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Annual Health Check 2008/09

Annual Health Check 2008/2009The Annual Health Check is a system of assessment for all NHS Trusts. The review is undertaken by the Healthcare Commission, which is responsible for carrying out independent assessments of the performance of every local NHS organisation. From April 2009, the Healthcare Commission will be replaced by the Care Quality Commission.

Standards for Better Health represent one strand of the Annual Health check. The results are designed to provide a full picture of the Whittington’s performance against the core standards set by the Department of Health.

Where were we in 2007/8?

The Healthcare Commission published the results of the 2007/8 Annual Health Check in October. The Whittington was rated as:
  • Quality of services – Good
  • Use of resources – Good
As part of last year’s assessment, the Whittington declared that it had all of the core standards for the full year.

Assessment in 2008/9

This newsletter will focus on the core standards aspects of the health check. As last year, each core standard has criteria set to identify the Trust's compliance. We have to then assure ourselves that we are reaching the standards set.

Our process for this year involved each individual director presenting, to the Chief Executive and another director, the evidence they had to demonstrate compliance with the standards for which they were the lead.

The Whittington's Audit Committee, which is chaired by one of our non-executive directors, met on 5 March to review in detail the final evidence informing the outcome for each of the 24 core standards.

We met with representatives of our governors, members of Islington and Haringey LINks and members of the Overview and Scrutiny Committees for Islington and Haringey at the beginning of March, to present an overview of the evidence and our proposed declaration to them. The Overview and Scrutiny Committees are able to send comments on our declaration to the Care Quality Commission. The Trust Board signed off our proposed declaration on 18 March, ahead the final submission date of 1 May 2009.

How did we gather the evidence?

The Director of Nursing and Clinical Development and her team manage the process. We put all the standards, and the elements and criteria that make up the detail to support them, into a spreadsheet. An executive director was allocated to each standard in order to oversee the assurance process and ensure that the evidence gathered was accurate and appropriate. Evidence was drawn together from all the trust meetings that have taken place during the year, where the various parts of the 24 standards have been discussed or monitored.

To ensure a wide discussion and input throughout the Trust, reports have also been made to the Clinical Governance Committee, which is a multidisciplinary group of clinical and non-clinical representatives. Membership also includes representatives from Haringey and Islington Primary Care Trusts. A number of other groups will also have had input, including clinical representatives from the Audit and Effectiveness Committee and the Clinical Guidelines Committee, and our Child Protection Committee.

How have we done in 2008/9?

This section will highlight a number of the core standards, which are of particular interest to our external partners, including Haringey and Islington Overview and Scrutiny Committees, and the Islington and Haringey LINks

First domain: Safety

Standards: C1a, b, C2, C3, C4a, b, c, d, e

The healthcare organisation has systems to ensure the risk of healthcare associated infection is reduced in accordance with the Health Act 2006 code of practice for the prevention and control of healthcare associated infections.

Highlights:
  • We have achieved a 48 per cent reduction in hospital acquired infection rates for Clostridium difficile.
  • There is a programme of basic infection control training in place for all hospital staff, including non- clinical staff.
  • The visible leadership programme has now been running for two year - this sees the trust’s matrons and senior nurses, including the Director of Nursing, in the clinical areas every week measuring compliance with the Matron Charter, the Hygiene Code and monitoring hand hygiene compliance. The team were the runners up in the infection control section of the 2008 Nursing Times annual awards.
  • Hand hygiene compliance among clinical staff has improved with most areas now achieving above 90 per cent.
  • We have made important changes to our antibiotic administration policy to reduce the risk of Clostridium difficile infection.
  • We now screen all patients having planned surgery for MRSA; all emergency patients have been screened on admission since December 2008.
Standard C4a: infection control

Infection control has been our top priority this year. We now monitor hand hygiene compliance monthly and have reviewed our antibiotic prescribing policies, to ensure that patients’ risk of infection is minimised. We have achieved a lot in the last year and will be declaring ourselves compliant with this standard.

Standard C4c: decontamination

We will be telling the Healthcare Commission that we are not able to say that we have been compliant with this standard for the whole of the last year. This is because our mattress store and cleaning mop washer room were both identified as needing urgent refurbishment when the Healthcare Commission visited us in January 2009 to look at the Hygiene Code.

All the work that needed to be done has been completed, and the Healthcare Commission were satisfied with the action we took.

Second domain: clinical and cost effectiveness

Standards: C5a, b, c, C6

The healthcare organisation can demonstrate how it takes into account nationally agreed best practice as defined in national service frameworks. NICE guidelines, national plans and nationally agreed guidance when delivering services, care and treatment.

Highlights:
  • Our processes for implanting NICE guidelines were reviewed in a visit from NICE. Strengths identified were our excellent links with the PCTs and the high level of commitment from Whittington clinicians to implement NICE guidelines.
  • We have further reduced the number of patients who are having to wait to be discharged to a nursing or other care home.
  • The length of stay for medical patients has also reduced, reducing the time that patients are in hospital and therefore reducing their risk of hospital acquired infection.
  • We have worked with the primary care trust to arrange for some patients coming to the Emergency Department to be seen by a GP on the same day instead.
Third domain: governance Standards: C7a, b, c, e, C8a, b, C9, C10a, b, C11a, b, c, C12

The healthcare organisation has effective arrangements in place for clinical governance-there are effective cooperate governance arrangements in place that accord with Governing the NHS: a guide for the NHS board.

Highlights:
  • The strategic objectives of the trust were reviewed this year to make sure that they are about the right priorities for the care of our patients.
  • The Whittington Employment Promise has been highlighted to staff, promoting dignity at work, staff development, health, safety and security of staff.
  • The trust has worked with the King’s Fund to continue its Leading to Success leadership programme. This year, staff from infection control, older people’s services, therapies and facilities have taken part.
  • All polices are now reviewed in terms of their impact on equality and training is now available to promote awareness around equality impact.
Standard 9: records management

We are not able to declare that we were compliant with the standard all year, because in September 2008 we lost some payroll computer disks containing the details of a large number of staff. The disks were subsequently found within the hospital, and there was no risk to staff, but the incident identified a need to tighten our procedures, which we have now done.

Fourth domain: patient focus Standards: C13a, b, c, C14a, b, c, C15a, b, C16

The healthcare organisation has taken steps to ensure that all staff treat patients, carers and relatives with dignity and respect at every stage of their care and treatment, and where necessary, takes action where dignity and respect are compromised.

Highlights:
  • The Whittington Promise sets out our commitment to treating patients in a clean hospital, in a caring manner whilst providing the best possible care.
  • Our management of complaints has improved again over the last year with a further reduction in complaints. Over 90 per cent of complaints have been replied to within the five weeks set by the Department of Health.
  • Every patient has access to an interpreting service. We have services to cover 29 languages; Turkish, Somali and Chinese are the commonest languages we provide interpreters for.
  • Hot drinks are now available via a drinks trolley service operating in the outpatients department through the support of our volunteers.
  • New food trolleys have also been introduced for the delivery and service of patient meals, including a themed children’s trolley. These have improved the quality of the food when it is served to patients.
  • The visible leadership programme continues to monitor care standards on a weekly basis.
  • We monitor all patient complaints for concerns about the quality of care, and issues of dignity and respect.
  • We have reviewed all our wards to ensure that they comply with Department of Health guidelines on single sex accommodation. Further building work is planned for later this year to improve privacy on the wards
Fifth domain: accessible and responsive care

Standards: C17, C18

The healthcare organisation ensures that all members of the population it serves are able to access its services on an equitable basis. It seeks the views of patients, carers and the local community including those from disadvantaged and marginalised groups.

Highlights:

  • We use the information from our patient surveys to help us improve our services to patients.
  • Regular focus groups allow us to consult directly with the public about the standard and breadth of service we offer.
  • Our new day treatment centre opened in April 2008, helping to give our patients faster access to their treatment
  • We have further reduced waiting times for admission to hospital and for outpatient appointments this year, ahead of Department of Health targets.
  • Over the year, 98.3 per cent of patients have been seen, treated and discharged or admitted within four hours of arriving at our emergency department, one of the best performances in London.
Sixth domain: care and amenities

Standards: C20a, b, C21

Care is provided in a secure environment, which protects patients, staff, visitors and their property, and the physical assets of the organization and manages the health, safety and environmental risks to patients, staff and visitors

Highlights:
  • We have increased the number of single sex wards in the hospital, and have further building work planned to improve the privacy on our remaining wards
  • The Visible Leadership team regularly audits the ward areas to ensure patient safety and dignity is maintained.
  • Our emergency department has been completely refurbished, and we opened a new children’s emergency department in December 2008.
  • The Healthcare Commission noted that all our wards were clean when they visited us in January 2009.
Seventh domain: public health

Standards: C22a, b, c, C23, C24

The healthcare organisation works with local partners to deliver the health and wellbeing agenda-policies are implemented to improve the health and well being of the workforce and provides advice and support to patients in relation to public health priority areas.

Highlights:
  • We continued with our total smoking ban in the hospital and grounds for staff and patients.
  • Our volunteers run a ‘no smoking patrol’ to prevent people smoking in the grounds of the hospital.
  • We run a smoking cessation service for staff and patients.
  • We run a number of joint services with local Primary Care Trusts and other providers, including smoking cessation clinics, alcohol liaison service, drug liaison service, mental health liaison service.
  • The teenage pregnancy midwifery service and 24 hour support line was launched this year and won a national prize.
  • We work with local GPs to ensure continuity of care at home for babies discharged from the neonatal intensive care unit.
  • We work with local GPs to ensure compliance with treatment plans for patients with sickle cell disease.
  • We have devised a flu pandemic plan in case of an outbreak of influenza.
  • We run a range of health promotion events during the year, using the Department of Health public health calendar, including healthy eating, flu vaccination and smoking cessation.
  • We promote health awareness amongst our staff, including a cycle to work scheme, stress awareness and management.
  • We have robust emergency plans in place for major incidents, which are regularly tested and supported by staff training.
What happens next?

If you would like a full copy of the Final Declaration, please visit our website www.whittington.nhs.uk after 1 May 2008, or contact Deborah Goodhart, Head of Communications on 020 7288 5983.

Other useful contacts
Last updated06 Apr 2009