Aintree University Hospital NHS Foundation Trust
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4
Introduction
Part 1. Statement on quality from the Chief Executive of the NHS Foundation Trust
5
Part 2. Priorities for improvement and statements of assurance from the Board
7
Priorities for improvement
Quality improvement priorities for 2014/15
Quality improvement priorities for 2015/16
7
22
Statements of assurance from the Board
Information on the review of services
Information on participation in clinical audits and national confidential enquiries
Participation in clinical research
Use of the CQUIN framework
Registration with the Care Quality Commission
Information on the quality of data
Performance against national quality indicators
Performance against key national priority indicators
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Part 3. Other Information
An overview of the quality of care offered by Aintree in 2014/15
Annex A: Statements from Stakeholders on Aintree’s Quality Account 2014/15
Annex B: Statement of Directors’ responsibilities in respect of the Quality Report
Annex C: Independent Auditor’s Limited Assurance Report to the Council of Governors of
Aintree NHS Foundation Trust on the Annual Quality Report
Annex D: Definitions of the performance measure indicators
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ON A TYPICAL DAY AT THE TRUST
We employ:
We test:
4512 WTE
5000 tubes of blood
274 MRSA swabs
We make:
On average 674 occupied beds (647 in
13/14)
We clean:
We see:
We provide:
Approx 2,125 patients in all Outpatients
Clinics (2,074 in 13/14)
2400 patients’ meals
136,677 sq meters of floor
500+ staff meals
219 patients in A & E (222 in 13/14)
We use:
We dispense:
540 Ward Medicines
372 Outpatient Medicines
1025 Take home Medicines
23,481 gloves
71,599 hand towels and tissues
17,309 wipes
5,672 needles/syringes
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Aintree University Hospital NHS Foundation Trust
Glossary
ACS
AED
MDT
MET
Multi Disciplinary Team
Medical Emergency Team
MEWS
MFU
Modified Early Warning System
Maxillo Facial Unit
AMI
Average Care Score
Accident & Emergency
Department
Acute Kidney Injury
Assessment, Management, best
Practice, Engagement,
Recovery Uncertain
Acute Myocardial Infarction
MRSA
AMU
ANNT
AQ
Acute Medical Unit
Aseptic Non Touch Technique
Advancing Quality
MSSA
MUST
NCEPOD
AQuA
Advancing Quality Alliance
NICE
AUH
BGM
CCG
C.Difficile
COPD
NIHR
NPS
NWC
OT
PAS
PE
Pulmonary Embolism
PID
Performance Information Delivery
CRN
Aintree University Hospital NHS
Blood Glucose Monitoring
Clinical Commissioning Group
Clostridium Difficile
Chronic Obstructive Pulmonary
Disease
Commissioning for Quality and
Innovation (payment framework)
Co-ordinated Systems for
gaining NHS Permission
Clinical Research Network
Methicillin-Resistant Staphylococcus
Aureus
Methicillin Sensitive Staph Aureus
Malnutrition Universal Screen Tool
National Confidential Enquiry into
Patient Outcome and Death
National Institute for Clinical
Research
National Institute for Health Research
National Patient Survey
North West Coast
Occupational Therapy
Patient Administration System
PLACE
DT
E4E
EDS
Diabetes Team
Energise for Excellence
Equality Delivery System
PROMS
PbR
RAG
ENP
Emergency Nurse Practitioner
FFT
GP
HAT
Friends and Family Test
General Practitioner
Hospital Acquired Thrombosis
R&D
RCA
RTT
SALT
SHMI
HAWD
Hand Washing
SIGMA
HCAI
HLO
HR
HSMR
Healthcare
High Level Objective
Human Resources
Hospital Standardised Mortality
Rate
International Classification of
Diseases
Infection Prevention and
Control
Information
Key Performance Indicator
SOP
SUI
TARN
Unify2
Patient Led Assessments of the Care
Environment
Patient Reported Outcomes
Payment by Results
Red Amber Green (traffic light
scoring system)
Research and Development
Root Cause Analysis
Referral to Treatment Time
Speech and Language Therapy
Summary Hospital Level Mortality
Indicator
Hospital Patient Administration
System
Standard Operating Procedure
Serious Untoward Incident
Trauma Audit and Research Network
National Reporting Hub
UTI
Urinary Tract Infection
VTE
Venous-Thromboembolism
WHO
YTD
World Health Organisation
Year to date
AKI
AMBER
CQUIN
CSP
ICD-10
IPC
IT
KPI
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Aintree University Hospital NHS Foundation Trust
Introduction
Quality Accounts are annual reports to the public, from providers of NHS services, about
the quality of services they provide. They also offer readers an opportunity to understand what
providers of NHS services are doing to improve the care and treatment they provide.
Quality in the NHS is described in the following ways:
Patient safety
This means protecting people who use services from harm and injury and providing treatment in a
safe environment.
Clinical effectiveness
This means providing care and treatment to people who use services that improves their quality of
life.
Patient experience
This means ensuring that people who use services have a positive experience of their care and
providing treatment with compassion, dignity and respect.
The aim in reviewing and publishing performance about quality is to enhance public accountability
by listening to and involving the public, partner agencies and, most importantly, acting on feedback
received by the Trust.
Aintree produces quarterly Quality Reports on the Trust’s priorities to show improvements to
quality during the year. This is so that Aintree can regularly inform people who work for the Trust,
people who use the Trust’s services, carers, the public, commissioners of NHS services, and local
scrutineers of quality initiatives and to encourage regular feedback.
As a report to the public, Aintree recognises how important it is that the information it provides
about the quality of care is accessible to all. This Quality Account, and ‘easier read’ accessible
versions of the Quality Account and the Trust’s Quality Reports, are published on Aintree’s public
website.
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Aintree University Hospital NHS Foundation Trust
Part 1 -
Statement on quality from the Chief Executive
The cornerstone of Aintree University Hospital NHS Foundation Trust’s philosophy is quality – to
deliver our vision of providing world class services for all our patients by getting it right for
every patient, every time.
We have successfully delivered Year 1 of our 3 year Quality Strategy with improvement
programmes aligned to our Quality Priorities to make care safer, more effective and improving the
patient experience.
We further developed and enhanced our quality governance arrangements following a
comprehensive review and received a rating of good across all our services from the Care
Quality Commission, the only trust in Liverpool to do so. We have achieved the majority of our
key performance indicators including the Referral to Treatment Time and Cancer access
standards with the exception of Cancer Screening but did not achieve the national access
standard of 95% for patients being treated within four hours in the Accident and Emergency
Department. However, we have put in place significant changes to improve patient flow and thus
the experience of our patients throughout the hospital and we are optimistic that we will achieve
this standard on an on-going basis from the second quarter of 2015/16.
The focus on patient safety is a priority for all our staff and this culture is embedded throughout the
Trust as was evidenced by the results of the national Inpatient Survey 2014 which showed that,
of the 78 trusts taking part, Aintree was the most improved with almost 4% fewer patients
reporting a problem. The Board was an early adopter of the Sign up to Safety pledge and we
encourage staff to report incidents so that we are able to improve the care given to our patients as
a result of learning from incident reports and investigations. During the year, we focussed our
work in infection prevention and control on reducing the number of patients contracting CDifficile
and MRSA and exceeded the national standard for the former but had two hospital-acquired MRSA
cases. We continued to make significant progress in reducing the numbers of hospital-acquired
pressure ulcers and consistently provided in excess of 95% harm free care as measured by
“Safety Thermometer”.
Once again we had a very positive peer review of our major trauma service which has delivered
excellent outcomes for patients across Cheshire and Merseyside. This reinforced the decision by
our commissioners to deliver the final phase of this service so that Aintree and the Walton Centre
become the single receiving site during 2015.
We were encouraged by the results of the National Staff Survey which reflected the sustained
improvement in staff engagement and built on our campaign “Proud of Aintree” which had been
led by the Chief Executive. In particular, we welcomed the increased score in the staff
recommendation of the Trust as a place to work or receive treatment. Staff have been
encouraged to improve patient experience and develop their own solutions to enhance their
services. The vision and values that we developed with staff have been embedded and ensured
that behaviours underpinned the strong patient-centred culture at Aintree.
The Trust’s Hospital Standardised Mortality Ratio (HSMR) continued to be one of the lowest in
the country and the crude death rate has reduced steadily during the year; however, we have a
significantly higher than expected Summary Hospital-Level Mortality Indicator (SHMI). The Trust’s
clinically led mortality work streams continued to focus on this and to drive improvements to make
care safer for our patients. No definitive conclusions can be drawn from an evaluation of these
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Aintree University Hospital NHS Foundation Trust
three indicators and as yet we are still unclear why we are an outlier on SHMI. This follows the
experience of many trusts in the North West of England and SHMI is being reviewed nationally.
Our national inpatient survey results indicate that we have sustained good levels of patient
satisfaction with inpatient care and the Trust has worked hard to support patients who are more
vulnerable or have increased needs. I am delighted that we won a national Compassion in Care
Award for our innovative work with Dementia patients.
I am extremely proud of the commitment and dedication of staff at Aintree and the
improvements they continue to make so that our patients receive the care they deserve. The
Board is fully committed to the delivery of the improvements described in the Trust’s Quality
Strategy and this Quality Account describes those achievements and our plans for next year.
Steve Warburton
Acting Chief Executive
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Aintree University Hospital NHS Foundation Trust
Part 2 -
Priorities for improvement and statements of assurance
from the Board
Quality improvement priorities for 2014/15
The Trust’s overarching three priorities for 2014/15 remain continual but include aspirational
standards in line with the new three-year Quality Strategy. Aintree has successfully delivered Year
One of our three year Quality Strategy (2014-2017) with improvement programmes aligned to our
Quality Priorities to make care safer, more effective and improving the patient experience.
Below is a summary of progress on the priorities agreed last year, which were monitored
throughout the year in the trust’s quarterly Quality Reports, which are presented at the Trust’s
Quality and Safety Committee and are available on Aintree’s website.
Priority 1: Patient safety improvement actions in 2014/15
Aintree said it would:
Provide care that is safe by reducing harm, through consistently delivering harm free care.
Aintree achieved:
What :
Delivering reliable harm free care, consistent across every ward, as measured by
‘Safety Thermometer’ (a survey that allows teams to measure harm and the
proportion of patients that are “harm free” during that working day) for hospital
acquired pressure ulcers; catheter associated urinary tract infections, venous
thromboembolism (blood clots) and patient falls. This measure excludes ‘old
harms’ which may have been present when the patient was admitted into the
Organisation.
How much:
Greater than or equal to 98% harm free care
When:
March 2015
Outcome:
In March 2015, the Trust achieved 97.63% which is just short of the year end
improvement goal of >98% harm free care although the mean score is 98.05%.
Harm Free Care (point prevalence for new harms)
(Data source: NHS Information Centre which is governed by a standard national definition)
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Aintree University Hospital NHS Foundation Trust
Aintree said it would:
Provide care that is safe by reducing harm by reducing hospital acquired methicillin sensitive
Staph aureus (MSSA) bloodstream infections.
Aintree achieved:
What :
Reducing MSSA bacteraemias
How much:
By 50% (14 cases 2014/15)
When:
March 2015
Outcome:
In Quarter 4, there have been 3 patients with MSSA bacteremia, and the yearend total is 19 cases. This is the lowest number of cases for the past 3 years and
there has been a 32% reduction from 2013/14.
Table: The number of MSSA Bacteraemias April 2014 – March 2015
Aintree achieved this priority by:




Undertaking post infection reviews of all cases to understand priorities for action.
Work regarding improvements in compliance with ANTT for clinical staff
Development and implementation of evidence based guidance for appropriate line
selection and the management.
Increasing the capacity of the IV team and access to specialist advice
(Data source: Health Protection Agency which is governed by a standard national definition)
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Aintree University Hospital NHS Foundation Trust
Aintree said it would:
Provide care that is safe by reducing harm by reducing hospital acquired Clostridium difficile
Aintree achieved:
What :
Reducing the number of Clostridium infection (CDI) cases
How much:
By 50% (37 cases 2014/15)
When:
March 2015
Outcome:
Year to date there have been 64 patients with CDI; Q1 16 cases, Q2 19 cases,
Q3 13 cases, Q 4 16 cases.
23 cases have been successfully appealed as there were no lapses in care that
could have contributed to the infection, and so for performance purposes the
Trust have had 41 cases, a 45% reduction on 2013/14.
Table: Clostridium difficile infection April 2014 – March 2015
Aintree achieved this priority by:
 Implementation of CDI action plan
 Maintaining the focus on prudent antibiotic prescribing and antibiotic stewardship. This
includes weekly antimicrobial ward rounds
 Ensuring the environment is clean and undertaking a deep clean programme in 2014/15
 Additional monitoring of the environment using Encompass UV tagging to enable focus
areas to be identified and changes in practice
 Continued focus on staff practice and most importantly hand hygiene
 The revision of the CDI guidelines to include the use of fidaxomicin for patients with
moderate and severe disease and the Polymerase Chain Reaction (PCR) test for GDH
positive patients. The guidelines are to be finalised following recommendations from the
external review.
(Data source: Health Protection Agency which is governed by a standard national definition)
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Aintree University Hospital NHS Foundation Trust
Aintree said it would:
Provide care that is safe by reducing harm through reducing in-patients falls with harm
Aintree achieved:
What :
Reducing the number of Inpatient Falls with harm
How much:
By 15%
Examples of harm from falls:
Low harm – a graze or a bruise
Moderate harm – a fracture of wrist or limb
Serious harm – a head injury resulting in permanent damage
Death – as a direct result of the fall
When:
By March 2015
Outcome:
The 15% reduction in falls with harm in one year is an ambitious quality
improvement goal. During 2014/15 a 8.3% reduction in falls with harm (low,
moderate, severe, death) has been achieved.
The chart below measures quality improvement and illustrates seven data points
below the mean which generally indicates special cause variation e.g. Falls
Collaborative work. Moving forward the Falls Collaborative will be extended into
the Year 2 Delivery Plan and the reduction in falls will be expressed as a rate to
enable benchmarking against comparable organisations.
Table: Falls with harm – Low, Moderate & Severe Harm Apr 14- March 15
Aintree progressed this priority by:
 Leading a multi trust falls collaborative
 Introducing an evidenced based multifactorial falls risk assessment (based on NICE
Guidance)
 Implementing blue alert wrist bands for patients at risk of falling
 Introducing a shared report to allow easier access to low rise beds
(Data source: Datix, the Trust’s Incident Reporting System which is not governed by a standard national definition)
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Aintree University Hospital NHS Foundation Trust
Aintree said it would:
Provide care that is safe by reducing harm through reducing hospital acquired pressure ulcers
Aintree achieved:
What :
Reducing all hospital acquired pressure ulcers
How much:
To reduce grade 2 pressure ulcers by 10%, and to eliminate grade 3 and 4
pressure ulcers.
The higher the grade of pressure ulcer, the more severe the injury to the skin and
underlying tissue.
Grade two - some of the outer surface of the skin (the epidermis) or the deeper
layer of skin (the dermis) is damaged, leading to skin loss. The ulcer looks like an
open wound or a blister.
Grade three - skin loss occurs throughout the entire thickness of the skin. The
underlying tissue is also damaged, although the underlying muscle and bone are
not. The ulcer appears as a deep, cavity-like wound.
Grade four - is the most severe type of pressure ulcer. The skin is severely
damaged and the surrounding tissue begins to die (tissue necrosis). The
underlying muscles or bone may also be damaged. People with grade four
pressure ulcers have a high risk of developing a life-threatening infection
When:
March 2015
Outcome:
The Trust has achieved our 2014/15 improvement goal with 69 Grade 2 pressure
ulcers reported (against a threshold of 72) and three Grade 3/4 pressure ulcers
(against a threshold of less than or equal to 4). Whilst every pressure ulcer is a
harm to our patients, the nursing staff on our wards are to be congratulated on
achieving an 11% reduction in harm from Grade 2 and a 40% reduction in Grade
3/4 pressure ulcers during 2014/15. This builds upon the significant reduction of
greater than 40% achieved last year.
Table: Hospital Acquired Grade 2 Pressures Ulcers April 2014 to March 2015
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Aintree University Hospital NHS Foundation Trust
Table: Hospital Acquired Grade 3 and 4 Pressures Ulcers April 2014 to March 2015
Aintree achieved this priority by:





Implementing the change package developed by the Pressure Ulcer Collaborative
Raised awareness of feet ulcers through the Feet First Campaign which included an at risk
foot assessment tool
Sharing and learning from incidents at Pressure Ulcer Prevention Group.
Monthly Trust wide lessons learned newsletter
100% compliance with position changes for at risk patients as part of Intentional Rounding
(regular ‘nursing rounds’, to check on patients and ensure that their fundamental care needs
are met) has supported the reduction in pressure ulcers.
(Data source: Datix, the Trust’s Incident Reporting System which is not governed by a standard national definition)
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Aintree University Hospital NHS Foundation Trust
Aintree said it would:
Provide care that is safe by reducing avoidable mortality
The metrics have been developed by the Aintree Business Intelligence team, in collaboration with
the clinical leads and project teams. All pathways have been identified via diagnosis (ICD-10)
coding, based on the presence of the relevant codes in any position of any episode of the spell.
Aintree delivered improvements on this priority through the following five work streams:
Workstream 1 achieved:
What :
Preventing harm and reducing avoidable mortality rates by implementing a
Pneumonia care bundle
How much:
All emergency admissions screened for pneumonia in acute assessment areas
(AED and AMU)
When:
March 2015 and on-going
Outcome:
Training on the pneumonia care bundle provided in AED and AMU is mandatory for
all junior doctors. The Screening Proforma is in use although completion is below
expected. There has been a lot of variation in the observed number of Pneumonia
discharges, month on month, from January 2011. To take into account seasonal
variation, the mortality rate for Pneumonia is aggregated into rolling 12 month rate
to provide a comparative indicator month on month. The rolling 12 month in
hospital mortality rate for Pneumonia for the period March 2014 to February 2015
is 20.4%, which is a decrease from the same period last year (22.3%).
Table: In-hospital death rate from Pneumonia, 2011 – 2015
(Data source: SIGMA, the Trust’s PAS which is not governed by a standard national definition)
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Aintree University Hospital NHS Foundation Trust
Workstream 2 achieved:
What :
Piloting Sepsis (blood poisoning) Six (Care Bundle)
How much:
In Accident & Emergency Department (AED) and the Acute Medical Unit (AMU)
When:
March 2015 and on-going
Outcome:
The Sepsis (blood poisoning) work stream commenced in December 2013 and the
Sepsis 6 care bundle was introduced into practice in AED in September 2014.
There has been an increase in the observed number of Sepsis discharges since
January 2011. This increase could be explained by changes within coding
practises, which may have resulted in these pathways being captured more
effectively. To take into account diversity of the population and seasonal variation,
the mortality rate for Sepsis is aggregated into a rolling 12 month rate to provide a
comparative indicator month on month. The rolling 12 month in hospital mortality
rates for Sepsis for the period March 2014 to February 2015 is 11.8%, which is a
decrease from the same period last year (13.8%). Next steps: to roll out the care
bundle to AMU by end March 2015.
Table: In-hospital death rate from Sepsis, 2011 - 2015
(Data source: SIGMA, the Trust’s PAS which is not governed by a standard national definition)
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Aintree University Hospital NHS Foundation Trust
Workstream 3 achieved:
What :
Introducing a risk assessment tool, care bundle and staff training for Acute Kidney
Injury (AKI)
How much:
In admission and assessment areas
When:
March 2015 and on-going
Outcome:
Guidelines and assessment Proforma all in place to support early identification of
patients at risk. The AKI metrics include pathways where a diagnosis of AKI has
been made and pathways where an acute deterioration in kidney function has been
identified. An e-alert system is in place linked to the Critical Care Outreach Team
to ensure early treatment. Improved patient information and communication with
primary care is in progress.
There has been an increase in the observed number of AKI discharges from the
end of 2013. The increase in the number of AKI pathways could be explained by
changes within coding practices, which may have resulted in these pathways being
captured more effectively. Because the AKI population is so diverse, changing
from month to month, the mortality rate is aggregated into a rolling 12 month rate to
provide a comparative indicator month on month. The rolling 12 month in hospital
mortality rate for AKI for the period from March 2014 to February 2015 is 19.8%,
which is a decrease from the same period last year (25.5%).
Table: In-hospital death rate from AKI, 2011 - 2015
(Data source: SIGMA, the Trust’s PAS which is not governed by a standard national definition)
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Aintree University Hospital NHS Foundation Trust
Workstream 4 achieved:
What :
Improvements in key areas of care for the deteriorating patient: Modified Early
Warning Score (MEWS), hypotension, identification of increasing oxygen
requirements, communication and training
How much:
Audit of MEWS for January to December 2014
When:
March 2015 and on-going
Outcome:
The MEWS audit tool was modified in 2013 and results of audit for January to
December 2014 reported in January 2015 demonstrated >90% compliance in the 6
areas measured. Results have been shared with ward managers to address those
areas of poor compliance.
Workstream 5 achieved:
What :
Improving overall end of life care and support for patients with a limited prognosis
How much:
Complete baseline audit and develop AMBER care bundle materials for
implementation. The AMBER care bundle encourages staff, patients and families
to continue with treatment in the hope of a recovery, while talking openly about
people's wishes and putting plans in place should the worst happen. It consists of
four elements:
 talking to the person and their family to let them know that the healthcare
team has concerns about their condition, and to establish their preferences
and wishes
 deciding together how the person will be cared for should their condition get
worse
 documenting a medical plan
 agreeing these plans with all of the clinical team looking after the person.
When:
March 2015
Outcome:
A baseline audit has been completed.
The AMBER Care Bundle has been implemented in Gastroenterology where staff
have been trained. Implementation on Ward 10 commenced on the 15th January
and started on Ward 11 on the 9th February. Thoracic Medicine has been identified
as the next area for implementation (education and preparation of wards and staff
prior to this).
Over 140 staff have been trained to date and a business case has been submitted
to extend the AMBER Care Bundle lead post from a one year post to three years to
enable Trust wide implementation.
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Aintree University Hospital NHS Foundation Trust
Priority 2: Clinical effectiveness improvement actions for 2014/15
Aintree said it would:
Provide care that is clinically effective by delivering reliable care, aiming to achieve 95% for
the appropriate care scores in the 5 existing Advancing Quality care bundle standards 7 days a
week
Aintree achieved the following appropriate care scores:
Clinical Focus
Group
AMI
Heart Failure
Hip & Knee
Pneumonia
Stroke
Joined AQ in
2010
Measure
(Denominator)
Year 1
Year 7
Oct08-Sep09
YTD
Apr14- Jan15
YTD
ACS
(Denominator2)
86.4%
94.89%
ACS
(Denominator2)
71%
ACS
(Denominator2)
82.3%
ACS
(Denominator2)
34.43%
ACS
(Denominator2)
*52.88%
*Oct 10 – Sept 11
Improvement
position

176
71.68%

286
88.37%

533
76.65%

895
69.14%

405
Table: Advancing Quality Appropriate Care Scores showing baseline scores in 2008/09 and year to date position in
2014/15
Key: The up arrow  indicates performance improvement and the down arrow  indicates
performance deterioration.
(Data source: Clarity Assure which is not governed by a standard national definition)
Aintree said it would:
Provide care that is clinically effective by delivering reliable care, working towards a 95%
standard for Intentional Rounding (regular, planned ‘nursing rounds’, to check on patients and
ensure that their essential care needs are met).
Aintree achieved:
What :
Improving compliance in key process measures for Intentional Rounding (also
known as comfort rounds)
How much:
Greater than or equal to 95%
When:
Outcome:
March 2015
The Quarter 4 snap shot audit showed that the Comfort checks being completed
up to audit hour was 94.1%.
Evidence that position changes had been completed for at risk patients was
100%.
Patients aware of comfort checks being completed regularly was also 100%.
Further improvements are planned for 15/16 as part of the year 2 Quality Strategy delivery plan.
(Data source: Case note audit which is not governed by a standard national definition)
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Aintree University Hospital NHS Foundation Trust
Aintree said it would:
Provide care that is clinically effective by delivering reliable care, working towards a 95%
standard for Peripheral Intravenous Cannula care.
Aintree achieved:
What :
Establishing a baseline measurement and Care Bundle for Peripheral Lines
How much:
Greater than or equal to 95% compliance for Care Bundle
When:
March 2015
Outcome:
The compliance with the care bundle for insertion of peripheral cannula was over
95% for all four quarters of 2014/15. The compliance for the on-going management
of peripheral cannula was consistently over 95% for the first three quarters in
2014/15 and 94% in Qtr 4.
Further improvements are planned for 15/16 as part of the year two Quality Strategy delivery plan.
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Aintree University Hospital NHS Foundation Trust
Priority 3: Patient experience improvement actions for 2014/15
Aintree said it would:
Deliver care that provides a Positive experience for patients and their families, working
towards a top 25% position in the national in-patient survey.
Aintree achieved:
Of the 78 trusts that the Picker Institute worked with for the 2014 Inpatients survey, Aintree ranked
20th which puts the Trust in the top 26%.
Table: Picker Inpatient Survey Results 2014 for participating NHS Trusts (lower scores are better).
(Data source: Picker In-patient Survey Results in February 2015 which is governed by a standard national definition)
Aintree said it would:
Deliver care that provides a Positive experience for patients and their families, working
towards a top 25% position in the national staff survey.
Aintree achieved:
An Overall Engagement Score in 2014 is 3.75; an increase from 3.74 in 2013.
This score is made up of 3 Key Findings:
KF22 Staff ability to contribute towards improvements at work
KF24 Staff recommendation of the Trust as a place to work or receive treatment
KF25 Staff motivation at work
The national average score for 2014/15 is 3.85 and despite the Trust achieving an improved score
in 2014/15 we have not secured a position in the top 25%.
Ranked against all acute trusts, Aintree is in 85th position out of 139 which means we are in the top
65% of acute trusts.
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Aintree University Hospital NHS Foundation Trust
Table: Picker Staff Survey Results 2014 for participating NHS Trusts (higher scores are better).
(Data source: Picker Staff Survey Results in February 2015 which is governed by a standard national definition)
Aintree said it would:
Deliver care that provides a Positive experience for patients and their families, working
towards a top 25% position in the national Friends and Family Test (FFT) Net Promoter Score
(NPS).
Aintree achieved:
Results published by NHS England in March 2015 puts Aintree in the top 20% of hospitals
providing NHS in-patient care as show Aintree in 31st position for the FFT NPS out of 167 NHS and
Independent Hospitals.
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Aintree University Hospital NHS Foundation Trust
100%
Best
performer
Inpatient FFT March 2015 - NPS summary
Worst
performer
90%
80%
FFT NPS score
70%
60%
50%
40%
30%
20%
10%
0%
Table: Friends and Family Test (FFT) In-Patient net promoter scores (NPS) in March 2015 for participating NHS Trusts
(higher scores are better).
Aintree achieved:
Results published by NHS England in March 2015 puts Aintree in the top 70% of hospitals
providing NHS A&E care as show Aintree in 92nd position for the FFT NPS out of 139 NHS
Hospitals.
Best
100% performer
90%
A&E FFT March 2015 - NPS summary
Worst
performer
80%
FFT NPS score
70%
60%
50%
40%
30%
20%
10%
0%
Table: Friends and Family Test (FFT) A&E net promoter scores (NPS) in March 2015 for participating NHS Trusts
(higher scores are better).
(Data source: NHS England publications which is governed by a standard national definition)
Page 21 of 74
Aintree University Hospital NHS Foundation Trust
Quality improvement priorities for 2015/16
These priorities have been developed and chosen based on:
Our vision to provide world class services for all our patients, with the common purpose of
‘getting it right for every patient, every time’. In August 2014, the Trust launched a new Quality
Strategy (2014-2017) to help to achieve improvements in the quality of our clinical services over
three years.
We have agreed a portfolio of projects that address local and national priorities to ensure that we
deliver the three elements of our definition of quality:
Priority 1: Care that is Safe
 We will focus on reducing harm and avoidable mortality by working with patients and
their families to reduce avoidable harm and improve outcomes.
Priority 2: Care that is Clinically Effective
 We will focus on the delivery of reliable care, not just in the eyes of clinicians but in the
eyes of patients and their families
Priority 3: Care that provides a positive experience for patients and their families
 We will focus on improving the delivery of patient and family centred care
We are focusing our work around projects to deliver these three quality improvement priorities. The
priority projects for 2015/16 are the same measurements outlined in our Year 2 Quality Strategy
delivery plan which is included in the Trust’s annual operational business plan.
The delivery of our quality projects will be supported by promoting access and uptake of staff
training on quality improvement knowledge and skills to bring about change in practice to embed
continuous improvement.
How progress to achieve the quality improvement priorities will be reported:
The Trust’s Hospital Management Board has approved a plan for the delivery of the quality
improvement priorities. Progress against this plan will be reported to the Quality & Safety
Committee via the Trust’s quarterly Quality Report and shared widely with governors,
members, local groups and organisations as well as the public.
How the views of patients, the wider public and staff were taken into account:
All of the priorities were identified through regular feedback and engagement, and by taking into
account the views of:




People who use the Trust’s services and carers, for example through receipt of feedback
through activities such as the Friends and Family Test, patient and carer surveys.
Staff and senior clinicians, for example through discussion at the Trust’s corporate governance
meetings.
Stakeholders and the wider public, for example through activities such as formal consultations
during the launched of the Quality Strategy.
Commissioners of NHS services, through contract negotiation and monitoring processes.
Page 22 of 74
Aintree University Hospital NHS Foundation Trust

Local Healthwatch through feedback from visits to services, at quarterly informal meetings and
via the Patient Experience Executive-led Group.
Priority 1: Care that is Safe by achieving a continuous reduction in avoidable harm.
Rationale for selection of this priority:
Occasionally patients will stay longer in hospital, or need additional monitoring or treatment as a
result of care that fell below our usual standards. Sometimes, despite our best efforts a patient may
experience harm. At Aintree, everyone endeavours to provide the highest standard of care and we
encourage our staff to voluntarily report any patient safety issues so that we can learn from our
mistakes. We have noted that only 10 to 20 per cent of errors are reported voluntarily but are
reassured that of these between 90 and 95% did not cause any harm to patients.
At Aintree we will use both our patient safety reports and the Safety Thermometer tool to ensure
that we immediately address all patient safety issues and we will improve patient care as a
consequence.
The Trust uses the Standardised Hospital Mortality Index (SHMI) and Hospital Standardised
Mortality Ratio (HSMR), to determine the expected range for the number of avoidable deaths at our
hospital. We are committed to reducing this number by reducing the number of patients who die as
a result of avoidable harm.
The way we are planning to do this is:
•
•
•
•
•
•
•
We will ensure that 98% of patients receive harm free care, consistent across every
ward, and will measure this via ‘Safety Thermometer’
We will demonstrate continuous improvement in the reduction of pressure ulcers; inpatient falls with harm and hospital acquired MRSA/MSSA Bloodstream Infections
We will continue to measurement missed doses of high risk critical medicines
We will establish surveillance project for Catheter Associated UTI
We will establish Hospital Acquired Thrombosis (HAT) Project
We will establish a Clostridium Difficile Collaborative
We will attempt to reduce the number of avoidable deaths by:
o Improving compliance in established care bundles for Pneumonia, Sepsis, Acute
Kidney Injury, The Deteriorating Patient and End Of Life Care
o Commencing baseline data analysis on stroke mortality
Priority 2: Care to be Clinically Effective.
Rationale for selection of this priority:
There is evidence of inconsistencies in the delivery of high quality care with some patients not
receiving all the care that is recommended as best practice; this applies to both inpatient and
outpatient services. The Institute for Healthcare Improvement has developed the concept of
“bundles” to help health care providers to reliably deliver the best possible care for patients
undergoing particular treatments with inherent risks. A bundle is a structured way of improving the
process of care and patient outcomes: a small, straightforward set of evidence-based practices
that, when performed together and reliably, have been proven to improve patient outcomes.
Page 23 of 74
Aintree University Hospital NHS Foundation Trust
Over the next two years we will endeavour to maintain consistently high standards and improve
care wherever we can. Our staff will work together to develop care bundles, train their colleagues
in their use and then carry out audits to ensure that they are being applied consistently. There will
be times where clinicians will use their expertise and experience to override the guidelines when
this is in the interest of the patient. Consistent application of patient care supports healthcare
providers to ensure that all patients receive every element of care that they require. This is
particularly relevant at weekends, when patients may experience a delay due to limited access to a
service. This result could lead to a poorer outcome for these patients.
Progress to achieve the priority will be measured as follows:
•
Work towards at least 95% delivery of reliable care, 7 days/week in Advancing
Quality Care Bundles for:
- Pneumonia
- Heart failure
- Hip and knee care
- Myocardial infarction
- COPD
• Continuous Improvement of Peripheral Intravenous Cannula care
• Establish a Nutrition and Hydration Collaborative
Priority 3: Care that provides a positive experience for patients and their families.
Rationale for selection of this priority:
A positive patient and family experience is of great importance to us. We understand that many of
our patients often experience life changing diagnoses and treatments, and it is our ambition to
make their experience the best that it can possibly be. In order to do this we recognise the need for
our staff to feel valued and supported.
There is much more that we need to do to improve patient and family care and we asked our
patients and their families for their views. They told us what was important to them and we
developed our three year (2014-17) Quality Strategy with those priorities in mind.
Progress to achieve the priority will be measured as follows:
•
•
•
•
•
•
Work towards a top 25% position for In-patient and Staff experience national surveys
Achieve higher than the NHS Merseyside and NHS England average in all measures in
the Friends and Family Test (FFT)
Improve length of time to respond to complaints
Establish communication project relating to patient experience including an innovative
human factors approach
Work with the League of Friends to develop family rooms
Continue to use patient stories to share learning across the Trust
Page 24 of 74
Aintree University Hospital NHS Foundation Trust
Statements of assurance from the Board
The purpose of this section of the report is to provide formally required evidence on the quality of
Aintree’s services. This allows readers to compare content common across all Quality Accounts
nationally.
Common content for all Quality Accounts nationally is contained in a double line border like this.
Information of the review of services
During 2014/15 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 36 of these relevant health services. The income generated by the
relevant health services reviewed in 2014/15 represents 100 per cent of the total income generated
from the provision of relevant health services by Aintree University Hospital NHS Foundation Trust
for 2014/15.
Information on participation in clinical audits and national confidential enquiries
During 2014/15 33 national clinical audits and 4 national confidential enquiries covered relevant
health services that Aintree University Hospital NHS Foundation Trust provides.
During 2014/15 Aintree University Hospital NHS Foundation Trust participated in 100% national
clinical audits and 100% national confidential enquiries of the national clinical audits and national
confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Aintree University Hospital NHS
Foundation Trust was eligible to participate in during 2014/15 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 2014/15, are
listed in the table below alongside the number of cases submitted to each audit or enquiry as a
percentage of the number of registered cases required by the terms of that audit or enquiry.
The high level of participation in clinical audit which is observed across the Trust demonstrates the
commitment of our clinical staff to improving the quality of care they provide.
Participating
Case achievement
(Yes/No)
National Clinical Audit/Enquiry Title
Acute
Adult Community Acquired Pneumonia
Adult Critical Care (Case Mix Programme - ICNARC)
Medical and Surgical Programme (NCEPOD)
- Sepsis
- Gastrointestinal Haemorrhage
- Lower Limb Amputation
- Tracheostomy Care
Yes
Yes
N/A data submission open
100%
Yes
Yes
Yes
Yes
National Emergency Laparotomy Audit
National Joint Registry - Hip, Knee
Replacements
Pleural Procedures
Severe Trauma (TARN)
Yes
Yes
N/A - study open
100%
100%
100% Questionnaires
50% Case-notes
64%
100%
Yes
Yes
87%
100%
and
Ankle
Page 25 of 74
Aintree University Hospital NHS Foundation Trust
National Clinical Audit/Enquiry Title
Participating
Case achievement
(Yes/No)
Blood and Transplant
National Comparative Audit of Blood Transfusion Programme
-
Patient information and Consent
Sickle Cell
Yes
Yes
100%
100%
Yes
Yes
Yes
Yes
Yes
100%*
100%*
100%*.
100%*
N/A - audit in progress
Yes
100%
Yes
Yes
Yes
100%
100%
100%
Cancer
Bowel Cancer
Head and Neck Cancer
National Lung Cancer Audit
Oesophago-gastric Cancer
Prostate Cancer
Heart
Acute Coronary Syndrome or Acute Myocardial Infarction
(MINAP)
Cardiac Arrhythmia - Heart Rhythm Management
Heart Failure (Heart Failure Audit)
National Cardiac Arrest Audit
Long term conditions
Inflammatory Bowel Disease - continuous data collection
Yes
75%
(retrospective submission Biological therapies audit)
National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme
-
Pulmonary Rehabilitation
Exacerbations of COPD
National Diabetes Audit
- NDA Adults
-
Diabetic Foot Ulcers
Renal Replacement Therapy (Renal Registry)
Rheumatoid Arthritis and Early Inflammatory Arthritis
Yes
Yes
Data collection in progress
N/A – data collection in
progress
Yes
N/A
no
case
ascertainment specified
N/A - Data collection in
progress for submission as
soon as online dbase is
available.
Yes
Yes
Yes
N/A - audit in progress
Yes
100%
Mental Health
Mental Health (Care in Emergency Departments)
Older People
Sentinal Stroke National Audit Programme (SSNAP)
-
Clinical audit
Yes
100%
-
Organisational audit
Yes
N/A
Yes
Yes
100%
N/A - Data collection in
progress for submission as
soon as online dbase is
available.
N/A - No minimum case
requirement. Page 26 of 74
Falls and Fragility Fractures Audit Programme
-
National Hip Fracture Database
Falls and Fragility Database
Older People (Care in Emergency Departments)
Yes
Aintree University Hospital NHS Foundation Trust
National Clinical Audit/Enquiry Title
Participating
Case achievement
(Yes/No)
Other
Elective Surgery PROMS Programme - Hernia, (Varicose
Veins not carried out by Aintree)
Elective Surgery PROMS Programme - Hip Replacement,
Knee Replacement
*subject to verification
Yes
75.5%
Yes
80.3% (Hips)
76.0% (Knees)
Actions arising as a result of national and local audits
The Trust Board has delegated authority for clinical audit to the Trust‘s Clinical Effectiveness Execled Group. Through this delegation, the reports of 13 national clinical audits were reviewed by the
provider in 2014/15 and Aintree University Hospital NHS Foundation Trust intends to take actions
listed in the table below to improve the quality of healthcare provided.
In addition, the reports of 147 local clinical audits were reviewed by the provider in 2014/15 and
Aintree University Hospital NHS Foundation Trust intends to take actions listed in the table below
to improve the quality of healthcare provided.
EXAMPLES OF NATIONAL AUDIT ACTIONS
Trauma Audit Research Network (TARN)

Overall performance is above the national average and second only to London
Inpatient Falls




New falls policy and care plan
Falls grab packs
Pharmacy web tool for medication review
Redesign of therapy documentation to include fear of falling
National Inflammatory Bowel Disease (4th Round)
It was noted that overall, the Trust’s performance was consistent with national standards and
exceeded those in IBD nurse attention and dietary. The following three key areas for local change
were identified:
 Treatment of anaemia – write local algorithm and circulate to MDT
 Discharge information – develop discharge pack
 Investigation of raw data, especially surgical rates and thrombotic events
National Head and Neck Cancer Audit (DAHNO) 9th Round



Automatic discussion of path at MDT
Cancer trackers now aware of path reporting.
More focus in MDT on WHO and ACE data collection
Sentinel Stroke National Audit Programme (SSNAP)
Aintree has made a significant improvement in its overall SSNAP score. The following
recommendations for actions were made: Increasing the percentage of suspected stroke patients receiving CT head scan within 1
hour, which remains low
 Continue to work towards 4 hour admission target of 90%
 Increasing provision of SALT input to assist patients in reaching SALT targets
 Improving MDT working to ensure rehab goals are set within 5 days of admission, which has
Page 27 of 74
Aintree University Hospital NHS Foundation Trust



worsened slightly
Maintaining high standards at AUH in patients receiving thrombolysis within 1 hour- Mersey
region is catching up in this area!
Improve formation of a joint health and social care plan on discharge. Increased
communication with social workers
Ensure arrangements in place for discharge with a stroke skilled ESD team for applicable
patients
National Diabetes inpatient Audit
Aintree is taking the following actions to improve care: Insulin Error Group – feedback to clinical areas
 Identifying patients with BG out of range
- Launch new blood glucose monitoring chart
- Introduce new BG lab linked blood glucose monitoring system – alert DT to patients
with blood glucose levels out of range
-Insulin icon on mobile cares and desk tops to be introduced
 Self-administration of insulin to be supported for safer practice
 Education
EXAMPLES OF LOCAL AUDIT ACTIONS
A Comparison of Traditional Discharge Letters with Electronic Discharge Letters - Time and
Quality
 All doctors completing discharge summaries to be aware that information is currently being
missed off the summaries and to ensure that it is provided
Review of the Accuracy and Effectiveness of Discharge Documentation in Communication
with Primary Care
 Provide education at a local level highlighting what is important to include in discharge
summaries
Evaluation of patient views of the Medical Day Case Unit (Ward 25)
 Haematology withdrawing from ward 25 and developing a new specialist unit on ward 24
 Utilise Listening into Action’s collaborative process.
 Collaborative team created
Patient Experience Chronic Kidney Disease (CKD) within Satellite OPD Facility
 Utilise existing resources to improve communication/education for staff and patients
 Promote active engagement and achieve successful outcomes
Antimicrobial Point Prevalence Audit
 Expand antimicrobial multidisciplinary ward rounds to cover all directorates (ENT, MFU,
cardiology)
 Ongoing informal teaching during multidisciplinary antibiotic ward rounds
 Compile/update directorate antibiotic guidelines
Clinical Audit of Physiotherapy Practice in Aintree Prosthetic and Wheelchair Centre (PAWC)
 There are no changes in practice as physiotherapy in PAWC is compliant with standard 4.5
BACPAR evidence based guidelines.
Service Evaluation of Patient Supplement Preference
 Ensure Compact is now prescribable on EPMA and in stock in Vanilla and Banana flavours
Page 28 of 74
Aintree University Hospital NHS Foundation Trust
Identification of Emergency Protocols and where to locate them
 SOP file should be in a standard location in each theatre area
 File folders to be purchased to ensure SOP files are easily accessed
Clinical Audit of Delayed Discharges for Day Case Spinal Surgery Patients
 To reschedule theatre lists so that patients reach second stage recovery before 3PM.
Clinical Audit of Re-admissions on the Surgical Assessment Unit/ EGSU
 Analgesic cards
 Patient Education/ Information Leaflet
Diabetes Dietitians' Patient Satisfaction Survey
 No change as feedback was very positive
Full details of the actions to be taken on all audits can be provided – please contact 0151 529 3782
for more details.
Participation in clinical research
The number of patients receiving relevant health services provided or subcontracted by Aintree
University Hospital NHS Foundation Trust in 2014/15 that were recruited during that period to
participate in research approved by a research ethics committee was 2000.
The Trust also has in the region of 8,000 patients registered in a retrospective rib fracture study.
Patients were recruited into NHIR adopted studies, commercially sponsored studies and Trust
sponsored studies.
Aintree was involved in conducting 368 clinical research studies during 2014/15. 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 368 studies open at
Aintree 230 met the NIHR national adoption criteria and these studies have been approved and
opened using the NIHR Co-Ordinated Systems for gaining NHS permission (CSP). Of the eligible
studies co-ordinated through CSP 100% were given permission to start within 30 days, with the
agreed NHIR recruitment goal being met All of the studies were established and managed with the
use of model Clinical Trial/Clinical Investigation Agreements which speed up contracting & trial
initiation between companies and the Trust.
All studies are closely monitored within the Research & Development Department to ensure that
studies are recruiting on time to meet the target recruitment. The aim is to maintain excellent
recruitment and to continually monitor the following 2 key performance criteria:
 NIHR High Level Objectives (HLO) - [NWC Clinical Research Network]
 Department of Health – Delivery and Performance data [PID] in clinical research.
The Trust is constantly reviewing its approval times and indeed, is meeting all of the HLO and the
PID timelines for NHS Approval.

Performance in Commercial Activity Time to Target – The figure associated with the
HLO and the PID objective is 80% and our figure as a Trust is running at approximately
65% for all commercial studies
Page 29 of 74
Aintree University Hospital NHS Foundation Trust


Initiation in Clinical Research - The Trust has a 70 day benchmark to recruit the first
patient into the study. This is a very challenging target and at present the Trust is running
at approximately 60% for all activity
Time taken for NHS Permission – all studies are issued with R&D approval within 30 days
of receipt of a valid research application
All studies have undergone research governance review to ensure research passports/letter of
access is issued appropriately. This initiative streamlines HR arrangements across organisations
to make it easier and quicker to commence approved studies.
High quality research at Aintree will ensure the best possible care for patients, promote the
reputation of Aintree as a centre of excellence (driving patient and purchaser choice) and facilitate
the recruitment and retention of the highest calibre of staff.
With the inclusion of clinical leads, data managers, pharmacy and AHP there are over 100 staff at
Aintree involved with research studies covering over 15 specialities across the Trust namely:
Cardiology, Stroke, Gastroenterology, Respiratory, Musculoskeletal, Diabetes & Endocrine, Cancer
(Head & Neck, Haematology, and General Surgery), Urology, General Surgery, Critical Care,
Dermatology, MFU, Respiratory Infection, Ophthalmology and Pharmacogenetics.
Over the past year at Aintree there has been progress in many areas, with many successful grant
applications and publications such as:







NIHR Research for Patient Benefit Grant (co-applicant)
Over 100 Publications in high impact scientific and medical journals.
Increased commercial income to support research across many therapeutic areas
Key member of Joint Research Office initiative
Successful bid in collaboration with the University of Liverpool for the CLAHRC which is the
Collaboration for Leadership in Applied Health Research and Care
Agreement for the development of a Clinical Research Facility based in the Clinical Science
Centre supported by a dedicated Clinical Research Facilities Manager ensuring all trials are
co-ordinated to a high standard and providing a safe and up to date clinical area for our
patients
Clinical Academic Programmes Leads with key stakeholders: Aintree involvement in
Cancer, Infection & MSK, Diabetes and Respiratory
Page 30 of 74
Aintree University Hospital NHS Foundation Trust
Use of CQUIN framework
A proportion of Aintree University Hospital NHS Foundation Trust income in 2014/15 was
conditional on achieving quality improvement and innovation goals agreed between Aintree
University Hospital NHS Foundation Trust and any person or body they entered into a contract,
agreement or arrangement with for the provision of relevant health services, through the
Commissioning for Quality and Innovation payment framework. Further details of the agreed goals
for 2014/15 and for the following 12 month period are available electronically at
http://www.aintreehospital.nhs.uk/AboutUs/Pages/Publications.aspx.
During 2014/15 the total income associated with the achievement of quality improvement and
innovation goals amounted to £5.093M. Aintree University Hospital NHS Foundation Trust received
£5.14M income for the associated payment in 2013/14.
An overview of the initiatives and performance during 2014/15 is outlined in the table below.
Key:
 = Achieved
Scheme
CQUIN GOALS IN 2014/15
Target
Performance
Implementation of STAFF
Friends & Family Test (FFT)
Above the
Picker
average in
both
questions
Friends & Family Test (FFT),
Early implementation of Day
Cases and Outpatients
1c
FFT increasing response rates
for In-Patients
Minimum of
25% in Qtr 1
and 30%/> in
Qtr 4
FFT increasing response rates
for A&E
Minimum of
15% in Qtr 1
and 20%/> in
Qtr 4
FFT further increasing
response rates for In-Patients
>40% in
March 2015
1d
2a
2b
NHS Safety Thermometer
Surveys
NHS Safety Thermometer
Friends & Family Test (FFT)
 = Under Achieved
1b
1e
NHS Safety Thermometer
National
1a
 = Partially Achieved
NHS Safety Thermometer
Improvement Goal for reducing
Pressure Ulcers
Achieved
Achieved above the
Picker average in
both questions
Full implementation
delivered in October
2014
100%
</=4 Grade 3
& 4s
</=72 Grade
2s
Overall response
rate was >30%
throughout 14/15
and was 44.8% in
Qtr 4
Overall response
rate was >20% in
Qtr1 - Qtr 4




Overall response
rate was 46.5% in
March 2015

100% of areas
completed monthly
survey and
submitted data
3 Grade 3 & 4
pressure ulcers
reported
69 Grade 2s
pressure ulcers
reported



Page 31 of 74
Dementia
Aintree University Hospital NHS Foundation Trust
Scheme
Target
Performance
3a
Dementia Risk Assessment
(new in 12/13)
90% achieved in Qtr
4
3b
Dementia Training Plan
Working
towards 90%
in Qtr 4
Increase
awareness
3c
Supporting Carers of people
with Dementia
4a
A Q – AMI
Appropriate Care Score
A Q – Heart Failure
Appropriate Care Score
4b
4c
Advancing Quality1
4d
4e
4f
4g
Local
4h
4i
4j
Communication
5a
5b
5c
5d
Ambulator
y Care
5e
6
Monthly
surveys
88.9%
71.20%
A Q – Pneumonia
72.5%
Appropriate Care Score
A Q – Hip & Knee Surgery
84.6%
Appropriate Care Score
A Q – Stroke
59.5%
Appropriate Care Score
A Q – COPD
50.0%
Appropriate Care Score
(new in 2014/15)
A Q – Hip Fracture
Working
Appropriate Care Score
towards
(new in 2014/15)
50.0%
A Q – Sepsis
Working
Appropriate Care Score
towards
(new in 2014/15)
50.0%
A Q – Diabetes
Working
Appropriate Care Score
towards
(new in 2014/15)
50.0%
A Q – Alcoholic Liver Disease
Working
Appropriate Care Score
towards
(new in 2014/15)
50.0%
In-patient
Discharge 90% in Qtr 4
Summaries sent in 24 hours
Patient Copy of Discharge 90% in Qtr 4
Summary for In-Patients
Day
case
Discharge 75% in Qtr 4
Summaries sent in 24 hours
A & E Discharge Summaries
sent within 24 hours (NEW)
Out-Patient Letters sent to GP 90% in Qtr 4
within 14 days
Implementation of ambulatory Project
emergency care pathways for Implementati
4 chronic ambulatory care on completed
sensitive conditions
Achieved
86.1% of staff
completed dementia
awareness training
Five surveys
undertaken each
month with Carers
94.89% cumulative
to January 2015
71.68% cumulative
to January 2015
76.65% cumulative
to January 2015
88.37% cumulative
to January 2015
69.91% cumulative
to January 2015
35.58% cumulative
to January 2015









2.56% cumulative
October 2014 to
January 2015
73.1% cumulative
September 2014 to
January 2015
25.81% cumulative
November 2014 to
January 2015
53.85% cumulative
January 2015

79.1% (Qtr 4)





79.1% (Qtr 4)
75% (Qtr 4)
55.1% (Qtr 4)
90% (Jan 14)
Pathways published
on Trust Document
Management
System




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.
Page 32 of 74
Aintree University Hospital NHS Foundation Trust
Effective
Discharge
7
Quality Dash-boards
8a
8b
8c
Performance
Implement a standardised
provider discharge checklist
within 24-48 hours of patient
discharge and ongoing audit of
compliance
Embed and
evidence
routine use of
discharge
checklist
Trauma Dashboards (a suite of
measures relating to Trauma
care services)
Quarterly
reporting
Renal Dashboards (a suite of
measures relating to Renal
care services)
Quarterly
reporting
Embedded checklist
since October 2013
and each quarterly
audit since has
shown an increased
compliance rate
Dashboards
reported and
discussed within
clinical teams each
quarter
Dashboards
reported and
discussed within
clinical teams each
quarter
Adult Critical Care Dashboards
(a suite of measures relating to
critical care services)
Quarterly
reporting
Dashboards
reported and
discussed within
clinical teams each
quarter
Increase
effectiveness
of
Rehabilitation after critical care
illness
Quarterly
reporting
Offer all renal dialysis patients
within the units to become
involved in tasks relating to
their dialysis
Dashboards
reported and
discussed within
clinical teams each
quarter
100% of patients
offered to participate
in their own tasks
but all are not
eligible to do so.
11
Extend Friends & Family Test
(FFT) to Dental Services
Offer 100%
of patients
under the
renal unit to
participate in
5 or more
dialysis tasks
Implement by
October
12
To explore and address any
health inequalities in the bowel
screening programme
Baseline
report and
action plan
Renal Shared
Care
Dental
FFT
10
Target
Bowel
Screening
Critical
Care
Rehab
9
Scheme
Achieved






FFT for dental was
formally launched in
October 2014

Baseline report and
improvement action
plan was completed
in December 2014

A congratulatory email shown below was sent out to all staff from Steve Warburton, Acting Chief
Executive:
“The Executive Team would like to extend its appreciation to all staff for their commitment and hard
work in successfully delivering 90.2% of this year’s CQUIN schemes – our best performance yet
which has secured £5.1M of income for the Trust.
Our successful CQUIN delivery was recognised by our CCG colleagues who praised the Trust for
the quality of services it provides to our patients.
This is a fantastic achievement for Team Aintree – many congratulations to all”
Page 33 of 74
Aintree University Hospital NHS Foundation Trust
Registration with the Care Quality Commission
Aintree University Hospital NHS Foundation Trust is required to register with the Care Quality
Commission and its current registration status is unqualified. Aintree has no conditions on
registration.
The Care Quality Commission has not taken any enforcement action against Aintree University
Hospital NHS Foundation Trust during 2014/15.
Aintree University Hospital NHS Foundation Trust has not participated in any special reviews or
investigations by the Care Quality Commission during the reporting period.
Information on the quality of data
NHS Number and General Medical Practice Code Validity
Aintree University Hospital NHS Foundation Trust submitted records during 2014/15 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:
99.9% for admitted patient care;
99.9% for outpatient care; and
96.8% for accident and emergency care
-
Which included the patient's valid General Medical Practice Code was:
99.9% for admitted patient care;
99.9% for outpatient care; and
99.6% for accident and emergency care
Information Governance Toolkit attainment levels (Information Governance)
Aintree University Hospital NHS Foundation Trust Information Governance Assessment Report
overall score for 2014/15 was 74% and was graded Green, Satisfactory.
Clinical coding error rate
Aintree University Hospital NHS Foundation Trust was not subject to the Payment by Results
clinical coding audit during 2014/15 by the Audit Commission.
Page 34 of 74
Aintree University Hospital NHS Foundation Trust
Statement on relevance of data quality and actions to improve data quality
Good quality information underpins the effective delivery of the care of people who use NHS
services and is essential if improvements in quality of care are to be made.
Aintree University Hospital NHS Foundation Trust will be taking the following actions to improve
data quality:
 work alongside the data platform team to develop an effective reporting mechanism based
upon the key data quality indicators.
 develop and deliver a data quality audit schedule, based upon data quality indicators, reviews
of specialty performance, concerns, issues and feedback from senior divisional and executive
leaders.
 develop an Implementation Plan for the Data Quality Strategy for the Trust to increase the
number of data sets measuring quantitative and qualitative performance metrics according to
national guidelines and in support of the six data quality dimensions and overseeing progress
of the plan once adopted
 provide the Head of Data Platforms with a monthly report relating to Data Quality KPIs and the
use of the online training tools to support the case for Executive level commitment for annual
mandatory data quality training
 review the Information Assurance Framework used by the Board to ensure correct assignment
of the data quality rating to each of the indicators based upon the agreed methodology.
Page 35 of 74
Aintree University Hospital NHS Foundation Trust
Performance against national quality indicators 2013/14 – 2014/15
Where available the data for the indicators has been obtained from the NHS Information Centre
Portal. Where this has not been available, other sources have been used. These sources have
been stated for each indicator. For a number of the national averages and ranges this data has
not been made available by the NHS Information Central Portal at the time of publication. The
Trust has stated ‘not available’ where this is the case.
Domain 1: Preventing People from dying prematurely - Summary Hospital-Level Mortality
Indicator (SHMI) value and banding Indicator
(1=Above Expected, 2= As Expected, 3= Below Expected)
Period
Trust Value
Trust
Banding
National
Average
Lowest NHS
Trust
Highest NHS Trust
Oct 13 – Sep 14
112
1
100
59.66
119.82
Jul 13 – Jun 14
115
1
100
54.07
119.82
Apr 13 – Mar 14
115
1
100
53.92
119.73
Jan 13 –Dec 13
113
1
100
62.36
117.58
Oct 12 – Sep 13
113
1
100
63
119
Jul 12 - Jun 13
113
1
100
63
116
Apr 12 - Mar 13
116
1
100
65
117
Jan 12 - Dec 12
117
1
100
70
119
Oct 11 - Sep 12
118
1
100
68
121
Data source: Health and Social Care Information Centre
Aintree University Hospital NHS Foundation Trust considers that this data is as described for the
following reasons:

The Trust has a higher than expected SHMI at 112.35 for the period October 2013 to
September 2014 as demonstrated in the table above. This is the lowest reported SHMI during
the period July 2010 to September 2014. Unlike HSMR, the SHMI indicator does include
deaths 30 days after discharge and therefore patients, including those on palliative care end of
life pathways, who are appropriately discharged from the Trust.
Aintree University Hospital NHS Foundation Trust intends to take the following actions to improve
this percentage, and so the quality of its services, by:

The Trust has an active avoidable mortality reduction group chaired by the Medical Director
with representation from all divisions and CCG’s. There are also 6 key work streams with
clinical leads each looking at improved care pathways, metrics and bundles to reduce
avoidable mortality.
Page 36 of 74
Aintree University Hospital NHS Foundation Trust
Domain 1: Preventing People from dying prematurely - Percentage of patient deaths with
palliative care coded at either diagnoses or specialty level (Context indicator)
Period
Trust
Performance
National
Average
Lowest NHS
Trust
Highest NHS Trust
Oct 13 – Sep 14
45.3%
25.32%
0.0%
49.4%
Jul 13 – Jun 14
42.08%
24.6%
7.4%
49.0%
Apr 13 – Mar 14
41.42%
23.6%
6.4%
48.5%
Jan 13 –Dec 13
41.13%
22%
1.3%
46.9%
Oct 12 – Sep 13
40.5%
21.2%
0.00%
44.8%
Jul 12 - Jun 13
41.7%
20.5%
0.00%
44.1%
Apr 12 - Mar 13
40.8%
20.3%
0.01%
43.9%
Jan 12 - Dec 12
41.0%
19.3%
0.01%
42.7%
Oct 11 - Sep 12
41.9%
19.0%
0.02%
43.3%
Data source: Health and Social Care Information Centre
Aintree University Hospital NHS Foundation Trust considers that this data is as described for the
following reasons:
 The Trust is a provider of specialist palliative care and the levels of palliative care coding are
entirely appropriate for the organisations profile.
Aintree University Hospital NHS Foundation Trust intends to take the following actions to improve
this percentage, and so the quality of its services, by:
 The Trust have a high quality palliative care service and are currently implementing the
AMBER care bundle to enhance the end of life care further.
Domain 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)
Period
Trust
Performance
National
Average
Lowest NHS
Trust
Highest NHS Trust
2014/15
61.10%
49.90%
0.00%
85.70%
2013/14
35.38%
37.65%
0.00%
71.43%
2012/13
46.48%
37.67%
11.11%
66.67%
2011/12
32.29%
39.26%
16.67%
70.00%
2010/11
37.08%
38.78%
23.33%
78.95%
Data source: Health and Social Care Information Centre (http://www.hscic.gov.uk/proms)
Aintree University Hospital NHS Foundation Trust considers that this data is as described for the
following reasons:
 The data source is the Health & Social Care Information Centre.
Aintree University Hospital NHS Foundation Trust intends to take the following actions to improve
this percentage, and so the quality of its services, by:
Page 37 of 74
Aintree University Hospital NHS Foundation Trust

The pre-operative department reinforcing the importance of patients completing the postoperative questionnaires and its impact on future patient experience
Domain 3: Helping people to recover from episodes of ill health or following injury - Patient
reported outcome scores for varicose vein surgery (Percentage of patients reporting an increase in
general health)
Period
Trust
Performance
National
Average
Lowest NHS
Trust
Highest NHS Trust
2014/15
66.70%
53.60%
0.00%
87.50%
2013/14
10.00%
41.74%
10.00%
70.00%
2012/13
53.85%
41.01%
14.29%
85.71%
2011/12
0.00%
42.10%
18.18%
78.57%
2010/11
0.00%
39.52%
0.00%
75.00%
Data source: Health and Social Care Information Centre
Aintree University Hospital NHS Foundation Trust considers that this data is as described for the
following reasons:
 Aintree is experiencing a decrease in the number of varicose veins operations carried out as
this is a procedure of lower clinical priority.
Domain 3: Helping people to recover from episodes of ill health or following injury - Patient
reported outcome scores for hip replacement surgery (Percentage of patients reporting an increase
in general health)
Period
Trust
Performance
National
Average
Lowest NHS
Trust
Highest NHS Trust
2014/15
N/A
90.00%
50.00%
100.00%
2013/14
73.33%
66.09%
33.33%
100.00%
2012/13
67.35%
65.62%
37.50%
90.00%
2011/12
64.23%
63.68%
25.00%
100.00%
2010/11
51.61%
61.09%
42.61%
91.67%
Data source: Health and Social Care Information Centre
Aintree University Hospital NHS Foundation Trust considers that this data is as described for the
following reasons:

The data source is the Health & Social Care Information Centre.
Aintree University Hospital NHS Foundation Trust intends to take the following actions to improve
this percentage, and so the quality of its services, by:

The importance of completion of the forms being reiterated to staff. Compliance will be
monitored on a weekly basis
Page 38 of 74
Aintree University Hospital NHS Foundation Trust
Domain 3: Helping people to recover from episodes of ill health or following injury – Patient
reported outcome scores for knee replacement surgery (Percentage of patients reporting an
increase in general health)
Period
Trust
Performance
National
Average
Lowest NHS
Trust
Highest NHS Trust
2014/15
100.00%
82.20%
33.30%
100.00%
2013/14
52.00%
56.62%
20.00%
100.00%
2012/13
57.38%
55.00%
33.33%
91.84%
2011/12
54.96%
53.89%
26.32%
88.89%
2010/11
49.68%
50.43%
32.32%
80.00%
Data source: Health and Social Care Information Centre
Aintree University Hospital NHS Foundation Trust considers that this data is as described for the
following reasons:

The data source is the Health & Social Care Information Centre.
Aintree University Hospital NHS Foundation Trust intends to take the following actions to improve
this percentage, and so the quality of its services, by:

The pre-operative department reinforcing the importance of patients completing the post
operative questionnaires and its impact on future patient experience
Domain 3: Helping people to recover from episodes of ill health or following injury Emergency readmissions to hospital within 28 days of discharge
Period
Trust
Performance
National
Average
Lowest NHS
Trust
Highest NHS Trust
Patients aged 0 to 15 years
2014/15
Not available
Not available
Not available
Not available
2013/14
Not available
Not available
Not available
Not available
2012/13
Not available
Not available
Not available
Not available
2011/12
0
10.01
5.10
13.58
2010/11
0
10.15
5.85
13.94
2009/10
0
10.18
6.38
14.44
2014/15*
14.46%
Not available
Not available
Not available
2013/14*
13.20%
Not available
Not available
Not available
2012/13*
13.42%
Not available
Not available
Not available
2011/12
11.76%
11.45%
8.96%
13.50%
2010/11
12.11%
11.42%
7.6%
12.94%
2009/10
12.34%
11.16%
7.3%
13.17%
Patients all ages
Data source: Health and Social Care Information Centre
* Data source is Trust generated, and includes all age groups
Page 39 of 74
Aintree University Hospital NHS Foundation Trust
Aintree University Hospital NHS Foundation Trust considers that this data is as described for the
following reasons:

The Trust readmissions rate is comparable to that expected.
Aintree University Hospital NHS Foundation Trust intends to take the following actions to improve
this percentage, and so the quality of its services, by:

The Trust continues to work with CCG teams, Accident and Emergency and local Mental
Health providers to reduce readmission and frequent AED attendee rates.
Domain 4: Ensuring that people have a positive experience of care - Responsiveness to
inpatients’ personal needs
Period
Trust
Performance
National
Average
Lowest NHS
Trust
Highest NHS Trust
2014/15
Not available
Not available
Not available
Not available
2013/14
74.50
76.90
67.10
86.70
2012/13
76.70
76.50
68.00
88.20
2011/12
77.50
75.60
67.40
87.80
2010/11
73.90
75.70
68.20
87.30
2009/10
76.50
75.60
68.60
86.00
2008/09
75.40
76.00
68.10
87.60
2007/08
76.00
75.30
66.80
86.50
2006/07
76.10
75.70
67.70
87.20
Data source: Health and Social Care Information Centre Indicators Portal, NHS Outcomes Framework Indicator 4.2
Aintree University Hospital NHS Foundation Trust considers that this data is as described for the
following reasons:

Data source is governed by a standard national definition and results reported from a statistical
data set on the Health and Social Care website.
Aintree University Hospital NHS Foundation Trust intends to take the following actions to improve
this percentage, and so the quality of its services, by:



Following an Expert Group Workshop during which all patient feedback was triangulated and
themed has identified the following projects for improvement in 2015/16:
o Exploration of opening visiting project
o
Patient and family shadowing and engagement
o
Family/dining rooms project
Purchased additional bi-annual patient feedback surveys from Picker to allow proactive
analysis and identification of any sub-optimal patient experience.
Acted upon recommendations made by Healthwatch Liverpool following an enter and view visit.
Page 40 of 74
Aintree University Hospital NHS Foundation Trust
Domain 4: Ensuring that people have a positive experience of care - Friends and Family Test
– In-patient Care
Period
Trust
Performance
National
Average
Lowest NHS
Trust
Highest NHS Trust
2014/15 – Q4
98.1
94.7
70.8
100
2014/15 – Q3
98.4
94.5
78.6
99.5
2014/15 – Q2
98.1
94.0
73.6
100
2014/15 – Q1
97.2
94.3
77.0
99.0
2013/14 – Q4
97.9
94.1
74.0
98.9
2013/14 – Q3
97.0
93.7
72.0
99.4
2013/14 – Q2
97.0
94.0
81.6
100
2013/14 – Q1
97.6
94.2
82.9
98.2
Data source: NHS England - Statistical Work Areas
Aintree University Hospital NHS Foundation Trust considers that this data is as described for the
following reasons:

Data source is governed by a standard national definition and results reported from a statistical
data set on the NHS England website.
Aintree University Hospital NHS Foundation Trust intends to take the following actions to improve
this score, and so the quality of its services, by:


Maintaining our proactive approach to monitoring patient feedback to ensure continuous
improvement in reported patient experience
Ensure that FFT reports are discussed at Divisional Assurance Meetings to identify outlier
wards
Domain 4: Ensuring that people have a positive experience of care - Friends and Family Test A&E
Period
Trust
Performance
National
Average
Lowest NHS
Trust
Highest NHS Trust
2014/15 – Q4
83.6
87.6
58.4
97.9
2014/15 – Q3
85.2
86.8
59.6
99.4
2014/15 – Q2
80.2
86.7
66.3
99.0
2014/15 – Q1
78.8
86.2
62.2
98.5
2013/14 – Q4
83.6
87.6
58.4
97.9
2013/14 – Q3
85.2
86.8
59.6
99.4
2013/14 – Q2
80.2
86.7
66.3
99.0
2013/14 – Q1
78.8
86.2
62.2
98.5
Data source: NHS England - Statistical Work Areas
Page 41 of 74
Aintree University Hospital NHS Foundation Trust
Aintree University Hospital NHS Foundation Trust considers that this data is as described for the
following reasons:
Patients have highlighted that the Trust needs to make improvements in the following areas to
improve the patient experience:

Privacy and Dignity

Catering

Communication

Waiting Times

Staff attitude
Aintree University Hospital NHS Foundation Trust has taken the following actions to improve this
score, and so the quality of its services, by:

Extended waiting room coffee shop hours and installed water fountains

Regular refreshment rounds throughout AED by the volunteers

Catering team have issued a bespoke menu: sandwiches, fruit, muffins, cereals, toast and a
hot meal in the evenings

Early intervention by senior clinician

Introduction of Advanced Nurse Practitioners

Direct pathways to specialties

Enhanced mental health resources by expanding the in-reach team

Primary care teams and community health nurses based in AED providing cover 7 days a week

Introduction of electronic display system in waiting room giving hourly updates on waiting times

Revised AED layout to create an ambulatory care area and Emergency Assessment Unit

Phase 1 of the new AED build is due for completion in May 2015 (Phase 2, May 2016)

Improved working environment for staff

Increase in both medical and nursing staffing numbers and review of skill mix

Regular department meetings with feedback on comments, concerns, complaints and
compliments

More face to face meetings to address concerns and complaints about care

AED patient information leaflet has been updated

Patient experience link nurse identified

GPs now receive electronic discharge letters for patients

The Trust also intends to take the following actions:

Working with our design team to provide a better environment for patients with dementia,
mental health and learning difficulties

Improving our services out of normal working hours (7 day working)

Continue to identify different pathways for patients to improve their experience and reduce
waits

Focus in on our frequent attenders, identifying case management of each of them

Better support following discharge to prevent patients needing to return to the Accident &
Emergency Department through improved community and social work liaison
Page 42 of 74
Aintree University Hospital NHS Foundation Trust
Domain 4: Ensuring that people have a positive experience of care - Percentage of staff who
would recommend the provider to friends or family needing care
Period
Trust
Performance
National
Average
Lowest NHS
Trust
Highest NHS Trust
2014
Not available
Not available
Not available
Not available
2013
64.73
64.84
39.57
88.51
Data source: Health and Social Care Information Centre
Aintree University Hospital NHS Foundation Trust considers that this data is as described for the
following reasons:

Data source is governed by a standard national definition and results reported from a statistical
data set on the Health and Social Care website.
Aintree University Hospital NHS Foundation Trust has taken the following actions to improve this
percentage, and so the quality of its services, by:





Communication and engagement events with managers to ensure they could understand
translate and own the survey outputs within their areas.
Listening into Action events ran throughout the year as a way to engage staff in ownership of
service improvements.
Appraisal training and improved performance reporting helped staff understand the importance
of having appraisals as well ensuring managers provided that support.
‘Staff Survey Heroes’ used to drive response rates and make connections to where
improvements have made a difference.
Piloted a series of staff retreats as an alternative approach to supporting attendance and
reducing the level of staff off work with stress
Further planned actions are:
 To ensure that all people who respond are accounted for in the national reports in 2015.
 To identify, understand reasons for lower levels of responses and to put in relevant support for
those areas to achieve higher response rates in 2015.
 To progress the overall action plan which has been developed to address areas for
improvement and share good practice
Domain 5: Treating and caring for people in a safe environment and protecting them from
avoidable harm - Percentage of admitted patients risk-assessed for Venous Thromboembolism
Period
Trust
Performance
National
Average
Lowest NHS
Trust
Highest NHS Trust
2014/15 (Q4)
Not available
Not available
Not available
Not available
2014/15 (Q3)
94.36%
95.96%
81.19%
100%
2014/15 (Q2)
95.21%
96.19%
86.37%
100%
2014/15 (Q1)
95.42%
96.16%
87.25%
100%
2013/14 (Q4)
95.25%
96.00%
78.86%
100%
2013/14 (Q3)
94.75%
95.84%
77.70%
100%
2013/14 (Q2)
92.43%
95.74%
81.70%
100%
2013/14 (Q1)
91.20%
95.45%
78.78%
100%
Data source: Health and Social Care Information Centre
Page 43 of 74
Aintree University Hospital NHS Foundation Trust
Aintree University Hospital NHS Foundation Trust considers that this data is as described for the
following reasons:

Data source is governed by a standard national definition and results reported from a statistical
data set on the Health and Social Care website.
Aintree University Hospital NHS Foundation Trust intends to take the following actions to improve
this percentage, and so the quality of its services, by:


Continuing with weekly performance emails on VTE risk assessment to wards and clinical
teams.
Establishing a new project regarding clinical engagement of staff in our acute assessment
areas
Domain 5: Treating and caring for people in a safe environment and protecting them from
avoidable harm - Rate of C. difficile Per 100,000 Occupied Bed days
Period
Trust
Performance
National
Average
Lowest NHS
Trust
Highest NHS Trust
2014/15
Not available
Not available
Not available
Not available
2013/14
32.2
14.7
0.0
37.1
2012/13
29.3
17.4
0.0
31.2
2011/12
25.0
22.2
0.0
58.2
2010/11
31.3
29.7
0.0
71.2
2009/10
37.8
35.4
0.0
92.0
2008/09
121.4
53.2
0.0
128.9
2007/08
73.1
89.7
0.0
224.0
Data source: Health and Social Care Information Centre
Aintree University Hospital NHS Foundation Trust considers that this data is as described for the
following reasons:

Data source is governed by a standard national definition and results reported from a statistical
data set on the Health and Social Care website.
Aintree University Hospital NHS Foundation Trust intends to take the following actions to improve
this percentage, and so the quality of its services, by:





Maintaining the focus on prudent antibiotic prescribing and antibiotic stewardship. This includes
weekly antimicrobial ward rounds
Ensuring the environment is clean and undertaking a deep clean programme in 2014/15
Additional monitoring of the environment using Encompass UV tagging to enable focus areas
to be identified and changes in practice
Continued focus on staff practice and most importantly hand hygiene
The revision of the CDI guidelines to include the use of fidaxomicin for patients with moderate
and severe disease and the Polymerase Chain Reaction (PCR) test for GDH positive patients.
The guidelines are to be finalised following recommendations from the external review.
Page 44 of 74
Aintree University Hospital NHS Foundation Trust
Domain 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
Trust
Performance
National
Average
Lowest NHS
Trust
Highest NHS Trust
Apr 14 – Sep 14**
0.2
0.49
0.00
82.86
Oct 13 – Mar 14*
0.17
0.65
0.00
2.27
Oct 12 - Mar 13*
0.17
0.63
0.00
4.75
Period
Data source: Health and Social Care Information Centre
*Data based on Medium Acute
** Data based on all acute providers
Aintree University Hospital NHS Foundation Trust considers that this data is as described for the
following reasons:

Data source is governed by a standard national definition and results reported from a statistical
data set on the Health and Social Care website
Aintree University Hospital NHS Foundation Trust intends to take the following actions to improve
this percentage, and so the quality of its services, by:

Completing actions from SUI investigations and ensure lessons learnt are disseminated Trust
wide.
Reporting against key national priorities
Aintree is required to report its performance with a list of published key national priorities, against
which the Trust is judged. Aintree reports its performance to the Board and the Trust’s regulators
throughout the year. Actions to address any areas of underperformance are put in place where
necessary. These performance measures and outcomes help Aintree to monitor how it delivers its
services.
Page 45 of 74
Aintree University Hospital NHS Foundation Trust
Performance against key national priorities from the Monitor Compliance Framework 2014/15
Targets and Indicators 2014/2015 Thresholds and Performance
Aintree University Hospital NHS Foundation Trust – Green ratings indicate that the Trust met the target and red that the target was under achieved.
Performance
Threshold
Safety
Clostridium Difficile
(Hospital Acquired
Infection)
As per trajectory agreed
with PCT (81 cases in the
year) - Cumulative
13
9
8
11
41 + 23
74 + 2
Safety
MRSA (Hospital
Acquired Infection)
Cancer - 31 day wait
for second treatment Surgery
Cancer - 31 day wait
for second treatment Drug treatment
Cancer - 62 day wait
for first treatment
Cancer - 62 day wait
for first treatment from
consultant screening
service
As per trajectory (0 cases
in year) – Cumulative
94% of patients treated
within 31 days
0
1
1
0
2
3
100%
100%
96%
98.70%
98.68%
98.8%
98% of patients treated
within 31 days
100%
100%
98%
100%
99.50%
100%
85% of patients treated
within 62 days
90% of patients treated
within 62 days (target
previously 81.8%)
83.4%
85.5%
88.4%
90.5%
86.95%
88.4%
82.6%
89.5%
85.6%
63.6%
80.08%
86.0%
Quality
Quality
Quality
RAG
Qtr 2
RAG
Qtr 3
RAG Qtr 4
RAG
RAG
Annual
2013/14
Indicator
Quality
Qtr 1
Annual
2014/15
Area
Page 46 of 74
Aintree University Hospital NHS Foundation Trust
Threshold
Qtr 1
Patient
Experience
18 week referral to
treatment waiting
times - admitted
18 week referral to
Treatment waiting
times - non admitted
18 week referral to
Treatment waiting
times – incomplete
90% of patients waiting
less than 18 weeks.
94.3%
93.5%
93.4%
93.4%
93.6%
93.1%
95% of patients waiting
less than 18 weeks.
98.4%
97.6%
97.7%
98.1%
97.9%
97.6%
92% of patients on an
incomplete pathway
97.7%
96.6%
97.3%
96.8%
*97.51%
97.3%
96% of patients treated
within 31 days
99.1%
99.4%
99.7%
99.2%
99.33%
99.0%
Patient
Experience
Quality
pathways
Cancer -31 day wait
from diagnosis to first
Qtr 2
RAG
Qtr 3
RAG
Qtr 4
RAG
Annual
RAG 2013/14
Indicator
Patient
Experience
RAG
Annual
2014/15
Area
treatment
Quality
Cancer -2 week wait
from referral to first
seen - all cancers
93% of patients seen
within 2 weeks
97.2%
97.9%
97.3%
96.0%
97.1%
97.4%
Quality
Cancer -2 week wait
from referral to first
seen - breast
symptomatic patients
Total time in Accident
and Emergency **
93% of patients seen
within 2 weeks
95.7%
96.1%
96.3%
94.1%
95.5%
94.1%
95% of patients waiting
less than 4 hours.
92.1%
92.2%
88.0%
89.7%
90.6%
95.5%
Patient
Experience
*The annual figure is different from the average of the monthly figures following adjustments made during the quality assurance work undertaken by our
auditors
**Includes Type 3 activity from November onwards 2013
Page 47 of 74
Aintree University Hospital NHS Foundation Trust
Part 3 -
Other information
An overview of the quality of care offered by Aintree – performance in 2014/15
Quality
Year
Reason for
Aintree performance
indicator
identified
selection
2012/13
2013/14
2014/15
Patient Safety
HSMR basket (used in line with the Dr
Improving our 2010
The Trust’s mission
Foster Intelligence methodology)
mortality
is to get it right for
ratings
by
every patient, every
99.65
91.77
87.05
reducing
time
by
SHMI
avoidable
strengthening patient
118
113.1
112
mortality
safety to reduce
rates of avoidable
Crude Death Rates (% of discharges
mortality.
registered as deceased)
3.53%
3.35%
3.29%
Mortality is measured by the use of national
reports such as Hospital Standardised
Mortality Ratio (HSMR) or Summary
Hospital-Level Mortality Indicator (SHMI) and
actual death numbers. These measures try
to predict whether the death rate in a
hospital is higher or lower than expected
based on statistical analysis of certain
medical conditions and outcomes that can
show whether a hospital needs to make
improvements in services.
(Data source: Dr Foster Intelligence which is governed
by a standard national definition)
2010
Reducing
weight
loss
and
dehydration by
aiming
for
95%
completion of
the
Malnutrition
Universal
Screening
Tool (MUST)
on admission
to hospital
2010
Reducing
avoidable
patient harms
from
VTE,
malnutrition,
falls
and
pressure
ulcers
Nutrition has been
identified as a key
area for improvement
nationally
from
findings
in
the
Francis
Report
(2013).
The
Malnutrition
Universal Screening
Tool (MUST) is now
recommended best
practice as a way to
screen patients’ to
identify and treat
adults at risk of
malnutrition whilst in
hospital.
The Trust’s mission
is to get it right for
every patient, every
time
by
strengthening patient
safety to reduce
rates of avoidable
harm.
Qtr 4 = 76% Qtr 4 = 70% Qtr 4 = 90%
completion
completion
completion
 Supported by established Project
Improvement Group
 Additional communications sent out Trust
wide to raise awareness
 MUST champions identified on wards to
drive performance
 Reviewing emerging trends for noncompletion to target performance
improvements
 Moving towards weekly performance
reporting
(Data source: aBI which is not governed by a standard
national definition)
818 patient 870 patient
harms (VTE harms (Qtr 4
not recorded) VTE harms
not available)
814 patient
harms (Qtr 4
VTE harms
not
available)
Supported by the launch of Aintree’s new 3
year Quality Strategy where its Priority 1
focus is on reducing harm and avoidable
mortality.
(Data source: Datix, the Trust’s Incident Reporting
System which is not governed by a standard national
definition)
Page 48 of 74
Aintree University Hospital NHS Foundation Trust
Quality
Year
indicator
identified
Clinical effectiveness
2010
Maintaining
the
national
standard
of
95%
for
completion of
Venous
Thromboembo
lism (VTE) risk
assessments
for
eligible
patients and
analyse root
cause of any
subsequent
hospital
acquired
thrombosis
(HAT)
Reason for
selection
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).
2012/13
Aintree performance
2013/14
2014/15
Qtr 4 91.4% Qtr 4 95% Qtr 4 94.5%
completion
completion
completion
Supported by weekly performance emails on
VTE risk assessment to wards and clinical
teams. VTE risk assessment performance is
also included in Aintree’s monthly Team
Quality Management Awards.
The Trust has secured a new VTE clinical
lead who has trialled a new system and
process for undertaking HAT RCAs. A full
HAT RCA report has been produced each
quarter which is presented to the Exec Led
Clinical Effectiveness Group then shared
with our CCGs.
(Data source: Unify2 which is governed by a standard
national definition)
Improving the 2013
quality
of
Dementia care
by
raising
awareness
and achieving
90%
completion of
Risk
Assessments
to
improve
diagnoses of
patients over
75 admitted as
an emergency
Dementia
is
a
significant challenge
for the NHS - 25% of
beds are occupied
by
people
with
dementia,
their
length of stay is
longer than people
without
dementia
and
they
often
receive suboptimal
care. Half of those
admitted to hospital
with dementia have
never
been
diagnosed prior to
admission and other
causes of cognitive
impairment such as
delirium
or
depression are often
missed.
Qtr 4 35.1% Qtr 4 72.6% Qtr 4 90.1%
completion
completion
completion
Due to successful team work and huge
efforts from our consultants and Junior
Doctors the dementia assessment standard
was achieved for the first time in January
and has been sustained throughout
February and March enabling the Trust to
achieve the 90% standard in Qtr 4.
 Planning & Commissioning Team review
performance on a daily basis and liaise
directly with the Dementia Super User to
target patients not yet screened.
 Supported by weekly performance
emails on Dementia risk assessment to
wards and clinical teams.
 The Consultant Clinical Lead now audits
step 2 breaches and step 3s on a weekly
basis.
 Dementia risk assessment performance
is also included in Aintree’s monthly
Team Quality Management Awards.
(Data source: Unify2 which is governed by a standard
national definition)
Page 49 of 74
Aintree University Hospital NHS Foundation Trust
Quality
Year
indicator
identified
2013
Increasing
compliance
against
the
WHO
Safe
Surgery
Checklist
Reason for
selection
WHO launched a
second Global
Patient Safety
Challenge, ‘Safe
Surgery Saves
Lives’, to reduce the
number of surgical
deaths across the
world. The checklist
is part of this
initiative and is a tool
for the clinical teams
to improve the safety
of surgery.
Aintree performance
2013/14
2014/15
Sign
in Sign
in
compliance compliance
99%
95%
Time
out Time
out
compliance compliance
96%
98%
Sign
out Sign
out
compliance compliance
95%
97%
Results show the Trust’s compliance
remains consistent with the previous year.
 Weekly audits are undertaken in all 4
theatres.
 Weekly team brief audit tool is utilised
 Compliance is published on the how are
we doing boards in each theatre area
 Monthly compliance audits are reported
to the Trust’s Quality & Safety
Committee.
2012/13
N/A
(Data source: Case note audit March 2015 which is not
governed by a standard national definition)
Patient experience
2010
Increasing
overall patient
experience rate
in National Inpatients Survey
Improving
communication
between
patients and
staff
Q1 Patients had
confidence and
trust in the
nurses treating
them
Q2 Patients
understood the
answers nurses
provided
Q3 Patients
understood the
answers
doctors
provided
Q4 Patients felt
involved in
discussions
about their care
2011
Understanding
experiences
of
service users and
their carers is
central to being
able to provide
high
quality
services
and
identify areas for
improvement.
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.
Rated experience as greater than 7/10
(previously rated “good” or “excellent”)
82%
82%
88.1%
National
average
82%
National
average
83%
National
average
84%
(Data source: Picker National In-patient Survey
Results in February 2015 which is governed by a
standard national definition)
Results of patients answering, yes always
and yes sometimes
Q1 89.2%
Q1 86.5%
Q1 96.1%
Q2 96.7%
Q2 96%
Q2 94.9%
Q3 96.4%
Q3 96.4%
Q3 96.5%
Q4 90.6%
Q4 89.3%
Q4 91.6%
Results show that the Trust has improved in
3 out of the 4 key communications questions
in 2014/15.
(Data source: Picker National In-patient Survey
Results in February 2015 which is governed by a
standard national definition)
Page 50 of 74
Aintree University Hospital NHS Foundation Trust
Quality
Year
indicator
identified
Improving the 2011
complaints
management
and
learning
from concerns
and complaints
Reason for
selection
The handling of
complaints
and
concerns should
be of a high
quality and robust
so
that
any
improvements are
highlighted
and
cascaded
throughout
the
trust in order to
continually
improve services
and share best
practice.
Aintree performance
2013/14
2014/15
Complaints
Patient Ethnicity
63 not stated 67 not stated 109 not
stated
288 White Br 247 White Br 179 White Br
1 Chinese
1 Mixed
White &
1 Indian
Asian
3 other White 3 other White 1 other White
2 other
1 White Irish 1 other
Ethnic
Ethnic
Total 358
Total 319
Total 290
2012/13
Concerns
Patient Ethnicity
446 not
303 not
stated
stated
553 White Br 690 White Br
2 Chinese
2 Indian
11 other
White
1 White Irish
Total 1013
2 other White
761 not
stated
337 White Br
1 Pakistani
1 Chinese
4 other White
Total 997
3 White Irish
Total 1107
(Data source: Datix, the Trust’s Incident Reporting
System which is not governed by a standard national
definition)
Total 481
Compliments
Total 586
Total 10598
To support the handling of complaints the
Trust’s
“Comments,
Concerns
and
Complaints” leaflets and posters are
available
on
wards/departments
and
reception areas for members of the public
and members of staff. There is also the
Patient Advice and Complaint Desk situated
on the ground floor of the main hospital
available to help.
(Data source: Datix, the Trust’s Incident Reporting
System which is not governed by a standard national
definition)
2012
Increasing
patient
experience
feedback
through
the
Friends
and
Family Test for
In-patients and
A&E
Overall response rate for In-patients &
Encouraging
A&E combined
service users and
their carers to March 2013
March 2014
March 2015
feedback on their
16.05%
32%
35.5%
experiences
is
central to being
able to provide
high
quality
services
and (Data source: Unify2 which is governed by a standard
identify areas for national definition)
improvement.
Page 51 of 74
Aintree University Hospital NHS Foundation Trust
Additional information on improving the quality of Aintree’s services in 2014/15
Below is a selection of the work over the past year that some of the Trust’s services, as detailed in
Part 2, Information on the review of services, have undertaken to improve the quality of the
services they provide.
Improving Patient Safety
Quality showcase
In August 2014, staff attended the first Quality Showcase, an event that celebrated the great work
being done throughout Aintree to provide harm free care to all our patients. The event marked six
months since the publication of Aintree’s Quality Strategy that describes our vision of providing
world class services for all our patients. Staff and stakeholders were invited to join both clinical and
non-clinical teams from across Aintree to find out more about the quality improvement work
underway that will help achieve our vision. Teams were on hand to provide information on areas
such as Infection Prevention and Control (IPC), Falls Prevention, Avoidable Mortality Reduction,
Pressure Ulcer Reduction and Management, Patient Experience, VTE, Medicine Safety and
Dementia Care.
Other teams manning information stalls included the Service Improvement team, Staff
Engagement and Organisational Development team, AQUA and the team from Main A theatres
who provided information on Aintree’s use of the WHO checklist.
The Showcase also highlighted the linkage between the Quality Strategy with NHS England’s Sign
Up To Safety campaign to improve patient care. The campaign objectives are closely aligned with
our Quality Strategy with a shared goal of ensuring patients receive the safest possible care.
Jan Dainty,
Lead Nurse
Quality and
Safety, with
Patricia
Elmore,
Therapies
Clinical Lead
on the Falls
Prevention
stand at
Aintree’s
Quality
Showcase
Page 52 of 74
Aintree University Hospital NHS Foundation Trust
Simulated training for junior doctors
As part of ongoing work to improve safety at Aintree, the hospital became the first in the country to
put its entire intake of 50 Foundation Year (F1) junior doctors through a simulated training
exercise. In order to make it as realistic as possible, the exercise was run on a one-to-one basis,
with the junior doctors being bleeped just a couple of days after they had started at Aintree. The
junior doctors were called to treat SimMan, an electronically controlled mannequin whose vital
signs varied to reflect a range of illnesses and clinical emergencies. SimMan is voiced remotely by
trainers to react to the care being provided by the junior doctors. The scenario involved the patient
deteriorating rapidly, one of the most dangerous situations for patients in real life. The 10-minute
training scenario tested each junior doctors’ clinical skills, situational awareness and decision
making and was followed by a video debrief. The exercised was developed by teams at Aintree in
partnership with the Health Education North West Centre for Patient Safety and Simulation.
Bethan
John,
Foundation
year 2
doctor, who
took part in
the SimMan
simulated
training
exercise
Nursing shared Leadership – challenges skills for life
Aintree’s Senior Nursing Team hosted a 1 day Nurse Conference in April 2015. The event
included a keynote address by motivational speaker and author Paul McGee (SUMO Guy).
The context for the day was that now, more than ever, Team Aintree needed to make wise choices
about our organisation and our future. Making the right choices in life is not an ability we are
magically born with, it has to be learnt like any other skill. That’s why it’s vitally important that
Aintree ask for help from the professionals – those with the experience, the tools and the
training. This is where SUMO comes in. Staff was introduced to dealing with change, building
better relationships, developing a resilient attitude to life, maintaining morale and motivation,
dealing with stress, inspiring confidence, releasing potential, building character, creating
possibility….. these and many other positive results are at the heart of SUMO – Mastering
Challenges… Skills for Life!
Page 53 of 74
Aintree University Hospital NHS Foundation Trust
Improving Clinical Effectiveness
The success of Aintree’s Emergency General Surgery Unit, which has improved outcomes for
patients, reduced time in hospital and improved survival rates, was marked at the European
Congress of Trauma and Emergency Surgery. The unit was the first of its kind developed in the
North West and one of just a few in the UK. The unit can receive patients requiring emergency
surgery from both the Emergency Department and also from GPs. Unit staff presented to the
congress, highlighting reductions in mortality and length of patient stay. The unit treats more than
7,000 patients each year. It was established in 2008 by Mr Richard Ward, now Medical Director,
because he believed it would lead to improved patient outcomes. The unit has a key role to play in
Aintree’s work in the Cheshire and Merseyside Major Trauma Centre Collaborative. Aintree’s
presentation in Frankfurt is thought to be the first time a British research paper has been published
to prove the effectiveness of a dedicated emergency general surgery unit.
Mortality Review Workstreams Information Day
The second Avoidable Mortality Reduction (AMR) Information Day in October 2014 was a success
with over 100 members of staff attending to get up to date on the work underway to reduce
avoidable mortality in Aintree.
The event was organised by Sandra Lamb, CCOT Coordinator/Deputy MET Coordinator, and Sue
Gallagher, Specialist Nurse Critical Care Outreach/MET, who brought together representatives
from the multi-disciplinary clinical teams leading the ground breaking work on the AMR
workstreams - Sepsis, Acute Kidney Injury, Pneumonia, The Deteriorating Patient and End of Life
Care. Staff were asked to make a five minute visit to each stand to find out more about how MDT
clinically-led groups are continuing the drive to improve the quality of care and get it right for every
patient, every time. Attendees took part in mini-scenarios based on real-life situations and had the
chance win prizes for testing their knowledge. Further Avoidable Mortality Reduction Information
events will be held in 2015.
Members of
the
Avoidable
Mortality
Reduction
Group
Page 54 of 74
Aintree University Hospital NHS Foundation Trust
Merseyside’s new leadership college for NHS and social care staff
Sir Robert Francis, who is leading the Government’s whistleblowing review, was guest of honour at
the official launch of the NHS Staff College at Aintree. This partnership with University College
London Hospitals NHS FT creates a unique learning environment for senior staff in the NHS,
supporting their leadership development. Dozens of doctors, nurses, allied health professionals
and managers have now benefitted from its combination of the best of learning from the NHS,
military and private sector.
Mr Richard
Ward, Medical
Director and
Nicola Firth,
Director of
Nursing and
Quality with Sir
Robert Francis
QC (centre) at
the launch of
the Staff
College at
Aintree
Aintree Accreditation and Assessment (AAA)
This process provides the Trust with assurance that the quality and safety of care is being
monitored and that action is being taken where any fundamental standards of care are not met.
The framework is designed around 14 standards which are matched to Care Quality Commission
(CQC) Domains. Each of the 14 standards contains between 10 and 20 individual elements that
are assessed and checked. Each standard is then rated as ‘Red’, ‘Amber’ or ‘Green’, depending
on the number of positive and negative answers. The ward then receives an overall rating of Red,
Amber or Green that is based on the results of the 14 standards. (See table below).
Red
Six or more red standards
Amber
Green
One - five red standards and /or less than seven green standards
0 red standards and minimum seven green standards (AAA Standard 14
must be green)
Achieved after three consecutive greens
‘ACE’ ward
Ward Managers receive immediate feedback on the day of the assessment and any urgent patient
safety concerns are escalated and resolved on the same day. The Ward Manager (WM) is
responsible for formulating a robust action plan that is agreed with the Matron and the relevant
Divisional Assistant Director of Nursing Services (ADNS).
Page 55 of 74
Aintree University Hospital NHS Foundation Trust
AAA Overall Results 2014-2015 (During quarters 1-4 (2014-15), 49 assessments in total have
been completed).
Total number of wards with a Green
rating
Total number of wards with an Amber
rating
Total Number of wards with a Red rating
Quarter 1
1
Quarter 2
5
Quarter 3
9
Quarter 4
6
9
10
7
7
1
0
1
2
When a ward’s overall rating is ‘Amber’ or ‘Red’ on two consecutive occasions and there is little or
no evidence of improvement, the Matron, the Divisional Assistant Director of Nursing Services and
the Director of Nursing and Quality will consider the actions that are required.
Equality & Diversity
During 2014/15, the Trust met all of the contracted Equality & Diversity milestones within the
Quality Schedule and has complied with its requirement to complete an EDS2 self-assessment
which has been reported to local Healthwatch Organisations. At the Liverpool presentation the
Trust acknowledged that it had further work to undertake on equality Impact assessments and the
Trust has already progressed this by commissioning an Equality & Diversity Consultant to advise
on this.
At the presentation to Sefton and Knowsley Healthwatch the Trust was asked for further
information on Transition Services which has been supplied.
The work on EDS2 self-assessment and improvement plan was due to report to the Trust’s Patient
Experience Executive Led Group in May but has been deferred to June and will report there then.
There is an objective on Equality & Diversity in our People and Organisational Development Plan
which will report to the Trust’s Workforce Executive Led Group and Quality and Safety Committee.
Page 56 of 74
Aintree University Hospital NHS Foundation Trust
Improving Patient Experience
National Compassion in Care Award for our innovative work with Dementia patients
Congratulations are in order for members of Team Aintree who won the award for “an organisation
that for promotes independence, maximises wellbeing and improves health outcomes” at the
inaugural NHS England Compassion in Practice Awards. Jane Cummings, Chief Nursing Officer
for England, presented Aintree with a Compassion in Practice award for “promoting independence,
maximising wellbeing and improving health outcomes” for patients with dementia. The award
recognises the significant amount of work staff at Aintree have undertaken to ensure that the
growing number of patients they treat who have dementia have the best experience possible, in
particular the introduction of a finger food menu designed to overcome many of the challenges
which patients with dementia often face when eating in hospital.
The finger food boxes, which have been praised by the Alzheimer’s Society, were developed by
Jane Green, Lead Nurse for Dementia, Sandra Higgins, the head of catering, plus chefs, dieticians,
patients and their families. Nicola Firth, Director of Nursing and Quality, said: “We see large
numbers of elderly patients with dementia and it is vitally important that we are able to provide safe
and effective care. Jane Green, our lead nurse for dementia, has done a huge amount of work with
staff across the hospital, from the wards to the kitchen, to ensure patients with dementia are
receiving the best care possible. I’m delighted this work has been recognised and this award is well
deserved.”
Jane Green,
Lead Nurse for
Older People
and Dementia,
and Nicola
Firth, Director
of Nursing and
Quality, with
members of
the catering
team, who
developed the
award-winning
finder food
boxes for
patients with
dementia.
Jane Cummings, Chief Nursing Officer England (pictured left), said: “Patients
are the focus of all our work, and it is patients who benefit from the care and
compassion demonstrated by the winners and finalists. The awards help us
share good practice in delivering better care, celebrate where we are today,
and will inspire future achievements.” The inaugural NHS England
Compassion in Practice Awards recognised examples of best practice which
Page 57 of 74
Aintree University Hospital NHS Foundation Trust
can inspire others to make “compassionate, personal care universal in the NHS.”
Aintree commended as Exemplar Hospital for Open & Honest Care
Aintree has made significant progress since it started as one of the initial pilot sites for the Open &
Honest Care NHS England programme in 2011.
Following a visit from NHS England in June 2014,
Aintree was praised for linking patient stories with
evidence of improvements made. Andrea Gillespie,
Compassion in Practice Programme Manager at
NHS England said: “You are doing extremely
excellent work and show great enthusiasm for what
you do.” Aintree was asked to share our best
practices at both an NHS England North event in
Leeds and at a National Conference in London
resulting in Aintree becoming a ‘Buddy Organisation’
for hospitals joining the Open & Honest Care Programme.
Aintree volunteers recognised for ‘enhancing patient experience’
Aintree’s volunteers have been recognised for their work in improving patient experience by the
National Association of Voluntary Services Managers (NAVSM). The team were presented with
the ‘Excellence in Voluntary
Service Management’ award in
November and were praised for
the way the volunteers service
engages volunteers to enhance
patient care and for its End of
Life Volunteer Companionship
Service. Gail Bruen, Volunteer
Manager, said: “I am delighted
to see the wonderful work of
our
volunteers
being
recognised
nationally.
The
volunteers provide a number of
valuable services, including
providing companionship for
patients who might otherwise be alone at the end of their lives, and they are always willing to do
whatever is asked of them. This award is well deserved.” Aintree’s Volunteer End of Life
Companionship Service was also recognised at the NHS England Compassion in Practice Awards
with the service being nominated in the ‘Improving experiences of care by embedding Compassion
in Practice into ways of working’ category.
Page 58 of 74
Aintree University Hospital NHS Foundation Trust
National award for Liverpool deaf health “rising star”
A hearing expert from Liverpool has been named as a rising star in her field.
Jennifer Fahy works as an Audiologist at Aintree University Hospital, where she has worked to
improve the hospital experience for patients and visitors who are deaf or hard of hearing.
She was presented with the “Rising Star” award in physiological services at the Healthcare
Scientist awards, which are run by England’s Chief Scientific Office, Professor Sue Hill OBE.
The award recognised Jennifer’s work to raise the profile and improve deaf awareness among her
colleagues at Aintree.
Jennifer said: “We have a lot of patients and visitors who have hearing difficulties and they are not
confined just to our Audiology service, so it’s really important that staff across the hospital
understand the needs of people
with hearing difficulties and are
able to provide as good an
experience as possible while they
are in our care.”
The award comes as Jennifer
prepares for Deaf Awareness
Week, which starts Monday 4
May, when she will be hosting
information stands in the hospital
so people can find out more about
deafness and hearing difficulties.
Jennifer’s work includes developing a deaf awareness training course for staff, securing funding for
personal communication devices in all wards and assessment areas for patients who may visit as
an in-patient without their hearing aid, and providing staff with advice on communicating effectively
with deaf or hard of hearing patients.
Page 59 of 74
Aintree University Hospital NHS Foundation Trust
Improvements made following learning from patient stories
Since April 2014 a patient story has been presented at Aintree’s Trust Board meeting
each month which is also included in the monthly NHS England Open & Honest Care
report along with the actions identified for improvement to address the feedback. Below
are some examples of improvements made following patient stores:
Mealtime improvements
1. The catering and dietetic teams have undertaken work to expand the selection of the
food available on the low residue menu which now includes additional choices for
those following a vegetarian diet. During the introduction of the menu, patients were
asked to provide feedback via a questionnaire attached to the menu.
2. The Catering Department has purchased new plate warmers and smaller meal trolleys
to ensure that the temperature of the meals is maintained once meals are ‘plated’.
Previously meals were ordered a day in advance and this resulted in wastage when
patients were discharged with some patients receiving a meal ordered by a previous
patient. The meal ordering system has now been improved so that meals are ordered
nearer to the time of delivery to ensure patients receive the food they want.
Communication
3. Issues relating to poor communication were a common theme across stories and at
the request of the Board of Directors, a full review of communication issues was
undertaken during 2014-15. A resulting paper was presented at Trust Board in
November 2014 which outlined the top five themes and trends emerging from a
number of sources of patient feedback. An Action Plan has subsequently been
developed to address specific issues relating to poor communication, with progress
against actions reported to the Patient Experience Executive Led Group and the
Workforce Executive Led Group
4. Patient feedback
Katie, a young patient with breast cancer has reported the positive impact that telling
her story has had. Improvements in the admission process gave Katie greater
confidence to come into hospital when she was feeling unwell, while prior to this she
would delay coming in for as long as possible. It also gave her the confidence to
speak to a cohort of healthcare students about her experience. The Clinical Nurse
Specialist (CNS) for Breast Cancer reports that Katie felt it gave her ‘permission’ to
speak out and challenge healthcare professionals.
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Aintree University Hospital NHS Foundation Trust
Environmental improvements
5. The environment in the Accident and Emergency Department (AED) was described as
being very hot and “like a greenhouse”, due to the glass panel on the roof. The AED is
currently undergoing improvement work as part of the new Urgent Care and Trauma
Centre (UCAT) which opens in May 2015. Three relative’s rooms are already
available in the AED area, and when building work is completed assessment rooms
will be larger. In addition there will be an improved waiting area with air conditioning
and comfortable chairs; and a coffee shop and vending machines will be available.
The Aintree Volunteers also offer refreshments and support to patients and their
relatives and carers between the hours of 7.30am and 11.30pm seven days per week.
6. The Corporate Nursing Team and Estates Department have been working in
collaboration to improve the environmental concerns raised in patient stories, and to
ensure that future refurbishment plans incorporate the views of patients. This work
has resulted in general improvements of the ward environment, for example; additional
handrails in toilets, new window blinds and curtains in the Coronary Care Unit (CCU)
to improve privacy and dignity, and replacement windows in the tower block to
eradicate draughts.
7. Following the story of a Coronary Care Unit (CCU) patient who described the effect of
not having access to a television, a television set has now been purchased for each
cubicle on the unit.
8. In response to several stories describing the heat in the hospital during summer
months, wards and departments have been provided with extra fans and cooling
systems.
An Aintree Patient and Staff Stories Intranet Portal has been established to enable
staff to access stories to use for training and educational purposes. The Portal which
is currently being populated will develop into a Story Library. There are plans for the
Corporate Nursing Team to work in partnership with the Communications Team to
ensure that the contents of the Patient and Staff Story Portal are accessible to all staff
in the organisation.
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Aintree University Hospital NHS Foundation Trust
Annex A: Statements from Stakeholders on Aintree’s Quality Account 2014/15
14/15 Aintree Collaborative Response from CCGs
South Sefton CCG, as co-ordinating commissioner, welcomes the opportunity to comment on the
2014/15 Quality Accounts for Aintree University NHS Foundation Trust. We have been working
closely with the Trust during the year, gaining assurance of the delivery of safe and effective
services. Their quality and performance is monitored through regular meetings where data is
shared, reviewed and discussed. We are pleased to see that the information presented within the
Quality Accounts is consistent with information supplied to the commissioners throughout the year
and considered within monthly Clinical Quality and Performance Group Meetings.
South Sefton CCG actively collaborates with Merseyside CCG colleagues to commission services
for their local population; ensure that the providers meet the required quality standards and
supports the priorities selected by the Trust last year. The work the Trust has undertaken,
described within this Quality Account has helped to improve patient safety and the quality of patient
experience and endorses the Trust’s commitment to the delivery world class care for all patients
by getting it right for every patient, every time.
As a CCG we note the positive improvements made regarding quality and governance culminating
in the Trust receiving a rating of good across all services from the Care Quality Commission in May
2014. The CCG welcomes the progress made on the 2014/15 quality priorities and acknowledges
the commitment to improving patient safety and reducing harm, in particular the reduction in
hospital acquired pressure ulcers and the Trusts on-going work to improve the quality of care for
people with Dementia, and their families and carers.
The NHS is striving to ensure that the patient experience of care is central to good quality of care
and is used to ensure that the care delivered is right for patients. We believe that approach taken
by Aintree reflects this and that the Quality Account accurately describes the journey that the Trust
has been on. The CCG’s continue to be supportive of the process that Aintree has undertaken to
proactively seek feedback from patients and carers and demonstrated how this has impacted upon
changes in service delivery.
South Sefton CCG is pleased to note the engagement with
stakeholders that led up to the publication of this Quality Account and commend the Trust for
taking its responsibilities for engagement seriously.
It is felt that the priorities for improvement identified for the coming year are both challenging and
reflective of the current issues across the health economy. We therefore commend the Trust in
taking account of new opportunities to further improve the delivery of excellent, compassionate and
safe care for every patient, every time.
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Aintree University Hospital NHS Foundation Trust
Ground Floor
Trinity Wing
Town Hall
Trinity Road
Bootle
L20 7AE
Catherine Beardshaw
Chief Executive
Aintree University Hospital NHS Foundation Trust
Longmoor Lane
LIVERPOOL
L9 7AL
Date:
Our Ref:
Your Ref:
18 May 2015
DAC/O&S
Contact:
Debbie Campbell
Telephone Number: 0151 934 2254
Fax Number:
0151 934 2034
email: debbie.campbell@sefton.gov.uk
Dear Ms.Beardshaw,
Aintree University Hospital NHS Foundation Trust – Quality Account 2014/15
As Chair of Sefton Council’s Overview and Scrutiny Committee (Health and Social Care) I am
writing to submit a commentary on your Quality Account for 2014/15.
Members of the Committee met informally on 13 May 2015 to consider your Quality Account,
together with representatives from the local CCGs.
We welcomed the opportunity to comment on the Quality Account and comments are outlined
below.
We recognised that the Trust faces many challenges and pressures. Attendees noted that the
Trust has demonstrated improvements and is making progress against measures. Additionally, we
look forward to the opening of the new urgent care and trauma centre.
We accepted your Quality Account for 2014/15 and you will not be requested to attend a formal
meeting of the Overview and Scrutiny Committee (Health and Social Care).
Yours sincerely,
Councillor Catie Page
Chair, Overview and Scrutiny Committee (Health and Social Care)
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Aintree University Hospital NHS Foundation Trust
Minicom: 0151 934 4657
Joint commentary on Aintree University Hospital NHS Foundation Trust Quality Account
2014-2015
Knowsley Council’s Health Scrutiny Sub-Committee and Healthwatch Knowsley welcome the
opportunity to comment on Aintree University Hospital NHS Foundation Trusts Quality Account
2014-2015.
At a meeting of the Council’s Health Scrutiny Sub-Committee on Monday 18th May, elected
members and members of Healthwatch Knowsley were provided with a detailed presentation of the
Trust’s Quality Account.
The Trust has split its Priorities for Improvement into three key priorities and set itself some
ambitious targets, particularly in relation to its key objectives for Priority 1 – Care that is Safe.
Members recognised that the Trust had performed fantastically in delivering harm free care across
every ward. It was also refreshing to see that the Trust had set ambitious targets in relation to
reducing MSSA bacteraemias and Clostridium Difficile, despite not fully achieving these targets.
Members felt that the Trust had been open and honest in demonstrating where it had not achieved
and hoped it would continue with this approach.
The work that had been done through ‘collaboratives’, particularly in relation to reducing falls and
pressure ulcers should be highly commended and could be exemplar practice for other Trusts.
Clearly testing out what works, trying out new initiatives and in-depth intelligence gathering and
research has enabled the Trust to make excellent progress in these areas.
The objective to reduce avoidable harm by mortality ratings is positive but there is further work to
be done. Members of the Sub-Committee and Healthwatch Knowsley felt strongly that the
information should be broken down by area and shared with local authorities in order to enable
them to identify potential patterns amongst their residents. It was felt particularly important in
relation to MUST (Malnutritional Universal Scoring Tool) screening as it would enable the local
authority to identify whether there were any particular dietary issues amongst Knowsley population.
In terms of priority 2 in delivering Care that is Clinically Effective, the Trust has again set itself
ambitious targets and delivered on many of these. This should be applauded. In particular, it was
felt that the Trust should be congratulated on the area of E-discharge as it was recognised that it
had made good improvement in this area (despite not meeting its 90% target).
The Committee and Healthwatch Knowsley supported the Trust in its work around Patient
Experience (Priority 3) and felt that the examples of using patient information to make
improvements were excellent. Schemes like Employee of the Month and Nurses Day were seen as
positive in terms of supporting and promoting positive staff morale. It was considered that the Trust
should share its complaints data more widely, with the local authority, so that any cross-cutting
issues (particularly around community provision) could be evaluated.
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Aintree University Hospital NHS Foundation Trust
It was also stressed, that the Trust should ensure that appropriate provision was made with family
of stroke patients to prepare for discharge. It was suggested that better signposting to support
groups would enhance patient and family member experience.
The Trust may also wish to consider how it could work more closely with other Trusts, such as the
Royal Liverpool and Broadgreen University Hospitals Trust and St Helens and Knowsley Teaching
Hospitals Trust through sharing best practice and Quality Accounts.
The Health Scrutiny Sub-Committee and Healthwatch Knowsley would like to thank Aintree
University Hospital Foundation NHS Trust for its Quality Account information.
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Aintree University Hospital NHS Foundation Trust
Aintree University Hospital NHS Foundation Trust – Quality Account Commentary.
The following commentary is a joint response from both Healthwatch Liverpool and Healthwatch
Sefton.
We would like to thank the Trust for the opportunity to comment on the Quality Account which was
received in a timely manner. Healthwatch Sefton attended a session in April following an invite
from the Trust to help provide comments on the readability of the document and provide
suggestions for any improvements. It is pleasing to note that the Trust will be producing a patient
friendly document which will help patients and the public have access to information on quality.
The information presented on a ‘typical day at the trust’ and the glossary is very useful to the
reader but a number of the terms used are medical and may require further explanation within the
narrative where they appear for the first time. We understand that this has now been included in
the final quality account. At the session we attended we also agreed with the Trust that the graphs
within the document needed to be changed to help the reader interpret them. The Trust agreed to
include short summaries along with the graphs in the final version.
Overall the document gives an honest assessment by the Trust and it is positive to see the Trust
has received improved feedback from patients in both the National Impatient survey and through
the Friends and Family test.
Aintree University Hospital has worked proactively with both Healthwatch Liverpool and Sefton
during the year. Both organisations have a seat on the patient experience executive led group
which meets on a monthly basis and the Trust holds quarterly meetings to share updates on the
quality account, the Equality Delivery System and other relevant issues.
Several of the aspirational priorities the Trust had set were not met, but it is positive to see
reductions made with pressure ulcers and the positive work the Trust has undertaken on reducing
falls. Last year Healthwatch Sefton acknowledged the work undertaken in the area of
communication and discharge summaries but noted that in-patient discharges needed further
improvement and we would welcome updates on this area.
We are aware of the work undertaken on Dementia by the Trust and performance in the CQUIN
goals in 2014/2015 which were achieved in quarter four and are aware of a steering group which
has been set up which looks at how the Trust can improve services for patients with Dementia.
Through our quarterly meetings we are also aware that the Trust is trying to improve Friends and
Family experience through the introduction of easy read information.
Information is included about work being undertaken for patients who have a learning disability of
are deaf/hard of hearing but there is no mention of the overarching strategy. We have requested
information about equality and diversity to be included in the document around what the Trust is
doing to ensure services are equitable.
In looking at the quality improvement priorities for 2015/2016, when reviewing priority 1, ‘Care that
is safe’ it is noted that only 10 – 20% of errors are reported voluntarily by staff. It would be useful to
know how the Trust will work on this to improve reporting as it is unclear how this will be
undertaken.
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Aintree University Hospital NHS Foundation Trust
Priority 3, ‘care that provides a positive experience for patients and their families’, states that
Healthwatch will be one avenue for feedback. Healthwatch Sefton has shared experience reports
with the trust. Engagement stands are held at the Trust on a monthly basis at a variety of locations;
Elective Care Centre, Hotel Entrance and Main Entrance. An evening stand in the main reception
has also been agreed. Aintree University Hospital should be encouraged by the positive
experience feedback we receive relating to quality of treatment and staff attitude. Areas where
consideration from the Trust has been asked for where experiences are not so positive include;
signage across the Trust, the time a patient waits for an appointment at the hospital, waits at
outpatient appointments and car parking (being able to park/ impact on being able to get to
appointments on time and impact on cost when appointments overrun). We will be working with the
Trust to review experiences which are shared with us by Sefton residents throughout the coming
year and have particularly asked for the issue of car parking to be reviewed further.
When looking at targets and indicators 2014/15 and the indicator for quality for total time in
accident and emergency (95% of patients waiting less than 4 hours), it is clear that work needs to
be undertaken. We would be keen to find out what plan is in place to address this moving forward.
It was good to note the information provided on local audit actions although the target or reason for
change would have been useful for the reader who would not have had any involvement in the
process.
It was interesting to note that the account do not include data on never events or serious or
Serious Untoward Incidents.
Healthwatch Liverpool and Sefton will be working with Aintree University Hospital to ensure we
receive regular updates on the work being undertaken on its equality and diversity milestones to
help provide ongoing assurance.
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Aintree University Hospital NHS Foundation Trust
Annex B: Statement of Directors’ responsibilities in respect of the Quality Report
The directors are required under the Health Act 2009 and the National Health Service Quality
Accounts Regulations to prepare quality accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual
quality reports (which incorporate the above legal requirements) and on the arrangements that
NHS foundation trust boards should put in place to support data quality for the preparation of the
quality report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:

the content of the Quality Report meets the requirements set out in the NHS Foundation
Trust Annual Reporting Manual 2014/15 and supporting guidance

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 2014 to March 2015

papers relating to Quality reported to the Board over the period April 2014 to March 2015

feedback from Commissioners dated 21/05/2015

feedback from Governors dated 15/04/2015 and 05/05/2015

feedback from Local Healthwatch organisations (Knowsley Council’s Health Scrutiny SubCommittee and Healthwatch Knowsley (joint response) dated 19/05/2015, Healthwatch
Liverpool and Healthwatch Sefton dated 19/05/2015)

feedback from Sefton Overview and Scrutiny Committee dated 18/05/2015

the Trust’s quarterly complaints and concerns reports dated 01/08/2015 (Q1), 11/11/2014
(Q2), 11/02/2015 (Q3), (Q4 to be provided)

the national patient survey dated February 2015

the national staff survey dated December 2014

the Head of Internal Audit’s annual opinion over the trust’s control environment dated
01/05/2015

CQC Intelligent Monitoring Report dated December 2014

the Quality Report presents a balanced picture of the NHS foundation trust’s performance over
the period covered;

the performance information in the Quality Report is reliable and accurate;
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Aintree University Hospital NHS Foundation Trust

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) as well as the standards to support data
quality
for
the
preparation
of
the
Quality
Report
(available
at
www.monitor.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the Board
27 May 2015
..............................Date.............................................................Chairman
27 May 2015
..............................Date............................................................Chief Executive
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Aintree University Hospital NHS Foundation Trust
Annex C: Independent Auditor’s Limited Assurance Report to the Council of
Governors of Aintree NHS Foundation Trust on the Annual Quality Report
Independent Auditors’ 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 of Aintree University Hospital NHS
Foundation Trust to perform an independent assurance engagement in respect of Aintree
University Hospital NHS Foundation Trust’s Quality Report for the year ended 31 March 2015 (the
‘Quality Report’) and specified performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance (the “specified
indicators”); marked with the symbol
in the Quality Report, consist of the following national
priority indicators as mandated by Monitor:
Specified Indicators
Specified indicators criteria
(exact section where criteria can be
found)
Percentage of incomplete pathways
within 18 weeks for patients on Annex D
incomplete pathways
Emergency re-admissions within 28 days
Annex D
of discharge from hospital
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Report in
accordance with the specified indicators criteria referred to on pages of the Quality Report as listed
above (the "Criteria"). The Directors are also responsible for the conformity of their Criteria with
the assessment criteria set out in the NHS Foundation Trust Annual Reporting Manual (“FT ARM”)
and the “Detailed requirements for quality reports 2014/15” 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 and the “Detailed requirements for quality
reports 2014/15”;
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 and the six dimensions of data quality set out in the “2014/15 Detailed guidance
for external assurance on quality reports”.
We read the Quality Report and consider whether it addresses the content requirements of the FT
ARM and the “Detailed requirements for quality reports 2014/15; and consider the implications for
our report if we become aware of any material omissions.
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Aintree University Hospital NHS Foundation Trust
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 2014 to March 2015 (the period);
Papers relating to quality report reported to the Board over the period April 2014 to March
2015;
Feedback from the Commissioners, South Sefton CCG received 21/05/15;
Feedback from Governors dated 15/04/2015 and 05/05/2015;
Feedback from Local Healthwatch organisations (Knowsley Council’s Health Scrutiny SubCommittee and Healthwatch Knowsley (joint response) received 19/05/2015, Healthwatch
Liverpool and Healthwatch Sefton received 19/05/2015);
Feedback from Sefton Council Overview and Scrutiny Committee (Health and Social Care)
dated 18/05/2015);
The trust’s quarterly complaints and concerns reports, dated 01/08/2014 (Q1), 11/11/2014
(Q2), 11/02/2015 (Q3);
The 2014 national inpatient survey;
The 2014 national staff survey;
Care Quality Commission Intelligent Monitoring Reports dated December 2014; and
The Head of Internal Audit’s draft annual opinion over the Trust’s control environment dated
01/05/2015.
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 2015, 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:

reviewing the content of the Quality Report against the requirements of the FT ARM and
“Detailed requirements for quality reports 2014/15”;
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Aintree University Hospital NHS Foundation Trust







reviewing the Quality Report for consistency against the documents specified above;
obtaining an understanding of the design and operation of the controls in place in relation to
the collation and reporting of the specified indicators, including controls over third party
information (if applicable) and performing walkthroughs to confirm our understanding;
based on our understanding, assessing the risks that the performance against the specified
indicators may be materially misstated and determining the nature, timing and extent of
further procedures;
making enquiries of relevant management, personnel and, where relevant, third parties;
considering significant judgements made by the NHS Foundation Trust in preparation of the
specified indicators;
performing limited testing, on a selective basis of evidence supporting the reported
performance indicators, and assessing the related disclosures; and
reading the documents.
A limited assurance engagement is less in scope than a reasonable assurance engagement. The
nature, timing and extent of procedures for gathering sufficient appropriate evidence are
deliberately limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for determining
such information.
The absence of a significant body of established practice on which to draw allows for the selection
of different but acceptable measurement techniques which can result in materially different
measurements and can impact comparability. The precision of different measurement techniques
may also vary. Furthermore, the nature and methods used to determine such information, as well
as the measurement criteria and the precision thereof, may change over time. It is important to
read the Quality Report in the context of the assessment criteria set out in the FT ARM the
“Detailed requirements for quality reports 2014/15 and the Criteria referred to above.
The nature, form and content required of Quality Reports are determined by Monitor. This may
result in the omission of information relevant to other users, for example for the purpose of
comparing the results of different NHS Foundation Trusts.
In addition, the scope of our assurance work has not included governance over quality or nonmandated 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 2015,
 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 and the “Detailed requirements for quality reports
2014/15”;
 The Quality Report is not consistent in all material respects with the documents specified
above; and
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Aintree University Hospital NHS Foundation Trust

the specified indicators have not been prepared in all material respects in accordance with
the Criteria and the six dimensions of data quality set out in the “Detailed guidance for
external assurance on quality reports 2014/15”.
PricewaterhouseCoopers LLP
Manchester
28 May 2015
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.
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Aintree University Hospital NHS Foundation Trust
Annex D: Definitions of the performance measure indicators for external audit
Independent Review of Quality Assurance:
An assurance opinion on data quality within the Quality Report is also provided by External
Auditors who are required to perform audit work on two nationally mandated performance
indicators and one local indicator chosen by the Trust Governors. The performance indicators and
their criteria are as follows:
Mandatory Performance Indicators
Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways –
Indicator criteria:
The number of patients on an incomplete pathway at the end of the reporting period who have
been waiting no more than 18 weeks as a percentage of the total number of patients on an
incomplete pathway at the end of the reporting period
Emergency re-admissions within 28 days of discharge from hospital - Indicator criteria:
The number of finished and unfinished continuous inpatient spells that are emergency admissions
within 0 to 27 days (inclusive) of the last, previous discharge from hospital as a percentage of the
number of finished continuous inpatient spells within selected medical and surgical specialities,
with a discharge date up to 31 March within the year of analysis.
Local Performance Indicator
Maximum waiting time of 31 days from diagnosis to first treatment for all cancers - Indicator
criteria:
Number of patients receiving first definitive treatment for all cancers within 31-days following a
diagnosis as a percentage of the total number of patients receiving first definitive treatment for
all cancers following a diagnosis (ICD-10 C00 to C97 and D05), measured from decision to
treat to first definitive treatment.
The above indicators subject to audit are identified by this symbol
within the report.
The limited assurance opinion from the External Auditors can be found in Annex C.
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