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 Quality Account Report 2016-17 PAGE 2 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. Quality Account Report 2016-17 PAGE 4 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.