framework. - The work of Internal Audit throughout the year to review and report upon control, governance and risk management processes, based on an audit plan approved by the Audit Committee. The work included identifying and evaluating controls and testing their effectiveness, in accordance with NHS Internal Audit Standards. Where scope for improvement was found, recommendations were made and appropriate action plans agreed with management. The Head of Internal Audit opinion is significant assurance. - Care Quality Commission (CQC) Quality and Risk Profile (QRP). - Clinical governance reports, including the Quality & Safety Report (see website). - Clinical audit programme (see Quality Report). Page 5

136 Papworth Hospital NHS Foundation Trust - Accounts for the year ended 31 March The assurance provided by the regular review of the various documents/reports that evidence the effectiveness of the controls in place to manage the risks to the organisation in achieving its principal objectives. - Advice from the Audit Committee on the implications of the result of my review of the effectiveness of the system of internal control. A plan to address weaknesses and ensure continuous improvement of the system is in place. - The Risk Management Group (RMG) has examined the overall risk profile of the Trust, and reported to the Trust Executive, as well as monitoring how the Risk Management Strategy is embedded into the culture of the Trust. Relevant committees focus on key risks in their own areas. - Monthly reports to the Board showing performance against Monitor s compliance framework. - Consultation with Patient and Public Involvement groups, e.g. Patient Experience Panel, Patient Forum and Patient and Public/Membership Committee. - The results of patient and staff surveys. - Results of Care Quality Commission unannounced inspection on the prevention and control of infections (last done in August 2009). - External Audit reports. - NHS Litigation Authority level two accreditation in respect of the Clinical Negligence Scheme for Trusts and the Risk Pooling Scheme for Trusts. - Close monitoring of financial performance and delivery on savings plans. - Maintaining cash flow and liquidity. - The achievement of a financial risk rating of 4 in Q1to Q3 and a level '5' in Q4. - Monitor assessment that during 2010/11 the Trust rated Green in Q1, Amber-Green in Q2 & Q3 and 'Green' in Q4 for governance arrangements. The Board of Directors received the assurance framework and assurance register at its September 2010 and January 2011 meetings. The assurance framework is underpinned by the Trust s objectives. During 2010/11 the assurance framework was further enhanced by the inclusion of an evaluation of risk appetite. Board consideration of the assurance framework is supported by minutes from the Quality and Risk Committee. Metrics for the Quality Report were considered and recommended to the Board by the Quality and Risk Committee. In 2009/10 an internal audit on infection control received the highest assurance level of substantial assurance. In 2010/11 an internal audit on Clinical Governance arrangements received an overall opinion of green. In the two latest data quality audits undertaken nationally for Commissioners on payment by results data (2009/10), the Trust s data quality arrangements were found to be of a high standard, with the Trust performing consistently above the minimum standards in the majority of areas. The Trust s performance on data entry was good, meeting at least the minimum national standards. The Audit Committee has reviewed the overall framework for internal control, and has recommended this statement to the Board of Directors. Conclusion No significant control issues (i.e. issues where the risk could not be effectively controlled) have been identified in respect of 2010/11. I am satisfied that all internal control issues raised have been, or are being, addressed by action plans and that these action plans are subject to appropriate monitoring. Signed: Stephen Bridge Chief Executive 2 June 2011 Page 6

137 Papworth Hospital NHS Foundation Trust - Accounts for the year ended 31 March 2011 Independent Auditors' Report to the Board of Governors of Papworth Hospital NHS Foundation Trust We have audited the financial statements of Papworth Hospital NHS Foundation Trust for the year ended 31 March 2011 which comprise the Statement of Comprehensive Income, the Statement of Financial Position, the Statement of Cash Flows, the Statement of Changes in Taxpayers' Equity and the related notes. The financial reporting framework that has been applied in their preparation is the NHS Foundation Trust Annual Reporting Manual issued by the Independent Regulator of NHS Foundation Trusts ("Monitor"). Respective responsibilities of directors and auditors As explained more fully in the Accounting Officer's statement set out on page 1, the Accounting Officer is responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view. Our responsibility is to audit and express an opinion on the financial statements in accordance with the NHS Act 2006, the Audit Code for NHS Foundation Trusts issued by Monitor and International Standards on Auditing (ISA's) (UK and Ireland). Those standards require us to comply with the Auditing Practices Board's Ethical Standards for Auditors. This report, including the opinions, has been prepared for and only for the Board of Governors of Papworth Hospital NHS Foundation Trust in accordance with paragraph 24(5) of Schedule 7 of the National Health Service Act 2006 and for no other purpose. We do not, in giving these opinions, accept or assume responsibility for any other purpose or to any other person to whom this report is shown or into whose hands it may come save where expressly agreed by our prior consent in writing. Scope of the audit of the financial statements An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of: whether the accounting policies are appropriate to the NHS Foundation Trust's circumstances and have been consistently applied and adequately disclosed; the reasonableness of significant accounting estimates made by the NHS Foundation Trust; and the overall presentation of the financial statements. In addition, we read all the financial and non-financial information in the Annual Report and Accounts to identify material inconsistencies with the audited financial statements. If we become aware of any apparent material misstatements or inconsistencies we consider the implication for our report. Opinion on financial statements In our opinion the financial statements: - give a true and fair view, in accordance with the NHS Foundation Trust Annual Reporting Manual, of the state of the NHS Foundation Trust's affairs as at 31 March 2011 and of its income and expenditure and cash flows for the year then ended; and - have been properly prepared in accordance with the NHS Foundation Trust Annual Reporting Manual. Opinion on other matters prescribed by the Audit Code for NHS Foundation Trusts In our opinion: - the part of the Directors' Remuneration Report to be audited has been properly prepared in accordance with the NHS Foundation Trust Annual Reporting Manual; and - the information given in the Directors' Report for the financial year for which the financial statements are prepared is consistent with the financial statements. Page 7

138 Papworth Hospital NHS Foundation Trust - Accounts for the year ended 31 March 2011 Matters on which we are required to report by exception We have nothing to report in respect of the following matters where the Audit Code for NHS Foundation Trusts requires us to report to you if: - in our opinion the Statement on Internal Control does not meet the disclosure requirements set out in the NHS Foundation Trust Annual Reporting Manual or is misleading or inconsistent with information of which we are aware from our audit. We are not required to consider, nor have we considered, whether the Accounting Officer's Statement on Internal Control addresses all risks and controls or that risks are satisfactorily addressed by internal controls; - we have not been able to satisfy ourselves that the NHS Foundation Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources; or - we have qualified our report on any aspects of the Quality Report. Certificate We certify that we have completed the audit of the accounts in accordance with the requirements of Chapter 5 of Part 2 to the National Health Service Act 2006 and the Audit Code for NHS Foundation Trusts issued by Monitor. Julian Rickett (Senior Statutory Auditor) For and on behalf of PricewaterhouseCoopers LLP Chartered Accountants and Statutory Auditors Cambridge 3 June 2011 Page 8