Download Quality Account - Aintree University Hospital NHS Foundation Trust

Quality Account
2015/16
Aintree University Hospital NHS Foundation Trust
1
2
Aintree University Hospital NHS Foundation Trust
Contents
Introduction
art 1. Statement on quality
P
from the Chief Executive of
the NHS Foundation Trust
art 2. Priorities for improvement
P
and statements of assurance
from the Board
On a typical day at the Trust
5
We employ:
4076 WTE
6
We make:
8
8
Quality improvement priorities for 2016/17
28
Statements of assurance from the Board
32
Information on the review of services
32
On average
653
occupied beds
(674 in 2014/15)
32
Participation in clinical research
38
Use of the CQUIN framework
38
Registration with the Care Quality Commission
43
Information on the quality of data
44
Performance against national quality indicators
45
P erformance against key national
priority indicators
57
Approximately
226 p/d
59
We dispense:
Annex A: Statements from Stakeholders
on Aintree’s Quality Account 2015/16
75
540
Annex E: Definitions of the performance
measure indicators
Ward Medicines
372
Outpatient Medicines
81
84
2400
patients’ meals
staff meals
patients in all
Outpatients Clinics
(2,125 in 2014/15)
An overview of the quality of care
offered by Aintree in 2015/16
Annex D: Independent Auditor’s Limited
Assurance Report to the Council of Governors
of Aintree NHS Foundation Trust on the
Annual Quality Report 136,677
sq. meters of floor
1,983 p/d
59
80
We clean:
500+
patients in A & E
(219 in 2014/15)
Annex B: Statement of Directors’ responsibilities
79
in respect of the Quality Report
MRSA swabs
We provide:
We see:
Information on participation in clinical audits
and national confidential enquiries Annex C: Statement from Trust Governors
5000
tubes of blood
261
Priorities for improvement
Quality improvement priorities for 2015/16
Part 3. Other Information
We test:
1025
Take home Medicines
We use:
26,586
gloves
67,982
hand towels and
toilet rolls
17,994
wipes
3,265
needles/syringes
500
In-patient Medicines
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Aintree University Hospital NHS Foundation Trust
Aintree University Hospital NHS Foundation Trust
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Glossary
aBI
Aintree Business Intelligence
MET
Medical Emergency Team
ACE
Aintree Champions Excellence
MEWS
Modified Early Warning System
ACS
Average Care Score
AED
Accident & Emergency Department
MRSAMethicillin-Resistant
Staphylococcus Aureus
AHSN
Academic Health Science Network
AKI
Acute Kidney Injury
AMBERAssessment, Management, best Practice,
Engagement, Recovery Uncertain
AMI
Acute Myocardial Infarction
AMU
Acute Medical Unit
ANTT
Aseptic Non Touch Technique
AQ
Advancing Quality
AQuA
Advancing Quality Alliance
ARLD
Alcohol Related Liver Disease
AUH
Aintree University Hospital NHS
CCG
Clinical Commissioning Group
C.DifficileClostridium Difficile
Maxillo Facial Unit
MSSA
Methicillin Sensitive Staph Aureus
MUST
Malnutrition Universal Screen Tool
NCEPODNational Confidential Enquiry into
Patient Outcome and Death
NEWS
National Early Warning Score
NICE
National Institute for Clinical Research
NIHR
National Institute for Health Research
NIHSS
National Institute of Stroke Health
NPS
National Patient Survey
NWC CRNNorth West Coast Clinical
Research Network
OH
Occupational Health
CDI
Clostridium Difficile Infection
ORMIS
Operating Room Management
Information System
CDT
Clostridium Difficile Toxin
OT
Occupational Therapy
CNS
Clinical Nurse Specialist
PAS
Patient Administration System
COPD
Chronic Obstructive Pulmonary Disease
CPD
Continuing Professional Development
PDSAPlan, Do, Study, Act
(improvement methodology)
CQUINCommissioning for Quality and
Innovation (payment framework)
PICC
Peripherally Inserted Central Catheter
PID
Performance Information Delivery
CRBSI
PROMS
Patient Reported Outcomes
PbR
Payment by Results
Catheter Related Bloodstream Infection
CSPCo-ordinated Systems for gaining
NHS Permission
CRN
Clinical Research Network
RAGRed Amber Green
(traffic light scoring system)
CXR
Chest X Ray
R&D
Research and Development
DQ
Data Quality
RCA
Root Cause Analysis
FFT
Friends and Family Test
RTT
Referral to Treatment Time
GDH
Glutamate Dehydrogenase
SALT
Speech and Language Therapy
GP
General Practitioner
HAT
Hospital Acquired Thrombosis
SHMI
Summary Hospital Level Mortality
Indicator
HLO
High Level Objective
HSJ
Health Service Journal
HSMR
Hospital Standardised Mortality Rate
SIGHT
Suspect, Isolate, Gloves,
hand washing, Test
ICD-10
International Classification of Diseases
SIGMA
Hospital Patient Administration System
ICE
Integrated Clinical Environment
SOP
Standard Operating Procedure
ICNARCIntensive Care National Audit
and Research Centre
SUI
Serious Untoward Incident
IPC
TARN
Trauma Audit and Research Network
Unify2
National Reporting Hub
Infection Prevention & Control
IVIntravenous
4
MFU
SBARSituation, Background, Assessment,
Recommendation
VTEVenous-Thromboembolism
IG
Information Governance
KPI
Key Performance Indicator
WCNNWalton Centre for Neurology
and Neurosurgery
MDT
Multi-Disciplinary Team
WHO
World Health Organisation
Introduction
Quality Accounts are annual reports to the public, from
providers of NHS services, about the quality of services
they provide. They also offer readers an opportunity to
understand what providers of NHS services are doing
to improve the care and treatment they provide
Q
uality in the NHS is described
in the following ways:
Patient safety
This means protecting people
who use services from harm and
injury and providing treatment in
a safe environment.
Clinical effectiveness
This means providing care and
treatment to people who use
services that improves their
quality of life.
Patient experience
This means ensuring that
people who use services have a
positive experience of their care
and providing treatment with
compassion, dignity and respect.
The aim in reviewing and
publishing performance about
quality is to enhance public
accountability by listening to
and involving the public, partner
agencies and, most importantly,
acting on feedback received by
the Trust.
Aintree produces quarterly
Quality Reports on the Trust’s
priorities to show improvements
to quality during the year. This
is so that Aintree can regularly
inform people who work for
the Trust, people who use the
Trust’s services, carers, the public,
commissioners of NHS services,
and local scrutineers of quality
initiatives and to encourage
regular feedback.
As a report to the public,
Aintree recognises how important
it is that the information it
provides about the quality of
care is accessible to all. This
Quality Account, and ‘easier
read’ accessible versions of the
Quality Account and the Trust’s
Quality Reports, are published
on Aintree’s public website.
Technical Phrases/Titles used in this document
Common Cause Variation
Natural Patterns
(what would have happened if we didn’t do anything)
Cumulative
Collective total
Mean
Average
Threshold
Target
Trajectory
This is the direction in which performance is proceeding.
Aintree University Hospital NHS Foundation Trust
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Part 1
Statement on quality from the Chief Executive
T
he cornerstone of Aintree University Hospital
NHS Foundation Trust’s philosophy is quality –
to deliver our vision of providing world class services
for all our patients by getting it right for every
patient, every time.
We have successfully delivered Year 2 of our
3 year Quality Strategy with improvement
programmes aligned to our Quality Priorities
to make care safer, more effective and improving
the patient experience.
We have achieved the majority of our key
performance indicators including the Referral to
Treatment Time and Cancer access standards with
the exception of Cancer Screening but did not
achieve the national access standard of 95% for
patients being treated within four hours in the
Accident and Emergency Department. Although this
was unacceptable in terms of patient experience,
we were assured that patient care was not adversely
affected. However, we have ensured that the
significant changes put in place to improve patient
flow have now been brought together holistically
under an Emergency & Acute Care Plan and we
are cautiously optimistic that we will achieve this
standard on an on-going basis from Qtr 2 of 2016/17.
The focus on patient safety remains a priority for all
our staff and this culture is embedded throughout
the Trust as was again evidenced by the results
of the national Inpatient Survey 2015 which
showed that, of the 81 acute trusts taking part,
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Aintree University Hospital NHS Foundation Trust
Aintree was in the top 20%, thereby exceeding our
aspirational goal of being in the top 25% by 2017.
The improvements in patient experience have been
recognised nationally and the PICKER Institute,
who carries out the inpatient survey on behalf of
NHS acute trusts, has visited Aintree to undertake
a research study relating to how our improvements
have been achieved.
We continue to encourage our staff to report
incidents so that we are able to improve the care
given to our patients as a result of learning from
incident reports and investigations. During the
year, we focussed our work in infection prevention
and control on reducing the number of patients
contracting CDifficile and MRSA and exceeded the
national standard for the former but unfortunately
had two hospital-acquired MRSA cases. We
continued to make significant progress in reducing
the numbers of hospital-acquired pressure ulcers
and consistently provided in excess of 95% harm
free care as measured by “Safety Thermometer”.
Once again we had a very positive peer review
of our major trauma service which has delivered
excellent outcomes for patients across Cheshire and
Merseyside. Commissioners have now decided that
the final phase of this service can be delivered so
that Aintree and the Walton Centre becomes the
single receiving site in July 2016.
The results of the National Staff Survey reflected
some improvement in staff experience
e.g. an increase in staff motivation at work but we
are concerned that there was a significant reduction
in the percentage of staff recommending Aintree
as a place to work and in the percentage of staff
agreeing that their role makes a difference to
patients and carers. Work is underway to explore the
underlying factors and to ensure any issues identified
are addressed through engagement work. In March
2016, the Board reaffirmed its commitment to the
Trust’s values which ensure that behaviours underpin
the strong patient-centred culture at Aintree.
We welcomed the significant improvement in the
Summary Hospital-Level Mortality Indicator (SHMI)
which demonstrated that Aintree was reporting
the 7th lowest SHMI in the North West and was no
longer an outlier. The Trust’s Hospital Standardised
Mortality Ratio (HSMR) continued to be one of the
lowest in the country and the crude death rate has
reduced steadily during the year although there was
a seasonal peak reported in December & January
which had happened in previous years. The Trust’s
clinically led mortality work streams have continued
to focus on reducing mortality by developing care
pathways and driving improvements to make care
safer for our patients.
governors. The improvements they all continue to
make so that our patients receive the care they
deserve are inspiring.
The Board is fully committed to the delivery of
the improvements described in the Trust’s Quality
Strategy and this Quality Account describes those
achievements and our plans for next year.
Steve Warburton
Chief Executive
I would like to pay tribute to the hard work and
dedication of staff at Aintree and the invaluable
assistance provided by our many supporters,
including volunteers, support groups, members and
Aintree University Hospital NHS Foundation Trust
7
Part 2
Priorities for improvement and statements of assurance
from the Board
Quality improvement priorities for 2015/16
T
he Trust’s overarching three priorities for
2015/16 remain continual but include
aspirational standards in line with the three-year
Quality Strategy. Aintree has successfully delivered
Year Two of our three year Quality Strategy (20142017) with improvement programmes aligned to
our Quality Priorities to make care safer, more
effective and improving the patient experience.
Below is a summary of progress on the priorities
agreed last year, which were monitored throughout
the year in the trust’s quarterly Quality Reports,
which are presented at the Trust’s Quality and Safety
Committee and are available on Aintree’s website.
Priority 1: Patient safety improvement actions in 2015/16
Aintree said it would:
Provide care that is safe by reducing harm by reducing hospital acquired methicillin sensitive Staph
aureus (MSSA) bloodstream infections.
Aintree achieved:
What:
Reducing MSSA bacteraemias
How much:
By 50% (to report no more than 10 cases 2015/16)
When:
March 2016
Outcome:
Cumulatively, there have been 25 patients with MSSA bacteraemia.
30
25
20
15
10
5
0
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Monthly
Apr-15
3.00
May-15
3.00
Jun-15
3.00
Jul-15
4.00
Aug-15
2.00
Sep-15
1.00
Oct-15
0.00
Nov-15
3.00
Dec-15
1.00
Jan-16
1.00
Feb-16
3.00
Mar-16
1.00
Threshold
10.00
10.00
10.00
10.00
10.00
10.00
10.00
10.00
10.00
10.00
10.00
10.00
Cumulatative
3.00
6.00
9.00
13.00
15.00
16.00
16.00
19.00
20.00
21.00
24.00
25.00
Trajectory
0.83
1.67
2.50
3.33
4.17
5.00
5.83
6.67
7.50
8.33
9.17
10.00
Chart 11: The number of MSSA Bacteraemias April 2015 – March 2016
(Data source: Health Protection Agency which is governed by a standard national definition)
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Aintree University Hospital NHS Foundation Trust
Aintree progressed this priority by:
• Presenting all MSSA bacteraemias to the IPC
Operational Group which enables themes to
be monitored.
oThe completed review of the peripheral line
management documentation and care plan.
• T
he main theme associated with MSSA
bacteraemias has been identified as poor
peripheral line management
oA bespoke IV pack has been agreed and an
improved site dressing agreed. These are due
to be rolled out from April 2016.
• A
n improving peripheral line management
and aseptic non touch technique (ANTT)
multidisciplinary review and action plan is in
place and is monitored at the IPC Operational
Group. The plan includes:
oThe ANTT training plan for medical staff has
been agreed.
oA review of the ANTT training package which
has been completed
oCompletion of a Trust video and revised
training material
• In collaboration with clinical teams, the IV Team
have been piloting the Vessel Health Preservation
Toolkit and have fed back to the national IV
conference. Following the pilot phase and review,
the Trust intends to implement this tool.
oThe establishment of a ‘super trainer’ group
to train and re assess all cascade trainers.
oWard managers to be additional
cascade trainers
Aintree said it would:
Provide care that is safe by reducing harm through reducing the number of patients with Ventilator
Acquired Pneumonia
Aintree achieved:
What:
To reduce the number of avoidable harms from Ventilator Acquired Pneumonia (VAP)
from 33 to 23
How much:
By 30% (to achieve less than 23 patients acquiring VAP)
When:
March 2016
Outcome:
Cumulatively, there have been 26 patients with VAP during 2015/16. The Trust did
not manage to meet its aspirational target of a 30% reduction but have reduced
the number of cases by 7 compared to 2015/14 which is a 21% reduction therefore
demonstrating continuous improvement.
Recently The Critical Care Network suggested a definition and method of data
collection for VAP for the region. The trial of this method of data collection started
on 23rd March 2016 and is quite complex therefore the new methodology might
lead to some fluctuations in data in the future.
Aintree said it would:
Provide care that is safe by reducing harm by reducing hospital acquired Clostridium Difficile Infection
Aintree achieved:
What:
Reducing the number of Clostridium Difficile Infection (CDI) cases
How much:
Less or equal to 23 cases in 2015/16
When:
March 2016
Outcome:
From April 2015 to March 2016 there have been 54 patients with CDI infection.
19 cases have been successfully appealed as there were no lapses in care, therefore
for performance there has been 35 cases, a 17% reduction on 2014/15.
Aintree University Hospital NHS Foundation Trust
9
40
35
30
25
20
15
10
5
0
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Monthly
Apr-15
4.00
May-15
3.00
Jun-15
0.00
Jul-15
0.00
Aug-15
2.00
Sep-15
5.00
Oct-15
2.00
Nov-15
2.00
Dec-15
2.00
Jan-16
7.00
Feb-16
3.00
Mar-16
5.00
Threshold
23.00
23.00
23.00
23.00
23.00
23.00
23.00
23.00
23.00
23.00
23.00
23.00
Cumulatative
4.00
7.00
7.00
7.00
9.00
14.00
16.00
18.00
20.00
27.00
30.00
35.00
Trajectory
1.92
3.83
5.75
7.67
9.58
11.50
13.42
15.33
17.25
19.17
21.08
23.00
Chart 12: Clostridium Difficile infection April 2015 – March 2016 (excluding appeals)
(Data source: Health Protection Agency which is governed by a standard national definition)
Aintree progressed this priority by:
• Implementation of the Annual Healthcare
Acquired Infection reduction delivery plan which
is monitored by the IPC Operational Group.
This includes actions to reduce CDI and other
healthcare associated infections.
• R
eviewing the antibiotic ward round programme
to ensure they go ahead on a more consistent
basis. A revised antibiotic stewardship portal is in
development providing more robust data to the
IPC Group on a monthly basis.
• T
he work of the CDI Collaborative is planned to
go through the IPC link worker group. (The IPC
link worker group is an established group of link
workers on wards/depts. who have an interest in
IPC and act as a champion in their area.) This will
involve simulation and visualisation to strengthen
messages regarding IPC.
• M
ulti-disciplinary ‘IPC Sweep’ continues to be
undertaken following every case of CDI. (The
‘sweep’ is a quick review of the ward area with
the ward manager, facilities and domestic services.
It aims to address any key issues to prevent
transmission)
• A
visit to Wrightington, Wigan and Leigh Trust
has recently been undertaken as they had
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Aintree University Hospital NHS Foundation Trust
reduced rates of CDI. In terms of the prevention
and management strategies, these were on par,
with the exception of three areas which need
further consideration:
oWrightington Wigan and Leigh has a dedicated
CDI cohort ward (Cohort ward is a ward
where you would cohort patients together
in one ward). The ward consists of all side
rooms. The patients are under the care of the
gastroenterologists and have input from other
relevant clinical teams.
oImplementation of a more robust weekly
review of patients with CDI infection. In
Aintree, this is currently undertaken by
the Infection Control Doctor and Infection
Prevention Nurse. In Wrightington, Wigan and
Leigh Trust, there is also a dietician review and
an anti-microbial pharmacist (a pharmacist who
advises on and monitors the use of antibiotics).
oThe Trust has a programmed deep clean and
minor works programme. This is undertaken
by bay on wards. Minor works are undertaken
and the bays are repainted annually. They are
subsequently deep cleaned. The Trust stated
this is turned around in 24 hours maximum.
Aintree said it would:
Provide care that is safe by reducing harm through improved Nutrition & Hydration
Aintree achieved:
What:
Improved nutrition and hydration through reliable completion of the Malnutrition
Universal Scoring Tool (MUST) and Fluid Balance Chart
How much:
Achieve greater than 95% compliance in MUST completion within 24 hours
of admission and greater than 95% compliance in the completion of Fluid
Balance Charts.
When:
March 2016
Outcome:
Completion of the Malnutrition Universal Screening Tool (MUST) was not achieved
during Qtr 4 (2015/16) with compliance at 87%. The cause for the decline in
compliance is under investigation.
The Planning & Commissioning Team has been working in partnership with the
Nutrition and Hydration Collaborative Leads to investigate barriers to reliable
completion of the electronic MUST tool, culminating in a Workshop during the
Nutrition and Hydration Collaborative Learning Session 2. Actions have now been
agreed and are progressing, with the Nutrition & Hydration Collaborative work being
taken forward into the Year 3 (2016/17) Quality Strategy Delivery Plan.
The Qtr 4 deliverable for achievement of 95% compliance with the completion of
Fluid Balance Charts is on hold pending feedback from the MEWS to NEWS Task and
Finish Group. Improvements in fluid balance recording also links closely with the
Intentional Rounding workstream and will be progressed as part of the 2016/17 Year
3 Quality Strategy Delivery Plan.
The Nutrition and Corporate Nursing Teams are supporting ward staff by providing
outreach support to clinical areas, as they deliver tests of change during the action
period prior to the next Nutrition and Hydration Collaborative Learning Session.
Aintree said it would:
Provide care that is safe by reducing harm through reducing in-patients falls with harm
Aintree achieved:
What:
Reducing the number of Inpatient Falls with harm
How much:
By a minimum of 15% from 687 to 584
Examples of harm from falls:
Low harm – a graze or a bruise
Moderate harm – a fracture of wrist or limb
Serious harm – a head injury resulting in permanent damage
Death – as a direct result of the fall
When:
By March 2016
Outcome:
A 15% reduction in the number of inpatient falls with harm is an aspirational target.
There were 77 Inpatient falls with harm in Qtr 4, giving a total of 554 in 2015/16
against a key quality goal of equal to or less than 584 by the end Qtr 4. Therefore the
15% aspirational goal has been achieved with a 19.4% reduction in inpatient falls
with harm in 2015/16. The current improvement follows on from the 8.6% reduction
in falls with harm achieved during 2014/15.
During 2015/16, the Trust has also achieved a 6.8% reduction in the number of
all in-patient falls compared to last year. We remain on a continual improvement
journey in the reduction of harm from falls.
Aintree University Hospital NHS Foundation Trust
11
700
600
500
400
300
200
100
0
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Monthly
Apr-15
47.00
May-15
74.00
Jun-15
58.00
Jul-15
48.00
Aug-15
55.00
Sep-15
49.00
Oct-15
53.00
Nov-15
44.00
Dec-15
47.00
Jan-16
31.00
Feb-16
23.00
Mar-16
25.00
Threshold
584.00
584.00
584.00
584.00
584.00
584.00
584.00
584.00
584.00
584.00
584.00
584.00
Cumulatative
47.00
121.00
179.00
227.00
282.00
331.00
384.00
428.00
475.00
506.00
529.00
554.00
Trajectory
48.67
97.33
146.00
194.67
243.33
292.00
340.67
389.33
438.00
486.67
535.33
584.00
Chart 13: Falls with harm – Low, Moderate & Severe Harm Apr 15- March 16
(Data source: Datix, the Trust’s Incident Reporting System which is not governed by a standard national definition)
Aintree progressed this priority by:
• Continuing to embed the Falls Collaborative
Change Package best practice. A revisit of the
Collaborative is planned for Qtr 2 in (2016/17)
• Improving medical compliance with completion
of the Multifactorial Falls Risk Assessment
document. The Clinical Lead for falls raised
awareness of this by presenting at Grand Round
during Qtr 3 2015/16
• C
ontinuing to work with the Estates Department
to ensure that bathrooms on inpatient wards
are updated to reduce the risk of harm from
falling in a bathroom. A new bathroom layout
has recently been completed in the Maternity
block refurbishment on Ward 3 and the template
will be used for all wards in the renovation
programme moving forward
• A
Thematic Review was undertaken with a report
presented at Falls Steering Group during Qtr 4
(2015/16). Key issues will be reported to Safety &
Risk Executive Led Group
12
Aintree University Hospital NHS Foundation Trust
• F oresight Falls Prevention work stream will be
resumed in Qtr 2 (2016/17), linking into Patient
Safety Officers Safety Huddle work
• A
‘SWARM’ (a group of health professionals
meeting in relation to a specific issue) work
stream will be developed as part of the Falls
Prevention Improvement Plan (2016/17).
SWARM is a multi-disciplinary ‘post fall’ Safety
Huddle aimed at preventing additional falls and
supporting post fall care
• A
monthly Falls Verification Meeting with
Divisional Governance Leads has been established.
Work continues to improve the data feed and
data cleansing for falls reported within Datix and
aBI (Aintree Business Intelligence).
• A
number of best practice sheets for monitoring
at risk patients have been developed, and the
‘Call Don’t Fall’ initiative has been relaunched
and shared with the Divisions. A Falls Prevention
Passport is in draft, awaiting review at Falls
Steering Group.
Aintree said it would:
Provide care that is safe by reducing harm through reducing the number of missed doses of Critical
Medicines
Aintree achieved:
What:
To reduce the number of missed doses of critical medicines
How much:
In Qtr 4, review the baseline measurement of missed doses of critical medicines and
agree target improvement for 2016/17
When:
March 2016
Outcome:
Overall, approx. 400,000 doses are scheduled to be administered for inpatients at
AUH each month. Around 10% are charted as omitted however this includes all nonadministration reason codes, both clinically appropriate and inappropriate. Between
0.3 - 2% of all doses are charted as omitted for an inappropriate reason (i.e. medicine
not available, prescription unclear and other).
With regard to critical medicines, an initial investigation over a 2 week period
identified 16,708 doses scheduled for administration. 3.8% (637 doses) were
charted as omitted. However, a full review of the reasons for omission could not
be undertaken. In order for this to be routinely achievable, an IT solution is being
investigated. Until this is resolved, validation of the data is not possible within current
staffing resources.
An integral part of the Medicines Safety Pharmacist business case is delivery of
this element of the quality strategy. Quality milestones have been built into the
case, which include validation of baseline data and targets for reductions in the
inappropriate omission of critical medicines. Without approval of, and recruitment
to, this post, the delivery of this element of the quality strategy will be hampered.
Aintree said it would:
Provide care that is safe by reducing harm through reducing hospital acquired pressure ulcers
Aintree achieved:
What:
Reducing all hospital acquired pressure ulcers
How much:
To reduce grade 2 pressure ulcers by 10%, and to eliminate grade 3 and 4 pressure
ulcers which means to report less than or equal to 62 grade 2 pressure ulcers and zero
grade 3 and 4 pressure ulcers.
The higher the grade of pressure ulcer, the more severe the injury to the skin and
underlying tissue.
Grade one – a red blanching area (not reported)
Grade two – some of the outer surface of the skin (the epidermis) or the deeper layer
of skin (the dermis) is damaged, leading to skin loss. The ulcer looks like an open
wound or a blister.
Grade three – skin loss occurs throughout the entire thickness of the skin. The
underlying tissue is also damaged, although the underlying muscle and bone are not.
The ulcer appears as a deep, cavity-like wound.
Grade four – is the most severe type of pressure ulcer. The skin is severely damaged
and the surrounding tissue begins to die (tissue necrosis). The underlying muscles or
bone may also be damaged. People with grade four pressure ulcers have a high risk of
developing a life-threatening infection.
When:
March 2016
Outcome:
From April 2015 to March 2016 there have been a total of 63 grade 2 pressure ulcers.
This means that the Trust has not met this Key Quality Goal for a 10% reduction.
Between April 15 and March 16 an 8.7% reduction in Grade 2 pressure ulcers has been
achieved. There has been one Grade 3/4 pressure ulcer occurring in Qtr 4, making a
total of 5 Grade 3/4 pressure ulcers in 2015/16. Root Cause Analysis investigation is
underway for the Qtr 4 incident.
Aintree University Hospital NHS Foundation Trust
13
70
60
50
40
30
20
10
0
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Monthly
Apr-15
5.00
May-15
7.00
Jun-15
4.00
Jul-15
3.00
Aug-15
6.00
Sep-15
5.00
Oct-15
5.00
Nov-15
4.00
Dec-15
4.00
Jan-16
6.00
Feb-16
7.00
Mar-16
7.00
Threshold
62.00
62.00
62.00
62.00
62.00
62.00
62.00
62.00
62.00
62.00
62.00
62.00
Cumulatative
5.00
12.00
16.00
19.00
25.00
30.00
35.00
39.00
43.00
49.00
56.00
63.00
Trajectory
5.17
10.33
15.50
20.67
25.83
31.00
36.17
41.33
46.50
51.67
56.83
62.00
Chart 14: Hospital Acquired Grade 2 Pressures Ulcers April 2015 to March 2016
(Data source: Datix, the Trust’s Incident Reporting System which is not governed by a standard national definition)
Aintree achieved this priority by:
• New Oxygen Nasal Cannula being introduced to
decrease the risks of patients developing pressure
ulcers behind their ears
• F ollowing the introduction of new patient
armchairs with an integrated pressure relieving
cushion, a multi-professional group to review
specialist seating has been established.
Recommendations and next steps will be
monitored through the Pressure Ulcer
Prevention Group
• A
Skin Safety Flowchart has been developed
to identify best practice for vulnerable patients
which includes accessing advice in the absence
of the Clinical Nurse Specialist (CNS) for Tissue
Viability
• T
he Nasogastric Tube Daily Checklist has
been amended to include guidance on the
management and prevention of pressure ulcers
for patients with nasogastric tubes. A new system
for securing nasogastric tubes has been tested and
14
Aintree University Hospital NHS Foundation Trust
introduced on the Critical Care Unit, and there
are plans to disseminate Trust wide.
• N
urse Leads continue to work collaboratively
with Sefton Clinical Commissioning Group,
with a view to improving the patients journey
and standardising practice across primary and
secondary care
• L istening into Action events (LiA) are planned for
early Qtr1 (2016/17), with a revisit of the Pressure
Ulcer Collaborative aimed for Qtr 2 (2016/17)
• A
n Intentional Rounding (Comfort Checks) Work
stream has been established.
Following a Grade 3 pressure ulcer in the Critical
Care Dept. a training programme for management
of the patient with spinal injuries has been
developed for critical care, working collaboratively
with Walton Centre for Neurology and Neurosurgery
and Southport Spinal Unit.
Aintree said it would:
Provide care that is safe by reducing harm through reducing the number of surgical site infections
Aintree achieved:
What:
To reduce the number of surgical site infections
How much:
To review baseline measurement of surgical site infections and agree target
improvement for 2016/17
When:
March 2016
Outcome:
Baseline measurement for 2015/16 of orthopaedic surgery continues. A review
undertaken in Qtr 3 was presented to the IPC Group on 16.02.16. It was agreed that
Public Health England data was not comparative and therefore it was difficult to
relate with other Trusts. However, it was agreed to identify and develop an Action
Plan to address any improvements in relation to reducing Surgical Site Infections in
Orthopaedic Surgery by undertaking an external review in 2016/17.
Aintree said it would:
Provide care that is safe by reducing harm through reducing Catheter Associated Urinary Tract
Infections (CAUTI)
Aintree achieved:
What:
To reduce the number of Catheter Associated UTIs (CAUTI)
How much:
To measure baseline performance of CAUTI to enable improvement target
to be set for 2016/17
When:
March 2016
Outcome:
Given the small numbers of 0.57 in March and a mean of 0.24 for 2015/16
of patients identified with a CAUTI this Key Quality Goal has been met therefore
improvement work streams will not be planned for 2016/17.
Chart 15: Catheters & UTIs (point prevalence)
(Data source: NHS Information Centre which is governed by a standard national definition)
Aintree University Hospital NHS Foundation Trust
15
Aintree achieved this priority by:
• Collecting monthly data via Safety Thermometer
which has been validated by the IPC Team and
found to be correct.
• S afety Thermometer data will continue
to be collected monthly and monitored for signs
of increase in CAUTIs.
Aintree said it would:
Provide care that is safe by reducing harm through reducing the number of Hospital Acquired
Thrombosis (HAT)
Aintree achieved:
What:
To reduce the number of avoidable harms from Hospital Acquired Thrombosis (HAT)
(hospital-acquired blood clots)
How much:
50% reduction in avoidable harm due to HAT with associated process errors or
omissions (i.e. non completion of VTE risk assessment or preventative treatment not
prescribed or given).
There were 19 avoidable harms due to HAT in 2014/15 therefore the target for
2015/16 is to report no more than 9 patients acquiring harm due to HAT.
When:
March 2016
Outcome:
From April 2015 to March 2016 there have been a total of 14 patients acquiring harm
due to HAT possibly as a result of omissions by hospital teams. This means that the
Trust has not met this Key Quality Goal for a 50% reduction although there have been
5 fewer cases than the previous year which is a 26.3% reduction. This continues to be
a priority improvement area in the Year 3 Delivery Plan.
16
14
12
10
8
6
4
2
0
Jun 15
Sep 15
Dec 15
Jun 15
0
Sep 15
7
Threshold
9
9
9
9
Cumulatative
0
7
10
14
2.25
4.5
6.75
9
Monthly
Trajectory
Dec 15
3
Chart 16: Trust Attributable HAT Harms for Qtrs 1 – 4 2015/16
(Data source: Datix, the Trust’s Incident Reporting System which is not governed by a standard national definition)
16
Mar 16
Aintree University Hospital NHS Foundation Trust
Mar 16
4
Aintree said it would:
Provide care that is safe by reducing
avoidable mortality
been identified via diagnosis (ICD-10) coding, based
on the presence of the relevant codes in any position
of any episode of the spell.
The measures have been developed by the Aintree
Business Intelligence team, in collaboration with the
clinical leads and project teams. All pathways have
Aintree delivered improvements on
this priority through the following five
work streams:
Workstream 1 achieved:
What:
To improve the diagnosis and management of Community Acquired Pneumonia (CAP)
How much:
Improve accuracy, understanding and interpretation of pneumonia data via improved
measures and data capture by Qtr 4.
When:
March 2016 and on-going
Outcome:
• A
programme of work commenced with the Coding department to improve the
accuracy of coded data for deaths in the trust where Consultants can directly
communicate with coders.
• A
“missed measures” report is now being produced monthly identifying which
patients in the Advancing Quality population had missed measures (namely related
to antibiotics and Chest X Ray (CXR) within 4 hours and of these, which of these
patients died.
Chart 17: In-hospital death rate from Pneumonia, 2011 – 2016
(Data source: SIGMA, the Trust’s PAS which is not governed by a standard national definition)
Pneumonia (based on the AQ population
definition) – each point reflects 12 months’ data to
take into account seasonal variation. Care is required
in interpretation; in the first 2 years since the start of
the work stream, the death rate due to pneumonia
has reduced. The death rate in the past 12 months
has stabilised at 18%.
Aintree University Hospital NHS Foundation Trust
17
Workstream 2 achieved:
What:
To improve early recognition and management of Sepsis (blood poisoning)
How much:
Review the impact of the outreach support team pilot on improving early recognition
and management of Sepsis by Qtr 4.
When:
March 2016 and on-going
Outcome:
1.Based on laboratory result triggers, the pilot Outreach Support Team reviews
patients with possible Sepsis and Acute Kidney Injury (AKI). The team assesses
whether each patient might have pneumonia, sepsis or AKI and ensures that the
appropriate care bundle is in place. On average 36% of patients reviewed by the
Outreach Support Team had sepsis. During the period April 2015 to February 2016
the Outreach Support Team initiated 502 care bundles out of a total of 1265 (40%)
care bundles initiated. The team also confirmed the initiation of the appropriate
care bundle by the parent team for the remainder of patients.
2.The chart below demonstrates common cause variation, but only 1 month away
from showing a reduction in the in-hospital death rate.
Chart 18: Crude Mortality Rate for patients with Sepsis Diagnosis (AQ definition) 2011 – 2016
(Data source: SIGMA, the Trust’s PAS which is not governed by a standard national definition)
The number of patients identified with sepsis has
increased significantly since August 2014. There has
been an apparent spike in patients identified with
sepsis in February 2016, which may be seasonal in
nature. The absolute number of in-hospital deaths
with a diagnosis of sepsis has followed an increasing
trend since January 2011, with a spike in February
2016. This should be interpreted in the context of
the increase in the number of patients with sepsis
identified. The crude (unadjusted for illness severity)
18
Aintree University Hospital NHS Foundation Trust
in-hospital mortality rate for patients identified
with sepsis has followed a relatively flat trend
until April 2015, with suggestion of a reduction in
mortality rate due to special cause variation since
April 2015. There has been an increase in crude
mortality rate since November 2015, which may be
seasonal in nature and is comparable with previous
winter peaks.
Workstream 3 achieved:
What:
Improve the recognition and management of Acute Kidney Injury (AKI)
(abrupt loss of kidney function)
How much:
By the end of Qtr 4:
1.Introduce a patient leaflet (used in 50% of cases)
2.Achieve 50% compliance target on Advancing Quality AKI measures
When:
March 2016 and on-going
Outcome:
Based on AKI 3 alerts, Outreach Support Team reviews patients with acute kidney
injury. The team ensures that the appropriate AKI care bundle (which captures
most of AQ AKI measures) is in place and also gives out patient care leaflets.
Early intervention has helped ongoing mortality reduction in patients with AKI.
Chart 19: In-hospital death rate from AKI, 2011 - 2016
(Data source: SIGMA, the Trust’s PAS which is not governed by a standard national definition)
AKI (based on the AKI Alert) – each point reflects
one month’s data, demonstrates a 30.8% reduction
in mortality from 26% to 18% (March 2014).
Aintree University Hospital NHS Foundation Trust
19
Workstream 4 achieved:
What:
To improve the management in key areas of care for the deteriorating patient:
Modified Early Warning Score (MEWS), hypotension, identification of increasing
oxygen requirements, communication and training
How much:
1.MEWS audit at 95% compliance.
2.Annual audit & report for 2015/16
3.100% use of SBAR tool in handover of deteriorating patient
4.Pilot key areas by 31 August 2015, rollout by 31 March 2016
When:
March 2016
Outcome:
1.Overall Trust Wide MEWS audit compliance for Qtr 4 = 95.5%
2.MEWS is reported on within the annual MET operational group report which is due
for completion at the end of April beginning of May 2016. In addition, an in-depth
analysis for all wards in relation to compliance in all 6 parameters audited is tabled
and distributed to Matrons and Nursing leads quarterly.
3.Due to poor uptake on the pilot wards the decision has been made to rerun the
Situation, Background, Assessment, Recommendation (SBAR) pilot on 25/04/16
4.Pilot key areas by 31/07/16, Trust roll out by end of Qtr 3 2016/17
Workstream 5 achieved:
What:
To improve the management of end of life care
How much:
In Qtr 4, audit the Amber Care Bundle (implemented in March 2015) to include:
1.Ongoing data collection and education in pilot areas.
2.12 month feedback to pilots (March 2016)
When:
March 2016
Outcome:
1.Ongoing data collection, audit and education to pilot areas.
2.Feedback provided to participants of the Avoidable Mortality Reduction Group
which included representatives from the pilot areas in addition to ongoing
implementation within the Trust.
20
Aintree University Hospital NHS Foundation Trust
Priority 2: Clinical effectiveness improvement actions for 2015/16
Aintree said it would:
Provide care that is clinically effective by delivering reliable care, aiming to achieve 95% for the
appropriate care scores in the 5 existing Advancing Quality care bundle standards 7 days a week
Aintree achieved the following appropriate care scores:
Clinical Focus
Group
Measure
(Denominator)
Year 1
Year 7
NW Ranking
Oct08 – Sep09
YTD
Apr15 – Jan16
YTD
Apr 2015 –
Jan 2016
AMI
ACS
(No of patients)
86.4%
97.7%
235
3rd out of
16 Trusts
Heart Failure
ACS
(No of patients)
71%
64.35%
331
10th out of
15 Trusts
Hip & Knee
Replacement
ACS
(No of patients)
82.3%
97.9%
418
3rd out of
20 Trusts
Pneumonia
ACS
(No of patients)
34.43%
72.16%
374
7th out of
14 Trusts
Improvement
position
Table 21: Advancing Quality Appropriate Care Scores showing baseline scores in 2008/09 and year to date position in 2015/16
New Measures introduced in 2014/15 and 2015/16
Clinical Focus
Group
Measure
(Denominator)
Year 1
Year 2
NW Ranking
Apr14 – Jan 15
YTD
Apr14 – Jan 15
YTD
Apr 2015 –
Jan 2016
COPD
ACS
(No of patients)
36.3%
Started Oct
2015
29.0%
279
6th out of
16 Trusts
AKI
ACS
(No of patients)
N/A
Started May
2015
47.0%
198
1st out of
16 Trusts
ARLD
ACS
(No of patients)
N/A
Started Jan
2015
49.5%
279
1st out of
14 Trusts
Diabetes
ACS
(No of patients)
N/A
Started Nov
2015
49.1%
320
1st out of
12 Trusts
Hip Fracture
ACS
(No of patients)
N/A
Started Oct
2015
14.1%
327
4th out of
13 Trusts
Sepsis
ACS
(No of patients)
N/A
Started Sept
2015
80.2%
484
1st out of
14 Trusts
Improvement
position
Table 22: Advancing Quality Appropriate Care Scores showing baseline scores in 2014/15 and year to date position in 2015/16
Note: First 3 months after start date are excluded by AQuA as this is considered an implementation and test period
Key: The up arrow
deterioration.
indicates performance improvement and the down arrow
indicates performance
(Data source: Clarity Assure which is not governed by a standard national definition)
Aintree University Hospital NHS Foundation Trust
21
Aintree said it would:
Provide care that is clinically effective by delivering reliable care, working towards a 95% standard
for Intentional Rounding (regular, planned ‘nursing rounds’, to check on patients and ensure that their
essential care needs are met).
Aintree achieved:
What:
Improving compliance in key process measures for Intentional Rounding
(also known as comfort rounds)
How much:
Greater than or equal to 95% when auditing in Qtr 4
When:
March 2016
Outcome:
Greater than 95% compliance with Intentional Rounding/Comfort Checks
has not been achieved for Qtr 4 (2015/16) with an overarching Trust compliance
of 94.4% in the delivery of reliable care. This however is a small improvement
on the Qtr 2 result (94%).
Key actions are in place to support additional improvements in relation to the reliable
completion of Intentional Rounding:
• A
Task and Finish Group for Intentional Rounding (Comfort Checks) has been
established. A revised Intentional Rounding tool is being tested on a small scale
using Plan Do Study Act (PDSA) quality improvement methodology. The new tool
will contain prompts and confirmation that appropriate manual handling and
pressure relieving aids are in use
• A
n Intentional Rounding Standard Operating Procedure, incorporating guidance
for completion is under development.
• A
Patient Information Leaflet and an ‘Aintree Cares’ laminated sign (which prompts
staff to complete reliable Intentional Rounding) are in final draft and awaiting
approval before Trust wide dissemination.
The Intentional Rounding Workstream has been carried forward into Year 3 of the Quality Strategy
Delivery Plan.
(Data source: Case note audit which is not governed by a standard national definition)
Aintree said it would:
Provide care that is clinically effective by delivering reliable care, through improvements to
Structured Ward Rounds
Aintree achieved:
22
What:
To improve the delivery of structured ward rounds
How much:
Report on the pilot in two clinical areas by end of March and develop a plan
for roll out.
When:
March 2016
Outcome:
Templates for the documentation to be used to support structured ward rounds has
been agreed for the two pilot areas (Acute Surgery and Cardiology). There has been
further slippage of the initiation of the pilots, largely due to operations pressures.
The pilots are now due to start in April with the intention to run for a maximum of
three months before rolling out across the Trust.
Aintree University Hospital NHS Foundation Trust
Aintree said it would:
Provide care that is clinically effective by delivering reliable care, reducing the number of Central
Line Infections
Aintree achieved:
What:
To reduce the number of central line blood stream infections (CRBSI) from 26 to 18
How much:
By 30% which is less or equal to 18 cases in 2015/16
When:
March 2016
Outcome:
Cumulatively, there has been 1 patient with CRBSI compared to 25 at the same time
last year. Data is being collected for March 2016.
30
Number of Cases
25
20
15
10
5
0
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Jan
Feb
CRBSI 2015-2016 (INFECTION CASES)
0
0
0
0
0
0
1
1
1
1
2
2
CRBSI 2014-2015
2
5
9
13
17
20
20
22
23
23
25
25
1.5
3
4.5
6
7.5
9
10.5
12
13.5
15
16.5
18
Trajectory 2015-2016
Mar
Chart 20: Cumulative Central Line Related Blood Stream Infections
(Data source: SIGMA, the Trust’s PAS, this is not governed by a standard national definition; the CDC definition of CLRBSI is used)
In 2014/15 the Trust established a baseline for
Central Line Related Blood Stream Infections
(CRBSIs) using the CDC definition this is outlined
on the left of Figure 1 below. This data has been
collected in 2015/16. Since the establishment of the
baseline the Trust increased the capacity within the
Intravenous (IV) Team and there are now 2.0 x WTE
and an IV Support Worker.
• The reductions in CRBSIs have been achieved by;
• A
dedicated IV team to insert PICC lines and
provide clinical support to ward teams
• T
he establishment of an Intravenous Access Group
which provides leadership in this area which
reports to the Trust Infection Prevention and
Control Committee.
• Improvements in education including; IV Link
nurse programme, Competency assessments,
Central Line management is now included in the
mandatory training (IV study day), Vascular access
device training includes theory and practice,
Central Line management is included in the
patients safety and induction for Junior Doctors,
IV resource folders are available on the wards.
• The continued implementation of ANTT
• T
he implementation of chlorhexidine patches and
alcohol impregnated caps for all central lines.
In 2015/16 the IV team have established a baseline
data for central line associated blood stream
infections (CLABSIs), refer to the right of Figure 1.
The definition for CLABSIs is not as narrow as for
CRBSIs and reflects the clinical picture. The baseline
data will form the basis for an improvement goal
in 2016/17.
Aintree University Hospital NHS Foundation Trust
23
CDC CRBSI
CDC CLABSI
At least one positive blood culture (BC)
obtained from a peripheral vein
POS. BC
(recognised pathogen) obtained
from at least one BC
LCBI 1
AND
this pathogen not being related to
an infection at another site.
Clinical manifestations of infections
(i.e., fever, chills, and/or hypotension)
No apparent source for the BSI except the catheter
Following criterion elements
LCBI 2
1. M
ust not occur within a timeframe
not exceeding 1 calendar day:
Positive
OR
catheter
culture semi
quantitative
(>15CFUcath.
segment) or
quantitative
(>1000 CFU/
cath.seg)
whereby the
same organism
(species and
antibiogram) is
isolated from
the catheter
segment and
peripheral
blood;
2. At
least one of the symptoms
Fever> 38^c/chills/hypotension
OR
3. P
os lab results not related to an
infection at another site
AND
Simultaneous
quantitative
blood
cultures with
a >5:1 ratio
CVC versus
peripheral;
Differential
period of
CVC culture
versus
peripheral
blood culture
positivity of
>2 hours.
4. C
ommon commensal cultures from
2 or more BC drawn on separate
occasions
Aintree said it would:
Provide care that is clinically effective by delivering reliable care, by improving compliance with the
Surgical WHO checklist
Aintree achieved:
What:
To achieve improved compliance with the WHO checklist for key process measures
for patients undergoing surgery
How much:
By Qtr 4, achieve:
1.100% compliance with the WHO checklist
2.Develop an electronic audit tool to improve data collection
When:
March 2016
Outcome:
1.For latest results of the WHO checklist see page 127 in Part 3.
2.The Trust is currently developing a replacement for the ORMIS Theatre
Management information system. The new system is scheduled to go live
with version 1 in July 2016. An electronic audit tool for the WHO checklist
is scheduled for development within version 1 of the Aintree Theatre
Management System (ATMIS).
24
Aintree University Hospital NHS Foundation Trust
Priority 2: Clinical effectiveness improvement actions for 2015/16
Aintree said it would:
Deliver care that provides a positive
experience for patients and their families,
working towards a top 25% position in the
national in-patient survey.
Aintree achieved:
Of the 81 trusts that the Picker Institute worked
with for the 2015 Inpatients survey, Aintree ranked
16th which puts the Trust in the top 20% therefore
exceeding the quality goal we set ourselves of being
in the top 25% for delivery in Year 3 of the Quality
Strategy.
The improvements in patient experience have been
recognised nationally as the most improved trust
and the PICKER Institute has visited the organisation
to undertake a research study relating to how our
improvements have been achieved.
Nicola Firth, Director of Nursing and Quality, said:
“Staff across our hospital, work incredibly hard
to ensure our patients have the best experience
possible. I am delighted that this is reflected in the
responses to the latest inpatient survey and we
are demonstrating real improvements within the
organisation”.
Chart 21: Picker Inpatient Survey Results 2015 for participating NHS Trusts (lower scores are better).
(Data source: Picker In-patient Survey Results in February 2016 which is governed by a standard national definition)
Aintree said it would:
Deliver care that provides a positive experience for patients and their families, working towards
a top 25% position in the national staff survey
Aintree achieved:
An Overall Engagement Score in 2015 is 3.77;
an increase from 3.76 in 2014.
This score is made up of 3 Key Findings:
KF22Staff ability to contribute towards
improvements at work
The national average score for 2015/16 is 3.79
and despite the Trust achieving an improved score
in 2015/16 we have not secured a position in the
top 25%.
Ranked against all acute trusts, Aintree is in 66th
position out of 100 acute trusts which means we
are in the top 66%.
KF24Staff recommendation of the Trust as a place
to work or receive treatment
KF25
Staff motivation at work
Aintree University Hospital NHS Foundation Trust
25
Aintree
Chart 22: Picker Staff Survey Results 2015 for participating NHS Trusts (higher scores are better)
The red line shows the average and the yellow line shows Aintree’s position
(Data source: Picker Staff Survey Results in February 2015 which is governed by a standard national definition)
Other key staff measures
The score for KF19 (KF26 in 2015), percentage of
staff experiencing harassment, bullying or abuse
from staff in the last 12 months is 21 (22 in 2014)
compared to the national average score of 26 (lower
scores are better on this indicator).
The score for KF27 (KF21 in 2015), percentage
believing that trust provides equal opportunities
for career progression or promotion, part of the
Workforce Race Equality Standard) is 85 (87 in
2014) compared to the national average score of 87
(higher scores are better on this indicator).
Aintree said it would:
Deliver care that provides a Positive experience for patients and their families, working towards
a top 25% position in the national Friends and Family Test (FFT) Likely to Recommend Score.
Aintree achieved:
A score of 98% (published by NHS England in March
2016) puts Aintree in the top 26% of hospitals
providing NHS In-patient care (including Day Cases),
and demonstrates that Aintree is in 44th position for
the FFT Likely to Recommend percentage out of 172
NHS and Independent Hospitals. The joint ranking
26
Aintree University Hospital NHS Foundation Trust
for In-Patients and Day Cases does not reflect an
accurate position of In-patient care as it has been
recognised that Day Cases cannot be benchmarked
due to diverse Day Case Services in acute trusts. The
average ‘likely to recommend’ score for In-patient
Care at Aintree in 2015/16 is consistently higher than
both NHSE and Merseyside averages.
Best
performer
Aintree
100%
Worst
performer
FFT Likely to Recommend Percentage Score
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Chart 23: Friends and Family Test (FFT) In-Patient (including Day Cases) Likely to Recommend % in March 2016 for participating NHS
Trusts (higher scores are better)
Aintree achieved:
Result of 86% published by NHS England in March
2016 puts Aintree in the top 50% of hospitals
providing NHS A&E care as show Aintree in 70th
position for the FFT NPS out of 141 NHS Hospitals.
There has been a noticed improvement in scores
since the opening of the new Urgent Care & Trauma
Centre in July 2015 and the March score for Aintree
is higher than both NHSE and Merseyside averages.
Best
performer
100%
Aintree
Worst
performer
90%
FFT Likely to Recommend Percentage Score
80%
70%
60%
50%
40%
30%
20%
10%
0%
Chart 24: Friends and Family Test (FFT) A&E Likely to Recommend % in March 2016 for participating NHS Trusts
(higher scores are better)
(Data source: NHS England publications which is governed by a standard national definition)
Aintree University Hospital NHS Foundation Trust
27
Quality improvement priorities for 2016/17
T
hese priorities have been developed and chosen
based on:
Our vision to provide world class services for all
our patients, with the common purpose of ‘getting
it right for every patient, every time’. In August
2014, the Trust launched a new Quality Strategy
(2014 – 2017) to help to achieve improvements in
the quality of our clinical services over three years
which is aligned with the Trust’s patient safety
improvement plan as part of the Sign Up to Safety
campaign.
We have agreed a portfolio of projects that
address local and national priorities to ensure
that we deliver the three elements of our definition
of quality:
Priority 1: Care that is Safe
We will focus on reducing harm and avoidable
mortality by working with patients and their
families to reduce avoidable harm and improve
outcomes.
Priority 2: Care that is Clinically Effective
We will focus on the delivery of reliable care,
not just in the eyes of clinicians but in the eyes
of patients and their families.
Priority 3: Care that provides a positive
experience for patients and their families
We will focus on improving the delivery of
patient and family centred care.
We are focusing our work around projects to
deliver these three quality improvement priorities.
The priority projects for 2016/17 are the same
measurements outlined in our Year 3 Quality
Strategy delivery plan which is included in the Trust’s
annual operational business plan.
The delivery of our quality projects will be supported
by promoting access and uptake of staff training
on quality improvement knowledge and skills to
bring about change in practice to embed continuous
improvement.
28
Aintree University Hospital NHS Foundation Trust
How progress to achieve the quality
improvement priorities will be reported:
The Trust’s Hospital Management Board has
approved a plan for the delivery of the quality
improvement priorities. Progress against this plan
will be reported to the Quality & Safety Committee
via the Trust’s quarterly Quality Report and shared
widely with governors, members, local groups and
organisations as well as the public.
How the views of patients, the wider public
and staff were taken into account:
All of the priorities were identified through regular
feedback and engagement, and by taking into
account the views of:
• P
eople who use the Trust’s services and carers,
for example through receipt of feedback through
activities such as the Friends and Family Test,
patient and carer surveys.
• S taff and senior clinicians, for example through
discussion at the Trust’s corporate governance
meetings.
• G
overnors and Foundation Trust Members
through Quality Account Meetings and Quality
of Care Committees
• S takeholders and the wider public, for example
through activities such as formal consultations
during the launch of the Quality Strategy.
• C
ommissioners of NHS services, through contract
negotiation and monitoring processes.
• L ocal Healthwatch through feedback from visits
to services, at quarterly informal meetings and via
the Patient Experience Executive-led Group.
Priority 1:
Care that is Safe by achieving a continuous reduction in avoidable harm
Rationale for selection of this priority:
Occasionally patients will stay longer in hospital,
or need additional monitoring or treatment as a
result of care that fell below our usual standards.
Sometimes, despite our best efforts a patient may
experience harm. At Aintree, everyone endeavours
to provide the highest standard of care and we
encourage our staff to voluntarily report any patient
safety issues so that we can learn from our mistakes.
We have noted that only 10 to 20 per cent of errors
are reported voluntarily but are reassured that of
these between 90 and 95% did not cause any harm
to patients.
At Aintree we will use both our patient safety
reports and the Safety Thermometer tool to ensure
that we immediately address all patient safety issues
and we will improve patient care as a consequence.
The Trust uses the Standardised Hospital Mortality
Index (SHMI) and Hospital Standardised Mortality
Ratio (HSMR), to determine the expected range for
the number of avoidable deaths at our hospital. We
are committed to reducing this number by reducing
the number of patients who die as a result of
avoidable harm.
The way we are planning to do this is:
• D
emonstrate continuous improvement in
the reduction of:
- hospital acquired pressure ulcers;
- in-patient falls with harm
- hospital acquired C Diff infections
- MRSA/MSSA bacteraemias
• R
educe the incidence of missed critical/high
risk medication doses
• R
eview baseline data on Surgical Site
Infections to identify areas for improvement
• Continue to reduce the number of:
- Hospital Acquired Thrombosis (HAT)
- Ventilator Acquired Pneumonia (VAP)
- Central Line Associated Infections
• W
e will attempt to reduce the number of
avoidable deaths by:
- E
nsuring patients diagnosed with
Community Acquired Pneumonia (CAP)
receive appropriate antibiotics within
4 hours of arrival
-C
ontinuing to embed all elements of the
Sepsis 6 bundle
-C
ontinuing to improve the recognition and
management of Acute Kidney Injury
- Improving compliance with national
requirements for CPR training and practice
to improve the care of The Deteriorating
Patient
-C
ontinuing to embed all elements of the
Amber Care Bundle across the Trust
Aintree University Hospital NHS Foundation Trust
29
Priority 2:
Care to be Clinically Effective
Rationale for selection of this priority:
There is evidence of inconsistencies in the delivery
of high quality care with some patients not receiving
all the care that is recommended as best practice;
this applies to both inpatient and outpatient
services. The Institute for Healthcare Improvement
has developed the concept of “bundles” to help
health care providers to reliably deliver the best
possible care for patients undergoing particular
treatments with inherent risks. A bundle is a
structured way of improving the process of care
and patient outcomes: a small, straightforward set
of evidence-based practices that, when performed
together and reliably, have been proven to improve
patient outcomes.
Over the next year we will endeavour to maintain
consistently high standards and improve care
wherever we can. Our staff will work together to
develop care bundles, train their colleagues in their
use and then carry out audits to ensure that they are
being applied consistently. There will be times where
clinicians will use their expertise and experience to
override the guidelines when this is in the interest
of the patient. Consistent application of patient
care supports healthcare providers to ensure that
all patients receive every element of care that they
require. This is particularly relevant at weekends,
when patients may experience a delay due to limited
access to a service. This result could lead to a poorer
outcome for these patients.
Progress to achieve the priority
will be measured as follows:
• W
ork towards at least 95% delivery
of reliable care, 7 days a week for the
completion of:
- Nutrition Risk Assessments
- Intentional Rounding Checklists
• E
stablish the baseline for recording of
Cumulative Fluid Balance and set goal for
improvement
• A
chieve 100% compliance in key process
measures within the Surgical WHO Checklist
Project Improvement Plan
• A
chieve improved ACS targets for existing
Advancing Quality Care Bundles in:
- Hip and Knee (ACS 80%)
- Pneumonia (ACS 77.8%)
- Sepsis (ACS 77.2%)
• A
chieve 50% ACS targets for new Advancing
Quality Care Bundles in:
- COPD
- Hip Fracture
- Diabetes
- Alcoholic Liver Disease
- Acute Kidney Injury
• Implement a structured approach to Ward
Rounds across relevant clinical areas
30
Aintree University Hospital NHS Foundation Trust
Priority 3:
Care that provides a positive experience for patients and their families
Rationale for selection of this priority:
A positive patient and family experience is of great
importance to us. We understand that many of our
patients often experience life changing diagnoses
and treatments, and it is our ambition to make their
experience the best that it can possibly be. In order
to do this we recognise the need for our staff to feel
valued and supported.
There is much more that we need to do to improve
patient and family care and we asked our patients
and their families for their views. They told us what
was important to them and we developed our three
year (2014-17) Quality Strategy with those priorities
in mind.
Progress to achieve the priority
will be measured as follows:
• W
ork towards a top 25% position for Inpatient and Staff experience national surveys
• A
chieve higher than the NHS Merseyside and
NHS England average in all measures in the
Friends and Family Test (FFT)
• Improve length of time to respond to
complaints
• Implement ‘patient shadowing’ programme
by following patients and their families
throughout their care experiences
• E
stablish a Patient Dining Room in the
Orthopaedic Trauma Ward
• Introduce Flexible Visiting into in-patient
wards
Aintree University Hospital NHS Foundation Trust
31
Statements of assurance from the Board
The purpose of this section of the report is to provide formally
required evidence on the quality of Aintree’s services. This
allows readers to compare content common across all Quality
Accounts nationally
Common content for all Quality Accounts
nationally is contained in a green line
border like this.
Information of the review of services
During 2015/16 Aintree University Hospital
NHS Foundation Trust provided 39 relevant
health services. Aintree University Hospital NHS
Foundation Trust has reviewed all the data
available to them on the quality of care in 39
of these relevant health services. The income
generated by the relevant health services
reviewed in 2015/16 represents 100 per cent of
the total income generated from the provision
of relevant health services by Aintree University
Hospital NHS Foundation Trust for 2015/16.
Information on participation in clinical audits
and national confidential enquiries
During 2015/16 34 national clinical audits and
5 national confidential enquiries covered relevant
health services that Aintree University Hospital
NHS Foundation Trust provides.
During 2015/16 Aintree University Hospital
NHS Foundation Trust participated in 97%
(33/34) national clinical audits and 100% national
confidential enquiries of the national clinical
audits and national confidential enquiries which
it was eligible to participate in.
The national clinical audits and national
confidential enquiries that Aintree University
Hospital NHS Foundation Trust was eligible
to participate in during 2015/16 are listed in
Annex C.
The national clinical audits and national
confidential enquiries that Aintree University
Hospital NHS Foundation Trust participated in,
and for which data collection was completed
during 2015/16, are listed in the table below
alongside the number of cases submitted to
each audit or enquiry as a percentage of the
number of registered cases required by the
terms of that audit or enquiry.
The high level of participation in clinical audit
which is observed across the Trust demonstrates
the commitment of our clinical staff to improving
the quality of care they provide.
32
Aintree University Hospital NHS Foundation Trust
Relevant National Clinical Audit/Enquiry Title
Participating (Yes/No)
Case Ascertainment
Acute
Adult Critical Care (Case Mix Programme - ICNARC) Yes
100%
Emergency Use of Oxygen
Yes
100%
Major Trauma Audit
Yes
100%
Medical and Surgical Clinical Outcome Review
Programme (NCEPOD) - Acute Pancreatitis
Yes
100%
National Complicated Diverticulitis Audit (CAD)
No
0% - a delay in submission
and communication issues
prevented participation
National Emergency Laparotomy Audit (NELA)
Yes
93%
National Joint Registry (NJR) - Knee replacement
Yes
100%
National Joint Registry (NJR) - Hip replacement
Yes
100%
Procedural Sedation in Adults (care in emergency
departments)
Yes
100%
VTE risk in lower limb immobilisation
(care in emergency departments)
Yes
100%
National Comparative Audit of Blood Transfusion
programme - Use of blood in Haematology
Yes
100%
National Comparative Audit of Blood Transfusion
programme - Audit of Patient Blood Management
in Scheduled Surgery
Yes
100%
Bowel Cancer (NBOCAP)
Yes
100%
National Lung Cancer Audit (NLCA)
Yes
100%
National Prostate Cancer Audit
Yes
100%
Oesophago-gastric Cancer (NAOGC)
Yes
100%
Acute Coronary Syndrome or Acute Myocardial
Infarction (MINAP)
Yes
95% (data collection still
in progress and likely to
increase)
Cardiac Rhythm Management (CRM)
Yes
100%
National Cardiac Arrest Audit (NCAA)
Yes
100%
National Heart Failure Audit
Yes
81% (data collection still
in progress and likely to
increase)
Blood and Transplant
Cancer
Heart
Table 23: Friends and Family Test (FFT) A&E Likely to Recommend % in March 2016 for participating NHS Trusts
(higher scores are better).
(Data source: NHS England publications which is governed by a standard national definition)
Aintree University Hospital NHS Foundation Trust
33
Relevant National Clinical Audit/Enquiry Title
Participating (Yes/No)
Case Ascertainment
Child Health Clinical Outcome Review Programme
- Chronic Neurodisability
Yes
N/A – study open
National Chronic Obstructive Pulmonary
Disease (COPD) Audit programme - Pulmonary
rehabilitation
Yes
100%
National Diabetes Audit - National Footcare Audit
Yes
N/A – data collection
still in progress
Long Term Conditions
National Diabetes Audit - National Inpatient Audit Yes
100%
National Diabetes Audit - National Core
Yes
100%
Renal Replacement Therapy (Renal Registry)
Yes
100%
Rheumatoid and Early Inflammatory Arthritis
Yes
52 cases (Due to coding
limitations the denominator
is unavailable to give a %)
Yes
N/A – study open
Mental Health
Child Health Clinical Outcome Review Programme
- Young People's Mental Health
Medical and Surgical Clinical Outcome Review
Programme (NCEPOD) - Physical and mental health Yes
care of mental health patients in acute hospitals
100%
Older People
Falls and Fragility Fractures Audit programme
(FFFAP) - Inpatient Falls
Yes
100%
Falls and Fragility Fractures Audit programme
(FFFAP) - National Hip Fracture Database
Yes
N/A – data collection
still in progress
Sentinel Stroke National Audit programme
(SSNAP)
Yes
N/A – data collection
in progress
UK Parkinson’s Audit - Occupational Therapy
Yes
100%
UK Parkinson’s Audit - Speech and Language
Therapy
Yes
100%
UK Parkinson’s Audit - Physiotherapy
Yes
100%
UK Parkinson’s Audit - Patient Management,
elderly care and neurology
Yes
100%
Elective Surgery PROMS Programme - Hernia,
(Varicose Veins not carried out by Aintree)
Yes
59% - April – September
2015 (still awaiting October
2015 – March 2016 data)
Medical and Surgical Clinical Outcome Review
Programme (NCEPOD) - Non-invasive ventilation
Yes
N/A – study open
National Ophthalmology Audit
Yes
N/A – data collection
still in progress
Other
Table 24
34
Aintree University Hospital NHS Foundation Trust
Actions arising as a result of national
and local audits
The Trust Board has delegated authority for
clinical audit to the Quality & Safety Board
Committee which receives assurance from the
Clinical Effectiveness Exec-led Group. Through
this delegation, the reports of 19 national clinical
audits were reviewed by the provider in 2015/16
and Aintree University Hospital NHS Foundation
Trust intends to take actions listed in the table
below to improve the quality of healthcare
provided.
In addition, the reports of 210 local clinical audits
were reviewed by the provider in 2015/16 and
Aintree University Hospital NHS Foundation Trust
intends to take actions listed in the table below
to improve the quality of healthcare provided.
EXAMPLES OF NATIONAL
AUDIT ACTIONS
National CEM Audit: Management of Severe
Sepsis and Septic Shock in Adults in the
Emergency Department
• T
o reinforce the use of the Sepsis Pathway
and highlight the importance at senior house
officer teaching sessions.
• F eedback to nurses to further highlight
importance.
• Adaptor for doing BC from cannula.
• Ensure doctors have gas codes.
Aintree University Hospital NHS Foundation Trust
35
Sentinel Stroke national Audit
Programme (SSNAP)
• N
IHSS to be completed for all probable
stroke patients as soon as possible after
admission/stroke diagnosis.
• If patients are not thrombolysed the reasons
why need to be clearly stated on SSNAP.
• SALT to record initial swallow assessment.
• A
ll strokes and probable strokes to be moved
to unit as soon as possible after admission.
• F ull protocol for four hour admission to
be written.
• If there is only one bed on the unit and a
stroke patient requiring it, they should be
admitted (the bed should not be reserved for
potential thrombolysis). A “Move list” /step
down list should be developed and updated
daily identifying patients who could move out
of the Stroke Unit if required. This should be
available for the ward and bed management
team during evenings and weekends when
there is no consultant on site. The stroke
clinician communication board needs to be clear
on which patients are outliers and which need
follow-up only.
• N
ursing care plans are being reviewed at
present. It would be our recommendation that
continence care plans are included with the
general care plan documents. The continence
assessment is currently being re-written to make
it more applicable to the general ward areas.
• It appears as though education regarding
the use of the new falls care plan needs to
be re-delivered. This could be provided by the
falls reduction specialist nurse and the falls
link nurses.
• T
here will be education regarding the use of
the multifactorial falls risk assessment tool upon
hospital induction and a relaunch to all the
medical staff in the hospital at a grand round.
• A
fter the re-launch we need to conduct our own
local audit of the use of the falls care plan and
associated documents.
• A
second fall prevention collaborative is planned
for March 2016 to re-focus the change package
and discuss and trial new ideas to reduce falls
using a quality improvement tool.
• T
eam to meet bed management to discuss
stroke pathway.
• T
he Falls Prevention Nurse is working in
collaboration with the Governance Team and
the Estates Department to help reduce falls
within the Trust.
• E
nsure all stroke ward referrals are seen as soon
as possible and with the same urgency as AED
referrals.
• T
he Falls Prevention Nurse is working with
ward staff to embed the falls prevention
change package.
• If a stroke has been clearly identified, move
urgently and not wait for consultant review.
National Audit of Pleural Procedures
• T
o explore solution of electronic joint health
and social care assessment record.
• N
ursing staff ideally should be present when
chest drains are inserted.
• To look at Sigma templates.
• O
bservations should be performed and
documented pre and post procedure.
National Falls and Fragility Programme –
Inpatient Falls
Key recommendations were made by the Royal
College of Physicians following the publication
of the national data. They recommended several
things that we already have at Aintree, including a
falls steering group, falls multidisciplinary working
group, audit of bed rail use and to use non-risk
stratification falls assessment tool. They also
recommend the multifactorial falls risk assessment
includes all the domains within the audit, which
ours does.
• T
he use of standardised dementia and delirium
assessment tools and care plans for these
conditions are recommended. Of these, only
the care plan for people with dementia is used
within this hospital at present. Dementia and
36
delirium assessments are undertaken but not
necessarily using standardised tools.
Aintree University Hospital NHS Foundation Trust
• A
im for 100% of the drains to be secured by
both sutures and dressing.
• Improve chest drain flushing - nursing staff
should be trained to do this.
National COPD Audit Programme: Pulmonary
Rehabilitation
The results show that we are currently performing
very well. It has been recommended to continue
with practice as it is.
National Audit of the Hip Fracture Database
National audit that is ongoing. Actions are
implemented as they arise. There are no changes
identified at this time.
EXAMPLES OF LOCAL AUDIT ACTIONS
Clinical Audit of Hand Hygiene
• C
ontinue with the ‘Stop Gel Go’ campaign for all
Trust staff.
• T
o distribute the ‘IPC in Your Hands’ pocket
guide, which has been developed, containing a
summary of the trust hand hygiene policy.
• S tudent Quality Ambassadors to continue to
undertake objective hand hygiene audits on
the wards and feedback at all levels of the
organisation, from frontline staff to board level.
Clinical Audit of High Impact Interventions
(HII) 4- Preventing Surgical Site Infections
• Continue to reinforce good practice.
• E
xplore the feasibility of expanding the range
of surgical site surveillance.
Clinical Audit of The Management
of Unexplained Diarrhoea
• C
ontinue to have SIGHT as a core feature of
clinical education.
• Include to SIGHT, diarrhoea and CDT
management in ‘IPC in Your Hands’ Pocket
Guide.
• IPC Team to continue Trust-wide side room plan
daily for site managers, to increase effectiveness
of side room utilisation and availability when
patients with diarrhoea require isolation.
Clinical Audit of Patient Experience
(NICE Declaration Audit)
• E
ngage with patients and those close to them to
seek views about their experience.
• P
romote staff engagement in the improvement
of patient care.
• E
nsure that the Board is aware of the key
themes emerging from complaints and the
actions taken to address them.
Clinical Audit of the use of the
Multifactorial Falls Risk Assessment (MFRA)
Tool and Bed Rails
Re-audit Monthly Modified Early Warning
System (MEWS Audit)
• Information should be made available to ward
managers to enable analysis of their own areas’
performance each month and action areas of
poor compliance.
• A
n e-mail reminder should be sent out to
all Matrons and ward managers each month
advising them that the ward results from the
monthly MEWS audit are available to view
on aBI.
• C
omplete a detailed analysis of each wards
performance and visit each ward to discuss
the results with the ward managers and offer
support and education where necessary.
• R
eview the audit tool to ensure that it is
fit for purpose.
Baseline Clinical Audit of Nursing
and Safeguarding Documentation
• T
o promote new documentation completion
requirements through a post audit result
walk round.
• E
mail out results/action plan and highlight key
areas for improvement to ward managers and
deputies.
• A
ttend Aintree Nurse Forum to provide update
and steer.
• T
o undertake a specific documentation senior
nurse walk around once a year to highlight
good practice and obtain staff feedback.
• F ocus on documentation update in ‘All About
Aintree.’ Develop new documentation induction
with clinical skills department.
• Investigate if we can create an interactive
e-learning module for nursing documentation.
Full details of the actions to be taken on
all audits can be provided – please contact
0151 529 3782 for more details.
• Promote MRFA at Grand Round.
• E
mbed good practice in Falls Change Package
and new Bed Rail assessment.
Aintree University Hospital NHS Foundation Trust
37
Participation in clinical research
The number of patients receiving relevant health
services provided or subcontracted by Aintree
University Hospital NHS Foundation Trust in
2015/16 that were recruited during that period
to participate in research approved by a research
ethics committee was just under 1900.
Patients were recruited into National Institute
for Health Research (NIHR) adopted studies,
commercially sponsored studies and Trust sponsored
studies. Aintree was involved in conducting 372
clinical research studies during 2015/16. Aintree
used national systems to co-ordinate the studies
in proportion to risk, when they met the NIHR
eligibility criteria for inclusion in the NIHR clinical
research network portfolio. Of the 372 studies open
at Aintree 209 met the NIHR national adoption
criteria and these studies have been approved
and opened using the NIHR Co-Ordinated Systems
for gaining NHS permission (CSP). Of the eligible
studies co-ordinated through CSP 100% were given
permission to start within 30 days, with the agreed
NHIR recruitment goal being met All of the studies
were established and managed with the use of
model Clinical Trial/Clinical Investigation Agreements
which speed up contracting & trial initiation
between companies and the Trust.
All studies are closely monitored within the
Research & Development Department to ensure
that studies are recruiting on time to meet the
target recruitment. The aim is to maintain excellent
recruitment and to continually monitor the
following 2 key performance criteria:
The improvement in patient health outcomes
in Aintree demonstrates that a commitment to
clinical research leads to the best possible care
and treatment for patients. High quality research
at Aintree will ensure the best possible care for
patients, promote the reputation of Aintree as a
centre of excellence (driving patient and purchaser
choice) and facilitate the recruitment and retention
of the highest calibre of staff.
With the inclusion of clinical leads, data managers,
pharmacy and AHP there are over 100 staff at
Aintree involved with research studies covering
over 15 specialities across the Trust namely:
Cardiology, Stroke, Gastroenterology, Respiratory,
Musculoskeletal, Diabetes & Endocrine, Cancer
(Head & Neck, Haematology, and General Surgery),
Urology, General Surgery, Critical Care, Dermatology,
MFU, Respiratory Infection, Ophthalmology and
Pharmacogenetics.
Over the past year at Aintree there has been
progress in many areas, with many successful grant
applications and publications such as:
• N
IHR Research for Patient Benefit Grant (Professor
Simon Rogers)
• O
ver 100 Publications in high impact scientific and
medical journals.
• Increased commercial income to support research
across many therapeutic areas
• Key member of Joint Research Office initiative
• N
IHR High Level Objectives (HLO) - [North West
Coast Clinical Research Network NWC CRN]
• A
greement for the development of a Clinical
Research Facility based in the Clinical Science
Centre
• D
epartment of Health – Performance Information
Delivery [PID] in clinical research.
Use of CQUIN framework
The Trust is constantly reviewing its approval times
and indeed, is meeting all of the HLO and the PID
timelines for NHS Approval.
• P
erformance in Commercial Activity Time
to Target – The figure associated with the HLO
and the PID objective is 80% and our figure as
a Trust is running at approximately 60% for all
commercial studies.
• Initiation in Clinical Research
The Trust has a 70 day benchmark to recruit
the first patient into the study. This is a very
challenging target and at present the Trust is
running at approximately 60% for all activity.
• T
ime taken for NHS Permission – all studies
are issued with R&D approval within 30 days of
receipt of a valid research application.
All studies have undergone a research governance
review to ensure research passports/letter of access
is issued appropriately. This initiative streamlines HR
38
arrangements across organisations to make it easier
and quicker to commence approved studies.
Aintree University Hospital NHS Foundation Trust
A proportion of Aintree University Hospital
NHS Foundation Trust income in 2015/16 was
conditional on achieving quality improvement
and innovation goals agreed between Aintree
University Hospital NHS Foundation Trust
and any person or body they entered into a
contract, agreement or arrangement with for
the provision of relevant health services, through
the Commissioning for Quality and Innovation
payment framework. Further details of the
agreed goals for 2015/16 and for the following
12 month period are available electronically at
http://www.aintreehospital.nhs.uk/AboutUs/
Pages/Publications.aspx.
During 2015/16 the total income associated
with the achievement of quality improvement
and innovation goals amounted to £5.692M.
Aintree University Hospital NHS Foundation Trust
received £5.093M income for the associated
payment in 2014/15.
An overview of the initiatives and performance during 2015/16 is outlined in the table below.
Key: Ref
4 = Achieved = Partially Achieved
Scheme
= Under Achieved
Target
Performance
Achieved
Baseline and
Monitor Numbers
Reduced from 20.3% in
Qtr 1 to 12% in Qtr 4
Improving Urgent and Emergency Care
1
Reducing the proportion
of avoidable emergency
admissions
4
Acute Kidney Injury Care
2
Four key items of information
included in the discharge
90% in Qtr 4
summary
Full implementation
delivered in February
2016. Performance in Qtr
4 was 62.7%
Identification of Sepsis
3a
Screened for Sepsis
70% in Qtr 4
94.1% in Qtr 4 (Jan &
Feb data only)
3b
Antibiotic Administration
within 1 hr
70% in Qtr 4
56.1% in Qtr 4 (Jan &
Feb data only)
4
Dementia Care
Step 1 - 88.8%
4a
Dementia Risk Assessment
90% in Qtr 4
Step 2 - 94.1%
Step 3 -100%
4b
Dementia Training Plan
Increase awareness
91% of staff completed
dementia awareness
training level 1
4
4c
Supporting Carers of people
with Dementia
Monthly surveys
Five surveys undertaken
each month with Carers
and reported to Board
4
Aintree University Hospital NHS Foundation Trust
39
Ref
Scheme
Target
Performance
95%
97.7% cumulative ACS
to January 2016
73.2%
64.4%* cumulative ACS
to January 2016
92.7%
97.9% cumulative ACS
to January 2016
77.9%
72.2%* cumulative ACS
to January 2016
50.0%
29.0% cumulative ACS
to January 2016
Achieved
Advancing Quality Care Bundles
5a
5b
5c
5d
5e
5f
5g
5h
5i
5J
A Q – AMI
Appropriate Care Score
A Q – Heart Failure
Appropriate Care Score
A Q – Hip & Knee Surgery
Appropriate Care Score
A Q – Pneumonia
Appropriate Care Score
A Q – COPD
Appropriate Care Score
A Q – Hip Fracture
Working towards
Appropriate Care Score
50.0%
A Q – Sepsis
Working towards
Appropriate Care Score
50.0%
A Q – Acute Kidney Injury
Appropriate Care Score
(new in 2015/16)
Working towards
A Q – Diabetes
Working towards
Appropriate Care Score
50.0%
A Q – Alcoholic Liver Disease
Working towards
Appropriate Care Score
50.0%
50.0%
4
4
14.1% cumulative ACS
to January 2016
4
80.2% cumulative ACS
to January 2016
4
47.0% cumulative ACS
to January 2016
4
49.1% cumulative ACS
to January 2016
4
49.5% cumulative ACS
to January 2016
4
*Please note introduction of new measures for Heart failure and Pneumonia introduced part
way through the year in October has significantly impacted on Trust performance.
GP Communications
6a
6b
In-patient Discharge
Summaries fully completed
and a copy given to patient
95% in Qtr 4
90.4% (Qtr 4)
In-patient Discharge
Summaries sent in 24 hours
95% in Qtr 4
69.0% (Qtr 4)
Out-Patient Letters fully
completed and
100%
95% in Qtr 4
Sent to GP within 14 days
40
93.2% in Qtr 4
96.2% in March
4
4
89% (Qtr 4)
6d
Day case Discharge
Summaries sent in 24 hours
90% in Qtr 4
(Technical error for 3
days in February)
4
6e
A & E Discharge Summaries
sent in 24 hours
80% in Qtr 4
81.7% (Qtr 4)
4
Aintree University Hospital NHS Foundation Trust
Ref
Scheme
Target
Performance
Achieved
Digital Maturity
6e
Baseline Assessment & Action
Plan
Completed
6f
Single instance of ICE for
GP radiology and pathology
requests and results
Progress has been
delayed through
supplier technical
difficulties
4
Effective Discharge
7a
Nursing Discharge Checklist
Completed
90% in Qtr 4
Trust compliance was
97.6% in Qtr 4
7b
Estimated Date of Discharge
established within 24 hours
90% in Qtr 4
49.7% in Qtr 4
7c
Clinical Management Plan
agreed with patient/carer
involvement
90% in Qtr 4
53.2% in Qtr 4
7d
Mediation issued in accessible
90% in Qtr 4
format
100% compliant
4
7e
Transformational change plan
Plan Delivered
implemented
Plan completed
4
7f
No of patients discharged
home before 1pm and 4pm
Continuous
improvement
1pm discharges – 43%
4pm discharges – 70.5%
4
4
Palliative Care/Amber Care Bundle (ACB)
Training on wards
completed
4
Qtr 4 263+ patients
identified for ACB
4
ACB patients to have
documented ceiling of
treatment
Qtr 4 – 100%
4
8d
ACB patients to have
documented discussion of
preferred place of care
Qtr 4 – 92%
4
8e
90% of discharged ACB
patients to have plan of care
communicated to GPs
Qtr 4 – 100%
4
8a
Staff training in agreed wards
8b
Increase in suitable patients
for ACB
8c
Continuous
improvement
Aintree University Hospital NHS Foundation Trust
41
Ref
Scheme
Target
Performance
Achieved
Transitional Care with Alder Hey Hospital
9a
Establish Project Team and
PID
Achieve Qtr 1
milestone
Achieved
4
9b
Recruit Project Manager
Achieve Qtr 1
milestone
Achieved
4
9c
Agree Transition Policy
Achieve Qtr 1
milestone
Achieved
4
9d
Collect patient cohort data
Achieve Qtr 1
milestone
Achieved
4
9e
Finalise agreed holistic service Achieve Qtr 2
model and standards
milestone
Achieved
4
9f
Submit business case and
secure commissioner funding
Achieve Qtr 2
milestone
9g
Staff Recruitment, service
mobilisation and end of year
report
Qtr 3 & Qtr 4
milestones
This was subject to a
timely response to the
business case
4
90% of data items
reported
90% of patients on
appropriate registries
and treatment plans
considered by MDT
4
4
Business Case complete
CCGs are exploring
funding streams
4
Specialist Services Schemes
10
Collaborate with the
Multi-system auto-immune
rheumatic diseases network
11
Increase effectiveness of
Rehabilitation after critical
care illness
90% of data items
reported
98.7% of rehab
assessments within 48
hrs and % assessed
on discharge and %
passports completed
12
Improving Dental Coding
Evidence from
Contracting Data
Working on an
appropriate and
consistent data set for
Oral Surgery
4
13
Bowel Screening Programme
– reducing health inequalities
Updates on
action plan
Actions identified
completed
4
Table 25: CQUIN initiatives and performance during 2015/16
42
Aintree University Hospital NHS Foundation Trust
Registration with the Care Quality Commission
Aintree University Hospital NHS Foundation
Trust is required to register with the Care Quality
Commission and its current registration status
is unqualified. Aintree has no conditions on
registration.
The Care Quality Commission has not taken any
enforcement action against Aintree University
Hospital NHS Foundation Trust during 2015/16.
Aintree University Hospital NHS Foundation Trust
has not participated in any special reviews or
investigations by the Care Quality Commission
during the reporting period.
The table below shows the CQC ratings grid for the services provided at the Trust following the review in
March 2014.
Safe
Effective
Caring
Responsive
Well led
Overall
Urgent &
Emergency
Good
Services (A&E)
Not Rated
Good
Good
Good
Good
Medical care
(including
Good
older people’s
care)
Good
Good
Good
Good
Good
Surgery
Requires
Good
Improvement
Good
Good
Good
Good
Intensive/
critical care
Good
Good
Good
Good
Good
Good
End of life
care
Good
Good
Good
Good
Good
Good
Outpatients
Good
Not Rated
Good
Good
Good
Good
It was recommended that the Division of Surgery
undertake the following improvement actions:
1.Update of the WHO Surgical Checklist
2.Consultation & Introduction of a new Checklist
& Standard Operating Procedure (SOP)
3.Final Version of the WHO Checklist SOP on Trust
Document Management Site (DMS)
4.Staff awareness raising
5.Audit of WHO checklist Implementation
6.Presentation of Results to Theatre Teams
7.Re-audit of WHO Checklist
8.Keep the Trust’s Safety & Risk Exec Led Group up
to date with progress
All actions above were completed by October 2014
and actions 4 to 8 are ongoing within the Trust.
Aintree University Hospital NHS Foundation Trust
43
Information on the quality of data
NHS Number and General Medical Practice Code Validity
Aintree University Hospital NHS Foundation
Trust submitted records during 2015/16 to the
Secondary Uses service for inclusion in the Hospital
Episode Statistics which are included in the latest
published data. The percentage of records in the
published data:
Which included the patient’s valid
NHS Number was:
99.8% for admitted patient care;
99.8% for outpatient care; and
97.0% for accident and emergency care
Which included the patient’s valid General Medical
Practice Code was:
99.9% for admitted patient care;
99.8% for outpatient care; and
99.8% for accident and emergency care
Information Governance Toolkit attainment levels (Information Governance)
Aintree University Hospital NHS Foundation
Trust Information Governance Assessment Report
overall score for 2015/16 was 74% and was graded
Green, Satisfactory.
Clinical coding error rate
Aintree University Hospital NHS Foundation
Trust was subject to the Payment by Results clinical
coding audit during the reporting period by the
Audit Commission and the error rates reported
in the latest published audit for that period for
diagnoses and treatment coding (clinical coding)
was 5.6%
• Secondary Procedures Incorrect 13.2%
• Primary Diagnoses Incorrect 6.5%
It is important to note that these results
cannot be extrapolated further than the actual
sample audited.
• Secondary Diagnoses Incorrect 5.0%
The services reviewed within the sample audit
during this period included:
• Thoracic procedures and disorders
• Renal procedures and disorders
• Primary Procedures Incorrect 5.2%
The clinical coding error rate of 5.6% is the best
performance for the Trust to date. Levels of
performance for coding of Thoracic procedures was
rated as Adequate whilst coding of renal procedures
was rated as Good by the external auditors.
Statement on relevance of data quality and
actions to improve data quality
Good quality information underpins the effective
delivery of the care of people who use NHS services
and is essential if improvements in quality of care
are to be made.
Aintree University Hospital NHS Foundation Trust
will be taking the following actions to improve
data quality:
• D
Q strategy and policies regularly reviewed and
kept up to date to ensure appropriate actions
are undertaken to improve the quality of data
recorded and reported
• D
evelopment and circulation of DQ reports to
facilitate improvement
• R
outine audits undertaken to validate the
quality of data
44
Aintree University Hospital NHS Foundation Trust
• R
egular coding undertaken to ensure
robustness of clinical data
• T
he Trust has invested in a DQ team with
particular focus on validating and improving
PAS data
• A
chievement of a minimum of level two
IG Toolkit for items particularly relating to
data quality.
Performance against national quality
indicators 2014/15 – 2015/16
Where available the data for the indicators has been
obtained from the NHS Information Centre Portal.
Where this has not been available, other sources
have been used. These sources have been stated
for each indicator. For a number of the national
averages and ranges this data has not been made
available by the NHS Information Central Portal at
the time of publication. The Trust has stated ‘not
available’ where this is the case.
Domain 1: Preventing People from dying prematurely (1 = Above Expected, 2 = As Expected, 3 = Below Expected)
Period
Trust
Value
Trust
Banding
National
Average
Lowest
NHS Trust
Highest
NHS Trust
Oct 14 – Sept 15 100.15
2
100
65.16
117.74
Jul 14 – Jun 15
2
100
66.05
120.89
Apr 14 – Mar 15 101.99
2
100
66.96
120.98
Jan 14 – Dec 14
107.59
2
100
65.53
124.34
Oct 13 – Sep 14
112
1
100
59.66
119.82
Jul 13 – Jun 14
115
1
100
54.07
119.82
Apr 13 – Mar 14 115
1
100
53.92
119.73
Jan 13 –Dec 13
113
1
100
62.36
117.58
Oct 12 – Sep 13
113
1
100
63
119
Jul 12 - Jun 13
113
1
100
63
116
Apr 12 - Mar 13
116
1
100
65
117
Jan 12 - Dec 12
117
1
100
70
119
Oct 11 - Sep 12
118
1
100
68
121
99.9
Table 26: Summary Hospital-Level Mortality Indicator (SHMI) value and banding Indicator
(Data source: Health and Social Care Information Centre)
Aintree University Hospital NHS Foundation Trust
considers that this data is as described for the
following reasons:
Aintree University Hospital NHS Foundation Trust
intends to take the following actions to improve this
percentage, and so the quality of its services, by:
• T
he Trust has an ‘as expected’ SHMI at 100.15 for
the period October 2014 to September 2015 as
demonstrated in the table above. Unlike HSMR,
the SHMI indicator does include deaths 30 days
after discharge and therefore patients, including
those on palliative care end of life pathways, who
are appropriately discharged from the Trust.
• T
he Trust has an active avoidable mortality
reduction group chaired by the Medical Director
with representation from all divisions and CCG’s.
• T
here are 5 key work streams with clinical leads
each looking at improved care pathways, metrics
and bundles to reduce avoidable mortality and
discussions are progressing with regard to adding
a 6th clinically led work stream in the fractured
neck of femur diagnosis group.
Aintree University Hospital NHS Foundation Trust
45
Domain 1: Preventing People from dying prematurely Period
Trust
Performance
National
Average
Lowest
NHS Trust
Highest
NHS Trust
Oct 14 – Sept 15
49.1%
26.7%
0.2%
53.5%
Jul 14 – Jun 15
48.7%
26.1%
0.0%
52.9%
Apr 14 – Mar 15
47.5%
25.8%
0.0%
50.9%
Jan 14 – Dec 14
46.5%
25.88%
0.0%
48.3%
Oct 13 – Sep 14
45.3%
25.32%
0.0%
49.4%
Jul 13 – Jun 14
42.08%
24.6%
7.4%
49.0%
Apr 13 – Mar 14
41.42%
23.6%
6.4%
48.5%
Jan 13 –Dec 13
41.13%
22%
1.3%
46.9%
Oct 12 – Sep 13
40.5%
21.2%
0.00%
44.8%
Jul 12 - Jun 13
41.7%
20.5%
0.00%
44.1%
Apr 12 - Mar 13
40.8%
20.3%
0.01%
43.9%
Jan 12 - Dec 12
41.0%
19.3%
0.01%
42.7%
Oct 11 - Sep 12
41.9%
19.0%
0.02%
43.3%
Table 27: Percentage of patient deaths with palliative care coded at either diagnoses or speciality level (Context indicator)
(Data source: Health and Social Care Information Centre)
46
Aintree University Hospital NHS Foundation Trust
considers that this data is as described for the
following reasons:
Aintree University Hospital NHS Foundation Trust
intends to take the following actions to improve this
percentage, and so the quality of its services, by:
• T
he Trust provides a number of regional and
specialist services and is a provider of specialist
palliative care therefore the levels of palliative
care coding are entirely appropriate for the
organisations profile.
• T
he Trust have a high quality palliative care
service and are currently implementing the
AMBER care bundle to enhance the end of life
care further.
Aintree University Hospital NHS Foundation Trust
Domain 3: Helping people to recover from episodes of ill health or following injury
Period
Trust
Performance
National
Average
Lowest
NHS Trust
Highest
NHS Trust
Oct 14 – Sept 15
49.1%
26.7%
0.2%
53.5%
Jul 14 – Jun 15
48.7%
26.1%
0.0%
52.9%
Apr 14 – Mar 15
47.5%
25.8%
0.0%
50.9%
Jan 14 – Dec 14
46.5%
25.88%
0.0%
48.3%
Oct 13 – Sep 14
45.3%
25.32%
0.0%
49.4%
Jul 13 – Jun 14
42.08%
24.6%
7.4%
49.0%
Table 28: Patient reported outcome scores for groin hernia surgery (Percentage of patients reporting an increase in general health)
(Data source: Health and Social Care Information Centre) (http://www.hscic.gov.uk/proms)
Aintree University Hospital NHS Foundation Trust
considers that this data is as described for the
following reasons:
• T
he data source is the Health & Social Care
Information Centre.
Aintree University Hospital NHS Foundation Trust
intends to take the following actions to improve this
percentage, and so the quality of its services, by:
• The pre-operative department reinforcing the
importance of patients completing the postoperative questionnaires and its impact on future
patient experience
• In addition, a Trust patient reminder letter has
been developed and supported by Healthwatch
colleagues to encourage patients to complete
and return the post-operative questionnaire so
the Trust can use the information to understand
where we are doing well and where we can make
further improvements in our hospital care.
Domain 3: Helping people to recover from episodes of ill health or following injury
Period
Trust
Performance
National
Average
Lowest
NHS Trust
Highest
NHS Trust
2015/16
Not available
Not available
Not available
Not available
2014/15
66.70%
53.60%
0.00%
87.50%
2013/14
10.00%
41.74%
10.00%
70.00%
2012/13
53.85%
41.01%
14.29%
85.71%
2011/12
0.00%
42.10%
18.18%
78.57%
2010/11
0.00%
39.52%
0.00%
75.00%
Table 29: Patient reported outcome scores for varicose vein surgery (Percentage of patients reporting an increase in general health)
(Data source: Health and Social Care Information Centre
Aintree University Hospital NHS Foundation Trust
considers that this data is as described for the
following reasons:
• A
intree is experiencing a decrease in the number
of varicose veins operations carried out as this is a
procedure of lower clinical priority.
Aintree University Hospital NHS Foundation Trust
47
Domain 3: Helping people to recover from episodes of ill health or following injury
Period
Trust
Performance
National
Average
Lowest
NHS Trust
Highest
NHS Trust
2015/16
Not available
Not available
Not available
Not available
2014/15
N/A
90.00%
50.00%
100.00%
2013/14
73.33%
66.09%
33.33%
100.00%
2012/13
67.35%
65.62%
37.50%
90.00%
2011/12
64.23%
63.68%
25.00%
100.00%
2010/11
51.61%
61.09%
42.61%
91.67%
Table 30: Patient reported outcome scores for hip replacement surgery (Percentage of patients reporting an increase in general
health) (Data source: Health and Social Care Information Centre)
Aintree University Hospital NHS Foundation Trust
considers that this data is as described for the
following reasons:
• T
he data source is the Health & Social Care
Information Centre.
Aintree University Hospital NHS Foundation Trust
intends to take the following actions to improve this
percentage, and so the quality of its services, by:
• T
he importance of completion of the forms being
reiterated to staff.
• In addition, a Trust patient reminder letter has
been developed and supported by Healthwatch
colleagues to encourage patients to complete
and return the post-operative questionnaire so
the Trust can use the information to understand
where we are doing well and where we can make
further improvements in our hospital care.
Domain 3: Helping people to recover from episodes of ill health or following injury
Period
Trust
Performance
National
Average
Lowest
NHS Trust
Highest
NHS Trust
2015/16
Not available
Not available
Not available
Not available
2014/15
100.00%
82.20%
33.30%
100.00%
2013/14
52.00%
56.62%
20.00%
100.00%
2012/13
57.38%
55.00%
33.33%
91.84%
2011/12
54.96%
53.89%
26.32%
88.89%
2010/11
49.68%
50.43%
32.32%
80.00%
Table 31: Patient reported outcome scores for knee replacement surgery (Percentage of patients reporting an increase in general health)
(Data source: Health and Social Care Information Centre)
Aintree University Hospital NHS Foundation Trust
considers that this data is as described for the
following reasons:
• T
he data source is the Health & Social Care
Information Centre.
Aintree University Hospital NHS Foundation Trust
intends to take the following actions to improve this
percentage, and so the quality of its services, by:
• The pre-operative department reinforcing the
48
Aintree University Hospital NHS Foundation Trust
importance of patients completing the postoperative questionnaires and its impact on future
patient experience
• In addition, a Trust patient reminder letter has
been developed and supported by Healthwatch
colleagues to encourage patients to complete
and return the post-operative questionnaire so
the Trust can use the information to understand
where we are doing well and where we can make
further improvements in our hospital care.
Domain 3: Helping people to recover from episodes of ill health or following injury
Period
Trust
Performance
National
Average
Lowest
NHS Trust
Highest
NHS Trust
Patients aged 0 to 15 years
2015/16
Not available
Not available
Not available
Not available
2014/15
Not available
Not available
Not available
Not available
2013/14
Not available
Not available
Not available
Not available
2012/13
Not available
Not available
Not available
Not available
2011/12
0
10.01
5.10
13.58
2010/11
0
10.15
5.85
13.94
2009/10
0
10.18
6.38
14.44
2015/16
Not available
Not available
Not available
Not available
2014/15*
14.46%
Not available
Not available
Not available
2013/14*
13.20%
Not available
Not available
Not available
2012/13*
13.42%
Not available
Not available
Not available
2011/12
11.76%
11.45%
8.96%
13.50%
2010/11
12.11%
11.42%
7.6%
12.94%
2009/10
12.34%
11.16%
7.3%
13.17%
Patients all ages
Table 32: Emergency readmissions to hospital within 28 days of discharge A
(Data source: Health and Social Care Information Centre)
* Data source is Trust generated, and includes all age groups
Aintree University Hospital NHS Foundation Trust
considers that this data is as described for the
following reasons:
Aintree University Hospital NHS Foundation Trust
intends to take the following actions to improve this
percentage, and so the quality of its services, by:
• T
he Trust readmissions rate is comparable
to that expected.
• T
he Trust continues to work with CCG teams,
Accident and Emergency and local Mental Health
providers to reduce readmission and frequent
AED attendee rates.
Aintree University Hospital NHS Foundation Trust
49
Domain 4: Ensuring that people have a positive experience of care
Period
Trust
Performance
National
Average
Lowest
NHS Trust
Highest
NHS Trust
2015/16
83.00%
77.30%
Not available
Not available
2014/15
77.30%
76.60
67.40
87.40
2013/14
Not available
76.90
67.10
86.70
2012/13
Not available
76.50
68.00
88.20
2011/12
77.50
75.60
67.40
87.80
2010/11
73.90
75.70
68.20
87.30
2009/10
76.50
75.60
68.60
86.00
2008/09
75.40
76.00
68.10
87.60
2007/08
76.00
75.30
66.80
86.50
2006/07
76.10
75.70
67.70
87.20
Table 33: Responsiveness to inpatients’ personal needs
(Data source: Health and Social Care Information Centre Indicators Portal, NHS Outcomes Framework Indicator 4.2)
Aintree University Hospital NHS Foundation Trust
considers that this data is as described for the
following reasons:
• D
ata source is governed by a standard national
definition and results reported from a statistical
data set on the Health and Social Care website.
Aintree University Hospital NHS Foundation Trust
intends to take the following actions to improve this
percentage, and so the quality of its services, by:
• F
amily/dining room’s project – the family
dining room project on Major Trauma Ward is
on hold pending the relocation of the ward. The
project on Ward 16 is expected to be completed
by the end of Qtr 1 2016/17.
• E
xploration of opening visiting project - the
Trust was invited to participate in NHS England’s
‘Always’ Events Programme and between
September 2015 and April 2016 in which the Trust
worked closely with the NHS England team to
pilot Flexible visiting on 2 wards. The project has
been taken forward into the Patient Experience
Improvement Plan for 2016/17 with rollout across
the organisation expected by the end of Qtr 4
2016/17.
• P
atient and family shadowing and
engagement - a pilot of 6 shadowing
experiences took place in Qtr 3 and Qtr 4 in
2015/16. This project has been carried forward
into the 2016/17 Patient Experience Improvement
Plan and Year 3 Quality Strategy Delivery Plan,
with milestones for completion each quarter.
50
Aintree University Hospital NHS Foundation Trust
• C
ontinued to purchase additional bi-annual
patient feedback surveys from Picker to allow
proactive analysis and identification of
any sub-optimal patient experience - The
questions to be included in this voluntary survey
are to be reviewed following receipt of our Picker
2015 survey results to ensure we are focussing
on those areas where we have not made any
improvements.
• T
he Trust received one Enter and View Report
from Healthwatch Liverpool in Qtr 4 2015/16.
Actions to address recommendations were
detailed in the Trust’s response of 31.3.2015.
Domain 4: Ensuring that people have a positive experience of care
Period
Trust
Performance
National
Average
Lowest
NHS Trust
Highest
NHS Trust
2015/16 – Qtr 4
96.0%
96.0%
72.0%
100%
2015/16 – Qtr 3
97.0%
96.0%
72.0%
100%
2015/16 – Qtr 2
98.0%
95.7%
74.0%
100%
2015/16 – Qtr 1
98.0%
95.0%
82.0%
100%
2014/15 – Qtr 4
98.1%
94.7%
70.8%
100%
2014/15 – Qtr 3
98.4%
94.5%
78.6%
99.5%
2014/15 – Qtr 2
98.1%
94.0%
73.6%
100%
2014/15 – Qtr 1
97.2%
94.3%
77.0%
99.0%
2013/14 – Qtr 4
97.9%
94.1%
74.0%
98.9%
2013/14 – Qtr 3
97.0%
93.7%
72.0%
99.4%
2013/14 – Qtr 2
97.0%
94.0%
81.6%
100%
2013/14 – Qtr 1
97.6%
94.2%
82.9%
98.2%
Table 34: Friends and Family Test – In-patient Care
(Data source: NHS England - Statistical Work Areas)
Aintree University Hospital NHS Foundation Trust
considers that this data is as described for the
following reasons:
Aintree University Hospital NHS Foundation Trust
intends to take the following actions to improve this
score, and so the quality of its services, by:
• D
ata source is governed by a standard national
definition and results reported from a statistical
data set on the NHS England website.
• M
aintaining our proactive approach to
monitoring patient feedback to ensure
continuous improvement in reported patient
experience
• E
nsure that FFT reports are discussed at Divisional
Assurance Meetings to identify outlier wards
Aintree University Hospital NHS Foundation Trust
51
Domain 4: Ensuring that people have a positive experience of care
Period
Trust
Performance
National
Average
Lowest
NHS Trust
Highest
NHS Trust
2015/16 – Qtr 4
86.0%
85.5%
46.0%
100%
2015/16 – Qtr 3
85.0%
87.0%
33.0%
100%
2015/16 – Qtr 2
87.0%
88.0%
62.0%
100%
2015/16 – Qtr 1
84.0%
87.7%
60.0%
100%
2014/15 – Qtr 4
83.6%
87.6%
58.4%
97.9%
2014/15 – Qtr 3
85.2%
86.8%
59.6%
99.4%
2014/15 – Qtr 2
80.2%
86.7%
66.3%
99.0%
2014/15 – Qtr 1
78.8%
86.2%
62.2%
98.5%
2013/14 – Qtr 4
83.6%
87.6%
58.4%
97.9%
2013/14 – Qtr 3
85.2%
86.8%
59.6%
99.4%
2013/14 – Qtr 2
80.2%
86.7%
66.3%
99.0%
2013/14 – Qtr 1
78.8%
86.2%
62.2%
98.5%
Table 35: Friends and Family Test A&E
(Data source: NHS England - Statistical Work Areas)
Aintree University Hospital NHS Foundation Trust
considers that this data is as described for the
following reasons:
Patients have highlighted that the Trust needs
to make improvements in the following areas to
improve the patient experience:
• Waiting Time
• Staff Attitude
• Diagnostics & Investigations
Aintree University Hospital NHS Foundation Trust
has taken the following actions to improve this
score, and so the quality of its services, by:
• Facilitating early senior assessment
• Improved communication about waiting times in
waiting areas
• D
evelopment of Ambulatory Emergency Care and
changes to pathway for accepted patients
• Better management of frequent attenders
• Enhanced Out Of Hours GP stream
• Improved provision of Ambulatory Care in AED
52
Aintree University Hospital NHS Foundation Trust
• F urther development of Advanced Nurse
Practitioner model
• R
evised AED escalation and ambulance handover
protocol
• Improved collaboration with Mental Health Team
• R
etrospective review of case presentations to
identify inappropriate delays
• Programme of work ongoing with OD team
• Regular departmental meetings continue
• Complaint themes shared with wider teams
• Improved working environment for staff
• R
etrospective review of case presentations to
identify inappropriate delays and appropriateness
of treatment
• P
lans to introduce medical support workers which
help reduce delays
• W
orking closely with Radiology to identify delays
in scans
Domain 4: Ensuring that people have a positive experience of care
Period
Trust
Performance
National
Average
Lowest
NHS Trust
Highest
NHS Trust
2015
70
70
46
85
2014
70
65
38
89
2013
65
65
40
89
Table 36: Percentage of staff who would recommend the provider to friends or family needing care
(Data source: Health and Social Care Information Centre)
Aintree University Hospital NHS Foundation Trust
has taken the following actions to improve this
percentage, and so the quality of its services, by:
• D
ata source is governed by a standard national
definition and results reported from a statistical
data set on the Health and Social Care website.
• U
nderstanding the deterioration in staff
recommending the organisation as a place to
work or receive treatment, especially in the
context of the Staff FFT feedback for Qtr 4
through engagement work.
Aintree University Hospital NHS Foundation Trust
considers that this data is as described for the
following reasons:
• W
ork is already underway with regard to the Self
Care programme and the recent “Mindfulness”
Lia event.
• A
ct on the feedback from the recent Investors in
People accreditation.
• Improving appraisal compliance and quality
through 2016/17
• Improving incident reporting and learning
from mistakes in response to the Learning from
Mistakes Report
Aintree University Hospital NHS Foundation Trust
53
Domain 5: Treating and caring for people in a safe environment and protecting them from
avoidable harm
Period
Trust
Performance
National
Average
Lowest
NHS Trust
Highest
NHS Trust
2015/16 – Qtr 4
94.74%
95.53%
78.06%
100%
2015/16 – Qtr 3
95.40%
95.50%
61.50%
100%
2015/16 – Qtr 2
96.10%
95.90%
75.00%
100%
2015/16 – Qtr 1
94.80%
96.00%
88.00%
100%
2014/15 (Qtr 4)
95.00%
96.00%
79.00%
100%
2014/15 (Qtr 3)
94.36%
95.96%
81.19%
100%
2014/15 (Qtr 2)
95.21%
96.19%
86.37%
100%
2014/15 (Qtr 1)
95.42%
96.16%
87.25%
100%
2013/14 (Qtr 4)
95.25%
96.00%
78.86%
100%
2013/14 (Qtr 3)
94.75%
95.84%
77.70%
100%
2013/14 (Qtr 2)
92.43%
95.74%
81.70%
100%
2013/14 (Qtr 1)
91.20%
95.45%
78.78%
100%
Table 37: Percentage of admitted patients risk-assessed for Venous Thromboembolism
(Data source: Health and Social Care Information Centre)
Aintree University Hospital NHS Foundation Trust
considers that this data is as described for the
following reasons:
Aintree University Hospital NHS Foundation Trust
intends to take the following actions to improve this
percentage, and so the quality of its services, by:
• D
ata source is governed by a standard national
definition and results reported from a statistical
data set on the Health and Social Care website.
• C
ontinuing with flashing purple dots on Ward
wipeboards highlighting patients without a VTE
risk assessment as a reminder for staff
• C
ontinuing with weekly performance emails on
VTE risk assessment to wards and clinical teams.
• P
erformance discussed at the Junior Doctor
Forums
• P
erformance data included in the Ward’s league
table to identify the monthly Team Quality
Management Awards
54
Aintree University Hospital NHS Foundation Trust
Domain 5: Treating and caring for people in a safe environment and protecting them from
avoidable harm
Period
Trust
Performance
National
Average
Lowest
NHS Trust
Highest
NHS Trust
2015/16
Not available
Not available
Not available
Not available
2014/15
27.5
15.1
0.0
62.2
2013/14
32.2
14.7
0.0
37.1
2012/13
29.3
17.4
0.0
31.2
2011/12
25.0
22.2
0.0
58.2
2010/11
31.3
29.7
0.0
71.2
2009/10
37.8
35.4
0.0
92.0
2008/09
121.4
53.2
0.0
128.9
2007/08
73.1
89.7
0.0
224.0
Table 38: Rate of C. difficile Per 100,000 Occupied Bed days
(Data source: Health and Social Care Information Centre)
Aintree University Hospital NHS Foundation Trust
considers that this data is as described for the
following reasons:
• D
ata source is governed by a standard national
definition and results reported from a statistical
data set on the Health and Social Care website.
Aintree University Hospital NHS Foundation Trust
intends to take the following actions to improve this
percentage, and so the quality of its services, by:
• Implementation of the HCAI Reduction Action
Plan and CDI action plan
• T
he revision of the CDI guideline to include
improved testing and treatment of patients
with moderate and severe disease CDI with
fidaxomicin. This aims to reduce relapse and has
the potential reduce the spore formation and
hence contamination of the environment.
• A
n external review from Professor Mark Wilcox
who is a national expert in CDI, took place in April
2015. Recommendations were monitored through
the Infection Prevention and Control Group.
These included;
- Clostridium difficile testing
- Optimisation of diarrhoeal control
- Antimicrobial prescribing
- Environmental cleaning/decontamination
-Engagement of staff with the IPC programme/
objectives
- Hand hygiene practices
• C
ontinued delivery of ward based CDI training
using the CDI grab pack
• T
he delivery of department based drop in IPC
mandatory training
• T
he CDI collaborative expert group and 1st
learning session was held in 2015. Due to
unforeseen circumstances with operational
pressures, the collaborative was not viable in its
current form. The training and improvements
were directed through the IPC Link Group.
• A limited deep clean programme of wards.
• A
ntibiotic ward rounds are undertaken on all
wards weekly and daily on Critical Care.
• T
he use of fidaxomicin has been agreed for the
use in patients with moderate and severe disease.
This treatment aims to reduce relapse and has the
potential reduce the spore formation and hence
contamination of the environment.
• IPC and CDI awareness has been the focus
of senior nurse walk rounds and feedback to
clinical staff
• T
he implementation of collaborative IPC ‘sweeps’
following a patient with CDI. This involves IPC,
domestic services, facilities and ward staff and the
aim is to identify and reduce risks associated with
transmission.
• T
he implementation of the successful Dragons
Den UV tagging system to monitor cleaning.
• C
ollaborative work with the CCG has continued
throughout the year. The health economy root
cause analysis tool is still in development and this
is being led by the CCGs.
Aintree University Hospital NHS Foundation Trust
55
Domain 5: Treating and caring for people in a safe environment and protecting them from
avoidable harm
Period
Trust
Performance
National
Average
Lowest
NHS Trust
Highest
NHS Trust
Apr 15 – Sep 15**
0.6
0.40
0.01
2.9
Apr 14 - Sept 14**
27.5
15.1
0.0
62.2
Oct 13 - Mar 14*
32.2
14.7
0.0
37.1
Oct 12 - Mar 13*
29.3
17.4
0.0
31.2
Table 39: Rate of patient safety incidents and percentage resulting in severe harm or death
(Data source: Health and Social Care Information Centre)
*Data based on Medium Acute
** Data based on all acute providers (non specialist)
Aintree University Hospital NHS Foundation Trust
considers that this data is as described for the
following reasons:
Aintree University Hospital NHS Foundation Trust
intends to take the following actions to improve this
percentage, and so the quality of its services, by:
• D
ata source is governed by a standard national
definition and results reported from a statistical
data set on the Health and Social Care website
• C
ompleting actions from SUI investigations and
ensure lessons learnt are disseminated Trust wide.
Reporting against key national priorities
Aintree is required to report its performance with
a list of published key national priorities, against
which the Trust is judged. Aintree reports its
performance to the Board and the Trust’s regulators
throughout the year. Actions to address any areas of
underperformance are put in place where necessary.
These performance measures and outcomes help
Aintree to monitor how it delivers its services.
56
Aintree University Hospital NHS Foundation Trust
100%
90.5%
100%
93.3%
98.4%
94% of patients
treated within
31 days
98% of patients
treated within
31 days
85% of patients
treated within
62 days
90% of patients
treated within
62 days (target
previously 81.8%)
Cancer - 31 day wait
for second treatment Surgery
Cancer - 31 day wait
for second treatment Drug treatment
Cancer - 62 day wait
for first treatment
Cancer - 62 day wait
for first treatment from
consultant screening
service
Safety
Quality
Quality
Quality
Quality
18 week referral to
90% of patients
Patient
treatment waiting times waiting less than
Experience
- admitted
18 weeks.
18 week referral to
95% of patients
Patient
Treatment waiting times waiting less than
Experience
- non admitted
18 weeks.
99%
97.4%
93.7%
57.1%
85.0%
100%
99.0%
0
As per trajectory
(0 cases in year) –
Cumulative
MRSA (Hospital
Acquired Infection)
Safety
0
14
As per trajectory
agreed with PCT
7
(46 cases in the year)
- Cumulative
Qtr 2
Clostridium Difficile
(Hospital Acquired
Infection)
Qtr 1
Threshold
Indicator
RAG
Area
96.9%
91.7%
90.5%
88.5%
100%
98.2%
1
20
Qtr 3
RAG
RAG
95.9%
90.60%
91.10%
78.40%
100%
100%
1
35
Qtr 4
Performance
97.1%
92.4%
89.80%
84.60%
100%
98.8%
2
35 + 19
Annual
2015/16
97.9%
93.6%
80.08%
86.95%
99.50%
98.68%
2
41 + 23
Annual
2014/15
Performance against key national priorities from the Monitor Compliance Framework 2015/16
Aintree University Hospital NHS Foundation Trust
Aintree University Hospital NHS Foundation Trust
57
RAG
RAG
Indicator
Threshold
Aintree University Hospital NHS Foundation Trust
95.1%
95% of patients
waiting less than
4 hours.
Quality
94.4%
95.0%
96.6%
99.4%
96.8%
Qtr 2
86.9%
95.7%
96.5%
98.3%
93.2%
Qtr 3
86.5%
94.20
95.3%
98.3%
94.1%
Qtr 4
90.6%
94.9%
96.0%
99.0%
95.7%
Annual
2015/16
RAG
RAG
RAG
RAG
90.6%
95.5%
97.1%
99.33%
*97.51%
Annual
2014/15
Table 40: Green ratings indicate that the Trust met the target and red that the target was under achieved.
*The annual figure is different from the average of the monthly figures following adjustments made during the quality assurance work undertaken by our auditors
**Includes Type 3 activity from November onwards 2013
Patient
Total time in Accident
Experience and Emergency ** A
93.6%
93% of patients
seen within 2 weeks
Cancer -2 week
wait from referral
to first seen - breast
symptomatic patients
95.5%
93% of patients
seen within 2 weeks
Cancer -2 week wait
from referral to first
seen - all cancers
Quality
100%
96% of patients
treated within
31 days
Cancer -31 day wait
from diagnosis to first
treatment
97.3%
Qtr 1
Quality
18 week referral to
92% of patients
Patient
Treatment waiting times
on an incomplete
Experience – incomplete pathways
pathway
A
Area
Performance
RAG
58
Part 3
Other information
An overview of the quality of care offered by Aintree – performance in 2015/16
Quality indicator
Year
Reason for
identified selection
Aintree performance
2013/14
2014/15
2015/16
Patient Safety
Improving our
mortality ratings
by reducing
avoidable
mortality
2010
The Trust’s mission
is to get it right
for every patient,
every time by
strengthening
patient safety
to reduce rates
of avoidable
mortality.
HSMR basket (used in line with the Dr Foster
Intelligence methodology)
91.77
88.69 (rebased)
87.81
112
100.15
SHMI
113.1
Crude Death Rates (% of discharges registered as
deceased)
3.35%
3.29%
3.09%
Mortality is measured by the use of national
reports such as Hospital Standardised Mortality
Ratio (HSMR) or Summary Hospital-Level Mortality
Indicator (SHMI) and actual death numbers. These
measures try to predict whether the death rate in a
hospital is higher or lower than expected based on
statistical analysis of certain medical conditions and
outcomes that can show whether a hospital needs
to make improvements in services.
(Data source: Dr Foster Intelligence which is governed by a
standard national definition)
Reducing
weight loss and
dehydration by
aiming for 95%
completion of
the Malnutrition
Universal
Screening Tool
(MUST) on
admission to
hospital
2010
Nutrition has
been identified
as a key area for
improvement
nationally from
findings in the
Francis Report
(2013). The
Malnutrition
Universal Screening
Tool (MUST) is now
recommended best
practice as a way to
screen patients’ to
identify and treat
adults at risk of
malnutrition whilst
in hospital.
Qtr 4 = 70%
Qtr 4 = 90%
Qtr 4 = 87%
completion
completion
completion
• A
dditional communications sent out Trust wide to
raise awareness
• M
UST champions identified on wards to drive
performance
• R
eviewing emerging trends for non- completion
to target performance improvements
• Moving towards weekly performance reporting
• Collaborative Improvement Project established.
(Data source: aBI which is not governed by a standard national
definition)
Aintree University Hospital NHS Foundation Trust
59
Quality indicator
Year
Reason for
identified selection
Reducing
2010
avoidable patient
harms from VTE,
malnutrition, falls
and pressure ulcers
The Trust’s mission
is to get it right
for every patient,
every time by
strengthening
patient safety to
reduce rates of
avoidable harm.
Aintree performance
2013/14
2014/15
2015/16
870 patient
harms (Qtr 4
VTE harms not
available)
814 patient
harms (Qtr 4
VTE harms not
available)
661 patient
harms
(inc VTE harms)
Supported by the delivery of Aintree’s 3 year Quality
Strategy where its Priority 1 focus is on reducing
harm and avoidable mortality.
(Data source: Datix, the Trust’s Incident Reporting System which
is not governed by a standard national definition)
Clinical effectiveness
Maintaining
2010
the national
standard of 95%
for completion
of Venous
Thromboembolism
(VTE) risk
assessments for
eligible patients
and analyse
root cause of
any subsequent
hospital acquired
thrombosis (HAT)
Improving
2013
the quality of
Dementia care by
raising awareness
and achieving 90%
completion of Risk
Assessments to
improve diagnoses
of patients over
75 admitted as an
emergency
60
Aintree University Hospital NHS Foundation Trust
In 2005, the House
of Commons
Health Committee
reported that an
estimated 25,000
people die from
preventable
hospital-acquired
VTE in the UK every
year. The risk of
hospital-acquired
VTE can be greatly
reduced by risk
assessing patients
and prescribing
them appropriate
prophylaxis
(preventative
measures).
Qtr 4 95%
completion
Dementia is
a significant
challenge for the
NHS - 25% of
beds are occupied
by people with
dementia, their
length of stay is
longer than people
without dementia
and they often
receive suboptimal
care. Half of
those admitted
to hospital with
dementia have
never been
diagnosed prior
to admission
and other causes
of cognitive
impairment such
as delirium or
depression are
often missed.
Qtr 4 72.6%
completion
Qtr 4 94.5%
completion
Qtr 4 94.7%
subject to
validation
Supported by weekly performance emails on VTE
risk assessment to wards and clinical teams. VTE risk
assessment performance is also included in Aintree’s
monthly Team Quality Management Awards.
The Trust has secured a new VTE clinical lead
that has trialled a new system and process for
undertaking HAT RCAs. A full HAT RCA report has
been produced each quarter which is presented
to the Exec Led Clinical Effectiveness Group then
shared with our CCGs.
(Data source: Unify2 which is governed by a standard national
definition)
Qtr 4 90.1%
completion
Qtr 4 88.8%
completion
Due to successful team work and huge efforts from
our consultants and Junior Doctors the dementia
assessment standard was achieved throughout Qtr
2 and Qtr 3 in 2015 but in Qtr 4 we achieved 88.8%
for Step 1, slightly missing the national standard.
• P
lanning & Commissioning Team review
performance on a daily basis and liaise directly
with the Dementia Super User to target patients
not yet screened.
• S upported by weekly performance emails on
Dementia risk assessment to wards and clinical
teams.
• T
he Consultant Clinical Lead now audits step 2
breaches and step 3s on a weekly basis.
• D
ementia risk assessment performance is also
included in Aintree’s monthly Team Quality
Management Awards.
Data source: Unify2 which is governed by a standard national
definition)
Quality indicator
Increasing
compliance
against the WHO
Safe Surgery
Checklist
Year
identified
Reason for
selection
2013
WHO launched
a second Global
Patient Safety
Challenge, ‘Safe
Surgery Saves
Lives’, to reduce
the number of
surgical deaths
across the world.
The checklist is part
of this initiative
and is a tool for the
clinical teams to
improve the safety
of surgery.
Aintree performance
2013/14
2014/15
2015/16
Sign in
compliance
99%
Sign in
compliance
95%
Not known
at the time of
reporting
Time out
compliance
96%
Time out
compliance
98%
Not known
at the time of
reporting
Sign out
compliance
95%
Sign out
compliance
97%
Not known
at the time of
reporting
An in depth Audit is taking place in May 2016
therefore the detailed results are not known at the
time of reporting.
However, the monthly audits reported to the Trust’s
Quality & Safety Committee against the briefing and
checklist completion is predominantly 100% across
all theatres.
Compliance continues to be published on the ‘How
are we doing boards’ in each theatre area.
(Data source: Monthly checklist monitoring 2015/16 which is not
governed by a standard national definition)
Patient experience
Increasing overall 2010
patient experience
rate in National
In-patients Survey
Understanding
experiences of
service users and
their carers is
central to being
able to provide
high quality
services and
identify areas for
improvement.
Rated experience as greater than 7/10 (previously
rated “good” or “excellent”)
82%
88.1%
87.7%
National
average 83%
National
average 84%
National
average 84.7%
Results show that Aintree has maintained the
improvement made in the previous year and note
that the Trust score is 3% above the national
average.
(Data source: Picker National In-patient Survey Results in
February 2015 which is governed by a standard national
definition)
Aintree University Hospital NHS Foundation Trust
61
Quality indicator
Improving
communication
between patients
and staff
Year
identified
Reason for
selection
2011
Clear
communication
between patients
and staff is a key
factor in improving
the patient
experience during
their hospital stay
by keeping them
informed about
their care.
Q1 Patients had
confidence and
trust in the nurses
treating them
Q2 Patients
understood the
answers nurses
provided
Aintree performance
2013/14
2014/15
2015/16
Results of patients answering, yes always and yes
sometimes
Qtr 1 86.5%
Qtr 1 96.1%
Qtr 1 96.7%
Qtr 2 96%
Qtr 2 94.9%
Qtr 2 96.1%
Qtr 3 96.4%
Qtr 3 96.5%
Qtr 3 95.0%
Qtr 4 89.3%
Qtr 4 91.6%
Qtr 4 91.9%
Results show that the Trust has improved in 3 out of
the 4 key communications questions in 2015/16.
(Data source: Picker National In-patient Survey Results in
February 2015 which is governed by a standard national
definition)
Q3 Patients
understood the
answers doctors
provided
Q4 Patients
felt involved in
discussions about
their care
Improving the
complaints
management and
learning from
concerns and
complaints
2011
The handling of
complaints and
concerns should be
of a high quality
and robust so that
any improvements
are highlighted
and cascaded
throughout the
trust in order
to continually
improve services
and share best
practice.
Complaints
Patient Ethnicity
67 not stated
109 not stated
133 not stated
247 White
British
179 White
British
197 White
British
1 Mixed White
& Asian
1 Pakistani
3 other White
1 other White
2 other White
1 White Irish
1 other Ethnic
1 other Ethnic
1 White Irish
Total 319
Total 290
Total 335
Complaints
Patient Ethnicity
303 not stated
761 not stated
151 not stated
690 White
British
337 White
British
1019 White
British
2 Indian
1 Pakistani
1 Chinese
1 Black African
1 Chinese
2 other mixed
4 other White
11 other White
3 White Irish
3 White Irish
Total 1107
Total 1188
2 other White
Total 997
(Data source: Datix, the Trust’s Incident Reporting System which
is not governed by a standard national definition)
62
Quality indicator
Year
identified
Reason for
selection
Aintree performance
2013/14
2014/15
2015/16
Compliments
Total 586
Total 10598
Total 13072
To support the handling of complaints the Trust’s
“Comments, Concerns and Complaints” leaflets and
posters are available on wards/departments and
reception areas for members of the public and staff.
An audit is now undertaken each month to ensure
there is a supply on each ward. There is also the
Patient Advice and Complaint Desk situated on the
ground floor of the main hospital available to help
members of the public, patients, carers and relatives.
This has enabled a greater increase in accessibility
to the Patient Advice and Complaints Team (PACT)
and an increase in concerns reported. The PACT
has benefited from the appointment of additional
members of staff providing continued customer
service.
(Data source: Datix, the Trust’s Incident Reporting System which
is not governed by a standard national definition)
Increasing patient
experience
feedback through
the Friends and
Family Test for Inpatients and A&E
2012
Encouraging
service users and
their carers to
feedback on their
experiences is
central to being
able to provide
high quality
services and
identify areas for
improvement.
Overall response rate for In-patients
& A&E combined
March 2014
March 2015
March 2016
32%
35.5%
31.1%
(Data source: Unify2 which is governed by a standard national
definition)
Aintree University Hospital NHS Foundation Trust
63
Additional information on improving the
quality of Aintree’s services in 2015/16
Below is a selection of the work over the past year
that some of the Trust’s services, as detailed in
Part 2, Information on the review of services, have
undertaken to improve the quality of the services
they provide.
Implementation of the Duty of Candour
Aintree has developed a comprehensive action plan
which has been signed off by the Trust Board.
Examples of some of the actions include:
• D
evelopment of a flow diagram of the Trust’s
Duty of Candour reporting process
• D
evelopment of a Patient Information Leaflet
to support the process for patients and families
• A
checklist for informing relevant person of
an incident including the need for an apology
along with template letters developed
• E
ducation and Awareness raising completed
through Trust wide communications
• A
ll investigation reports agreed and signed off
at the Weekly Meeting of Harm which is led by
the Trust Medical Director
• D
iscussed with Commissioners at Contract
Review Meetings.
64
Aintree University Hospital NHS Foundation Trust
Improving Patient Safety
Quality showcase
In October 2015, staff attended the second Quality
Showcase, an event that celebrated the great work
being done throughout Aintree to provide harm
free care to all our patients. The event marked
twenty months since the publication of Aintree’s
Quality Strategy that describes our vision of
providing world class services for all our patients.
Staff and stakeholders were invited to join both
clinical and non-clinical teams from across Aintree
to find out more about the quality improvement
work underway that will help achieve our vision.
Teams were on hand to provide information on
areas such as Infection Prevention and Control (IPC),
Falls Prevention, Avoidable Mortality Reduction,
Pressure Ulcer Reduction and Management,
Patient Experience, VTE, Medicine Safety and
Dementia Care.
Other teams manning information stalls included
the Palliative Care team, Staff Engagement and
Organisational Development team, AQUA and
the team from Main A theatres who provided
information on Aintree’s use of the WHO checklist.
The Showcase also highlighted the linkage between
the Quality Strategy with NHS England’s Sign Up
To Safety campaign to improve patient care. The
campaign objectives are closely aligned with our
Quality Strategy with a shared goal of ensuring
patients receive the safest possible care.
Staff Flu Jab Uptake
Aintree was one of just 18 trusts in the country
to reach the 75% for flu jabs.
Through dogged determination and innovative
ideas, the flu campaign was a resounding
success for Aintree. The campaign success was
a perfect example of employees across all levels
understanding the benefit of this immunisation
and doing what they could to ensure its success.
“Employees across all levels understand
the benefit of flu immunisation and do
what they can to ensure its success”
Many health care workers went the extra mile and
were trained up as ‘flu link immunisers’ by OH team
members they were then able to immunise their
colleagues within their respective workplaces! The
OH team worked relentlessly in many locations
and across the 24hour period to ensure maximum
opportunity for uptake. Initiatives such as ‘jab at
the hut’ and ‘pop up clinics’ were deployed as well
as the ability to drop into the department at the
convenience of the individual. The offer of novelty
pens, sweets and coffee vouchers were presented
and greatly received by those who had the
vaccination and there were also initiatives such as
early bird prizes to those staff who engaged at the
launch of the campaign.
Pictured left to right Andrea Heaton, Infection Prevention
& Control Specialist Nurse, Damian Burns, Infection
Prevention & Control Specialist Nurse, Anne Jones,
Infection Prevention & Control Support Worker and Ruth
May Infection Prevention & Control Clerical Officer.
The support from the Comms team was pivotal
in ensuring all employees were clear on locations
and times when clinics were being held as well
as clarifying the need for us to champion the ‘flu
fighters’ cause. This campaign showed the ability
to deliver on a mammoth tasking through cross
networking and collaboration and through us
all being clear on the message relating to why as
a public health intervention, the flu vaccination
campaign is the right thing to do for us as
employees and for our patients!
Patient at a Glance Boards
Every patient will have one of these boards (pictured
below) above their bed space. The purpose of the
boards is to be able to identify quickly from the end
of the bed key details about the patient including
their preferred name and any elements of care, such
as risk of falling and communication difficulties, that
are important for any staff member interacting with
patient to be aware of.
Bed number, Name, Name I like to be called,
Named Nurse and Consultant should be completed
by the nurse caring for the patient on admission to
the ward.
In addition the section labelled “What matters most
to me” should be completed after discussion with
the patient. This could relate to anything the patient
feels is important relating to their care. Patients
should be reassured that this is optional.
Aintree University Hospital NHS Foundation Trust
65
Education Improvement Plan
The Trust is committed to the provision of excellence
in education and learning to ensure that its
workforce and learners joining us for part of their
training are equipped to deliver the needs of our
patients now and in the future.
An education Improvement Plan was agreed in
August 2015 and a new Head of Education &
Learning recruited. All education functions (clinical
skills, resource, simulation, learning & development
and medical education) merged under one umbrella
in December 2015. In addition, developments are
underway to improve lives for junior/trainee doctors
for example a full review of rotas was commissioned,
protected teaching/hours of work monitoring
policy developed and a Trainee bulletin introduced
to improve communication. All developments
were summarised in a presentation for the Health
Education North West (HENW) visit in February 2016
and initial feedback recognised that improvements
had been made but was acknowledged that further
work is required and the Trust are now awaiting
the final report. Within the next 12 months, the
following roles will be developed; medical support
Registered Nurse (RN) Revalidation
Pictured above, dozens of doctors in training at Aintree took the
chance to thank colleagues for helping them out in their first days
– with two special banners.
worker role, advanced nurse roles and physician
associate learners as part of a pilot with HENW and
Liverpool University.
In addition, mandatory training has been reviewed
with improvements made to the Trust’s on line
learning process and increased face to face learning
for level 1 mandatory training modules and blocked
refresher days introduced for level 2 training.
• 4
50 practice hours or 900 if revalidating as both a
Registered Nurse and Midwife
• 3
5 hours CPD including 20 hours participatory
learning
• Five pieces of practice related feedback
• Five written reflective account
• Reflective discussion
• C
omplete the online mandatory health and
character declaration
• Professional indemnity arrangements
Pictured above is Nicola Firth, Director of Nursing (middle)
with two Aintree nurses collecting their RN Revalidation
Portfolios on one of the collection dates which have been
taking place since January, 2016.
Revalidation is an addition to the annual PIN Expiry
date that all Registered Nurses are still required
to renew to maintain their registration with the
Nursing and Midwifery Council (NMC). Revalidation
is required every three years.
Revalidation builds on existing renewal
requirements by introducing new elements which
encourage Registered Nurses and Midwives to
reflect on the role of the Code in their practice and
demonstrate that they are ‘living’ the standards set
out within it.
The requirements for revalidation over a period of
three years include:
66
Aintree University Hospital NHS Foundation Trust
The Corporate Nursing Team is ensuring that staff
are provided with lots of support and resources
to help them through the new process starting in
April 2016.
Developments include:
• R
N Revalidation Focus Groups arranged at various
times of the day to provide flexibility for all RNs
to attend at the most convenient time.
• A
Registered Nurse (RN) Revalidation webpage
with access to lots of information and advice in
addition to a Frequently Asked Questions (FAQ)
section
• A
Revalidation Portfolio has been provided for
every RN to collate evidence/information
• Standardised documentation
Learn, Excel, become an
Aintree Professional (LEAP)
Aintree are confident that
student nurses can go from a new
member of nursing staff to an
Aintree Professional – The LEAP
programme allows them to Learn,
Excel and become an Aintree
Professional.
The LEAP programme supports
student nurses through their first
6 months at Aintree University
Hospital NHS Foundation
Trust, equipping them with a
practical “toolkit” of skills and
experiences which they can use
to develop themselves into a
full–fledged member of Aintree’s
healthcare team.
Introduction to Patient
Safety and Human Factors
in Healthcare
Aintree have undertaken a great
deal of work with the University,
HEE North West, AHSN and AQuA
over the last 12 months to build
a collaborative network around
Human Factors. The Assistant
Director of Organisational
Development in conjunction with
Our innovative 6 month
programme is led by Nurse
Educators in our Senior Nursing
Team with proven ability to coach
and mentor nurses. The course
will add to their transition to
the role of Staff Nurse and will
enhance their clinical expertise,
help them master complex
concepts, sharpen their critical
thinking ability, promote career
advancements and develop their
leadership potential.
In addition to having the personal
and professional support of their
one-on-one preceptor, they will:
• A
ttend classes taught by
Nurse Educators, experienced
clinicians and resource experts
the team at the Simulation Centre
have developed a pathway of
education and training up to and
including higher academic study.
Through working in partnership
the following programmes have
been developed:
• Introduction to Human Factors
– half day course available for
all staff at Aintree.
• Apprenticeship in Human
in Patient Advocacy, Patient
Satisfaction, Pastoral Care,
Risk Management and
Palliative Care
• P
articipate in a variety of
learning experiences: lectures,
hands-on practice, skills labs,
large and small group activities
and clinical scenarios
• L earn from others, their
own experience and from
feedback through discussions
with their peers
• G
et encouragement, coaching
and professional development
support through discussions
with their LEAP Nurse Educator.
Factors and Non-Technical
Skills – 6 month programme
facilitated by simulation centre
and funded by HEENW
• A
pplied Human Factors
programme – 5 day course for
teams supported by AQuA
• “
Introduction to Human
Factors and Patient Safety in
Healthcare” – 20 credit module
at Master’s Degree Level
Aintree University Hospital NHS Foundation Trust
67
across the hospital and is running alongside the
Trust’s discharge programme, which is working in
partnership with community and Local Authority
providers to improve patient flow across the whole
system. The EACP is based on a set of principles
which form a framework for implementation to
develop one vision/ model of care for the Trust to
improve the quality of care for emergency patients.
The new Urgent Care and Trauma Centre
Opens with new Model of Care
Phase 1 of Aintree’s new Urgent Care and Trauma
Centre (UCAT) opened on 10 June 2015. The new
centre is one of the most modern Emergency
Departments in the North West, providing major
trauma and resuscitation, major and minor illness
and injury services. It also supports the hospital’s role
in the regional major trauma centre collaborative,
treating critically-injured patients from across
Merseyside and Cheshire.
An Emergency & Acute Care Programme (EACP)
has been developed to improve patient flow
Underpinning the principles are clear clinical
pathways and protocols with measurable
performance metrics. Some of the key elements
are early Senior Review across all teams, improved
communication to facilitate coordination (board
huddles), one ‘Medical Take’ with clear roles and
functions, protected Assessment Capacity in A&E
and Assessment units and clear patient flow rules
in and out of hours. A dedicated Programme
Manager with the support of teams for each of the
5 workstreams (Medical Assessment, A&E, Frailty,
Ward processes and Surgical Assessment & Critical
Care) is in place.
Phase two is currently underway to convert the old
Accident and Emergency Department into a centre
for minor injuries, with a medical assessment unit
and an observation ward.
There will also be a new 24 bed Critical Care Unit
on the first floor, after the space has been
reconfigured. The project is expected to be
completed in Winter 2016.
Major Trauma Centre (MTC)
• C
heshire and Merseyside Major Trauma Network
maintained its position within the top 3
performing networks in the country as measured
by survival rates
• P
erformance is consistently above the national
average for all but one of the quality measures
outlined within the quarterly TARN Major Trauma
Quality dashboard
• M
ost significant improvement in performance is
that 63.1% of the Trauma Team patients are now
receiving a CT scan within 30 minutes of arrival
at the MTC, against a national average of 42.4%.
This achievement was enabled by the opening of
the new CT scanner co located in AED as part of
the Phase 1 of the UCAT development completed
in June 2015
68
nominated by a patient and her family. The
patient quoted “The treatment I received from
the staff in the trauma ward was second to
none. Royalty would not have been treated
better”
• F ollowing completion of a comprehensive
feasibility study NHS England agreed to move
to a single receiving site at Aintree commencing
July 2016
• S haron Scott, the Clinical Director for Major
Trauma, was runner up and highly commended in
the Clinical Leader category of the National HSJ
Awards in November 2015 and Clinical Leader of
the year in the annual Proud of Aintree Awards
• T
he Major Trauma Ward Team was shortlisted
for the Proud of Aintree Award after being
• M
ajor Trauma Ward awarded Aintree ACE ward
status in January 2016.
Aintree University Hospital NHS Foundation Trust
Aintree Accreditation and Assessment (AAA)
This process provides the Trust with assurance that
the quality and safety of care is being monitored
and that action is being taken where any
fundamental standards of care are not met.
(CQC) Domains. Each of the 14 standards contains
between 10 and 20 individual elements that are
assessed and checked. Each standard is then rated as
‘Red’, ‘Amber’ or ‘Green’, depending on the number
of positive and negative answers. The ward then
receives an overall rating of Red, Amber or Green
that is based on the results of the 14 standards.
(See table below).
The framework is designed around 14 standards
which are matched to Care Quality Commission
Red
Six or more red standards
Amber
One - five red standards and /or less than seven green standards
Green
0 red standards and minimum seven green standards (AAA Standard 14 must be green)
‘ACE’ ward
Achieved after three consecutive greens
Ward Managers receive immediate feedback on the
day of the assessment and any urgent patient safety
concerns are escalated and resolved on the same
day. The Ward Manager (WM) is responsible for
formulating a robust action plan that is agreed with
the Matron and the relevant Divisional Director of
Nursing Services (DDNs).
End of Year Results (2014/15) & Quarters, 2 and 3 Results (2015/16)
Status at end of
Qtr 4 2014/15
Status at end of
Qtr 1 2015/16
Status at end of
Qtr 2 2015/16
Status at end of
Qtr 3 2015/16
Total number of wards/
departments with a Blue
(ACE) rating
0
1
4
6
Total number of wards/
departments with a
Green rating
11
10
10
11
Total number of wards/
departments with an
Amber rating
12
15
14
10
Total Number of wards/
departments with a
Red rating
2
0
0
2
When a ward’s overall rating is ‘Amber’ or ‘Red’ on
two consecutive occasions and there is little or no
evidence of improvement, the Matron, the Divisional
Director of Nursing Services and the Director of
Nursing and Quality will consider the actions that
are required.
Aintree University Hospital NHS Foundation Trust
69
Some of our ACE wards below being presented with their awards.
Ward Manager Pippa Storey and team Ward
17 (formerly Ward 16) pictured left receiving
the first ACE award, given by Aintree. Wards
have to achieve three consecutive assessments
that are rated as ‘Green’. The assessments
take place every six months, so this is an
indication that wards are consistently
achieving good standards of quality and
safety with regard to patient care.
The Aintree Frailty Unit (Ward 30) pictured
left receiving their ACE award in February
2016. Ward 30 had to apply to become an
ACE ward and the panel that makes the
decision consists of a Non-Executive Director,
the Director of Nursing and Quality, the
Deputy Director of Nursing and Quality and
the Corporate Assistant Director of Nursing.
Ward 30 was the 7th ward to achieve ACE
status and the second within the Department
of elderly medicine.
Named as European centre of excellence for Rheumatology
Aintree is a national Centre of Excellence
for the treatment of Behçets Disease
(pronounced ‘Betjets’), a rare and debilitating
inflammatory disease that causes a range of
serious and painful problems. Patients have
access to quicker diagnosis and specialist
treatment all in one place at Aintree and are
often the first in the country to benefit from
the latest research into the condition that
affects just 1 in 70,000 people in England. The
centre was developed following a successful
joint bid by Aintree and the Behçets
Syndrome Society and led by Professor
Robert Moots, pictured left, a renowned
international authority on Behçets Disease.
70
Aintree University Hospital NHS Foundation Trust
Aintree 2 Home
The Aintree 2 Home Unit is a
nurse and therapy led unit that
provides specialised in-patient
clinical care and support to
patients who no longer need
acute hospital care but are
waiting on assessments or
arrangements to be made prior
to being discharged home or to
another care setting.
What is the
Aintree 2 Home Unit?
Patients transferred to the
Aintree 2 Home Unit have been
assessed as medically fit by their
clinical team and no longer in
need of acute hospital care but
will be waiting on assessments or
arrangements to be made before
being ready for discharge.
These assessments or
arrangements can include
patients waiting on assessments
from therapists, social services
or discharge coordinators and
patients waiting on a package
of care or delivery of equipment
before being discharged.
The aim of the Aintree 2 Home
Unit is to provide continued
clinical care while preparing
patients for discharge to home
or an appropriate care setting.
The unit is staffed by a
dedicated team of nurses
and therapists including our
Aintree@Home team who provide
support to ensure patients
are transferred home or to an
appropriate care setting in the
best possible physical, mental
and emotional state.
Aintree at Home (A@H) has
supported Assessments in the
hospital that don’t always
identify the needs of the patient
at home. The team achieved
66% same day of discharge visits
which creates smooth discharge
of our patients and improves
their care & experience. Patients
are most at risk within 72 hours
post discharge to re-present at
the Emergency Department and
some re-admissions could have
been prevented with minimal
intervention at home.
The majority of complaints the
hospital receive are around
discharge: A@H team frequently
resolve issues that patients and
families have post discharge. In its
first year of service delivery A@H
saved over 2000 bed days and
prevented over 300 readmissions.
Aintree @Home was nominated
in the HSJ awards in 2015/16. Improving Patient Experience
Equality & Diversity – FFT Demographic
Breakdown
The quarterly Patient Experience Feedback Report
provides information on patient demographics
(patient age, gender, disability and ethnicity) which
enables us to review if any of our patients groups
are less satisfied with their care or treatment.
Disability is only collected of Inpatients via
completion of the FFT postcard (this is following
Information Governance guidance).
Patient Ethnicity – Based on the new FFT automated
ethnicity collection, ‘British’ has been added to the
previous five groups. It should be noted that this
patient base may differentiate in ethnicity however
these are captured as ‘British’ within the Trust
hospital patient records system.
Aintree University Hospital NHS Foundation Trust
71
Finalists in the Patient Experience Network National
Awards (PENNA) in 2015
June Taft, Assistant Director
of Corporate Nursing,
Anna Morris, Lead Nurse
for Patient Experience
and Matt Norris, Data
Information Officer in the
Patient Experience Team
pictured at the PENNA
Awards where they were
one of the finalists for the
Measuring, Reporting and
Acting category for their
work on Aintree’s Shared
Improvements Dashboard.
Twiddlemuffs for patients
with Dementia
Twiddlemuffs are a knitted band to which items are
attached to allow patients with dementia to twiddle
in their hands. They are being introduced into the
Trust onto one of the orthopaedic wards from April
2016. The introduction of the twiddlemuffs will
coincide with a project where we are converting a
traditional ward dayroom into a communal lounge
and dining area.
The Twiddlemuffs are being knitted and supplied by
Swan Women’s Centre, a local charity.
72
Aintree University Hospital NHS Foundation Trust
Fresh as a Daisy
Innovation
New Registered
Nurses in the Trust
wear a ‘Fresh as a
Daisy’ badge for the
first three months
of their preceptorship to signify
their newly qualified status, and
to highlight that they may need
additional support and guidance.
The badge, which has a dark blue
background with a white daisy, is
presented to them by the Director
of Nursing & Quality during their
Trust Induction.
NHS England Always Event
In August 2015 NHS England in
collaboration with Picker Institute
Europe and the Institute for
Healthcare Improvement (IHI)
invited the Trust to join the pilot
for Always Events; an innovative
new initiative to support the
effective delivery of person
centred care.
An Always Event is a clear, actionoriented, and pervasive practice
or set of behaviours that provides:
• A
foundation for partnering
with patients, service users and
their carers;
• A
ctions that will ensure
optimal care experiences and
improved outcomes; and
• A
unifying force for all that
demonstrates an ongoing
commitment to person and
family centred care.
Always Events are aspects of
the care experience that are so
important to patients, service
users and carers that health care
providers must perform them
consistently for every patient,
every time. They are co-produced
and designed within each health
or social care setting dynamically,
ensuring that the Always Events
remain relevant and are true to
their target population.
The Always Events programme
has three distinct phases, designed
to help teams plan, test and
measure a single Always Event:
1.Set-up
2.Planning and testing change
3.Measurement and evaluation
Aintree ran a workshop with the
Divisions and the Patient Advice
and Complaints Team (PACT)
and an emerging theme from all
forms of feedback was visiting
hours.
As part of the Trusts 2015/16
Patient Experience Improvement
Plan a patient, staff and public
engagement exercise was
undertaken from 31/08/15 to
13/09/15 to ascertain the views
of our stakeholders in relation
to visiting times for inpatients at
Aintree University Hospital.
The survey was completely
anonymous and was designed to
support any decisions made on
visiting times going forward.
Five core questions were asked
and options were provided for
respondents to leave free-text
comments. Participants were also
asked two demographic questions
about their gender & age and
how long had passed since their
last hospital visit.
A total of 281 responses were
received from a range of Patients,
Relatives, Carers, Foundation Trust
Members, Doctors and Nurses.
75% of respondents supported
Flexible Visiting as opposed to
Open Visiting.
An Aim Statement was developed
that by December 2016 ‘95% of
patients have access to a relative
or carer to give them support
when they need it’.
2 pilot wards were identified –
Ward 23 (Respiratory Medicine)
and Major Trauma Ward, and in
January 2016 the testing phase
began.
Although the project with
NHS England finished in April
2016, the project is being taken
forward in the Patient Experience
Improvement Plan 2016/17 with
rollout of flexible visiting across
the organisation by the end of
Qtr 4 2016/17.
Improvements made following learning from patient stories
Since April 2015 a patient story
has been presented at Aintree’s
Trust Board meeting each month
which is also included in the
monthly NHS England Open &
Honest Care report along with the
actions identified for improvement
to address the feedback. Below are
some examples of improvements
made following patient stores:
Mealtime Improvements
1.A patient’s husband described
unsuitable plastic cutlery and
bruised fruit being presented to
his wife and meals that were not
hot enough. Following this, the
catering team have changed to
better quality disposable cutlery,
fresh fruit has been replaced with
fruit pots which are more suitable
for neutropenic patients, and the
Haematology Ward have their
meals delivered first.
Communication
2.Following on from Erik’s Story,
in May 2015, following approval
at Patient Experience Executive
Led Group a revised Outpatient
Leaflet was completed and went
to print.
3.The Communications Team
at Aintree is compiling a list of
all the different patient support
groups that run at Aintree to help
promote activities and to develop
engagement opportunities.
Patient Feedback
4.A written story from a renal
patient who discusses the
difficulties she has as a result of
her condition. She talks about
how she worked hard to manage
her weight, diabetes and fluid
balance, with the support of the
renal team.
Environmental Improvements
5.Following the story of a
patient with thalidomide,
ongoing refurbishment of the
ward areas continues; and access
to bathrooms and toilets are
under review as a part of this
process. In addition, a number
of environmental improvements
were made following Erik’s Story,
which related to the experience
of a patient with end stage
pancreatic cancer. Erik and his
wife felt that environmental
issues in the Accident &
Emergency Department led to
his sub-optimal experience, and
many of these have been resolved
since the opening of the Urgent
Care & Trauma Centre (UCAT) in
June 2015.
Aintree University Hospital NHS Foundation Trust
73
Equality & Diversity (ED) Update
In 2015/16 we have continued with our momentum
in relation to the 4 year strategy implementation of
Equality and Diversity. Our intent to embedded ED
across the Trust in our everyday practice remains a
key focus area. Examples of this are as follows:
Stakeholder Area
Examples of Integrated ED activity
Workforce
Targeted interviewing of staff to gauge their understanding of ED
and its impact upon patient care.
Following findings of above strengthened ED training materials and
accessibility of training.
Bespoke training to identified groups to ensure full appreciation of ED.
Appointment of Organisational Health and Effectiveness Lead to network
at strategic level to ensure compliance and proactivity in this regard.
Operations/Estates
Full Quality Impact Assessment of Urgent Care and Trauma Centre to
ensure full accessibility and to comply with Dementia Friendly aspiration.
Roll out of loop hearing system in outpatient department areas.
Patient Experience
Developed a Learning Disability CQUIN to ensure unique needs are met.
Targeted awareness weeks for all service users for example Deaf
Awareness Week
Review and update of translation service guidelines to ensure fit for
purpose and relocated to patient access team.
Using Friends and Family Test feedback analysis for 2015/16 corroborates
that there are no reported incidents of discrimination against the
LBGT community.
Corporate Governance
ED objectives – progress reported at Workforce Exec Led Group via Board
report and assurance submission
In further streamlining of ED, it is accepted
that there is a need for the establishment of a
comprehensive working group comprising of the
following representation:
• Workforce
• Operations
• Facilities and Estates
• Patient Experience
• Corporate Governance
• Healthwatch
74
Aintree University Hospital NHS Foundation Trust
Representation and engagement from networks
and key stakeholders will offer guidance to ensure
delivery of ED objectives. The working group will
assist in the embedding across the trust on how
we value Equality, Diversity, Inclusion and Human
Rights. There will be a focus on the delivery of
appropriate communication and awareness and
connectivity in all that we do. Furthermore the
group will also ensure an effective means of
reporting in relation to Equality and Diversity to
assist with proactive embedding of this across the
entire Trust.
Annex A: Statements from Stakeholders on Aintree’s Quality Account 2015/16
South Sefton, Liverpool and Knowsley Clinical
Commissioning Group – Quality Account Statements
– Aintree University Hospital NHS Foundation Trust
this is reflected throughout the account with work
continuing on the reporting of incidents and the
embedding of learning across the organisation.
South Sefton, Liverpool and Knowsley CCGs
welcome the opportunity to jointly comment on The
Aintree University Hospital NHS Foundation Trust
Draft Quality Account for 2015/16. We have worked
closely with the Trust throughout 2015/16 to gain
assurances that the services they delivered were
safe, effective and personalised to service users. The
CCGs share the fundamental aims of the Trust and
supports their strategy to deliver high quality, harm
free care. The account reflects good progress on
most indicators.
Of particular note, is the work the Trust has
undertaken to improve outcomes on the following
work streams for example:-
We have reviewed the information provided within
the Quality Account and checked the accuracy of
data within the account which was submitted as
part of the Trusts contractual obligation. All data
provided corresponds with data used as part of the
on-going contract monitoring process.
This Account indicates the Trust’s commitment to
improving the quality of the services it provides
for commissioners supports the key priorities for
improvement of quality during 2015/16.
• Priority 1: Care that is Safe
• Priority 2: Care that is Clinically Effective
• P
riority 3: Care that provides a positive experience
for patients and their families
This is a comprehensive report that clearly
demonstrates progress within the Trust. It identifies
where the organisation has done well, where
further improvement is required and what actions
are needed to achieve these goals. The Quality
Account sets out the priorities for improving patient
safety, patient experience and clinical effectiveness
across all services provided by the Trust. Although,
the Trust has acknowledged they did not achieved
the A&E four hour target, the CCG’s are supportive
of the response to improve patient flow and the
development of the Emergency and Acute Care Plan.
On the most recent visit to the Trust Commissioners
were assured on the care provided to individuals via
patient feedback and staff discussions within A&E
and Acute Medical Unit (AMU).
Through this Quality Account and on-going quality
assurance process the Trust clearly demonstrates
their commitment to improving the quality of care
and services delivered. Aintree University Hospital
Foundation Trust continues to develop innovative
ways to capture the experience of patients and
their families in order to drive improvements in the
quality of care delivered.
The Trust places significant emphasis on its safety
agenda, with an open and transparent culture, and
• Reducing the number of inpatients falls
• Reducing all hospital acquired pressure ulcers
• T
o reduce the number of central line blood stream
infections (CRBSI) from 25 to 1
• M
ortality - Commissioners welcomed the
significant improvement in the Summary
Hospital-Level Mortality Indicator (SHMI) which
demonstrated that Aintree was reporting the 7th
lowest SHMI in the North West and was no longer
an outlier. The Trust’s Hospital Standardised
Mortality Ratio (HSMR) continues to be one of the
lowest in the country.
The CCGs would like to acknowledge out of the 81
trusts which engaged in the 2015 Inpatients survey,
Aintree ranked 16th which puts the Trust in the
top 20% of respondents which has exceeded the
quality goal Aintree established. It is also noted
the continued positive response rate in relation to
Friends and Family Test for both A&E and Inpatients
stays; this helps provide further assurance for
patients experience across the Trust footprint.
The Trust should also be commended regarding the
engagement of the clinical teams on the process
of reviewing all cases of C.Difficile and the CCGs
acknowledge the number of cases which have no
identifiable lapses in care. This has demonstrated
ownership of learning amongst respective clinical
teams across the Trust. The Trust met the national
targets for C.Difficile and continues to work to their
own internal stretch target.
Commissioners are aspiring through strategic
objectives and 5 year plans to develop an NHS
that delivers great outcomes, now and for future
generations. This means reflecting the government’s
objectives for the NHS set out in their mandate to us,
adding our own stretching ambitions for improving
health and delivering better services to go even
further to tailor care to the local health economy.
Providing high quality care and achieving excellent
outcomes for our patients is the central focus of our
work and is paramount to our success.
It is felt that the priorities for improvement
identified for the coming year are both challenging
and reflective of the current issues across the health
economy. We therefore commend the Trust in taking
account of new opportunities to further improve the
delivery of excellent, compassionate and safe care
for every patient, every time.
Aintree University Hospital NHS Foundation Trust
75
Aintree University Hospital
NHS Foundation Trust
Quality Account 2015/2016
Commentary
Healthwatch Sefton welcomes the opportunity
to comment on this Quality Account. We have
attended 2 sessions (May 2016) to review the
readability of the draft account and provide
comments and suggestions for improvements.
Healthwatch Sefton welcomes the Trusts
commitment again this year of producing a
summary version of the accounts. Healthwatch
Sefton would like to thank the Trust for their
open and transparent way of working during
2015/16 and would like to comment on the
following areas:
Care that is safe: the target of reducing MSSA
bacteraemia by 50% (less than or equal to
10 cases) was not met. There was an increase
of 6 more cases than in 2014/15 but moving
forward, the Trust has a clear plan in place. It
is good to see that during this period there
have been reductions for ‘in-patient falls with
harm’, Clostridium infection (CDI), and catheter
associated UTIs. The work to reduce the number
of inpatient falls with harm should be highlighted
with a 19.4% reduction from 2014/15. An 8.7%
reduction in grade 2 pressure ulcers (against a
target of 10% was made but 5 grade 3/4s were
reported, 2 more than in 2014/15. It is positive
to see the Trust have a Root Cause Analysis
Investigation underway for the Quarter 4
incident.
Care that is clinically effective: It was
positive to note the 96% reduction in Central
Line Infections (CRBSI) with only 1 patient being
reported with (CRBSI) compared to 25 during
2014/2015.
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Aintree University Hospital NHS Foundation Trust
Care that provides a positive experience for
patients and their families: The Trust works
in partnership with Healthwatch Sefton. We
hold regular hospital stands in outpatient and
reception areas. We have a seat on the Exec Led
Patient Experience group which we attend on a
monthly basis and informal quarterly meetings
with executives are held. Healthwatch Sefton
produces experience reports, which are always
responded to in full and within the set timescales.
We have worked on a number of initiatives with
the Trust including engaging on flexible visiting
and patient shadowing. The account highlights
the results from the Picker In-patient survey, the
Trust being ranked 16th (out of 81 Trusts). The
‘Friends and Family Test’ also reports positively
with the % likely score for in-patients averaging
at 98% for 2015/16 which is consistently higher
than both NHS England and Merseyside averages.
We note the Trusts performance against CQUINS
set nationally and locally and welcome the work
on transitional care with Alder Hey Hospital. We
hope over the coming year the underachievement
of the local scheme for in-patient E discharges
within 24 hours can be met.
Healthwatch Sefton would like to note the work
which the Trust has undertaken during 2015/16
in setting up a steering group for Dementia and
one for Learning Disabilities. The work to ensure
Friends and Family information is available in
alternative formats including easy read should
be commended. Unfortunately there has been
no communication with us over the past 12
months on Equality Delivery System priorities and
work. Moving forward the Trust has responded
positively to working more closely to share
updates with us.
Aintree University Hospital
NHS Foundation Trust
Quality Account Commentary
Healthwatch Knowsley
Healthwatch Knowsley welcomes the opportunity
to provide this commentary in support of the
Aintree University Hospitals NHS Foundation Trust
Quality Account for 2015/16. The Quality Account
report was provided to Healthwatch Knowsley in
a timely manner and presented thoroughly during
a question and answer session held in May.
During the last twelve months the partnership
working and challenges provided through
Healthwatch Knowsley has been welcomed
by the Trust. Healthwatch Knowsley has been
represented at the Patient Experience Executive
Led Group which has proved to be a good
point of contact with the Trust. In addition,
Healthwatch Knowsley has taken part in working
parties focussing on Dementia, Learning Disability
and Bereavement. Healthwatch Knowsley hold
regular information stands at the Trust which
provides an opportunity to hear patient feedback
in real time.
The Trust has made considerable progress in
working towards its Key Priorities of Care that is
Safe, Clinically Effective and provides a positive
experience for patients and their families.
Healthwatch Knowsley also acknowledges the
transparency and honesty that they Trust has
displayed in those areas that have proved to be a
challenge and the targets were not met.
Infection Control, Pressure Ulcers and Falls
continue to provide challenges to the Trust, and
we are pleased to note that these will continue to
be a focus for the Trust in 2016/17.
The Trust has continued to have a focus on
maximising patients opportunities to comment on
the service they have received and this is reflected
in the high level of responses received to the
Friends and Family Test, together with evidence
that PALS contacts, complaints and compliments
have all increased. The Trust has faced some
challenges in responding to the complaints in a
timely manner, but Healthwatch Knowsley is kept
abreast of progress on this issue.
Healthwatch Knowsley looks forward to
continuing to work closely with the Trust in the
coming year, and building on the progress made.
We will continue to provide the Trust with Patient
Experience Reports and to triangulate them
against the Trust information through our
agreed protocol.
Healthwatch Knowsley congratulates the Trust
in becoming one of the top 20% hospitals for
Patient Satisfaction in England.
Aintree University Hospital NHS Foundation Trust
77
Healthwatch Liverpool welcomes the opportunity
to provide a commentary on this Quality Account
for 2015/16. This commentary only relates to the
issues covered in the Quality Account.
The target for intentional rounding was not
achieved, but Healthwatch Liverpool is pleased to
see that this is audited and monitored, and will
continue to be so in the coming year.
The data in this quality account is clearly
presented, and the ‘typical day at the Trust’
segment provides a good illustration of the
work the Trust carries out, showing some of
the pressures the Trust experiences including
a rise in Accident and Emergency attendances.
Healthwatch notes there have been increased
waiting times for patients attending A&E,
although this is largely a reflection of
system-wide issues.
Healthwatch welcomes the introduction
of ‘Patient at a Glance Boards’ in the busy
environment of the wards, provided that the
patients’ privacy and dignity are preserved as
much as possible. Healthwatch Liverpool carried
out an Enter and View visit to the Frailty Unit, and
was pleased to see the Aintree 2 Home initiative
developed, as this should support patients to go
home quicker and in a safe manner.
The Trust set itself high targets for quality
improvements for this year. Although not all of
these targets were met, Healthwatch believes
that improvements were made, and was pleased
to note that the Trust’s Summary Hospital-Level
Mortality Indicator (SHMI) mortality rates were
reduced and are now more in line with
other Trusts.
The report provides clear examples of actions
taken by the Trust to improve services, e.g. the
actions that were taken to lower the number of
pressure ulcers occurring. It is also positive to see
that the actions taken include learning from good
practice elsewhere, as in the example of Aintree
staff visiting another Trust to learn what that Trust
did to combat Clostridium Difficile infections.
The report shows that more work needs to be
done regarding the provision of medication to
inpatients, and Healthwatch looks forward to
learning more about what impact the proposed
actions will have to reduce the potential risks.
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Aintree University Hospital NHS Foundation Trust
Healthwatch was pleased to note that the
Trust appears as the most improved for patient
experience in the 2015 Picker inpatient survey,
and is looking forward to how the flexible visiting
pilot being rolled out across other areas of the
Trust will be reflected in feedback from patients
and visitors in the coming year.
The feedback from the Friends and Family test
was slightly more mixed. Healthwatch Liverpool
worked with Healthwatches from Sefton and
Knowsley to carry out a joint Listening event at
the Trust in April 2016, and will add the patient
feedback from that to add to the overall picture.
Healthwatch Liverpool will use Patient Opinion to
this aim as well.
Throughout 2015/16 the Trust has continued
to engage well with Healthwatch Liverpool
about the patient experience and quality of
services. Healthwatch Liverpool looks forward to
continuing engagement with University Hospital
Aintree NHS Foundation Trust in 2016/17.
Annex B: Statement of Directors’ responsibilities in respect of the Quality Report
The directors are required under the Health Act
2009 and the National Health Service Quality
Accounts Regulations to prepare quality accounts
for each financial year.
Monitor has issued guidance to NHS foundation
trust boards on the form and content of annual
quality reports (which incorporate the above legal
requirements) and on the arrangements that NHS
foundation trust boards should put in place to
support data quality for the preparation of the
quality report.
In preparing the Quality Report, directors are
required to take steps to satisfy themselves that:
• t he content of the Quality Report meets the
requirements set out in the NHS Foundation
Trust Annual Reporting Manual 2015/16 and
supporting guidance
• t he content of the Quality Report is not
inconsistent with internal and external sources
of information including:
−board minutes and papers for the period
April 2015 to March 2016
−papers relating to Quality reported to
the Board over the period April 2015 to
March 2016
−feedback from Commissioners dated
13/05/2016
• t he Quality Report presents a balanced picture of
the NHS foundation trust’s performance over the
period covered;
• t he performance information in the Quality
Report is reliable and accurate;
• t here are proper internal controls over the
collection and reporting of the measures of
performance included in the Quality Report, and
these controls are subject to review to confirm
that they are working effectively in practice;
• t he data underpinning the measures of
performance reported in the Quality Report is
robust and reliable, conforms to specified data
quality standards and prescribed definitions, is
subject to appropriate scrutiny and review; and
• t he Quality Report has been prepared in
accordance with Monitor’s annual reporting
guidance (which incorporates the Quality
Accounts Regulations) as well as the standards to
support data quality for the preparation of the
Quality Report (available at www.monitor.gov.uk/
annualreportingmanual).
The Directors confirm to the best of their knowledge
and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the Board
−feedback from Governors dated 13/04/2016,
04/05/2016 and 10/05/2016
−feedback from Local Healthwatch
organisations: Healthwatch Sefton dated
16/05/2016, Healthwatch Knowsley dated
12/05/2016, and Healthwatch Liverpool
dated 16/05/2016)
Chairman
Date: 26 May 2016
−feedback from Sefton Overview and Scrutiny
Committee dated 18/04/2016
−the Trust’s quarterly complaints and
concerns reports dated 20/08/2015
(Qtr 1),19/11/2015 (Qtr 2), 21/03/2016 (Qtr 3),
(Qtr 4 to be provided)
Chief Executive
Date: 26 May 2016
−the national patient survey dated
February 2016
−the national staff survey dated
December 2015
−the Head of Internal Audit’s annual opinion
over the trust’s control environment dated
25/05/2016
−CQC Intelligent Monitoring Report dated
May 2015
Aintree University Hospital NHS Foundation Trust
79
Annex C: Statement from Trust Governors
Governors have a role in ensuring that the voice of
our patients, members and local community is at the
heart of the Trust’s decision-making. This provides
Governors with the opportunity to get involved
where appropriate in the quality improvement work
undertaken by the Trust.
One of the responsibilities of the Council of
Governors is to approve the local quality indicator
for the purpose of external audit (as detailed
on page 84). This was discussed and agreed at
a workshop in February 2016 and subsequently
ratified at the formal Council of Governors’ meeting
in March 2016. The workshop in February also
provided Governors with an opportunity to look
back at our performance on our quality objectives
over the year and provide their views on the priority
quality goals for 2016/17.
In 2015/16, Governors supported and contributed
to improving the quality of care that the Trust
provides through, for example, the Collaborative
to reduce the number of patient falls and the work
undertaken on discharge planning including the
Multi-Disciplinary Accelerated Discharge Event.
Governors have started to get involved in other
collaborative initiatives, for example, hydration
and nutrition for patients and these will be taken
forward in 2016/17.
Governors challenge the Executive and senior
managers and receive assurance on the three key
elements of the Trust’s Quality Strategy (i.e. care that
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Aintree University Hospital NHS Foundation Trust
is safe, care that is clinically effective and provides a
positive experience for patients and their families)
at the Governor-led Quality of Care Committee and
also at the formal Council of Governors’ meetings
where they challenge the Non-Executive Directors
on quality & safety. Governors also take part in the
Director Walkrounds which follow patient pathways
and which provide an opportunity for Governors to
observe how the Trust is working and delivering the
Quality Strategy.
Governors keep themselves abreast of local and
national developments by attending externally
facilitated workshops and seminars, enabling them
to be more informed when reviewing Aintree’s
Quality Account which they do at the beginning
of each financial year. Governors comment on the
accessibility of the Quality Account for members and
wider stakeholder groups. In addition, Governors
contribute to the Quality Account Summary leaflet
which is made available to the public and is used by
the Governors to promote the quality improvement
work of the Trust when they engage with our
members.
Signed on behalf of Aintree’s Council of Governors
Pamela Peel
Lead Governor
Annex D: Independent Auditor’s Limited Assurance Report to the Council of
Governors of Aintree NHS Foundation Trust on the Annual Quality Report
We have been engaged by the Council of Governors
of Aintree University Hospital NHS Foundation Trust
to perform an independent assurance engagement
in respect of Aintree University Hospital NHS
Foundation Trust’s Quality Report for the year ended
31 March 2016 (the ‘Quality Report’) and specified
performance indicators contained therein.
Specified Indicators
Scope and subject matter
The indicators for the year ended 31 March
2016 subject to limited assurance (the “specified
indicators”) marked with the symbol A in the
Quality Report, consist of the following national
priority indicators as mandated by Monitor:
Specified indicators criteria
(exact page number where criteria can be found)
Percentage of incomplete pathways within 18 weeks
for patients on incomplete pathways at the end of
the reporting period.
Annex C – page 20
Percentage of patients with a total time in A&E of
four hours or less from arrival to admission, transfer
or discharge.
Annex C – page 21
Respective responsibilities of
the Directors and auditors
The Directors are responsible for
the content and the preparation
of the Quality Report in
accordance with the specified
indicators criteria referred to on
pages of the Quality Report as
listed above (the “Criteria”). The
Directors are also responsible for
the conformity of their Criteria
with the assessment criteria
set out in the NHS Foundation
Trust Annual Reporting Manual
(“FT ARM”) and the “Detailed
requirements for quality
reports 2015/16” issued by the
Independent Regulator of NHS
Foundation Trusts (“Monitor”).
Our responsibility is to form a
conclusion, based on limited
assurance procedures, on
whether anything has come to
our attention that causes us to
believe that:
• T
he Quality Report does
not incorporate the matters
required to be reported on
as specified in Annex 2 to
Chapter 7 of the FT ARM and
the “Detailed requirements for
quality reports 2015/16”;
• T
he Quality Report is not
consistent in all material
respects with the sources
specified below; and
• T
he specified indicators have
not been prepared in all
material respects in accordance
with the Criteria set out in
the NHS Foundation Trust
Annual Reporting Manual
(“FT ARM”) and the “2015/16
Detailed guidance for external
assurance on quality reports”.
We read the Quality Report and
consider whether it addresses
the content requirements of
the FT ARM and the “Detailed
requirements for quality reports
2015/16; and consider the
implications for our report if we
become aware of any material
omissions.
We read the other information
contained in the Quality Report
and consider whether it is
materially inconsistent with the
following documents:
• B
oard minutes for the financial
year, April 2015
to March 2016 (the period);
• P
apers relating to quality
report reported to the Board
over the period April 2015 to
the date of signing this limited
assurance report;
• F eedback from the
Commissioners South Sefton
CCG received 13/05/2016;
• Feedback from Governors;
• F eedback from Local
Healthwatch organisations
(Feedback from Local
Healthwatch Organisations:
Healthwatch Sefton dated
16/05/2016, Healthwatch
Knowsley dated 12/05/2016,
and Healthwatch Liverpool
dated 16/05/2016.
• T
he Trust’s complaints report
published under regulation 18
of the Local Authority Social
Services and NHS Complaints
Regulations 2009;
• T
he 2015 national and local
patient survey;
• T
he 2015 national and local
staff survey;
• C
are Quality Commission
Intelligent Monitoring Reports
dated May 2016
Aintree University Hospital NHS Foundation Trust
81
• T
he Head of Internal Audit’s
annual opinion over the Trust’s
control environment.
We consider the implications for
our report if we become aware
of any apparent misstatements
or material inconsistencies with
those documents (collectively,
the “documents”). Our
responsibilities do not extend to
any other information.
Our Independence
and Quality Control
We applied the Institute of
Chartered Accountants in England
and Wales (ICAEW) Code of Ethics
[which includes independence
and other requirements founded
on fundamental principles of
integrity, objectivity, professional
competence and due care,
confidentiality and professional
behaviour].
We apply International Standard
on Quality Control (UK & Ireland)
1 and accordingly maintain a
comprehensive system of quality
control including documented
policies and procedures regarding
compliance with ethical
requirements, professional
standards and applicable legal
and regulatory requirements.
Use and distribution
of the report
This report, including the
conclusion, has been prepared
solely for the Council of
Governors of Aintree University
Hospital NHS Foundation Trust
as a body, to assist the Council
of Governors in reporting
Aintree University Hospitals
NHS Foundation Trust’s quality
agenda, performance and
82
Aintree University Hospital NHS Foundation Trust
activities. We permit the
disclosure of this report within
the Annual Report for the
year ended 31 March 2016, to
enable the Council of Governors
to demonstrate they have
discharged their governance
responsibilities by commissioning
an independent assurance report
in connection with the indicators.
To the fullest extent permitted by
law, we do not accept or assume
responsibility to anyone other
than the Council of Governors
as a body and Aintree University
Hospital NHS Foundation Trust
for our work or this report save
where terms are expressly agreed
and with our prior consent
in writing.
Assurance work performed
We conducted this limited
assurance engagement in
accordance with International
Standard on Assurance
Engagements 3000 (Revised)
‘Assurance Engagements other
than Audits or Reviews of
Historical Financial Information’
issued by the International
Auditing and Assurance Standards
Board (‘ISAE 3000 (Revised)’).
Our limited assurance procedures
included:
• r eviewing the content of the
Quality Report against the
requirements of the FT ARM
and “Detailed requirements
for quality reports 2015/16”;
• r eviewing the Quality Report
for consistency against the
documents specified above;
• o
btaining an understanding
of the design and operation
of the controls in place in
relation to the collation and
reporting of the specified
indicators, including controls
over third party information
(if applicable) and performing
walkthroughs to confirm our
understanding;
• b
ased on our understanding,
assessing the risks that the
performance against the
specified indicators may be
materially misstated and
determining the nature,
timing and extent of further
procedures;
• m
aking enquiries of relevant
management, personnel and,
where relevant, third parties;
• c onsidering significant
judgements made by the
NHS Foundation Trust in
preparation of the specified
indicators;
• p
erforming limited testing,
on a selective basis of evidence
supporting the reported
performance indicators,
and assessing the related
disclosures; and
• reading the documents.
A limited assurance engagement
is less in scope than a reasonable
assurance engagement. The
nature, timing and extent
of procedures for gathering
sufficient appropriate evidence
are deliberately limited relative
to a reasonable assurance
engagement.
Limitations
Non-financial performance
information is subject to more
inherent limitations than
financial information, given the
characteristics of the subject
matter and the methods used for
determining such information.
The absence of a significant body
of established practice on which
to draw allows for the selection
of different but acceptable
measurement techniques which
can result in materially different
measurements and can impact
comparability. The precision
of different measurement
techniques may also vary.
Furthermore, the nature and
methods used to determine
such information, as well as the
measurement criteria and the
precision thereof, may change
over time. It is important to read
the Quality Report in the context
of the assessment criteria set
out in the FT ARM the “Detailed
requirements for quality reports
2015/16 and the Criteria referred
to above.
The nature, form and content
required of Quality Reports are
determined by Monitor. This
may result in the omission of
information relevant to other
users, for example for the
purpose of comparing the results
of different NHS Foundation
Trusts.
In addition, the scope of our
assurance work has not included
governance over quality or
non-mandated indicators in
the Quality Report, which have
been determined locally by
Aintree University Hospital NHS
Foundation Trust.
Conclusion
Based on the results of our
procedures, nothing has come to
our attention that causes us to
believe that for the year ended 31
March 2016:
• T
he Quality Report does
not incorporate the matters
required to be reported on
as specified in Annex 2 to
Chapter 7 of the FT ARM and
the “Detailed requirements for
quality reports 2015/16”;
• T
he Quality Report is not
consistent in all material
respects with the documents
specified above; and
• t he specified indicators have
not been prepared in all
material respects in accordance
with the Criteria set out in the
NHS Foundation Trust Annual
Reporting Manual (“FT ARM”)
and the “Detailed guidance for
external assurance on quality
reports 2015/16”.
PricewaterhouseCoopers LLP
Manchester
26 May 2016
The maintenance and integrity of
the Aintree University Hospital NHS
Trust’s website is the responsibility of
the directors; the work carried out by
the assurance providers does not involve
consideration of these matters and,
accordingly, the assurance providers
accept no responsibility for any changes
that may have occurred to the reported
performance indicators or criteria
since they were initially presented
on the website.
Aintree University Hospital NHS Foundation Trust
83
Annex E: Definitions of the performance measure indicators for external audit
Independent Review of Quality Assurance:
An assurance opinion on data quality within the
Quality Report is also provided by External Auditors
who are required to perform audit work on two
nationally mandated performance indicators and
one local indicator chosen by the Trust Governors.
The performance indicators and their criteria are
as follows:
Mandatory Performance Indicators
Percentage of incomplete pathways within 18
weeks for patients on incomplete pathways
The reported indicator performance has been
calculated based on all patients recorded as having
been referred to the FT for consultant led services
and who are on incomplete pathways at the end
of the period. Completeness of this information is
therefore dependent on the complete and accurate
entry of data at source (referrals received for
consultant led services) and the complete recording
of all those on incomplete pathways at period
end; it is not possible to check completeness to
source because referrals may be received through
different routes, for example, by letter, fax or via
the live ‘Choose and Book’ system or may have been
received in a prior period. Patients who have not
been identified within the population will therefore
not be included in the indictor calculation however,
to the best of our knowledge, the information
is complete.
Percentage of all A&E attendances where the
patient spends four hours or less in A&E from arrival
to transfer, admission or discharge
The reported indicator performance has been
calculated based on all patients recorded as having
attended A&E. Completeness of this information is
therefore dependent on the complete and accurate
entry of data at source by the clinician who carries
out initial assessment or by A&E reception. Patients
who have not been correctly registered in A&E will
therefore not be included in the indictor calculation
however, to the best of our knowledge, the
information is complete.
Local Performance Indicator
Emergency re-admissions within 28 days of discharge
from hospital.
The reported indicator performance has been
calculated based on all emergency re-admissions to
the FT within the reporting period, recorded in our
records as having been re-admitted within 28 days
of discharge form hospital. Completeness of this
information is therefore dependent on the complete
and accurate entry of data at source. Patients who
have not been identified within the population will
therefore not be included in the indictor calculation
however, to the best of our knowledge, the
information is complete.
The above indicators subject to audit are identified
by this symbol A within the report.
The limited assurance opinion from the External
Auditors can be found in Annex D.
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Aintree University Hospital NHS Foundation Trust
Have your say
If you would like to know more about how your views can inform future quality
improvements in health services, please contact your local Healthwatch group.
Healthwatch Sefton
[email protected]
Freephone 0800 206 1304
Mobile/Text 07434810438
Healthwatch Knowsley
[email protected]
0151 449 3954
Healthwatch Liverpool
[email protected]
0300 777 7007
Mobile/Text 07842552878
Become a Trust member
Membership of Aintree University NHS Foundation Trust is open to anyone with an interest
in their hospital. It is free, and there are no obligations, but it gives you a chance to have
your say and vote for Governors who represent you.
For further information, please contact the Membership Office on:
0151 529 4705
[email protected]
www.aintreehospital.nhs.uk
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Aintree University Hospital NHS Foundation Trust
85
For further information please contact:
Director of Nursing & Quality
Aintree University Hospital NHS Foundation Trust
Longmoor Lane, Liverpool L9 7AL
0151 525 5980
www.aintreehospital.nhs.uk
Twitter: @AintreeHospital Facebook: AUHNHS