Quality Account 2016/17

Transcription

1 Quality Account 2016/17

2 P2

3 Index Statement of the Chairman and the Chief Executive Statement of Directors responsibilities in respect of the Quality Account What is a Quality Account? Looking Back - progress on our improvement priorities from Review of other quality areas in Key Performance Indicators Quality Improvement Priorities for Review of Services Updates from our Clinical Services What our stakeholders say about us Acknowledgement and feedback Glossary Appendices Appendix 1 National and Local Clinical Audit activity Appendix 2 Complaints and Patient Advice and Liaison Service (PALS) information for Appendix 3 Independent Accountant s Limited Assurance Report P3

4 Statement of the Chairman and the Chief Executive Statement of the Chair I am delighted to welcome you to our Quality Account. This sets out the progress we have made in improving our services in the past year, which included gaining a rating of Good from the Care site was inspected. My gratitude is extended to the staff, volunteers and Board of Mid Essex Hospital Services NHS Trust, whose daily commitment to providing safe, high quality care to our patients made this possible. Looking ahead, that commitment to delivering high quality care is being taken forward through collaborative working with our colleagues in the Basildon and Southend Trusts as part of the Mid and South Essex Success Regime, I hope you will welcome our plans for and beyond. Professor Sheila Salmon Chairman P4 Statement of the Chief Executive Our Quality Account for charts the progress we have made towards meeting the quality standards and initiatives we set ourselves last year and shares our plans for the year ahead. My thanks are extended to everyone connected with the Trust, and especially our staff and volunteers who contributed to our success in the past year. Providing the right care for our patients in the right place is the driving force behind what will be a key element of developments in and beyond. We will work together with our colleagues in the Trusts of Basildon and Southend to create specialist hubs serving the patients of the three Trust areas with the best available expertise. Clare Panniker Chief Executive

5 quality care initiative, we have been working throughout the year to change our management and Board meeting structures to support the Mid and South Essex Success Regime. With those changes in place, we can align the quality agendas of the three Trusts based on experience gained from all three Trust areas. Within the Mid Essex Trust, we have enjoyed some notable quality based successes over the year, including being assessed as Good overall by the Care Quality Commission when they reported following inspection in the summer. All areas within the Trust had improved since the previous inspection with the Burns and Plastics Service assessed as Outstanding. My hope is that all our staff and volunteers will be able to share and enjoy that tremendous achievement. In the year, we have worked to embed our agreed values and behaviours within the cultural fabric of the Trust. This important step was a key priority for the Trust as we know that when staff work as a kind, professional and positive team, both quality outcomes for patients, and job satisfaction for staff improve. That ability to co-operate to deliver best outcomes and best value will serve the Trust well when working with other Trusts and health economy partners. The year has seen some major quality improvement initiatives achieved under the supervision of the newly appointed Trust Managing Director and Trust Chief Operating These included the introduction of an Emergency Village to better utilise the facilities for the provision of urgent and emergency care across the Hospital, the creation of a Frailty Unit and a number of multi-disciplinary and multi-agency initiatives to reduce the number of medically would have been better served by a move to their next place of care. Similarly, the Board has worked tirelessly to create the right environment to promote the provision of quality care not only in the Trust but across mid and south Essex. The creation of this Account has incorporated the input, effort and views of many contributors and I extend my thanks to them In this Account we report upon improvements made and future planned improvements. I hereby state that to the best of my knowledge the information contained within this Quality Account is accurate. P5

6 Statement of Directors responsibilities in respect of the Quality Account The directors are required under the Health Act 2009 to prepare a Quality Account for each Quality Accounts (in line with requirements set out in Quality Accounts legislation). In preparing their Quality Account, Directors should take steps to assure themselves that: the Quality Account presents a balanced picture of the Trust s performance over the reporting period; the performance information reported in the Quality Account is reliable and accurate; there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to the data underpinning the measures of performance reported in the Quality Account the Quality Account has been prepared in accordance with any Department of Health guidance. By order of the Board Date: 30 June Chair P6

7 What is a Quality Account? NHS organisations are required to produce an annual Quality Account providing information about the quality of services they deliver. As a healthcare provider it is our aim to provide high quality services by working collaboratively with our patients and their families and carers and with our healthcare partners. By monitoring our performance against a variety of quality measures we can continuously review and, where necessary, improve the services we provide. The quality measures we use include those which we have selected in collaboration with our staff and service users and national indicators developed by the Department of Health. This Quality Account provides details of our progress against these quality measures in the last 12 months and our plans for improvement in the year In developing our report, we have tried to use non-technical language so that it is as easy to read as possible. In some cases, use of technical terms was unavoidable and we have therefore included a glossary at the end of the document. P7

8 Looking back progress on our improvement priorities from Priority 1: Reducing avoidable harm and engaging and enabling staff to continuously improve services 1.a To improve emergency and hospital Rationale: In recent years the NHS has seen a dramatic rise in attendances at acute trusts which in turn leads to a rise in challenge. in achieving the 4 hour emergency access standard whereby people who come to an Emergency Department (ED) should be seen and treated within 4 hours of arrival. These same challenges impact on appropriate placement of patients on admission and timely discharge to the appropriate place of care. Aim: The system resilience improvement plan was developed to provide a healthcare economy approach. This improvement plan required the Trust to: pilot and then roll out bundle across the Trust; implement home to the Frailty Unit; establish Multi-disciplinary, Accelerated Discharge Events (MADE); embed internal professional standards; and review the workforce in ED and the Clinical Operations Team. What we achieved This was an ambitious and challenging improvement priority for the Trust that set out to deliver change within the Trust and across the health economy. The SAFER bundle is a practical tool to reduce delays for patients in adult inpatient wards (excluding maternity). The wards within Mid Essex Hospital Services NHS Trust (MEHT) have been collaborating with the Emergency Care Improvement Programme during to and the concept of Red and Green days to assist in reducing delays for patients in adult inpatient wards. Further information is available on page 51. All wards within Medicine are now using the SAFER bundle. The implementation of both the SAFER care bundle and the Red/Green days have allowed staff to optimise capacity while giving excellent patient care and experience and ensures that patients coming in through our front door go to the right place Implementation of Home to Assess was delayed in 2016/17 but is to be progressed in 2017/18. The bed management process has been throughout the organisation. This will be further enhanced with the implementation of our new Electronic Patient Record system in May P8

9 The Frailty Assessment Unit opened in September 2016 providing rapid assessment, treatment and care planning for frail older people presenting to the Emergency Department (ED) and the Emergency Assessment Unit (EAU). Please refer to page 51 for more information on this innovative project. The integrated discharge team has been developed to aid us in discharging patients from hospital in a more timely manner. The workforce in ED and the Clinical Operations Team have been reviewed and strengthened. P9

10 P10 1.b To reduce harm from falls through use of falls multifactorial risk assessment Led by: Director of Nursing Rationale: The risk of patients falling whilst in hospital is a recognised risk. In-patient falls that result in moderate or severe harm increase pain, reduce independence and stay. Aim: To ensure that the multifactorial risk assessment is carried out and supports the delivery of appropriate individualised patient care. What we achieved: There has been an overall decrease in all falls with serious harm by 23% from this time last year to now. Key work streams supporting this improvement have been a ward based training programme supported by local simulation exercises and an on-going audit to monitor completion of the eligibility criteria and the multifactorial risk assessment where indicated. The audit has shown that throughout the year completion of the eligibility criteria has remained at or above the target of 90%. Completion of the multifactorial risk assessment remains below the target and an e-learning programme has been developed to support the ward based training programme and improve awareness. By March 2017, 60.95% of relevant staff had completed this training package. We were pleased to note that the amount of falls per month have been calculated per 1000 occupied bed days, the national average set in 2015 is 6.63%. MEHT were below this number for nine months of the to minimise falls in bathrooms and toilets has resulted in a reduction to 11% of falls taking place in these locations with no serious harm resulting from these remaining falls. The work to reduce avoidable harm from falls will remain a key priority for c Reducing Surgical Site infection and avoidable readmission in caesarean section and major gynaecological surgery Led by: Director of Nursing Rationale: Surgical site infections have acknowledged morbidity in terms of delayed recovery, poor patient experience and prolonged bed stays. Aim: To improve safety and enhance the patient experience by reducing surgical site infections. What we achieved: In gynaecology there was a 50% reduction in reported surgical site infections in the year April 2016 to March 2017 compared to the previous year. This was achieved by: Continuing to implement the use of patient wipes prior to surgery and constantly reviewing the use of skin preparation prior to surgery; Improving the training on surgical site surveillance and nominating a surgical surveillance lead on the gynaecological ward; Undertaking a quarterly audit of the surgical site infections reported from gynaecological surgery and caesarean section and readmissions with suspected surgical site infections;

11 The completion of a concise report for all gynaecology readmission by the gynaecological consultant risk lead. In maternity, action to reduce surgical site infection as a result of Caesarian Section included: Investigating all maternal readmissions post caesarean section led by the obstetric consultant risk lead; Undertaking a case review to ensure lessons were learnt. In 2017, with the support of the anaesthetic, midwifery and obstetric teams we are in the process of introducing the Enhanced Recovery Programme for women undergoing a planned caesarean section. The purpose of this programme is to reduce post-operative complications. In line with the Department of Health s recommendations we are introducing a care which encourages the involvement of women and their families in pre-operative preparation and post-operative care. The aim of the programme is to optimise women s health prior to surgery as the women will be directly involved in their preparation and recovery processes. It is earlier physical and psychological recovery. The multidisciplinary team approach to manage women before, during and after their operation also aims to enhance their experiences, ensuring earlier mobility with the best postoperative rehabilitation. 1.d Increase Board visibility (15 steps) Led by: Director of Nursing Rationale: When Board members are visible in the workplace there are opportunities to improve the quality of patient care by viewing the ward and care environment from the patient s perspective and reinforcing our commitment to high standards of care Aim: To increase director visibility across the Trust and to support improved patient experience and staff engagement. What we achieved: The Board has walking onto a ward or clinical area. Whilst impromptu visits to wards and departments by Board members were in place, the opportunity to develop this element of Board to Ward visibility was taken when Non- Executive Directors were on site between closed and public Board sessions. Findings from the visits were shared immediately in the wards and departments at the conclusion of each visit followed by the Directors meeting together to give collective and minuted feedback. This minuted feedback was shared with senior staff for later action. P11

12 The feedback process has continued in the latter part of the year when the emphasis of the visits was altered to make the visits themed around issues known to be affecting the Trust or clinical area. The visits continue to be undertaken by joint groups of Executive and Non-Executive Directors and have proved valuable, not only in relation to giving valuable insight into the workings of the Trust but also giving staff the observations and concerns directly with the Board. The programme will continue in e Values based appraisal and recruitment to be in place Led by: Director of HR Rationale: Staff who are recruited and regularly appraised against an agreed set of values identify more effectively with the organisation s shared vision and take greater personal responsibility for their contribution. Aim: To implement values based recruitment and appraisal processes. What we achieved: The Trust s new Values and Behaviours were launched in March The process of embedding the key elements commenced with a series of targeted workshops based, in part, on feedback from a survey of new recruits. Two workshops took place in May 2016 to review Nursing, Allied Health, and Administrative job descriptions establishing key behavioural requirements for each role. Feedback from the workshops and the recruitment survey enabled us to build a composite picture of successful values based recruitment (VBR). Managers were then nominated for a train the trainer programme and VBR is now being embedded with the support of an online system. We are also carrying out a continuous survey of new recruits to ask about their experiences of the new recruitment process and how well VBR is being integrated into the established process. The appraisal process was also comprehensively reviewed. Paperwork now appraisee s understanding of their contribution to the Trust s values and behaviours. Bespoke coaching and training workshops were provided with an emphasis on the importance of behavioural integrity. This coaching programme will continue and during the last quarter of 2016/17 an audit will be carried out to assess how successfully the values based approach has embedded. 1.f Develop a communication strategy with a consistent approach Led by: Managing Director Rationale: There is increasing evidence to demonstrate a correlation between an engaged workforce and improved patient experience. For this reason the communications strategy includes a aimed at ensuring staff are informed and involved. The national staff survey and quarterly staff FFT surveys highlighted opportunities to improve staff engagement across the Trust. Aim: To support embedding of the Trust s new values and behaviours and develop a focused approach to improve meaningful engagement with staff across the Trust. P12

13 What we achieved: During the year we introduced a number of new initiatives to support and embed the new values and behaviours and to deliver more effective communication. We introduced a monthly Recognition extra mile ; We held a dedicated week of Week ; Introduced various forums for staff to meet with the executive team such as and Managing Director monthly staff forum, and ad hoc Managing Director Improvements in staff engagement were with the overall percentage of staff who would recommend the organisation as a place to work up from 64% to 71% and to receive treatment and care up from 70% to 76%. 1.g Improved clinical communication Rationale: Safe and effective care is dependent on the quality of communication between the patient and members of the healthcare team. With an increasingly frail must include documentation of timely discussion, handover and decision making on treatment escalation plans. Aim: To develop strategies for improved clinical communication on admission, at handover and at discharge of key clinical decision making. What we achieved: Treatment escalation planning During , a clinical lead was appointed to develop a policy on treatment escalation plans. This work will support the availability of information about, and appropriate limitations to, interventions which are likely to be futile or contrary to the patient s wishes. This work has progressed and it is anticipated the policy will launch in May Clinical Handover Implementation of an electronic system now supports nurses in recording patient observations and improves track and trigger scoring. Implementation of modules to support automated escalation when patients deteriorate and clinical handover are being explored for Discharge information The provision of a timely discharge summary for a patient s GP supports continuous care delivery. During the target of over 95% of inpatients having a discharge summary sent has not been achieved with the rate consistently close to or just above 90%. It is anticipated that the implementation of the new Electronic Patient Record will increase this performance during P13

14 1.h Improve Quality Improvement capability Led by: Director of Nursing Rationale: As part of Mid Essex Hospital Services NHS Trust s ambition to improve services and the quality of care provided to patients, the Trust has implemented a quality improvement and change management development programme. P14 Aim: To increase the capability of staff to design services that meet the patient s needs. What we achieved: Forty two staff attended workshops in summer 2016 and the improvement programme launched in autumn 2016 with 16 staff participating in wave 1 and 38 staff currently participating in wave 2. As part of the continued ambition to redesign services that place patients at the centre of all that the Trust does, the quality will be expanded in 2017/18 to ensure that the Trust has the right skills in place for continuous improvement. Sign Up to Safety Campaign The Trust committed to the Sign Up to Safety Campaign in Each year, the improvement priorities associated with the campaign are reviewed and reported within the Trust s Quality Account. In , the Trust participated in the two year anniversary activity with displays in the atrium and ward visits celebrating progress and sharing lessons learnt. 1.i Improving the quality of care for our patients through delivery of the Ward/ Department Accreditation system Led by: Director of Nursing Rationale: A ward-based performance assessment framework supports a culture of safety by helping nurses monitor the quality of care in their own areas. It supports communication, accountability, team working and leadership, empowering staff to focus their attention on improvement and ensures patients are placed at the centre of the provision of services. Aim: To develop and implement a ward based accreditation scheme. What we achieved: During a system was developed that goes further than existing accreditation systems. It not only ensures baseline standards are met but is also a vehicle for real ground level staff engagement and a means of rewarding departments for excellent practice which is shared across the trust. The approach taken is an accreditation for excellence which fosters positivity, generating healthy competition which motivates a desire for excellence. Therefore the MEHT accreditation standards are Bronze, Silver, Gold and Platinum.

15 Accreditation is based on achieving indicators aligned with the corporate vision and objectives, with each level having a unique set of metrics encompassing existing standards with the addition of new aspirational standards for silver and above. Assessments commenced in January 2017 Chief Nurse on 9th February 2017 with six wards achieving Bronze accreditation. There were two wards who were able to meet the requirements of Silver accreditation at their The assessment process will continue into Priority 2: Clinical Effectiveness, Increasing the reliability of care 2.a Improve the early recognition and management of patients with sepsis Rationale: Sepsis accounts for 44,000 deaths across the UK each year. Early recognition and management of sepsis can reduce mortality and avoid unnecessary intensive care admissions. Aim: To monitor the use of the Sepsis 6 care bundle and to continuing education and training for staff to drive improvement. What we achieved: The Sepsis Team have implemented a comprehensive programme of, and the care delivered to, patients with sepsis. This programme has developed throughout from an on-going audit of compliance with the Sepsis 6 care bundle and included a comprehensive communication strategy, targeted education packages, Sepsis Trolleys in A&E, increasing the Early Senior P15

16 Assessment Triage from one bed to four, introduction of a maternity screening tool and pack, public awareness stands, and raise awareness amongst the public. The on-going data collection indicates that April 2016, particularly with key indicators such as giving antibiotics within one hour of arrival at A&E. Please refer to Chart 1. It is pleasing to note that the number of patients admitted to the Intensive Care Unit with sepsis has reduced despite the number of patients with an indicator for sepsis increasing. We remain committed to further improvement and will continue to focus on this area of care in The aim for is to improve care and recognition of patients with or at risk of sepsis throughout the Trust. This will involve targeted support for all wards and departments. Chart 2 Admissions to intensive care or high dependency care with sepsis over the last two years Chart 1 Compliance with the Sepsis 6 bundle in P16 Sustainable improvement is reliant on screening and education to ensure patients are treated appropriately in the early stages. In the Emergency Department, screening has been carried out consistently for over 80% of patients and we aim to sustain and improve this performance. 2.b Develop Trust response to National Safety Standards for Invasive Procedures incorporating a Human Factors approach Led by: Director of Nursing, Chief Medical Rationale: The National Safety Standards for Invasive Procedures (NatSSIPs) were published by NHS England in September 2015 to support learning from harm, near misses and never events. By having effective standards in place to govern the processes associated with invasive procedures and by training staff in team skills or human factors, an improved safety culture can be established and maintained.

17 Aims: The aim in was to establish a working group to support the implementation of this national guidance and to continue with the delivery of human factors training for staff. What we achieved: During A working group was established to identify the specialist areas where bespoke guidance would be helpful; An overarching guidance document has been developed in draft and has been circulated to the group for comments; Bespoke safety checklists and guidance has been developed in Interventional Radiology and for the insertion of Central Venous Catheters; Internal audit and Commissioner led audit have taken place across the Trust to monitor performance and identify areas of practice for improvement; and The Human Factors programme has continued to be delivered throughout the year and to be well evaluated by those that attend. To date 347 staff have attended the training. 2.c Improve End of Life Care Led by: Director of Nursing Rationale: Dealing with death and dying is upsetting and stressful for patients and those close to them. We strive to always provide the best end of life care possible, ensuring people are treated with dignity and respect, kept informed by their healthcare team and are involved in decision making. Aim: We aimed to enhance End of Life care for patients and their relatives and carers, by developing an End of Life Strategy and delivering the End of Life improvement plan. What we achieved: Sustained improvements in End of Life care continued during A summary of the improvements achieved are included below with further details on page 24. A Mid Essex Live Well - Die Well Strategy for aligned to the Ambitions for Palliative and End of Life Care was developed; The Trust participated in the National Care of the Dying audit; We revised the documentation we use to assess and plan care for patients who are in the last days of their life; We provided educational sessions aimed at all staff groups as well as system wide events that involved stakeholders from across the Mid Essex locality; A bereavement survey was introduced to allow us to learn from the relatives of patients who have died in our hospital; The Trust signed up to the Gold Standards Framework, a national quality improvement programme for End of Life Care; The swan symbol, synonymous with care in the last days of life and bereavement, was introduced. P17

18 2.d Improve Mortality review Rationale: Reviewing case records of patients who have died is an opportunity to learn what went well with a patient s care and where there are aspects of their care that could have been improved. All notes of patients who die in hospital are viewed by the Medical Examiners and any We have made plans to establish mortality leads who will undertake the reviews in accordance with the new national guidance on Learning from Deaths. This will be supported by a quality assurance process using criteria-based case selection, discussion, learning and quality improvement. Many of the clinical teams have established mortality reviews in place but these are based within departments and learning is not reliably shared across the Trust. The Structured Judgement Review has a two review and the second tier is an in-depth analysis undertaken if the care of a patient is assessed as falling below acceptable standards or if the death was judged to have been avoidable. P18 Aim: To introduce a whole Trust approach to the two-tier mortality review using a structured judgement approach with the aim to target appropriate case note review at tier one each month using the structured process. What we achieved: In stage one we have introduced a Retrospective Case Record Review of the notes of patients who have died at the Trust. We are using the template produced by the Royal College of Physicians. We are currently reviewing 20-30% of deaths per month and sharing any learning through the Mortality Review Group back to the clinical teams. This review looks at the patient s journey from initial care, care during stay, care at the end of life and scores care overall, looking for any evidence of avoidability. Priority 3: Improving Patient Experience 3.a Embed listening events for patients and staff Led by: Director of Nursing Rationale: A key work stream from the Culture Project was to regularly carry out listening events to enable our patients to tell us about their experiences of our hospital. This also helped us to assess whether the implementation of the new Values and

19 Behaviours were having a positive impact on the patient experience. Aim: A series of listening events were planned for the year. The areas included Emergency Care, Day Surgery, Surgical Wards, Medical Wards, Maternity and Children s Services. What we achieved: All of the listening events were undertaken as planned. A recent example of a listening event involved the Surgical Wards. An In Your Shoes listening event took place in November which was attended by 16 patients who told their story to staff. When they were asked what would have made the biggest difference to their stay, the key theme was for staff to take more time to talk to them about their care. A thematic analysis of all the feedback was completed and presented back to the clinical teams to help them determine where they could improve their services for their patients. The outcome of this was also shared with the patients who attended the listening event. Next year, a new schedule of listening events is planned. These will all be In Your Shoes sessions as it has been recognised that this methodology provides a rich amount of patient feedback that gives the detail which helps our staff make the changes that will make a positive difference. 3.b Improve the environment and make our wards quieter and more restful, especially at night Led by: Director of Nursing Rationale: Patients reported through listening events and National Surveys that our wards can be noisy at night affecting their ability to rest and recover. Aim: A work stream to establish and address the main causes of noise at night was led by the Patient Experience Team working closely with clinical staff. What we achieved: An audit was carried noise at night were hospital staff activities. Subsequently the Trust developed a 10 point success plan for all staff groups to adopt including: ward; Reducing the volume of telephones at night; Reminding staff of the importance of talking in hushed tones; Reminding staff of the importance of wearing soft soled shoes; Porters and estates staff to keep bleeps/radios on mute; Reduce the use of alarms where possible. which alert staff when noise levels reach unacceptable levels. These will be used in a pilot programme where the implementation of will be tested. P19

20 P20 Staff engagement is key to the success of this initiative and each ward will have an the programme. A communication campaign is also planned to support this initiative. 3.c Improve the management of pain for inpatients Led by: Director of Nursing Rationale: During the patient listening events in , patients reported that we were not always managing their pain in a timely and effective manner. Aim: An improvement plan was developed as part of the Culture Project to address any short falls in pain management across the needed support in complying with the agreed guidance. These wards developed plans to improve. What we achieved: On-going audits of pain management take place across the inform the plan for further improvements. The achievements made to date are: Successful recruitment of three pain Clinical Nurse Specialists who will support the delivery of the new training programme; All front line nursing staff of all grades will complete the pain training programme. The programme will cover pain physiology, pharmacological and non-pharmacological methods of pain relief. The key aim is to ensure a consistent approach to the delivery of appropriate pain assessment and management; Newly appointed junior doctors will also receive dedicated training from a Pain Consultant and a Clinical Nurse Specialist; This work stream is led by a multiprofessional working party. In the coming year there are plans for a Pain Consultant to join the ward rounds on the that are supported by the senior Clinical Nurse Specialist. This model has been wellevaluated by staff across the disciplines. 3.d Improve the mechanisms for learning from clinical incidents Led by: Director of Nursing Rationale: We know that despite our aspiration to always provide excellent care for our patients, things will occasionally go wrong. It is important that we react to any serious incident by being open and honest with those involved, by investigating what affected and learning for the future. Aim: In we wanted to embed a process for sharing what has been learnt from serious incident investigations across the Trust. What we achieved: We developed a template that can be completed after an investigation to share what the incident was, the situation, the background leading up to the incident, an assessment of what went well and what went wrong and what the Trust and individuals can do to stop the same thing happening again. These incident summaries or Trust Safety Alerts are circulated by to all staff.

21 As with the investigation process, the aim is to avoid blaming individuals but identify issues in the systems and processes that allowed an error to occur. This encourages a pro-active safety culture where staff are incidents and near misses. We developed intranet content so that these incident summaries could be saved on the Trust Intranet allowing staff to easily access previous versions. We also made arrangements for them to be stored locally in clinical areas. The Trust Safety Alerts have been very well received, with staff feeding back that they Please refer to page 34 for more information on Patient Safety Incidents. P21

22 Review of other quality areas in P22 Many other quality initiatives were developed and progressed across the Trust during In addition the Department of Health have developed a number of national indicators for good quality services and MEHT performance against these indicators should be reported within this account. These indicators are included in detail below and include our performance and, where it is available, the national average and the range from lowest to highest performance amongst NHS Trusts. Mid and South Essex Success Regime Work led by local clinicians over the last mid and south Essex. We are now narrowing these down to one or possibly two preferred business case to support the vision. An options appraisal process is taking place over the next two weeks to achieve this. What is the options appraisal process? In summary, the appraisal process will that have been discussed widely with local people: 1. Clinical quality, outcomes and patient safety 2. Sustainability of the clinical workforce 3. Access 4. The outcome of the options appraisal process will then be shared with staff across the three Trusts and the media before the before the Success Regime Programme Board agrees its recommendations at the end of March. The main evidence to support the process includes: Feedback from service users (from three phases of discussion and engagement that took place between April and October 2016); The outcome of working groups of clinicians (between April 2016 and February 2017, including a review by the independent East of England Clinical Senate); An external review of clinical evidence and national guidance (undertaken by the Eastern Academic Health Science Network); The outcome of a Financial Oversight Group. Three appraisal panels are being asked to score the options against the agreed weighted criteria. The three panels are: Service user panel, comprising three Clinical Commissioning Group (CCG) areas and with a balance of health and care interests; Clinical experts panel, comprising nationally recognised experts who are independent of services in mid and south Essex; Finance experts panel, comprising organisations in the Success Regime. This panel will concentrate just on The conclusions of these three panels and the wider evidence assembled will then be presented to a group of clinical and organisational leaders on 22 February 2017.

23 This system leaders group will score each of the options against the criteria. Going forward, a full Business case is being developed prior to full public consultation expected in the late autumn of 2017 ahead of decision making in the spring of Electronic Patient Record implementation During an ambitious project to implement an Electronic Patient Record (EPR) has been progressed within the Trust. This large scale change project has been supported by a dedicated team with a mix of internal seconded staff and external experts and by scrutiny of the programme by NHS Digital. Ten units including Emergency Care, Requesting and Results, Clinical documentation, Maternity, e-prescribing, Care Plans and Advanced Bed Management information and reporting are to be included in the launch planned for May 2017 following a full dress rehearsal in April This full EPR solution with standardised processes will form the basis for sharing patient information across the Trust and the wider health economy once fully deployed. Replacement of legacy systems will support improved clinical outcomes, process In addition, improved communications with local GP and health care providers will be supported. Continuing focus on Dementia care The quality initiatives aimed at improving the care and experience of people with dementia continue to be embedded and are making a real difference to patients and carers. Over the last year the Dementia Steering Group have introduced the following: The Daily Sparkle, a newspaper which is full of articles, quizzes, old news stories, puzzles, sing-alongs and entertainment geared towards stimulating the mind and improving launched on 27th May 2016 and has proved a useful resource in supporting meaningful activity plans for people with dementia. The Trust is grateful to the this initiative. The Dementia Steering Group have worked with Notley ward who have created a day room and are running regular themed social events. These have included a Queen s Birthday afternoon tea, a valentines party, a events have been thoroughly enjoyed by patients, relatives and staff alike. Plans are underway to create dementia-friendly day rooms on the Care of the Elderly wards providing direct access into the gardens. Throughout the past year the Trust have facilitated musicians playing ageappropriate and interactive music on Care of the Elderly wards. This has been incredibly positive with examples of patients who have been struggling to mobilise actually joining in the dancing! The Dementia Steering Group are also working with Estates & Facilities P23

24 P24 to open the second dementia-friendly garden in the coming year. End of Life Care People with advanced life threatening illnesses and their families should expect good end of life care. In 2016 a Mid Essex Live Well - Die Well Strategy aligned to the Ambitions for Palliative and End of Life Care was developed. The Trust participated in the National Care of the Dying audit and the results published in 2016 demonstrated that we have made improvements with recognition of the dying patient and need for specialist care, but that we should focus more on advance care planning including having earlier discussions about ceilings of care and end of life plans. In response the Trust signed up to the national quality improvement programme, the Gold Standards Framework. This initiative supports early recognition of patients who are coming to the end of their life and subsequent advance care planning. The work will improve communication and co-ordination between the hospital and community whilst improving staff skills escalation plans described on page 13 supports this area. We have amended and updated the End of Life Care Plan supporting assessment and care planning for patients who are in the last days of their life. The changes to the care plan have improved the documented care for these patients as well as the communication between the multidisciplinary team providing care. Education and training has been delivered through formal taught sessions aimed at all staff groups as well as system wide events involving the Mid Essex locality including our commissioners, the community and local hospice. The Trust is also supported by the local Hospice in-reach initiative on two wards In order to seek feedback from relatives of patients who have died in our hospital, we introduced a bereavement survey. We are now able to gain a better understanding of where we have delivered excellent end of life care and where we need to make improvements. We have recently introduced the swan Hospital to promote dignity and respect for patients and those important to them whilst ensuring end of life choices are observed. occasions including signage on wards, documentation, linen bags for the property of deceased patients. As well as caring for the patient we also support those important to them in a number of ways including offering the patient a side room to allow for privacy, open visiting, a put-up bed so visitors can stay overnight and ensuring spiritual needs are met. End of Life discharge has been highlighted as an area that requires improvement in We recognise that discharges are not always timely due to a number of constraints within the system however, the Trust is committed to supporting patients in achieving their preferred place of care. Building on the work of the Gold Standards Framework Programme we will be focusing on advance care planning and supporting patients with end of life decisions.

25 Hospital In partnership with Essex County Council, the Chelmer Valley Park and Ride shuttle bus pilot scheme was successfully implemented during Following the pilot, the service was formalised and it is currently being delivered by Community Link. The smaller shuttle bus now provides a regular 23 minute direct service between the hospital and the park and ride between 7am to 7pm Monday to Friday. This service continues to grow in popularity and has been positively reviewed by many patients who use it on a regular basis. In December 2016 a subsidy was introduced for our staff to use the service supporting a wide range of sustainable transport initiatives to meet the ambitions set out in our Access to To further improve access to our hospitals we continue to work closely with other local community transport providers and we actively promote the use of public transport services for anyone visiting our hospital sites. Since 2014, the Trust has received accreditation for travel planning activities that are set out in our Travel Plan. The incentives and facilities that will enable our staff and patients to travel more sustainably. Our travel plan sets out our ambition to reduce single car journeys to the site and to encourage staff to consider healthy travel as part of their commute to work. Engaging with our Community Natural Health Service Project The Natural Health Service Project focuses on improving the health of the community through providing physical activities and educational garden volunteer opportunities St. Peter s Hospital in Maldon. The project forms part of the wider implementation of the Trust s Sustainable Development Management Plan, published in 2014, when the Trust Board agreed and adopted a strategy to maintain momentum towards becoming a more sustainable and responsible healthcare organisation. Over the last 12 months this project has been recognised on a national level. Accolades included winning an NHS Sustainability Award and a HefmA award. The Trust was also shortlisted for the prestigious Health Service Journal Awards 2016, which aims achievements in the NHS. Last year, we worked closely with 14 local volunteer groups and organisations - with more than 200 volunteers - to care for our woodlands, grounds and gardens, including the community vegetable garden and fruit tree orchard. We also opened the new dementia- Braxted Ward. The garden has made an enormous difference to patient experience reducing behaviour which is perceived to be challenging. garden, a second dementia-friendly garden is now in development in the courtyard adjacent to Baddow Ward. All the funds needed to complete this garden have now been raised and physical site works are planned to start in March P25

26 Key Performance Indicators Summary Hospital-level Mortality Indicator The Summary Hospital-level Mortality Indicator (SHMI) reports on mortality at Trust level across the NHS in England. The SHMI covers all deaths of patients admitted to hospital and those that occur up to 30 days after discharge from hospital and is the ratio between the actual number of patients who die and the number that would be expected the characteristics of the patients treated. The Health and Social Care Information Centre produce the SHMI together with the number of patients coded as receiving palliative care as this provides context to the mortality data. Table 1 below indicates the value and banding of the SHMI for the Trust for the reporting period. The Trust has consistently maintained the SHMI relative risk rate within the expected range over the last 12 months. Table 1: MEHT SHMI for the period January 2015 to December 2016 Source: NHS Digital October 2015 to September 2016 (Rolling 1 year period, 6 months in arrears) Table 2: Percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the period Source: P26

27 The Trust considers that this data is as described for the following reasons: the data is reported and monitored externally to the Trust and is based on data published by the Health and Social Care Information Centre. Table 2 provides the percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the Trust for the reporting period. Mortality is monitored by the Mortality Review Group. Improving the review of mortality was for and details of progress are available on page 18. The Mortality Review Group have developed an improvement plan for to ensure there is full understanding of the factors resulting in the raised HSMR. This improvement plan includes requirements for a clinical coding review and case note review by clinicians. Within the improvement plan for , the Trust will implement in full the requirements of the National Quality Board s Learning From Deaths guidance. The Trust recognises an alternative mortality indicator, the Hospital Standardised Mortality expected. This indicator assesses groups of patients with conditions that commonly result in death (such as heart attacks or strokes), to see how many, on average in England, survive their stay in hospital. It is well recognised that Mortality rates in themselves cannot be interpreted as a measure of clinically unexpected deaths but rather can act as a smoke signal representing issues with documentation, clinical coding or clinical care. P27

28 Helping people recover from illness Outcome Measures (PROMs) Patients undergoing elective inpatient surgery for four common elective procedures (hip and knee replacement, varicose vein surgery and groin hernia surgery) are asked to complete questionnaires before and after their operations. These Patient Reported Outcome Measures (PROMs) were designed to calculate health improvement from a patient perspective by asking them about their health and quality of life before and after Unfortunately many of the sample sizes within the most recently available dataset health gain for primary knee replacement was above the national average. The Trust values patient feedback on their experience of healthcare services and uses this information to drive continuous improvement and the engagement and listening events that proved so successful in will continue in Table 4: Health gain from nationally available data Table 3 provides the most recent data on participation rates. The Trust notes that on the whole participation rates are in line with or exceed the national average. Table 4 provides an overview of the health gain from nationally available data. The Trust considers that this data is as described for the following reasons: The data is collected independently of the Trust by an approved provider and analysed and published by the Health and Social Care Information Centre. Table 3: Participation rates, provisional data published May 2017 P28 Source: HSCIC website, Quality Accounts, Domain 3 - Helping people to recover from episodes of ill health or following injury, PROMS; patient reported outcome measures

29 Patient Safety Thermometer The NHS Safety Thermometer is a national data collection which records the presence or absence of four harms on a given day every month. The harms included are pressure ulcers, falls, urinary tract infections (UTIs) in patients with a catheter and new venous thromboembolisms (VTEs). This comprehensive dataset helps us to identify where we need to focus our attention to improve the quality of services. The tables below show performance in Chart 3 shows the patients reported as having harm free care by month during the period April 2016 to March For this quality indicator the higher the score the safer the care. The overall level of harm free care reported 95.69%. Chart 3 provides details of the type of harm reported during the period by month. The Trust recognised during that the data recorded was not always accurate. In particular, the submissions on Pressure Ulcers, new Venous Thromboembolisms and Urinary Tract infections in patients with a urinary catheter often skewed the overall results. In order to aid staff on the wards collecting the data, additional guidance was developed and where possible specialist teams supported validation of the data before submission. This additional support will continue in Chart 3: monthly data for harm free care for the 12 months to March 2017 Source P29

30 Pressure ulcers are caused by sustained pressure being placed on a particular part of the body. This interrupts the blood supply to the affected area of skin causing damage. People with normal mobility do not develop pressure ulcers, as their body automatically makes hundreds of regular movements that prevent pressure building up. Patients admitted to hospital can be at risk of developing pressure damage for a number of reasons. pleased that no patients acquired grade 4 pressure ulcers during their stay. We believe this contributed to the apparent monthly variation in the numbers of inherited and new pressure ulcers reported via the Safety Thermometer each month. In , preventing pressure damage in our patients will be one of the Trust s key Quality Improvement Priorities. In , the Trust had a number of changes in the corporate nursing team who provide clinical support to ward staff on preventing and treating pressure damage. Despite these challenges, the Trust was Chart 4: monthly data for types of harm for the 12 months to March 2017 P30 Source

31 Venous thromboembolism (VTE) It has been estimated that every year in England 25,000 deaths occur as a result of hospital-acquired VTE. In many cases, deaths resulting from blood clots that develop during an inpatient stay are preventable. It is therefore important that adult patients are assessed for their risk of developing a clot when they are admitted to hospital so that preventative measures can be put in place to reduce the risk. The percentage of our patients, who are assessed for their risk of developing a VTE, is an important measure of the quality of care we provide. This information is collated and reported on both within the Trust and externally to our commissioners and regulators. Our reported performance on risk assessment for VTE is above the average for England. Please see Table 5 below. The Trust considers that this data is as described for the following reasons: we recognise that work is required to ensure we are appropriately reporting those patients. being assessed, against those patients eligible for assessment in line with NICE guidance. The Trust intends to take the following actions to improve VTE risk assessment: A review of this clinical pathway has been undertaken; and The Trust has invested in an IT solution to support a move away from the paper based system of capturing and reporting when a patient has had a VTE risk assessment; Implementation of this electronic system has been delayed in however we hope to transition to the new reporting system early in A new chair has recently been appointed to the Thrombosis Group and this will provide a forum to drive continuous improvement in the way we assess and treat patients at risk of hospital-acquired VTE Table 5: the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period Source P31

32 The number of cases of acquired Clostridium marker of effective infection prevention and control practice. Each healthcare provider is required to report monthly on the number allows national data to be collated and monitored. Please refer to Table 6 below. The local data for indicates 35 has successfully appealed against 19 cases through demonstrating to an external scrutiny panel that the management of the patients infection was compliant with national and local policy. We are pleased to note that the most recent national data, for shown in Table 6 below, demonstrates that MEHT remained well below the national average in spite of challenging targets and complex patients. The increase in the number of cases in is a concern. It is not clear why there has been an increase in numbers, but it may The Trust considers that this data is as described for the following reasons: the Trust close surveillance. The Infection Prevention Team maintain a database which tracks the and addressed. Table 6 amongst patients aged 2 or over during the reporting period Source: National Data P32

33 The Trust will continue to take the following actions to minimise the risks of all hospital acquired infections. The measures that 72 hours of admission to hospital, all bays and siderooms associated with the patient s admission episode are terminally cleaned. a ward, selected areas will be terminally cleaned and enhanced cleaning commenced throughout the ward. 72 hours) are sent for Ribotyping. This is a unique to a species. Different ribotypes indicate that cases are unlikely to be due to person to person transmission. It is likely that a number of the general population are pre-colonised with C. patient is admitted and prescribed antibiotics for sound clinical reasons. Local panel reviews are held for cases The panel looks at all aspects of care before and after the result is reported including antibiotic prescribing, time of sampling and isolation, documentation, treatment of cleanliness of the environment. communicated trust-wide. However, as stated earlier many cases are found to be completely compliant with guidance and are successfully appealed at the scrutiny panel hosted by the Clinical Commissioning Group. Patients associated with the same ward in the Trust do not tend to be colonised with the same strain and this indicates that transmission between patients is rare. P33

34 Patient Safety Incidents Incident reporting It is recognised that in organisations providing complex healthcare, things will sometimes go wrong with the potential for patient harm. By reporting such incidents and near misses, an organisation can learn and improve the way healthcare is delivered. The rate of patient safety incidents reported relative to activity, and the number and percentage of patient safety incidents that result in severe harm or death, are important indicators of an NHS provider s safety culture. A high incident reporting rate usually indicates a more mature safety culture. The Trust s most recent reporting rate per 1,000 bed days was 0.31%. Table 8 provides national comparative data for this and the previous reporting period. Table 9 provides more recent local data on incident reporting. The Trust considers that this data is as described for the following reasons: whilst reporting rates have increased month on month, there remains an inconsistent level of reporting across different staff groups and departments. The Trust implemented a number of actions in to support staff in reporting incidents. We anticipate these actions will sustain and further improve the current improved reporting rate seen in the most recent NRLS publication. Trust staff continue to receive training on reporting incidents and near misses at induction and investigation training. Actions include: We established a Datix User Group and completed a staff survey to understand how we could improve the incident reporting system. As a result we have changed the web-based report form and revised the incident categories so they are more intuitive; In we will continue to work with staff to encourage reporting and local learning through ward and department safety huddles, department governance meetings and across the Trust through our safety alerts. Further information on how we learn when things go wrong is provided on page 20. Table 7: NRLS incident data for the periods 1st October 2015 to 31st March 2016 and 1st April 2016 to 30th September 2016 P34 Source:

35 Table 8: local incident reporting data Never Events Never events are serious incidents that have been designated by NHS Improvement as preventable as barriers and guidance exist to stop them from ever occurring. Serious Incidents Some incidents that occur in the NHS incidents in healthcare are uncommon but when they occur in the Trust, we ensure these are thoroughly investigated so that action can be taken to mitigate the risk of similar incidents occurring in the future. Duty of Candour The Duty of Candour Regulation ensures that providers are open and transparent with people who use their services and other relevant persons. The guidance sets wrong with care and patients are harmed including informing people about the incident, providing an apology, providing reasonable into what happened. The Trust has a process in place to ensure harm, it complies with these requirements. The clinician responsible for the patient s care or for the investigation into what went wrong will initially discuss the concerns with the patient or nominated person. Once shared at a face to face meeting and a hard copy of the report provided. If the patient or nominated person does not wish to have a face to face meeting, then the report is provided by post. On-going monitoring of compliance ensures that these requirements are met. Each never event has the potential to cause serious patient harm or death. However, serious harm or death is not a criteria for an incident to be categorised as such. From April 2016 to February 2017, 380 Never Events were reported across the NHS in England. In the Trust, 4 never events were reported in the period April 2016 to March Each incident has been or is being rigorously investigated so that lessons can be learned. Details are provided below. Two cases of wrong site surgery. The incorrect tooth was extracted in one case. Fortunately this was recognised immediately after the operation was completed and had no long term impact on the patient. As a result of this incident, procedures for facial marking of the correct quadrant were put in place and staff were reminded that abbreviations must not be used on the consent form. An incorrect lower lip lesion was removed due to issues with site marking. This incident remains under investigation. One case of wrong implant/prosthesis. One wrong sided component of a knee implant was inserted. The patient is being followed up and at this time it is thought unlikely this will impact on mobility. As a result of this incident, the importance of the surgical pause before the surgery begins has been reinforced. P35

36 One case of retained foreign object post procedure. In maternity, following delivery, a special swab was left in situ in error. As a result the packs used no longer contain this type of swab. Understanding and minimising the use of physical restraint People who present at the Trust with challenging behaviour are at higher risk of being subjected to restrictive interventions. Those patients with cognitive impairment and altered states of consciousness are the most likely to be subject to these interventions which place them, and to a lesser degree, staff and those who provide support, at risk of physical and/or emotional harm. Restrictive interventions should only ever be used as a last resort and only then for the shortest possible time. The Trust has adopted national guidance as follows: the use of recovery-based approaches; Reports on incidence of restraint are provided to the Trust Board and our Commissioners; Restrictive interventions are only carried out by competent people trained restraint methods; Where a restrictive intervention has to be used, it always represents the least restrictive option to meet the immediate need; Awareness training is used to ensure staff understand their responsibilities and are competent in recognising unmet needs; use de-escalation techniques; adhere to and apply the principles of government legislation; On admission individualised support plans, incorporating behaviour support plans, are implemented for all people who use services who are known to be at risk of being exposed to restrictive interventions. Chart 5 below provides details of the number of incidents of physical restraint by month for the 12 month period. For each incident a review panel is held so that lessons are learned and feedback offered to staff. The majority of restrictive interventions carried out are assessed as unavoidable and the incidents tend to occur in the Emergency Department out of hours and at weekends and involve people with Mental Health issues. In funding for a mental health nurse to be recruited to the Emergency Department has been sought. Their role will include supporting the emergency village with mental health training and development in line with best practice. Chart 5 Numbers of reported incidents of physical restraint during the period P36 Source: Trust DATIX incident reporting system

37 Readmissions within 28 days Readmission to hospital within 28 days of discharge can be an important measure of the quality of care provided to patients. The reasons for readmission are often complex with no single causal factor. However there are opportunities to help prevent potentially avoidable readmissions by reviewing where organisations have low readmission rates. National data has not been published recently, however it is a requirement that it be included within the Quality Account. Please refer to Table 9. The Trust considers that the data published in 2013 is as described for the following reasons. The data is collated nationally and is published by the Health and Social Care Information Centre. The most recent nationally published data is from 2011/12 indicating that the Trust had a favourable readmission rate at that time. More recent local data indicates there has been a rise in the rate of readmissions and the Trust intends to take the following actions to understand and improve our readmission rates. Our operational and quality improvement teams are working together to understand whether the increase is due to natural variation or whether there are underlying issues that can be addressed. If required, collaborative work with the clinical teams will follow to ensure care provision is reviewed in detail and any issues addressed. Table 9 National comparison to England and other Medium Acute Trusts data for the percentage of patients readmitted within 28 days of being discharged from a hospital during 2011/12. Local data for is also provided below Source Data: The NHS IC Indicator Portal - Hospital Episode Statistics : Indirectly age, sex, method of admission, diagnosis, procedure standardised percent *Source: local Patient Administration system, Information Services P37

38 Patient and Staff Experience Patient Friends and Family Test The Friends and Family Test (FFT) was introduced in 2013 to help service providers and commissioners understand how and the services we provide and where improvements can be made. The FFT asks people if they would recommend the services they have used to their friends and family and offers a range of responses. The survey is a quick and anonymous way for patients to give real time feedback on the Trust s inpatient areas, accident and emergency, maternity and outpatient services. Table 10 below provides details of the Trust performance for our inpatients and patients attending our Emergency Department. Feedback from the FFT is shared widely across the Trust. The information is shared locally via departmental meetings encouraging staff ownership for delivering improvements and also at Divisional and Executive level to allow performance to be monitored. Key points of note are: The Inpatient FFT score is now consistently over 93% of patients recommending our services; The FFT score for A&E has increased The FFT score for our Maternity services is 98% with a response rate of 20%; The Outpatient score has remained at 84%. Table 10 provides the results of the NHS Friends and Family Test for Mid Essex Hospital Trust P38 Source:

39 The Trust considers that this data is as described for the following reasons. The data is reported and monitored externally to the Trust and is based on data published by the Health and Social Care Information Centre. Historically the level of local ownership for performance in the patient FFT has varied. During the last year the Trust recognised that the response rates and scores for a number of areas should improve. As a result the Trust will continue with the following actions to drive further improvements: A new strategy developed by the Site Director of Nursing will support improved local ownership to ensure the FFT feedback is used by ward and department teams to understand the patient experience and where improvements are needed; Guidance on responding to the feedback received is being provided on an on-going basis; Wall mounted feedback stations within Did are planned for ; and your Shoes listening event is planned to take place in July 2017 with the support of the Patient Council. Trust responsiveness to patient needs Patient experience is a key measure of the quality of care. The NHS should continually strive to be more responsive to the needs of those using its services, including needs for privacy, information and involvement in decisions. Improving hospitals responsiveness to personal needs is a key indication of the quality of patient experience. This score is based on the average of Inpatient Survey: Were you involved as much as you wanted to be in decisions about your care and treatment? staff to talk to about your worries and fears? Were you given enough privacy when discussing your condition or treatment? Did a member of staff tell you about medication side effects to watch for when you went home? Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital? Table 11 below provides the most recent Trust and national comparative data available for and Table 11 provides details of the responsiveness to the personal needs of its patients during the reporting period *Source: the National Patient Survey Programme P39

40 The Trust considers that this data is as described for the following reasons: it is collected independently from the Trust and published by the Quality Commission and based on patient feedback. Overall the Trust has improved from the previous year for being responsive to the personal needs of our patients. The Trust intends to take the following actions to improve the staff responsiveness to patients: Empower our patients to ask questions about their care and be involved in decision making; Improve the information we give to patients when they are being discharged home to include who to contact if they become worried and information about their medication; electronic patient records system; Review and improve our discharge processes; and Continue to embed our staff values and behaviours. Improving responsiveness on wards and at discharge will be a quality improvement priority for Staff Friends and Family Test In April 2014, NHS England introduced the Staff Friends and Family Test (FFT) in all NHS trusts in England. The vision is that all staff should have the opportunity to feedback their views on their organisation at least once per year. It is hoped that Staff FFT will help to promote a big cultural shift in the NHS, where staff have further opportunity and of staff are increasingly heard and are acted upon. Staff are asked how likely they would be to recommend the NHS services they work in to friends and family who need similar treatment or care. Table 12 below provides the most recent comparative data for the FFT staff test within the National Staff Survey. The Trust considers that this data is as described for the following reasons: it is collected and analysed independently of Performance against this indictor has improved both since the previous survey and number of initiatives developed to improve communication and engagement with staff as described on page 12. The Trust intends to take the following actions to improve the staff FFT response further: We did involving the Staff Culture Hub; Trust Board to continue with 15 steps initiative; and Promotion of the Managing Director Table 12 Survey P40 Data Source com/page/1056/home/ NHS-Staff-Survey-2016/

41 NHS Staff Survey Nationally, the NHS Staff Survey results provide an important measure of staff experience and well-being. The annual survey asks NHS staff to give their views anonymously about their experiences at work. Table 13 below provides data on the percentage of staff responding that they experienced harassment, bullying or abuse from staff in the last 12 months. The Trust considers that this data is as described for the following reasons: Extensive work continues to improve the Trust s culture and embed the Trust s Values and Behaviours; The Trust has a Bullying and Harassment policy; There is increased communication with regard to cascading learning; The Trust has a Speak Up Policy and there is an awareness of the Policy and that matters can be raised in The Trust intends to take the following actions to maintain the improved performance in these areas: improve the timescales for progressing cases appropriately and the communication with all participants; and agree a Standard Operating Procedure to improve how the Trust responds and escalates if the matter is not progressing appropriately. Table 13 below provides data percentage of staff believing that the Trust provides equal opportunities for career progression or promotion. The Trust considers that this data is as described for the following reasons: Adverts are clear that the Trust applies Equal Opportunity; Occupational Health work closely with managers when there is the need for consideration regarding adjustments required to the role; HR work with managers to support and manage reasonable adjustments as required. The Trust intends to take the following actions to maintain the improved performance in these areas: The E&D group is being reinvigorated An appointment to the role of Equality Advisor is being considered across our partnership Success Regime Trusts; Minority groups will be supported to access NHS leadership courses. Table 13: provides national comparative NHS Staff Survey data for the Trust Source: nhsstaffsurveys. com/page/1056/ Home/NHS-Staff- Survey-2016/ P41

42 Quality Improvement Priorities for In developing this Quality Account, we have consulted with our clinicians, executive team and our Patient Experience Group to identify priorities for improvement in The priorities information on patient harm that occurred in and initiatives linked to our Patient Safety and Quality Strategy. Table 14: Quality Improvement Priorities for P42

43 Table 14: Quality Improvement Priorities for (continued) P43

44 Review of Services During the period April 2016 to March 2017, Mid Essex Hospital Services NHS Trust provided and/or sub-contracted 96 NHS services. Mid Essex Hospital Services NHS Trust 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 represents 100 % of the total income generated from the provision of NHS services by the Mid Essex Hospital Services NHS Trust for reporting period April 2016 to March Goals Agreed with Commissioners A proportion of Mid Essex Hospital Services NHS Trust s income in April to March was conditional on achieving quality improvement and innovation goals agreed between the 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 (CQUIN). The Trust has plans in place to deliver all CQUIN standards agreed for 2016/17. Risks related to potential non-delivery of standards are monitored through the monthly CQUIN discussions with the responsible owners. Please refer to Table 15 below for further details. The commissioners have indicated that the likely adverse impact on the year end NHSE CQUIN position is a 100k reduction on the paid to the Trust in the annual contract. Table 15: Performance against CQUINs for P44

45 Participation in Clinical Audit National Clinical Audit Participation review and the actions the Trust intends to take to improve the quality of healthcare are provided in Table 2, Appendix 1. Clinical audit is an important quality improvement process for the Trust. Participating in relevant national clinical an important opportunity for the Trust to benchmark the quality of its services against those of other providers and to improve During the period from 1 April 2016 to 31 March 2017, 41 national clinical audits and NHS services that Mid Essex Hospital Services NHS Trust provides. During that period, the Trust participated in 88% of the national audits and 100% of the to participate in. The national clinical audits and national Hospital Services NHS Trust was eligible to participate in during the period 1 April 2016 to 31 March 2017 are listed in Table 1 in Appendix 1. The national clinical audits and national Hospital Services NHS Trust participated in and for which data collection was completed during the period 1 April 2016 to 31 March 2017, are listed alongside the number of cases submitted to each audit or enquiry as a percentage of the number of cases required by the terms of that audit or enquiry where this information is available. Improving services through participation in local clinical audit The scope of the Trust s local clinical audit programme demonstrates engagement amongst our healthcare professionals with continuous service improvement. The process provides an opportunity for comparing the quality of the services the Trust provides against best practice. The reports of 10 local priority clinical audits were reviewed by the Trust and details of action that the Trust has taken to improve the quality of healthcare provided following local audit is provided in Table 3, Appendix 1. The reports of 24 national clinical audits were reviewed by Mid Essex Hospital Services NHS Trust during the period 1 April 2016 to 31 March 2017 and the details of the P45

46 Participation in Clinical Research Active participation in clinical research demonstrates the commitment of the Trust to improving the quality of care we offer our patients and to the wider health economy. The number of patients receiving NHS services provided or sub-contracted by MEHT in the period 1 April 2016 to 31 March 2017 that were recruited to National Institute for Health Research-adopted research was This research is always approved by a Research Ethics Committee. The Trust was involved in conducting 91 NIHR-adopted clinical research studies (studies open to recruitment) during approved during and a further 115 study amendments were approved. The most active research areas this year were Burns and Plastics, Oncology, Renal, Rheumatology and Dermatology. Clinical were also opened this year. There were 58 publications that have resulted from our involvement in healthcare research, which shows our commitment to transparency and desire to improve patient outcomes and experience across the NHS. For our vision is to embed a research culture within the Trust to ensure that we are working in unison to improve our quality of care and patient satisfaction. We will continue to include patients in NIHR research studies and strive to develop our own home grown research. Data Quality Good quality information underpins the effective delivery of patient care and is essential in informing the improvement of services. Improving data quality can therefore improve patient care and value for money. NHS Number and General Medical Practice Code Validity Mid Essex Hospital Services NHS Trust submitted records during 1 April 2016 to 31 March 2017 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics. The percentage of records in the published data which included the patient s valid NHS number for the period April 2016 to February 2017 was: 99.7% for admitted patient care; 99.9% for outpatient care; and 98.1% for accident and emergency care. The percentage of records in the published data which included the patient s valid General Medical Practice Code was: 99.9% for admitted patient care; 99.9% for outpatient care; and 99.9% for accident and emergency care. P46

47 The key data quality successes throughout were: cleansing of data held on Patient Administration System (PAS) to support migration to the Trust s new Electronic Patient Record; continued development of daily data quality reports identifying errors as they occur; undertaking of local training sessions for PAS users requiring additional support to reduce data quality errors. Clinical coding error rate Clinical Coding is the translation of medical terminology written by the clinicians to describe the patient s diagnosis and treatment into nationally standardised codes. This information is vital to support: the delivery, planning and monitoring of patient care services; the planning and management of Trust services; the collection of income. The key clinical coding successes throughout were: the Team exceeded the percentage of completed coding targets set by Commissioners throughout the year with over 98.5% of episodes coded by the agreed date; one Senior Coder successfully achieved their National Accredited Clinical Coding Exam; successful appointment of a Clinical Coding Trainer Manager to support a further two Trainee Clinical Coders to continue the essential function of recruiting new staff to the Clinical Coding profession; successful appointment of a Clinical Coding Auditor Manager to support the improved internal Clinical Coding audit programme including mortality audits and individual coding audits; development of strong networking links in particular with Essex Success Regime colleagues and promotion of Clinical Coding across the organisation via a Trust-wide screensaver and attendance at Trust wide events such as Marquee Week. There was an external Clinical Coding Audit as part of the Information Governance Toolkit requirements. The results (shown below) were extremely encouraging with Level 3 (the highest level) being achieved for the second year in succession at the Trust. % Diagnosis coded correctly Primary 96.50% Secondary 98.98% % Procedures coded correctly Primary 99.22% Secondary 99.46%. the continued review and update of Outpatient Procedure forms in line with the Electronic Payment Record to help ensure appropriate activity is recorded and the correct income is received; P47

48 Information Governance Mid Essex Hospital Services NHS Trust Information Governance Assessment Report overall score for April to March was 66% and was graded GREEN from the Information Governance Toolkit indicating Level 2 compliance. Care Quality Commission The Care Quality Commission (CQC) is the organisation which regulates and inspects health and social care services in England. All NHS hospitals are required to be registered with the CQC in order to provide services and are required to meet fundamental standards in order to retain their registration. Mid Essex Hospital Services NHS Trust is required to register with the CQC and at 31st March 2017 was registered with no conditions attached to that registration. The CQC has not taken enforcement action against Mid Essex Hospital Services NHS Trust during April 2016 to March 2017 and that had been made following their hospital inspection, including the progress within Urgent and Emergency Care. An improvement plan has been developed and is being implemented to address the the December 2016 report resulting in requirement notices. These recommendations are being addressed as detailed in Table 16. CQC Rating December 2016 Mid Essex Hospital Services NHS Trust was subject to a CQC focused review of those services that were rated as November 2014 hospital inspection. P48 review were published in December 2016 and the Trust was rated as Good overall with Burns and Plastics rated and Emergency Care rated as refer to the CQC grid in the right hand column.

49 Table 16: CQC - Trust actions developed in response to CQC recommendations P49

50 Updates from our Clinical Services Medicine and Emergency Care Emergency Village Mid Essex Hospital Services NHS Trust have the 4 hour emergency access standard whereby people who come to an Emergency Department (ED) should be seen and treated within 4 hours of arrival. In some cases this will not be the case due to individual clinical need but in general this standard should be met in 95% of cases. Our performance over the year is shown by quarter in Table 17 below. During , we have continued to focus on making improvements to support timely review of patients in the ED and so effective A fundamental change to the delivery of emergency care was the development of the Emergency Village. This enhances understanding of where patients need to be in the department, decreasing bottlenecks for patients and balancing demand with capacity throughout the Emergency Village. This included launching the Acute Medical Unit; the Emergency Short Stay; the Frailty Assessment Unit (FAU) and the Early Senior Assessment and Treatment Unit (ESAT). Table 17: Performance against the 4 hour standard We have developed new ways of working to improve patient experience in the ED with the support of the Emergency Care Improvement Programme (ECIP): Streaming we now have dedicated, experienced staff to direct patients to the most appropriate area for their condition; The ESAT unit has allowed us to transfer patients from ambulances to a designated area within the ED in a timely fashion and allow ambulances to return to actively transporting patients; Trackers dedicated staff in place to ensure patients move through the department in a timely manner and that all requested investigations are undertaken and results obtained; The Ambulatory Care Unit takes patients from the ED allowing this team to focus on those presenting as seriously ill, the injured or with minor illness and injury. This Unit provides a patient focused service where some conditions may be treated without the need of an overnight stay in hospital. The patient receives the same medical treatment they would previously have received as an inpatient. P50 Source: local data, Information Services

51 opened in September 2016 (see below). The FAU aims to provide rapid assessment, treatment and care planning for frail older people presenting to the ED and the Emergency Assessment Unit. This Essex, combining expertise from MEHT provider. It has been an exciting six months since we opened the unit and we have seen innovative collaborative working between the Trust and the community teams. This has resulted in reduced length of stay for frail older people in the hospital so that they are cared for in the most appropriate care setting. The Frailty Team is based in the Emergency Village and offers a 7 day consultant led service that aims to see older frail people as soon as possible, avoiding unnecessary delays in the emergency department and providing timely high quality care. Frailty Unit In September 2016, we opened our Frailty Unit with a multidisciplinary Frailty Team at the front door for the rapid assessment, treatment and care planning for frail older people. The team consists of Medicine for the Elderly doctors, therapists, specialist community frailty nurses, and dedicated social workers and the core nursing staff. A person with clinical frailty admitted to the acute hospital is more likely to have increased length of stay, increased hospital complication rate, increased readmission rate and increased risk of inpatient death. Early recognition of frailty in the acute hospital setting leads to rapid assessment resulting in clear medical diagnoses, development of rehabilitation goals, escalation of care decisions and focused discharge planning. Opportunities to extend the service are being explored with options to offer a GP telephone hotline and potential direct access to the unit for appropriate patients. One of the Trust s key quality improvement priorities for was to improve Progress with the suite of initiatives that underpinned this improvement plan is summarised on page 8. The wards within MEHT have been collaborating with the Emergency Care Improvement Programme during to and the concept of Red and Green days to assist in reducing delays for patients in adult inpatient wards. best practice. S - Senior Review. All patients will have a senior review before midday by a clinician able to make management and discharge decisions. A - All patients will have an Expected Discharge Date (EDD) and Clinical Criteria for Discharge (CCD), set by assuming ideal P51

52 P52 recovery and assuming no unnecessary waiting. F - Flow of patients to commence at the earliest opportunity from assessment units to inpatient wards. Wards routinely receiving patients from assessment units will ensure E - Early discharge. 33% of patients will be discharged from base inpatient wards before midday. R - Review. A systematic multi-disciplinary team (MDT) review of patients with extended lengths of stay (>7 days also known as mind set. Red and Green Days management system to assist in the journey. This approach is used to reduce internal and external delays as part of the Green Day - A patient who is receiving active treatment or therapy towards their clinical criteria for discharge. Red Day - A patient who does not have a clear plan of care, or who is waiting for further treatment/intervention or decision. Red days are dealt with by the ward staff and escalated appropriately through the system when they are unable to deal with them. Red days can be observed and interrogated for larger system blockages and this has highlighted areas where processes have required review. The implementation of both the SAFER care bundle and the Red and Green Days initiative have allowed staff to optimise capacity while giving excellent patient care and experience and ensures that patients coming in through our front door go to the Stroke Service continues to provide one of the best stroke services in the country. Publication of national data has seen the service at highest that can be attained. This high level status has been consistent over the last year placing the service in the top 18% in the country. The stroke service which operates twentyfour hours a day, continues to see a rise in the number of patients that it treats, both stroke and patients that need to access our TIA clinics. These clinics which are held daily are fundamental in facilitating stroke prevention care to the people of Mid Essex. Despite the constant rise in patient numbers the service continually offers quick and performance being one of the best in the region. The service continues to develop and in line with national guidance we work closely with a neighbouring Trust to access thrombectomy services where a clot is surgically removed from a blood vessel in suitable patients.

53 Dermatology In 2016 the Dermatology Service established a One Stop Dermatology Clinic for 2 Week Wait suspected skin cancer referrals. This reduced the wait for 2 Week Wait minor ops and where clinically necessary, enables a faster referral to Plastic Surgery. The introduction of a weekly nurse and therapy led burns outreach clinic in Ely to provide care closer to home for patients living in the North of the catchment area. These One Stop Dermatology clinics are held once a week with three Dermatology Consultants in the clinic. Patients are able to have both an outpatient consultation and their minor op all in one attendance. This has proved to be a very positive patient experience and enabled patients to be seen, have minor operative procedures done and be followed up within 28 days on the Skin Cancer Pathway. It has also helped to reduce 14 day referral pathway to 7 days. This has ensured that Dermatology has consistently delivered above the 93% standard for 2 Week Wait referrals on the Skin Cancer Pathway. We are planning, with substantive recruitment to current Dermatology Consultant vacancies, to establish a second One Stop Dermatology Clinic. Burns and Plastics Service The regional plastic surgery service now covers a population of 3.2 million and the regional burns service services a population of 9.8 million. During : Specialist burns and plastics services inspection (Dec 2016); The commissioning of a new hand and assessment unit for the St Andrews Centre due to open May 2017; and Women s & Children s Services Maternity and Neonatal Services In the Maternity Services a number of initiatives were progressed in addition to our stated aim for to reduce surgical site infection following caesarian section. Please refer to page 10 for more details on this As part of the work to support and participate in the Government s initiative to reduce stillbirths and early neonatal deaths by 50% by 2020, Maternity Services have: Introduced the Saving Babies Lives Care Bundle (NHS, England) which management of babies at risk; Successfully bid for 40,000 from NHS Education to fund patient safety training supporting multi-professional learning and improving the delivery of safe care; Applied for the Maternal and Neonatal Safety collaborative (NHS 53

54 Improvement) allowing MEHT to improve services in line with national guidance; Secured the funding to provide two Cardiotocograph Master Classes, presented interpretation of electronic fetal heart monitoring. The study days also included CTG competency assessments; Improved pathways and knowledge of management of sepsis; Successfully employed two newly funded obstetric consultants supporting the provision of services for women across maternity and recommendations; Commenced antenatal telephone triage to support women with the provision of advice and reducing the number of unnecessary attendances to the Day Assessment Unit; per week across three locations. Women are also offered the Hypnobirthing book and the CD. This service provision is currently being audited to evaluate uptake and outcomes. Replacement model for Supervisors approved a replacement model to ensure that a recognised system is in place from 1st April 2017 to provide support to women and midwives in line with NHS England s proposals; Maternity involvement in local service attended the Essex Baby Show to promote Mid Essex Maternity Services and to seek the views of women as service users; Hour of Care audit and are continuing to implement actions. 54 Charity funding for new neonatal incubators which will ensure premature and unwell babies can be cared for safely. In addition to the work supporting Saving Babies Lives, other initiatives progressed in are summarised below. introduction of HypnoBirthing classes was fully implemented this year as part of Project 2%. This on-going innovation aims to continue to reduce Caesarean section rates by optimising normal birth rates. HypnoBirthing gives parents tools to minimise the fear-tension-pain cycle, resulting in shorter, more comfortable births. This year a further 14 midwives have been trained in the therapy, and we are now able to offer three classes Gynaecology Service In Gynaecology a number of initiatives were progressed in addition to our stated aim for to reduce surgical site infection following major gynaecological surgery. Please refer to page 10 for more details on Other initiatives are summarised below.

55 We provided an additional outpatient hysteroscopy clinic this year to improve patient choice and access; Our patients experience has been improved by the implementation of Myosure. This option allows surgeons creating an incision in the abdomen or removing the uterus (hysterectomy) and avoiding the need for a general anaesthetic and hospital admission; We purchased additional hysteroscopy scopes to improve the service we can offer to our patients being treated at Braintree Community Hospital; We implemented a nurse-led pessary clinic, improving accessibility to gynaecology services; Our nurse colposcopist successfully completed her training enabling delivery of autonomous treatments to women attending the colposcopy suite; We successful recruited into a newly funded gynaecologist consultant post, with funding for a further post secured. Children s Services A number of service developments occurred in the period including within the Children s Emergency Department (ED). There has been an increase in children s nursing establishment in in-patients and ED as well as an increased senior nurse establishment. In addition two newly funded paediatric consultant posts were successfully recruited to, supporting the provision of services for children in the ED, neonatal services and in-patient ward setting; Improvements were made to the clinical pathways and staff knowledge in relation to the care of critically unwell management of sepsis; Charitable funds were allocated that for adolescents as well as children s play equipment which allows unwell children and their siblings to play outside while continuing their treatment. Feedback from external agencies about the service has been positive: When the NMC undertook an educational visit, they reported that all standards had been achieved demonstrating that student nurses are receiving training that allows them to qualify as nurses. When the CQC visited the Children s Emergency Department to undertake a focused review in January 2017, they reported that they were reassured that changes had been made following a serious incident investigation. Improvements in pathways of care and knowledge of critically unwell children were acknowledged. Furthermore, improvements in the were evident. primarily the ED discharge safety net and the movement of staff from other areas into ED and these are being addressed. P55

56 P56 Cancer and Clinical Support Services A New Division This is a newly formed Division following a restructure of services aimed at continuous improvement in the delivery of high quality Support Services. The Division is characterised by high versatility expanding over 13 distinct services offered by the Trust. We have implemented an operational structure which brings all these areas of practice under the umbrella of The division has been clear in its role to provide quality support to all services in the Trust and achieve the highest standards of care. To achieve this, we have developed an approach based on enhancing effective communication and a collaborative culture leadership. to Quality and Patient Safety Alignment of managerial and governance structures; Improved mechanisms for learning from incidents; leadership requirements; for escalation e.g. theatre utilisation and oncology; Integration of services under unifying management such as chemotherapy and support care unit (Day Therapies) to enable seamless patient care, clearly enhancing patient experience; Enablement of collaborative models of care with other Divisions and external stakeholders. Palliative Care Medicine Active participation and development of Mid Essex Live well Die well strategy and End of Life care; Facilitation of Safe EoL Discharges. Microbiology/ID Medicine Early ID review of relevant patients; Facilitation of safe discharges from Emergency Village and inpatient wards; Critical role in early recognition and management of patients with sepsis. Microbiology/ID Urology Creation of complex UTI clinics to enable reduction of admissions for this patient group. Haematology and Day Therapies unit for the whole of the Trust. R&D and Pharmacy Increased contribution to the availability of new and novel treatments for our patients. Engagement with GP and Academic communities

57 Other Individual Services Theatres, anaesthetics and Intensive Care Unit Theatres have gone through some changes in 2016 and We have recently been awarded the new ISO 9001:2015. This is based on criteria for a quality management system. The standard highlights that there is a culture of continual improvement and this supports good quality of care and services. Changes have been made to theatre recovery by separating general anaesthetic from local anaesthetic recovery to ensure a better patient experience. The theatre department have introduced a safety brief for all staff and this has enhanced the safety culture. In addition during this period we: Introduced the Extended / Overnight Recovery Service for Carefully Selected High Risk Elective Patients, this reduces the burden on Critical Care; Obtained excellent ICNARC data for the Intensive Care Performance, putting the unit in the top 10% of the country; Worked closely with other specialties, such as interventional radiology to provide support and assistance in maintaining safety and developing patient pathways. Critical Care is pleased to announce the launch of a new in-house Acute Care Course called Management of the Acutely Ill Adult. This course will equip registered nurses with the theoretical understanding, and clinical support the care of the deteriorating patient within any clinical setting. This development has been made possible through collaboration with the University of Essex, allowing students to obtain credits should they wish to self-fund. This has provided an opportunity for shared learning with our ESR partners. A further two courses Pathology disciplines: Histopathology, Biochemistry, Laboratory Haematology (including coagulation and blood transfusion), Immunology and Microbiology. We are processing more than 6 million samples per year (April 2017) with a year on year increase (4.8 million tests in April 2011). Pathology s operational integrity is crucial for diagnosis and the treatment provided to all patients. In this period the Department: Introduced Essex Blood Runners; Upgraded instruments in some disciplines, with introduction of new arrays of tests; Worked towards stream lining requests and booking in at source of samples; Worked at introducing molecular testing (microbiology); Supported the Trust in meeting its Infection Control targets; Actively participate and led in some of the discussions for the development of regional Pathology Services and creating a sustainable Pathology Workforce within the Success Regime. P57

58 P58 Our staff are proud to be working more often behind the scenes supporting our patients and ensuring the safety of their journey from diagnosis to cure. Radiology The CQC Report in December 2016 rated outpatients and diagnostics as good. Good governance arrangements were highlighted in the report, with a dedicated governance lead working within the Radiology Department. The 6 week diagnostic waiting time standard (DM01) has been achieved throughout 2016/17, despite increases in activity; The department successfully bid to become part of the radiology registrar training rotation for the East of England. and will be based at MEHT throughout their training; Excellent professional development opportunities for radiographic staff have been maintained and expanded leadership and management, research, CT, MRI, ultrasound and radiographer reporting. This encouragement of extended role and advanced practice has maintained and expanded the highly skilled radiographic workforce; The department has worked in partnership with the CCG and MacMillan as a pilot site for MultiDisciplinary Diagnostic Centre / Rapid Access Diagnostics. This innovation has lead to earlier cancer diagnosis for several patients; radiology suite and patient recovery area was installed and opened in April This upgraded facility provides high quality imaging for patients undergoing emergency and elective IR procedures. Haematology In 2013/14 the department was subjected to two external review including one by the Royal College of Pathologists. The implementation of actions deriving from the reviews under expert leadership, has delivered to the Trust and the region an engaging, caring, responsible and strongly performing Haematology Team. The Team has worked with colleagues at the Success Regime pioneering the integration of expert haematology services across the region. of 2 week wait times and there are no haematology breaches; All new patients are seen within 12 weeks with the majority seen within 8 weeks. This is the shortest wait in the whole of Essex as patients have been referred to us from all other areas as choose and book; According to National Cancer Patient Survey 2016/17 target compliance is consistently above average; supporting the general medical and surgical teams; Reduction of inpatient referral to review waiting times. The majority of patients are seen within 24 hours;

59 Revival of Clinical Nurse Specialist telephone clinics increasing patient satisfaction; Improved nurse lead bone marrow aspiration services positive patient experience; Improved anticoagulant clinic turn around and patient satisfaction; Numerous changes in haematology diagnostic laboratory leading to improvement in all KPI measures, quality and cost of service; The Division within Mid and South Essex Success Regime (SR) Various departments of the Division have already integrated their services in relation to the Success Regime (Pharmacy) or pioneering the SR vision (Cancer, Diagnostics and Clinical and Oncology Related Services - haematology, oncology, interventional radiology, ultrasound and Sterilisation Unit). The Divisional Director provides Clinical SRO oversight to the Clinical Support Services Steering Group of the ESR. complaints. Cancer Cancer Services have worked in partnership with the Essex Success Regime throughout 2016/17 and have a collaborative approach across Mid and South Essex Hospitals to achieve 62 day performance standard of 85% compliance in July 2017; Cancer Services MDT team have been in place for a period of 3 years with little staff turnover and all competent in their Cancer Services have seen two upgrades for Somerset Cancer Register in 2016/17 which has enabled improved tracking/recording and reporting of cancer datasets; Initiated COSD (cancer outcome services dataset) to enable completeness of required national datasets from Somerset Cancer Register in 2017/18. Medical Revalidation Revalidation is the process by which all licensed doctors are required to demonstrate on a regular basis that they are up to date able to provide a good level of care. This means that holding a licence to practice is an indicator that the doctor continues to meet the professional standards set by the General Medical Council (GMC). patients that their doctor is being regularly checked by their employer and the GMC. Licensed doctors have to revalidate every based on core guidance. MEHT acts as a P59

60 designated body for all doctors employed by the Trust who are not in a recognised training programme and this relationship is called a prescribed connection. The appointed to lead the process. Since revalidation started in December 2012 the positive recommendations. All doctors who had a prescribed connection to MEHT prior to 1st April 2013, and remain in our employ, have been revalidated. During 2016/17, 330 doctors have undergone enhanced appraisal with an overall appraisal rate of 95.9%. Doctors in recognised training programmes are assessed and revalidated via the relevant training body. The Trust has updated the Medical Appraisal and Revalidation Policy, continued to recruit and train medical appraisers and provide workshops for doctors new to appraisal. We have linked with colleagues at Basildon and Southend to run training events for all our appraisers. Nurse Revalidation The Nursing Midwifery Council exists to protect the public by ensuring only those who meet their practice requirements are allowed to practice as a registered nurse or midwife. Staff have embraced the revalidation process and feedback has been positive, in particular The Trust continues to support nurses and midwives through provision of a monthly dedicated Revalidation workshop, and a monthly workshop dedicated for those P60

61 What our Stakeholders say about us Health Overview and Scrutiny Committee (HOSC) The Essex HOSC discussed its approach to Quality Accounts at its last meeting on 20 March Due to imminent county council elections, the Essex Health Overview and Scrutiny Committee does not intend to comment individually on NHS Quality Accounts this year. This should in no way be taken as a negative response. The Committee has, in the main, been content with the engagement of local healthcare providers in its work over the past year. The Committee is aware that local Healthwatch also reviews Quality Accounts and is content that they can represent the patient and public voice and comment accordingly. Health and Wellbeing Board and Wellbeing Board I have been asked by the Board Chairman to comment on NHS annual reports/accounts. and I have no further comments to add. The staff and management should be thanked for their continuing professionalism and dedication. I would note the considerable interest within the county council around the ongoing STP and the opportunities and challenges that this presents. Dr. Michael Gogarty Director Wellbeing, Public Health and Communities Essex County Council P61

62 Response to MEHT Quality Account from Healthwatch Essex Healthwatch Essex is an independent organisation working to provide a voice for the people of Essex in helping to shape and improve local health and social care services. We believe that health and social care services should use people s lived experience to improve services. Quality Accounts are an important way for local NHS services to report on their performance by measuring patient safety, the effectiveness of treatments, and patient experience of care. They also present a useful opportunity for Healthwatch to provide a critical, but constructive, perspective on the quality of services, and we will comment where we believe we have evidence grounded in people s voice and lived experience that is relevant to the quality of services delivered by MEHT. We re pleased to acknowledge that it has been a successful year overall for the Trust which is which included reducing harm and enabling staff to improve services; increasing the reliability of care; and improving patient experience. A key component of this last one has been to listen to patients about their experiences of care at the Trust. We re pleased to see the completion of a year of regular listening events, which provided opportunities for patients to share their stories and feedback with staff. Analysis of the arising themes is reported to have been undertaken and shared with staff allowing them to plan and implement improvements. Healthwatch Essex welcomes the number of measures introduced to improve staff responsiveness to patients by empowering patients to ask questions, and be involved in decisions about their care, as well as by improving the information they receive when being discharged home or on to another service. This last point is particularly salient to our review of patient and staff experience of hospital discharge published in late 2016 which, while highlighting many areas of good practice, also found the need to improve information provision and communication, and to view patients as active agents in their care. Relatedly, we welcome the news of the new Electronic Patient Record system which will form the basis of patient information sharing across the Trust and with The Trust concedes that there is always more work to be done to increase the consistency relevant changes were made to ensure they do not happen again. MEHT also seems to be consistently below the England average score in the Friends and Family Test, although its score services sits at an impressive 98%. The Trust states that it is implementing measures to improve the overall FFT score, and we look forward to seeing the outcomes of these next year. P62

63 Healthwatch Essex runs an Information Service which provides information to service users and healthcare professionals about health and care services in Essex. People also contact us to share their experiences of care in the County too. Coupled with our online Feedback Centre, we are able to collect information relating to patient, family, and carer experiences of services and share it with providers and commissioners. In the last year we received 62 contacts from people providing information about services provided by MEHT, both positive and negative, which we have shared with the Trust, and which will be investigated in the case of detailed negative comments, common themes and areas where improvement can be made. Similarly, the outcome of the reviews received at our Feedback centre have been shared. Whilst MEHT s Quality Account presents a positive overall picture of the care provided at the Trust, there have been examples where this could have been better and it is useful to dig down into individual patient experiences, to hear from patients directly and to share this with the Trust to work together to improve patient experience. Healthwatch Essex believes that understanding what it is like for the patient, the service user and the carer to access services should be at the heart of transforming the NHS and social care as it meets the challenges ahead of it. P63

64 P64 Mid Essex CCG Response to Mid Essex Hospital Services NHS Trust 2016/17 Quality Accounts As the lead commissioner of services provided by Mid Essex Hospital Services NHS Trust (MEHT) across a number of sites, Mid Essex Clinical Commissioning Group (MECCG) welcomes this Quality Account as a commitment for open dialogue with the public and stakeholders regarding the quality of care provided by MEHT. Assurance from MECCG is required to ensure that the information in this Quality Account is accurate, fairly interpreted, and representative of the range of services delivered. MECCG is aware that it is commenting on a draft version of this Quality Report, any comments published version. MECCG is however unable to assure all data reported, as some data may have been provided or updated prior to publication. You describe processes to monitor your own progress through the year, for all elements of patient safety, clinical effectiveness and patient experience these appear robust. It has been a challenging year with unprecedented demand for services, but very encouraging that for a second year there has not been a grade 4 pressure ulcer, due to any lapse in policy. It was pleasing to see the overall improvement in your Care Quality Commissioning (CQC) rating from requires improvement to good, following their visits in June 2016 and January You give a comprehensive description of your participation in and learning from clinical undertaken. MECCG notes your performance in relation to Summary Hospital Mortality Index (SHMI) has remained as expected for the period reported to September 2016 and that an alternative mortality indicator, Hospital Standardised Mortality Rate (HSMR) has you as higher than expected, also that you have a Mortality Review Group to oversee your development plan into 2017/18. Your Quality Improvement Priorities for 2017/18 are: Accreditation scheme Sepsis End of Life care Pain management Support when things go wrong Some of which will develop schemes already underway. Prevention and care of pressure ulcers Clinical communication Human Factors Learning from listening events Information on discharge In conclusion MECCG considers Mid Essex Hospital Services Quality Accounts for 2016/17 as providing an accurate and balanced picture of the reporting period. MECCG supports the Trust in moving forward to work with its new partners and to continue to implement its efforts and initiatives to improve the quality of their services. Rachel Hearn Acting Director of Nursing and Quality Mid Essex Clinical Commissioning Group May 2017

65 Acknowledgements and feedback Acknowledgements The Trust Board would like to thank the Corporate and clinical teams and the many individuals and groups representing patients and the public for their contribution to the Quality Account for In particular the Trust is grateful for those senior clinicians, clinical teams, key priorities for improving quality in Feedback To continue to drive forward improvement, we welcome feedback from readers about the information we include in our Quality Account. If you would like to comment or request further information please contact our Communications Team. Post: MEHT Communication Team Court Road Chelmsford Essex CM1 7ET Details of any amendments made subsequent to the account being shared with stakeholders in May 2017 and prior to publication in June 2017 are provided below. Medical and Nursing Revalidation Responses from Essex County Council Mid Essex CCG Health Overview and Scrutiny Committee Year end data for key performance indicators P65

66 Glossary Clinical audit Measures the quality of care and services against agreed standards and suggests or makes improvements where necessary. Clinical coding assigning a code for every inpatient stay process enables patient information to be easily sorted for statistical analysis. Clostridium A spore-forming bacterium which is present as one of the normal bacteria in the gut of up to 3% of healthy adults. People over the age of 65 are more susceptible to developing illness due to these bacteria. C is altered, allowing C bacteria to watery diarrhoea. Procedures such as enemas, gastro-intestinal surgery, and drugs such as antibiotics and laxatives cause disruption of the normal gut bacteria and increase the risk of developing C diarrhoea. Comfort rounds Nurses proactively visiting patients on an hourly basis, in addition to their usual rounds. Commissioners Organisations that buy services on behalf area. They may purchase services for the population as a whole, or for individuals who Commissioning for Quality & Innovation (CQUIN) The CQUIN payment is a national framework for quality improvement schemes. It makes a proportion of provider income conditional on the achievement of ambitious quality improvement goals and innovations agreed between commissioner and provider, with active clinical engagement. The CQUIN framework is intended to reward genuine ambition, encouraging a culture of continuous quality improvement in all providers. Department of Health The department of the UK government responsible for policies on health, social care and the NHS in England. Duty of Candour The duty of candour places a legal obligation on all providers of health and adult social care requirement to be open with patients when things go wrong. Providers should establish the duty throughout their organisations, ensuring that honesty and transparency are the norm in every organisation registered by the CQC. Failure to rescue A failure in the recognition or management of a patient whose condition deteriorates. Francis Report In June 2010 the Secretary of State for Health, announced a full public inquiry into the role of the commissioning, supervisory and regulatory bodies in the monitoring of Mid Staffordshire Foundation NHS Trust. The Inquiry was chaired by Robert Francis QC, and reported to the Secretary of State making recommendations based on the lessons learnt from Mid Staffordshire. Healthcare Associated Infection An avoidable infection that occurs as a result of the healthcare that a person receives. P66

67 Hospital Standardised Mortality Ratio The Hospital Standardised Mortality Ratio is the ratio of observed deaths to expected deaths for a basket of 56 diagnosis groups which represent approximately 80% of in hospital deaths. It is a subset of all and represents about 35% of admitted patient activity. Human Factors Human factors encompass all those behaviour. In a work context, human factors are the environmental, organisational and job factors, and individual characteristics which Joint Health Scrutiny Committee (known as Overview and Scrutiny Committees (OSCs)) Since January 2003, every local authority with social services responsibilities has had the power to scrutinise local health services. OSCs take on the role of scrutiny of the NHS not just major changes but the on going operation and planning of services. They bring democratic accountability into healthcare decisions and make the NHS more publicly accountable and responsive to local communities. Methicillin Resistant Staphylococcus Aureus (MRSA) An antibiotic-resistant form of a common bacterium called Staphylococcus Aureus that can cause infection in a range of tissues such as wounds, ulcers, abscesses or bloodstream. Staphylococcus Aureus is found growing harmlessly on the skin in the nose in around one in three people in the UK. Outcome and Death (NCEPOD) NCEPOD undertake studies and identify best practice through detailed case note review of the management of patients. NHS Number used to help healthcare staff and service providers match you to your health records. National Institute for Health Research (NIHR) maintains a health research system in which the NHS supports outstanding individuals conducting leading edge research focused on the needs of patients and the public. It is funded through the Department of Health to improve the health and wealth of the nation. Costing Templates are required documents for any research and development submission and are used for generating commercial study costs to provide cost transparency and predictability when negotiating local site budgets. National Reporting & Learning System (NRLS) The National Reporting and Learning System (NRLS) is a central database of patient safety incident reports from all NHS healthcare organisations. No harm Low harm minor injury, can be treated with as a skin tear Moderate harm injury requiring more than such as a fractured wrist Severe harm injury with a permanent disability, such as a fractured hip Death National Safety Standards for Invasive Procedures (NatSSIPs) The NatSSIPs were published by NHS England in September The document Harmonise and Educate. The NatSSIPs are based on national learning from harm, P67

68 P68 near misses and never events and provides a strong systemic barrier to preventing harm during invasive procedures. Invasive procedures include not only surgery, but any procedure where a hole is made in the patient s body and consent is required. National Institute for Health Research (NIHR) A body created by the Department of Health to support outstanding individuals working in world-class facilities who are conducting leading-edge research focused on the needs of patients and the public. Never Event These are serious patient safety incidents not occur as the risks are known and preventative measures available. NEWS NEWS is an early warning scoring system based on a patient s physiological measurements. Six simple physiological parameters form the basis of the scoring system - respiratory rate, oxygen saturations, temperature, systolic blood pressure, pulse rate and level of consciousness. A score is allocated to each as they are measured, extreme the parameter varies from the norm. The score is then aggregated and used to timely intervention by the clinical team. Percutaneous endoscopic gastrostomy (PEG) and medicines directly into the stomach by passing a thin tube through the skin into the stomach Patient Reported Outcome Measures (PROMs) PROMs measure quality from the patient perspective. Initially covering four clinical procedures, PROMs calculate the health gain after surgical treatment using pre and post-operative surveys. Quality Domains domains of quality: Patient Safety - doing no harm to patients Clinical effectiveness - measured using survival rates, complication rates, measures of clinical improvement, and patient-reported outcome measures Patient experience - care should be characterised by compassion, dignity and respect. Relative Risk Readmission or Standardised Readmission Ratio Relative Risk Readmission or Standardised Readmission Ratio (SRR) is the relative risk of 30 day emergency readmissions, (observed number of emergency readmissions compared to expected). Research Clinical research and clinical trials are an everyday part of the NHS and often conducted by medical professionals who also see patients. A clinical trial is a particular type of research that tests one treatment against another. It may involve either patients, or people in good health, or both. Risk Assurance Frameworks Documents that map out risks to Directorates or the Trust achieving their objectives and the progress with actions developed to address these risks. Root Cause Analysis (RCA) A structured investigation of an incident to ensure effective learning to prevent a similar event happening.

69 Sepsis Sepsis is a life threatening condition that arises when the body s response to an infection injures its own tissues and organs. Sepsis leads to shock, multiple organ failure and death especially if not recognised early and treated promptly. Sign Up to Safety Sign up to Safety is designed to help realise the ambition of making the NHS the safest healthcare system in the world by creating a system devoted to continuous learning and improvement. Sign up to Safety aims to deliver harm free care for every patient, every time, everywhere. It champions openness and honesty and supports everyone to improve the safety of patients. Standardised Hospital Mortality Indicator (SHMI) The SHMI is like the HSMR, a ratio of the observed number of deaths to the expected number of deaths. However, this is only applied to non-specialist acute providers. The calculation is the total number of patient admissions to the hospital which resulted in a death either in-hospital or within 30 days post discharge. Thrombolysis This means dissolving blood clots by injecting a special clot-dissolving drug into the artery directly into the blood clot. This can and may avoid the need for an operation. Once a clot starts to form it may continue to get bigger until the whole vessel is blocked. Although the blood clot can be removed by an operation, it is also possible to dissolve the clot. Venous thrombo-embolism (VTE) A condition in which a blood clot (thrombus) forms in the vein. These blood clots are a known complication of immobility and surgery. WHO Surgical Checklist A checklist developed to be completed for every patient undergoing a surgical procedure. Supervisors of Midwives (SOMs) SoMs help midwives provide safe care for families. They make sure that the care provided by midwives is given in the right place and by the right person. SoMs are experienced midwives who have had additional training to enable them to help midwives provide the best quality midwifery care. They oversee the work of the midwives and meet with them regularly to ensure that high standards of care are provided. They also guide and support midwives in developing their skills and expertise. P69

70 Appendices Appendix 1 Clinical Audit Table 1 Relevant National Clinical Audit Participation Table 2 Review of relevant national clinical audit reports published in Table 3 Learning from local clinical audits in Appendix 2 Complaints and Patient Advice and Liaison Service information for Appendix 3 INDEPENDENT ACCOUNTANT S LIMITED ASSURANCE REPORT TO THE DIRECTORS OF MID ESSEX HOSPITAL SERVICES NHS TRUST ON THE ANNUAL QUALITY ACCOUNT. P70

71 Appendix 1, Table 1 Relevant National Clinical Audit Participation TBC indicates data was not available at the time of publication P71

72 Appendix 1, Table 1 (cont) Relevant National Clinical Audit Participation P72

73 Appendix 1, Table 1 (cont) Relevant National Clinical Audit Participation P73

74 Appendix 1, Table 2 Review of relevant national clinical audit reports published in P74

75 Appendix 1, Table 2 (cont) Review of relevant national clinical audit reports published in P75

76 Appendix 1, Table 2 (cont) Review of relevant national clinical audit reports published in P76

77 Appendix 1, Table 2 (cont) published in P77

78 Appendix 1, Table 3 Learning from local clinical audits in P78

79 Appendix 1, Table 3 (cont) Learning from local clinical audits in P79

80 Appendix 2 Complaints and Patient Advice and Liaison Service (PALS) Information for The Trust saw a slight increase of 7.5% in the number of Formal Complaints received in 2016/17 compared to 2015/16. The number of formal complaints received is expected to remains comparable to previous years. This increase is likely to be due in part to the increased information available throughout the hospital encouraging patient feedback and information on how to contact the PALS & Complaints Department. There was a larger increase (12%) in the number of PALS Concerns received. This increase in PALS Concerns is extremely positive, as it indicates that the PALS Service is being accessed by patients and service users more frequently and the issues being raised are being addressed and resolved quickly, thus preventing an increase in formal complaints. This increase is most likely due to the service being located in an extremely accessible area of the hospital, and the service being highlighted throughout the to appendix 2 table 1 below. Table 2 below shows the top three main subjects of Formal Complaints per year. Each of the main subjects has various sub-subjects. The main subject of Clinical Treatment is large and covers a number of sub-subjects such as; Care from doctor/ consultant, Nursing care, Coordination of treatment, staff competency, treatment didn t have expected outcome, missed bony injury etc. In line with the Local Authority Social Services and NHS Complaints Regulations 2009, the Trust produces regular reports. These reports highlight numbers received, main themes and trends as well as lessons learnt. The quarterly and annual complaints report is discussed at the public Trust Board meeting. Regular complaints reports are also sent to the Senior Management Group and the Patient Safety & Quality meetings, where trends and learning are highlighted. P80

81 Appendix 3 Independent Chartered Accountant s Limited Assurance Report to the Directors of Mid Essex Hospital Services NHS Trust on the Annual Quality Account We have been engaged by Mid Essex Hospital Services NHS Trust to perform an independent assurance engagement in respect of Mid Essex Hospital Services NHS Trust s Quality Account for the year ended 31 March 2017 ( the Quality Account ) and certain performance indicators contained therein as part of our work. NHS trusts are required by section 8 of the Health Act 2009 to publish a quality account which must include prescribed information set out in The National Health Service (Quality Account) Regulations 2010, the National Health Service (Quality Account) Amendment Regulations 2011 and the National Health Service (Quality Account) Amendment Regulations 2012 ( the Regulations ). Scope and subject matter The indicators for the year ended 31 March 2017 subject to limited assurance consist of the following indicators: Percentage of patients risk assessed for venous thromboembolism (VTE); and Percentage of reported patient safety incidents resulting in severe harm or death We refer to these two indicators collectively as the indicators. Directors responsibilities The Directors are required under the Health Act 2009 to prepare a Quality Account for Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the Regulations). In preparing the Quality Account, the Directors are required to take steps to satisfy themselves that: the Quality Account presents a balanced picture of the Trust s performance over the period covered; the performance information reported in the Quality Account is reliable and accurate; there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls they are working effectively in practice; the data underpinning the measures of performance reported in the Quality Account is robust and reliable, and is subject to appropriate scrutiny and review; and the Quality Account has been prepared in accordance with Department of Health guidance. compliance with these requirements in a statement of directors responsibilities within the Quality Account. Our responsibilities Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations; the Quality Account is not consistent in all material respects with the sources Auditor Guidance issued by the Department of Health in March 2015 ( the Guidance ) as supplemented by the Quality Accounts: Reporting P81

82 P82 Arrangements 2016/17 letter dated 6 January 2017; and the indicators in the Quality Account of limited assurance in the Quality Account are not reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Guidance. We read the Quality Account and conclude whether it is consistent with the requirements of the Regulations and to consider the implications for our report if we become aware of any material omissions. We read the other information contained in the Quality Account and consider whether it is materially inconsistent with: Board minutes for the period April 2016 to June 2017; papers relating to quality reported to the Board over the period April 2016 to June 2017; feedback from the Commissioners dated May 2017; feedback from Local Healthwatch dated 26 June 2017; feedback from the Essex Health and Wellbeing Board dated 16 May 2017; the Trust s complaints report published under regulation 18 of the Local Authority, Social Services and NHS Complaints (England) Regulations 2009, dated September 2016; the latest national patient survey dated 31/05 / 2017; the latest national staff survey dated 07/03 /2017; the Head of Internal Audit s annual opinion over the Trust s control environment dated 01 /06/ 2017; and the annual governance statement dated 31 /05 / We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with these documents (collectively the documents ). Our responsibilities do not extend to any other information. This report, including the conclusion, is made solely to the Board of Directors of Mid Essex Hospital Services NHS Trust as a body in accordance with the terms of our engagement letter dated 27 June Our work has been undertaken so that we might state to the Directors those matters we have agreed with them in our engagement letter and for no other purpose. We permit the disclosure of this report to enable the Board of Directors to demonstrate that they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permissible by law, we do not accept or assume responsibility to anyone other than the Board of Directors as a body and Mid Essex Hospital Services NHS Trust for our work or this report or for the conclusions we have formed save where terms are expressly agreed and with our prior consent in writing. Assurance work performed We conducted this limited assurance engagement under the terms of the Guidance. Our limited assurance procedures included: evaluating the design and implementation of the key processes and controls for managing and reporting the indicators; making enquiries of management; testing key management controls; limited testing, on a selective basis, of the data used to calculate the indicator back to supporti ng documentation; comparing the content of the Quality Account to the requirements of the Regulations; and reading the documents.

83 A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The nature, timing and extent appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations is subject to more inherent limitations characteristics of the subject matter and the methods used for determining such information. established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Account in the context of the criteria set out in the Regulations. The nature, form and content required of Quality Accounts are determined by the Department of Health. This may result in the omission of information relevant to other users, for example for the purpose of comparing the results of different NHS organisations. In addition, the scope of our assurance work has not included governance over quality or non mandated indicators which have been determined locally by Mid Essex Hospital Services NHS Trust. indicators For the two indicators subject to testing, evidence to support all six dimension of data validity and completeness of the value reported for the percentage of patients risk assessed for venous thromboembolism; and accuracy, relevance and completeness of the value reported for the percentage of patient safety incidents resulting in severe harm or death. Based on the results of our procedures, with the exception of the matter reported in above, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2017: the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations; the Quality Account is not consistent in all material respects with the sources the indicators in the Quality Account subject to limited assurance have not been reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Guidance. BDO LLP Chartered Accountants Ipswich, UK Date: 30 June 2017 P83

84 At our best, we are a...