Quality Account 2012/13 - Gloucestershire Hospitals NHS Trust

Quality 

Account 

2012/13 

GHNHSFT Quality Account 2012/13 

1

Table of contents 

What is 

a quality 

account? 

Introduction 4 

Our Priorities 8 

Safety 14 

Clinical Effectiveness 24 

Patient Experience 36 

Statements of assurance 46 

Review of Quality Performance 66 

Statements from stakeholder organisations 72 

Glossary of abbreviations and terms 84 

A Quality Account is an annual report 

about the quality of services provided 

by an NHS healthcare organisation. 

Quality Accounts aim to increase public 

accountability and drive quality improvements 

in the NHS. Our Quality Account looks back 

on how well we have done in the past year at 

achieving our goals. It also looks forward to 

the year ahead and defines what our priorities 

for quality improvements will be and how 

we expect to achieve and monitor them. 

Glossary Symbol 

This symbol

01 

Introduction 

We are committed to 

providing excellent care 

of the highest quality 

for all our patients 

4 GHNHSFT Quality Account 2012/13 


5

1 INTRODUCTION 1 INTRODUCTION 

Statement from Chief Executive 

I am pleased to introduce the 

Gloucestershire Hospitals NHS Foundation 

Trust Quality Account for 2012/13. 

This is our fifth Quality Account and I 

hope that once again, this report will 

demonstrate our strong commitment to 

delivering care of the highest quality. 

The delivery of high quality services has always 

been at the heart of our organisation and we 

want people to have complete confidence 

that our hospitals will provide the best care 

for all patients. Our vision as an organisation 

is to provide safe, effective and personalised 

care, every patient, every time. This vision is 

underpinned by four strategic objectives: 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

Our patients: to improve year on year 

the experience of our patients 

Our business: to ensure our 

organisation is stable and viable with 

resources to deliver its vision 

Our staff: to further develop a highly 

skilled, motivated and engaged workforce 

which continually strives to improve 

patient care and the Trust’s performance 

Our services: to improve year on 

year the safety of our organisation 

for patients, visitors and staff and 

the outcomes for our patients 

Our quality framework is based on the three 

dimensions of quality as described by Lord 

Darzi’s NHS Next Stage Review (2008): 

ÆÆ 

ÆÆ 

ÆÆ 

Safety 

Clinical effectiveness 

Patient experience 

2012/13 has been another busy and challenging 

year for us. Thanks to the determination and 

focus of our staff, we made significant and 

essential improvements to our emergency 

care pathway, employing new staff, improving 

facilities and by working with partners to 

reduce the pressure on our staff and services. 

While we are pleased with our performance 

in this area, we are not complacent and 

we know that in order to maintain high 

quality, safe and effective emergency care 

we will need to consider our approach to the 

provision of this service in the coming year. 

Another key quality improvement in 2012/13 

has been in our care for stroke patients. The 

percentage of patients spending 90% of 

their inpatient stay on a specialist stroke ward 

has increased and we are now achieving this 

target. This is the result of a move of our 

stroke services onto one site and demonstrates 

how the careful reorganisation of services 

can deliver real benefits for patients. 

I am pleased to report that we have exceeded 

our targets for several quality improvement 

priorities in the last 12 months. Our excellent 

performance in safety programmes to 

standardise and improve care for patients with 

sepsis and venous thromboembolism, as well 

as reduce the incidence of these potentially 

fatal conditions are making a real and positive 

difference to clinical outcomes for patients. 

There are also interesting and challenging 

times ahead. Like all NHS organisations we 

face increasing demands on our services; 

a growing population with an extending 

lifespan, access to new medicines and rapid 

advances in technology. We respond to these 

demands by exploring new and better ways 

of working, using the creativity of our staff 

to help us transform the way we deliver 

services. Innovation is essential for the NHS 

and there are many examples of our success 

in this area. During the year ahead we will 

be progressing one of our most ambitious 

innovations to date – a digital patient 

records system called SmartCare which will 

revolutionise communication in our hospitals. 

The Francis Report, published in February 

this year, contains many recommendations 

which have quality of care at its heart. The 

best way for us to improve our organisational 

culture is to ensure patients are at the 

centre of everything we do. We will learn 

from our mistakes and encourage greater 

involvement of patients and carers in the 

review of our services, giving us a valuable 

insight into how well care is delivered. 

Throughout this report we have shared 

some positive feedback and comments 

from patients. However, we know that on 

occasion we do not get it right and patients’ 

expectations or our own high standards are 

not met. When this happens we must learn 

from what went wrong and understand 

how we can integrate this learning into 

on-going and continuous improvement. 

As a result of the Health and Social Care Act 

2012 which came into force on April 1, 2013, 

the commissioning landscape has also shifted 

significantly and we look forward to working 

with our new partner organisations in 2013/14. 

Maintaining our excellent quality standards will 

be essential if we are to compete effectively 

with other qualified providers and our real 

commitment to success in this area will equip 

us to deal with any challenges which lie ahead. 

The pursuit of quality is a constant journey and 

this account cannot cover everything we have 

achieved in the past year or hope to achieve 

in the coming months. I hope however, that 

this report provides some insight into the work 

being carried out in our hospitals every day to 

make sure quality remains our central focus. 

I can confirm that to the best of my 

knowledge the information contained 

in this Quality Account is accurate. 

Dr Frank Harsent 



7

02 

Our Priorities 

We can improve the quality 

of our services by working 

together to reach our goals 



9

2 OUR PRIORITIES 


Each year our Quality Committee 

agrees a set of core priorities which 

help us improve the quality of the 

care we provide to patients. 

Some of these priorities are identified because 

they are important to our regulators



Priorities for improving quality in 2012 / 13 

Priorities for improving quality in 2013 / 14 

Priorities 

Incomplete 

from last year 

National 

priority for 


Issue for 

commissioners 

/ CQUIN 

Issue for 

HCCOSC 

Issue 

for LINk 

Issue for 

Governors 

Poor 

performance 

Priorities 

Incomplete 

from last year 

National 

priority for 

2013/14 

Issue for 

commissioners 

/ CQUIN 

Issue for 

HCCOSC 

Issue for LINk 

Issue identified 

internally 

1. Safety 

1. Safety 

Emergency 

care pathway 

 

Emergency care pathway 

Management of sepsis 

NHS Safety Thermometer 

NHS Safety Thermometer 

including; 

 

 

VTE assessment 

Sepsis six 

 

ÆÆPressure sores 

ÆÆCatheter induced UTI 

ÆÆVTE 

ÆÆFalls 

Medicines management 

2. Clinical Effectiveness 

Readmission rates 

Dementia 

2. Clinical Effectiveness 

Implement all NICE Quality 

standards 

 

Cardiac Output Monitoring 

during surgical procedures (HII) 

 

Acute Kidney Injury 

 

 

(PQ) 

Readmission rates 

COPD admissions bundle 

 

Dementia 

3 Million Lives (telehealth) 

 

(PQ) 

Avoidable renal failure 

 

Digital First 

 

 

(PQ) 

Cardiac output monitoring 

during surgical procedures 

 

 

Exploitation of IP 

 

 

(PQ) 

3. Patient Experience 

Supporting clinical programmes 

 

Discharge experience 

3. Patient Experience 

Responsiveness 

with emphasis on: 

ÆÆCommunication about 

treatment options 

ÆÆPeople with visual and 

hearing impairment 

ÆÆHydration 

and nutrition 

 

 

 

 

Family and Friends test 

Information for carers of people 

with dementia 

 

Personal care 

ÆÆPrivacy and dignity 

ÆÆInvolvement in decisions 

 

(PQ) 

 

Patient experience escalator 

Improving the discharge process 

Patient experience escalator 

PQ = pre-qualification requirement for CQUINs 



13

2 OUR PRIORITIES: SAFETY 


02 

Our Priorities: 

Safety 

How well have we done this year? 

Improving the management of sepsis 

Worldwide, sepsis kills more than 1,400 

people every single day. In the UK alone, it is 

estimated that more than 37,000 people die 

every year. This means that more people die 

each year from sepsis than from lung cancer, 

and from breast and bowel cancer combined. 

Sepsis is a life-threatening condition that arises 

when the body’s response to an infection 

injures its own tissues and organs. Sepsis 

can lead to shock, multiple organ failure and 

death, especially if not recognised early and 

treated quickly. Each month our hospitals’ 

Emergency Department treats between 

40 and 50 patients with severe sepsis. 

During the past two years we have had 

increasing success in implementing the ‘Sepsis 

Six’ – a simple set of six tasks which should be 

delivered by doctors or nurses within one hour 

of diagnosis. The targets in 2012/13 were to 

ensure that 75% of patients with severe sepsis 

should receive all six elements of the Sepsis Six 

within one hour of diagnosis in the Emergency 

Department and in inpatient areas, 50%. 

We are pleased to report that we have 

performed extremely well (see Fig. 1), making 

a significant improvement to the quality 

of care we provide for sepsis patients. The 

commitment of our clinicians to exceeding our 

goals has been vital in our continuing success 

in this area. We have introduced a range of 

system improvements throughout the year and 

held a number of education sessions, study 

days and café-style events to promote and 

communicate new procedures, reviewed and 

amended the format of patient documents, and 

implemented a wide-ranging communications 

campaign including Sepsis Six screensavers. 

Figure 1: Achievement of Sepsis 6 in Emergency Departments 

100 

90 

80 

70 

% OF TARGET ACHIEVED 

60 

50 

40 

30 

20 

10 

0 

Apr-12 

May-12 

Jun-12 

Jul-12 

Aug-12 

Sep-12 

Oct-12 

Nov-12 

Dec-12 

Jan-13 

Feb-13 

Mar-13 

Data 

Target 



15



Implement the NHS Safety Thermometer 

Improve the emergency care pathway 

Figure 2: Safety Thermometer audit 

The NHS Safety Thermometer was 

developed as a survey instrument that 

allows hospitals to measure the proportion 

of patients that are ‘harm free’ during their 

stay. It is based around four key nationallyrecognised 

indicators of harm to patients: 

ÆÆ 

ÆÆ 

ÆÆ 

pressure sores 

falls 

venous thromboembolism (VTE)



ÆÆ 

ÆÆ 

reducing unnecessarily long stays in hospital 

for patients who are ready to leave hospital 

further development of Surgical 

Assessment Units to assist with patients 

who are referred to hospital by their GP. 

This successful programme of work has 

contributed to good performance against 

the four hour target and in December 

2012 Monitor announced that the Trust 

was no longer in significant breach of its 

terms of authorisation. We were able to 

provide significant evidence that the Trust 

had addressed Monitor’s concerns. 

Maintaining this performance has been 

challenging for us in the last quarter of 

the year, partly due to an unprecedented 

number of attendances at our 

Emergency Departments (see Fig. 4). 

"Thank you 

@gloshospitals Ward 

6b for your care & 

support during my stay, 

am very grateful for 

all the hard work you 

invest in your patients" 

Figure 4: Emergency Department 4 hour target 

Twitter, January 2013 

100% 

95% 

90% 

85% 

80% 

75% 

Apr-12 

May-12 

Jun-12 

Jul-12 

% OF TARGET ACHIEVED 

Aug-12 

Sep-12 

Oct-12 

Nov-12 

Dec-12 




Grand total CGH GRH Target 



19



Priorities for the year ahead 

Improve the emergency care pathway 

As outlined in the previous chapter, we have 

made progress this year in achieving the 

national target to see, treat, admit or discharge 

95% of patients within four hours of their 

arrival at the Emergency Department. This 

remains a priority for us and in 2013/2014 

our focus will move to sustaining this good 

performance, examining the flow of patients 

throughout the hospital and looking at how 

we can reduce the amount of time patients 

stay in hospital once they are clinically fit 

to leave. Following a public consultation 

in the early part of 2013, we expect to 

be making changes to the provision of 

emergency care to ensure that the sickest 

patients are seen by skilled specialist staff. 

“We hope to build on 

our success in the past 

year by continuing 

to work closely with 

doctors, nurses and 

other healthcare 

professionals” 

Improve the management of sepsis 

We hope to build on our success in the 

past year by continuing to work closely 

with doctors, nurses and other healthcare 

professionals to review the way patients 

with sepsis are managed and increase the 

percentage of patients who receive the 

Sepsis Six. We will hold regular sessions with 

clinicians to discuss new ways of encouraging 

staff to ‘think sepsis’ using the ‘Plan, Do, 

Study, Act’ (PDSA) methodology



Our hospital pharmacists, as experts in 

medicine, provide advice and support 

to ensure the safe, evidence-based use 

of medicines. Working alongside senior 

clinicians they have produced guidance to aid 

the correct choice and dose of medication 

– known as a formulary. To improve the 

ability of clinicians to access and implement 

its recommendations, the formulary is now 

web-based, demonstrating compliance 

with NICE technology appraisals

2 OUR PRIORITIES: CLINICAL EFFECTIVENESS 


02 


Clinical Effectiveness 


Implement all NICE quality standards 

NICE quality standards are a concise 

set of statements designed to drive 

and measure quality improvements 

within a particular area of care. 

The standards are derived from the best 

available clinical evidence, such as NICE 

guidance. According to the NHS National 

Institute for Health and Clinical Excellence, 

the quality standards should enable: 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

health and social care professionals 

and public health professionals to 

make decisions about care based on 

the latest evidence and best practice 

people receiving health and social care 

services, their families and carers and the 

public to find information about the quality 

of services and care they should expect 

from their health and social care provider 

service providers to quickly and easily 

examine the performance of their 

organisation and assess improvement 

in standards of care they provide 

commissioners to be confident that 

the services they are purchasing are 

high quality and cost effective and 

focussed on driving up quality. 

This year we identified a clinical lead for each 

of the standards and have put in place a 

process to assess our ability to measure each of 

the 24 quality standards. We have made good 

progress and report regularly to the Quality 

Committee. 14 of the 24 Standards have been 

reviewed and assessed, 6 have been partially 

assessed, 3 required further assessment 

and one was not applicable to the Trust. 

Reduce the incidence of avoidable 

renal failure (or Acute Kidney Injury) 

Acute Kidney Injury (AKI) is a sudden loss of 

kidney function and is strongly associated 

with mortality and increased lengths of 

stay. In a hospital environment there are 

a number of reasons why a patient may 

develop an AKI, for example through 

infection or as a result of dehydration. 

A number of innovative ideas have helped us 

significantly reduce the number of patients 

affected by AKI in our hospitals this year. In 

particular, a plan to ‘flag’ adverse results from 

a key blood test indicating a high risk of AKI 

on the pathology results computer system has 

been implemented, with excellent results. 

By September 2012, we had a target to 

treat 30% of all patients ‘flagged’ on 

the pathology system as being at risk of 

AKI with a ‘care bundle’



hours. This care bundle prescribes: 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

a review by a senior clinician 

a fluid balance assessment for the patient 

a review of medication to ensure drugs 

prescribed do not adversely affect kidneys 

a repeat creatinine test (a blood test 

which measures kidney function) 

By December 2012 this target increased 

to 45% and by the end of March 2013 it 

increased to 60%. By identifying and treating 

a potential AKI at an early stage we have 

been able to significantly reduce the incidence 

of this serious condition and improve the 

quality of care for these patients (see Fig. 5). 

Reduce readmission rates 

Reducing unnecessary readmissions to hospital 

is better for patients and better for the NHS. 

In June 2012 a clinical review was carried 

out to understand which readmissions are 

truly avoidable and identify any actions in 

our hospitals or in the community which 

could have prevented readmission. 

The review found that 21% of readmissions 

within 30 days were avoidable by actions that 

could have taken place in our trust, primary 

care or community services within the existing 

systems and services (see Fig. 6). This value 

accords with the national guidance estimate 

of between 20-25% readmissions being 

avoidable. A number of service developments 

were identified for targeting funding for post 

discharge support which could help to prevent 

future readmissions. See p30 for more details. 

Increase the use of cardiac 

output monitoring 

During operations anaesthetists use a variety 

of equipment to monitor patients to ensure 

that they are stable and comfortable. Cardiac 

output monitoring is one of the tools that 

can be used; it gives information on the 

blood volume circulating each time the heart 

beats and allows anaesthetists to give fluids 

accurately throughout surgery. Having the 

right level of fluids can help speed up recovery 

and reduce post-operative complications. 

In 2012/13 we had a locally agreed target 

to increase the use of cardiac output 

monitoring. In order to achieve this, we 

targeted complex and long procedures that 

can be higher risk and patients who have 

risk factors that make them less stable. Our 

target was to achieve 20% usage of cardiac 

output monitoring in this defined group of 

patients by the end of March 2013. Figure 

7 on p29 shows that we have made good 

progress and have exceeded the target. 

Figure 5: Compliance with the AKI bundle 

RATIO PER 1000 BEDDAYS 

Figure 6: Total Readmission Activity 

RE-ADMISSION RATE % 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

7% 

6% 

5% 

4% 

3% 

2% 

1% 

4,500 

4,000 

3,500 

3,000 

2,500 

2,000 

1,500 

1,000 

500 

0% 

0 

April 

May 

June 

July 

August 

September 

October 

November 

December 

January 

February 

March 

Apr-12 

May-12 

Jun-12 

Jul-12 

Aug-12 

Sep-12 

Oct-12 

Data 

Nov-12 

Target 

Dec-12 




OCCUPIED BED DAYS (RE-ADMISSIONS) 

Occupied Bed Days % Re-Admissions Average 2012/13 



27



Improve diagnosis of dementia 

continued priority for us during 2013. 

Figure 7: Rate of Cardiac output monitoring 

In England today there are an estimated 

670,000 people living with dementia. This is 

expected to double in the next 30 years. In our 

hospitals, one in four patients may experience 

cognitive impairment (problems with memory 

and processing thoughts) and around 180 

patients with a diagnosis of dementia are 

discharged each month. Building on the 2009 

publication of a National Dementia Strategy, 

in March 2012 the Prime Minister’s Dementia 

Challenge was launched, with the aim of 

driving improvement in three core areas: 

ÆÆ 

ÆÆ 

ÆÆ 

awareness 

quality care 

research 

Early diagnosis is vitally important for dementia 

patients and their carers, as it enables them 

to understand the condition, access the 

right treatment to help relieve symptoms 

and give them time to plan for the future. 

Improving the diagnosis of dementia in 

hospital is a core objective for us. During 

2012 our dementia strategy focussed on 

delivering actions to support the assessment 

of patients who may have dementia, the 

launch of our best practice clinical pathway 

and increased awareness of the needs of 

patients with dementia in hospital. In April 

we set up a Dementia CQUIN Steering Group 

to develop and oversee the implementation 

of actions to help identify patients with 

symptoms of memory loss, forgetfulness 

or confusion on admission. This is a 

There have been a number of 

highlights this year. We have: 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

trained more than 5,000 members of 

staff in dementia care level one and 1,640 

members of clinical staff at level 2 

held eight dementia champion events, 

attended by 100 dementia champions 

held training sessions for volunteers to 

help them support dementia patients 

further developed an intranet page with 

information for staff about dementia and 

links to relevant patient/carer documents 

continued to work in partnership 

with key organisations, particularly 

the Gloucestershire Alzheimer’s 

Society who are members of our 

internal Dementia Steering Group 

held a seminar on dementia for 

our foundation trust members 

established a ‘confusion pro forma’ 

used to assess all patients admitted as 

an emergency and over the age of 75, 

for dementia. This is part of the clinical 

care pathway also launched in 2012 

developed and launched a patient/ 

carer document called 'Tell us about 

you' to support those who would 

like to share information with us 

about their specific health needs. 

% OF PATIENTS RECEIVING CARDIAC OUTPUT MONITORING 

30% 

25% 

20% 

15% 

10% 

5% 

0% 

Q1 

Q2 

Q3 

Q4 

% receiving cardiac output monitoring Year end target 



29





We are leading on two initiatives to help reduce 

readmission rates this year. Firstly, we are 

developing cross-organisational management 

plans for patients who frequently attend and 

are readmitted to our hospitals. We have 

also started a pilot to establish the benefits 

of making phone calls to a defined group 

of patients after they have been discharged 

from our Acute Care Units or specialty wards 

following admission with respiratory conditions 

or chest pain. A nurse will ask the patients 

how they are, following their discharge from 

hospital, and can advise on medication or 

any follow-up treatment they may need. 

We continue to work closely with 

our commissioners to improve the 

integration of acute and community 

care. We will also continue to monitor 

readmission rates to measure and 

evaluate the success of these projects. 

Improve diagnosis and care for 

patients with dementia 

In early 2013 we submitted a joint bid for 

funding with our community healthcare 

partners, as part of the NHS Dementia 

Friendly Care Environment scheme. The 

scheme is aimed at improving healthcare 

environments for patients with dementia. 

As a result of feedback from patients, carers 

and staff including our dementia champions 

we have proposed several improvements 

to our hospital ward areas including: 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

establishing an environment which 

encourages dementia patients to 

socialise, away from clinical areas 

providing an area of quiet, calming space 

to support the care and management 

of patients with delirium, patients who 

may be experiencing behaviours that 

challenge and to enhance end of life care 

providing concise signage, themed bays 

and pictograms to help dementia patients 

find their way around the wards 

provide artwork for the ward areas to help 

dementia patients orientate themselves 

and stimulate conversation with others. 

This year we will continue to work with our 

key partners, including the Gloucestershire 

Alzheimer’s Society, to identify new ways 

to support patients and carers. We are 

committed to listening to and learning from 

the experience of carers. We are developing 

a leaflet for carers of people with dementia 

and will introduce a method of capturing 

carers' feedback on their experiences. This 

feedback will then be used to further develop 

our dementia services and help inform the 

content of our staff training programme. 

Throughout 2012 our dementia training and 

champion development programmes have 

reflected what we've learned to date from 

listening to patient and carer experience 

and we will build on this during 2013. 

"Our dementia training and 

champion development 

programmes have 

reflected what we've 

learned to date from 

listening to patient and 

carer experience." 

Increase the use of cardiac output 

monitoring during surgical procedures 

The use of this technology will continue to be 

a priority in 2013/14 and will appear within 

national guidelines. We plan to expand the 

use of cardiac output monitoring to a wider 

group of procedures and patients than the 

group identified in 2012/13 (see p29). 

We have already increased our training in the 

use of cardiac output monitoring technology 

and will increase the number and variety 

of machines we have available for use. 

Reduce the incidence of avoidable 

renal failure (Acute Kidney Injury) 

Our ambition this year is to increase further the 

percentage of at risk patients receiving the AKI 

‘care bundle’ (see p25–26 for more details). In 

particular the safety team will be working with 

clinical staff to improve consistency across all 

wards in fluid management. Fluid management 

is important because it allows healthcare staff 

to monitor the hydration of a patient and 

ensure they do not become dehydrated. 

Improve care for patients with Chronic 

Obstructive Pulmonary Disease (COPD) 

Chronic Obstructive Pulmonary Disease (COPD) 

is the name for a collection of lung diseases 

including chronic bronchitis, emphysema 

and chronic obstructive airways disease. 

People with COPD have difficulties breathing, 

primarily due to the narrowing of their 

airways. COPD is one of the most common 

respiratory diseases in the UK, affecting 

more than 3 million people nationwide. 

Patients with COPD often attend hospital 

regularly, so it is acknowledged that 

standardising and improving the way that 

they are treated will benefit both the patient’s 

experience and reduce pressure on services. 

The British Thoracic Society, in partnership 

with NHS Improvement, have used the 

‘care bundle’ approach to propose a new 

method of treating and caring for patients 

with COPD. When implemented they expect 



31



the following benefits to be realised: 

ÆÆ 

ÆÆ 

ÆÆ 

creation of a multidisciplinary 

team confident in quality 

improvement methodologies 

an improved experience of care for 

patients admitted with COPD and 

community acquired pneumonia (CAP) 

a shorter length of stay, reduced mortality 

and reduced re-admission rates for 

patients admitted with COPD and CAP. 

Care bundles are a simple way of focusing 

improvement efforts on a set of actions which 

help achieve a specific aim. In the coming year 

we will be implementing this care bundle. 

Supporting clinical programmes 

Our commissioners for 2013/14, the 

Gloucestershire Clinical Commissioning Group, 

intend to adopt the clinical programme 

approach to commissioning which enables 

them to consider service development related 

to clinical pathways of care. This CQUIN relates 

to clinicians within the hospitals trust playing a 

full part in these clinical programme groups. 

Pre-qualification criteria 

In its ‘Innovation Health and Wealth, 

Accelerating Adoption and Diffusion in the 

NHS’ report, the NHS nationally set out that 

from April 1, 2013 all trusts must comply with a 

number of ‘high impact interventions’ in order 

to qualify for CQUIN payments (see p57 to 

find out more about CQUINs). In the category 

of Clinical Effectiveness, these criteria are: 

Cardiac output monitoring 

See pages 26 and 29. 

3 Million Lives 

The Department of Health (DH) believes 

that, nationally, at least three million people 

with long term conditions and/or social 

care needs could benefit from the use of 

what is known as ‘telehealth’ and ‘telecare’ 

services. In Gloucestershire we are currently 

running schemes in both these areas: 

ÆÆ 

ÆÆ 

Telecare: This provides equipment, 

such as smoke, fire and falls alarms, 

to enable vulnerable people to remain 

living independently. Jointly run by 

Gloucestershire Care Services and 

Gloucestershire County Council, the 

service currently supports around 

1800 people in the county. 

Telehealth: Building on the success of 

a local ‘specialist’ telehealth service 

started in 2008 for around 180 patients, 

Gloucestershire's Clinical Commissioning 

Group is now working in partnership with 

Tunstall’s Health to deliver telehealth on a 

‘large scale’ for up to 2000 patients with 

long term conditions. Patients at home 

take regular readings of their vital signs 

(eg. blood pressure, temperature) which 

are then monitored remotely by their 

healthcare team, usually in the GP practice. 

Implement Digital First initiatives 

Digital First is a term for a Department 

of Health initiative which aims to reduce 

unnecessary face-to-face contact between 

patients and healthcare professionals by 

incorporating technology, for example phone or 

email, into these interactions. We have already 

implemented many of the suggested changes: 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

appointment reminders 

electronic discharge summaries 

remote communication of test results 

remote secondary care follow-up (in 

some services eg. pain management) 

We know we could do more to improve 

electronic communications with GPs – 

both when providing advice and guidance, 

and sending letters following outpatient 

appointments. We can also further reduce 

hospital visits when patients would prefer 

a ‘virtual’ visit or phone call. Although 

these schemes are mainly led by partner 

organisations, there are small groups of 

patients under the care of our specialist 

teams who might benefit from using 

telehealth. We plan to pilot its use for 

children with respiratory illnesses, and adults 

receiving peritoneal dialysis at home. 

Another project helping us improve quality 

through the use of digital technology is 

SmartCare. This is an exciting project that will 

enable us to develop and improve the use 

of clinical information across our hospitals. 

The SmartCare project will be a major 

investment in the infrastructure upon 

which we, and the wider NHS, relies in 

order to support the provision of safe, 

consistent and effective care for patients 

as well as providing real-time information 

through an Electronic Patient Record for 

both clinical and business information. 

SmartCare is a collaborative project for 

an integrated clinical system with: 

ÆÆ 

ÆÆ 

ÆÆ 

Gloucestershire Hospitals 

NHS Foundation Trust 

North Devon Healthcare NHS Trust 

Yeovil District Hospital NHS 

Foundation Trust 

We are currently in the process of procuring a 

system and plan to identify a preferred supplier 

shortly to enable deployment of SmartCare 

by early 2014. The deployment is expected to 

take up to two years for full go-live status. 



33


Establish clear process to enable the 

exploitation of Intellectual Property (IP) 

Innovation is about converting knowledge 

and ideas into a benefit - delivering value 

by implementing new ideas and doing 

things differently. Innovation can transform 

patient outcomes, improve quality and 

productivity as well as contribute to the wider 

economic growth of the country. It may 

relate to services, processes or products. 

We encourage our staff to bring forward 

ideas for new products. Each idea is 

assessed carefully to identify any potentially 

valuable intellectual property (IP) and 

opportunities for commercial exploitation. 

Projects with potential are supported by our 

innovation leads and specialist advisors. Our 

Innovation Panel oversees the management 

of our IP portfolio. The panel is chaired 

by Non-Executive Director, Clive Lewis. 

The Intellectual Property Policy offers staff 

the opportunity to share the benefits of 

any revenue from commercialisation. 

In 2013/14 we will continue to contribute 

to the implementation of the government’s 

strategy “Innovation, Health and Wealth”, 

through: raising awareness of the part 

innovation can play in meeting the 

challenges of the NHS and the benefits to 

patients, the NHS, the Trust and its staff 

ÆÆ 

drawing attention to the potential IP 

value of novel ideas and the importance 

of protecting the Trust’s IP assets 

ÆÆ 

ÆÆ 

ÆÆ 

encouraging staff to bring their projects 

forward for assessment, with the 

opportunity to have a share in any revenue 

generated from commercialisation 

supporting projects, working with 

specialist advisors to take forward 

key projects - in collaboration, where 

appropriate, with commercial partners 

working with partners from across 

the NHS, academia and industry as 

members of the emerging Academic 

Health Science Network

2 OUR PRIORITIES: PATIENT EXPERIENCE 


02 


Patient Experience 

We place great value in knowing 

and understanding the experiences 

of our patients and their carers and 

relatives. It is those experiences 

that continue to help us plan and 

deliver high quality healthcare. 

To ensure we provide a consistently excellent 

service we have Patient Experience Groups that 

drive and support clinical teams to improve. 

The groups are chaired by the Trust’s Director 

of Nursing and have a diverse membership 

including patient/carer representation and 

Governors. These groups have responsibility 

for identifying key areas for improvement 

arising from all patient and carer feedback, 

assisting with the development of improvement 

plans and monitoring their implementation. 

Both groups report to the Quality Committee, 

ensuring that issues and developments relating 

to the experience of our patients remains 

at the forefront of the committee’s agenda. 

Those of our members




Over the past year we have made good 

progress against many of the priorities 

set during 2012/13. To help us judge the 

quality of care provided, we have set 

out our performance in relation to each 

individual priority for the past year: 

Improving the discharge experience 

of patients and carers 

Improving the flow of patients through 

our hospitals is vital if we are to meet our 

targets for seeing, treating and admitting 

or discharging patients within four hours 

of their arrival at the ‘front door.’ 

Our business intelligence information system, 

known as Analyzer, has this year enabled 

us to track our discharges, including the 

time of day patients are discharged from 

our hospitals. Our Length of Stay Steering 

Group reviews all aspects of the discharge 

process and how it can be improved. We 

have launched a 'discharge tool kit' which 

helps staff plan and communicate a patient's 

discharge from hospital, and continue to 

monitor the experience of our patients. A 

recent unannounced visit by the Care Quality 

Commission in February 2013 reviewed our 

discharge processes and we were found 

to be compliant with their standard. 

Improving communication 

about treatment options 

A project took place this year to improve 

communication between colleagues, 

between staff and patients and between 

staff and a patient's family or carer. We 

know from our own surveys that if patients 

feel involved in the decisions made about 

their care and treatment, their experience 

of our services is often greatly improved. 

"We know from our own 

surveys that if patients 

feel involved in the 

decisions made about 

their care and treatment, 

their experience of 

our services is often 

greatly improved." 

Over a period of four weeks, key methods of 

improving communication were trialled on 

four wards. These methods included nurses 

introducing themselves to their patients 

at the beginning of their shift, checking 

patients have understood the information 

given to them, having patient information 

leaflets available on the most common 

procedures or conditions. In addition, the 

project also trialled the use of a protected 

period of time set aside for staff to update 

family members or carers on their patient’s 

condition or arrangements for discharge. 

Improving the experience of those 

with visual and hearing impairment 

We have continued to work with patients and 

improved our collaboration with Gloucester 

Deaf Association (GDA) and the Gloucestershire 

County Association for the Blind (GCAB). 

We have set up a project group with a remit 

of enhancing communication and accessibility 

for people with hearing or visual impairment 

- from the beginning of an outpatient's 

journey in reception, to the waiting room 

and consultation. As a result, reception staff 

now ask if a patient has a visual or hearing 

impairment at the point of arrival. Stickers 

which indicate the impairment are then put 

onto the patient’s documentation, allowing 

staff to adjust their methods of communicating 

when calling a patient for an appointment or 

during consultation. We have also developed 

and put up posters in all outpatient reception 

areas which provide information about 

sensory impairment and how we can help. 

As a result of feedback from patients a 

project to re-design and develop new signage 

to aid navigation around our hospitals is 

underway. Developed in accordance with 

the relevant guidelines, the signs are then 

presented to GCAB for feedback and 

any amendments or suggestions acted 

upon. The project is being led by patient 

representatives and as a result, the new 

signage has been developed by looking at the 

hospital site through the eyes of a patient. 

Improving the hydration 

and nutrition of patients 

Getting the basics right, making sure our 

patients are well nourished and adequately 

hydrated while in our hospitals, is vitally 

important if we are to provide good quality 

healthcare. The consequences of poor 

nutrition and hydration are well documented 

and include an increased risk of infection, 

delayed wound healing, decreased muscle 

strength, constipation, depression and in 

extreme cases, premature death. Certain 

groups of patients are more vulnerable 

to dehydration and malnutrition as they 

may be unable to or have difficulty in 

feeding or drinking without assistance. 

To help encourage patients with dementia 

to recognise food and drink close to them 

and therefore eat and drink more, this year 

we have been testing the use of specialist 

coloured crockery and glasses. The results 

of this project are now being evaluated and 

a plan for implementation developed. 

Specific improvement projects involving 

the recognition and treatment of patients 

with acute kidney disease, which is closely 

associated with dehydration, have been 



39



successfully implemented this year (see p25). 

Patients who may be at risk of kidney injury 

are diagnosed at an early stage so staff can 

make sure they are well hydrated and their 

care is promptly reviewed by a senior clinician. 

We are also trialling the use of a hands-free 

drinks system, known as the ‘Hydrant’ on our 

wards. The Hydrant is a bottle attached to 

the patient’s bed designed to give patients 

access to fluids at all times without have 

to reach for or hold a drink. Its design also 

enables staff to accurately measure how much 

fluid the patient has consumed. This national 

study will be completed next year. Visit www. 

hydrateforhealth.co.uk for more information. 

The patient experience escalator 

Responding to patient and carer feedback 

Our priority in 2012/13 was to focus on 

creating opportunities for our patients and 

carers to share their views. Without feedback 

we cannot know what people think about the 

services they have received or expect to receive. 

During the year we have developed an online 

feedback form through our website. All 

feedback is used to either praise staff for the 

excellent care or service they have provided, or 

used to make improvements where needed. 

Our online feedback page ‘how are we 

doing?’ has been developed and given a 

prominent position on the home page. 

This is used by patients and carers to share 

positive feedback as well as comments or 

concerns about their personal experiences. 

We have also developed a new web page 

which demonstrates how we have responded 

to the feedback and ideas received – called 

‘What you said and what we did.’ This page 

is also linked to the websites of our partner 

organisations such as Carers Gloucestershire. 

In partnership with these carer and patient 

support organisations, we worked to increase 

awareness of how to raise a concern or make a 

complaint. We have also linked our feedback 

form to partner organisations’ websites. 

In order to improve methods of providing 

feedback from our younger patients and 

their carers, we designed and developed 

a ‘Your experience counts’ comment 

card which can be found in the children’s 

outpatients departments and on the wards. 

Promoting shared decision making 

Working in partnership with the Patients 

Association and with the support of volunteers 

we have established an “Observation of Care” 

tool which is used to identify the experiences of 

patients who do not have a voice due to their 

illness. This may be as a result of dementia or 

another cognitive impairment. An ‘observation’ 

is sitting and watching what happens on a 

ward, waiting area or an admission unit. 

The observational tool provides staff with 

an opportunity to take dedicated time out 

to stop, look and listen to what happens to 

a patient; to understand how day-to-day 

routines and behaviours may be detrimental 

to a patient’s well-being. Observers use 

their senses to see what happens focusing 

upon the human interactions between staff 

and patients and then recording how they 

felt about what they saw and heard. It is a 

qualitative tool to provide a measure of the 

quality of interaction between staff, patients 

and visitors and is designed to develop sensitive 

communication within a ward or department. 

Attitudes of staff and improving leadership 

In 2012 we launched the Kindness and 

Respect Behaviour Standards which 

clearly define the quality of behaviour and 

communication our patients, visitors and 

colleagues should expect from all staff. 

The standards were put together for 

staff, by staff with the involvement of 

patient representatives so that: 

ÆÆ 

ÆÆ 

ÆÆ 

everyone is clear about what is 

acceptable behaviour at work 

we recognise and reward 

positive role models 

we expect poor behaviour to be addressed 

and we all know that action will be taken 

This year we have continued to embed these 

standards into all of our internal processes, 

appraisals and training programmes. 

We already know that the majority of our staff 

behave in a professional manner but members 

of staff whose kind and considerate behaviour 

exemplifies the standard have been recognised 

and nominated for a Kindness and Respect 

Award which are made on a monthly basis. 

There is now a full range of training and 

development tools for staff and managers 

who need help to take action to make 

improvements. New training sessions 

have been developed which range from 

‘Having Difficult Conversations’ to ‘Making 

a Difference on the Telephone’. 



41




The Friends and Family test 

This year, in line with national guidance, we 

will be carrying out the Friends and Family 

test. This is a simple question that patients will 

be asked about the care they have received 

as an inpatient or in an A&E department. 

This question is: How likely are you to 

recommend our ward/A&E to friends and 

family if they needed similar care or treatment? 

Patients are encouraged to explain why they 

gave a particular score, so we can use this 

insight to improve services in the future. 

The test aims to encourage patient feedback, 

show patients that their views and experiences 

matter to us, improve patient care and let 

people know where they can get the best 

care. The results of the test will allow patients 

and the public to compare healthcare services 

and clearly identify the best performers as 

well as those which need to improve. 

We started to roll out this project in the 

two Emergency Departments (A&Es) 

and 39 inpatient wards in April 2013. 

Personal care: Privacy and dignity, 

involvement in decisions 

Our focus this year will be to further develop 

the work started on the privacy and dignity 

agenda. We will do this by working closely with 

the clinical teams, listening to patients, carers 

and staff to ensure that privacy and dignity 

is central to the care delivered. We will do 

this by identifying areas of excellent practice 

and embedding the practice in all areas. For 

example we will closely monitor patient and 

staff communication, making sure patients 

understand decisions made about their care. 

Improve the discharge process 

We are committed to involving patients 

and their carers in the process of discharge 

planning. Patient and carer feedback gathered 

through our patient experience surveys, and 

also monitored through the complaints process, 

has highlighted this as an area in which we 

need to focus improvements. We will ensure 

that we fully involve the patient, their carer 

and family members in the discharge process, 

we are committed to providing information 

on who to contact and advice on the purpose 

of medications and side effects. We will be 

undertaking a review of our processes and 

this will involve a countywide engagement 

event for our Foundation Trust members, 

governors and partner organisations. 

Patient experience escalator 

Building upon the good foundations achieved 

from last year's Patient Experience Escalator 

CQUIN, we will continue to focus on the 

five domains. Whilst responding to patient 

and carer experience we will have greater 

transparency with results being available on 

the Trust website. We aim to increase Trust 

membership among working age men and 

women, who are a hard-to-reach group. Our 

Foundation Trust members events will have 

a focus this year on issues such as Organ 

Donation and Disability Equality. The attitudes 

of our staff will continue to be celebrated 

through our Kindness and Respect awards. 

Within leadership, our Executive Team 

will undertake visits at night to wards and 

departments to engage with staff and patients. 

Pre-qualification criteria 

In its ‘Innovation Health and Wealth, 

Accelerating Adoption and Diffusion in the 

NHS’ report, the NHS nationally set out that 

from April 1, 2013 all trusts must comply 

with a number of ‘high impact interventions’ 

in order to qualify for CQUIN payments (see 

p57 to find out more about CQUINs). In the 

category of Patient Experience, this is: 

Information for carers of 

people with dementia 

Building on our established partnership with 

the Gloucestershire Alzheimer’s Society we are 

currently reviewing our written information for 

dementia patients and their carers, with the 

aim of providing carers with the information 

they need in one place. We will learn more 

about the experiences of carers of patients with 

dementia, and aim to use their feedback to 

help inform our training programmes into the 

future so that staff can truly understand what 

it is like to care for a patient with dementia. 



43

Case 

Studies 

A carer's story 

Involving patients 

Learning from feedback 

S-J has a profound multiple learning 

disability, cerebral palsy, epilepsy and no 

formal communication. She is an essential 

wheel chair user and has a PEG, a tube that 

is placed into a patient’s stomach to feed 

them. She needs help with all activities 

of living and is dependent on carers. 

She needs to have carers with her who are familiar to 

her for her to feel safe. S-J had been under the care of 

paediatricians for years, and coming up to age 18 it was 

decided she should start using adult services. However 

the transition did not go well and S-J and her carer had 

a very poor experience the first time they used adult 

services which resulted in the carer making a complaint. 

In order to make improvements, the learning disability 

liaison nurses arranged a meeting with the carer, 

her social worker, S-J’s mother, staff from children’s 

services and from adult services (ACUA), the ward 

sister from the ward she had attended and the 

learning disability liaison nurse. There was learning 

on all sides and negotiation and compromise was 

necessary to reach a workable solution to ensure S-J’s 

needs and the needs of her carer could be met. 

In S-J’s case the outcome was that S-J would have a 

support plan that outlined all her health needs and how 

they would need to be met in adult care. This included 

equipment needs and where the equipment would be 

found as unlike in child services where the equipment 

was all on the unit; in adults it wasn’t all on one ward 

but located on different wards or in the equipment 

library. There was some equipment that had been 

available in child services but wasn’t in adult services so 

equipment was bought in by the Trust. This would not 

only benefit S-J but would be useful for other patients. 

In paediatric services S-J had direct access to the 

children’s in-patient unit, this meant that she did not 

have to be admitted via the Emergency Department. 

It was agreed that due to her specific equipment needs, 

if S-J needed to be admitted then her carer or GP 

could contact the ACUA ward at Gloucestershire Royal 

Hospital, prior to admission. Staff at ACUA would refer to 

the support plan, make sure they had all the equipment 

that S-J required and then contact S-J’s carer who 

could then bring S-J straight to ACUA. The only time 

they would need to go to the ED

03 

Statements of assurance 

We share information about 

our services so you can make 

an informed judgement about 

the quality of care we provide 



47

3 STATEMENTS OF ASSURANCE 


The following section includes 

responses to a nationally defined set 

of statements which will be common 

across all Quality Accounts. 

The statements serve to offer 

assurance that our organisation is: 

ÆÆ 

ÆÆ 

ÆÆ 

performing to essential standards, 

such as securing Care Quality 

Commission registration 

measuring our clinical processes and 

performance, for example through 

participation in national audits 

involved in national projects and 

initiatives aimed at improving quality 

such as recruitment to clinical trials. 

Information on the Review of Services 

The purpose of this statement is to ensure 

we have considered quality of care across 

all our services. The information reviewed 

by our Quality Committee is from across 

all clinical areas. Information at individual 

service level is considered within our 

divisional structure and any issues emerging 

escalated to the Quality Committee. 

During 2012/13 Gloucestershire Hospitals 

NHS Foundation Trust provided and/ 

or subcontracted 42 NHS services. 

Please see Table 1 for more detail. 

Table 1: Provided and/or subcontracted services for 2012/13 

Acute Care 

The Trust has reviewed the data available 

to us on the quality of care in all of these 

NHS services. The income generated by the 

NHS services reviewed in 2012/13 represents 

100% of the total income generated from the 

provision of NHS services by Gloucestershire 

Hospitals NHS Foundation Trust for 2012/13. 

Neonatal Care 

Ambulatory Care 

Anaesthetic Services 

Audiology (Hearing Services) 

Breast Screening 

Breast Surgery 

Breast Radiology 

Cardiology 

Chemotherapy 

Clinical Haematology 

Critical Care 

Colorectal Surgery 

Dermatology 

Diabetes 

Ear, Nose and Throat 

Emergency Department 

Endoscopy 

Fertility Services 

Gastroenterology 

General Old Age Medicine (GOAM) 

Gynaecology 

Gynae-oncology 

Maternity 

Neurology 

Nuclear Medicine 

Occupational Therapy 

Oncology 

Ophthalmology 

Optometry 

Oral and Maxillo-facial Surgery 

Orthoptics 

Pathology 

Paediatrics 

Palliative Care 

Physiotherapy 

Radiology 

Radiotherapy 

Renal 

Respiratory Medicine 

Rheumatology 

Stroke 

Trauma & Orthopaedics (T&O) 

Upper Gastro-intestinal Surgery 

Urology 

Vascular Surgery 



49



Information on participation in Clinical Audit 

The purpose of this statement is to 

demonstrate that we monitor quality 

in an ongoing, systematic manner. 

From 1 April 2012 to 31 March 2013, 34 

national clinical audits and four national 

confidential enquiries covered the NHS 

services that Gloucestershire Hospitals 

NHS Foundation Trust provides. 

During that period Gloucestershire Hospitals 

NHS Foundation Trust participated in 31 

(91%) of national clinical audits and four 

(100%) national confidential enquiries of 

the national clinical audits and national 

confidential enquiries in which it was eligible 

to participate. Of the three audits where 

the Trust did not participate there were 

justifiable reasons for non- participation 

in 1 (please see table on p52–53). 

The national clinical audits and national 

confidential enquiries that Gloucestershire 

Hospitals NHS Foundation Trust was eligible to 

participate in from 1 April 2011 to 31 March 

2012 are listed in the table on p52–53. 

The national clinical audits and national 

confidential enquires in which Gloucestershire 

Hospitals NHS Foundation Trust participated, 

and for which data collection was completed 

during 1 April 2012 – 31 March 2013 are listed 

in the table on p52–53, alongside the number 

of cases submitted to each audit or enquiry as 

a percentage of the number of registered cases 

required by the terms of that audit or enquiry 

or a straight percentage of cases submitted 

The reports of 21 (100%) national clinical 

audits/confidential enquiries participated 

in were reviewed by the provider in 2012 

– 2013. Ten reports are still awaited. The 

actions Gloucestershire Hospitals NHS 

Foundation Trust intends to take to improve 

the quality of healthcare provided are 

summarised in the table on p52–53. 

The reports of more than 2,000 local 

clinical audits were reviewed in 2012 - 

2013 and Gloucestershire Hospitals NHS 

Foundation Trust either has or intends 

to take the following actions to improve 

the quality of healthcare provided: 

ÆÆ 

ÆÆ 

ÆÆ 

the completion of consent forms 

has considerably improved since 

the introduction of the consent 

audit rolling programme 

a gynaecology post-operative pain 

re-audit indicated considerable 

improvement. This arose from changes 

in peri-operative and post-operative 

administration of various drugs that had 

been recommended by the previous audit 

an Oral Maxillo Facial Surgery (OMFS) 

audit identified the need to improve 

the use and reporting of radiographs 

in OMFS. This is to be implemented 

ÆÆ 

for vaginal birth after caesarean section 

new documentation was developed to 

ensure the management plan was fully 

documented 

Clinical Audit has been an integral part in 

the Trust’s CQUIN programme for the years 

2012/2013, providing evidence information 

for a number of priority measures such 

as venous thromboembolism, sepsis, 

acute kidney injury and the NHS Safety 

Thermometer. Additionally, clinical audit has 

also provided information for other national 

projects eg. the Saving Lives campaign. 

This high level of participation demonstrates 

that quality is taken seriously by our 

organisation and that participation is 

a requirement for clinical teams and 

individual clinicians as a means of 

monitoring and improving their practice. 



51

Participation in National Audits 

Audit title 

Did the Trust 

Participate? 

Number of case submitted / number required Was the report reviewed? Actions taken as a result of audit / use of the database 

Peri and Neonatal 

Neonatal Intensive 

and Special Care Audit 

Programme (NNAP) 

Yes 

487 patients entered between 01/04/12 

and 31/12/12. 100% submitted 

Yes – Paediatric Governance 

The Trust participates via the ‘Badger’ system. This is the database used to record all the NICU activity. 

The data is used internally for benchmarking against similar units 

Children 

Fever in Children (College 

of Emergency Medicine) 

Yes 40/40 100% submitted 

2012 report not yet available 

Previous British Association of 

Emergency Medicine (BAEM) 

reports reviewed at ED Clinical 

Governance 

Actions taken as a result of previous paediatric BAEM audits include: 

Advice sheet for patient/carers for feverish children being investigated 

NICE guidance for feverish children now included in junior doctors induction and in folder in 

department 

National Diabetes Audit 

(NDA) paediatric 

Yes 

279/279 patients (3210 records) 

100% submitted 

Await 2012 report. 2011 

report reviewed at Paediatric 

Governance 

Hba1c is slightly better than previous years but still needs improvement. Documenting the care 

processes has been improved (mainly done by the nurses). The audit has highlighted a need for a 

dedicated diabetes administrator to input the data and chase up all the appointments and other annual 

screening processes. 

Epilepsy 12 

(Childhood epilepsy) 

Yes 

63/63 


Yes – Paediatric clinical 

governance 

Actions taken as a result of the audit include: Appointment of paediatric epilepsy nurse, assessment 

of emotional and behavioural problems included in junior doctors' training, first seizure care pathway 

being developed. 

Acute Care 

National Cardiac 

Arrest Audit 

Yes 60/60 – 100% submitted Yes – Resuscitation committee 

Results showed good compliance. As a result of audit there was a review of the ‘Deteriorating Patient’ 

documentation and the ceiling of treatment was adjusted to minimise inappropriate interventions eg. CPR 

Fractured neck of femur 

(College of Emergency 

Medicine) 

Yes 30/30 – 100% submitted 

2012 report not yet available 

Previous BAEM reports reviewed 

at ED Clinical Governance 

Actions taken as a result of previous BAEM audits include: Increased use of pain score and appropriate 

analgesia 

Renal Colic Yes 30/30 – 100% submitted 

2012 report not yet available. 

Previous BAEM reports reviewed 

at ED Clinical Governance 

Actions taken as a result of previous BAEM audits include: Development of a local pain policy 

Adult Critical Care 

(ICNARC) 

Yes 

Between 700-800 admissions annually 


Yes – Quarterly business and 

mortality meetings 

The reports provide information on mortality rates, length of stay, etc and provide the Trust with an 

indication of our performance in relation to other ICUs. The current SMR is around 0.8, meaning that fewer 

patients die than would be expected according to the model used. 

Where trends are identified then these allow us to make recommendations about changes to practice. 

Data is also collected on hospital-acquired infection rates (C.diff, central venous catheter infections, MRSA, 

ventilator-associated pneumonia) as part of our involvement in the SW IHI program. There has not been a 

central venous catheter infection since data collection began in 2010. 

Standards are reviewed against those proposed as quality indicators by the Intensive Care Society (but yet to 

be published). To date the Trust is compliant with all these. 

NHS Blood and 

Transplant: potential 

donor audit 

Yes 381/381 – 100% of all auditable deaths Yes – Trust Board 

In Gloucestershire (as of November 2012) since 1st April 2012 

Æ Æ 27 individuals had received an organ 

Æ Æ 21 patients had the gift of sight through corneal transplant 

Æ Æ 38% of the population are on the organ donor register 

Æ Æ 4 patients had died on the waiting list 

Æ Æ 83 patients are awaiting a transplant 

BTS (suite) audit No N/A N/A 

The trust is now actively participating in the: 

Æ Æ COPD Admission care bundle 

Æ Æ COPD Discharge care bundle, 

Æ Æ Community Acquired Pneumonia care bundle 

Long term conditions 

National Diabetes Audit 

(NDA) ADULT 

Yes 

All in patients on the snapshot day submitted – 


2011 report reviewed by 

Countywide Diabetes Group 

Await report for 2012/2013 

The following changes were made as a result of the audit: 

Æ Æ Introduction of hypo boxes onto the wards with regular audits of their use 

Æ Æ Increased education and training to staff 

Æ Æ Daily (Monday through Friday) ward rounds by diabetes team to key areas at CGH and GRH 

Æ Æ E referral service set up – patients continue to be seen within 12 working hours of referral 

Æ Æ Improvement in the foot service 

Æ Æ Looking at insulin self-administration for inpatients 

Heavy Menstrual Bleeding 

(HMB) No, but 

This was discussed at Gynaecology governance 

and the Trust decided not to participate as it 

has already undertaken two significant audits 

(involving patient participation) in HMB. This audit 

would be repeating work already undertaken 

N/A 

The results obtained were as follows: 

National Requirements Trust achieved 

75% Overall satisfaction rate 83% 

30% Amenorrhoea rates 54% 

75% Reduction in Menstrual blood flow 81% 

Less than 2% immediate complication rates 0% 

In all instances the Trust exceeded the national standard requirements, therefore comparison with the 

national standards demonstrated that no changes were needed. 

National Pain Audit Yes 73 patients submitted within audit guidelines Yes – Pain Team 89% of patients remembered receiving advice on pain management 

Ulcerative Colitis and 

Crohn’s disease (UK IBD 

audit) 

Yes 

The Trust submitted 20 Crohn’s and 7 cases of UC. 

This exceeded the minimum requirement. Note; 

Data collection for IBD 4 has just started and the 

trust is participating which focuses on the care for 

the acute colitis patient 

Yes – Gloucestershire 

Gastroenterology Group and IBD 

Quality Improvement Programme 

Development of an ‘Acute Colitis Pack’ detailing the agreed pathway for a patient admitted with acute 

colitis. Action plan developed following the IBD QIP assessment 

Parkinson Diseased Audit Yes 

30/30 – 100% submission 

Yes – Regular Parkinson Disease 

meeting 

Review of documentation and changes to existing documentation to ensure more complete review of 

patients and more consistent information collected 

Adult asthma Yes Data collection in progress 

None yet published as 

still in first year of audit 

Not applicable 

National Audit of 

Dementia 

Yes 120/120 - 100% submission 

2012 report not yet available. 

2011 report reviewed by Trust, 

Dementia Programme Managers 

Board, dementia project group 

The national audit identified a lack of care pathway, lack of recognition of delirium, difficulty in 

accessing intermediate care. Actions on these have been incorporated into the Trust action plan on 

dementia. 



53

Participation in National Audits 

Audit title 

Did the Trust 

Participate? 

Number of case submitted / number required Was the report reviewed? Actions taken as a result of audit / use of the database 

Elective Procedures 

National Joint Register 

(NJR) Hip and knee 

replacements 

Yes Yes – Trust continues to submit. 100% submission 

Yes. Annual report is reviewed 

at Governance meetings 

Data is entered retrospectively. Action is taken as necessary eg. metal on metal hip replacement 

Adult cardiac 

interventions coronary 

angioplasty 

Yes 608/650 – 94% eligible patients 

Yes – Cardiology audit cycle 

on an annual basis. Monthly 

Mortality and Morbidity meetings 

Data on unit and operator specific mortality is generated from data returns to NICOR. From June this 

year, the NHS Medical Director, Sir Bruce Keogh, requires data to be provided to allow publication of 

operator specific outcomes (ie. tagged to GMC number and Unit). As in previous years, the clerical and 

IT support for this work is minimal. It is likely that this will be a factor in any data quality/publications. 

Cardiovascular Disease 

Myocardial Infarction 

National Audit Project 

(MINAP) 

Yes 100% for patients with ST elevation MI 

Yes – Shared with regional, 

network and local colleagues 

Emphasis on improving timings of response. Analysis of patients with timings outside set standard. 

Greater liaison with GWAS 

Heart Failure Audit Yes 

A minimum of 20 patient per month; trust compliant 

with audit requirements 

Yes – At relevant cardiology 

meetings 

Ongoing 

Acute Stroke SINAP No 

The Trust does not contribute to SINAP but has contributed to SSNAP (the organisational audit) and 

will participate in the online SSNAP (which replaces SINAP) data collection in due course. 

National sentinel 

stroke audit 

Yes 60/60 – 100% Yes 

In the past the audit has led to a review of time spent in a stroke unit and of the availability of therapy 

resources and a stroke coordinator. It has been a considerable driver for change within the Trust 

Renal Disease 

Renal registry: Renal 

replacement therapy 

Yes 

100% of renal dialysis and transplant patients 

registered 

Yes – Renal Team latest report is 

14 th annual report 

Trust is generally compliant and no changes to practice are required 

Cancer 

National Lung Cancer 

Audit (NLCA) 

Yes 

2012 Annual Report 

323 (132%) of patients submitted 

Yes by 3CCN 96% discussed at MDT. Audit work is currently being undertaken relating to small, cell lung 

National Bowel Cancer 

Audit Programme 

(NBOCAP) 

Yes 

2012 Annual report 

2011 Annual report in ( ) 

389 (225) cases submitted 

Yes by 3CCN 

81% (51.5%) case ascertainment 

94% (50.8%) data completeness for patients who had major surgery 

DAHNO: 

Head and Neck cancer 

Yes 2011 annual report 105 cases submitted 

2012 annual report not yet 

published. Yes by 3CCC 

As a result of the 2011 report: 

Æ Æ 90% had both T and N recorded 

Æ Æ 95.7% of new cases discussed at MDT 

As a result the following was agreed 

Æ Æ To continue to improve data collection 

Æ Æ To review use of one stop clinics and ways of improving bookings 

National Oesophagogastric 

cancer 

Yes 

2012 annual report 

534 Cases submitted by 3CCN 

Yes by 3CCN 

Trauma 

National Hip Fracture 

Database (NHFD) 

Yes 

GRH –100% submissions (727 since April 2011) 

CGH – 100% submissions (303 patients in 2012) 

Yes at Clinical governance 

meeting and NOF strategic 

meetings 

Trust has participated since 2008. NICE recommends cemented arthroplasties and the data was used 

from the Hip Fracture data base to support a change in practice at GHNHSFT. GOAM input is needed 

within 72 hours of admission. Theatre lists were reordered to try to ensure smaller cases are first on 

the list so there is time for the GOAM team to review. Future work will revolve around length of stay. 

TARN: Severe Trauma Yes Yes – First full year of participating N/A Not applicable 

National falls and bone 

health 

Yes 60/60 – 100% submission 

Yes – Team Divisional and 

medicine board 

This has resulted in improvement in numbers being assessed for postural BP, vision and in written 

information being given out. A countywide patient satisfaction questionnaire for the falls clinics is 

currently being undertaken. All the work on the falls CQUIN will have also had an impact on the care 

on in-patients. 

Blood transfusion 

National comparative 

audit of blood 

transfusions: Suite of 

changing topics 

2011/2012 National 

Comparative Audit of Use 

Blood in Adult Medical 

Patients 

Yes 100% submission 

Changes will be made as necessary after presentation to HTT and HTC 

Reports Available January 2013. 

To be reviewed by Hospital 

Transfusion Committee and 

Hospital Transfusion team 

Yes 100% submission Changes will be made as necessary after presentation to HTT and HTC 

Miscellaneous 

Risk factors – NHS Health 

Promotion in Hospital 

Yes 100/100 – 100% Submission Await report 

Of the eight standards the trust met five. Non-compliance was assessment of smoking, alcohol and 

physical activity 

Child Health CHR–UK Yes Data collection in progress for less than 6 months 

NCEPOD Yes Ongoing data collection 

National Elective Surgery 

PROMS: Hip replacement, 

Knee replacement, Hernia, 

Varicose veins 

Yes 

Average participation 

Æ Æ Groin hernia 69% 

Æ Æ Hip replacement 80% 

Æ Æ Knee replacement 68% 

Æ Æ Varicose vein 39% 

Yes 

By surgical lead to the Division 

Actions taken with the division: 

Æ Æ Monthly monitoring of patient participation and forms returns from wards. 

Æ Æ Weekly volunteer who visits wards to collect forms. 

Æ Æ Regular reports by Consultant lead to surgical division 



55



Participation in Clinical Research 

The inclusion of this statement 

demonstrates the link between 

our participation in research and 

our drive to continuously improve 

the quality of services. 

The number of patients receiving NHS services 

provided or subcontracted by Gloucestershire 

Hospitals NHS Foundation Trust in 2012/13, 

which were recruited during that period to 

participate in research approved by an NHS 

research ethics committee, and included on 

the National Institute for Health Research 

(NIHR) Portfolio is currently 667. This figure 

includes recruitment recorded on the NIHR 

Internet Portal up to December 2012. 

This figure is likely to increase over the 

following months as participants recruited 

to research studies in the second half 

of the financial year continue to be 

reported. If recruitment continues at a 

similar rate, we can expect a final total for 

2012/13 at around 1000 participants. 

This would be slightly higher than 2011/12 

but lower than the final total for 2010/11. 

This is mainly due to the loss of a number of 

high recruiting studies in the last couple of 

years. Three of these studies recruited 1133 

participants between them, accounting for 

53% of the total recruitment in 2010/11. 

Without those studies, the recruitment for 

2012/12 will inevitably be lower than the 

expected year on year increases expected 

by the National Institute for Health 

research, but close to the target of 1200 

set by the Western Comprehensive Local 

Research Network, taking into account 

variations in the available study portfolio. 

As the Gloucestershire R&D Consortium 

Delivery Budget is dictated by activity, the 

reduction in recruited participants is likely 

to result in a lower allocation of Delivery 

Funding in 2013/14. This could have 

consequences for supporting the research 

delivery infrastructure, so careful local portfolio 

management will be important in ensuring 

maximum recruitment opportunities. 

During 2012/13, Gloucestershire Hospitals NHS 

Foundation acted as host to 72 new studies 

approved from 1st April 2012. Of these studies 

44 were adopted to the NIHR Portfolio. In total 

the trust was contributing/recruiting to around 

180 Portfolio Studies over the 12 month period. 

This is an increase over the 139 Portfolio 

studies contributed/recruited to in 2011/12. 

There was a wide range of clinical staff 

participating in research approved by an 

NHS Research Ethics Committee during 

2012/13. These staff participated in research 

covering the majority of medical specialties 

across all four Divisions in Gloucestershire 

Hospitals NHS Foundation Trust. 

Information on the use of the Commissioning for Quality & 

Innovation (CQUIN) framework 

The CQUIN payment framework aims to 

support the cultural shift towards making 

quality the organising principle of NHS 

services by embedding quality at the heart 

of commissioner-provider discussions. 

The level of the Trust’s income in 2012/13 

which was conditional upon achieving locally 

agreed quality and innovation goals was 

£8,395,920 out of a total planned income from 

our host, associate and specialist commissioners 

of £384.396m. In line with national rules 

this represented about 2.5% of income. 

The CQUIN schemes agreed with NHS 

Gloucestershire, the rationale behind them 

and the associated payments for 2012/13 

can be seen in Table 1. These include four 

nationally mandated, five local schemes and 

three schemes from specialised commissioning. 

Current indications are that we will be 

successful in securing the majority of this sum. 

The main areas of risk are patient experience 

measures and breast feeding for neonates. 

It is anticipated that there will be a shortfall 

of between £500k and £1m. The final figure 

will not be known until end of year audits 

have been completed for some schemes. 



57



Table 1: 2012/13 CQUIN goals 

Table 2: 2013/14 CQUIN goals 

Goal 

No. 

Measure 

Description 

Weighting as % of 

contract value 

Potential value 

of goal £ 


domain 

Goal 

No. 

Measure 

Description 




of goal £ 


domain 

National CQUIN goals (including specialised element) 

– 

Compliance with 

3 Million Lives 

The national programme to 

roll out telehealth and telecare. 

Gateway 

Access to 

CQUIN monies 

Clinical 

Effectiveness 

1 VTE 

Continuation of nationally mandated goal. Weighting 

set: Risk assessment 90%. Prophylaxis 90% 

0.125 401,250.00 Safety 

– 

Intellectual property 

and commercialisation 

Clear processes in place to exploit 

commercial intellectual property 

Gateway 

Access to 

CQUIN monies 

Business 

development 

2 

Patient Experience 

- personal needs 

National CQUIN based on the annual inpatient survey 0.125 401,250.00 

Patient 

Experience 

– Dementia Signposting of carers with dementia to relevant services Gateway 

Access to 

CQUIN monies 

Safety 

3 Dementia 

Screening, risk assessment and referral to a 

specialist for all admissions over the age of 75 

0.125 401,250.00 Safety 

National CQUIN goals (including specialised element) 

4 Safety Thermometer 

Data collection for all patients in four harm areas: VTE, 

pressure ulcers, falls, and UTI in patients with catheters 

0.125 401,250.00 Safety 

1 VTE 

1. Risk assessment 95% 

2. RCA on hospital acquired thrombosis 

0.125 tba Safety 

Local CQUIN goals 

2 Friends and family test 

Adult inpatient services and ED from Apr 13. Maternity 

from Oct 13. Improvement in staff recommendation 

0.125 tba 

Patient 

Experience 

5 

6 

Cardiac output 

monitoring 


escalator 

Monitoring technology recommended for patients 

undergoing major or high risk surgery 

Multi - level goal on organisational 

responsiveness to patient experience 

0.125 401,250.00 

0.375 1,203,750.00 

Clinical 

Effectiveness 

Patient 

Experience 

3 Dementia 

All patients aged >75 admitted as emergency: 

ÆÆ1. Case finding, assessment & specialist 

ÆÆ2. Dementia clinical leadership plus staff training 

(new for 13/14) 

ÆÆ3. Supporting Carers (new for 13/14) 


7 Sepsis management Implementation of the Sepsis 6 care bundle 0.250 802,500.00 Safety 

8 Acute kidney injury Avoidance, detection and management of AKI 0.250 802,500.00 Safety 

4 Safety Thermometer 

Monthly surveying of all patients to collect data 

on 3 outcomes:1. Pressure Ulcers 2. Falls 3. UTI 

in patients with catheters. Indicators for GHT will 

be:1. Data collection plus 2. Reduction targets 


9 

Supporting clinical 

change programme 

Promotion of clinical engagement and system 

change to deliver the QIPP programme 

1.000 3,210,000.00 

Contract 

performance 

Local CQUIN goals 

5 

COPD Admission 

Care Bundle 

Care bundle approach using BTS best practice 

guidelines for admission COPD patients 

0.200 tba 

Clinical 

Effectiveness 

Specialised CQUIN goals 

10 Quality dashboards 

11 Neonatal 

12 Renal 

Completion and return of data to support 

national registries of clinical information 

Improvement in monitoring of screening for 

retinopathy of prematurity, catheter infections 

and fed on breast milk at discharge 

To increase the proportion of patients receiving Home 

dialysis, to encourage the use of Renal Patient View 

during nephrology outpatient attendance and to actively 

offer choice of patients with CKD to access RPV 

0.250 46,365.00 

1.000 194,733.00 Safety 

0.750 129,822.00 Safety 

Summary 2.500 8,395,920.00 

Clinical 

Effectiveness 

6 


escalator 

Multi - level goal on organisational 

responsiveness to patient experience 

0.200 tba 

7 Sepsis management Implementation of the Sepsis 6 care bundle 0.200 tba Safety 

8 Acute kidney injury Avoidance, detection and management of AKI 0.200 tba Safety 

9 

10 

Medicines 

Management 

Supporting Clinical 

Change Programmes 

Related to antimicrobial stewardship and joint formulary 0.200 tba 

Promotion of clinical engagement and 

system change to deliver the QIPP programme 

1.000 tba 

Patient 

Experience 

Clinical 

Effectiveness 

Clinical 

Effectiveness 

The proposed quality incentive goals for 

2013/14 are summarised in Table 2. There is 

a high level of overlap between these goals 

and the priorities in our Quality Account for 

2013/14. This demonstrates the high level of 

active engagement with our commissioners in 

quality improvement. It has been confirmed 

from national guidance that the value of 

CQUIN schemes in 2013/14 has again been set 

at 2.5% of total patient care income value. 

A major change for 2013/14 is the introduction 

of pre- qualification goals, which have to 

be achieved in order to qualify for CQUIN 

payments. These were first promoted in 

Innovation, Health and Wealth. These 

schemes are also shown in Table 2. 

Specialised CQUIN goals 

11 Quality dashboards 

Continue from 12/13. Completion and return of data 

to support national registries of clinical information 

0.25% tba 

Clinical 

Effectiveness 



59



Table 2: 2013/14 CQUIN goals (cont.) 

The Care Quality Commission 

Goal 

No. 

Measure 

12 Neonatal 

13 Neonatal 

14 Radiotherapy 

Description 

Continue from 12/13 Retinopathy of 

prematurity (ROP) screening. 

Timely administration of total parenteral 

nutrition (TPN) in preterm infants. 

Improving the proportion of IMRT 

with Level 2 imaging IGRT 




of goal £ 

0.25% tba Safety 

0.375% tba 

0.375% tba 

15 Renal Avoidance, detection and management of AKI 0.375% tba Safety 

16 Specialised Cancer Access to and impact of clinical nurse specialist 0.375% tba 


domain 

Clinical 

Effectiveness/ 

Patient 

Satisfaction 

Safety/Clinical 

effectiveness/ 

Patient 

Experience 

Patient 

Experience 

The Care Quality Commission (CQC) is 

the independent regulator of health and 

adult social care services in England. 

From April 2010, all NHS Trusts have 

been legally obligated to register with 

the CQC. Registration is the licence to 

operate and to be registered, providers 

must, by law, demonstrate compliance 

with the regulatory requirements of the 

CQC (Registration) Regulations 2009. 

Gloucestershire Hospitals NHS Foundation Trust 

(GHNHSFT) is registered with the CQC without 

conditions. This means that the Trust has 

continued to demonstrate compliance with the 

regulations. 

The Care Quality Commission has reviewed the 

Trust twice in the past year. 

The first review was a responsive review of 

Cheltenham General Hospital on 12 July 2012 

and involved the assessment of seven core 

standards. The CQC concluded that the Trust 

met six of the standards fully and had a minor 

concern involving record keeping. More details 

on this can be found below and an action 

plan to address this concern has now been 

developed. The full report is available on the 

CQC website www.cqc.org.uk 

In summary the CQC at Cheltenham Hospital 

findings were as follows: 

Outcome 01: People should be treated 

with respect, involved in discussions 

about their care and treatment and able to 

influence how the service is run. 

Patient's views and experiences were taken into 

account in the way the service was provided 

and delivered in relation to their care. Their 

privacy, dignity and independence were 

respected. 

Outcome 04: People should get safe and 

appropriate care that meets their needs 

and supports their rights. 

Patients’ needs were assessed and care and 

treatment was planned and delivered in line 

with their individual care plans in most cases. 

The provider was meeting this standard 

Outcome 07: People should be protected 

from abuse and staff should respect their 

human rights. 

Patients who use the service were protected 

from the risk of abuse, because the provider 

had taken reasonable steps to identify the 

possibility of abuse and prevent abuse from 

happening. The provider was meeting this 

standard. 

Outcome 09: People should be given the 

medicines they need when they need 

them, and in a safe way. 

Patients were protected against the risks 



61



associated with medicines because the provider 

has appropriate arrangements in place to 

manage medicines. The provider was meeting 

this standard. 

Outcome 13: There should be enough 

members of staff to keep people safe and 

meet their health and welfare needs. 

There was enough qualified, skilled and 

experienced staff to meet patients’ needs. The 

provider was meeting this standard. 

Outcome 16: The service should have 

quality checking systems to manage risks 

and assure the health, welfare and safety 

of people who receive care. 

The provider had an effective system to 

regularly assess and monitor the quality of the 

service that patients receive. The provider was 

meeting this standard. 

Outcome 21: People's personal records, 

including medical records, should be 

accurate and kept safe and confidential. 

Patients were not fully protected against 

the risk of unsafe or inappropriate care and 

treatment because accurate records were not 

always kept of the administration of medicines. 

Staffing level records were incomplete and 

some care records were inaccurate and had 

omissions. The provider was not meeting this 

standard. We judged that this had a minor 

impact on people using the service and action 

was needed for this essential standard. The 

CQC re-visited Cheltenham Hospital on the 

18th February 2013 and found the Trust to be 

fully compliant to this standard. 

In summary the CQC findings at 

Gloucestershire Royal Hospital on the 5th 

February 2013 were as follows: 

Outcome 01: People should be treated 

with respect, involved in discussions 

about their care and treatment and able to 

influence how the service is run. 

People's privacy, dignity and independence 

were respected. People's views and experiences 

were taken into account in the way the service 

was provided and delivered in relation to their 

care. 

Outcome 6: People should get safe 

and coordinated care when they move 

between different services. 

People's health, safety and welfare was 

protected when more than one provider was 

involved in their care and treatment, or when 

they moved between different services. This 

was because the provider worked in cooperation 

with others. 

The Trust continues to receive monthly Quality 

Risk Profiles from the CQC. The CQC Quality 

and Risk Profile currently declares no significant 

risks to compliance with any of the 16 essential 

standards for quality and safety. 

Quality of Data 

Good quality data underpins the 

effective delivery of patient care 

and is essential if improvements in 

quality of care are to be made. 

The patient NHS number is the key 

identifier for patient records. Accurate 

recording of the patient’s General Medical 

Practice Code is essential to enable the 

transfer of clinical information about a 

patient from a trust to the patient’s GP. 

"Good quality data 

underpins the effective 

delivery of patient care" 


will be taking the following action to improve 

data quality: 

ÆÆ 

ÆÆ 

ÆÆ 

review existing reports structure 

and access methods 

review usage within the organisation 

improve existing monitoring reports 

which identify areas of concern eg where 

we have insufficient data to raise a bill 

(leading to missing income), the NHS 

number is missing and where we do not 

hold an ethnic category for a patient. 

This information is used in national and 

local data sets to measure equity of 

access to and take up of our services. 

Gloucestershire Hospitals NHS Foundation 

Trust submitted records during 2012/13 to the 

Secondary Users Service (SUS) for inclusion 

in the Hospital Episode Statistics which are 

included in the latest published data. 

In data published for the period April 2012 

to February 2013, the percentage of records 

which included a valid patient NHS number 

was: 

ÆÆ 

ÆÆ 

ÆÆ 

99.8% for admitted patient care 

(national average: 99.0%) 

99.8% for outpatient care 


98.2% for accident and emergency 

care (national average: 94.9%) 

The percentage of published data which 

included the patient’s valid GP practice code 

was*: 

ÆÆ 

ÆÆ 

99.9% for admitted patient care 


99.9% for outpatient care 




63



ÆÆ 

100% for accident and emergency 

care (national average: 99.7%) 

A comprehensive suite of data quality reports 

covering the Trust’s main operational system 

(PAS) is available and acted upon. These are 

run on a daily, weekly and monthly basis and 

most are now available through the Trust’s 

Business Intelligence system, Analyzer. These 

include areas such as:- 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

outpatients including attendances, 

outcomes, invalid procedures 

inpatients including missing data such 

as NHS numbers, theatre episodes 

critical care including missing data, 

invalid Healthcare Resource Groups. 

These are derived by a complex algorithm 

from diagnosis and procedure codes 

assigned to a patient's stay in hospital 

plus some simple demographic data 

(age, sex) to produce a large set of 

codes which group together treatments 

with similar resource consumption 

A&E including missing NHS 

numbers, invalid GPs 

waiting list including duplicate 

entries, same day admission 

On a weekly basis this missing/incorrect data is 

chased and input/rectified. 

The Trust Data Quality Policy is published on 

the intranet setting out responsibilities for data 

quality. 

All Trust systems have an identified system 

manager with data quality as a specified duty 

for this role. System managers are required 

under the Clinical and Non- Clinical Systems 

Management Policy to identify data quality 

issues, produce data quality reports, escalate 

data quality issues and monitor that data 

quality reports are acted upon. 

Information Governance 

The Trust’s Information Governance 

Assessment Report score for 2012/13 remains 

77% and is graded green. 

The Information Governance Toolkit is available 

on the Connecting for Health website www. 

igt.connectingforhealth.nhs.uk. 

The information quality and records 

management attainment levels assessed within 

the Information Governance Toolkit provide 

an overall measure of the quality of data 

systems, standards and processes within an 

organisation. 

The effectiveness and capacity of these 

systems is routinely monitored by the Trust's 

Information Governance Committee and a 

performance summary is presented to the Trust 

Board annually in March. 

Clinical Coding Error Rate 

Clinical coding translates the medical 

terminology written by clinicians to describe 

a patient’s diagnosis and treatment into 

standard, recognised codes. The accuracy of 

this coding is a fundamental indicator of the 

accuracy of the patient records. 

The Trust was subject to an audit of clinical 

coding accuracy during the reporting period 

by the Audit Commission under its Payment by 

Results Data Assurance Framework. 

The error rates for diagnosis and treatment 

coding for 2012/13 were: 

ÆÆ 

primary diagnosis incorrect 6.0% 

ÆÆ 

secondary diagnosis incorrect 14.2% 

ÆÆ 

primary procedures incorrect 2.0% 

ÆÆ 

secondary procedures incorrect 9.0% 

These error rates have increased in the past 12 

months. The net impact of these errors was 

that we over-charged commissioners by £2,900 

on a total bill of more than £100million. 

The results should not be extrapolated further 

than the actual sample audited, which in 

2012/13 was general abdominal and lobar 

pneumonia in admitted patient care. 

We will be taking the following 

actions to improve data quality: 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

provide further training and re-emphasise 

guidance to coders on the need to 

record mandated co-morbidities, in 

particular current smoker status. 

ensure that all procedures, including 

scans and secondary procedures 

such as biopsies, are coded. 

introduce a process for ensuring 

coders check the radiology system to 

ensure scan codes are not omitted. 

ensure that the code 251.8 is 

consistently assigned to denote 

the Liverpool Care Pathway. 

keep staffing levels under review to ensure 

workload is manageable and consistent 

with delivering high quality coding. 



65

04 

Review of Quality 

Performance 

Understanding how well 

we are doing helps us 

improve for the future 



67

4 REVIEW OF QUALITY PERFORMANCE 4 REVIEW OF QUALITY PERFORMANCE 

The following section presents 

information relating to the quality 

of the services that we provide. 

The information will outline our performance 

against National Priorities and Core Standards 

as well as the measures agreed locally as 

part of our Quality Account last year. 

Overview of Performance against the 2012/13 National Priorities 

and Core Standards 

National Priority 2009-10 2010-11 2011-12 2012-13 

National 

Target for 

2012-13 

Clostridium difficile year on year reduction 

ÆÆPost 48 hrs 126 116 92 67 73 

MRSA bacteraemia at less than half the 2003/4 level 

ÆÆPost 48hrs 6 2 3 2 1 

Performance against selected metrics 

The following tables show the Trust’s 

performance for 2012/13 and the last 

three financial years for a selection of 

indicators relating to safety, clinical 

effectiveness and patient experience. 

We have chosen to include the same indicators 

as in past years to enable patients and the 

public to understand performance over time. 

In addition, we have also chosen this year to 

present the full range of measures reviewed on 

a quarterly basis by the Quality Committee. 

These measures have been chosen because we 

believe the data from which they are sourced 

is reliable and they represent the key indicators 

of safety, clinical effectiveness and patient 

experience within our organisation. 

18 week maximum wait from point of referral to treatment (admitted patients) 91.0% 88.9% 89.4% 92.4% 90% 

18 week maximum wait from point of referral to treatment (non-admitted patients) 96.3% 97.2% 98.4% 97.8% 95% 

Maximum waiting time of four hours in A&E from arrival to admission, transfer or discharge 

(GHNHSFT only) 1 

96.2% 94.97% 92.8% 94.7% 95% 

Maximum waiting time of 31 days from decision to treat to first treatment for all cancers 99% 99.7% 99.4% 99.7% 96% 

Maximum waiting time of 31 days from decision to treat to subsequent treatment: surgery 99.4% 99.8% 100% 99.8% 94% 

Maximum waiting time of 31 days from decision to treat to subsequent treatment: drugs 99.7% 100% 100% 100% 98% 

Maximum waiting time of 31 days from decision to treat to subsequent treatment: radiotherapy N/A 100% 100% 99.9% 94% 

Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers 

(including rare cancers) 

Maximum waiting time of 62 days from urgent referral from national screening programme 

to first treatment 

Maximum waiting time of 62 days from urgent referral from consultant upgrade suspected 

cancer referrals 

Maximum waiting time of two weeks from urgent GP referral to first outpatient 

appointment for all urgent suspected cancer referrals 

Maximum waiting time of two weeks from urgent GP referral to first outpatient 

appointment for patients referred with non cancer breast symptoms 

84.1% 85.4% 85% 85.2% 85% 

99.4% 98% 95.5% 94.8% 90% 

91.7% 92.7% 88.6% 98.3% 90% 

93.3% 93.6% 92.2% 92% 93% 

91.9% 90.6% 89% 96.2% 93% 

1. From 2010/11 this measure changed from countywide to GHNHSFT only. 



69

4 REVIEW OF QUALITY PERFORMANCE 4 REVIEW OF QUALITY PERFORMANCE 

Performance against selected metrics 

Performance against selected metrics (cont.) 

Measure 2009-10 2010-11 2011-12 2012-13 

National 

Target 


National 

average 


Measure 2009-10 2010-11 2011-12 2012-13 

National 

Target 


National 

average 


Safety Measures 

Clinical Effectiveness Measures 

Adverse event rate 61 34.19 17.61 15.58 * - N/A 

Never events 2 2 4 2 0 N/A 

Reduce harm from falls (per 1000 bed days) N/A 1.62 1.59 1.6 † - N/A 

Reduce errors in medication (per 100 bed days, ward areas only) N/A 2.26 1.94 2 † - N/A 

Reduce pressure sores N/A 101 99 76 § - N/A 

Number of patients discharged with Deep Vein Thrombosis (DVT) or 

Pulmonary Embolus (PE) per 1000 discharges 

12.6 14.6 9.0 N/A - N/A 

Percentage of patients risk assessed for VTE - - 94.20% 93.7% 90% - 

Rate of patient safety incidents based on internal database - - 10238 10718 - - 

Percentage resulting in severe harm or death (which equates to Serious 

Untowards Incidents reported with harm or death) 

- - 0.30% 0.26% - N/A 

Rate of C.diff (per 10,000 bed days cases >2 years) - - 3.38 2.25 - - 

Summary Hospital-level Mortality Indicator (SHMI) - - 97.4 97.3 ‡

05 

Statements from 

stakeholder organisations 

Good working relationships 

with our partners are central 

to our plans to improve quality 



73

5 STATEMENTS FROM STAKEHOLDER ORGANISATIONS 5 STATEMENTS FROM STAKEHOLDER ORGANISATIONS 

Gloucestershire Local Involvement Network (LINk) comments on 

the Quality Account 2012/13 

Gloucestershire LINk welcomes 

the opportunity to comment on 

Gloucestershire Hospitals NHS 

Foundation Trust’s 2013 Quality Account. 

The following comments have been 

compiled by a group of LINk members. 

General Comments 

While we appreciate the need for our 

comments to be on an early draft, the 

incomplete tables make it impossible for 

us to comment on the whole document. 

The presentation of this year’s report is 

user friendly, and the intention to have 

the document primarily web based is a 

good one. The inclusion of pictures of real 

patients helps bring the document to life. 

Although there are a number of references 

to carers as well as patients in the 

document we think it could be improved 

by a having a separate section relating to 

work done by the Trust with carers. 

Specific Comments 

Our Priorities: Priorities for 

Improving Quality 

We were particularly pleased to have the 

opportunity to give you views on the 

priorities for 2013/14 in January. Taking 

into consideration the views that we 

collected from the public, we do not wish 

to change or add to these priorities. 

We were pleased to see that there was a 

clear improvement in the quality of care 

provided for sepsis patients during the year. 

This is clearly illustrated in the graphs. 

Our Priorities: Priorities for the Year Ahead 

ÆÆ 

Improve the Emergency Care Pathway 

We are aware of the considerable efforts 

made by a large number of Trust staff 

to improve the Emergency Care Pathway 

but we remain concerned that the 

A&E waiting times are still too high. 

ÆÆ 

Implement the NHS Safety Thermometer 

It would be better if the actual 

incidence of pressure sores within the 

Trust, compared with the national 

incidence was mentioned here. 

Our Priorities: Clinical Effectiveness 

ÆÆ 

Reduce the incidence of avoidable renal 

failure for Acute Kidney Injury 

We recognise that the Trust has made 

considerable progress in identifying 

potential Acute Kidney Injuries 

ÆÆ 

Improve Diagnosis of Dementia 

Gloucestershire LINk has evidence that 

the emphasis by the hospital in improving 

the diagnosis of dementia and the care of 

patients with dementia is being actually 

achieved. 

Improving services for dementia is 

one of the priorities identified by LINk 

from the comments they have received 

as well as from members’ personal 

experience. An explanation of the use of 

dementia champions would be helpful. 

ÆÆ 


The integration of acute and community 

care into a seamless service for patients are 

one of LINk highest priorities. We will be 

very interested in the results of this pilot. 

Our Priorities: Patient Experience 

ÆÆ 

Improving the discharge experience of 

patients and carers 

In spite of considerable efforts by the 

hospital staff, the discharge experience 

for both patients and carers is an 

area which still needs considerable 

improvement. A number of the problems 

are not within the control of the trust. 

The Patient Experience Escalator 

ÆÆ 

Responding to patient and carer feedback 

This is an essential priority for the Trust 

but the details in this Quality Account 

seem to emphasise improving the ability to 

make comments for the computer literate 

and a proportion of the population are 

not able to make comments in this way. 

Barbara Marshall 

Chair of Gloucestershire LINk 

28 March 2013 



75


Health, Community and Care Overview and Scrutiny Committee 

Comments on the GHNHSFT Quality Account 2012/13 

The Health, Community and Care 

Overview and Scrutiny Committee 

(HCCOSC) welcome the opportunity 

to comment on the Gloucestershire 

Hospitals NHS Foundation Trust’s 

Quality Account 2012/13. 

The committee was pleased to note that 

Monitor has removed the Trust from significant 

breach relating to its A&E performance, and 

the associated improvements to the emergency 

care pathway. However despite this A&E 

remains a significant challenge for the Trust. 

The Trust has put forward proposals on 

changes to the delivery of urgent and 

emergency care in Gloucestershire which 

are currently out for consultation. The 

committee has debated these proposals 

and given initial feedback to the Trust. 

It will, however, be up to the new Health 

and Care Overview and Scrutiny Committee 

in the new council to receive and debate 

the outcome report from this consultation 

and the final change proposals. 

Managing public expectations is important. 

The committee was therefore pleased to 

welcome the Trust’s decision to create a 

resource on its website which demonstrates 

waiting times for the emergency departments 

and minor injury units across the county. 

Members are pleased to note that this 

page has been shortlisted for the Public 

Sector Communications Awards 2012. 

Other challenges for the Trust include how 

it can rebuild the trust of the general public 

following the adverse publicity and public 

reaction relating to the whistle-blower 

interview with BBC Radio Gloucestershire 

in January 2013; the result of the latest 

staff survey undertaken by the Trust also 

indicates that staff morale is low. 

The publication of the Francis Report on 

the care provided by Mid Staffordshire NHS 

Foundation Trust has also had cause to focus 

people’s minds on the delivery of care across 

all Trusts. The committee has been assured 

by the Chair of the Hospitals Trust that the 

Board takes these matters seriously and has 

commissioned activity to address these issues. 

The committee welcomes this work, 

and in particular that the Trust will be 

ensuring that staff are engaged with 

and help drive this work forward. 

The committee is clear that the design and 

delivery of services must be patient focused 

so it is good to see that this is reflected within 

this Quality Account. It was also good to hear 

this message reiterated by the Chair of the 

Trust at a recent meeting of the committee. 

The decision, by the Trust, to ensure that 

clinicians lead on service change proposals has 

made a real difference in helping members of 

the committee understand the reasons behind 

the service change proposals. This approach 

has enabled a clear and robust dialogue 

between the Trust and the committee. 

The committee has developed a good 

professional relationship with the Trust 

and I hope that this will continue into the 

new council and the new Health and Care 

Overview and Scrutiny Committee. 

I would like to thank Professor Clair Chilvers, 

Dr Frank Harsent, and Dr Sally Pearson 

for attending committee meetings and 

responding to members many questions in 

a positive and helpful manner. I would also 

like to thank Dr Sally Pearson for attending 

the committee’s work planning sessions. Her 

thoughtful and timely contributions have 

been of great benefit to the committee. 

Cllr Stephen McMillan 

Chairman 

HCCOSC 



77


Clinical Commissioning Group comments on the GHNHSFT Quality 

Account 2012/13 

Gloucestershire Clinical Commissioning 

Group (CCG), on behalf of its predecessor 

NHS Gloucestershire, has taken the 

opportunity to review the Quality Account 

prepared by Gloucestershire Hospitals NHS 

Foundation Trust (GHNHSFT) for 2012/13. 

We are very pleased that GHNHSFT has been 

working closely alongside NHS Gloucestershire 

and the shadow CCG during 2012/13 to 

maintain and further improve the quality of 

commissioned services. GHNHSFT has also 

been co-operative in building new clinical 

and managerial relationships in preparation 

for the CCG to take over commissioning 

responsibility from 1st April 2013. 

GHNHSFT has been open and transparent 

regarding challenges and concerns, whilst 

being supportive of and engaged with the 

development of initiatives such as the Joint 

Formulary, Map of Medicine and Your Health, 

Your Care strategy – our shared vision for 

the future. They have demonstrated further 

improvement of the safety, effectiveness and 

patient experience of services across a wide 

range of specialties, with particular progress 

made in the assessment and care of patients 

with acute kidney injury (AKI) or sepsis. 

The CCG very much welcome GHNHSFT’s 

strong focus on patient experience and 

quality of care, which demonstrates a joint 

commitment to delivering high quality 

compassionate care. We look forward 

to developing a whole health and social 

care community clinical programme 

approach towards commissioning and 

delivering services, with a strong emphasis 

on clinical leadership and engagement. 

Integrated care will be delivered according 

to agreed pathways and standards, with 

strong user and carer involvement being 

evident from prevention to end of life. 

There are robust arrangements in place with 

GHNHSFT to agree, monitor and review the 

quality of services. The Clinical Quality Review 

Group continues to meet bi-monthly and brings 

together GPs, senior clinicians and managers 

from both GHNHSFT and Gloucestershire 

CCG. We have received assurance throughout 

the year from GHNHSFT in relation to key 

quality issues, both where quality and safety 

has improved and where it occasionally fell 

below expectations with remedial plans put in 

place and learning shared wherever possible. 

The priorities for 2013/14 have been developed 

in partnership and Gloucestershire CCG 

endorse the proposals set out in the Quality 

Account. Gloucestershire CCG is very pleased 

with the approach taken by GHNHSFT, which 

is reflected in the Quality Account, to persist 

with and reinforce the values of honesty, 

transparency and effective engagement with 

stakeholders. Upholding these values ensures 

that the population of Gloucestershire will 

maintain trust and confidence in these core 

NHS services. GHNHSFT are in a strong 

position to manage both present and future 

challenges, and to work with Gloucestershire 

CCG to deliver best value effective care 

for the people of Gloucestershire. 

Gloucestershire CCG can confirm that we 

consider that the Quality Account contains 

accurate information in relation to the quality 

of services that Gloucestershire Hospitals 

NHS Foundation Trust provides to the 

residents of Gloucestershire and beyond. 

Dr Charles Buckley 

Clinical Commissioning Lead for Quality 

Gloucestershire Clinical Commissioning Group 

Marion Andrews-Evans 

Executive Nurse and Quality Lead 

Gloucestershire Clinical Commissioning Group 



79


Independent Auditor’s Report to the Board of Governors on the 


We have been engaged by the Council of 

Governors of Gloucestershire Hospitals 

NHS Foundation Trust to perform an 

independent assurance engagement 

in respect of Gloucestershire Hospitals 

NHS Foundation Trust’s Quality Report 

for the year ended 31 March 2013 

(the “Quality Report”) and certain 

performance indicators contained therein. 

Scope and subject matter 

The indicators for the year ended 

31 March 2013 subject to limited 

assurance consist of the national priority 

indicators as mandated by Monitor: 

ÆÆ 

C. difficile 

ÆÆ 

Maximum waiting time of 62 

days from urgent GP referral to 

first treatment for all cancers 

We refer to these national priority 

indicators collectively as the “indicators”. 

Respective responsibilities of 

the Directors and auditors 

The Directors are responsible for the 

content and the preparation of the Quality 

Report in accordance with the criteria set 

out in the NHS Foundation Trust Annual 

Reporting Manual issued by Monitor. 

Our responsibility is to form a conclusion, 

based on limited assurance procedures, 

on whether anything has come to our 

attention that causes us to believe that: 

ÆÆ 

ÆÆ 

ÆÆ 

the Quality Report is not prepared in 

all material respects in line with the 

criteria set out in the NHS Foundation 

Trust Annual Reporting Manual; 

the Quality Report is not consistent in 

all material respects with the sources 

specified in paragraph 2.1(2) of Monitor's 

2012/13 Detailed Guidance for External 

Assurance on Quality Reports; and 

the indicators in the Quality Report 

identified as having been the subject of 

limited assurance in the Quality Report 

are not reasonably stated in all material 

respects in accordance with the NHS 

Foundation Trust Annual Reporting Manual 

and the six dimensions of data quality 

set out in the Detailed Guidance for 

External Assurance on Quality Reports. 

We read the Quality Report and consider 

whether it addresses the content 

requirements of the NHS Foundation Trust 

Annual Reporting Manual, and consider the 

implications for our report if we become 

aware of any material omissions. 

We read the other information contained 

in the Quality Report and consider whether 

it is materially inconsistent with: 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

Board minutes for the period 

April 2012 to May 2013; 

Papers relating to quality reported 

to the Board over the period 


Feedback from the Commissioners 

dated 26/03/2013; 

Feedback from local Health-watch 

organisations dated 28/03/2013; 

Feedback from Governors 

dated 11/03/2013; 

The Trust’s complaints report published 

under regulation 18 of the Local Authority 

Social Services and NHS Complaints 

Regulations 2009, dated 16/04/2012; 

The 2012 national patient survey 

published by the Care Quality 

Commission in April 2013; 

The 2012 national staff survey 

dated 1/03/2012; 

Care Quality Commission quality 

and risk profiles dated 2/04/2012, 

31/05/2012. 30/06/2012, 31/07/2012, 

ÆÆ 

30/09/2012, 31/10/2012, 30/11/2012, 

31/01/2013, 28/02/2013; and 

The Head of Internal Audit’s annual 

opinion over the Trust’s control 

environment dated May 2013. 

We consider the implications for our report 

if we become aware of any apparent 

misstatements or material inconsistencies 

with those documents (collectively, the 

“documents”). Our responsibilities do 

not extend to any other information. 

We are in compliance with the applicable 

independence and competency requirements 

of the Institute of Chartered Accountants in 

England and Wales (ICAEW) Code of Ethics. 

Our team comprised assurance practitioners 

and relevant subject matter experts. 

This report, including the conclusion, has been 

prepared solely for the Council of Governors 

of Gloucestershire Hospitals NHS Foundation 

Trust as a body, to assist the Council of 

Governors in reporting Gloucestershire 

Hospitals NHS Foundation Trust’s quality 

agenda, performance and activities. 

We permit the disclosure of this report 

within the Annual Report for the year ended 

31 March 2013, to enable the Council 

of Governors to demonstrate they have 

discharged their governance responsibilities 

by commissioning an independent assurance 

report in connection with the indicators. 



81


To the fullest extent permitted by law, we 

do not accept or assume responsibility to 

anyone other than the Council of Governors 

as a body and Gloucestershire Hospitals 

NHS Foundation Trust for our work or this 

report save where terms are expressly agreed 

and with our prior consent in writing. 

Assurance work performed 

We conducted this limited assurance 

engagement in accordance with International 

Standard on Assurance Engagements 

3000 (Revised) – ‘Assurance Engagements 

other than Audits or Reviews of Historical 

Financial Information’ issued by the 

International Auditing and Assurance 

Standards Board (‘ISAE 3000’). Our 

limited assurance procedures included: 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

Evaluating the design and implementation 

of the key processes and controls for 

managing and reporting the indicators. 

Making enquiries of management. 

Testing key management controls. 

Analytical procedures 

Limited testing, on a selective basis, of 

the data used to calculate the indicator 

back to supporting documentation. 

Comparing the content requirements 

of the NHS Foundation Trust Annual 

ÆÆ 

Reporting Manual to the categories 

reported in the Quality Report. 

Reading the documents 

A limited assurance engagement is smaller 

in scope than a reasonable assurance 

engagement. The nature, timing and extent of 

procedures for gathering sufficient appropriate 

evidence are deliberately limited relative 

to a reasonable assurance engagement. 

Limitations 

Non-financial performance information is 

subject to more inherent limitations than 

financial information, given the characteristics 

of the subject matter and the methods 

used for determining such information. 

The absence of a significant body of 

established practice on which to draw 

allows for the selection of different but 

acceptable measurement techniques 

which can result in materially different 

measurements and can impact comparability. 

The precision of different measurement 

techniques may also vary. Furthermore, the 

nature and methods used to determine such 

information, as well as the measurement criteria 

and the precision thereof, may change over 

time. It is important to read the Quality Report 

in the context of the criteria set out in the NHS 

Foundation Trust Annual Reporting Manual. 

The scope of our assurance work has not 

included governance over quality or nonmandated 

indicators which have been 

determined locally by Gloucestershire 

Hospitals NHS Foundation Trust. 

Conclusion 

Based on the results of our procedures, nothing 

has come to our attention that causes us to 

believe that, for the year ended 31 March 2013: 

ÆÆ 

ÆÆ 

ÆÆ 

the Quality Report is not prepared in 

all material respects in line with the 

criteria set out in the NHS Foundation 

Trust Annual Reporting Manual; 

the Quality Report is not consistent in 

all material respects with the sources 

specified in Monitor's 2012/13 Detailed 

Guidance for External Assurance on 

Quality Reports paragraph 2.1(2); and 

the indicators in the Quality Report 

subject to limited assurance have not been 

reasonably stated in all material respects 

in accordance with the NHS Foundation 

Trust Annual Reporting Manual. 

[Draft copy – audit not complete] 

Grant Thornton UK LLP 

Chartered Accountants 

Hartwell House, 55-61 Victoria 

Street, Bristol, BS1 6FT 

Date: 



83


Statement of Directors’ Responsibilities in respect of the Quality 

Account 2012/13 

The directors are required under the 

Health Act 2009, National Health Service 

(Quality Accounts) Regulations 2010 

and National Health Service (Quality 

Account) Amendment Regulation 2011 

to prepare Quality Accounts for each 

financial year. The Department of Health 

has issued guidance on the form and 

content of annual Quality Accounts (which 

incorporate the above legal requirements). 

In preparing the Quality Account, 

directors are required to take steps 

to satisfy themselves that: 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

the content of the Quality Account meets 

the requirements set out in the NHS 

Foundation Trust Annual Reporting Manual; 

the content of the Quality Account is not 

inconsistent with internal and external 

sources of information including; 

board minutes and papers for the 

period March 2013 to May 2013; 

papers relating to Quality reported 

to the Board over the period 


feedback from the commissioners 

dated 26/03/2013 

feedback from the Governors 

dated 11/03/13 

ÆÆ 

feedback from LINk dated 28/03/2013 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

ÆÆ 

the Trust’s complaints report published 

under regulation 18 of the Local Authority 

Social Services and NHS Complaints 

Regulations 2009, dated 16/04/2012 

the 2012 National Patient Survey 

published by the Care Quality 

Commission in April 2013 

the 2012 National Staff Survey 

dated 01/03/2013 

the Head of Internal Audit’s annual 

opinion over the Trust’s control 

environment dated May 2013 

Care Quality Commission quality and 

risk profiles dated 02/04/12, 31/05/12, 

30/06/12, 31/07/2012, 30/09/12, 31/10/12, 

30/11/2012, 31/01/13, 28/02/13; 

the Quality Accounts presents a 

balanced picture of the Trust’s 

performance over the period covered; 

the performance information reported in 

the Quality Account is reliable and accurate; 

there are proper internal controls over 

the collection and reporting of the 

ÆÆ 

ÆÆ 

measures of performance included in the 

Quality Account, and these controls are 

subject to review to confirm that they 

are working effectively in practice; 

the data underpinning the measures 

of performance reported in the Quality 

Account is robust and reliable, conforms 

to specified data quality standards and 

prescribed definitions, is subject to 

appropriate scrutiny and review; and 

the Quality Account has been prepared 

in accordance with Monitor’s annual 

reporting guidance (which incorporates 

the Quality Accounts regulations) 

published at www.monitor-nhsft.gov.uk/ 

annualreportingmanual, as well as the 

standards to support data quality for the 

preparation of the Quality Account. 

The directors confirm to the best of their 

knowledge and belief they have complied 

with the above requirements in preparing the 

Quality Account. 

By order of the Board 

Dr Frank Harsent 

Chief Executive 


May 2013 

Prof Clair Chilvers 

Chair 


May 2013 



85

06 

Glossary of 

abbreviations and terms 



87

6 GLOSSARY 6 GLOSSARY 

Academic Health 

Science Networks 

Academic Health Science Networks are new partnerships responsible for driving improvements in 

patient care by sharing innovations across the NHS. Their creation was announced in December 2011 

in the Government’s ‘Innovation, Health and Wealth’ report as a way to align education, clinical 

research, informatics, innovation, training, education and healthcare delivery at a local level. 

Care bundle A care bundle is a set of clinical interventions that, when used together, significantly improve patient care. 

Commissioners 

Emergency Department 

Gloucestershire LINk 

Governors 

Members 

NICE technology 

appraisals 

Plan, Do, Study, Act 

Regulators 

Venous 

thromboembolism (VTE) 

From April 1, 2013, our commissioners will be the Gloucestershire Clinical Commissioning Group. Commissioning is the 

process of assessing the needs of a local population and putting in place services to meet those needs. Commissioners 

are those who do this and who agree service level agreements with service providers for a range of services. 

Otherwise known as A&E 

Gloucestershire’s Local Involvement Network (LINk) is an independent voluntary body made up of 

individuals, community groups and organisations across the county, who work together to influence, 

improve or change the way local health and social care services are planned and delivered. This 

organisation will cease to exist on April 1, 2013 and will be replaced by Healthwatch. 

Members can become more involved by standing for election as a governor and representing 

their fellow members’ views on the Council of Governors. Governors play an important role in 

the governance of the Trust. They represent the views of patients, carers and patients. 

As an NHS Foundation Trust we are accountable to our local community. This means we give 

greater say in how we’re run to local people, staff and all those who use our services including 

patients, their families and carers. Each foundation trust must recruit ‘members’ to reflect 

these groups and help us ensure that we are providing the best service we can. 

These are recommendations by the National Institute for Clinical Excellence (NICE) on the use of new and 

existing medicines and treatments within the NHS in England and Wales. Examples include medicines, 

medical devices, diagnostic techniques, surgical procedures and health promotion activities. 

A method of implementing change by trialling and testing new methodology or working 

practice on a small scale, before evaluating and deciding whether to progress further. 

The Care Quality Commission (CQC) regulates all health and adult social care services in England, including 

those provided by the NHS, local authorities, private companies or voluntary organisations. It also 

represents the interests of people detained under the Mental Health Act. Monitor is also another regulatory 

body, responsible for safeguarding choice, protecting and promoting the interests of patients. 

This is a disease that includes Deep Vein Thrombosis (DVT) and pulmonary embolism (PE) 



89

6 GLOSSARY 6 GLOSSARY 

“My son spent 26 days in the 

critical care unit and this was the 

most amazing hospital unit I have 

ever known. The staff from top to 

bottom were exceptional and the 

most caring, professional people I 

have ever had the fortune to meet. 

My son has a serious disability and 

this was so well catered for and 

did not have any bearing on the 

way he was treated by all the staff. 

Some would say that it was a 

shame we were in [hospital] all 

through the Olympics, but I would 

say team GB cannot hold a candle 

to the team spirit and personal 

application that I witnessed. I can 

proudly say I witnessed first-hand 

team GRH and every one of them 

deserves a gold medal.” 

Relative of patient at Gloucestershire Royal 

Hospital, August 2012, NHS Choices 



91

Our Quality Account forms 

part of a larger range of Trust 

documents for 2012/13. 

To read any of these documents visit 

www.gloshospitals.nhs.uk 

Equality 

Report 


Annual 

Report 


92 

GHNHSFT Quality Account 2012/13

Quality Account 2012/13 - Gloucestershire Hospitals NHS Trust

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