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    Papworth Hospital NHS Foundation Trust

    Quality Report 2016/17

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    Contents

    Part 1 Statement of Quality from the Chief Executive

    3

    Part 2 Priorities for improvement and statements of assurance from

    the Board

    5

    Priorities for 2017/18 9

    Priority 1 Sign Up to Safety 10

    Priority 2 Recruitment and Retention 15

    Priority 3 Quality improvement 18

    Priority 4 Understanding the Harm caused to Patients 19

    Priority 5 Realise the Quality Benefits from the EPR Implementation 20

    Statements of assurance from the Board

    22

    Part 3 Other Information

    34

    Patient Safety Domain 37

    Patient Experience Domain 50

    Clinical Effectiveness of Care Domain 59

    Annex 1 What others say about us

    Annex 2 Statement of Directors responsibilities in respect of the Quality

    Report

    Annex 3 Limited Assurance Report on the content of the Quality Report and

    Mandated Performance Indicators

    Annex 4 Mandatory performance indicator definitions

    Glossary

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    Part 1 Statement on quality from the Chief Executive

    ---------------------------------------------------------------

    -------------------------------------

    This Quality Account sets out the approach we are continually taking to improve quality at Papworth Hospital and translates our Quality Strategy into improvements in patient care. I am therefore delighted to introduce my first Quality Account for Papworth Hospital - a view of the quality of services we provided during 2016/17. Significant progress was made this year in relation to building the New Papworth Hospital. It was wonderful for me to see so many of Papworths friends and supporters at the topping-out ceremony in November 2016 where the true scale and ambition of the project became clear. The 400-day milestone has now been passed and we can begin to look forward to treating our patients in state-of-the-art, purpose built facilities on the Cambridge Biomedical Campus (CBC). The move to the CBC will allow Papworth Hospital to work alongside some of the worlds leading healthcare companies and organisations including Cambridge University Hospitals, giving patients immediate access to a range of services. Fund raising has also commenced to expand cardiorespiratory research in Cambridge, with the creation of a new Heart and Lung Research and Education Institute (HLRI) jointly established by Papworth Hospital and the Cambridge University, to sit alongside the new Papworth Hospital. The Institute will allow for significant expansion of the current heart and lung disease research capacity.

    The last year has seen many successes in innovation and research. These include the ongoing successful clinical application of the DCD heart transplant research programme, a paper in Science from the CF team and Papworth Hospital joining the new Mesothelioma Network. Papworth innovation won the software/ ICT/Assistive Technology category in the 2016 HEE NHS Innovation Competition with an App that automatically matches organ donors to an ideal recipient from a pool of potential candidates without the need for manual selection.

    At Papworth we pride ourselves on the ability to deliver state of the art medicine with excellent outcomes. However it is important always to strive for improvement in the care given to our patients and look at new and innovative ways to do this. High quality care is only achieved when all three dimensions of care (safety, clinical effectiveness and positive patient experience) are present, not just one or two of them, and our Quality Strategy and Quality Account priorities re-confirm our commitment that every patient has the right to feel safe and cared for whilst accessing our services. Whether we are caring for our patients here in our existing buildings or in the new building, patients can expect the same attention to detail and high levels of care from every member of our staff.

    Papworth has a track record of providing good quality care, treatment delivery and a reputation for being open, honest and transparent to enable sharing and learning when things go well or indeed when things go wrong. The most recent Care Quality Commission visit in December 2014 rated the Hospital as Good overall with Outstanding in care and effectiveness.

    Performance against national and local quality indicators are reported to the Board of Directors and Council of Governors. Our commitment to high quality care will continue through our quality priorities for 2017/18, which have been developed in consultation with clinical staff, governors and other stakeholders and reflect the specialist nature of our work. These priorities will be addressed later in the Quality Accounts.

    The support of all our stakeholders is vital to us in maintaining and building on our current achievements. I would like to thank all our staff, governors, volunteers and patient support groups for their input and support in helping us to progress against our objectives during the year. The information and data contained within this report have been subject to internal review and, where appropriate, external verification. Therefore, to the best of my knowledge, the information contained within this document reflects a true and accurate picture of the quality performance of the Trust.

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    Stephen Posey Chief Executive May 2017

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    Information about this Quality Report We would like to thank everyone who contributed to our Quality Report. Every NHS trust, including NHS foundation trusts, has to publish a Quality Account each year, as required by the NHS Act 2009, in the terms set out in the NHS (Quality Accounts) Regulations 2010. NHS foundation trusts are also required by NHS Improvement (NHSI) to publish a Quality Report as part of the foundation trusts Annual Report and Accounts. The Quality Report includes all the requirements of the Quality Account regulations but includes additional requirements as set out by Monitor in its Annual Reporting Manual and in the document entitled Detailed requirements for quality reports. Foundation Trusts are given the option of either publishing their whole Quality Report as their Quality Accounts or removing the additional Monitor requirements. Papworth publishes its Quality Report in its entirety as its Quality Accounts. References to Quality Report and Quality Account should therefore be treated as the same throughout this document. See glossary. Part 2.2 Statements of Assurance by the Board includes a series of statements by the Board. The exact form of these statements is specified in the Quality Account regulations. These words are shown in italics. Further information on the governance and financial position of Papworth Hospital NHS Foundation Trust can be found in the various sections of the Annual Report and Accounts 2016/17.

    To help readers to understand the report, a glossary of abbreviations or specialised terms is included at the end of the document.

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    Part 2 Priorities for improvement and statements of assurance from the Board

    ---------------------------------------------------------------

    -----------------------------------2.1 Priorities for

    improvement

    Welcome to Part Two of our report. It begins with a summary of our performance during the past twelve months compared to the key quality targets that we set for ourselves in last years quality report. The focus then shifts to the forthcoming twelve months, and the report outlines the priorities that we have set for 2017/18, and the process that we went through to select this set of priorities. This will be followed by the mandated section of Part 2, which includes mandated Board assurance statements and supporting information covering areas such as clinical audit, research and development, Commissioning for Quality and Innovation (CQUIN) and data quality. Part 2 will then conclude with a review of our performance against a set of nationally mandated quality indicators.

    Summary of performance on 2016/17 priorities Our 2015/16 Quality Report set out our quality priorities for 2016/17 under the three quality domains of patient safety, clinical effectiveness and patient experience. See our 2015/16 Quality Account for further detail: http://www.papworthhospital.nhs.uk/docs/accounts/Papworth-Hospital-Quality-Report-16-06-22.pdf The following table summarises the five quality improvement priorities identified for 2016/17 along with the outcomes. The first priority relates to the 3-5 year Sign up to Safety Plan and the results / achievements are after 2 years. The Sign up to Safety programme continued through 2016/17. The goals from 2015/16 were carried over and progress monitored on a quarterly basis with an annual report in 5 areas (including the new project, number 6) with the 5

    th priority improving physiological

    assessment in patients with Duchenne Muscular Dystrophy having been completed in 2015/16:

    Goals 2016/17 Outcomes 1 Sign Up to Safety

    Acute Kidney Injury (AKI)

    50% of Cardiac surgery and PPCI patients who develop AKI will be managed using the AKI pathway by 2017On-going

    10% reduction in incidence of AKI in cardiac surgery and PPCI patients by April 2018On-going

    *Monthly data is collected and shows us that results

    continue to fluctuate month by month on the incidence

    of AKI in both our Cardiology and Cardiothoracic

    patient populations. Stage 1 AKI remains at around

    30% incidence with our cardiothoracic patients and

    approximately 10% with our Cardiology patients, which

    is in line with the national average.

    Formal handover within Thoracic Medi