quality report 2014

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2013-14

The Hillingdon HospitalsNHS Foundation Trust

quality report

Improving your local hospitals – our report to you

The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01

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contentsAbout the Trust’s Quality Report 4

Executive summary 4

Part 1 Statement from the Chief Executive 6

Part 2 Review of quality priorities for improvement 8

Key quality achievements for 2013-14 8

2.1 Looking back… 9

Quality priorities for improvement 2013-14 – How did we do? 9

2.2 Performance against Core Quality Indicators 2013-14 16

2.3 Looking forward… 20

Our new Clinical Quality Strategy 20

Quality priorities for improvement in 2014-15 20

Patient Safety Collaborative Programme 27

2.4 Formal statements of assurance from the Board 27

Provision of NHS Services 27

Participation in clinical audit 28

Participation in research 33

Lessons learned from Serious Incidents 34

Goals agreed with our commissioners 35

Care Quality Commission registration 35

Data quality 37

Information governance toolkit 37

Clinical coding error rate 37

Part 3 Other key quality improvements we have made in 2013-14 38

Annex one 49

Part 4 Statements from our stakeholders 49

4.1 Statement from Hillingdon Clinical Commissioning Group (CCG) 49

4.2 Statement from our local Healthwatch (formerly LINks) 50

4.3 Statement from External Services Scrutiny Committee 51

4.4 The Hillingdon Hospitals NHS Foundation Trust response

to the consultation 53

4.5 Independent Auditor’s Report 55

Annex two 57

4.6 Statement of Directors’ responsibilities in respect of

the Quality Report 57

Glossary 58

The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401

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About the Trust’s Quality Report

What is the Quality Report?This is produced for the public by NHS healthcare

providers about the quality of services they deliver.

All NHS providers strive to achieve high quality

care for all their patients, and the Quality Report

provides the Trust an opportunity to demonstrate

its commitment to quality improvement and show

what progress we have made in 2013-14. The

Quality Report is a mandated document which is

laid before Parliament before being made available

on the NHS Choices website and our own website –

(www.thh.nhs.uk).

What is included in the Quality Report?The Quality Report is a statutory document that

contains specific mandatory statements and

sections. There are also three areas that are

mandated by the Department of Health (DH)

which give us a framework in which to focus our

quality improvement programme. These are patient

safety, patient experience and clinical effectiveness.

The Trust undertook extensive consultation and

engagement in developing this report to ensure that

the quality improvement priorities reflect those of

our patients, our staff and our partners and

the wider public.

Part 2 of the report highlights the Trust’s quality

priorities and includes:

• The areas identified for improvement in 2013-14

• What the priority was

• How we performed against the targets

• And what this means for our patients.

There is also a section in Part 2 on the quality

priorities that have been identified for improvement

projects in 2014-15.

There is a useful glossary at the back of the report

which lists the abbreviations and terms included in

the document.

Executive summaryThis Executive Summary provides a very brief

overview of the information in this year’s report.

The Quality Report is a summary of our performance

during 2013-14 in relation to our quality priorities

and national requirements. The detail of our key

quality achievements and improvements are outlined

in the main body of the report. Overall the Trust has

performed very well across a wide range of core

quality indicators during this past year which has

resulted in us achieving green status for governance

in Monitor’s risk rating system. Particular successes

include the reduction in the Trust’s mortality rate, the

reduction in Health Care Associated Infections and

achieving Level 2 status in our recent NHS Litigation

Authority risk management standards assessments

for acute general and maternity care.

To demonstrate progress against our quality priorities

during 2013-14 we have included information that

shows how clinical teams have changed the way

they deliver care in order to improve the quality of

services for patients in our hospitals. Even though

our five priorities for 2013-14 have not been fully

achieved, some elements of the improvement work

have been fully realised and targets met. Some

examples of our achievements in the five priority

areas are listed below. Finally we have set out our

quality priorities for 2014-15 and the targets we

aim to achieve.


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Quality Priorities for Improvement 2013-14 – How did we do?

Quality priority How did we do?

The First Contact Project – Improving the Outpatient Experience

Reduced call abandonment rate (target <10%) 12% – improved by 16% from 2012-13

Reduced ‘Did Not Attend’ rates for outpatient appointments (target 8%)

Reduced by 0.6% to 9.1%

Improving People’s Experience of Leaving Hospital / Improving Inpatient Care

Achieve average Length of Stay to 3.5 days Reduced from 4 to 3.6 days

Earlier therapy and specialist review for >400 patients 463 patients via our ‘Home Safe’ project

Improving Emergency Care

Reduction of Hospital Standardised Mortality Ratio (HSMR) to London average

Achieved lower than national average, but remains slightly above London average

Improved response rate for A&E in the Friends and Family Test 19.4% – against a national target of 15%

CQUINS (Commissioning for Quality and Innovation)

Electronic requesting for radiology and pathology 100% achievement

Improving the experience of both patients and staff (measured using the ‘Friends & Family’ Test)

100% achievement

Embedding our culture and values framework – CARES

Staff completing their Personal Development Review (PDR) Achieved 84% against a target of 90%

Improved result in Compassionate Care question as part of the local patient experience survey

Achieved 96% against a target of 85%

Quality Priorities for Improvement in 2014-15 – What do we aim to do?

• Continuing to Improve the Outpatient

Experience

• Continuing with the Improving Inpatient

Care Project

• Improving patient safety in Emergency and

Maternity Care

• Introducing and embedding patient care

bundles/pathways

• Improve responsiveness to patient need.

During 2013-14 the Trust has published a new

Clinical Quality Strategy to support its delivery of

high quality care over the next three years. The

purpose of the new Strategy is to provide a structure

for delivering quality governance to ensure ongoing

improvement in the quality and safety of patient

care. The quality priorities outlined in this year’s

Quality Report reflect the clinical quality priorities

outlined in our Strategy.

The mandated statements/sections within this

Quality Report include information on our

participation in national audits and our research

activity during 2013-14. In addition, information is

provided on our registration as a healthcare provider

with the Care Quality Commission (CQC) and the

result of our unannounced visit during 2013.

This Quality Report and the priorities for 2014-

15 are presented as a result of consultation and

engagement with our Foundation Trust members,

our Governors, our staff, Healthwatch and our

Commissioners.


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This Quality Report provides the Trust an opportunity

to demonstrate our commitment to delivering

high quality care to all. It outlines our quality

improvement work and the progress we have

made in 2013-14. I am extremely proud of our

achievements and of the ongoing commitment

from our staff in striving to continue to improve the

care and services that we deliver. I know that what

patients want is reassurance that they can trust their

local hospital to provide reliable, high standards

of care 24 hours a day, seven days a week. This

Quality Report confirms our commitment to you

to achieve this and ensures that we always put our

patients at the forefront of service development

and improvement. In this report you will read of the

extensive quality improvement work that has been

taking place across our hospitals to support this

ethos and the elements of clinical care and service

delivery that we aim to further improve to provide

the safe and high quality care that our patients

expect and deserve.

Within North West London the ‘Shaping a Healthier

Future’* (SaHF) programme outlines a five year

strategy which places the Hillingdon Hospital site as

one of the five major hospitals for providing a full

range of 24/7 emergency care in the region. The

programme is based on implementing the London

Health Programme (LHP) quality standards for

emergency care across all the major hospitals and in

all specialties that take part in the provision of this

service. The Trust has undertaken a self-assessment

on its current position against these standards and

key actions are being driven forward as part of our

clinical quality strategy. The SaHF programme also

places an emphasis on the provision of a wider

range of out-of-hours primary and urgent care, and

we are working closely with our GP commissioners

and other providers to ensure that across the

healthcare community patient care is provided

in the right place at the right time.

During 2013-14 there has been an increased

focus on how we measure and monitor quality at

the Trust. The Trust has considered

and made reference to key NHS

investigations and reviews,

and in particular the Francis

Inquiry into the failings at Mid

Staffordshire NHS Foundation

Trust where the standard of

services put patients at risk. Not

only was this a salutary reminder

that things can go wrong when

quality is not put at the heart of what we do but

it has also served to focus us all on continuously

striving to provide the safest possible care. Our

new Clinical Quality Strategy outlines the learning

and recommendations from the Francis Report

and other key quality reviews; these underpin our

key aims and objectives for quality improvement.

In addition we have reviewed our current quality

performance alongside national and regional quality

data and referenced local feedback from both staff

and patients in informing our new Strategy. We

have also undertaken a thorough review of our

governance structures and processes in relation to

delivering a robust quality management system

in accordance with Monitor’s Quality Governance

Framework.

We have performed very well on our quality

performance during 2013-14 across a wide range of

indicators which has resulted in us achieving green

status for governance with regard to Monitor’s risk

rating system. Under the Care Quality Commission’s

new Intelligent Monitoring System of acute trusts

(where trusts are assessed against 188 different

indicators) we have been assessed as being in

Part 1Statement from the Chief Executive

* http://www.healthiernorthwestlondon.nhs.uk/

INCREASED FOCUS


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view and to highlight the areas that we know we

need to focus on to make our services even more

safe and of a higher quality.

In developing our quality priorities for 2014-15

we have made reference to national best practice

and reviewed our current quality performance in

line with local, regional and national performance.

The report is the result of consultation with a wide

group of stakeholders, including our Governors,

Commissioners, People in Partnership and our local

Healthwatch.

I hope that this Quality Report provides you with a

clear picture of how important improvement and

safety are to us at The Hillingdon Hospitals NHS

Foundation Trust.

I confirm that to the best of my knowledge the

information in this document is accurate.

Yours sincerely

Shane DegarisChief Executive

The Hillingdon Hospitals NHS Foundation Trust

28th May 2014

the lowest level of risk category (band 6) for two

consecutive assessment periods. We have also

achieved Level 2 status in our recent NHS Litigation

Authority (NHSLA) and the Clinical Negligence

Scheme for Trusts (CNST) maternity assessments.

This demonstrates the Trust has robust risk

management processes in place which have been

checked for compliance and that staff see it as one

of their concerns to keep patients safe. In addition,

the Trust was Highly Commended in the 2013 Dr

Foster Hospital Guide awards for the improvement

in its performance for weekend emergency HSMR

(Hospital Standardised Mortality Ratio). This is

recognition of the good work that has been done to

not only improve weekend mortality but importantly

to maintain overall performance.

We have received over 15,800 patient responses

to the Friends and Family Test (FFT) during 2013-14

with the majority of patents recommending our

wards and emergency department to family and

friends. Where problems were highlighted we have

looked to address these. An example of this is our

Comfort at Night programme, recognised as a very

positive outcome on action taken as a result of

feedback from the FFT.

Despite a very positive quality performance record

for 2013-14, we are not complacent. Weaknesses

in our systems are dealt with promptly and openly

to ensure that better and safer systems of care can

be developed. The aim of this report is not only to

report on our achievements and the improvements

we have made in the last year but to give a balanced


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In this part of the report we tell you about the quality of our services and how we have performed in the areas

identified for improvement in 2013-14. These areas are called our quality priorities and they fall into the three

areas of quality as mandated by the Department of Health (DH): patient safety, patient experience and clinical

effectiveness, and we are required to have a minimum of one priority in each area.

Firstly, the information below provides an overview of some of our key quality achievements in 2013-14.

These are important indicators for the public and our key stakeholders to provide assurance on the quality

of care and services that are delivered at the Trust:

Part 2Review of Quality Priorities for Improvement

*There are four NHSLA/CNST Levels: 0, 1, 2 and 3 being the highest level – higher levels indicate a reliable, robust and embedded risk management system across an organisation.

Key Quality Achievements during 2013-14

Achieved Level 2 accreditation for NHS Litigation Authority standards*

Dr Foster Good Hospital Guide – Highly Commended for improvement on weekend mortality

Achieved Level 2 accreditation for Clinical Negligence Scheme for Trusts (CNST) for Maternity standards*

Monitor – the Trust is rated green (no Evident concerns) for its performance on quality

Care Quality Commission – achieved Band 6 (lowest level of risk) in two consecutive assessments

Trust ranks among the best in London for patients on the fractured hip pathway


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insight about the challenges patients face when

booking outpatient appointments. The group have

reviewed the quality targets concerning reducing

the call abandonment rate, answering calls in 60

seconds and call resolution. Times that patients are

more likely to contact the Outpatient Appointment

Centre (OAC) were suggested and a system has

been introduced which enables an increase in staff

to cover high call volumes. The opening times of the

OAC were discussed and it was felt these offered

patients choice and good accessibility.

For improving the target of where patients do

not attend their appointment it was agreed

that patients should have an option to cancel

their appointment without being transferred

to a call agent. Following introduction of this

streamlined cancellation service during the latter

part of 2013-14 the DNA rate has fallen below

the target of 8%. Furthermore in February

2014 work commenced to pilot an enhanced

reminder service to one specialty and the impact

is currently being tracked. Evaluation of this pilot

will report on-going work in 2014. Also, following

feedback from patients, the text message format

was changed to include the specialty of the

appointment.

In addition, an Electronic Document Transfer

system (EDT) is being introduced which supports

the delivery of clinical documentation securely

between secondary and primary care in real

time. The EDT Hub will be used to send clinical

correspondence such as attendance notifications

and outpatient letters from Q2 onwards.

LOOKING BACK jPart 2.1 Quality priorities for improvement 2013-14 – How did we do?

PRIORITY 1

The First Contact Project – Improving the outpatient experience

We said: We would continue with the First Contact Project

(improving the outpatient experience) to further

embed the way patients are contacted and

reminded about their appointments. The Call

Management System (CMS) which was introduced

in 2012 needed further development during 2013-

14 to ensure we were getting our messages right

for patients. We also wanted to further centralise

bookings of new and follow-up outpatient

appointments across the Trust, having only partially

achieved our plans during 2012-13.

How did we do?

We have been successful in significantly reducing

the call abandonment rate to just 12% and realising

improvement across the other key indicators. It has

been recognised that the targets that were set for

2013-14 for this project were very ambitious and

based on performance in the private sector. During

2013-14 a working group has been meeting to

further facilitate this service development and add

Annual Quality Report Projects KPI Dashboard 2013-14

2011-2012 2012-2013 2013-14 2013-14Target

Reduced call abandonment rate N/A 28% 12% <10%

No of telephone calls answered within 60 seconds

N/A N/A 75% 95%

Resolution of queries in the first contact with patients

N/A N/A 55% >90%

Reduced DNA rates for outpatient appointments

9.8% 9.7% 9.1% 8%


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and to reduce any unnecessary lengths of stay in

hospital, as well as reducing readmissions. We said

we would improve the discharge process by better

co-ordination of teams and closer working together

with doctors, nurses, pharmacists and therapists

when reviewing a patient’s needs before they

leave hospital.

How did we do? The specific goals we set for the project and the

performance are outlined below.

The Improving Inpatient Care Programme has

continued to evolve and has been focussed on a

number of key services that either avoid hospital

admissions or reduce length of stay by ensuring

comprehensive consultant-led assessment at an

early stage in the patient’s pathway. Last year we

also said that we would implement new electronic

whiteboards to provide reminders of all patients’

next steps for all teams who work on the wards. A

new electronic white board system has now been

implemented, with full roll out to every ward now

completed. This has improved communication

between all staff on the wards, improved the daily

handover and now the staff can clearly see what

each patient is waiting for, and act promptly to

ensure minimal delays.

The ambulatory care service that has previously

focussed on seeing and treating patients presenting

with deep vein thrombosis has now expanded to

include conditions such as community acquired

pneumonia, kidney infections and pulmonary

embolus. On average when compared with the

What does this mean for our patients?The outpatient pathway has been a key area of

focus for the Trust over the past few years in really

driving forward improvement around the patient

experience and that the systems we have in place

become much more efficient. The local outpatient

experience survey demonstrates that patients are

generally satisfied with the experience within the

outpatient department with an overall satisfaction

score of 87% across a range of indicators. We have

heard through our local Healthwatch however

that there are a number of elements in relation to

the outpatient pathway that need to continue to

improve, particularly in relation to the number of

appointment letters that a patient may receive and

the resolution of enquiries to the OAC. This is why

our improvement work will continue as a priority

into 2014-15 as identified by our FT members, our

local Healthwatch and our staff.

PRIORITY 2

Improving people’s experience of leaving hospital/improving inpatient care

We said:We would continue with the Leaving Hospital

Project to further improve the patient journey

through the hospital thereby decreasing length

of stay and to ensure an improved experience for

patients leading up to and including discharge

from hospital. We advised that we had reviewed

our goals and priorities and re-launched the project

as ‘Improving Inpatient Care’. Our aims were to

enhance early assessments for elderly people

Annual Quality Report Projects KPI Dashboard 2013-14

2012-2013 2013-14 2013-14Target

Reduce average length of hospital stay (LoS) by 12%, achieving average LoS to 3.5 days (national upper quartile level)

4 3.6 – Trust overall3.5 – elective

inpatients

3.5

Percentage of discharges leaving hospital before midday 29% 23.6% 40%

Earlier therapy and specialist review (numbers of patients via ‘Home Safe’ project)

N/A 463 400

Reduction in avoidable readmissions by 230 cases 3401 20 fewer 3171


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organised resulting in discharges happening much

later in the day. New initiatives to be explored in

the forthcoming year include opening a medication

dispensary on the new acute medical unit. This is

expected to reduce the time that patients wait for

their medications resulting in an increased number

of earlier discharges per day.

Reducing readmission rates is a key priority for the

Trust in achieving high quality care. Despite aiming

to reduce readmissions our current workstreams

have not had significant impact in 2013-14.

Readmissions to hospital within 28 days in 2012-

13 was 105.2 and in 2013-14 it reduced to 102.9

slightly above the national average of 100 (this

data is sourced from Dr Foster and is a standardised

measure that looks at case-mix, identifying whether

we have more or less or the same readmissions as

would be expected).

A recent audit that was undertaken in partnership

with Hillingdon CCG has revealed that there are

opportunities to improve the existing workstreams

to improve communication and documentation

across primary and secondary interfaces and also

to support increased empowerment of patients to

manage their own condition more effectively. The

audit findings also suggested there is an opportunity

to work with local nursing homes to provide their

staff with advice and guidance on management of

common conditions where admission to hospital

could perhaps be avoided. This work will be driven

forward in 2014-15 as part of our clinical quality

strategy and action plan.

PRIORITY 3

Improving emergency care

We said:We would improve emergency care by aiming

to achieve key elements of the London Health

Programme Emergency Care Standards. We advised

that nationally there is evidence to show that there

are significant differences in the mortality rates for

patients admitted as an emergency during the week

compared with patients admitted as an emergency

previous year the service now treats an additional

200 patients per month.

The ‘Home Safe’ team has evolved from the acute

care of the elderly service that was previously piloted

in the emergency assessment ward and is working

proactively with community services and Age UK to

provide expert clinical review. The level of specialist

input facilitates high quality patient discharge for the

care of the elderly group. The ‘Home Safe’ team, led

by a consultant geriatrician provide a high quality

multidisciplinary care team review and provide

individualised plans of care that may include referral

to a variety of services both in and out of hospital.

Overall, length of stay has continued to reduce

within the division of Medicine (by 0.7 days for

2013-14) and since the formal introduction of

‘Home Safe’ in January 2014, the average length of

stay for care of the elderly has fallen from 14 days

to 11.5 days for two consecutive months. From

November 2013 until end of March 2014 the ‘Home

Safe’ team screened 463 patients and assessed 189

patients. 118 of these patients were able to be sent

home at an earlier stage with 58 receiving additional

support from a range of services.

What does this mean for our patients?

Reducing the length of stay in hospital for our

patients means that they spend less unnecessary

time in hospital. The ‘Home Safe’ project ensures

there is a multidisciplinary approach to planning

for discharge as soon as the patient is admitted.

Going forward there are plans to expand the service

to be able to offer ‘Home Safe’ discharge from

our specialty wards. This will mean that patients

who have undergone surgery or who have had an

extended length of stay in hospital will also be able

to benefit from this innovative new service.

Although length of stay has achieved the target

during 2013-14 we have not been able to improve

further on patients leaving hospital before midday.

Our local Healthwatch have advised us that they

continue to receive this feedback and that this

is a real concern for our patients, often waiting

for medication or for community services to be


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Reduction of HSMR to London average During 2013-14 trust weekday and weekend

mortality rates have reduced based on bench-

marking data available from Dr Foster (historically

re-based annually). The overall Hospital Standardised

Mortality Ratio (HSMR) is currently lower (84.1) than

the national average for weekdays (up until February

2014) with statistical significance. HSMR is also

lower than the national average at the weekends

(98.2) however for 2013-14 it remains slightly

above the London average. The Trust is tracking

the HSMR at specialty level within clinical divisions

and is carrying out regular reviews of all deaths

in hospital.

Participation of attending A&E patients in the Friends and Family Test We advised that we wanted to improve the

participation in the Friends and Family Test in the

Accident and Emergency Department because

participation had been 8% for 2012-13 against

a target of 15%. There has been significant

improvement in this area where the trust now has

the second highest response rate of all emergency

departments in London. Our overall response rate

for 2013-14 is 19.4% against the national target of

15%. The Friends and Family Test reports a net-

promoter score whereby the patient would either

highly recommend or recommend the emergency

department to their friends and family. The vast

majority of comments are extremely positive (see

page 127) and very importantly actions have been

taken where there have been recommendations

for improvement.

What does this mean for our patients?We are committed to ensuring that the care we

deliver to patients who are admitted as an emergency

is of the highest quality in relation to patient safety,

patient experience and clinical effectiveness. We have

been commended by Dr Foster for our reduction in

HSMR for weekend mortality; this means that our

patients are receiving improved care throughout the

week. We will continue to focus on this improvement

work during 2014-15 in relation to implementing the

London Quality Standards.

at the weekend and that nationally, and in London,

reduced service provision at weekends has been

associated with a higher mortality rate.

We stated that as a Trust we are committed to

achieving these quality standards and that we had

already invested in additional senior doctor time,

out of hours Monday to Friday and also at the

weekends. Notably we had provided consultant

ward rounds twice a day on our medical

Emergency Assessment Unit (EAU).

The focus of work for 2013-14 was to ensure that

there was a senior doctor (consultant level) review

within 12 hours of a patient being admitted to

the hospital and that we would aim to reduce

the measure of mortality known as the Hospital

Standardised Mortality Ratio to the London average

and reduce the variation between weekday and

weekend mortality. We also stated that we would

improve participation of attending patients in the

Friends and Family Test so that we could better

gauge the patient’s experience of emergency care.

How did we do?Consultant review within 12 hours of decision to admitThe trust has made

further investments in our

Emergency Department

and EAU resulting in

increased consultant cover

seven days per week. The rapid assessment service is

now well embedded in the department and means

that all emergency admissions benefit from an

initial review by a senior doctor. The January audit

showed that 64% of patients were reviewed by a

consultant within 12 hours once admitted to the

EAU against a target of 90%. Additional investment

in the consultant body in 2014-15 will enable further

expansion of ambulatory care pathways and will

ensure that the vast majority of patients are seen by

a consultant within 12 hours of admission. This will

be a key focus in 2014-15 as part of the London

Quality Standards recommendations and our local

action plan.

HOW DID WE

DO?


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PRIORITY 4

CQUINS (Commissioning for Quality and Innovation)

The key aim of the Commissioning for Quality

and Innovation (CQUIN) framework is to secure

improvements in quality of services and better

outcomes for patients, whilst also maintaining

strong financial management. In 2013-14 there

were ten Acute CQUIN schemes agreed, six of

which were locally derived by Hillingdon Clinical

Commissioning Group. In 2013-14 we have

achieved 78.6% of our acute CQUIN target

demonstrating a material improvement on

2012-13 in which we achieved 73%.

CQUIN Targets for 2013-14 Achievement Commentary

National Schemes

Improving the experience of both patients and staff (measured using the ‘Friends & Family’ Test)

100% achievement

Promoting ‘harm free’ care for patients (as measured by the Patient Safety Thermometer)

Partial achievement

The Trust had a challenging target of 50% reduction in pressure ulcers (as measured by the Patient Safety Thermometer) for 2013-14 and started the year lower than the national average. The Trust achieved an overall year-end reduction of 37% but continues to see significant variation in the number of community acquired pressure ulcers and so will need to continue to work with community colleagues to best support and reduce these for 2014-15.

Improving services for patients with dementia

Partial achievement

As part of the 2013-14 dementia CQUIN the Trust was required to provide complete monthly carers’ surveys, implement staff training and to find, assess, investigate and refer 90% of elderly patients admitted through emergency methods. The Trust has achieved both the training and carers surveys but despite significant improvement of 70%, has been unable to achieve the 90% target.

Preventing blood clots 100% achievement

How did we do?See table below.

What does this mean for our patients?The CQUIN framework supports improvements in

the quality of services and aims to provide better

outcomes for patients. It enables commissioners

to reward excellence, by linking a proportion of

healthcare providers’ income to the achievement

of local quality improvement goals. Having fully

and partially achieved nine out of the ten CQUINS

for 2013-14 will mean that the quality of our

services and the care that we deliver to

our patients has improved.


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CQUIN Targets for 2013-14 Achievement Commentary

Local & Regional Schemes

‘Home Safe’ (enables patients to be safely discharged sooner from hospital)

100% achievement

Consultant assessments within 12 hours of emergency admission

Not achieved The Trust had a target of consultant assessments within 12 hours of emergency admission however this has proved particularly difficult to achieve with performance of between 50 and 60%.

Electronic requesting for radiology and pathology

100% achievement

Improving Colorectal services Partial achievement

This included reducing wait times for colonoscopies, comprehensive post-operative assessment by a geriatric specialist, and GP education. The Trust was successful in all but the GP education element where a small take up by GP practices made the face to face element particularly challenging.

Improving communications between GPs and hospital consultants

Partial achievement

The Trust achieved its target to develop referral pathways with local GPs but did not fully achieve the target to provide an advice line service for GPs calling with condition-specific queries. 80% of calls from GPs were connected but the small volume of calls in some specialties meant that it was difficult to achieve the target of 92.5%. This CQUIN continues to have focus with roll out to additional specialties.

Reducing the length of time patients wait for treatment in A&E

Partial achievement

A&E Rapid Access and Triage was a success within the first three quarters, however the Trust was not able to sustain reduced waits over the winter months leading to partial achievement of the CQUIN of 75%.


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pressures during winter resulted in staff not being

able to be released to attend training, therefore a

decision was made to postpone sessions and re-start

them in April 2014.

Learning from complaints – improving behaviour and attitude We said that we would ensure that all complaints

were addressed using the CARES framework and

that we would make the framework an integral part

of the investigation process to identify behavioural

and attitudinal issues as well as the technical aspects

so that we can learn from them. There have been

significant changes in our Complaints Management

Unit team during this year; this has meant that

the focus has been on ensuring that complaints

are investigated thoroughly and within the agreed

timescale. Many of our senior sisters and matrons

now successfully use the CARES framework when

investigating and sharing the complaint with their

teams. In this way they can bring the CARES values

to ‘life’ encouraging individuals to evaluate whether

they have demonstrated the expected attitude and

behaviour.

Our key targets also included improvement in

the communication, involvement, information

and compassionate care questions in our local

satisfaction survey:

Performance Indicator

Performance 2013-14

Target for 2013-14

Communication, involvement and information – using the cluster of questions in the inpatient survey

89% Improve baseline

(88%) result by 2%

Compassionate Care – ‘overall were you treated with kindness and understanding while you were in the hospital’?

96% Achieve 85%

PRIORITY 5

Embedding our culture and values framework – CARES

We said:Our goal was to deliver the best possible experience

to our patients and to our staff. We felt we could

make real improvement in this area through

embedding our culture and values framework, CARES

(Communication, Attitude, Responsibility, Equity

and Safety). Formally launched in May 2012 CARES

provides clear core values supported by a framework

that sets out the standard in terms of attitude and

behaviours we expect from our staff. This supports

our staff to deliver care with compassion as well as

ensuring it is safe and effective.

How did we do?

Performance Indicator

Performance 2013-14

Target for 2013-14

Staff completing their Personal Development Review (PDR)

84% 90%

Staff completing the Customer Care Training

50% 33%

Whilst the target was not achieved for staff

completing their PDR, this is a good return given the

extension of the Talent Management (TM) process

to around 500 staff – significantly more than the

previous year. The TM process incorporates a more

detailed review for each individual and as a result

requires much more time for both preparation and

conversations with staff members.

The Customer Care Training was introduced to raise

awareness of our CARES values to all of our staff

so that they could understand the impact of their

behaviours on patients and their colleagues. We

have not achieved our target because additional


16

sources and is presented in line with the detailed

Monitor guidance.

Data InconsistenciesA number of indicators are showing changes to

2012-13 data that was published in last year’s

Quality Report. There are several reasons for

this as follows:

1. The statutory timescale within which the

Quality Report is published is very tight. Not all

of the latest data was available at the time of

publication last year and so the Trust has taken

the opportunity to update 2012-13 indicators

with full year updates which are now available

2. National Indicators based on statistical methods

by definition require re-basing (e.g. standardised

readmissions, HSMR, SHMI)

3. Data quality or data completeness issues may

have affected last year’s indicators. If these have

been identified then they have been rectified in

this year’s report.

What does this mean for our patients?Improvement in the patient experience indicators

outlined above demonstrate that the measures we

have put in place this year such as staff receiving

feedback on CARES as part of their personal

development review and the delivery of an extensive

programme of customer care training has had a

positive impact on staff attitude and behaviours. We

will continue to deliver on improving staff attitude

and behaviour in line with our CARES values in the

forthcoming year; some of these workstreams are

outlined in Priority 5 for 2014-15.

Part 2.2 Performance against Core Quality Indicators 2013-14

In this part of the report the Trust is required

to report against a core set of national quality

indicators to provide an overview of performance in

2013-14. The following page provides information

which has been obtained from the recommended


17

2012

-13

Perfo

rman

ce20

13-1

4 Ta

rget

2013

-14

Perfo

rman

ceLo

ndon

Tru

stsNa

tiona

lBe

nchm

ark

Sour

ceBe

nchm

ark

Perio

dLo

wes

t Per

form

ing

Trust

High

est P

erfo

rmin

g Tru

st

1: S

umm

ary H

ospi

tal-L

evel

M

orta

lity (

SHM

I)0.

9 (A

s Ex

pect

ed)

As E

xpec

ted

or Lo

wer

Than

Ex

pect

ed

0.89

(As

Expe

cted

)n/

an/

aHS

CIC

Oct-2

012

to

Sep-

2013

WYE

VAL

LEY

NHS T

RUST

, 1.

1859

Band

1 (H

ighe

r tha

n Ex

pect

ed)

The W

hitti

ngto

n Ho

spita

l NHS

Trus

t0.

6301

Band

3 (L

ower

Than

Exp

ecte

d)

2: th

e pe

rcen

tage

of p

atien

t dea

ths w

ith

pallia

tive

care

code

d at

dia

gnos

is19

.80%

n/a

23.0

%23

.6%

20.9

%HS

CIC

Oct-2

012

to

Sep-

2013

T AUN

TON

AND

SOM

ERSE

T NH

S FO

UNDA

TION

TRUS

T 0%

EAST

AND

NOR

TH H

ERTF

ORDS

HIRE

NHS

TRUS

T44

.9%

3: E

mer

genc

y rea

dmiss

ions

to h

ospi

tal w

ithin

28

day

s of d

ischa

rge

from

hos

pita

l: chi

ldre

n of

ag

es 0

-15

[Sta

ndar

dise

d] (C

rude

)

[9.1

1%]

(5.6

0%)

n/a

[8.2

8%]

(6.2

8%)

[7.8

1%]

[10.

01%

][H

SCIC

][P

AS]

2011

-12

[Sta

ndar

dise

d]20

13-1

4 [C

rude

]

THE

ROYA

L WOL

VERH

AMPT

ON

HOSP

ITALS

NHS

TRUS

T 14

.94%

AINT

REE

UNIV

ERSI

TY H

OSPI

TALS

NHS

FOU

NDAT

ION

TRUS

T (P

lus 5

0 ot

her T

rusts

)0%

4: E

mer

genc

y rea

dmiss

ions

to h

ospi

tal w

ithin

28

day

s of d

ischa

rge

from

hos

pita

l: Adu

lts o

f ag

es 1

6+ [S

tand

ardi

sed]

(Cru

de)

[11.

88%

](7

.55%

)n/

a[1

2.11

%]

(7.6

2%)

[12.

17%

][1

1.45

%]

[HSC

IC]

[PAS

]20

11-1

2 [S

tand

ardi

sed]

2013

-14

[Cru

de]

SHEF

FIELD

CHI

LDRE

NS N

HS

FOUN

DATI

ON TR

UST

17.1

5%

QUEE

N EL

IZAB

ETH

HOSP

ITAL N

HS TR

UST

(Plu

s 45

othe

r Tru

sts)

0%

5: C

lostr

idiu

m d

iffici

le23

case

s(1

8.0

Case

s pe

r 100

,000

be

dday

s)

14 C

ases

(A

bsol

ute)

12 C

ases

(8.5

Cas

es

per 1

00,0

00

bedd

ays)

17.0

Ca

ses p

er

100,

000

bedd

ays

17.3

Cas

es

per 1

00,0

00

bedd

ays

PHE

2012

-13

North

Tees

& H

artle

pool

had

61

Trust

ap

ortio

ned

Case

s (30

.8 ca

ses p

er 1

00,0

00

bedd

ays)

Follo

win

g Tru

sts h

ad Z

ero

Case

s of C

diff

in 2

012/

2013

,Al

der H

ey C

hild

ren’

s, Bi

rmin

gham

Wom

en’s,

Liver

pool

Wom

en’s,

Moo

rfield

s Eye

Hos

pita

l,Qu

een

Vict

oria

Hos

pita

l

6: V

enou

s Thr

ombo

emol

ism (V

TE)

91.9

%95

.0%

95.2

%95

.5%

95.7

%NH

S En

glan

dAp

r-201

3 to

Feb

2014

(Nat

iona

l/Lo

ndon

)Oc

t-201

3 to

De

c-20

13 (L

owes

t/Hi

ghes

t Per

form

ers)

77.7

% -

NORT

H CU

MBR

IA

UNIV

ERSI

TY H

OSPI

TALS

NHS

TRUS

T

100.

0% -

BRID

GEW

ATER

COM

MUN

ITY

HEAL

THCA

RE N

HS

TRUS

T; QU

EEN

VICT

ORIA

HOS

PITA

L NHS

FOU

NDAT

ION

TR

UST;

ROYA

L NAT

IONA

L HOS

PITA

L FOR

RHE

UMAT

IC

DISE

ASES

NHS

FOU

NDAT

ION

TRUS

T; SO

UTH

ESSE

X PA

RTNE

RSHI

P UN

IVER

SITY

NHS

FOU

NDAT

ION

TRUS

T

7: P

ROM

S (H

ealth

Gai

n), G

roin

Her

nia,

EQ-

5D

Inde

x/VA

S0.

119/

-0.0

750.

1/4.

471

n/a

0.08

6/-0

.874

HSCI

CAp

r-201

3 to

De

c-20

13-0

.033

BMI -

F AW

KHAM

MAN

OR H

OSPI

TAL

-0.0

29GU

Y’S A

ND S

T THO

MAS

’ NHS

FO

UNDA

TION

TRUS

T

0.39

9NU

FFIE

LD H

EALT

H, IP

SWIC

H HO

SPITA

L0.

24DA

RTFO

RD A

ND G

RAVE

SHAM

NHS

TRUS

T

8: P

ROM

S (H

ealth

Gai

n), H

ip R

epla

cem

ent,

EQ-5

D In

dex/

VAS

0.39

6/12

.992

0.46

7/11

.239

n/a

0.43

9/11

.663

HSCI

CAp

r-201

3 to

De

c-20

130.

179

HOM

ERTO

N UN

IVER

SITY

HOS

PITA

L NH

S FO

UNDA

TION

TRUS

T

0.64

1BM

I - TH

REE

SHIR

ES H

OSPI

TAL

0.63

4EA

ST A

ND N

ORTH

HER

TFOR

DSHI

RE N

HS TR

UST

9: P

ROM

S (H

ealth

Gai

n), K

nee

Repl

acem

ent,

EQ-5

D In

dex/

VAS

0.26

7/4.

827

0.32

4/2.

691

n/a

0.33

/5.8

HSCI

CAp

r-201

3 to

De

c-20

130.

028

SPIR

E LE

EDS

HOSP

IT AL

0.20

2W

ALSA

LL H

EALT

HCAR

E NH

S TRU

ST

0.57

3BM

I - TH

E CL

EMEN

TINE

CHU

RCHI

LL H

OSPI

TAL

0.48

7NO

RTH

TEES

AND

HAR

TLEP

OOL N

HS F

OUND

ATIO

NTR

UST

10: F

riend

s and

Fam

ily Te

st qu

estio

n 12

d –

‘If

a fri

end

or re

lativ

e ne

eded

trea

tmen

t I w

ould

be

hap

py w

ith th

e sta

ndar

d of

care

pro

vided

by

this

orga

nisa

tion’

59%

(46%

ag

ree

13%

stro

ngly

agre

e)

n/a

62%

(46%

agr

ee16

% st

rong

ly ag

ree)

67%

n/a

Pick

er In

stitu

te20

13M

id Yo

rksh

ire H

ospi

tals

NHS T

rust

and

North

Cum

bria

Uni

versi

ty

Hosp

itals

NHS T

rust

(33%

agr

ee 7

% st

rong

ly ag

ree)

Salfo

rd R

oyal

NHS

FT

89%

(42%

agr

ee47

% st

rong

ly ag

ree)

11: T

rust’

s res

pons

ivene

ss to

per

sona

l nee

ds

of o

ur p

atien

ts65

%n/

a66

.4%

n/a

n/a

n/a

n/a

n/a

n/a

12: [

a] Th

e nu

mbe

r, and

whe

re a

vaila

ble,

rate

of

pat

ient s

afet

y inc

iden

ts re

porte

d w

ithin

the

perio

d, a

nd;

[b] t

he n

umbe

r and

per

cent

age

of su

ch

patie

nt sa

fety

incid

ents

that

resu

lted

in se

vere

ha

rm o

r dea

th

4758

, 8.0

%38

, 0.8

%n/

a52

42, 8

.9%

56, 1

.1%

1256

9,

7.0%

138,

1.1

%

1332

07,

7.4%

893,

0.7

%

NRLS

Apr-2

013

to

Sep-

2013

Base

d on

[a] W

ALSA

LL H

EALT

HCAR

E NH

S TRU

ST(4

888,

14.

49%

)Ba

sed

on [b

] BAS

ILDON

AND

TH

URRO

CK U

NIVE

RSIT

YHO

SPITA

LS N

HS F

OUND

ATIO

N

TRUS

T (1

06, 3

.1%

)

Base

d on

[a] W

RIGH

TING

TON,

WIG

AN A

ND LE

IGH

NHS

FOUN

DATI

ON TR

UST

(153

9, 3

.54%

)Ba

sed

on [b

] THE

ROT

HERH

AM N

HS F

OUND

ATIO

NTR

UST

(0, 0

%)

13: S

elf ce

rtific

atio

n ag

ains

t com

plia

nce

with

re

quire

men

ts re

gard

ing

acce

ss to

hea

lthca

re

for p

eopl

e w

ith a

lear

ning

disa

bilit

y

Fully

Com

plia

ntFu

llyCo

mpl

iant

Fully

Com

plia

ntn/

an/

an/

an/

an/

an/

a


18

Indicator 5: The Trust successfully achieved a significant

reduction in Clostridium difficile (C. diff) this year

and reported 12 cases, a 48% reduction from

the previous year’s total of 23. This was achieved

through a number of focused activities across the

organisation as outlined on page 122. The Trust

intends to take the following actions to improve on

this indicator and so the quality of its services:

• Undertaking further work on antimicrobial

prescribing including monitoring compliance to

policy by specialty. This will be reflected in audits

undertaken by clinical teams in the next year.

Indicator 6:The Trust has shown an improvement over the last

three years. This was a CQUIN for 2013-14 and

there was 100% achievement in relation to the

CQUIN requirements; this has supported the Trust in

achieving this target. The Trust intends to take the

following actions to maintain the performance on


• Monthly monitoring of VTE performance via

the Patient Safety Thermometer

• To continue with Root Cause Analysis

investigation of hospital acquired VTEs.

Indicator 7:The Trust has significantly better outcomes reported

for Groin Hernia repair with the pre-operative

participation rate being well above the national

average however the drive on post-operative

responses needs significant attention. The Trust



• Promotion of the importance of the patient

responding to the survey

• Improve data collection, submission and

response rates through governance forums with

clinical leadership driving this forward to ensure

we achieve compliance.

Indicator 8 and 9: For the Knee replacement PROMs performance the

most recent figures available for comparisons of

national data indicate we are only marginally below

the national average score. The Trust intends to take

Supporting Information about the indicators required in accordance with the Quality Account regulations The Hillingdon Hospitals NHS Foundation

Trust considers that this data is as described

for the following reasons:

Indicator 1:National reporting shows the Trust to be within the

‘As Expected’ range and that it has had a stable

ratio over the past three years. The Trust intends to

take the following actions to further improve on


• Improve the variation between weekdays

and weekends by implementing the London

Quality Standards

• Examine any specialty outliers.

Indicator 2: During the last year there has been a marked increase in

our palliative care coding towards the national average.

This is in line with rates of palliative care coding

having increased nationally. Dr Foster has reported

that it is unclear as to whether this is as a result of

increased number of patients receiving palliative care

or improvements to the clinical coding processes for

these patients or whether there have been changes to

the way trusts interpret the guidance around coding

of palliative care. It is noted that there is also significant

variation in coding rates across trusts. The Trust intends

to take the following actions to maintain performance

on this indicator and so the quality of its services:

• Monitor performance and ensure that reporting

systems are robust and efficient through audit.

Indicators 3 and 4: The Trust is aware from a variety of data sources that

the figures are higher than expected for the +16 age

group. The Improving Inpatient Care initiative has

been working to reduce this rate during 2013-14 as

outlined on pages 90 and 91. The trust intends to

take the following actions to further improve on


• Continuing with the Improving Inpatient Care

project as a Quality Priority for 2014-15 as

outlined on page 103 and 104

• Develop improved integrated care pathways.


19

intentional rounding principles and taking action on

feedback provided through the Friends and Family

Test have supported staff in responding to patient

needs in a much more timely and proactive way.

Embedding our CARES values has also supported

staff in demonstrating the right behaviours when

responding to patients’ needs. The Trust intends

to take the following actions to improve on this

indicator and so the quality of its services:

• Delivering on priority 5 for 2014-15

outlined on pages 106.

Indicator 12: Following the publication of the Francis Report and

several reviews that followed, such as Berwick and

Keogh, the Trust has supported a safety culture

where staff feel able to report incidents. Staff have

been encouraged to be open and honest so that we

can learn from when things go wrong in order to

improve the quality of care we provide. Our reporting

rate to the National Reporting and Learning Service

has increased from 6.6 (1 April 2012 – 30 September

2012) to 8.33 (1 April 2013 – 30 September 2013).

The increase in incident reporting will also result

in an increase in those incidents that resulted in

severe harm or death. The Trust intends to take the

following actions to improve on this indicator and

so the quality of its services:

• Continue to raise awareness of the importance

of incident reporting

• Ensure there is thorough investigation of all

severe/death reported incidents to support

learning and changes in practice.

Definitions of the two mandated indicators for substantive sample testing by the Trust’s auditors are:1. Percentage of patients receiving first definitive

treatment for cancer within 62 days of an

urgent GP referral for suspected cancer.

2. C. difficile.

the following actions to improve on this indicator

and so the quality of its services:

• Since the Professor Briggs report ‘Getting it Right

First Time’ (2012), we have pulled together a

detailed action plan. An Orthopaedic consultant

has been nominated as the clinical lead and on

reviewing the Trust’s results it was considered

that a deep dive into the make-up of the

PROM score which comprises of participation

rate, health gain and patient satisfaction was

required. In all aspects Hip surgery results

performed better than the national average

however performance on the Knee PROM

was below national average in the patient

satisfaction element.

• The review on post-operative outcomes for

the Knee PROM showed that our scoring for

participation rate is above national average

however we had a dramatic drop in our EQ-5D

responses for Mobility, Self-Care, Usual Activity

and Anxiety. The ‘Pain’ element however has

seen the biggest improvements year on year

within knee surgery. We are actively encouraging

all patients to attend our joint school to ensure

their expectations of recovery are discussed

at length.

Indicator 10: This indicator has improved on the previous year by

3% although further work is required to ensure we

are in line with the London trusts’ average. The Trust



• More in-depth scrutiny of the results is taking

place, enabling targeted support, action

planning and interventions within the Divisions

and Departments, to improve advocacy

• Our first Staff Friends and Family Test will run

from 19th May which will support us receiving

immediate feedback from staff on this element.

Indicator 11: We have improved our performance in relation

to this indicator during this past year and seen

significant improvement in many areas covered in the

national patient survey and local patient surveys in

relation this element of care. Our implementation of


20

Key principles that support our strategy and

which have been key recommendations from

national investigations include:

• Always putting the patient first

• Clearly understood fundamental standards

of care and measures of compliance

• Openness, transparency and candour

throughout our organisation

• Improved support for compassionate and

committed nursing

• Strong and patient centred leadership

• Accurate, useful and relevant information.

The Strategy will help to ensure that the ethos

of a clinically-led, quality and patient-focused

organisation is strengthened and that the Trust

Board is provided with robust and detailed

information on quality so that it can be assured that

the clinical quality agenda is being appropriately

identified, assessed, addressed and monitored.

The clinical priorities outlined in the Strategy reflect

the quality priorities outlined in this year’s Quality

Report.The full Clinical Quality Strategy is available

via our website at: http://www.thh.nhs.uk/

patients/safety/index.php.

Quality priorities for improvement in 2014-15

In this part of the report, we tell you about the

areas for improvement in the next year in relation

to the quality of our services and how we intend

to assess them. We call these our quality priorities

and they fall into three areas: patient safety, patient

experience and patient outcomes.

In arriving at these priorities, agreed by the Trust

Board, there was a process of engagement with our

foundation trust members, our governors, our staff,

Healthwatch and our commissioners. In addition,

the Trust triangulated data from several sources to

identify themes and recurring trends. Over the last

year there has been more active engagement with

our local Healthwatch including incorporating their

members on several of our Trust working groups.

LOOKING fOrwArd fPart 2.3 Our new Clinical Quality Strategy

The Trust has published a new Clinical Quality

Strategy (2013-2016) to support its delivery of

high quality care over the next three years. The

purpose of the new Strategy is to help the Trust

achieve its vision ‘To put compassionate care, safety

and quality at the heart of everything we do’. The

Strategy provides a structure for delivering quality

governance to ensure ongoing improvement in the

quality and safety of patient care. It builds on the

local and national context of service change that so

critically affects quality of care for all its patients and

ensures that the trust’s approach and commitment

to high quality care is clearly defined.

The Strategy also outlines the responsibilities of

its staff and is supported by the Trust’s culture

and values framework, CARES (Communication,

Attitude, Responsibility, Equity and Safety) which

embraces a culture that empowers staff to report

incidents and raise concerns about quality in an

open, blame-free working environment. The

Strategy will ensure that clinical quality governance

and risk management are integrated into the Trust’s

culture and everyday management practice and that

all members of staff are clear on their role and the

drive to continually improve the quality of care.

In building its Strategy the Trust has considered the

local and regional health economy and national

contexts and has made reference to key NHS

investigations, such as the Francis Report and the

Berwick and Keogh reviews. The Trust has also

reviewed its current position in relation to key

quality and performance data alongside other

acute providers in order to focus its priorities and

to be in line with local, regional and national best

performance. The priorities focus on those areas

which are the most important based on a balance

of greatest impact on patient care, national

profile and public profile, as well as those where

performance is below expected.


21

Quality Report 2013-14 Consultation

Respondent Category Quality Priority Topic 2014-15

Patient Safety

Staff • Implementing the Emergency and Maternity Care Standards

• Reduction in weekend mortality

• Improve pathways/bundles of care to provide reliable care

• Achieving reduction in patient harms. such as falls/pressure ulcers, associated with the Patient Safety Thermometer

• Improve staff / patient ratios

• Improving staff feedback mechanisms in relation to incidents

Healthwatch • Better support for patients discharged from Accident and Emergency

• Ensure proactive care ward rounds are happening as expected particularly in relation to continence care in inpatient areas and A&E

Governors and FT members

• Better support for patients discharged from Accident and Emergency

GP Commissioners • Implementing the Emergency and Maternity Care Standards – especially senior clinician review 7 days a week

Patient Experience

Staff • Improve responsiveness to need

• Improve learning from patient feedback

• Review of complaints management

• Improve staff / patient ratios

• Continuing with improving the outpatient experience

• Continuing with the improving inpatient care project (includes leaving hospital) – reduce length of stay

Healthwatch • Improvements in the outpatient appointment system/call management system – continuing with improving the outpatient experience

• Improvement in the management of letters for outpatient appointments

• Improve medical engagement/staff attitude – further work on CARES

• Look at other ways of getting patient feedback

• Display information on patient experience feedback on information boards on each ward/department

• Improve the participation in the Friends and Family Test in some areas

• Ensure new pathways of care include metrics on the patient experience

This has proved valuable in being able to hear on an

ongoing basis the feedback it receives from people it

engages with.

During the consultation period there was a strong

opinion from our stakeholders that we should

continue with some of our projects started in the

previous year/s where further outcomes needed

to be achieved to fulfil their potential. Hence

the projects relating to an improved outpatient

experience and improving inpatient care with

effective discharge are being retained.


22

Respondent Category Quality Priority Topic 2014-15

Governors & FT members • Improvements in the outpatient appointment system – continuing with improving the outpatient experience

• Improve medical engagement/staff attitude – further work on CARES culture and values

• Look at other ways of getting patient feedback

• Improvements in hospital patient transport

• Improving the hospital grounds

GP Commissioners • Achieving the A&E target

Patient Outcomes

Staff • Improving admissions avoidance/ambulatory care pathway

• Implementing the Emergency and Maternity Care Standards

• Reducing number of readmissions

• Improving diagnostic reporting times

• Drive forward early supported discharge work streams

• Improve Dementia indicator – FAIR assessment

Healthwatch • Better support for patients discharged from Accident and Emergency

• Improvement in improving inpatient care workstream to ensure actions are being progressed as planned

• Understanding outcomes for patients with regard to early supported discharge schemes

Governors and FT members

• Better and quicker access for tests

GP Commissioners • Consultant access for GPs

• Achieving the A&E target

The Board considered all of the suggestions put forward and the priorities below have been recommended for

inclusion in the Quality Report for 2014-15. These have been identified as falling under the three domains of

safety, clinical effectiveness and patient experience as follows:

No. Priority Safety Clinical Effectiveness

Patient Experience

1 First Contact – Continuing to Improve the Outpatient Experience

2 Continuing with the Improving Inpatient Care Project

3 Improving patient safety In Emergency and Maternity Care

4 Introducing and embedding patient care bundles/pathways

5 Improve responsiveness to patient need

Further information on these priorities and what we will be measuring in 2014-15 can be found on the

following pages.


23

Our aims for 2014-15: The performance targets we will use to measure the

impact of the changes and new initiatives are:

Percentage of clinics cancelled with six weeks’ notice Performance for 2013-14 shows that 2.3% of clinics

were cancelled with less than six weeks’ notice

(average of 115 clinics per month). The target for

2014-15 is set at 1.5% (75 clinics per month); this

will provide some tolerance for unexpected leave/

urgent reasons.

Clinic UtilisationIn 2013-14 new information software was designed

to enable managers and clinicians to have better

visibility about the activity in their outpatient services.

This information will assist in planning capacity to

meet the referral demand. The data for 2013-14

shows that 85.6% of outpatient slots were utilised.

The target for 2014-15 is set at 90%. This will provide

some flexibility to manage changes in demand.

Local outpatient experience survey The aim is to achieve an overall satisfaction target

of 88%. Patient experience will be monitored via a

local survey on a quarterly basis. Patients are asked

six questions covering staff attitude, communication

about waiting times, respect and dignity and overall

satisfaction. This target will enable monitoring of

experience which is implicit across the different

development areas. Current performance against

the existing questions averages 87%.

PRIORITY 2

Continuing with the Improving Inpatient Care Project

Why is this one of our priorities? Reducing the length of stay for inpatients has been

a priority service improvement goal for a number

of years. We know that the longer patients are in

hospital, the more risks there are to the patient, and

fundamentally, we know people do not want to

be in hospital. We want to remove all unnecessary

waits and support our patients to return to their

PRIORITY 1

Accessible and Responsive Services – Continuing to improve the outpatient experience

Why is this one of our priorities?The Trust’s outpatient productivity scheme has

highlighted areas in appointment management

(listed below) that would benefit from further service

redesign. In addition, our patients are telling us

that they continue to experience some difficulties

with the booking of their appointments and

communication with the hospital.

• The introduction of information software that

assists in planning outpatient capacity to meet

the referral demand.

• Management of appointment cancellations will

move from the Patient Administration System

(PAS) team to the outpatient appointment

centre (OAC). This will ensure greater scrutiny

of appointment cancellations and challenge to

specialities.

• Correspondence about appointments will

be centralised to improve the accuracy and

consistency of information given to patients.

How are we doing so far?Although we have made many improvements in

the last few years we recognise that there are still

concerns from patients about their experience of

the outpatient pathway. We have changed the way

patients are contacted and are reminded about their

outpatient appointments. We have reduced the

call abandonment rate when patients are making

calls to the OAC and very recently our DNA rate

has reduced (please see Priority 1 for 2013-14).

Continuing with this priority has come from a

number of sources, including the public membership

focus group and from our local Healthwatch.


24

Cellulitis, Pyelonephritis and Pulmonary Embolism.

An important part of developing this service further

will be to gauge the patient’s experience of this

type of service so that we can be assured that it is

effectively meeting the needs of our patients.

Early supported discharge workstreamThe aim of this workstream will be to assess in

excess of 300 patients on the ‘Home Safe’ pathway

over a three-month period and to provide a

comprehensive geriatric assessment for patients

requiring multidisciplinary team input. In addition

we wish to expand the service from the EAU to

incorporate patients who have had an inpatient

stay on one of the specialty wards.

Specific targets include:

• Achieve a reduction in our length of stay of three

days for patients over the age of 65 years old

who are eligible for the ‘Home Safe’ programme

• Division of Medicine to monitor the patient

experience of the ‘Home Safe’ pathway as a

key metric.

Leaving Hospital Improvement Project, including discharge from A&E

• To aim to discharge =/>25% of our patients

from the inpatient wards before midday

• We aim to achieve a target of 72% of patients

leaving hospital with a positive experience

through the use of the ‘Leaving Hospital’

questionnaire.

PRIORITY 3

Improving patient safety in Emergency and Maternity Care

Why is this one of our priorities?There is national and London data to show that

there are significant differences in the mortality

rates for patients admitted as an emergency during

the week compared with patients admitted as

an emergency at the weekend. Reduced service

provision at weekends has been associated with this

higher mortality rate. In response to the data, the

London Quality Standards (LQS) were developed

homes safely and be supported in the community

as soon as clinically appropriate. The need for

improvement in this area has been identified from

a variety of sources including information from our

local Healthwatch referencing patient feedback of

lengthy delays on the day of discharge, priorities

within our new Clinical Quality Strategy and the

aim to work with our local health and social care

partners in delivering integrated care pathways and

more care in the community. In addition, Dr Foster

Intelligence data shows the trust to be an outlier in

relation to its readmission rate.

How are we doing so far?Following the successful introduction of our

‘Home Safe’ project we want to make sure that

the principles adopted for this project are shared

in order to examine additional opportunities for

early supported discharge schemes. We have

implemented our leaving hospital principles

across all of our wards and we have reviewed our

goals and priorities. The overall objective of this

programme of work is to ensure we provide an

improved experience to all inpatients by improving

the patient journey, timeliness of interventions and

thereby decreasing their overall length of stay. Our

performance for this past year is outlined under

Priority 2 in the priorities for 2013-14.

Our aims for 2014-15 are:

Reducing readmissionsThe rate of readmissions will be tracked per

specialty and will be benchmarked against national

figures for readmission rates. Specialties that are

currently showing high rates of readmissions will

be scrutinised to identify different pathways of

care. The aim is to reduce readmissions in relevant

specialties by 1%-2%.

Ambulatory care pathway The aim is to see > 200 patients per month with

the expectation that 80% – 90% of patients would

be suitable to be treated via ambulatory pathways

of care. The aim of developing this service further

is to increase capacity and treat a broader range

of conditions to include Deep Vein Thrombosis,


25


• Seven day working for Emergency Care with

earlier senior decision-making seven days a week:

– Achieve consultant physician presence at

weekends in Medicine 12hrs/day

– Patients seen by a consultant within

12 hours within Medicine, Surgery,

Paediatrics and Gynaecology

• Access to multi-professional assessment and

radiological diagnostics and reporting within

specified timeframes.

PRIORITY 4

Introducing and embedding patient care bundles/pathways

Why is this one of our priorities?Care bundles/pathways are tools that include a

collection of healthcare interventions and that can be

used to manage the quality of care that is delivered

by standardising care processes. It has been shown

that their implementation reduces variability in

clinical practice and improves patient outcomes in

the acute care setting. They promote more organised

and efficient patient care based on evidence-based

practice, whereby locally agreed standards help a

patient with a specific condition or diagnosis receive

a consistently high standard of care.

How we are doing so far?The Trust has demonstrated good progress in

this area in order to support high quality care

introducing care bundles and improved clinical

care pathways for a variety of diagnoses and care

interventions. However there is more work to be

done to ensure the well-recognised care bundles/

pathways are truly embedded and that where there

are gaps in consistency of approach to best practice

for particular diagnoses that these are addressed.


• Implement the Acute Kidney Injury (AKI)

Pathway, in line with a London wide AKI

pathway and show some improvement

• Sepsis Care Bundle to achieve =/> 70%

compliance

to try and describe what good care should look

like and to ensure that there was a well-recognised

minimum quality of care that patients attending

an emergency department or admitted as an

emergency should expect to receive in every acute

hospital in London. Similarly, the maternity services’

quality standards represent the minimum quality

of care women who give birth should expect to

receive. As part of the Shaping a Healthier Future

(SaHF) programme there is proposed expansion of

our maternity facilities to allow for an anticipated

increase in births taking the total number to 6,000

each year. This expansion in facilities will enable the

Trust to make improvements in the models of care

offered and to support the LQS, in particular by

providing a dedicated midwifery-led unit to provide

additional choice for women.

At the end of 2013 London’s hospitals were asked

to self-assess their progress towards meeting the

standards and provide information on action taken

in acute medicine and emergency general surgery

services throughout 2012-13. The results from our

self-assessment highlight our progress towards

meeting the LQS, as well as the need to continue

on the journey of improvement and investment.

In addition, feedback from our staff and our

commissioners highlights the need for us to drive

forward this improvement work in 2013-14.

How are we doing so far?We have already invested in additional senior doctor

time, out of hours Monday to Friday and at the

weekends. Notably we have provided consultant

ward rounds twice a day on our medical EAU. This

has ensured that our patients continue to receive

care from our most senior doctors irrespective of the

day of the week. We have found some elements

of this work challenging however the Trust is fully

committed to implementing the standards in a

phased approach over the forthcoming years.


26

timescale for conclusion. In 2014-15 we aim to

undertake a complaints review in line with the

recommendations from Designing Good Together

(DGT): Transforming Hospital Complaint Handling

(2013) and develop a local action plan.

The Trust has always carried out an annual ward

staffing review but the outcomes of these reviews

have not generally been reported to the Trust Board.

In addition, professional judgement has been the

main approach used to inform the review. New

guidance from the National Quality Board has set

out a more robust approach to ensure that we have

the right skills, in the right place at the right time. To

improve ‘Care at the Bedside’ we will implement a

quarterly cycle of acuity and dependency assessment

with quarterly reports received by the Nursing and

Midwifery Assembly and a bi-annual paper to the

Trust Board setting out the outcome of a review of

staffing levels and skill mix.

Our CARES (Communication, Attitude, Responsibility,

Equity and Safety) values and associated behavioural

framework were launched in May 2012. To

raise awareness of the values and to help staff

to understand their application a customer care

programme was procured. The programme was

developed using patient complaints, feedback from

staff and incidents to ensure the scenarios included

local issues that staff could relate to. The programme

was introduced in June 2013 and so far 1,087 staff

members have completed the programme. We

will continue to deliver Customer Care training to

our staff and we will aim to incorporate the CARES

behaviours as a weighted element of performance

related pay progression and for this to be fully

implemented by 2015-16. We will reward staff who

demonstrate the expected behaviours through the

staff awards event, giving recognition to staff that

do a good job. We will also introduce the Staff FFT

questions to measure staff engagement levels as an

indicator of their attitude towards the organisation.

Our aims for 2014-15:

• Improvement in baseline compassionate care

indicator (baseline to be established calculated

from Q1 result)

• FAIR assessment completed for >90% of

elderly patients per quarter

• To achieve a 20% reduction in falls

without harm

• Catheter Care Bundle to achieve =/> 95%

compliance

• Improvement against the NHS Safety

Thermometer with focus on pressure sores –

to realise a 25% reduction, from a baseline of

3.2% to a final value of 2.4%.

PRIORITY 5

Improve responsiveness to patient need

Why is this one of our priorities?Patient experience is a recognised element of high-

quality care and understanding and improving how

patients experience their care is key to delivering

high-quality services. Using a variety of different

approaches and seeking feedback from different

pathways will help staff to gain greater insight

into our patients’ perspective of their care. Key

stakeholders (our staff, our Governors, Healthwatch)

advise us that we need to ensure that there is focus

on improving the patient experience further and

that our services, and how they are delivered, are

truly responsive to individual patient needs.

How we are doing so far?The Trust participates in the annual national patient

survey programme and in addition a number of

local patient surveys have also been developed

and implemented. The Friends and Family Test has

also been fully rolled out to inpatient areas, the

emergency department and maternity. This will be

rolled out to outpatients and day care settings in

2014-15.

During 2013 our Complaints Management Unit

went through an unsettled period with a change in

management and support staff. With a substantive

team now in place a number of changes have

already taken place which include more robust

processes for managing open complaints aiming

to always contact the complainant by telephone to

discuss their concerns and agreeing an appropriate


27

improvement and patient safety work and will look

to the collaborative for support and structure. The

Director of Nursing and Patient Experience has been

appointed as the trust director with responsibility

to oversee medication error incident reporting and

learning and the Terms of Reference for a multi-

professional group to drive forward this work are

being drawn up.

NHS England has advised that there is unlikely to

be significant additional funding available through

this programme to purchase additional capacity for

improvement activity. Healthcare organisations will

be expected to undertake quality improvement as

part of their usual business.

Part 2.4 Formal statements of assurance from the Board

Information for our regulatorsOur regulators need to understand how we are

working to improve quality so the following two

pages are specific messages they have asked us

to provide:

Provision of NHS ServicesDuring 2013-14 The Hillingdon Hospitals NHS

Foundation Trust provided medicine, surgery, clinical

support services and women’s and children’s NHS

services. The Hillingdon Hospitals NHS Foundation

Trust has reviewed all the data available to them

on the quality of care in all of these relevant health

services. The income generated by these relevant

health services reviewed in 2013-14 represents 100%

of the total income generated from the provision of

the relevant health services by the Hillingdon Hospitals

NHS Foundation Trust for 2013-14.

• 50% of additional staff (from 2013-14) to

receive customer care training

• Friends and Family Test – Q4 response rates

>20% A&E / >30% Inpatients

• Friends and Family Test – March 2015 response

rate >40%

• Improvement in the net promoter score of FFT

for inpatient and A&E surveys.

Our quality priorities will be monitored by the

individual clinical and management teams, through

their divisional performance reviews and quarterly

through reports to the Board or Board Committee

and the results will be reported in the 2014-15

Trust Annual Report.

Patient Safety Collaborative Programme

The Berwick Review which was commissioned

following the Mid Staffordshire Hospitals enquiry

and the publication of the Francis Report includes

recommendations to ensure a robust nationwide

system for patient safety. The challenge is for our

whole healthcare system to systematically support

and foster a culture of continual learning and

improvement that supports staff to provide the

safe care they all want to, ensuring patients are at

the centre of care. NHS England’s Patient Safety

Domain and NHS Improving Quality have therefore

introduced the Patient Safety Collaborative

Programme with the formation of 15 Patient Safety

Collaboratives (PSCs), enabled to create and nurture

sustainable local continual learning environments.

This fundamental focus on continual learning

systems will encourage the kind of organisation

and system-wide patient safety culture that can

deliver definitive improvements in specific patient

safety issues and build local capability and energy

for change.

One of the core clinical priorities is ‘Medication

Errors’ – the prescribing, dispensing and

administration of medicines is a huge area where

error and poor process has the potential to affect

large numbers of patients, making this a priority

area for reducing harm. The Trust will ensure

that it actively participates in this key piece of


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Audit Participated Cases submitted

Acute Myocardial Infarction Yes 100%

Adult Critical Care Case Mix Programme No N/A. Decision to not participate in this audit by clinical leads; to be reviewed in 2014-15.

National Bowel Cancer Audit Programme Yes 100%

National Chronic Obstructive Pulmonary Disease Audit Programme

Yes Data submission in progress

National Adult Diabetes Audit, includes National Diabetes Inpatient Audit (NADIA)

Partial Participation in NADIA only – 35 patients included in the audit. The trust is reviewing National Adult Diabetes Audit requirements with a view to participate fully in the future.

National Paediatric Diabetes Audit (Royal College of Paediatric and Child Health)

Yes 100%

Elective Surgery (National Patient Reported Outcome Measures (PROMS) Programme)

Yes Percentages unavailable, numbers are:Hip replacements – 255Knee replacements – 297Groin hernia – 138Varicose veins – 10

Emergency Use of Oxygen (British Thoracic Society) No N/A. Non participation was as a result of local clinical decision. Trust is reviewing requirements with a view to participate in 2014-15.

Epilepsy 12 Audit (Royal College of Paediatrics and Child Health) National Childhood Epilepsy Audit

Yes 100%

Falls and Fragility Fractures Audit Programme including National Hip Fracture Database

Yes 100%

Head and Neck Oncology (Data for Head and Neck Oncologists)

Yes 100%

Heart Failure Audit Yes Expected 75%

Participation in clinical audit

National auditsDuring 2013-14, 29 national clinical audits and

three national confidential enquiries covered

NHS services that The Hillingdon Hospitals NHS

Foundation Trust provides.

During that period The Hillingdon Hospitals NHS

Foundation Trust participated in 86% of national

clinical audits and 100% of national confidential

enquiries for which it was eligible to participate in.

The national clinical audits and national confidential

enquiries that The Hillingdon Hospital NHS

Foundation Trust was eligible to participate in during

2013-14 are listed below alongside the number

of cases submitted to each audit or enquiry as

a percentage of the number of registered cases

required by the terms of that audit or enquiry.


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Audit Participated Cases submitted

Inflammatory Bowel Disease Yes 100% for the inpatient audit. Trust not currently participating in Biologic Therapy Audit, following recruitment of Biologic’s Co-ordinator it is expected we will participate going forward.

National Lung Cancer Audit Yes 100%

Moderate or severe asthma in children (College of Emergency Medicine)

Yes 100%

National Audit of Seizures in Hospitals Yes 100%

National Cardiac Arrest Audit Yes 100% in hospital cardiac arrests. The trust needs to extend this to ensure we include pre-hospital cardiac arrests – this has been put in place from January 2014.

National Comparative Audit of Blood Transfusion – Audit of the use of Anti-D

Yes 100%

National Emergency Laparotomy Audit (NELA) Yes Data submission in progress

National Joint Registry Yes Hillingdon: 62%

Mount Vernon Treatment Centre: 92%

National Neonatal Audit Programme Yes 100%

National Oesophago-gastric Cancer Audit Yes 100%

Paediatric Asthma (British Thoracic Society) Yes 100%

Paediatric Bronchiectasis (British Thoracic Society) Yes 100%

Paracetamol overdose (College of Emergency Medicine)

Yes 100%

Rheumatoid and early inflammatory arthritis No N/A. Non participation is as a result of local review/decision and is being added to the risk register.

Sentinel Stroke National Audit Programme Yes 100%

Severe Sepsis and Septic Shock (College of Emergency Medicine)

Yes 64%

Trauma Audit & Research Network Yes 22.9%

Clinical Outcome Review Programmes

Maternal, New-born and Infant Clinical Outcome Review Programme (MBRRACE-UK)

Yes 100%

Lower Limb Amputation (National Confidential Enquiry into Patient Outcome and Death (NCEPOD)

Yes Data submission in progress

Subarachnoid Haemorrhage (NCEPOD) Yes 100%


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Taking actionsThe reports of 12 national clinical audits were reviewed by the provider in 2013-14 and The Hillingdon Hospitals

NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided.

Audit Actions

National Comparative Audit of Blood Transfusion – Blood Sample Labelling and Collection

Frequency of training for staff on blood transfusion has been reduced from annually to every two years and this is now in line with recommendations from the Medicine and Healthcare Products Regulatory Agency and National Patient Safety Agency. This will result in the Trust being better able to train all relevant staff within the new extended time period. Also training sessions have been increased in frequency and this has resulted in 78% of relevant staff now trained.

The trust Blood Transfusion Policy has been updated and now has zero tolerance for incorrect labelling. A process is being implemented where the Transfusion Practitioner receives a weekly report from the Pathology Lab on the number of incorrectly labelled samples, the areas and the member of staff responsible. This will be investigated and staff reminded of the correct protocol and the importance of ensuring all information is completed and correct.

National Lung Cancer Audit A spirometer is to be purchased in order to improve our figures regarding measurement of respiratory function. Spirometry is an important part of the patient assessment for curative treatments such as surgery and radical radiotherapy and is also a key indicator in the National Lung Cancer Audit data fields.

National Oesophago-gastric Cancer Audit

Treatment for Oesophago-gastric cancer patients is part of a pathway within the London Cancer Alliance (LCA). The trust works closely with the specialist centres involved and follows the LCA guidelines as part of its action plan in response to the audit.

National Cardiac Arrest Audit (NCAA)

The trust joined NCAA in July 2013. We have received our first report and have reviewed our practice within this. As we continue to receive the quarterly reports an action plan identifying any required improvements will be developed. We recently identified that we had not submitted all required patients for the first quarter, as we did not include pre-hospital cardiac arrests; we have now amended this and submit all required patients.

National Diabetes In-patient Audit

As a result of the audit a programme of hypoglycaemia training is now in place – approximately 70% of staff have undertaken this. In addition, a pilot has taken place using a revised hypoglycaemia proforma, which has proven successful for use in the Trust.

Falls and Fragility Fractures Audit Programme including National Hip Fracture Database (NHFD)

Overall, the trust performed well in this audit. One area for improvement was collection of follow up data once the patient has been discharged from hospital. A process has now been put in place where we are working with Hillingdon Community Rehabilitation Team to capture available follow up information and provide this back to the Trust for submission to NHFD.


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Audit Actions

National Neonatal Audit Programme

Neonatal Unit notes have been modified with a prompt for senior consultation with parents within 24 hours. Year on year the percentage of parents seen by senior staff within 24 hours is increasing – we do try to ensure that parents are spoken to as soon as possible after admission.

The division is continuing to focus on improving breast feeding rates for all babies of all gestations. ‘Hot on Cold Babies’ is currently being promoted to prevent hypothermia in the new-born.

Sentinel Stroke National Audit Programme

As part of implementation of recommendations from this audit, the trust intends to review the Early Supported Discharge pathway and potential implementation.

College of Emergency Medicine Renal Colic

After reviewing the results of the renal colic audit we identified issues regarding note keeping especially when it came to recording pain scores and adequate analgesia. To improve practice, on induction days junior doctors are educated by one of our consultants on the importance of adequate record keeping and the necessity to record and re-evaluate pain scores. The Accident and Emergency (A&E) Department Matron also has regular sessions with the nursing team during handovers and sisters’ meetings reminding the nurses about the importance of pain score documentation and reassessment. An A&E Registrar and a Radiology consultant are in the process of developing a renal colic pathway which will include a pain relief protocol. Once the pathway is ready a separate A&E renal colic pathway for patients over 65 years of age, which will include instructions regarding the exclusion of Abdominal Aortic Aneurysm, will be developed.

College of Emergency Medicine Fractured Neck of Femur

This audit identified issues regarding the recording of pain scores and adequate analgesia. The education that takes place in Accident and Emergency (A&E) will cover patients with a Fracture Neck of Femur. One of the A&E consultants has also written to all staff reminding them of the importance of recording and re-assessing pain scores.

Alcohol Related Liver Disease: Measuring the Units (NCEPOD)

Some work has already been put in place for this group of patients including: an update to our nursing assessment booklet which now includes an alcohol assessment – this was put in place from July 2013; an Alcohol and Liver Disease study day took place on 28th March 2014, to further educate and support Nurses and Allied Healthcare Professionals.

The trust is currently working with Central North West London Foundation Trust on the further implementation of the recommendations within this NCEPOD report. CNWL have employed an Alcohol Nurse Specialist who is helping to support patients with alcohol-related admissions to engage with community alcohol services.

Subarachnoid Haemorrhage: Managing the Flow (NCEPOD)

As a result of the recommendations within this NCEPOD report the trust is in the process of reviewing and updating relevant clinical guidelines.


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Local audits The reports of 81 local clinical audits were reviewed by the provider in 2013-14 and examples of The Hillingdon

Hospitals NHS Foundation Trust actions to improve the quality of healthcare provided:

Clinical Record Keeping Standards Audit

During 2013-14 the trust reviewed and updated our clinical record keeping standards and have agreed that audit against these will take place every six months. To improve record keeping standards stamps are being provided to help to clearly identify who wrote in the patient record, their designation and their bleep number. A small project group has been developed to improve standards within the division of Medicine – a teaching session to all foundation year doctors has been organised and posters are being produced promoting the trust record keeping standards.

Re-audit of Staff Survey of Caring for Vulnerable Patients including those with a Learning Difficulty

We have continued to drive improvements through Safeguarding Adults/Learning Disability training, specifically raising awareness to use pictorial easy read information, Patient Administration System alert and Patient Passport. It is highlighted, within training, that all information is available on dedicated Safeguarding Intranet pages.

Preventing Surgical Site Infection re-audit

We are in the process of purchasing ‘additional’ thermometers and evaluating evidence on new patient warming systems.

Do Not Actively Resuscitate (DNAR) re-audit

To make sure we involve patients/families in the DNAR decision-making process we are in the process of producing a leaflet. This will help to inform them of the DNAR process and what discussions/decision will take place.

WHO Surgical Safety Checklist Audit

To raise continued awareness on the use of the WHO surgical safety checklist posters are displayed in Theatres. A teaching session in March 2014 at the theatre/anaesthetic departmental meeting included WHO, Consent and Sedation. One of our anaesthetic consultants is producing a presentation for e-induction and will include this in local induction packs for all staff (doctors/nurses/other theatre staff).

WHO Surgical Safety Checklist and SWAB Count in Maternity

To reinforce the requirements for use of the WHO Checklist and SWAB count processes, standard risk management training, in Maternity, has been changed to include this. Future plan is for 2 Maternity theatre staff to attend a full theatre training course to enhance their knowledge and skills to disseminate within the service.

Safe Sedation A teaching session took place in March 2014 at the theatre/anaesthetic departmental meeting which included WHO, Consent and Sedation. The WHO checklist has been revised to include safe sedation elements.

Paediatric Casualty Card Audit in Minor Injuries Unit (MIU)

A stamp has been purchased and is in use to provide proof that copies of all paediatric notes are sent to the Paediatric Liaison Health Visitor. Awareness has been raised and any necessary further training provided to ensure GP registration is checked electronically, this is then documented in children’s notes – re-audit has shown 100% compliance.

Supporting Carers of People with Dementia

To improve information provided to carers, dementia resource folders are being distributed to all wards within the hospital. The folders include information such as, leaflets on different types of dementia and local contacts to go to for support.


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Mortality Audit Process An initial mortality audit took place and was reported on in September 2013. Actions include the process where a list of National Early Warning Score (NEWS) calls is handed out at Medical hand-back meeting on Monday mornings so that patients who have needed urgent review out of hours are prioritised for review, by the appropriate teams. A further action includes nursing progress notes being recorded on the same progress sheets as medical entries. This will help medical staff to better monitor events relating to patients. In October 2013 the Trust introduced an ongoing Mortality audit to help to ensure we consistently provide high quality care for all patients who die in hospital. The first full report was presented to our Quality and Risk Committee in April 2014.

Participation in research

Commitment to research as a driver for improving the quality of care and patient experience The number of patients receiving relevant NHS

health services provided by The Hillingdon

Hospitals NHS Foundation Trust in 2013-14 that

were recruited during that period to participate in

research approved by a research ethics committee

was 650.

The Hillingdon Hospitals NHS Foundation Trust has

a good track record for research for a hospital of its

size. We are continuing with our strategy to broaden

our research portfolio and this has enabled us to

offer a greater number of patients, from different

clinical areas the opportunity to participate in

research. This year we invested in a research nurse to

support our Cardiologists and Diabetes consultants

as a means of increasing commercially funded and

portfolio-adopted research activity in these areas.

This post is now fully funded by the commercial

income it generates.

Participation in clinical research demonstrates the

trust‘s commitment to improving the quality of care

we offer and to making our contribution to wider

health improvement. This allows our clinical staff to

stay abreast of the latest treatment possibilities while

active participation in research allows our patients

access to new treatments that they would otherwise

not have. With this in mind we aim to offer our

patients the opportunity to participate in a wide

range of clinical research projects. These studies are

both funded by the pharmaceutical industry and

by the Department of Health via the North West

London Comprehensive Research Network (CLRN).

We received £464,284 in 2013-14 from the CLRN

for this work.

The money generated from this research activity

funds research nurses and data managers to

support the clinicians in this work. The majority

of our studies are National Institute for Health

Research (NIHR) portfolio-adopted multi-centre

studies where we are acting as a recruiting site on

behalf of the lead centre. Our research portfolio is

a balance of observational and treatment studies

across many clinical areas in the Trust including

Cancer, Stroke, Haematology, Paediatrics and many

of the General Medicine and Surgical Specialties.

This year we plan to become more research active

in Ophthalmology, Obstetrics and Rheumatology.

We also support PhD and Masters Students from

the local universities giving them access to our

patients and staff for their projects.

During 2013-14 we had 63 open or follow-up

studies. We recruited 639 patients into 40 NIHR

Portfolio Studies, supported the repatriation of

ten patients recruited into treatment studies at

other hospitals and supported six Masters or PhD

student studies.

All of our research activity is scrutinised for quality

and compliance to the standards expected by the

Research Governance Framework. In addition we

work to comply with the Department of Health

NIHR objectives.


34

Lessons learned from Serious IncidentsDuring 2013-14, the trust reported ten ‘Serious Incidents’ and two ‘Never Events’ where panel investigations were

conducted. Protecting patients from avoidable harm is something to which there is universal agreement and the

Trust has clearly defined processes and procedures to follow to help avoid these events occurring. Lessons learnt as

a result of the Serious Incidents include:

Area Division Summary

1:1 observation of patients with increased observation need

All divisions Review of the trust’s ‘Specialling’ Policy on the 1:1 supervision of patients

Nursing documentation All divisions A patient specific risk assessment form, an individual patient care plan outlining level of observation and a behavioural monitoring chart included in the revised specialling policy

Availability of specialist nursing staff

All divisions Recruitment of Registered Mental Health Nurses to the nurse bank

Specialist training for nursing staff

Medicine Introduction of mental health training for nursing staff in A&E and the Emergency Admissions Unit (EAU)

Specialist psychiatric input Medicine Work with CNWL on raising awareness and availability of the psychiatric liaison service

Safety in A&E and EAU Medicine Environmental health and safety risk assessments completed

Managing Sepsis All divisions New sepsis care bundle created and launched. Full audit and review of the ‘Bundle’ undertaken

Managing the Deteriorating Patient

All divisions Reinforcing the ‘Patient At Risk’ policy – discussed at staff meetings and information provided within departments

Mortality Reviews All divisions Implementation of a robust mortality review process

Record Keeping All divisions Best practice training and medical notes audit programme

Specialist Referral Pathways and Processes

All divisions Review of referral pathways and processes to ensure these are robust and gaps are identified

Escalating Concerns - medical management of a patient

All divisions Importance of early escalation to highest level reinforced with staff where medical management issues cannot be resolved

Neurosurgical pathway to tertiary centre

Medicine Involvement of tertiary centre to resolve issues associated with neurosurgical referral process and pathway

Clinical management/pathway for patients requiring limb amputation for non-vascular/trauma reasons

Surgery Decisions on consultant responsibility, operation arrangements and availability of vascular services as part of North West London vascular network agreements

Clinical handover of care from the Intensive Care Unit

Surgery Agreed protocol for handing-back the care of an ITU patient to the parent team communicated to consultants

Review of CT scans C & CSS Reinforced to all consultant radiologists that the review of CT scans should take place in multi-plane views


35

Further details of the agreed goals for 2013-2014

and for the following 12 month period are available

electronically at: www.thh.nhs.uk.

Care Quality Commission registration The Hillingdon Hospitals NHS Foundation Trust is

required to register with the Care Quality Commission

and its current registration status is that it is registered

without conditions. The CQC paid an unannounced

visit in October 2013 as part of their planned review

of the Trust. The report issued from this visit stated

the Trust was not fully compliant with the Essential

Standards of Quality and Safety; one moderate

staffing concern was raised and two minor concerns

regarding cleanliness and infection control, and safety

and suitability of premises. The Trust set out an action

plan to close the gaps in compliance and awaits

further CQC inspection to review its compliance level.

An action plan was submitted to the CQC and further

updates on progress have been provided.

Area Division Summary

Discussion of emergency gastrointestinal cases

Surgery Patients with an emergency acute gastrointestinal problem are discussed in an appropriate forum (x-ray/MDT meeting) regardless of the primary specialty of the admitting team

Care of the seriously ill woman in Maternity

Maternity Training completed by all staff on the recognition of the seriously ill woman, including the completion of the Maternity Early Warning System (MEWS) chart and the escalation procedures

Mentoring of student midwives

Maternity Ensuring the mentoring of students is to Nursing and Midwifery Council standards – mandatory training incorporates the responsibilities of the mentor

WHO Maternity surgical safety checklist

Maternity WHO Maternity surgical safety checklist reviewed and strengthened and documentation standard improved

Maternity theatre processes Maternity Review of Maternity Theatre processes including pre, intra and post-operative procedure

Midwifery staff training in surgical competencies

Maternity Clarity on training, responsibilities and accountability in relation to surgical/operative procedures

Review of surgical swabs Maternity Review of surgical swabs in maternity theatres/labour rooms

Patient advocacy All divisions Importance of patient advocacy in decision-making where mental capacity may be affected or a patient is vulnerable

Review of Safeguarding Policy

All divisions To ensure there is clarity on the importance of escalation and 2nd/3rd opinions in relation to mental capacity assessments

Goals agreed with our commissioners (CQUINs) A proportion of The Hillingdon Hospitals NHS

Foundation Trust’s income in 2013-14 was

conditional on achieving quality improvement and

innovation goals agreed between The Hillingdon

Hospitals NHS Foundation Trust and any person

or body we entered into a contract, agreement

or arrangement with for the provision of relevant

health services, through the Commissioning for

Quality and Innovation payment framework.

Total CQUIN income for 2013-14, is expected to be

£2,943,523 for National and Local schemes, and

£234,314 (91% of potential available income) for

Specialised Commissioning which includes 100%

achievement of drugs QIPP at 1.1% of contract

value. In the previous year (2012-13) total income

for National and Local schemes was £2,719,136

(73% of potential available income) and £78,858

(100% of potential available income) for Specialised

Commissioning.


36

right time is now in place; acuity and dependency is

reviewed using accredited tools and this information

used when agreeing staffing establishment and

skill mix; ward leaders have been appointed on

each extra capacity ward along with a small team

of substantive staff. This forms a core team of

experienced nurses with additional nurses

recruited from the nurse bank as

required. Staff are encouraged to

escalate and report all occasions

when staffing levels fall below the

established profile using the trust

incident system.

Moving forward, the trust’s processes

for CQC compliance will be internally

assessed using both the established desk-top style

review of outcomes, and a revised peer review

process which will be based on different levels

of review and frequency from daily ward based

checks to monthly Executive/Non-Executive led

Observations of Care ward visits and external peer

review from another NHS trust.

The Hillingdon Hospitals NHS Foundation Trust

has not participated in any special reviews or

investigations by the CQC during the reporting

The actions taken include – for cleanliness and

infection control: cleaners and cleaning supervisors

have been reminded of the standards required and

performance will be monitored through regular

cleaning audits. The Waste Manager has ensured

wards are reminded not to overfill clinical waste

bins – monitored as part of the monthly audit

process; a revised curtain changing template has

been devised; increased auditing around cleaning

medical equipment, checking protective covers

on equipment, inspections around catheters and

wound drains are carried out fortnightly. For safety

and suitability of premises – all estates staff have

been reminded of the safety standards required;

the improved maintenance requirements have

been carried out; regular environment audits occur

e.g. PLACE (Patient-Led Assessment of the Care

Environment) and mini PLACE, actions that arise

from these are monitored by the PLACE group

which includes estates and nursing staff.

For staffing: the staffing level and skill mix on

each ward is being reviewed against best practice

guidance and where required staffing mix realigned

to reflect these recommendations. A bi-annual

establishment review to ensure that the right people

with the right skills are in the right place at the

MOVING FORWARD


37

period. The Care Quality Commission has not taken

enforcement action against the Hillingdon Hospitals

NHS Foundation Trust during 2013-14.

Data qualityThe Hillingdon Hospitals NHS Foundation Trust

submitted records during April – January for

2013-14 to the Secondary Uses Service (SUS) for

inclusion in the Hospital Episode Statistics (HES)

which are included in the latest published data. The

percentage of records in the published data which

included the patient’s valid NHS number was:

• 98.5% for admitted patient care

• 99.8% for outpatients care

• 96.7% for accident and emergency care.

The percentage records in the published data

which included the patient’s valid General Medical

Practitioner Code was:

• 100% for admitted patient care

• 100% for outpatient care

• 100% for accident and emergency care.

These figures are based on the SUS DQ Dashboard

released by the HSCIC covering the period Apr-

2013 to Jan-2014. The Hillingdon Hospitals

NHS Foundation Trust will be taking forward the

following actions to improve data quality:

• The Trust will continue its Integration Engine

programme to link disparate clinical systems

across the Trust, enhancing the quality of

electronic patient information

• The Trust will continue to review and action

data quality issues at its data quality meetings

• Daily data quality reports are published on the

Trust’s web based management information

system for action and rectification.

Information governance toolkitThe Hillingdon Hospitals NHS Foundation Trust’s

Information Governance Assessment Report overall

score for 2013-14 was 81%. This is termed as

unsatisfactory as one of 43 requirements relevant

to the Trust remains at level 1; all the other scores

are at level 2 or 3. The level 1 score relates to the

fact that currently 70% of staff have undertaken

their information governance training rather than

the required 95% annually. An action plan is in

place to drive compliance to the required level going

forward which includes a revised approach to the

annual refresher training and improved performance

management of non-compliance.

Clinical coding error rate THHFT was not subject to the Payment by Results

Clinical Coding Audit during 2013-14 by the

Audit Commission.


38

Trust’s performance on the 62 day cancer waiting

time however reduced by 3.2%; this pathway

relates to patients we treat here who breach but

also patients we refer to tertiary specialist centres

that then go on to breach the 62 day pathway. In

2013-14 we saw an increase in shared breaches, up

from 19 to 46 – the Trust has to accept half of each

of those breaches even though the patient did not

breach the pathway whilst at our hospital. In 2012-

13 we accounted for 306 pathways with 11 full

breaches and 19 shared breaches. In 2013-14 there

were 338.5 pathways with ten full breaches and

46 shared.

Extensive re-modelling has been undertaken with

other providers to ensure that the care of patients on

complex pathways is properly co-ordinated between

organisations. This means that patients can have

their procedure booked at another hospital while

they are still undergoing investigations at this Trust.

Indicators 8-10 – Referral to treatment waiting timesAll 18 week targets for both admitted and non-

admitted patients were achieved and exceeded.

The Trust consistently achieves this target and has

been one of the strongest performers in London

for the past three years. The Trust’s continued high

performance means that other organisations have

been in contact requesting support with delivering

their elective 18 week activity. In the last year the

Trust supported two organisations in undertaking

elective work.

Indicator 12 – Accident and Emergency (A&E) waiting times

In this part of the report we have included other

key quality indicators which have been selected

by the Board in consultation with stakeholders.

They represent those indicators that are of national

importance that patients will want to know about

and they include targets used by Monitor as part of

Monitor’s Risk Assurance Framework. The indicator

set includes patient experience, patient safety

and clinical effectiveness indicators. The indicators

covered in this year’s report are consistent with those

from last year’s Quality Report. Narrative has been

provided on some of these indicators to outline

our performance.

Details are in the Table on page 39.

Indicator 2 – Readmissions to hospital within 28 days Despite several initiatives undertaken by the Trust,

the Clinical Commissioning Group, Social Services

and Intermediate Care, in 2014 there has been little

change in the performance over the previous year.

This continues to be a priority area in 2014-15.

Indicator 3 – Non-clinically justified single sex accommodation breach There was one mixed sex breach during 2013-14.

This occurred when a patient was deemed fit to

be discharged from the Intensive Therapy Unit but

there was no suitable step down bed available

within six hours.

Indicators 4-7 – Cancer performance The Trust successfully achieved all of the cancer

access targets for the second year in a row. The

Part 3 Other key quality information and improvements we have made in 2013-14


39

2012

-13

Perfo

rman

ce20

13-1

4 Ta

rget

2013

-14

Perfo

rman

ceLo

ndon

Trus

tsNa

tiona

lBe

nchm

ark

Sour

ceBe

nchm

ark

Perio

d

1: In

Hos

pita

l Sta

ndar

dise

d M

orta

lity R

atio

96.7

(89.

6 - 1

04.2

)<1

0087

.6 (8

0.6

- 95.

1)81

.8 (8

0.6

- 83

.0)

100

Dr Fo

ster

Apr-2

013

to Fe

b-20

14

2: R

eadm

issio

ns to

hos

pita

l with

in 2

8 da

ys10

5.2

(102

.2 -

108.

2)<1

0010

2.9

(99.

3 -

106.

7)95

.8 (9

5.2-

96

.4)

100

Dr Fo

ster

Apr-2

013

to N

ov-2

013

3: N

on cl

inica

lly ju

stifi

ed si

ngle

sex

acco

mm

odat

ion

brea

ch, r

ate

per 1

,000

fini

shed

cons

ulta

nt e

piso

des

0.05

%0.

0%0.

02%

0.50

%0.

20%

NHS

Engl

and

Apr-2

013

to Fe

b-20

14

4: C

ance

r: Tw

o w

eek

wai

t fro

m G

P re

ferra

l to

seei

ng a

spec

ialis

t (su

spec

ted

canc

er)/(

brea

st sy

mpt

oms)

97.9

%98

.0%

93.0

%93

.0%

97.9

%94

.7%

95.0

%95

.3%

95.6

%95

.5%

NHS

Engl

and

Apr-2

013

to D

ec-2

013

5: C

ance

r: 31

day

max

imum

wai

t fro

m d

iagn

osis

to fi

rst t

reat

men

t 99

.2%

96.0

%99

.3%

97.9

%98

.3%

NHS

Engl

and

Apr-2

013

to D

ec-2

013

6: C

ance

r: 31

day

max

imum

wai

t fro

m d

iagn

osis

to su

bseq

uent

trea

tmen

t, dr

ug o

r sur

gery

100.

0%10

0.0%

98.0

%94

.0%

100.

0%10

0.0%

99.7

%95

.8%

99.8

%97

.0%

NHS

Engl

and

Apr-2

013

to D

ec-2

013

7: C

ance

r: 62

-day

max

imum

wai

t fro

m re

ferra

l by G

P/sc

reen

ing

serv

ice/c

onsu

ltant

upg

rade

to tr

eatm

ent

93.5

%93

.9%

98.6

%

85.0

%90

.0%

85.0

%

90.3

%97

.8%

96.9

%

82.9

%93

.1%

92.2

%

85.8

%94

.5%

92.1

%

NHS

Engl

and

Apr-2

013

to D

ec-2

013

8: R

efer

ral t

o tre

atm

ent w

aitin

g tim

es -

adm

itted

97.4

%90

.0%

97.1

%90

.2%

91.4

%UN

IFY2

Apr-2

013

to Fe

b-20

14

9: R

efer

ral t

o tre

atm

ent w

aitin

g tim

es -

non

adm

itted

98.8

%95

.0%

98.6

%96

.8%

96.9

%UN

IFY2

Apr-2

013

to Fe

b-20

14

10: R

efer

ral t

o tre

atm

ent w

aitin

g tim

es -

Inco

mpl

ete

97.3

%92

.0%

97.4

%92

.8%

94.1

%UN

IFY2

Apr-2

013

to Fe

b-20

14

11: F

ract

ured

nec

k of

fem

ur e

mer

genc

y pat

ient

s in

thea

tre w

ithin

36

hour

s88

.4%

90%

92.4

%n/

an/

aLo

cal I

ndica

tor

n/a

12: T

otal

tim

e in

A&E

: 4 h

ours

or l

ess (

All T

ypes

/ Typ

e 1)

96.7

%94

.6%

95.0

%96

.0%

92.1

%95

.5%

92.6

%95

.7%

93.5

%UN

IFY2

100.

0%

13: N

umbe

r of l

ast m

inut

e el

ectiv

e op

erat

ions

canc

elle

d fo

r non

clin

ical r

easo

ns0.

61%

0.8%

0.85

%0.

83%

0.79

%NH

S En

glan

dAp

r-201

3 to

Dec

-201

3

14: P

erce

ntag

e of

pat

ient

s not

trea

ted

with

in 2

8 da

ys o

f hav

ing

oper

atio

n ca

ncel

led

for n

on-c

linica

l rea

sons

6.0%

0%0.

0%4.

3%5.

1%NH

S En

glan

dAp

r-201

3 to

Dec

-201

3

15: P

erce

ntag

e of

wom

en in

the

rele

vant

PCT

pop

ulat

ion

who

hav

e se

en a

mid

wife

or a

mat

erni

ty h

ealth

care

pr

ofes

siona

l, fo

r hea

lth a

nd so

cial c

are

asse

ssm

ent o

f nee

ds, r

isks a

nd ch

oice

s by 1

2 w

eeks

and

6 d

ays o

f pr

egna

ncy

80.4

%95

%83

.1%

77.0

%86

.1%

NHS

Engl

and

Jan-

2013

to M

ar-2

013

16: P

erce

ntag

e of

wom

en in

the

rele

vant

PCT

pop

ulat

ion

who

hav

e se

en a

mid

wife

or a

mat

erni

ty h

ealth

care

pr

ofes

siona

l, fo

r hea

lth a

nd so

cial c

are

asse

ssm

ent o

f nee

ds, r

isks a

nd ch

oice

s by 1

2 w

eeks

and

6 d

ays o

f pr

egna

ncy (

exclu

ding

late

Ref

erra

ls)

93.2

%95

%97

.2%

n/a

n/a

Loca

l Ind

icato

rn/

a

17: S

troke

pat

ient

s: Pe

rcen

tage

of P

atie

nts t

hat h

ave

spen

t at l

east

90%

of t

heir

time

on th

e st

roke

uni

t99

.6%

80%

97.3

%94

.3%

84.8

%NH

S En

glan

d20

12/2

013

18: S

troke

pat

ient

s: Pe

rcen

tage

of h

igh

risk

Tran

sient

Isch

aem

ic At

tack

(TIA

)/min

i stro

ke p

atie

nts w

ho a

re

treat

ed w

ithin

24

hour

s10

0%75

%10

0%81

.2%

74.0

%NH

S En

glan

d20

12/2

013

19: M

etici

llin-R

esist

ant S

taph

yloco

ccus

Aur

eusis

(MRS

A)1

case

s (0.

8 Ca

ses p

er

100,

000

bedd

ays)

01

Case

(0.7

Cas

es

per 1

00,0

00

bedd

ays)

1.7

Case

s pe

r 100

,000

be

dday

s

1.2

Case

s pe

r 100

,000

be

dday

s

PHE

2012

/201

3

20: I

npat

ient

Exp

erie

nce

Prog

ram

me

(loca

l sur

vey r

esul

ts)

88%

88%

91%

n/a

n/a

n/a

n/a

21: O

utpa

tient

Exp

erie

nce

Prog

ram

me

(loca

l sur

vey r

esul

ts)

87%

88%

87%

n/a

n/a

n/a

n/a

22: M

ater

nity

Exp

erie

nce

Prog

ram

me

(Loc

al su

rvey

resu

lts)

86%

87%

86%

n/a

n/a

n/a

n/a

23: I

ndep

ende

nt a

sses

smen

t of c

lean

lines

s of h

ospi

tal*

- Ver

y Hig

h Ri

sk a

reas

- Hig

h ris

k ar

eas

87%

95%

92%

94%

95%

n/a

n/a

n/a

n/a

24: P

erce

ntag

e of

com

plai

nts r

espo

nded

to w

ithin

agr

eed

times

cale

74.5

%90

%73

.6%

n/a

n/a

n/a

n/a

Defin

ition

s for

the

indi

cato

rs a

re in

clude

d in

Mon

itor’s

‘Risk

Ass

essm

ent F

ram

ewor

k’ (a

vaila

ble

on h

ttp://

ww

w.m

onito

r.gov

.uk/

raf).


40

Indicator 15 – Percentage of women who have seen a midwife or maternity healthcare professional within 12 weeks and six days of pregnancyThere is now an identified lead within the Clinical

Commissioning Group to work on this project.

This work includes proactive public engagement

through dissemination of information in public

venues such as children’s centres and public libraries

as well as potentially working with local shops that

sell pregnancy tests, offering leaflets with relevant

information around when and how to book to

encourage early engagement. This is an ongoing

piece of work which includes public health and the

Trust supporting the process.

Indicator 21 & 22 – Outpatient and Maternity local patient experience surveys There has been detailed examination of the key

issues identified by our patients when attending the

outpatients department during this past year. As a

result improvement actions have been implemented

across the various specialties. The department is now

piloting the FFT which will allow for more immediate

feedback from patients. As a result the local patient

experience survey has changed and reporting on this

will take place on a quarterly basis.

The Maternity Unit has continued to ensure that it

learns from women’s feedback on their experience

of maternity care. Engagement activities during

the year have included meeting with the Afghan

Women’s Group to better understand their needs

and their expectations of Maternity Services. Staff

have also been involved in presenting patient

stories at the Experience and Engagement Group.

Through the Maternity Services Liaison Committee

staff are receiving direct feedback of women’s

experience through the ‘Walk the Patch’ initiative.

For the forthcoming year the staff hope to engage

with the Travelling Community to understand their

experiences and expectations as well as being

involved in further future public engagement events.

The maternity unit has now been incorporated in to

the Friends and Family Test initiative.

The Trust achieved the target for 95% (all types)

of patients to have a total time in A&E of less than

four hours, with a mean performance throughout

the year of 96%. Initial performance was affected

by a challenging start to the year (April and May)

when the Trust did not meet the required standards.

An extensive review was undertaken and a number

of measures were introduced which improved

performance.

Additional winter funds were made available to the

A&E department for the final quarter of the year.

Extra medical, nursing and phlebotomy staff were

recruited. In addition, on site senior managerial

support was provided over the weekend. This had a

significant positive impact on performance, and the

Trust achieved 96.8% in quarter four.

The number of acutely unwell patients continued to

increase throughout the year. Between April 2013

and February 2014, 1,777 ‘blue light’ ambulances

attended the trust compared to 1,633 for the

same period last year. This represents an 8.8%

increase (144 attendances). Blue light ambulances

convey the sickest patients to the hospital who

require admission to the A&E resuscitation unit and

intensive support. It takes on average seven hours

to stabilise patients before they can be transferred

to another location in the hospital. On average 4.8

patients per day are treated in the resuscitation unit.

Despite the increase in the number of blue light

conveyances, non-elective (unplanned / emergency)

admissions are slightly down on the previous year.

During 2012-13 there were 23,672 non-elective

admissions compared to 23,442 for 2013-14. This

is equates to an average decrease of 4 admissions

per week.

Indicator 13 – Number of last minute elective operations cancelled for non-clinical reasons The total number of operations cancelled on the

day for non-clinical reasons was 203. The majority

of these cancellations were due to short notice

surgeon/anaesthetist illness.


41

• Continue to review improvement work at the

Safeguarding Committee, including action plans

based on patient and carer feedback, and work

collaboratively with the Community Learning

Disability Team.

Patient SafetyDuring 2013-14 we have undertaken targeted work

to reduce patient harms and we have achieved the

following improvements to ensure that we keep our

patients safe:

Indicator 23 – Independent assessment of cleanliness of hospitalThe monthly cleaning audits, local patient

satisfaction surveys and the Friends and Family Test

feedback has all indicated a significant improvement

in cleaning services during 2013-14. The cleaning

audits taking place during the latter part of the year

have been showing an average score of 95% each

month, which is in line with the standards expected

in the National Standards of Cleanliness in the NHS.

Indicator 24 – Percentage of complaints responded to within agreed timescalesIn 2013-14 the number of complaints due for

response was 405, compared to 503 in 2012-13;

this represents a reduction of 19%. The response

rate was 73.6% which means that 298 of the 405

complaints were answered within the timescale

agreed with the complainant.

It is important to note that the Complaints

Management Unit went through a period of

significant change this year, with the long term

Complaints Manager leaving, followed by the

two Complaints Administrators. Following a

new permanent appointment to the Complaints

Manager post in December 2013, enhanced

processes were established and new ways of

working introduced. An analysis of the performance

for the first three quarters of the year identified that

the complaints team was working on a ‘just in time’

basis. This meant that there was limited time to get

the response letters approved or to get additional

information if the reply was not complete. The new

Complaints Manager has implemented a number of

control measures in order to enhance performance

and support the divisions in meeting their deadlines.

The focus of these measures is twofold – timeliness

and quality of response. Performance improved in

March 2014 to 90.6%.

Indicator 25 The Tust continues to fully comply with the

requirements regarding access to healthcare for

people with a learning disability. The Trust intends to

take the following actions to maintain performance

on this indicator and so the quality of its services:

*Please note that the percentage shown is the overall percentage of harm free care, as measured by the Patient Safety Thermometer (PST), includes patients admitted into the Trust with pre-existing pressure ulcers, ‘old’ urinary tract infections (UTIs) in patients with catheters. Old UTIs are defined as those where treatment had started outside of the Trust and old VTE (defined as those where treatment for the VTE started outside of the Trust).

48% reduction in Clostridium difficile infections

94.5% of patients have received harm free care as measured by the PST*

National average is 93.1%

15.7% reduction in patient falls

38% reduction in patient falls resulting in a fracture

37% reduction in pressure ulcers as measured by the PST

Venous Thromboembolism (VTE) assessment compliance – 95.2%

Reducing patient harms – improving safety


42

0

5

10

15

20

25

30

35

40

2013

-14

2012

-13

2011

-12

2010

-11

2009

-10

2008

-09

2007

-08

2006

-07

2005

-06

2004

-05

2003

-04

24

30

24

38

30

17

10

4 41 1

for 2013-14. Whilst this is over NHS England’s zero

tolerance approach with a zero target, it is well

within the limit set by Monitor.

The one attributed case was complex with multiple

admissions across two acute trusts over a five month

period. Under the new MRSA infection review

system the case ultimately lies with the organisation

that has the most learning opportunities, and for

this case it was the acute sector across two trusts.

Due to the constraints of the new process only one

acute trust can be recorded and this is the one

where the blood culture was taken.

Clostridium difficile2013-14 was a challenge for the Trust as our

C. diff objective target reduced to 14 cases from

24 the previous year. Having finished the previous

year (2012-13) under the objective – with 23 cases

– achieving a reduction of nine further cases in one

year required a significant amount of attention. It

was therefore a major achievement to complete the

year reporting only 12 cases. This is a 48% reduction

in 12 months and a substantial accomplishment.

The trust had learnt through detailed investigation

in 2012-13 that for the previous 23 cases some

samples should not have been included for

testing. This was either due to the patient taking

laxatives or samples not taken early enough when

admitted with diarrhoea. Ongoing work from 2012-

A key part of ensuring a safety culture throughout

the organisation is to engage with staff – this is an

important part of our new clinical quality strategy.

Listening and learning from the multi-disciplinary

team is a key part of creating a strong culture of

openness and candour. As part of widening the

scope of engagement, the Medical and Nurse

Directors have scheduled meetings with junior

doctors, student nurses and therapists to gain a

granular understanding of how our organisation

can improve both patients and staff experience. In

2013-14 the Trust Board received feedback from

our junior doctors on how we could make further

improvements in our safety culture.

Through triangulating the themes that we have

amassed via complaints, feedback and surveys this

presents opportunities to conduct deep dives into

our services for patients. The Trust has just approved

for 2014, the implementation of Schwartz rounds

which will include executive leadership and enhance

ward to board feedback and action.

Infection Control Prevention and Control

MRSAThe Trust has sustained performance for a second

year reporting only one MRSA bloodstream infection

MRSA bloodstream infections


43

feedback enables our staff to gain a real insight into

the patient’s experience of care. We use a number

of different approaches, all of which provide us

with information about what we are doing well

and where we need to improve. These include:

• National and local surveys

• PALS concerns

• Compliments/Complaints

• Friends and Family Test

• Observations of Care.

What our patients have told us in our local surveys for inpatient care:

13 has therefore focused on staff understanding

when samples should be sent and clear

involvement with the clinical team.

A key development for this year has been a new

‘Bristol Stool Chart’. This new chart now includes

easy identification of those patients with a history of

bowel surgery or chronic bowel condition as well as

clear information on laxatives and their effectiveness.

Using this new chart is now standard practice across

the organisation and this has really supported clinical

decision making.

Work has also been ongoing on antimicrobial

prescribing and this year the organisation further

engaged senior colleagues with a ‘Start Smart Then

Focus’ action plan based on the Department of

Health guidelines. Antimicrobial performance was

also reviewed with a move from focusing on just

‘restricted’ antibiotics but to all other antibiotics and

the compliance to policy by specialty. This will be

reflected in audits undertaken by clinical teams in the

next year.

Patient Experience – Listening to our patientsWe aim to be a listening and learning organisation.

We want concerns that are raised by patients to be

understood, shared and responded to. Listening to

158

76

24 2325

12

0

20

40

60

80

100

120

140

160

2013-142012-132011-122010-112009-102008-09

Source: Local inpatient survey 2013-14 year end results

96% of our inpatients were treated with kindness and understanding

89% for communication, involvement and information

93% for our responsiveness to patient needs

Clostridium difficile toxin positive


44

• Overall, experience was very poor…very good

(score 1 very poor to 10 very good)

• Saw or was given information about how to

complain.

There were no significant deteriorations from last

year’s survey however our scores were lower in

seven questions:

• Privacy when being examined / treated in A&E

• Involved in decisions about care or treatment

• Anaesthetist explained how he/she would

anaesthetise and control pain

• Involved in decisions about discharge

• Given enough notice about discharge

• Told about medication side effects when

going home

• Given written and printed information

about medicines.

The Trust was worse than most other trusts

in only two questions:

• Privacy when being examined / treated in A&E

• Cleanliness of the room or ward.

National Patient SurveyA survey of inpatients is part of the annual

mandatory survey programme for acute trusts;

this assists organisations to find out about the

experience of patients when receiving care and

treatment at their hospitals. Between September

2013 and January 2014, a questionnaire was sent to

850 recent inpatients at each trust. Responses were

received from 344 patients that had been inpatients

in July 2013 at the Hillingdon Hospitals.

Based on the patients’ responses to the survey

the Trust scored ‘About the Same’ as most other

trusts that took part in the survey for all of the

key grouped sections of the survey. The Trust has

improved in 48 questions from the 2012 survey, and

has seen significantly higher scores (improvement) in

the following areas:

• Admission date changed by the hospital

• Feeling threatened whilst in hospital by other

patients or visitors

• Response to the call bell

• Hospital staff discussing adaptations required at

home after discharge

How we have responded to patient experience feedback

• Breakdown in communication about discharge plans

• We’ve revised discharge planning documentation

Complaint

• ‘I don’t always know what the uniforms mean’

• We’re creating uniform posters and information for the intranet to describe uniforms and roles

Observations of Care

• ‘It’s too bright and noisy at night’

• Comfort at Night campaign

• We’ve implemented a standard for lights out at night

Friends and Family Test

Listening and Improving


45

Historically, there has been a small year on year

improvement in the question about cleanliness of

the ward. It is disappointing that the result this year

still places us in a position that is worse than most

other trusts. However, following cleaning services

moving ‘in house’ there was a comprehensive review

of cleaning schedules and frequencies across all areas

of the Trust, with many areas having an increase in

cleaning input hours. This took shape from mid-

August 2013 and was refined through September

and October onwards which unfortunately was

after the sample period for this survey.

The monthly cleaning audits, local patient

satisfaction surveys and the Friends and Family Test

feedback has all indicated a significant improvement

in cleaning services since that time. The cleaning

audits taking place have been showing an average

score of 95% each month, which is in line with the

standards expected in the National Standards of

Cleanliness in the NHS.

The Board and the Trust’s Experience and

Engagement Group will be driving forward the

improvements that we expect to see in all areas that

are reflected in the National Patient Survey.

DETRACTORS PASSIVE

NET PROMOTER SCORE =% PROMOTERS – % DETRACTORS

PROMOTERS


46

November 2012Inpatients and A&E

Department

September 2013Maternity

May 2014Several Outpatients

and Day care settings

Friends and Family TestThe Friends and Family Test (FFT) provides a simple

way of gathering feedback about patient experience

to drive improvement. It is a simple standardised

question which asks patients to consider their recent

experience in the hospital and rate how likely they

would be to recommend that particular ward,

service or department to a friend or family member

if they required similar care or treatment.

The patient can choose from six responses ranging

from ‘extremely likely’ to ‘extremely unlikely’,

with a ‘don’t know’ option for those who remain

undecided. Most importantly we also ask patients

a further question: what was good about your

care, and what could be improved. The comments

received help us to gain an insight into the

experience and understand what really matters

to patients and identify areas for improvement.

To calculate the results we use a Net Promoter Score.

The idea is simple: if you like using a certain product

or doing business with a particular company you like

to share this experience From the answers given three

groups of people can be distinguished. These are:

• Promoters – people who have had an

experience which they would definitely

recommend to others

• Detractors – people who would probably

not recommend you based on their experience,

or couldn’t say

• Passive – people who may recommend you

but not strongly.

This gives a score of between -100 and +100,

with +100 being the best possible result.

The FFT has been implemented using a phased

approach. This is illustrated below.

During 2013-14 over 15,800 patients completed

an FFT survey.

Our March 2014 scores are set out below:

• The inpatient score was 71, this is based

on 557 responses

• The A&E score was 62, this is based on

419 responses

• The maternity score was 67, this is based

on 231 responses.

The overall Trust score for March 2014 was 67.


47

How do our FFT results compare with others?Our response rates are considerably higher

for both inpatient areas and A&E.

We do much better than the national and London

average in relation to fewer ‘extremely unlikely’ /

‘unlikely’ scores for both inpatient areas and A&E.

We have a higher number of ‘extremely likely’ / ‘likely’

responses for A&E however it is slightly lower than

national and London average for inpatient areas.

We do much better than the national and London

average in relation to fewer ‘extremely unlikely’ /

‘unlikely’ scores for both inpatient areas and A&E.

Response rates

Positive responses (extremely likely/likely)

Negative responses (extremely unlikely/unlikely)

0%National London THHFT

National London THHFT


10%

20%

30%

40%

50%

13%

87.3%

5.9%

29.1%

93.7%

1.7%

15.2%

88%

5.6%

31.3%

92.7%

2.1%

19.4%

88.7%

2.6%

42.8%

91.2%

1.5%

84%

86%

88%

90%

92%

94%

96%

0%

1%

2%

3%

4%

5%

6%

7%

Responserate AE

Responserate IP

Extremelylikely/likelyAE

Extremelylikely/likelyIP

Extremelyunlikely/unlikely AE

Extremelyunlikely/unlikely IP




10%

20%

30%

40%

50%

13%

87.3%

5.9%

29.1%

93.7%

1.7%

15.2%

88%

5.6%

31.3%

92.7%

2.1%

19.4%

88.7%

2.6%

42.8%

91.2%

1.5%

84%

86%

88%

90%

92%

94%

96%

0%

1%

2%

3%

4%

5%

6%

7%

Responserate AE

Responserate IP








10%

20%

30%

40%

50%

13%

87.3%

5.9%

29.1%

93.7%

1.7%

15.2%

88%

5.6%

31.3%

92.7%

2.1%

19.4%

88.7%

2.6%

42.8%

91.2%

1.5%

84%

86%

88%

90%

92%

94%

96%

0%

1%

2%

3%

4%

5%

6%

7%

Responserate AE

Responserate IP






48

Friends and Family Test

What patients have told us is good about their care

What patients have told us could be improved

“The midwives were polite and reassuring, if I had any worries or

concerns they helped me through them”

“The only thing that could be improved is the slamming of the

treatment room door, which shakes the whole

ward. When you are trying to get off to sleep

it is annoying”

“It would be helpful if patients could be

introduced to contacts when they come to the

bedside”

“My partner had to wait for an hour before being

told where I had been moved to, after he was asked to leave whilst I was being examined”

“Smiling, welcoming faces that are caring and provide

personal care by listening and knowing the patient rather

than treating me like a robot”

“Everything was perfect, the treatment and the

information given by the doctor. I felt that I am in

safe hands”

ActionOur estates team have checked the

door and made some adjustments to reduce the noise

ActionWe are going to support a national

campaign locally by encouraging our staff to start every contact with a patient by

introducing themselves by name and role

ActionStaff have been reminded of the

importance of keeping family members informed in these circumstances


49

We acknowledge the progress made to date on specific

goals for 2013-14 and the areas of underperformance

but would like to emphasise that these still remain areas

of focus and priority in the forthcoming year. In particular

the consultant review within 12 hours of decision to

wait, the reduction of HSMR to London average and

continuing to embed the culture and values framework.

We would like to commend the work being undertaken

in relation to the reduction in HSMR for weekend

mortality and look forward to seeing a continuation of

this improvement work during 2014-15 in relation to

implementing the London Quality Standards.

We acknowledge 100% participation in the National

Clinical Audit Programme and the commitment to

research as a driver for improving the quality of care

and patient experience.

We also recognise some of the challenges the Trust faces

with the fabric and estate and how this impacts on the

quality of our care for patients and how Estates have

been working hard to address some of these issues.

We are very happy to work collaboratively with you to

help shape how we move the quality agenda forward

both from a commissioner and provider perspective.

Given the publication of the Francis Inquiry and

subsequent Berwick, Keogh and Cavendish reports

clearly our agendas will continue to evolve further

as we embed the recommendations.

Overall we welcome the vision described within the

Quality Account, agree on the priority areas and will

continue to work with the Trust to continually improve

the quality of services provided to patients.

We look forward to receiving the final version

which will include an easy read format.

Yours sincerely,

Dr Ian GoodmanChair Hillingdon CCG

16th May 2014

Annex 1 Statements from our stakeholders

Statement from Hillingdon Clinical Commissioning Group (CCG)

The Hillingdon Clinical Commissioning Group

welcomes the opportunity to provide this statement

on The Hillingdon Hospitals NHS Foundation

Trust Quality Accounts. We confirm that we have

reviewed the information contained within the

Account and checked this against data sources

where this is available to us as part of existing

contract/performance monitoring discussions and

is accurate in relation to the services provided.

This Quality Account has been reviewed within

Hillingdon Clinical Commissioning Group and by

colleagues in the Brent Harrow Hillingdon (BHH)

Federation of Clinical Commissioning Groups

and NHS North West London Commissioning

Support Unit.

We have reviewed the content of the Quality

Account and confirm that this complies with the

prescribed information, form and content as set out

by the Department of Health. We believe that the

Account represents a fair and robust summary of

the overview of the quality of care at the Trust for

the services covered in the report.

We have taken particular account of the identified

priorities for improvement for the Trust and how this

work will enable real focus on improving the quality

and safety of health services for our local population.

We agree with the priorities for improvement and

particularly welcome a focus on improving patient

safety in Emergency and Maternity care, embedding

patient care bundles and pathways and an improved

responsiveness to patient need.

We are pleased to see the development of a new

Clinical Strategy and look forward to reviewing how

this is being embedded in the coming year. We

welcome the focus within this Strategy on the Trust’s

approach to safety and compassion in care.


50

were perhaps overly ambitious and this has

been taken into account in our assessment

of this year’s performance.

The Trust should be congratulated on those priorities

where it has clearly shown improvement this year.

We are particularly delighted to see the joint work

with Age UK and community services, which has led

to a reduced length of stay for elderly patients.

Whilst there is some reference to 12-13 versus

13-14 performance in the Quality Report, this is

mainly in relation to national CQUINs, or other

national targets rather than the local targets. As

the quality account reporting process is now well

established and previous data is available, we feel it

would be helpful for the general public to now see

performance over time which would demonstrate

continuous improvement. This would be specifically

useful where the priorities are part of a long term

programme, such as the First Contact project which

has been a priority for the last 3 years. We would

suggest this could be achieved by publishing a table

outlining 11-12, 12-13 and 13-14 performance,

with 14-15 targets. This would give a clear and

easily understood view of performance over time,

and would demonstrate continuity, consistency

and where progress has been made.

We support the Trust in their choice of 2014-15

quality priorities and thank them for taking into

account the views of Healthwatch and the wider

public membership. Having previously indicated that

last year we questioned the ambitiousness of some

of the targets and the affect this would have on

patient expectation, this year we feel the opposite

has happened. Some set targets seem easily

obtainable, such as discharging at least 1 patient

from each acute inpatient ward area before 12pm.

We would like to see realistic targets set that are

neither easily achieved, nor totally unattainable.

Healthwatch Hillingdon look forward to continuing

the relationship we have with the Trust and working

with them, through a joint commitment, to focus

on the monitoring and improving of quality. We are

especially pleased about two initiatives agreed with

Statement from our local HealthWatch

IntroductionHealthwatch Hillingdon wishes to thank the Trust for

the opportunity to comment on the Trust’s Quality

Report for the year 2013-14.

Healthwatch Hillingdon has a close working

partnership with the Trust. We welcome their

continued commitment to engage with us and the

value the Trust places upon our relationship. We

meet regularly with The Chief Executive Officer, the

Chair and Director of Nursing of the Trust, are lead

assessors for the Patient Led Assessment of the Care

Environment, and Healthwatch representatives sit on

a number of important groups to monitor patient

experience and quality.

Through our work we have witnessed and

acknowledge the Trust’s commitment to improve the

quality of the services they provide and their desire

to have a positive impact upon the experiences of

their patients.

Quality ReportIn the main, Healthwatch Hillingdon found this year’s

Quality Report, well set out, logical and easy to read.

It is an honest and balanced assessment of the Trust’s

performance on the quality of their services.

We are again pleased that the Trust has been candid

in its reporting, acknowledging that although

there are many areas in which they have shown

improvement, they have recognised where targets

have not been met and have committed to making

further improvements through their 2014-15

priorities. We are however uncomfortable with

the use of the label “partially achieved”. This term

does not give a clear indication to the public of

achievement and although the Trust has been frank

in giving a full explanation where targets were not

fully achieved, it was felt that for some targets,

“not achieved” would be a fairer reflection of

accomplishment. We would however acknowledge

that in our response to last year’s quality report we

did indicate that some of the targets set by The Trust


51

for its work to improve weekend emergency

HSMR (Hospital Standardised Mortality Ratio) from

2011-12 to 2012-13 whilst also maintaining overall

performance.

Although it is understood that the format

and content of the Quality Report is largely

predetermined, the Committee believes that it

would benefit from a simpler configuration to

ensure that it is more easily read and understood.

For example, the data contained within the report

which illustrates what the Trust has achieved in

comparison to its targets (and supported by a

commentary) is not set out as simply as

it could be.

The Trust’s five Quality Priorities during

2013-14 were:

1. The First Contact Project – improving the

outpatient experience

2. Improving people’s experience of leaving

hospital / improving inpatient care

3. Improving emergency care

4. CQUINS (Commissioning for Quality and

Innovation)

5. Embedding out culture and values

framework – CARES

the Trust for 2014, which will see us work together

to look at the quality of mealtime provision, through

the Patient Assessment of the Care Environment

programme and quarterly scheduled meetings,

which will review the progress of quality priorities

and take an overview of quality through the

evaluation and comparison of patient experience,

complaints, and friends and family data.

Graham HawkesChief Executive Officer

Healthwatch Hillingdon

9th May 2014

Statement from External Services Scrutiny Committee

Response on behalf of the External Services Scrutiny Committee at the London Borough of HillingdonThe External Services Scrutiny Committee

welcomes the opportunity to comment on the

Trust’s 2013-14 Quality Report and acknowledges

the Trust’s commitment to attend its meetings

when requested. The Committee is particularly

pleased to note that the Trust has been highly

commended in the Dr Foster Hospital Guide 2013


52

It is noted that the Trust has developed five key

areas for improvement in 2014-15 on which the

following draft Quality Priorities for 2014-15

have been based:

1. Continuing to improve the outpatient experience

2. Continuing with the improving inpatient care

project

3. Improving patient safety in emergency and

maternity care

4. Introducing and embedding patient care

bundles / pathways

5. Improve responsiveness to patient needs

Looking forward, improvements to the outpatient

and inpatient experiences have been deemed

important enough to again be included in this year’s

priorities. The Committee welcomes this move and

looks forward to seeing improvements over the next

year. Overall, the Committee is pleased with the

continued progress that the Trust has made over the

last year but notes that there are a number of areas

where further improvements still need to be made.

We look forward to being updated on the progress

of the implementation of priorities outlined in the

Quality Report over the course of 2014-15 and

the impact that the Clinical Quality Strategy has

in supporting the delivery of high quality care.

Although the Committee recognises the amount of

work that has been undertaken by the Trust over

the last year with regard to achieving its Quality

Priority targets, it is disappointing to note that none

of them had been achieved in full (all five priorities

had resulted in ‘partial achievement’ overall).

However, the Trust’s achievements with regard to

the reduction of mortality rates and Health Care

Associated Infections should be celebrated.

Insofar as The First Contact Project is concerned,

it is noted that the Call Management System that

was introduced in June 2012 has needed further

development over the last year. However, the

Committee is disappointed to note that the call

abandonment rate for outpatient appointment

queries was 12% (missing the target of 10%).

Furthermore, only 75% of calls were answered

within 1 minute (the target was 95%) and just

90% were answered within 2 minutes. As such, the

Committee is reassured to note that improvements

to the outpatient experience will continue to be a

priority for the Trust over the next year and we look

forward to seeing significant improvements.

The Committee is pleased to note that, following

an audit and the identification of work stream

improvements, work will continue during

2014-2015 to reduce the number of avoidable

readmissions. Despite aiming to reduce readmissions

over the last three years, these have remained

fairly static: 7.5% in 2011-12; 7.8%

in 2012-13; and 7.6% in 2013-14.

We would like to congratulate the Trust on

achieving a 19.8% response rate for the Friends

and Family Test (FFT) within the A&E Department

between April 2013 and February 2014 (the target

was 15%) – this is a vast improvement on the

8% response rate in 2011-12. It is noted that FFT

will be rolled out to Outpatients and Day Care

settings during 2014-15 and it is hoped that a good

response rate will be achieved in these areas.


53

within the report; this also allows patients to see

our performance over time on some of our local

indicators, where this information is available. It is

hoped that this will also address a concern raised

from the External Services Scrutiny Committee on

presentation of the information and readability.

Our commissioners and the External Services

Scrutiny Committee have recognised and

commended our work to improve weekend

emergency HSMR (Hospital Standardised Mortality

Ratio) whilst also maintaining overall performance,

and our commitment to deliver improvements

in Maternity and Emergency Care in relation to

the London Quality Standards. It has also been

acknowledged that there is a firm commitment

once again this year to continue to improve the

patient’s experience of care, having made good

improvements on this in 2013-14 in the National

Patient Survey, the Friends and Family Test and

our local patient experience surveys.

Our stakeholders have recognised that we have

presented an honest and robust summary of

the overview of quality of care at the Trust,

acknowledging, alongside our achievements, that

some targets have not been met and that we

are committed to making further improvements

in 2014-15. This was taken as feedback from

Healthwatch in last year’s report. This year we

have been very thorough in our assessment of our

current position in relation to the priorities we have

set and have endeavoured to set realistic goals

that are both achievable but also stretching. Our

local Healthwatch rightly noted that a target of

discharging one patient per ward before midday as

part of the Improving Inpatient Care Project did not

appear very ambitious – this has been amended in

the report to ensure the percentage of patients that

we aim to discharge by midday as part of our overall

patient discharges per day is clear.

We look forward to continuing our very positive

working relationships with our key stakeholders to

support the delivery of improved quality of care and

patient experience, and in particular working with

Healthwatch on the Patient Led Assessment of the

The Hillingdon Hospitals NHS Foundation Trust response to the consultation

The Hillingdon Hospital NHS Foundation Trust

thanks all its stakeholders for their comments

about the 2013-14 Quality Report.

The Trust is pleased that our key stakeholders

recognise the trust’s commitment to improve the

quality of the care and services that we provide

and to work closely with them in achieving further

improvement. The Trust enjoys a good working

relationship with both Healthwatch and with the

Hillingdon Clinical Commissioning Group and it

looks forward to further collaborative working to

help shape the quality agenda and the delivery of

safe, high quality care.

The Trust is also pleased that its key stakeholders are

in agreement with its quality priorities for 2014-15,

recognising where we have made good progress

in quality improvement across a range of quality

indicators and also where further work needs to be

driven forward to realise the expected outcomes

that we wish to achieve. The Trust has taken

comments on board as part of the consultation for

the Quality Report and as such these are aligned

with our partners’ views on where we need to

focus our efforts. These are recognised by our

key stakeholders and it is very positive that both

Healthwatch and our local commissioners wish to

continue to work closely with us on projects such

as the ‘Accessible and Response Services project –

continuing to improve the outpatient experience’

and more generally on the monitoring and

improving of quality.

The trust acknowledges the feedback from

Healthwatch on the categorisation of achievement

for the quality priorities for 2013-14 (achieved;

partially achieved and not achieved) and as such

has reviewed the presentation, so that it is not

confusing to our patients and the public as to how

we have performed. To help understand the Trust’s

position information has now also been included

in simple tables to reduce some of the narrative


54

even more robust and inclusive approach for next

year – our aim will be to host a large stakeholder

event earlier on in the process so that we can ensure

wide engagement and have the opportunity of

following up on the outputs from the event in a

planned and timely way.

Care Environment and a quarterly review of quality data

so that progress of the quality priorities can be reviewed

and an overview of quality provided.

We are keen to learn from our consultation exercise on

the Quality Report for this year so that we can have an


55

We refer to these national priority indicators

collectively as the ‘indicators’.

Respective responsibilities of the directors and auditorsThe directors are responsible for the content and

the preparation of the quality report in accordance

with the criteria set out in the NHS Foundation Trust

Annual Reporting Manual issued by Monitor.

Our responsibility is to form a conclusion, based

on limited assurance procedures, on whether

anything has come to our attention that causes

us to believe that:

• the quality report is not prepared in all material

respects in line with the criteria set out in the

NHS Foundation Trust Annual Reporting Manual;

• the quality report is not consistent in all material

respects with the sources specified in the

Detailed Guidance for External Assurance on

Quality Reports; and

• the indicators in the quality report identified as

having been the subject of limited assurance in

the quality report are not reasonably stated in

all material respects in accordance with the NHS

Foundation Trust Annual Reporting Manual and

the six dimensions of data quality set out in the


Quality Reports.

We read the quality report and consider whether

it addresses the content requirements of the NHS

Foundation Trust Annual Reporting Manual, and

consider the implications for our report if we

become aware of any material omissions.

We read the other information contained in the

quality report and consider whether it is materially

inconsistent with:

• board minutes for the period April 2013 to 27

May 2014;

• papers relating to quality reported to the board

over the period April 2013 to 23 May 2014;

• feedback from the Commissioners;

• the 2013 national staff survey;

• Care Quality Commission quality and risk

profiles;

Independent Auditor’s Report to the Council of Governors of The Hillingdon Hospitals NHS Foundation Trust on the Quality Report

We have been engaged by the Council of Governors

of The Hillingdon Hospitals NHS Foundation Trust to

perform an independent assurance engagement in

respect of The Hillingdon Hospitals NHS Foundation

Trust’s Quality Report for the year ended 31st March

2014 (the ‘Quality Report’) and certain performance

indicators contained therein.

This report, including the conclusion, has been

prepared solely for the Council of Governors of The

Hillingdon Hospitals NHS Foundation Trust as a body,

to assist the Council of Governors in reporting The

Hillingdon Hospitals NHS Foundation Trust’s quality

agenda, performance and activities. We permit the

disclosure of this report within the Annual Report

for the year ended 31st March 2014, to enable the

Council of Governors to demonstrate they have

discharged their governance responsibilities by

commissioning an independent assurance report in

connection with the indicators. To the fullest extent

permitted by law, we do not accept or assume

responsibility to anyone other than the Council of

Governors as a body and The Hillingdon Hospitals

NHS Foundation Trust for our work or this report,

except where terms are expressly agreed and with

our prior consent in writing.

Scope and subject matterThe indicators for the year ended 31st March 2014

subject to limited assurance consist of the national

priority indicators as mandated by Monitor:

• Number of clostridium difficile infections

reported; and

• Maximum 31 day cancer waiting time from

Decision to Treat a Cancer diagnosed patient to

the beginning of treatment (first day definitive

treatment).


56

LimitationsNon-financial performance information is subject to

more inherent limitations than financial information,

given the characteristics of the subject matter and

the methods used for determining such information.

The absence of a significant body of established

practice on which to draw allows for the selection

of different, but acceptable measurement

techniques which can result in materially different

measurements and can affect 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 of these

criteria, may change over time. It is important to

read the quality report in the context of the

criteria set out in the NHS Foundation Trust

Annual Reporting Manual.

The scope of our assurance work has not included

governance over quality or non-mandated indicators

which have been determined locally by The

Hillingdon Hospitals NHS Foundation Trust.

ConclusionBased on the results of our procedures, nothing has

come to our attention that causes us to believe that,

for the year ended 31 March 2014:

• the quality report is not prepared in all material

respects in line with the criteria set out in the

NHS Foundation Trust Annual Reporting Manual;

• the quality report is not consistent in all material

respects with the sources specified in the


Quality Reports; and

• the indicators in the quality report subject to

limited assurance have not been reasonably stated

in all material respects in accordance with the

NHS Foundation Trust Annual Reporting Manual.

Deloitte LLPChartered Accountants

St Albans

29th May 2014

• Care Quality Commission intelligent monitoring;

• the Head of Internal Audit’s annual opinion

over the trust’s control environment dated

27 May 2014; and

• any other information included in our review.

We consider the implications for our report if we

become aware of any apparent misstatements or

material inconsistencies with those documents

(collectively the ‘documents’). Our responsibilities

do not extend to any other information.

We are in compliance with the applicable

independence and competency requirements of

the Institute of Chartered Accountants in England

and Wales (ICAEW) Code of Ethics. Our team

comprised assurance practitioners and relevant

subject matter experts.

Assurance work performedWe conducted this limited assurance engagement

in accordance with International Standard

on Assurance Engagements 3000 (Revised) –

‘Assurance Engagements other than Audits or

Reviews of Historical Financial Information’ issued by

the International Auditing and Assurance Standards

Board (‘ISAE 3000’). Our limited assurance

procedures included:

• Evaluating the design and implementation of the

key processes and controls for managing and

reporting the indicators.

• Making enquiries of management.

• Testing key management controls.

• Limited testing, on a selective basis, of the

data used to calculate the indicator back to

supporting documentation.

• Comparing the content requirements of the NHS

Foundation Trust Annual Reporting Manual to

the categories reported in the quality report.

• Reading the documents.

A limited assurance engagement is smaller in

scope than a reasonable assurance engagement.

The nature, timing and extent of procedures

for gathering sufficient appropriate evidence

are deliberately limited relative to a reasonable

assurance engagement.


57

– The Head of Internal Audit’s annual opinion

over the Trust’s control environment dated

April 2014

– CQC Quality and Risk Profiles dated from 1

April 2013 to 31 March 2014.

• The Quality Report presents a balanced picture

of the NHS Foundation Trust’s performance over

the period covered;

• The performance information reported in the

Quality Report is reliable and accurate;

• There are proper internal controls over the

collection and reporting of the measures of

performance included in the Quality Report, and

these controls are subject to review to confirm

that they are working effectively in practice;

• The data underpinning the measures of

performance reported in the Quality Report is

robust and reliable, conforms to specified data

quality standards and prescribed definitions, is

subject to appropriate scrutiny and review; and

• The Quality Report has been prepared in

accordance with Monitor’s annual reporting

guidance (which incorporates the Quality

Accounts Regulations) as well as the standards

to support data quality for the preparation of the

Quality Report (available at www.monitor.gov.

uk/annualreportingmanual).

The Directors confirm to the best of their knowledge

and belief they have complied with the above

requirement in preparing the Quality Report.

By order of the Board

Shane DeGarisChief Executive

28th May 2014

James ReidInterim Chair

28th May 2014

Annex 2 Statement of Directors’ responsibilities in respect of the Quality Report

The Directors are required under the Health Act

2009 and the National Health Service (Quality

Accounts) Regulations 2010 as amended to prepare

Quality Accounts for each financial year.

Monitor has issued guidance to NHS Foundation

Trust Boards on the form and content of Annual

Quality Reports (which incorporate the above legal

requirements) and on the arrangements that NHS

Foundation Trust Boards should put in place to

support the data quality for the preparation of the

Quality Report.

In preparing the Quality Report, Directors are

required to take steps to satisfy themselves that:

• The content of the Quality Report meets the

requirements set out in the NHS Foundation

Trust Annual Reporting Manual 2013-14;

• The content of the Quality Report is not

inconsistent with internal and external sources of

information including:

– Board minutes and papers for the period

April 2013 to May 2014

– Papers relating to quality reported to the

Board over the period April 2013 to

May 2014

– Feedback from the Commissioners dated

16th May 2014

– Feedback from the Governors dated

28th April 2014

– Feedback from Healthwatch dated 9th May

2014

– The Trust’s Complaints Report published

under Regulation 18 of the Local Authority

Social Services and NHS Complaints

Regulations 2009, dated 28th May 2014

– The latest national patient survey published

8th April 2014

– The latest national staff survey 25th February

2014


58

Glossary

A

Ambulatory Care Pathway Allows patients who are safe to go home be managed promptly as

outpatients, without the need for admission to hospital, following an

agreed plan of care for certain conditions.

B

Berwick Review Commissioned following the Mid Staffordshire Hospitals enquiry and

publication of the Francis Report. The review includes recommendations to

ensure a robust nationwide system for patient safety.

C

Call Management System (CMS) A database, administration, and reporting application designed for complex

contact centre operations with high call volume.

Care Pathway Anticipated care placed in an appropriate time frame which is written and

agreed by a multidisciplinary team.

Care Quality Commission (CQC) The independent regulator of health and social care in England.

www.cqc.org.uk

Care Quality Commission (CQC)

Intelligent Monitoring System

A form of monitoring to give CQC inspectors a clear picture of the areas of

care that need to be followed up within an NHS acute trust. Together with

local information from partners and the public, this monitoring helps the

CQC to decide when, where and what to inspect. 160 acute NHS trusts are

grouped into six priority bands for inspection based on the likelihood that

people may not be receiving safe, effective, high quality care. Band 1 is the

highest priority trusts and band 6 the lowest.

Cellulitis Cellulitis is an infection of the skin and the tissues just below the skin

surface. Any area of the skin can be affected but the leg is the most

common site.

Clinical audit A quality improvement process that seeks to improve patient care and

outcomes by measuring the quality of care and services against agreed

standards and making improvements where necessary.

Clinical Negligence Scheme for

Trusts (CNST) – Maternity

Administered by the NHS Litigation Authority (NHSLA), provides an

indemnity to members / their employees in respect of clinical negligence

claims. Trusts are assessed on their level of risk management against

detailed standards.

Clostridium Difficile infection A type of infection that occurs in the bowel that can be fatal. There is a

national indicator to measure the number of C. Difficile infections that

occur in hospital.

Comfort at Night campaign This campaign supports reducing disturbances at night and includes

increasing staff awareness of the issue and changing staff attitude ensuring

that essential nursing and midwifery standards are applied.


59

Commissioning for Quality and

Innovation (CQUIN)

A payment framework enabling commissioners to reward quality by linking

a proportion of the trust’s income to the achievement of local quality

improvement goals.

Community Acquired

Pneumonia

Inflammatory condition of the lung usually caused by infection and acquired

from normal social contact (that is, in the community) as opposed to being

acquired during hospitalisation.

D

Department of Health (DH) The government department that provides strategic leadership to the NHS

and social care organisations in England. www.dh.gov.uk

Dr Foster An organisation that provides healthcare information enabling healthcare

organisations to benchmark and monitor performance against key

indicators of quality and efficiency.

E

Eighteen (18) week wait A national target to ensure that no patient waits more than 18 weeks from

GP referral to treatment. It is designed to improve patients’ experience of

the NHS, delivering quality care without unnecessary delays.

Electronic Document Records

System

This helps the trust to manage clinical records in electronic format making

records management more efficient and ensuring patient records are more

accessible to clinicians.

F

FAIR assessment for dementia Find, Assess, Investigate and Refer (FAIR) - The identification of patients

with dementia and other causes of cognitive impairment that prompts

appropriate referral and follow up after they leave hospital and ensures that

hospitals deliver high quality care to people with dementia and support

their carers.

Foundation Trust (FT) NHS foundation trusts were created to devolve decision making from

central government to local organisations and communities. They still

provide and develop health care according to core NHS principles - free

care, based on need and not ability to pay.

Friends and Family Test (FFT) An opportunity for patients to provide feedback on the care and treatment

they receive. Introduced in 2013 the survey asks patients whether they

would recommend hospital wards, A&E departments and maternity services

to their friends and family if they needed similar care or treatment.

G

‘Getting it right first time’ (GIRFT) The ‘Getting it right first time’ (GIRFT) report published by Professor Briggs

in late 2012, considered the current state of England’s orthopaedic surgery

provision and suggested that changes can be made to improve pathways of

care, patient experience, and outcomes with significant cost savings.

Governors The Hillingdon Hospitals NHS Foundation Trust has a Council of Governors.

Governors are central to the local accountability of our foundation trust and

helps ensure the trust board takes account of members and stakeholders

views when making important decisions.


60

GP Commissioners GP Commissioners are responsible for ensuring adequate services are

available for their local population by assessing needs and purchasing

services.

H

Health and Social Care

Information centre (HSCIC)

The HSCIC is an Executive Non Departmental Public Body (ENDPB) set up

in April 2013. It collects, analyses and presents national health and social

care data helping health and care organisations to assess their performance

compared to other organisations.

Healthwatch (formerly LINk) Healthwatch is a new independent consumer champion that gathers and

represents the views of the public about health and social care services in

England. http://www.healthwatch.co.uk

Hospital Episode Statistics (HES) The national statistical data warehouse for the NHS in England. ‘HES’

is the data source for a wide range of healthcare analysis for the NHS,

government and many other organisations.

Hospital Standardised Mortality

Ratio (HSMR)

A national indicator that compares the actual number of deaths against

the expected number of deaths in each hospital and then compares Trusts

against a national average.

I

Indicator A measure that determines whether the goal or an element of the goal has

been achieved.

Inpatient A patient who is admitted to a ward and staying in the hospital.

Inpatient Survey An annual, national survey of the experiences of patients who have stayed

in hospital. All NHS trusts are required to participate.

K

Keogh Review A review of the quality of care and treatment provided by those NHS

trusts and NHS foundation trusts that were persistent outliers on mortality

indicators. A total of 14 hospital trusts were investigated as part of this

review.

L

Local Clinical Audit A type of quality improvement project involving individual healthcare

professionals evaluating aspects of care that they themselves have selected

as being important to them and/or their team.

London Health Programme

Standards

Programme to improve the quality and safety of acute emergency and

maternity services based on achieving key standards of practice.

M

Monitor The independent regulator of NHS foundation trusts.

http://www.monitor.gov.uk

Multidisciplinary team meeting

(MDT)

A meeting involving healthcare professionals with different areas of

expertise to discuss and plan the care and treatment of specific patients.

Meticillin-resistant

staphylococcus aureus (MRSA)

A type of infection that can be fatal. There is a national indicator to

measure the number of MRSA infections that occur in hospitals.


61

N

National Clinical Audit A clinical audit that engages healthcare professionals across England and

Wales in the systematic evaluation of their clinical practice against standards

and to support and encourage improvement and deliver better outcomes in

the quality of treatment and care.

The priorities for national audits are set centrally by the Department of

Health and all NHS trusts are expected to participate in the national audit

programme.

National Reporting and Learning

System (NRLS)

The National Reporting and Learning System (NRLS) is a central database

of patient safety incident reports submitted from health care organisations.

Since the NRLS was set up in 2003, over four million incident reports have

been submitted. All information submitted is analysed to identify hazards,

risks and opportunities to continuously improve the safety of patient care.

Never events Never events are serious, largely preventable patient safety incidents

that should not occur if the available preventative measures have been

implemented. Trusts are required to report nationally if a never event occurs.

NHS Litigation Authority (NHSLA) Established to indemnify NHS trusts in respect of both clinical negligence

and non-clinical risks. It manages both claims and litigation and has

established risk management programmes against which NHS trusts are

assessed.

NHS number A 12 digit number that is unique to an individual, and can be used to track

NHS patients between organisations and different areas of the country. Use

of the NHS number should ensure continuity of care.

O

Operating Framework An NHS-wide document outlining the business and planning arrangements

for the NHS. It describes the national priorities, system levers and enablers

needed to build strong foundations whilst keeping tight financial control.

Outpatient A patient who goes to a hospital and is seen by a doctor or nurse in a clinic,

but is not admitted to a ward and is not staying in this hospital.

Overview and Scrutiny

Committee (OSC)

OSC looks at the work of NHS trusts and acts as a ‘critical friend’ by

suggesting ways that health-related services might be improved. It also

looks at the way the health service interacts with social care services, the

voluntary sector, independent providers and other Council services to jointly

provide better health services to meet the diverse needs of the area.

P

PAS – Patient Administration

System

The system used across the trust to electronically record patient information

e.g. contact details, appointment, admissions.

Pressure ulcers Sores that develop from sustained pressure on a particular point of the

body. Pressure ulcers are more common in patients than in people who are

fit and well, as patients are often not able to move about as normal.


62

Priorities for improvement There is a national requirement for trusts to select three to five priorities

for quality improvement each year. This must reflect the three key areas of

patient safety, patient experience and patient outcomes.

PROMs (Patient Reported

Outcome Measures)

PROMs collect information on the effectiveness of care delivered to NHS

patients as perceived by the patients themselves. Hospitals providing four

key elective surgeries invite patients to complete questionnaires before and

after their surgery The PROMs programme covers four common elective

surgical procedures: groin hernia operations, hip replacements, knee

replacements and varicose vein operations.

Pulmonary Embolism (PE) A blood clot in the lung.

Pyelonephritis A kidney infection that can cause an unpleasant illness which is sometimes

serious.

R

Re-admissions A national indicator. Assesses the number of patients who have to go back

to hospital within 30 days of discharge from hospital.

Root Cause Analysis (RCA) A method of problem solving that looks deeper into problems to identify

the root causes and find out why they’re happening.

S

Safety Thermometer The NHS Safety Thermometer is a local improvement tool for measuring,

monitoring and analysing patient harms and ‘harm free’ care. http://www.

hscic.gov.uk/thermometer

Schwartz Round This offers healthcare staff scheduled time to openly and honestly discuss

the social and emotional issues they face in caring for patients and families.

Secondary Uses Service (SUS) A national NHS database of activity in trusts, used for performance

monitoring, reconciliation and payments.

Sepsis A potentially fatal whole-body inflammation (a systemic inflammatory

response syndrome) caused by severe infection.

Serious Incidents An incident requiring investigation that results in one of the following:

• Unexpected or avoidable death

• Serious harm

• Prevents an organisation’s ability to continue to deliver healthcare services

• Allegations of abuse

• Adverse media coverage or public concern

• Never events.

Shaping a Healthier Future

(SaHF)

A programme to improve NHS services for people who live in North West

London bringing as much care as possible nearer to patients. It includes

centralising specialist hospital care onto specific sites so that more expertise

is available more of the time; and incorporating this into one co-ordinated

system of care so that all the organisations and facilities involved in caring

for patients can deliver high-quality care and an excellent experience.


63

Single sex accommodation A national indicator which monitors whether ward accommodation has

been segregated by gender.

Summary Hospital-level Mortality

Indicator (SHMI)

The Summary Hospital-level Mortality Indicator (SHMI) is an indicator which

reports on mortality at trust level across the NHS in England. The SHMI

is the ratio between the actual number of patients who die following

hospitalisation at the trust and the number that would be expected to die

on the basis of average England figures, given the characteristics of the

patients treated there.

V

Venous thromboembolism (VTE) An umbrella term to describe venous thrombus and pulmonary embolism.

Venous thrombus is a blood clot in a vein (often leg or pelvis) and a

pulmonary embolism is a blood clot in the lung. There is a national indicator

to monitor the number of patients admitted to hospital who have had an

assessment made of the risk of them developing a VTE.

Languages/ Alternative Formats

Please call the Patient Advice and Liaison Service (PALS) if you require this information in

other languages, large print or audio format on: 01895 279973. www.thh.nhs.uk

Languages/ Alternative Formats Please ask if you require this information in other languages, large print or audio format. Please contact: 01895 279973 Fadlan waydii haddii aad warbixintan ku rabto luqad ama hab kale. Fadlan la xidhiidh 01895 279 973

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