AINTREE
AINTREE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST QUALITY ACCOUNT 2009/10
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Contents
Part One: Statement on Quality........................................................................................................98
Part Two: Priorities for Improvement and Statements of Assurance from the Board ...................100
2.1
Priorities for Improvement ............................................................................................. 100
2.1.1
Progress in 2009/10 against Key Priorities for Action .................................................... 100
2.1.2
Key Priorities for Action 2010/11.................................................................................... 100
2.2
Statements of Assurance from the Board....................................................................... 101
2.3
Clinical Audits and National Confidential Enquiries........................................................ 101
2.3.1
Participation in Clinical Audits and National Confidential Enquiries .............................. 101
2.3.2
Actions Arising from Clinical Audits and National Confidential Enquiries ...................... 103
2.4
Participation in Clinical Research.................................................................................... 104
2.5
Use of CQUIN Framework ............................................................................................... 104
2.6
Registration with the Care Quality Commission ............................................................. 106
2.7
Information on the Quality of Data ................................................................................ 106
Part Three: Overview of the Quality of Care................................................................................... 108
3.1
Patient Safety..................................................................................................................108
3.1.1
Infection Prevention and Control ................................................................................... 108
3.1.2
Nutrition..........................................................................................................................109
3.1.3
Falls .................................................................................................................................110
3.2
Clinical Effectiveness....................................................................................................... 111
3.2.1
Advancing Quality ........................................................................................................... 111
3.2.2
Nursing Care Assessment Collaborative ......................................................................... 111
3.2.3
Rescuing the Acutely Ill Patient....................................................................................... 112
3.3
Patient Experience .......................................................................................................... 114
3.3.1
Implementing our Quality and Patient Experience Strategy .......................................... 114
3.3.2
Patient and Customer Excellence Initiative .................................................................... 114
3.3.3
Developing a Trust Level Patient Experience Questionnaire.......................................... 115
3.4
Key National Priorities..................................................................................................... 116
Figure 5 – Performance against key national priorities ................................................................. 116
Annex A: Statements from PCTs, LINks and Overview and Scrutiny Committees..........................117
Glossary...........................................................................................................................................123
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Part One: Statement on Quality
The Trust adopted the strapline “Where quality matters” early in 2010, following extensive discussion
among the Trust Board. This phrase sums up the approach adopted by all our staff, whether in clinical
or support roles. The evidence can be found in this Quality Account, which details the progress being
made across a range of initiatives at the Trust.
Of course, everyone would instinctively agree that there should be a focus on quality. The challenge is
taking this admirable sentiment and turning it into measurable improvements in frontline patient care.
This Quality Account explains how we are doing this at the Trust.
Through CQUINs, financial rewards will increasingly be attached to demonstrable improvements in
services. However, the Trust does not want to improve the quality of our services simply to gain
income. We want to improve quality because it is what our patients and staff want. We want to do it
because it is the right thing to do.
This will not be easy. The financial challenges to the NHS over the next four years are well-known. The
Trust has a very strong record on financial issues and, through the work of our staff, we will deliver the
efficiencies required. However, the constant reminder provided by “Where quality matters” means that
we will sustain a solid financial foundation without compromising our vision.
The Trust published its first Quality Report last year, and we also developed our Quality Strategy. The
strategy identified three key areas of Quality – patient safety, clinical effectiveness and patient
experience. From all the achievements since, it is challenging to select specific work streams for
highlighting, as they are all important and impact on the treatment of hundreds of thousands of patients.
However, the following achievements are certainly worth noting:
• An increase in the number of lives saved by our teams – Hospital Standardised Mortality rates
establish the predicted rate of deaths in hospitals, taking into account the nature of patients being
treated. The benchmarked standard is 100, and our figure for 2009/10 was 75.8. This means that,
through the year, there were 363 fewer deaths than would have been expected at our hospitals.
This is probably the ultimate rating of Quality in a Trust, and it is a fantastic result.
• The sharp reduction in C. difficile infection – we saw a 70% reduction in rates this year, the result of
a sustained effort by staff, a comprehensive education and engagement programme, changes to
antibiotic prescribing practice and investment. We have made good progress, but still have some
way to go to match the best in the country. We must sustain our efforts to reach that standard.
• The introduction of the Medical Emergency Team (MET) – a 24/7 team of medical and nursing staff
who help patients who are deteriorating rapidly. The team is the first of their kind in the North West,
and have already helped hundreds of patients. The work of our MET and our hospital out-of-hours
team won the Safe Care out of Hours award at the NHS North West Junior Doctors Advisory Team
awards for 2010.
These are fine achievements, but they are far from the only ones detailed in this account. However, we
must not become complacent. As we raise quality standards, patients and staff will increasingly see
some of these excellent achievements as the basic level. So we will maintain our focus and will build on
our successes to date. The Trust’s strapline “Where Quality Matters” will be a constant reminder of our
challenge. The determination of our dedicated staff means that we will live up to this expectation, and
establish that quality really does matter at our Trust.
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James Birrell, Chief Executive,
Aintree University Hospitals NHS Foundation Trust. 99
Part Two: Priorities for Improvement and Statements of Assurance
from the Board
2.1
Priorities for Improvement
2.1.1
Progress in 2009/10 against Key Priorities for Action
Within our 2008/09 Quality Report the Trust Board identified the following key priorities for action:
Priority 1: To reduce the incidence of hospital acquired C. difficile by 10% in the next year and to
achieve the improvement trajectory that is required for 2011/12.
Priority 2: To fully implement a Quality/Patient Experience Strategy which focuses on three key areas
of; compassion and dignity with care provision, the healthcare environment and patient and public
involvement.
Priority 3: To undertake Patient Experience Surveys in all Directorates across the Trust and to use the
results of these surveys to develop action plans to address both the trends and areas of concern that
have been highlighted with the ultimate goal of making real improvements to clinical practice and
quality of patient care.
It is pleasing to be able to report that the Trust has achieved each of these key priorities in 2009/10.
More information about contribution these priorities have made to improve the quality of care provided
is set out in Part three a - Overview of the Quality of Care:
•
•
•
•
Paragraph 3.1.1 covers progress on infection prevention and control;
Paragraph 3.2.1 covers progress against the nursing care assessment collaborative;
Paragraph 3.3.1 details progress on our Patient Experience Strategy; and
Paragraphs 3.3.2 and 3.3.3 relate to actions as a result of patient experience survey
feedback.
These priorities will continue to be a focus for quality and service improvement activities during
2010/11.
2.1.2
Key Priorities for Action 2010/11
In line with the Darzi Report, ‘High Quality Care for All’, the Trust Board in consultation with local PCTs,
Links and the Governors has identified three priorities for quality improvement during 2010/11. These
are:
Priority 1: Saving lives - The Trust has set an ambitious target to save an additional 300 lives by April
2012. This will be measured through the monthly monitoring of HSMR using national systems.
Priority 2: Patient safety – To reduce the percentage of moderate or severe clinical incidents by 20%
by 2012. – Progress will be monitored using recorded incidents via the Trust incident reporting system
(Datix)
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Priority 3: Patient experience – To increase by 20% the number of patients who rate their experience
as good or excellent by 2012. – Information relating to patient experience will be captured each month
using the new patient experience questionnaires and the patient experience tracking software.
Performance against these three overarching priorities will be monitored by the Board through the
receipt of a monthly Corporate Performance Report.
2.2
Statements of Assurance from the Board
During 2009/10 Aintree University Hospitals NHS Foundation Trust has continued to provide a range of
36 key NHS services, delivered through 11 Clinical Business Units and grouped into the three
Divisions of Medicine and Emergency Care, Anaesthetics and Surgery and finally Clinical Support
Services. As mentioned in paragraph 2.1, in order to review the quality of services provided, the Trust
Board receives a monthly Corporate Performance Report which includes indicators on the quality of
service provision across the three domains of patient experience, patient safety and clinical
effectiveness. Therefore during 2009/10 the Trust Board has reviewed all of the data available to them
on the quality of care for all of the NHS services provided by the Trust.
Aintree University Hospitals NHS Foundation Trust does not provide private health care and therefore
the income generated by the NHS services reviewed in 2009/10 represents 100% of the total income
generated from the provision of health services by Aintree for 2009/10.
2.3
Clinical Audits and National Confidential Enquiries
During 2009/10, 36 national clinical audits and 4 national confidential enquiries covered NHS services
that Aintree University Hospitals NHS Foundation Trust provides.
2.3.1
Participation in Clinical Audits and National Confidential Enquiries
During 2009/10 36 national clinical audits and 4 national confidential enquiries covered NHS services
that Aintree University Hospitals NHS Foundation Trust provides.
During 2009/10 Aintree University Hospitals NHS Foundation Trust participated 97% of national clinical
audits and 100% of national confidential enquiries of the national clinical audits and national
confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Aintree University Hospitals NHS
Foundation Trust was eligible to participate in during 2009/10 is provided below.
The national clinical audits and national confidential enquiries that Aintree University Hospitals NHS
Foundation Trust participated in during 2009/10 is also provided below.
The national clinical audits and national confidential enquiries that Aintree University Hospitals NHS
Foundation Trust participated in, and for which data collection was completed during 2009/10, are listed
below alongside the number of cases submitted to each audit or enquiry as a percentage is provided
below.
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Continuous Audits
•
•
•
•
•
•
•
•
•
•
•
•
•
National Diabetes Audit
Intensive Care National Audit & Research Centre- Case Mix
Programme Dataset: Adult Critical Care Units
National Elective Surgery Patient Reported Outcome Measures:
Hip Replacements, Knee Replacements, Hernia, Varicose Veins
National Joint Register : hip and knee replacements
Renal Registry: renal replacement therapy
National Lung Cancer Audit: Lung Cancer
National Bowel Cancer Audit Programme: Bowel Cancer
British Association of Head & Neck Oncologists: Head and Neck
Cancer
Myocardial Infarction National Audit Project (inc ambulance care):
Acute MI & other Acute Coronary Syndromes
Heart Failure Audit
National Hip Fracture Database: Hip Fracture
Trauma Audit Research Network: Severe Trauma
NHS Blood & Transplant: Potential Donor Audit
Intermittent
•
•
•
•
•
•
•
•
•
•
National Kidney Care Audit - Transport
National Sentinel Stroke Audit
National Audit of Dementia: Dementia Care
National Falls and Bone Health Audit (Pilot)
National Comparative Audit of Blood Transfusion: Audit of the
Blood Collection Process, Audit usage of 'O' Negative Blood Audit,
Audit of the use of Fresh Frozen Plasma
British Thoracic Society: Adult Asthma
College of Emergency Medicine: Pain in Children
College of Emergency Medicine: Asthma
College of Emergency Medicine: Fracture Neck of Femur
National Inflammatory Bowel Disease (IBD)
One-off: All Patients
Participated
% Cases
Submitted
Yes
Yes
100%
100%
Yes
100%
Yes
Yes
Yes
Yes
Yes
100%
100%
100%
100%
100%
Yes
Yes
Yes
Yes
Yes
100%
100%
100%
100%
100%
Participated
% Cases
Submitted
Yes
Yes
Yes
Yes
Yes
100%
N/A
N/A
100%
100%
Yes
No 1
Yes
Yes
Yes
100%
Yes
100%
100%
100%
% Cases
Submitted
100%
N/A
N/A
% Cases
Submitted
N/A
Yes
100%
Participated
National Mastectomy and Breast Reconstruction Audit
National Oesophago-gastric Cancer Audit
Royal College Physicians Continence Care Audit
Yes
Yes
Yes
Other (Additional to those Specified in Account Guidance)
Participated
•
•
•
•
•
Royal College of Radiologists: National Audit of Diagnostic
Adequacy, Accuracy and Complications of Image-guided or
Assisted Liver Biopsy
National Audit: Time from Disease Onset to DMARD (Disease
Modifying Anti-rheumatic Drug) Treatment in Early Rheumatoid
1
The reason for non-participation in the audit regarding the Royal College of Emergency Medicine’s: Pain in Children was
due to the Trust considering whether to participate due to the minimal number of Children the Trust treats and the very well
respected local Children’s Acute Trust that is situated locally.
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•
•
•
Arthritis
National Audit of the Management of Familial
Hypercholesterolaemia
National Care of the Dying Audit
Prescribing Errors Identified by Pharmacists (General Medical
Council Sponsored by EQUIP)
Confidential Enquiries
•
•
•
•
Parenteral Nutrition
Elective & Emergency Surgery in the Elderly
Cosmetic Surgery
Peri-Operative Care Study
Yes
N/A
Yes
Yes
100%
100%
Participated
Yes
Yes
Yes
Yes
% Cases
Submitted
100%
100%
Ongoing
Ongoing
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.
2.3.2
Actions Arising from Clinical Audits and National Confidential Enquiries
The Trust Board receives the Clinical Audit Annual Report which details key Clinical Audit issues. The
Trust Board also has access to every audit conducted within the Trust via the Directorate Clinical Audit
Reports which are available via the Trust intranet site.
The reports of 2 national clinical audits were reviewed by the Trust in 2009/10 and Aintree University
Hospitals NHS Foundation Trust intends to take the following action to improve the quality of healthcare
provided is:
National Care of the Dying Audit
•
•
•
•
Increase uptake of Liverpool Care of the Dying Pathway within Aintree
Sustain Liverpool Care of the Dying Pathway Facilitator post
Introduce version 12 of the Liverpool Care of the Dying Pathway
Further clinical audit regarding Liverpool Care of the Dying Pathway within the Trust
Prescribing Errors Identified by Pharmacists (General Medical Council Sponsored by EQUIP)
•
•
•
•
•
•
•
Continue the training programme for 3rd and 5th year medical students, provided by the Education
and Training Pharmacist
Ensure all F1 and F2 doctors undertake the Trust’s induction programme on safe prescribing and
that they pass the e-assessment on the Medicines Policy and on calculations before being allowed
to prescribe
All Consultants and Registrars should undertake the mandatory training on medicines management
All Registrars should undertake the planned training on Medicines management provided by the
Deanery
Continue the work to implement the NPSA alert on Medicines Reconciliation
Ensure sufficient pharmacists are available to provide a clinical service screening all prescriptions
to pick up errors
Encourage the reporting of drug errors via the Datix system
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•
Chief Pharmacist to produce a quarterly audit of Drug errors to be discussed at the Drugs and
Therapeutics Committee
The reports of 33 local clinical audits were reviewed by the provider in 2009/10 and the action the
Trust intends to take as a result of these audits to improve the quality of healthcare provided is
available from Dr Gary Francis, Medical Director.
2.4
Participation in Clinical Research
The number of patients receiving NHS services provided by Aintree University Hospitals NHS
Foundation Trust that were recruited for NIHR studies during that period to participate in research
approved by a research ethics committee was 1,727. Data for non-NIHR studies were not collated
during this time. However, this data is now collated on the NIHR portal and on the Trust’s database.
The Trust’s increasing level of participation in clinical research demonstrates our commitment to
improving the quality of care we offer and to making our contribution to wider health improvement. We
are committed to developing NIHR grants and fully engaging with our regional Networks.
Aintree was involved in conducting 230 clinical research studies. Aintree used national systems to
manage the studies in proportion to risk, when they met the NIHR national criteria for adoption onto the
NHIR portal. Of the 230 studies open at Aintree, 60 met the NIHR national adoption criteria. These
studies are closely monitored within the R&D department to ensure they recruit within the agreed time
and to the agreed recruitment target. Going forward, we now have systems in place to provide data to
support this. Of the eligible studies given permission to start 80% were given permission by an
authorised person less than 30 days from receipt of a valid complete application. 100%, of the NIHR
studies, were established and managed under national model agreements. This was to include the
suite of model clinical trial agreements and the HR Good Practice, Research Passport Guidelines. All
230 have undergone a governance process to determine if a research passport or letter of access was
appropriate, in order to speed up the Research & Development process. In 2009/10 the National
Institute for Health Research (NIHR) supported 60 of these studies through its research networks.
2.5
Use of CQUIN Framework
A proportion of Aintree University Hospitals NHS Foundation Trust income in 2009/10 was conditional
upon achieving quality improvement and innovation goals agreed between Aintree University Hospitals
NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement
with for the provision of NHS services, through the Commissioning for Quality and Innovation payment
framework. Further details of the agreed goals for 2009/10 and for the following 12 month period are
available on request from the Director of Finance and Business Services at Aintree University Hospitals
NHS Foundation Trust
The Trust was successful in meeting all of the quality improvement goals set by commissioners and an
overview of the initiatives taken forward during 2009/10 and the improvements in patient care achieved
is detailed below:
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CQUIN Initiative
Outcomes Achieved
Development of a Quality
In June 2009, the Trust published its first Quality Strategy which set
Improvement Strategy and Plan out ambitious targets to save lives, improve patient safety and improve
patient experience as documented in section 2.1.2. Progress against
these targets is monitored via the Trust Quality Dashboard which is
presented as part of the Trust Monthly Corporate Performance Report.
To fully participate in the NHS
Northwest Advancing Quality
Programme
The Advancing Quality initiative comprises of three elements: clinical
effectiveness, patient reported outcomes and patient experience.
• From April 2009 the Trust has monitored the delivery of evidenced
based care pathways for patients with acute myocardial infarction,
heart failure, pneumonia or hip and knee surgery. As a result of
the programme a number of service improvement initiatives have
been taken forwarded which have improved patient care. These
are documented in detail in section 3.2.2.
• Participation in the Patient Reported Outcome Measures
(PROMS) survey for hip and knee surgery requires patients to be
surveyed prior to surgery and six months after surgery. In general
the collated results from surveys undertaken prior to surgery
indicate that Aintree patients have higher levels of health need
and higher levels of co-morbidities.
• From January 2010 the Trust has participated in the Patient
Experience Survey. To date 72.7% of patients surveyed were
happy to recommend Aintree to a friend or relative.
Delivery of MRSA screening for In October 2009, 37% of all patients were screened for MRSA on
elective and non elective
admission. By March 2010 this had increased to 88% of all patients
patients
screened on admission. The MRSA screening programme has
contributed to the significant reduction in MRSA cases observed in
2009/10.
Participation in the stroke
sentinel audit
Performance against the stroke sentinel audit provides a composite
score of the quality of stroke services provided. In June 2006, the
Trust achieved a composite score of 73 against the key indicators
used in this audit. In June 2008, the composite score had improved to
83 against the key indicators used demonstrating an improvement in
the quality of stroke care provided. The results of the 2010 audit will
be available at the end of February 2011.
Delivery of Productive Ward
Initiative
Three pilot wards have each implemented the 3 core modules: These
are ‘Knowing How we are Doing’; ‘The Well Organised Ward’ and
‘Patient Status at a Glance’. Whilst the impact from the modules is not
yet fully evaluated, staff on these wards have made changes that have
increased direct contact nursing time and improved patient safety.
They have also reduced stock levels and therefore reduced waste.
• The 3 pilot wards have now started the ‘process’ modules.
• There have been several small changes to practice as nursing
staff analyse and better understand their patients’ experience,
how the ward looks through a patient’s eyes and what actually
happens on their wards.
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•
The next 5 wards commenced mid April 2010.
Percentage of fractured neck of •
femur patients operated on
within 24/48 hours of admission
•
In April 2009, 83% of fractured neck of femur patients were
operated on within 24 hours and by February 2010 this had
increased to 94% of patients.
In April 2009, 87% of fractured neck of femur patients were
operated on within 48 hours and by March 2010 this had
increased to 100% of patients.
These improvements have reduced the time fractured neck of femur
patients have to stay in hospital
Full implementation of the
nursing care assessment
initiative including patient
sensitive indicators for:
• Pain Management
• Patient Observation
• Falls Assessment
• Tissue Viability
• Nutritional Assessment
• Medication Assessment
• Infection Control
Assessment
2.6
One component of the Trust Patient Experience Strategy is to focus
on compassion and dignity with care provision. With this aim in mind
the Trust has implemented nursing care assessment initiative across
all wards. As a result of this initiative:
• Patient sensitive indicators are now monitored Trust-wide on a
monthly basis by two independent audit assistants who update the
Trust’s database and send out results to relevant managers.
• Managers write a monthly action plan addressing any areas of
weakness highlighted and these plans are monitored by the
respective Matron.
As of February 2010, patient sensitive indicator results form part of the
Trust’s Quality Dashboard providing an opportunity to examine patient
care delivery at ward, clinical business unit, Divisional or Trust level.
More information on progress against this initiative is found in section
3.2.1.
Registration with the Care Quality Commission
As a provider of NHS services Aintree University Hospitals NHS Foundation Trust is required to register
with the Care Quality Commission. It is pleasing to be able to report that the Trust’s current registration
status is classed as unqualified and the Care Quality Commission has not taken any enforcement
action against Aintree University Hospitals NHS Foundation Trust during 2009/10. Nor is the Trust
subject to periodic review by the Care Quality Commission.
Aintree University Hospitals NHS Foundation Trust has participated in one special review of Infection
Prevention and Control by the Care Quality Commission during 2009/10. There were no breaches and
the conclusion of the review was that the Trust was compliant with the Care Quality Commission
registration for Infection Prevention and Control.
2.7
Information on the Quality of Data
Aintree University Hospitals NHS Foundation Trust submitted records during 2009/10 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: 99.7% for admitted patient care; 99.8% for outpatient care;
and 98.3% for accident and emergency care.
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• The patient's valid General Practitioner Registration Code was: 99.97% for admitted patient care;
99.83% for outpatient care; and 99.83% for accident and emergency care.
Aintree University Hospitals NHS Foundation Trust’s score for 2009/10 for Information Quality and
Records Management, as assessed using the Information Governance Toolkit, was 90% which
represents a significant improvement from the score of 78% which was received in 2008/09.
Aintree University Hospitals NHS Foundation Trust was also subject to the Payment by Results
admitted patient care clinical coding audit during the reporting period by the Audit Commission. The
overall HRG error rates reported in the latest published data for that period of diagnoses and treatment
coding were 10.7%.
The services audited during this period and the error rates for diagnosis codes and treatment codes
from this audit are shown below:
2009/10 PbR Admitted Patient Care Clinical Coding Audit
Area Audited
Finished Consultant Episodes Reviewed
General Medicine (National Theme)
100
A&E (Specialty level)
100
HRG LA – Renal Procedures and
Disorders
(Sub chapter level)
70
HRG WA127 – Complications of
procedures without cc (HRG level)
30
% Procedures Coded
Incorrectly
Overall 2
Primary
7.8%
Secondary
19.5%
% Diagnoses Coded
Incorrectly
Primary
19.3%
Secondary
22.5%
In order to improve the quality of clinical coding the Trust now employs two clinical coders with the
Accredited Clinical Coder qualification, one of whom also holds the Connecting for Health Approved
Auditor status. As senior members of the team they have developed an action plan which includes:
• Introducing a programme of internal audit to support the improvement of coding standards,
• Arranging foundation, refresher, audit and trainer assessment training for all clinical coding staff as
appropriate.
2
It is important to note that because of the small sample sizes these results cannot be extrapolated further than the actual
sample audited.
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Part Three: Overview of the Quality of Care
The Trust Quality Strategy includes three over arching aims to be delivered by 2012. This section of the
Quality Account aims to present an overview of progress against the Quality Strategy and of the quality
of care provided during 2009/10 under the key headings of: patient safety, clinical effectiveness and
patient experience:
Patient Safety: To reduce the percentage of moderate or severe clinical incidents by 20% by 2012.
Progress in 2009/10: Patient safety incidents reported per month have reduced from 366 in January
2009 to 312 in January 2010 which equates to a 15% reduction.
Clinical Effectiveness: By 2012, to save an additional 300 Lives over 3 years.
Progress in 2009/10: The predicted HSMR for a hospital is 100. For the year 2008/09 Aintree’s HSMR
was 94.0. For the period April 2009 to March 2009 Aintree’s HSMR was 75.8. This means that the
Trust had 363 fewer deaths than predicted, thus achieving the 3 year target in the first year.
Patient Experience: By 2012, to increase by 20% the number of patients who rate their experience as
good or excellent.
Progress in 2009/10: The 2008 national patient survey questions were themed into 10 categories,
which are scored for improvement as worse, about the same or better. Aintree’s results for 2008
demonstrated that we have stayed about the same in all areas. During 2009/2010 Aintree has invested
significantly in services to enhance patient experience and improve patient feedback and although
many of the initiatives are in the early stages of development, service developments are already
beginning to benefit from this enhanced dialogue with patients.
This section of the Quality Account also provides more detail on specific quality improvement initiatives
which have been taken forward, during 2009/10, including those which were identified as priorities
within the 2008/09 Quality Report, again under the three key headings of patient safety, clinical
effectiveness and patient experience.
3.1
Patient Safety
Ensuring patient safety is central to everything Aintree University Hospitals NHS Foundation Trust does. During
2009 / 2010 the Trust worked alongside national and international agencies to support the development of
safety initiatives across all services and will continue to maintain these relationships to further improve safety.
3.1.1
Infection Prevention and Control
Overarching aim - Infection prevention and control is a large topic with many aspects: Nearly 7% of all
healthcare associated infections (HCAI) are primary bloodstream infections; not only are they relatively
common, but they carry a substantial risk of serious morbidity and mortality. This collaborative project is
focusing on the key aspect of reducing infection and helping to promote a safety culture within the
Trust. It aims to reduce primary bloodstream infections by:
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•
Improving compliance with High Impact Intervention (HII) 2: Peripheral intravenous cannula care
bundle; this reduces the relative risk of a bloodstream occurring due to poor line care
• Using topical suppression treatment on patients assessed as high risk from acquiring an infection
by endogenous spread (e.g. patients with large wounds or invasive devices such as peripheral or
central lines)
Quality improvements achieved in 2009/10: This collaborative has contributed to a 69.8% reduction
the number of C. difficile infections reported during 2009/10. As at the 29th March 2010, the Trust
observed 103 cases of C. difficile against a target trajectory of 180. The target trajectory which has
been set for 2010/2011 is 145 cases for the year. This achievement clearly indicates that the Trust has
more than delivered against priority one set in the 2008/09 Quality Report: “To reduce the incidence of
hospital acquired C. difficile by 10% in the next year and to achieve the improvement trajectory that is
required for 2011/12.” As at 1 June 2010 the Department of Health have yet to set the absolute
numbers for the 2011/2012 trajectory.
The Trust has also seen a 35.7% reduction in MRSA infections in comparison to 2008/09 and has also
over achieved against its national target to reduce MRSA infections in 2009/10: As at 29th March 2010,
there were 17 cases reported against a trajectory of 23.9. The target that has been set for 2010/11 is
for there to be only 8 cases of MRSA infection for the year. The green lines on the graphs below
indicate case numbers during 2009/2010.
Figure 1 – 2009/10 C diifficle Cases against 2008/09
3.1.2
Figure 2 – 2009/10 MRSA Cases against 2008/09
Nutrition
Overarching aim – The results of audit have demonstrated that up to 40% of patients admitted to
Aintree Hospital are malnourished. Therefore, the aim of this collaborative therefore is to improve the
identification, assessment and treatment of malnourished patients admitted to Aintree University
Hospitals NHS Foundation Trust.
Quality improvements achieved in 2009/10: A new simplified electronic dietetic referral form and
electronic screening tool have been developed and staff on collaborative wards have been trained on
how to use the new screening tool. This screening tool will provide real time information regarding the
assessment and treatment of malnourished patients which can be broken down to a Divisional,
Directorate and Ward based level. This should result in all of our patients receiving sufficient assistance
to help them meet their nutritional requirements.
It is anticipated that further progress against the collaborative objectives will be reported in the 2010/11
Quality Account.
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3.1.3
Falls
Overarching aim - The overall aim of the falls collaborative project is to reduce ‘avoidable harm’ and
enhance patient safety and in doing so to improve clinical quality and patient experience. Based on the
2008 - 2009 baseline data the key aim of the project is to reduce the number of falls incidents across all
Trust wards by: 10% in year 1, 20% in year 2 and 30% in year 3.
Quality improvements achieved in 2009/10: The collaborative team have developed a new falls risk
assessment process and a new falls proforma which is being implemented across the Trust. This
initiative has contributed to the achievement of a 6.6% reduction in falls against the baseline data
(number of falls showing in red below). In order to address the shortfall against the baseline and further
improve the reduction, additional service improvement and informatics resource is being deployed to
support the falls team during 2010/11. This collaborative is also contributing to the Trust’s overarching
priority for 2010/11: “To reduce the percentage of moderate or severe clinical incidents by 20% by
2012.”
Figure 3 - 2009/10 Falls data against 2008/09
1594
1488
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3.2
Clinical Effectiveness
3.2.1
Advancing Quality
Overarching aim – Evidence from the USA has demonstrated that when patients are given appropriate
‘care bundles’ it improves both patient experience and patient outcomes as evidenced by reductions in
mortality, reduced levels of patient readmissions, lower levels of complications and reduced length of
stay. The principle of ‘care bundles’ has been adopted by Aintree and is known as, Advancing Quality.
At present four clinical areas are included; these are: heart attack, heart failure, pneumonia and hip and
knee surgery. Each clinical area has a specific set of clinical interventions to be achieved.
Quality improvements achieved in 2009/10: In December 2009, the Trust’s Advancing Quality
performance as a measure of the % of times patients receive the correct intervention at the right time
during their hospital stay was:
•
•
•
•
AMI – 96.8%
Heart Failure – 77.9%
Pneumonia – 84.8%
Hip and knee surgery – 94.6%
Since the start of the programme performance for heart attack and hip & knee surgery has remained
consistently high, at above 90%. Performance for heart failure and pneumonia has improved since,
January 2009, which indicates there has been an increase in the % of times that these patients are
receiving the correct clinical intervention at the right time during their hospital stay. The improvements
in the quality of care and patient outcomes as a result of the Advancing Quality programme are
evidenced by reductions in mortality, reduced levels of patient readmissions, and reductions in length of
stay and are also show below in Figure 4.
Figure 4 - Advancing Quality – Reductions in mortality, length of stay and readmission since 2008
Clinical Area
Mortality
Length of Stay
Readmissions
3.2.2
AMI
Heart Failure
Hip & Knee
Pneumonia
AMI
Heart Failure
Hip & Knee
Pneumonia
AMI
Heart Failure
Hip & Knee
Pneumonia
2008/09
2009/10
15.2%
7.0%
2.2%
21.5%
11.0
13.4
10.8
13.1
58
91
84
156
13.8%
7.5%
1.3%
19.8%
10.7
13.0
10.5
11.5
21
50
46
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Change
Nursing Care Assessment Collaborative
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Overarching aim - One component of the Trust’s Patient Experience Strategy is to focus on
compassion and dignity with care provision. With this aim in mind the Trust has implemented nursing
care assessment initiative across all wards which will provide information across a range of patient
sensitive indicators, including: Pain Management, Patient Observations, Infection Control, Nutrition,
Tissue Viability, Falls Management and Medicines Management. The aim of this collaborative is to:
• Improve the quality of patient care by monitoring performance against patient sensitive indicators
• Provide the Trust Board with appropriate levels of assurance about the quality of care provided
Quality improvements achieved in 2009/10: Since the start of the project there has been an
increase in the numbers of patients whose care needs are regularly assessed against each of the 7
agreed patient sensitive indicators, in early 2009 only 25% of wards were covered by the tool, as from
October 2009, 100% of wards were using the tool. At a ward based level this data is being used to
improve the quality of care for patients. The next phase of the project will be to link the results of the
nursing care assessment project to the findings of patient experience surveys. It is hoped that this
correlation will allow the Trust to fully demonstrate that the aim of providing “compassion and dignity
with care provision” is being fully achieved.
3.2.3
Rescuing the Acutely Ill Patient
Overarching aim – Aintree University Hospitals NHS Foundation Trust has established a Medical
Emergency Team whose overarching aim is to provide 24 hour, 7 days per week critical care expertise
to respond to the medical needs of all acutely ill patients. The Medical Emergency Team also aims to
provide senior clinical support to ward based nursing staff and junior doctors and to improve the
education of medical and nursing staff in the recognition and management of acute illness. It is
anticipated that this initiative will contribute to:
• A year on year reduction in the number of cardiac arrest calls within the hospital and an increase in
the amount of appropriate ‘Do Not Attempt Resuscitation’ decisions for those patients who need
end of life care.
• From year two, a 50% reduction in serious untoward incidents related to failure to escalate patient
deterioration, with zero incidents within 5 years.
• Improving the quality of patient care and patient satisfaction with a subsequent reduction in the
number of complaints related to failure to recognise and manage acute illness.
Quality improvements achieved in 2009/10: Early data on the operational performance of the MET
team appear to indicate an increase in the number of appropriate ‘Do Not Attempt Resuscitation’
decisions, and a 29% reduction in the number of cardiac arrest calls. The review also provides
evidence that patients are transferred to different care settings based on the level of intervention they
require.
As the only multi-disciplinary rapid response team in the Merseyside and Cheshire region, and one of
only a few in the UK; the Aintree Medical Emergency Team is already being locally recognised as the
most effective way to provide sustained and measurable improvements in patient safety relating to the
early recognition and clinical management of acute illness. At the recent NHS North West Conference
the Aintree Medical Emergency Team was awarded the ‘Safe Care Out of Hours Award’ 2010. In
addition, three other local NHS Acute Trusts have been in contact with a view to adopting the Aintree
model in their hospitals. This collaborative is also contributing to the Trust’s overarching priority for
2010/11: “To save an additional 300 lives over three years.”
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3.3
Patient Experience
3.3.1
Implementing our Quality and Patient Experience Strategy
Overarching aim - To fully implement a Quality/Patient Experience Strategy which focuses on three
key areas of; compassion and dignity with care provision, the healthcare environment and patient and
public involvement.
The principles within Department of Health’s “Making the Experience Count" Report has led to the
merger of Trust’s Patient Advice and Liaison service (PALS) and the Complaints Department: its focus
is to ensure that patient experience is captured and is acted upon throughout the organisation and to
build a culture of Customer Service Excellence.
Quality improvements achieved in 2009/10: The Customer Services Department has now been
established and the Trust’s commitment to improving the patient experience is now clearly evident
throughout the hospital; e.g. offering health and well being days through out the year which provide
patients with the opportunity to participate in Reiki, hand massage, Indian head massage; providing a
library service on Tuesdays, providing monthly entertainment for patients on elderly wards.
This collaborative is contributing to the Trust’s overarching priorities for 2010/11: “To increase by 20%
the number of patients who rate their experience as good or excellent by 2012.”
3.3.2
Patient and Customer Excellence Initiative
Overarching aim - The Trust fully recognises that all staff play a vital role in identifying and delivering
improvements to enhance the experience of patients and staff. The aim of this collaborative is to use
real time patient feedback to design and implement service improvements which will enable the Trust to
prioritise and focus on key areas to transform the quality of care provided.
Quality improvements achieved in 2009/10: The collaborative has used the results of the last
National Inpatient survey, analysis from the Quality Strategy consultation event and complaint themes
to identify the top 4 lowest performing areas requiring improvement which were all themed around poor
communication between patients and staff. This feedback has supported the development of a Patient
Information Manual and a patient welcome letter which will be placed on each patient’s bed on the day
of their admission. The aim of the letter is to try and help all patients feel at ease at the start of their
hospital stay by providing them with ward specific details and inviting them to contact the ward manager
if anything relating to their care or treatment does not meet their expectations. This collaborative is
contributing to the Trust’s overarching priorities for 2010/11: “To increase by 20% the number of
patients who rate their experience as good or excellent by 2012.”
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3.3.3
Developing a Trust Level Patient Experience Questionnaire
Overarching aim - Aintree University Hospitals NHS Foundation Trust developed its own in house
patient experience questionnaire (PEQ) in June 2009 to proactively monitor patient feedback on a
monthly basis to ensure the Trust achieves a score equal to or better than in the next National Inpatient
Survey (2009) average in all areas.
Quality improvements achieved in 2009/10: The Trust now receives automatic analysis of patient
feedback broken down by ward to allow speedier feedback to inform action planning and monitor real
improvements in quality care and clinical practice as a result of patient feedback. As the year has
progressed staff have become increasingly responsive to patient needs and keep them better informed
about their care.. In addition the data shows that consistently more than 90% of patients would
recommend Aintree to a friend or relative. Demonstrating that the work of this collaborative is
contributing to the Trust’s overarching priority for 2010/11: “To increase by 20% the number of patients
who rate their experience as good or excellent by 2012.” .During 2010, a sample of patients on 100% of
all inpatient areas will be surveyed every month. This information will be directly fed back to the wards
to support improvement.
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Part Three b: Performance against Key National Priorities and
National Core Standards
3.4
Key National Priorities
An overview of performance in 2009/10 against the key national priorities from the Department of
Health in accordance with the key indicators in Appendix B of Monitor’s compliance framework is shown
in Figure 5. Green dots indicate that the Trust met the target and amber that the target was only
partially met.
In December 2009, the Board of Directors of the Trust declared compliance against the entire 24 core
Standards for Better Health for the period 01 April 2009 until 31 March 2010.
Figure 5 – Performance against key national priorities
Appendix B - Targets and National Core
Standards 2009/10
Table 1: Weightings and thresholds for targets and national core standards
Targets - Weighted 1.0 (National Requirement)
Clostridium difficile year on year reduction (to fit the
trajectory for the year as agreed with PCT –
assumed a 15% reduction if no level agreed in a
contract)
MRSA – maintaining the annual number of MRSA
bloodstream infections at less than half the 2003/04
level (assumed target is 50% of 2003/04 if no level
agreed in a contract)
Maximum waiting time of 31 days for subsequent
treatments for all cancers
Maximum two month wait from referral to treatment
for all cancers
For admitted patients, maximum time of 18 weeks
from point of referral to treatment
For non-admitted patients, maximum time of 18
weeks from point of referral to treatment
Targets - Weighted 0.5
Maximum waiting time of four hours in A&E from
arrival to admission, transfer or discharge
People suffering heart attack to receive thrombolysis
within 60 minutes of call (where this is the preferred
local treatment for heart attack)
Maximum waiting time of two weeks from urgent GP
referral to date first seen for all urgent suspect
cancer referrals
Maximum waiting time of 31 days from diagnosis to
treatment for all cancers
Screening all elective in-patients for MRSA
Threshold
Weighting
52
1
6
1
95%
1
85%
1
90%
1
95%
1
98%
0.5
68%
0.5
93%
0.5
96%
0.5
-
0.5
Q1 Q2
Q3
Q4
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Annex A: Statements from PCTs, LINks and Overview and Scrutiny
Committees
From NHS Knowsley’s perspective we would lend our support to the quality account produced
by Aintree University Hospitals NHS FT and in particular to the following areas:
NHS Knowsley acknowledges and supports the efforts of the Trust to reduce C Difficile
infections in 2009-10. We note that the Trust has reduced the number of cases by 70%
compared to 2008-09 levels. We also note that this progress is reflected in Monitor’s
assessment of the Trust improving its rating in Q3 of 2009-10. This is in recognition that the
FT Board has de-escalated the Trust at Q3 as they are found to have made sufficient progress
in dealing with C Difficile infections which provides further assurance to the PCT.
NHS Knowsley considers that the Trust and its co-ordinating PCT, NHS Sefton, have put in
place a robust monthly performance reporting system with a significant and consistent
emphasis on quality. Trust managers and staff are open and honest in all discussions relating
to the quality of services provided and genuine in their approach to seeking to improve the
quality of services provided to Knowsley patients.
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The Trust wishes to recognise the positive contribution of Sefton LINk to the preparation of the Quality
Account 2009/10.
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Glossary
AMI
cc
C. difficile
CQUIN
DNAR
EQUIP
F1
F2
HCAI
HRG
HR
HSMR
LINk
MET
MRSA
NCEPOD
NICE
NIHR
NPSA
NSF
PALS
PCT
PEQ
PROMS
PbR
R&D
Acute Myocardial Infarction
Complications and Co-morbidities
Clostridium Difficile
Commissioning for Quality and Innovation payment framework
Do Not Attempt Resuscitation
Electronic quality information for the public
Foundation year one doctor
Foundation year two doctor
Healthcare Associated Infections
Health Related Resource Groups
Human Resources
Hospital Standardised Mortality Rate
Local Involvement Network
Medical Emergency Team
Methicillin-Resistant Staphylococcus Aureus
National Confidential Enquiry into Patient Outcome and Death
National Institute for Clinical Excellence
National Institute for Health Research
National Patient Safety Agency
National Service Framework
Patient Advice and Liaison Service
Primary Care Trust
Patient experience questionnaire
Patient Reported Outcome Measures
Payment by Results
Research and Development
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