University of North Staffordshire CHI Report

North
Staffordshire
Hospital
NHS Trust
MARCH 2002
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Report of a clinical governance review at
North Staffordshire
Hospital NHS Trust
MARCH 2002
Commission for Health Improvement 2002
Items may be reproduced free of charge in any format or medium provided
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Improvement and the title of the document specified.
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First published 2002
ISBN 0 11 702982 3
Foreword v
CHIs findings questions and answers vii
Executive summary x
What is clinical governance? xiv
Clinical governance reviews xiv
1. Introduction 1
Acknowledgements 2
2. The trusts context 3
The trusts nature and size 3
The local population 4
Financial context 4
3. The patient experience 5
Clinical effectiveness and outcomes of care 5
Access to services 6
Organisation of care 9
Humanity of care 12
The environment 13
4. Use of information 15
Information about the patient experience 15
Information about resources and processes 17
CONTENTS iii
Contents
5. Resources and processes 19
Patient and public involvement 19
Risk management 22
Clinical audit 24
Research and effectiveness 27
Staffing and staff management 29
Education, training and continuing personal and
professional development 33
6. Strategic capacity 36
Leadership 36
Accountabilities and structures 37
Direction and planning 37
Partnerships with the patients and the public 38
Partnerships with other health and social care organisations 38
Appendices 40
A. The review team 40
B. Sources of evidence 41
C. CHIs assessments of clinical governance 42
D. Glossary 45
iv CLINICAL GOVERNANCE REVIEW AT NORTH STAFFORDSHIRE HOSPITAL NHS TRUST
This report looks at clinical governance in the North Staffordshire Hospital NHS Trust.
The report is in two main parts. The first is a question and answer section, which is
designed to tell the public what CHI found in an easy to understand way. The second
part is intended principally to be of value to the trust itself, so that it knows in detail,
and in a language it will understand, what CHI found and where it needs to take
action. The second section will also be of interest to other NHS organisations in the
area and to the wider NHS as there are lessons that the whole NHS should take note
of.
FOREWORD v
Foreword
vi CLINICAL GOVERNANCE REVIEW AT NORTH STAFFORDSHIRE HOSPITAL NHS TRUST
Q What is the trust like? And what does it do? What kind of population does it
serve?
A North Staffordshire Hospital NHS Trust is a large acute trust serving a population
of 470,000 across the Stoke-on-Trent area. It provides emergency care, general
health services and some specialist services, for example, cancer services, from a
number of sites: City General Hospital, Royal Infirmary, Central Outpatient and
Pathology Departments, Haywood Hospital and the satellite clinics at Shelton and
Hanley.
Q What if anything did CHI find that the rest of the NHS can learn from?
A The trust has involved patients and the public at the highest level in helping to
shape patterns of service for the future and in developing plans for the new single
site hospital.
Patients and relatives have been involved in helping change the care given at the
end of a persons life in order to help make the dying experience less distressing
for both the patient and their relatives.
The trust protects staff by adopting a zero tolerance stance when dealing with
violent and abusive patients and relatives. This has received national recognition.
The A&E department houses a crche, staffed by play therapists. This can be used
by all children coming to the department, whether for treatment or with relatives.
Q What if anything did CHI find that is cause for concern?
A CHI was concerned with the level of supervision, workload and work patterns of
junior doctors working within medicine. We felt this posed a potential risk to
patients and have informed the trust that urgent action must be taken to address
the situation.
The trust has started to address the situation by undertaking a medical services
review and responding to the recent Winter Emergency Services Team (WEST)
report.
CHIS FINDINGS QUESTIONS AND ANSWERS vii
CHIs findings
questions and answers
Q To what extent does the trust board and the senior management team have the
information they need about the quality of patient care? To what extent does
the board refer to it? Does it compare itself with other trusts? Does it use the
information to monitor the services and to help make decisions about
priorities? How is this reflected in the teams that deliver services to patients?
A There are several weaknesses in the trusts information management and
technology strategy and systems; therefore, the trust has difficulties in retrieving
and using information effectively to underpin the delivery of patient care. The
trust is aware of the problems and is planning changes to the systems and the
way it uses information.
CHI has asked the trust to take an in depth look at the outcomes of care and
benchmark these and clinical practice with other organisations in order to learn
about acceptable outcomes of care and up to date good practice.
Q Does the board and the senior management team make sure that they receive
regular information from patients about what they think of the services? Do
they have a positive attitude towards complaints and take complaints seriously?
Do they make sure staff have a positive attitude towards complaints and that
they learn from them? How is this reflected in the teams that deliver services
to patients?
A The board receives information from patients about some of the trusts services
and this information, along with community health council (CHC) reports, are
used to improve services for patients.
The trust has made good progress in improving the way it handles complaints by
providing staff training. Changes to practice have been made as a result of
complaints. However, the trust still needs to improve the length of time it takes to
resolve complaints.
Q Does it involve patients and their relatives in helping to plan and improve
services in the trust as a whole and in specific services?
A At a strategic level, CHI found excellent examples of patient involvement in the
development of services. However, although patients and relatives are involved in
planning and improving services with some of the clinical teams, this
involvement is not consistent across the trust.
Q Does the trust have the staff it needs to deliver the services? Does it manage
its staff well? Does it supervise junior staff and trainees adequately? Does it do
the necessary routine checks on doctors and nurses?
A The trust has recently recruited 140 nurses from the Philippines boosting the
number of nurses on the wards. Staff shortages only tend to exist in areas were
there are national shortages of staff, for example, in some specialist areas like
radiology and physiotherapy.
Systems for checking on nurses and doctors registration are in place and appraisal
systems have been implemented, although not all staff have had a recent appraisal.
viii CLINICAL GOVERNANCE REVIEW AT NORTH STAFFORDSHIRE HOSPITAL NHS TRUST
Supervision of staff is generally good, except in medicine. CHI has expressed
major concerns about the supervision of junior doctors working in medicine.
Staff felt that the trust was a good place to work.
Q How well do the trust and the staff anticipate things that might go wrong?
Does the trust encourage staff to report problems? Does it have systematic
methods for collecting information about risks to patients? Does it have
systems for making sure managers and staff learn from mistakes?
A Clear structures and strategies are in place for the management of risk. There are
good systems in place for reporting risks and staff feel comfortable about doing
so. Information on risks and resultant change to practice are disseminated across
the trust, although more work needs to be done to ensure staff at grass roots level
are kept informed.
Priority needs to be given to the management of infection control across the trust.
Q Does the trust make sure that the clinical staff keep up to date? Does it
support research? Does it make sure the clinical treatment and care are based
on the most up to date evidence of good practice? Does the trust make sure
the staff comply with national guidelines?
A The trust has a strong commitment to the professional development of its staff.
Support is provided for the implementation of evidence based practice and there
is good evidence of joint research and clinical audit taking place with the other
health and social care organisations in the area.
Systems exist to disseminate national guidelines but the trust needs to ensure
these are implemented.
Q How effective is the leadership of the trust? Does it have a positive attitude to
feedback from outside? How well does it work with other organisations locally?
Does it have good clinical leadership?
A The trust is committed to implementing the clinical governance agenda. There is a
new management team in place who are providing strong leadership and a clear
vision for the future. Board members do need to strengthen their communication
links with the clinical teams and encourage more cross team communication. New
clinical governance board arrangements are aimed at improving communication
and leadership for clinical governance priorities.
The trust has worked hard to develop clinical leaders. However, there is a need to
develop strong clinical leadership in medicine.
Although there are some good examples of partnership working at different levels
within the trust, this is not consistent. The trust needs to take a proactive
approach to progressing partnerships in order to improve services for patients.
CHIS FINDINGS QUESTIONS AND ANSWERS ix
Introduction
North Staffordshire Hospital NHS Trust serves a population of approximately 470,000.
In comparison to other trusts, North Staffordshire Hospital NHS Trust treats three
times as many patients than the average for trusts in England.
The trust is located over a number of sites in the Stoke-on-Trent area: City General
Hospital, Royal Infirmary, Central Outpatient and Pathology Departments, Haywood
Hospital and the satellite clinics at Shelton and Hanley.
As part of the rolling programme of reviews, the Commission for Health Improvement
(CHI) conducted a clinical governance review at North Stafforshire Hospitals NHS
Trust (the trust) between 1 October 2001 and 27 March 2002.
The review looked in depth at arrangements in three clinical teams that provide care
for patients who:
I require obstetric and gynaecological care
I are admitted as a general medical patient
I are admitted for treatment of a fracture neck of femur
Patient/service user experience
The trusts performance against national clinical indicators shows some variation from
the averages of comparable trusts. The mortality rates following myocardial infarction
(MI) and emergency surgery are significantly higher than the average in England.
Access to inpatient waiting lists is good, although a large number of operations are
cancelled on the day of surgery. There is a considerable wait for an outpatient
appointment, but the trust does achieve the two week wait target for cancers and the
majority of patients are seen within 30 minutes of arriving in the outpatient
department. Patients can expect long waits in accident and emergency (A&E) and the
medical assessment unit (MAU) due to capacity and staffing problems in the medical
division.
CHI found that staff treated patients in a respectful and dignified manner and every
effort was made to maintain privacy despite some challenging environments. Many of
the trusts buildings are old and the dcor is shabby. A&E and outpatient departments
are crowded, but most areas are clean. A&E has good facilities for children. The food is
deemed to be reasonable, if basic, and patients usually get what they have ordered.
x CLINICAL GOVERNANCE REVIEW AT NORTH STAFFORDSHIRE HOSPITAL NHS TRUST
Executive summary
There is a good selection of menus for patients requiring special diets, such as people
with diabetes. Provision of food for patients from ethnic minority populations is
sometimes inappropriate. A multifaith chaplaincy service is available 24 hours a day.
Assessments of technical components of clinical
governance
Component Assessment Key findings
Patient and public III I A wide range of activity at strategic level.
involvement I Some alignment of activity with worthwhile
development in the majority of areas.
I The trust has a health panel made up of
patients and the public.
Risk management II I Good progress made in a short period of time.
I Good strategic grasp and considerable.
implementation.
I Open and supportive culture.
I Potential area of clinical risk lack of
supervision for junior doctors in medicine.
Clinical audit II I Some good examples of clinical audit led
by enthusiastic individuals.
I High profile clinical audit department.
I Little evidence of the trust board influencing
audit.
Research and effectiveness III I Clear structures and strategies.
I Robust research governance arrangements.
I Good R&D programmes.
Staffing and staff II I Committed and dedicated workforce.
management I Open and supportive culture.
Education, training and II I Commitment to education and training
continuing personal and recognised by staff.
professional development I Good opportunities.
I Very good leadership development
programmes.
Use of information I I Out of date strategies and systems.
I Many weaknesses in the system and lack
of confidence in information management
capabilities.
I Trust is addressing the problems.
A description of how CHI makes its assessments is in appendix C.
EXECUTIVE SUMMARY xi
Strategic capacity
Both the trusts non executive and executive teams have undergone considerable
change over the last year. The new team members have given impetus to progressing
the strategic direction and leadership of clinical governance, thus ensuring that all the
components of clinical governance are integrated. The trust has recognised that a
number of key areas need strengthening and some changes need to be made to service
delivery patterns to improve services for patients. Plans to develop new ways of
working and a new single site hospital are underway.
The trust has had some bad press in recent years following some serious untoward
incidents. However, the trust has learned from these and has developed robust
mechanisms and practices to safeguard patients; it is also training staff to manage
clinical risk more effectively. However, the trust must remain vigilant. The research
governance framework should ensure safe and ethical practice occurs when patients
are involved in research.
CHI is concerned about the potential risk posed to patients because of the working
patterns, workload and lack of supervision of junior doctors in the medical division.
The trust has taken some steps to address the problems through undertaking a medical
services review, responding to the Winter Emergency Services Team (WEST) report and
adjusting work rotas, but CHI found evidence that many of the problems were still in
existence.
Key areas for action
CHI expects the trust to review all aspects of the report and consider what action is
needed. In two areas CHI believes that there is an increased risk to patient safety that
require urgent action by the trust:
I An investigation into reasons for the high mortality rates, low discharge rates and high
number of readmissions must be undertaken. The trust must ensure practice is evidence
based. CHI urges the trust to undertake benchmarking of good practice in other NHS trusts
and make changes to practice accordingly.
I The trust must take urgent action to address problems related to workload, work patterns
and supervision of junior doctors working in the medical division. In doing so, issues of
medical staffing levels, multidisciplinary team working, leadership and culture must be
addressed.
CHI has identified four areas for action of strategic importance that are necessary to
improve clinical governance in the trust:
I The trust needs to take action to address issues of capacity through appropriate demand
management, forward planning, working more closely with partner organisations and
developing processes that allow access to beds for both emergency and elective admissions,
and prevent inappropriate admissions.
I The trust must take action to implement arrangements that facilitate a patient pathway
approach to care, in order to integrate all professionals involved in the delivery of care and
deliver the most appropriate package of care for patients.
I CHI found that clinical governance is currently somewhat fragmented and not clearly
understood throughout the organisation. The trust should take action to develop a cohesive
strategic framework for clinical governance that incorporates a multidisciplinary model of
service delivery that puts the patient firmly at its core.
xii CLINICAL GOVERNANCE REVIEW AT NORTH STAFFORDSHIRE HOSPITAL NHS TRUST
I The trust should ensure that IM&T strategies and implementation become an integral part of
the clinical governance agenda. High quality information must be available and managed
appropriately to support the trust in the delivery of quality treatment and care. The trust
must take action to address this now ahead of implementation of electronic patient records
(EPR).
Notable practice
CHI found ten examples of notable practice that are worthy of sharing within the trust
and, more widely, across the NHS:
I Every patient on the inpatient waiting list is given the name of a member of the trusts
patient access team, who they can contact directly if they have any problems. GPs and
outside agencies can also contact the team to enquire about waiting lists.
I The chaplaincy service has conducted focus groups with recently bereaved people to
establish the type of service relatives and friends would like to be offered at this difficult
time. This has been used to develop the trusts end of life policy and changes to practice have
been made to ensure that the dying experience is made as positive and caring as possible.
I The A&E department houses a crche, staffed by play therapists. All children coming into the
department can use this facility, whether for treatment or with relatives.
I The health panel (made up of patients and public), in partnership with the trust, have
organised two workshops and a patient partnership conference that focused on what clinical
governance means for patients.
I A black and ethnic minority working group has been set up to help the trust improve the
information it provides for patients from these communities.
I The trust has recently undertaken a pilot study to introduce red do not resuscitate (DNR)
forms that can be easily recognised in the notes. There are now plans in place to roll this out
throughout the trust.
I Obstetrics and gynaecology have implemented a coordinated approach to both clinical audit
and research activity through the development of a coordinator post. This post provides
assistance in undertaking audit and research activity, help with writing bids for funding,
assistance with writing for publication, help in identifying changes in practice (ensuring that
audits of the effectiveness of these practices are undertaken) and ensuring that audit and
research inform each other.
I An audit of research governance issues is currently being undertaken to ensure research
projects are being managed appropriately; for example, auditing of informed consent for
participation in research. The results will be widely available and the audit will become an
integral part of the clinical audit cycle.
I The trusts zero tolerance strategy has been published nationally.
I The trust and executive board have ratified a charter produced by staff. The charter pinpoints
key rights, as well as responsibilities for staff, including a safe and healthy working
environment, training to ensure people can carry out their jobs safely and efficiently, equal
opportunities, clear job descriptions, occupational health and counselling services and
employee friendly working environments.
Action following the review
The trusts action plan in response to this report will be available from the North
Staffordshire NHS Trust, Trust Headquarters, Royal Infirmary, Princes Road, Hartshill,
Stoke-on-Trent, ST4 7LN and on CHIs website (www.chi.nhs.uk). Further copies of
this report are also available from the CHI website.
EXECUTIVE SUMMARY xiii
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A First Class Service and Quality Care and Clinical Excellence define clinical
governance as
a framework through which NHS organisations are accountable for continuously
improving the quality of their services and safeguarding high standards of care by
creating an environment in which excellence in clinical care will flourish.
1
The purpose of clinical governance is to ensure that patients receive the highest
quality of NHS care possible. It covers the organisations systems and processes for
monitoring and improving services, including:
I patient consultation and involvement
I clinical risk management
I clinical audit
I research and effectiveness
I staffing and staff management
I education, training and continuing personal and professional development
I the use of information to support clinical governance and health care delivery
Effective clinical governance should therefore ensure:
I continuous improvement of patient services and care
I a patient centred approach that includes treating patients courteously, involving
them in decisions about their care and keeping them informed
I a commitment to quality, which ensures that health professionals are up to date in
their practices and properly supervised where necessary
I a reduction of the risk from clinical errors and adverse events as well as a
commitment to learn from mistakes and share that learning with others
Clinical governance reviews
CHI is carrying out a rolling programme of reviews in every NHS health organisation
in England and Wales to provide independent and systematic scrutiny of the clinical
governance arrangements in each trust.
Reviews take around 24 weeks to complete from starting the review to having a report
ready for publication. This timescale is long enough to collect and analyse data
rigorously but intensive enough to mean that the evidence on which the review
findings are based is current and useful.
xiv CLINICAL GOVERNANCE REVIEW AT NORTH STAFFORDSHIRE HOSPITAL NHS TRUST
What is clinical governance?
1
A First Class Service: Quality in the New NHS, Department of Health, 1998.
Each review follows the same timetable:
PRE VISIT PREPARATION (15 WEEKS)
During this phase, CHI collects and analyses data and documents about the trust and
its services from a wide variety of sources. It examines the national data available,
asks the trust to put together information that will demonstrate how clinical
governance works, talks to local organisations involved in providing health and social
care and holds individual meetings with members of the public and other local
organisations such as patient groups. It also collects information from a sample of
patients about their recent hospital experience. All of the information collected is used
to identify areas for detailed review during the site visit and to brief the review team.
SITE VISIT (1 WEEK)
A CHI review team visits the trust to interview trust staff, observe practice, verify
information already obtained and gather further information. Each team normally
comprises a nurse, a doctor, an NHS manager, a lay member and another clinical
professional who is not a doctor or a nurse, for example a pharmacist or
physiotherapist. The aim of the visit is to collect information about how well clinical
governance is working throughout the organisation and to examine the experience of
patients first hand.
PRODUCTION OF REPORT (8 WEEKS)
The review team brings together all the evidence it has collected about the trust to
agree its key findings and form an assessment of clinical governance arrangements.
These are presented to the trust four weeks after the visit and then turned into a
written report.
After the site visit, CHI runs a workshop with the trust to help it consider the areas for
action in CHIs report, identify its future priorities and translate them into achievable
and measurable objectives. The trust then draws up an action plan, which is approved
and monitored by the regional office or, in Wales, the National Assembly. In some
cases, the action plan will involve other organisations in the local health community
that are involved with the trust in providing health and social care.
The review at North Staffordshire Hospital NHS Trust started in October 2001. The
review visit (stage 2) took place between 14 and 18 January 2002. During the review
information was received from more than 120 patients, carers, GPs and other members
of the public. Ninety two meetings were held with trust staff involving more than 200
individuals. Full details of sources of evidence are in appendix B.
WHAT IS CLINICAL GOVERNANCE? xv
xvi CLINICAL GOVERNANCE REVIEW AT NORTH STAFFORDSHIRE HOSPITAL NHS TRUST
The review
1.1 The Commission for Health Improvement (CHI) conducted a clinical governance
review at Staffordshire Hospital NHS Trust (the trust) between October 2001 and March
2002. The review is part of a rolling programme of reviews of all NHS organisations
that will provide robust assessments of their arrangements for clinical governance.
1.2 The review looked in depth at arrangements in three clinical teams that provide
care for patients who:
I require obstetric and gynaecological care
I are admitted as a general medical patient
I are admitted for treatment of a fracture neck of femur
1.3 The clinical teams were defined to include staff in other departments who look
after the patients at some point in their care including those in accident and
emergency (A&E), the professions allied to medicine such as pharmacy, the therapies,
imaging, support services and anaesthetics.
1.4 The teams were selected following analysis of the trusts own information and
data, reports of other external reviews of the trust and after local consultation. They
were chosen to illustrate a range of challenges and achievements in clinical
governance.
1.5 The purpose of this report is to give an objective description of clinical governance
arrangements, which will enable the trust to identify areas for improvement and help
spread knowledge throughout the NHS.
1.6 The report has four main chapters:
I chapter 3 describes the common experiences of patients cared for by the trust,
including their outcomes following hospital treatment
I chapter 4 examines the extent to which the trust uses information about the
experiences of patients and about the performance of its staff and processes to help
improve services
I chapter 5 looks at how the trust ensures that its staff are able to provide the best
care and treatment of patients, for example through training, supervision and
education, and at the processes the trust uses to check and improve the quality of
its services
I chapter 6 describes the capacity of the trust to implement clinical governance and,
through it, improve services for patients
CHAPTER 1 : INTRODUCTION 1
1 | Introduction
1.7 CHI is developing its review methods so that the topics covered by these four
chapters can be assessed in a way that is reliable, fair and consistent. This work is still
underway and in this report assessments are made of the topics in chapters 4 and 5
only; the topics covered in chapters 3 and 6 are described but not assessed. A fuller
description of CHIs method for assessing clinical governance is in appendix C.
1.8 Judgments and conclusions published in this report are those of the CHI alone. In
reaching its judgments and conclusions CHI uses information received from many
organisations, staff of the body under review and members of the public. The
contribution of these organisations and individuals is gratefully acknowledged but CHI
remains responsible for the contents of the report and the evidence it relies upon in
reaching its conclusions.
1.9 The trusts action plan in response to this report will be available on CHIs website
(www.chi.nhs.uk) or from North Staffordshire Hospital Trust, Trust Headquarters,
Royal Infirmary, Princess Road, Hartshill, Stoke-on-Trent, SA4 7LN. Further copies of
this report are also available from the CHI website.
Acknowledgements
1.10 CHI would like to thank staff of local organisations, patients and members of the
public who contributed to this review. Within the trust, CHI would particularly like to
thank:
I Mr Stephen Eames, Chief Executive
I Dr Pat Chipping, Medical Director
I Mr Peter Blythin, Director of Nursing and Operations
I Mrs Lyn Ford, Clinical Risk Manager (trust coordinator) and her team
I all the staff who gave time to speak to the review team and who provided
information
2 CLINICAL GOVERNANCE REVIEW AT NORTH STAFFORDSHIRE HOSPITAL NHS TRUST
The trusts nature and size
2.1 North Staffordshire Hospital NHS Trust is a large acute trust and is located over a
number of sites in the Stoke-on-Trent area: City General Hospital, Royal Infirmary,
Central Outpatient and Pathology Departments, Haywood Hospital and the satellite
clinics at Shelton and Hanley.
2.2 A&E has recently been refurbished and includes an area specially designed for
children. It is located at the Royal Infirmary along with the trauma centre,
neurosciences, renal, cardiac and cancer services.
2.3 The City General Hospital is approximately one mile away and provides the main
medical, surgical, orthopaedic, childrens, maternity and gynaecology services. Central
Outpatients and Pathology lies between the two sites.
2.4 The Haywood Hospital is located in the town of Burslem, about five miles away,
and provides rheumatology and rehabilitative services. A walk in centre is also located
on this site.
2.5 The trust is working with its partners across health and social services in the area
to change the way services will be delivered to people in the coming years. The
project, called Fit for the Future, costs approximately 200 million and includes
building a new single site hospital at the City General, replacing the old, outdated
buildings at both the City General and Royal Infirmary. Changes will also be made to
local surgeries, clinics and community hospitals. It is hoped that the project will be
completed by 2008.
2.6 There are approximately 1400 beds within the trust and it employs around 6,500
staff (2000/2001).
2.7 The trust, in conjunction with Staffordshire University, provides training for
nurses, midwives and allied health professionals. Postgraduate training for doctors is
provided through Keele University. Approval has been granted for an undergraduate
medical school that the trust is developing in collaboration with Keele University; the
first 50 students are due to arrive in September 2002 and will be extended to take a
total of 130 students per year.
2.8 North Staffordshire Hospital NHS Trust provides general services to people in the
local area (88% of activity relates to people living locally) and specialist services
including heart, kidney, brain injury/illness, cancer and childrens intensive care to
this population and those across south Staffordshire, Shropshire and Cheshire.
CHAPTER 2 : THE TRUSTS CONTEXT 3
2 | The trusts context
2.9 The trust has a significantly higher number of finished consultant episodes,
outpatient and A&E attendances compared with the England average and all three
measures are higher than for comparable trusts. The largest speciality is general
medicine.
2.10 In the recently published acute performance ratings, the trust achieved two stars.
The local population
2.11 The trust mainly serves the population of the North Staffordshire Health
Authority, whose estimated population is 470,000. The health authority is part of the
coalfields cluster group and is ranked 46 out of 99 on the Townsend and 52 out of 99
on the Jarman index comparing poverty and wealth. These figures suggest an average
level of deprivation, although Stoke-on-Trent is both a health action zone and an
education action zone, in recognition of the challenging social and economic
conditions in that particular area.
2.12 The local population has slightly less children under 10 years of age and adults
between 25 and 44 than the average population in England.
2.13 National indicators show that the local population has a higher rate of illness
than the national average. The standardised illness ratio is 22% higher for men and
20% higher for women. The standardised permanent illness ratio is 43% higher than
the England average for men and 34% higher for women.
2.14 The local death rates are 11% higher than the national average. The high level
performance indicators published in July 2000 show that death rates in 1996-1998 for
people under 75 years of age in north Staffordshire are 9% higher for cancers and
25% higher for circulatory diseases.
2.15 North Staffordshire has an ethnic minority population of just over 2%, compared
to the England average of 6.2%. The most significant ethnic minority group in the
area is Asian (1.5% of the population). These figures are derived from the 1991 census
data and, therefore, may be out of date.
Financial context
2.16 Although not directly related to the quality of services provided nor to clinical
governance procedures, financial health measured in terms of adequate income and
expenditure and efficient use of resources gives a sense of how well a trust may be
able to perform.
2.17 In the year 2000/2001 the trust received the largest proportion (89.6%) of its
193,823 million income from health authorities. In the same year the trust met all its
financial targets having addressed the financial difficulties of recent years.
Chapter 3 describes the common experiences of patients cared for by the trust. The term patient
experience includes the clinical effectiveness and outcomes of care; patients access to services;
the ease with which patients progress through their care or treatment; the privacy, dignity and
respect given to patients; and the environment in which care is provided.
KEY FI NDI NGS
From the data available, the trusts performance against national clinical indicators showed
some variation from the averages of comparable trusts. Myocardial infarction and emergency
post surgery mortality in particular are significantly higher than the average.
The trust has made significant improvements in reducing inpatient waiting lists but there are
still long waits for an outpatient appointment.
A large number of operations are cancelled on the day of surgery, many following admission
to hospital. A performance improvement plan relating to cancelled operations has been
developed in conjunction with partner organisations and sets out actions to be achieved.
Additional surgical beds have also been introduced to support protected elective activity.
However, there is a need to align emergency and inpatient admissions to improve services for
patients.
CHI found several barriers to effective discharge of patients. A whole systems approach is
required to ensure both access to services and discharge planning arrangements improve.
The staff in the trust should be commended on their commitment to their work.
Clinical effectiveness and outcomes of care
3.1 In July 2000 the NHS Executive produced its set of clinical indicators for
1998/1999. The national clinical indicators contain information related to both
emergency and non emergency mortality. Figure 3.1 below indicates that both the 30
day perioperative emergency mortality and the 30 day mortality following acute
myocardial infarction are significantly higher than the average for England.
Figure 3.1
(England average = 100)
North England Index
Staffordshire
Perioperative emergency mortality 4,500 3,867 116
Perioperative non emergency mortality 559 478 117
Mortality following fractured neck of femur 9,290 9,070 102
Mortality following myocardial infarction 14,191 10,070 142
Source: National Clinical Indicators, NHS Executive, July 2000.
CHAPTER 3 : THE PATIENT EXPERIENCE 5
3 | The patient experience
3.2 Discharge rates for fractured neck of femur and stroke are lower in the trust than
both the average for England and the average for similar trusts. Emergency
readmission rates are higher and are shown in figure 3.2.
Figure 3.2
Fractured neck Stroke Emergency
of femur Readmissions
discharge discharge
rate (%) rate (%)
North Staffordshire 41.9 42.1 5,513
Comparable trusts 47.6 47.1 5,271
England 47.8 47.2 5,275
Source: National Clinical Indicators, NHS Executive, July 2000.
3.3 Indicators for fractured neck of femur suggest that the percentage of patients
receiving an operation on the same day or following day decreased from 60% in 1998
to 48% in 2000/2001.
3.4 The trust is aware that, in comparison with other trusts, their mortality rates in
some areas are high. They believe this to be a result of the poor health of the
population. However, some of the mortality rates are unacceptably high and CHI has
identified that action must be taken to address the situation.
KEY AREAS FOR ACTION
I An investigation of reasons for the high mortality rates, low discharge rates and the high
number of readmissions must be undertaken. The trust must ensure practice is evidence
based. CHI urges the trust to undertake benchmarking of good practice with other NHS
trusts and make changes to practice accordingly.
I The trust should ensure that it adheres to royal college guidelines.
Access to services
3.5 The trusts management of inpatient waiting lists has significantly improved in
recent years and is slightly better than the national average, with only 2% of patients
waiting over 12 months for admission to hospital. CHI found evidence that since the
introduction of the patient access centre (for people waiting for inpatient treatment
only) there had been a major improvement in the information available about access
to beds. There were also some major improvements in scheduling patients for their
operation, thus helping the trust to meet national targets.
NOTABLE PRACTICE
I Every patient on the inpatient waiting list is given the name of a member of the patient
access team who they can contact if they have any problems. GPs and outside agencies can
also contact the team to enquire about waiting lists.
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3.6 CHI found evidence that a large number of admissions for operation were
cancelled on the day of surgery. The percentage of operations cancelled on the day of,
or after admission, for a non medical reason, is 42% higher than the national average,
although there has been an overall reduction in the number of cancelled operations
during 2000/2001, as a result of changes in working practices.
3.7 The trust, in conjunction with partner organisations, has developed a performance
improvement plan relating to cancelled operations. Additional surgical beds have also
been introduced to support protected elective activity.
PATIENT COMMENT
I I had my operation cancelled four times. I was not told until the day of my operation and,
on one occasion, I was admitted, I waited all day and was then told I would have to go home
as there wasnt a bed for me.
STAKEHOLDER COMMENT
I A lot of patients complain to the community health council that their operations have been
cancelled. Some patients have been cancelled on the day of surgery.
3.8 A high level task group, led by the chief executive, has been meeting to make
recommendations aimed at improving the situation in the coming year. The trust is
currently progressing a performance improvement plan that they have agreed with the
NHS West Midlands regional office in an effort to reduce the number of patients
whose operations are cancelled.
3.9 The outpatient situation is much worse, with only 80% of outpatients being seen
within 26 weeks.
PATIENT COMMENT
I I was told that it would be 2003 before I would see a specialist about my cataracts. I got a
letter in June stating that there was a long waiting list and therefore I could not be given a
date. I have phoned three or four times and have spoken to a syndicate of secretaries who
give you different information.
3.10 The total outpatient waiting list for the trust at 1 April 2001 was 17,887; by
August 2001 this had increased to 25,890. The trust responded to this situation by
making changes to the management of outpatient waiting lists, with clinicians and
managers working proactively to improve the situation. Some improvements have
been seen and the outpatient waiting lists have now been reduced by 11%.
3.11 A number of other initiatives are being progressed in order to address the
situation. These include joint approaches to the delivery of patient care between
primary and secondary care, the introduction of a partial booking system, patients
having their operations in private hospitals and dermatology clinics being held in
community locations. The trust was also successful in gaining Action On initiative
funding in orthopaedics, dermatology, ear, nose and throat and ophthalmology.
Dedicated trauma lists for orthopaedic patients have been introduced at weekends
resulting in a reduction in the number of cancelled elective orthopaedic operations.
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3.12 In 2000/2001, the trust achieved the two week wait target for patients with
suspected cancer.
3.13 The percentage of outpatients that do not attend for their appointment is
significantly better than the national average at only 9%.
3.14 The 30 minute wait in outpatient clinics is met in 91% of cases, with all patients
being seen within one hour.
PATIENT COMMENT
I I was sent for various tests. I didnt have to wait long and all the staff were friendly.
3.15 The A&E department recently underwent refurbishment and now includes the
provision of facilities specifically for children.
3.16 Despite the high number of emergency cases, 74% of patients coming to the
department were assessed and treatment commenced within two hours. However, CHI
found that patients often have to wait on a trolley for long periods of time for a bed to
become available elsewhere in the hospital, particularly in the medical assessment
unit.
3.17 CHI was informed that patients referred by A&E to the medical team often have a
long wait to be seen. We were told that the medical doctors were often busy dealing
with patients at the City General and were therefore not readily available to see
medical patients waiting in A&E.
PATIENT COMMENTS
I I had to wait nine hours on a trolley for a bed. I wasnt told why but I was given food and
lots of cups of tea. The doctors and nurses were very busy but still had time to talk to you.
I The staff in A&E are excellent. When I arrived they knew all my information.
STAFF COMMENT
I A&E services are being compromised, there is always a backlog of medical patients waiting
for a bed in the medical assessment unit. As a result staff are having to care for sick medical
patients in an environment geared to dealing with emergencies.
3.18 During the visit we noted very positive relationships and effective team working
between the staff in the A&E department. A&E staff have developed excellent
relationships with the Staffordshire Ambulance Service NHS Trust.
3.19 Patients can be admitted to the medical assessment unit from A&E or their GP.
Paramedic ambulance teams bring patients with chest pain and strokes directly to the
unit. Seventy five percent of patients coming to the unit are treated within two hours,
but then experience a long wait in the unit for a bed on an appropriate ward.
STAKEHOLDER COMMENTS
I Access to medical beds is difficult. The medical assessment unit is always full.
I Some of our members have reported that they have had to wait up to eight hours to see a
doctor.
I There is a problem with the interface between A&E and the medical assessment unit
because they are on different sites.
PATIENT COMMENTS
I I had to wait a long time to see a doctor, the ward was full, there seemed to be too many
people there and some didnt have a bed they had to sit on chairs.
I The medical assessment unit is staffed by very experienced nurses that give you confidence.
3.20 CHI was informed that approximately 90% of patients coming to the medical
assessment unit would be admitted to a hospital bed. The trust is currently
undertaking a review of medical services; this commenced in October 2001 and is due
for completion in March 2003. They hope this will address the organisation of care in
the medical assessment unit and throughout the medical division.
3.21 Patients can also access services through the NHS walk in centre situated at the
Haywood Hospital. The centre has been established in partnership with North Stoke
Primary Care Trust and provides a nurse led service for minor injuries and ailments.
I The trust needs to take action to address issues of capacity through appropriate demand
management and forward planning. It should develop integrated processes that allow
access to beds for both emergency and elective admissions and ensures all admissions
are appropriate.
I The trust must continue to focus attention on reducing the length of wait for an outpatient
appointment.
I CHI would encourage the trust to pursue and complete the medical services review with
some urgency. With regard to the medical assessment unit, this should include a review of
protocols for admission, a review of the organisation of care, a review of the senior medical
cover and the development of nurse led services.
Organisation of care
3.22 North Staffordshire Hospital NHS Trust is organised into six clinical divisions:
anaesthesia and surgery; clinical support services; locomotor; medical; specialised
services; and women and childrens services.
3.23 Each of these is then made up of smaller more specialised directorates; for
example, the specialised services division includes directorates that treat illnesses and
injuries affecting the heart, brain and kidneys, as well as a whole range of cancers.
3.24 The corporate services division provides support services such as looking after the
buildings, catering and laundry services.
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3.25 CHI found some good examples of inter divisional working, including the trusts
cancer board and network and the stroke musculoskeletal appointment slot hospital
early referral system (SMASHERS) project in the locomotor division. This project also
involves the North Staffordshire Combined Healthcare NHS Trust (another trust in the
area that provides community, mental health and learning disability services).
However, other than a small number of good examples, we found a general lack of
communication and working across and between the clinical divisions. Allied health
professionals told CHI that they didnt feel part of some teams.
STAKEHOLDER COMMENT
I The divisions work in silos; this puts barriers in the way of patient care.
3.26 The trust is very much aware of the transportation problems caused by split site
working. Patient transport services are provided through a combination of the trusts
own transport services and a contract with Staffordshire Ambulance Service NHS
Trust. The trust and the ambulance service have built good relationships, but there is a
recognition of the need for further streamlining of policies, protocols and procedures
to ensure common working practices. CHI would urge that this work is progressed.
3.27 A team of six bed managers are responsible for ensuring patients are found a bed
once a decision to admit them to hospital has been made. We were told that this was
always difficult and patients were often placed on wards that did not specifically deal
with their clinical condition (these patients are known as outliers).
3.28 There is generally only one bed manager on duty during a shift, covering both
the City General and the Royal Infirmary. CHI found evidence of clearly documented
escalation and emergency policies to support bed management.
3.29 CHI found evidence that there were often between 50 and 80 medical patients
being nursed on non medical wards at any given time. The figure reached 134 during
CHIs visit. The trust has had to cancel many elective operations because of lack of
beds.
3.30 CHI was informed that, in some cases, the team structure and the bed situation
made the delivery of care difficult, especially if staff were not used to dealing with a
patient with a particular type of condition.
3.31 A number of stakeholders and several members of staff informed us of the large
numbers of inpatients waiting for scans. During the week of our visit there were
approximately 20 people waiting for scans.
STAKEHOLDER COMMENT
I Stroke patients only get referred to the stroke team if they are on a medical ward. They also
dont get proper aids. Some have to wait a long while for their scans; we know this should
happen as soon as they are admitted.
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PATIENT COMMENTS
I I had been admitted with severe headaches but I had to wait for a week for a scan.
I My mother was old and needed a bit of help with things generally. She had been in hospital
several times with her chest, but she went to a ward where no one seemed to know what
was happening to her, the doctor didnt come for days and she didnt have any physio.
3.32 Delayed discharges are a particular problem for the trust. During January 2002
there were 166 delayed discharges, many of which were outliers. CHI was informed
that patients were waiting for a bed in a community hospital, for social services to
find alternative accommodation or for home support arrangements to be put in place.
3.33 The trust employs a team of discharge coordinators, whose role is to ensure that
patients are involved in decisions about their care on discharge. The team links with
the community services and hospital social worker. In an effort to address the number
of delayed discharges the discharge coordinators can spot purchase beds in
nursing/residential homes for appropriate patients.
3.34 There is general agreement by all health and social services partners that there is
a lack of intermediate care beds in the area. There are plans to address this in the Fit
for the Future project by the provision of an additional 86 intermediate care beds and
an extra 40 beds for specialist stroke rehabilitation.
3.35 Day case overstays are those patients the trust planned to treat as a day case who
then have to stay in overnight. The trusts overall day case overstay rate of 7% is
higher than the national average (4.1%). The trust states that one of the key reasons
for this is their practice of operating in the morning, afternoon and evening.
Inevitably, this results in some evening patients staying overnight. Specialties with
higher overstay rates than the national average include neurology, nephrology, ear,
nose and throat, rheumatology, paediatrics and trauma and orthopaedics. Specialties
with lower than average rates include cardiothoracic surgery, thoracic medicine and
endocrinology.
3.36 The national high level performance indicators place the trusts readmission rate
at 5%. This is higher than the national readmission rate of 3.4%.
I The trust must move towards a patient pathway approach to care in order to integrate all
professionals involved in the delivery of care.
I It is essential that the wide range of staff in A&E and allied health professionals are involved
in the review of medical services.
I The trust must work closely with their partners to address the delayed discharge situation,
ensuring that discharge planning commences on admission, that delays in the process are
eradicated and that a whole health economy approach to bed management is developed.
I The trust must work in collaboration with their partners to examine the demand for services
with the local health economy.
I CHI advises the trust to investigate the reasons for the high rates of day case overstays and
readmissions. Planning mechanisms need to be developed to ensure only appropriate
patients have their operations undertaken as a day patient.
I CHI urges the trust to review the delivery of imaging services in order to improve efficiency
and patient access.
Humanity of care
3.37 We observed that staff treated patients in a dignified manner and every effort was
made to respect patients privacy, despite some challenging environments. Patient
diary extracts and comments from stakeholder events confirmed the caring nature of
most staff.
PATIENT COMMENTS
I I cannot speak highly enough of the staff. Staff are pleasant, helpful and dedicated.
I All staff try very hard in difficult circumstances.
I Some of the consultants are rude and a bit arrogant, but other doctors were fine.
STAFF COMMENTS
I Ive found all staff dedicated and caring, but they are frustrated with the workload,
resources and environment.
3.38 The trust does not fully comply with the requirements for single sex
accommodation due to the configuration of the wards but staff try to accommodate
patients in single sex bays where possible. The majority of areas have single sex
washing and toilet facilities.
3.39 In the medical assessment unit many patients are assessed and cared for in chairs
in an area lacking any form of privacy. This makes it difficult for the staff to have
private conversations with patients.
3.40 CHI observed that in the medical wards in the Nines Block beds are placed very
close together and that patients do not have much personal room. Maintaining privacy
and dignity appeared difficult and carrying out resuscitation would be extremely
difficult. We felt that staff were doing their best in a challenging environment.
3.41 Many patients commented on the quality and delivery of the food, which was
generally felt to be of a high standard, if basic, and patients usually received what
they had ordered. The menus are varied and there is good choice for patients requiring
special diets. Getting food at night and at unusual times appeared to be no problem,
although CHI was informed that there was a lack of appropriate food for patients from
ethnic minority communities.
3.42 Although all wards and departments have a comprehensive list of interpreters,
CHI was informed that normal practice was to use relatives as interpreters. Staff were,
however, aware that the trusts policy encouraged the use of interpreters.
3.43 A multifaith chaplaincy service is provided 24 hours per day, although there is no
Imam in post at present. There is a multifaith chapel and a mosque on site, but CHI
was informed that the mosque is only used by staff.
3.44 The trust has developed an initiative to help people find their way around by
providing site maps, identifying architectural features and explaining how to read the
signs. Hostesses are also available at the reception areas to take patients to wards and
departments. The League of Friends and the Womens Royal Voluntary Service are also
involved in this initiative. However, CHI found that some of the signage was poor and
noted that several people still had difficulty finding their way.
PATIENT COMMENT
I There are dietary problems for ethnic minorities, for example, there is no Halal food except
what the family brings. They think they produce ethnic food but what they do produce is
inedible. Menus need to be in other languages, as do instructions on medicines, as many
people cannot read them.
NOTABLE PRACTICE
I The chaplaincy service has conducted focus groups with recently bereaved people to
establish the type of service relatives and friends would like to be offered at this difficult
time. This has been used to develop the trusts end of life policy and changes to practice have
been made to ensure that the dying experience is made as positive and caring as possible.
I The trust should ensure that they are able to cater for the dietary and spiritual needs of
people from ethnic minority communities. Use of the mosque should also be available to
patients and their relatives and an Imam should be appointed.
I The trust should take action to address issues of confidentiality in the medical assessment
unit.
The environment
3.45 The current trust estate reflects a piecemeal historical pattern of development. The
Royal Infirmary is generally in a poor condition with a range of old Victorian
buildings that are not appropriate for todays service needs. Access to the hospital is
particularly poor. The City General has been developed over recent years but some old
buildings remain. Approximately 70% of the buildings have been deemed to be in
physical condition category C, which means they are unacceptable for high quality
patient care.
3.46 The Fit for the Future project states that all acute services should be moved to a
new hospital on the City General site. In addition the trust and its partner
organisations plan to develop the community hospital services to deliver intermediate
care alongside the primary care services.
3.47 In the meantime the trust has started to upgrade the main reception areas,
public/visitor toilets and some of the ward areas to bring them up to a satisfactory
standard of decoration and cleanliness.
3.48 CHI observed that generally the public areas and many of the wards were clean
although the dcor was often shabby. However, some wards appeared quite dirty.
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3.49 Space is a major problem in A&E. At the time of the visit six patients were being
cared for in the resuscitation room which contains only four cubicles. Care could,
therefore, be compromised due to the availability and difficulty in accessing
emergency equipment. Patients privacy and dignity was also being compromised. A
lockable examination cubicle was available for patients who required a high degree of
privacy.
3.50 The A&E waiting room appears small for the number of people waiting, although
there are good facilities for relatives, including a quiet and comfortable private room.
3.51 Children are cared for in the specifically designed paediatric assessment area. The
assessment areas, crche and family waiting facilities were developed following wide
consultation with the public and children coming into the department. Local people
were also involved in helping to raise money for the area. CHI commends the trust on
the development of this area.
3.52 The fracture clinic waiting area is also small and the consulting rooms afford
little privacy. Consultants could be heard talking to patients and speaking into
dictaphones.
3.53 The plaster room in the fracture clinic was very noisy, dusty, dirty and there was
water all over the floor. Two patients were having their plaster removed whilst sharing
one examination couch. There were no facilities for children in either the waiting
room or the plaster room.
3.54 Some of the older wards were very cluttered and have little storage space. CHI felt
that the toilets on a number of wards were too small and saw that nurses had some
difficulty assisting patients to the toilet. The trust has acknowledged the inadequacies
of some areas and is progressing a programme to update them.
3.55 Many patients and stakeholders commented that there was a general lack of
facilities for relatives to get refreshments out of hours. The trust have agreed to review
this situation.
NOTABLE PRACTICE
I The A&E department houses a crche, staffed by play therapists. All children coming into the
department can use this facility, whether for treatment or with relatives.
I The trust is urged to continue work to improve the environmental standards in wards,
departments and in its grounds to bring them up to acceptable standards.
I The trust should take action to improve the environment and practices in the fracture clinic.
I The trust must make every effort to ensure that staff, patients and the local community are
involved in shaping the environment for care delivery in the new hospital.
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The availability and use of clinical information and information about the performance of the
trusts staff and processes underpins the trusts ability to improve services. This chapter examines
what information is available and how effectively it is used by the trust.
ASSESSMENT I
Little or no progress at strategic and planning level, or at operational level.
The trust acknowledges that the information management and technology (IM&T) strategy,
written in 1999, is out of date. It was based on the in house hospital information system
(HISS), which was first established in 1992.
CHI found a growing concern regarding the weakness of the system and a general lack of
confidence in the system. The information available from HISS just meets statutory
requirements but does not lend itself to the retrieval of clinical information. There is a
general lack of use of information to inform the clinical governance agenda. CHI found the
HISS to be a major drawback to organisational development.
The trust has decided that the HISS system should be replaced as part of the Electronic
Patient Record (EPR) project. The West Midland Regional Office of the NHS Executive has
complemented the Local Implementation and EPR strategies.
The trust has recently appointed a board level director who will lead the development of
IM&T and knowledge management in the future.
Information about the patient experience
4.1 Most wards and departments carry out regular patient satisfaction surveys. A
comment card system has been in operation since 1993 and reports are presented to
the board. In 1999, a review of the system found it achieved a low response rate. Other
than this system, CHI found no unified trust wide approach to this and no evidence of
sharing mechanisms for improving services.
4.2 CHI found evidence of a number of stand alone databases, such as a diabetic
register covering 85% of the population and of systems used to provide information
about infection control and discharges.
4.3 CHI found evidence that the trust uses patient information from complaints to
advance practice. Examples of such changes include: notices displayed in the cardiac
unit to instruct about the removal of pacing wires; a new system of handover in
obstetric and gynaecology; an appointments coordinator in the nutrition and dietic
department to deal with all diabetic referrals; clear guidelines for transporting patients
around the hospitals and the introduction of new documentation that incorporates the
physical, psychological and social needs of the patients. These are only a few examples
of changes made following complaints from 1999/2000.
CHAPTER 4 : USE OF INFORMATION 15
4 | Use of information
4.4 In 2000/2001, the trust received 587 complaints of which only 190 were concluded
locally within the national target of four weeks. There were 279 concluded locally but
outside that timescale and, at the end of the year, 118 were still being dealt with. There
were nine requests for independent review, six of which were resolved by local
resolution and three that are continuing. The Health Service Ombudsman undertook
one investigation and found in favour of the complainant.
4.5 The trust paid out on 29 claims during 2000/2001.
I The major complaint reported to the CHC is about the length of time that the trust take to
resolve complaints.
I The trust is proactive about complaints handling, they have done lots of work and lots of
training in complaints handling but they do seem to take a long time.
4.6 The in house information system has major limitations and does not provide
clinical information required to help improve patient care and support clinical
governance throughout the organisation.
4.7 Pathology, radiology and renal systems have already been procured and are at
different stages of implementation. The genito urinary medicine system and network
are currently being upgraded in order to ensure data confidentiality.
4.8 The hospital information system had operated via terminals, therefore access to
personal computers (PCs) has been limited and patchy. The trust is now pursuing the
procurement and roll out of PCs throughout its hospitals.
4.9 Many of the clinical teams collect their own clinical data for use within the
directorates and divisions, some of which is of a high quality. Many of these systems
are paper based. The information tends to be used for individual needs and directorate
performance. CHI found limited use of data collection to change practice, although
good examples exist in obstetrics such as the achieving sustainable quality in
maternity services initiative.
4.10 The trust does not currently have an intranet. A pilot project will be undertaken
in February 2002 and will include some basic management and corporate information.
A basic electronic newsletter allows the electronic circulation of some information.
4.11 The IM&T directorate receives several ad hoc requests per day for information
from directorates and generally can help. Most of the staff we spoke to report that they
found the IM&T staff very supportive and helpful. CHI was informed that few
individuals were aware of the scope of information that was available and most didnt
know how to retrieve it.
STAFF COMMENT
I I can usually get what I want but you have to question the quality of the data. I think the
performance data is accurate.
4.12 CHI found that ownership of information throughout the trust is a major problem.
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4.13 The Caldicott guardian is the associate medical director clinical governance. We
found that many people knew the name of the Caldicott guardian but did not
understand about Caldicott principles. The trust has a Caldicott policy and has
implemented a training programme to ensure that staff understand the Caldicott
principles.
4.14 In many wards and departments noticeboards with patient names were in
evidence. Staff were unaware of the implications of having these noticeboards in
public areas. CHI also observed patient notes left on top of unattended desks, unlocked
notes trolleys left in the middle of wards and notes and x-rays left in boxes open to
public access.
4.15 A number of staff were aware of data security and confidentiality issues and
there were many examples of good practice, such as leaflets and poster displays
explaining confidentiality. However, several members of staff thought this related just
to using the computer, telephone and fax machine.
Information about resources and processes
4.16 The IM&T directorate has focused on the development of robust waiting list
management. Up to date information regarding patient access issues is prepared each
Monday evening in readiness for the trusts performance management meeting on
Tuesday mornings.
4.17 CHI did not find any robust mechanisms at clinical team level for the use of
clinical information. We did find some ad hoc use of clinical information within
certain directorates/divisions, though this was often limited.
4.18 The trust employs seven IM&T trainers and has three IT training rooms. IT skills
training is provided during the induction programme; additional training is available
on how to use a computer and how to use the hospital information system (HISS).
Many staff said they were not aware of any IT training and only a very few said they
had received training on how to use the hospital information system.
4.19 To date, IM&T has not been part of the clinical governance agenda.
4.20 Links with GPs are limited, although by March 2002, approximately 60% of
practices will have access to pathology results. The trust works closely with the North
Staffordshire Combined Healthcare NHS Trust in terms of local technical agreements
and technical developments. The involvement of primary care trusts varies and is
dependant on the enthusiasm of individuals within those organisations.
4.21 The trust believes it has robust project management arrangements in place to
pursue the implementation of an electronic patient record system. It is envisaged that
the core administration elements will be implemented by summer 2003. However, CHI
found a total disconnection between planning for the future and current practice.
CHAPTER 4 : USE OF INFORMATION 17
I Urgent action needs to be taken to improve the time taken by the trust to respond to
complaints.
I Trust wide approaches should be further developed in order to ascertain patient satisfaction
with services. Results from all patient satisfaction surveys should be bought to the attention
of the trust board. Mechanisms for improving services should be shared across the trust and
the results of change monitored and reported accordingly.
I The trust needs to monitor the capacity of the current hospital information system closely
and must select areas for improvement before the implementation of electronic patient
records in 2003.
I The trust should ensure that IM&T strategies and implementation become an integral part of
the clinical governance agenda.
I The trust needs to speed up the implementation of new hardware within clinical areas to
ensure that all clinical areas can access email and the intranet and internet.
I The trust must formalise processes to ensure that clinical teams are able to access the
clinical data that is available.
I Current IM&T training provision needs to be more focused and targeted at key clinical staff.
An extensive training needs analysis will need to be undertaken in preparation for the
introduction of electronic patient records. CHI urges the trust to start this in the near future
and plan appropriate training programmes.
I The trust should ensure that any system procured has robust mechanisms for collating high
quality clinical information. The system should have the capability to draw on existing data
and integrate the current stand alone systems.
I CHI urges the trust to work in collaboration with its partners to ensure the local
implementation plan is implemented. Some of the content and timeframes require
adjustment.
This chapter looks at how the trust ensures that its staff are able to provide the best care and
treatment of patients, for example through training, supervision and education, and at the
processes the trust uses to check and improve the quality of its services
ASSESSMENT I I I
Good strategic grasp and substantial implementation. Alignment across the strategic and
planning level, and the operational level of the trust.
CHI found considerable evidence of excellent development of patient consultation and
involvement at strategic level.
The trust has a patient partnership and participation strategy, has had an active patient
advocacy service for over a decade and has developed a health panel of patients and the
public to help share service delivery and facilities for the future.
Patient consultation and involvement at operational level lacks consistency, although most
directorates/divisions have developed good practices. Plans are in place to ensure a consistent
approach is taken across the organisation.
Patient and public involvement
5.1 The trust has an up to date, clear, ratified strategy for patient involvement. The
patient partnership and participation strategy includes a corporate action plan with
22 objectives.
5.2 The trust has had a patient advocacy service and a patient partnership steering
group for several years. They offer patients, carers and the wider public the
opportunity to be involved in planning, delivery and monitoring of services. The trust
has established a health panel of patients, carers and local people who can be called
upon to advise on a wide range of issues. The health panel has enabled the trust to
host numerous events to inform the Fit for the Future project. The trust should be
commended for adopting this approach.
5.3 Work is already underway to expand the patient advocacy service in line with the
aspirations of the NHS Plan. A bid has been put to the West Midlands Regional Office
for funding to start a pilot study for a patient advice and liaison service (PALS) and
patient forum and also to facilitate training for PALS.
5.4 The trust plans to appoint a project manager who will be responsible for the
development and implementation of a centralised patient information centre.
5.5 The trusts patient partnership and participation coordinator is a member of the
Health Authoritys (HAs) patient partnership group and staff contribute to work within
the trust.
CHAPTER 5 : RESOURCES AND PROCESSES 19
5 | Resources and processes
NOTABLE PRACTICE
I The health panel, in partnership with the trust, has organised two workshops and a patient
partnership conference that focused on what clinical governance means for patients.
I A black and ethnic minority working group has been set up to help the trust improve the
information it provides for patients from these communities.
5.6 Through the work of the patient partnership and participation steering group
patient appointment and admission letters have been redesigned and standardised.
They include site maps, regional maps, bus route details and other general
information.
5.7 A programme of focus groups has taken place with some specific user groups, such
as patients with cancer, diabetes and haematology and respiratory conditions. These
have resulted in a number of changes of practice, for example, a private room has
been made available for breaking bad news to haematology patients and relatives.
5.8 The concept of public involvement has achieved recognition across the trust and is
a key element of the corporate business plan. Each division has a lead manager
responsible for the implementation of a divisional plan to complement the corporate
plan. A steering group is responsible for monitoring the application and relevance of
the plans and ensuring the strategic objectives are met.
5.9 The trust is currently undertaking the National Acute Hospitals Inpatient Survey.
Most departments seek patients views about the service. CHI found that some
departments dont involve patients in any other way. Examples of good patient
involvement include the diabetes service, the hysterectomy support group, the
development of paediatric facilities in A&E and the estates department.
5.10 The Community Health Council (CHC) makes frequent visits to the trust. The CHC
reports that it has good relationships with the trust and that the trust responds to most
of the issues it raises. The CHC reported that there was a considerable amount of praise
for the staff and that patients appreciate the work they do under difficult conditions.
Issues that have concerned the CHC include lack of cleanliness, waste disposal, poor
management of particular wards, nutrition and dietary advice and communication
with patients.
STAFF COMMENT
I We do try and have a patient focus and a lot of us support the corporate push but much
depends on the consultants in the directorates and divisions. If they are supportive things
get done, if not, its very difficult.
I There is a big problem with culture, some consultants dont like patients being involved.
I The trust is constructive, it is very open and does value and consider the views of patients
and other organisations.
5.11 Customer care training began in April 2001. A phased approach was adopted and
training has been delivered in a number of ways such as inclusion in the corporate
induction programme, programmes targeted at staff working in reception areas and
via a National Vocational Qualification (NVQ) for staff who have a significant amount
of contact with service users, internal and external stakeholders and the public.
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5.12 The trust has formal mechanisms for reporting and handling both verbal and
written complaints. Every attempt is made to resolve verbal complaints at ward or
department level, but if they are not resolved at this level they must be reported to the
complaints department. All written complaints are registered with the department.
5.13 A report providing an analysis of complaints is presented monthly to each
directorate and is reviewed at the directorate clinical governance meetings. A quarterly
report is presented to the trust board detailing the number and nature of complaints
received by each division.
PATIENT COMMENTS
I I dont think they listen to verbal complaints, I didnt receive a response although I asked for
one and have been told several times that I would get one.
5.14 Some of the staff we spoke to had been trained in complaints handling, many
had not. We found that there were some differences of opinion on how to handle
verbal complaints.
5.15 CHI saw cards and letters of thanks prominently displayed on notice boards.
5.16 The trust has a do not resuscitate (DNR) policy and has developed appropriate
patient records to document the involvement of the patient and carers in the decision.
All nursing and medical staff we spoke to were aware of the DNR policy but
commented that they would have to look through the notes to find the
documentation; consequently it could be missed.
NOTABLE PRACTICE
I The trust has recently undertaken a pilot study to introduce red DNR forms that can be easily
recognised in the notes. There are now plans in place to roll this out throughout the trust.
5.17 The trusts consent policy gives clear guidelines on who can obtain consent and
makes explicit the need to identify the risks and benefits of proposed treatments. We
found evidence that consent is taken by the practitioner who is able to carry out the
procedure in accordance with national guidelines.
5.18 A standard for the production of patient information has been developed. A
system to review all information has been developed and help is available to support
the production of appropriate written information for patients. A patient information
booklet was in evidence on all patient lockers, but was only available in English.
I The trust must ensure that formal mechanisms exist, at all levels and with all staff groups, to
involve patients. The trust must ensure these are monitored and that good practice is shared
throughout the trust and used by all to inform service delivery.
I The trust should ensure that all staff are offered training in complaints handling and
customer care and proactively encouraged to undertake it.
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Risk management
ASSESSMENT I I
Worthwhile progress and developments at strategic and planning levels and at operational
level but not across the whole organisation.
The trust has developed comprehensive and robust risk management processes and is
committed to ensuring lessons are learned from adverse events.
Staff feel able to report both clinical and non clinical risks within a culture that is open and
supportive.
Considerable progress has been made within the last year and the trust should be commended
for its progress and approach to risk management.
Currently risk management is not an integrated part of the wider quality and clinical
governance agendas. CHI found that many staff at grass roots level were unaware of some of
the initiatives being progressed, whist others were not fully signed up to the trust processes.
5.19 The trusts clinical risk management strategy states that effective risk
management leads to better communication and cooperation throughout the
organisation and ensures an open and blame free environment in which incidents are
identified, assessed early and action is taken to ensure events are managed in a
positive and responsive way.
5.20 All reported incidents are recorded on a computerised system. This allows for
early recognition of potential risk areas and the identification of trends, thus allowing
appropriate changes to practice. The trust has a single incident reporting system
covering all clinical areas.
5.21 A clinical risk management panel meets twice a month and provides quality
control on the management and investigation of serious adverse incidents and ensures
lessons learned from these are fed into practice.
5.22 The trust has established risk registers for each division and, as part of this, a
programme of risk assessments across all clinical divisions, began in September 2000.
The trust is currently undertaking a pilot of an electronic risk assessment tool to aid
ongoing organisational analysis of risk and the prioritising of risk prevention plans.
5.23 A systematic programme of educational sessions on clinical risk management is
in place. Staff reported that they had been made aware of the policy at the induction
programme and many had received further training. Not all staff had been offered the
opportunity to undertake training.
5.24 The majority of staff CHI spoke to said they felt able to report both clinical and
non clinical incidents within a culture that is open and supportive. A small number
expressed concern that not every incident was reported and that medical staff felt it
was not their responsibility to report incidents.
STAFF COMMENT
I I feel I could speak up if I saw an area of risk. There is an open culture, its much more about
learning from what has happened than trying to blame someone.
5.25 The trust has identified five key streams of trigger events: administration of
medicines; specimen collection and transportation; patient falls; nurse staffing levels
and intra hospital transfers. These have been used to provide learning opportunities
for staff, for example, an education programme on patient falls that has resulted in the
development of a falls risk assessment tool.
5.26 Discussions on risk management take place in the directorate clinical governance
meetings where feedback from incidents should be reported. Staff told CHI that they
often did not receive feedback on an incident that they were involved in or reported
on and therefore did not feel involved in the identification and development of
changes in practice.
5.27 CHI noted that the obstetric unit had taken a proactive approach to clinical risk
management in a variety of ways. Examples include the audit of daily partograms,
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the training of midwives to provide care to critically ill mothers, the inclusion of risk
factors in the intra partum care record, the relocation of the midwife led unit close to
the labour ward and benchmarking against national standards.
5.28 The annual report on control of infection 1999/2000, stated that the trust had
experienced 546 methicillin resistant staphyloccus aureus (MRSA) outbreaks and 91
cases of clostridium difficile in that year. CHI found evidence that the number of
patients acquiring MRSA was rising and the trust could not accommodate all these
patients in single rooms.
5.29 We found that the infection control team encourages hand washing or alcohol
rubs as a means of control. CHI found that on most of the wards we visited hand
washing facilities were adequate. However, we observed that some members of staff
did not wash their hands between dealing with patients, did not use gloves to deal
with blood products and kept gloves and aprons on whilst answering the telephone.
5.30 An audit of MRSA on manual handling devices, such as slings and slides has
highlighted deficiencies in cleaning. An infection control plan is produced annually.
5.31 The trust has recently made several infection control nurse (ICN) appointments.
The team now comprises five full time equivalent nurses. This is slightly above the
nationally recommended level of one ICN per 250 beds.
PATIENT COMMENT
I I picked up MRSA whilst in there. It put my recovery back but they didnt really seemed too
bothered.
5.32 The trust achieved accreditation at level 2 of the clinical negligence scheme for
trusts (CNST) and has been urged to go forward for level 3 assessment. Recognition
was given that the trust is implementing an effective clinical risk management system
that is actively encouraging a culture of openness amongst its staff.
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A graphic record of the course of labour.
5.33 In pathology, all departments except histopathology and cytology have clinical
pathology accreditation (CPA); this is a nationally recognised standard of excellence.
5.34 CHI was informed that junior doctors working in medicine were often
inadequately supervised and often left alone on wards, particularly on the medical
assessment unit (MAU). During an evening visit we found only two junior doctors
covering MAU, which was full to capacity, with a further junior doctor covering MAU
and emergency admissions; one junior doctor covered the medical wards and one
covered medical outliers but these patients could be on wards on either site. CHI felt
this situation posed a potential clinical risk to patients. This was brought to the
attention of the trust.
5.35 Through the medical services review and in response to reports from royal
colleges and the development of the medical school the trust has undertaken a
considerable amount of work to address this situation. However, CHI was informed
that despite this, the situation remains difficult.
I The trust must take urgent action to address problems related to workload, work patterns
and supervision of junior doctors working in medicine.
I The trust needs to develop audit programmes to ensure any changes in practice, made
following the identification of a clinical risk, are effective.
I The trust must continue to develop its clinical risk management processes, ensuring that
they become integrated with the wider quality and clinical governance agenda.
I Action needs to be taken to ensure that all staff are encouraged to report and record
incidents and that feedback and learning from incident reporting is consistent across the
trust.
I The trust must take action to address the rise in MRSA, implement good practice in infection
control and ensure policies are understood and complied with.
Clinical audit
ASSESSMENT I I
CHI found little evidence of the trust board influencing the strategic agenda for clinical audit
but there is considerable enthusiasm and worthwhile development at operational levels.
The trusts clinical audit department has a high profile both locally and nationally and
provides good training and support for the audits it gets involved with. However, CHI found
that many audits did not receive the support of the department, with staff investing long
periods of their own time conducting paper based searches. No mechanisms exist to recognise
the results of these. CHI found that the audit department appears to be involved with high
profile audits.
There is a large amount of audit activity, both involving the audit department and individually
led, with some evidence of change in practice as a result. However, there is little evidence of
reauditing to ensure change is effective and little evidence of the audit programme being
integrated with wider quality initiatives.
There are some examples of audit activity with partner organisations but limited evidence of
patient involvement in the design and planning of audit programmes.
5.36 The clinical audit director takes the lead for clinical audit within the trust. The
divisions decide priorities for clinical audit after discussion with the clinical
directorates and senior managers within the divisions. There is no evidence of the trust
board influencing the strategic direction of clinical audit.
5.37 CHI was informed that in the near future the clinical governance board would
agree the audit programme for the trust and receive the clinical audit annual report
plus individual reports with details of specific issues. At present implementation of
changes in practice following audit is the responsibility of the individual divisions and
therefore changes to practice may not happen.
5.38 The clinical audit department provides clinical audit services to both the North
Staffordshire Hospital NHS Trust and the Combined Healthcare NHS Trust. The annual
budget for North Staffordshire Hospital NHS Trust is 256,585, which provides for the
employment of the clinical audit staff, equipment and clinical audit training.
5.39 Staff in the clinical audit department are organised into four clinical teams, each
led by a senior clinical advisor. Three of the teams provide support to the trust; each
division has its own identified audit team.
5.40 Proposals for clinical audit are put forward by clinical teams and prioritised by
the clinical directors within the divisions. CHI found little evidence of widespread staff
or patient involvement in the decision making process. Each audit is developed by a
steering group of relevant staff, facilitated and assisted by a member of the clinical
audit department. The audit department is unable to facilitate all audit priorities and is
therefore selective about those that it is involved in.
5.41 The trust has developed a comprehensive approach to training in clinical audit.
The clinical audit department provides a wide range of multidisciplinary training in
the principles and practice of clinical audit including aspects of evidence based
practice.
5.42 The department has been recognised as an exemplar of good practice for training
by independent bodies such as the Kings Fund and CASPE Healthcare Knowledge
Systems Limited.
5.43 CHI found that many audits were carried out using paper based systems and
required extensive searching through notes.
STAFF COMMENT
I If the audit department cannot support the audit you want to do then you spend hours,
most of which is in your own time, going through notes to get information, people are put
off undertaking audits because patient care has to come first.
NOTABLE PRACTICE
I Obstetrics and gynaecology has implemented a coordinated approach to both clinical audit
and research activity through the development of a coordinator post. This post provides
assistance in undertaking audit and research activity, help with writing bids for funding and
writing for publication, help in identifying changes in practice, ensuring that audits of the
effectiveness of these practices are undertaken and ensuring that audit and research inform
each other.
5.44 Nursing has recently developed a set of 30 evidence based patient care standards
along with a programme for their implementation and an action plan identifying a
programme of future audits.
5.45 CHI found some evidence of patient and carer involvement in clinical audit
including the impact of the Parkinsons disease nurse led service, an audit of
documentation used on wards 64 and 65 and an audit of stroke management.
5.46 CHI found several examples of audit topics and findings being openly discussed
in directorate clinical governance meetings and various team meetings. However, we
found little evidence of sharing and dissemination across the trust.
5.47 There are a number of examples of audit leading to change in practice. On
completion of each project an action plan is drawn up to implement appropriate
change. An annual report is presented to the trust board. However, there was limited
evidence of reauditing of the result of the initial audit, to ensure that any changes
made had improved practice and patient care.
5.48 CHI found evidence that many areas were undertaking audits without the
involvement of the clinical audit department but these were often not fed into the
trusts audit system. Staff reported that a system did not exist to do this.
5.49 Clinical audits have been undertaken in partnership with the North Staffordshire
Combined Healthcare NHS Trust, and other local hospital trusts, the North
Staffordshire Medical Audit Advisory Group (MAAG), the Staffordshire Ambulance
Service NHS Trust and voluntary organisations. During 2001/2002 the trust plans to
undertake audit with the local education department on hearing aids, with health
promotion on smoking cessation and social services on looked after children.
5.50 CHI found several examples of multiprofessional audit and work across teams, for
example, an audit of the fractured neck of femur pathway that also involves social
services.
5.51 CHI was informed that guidelines from the National Institute of Clinical
Excellence (NICE) are disseminated via the clinical governance group but the trust
cannot guarantee that these are being passed down to junior staff and it cannot
guarantee that they are being used.
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I CHI recommends that the trust takes a strategic approach to clinical audit. Priorities for
audit should be driven by clinical and organisational need. Audits should involve the
multidisciplinary team, be supported by the clinical audit department and audit results
should be disseminated throughout the trust in order to inform patient service delivery.
I A systematic approach should be taken to implementing changes in practice identified by
audit. We recommend that reauditing takes place to ensure that changes to practice, made
as a result of audit, are effective in improving patient care.
I NICE guidelines and any other evidence based standards should be incorporated into practice
and audited to ensure their implementation.
I There is a need to link clinical audit and research to ensure that audit informs research and
vice versa.
Research and effectiveness
ASSESSMENT I I I
Good strategic grasp and substantial implementation. Alignment across the strategic and
planning level, and the operational level of the trust.
CHI found evidence of substantial implementation of research and development across both
strategic and operational levels.
The trust has clear structures, strategies, lines of accountabilities and a robust research
governance framework that has been developed following some high profile difficulties with
research practice in the past.
A research and development consortium has been developed in partnership with the North
Staffordshire Combined Healthcare Trust and there is a comprehensive multidisciplinary
research and development programme (R&D).
The trust needs to ensure that research findings inform the delivery of evidence based
practice at all levels of the organisation.
5.52 Research practice in the trust has received some bad press in recent years. The trust
has learnt from this and now has robust mechanisms to safeguard patients. The trust has
a clear strategy and structures for managing research and development (R&D). The
director of R&D takes the lead for research activity within the trust. All research
proposals must go through the trusts R&D executive committee to ensure they are of a
high quality. Only then can they be passed to the local research ethics committee (LREC).
5.53 The trust, in partnership with the North Staffordshire Combined Healthcare NHS
Trust has formed an R&D consortium. Since the establishment of the consortium clear
management arrangements have been put in place. The consortium management
board oversees R&D across the two trusts. This board has membership from Keele
University, the trusts main postgraduate link. The consortium has also established
good links with Staffordshire, Manchester and Birmingham universities.
5.54 A dedicated R&D office provides statistical advice and internet access to national
research registers. The annual R&D report (2000/2001) demonstrates a successful year,
attracting funding in grants and awards amounting to 10 million.
5.55 The trust has an up to date and clearly documented research governance
framework in place. Staff involved in research were well informed on this and copies
are sent to all those expressing an interest in undertaking research.
5.56 The research agenda is designed to inform evidence based practice in the delivery
of healthcare to the residents of north Staffordshire now and in the future. Research
activity centres around four key programmes: clinical and cellular engineering, health
service research, genetic predisposition and the molecular pathology of disease and
clinical trials. Each area has a programme director who helps shape the overall
direction of research within the programmes.
5.57 An information leaflet for patients and parents of patients, entitled Clinical
Research Why get involved? aims to raise awareness of research issues and helps
them decide whether they wish to take part in any research programmes they may be
asked about. An audit of the readability of the leaflet has been undertaken. No
information is available specifically about children.
5.58 The research governance framework and the LREC require consent to be sought
from all patients who are to be involved in research. Those undertaking research sign
up to these principles and will be held to account and face disciplinary procedures if
they do not adhere to them.
PATIENT COMMENTS
I No consent was obtained for my child to be involved in research. I am still in dispute with
the trust.
I I am happy to be involved in research. I was fearful because Id read all about things in the
newspapers but the trust have been up front with me and explained everything fully. I had to
sign a consent form to say I agreed to be involved.
STAKEHOLDER COMMENT
I The trust have had a hard time with research in the past, they have learnt their lessons and
now must have one of the most robust mechanisms you could find.
5.59 CHI found some evidence, at directorate level, that a number of national
standards were being implemented. However, some directorates are finding this
difficult, for example, the guidance from the gynaecology clinical outcomes group is
still not being implemented despite the standard coming out in 1999.
5.60 The trust is making some progress in developing a care pathway approach to
care, for example, A&E has developed a care pathway for vulnerable adults. A number
of staff interviewed informed CHI that often pathways were only used by one or two
disciplines and that the pathway would stop when a patient moved into another
directorate. We were informed that not everyone agreed with their use.
5.61 Several clinical areas have developed evidence based practice guidelines, policies
and procedures and standards for treatment and care.
5.62 A good library and access to health related databases are available at the medical
institute for all staff. We were informed that there were also libraries on each site that
staff could use.
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5.63 Some individuals commented that it was often difficult to access library facilities
due to the pressure of work and felt they would be able to incorporate evidence into
their practice better if they could access the internet on their wards or in their
departments. The trust plans to invest in more computers for clinical areas that will
make access easier.
NOTABLE PRACTICE
I An audit of research governance issues is currently being undertaken to ensure research
projects are being managed appropriately, for example, auditing of informed consent for
participation in research. The results will be widely available and the audit will become an
integral part of the clinical audit cycle.
I The trust must develop mechanisms to ensure that research informs practice through the
development of evidence based standards. These should then be audited and the results used
to inform future research programmes.
I The trust needs to establish a strategic framework for the development and implementation
of standards and evidence based, integrated care pathway approaches to care.
Staffing and staff management
ASSESSMENT I I
CHI was impressed with the commitment and dedication of staff and found worthwhile
development at both strategic and operational levels although some inconsistencies exist.
The trust has implemented a Beyond Hierarchy project aimed at creating a climate of staff
involvement and empowerment and a staff charter has been developed by staff. CHI found
evidence that these had a positive effect on the working environment.
The trust needs to progress work to improve communication across the trust, improve medical
staffing levels in the medical division and change the culture in some divisions.
5.64 The trust board ratified the human resources (HR) strategy in May 2001. The trust
has established an HR subcommittee to oversee the strategic development of HR in line
with national frameworks and local service objectives.
5.65 The board has made a commitment to taking forward actions to achieve
accreditation of the Governments Improving Working Lives standard.
NOTABLE PRACTICE
I The trust and executive board have ratified a charter produced by staff. The Staff Charter
pinpoints key rights, as well as responsibilities for staff, including a safe and healthy working
environment, training to keep people up to speed so that they can carry out their jobs safely
and efficiently, equal opportunities, clear job descriptions, occupational health and
counselling services, and employee friendly working environments.
5.66 The trust commissioned the University of Birmingham to undertake a survey that
identified how effective the trust had been in involving staff in influencing
improvements in the trust and in improving working lives.
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5.67 The trusts approach to corporate health and safety management and its Beyond
Hierarchy project have both received Beacon Site status. The Beyond Hierarchy
initiative was developed to create a climate of staff involvement and empowerment
with the primary aim of encouraging staff to work together and influence the way in
which the trust is organised. Staff CHI spoke to all said this had had a positive effect
on the work environment.
5.68 CHI found evidence of employee friendly policies, for example, career break and
retainer schemes that mean staff can take unpaid leave for between three and 12
months for a variety of reasons, including education, travel and personal development.
5.69 Core and team briefings from the boards are cascaded throughout the
organisation every month. Some junior staff informed us they were not kept informed
of what was going on in the trust. The scheme is to be evaluated for its effectiveness.
STAFF COMMENTS
I There doesnt seem to be a hierarchical structure in the trust.
I There is support for staff from management but it does take a long time to get things
changed
I The staff charter is very positive, however, communication is a problem, and things dont
seem to get cascaded through to ward level.
5.70 A revamped corporate induction programme has been available since 31 March
2001; all new staff are required to attend.
5.71 All staff attend a full day induction programme and clinical staff are required to
attend another half day session. Junior medical staff are not allowed onto clinical
areas without receiving induction training and occupational health clearance.
5.72 The induction programme for nurses recruited from the Philippines is particularly
thorough. Staff have been offered the opportunity to take additional English lessons
and all receive a welcome and welfare pack that goes above and beyond those offered
by many organisations that have undertaken overseas recruitment. Sessions were also
held with ward staff to prepare them for the arrival of the overseas recruits,
particularly focusing on the responsibilities for supervising the nurses practice. CHI
commends the trust on its approach to the recruitment of nurses from overseas.
5.73 A performance management framework exists but its effectiveness across the
trust is patchy. The trust is committed to ensuring appraisal for all consultants and
career grade doctors. However, we were informed that some consultants were not
willing to implement performance appraisal, as they do not agree with the principles.
CHI was informed that about a quarter of all other staff had not had an appraisal
recently. All catering and hotel services staff have received appraisals during the last
12 months.
5.74 Midwives reported that they were always able to meet their midwifery
supervision requirements. Nurses and AHP reported that they often found little time
for clinical supervision.
5.75 Some junior doctors appear to achieve their protected time for training and have
access to support from the director of postgraduate medical education. However, CHI
was informed that some SHOs are not allowed to take advantage of their protected
teaching time, as the wards are too busy.
5.76 The trust is having difficulty achieving the New Deal for junior doctors (SHOs).
The trust has 254 junior doctors working on 39 rotas. At the last report to the NHS
West Midlands regional office (September 2001) there were 111 junior doctors on 11
rotas who did not comply. CHI was assured that the trust had monitored the rota in the
autumn and it was compliant. However, we were informed that most junior doctors in
medicine were still working as they had done prior to changes in the rota.
5.77 A working party, including SHO representation, has been established to look at
addressing the New Deal.
5.78 There were a number of concerns raised regarding consultant support and
supervision for junior doctors working in medicine. We were told of a number of
occasions when it was felt that there was a lack of support both during the day, and
when problems arise whilst on call. The trust has acknowledged that medical staffing
at all levels is under resourced in medicine. This is due to be addressed as part of the
medical services review.
STAFF COMMENTS
I Despite the problems the hospital is a good hospital, although terribly busy and incredibly
hard work, especially on wards.
I I came here because I wanted to work with X, its been a much better experience that Ive
had previously and Ive had excellent support and learning opportunities, but I think that
depends on how keen your consultant is.
5.79 The trust has appropriate mechanisms in place to check the registration status of
staff. A policy has been developed to ensure staff fulfil their requirement to re register,
including checking on bank, agency and locum staff.
5.80 The HR strategy is designed to ensure that the trust has the right number of staff,
working in the right place, with the right skills and support to enable them to perform
their role to the best of their ability.
5.81 The trust has 5,143 full time equivalent staff. This is over 50% more than a
comparable large trust. This figure must be viewed in context; the trust has 28% more
beds and undertakes around 30% more activity than comparable trusts. The trust has
recently developed a workforce plan that takes account of skill mix and workload
indicators such as bed occupancy, patient activity and the population served.
5.82 The trust generally has a stable workforce; many of the staff have never worked
in another NHS trust. The main recruitment problem facing the trust is recruiting staff
to posts where there are national shortages, like medical physics, radiology, some of
the AHPs, intensive care nursing, A&E and orthopaedic consultants. CHI found
evidence of proactive recruitment practices, for example, return to nursing practice
programmes and study leave incentives for professions hard to recruit to.
5.83 The trust has recently recruited 140 nurses from the Philippines and is expecting
more shortly. Staff and stakeholders reported that in some areas there appeared to be
insufficient nursing staff.
5.84 A trust workforce plan is currently being developed as part of the Fit for the
Future project.
STAFF COMMENTS
I We never seem to have enough staff on wards, we are always fire fighting, I dont know
who makes the decisions about staffing levels.
PATIENT COMMENTS
I There are problems in maternity. When I was there one midwife was covering three of us
who were about to give birth.
I The trust seems to expect nurses and doctors to work long hours without breaks.
5.85 A limited occupational health service is provided by the trust. A recall
programmes for Hepatitis B immunisation began in January 2002 although no
programme exists for health monitoring, as required by health and safety law.
However, a staff support service, providing counselling and stress management
services has been in place since 1993. Staff commented that this was an excellent
service.
5.86 A new harassment and bullying policy has been developed with the help of staff
focus groups. The policy is currently under consultation with staff representatives.
5.87 CHI found evidence of an extensive programme of training to help staff deal with
violence and aggression. The trust has received national recognition for the work it
has done on violence and aggression, in partnership with Staffordshire police.
5.88 The trust has an equal opportunities policy. All staff CHI spoke to were aware of
its existence.
NOTABLE PRACTICE
I The trusts zero tolerance strategy has been published nationally. The trust should be
commended on its approach to safeguarding staff.
I The trust must take urgent action to address all of the cultural and medical staffing issues in
the medical division.
I The trust should review the current nursing and midwifery workforce levels and develop
mechanisms to ensure that each ward and department has the appropriate number of nurses
and midwives.
I CHI urges the trust to make improvements to the occupational health service and as a
minimum meet the monitoring requirement required by health & safety law.
I The trust needs to develop mechanisms to ensure that all staff have access to clinical
supervision and protected teaching time.
I The trust must develop mechanisms to ensure that all staff have regular appraisal.
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Education, training and continuing personal and
professional development
ASSESSMENT I I
The trust demonstrates a clear commitment to education, training and continuing
professional development and CHI found that this commitment is recognised by staff across
the trust.
The trust has made considerable efforts to align activity across strategic, planning and
operational levels of the organisation, this is especially so in nursing and midwifery. CHI
found evidence that most staff have good access to both mandatory training and professional
development. However, there are several areas where there are inconsistencies between
strategic and operational level and inconsistencies within the divisions.
The trust will need to consider an increase in staff and resources to support the development
of medical education across the trust in light of the medical school developments.
5.89 The trust does not have a strategic training and development plan, however a
health economy organisation plan has been developed and was ratified by the health
economy partnership board in January 2002. The trust states that it encourages life
long learning but the trust needs to ensure that the meaning of this is communicated
to staff.
5.90 Training and development is organised according to professional groups, the
heads of these professional groups are accountable to the executive board.
5.91 Budgets to support continuous professional development are held by the director
of nursing and operations for nurses, the medical director for career grade doctors,
postgraduate deans for junior doctors medical and dental education and the directors
of the AHPs. In addition, the divisions have study leave budgets that are allocated on
priorities each year and the organisational development department holds a budget of
37,000 which is primarily allocated to team, department and divisional learning and
development.
5.92 CHI found evidence that the trust encourages access to mandatory training and
professional development. However, CHI found that some wards and departments do
little to foster this encouragement and staff have to pay for study themselves and
attend courses in their own time. Course attendance records are held either in wards
and departments, the organisational development department or by the heads of the
occupational group, depending upon the type of training.
5.93 We found a considerable amount of evidence of information relating to education
and training opportunities which is circulated widely throughout the trust. A
newsletter has been developed to advertise general training opportunities and these are
routinely posted on noticeboards and in Trust-wide News. A practice development unit
(PDU) has been set up to support nursing and midwifery education and training.
Weekly education meetings support and underpin formal educational programmes for
junior medical staff.
5.94 Training needs are identified via the appraisal process and fed into the divisional
training and development. Resources are identified either within the divisions or fed
through to the organisational development department. Ring fenced resources are
available for professional and leadership education and development. CHI found
evidence of inconsistencies with the appraisal process and therefore the current
method of identifying training needs may not provide an accurate picture.
STAFF COMMENTS
I There are good opportunities for training. I have found that the trust is very supportive both
in terms of funding training and study leave.
I Mandatory training provision is good, funding is always found for these.
I You have to pay for professional courses yourself and do them in your own time.
5.95 NVQs are available in business administration, management (for all staff) and
care (up to level 2) for health care assistants. A number of health care assistants
informed us that they would like opportunities to progress to level 3.
5.96 Junior medical staff have protected teaching time and lunchtime learning
sessions. Some junior doctors reported that they were not always able to take
advantage of this.
5.97 CHI found that leadership development was well supported. Many nurses and
midwives have undertaken or are undertaking the national nurse LEO programme and
the trust is supporting several clinical staff through the Shropshire and Staffordshire
Leadership programme. The trust has also implemented its own development
programme for nurses and clinical leaders programme aimed at medical staff. The trust
is commended on its approach to leadership development and succession planning.
5.98 The trust encourages the secondment of clinical staff into management projects
and roles, for example to the PDU, undergraduate medical school, the Fit for the
Future project and the EPR benefit realisation project.
5.99 CHI found evidence of a large number of ad hoc education and training
opportunities such as lunchtime learning sessions, in house study sessions, conferences
and ward and departmental training, many of which are multidisciplinary. The director
of nursing and operations offers nurses and midwives weekly opportunities to shadow
him, which many nurses and midwives have taken up.
5.100 Pharmacy technicians have been encouraged to develop their role. A member of
staff won the National Pharmacy Technician of the Year award for 2000 in recognition
of work undertaken to extend the use of IT to improve information to pharmacists and
the trust board on quality standards, drug expenditure and cost savings.
5.101 The trust has appointed two consultant nurses, one in rehabilitation and one in
cardiothoracic surgery.
5.102 The trust has links with Keele University for medical education and the
development of the medical school and with Staffordshire University for both pre and
post registration education for nurses and midwives. The trust also has links with
Manchester and Birmingham universities.
5.103 The trust has been awarded additional specialist registrar training places in
paediatrics and cardiology; a number of junior doctor posts in medicine have been
temporarily withdrawn and a specialist registrar post in haematology is no longer
included in the University of Birmingham rotation.
5.104 A number of royal collages have visited the trust within the last two years
with generally favourable reports. The Pre-Registration House Officer Inspection
(January 2001) identified some major problems in medicine that must be addressed in
order to promote an appropriate learning environment. These include the very heavy
workload, excess clerical work, loss of continuity to care, ward rounds not occurring,
no post take review with a consultant and poor team working. Regular ward rounds
have now been introduced but CHI found that many of the other areas for action had
not been completely addressed.
5.105 The recent English National Board visit, in conjunction with Staffordshire
University, concluded that in all the areas visited, there was a strong cohesive culture
of team working within nursing and the appropriate implementation of models of care,
both of which provide positive support for the student learning experience.
I The trust must develop appropriate clinical leadership within the medical division and
provide support in addressing the problem areas.
I The trust must take action within the medical division to rectify all the issues identified in
the Pre-Registration House Officer Inspection.
I The trust should take action to ensure a consistent approach to education, training and
continuing professional development that offers all staff equal opportunities.
I Appropriate mechanisms for undertaking training needs analysis need to be developed.
This chapter describes the capacity of the trust to implement clinical governance and, through it,
improve services for patients.
KEY FI NDI NGS
CHI found evidence of strong, proactive leadership with a clear vision about the future. The
new executive team and strengthened management structures offer the potential to develop
the clinical governance agenda and fully integrate the components of clinical governance.
The trust board needs to strengthen its communication links with the divisions and provide
support and guidance in the development of a shared approach to clinical governance.
There is a need to mirror the strategic approach to partnership working at operational level in
order to establish effective cross divisional working and sharing of good practice.
The trust needs to take action to ensure that members of the public are provided with the
opportunity to shape the delivery of services in all clinical areas in the same way as they have
done at strategic level.
Leadership
6.1 The trusts executive team has undergone considerable change over the last year.
The new chief executive and other members have given new impetus to progressing
the strategic direction and leadership of clinical governance. Clinical governance has
to date been somewhat fragmented. Work on the components has been progressed but
there is little evidence of the integration of the components.
6.2 There has been renewed recognition that, if the trust is to progress with the
implementation of the clinical governance framework and the modernisation agenda,
a number of key areas within the trust need strengthening and current service delivery
patterns need to change. The trust is in the process of appointing an executive director
of IM&T/knowledge management and has recently appointed an executive director of
human resources.
6.3 Staff informed CHI that they liked and respected the senior management team. We
were told that the open management style was improving communications and that a
positive, listening culture was developing. Staff reported that they have confidence in
the new executive team and its ability to provide the strategic direction for the
organisation. However, staff also felt that, at present, there was some disconnection
between the corporate and divisional agendas, as well as a disconnection between
divisions.
6 | Strategic capacity
STAFF COMMENT
I There is a need to alter the mind set, particularly in some divisions, in order to integrate all
professions and stop divisions and directorates working in isolation.
6.4 Staff told CHI that they had seen members of the executive team, particularly the
director of nursing and operations, out and about around the trust. Very few of the
staff CHI spoke to, other than senior clinicians and managers, knew who the
non executives were or what their role was.
6.5 The executive team are perceived both from within the trust and by external
organisations to provide strong leadership for the trust.
Accountabilities and structures
6.6 The medical director is accountable for clinical governance on behalf of the chief
executive. A number of aspects of clinical governance, notably controls assurance and
clinical risk management, sit with the executive director of nursing. Close working
relationships ensure a joint approach. An associate medical director has lead responsibility
for ensuring that the clinical governance agenda is progressed at operational level.
6.7 The trust board has delegated responsibility for clinical governance to the clinical
governance board. Membership of the board includes CHC and patient representation.
6.8 The divisions have established their own clinical governance groups. The groups
meet monthly and their main functions are to develop, advise on, coordinate and
provide the framework for quality improvement and clinical governance throughout
the divisions.
6.9 The clinical governance accountability report 2000/2001 states that the trust has
an impressive agenda of strategic and clinical governance priorities to address over the
next five years. As part of the enhanced focus on the convergence of risk and clinical
governance the trust has recognised the need to ensure lessons are learned and fed
back into practice.
Direction and planning
6.10 The trust has reviewed the services it provides and how resources will support
future potential capacity. However, the trust needs to take action to deal with current
capacity problems and improve patient flow through the care system.
6.11 The Fit for the Future project and the modernisation agenda, including the
implementation of the electronic patient records, are all examples of the trusts
commitment to face and meet the challenges in the NHS Plan. CHI found that the trust
recognised the key role health economy partners in north Staffordshire had played in
these developments.
CHAPTER 6 : STRATEGIC CAPACITY 37
6.12 In focusing on the future performance of the organisation the trust must ensure
the integration between the operational level and the trust board. Resources must be
aligned to support clinical service delivery.
STAFF COMMENTS
I A lot of services get excluded from decision making.
I Management are more concerned with meeting targets than treating patients.
Partnerships with the patients and the public
6.13 CHI found some very good examples of involvement of patients and the public.
The CHC carries out regular visits to wards and departments with the support of the
trust. The CHC reported that the trust often contacts them to look at specific areas on
their behalf.
6.14 The trust has had a patient advocacy service for a number of years and is keen to
progress its PALS service. We would encourage the trust to ensure patient involvement
at all levels.
Partnerships with other health and social care
organisations
6.15 The trust has good working relationships with both West Midlands Regional
Office and North Staffordshire Health Authority. Statutory stakeholders indicated that
greater effort was needed in forging stronger partnerships, particularly with PCTs and
social services.
STAKEHOLDER COMMENT
I The trust see themselves as the major players, they need to stop believing they are self
sufficient and work in true partnership to achieve this vision for the future.
6.16 The trust has some already well established clinical links and participates in
clinical networks. The trust will need to build on and extend these links to ensure
appropriate services are delivered to the public in the future.
I CHI found that clinical governance is currently somewhat fragmented and not clearly
understood throughout the organisation. The trust should take action to develop a cohesive
strategic framework for clinical governance that incorporates a multidisciplinary and multi
agency model of service delivery that puts the patient firmly at its core.
I Action needs to be taken to develop more effective links between the divisions and the trust
board. This will include:
G the establishment of effective communication links between the trust board and staff at
operational level in order to develop a shared approach and ownership of the clinical
governance agenda
G the provision of support and guidance
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I The trust should take action to build on and further develop effective partnerships
throughout the whole health economy and lead the development of clinical networks.
I The trust should take action to ensure staff understand the role that the non executive
directors play in the delivery of services to patients.
I The trust must ensure that all the components of the Fit for the Future project are
progressed and communicated effectively. The project must be reviewed continuously to
ensure it has the capacity to deliver the requirements for future service delivery.
CHAPTER 6 : STRATEGIC CAPACITY 39
Sue Mackie
Assistant Director Clinical Governance
Ealing Hospital NHS Trust
Yi mien Koh
Director of Public Health and Health Policy
Kensington, Chelsea and Westminster Health Authority
Jane Darling
Superintendent Radiographer for Special Procedures in Radiology/Cardiology
Eastbourne Hospitals NHS Trust
Dawn Johnston
Head of Midwifery and Paediatrics
Dartford and Gravesham NHS Trust
Rebecca Pritchard (lay member)
Clerk to the Council, Brierley Town Council
David Whittaker (lay member)
Educational Management Consultant
The CHI review manager was Karen Wilson
APPENDIX A
The review team
CHI collected information about the trust and its services from a wide variety of sources
including:
I national data about trust activity
I the trusts data about each episode of patient treatment
I the trusts own reports about its clinical governance activity
I reports of other external reviews of the trust, for example made by the Audit Commission
and the royal medical colleges
I interviews with patients, trust staff and representatives from local health and social care
organisations and
I diaries completed by recent patients
Details of the number of individuals and organisations who provided information are given in
the table below.
Number
Stakeholders for example, patients, carers, GPs, local public
I meetings* 25
I letters, e-mails and phone calls 14
I diaries 50
Organisations for example, health authorities, social services, primary
care groups, community health council
I meetings* 12
I letters, e-mails and phone calls 2
Trust staff
I interviews* 94
* These refer to numbers of meetings and interviews held. The numbers of individuals is higher as some stakeholders,
organisations and staff were seen in groups.
APPENDIX B : SOURCES OF EVIDENCE 41
APPENDIX B
Sources of evidence
CHI is introducing a systematic framework for assessing clinical governance in trusts so that
judgements made in reports of reviews are reliable, fair and consistent. The assessment
framework is being developed with the National Clinical Governance Support Team in England
and the Clinical Governance Support and Development Unit in Wales. This will ensure that
consistent messages are given to trusts about clinical governance.
CHIs model for clinical governance (Figure 1) illustrates its belief that effective clinical
governance depends upon a culture of continuous learning, innovation and development and
will improve patients experiences of care and treatment in hospital. Over time, CHI will use the
information it accumulates from reviews to help to determine which aspects of clinical
governance are the most important for improving patients experiences and outcomes.
Figure 1: CHIs model for clinical governance
Work is in progress to identify the dimensions of the patient experience and outcomes under
the Results part of the model so that CHI can assess the information it collects about what it is
like to be a patient and interpret information about clinical processes and care outcomes.
CHI evaluates clinical governance by exploring three key, interlinked areas identified in the
model:
I Strategic capacity: how far does the trusts leadership set a clear overall direction that
focuses on patients? How well is it integrated throughout the trust?
I Resources and processes: how robust are its processes for achieving quality improvement,
such as consultation and patient involvement and clinical audit? How effective are the
trusts arrangements for staff management and development?
I Information: what information is available about the patient experience, outcomes,
processes and resources, and how does the trust use it strategically and at the level of
patient care?
APPENDIX C
CHIs assessments of clinical
governance
Each of these areas comprises a number of components that CHI examines in every trust. CHI
has so far identified seven components of Resources and processes and Use of information
(Figure 2). Work is being carried out to identify the components of Strategic capacity.
Figure 2: Components of clinical governance resources and processes and information
Resources and processes Component
(i) processes for quality Consultation and patient involvement
improvement Clinical audit
Clinical risk management
Research and effectiveness
(ii) staff focus Staffing and staff management
Education, training and continuing professional and personal development
Information Use of information to support clinical governance and health care delivery
CHIs review teams assess how well clinical governance is working throughout the trust by
making enquiries about each of these seven components at corporate and directorate levels and
in clinical teams. This involves collecting information systematically about review issues that
have been defined for each component. CHI will introduce similar methods to assess
information collected about components of strategic capacity in future rounds of reviews.
There is wide variation within trusts in progress made developing the component parts of
clinical governance. At this stage of development, CHI believes it is most useful to trusts to
assess each component separately to help them prioritise their development of clinical
governance and will not make judgements to produce an overall rating for a trust. On the basis
of the evidence collected, CHIs reviewers assess each component against a four point scale:
I. Little or no progress at strategic and planning level, or at operational level
The lack of strategy and implementation means that the organisation does not have the systems
and processes for it to be sure that adequate quality of care and services are (or are not) being
achieved. Systems for improving the quality of care and services through systematic learning
do not exist or are underdeveloped.
There may be isolated examples of strategy development or where progress has been made
implementing elements of clinical governance often the result of an individuals enthusiasm
and initiative, rather than part of organisational development.
II. Worthwhile progress and development at strategic and planning levels but not at
operational level
or
Worthwhile progress and development at operational level but not at strategic and
planning levels
or
level but not across the whole organisation
The organisation does not have comprehensive systems and processes for it to be sure that
adequate quality of care and services are (or are not) being achieved. Systems for
improving the quality of care and services through systematic learning are not fully
developed. However, there will be examples where:
I a coherent strategy has been developed but where implementation of it has not yet
occurred; or
APPENDIX C : CHIS ASSESSMENTS OF CLINICAL GOVERNANCE 43
I parts of the organisation have implemented sound systems and processes but these are
not connected to strategy development; or
I there is coordinated strategy development and implementation, but not covering all
aspects of the component of clinical governance or not involving all parts of the
organisation.
III Good strategic grasp and substantial implementation. Alignment across the strategic and
planning level, and the operational level of the trust
The activity is explicitly part of the organisations strategy for clinical governance and
systems and processes are implemented in most parts of the organisation.
The organisations systems provide it with information that the quality of care and services
are (or are not) being achieved in most parts of the organisation. There are systems for
identifying and correcting deficiencies and for taking preventative measures to ensure that
they do nor recur, through systems for improving the quality of care and services though
systematic learning may not be fully developed.
IV Excellence coordinated activity and development across the organisation and with
partner organisations in the local health economy that is demonstrably leading to
improvement. Clarity about the next stage of clinical governance
There is good understanding across the organisation at Board, executive team and clinical
team levels about the place that the activity plays in safeguarding and improving the quality
of care and services. There is coordinated development across the organisation and with partner
organisations in the local economy e.g. other NHS organisations, local authorities, voluntary
groups.
Systems and processes are mature such that there is systematic learning from them that has
lead to strengthening of patients safety and to improvements in the quality of care and
services.
A&E see accident and emergency.
accident and emergency the part of the
hospital concerned with the immediate
treatment of patients who have had an
accident or who require medical or
surgical emergency care.
accountability responsibility, in the
sense of being called to account for
something.
Action On an NHS Modernisation
Agency initiative that supports the
management of change in a particular
area of practice, for example, waiting
lists.
action plan an agreed plan of action
and timetable that makes improvements
to services, following a clinical
governance review.
acute care/trust/hospital short term (as
opposed to chronic, which means long
term).
Acute care refers to medical and
surgical treatment involving doctors
and other medical staff in a hospital
setting.
Acute hospital refers to a hospital that
provides surgery, investigations,
operations, serious and other
treatments, usually in a hospital setting.
advocacy/advocate a scheme which
represents individual patient views or
concerns An advocate is a person
unrelated to a patient who can speak on
their behalf and make a case for their
welfare.
allied health professionals professionals
regulated by the Council for Professions
Supplementary to Medicine (new Health
Professions Council). This includes
professions working in health, social
care, education, housing and other
sectors. The professions are art
therapists, music therapists and
dramatherapists, prosthetists and
orthotists, dieticians, orthoptists,
occupational therapists,
physiotherapists, biomedical scientists,
speech and language therapists,
radiographers, chiropodists and
podiatrists, ambulance workers and
clinical scientists. Also called
professionals allied to or supplementary
to medicine.
appraisal an assessment or estimate of
the worth, value or quality of a person
or service or thing.
audit, clinical audit an examination of
records to check their accuracy. Often
used to describe an examination of
financial accounts in a business.
In clinical audit those involved in
providing services assess the quality of
care. Results of a process or
intervention are assessed, compared
with a preexisting standard, changed
where necessary, and then reassessed.
baseline assessment a look at what is
currently happening, usually with a
view to making a change or
improvement.
benchmarking a process of comparison
with similar groups to see how local
practice matches that in similar
situations elsewhere.
Caldicott guardian a senior healthcare
professional in each NHS organisation
who is responsible for safeguarding the
confidentiality of patient information.
Dame Fiona Caldicott reviewed the
protection and use of patient
information in 1997 and made 16
recommendations. These included the
establishment of a guardian, who is a
senior person in each health
organisation and responsible for
safeguarding the confidentiality of
patient information.
cancer centre a major provider of
(usually) specialised cancer services,
and is at the hub of the cancer
network. A cancer unit is (usually) a
district general hospital (at a spoke)
which deals with most patients, but
refers specific cases to the cancer
centre.
APPENDIX D : GLOSSARY 45
APPENDIX D
Glossary
cancer network a new structure for
bringing together the organisations and
people who commission and provide
services in the field of cancer to deliver
a comprehensive cancer service for an
area covering a population of about one
to two million people.
care pathway a description of the
journey taken (or intended to be taken)
through a clinical service. Some have
defined it as a defined set of treatment
and care steps designed to meet the
particular need of each patient.
care process the description of what
happens to a patient from the time they
enter the health service.
carers eople who look after their
relatives and friends on an unpaid,
voluntary basis often in place of paid
care workers.
Career grade doctors Casemix the
variety and range of different types of
patients treated by a given health
professional or team.
CHI see Commission for Health
Improvement
CHKS Limited (formerly CASPE
Healthcare Knowledge Systems Limited)
a company that compares hospitals
clinical activity with other
organisations that are locally relevant.
Typical comparisons can be at trust,
hospital, specialty and procedure or
diagnosis level. Examples of CHKS
appraisals include risk assessments.
clinical any treatment provided by a
healthcare professional. This will
include, doctors, nurses, AHPs etc.
Non clinical relates to management,
administration, catering, portering etc.
clinical audit the continual evaluation
and measurement by health
professionals of how far they are
meeting standards that have been set
for their service. Standards can be set
by health professionals themselves, or
others. Successful clinical audit also
involves changing practice to meet the
standards.
clinical director the clinician (often a
doctor) who is accountable for clinical
and sometimes management elements
of service delivery.
clinical effectiveness for individuals, the
degree to which a treatment achieves
the health improvement for a patient
that it is designed to achieve.
for whole organisations, the degree to
which the organisation is ensuring that
best practice is used whenever
possible.
clinical governance refers to the quality
of health care offered within an
organisation.
clinical governance review a review of
the policies, systems and processes used
by an organisation to deliver high
quality health care to patients. The
review looks at the way these policies
work in practice (a health check for a
health organisation).
clinical governance review report an
objective description of the policies in
place and how they work to ensure
good quality patient care. The purpose
is to identify areas for improvement and
to encourage the spread of good ideas.
It does not cast judgment on members
of staff, and it does not classify the
quality of care provided.
clinical incident something (usually an
error) that occurs in a hospital or in the
community where actual or potential
harm may have been experienced by
patients or the public.
clinical indicators selected
measurements of clinical care which
help NHS staff to judge how well they
are doing. Government publishes some
of these annually.
clinical information information about
treatments given to a patient by a
health professional. Could also mean
information collected by the
organisation about clinical practice (of
individuals or teams).
clinical networks a group of services
which work together across
organisational boundaries to provide
better patient care. For example, in
cancer services where the cancer unit
and the cancer centre work together to
care for patients. Similarly a group of
surgeons may work together across a
district to provide a full service to a
number of hospitals.
clinical outcome the effect of a
treatment on the health or well being of
an individual.
clinical practice methods of delivering
health care.
clinical risk something associated with
healthcare which could cause harm.
clinical risk management understanding
the various levels of risk attached to
each form of treatment and
systematically taking steps to ensure
that the risks are minimised.
clinician/clinical staff a fully trained
health professional doctor, nurse,
therapist, technician etc.
clinical negligence scheme for trusts
(CNST) an insurance scheme for
assessing a trusts arrangements to
minimise clinical risk which can offset
costs of insurance against claims of
negligence. Successfully gaining CNST
standards (to level one, two, three)
reduces the premium that the trust must
pay.
clostridium difficile a bacterium that
causes serious diarrhoea and vomiting,
often in older people. It is difficult to
treat with standard antibiotics, and
therefore can be a significant problem
when it occurs.
combined clinic a clinic for patients
where they will meet all (or most) of the
clinicians likely to be involved in their
care and possibly some others, such as
specialist nurses.
(CHI) independent national body
(covering England and Wales) to
support and oversee the quality of
clinical governance in NHS clinical
services.
community care health and social care
provided by health care professionals,
usually outside hospital and often in the
patients own homes.
Community Health Council (CHC) a
statutory body sometimes referred to as
the patients friend. CHCs represent the
public interest in the NHS and have a
statutory right to be consulted on health
service changes in their area.
computed tomography (CT) scan a scan
using x-rays that shows a detailed cross
section of tissue structure in the body.
Often used to help diagnose or monitor
conditions affecting the abdomen, head
or chest.
consent permission, from a patient or
sometimes a patients nearest relative,
to allow a health treatment or
investigation to happen.
consultant a fully trained specialist in a
branch of medicine who accepts total
responsibility for specialist patient care.
(For training posts in medicine see
specialist registrar, senior house officer
and preregistration house officer.)
Core income money that is given to an
organisation by the government to
provide healthcare services for local
people.
cost improvement programme treating
more patients for the same amount of
money (or the same number for less, so
called cash releasing cost
improvement).
CPA clinical pathology accreditation.
day case overstay rate a measurement of
the number of patients intended to be
treated as a day case who need to stay
overnight.
day case patient a patient who is
admitted to hospital for treatment but
does not need to stay overnight. Usually
offered to patients requiring minor
surgery.
did not attend (DNA) usually used to
refer to patients who missed their
outpatient appointment.
discharge planning a thorough
assessment of the needs of the patient
when they leave hospital and return to
their home, or another place. It often
includes joint work between the
hospital and social services to plan how
patients can leave hospital as soon as
possible to continue their rehabilitation
in the community.
DNA see did not attend.
do not attempt resuscitation (DNAR) or
do not resuscitate (DNR) an instruction,
which says that if a patients health
suddenly deteriorates to near death, no
special measures will be taken to revive
their heart. This instruction should be
agreed between the patient and doctor
or if a patient is not conscious, then
with their closest relative.
elective a planned hospital procedure as
opposed to one carried out in an
emergency.
electronic patient records (EPR) details
of patients and patient care stored
electronically rather than on paper. An
aim of the NHS is to work towards
storing records electronically rather
than on paper.
emergency admissions an unplanned
admission to hospital as a result of an
emergency such as an accident or a
sudden illness. This is usually through
A&E department or through a GP
organising an immediate admission.
English National Board (ENB) a public
body that approves higher educational
institutions in England to conduct
nursing, midwifery and health visiting
education programmes.
evidence based clinical guidelines
guidelines (drawn up to assist
clinician/patient decisions in specific
clinical circumstances) that have been
produced from a sound research base.
evidence based practice clinical staffs
use of recent research or new guidelines
to guide their practice. These practices
include searching for evidence to guide
clinical decisions, critically appraising
the evidence to make sure that it applies
to the patient in question, applying it
and auditing success. Evidence based
practice also relates to the application
of clinical guidelines.
finished consultant episode (FCE) a
period of continuous consultant
treatment under a specific consultant. If
a patient is transferred from one
consultant to another it will be counted
as two FCEs.
fractured neck of femur a broken leg
bone, right next to the socket in the hip
joint.
general medicine a branch of medicine
concerned with a variety of medical
disorders.
general practitioner (GP) a family
doctor, usually patients first point of
contact with the health service.
general surgery the branch of surgery
which covers a broad range of
conditions.
governance assessment, control,
monitoring.
GP see general practitioner.
gynaecology a branch of healthcare
which is concerned with conditions
affecting the female reproductive
system.
health action zone (HAZ) regional
initiatives set up by the government to
improve health in targeted areas of poor
health and deprivation.
HAZs are made up of members from the
NHS, local authorities voluntary and
private sectors, coordinated by a local
partnership board.
health authority (HA) statutory NHS
body responsible for assessing the
health needs of the local population,
commissioning health services to meet
those needs and working with other
organisations to build healthy local
communities.
health community or health economy all
organisations with an interest in health
in one area including the community
health councils, and voluntary and
statutory organisations.
health improvement programme (HimP)
a locally agreed work programme to
improve health and which delivers the
national priorities and targets.
Health Service Ombudsman investigates
complaints about failures in NHS
hospitals or community health services,
about care and treatment, and about
local NHS family doctor, dental,
pharmacy or optical services.
Anyone may refer a complaint but
normally only if a full investigation
through the NHS complaints system has
been carried out first.
inhouse information system (HISS) an
information system, developed by North
Staffordshire NHS Trust that collates
information about all patients
admission and stay in hospital, for
example, their date of admission and
how long they have been in hospital,
how long they have waited for an
operation etc. From this the trust is able
to identify the total activity in a given
period, for example, the number of
patients waiting for an operation.
histopathology specialising in the study
and diagnosis of diseases of tissue cells.
Improving Working Lives a Department
of Health initiative launched in 1999. It
includes standards for developing
modern employment services, putting in
place work/life balance schemes and
involving and developing staff.
incident reporting system a system
which requires clinical staff to report all
matters relating to patient care where
there has been a special problem.
incidents something which has
happened that is out of the ordinary
which may be harmful to patients.
independent review stage two of the
formal NHS complaints procedure, it
consists of a panel, usually with three
members, who look at the issues
surrounding a complaint.
infection control a set of procedures to
prevent the spread of infection. This
will include washing of hands, use of
sterile equipment etc.
information management and
technology (IM&T) a term that
encompasses the way an organisation
manages its information using
technology, ie the computer system for
handling its information more
effectively.
inpatient a patient who stays overnight
in hospital.
integrated (general and geriatric)
medicine a model of care for older
people where general physicians and
geriatricians work together.
integrated care pathway see care
pathway above.
intervention a treatment given to a
patient by a health care professional.
intranet an organisations own internal
internet which is usually private.
Investors in People a national quality
standard which sets a level of good
practice for improving an organisations
performance through its people.
individual performance review (IPR)
usually an annual process to look at
staff performance against previously
agreed objectives.
information technology (IT) includes use
and supply of all computer systems.
Jarman score or index the measurement
of deprivation in the population based
on census data.
junior doctors usually refers to doctors
working in a hospital who are not
consultants. Consultants are referred to
as senior doctors.
Kings Fund accreditation a process by
which health services are audited for
quality. It is no longer run by the Kings
Fund but by an independent not for
profit charity called Health Quality
Service.
lay member a person from outside the
NHS who brings an independent voice
to CHIs work.
leading empowered organisations (LEO)
programme a three day training
programme designed to equip health
care professionals for leadership and to
make changes in NHS organisations.
local research ethics committee (LREC) a
committee which approves research
projects on ethical grounds.
medical the branches of medicine
concerned with treatment through
careful use of drugs as opposed to
(surgical) operations.
medical admissions unit an area where
patients can go after they have been
admitted via A&E which allows the
patients assessment and treatment to
begin immediately. Patients may be
discharged directly from an admissions
unit, or may be transferred to a ward
for longer term care (i.e. usually more
than a day).
medical director the term usually used
for a doctor at trust board level (a
statutory post) responsible for all issues
relating to doctors and medical and
surgical issues throughout the trust.
Methicillin resistant staphylococcus
aureus (MRSA) a bacterium resistant to
a wide range of antibiotics. If a patient
is infected they can become seriously
ill, or may die (this is more likely if the
patient is already unwell).
morbidity rates information relating to
numbers of people affected by disease,
expressed as a rate (for example, the
number of cases per 10,000 population).
mortality rate the number of deaths in a
given period and for a given size of
population.
modern matron used in the NHS Plan
(2000) to describe a senior nurse with
clear authority at ward level. They will
control resources to sort out the
fundamentals of care, including
resolving clinical issues, such as
discharge delays, and environmental
problems such as cleanliness.
The NHS Plan requires that by April
2002, every hospital will have such
senior nurses who are easily identifiable
to patients and who are accountable for
a group of wards.
multidisciplinary team a group of people
who are from different professional
backgrounds concerned with the
treatment and care of patients, who
meet regularly to discuss patient
treatment and care.
myocardial infarction (MI) a heart
attack.
national confidential enquiry into
perioperative deaths (NCEPOD or CEPOD)
concerned with maintaining high
standards of clinical practice in
anaesthesia and surgery, through audit
of hospital deaths which occur within 30
days of any operation. This activity has
resulted in the production of guidance
for NHS hospitals about how to run
some elements of surgical practice (e.g.
the provision of adequate facilities out of
hours). Generally, hospitals are expected
to comply with these standards.
national data set a standard set of data
items (statistical evidence), concepts and
definitions to enable the production of
national and nationally comparable data.
National Institute for Clinical Excellence
(NICE) a part of the NHS set up to
provide clinical staff and the public in
England and Wales with guidance on
current treatments.
national performance indicators
statistics recorded by the Department of
Health on a range of specific treatments
to allow comparison and measurement
of NHS organisations. Also called
national indicators.
National Service Framework (NSF)
guidelines for the health service from
the Department of Health on how to
manage and treat specific conditions, or
specific groups of patients e.g. Coronary
Heart Disease NSF, Mental Health NSF.
Their implementation across the NHS is
monitored by CHI.
national targets a nationally agreed
target that all NHS organisations must
achieve. It includes waiting times for
appointments.
New Deal for junior doctor hours a
national standards for the number of
hours that junior doctors are allowed to
work.
NHS performance rating an annual
summary of the performance of NHS
organisations by the Government, also
called star ratings, Organisations are
given a number of stars ranging from 0
(lowest) to 3 (excellent) to reflect their
performance on a set of key indicators.
This rating will affect an organisations
funding and its degree of autonomy.
Performance ratings for NHS trusts were
published in September 2001.
NHS regional office offices responsible
for the strategic management of the
NHS and monitor the performance of
health authorities, trusts and primary
care trusts in England. They are part of
the Department of Health and the
people who work there are civil
servants. There are eight regional
offices of the NHS executive in
England.
NHS trust a self governing body in the
NHS, which provides health care
services. They employ a full range of
health care professionals including
doctors, nurses, dieticians,
physiotherapists etc.
Acute trust -provides medical and
surgical services usually in hospital.
Community trust provides local health
services, usually in the community, eg
district nurses, chiropodists etc.
Combined trust community and acute
trust services under one management.
Primary care trust new organisations
that will be able to provide care usually
available from general practitioners and
their teams.
nursing director or chief nurse or chief
nursing officer the term usually used for
a nurse at trust board level responsible
for the professional lead on all issues
relating to nurses and nursing
throughout the trust.
occupational therapist a trained
professional (an allied health
professional) who works with patients
to assess and develop daily living skills
and social skills.
ombudsman see national health service
ombudsman above.
orthopaedics a branch of surgery
concerned with disorders and treatment
of the joints and bones.
outcome all the possible results that
may occur from a treatment, service or
prevention programme.
outcomes of patient care the end result
of a patients treatment (can be
interpreted widely or narrowly).
outliers patients who are placed on a
ward for patients of a different specialty
when beds are not available within their
intended ward (e.g. a medical patient
placed on a surgical ward).
outpatient services provided for patients
who do not stay overnight in hospital.
outreach clinic a clinic for outpatients
held near to where they are rather than
in the hospital where they may have
received treatment.
paediatric services healthcare services
for children.
patient administration system (PAS) a
networked information system used in
NHS trusts to record information about
inpatient and outpatient activity.
patient advice and liaison service (PALS)
a new service proposed in the July 2000
NHS plan due to be in place by 2002,
that will offer patients an avenue to
seek advice or complain about their
hospital care.
patient centred care a system of care or
treatment is organised around the needs
of the patient.
patient diaries the organisation
reviewed by CHI randomly selects
patients who have been treated over the
past two months. Diaries are sent to
them to complete about the care they
received. The patient returns the
completed diary to CHI.
patient involvement the amount of
participation that a patient (or patients)
can have in their care or treatment. It is
often used to describe how patients can
change, or have a say in the way that a
service is provided or planned.
patient pathway or journey see care
pathway above.
performance assessment framework NHS
arrangements for monitoring and
reporting the performance of local
health services. It covers six key areas
of NHS performance: health
improvement; fair access to services;
effective and appropriate delivery of
health care; outcomes from health care;
efficient use of resources; high quality
experience for patients and carers.
There is a number of prescribed
performance indicators under each
heading.
performance indicators measures to
indicate how well an organisation is
performing.
performance management using a
review process (usually results delivered
against objectives set) to assess how
well a person, team or service is
working.
performance monitoring a permanent,
ongoing system which records how a
particular service or procedure is carried
out and how well it meets targets or
standards.
perioperative literally, around the time
of the operation. In the context of a
CEPOD defined perioperative death, this
occurs within the period of 30 days
after an operation, including the
operation day.
physiotherapy the use of exercise,
massage and other physical means to
improve health and wellbeing.
preregistration house officer (PRHO) the
most junior grade of trainee doctor in a
hospital. Such doctors have only
provisional registration with the GMC
and must complete a year as such
before becoming fully registered.
primary care family health services
provided by GPs, dentists, pharmacists,
opticians, and others such as
community nurses, physiotherapists and
some social workers.
primary care trust (PCT) primary care
trusts are evolving from primary care
groups. They will have the same
functions as primary care groups but
will also commission some secondary
health care services for their population
and directly provide some community
health services.
protocol a policy or strategy which
defines appropriate action.
quality assurance framework a way of
tackling and understanding how an
organisation promotes quality.
radiographer (two branches either
diagnostic or therapeutic) a diagnostic
radiographer produces and interprets
images of the body to diagnose injury
and disease. A therapeutic radiographer
plans and delivers prescribed treatment
using x-rays and other radioactive
sources.
radiology the branch of medicine
concerned with diagnosis and
investigation of disease, primarily using
x-rays and other imaging techniques.
randomised controlled trial (RCT) a type
of experiment used to compare the
effectiveness of different treatments.
The crucial feature of this form of trial
is that patients are assigned at random
to groups which receive the
interventions being assessed or control
treatments. RCTs offer the most reliable
(i.e. least biased) form of evidence on
effectiveness.
readmission rates the rate at which
patients have to go back to hospital as
inpatients for treatment related to a
recent admission for the same
condition.
regional office see NHS regional office
above.
rehabilitation the treatment of residual
illness or disability which includes a
whole range of exercise and therapies
with the aim of increasing a patients
independence.
review team a group of about six people
from a range of backgrounds who
conduct the review visit.
rheumatology the branch of medicine
concerned with treatment of disorders
of the joints, bones and muscles.
risk assessment an examination of the
risks associated with a particular service
or procedure.
royal colleges there are over 20 royal
colleges, each representing the
professionals within a particular branch
of medicine including the Royal College
of Nursing the RCN.
sampling technique one of the ways of
selecting a sample to examine
something in more depth.
secondary care specialist care, usually
provided in hospital, after a referral
from a GP or health professional.
senior house officer (SHO) the position
gained by doctors after they are
registered as a doctor by the GMC. SHO
is the second tier of trainee doctor (after
preregistration house officer) in a
hospital.
service agreements formal agreements
between different trusts and their local
health authority or primary care
groups/trusts about the amount and
nature of services to be provided. For
example a trust may be contracted by a
primary care trust to deliver 200
cataract operations, 70 hip replacements
per year under a service agreement.
service user group a group of patients
who have used a particular service who
meet with the providers of the service to
make suggestions for improving it.
specialist a clinician most able to
progress a patients diagnosis and
treatment or to refer a patient when
appropriate.
specialist registrar (SpR) a training
position for doctors which allows them
to gain some specialist knowledge in
the field of medicine in which they wish
to become a consultant. It is more
senior than a senior house officer (used
to be called registrar or senior registrar).
Once SpRs have completed their
programme, they are eligible to apply
for consultant posts.
stakeholders a range of people and
organisations that are affected by, or
have an interest in, the services offered
by an organisation. In the case of
hospital trusts, it includes patients,
carers, staff, unions, voluntary
organisations, community health
councils, social services, health
authorities, GPs, primary care groups
and trusts in England, local health
groups in Wales.
standardised mortality ratio (SMR) a
measure used to compare death rates,
taking into account differences in age
and sex. It is the number of deaths in a
particular patient group, expressed as a
percentage of the average. It is adjusted
for differences in the age and sex
distribution of the patients involved.
Figures over 100 indicate more deaths
than average.
star rating (see also NHS performance
rating) an annual summary of the
performance of NHS organisations by
the Government. Organisations are
given a number of stars ranging from 0
(lowest) to 3 (excellent) to reflect their
performance on a set of key indicators.
This rating will affect an organisations
funding and its degree of autonomy.
Performance ratings for NHS trusts were
published in September 2001.
statutory/statute refers to legislation
passed by Parliament.
strategy a long term plan for success.
summary of evidence a confidential
report written by CHI, using patient
data and internal reports provided by
the organisation and nationally
available data. It will include findings
from the stakeholder meetings. It will
indicate which areas of the organisation
are to be reviewed.
surgery involves treatment in an
operating theatre under anaesthetic.
terms of reference the rules by which a
committee or group does its work.
tertiary care when a hospital consultant
decides that more specialist care is
needed. The patient will be referred by
their local doctor/hospital to a specialist
unit, e.g. specialist burns units,
childrens units, heart units etc.
Townsend Indicator a measure of levels
of material deprivation in an area. The
score takes account of four variables:
unemployment, overcrowding (living
conditions), lack of owner occupied
accommodation (an indicator of wealth)
and lack of car ownership (an indicator
of income).
trauma a powerful shock, injury or
wound to the body that may have long
lasting effects.
trauma list the planned operation list
for patients with trauma.
trauma service a service that provides
care for the treatment of injuries. Often
associated with accident and emergency
departments, and sometimes linked to
orthopaedics.
triage a brief assessment of patients,
usually when they first arrive in A&E,
to assess how serious their illness or
injuries are and to allocate the priority
in which they should be seen by a
doctor.
trust board a group of about 12 people
who are responsible for major strategy
and policy decisions in each NHS trust.
Typically comprises a lay chairman, five
lay members, the trust chief executive
and directors.
waiting lists the number of people
waiting for a planned procedure at an
acute or community hospital.
WEST Winter Emergency Services Team.
whistle blowing the act of informing a
designated person in an organisation
that patients are at risk (in the eyes of
the person blowing the whistle). This
also includes systems and processes that
indirectly affect patient care.
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MARCH 2002
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