Quality Account Report 2016-17
‘Saving Lives, Improving Lives’ CONTENTS
page PART 1 - Statements on Quality 1.1 Statement on Quality on behalf of the Board 2 1.2 Introduction 5 1.3 Purpose of a Quality Account 5 1.4 How the Quality Account was produced 5 1.5 About the Trust 6
PART 2 - Priorities for Improvement and Statements of Assurance from the Board 2.1 Priorities for Improvement 2017-18 8 2.2 Statements of Assurance from the Board of Directors 10 2.2.1 Review of Services 10 2.2.2 Participation in Clinical Audit 13 2.2.3 Participation in Clinical Research 42 2.2.4 Use of the CQUIN Payment Framework 42 2.2.5 Statements relating to the CQC 44 2.2.6 Data Quality 47 2.2.7 NHS Number and General Medical Practice Code Validity 49 2.2.8 Information Governance Toolkit attainment levels 49 2.2.9 Clinical Coding Error Rate 49
PART 3 - Review of Quality Performance 3.1 Quality Improvements at PAHT 50 3.1.1 High-level plan 50 3.1.2 Quality Improvement Programmes 51 3.2 Review of Performance against Priorities for 2016-17 82 3.2.1 Patient Safety Priorities 82 3.2.2 Clinical Effectiveness Priorities 84 3.2.3 Patient Experience Priorities 86 3.3 NHS England Core Quality Account Indicators 88 3.3.1 Summary Hospital Mortality Indicator (SHMI) 88 3.3.2 Patient-reported Outcome Measures Scores (PROMS) 90 3.3.3 Patients readmitted to the Trust within 28 days of discharge 93 3.3.4 Responsiveness to patients’ personal needs 94 3.3.5 Staff recommending the Trust as a care provider to family and friends 97 3.3.6 Patients recommending the Trust’s A&E service to family and friends 98 PAGE 1
3.3.7 Percentage of patients risk-assessed for venous thromboembolism 99 3.3.8 Rate (per 100,000 bed-days) of C.difficile infection in patients over two years old 102 Number and rate of patient safety incidents reported in the Trust, with number and percentage 3.3.9 104 resulting in severe harm or death 3.4 Additional Core Information Requested by NHS England 107 3.4.1 Implementation of the Duty of Candour 107 3.4.2 NHS Staff Survey results 108 3.5.1 Reducing the risk around missed and delayed diagnosis 109 3.5.2 Progress of the Falls Prevention Strategy 111 3.6 National Quality Standards 114 3.6.1 Referral to Treatment 114 3.6.2 Diagnostic wait times 115 3.6.3 A&E waiting times 117 3.6.4 Cancer waiting times 118 3.6.5 Single-sex accommodation breaches 119 3.6.6 Cancelled operations 120 3.7 Building a positive future 122 3.7.1 NMGH Care Organisation 122 3.7.2 The Royal Oldham Hospital Care Organisation 125 3.7.3 Fairfield General Hospital and Rochdale Infirmary Care Organisation 128 3.8 What others say about the Trust 132 3.8.1 North East Sector NHS Commissioner Response 132 3.8.2 Local Health Watch organisations 133 3.9 Statement of Directors’ responsibilities in respect of the Quality Account 134 Independent auditors limited assurance report to the Directors of Pennine Acute Hospitals NHS 3.10 134 Trust on the Annual Quality Account 3.10 Independent auditors limited assurance report to the Directors of PAHT on the Quality Account 134
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PART 1
1.1 Statement on Quality on behalf of the Board Welcome to our Quality Account Report which describes the progress the Trust has made during the year 2016-17. This report is a public document. It summarises how the Trust has performed in relation to a number of important national and local clinical performance standards and key quality and patient safety indicators over the last year.
These standards include key areas around patient experience that are important to patients and their families who choose to be treated and cared for across the four hospitals run by the Trust and by our staff who work out in the community and in people’s homes.
The report also describes the developments and progress that has been made against key quality indicators, and outlines the proposed next steps for improvement and priorities in 2017/18. Where possible, we have made comparisons with other Trusts, and/or our own performance in previous years in order to monitor progress.
Part 1 introduces the Quality Account and the Trust.
Part 2 identifies the Trust’s quality priorities for next year, three in each of the three domains of quality: patient safety; clinical effectiveness; and patient experience. It also includes the statutory statements of assurance from the Board of Directors.
Part 3 reports the Trust’s progress in relation to the nine quality priorities that were described in last year’s Quality Account. It then reports the Trust’s performance in relation to NHS England’s core quality indicators.
Although it has not been specifically requested, we have also reported on the following national quality standards: ●● Referral To Treatment (RTT) times ●● Diagnostic waiting times ●● A&E waiting times ●● Cancer waits – 2/52; 31/7; 62/7; ●● Mixed-sex breaches ●● Cancelled operations CQC Rating In August 2016, the Care Quality Commission (CQC) published its report and findings following its inspection of the Trust in February and March 2016.
The Chief Inspector of Hospitals for England gave the Trust an overall rating as ‘Inadequate’. Although the CQC inspectors mostly saw Trust staff “treating patients in a compassionate and sensitive way”, they reported concerns about the systems and procedures that are in place to keep people safe and free from harm.
The CQC can give one of four ratings to Trusts and its services: ‘Outstanding’, ‘Good’, ‘Requires Improvement’, or ‘Inadequate’. A team of CQC inspectors found the Trust provided services that were Good for ‘Caring’, but were deemed overall ‘Inadequate’ for being ‘Safe’ and ‘Well-Led’, and ‘Requires Improvement’ to be ‘Effective’ and ‘Responsive’. PAGE 3
Our priority The CQC inspected all four of PAHT’s hospitals and community has been to keep services and rated them as: ●● Rochdale Infirmary rated ‘Good’ key services ●● Fairfield General Hospital in Bury rated ‘Requires running safely and Improvement’ ●● North Manchester General and The Royal Oldham Hospitals to ensure patients rated ‘Inadequate’ receive good safe ●● All community services rated ‘Good’ across all CQC domains ●● ‘Outstanding’ rating given for Caring in the community End of treatment in a Life Service timely manner. ●● Outpatients, x-ray and diagnostic services rated ‘Good’ across all hospital sites
We have been very open and honest since the CQC published its report. We believe the report held up a mirror for us to see what was happening and reflected what many staff across the organisation had been saying for some time: that there were issues relating to staffing pressures, systems which didn’t allow the Board of Directors to understand risks experienced on a ward or department, and a culture which began to tolerate inappropriate standards or behaviours.
The issues identified here at Pennine could occur in any organisation if allowed to go un-checked. Evidence shows that staff are best placed to know what needs to be done to improve their ward or department.
As Chief Executive of Salford Royal Hospital, one of only seven Trusts in the country to be rated “outstanding” by the CQC, since joining Pennine I, together with my senior team, have been listening to staff and using Salford’s systems, experience and learning to help support staff across this Trust to drive the improvements and changes that are necessary to ensure services are of high standard and are safer, more reliable and sustainable for the future.
Improvement Journey We did not wait for the publication of the CQC’s report in August 2016 to put an improvement plan in place to support staff and patients. Our priority has been to keep key services running safely and to ensure patients receive good safe treatment in a timely manner.
Since April 2016, real improvements and encouraging progress have been made. A comprehensive improvement plan is being implemented in response to both the CQC report and the diagnostic review and assessment undertaken by Salford Royal NHS Foundation Trust.
The Pennine Acute Trust’s Improvement Plan was approved by the CQC and endorsed by the Pennine Improvement Board, chaired by Jon Rouse, Chief Officer of Greater Manchester Health and Social Care Partnership, and PAHT’s Board of Directors on 17 October 2016.
The plan aims to deliver improvements across a range of services and areas to ensure services run by the Trust are safer, more reliable, efficient and effective. The plan sets out the immediate improvement actions that have needed to be taken to stabilise services and to create the right conditions upon which the Trust can continue to improve.
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The CQC’s 77 ‘Must Do’ and 144 ‘Should Do’ actions in its report have been mapped to the themes and deliverables contained within our Improvement Plan. The impact of the actions on patient care, outcomes and staff are being monitored and assessed through measurement dashboards. These 15 high level metrics are linked under the five CQC domains of: Safe, Effective, Caring, Responsive and Well-Led.
The high level indicators that are being measured include national performance standards of care and performance at each hospital site, for example, mortality rates, number of cardiac arrests, reported pressure ulcers, Serious Incidents & Postpartum Haemorrhage, length of stay for elective patients, readmissions, formal complaints, staffing levels and staff absence, cancelled appointments, and median time from A&E arrival to admission and also to treatment.
All actions in the Improvement Plan are integrated into these six main improvement themes: ●● Improving Fragile Services: stabilising staffing across Urgent Care at NMGH, Maternity Care, Paediatric, Critical Care; new models of care where needed ●● Improving Quality: Improving Safety, Effectiveness, Patient Experience; large-scale improvement learning collaboratives focusing on key clinical areas and patient care ●● Improving Risk & Governance: implementation of new risk and governance arrangements to protect patients; review of all safeguarding systems and processes ●● Improving Operations & Performance: focus on improving data quality, patient flow systems, pathway management, models of care ●● Improving Workforce and Safe Staffing: focus on safe staffing levels. Greater emphasis on staff engagement, recruitment and retention ●● Improving Leadership & Strategic Relations: clinical leadership development and strengthening local hospital operational management with triumvirate structure for each site with lead doctor, nurse, manager underpinned by a governance accountability framework.
Stabilising fragile services It is recognised that these improvements cannot be done in isolation; we are working closely and positively with our health and social care partners across Greater Manchester to look at ways to strengthen medical and nurse staffing, strengthen models of care, and support frontline staff. Effort to support improvements in our emergency and maternity departments is great evidence of how our new devolution arrangements across GM are working for the benefit of patients.
During 2016/17 the Trust has focused on stabilising key fragile services and strengthening areas that need attention, but also to build on some of Pennine’s specific strengths and examples of best clinical service models and delivery. This includes the integrated care and Oasis medical dementia unit at Rochdale, integrated and community services at North Manchester, Community End of Life Care, and the specialist Stroke Service at Fairfield General Hospital.
The Trust improvements are part of wider North East Manchester and City of Manchester sector development that includes out of hospital care, community and primary care, and the way that services are commissioned.
Strengthening Leadership A number of key appointments have been made at the Trust since April 2016 to strengthen senior leadership at Board and Executive Director level and to support the development of a site-based leadership model for each hospital and our community services. PAGE 5
The implementation of our new site-based leadership teams for our hospitals and locality areas is critical to our improvement journey where operational decisions, ownership and accountability for managing our services will be strengthened through this new structure. The additional leadership of a medical, nursing, finance and managing director at a local level will drive quality improvement on a local site basis at a more impactful pace.
The priority is for all of the Trust’s services to meet the high standards that patients expect and deserve. With the commitment and involvement of staff and close working with partner agencies across each locality, and through the delivery of the Pennine Improvement Plan and Quality Improvement Strategy, the Trust is determined that it can achieve great things so that PAHT, like Salford Royal, becomes one of the best and safest NHS Trusts in the country.
I am convinced and optimistic that we will become stronger as a result of the CQC report. I am delighted to have been asked to lead the Pennine Acute Trust on this improvement journey, uniting it with colleagues at Salford Royal, and look forward to reporting the improvements that our staff will have made in next year’s Quality Account report.
The quality priorities and key indicators set out in this report have been measured using our internal information systems and processes, including information that we have submitted externally, as well as information from participation in national NHS surveys. Our governance and assurance structure ensures that all such information is reviewed and monitored throughout the year
To the best of my knowledge, the information in this document is accurate.
Sir David Dalton Chief Executive 1.2 Introduction Quality Accounts are annual reports to the public from providers of NHS healthcare services about the quality and standard of services they provide. They are required by Government to help NHS Trusts, including providers of hospital acute services, community health services and mental health services, maintain focus and improve the quality of care for patients. 1.3 Purpose of a Quality Account Quality Accounts have become an important tool for strengthening accountability for quality within NHS Trusts and for ensuring effective engagement of Trusts’ Boards of Directors in the quality improvement agenda. By producing a Quality Account, Trusts are able to demonstrate their commitment to continuous evidence-based quality improvement and to explain their progress to patients and their families, the public and those who have an interest in the services that the Trust provides. This report is the eighth Quality Account published by The Pennine Acute Hospitals NHS Trust. 1.4 How the Quality Account was produced We have welcomed comments from staff, our external partners and patient representatives on what information should be included in this year’s Quality Account report in addition to the mandated content as set by the Department of Health.
Production of the report has been overseen by our Chief Nurse, Director of Governance, and other senior staff. The outline content was approved by the Executive Quality and Patient Experience Governance Committee in February 2017. The final version of the Quality Account report was approved and ratified by the Audit Committee, on behalf of the Board of Directors on 24 May 2017.
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1.5 About the Trust As one of the largest Trusts in the country, it is our responsibility to develop and deliver high quality healthcare services around the needs of our patients, their families and the communities we serve.
Our patients … come primarily from the communities of Bury, Prestwich, North Manchester, Oldham, Heywood, Middleton, Rochdale and parts of East Lancashire. Our population of approximately 820,000 is demographically diverse and is spread across both urban and rural landscapes including some significant areas of deprivation. Some of our patients face health inequalities, and chronic disease.
Our staff … are highly committed, skilled and professional. We employ around 9000 staff.
Our services … include hospital services at North Manchester General Hospital in Crumpsall, Fairfield General Hospital in Bury, The Royal Oldham Hospital, and Rochdale Infirmary. We also run the Floyd Unit (neurological rehabilitation) at Birch Hill Hospital in Rochdale. We also provide a range of community and integrated healthcare services across the north part of the city of Manchester, and integrated healthcare and intermediate tier services across Heywood, Middleton and Rochdale.
We have three NHS contracts for acute, community and specialist services, which detail commissioning requirements in terms of finance, activity, performance and quality. In addition, a number of specialist services previously included in the acute contract continue to be migrated into the Trust’s contract with the North West of England Specialised Commissioning Group.
Our Vision … ‘Saving Lives, Improving Lives’ … improving the health and wellbeing of the people and communities that we serve.
This is delivered by working with our partner agencies and particularly our local clinical commissioning groups (CCGs). These are NHS Oldham, NHS Heywood, Middleton and Rochdale, NHS Bury and NHS Manchester. Our CCGs are led by local family doctors (General Practitioners) and they commission (purchase) services from the Trust and other healthcare providers for their local populations. They are responsible for deciding what services are commissioned and how local taxpayers’ money is spent on healthcare services.
Our Values … guide every action we take. They determine how we work and the promise we make to our patients, their families, the public and each other as colleagues. Our vision is driven by three key Trust values. We are: Quality Driven, Responsible, Compassionate.
Our Strategic Goals ….support our vision. We have developed Strategic Goals along six domains:
1. Our services - to provide excellent care to our patients in our hospitals and community services;
2. Partnerships - to work with our partners and local people to build resilient and sustainable local services for the communities we serve;
3. People – to support our staff to provide the best care by developing their skills and nurturing their talent;
4. Leadership - to support values-based leadership which role models the behaviours we expect from everyone;
5. Quality, governance and performance – to achieve high reliability and high performance across all of our services;
6. Sustainability - to deliver strong productivity which will ensure financial sustainability PAGE 7
Our Corporate Priorities … set the overall direction for the Trust, both in terms of how our services are delivered and the expectations on our staff. Quality of care and patient safety is the cornerstone of everything we do and everything our staff believe in. Our Trust priorities for 2017-18 are rolled from previous years, as set out below: ●● Pursue quality improvement to assure safe, reliable and compassionate care ●● To deliver financial plan to assure sustainability ●● To support our staff to deliver high performance and improvement ●● To improve care and services through integration and collaboration ●● To demonstrate compliance with mandatory standards
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PART 2
2.1 Priorities for Improvement 2017-18 In August 2016, the Care Quality Commission rated our clinical services as ‘inadequate’. This is a significant challenge to us all but Pennine has some of the most talented staff in the NHS and the new Quality Improvement Strategy aims to provide a framework for which these dedicated staff can band together and improve broken systems and processes of care that are letting us and our patients down.
In March 2016 a new era dawned at Pennine Acute Hospitals NHS Trust, with the opportunity to join a new collaboration with Salford Royal NHS Foundation Trust. This move opened new opportunities for collaboration and improvement and coupled with robustly executed service development, organizational cultural development and governance plans, the Pennine staff will turn promises of improvement into results.
Several comprehensive diagnostics have taken place in the last two years and these have informed the creation of a new QI strategy for Pennine. This includes the CQC report that incorporated the views of patients and other stakeholders. The priorities for 17/18 are the main aims of the Quality Improvement (QI) strategy, which is currently in consultation with frontline staff. After they have had a chance to shape the detail of the strategy, we’ll be ready to publish and move ahead with implementation. Here, we present the aims of the strategy, which will also be our priorities for the 2017-18 reporting period. This strategy has been designed to harness the expertise of frontline staff and will be focused on building QI capability to staff and leadership both medical and non-medical. It is built on the knowledge that our staff are the best asset we have and we aim to provide the tools and space for learning, collaboration and improvement that will see our staff transform this Trust from ‘inadequate’ to ‘good.’
What we aim to Improve Aim: NO AVOIDABLE DEATHS As measured by: HSMR, SHMI (these are standardised measures of mortality that show the number of actual deaths against the number of “expected” deaths - based on certain criteria. For more information please see section 3.3.1)
Improvement of reliability in recognising deterioration
Improvement of first 48 hour care standards
We will aim specifically to improve recognition and treatment of the deteriorating patient. This will include increasing reliability to existing deterioration detection systems to reduce cardiac arrests and increase early treatment of patients with sepsis.
The first 48 hours of an emergency admission are crucial, and by redesigning our emergency pathways in the first 48 hours, we will ensure patients receive systematic review by the right clinicians during this critical timeframe. In addition, we aim to ensure that pathways are in place to address the unique needs of the frail elderly population. PAGE 9
Aim: REDUCE HARM TO PATIENTS As measured by: Patient safety thermometer and locally created measures for: pressure ulcers, venous thromboembolism, catheter associated urinary tract infections, falls
Harm is suboptimal care which reaches the patient either because of something we shouldn’t have done or something we didn’t do that we should have done. Hospital acquired infections, pressure ulcers, catheter related UTI’s and inpatient falls are examples of harm which are commonplace. Despite the extraordinary hard work of healthcare professionals patients are harmed in hospitals every day. Fortunately catastrophic events are rare but we must acknowledge that unintentionally a significant number of our patients experience some harm.
Our first priority is being open about errors and adverse events with our patients and families. Shedding light on these problems will allow us to join together to build systems to avoid the unintended consequence of patient harm.
We will focus on testing and implementing harm reduction strategies that have been successful elsewhere, including a focus on appropriate antibiotic prescription, as well as working with frontline staff to create harm reduction interventions fit for Pennine.
Aim: IMPROVE RELIABILITY TO KEY PATIENT PATHWAYS As measured by: The measures of improvement will depend upon the specific areas of improvement chosen once the pathways are mapped, and will be identified at that point.
It is widely acknowledged that aspects of health care do not perform as well as they should. Studies have shown that there is inconsistency in the delivery of high quality care and that patients often only receive a fraction of the care that is recommended. Reliability science can help health care providers redesign systems to make sure more patients receive all the elements of care they need.
We will use the principles of reliability science to underpin our approach to reducing harm and avoidable mortality and in the following pathways in particular: maternity and frailty.
Measurement, monitoring, and reporting All of our improvement projects follow a structure which monitors and measures performance using measurement for improvement principles and defined at the outset in a project initiation document. Progress is reported to the Executive Quality and Patient Experience Committee, chaired by the Executive Nurse Director.
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2.2 Statements of Assurance from the Board of Directors 2.2.1 Review of Services In 2016-17, The Pennine Acute Hospitals NHS Trust provided and/or subcontracted 58 NHS services, as shown in the table below.
Division of Medicine Integrated and Community Services Division ●● Acute Medicine ●● Community nursing ●● Cardiology (includes coronary care) ●● Audiology, ●● Clinical Haematology ●● Diabetes, ●● Diabetes and Endocrinology ●● Urgent/Crisis Response (including IV therapy) ●● Elderly Care-acute ●● Care of the Elderly ●● General Medicine ●● Expert patient programme ●● Infectious diseases ●● Falls prevention ●● Oncology (includes tumour chemo for breast, ●● Specialist Palliative care, gynaecology & colorectal) ●● Intermediate Care and Re-ablement ●● Respiratory ●● Neuro Rehabilitation and stroke ●● Stroke ( inpatient & OPD) ●● Nutrition and Dietetics ●● Urgent Care (A&E) ●● Dementia care Division of Surgery & Anaesthetics ●● Occupational Therapy ● ●● Anaesthetics ● Ophthalmology ● ●● Breast ● Orthoptics, ● ●● Colorectal Surgery ● Orthotics, ● ●● Critical Care ● Pain Medicine ● ●● Ear, Nose and Throat Surgery ● Respiratory ● ●● Gastroenterology ● Physiotherapy ● ●● General Surgery (including acute surgery) ● Podiatry ● ●● Maxillofacial ● Rheumatology ● ●● Specialist Dental (including orthodontics) ● Sexual health ● ●● Trauma and orthopaedics ● Speech and language therapy ● ●● Urology ● Urgent Care – UCC and CAU ●● Vascular Support Services Division Women’s and Children’s Division ●● Anticoagulant Services ●● Midwifery ●● Chemotherapy Services ●● Gynaecology & Obstetrics ●● Main Outpatients ●● Neonatology ●● Neurophysiology ●● Paediatrics. ●● Pathology ●● Pharmacy ●● Radiology PAGE 11
The Pennine Acute Hospitals NHS Trust has reviewed all the data available to them on the quality of care in all of these NHS services. The Trust acknowledges that the review of some services is varied, but has defined “review of services” as having participated in one of more of the following reviews: ●● Clinical audit activity – national and local ●● Cancer Quality Assurance process (formerly Cancer peer review) – may be ‘internal validated’ or ‘external.’ ●● CQUIN schemes ●● Review of clinical data – e.g. outcomes, Dr Foster, external submissions, internal dashboards ●● Staff or patient surveys ●● CCG review
Clinical Cancer CCG Service Audit CQuIN data Surveys QA review collection Acute Medicine ✓ ✓ ✓ ✓ Anaesthetics ✓ Anticoagulant Services ✓ Audiology ✓ Breast ✓ ✓ ✓ ✓ Cardiology (includes coronary care) ✓ ✓ Care of the Elderly ✓ ✓ Chemotherapy Services ✓ ✓ ✓ Clinical Haematology ✓ ✓ ✓ Colorectal Surgery ✓ ✓ ✓ ✓ Community nursing ✓ Critical Care ✓ ✓ Dementia care ✓ ✓ Diabetes and Endocrinology ✓ ✓ Diabetes (community) ✓ ✓ Ear, Nose and Throat Surgery ✓ ✓ ✓ ✓ ✓ Elderly Care-acute ✓ ✓ ✓ Expert patient programme ✓ ✓ Falls prevention ✓ ✓ Gastroenterology ✓ ✓ ✓ ✓ ✓ General Medicine ✓ ✓ ✓ ✓ General Surgery (including acute surgery) ✓ ✓ Gynaecology & Obstetrics ✓ ✓ ✓ ✓ Infectious diseases ✓ Intermediate Care and Re-ablement ✓ Main Outpatients ✓ Maxillofacial ✓ ✓ ✓ ✓
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Clinical Cancer CCG Service Audit CQuIN data Surveys QA review collection Midwifery ✓ ✓ ✓ Neonatology ✓ ✓ ✓ Neuro Rehabilitation and stroke ✓ ✓ ✓ Neurophysiology ✓ Nutrition and Dietetics ✓ ✓ Occupational Therapy ✓ Oncology (includes tumour chemo for ✓ ✓ ✓ ✓ ✓ breast, gynaecology & colorectal) Ophthalmology ✓ Orthoptics, ✓ Orthotics, ✓ Paediatrics ✓ ✓ ✓ ✓ Pain Medicine ✓ Pathology ✓ Pharmacy ✓ Physiotherapy ✓ ✓ Podiatry ✓ Radiology ✓ Respiratory ✓ ✓ ✓ ✓ Respiratory (community) ✓ ✓ ✓ ✓ Rheumatology ✓ ✓ Sexual health ✓ Specialist Dental (including orthodontics) ✓ Specialist Palliative care, ✓ ✓ ✓ Speech and language therapy ✓ Stroke ( inpatient & OPD) ✓ ✓ ✓ Trauma and orthopaedics ✓ ✓ ✓ Urgent Care – UCC and CAU ✓ ✓ ✓ Urgent Care (A&E) ✓ ✓ ✓ ✓ Urgent/Crisis Response (including IV ✓ therapy) Urology ✓ ✓ ✓ ✓ Vascular ✓ ✓ ✓
The income generated by the NHS services reviewed in 2016-17 represents 100% of the total income generated from the provision of NHS services by The Pennine Acute Hospitals NHS Trust for 2016-17. PAGE 13
2.2.2 Participation in Clinical Audit National clinical audits are commissioned by the Healthcare Quality Improvement Partnership (HQIP) which manages the National Clinical Audit and Patients Outcome Programme (NCAPOP). Priorities for the NCAPOP are set by the Department of Health with advice from the National Clinical Audit Advisory Group (NCAAG). Audits are largely funded directly by the Department of Health, but some are funded from subscriptions paid by NHS provider organisations. National confidential enquiry is a form of national clinical audit and is a method of assessing the quality of care to help identify potentially avoidable factors that are known to be associated with adverse outcomes.
Undertaking clinical audit and acting on findings is a way of improving the quality of care we provide to patients, and the Trust aims to participate in all relevant audits. During 2016-17 39 national clinical audits and four national confidential enquiries covered NHS services that the PAHT provides.
During that period, the Trust participated in 100% of the national clinical audits and 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 the PAHT was eligible to and did participate in, and for which data collection was completed during 2016-17, are listed below alongside the number of cases submitted to each auditor enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.
% of cases Service Name of audit / focus area submitted 1. Neonatal intensive and special care (NNAP) 100 Peri and Maternal, New-born and Infant Clinical Outcome Review Programme Neo-natal 2. 100 (MBRRACE-UK) 3. Child health clinical outcome review programme (NCEPOD) 100 Children 4. Paediatric Pneumonia (BTS)* 100 (to date) 5. ICNARC (Case Mix Programme) 100 6. Medical and Surgical Clinical Outcome Review Programme (NCEPOD)* 100 Acute 7. National Emergency Laparotomy Audit (NELA) 100 8. National Joint Registry (NJR)* 100 9. Stress Incontinence Audit* 100 10. Diabetes (National Adult Diabetes Audit) 100 11. Diabetes (National Paediatric Diabetes Audit) 100 Long-term 12. Inflammatory bowel disease (IBD) programme* 32 Conditions 13. National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme* 100 14. Rheumatoid and early inflammatory arthritis* 100 15. Adult Asthma (BTS)* 100 16. Learning Disability Mortality Review Programme (LeDeR)* 100
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% of cases Service Name of audit / focus area submitted 17. Elective Surgery (National PROMs Programme)** 63 18. National Ophthalmology Audit *** 100 Elective 19. Nephrectomy Audit* 100 Procedures 20. Percutaneous Nephrolithotomy (PCNL)* 100 21. Endocrine & Thyroid National Audit TBC **** 22. Bowel cancer (NBOCAP) ***** 101 23. Head & Neck Audit* 100 Cancer 24. Lung cancer (NLCA) 100 25. Oesophago-gastric cancer (National Audit O-G Cancer) 100 26. National Prostate Cancer Audit (CEU-RCSE) 100 27. Acute coronary syndrome or Acute myocardial infarction (MINAP) 100 28. Cardiac Rhythm Management (CRM) 100 Cardiovascular 29. Coronary angioplasty / National Audit of PCI (NICOR) 100 Disease 30. National Cardiac Arrest Audit (ICNARC)* 100 31. National Heart Failure Audit (NICOR)* 100 32. National Vascular Registry 100 Blood 33. National Comparative Audit of Blood Transfusion programme 100 34. Falls and Fragility Fractures Audit Programme (FFFAP) 100 Older People 35. Sentinel Stroke National Audit Programme (SSNAP) 100 36. National Dementia Audit 100 37. Major Trauma (Major Trauma and Research Network) 100 Trauma 38. Adult Asthma Care - Emergency Department (RCEM)* 100 39. Severe Sepsis & Septic Shock (RCEM)* 100 * The Trust has registered to participate and is awaiting publication of the audit results. ** PROMs (Patient Reported Outcome Measures) is a project that measures a patient’s health-related quality life following surgery using pre and post-operative surveys. As patients can choose whether to participate in PROMs, the percentage represents the take-up rate rather than the percentage of cases submitted by the Trust. In addition the information provided is from 1st April to 30th November 2016 (as no further data is available). *** The first report was published April 2016 and was based on historic data providing a mechanism for refinement of the methodology. Information included in this initial report is limited as the audit is in a developmental phase. Following the first prospective data collection period covering surgery undertaken from September 2015 to August 2016, full reporting will come into effect. This will include case complexity adjusted outcomes for surgical complications and visual acuity loss from cataract surgery for named consultant and independent surgeons, and for named surgical centres. This report is currently awaiting publication therefore case ascertainment will only be available at this point. **** Late registration and data submission awaiting confirmation from national team. ***** Percentage calculated against the number of expected cases based on historic HES data. PAGE 15
NCEPOD Cases Submitted Cancer in young children, teens and young adults 100% Adolescent mental health 100% Chronic Neurodisablity 100% Non-invasive Ventilation 100%
List of acronyms to the above tables BTS British Thoracic Society CEU Clinical Effectiveness Unit COPD Chronic Obstructive Pulmonary Disease CRM Cardiac Rhythm Management FFFAP Falls and Fragility Fracture Audit programme IBD Inflammatory bowel disease ICNARC Intensive Care National Audit & Research Centre MINAP Myocardial Ischaemia Audit & Research Centre MBRRACE Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK NBOCAP National Bowel Cancer Audit Programme NCEPOD National Confidential Enquiry into Patient Outcome and Death NELA National Emergency laparotomy Audit NICOR National Institute for Cardiovascular Outcomes Research NJR National Joint Registry NLCA National Lung Cancer Audit NNAP National Neonatal Audit Programme O-G Oesophago-gastric PCNL Percutaneous Nephrolithotomy PROMs Patient Reported Outcome Measures RCEM Royal College of Emergency Medicine RCSE Royal College of Surgeons of England SSNAP Sentinel Stroke National Audit Programme
National Clinical Audits with low percentage data submission Data submission to the inflammatory bowel disease audit has proven difficult during 2016 and the IBD Clinical Lead expressed concerns relating to the directorate’s inability to provide sufficient data to this national audit. His concerns around this were highlighted to, and discussed with, the Clinical Director and Medical Director in December 2016 where potential solutions were explored to improve compliance and quality in 2017. These include: ●● An MDT alongside Biologics clinic to safely manage the complex cohort and use the limited resources to their full potential. ●● An investment in recruiting three IBD nurses. ●● An IBD Registry (the Trust registered in March 2017).
The above issues have subsequently been added to the directorate’s risk register.
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The data submission to the National Patient Reported Outcome Measures (PROMs) Programme has increased from 26% in 2015/16 to 63% in 2016/17, although this is not as expected there continues to be changes made across the Trust in the reduction of patients attending pre-operative assessments. The orthopaedic directorate is currently recruiting patients both at pre-operative assessment and on the day of surgery and the process will be monitored against expected case submission.
Learning from National Clinical Audits The reports of 19 national clinical audits were received by the Trust in 2016-17 and have been reviewed. The Pennine Acute Hospitals NHS Trust has taken or intends to take the following actions to improve the quality of healthcare provided.
Key findings Response NATIONAL BOWEL CANCER AUDIT The 2016 Annual Report is the seventh report produced and includes The audit was presented at the Upper & data on over 30,000 patients diagnosed with bowel cancer between Lower GI Audit & Governance meeting 1st April 2014 and 31st March 2015. in March 2017 and the final action plan ●● The Trust has submitted 101% of its cases to the national audit. was completed by 31st March 2017. This included: ●● Pre-treatment staging was documented in 88% of cases. ● ●● Performance status was documented in 100% of cases. ● Review measures to admit patients on day of surgery potentially reducing LOS ●● 100% were seen by clinical nurse specialist. by 33%’ (as the Trust is currently an ●● Laparoscopic surgery was attempted in 75% of cases compared outlier in terms of local peers). to 53% regionally and 61% nationally. ●● Improvements to be made on the ●● The Trust’s adjusted 90-day unplanned readmission rate was 9.9% documentation of ‘permanent stoma’ compared to 10.3% regionally and 10.1% nationally. to reduce the APER (abdomino-perineal ●● The Trust’s adjusted 18 month stoma rate was 58% and this is excision of the rectum) rate. comparable with the region and nationally, where the stoma reversal rate was 50%. ●● Reviews of historic practice in terms ●● The Trust’s 90 day mortality rate was 7.8% compared to 4.7% of neo-adjuvant treatments will be regionally and 3.8% nationally. undertaken as the Trust has a higher rate than nationally reported (although ●● The Trust’s 2 year mortality rate was 24.9% compared to 22.5% 1/3 higher participation figures than regionally and 20.9% nationally. its peers). Colleagues asked to look at 2011, the two year mortality rate has fluctuated between 33.9 and practice and assess. 22%. In comparison to the 2013/2014 period there has been a 2.9% increase against the national figure, which itself has shown a ●● Review of the deaths during 2014-15 reduction of 1.1%. will be undertaken. This is crucial to investigate this further; findings to be disseminated and shared to ensure continual improvement. PAGE 17
Key findings Response NATIONAL OESOPHAGO-GASTRIC CANCER AUDIT The National Oesophago-Gastric Cancer Audit 2016 Annual Report The results of the audit were published in describes the care received by patients diagnosed with High Grade November 2016 and have been reviewed Dysplasia (HGD) and Oesophago-Gastric (OG) cancer between 1st by the multi-disciplinary team. They have April 2013 and 31st March 2015, and their outcomes. developed an action plan set against the ●● The Trust submitted more than 90% of its cases to the audit. national recommendations. ●● The proportion of patients with an initial staging CT scan recorded Regular updates against the plan will be was 81% for the Trust compared to 87% nationally. provided at the MDT meetings. ●● The Trust provides initial treatment and those patients requiring surgical intervention are seen at Salford Royal Foundation NHS Trust. ●● In addition, the Trust patients are submitted to the national database via Salford. NATIONAL LUNG CANCER AUDIT The Trust compared favourably nationally and against peers in the The Trust continues to validate its data local network, particularly in relation to discussion at MDT, and being prior to submission, and is committed to seen by a cancer nurse specialist. continuing to make improvements against the national findings. NATIONAL PROSTATE CANCER AUDIT Discrepancies in the published data for the Trust have resulted in a In terms of actions at a local level, the review of the national data set. The Trust is working with the national clinical audit team is collating the audit prostrate cancer audit team to identify why only 319 patients’ data, results at a local level for the 300+ cases of the 525 submitted, have been uploaded to the national dataset. that did make it into the audit. Public Health England’s National Cancer Registration and Analysis Service (NCRAS) have identified that all 525 patients submitted by These findings can assist in a provisional Pennine Acute Hospital NHS Trust for April 2014-March 2015 are action plan and an early indicator for in the NPCA dataset, and that all these men had RW6 as a provider potential concern areas. The team are still coded in at least one their records. However, it was not always in the process of reviewing the findings and possible to recognise the Pennine Acute Hospitals as the diagnosing are concentrating on any area that did not Trust due to the shared pathways (CMFT & Christie are radical care match to the national average. providers). The NCRAS team is working with the Trust to revise the means of defining the Trust where a patient was diagnosed, and the The team is also reviewing data recording corresponding date of diagnosis, for the purpose of the NPCA. This at a local level, to identify any solutions, approach will take account of all the records for each individual which include the possibility of data be patient. overwritten. The Trust’s urology cancer lead has contacted the NPCA lead with concerns that the wrong information depicts the Trust against peers incorrectly, and to enquire about a retraction from the public domain. The national lead has acknowledged the comments and is working to provide a solution.
Quality Account Report 2016-17 PAGE 18
Key findings Response NATIONAL DIABETES INPATIENT AUDIT The audit sets out to measure the quality of diabetes care provided to The team has been asked to develop an people with diabetes while they are admitted to hospital action plan which can be transposed to site Prevalence based working. ●● People with diabetes occupied 16.1% of PAHT beds. There is now a diabetic steering group ●● 7.0% had Type 1 diabetes and 16.9% had insulin treated Type 2 who will be responsible for monitoring diabetes. improvements in diabetes across the Trust. ●● 90.7% of inpatients with diabetes had been admitted as an The Trust has recruited additional members emergency. of staff to the diabetes nursing team. Patient contact Since the publication of this report 40.6% ●● 30.0% of inpatients with diabetes were seen by a member of the of patients are seen by a member of diabetes team, compared to 35.8% nationally. the diabetes team compared to 34.1% nationally. ●● Of 30.0% of patients, 60.0% had been seen by the multidisciplinary diabetic foot team within 24 hours of admission compared to 58% nationally. Staffing ●● 43.6% of diabetes consultants’ time was spent on the care of patients with diabetes ●● 43.6% of diabetes specialist nursing time was spent on the care of patients with diabetes Medication errors and patient harm ●● 31.7% of PAHT patients’ drug charts that were reviewed had at least one or more medication error; 14.9% had at least one prescription error; and 25.2% of patients with diabetes experienced at least one management error compared to 38.1% nationally. ●● Of the patients who were on insulin, 16.7% experienced one or more insulin (prescription or management) error, compared to 22.6 nationally ●● 7.4% of inpatients with diabetes had been on an insulin infusion in the last 7 days. ●● 26.6% of inpatients had mild hypoglycaemic episodes, which is comparable nationally. 10.2% had severe hypoglycaemic episodes during the stay, compared to 9.9% nationally. Foot disease and foot risk assessment Of inpatients that were admitted specifically for the management of their diabetes or a diabetic complication, 23.5% were admitted with an active foot ulcer. ●● 44.7% had a risk assessment received within 24 hours of admission to PAHT compared to 28.7% nationally. PAGE 19
Key findings Response NATIONAL DIABETES IN PREGNANCY The results of the third annual report, which was published in The results of the audit have been sent to October 2016, identified key findings in a number of areas for the the sites leads, and were presented at the Trust against national results, one being that few women were Obstetrics & Gynaecology audit meeting on prepared for pregnancy in the ways recommended in the NICE 15th March 2017. guideline NG3: The team has requested site-based data to ●● Nationally 15.5% of women with type1 diabetes had first identify specific areas for improvement and trimester HbA1c <48mmol/mol recorded: as there were fewer to develop action plans. than 10 patients for PAHT, no value is available. ●● Nationally 35.8% of women with type 2 diabetes had first trimester HbA1c <48mmol/mol recorded the Trust had 26.4% recorded.
The Trust results highlight that we are not meeting at least the national targets of 15.5% for type 1 and 35.8% for type 2 diabetes ●● Nationally 40.3% of women with type1 diabetes had a 24 weeks plus HbA1c <48mmol/mol recorded: the Trust recorded 21.6%. ●● Nationally 72.9% of women with type2 diabetes had a 24 weeks plus HbA1c <48mmol/mol recorded, the Trust had 60.6% recorded.
The Trust results highlight that we are not meeting at least the national targets of 40.3% for type1 and 72.9% for type2 ●● Nationally 52.7% of women with type1 diabetes had first contact with antenatal team; the Trust recorded 72.2%, performing well above the national level ●● Nationally 36.5% of women with type2 diabetes had first contact with antenatal team; the Trust had 42.2% recorded, performing just above the national level ●● Nationally 44.5% of women with type1 diabetes were taking 5mg folic acid prior to pregnancy, the Trust recorded 43.6% ●● Nationally 23.1% of women with type2 diabetes were taking 5mg folic acid prior to pregnancy, the Trust recorded 25.3%
Quality Account Report 2016-17 PAGE 20
Key findings Response NATIONAL PAEDIATRIC DIABETES AUDIT ●● 95.1% of the patients attending PDU at PAHT have type I The results have been discussed at the diabetes divisional quality & performance committee. ●● 2.3% of the patients attending PDU at PAHT have type II diabetes The results to be benchmarked against ●● In the remaining 2.6% cases they attended the PDU for other practices of care where high levels of reasons or this data was incomplete. performance have been found. ●● 80.8% of the patients attending PDU at PAHT are screened for Continue to work with the network and thyroid disease quality assurance (peer review) to support achieving quality improvements across the ●● Median HbA1c for patients attending PDU at PAHT is 69mmol/ service. mmol The 12th report demonstrates continued improvement in outcomes. It also highlights that current strategies in place are helping improve outcomes.
NATIONAL HIP FRACTURE DATABASE 2015 In total the Trust has submitted 737 cases to the national database As a result of this audit the sites have (358 cases from NMGH and 379 cases from TROH). reviewed their individual reports and have ●● Admitted to orthopaedic ward within 4 hours: NMGH 45.2%; developed action plans to improve where possible the areas that don’t meet the TROH 40.3%; national 43.9% expected BPT standards. ●● Mental test score completed on admission: NMGH 98.9%; TROH 98.4%; national 94.8% This includes ensuring that patients are mobilised out of bed the day after surgery ●● Perioperative medical assessment: and review of the pathway to ensure ●● NMGH 98%; TROH 93.9%; national 87.5%. patients are admitted to an orthopaedic ●● Mobilised out of bed on the day after surgery: NMGH 64.5%; ward to meet the 4 hour target. TROH 96.7%; national 76.1% Regular reviews are undertaken on the data ●● Received falls assessment: submitted to the national dataset. ●● NMGH 100%; TROH 99.1%; national 97% ●● Received bone health assessment: ●● NMGH 99.1%; TROH 98%; national 97.2% ●● Met all criteria for best practice tariff: ●● NMGH 45.8%; TROH 55.1%; national 65.6%. The Trust hospitals are in the lowest quartile for meeting all criteria for best practice tariff. Royal Oldham Hospital is placed in the 3rd quartile for patients being admitted to an orthopaedic ward within 4 hours of admission and having a mental test score completed on admission, whereas North Manchester General Hospital is in the 2nd quartile for these two measures. PAGE 21
Key findings Response NATIONAL JOINT REGISTRY 2015 The results of the audit have identified that the Trust is achieving the The directorate is continuing to review the following (expected national target of >95%): data and improve the patient pathway. ●● FGH - 92.8% of patients were consented Work continues supporting the clinical ●● NMGH - 97.1% of patients were consented teams to improve the data submission in a timely manner across the Trust. ●● ROH - 98.3% of patients were consented % of patients consented who had a valid NHS number (the expected target is 95% nationally): ●● FGH - 99.8% ●● NMGH - 99.1% ●● ROH - 99.6 NEONATAL INTENSIVE AND SPECIAL CARE 2015 The audit data covered ten key areas of neonatal care. Nationally, The report has been sent to the Neonatal three demand particular attention: Directorate leads and all the neonatologist consultants, and will be presented at ●● Two-year follow-up – there has been an improvement in the rate the neonatal and peri-neonatal mortality of follow-up of very preterm babies (54% in 2014, 60% in 2015). meeting in May 2017. However, there is considerable variation between networks, with the best performing network achieving recorded follow- up on almost three times the number of babies than the lowest performing. ●● Temperature on admission – more than one in four babies who had their temperature recorded within an hour after birth were too cold, a major concern given the recognised association between hypothermia and increased mortality and morbidity. ●● Recorded consultation with parents – there has been little or no overall progress since 2012 with this basic, but essential, standard of parental partnership in care. This is very disappointing, meaning that one in ten parents still did not have a recorded consultation with a senior member of the neonatal team within 24 hours of their baby’s admission to the unit.
Quality Account Report 2016-17 PAGE 22
Key findings Response MATERNAL, NEW-BORN AND INFANT CLINICAL OUTCOME REVIEW PROGRAMME The enquiry found that in some cases diagnosis of heart disease The report was presented and discussed in young women was overlooked and for others, who knew they at the Obstetrics and Gynaecology audit had heart disease, care was fragmented. Nationally, over a quarter meeting on 15th March 2017. of women who died during pregnancy or up to six weeks after Risk triggers are already in place for pregnancy died from a cardiovascular cause; the leading cause of pregnant women when cardiovascular maternal death in the UK. problems are identified at booking. Nationally, the report highlighted many instances when pregnant and The key action is that when any pregnant postpartum women had clear symptoms and signs of cardiac disease, woman presents with chest pain in A&E which were not recognised because the diagnosis was not considered then a cardiology consultation is sought. in a young pregnant woman. There was evidence of excluding rather than making a diagnosis in women who presented repeatedly for ●● A new pathway has been approved and care. is to be developed in collaboration with Despite blood pressure problems, pre-eclampsia and related A&E and obstetric directorates. complications being very common in pregnancy, maternal deaths from these conditions are at their lowest rate ever. Now in the UK less than one woman in every million women dies from a blood pressure disorder of pregnancy, a great success of maternity care in the UK. The report also contains messages for the future care of women with early pregnancy conditions including ectopic pregnancy and those women in pregnancy or soon after who require critical care. PAGE 23
Key findings Response NATIONAL BLOOD TRANSFUSION AUDIT PROGRAMME: USE OF RED CELLS AND PLATELETS The Trust audited 33 adult patients and 46 transfusion episodes with The results of the audit have been shared the following results: with the blood transfusion team and clinical 1. Clinical staff should measure haemoglobin prior to transfusion of teams across the Trust. red cells in haematology patients (within 24 hours for inpatients The findings have identified that the Trust is and 72 hours for day patients); meeting the national standards in a number of areas and the team have identified areas The Trust achieved 92.9% (nationally 91.4%) for day patients and for improvement in standards 2, 3 and 4. 100% (nationally 98.7%) for inpatients. The Trust is performing within the top 80% of hospitals. Currently the Clinical Lead and the blood transfusion team are developing an action 2. Clinical staff should only transfuse red cells in normovolaemic plan to support improvements against haematology inpatients without additional risk factors standards 2, 3 and 4 part of which will (cardiovascular disease or signs or symptoms of cardiovascular be through blood transfusion awareness compromise, severe sepsis or acute cerebral ischaemia) if their training. pre-transfusion Hb is less than 70g/L.;
The Trust achieved 10.0% (nationally 17.1%) performance for this standard and was outside of the top 5% of hospitals.
3. Clinical staff should only transfuse prophylactic platelets in patients with a reversible cause for bone marrow failure and no other risk factors for bleeding if their pre-transfusion platelet count is below 10 × 109/L (within 24 hours for inpatients and 48 hours for day patients);
The Trust achieved 50.0% (nationally 61.0%).
4. Clinical staff should avoid routinely prescribing prophylactic platelet transfusions to patients with irreversible chronic bone marrow failure;
The Trust achieved 62.5% (nationally 42.7%) showing a high level of achievement in this standard, within the top quarter of hospitals. This shows strong support for good transfusion practice in haematology patients.
5. For patients receiving prophylactic platelet transfusions, clinical staff should prescribe no more than one adult therapeutic dose;
The Trust achieved 92.3% (nationally 92.6%)
Quality Account Report 2016-17 PAGE 24
Key findings Response NATIONAL VASCULAR REGISTRY 2015 At present the Trust’s case ascertainment for lower limb amputation is In January 2017 the Vascular unit major good at just over 70%, compared to the national average of 50%. In amputation pathway was launched. addition the Trust’s outcomes for lower limb amputations are below A CCG healthcare professional now attends the national average. the bimonthly vascular clinical governance meetings with a positive impact by assisting in improved patient pathways. More data is being collected prospectively for entry to the NVR. Pennine Acute Hospitals performs the highest number of carotid A joint meeting with the stroke team took operations per year in England. Results show we are performing place on 2nd March 2017. As an outcome above average in terms of outcomes for patients having a carotid of this meeting a draft CEA shared pathway endarterectomy (CEA). policy has been developed and distributed for comment. Local audit results are to be presented in poster form at the next UK Stroke Forum at the request of the Stroke Clinical lead for Strategic network and senate across Greater Manchester. Outcomes in 2015 for abdominal aortic aneurism shows the Trust The vascular team will continue to monitor is achieving good clinical outcomes and performing within our the clinical outcomes to ensure continued expected range for major surgical procedures. sustainability in performance. The very low case ascertainment across the UK for endovascular The vascular team are continuing to procedures was disappointing and it prevented the NVR from making encourage a more active approach to any firm statements about the national picture. However the data submitting data on endovascular lower limb Pennine Acute Hospitals submitted shows care was being delivered procedures to the NVR. safely. MINAP The eighth annual report was published in January 2017. In total The report has been sent to the cardiology 1053 nSTEMI patients were admitted across the Trust. The key leads to develop an action plan linked to the findings for the Trust were: audit recommendations. ●● 94.2% of nSTEMI patients were seen by a cardiologist; 0.9% less than the national average (95.1%). ●● Only 15.8% of nSTEMI patients were admitted to a cardiac ward. However, of those patients admitted directly to the hospital that has angiography capability prior to discharge, this was 92.9%; 13.1% above the national average (79.0%). ●● Secondary medication (which includes beta blocker, ACEI or ARB, statin, aspirin, aldosterone antagonist, thienopyridine inhibitor and ticagrelor), was given to 95.1% nSTEMI patients; which is the same as the national average. PAGE 25
Key findings Response NATIONAL HEART FAILURE AUDIT 2015 The purpose of this audit is to drive up standards of care during the The audit findings have identified a acute admission phase to achieve better patient outcomes. This can reduction in heart failure nurse input and be accomplished by capturing data on clinical indicators that have the lead nurse has undertaken a review of a proven link to improved outcomes, encouraging the increased the service which has resulted in a business use of clinically recommended diagnostic tools, implementing use case being put forward for the recruitment of disease-modifying treatments, and by robust referral pathways. of more heart failure nurses. During hospital admission: The ambulatory care pathway has been ●● 74% of patients had an echo (91.7% nationally). amended and once agreed by the team the ●● 44% of patients were admitted to a cardiology ward (48.1% policy will disseminated across the Trust. nationally). The Heart Failure Nurse Lead has attended ●● Input from a consultant cardiologist was 32% (58.6% nationally). directorate meetings and presented the pathway at FY2 training sessions. ●● The number of patients seen by heart failure specialists (i.e. nurses and doctors) has decreased to 44% this year from 51%. In addition a separate validation of the data ●● The prescription of key disease-modifying medicines for patients is being undertaken linking to a lack of robust internal processes. with heart failure and a reduced LVEF on discharge for those patients prescribed ●● ACEI/ARB 70% (72.2% nationally), ●● Beta blocker 66% (85.7% nationally) ●● MRA 42% (52.6% nationally). ●● The number of patients who received discharge planning was 61%, (national target 87%). ●● Cardiology follow up referral was at 42%, (national target 52.2%). ●● Referral for heart failure nurse follow-up is 67%, (national target 57.9%): for patients with LVSD the national referral rate is 69.7% and the Trust is achieving the target of 89%.
Quality Account Report 2016-17 PAGE 26
Key findings Response NATIONAL CARDIAC RHYTHM MANAGEMENT AUDIT The aim of the CRM Audit is to examine the implant rates and The cardiology team has reviewed the audit outcomes of all patients who undergo pacemaker, ICD and CRT results and are working to ensure that their implantation procedures in the UK, against national and international unit meets the national targets. standards defined by NICE and other specialist organisations. The service identified the need for a devices ●● The pacemaker implant rate is at 466, both new and replacement implanter for the TROH and this post device implant procedures across PAHT, which includes Rochdale has been recently recruited. Providing a Infirmary, Fairfield General Hospital and North Manchester similar service across the Trust will increase General Hospital sites. There is no national target for the the number of referrals and increase the number of submissions but the data does look at the number of number of implantations. implantation activity throughout the year for implanting hospitals ●● The percentage of atrial based pacing implants, as a proportion of all new implants for sick sinus syndrome, was at 80%, which is lower than the UK national average target. ●● The percentage of ICD implants for primary prevention is at 47%, which is 3% lower than the national target. However, the secondary prevention is at 53% and this is above the national target by just over 1%. ●● The percentage of CRT-D implants, for primary prevention is at 53%, which is much lower than the national target by 23.9%. ●● The secondary prevention is at 47% and this is above the national target by 24%. NATIONAL PERCUTANEOUS CORONARY INTERVENTION (PCI) AUDIT The audit of PCI is a continuous audit that collects information about The team has reviewed the results and have all percutaneous coronary intervention procedures undertaken in all developed an audit sheet collecting weight, NHS hospitals and the majority of private hospitals in the UK. height and creatinine, and follows the patient through to the Silver Heart Unit. ●● The Trust achieved > 98% in data completeness in all but the following two areas: Discussion has taken place at the cardiology • weight & height not recorded in 65% of cases specialist nurse meetings highlighting the • creatinine levels not recorded in 77% of cases need to complete the audit sheet in order to improve data completeness. ●● The number of eligible records for arterial access has decreased by from 473 to 438 (7.4%) The document is also being used for the in- patient PCI procedures. ●● 32% of nSTEMI patients were treated with PCI within 72 hours from admission, which is lower than the national average of The lead nurse is monitoring the completion 54.3%. of the audit sheet (ensuring that the areas to support data completion are being ● ● 56.9% of procedures used right or left radial access, which is completed). lower than the national target of 75%. PAGE 27
Key findings Response SENTINEL STROKE NATIONAL AUDIT PROGRAMME (SSNAP) 2016 The data submitted for stroke patients demonstrates that the Trust The overall level of compliance with the has provided good quality care, with all indicators being above the quality of care measures provides assurance national average. The data is published on a quarterly basis. The that the Stroke Unit is providing care following figures represent the patient centred care from August to consistent with good practice. November 2016: The team reviews the data at the Stroke ●● Directly admitted to a stroke unit within 4 hours: 88.3% (58.5% Directorate meetings for information nationally). provided from the national team each ●● Patients who spent at least 90% of their stay on unit: 98.3% quarter, and continues to act on the findings (84.8% nationally). as appropriate. ●● Proportion of eligible patients according to the Royal College of Physicians (RCP) guidelines given thrombolysis 96.7% (88.1% nationally). ●● Proportion of patients who were thrombolysed within 1 hour: 85.3% (63% nationally). ●● Assessed by a stroke specialist consultant physician within 24 hours 98.3% (81.9% nationally). ●● Assessed by a nurse trained in stroke management within 24 hours 97.7% (90.1% nationally). ●● Swallow screen given within 4 hours 98.5% (74% nationally). ●● Formal swallow assessment given within 72 hours 100% (87.2% nationally). ●● Assessed by an occupational therapist within 72 hours 100% (91.7% nationally). ●● Assessed by a physiotherapist within 72 hours: 100% (95.1% nationally). ●● Assessed by a speech and language therapist within 72 hours 99.5% (89% nationally). ●● Screened for nutrition and seen by a dietician by discharge 85.7% (83.3% nationally). ●● Continence plan drawn up within 3 weeks 86.2% (92.0% nationally) ●● Mood and cognition screening by discharge 99% (91.9% nationally). ●● Receiving joint health and social care plan on discharge 100% (90.6% nationally). ●● Treated by a stroke skilled early supported discharge team 71.5% (34.5% nationally).
Quality Account Report 2016-17 PAGE 28
Key findings Response NATIONAL EMERGENCY LAPAROTOMY AUDIT 2016 The results of the second national report, which were published in Since the publication of this report the July 2016, identified the Trust had performed well in a number of teams have worked to improve the areas, though some site differences were observed. number of completed cases submitted; with currently 100% of cases submitted to Case ascertainment was poor with the Trust only achieving an the national database and 76% are fully average of 45% - 42% (NMGH) and 48% (TROH). completed. CT reported before surgery: In addition all other areas (with the ●● 69% NMGH; 71% TROH (83% nationally). exception of specialist care of the elderly ●● Risk was documented before surgery: input) have improved; the teams on both ●● 33% NMGH; 84% TROH (64% nationally). sites are more engaged and have taken ownership of the audit and are monitoring ●● Arrival in theatre in timescale appropriate to urgency: their own data more proactively. ●● 75% NMGH; 82% TROH (82% nationally). The Trust submitted and validated 100% of ●● Preoperative review by a consultant surgeon and anaesthetist cases and this will be reflected in the 2017 when risk of death is ≥5%: report due to be published in July 2017. 67% NMGH; 85% TROH; (57% nationally). ●● Consultant surgeon and anaesthetist present in theatre when risk of death is ≥5%: ●● 85% NMGH; 88% TROH; (74% nationally). ●● Admission to critical care following surgery when risk of death is >10%: ●● 79% NMGH; 92% TROH (85% nationally). ●● Assessment by care of the elderly specialist in patients >70 years: 3% of cases for both sites (10% nationally).
Local Clinical Audit The reports of 21 local clinical audits were reviewed by the Trust in 2016-17 and the Pennine Acute Hospitals NHS Trust intends to take the following actions to improve the quality of healthcare provided.
Key findings Response COMPLIANCE WITH PATIENT SAFETY ALERT, STORAGE OF THICKENING AGENTS This audit showed that the Trust was storing all thickening agents Educate and remind all nursing staff of patient in the kitchen in all areas, and that if patients require thickening care alert (PCA) 19 in daily meetings agents, they are not always risk assessed appropriately (42.8%) Introduce nursing risk assessment tool Though the patients who are capable of doing so are encouraged template to those already in use for nursing to make their own drinks, they may not be able to determine what documentation the right quantity is and this can result in harm. All agents must be stored in the kitchen; this Where the thickening agent is stored on the drinks trolley, the drink will reduce risk and ensure best practice is is made for the patient. But there is a risk of accidental ingestion if followed it is within reach of patients. Any thickening agents that are used should be only given by the clinical staff on the wards PAGE 29
Key findings Response LESSONS LEARNT AUDIT In total 13 serious incidents, 7 inquests, and 3 patient safety alerts The results of the audit were presented were reviewed. at the Divisional Quality & Performance committees in July 2016 for information and The greatest numbers of actions related to training compliance, but to disseminate across the directorates. this also had the lowest level of completion with 79% being amber or red. Since that time, the new Director of Patient Safety has been introducing Salford’s ‘Lessons Actions related to developing or reviewing policy, protocols and Learned’ programme into Pennine. documentation showed the highest level of completion (94%) although compliance with policies and protocols was only 56%.
Communication to staff had the second highest numbers of related actions and (excluding those categories with very low numbers of actions) also showed the second highest rate of completion at 65.5%.
The divisions with the greatest compliance are Integrated and Community, and Support Services, though the overall numbers of actions for these are low.
Anaesthetics and Surgery had the most actions reviewed, and showed the lowest full compliance of the divisions with 40.5%. Women and Children’s had compliance with 43%; and Medicine with 57% of their actions.
Whilst reviewing the documents to identify auditable standards, a number of actions were not ed that were not amenable to audit, for example “raising awareness.” Although it is possible to demonstrate communication of outcomes and follow this up by obtaining records of handover, ward meetings and minutes of meetings, this does not provide assurance that staff have taken on board and embedded good practice into their everyday roles and responsibilities. REDUCING THE RISK OF CLOSTRIDIUM DIFFICILE INFECTION The purpose of the audit was to reduce the risk factors for C. The results of the audit have been discussed difficile infection, and ultimately reduce the rates of CDAD with the clinical director and presented, (clostridium difficile associated disease) in the patients being highlighting the responsibilities of usage of PPI treated with PPIs and antibiotics at the The Royal Oldham Hospital. and antibiotics.
Standard: All patients high-risk for CDAD, who take a PPI and are Discussion taking place with ePMA team to requiring antibiotics, should have their PPI reviewed and stopped if assess the feasibility of having a pop up alert possible, or changed to ranitidine. requesting appropriateness of antibiotics on ●● In the 1st audit cycle compliance of the above standard was PPIs for this cohort of patients. met in 65.3% of cases. ●● In the 2nd audit cycle compliance of the above standard was met in 87.2% of cases.
Quality Account Report 2016-17 PAGE 30
Key findings Response COMPLETION OF DNACPR FORMS ON G2, ROH The purpose of this audit was to determine the practice on the The audit has been presented at the Trust completion of DNACPR forms and the associated discussions gastroenterology clinical governance meeting, with patients and their families on ward G2 at The Royal Oldham and discussed with both the clinical and Hospital. managerial teams.
The standard for all criteria is 100%. The junior doctors’ ward induction document has been amended so that it now includes a ●● Only 75% DNACPR forms were clearly visible at the front of the section on DNACPR decisions and guidance. patients’ notes. ●● Only 67% DNACPR forms were countersigned by a consultant The audit results have been reported to the within 24 hours of being completed. frontline medical staff as they are commonly involved with completing DNACPR forms at an ●● In 89% of cases, discussion with patients was documented on early stage in a patient’s hospital admission. the DNACPR forms ●● 75% of cases had a mental capacity assessment recorded in Discussion with nursing staff and ward clerks their clinical record and documented evidence that discussion on G2 and have asked that they check that with next of kin had taken place. the forms are filed in the correct place. ●● 60% of DNACPR discussions were clearly documented in the patients’ clinical records. ●● In the remaining 40%, the DNACPR decisions were carried over from the community and therefore it was not deemed necessary to re-discuss.
FALLS AUDIT – INTEGRATED AND COMMUNITY The purpose of this audit was to review the appropriateness The results of the audit have provided the and effectiveness of prevention and management of falls within division with real-time data that has been community bed based units. used to develop a quality improvement plan which will benchmark implementation and The standard for all criteria is 100%. improvements in a timely manner. ●● 49% of patients Trust-wide had a specialist physiotherapy The key recommendation was to develop a assessment within 24 hours of being identified as a falls risk. bespoke Fallsafe Bundle more relevant to the ●● 59% of patients Trust-wide had a golden leaf symbol displayed community setting linked to staff knowledge above their bed. and skills training programme. ●● 27% of patients Trust-wide had a cognitive assessment This is now in use across the community beds completed. and bespoke training is being delivered. ●● 54% of patients Trust-wide had a ‘forget me not’ symbol displayed if required. ●● 64% of patients Trust-wide had a risk assessment reviewed if they had fallen on the unit. ●● 64% of patients Trust-wide had a post fall action plan completed if they had fallen on the unit. PAGE 31
Key findings Response COMPLIANCE WITH COMMUNITY NURSE CONTROLLED DRUG POLICY The purpose of this audit was to assess compliance against Trust The audit highlighted eight recommendations; policies and NICE guidance regarding controlled drugs, highlighting each has named leads and the teams have areas of good practice and any gaps in compliance. developed a series of processes to ensure implementation of the plan. The standard for all criteria is 100%. The results have been discussed at team ●● 94% of prescribers provided a dated handwritten authorisation, meetings and it has been stressed that clearly detailing the drug, dose and route of administration in compliance must be 100% in all cases. the patient record ●● 69% of controlled drugs were counted, documented and Re-audits are planned for November 2017 to signed at each visit assess compliance against the policy following additional training sessions. ●● 67% of clinicians documented their signature, name and job title on all controlled drugs documentation ●● Only 11% of entries were contemporaneous ●● Only 9% of community nurses discussed with patients and their carers the administration and expected effects of taking controlled drugs and document this within the patient record ●● Only 3% of patients receiving drugs via a syringe driver were provided with a syringe driver information leaflet ●● 86% of records showed that controlled drugs destroyed by clinicians, had documentation dated and signed by a registered member of staff and only 66% signed by a witness ●● 63% of records had documented evidence of DOOP kits being used to destroy unused controlled drugs. ●● 89% of team members could discuss points relevant to controlled drugs and administration in line with Trust policy
Quality Account Report 2016-17 PAGE 32
Key findings Response GLUCOSE TESTING IN PATIENTS ADMITTED WITH NECK OF FEMUR FRACTURE A major clinical incident three years ago involved a patient with The audit results were presented at the A&E undiagnosed diabetes, who was admitted with a fractured neck Audit meeting at NMGH on Friday 27th May of femur, and died due to complications from the diabetes. 2016. Following this, a new protocol was introduced in which all patients No action was required as the results admitted with a diagnosis of a fractured neck of femur would demonstrated that current practice was at a have a laboratory glucose test prior to referral to the Trauma and satisfactory level. Orthopaedic team.
The standard for all criteria is 100%.
●● Out of 20 patients identified, 19 had a laboratory glucose checked on admission which was identifiable on the Pathology Lab centre system. ●● All 20 patients had some form of glucose testing performed in the form of laboratory or capillary, checked on admission. The one patient who did not have a laboratory glucose checked on admission was a patient with known type 2 diabetes, which was tablet controlled, who was placed on a capillary blood glucose chart from admission. ●● Further to the implementation of the new protocol, A&E staffs were successful in implementing this change and 95% of patients had laboratory glucose check done on admission.
DELIRIUM: PREVENTION, DIAGNOSIS AND MANAGEMENT WITHIN THE INPATIENT ORTHOPAEDIC PHYSIOTHERAPY TEAM AT NMGH The aim of the audit was to establish how current practice Results have been shared with all compares to the NICE guidelines CG 103 and, where necessary, physiotherapists (who practice on the form and implement a relevant action plan to drive improvement as orthopaedic trauma wards) at their team appropriate. meeting.
The standard for all criteria is 100%. They have been encouraged to maintain good standards of practice in relation to this ●● It is standard practice for physiotherapy staff to encourage particular guideline. mobility, walking and exercises with patients admitted to an orthopaedic ward following their surgery; irrespective of their As the audit demonstrated 100% compliance age and cognitive function. The results of the audit confirmed against the standards the re-audit is planned that this is taking place on a consistent basis. to be undertaken in 2 years’ time (unless there ●● The audit demonstrated full adherence to the physiotherapy is a decrease in practice and or the standards practice recommended in the NICE guideline for delirium for change). patients admitted to the orthopaedic trauma ward at NMGH. PAGE 33
Key findings Response AUDIT OF UPPER LIMB PHYSIOTHERAPY ASSESSMENT AND TREATMENT The purpose of the audit is to improve the treatment provided to The results of the audit have been fedback to patients with regard to their upper limb physiotherapy assessment the physiotherapy team highlighting the new and treatment following a stroke. RCP guidelines for stroke.
The standard for all criteria is 100%. In addition all rotational staff have been made aware of documentation standards. ●● 80% of patients had a problem list documented. ●● 75% of patients had a treatment plan documented. A review is being undertaken on the upper limb checklists ensuring that they reflect the ●● 58% of patients had their treatment plan evaluated during changes in the RCP guidance. subsequent therapy sessions. ●● 64% of patients were given the opportunity to practice activities within their capacity during therapy sessions and only 45% of patients were given opportunities to practice independently of therapy sessions. ●● 37% of patients who did not have 45 minutes of therapy had a documented reason as to why not.
ADHERENCE TO, AND EFFECTIVENESS OF BLOOD GLUCOSE MONITORING AT NMGH In the spring of 2015, a new blood glucose monitoring document The results of the audit have been presented was rolled out across the Trust in a bid to document patients’ blood and it was agreed that there was a need glucose levels more accurately. to assess the understanding of the nursing team on blood glucose monitoring and to The standard for all criteria is 100%. ascertain any barriers to the effective use of ●● In the first 48 hours of admission, 42% of patients had their the required documentation. blood glucose measured appropriately. In addition it was agreed that the use of ●● After the first 48 hours of admission, 62% of patients had their algorithms is easier to follow than lines of blood glucose measured appropriately. prose – work is being undertaken to collate ●● 50% of episodes of hypoglycaemia are accompanied by a algorithms to incorporate cut-off values in all sticker in the patient notes. the algorithms, e.g. at what level does low ●● 50% of episodes of hypoglycaemia are escalated appropriately. blood glucose need to be escalated. ●● In patients who have an episode of hypoglycaemia, 100% have their blood glucose rechecked appropriately. ●● 60% of patients with two consecutive readings of blood glucose greater than 15mmol/L had their ketones checked. ●● All patients who had a blood glucose reading of more than 15mmol/L on two consecutive occasions, and who were positive for ketones, were escalated appropriately.
Quality Account Report 2016-17 PAGE 34
Key findings Response URINALYSIS IN UTI Observations on the Acute Medical Unit at North Manchester Staff in AMU (nursing, healthcare assistants General Hospital (NMGH) suggest that urinalysis is not routinely and doctors) have been made aware of the carried out where it is indicated. In addition, when urinalysis is new documentation and the use of the sticker performed, results are not always documented and the majority system that has been developed. of clinicians agree that finding results in clinical notes can be very The stickers are easily accessible across the difficult. This audit was undertaken to identify the extent of these unit e.g. in the sluice room problems and guide an action plan to address the issues with a view to improving practice and patient care. The doctors have been made aware that it is their responsibility to clearly document these The standard for all criteria is 100%. results in the notes where appropriate i.e. ●● A urinalysis was performed to confirm diagnosis of a UTI in only ward round entry. 64% of cases. A re-audit is planned to take place in May ●● Urinalysis results were documented in only 44% of cases and 2017. were easily accessible / visible in only 20% of cases. ●● Only 84% of MSUs (midstream urine samples) were sent for cultures and sensitivities and only 52% of sensitivities were available before discharge. ●● Only 8% of patients had antibiotics changed/prescribed according to sensitivities.
IDENTIFICATION OF NEONATES REQUIRING BCG VACCINATION Manchester’s incidence of TB has recently dropped below The results of the audit have been discussed 40/100,000 and so babies on the postnatal ward born to parents with the project lead and clinical audit lead living in Central Manchester, Salford, M8, M9, and M40 are no regarding the national shortage of vaccination longer automatically being given the BCG. This change from at the time of the audit, and which continues. giving BCGs to all babies living in the areas listed, to targeting The results of the audit were presented in those who are now classified as high-risk, started on the 1st April January 2017 with further audits planned to 2016. This means that it is now even more important to make sure monitor vaccination programme. that all babies who should be vaccinated are identified, according to the screening questions e.g. country of birth of parents and The shortage of BCG vaccine is noted on the grandparents and also family history of TB. divisional risk register.
●● The audit highlighted that only 68% of babies that require a BCG vaccination after birth on the postnatal ward were identified. ●● It is not a local practice to identify babies eligible for a BCG vaccination before birth. At the time of the audit there was a national shortage of vaccination. This meant that babies were not always being vaccinated before discharge from hospital. (If there were not enough babies requiring BCGs it was felt a waste of resources to open a vaccine vial that could be used for 8-10 babies: they are invited back to clinics so that larger groups can be vaccinated together). PAGE 35
Key findings Response APPROPRIATENESS OF ANTIBIOTIC PRESCRIBING IN A&E FOR ADULT OUTPATIENTS 115 antibiotics were prescribed for A&E patients between 16th and A meeting took place in August 2016 with the 29th November 2015. A&E prescribers to highlight the prescribing ●● 80 were indicated for conditions within the antibiotic policy of antibiotics for chest infections, including • 59% complied with the policy not prescribing when there are no signs • 41% did not comply. of infection unless confirmed by tests; this included usage and doses for COPD patients. ●● 35 were indicated for conditions that were not included in the antibiotic policy. Continuous monitoring of antibiotic usage in A&E has been on-going since July 2016. Areas of good practice: ●● Antibiotic dose for UTI was appropriate on 96% of occasions where the choice was appropriate. ●● Antibiotic choice for cellulitis was appropriate on 90% of occasions. Areas for improvement: ●● Antibiotic choice for ear infections was inappropriate on 50% of occasions. ●● Antibiotics prescribed for wounds or laceration injuries were inappropriate on 65% of occasions. ●● Co-amoxiclav was prescribed inappropriately in 71% of occasions out of which eleven indications did not exist within the antibiotic policy.
AUDIT OF PRE-OP NOTES IN GENERAL AND VASCULAR SURGERY Given the established importance of good record-keeping in clinical The results of the audit were presented at the practice, the aim of this audit was to assess current practice within vascular and surgical audit meetings. the surgical department at The Royal Oldham Hospital; with a The operation notes have been re-designed to fundamental aim of improving patient safety and maintaining a ensure that the Royal Colleges’ standards will high standard of patient care. be met. The standard for all criteria is 100%. The vascular team has liaised with the theatre ●● 100% of post-operative notes had a documented named staff and informed colleagues of new op note surgeon; name of procedure and post-operative care now available in all vascular theatres. instructions. ●● 93% of post-operative notes had a documented date; and just 16% a documented time. ●● Blood loss was documented in 7% of post-operative notes. ●● 34% of post-operative notes had documented antibiotic prophylaxis; and DVT prophylaxis was documented in 21%. ●● Patient demographics were complete in 91% of the post- operative notes assessed.
Quality Account Report 2016-17 PAGE 36
Key findings Response VASCULAR SURGICAL SITE INFECTION (SSI) AUDIT The aim of this audit was to review the incidence of groin The results of the audit to be presented to infections and the degree of correlation between infection and highlight the audit findings and action plan known risk factors. to support implementation of the audit ●● 14% of patients acquired a 30 day post-op SSI – target is 3%. recommendations. ●● 87% of patients were administered prophylactic antibotics – ●● Develop a SSI risk assessment tool target is 100%. ●● Doors leading into the hybrid area to be ●● 97% of patients received appropriate first line prophylactic kept closed at all times antibiotics – target 100%. ●● Limit the number of personnel within All seven patients had a number of risk factors that are known to theatres increase the risk of SSIs. ●● Adherence to the surgical theatres work- ●● 100% of patients were given prophylactic antibotics within 60 wear policy. minutes before skin incision ●● Prophylactic antibiotics to be added to ●● 57% of patients with an aquired post op SSI had their the WHO pre-op checklist – to act as operation in theatre 3 a reminder to ensure all patients are administered the appropriate antibiotic ●● 100% of patients received appropriate first line prophylactic and within the best practice timeframe. antibiotics.
GP REFERRAL PATHWAY FOR BRONCHIOLITIS The purpose of the audit was to assess GPs’ adherence to the The team has devised a tiered action plan as bronchiolitis pathway when making the referral to the paediatric follows: team. ●● Trust to continue to arrange CPD sessions The standard for all criteria is 90%. with GPs on bronchiolitis management and to revisit the referral pathway. This ●● Two thirds of the referrals were for mild cases of bronchiolitis. would be helpful in areas with high referral ●● These cases could have been managed in the primary settings rates (postcodes M8 and M9). with a period of observation and CCNT follow up. ●● Education programme should be offered ●● This would greatly reduce the burden on the already limited again for Bury GPs. hospital resources. ●● New doctors to be aware of the referral ●● The compliance for the ManchEWS observations (particularly pathway so that they can ask appropriate the oxygen saturation) and feeding assessment in the primary questions and offer appropriate advice settings were below the set key standards. when contacted by the GPs i.e. to ●● The reasons could be due to time constraint for observing each be included as part of the induction patient, lack of equipment or untrained staff who may not be programme for new doctors joining familiar with the use of the oxygen saturation monitor. paediatrics. PAGE 37
Key findings Response APPROPRIATE REQUESTING OF MRI Magnetic resonance imaging (MRI) should be used to reduce The results of the audit have been shared with radiation in situations where multiple imaging is required. For the Trust Inflammatory Bowel Disease Lead diagnosis of inflammatory disease of the small bowel (Crohn’s and to date the following actions have been disease) there is no consensus regarding initial imaging. NICE implemented: guidance recommends ultrasound scan (US) or MRI in conjunction ●● Referrals for dedicated US of the small with endoscopy if inflammatory markers are raised. Other literature bowel have been increased has indicated that US, computed tomography (CT) and MRI are ●● A review of a new patient pathway for low comparable in imaging small bowel pathology. Magnetic resonance suspicion for IBD elastography (MRE) is frequently used as a first line investigation in ●● A re-audit will be undertaken in 2018. suspected cases of small bowel inflammatory bowel disease (IBD) in PAHT.
The clinical history of 495 cases was examined for evidence of known Crohn’s disease and the results highlighted that: ●● The clinical history of those with no known history of Crohn’s (n=301, 60%) was further evaluated. ●● Almost three quarters (72.4%) of those with no known Crohn’s disease also did not have any past medical history of GI disease, other imaging findings or endoscopic findings. ●● MRE diagnosed small bowel pathology in only a small proportion of cases referred. ●● The likelihood of a positive finding is increased in specific subgroups, e.g. endoscopic or CT findings. ●● MRE picks up a significant number of incidental findings including large bowel pathology – these patients then require further investigation. ●● Faecal calprotectin was only mentioned in one clinical history: this should be utilised more effectively. ●● US small bowel does not require bowel preparation, costs around a third of MRE and is comparable in sensitivity and specificity.
Quality Account Report 2016-17 PAGE 38
Key findings Response DENTAL TRAUMA IN ANAESTHETICS The rationale for this audit came from a clinical incident in which The results of the audit have been shared a patient undergoing an elective procedure experienced an un- with the anaesthetic department at the audit eventful anaesthetic but was later found to have a broken tooth. and governance meeting. A comprehensive action plan was developed based on the audit A review of the local policy / guideline was initiated to assess the findings including: effectiveness of the Trust’s compliance to recommended practice and assist the anaesthetists in case of accidental trauma and Development of department / Trust guidance subsequent management. on the management of dental trauma, including guidance on what to do if a tooth A retrospective audit reviewed incidents reported over a 12- cannot be found and when to complete a year period (2004-16) alongside a ‘spot check of consent’ audit Trust incident form. This is now implemented undertaken at The Royal Oldham Hospital (TROH) in June 2016. and available via the Trust intranet. Aims - to quantify the magnitude of the problem in the Trust Use of ‘new’ anaesthetic charts at TROH with and the Division of Anaesthetics, to improve documentation, to prompt for consent. safeguard against medico legal claims and to form a guideline for the department. Re-audit (pre-op documentation) scheduled for August 2018. Retrospective Audit ●● 279 dental incidents were reviewed, of which 59 were found to be related to anaesthetic dental injuries. ●● 61% were found to occur during intubation; in 33% of cases it was impossible to tell when the incident occurred due to poor documentation. ●● There were two reported cases of damage to identified healthy teeth both, of which received intraoperative intervention from the maxillary-facial team.
Spot Check Consent Audit ●● 42 patients reviewed over two days. Documentation of current dentition was identified in 88% of cases but only 38% went on to document the risk of dental trauma. PAGE 39
Key findings Response CAROTID ENDARTERECTOMY (CEA) PATHWAY In England and Wales alone, over 80,000 people are hospitalised The results of the audit were disseminated with acute stroke each year; the risk of completed stroke is much widely throughout the vascular team and the lower in studies of emergency treatment in specialist stroke services Trust, being presented at the Vascular MDT on compared to non-urgent settings. Patients with suspected TIA 22/09/2016: minutes were submitted to audit should have a full diagnostic assessment urgently without further and governance meetings to provide evidence. risk stratification. The Trust must demonstrate compliance to audit A comprehensive action plan was collated, against NICE Guidance CG68 - Stroke and transient ischaemic and actions have been implemented: attack in over 16s: diagnosis and initial management (2008), and at local levels Trusts must ensure that vascular departments audit Action: Raise awareness by presenting audit practice of the carotid endarterectomy pathway. PAHT does this findings at the Multidisciplinary Team Meeting annually to provide this assurance. on 22/09/2016.
A retrospective audit on data extracted from the National Vascular Outcome: Lead Clinician presented the audit Registry for all patients who have undergone CEA over a 12 month findings and a copy of the presentation and period between 01/01/2015 – 31/12/2015 at TROH. attendance register has been submitted as evidence. Total number of CEA procedures identified was 113. Action: Raise awareness and present local and The results against NICE CG68 standards are depicted below - the national outcomes via a banner format at the standard is 100%: PAHT annual public meeting 6/10/2016. ●● 66.6% of patients had surgery within 2 weeks from onset of Outcome: A banner was designed for the stroke or TIA. public meeting. Evidence of the banner ●● 72.5% undergo surgery within 7 days of referral and attendance at the meeting has been ●● 62.7% assessed and referred within 1 week of onset of submitted as evidence. symptoms of stroke or TIA Action: Clinical Audit Department to send ●● 69.6% operated on within 24hrs of admission copies of the carotid endarterectomy pathway ●● 37.5% return to Stroke Unit for on-going rehabilitation within report to the stroke team. 24 hours of surgery Outcome: The carotid endarterectomy Although limited assurance to standard was identified from the pathway report has been submitted audit the PAHT figures are higher than the national averages for (16/10/2016) to the clinical audit supervisor, the same time period. auditor and clinical director for comment.
Quality Account Report 2016-17 PAGE 40
Key findings Response SEPSIS IN SURGICAL INPATIENTS Sepsis is a major cause of death in the UK and is consistently The results of the audit were disseminated within the top three causes of death reported monthly at PAHT widely throughout the General Surgery An audit and re-audit against NICE guidance NG51 outlining the Directorate and the Trust, being presented at management of Sepsis. the General Surgery Audit and Governance meeting 16/12/2016. Minutes were submitted The aim was to assess adherence to sepsis 6 guidelines amongst to provide evidence. general surgical patients, (standard 100%) and concurrently assess the correlation with 30-day morbidity and mortality. A comprehensive action plan was collated, ●● IV Antibiotics (within 1 hour), containing the below elements. All actions have been implemented. ●● adequate IV fluids, ●● provide oxygen, Action - Production of presentation using NICE guidelines for recognition, diagnosis and ●● monitor UO, management of sepsis ●● take 2 blood cultures from 2 separate sites, Outcome – Session delivered 16/12/16 ●● check lactate level. Electronic version of presentation, feedback This was a prospective audit performed over a week from 14th- from teaching session and register of 20th November 2016. The study population consisted of general attendees obtained for evidence surgical patients on Ward T5, The Royal Oldham Hospital, identified Action - Poster production using research on as septic during this period. qSOFA ●● Four patients were diagnosed with sepsis. Outcome - Completed - Poster produced and ●● All patients were managed in accordance with the Sepsis 6 used as part of teaching session on 16/12/16 guidelines and received treatment with antibiotics within one hour of diagnosis. The planned re-audit was undertaken in March 2017 and as a result it was agreed that ●● All blood samples were taken for culture and lactate levels and the new cohort of SHOs need to continue intravenous fluids were prescribed. delivering teaching sessions to the FY1s on ●● 75% were given oxygen however the fourth cases contained this topic. poor documentation therefore it was impossible to determine if this was omitted or simply not documented. ●● 75% documented catheterisation. In this case failure to meet the standard set may be in part due to again lack of documentation ●● No patients included within this audit had two sets of blood cultures; ●● In all cases there was documented use of the SIRS criteria in clinical assessment.
The 30-day mortality rate for patients included in this audit was 0% and no patients required a further operation.
The audit demonstrated limited levels of assurance to Sepsis 6 guidelines. PAGE 41
Key findings Response LUMBAR PUNCTURES BASED ON CRP RESULTS NICE Guidelines for ‘Neonatal infection (early onset): antibiotics The results of the audit were presented at the for prevention and treatment’ (CG149) states babies with any red audit meeting November 2016. flags or two or more non-red flags or clinical indicators – indicates Advice from the meeting; this audit is strongly investigations and antibiotic therapy. recommended to include CSF cell count Babies with no red flags or only one risk factor/clinical indicator findings. CSF culture often shows no growth should be monitored, using clinical judgement on whether to but cell counts can lead to indications for withhold antibiotics or not. As part of this protocol a CRP 18-24 meningitis treatment. hours after the first indicates to consider performing an LP if: ●● Raise the study group’s threshold for ●● CRP of 10mg/litre or greater; or lumbar punctures based on CRP to 20 mg/ ●● positive blood culture; or litre ●● does not respond satisfactorily to antibiotics. ●● Re-audit to include cell count of CSF in 2017-18. This audit questioned if the threshold of CRP of 10mg/litre should be raised: each baby who requires an LP must be admitted, observed for four hours in the SCBU post-procedure, and have an admission and discharge Badger completed. The Badgers done for these patients are often of a much lesser quality.
86 babies had a lumbar puncture: 51 of these babies met the criteria of: ●● no clinical signs shown ●● first CRP <10 mg/litres ●● 18-24 hours CRP >10 mg/litres
The average 18-24 hour CRP was 42.78 (highest 147.6, lowest of 11.8). The average increase in CRP from the first reading was 38.
Based on these findings, lumbar punctures are being overdone due to the interpretation of guidelines.
Quality Account Report 2016-17 PAGE 42
2.2.3 Participation in Clinical Research The Trust is committed to research and transformation as a driver for improving the quality of care we provide to our patients. It enables our staff and the wider NHS, regionally and nationally, to improve the current and future health outcomes of the people we serve. Only by carrying out research into “what works” can we continually improve treatment for patients, and understand how to focus NHS resources where they will be most effective.
We currently support 374 research studies, of which 124 are clinical trials involving medicinal products. Our engagement with clinical research demonstrates the Trust’s commitment to testing and offering the latest medical treatments and techniques. During 2016-17, we recruited patients to 117 National Institute for Health Research Clinical Research Network (NIHR CRN) clinical research studies. The number of patients receiving NHS services provided or sub-contracted by the Trust in 2016-17 that were recruited during that period to participate in research approved by a research ethics committee was 3030. This level of participation demonstrates the Trust’s commitment to research.
The Trust’s reputation for attracting, initiating and delivering high quality industry trials has continued to grow this year, with the Trust currently supporting over 90 industry sponsored trials. Our excellent reputation with industry culminated in us being named as the ‘NHS Clinical Research Site of the Year” at this year’s Pharma Times International Clinical Researcher of the Year awards. The annual International Clinical Researcher of the Year competition is designed to challenge, recognise and reward the talent and passion of industry and academic researchers from all over the globe. To be named NHS research site of the year is a fantastic achievement and an independent stamp of endorsement, highlighting our excellence in the field of clinical research.
In addition to the above, the Trust had two finalists in the Clinical Research Nursing category at this year’s Nursing Times awards. The entries entitled “Improving access to NIHR CRN studies” and “Development of a research orientated high risk cardiovascular clinic” were both selected for the final. Having two finalists in this prestigious event was a fantastic achievement and the judging panel commended us on the high quality of our entries.
A new bespoke clinical research facility has opened on our Royal Oldham Site. This facility has dedicated clinical space that can accommodate up to eight adult research participants. There is also a separate unit specifically for paediatric research. Previously participants were quite often seen in outpatient clinics which sometimes lacked capacity in terms of space to carry out research activities. The new unit allows a number of participants to be seen simultaneously for screening, randomisation, study visits and procedures, and follow-up visits.
A number of Pennine employees were recognised for their contributions in the Greater Manchester Clinical Research Awards at a ceremony held in November 2016. Denise McSorland was the winner of the Research Nurse of the Year category for her significant contribution to research over 20 years. The pharmacy research team were runners up in the outstanding contribution category.
2.2.4 Use of the CQUIN Payment Framework The CQUIN framework encourages quality improvement by financially rewarding organisations that achieve specific quality indicators that are agreed with their commissioners during contract discussions.
A proportion of PAHT’s income for 2016-17 was conditional on achieving quality improvement and innovation goals agreed between the Trust and any person or body we entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. Detailed CQUIN performance is discussed at each contract meeting with the local CCGs, the Clinical Quality Leads’ meeting, PAGE 43
and the Divisional and Trust-wide Quality and Performance meetings. Information regarding CQUINs is available via the NHSE website: ●● https://www.england.nhs.uk/wp-content/uploads/2015/03/9-cquin-guid-2015-16.pdf ●● https://www.england.nhs.uk/nhs-standard-contract/cquin/cquin-16-17/
For 2016-17 there were contract CQUIN indicators, some of which were nationally defined, some regional and some local with an associated value of approximately £11m. As a result of participation in the CQUIN framework in 2016- 17, the Trust continues to make significant improvements to patient experience and outcomes, and estimate recovery to be in the region of £10.9m from Commissioners for the achievement of CQUIN schemes.
The Trust has agreed a plan with its Commissioners for 2017-18 to recover £7.1m from CQUIN payments. Acute contract schemes are now nationally mandated whereas ‘specialised commissioning’ schemes are agreed separately from the nationally mandated schemes. The reduction in the financials achievable for 2017-18 is as a result of amendments to the percentage share of the 2.5% CQUIN value available, with 1% being held in escrow in relation to Sustainability and Transformation Funding. These indicators, the percentage weighting assigned to each, and the approximate associated financial value is outlined in the table below.
17/18 CQUIN Schemes Approx Type Name of Indicator CQUIN % Value £s Acute and Community NHS staff and wellbeing. 14.04% 997,080 Acute Reducing the impact of serious infections 13.70% 973,144 Improving physical healthcare to reduce premature mortality Community 0.34% 23,936 in people with serious mental illness (PSMI) Improving services for people with mental health needs who Acute 13.70% 973,145 present in A&E. Acute Offering advice and guidance 13.70% 973,145 Acute E-referrals (Y1) 13.70% 973,145 Acute Pro-active and safe discharge 13.70% 973,145 Supporting Proactive and Safe Discharge – Community Community 0.34% 23,935 Providers Acute: 2018-19 Preventing ill health by risky behaviours 0.34% 23,935 Community: 2017-19 Community Wound Care 0.34% 23,935 Community Personalised care and support planning 0.34% 23,935 NHS England Improving HCV treatment pathways through ODNs 8.32% 591,029 Nationally standardised Dose banding for Adult Intravenous NHS England 0.70% 50,000 Anticancer Therapy (SACT) NHS England Activation System for Patients with Long Term Conditions 0.84% 60,000 NHS England Medicines optimisation 3.09% 219,523 NHS England LOCAL - Neonatal Community Outreach 2 Year CQUIN 2.82% 200,000
Quality Account Report 2016-17 PAGE 44
2.2.5 Statements relating to the CQC The Pennine Acute Hospitals NHS Trust is required to register with the Care Quality Commission and its current registration status is “registered with conditions” as a result of the inspection during February / March 2016 (see below).
The CQC has not taken enforcement action against the Pennine Acute Hospitals NHS Trust during the period 2016- 17, though alongside the publication of the report, the CQC announced in a press statement that “such is the level of concern that we have around quality and safety that in line with normal policy we would have considered recommending the Trust should go into special measures …”
However, the statement acknowledged the additional investigations into the challenges faced by the Trust that was undertaken by the leadership team from Salford (that had assumed leadership of the Trust immediately following the inspection) and the improvement plans that this review had generated.
The Pennine Acute Hospitals NHS Trust has not participated in special reviews or investigations by the CQC during the reporting period, though there has been close monitoring of progress of improvement actions following on from the CQC inspection in February / March 2016. The formal report of findings was published in August 2016, but improvement work had already begun following feedback from the CQC at the time of the inspection (see section 3.1.1). This was to take immediate action to support what the CQC identified as “fragile services:” urgent care; maternity; paediatrics; and critical care in Oldham.
The overall rating for the Trust was inadequate: Safe Effective Caring Responsive Well-led Overall Requires Requires Inadequate Good Inadequate Inadequate Improvement Improvement
The summary ratings by site were as follows:
North Manchester General Hospital Service Safe Effective Caring Responsive Well-led Overall Urgent and emergency Requires Inadequate Good Inadequate Inadequate Inadequate services Improvement Requires Requires Medical care Inadequate Good Inadequate Inadequate Improvement Improvement Requires Requires Requires Requires Surgery Good Good Improvement Improvement Improvement Improvement Requires Critical care Good Good Good Good Good Improvement Maternity and Requires Requires Inadequate Good Inadequate Inadequate gynaecology Improvement Improvement Services for children and Requires Requires Requires Inadequate Inadequate Inadequate young people Improvement Improvement Improvement End of life care - Requires Good Good Good Good Good Hospital Improvement PAGE 45
Service Safe Effective Caring Responsive Well-led Overall Outpatients and Good Not rated Good Good Good Good diagnostic imaging Requires Requires Overall Inadequate Good Inadequate Inadequate Improvement Improvement
The Royal Oldham Hospital Service Safe Effective Caring Responsive Well-led Overall Urgent and emergency Requires Requires Requires Requires Good Good services Improvement Improvement Improvement Improvement Requires Requires Requires Requires Medical care Good Good Improvement Improvement Improvement Improvement Requires Requires Requires Surgery Good Good Good Improvement Improvement Improvement Requires Requires Critical care Inadequate Good Inadequate Inadequate Improvement Improvement Maternity and Requires Requires Inadequate Good Inadequate Inadequate gynaecology Improvement Improvement Services for children and Requires Requires Requires Inadequate Inadequate Inadequate young people Improvement Improvement Improvement End of life care - Requires Requires Requires Good Good Good Hospital Improvement Improvement Improvement Outpatients and Requires Not rated Good Good Good Good diagnostic imaging Improvement Requires Requires Overall Inadequate Good Inadequate Inadequate Improvement Improvement
Rochdale Infirmary Service Safe Effective Caring Responsive Well-led Overall Urgent and emergency Requires Requires Requires Good Good Good services Improvement Improvement Improvement
Medical care Good Good Good Good Good Good
Surgery Good Good Good Good Good Good
Outpatients and Good Not rated Good Good Good Good diagnostic imaging
Overall Good Good Good Good Good Good
Quality Account Report 2016-17 PAGE 46
Fairfield General Hospital Service Safe Effective Caring Responsive Well-led Overall Urgent and emergency Requires Requires Requires Requires Good Good services Improvement Improvement Improvement Improvement Requires Requires Requires Requires Medical care Good Good Improvement Improvement Improvement Improvement Requires Requires Requires Surgery Good Good Good Improvement Improvement Improvement Requires Requires Requires Critical care Good Good Good Improvement Improvement Improvement End of life care - Requires Requires Requires Requires Good Good Hospital Improvement Improvement Improvement Improvement Outpatients and Good Not rated Good Good Good Good diagnostic imaging Requires Requires Requires Requires Requires Overall Good Improvement Improvement Improvement Improvement Improvement
Community services Service Safe Effective Caring Responsive Well-led Overall «« End of life care Good Good Good Good Good Outstanding Children, young people Good Good Good Good Good Good and families
Community adults Good Good Good Good Good Good
Community inpatients Good Good Good Good Good Good
The Trust reviewed the published reports and noted all the mandated actions (“must do”) and advisory actions (“should do”). These were circulated to the divisional leads, and mapped to executive assurance groups to monitor progress of assurance from the divisions. They were also incorporated within the improvement plans (see section 3.1.1). Most of the mandated and advisory actions have been considered as Trust-wide actions, even though they might have been directed at a specific service or site. This is to ensure that all areas are improving and learning from the findings of the inspections across all the sites.
The Trust met with representatives and the Head of Inspection for the CQC in both December and February to review and update on progress against the agreed action plan and priorities following the February 2016 inspection. Focus was given to the fragile services of maternity, paediatrics, critical care and urgent care, reviewing the ‘must dos’ that had been outlined in the final published report of August 2016. The CQC were supportive of the direction of travel and progress made to date, in particular the Quality Improvement strategy and plans for staff engagement and organisational development. The Trust is expecting a follow up visit and assessment during the course of 2017/18 which will comprise of a planned inspection, an unannounced inspection of a core service and a well led review. PAGE 47
Statement of Purpose It is a statutory obligation of the Trust to notify the CQC of any changes in our premises or the type of services provided. The Statement of Purpose was comprehensively reviewed in July 2016 when a number of amendments were made including transferring the document to the template supplied by the CQC. Service leads were asked to review their information again in December 2016, and it is planned that this will be undertaken each quarter during the period of transition for the Trust’s services. A new certificate of registration was issued by the CQC in January 2017.
Nominated Individual Mrs Elaine Inglesby-Burke, Chief Nurse, is the Nominated Individual for the Trust’s CQC registration since being appointed as Chief Nurse on 1st August 2016.
2.2.6 Data Quality Good quality information underpins sound decision making within the Trust and contributes to the improvement of healthcare services. There is a dedicated Data Quality Department, part of Information Management and Technology (IM&T), which concentrates on the electronic systems in use at the Trust. It works to an annual programme of audits which is agreed by the IM&T Steering Group (ISG): this is a governing group for data quality at the Trust, chaired by the Director of Finance and represented at a senior level with executive members, Divisional Directors (clinical and non-clinical), Finance, Commissioning and IM&T senior managers.
Quality Account Report 2016-17 PAGE 48
There is an approved Data Quality Strategy and Data Quality Policy in place which are reviewed and approved by the Data Quality Assurance Group (DQAG) and ISG annually, or more frequent if required. Adherence to the policies is monitored via data quality audits and the findings are presented and recorded via the CQAG to the ISG that reports into the Executive Finance, Information & Capital Governance Committee.
There is a structured approach to the department’s work, both day-to-day work and the annual programme of audits which are supplemented by bespoke audits identified as requiring a focus and improvement linked to the following: ●● Accuracy and timeliness of data collection for key datasets ●● Baseline audits and reviews for Urgent Care ●● Baseline audits and reviews for key patient pathways (Accident & Emergency, and Referral to Treatment times) ●● Quality Account ●● Data Quality improvement work-streams ●● Service Reviews ●● Information Governance Toolkit ●● Contract KPIs ●● Adverse variances in Trust activity recording
However, it has been identified that the Trust has some data quality issues in relation to validating the grading of reported incidents. A new incident management system has been purchased and this will support more timely and accurate validation. It is planned to be implemented throughout the Trust during Q1 2017-18
The Trust will be taking the following additional actions to improve data quality:
1. Improve the recording of Outpatient Procedures in the following specialties by training clinicians and staff and increase routine audits to maintain improvements: ●● Trauma & Orthopaedics ●● Urology ●● Breast Surgery ●● General Surgery ●● Oral & Maxillofacial Surgery ●● Ear Nose & Throat
2. Improve the recording of a patient’s treatment information including co-morbidities for select specialties to support patient care and accurate reflection of the Trust’s mortality ratio as follows: ●● Cardiology - stroke ●● Pneumonia ●● Chronic Obstructive Pulmonary Disease (COPD) ●● Urinary Tract Infections ●● Acute Kidney Failure (AKI) ●● Cardiac Pacing ●● Upper GI Tract PAGE 49
3. Improve the recording of Accident and Emergency data to ensure that it is reflected in the systems used for our urgent care patients admitted by: ●● Undertaking baseline audits to understand key issues with data quality ●● System upgrades and changes to support accurate data capture of data ●● Devising and delivering training for clinical staff in A&E ●● Monitoring and reviewing data quality to maintain improvements
2.2.7 NHS Number and General Medical Practice Code Validity The Pennine Acute Hospitals NHS Trust submitted records during 2016-17 to the Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics which are included in the latest published data.
The percentage of records in the published data submitted to the SUS which included the patient’s valid NHS number was: ●● 99.8% for admitted patient care; ●● 99.8% for outpatient care; and ●● 98.7 % for accident and emergency care.
The percentage of records in the published data which included the patient’s valid General Medical Practice Code was: ●● 100% for admitted patient care; ●● 99.9% for outpatient care; and ●● 100% for accident and emergency care.
2.2.8 Information Governance Toolkit attainment levels Information Governance regulates how NHS and social care organisations handle information, particularly confidential or sensitive personal or corporate information. The Pennine Acute Hospitals NHS Trust’s Information Governance Assessment report score overall for 2016-17 was 68%, and was graded green (satisfactory).
Key areas for improvement are linked to cyber security and continuation of data flow mapping and aligning of contracts with associated information sharing agreements.
2.2.9 Clinical Coding Error Rate The PAHT was not subject to the Payment by Results clinical coding audit during 2016-17 by the Audit Commission / regulatory bodies that decide which NHS Trust is to be audited for clinical coding. This year the Trust has not been subject to a Clinical Coding Assurance Framework Audit.
Following an annual clinical coding audit in line with the IG Toolkit requirement 505, the Trust achieved level 2 based on the error rates for diagnosis and treatment coding as detailed on the table.
Audit Area Compliance Primary Diagnosis 92.50% Secondary Diagnosis 92.61% Primary Procedure 94.77% Secondary Procedure 94.81%
Quality Account Report 2016-17 PAGE 50
REVIEW OF PART 3 QUALITY PERFORMANCE
3.1 Quality Improvements at PAHT 3.1.1 High-level plan Since August 2016, the Trust has an overarching improvement plan in place, outlining immediate actions which would help the Trust stabilise its services and create the right conditions upon which to continue to improve and ultimately transform care delivery across Pennine. Progress against the plan is discussed at each public board meeting and delivery is monitored by the Pennine Improvement Board. This board includes external representatives from the local health and care economies, and is chaired by the Chief Officer of the GM Health and Social Care Partnership. This ensures there is a shared understanding and collective commitment to the delivery of the improvement plan, including the resources that need to be made available to enable the changes to happen.
The plan was developed from two sources. First were the immediate patient safety concerns that the CQC raised with the Trust during their inspection in February/ March 2016. These related to four main service areas, referred to as the fragile services: ●● Maternity; ●● Children’s services; ●● Urgent Care; and ●● Critical Care
Secondly, were the key areas for improvement identified by the senior executives from Salford Royal NHS Foundation Trust, during their review into the causes of risk to patient safety and care sustainability. The other key areas for improvement identified by the SRFT review were: ●● Patient safety, harm and outcomes; ●● Systems of assurance and governance arrangements; ●● Operational management and data quality; ●● Workforce capacity and capability; and ●● Leadership and external relations.
A number of improvement projects have been developed within each of these areas, and together these form the Quality Improvement Programme coordinated by the Interim Director. Each project contains various work streams and these incorporate all the recommendations made by the CQC (“must-do” and “should do” actions - see section 2.2.5) where relevant.
The overarching Project Plan is being dis-aggregated into Care Organisation level improvement to enable a more focused, site-specific transformation strategy, in addition to providing clearer ownership and accountability for project tasks. The assurance framework will be adapted to reflect the new arrangements. PAGE 51
3.1.2 Quality Improvement Programmes A summary of the key work-streams of each project, and the progress, is shown in the tables below. Some of these projects incorporated or superseded some of the ‘priorities for improvement for the forthcoming year,’ that were set out in the 2015-16 Quality Account. These are noted below where applicable.
Project: Urgent Care improvement (including Ambulatory Care) Aim: stabilisation of service
Work-stream Summary of actions completed Impact Staffing Medical consultant rota supported via Salford Total additional cover 24 PAs giving 90 hours Royal FT and Central Manchester FT consultants per week senior consultant shop floor cover. resulting in additional 18 PAs per week. Greater senior presence has increased clinical Consultant post from ROH moved to NMGH leadership and support for junior staff with resulting in additional 5 PAs per week. decision-making. Core of 5 consultant CCT Certificated (3 x PAHT Additional workforce has supported the substantive and long term locums). stabilisation of the department. Introduction of 12 hours per day 7 day GP cover On average 30 patients per day now seen to support primary care presentations. by GP. Doctor recruitment programme. Increase in Speciality Doctor at Rochdale from 0.75 to 1.75. An increase in consultants from 4.80 wte at NMGH to 6 WTE Directors of nursing have undertaken a review of At the end of March, an increase in qualified ED nursing establishments, workforce paper has nurses at FGH ED from 41 wte to 45.61 wte, been agreed at Trust board. and an increase in HCA in ED from 40.38 to 44.05. The Trust has 303 more staff across medicine and urgent care than this time last year, with 122 new nurses offered jobs to start in September. As part the preceptorship programme we also have 35 newly qualified nurses who joined the EDs in March and 13 other staff now on our programme. Additional workforce has supported the stabilisation of the department.
Quality Account Report 2016-17 PAGE 52
Work-stream Summary of actions completed Impact Staffing An additional registered nurse has been in place It is too early to assess the full impact of since December 2016 on each shift in each ED. these roles, but the median time in ED has They are predominantly to support minor injuries, stabilised. but can be utilised to support care of majors patients when required. A successful pilot scheme for a Tracker Role has These roles will commence in April 2017. been undertaken and a job description is being developed. The A&E Tracker role will “trouble-shoot” any issues arising to improve patient flow throughout all EDs. National innovative recruitment campaign This commenced in February 2017, and focused around acute physicians but also there has been good initial levels of interest encompassing other specialities. in the vacancies. Ambulatory Ambulatory care process reviewed, PDSA cycles Non-elective LOS reductions from 5.9 to 5.2 care undertaken, work with NWAS in place on direct days over last 12 months. triage from ED to ambulatory care 30-day readmissions down by 0.7% to 5.6% NMGH rollout of Trusted Assessor framework. Left without being seeing rates down from 6.8% to 4.9%. Attendance to admission rates improved and maintained below national average. An audit of the use of exclusion criteria for This has led to better patient flow and Ambulatory Care has been delivered in January to patient experience throughout the ED dept. confirm the right patients are being progressed and helps free up time for clinicians to through the pathway. attend to more major injuries. A pilot at NMGH recently found that 15% of patients in ED are suitable for Ambulatory Care, and the Trust has set a target of 20% to achieve for coming months. Staff All newly qualified staff have a six-week Performance Development review (PDR) development supernumerary preceptorship, in excess of the rates across all EDs have increased from period defined in the Trust policy. All newly 49% to 89% (nursing and medical staff qualified nurses have an identified mentor and combined). preceptorship. PDRs enable staff to improve their development and skills and which will lead to increased patient quality and care. PAGE 53
Work-stream Summary of actions completed Impact Working ‘Emergency Department Extended Wait Policy’ This provides clear guidelines for clinicians differently has been reviewed with clear escalation and which empowers them to make appropriate reporting procedures defined, in line with Greater clinical decisions. Manchester processes. The number of 4-12 hour target breaches had decreased since the introduction of the policy in December 2016: 621 in December to 459 in March 2017. Service NMCCG have approved business case for the Two additional community support nurses development extended crisis response service for the remainder are in post to support delivery of the service. of 2016-17. Funds have been agreed for additional support workers and building improvements. The new discharge lounge at TROH has been This has helped alleviate unnecessary waits completed and is now live and running. for patients to be discharged and has led to improvements in freeing up capacity throughout the department. The numbers of 12 hour breaches has improved from 85 in December 2016 (when the lounge was opened) to 54 in March 2017.
Quality Account Report 2016-17 PAGE 54
Work-stream Summary of actions completed Impact Patient flow ‘Streaming to Primary Care’ Process has been This has improved the patient journey developed and is now live in Rochdale. It enables and efficiency and safety of the patients patients requiring urgent specialist assessment requiring specialist assessments at the to be streamed directly to an appropriate Rochdale site. From Dec 2016 to end March assessment unit. 2017, there were no 4-hour breaches from 456 patients on the Primary Care Pilot. Identification and commissioning of interim beds This facilitates timely discharges at Fairfield in partnership with the local authority. site, by having increased capacity for A ‘Trusted Assessor’ role has been developed patients and by eliminating the need and implemented so patients are assessed by for separate assessments by different just one healthcare professional, on behalf of all professional groups. professional groups.
Project: Maternity Care improvement Aim: stabilisation of service
Work-stream Summary of actions completed Impact Safe midwifery Appointments have been made to Director Strengthening of leadership, improved focus staffing of Midwifery, Practice-based Educator, on training. Increase in staff development and Deputy Head of Midwifery, Inpatient education. matron and labour ward matron. Compliance with training targets. Safe medical Recruitment of additional consultants for Implementation of 168 hour-week consultant staffing labour ward. resident cover on labour ward at the ROH being worked toward. Twilight shifts established. Strengthening of medical staffing rotas across all sites. Proposals for new rotas for both sites under development. Consultant job planning process All consultant job plans completed and on-call undertaken. consultants meet the RCOG recommendations and non-resident consultants can attend labour ward within 30 minutes of call out. PAGE 55
Work-stream Summary of actions completed Impact Managing risk Implementation of risk assessment tool for Tools implemented and audits of effectiveness use within Maternity including EWS for planned. adults and neonates. Review the internal governance structure Full review of governance and risk structures including Complaints, Risk and Project completed. Historic cases completed and Management. moved into real time case management. Improvement in the management of Strengthened the process for management Clinical Incidents, support development of incidents, including feedback to staff, of culture in which lessons are learned - establishment of comprehensive feedback including feedback mechanisms. mechanism. Focus on key themes with development of on key work streams to ensure repeated incidents are reduced. Mortality and Addition of Midwives to the TOR for Comprehensive review of all cases provided at morbidity meetings, and for matrons to attend the M&M meetings. Focus on learning lessons as a minimum. Administrative support and wide ranging attendance from across provided to ensure support to meetings. the Division achieved, alongside attendance monitoring. Communication Review of communication across the Implementation of core huddles. Division. SBAR handovers in place. Newsletter for all staff. Strengthening of local meetings to improve communications QI Quality improvement methodology is being Greater focus on understanding the data embedded into the review of services within individual services. Development of across W&C. comprehensive dashboards to ensure attention on key areas is achieved. Variation in service delivery achieved across a number of metrics. Capacity and Comprehensive capacity and demand work Identification of areas requiring attention. demand completed for all services in W&C. Development of action plans, work programmes and a number of task and finish groups to drive improvement work through. Single site Significant infrastructure in place to Milestones established to monitor transfer. preparation support the early transfer of W&C services.
Quality Account Report 2016-17 PAGE 56
Project: Paediatric Care improvement Aim: stabilisation of service
Work-stream Summary of actions completed Impact Workforce Appointment of Patient Flow Co-ordinators Weekly length of stay meetings established. to review patients with length of stay of Shortening of pathways and length of stay over 4 days, and introduce a system to across a number of pathways e.g. asthma. capture and monitor patients needing LOS dashboard established to benchmark higher levels of care. performance and used to drive further improvement. Managing risk Paediatric escalation audit has been Development of paediatric capacity escalation completed. guidelines to ensure prompt escalation and reduction in transfers of children out of the service. Review of existing clinical guidelines. Work is in progress to complete the review. Implementation of risk assessment tool for MANCHEWS assessment tool embedded into use within Paediatrics including EWS at clinical practice. Oldham. Governance Review the internal governance structure Full review of governance and risk structures including Complaints, Risk and Project completed. Historic cases completed and Management. moved into real time case management. Improvement in the management of Clinical Strengthened the process for management Incidents, support development of culture of incidents, including feedback to staff, in which lessons are learned - including establishment of comprehensive feedback feedback mechanisms. mechanism. Focus on key themes with development of on key work streams to ensure repeated incidents are reduced. Mortality and Review of ToR: it is now compulsory for Comprehensive review of all cases provided at morbidity matrons to attend. All nursing staff band 6 the M&M meetings. Focus on learning lessons and over are invited to attend. and wide ranging attendance from across the Division achieved, alongside attendance monitoring. Training Plan for medical and nursing staff to be Training needs assessment carried out to ensure trained in advanced paediatric life support that training in life support is appropriate and paediatric intermediate life support to job role and skill level required. This is comprehensively in place alongside a sustainability plan. PAGE 57
Work-stream Summary of actions completed Impact Communication Engagement sessions to ensure staff have “Going for Gold” staff involvement sessions the opportunity to contribute to service have enable staff to drive services changes and improvements. undertake tests of change to implement new ideas and plans.
RESPECT feedback boards established. “Tops and Pants” initiative - Patients, National initiative which has been embraced Parents. in paediatrics encouraging families/carers and young people to give feedback on their experience. Review of capacity and demand New services models and ward configuration within Outpatient areas (NMGH) and being trialled to test effectiveness of proposed inpatient / POAU areas (ROH) - making models. recommendations to improve service provision identifying benefits realisation. Clinical practice 23:59 paediatric assessment unit has been Significant reduction in length of stay in ED for established at Oldham. children requiring an inpatient or observation bed. Reduction in transfers of children out of Pennine for secondary care bed needs. On- going monitoring and assessment to understand effectiveness of services.
Quality Account Report 2016-17 PAGE 58
Project: Critical Care improvement Aim: stabilisation of service
Work-stream Summary of actions completed Impact Recruitment & A medical and nursing business case has Approval of the business case has enabled the Retention: been approved and is being implemented: service to work towards full staffing compliment 2.98 qualified nurse posts were approved and will lead to improved performance and Medical and for FGH, 5.01 for ROH and 3.14 for NMGH. patient safety over the next 6 to 12 months. Nursing 4 additional consultants and 7 speciality At end March, there were 0.33 qualified nurse doctors were approved for ROH. vacancies at FGH, 4.19 at ROH and 2.72 at Overseas recruitment of speciality doctors NMGH. However, the position continues to is on-going and to date one is in post in fluctuate. ROH with a further three to start June / July There is still a shortfall of 8 consultants at ROH 2017. However, all overseas recruits need (including the additional posts from the business a six-month induction so won’t be in the case), 1 at FGH from a recent resignation, and numbers on the rota independently until 1.5 at NMGH. December 2017. 3 remaining speciality doctor posts at ROH, and Nursing recruitment is on-going with some 2 between FGH and ROH, are being actively appointments already made, and working recruited to. within the numbers. The vacancies pose an on-going risk/challenge A matron for ROH ICU has been recruited for the service. and is in post: this role has added a greater level of experience, and leadership to the team. Advanced Two ACCP trainees have been appointed These roles will enhance the staff cohort by Critical Care and commenced a 2-year training stabilising the units’ reliance on agency staff Practitioners programme in Feb 2017. and will lead to greater stability within the units (ACCP) participating in the ‘resident’ layer of the rota. A further two are to commence in Feb 2018. Equipment/ A funding case for a new 24-bedded Critical These developments will ensure that the service Care Unit at Oldham has been submitted to is safe and fit for purpose, and comply with the Environment the Treasury and is awaiting final approval in mandated requirements (NHS England’s ‘D16’ August 2017. standard contract for adult critical care, and the Department of Health’s ‘HBN-04-02’ guidance on planning and design of critical care units). Governance With support from the newly appointed The introduction of a designated site lead has led ROH site lead, and a unit manager to more robust governance and clinical expertise undertaking additional governance at site level. responsibilities, a bi-weekly mortality and There is a focus on the learning outcomes of morbidity meeting was established. This these meetings. The new structure and processes developed to becoming a joint site meeting need to become embedded. over the ensuing months. PAGE 59
Work-stream Summary of actions completed Impact Education/ Work to improve compliance with There has been a significant increase in the Training mandatory training and PDR completion has number of staff appraisals completed and the been delivered in terms of addressing and directorate are on track. identifying the gaps. The nursing staff with personal development plans in place at 31st March 2017 was: ●● FGH 100% ●● TROH 89% ●● NMGH 100%
Project: Deteriorating patient (incorporating the quality priority “to improve early identification and management of patients who are deteriorating”) Aim: To reduce the rate of cardiac arrests by 50% by 30th November 2017
Work-stream Summary of actions completed Impact National early NEWS observation chart pilot completed. From pilot feedback, staff feel more confident warning score The final version of the NEWS observation in identifying and knowing when to escalate a (NEWS) chart chart is being rolled out across the Trust deteriorating patient. from 7th April 2017 with aligned training. Sepsis drive Sepsis e-learning module developed and Better training and education will enable staff to has been made ‘essential job training’ for all recognise and respond to sepsis in a more timely clinical staff in emergency departments and way to improve care. treatment units; training is to be completed by Q1 2017/18.
The sepsis screening and action tool has been ratified by the sepsis steering group and will be rolled out across the Trust in April 2017.
A Sepsis communication drive is planned for the week of 3rd April 2017. Deteriorating This was held on 1st March 2017. Each Overall, staff reported more confidence in 1) Patient innovation ward updated on their tests of identifying, 2) escalating and 3) managing the Collaborative change. A focus was placed on uDNARCPR deteriorating patient. – Learning in the latter half of the day. Session 2
Quality Account Report 2016-17 PAGE 60
Project: Infection prevention – Clostridium difficile infection reduction – 90 day improvement cycle Aim: to improve hand hygiene compliance and antibiotic stewardship
Work-stream Summary of actions completed Impact Antimicrobial Urinary tract infection screening toolkit Initial audit results reviewed and areas for stewardship developed to support effective and accurate improvement have been identified. diagnosis of UTI with appropriate antibiotic The next stage will be to monitor and review prescribing. the use of the screening toolkit on AMU. Staff engagement and training complete.
Antimicrobial stewardship tests on ROH AMU commenced 28th February and impact of test to be reviewed week commencing 3rd April 2017. Improving hand Staff education of ‘patient hand hygiene At the half-way stage of the test period the hygiene for moments’ (the occasions when patients should average increase in patient hand hygiene patients using undertake hand hygiene) is completed. compliance was: an innovative Patient awareness posters and leaflets have been ●● Ward 18 at FGH 74% five moments developed. ●● Ward T3, ROH, 74% of hand hygiene model. Hand hygiene wipes made available to all patients.
Patient Hand Hygiene first cycle complete; test sites are ROH Ward T3 and FGH Ward 18.
Pilot has also been extended to three other wards for additional reliability / validity.
Project: Pressure ulcer reduction Aim: (proposed) 30% reduction in grade 2; and 50% reduction in grades 3 and 3 pressure ulcers by April 2018
Work-stream Summary of actions completed Impact Scoping Expert meeting was held 30th March. Driver diagram formulated.
Ward involvement / project structure agreed.
Attendees introduced to the proposed methodology. Project initiation document is in This will prepare for the initial learning event to development and will be presented to May commence the programme at the end of June EQPE by Tyrone Roberts. 2017. PAGE 61
Project: NAAS ward accreditation (nursing assessment and accreditation system) (incorporating the quality priority “to implement the accreditation programme for wards and departments across the Trust”) Aim: to conduct an initial assessment on all 59 wards by w/c 14th July 2017
Work-stream Summary of actions completed Impact NAAS: Salford documentation reviewed to reflect A tested tailored methodology in place to roll out preparation and PAHT needs and pilot completed on nine Trust-wide. pilot. wards. Implementation To 31st March, 25 first assessments and Action plans have been developed by the of NAAS three reassessments have been undertaken. relevant ward managers and improvements implemented. 14 wards were graded red, 8 amber and 6 green. These improvements will be validated in the re- inspections.
Wards scoring red have two weeks to complete their action plan, and are then reassessed after eight weeks.
If wards are graded red for a second time, the senior nursing team meets with the Director of Nursing to compile and agree the action plan.
Targeted priority and support is given to these areas. Implementation Improvements made in the areas identified These improvements have resulted in the NMGH of action plans as required in the pilot ward. pilot ward going from red to amber, and the FGH pilot ward going from red to green. Action plan implementation is monitored by the relevant divisional senior nursing These improvements reflect a direct improvement team. in patient experience and safety. Leadership Three corporate matrons have been They will commence in post in May 2017. recruited to work with the NAAS team.
Quality Account Report 2016-17 PAGE 62
Project: Help-line implementation Aim: To have a phone, manned 24/7 on each site by a senior member of staff, that patients and their families can use to raise urgent concerns
Work-stream Summary of actions completed Impact The helpline During December 2016 and January 2017 Information from the calls placed to the helpline scheme the help line scheme was successfully contributes to identifying areas for safety or provides a piloted within the Trust. patient experience improvement within the Trust. mechanism The implementation phase of the scheme Since the implementation of the scheme, there for patients or was completed during February and March have been six calls made to the helplines; four their families to 2017: a total of 78 wards and departments of which were at NMGH, and two at TROH. contact a senior across all four hospital sites and off-site All six calls were successfully managed without member of premises such as the Trust’s intermediate escalation to the executive for intervention, staff who has care homes and the rehabilitation unit. though one call was escalated for information. responsibility to respond to their Each of the sites is responsible for managing call. an on-call rota 24/7.
Help line is now The helpline scheme is advertised by available across displaying posters in each of the bed/bay the Trust. areas. In addition, each ward & department entrance has a larger A3 sized multi-lingual version of the poster. PAGE 63
Project: Mortality reduction (incorporating the quality priority “to review and improve the Trust’s independent mortality review processes”) Aim: year on year improvement in HSMR to be in top 10% of acute Trusts
Work-stream Summary of actions completed Impact Analyse relevant Identification of the five clinical conditions Further analysis is focusing on these areas. information showing most excess deaths: pneumonia; This will ensure independence and objectivity in to gain a full UTI; stroke; COPD; and renal failure. the review. It is expected to report at the end of understanding Agreement with Dr Foster that they will May 2017. of the current conduct the clinical review of excess deaths position Areas for improvement identified: at FGH. ●● accuracy of primary diagnosis coding Clinical documentation / coding review ●● accuracy of comorbidity coding of case notes in the alerting conditions It has been recognised that introduction of completed internally (doctor and coder a summary of care document will make a working together). significant impact. Internal review of low-risk deaths in April / Review identified some deaths were not low- May 2016 completed. risk and had been wrongly classified from documentation / coding.
A quarterly review of the lowest risk deaths will now be undertaken routinely ‘Mortality time-lines’ have been created, Initial review shows a rise in HSMR following mapping the timeframes of significant implementation of the Evolve system, and operational issues against changes in following the reduction in coding deadline mortality rates. timescale.
These timelines will be kept as routine work to support analysis of varying rates. Maximise the Processes and responsibilities for This informed the training needs analysis. effective use routine surveillance of Dr Foster, and for of available investigating alerts, have been agreed. information Process flowchart developed. systems Training needs analysis for different staff Training schedule agreed with Dr Foster. groups has been completed. Training in Dr Foster system commenced. Staff able to use the system effectively to identify areas for further investigation.
Quality Account Report 2016-17 PAGE 64
Work-stream Summary of actions completed Impact Ensure accuracy 60 sets of case notes have been reviewed Key areas for improvement have been identified of clinical for accuracy: doctor and coder working and communications prepared and sent to documentation together. doctors. and coding Findings to be incorporated into coding training sessions. Review of coding processes for discharged Standard Operating Procedure agreed. and deceased patients completed. Identified the requirement for a summary of care document for deceased patients, and this is being developed in association with the end of life care group and IT. Improving Routine monthly reviews continued, and Reports will now be circulated two months mortality backlog has been addressed. after the month of the deaths: this will facilitate surveillance with timely actions and better links with speciality the development reviews. of a systematic Requests to the new care organisations This will be required with the forthcoming new and cohesive to nominate staff from other professional national methodology. approach disciplines for the core review team. Review of each speciality’s approach to Identification of best practice and agree the mortality case reviews at clinical governance benchmark and core requirements for local meetings. mortality review. Development of standard templates for To provide clear guidance for the speciality leads local investigation and reporting, including in relation to their responsibilities and processes. core agenda for governance meetings.
Acting on The structure and processes for sharing This will facilitate sharing and learning from findings findings from all mortality reviews, including findings. and making approval and monitoring implementation of improvements actions, has been agreed and standardised. Strengthening Mortality Surveillance Group has been All mortality information is now channelled governance established - will receive reports relating through the same group to facilitate arrangements to all mortality investigations, and monitor monitoring. progress of improvements. The core standards and ToR for “M&M” To provide clear guidance for the speciality leads meetings (or for the “M&M” component of in relation to their responsibilities and processes. clinical audit meetings) have been agreed and disseminated to the directorates. Site Medical Directors have been asked The mortality leads will lead mortality to nominate mortality leads for each site/ governance on behalf of the site medical speciality. directors. PAGE 65
Project: End of Life and Bereavement Care Aim: Equitable care irrespective of place of dying - every patient - every time.
Work-stream Summary of actions completed Impact End of Life Care ●● Ward walks throughout Trust incorporating Raise awareness of EOLC initiatives to staff updates on: and increase knowledge. • Individual plans of care and support for Empower staff members. the dying person • Rapid transfer pathway • Recording time of death and reasons for this • Recording care given at end of life, at death, after death • Recording care given to relatives
●● Guides / uniformed groups initiative for provision of ‘comfort packs’. ●● Revised notification of death form. ●● Revised mortuary deceased person bag form.
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Work-stream Summary of actions completed Impact Implementation For patients and relatives: Increase standards of care within of swan symbol ●● Swan signs in A5 and A4 for all wards and bereavement by staff relating a best practice to represent departments. model to care delivery provided to our end of life and patients and families. ●● Swan magnets for patient boards. bereavement ●● Swan patients’ property bags. care For staff (to raise awareness / profile): ●● posters – the meaning of the swan. ●● Various accessories, e.g. swan calendars, pens, post-its, notepads, A7 pocket cards. ●● Swan pin badges for uniform lapel to be issued to staff as appropriate. End of Life ●● End of life care resource files revised and fully Increase in staff knowledge in relation to Care and updated with new initiatives, signposting resources available for bereavement and Bereavement to education, policies and webpage, swan EOLC, providing quick reference guides and model, spiritual care, and delivered back to resources at close hand. the wards. This will in turn increase the quality of care ●● End of life care storage boxes for all wards delivery and ensure we are providing choice and departments containing: and options as appropriate at the EOL. • All swan merchandise • Comfort packs • Personal message cards • Sympathy cards • Lock of hair pouches • Ring/treasure boxes • Religious and spiritual aids such as The Bible, The Quran, rosary beads etc. • Relevant information leaflets PAGE 67
Work-stream Summary of actions completed Impact Education and ●● Launch of monthly end of life care and Increase education, knowledge, confidence Training bereavement care study days Trust-wide for & competence of all staff groups across all staff. the organisation and provide them with ●● Real time coaching provided on wards; Trust- ownership and engagement in relation to wide but with an initial focus on NMGH and bereavement/EOLC. ROH. ●● Bereavement and all end of life care, incorporated into existing modules of palliative and end of life care education running four times a year Trust-wide. ●● Bereavement, tissue donation and all end of life care incorporated into link professional meetings, running three full days a year Trust-wide. ●● Regular slots on NMGH ED mandatory training days – aim to establish the same for each site. ●● Focus on appropriate use of the individual plan of care and support for the dying person along with the communication diary. ●● uDNACPR – audit, improvement, education throughout the Trust and launching three half-day conferences. End of Life Work on-going with patient experience team Increased support and experience for Support to ensure a safe effective service of volunteers patients and families at the EOL. Volunteers Trust-wide, who follow a structured role description with Trust governance and support mechanisms. Link Currently a revised title and contract being Increased knowledge, confidence and Professionals developed to incorporate the NAAS and competence of bereavement/EOLC which individual appraisal systems. will be cascaded back to clinical areas. Bereavement Job descriptions for dedicated bereavement Improved quality, experience and support Nurses nurses for each care organisation are finalised to our bereaved families across the awaiting agreement prior to advertising. organisation. Bereavement Dedicated bereavement ‘swan suites’ for NMGH, Improved quality, experience and support Offices ROH and FGH/RI. to our bereaved families across the ●● Areas identified. organisation. ●● Agreed building plans. ●● Furnishings ordered.
Quality Account Report 2016-17 PAGE 68
Work-stream Summary of actions completed Impact Swan Suites Collaboration with the theatre departments Improved quality, experience and support across the organisation to develop their own to our bereaved families across the swan suites. organisation. Multi Faith Formation of a multi faith ‘care after death’ Improved care after death for our faith Group group to ensure a quality service, meeting the communities. faith communities’ needs and reviewing current guidelines. Work with ●● Partnership working. Coroner and ●● Specific joint initiative around patient GMP identification by families. Service review Service review undertaken of the Specialist Appropriate access to a workforce meeting Palliative & EOLC teams across the organisation. the SPC/EOLC needs of our patients and families 24/7. Work with ●● Review of mortuary services. Improved experience for patients and mortuaries ●● Review of the environmental facilities for families. families. Appropriate provision and access to mortuary services Trust-wide. Work with Review of historical working practices. Adherence to safe working practices. Portering staff Data collection Collection of key data following every death of Ability to produce regular reporting of data every patient across the organisation. so identification of gaps, compliance can be addressed appropriately.
Project: Hospital at Night Aim: to review the night practitioner and night management teams to enhance patient flow and improve out-of- hours safety for patients.
Work-stream Summary of actions completed Impact Activities of Audit results collated by night teams on each site using Highlighted the variation in Hospital at the data collection tool and presented to the hospital at practices between sites. Night team night steering group. This information will be used to develop the improvement plan for work to progress in 2017-18. PAGE 69
Project: Safeguarding and medicines safety Aim: 12 month work plan for improvement
Work-stream Summary of actions completed Impact MCA/DoLS ●● Clinical Medical Champion has been identified for Improved understanding of process Training MCA/DoLS. for staff and improved care for ●● Extra MCA/DoLS sessions have been delivered to patients and families. key areas across the Trust since Q3 during reaching a total of 354 staff by end of Q4. Added to the other training in which MCA/DoLS is covered (Safeguarding, MCA/DoLS Master class, Dementia study day, Patient Safety training days) a total of 1772 staff have received MCA/DoLS training during 2016-17. ●● NAAS returns will be used to identify ‘hot spot’ wards which are offered extra drop in sessions to provide additional training for MCA/DoLS. ●● First MCA/DoLS master class was held in November 2016. Additional classes will be held in May 2017. Level 3 ●● Mandatory Safeguarding Adult Level 3: although Improved understanding of process Safeguarding there is an annual decrease of 4% at Q4, there is a for staff and improved care for Adult Training 2% increase since Q3 and a 9% increase since Q2. patients and families. ●● Overall percentage uptake of training is at 73% for Safeguarding Adults Level 3 against an internal target of 80%. It should be noted that the apparently slow rise in percentage uptake is largely due to the 22% rise in headcount. If we were to look at the percentage uptake at Q4 alongside the headcount given for Q4 last year we would see an uptake of 88% for Level 3 Safeguarding Adults training (15% increase). ●● Training compliance figures disaggregated per Care Organisation by ward/dept to support local leadership accountability.
Quality Account Report 2016-17 PAGE 70
Work-stream Summary of actions completed Impact Level 3 ●● Mandatory Safeguarding Children Level 3 is showing Improved understanding of process Safeguarding a sustained increase at 75% (against the 80% for staff and improved care for Children Training target), and is 12% higher at Q4 than the same patients and families. period last year. This is particularly encouraging in light of the headcount, which has increased by 31%. If we were to look at the percentage uptake at Q4 alongside the headcount given for Q4 last year we would see an uptake of 98% uptake of Level 3 Safeguarding Children training (23% increase). ●● Training compliance figures disaggregated per Care Organisation by ward/dept to support local leadership accountability. Children Caring ●● An additional question regarding caring Improved understanding of process Responsibilities responsibilities has been incorporated into the for staff and improved care for proforma when a child attends A&E. This has been patients and families. uploaded to Symphony and available to all EDs and UCC. ●● Successful implementation of a project to turn off paper in the children’s area and have electronic patient records only. Dementia ●● Dementia training video produced and used at all Improved understanding of process Trust inductions. for staff and improved care for ●● Dementia screening process reviewed and the first patients and families. two stages of the process have been incorporated into the nursing admission process. ●● Training sessions provided on each site to ensure staff understand the assessment process. Falls ●● Falls management leaflets have been made available Improved understanding of process on wards for both patients and visitors to read. The for staff and improved care for Trust have adopted the Royal College of Physicians patients and families. leaflet; ‘Falls prevention in hospital: a guide for For additional information, please patients, their families and carers’, and this was see section 3.5.2 ratified at Safeguarding Committee in November ’16. Medicines ●● Internal audit review of medicines management Identified areas for improvement. Management completed. Outcome to be reported at improvement Improved care for patients. board, CEC and Audit committee. ●● Clear reporting mechanisms provided through CEC for medicines management assurance. ●● Themes identified through NAAS to support improvement via localised action plans. PAGE 71
Project: Risk and Governance - systems and management of claims, complaints, inquests, and incidents (incorporating the quality priority “to improve the Trust’s responsiveness to complainants”) Aim: 12 month work plan for improvement
Work-stream Summary of actions completed Impact Claims ●● Draft policy developed and awaiting sign off. Consistent approach to managing ●● EL/PL claims are now in-house and recorded all aspects of claims and on the Safeguard system, along with clinical identification of themes across the negligence claims. organisation. ●● For all governance areas that use Safeguard – preliminary works have been completed to create the modules on the new Datix Risk Management System and will commence testing of these modules in April 2017. Complaints ●● Developed reports per Care Organisation which Reduction in backlog and improved detail the number of outstanding complaints management of complaint against trajectory. responses. ● ● New Interim Head of Complaints, PALS and Legal There were no complaints over 100 Services commenced in post March 2017. days at 31 March 2017. ●● KPIs agreed with CCGs for 2017-18. ●● Additional support provided by all CCGs. ●● No outstanding MP complaints. Inquests ●● All inquest leads have now moved towards case Improved relationships with management. coroners, improved information ●● The backlog in the email system has been sharing with families. reduced and all inquest leads are now up to date Clear local accountability with with all cases. The inquest outcome backlog has clinicians and support for been completed. attendance at coroners court. ●● All SOPs have been produced and formally ratified. ●● Inquest Review Lead and Datix Project Manager have met to design the inquest modules. ●● 8 inquest training sessions have been delivered across the Trust. Incidents ●● All 2015 serious incidents have been signed off Reduction in backlog and improved and completed by divisions. At the end of March, learning and improved care delivery there were three Q4 15-16 serious incidents for patients. outstanding. Improved support for families with ●● Continued support provided by CCGs. senior manager identified for Duty of Candour (see section 3.4.1).
Quality Account Report 2016-17 PAGE 72
Project: Improve patient flow – including bed management, implementation of the SAFER care bundle and system resilience (incorporating the quality priority “to improve timely access for patients requiring urgent care”) Aims: Bed Management - Implement a robust bed management structure through the standardisation of bed management meetings, documentation and escalation procedures, to improve patient flow and A&E performance standards.
SAFER - to implement the SAFER patient flow bundle across all wards by the 31st March 2017, in order to comply with national requirements.
System resilience - to expedite patient discharges to reduce length of stay and delays in transfer of care.
Work-stream Summary of actions completed Impact Bed Management A baseline assessment of bed management Areas for improvement were identified meetings, engagement, checklists, processes, which informed the project. roles and responsibilities across three sites has been completed.
This included testing of: ●● standardising new roles and responsibilities ●● bed meeting format and guidance. Bed Management Amendments to the Sit Rep ensuring a clear set The trial of Sit Rep was a success, of daily core actions are agreed and documented. and the trial form is still in use as the This includes introducing a SBAR safety huddle at everyday way of reporting. However, it weekends. is not always possible for the ‘huddle’ to take place at weekends, depending This has been tested at FGH, and awaiting a date upon site pressures. to be tested at ROH. As an alternative, individual face-to- face conversations take place with each areas’ consultants or representatives. Bed Management Escalation triggers have been extracted from This will inform the development of Escalation Policy relevant policies and procedures and collated. escalation policy and action cards. Bed Management Five letters have been produced which relate to These will append to the Discharge Supporting Choice different situations where patients are reluctant Policy once reviewed, and will provide for Reluctant Leavers to leave the hospital. confidence for staff in managing patients who are reluctant to leave. PAGE 73
Work-stream Summary of actions completed Impact SAFER SAFER rollout commenced on 26 July 2016, Data for the measures identified shows with the ‘exemplar ward programme’ wards very little improvement at 31 March commencing implementation from September. 2017, from the June 2016 baseline (see The full roll-out was completed on 7th February table below). 2017, with 55 wards and departments across the NAAS assessments across 23 areas Trust being included. showed that on just under half of these Outcome measures: the staff were unaware of SAFER and ●● Length of stay, didn’t have robust board rounds or white boards in place. ●● Discharges/transfers before 12noon, ●● >6 day length of stay (‘stranded patient metric’).
Indicator FGH NMGH TROH RI Trust Jul 16 Jul 16 Jul 16 Jul 16 Jul 16 Date Jun 16 to Mar Jun 16 to Mar Jun 16 to Mar Jun 16 to Mar Jun 16 to Mar 17 17 17 17 17 Average LoS 4.40 4.44 3.26 3.37 3.62 3.58 1.6 1.93 3.53 3.59 % discharged 16 15 15 13 16 17 18 16 15 15 before 12 LOS >6days 128 106 163 182 200 202 5 4 496 494
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Work-stream Summary of actions completed Impact SAFER The Emergency Care Improvement programme team (part of NHS Improvement) has supported the Trust with the review of the initial impact, and areas for improvement have been identified.
Future priorities include: ●● Improving discharge lounge facilities. ●● Site leadership teams to identify clinical, nursing and managerial site SAFER leads. ●● Reviewing the measures in order to capture the actual impact. The site leadership teams will confirm actions and next steps for each site in relation to these.
System resilience: Trusted assessments for re-ablement Services for A reduction in average length of stay Trusted Assessor each NES locality are now completed by acute from the point of referral to discharge occupational therapists and physiotherapists at home has been achieved. all sites for all patients requiring the service. Pre-project measure: 2.5 days A Trusted Assessment form has recently been (median). Range 1 – 7 day created for Intermediate Care beds. This is Post-project measure: 0.5 days currently being trialled at Fairfield General (median). Range 0 - 0.5 days Hospital and North Manchester General Hospital. Occupational therapists and physiotherapists are now able to complete assessments for patients that require Intermediate Care beds in Bury and North Manchester. System resilience: FGH and Rochdale Infirmary have commenced The HMR D2A Pathway has had a Discharge To Assess pilot of D2A using SRG funding for Rochdale positive impact on reducing delayed (D2A) patients. transfers of care for HMR patients at Fairfield General Hospital and ROH has been piloting D2A for low level Rochdale Infirmary. This has been done patients, and now wish to refresh their model in by discharging up to 80% of their order to adopt a model similar to Rochdale. medically-optimised patients who are awaiting assessments, and ensuring that these are completed outside of a hospital, regardless of their needs.
The D2A project that was piloted at The Royal Oldham Hospital targeted patients with limited care needs only. To have a greater impact, the Oldham Urgent Care Alliance will be looking to expand this project to replicate the model in Rochdale in quarter 1, 2017-18. PAGE 75
Project: Data quality (PAS upgrade, RTT and training, booking and scheduling review) Aim: To cleanse and improve data quality in PAS / RTT in line with the required standard.
Work-stream Summary of actions completed Impact PAS data The master files on the system have been Accurate data is retained on PAS. cleansing cleansed, and updated, e.g. in relation to Accurate up to date lists, e.g of current consultant attribution, clinical specialities, consultants, facilitates accurate completion of and appointment type. new entries.
This work will be completed by August 2017, prior to the planned upgrade. RTT An external elearning package has been The training has helped to ensure accuracy rolled out to the booking and scheduling of data recorded, e.g. codes used for certain team, and all members have completed it. pathways etc. A permanent RTT trainer has been Classroom-based, role specific training will be appointed – commenced in post December provided, and updated accordingly. 2016. Booking and Review of service looking at the systems and Differences in the clinical teams’ processes to scheduling processes in place at Rochdale (centralised short-notice cancellations have been identified improvement service). and will inform actions to reduce these. 12 staff engagement sessions have been Core improvements have been identified to held – these included process mapping of inform future plans and actions. clinical specialities’ individual pathways. A patient experience survey has been This has provided a baseline assessment of undertaken. patients’ views of the booking processes and improvement actions identified. Work to standardise OPA outcome forms Awaited. has been commenced. KPIs for the booking and directorate teams Awaited. are being developed.
Quality Account Report 2016-17 PAGE 76
Project: Data quality in Emergency Department (ED systems, breach analysis) Aim: Provide assurance regarding data quality in ED following MIAA review in 2016.
Work-stream Summary of actions completed Impact Analysis of An audit of clock stops between 3 hours 30 This provided assurance regarding live clock stops minutes and 4 hours was undertaken to verify processing of patient data in the Emergency the validity of the data. Departments.
This showed an error rate of 1.5% with little A quarterly point prevalence audit of clock variation between sites. stops before 4 hours will be undertaken to provide continues assurance. Breach analysis The processes for breach validation have Improved quality and assurance regarding been standardised and documented. This is standards of breach validation for the Trust. undertaken across all sites by a central team based at Oldham. ED systems Supporting data related to the implementation Provided a feedback mechanism for quality of the Extended Waits Policy, e.g. response by improvements in ED care, for specialties specialities within 1 hour, is provided to the and directorates to identify actions for directorates. improvement. ED systems Job descriptions for certain roles in ED, e.g. Improved quality and assurance regarding tracker roles, have been revised to provide clarity standards for data quality in the Emergency in relation to responsibilities for data quality. Department. Data Worked alongside the Data Quality Engagement Across the data set range, Oldham has interrogation Officer at the Public Health Institute to improved from 51-100% compliance in July for patients understand how to improve compliance with the 2016 to 92-100% in November 2016. attending ED College Of Emergency Medicine’s Trauma and Correct data will enable better identification with assault Injury Intelligence Group (TIIG) data. of areas of risk to facilitate targeted related issues An internal audit of data entry identified errors in improvements by Public Health to improve the data being extracted by TIIG, which has been public safety. rectified. PAGE 77
Project: Safe Staffing / Recruitment and Retention Aim: To ensure safe staffing in every department
Work-stream Summary of actions completed Impact Recruitment 19 staff videos and 4 case studies now on www. Will track number of people viewing pages marketing pat.nhs.uk/working-for-us/meet-the-team that are being promoted.
Trust fleet vehicles now displaying RECRUITING 55 applications received, 43 shortlisted NOW magnetic signs, signposting to vacancies (18 of which were external), 29 attended webpage/social media. interview with 18 appointed (of which 7 were external). Two of those appointed RECRUITING NOW banners have been produced applied as a direct result of hearing the radio and will shortly be installed in each site. adverts on Key 103 and Heart. Joint recruitment banner stand for PAHT/SRFT produced for use at events.
Intranet article developed to showcase recruitment marketing activity http://nww.pat. nhs.uk/corporate-departments/HR/nursing- and-midwifery-recruitment.htm
Radio adverts for Band 6 Nurse vacancies ran in January on Revolution Radio, Key 103 and Heart Radio. Recruitment Attendance at RCN Manchester event - 140 Newly-qualified recruitment event: roles events communications made, all received personal were offered to 39 (adult-trained) nurses emails and offer of applying for role. Dedicated and two paediatric students were passed vacancy advert created for applications relating for interview to the paediatric management to this event. team.
Newly qualified recruitment event – 47 attended Two further paediatric students were for interview (45 adult and 2 Paediatric). identified at shortlisting.
Facebook/ Twitter – six candidates attended as a result of seeing our campaign.
RCN Jobs Fair - eight candidates attended following their visit to our stand or due to a friend’s referral. Safer staffing A further 16 band 6 nurses appointed (7 external) through Trustwide campaign, resulting in 44 appointed in total against the 100 agreed.
Quality Account Report 2016-17 PAGE 78
Work-stream Summary of actions completed Impact Workforce The Trust was successful in its GM bid, being Trainees have been placed across both acute transformation allocated 48 trainees - both internal and external and community services and specialties. candidates. They are either on secondment from their substantive post or on a two-year fixed- term contract.
The two-year programme commenced in January 2017.
The trainees will be supported by two Clinical Educator Facilitators who are funded by HENW (Health Education North West). New roles to support existing professions, e.g. The aim is to have staff with the right skills physician associates, trainee nurse associates, and competencies to deliver excellent care. and pharmacy technicians have been introduced.
We have also expanded our approach to advanced practitioners across different professional groups – nurses, physiotherapists, pharmacists and paramedics. Staff Introduction of Go Engage staff engagement Ensure that staff we have trained and engagement framework. developed remain within the organisation. and retention A new improved exit questionnaire to has been To have a better understanding of the launched. reasons why staff have left the Trust, and to take action to address them. PAGE 79
Project: Healthy, Happy, Here Aim: Improve the health and wellbeing of the workforce by raising awareness, promoting and embedding health and wellbeing into the Trust. Over time this will assist in reducing stress, increasing morale and improving the quality of care for patients.
Work-stream Summary of actions completed Impact Healthy Implementation of podiatry, physio and Improved health and wellbeing of staff. counselling services offered by Occupational Health Services. Staff Support Networks arranged. The BME and disabled staff networks have been implemented along with mentoring scheme for BME staff which has seen a positive impact on the individuals’ morale. Happy Implementation of a new Values Based Having a viable and engaged workforce is a Appraisal Framework. key priority for the Trust, which is supported by staff being able to have regular discussions with their supervisor /manager. These are on- going conversations to review the previous year and look forward and plan for the next so that relevant objectives are set. It is also an opportunity for an aspirational discussion about job role/future career to take place. Launch of the Pioneer Programme and Pulse Analyse staff engagement within the Survey. organisation which will help form improvement plans. Here Centralisation of the medical staffing To improve efficiency and quality of service. function Implementation of the Trac recruitment To improve efficiency and quality of service. system. Reducing time to recruit resulting in reduced reliance on agency staff. Implementation of a new on-line exit To obtain better feedback from staff who are questionnaire. leaving the Trust, to support retention of staff. Over recruitment of HCSWs to build up a To reduce the reliance on agency staff resulting in pool. improved quality of care for patients.
Quality Account Report 2016-17 PAGE 80
Project: Leadership – Clinical Aim: To ensure that the Trust’s leaders have the confidence and capability to be effective leaders
Work-stream Summary of actions completed Impact Transforming Programme was delivered to all senior Delegates valued the opportunity to take part, leaders divisional and directorate triumvirate and felt that it improved self-knowledge as programme leaders. leaders.
Six days of training over a 14-month period. An opportunity to work in different ways with colleagues across the Trust. Programme combined individual and group work, with some external speakers. Attendance and level of participation was good overall. Feedback was obtained on final day of programme (Dec 16) – from which Leaders felt they’d made changes to their a summary paper was drafted for the leadership and communications styles. Workforce and Organisational Development Leaders had a better understanding of the Committee, which will inform development context they operate in. of future programmes. However, some of the group work was not as effective as it might have been. (This will be considered in developing future programmes). The Pennine The programme, delivered to 70 band The Festival of Learning showcased a number of Ward 7 ward managers, was completed in Innovative project ideas were apparent including: Managers’ November: four cohorts participated in ●● Reduction in falls in transferred patients. Leadership five days of experimental, action and ●● Reviewing discharge process. Programme simulation learning over one year. ●● End to end process for improving quality of The programme was co-designed and care for nephrostomy patients. co-delivered with the senior nurse leaders, ●● Improving the response rates to call bells. clinical simulation team and Salford ●● Introduce improvements in treatment room University. processes following audit data. Scenarios with subject matter experts ●● Improvement in detection and escalation of helped to maximise learning through early warning score. solution focussed and guided reflection. ●● Continued reduction of C.Difficile. Input was variable from internal senior nurse The transferability of projects using “learn & due to operational issues and organisational spread” methodologies was explored, whilst the changes. themes could be trended to particular groups The quality improvement component to such as deteriorating patient collaborative. the programme concluded with a ‘Festival It was felt that more work could be done with the of Learning’ where the participants shared projects as it is really important to acknowledge their projects with key stakeholders. that the ward managers’ work has been listened to and appreciated by the Trust’s senior nursing team and that this work continues. PAGE 81
Work-stream Summary of actions completed Impact Executive Programmes of Executive ‘work-with’, Nurse Heightened visibility of the executives and senior Visibiblity Director Friday walk-rounds, and patient management for clinical staff. safety walk-rounds, have been introduced. Improved understanding of the key issues by senior leadership.
Project: Leadership – Site-based Aim: To support the formation and effectiveness of the Care Organisations’ leadership from April 2017 onwards
Work-stream Summary of actions completed Impact Care Discussion and consideration of options Organisation for the leadership structure for the new leadership organisations. Programme in development - for delivery during next financial year.
This will include programmes for:
●● Care Organisation ‘quartets’ (Managing Directors, Medical Directors, Directors of Nursing, and Finance Directors). ●● The committee in common. ●● Pennine Nurses’ Leadership Programme (from SRFT programme). ●● Pennine Consultants’ programme (working in partnership with an external company).
Quality Account Report 2016-17 PAGE 82
3.2 Review of Performance against Priorities for 2016-17 Nine priority areas for improving quality in the year were set out in the 2015-16 Quality Account. They each included outline plans for implementation and the proposed methodology for monitoring progress. Three priorities were identified for each of the domains of quality.
They were:
Patient Safety ●● To report on harm occurring to patients, including instances of pressure ulcers, falls, infections and venous thromboembolisms ●● To implement the safety standards for invasive procedures in all interventional areas across the Trust ●● To improve early identification and management of patients who are deteriorating Clinical effectiveness ●● To review and improve the Trust’s independent mortality review processes ●● To improve compliance with NICE guidelines ●● To implement the Accreditation Programme for wards and departments across the Trust
Patient experience ●● To improve the Trust’s responsiveness to complainants ●● To improve timely access for patients requiring urgent care ●● To review the Trust provision of access to interpreters
The progress made in these priorities is summarised below. Some of them were superseded by, or incorporated within, projects of the post-CQC Quality Improvement programme and the progress and impact of these has already been reported (see section 3.1.2). Some of the projected timetables for implementation were adjusted in accordance with other work and developments, and a review of governance arrangements necessitated a change from the planned process for monitoring progress in some cases.
3.2.1 Patient Safety Priorities To report on harm occurring to patients, including instances of pressure ulcers, falls, infections and venous thromboembolisms (VTE) The rationale was to enhance the existing Patient Safety Thermometer data (point-prevalence audit) to give more information of the incidences of harm to help identify areas for improvement. The plan was to set up monthly reporting into the Corporate Performance Report on the internal harm-free care bundle, which is reported to the Board of Directors.
This work was incorporated within the QI safety work-streams, which include objectives to have reliable data in place. It is acknowledged that falls data is correct, pressure ulcer data is improving, and that processes for data relating to catheter-associated urinary infections needs review. The information is incorporated into the performance report. PAGE 83
To implement the safety standards for invasive procedures in all interventional areas across the Trust This was a national directive (LocSSIPS – local safety standards for invasive procedures) from NHS England. It related to an area where there had been a number of patient safety incidents reported in the Trust, so was therefore included as a priority. The aim was that each clinical area undertaking interventional procedures would implement appropriate local patient safety procedures using a safety checklist based on the WHO surgical safety checklist, and that audits would show 95% compliance.
A list of NatSSIPs (national standards) was provided as a template and Trusts were required first to identify all procedures undertaken across clinical settings that these would be applicable to. Following this, LocSSIPs were to be developed and implemented. The local standards were to be bespoke to the procedure, but similar procedures could be grouped where appropriate.
A task and finish group of clinicians, supported by the clinical governance team, was formed to implement this programme. A scoping exercise was undertaken to identify relevant invasive procedures (and any standards and checklists already in place) was completed and a master list of these procedures was created.
An overarching policy has been created, and was approved by the Executive Clinical Effectiveness Governance Committee in March. A staff guide summarising the principles for developing and using LocSSIPS has been written to accompany the policy: this is based on a document produced by Barts Trust, with their permission.
The policy, staff guide and master list of invasive procedures was formally handed over to the Care Organisations after it was ratified. All Care Organisations have been tasked with reviewing areas for what is already in place, and revise their procedures accordingly where these don’t already meet the minimum standards. Responsibility for auditing compliance, which will include implementation of the process and document review, lies with the relevant speciality. Capacity for this is incorporated in the clinical audit forward programmes.
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To improve early identification and management of patients who are deteriorating This was identified as a priority when staff were consulted for their views on the proposed Quality Strategy, and it was a theme in reported incidents and complaints received. It was superseded by the Quality Improvement collaborative “identifying and early intervention for the deteriorating patient,” and has been reported in section 3.1.2
3.2.2 Clinical Effectiveness Priorities To review and improve the Trust’s independent mortality review processes The rationale for this being included as a priority was to build on the independent mortality review process that has commenced in August 2015. It was recognised that this was an area the Trust could enhance with further developments. It was incorporated into the wider “mortality reduction” project, with the aim to bring about year-on- year reduction in the Trust’s HSMR (hospital standardised mortality rate). See section 3.1.2
To improve compliance with NICE guidelines The rationale for selecting this as a priority was that during the preparations for the CQC inspection it had been identified that the process for assuring compliance with NICE guidance needed more rigour. A large number of baseline assessments had not been completed, and in some instances compliance with guidance was recorded though the completed assessments were not supported with sufficient evidence.
The aim was to have all the baseline assessments completed with appropriate evidence stored, action plans in place to address gaps, and audits of guidance assessed as compliant being undertaken as part of the divisional audit programme. There was to be clear accountability and governance arrangements in relation to NICE guidance, led by clinical directors and speciality clinical leads, and monitored by the Trust Clinical Audit and Effectiveness Committee.
Progress overall Significant progress has been made completing overdue baseline assessments and collating relevant evidence. To achieve this, the quality team has supported divisional leads and delivered a number of 1:1 workshops to clinicians. An e-learning package has been created which is available to all clinicians to use as a resource when completing the NICE baseline assessments.
Robust reporting arrangements are now in place: the divisions are sent a weekly update of all the outstanding baseline assessments and action plans. This has enabled the divisions to embed a clear escalation process for the NICE guidance that is overdue, with the outstanding guidance being reviewed by the divisional management team. This has been particularly successful in the divisions of Surgery, Women’s and Children’s and Integrated Community Services.
The plan for 2017-18 is to: ●● complete the backlog of baseline assessments; ●● undertake audits of the guidance stated to be compliant; and ●● create and implement action plans for guidance stated to be non-compliant
The new site-based leaders will be responsible for compliance with NICE guidance in their areas, and to take action in respect of the risks associated with being non-compliant. The Integrated Community Services division designated ‘NICE champions’ which proved successful in progressing this work, and the sites will be encouraged to adopt this approach. PAGE 85
Baseline assessments The table below shows the progress made during the year with NICE guidance completion.
April July October January end Mar Guidance status 2016 2016 2016 2017 2017 Guidance Out of date 94 *246 151 92 29 under review Within timeframe 14 12 3# Compliant 318 *150 194 267 423 **category Partially compliant 90 124 136 139 reassigned Non-compliant 13 14 19 21 127
* These anomalies were due to it being identified that, in some cases, guidance had been stated as compliant without sufficient supporting documentation available. **Guidance that has previously been assessed as “partially compliant” has been reassessed as “non-compliant,” as it was difficult to quantify the extent of compliance, and some classifications were ambiguous. # received during March – awaiting allocation to speciality
Action Plans For guidance that is non-compliant, action plans to address areas of non-compliance are created and implemented in order to become compliant. As the Trust moves to its care organisation structure, actions plans will be in place at each organisation where the guidance is applicable: this means that each organisation will have to complete these in order for overall Trust compliance to be acknowledged.
Audit programme From 2016 to present 18 audits have been completed that are linked to NICE guidance, with specific elements of the guidance selected for audit. These were reported in section 2.2.2; local clinical audit. Going forward, the care organisations will link the specific elements of guidance for audit with the action plans.
To implement the Accreditation Programme for wards and departments across the Trust This priority was supported by the commissioning groups within the CQUIN framework. The scheme was devised as a framework to measure the quality of care and to strengthen professional leadership. It was superseded by the NAAS (nursing assessment and accreditation system) that had been implemented successfully at Salford Royal and was introduced by the new leadership team. See section 3.1.2
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3.2.3 Patient Experience Priorities To improve the Trust’s responsiveness to complainants This rationale for this as a priority was to support the Trust’s complaints improvement plan which focused on timeliness and quality of responses, and learning. A new policy and process was in place for 2016-17, and performance metrics were agreed with the commissioners. This was incorporated into the Quality Improvement programme in the “Risk and Governance” project which also includes management of incidents, inquests and claims, and review of the governance systems. See section 3.1.2
To improve timely access for patients requiring urgent care This was identified as a priority as it had become an area of increasing concern during 2015-16, particularly during Q4 when performance in relation to the 4-hour access target was significantly deteriorating and an unprecedented number of 12-hour trolley waits were reported. The aim was to support the existing urgent care improvement plan to help the Trust achieve the national standards.
Following the CQC inspection and the concerns that were raised relating to urgent care service a revised urgent care plan was approved as part of the Quality Improvement programme, which is being monitored by the Greater Manchester Improvement board. See section 3.1.2
To review the Trust provision of access to interpreters The rationale to include this as a priority was that feedback from patients and their carers, and concerns raised internally by management, indicated that this was a key area for improvement. The aim was to implement a revised policy and procedures, which would increase the usage of interpreters within the Trust and reduce the number of complaints relating to availability of interpreters. Increased use of telephony interpreting results in improved patient experience, and decreased appointment cancellation due to interpreter not being available, and it is also more cost- efficient for the Trust, as there is no travel time for the interpreters.
In July 2016 a programme of work was initiated by the Interpretation and Translation Service (ITS) and the Transformation Team. The main aims were:
●● To amend the ITS policy to promote of the use of telephone interpreting for all types of appointments, where appropriate. ●● To implement a new IT interpreter booking / management system to improve the allocation of internal and external interpreters; in addition to providing ITS activity Trust-wide. A revised Standard Operating Procedure has been approved and will be published in April 2017. This will complement the service and provide more detailed information regarding equipment, criteria for telephony use, and staff roles and responsibilities. Training and equipment requirements have been scoped for each clinical area; and the departments will review their IT requirement following the scoping exercise.
The promotion of telephone interpretation commenced in the Outpatient G and Infectious Disease clinics in November 2016, following formal confirmation of a new service provider. Further roll out of the service across Outpatients at NMGH was agreed following a successful ‘go live’ week (20th February 2017): any operational matters regarding service delivery such as the timeliness of connecting to telephone interpreting calls are responded to when they develop. PAGE 87
The Interpretation and Translation Service (ITS) and the Transformation Team monitor the progress of the scheme bi- weekly, and report to the Patient Experience Committee.
Next steps The transition to increased telephone interpreting is proving a gradual process with many staff still accustomed to utilising face to face interpreters.
In order to assess the impact of the programme of work we will be consulting with patients and staff using ITS in the trial areas during April 2017.
A series of communications to staff promoting the use of telephony is planned for mid-April, and will be supported by training on how best to utilise this option of interpreting.
A patient experience survey will also be undertaken from late April to early May 2017 to benchmark patients’ current experience of interpretation services, as the service develops.
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3.3 NHS England Core Quality Account Indicators This section shows the Trust’s progress and performance for each of NHS England’s ‘core set of indicators’ that all Trusts are required to report against in their 2016-17 Quality Accounts, where the indicator is applicable to them. For the PAHT these indicators are:
●● SHMI – Summary Hospital Mortality Indicator – with regard to • the Trust’s summary SHMI • the % of patient deaths with palliative care coded
●● PROMS – Patient-reported Outcome Measures Scores – for • Groin hernia surgery • Varicose vein surgery • Hip replacement surgery • Knee replacement surgery
●● Patients readmitted to the Trust within 28 days of discharge ●● Responsiveness to patients’ personal needs ●● Staff recommending the Trust as a care provider to family and friends ●● Patients recommending the Trust’s A&E service to family and friends ●● Percentage of patients risk-assessed for venous thromboembolism ●● Rate (per 100,000 bed-days) of C difficile infection in patients over two years old ●● Number and rate of patient safety incidents reported in the Trust, with number and percentage resulting in severe harm or death 3.3.1 Summary Hospital Mortality Indicator (SHMI) The SHMI is a ratio of the actual number of patients who die following hospitalisation, and the number that would be expected to die, given the characteristics of patients treated by that Trust. It is published each quarter and is based on 12 months’ data, 6-18 months previously. Data to produce the SHMI for the whole year 2016-17 will not be available nationally until October 2017.
The data used to calculate the SHMI includes all deaths in hospital, plus those deaths occurring within 30 days after discharge from hospital, though it does not adjust for palliative (end of life) care because of the unreliability of coding. Some hospitals, therefore, may appear to have a higher death-rate if patients are admitted for care in the last days of life or if they are discharged home to die if that is their preference.
The SHMI can be used by hospital Trusts to compare their mortality outcomes to the national baseline. The Trust, the Care Quality Commission, and local clinical commissioning groups use it as a ‘smoke alarm’ to identify potential areas of concern for investigation into clinical outcomes. However, the SHMI should not be used to directly compare mortality outcomes between Trusts and it is inappropriate to rank Trusts according to their SHMI. It requires careful interpretation and should be used in conjunction with other indicators and information from other sources (e.g. patient feedback, staff surveys and other similar material) that together form a holistic view of Trust outcomes.
The data made available to the Trust by the Health and Social Care Information Centre (HSCIC) with regard to:
a) the value and banding of the summary hospital-level mortality indicator (“SHMI”) for the Trust for the reporting period is shown below: PAGE 89
Time Period Pennine Acute National Baseline Highest Score Lowest Score Jul’14 - Jun’15 102.2 100 120.89 63.03 Oct’14-Sep‘15 104.9 100 117.74 65.16 Jan’15-Dec‘15 107.9 100 117.31 66.88 Apr’15-Mar‘16 111.5 100 117.83 67.86 Jul’15-Jun‘16 112.2 100 117.12 69.39 Oct’15-Sep‘16 112.7 100 116.39 68.97
The Pennine Acute Hospitals NHS Trust Score has been “higher than expected” for SHMI since the publication in October 2016 (April 2015-March 2016 data). b) the % of patient deaths with palliative care coded at either diagnosis or speciality level for the Trust for the reporting period is shown below.
Time Period Pennine Acute National Baseline Highest Score Lowest Score Jul’14 - Jun’15 21.4 26.0 52.91 12.37 Oct’14-Sep‘15 21.3 26.6 53.51 11.75 Jan’15-Dec‘15 22.0 27.7 54.75 11.5 Apr’15-Mar‘16 21.6 29.0 54.60 10.58 Jul’15-Jun‘16 20.7 29.7 54.83 13.01 Oct’15-Sep‘16 19.8 30.2 56.27 11.75
The palliative care indicator is a contextual indicator: it does not contribute to the SHMI.
The rate is fairly consistent each year however there has been a slight reduction in the last 12 months which is under review. In order for palliative care to be coded, the patient must have received input from a specialist palliative care clinician, and this must be documented accordingly in the clinical records. The Trust has vacancies in the specialist palliative care team.
The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: there are nationally regulated assurance processes in place to ensure the accuracy and validity of the data prior to publication. The Pennine Acute Hospitals NHS Trust has taken the following actions to improve this percentage and so the quality of its services, with the introduction of a mortality reduction plan as part of the overarching quality improvement programme. There are actions in six key areas: ●● analyse relevant information to gain a full understanding of the current position; ●● maximise the effective use of available information systems; ●● ensure accuracy of clinical documentation and coding; ●● improving mortality surveillance with the development of a systematic and cohesive approach; ●● acting on findings and making improvements; and ●● strengthening governance arrangements. (See section 3.1.2 for additional information)
Hospital Standardised Mortality Ratio (HSMR) is another means by which the Trust monitors its mortality rates. HSMR calculations enable the comparison of mortality rates between hospitals serving different communities by
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including a variety of factors such as the age and sex of patients, their primary clinical diagnosis and complicating factors, and their length of stay in hospital. HSMR is based on the likelihood of a patient dying of the condition with which they were admitted to hospital. This means the methodology relies on accurate diagnosis and record-keeping by doctors, and appropriate data coding of patients’ records.
If a Trust has an HSMR of 100, this means that the number of patients who died is exactly as would be expected. Values above 100 suggest a higher than expected mortality would therefore be a ‘smoke alarm’ for further investigation to identify potential problems or where patient care can be improved.
The latest year-to-date HSMR (April to February 2017) figures show the Trust’s score is 101.1. This is a continued increase from the 97.73 reported last year, and 83.05 the previous year, but is a reduction on the previous quarter’s release which was 103.18. The increase is partly due to a rebasing of Dr Foster data but there are a number of clinical conditions where the Trust is alerting, showing an increased number of ‘excess’ deaths (higher number than expected). The Trust is investigating the possible causes for these as part of the mortality reduction plan, and this review is expected to report in May 2017. Its findings will identify specific actions to inform the next stages of the plan. (see section 3.1.2 for additional information)
3.3.2 Patient-reported Outcome Measures Scores (PROMS) NHS Trusts are required to report on patient-reported outcome measures (PROMs), short questionnaires given to patients to complete. The information is collected on NHS patients undergoing elective (planned) hip or knee replacements, groin hernia surgery and varicose vein procedures. PROMs are a means of gaining an insight into the way patients perceive their health, and the impact that treatments or adjustments to lifestyle have on their quality of life, by measuring their health status or health-related quality of life at a single point in time.
The first questionnaire is given at the time of pre-operative assessment or on the day of admission to hospital. A second questionnaire is sent out three months after surgery for varicose vein and groin hernia procedures, and six months from date of surgery for hip or knee replacements. The data from the pre-operative questionnaire compared to the post-operative questionnaire links to a specific set of questions that nationally recognise the following:
●● EQ-5D Health Status – includes living arrangements, mobility, able to self-care, daily activities and mental status. ●● EQ-VAS – this is a visual analogue scale that asks the patient on the day they are completing the questionnaire to assess their own state of health ranging from 0 (worse imaginable health state) up to 100 (best possible imaginable health state).
The ‘Oxford Hip and Knee Replacement’ and the ‘Aberdeen Varicose Vein’ scores are also used as an additional measure of assessing health and overall outcomes of surgery.
Data for the year 2016-17 is available only up to 30th September 2016, as some follow-up questionnaires are not due to be sent out to patients.
From 1st April 2016 to 30th September 2016, the Trust had 1,108 eligible hospital episodes, for which 696 pre- operative questionnaires were returned; a participation rate of 62.8% compared to 76.2% nationally.
318 post-operative questionnaires were sent out, of which 104 have been returned; a response rate of 32.7% compared to 41.1% nationally. The table below compares the Trust with others in the region. PAGE 91
Questionnaire % Trust 2015-16 (to 30th September) Pre-operative Post-operative Bolton NHS Foundation Trust 67.5 40.2 Central Manchester University Hospitals NHS Foundation Trust 32.2 20.4 Pennine Acute Hospitals NHS Trust 62.8 32.7 Salford Royal NHS Foundation Trust 25.1 23.8 Stockport NHS Foundation Trust 91.7 30.9 Tameside Hospital NHS Foundation Trust 52.8 37.5 University of South Manchester NHS Foundation Trust 73.0 35.6 Wrightington, Wigan and Leigh NHS Foundation Trust 86.1 36.7 England 76.2 41.1
The following table demonstrates the numbers and % of all patients completing both questionnaires, comparing the Trust with other Trusts nationally (all procedures).
The table below shows the percentage of patients who reported an improvement in their health following their procedure in 2016-17 (to date), compared to other local Trusts and nationally. The comparative figures for 2015-16 are shown in italics
Groin Hernia % Hip replacement % Knee replacement % Varicose vein % Trust 2016-17 EQ-5D EQ VAS EQ-5D EQ VAS EQ-5D EQ VAS EQ-5D EQ VAS Pennine Acute Hospitals NHS Trust 45.2 51.7 100 69.2 82.4 63.6 54.3 41.2 England 50.9 40.5 89.7 67.8 82.1 59.4 51.3 40.7 Bolton NHS Foundation Trust 50.0 33.3 100 33.0 84.6 46.2 60.0 16.7 Central Manchester University 46.2 30.8 100 71.4 78.6 53.3 - - Hospitals NHS Foundation Trust Salford Royal NHS Foundation Trust 80.0 60.0 100 90.0 100 66.7 - - Stockport NHS Foundation Trust 46.7 27.3 100 64.7 93.3 75.0 - - Tameside Hospital NHS Foundation 43.8 31.3 72.7 50.0 77.4 46.7 35.3 33.3 Trust
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University of South Manchester NHS 52.4 39.1 90.9 45.5 77.3 60.0 - - Foundation Trust Wrightington, Wigan and Leigh NHS 47.2 41.2 94.3 74.4 82.4 57.6 - - Foundation Trust Pennine Acute Hospitals NHS Trust 64.7 37.5 85.7 75.0 100.0 83.3 50.0 - (2015-16) England (2015-16) 49.4 36.7 85.6 65.1 77.5 54.5 52.0 39.8
The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: there are nationally regulated assurance processes in place to ensure the accuracy and validity of the data.
The Trust acknowledges there are difficulties in patients completing questionnaires. This might be due to lack of opportunity with the introduction of pre-operative telephone assessments, or unwillingness by some patients to participate because of an increase in other surveys and questionnaires. Patients who complete their pre-operative assessment by telephone are encouraged to complete the pre-operative questionnaire on the day of surgery, but this is not always feasible.
During 2016-17 the Trust implemented the following: ●● Patients attending pre-operative assessment have been asked to complete the pre-operative questionnaire ●● Patients who complete their pre-operative assessment by telephone are asked to complete the pre-operative questionnaire on the day of surgery. This action has seen an increase in the number of completed questionnaire submitted. ●● In 2016-17 feedback on the participation rates were produced on a quarterly basis. ●● New posters were displayed in Pre-operative Assessment Areas and Day Surgery Units. ●● Discussions with patients which includes expected outcome of surgery continues to improve.
As a result of these actions: ●● More patients are completing the questionnaires. ●● There is an increased awareness of the programme amongst staff. ●● Health gains have been achieved. ●● Patients completing the questionnaires have a better understanding of PROMs.
The Pennine Acute Hospitals NHS Trust intends to take the following actions to improve this percentage and so the quality of its services, by acting on the findings of a further review of how it recruits patients. The outcome of the review includes the same recommendations as in the previous year for the Trust, which were to: ●● Ensure all patients are requested to complete the pre-operative questionnaire ●● Continue to provide feedback on the outcome data and benchmark health gains against Trusts in the North West and national results. ●● Update the posters within the pre-operative assessment areas ●● Continue discussions with patients which includes expected outcome of surgery.
Participation rates have improved since last year, and the Trust anticipates that there will be improvements in response rates and outcomes in the reporting by the HSCIC on the final completion of 2016-17 data. The Trust continues to work to improve participation and anticipates that there will be improvements in response rates and outcomes in the reporting by the HSCIC 2017-18. PAGE 93
3.3.3 Patients readmitted to the Trust within 28 days of discharge If patients are readmitted as an emergency following discharge from hospital, this can indicate that there have been difficulties or complications with their follow-up care and treatment. Monitoring the numbers of emergency readmissions, and comparing against other Trusts, helps us to identify areas for improvement to services and processes which can help to reduce and avoid emergency admissions wherever possible.
The Trust monitors the number of readmissions and the rate using the Dr Foster Intelligence tool. It shows the % of patients aged 0 to 14, and 15 or over, who are readmitted to one of the Trust’s hospitals within 28 days of being discharged from one of the Trust’s hospitals during the reporting period. A lower percentage shows that fewer patients have been readmitted as an emergency following discharge. The data is six months in arrears as it is compared to others in the Trust’s peer group. Dr Foster will publish the next set of data again in Sept 2017.
Dr Foster 28 day Readmission Data; October 2015 to September 2016: Age range Pennine Acute All Acute Peers Higher than expected Lower than expected All patients 8.21% 8.10% 10.53% of Trusts 5.7% of Trusts 0-14 years 11.83% 9.11% 14.46% of Trusts 4.18% of Trusts 15+ years 7.55% 7.96% 10.83% of Trusts 6.30% of Trusts
The Trust’s overall comparisons with previous years is shown in the table below:
Time Period Admissions Readmissions Readmission % October 2015 to September 2016 175189 14386 8.21% October 2014 to September 2015 194694 17030 8.77% October 2013 to September 2014 199819 17476 8.76% October 2012 to September 2013 202308 17895 8.86%
The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: there are nationally regulated assurance processes in place to ensure the accuracy and validity of the data.
The Pennine Acute Hospitals NHS Trust has taken the following actions to improve this percentage and so the quality of its services, by responding to Dr Foster alerts, and to local data that shows the Trust as an outlier for particular procedures or treatment.
Key procedures identified as being outliers in 2016-17 are as follows: ●● Appendicectomy ●● Catheterisation of heart ●● Hysteroscopy ●● Drainage of lesion of skin ●● Laparoscopy ●● Lower female reproductive organs ●● Procedure on skin ●● Therapeutic endoscopic operations on urethra
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The Trust’s overall readmission rate has reduced by 0.56% compared to last year and progress on any actions taken to improve the areas identified above is monitored via local Quality & Performance Committees to reduce readmission rates in the future. The data provided is reviewed by the services, and consideration given to review of care pathways or other relevant systems and processes.
3.3.4 Responsiveness to patients’ personal needs To improve the overall quality of patient experience and care, it is vital we collate, review and act on patient feedback. The national inpatient survey includes five specific questions which relate to the Trust’s responsiveness to patient needs and perceptions, which enable us to assess and measure whether it has been consistently achieved. The results for the last 3 years are shown in the table below:
National External Specific Questions 2014 2015 2016 Average Benchmark: 2016 the Trust was Q35. Were you involved as much as you wanted within the bottom 45% 48% 49%↑ 44% to be in decisions about your care and treatment? 50 hospitals. Q38+. Did you find someone on the hospital staff within the bottom 61% 65% 66%↑ 62% to talk to you about your worries and fears? 50 hospitals. Q40. Were you given enough privacy when within the top 27% 29% 26%↓ 24% discussing your condition or treatment? 30 hospitals. Q63+. Did a member of staff tell you about within the bottom medication side-effects to watch for when you 68% 62% 71%↑ 61% 20 hospitals. went home? Q69. Did hospital staff tell you who to contact within the bottom if you were worried about your condition or 28% 25% 26%↑ 20% 40 hospitals. treatment after you left hospital?
The Picker Institute, which administers the survey, presents the results in the form of “problem scores”, i.e. the percentage of patients who have indicated by their response that this particular aspect of their care could have been improved. Therefore, lower scores are better.
The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: there are nationally regulated assurance processes in place to ensure the accuracy and validity of the data.
The Pennine Acute Hospitals NHS Trust intends to take / has taken the following actions to improve this percentage and so the quality of its services, by introducing over 2016/17 initiatives to drive through quality and consistency of care, such as Safer Start programme of work, which commenced in July 2016 to improve patient flow and discharge; this was introduced Trust wide in over 55 wards, with the focus on the traditional ward areas. It is envisaged that the initiative will address the underlying patients concerns relating to discharge; this will be supported, and improvements monitored through the Nursing Assessment and Accreditation System (NAAS).
The Trust’s transition to Care Organisations will assist the respective senior management teams to identify and respond to the themes emanating from their sites. The Care Organisations will be working with Picker and the Patient Experience Department in early May 2017 to analyse and develop improvement plans that will augment the current Quality Improvement Plans developed following the 2016 CQC Quality Report. The improvement plans will PAGE 95
be monitored through the Patient Experience Committee and Executive Quality and Patient Experience Committee. The Trust will also review and where required update the Patient Experience Strategy in order to strengthen patient engagement and co-production of service improvement, with patients, carers and the public participation to ensure learning from their experiences enhance patient care.
The Trust had overall not achieved a significant improvement on a specific question within the 2016 national inpatient survey; however, specific sites received better response rates than the Trust average in certain aspects of care. Fairfield General Hospital performed significantly better than the Trust average on five questions, as seen in the table below:
Aspect of Care FGH Trust Q16. Hospital: bothered by noise at night from staff 11% 21% Q18+. Hospital: toilets not very or not at all clean 1% 6% Q22+ Hospital: food was fair or poor 26% 38% Q23 Hospital: not offered a choice of food 17% 27% Q26 Doctors: did not always have confidence and Trust 15% 24% Lower scores are better
North Manchester General Hospital’s results predominately mirrored the Trust’s average percentage score: the few stronger scores are noted below: Aspect of Care NMGH Trust Q14+ Hospital: patients using bath or shower area who shared it with opposite sex. 5% 10% Q21+ Hospital: not always able to take own medication when needed to. 34% 41% Q48+. Surgery: questions beforehand not fully answered 23% 28%
Royal Oldham Hospital results contained five questions that were higher than the Trust average: Aspect of Care ROH Trust Q38+ Care: could not always find staff member to discuss concerns with 61% 66% Q54 Discharge: not given notice about when discharge would be 37% 45% Q59+. Discharge: did always get enough support from health or social care professionals 41% 47% Q60+ Discharge: did not always know what would happen next with care after leaving 52% 57% hospital Q67+ Discharge: family or home situation not considered 40% 45%
The Trust’s results overall were significantly worse than average in 28 questions, compared to 20 in 2015 and 29 in
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2014. These are shown below: National National Specific Questions 2014 2015 Average Average 2015 2016 2016 Admission: had to wait long time to get to bed on ward 36% 41% 32% 43% 36% Hospital: not always able to take own medication when - N/A N/A 41% 34% needed to Hospital: not offered a choice of food 27% 26% 20% 27% 20% Doctors: did not always get clear answers to questions 35% 35% 30% 38% 30% Doctors: did not always have confidence and Trust 24% 23% 19% 24% 18% Nurses: sometimes, rarely or never enough on duty - 42% 38% 45 % 40 % Care: staff did not always work well together - 23% 21% 27% 22% Care: wanted to be more involved in decisions 45% 48% 41% 49% 44% Care: did not always have confidence in the decisions made 28% 32% 27% 33% 27% Care: not enough (or too much) information given on - 23% 20% 24% 19% condition or treatment Care: not always enough emotional support from hospital staff 50% 43% Care: staff did not do everything to help control pain 36% 35% 29% 37% 29% Surgery: risks and benefits not fully explained - 22% 19% 26% 17% Surgery: questions beforehand not fully answered - 26% 21% 28% 21% Surgery: results not explained in clear way - 33% 31% 38% 30% Discharge: did not always know what would happen next with - N/A N/A 57% 48% care after leaving hospital Discharge: not given any written/printed information about 37% 38% 33% 44% 36% what they should or should not do after leaving hospital Discharge: not fully told purpose of medications 31% 32% 25% 34% 25% Discharge: not fully told side-effects of medications - 62% 59% 71% 76% Discharge: not told how to take medication clearly - 26% 24% 32% 24% Discharge: not given completely clear written/printed 33% 34% 27% 33% 28% information about medicines Discharge: not fully told of danger signals to look for 62% 63% 56% 68% 57% Discharge: Family or home situation not considered 38% 45% 36% 45% 37% Discharge: not told who to contact if worried 28% 25% 20% 26% 20% Overall: not treated with respect or dignity 21% 16% Overall: rated experience as less than 7/10 16% 21% 15% 20% 15% Overall: not asked to give views on quality of care - 73% 69% 78% 70% Overall: Did not receive any information explaining how to 64% 68% 59% 67% 60% complain
As mentioned earlier, the Care Organisations will be working with Picker and the Patient Experience Department in early May 2017 to analyse and develop improvement plans that will augment the current Quality Improvement plans to address the themes identified from the above responses. Triangulation of quality metrics information from sources PAGE 97
such as PALS, complaints, friends and family test, and local patient surveys will support in the identification of areas in need of improvement.
3.3.5 Staff recommending the Trust as a care provider to family and friends In April 2014, NHS England introduced a staff Friends and Family Test (FFT) in all NHS Trusts providing acute, community, ambulance and mental health services in England. It is a quicker feedback mechanism than the existing NHS annual staff survey, and it was hoped that it would also promote a cultural shift in the NHS, where staff have opportunity and confidence to speak up, and where their views are increasingly heard and are acted upon to improve things for staff and patients.
It consists simply of two questions (with options to give free text feedback for each) through which NHS Trusts can take a ‘temperature check’ of how staff are feeling: better staff morale is known to correlate with improved patient outcomes.
The Trust, using the support of the Picker Institute, has sent the staff FFT to hundreds of our staff for their feedback every three months since April 2014. The staff FFT in quarters 1, 2 and 4 is a separate survey, whereas the question for quarter 3 is asked as part of the staff survey and is phrased slightly differently. Picker Institute, who run both the staff survey and the staff FFT for the Trust, therefore advise against comparing Q3 results with the other quarters’ results.
The table below shows the Trust’s score - the percentage is based on the number of staff who answered “very likely”
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or “likely” to each question.
2015-16 2016-17 Staff FFT Question Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 How likely are you to recommend
National benchmarking is difficult due to the different ways Trusts conduct the survey and the number of staff who are asked. However, average scores are reported by NHS England at a national level. At quarter 2 the average percentage of staff who would recommend their organisation to friends and family in need of care and treatment was 82% compared with 62% for this Trust. The percentage of staff who would recommend their organisation to friends and family as a place to work was 66%, compared with 56% for this Trust.
When the Trust is benchmarked with NHS England-Greater Manchester the average percentage of staff who would recommend their organisation to friends and family in need of care and treatment was 82% compared with 62% for this Trust. The percentage of staff who would recommend their organisation to friends and family as a place to work was 64%, compared with 56% for this Trust.
The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: there are nationally regulated assurance processes in place to ensure the accuracy and validity of the data.
The Pennine Acute Hospitals NHS Trust has taken the following actions to improve this percentage and so the quality of its services, by directly engaging with staff to gain a better understanding of their issues and concerns to identify appropriate action. These actions have been incorporated into the Healthy Happy Here Plan (see section 3.1.2) and progress is reported to the Workforce and Leadership Programme Board. As the Trust progresses along its quality improvement journey and begins to implement changes that demonstrate tangible improvement, it is expected that the percentage of staff recommending the Trust to F&F for care and treatment will increase. However, the large scale organisational change the Trust is going through over the next two years has an impact on the staff perceptions and this is evident in the FFT scores.
3.3.6 Patients recommending the Trust’s A&E service to family and friends The Trust continues to gather and act on patients’ feedback via the national Friends and Family Test (FFT): upon discharge patients are invited to offer their opinion as to whether they would recommend a friend or family member to be treated at the Trust. Different modes of FFT data collection are available; cards, SMS/Text messaging; and interactive voice messaging, and is guided by the staff for that particular area and patient feedback. The mode of collection should be influenced by the type of patient groups being served, for instance the Wolstenholme Intermediate Care Service is better suited to have cards as older patients are more comfortable with this than SMS; whilst A&E patient are found to respond better to SMS and automated calls. The mode of collection can be changed or added to if required.
The Trust will be undertaking a programme of work with patients, staff and partner organisations, beginning in May PAGE 99
2017. The aim is to improve the Trust’s response rates to the best national quintile of 20% for A&E, and to 40% for inpatients, through ensuring FFT is adequately promoted and accessible to the widest range of patients possible. This will be supported by actions such as awareness sessions for staff, and awareness events for patients and their families, accessible current FFT information on how to participate including the use of response cards in the most frequently used languages for our communities, and age / ability appropriate. For example, bespoke cards using the ‘Tops and Pants’ theme are being developed for children and young people. The progress of the refocus on FFT work will be reported to and monitored by the Patient Experience Committee and Executive Quality and Patient Experience Committee.
Local managers are encouraged to display FFT patient themes, changes implemented due to feedback, and ratings on the ward-based ‘Open and Honest’ boards, alongside information such as staffing profiles for that day, and the name of ward manager.
The percentages of patients that would recommend the Trust’s departments for 2016 are shown below:
2014-15 2015-16 2016-17 Patient FFT - area Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 A&E N/A N/A N/A 50% 78% 74% 73% 72% 82% 82% 81% 82% Maternity N/A N/A N/A 0% N/A 96% 83% 84% 95% 96% 95% 95% Outpatients N/A N/A 19% 49% 65% 53% 67% 96% 88% 87% 89% 88% Inpatients N/A N/A N/A 0% N/A 98% 98% 98% 98% 96% 96% 97% Day case N/A N/A 9% 59% 76% 72% 74% 89% 90% 90% 89% 88% Community N/A N/A N/A 61% 74% 81% 86% 89% 93% 96% 90% 91%
The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: Response rates for maternity (births) is averaging at 95%, which remains high for Trusts of its size in relation to response rates but slightly below the current national average of 97%. Recommendation rates for A&E remain low at an average of 82%, with the national average standing at 87%. Inpatient recommendation rate is 97% above the national average at 96% placing this Trust in the top 30% of hospitals for its size.
The Pennine Acute Hospitals NHS Trust intends to take / has taken the following actions to improve this percentage and so the quality of its services, as follows:
As stated earlier, a programme of work has commenced to refocus and strengthen the use of FFT across the Trust through education and communication via various media to staff and patients. This is in addition to ensuring increasing the level of access for all patients as appropriate to have the ability to provide feedback on their care and for action to be taken to share learning and implement improvements where required.
3.3.7 Percentage of patients risk-assessed for venous thromboembolism Thrombosis is the term used to describe a blood clot forming inside a blood vessel. The most common form of thrombosis is a deep vein thrombosis (DVT) which occurs in the leg. If part of the clot breaks off it will travel through the circulation to the lungs: this is known as a pulmonary embolism which is serious and can be life-threatening.
It is believed that many cases of thrombosis are potentially preventable if patients have appropriate prophylaxis
Quality Account Report 2016-17 PAGE 100
(preventative measures) to reduce the risk. These measures include having injections to thin the blood and wearing support stockings to assist circulation. In order to determine what is appropriate for each patient, a risk assessment must be completed.
Goal: for 95% of patients to have VTE risk assessments within 24hrs admission to hospital Outcome: target achieved – more than 95% of patients had VTE risk assessments undertaken
Table showing VTE Assessments: April 2016 to March 2017 (patients aged 18+)
Pennine Acute Hospitals NHS Trust England overall Month No of No of No of No of % assessed % assessed admissions assessments admissions assessments Apr 16 12643 12199 96.46% 1205464 1153703 95.71% May 16 13274 12802 96.44% 1234261 1182161 95.78% Jun 16 13400 12918 96.40% 1259782 1205501 95.69% Jul 16 12920 12434 96.24% 1235402 1182094 95.68% Aug 16 13206 12749 96.54% 1239141 1182479 95.43% Sep 16 13197 12703 96.26% 1234202 1177530 95.41% Oct 16 13545 12922 95.40% 1238672 1186018 95.75% Nov 16 13981 13463 96.29% 1270126 1217613 95.87% Dec 16 12804 12306 96.11% 1180707 1125194 95.30% Jan 17 13415 12890 96.09% 1244981 1189981 95.58% Feb 17 12279 11762 95.79% 1162046 1110106 95.53% Mar 17 13974 13432 96.12% 1329107 1269196 95.49%
The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: the data is scrutinised by external auditors who have confirmed the robustness of the process for data validation. The Pennine Acute Hospitals NHS Trust has taken the following actions to improve this percentage and so the quality of its services, by aiming to meet all the other requirements of NHS England’s VTE Prevention Programme, as summarised in the table below:
NHS England’s requirement Process in Pennine Acute Trust Pathways to be in place to identify hospital The Trust’s VTE team is alerted to cases of VTE via different routes. acquired VTEs They are notified if patients are scanned for either a DVT or PE, and also by the bereavement service if DVT or PE is listed on a death (Defined as a VTE occurring either within certificate. 72 hours of admission or within 90 days of a hospital discharge). PAGE 101
NHS England’s requirement Process in Pennine Acute Trust A root cause analysis (RCA) investigation An RCA investigation is initiated by the VTE nurse to identify if to be undertaken for all confirmed cases appropriate medication was prescribed and administered during the of hospital-acquired VTE, and that these patient’s admission. Additional information is requested from the are provided to the commissioners. clinical team to complete the RCA, and once they are concluded the reports are shared with the commissioner quality leads. Most of the RCA investigations conclude that the VTE event was unavoidable, that is that all the necessary measures were taken.
It was anticipated that the back log of RCAs would be resolved by distributing RCAs out for completion to the patients’ consultants. However, due to competing pressures, the timescales for completion of the RCAs overall remains poor, and the back-log that was reported last year still persists.
The system of completing the RCAs is still under review, and it remains a priority to improve their timely completion with an increased input from the clinical teams. One change being considered is to review, and where possible reduce, the amount of information that is required for completion of the form: this will reduce the length of time each takes. Local audits to be undertaken to ascertain Audits of compliance have been undertaken in high risk areas on the percentage of patients receiving the use of anti-embolic stockings, risk assessment and re-assessment appropriate prophylaxis after being risk compliance, use of appropriate prophylaxis and provision of patient assessed. information.
Additionally, over the year the following has also been completed: ●● Completion of guidelines for the diagnosis and management of deep vein thrombosis and pulmonary embolism in adult inpatients and outpatients. ●● Community partners in attendance at VTE Committee meetings, to ensure they are aware of the number of VTEs occurring within the community.
Future goals to be achieved: ●● Training for nursing staff to improve the use and ensure accurate documentation for anti-embolic stockings ●● Trial of VTE electronic risk assessment which has been developed during the last year. ●● Tri-annual update of the policy for the prevention of venous thromboembolism ●● Undertake Trust-wide audits of compliance with VTE risk assessment and re-assessment, prescribing and administrating of prophylaxis when indicated by the risk assessment, and provision of information to patients/ carers. ●● Finalise the pathway and process for fulfilling the duty of candour with VTE Committee and governance team, and implement this once it is agreed. ●● Continue to increase mandatory training compliance. Although the percentage of staff trained has reduced slightly from last year, the overall numbers of staff trained has increased. This is because there is now a larger group of staff requiring training, with the target staff numbers having increased by 812 to 2610. Of these, 1866 staff members (71%) have completed the training, compared to 1348 of 1798 (75%) in 2015-16.
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3.3.8 Rate (per 100,000 bed-days) of C.difficile infection in patients over two years old Our drive to reduce the numbers of patients with healthcare acquired infections (HAIs), such as methicillin resistant staphylococcus aureus (MRSA) and clostridium difficile infections (CDI), across our hospitals and community services is a top priority and is a key aim within our quality improvement programme. Our HAI performance, including reported cases of MRSA and CDI, are reported to our Trust Board of Directors, and the data is publically available and also reported back to our staff.
Our national objective was to have fewer than 55 cases of CDI for 2016-17: we reported 58. Although this is a slight increase from 56 in 2015-16, it is a reduction of 84.2% on the 356 cases reported in 2008-09, as shown in the chart below.
Each case of Clostridium difficile is investigated to understand any lessons learnt so that risks are reduced; for example, by improving infection prevention strategies or antibiotic prescribing.
The cases are individually reviewed with colleagues from neighbouring CCGs to ascertain and share mutual ideas for improvement. These clinical reviews have confirmed 54% of the CDI cases reported this year to be unavoidable, with no lapses in care identified. Areas for improvement have been identified, specifically in relation the knowledge and understanding by healthcare professionals of how to interpret symptoms of diarrhoea and link this to risks for CDI infection. To support this, a risk assessment tool to aid in the rapid clinical diagnosis for patients with diarrhoea has been introduced. This is audited and compliance will form part of each ward’s performance metrics for 2017/18.
Additionally, the Infection Prevention Team has introduced a pilot scheme of diarrhoea ward rounds to support ward teams with assessing patients with diarrhoea for risk of CDI. It is hoped that the pilot evaluation will identify weaknesses in knowledge which can be targeted for further training in 2017.
The Trust’s rate (per 100,000 bed days) cases of c.diff from April 2016 to March 2017 has been reported as 14.31. Comparison with local peers and against the national average over the previous three years is shown in the table below: PAGE 103
Rate (per 100,000 bed days) cases of April 2014 – April 2015 – April 2016 – Clostridium difficile March 2015 March 2016 March 2017 NW Trust average 16.8 15.7 14.10 Best performing NW Trust 10.1 6.1 4.97 (excluding specialist hospitals) Worst performing NW Trust 27.5 26.3 28.99 (excluding specialist hospitals) Pennine Acute Hospitals NHS Trust 17.7 14.1 14.31
The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: The national benchmark for all acute hospitals for Clostridium difficile infections is reported as the rate per 100,000 bed days and this remains comparable to other hospitals of similar size across England, and within the top four Greater Manchester Trusts.
The Pennine Acute Hospitals NHS Trust has taken the following actions to improve this percentage and so the quality of its services, by
●● Improving our infection prevention and control practices to support clinical assessment and isolation of patients with diarrhoea by using a risk assessment tool. This is audited and compliance will be part of ward performance metrics for 2017/18. ●● Additional hours of cleaning and disinfection of wards where patients are particularly vulnerable ●● A change of disinfectant wipes to aid the cleaning of equipment after a review of the efficacy data has been completed.
Additionally in 2017-18, we will continue our focus on good practice to reduce healthcare acquired infections, working with staff to: ●● Ensure rapid clinical assessment for patients with diarrhoea for risk of CDI, is part of routine clinical practice and share with other specialist colleagues for wider adoption. ●● Sustain and continually improve antibiotic prescribing to enhance and support the national “Start Smart, then Focus” antibiotic stewardship programme. This will be achieved through audits of antibiotic prescribing and feedback to clinical teams. ●● Evaluate an innovative programme of emphasis on improving facilities and support for patient hand hygiene as a quality improvement programme. ●● Continue to promote high standards in hand hygiene through the expansion of a red/yellow /green card scheme to highlight missed opportunities or evidence of good practice. ●● Review further innovative methods of evaluating environmental cleaning and surface contamination through the use of UV light decontamination. A closely-related indicator is to eliminate MRSA bacteraemias (blood stream infections): the national target for all acute hospitals in 2016-17 was zero. We reported one case.
We continue work to reduce all bacteraemias including MRSA with:
Quality Account Report 2016-17 PAGE 104
●● a programme of screening high-risk patients on admission ●● provision of topical treatments for those at risk of MRSA infection, including an antiseptic body wash which is continued for the duration of a patient’s stay.
An investigation involving the clinical and nursing team is undertaken for each MRSA and actions from lessons learnt are implemented with specified training in the area of clinical practice requiring improvement.
During 2017-18: ●● A multi-disciplinary group will focus on improving the diagnosis and rapid treatment of severe sepsis. This forms part of the Trust’s patient safety programme. ●● The Department of Health review on Antimicrobial Resistance (AMR) was published in September 2016, with the expectation that we will continue to drive forward the UK AMR Strategy. These includes setting new ambitions to reduce infections and prescribing and introduce new quality indicators including a reduction in healthcare associated Gram-negative bloodstream infections in England by 50% and reduce inappropriate antibiotic prescribing by 50%, with the aim of being a world leader in reducing prescribing by 2020. ●● To support this new initiative, we will implement improvement programmes to further enhance antimicrobial prescribing stewardship and improve the prevention and early diagnosis strategies for urinary tract infections which are the main risk factor for gram negative blood stream infections.
3.3.9 Number and rate of patient safety incidents reported in the Trust, with number and percentage resulting in severe harm or death NHS Trusts must submit the details of patient safety incidents to the National Reporting and Learning Service (NRLS) regularly. The NRLS provides comparative feedback to Trusts twice yearly; six months after the reporting period. Trusts can use this information to identify and address areas of low reporting, as high-reporting Trusts are considered to have a stronger safety culture.
The information in the table below has been extracted from the NRLS system and shows the Trust’s performance for the reporting periods October 2015 to March 2016 (published September ‘16) and April to September 2016 (published April ‘17). The table also compares the Trust’s performance against its peer group - a cluster of the 11 North (Lancashire and Greater Manchester) regional Trusts.
PSIs Resulting in PSIs total PSIs Resulting in death Severe Harm NRLS Measure Oct ’15 – Apr ’16 – Oct ’15 – Apr ’16 – Oct ’15 – Apr ’16 – Mar ’16 Sep ‘16 Mar ’16 Sep ‘16 Mar ’16 Sep ‘16 14 13 6 5 National average number 4818 4955 (0.291%) (0.262%) (0.125%) (0.101%) 57 75 37 36 Maximum number for peers 11910 11835 (0.479%) (0.634%) (0.311%) (0.304%) Minimum number for peers 3990 5107 1 (0.25%) 0 0 0 57 72 37 26 Pennine Acute number 7047 7098 (0.809%) (1.014%) (0.525%) (0.366%) PAGE 105
PSIs Resulting in PSIs total PSIs Resulting in death Severe Harm per 1000 bed days Oct ’15 – Apr ’16 – Oct ’15 – Apr ’16 – Oct ’15 – Apr ’16 – Mar ’16 Sep ‘16 Mar ’16 Sep ‘16 Mar ’16 Sep ‘16 0.3 0.3 0.1 0.1 National average 39.6 40.8 (0.758%) (0.735%) (0.253%) (0.245%) 1.4 1.0 0.5 0.4 Maximum value for peers 57.5 60.6 (2.435.%) (1.650%) (0.870%) (0.660%) Minimum value for peers 35.3 36.6 0.0 0 0 0 0.8 1.0 0.5 0.4 Pennine Acute value 35.3 36.6 (2.66%) (2.732%) (1.416%) (1.093%)
The Trust has reported a small increase in the total number of incidents reported to the NRLS in each 6 month period. In October ’15 to March ’16, there was a 2.81% increase from the 6854 reported in April to September ’15; and the number for April to September ’16 showed a further 0.7% increase.
The number of deaths reported has reduced in the April to September 2016 period. This is due to the figure for Oct’15 to Mar’16 being falsely elevated because of a number of historical incidents were reported in this period following a ‘look-back’ exercise. The number of severe harm incidents has increased in the April to September 2016 period: this can be attributed to the high numbers of reports of patients waiting for admission for more than 12 hours in ED, which is shown in the chart on page 90.
The Trust’s rate of reporting (per 1000 bed days) has increased in both periods but remains below the national average and is the lowest overall in its peer group. Though there is no national target, we aim to be in the mid-range of the peer group, which would demonstrate a good open and honest reporting culture. Within the numbers reported overall, we would aim to have a higher rate of reports relating to near misses / no harm incidents, which provide opportunity to learn from these and from investigations of less serious incidents. For incidents resulting in death or severe harm the Trust is the highest in its peer group, and we aim to see a reduction in these grades of incidents. There are a number of quality improvement work-streams in progress (see section 3.1.2) that will contribute to the delivery of harm-free care as they are implemented.
The Pennine Acute Hospitals NHS Trust considers that the number of incidents is as described, but has some concerns in relation to the accuracy of some of the grading. Although all reported incidents are reviewed by governance processes, it has been noted that there are sometimes delays in verifying the grading. This is due to the wish to obtain as much information as possible before assigning a grading, and the lack of resource to undertake initial reviews. However, in respect of the 12-hour breaches in ED, there has been scrutiny by the CCGs as the quality leads have worked with the governance team within the Trust to validate the high numbers of these incidents.
The Trust has taken the following actions to improve the quality of its services. Since April 2016 the Safeguard Systems Manager has delivered training sessions in wards, departments and health centres to promote improvement in both the standard of incident reporting and the way managers respond on-line. From April 2016 to March 2017 there has been an 11% increase in the number of patient incidents reported. Divisional Governance Managers have supported staff in the departments when responding to incidents with root cause analysis investigations.
The Trust will be introducing a new risk management system, Datix, during the coming months, which includes a module for incident reporting. The system offers features that will support the early review and verification of incidents.
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Serious Untoward Incidents From 1 April 2016 to 31st March 2017, the Trust has reported 775 serious incidents (SIs): this is a significant increase from 275 reported in 2015-16, and 102 in 2014-15. The main reason for this is that the Trust has reported a large number of incidents where patients have waited in ED for over 12 hours from the decision to admit them. In total there were 641 such incidents reported, accounting for almost 83 % of all SIs in 2016-17. This is illustrated in the chart below:
Serious Incidents reported from Sept 2015 to March 2017: 12 hour breaches shown separately 160
140 ED 12-hr breach All other S.Is 120 100 80
No. of SIs 60 40 20
0 … - 15 16 16 16 17 17 16 17 15 16 16 16 15 16 15 16 16 16 ------May Jul Jan Jan Jun Oct Oct Apr Sep Feb Sep Feb Dec Dec Aug Nov Nov Mar Mar
Improvements Throughout 2016-17 processes for identifying and responding to Serious Incidents have been improved. At the beginning of 2016-17 there were a large number of outstanding serious incident investigations which had breached the date for response, the Trust invested in a number of temporary governance managers to support the divisions in addressing them.
Targets were set to address tranches of overdue incidents according to the original due dates given by commissioners. By December 2016 all serious incidents originating in 2015 had been investigated.
Between April 2016 and December 2016, 478 incidents investigations were completed, 342 of which related to Emergency Department breaches. The CCGs have supported the Trust with the investigation and closure of these incidents. A further 154 serious incident investigations, including 129 emergency department breaches, were completed and forwarded to commissioners between January and February 2017.
Since December 2016 potential serious incidents have been reviewed by Divisional Directors and escalated to Directors of Nursing/ Medical Directors for the Care Organisations to determine if a serious incident has occurred.
Monitoring mechanisms have been set in place in which Divisional Directors of Nursing meet with the Director of Patient Safety to review open incidents and update on progress.
A series of Serious Incident Review Panel meetings with Care Organisaton Directors of Nursing have been put in place and will review and improve the quality of investigations and action plans going forward. PAGE 107
Never Events The Trust has reported eight never events in 2016-17. These were: three instances of wrong-site surgery; three instances of foreign objects retained post-operatively; and two cases of the wrong implant or prosthesis being used. This is a sharp increase from the one never event that was reported during 2015-16, which related to a wrong implant/prosthesis.
This is in part due to the retrospective nature in which some never events are identified: two of the eight never events reported in 2016 -17 related to events outside that time period, for example one case of a retained foreign object post operatively related to an operation in 2012 but was not identified until further surgery in 2016.
In order to reduce the number of never events, the Trust has undertaken some specific actions: ●● An overarching policy for swab, needle and instruments for all departments where invasive procedures take place was approved at the Clinical Effectiveness Committee in March 2017 as part of the wider NatSIPPs work (see section 3.2.1) ●● Following the never event with the wrong size implant, a second time out was introduced prior to any opening of prosthesis. The full team stop. The implant is confirmed against the expectation of the surgeon, the consent form and any other relevant documentation. The site is also verified with the consent. Sizes are then visibly displayed on the swab, needle and instrument board.
Other work in progress: ●● Bespoke procedural checklists, by directorate, are to be developed once agreed at the clinical effectiveness committee. ●● Improved visual WHO communication to be displayed via a whiteboard in theatre. ●● Launch of the overarching policy and NatSIPPs now this has been agreed. 3.4 Additional Core Information Requested by NHS England In addition, NHS England requested that, where possible Trusts also include information relating to: ●● Implementation of the Duty of Candour ●● Patient Safety Improvement Plan – this is now incorporates within the Quality Improvement plans (section 3.1) ●● NHS Staff Survey results – indicators relating to bullying and harassment, and Workforce Race Equality Standard ●● CQC ratings grid or, where not available, the Trust’s self-assessment (see previous section 2.2.5).
3.4.1 Implementation of the Duty of Candour In line with the Duty of Candour regulations that came into force on 27 November 2014, the Trust continues to work to ensure that we are open and transparent with patients who use our services, and specifically when things go wrong with their care and treatment. A number of changes have been implemented to improve compliance with this important requirement.
In December 2016, the Trust implemented a process in which the allocation of a family liaison officer to discharge the Duty of Candour has been overseen by the site Directors of Nursing and Medicine.
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●● The online form used by managers to respond to incident investigations has been modified to automatically display the Duty of Candour requirements where patient harm is reported as moderate, severe or death. ●● A weekly Duty of Candour log is circulated automatically to clinical divisions via the Trust’s risk management system to enable divisions to monitor outstanding Duty of Candour requirements. ●● The ‘Trust Welcome,’ delivered to all new starters, now includes information on Duty of Candour and the key actions required where it applies. ●● Training slides for Duty of Candour have been provided by the Trust’s solicitors and are accessible through the Clinical Governance intranet pages. A training video using examples and Trust staff has also been produced. From April 17, a series of half-day training sessions will be provided by Trust solicitors: Duty of Candour will be one of the areas covered alongside root cause analysis investigation and report writing training.
3.4.2 NHS Staff Survey results The NHS Staff Survey is an annual survey, first run in 2003, and is required by NHS England for all NHS Trusts in England.
There is a significant body of evidence that demonstrates the link between high levels of staff satisfaction and engagement with better patient experience and outcomes. The quality of care that patients receive depends first and foremost on the skill and dedication of NHS staff. Engaged staff are more likely to have the emotional resources to show empathy and compassion, despite the pressures they work under. Individuals who are committed to their organisations and involved in their roles are more likely to bring their heart and soul to work, take the initiative, ‘go the extra mile’ and collaborate effectively with others. (Kings Fund, Staff Engagement 2015). The importance of the staff survey results therefore links to a number of the Trust’s strategic priorities.
The Picker survey was sent to all staff across different divisions, directorates and professions throughout the Trust; 9103 in total. The survey was conducted from October to early December 2016. The response rate to this survey was 45% with 4068 staff completing the survey. This was a significant improvement from the 2015 response rate which was 21%.
The results of the 2016 NHS England survey are summarised into 32 Key Findings grouped into nine themes: ●● Appraisals & support for development ●● Equality & diversity ●● Errors & near misses ●● Health and wellbeing ●● Job satisfaction ●● Managers ●● Patient care & experience ●● Violence, harassment & bullying ●● Working patterns
PAHT compares favourably against other Trusts in two areas; percentage of staff working extra hours, and percentage of staff experiencing discrimination at work, have both reported lower than average. The survey also reported a significant increase in satisfaction with staff having opportunities with flexible working. The key area of staff motivation at work has also increased marginally from last year’s survey; we will be working to keep this momentum going. PAGE 109
Staff reported a deterioration in the percentage of staff experiencing physical violence from patients, relatives or the public in the last twelve months and this will be an area of focus for 2017, as will strengthening clinical and site leadership and increasing frontline staffing numbers.
Overall the staff engagement scores are stable having changed little from the 2015 survey. Encouragingly, the staff group engagement score for our adult general nursing workforce and HCAs/nursing assistants (which make up the largest proportion of the Trust’s workforce) has increased significantly from 3.67 to 3.72. This shows that in the face of the huge amount of pressures our nursing workforce are under, more of our frontline clinical staff have more confidence in the future, feel better engaged and can see they are being listened to and supported.
Work continues against the milestones of the Healthy Happy Here plan (see section 3.1.2) which was introduced in 2015 and refreshed in 2016. The aims are to support recruitment and retention, and improve morale and attendance levels; both of which are key in the Trust’s drive to become an employer of choice.
Supplementary to those milestones, and following the results of the 2015 survey, a number of actions were implemented from April 2016 onwards. These were aimed at further improving staff engagement and included:
Action Outputs Appointment of a Staff ●● introduction of a quarterly pulse check staff engagement survey, which provides a Engagement Lead and regular sense check of how staff are feeling; Advisor ●● establishment of a Staff Engagement Steering Group to oversee all matters related to staff engagement ●● establishment of ‘reward and recognition’ focus groups and resultant action plan ●● adopting tactical measures to increase visibility and engagement with directors and senior managers ●● introduction of staff engagement pioneers programme, working with teams to improve staff engagement and support service improvement
Work will continue on the above and further actions agreed from this year’s results throughout 2017.
Additional Information requested by the Commissioners
3.5.1 Reducing the risk around missed and delayed diagnosis Improvements to systems and processes to reduce the incidence of missed and delayed diagnosis have continued through the year. This work is overseen by the Diagnostics Improvement Group (DIG) which reports to the Executive Clinical Effectiveness Governance Committee, chaired by the Chief Medical Officer. Some key developments during the year are:
The CRIS communicator is being trialled as a means of emailing consultants about urgent, unexpected results or results which have been amended. Acute Medicine at Fairfield General Hospital and Urology are the two potential chosen areas.
An electronic tracker for all tests has been developed and is being trialled in Urology. This will assist consultants’ PAs in tracking tests and results.
Unfortunately, this work has not progressed as quickly as hoped due to a number of competing priorities, and the removal of some agency staff who were supporting the project.
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In addition, radiologists have been reminded of the need to ensure unexpected findings are referred to the Rapid Access Clinic. All clinicians have been reminded about the need to comply with the ‘Your Request, Your Responsibility’ policy.
In November 2016 an audit linked to ‘your request; your responsibility’ was undertaken to assess compliance with requests for tests being documented and results being reviewed and acted upon in a timely manner. The audit reviewed the radiology, bloods, microbiology and histology/cytology tests of 51 patients: it identified a total of 117 tests were undertaken, of which 79 had abnormal results. The audits have been undertaken each month, and reported back to the Diagnostic Improvement Group. The latest audit from March 2017 identified the tests of 58 patients were reviewed: a total of 118 tests, of which 57 had abnormal results. The overall results (all metrics) of the November audit, compared with the March 2017 audit, are summarised in the table below:
All tests All abnormal tests Tests November March November March Target (n=117) (n=118) (n=79) (n=57) Radiology 70% 92% 72% 95% 100% Blood 68% 78% 76% 82% 100% Microbiology 58% 52% 77% 50% 100% Histology/Cytology 50% 83% 70% 88% 100%
The results of the audits have been sent to the participating directorates/specialities requesting that the results are discussed at their next Audit & Governance meeting and that if required an action plan is developed to improve timely reviews of tests and taking the appropriate steps to act on abnormal test results.
Some IT-related issues, e.g. access to systems and tracking of the source of requests, have been highlighted and under review. Ultimately an Electronic Patient Record will help to provide a more robust solution for tracking of requests and results. Current timescales for this suggest it will be implemented during 2018-19. PAGE 111
3.5.2 Progress of the Falls Prevention Strategy The Trust employed a falls team of two registered nurses in May 2016. The team’s remit was to reduce the number of patient falls, and to reduce the severity of injuries that patients sustain from falls. Prior to this, a project team led by the Orthopaedic Physician had introduced the Royal College of Physicians’ national initiative, ‘Fallsafe’. A complete bundle, which included a falls risk assessment, interventions and a post-fall action plan, was developed and implemented in February 2016. Following this, the falls figures began to reduce (see chart below).
Number of falls reported April 2015 to March 2016; and April 2016 to March 2017.
A baseline audit was undertaken in June 2016 in the five wards in each site reporting the highest numbers of falls. This showed that although all wards were using the Fallsafe bundle, there was varying compliance with the quality of completion. It was also identified that some basic nursing elements could be improved within the bundle to facilitate its completion. The bundle has been revised and a draft has been circulated for consultation at the time of this report.
The audit also showed that there had been a lack of training on how to use the document to support patient care, and this will be incorporated with the launch of the new bundle. The results of the audit became the basis of how the training plan was developed.
The falls team receives copies of all falls incidents: this enables a database to be maintained to monitor trends and build reports. If a patient has more than one fall, the team contact the ward to offer advice and support for that patient to prevent further falls. If a particular ward is reporting several falls the team carries out an audit of the ward and training to identify areas for improvement and reduce the incidence of falls. The team also encourage staff to report ‘near misses’ so interventions can be put in place to prevent an actual fall.
If a patient sustains a fall with harm, the falls team supports the governance team with the actions required, for example with completion of 72hr reviews for falls with severe harm. The team receives copies of completed root cause analysis investigation reports and contributes to the development of action plans to ensure they are pertinent to the area and that they address the lessons learned.
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The falls team has also supported the Trust to prepare for inquests, with preparation of statements and providing evidence in the inquest with the work done so far to improve practice around falls. The team has made changes acting on the outcome of the inquests, for example introducing ‘bay nursing’ and ‘bay tagging,’ providing staff with an easy-read guide to completing the Fallsafe bundle, and providing supporting guidance on how to complete neurological observations and lying and standing blood pressure readings. The team has discussed the lessons learned at ward managers’ meetings, training sessions, and site safety meetings to cascade the information accordingly.
The team identified a lack of training in falls prevention. An e-learning package was available for staff to complete, but it was not fully compatible with the IT systems in many areas. The team introduced face-to-face training whilst the issue was being resolved and since July 2016 over 700 staff have attended training sessions; either bespoke to their area or standard training sessions. These sessions have been accredited for mandatory training requirements. The team has also been involved in various staff training days to increase staff awareness about falls prevention. The issues with the e-learning package have not been rectified to date therefore the team has produced an in-house package for staff. In total, with staff that have been able to access the e-learning package a total of over 1600 staff have undertaken falls awareness training during 2016-17.
In June 2016 a post-fall checklist was introduced, which is completed by the matron. It measures compliance with the Fallsafe bundle prior to the patient falling, and whether all the post-fall actions have been carried out, to ensure appropriate care is being provided. It enables the matrons to assess gaps in practice and support ward managers to improve practice in their areas. Compliance rates have improved from 22% at launch, to 61%. To improve this, from January 2017 the ward managers on some sites are completing their own checklists, and this is being rolled out to all areas. This also encourages local accountability for falls.
Compliance with the Fallsafe bundle has improved since this process was implemented. For example, completion of the bundle within four hours of admission has improved from 36% in June 2016 to 88% in March 2017 average across all the sites. Informing families about a fall has improved from 56% to 96% (average) for the same period.
The Trust audit showed lack of compliance with the Intentional Rounding and Enhanced Patient Observation policies for patients that were identified as being at risk of falling. The falls team contributed to the review and updating of these policies to improve practice. For example, intentional rounding of all patients will now take place every hour during the day; two-hourly at night. To support compliance with these policies, the falls team incorporate them into their training so staff have a practical understanding of the expectations of care they deliver to patients. The team also delivered four Patient Safety training days, based on the policies, to provide appropriate skills and knowledge for staff to incorporate into their practice. The training days incorporated content from all the speciality teams within the safeguarding team, and brought these together with case studies on the day.
The findings from the national bedrail audit showed that the risk assessment in use did not adequately support the practice on the wards, and it was identified that a more appropriate risk assessment was required. This was done, in association with a revision of the bedrail policy. Bedrail magnets have also been ordered for bed boards so they indicate whether a patient has had bedrails recommended or not, to improve safety and practice.
In September 2016, the Falls Champions’ group was set up: this was initially very well attended but unfortunately attendance has dwindled due to staff not being able to leave the wards for varying reasons. This was found to be an issue with many ‘link nurse’ meetings, so the Safeguarding Team established the ‘Vulnerable Adults Professional Leads.’ This group meeting is attended by the ward managers, matrons, and any other relevant staff to receive updates from all the specialities. The meetings are held on all sites, at the same time, to deliver the same messages, and are led by the Safeguarding Team. PAGE 113
However, as falls is a high priority for the Trust, the falls champions’ group will continue by email contact each month, and a quarterly meeting. An initial ‘Falls Champions’ Expert day’ was held in March 2017, and another is planned for April. The aim of these days is to provide the falls champions with the knowledge and skills to act as ward resources for falls.
Finally, an ‘equipment amnesty’ has been held across the Trust to ascertain what falls sensors are in use, as previously wards were buying their own equipment. Falls Sensor Trials have been completed to identify the most appropriate equipment to use in the Trust: this will be managed via a virtual library supported by a full maintenance programme provided by the medical devices team.
In the forthcoming year the team will provide ‘intense support’ for wards that have high incidence of falls, bank and agency usage, or poor patient satisfaction feedback. The aim is to help ensure patients receive the appropriate medical and nursing care, reduce falls and reduce the length of stay in hospital. This will commence in April 2017 on a pilot ward. The team provides a month of intense support, based on the ward carrying out observations of care, providing support and advice. The team will also arrange relevant bespoke training to provide staff with a virtual tool bag of skills and knowledge, especially around cognitive impairment and how to manage the patients’ individual needs. Volunteers from the Patient Experience Team are being recruited to assist, in addition to a company that provides ‘Reminiscence Screens’ that have interactive activities to use to engage patients.
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3.6 National Quality Standards 3.6.1 Referral to Treatment National and local NHS standards require patients to be admitted for surgery or scheduled (elective) services within 18 weeks of referral by their GP. This standard is known as 18 weeks Referral to Treatment (RTT). The incomplete standard divides the number of open (untreated) patients waiting less than 18 weeks of referral to the hospital by the total number of open (untreated) patients waiting. The national operational target allows a tolerance for patient choice and clinical complexity and is set at 92% or over.
The number of untreated patients waiting exceeding 18 weeks is called the backlog. The graph below describes the Trust’s performance over time. The blue line shows the number of untreated (open) pathways exceeding 18 weeks (the backlog) over time. The green shaded area shows the operational tolerance described by the 92% standard, to account for patient choice of appointments and clinical complexity. The Trust has remained within the national tolerance (the green shaded area) and has therefore passed the target every month this year.
RTT Open Pathways Backlog (+18 weeks) 92% Tolerance Backlog Actual 3,000 2,500 2,000 1,500 1,000 500 0 16 17 15 16 16 17 16 17 15 16 15 16 15 16 15 16 15 16 15 16 15 16 15 16 ------Jul Jul Jan Jan Jun Jun Oct Oct Apr Apr Feb Feb Sep Sep Dec Dec Aug Aug Nov Nov Mar Mar May May
Like many other NHS Trusts across Greater Manchester and the country, we have experienced pressures during 2016- 17. The chart reflects the pressures and shows a reduction in performance between Feb-16 and Jul-16, which has subsequently stabilised. Work is being undertaken at speciality level to improve performance and make reporting systems and processes better.
Year / Comparison Incomplete: Target 92% Apr-15 to Mar-16 Pennine Acute Trust 96.4% National 92.2% Regional 93.4% PAGE 115
Year / Comparison Incomplete: Target 92% Apr-15 to Mar-17 Pennine Acute Trust 92.7% National 90.4% Regional 91.7%
England as a whole has missed the incomplete standard since and including December 2015 – The most recently published information is shown in the table below.
3.6.2 Diagnostic wait times The Trust carries out on average 16,700 diagnostic tests/procedures each month relating to Imaging, Physiological Measurement and Endoscopy. There are approximately 11,000 patients on our waiting list each month, with 3.12% of patients waiting longer than six weeks for their test / procedure. This is a slight increase from last year (3.02%)
The table and charts below show the number of patients waiting longer than 6 weeks each month and the type of tests / procedures.
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Area 16 16 16 16 16 16 16 16 16 17 17 17 MRI 140 28 3 2 0 0 3 9 25 5 0 0 CT 1 0 0 0 0 0 0 0 0 0 0 0 Non-obs Ultrasound 3 2 0 3 0 0 0 0 2 0 0 2 Barium Enema 0 0 0 0 0 0 0 0 0 0 0 0 De XA Scan 0 0 0 0 0 0 1 0 0 0 0 0 Audiology 0 0 0 0 9 16 0 0 0 0 0 0 Cardiology -Echo 0 0 4 1 97 21 35 0 0 0 0 0 Cardiology – 0 0 0 0 0 0 0 0 0 0 0 0 Electrophysiology Peripheral 0 1 0 0 0 0 0 2 0 11 0 0 Neurophysiology Sleep Studies 0 0 0 0 5 0 0 0 0 0 0 0 Urodynamics 0 1 0 1 0 0 1 3 1 0 0 0 Colonoscopy 195 240 192 444 497 298 21 29 35 24 23 25 Flexi Sigmoidoscopy 54 72 52 97 95 64 3 5 5 6 3 8 Cystoscopy 15 3 28 25 2 2 3 2 0 1 0 0 Gastroscopy 142 97 208 355 266 193 14 25 29 41 10 30 Total 550 444 487 928 971 594 81 75 97 88 36 65
Quality Account Report 2016-17 PAGE 116
The chart below shows the number of patients waiting over six weeks for a diagnostic test or procedure, by month
Waits over six weeks at month end: 2016-17
500
450 MRI
400 Cardiology - Echo Colonoscopy 350 Flexi sigmoidoscopy 300 Gastroscopy 250
200
150
100
50
0 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
There was an increase in patients waiting longer than six weeks during the first half of 2016 which peaked in August 2016, although patients waiting for MRI and Echo were low compared to other tests. The number of patients waiting over 6 weeks was greatest for those having an endoscopy type procedure and may be attributed to the implementation of NICE GP cancer referral guidance, as part of the national cancer strategy, which aims to improve cancer survival rates by lowering the criteria for GPs to refer patients for endoscopy.
Overall, the number of patients in the diagnostic part of an urgent pathway has increased considerably. The demand for colonoscopy has increased by 9.74% from the previous year, and this is compounded by a reduction in capacity due to staff availability and available slots. However, as the chart depicts, the number of 6 week breaches has reduced dramatically since the August rise which is due to improvements in the service as follows: ●● Procuring additional capacity from the independent sector (Care UK) ●● Recruitment of additional clinical staff to undertake endoscopy activity ●● Additional lists from nurse endoscopists ●● Additional lists for colorectal surgery to support ‘straight to scope’ ●● Improvement work to reduce sickness and absence ●● Collaboration with the Trust’s Project Management Office to improve in key areas ●● Improving patient pathways to create capacity to meet demand PAGE 117
3.6.3 A&E waiting times The Department of Health’s national 4-hour Emergency Care Access Standard requires at least 95% of patients to be seen, treated, admitted, transferred or discharged within four hours of attendance at an A&E department, urgent care centre or NHS walk-in centre. An additional standard is that no patient should wait more than 12 hours from the decision to admit.
We understand how important these standards are for patients and their families, and work hard to ensure our patients are seen as quickly as possible across our three Accident & Emergency departments at North Manchester General Hospital, Fairfield General Hospital and The Royal Oldham Hospital, as well as our Urgent Care Centre (UCC) at Rochdale Infirmary. Like most Trusts across the country, we are finding this a challenge due to the flow of patients in and out of hospitals and the large numbers of admissions of patients, particularly those who are elderly and with complex and chronic health conditions.
The Trust’s monthly performance for each of our sites, across all A&E quality indicators, are available on our website under quality and performance at www.pat.nhs.uk. The table below shows the performance for the Trust by quarter and total for the year for 2016-17, with comparison to 2015-16.
Department / 2015-16 (%) 2016-17 (%) standard Q1 Q2 Q3 Q4 year Q1 Q2 Q3 Q4 year 4 hour FGH A&E 90.6 89.4 77.9 77.9 83.9 84.6 84.3 79.6 81.8 82.1 4 hour ROH A&E 92.6 88.6 77.6 73.3 81.9 87.9 85.5 77.4 71.9 81.2 4 hour NMGH A&E 91.6 86.1 76.7 74.5 83.2 77.7 76.9 73.4 74.0 75.7 4 hour RI UCC 98.0 98.7 98.1 95.9 97.7 97.8 96.6 97.2 97.6 97.3 4 hour Trust overall 92.6 89.7 80.7 78.3 85.3 85.7 84.4 79.6 78.7 82.2 12 hour trolley wait 0 1 6 198 205 71 105 299 312 787 (reportable)
The Trust overall performance in the A&E 4 hour target for 2016-17 was significantly below the England average of 89.1%.
However, this target has been challenging to achieve throughout the last year, in which over a third of a million patients requiring urgent care presented to our hospitals. October to January was a particular busy and difficult period for A&Es across our patch and nationally, and we reported a larger number of longer waits than usual for patients to be admitted to a hospital ward after being seen by an A&E doctor, particularly at our North Manchester site. The situation improved in the New Year but services have still been facing pressures due to patients not being discharged from our hospital wards back home or in the community and therefore not freeing up beds as quickly as required.
Bed capacity has, however, been increased through resilience schemes and the deferral of routine elective inpatient work at various times throughout the year. Delayed discharges remain a significant pressure and non-elective length of stay has increased slightly when compared to last year. Industrial strike action has also had an impact within the last financial year.
We are working hard to improve our performance, reduce waiting times and find ways to manage the demands on our services. Following a four day rapid improvement event supported by the TDA in January 2016, nine work-streams emerged from this and these all feed into the delivery of the Urgent Care Improvement Plan (see section 3.1.2). This Improvement Plan is high priority for the Trust in order to deliver the improvements identified by the Care Quality Commission.
Quality Account Report 2016-17 PAGE 118
We have recently introduced a new arrangement through our new Decision to Admit Policy (DTA) to speed up admission for those who need it and we have also been working closely with our colleagues in primary care, community care and social services to improve patient flow in and out of our hospitals and to speed up treatment and discharge for our patients.
Patient safety remains our priority and our staff are working extremely hard to triage and treat those with serious conditions, those who require urgent attention, and critically ill patients brought in by ambulance as a priority. Any patient that is recognised as ‘frail’ is immediately placed on a bed and measures put in place to ensure they suffer no harm from pressure damage etc. All patients who are expected to or have waited 6 hours in A&E are transferred onto a bed where all risk assessments are carried out (falls, pressure areas, VTE etc.)
We continue to work closely as a local healthcare system with our NHS primary care, community care and social care colleagues to speed up treatment, admission and discharge times for our patients. For example, at our A&E department at North Manchester, a number of measures have been put in place to support staff in A&E to stabilise and strengthen the service. This involves enhanced GP and primary care input directly into the department from Manchester GPs, enhanced community services, and increased physiotherapy and pharmacy staff in A&E. Additional temporary A&E consultant cover from senior clinicians has also been offered from other neighbouring Trusts at the Manchester RoyaI Infirmary and Salford Royal.
The Trust has made it a priority on abolishing 12 hour waits/breaches for patients brought to A&E needing to be admitted. Significant progress has been made since January 2017 in reducing the number of 12 hour breaches across all of our hospital sites.
3.6.4 Cancer waiting times The Trust provides cancer services for all of the main cancer tumour groups, including palliative care services. Each tumour group has an established multidisciplinary team (MDT), comprising doctors, specialist nurses and other health professionals from different health disciplines. Diagnosing cancer as early as possible and starting treatment quickly are key factors to improving survival for many cancers, and meeting the national targets is a priority for the Trust. The performance data for the year shows that the % national targets have been achieved for the two-week wait standard, 31-day first treatment standard, 31-day subsequent treatment standard (drug), and the 31-day subsequent treatment standard (surgery). Unfortunately the Trust has failed the remaining standards.
The breast symptom non-achievement was due to failing Q1 and Q2. Q1 was predominantly due to patient choice delays: 68 breaches of which 58 were patient choice. Q2 failure was due to significant capacity issues caused by consultant sickness and absence of a locum consultant: 254 breaches of which 183 were capacity issues and 65 patient choice. Additional capacity has now been put in place resulting in compliance of the standard for both Q3 and Q4.
The 62 day cancer GP referral standard was below the 85% target for Q1 and Q4. Q1 achieved 84.6% with 87 breaches of which 55 were due to late referrals to treating Trust; and Q4 achieved 80.3% with 92 breaches of which 49 were due to late referrals to treating Trust. The 62 day screening standard was below target for all quarters: as treatment numbers are low a small number of breaches can result in failing the target. The majority of the breaches have been cited as due to late referrals to treating Trust and capacity issues. The 62 day consultant upgrade standard was below target for Q4 only, with 23 breaches of which 17 were due to late referrals to treating Trust.
Finally, for the 62 day GP referred local standard, non-achievement relates to patients breaching 62 days who have not been transferred to tertiary providers within Greater Manchester within locally agreed timescales: this results with the breach being fully reallocated to PAHT as opposed to shared between the two Trusts. This was a result of an PAGE 119
unusually high number of breaches caused by a range of reasons such as patient choice, medical reasons, complex pathways, and capacity issues.
National target 2015-16 % achievement 2016-17 % achievement Q3 standard target % Q1 Q2 Q3 Q4 Year Q1 Q2 Q4 Year (prov) two-week wait 93 92.5 91.9 96.6 95.7 94.2 94.9 93.9 95.6 92.6 94.3 breast symptom 93 97.5 69.7 96.3 93.3 89.1 90.8 58.7 97.6 95.1 85.6 31/7 day first 96 99.8 100 99.4 99.5 99.7 98.9 99.8 98.6 99.1 99.1 treatment 31 day subsequent 98 100 100 100 100 100 100 100 100 100 100 - drug 31 day subsequent - 94 97.3 100 100 100 99.2 100 96.3 100 100 99.1 surgery 62 day cancer GP 85 83.4 85.3 88.7 81.3 85.2 84.6 85.8 85.6 81.3 84.3 Referral Standard 62 day Screening 90 87.0 86.5 97.0 65.2 85.3 71.4 46.9 63.9 61.1 60.8 Referral Standard 62 day Consultant 85 90.1 88.0 90.5 86.7 88.8 87.0 86.4 85.3 79.9 84.7 Upgrade Standard 62 day cancer GP referral local n/a 76.4 79.9 84.8 76 TBC 80.1 81.8 81.2 74.1 79.3 standard **
** this is a local agreement between Manchester providers to repatriate breaches based on agreed timescales
The Trust is continuing to work closely with other organisations within Greater Manchester on areas of service development to enable timely pathways and improved patient experience.
3.6.5 Single-sex accommodation breaches The Trust has seen a marked increase in the number of breaches of our Single Sex Accommodation Policy, particularly since July 2016, as seen in the charts below.
Year Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total 2013-14 0 0 0 0 0 15 7 15 0 0 0 0 37 2014-15 0 0 0 0 0 0 0 0 0 0 0 0 0 2015-16 4 3 10 0 0 0 0 11 0 11 8 11 58 2016-17 8 6 3 18 10 19 19 30 24 55 30 60 137
Quality Account Report 2016-17 PAGE 120
70 Single-sex Accomodation Breaches 60 2013-14 to 2016-17 50
40
30
20
10
0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2013-14 2014-15 2015-16 2016-17
The breach figures include not only the patient who experienced the delay in step down, but also all other patients in that bay (e.g. a four bedded area with one patient delayed would register as four breaches).
The breaches are all related to the timeliness of step down from critical care areas where mixed sex accommodation is permitted, to ward areas where it is not. Priority for available beds in wards was given to patients requiring admission from A & E. The greatest percentage of breaches (over 91%) occurred on the North Manchester site. The management teams continue to focus attention on this area.
Revised single sex accommodation policy and processes were implemented from May 2016, along with an escalation policy to try to avoid potential breaches. The criteria that constitute a breach are clearly stipulated within this. An investigation into breaches is conducted and a template detailing the reasons completed within 72 hours, to be signed off within seven days by the division. Breaches are recorded on Safeguard and then validated internally before the information is submitted to NHS England.
3.6.6 Cancelled operations The Trust has treated 85027 elective inpatients during this year. It is sometimes necessary to defer routine non-urgent treatments in order to accommodate more urgent patients and, as reported nationally, urgent care demand has been particularly high this year. The Trust cancelled 1129 operations in the last 12 months; 1.3% of the total number of elective patients treated. This is a slight increase from 1.12 the previous year.
The table below shows Pennine’s performance by month, 2016-17.
Elective Cancelled % Cancelled 28 day % 28 day Month Inpatients Operations Operations breaches Breaches Apr 6719 64 0.95 10 15.63 May 7070 68 0.96 3 4.41 June 7290 83 1.14 4 4.82 PAGE 121
Elective Cancelled % Cancelled 28 day % 28 day Month Inpatients Operations Operations breaches Breaches July 6866 92 1.34 3 3.26 August 6961 69 0.99 5 7.25 September 7222 75 1.04 4 5.33 October 7432 120 1.61 4 3.33 November 7757 133 1.71 3 2.26 December 6334 61 0.96 5 8.20 January 6984 123 1.76 8 6.5 February 6626 120 1.81 4 3.33 March 7766 121 1.56% 6 4.96 Total 85027 1129 1.33% 59 5.23
The Trust has worked hard to rearrange appointments and performs well against the 28 day standard compared to peers, as demonstrated in the table below which is based on published results. Of the 1129 cancellations there were only 59 patients who did not have their operation within 28 days of the cancellation.
2014-15 2015-16 Peer % patients treated within 28 days of cancelled operation Q1 Q2 Q3 Q4 Total Q1 Q2 Q3 Q4 Total Pennine 97.72 98.95 99.61 99.68 99.08 92.09 94.92 96.18 95.05 94.77 North of England 94.88 97.16 96.69 95.33 95.98 93.80 94.92 94.53 92.71 93.97 National 92.81 94.12 94.06 92.02 93.17 91.59 93.66 92.70 92.14 92.53
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3.7 Building a positive future The Trust has faced a very difficult and challenging chapter, particularly following the publication of the Care Quality Commission’s (CQC) report and rating for the Trust in August 2016.
The Trust’s new leadership team under the direction of Chairman, Mr John Potter, and Chief Executive, Sir David Dalton, believe the CQC’s findings mark the start of a new journey of improvement that will result in the hospitals and community services provided by the Trust becoming safer and more reliable – and in time, being amongst the best in the country.
The progress that has been made over the last year to make services safer and more reliable has been encouraging. Our staff recognise there is still a lot more work that needs to be done over the next year as part of the Trust’s improvement journey.
The information set out in this section highlights some of the key developments and progress that have been made for each of our hospital sites and community services, now what we are calling our locally-based care organisations.
3.7.1 NMGH Care Organisation New £5m Intermediate Care Unit The future of North Manchester General Hospital has a vitally important role to play in providing a range of local hospital services to a population with complex long-term chronic health needs. In September 2016, construction work started on the Trust’s new £5m purpose-built 24 bed community Intermediate Care Unit situated in the grounds at North Manchester General Hospital. The unit is a joint partnership between the Trust, our local NHS commissioner PAGE 123
North Manchester Clinical Commissioning Group (CCG), and Manchester City Council. The new unit, which is due to be completed and open by December 2017, will become part of the Trust’s Community Assessment and Support Service (CASS), a new integrated service delivery model that aims to avoid admissions, reduce length of stay and improve patient and carer experiences by providing better access to the right intervention, at the right time, delivered by the right healthcare or social care worker.
The majority of patients who access intermediate care services are over 75 years of age and the new unit will provide an enhanced service for community patients who require a period of rehabilitation. The unit will also support patients who do not require, or no longer need, specialist acute hospital care and treatment, but who do still need support within a community setting. The unit will offer patients support in the transition period between illness and recovery.
Since November 2014 the Trust has been providing nine temporary intermediate care beds at North Manchester General Hospital on ward J5 in the main hospital building. These are in addition to 15 beds currently at Henesy House, a residential home in Collyhurst, Manchester. This new Intermediate Care Unit will replace all of these beds
Improving Safety in Primary Care award In July 2016 staff within the Trust’s Community Crisis Response Service in North Manchester won the ‘Improving Safety in Primary Care’ award at the national 2016 Patient Safety Awards.
The community Crisis Response Service aims to improve health and social care in patients that have reached a crisis point, that previously would have presented at Urgent Care or been placed in 24 hour care. The team support people in their own home environment wherever possible, and include staff such as nurses, Therapists, and Social Workers.
Studies show that the function of older people is reduced significantly within 48 hours of being admitted to hospital, and in patients with any form of mental health need, there is evidence of increased mortality, increased length of stay, loss of independence and higher rates of admissions to care homes.
An inter-disciplinary team was set up to provide a rapid response to referrals from any health or social care professional, for patients with a North Manchester GP, serving 36 practices and a growing population in excess of 189,000. The team is able to assess the patient in their own home within one to three hours.
Our community services team at North Manchester are able to manage some very seriously ill people in their own homes, and over 90 per cent of patients would have otherwise been admitted to hospital. Crisis Response is now an essential service that provides a valued alternative for patients in the community preventing them attending hospital.
New Needle-free vaccine An innovative public health initiative which has been launched at North Manchester General Hospital is not to be sniffed at in the fight against flu! As part of this year’s national flu programme, pre-school children and older children in at risk groups who attend the paediatric emergency department at North Manchester General have been offered a needle-free flu vaccine.
The pilot, organised by Dr Rachel Isba, consultant in paediatric public health medicine and who works in the Trust’s emergency department, is believed to be the first of its kind in the country and is being organised in conjunction with colleagues in Greater Manchester Health and Social Care Partnership (GMHSCP).
The nasal spray which is squirted up the children’s nose will protect them from the flu virus. According to Public Health England, in flu vaccine pilot areas (2014/15) where primary school age children were given the nasal spray vaccine, the rates of hospital admissions due to confirmed influenza in that age group were down by 93%.
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Specially trained nursing staff will be able to give the vaccination to children in the department as part of their routine work and the initial scheme will run from 9am to 5pm, Monday to Friday, throughout October, November and December.
The North Manchester Macmillan Palliative Care Support Service In March 2017, staff who work within The North Manchester Macmillan Palliative Care Support Service (NMMPCSS) were recognised for their work with a top International Journal of Palliative Nursing award. The Service won the Multidisciplinary Teamwork Award.
Based at the Cornerstones Centre in Beswick, the Service is regarded as an excellent model of integrated community- based care for patients requiring end of life care and support.
Since its launch in 2015 the service has: ●● Increased the number of patients identified on Palliative Care Registers from 380 to 826 ●● Helped 88 percent of patients achieve their preferred place of care ●● Contacted all patients on the day of their referral ensuring timely access for all ●● Increased the number of patients creating an Advance Care Plan stating wishes about their care from 30 percent in 2015 to 79 percent in 2016 ●● Seen month on month increases in volunteer support for patients ●● Been rated as Outstanding for caring at the Trust’s CQC inspection in 2016. PAGE 125
The Service was devised and implemented by The Macmillan Cancer Improvement Partnership (MCIP), a partnership between Macmillan, The Pennine Acute Hospitals NHS Trust, the Manchester CCGs, St Anne’s Hospice, Manchester City Council, patients and carers.
The Service, which operates every day of the week, is for any patient registered with a North Manchester GP with a life limiting illness who has palliative care needs. Patients, carers and professionals are able to refer into the Service making it more accessible for patients.
NMMPCSS provides input to manage complex symptoms and needs, psychological, social and spiritual support. Staff can also signpost patients to a wide number of volunteer and advisory services.
Half a million pounds investment in specialist radiology room Patients will benefit from better quality images and reduced radiation dose as a result of a £500,000 investment in a specialist radiology room at North Manchester General Hospital which opened this year.
The fluoroscopy room has undergone a make-over and had 10 year old equipment replaced and updated to the latest models. A new Toshiba Ultimax-I fluoroscopy machine has been installed and the room has been redecorated and remodelled to provide an extra door into the room to avoid staff being irradiated.
Fluoroscopy is the study of moving body structures, similar to an x-ray movie. A continuous beam is passed through the body part being examined with the beam then transmitted to a TV-like monitor so that the body part and its motion can be seen in detail. As an imaging tool, fluoroscopy allows physicians to look at many body structures including the skeletal, digestive, urinary, respiratory and reproductive systems.
Our fluoroscopy service at North Manchester sees around 2,600 patients per year. It is used to diagnose and treat patients who have gastrointestinal problems, including problems with the stomach and throat, through to paediatric imaging and hysterosalpingograms which is an examination for ladies who are trying to get pregnant.
3.7.2 The Royal Oldham Hospital Care Organisation Maggie’s Oldham Cancer Centre In June 2016, construction work started on site at The Royal Oldham site for a new Maggie’s cancer centre.
Maggie’s is the national charity that provides free practical, emotional and social support for people with cancer and their family and friends. The new centre will be named ‘Maggie’s Oldham, The Sir Norman Stoller Centre’ and will be the charity’s second facility in Greater Manchester.
Maggie’s Oldham has been designed by acclaimed architects dRMM and was developed by Maggie’s working in partnership with the Trust to enhance the cancer care and support already on offer. Every year 50,000 people in the North West are diagnosed with cancer. As the number of people living with cancer increases, support becomes even more important.
Once open, Maggie’s Oldham will give visitors access to Maggie’s evidence based programme of support, including psychological support, benefits advice, nutrition workshops, relaxation and stress management, art therapy, tai chi and yoga.
The Centre is due to open in summer 2017 and is predicted to receive 10,000 visits every year, many of whom will use it to relax before or after treatment and to share experiences with other cancer patients.
The Trust already benefits from having The Christie at Oldham facility on the grounds of The Royal Oldham Hospital which provides high quality cancer services.
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Trust leads the way with UK’s first NHS use of hand held pain relief treatment The Trust has been helping patients trial a new pain reliving drug that can be self-administered via a hand held device. The Trust is the first NHS Trust in the UK to use the pioneering technique. Using a hand held device eliminates the risks associated with traditional intravenous pain relief.
This year the Trust has been using one Zalviso device at The Royal Oldham Hospital as part of an evaluation process, where 40 patients will try out the device. Another Zalviso device will be introduced at North Manchester General Hospital soon for evaluation purposes.
It is a novel technique that is currently used in Europe and we are proud to be the pioneers in this country. This technique is non-invasive and the analgesia provided does not require intravenous access thus reducing patient risks.
Following the evaluation, the Trust will share its findings and experiences throughout this process with other NHS Trusts.
The first NHS patient to use the device in the UK is local man Peter Fletcher, 81, who has used the device to ease post- operative pain following colorectal surgery. PAGE 127
Baby Minnie makes history with new MRI scan Baby Minnie Macfarlane from Lees in Oldham made history when she was 11 days old. Born on 11 March 2016, she was the first baby at The Royal Oldham Hospital to undergo a landmark scan using new equipment which allows new born babies to have MRI scans.
Previously new born babies would have had to have been transferred to another hospital Trust if they needed a MRI scan at such an early age, but thanks to the investment in the neonatal MRI compatible monitoring, babies can now be scanned in the radiology department at Oldham.
As the hospital cares for high risk infants who are transferred to the level three neonatal unit, for therapeutic cooling to reduce the risk of brain injury, MRI scanning is helpful to assess the risk of any long term problems.
MRI imaging of babies is a more complex procedure than the imaging performed in adults.
The scanning parameters need to be optimised to enable detailed imaging of the small and newly developing brain and extra protection must also be provided to the infant to protect their developing organs.
Baby Minnie paved the way and underwent a scan modelling the aptly named mini-muff ear protectors which protect the ears from the loud noise that the scanner makes.
The new service for scanning neonatal patients will greatly improve our assessment of babies at high risk of brain injury, and allow more detailed imaging for early diagnosis of problems, without the need for a transfer to a different hospital.
Investment in Maternity equipment As part of the Trust’s improvement plan, £340,000 has been invested on new electronic fetal monitoring equipment to support staff across our maternity services.
The new equipment is being installed into the labour wards and obstetric theatres at our two maternity units at North Manchester and The Royal Oldham hospitals where over 9,000 babies are born each year.
Previously staff have used monitors at the bedside and a paper recording of the baby’s heart rate traced. The new K2 system provides a central electronic monitoring and archiving solution for the fetal heart during labour.
The equipment will improve patient care by having an electronic recording at the bedside, and it can also be used remotely and reviewed by other doctors and midwives, so that advice and support can be given if required.
Misinterpretation of the fetal heart rate trace (CTG) is a common feature in labour care throughout the world. The aim of switching to a new electronic e-CTG monitoring and archiving system is to reduce harm by making it easier for staff to interpret CTGs using an approved electronic system. This will lead to appropriate and timely intervention by our doctors and midwives where necessary.
In addition to the fetal monitoring equipment the Trust has also rolled out a new computerised system called the Antenatal Paediatric Alert system which was developed by the Trust. This system promotes appropriate sharing of information between midwives, obstetricians and paediatric staff at The Royal Oldham Hospital and Rochdale Infirmary.
Staff have enthusiastically embraced the new system, which allows midwives and obstetricians to send alerts to staff in the paediatric and neonatology teams about information that may affect the care of the unborn child. The alert is used to document a postnatal care plan on the mother’s electronic notes where it can be accessed by all clinicians who need to see this information. A ‘live’ report also lists all women who have had an alert sent, and their up to date plan of care, for staff working on the labour ward, birthing centre and post-natal ward at The Royal Oldham Hospital.
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3.7.3 Fairfield General Hospital and Rochdale Infirmary Care Organisation New Rochdale “Provider Partnership” forms new multi-disciplinary neighbourhood teams In May 2016, over 200 community based care staff from a variety of backgrounds transferred to work for the Trust, based at Rochdale Infirmary, as part of a new integrated health and social care service for Rochdale borough.
The new services have been commissioned by NHS Heywood, Middleton and Rochdale CCG through a new £9m contract to deliver a range of health and care services through integrated teams who work in the community.
Integrated community health and care teams now provide community nursing and therapy services for adults, treatment room services, expert patient (health promotion) services, neurological-rehabilitation, amputee services, epilepsy services, stroke early supported discharge services and pulmonary rehabilitation. The teams also provide the out-of-hours adult community nursing service.
Trust staff are working in the community as part of a unique partnership with local organisations including Age UK Rochdale, BARDOC (Bury and Rochdale Doctors on Call), GP Care Services Ltd, Greater Manchester Carers Trust, Link4life, Rochdale Borough Council, Rochdale Housing Initiative, and VIC (Veterans in Communities).
Rochdale is leading the way in providing truly integrated health and social care services. Through this partnership approach, patients and local people are benefiting from greater joined-up working between the local NHS, social services and local care and community organisations.
Radiology Services strengthened Radiology services at Rochdale Infirmary have been strengthened following the investment and creation of a third digital x-ray room on the hospital site.
Over £220,000 has been invested in a new x-ray room which houses state-of-the-art equipment to produce images of the inside of the body to diagnose a range of conditions. The digital x-ray machine allows the equipment to be used much like a digital camera so that the acquired images can be viewed immediately and repeated if necessary without causing unnecessary distress to the patient. This will result in a faster radiology service with better image quality.
The x-ray room has also been relocated from the outpatient department at Rochdale Infirmary to within the main x-ray department, allowing for improved team working.
Productivity and patient throughput in the department are expected to increase as radiology staff do not have to leave the room now to process the images as they are available immediately on the machine in the room. Previously a computed radiography (CR) x-ray machine was used which involved the use of an x-ray cassette which needed processing after the image was taken in a different location.
With this new equipment the Trust has massively improved the patient experience at Rochdale Infirmary by reducing waiting times, increased resolution of images, and lower radiation dose, all in a state of the art diagnostic facility.
New Gastrointestinal Unit opened In October 2016, the Trust opened a new purpose-built gastro-intestinal (GI) physiology unit at Rochdale Infirmary for patients with gastrointestinal problems.
Now housed in a larger purpose-built unit on level A in the Infirmary, the unit houses state-of-the-art equipment with separate rooms for undertaking upper and lower GI function tests, office accommodation and a patient consenting room. PAGE 129
The unit offers a wide range of GI physiological studies for the assessment and investigation of patients with swallowing problems, gastro-oesophageal reflux disease and non-cardiac chest pain.
The unit now enables doctors to undertake two separate procedures at the same time, thereby reducing waiting times. The GI physiology unit receives approximately 400 new referrals for upper and lower GI function tests per year, and provides biofeedback therapy to approximately 200 patients with ano-rectal dysfunction.
New 23 hour day surgical beds This year our Day Surgery and Operating Theatre Department at Rochdale Infirmary opened eight new 23 hour post- operative beds. These new 23 hour beds mean that Rochdale patients will stay in one department from admission to discharge and will not need transferring to another hospital.
The expansion of the unit is helping to relieve bed pressures and reduce cancelled operations at our other hospital sites. It is also helping reduce time and costs for the ambulance service, freeing up ambulance crews to attend local emergencies.
The Day Surgery and Operating Theatre Department at Rochdale Infirmary opened in 2000, and was purpose built to accommodate a variety of surgical specialities for Inpatient, Day Case Elective and Emergency/Trauma procedures. The department has become a centre of excellence for day surgery procedures in General Surgery, Orthopaedics, Plastics, Oral, Pain, Vascular, Ophthalmology, Gynaecology and develop clinics for Urology and Lithotripsy. In 2016 the department cared for 11,069 patients undergoing surgical procedures.
Quality Account Report 2016-17 PAGE 130
New pilot helps people avoid Urgent Care Local patients from Rochdale borough are benefiting from a new pilot scheme, which started in November 2016, providing an emergency response vehicle manned by a multi-disciplinary team of healthcare professionals that goes out in the community to people’s homes.
Known as HEATT (Heywood Middleton Rochdale Emergency Assessment & Treatment Team) this consists of a senior paramedic and an advanced nurse practitioner from the local Urgent Community Care Team who have access to specialist services for patients i.e. pharmacy\medication support, social care, access to a local GP and enhanced diagnostics. The team respond to emergency calls and assess and treat people in their own home and where safe, maintain them in their own home in a ‘virtual bed’ or community setting.
HEATT calls are identified from IT systems following 999 calls to the ambulance service for appropriate patients aged 18 years or over who reside within the Heywood, Middleton and Rochdale area. The HEATT service aims to target calls where there is an opportunity to avoid an emergency admission or A&E attendance, and provide care for patients in their own home or community setting rather than an acute hospital.
HEATT is a collaborative project between the community health and social care teams Rochdale, provided by the Trust and our partners including the North West Ambulance Service NHS Trust (NWAS), funded by HMR CCG.
This rapid response team comprising of a senior paramedic and an advanced nurse practitioner ensures that care is brought to patients, and we have moved away from transporting patients to where care is traditionally provided, i.e. hospitals.
Since the service commenced at the end of November 2016, the HEATT service has helped 88% of patients avoid the need to be taken to A&E or the Urgent Care Centre at Rochdale by providing care in their own home or community setting.
New MRI scanner at Fairfield In January 2017 a new magnetic resonance imaging (MRI) unit at Fairfield General Hospital was officially opened.
The Trust has invested over £2.2m on the new scanner and subsequent building work to house it. The unit contains a new state-of-the-art MR scanner which will provide images for around 6,000 patients a year. Housed in a brand new unit which is accessed via the radiology department at the front of the hospital, the new equipment scanned its first patient in mid-December.
Manetic resonance (MR) scanning works by creating very strong magnetic fields and radio frequency waves to produce incredibly detailed images of inside the body without the use of ionising radiation or invasive procedures.
The new installation also means that Bury residents will no longer have to travel to Rochdale Infirmary to be scanned. It will be used for all Trust inpatients and outpatients, and Bury GP patients.
Investment in the new scanner supports the Trust’s strategy for providing dedicated specialist stroke services at Fairfield General Hospital as it will allow clinicians to make a quicker stroke diagnosis.
Getting it Right for people with a Learning Disability The year the Trust signed up to Mencap’s ‘Getting it right charter’ to show our commitment to improving healthcare and treatment for people with a learning disability.
People with a learning disability experience poorer health and poorer healthcare than the general population, with research exposing how 1,200 people with a learning disability die avoidably every year in the NHS. PAGE 131
Mencap worked in partnership with a number of organisations to produce a charter for healthcare professionals, to help them work towards better health, wellbeing and quality of life for people with a learning disability. The charter reminds us to see the person, not their disability, and to make any reasonable adjustments to care that they may need to ensure that their journey of care is person centred and the best that it can be.
To show our commitment to ‘getting it right’ the Trust has also this year employed a Learning Disability Liaison Nurse and has committed to fulfilling all nine points of the ‘getting it right charter.’
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3.8 What others say about the Trust 3.8.1 North East Sector NHS Commissioner Response Thank you for asking us to comment in response to your Quality Account – Saving Lives, Improving Lives’. I am pleased that we had the opportunity to give feedback in February into the production of this report.
2016-2017 was a year of great change for PAHT, with the recognition by all stakeholders that the previous arrangements were failing local residents in the care and services they deserved. The Care Quality Commission (CQC) and the 100 day diagnostic evaluation led by a team from Salford Royal Foundation Trust provided clear focus of the quality issues and presented a new beginning for the Trust’s stabilisation and quality improvement journey.
The Improvement Board hosted by Greater Manchester Health and Social Care Partnership with key senior directors from the Trust, the North East Sector CCGs, NHS Improvement and the CQC has successfully provided direction and sought assurance on the progress of the Trust’s CQC Quality Improvement Action Plan.
The CQC Action Plan and the refreshed draft Quality Strategy “Igniting Quality Improvement” which you have developed and are building on have formed the platform for your quality improvement agenda. The improvements we would expect to see in 2017-2018 that are of particular importance to us as commissioners are:
Care and Treatment: ●● Processes to eliminate long waits in your emergency departments ●● Processes to ensure there are no Never Events across the organisation ●● Computer IT solutions to reducing the risk around missed and delayed diagnosis particularly in chest radiology ●● Improvements to Maternity Services with all women describing positive experiences in care and treatment ●● Improvements in cleaning, hand hygiene and other infection control and prevention measures ●● Building on the progress of the Falls Prevention Strategy ●● Continuing the excellent programme of the Nursing Assessment and Accreditation System
Staff recruitment and support ●● Strategy for staff recruitment and retention; including flexible working and the plans to use the workforce in new and innovative ways, for example, Physician Assistant type roles and the Nursing Associate role. ●● Promoting outstanding practice and recognising the dedication of the Trust’s excellent staff.
Engagement with local partners ●● Plans for engaging with all stakeholders in the formation of Local Care Organisations; being open to change processes to enable working in new ways to deliver health care by the right person at the right time in the right place. The Quality Account details much of the improvement work seen over the previous year and it is a transparent and honest account of the organisation.
Additionally we want to commend the front line staff for their dedication and resilience shown through the previous 12 months who are embracing change and are positively supporting the Trust’s senior leaders. PAGE 133
3.8.2 Local Health Watch organisations Thank you for the draft copy of your quality accounts and the opportunity to comment. The document clearly outlines the challenges and opportunities facing Pennine Acute during the forthcoming year.
We note the overall rating of the Care Quality Commission (CQC), following its inspection of the Trust in March 2016.
A number of the issues were raised by Healthwatch, prior to the inspection, but no-one at that time seemed prepared to listen, so it came as no surprise to read that staff across the organisation had also expressed genuine concerns.
Thankfully, the Chief Executive of Salford Royal has realised the need for a change of culture and, together with his senior team, has already been listening to staff and supporting them to bring about the changes which are necessary ‘to ensure patients receive good safe treatment in a timely manner’.
We note the actions in the Improvement Plan and, in particular, the six main improvement themes and aims for the current year (2017-18).
At this point in time, it would be inappropriate to comment on specific areas but there are some basic issues which appear within the report, that give cause for concern. 1. Inconsistencies across specialties 2. Poor communication 3. Lack of relevant training 4. Failure to complete forms/records, especially those relating to information regarding treatment given to patients 5. Lack of compliance with standard procedures/policies 6. Failure to provide patients (within the community) with relevant information/guidance 7. The significant increase in Serious Untoward Incidents 8. The number of 12-hour A & E breaches
We are pleased to note the wide range of improvement projects that have been developed during the year and the huge recruitment programme which has taken place, in response to recommendations made by the CQC. Hopefully, better governance and a more positive culture within the organisation, will eradicate most of the concerns expressed above.
Healthwatch Bury looks forward to working with the Trust, through the NE Sector Healthwatch/PAHT Forum, and monitoring the results of the many initiatives which are presently taking place. Healthwatch Bury | May 2017
Healthwatch Rochdale have noted the contents of the report and have no further comments to make. Kate Jones; CEO
Quality Account Report 2016-17 PAGE 134
3.9 Statement of Directors’ responsibilities in respect of the Quality Account The directors are required under the Health Act 2009, National Health Service (Quality Accounts) Regulations 2010 and National Health Service (Quality Account) Amendment Regulation 2011 to prepare Quality Accounts for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts, which incorporate these legal requirements.
In preparing the Quality Account, directors are required to take steps to satisfy themselves that: ●● the Quality Accounts presents a balanced picture of the Trust’s performance over the period covered; ●● the performance information reported in the Quality Account is reliable and accurate; ●● there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, 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 Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and ●● the Quality Account has been prepared in accordance with Department of Health guidance.
The directors confirm to the best of their knowledge and belief they have complied with the requirements in preparing the Quality Account.
By order of the board
Chairman and Chief Executive – 26 May 2017 3.10 Independent auditors limited assurance report to the Directors of Pennine Acute Hospitals NHS Trust on the Annual Quality Account We are required to perform an independent assurance engagement in respect of Pennine Acute Hospitals NHS Trust’s Quality Account for the year ended 31 March 2017 (“the Quality Account”) and certain performance indicators contained therein as part of our work. NHS Trusts are required by section 8 of the Health Act 2009 to publish a Quality Account which must include prescribed information set out in The National Health Service (Quality Account) Regulations 2010, the National Health Service (Quality Account) Amendment Regulations 2011 and the National Health Service (Quality Account) Amendment Regulations 2012 (“the Regulations”).
Scope and subject matter The indicators for the year ended 31 March 2017 subject to limited assurance consist of the following indicators:
●● Percentage of patient safety incidents resulting in severe harm or death ●● FFT patient element score We refer to these two indicators collectively as “the indicators”. PAGE 135
Respective responsibilities of the Directors and the auditor The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the Regulations).
In preparing the Quality Account, the Directors are required to take steps to satisfy themselves that:
●● the Quality Account presents a balanced picture of the Trust’s performance over the period covered; ●● the performance information reported in the Quality Account is reliable and accurate; ●● there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, 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 Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review; and ●● the Quality Account has been prepared in accordance with Department of Health guidance.
The Directors are required to confirm compliance with these requirements in a statement of directors’ responsibilities within the Quality Account.
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 Account is not prepared in all material respects in line with the criteria set out in the Regulations; ●● the Quality Account is not consistent in all material respects with the sources specified in the NHS Quality Accounts Auditor Guidance (“the Guidance”); and ●● the indicators in the Quality Account identified as having been the subject of limited assurance in the Quality Account are not reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of the Regulations and to consider the implications for our report if we become aware of any material omissions.
We read the other information contained in the Quality Account and consider whether it is materially inconsistent with: ●● Board minutes for the period April 2016 to May 2017; ●● papers relating to quality reported to the Board over the period April 2016 to May 2017; ●● feedback from the Commissioners dated 23/05/2017; ●● feedback from Local Healthwatch dated 25/04/2017 and 23/05/2017; ●● the Trust’s complaints report published under regulation 18 of the Local Authority, Social Services and NHS Complaints (England) Regulations 2009, dated 27/04/2017; ●● the latest national patient survey dated February 2017; ●● the 2016 national staff survey; ●● the Head of Internal Audit’s annual opinion over the Trust’s control environment dated March 2017; ●● the annual governance statement dated 26/05/2017; and ●● the Care Quality Commission Inspection Report dated 12/08/2016.
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We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with these documents (collectively the “documents”). Our responsibilities do not extend to any other information.
This report, including the conclusion, is made solely to the Board of Directors of Pennine Acute Hospitals NHS Trust.
We permit the disclosure of this report to enable the Board of Directors to demonstrate that they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permissible by law, we do not accept or assume responsibility to anyone other than the Board of Directors as a body and Pennine Acute Hospitals 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 under the terms of the Guidance. Our limited assurance procedures included:
●● evaluating the design and implementation of the key processes and controls for managing and reporting the indicators; ●● making enquiries of management; ●● testing key management controls; ●● limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation; ●● comparing the content of the Quality Account to the requirements of the Regulations; and ●● reading the documents. A limited assurance engagement is narrower 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 Account in the context of the criteria set out in the Regulations.
The nature, form and content required of Quality Accounts are determined by the Department of Health. This may result in the omission of information relevant to other users, for example for the purpose of comparing the results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or non-mandated indicators which have been determined locally by Pennine Acute Hospitals NHS Trust. PAGE 137
Basis for disclaimer conclusion As set out on page 105 of the Trust’s Quality Report, the Trust currently has concerns with the accuracy of data on which the percentage of patient safety incidents resulting in severe harm or death is based. This is primarily due to delays in data being validated.
We are also unable to comment on the timeliness and the validity of the data used to calculate the FFT patient element score as the responsibility lies with the service organisation who collate the data for the indicator and not Pennine Acute Hospitals NHS Trust.
As a result of these issues, we are unable to give limited assurance on ‘the percentage of patient safety incidents resulting in severe harm or death’ and the ‘FFT patient element score’ indicators included in the Quality Report for the year ended 31 March 2017.
Disclaimer qualified conclusion Based on the results of our procedures, with the exception of the effects of the matters reported in the ‘Basis for disclaimer conclusion’ paragraphs above, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2017:
●● the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations; and ●● the Quality Account is not consistent in all material respects with the sources specified in the Guidance.
KPMG LLP Chartered Accountants 1 St Peter’s Square Manchester M2 3AE
30 May 2017
Quality Account Report 2016-17 Trust Headquarters North Manchester General Hospital Delaunays Road Crumpsall M8 5RB
Tel: 0161 624 0420
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