quality report and account 2012/13 - aintree ......our national inpatient survey results indicate an...

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QUALITY REPORT AND ACCOUNT

2012/13

2

Glossary

A&E aBI ACPs AMI AQ AQuA AQUIPS AUH BGM BSI CBM Cc C.difficile COPD CQUIN CSP DME DNA DNAR DVT E4E ENT EPMA EQUIP FCEs FFT FY1 FY2 FRASE GP HCAI HRG HR HSMR IPC IQIPS JAG LiA LINk MAU MET MEWS MFU MRSA

Accident & Emergency Department Aintree Business Intelligence Advanced Care Plans Acute Myocardial Infarction Advancing Quality Advanting Quality Alliance Advancing Quality Improvement Programmes Aintree University Hospital NHS Foundation Trust Blood Glucose Monitoring Blood Stream Infections Clinical Business Manager Complications and Co-morbidities Clostridium Difficile Chronic Obstructive Pulmonary Disease Commissioning for Quality and Innovation (payment framework) Co-ordinated Systems for gaining NHS Permission Department of Medicine for the Elderly Did Not Attend Do Not Attempt Resuscitation Deep Vein Thrombosis Energise for Excellence Ear, Nose and Throat Electronic Prescribing and Medicines Administration Electronic quality information for the public Finished Consultant Episodes Friends & Family Test Foundation year one doctor Foundation year two doctor Falls Risk Assessment General Practitioner Healthcare Associated Infections Health Related Resource Groups Human Resources Hospital Standardised Mortality Rate Infection Prevention and Control Improving Quality in Physiological Diagnostic Services Joint Advisory Group Listening into Action Local Involvement Network Medical Assessment Unit Medical Emergency Team Modified Early Warning System Maxillo Facial Unit Methicillin-Resistant Staphylococcus Aureus

MUST NCEPOD NICE NIHR NHS NPSA NSF PALS PCT PEQ PEMS PROMS PbR QIPP RAG R&D RCA RTT SHA SIGMA SSKIN SOP Unify2 USA UTI VTE WTE

Malnutrition Universal Screening Tool National Confidential Enquiry into Patient Outcome and Death National Institute for Clinical Excellence National Institute for Health Research National Health Service National Patient Safety Agency National Service Framework Patient Advice and Liaison Service Primary Care Trust Patient Experience Questionnaire Patient Experience Measures Patient Reported Outcome Measures Payment by Results Quality, Innovation, Prevention & Productivity Red Amber Green (traffic light scoring system) Research & Development Root Cause Analysis Referral to Treatment Strategic Health Authority Hospital Patient Administration System Surface Skin, Inspection, Keep Moving, Incontinence, Nutrition Standard Operating Procedure National Reporting Hub United States of America Urinary Tract Infection Venous-Thromboembolism Whole Time Equivalent

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Contents

Glossary ............................................................................................................................ 2

Part One: Statements on Quality ....................................................................................... 5

1.1. Statement from the Chief Executive .................................................................... 5

1.2 Trust Profile ......................................................................................................... 7

1.3 New Service Developments ................................................................................... 7

Part Two: Priorities for Improvement, Statements of Assurance from the Board ................ 8

2.1 Priorities for Improvement ................................................................................... 8

2.1.1 Progress against Key Priorities for Action 2012/13 .............................................. 8

2.1.2 Key Priorities for Action 2013/14 ......................................................................... 9

2.2 Statements of Assurance from the Board .......................................................... 10

2.2.1 Review of Services ............................................................................................ 10

2.2.2 Participation in Clinical Audits and National Confidential Enquiries.................... 10

2.2.3 Actions Arising from Clinical Audits and National Confidential Enquiries ........... 10

2.2.4 Participation in Clinical Research ...................................................................... 11

2.2.5 Use of CQUIN Framework ................................................................................. 11

2.2.6 Registration with the Care Quality Commission ................................................. 15

2.2.7 Information on the Quality of Data ..................................................................... 16

2.2.8 Performance against core National Quality Indicators ....................................... 18

3.1 Identifying Quality Improvement Priorities for Reporting .................................... 30

3.2 External Assurance Mechanisms ...................................................................... 30

3.3 Patient Safety .................................................................................................... 32

3.3.1 Infection Prevention and Control ....................................................................... 32

3.3.2 Energise for Excellence (Reducing Pressure Ulcers, Falls, UTI’s, Weight Loss &

Dehydration) .................................................................................................................... 33

3.3.3 Safety Thermometer .......................................................................................... 36

3.3.4 Transparency Project ........................................................................................ 37

3.4 Clinical Effectiveness......................................................................................... 37

3.4.1 Review of Mortality Indicator .............................................................................. 37

3.4.2 Advancing Quality ............................................................................................. 39

3.4.3 VTE Risk Assessment ....................................................................................... 41

3.4.4 Rescuing the Acutely Ill Patient ......................................................................... 42

3.4.5 Reducing COPD Readmissions ......................................................................... 43

3.4.6 Reducing Readmissions within 48 Hours to Critical Care .................................. 43

3.4.7 Improving Dementia Care (NEW) ...................................................................... 43

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3.5 Patient Experience ............................................................................................ 45

3.5.1 Complaints ........................................................................................................ 45

3.5.2 Improving Communication between Patients and Staff ...................................... 46

3.5.3 Patient Experience Questionnaire (PEQ)........................................................... 47

3.5.4 Improving Patient Experience in Endoscopy ...................................................... 48

3.5.5 “Have I Made a Difference” Cards ..................................................................... 49

3.5.6 Equality Delivery System ................................................................................... 50

3.5.7 Friends & Family Test (FFT) .............................................................................. 51

3.5.8 Nursing Care Assessment through Comfort Rounds ......................................... 52

3.5.9 Redesign of Ear, Nose & Throat Services ......................................................... 53

Part Three b: Performance against Key National Priorities .............................................. 54

3.6 Key National Priorities – Department of Health’s Operating Framework ............ 54

Annex A: Statements from PCTs, Healthwatch and Overview and Scrutiny Committees . 56

Annex B: Statement of Directors’ responsibilities in respect of the Quality Report ........... 62

Annex C: Participation in Clinical Audits and National Confidential Enquiries during

2012/13. .......................................................................................................................... 64

Annex D: Actions Arising as a Result of National and Local Audits .................................. 66

Annex E: Performance against key National Priorities ..................................................... 68

Annex F: Limited Assurance Report on the content of the Quality Reports ...................... 70

ON A TYPICAL DAY AT THE TRUST

We see: 875 patients in Outpatients 235 patients in A & E We dispense: 65 prescriptions for inpatients 330 outpatient prescriptions 870 take home prescriptions We test: 5000 tubes of blood 274 MRSA swabs

We clean: 105,459 sq meters of floor We make: 720 inpatients beds We provide: 2400 meals We use: 17,598 gloves 114,746 hand towels and tissues 17,132 wipes 3,902 needles/syringes

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Part One: Statements on Quality

1.1. Statement from the Chief Executive

Aintree University Hospital NHS Foundation Trust is absolutely

committed to the delivery of high quality, safe patient care.

This strategic objective has driven the work we have done in recent years and the three quality priorities for 2013/14 build on the work we have done over the last three years. We achieved many things during 2012/13, our Hospital Standardised Mortality Ratio (HSMR) continued to be one of the lowest in the country however, the Summary Hospital-Level Mortality Indicator (SHMI) introduced more recently gave different results and we are working very hard to find out why this is.

Last year we made significant progress in reducing the numbers of hospital-acquired pressure ulcers and falls resulting in harm. We also achieved the national target to reduce the risk of blood clots (VTE) and I am particularly proud that we achieved the annual 62-day cancer target for the first time in many years. Unfortunately, we exceeded our target for C-Difficile and MRSA and again, much work is focussed on ensuring we can achieve the challenging reduction in numbers in 2013/14. Our national inpatient survey results indicate an improved position in terms of the high level of patient satisfaction with inpatient care. In particular, the Endoscopy and Audiology departments were accredited and we were extremely pleased to hear that patients were very complimentary about the service they received. The Trust also achieved level 3 in the NHS Litigation Authority (NHSLA) risk management standards in June 2012 demonstrating that the Trust has robust risk management systems in place and that we place a strong emphasis on patient safety.

There have been significant operational challenges throughout 2012/13 and these have been experienced by many similar Hospital Trusts. These challenges include:

Higher numbers of patients with complex illness attending our Accident & Emergency (A&E) department and being admitted onto our wards. This has meant that we have not always been able to see patients as quickly as we would have liked although we did meet our 2012/13 target for seeing 95% of our patients within 4 hours in our A&E department.

Some specialties are also experiencing difficulty in admitting patients for treatment within 18 weeks of referral but the Division of Surgery are working very hard to improve this and have made some real progress in recent months.

The failure to achieve these standards, together with the Infection Prevention & Control breaches, has resulted in the Trust being given a red governance rating at Q4. However, early indications in the first quarter of 2013/14 are that the Trust is on trajectory to achieve all targets with the exception of A&E.

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During the year, we started a programme to engage with our staff called Listening into Action (LiA). This programme is designed to involve and empower staff in identifying what could be done to improve services. Initial feedback from this is very positive with some really good examples of improvements in patient care.

I continue to be humbled by the compassion, commitment and expertise that our staff demonstrate when driving forward these improvements on behalf of patients and the Board will continue to support their work.

Catherine Beardshaw Chief Executive

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1.2 Trust Profile

Aintree University Hospital NHS Foundation Trust was established on 1st August 2006 as a public benefit corporation authorised under the National Health Service Act 2006. The Trust provides general acute health care to a population of 330,000 people in North Merseyside and surrounding areas, and also works with a range of partners to provide services in the community. The Trust is a major teaching hospital of the University of Liverpool and its tertiary centres provide specialist services to a much wider population of around 1.5 million in Merseyside, Cheshire, South Lancashire and North Wales. The Trust serves a population which has some of the most socially deprived communities in the country, with high levels of illness. Merseyside has some of the worst rates for heart disease and cancer in the UK, and has also been associated with a culture among patients of low empowerment over their health. The Trust is a large hospital providing Accident & Emergency services and a wide range of acute and non-acute specialties, plus outpatient and day surgery services. The Trust’s services are managed through Clinical Business Units grouped within three main Divisions – Medicine, Surgery and Clinical Support Services. Specialist services are provided in Respiratory Medicine, Rheumatology, Maxillofacial, Endocrinology, Nephrology and Liver Surgery.

1.3 New Service Developments

The opening of a new £1.2m ultraclean theatre for Maxillofacial and Ear, Nose and Throat patients and a new ultraclean theatre for A&E and trauma patients.

The expansion of Critical Care and upgrading of ward 9 and 11 helping bring our cardiology services together in state-of-the-art facilities.

The provision of a new Knowsley Community Diabetes Service.

The University of Liverpool School of Clinical Sciences has a major presence at Aintree University Hospital including Metabolic Medicine, Surgery, Oncology, Head & Neck, Endocrinology/Weight Management, Thoracic Medicine and Rheumatology. The Trust is a recognised centre for multidisciplinary health research and enjoys strong relationships with the University of Liverpool, Edge Hill University, Liverpool John Moores University and other NHS Trusts. This is reinforced by Aintree’s involvement as a founding member of Liverpool Health Partners, the regional Academic Health Sciences System. The Trust is one of the largest employers locally with more than 4,800 staff and has a close working relationship with staff through the Partnership Forum. We aim to reflect the diversity of local communities and have spent time over the year developing new and existing partnerships with local people, patients, neighbouring NHS organisations, local authority, charitable bodies and GPs. We strive to recruit and retain the best staff: the dedication and skills of our employees are what make our hospital successful. Aintree University Hospital has 706 inpatient beds. During 2012/13 the Trust handled 71,369 spells of inpatient and day case care, 325,428 outpatient attendances and 86,375 attendances to the Accident and Emergency Department. At the end of 2012/13 the Trust had fixed assets of just over £174 million and an annual income in excess of £280 million.

Accreditation as the provider of major trauma services for Cheshire & Merseyside ensuring trauma patients receive fast access to specialist treatment.

The delivery of joint vascular services across North Mersey to improve the health outcomes for patients.

The development of the Liverpool Clinical Laboratories, to provide a high quality service with sufficient flexibility to respond to demands from GPs and other providers.

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Part Two: Priorities for Improvement, Statements of Assurance

from the Board

2.1 Priorities for Improvement

2.1.1 Progress against Key Priorities for Action 2012/13

High level progress against the three objectives is shown below and identifies a positive

picture of progress:

Objective Baseline in 2008/9

Progress in 2009/10

Progress in 2010/11

Progress in 2011/12

Progress in 2012/13

Improvement Outcome

Priority 1: Saving lives (Clinical Effectiveness) Maintain saving an additional 100 lives more than expected

Oct 08 – Sept 09,

1827 expected deaths,

1679 actual

Oct 09 – Sept 10,


1465 actual 221 below expected

Oct 10 – Sept 11,


1383 Actual 265 below expected

Oct 11 – Sept 12

895 expected deaths, 728 actual 167 below expected

Feb 12 – Jan 13

1623 expected deaths, 1523 actual 100 below expected

Achieved 100 additional lives than expected

(Data source: Dr Foster, All Diagnosis which is not governed by a standard national definition) Priority 2: Patient safety Maintain

reduction in

Moderate /

Severe

Harm

incidents

268

Incidents

reported

No more

than 268

incidents

to be

reported

312 actual

No more

than 250

incidents

to be

reported

172 actual

No more

than 232

incidents

to be

reported

150 actual

No more

than 150

incidents

to be

reported

143 actual

7 less

than our

trajectory

have

been

reported.

(Data source: Datix internal reporting system which is not governed by a standard national definition)

Priority 3: Patient experience Maintain

improvement

in ‘good and

excellent’

ratings

69% 69% 89.8% 91% 95.13% Improved

by 4.13%

on last

year’s

results

(Data sources: In previous years this has been measured using the Picker In-Patient Survey results for one question around overall patient satisfaction of the care received. The 2012 survey now correlates 12 questions to rate the ‘overall satisfaction’ which is no longer a direct comparison. The Results for 2012/13 are derived from the Trust’s internal PEQ, which is not governed by a standard national definition)

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Progress made in 2012/13 and previous years against quality improvement initiatives that contribute to the delivery of the Trust’s overarching priorities which were identified for action in the 2011/12 quality report can be found in Part Three – Overview of the Quality of Care on pages 30 - 53.

2.1.2 Key Priorities for Action 2013/14

Our position is that safety, patient experience and positive clinical outcomes are the essential elements of quality. Therefore this approach is continuous and is the basis for our quality priorities each year. The Trust Board in consultation with local Commissioners, LINks and the Governors has identified three overarching priorities for quality improvement during 2013/14 and these are aligned to the Trust’s approach to quality improvement. These priorities are derived from three sources: evaluation of the Trust’s performance over the past year against its quality and safety indicators; national and local priorities and emerging themes from patient, staff and public feedback. The Trust’s overarching three priorities for 2013/14 remains constant:

Priority 1: Positive Clinical Outcomes (Clinical Effectiveness) - The Trust will improve its mortality ratings. This is measured through the monthly monitoring of Hospital Standardised Mortality Ratio, Summary Hospital-Level Mortality Indicator (SHMI) using national systems and crude death numbers.

Priority 2: Patient Safety – To reduce avoidable harm in the areas of; Venous Thromboembolism (VTE), preventing malnutrition, falls and pressure ulcers. Progress is monitored using recorded incidents via the Trust incident reporting system (Datix) and the recording of risk assessments on Sigma.

Priority 3: Patient Experience – To improve patient experience measured by results from the Trust’s In-house Patient Experience Questionnaire (PEQ), the National In-Patient Survey and from the new Friends & Family Test.

Performance against these three overarching priorities is monitored by the Board through the receipt of a monthly Corporate Report and Quarterly Quality Account.

The Trust will be undertaking a number of service improvement projects and improving the skills of its workforce to deliver these overarching goals in 2013/14. Priorities for delivery include:

The Trust’s response to the Francis report

Commissioning for Quality and Innovation (CQUIN) Goals

Improving Out Patient Appointment Processes to reduce “Did Not Attends” (DNAs)

Investment in Additional Nursing Staff

Ongoing Ward Refurbishment Programme

Improving Emergency Care Pathways and embedding the capacity management model

Developing our approach to 7 Day Working

Electronic Prescribing for Chemotherapy

Providing Services in the Community i.e. diagnostic, assessment and treatment services

Improving the care of the frail elderly

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Development of clinical standards and the Aintree ward assessment and accreditation system

Progress against the Trust’s agreed Equality Objectives

2.2 Statements of Assurance from the Board

2.2.1 Review of Services

Aintree University Hospital NHS Foundation Trust is a large teaching hospital with approximately 720 in-patient beds. The Trust provide a range of services and provide specialist care to people who need expert help with kidney, liver, intestine and respiratory conditions or treatment for Head and Neck Cancer. During 2012/13 Aintree University Hospital NHS Foundation Trust provided 36 relevant health services. Aintree University Hospital NHS Foundation Trust has reviewed all the data available to them on the quality of care in all of these services through the monthly Corporate Report such as results from local and national surveys, CQC Quality Risk Profiles, patient complaints and GP concerns. This report includes data on three dimensions of quality – patient safety, clinical effectiveness and patient experience. The income generated by the relevant health services reviewed in 2012/13 represents 100 per cent of the total income generated from the provision of relevant health services by Aintree University Hospital NHS Foundation Trust for 2012/13.

2.2.2 Participation in Clinical Audits and National Confidential Enquiries

During 2012/13 30 national clinical audits and 4 national confidential enquiries covered relevant health services that Aintree University Hospital NHS Foundation Trust provides. During 2012/13 Aintree University Hospital NHS Foundation Trust participated in 87% of the national clinical audits and 75% of the national confidential enquires 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 2012/13 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 2012/13, are listed in Annex C 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.

2.2.3 Actions Arising from Clinical Audits and National Confidential Enquiries

The Trust Board has delegated authority for clinical audit to the Trust Assurance Committee. Through this delegation the reports of 21 national clinical audits were reviewed by the provider in 2012/13 and Aintree University Hospital NHS Foundation Trust intends to take the actions listed in Annex D to improve the quality of healthcare provided.

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In addition, the reports of 100 local clinical audits were reviewed by the provider in 2012/13 and Aintree University Hospital NHS Foundation Trust intends to take the actions listed in Annex D to improve the quality of healthcare provided.

2.2.4 Participation in Clinical Research

The number of patients receiving relevant health services provided or subcontracted by Aintree University Hospitals NHS Foundation Trust in 2012/13 that were recruited during that period to participate in research approved by a research ethics committee was 2840. 1268 of this total were recruited into studies adopted by the NIHR and 1572 were recruited into non NIHR studies.

Aintree was involved in conducting 302 clinical research studies during 2012/13. 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 302 studies open at Aintree 175 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 35 days with a median time of 13 days. All of the studies were established and managed with the use of model Clinical Trial/Clinical Investigation Agreements which speed up contracting 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. All studies have undergone research governance review to ensure research passports/letter of access are issued appropriately. This initiative streamlines HR arrangements across organisations to make it easier and quicker to begin approved studies.

The improvement in patient health outcomes at Aintree demonstrates that a commitment to clinical research leads to the best possible care and treatment for patients. High quality research at the core of activity 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.

We have over 100 staff at Aintree involved with research studies covering over 15 specialities over the Trust namely: Cardiology, Stroke, Gastroenterology, Respiratory, Musculoskeletal, Diabetes & Endocrine, Cancer (Head & Neck, Haematology, and General Surgery), Urology, General Surgery, Critical Care, Dermatology, Maxillofacial Unit, Respiratory Infection, Ophthalmology and Pharmacogenetics.

Over the past year at Aintree there has been progress in many areas, with many successful grant applications such as an NIHR Research for Patient Benefit Grant, an NIHR Fellowship Grant and an NIHR Professorship. We have had over 100 publications of work in high profile scientific and medical journals associated with NIHR studies, and presentations of work at scientific meetings both internationally and in the UK.

2.2.5 Use of CQUIN Framework

A proportion of Aintree University Hospital NHS Foundation Trust income in 2012/13 was conditional upon 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 2012/13 and for the following 12 month period are available on line at:http://www.monitor-nhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile .php?id=3275

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During 2012/13 the total income associated with the achievement of quality improvement and innovation goals amounted to £5.4M. Aintree University Hospital NHS Foundation Trust received £2.814M income for the associated payment in 2011/12. An overview of the initiatives taken forward during 2012/13 is outlined in the table below. More information about their contribution to improving patient care and how we endeavor to improve our performance is outlined in Part three – Overview of the Quality of Care.

Key: == AAcchhiieevveedd == PPaarrttiiaallllyy AAcchhiieevveedd == UUnnddeerr AAcchhiieevveedd

CQUIN GOALS

Scheme Target Performance Achieved

Na

tion

al

1 Reduce avoidable death,

disability and chronic ill health

from (VTE),

VenousThromboembolism

90% each

month

>90% VTE

assessment level

each month

2 Improve responsiveness to

personal needs of patients

69.9 =100%

payment

68.9 = 50%

payment

68.5 (NB – this is a

score derived from

the results of 5

questions within the

National Inpatient

Survey)

FFuurrtthheerr ddeettaaiillss oonn PPaattiieenntt RReessppoonnssiivveenneessss aarree pprroovviiddeedd oonn ppaaggee 2255

3 NHS Safety Thermometer 100% 100% of areas

completed monthly

survey and

submitted data

4 Dementia Risk Assessment

(new in 12/13)

90% 33.3% within 72

hours despite 60%

assessment

completion

FFuurrtthheerr ddeettaaiillss oonn DDeemmeennttiiaa ccaann bbee ffoouunndd oonn ppaaggee 4433

Re

gio

na

l

Ad

van

cin

g Q

ualit

y1

5a A Q - AMI 95% 100% cumulative to

December

5b A Q – Heart Failure 86.36% 87.97% cumulative

to December

5c A Q - Pneumonia 85.92% 74.04% cumulative

to December

FFuurrtthheerr ddeettaaiillss oonn AAQQ PPnneeuummoonniiaa ccaann bbee ffoouunndd oonn ppaaggee 3399 5d A Q – Hip & Knee Surgery 95% 97.87% cumulative

to December

1 NB – please note that AQ results are released sometime after the actual end of the quarter

and so the figures within this table represent the most current results available.

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5e A Q – Stroke Composite

Process Score

Stroke Appropriate Care

Score

90% 90.62% cumulative

to December

50% 50.71% cumulative

to December

5f A Q – Patient Experience

Measures (PEMS)

10%

per Qtr

14.4% at the end of

Qtr 1

Cumulative

25%

10.7% cumulative to

February 13

Loca

l

Co

mm

unic

ation

6a Communication – In-patient

Discharge Summaries

70% in Qtr

4

39% (Qtr 3)

Communication – In-patient

Patient Copy Discharges

70% in Qtr

4

57% (Qtr 4)

6b Communication – Day case

Discharge Summaries

50% in Qtr

4

36% (April 13)

6c Communication – Out-Patient

Letters

70% in Qtr

4

45.86% (Qtr 3)

Achievement of targets has been very challenging due to technical issues and IT

system connectivity. This CQUIN goal remains a priority for 2013/14.

Me

dic

ines

Ma

na

ge

me

nt

7a Prescribing Audits 3 3 prescribing audits completed

7b Medicines Management – PbR

excluded Drugs

Contain

Minimum

dataset for

GPs

All dataset

requirements

delivered

En

erg

ise

Fo

r E

xce

llence

8a Pressures Ulcers Grade 3&4s Less than

or equal to

8

5 Grade 3 1 Grade 4

8b Reduce Moderate & Severe

Falls

All adults assessed using

FRASE & care plan in place

Less than

or equal to

10

90%

10 moderate/severe falls have been reported during

12/13 In November 2012,

96% of inpatients

received a FRASE

assessment and of

those identified at

risk 99% had a care

plan in place.

8c MUST tool used on admission To improve

on baseline

and working

towards

95% for

screening

and 100%

of high risk

patients

receiving a

care plan

76.42% of patients screened using

MUST tool

90% of those at risk

received a care plan

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8d Fit and Well to Care Two Acuity

Audits

completed

One completed in

May 12 and one

completed in

February 13

En

d o

f L

ife

Care

9a Advance Care Planning

(ACPs) for Renal Patients

No of ACPs offered & completed

85% of ACP sent to GPs 80% of staff

trained

83 ACPs offered

69 being completed

100% finalised

plans sent to GPs

92% of nursing staff

and 95% of medics

trained

9b Volunteer Support Project

No of

Volunteers

trained

No of

fulfilled

requests to

the

Volunteer

Companion

ship Service

Evaluation

& Audit to

be

completed

30 Volunteers

trained

82 fulfilled requests

to the service

Evaluation & Audit

completed

Dia

be

tes I

n-P

atien

t C

are

10a Diabetes In-Patient Care – Lab

Linked Blood Glucose

Monitoring

Preparation

for the

laboratory-

linked blood

glucose

monitoring

system and

training of

appropriate

staff

Implementation of

new system is

complete and 1,204

staff trained

between 12 Feb –

22 Mar 13

10b Diabetes In-Patient Care –

Poorly controlled patients

Audit of

poorly

controlled

patients

seen by the

diabetes in-

reach team

Audits completed as

required and in

March 87.8% of

proformas were

sent to the GPs.

10c Diabetes In-Patient Care – GP

Proforma

Electronic

proforma to

be

developed

by Qtr 3

75% of

completed

Electronic proforma

developed in Qtr 3

and during Qtr 4 an

average of 82%

each month was

sent to GPs

15

proformas

sent to GPs

in Qtr 4

Q

ualit

y D

ash-b

oa

rds

11a Trauma Dashboards (a suite of

measures relating to Trauma)

Quarterly

reporting

Dashboards

reported and

discussed within

clinical teams each

quarter

11b Renal Dashboards (a suite of

measures relating to Renal)

Quarterly

reporting

Dashboards

reported and

discussed within

clinical teams each

quarter

Re

na

l T

he

rap

ies

12a Patients receiving Peritoneal

Dialysis

12.5%

(subject to

patient

choice)

10.7% of patients

chose to receive

Peritoneal Dialysis

12b Patients receiving home

haemodialysis

5%

(subject to

patient

choice)

4.2% of patients

chose to receive

Home

Haemodialysis

13 Pre-emptive Transplant

Patients

2

(subject to

patient

suitability)

3 suitable patients

received their

transplant prior to

starting dialysis

(pre-emptive)

2.2.6 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 is unqualified. Aintree University Hospital NHS Foundation Trust has no conditions on registration.

The Care Quality Commission has not taken any enforcement action against Aintree University Hospital NHS Foundation Trust during 2012/13. Aintree University Hospital NHS Foundation Trust has participated in one unannounced inspection by the Care Quality Commission relating to the following areas during 2012/13:

Outcome 4 (Care and Welfare of people who use services) for reassessment

Outcome 5 (Meeting Nutritional Needs) for reassessment

Outcome 7 (Safeguarding) for a new planned review

Outcome 9 (Management of Medicines) for reassessment

Outcome 14 (Supporting Workers) for reassessment

Outcome 16 (Quality of Service) for a new planned review

Outcome 17 (Complaints) for reassessment

Outcome 21 (Record Keeping) for additional review Aintree University Hospital NHS Foundation Trust has taken the following action to address the conclusions or requirements reported by the Care Quality Commission:

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discussed and shared an action plan focussed on addressing two areas of non compliance of minor impact and improvement action required against Outcome 9 (Management of Medicines) and Outcome 21 (Record Keeping)

Aintree University Hospital NHS Foundation Trust has made the following progress by 31 March 2013 in taking such action:

Incorporated the actions into the Quality, Safety and Patient Experience Improvement Programme.

It should be noted that the non compliance against the two standards will not impact on the governance rating for the Trust from Monitor.

2.2.7 Information on the Quality of Data

NHS Number and General Medical Practice Code Validity

Aintree University Hospital NHS Foundation Trust submitted records during 2012/13 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 99.1% for accident and emergency care

Which included the patient's valid General Practitioner Registration Code was: 99.9% for admitted patient care; 99.9%; for outpatient care; and 99.9% for accident and emergency care

Information Governance Toolkit Attainment Levels

Aintree University Hospital NHS Foundation Trust Information Governance Assessment Report overall score for 2012/13 was 73% and was graded Green, satisfactory.

Clinical Coding

NHS Foundation Trust received 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) were (8.7%)

• Primary Diagnoses Incorrect [5.1%] • Secondary Diagnoses Incorrect [10.7%] • Primary Procedures Incorrect [5.6%] • Secondary Procedures Incorrect [0%].

The services audited during this period included (Admitted Patient Care non-elective short stay admissions through A & E). It is important to note that these results cannot be extrapolated further than the actual sample audited.

17

Improving Data Quality

Aintree University Hospital NHS Foundation Trust is taking the

following actions to improve data quality:

Reviewing the Trust Data Quality Implementation Strategy to ensure that it meets with operational objectives

Apply the learning derived from the pilot data quality initiative to other specialties across the Trust through sharing knowledge and preventing repetition of errors within working practice

Continued delivery of the data quality programme and collaborative working with the Information Governance Programme to ensure that the Trust Data Quality Implementation Strategy and Performance Metrics are aligned and approved for implementation

Undertaking an extensive review of the data quality key performance indicators to include an increased number of key data sets measuring quantitative (missing values and data validation) and qualitative (performance against dimension) performance metrics according to national guidelines and operational requirement

Aintree University Hospital NHS Foundation Trust has taken the

following actions to improve data quality:

Undertaken an extensive review of the data flows supporting a high volume specialty within the Trust, initiating a pilot site approach within Urology to determine common data quality problems and issues impacting upon day to day operational management

Introduced a number of measures supporting the improvements of data quality at an operational level which have included a reduction in the number of steps within operational processes, a reduction in the deviations from national data quality standards and a concerted effort to move away from a high dependency on manual paper based systems towards Corporate electronic data stores

Extended the consistency and application of data quality standards throughout the Trust through securing advice and guidance from national organisations and review bodies such as the Audit Commission and the Health and Social Care Information Centre and the Francis Report (Public Enquiry)

Undertaken a series of data quality initiatives to support various specialties and divisions within the Trust. This has included providing technical expertise in the production of data flow diagrams for care pathways for Cardiology, Cancer and Trauma

Supported the exploration of the Trust SHMI mortality indicators through providing a supporting role to the Clinical Recording and Coding Task and Finish Review Group, reviewing the way SIGMA requires line by line episodic coding through each episode of a patient spell and identifying Trusts displaying consistently good spell-to-episode ratios

Continued to support the Divisional Surgical Performance Team and Assistant Director of Performance by providing Data Quality key performance indicators regarding missing outcomes.

2.2.8 Performance against core National Quality Indicators - 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.

Reporting Period

2012/13 2011/12

Related NHS

Outcomes Framework

Domain

Quality Indicator Trust performance National average

National performance

range

Trust performance

National average


range

1:

Preventing

People from

dying

prematurely

2: Enhance

quality of life

for people

with long-

term

conditions

Summary Hospital-Level Mortality Indicator (SHMI): SHMI value and banding

April 2011 to Mar 2012

113 100 71.02-124.75 July 2010 to

June 2011

112.7 100 Not available

July 2011 to June 2012

116.4 100 71.08-125.59

Oct 2010 to

Sept 2011


Oct 2011 to Sept 2012

118.2 100 68.49-121.07 Jan 2011 to

Dec 2011


Not yet available 2010/11 110.2 100 Not available

Reasons Improvement Actions

Aintree University Hospital NHS Foundation Trust considers that this data is as described for the following reasons: The data presented within SHMI does not effectively triangulate with other mortality statistics used by the Trust, for example HSMR and Crude mortality rates, which remain within normal

Aintree University Hospital NHS Foundation Trust

has taken the following actions to improve this

score and so the quality of its services, by ;

Undertaking detailed analysis of the

19

limits. The Trust is justifiably proud of its excellent Palliative care services and the extensive care provided to a complex population with high levels of health and social care demands. Recent improvements in service provision and data capture / coding, will not be reflected in the SHMI immediately due to both the lack of timeliness of the measure and the fact it uses 3 years worth of data as a benchmark.

differences between HSMR and SHMI

Undertaking detailed independent case note evaluations of patients who have died in the Trust to ascertain areas for service improvement.

Undertaking further detailed independent analysis to understand how a mortality reduction programme may be further enhanced.

Developed detailed mortality monitoring reports to facilitate regular patient level reviews by clinical teams.

Developed a capacity management programme to support the improvement of patient flow through the organisation.

Implemented a Trust Emergency Medical Team to intervene early as patients deteriorate.

Enhance and support the palliative care team to support patients and relatives before and after death.

Undertaken proactive ad hoc formal patient mortality reviews where patterns of mortality are seen to be outside of that which is expected.

Reporting Period

2012/13 2011/12



range

Trust performance

National average


range

Percentage of admitted patients whose treatment

April 2011 to

Mar 2012

3.34% 1.02% 0-3.4% Not available

20

included palliative care; and


3.29% 1.05% 0-3.3% Not available


3.19% 1.07% 0-3.2% Not available

Not yet available Not available


Aintree University Hospital NHS Foundation Trust considers that this data is as described for the following reasons:

Data Source is Dr Foster Information.




Continuing to monitor palliative care interventions, internally and externally in great detail

Reporting Period

2012/13 2011/12



range

Trust performance

National average


range

Percentage of admitted patients whose deaths were included in the SHMI and whose treatment included palliative care (Context indicator)

April 2011 to Mar 2012

44.05% 18.1% 0-44.2% Not available


42.86% 18.6% 0.3-46.3% Not available


41.89% 19.2% 0.2-43.3% Not available

Not yet available Not available

21







High levels of appropriate palliative care interventions continuing at the Trust. This is in the best interest of patients and their relatives.

Reporting Period

2012/13 2011/12

Related NHS

Outcomes Framework

Domain

Quality Indicator Trust performance

National average


range

Trust performance

National average


range

3: Helping people to recover from episodes of ill health or following injury

Patient reported outcome scores for groin hernia surgery (Percentage of patients reporting an increase in general health)

Pre op – 79.92%

Post op – 84.88%

Pre op – 78.58%

Post op – 87.65%

Pre op –

-59.4 to 100%

Post op –

-34.9 to 100%

Pre op - 71.35%

Post op - 82.77%

Pre op – 78.87%

Post op - 87.62%

Pre op –

-53.6 to 100%

Post op –

-59.4 to 100%



The data source is the Health & Social Care Information Centre.




The pre-operative department reinforcing the importance of patients completing the post operative questionnaires and its impact on

22

future patient experience

Reporting Period

2012/13 2011/12


National average


range

Trust performance

National average


range

Patient reported outcome scores for varicose vein surgery (Percentage of patients reporting an increase in general health)

Numbers of cases are too low to report on Numbers of cases are too low to report on

Aintree is experiencing a decrease in the number of varicose veins operations carried out as this is a procedure of lower clinical priority.

Aintree is experiencing a decrease in the number of varicose veins operations carried out as this is a procedure of lower clinical priority.

Reporting Period

2012/13 2011/12


National average


range

Trust performance

National average


range

Patient reported outcome scores for hip replacement surgery (Percentage of patients reporting an increase in general health)

Pre op –

8.10%

Post op – 59.05%

Pre op – 34.44%

Post op – 77.22%

Pre op –

-59.4 to 100%

Post op –

-59.9 to 100%

Pre op – 21.10%

Post op – 70.26%

Pre op – 35.63%

Post op – 77.03%

Pre op –

-59.4 to 100%

Post op –

-59.4 to 100%






23


The importance of completion of the forms being reiterated to staff. Compliance will be monitored on a weekly basis

Reporting Period

2012/13 2011/12


National average


range

Trust performance

National average


range

Patient reported outcome scores for knee replacement surgery (Percentage of patients reporting an increase in general health)

Pre op – 38.23%

Post op – 65.64%

Pre op – 39.20%

Post op – 71.10%

Pre op –

-59.4 to 100%

Post op –

-59.4 to 100%

Pre op – 24.69%

Post op – 63.44%

Pre op – 40.87%

Post op – 70.79%

Pre op –

-59.4 to 100%

Post op –

-59.4 to 100%







The pre-operative department reinforcing the importance of patients completing the post operative questionnaires and its impact on future patient experience

Reporting Period

2012/13 2011/12

Related Quality Indicator Trust performance National National Trust National National

24

NHS Outcomes Framework

Domain

average performance range

performance average performance range

3. Helping people to recover from episodes of ill health or following injury

Emergency readmissions to hospital within 28 days of discharge

Qtr 1:

Age 0-14 = 0%

Age 15+ = 13.2%

Not available Not available Qtr 1:

Age 0-14 = 0%

Age 15+ = 13.4%

Not available Not available

Qtr 2

Age 0-14 = 0%

Age 15+ = 13.6%

Not available Not available Qtr 2

Age 0-14 = 0%

Age 15+ = 13.5%


Qtr 3

Age 0-14 = 0%

Age 15+ = 13.8%

Not available Not available Qtr 3

Age 0-14 = 0%

Age 15+ = 12.9%


Qtr 4 – Not available Not available Not available Qtr 4

Age 0-14 = 0%

Age 15+ = 13.4%







percentage, and so the quality of its services, by:

Reviewing the non elective pathway

Improving follow up at discharge

Clinical case by case review of individual cases where we are an outlier

Aintree at home provides step down care

25

Reporting Period

2012/13 2011/12

Related NHS

Outcomes Framework

Domain



range

Trust performance

National average


range

4: Ensuring that people have a positive experience of care

Responsiveness to inpatients’ personal needs

68.5 68.1 62.2 – 84.4 68.9 67.4 Not available



Data source is governed by a standard national definition and results reported from a statistical data set on the DH website.


intends to take the following actions to improve

this score and so the quality of its services, by:

contacting those Trusts with the highest scores to learn from best practice and develop an action plan for improvement

Increasing the in-house PEQ response rates

request remedial action by the service to any dissatisfaction in response to these questions and monitor for improvement improving the reporting of the in-house PEQ collected data within Executive and Divisional reports

Reporting Period

2012/13 2011/12

Related NHS

Outcomes Framework

Domain



range

Trust performance

National average


range

4: Ensuring Percentage of 3.68 3.57 Best = 4.08 3.66 3.50 Best = 4.05

26

that people have a positive experience of care

staff who would recommend the provider to friends or family needing care Percentage figures are not available for 2011/12 or 2012/13. Therefore, we have included the Trust score out of a maximum 5, from the 2011 and 2012 NHS national staff surveys.






this score and so the quality of its services, by:

Promotion of an environment which encourages healthy, honest and supportive working relationships

Develop and Implement the Aintree Essential Clinical and Ward Standards

Develop and implement the Aintree Engaging Change model (thirteen improvements projects are already underway using our Listening into Action model)

Delivery of a behavioural leadership development programme

Reporting Period

2012/13 2011/12

Related NHS

Outcomes Framework

Domain



range

Trust performance

National average


range

5: Treating and caring for people in a safe environment and protecting

Percentage of admitted patients risk-assessed for Venous Thromboembolism

Qtr 1 93.5% 93.4% 80.8%-98.3% 71.6% 84.1% 71.6-90.9%

Qtr 2 91.7% 93.9% 65.9%-100% 80.9% 88.2% 20.4%-100%

Qtr 3 92.6% 94.2% 74.8%-100% 93.7% 90.7% 32.4%-95.6%

Qtr 4 91.5% 94.3% 73.9%-100% 98.6% 92.5% 69.8%-99.1%

Overall 92.37% 93.88% 86.52% 88.98%

27

them from avoidable harm






percentage, and so the quality of its services, by:

Mid month monitoring reports at specialty and consultant level are sent out to Clinical Head of Divisions to enable proactive performance management

VTE champions introduced on each ward as part of patient safety officer role

Ward Managers along with Matrons monitor daily performance for their own wards/areas

Reporting Period

2012/13 2011/12

Related NHS

Outcomes Framework

Domain



range

Trust performance

National average


range

5: Treating and caring for people in a safe environment and protecting them from avoidable harm

Rate of C. difficile Per 10,000 Occupied Bed days

Qtr 1 1.32 1.65 0-2.58 2.93 2.41 0-4.36

Qtr 2 3.52 1.54 0-2.27 1.76 2.23 0-3.31

Qtr 3 3.52 1.67 0-2.52 2.35 1.99 0-2.39

Qtr 4 2.20 1.64 0-2.45 2.20 1.75 0-2.09

Overall 2.64 1.62 0-2.58 2.31 2.10 0-4.36



Data source is governed by a standard national



rate and so the quality of its services, by:

28

definition and results reported from the Health Protection Agency’s MESS database.

An improved system for measuring and disseminating antibiotic prescribing compliance is being rolled out across the Trust. This will allow prescribing compliance to be reviewed to a ward/department or consultant team level.

The Trust domestic service contracts manager has undertaken a review of the domestic cleaning schedules to ensure that they are fit for purpose. These revised schedules are currently being rolled-out. In concert with this a related but separate cleaning schedule is being rolled-out to the nursing staff related to equipment and similar near patient equipment.

The Trust is evaluating a new system to objectively assess the efficacy of the cleaning process. This will allow for a regular report or dashboard to be created which provides clarity about where improvements might need to be made (if applicable) regarding cleaning processes.

Reporting Period

2012/13 2011/12

Related NHS

Outcomes Framework

Domain



range

Trust performance

National average


range

29

5: Treating and caring for people in a safe environment and protecting them from avoidable harm

Rate of patient safety incidents and percentage resulting in severe harm or death

Total = 11

(0.20%)*

0.2% (up to September

2012)

Not available Total = 8 (0.15% of total)

0.2% Not available



It is Aintree’s own data source.

*Please note the NHS Information Centre has only made available data for the first 6 months of the year. The overall annual figure, as calculated using the Trust’s Datix reporting system, is 0.20% (being 11 severe/death incidents and 5550 incidents reported in total).



this percentage, and so the quality of its services,

by:

Completing actions from SUI investigations and ensure lessons learnt are disseminated Trust wide.

30

Part Three a: Overview of the Quality of Care

3.1 Identifying Quality Improvement Priorities for Reporting

Aintree Hospital NHS Foundation Trust has published Quality Accounts for four years and has developed an ongoing process for establishing the quality priorities. Last year the Trust agreed the following priorities for improvement from its performance dashboard: improving Patient Experience and investigating our higher headline figure of Summary Hospital Mortality Indicator (SHMI). Venous-Thromboembolism, Safety Thermometer, Dementia Risk Assessment and Patient Responsiveness were identified as national priorities and Advancing Quality was highlighted as a regional priority. From feedback from stakeholders identified below and trend risk analysis the following priorities were identified:

Infection Prevention and Control,

Reducing Pressure Ulcers, Falls, UTI’s, Weight Loss & Dehydration

Progress against the Trust’s agreed Equality Objectives

Comfort Rounds

Friends & Family Test.

The list of contenders had to contribute to the delivery of the Trust’s three overarching priorities indentified for action in the 2011/12 quality report, of which progress can be found on page 6. The Trust found that the final selection became virtually self-selecting following this process in that there was wide consensus on what should be the final priorities. Throughout the year feedback on areas for improvement has been gathered from:

Liverpool, Sefton and Knowsley LINks through the Patient Experience Sub Committee and through Trust quality progress presentations to LINk members

Trust Governors through Board of Governor meetings and Joint Governor/Non-Executive Director/Executive Director Workshops

Lead Commissioner, Associates and local GP Clinical Commissioning Groups at PCT CQUIN meetings and Quality Review Meetings

Trust Staff at Nurse Focussed Groups, Chief Executive Monthly meetings with Consultants, Senior Management Team Meetings including clinical leaders and the Quality Board

Customer Care Reports

External Reports i.e. Picker Survey

Local Community Reaching Out Event Events.

3.2 External Assurance Mechanisms

External Quality Assurance and support provided by Governors and LINks:

Public and patient governors and LINks have contributed to the production of the Trust’s Quality Account summary which was reviewed for transparency, lay language and professional design.

LINks and governors also provided the Trust with important patient feedback at the ‘You said, we did Event’ in June which covered Quality Improvement and Equality and Diversity.

LINks have participated in the Trust’s Patient Experience Group and Patient Experience Sub Committee meetings throughout the year.

LINks accepted an invitation to sit on the Aintree Catering and Nutrition Sub Group which met in December and committed to attend future meetings.

LINks have held their regular monthly stand throughout the year in the Elective Care Centre collecting patient comments.

31

To improve the hospital’s signage, the Trust held a Way Finding Event in November 2012 which was supported by a Knowsley LINk member.

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 mandated this year by Monitor. The performance indicators and their criteria are as follows: Mandatory Performance Indicators

C. Difficile - Indicator criteria:

C. Difficile is defined as a case where the patient shows clinical symptoms of C. Difficile infection and has a positive laboratory test result recognised as a case according to the Trust's diagnostic algorithm. Positive results on the same patient more than 28 days apart should be reported as separate episodes, irrespective of the number of specimens taken in the intervening period or where they were taken.

Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers - Indicator criteria: Number of patients receiving first definitive treatment for cancer within 62-days following an urgent GP referral as a percentage of the total number of patients receiving first definitive treatment for cancer following an urgent GP. Mandatory Local Performance Indicator Patient Safety Incidents resulting in severe harm or death – Indicator criteria: Patient safety incidents reported to the National Reporting and Learning Service (NRLS), where degree of harm is recorded as ‘severe harm’ or ‘death’, as a percentage of all patient safety incidents reported The limited assurance opinion from the External Auditors can be found in Annex G on page 61. In addition, the following priority areas have been subjected to further independent audit/review:

C Diff – PricewaterhouseCoopers

Cancer - 62 day RTT - PricewaterhouseCoopers

Advancing Quality – Audit Commission

SHMI – Dr Foster and Advancing Quality Alliance (AQuA)

Endoscopy – Joint Advisory Group on Endoscopy

Audiology – IQIPS The following section of the Quality Account aims to present an overview of progress against the quality improvement initiatives and of the quality of care provided during 2012/13 under the key headings of: patient safety, clinical effectiveness and patient experience. Each of the following quality improvement initiatives are subject to the relevant accountability and assurance structure governed under Safety & Risk, Clinical Effectiveness, Patient Experience and Workforce which includes:

Weekly/Monthly Operational Working Groups

Monthly/Bi-monthly Sub Committee Meetings

Monthly progress updates to the Trust Assurance Committee

Quarterly report to the Audit Committee

32

3.3 Patient Safety

In June 2012, the Trust was re-accredited with NHS Litigation Authority (NHSLA) Level 3 status for the second time. Level 3 is currently the highest level achievable and demonstrates that Aintree has very well-established risk management systems and a strong culture of safety. The Trust is proud of the infrastructure implemented following the completion of a three year Safety Programme with Johns Hopkins Hospital, Baltimore, USA to monitor patient safety:

A Patient Safety Officer on every ward, in theatres and pharmacy.

Weekly Meeting of Harm, mirroring the Johns Hopkins model, chaired by the Medical Director where all incidents of harm are reviewed. The Trust has improved safety by consequent changes to practice.

A corporate safety champions role in each of the Divisions

Junior Doctors are asked to lead on patient safety projects within the Trust.

Introduction of Comprehensive Unit Based Safety Programmes (CUSPs), where multi-disciplinary teams of staff including house keepers, porters and clinical staff ask themselves the following questions:

o How will our next patient be harmed? o How can we prevent that harm?

This initiative was introduced on 9 wards last year and rolled out to Pharmacy and Microbiology this year.

3.3.1 Infection Prevention and Control

Safety Improvement:

Reducing the risk of meticillin resistant Staphylococcus aureus (MRSA) blood stream infections and Clostridium difficile toxin related infections

Why:

Around 10% of the population may be colonised with MRSA in their noses and on their skin. Some of these carriers go on to develop a clinical infection requiring treatment and a very small proportion go on to develop a significant infection requiring blood cultures to be taken to help guide treatment. MRSA infections are significant as they are resistant to some antibiotics and may be more difficult to treat. A significant proportion of the hospital patient population (around 3-8%) harmlessly carry C. diff in their gut, the prevalence is as high as 30% in patients aged 75 years and older. Following antibiotic use, this harmless carriage can swiftly develop into serious and sometimes life-threatening infections. Once in the environment, the bacteria can survive for prolonged periods as a spore before infecting other patients leading to cross-transmission and secondary cases.

What : To sustain a reduction in the preventable cases

How much:

The target for 2012/13 was to have no more than: 2 hospital attributable MRSA cases and 53 hospital attributable C. diff cases

By When: March 2013

Outcome:

7 hospital attributable MRSA cases 70 hospital attributable C. diff cases

Progress: Target Under Achieved

33

Improvements Achieved:

We have introduced a more specific plan of care for peripheral cannulae (peripheral cannulae were particularly linked to MRSA bloodstream infections in reviews of cases)

The Trust has introduced a number of safety devices to reduce the likelihood of device related infections such as pre-filled flush syringes, non-ported safety cannulae (ported cannulae are shown to increase the likelihood of bloodstream infections) and standardised needleless connectors

The relevant wards and departments audit their practices at least monthly and address non-compliance which is reported through the Trust governance structure through the monthly IPC Group

There have been successful drives to improve compliance with MRSA admission screening in line with the national and Trust guidance

The use of hydrogen peroxide vapour (Bioquell) for decontaminating bed spaces/rooms related to patients with C. diff has been re-introduced

The cleaning of near patient equipment which is the responsibility of nursing staff to clean is now clearly audited with same day feedback to ward managers and matrons. This has improved the visibility of equipment cleanliness

Further Improvements Identified:

The Trust target for 2013/14 is to have 0 hospital attributable MRSA cases and no more than 43 hospital attributable C. diff cases

The Trust is establishing a vascular access group to review policy, guidance, education and surveillance of key practices related to bloodstream infections

The Trust is developing a programme to reinforce staff awareness of asepsis and linked practices; to include the use of 1-to-1 education, competency assessment and better reference materials

Improved antibiotic stewardship and improved documentation regarding antibiotic stewardship

The IPC team will be encouraging greater involvement for staff in the delivery of safe care in their wards/departments specifically related to IPC

Improved stewardship for antibiotic prescription

Revised post-incident review process

Improved collaborative working with C. diff management as part of the whole health economy

Enhanced Divisional scrutiny of HCAI in their related departments

(Data source: Health Protection Agency which is governed by a standard national definition)

3.3.2 Energise for Excellence (Reducing Pressure Ulcers, Falls, UTI’s, Weight Loss & Dehydration)

Safety Improvement:

Energise for Excellence is a national call to action for all nurses to provide excellent compassionate harm free nursing care. The Trust wishes to demonstrate continuous improvement by building on our existing scheme by stretching goals beyond our existing commitments.

Why: This scheme focuses on those areas of harm that matter most to our patients and their families. The Trust wishes to continue to provide our patients, commissioners and regulators with confidence that the hospital strives to provide harm free care for all our patients but especially for those most vulnerable.

What : Pressure Ulcers To reduce the number of hospital acquired grade 3 & 4 pressure ulcers To record and monitor all newly acquired grade 2 pressure ulcers

34

How much:

Less than 8 grade 3 & 4 hospital acquired pressure ulcers to be reported during 12/13

By When: March 2013

Outcome:

Hospital acquired pressure ulcers reported during 12/13: 5 grade 3 1 grade 4 165 grade 2

Progress: Target Achieved


A SOP has been developed for ward staff to utilise based on the SSKIN Bundle and rolled out across the Trust.

The policy for pressure ulcer prevention has been updated and approved in January 2013.

Root cause analysis completed for all Grade 3 & 4 pressure ulcers. A new validation process has been introduced which will ensure robustness of classification and timeliness of sign off process.

A point prevalence took place in October 12 and 91% of patients had a waterlow risk assessment undertaken. 55% of patients had a waterlow score of over 10 indicating they were at risk of pressure ulcers.

A referral arranged to the District Nursing Team and details copied to the GP for any patients leaving hospital with a grade 3 or grade 4 pressure ulcer that has not completely healed.

Work is now underway to develop an electronic risk assessment / care plan.

Established a Pressure Ulcer Collaborative.

What : Falls

To reduce the number of moderate or severe falls

In-patients to be risk assessed for falls using an appropriate tool and a care plan provided for those identified at risk of falling

How much:

Less than or equal to 10 moderate or severe falls to be reported 95% of in-patients to be risk assessed and 95% of those at risk have care plans in place

By When: March 2013

Outcome:

10 moderate/severe falls have been reported during 12/13

In November 2012, 96% of inpatients received a FRASE assessment and of

7

21

8

17 15

18

9

16 17 17 17

9

0

5

10

15

20

25

30

35

Ap

r

May

Jun

Jul

Au

g

Sep

Oct

No

v

Dec

Jan

Feb

Mar

Pre

ssu

re U

lce

r In

cid

en

ts

Month

Trust Pressure Ulcers

2011/2012

2012/2013

1 1

0 0 0

1 1

0 0

3

2

1

0

1

2

3

4

Ap

r

May

Jun

Jul

Au

g

Sep

Oct

No

v

Dec

Jan

Feb

Mar

Falls

Inci

de

nts

Month

Trust Falls (Moderate - Severe)

2011/2012 2012/2013

35

those identified at risk 99% had a care plan in place.



Falls Documentation Reviews, Patient Experience Interviews and Staff Questionnaires have been completed and published as part of the NHS Transparency Study for the 10 falls cases causing moderate/severe harm.

The Trust is committed to ensuring that patient harm from falls remains a high priority and has recently undertaken a Trust wide Falls Equipment Inventory and Staff Training Needs Analysis.

What : Weight Loss & Dehydration

Demonstrate % improvement from baseline of adult in-patients screened for malnutrition on admission using the MUST tool

For those patients with a score of 2 or more to receive an appropriate care plan.


Snapshot audit undertaken in December

resulting in 76.42% of patients being screened

for malnutrition within 24 hours on admission.

Of those patients with a score of 2 or more it

is estimated that over 90% received an

appropriate care plan from the dietician due to

the significant increase in the number of

referrals received from the wards.


Further amendments required to the electronic MUST proforma to prevent unnecessary referrals of patients scoring less than 2.

How much:

Improvement on baseline and working towards 95% compliance using the MUST tool on admission Working towards 100% of patients scoring 2 or more having a care plan in place

By When: March 2013

Outcome:

76.42% of patients being screened using MUST from a baseline of 75% 90% of those at risk received a care plan


What : Urinary Tract Infections (UTIs) To establish a baseline at end of year using 12 months of incidence rates provided by Safety Thermometer results


Measurement work completed through the monthly safety thermometer surveys.


Look at identification of Catheter related UTI’s through the Path Lab System.

How much:

Understand baseline position on UTIs

By When: March 2013

Outcome:

12 months of results provided by Safety Thermometer shows an incidence rate of 155


(Data source: Datix which is not governed by a standard national definition)

36

3.3.3 Safety Thermometer

Safety Improvement: Safety Thermometer

Why:

Point prevalence indicator which measures the level of harm within 100% of in-patients clinical areas (catheter associated UTI, falls, pressure ulcers & VTE)

What : A survey undertaken on 1 day in a month (snapshot in time) to identify areas for improvement (harm reduction)

How much: Monthly measurements from March 2012 (100% of areas)

By When: Year on year reduction to be agreed

Outcome: In March 2013, Harm Free Care (excluding ‘old harms’) was 97.3%


100% of all in-patient areas, including Theatre Recovery

Safety Thermometer: Proportion of patients with each type of Harm


New version implemented in April 2012

Data collection by patient safety officers

100% of data collected on same day in all areas

Matrons given access to review individual ward harms

Created an NHS Safety Thermometer Dashboard on aBI


Improvement goal to be agreed for biggest harm area which is new pressure ulcers

Will be an ongoing priority for the Trust for 13/14

(Data source: NHS Information Centre which is governed by a standard national

definition)

37

3.3.4 Transparency Project

Safety Improvement:

Transparency Project

Progress:

Target

Achieved

The Transparency of Care Project continues to investigate all falls resulting in a harm and all hospital acquired pressure ulcers (grades 2, 3 & 4). Staff & patients from the ward that reports the incident continue to be surveyed and the information is written up in a formal report which is published on the Trust’s Internet site for public access.

3.4 Clinical Effectiveness

In 2012/13, we developed a leadership programme for different staff levels from supervisors through to senior clinical leaders and enhanced this through working in partnership with University College London to establish a Leadership College. This will enable our staff to become the best they can be and also provides the opportunity to develop leaders in the local community to effect real change.

Revalidation is the process by which licensed doctors are required to demonstrate on a regular basis that they are up to date and fit to practise. Revalidation aims to give extra confidence to patients that their doctor is being regularly checked by the hospital where they are employed and the General Medical Council (GMC). The NHS started revalidation nationally in December 2012.

The Trust has made the following progress to date:

An appraisal system and associated processes that are fit for the purpose of revalidation have now been embedded within the Trust. All required organisational readiness self assessments have been completed and the Trust has been RAG rated ‘Green’ by the Strategic Health Authority in relation to it’s organisational readiness for revalidation.

All active appraisers have received appropriate training and quality assurance processes for the assessment of appraiser performance are underway. All doctors have been scheduled for an annual appraisal and have completed multi-source feedback where required.

All 38 of the first tranche of doctors due to be revalidated by the 28th March 2013 have had recommendations made against them to the GMC by the Trust's responsible officer.

3.4.1 Review of Mortality Indicator

Clinical Effectiveness Improvement Area:

Improving mortality rates, enhancing patient care and ensuring

accurate reporting.

Why:

Aintree continues to report a good Hospital Standardised Mortality Ratio rating (HSMR), an indication of lower than average mortality, but the new national mortality indicator - Summary Hospital Mortality Indicator (SHMI), presents a significantly higher headline figure than expected. Whilst there are significant methodological differences between the indicators, Aintree is using detailed external analysis and reporting to improve both clinical care and the accuracy of information to support external data submissions.

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What :

This year we have undertaken multiple, in-depth examinations and independent reviews of the reasons behind our high SHMI rating and low HSMR. This allows the Trust to focus improvement activities to reduce mortality rates. Two key independent analyses have been completed, which highlight similar areas for enhancement and service development. In addition to this, the Trust has already embarked upon a comprehensive programme of improvements and will take a positive steer from the reviews commissioned. The reviews themselves, highlighted a number of areas for further development (many of which have already been implemented), these include;

The setting up of mortality Action team / Taskforce

The development of a ‘Mortality Reduction Plan’, based upon a mortality reduction driver diagram

Detailed mortality reports at a Trust / Divisional and Directorate level to be produced.

Improving recording and standard of record keeping by clinical staff.

Enhancing clinical staff contact with the coroner

Enhancing the role for the Trust’s clinical recording and coding group with greater links to the clinical teams, looking at enhancing clinical contact with the teams and reducing residual and non specific coding.

Improving reporting and audit of cardiac arrests

Reducing consultant / physical moves within a patient pathway.

Continued improvements in Heart Failure, Stroke and Pneumonia CQUINS.

Continuing the work to reduce infections, incorporating sepsis and central care line bundles.

The reports also indicate that commissioners should regard a high SHMI as a whole systems issue, particularly focussing on tracking patients post discharge and care of the dying.

Outcome:

Due to the nature of SHMI, measuring the direct effect of any changes and service developments in the Trust would not show immediately in the numbers, although other measures (HSMR) would be more sensitive. HSMR remains low, but specifically, significant reductions in some key SHMI areas are noted amongst other things. These are:

Mortality from non specific chest pain now shows no significant variation for the benchmark (following a ‘peak’ in June 2012).

Mortality from non specific codes (residual codes) – is now exactly that which would be expected.

Stroke advancing quality scores are significantly improved and above target.

A new reporting structure is in place to facilitate clinician led mortality reviews.

Enhanced clinician engagement with coders, with many coding staff working with clinicians in care environments such as operating theatres.

Clinicians are now issued with guidance cards re coding and documentation.

Palliative care service intervention is shown to be appropriate and high quality

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Independent case note review of deaths indicates that the vast majority of patients received high quality and appropriate care prior to death.

Improvement Actions

The key improvement action from this work is to continue with the programme already being implemented and embrace the key recommendations from the various reports. Central to this is enhancing clinical engagement in the mortality review process, continuing the implementation of the medical model and providing effective feedback to monitor progress.


Improvements in real time mortality monitoring

Real time audit of clinical coding for deceased patient records

Increased clinical scrutiny of mortality

Improvements in clinical recording

Reduced errors in data submissions

Trust wide focus on mortality improvement from the Chief Executive and Medical Director.

3.4.2 Advancing Quality

Clinical Effectiveness Improvement:

Advancing Quality

What:

Advancing Quality is a clinically-led quality improvement programme which commenced across the North West of England in 2008 to drive up standards in healthcare, reduce variation and reduce avoidable mortality.

Why:

The principles of the programme are that if patients are provided with the right care at the right time in their care pathway it will minimise mortality, re-admission rates, complications and the length of time patients spend in hospital. Evidence indicates that when patients are given appropriate ‘care bundles’ it improves both patient experience and patient outcomes. Each clinical focus groups has a defined set of interventions which are included within the ‘care bundle’. Operating in specific clinical areas, the AQ quality indicators aim to ensure every patient receives the same high standard of care in every hospital by focusing on adherence to key evidence based clinical interventions, patient experience and clinical outcomes. For 2012/2013 our Trust took part in 5 Clinical Focus Groups, namely:

Acute Myocardial Infarction (AMI)

Heart Failure (HF)

Pneumonia (PN)

Hip and Knee (H&K)

Stroke (Stroke) Each of these started the AQ programme in October 2008 with the exception of Stroke which joined the programme in October 2010. In addition, the Trust also took part in the Patient Experience Measure exercise.

Achievement Performance is assessed on the basis of the composite process score. For 2012/2013 the targets were:

AMI (Target 95%)

Heart Failure (Target 86.36%)

Hip and Knee (Target 95%)

Pneumonia (Target 85.92%)

Stroke (Target 90%)

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CPS (Composite Process Score) – percentage of the total measures delivered ACS (Appropriate Care Score) – measure of those patients that receive all the measures appropriate to the individual care needs Denominator 1 = Number of care measures Denominator 2 = Number of patients The percentage of patients receiving the right care at the right time in their care pathway has been maintained for 4 of the 5 clinical focus groups (AMI, Heart Failure and Hip & Knee elective replacement surgery and Stroke. Note * indentifies changes to data reported in 2011/2012 resulting from data validation exercise (completed August of each year). Problems also experienced with the algorithms in the reporting software.

Clinical Focus Group

Measure (Denominator)

Period 1 Period 2 Period 3 Period 4 Period 5

Oct08-Sep09 (PTE)

Oct09-Mar10 (PTE)

Apr10-Mar11 (YTE)

Apr11-Mar12 (YTE)

Apr12-Dec12 (YTD)

AMI CPS (Denominator1)

93.33%

97.69%

98.73%* 246

98.72% 564

100% 477

ACS (Denominator2)

86.4%

98%

97.62% 126

95.29 255

100% 228

Heart Failure

CPS (Denominator1)

82.2%

77.6%

87.85%* 276

82.21% 579

87.97% 405

ACS (Denominator2)

71%

73.68%

71.30% 115

61.83% 241

75.16% 165

Hip & Knee CPS (Denominator1)

92.04%

93.08%

92.81%* 1,499

95.89%* 3,365

97.87% 2,298

ACS (Denominator2)

82.3%

68.97%

79.62% 314

90.33% 703

89.98% 479

Pneumonia CPS (Denominator1)

73.72%

82.82%

84.7%* 869

75.69% 2,304

74.04% 2,061

ACS (Denominator2)

34.43%

46.67%

61.35% 282

34.74% 593

37.64% 573

Stroke Joined AQ Oct 2010

CPS (Denominator1)

N/A N/A 89.58%

89.88% 2,362

90.62% 1,735

ACS (Denominator2)

N/A N/A 54.73%

48.06% 387

50.71% 280

Impact The impact of taking part in the AQ programme can be linked to the following assessment of Mortality, Length of Stay and Readmission assessments which is shown in the table below.

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(Data source: Dr Foster & Clarity Assure which is not governed by a standard national definition)

Delivery against last year’s identified proposals to achieve further improvements:

During 2012/13 Trust clinicians have attended the North West collaborative meetings so that best practice from other organisations can be adopted within Aintree.

During 2012/13 the Trust agreed to explore options for real time data collection so that clinicians can review performance and implement changes to improve the quality of care in a timely manner. Three companies were contacted regarding “live data” collection systems. The Stroke team are in discussions with one company to trial a system for one a one month.

To improve the AQ pneumonia performance in 2012/13 the Trust has:

Greater Consultant leadership in AQ Pneumonia to review pneumonia patients’ case notes to ascertain whether the outcomes for AQ Pneumonia are being recorded properly i.e. antibiotics and to understand better areas for improvement.

Greater engagement with Accident and Emergency

Delivered teaching to medical staff in A&E, MAU and to the FY1 and FY2 doctors in the most appropriate care pathway for community acquired pneumonia

Instigated weekly team meetings with colleagues including consultants, nursing, and corporate support colleagues.

Changes to data reported in 2011/2012 is as a result of data validation exercise

(Data source: Dr Foster & Clarity Assure which is not governed by a standard national definition)

3.4.3 VTE Risk Assessment

Clinical Effectiveness

VTE Risk Assessment

Why:

Venous thromboembolism (VTE) is a term that covers both deep vein thrombosis and its possible consequence: pulmonary embolism (PE). A deep vein thrombosis (DVT) is a blood clot that develops in the deep veins of the leg and if the blood clot becomes mobile in

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

AMI 14.1% 15.2% 12.2% 9.2% 4.8% 6.7%

Heart Failure 10.5% 7.0% 7.5% 7.7% 9.2% 16.0%

Hip Replacement 0.7% 0.3% 0.0% 0.3% 0.3% 0.0%

Knee

Replacement0.0% 0.0% 0.0% 0.0% 0.3% 0.4%

Pneumonia 22.9% 22.1% 20.2% 19.8% 20.4% 20.7%

AMI 9.1 10.7 10.6 9.8 10.2 11.1

Heart Failure 12.0 12.3 13.4 12.5 13.0 15.7

Hip Replacement 8.6 6.8 7.2 6.1 6.0 6.9

Knee

Replacement6.3 5.1 5.6 5.7 5.9 6.1

Pneumonia 11.1 12.6 11.8 10.9 11.5 11.4

AMI 12.9% 14.7% 13.1% 17.4% 14.7% 16.3%

Heart Failure 15.6% 12.0% 17.6% 9.9% 15.1% 16.3%

Hip Replacement 15.1% 13.6% 11.7% 11.0% 9.0% 6.0%

Knee

Replacement8.5% 5.4% 9.2% 8.6% 6.6% 8.5%

Pneumonia 12.9% 14.4% 14.9% 15.2% 13.9% 12.7%

Increase of 5% or more

Increase of less than 5%

Improvement

Readmissions

TrendClinical Area

Mortality

Length of Stay

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the blood stream it can travel to the lungs and cause a potentially fatal blockage (PE). 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).

What :

Implement a Trust wide VTE risk assessment tool to ensure in-patients at risk of VTE are identified and receive correct treatment

How much: 90% of patients risk assessed for VTE on admission

By When:

Every month during 12/13

Outcome:

On average 92% of patients are having a VTE risk assessment completed each month.

Progress: Target

Achieved


Since April 2012 the Doctors complete the VTE risk assessment using an electronic proforma on Sigma providing real time data capture which enables automated performance reporting on aBI

Mid month monitoring reports at specialty and consultant level are sent out to Clinical Head of Divisions to enable proactive performance management

The Trust has exceeded the threshold of risk assessing 90% of eligible patients each month over the last 12 months

Training is provided to Junior Doctors on induction

VTE champions introduced on each ward as part of patient safety officer role

Ward Managers along with Matrons monitor daily performance for their own wards/areas


Drive continuous improvement in performance to achieve the 95% threshold for

2013/14. This remains a high priority for the Trust.

(Data source: Unify2 which is governed by a standard national definition)

3.4.4 Rescuing the Acutely Ill Patient


Rescuing the Acutely Ill Patient - The Aintree Medical Emergency Team (MET)

Progress:

Now

embedded as standard practice

Sustained improvement in Modified Early Warning System (MEWS) compliance audit results following MEWS re-launch day in April 2012

MEWS Information Spinner won the 2012 NHS Merseyside Quality Award

New MEWS chart launched on 29th April 2013

The Aintree MET Model adopted by 2 other local Trusts

The Aintree MET is now fully embedded as standard practice within the Trust and will not be reported on in future Quality Accounts.

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3.4.5 Reducing COPD Readmissions


Quest Reducing Avoidable Readmissions (within 30 days of discharge)

Progress:

Now embedded as standard practice

A modified BTS (British Thoracic Society) Chronic Obstructive Airways (COPD) discharge care bundle was successfully piloted on ward 23 and is to be rolled out to the respiratory wards. The care bundle is delivered to patients admitted with a history of COPD and the aim is prevent an avoidable readmission due to exacerbation of COPD, whilst improving quality of care and improving patient experience. Specific Care Bundles Steps include:

- Offering smoking cessation assistance - Assessment for Pulmonary Rehabilitation - Written COPD Patient Information - Assessment of Inhaler Technique - ‘Check Up’ phone call in the immediate days following discharge - Formal handover to community respiratory services

The Quest readmission project was formally closed in November 2012 and Quest are in the process of launching the work streams for 2013/2014.

3.4.6 Reducing Readmissions within 48 Hours to Critical Care

Clinical Effectiveness Improvement Area:

Reducing Re-admission within 48 hours to Critical Care Department

Progress:

Now


The new transfer process has been extended throughout the Trust.

We continue to drive and monitor this improvement through audit on a monthly basis as a Departmental Key Performance Indicator therefore will not be reported on in future Quality Accounts.

3.4.7 Improving Dementia Care (NEW)


Improving the quality of dementia care in an acute hospital setting

Why:

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. Referral out to appropriate specialist community services is often poor for these patients.

What :

Improve awareness and diagnosis of dementia, using risk assessment, in an acute hospital setting

How much:

Trust to achieve 90% in the following areas for patients admitted as an emergency aged over 75 years: 1. Dementia case finding 2. Diagnostic assessment for dementia within 72 hours 3. Referral for specialist diagnoses

By When: For 3 consecutive months within any quarter in 12/13

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Outcome:

On commencing of manual data collection processes Trust wide in February, the Trust has achieved completion of the Dementia risk assessment within 72 hours as follows: 36.8% for February 2013 and 33.3% in March 2013

Progress: Under Achieved

The dementia risk assessments completed in March 2013 was actually 60% but 26.7% were outside of the time threshold of 72 hours.


Project team established to oversee the service improvement initiative.

An electronic dementia assessment tool was developed in August.

Piloting of the electronic proforma in October revealed that its functionality had been severely affected by the Sigma upgrade which went live in August.

A paper system commenced on wards 31, 33, 25, 17 and MAU with manual collection of results data in December.

A super user has been recruited and trained to collate the completed assessments and input the results into a simplified collection proforma on Sigma allowing the Trust to report on the data.

Trust wide roll out of the paper tool went live at the end of January 2013.

Trust wide communication initiated in January and February to raise awareness.

Awareness sessions have been completed with medical and nursing staff on all wards to ensure that staff is informed of the need for dementia risk assessment to be completed and ensure Medical staff completes the risk assessments.

Performance has increased since roll out but further work is required.

The Trust has recruited a dementia lead matron who took up post in February.

The Trust is involved in the (AQuA): Dementia Improvement community. As part of this work, quarterly audits have been returned. The audits have taken place on 1 ward in the Trust. The standards within the audits have looked at Dignity and Respect – dementia champions, information, personalised care and single sex accommodation. Environment – ward environment, minimising moves, recreation, dementia identifier and support scheme, and estates.

The Trust has recently been successful in securing £15,000 Regional Innovation funding (RIF) – QIPP and Innovation team - for the ‘Dementia Trained Volunteer Programme’. The volunteers will receive dementia awareness training; this will equip them with the necessary skills to enable them to support the carers of patients who have dementia. The project will start on 1 ward within the DME and then be rolled out across the Trust. The money will be used to facilitate dementia awareness training, purchase and provide fold down beds for carers should they wish to stay, purchase and provide modified cutlery and crockery and facilitate the following activities for patients: hand and shoulder massage, aromatherapy, reminiscence therapy and low impact exercise programme. Start date: February 2013.


Move to an electronic proforma and coloured dot system on the electronic whiteboards within the wards as soon as possible to support staff to increase performance on the risk assessments completed.


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3.5 Patient Experience

Quality of care includes quality of caring. This means how personal care is – the compassion, dignity and respect with which patients are treated. It can only be improved by analysing and understanding patient satisfaction together with their experiences. Monitoring and gathering evidence on patient experience from a variety of sources enables the Trust to measure the service it provides for patients in a particular way by identifying trends in areas of good and poor practice which can then be addressed. The different procedures and data capturing mechanisms in place for obtaining patient feedback are:

Complaints

National Patient Surveys

The Patient Experience Questionnaire (PEQ)

Exit Cards for patients to complete on discharge

'Have I Made a Difference?' cards (HIMAD)

Patient Stories

Graffiti Wall

Focus Groups

3.5.1 Complaints

The complaints process is an important source of data and feedback for the Trust in its plan to improve the patient experience. This year, the Customer Services Department has supported the Clinical Divisions to fully integrate complaint management and ownership at a local level. A two day event involving the Customer Services Team and Divisional Clinical Business Managers and Assistant Directors of Nursing and Allied Health Professionals was held in August 2012. The review identified the challenges the Divisions and Customer Services face to have clearer lines of communication between the departments to monitor progress against complaint response deadlines, as well as improving the quality of these responses. The event highlighted the need to be more proactive in learning lessons and improving service developments that are then shared across Divisions. The outcome from this event has led to a commitment to further review the complaint investigation and response processes within the Divisions. Monthly meetings between the Head of Complaints and the Divisional CBM’s are taking place and future developments are reported through the Professional Nurses Forum and Divisional Clinical Governance meetings as well as the Patient Experience Sub Committee and at Trust Board. To ensure that lessons have been learnt and patients, carers experiences are listened to, patients have shared their experiences in a variety of ways: through the recording of educational DVDs, telling their story in person or having their experiences recorded and shared through power point presentations i.e. as part of a teaching programme about the care of older people and at complaint and being open meetings. The introduction of a graffiti wall in Theatres and Intensive Care has enabled staff to have a greater understanding of their patients’ needs. This approach allowed patients, relatives, visitors and staff to record their comments, feelings and suggestions about the service that they received and experienced within specific wards and departments. The Trust welcomes complaints from all sections of the population. The complaints procedure is available in an accessible format on request and any information received is recorded by ethnicity, wherever possible (see Table 1 below).

Data Source Number of Patients

Patient Ethnicity

Compliments 463 Not stated

18 White – British

Total 481

Comments 95 Not stated

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1 White – British

Total 96

Concerns 446 Not stated


2 Chinese

11 Other – White

1 White – Irish

Total 1013

Complaints 63 Not stated


1 Chinese

1 Indian

3 Other – White

2 Other ethnic category

Total 358

3.5.2 Improving Communication between Patients and Staff

Patient Experience Improvement:

Patient Experience – Improving Communication

Why:

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.

What :

Four key areas of communication were identified for improvement from the results of the 2009 national in-patient survey.

How much:

From a baseline of 69% to improve by 20% in the 4 key questions within 24 months. This was achieved in 2011/12 but the Trust is now monitoring continuous improvement.

By When:

2012 National Picker in-patient survey (results available in February 2013)

Outcome:

Patients have reported that communication has improved in the 4 key communication questions

Progress: Continuous Improvement Partially Achieved

Patient Experience Results on the 4 key areas around communication

March 2011

March 2012

March 2013

Q1. Patients felt that nurses did have knowledge/or a good awareness of their condition

83.71% 85.8% 75.0% (all/most nurses knew enough)

14.2% (only some nurses knew enough)

2.0% (none knew enough)

8.7% (can’t say or not answered)

Problem score for the Trust is 16% which

is exactly the same score as the national

average.

Q2. Patients understood the answers nurses provided

80% 93.6% 96.7% (yes always, yes sometimes)

Q3. Patients understood the answers doctors provided

79.39% 93.5% 96.4% (yes always, yes sometimes)

Q4. Patients felt involved in discussions about their care

79.69% 88% 90.6% (yes always, yes sometimes)

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The Trust has achieved continuous improvement in 3 out of the 4 key communication questions

To understand the results of Q1 in the table above, the Trust has reviewed the nursing workforce by undertaking two 4 week audits of patient dependency. The first was completed in May 2012 and the second in February 2013 to ensure results are viewed over time and take into account seasonal variations.

Results have been presented to the Executive Team, Divisional Assistant Directors of Nursing, Matrons and Ward Managers together with an action plan.

The evidence base will support workforce plans for nursing that accurately predict and enable resources to be indentified to meet patient and service requirements.

Further Improvements Identified: Improvement areas highlighted from the survey have been incorporated into an action plan and progress is monitored by the Patient Experience Sub Committee.

(Data source: Picker Survey results in February 2013 which is governed by a standard national definition)

3.5.3 Patient Experience Questionnaire (PEQ)

Patient Experience

Patient Experience (NEW)

Why:

The Trust has a moral, commercial and legal duty (e.g. Health and Social Care Act 2012) to take the view of local patient into account when delivering services

What :

Patient Feedback collected via the Patient Experience Questionnaire

How much:

Between March 2012 and March 2013 ( the period under review 1807 PEQ were collected

By When:

1/3/2012-31/3/2013

Outcome:

Improved patient satisfaction

Progress:

Target Achieved

0%

20%

40%

60%

80%

100%

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Average %

Putting You First

Putting You First

... At all times … Most of the time … Sometimes … Rarely … Never

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Average %

Receiving prompt attention

Receiving prompt attention

... At all times … Most of the time … Sometimes … Rarely … Never

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On average 9 out of 10 patients rate us either good or excellent in the following areas: “Putting You First” (good and excellent score = 96.5% compared to 95% last year There was a similar story with “ Receiving Prompt Attention” good and excellent score = 96% compared to 94% last year and also with “ Showing we care” good and excellent score = 95.3% compared to 95% last year. The 1807 patients surveyed over the last year gave the Trust an average of 8.84 out of 10 which was also a slight improvement on the score of 8.74 in the previous year.


The Trust realises that some part of these very high scores may be due to patients being asked there opinion whilst still on the wards, by ward clerks and housekeepers. Furthermore, it has been recognised that the Patient Experience Questionnaire has become a lengthy document which needs to be condensed to encourage patients to complete it. Therefore in quarter 1 of 2013/2014, the Trust’s Patient Experience Lead is embarking upon a Listening Into Action approach to revise the Patient Experience Questionnaire taking into account patient’s views upon how/when they wish to be asked about their experience and what the questionnaire should include. Staff will also be consulted around how best to achieve maximum response rates and a trial of the improved Patient Experience Questionnaire is due to take place in quarter 2 of 2013/2014. The consultation will also include our Healthwatch colleagues and will be monitored through the Patient Experience Sub Committee. Following the trial period, when it is appropriate the new Patient Experience Questionnaire and collection approach will be agreed and signed off by the Patient Experience Sub Committee. With regard to monitoring response rates, the Patient Experience Questionnaire returns are now monitored via the Ward to Board dashboard and are rag scored against the target of 20 per ward per month.

(Data source: aBI which is not governed by a standard national definition)

3.5.4 Improving Patient Experience in Endoscopy

Patient Experience Improvement:

Patient Experience in Endoscopy using Exit Cards

Progress:

Now


Since the introduction of exit cards, the service has learned from the patient feedback and introduced improvements that enhance the patient experience. The graph opposite highlights that patients using the service in December 12 state that they got the care that mattered to them at all times.

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Outcome:

The Joint Advisory Group (JAG) on Endoscopy accredited Aintree’s service with no recommendations for action following a review visit. The final report describes the service as “an excellent, patient-centred service” with a team who were “open to change and development” having created a training culture and a vision for a “seamless patient experience”. Congratulations go to the Endoscopy team for this very positive accreditation.

The following are direct quotes from patients feeding back in December 2012 what we did well:

Patient experience of Endoscopy services will feature in the next phase of the Friends and Family Test therefore will not be reported on in future Quality Accounts as a separate initiative.

3.5.5 “Have I Made a Difference” Cards

Patient Experience Improvement Area:

Patient Experience: “Have I made a Difference cards” (NEW)

Why:

The Trust uses a system of ‘ have I made a difference cards’ which capture what patients say about staff who have exceeded their expectations

What :

The cards are available throughout the hospital on wards and in public areas

How much:

The number of HIMAD collected was 328

By When: These comments are from a period April 2012- March 2013

Outcome:

Two staff, in particular, were judged to have delivered excellent customer service over the period due to comments below received from patients:

Progress: Now embedded as standard practice


The winner of the award was

David Sloan, Health Care Assistant, AED

“Treated me with respect and care”

“Very polite and willing to help in anyway

possible”

“Was dead sound making me laugh and

took good care taking bloods”

“Excellent attitude and kept me informed”

“Treated my mum with utmost respect, very

polite, nothing was too much trouble, credit

to the hospital, well done.”

Picture right: Jill Byrne, Director of Nursing presenting David Sloan with the Trust’s Excellence Award

“Everything from initial

consultation with nurse to

procedure staff friendly &

helpful”

“Explained the procedure fully to me & all staff was caring & considerate”

“Everything, the care I received was brilliant”

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The runner up was Hayley Thornton, Staff Nurse, HAC “Excellent attitude towards patient’s, helps

anybody including staff too”

“Is very helpful and friendly, you feel

confident that she ensures all issues are

dealt with”

“Made me feel better”

“Very kind and helpful”

“Rang my husband with a message for me

and was very helpful”

Picture right: Jill Byrne, Director of Nursing presenting Haley Thornton with the Trust’s Excellence Award


Both members of staff were honoured at the Trust Quality Award evening in November 2012. The ‘Have I made a Difference’ award was such a success that it is held annually. Nominations are currently being collected for the 2013 event.

3.5.6 Equality Delivery System

Patient Experience

Improvement Area:

Equality Delivery System (EDS) 2012/13

Why The Trust has adopted the EDS in order to implement the Equality Act 2010 and to mainstream equality & diversity.

What :

The following EDS outcomes have been prioritised by the Trust for action:

1) EDS Outcome 1.3 (EDS Goal 1 – Better health outcomes for all) Changes across services for individual patients are discussed with them, and transitions are made smoothly

EDS Outcome 2.2 (EDS Goal 2 – Improved patient access and experience)

Patients are informed and supported to be as involved as they wish to be in their diagnosis and decisions about their care, and to exercise choice about treatments and places of treatment

2) EDS Outcome 2.3 (EDS Goal 2 – Improved patient access and experience) Patients and carers report positive experiences of their treatment and care outcomes and of being listened to and respected and of how their privacy and dignity is prioritised

EDS Outcome 2.4 (EDS Goal 2 – Improved patient access and experience) Patients’ and carers’ complaints about services, and subsequent claims for redress, should be handled respectfully and efficiently EDS Outcome 4.1 (EDS Goal 4 – Inclusive leadership at all levels) Boards and senior leaders conduct and plan their business so that equality is advanced, and good relations fostered, within their organisations and beyond.

How much:

The Trust was assessed by the Commissioner & LINk organisations in 2011/12 as: “a developing Trust with good practise for some protected groups and plans to extend this across other protected groups.”

Letter to CEO from Trish Bennett Director of Service Improvement, 27 March 2012

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By When: The Trust’s next assessment with Healthwatch has been arranged to take place on 19th April 2013.

Outcome: The Trust is moving towards “Achieving” stage in the above EDS outcomes.

Progress: The Healthwatch following their assessment on 19th April 2013 will confirm what further progress the Trust needs to make.

Improvements

Achieved:

The Board has been trained in Equality & Diversity

The Board has identified a Non-Executive Director on an E&D Champion

Preliminary review of Data and IT Systems has been undertaken

Data Task & Finish Group is being established to undertake a full review of Data and IT Systems capability and capacity to record protected characteristics

Partnership approach to consultation and engagement across Merseyside has been established and £3k has been secured from the CCG’s to further support this work.

Interpretation & Translation Service has been enhanced and re-launched on 1st April 2013

EDS “Call for Evidence” has been completed in readiness for the Healthwatch assessment on 19th April 2013.

Further

Improvements

Identified:

EDS is monitored by the EDHR Group which reports to the Trust’s Workforce Sub-Committee through to the Board as part of assuring the Board on its responsibilities around Equality & Diversity.

3.5.7 Friends & Family Test (FFT)

Patient Experience:

Introduction of the Friends & Family Test (NEW)

Why:

The 2011/12 national inpatient survey showed that only 13 per cent of patients in acute hospital inpatient wards and A&E departments were asked for feedback. In May 2012, the Prime Minister set out his intention to implement one standardised question to be asked of all NHS patients to improve their experience in line with Domain 4 of the NHS Outcomes Framework. The Prime Minister called this test the Friends and Family Test (FFT). The FFT will provide timely, granular feedback from patients about their experience. Trust responses are to be published both nationally and locally to inform patient choice and to drive hospital improvement. This is a mandatory obligation to be in place by 1st April 2013.

What : Friends and Family Test, one standardised question: ‘Would you recommend the hospital to your friends and family? The Trust is expected to survey 100% of acute adult inpatients, and patients discharged from Accident and Emergency within 48 hours following their discharge, and to obtain an initial minimum response rate of 15% of discharged inpatients and 15% of discharged AED patients. During the next 12 months the Trust is required to deliver the following: FFT increased response rate to 20% or over FFT phased expansion to other areas Improved Performance on the Staff Friends and Family Test in the Annual Staff Survey

How much: A minimum of 15% response rate

By When: April 2013

Outcome: 16.05% in March 2013

Progress: TTaarrggeett AAcchhiieevveedd

52


Communications plan implemented including:

Advertisement of FFT using T Shirts, Lambanana displays, internal banner stands, large external banners outside hospital (on railings and multi storey car park)

FFT information available on Website

Advertised and updates provided in All About Aintree and Aintree News

New patient comment boxes installed on every ward and in AED

Message of the week throughout March on all hospital pc monitors

Customer Service Manager attended Divisional meetings, Ward Manager away Day, Ward Meetings to promote FFT

Process of daily collection of cards across the Trust and inputting of data implemented

Reports set up to monitor percentage returns and net promoter scores which can be accessed by Ward Managers and Matrons


Meeting arranged with Healthwatch Sefton, Knowsley and Liverpool to discuss how the results will be presented to our patients, reports etc

Exploring the possibility of introducing SMS text messaging for Accident and Emergency Patients to increase participation.


3.5.8 Nursing Care Assessment through Comfort Rounds

Patient Experience:

Comfort Rounds Comfort Rounds is a system where patients are checked regularly to ensure their care needs are met and the patient receives a positive experience and their dignity is maintained.

Progress:

Now


Since the introduction of comfort rounds for all wards in December 2011, the following

impacts have been observed at the Trust:

On comparing the number of pressure ulcers (HA Grade 2, 3 and 4) reported between Jan-

Dec in 2011 and the same period in 2012 it is shown that the Trust has seen a reduction

from 283 in 2011 to 187 in 2012/13.

In September 2012, the Trust developed an audit tool to monitor hourly compliance and the first audit took place between 5-11th of October 2012. The headline result is that

53

compliance is higher in the over 70’s patients on medical wards. The Trust has developed a new, simpler comfort round check list form which has been tested on 6 wards to improve compliance. This will be launched trust wide at the Harm Free Care event on the 4th of June 2013. The Trust has been selected to be a demonstrator site in one of the national Quality Forums, ‘Releasing Time to Care’ and in part focuses on standardisation of patient comfort rounds. Aintree are buddying with Blackpool FT and Salford FT in developing a consistent approach to introducing hourly comfort rounds.

3.5.9 Redesign of Ear, Nose & Throat Services

Patient Experience:

Improving clinics for Deafness, Tinnitus and Balance problems

Progress:

Now


Since the introduction of ‘the Audiology led one stop clinics’ last year, several other Trusts

have visited and shown an interest in the Aintree model.

The Head of Audiology Services has presented at a British Tinnitus Association conference

highlighting our model at a national level and has been invited to sit on the British Tinnitus

Association Professional Advisory Committee.

Outcome:

United Kingdom Accreditation Service assessed the Audiology Department against the IQIPS Standard in February 2013. The overall conclusion was that the Department was seen to provide a professional, efficient and effective service to patients, referrers and staff.

Their recommendation was to offer Accreditation to the Service following completion of 4 improvement actions identified as low risk. The assessment reported on Patient Experience as follows:

“The patient experience at the Elective Care Centre, University Hospitals Aintree was seen to be excellent. At the peripheral sites, where the service does not have overall responsibility or ownership of the environment or facilities, it was also very good. The service provides a very caring and supportive service to its patients. Discussions with several patients were very complimentary about the service across all sites” The tinnitus services were mentioned as a strength in the recent IQIPS report.

The following are direct quotes from patients on the patient satisfaction questionnaire undertaken in April 2012:

Patient experience of Audiology services will feature in the next phase of the Friends and Family Test therefore will not be reported on in future Quality Accounts as a separate initiative.

“Professional and caring

staff”

“First time somebody

has taken my tinnitus

seriously and made me

feel at ease”

“Friendly efficient

service”

“Short waiting time”

54

Part Three b: Performance against Key National Priorities

3.6 Key National Priorities – Department of Health’s Operating Framework

The 2012/2013 Department of Health Operating Framework identified a number of key areas of focus relating to the maintenance of service quality, a summary of the performance in these key areas is provided below:

Referral to Treatment Times

Throughout 2012/2013 the Trust has performed consistently well in ensuring patients are treated in a timely manner, although due to bed pressures and the increasing acuity of patients, the latter end of the financial year showed a drop in admitted performance. A review of the annual performance of the Trust indicates that apart from the admitted median wait all other Referral to Treatment time thresholds have been met; further detail is set out below: Admitted clock stops:

% within 18 weeks - Target 90% - Performance = 92.1%

Median Wait –Target 11.1 Weeks – Performance = 11.6 weeks,

95th Percentile – Target 23 Weeks – Performance = 20.4 Weeks Non admitted clock stops:

% within 18 weeks – Target 95% - Performance = 98%

Median Wait – Target 6.6 weeks - Performance = 5.1 weeks

95th Percentile - Target 18.3 weeks - Performance = 15.8 weeks

Incomplete pathways

% within 18 weeks – Target 92% - Performance = 95.4%

Median Wait – Target 7.2 weeks - Performance = 5.1 weeks

95th Percentile - Target 28 weeks - Performance = 17.5 weeks

Accident and Emergency Services

During 2012 / 2013 the Trust, like many Trusts in the region, was challenged by increasing attendance numbers, generally higher acuity of patients and delays in discharging patients from the wards for various social and medical reasons. Despite this, the Trust achieved an annual performance above target at 95.17% (target 95%). The autumn and winter periods proved to be significantly difficult with the Trust not achieving the 95% target in the final quarter of the year. This is also reflected in an increase in the median wait time to see a clinician rising slightly to 105 minutes from 92.5 minutes last year. Fewer patients are leaving the department without being seen, however there is a slight increase in re attendances for any condition (8.2%) against a target of 5%. Only 2% of patients reattended for treatment of the same condition. During the year the Trust has been working very closely with the North West ambulance to both improve compliance of completion of the Hospital Arrival Screens and ensure a rapid turnaround, allowing the ambulances to be back on the road to attend to more patients. Arrival screen completion has improved latterly to 80% (as at the last week in the year) and handover to clear times of around 11 minutes are average (target 15 minutes), with 84% of patients being handed over in less than 15 minutes.

All patients arriving by emergency ambulance are immediately triaged and seen by a decision-making clinician within the 15 minute target.

Healthcare Associated Infections

Unfortunately more cases of Clostridium Difficile Toxin (CDT) and MRSA were reported this year than last, in line with a corresponding increase in community acquired infections. 70 cases of CDT and 7 cases of MRSA were reported. All cases of hospital acquired infection undergo a detailed analysis to understand the root cause of the infection and address any issues with patient management. This

55

analysis indicated that the vast majority of patients who were CDT positive were managed as per best practice guidance which was independently verified. Any lessons to learn that were identified in the root cause analysis were disseminated across the organisation.

Eliminating Mixed Sex Accommodation

During 2013 / 2013 the Trust has reported 7 Mixed Sex Accommodation breaches this is a reduction of 83 from the previous year. As indicated in last years report, these breaches mainly relate to patients requiring transfer to another ward following treatment within an intensive care facility and it was anticipated that these breaches would reduce following the extension of the facility. This has indeed been the case, with no breaches being reported between September 2012 and April 2013.

End of Life Care

The Trust is a pioneer in the delivery of End of Life care, with an active consultant led specialist palliative and end of life care team. Working closely with Woodlands Hospice (which is on site), primary care and the inpatient teams, the Trust aims to provide high quality supportive care to people and their families living with long term and end of life conditions.

Cancer Reform and Screening

Over the latter quarters of 2012/2013, the Trust has consistently met all the Cancer waiting times targets, with only the 62 day screening target not being met in the first two quarters of the year. Monitor has set a revised screening target for the Trust at 81.8%. As the Trust only screens patients with bowel cancer (breast and cervical cancer screening is done elsewhere) achieving the screening target has been problematic due to low numbers. The NHS cancer Intensive Support team has been working with and validating the approaches taken in the Trust to improve Cancer performance. Consistently positive performance has been noted in most tumour sites during the year. Reorganisation of cancer trackers, enhanced clinical involvement in tracking, newly developed cancer data monitoring tools and a ‘hands on‘ approach taken by senior leaders and clinicians to achievement of the targets has contributed to this improvement in performance.

Stroke

The average monthly performance of the Trust, in ensuring that 80% of patients spend 90% of their time on an acute Stroke unit is 83.2%, with only May and August showing a drop just below the target level. The Trust is a Hyper Acute Stroke Centre and work is ongoing in the development of clinical partnerships with the Royal Liverpool University Hospital. The Trust continues to be one of the national high performers in terms of the timeliness of thrombolysis following admission for Stroke. The Trust is on target to implement a 24 hour, seven day a week Stroke nurse clinician service from the 01 August 2012. This will further improve and enhance an already excellent service.

Emergency Readmissions

Using Dr Foster Intelligence (DFI) data as a comparison, between November 2011 and October 2012, the 28 day emergency readmission rate at the Trust was 8.4%, taking into account case mix adjustment, which is comparable to that expected by DFI (8.3%) (6225 readmissions against 6137 expected). The Trust continues to work with CCG teams, Accident and Emergency and local Mental Health providers to reduce readmission and frequent AED attendee rates.

An overview of performance in 2012/13 against the key national priorities from the

Department of Health in accordance with the key indicators in Annex B of Monitor’s

compliance framework is shown in Annex E.

56

Annex A: Statements from Commissioners, Healthwatch and

Overview and Scrutiny Committees

2012/13 Aintree Quality Account Collaborative response from CCGs In line with the NHS (Quality Accounts) Regulations 2011, the collaborative commissioners for Aintree University Hospitals NHS Foundation Trust (South Sefton, Liverpool and Knowsley CCGs) can confirm that they have reviewed the information contained within the account and checked this against data sources made available to them through the Clinical Quality and Performance meeting held in May 2013 and that it is accurate in relation to the services provided by the Trust, in addition they can confirm that the account complies with the prescribed information, form and content as set out by the Department of Health. The commissioners were impressed by the annotated comments contained within the Chief Executive’s statement made by Catherine Beardshaw which added a more personal touch to the document. The commissioners believe that the account represents a fair and balanced view of the 2012/13 progress that Aintree University Hospitals NHS Foundation Trust has made against the identified quality standards. The Trust has complied with its contractual obligations and has made good progress over the last year with evidence of improvements in key quality and safety measures, however there are two areas of development which commissioners believe will further enhance future Trust quality monitoring and accounts. The commissioners believe that it would be beneficial to address reporting of data where appropriate on local/national profiles and that it would be beneficial for the Trust to benchmark itself against comparable peers. Secondly, the commissioners believe that patient mortality information should be presented in a format so as to be clear for the public and patients to understand. It is acknowledged that this issue is being addressed by the Trust following feedback received from patient groups. Overall the commissioners welcome the vision described within your Quality Account, agree on the priority areas and they will continue to work with the Trust to improve the quality of services provided to patients. The commissioners are supportive of the process Aintree University Hospitals NHS Foundation Trust has taken to engage with patients, staff and stakeholders in developing a set of quality priorities and measures for 2013/14 and they commend the Trust’s commitment to further improvement. South Sefton CCG Liverpool CCG Knowsley CCG

57

HealthwatchSefton

Sefton CVS

3rd Floor, Suite 3B

North Wing, Burlington House,

Crosby Road North, Waterloo

L22 0LG

Tel:(0151) 920 0726 ext 240

[email protected]

www.healthwatchsefton.co.uk

Aintree University Hospital NHS Foundation Trust – Quality Account Commentary.

Healthwatch Sefton would like thank the Trust for the opportunity to comment on the Quality

Account and hopes to work like its predecessor Sefton LINk with the Trust as a critical friend.

This response was completed following a review of the draft copy of the account and from a

presentation event which was attended by the Healthwatch Sefton Manager.

Over the last 12 months work has been on-going with the Trust. A Sefton LINk representative

has regularly attended the ‘Patient Experience sub committee’ and the Patient Experience

Action Group. Independent patient, carer and visitor experiences of the Trust were gathered

by holding patient experience stands in the elective care centre. A presentation to the

pharmacy department was facilitated during 2012 following the review by Sefton LINk of

hospital discharge procedures. Sefton LINk was involved in the work of the Trust in providing

safe care 7 days a week.

It is positive to see year on year achievements to reduce avoidable death, disability and

chronic ill health from Venous-Thromboembolism (VTE) with an average of 92% patients

having a VTE risk assessment completed each month. We would like to congratulate the Trust

in achieving progress this year with all 3 key priorities.

It is disappointing to see that the local Communication CQUIN targets were not met. We are

aware that Sefton LINk had focussed some work on discharge in relation to the Trust and as a

new organisation we would be keen to see improvements in the coming year, this being a

CQUIN target which we are told will remain a priority. We are aware however that

achievement of targets has been challenging due to technical issues and IT systems and

would welcome ongoing dialogues with the Trust about performance in this area.

Work with the Trust on Nutrition and Catering has progressed over the last year with Sefton

LINk having a seat on the Trusts sub group for Catering and Nutrition. It was pleasing to see

that 76.42% of patients were screened using the MUST tool (snapshot audit undertaken in

December 2012) but we would like to see the number of patients screened increase over the

coming year.

We are pleased that the Trust is acting on recommendations from the Francis Report and

undertaking targeted work on actions.

We are aware that the target for Improving Dementia Care was not achieved, it being reported

that there was a problem with IT systems. We were pleased to see the further improvements

identified by the Trust to improve this area and look forward to reviewing progress.

The account includes a glossary and has been structured in a way which helps the reader

understand the information and again similar to last year the Trust has been proactive in

inviting stakeholders to review how information within the account can be produced into a

summary document/leaflet.

58

As a new organisation we look forward to our work with the Trust to ensure that local people

receive quality services and report positive experiences.

University Hospital Aintree NHS Foundation Trust - Quality Account Commentary

2012/13 Healthwatch Liverpool (scrutiny) welcomes the opportunity to provide a commentary on this Quality Account, and to be able to build on the work that was done by Liverpool LINk in previous years. As part of the continued engagement with the Trust, LINk representatives regularly attended meetings at two key patient experience sub committees and participated in a consultation around extending the availability of hospital services to 7 days per week. When questions have been asked or concerns raised the Trust has shown willingness to address these. Healthwatch Liverpool was also asked to comment on the proposed quality priorities for 2013-14. This commentary only relates to the issues covered in the Quality Account.

From the evidence provided in this Quality Account, the Trust has to be congratulated for achieving all 3 key priorities for action in 2012-13. Many improvements were made throughout the year, and patient safety targets were largely, though not all, met. We are particularly pleased to see the embedding of hourly ‘comfort rounds’ on wards. We would like to see some audit figures for compliance with this in future quality accounts.

The Trust acknowledges there are areas where it has been underachieving and needs to improve, and a summary of measures taken has been provided in the Quality Account. Not all Commissioning for Quality and Innovation (CQUIN) goals were met, with a particularly low rate for the national dementia CQUIN – although this has been a challenge for all trusts.

One area that raised concern was the higher than expected Summary Hospital-Level Mortality Indicator (SHMI) mortality rates. The Trust has been working actively on discovering where this originated, especially when contrasted with the Hospital Standardised Mortality Ratio (HSMR) which is calculated in a different manner and was better than average. It is vital that the Trust continues to have lowering mortality rates as one of its key priorities for 2013-14.

Patient feedback is used by the Trust to introduce improvements. This year’s data used for the Quality Account was not from the Picker In-Patient Survey but from Aintree’s own patient experience questionnaires. Healthwatch recognises that the Trust has worked hard to ensure the new ‘Friends and Family Test’ has been implemented on time, and that this will supply data that is standardised and can be compared to data from other Trusts.

Whilst the Trust has been making improvements across some of the Equality Delivery System outcomes, for example by better provision of translation and interpreting systems, including for British Sign Language (BSL), currently not all protected characteristics are covered and so more work is needed on this.

Healthwatch Liverpool looks forward to continuing engagement with University Hospital Aintree NHS Foundation Trust in 2013/14.

Edwin Morgan, Health and Social Care Ambassador for Liverpool LINk

59

Aintree University Hospitals 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 2012/13. 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. This commentary covers the

period 1st April 2012 to 31st March 2013 and we are therefore making this commentary on

behalf of Knowsley LINk.

During the last twelve months the partnership working and challenges provided previously

through Knowsley LINk and through Healthwatch Knowsley has been welcomed by the Trust.

Both Knowsley LINk and Healthwatch Knowsley have been represented at the Patient

Experience Sub-Committee and the Patient Experience Group; these groups have proved to

be a good point of contact with the Trust. In addition, community members have been

involved in consultation on ‘Providing Safe Care 7 days a week’, as well as facilitating a focus

group on the Inpatient Information Booklet. We have also worked in partnership with

neighbouring LINks/Healthwatch organisations to hold patient experience information stands

at the Hospital.

It is felt that the Priorities for Improvement identified for the coming year are both challenging

and reflective of the issues Community Members, Service Users and Healthwatch participants

are keen to see addressed. It is welcomed that the trust are concentrating on a response to

the Francis Report and are acting on its recommendations, as well as the development of the

Aintree ward Assessment and Accreditation system, to help improve patient safety and the

quality of care on each ward. We look forward to seeing how these new systems will further

support the development of the trust in achieving its priorities in the future. Healthwatch

Knowsley also welcomes the Trusts commitment to developing a summarised community

focused edition of the Quality Accounts.

Healthwatch Knowsley would challenge the trust to ensure that the needs of the whole

community are considered in relation to the development or redesign of services. For example,

visitors supporting patient mealtimes; ensuring that this is accessible to all patients and their

visitors and to consider the needs of the community it serves.

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Sefton Council

www.sefton.gov.uk Ground Floor, Trinity Wing, Town Hall, Trinity Road Bootle, L20 7AE

To:- Aintree University Hospital NHS Foundation Trust

Date: 22 May 2013 Our Ref: DAC/O&S

Your Ref: Please contact: Debbie Campbell Contact Number: 0151 934 2254 Fax No: 0151 934 2034 e-mail: [email protected]

Dear Sir / Madam,

Draft Quality Account 2012/13

Sefton Council’s Overview and Scrutiny Committee (Health and Social Care) welcomed the submission of the Trust’s Quality Account and the opportunity to provide a commentary on it.

The Committee formally received and reviewed the Quality Accounts at its meeting held on

21st May 2013, and a copy of the relevant Minute from the meeting is attached, for your

information.

Yours faithfully,

Debbie Campbell

Senior Democratic Services Officer

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OVERVIEW AND SCRUTINY COMMITTEE (HEALTH AND SOCIAL CARE) – TUESDAY

21ST MAY, 2013

12. AINTREE UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

The Committee received a presentation from Deborah Simm, Planning and Commissioning

Manager; Andrea Thomas, Assistant Director of Nursing for Surgery Division; and June Taft,

Quality and Safety Lead Nurse; Aintree University Hospital NHS Foundation Trust on the

Trust’s draft Quality Account for 2012/13 and the work of the Trust in general.

The presentation outlined information on the following:-

an overview of Trust activities for 2012/2013;

an overview of the Quality Account for 2012/13;

new service developments at the Trust;

priorities for improvement and performance reported against last year’s priorities;

priorities for improvement and key priorities for action in 2013/14;

service improvement priorities for delivery in 2013/14;

an overview of the quality of care offered by the trust based on performance of twenty improvement initiatives chosen through stakeholder consultation during the last year;

achievements to support patient safety;

patient safety and the energise for excellence objective (reducing pressure ulcers);

achievements to support clinical effectiveness;

clinical effectiveness and the venous thromboembolism (VTE) risk assessment;

achievements to support patient experience;

patient experience and the friends and family test (FFT); and

key performance indicators for Improvement.

The Committee had previously been supplied with the full version of the Trust’s draft Quality

Account.

A Member of the Committee referred to an issue of a ward that had recently been closed then re-opened in order to take pressure off the Accident and Emergency unit. The Trust representatives considered that the ward concerned was likely to have been used to alleviate winter pressures on the Trust and that it had been closed in order to re-locate it. They indicated that they would confirm the situation. A Member of the Committee referred to a Care Quality Commission report that had been published in January 2013. Management of medicines and records had been found to not meet the standards required. The Trust representatives indicated that action plans were now in place to address these areas of concern.

RESOLVED

That the draft Quality Account for 2012/13 from the Aintree University Hospital Foundation

Trust be received and reviewed.

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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 Foundation Trust boards should put in place to support the data quality for the preparation of the Quality Report. In preparing the Quality Report, Directors are required to take steps to satisfy themselves that:

The content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2012-13;

The content of the Quality Report is not inconsistent with internal and external sources of information including:

- Board minutes and papers for the period April 2012 to June 2013; - Papers relating to Quality reported to the Board over the period April 2012 to

June 2013; - Feedback from the commissioners dated 28th May 2013; - Feedback from governors dated 17th April 2013; - Feedback from Local Healthwatch organisations dated 17th May 2013; - The Trusts complaints report published under regulation 18 of the Local

Authority Social Services and NHS Complaints Regulations 2009, dated 27/09/2012 (Q1), 30/01/2013 (Q2), 27/03/2013 (Q3)

- The Picker Institute national patient survey published in February 2013; - The latest CQC national staff survey published in 2012 - The Head of Internal Audit’s annual opinion over the Trust’s control

environment presentation at the Audit Committee meeting on 2nd May 2013; - Care Quality Commission quality and risk profiles dated 31/03/13; 31/01/13;

30/11/12; 31/07/12; 30/09/12; 30/11/12; and 28/02/13;

The Quality Report presents a balanced picture of the NHS foundation Trusts performance over the period covered;

The performance information reported in the Quality Report is reliable and accurate;

There 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;

The 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 the Quality Report has been prepared in accordance with Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations) (published at www.monitor-nhsft.gov.uk/annualreportingmanual) as well as the standards to support data quality for the preparation of the Quality Report (available at www.monitor-nhsft.gov.uk/annualreportingmanual).

63

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

Date: 29 May 2013 Chairman

Date: 29 May 2013 Chief Executive

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Annex C: Participation in Clinical Audits and National Confidential

Enquiries during 2012/13.

National Clinical Audits and Confidential Enquiries Participating

Yes/No % Cases

Submitted

Acute Care

Adult community acquired pneumonia (British Thoracic Society) Yes N/A

Adult critical care (Case Mix Programme – ICNARC CMP) Yes 100%

Emergency use of oxygen (British Thoracic Society) No -

†Medical and Surgical programme: National Confidential Enquiry into Patient Outcome and Death (NCEPOD)

SAH

Alcohol Related Liver Disease

Cardiac Arrest Procedures

Yes Yes Yes

28% 66% 66%

National Joint Registry (NJR) Yes 100%

Non-invasive ventilation - adults (British Thoracic Society) Yes N/A

Renal colic (College of Emergency Medicine) Yes 90%

Severe trauma (Trauma Audit & Research Network, TARN) Yes *100%

Blood and Transplant

National Comparative Audit of Blood Transfusion programme

National Audit of Blood Sample Collecting and Labeling 2012

National Comparative Audit of Medical Use of Red Cells (part2)

Yes

100%

N/A

Potential donor audit (NHS Blood & Transplant) Yes 100%

Cancer

Bowel cancer (NBOCAP) Yes *100%

Head and neck oncology (DAHNO) Yes N/A

Lung cancer (NLCA) Yes *100%

Oesophago-gastric cancer (NAOGC) Yes 100%

Heart

Acute coronary syndrome or Acute myocardial infarction (MINAP) Yes N/A

Cardiac arrhythmia (HRM) Yes 100%

Heart failure (HF) Yes 93%

National Cardiac Arrest Audit (NCAA) Yes N/A

National Vascular Registry Yes 100%

Long Term Conditions

Adult asthma (British Thoracic Society) No -

Adult bronchiectasis (British Thoracic Society) No -

Diabetes (Adult) ND(A), includes National Diabetes Inpatient Audit (NADIA)

Inpatient Audit (NADIA)

National Diabetes Inpatient Audit (NADIA)

Yes

N/A N/A

Inflammatory bowel disease (IBD) Yes N/A †National Review of Asthma Deaths (NRAD) No -

65

National Clinical Audits and Confidential Enquiries Participating

Yes/No % Cases

Submitted

Renal replacement therapy (Renal Registry) Yes 100%

Older people

Carotid interventions audit (CIA) Yes N/A

Fractured neck of femur Yes 100%

Hip fracture database (NHFD) Yes 100%

National audit of dementia (NAD) Yes 100%

Parkinson's disease (National Parkinson's Audit) No -

Sentinel Stroke National Audit Programme (SSNAP)

SINAP

SSNAP

Yes

*100% N/A

Other

Elective surgery (National PROMs Programme) Yes N/A

NB. † Denotes Confidential enquiry

N/A denotes that participation rates could not be calculated. Reasons for this include data collection ongoing and not complete for the reporting period, or the rate cannot be calculated due to lack of denominator data on qualifying cases e.g. HES data does not distinguish between STEMI and nSTEMI (MINAP).

*Denotes data submission that exceeds the number of required cases.

66

Annex D: Actions Arising as a Result of National and Local Audits

EXAMPLES OF NATIONAL AUDIT ACTIONS

UK Renal Report

A plan to increase capacity for our renal replacement therapy programme is required in conjunction with the Trust, Kidney Care Network and North West Specialised Commissioners

Develop a business case to look at running a transplant clinic at Aintree Renal Centre

Continuous investment in new IT CyberRen to enable data input the can be submitted directly to the Renal Registry

Appointment of a renal information manager

Improve and maintain the high standards of delivery of care. Mortality audit may be useful

Interrogated RLBUHT Proton team as to failure of completion of data

Highlighted the poor data completion at the Cheshire and Mersey Kidney Care Network

Renal IT lead aware of poor completion of data and highlighted in the Directorate Operational meeting

Presentation of Renal Registry report to Renal Department (medical staff, nursing staff and dieticians to raise awareness and to improve number of patients achieving Renal Association Standards

Home Therapies team made aware of lack of data input and to implement ways to improve

Work with vascular team to clear waitlist since vascular transfer to the Royal

National Diabetes Audit

New clinic proforma designed and piloted

Database to be updated to include all National Diabetes Audit indicators

Education of medical and nursing staff to importance of accurate and complete data collection

Regular internal audits to support the above actions

National Diabetes Inpatient Audit

Initiatives already in place

Head and Neck Cancer

Issues surrounding the completeness of data submitted were reviewed by the Clinical Effectiveness Sub Committee (CESC). Progress with issues identified to be reported to CESC in three months

Trauma Audit Research Network (TARN)

There will be no actions at this time as targets are being met. Changes will be made in the financial year with the Trust becoming a Major Trauma Centre.

National Audit of Dementia

Clinical Lead has been appointed

Training of staff and awareness

Changes in the dementia management process are in progress

National Re-Audit of the use of Group O RhD Red Cells

O Negative stock holding levels to be monitored via Hospital Transfusion Group

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EXAMPLES OF LOCAL AUDIT ACTIONS

Venous Thromboembolism Policy Monitoring

Arrange for, and start, education for Medical Staff and relevant nurses regarding the importance of completing and filing the VTE assessment forms appropriately.

Present session on VTE at Grand Round (educational meeting open to all medical staff).

Disseminate VTE audit report to Clinical Directors for information/action to inform medical staff.

Old versions of the VTE-RAT form to be removed from every ward and replaced with new versions.

Purple dot system is to be superseded by moving to SIGMA electronic system.

Present session on VTE at Grand Round (educational meeting open to all medical staff)

If decided to update the policy – arrange for update and dissemination as appropriate

Update VTE policy

Liaise with the Surgical Division as to the need to provide surgical patients with anti-embolic stockings and to document the provision and size of anti-embolic stocking provided

Consider updating the policy to include urgent radiology requests being made by telephone rather than Sigma.

Discharge

Director of Operations to email the audit report to divisional leads with a request that they cascade the information to all relevant staff Trust-wide with a reminder that they must follow the requirements of the policy.

Arrange for a summary of the Discharge Policy audit results be reported in ‘All About Aintree’ for all Trust Staff together with a reminder of the key points contained within the Policy and a link to the Policy.

Arrange for a summary of the Discharge Policy audit results included in the presentation slides used in the Grand Round, F1 & F2 Training, Junior Doctor Induction and the Professional Nursing Forum awareness raising and communication sessions.

Child Protection Referrals from Aintree

No changes in practice indicated as Trust performed well

Safeguarding adults policy audit

Rewrite safeguarding adults policy and remove the discharge planner as key contact and incorporate the safeguarding lead matron in this role.

Improve Datix reporting for all safeguarding incidents by delivering education awareness sessions, which should include the Alerter Algorithm

NICE PH24: Preventing The Development of Harmful and Hazardous Drinking

SMASH and Addaction to facilitate educational sessions with A&E

A selection of A&E staff to spend time at Addaction/SMASH

New referral form to be devised in tick box format

Clinical Audit of Pressure Ulcers assessed using the Waterlow Risk Assessment Tool

Implement an electronic risk assessment Full details of the actions to be taken on all audits can be provided – please contact 0151 529 3782 for more details.

Annex E: Performance against key National Priorities

Green ratings indicate that the Trust met the target, amber that the target was only partially met and red that the target was under achieved.

Targets and Indicators 2012/2013 Thresholds and Performance


Performance

Area Indicator Threshold Qtr 1 RAG Qtr 2 RAG Qtr 3 RAG Qtr 4 RAG Annual RAG

Safety Clostridium Difficile (Hospital Acquired Infection)

As per trajectory agreed with PCT (53 cases in the year) - Cumulative

9 G 22 G 24 R 15 R 722 R

Safety MRSA (Hospital Acquired Infection)

As per trajectory (4 cases in year) – Cumulative - de minimis level 6 2 G 2 A 1 A 2 R 7 R

Quality Cancer - 31 day wait for second treatment - Surgery

94% of patients treated within 31 days 100% G 96.7% G 99.1% G 97.8% G 98.4% G

Quality Cancer - 31 day wait for second treatment - Drug treatment

98% of patients treated within 31 days 100% G 100% G 100% G 100% G 100% G

Quality Cancer -31 day wait from diagnosis to first treatment

96% of patients treated within 31 days 97.6% G 97.30% G 98.9% G 99.4% G 98.2% G

2 Two of the C.Diff cases were successfully appealed therefore subsequently removed from the reported performance to Monitor after agreement with Commissioners.

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Quality Cancer -2 week wait from referral to first seen - all cancers

93% of patients seen within 2 weeks 95.6% G 96.6% G 97.1% G 98.0% G 96.8% G

Quality Cancer -2 week wait from referral to first seen - breast symptomatic patients

93% of patients seen within 2 weeks

98.3% G 94.30% G 100% G 93.9% G 94.9% G

Quality Cancer - 62 day wait for first treatment

85% of patients treated within 62 days 86.2% G 86.0% G 91.3% G 86.1% G 87.49% G

Quality Cancer - 62 day wait for first treatment from consultant screening service

90% of patients treated within 62 days (target under review) – Revised target 81.8% 80% R 63.6% R 94% G 92% G 88.2% G

Quality Total time in Accident and Emergency

95% of patients waiting less than 4 hours. 95.4% G 97.4% G 95.1% G 92.8% R 95.17% G

Patient Experience

18 week referral to treatment waiting times - admitted

90% of patients waiting less than 18 weeks. 94.0% G 93.4% G 91.9% G 89.6% R 91.9% G

Patient Experience

18 week referral to Treatment waiting times - non admitted

95% of patients waiting less than 18 weeks. 98.9% G 98.4% G 97.3% G 97.7% G 98% G

Patient Experience

18 week referral to Treatment waiting times – incomplete pathways

92% of patients on an incomplete pathway

98.9% G 98.4% G 97.3% G 97.7% G 98% G

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Annex F: Limited Assurance Report on the content of the Quality

Reports

Independent Auditor’s Limited Assurance Report to the Council of Governors of Aintree University Hospital NHS Foundation Trust on the Annual Quality Report We have been engaged by the Council of Governors 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 2013 (the ‘Quality Report’) and specified performance indicators contained therein. Scope and subject matter The indicators for the year ended 31 March 2013 in the Quality Report that have been subject to limited assurance consist of the following national priority indicators as mandated by Monitor:

1. Number of Clostridium difficile infections; and

2. Maximum cancer waiting time of 62 days from urgent GP referral to first treatment for all cancers.

We refer to these national priority indicators collectively as the “specified indicators”. 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 assessment criteria referred to in Annex B of the Quality Report (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”) 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:

The Quality Report does not incorporate the matters required to be reported on as specified in Annex 2 to Chapter 7 of the FT ARM;

The Quality Report is not consistent in all material respects with the sources specified below; and

The specified indicators have not been prepared in all material respects in accordance with the Criteria.

We read the Quality Report and consider whether it addresses the content requirements of the FT ARM, 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:

Board minutes for the period April 2012 and up to the date of signing this limited assurance report (the period);

Papers relating to Quality reported to the Board over the period;

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Feedback from the Commissioners (South Sefton Clinical Commissioning Group, Liverpool Clinical Commissioning Group and Knowsley Clinical Commissioning Group) dated 28/05/13;

Feedback from Governors in the form of an annotated draft quality report reviewed at the Quality Account readability and summary development meeting attended by governors on 17/04/13;

Feedback from local Healthwatch organisations – Healthwatch Sefton, Healthwatch Knowsley and Healthwatch Liverpool as provided on 17/05/013;

The Trust’s 4Cs (Comments, Compliments, Concerns and Complaints) reports dated 27/09/2012 (Q1), 30/01/2013 (Q2), 27/03/2013 (Q3). Q4 and annual report not available at the time of audit;

Feedback from other stakeholders involved in the sign-off of the Quality Report:

Sefton Council Overview and Scrutiny Committee dated 22/05/13;

The 2012 Picker national patient survey dated February 2013;

The 2012 Picker national staff survey;

Care Quality Commission quality and risk profiles dated 31/03/13; 31/01/13; 30/11/12; 31/07/12; 30/09/12; 30/11/12; and 28/02/13; and

Head of Internal Audit’s annual opinion over the Trust’s control environment as presented to the Audit Committee on 02/05/13.

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. We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts. 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 Hospital NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2013, 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 ‘Assurance Engagements other than Audits or Reviews of Historical Financial Information’ issued by the International Auditing and Assurance Standards Board (‘ISAE 3000’). Our limited assurance procedures included:

Evaluating the design and implementation of the key processes and controls for managing and reporting the indicators

Making enquiries of management

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Limited testing, on a selective basis, of the data used to calculate the specified indicators back to supporting documentation.

Comparing the content requirements of the FT ARM to the categories reported in the Quality Report.

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 and the Directors’ interpretation of the Criteria in Annex B of the Quality Report. 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/organisations/entities. 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 2013,

The Quality Report does not incorporate the matters required to be reported on as specified in annex 2 to Chapter 7 of the FT ARM;

The Quality Report is not consistent in all material respects with the documents specified above; and

the specified indicators have not been prepared in all material respects in accordance with the Criteria.

PricewaterhouseCoopers LLP Chartered Accountants 101 Barbirolli Square Lower Mosley Street Manchester M2 3PW

29 May 2013

The maintenance and integrity of the Aintree University Hospital NHS Foundation 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.

quality report and account 2012/13 - aintree ......our national inpatient survey results indicate an...

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