LAS Quality Strategy - Vision 2020 and Annual Quality Account 2018-2019 · goals and targets for London Ambulance Service (LAS) in providing high-quality services over the next year

Quality Strategy : Vision 2020 andAnnual Quality Account 2018-2019

ContentsForeword 1

Section 1: 3

Introduction to our Quality Strategy and Accounts 2018/19

What is the Quality Strategy?

Section 2: 12

Looking Forward: Our Quality goals and targets 2018-19

Section 3: 21

Looking Back: Quality performance 2017-18

Section 4: 28

Statements of assurance from the Board

Section 5: 36

Reporting on core indicators

Section 6: 45

Other services

Section 7: 49

Feedback from our partners and stakeholders

Appendix 1: 52

Clinical Audit : Learning outcomes

Appendix 2: 55

CQUINS 2017-18 and 2018-19 : UPDATE

London Ambulance Service NHS Trust

ForewordThe London Ambulance Service is the only pan London Trust and is thebusiest ambulance service in the country responding year on year toincreasing demands. Our Trust was inspected February 2016 by theCQC, who gave us an overall rating of ‘requires improvement’ in theirfinal report. The care we give to patients was rated as outstanding, anumber of services were rated as ‘good’ but the standards observedwere not consistent nor of the quality the Trust aspires to deliver.During the year we have delivered a comprehensive action plan andexternal assessment confirms what we know, that our services haveimproved over the last two years. However we also know there isfurther improvement to make to achieve our vision of providing aworld class service. Through this strategy, we want to strive for‘outstanding’ Care Quality Commission (CQC) rating across our sites and services by 2020.

These are undeniably challenging times for healthcare, with NHSservices under increased pressure due to our ageing and growingpopulation. However, with these challenges, we have an excitingopportunity when it comes to improving healthcare quality.

We hope our commitment to improvement and our determination toget things right for our patients, people and stakeholders is clear in thisstrategy. We are working to harness opportunities to continuouslyimprove in order to provide safe, high quality, patient-centred care forall our patients. In addition we need to ensure that our staff areprovided with the skill and support to deliver the right care and feelmotivated and able to do so.

To achieve this, we are rolling out a programme of qualityimprovement and human factors training and developing our systemsand processes to build an organisation-wide culture of continuousimprovement. At the same time, patients will have a stronger voicethan ever before, and we have begun and will continue to work moreclosely with the people and communities we serve to make sure thatthe care they receive is centred on their needs.

This strategy is the plan by which we will continue our journey toachieve our ambitions and a positive outcome in subsequent CQCinspections as continuous quality improvement becomes our business as usual.

Dr Patricia BainChief Quality Officer

1London Ambulance Service NHS Trust

Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019

Statement of Directors responsibilitiesThe directors are required under the Health Act 2009 and the NationalHealth Service (Quality Accounts) Regulations to prepare Quality Accountsfor each financial year.

NHSI has issued guidance to NHS trust boards on the form and content ofannual quality accounts (which incorporates the above legal requirements)and the arrangements that NHS trust boards should put in place to supportthe data quality for the preparation of the quality account. The LondonAmbulance Service, whilst not a Foundation Trust has prepared the annualquality account in line with this guidance ensuring directors have takensteps to satisfy themselves that:

• The content of the Quality Account meets the requirements set out inthe NHS Foundation Trust Annual Reporting Manual 2018/19 andsupporting guidance

• The content of the Quality Account is not inconsistent with internal andexternal sources of information including:

– board minutes and papers for the period April 2017 to March 2018

– papers relating to quality reported to the board over the period April2017 – March 2018

– feedback from commissioners dated April 2018

– feedback from Overview and Scrutiny Committee dated March 2018

– the Trust’s complaints report published under regulation 18 of theLocal Authority Social Services and NHS Complaints Regulations 2009,dated May 2018

– the 2017 national staff survey

• The quality report presents a balanced picture of the NHS trust’sperformance over the period covered

• The performance information reported in the quality report is reliableand accurate

• There are proper internal controls over the collection and reporting ofthe measures of performance included in the quality report, and thesecontrols are subject to review to confirm that they are workingeffectively in practice

• The data underpinning the measures of performance reported in thequality report is robust and reliable, conforms to specified data qualitystandards and prescribed definitions, is subject to appropriate scrutinyand review and

The Directors confirm to the best of their knowledge and belief they havecomplied with the above requirements in preparing the quality report.

By order of the Board

Chair Date

Chief Executive Date

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Section 1:

Introduction to our QualityStrategy and Accounts 2018/19The quality strategy for the Trust, aims to bring togetherour plans in line with over overarching strategy, businessplanning process and the CQC quality assessmentframework. The purpose of the strategy is to set out thegoals and targets for London Ambulance Service (LAS) inproviding high-quality services over the next year and,therefore, delivering our vision and objectives.



Developing our Trust-widestrategyWe recently published a document entitled ‘Ourstrategic intent 2018/19 – 2022/23’, it sets out ourambition and describes how we plan to evolve in orderto achieve improved outcomes and a better experiencefor patients.

It formed the basis for a six-week period of consultationthat took place with internal and external stakeholdersduring November and December 2017, the mainpurpose of which has been to ensure that we fullyaddress the needs of patients, our staff, partner NHSorganisations and other business partners acrossLondon.

We are working with many of our stakeholders andbusiness partners, including the CQC, to co-design ourfinal strategy, which is due for release early 2018.

Our trust strategy focuses on improvement, andtherefore supports delivery of our vision and objectives.It sets out a number of the key enablers and examplesof the projects required to improve performance toillustrate the breadth of our work programme.

These objectives have quality embedded in them. Thisshows the commitment and reality that quality drivesall that we do.

The Trust’s visionThe London Ambulance Service is uniquely placed toplay a wider role within the London health economy.

Our ambition is to become a world-class ambulanceservice for a world-class city: London’s primaryintegrator of access to urgent and emergency care onscene, on phone and online.

This vision will be delivered through the achievementof the Trust’s strategic objectives, which are:

• Acting as a multi-channel single point of access andtriage to the urgent and emergency care systemacross London.

• Providing a high quality and efficient differentiatedclinical service that better matches care to patienturgent and emergency needs.

• Using our influence and working with partners toensure a consistent approach to urgent andemergency care.

Our Purpose

We exist to:

• Provide outstanding care for all of our PATIENTS

• Be a first class employer, valuing and developing theskills, diversity and quality of life of our PEOPLE

• Provide the best possible value for the tax payingPUBLIC, who pay for what we do

• PARTNER with the wider NHS and public sector tooptimise healthcare and emergency servicesprovision across London

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What is the Quality Strategy?Our quality strategy is the plan through whichwe focus on the quality of clinical care and toensure that we continuously improve ourservices. It ensures that quality drives the overalldirection of our work and that the patient is atthe centre of everything that we do.



This strategy sets out our definitionof quality, and describes our visionand direction, ensuring that qualityis our number one priority. It setsout our five domain quality goalsand associated targets and anumber of projects which we mustfocus on to ensure we can evidencethat our services are safe, effective,caring, well led and responsive. Italso describes the governancearrangements to ensure deliveryand sustainability from 2018/19. Thestrategy also outlines our currentposition, showing theimprovements we have made in our2017-18 Quality Account prioritiesand what we are building on goingforward.

It is ambitious, setting out ourcommitment to make qualitycentral to all that we do. It alsoreinforces that wherever possible,our focus will be on embracing newways of working to improve care forpatients and integrating healthcareacross the wider integrated urgentand emergency care system.

It provides a modern approach tocontinuous improvement andacknowledges that our people arecentral to delivering our strategy.

We will use the implementation ofthe Quality Strategy to strengthenconfidence and pride in the serviceswe provide. We want patients to beconfident that the Trust is amongthe best in the world.

We want people working in andwith the Trust to be confident that

they are providing the best servicethey can, are valued and areimportant. We recognise theimportance of building a culturewhere quality and its continualimprovement is our priority and weare committed to doing so. Wewant a shared pride in the Trust andassurance that it is the very best itcan be.

How we developed the strategyThe strategy has been informed bythe reports and recommendationsfrom key stakeholders, staff andpatient representatives and the CQCframework. We also assessed ourprogress against priorities in our lastquality account.

Comparison was also undertaken oftrends and variation from a rangeof intelligence including:

• Patient surveys

• Staff surveys

• Governance data, e.g. incidents,complaints, claims and audit

This was then merged withfeedback from key stakeholders,including our people and ourcommissioners.

We have therefore been careful todevelop goals and targets that aremeasurable whilst trying toencapsulate our commitment to thequalitative elements of our work.This will provide clarity for ourpatients and external stakeholders,and ensure that our people havetangible, measurable and

reportable goals to aim for. Thesetargets will be redefined each yearin our annual quality account, withprogress monitored through theTrust’s governance system. Webelieve that if we can meet ourtargets under each quality domain,we will see significantly improvedoutcomes for our patients and abetter working environment for ourpeople. Our goals and targets havebeen selected to have the highestimpact across the Trust and arepurposely challenging.

We recognise in particular that weneed to improve many of ourprocesses and systems to ensurebetter outcomes and experience forour patients. A series of Trust-wideimprovement projects, informed byour CQC inspection action plan anda review of the key lines of enquirythat the CQC use, have beenestablished to deliver specific timebound programmes of work.

What is our definition of quality?We have based our definition ofquality on the CQC’s framework,which draws on the Francis, Keoghand Berwick reviews andrecommendations.

Our approach aligns Berwick’simprovement principles which areembodied within safe, effective,caring, responsive and well leddomain. The combination ofperformance in each of the fivedomains determines the overallquality of the healthcare weprovide. We believe that we canimprove services only by supportingcontinuous improvement in all areashence our commitment to thisdriver.

The previous quality account andimprovement programme for theTrust focused on making immediatequality improvements and ensuringthat we achieve a rating of ‘good’in our CQC inspection, this strategyand our priorities for 2018-19 andbeyond will strive to bring the trustto an ‘outstanding’ rating.

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The quality domainsThe quality domains are outlined below, together with the descriptor ofwhat these mean. The domains match those used by the CQC to ensure weare focused on making improvements which are aligned with ourregulatory body’s expectations.



The leadership, managementand governance of theorganisation assures thedelivery of high qualityperson-centred care,supports learning andinnovation, and promotes an open and fair culture

Services are organised so that they meet people’s needs

People’s care, treatmentand support achievesgood outcomes, promotesagood quality of life andis based on the bestavailable evidence

Staff involve and treatpeople with compassion,kindness, dignity andrespect

Safe Caring

Effective Well LedResponsive

People are protectedfrom abuse andavoidable harm

Delivering the Strategy:

How will the strategy be delivered and progressmonitored?

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Quality Goals and Targets

The strategy will be deliveredthrough the achievement of ourquality goals, which are supportedby specific annual targets. These areoutlined under each quality domainand have been chosen to ensurethat we focus on makingimprovements where they are mostneeded, and on sustainingimprovements that have alreadybeen achieved. We believe that ifwe can meet our goals and targetsin these priority areas, we will seesignificantly improved outcomes forour patients and a better workingenvironment for our staff. The goalsand targets under each domain will

be incorporated into the qualityreport and performance scorecards,ensuring they can be tracked fromstation to board. This will provideclarity on the Trust’s priorities andwill show the impact of theimprovements we have made.

Building Delivery Capacityand capability

Delivering the strategy will bepredicated on ensuring we have theright skills and capacity across theorganisation. The outline planbelow sets out the key activities toachieve this aim, are detailed in ourimplementation plan.



Two key aims:

1.To acceleratedelivery of thehighest quality,best value care,and best staffexperience acrossLAS by 2020

2.To embedcontinuousimprovementinto dailyoperations at LAS and toensure bestsupport toservices acrossLAS

Build will

Create alignmentand deploy

infrastructure

Build improvementcapability and

capacity

Apply, monitorassure

Listen to staff and patients to determine priorities1Develop and tell our quality/QI narrative2Celebrate successes, showcasing existing work3Hold learning and awareness events4Visits to exemplar sites5Set up QI microsite (intranet and internet)6Develop a network of Quality Champions7

Have patient/carer involvement in all improvement work1Align service strategies, objectives, expectations and2reporting with improvement aims; also align key trustinitiatives, e.g., Quality Account, Clinical Quality indicators,Align individual goals/time with improvement aims (job3plans, appraisal, prof. development)Develop informatics & analytics to support improvement4

Initial assessment of current capability, gaps & priorities1Recruit core QI team & establish internal secondments2Find and train experts3Build capability & capacity in different intensities &4formatsa. Introductory trainingb. In-depth longitudinal/applied training for teamsc. Develop coaches to support teams & initiativesExecutive and Board development5Embed in professional and leadership education 6

Through two main tracks – with rigorous measurement ofquality and efficiency/quality assurance framework

Major trust initiatives, incl: Patient and staff /volunteers1involvement programme; Strategy LAS Vision2020:Strategic, service/pathway redesign Local priorities: Each sector/station to work to a local QI2objective

Building the WillIntegral to all programmes must bethe aim of robust patient and staffinvolvement so they support thedevelopment of what represents ahigh quality and efficient service. Itis important that we continue toexplore further ways of gettingfeedback from staff via QualityChampions, patient and carers andcommunity groups, in addition toour continued engagement withthe Patients Forum. The patientinvolvement teams will develop aframework to ensure these aimsand the successes they have alreadyachieved are embedded.

The importance of ensuring that wetake every opportunity to engagewith examplar sites partners in theredesign of services and pathways inorder to secure the right outcomesis articulated in our organisationalstrategy. Supporting thisprogramme will be acommunication strategy thatincludes intranet and internetdevelopment.

Creating alignmentAlongside the quality goals andtargets, we have developedmeasurable and structuredimprovement projects aligned toour strategic and businessobjectives. These projects have beeninformed by analysis of a number ofmeasures of our performanceincluding:

• Our strategic intent

• current performance againstnational and local targets

• our quality account

• areas of known risk

• our CQC inspection and reportduring 2018

• review of the key lines ofenquiry that the CQC publish.

Each project has been assessed fortheir potential to positively impacton the Trusts strategic goals andtargets and we are confident thatwe have the necessary work in

progress to deliver the requiredimprovements. Progress with theseimprovement projects will bereported via the Trust’s governanceand performance managementstructures. This will allow us tomeasure and monitor themilestones, outcomes andtimeframes of the projects, withclear lines of accountability andresponsibility to the project owners.Executive oversight of quality ofcare in the Trust is through theQuality Oversight Group, which willreport quarterly progress andexception to the Quality AssuranceCommittee. Trust board reportingwill occur on a quarterly basis. Ourannual Quality Account will reporton progress against the strategyand confirm the targets for thefollowing year.

Building Capability to deliverthe strategyWe recognise that our staff are thekey to delivering the strategy andwe need to train and supportpeople to make continuousimprovement and improve systemsand processes. We have thereforeagreed to adopt a standardisedapproach to improvement Plan,Do,Study, Act (NHSI QSIR model) toensure staff have the tools theyneed to sustain improvement. Thecapabilities needed to drive thissystem of wide improvement andwhich staff will be trained inincludes:

• An understanding of HumanFactors

• Concept of safety systems

• Driver diagram development

• Improvement methodologies,including Plan Do Study Act(PDSA), Lean, Patient flowstudies

• Change management principles

• Measurement skills andknowledge

• Flow and service re-designmanagement

Evidence internationally (IHI)suggest for an organisation the sizeof LAS that a commitment totraining at a minimum, 1-3% of theworkforce in improvement methodsis required for continuousimprovement (Table 2 below) Aprogramme to identify andpriorities the appropriate staff at alllevels and utilisation of ‘train thetrainer’ techniques will build thecapacity required. A small team ofstaff trained in providing QImethodology and Human Factorsapproaches will provide the staffwith the skills and tools to empowerthem to lead their own QI projects.QI improvement plans will bedeveloped by staff at every level,with the focus to build capacityacross, the workforce.

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High Impact Innovations (DH 2012)requires NHS Trusts to prove tocommissioners that they areimplementing technological andinnovative solutions to improvequality. As a Trust we are alreadyexploring the use of technology viathe roll-out of hand held devices tofrontline staff, e-PCR development,tele-medicine/skype. Opportunitiesto explore technology further areoutlined in our IM&T strategy.

Applying continuous assessmentand improvementMajor trust initiatives, with rigorousmeasurement of quality andefficiency programmes and localsector and station QI objectives willbe designed. Monitoring and

reporting on our programmes andensuring we respond to anyemerging risks will be achieved viaour quality assurance framework.The main response to the outcomesfrom these various reportingmechanisms will be:

• Immediate risk mitigation ifnecessary) and review/update ofrisk registers

• Identification of a qualityimprovement activity: station,sector and trust wide using anagreed criteria and methodology

• Consideration of ‘intensivesupport programme’ in areasthat are not consistently meetingstandards – using the approach

that is currently in place for theNorth East sector.

• Consideration of a Deep Divereview

The streamlining of governance and‘floor to Board’ assurance structureswill support the delivery of highquality and efficient care with earlyidentification of risks, monitoringperformance issues quickly toensure we continuously improve.The further development andembedding of these frameworkswill continue through to 2018-2019and will support the developmentof a continuous improvement andlearning culture.



5. Experts

5. E

xper

ts

1. Front line staff

2. Clinical &operational

leaders

3. Coaches*

4.Exec &Board

* Coaches drawn from wide varietyof professions and grades

Totalpotentialneeded

Eventualcoverageneeded

Knowledge/skills needed What’s involved

5,000 100%

• Introduction toimprovement & model forimprovement

• Identifying issues,developing & testing ideas

• Measurement & variation

• Introductory e-learningsessions (incl. at induction)

• Online/self-accessed• Over 3 year period

400 100

• Deeper understanding ofimprovement methods,variation and measurement

• Goal-setting, leading andmanaging for improvement

• Applied learning in teams overtime linked to opportunities inreal work

• Access to coaching• Embedding into existing

programmes

Experts 10

• As above, plus sophisticatedenabling and coaching skillsfor individuals and teams

• Applied learning andreflection in coaching teamssupported by classroomprogramme

250 250

• Direction-setting, “mood” & leading for improvement

• Link to strategy and overallpriorities; appreciation ofsystems; making variationand trends visible

• Self-determined but typicallyincludes: mix ofindividual/group; sessions withexternal experts; peervisits/”Board-to-Station”;quality assurance visits”

n/aAll Boardmembers

• Deep Dive methodologyincluding of QI theory andscience

• Spread and implementation• Coaching/mentoring,

teaching• Knowledge-generation and

research• Measures for decision

makers

• Careful objective-setting,review and planned (career)development

• Applied learning throughdoing/coaching

• Reflection and peer support• “Masterclasses”• Individually-tailored• Board Development Session

June

QI capability model for LAS – by staff group and roleTable 2 QI Capability Model

Section 2:

Looking Forward: Our Qualitygoals and targets 2018-19Our goals are set out under each of the qualitydomains. The targets which support the delivery ofthese goals have been developed for our year one ofthe strategy. Each year we will review progress andensure our targets are focused on areas whereimprovement is most needed and will be definedwithin our annual quality account.

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Target 1

We will implement Health Assurereporting and Monitoring system toensure that we have real-timemonitoring of our complianceagainst the CQC key lines ofenquiry, clinical audits, NICEguidance, national alerts, at everylevel in the organisation.

This system will provide assuranceto the Board and our regulators andpatients that we are meeting thehigh standards of care and safetyconsistently across the wholeorganisation. Scorecards will beavailable from station to Board andwill be used to monitor progress viaour governance and assuranceprocesses. We will be able toidentify areas for improvementmore quickly and focus our effort inthese areas. Our regulators will beable see, assess and access evidencewith regard to our improvementstatus at the ‘touch of a button’.

Target 2

Improving Hospital Handover DelaysNational emergency careperformance metrics set a standardfor emergency patients arriving athospital by ambulance to be

handed over to, and the ambulancetrolley cleared by, the receivingacute Trust within 15 minutes ofarrival to enable the ambulances torespond to the next 999 patient.

Ambulance handover performanceacross London remainedchallenging throughout 2015/16and 2016/17; this continued into2017/18 with patient’s frequentlyexperiencing handover delays inexcess of 15 minutes following theirarrival at emergency departments(EDs). Between January andSeptember 2017, 62% of thepatients conveyed by the LondonAmbulance Service (LAS) to an EDexperienced a delay, waitingbeyond the target of fifteenminutes for handover to on-goingcare. In the context of productiveambulance cover hours beyond thatfifteen minute target, 49,494 hourswere lost while delayed at an EDand this equates to 4,125 losttwelve hour ambulance shifts in thesame period.

It is recognised that hospitalhandover delays is a multi-factorialsystem problem and we need towork together to identify issues ateach stage and resolve them. TheLAS will continue to work with keystakeholders from across London inan approach to assuring the safetyof ambulance handovers anddelivering improved performanceand a reduction in the averageduration of ambulance handoversacross London during 2018-19.

Target 3

During 2016-17 the Trust madesignificant improvements inmedicines management in terms ofensuring the tracking andmonitoring of drugs at station level.The next phase is to ensure that wehave the most secure environmentsto store and monitor drug usage.The second phase of the securedrug room programme, that entailsre-designing the stationenvironment, fitting CCTV camerasand more secure locking systemswill be rolled out across 2018-19. Inaddition we have re-designed thevehicle based bags that paramedicsand other staff use when attendingpatients. This provides the teamswith more secure storage and anability to store all equipment that isrequired on scene in one holdall.

90% implementation ofHealth Assure functionalityby December 2018

Handovers over the 15, 30and 60 minute target andtotal time lost, to reducequarter on quarter againstthe same period in2017/18

100% completion ofsecure drug rooms roll-outacross all sectors by March2019 to agreed stations



Goal: To eliminate avoidable harm topatients in our care as shown througha reduction in number of incidentscausing severe and extreme harm. We believe harm is preventable notinevitable.

We want to ensure our patients are assafe as possible while under our careand that they are protected fromavoidable harm. Our goal will be to bebelow the national average for thenumber of incidents causing severe and

extreme harm in year one and continueto reduce the number throughout theyears of the strategy. Throughout yearone of our Quality Strategy, we will befocusing on achieving sustainableimprovements in the target areasoutlined below; these targets aim toreduce avoidable harm in specificpriority areas and set the trajectory toensure that we can achieve our goal ofeliminating avoidable harm by the endof year three.

SafePeople are protectedfrom abuse andavoidable harm

Target 4

During the latter half of 2016 itbecame apparent that there were anumber of cases wheredefibrillation was being delayedduring the management of cardiacarrest. This trend continued intoearly 2017 and triggered a thematicanalysis. Whilst it was believed thatthe apparent increase in incidentsmight be related to the increasednumber of defibrillator datadownloads by Advanced ParamedicPractitioners (APPs) coupled with asignificant drive to increasereporting of potential incidentsthrough the online incidentreporting system (Datix). It was

identified that further work wasneeded to understand the rootcauses and ensure that learning toprevent recurrence was embeddedacross the Trust.

It is clearly recognised that thechallenges of managing a pre-hospital cardiac arrest are verydifferent to in-hospital where thecardiac arrest team is made up ofdifferent clinicians with per-determined and specific roles andwho will have worked as a teamtogether. The crew resourcemanagement challenges of pre-hospital cardiac arrest cannot beunderestimated – the crews maynever have met each other, therewill be public and family to support

and manage and the equipmentwill initially be remote form thepatient. The LAS has been acceptedon human factors train the trainerprogramme supported by UCLH.During 2018-19, in conjunction withall other aspects of risk reductionand pathway development, we willdeliver training to relevant staff toimprove the management of thesedifficult scenarios with the aim ofreducing these incidents further.

Increase the number ofdefibrillator downloadsyear-on-year to 20% byend of 2019.

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Target 1

Our work supporting patients withmental health and in sometimescomplex medical conditions hasbeen acknowledged as exemplary.As part of our Strategic Intent, weare aiming to improve and developservices that be recognised as‘pioneering’ in relation to thispatient group. Our aim is to ensurewe have system wide collaborationwith all healthcare services toprovide ‘seamless’, timely and themost appropriate care for thesepatients.

We will continue to work with keystakeholders to provide the bestpossible outcome for these patients.This work will include supportingpatients who frequently call theservice during crisis or to requesthelp that is not necessarily providedby the emergency services. We willbe increasing our resource internallyto enable our expert staff to workclosely with providers for example,social services, to put keyinterventions in place more rapidlyand consistently across the pan-London service provision.

Target 2

Our strategy to become London’sprimary integrator of access tourgent and emergency care onscene, on phone, on line, requiressignificant changes to the way inwhich we deliver services to ourpatients. As part of this strategy isthe recognised need to widen andincrease our patient involvement inboth the development of these newservices and the monitoring of theirsuccess. The Trust will thereforedevelop a Patient InvolvementFramework (PIF), with the supportof patients, public, specific patientvoluntary groups to ensure we havegenuine involvement andparticipation and that the view ofthese groups are considered in anywide scale changes that we make.The new framework will also enableus to capture feedback from a morediverse patient population throughthe introduction of data collectionmethods, use of informationtechnology, that will enable thetrust to directly compare howdifferent groups respond to andidentify specific issues and theinterventions to improve these.

Target 3

The LAS currently provides care toup to 9000 women a year atdifferent stages in pregnancy, theservice covers 26 maternity unitsand three standalone birth centres.

The services is recruiting the firstPractice Leads for Pre HospitalMaternity Education across the LAS,and in the UK. They will form theMaternity team, alongside theConsultant Midwife, to lead thedevelopment of the Pan LondonMaternity Pioneer Service.

Maternity Pioneer Service:The pan London maternity modelwill aim to:

1. a) Provide midwifery expertisewithin the control roomenvironment allowing the abilityto reduce the number ofambulance conveyances (up to20% reduction)

b) Provide a midwife advice lineto provide a resource to staffboth in the control room and onscene at a maternity episode ofcare (increasing expert advicecapacity to 50% of calls fittingcriteria).

2. Provide midwifery expertisewithin a response vehicle alongsideambulance clinicians to bedispatched to imminent birth callsDevelop a commissioning model forpre-hospital birth, when providedby midwives within the emergencyservices.

Reduction in callsgenerated by thosepatients classified asfrequent callers from April2018 baseline

Evidence of patientinvolvement in all QI andservice re-designprogrammes.



Goal: To provide our patients with thebest possible experience. Improvingthe care we give to vulnerable groups.

We know that treating our patientswith compassion, kindness, dignity andrespect has a positive effect onrecovery and clinical outcomes. Toimprove their experience, we need tolisten to our patients, their families andcarers, and respond to their feedback.

We will aim to improve our position,with our goal being to have patientinvolvement in all service redesignprogrammes and a patient involvementframework developed to apply thisgoal consistently. The indicatorsoutlined below will support this goaland help us determine whether ourservices are caring and patient centredin all aspects.

Staff involve and treatpeople with compassion,kindness, dignity andrespect

Caring

The pan London model will pilotthe response model in a sectoracross London (aligned to the LocalMaternity System/STP footprint).

Alongside the Pioneer Model, a co-designed and co-developed patientand staff engagement model will beused to drive quality improvementacross the maternity care model.

Reduce the number ofambulance conveyance(20%). Employ two wholetime equivalent practicedevelopments midwivesand deliver a trainingprogramme 2018-19.

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Target 1

We have chosen this target toensure that we get the best clinicaloutcomes for our patients.Changing the way in which wedeliver care and increasing thedelivery of care using a multi-disciplinary approach requires afundamental review of the type andquality of training that we provedto our staff. In addition it isimportant that we ensure staff havethe time to attend training, aconstant pressure with theincreasing demand on deliveringthe service we provide. We willcarry out a root and branch reviewduring the early part of 2018 toinform an improvement programmeto ensure that : systems andprocesses are robust with stronggovernance frameworks; thetraining is appropriate and easilyaccessible; a revised trainingprogramme to include any furthertraining requirements highlightedto meet the changing nature ofdelivery, the programmes oftraining align to operationaldelivery, and to ensure that staff arereleased to attend training andmeet statutory requirements. Wewill also identify potential incomegeneration, potential opportunitiesand have an identified ‘trainingbrand’. Ultimately the aim is toensure our staff continue to provideclinically effective care based onbest practice guidance.

Target 2

During 2017-18 the LAS, as with allother ambulance services,implemented the AmbulanceResponse Pilot (ARP). The newresponse targets set out differentresponse categories and set out anapproach that requires Trusts toreport on new quality indicators.During 2018-19 the LAS will workwith the business intelligence teamto ensure that we develop methodsto collate and report on these newindicators. In doing so we will haveclear evidence of areas were wehave improved patient outcomesand also have the ability tohighlight areas were we may not bemeeting the standards of care thatwe strive to deliver.

Target 3

We recognise that people are thekey to delivering our qualitystrategy. We therefore must makesure that we are supporting andtraining our people to makeimprovement continuously as wellas carrying out their roles. We wantto implement new ways of workingto improve our processes, systemsand services with transparentmeasurement and track progress.We have therefore decided toadopt a standardised approach toquality improvement to make thispossible. The NHSI methodology isdesigned to support and encourageour staff by providing them withthe tools they need to makesustained improvements. We wantthis to stimulate a culture oflearning and development inimprovement and ensure thatchange becomes the way of doingthings in the Trust. As part of thisprocess, the Trust has gainedfinancial support during 2017-18 toincrease the capability in relation toboth Quality Improvement andHuman Factors trainingprogrammes. We will set out animplementation plan that enables acritical mass of staff to be trainedand also ensure this is aligned toour quality assurance processes toprovide continual feedback,reporting and learning (see outlineplan in section 1).

Root and branchindependent trainingreview completed.

Implementation plandeveloped by September2018

New quality Indicatorsdeveloped and beingreported via performancescorecards by December2018



Goal: Ensure staff complaints inproviding ‘best practice’ care and to bein the top quartile for all nationalclinical audit outcomes.

Clinical audit is a key improvement toolthrough which we continually monitorand improve the quality of care thatwe provide. By fully taking part innational clinical audit programmes, weare able to benchmark ourperformance against our peers, ensure the care we provide is evidence-based and measure improvements on a

year-by-year basis.

We aim to be in the top quartile foroutcomes for all those national clinicalaudits in which we are eligible toparticipate and where data is analysedthis way. This enables us to haveevidence that each of our services iseffective and promotes a good qualityof life for our patients. Furtherassurance of this will be provided bycompliance and training that meets thechanging nature of service delivery.

People’s care, treatmentand support achievesgood outcomes, promotesagood quality of life andis based on the bestavailable evidence

Effective

Target 4

The changing nature of ouroperating model, requires us toreview the way in which our staffare allocated to their shifts. TheDirector of Operations will continueto work with colleagues to roll outthis significant piece of worksupported by our new Forecasting &Planning Team. A Trust-wide reviewof rosters will be completed byMarch 2018 with implementationdue in summer 2018.

QI training plan agreedand 100% of identifiedkey cohorts trained bySeptember 2018

At least 2 Sector rosterreviews completed bySeptember 2018 andremaining sectors by April2019

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Target 1

Over the last 12 months the Trusthas consistently been one of thestrongest performing ambulanceservices. It is currently the thirdhighest national performer inimplementing the new ARPstandards.

Additional recurrent funding hasbeen secured over the last sixmonths for additional frontline andEmergency Control Services staff,and we have also introduced anadditional Incident Response Teamto further strengthen our resiliencecapability.

Target 2The Patient Experience Team isworking with the sector teams toprovide feedback and actions toenable learning from complaints.We continue to respond withintimelines for complaints, meetingthe majority of patient responsewithin 35 days.

Throughout 2018-19 we will focuson improving further our processes

in dealing with complaints from thepatients and public we serve. Wewill undertake a review of ourcomplaints responses, supported byour patients, to ensure that ourcomplaints responses include theappropriate information andexpress our apologies in a genuineway. We will aim to further improvethe turnaround time for our lettersand include more information inrelation to the lessons we havelearned. In addition we will

continue with our patient and staffstories at the Board, which havebeen instrumental in making surethe executive team understandbetter the experiences of ourpatients and staff.

We will review ouroperational model byquarter three and worktowards delivering therevised standards as setout in ARP.

Over 75% of complaintsletter being responded towithin the 35 day timescale



Goal: To consistently meet all relevantnational performance targetsstandards through responsive patientpathways in year one, and exceedthem by year three.

Having responsive services that areorganised to meet people’s needs is akey factor in improving patientexperience and in preventing delays totreatment, which can cause harm toour patients. Our engagement events

have shown that our patients agree.

To do this, we will continue to reviewour processes to ensure they are asefficient as possible, while keeping theneeds of our patients central.

As well as the national targets above,we will focus on the following targetsto improve our responsiveness as aTrust to patients who complain.

Services are organised so that they meet people’s needs

Responsive

Well ledDuring 2017-18 we havestrengthened our leadership team,our governance systems andprocesses and set out key strategiese.g. People and OrganisationalDevelopment, IM&T, which will actas key enablers going forward tothe delivery of our strategicobjectives.

Target 1

Our statutory and mandatorytraining programmes ensure thesafety and well being of staff andpatients. During 2017-18 we movedthe majority of our training to on-line e-learning and alsoimplemented a new reporting toolon ESR to improve the ability tomonitor and report compliance. We have chosen a target of 85%compliance to demonstrate that ourstaff comply with statutory and

mandatory requirements whichhave a direct impact on patientsafety.

Target 2

Fully implement our leadershipdevelopment programmes at alllevels and develop a culture ofprofessionalism, with all staff clearabout their roles andresponsibilities.

Will continue to implement theP&OD strategy through 2018-19 andprogress the addition of activityoutlined below:

• Implement our Trust strategyand refresh supportingstrategies. Working with STPs indeveloping and implementingsystem-wide improvements .

• Complete re-structures.

• Develop and implement staffcommunications andengagement model.

• Continue to strengthen RiskManagement systems andprocesses.

• Continued implementation ofthe Quality Improvement Planand Quality Improvementcapability across theorganisation.

• Maintain the focus on cultureand holding people to account.

• Developing a culture ofprofessionalism, with all staffclear about their roles andresponsibilities.

• Complete re-negotiation interms and conditions of annualleave and flexible working.

• Continue to strengthen IM&Tresilience.

• Continue to develop andimplement WRES improvementprogramme

• Continue to develop andimplement Equality and DiversityAction Plans

85% compliance withstatutory and Mandatorytraining 2018-19

Leadership programmedeveloped andimplementation plan inplace

20



Goal: To increase the percentage of ourpeople who have been trained andprovided with leadershipdevelopment.

Evidence shows that people who areengaged and happy in their jobs,respected and given opportunities tolearn provide better care for their

patients. Our goal is to increase thepercentage of people who wouldrecommend our Trust as a place ofwork. By supporting our people todevelop, we are improving the cultureand ethos of the Trust – both as a place to work, and as a patient. Thisgoal will be supported by the targetsoutlined below.

The leadership, managementand governance of theorganisation assures thedelivery of high qualityperson-centred care,supports learning andinnovation, and promotes an open and fair culture

Well Led

Equality and DiversityAt LAS we are committed to promoting equality of opportunity anddiversity to enhance our inclusion work. LAS has committed to ensurethat equality, diversity and human rights are embedded in all areas ofour employment, planning and service delivery. We strive to provideexcellence in all we do and recognise the value that Inclusion brings. Weare committed to ensuring that all our employees are treated withdignity and respect and given equal opportunity and encouragement toprogress and develop within the organisation.

We strongly believe that diversity and inclusivity in all its forms deliversgreater impact in the work we do and enhances the services we deliverto Londoners. Our commitment to the principles of Diversity andInclusion informs all of our work with our people.

Section 3:

Looking Back: Quality performance 2017-18The progress against our targets and goals we set outin our Quality Account 2017-18 are outlined here,under the quality domain headings.



Quality Priorities 2017-18The priorities for 2017-18 as set outin our previous Quality Account(2016) are highlighted belowagainst the 3 domains for quality,Patient Safety, Experience andEffective care. Progress against eachof the domains is provided, whererelevant impact key performanceindicators are included

Patient Safety

During 2017-18 we introduced andestablished a new integratedQuality & Assurance directoratewhich aligns quality functions intoone directorate. Recruitment tonew posts has now concluded andthe structure brings both anincrease in capacity and capabilityto the quality agenda across thetrust. Quality governanceframeworks have been reviewedand rationalised with clear lines ofreporting via new Terms ofReference, minutes and key issuereports to provide assurance andallow escalation of issues from‘floor to Board’. A risk managementimprovement programme has alsobeen developed and continues tobe implemented to identify keysafety and quality risks moreaccurately and to ensure staff aretrained in identifying risks andregularly review and assess risks topatient safety and quality of care.

Target 1: Development ofpathways for patientswho fall, have mentalhealth issues, are at theend of life and bariatric.

Our strategic intent document,developed during 2017-18 , sets outthe further system wide pioneeringservices we aim to develop anddeliver during 2018-19 andonwards. This year work hasprogressed in relation to mentalhealth support, with increasedtraining, alternative care pathwaydevelopment, data sharingalongside the recruitment of anadditional 3 mental healthprofessionals to provide advice inthe clinical hub and support theinitiation a mental health responsecar. This is a pilot to enable mentalhealth clinicians to work alongsideparamedics to respond to patientsundergoing a mental health crisis,and commenced in December 2017.This will be evaluated and, ifsuccessful, rolled out to othersectors.

In addition the Trust has beensuccessful in gaining funding forthree full time staff to providededicated support to End of Lifecare providing advice and trainingfor staff in giving support tofamilies and patients at end of life.In addition clinical audit, alternativecare pathway utilisation and servicedevelopment will also be part ofthis remit.

A Bariatric equipment business caseis being presented to ELT at the endof February 2018, this outlines asignificant investment, this willneed to align to the current logisticswork programmes and consider theimpact of the ARP future operatingmodels. In addition considering thetype of equipment and support werequire to ensure these patientshave effective and dignified care.

Target 2: Improve andembed learning fromincidents

A learning and quality improvementframework was agreed by theBoard in November 2017 and is nowbeing implemented, supported by acommunication strategy.Implementation will be complete byMarch 2018 and continuousembedding of the framework willcontinue, supported by the revisedquality assurance framework. Inaddition monies to train a cohort ofstaff in quality improvementmethodology and human factorswas also provided by NHSI. Thisprogramme of work will start in July 2018 and continue throughout2018.

We have evidence of learning fromincidents from the inclusion offeedback in core skills refreshercourses, various changes to workingpractices, i.e. ventricular fibrillation,managing patients with spinalinjuries. During 2017-18 we had anindependent review by our internalauditors (KPMG) who gave the TrustSignificant Assurance rating withregard to the serious incidentinvestigation and learning process.

In addition our no/low harmreporting rates have improved to acurrently in the higher quartilecompared to national benchmarkedlevels during 2017-18. LAS are nowreporting over 90% of incidentswithin the no/low harm category(see charts opposite).

22



Learning from experienceBelow show some examples ofwhere the Trust have madeimprovements as a result of seriousincident investigations:

Change in practice regarding1the management of cardiacarrests as a result of a significantnumber cases concerningdelayed defibrillation

Changes within the Gazetteer2system to improve the accuracyof locations across London

Policies that have been3identified to be unfit forpurpose have been reviewedand updated

Improved training, compliance4audits and the development of anew policy for the managementof breached Patient GroupDirections

Guidance issued to staff on the5

management of paediatricpatients with particular focus onthe measurement of oxygensaturations

Development of a feedback6mechanism of all maternityrelated incidents to thematernity training programme

Process for investigating and7managing thematic reviews ofsimilar incidents. For example;delayed defibrillation and theNon-emergency TransportService

Equipment concerns highlighted8to the equipment replacementprogramme which assisted inthe development of businesscases to replace specific piecesof equipment

Learning from incidents training9delivered to all EOC staff andincluded on the paramedicacademy courses

Incorporation of case studies to10the internal leaning fromincidents Insight magazine

Changes to practice included in11core skills refresher courses forboth EOC and frontlineoperations

Case studies included in the12internal Clinical Updatemagazine



Patient Experience

Target 1: Effective andconsistent risk assessmentcompleted for patientspresenting with a mentalhealth crisisRevision to the risk assessment tooland training have been introducedduring the year, we have seen animprovement in the quality ofmental health assessments, with acurrent average of 91% of corecriteria being recorded asdemonstrated through themonitoring of monthly clinicalperformance indicators. In additionbespoke training has been deliveredby our mental health nurses to staffwithin our emergency operationcentres, call handling staff andclinicians; to specialist responseteams such as the joint responseunit; to specific cohorts of staff suchas incident response officers andclinical team leaders (with over 200staff trained in specific areas such asmental capacity). We anticipate theintroduction of mobile devices willfurther improve our ability to carryout and record assessments real-time with guidance immediatelyavailable from various ‘apps’ thatstaff can access quickly on-scene.

Target 2: Improvedcompliance with InfectionControl standardsInfection control issues identifiedinternally and through CQC, haveimproved significantly, we areseeing the majority of sectorsshowing over 90% compliance

against their monthly performanceon hand hygiene. Infection controlpractices at A&E have alsoimproved, vehicle cleaning remainsan area of focus as does hygienestandards in some identifiedstations. These are being closelymonitored through regular qualityassurance visits. We will utilise morefully the Perfect Ward app to allowdigital uploads of data from stationvisits during 2018-19

Target 3: Ensure patients havetimely and appropriate accessto services

System wide demand managementprojects to improve care andexperience of patients have seenimproved response times, with theTrust meeting the majority oftargets consistently.

Work undertaken with specificfrequent callers has shown

considerable reductions utilising amulti-agency approach to casemanagement to our highest volumecallers. However we are reviewingthe resources required to supportthe delivery of a programme toincrease the potential of reducingthe significant impact this patientgroup have on demand in 2018-19.The aim will be to enable casemanagement to be undertaken fora larger number of cases throughincreasing capacity within thecurrent dedicated frequent callerteam, allowing increasedinvolvement in system wideinitiatives, evaluation ofinterventions on patient outcomes,patient experience, operational andsystem wide performance.

Trust-wide performance: Consistently meets response targetsunder the new operational modelas outlined on page 38, Table 12.

24



Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

Trust Overall 97.0% 97.0% 94.8% 94.3% 96.8% 95.7% 93.0% 95.0% 95.0% 93.0% 91.0%

North East 95.0% 95.0% 97.8% 96.2% 96.0% 97.0% 98.0% 98.0% 98.0% 98.0% 97.0%

North Central 99.0% 99.0% 82.5% 91.2% 97.0% 97.0% 97.0% 90.0% 97.0% 91.0% 97.0%

North West 99.0% 99.0% 98.3% 98.0% 98.0% 96.0% 96.0% 93.0% 96.0% 98.0% 98.0%

South East 99.0% 98.0% 98.3% 95.5% 97.0% 98.0% 99.0% 97.0% 95.0% 95.0% 99.0%

South West 97.0% 97.0% 94.0% 94.0% 96.0% 98.0% 99.0% 97.0% 95.0% 95.0% 96.0%

Others 95.0% 95.0% 100.0% 91.0%

HART 65.0% 81.0% 89.0% 80.0% 65.0%

NETS 93.0% 93.0% 9.3% 91.0% 88.3% 96.0% 95.0% 83.0% 87.0% 85.0%

Table 3

Clinical Effectiveness

Target 1: Improve outcome asreported Ambulance QualityIndicators

We have implemented andconstantly measure best practicemodels of care following theintroduction of the AmbulanceResponse Programme (ARP) inOctober 2017. Currently we are 3rd

best performing ambulance trustnationally against these responsetime indicators.

We have maintained our programmeagainst the Stroke Care bundles at96%. However, in relation to STEMIpatients we are below the nationalaverage. We will continue to focuson this.

Target 2: Standardise hospitalhandovers including the useof NEWs for the sickestpatients

We recognised that hospitalhandover delays is a multi-factorialsystem problem and we needed towork together to identify issues ateach stage and resolve them. TheLAS has worked with keystakeholders from across London inan approach to assuring the safetyof ambulance handovers anddelivering improved performanceand a reduction in the averageduration of ambulance handoversacross London.

ED Site visits up to October 2017

The Emergency Care ImprovementProgramme (ECIP) were tasked tocomplete a series of site visits andassessments leading toimprovement recommendations atvarious acute hospitals. Follow upvisits commenced in October/November to measure progressagainst the individualrecommendations made by ECIP.This work has also includedwidespread sharing of Patient Flowguidance with operational leads ateach acute site and theidentification of LAS contacts fortrusts.

LAS engagement managers haveworked with their local EDs tosupport ECIP led initiatives designedat reducing the potential forhandover delays to occur. Byidentifying patients who couldeither wait or be seen in a hospitalchair (#fit2sit). Or throughreviewing the conveyance choicesmade by LAS clinicians (Front DoorChallenge); for example could theirpatient of been seen in anotherarea of the department, or havebeen conveyed/referred to analternative pathway.

Sharing of LAS predicted dataPredictions of LAS activity forconveyance numbers by day ofweek/hour to each ED were sharedto support stakeholders in theirwinter planning. LAS predictedactivity is shared weekly with theNHS E Winter Room for inclusion inits daily update report

Cohorting process

Patient cohorting is a processwhereby ambulance clinicianshandover the care of their patientto an ED clinician immediately aftertriage regardless of bed availability.This can allow ambulances tobecome available for dispatch toanother incident more quickly; it isthe responsibility of Acute Trusts toimplement and staff this.Ambulance-led cohorting is thesame process, but is implementedand staffed by the LAS because it isfelt that the risk of not doing sowould be to the significantdetriment of the Trust and patientsafety. A standard process forCohorting across London includingthe triggers and reporting processfor when it can be used has beendesigned and implemented with theagreement of NHS E.

NEWS is based on a simple scoringsystem which allocates a score tophysiological measurements in adultpatients. The aggregate NEWS scoreprovides an indication of howunwell the patient is. Patients areassessed and attributed a score andcategory (Red ≥7, Amber 5-6 andGreen <5) the categories areregarded as high, medium and lowrisk respectively. The trial started on21.12.17, a NEWS card is attached tothe patient whilst waiting wherehandover is delayed and/orcohorting is implemented. The cardis contained within a plastic wallet,an elastic band is used to attach thecard to the patient’s wrist. The cardis folded to ensure that theappropriate red, amber or green



2017-18* 2016-17

LASaverage

National average(Range)

LASaverage


STEMI patients 69.9%76.5%

(64.3% – 91.7%)70.6%

79.3% (60.5 – 90.8)

Stroke patients 96.9%97.1%

(94.1% - 99.8%)96.8%

97.6% (94.4 – 99.2)

*At the point of preparation of this Quality Account, NHS England reported data for April to September 2017.

Table 4

page is visible before being placedinto the plastic wallet which is thenattached to the wrist of the patient.It is intended that staff wouldcommence use of NEWS cardswhere the anticipated wait is likelyto exceed 30 minutes and in allcases where Cohorting iscommenced. The NEWS is reassessedevery 30 minutes until the patient ishanded over to ED staff. The trialaims to assess the impact ofhandover delays on patients,assisting in the identification ofunwell or deteriorating patients.

Performance update Jan 2018As the following charts highlighthospital performance in 2017/18when measured by handovers overthe 15, 30 and 60 min target andtotal time lost has improved againstthe same period in 2016/17

Our work on hospital handovers hasbeen recognised as outstandingpractice and has played a significantrole in reducing waiting times forpatients, we will continue this workthrough 2018-19.

26



Table 5

Table 6

Table 7

Table 8

Target 2: Develop a mortalityand morbidity review process

We have introduced a mortalityreview group to ensure informationis available in relation to specificgroups/themes to target learningand improvement. We are alsoworking with other ambulance trustto ensure we have a standardisedapproach to share learning acrossdifferent organisations. Theoutcome of the analysis isaggregated with information fromSIs, incidents, complaints, claims toprovide identification of themesand focus improvement efforts.Preventing Future Deaths noticesare now reported into this groupand also discussed at QualityOversight Group to enable thematicanalysis of trends across allincidents.

We are also working with otherambulance services to agree astandardised approach to mortalityreviews and to share learning acrossdifferent services.

ConclusionOur progress during 2017-18 hasbeen significant and has broughtabout much improved outcomes forour patients, as demonstrated inthis section of the report. We willstrive to continually improve andsustain that improvement throughour quality improvement plans for2018-19 and beyond.



Section 4:

Statements of assurance from the BoardStatements mandated by NHS EnglandEach year we are required to report a number of mandatory statements,which you will find reported in this section:

Data Quality AssuranceThe London Ambulance Servicemanages data quality for Accident& Emergency information, using abespoke application developedinternally. All information receivedfrom the 999 CAD system,Command Point, Mobile DataTerminals (MDT) and Patient ReportForms (PRFs) is processed throughthis application. Within theapplication, records that satisfy anyof the pre-defined validation rulesare presented for reviewing, andcan be amended where necessary, ifthere is adequate evidence availableto do so.

Records are reviewed for:• Illogical time sequences between

timestamps

• Unlikely gaps betweentimestamps

• Incorrect hospital codes

• Missing timestamps where onewould be expected

• Conveyances by non-conveyingvehicles

• Patient Handover breaches athospital

• Mismatched Patient ReportForms (PRFs)

• Discrepancies betweenCommand Point, MDT, and PRFdata

A facility is available to allow staffoutside of ManagementInformation to request a review ofany data items. These data qualityqueries are submitted via the

Business Intelligence (BI) Portal forconsideration by the Data Qualityteam to ensure that they meetagreed rules. No-one outside of theData Quality team within MI canmake amendments to any records.There is an audit history for anyrecord flagged for reviewing, andall changes and actions taken (ornot taken as the case may be) arelogged with the username/changemade/date/time.

All reports produced by the BusinessIntelligence team follow a pre-determined check list to ensureaccuracy and compliance withAmbulance Quality Indicatorguidance. Every report is peerreviewed and approved by a seniormember of the team prior topublication

A report demonstrating complianceagainst the Ambulance QualityIndicators (AQI) guidelines issubmitted annually to ExecutiveLeadership Team (ELT) for approval.A data quality strategy is underdevelopment to be approved by theTrust Board in 2018.

IncomeThe income generated by the NHSservices reviewed in 2017 represents100 per cent of the total incomegenerated from the provision ofNHS services by the LondonAmbulance Services NHS Trust for2017/18.

28



Clinical Effectivenessand AuditThe London Ambulance Service NHSTrust has a robust clinical audit andresearch programme that focuseson both local and national areas ofpriority. In 2017/18 the LASexamined the care provided to awide range of patients includingthose that had a heart attack,cardiac arrest, stroke, trauma,mental health related conditionsand paediatric care. Our researchprogramme continued to grow andalongside our existingcardiovascular studies (including theworld’s largest randomisedcontrolled trial of adrenaline incardiac arrest), we launched a newrandomised control trial examiningwhether immediate coronaryangiography and percutaneouscoronary intervention can improvesurvival from cardiac arrest.

In addition to continuouslyassessing the care provided to

cardiac, stroke and trauma patients,during 2018-19 we will focus onsepsis care with the introduction ofa new continuous registry. We willalso continue to audit theappropriateness of decisions madefor patients who are discharged atscene and then re-contact theService within 24 hours havingseverely deteriorated or diedunexpectedly.

Clinical auditDuring 2017/18, only one nationalclinical audit and no nationalconfidential enquiries covered NHSservices that the London AmbulanceService NHS Trust provides. Duringthat period, the London AmbulanceService NHS Trust participated in100% of national clinical audits,which it was eligible to participate in.

The national clinical audit andnational confidential enquiries thatthe London Ambulance Service NHSTrust was eligible to participate induring 2017/18 are as follows:-

NHS England Ambulance QualityIndicators: Clinical Outcomemeasures covering:

• Outcome from cardiac arrest –Return of SpontaneousCirculation (ROSC)

• Outcome from cardiac arrest –Survival to discharge

• Outcome from acute ST-elevation myocardial infarction(STEMI)

• Outcome from stroke

The national clinical audits that theLondon Ambulance Service NHSTrust participated in, and for whichdata collection was completedduring 2017/18, are listed belowalongside the number of casessubmitted to each audit as apercentage of the number ofregistered cases required by theterms of that audit.

The London Ambulance Service NHSTrust submitted the following



National Clinical AuditNumber of

cases eligiblefor inclusion

Number ofcases

submitted

Percentageof cases

submitted

NHS England AQI: Outcome from cardiac arrest – ROSCOverall groupa)Utstein comparator groupb)

a) 1,962b) 263

a) 1,962b) 263

100%

NHS England AQI: Outcome from cardiac arrest – Survivalto discharge

Overall groupa)Utstein comparator groupb)

a) 1,881b) 235

a) 1,881b) 235

100%

NHS England AQI: Outcome from acute STEMIPrimary percutaneous coronary intervention (PPCI)a)delivered within 150 minutes of call.Care bundle delivered (includes provision of GTN,b)aspirin, two pain assessments and analgesia)

a) 658b) 1,531

a) 658b) 1,531

100%

NHS England AQI: Outcome from stroke Face Arm Speech Test (FAST) positive stroke patientsa)potentially eligible for thrombolysis, who arrive at ahyper acute stroke centre within 60 minutes of call.Care bundle delivered (includes assessment of FAST,b)blood pressure and blood glucose)

a) 3,737b) 6,411

a) 3,737b) 6,411

100%

Table 9

information regarding the provisionof an appropriate care bundle toSTEMI and stroke patients to NHSEngland for the reporting period2017/18 and 2016/17.

The London Ambulance Service NHSTrust considers that the data in thetable above is as described for thefollowing reasons: data arecaptured by the LAS from clinicalrecords completed by ambulancestaff attending patients as part ofon-going clinical quality monitoringin line with the technical guidancefor the Ambulance QualityIndicators and reported directly toNHS England.

The reports of the above nationalclinical audits were reviewed by theprovider in 2017/18 and the LondonAmbulance Service NHS Trust hastaken actions to improve the qualityof healthcare provided as set out inAppendix 1.

CQUINSA proportion of London AmbulanceService NHS Trusts income in2017/18 was conditional onachieving quality improvementgoals within the contract. The2017/18 CQUIN schemes were setaccording to the Commissioning forQuality and Innovation paymentframework and either setnationally, or agreed with the leadCommissioner, Brent CCG, acting onbehalf of the pan-London CCGs.Further details of the agreed goalsfor 2017/18 are detailed inAppendix 2. Achievement will beconfirmed following the final Q4submission, due in April 2018.

Serious Incidents (SIs)A total of 459 cases were reviewedby the Serious Incident Group in2017/18. Of these, 92 incidents weredeemed to meet the criteria to bedeclared as serious to NHSE.

In July 2017 the SI investigationprocess was reviewed andsignificant changes made. Theprocess was launched in August2017. Improvements were made tothe DatixWeb system to enableclearer monitoring and enhancecompliance with internal andexternal deadlines. Current LeadInvestigators across the Trustattended an update/refreshertraining day and the Quality,Governance and Assurance Teamprovide serious incidentinvestigation training each monthfor new investigators. As of March2018 a total of 57 managers havebeen trained to investigate seriousincidents. To assist in times of highoperational demand, significantefforts have been made to utilisemanagers from other areas of theTrust. Of the 57 trainedinvestigators 38 are operationalmanagers and 19 are from non-operational backgrounds.

Currently the Trust does not haveany serious incident investigationsthat have breached the 60 workingday deadline to the CCG. DuringJanuary 2018, the Trust instructedKMPG to undertake an independentaudit of the revised serious incidentprocess. The outcome of thisprovided significant assurance thatthe Trust was investigating incidentseffectively, actions were taken in a

timely manner, patients andrelatives were informed and staffwere supported.

Quarterly thematic reviews haveshown issues concerning callhandling and dispatch and clinicaltreatment. Themes from the reviewshave been shared across the Trustand actions to address the concernshave been incorporated into anintensive actions plan for theEmergency Operations Centre(EOC). Additional actions have beentaken in relation to the clinicaltreatment concerns and are detailedbelow.

Learning from experienceBelow show some examples ofwhere the Trust have madeimprovements as a result of seriousincident investigations:

Change in practice regarding13the management of cardiacarrests as a result of a significantnumber cases concerningdelayed defibrillation

Changes within the Gazetteer14system to improve the accuracyof locations across London

Policies that have been15identified to be unfit forpurpose have been reviewedand updated

Improved training, compliance16audits and the development of anew policy for the managementof breached Patient GroupDirections

Guidance issued to staff on the17management of paediatricpatients with particular focus on

30



2017-18* 2016-17

LASaverage


LASaverage


STEMI patients 69.9%76.5%

(64.3% – 91.7%)70.6%

79.3% (60.5 – 90.8)

Stroke patients 96.9%97.1%

(94.1% - 99.8%)96.8%

97.6% (94.4 – 99.2)

*At the point of preparation of this Quality Account, NHS England reported data for April to September 2017.

Table 10

the measurement of oxygensaturations

Development of a feedback18mechanism of all maternityrelated incidents to thematernity training programme

Process for investigating and19managing thematic reviews ofsimilar incidents. For example;delayed defibrillation and theNon-emergency TransportService

Equipment concerns highlighted20to the equipment replacementprogramme which assisted inthe development of businesscases to replace specific piecesof equipment

Learning from incidents training21delivered to all EOC staff andincluded on the paramedicacademy courses

Incorporation of case studies to22the internal leaning fromincidents Insight magazine

Changes to practice included in23core skills refresher courses forboth EOC and frontlineoperations

Case studies included in the24internal Clinical Updatemagazine

Future developmentsDuring 2016/17 the Chief QualityOfficer led an in-depth review ofthe serious incident process with theobjectives to review the time takento investigate incidents and improvethe sharing of learning frominvestigations. The reviewed processamended and three nominatedExecutive Directors now form apanel for reviewing and signing offreports.

The focus for 2018/19 will becentred on the development of theQuality Governance and AssuranceTeam. To date the team has a newlyappointed Head of QualityGovernance and Assurance, currentroles have been reviewed, jobdescriptions developed or updatedand clear lines of responsibility havebeen assigned. Work will continueto appoint a dedicated risk managerand a team of business partners toprovide an additional level ofsupport to the serious incidentprocess and lead investigators.

Duty of CandourDuty of Candour training is part ofthe mandatory training for allrelevant members of staff and isvalid for three years. Currently 4,446(87%) members of staff havecompleted the training.Additionally all Lead Investigatorsare provided with the regulation 20compliance requirements, its placewithin the serious incident processand the history of the regulation.

The role of the lead investigator willinclude the requirement to have arobust working knowledge of theDuty of Candour process and theseindividuals will be responsible forensuring compliance will allinvestigations assigned to them.Further support regarding the Dutyof Candour is found in both therevised Duty of Candour Policy andSerious Incident Policy. To improvethe monitoring of Duty of Candourcompliance in relation to seriousincidents and those graded asmoderate harm, the Datix Websystem was developed to include asection dedicated to the individualstages and allows for compliancereports to be reviewed.



CQCFollowing the June 2016 CareQuality Commission (CQC)inspection of the service, the LASdeveloped a Quality ImprovementProgramme (QIP) which was a singleoverarching plan to address qualityimprovement in the Trust. A clearprogramme of delivery,accountability and governance wasestablished, led by the Chief QualityOfficer and supported by aProgramme Management Office(PMO), to ensure oversight andleadership in the delivery of our QIP via Executive Leadership Teammeetings and via Quality Oversightgroup, Quality AssuranceCommittee and Board.

This Quality Improvement plan hasbeen delivered the majority ofactions completed, with a numberof actions being incorporated intobusiness as usual for Directorates;projects of a more complex nature,which are yet to be completed, arebeing incorporated into the 2018/19Business Plan.

The CQC has conducted a Well-Ledinspections of The LondonAmbulance Service NHS Trust onMarch 21st and 22nd 2017 . Twounannounced visits were alsocarried out in:

• Emergency Operations Centres

• Urgent and Emergency Care sites

The final report will not beavailable prior to the publication ofthe annual Quality Account,however initial feedback is positiveand the report will be available inMay 2018.

SafeguardingThe London Ambulance Service NHSTrust are continuing to ensure thesafeguarding of children and“adults at risk” this remains a focalpoint within the Trust, which iscommitted to ensuring all personswithin London are protected at alltimes.

The Trust has seen an increase ofincidents and safeguarding concernsraised by our staff to 1.95%reporting around 1800 concerns amonth to the local authorities. TheTrust has recruited a full timeadministrator to assist with theincreased workload.

During the year we have introducedtwo new policies:• Safeguarding supervision

policy

• Chaperone policy

We have also improved ourgovernance arrangements andintroduced several quality assurancepractice review groups thatscrutinize concerns raised by staffand ensure best practice to protectthose at risk.

• Child Death Review Group

• Safeguarding Incident ReviewGroup

• Care Home Review Group

• Prevent Review Group

The Trust continually seeks to learnfrom practice and detailed below issome of the learning fromsafeguarding cases in 2017-18:

• A Safeguarding Adult Review(SAR) Found that the LAS andother agencies failed to notifythe police of severe neglect, weare now working in partnershipwith the police and haveproduced materials on theimportance of involving thepolice in safeguarding cases andprovided training to over 90% ofclinical staff. We have also written an articletor the Trust “Clinical News”

• Following a Serious Case Review(SCR) it was felt staff did notgain enough information abouta situation and missed vital facts.We have since improved oursafeguarding training andincluded a section onprofessional curiosity.

• The Trust has also introduced anescalation policy for repeatsafeguarding concerns raised bystaff, this is a result of severalcase reviews which identified wemade multiple referrals forpatents, but these wereunsighted and no additionalaction was taken.

The Trust continues to improve itssafeguarding practice and during2017-18 has:

• Established pathway for youngviolence referrals to “RedThread”

• Increased partnership workingand engagement

• Introduced safeguardingsupervision

• Fully integrated 111safeguarding into Trust processes

• Improved response forsafeguarding information topartners through recruitment ofa full time administrator.

The Trust has a good workingrelationship with a wide range ofpartners. Working in Partnership isvital to protect people from abuseand neglect. The SafeguardingTeam continues to support andeducate staff to recognize the signsof abuse and neglect, reportconcerns and monitor and assuresafeguarding practices through ongoing audit review groups.

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Safeguarding

Children, young people and adults at risk

Staff SurveyFor 2017 the survey was sent to allTrust staff electronically for the firsttime. Of 4970 eligible employees2664 questionnaires werecompleted, giving an overallresponse rate of 54%. This is thehighest ever response rate for the Trust and supports thedetermination of the ExecutiveTeam to gain extensive feedback onthe employee experience to informdevelopments and focus for2018/19.

The average response rate across allAmbulance Trusts was 46%. LAS’response rate is thereforesignificantly higher than otherAmbulance Trusts.

The main published report sees thefindings of the questionnairessummarised by the national surveycentre Picker Europe, on behalf ofthe Department of Health,presented in the form of 32 KeyFindings (KF). This year the KeyFindings are presented under ninethemes listed below:

• Appraisals and support fordevelopment

• Equality and diversity

• Errors and incidents

• Health and wellbeing

• Job satisfaction

• Managers

• Patient care and experience

• Violence, harassment andbullying

• Working patterns

Overall indicator of staffengagement

The staff engagement score rangesfrom 1 to 5, with 1 indicating thatstaff are poorly engaged (with theirwork, their team and their Trust)and 5 indicating that staff arehighly engaged.

The Trust score was 3.36 comparedwith 3.39 in 2016.

The overall indicator for staffengagement is calculated usingthree key findings:• Staff recommendation for the

Trust as a place to work orreceive treatment

• Staff motivation at work

• Staff ability to contributetowards improvements at work

Summary of Key Improvements andDevelopments

The categories where the Trust hasperformed better are:• Working patterns

• Patient care and experience

• Reporting incidents

The categories where the Trustperformed less well are:• Violence, harassment and

bullying

• Equality and Diversity

The key findings whichbenchmarked higher than otherAmbulance Trusts were:• % satisfied with the

opportunities for flexibleworking

• Effective team working

By key finding, the areas where theTrust needs to focus improvement is:• % staff appraised in last 12

months

• % believing the organisationprovides equal opportunities tocareer progression/promotion

• % reporting goodcommunication between seniormanagement and staff

• % agreeing that their role makesa difference to patient/serviceusers

• % experiencing harassment,bullying or abuse from staff inlast 12 months

• % reporting most recentexperience of harassment,bullying or abuse

Key staff groups

Gender

Women had more positive scoresoverall than men (26 out of the 32key findings). Women had a staffengagement of 3.43 compared with3.34 for men. Slightly less womenhad appraisals (73% v 75%) andalso scored higher in levels of workrelated stress and attending workdespite feeling unwell. None ofthese scores were statisticallysignificant differences.

Black and Ethnic Minority staff

In 21/32 key findings BME staff hada more positive response than whitestaff. An additional 2 key findingshad the same score. BME staff had astaff engagement score of 3.43



compared with 3.36 for white staff.BME staff had higher levels of jobsatisfaction except for theirperceived ability to contributetowards improvements at work.BME staff reported higher rates ofexperiencing bullying andharassment from white staff (38% v31%) and a slightly lower rate ofreporting (30% v 31%). Levels ofappraisal were 5% less for BME staffand they also rated the quality oftraining lower.

The scores with the most significantdifference were in relation toEquality and Diversity. 37%reported experiencingdiscrimination at work comparedwith 26% of white staff and 47%felt that the organisation providesequal opportunities for careerprogression and promotioncompared with 62% of white staff.

Taking Action

All actions will be later found by anetwork of Staff Survey Champions,these have been identified to create

and deliver action plans locallyacross all areas of the Trust.Champions have been encouragedto work with their local union repsin taking forward this work. EachChampion has been provided with asurvey report for their area and willengage with their colleagues toidentify the areas for improvementand potential actions. It wasrecommended that each action planfocused on 3 actions.

Champions came together toprovide them with an overview ofthe staff survey outcomes and atoolkit to support the developmentof action plans. Follow up eventswill be planned during the year toprovide an opportunity to updateon progress, share ideas andprovide support in the developmentand delivery of action plans.Basecamp (an online sharingplatform) has been set up as adocument repository and as an areato share information and providepeer support.

As each local area has been asked to

identify 3 actions, the Trust decidedupon a Corporate action plan tosupplement this with 3 Service wideactions based on the 3 key findingswhich had a statistical decrease in2017.

These are:• % believing the organisation

provides equal opportunities forcareer progression (by 14%)

• % able to contribute towardsimprovement at work (by 4%)

• % reporting goodcommunication between seniormanagement and staff (by 3%)

34



Freedom to speak upFreedom to Speak UpGuardians have beenintroduced in each NHS Trust,as a result of therecommendations in theFrancis Report. A Guardianwas appointed at the LAS inOctober 2016, andundertook this role inaddition to her core role asHead of Patient & PublicInvolvement and PublicEducation. She steppeddown at the end ofDecember 2018, to bereplaced by a full-timeinterim Freedom toSpeak Up Guardian, whowas tasked withpromoting the role inthe Trust and facilitating therecruitment of a permanentGuardian.

Since the role was introduced theTrust has:• Announced the role in the

internal Routine InformationBulletin and produced a leafletto be attached to staff payslips.

• Established a Freedom to SpeakUp LAS group, with dates tomeet quarterly.

• Agreed reporting arrangementsto the Trust Board.

• Designed a secure recording andreporting module on Datix,which is only visible to theFreedom to Speak Up Guardian.

• Hosted a successful visit bycolleagues from the NationalGuardian’s Office.

• Had its Freedom to Speak Uparrangements audited by KPMG.The LAS was the first NHSorganisation to have taken thisaction.

The LAS Guardian has attended thenational launch and undertaken theFreedom to Speak Up training. Heis a member of the London regionalnetwork and national ambulance

network for Freedom to Speak UpGuardians.

Since the role has been introduced,a total of 9 concerns have beenreported. The majority of thesehave related to a bullying cultureacross a team or part of theorganisation, two have related totrust processes, two to patientsafety concerns, and the remainingthree have been related toinfrastructure, to seek advice, or togive ideas about possibleimprovements. Feedback has beenvery positive from staff who haveused this method of raisingconcerns, indicating that is amethod of engaging with staff thatshould be developed further overthe coming year.

InformationGovernanceLondon Ambulance Service NHSTrust Information GovernanceAssessment Report overall score for2017/18 reached 83% satisfactory,Level 2 for all requirements.

National ReportingLondon Ambulance Service NHSTrust did not submit records during2016/17 to the secondary usersservice for inclusion in the HospitalEpisode Statistics.

London Ambulance Service NHSTrust was not subject to thePayment by Results clinical codingaudit during 2016/17 by the AuditCommission.



OpenLearning from

mistakes Honest

Freedom to

If something is not right, speak up. There are many ways to raise a concern, such as withyour team leader, line manager or through Datix. If you feel your concern has not been addressed, you can contact our Freedom to Speak Up Guardianconfidentially on: [email protected] more information, search for “freedom to speak up” on the Pulse.

Section 5:

Reporting on core indicatorsIn October 2017/18 the ambulanceresponse categories changedfollowing the nationalimplementation of AmbulanceResponse Programme. The figuresbelow will therefore represent thecategory achievements to Octoberand the changed categories fromOctober to March 2018.

April to October categoriesCat A These are calls or incidentscategorised as immediately lifethreatening, Cat A subdivides intoRed 1 and Red 2. The categories arebased on AMPDS codes provided bythe Department of Health.

Category A % reached in 19 mins:The percentage of Cat A incidentswhere any responder capable ofconveying a patient arrived at thescene of an incident within 19minutes. This is measured fromclock start to when the firstconveying vehicle (MRU/CRU – ifonly vehicle) arrives on scene. Thetarget is 95% within 19 minutes.

Red 1This is a subcategory of Cat A, theseare the category of calls that aredeemed the most time critical, witha requirement for an emergencyresponse arriving at the scene of anincident within 8 minutes (75%Target). This is measured from callconnect to when the first responderarrives on scene.

Red 2This is a subcategory of Cat A, theseare the category of calls that aredeemed serious but lessimmediately time critical, with arequirement for an emergencyresponse arriving at the scene of anincident within 8 minutes (75%Target). This is measured fromeither first dispatch, determinant or240 seconds and the clock stops

when the first responder arrives onscene.

Table 11 demonstrates ourachievement of these category callsduring 2017-18 from April toOctober.

The month on month performancefor A8, A19 and the year endposition.As the AmbulanceResponse Programme wasimplemented on the 1st November2017, year end position is calculatedfrom April to 31st October 2017.Byway of comparison, the 2017/18year end position shows aconsiderable improvement at thesame point for 2016/17. (from Aprilto October 2016).This improvementis more noticeable for the A8, Red 1(R1) and Red 2 (R2) measures. Theoverall A8 measure increased by4.51% from 66.01% in 2016/17 to70.5% in 2017/18. Red 1performance increased by 5.27%,from 68.64% in 2016/17 to 73.9% in2017/18.Red 2 performanceimproved by 4.47% from 65.93% to70.40%.

36



A8 A19

R1 R2 A R1 R2 A

Apr-17 79.38% 73.63% 73.83% 98.98% 95.44% 95.56%

May-17 73.71% 71.90% 71.96% 98.60% 94.94% 95.06%

Jun-17 73.61% 69.75% 69.88% 98.38% 94.26% 94.39%

Jul-17 72.51% 68.55% 68.69% 98.64% 94.01% 94.17%

Aug-17 74.47% 72.05% 72.14% 98.54% 94.32% 94.47%

Sep-17 70.70% 68.47% 68.54% 98.23% 93.75% 93.90%

Oct-17 73.28% 68.65% 68.82% 98.90% 94.79% 94.94%

2017/18 73.90% 70.40% 70.52% 98.61% 94.50% 94.64%

Table 11

System Indicators – Post ARPImplementation

The above table shows the six keyindicators and our performancesince the Ambulance ResponseProgramme was implemented(November 2017).Performance in all 6 measures improved in January2018, seeing a reduction of the timetaken to respond to patientscompared to December. The mostsignificant improvement was seen incategories 3 and 4 where there was

a reduction of over 30 minutes forC3 and C4 90th centiles. The C1mean performance has been stableweek on week since November2017, which is reflected in themonthly performance. Januarys2018 shows a reduction by 15 seconds to 7 minutes and 8 seconds. This is marginally abovethe national standard of 7 minutes. C1 90th centile shows each monthlyperformance successfully within thenational standard of 15 minutes,this is also reflected in the year to

date position at 11 minutes and 46 seconds. C2 mean is above the 18 minutes by a few minutes eachmonth. The year to date positionshows 3 minutes and 14 secondsabove the national standard. C4 90th centile has remained within the national standard of 3 hours every month since theimplementation of ARP. The year to date performance is within thenational standard by a substantial28 minutes and 5 seconds.



System Indicators Post ARPimplementation

C1 Mean

(00:07:00)

C1 90th

Centile(00:15:00)

C2 Mean

(00:18:00)

C2 90th

Centile(00:40:00)

C3 90th

Centile(02:00:00)

C4 90th

Centile(03:00:00)

November 2017 00:07:03 00:11:28 00:18:25 00:36:28 02:13:10 02:28:48

December 2017 00:07:23 00:12:04 00:24:07 00:51:08 02:58:23 02:51:44

January 2018 00:07:08 00:11:43 00:20:23 00:42:05 02:24:59 02:19:05

Current YTD (2017/18)*_* From 1st November 2017 –

11th February 201800:07:13 00:11:46 00:21:14 00:44:13 02:32:34 02:31:55

Table 12

Complaints andPatient Advice &Liaison (PALS)

IntroductionPatient experience and feedback isa rich source of information thatallows us to understand whetherour services are meeting thestandards we set ourselves andmeeting patients’ expectations.With these objectives very much inmind, we take all patient andstakeholder feedback very seriouslyand do our best to offer acomprehensive response, clearlyidentifying any lessons and usingthese to improve our service, whereappropriate.

It is important to ensure thatpatients’ voices can be heard. Tothis end, and to compliment theinformation we already haveavailable, this year we introducedtwo new leaflets under the bannerof ‘Talking With Us’. The first isavailable on all ambulances,

providing information about howto make a complaint or to thankour staff; the second is sent outwith every complaint response,inviting complainants to feedbackon their experience of making acomplaint.

ActivityYear ending March 2018, thevolume of complaints droppedslightly, totalling 938 against 1016in 2016/17. Enquiries continue toincrease 4277 against 4215 beingreceived in 2016/17. The PTS servicehas reduced dramatically, nowoperating as NETS. NHS 111complaints (via LAS) are also hostedby the team.

The Resource Escalation Action Plan(REAP) was used during persistentperiods of high 999 call demandmeant that the REAP level for thisyear was mostly implemented atmoderate or severe. The dailyaverage for 999 calls is currently5185. The average percentage ofcomplaints received against callsattended is [0.08%].

Complaint risk score – to21/02/18During 2017/18, 26 complaints andone PALS enquiry were referred tothe Serious Incident Group. Ofthese, eight were declared as aSerious Incident.

Complaint outcomes detailsIf a complaint is upheld, learningwill be noted and actionedaccordingly. This can involve a rangeof measures including feedback,reflective practice and bespoketraining held locally, with emergingthemes reported to the relevantdepartment/Governance Committeeto consider action. The PatientExperience Annual Report,published later this year, willprovide a comprehensive analysis.

Table showing complaint outcomesof closed complaints 2017/18

Risk grade 2017/18 Data

Low 807

Moderate 125

Significant 5

High 1

Total 938

2017/18 Data

Not upheld 483

Partially upheld 117

Referred to other Agency 102

Upheld 83

Actioned 29

Under investigation 124

Total 938

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Themes

These continue to be dominated bydelay and staff conduct. However,many complaints increasinglyinvolve multiple issues, for example,call management + a delayedresponse + attitude of crew staff +care provided.

The top five key subjects were asshow in table above:

Performance

We have been able to achieve asignificant improvement inthroughput performance targets.Year to date performance is 82%responses within 35 working days.

To achieve this the followingmeasures have been actioned• Improved resourcing to Quality

Assurance team

• Closer relationship with QGAMs

• Changes in some of themethodological processes theteam use

• Changes in administrativepractice at the Executive Office.

• Weekly review of complaintsagainst target response times

We do however continue toexperience external factors that caninfluence performance, for exampletelephony and IT problems.

Examples of learningComplaints continue to be apowerful tool to describe patients’experiences and the learning thathas resulted are presented to thePatient Feedback and LearningGroup.

Staff attitude

Our practice when we receive acomplaint about staff attitude andbehaviour is to additionally reviewthe care provided, which has oftendemonstrated a correlation.



Complaints by subject 2017/18 April May June July Aug Sept Oct Nov Dec Jan Feb Mar Total

Delay 21 17 16 14 26 9 22 33 19 17 40 21 255

Conduct 16 19 24 19 19 16 17 25 20 22 23 20 240

Road handling 12 11 13 14 10 7 14 9 7 6 10 6 119

Treatment 1 2 5 1 7 5 16 8 9 8 14 4 80

Non-conveyance 3 0 4 12 0 1 6 1 7 6 3 4 47

Totals (above) 53 49 62 60 62 38 75 76 62 59 90 55 741

Annual totals 66 70 77 73 86 51 94 85 84 74 102 76 938

Table 13

Example one - delay/call management

Complaint from patient’s mother that there was a delay in attendingher daughter when she experienced a seizure.

On assessment questioning, it was confirmed that the patient was hadexperienced a grand mal seizure, which was still in progress. Thispresentation amounts to a high priority emergency with a FastResponder and an ambulance being sent whilst the call was in progress.The call handler stayed on the line and the patient stopped fitting andrecovered. At this point, her symptoms were determined at a lowerpriority. The Fast Responder was duly stood down (as they aremaintained to be sent to patients determined at a high priority. Theambulance crew were similarly diverted in favour of a patient assessedas a higher priority emergency. Satisfied that the patient was not at anyimmediate risk, the call handler concluded by explaining that anambulance would be arranged but it could take up to 45 minutes forhelp to arrive, so a further 999 call should be made if the patient’scondition changed in the interim.

The Quality Assurance evaluation found that the initial highest priorityshould have been maintained as the event should be assessed as acontinuous fit in view of the duration. Given the complexity of thepatient’s care arrangements, we agreed to arrange a specificemergency care component of the patient’s care plan.

40



Example two - staff attitude call handler

Complaint from relative about the way she was spoken to when shemade the 999 call about a patient who had collapsed The call hander had difficulties in establishing whether the patient wasbreathing and was very assertive in trying to calm the caller down sothat she could clarify this. However, they did not manage the situationvery well, deviating from the prescribed questioning, omitting to usethe breathing detector tool, failing to verify the location or to applyappropriate customer service skills. As well as feedback being given tothe call hander concerned, we recommended the case be used as atraining example in managing challenging calls.

Example three - attendingstaff attitude

Complaint from the patientabout the aggressive mannertowards herThe patient was a familiar callerto 999 and made multiplecomplaints about ambulancestaff We had worked with thehealth and social careprofessionals responsible forher care to establish anemergency care component ofher plan but we continued tolook at each case on its merits.On this occasion, although wefound that the overarching careprovided was reasonable andthat the paramedic needed tobe assertive, his use of painstimulus was unnecessary.

Example four – treatment

Complaint from patient that anebuliser was not administeredafter she suffered an asthmaattackIt would seem that the paramedicfelt the patient had a chestinfection. However, theinformation detailed in theassessment record was minimal,which made it problematic toconclude a nebuliser should havebeen used. This is because a chestinfection of itself does notmandate a nebuliser, chestinfections can precipitate asthma.We concluded that if there wasany suggestion of a wheeze orexacerbation of asthma, then anebuliser probably should havebeen given. Extensive feedbackwas given to the Paramedic withan emphasis on the importance ofrecording the assessment record toan optimum level. They were alsoasked to jointly review thetreatment protocols in relation topatients with symptoms similar tothis presentation.

Example five – treatment –Ombudsman/EOC

Notes on methodology:For recording purposes,complaints about a delay in anambulance response areattributed to EOC although werecognise that local operationalresourcing may have played acontributory role.

As far as the outcome category, wetake the view, accepted by theHealth Service Ombudsman that adelay in an ambulance responsedoes not of itself indicate a failurein service delivery.

The criteria we use in upholding acomplaint is where a significantshortcoming is identified, forexample that the EMD applied thewrong clinical triage protocolwhich in turn gave a lower prioritydeterminant than should havebeen the case. This is applied inaccordance with our holisticapproach, which has been cited asbest practice by the Ombudsman.This means that we look intorelated issues irrespective of whatthe complaint is about, or wherewe identify issues not complainedabout. Thus where a complaint isnominally about the call handler’smanner, we will arrange a QualityAssurance (QA) evaluation reviewto ensure the call was triaged atthe apposite level of priority. We

also apply the Ombudsman’sprinciples for remedy, includingmaking financial recompensewhere appropriate.

In terms of performance, weconcur with the Francis report inthat complaints management is anorganisational, not adepartmental, responsibility. Assuch, throughput is a largelydetermined by the contribution ofother departments, which can becompromised by significantdemand to the Trust. We havenow devised a means by which wecan provide evidence ofperformance across thedepartments concerned.

Those cases where there has beena protracted delay reflect wherethe matter under investigationwas declared as a Serious Incident(SI), the ensuing report being usedto as the substantive response tothe complaint. The delays weretherefore once again completelyoutwith the control of the PEDteam although the Trust are nowmaking strides in achievingimproved SI completion.

Themes• Delay caused by demand

exceeding resourcing. On somerecent occasions, less thanadequate resourcing to EOC hasbeen identified.

• Triage errors, including technicaland procedural errors

• Poor staff attitude

• The practice of applying‘workarounds’

• Confusion in the application ofthe health professional protocol,both internally and externally,post ARP.

Learning from these themes

1. Complaint from family who wereunhappy with the Serious Incidentreport, the key issues being thedelay in an ambulance being sentand the care provided to thepatient, who later died. Althoughthe Ombudsman did not uphold thecomplaint in relation to the matterscomplained about, the report foundthat the practice in applying‘workarounds’ to enable a higherpriority response to particularpatient symptoms amounted tomaladministration.

The ‘workarounds’ the Ombudsmanreferred to were limited to veryspecific circumstances and put inplace having been determinedlocally and based on other drivers(for example a Preventing FutureDeaths notice, issued by theCoroner in an unrelated case) toensure a more commensurate levelof priority could be achieved, in theinterests of patient care. Weexplained that some of these wouldno longer be needed when theTrust moved to use a newer versionof MPDS. Solutions for theremaining issues, including theworkaround that was at issue in thiscase, have been resolved followingliaison with the InternationalAcademies of Emergency Dispatchand the Association of AmbulanceChief Executives, in the light of new

Ambulance Response Programme(ARP) standards. Finally, we agreedto share the learning from this casewith all UK ambulance services

Ombudsman cases

The Ombudsman continues toinvestigate a high proportion ofcomplaints across all NHS Trusts,especially where a death hasoccurred.

Pie chart showing requests by theOmbudsman and outcomes:



Patient Engagement

The LAS Patients’ ForumThe Trust continues to work closelywith its Patients’ Forum, anindependent lay organisation thattakes an overview of the Trust fromthe point of view of service users,carers and the public. The Forumprovides representatives for all theTrust’s governance committees andits own monthly meetings arehosted at LAS Headquarters,supported by the Patient & PublicInvolvement Team.

In the year 2017-18, Patients’ Forummeetings included the followingtopics and speakers:

• Delivering safe and effectiveemergency and urgent care inLondon, presented by theDirector of Operations

• Developing higher quality care,presented by the DeputyDirector of Nursing & Quality

• Demand management,presented by the DeputyDirector of Operations(Emergency Operations Centre)

• The CQC report findings,presented by the Chief QualityOfficer

• Race equality in the LAS,presented by the Director ofPeople and OrganisationalDevelopment

• The Ambulance ResponseProgramme, presented by theAssistant Director of Operationsfor Service Improvement

• Patient & Public Involvement inthe LAS, presented by the Headof Patient & Public Involvement

• The flu epidemic and vaccination

campaign, presented by Dr SamPerkins from Public HealthEngland

Patients’ Forum members meetregularly with senior LAScolleagues, LAS commissioners andother key organisations such as theCQC, to highlight areas of goodpractice and areas wheredevelopment is required.

Patients’ Forum members have beendirectly involved throughout theyear in the development of the LASAcademy. Together with staff fromthe Academy, they have formed aPatient and Public InvolvementPanel, and attend steering groupmeetings. They have developed ateaching programme detailingpatient and public involvement inthe Academy’s syllabus, and takepart in assessment centres for therecruitment of students.

42



Friends and Family Test (FFT)The Trust continues to recordFriends & Family Test (FFT) responsesfrom Patient Transport Service andSee & Treat patients, although theresponse rate remains low. The totalnumber of FFT responses received inthe year 2017-18 was334. Almost allpatients who responded to thequestion said they would either be“extremely likely” or “likely” torecommend their friends and familyto the LAS if they needed similarcare or treatment.

The National Ambulance ServicePatient Experience Group is indiscussions with NHS England andNHS Improvement, to highlight thelimitations of this methodology forambulance service patients anddiscuss alternative methods ofpatient engagement.

Community Engagement EventsThe LAS remains committed tosupporting a wide range of patientengagement and public educationevents with LAS presence requestedat654 events in the year 2017-18. Ofthese, we were able to attend 506,77% of all requests made. This isdue to the ongoing support of over1,200 staff on our database, withover 300 individuals taking part inmultiple events, often in their owntime.

We have created a closed Facebookgroup for staff involved in publicengagement, as another method ofcommunication. Through this groupwe provide information about theteam and about forthcomingevents, and staff can post their ownideas and questions for members ofthe team to answer. This has beenextremely successful and the grouphas over 600 members.

The four part-time Public EducationOfficers continue to focus mostly onactivities involving children andyoung people, such as awarenesssessions on the dangers of carryingknives and of using alcohol andother legal highs, careers in the LAS,and multi-agency road safety events

such as Safe Drive Stay Alive andBiker Down. Many of these arecarried out with partnerorganisations.

Blue Light CollaborationWe are working closely with ourpartners on the “prevention” sub-group of the Blue LightCollaboration project, to ensure wemake the best use of the resourcesavailable and share good practice.The Head of Patient & PublicInvolvement and Public Education isan active member of the steeringgroup and has now also facilitatedthe inclusion of the LAS Head ofFirst Responders in the group.

One of the Public Education Officershas led on a key project as part ofthis work, piloting a scheme whichinvolved all the blue light servicesattending schools in the LondonBorough of Haringey. Pupilsparticipated in a range of sessions,rotating between them during a

school day. The LondonAmbulance Service sessionsfocused on the consequencesof carrying knives, and CPR(basic life support) training.The pilot has been evaluatedand has been shown to behighly effective. A bid is nowbeing submitted, with the aimof rolling out the scheme toother London boroughs.

Co-production and co-designactivitiesCo-production and co-design arepowerful ways to maximise thebenefit of patient involvement,both for patients and for staff.

Following the Insight Project,funded in 2016-17 by the NHSEngland Insight Team, a range ofco-production activities havecontinued to gather momentum.These have focused on threespecific patient groups: those withsickle cell disease, COPD (chronicobstructive pulmonary disease) andpersonality disorder. Some patientsfrom those groups (sickle cell andpersonality disorder) have takenpart in developing and deliveringtraining packages for LAS staff,whilst others have taken forwardideas such as carrying healthinformation “passports” or crisiscards (COPD and sickle cell) andhow to get information across in a999 call. Members of the personalitydisorder group delivered apresentation at the SafeguardingConference this year, and havemade a film for use in staff training.We are talking to the Sickle CellSociety about children and youngpeople making a film about pain,for use in the LAS Academy’smodule on pain management.

Discussions have commenced withHealthwatch London, with a view tocommissioning a local Healthwatchgroup to carry out co-productionand co-design activities to supportthe new LAS Strategy. This work islikely to focus on the four ‘pioneer’services: mental health, maternity,falls and end of life care.



Talking with us

Complaints and thanking our staff

Talking with us

Complaints and thanking our staff

The Trust also hosted an event forits Partnership Reference Group(PRG), which is made up ofHealthwatch and voluntary sectororganisations, to get the group’sfeedback on its strategic intent.Earlier in the year we held a PRGevent focusing on volunteering, toshare information about differentschemes and learn from PRGmembers’ experiences.

Staff development and trainingThe Patient & Public InvolvementTeam ran a four-day course inOctober for staff who volunteer toundertake patient engagementwork for the Trust. The course hasbeen running for a number of yearsnow and is well-established, beingupdated and adapted each yearaccording to the feedback receivedand the Trust’s changing publiceducation priorities. The course

includes skills training (e.g.presentation skills), knowledge (e.g.disability awareness) and self-awareness activities such as anintroduction to the Myers-BriggsType Indicator (personality types).This year, because of the links madethrough the Blue LightCollaboration work, we were ableto use the London Fire Brigade’straining facilities, free of charge.

The Patient & Public InvolvementTeam has purchased an onlinedisability awareness trainingprogramme, which any member ofLAS staff can use at no extra cost.The course includes modules on arange of disabilities and givespractical tips and information abouthow best to communicate withpeople affected by thosedisabilities, and how to provide andadapt services for them.

Every other month the Trust Boardhears a patient story, usually tolddirectly by the patient involved. Thishelps to ensure patients feel heardby the organisation, and providesan opportunity for Board membersto hear about patients’ experiencesfirst-hand.

44



Section 6:

Other services5a : Non-EmergencyTransport ServicesThe Non-Emergency Transportservice (NETs) which commenced inJune 2015 has continued to grow.This service supports our core A&Eservice in transporting the lowestacuity patients to healthcarefacilities where there is little or noclinical intervention required enroute. As a result we are able toincrease the availability of frontlinecrews to attend life threateningcalls made to the service and ensurelower acuity patients receivetransport within an agreedtimeframe providing for a betterpatient experience.The number of journeys completedby NETs has continued to grow inline with the development of theservice with delivery rising fromapproximately 100 journeys a weekat commencement to approximately800 journeys a week by the end ofthe financial year. We areimplementing plans to reach atarget of 900 journeys per week.The increase in delivery of journeysis shown in the following graph:

The NETs pre-plan mental healthcommunity assessment journeyrequests via our e-booking systemand use have now been rolled outto all the Mental Health Trusts inLondon. This project has beenhighly successful with the majorityof this cohort of mental healthservice users now seeing transportarriving at the commencement oftheir assessment or within 30minutes. Following on from theMental Health Transport project theService has also seen the pre-booking of journeys for end of lifecare patients where journeys aretime critical rolled out and thisservice is now operating from threehospices. The service is currently

engaged in the roll out of thisservice to all other Hospicesoperating within the London area.

In line with the growth of NETs,there has been an increase in thenumber of NETs operational stafffrom 90 to 120. The introduction of13 apprentices last year under thenational apprentice scheme havenow completed their first year withus and have been employed by theService with some working on NETsand some have been successful inapplications to further progress andare now currently training tobecome TEACs.

All existing staff (PTS and NETs)have completed Core SkillsRefresher training during the yearwhich has included Infection,prevention & control, Safeguarding,Prevent, Sepsis, Dementia, Patientreport forms and End of life care. Inaddition other statutory andmandatory training was deliveredby e-learning.

Both of these services are animportant part of our core businessand they are fully integrated intoour quality governance processes.



5b: South East London 111 - 2017/18

This report has been prepared toreview the activity within LAS 111South East London (SEL) for 2017/18and has been broken down intonine key areas.

• Care Quality Commission Update

• Workforce Transformation

• Procurement of future services

• Incidents, complaints andfeedback

• Call Quality and monitoring

• Safeguarding

• Patient Experience

• Training

• Pilots and Innovation

Care Quality CommissionUpdateFollowing CQC recommendationsfrom the inspection in September2016 (rated “Good” overall) SEL111has continued to improvesubstantive staffing, more thanhalving the percentage WTEvacancy rate since April 2017. A gapanalysis has been undertaken andthere is an IM+T Project Plan inplace to address the remainingissues. Finally open forums havecommenced whereby Staff have anopportunity to meet with the HRManager and 111 OperationsManager.

Workforce TransformationBy 31st March 2019 all NHS111

services are required to haveevolved into an Integrated UrgentCare service, providing a “consultand complete” service, reducingreferrals to other areas of the NHS.SEL are undertaking Phase 1 of thework required, having employed anIntegrated Urgent Care WorkforceTransformation Manager to overseethe process.

Procurement of FutureServicesIn January 2018, LAS was awardedthe NHS 111 Integrated Urgent Careand clinical assessment service inNorth East London.

Mobilisation of the new service is inprogress and LAS are due tocommence Service delivery fromAugust 2018. Future Annual QualityAccount reports will include NELService performance.

Procurement has commenced forthe future service for South EastLondon and a bid will be submittedby 13 March 2018 for the servicewhich is currently due to go live inOctober this year.

Incidents, complaints andfeedback

Incident detailsTwo Serious Incidents were declaredthis year, both related to clinicaladvice and have been investigated,with all actions completed to ensuremitigation of future incidents.Incidents reported relate to a rangeof issues at LAS 111. A key trendidentified over the last year hasbeen errors in the referral ofpatients into an Out Of Hours(OOHs) service. The process forreporting and feeding back theseincidents has changed and an actionplan put in place to decrease theamount of incorrect referrals.

Feedback from Health CareProfessionalsThe main services /departments thatwe receive feedback from are theLAS crews and the GP Out of Hours(OOH) providers. The majority relateto the perceived inappropriatenessof the referral and whilst severalhave been upheld, some are due toa lack of understanding of the 111system. Considerable effort hasbeen put into improvingunderstanding and communicationchannels between the 111 and 999services; and also improvingunderstanding between the 111service and OOHs services, e.g.including them in End to Endreviews and engaging in workshopsto promote collaboration betweenservices.

46



Type Mar 18 Feb18 Jan 18 Dec 17 Nov 17 Oct17 Sep17 Aug17 July 17 Jun17 May 17 Apr 17

Serious incidents 0 0 0 0 0 0 0 0 1 1

Incidents 120 184 112 150 133 180 88 80 87 82

Complaints (formal) 8 19 3 5 7 7 5 4 2 8

HCP feedback 2 3 2 2 4 0 3 2 2 5

Compliments 4 6 1 1 3 2 3 2 0 6

Authorisedconfidentiality breaches

18 11 8 8 15 12 11 7 18 18

Wrong OOHs GP referrals

39 68 39 39 39 32 36 32 25 18

Table 14

Feedback to Health CareProfessionals12 feedback forms have been sentto other providers of care. Staff areencouraged to raise issues wherethe actions of other healthcareproviders have resulted in a delay inpatient care, or where a procedureappears to be unsafe orinappropriate. The most commonissues are with regard tocommunication issues and handoverof patients between services such asGP OOH Providers failures to acceptpatient referrals due to patientlocation, or disputes causing delayto patient care.

Authorised confidentialitybreachesAuthorised confidentiality breachesare logged when a patient has beenreferred to a service without theirconsent and/or knowledge. Thebreaches are used for patientswhere it is deemed not safe to leavethem without further assistance orin the case of safeguarding, not safeto notify them i.e. domestic abusewhere the assailant is still on thepremises. The breaches areauthorised at the time of theincident by a senior clinician withinthe call centre.

ComplimentsTwenty-eight (28) compliments havebeen received relating to both theservice and individuals undertakingpatient contact duties. Recognitionfor staff has increased, ascompliments continue to bepublished in the Trust’s weeklybulletin in addition to being

displayed on site noticeboards.

Call quality and monitoringWe have continued to exceed therequired standard for 1% of callaudits every month including thewinter months where demands onthe service increased. Each staffmember has a minimum of 3 callsaudited each month. Whereperformance issues are identifiedthe level of audit is increased. SinceOctober 2017 compliancepercentage (target 86%) has notbeen achieved. An action plan is inplace to improve compliance with afocus on key themes identifiedduring audits.

End to End call auditsMonthly end to end call reviews areundertaken at LAS111. This year atotal of 50 calls were audited by thesenior management team, includingthe Trust’s Assistant MedicalDirector and South East LondonClinical Lead. The audits areattended by healthcareprofessionals from the areas offocus which ensures their input andto improve partnership working,communication and practice. Theend to end audits have allhighlighted areas of good practicebut also areas that require someimprovement and action plans havebeen put in place to addressconcerns.

SafeguardingSafeguarding referrals haveremained fairly static for both adultsand children. The LAS 111 servicehas referred 415 people in total toSocial Services which equates to

circa 0.15% of all calls taken.Referrals for adults were predom-inantly for welfare concerns and forchildren for safeguarding issues.

As a large proportion of referralsstem from information provided ina patient’s Special Patient Notes(SPN), a deep dive into thetimeliness and validity of these SPNsis underway. Early data has beenpresented at the South East LondonClinical Governance meeting. Itsuggests more can be done byexternal agencies to increase thereliability of this information.

Patient ExperienceThe 111 patient surveys are senteach month to around 300 patients,an increase from 250. The averageresponse has increased from lastyear to 38 a month (from 29 amonth). Work is ongoing toexamine new ways to enablepatient feedback, including thepossible use of email or textmessaging. This includesengagement with the SE Londonpatient representative to design asurvey which will encourage ahigher response level.

Language lineSpanish continues to be the mostrequested language, followed byArabic and Portuguese. The averagecalls per month has increased from106 in 2016/17 to 137 in 2017/18.

TrainingAll staff have undertakenmandatory training relating tochanges made to the 111 call



Call Audit Data

Mar 18 Feb 18 Jan 18 Dec 17 Nov 17 Oct 17 Sep 17 Aug 17 Jul 17 Jun 17 May 17 Apr 17

Calls answered at 111

34,941 35,721 22,361 22,346 25,361 20,242 28,321 26,015 28,656 28,381

% Call audits (target >1%)

1.2% 1.1% 1.7% 1.6% 1.4% 1.5% 1.2% 1.5% 1.4% 1.4%

No. Call audits 423 376 378 427 356 308 341 379 406 398

No. Call Handler audits

246 218 224 254 210 191 177 211 225 223

No. Clinical Advisor audits

177 158 154 173 146 117 164 168 181 175

% Compliance (target >86%)

80% 85% 83% 84% 88% 90% 89% 90% 88% 88%

Table 15

management system “Pathways”with two version updates (13 and14) being completed, the latter inNovember 2017. Following theresponse to a Serious Incident, aTOXBASE calculation and overdosemanagement training refresher wasintroduced to all clinicians. A pilotdemonstrating the success of criticalthinking and probing skills workshop led to the mandatoryintroduction of this training. Thistraining is in addition to the fullcompliance to statutory andmandatory training as required bythe London Ambulance Service NHSTrust. Agency staff are given allmandatory training includingsafeguarding and also offeredplaces on all workshops that areappropriate.

Pilots and Innovation• LAS 111 has been actively

involved in a number of pilotsthroughout the year including

• Direct booking patients under 5years old into OOHsappointments

• Direct bookings in to GP hubsacross additional boroughs

• Implementation of *567 accesslines into BAU

• Expanding direct referralpathway for patients presentingwith Mental Health difficulties tocover all 6 boroughs.

• Introduction of 111 online forSEL

• Enhanced clinical assessment forED dispositions

• Working groups to introduce theability to access additionalpatient records to inform clinicaldecision making and allow staffaccess to electronic prescriptiontracker.

48



Section 7:

Feedback from our partnersand stakeholdersWe are obligated to givestakeholders the opportunity tocomment on our Quality Accountand to then publish their commentsin full. This year we invited thefollowing organisations/groups torespond.• The London Ambulance Service

Commissioners 27 April 2018

• Patients’ Forum response dated14 May 2018

• Healthwatch were provided withthe draft Quality Accounts inMarch 2018 for comment

We would like to thank thoseorganisations/groups for taking thetime to read and respond. Theircomments are published in thissection. To be inserted oncereceived


Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019 – Appendix

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3 Patients’ Forum Ambulance Services (London) Ltd. Registered in England. Registered office: 6 Garden Court, Holden Road, Woodside Park, London, N12 7DG Company limited by guarantee. Company number: 6013086

care will improve when the workforce better understands and mirrors the population treated and cared for by the LAS.

RECOMMENDATION- 3: ALL LAS PUBLICATIONS SHOULD ENSURE THE VISIBILITY OF ETHNIC DIVERSITY IN ITS WORKFORCE

4) “Quality is our number one priority”. (page 6)

We would suggest that “Safety and Quality” should be the first priority for the LAS.

5) “Goals and targets that are measurable” (page 6) We would expect this to include recommendations arising from the public and patients’ voices.

6) Safe – (page 13)

We suggest that this section should refer to ‘moderate harm, severe harm and death’ in compliance with the statutory Duty of Candour. Target 2 – Hospital Handover Delays – We fully support the LAS goal (to reduce handovers in excess of 15 minutes by a quarter), although we believe that there should be no handovers at all in excess of 15 minutes. There are no 30 or 60 targets as suggested in the QA. A 30 and 60 minute handover is a breach of the national agreement on handovers. We suggest that the QA states what the LAS expects of STPs, CCGs and hospital trusts to deal with this appalling problem. Patient safety is at the heart of everything the LAS does, and in our view more assertive action is required to protect patients from unacceptable delays. RECOMMENDATION- 4: THE LAS SHOULD PUBLISH ITS STRATEGY TO OBTAIN GREATER SUPPORT FROM STPs, CCGs AND HOSPITAL TRUSTS TO SUBSTANTIALLY REDUCE HANDOVER WAITS IN EXCESS OF 15 MINUTES.


7) Caring – (page 15) Target One – Mental Health Care

a) The publication which described the LAS mental health work as exemplary should be referenced in the QA.

b) We strongly support the employment of mental health nurses in the clinical hub, the enlargement of the team and the development of Advanced Mental Health paramedics. We also support the trial of a paramedic and mental health nurse working together to enhance mental health care. We see this as an important step in the direction of

developing LAS Advanced MH paramedics. RECOMMENDATION-5: THE LAS SHOULD DEVELOP IN LIAISON WITH THE FORUM A PROPOSAL FOR ADVANCED MENTAL HEALTH PARAMEDICS

c) We would like to see effective methodologies developed to obtain

information from patients who have been sectioned under s135 or s136, and cared for by LAS staff. Similarly, patients who use the NET service should be able to comment on the service when NETS is used to provide transport for them, in connection with assessment or sectioning under the Mental Health Act. Methodologies need to be specifically designed for this purpose (see for example the Insight methodology).

RECOMMENDATION- 6: THE LAS SHOULD DEVELOP IN LIAISON WITH THE FORUM, METHODOLOGIES TO GATHER

QUALITATIVE DATA FROM PATIENTS RECEIVING MENTAL HEALTH CARE AND THOSE RECEIVING BARIATRIC CARE, TO ASSESS THE QUALITY OF CARE THEY HAVE RECEIVED.

Target Two – PPI – PIF a) We strongly support the LAS goal of having patient involvement in all

service redesign programmes and a patient involvement framework (PIF) developed to apply this goal consistently (page 15). However, we note that there is already an LAS PPI strategy and LAS Action Plan, which should be integrated.

50 London Ambulance Service NHS Trust

Trisha Bain Chief Quality Officer London Ambulance Service May 14th 2018 QUALITY ACCOUNT (QA) 2018 – PATIENT FORUM RESPONSE Dear Trisha, we are delighted to present the Forum’s response to your 2018 Quality Account. We have valued working with Briony Sloper and yourself over the past year and appreciate your tireless work to implement critical changes to the operation of the LAS and enhance the quality of care for patients. This has included the development of the Quality Oversight Group that brings together all of the major players responsible for the safety and quality of services. The continuing development of end of life care, mental health care and midwifery services are major areas that we commend in terms of enhanced patient care. Our assessment of the Quality Account and our Recommendations to the Board are as follows: 1) We welcome the following statements of LAS commitment to patient and public involvement contained within the QA: • Patients will have a stronger voice that every before (page 1) • The patient is at the centre of everything that we do (page 5) • Listen to staff and patients to determine priorities (page 9) • Have patient/carer involvement in all our improvement work (page 9) • Integral to all programmes must be the aim of robust patient and staff

involvement (10) • We need to listen to our patients, their families and carers, and respond to

their feedback (15) • Our goal being to have patient involvement in all service redesign

programmes and a patient involvement framework developed to apply this goal consistently (page 15)

• We need to widen and increase our public involvement in both the development of these new services and monitoring of their success. (15)


• A co-designed an co-developed patient and staff engagement model will be used to drive quality improvement across the maternity care model (16)

• Services are organised so that they meet people’s needs (19)

RECOMMENDATION-1: THE LAS SHOULD CONTINUOUSLY DEMONSTRATE THAT ACTION IS BEING TAKEN BY THE TRUST AS A RESULT OF RECOMMENDATIONS MADE TO THE LAS BY THE PATIENTS’ FORUM AND HEALTHWATCH IN THE ANNUAL QUALITY ACCOUNT.

The LAS accepts this recommendation 2) Integration of PPI work-streams in the LAS

PPI work-streams in the LAS are not yet integrated. The PPI team led by Margaret Luce carries out excellent work, e.g. the Insight project and continuous work with communities across London. This team has a well developed PPI Action plan and Patient Engagement Strategy (2016-2020) (see also PPI Annual Report). This work is not integrated with other major PPI work-streams, e.g. the engagement exercise which preceded publication of the LAS strategy and the streams of work that are being progressed following adoption of the LAS overall strategy. We would strongly recommend integration of all PPI streams of work to ensure effectiveness, consistent quality and evidence-based practice, e.g. to ensure that the public voice influences LAS practice, policy and strategy. RECOMMENDATION-2: THE LAS SHOULD INTEGRATE ALL PATIENT AND PUBLIC INVOLVEMENT WORK-STREAMS IN ORDER TO ENSURE THAT THE SHARED EXPERTISE OF THE PPI TEAM AND OTHER DEPARTMENTS INFORMS ALL PPI WORK IN THE LAS INCLUDING THE PIONEER PROJECTS

3) Ethnic Diversity within the LAS

Images of LAS staff in the QA and other document show virtually no diversity, which is recognised as a major issue by the communications team. This happens repeatedly in LAS publications, suggesting that the Communications Department needs to ensure that they produce more relevant material. The LAS public website has been positively modified in its presentation in this respect. We commend the proactive and continuous work that is now taking place across London to recruit staff that reflect the city’s population. Patient

e

We


Yours sincerely Malcolm Alexander

Chair Patients’ Forum for the LAS 07817505193

COMPANY SECRETARY

John Larkin Registered Office: 6 Garden Court, Holden Road, Woodside Park, N12 7DG

PRESIDENT OF THE FORUM

Dr Joseph Healy [email protected]

CHAIR Malcolm Alexander [email protected] Tel: 07817505193

HACKNEY HEALTHWATCH

VICE CHAIR Sister Josephine Udine [email protected]

VICE CHAIR Angela Cross-Durrant [email protected]

EXECUTIVE COMMITTEE

Audrey Lucas

ENFIELD HEALTHWATCH

EXECUTIVE COMMITTEE

Lynn Strother

CITY OF LONDON HEALTHWATCH

EXECUTIVE COMMITTEE

Beulah East

EXECUTIVE COMMITTEE

Adrian Dodd

WALTHAM FOREST HEALTHWATCH



b) The Patient’ Forum is a centre of excellence for PPI work and many of our members have considerable expertise in the field. We hope that the learning from the recent LAS strategy engagement exercise, will provide valuable reflection for the next steps in the development of PPI in the LAS.

c) We would suggest considerable care is needed in agreeing a methodology to a collect data from patients, as there are no effective generic systems for collecting data from patients who use emergency

ambulance services. A great deal of money could be wasted on ineffective systems. The Friends and Family test demonstrates this point well and led to the development of the Insight projects.

d) We strongly support the Target 2 recommendation regarding evidence of PPI in all QI and service design programmes.

RECOMMENDATION-7: THE PROPOSED PIF SHOULD BE DEVELOPED IN LIAISON WITH THE TEAM THAT HAS DEVELOPED THE LAS PPI STRATEGY AND ACTION PLAN Target Three – Development of a team of practice leads for pre- hospital maternity education We strongly support Target Three and have been involved in the selection of the two midwives to carry out this role. 8) Effective – Target Two – ARP – We are pleased that more work is being carried out on the presentation of data. Compared with previous data sets (pre- ARP) we find the current data sets unhelpful in determining the how well the LAS is performing. Handover data is now of good quality. RECOMMENDATION-8: ARP DATA SHOULD BE PRODUCED THAT IS ACCESSIBLE TO THE PUBLIC AND BASED ON PERFORMANCE IN EACH LONDON BOROUGH.


9) Responsive – Target 2– Complaints investigations – This section is excellent. We would like to see the investigation time for complaints reduced to 30 working days in 2018, and to have access to systematic data on the findings and recommendations from complaints. We have been attempting to review complaints for the past year without success, despite the support of the Chief Quality Officer and Patient Experiences Department for this audit activity. We believe the 75%, 35 days target is much too low and compares unfavourably with most other NHS and Foundation Trusts. RECOMMENDATION- 9: THE LAS SHOULD REDUCE THE TARGET TIME FOR INVESTIGATION OF COMPLAINTS DOWN TO 30 DAYS RECOMMENDATION-10: THE LAS SHOULD DESIGN A SYSTEM TO ALLOW ACCESS, WITH THE CONSENT OF THE COMPLAINANT, FOR THE FORUM TO EXAMINE COMPLAINTS DATA FOR THE PURPOSES OF AUDIT Quality Account – we believe it is essential that the LAS works with the Forum to implement recommendations made to the LAS in the Forum’s submission to the QA. This would be a good test of responsiveness and would demonstrate that the LAS values public involvement in the development of its services. RECOMMENDATION-11: ISSUES RAISED BY THE FORUM IN THE QUALITY ACCOUNT SHOULD BE SUBJECT TO ONGOING DISCUSSION WITH THE LAS REGARDING IMPLEMENTATION. 10) Well Led – Target 2 – LAS Strategy a) The LAS did not carry out a reasonable consultation exercise on the overall LAS strategy during the engagement period. Only one small short meeting was held with public participants. The Forum’s detailed submission received no response despite several requests, until May 2018. We strongly Recommend the LAS carries out a detailed public involvement exercise on the content and implementation of their strategy and follows the lead of the Quality team which is inclusive and works closely with the Forum. We commend Whose Shoes PPI event of May 12th RECOMMENDATION-12: ALL LAS STRATEGIES SHOULD BE SUBJECT TO AN AGREED PUBLIC ENGAGEMENT AND INVOLVEMENT PROTOCOL AND METHODOLOGY BEFORE PUBLICATION.

Appendix 1: Clinical Audit : Learning outcomes

Below are the actions taken following audits during2017-18:• Continued clinical education provided to staff

through face-to-face training and publication ofupdates in bulletins and newsletters

• Release of infographics promoting the key monthlyfindings

• Feedback regarding inappropriate triage decisionsand extended times provided to clinical staff byQuality, Governance and Assurance Managers

• Continued use of the “Clinical Information andSupport Overview” tool to facilitate discussionswith clinicians and Clinical Team Leaders regardingclinical audit findings, illness coding and time spenton scene

The reports of 10 local clinical audits were reviewedby the provider in 2017/18 and the London AmbulanceService NHS Trust intends to take the following actionsto improve the quality of healthcare provided againsteach as detailed below.

Documentation of EZ-IO® Intra-osseous System use• Distribute an infographic reporting improvements

made and reiterating the importance ofdocumenting needle size and a named anatomicalsite and side when gaining intra-osseous (IO) access

• Publish an article in the Trust-wide clinicalnewsletter to share keys findings and actions

• Create a prompt card documentation reminder tobe inserted in EZ-IO kit bags

• Amend the Patient Report Form (PRF) User Guideto specify that IO needle size should bedocumented in millimetres

• Share report with the LAS Clinical Education andStandards Department

Assessment and transport decisions of patients withmajor head injuries• Define the illness codes for major and minor head

injuries in the PRF User Guide

• Distribute the key findings in a Trust-wide clinicalnewsletter, together with an infographic displayedin all ambulance stations

• Make the ‘Management of Minor Head Injuries’assessment tool more available for all clinicians

• Share report with the Joint Royal CollegesAmbulance Liaison Committee (JRCALC) GuidelineDevelopers and Contributors and seek furtherclarity regarding the assessment and managementof head injuries

• Re-audit whether there has been an improvementin the recognition and management of clinicallysignificant head injuries

Patients who severely deteriorated or diedunexpectedly within 24 hours of being discharged atscene• Declare seven serious incidents identified by this

continuous audit

• Flag one case to another organisation for them todeclare as a serious incident

• Provide constructive and positive feedback toindividual crews, where necessary

• Share the findings of this audit with NHS Englandand suggest the Ambulance Quality Indicator re-contact data guidance is amended to excludepublic places

• Continue with the Continuous Re-Contact ClinicalAudit in 2017-2018, with the inclusion of NHS 111referrals and Hear & Treat assessments

• Write an article for the Trust-wide clinicalnewsletter focussing on the importance ofconsistent discharge documentation

• Create a short animation focussing on consistentdischarge documentation for the LAS intranet andFacebook group

• Write a case study for the LAS Insight Magazinedemonstrating good patient assessment anddischarge documentation and evidencing fullpatient assessment on the PRF

• Continue to monitor the decisions made for 50%of patients not conveyed to hospital and facilitatethe provision of individualised feedback toclinicians

Administration of dexamethasone• Share report with the JRCALC Guideline Developers

and Contributors and seek further clarity regardingwhether mild croup is an indication fordexamethasone

• Distribute the key findings in a Trust-widenewsletter, together with an infographic displayedin all ambulance stations

• Share the findings with the LAS BusinessIntelligence Team, specifically the number of timesdexamethasone was miscoded in the sample

• Undertake a re-audit to assess whether there hasbeen an improvement in documentation ofindication for dexamethasone administration

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Appendix – Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019


Administration of ondansetron• Share keys findings and necessary actions with

clinicians through the publication of an article in aTrust-wide clinical newsletter and a correspondinginfographic to be displayed at all ambulancestations

• Distribute an infographic highlighting howondansetron and other drugs should be given

• Share report with the LAS Medicines ManagementGroup and Clinical Tutors

• Care provided to the patients with a genuineillness or injury at Exercise Unified Response

• Explore the feasibility of including event call signsin the Clinical Performance Indicator auditprogramme

• Consider the suitability and training needs ofclinicians not normally deployed on frontline dutiesat events

• At events, share the LAS PRF User Guide withclinicians not normally deployed on frontline duties

• Share report with the LAS Department forEmergency Preparedness, Resilience and Response,the Medical Directorate, Cycle Response Unit andCommunity First Responders

• Analgesia given to adult patients

• Distribute to all ambulance stations the keyfindings in an infographic

• Share report with the LAS Medicines ManagementGroup, the Medical Directorate and Clinical Tutors

• Include whether or not adequate analgesia wasgiven in future clinical audits

Care given to patients with a suspected mental healthdisorder• Consider continuously auditing the care provided

to patients with an undiagnosed psychiatricproblem, or carry out a re-audit once all actionshave had sufficient time to take effect

• Record a Q&A session with the Service’s MentalNurses outlining the importance of undertaking athorough patient assessment

• Share findings with clinicians in a Trust-wideclinical newsletter, together with physicalconditions which may mimic a mental healthcondition

• Share keys findings in an infographic to bedisplayed at all ambulance stations

• Promote the LA383 (Adult Mental HealthAssessment Form) at Sector Quality Meetings

• Review the wording of the ‘psychiatric problem –undiagnosed’ illness code

Use of adrenaline (1:1,000) re-audit• Produce an allergic reactions and asthma tool for

the LAS Digital Pocket Guide application

• Create a short video presentation of the stages ofallergic reaction and asthma, and when adrenaline(1:1,000) is indicated for publication on theService’s intranet and Facebook page


• Review all training materials related to adrenaline(1:1,000)

• Share report with the LAS Medicines ManagementGroup

• Undertake a re-audit once all actions have hadsufficient time to take effect to determine whetherthere has been an improvement in adrenaline(1:1,000) administration

Documentation of mental capacity assessments• Produce a guidance animation of the key principles

of the Mental Capacity Act and what constitutes athorough mental capacity assessment

• Write a case study for the LAS Insight magazinewhich promotes positive learning from experience


• Review the current LA5 (Capacity tooldocumentation for the treatment of patients whoare unable to consent)

• Update the downloadable LA5 on the LAS intranetand arrange removal of the old LA5s in circulation

• Share report with the LAS clinicians and MentalHealth Nurses in the Clinical Hub

In addition, a further 5 local clinical audits werestarted by the provider in 2017/18 as detailed below.

Management of paediatric pyrexia re-auditThe LAS 2012 Paediatric Pyrexia Clinical Audit foundthat patients aged 2-8 years with pyrexia ofunascertained origin were often not appropriately re-assessed before a decision was made to dischargethem at scene, and the patient’s medical history wasnot always considered. Following training and raisingawareness of the guidance and protocols, this re-auditassess the appropriateness of discharge decisions forpaediatric patients with pyrexia.

Decision making surrounding paediatric conveyanceFollowing national concerns from the Royal College ofPaediatrics and Child Health regarding the amount of


Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019 – Appendix

infants left at home following ambulance attendance,a baseline clinical audit was undertaken on patientsaged under 1 year old who were discharged at scene.As a result, the LAS issued a paediatric conveyancepolicy stating that: all patients under 2 years shouldbe conveyed to a hospital; patients aged 2-5 yearswho are not conveyed must be referred to their GP orsuitable Health Care Professional (HCP), and patientsaged 6-12 years who are not conveyed should bestrongly considered for referral to their GP or asuitable HCP. This clinical audit aims to assess whetherconveyance decisions for patients aged 0-12 years arein line with this LAS protocol.

Administration of hydrocortisone re-auditIn 2013 the LAS Hydrocortisone Clinical Auditidentified an underuse of hydrocortisone in thetreatment of acute severe and life-threateningasthma. A number of actions were taken as a result.This re-audit will assess whether the actionsimplemented following the previous clinical audithave led to increased use of hydrocortisone forpatients with acute severe and life-threateningasthma.

Transient loss of consciousness (TLoC) re-auditThe LAS 2013 TLoC Clinical Audit found that whilstsome elements of history taking and assessment werewell completed; aspects more specific to TLoCrequired improvement. A voluntary study day was runto highlight the importance of history taking and aprompt card was produced and issued to assistclinicians with the management of TLoC. Despite theinitiatives to improve care, in 2016 a review of theNational Institute for Health and Care Excellence(NICE) quality standard for TLoC showedimprovements were still needed. In addition, in2016/17, two incidents were reported relating to thecare of TLoC patients. This clinical audit aims todetermine whether patients presenting with TLoC arebeing assessed, treated and managed in line with the LAS,NICE and UK Ambulance Service Clinical Practice guidelines.

Management of intentional overdoseThis clinical audit aims to address concerns raised bythe LAS 2013 Overdose Clinical Audit which foundpatients triaged as having no life-threateningsymptoms often received a response outside of thecommissioned target, when some of them required apre-alert to hospital. In addition, five incidents havebeen reported on the Trust’s incident reporting systemwhere there was a delay responding to a patient whohad overdosed, two of which were declared as seriousincidents. This clinical audit aims to: assess if patientswho have taken an intentional overdose are beingtriaged appropriately; examine any reasons for longerthan average on scene times, and determine ifpatients who have taken an intentional overdose who

are not conveyed are being appropriately assessedand referred.

The London Ambulance Service NHS Trust undertakesa programme of local Clinical Performance Indicatorsthat monitors the care provide to six patient groups(cardiac arrest, difficulty in breathing, glycaemicemergencies, mental health, severe sepsis and patientsthat were discharged on scene) and quality assures thedocumentation on 2.5% of all clinical recordscompleted. We also undertake five continuous auditsthat monitor the care provided to every patient whofalls within the following groups: cardiac arrest,STEMI, stroke, major trauma, discharged at scene butre-contacted the Service within 24 hours havingseverely deteriorated or died unexpectedly.

The Trust also submit data to the National Out-of-Hospital Cardiac Arrest Outcomes project, a registry ofout of hospital cardiac arrests in England. This registryis being used to look at the national variations inoutcomes of cardiac arrest and provide evidence tohelp inform treatment and improve survival amongstthis patient group. During 2017/18 we provided 4,432cases to the registry.

Participation in clinical research demonstrates theLondon Ambulance Service NHS Trust’s commitment toimproving the quality of care we offer andcontributing to wider healthcare improvement.Clinical research ensures our clinical staff keep up todate with the latest possible treatment options andtheir active participation leads to improved patientoutcomes. The number of patients receiving relevanthealth services provided or sub-contracted by theLondon Ambulance Service NHS Trust in the first 3quarters of 2017/18 that were recruited during thatperiod to participate in research approved by aresearch ethics committee was 683. These patientswere recruited into a range of interventional andobservational studies. These studies were:

ARREST: A randomised controlled trial exploringwhether immediate coronary angiography andpercutaneous coronary intervention can improvesurvival from cardiac arrest

RIGHT-2: A randomised trial that aims is to determinewhether glyceryl trinitrate (GTN) improves outcome inpatients with ultra-acute stroke when administered assoon as possible after onset.

In 2017/18 145 members of clinical staff receivedprotocol training to enable them to participate ininterventional and observational research at theLondon Ambulance Service NHS Trust.

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Appendix – Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019


Appendix 2: CQUINS 2017-18 and 2018-19 : UPDATE



Goal No. Goal Name Description of goal

1A National: Introduction of Health and WellbeingInitiatives

– Improving Staff Health and Wellbeing

Percentage point improvements to staff survey resultson 3 questions against a 2015/16 baseline.

1B National: Introduction of Health and WellbeingInitiatives

– Healthy food for NHS staff, visitors and patients

Continuing improvements to healthy food provisiondelivered in 16/17 and extending requirements for17/18, 18/19.

1C National: Introduction of Health and WellbeingInitiatives

– Improving the uptake of flu vaccinations for frontline staff within Providers.

Achieving an uptake of flu vaccinations by frontlineclinical staff of 70% for 2017/18

12 National:Ambulance Conveyance A reduction in the proportion of ambulance 999 callsthat result in transportation to a type 1 or type 2 A&EDepartment.

STP1 National:Supporting Local Areas Support engagement with local STP initiatives

STP2 National:STF Control Total Delivery of financial controls – Risk Reserve

L1 Local:Implementing the Digitalisation Enablers Providing the frontline, clinical staff at LondonAmbulance with personal issue mobile devices.

CQUIN Description Total AvailableEstimated Achieved

Estimated PercentageAchieved

National Health and Wellbeing

Improvement of health and wellbeing of NHS staff £260,562.00 £65,140.50 25%

Healthy food for NHS staff, visitors and patients £260,562.00 £260,562.00 100%

Improving the uptake of flu vaccinations for front line staff £263,701.00 £65,925.25 25%

Ambulance Conveyance £784,825.00 £549,377.50 70%

Mobile Devices for Frontline Staff £3,139,299.00 £3,021,575.29 96%

STP Engagement £1,569,650.00 £1,506,864.00 96%

STF Delivery (Control Total) £1,569,650.00 £1,569,650.00 100%

Total CQUIN £7,848,249.00 £7,039,094.54 90%

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LAS Quality Strategy - Vision 2020 and Annual Quality Account 2018-2019 · goals and targets for London Ambulance Service (LAS) in providing high-quality services over the next year