Case Studies

 Hinchingbrooke Health Care NHS Trust
CHKS Quality of Care Award Winner 2009

Poole Hospital NHS Foundation Trust
CHKS Patient Safety Award Winner 2009

Cardiff & Vale NHS Trust
CHKS Data Quality - Wales Award Winner 2009

Salisbury NHS Foundation Trust 
CHKS Patient Safety Award Winner 2008 

East Kent Hospitals NHS Trust
CHKS Data Quality (England) Award Winner 2008

 
Hinchingbrooke Health Care NHS Trust
CHKS Quality of Care Award 2009

Making quality core to survival at Hinchingbrooke Health Care NHS Trust

The winner of the CHKS Quality of Care Award this year is Hinchingbrooke Health Care NHS Trust.  It has introduced a number of new initiatives over the past year to improve the quality of care provided to patients.  As chief executive Mark Millar explains, the trust is being made fit for purpose' for the future. He says that the trust has historically been ‘financially challenged' and is currently awaiting a decision from the government on its future governance arrangements.

However, in order to ensure improvements remain on track, the trust has launched a ‘Sustainable Hospital' programme.  ‘We want to get the hospital to a position where it is sustainable financially and clinically,' says Mr Millar. Wards have been refurbished, with the addition of electric sliding doors and five-bed bays with en-suite shower and toilet facilities. 

‘We are trying to empower ward managers in patient safety and quality of care,' Mr Millar says. The main trust site has a state-of-the-art NHS treatment centre created through a private finance initiative scheme. ‘It is our aspiration that the main hospital is brought up to the same standards in terms of quality of care as the treatment centre,' Mr Millar adds.

 

Poole Hospital NHS Foundation Trust
CHKS Patient Safety Award Winner 2009 

Patient Safety Award winner Poole Hospital NHS foundation Trust has developed the ‘Poole approach'. Martin Smits, the trust's director of nursing and patient services, explains that this is an ‘objective mission statement' about how the trust wants to be as an organisation. ‘It is about being professional and open about things to do with patient safety,' he says.

The trust is proud of the fact that National Patient Safety Agency figures show it has a lot of reports of incidents and near-misses because it believes that demonstrates that staff are reporting patient safety issues correctly. ‘We have got staff engaged in reporting and the once we have the data, we are working with them to find solutions so that we learn and try to improve,' Mr Smits explains.

Using its patient safety data, the trust recently became concerned about the number of patients with pressure ulcers. ‘We talked to the staff about this and developed a grading system.  We also introduced a hotline that gives staff access to a pressure sore team, who come and give advice and help.'

Mr Smits says that it is thanks to the more honest and open approach to reporting patient safety issues that this has been developed.  ‘Traditionally, we would have had the data and we would have looked at it and not done anything. This has changed.'

Cardiff & Vale NHS Trust
CHKS Data Quality Award - Wales Winner 2009

Higher mortality rates are expected at tertiary centres such as Cardiff and Vale NHS Trust, where patients attend from across Wales for a range of specialist services. However, when mortality rates at the trust were examined two years ago, the board decided on a detailed review at speciality level to establish whether or not the statistics were painting a true picture. CHKS was brought in review the trust and identify patient details in three specialties where the CHKS statistical model indicated that some patients would not have been expected to die. In each specialty, about 20 patient records were selected.  The three lead clinicians were presented with the results, and given an explanation of the CHKS approach, which identified where mortality was unexpectedly high.

The next step was for the consultants to work with the clinical coding team to audit the case notes.  After adjustments to the coding, the data was resubmitted, and the statistics showed no ‘excess' deaths overall.

The trust has now decided to roll out the process across every specialty and workshops are planned for clinicians, managers and coders to learn how to ensure mortality statistics are accurate.  Jenny Jones, the trust's clinical governance manager, says: ‘Clinicians need to understand why coders can't code; part of the work we have done is to link clinicians with the relevant coders to get them to talk to each other and work through their cases.'

 
Salisbury NHS Foundation Trust
CHKS Patient Safety Award Winner 2008

Best practice leads to safer hospital environment

Instilling a culture of safety throughout the organisation has been a top priority for Salisbury NHS Foundation Trust for a number of years. It is this commitment that led to the trust winning the CHKS Patient Safety Award in 2008.

Taking responsibility for patient safety is Director of Nursing Tracey Nutter. She explains: "We have introduced a number of projects including reducing hospital mortality and infection rates. While I have the overall responsibility for patient safety, the Chief Executive, other Executive Directors and the wider Trust Board take an active role in developing the safety agenda and the Medical Director leads on specific aspects of safety work, such as the mortality project."

Focusing on mortality
Five years ago a mortality group was set up to focus on reducing preventable deaths and helping patients expecting to die, to die with more dignity. The mortality group has played an important role in raising awareness of the importance of reducing mortality and associated issues with clinical staff. Tracey Nutter says: "The development of mortality groups at directorate level has resulted in more open discussion and learning taking place within and between clinical teams and across specialty areas."

Other projects include the implementation of the Early Warning Scoring System, which makes it easier for staff to assess when a patient's condition is getting worse and take action. This is currently achieving audited compliance of 96%. Other initiatives include a 24-hour Critical Care Outreach service to support ward staff in delivering care to cardiac arrest patients, improvements in handover to night teams, the introduction of the Global Trigger Tool that helps the trust understand the main causes of harm in the hospital and the introduction of VTE assessment for all patients admitted to hospital for which the Trust recently achieved exemplar status.

Reducing hospital-acquired infections
Improvements in hospital mortality have been mirrored in the trust's achievements in reducing hospital-acquired infections. "We have a target zero approach to both MRSA bacteraemia and C.difficile and managing the prevention and control of infection is viewed as everyone's responsibility", says Tracey Nutter. Infection control is monitored from the ward right through to the board and initiatives such as the "bare below the elbow" policy for all clinical staff and a change from the traditional nurse's uniform to "all scrubs" for nursing and therapy staff have led to significant improvements.

In the last three years, cases of MRSA have reduced from 21 to 7 per annum and are continuing to fall. Cases of C.difficile are currently reducing by 75%. This has put the Trust in the upper quartile performance for reducing infection rates and efforts continue to reduce rates and sustain improvements.

"Winning the CHKS Patient Safety Award was a welcome recognition of the hard work everyone at Salisbury has put into creating a safe environment for our patients" concludes Tracey Nutter. "The challenge now is to maintain our high standards through a continual programme of monitoring and improvement."

East Kent Hospitals NHS Trust
CHKS Data Quality (England) Award Winner 2008

Training the spotlight on clinical coders

Improving the quality of clinical coding is a priority for all NHS organisations. Robin Gammon explains how an award-winning Trust is transforming the skills of its clinical coders.

The NHS Operating Framework for 2008/9 calls on all organisations to focus on coding in the drive for world-class patient care. But do clinical coders have the skill and knowledge required to undertake this increasingly important task?

At East Kent Hospitals University NHS Trust, the clinical coding team is well positioned to deliver on the priorities set out in the Operating Framework. Two years into a structured training programme, the quality of clinical coding has improved to such an extent that the Trust was named as this year's winner of the CHKS Data Quality Award for England.

Back in February 2006, though, the situation was very different. Training had been neglected for a number of years and the first task of a newly-formed project team was to establish standards and introduce processes to ensure that coders received the information they needed to produce timely and accurate coding.

A training programme was then designed to build on the knowledge and skills of every member of the clinical coding team, with the ultimate aim of achieving the Accredited Clinical Coder (ACC) qualification.

Beginning in late 2006, the Clinical Coding Foundation Course was run locally for eight members of the coding team. Developed by the NHS Classifications Service, the course aims to provide coders with a thorough grounding in the theory of classification and provides opportunities to develop practical skills in clinical coding. The course was repeated the following year for other members of the team, alongside a Refresher Course for those with more experience.

The training programme is now in its next stage of development as more of the team are encouraged to take the ACC qualification. The focus is on Specialty workshops, with maternity and orthopaedics to be covered first, along with Refresher and Revision courses as the exam date looms. Building in-house training and audit capabilities is a priority alongside a greater level of clinical engagement as the introduction of HRG4 approaches.

Clinician involvement in the coding process will ensure that the HRG allocation under the new, more complex system will be accurate and comprehensive. The additional procedures and interventions that will need to be tracked on the clinical record will have a significant impact on the coding team and training will be put in place to support them.  There is also a plan to allocate a clinical coder to a directorate specifically to look at improving the process from medical notes to coding.

The need to grow a strong clinical coding team now means the Trust recruits graduate level staff with knowledge of anatomy and physiology and a commitment to undertake the ACC qualification. This is particularly important since a national shortage of ACC-qualified staff has led in the past to problems for Trusts recruiting to Head of Clinical Coding and Site Clinical Coding Manager posts where the ACC qualification is mandatory.

Coders at East Kent Hospitals University NHS Trust are reaping the benefits of their training, not least through the high profile they have gained throughout the Trust as a result of winning the CHKS data quality award. Singled out to share best practice by South East Coast SHA Chief Executive Candy Morris, the team is working with the SHA's Head of Knowledge Management, Samantha Riley, to maximise the learning experience across the region.

Robin Gammon is Deputy Director of Information at East Kent Hospitals University NHS Trust.

"Data quality is critical to ensuring that clinicians and commissioners have the best available information to support them in providing high quality care to patients. For this reason, data quality is a key component of the SHA's recently approved Knowledge Management Strategy. I am delighted that East Kent Hospitals NHS Trust has been awarded the CHKS Data Quality award for England, and endorse this approach as we strive to deliver high quality care for all in Kent, Surrey and Sussex."  Candy Morris, Chief Executive, NHS South East Coast.

A version of this article appeared in the Health Service Journal on the 26th March 2009.