KF4 Effective team working 3.85 3.74 Highest (best) 20% KF6 Percentage of staff receiving training, learning or development in the last 12 months 85% 81% Highest (best) 20% KF27 Percentage of believing the trust provides equal opportunities for career progression or promotion 91% 87% Highest (best) 20% KF28 Percentage of staff experiencing discrimination at work in the last 12 months 9% 11% Lowest (best) 20% KF7 Percentage of staff appraised in the last 12 months 89% 85% Above (better than) average Bottom 5 Ranking Scores– compared to other acute Trusts in England Key Finding Score 2014 National Average Ranking KF3* Work pressure felt by staff 3.20 3.07 Highest (worst) 20% KF12* Percentage of staff witnessing potentially harmful errors, near misses or incidents in the last month 44% 34% Highest 20% KF16* Percentage of staff experiencing physical violence from patients, relatives or the public in the last 12 months 19% 14% Highest (worst) 20% KF17* Percentage of staff experiencing physical violence from staff in the last 12 months 4% 3% Highest (worst) 20% KF18* Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in the last 12 months 34% 29% Highest (worst) 20% relevant
AFFINITE National audit of blood transfusion practice 1 (RAFT) Reducing Arthritis Fatigue Rheumatoid arthritis research 33 A national survey of patient reported outcome anaesthesia Research into patients experience of their anaesthetic 29 Access to Cancer Therapies (ACT) Patients experiences of using the cancer drugs fund 10 At Risk - Fabry Research into a very rare genetic condition 2 Attitudes and beliefs surrounding the fertility issues of young women with breast cancer Exploring the consequences for their fertility of women following breast cancer treatment 1 Biliary Cancer QoL Validation Validating a quality of life questionnaire 1 Bridging the Age Gap in Breast Cancer Breast cancer study for ladies over 70 10 BSRBR-AS Registry for people with Ankylosing Spondylitis 1 ChOPIN For patients with a range of problems that lead to oesophageal cancer 2 COCO90s Involving people in the children of the 90's study who are now having children of their own 3 Computerised Adaptive Testing for EORTC QLQ-C30 Validating a series of quality of life questionnaires 169 CUP ONE For patients with cancer for whom the type of primary tumour is unknown 4 Developing and testing a new RA stiffness PROM For patients with rheumatoid arthritis 12 DRN 552 (Incident and high risk type 1 diabetes cohort - ADDRESS-2) Research for people with type 1 diabetes and their siblings 4 DRN100 (TrialNet) Research for people with type 1 diabetes and their children 1 EMR200592-001 (MAESTRO) Researching a new drug for patients with pancreatic cancer 1
In 2014/15 we said our No. 3 goal was: Infection control. This has been a Quality Priority for the last four years because it has such a high impact on patient safety. We have not made the progress we would wish and are continuing to have a high focus on this area. No patient will have an MRSA bacteraemia No more than patients will have an MSSA bacteraemia in year No more than 17 patients will acquire Clostridium difficile infection in year We will have implemented an antimicrobial reduction strategy and a stewardship team We did not achieve our infection control targets this year. The Trust recorded 2 patients as positive for MRSA bacteraemia from April 2014 – March 2015. The Trust has reported a total of eleven cases of MSSA bacteraemia for 2014/2015 against the trajectory of three cases. To date there have been 20 cases of hospitable attributed Clostridium difficile reported; 7 of those cases have been associated with a lapse in care, for example, inappropriate antibiotic prescribing. The remaining 13 cases have been scrutinised and assessed as unavoidable. The antimicrobial stewardship programme is now embedded in the with daily antimicrobial audits of compliance undertaken by the Consultant Microbiologist and Antimicrobial Pharmacist. In 2014/15 we said our No. 4 goal was: Venous Thromboembolism (VTE) VTE (a blood clot) is a major contributor to severe illness or death in the UK. We have improved our performance and embedded this change in our clinical practice. We will achieve the 95% national target for quality standards relating to VTE. We will develop a database and mechanism to work in “real time” so that we know which, if any, patients have not been assessed. The has achieved the 95% national target consistently each month since May 2014. A database and dedicated VTE clerk are in place to monitor assessments of patients.
In 2014/15 we said our No. 6 goal was: Leadership development. We have invested significantly in developing leadership potential in our staff. We will have developed the Clinical Advisory Group and Nursing and Midwifery Committee into advisory groups. We will utilise the Quality Improvement Hub to develop leadership for patient safety improvement for clinical staff We will develop the Care Maker programme to facilitate nursing front line leadership skills. We will maintain the number of staff on national NHS leadership programmes. We will reserve time each month for Executive Directors and senior managers to leave their offices and spend time with patients and staff throughout the Hospital. We have developed the Clinical Advisory and Nursing and Midwifery Committee into advisory groups. Our Quality Improvement Hub has extended its improvement work with clinical staff – providing regular reports on progress to our Quality & Governance Committee. 15 staff members have signed up to the national Care Maker programme. This has helped to raise awareness of the Chief Nursing Officer’s campaign to champion compassion in health care. We have increased the number of on national leadership programmes from 23 (2013/14) to 27 (2014/15). Each month our Executive Directors carry out an ‘Executive walk –round’. All of our service areas have been visited in this way during the year.
This table sets out our 3 key targets for Patient Experience last year and outlines how we have performed on each. Our Patient Experience Quality Priorities and why we chose them What we aimed to achieve How did we do? In 2014/15 we said our No. 1 goal was: Continue to support and strengthen the Patients’ Council. We recognise that our ability to measure Patient Experience is critical to making changes and supporting in delivering best care. Our Patients’ Council has a remit to challenge and hold us to account on the delivery and improvement of an excellent patient experience. We will work with the Patients’ Council to improve the Trust score on the national inpatient survey for two questions; H4. “Did not receive any information explaining how to complain” B7. “Didn't get enough information ward routines” We will collect real-time ‘patients’ stories’ with trained volunteers and staff. We will develop and implement a survey of inpatients the direct prompts from the CQC caring domain. Despite our efforts to increase the visibility of the PALs team and improving publicity posters and patient information leaflets, the 2014 inpatient responses to question H4 “Did not receive any information explaining how to complain” remained unchanged. Question B7. “Didn't get enough information ward routines” was removed from the national survey – although the Trust can demonstrate efforts to improve patients and carers experiences of this via, for example ‘My Bedside Book’ (section 2.2 of this report) We have collected the stories of patients with support from our Patients’ Council and our complaints and PALs team. We have reported these stories to the Board. Our Patients’ Council have developed a survey for inpatients using the CQC caring domain – and extended the use of this to our Emergency Department. In 2014/15 we said our Fully implement the Friends and Family We will have met the national requirements We have achieved the Friends and Family Test
No. 2 goal was: test and improve the number of people who would recommend the Trust. This is a national requirement and the measure helps us to understand the patient experience It is also one of the “learning milestones” we have set in our ‘Patient Experience Strategy’. for rolling out the Friends and Family programme. We will have met the national requirement for improving the response rate We will have improved on the proportion of staff who would recommend the hospital to family and friends in the national staff survey. national targets for patients – which has been rolled out this year to incorporate all outpatient departments and children’s services. The are also achieving the national requirement for improving the response rate, with 40% of inpatients and 20% of Urgent Care patients now completing the Friends and Family Test. However the proportion of staff who would recommend the hospital to friends and family has remained unchanged. In 2014/15 we said our No. 3 goal was: Improving the complaints process 80% patients will receive a response within target All staff involved in the complaint will receive a copy of resulting actions. Clinical issues identified by complaints will initiate quality improvement in the Hub. We will increase the number of patients contacted by telephone and offered a meeting as a means of resolving a complaint. The Trust has not achieved a consistent 80% response rate with the yearly monthly average recorded at 71.8%. All staff involved have received a copy of the resulting actions. We achieved this target on one occasion following complaints around treatment escalation. All patients have been telephoned and offered a meeting where contact details have been available.
On the following pages we set out tables showing our chosen priorities for improvement in the 3 key what success looks like - how we will monitor and measure our progress to achieve these priorities; and How we will report progress to achieve these priorities. Our Quality Priorities for 2015/2016 4.4 Patient Safety This table sets out our 6 key priorities for patient safety in the next twelve months and outlines how we will measure and report progress. Our Patient Safety Quality priorities for 2015/16 and why we chose them What will success look like How we will monitor, measure and report our progress
Pressure sore reduction: Pressure sores are debilitating for patients and largely avoidable injuries which cost the NHS millions of pounds every year. By working together with key community and Primary Care providers across North Somerset we want to considerably reduce avoidable pressure sores for our patients. 10% less patients will acquire a pressure ulcer during2015/16 We will continue to partner with community colleagues to improve our documentation so that is more aligned and our care is improved. We will report on the numbers and of pressure ulcers, and the corrective action being taken, in our monthly Safety Thermometer and our ‘Performance Assurance Framework’ (reviewed by senior patient-facing staff). Our Trust Board will also receive a full report at three public meetings. Reducing Falls: Although the Trust has done a lot of work on reducing the incidence of falls, we want to continue to improve performance in collaboration with the community and primary care services. No more than patients will have a fall resulting in moderate harm or worse whilst in our care. No more than five patients will have had a fall whilst in our or our community partners care in each months prevalence snap shot survey as measured by the NHS Safety Thermometer by March 2016 We will report on the numbers and severity of falls, in our monthly Safety Thermometer and our ‘Performance Assurance Framework’ (reviewed by senior staff). Our Trust Board will also receive a full report at three public meetings. Infection control: Our aim is that no patient will be harmed by a preventable infection whilst in our care. We will continue to focus our efforts on achieving this. No patient will have an MRSA bacteraemia. No more than three patients will have an MSSA bacteraemia in year No more than 18 patients will acquire Clostridium difficile infection in year We will monitor progress through monthly infection prevention and control meetings. The Director of Infection Prevention and Control will produce a quarterly report for the Quality and Governance Committee. Our Trust Board will also receive a full report at each bimonthly public meeting.
We will ensure that the safety and quality of care is the top priority at meetings This will help us ensure that the quality and safety of care is central to all we do. An agenda template that prioritises the safety and quality of care will be developed by the Trust and used by all committee Chairs. Our Trust secretary will assess its use and report to the Board as part of the annual review of committee structure and effectiveness. 4.5 Patient Experience This table sets out the 3 targets for Patient Experience in the next year and how we will measure and monitor our progress. Our Patient Experience quality priorities for 2015/16 and why we chose them What success will look like How we will monitor, measure and report our progress We will improve our mechanisms to listen to the experiences of vulnerable and seldom heard groups. The Trust is committed to improving and extending the ways it listens to the experiences of patients – so that we can continuously improve our care. Our Patient Experience Review will prioritise and commission two reports focussing on the care received by vulnerable and seldom heard groups. We will review what these groups tell us and monitor any required actions via our Patient Experience Review Group which reports to our Quality & Governance Committee. We will review and improve our hospital environment to support patients with dementia. The Trust recognises that patients with dementia are particularly vulnerable in the acute hospital environment and would like to do more to support this. We will introduce Dementia Bus at key points in our corridors and specialist clocks in our care of the elderly inpatient wards. Our Dementia Liaison will provide specialist advise in all major refurbishments to ensure that we maximise opportunities to make our facilities supportive to this patient group. We will continue to review and report on the experiences of patients and carers via reports to our Safeguarding Committee.
We will ensure that our Executive talk regularly to patients their experience of care using the ‘My bed’ initiative This will ensure that senior managers continually update understanding of patients’ views of the care in the hospital. All of our Executive Directors will participate in the ‘My bed’ initiative and will talk to the patient in that bed about their experiences at least once per month. Our Patient Experience Review Group will review feedback from Executives in terms of ‘What did you find useful? 4.6 Clinical Effectiveness This table sets out the 4 key priorities for the next year on Clinical Effectiveness and outlines how we will measure and monitor our progress. Our Clinical Effectiveness quality priorities for 2015/16 and why we chose them What success will look like How we will monitor, measure and report our progress Embedding the Keogh review of mortality. The care of 50% of deceased patients’ will be reviewed using the Global Trigger Tool. Progress will be monitored by quarterly reports from the Quality Improvement Hub to the Clinical Advisory Group and Quality and Governance Committee. Best practice in managing patients with sepsis It has been proven that by following six best practice patients recover sooner. By the end of March 2016 85% of patients admitted with sepsis will have the Sepsis 6 standards administered within one hour. Progress will be monitored by quarterly reports from the Quality Improvement Hub to the Quality and Governance Committee.
Best practice in managing patients with a fractured neck of femur It has been proven that by following certain best practice steps patients are more likely to return to previous levels of mobility and be able to stay in their own home following this fracture. We will embed the improvements we have made and attain best practice standards for 60% of patients. We will do this by; completing pre and post operative assessment of mental state improving time to surgery (i.e. within the 36 hours target) ensuring geriatrician assessment occurs within 72 hours of admission Progress will be monitored by quarterly reports from the Quality Improvement Hub to the Clinical Advisory and Quality and Governance Committee. Best practice in managing patients with pneumonia Our audit of our care discovered that although hospital acquired pneumonia was well identified and antibiotics rapidly commenced, a quality improvement project is underway to raise awareness, appropriately prescribe antibiotics and improve documentation. Progress will be monitored by quarterly reports from the Quality Improvement Hub to the Clinical Advisory Group and Quality and Governance Committee.