1. Our improvement plan & our progress At Buckinghamshire Healthcare NHS Trust we are committed to ensuring our patients’ experience of our services is a good one. We take the quality of our care very seriously and constantly strive to improve and develop. We have developed our Quality Improvement Strategy accompanied by the Quality Improvement Plan which builds on the actions identified as part of the Keogh review. Our top goal is to deliver safe and compassionate care every time. We will do this by reducing harm, reducing mortality and providing a great patient experience. We continue to engage with our staff, patients and the local public along the way. We want to know, and hear back from you, whether the changes we are making are having the right impact and learn from what you, the public, have to say. We have held seven ‘Big Conversations’ with our local communities and as a result are acting on what we have been told. We will be reporting back through our website. There will be regular updates on NHS Choices and subsequent longer term actions will be included as part of a continuous process of improvement. What are we doing? Keogh review made 17 recommendations on 11 July 2013. Initial actions have been signed off into our ongoing quality improvement plan. The progress we have made was acknowledged by those attending the follow-up Risk Summit chaired by NHS England on the 4 December 2013. Specifically, Keogh said that we need to: Strengthen leadership at Board level and improve some of the Board processes – this is important because the Board sets the direction for organisational culture and leads organisational change Strengthen processes within our urgent care pathways. This is important because strengthening these processes will improve patient experience and may have a positive impact on clinical outcomes. Strengthen how we learn from patient experience. This is important because patient feedback is an important element of quality and we can more quickly identify areas for improvement. Improve the way data is used to provide intelligent information in relation to clinical effectiveness and operational performance data. This is important because such information is key to strategic decision making and for understanding our quality and patient experience. Formally review staffing levels and skill mix and take action where appropriate. This is important because having the right staff numbers and with the right skills is central to the delivery of a quality service. This ‘plan & progress’ document shows how we are making these improvements and demonstrates how we’re progressing against the plan. This document builds on the ‘Key findings and action plan following risk summit’ document which we agreed immediately after the review was published: (http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx).http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx While we take forward our plans to address the Keogh recommendations, the Trust is in ‘special measures’. More information about special measures can be found at: http://www.ntda.nhs.uk/blog/2013/07/16/nhs-tda-places-five-trusts-in-special-measures/http://www.ntda.nhs.uk/blog/2013/07/16/nhs-tda-places-five-trusts-in-special-measures/ Oversight and improvement arrangements have been put in place to support changes required. More detail is shown further in the document.

2. Our improvement plan & our progress Who is responsible? Our actions to address the Keogh recommendations have been agreed by the Trust Board Our Chief Executive, Professor Anne Eden, is ultimately responsible for implementing actions in this document. Other key staff are the Medical Director Dr Tina Kenny and the Chief Nurse and Director of Patient Care Standards, Professor Lynne Swiatczak (and as from April 2014 Carolyn Morrice) as they provide clinical leadership within the organisation. The Chief Operating Officer and Director of Human Resources also play key roles in the delivery of the plan. Dr Stephen Dunn is our Trust Development Authority representative and he is helping us to implement our actions by supporting & performance monitoring the delivery of this plan. In addition an Improvement Director from the Trust Development Authority, Marie-Noelle Orzel, is working with the Trust to support the delivery of the plan. At a follow-up meeting held on 4 December, Trust staff outlined the improvements made to patient care over the past six months. Representatives from the Trust Development Authority, NHS England, Care Quality Commission and local CCGs thanked staff for the tremendous amount of work that had been undertaken in response to the Keogh recommendations and expressed that real progress had been made and demonstrated, with all areas of concern addressed. In March 2014 the Trust was inspected by the CQC’s Chief Inspector of Hospitals, it is expected to report back in the next two months If you have any questions about how we’re doing, contact us on everypatientcounts@buckshealthcare.nhs.uk.everypatientcounts@buckshealthcare.nhs.uk How we will communicate our progress to you Details of our action group and action plan have been published in a dedicated area on our website - http://www.buckshealthcare.nhs.uk/everypatientcounts- http://www.buckshealthcare.nhs.uk/everypatientcounts A report will be presented to and discussed at our Board every month – these meetings are held in public bi-monthly and anyone is welcome to come along and listen We developed a blog - http://everypatientcounts.wordpress.com/ - to share the work we are doing to improve and develop care, quality and the patient experience. And we want people to get involved by posting their comments and questions, sharing ideas or participating in discussionshttp://everypatientcounts.wordpress.com/ We will also use twitter to update and engage people – follow us http://twitter.com/BucksHealthcarehttp://twitter.com/BucksHealthcare We will be reporting to the Buckinghamshire Health and Adult Social Care Select Committee with regular updates Members of the Trust will receive frequent email updates, as will other key stakeholders such as our local Healthwatch, councils, MPs, commissioners and our patient experience group We are working with our local commissioners so that GPs are kept up-to-date with our progress We will actively work with our local media – ensuring they are provided with updates and an opportunity to ask questions through our public Board meetings A dedicated section has been set up on our staff intranet, providing regular updates and an opportunity for staff to post comments and ask questions. As we progress against our action plan, we will continue to use our weekly staff bulletin and monthly team brief to provide updates. Divisional Boards and professional meetings, for example our Nursing & Midwifery Board, discuss this action plan as a standing item at their monthly meetings. - In January 2014, we launched the Trust’s new Quality Improvement Strategy, which directs our ongoing quality improvements

3. What have we delivered so far? The Trust is now reviewing every patient death in a detailed and systematic way. This has helped us to quickly identify if there are clinical improvements we need to make. We have set up a Learning Collaborative for the care of the acutely unwell patient. Initial focus has been around use of the Early Warning Scores and fluid management. A dedicated phoneline has been established for healthcare professionals in community services to access GP support more quickly out-of-hours Additional doctors are working at weekends in Stoke Mandeville Hospital to support emergency medical patients on the wards and ensuring that each and every patient admitted at the weekend is reviewed on a daily basis A review of nurse staffing levels and skill mix has taken place and wards sisters and charge nurses are receiving clear information about the staffing levels and skill mix for their areas. The Board has approved an investment to increase numbers of nurses on ward areas. We have reviewed urgent patient transfers between our two acute sites and confirmed the small number of transfers undertaken (2-3 per day) are safe and clinically effective. We have also determined ongoing monitoring criteria Our recruitment programme continues and there has been some success, although there is still a way to go. A new process for auditing medical patients taken to ITU within 72hrs of admission has been put in place – allowing doctors to identify sub-optimal care and learn the lessons in real-time The new Quality Improvement Strategy vision and goals have been agreed by the Trust Board along with the supporting improvement methodology. We have trained over 400 staff to become Quality Ambassadors, with more to follow. This is helping us to strengthen our quality culture in the organisation. We have installed dashboards outside every ward so patients and visitors can easily see how well it is performing in key areas such as infection control, falls and the patient experience. The Health & Social Care Information Centre has published the Summary Hospital-Level Mortality Indicator (SHMI) statistics for the period April 2012 to March 2013, revealing that the mortality rate for Buckinghamshire Healthcare NHS Trust has reduced, placing the Trust in the ‘as expected’ range. Since 2010 it had recorded ‘higher than expected’ mortality rates. We have carried out a series of ‘big conversation’ events, a county-wide listening and engagement programme to help shape our continuing quality improvement programme. Seven public events took place between November and February 2014. Smaller focus groups also took place and people were able to participate online. Full details and the report are available at www.buckshealthcare.nhs.uk/abc.www.buckshealthcare.nhs.uk/abc The Dr Foster Good Hospital Guide 2013, published on Friday 6 December, shows that the mortality rate for hospitals in Buckinghamshire has continued to improve over the last year. The Hospital Standardised Mortality Rate for the year April 2012 – March 2013 is now in the ‘as expected range’ for the first time in recent years. We also performed better than the national average for urgent readmissions, having surgery within two days for a broken hip, and urgent access to MRI scans. At the follow-up meeting held on 4 December, Trust staff outlined the improvements made to patient care over the past six months. Representatives from the Trust Development Authority, NHS England, Care Quality Commission and local CCGs thanked staff for the tremendous amount of work that had been undertaken in response to the Keogh recommendations and expressed that real progress had been made and demonstrated, with all areas of concern addressed.

4. Our improvement plan This table shows the actions we’re taking to address the concerns about the quality of our services which were raised in the Keogh report. It also shows how we are progressing against our actions. Summary of Keogh Concerns Summary of Urgent Actions RequiredAgreed Timescale External Support/ AssuranceProgress B/G/R/ narrative Patient Safety We will work with patient and carer group/NHS 111 provider and Clinical Commissioning Groups to improve functionality of NHS 111 for this healthcare system. End Dec 13Support provided from South Central Ambulance Service who now run NHS 111 locally. Urgent Care Pathways for emergency patients We will review the way in which patients are transferred between hospital sites to make sure we deliver high quality of care and ensure clinical effectiveness, positive patient experience and patient safety at all times. Our doctors and nurses will continue to focus on identifying and appropriately managing patients at risk of deterioration admitted as emergencies. We will perform an audit of medical patients admitted to ITU within 72 hours of admission. This will allow an assessment of timely identification and management of acutely ill patients, including the response to deterioration. We will review the doctor cover for out of hours, including week-ends, for medical patients and put in place additional cover at these times as soon as possible if required. We will introduce metrics, presented in Board reports, to measure capacity for care on speciality wards and the monitoring of patient placement in speciality. End Sept 2013 End Oct 2013 End Dec 13 Clinical and operational effectiveness: organisation wide monitoring We will carry out a review of our patient safety culture using the Manchester Patient Safety Framework (MaPSF). When we have completed the review of the patient safety culture we will produce a new integrated quality and patient safety strategy. We will explain how this strategy is going to be implemented and monitored. We will bring together all improvement projects into this new quality and patient strategy and this will include consideration of things that are associated with the apparently high mortality. We will use a recognised improvement methodology such as Intermountain to support these projects. End Oct 13 End Nov 13 External support required to assist in pulling existing quality approaches into one combined strategy. NHS Improving Quality is a source of support. Review practice at peer hospital, Salford Royal NHS Foundation Trust. Support from Healthy Bucks Leaders network.

5. Our improvement plan continued… Summary of Keogh Concerns Summary of Urgent Actions RequiredAgreed Timescale External Support/ AssuranceProgress B/G/R/ narrative Patient Experience We will collect and review patient experience information from all wards in the hospitals. We will make sure that our Divisions have a clear structure and sufficiently skilled individual clinicians to lead on clinical governance. This includes responding to and learning from patient feedback from complaints and Patient Advice and Liaison Service (PALS), learning from incidents and claims and clinical audit. We will put in place consistently high standards for addressing patient complaints across all divisions with clear Board level accountability. We will put in place an effective process for capturing and reviewing the experience of patients presenting acutely to the Trust End Dec 13 The governance processes in Divisions have been strengthened and this action will be signed off when the re is clear evidence that the processes are working. Workforce: inadequate medical staffing levels and skills mix We will review the staffing levels and skill mix throughout the organisation (including senior support for Junior doctors), working towards high quality seven day cover arrangements for all services, to address concerns about weekend and out of hours care. This will include review of services in community hospitals in relation to their sustainability at the current level of use and include a review of capacity across acute and community teams to ascertain speciality requirements along the urgent care pathway. We will develop a recruitment and retention plan based on the staffing levels and skill mix review to address the difficulties in recruiting nursing staff and the significant variation in the make-up of staffing levels on individual wards between Trust staff and bank or agency staff. We will review our current training and development plan against a training needs analysis and implement changes e.g. Administering intravenous antibiotics or fluids. We will continue to carry out a variety of two-way communications in the organisation and these will be included in the safety culture review and development of quality and patient safety strategy. End Dec 13 External reviewer nominated by Trust Development Authority. Work with Salford Royal NHS FT as peer Trust Clinical Commissioning Group (CCG)support if more capacity is required and support around integrated care pathways with primary care. NHS Improving Quality 7 day working team support Governance We have procured a rapid Board Development review and programme, which will provide a baseline of Board capacity and capability, including the Board grasp of safety tools and this will focus on all six key elements of the Rapid Responsiveness Review Report. We will revise our Board reports, including metrics such as mortality, Friends and Family data, and allowing improved level of detail to Divisional level. The Board Development review will assess the Board's approach to risk management in order for the Board to proactively plan, monitor and manage risks to patient safety, and ensure key risks are identified at all levels of the organisation and appropriately fed through to the corporate risk register. We will review our governance structure and processes to ensure that it is fit for purpose End July 13 End Oct 13 Support from NHS Leadership Academy for the procurement process. Support from KPMG in undertaking the review.

6. How our progress is being monitored and supported This table shows how and when we are checking that the actions we’re taking are making a real difference across our clinical services. It also highlights how we will be communicating our progress to our local community. Oversight and improvement actionTimescaleAction owner TDA has approved the Board development package agreed with external provider. Leadership is driving turnaround in the trust. ImplementedTrust Monthly accountability meeting with TDA to track delivery of action plan.Jul 2013 to July 2014Trust Chief Executive/Special Measures Director Partnership working with Salford NHS FT as a high performing provider organisation. This will provide best practice guidance and peer support and challenge. Commenced Aug 2013 and ongoing Trust Chief Executive Access support from partnership working as appropriate with the Academic Health Science Network, NHS Improving Quality and the NHS Leadership Academy. April 2014NHS England Appointment of an Improvement Director (Marie Noelle Orzel) by TDA, who will provide expertise to the trust Board on how to improve our services and check that we’re meeting our promises to deliver our improvement plan. October 2013TDA Meetings of the Trust Board sub-committee on Every Patient Counts action plan which will review evidence about how the trust action plan is being delivered, and embedded to improve services. weekly Sept 2013 to January 2014 Trust Chief Executive Officer Trust Reporting to the public about how our trust is improving via briefings to local media, use of digital media and bi-monthly public board meetings. MonthlyTrust Chief Executive Officer Agreement and regular reporting of quality measures to demonstrate that the actions are leading to improved quality of care for patients. MonthlyTrust Chief Executive Officer /TDA Quality governance review refresh being carried out by external provider.End DecTrust Chief Executive Officer External Scrutiny of our new ways of working/of the quality of our services by a Quality Surveillance Group (QSG) composed of the trust CE, NHS England Area Team, CCGs etc… Sept 2013 to July 2014Trust Chief Executive Officer /Special Measures Director/Clinical Commissioning Groups Re-inspectionBy April 2014CQC Key for progress reports Blue -delivered Green – on track to deliver Narrative – disclose delays/risks/plan to recover Red – not on track to deliver