quality account 2015/16 · quality account 2015/16 3 - safeguarding 34 - equality, diversity and...

Safe | Kind | Effective

QUALITY ACCOUNT 2015/16

2 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST

CONTENTS

PART ONE .................................................................. 04Summary statement on Quality from the Chief Executive 04

Statement of Directors’ responsibilities in respect of Quality Report 07

PART TWO .................................................................. 08Priorities for Improvement in 2016/17 08

- Safety 08- Experience 08 - ClinicalEffectiveness 08 - Capacity and Capability 08

Review of Services 11

- ParticipationinClinicalResearch 11- ResearchActivity 12 CentreForIntegratedHealthcareScience 12- ParticipationinClinicalAudits 12- GoalsagreedwithourcommissionersviatheCommissioning forQualityandInnovationFramework(CQUIN) 15- CareQualityCommissionRegistration(CQC) 16- DataQuality 16

West Cheshire Clinical Commissioning Group Commentary 19

PART THREE ............................................................. 20How we have delivered our priorities in 2015/2016 20

- PatientExperience 20- Effectiveness 20- Safety 22

Other Quality Improvements in 2015/2016 25

Working in Partnership: What our Governors have said 25

- InfectionPreventionandControl 26- RiskManagement 30

3QUALITY ACCOUNT 2015/16

- Safeguarding 34- Equality,DiversityandHumanRights 36- CancerPeerReview 37- TraumaPeerReview 38- NationalCancerPatientExperienceSurvey(NCPES) 38- Transparency–‘Howarewedoing?’ 38- AdvancingQualityReport 39- PatientSurveys 40- MaternitySurvey 41- FriendsandFamilyTest2015-2016 42- StaffSurvey 42- ManagingandRespondingtoExternalRecommendations 43- SummaryHospitalMortalityIndicator(SHMI) 44- PatientReportedOutcomeMeasures(PROM) 44

Quality Measures 46

- Effectiveness 46- AdvancingQuality 46- Responsiveness 47- MonitorComplianceTargets 47

PART FOUR ............................................................... 50Written Statement from Other Bodies 50

- Governors’QualityAccountStatement 50

- HealthwatchCheshireWest 51

- AdvancingQualityMeasures 53

- PatientRecordedOutcomeMeasures 56

APPENDIX ................................................................. 58Appendix 1 – Glossary & Abbreviations 58

INDEPENDENT AUDITOR’S REPORT ............................ 62


PART ONESUMMARY STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE At this time every year, Foundation Trust hospitals across the country publish their Quality Accounts to provide assurances to their local population, patients and partner organisations about the delivery and standards of care that can be expected. Ourvisionistodelivercarelocallythatmakesourstaffandourcommunityproudbybeingsafe,kindandeffectiveineverythingthatwedo.AsChiefExecutive,Iamincrediblyproudofwhatwehaveachievedandweaimtodoevenbetterinthemonthsahead.IhopethatyoufindthisQualityAccountusefulasitdescribesourachievementstodateandourplansforthefuture.WeknowthatgreatstaffexperiencesatTheCountessleadtogreatpatientexperiences.A series of major service developments and achievements have come to fruition this year, energising our optimism and ambition for the future. These include:• TakingresponsibilityforrunninganewPrimaryCareUnitthateasespressuresbytriagingpatientsarrivinginAccident&Emergencywhohaveminorillnessesorailments

• Welcoming#hellomynameiscampaignfounderKateGrangerMBEtotheTrusttomeetwithnursingandmedicalstaffsupportinghercampaigntogetbasicintroductionsrightforpatients

• LaunchinganewDischargetoAssessserviceatEllesmerePortHospital,toprovidefrailpatientswithrecuperationsupportedbynurses,therapistsandsocialcare

• SupportinganationaleducationalprojectfortheBritishAssociationofDayCaseSurgerywithfilmcrewsworkingwithCountesssurgeonsandanaesthetistsinourJubileeDayCentre

• Holdinganofficialopeningceremonytocelebratehavinganewstate-of-the-artCT

scannerinRadiologythattakeshighqualityimagestosupportfasterdiagnostics

• Runningarangeofcommunityeventstosecurefeedbackonservices,offercareeradvicetolocalsecondaryschoolchildrenaboutNHSopportunities,raiseawarenessofdiabetesandhelpolderpeoplegetadviceonkeepingwarmoverwinter

• Achievingthetopratinginourstrokeauditandgoingontowinaregionalawardforinnovationinstrokeservices

• Startinginteractive‘ShowMetheMoney’sessions,ledbyourfinanceteamtoraiseawarenessabouthowtheNHSisfunded

• Showcasingpioneeringworklinkingauditstoincidentreportingatnationalhealthcarepatientsafetyforums

• SupportingNorthWestAmbulance’s#findthedefibcampaigntohighlightavailabilityofequipmentinpublicareas,inordertosupportresuscitation

• PartneringwiththeBritishRedCrossforanewdischargeservicetohelppatientsgethomesafelyandmorequicklyfromhospital

• Launchinganon-linebookingserviceforphlebotomyappointments

• StartingtheNewYearbyprovidingarangeofnewfitnessinitiativestosupportstaffwellbeingandresilienceinwork–rangingfromfitnessclassestomindfulnesssessions

• TheopeningofinnovationspaceatBacheHall,aspartofanewpartnershipwiththeUniversityofChester


• Unveilinganewmemorialfeature,toraiseawarenessandpaytributetothesignificanceoforgandonationhereatTheCountess

• PilotingnewmodelsofGPassessment andelderlymedicineconsultantsbasedinA&Etoeasepressureswithpatientflowanddemandsforbeds

Disappointingly,thisyearwehavehadtwo“never”events.Itisclearfromthereviewsthatlessonsneedtobelearned,andthesehavebeenreinforcedwithinteams.Wewillcontinuetomonitortheactionthatwehaveinplacesupportedbythecampaignworkfrom‘SignuptoSafety’.ThisisacampaignthattheTrusthasjoinedtosupportthereductionofpatientharm.Apartofensuringthesafetyofourpatientsandstaffisourfluvaccinecampaign.Thisyear,wehadatotalof74.1%offrontlinehealthcareworkersvaccinatedintheflucampaign,againplacingtheTrustamongthehighestperforminginthecountry.Nationalstaffsurveyresultsshow74%ofstaffatTheCountessagreethatifarelativeorfriendneededtreatmenttheywouldbehappywiththestandardofcareprovidedbythisorganisation,comparedwiththenationalaverageof70%.Over the last year, a wide range of other award accolades have been bestowed on high performing clinical teams and role models within the Trust including:• ThehospitalbeingshortlistedasTrustoftheYearinthe‘NationalPatientSafetyAwards2015’

• Strokecareserviceswinningthe‘MostInnovativeNHSTeam’categoryattheNorthWestCoastResearchandInnovationAwards2015

• HumanResourcesandOrganisationalDevelopmentbeinghighlycommendedinthe‘CharteredInstituteofProfessionalDevelopmentPeopleManagementAwards2015’

• ThehospitalprocurementteambeingshortlistedintheHSJ‘ValueinHealthcareAwardsforValueandImprovementinProcurement’

• TheCountess‘CareoftheElderly’projectsecuringthemostcommunityvotesandwinning£25,000fromAvivaforinvestmentindementiaservices

• LeadTissueViabilityNurseSpecialistCarolynneSinclairbeingshortlistedforhercollaborativeapproachtowoundcareproductselectionatthe‘NorthWestExcellenceinSupply’Awards

• SeniorBuyerfortheTrust,CarolinePhelanbeingnominatedforthe‘NHSProcurementRisingStar’awardattheNorthWestExcellenceinSupplyAwards

• CateringleadsCraigHoughandSueMillerwereshortlistedforthe‘NationalCostSectorCateringAwards2016’

• ProcurementwinningtheGO‘ExcellenceinPublicProcurementAwards2016’

• Feedbackandunderstandinginthequalityofservicesprovided,haspromptedinvolvementinarangeofinitiativestofosteracultureoftransparencyandinclusivity

• Boardmeetingsarecarriedouttounderstandpartnershipperspectives.Thiscanbethroughpatientstories,staffstoriesanddiscussionsontopicalissues,e.g.qualityinmaternityservices,supportforcarers,complexityofappointmentbookingsystems


• Staff,unionpartners,andgovernorssupportingaprogrammeofindependentwalkaboutswherestaffcanprovideaninsightintoworkingfortheTrustandhighlightanypatient/staffsafetyconcernsandshowcasetheirachievements

• Governorsparticipatingin‘sitandsee’observationalvisitstotheward

• OurhospitalistheonlyNHSproviderinthecountrytoachievetheNavajoCharterMark,measuringhowsensitiveandinclusiveanorganisationisinlookingafterpatients,carersandstaffwhoidentifyasLesbian,Gay,Bisexual,orTransgender(LGBT).

Therehavealsobeenchallengesattimes,andIknowstaffhaveoftengonetheextramiletomakesureourpatientsreceivethequalitycaretheydeserve.Whilsttherearethingswecouldandwillimproveon,Iremainhumbledbythemanylettersofthanksthataresenttomeaboutthecarethathasbeengiventoourpatients.Manyofourstaffarenamedbyfamilieswantingtothankthemforthecarewehavedelivered.Thisyear,wehaveensuredthatthestaffawardsrecognisethepositivefeedbackatourregularawardceremonies.

ThelatterpartofthisyearhasseenthehospitalsupporttheworkoftheDepartmentofHealth’sefficiencyprogramme.WewereakeycontributortotheCarterreport.ThereportoutlinedareasforchangeandtheTrustislaunchingitsaimsupportedbyanumberofworkstreamstobecomethe‘Model Hospital’andthiswillbeablueprintforotherorganisationstofollow.Withthecurrentfinancialconstraints,Idon’tunderestimatethechallengesaheadbutsupportedbyour‘Model Hospital’,Iamconfidentinthestaffandthatwecandeliveronthese.Tomyknowledge,IdeclarethattheinformationwithinthisdocumentisatrueandaccuratereflectionofthequalityofcaredeliveredbytheCountessofChesterHospitalNHSFoundationTrust.

Whilst there are things we could and will improve on, I

remain humbled by the many letters of thanks that are sent to me about the care that has

been given to our patients.

Onbehalfof

Tony ChambersChief Executive 24thMay2016


STATEMENT OF DIRECTORS’ RESPONSIBILITIES IN RESPECT OF QUALITY ACCOUNTSThe directors are required under the Health Act 2009 and the National Health Service Quality Accounts Regulations to prepare quality accounts for each financial year. MonitorhasissuedguidancetoNHSFoundationTrustBoardsontheformandcontentof annualqualityreports(whichincorporatetheabovelegalrequirements)andonthearrangementsthatNHSFoundationTrustBoardsshouldputinplacetosupportdataqualityfor thepreparationofthequalityreport.In preparing the quality report, directors are required to take steps to satisfy themselves that:• thecontentofthequalityreportmeetstherequirementsassetoutintheNHSFoundationTrustAnnualReportingManual2014/15;

• thecontentofthequalityreportisnotinconsistentwithinternalandexternalsourcesofinformationincluding:

- BoardminutesandpapersfortheperiodApril2015toMarch2016

- Papersrelatingto‘quality’reportedtotheBoardovertheperiodApril2015toMarch2016

- FeedbackfromWestCheshireClinicalCommissioningGroup(CCG)May2016

- FeedbackfromCouncilofGovernorsdatedApril2016

- FeedbackfromHealthwatchCheshireWestdatedMay2016

- TheTrust’scomplaintsreportpublishedunderregulation18oftheLocalAuthoritySocialServicesandNHSComplaintsRegulations2009,2015

- The2015nationalpatientsurvey - The2015nationalstaffsurvey,

receivedJanuary2016 - Theheadofinternalaudit’sannualopinion

overtheTrust’scontrolenvironmentdatedfortheperiodof2014/15

- CQCIntelligentMonitoring,December2015: - Thequalityreportpresentsabalanced

pictureoftheNHSFoundationTrust’sperformanceovertheperiodcovered

- Theperformanceinformationinthequalityreportisreliableandaccurate

- Thereareproperinternalcontrolsoverthecollectionandreportingofthemeasuresofperformanceincludedinthequalityreport,andthesecontrolsaresubjecttoreviewtoconfirmthattheyareworkingeffectivelyinpractice

- Thedataunderpinningthemeasuresofperformanceinthequalityreportisrobustandreliable,conformstospecifieddataqualitystandardsandprescribeddefinitions,andissubjecttoappropriatescrutinyandreview

- ThequalityreporthasbeenpreparedinaccordancewithMonitor’sannualreportingguidance(whichincorporatestheQualityAccountsRegulations)aswellasthestandardstosupportdataqualityforthepreparationofthequalityreport

- TheDirectorsconfirmtothebestoftheirknowledgeandbeliefthattheyhavecompliedwiththeaboverequirementsinpreparingthequalityreport

- ByorderoftheBoard

Sir Duncan Nichol CBE Chairman

Onbehalfof

Tony Chambers Chief Executive24thMay2016


PART TWOPRIORITIES FOR IMPROVEMENT IN 2016/2017Work we have undertaken in the previous year continues to support the Trust’s 2014-2017 Quality Improvement Strategy which is reflected in the Trust’s annual plan. The following information focuses on our key priorities for the next year.TheTrustremainscommittedtoimprovingpatientsafety,qualityandoutcomes.Ourchoicesandthoseofthelocalpopulationweservearereflectedinourprioritiesgoingforward.InFebruary,ourhospitalandtheservicesitprovidesunderwentitsfullCQC(CareQualityCommission)inspection.Itistooearlytohavethefullresultbutwewouldexpectittoreflectthecurrenthighlevelofassuranceofband5ratingthattheCQCgaveusin2015.TheTrustembracedthevisitfromtheCQCanditgaveusarealopportunitytoshowcasethesafe,kindandeffectivecarewebelievethatwedeliver.Aftertakingintoaccountalloftheabove,ourkeyprioritieshavebeenchosentoreflectthethreedomainsofqualitydefinedasfollows:

> SAFETY (#SAFE)• Improvingandincreasingthesafetyofany careorserviceprovided.

> EXPERIENCE (#KIND)• Improvingtheexperienceasdescribed by‘you’,ourpatient,whenusingtheservice foranyreason.

> CLINICAL EFFECTIVENESS (#EFFECTIVE)

• Improvingtheoutcomeofany assessment,treatmentandcareyou receiveinordertooptimisehealthand wellbeingatallstagesofillness.

> CAPACITY AND CAPABILITYThe‘PatientSafetyTeam’isprovidingastrongcorporateapproachinfacilitatingqualityandsafetyinitiativesanditmonitorstheorganisation’sprogress.Theteamhasledonanumberofareasofworkandsupportsatrulypatient-centredsafetyfocusatwork.Throughoutthedocumentyoumayseeterminologythatyouarenotfamiliarwith.Tohelpyou,wehaveincludedaglossaryoftermsatthebackofthedocumentinAppendix1.


Safety (#Safe)

Aim Rationale Monitored Measured

Improvepatientdietaryinstructionsfor OGD

Improvepatientconcordancewithadvice

DivisionalBoard

Reducingthenumber ofcancellations

Reducetheriskofhospitaladmissionbyperformingcystoscopyintheoutpatientsetting

Improvepatientsafety DivisionalBoard

Monitornumbersintheoutpatientsetting

Commence‘preassessment’clinicsforcertainradiologicalexaminations

Improvepatientcomplianceandsafety

DivisionalBoard

Reducethenumber ofwastedslots

Experience- (#Kind)


Usingthegovernorstoestablishapeerreviewprocesstoreviewcomplaintresponses

Toensurethatresponsesareempatheticandresponsivetopatientconcerns

Patient Experience OperationalGroup Bythereturnrate

Attendanumberofestablishedserviceuserssupportgroups

Gainabetterunderstandingoftheviewsofourserviceusers

Patient Experience OperationalGroup

Obtainfeedbackandfactorintoproposedservicedevelopments

Reviewthecarerstrategymeasures

Toensurethestrategyiseffective

Patient Experience OperationalGroup Satisfactionaudit

Effectiveness- (#Effective)


Increaseeffectiveness ofthemodelofdischarge toassess(D2A)

Ensurethatpatientsspendonlytheminimumamount oftimeinacutehospitalcare

DivisionalBoard

Thenumberofpatientswhoreturntotheirusualplaceofresidence

Trialpartialbookingincolposcopy Tosupportpatientchoice. Divisional

Board

Evidenceofserviceimprovementtoreducethe‘Didnotattend’rates

Whilst focusing on the above areas, we will also continue to: • MaintainhighstandardsofinfectionpreventionandcontrolasdetailedintheHealthAct2009• Embedour2014-2015CommissioningforQualityandInnovation(CQUIN)initiativessotheybecome‘businessasusual’,andworktoimplementthenewCQUINprogrammetosupporttheintegratedmodelofcareacrossWestCheshire

• Meettherequirementsofourqualitycontractwithourcommissionersbothlocalandspecialist• Continuetodevelopourworkforcetoensuretheyhavetherightskillsandvaluestodeliverqualitycareinthemosteffectiveandcaringway

• Continuewithourprogrammeofdevelopmentrelatingtonewinitiatives• Focusonthe‘Model Hospital’changes

10 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST10 COUNTESSOFCHESTERHOSPITALNHSFOUNDATIONTRUST


REVIEW OF SERVICES During the reporting period, the Countess of Chester Hospital NHS Foundation Trust provided and contracted 49 services. These are included in our statement of purpose. TheCountessofChesterHospitalNHSFoundationTrusthasreviewedallthedataavailableonthequalityofcareintheformofaudits,bothlocalandnational,andthereareanumberoflocalmechanismsinplacetoensurethatdataregardingqualityofcareismonitoredandimprovedinallofourservicesasfollows:• Servicedimensions,suchaspopulationdemographics,tradingaccountpositionandwhetherornottheserviceiscore

• Servicedelivery,whichlooksataspectsrelatingtomeetingperformancestandards,targetsandqualitystandards

• Servicedesign,whichreviewswheretheserviceislocated,e.g.centralorcommunity

• Servicedevelopment,whichexploresplannedchangestoservicesoverthenextfiveyears

• Servicedecisions,whichconsiders-basedontheabove,iftheTrustisbestplacedtodelivertheserviceinitscurrentform

IncomegeneratedbytheNHSservicesin2015/2016represents94.8%ofthetotalincomegeneratedfromtheprovisionofNHSservicesbytheCountessofChesterHospitalNHSFoundationTrustfor2016/2017.

> PARTICIPATION IN CLINICAL RESEARCHTheCountessofChesterHospitalNHSFoundationTrustispartoftheNorthWestCoastClinicalResearchNetwork(NWCCRN)whichfundsNHSresearchactivityinthehospital.Asmallproportionofcommercialresearchisalsoundertaken.The Research and Innovation department successfully delivers research in the following clinical specialties:• Ageing• Anaesthesia• Cancer• Cardiovasculardisease• Children• Critical care• Dermatology• Diabetes• Gastroenterology• Haematology• Mentalhealth• Microbiology• Musculoskeletaldisorders• Renaldisorders• Reproductivehealth&childbirth• Respiratorydisorders• Stroke• Surgery


> RESEARCH ACTIVITYThenumberofpatientsreceivingNHSservicesprovidedorsub-contractedbytheCountessofChesterHospital2015/16thatwererecruitedduringthatperiodtoparticipateinresearch-approvedbyaresearchethicscommitteewas704.Inthiscomingyear,weexpecttorecruitaround800patientsontoresearchstudies,asmallreductionfromthepreviousyear.Thisisduetotheincreasingcomplexityofthestudiesandthemorestringentrequirementsthatareaskedforbythestudysponsors.Manythousandsofpatientseachyeararescreenedbyourclinicalstaff,ofwhichonlyasmallproportionareactuallyrecruitedsuccessfully.

> CENTRE FOR INTEGRATED HEALTHCARE SCIENCE

TheTrustisworkingcloselywiththeUniversityofChesterandhascreatedtheCentreforIntegratedHealthcareScience,basedatBacheHallinChester.Ourobjectiveistobringtogetherclinicalresearch,innovation,andinitiallypostgraduatemedicaleducation–togetherinoneplace,forthebenefitofourpatientsandlocalpopulation.Wewillworkcloselywithotherlocalhealthcarepartners,includingCheshireandWirralPartnershipNHSFoundationTrustandWirralUniversityHospitalsNHSFoundationTrust,fromaresearchperspective.WearesupportedinouraimsbytheNorthWestCoastClinicalResearchNetwork,andtheNorthWestCoastAcademicHealthScienceNetworkininnovation.

> PARTICIPATION IN CLINICAL AUDITSDuring2015/16,TheCountessofChesterHospitalNHSFoundationTrustengagedin35nationalclinicalauditsincludingthreeNationalConfidentialEnquiriesintoPatientOutcomeandDeath(NCEPOD).Thisequatestoparticipationin92%ofrelevantnationalclinicalauditsand100%ofnationalconfidentialenquiries.ThenationalclinicalauditsandnationalconfidentialenquiriesthattheCountessofChesterHospitalNHSFoundationTrustwaseligibletoparticipateinandforwhichdatacollectionwascompletedduring2015/16arelistedonthefollowingpage,alongsidethenumberofcasessubmittedtoeachauditorenquiryasapercentageofthenumberofregisteredcasesrequiredbythetermsofthatauditorenquiry.

12 COUNTESSOFCHESTERHOSPITALNHSFOUNDATIONTRUST


National Audits 2015/16 ParticipationData collection

completedRate of case

ascertainment

TraumaAudit&ResearchNetwork Yes Rolling 100%

AuditofCriticalCare(ICNARC) Yes Rolling Notavailable

NationalDiabetesAudit Yes Yes 100%

NationalFootCareAudit Yes Yes Notavailable

NationalDiabetesInpatientAudit Yes Yes Notavailable

NationalPregnancyinDiabetesAudit Yes Yes Notavailable

NationalElectiveSurgeryPatientReportedOutcomeMeasures(PROMs) Yes Rolling Variableacross

fourconditions

MyocardialInfarctionNationalAuditProject(MINAP) Yes Rolling 99.7%-

(Un-validated)

NationalEmergencyLaparotomyAudit Yes Rolling 100%

CollegeofEmergencyMedicine:Vitalsigns Yes Yes 100%

CollegeofEmergencyMedicine:Proceduralsedation Yes Yes 100%

CollegeofEmergencyMedicine:VTEinpatientswithlowerlimbmobilisation Yes Yes 100%

NationalOphthalmologyAudit No NA NA

NeonatalIntensiveandSpecialCare(NNAP) Yes Yes Notavailable

SentinelStrokeNationalAuditProgramme(SSNAP) Yes Yes >90%

BritishAssociationofUrologicalSurgeons:NephrectomyAudit Yes Yes Notavailable

BritishAssociationofUrologicalSurgeons:PercutaneousNephrolithotomy Yes Yes Notavailable

UKIBDAudit Yes Yes Notavailable

NationalComparativeAuditofBloodTransfusion:BloodManagementinScheduledSurgery

Yes Yes Notavailable

Cardiacarrhythmia Yes Rolling Notavailable

NationalVascularRegistry Yes Rolling 66%

Hip,kneeandanklereplacements(NationalJointRegistry) Yes Rolling Notavailable


National Audits 2015/16 ParticipationData collection

completedRate of case

ascertainment

LungCancer Yes Rolling 100%

BowelCancer Yes Rolling 87%

Oesophago-gastricCancer Yes Rolling 61-70%

NationalCOPDAudit Yes Yes Notavailable

RheumatoidandEarlyInflammatoryArthritis Yes On-goinguntil2017 Notavailable

FallsandFragilityFracturesAuditProgramme Yes Rolling 100%(NAIF)

MBRRACE Yes Rolling Notavailable

HeartFailure Yes Rolling 100%

RenalRegistry Yes Rolling Notavailable

ChildHealthReviews Yes Rolling Notavailable

ProstateCancer Yes Rolling 76%

NationalPaediatricDiabetesAudit Yes Yes Notavailable

BTSPaediatricPneumonia No NA NA

BTSAdultAsthma No NA NA

NCEPOD:AcutePancreatitis Yes Yes 100%

NCEPOD:Non-invasiveventilation Yes Inprogress NA

NCEPOD:Physicalandmentalhealthcareofmentalhealthpatientsinacutehospitals Yes Yes 100%

Thereportsof37nationalclinicalaudits,including2NCEPODswerereviewedbytheTrustin2015-16andtheTrustintendstotakeactionstoimprovethequalityofhealthcareprovidedincludinginthefollowingareas:• Cardiology• Stroke• A&E• Transfusion• Vascularsurgery• Diabetes• Obstetrics• Neonatology• Elderlymedicine

Thereportsofmorethan80localclinicalauditswerereviewedbytheTrustin2015/16.TheTrustintendstotakethefollowingactionstoimprovethequalityofhealthcareprovided,thisincludes:• DevelopmentoftrainingworkshopsfornursingstudentsinthecareofParkinson’sDiseasepatients

• AimtodevelopaspecificclinicforAtrialFibrillation/DCcardioversionpatients

• Establishmentofnewdrop-inclinicforbloodpressuremonitoringforrenalpatients

• Developmentofnewmajoramputationpathway

Theaboveisnotanexhaustivelistofactionstaken.


> GOALS AGREED WITH OUR COMMISSIONERS VIA THE COMMISSIONING FOR QUALITY AND INNOVATION FRAMEWORK (CQUIN)

In2015/16yeartodate,theTrusthasachievedtwoofthelocalCQUINsfully,andtherestwerepartiallyachieved.TheTrustachievedoneofthenationalCQUINsfullyandpartiallyachievedtheothertwo.YeartodateithasachievedalltheSpecialistCommissioningCQUINS.

Asusual,theCQUINframeworkwasagreedinpartnershipwiththeClinicalCommissioningGroup(CCG)andinvolvedcloseworkingwithcliniciansfrombothprimaryandsecondarycare.Thishassupportedthestartoftheintegrationofservicestosupportthepatientpathway.

Disappointingly,anddespitethebesteffortsoftheclinicalteamsthisyear,CQUINhasbeenarealchallengeinanumberofareas.Theincreaseinthenumberofpatientswhohavebeendelayedinhospital,despitebeingmedicallywellenoughtogohasledtoanincreasinglengthofstaysintheareasagreed.Thismeasurewasoneofanumberofindicatorsthatthehospitalwasusingtomeasureitssuccessrate.

Thelocalandnationalschemesaredescribedbelowwiththeachievementstodate.

CQUIN Outcome Achieved

EmergencyCareIntensiveSupportTeam(ECIST) ToimplementtheECISTactionplan. Yes

Thelongertermneedofpeopleinanacutephaseofcareisdeterminedquicklyandarrangementsmadefortheirongoingneeds

Todeviseasystemthatwillensurerapidassessmentofpatientsduringthe72houracutephaseofadmissiontotheFrailtyUnit

Yes

Patientswillbecaredforinthe mostappropriatesettingfortheirneeds,withafocusonbringing careoutofthehospitalsettingandclosertohome.

WorkwithallpartnerstodevelopajointplantosupportimplementationofasharedapproachtominimiselengthofstayinhospitalandincreasingsupportoutsideofthehospitalsettingwithintheEmeraldUnit.

No

Providerssee'incidents'asopportunitiestolearnandimprovethequalityofcareforpatients

Toworkwithpartnersinundertakingpeerreviewsofselectedincidents,toidentifylearningandimplementimprovementsbasedonthese.

Yes

DementiaandDelirium(NATIONAL)

Toincentivisetheidentificationofpatientswithdementiaanddelirium,aloneandincombinationalongsidetheirmedicalconditions,topromptappropriatereferralandfollowupaftertheyleavehospitalandtoensurethathospitalsdeliverhighqualitycaretopeoplewithdementiaandsupporttheircarers.

Yes

UrgentandEmergencyCareMenu Reducingtheproportionofavoidableemergencyadmissionstohospital Partial

UrgentandEmergencyCareMenuToimproverecordingofdiagnosisratesinA&Eandareductionintherateofmentalhealthre-attendancesatA&E

Partial

AcuteKidneyInjury(AKI)

ToimprovethefollowupandrecoveryofindividualswhohavesustainedAKI,reducingrisksofreadmission,re-establishingmedicationforotherlong-termconditionsandimprovingfollowupofepisodesofAKIwhichisassociatedwithincreasedcardiovascularriskinthelong-term.

Partial


AproportionoftheTrustsincomein2015/16wasconditionalonachievingqualityimprovementandinnovation(CQUIN)goalsagreedbetweenusandourcommissionerandanypersonorbodytheyenteredintoacontract,agreementorarrangementwithfortheprovisionofrelevanthealthservices,throughtheCommissioningforQualityandInnovationpaymentframework.Furtherdetailsoftheagreedgoalsfor2015/16andforthefollowing12monthperiodareavailableelectronicallyatwww.coch.nhs.ukIn2015/16,theTrustachieved£2,825,357ofthe£3,200,000availableforitsCQUINgoalsachievement

> CARE QUALITY COMMISSION REGISTRATION (CQC)

TheTrustisrequiredtoregisterwiththeCareQualityCommission(CQC),andcurrentlyitis‘registered’,withnoconditionsattachedtoregistration.TheCQChasnottakenenforcementactionagainsttheTrustduring2015/16.Thisyear,theCQChasassessedthehospitalusingits‘IntelligentMonitoring’tool.Themodelmeasuresanumberofdifferentindicatorsthatgiveanoverallbandfrom1-6.TheTrusthasbeenplacedinBand5inOctober2016,demonstratingahighareaofcomplianceandassurance.OurhospitalwasnotrequiredtoparticipateinanyspecialreviewsbytheCQCin2014/2015.Thehospitalhasrecentlyhaditsfullinspection;howeverthereportcouldtakejustover50daystobereturnedtothehospital.Oncethereportisagreed,thehospitalwillensurethatitispublishedinfullonitswebsiteforfullpublicviewing.

> DATA QUALITY During2015/16,TheCountessofChesterHospitalNHSFoundationTrustsubmitteddatatotheSecondaryUsesService(SUS)forinclusioninthenationallypublishedhospitalepisodestatistics.

Based on the data submitted, the SUS Data Quality Dashboard reported at month nine that:• ThepercentageofrecordswhichincludedavalidNHSnumberwas:

- 99.8%foradmittedpatientcare; - 99.8%foroutpatientcare; - 98.4%foraccidentandemergencycare

• Thepercentageofrecordswhichincludedavalidgeneralpracticecodewas:

- 99.9%foradmittedpatientcare; - 100%foroutpatientcare; - 99.9%foraccidentandemergencycare

The following actions were undertaken during the period to improve overall Trust data quality:• Alladministrativeandclericalstaffinvolvedintheoperationalmanagementofpatientswaitingtobeseen,undertookadetailedprogrammeoftrainingrelatingtothekeyaspectsofoperationalpatientadministration,helpingtoimproveknowledgeanddataquality;

• TheHealthcareEvaluationData(HED)clinicalbenchmarkingtoolisnowbeingutilisedtoidentifyvariationinclinicalperformance.Identifiedvariationscansometimesrelatetoissuesofdataquality;whenidentified,theseareaddressedaccordingly;

• AnewweeklyprocessfortheupdatingofdeceasedpatientsontheTrustElectronicPatientRecordsystemusingthenationalDemographicBatchService(DBS)hasbeenimplemented.ThishasenabledweeklyupdatestoallpatientsontheMasterPatientIndex(MPI)improvingthequalityoftheindices;

• ThenewPerformanceInformationSystemhasbeenimplementedenablingthedevelopmentandimplementationofseveraloperationaldashboards.Thesedashboardsareassistinginthereal-timeidentificationandrectificationofsomeaspectsofpoordataqualityintheatresandtheemergencydepartment.

• TheOperationalDataQualityGroupisestablishedtooverseekeyaspectsofdataquality.Reportingbi-annuallytotheTrustInformaticsBoard,thegroupmonitors,analysesandaddressesissuesinrelationtodataquality,escalatingissuesasappropriate,andensuringthatthereisdemonstrableyearonyearimprovement.


TheTrustwasindependentlyauditedbyPriceWaterhouseCoopers(PWC)onbehalfofMonitorearlyin2016,aspartofthereferencecostassuranceauditprogramme,toassesstheTrustPaymentbyResults(PBR)process.Theauditincludedareviewofhowdataisprocessed,managedandvalidatedforaccuracyandconsistencybyTrustoperationalandBusinessIntelligenceservices.ItalsoassessedhowtheTrustinvolvescliniciansinthereviewandvalidationofdatacollectedandreported.Theresultsofthisauditarestillpending.

Clinical Coding Error Rate

TheTrustwasnotrequiredtoundertakeaPaymentbyResultsclinicalcodingauditduring2015/16bytheAuditCommission.ThemostrecentindependentClinicalCodingauditwasundertakenbyMerseyInternalAuditAgency(MIAA)inSeptember2015.ThisannualauditisamandatoryrequirementoftheInformationGovernanceToolkit(IGT).Theauditcheckstheaccuracyofclinicalcodingacrossallspecialities,basedonarandomisedsampleof200finishedconsultantepisodes.Theresultsofthisyear’sauditprovided‘SignificantAssurance’andconfirmedcodingaccuracyofover92%forboththeprimarydiagnosesandprimaryprocedures.ThislevelofaccuracyhasallowedtheTrusttoself-assesshavingachievedIGTLevel2compliancein2015/16forclinicalcodingaccuracy.

17QUALITYACCOUNT2015/16


Mandated Indicators

For ease of the reader, the table below lists the indicators and some results, or the page on which the report can be found:

Subject IndicatorPage

Number

MortalitySummaryHospitallevelMortalityIndicator(SHMI)andthe%ofpatientdeathswithapalliativecarecodedatdiagnosisorspecialitylevel

44

CareofpatientswithasuspectedSTelevationAcuteMyocardialInfarction(HeartAttack)

ThesepatientsreceivecareattheregionalcentreatLiverpoolHeartandChestHospitalOtherheartattackdata

46

Careofpatientswithasuspectedstroke %ofpatientswithappropriatecarereceived 13

Patientreportedoutcomemeasures(PROMs)following:GroinherniaVaricoseveinsurgeryHipandkneereplacement

TrustdataregardingPROMs 44

Readmissiontohospitalwithin 28daysofdischarge

%patientswhoarereadmittedasanemergencywithin28daysofdischarge 46

Staffsurvey %ofstaffwhowouldrecommendtheorganisationasaplaceofworkortoreceivetreatment 42

ClostridiumDifficile Rateper100,000beddaysamongpatientsaged2orover 28

PatientSafetyIncidents Numberofreportedper100admissionsthatcausedsevereharmordeath 30


WEST CHESHIRE CLINICAL COMMISSIONING GROUP COMMENTARYWe are committed to commissioning high quality services from our providers and we make it clear in our contract with this Trust the standards of care that we expect them to deliver. We manage their performance through regular progress reports that demonstrate levels of compliance or areas of concern. It is through these arrangements that the accuracy of this Quality Account has been validated. TheTrustiscommendedontheachievementsindeliveringhighqualitystrokecareevidencedthroughachievingexcellencelevelsofcompliancewhenauditedagainstbestpractice.TheTrusthasnotperformedwellagainstpeersintheAdvancingQualityschemeinanumberofpathwaysand,basedoninformationtoJanuary2016,areunlikelytoachievemostofthetargetsset.Thisisdespiteprovidingreassurancein2014-15thatwewouldseesustainedimprovementsthisyear.Wearepleasedtonotetheprogressindeliveringanimprovedfrailtypathwaybothwithinandoutsideofthehospital,andrecogniseyourongoingcommitmenttothepartnershipworkingthatstrengthensthesuccessofthiswork.WesharedwithyouanumberofconcernsreportedbyGPsaboutdelaysinthemreceivingtimelyradiologyreports.Weacknowledgethroughtheintroductionofroutinesharingofperformancelevelswenowhaveaclearerunderstandingofthechallengestoimprovingthis.InrecognitionoftheimportanceoftimelyreportsfollowinginvestigationstoGPsandpatientsweanticipatethatyourplansin2015-16toremedythiswilldeliverimprovements.WeacknowledgethehardworkoftheTrustinits“zerotolerance”approachtohealthcareassociatedinfectionsandsupporttheTrustsdeterminationtomaintainrobustinfectionpreventionandcontrolpractices.FailuretocomplywiththisgoodpracticewasevidentinthepostinfectionreviewsintothecasesofavoidableMRSA.Thesereviewsarepositiveexamplesofyoureffortstolearnfromincidents,alongwiththeprocessesintheTrustforsharinglearning.

Wearepleasedtoseetheeliminationofthevariationbetweenoverallmortalityratiosandweekendmortalityratios.Itisofconcernthatyouhavehad2NeverEventsandthatopportunitiestoembedlearningfrompreviousNeverEventsandSeriousIncidentsin2014-15maynothavebeenimplementedsuccessfullyinalldepartmentswhoundertakeinvasiveprocedures.Ofsignificantassurancethoughgoingforwardisthemajorpieceofworkdoneacrossallareasofthehospitalundertakinginvasiveprocedurestomapperformanceagainstnewnationalsafetystandardsforinvasiveprocedures.Theleadershipandstandardofservicedeliveryacrosschildrenandadultsafeguardinghasconsistentlybeenregardedaspositivebypartners.TheTrust’seffortstoincreasepatientfeedbackandbetterunderstandtheexperienceofpeopleaccessingtheTrust’sservices,isnotedandwelcomed.DuringtheyearweraisedconcernsaboutthecomparativelylowreturnrateofFriendsandFamilyTestSurveysandasaconsequenceofyourdecisiontoinvestinatextsystemthereturnrateimprovedsignificantlyinoutpatients.Welookforwardtoseeingthisrateincreaseduring2016-17acrossalltheservicelines.WesupporttheprioritiesthattheTrusthasidentifiedfortheforthcomingyearandlookforwardtocontinuingtoworkinpartnershipwithyoutoassurethequalityofservicescommissionedin2016-17.

May 2016


PART THREEHOW WE HAVE DELIVERED OUR PRIORITIES IN 2015/16> PATIENT EXPERIENCE Howhaveweimprovedourpatients’experience?We wanted to:

Improve the patient experience by holding a patient/service user engagement event(s)

Thehospitalhasheldthreeengagementeventsthisyear.Althoughtheywerenotwellattended,itprovedausefulexperiencetoengagewiththepublic.TheDeputyDirectorofNursingandthenHospitalGovernoralsoattendedaGeneralPracticePatientParticipationGroup.Thiswasaveryinteractivesessionandalthoughthereweremanypositiveexperiencesforourpatients,thereareanumberofareasweneedtoimproveonandthesehavebeensharedwiththerelevantteams.

Reflect the public voice in recruitment of identified ‘other’ staff groups

Thishasbeenmoreofachallengetoachieve.Areasinthehospitalhavebeenreminded,whereappropriatetoinvolveagovernorintherecruitmentselection.

Improve family and patient experience by the use of patient experience volunteers

Thehospitaltrainedaverysmallgroupofvolunteerstosupportobtainingfeedbackfromourpatients.Volunteershavealsobeeninvolvedinthe‘MyLife’projectwhichinvolvesusinglocalhistoryandpicturesonanelectronicboard.

> EFFECTIVENESSTheAmbulatoryCareUnitcontinuestooperatesixdaysperweek–wehavetrialledtheunitbeingopenonaSunday.However,thethroughputhasnotbeensufficienttojustifytheresource.Wehaveextendedpathwaystoincludenumbersofclinicalpathwaysofgoodclinicalpracticewhichsupportthepatient’swishesofbeingtreatedinadaycaresetting.InNovember2015,welaunchedaGPto CliniciancallsystemtoallowaGPringingSinglePointofAccessforapotentialmedicaladmissiontheopportunitytodiscussthepatientwithanacutephysician.During November 2015 and January 2016, 614 calls were taken and signposted as below:

LocationNumber of calls/patients

GPAssessmentUnit(Ward46) 133

AmbulatoryCareUnit 158

EmergencyMedicine 267

Hospital@Home 9

SurgicalReferral 13

GPtomonitor 18

Other(accesstoother service/outpatients) 22

InFebruary2016,werelocatedtheunitandarenowdevelopinganextendedGPadmissionsunitonWard46for2016/17.

21QUALITY ACCOUNT 2015/16 21QUALITYACCOUNT2015/16


Pilot the option to an identified group of patients of a Skype clinic follow up consultation

Historically,theColorectalClinicalNurseSpecialistTeamhavefolloweduptheirenhancedrecoverypatientswithatelephoneconsultationpostdischarge.However,tomoveforwardwiththetimesandofferourpatientsanalternative/interactivemethodofcommunication,itwassuggestedwecoulduseSkype.InNovember2014,wecarriedoutapilotforsixmonthswhichprovedtobeanoverwhelmingsuccesswiththepatientswhochosetoenterthepilot.Aswithanything,therewereafewteethingproblemsbutthiswasmainlyduetopoorinternetconnections.Followingthepilot,wehavenowintegratedthismethodofconsultationintoourroutinepost-operativefollowup.Allcolorectalpatients(elective)areofferedtheoptionoffollowupviaSkypeortelephoneatpre-assessmentandgiveninformationaboutSkypeatthattime.Allemergencycolorectaladmissionsarespokentopriortodischargeaboutwhatformoffollowuptheywouldlike.InSeptember2015,wehaveuptothreeSkypeclinics–Mondayafternoon,WednesdaymorningandFridaymorning.Currently,theyaretwohourclinicswithhalfanhourallocatedslots.TheWednesdayclinicalsoactsasanemergencystomaSkypeclinicforpatientsthathaveanyproblemsorweredischargedontheMondayafternoon/Tuesdaymorning.The introduction of Skype has worked well for our patients as a specialised area and has been a success in the following ways:• Ithasreducedthenumberofhomevisitscarriedoutbythestomacareteam,andinsomecasesithasremovedtheneedforadistrictnursevisit

• Ithasreducedourpatientsneedingtoattendhospitalforwoundreviews

• Ithasfacilitatedpatientswhohavewishedtorecuperatewithrelativeswhoarenotlocal,andwhohavebeenabletomorefreely,knowingtheywillhaveafacetofaceinteraction

Althoughallverbalfeedbackhasbeenexcellentfromthepatientandtheirrelatives,wearecurrentlyrunninganaudittoofficiallyrecorditsimpact/effectiveness.

What does the future hold?

Thereareendlesspossibilitiesforthecolorectal/stomacaredepartmenttodeveloptheuseofSkypeconsultationswhichisveryexcitingforusasspecialistnursesandthepatients.Wehaverecentlyreceivedadonationfromoneofourpatients,whichhasenabledustopurchasefivetabletdevicesthatwillbelongtothedepartment.Thiswillallowustoprovidepatientswithnoaccesstoacomputerathomewithatablet,enablingthemtouseSkypeandforthosepatientsthatdonothaveinternetwillbeabletoaccessSkype.

> SAFETYTo reduce unnecessary frail elderly admissions

Ourfrailtyservice–nowknownasCommunityHealthyAgeingTeamarebasedinEllesmerePorthospital.TheteamreceivesreferralsfromGPs,CommunityCareTeamsandotherhealthprofessionals.Itoffersacomprehensiveassessmentinconjunctionwithafullmulti-disciplinaryteam(MDT)andwellbeingcoordinatorfromAgeUK.ItalsohasaclinicatTarporleyhospitalandprovideshomevisitsacrossWestCheshire.TheteamworkscloselywitheachpracticeandtheCommunityCareTeam,supportingtheminregardstotheolderperson’sneedsandwhereverpossibleallowingthemtostayathome.TheCentreforHealthyAgeingalsoprovidesafallsclinic,lowlevelexerciseclasses,movementdisorderclinicandaccesstoawellbeingco-ordinator.InJuly2015,thehospitaldevelopedanAcuteFrailtyWardwhichhastwicedailyconsultantwardroundsanddailyMDTprovidingapatientcentredandtargetedapproachtowardsdischarge.ThisisledbythecareoftheElderlyConsultantTeamandtheyidentifyappropriatepatientsfromEmergencyMedicineandAcuteMedicinedailytobeacceptedontoourfrailtyward.TheMDTconsistsofmedical,nursing,pharmacy,therapiesanddischargestaffallworkingtogethertoachievethebestoutcomeforeachpatientandfamily.


In July 2015, we launched a Discharge to Assess (D2A) project providing alternative

locations (outside of the acute hospital site) for patients’ on-

going assessment needs.


To improve patient safety in Interventional Radiology (IR)

Itwasdecidedinearly2015,toappointaRadiologyPatientSafetyLeadwhowouldreporttotheRadiologyDepartmentandtheHeadofRiskandPatientSafety.Belowisatablewhichshowstheincreaseofthenumbersreported.

Radiology Incidents

2013 2014 2015

201 242 404

The2015figuresshowalmosta100%increaseinreporting.Thisincreasewasanticipated,asthisnowdemonstratesapositivereportingcultureoftheRadiologyDepartment.ThroughtheRadiologyPatientSafetyLead,theRadiologyDepartmentcanobtainmoredirectfeedbackrelatingtospecificincidents.Goingforward,thethemesandtrendsfromthereportedincidentswillbemonitoredandactionedensuringarobustpatientsafetyculture.

Radiology reporting

InMarch2016,theTrustinvestedinanewPACSsystemsuppliedbyCarestream.ThissystemwillprovidetheRadiologyDepartmentwithanimprovementinreportingefficiencywhichwillreducetheturnaroundtimeforreportsfollowinginvestigations.Inaddition,theTrusthascommencedmonthlymonitoringKPIsforGPreportingturnaroundtimesandiscommittedtodeliveringasignificantimprovementinreportturnaroundin2016/17.


OTHER QUALITY IMPROVEMENTS IN 2015/16> WORKING IN PARTNERSHIP:

WHAT OUR GOVERNORS HAVE SAIDTheCouncilofGovernorsispleasedtobeanintegralandsignificantpartnerintheTrust.Thegovernors’‘QualityForum’,isanopengroupforallgovernorsthatmeetsregularlyandreceivesupdatesfromseniormembersofstaff,membersoftheBoardandexecutiveteamandothers.ThisincludestheDeputyDirectorofNursingwhoupdatesonqualityandsafetyatalmosteverymeeting.Presentationsarefrequentlygivenandgovernorsarerobustinquestioningandcommentingonthecontentandplans.TheCouncilofGovernorsverymuchappreciatesthatthereisclearopennessinthesharingofinformationwiththem.GovernorshavemanyopportunitiestoparticipateincommitteesandworkinggroupsintheTrust.TheseincludetheDisabilityandEqualityGroup,theRace,ReligionandBeliefGroup,theOrganDonationCommitteewhichischairedbyagovernor,theWayfindingworkgroup,StopSmokingworkinggroup,theMedicalDevicesGroupandmanyothers.OnegovernorattendstheQuality,SafetyandPatientExperienceCommitteeandisnowpreparingtotakethefeedbackreceivedbygovernorsandexplorewaysofrespondingtopatientsandthepublicaboutthoseconcernsandinformthemofanyactiontaken.GovernorscontinuetomakeunannouncedvisitstowardsandpublicareasoftheTrustfor‘sitandsee’visits.Feedbackfromtheseisalsoactedupon.

TheTrusthaditsfirstfullCareQualityCommissioninspectionduringtheyearandgovernorswereregularlyinformedandparticipatedinpreparationsforthisvisit.AgroupofgovernorsmetwiththeinspectorsandwasenthusiasticabouttheTrustandrolethattheCouncilofGovernorshasintheTrust.Governorsunderstandandsupporttheneedforamoreintegratedapproachtohealthandsocialcareandtrytopromotethisbyattendingothercommunitygroupsandbyparticipatinginevents.TheyattendtheirPatientParticipationGroups,theHealthandWellBeingBoardmeetings,Healthwatch,theClinicalCommissioningGroupmeetings,aswellaslocalpatientsupportgroups,suchastheHeartSupportGroup.TheCouncilofGovernorsisastrongteamofrepresentativeswithavarietyofskillsandexperienceandtheymuchappreciatetheopportunitytocontributetotheQualityAccount.Theyareproudoftheirhospitalandwillcontinuetoworktoensureitprovidesgoodsafeandeffectivecareinakindway.OurchosenindicatortobeauditedfortheTrustwasMyocardialInfarctionNationalAuditProgram(MINAP).TheTrustcompliancefordatacompletenessandaccuracyin2015/16is99.7%comparedto94.6%in2014/15accordingtotheUniversityCollegeLondon(UCL),whoreportsonthedatareporting.Althoughun-validated,the2015/16positionhasdemonstratedgoodcompliance.


> INFECTION PREVENTION AND CONTROLDescription of the issues and rationale for prioritising

Ensuringthatavoidablehealthcareassociatedinfectionsdonotoccurisanessentialaspectofqualityhealthcareprovision,withrobustinfectionpreventionandcontrolpracticesbeingakeycontributiontopatientsreceivingsafeandeffectivecare.Reducingthenumberofhealthcareassociatedinfectionsidentifiedwithintheorganisationremainsahighpriority,maintainingthefocusonriskreductiontopatients,visitorsandstaff.Theroutineimplementationofeffectiveinfectionpreventionandcontrolmeasureswithindailypracticeisessentialtoachievingthisaim,andmustincluderobustsystemstomonitor,evaluateandtoimprovewhenidentifiedasnecessary.Antimicrobialstewardshipisalsoanationalandinternationalpriorityensuringthataccesstoworkingantimicrobialsissustainableintothefuture.Thisplacesanevengreaterfocusoninfectionpreventionasresistancetothedrugsthatweusetotreatinfectionsincreases,renderingthemineffective.TheTrustplanstomaintaintheintensityofbothinfectionpreventionandcontrolandantimicrobialstewardshipatalllevelsoftheorganisation,sustainingour‘zerotolerance’approachtopreventableinfectionfrom‘boardtoward’,andwiththefocusremainingonriskassessmentandriskreductionstrategies.

Objectives for 2016-17:• TohavezeropreventableMRSAbacteraemiacaseswithintheyear

• Tohave24orfewercasesofclostridium difficileinfectionwithintheyear

• Toenhancefocusonantimicrobialstewardshipstrategies,incorporatingthe‘StartSmartThenFocus’approach

• Toconsistentlymaintain95%complianceorabovewithhandhygienepractices

• Toconsistentlyachieve95%complianceorabovewithMRSAscreeningrequirementsforemergencyandelectiveadmissions

• Tomaintainlocalsurveillancesystems, includingthoseforantimicrobialresistantorganisms,andmaintainallmandatorysurveillancerequirementsaspartofnationalsurveillanceprogrammes

2015-16 results:• 25casesofclostridiumdifficileinfectionreported(setagainstatrajectoryofnomorethan24caseswithintheyear).Thisisareductionfromthe29casesreportedinthepreviousyear(2014-15).

• 3avoidablecasesofMRSA bacteraemiaidentified,againsttheobjectiveofzeroavoidableMRSAbacteraemiawithintheyear.

• Successinmaintainingaveragehandhygienecomplianceabovethe95%minimumcompliancelevelfortheyear(Averagecompliancescorefortheyearcalculatedat96%).

• StrengthenedfocusonimprovingcompliancewithMRSAscreeningrequirementsforemergencyandelectiveadmissions–localsurveillancesystemscontinuetodemonstrateadownwardtrendinMRSAidentifiedwithintheorganisation.

• Successinmaintainingan‘unconditional’registrationstatuswiththeCQC.


5

Num

bero

fCases

Month

4

0Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16

1

2

3

MRSA Bacteraemia 2015- 16

Total Clostridium Difficile Cases 2015/16 (cumulative)

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

3 4

5 6

7 8

9

12

15

18

21

24

3

6 6 7

15 16

18

21 22 22

25

4038363432302826242220181614121086420

NationalObjective CumulativeActual

2015-16objective Post-48hravoidable Post-48hrunavoidable Contaminant


Clostridium Difficile Comparison Data 2011-16

Hand Hygiene Compliance Data 2015-16

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

10

8

0

92%

93%

94%

95%

96%

97%

98%

99%

100%

2

4

6

2011-12Actual 2012-13Actual 2013-14Actual 2014-15Actual 2015-16Actual

ClostridiumdifficileinfectionreportedwithintheTrustamongstpatientsaged2oroverduringthereportingperiod’-25 cases equate to 12.24 per 100,000 bed days.

Objective% Compliance%

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16


Planned Focus for 2016-2017:• Thecorporateinfectionpreventionandcontrolassuranceframework,incorporatingnationalchangestotheHealthandSocialCareAct(2008):CodeofPracticeonthePreventionandControlofInfectionsandRelatedGuidance;ensuringthatthiscontinuestosupportallrelatedactivity,includinghealthcareassociatedinfectionregistrationrequirements.

• Maintainsystemsof‘alertorganism’reviewtoensurethatcolonisedpatientsorthosewithassociatedinfectionsaretreatedpromptlyandappropriatelytotheirbenefitandforwiderpublichealthwithinthepatientpopulation.

• Maintainnewandestablishedsystemsforpromotingbestpracticetoreducethenumberofclostridiumdifficileinfectionsvialearningfromrootcauseanalysesandnationalevidencebase.

• Strengthenantimicrobialstewardshipacrosstheorganisation,ensuringappropriateantimicrobialuseandriskreductionassociatedwithantimicrobialresistance,utilisingtheinformationandresourcesprovidedbythe‘StartSmartThenFocus’approach.

• MaintainnewandestablishedsystemsforpromotingbestpracticetoreducethenumberofMRSAbacteraemiacasesvialearningfromrootcauseanalysesandnationalevidencebase.

• Maintainestablishedlevelsofcleanliness,bothwithintheenvironmentandforequipment,ensuringcompliancewithnationalcleaningfrequenciesandworkingcollaborativelywithfacilities.

• Maintaintheinfectionpreventionandcontrolauditandsurveillanceprogrammes,includingsurgicalsiteinfectionsurveillance,addingtotheseastheneedisidentifiedandensuringcompliancewithnationalmandatorysurveillanceprogrammesanddatareporting.Utiliselocalsurveillancetopromptlyidentifyoutbreaksorperiodsofincreasedinfectionincidence,includingbutnotexclusiveofclostridiumdifficile,MRSA,plusothermultidrugresistantorganisms.

• Maintaintrainingandeducationprogrammesforallstaffgroups,consistentlyreinforcingtheroutineimplementationofinfectionpreventionandcontrolstandardsandantimicrobialstewardshipforallpatients,allofthetime.

• Maintainsystemsofinformationdisseminationtoensurethattheworkforceremainsinformedandengagedonperformanceagainstagreedobjectivesforhealthcareassociatedinfectionreduction,adaptingtheseascircumstancesdictate.

• Ensurethatthehealthcareenvironmentisfitforpurpose,workingcollaborativelywithestatesandfacilities.

• Continuallyassessanynewdevelopmentsininfectionpreventionandcontrol(regionally,nationallyorinternationally)toinformandimproveonpractice.

• Maintainasystemofpolicydevelopmentandreviewinconjunctionwithrevisedoremergingevidence-base.

• Ensurethathealthcareworkersremainadequatelyprotectedfrominfectionriskswithintheworkplaceanddonotasindividualsposeaninfectionrisktoothers.

• Maintainsystemstoprovideaccuratehealthcareassociatedinfectioninformationforpatients,visitorsandotherhealthcareproviderstominimiserisksassociatedwiththetransmissionofinfection,workingcollaborativelywithhealthcareproviders.


> RISK MANAGEMENTTheTrust’sriskmanagementstrategyprovidesaframeworkformanagingriskacrosstheorganisation.Therolesandresponsibilitiesofallstaffinrelationtotheidentificationandmanagementofriskareidentifiedinthisandotherrelatedpolicies,e.g.IncidentReporting.ThestrategysetsouttheroleoftheBoardofDirectorsandstandingcommittees,includingtheCorporateDirectorsGroupwhichischairedbytheChiefExecutiveandhasdelegatedresponsibilityforoverseeingandmonitoringtheriskmanagementandassuranceframeworkprocess.ThegroupdrawsassurancefromtheQuality,SafetyandPatientExperienceCommittee(QSPEC)andotherunderpinningcommittees.Tosupportlisteningtostaff,theTrusthasanumberofformalandinformalsystemsincludingaprogrammeofExecutive‘walk-rounds’,theuseofsafetybriefingsand“huddles”,Executivepresencewithintheinductionprocessforallnewstartersandtheroll-outofthe‘SpeakoutSafely’campaign.Theriskmanagementstrategyandsupportingproceduressetoutthekeyresponsibilitiesformanagingriskwithintheorganisation,includingwaysinwhichtheriskisidentified,evaluatedandcontrolled.ThecontinueduseoftheHealthandSafetyExecutive’s“fivestepstoriskassessment”modelensuresthataconsistentapproachisappliedtoassessingandrespondingtoclinicalandnon-clinicalrisksandincidents.FurtherprogresshasbeenmadeoverthepastyeartostrengthentheTrust’sriskmanagementsystemsandprocesses.Thisinvolvestherecordingofriskslocallyontodepartmental/wardriskregisters.Staffaretrainedandequippedtomanageriskinawayappropriatetotheirauthorityandduties.AllnewstaffreceiveanoverviewoftheTrust’sriskmanagementprocessesaspartofthecorporateinductionprogramme,supplementedbylocalinductionandorganisedbylinemanagers.Furthereducationisprovidedwithcyclicalmandatorytrainingundertakenbybothclinicalandnon-clinicalstaff;theriskcontentforthisprogrammewasupdatedin2015.Thetrainingneedsofstaffareidentifiedthroughannualperformanceanddevelopmentappraisals.TheTrust’srobustriskmanagementprocesseswererecognisedduring2015/16whenshortlistedinthe‘TrustoftheYear’categoryatthenationalPatientSafetyAwards.

Althoughnotawinneronthisoccasion,theshortlistingwasanopportunitytodemonstratehowtheTrusthasembeddedriskandsafetyprocessesaspartofthecultureoftheorganisationandmakingit‘everybody’sbusiness.’Risk management is well embedded in the organisation in a variety of ways:• TheTrustreceivesassurancefromthe NationalReportingandLearningSystem onreportingperformance.

• TheTrusthasanestablishedprocessforlearningfrompastharmsandthereviewofincidentsofconcern,suchaswhereathemeisevidentorwhereseriousharmhas(orcouldhave)occurred.Thisissupportedbytheelectronicriskmanagementsystem,whichenablesthelinkingofincidentsforthematicreviewandalsolearningfromcomplaints,claimsandHMCoroner’sInquests.

TheExecutiveSeriousIncidentPanel,chairedbytheDirectorofNursingandQualitymeetseachweektoreviewanyincidentinwhichapatienthassustainedamoderateharmorgreater,orincidentswhereatrendisevident.AgreementisreachedregardingthelevelofinvestigationandinlinewiththeSeriousIncidentFramework.ThesearereportedexternallytoStEIS(theNationalFrameworkforReportingandLearningfromSeriousIncidentsrequiringInvestigation).Theseincidents,thequalityofthereviewandreport,anditssubsequentactionplan,aremonitoredinternallyviaamonthlyreporttotheQSPECandviathemonthlyCCGSeriousIncidentMeeting.During2015/16,theTrustreported70incidentstotheClinicalCommissioningGroup(CCG)andNHSEngland–thisequatesto0.6%ofallincidentsreportedwithintheTrustinyear(n=12374)


2015/16 Serious Incidents for Quality Account

Incident Category

StEIS Incident TypeTotal

Number of Incidents

PressureUlcers

HospitalAcquiredGrade3PressureUlcer 5

HospitalAcquiredDeteriorationofExistingPressureUlcertoGrade3 12

HospitalAcquiredGrade4PressureUlcer 2

HospitalAcquiredDeteriorationofExistingPressureUlcertoGrade4 2

21

Infection Control

CDIandHealthcareAcquiredInfections 5

MRSABacteraemia 3

8

SeriousIncidents

SurgicalIncident 4

WrongSiteSurgery(NeverEvent) 1

UnexpectedAdmissiontoNeonatalIntensiveCareUnit 1

Maternity/ObstetricIncident:MotherOnly Retainedtamponpostprocedure(NeverEvent) 1

DiagnosticIncident 8

MedicationIncident 4

TreatmentDelay 6

MedicalDevice/DisposableIncident 2

Slips,Trips&FallsIncident 4

SuboptimalCareofDeterioratingPatient Regulation28 1

Maternity/ObstetricIncident:Mother&Baby 1

FailuretoObtainBedforChild 1

AdverseMediaIncident 2

Abuse/AllegationofAbusebyStaff 2

Maternity/ObstetricIncident:BabyOnly 2

ConfidentialInformationLeak 1

41

Total 70

*Tonote:thatNHSEhaveagreedto‘declassify’the12hourEDbreachesduetonoharmbuttheyareincludedinthesefiguresastheyhavenotyetbeenremovedfromourStEISrecords

*Tonote:StEISwasupdatedwiththeSIFrameworkandcriteriaon19thMay2015sosomeoftheincidentcategorieslookdifferentfrompreviousyears


Thereweretwo‘neverevents’reportedduringthisperiod,one‘wrongsitesurgery’andone‘retainedforeignproductpost-procedure’.SignificantprogresshasbeenmadeintheyeartofurtherdevelopawholetheatreteamapproachtosafetyandfullengagementwiththeWHOSaferSurgerychecklist–withparticularfocusuponthepre-briefingstage.ThishasbeenreiteratedviathelaunchoftheNationalSafetyStandardsforInvasiveProcedures(NatSSIPs),followingwhichascopingexerciseoftheTrustwasundertaken.Misidentificationremainsthethemeacrossanumberofincidentswhichtriggeredpatientsafetyreviews.TheseclinicalrisksfeaturewithintheTrust’sSignuptoSafetyImprovementPlansandwillcontinuetobeafocusgoingforward.

How do we learn?

Thehospitalteamslearnfromgoodpracticethrougharangeofmechanismsincludingclinicalsupervision,reflectivepractice,individualandpeerreviews,performancemanagement,continuingprofessionaldevelopment,clinicalauditandtheapplicationofevidencebasedpractice.Inaddition,weconducttriangulationofrisksandprovidefurtherbespoketrainingwherenecessary.TheHighQualityCareCostsLessworkstreamsprovidefurtheropportunitytoidentify,shareandlearnfromgoodpractice.LessonslearnedandgoodpracticeissharedthroughouttheTrustviamechanismssuchastheQSPEC,theOperationalDeliveryCommitteeandthemonthly‘Safe,KindandEffective’bulletins.Thehospital’sintranet-whichourstaffhaveaccessto,hasbeenrefreshedandincludesasectiondedicatedtoriskandpatientsafetyissues.Inaddition,lessonslearnedarefedbackthroughvariousteammeetingsandotherlearningopportunities.TheQSPECasasub-committeeoftheBoardhaveprovidedassurancethattheTrustiscompliantwithkeyrecommendationsfromnationalreportsandinquiries.TheCommitteealsomonitorstheprogressofanyhighriskclinicalissuesandseriousincidentactionplans(including‘neverevents’).

TheHeadofRiskandPatientSafetyprovidesamonthlyassurancereporttotheQuality,SafetyandPatientExperienceCommitteeoutliningtheTrust’scurrentperformanceinrelationtoseriousincidentinvestigations,associatedactionplansandlearning.EscalationofriskismanagedviatheCorporateDirectorsGroup,wheretheExecutiveRiskRegisterisreceivedandchallenged.Clinicalauditismonitoredonamonthlybasiswiththecurrentauditprogrammesenttospecialtiesfortheirreview.Divisionalreportsarealsoreceivedprovidingupdatesofquarterlyactivity.NationalauditactivityismonitoredthroughtheClinicalImprovementandAssuranceCommittee.TheClinicalImprovementandAssuranceManagerhasintroducedabespokemodulewithintheTrust’sriskmanagementsystemwhichsupportstheintegrationofincidents,claimsandcomplaintswithinourauditprogramme.Thisworkhasreceivednationalinterest,andwaspresentedatthenationalPatientFirstCongressinNovember2015.

How we are implementing the duty of candour

TheTrusthastakenthedutyofcandourlegislationseriously.Allstaffreceivesinformationatinduction,supportedbyaleafletthroughtheinductionprocessanddutyofcandourisdiscussedduringthewelcomeeventandallmandatorytrainingsessions.ThereisaninformationsectiondedicatedtodutyofcandourguidanceandcasestudiesontheTrust’sintranetpages.InFebruary2015adutyofcandourpaperwaspresentedtotheQSPECbyAlisonKelly,DirectorofNursing&Quality,givinganoverview,assessmentandrecommendationsontheguidance.Ourpolicyforinvestigatingincidentshashaditssectionon‘beingopen’reviewedandnowincludesarobustdetailedsectionondutyofcandour.


Our Patient Safety Improvement Plan

TheTrust’sQualityImprovementStrategy2014-17outlinesthecommitmenttodeliveringconsistentlysafecare,takingactiontoreduceharmtopatientsinourcare,andmovingfrom‘goodtogreat’inourgoaltoachieveexcellenceinallwedo.ByparticipatinginNHSEngland’sSignUptoSafetyinitiative,andtheoverarchinggoalofreducingavoidableharm,theTrusthasdevelopedaSafetyImprovementPlan–thebasisofwhichistheanalysisofourlocalincidentandclaimsdata.This analysis has identified six safety work streams that, it is expected, will significantly reduce harm, these are:• Safety work stream 1: Improveteameffectivenessandsafetycultureintheoperatingtheatres.

• Safety work stream 2: Reducethenumberofmoisturelesionsandgradetwopressureulcerswithintheorganisation,withfocusuponmedicaldeviceassociatedpressureulcers.

• Safety work stream 3: DeveloparobustsystemtoidentifybabiesatriskofIUGR,enablingrobustmonitoringoffoetalgrowthandareductioninharm/stillbirthrate.

• Safety work stream 4: Workacrossthehealthcommunitytoimprovethemanagementofpatientswithsepsispre-hospitalandonadmission.

• Safety work stream 5: Improvesafetyintherequestsforradiologicalinvestigations.

• Safety work stream 6: Reducethenumberofpatientfalls resultinginseriousharm

TheSafetyImprovementPlanisaimedatimprovingthehealthoutcomesandeffectivenessofourcare.Itaimstoreduceavoidableharm,therebyimprovingthepatientexperience.FurtherdevelopmentoftheTrust’s‘safetyculture’isessentialsothatthedeliveryofsafeandevidenced-basedcarebecomesembeddedintheday-to-daypracticesofallTruststaff.InJanuary2015,theTrustappliedforconsiderationofanNHSLitigationAuthority(NHSLA)incentivepayment-afinancialreimbursementofupto10%oftheTrust’sNHSLAannualcontribution.TheTrustwasunsuccessfulinachievingtherequiredpassmarkanditshouldbenotedthatofthe249bidssubmittedintotalfortheincentivisedpayment,only67weresuccessful.


> SAFEGUARDINGSafeguarding Children & Identifying and Supporting Victims of Domestic Abuse

OursafeguardingresponsibilitiesareatoppriorityfortheTrustandthisisoverseenbyourDirectorofNursingastheExecutiveLeadforSafeguardingandChairofthehospitalSafeguardingStrategyBoard.Ourdedicatedandexperiencedteamleadsonensuringatimelyandappropriateresponsetosafeguardingchildren’sanddomesticabuseissuesinallareasacrosstheTrust.OurSafeguardingChildrenandDomesticAbuseprocessesareembeddedintrainingandclinicalsupervision.During 2015/16: • TheSafeguardingChildrenandDomesticAbuseTeamhasreceivedandensuredanappropriateresponseto532SafeguardingChildrenNotificationsfromacrosstheTrust.

• Theteamhasdealtwithandsupervisedmidwivesin191safeguardingchildrencasesinvolvingunbornchildren.

• Thishasincluded288referralstochildren’ssocialcare.Thishastakenplacebecauseofconcernsaboutapotentialriskofsignificantharmtochildrenandyoungpeople,includingunbornchildren.

Quality Standard QS116 February 2016

Inallsafeguardingchildren’sanddomesticabusecasesidentified,therewillalwaysbeamulti-agencyapproachtoensuringallinformationavailableiscollatedandincludedinourinitialactionplanning.Thiswillincludeworkingwithourhealthcolleaguesinotheragencies,police,andchildren’ssocialcareandearlysupportservices.

This year we have undergone the following reviews:• LocalSafeguardingChildren’sBoardSection11(2004Children’sAct)auditofcompliancewithexcellentoutcomes.

• CareQualityCommissioninspection-Verbalcommentsfromtheinspectionregardingoursafeguardingchildrenanddomesticabuseprocesseswereextremelypositive.

TheSafeguardingChildrenandDomesticAbuseTeamlookforwardtotheyearaheadandremainabsolutelycommittedtoensuringtheappropriateandtimelyresponsetoallSafeguardingChildrenandDomesticAbuseissuesthatariseacrosstheTrust.ThisincludesanongoingandincreasedfocusonissuessuchasChildSexualExploitationandFemaleGenitalMutilation(FGM).

Adults

TheAdultSafeguardingandLearningDisabilityCoordinatorhasbeenagreatassetduringtheyearhavingbuiltontheawarenessraisedpreviously,andincreasingtrainingcompliance.Wehavesupportedourcommissionersinsafeguardingwhichhasreallyensuredawholeareaapproach.WiththeGovernmentstrategyregardingPREVENT,thecoordinatorwillbepivotalinensuringthetraininganddeliveryofthestrategy.Weknowthereisstillworktodotoensurethatadultsafeguardingcontinuestoberecognisedasaprioritybyallstaffandrespondedtoappropriately.Duringtheyear,thehospitalhaslaunchedpointsofcontactandnamedleadsforadultsafeguarding.Weareconfidentthatwearemakingrealprogresstokeepourpatientssafe.


> EQUALITY, DIVERSITY AND HUMAN RIGHTS

Wenowhaveawell-developedequalitygovernanceframework,whichincludespatientsandthirdsectororganisations,fromacrossthefullrangeofprotectedcharacteristics.Thereareinclusionandengagementactivitieswithprotectedgroups,forexample,disabledpeople,whoareakeyelementtoeffectiveequalitygovernance.ThisissupportedbyourEquality,DiversityandHumanRightsStrategyGroupandtheequalitysubgroupsthatreportintoit.Thefollowingachievementsin2015-2016 areaconsequenceofourtransparent,inclusiveandengagingequality,diversityandhuman rightsagenda.We are proud to say we have:• AttainedaveryhighequalityperformanceratingintheNHSequalitydeliverysystem2assessment,with15outof18individualoutcomesbeingratedas“Achieving”andtheremainingthreeoutcomesbeingratedas“Excelling”.

• Welaunchedourinauguralcarer’sstrategytobetterinvolvecarersincareandincludethemintheplanningandreviewofcaredeliveryandservices

• Continuedpartnershipworkingwithagencies,co-facilitatinghealthandwellbeingforumswitharangeofseldomheardprotectedgroups,inordertoobtainstakeholderfeedbackonservicesandhealthneeds

• RetainedtheNavajoLGBTIchartermarkforourpolicies,servicesandengagementwithpeoplewhoidentifyaslesbian,gay,bisexual,transgenderandintersexed

• Introducedareasonableadjustmentsflaggingsystemtosupportpatientswithlearningdisabilitiesorwholackmentalcapacity

• Retainedthe“TwoTicks”: - Positiveaboutdisabled

people accreditation forourcommitmenttostaffthathasadisabilityandengagementwithdisabilitygroups

- ReceivedtheannualnationalNHS‘LeadershipAcademyAward’forinclusiveleadershipforcontinuedequalityperformanceanddevelopingaculturethatpromotesandsustainsequalityandhumanrights.

• PublishedourinauguralWorkforceRaceEqualityStandard(WRES)submission

Goingforward,thehospitalwillcontinuewithitsengagementandcollaborationwithstakeholdergroupsrepresentingtheprotectedcharacteristics.


> CANCER PEER REVIEWThequalitysurveillanceprogramme,formerlyknownastheNationalPeerReviewProgramme(NCPRP)isthequalityassuranceprocessfortheNHSwithafocusoncancerservices.Theprogrammecontinuedinto2015withthecancermulti-disciplinaryteams(MDTs)attheCountessofChesterHospitalbeingrequiredtoself-assessthecomplianceoftheirserviceagainstnationallyagreedmeasures.Thefollowingteamswererequiredtoundergointernalvalidationoftheirself-assessment(SAIV)bytheTrust:LocalUpperGI,Lung,Breast,HeadandNeck,AcuteOncology,CancerofUnknownPrimary(CUP),LocalUrologyandLocalSkinMDTs.Inaddition,thehaematologyservicewassubjecttoanexternalvisit,althoughthiswasheldatWirralUniversityHospitalTrustwhichhoststheMDT.Alloftheteamswereabletodemonstrateareasofgoodclinicalpracticeandawholeteamapproachwasseeninmanysites.Outcomeswerecomparablewithorbetterthannationalaverages.Noimmediaterisksorseriousconcernswereraised,althoughsomeconcernswerehighlightedwhichhavebeenincorporatedintotheindividualteams’workprogrammesasareastobeaddressedinthenexttwelvemonths.Thereweresomesharedconcernswhicharosefromthejointassurancemeetings.Oneofthesewasaroundtheattendanceofcoreteam

membersatMDTmeetings.However,thisremainsattributableinparttoachangeinthemeasureandtheaccuraterecordingofattendanceatMDTmeetingstocomplywithrequirements,inadditiontostaffrecruitment.ThereisstillachallengearoundoncologycoveratsomeMDTmeetingsduetooncologistavailabilityfromClatterbridgeCancerCentre(CCC).Theoutcomeoftheexternalvisittothehaematologyteamconcludedthatthereviewerswereinagreementwiththeteamself-assessmentandgoodpracticewasrecognised.However,concernswereraisedaroundoncologycoverandlackofuptaketotheregionaldiagnosticservice,whichhavebeenrespondedto.Therearestillsomeoutstandingactionsfrompreviouspeerreviewvisitsincludingthelackofelectronicprescribingforintravenouschemotherapy.TheTrustislookingtolinkwiththesystemcurrentlybeingdevelopedatCCC.ThereisalsoaplannedexternalvisittotheCancerofUnknownPrimaryteaminFebruary2016,althoughtheMDTmeetingforthisishostedatCCC.WearecurrentlyawaitingconfirmationfromtheQualitySurveillanceTeamastohowtheprogrammewilldevelopinthefutureasfurthernationalchangesareplanned.Untilsuchinformationisreceived,theTrustwillcontinuewiththecurrentprogrammeasisconsideredbestpractice.


> TRAUMA PEER REVIEWThehospitalhasbeenauthorisedasaTraumaUnit(TU)since2012anditformsanintegralpartoftheCheshireandMerseysidemajortraumanetwork.TheCountessofChesterHospitalTraumaUnitstabilisesmajortraumapatientspriortoatransfertotheMajorTraumaCentreCollaboration(MCCT).Italsoprovidesassessmentandtreatmentoftraumapatientswithlesssevereandcomplex,butstillseriousinjuries.Ourhospitalunderwentapeertraumareviewin2015.Therewereseveralareasofnotablepractice;examplesincludingdedicatedpaediatricorthopaedicsurgeonsandanaesthetistson-site.Traumasimulationtrainingconductedintheemergencydepartment,empowerednursestoactivatetraumateamswhichsubsequentlyledtoanincreaseintraumacallactivation.Therewasagoodaccreditationoftraumadataat96.9%.ThereviewerscommendedtheteamfortheirabilitytoofferinterventionalradiologyfortraumapatientsthroughtheTrusthostingtheSouthMerseyarterialservice.Theteamhighlightedareasforthehospitaltoimprove.ExamplesincludetheneedforaTraumaNurseCoordinatorandimprovementintheadministrationofTranexamicAcidtotraumapatientswithinthreehours.ATraumaNurseCoordinatorcameintopostinAprilof2015.Overthelastyear,thisrolehashelpedtoimprovethesystemforpatientsrepatriatedfromtheMCCTwitha48hourtimeframe.Amultidisciplinaryteamapproachhasalsobeenestablishedforallrepatriatedtraumapatientstorapidlyidentifyandplanfortheirrehabilitationneeds.TherehasbeenanimprovementoftheaccreditationdataforTARNfrom96.9%to98.9%withasignificantchangereflectedintheTARNDashboardcompliancedata.Furtheractionplansandoperationalpoliciesarebeingdevelopedtoensuretheareashighlightedareimproved.

> NATIONAL CANCER PATIENT EXPERIENCE SURVEY (NCPES)

TherewasnoNCPESfor2015withresultsfromthe2014surveyonlybeingavailableinAugust2014.Atthiscurrenttime,surveysarebeingsentoutforthe2015/16surveyinwhichtheTrustisparticipating.Throughout2015,wecontinued

toworkonpreviouslyidentifiedactionsaroundsupportandinformationforcancerpatients.TheCountessofChesterHospitalhasbeenpartoftheMacmillanCancerSupporteHNApilot.ThisisbuiltonaholisticneedsassessmentandprovidesanelectronicformoftheassessmentusinganiPad,withtheaimofidentifyingpatients’mainconcernsandenablingthemtoaccesstheappropriatesupport.Attheendof2015,fivesiteswerelivewitheHNAwithafurtherthreesitesplanningongoingliveearly2016.Inaddition,localsurveyshavealsobeenundertakentoensureweareworkingtoimprovetheexperienceofpatientswithacancerdiagnosisseenattheCountessofChesterHospital.

> TRANSPARENCY – ‘HOW ARE WE DOING?’

Wearedevelopingthe‘Howarewedoing’webpage.Thisyear,theinformationdisplayedonthepublicwebsitehasgrown.Wewillcontinuetobetransparentandpublishasmuchinformationaspossible.Each month, we continue to publish the following information on our website: • Pressureulcers• Fallswhilstinhospital• Nursestaffinglevels• Nursestaffingreviews• Nursestrategyupdates• AdvancingQualityindicatorsforconditions suchasheartfailureandheartattacks

• Patientsatisfactionscoresfrom ‘FriendsandFamily’

• Patient experience report

Webelievethatthiswillhelpassurethepublicofthecontinualworkandcommitmenttodeliverhighqualityandsafepatientcare.Duringtheyear,wehaverelaunchedournursingcaremetricsfollowingacompleteseniornursereview.Ourcompliancecurrentlystandsatover90%.Ourseniornursingteamhascontinuedtobeoutandaboutonthewardsanddepartments,monitoringpatientcareinrealtime.


• Hipandkneereplacement• Strokecare• ChronicObstructivePulmonaryDisease(COPD)• Diabetes• Hipfracture• Acutekidneyinjury• Sepsis• Alcoholrelatedliverdisease

Dataiscollectedretrospectivelytoallownotestobeclinicallycodedfirstandthenmatchedtotheaboveconditionrelatedpathways.DisappointinglytheAdvancingQuality(AQ)regionalCQUINShavecontinuedtounderperformdespitetheTrusthavingaplantoimprove.Workisongoingtosupportthesepathwaysandtheywillbecontinuallymonitored.

Current status:

TheAdvancingQualitydataisretrospective.WearecurrentlyverifieduptoJanuary.Wehavecontinuedtofindtheseareasachallengetoachieveandarenotlikelytoachieveanyofthesefully.However,someofthechangesputinplacethisyearwillsupporttheongoingefforttoimprove.

> ADVANCING QUALITY REPORT

Aim:• Toensurepatientsreceivethebestpracticeindicatedfortheircondition

• Topromotetimelyrecoverywithgoodclinicaloutcomes

Description of the issues and rationale for prioritising:

TheTrusthasbeenpartoftheNorthWestAdvancingQualityprogrammeforoversevenyearsforanumberofconditions.The programme supports the implementation of set pathways of care across the identified conditions of: • Acuteheartattack• Heartfailure• Communityacquiredpneumonia

39QUALITYACCOUNT2015/16


> PATIENT SURVEYSIn Patient 2015

Thissurveyhashighlightedthemanypositiveaspectsofthepatientexperience:• Overall:87%ratedcare7+outof10.• Overall:treatedwithrespectanddignity-82%.• Doctors:alwayshadconfidenceandtrust-80%.

• Hospital:roomorwardwasvery/fairlyclean-96%.

• Hospital:toiletsandbathroomswerevery/fairlyclean-95%.

• Care:alwaysenoughprivacywhenbeingexaminedortreated-91%.

2014 Results

Overall:84%ratedcare7+outof10.• Overall:treatedwithrespectanddignity-81%.• Doctors:alwayshadconfidenceandtrust-81%.

• Hospital:roomorwardwasvery/fairlyclean-97%.

• Hospital:toiletsandbathroomswerevery/fairlyclean-96%.

• Care:alwaysenoughprivacywhenbeingexaminedortreated-90%.

Mostofourpatientsarehighlyappreciativeofthecaretheyreceive.However,itisevidentthatthereisalsoroomforimprovingthepatientexperience.ActionswillbeagreedtosupportimprovementsandthesewillbemonitoredviathePatientExperienceOperationalGroup(PEOG)

SignificantlyBETTERon 4questions

SignificantlyWORSEon 1question

Thescoresshownosignificantdifferenceon57questions

Have we improved since the 2014 survey?

Atotalof62questionswereusedinboththe2014and2015surveys.Compared to the 2014 survey, your Trust is:


> MATERNITY SURVEYIn2014,thehospitalparticipatedinthenationalmaternitysurvey.Theresultsaredisplayedbelow.Thematernityservicehasanumberofactionstheyareprogressingtocontinuallyimprovetheserviceitprovidestowomen.

How do we compare to other Trusts?

The survey showed that our Trust is:







Have we improved since the 2013 survey?

Atotalof44questionswereusedinboththe2013and2015surveys.Compared to the 2013 survey, our Trust is:


> FRIENDS AND FAMILY TEST 2015-2016 TheFriendsandFamilyTest(FFT)hasbeenimplementedinalladultinpatientareasattheTrust,aswellasoutpatientareasand,morerecently,ourchildren’sward.Attheendof2015,thehospitalchangedthecompanythatsupportstheimplementation.Asaresultofthischange,wehaveseenasignificantincreaseinresponserates,particularlyfrompatientswhohaveattendedouroutpatientclinics.Wenotonlyreceivefeedbackbytextmessageandcardsbutalsofrominteractivevoicemessaging(IVM).Resultssofarhavebeenhugelypositive.Lastyear,inouroutpatientdepartmentwereceivedveryfewresponses(68).FollowingthelaunchinJanuary2016,wehavereceived17,349responsesbasedonthe56,458surveyssent(givingaresponserateof28.3%).11,359responseshavebeenreceivedbytext,5,466byIVMand524viapostcard.91%ofourpatientswhorespondedwouldrecommendthetreatmenttheyreceivetofriendsandfamily.Havingsuchdetailedinformationwillenableustoexaminetheareasthatneedtobeimproved.

> STAFF SURVEY OneofthewaysthatwemonitorstaffengagementisthroughthenationalNHSstaffsurveywhichisconductedeachyearbytheTrust,theresultsofwhichareusedbytheCareQualityCommission(CQC),ourCommissionersandotherstoassessourperformance.InpartnershipwithourTradeUnioncolleagues,operationalcolleaguesandmedicalrepresentatives,withgovernancefromthePeopleandOrganisationalDevelopmentcommittee,thehospitaldevelopedanactionplantoaddressareasofconcern.Ourresultsarepublishednationallyonthewebsite.Inadditiontothis,wealsomonitorthefeelingsofourstaffviatheNationalStaffFriendsandFamilyTest.Forthefifthyearrunning,wesurveyedallofourstaffratherthanarandomsample,aswebelieveitisimportanttogiveallourstafftheopportunitytocomment.Ourresponseratefor2015was40%(areductionof1%on2014)andwasslightlybelowaverage(40%),althoughwereceivedalmost1500responses.Inpart,thismaybedowntotheincreasedrequirementsforustoadditionallysurveystaffthroughtheStaffFriendsandFamilyTestandotherlocalsurveystotestthetemperaturethroughouttheorganization.Of the 32 key findings:-• 4(comparedagainst11in2014)haveshownimprovementsince2014

• 17(comparedagainst1in2014)haveremainedthesame

• 1(comparedagainst15in2014)hasdeteriorated• 10(comparedagainst2in2014)cannotbecomparedduetochangesinthequestions.


Response rate 2015 compared with 2014

2014 2015Change

Trust National Average Trust National Average

ResponseRate 41% 42% 40% 41% -1%

Areas of Improvement and positive findings indicated in the best 20% of Acute TrustsAreas where staff experience has worsened compared to 2014

Future priorities

Aninitialsummaryplanhasbeendevelopedwithclearresponsibilities,suggestedexecutiveleadsandtimescalesputinplace.ThePeopleandOrganisationalDevelopmentCommitteewilloverseetheprogressoftheactionplan,withthenominatedleadspersonallyreportingintotheCommitteeonaregularbasis.Theresultsofthesurveyandtheprogressweintendtomakeduring16/17willbeanintegralelementofourworkaroundthe‘Model Hospital’andwillsupportusinmeasuringourprogressonourculturaljourney.

Quarterly Friends and Family

Eachquarter,theTrustalsoactivelyoffersallstafftheopportunitytoparticipateinasurveyaskingthefollowingquestion:

Would you recommend the Trust to your friends and family?

Staff F and F 2015/16

Countess Q1 Countess Q2National Average

Lowest Scoring

Highest Scoring

Results% 77% 88% 78.9% 48% 100%

MentalHealthTrust AmbTrust

> MANAGING AND RESPONDING TO EXTERNAL RECOMMENDATIONSDuring2015/16,theTrustreceived,monitoredandtookactiononanumberofexternalreviewstoascertainwhethertherewereanyimplicationsfortheTrust.ThesereviewswereintheformofNationalConfidentialEnquiriesintoPatientOutcomesandDeath(NCEPOD),orinvestigationreportsintoeventsinotherTrustsorhealthcareproviders.Inallcases,therearerobustsystemstoreceiveandacknowledgetheserecommendations,conductananalysis,identifyanygapsandinitiaterelevantactionplans.Thissystemissubjecttoaprogrammeofaudittoprovideassurance.


> SUMMARY HOSPITAL MORTALITY INDICATOR (SHMI)TheSHMIvaluespublishedinthelastyearare:

Year COCH SHMI ALL Trust Average Best Trust Worst Trust

Oct14-Sep15 1.04 1.03 0.69 1.26

Jul14-Jun15 1.06 0.96 0.69 1.24

Apr14-Mar15 1.05

Jan14-Dec14 1.10

Note: These values were all within the “as expected” range.ThemostrecentavailableHospitalStandardisedMortalityRatios(HSMR)isfortheperiodJanuary–December2015andis95.81.Withinthis,theHSMRforweekdayadmissionswas96.42andforweekendadmissions93.81.Therefore,wehavesuccessfullyeradicatedthegapthatsawweekendadmissionmortality,asevidencedbyHSMR,beingsignificantlyworsethanthatforweekdayadmissions.ItwasreportedintheQualityAccounts2014/15,thattheTrusthadbeenrequiredtocompilearesponsetotheCQCfollowingnotificationofamortalityoutlieralertfor‘epilepsy,convulsions’.

> PROMS – PATIENT REPORTED OUTCOME MEASURESPatientsreceiveaquestionnairebeforeandaftertheiroperationaskingabouttheirhealthandqualityoflife.Theresultsarecomparedagainsteachothertoseeifthereisanimprovement,ornot,post-operation.Therearethreewaysofmeasuring:• EQ-VAS-patientsuseavisualscaletorecordtheirhealth• EQ-5D–patientshaveachoiceofstatementstochooseonethatbestdescribestheirhealthatthetime.• OxfordHip/KneeandAberdeenvaricosevein–conditionspecificquestionse.g.askingaboutjointpain,varicoseveinskinrelatedconditionsandinterferencewithsocialanddomesticactivities.

Hip replacement 15/16 EQ-VAS EQ-5D Index Oxford hip Score

Increase 60 88.9 100

Same 20 11.1 0

Decrease 20 0 0

Knee replacement 15/16 EQ-VAS EQ-5D Index Oxford hip Score

Increase 80 80 80

Same 0 0 0

Decrease 20 20 20


Varicose Vein 15/16 EQ-VAS EQ-5D Index Aberdeen VV Question

Increase 50 80 66.7

Same 16.7 20 0

Decrease 33.3 0 33.3

Groin Hernia 15/16 EQ-VAS EQ-5D Index

Increase 40.7 61.5

Same 18.5 26.9

Decrease 40.7 11.5


QUALITY MEASURES > EFFECTIVENESS

Age readmissions within 28 days Admissions %

0-15 563 5268 10.69

16+ 2630 48145 5.46

Total 3193 53413 5.98

> ADVANCING QUALITY

Indicator Threshold April May June July Aug Sept Oct Nov Dec

Hip&Knee 92.7% 70.0% 86.0% 61.0% 72.0% 92.0% 91.0% 88.0% 78.3% Notavailable

CommunityAcquiredPneumonia

75.1% 64.0% 63.0% 80.0% 80.0% 72.0% 78.0% 61.0% 51.0% 61.7%

HeartFailure 79.3% 59.0% 55.0% 84.0% 93.0% 80.0% 82.0% 60.0% 69.0% 80.0%

AcuteMI 94.2% 65.0% 100.0% 87.0% 94.0% 94.0% 86.0% 92.0% 100.0% 93.3%

COPD 50.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

FracturedNeck ofFemur 50.0% 12.0% 6.0% 16.0% 14.0% 26.0% 21.0% 0.0% 7.0% 4.5%

Sepsis 50.0% 29.0% 36.0% 37.0% 37.0% 46.0% 26.0% 29.0% 25.0% 28.6%

AKI 50.0% X X 5.0% 0.0% 8.0% 0.0% 0.0% 10.0% 0.0%

Diabetes 50.0% 11.0% 10.0% 0.0% 15.0% 0.0% 0.0% 29.0% 0.0% 28.6%

AlcoholRelatedLiverDisease 50.0% 25.0% 20.0% 33.0% 25.0% 17.0% 43.0% 17.0% 33.0% Not

available

Note: the following data is the Trust’s audited data and may be subject to change


> RESPONSIVENESSTheTrustismandatedtoreportitsresponsivenesstopatient’sneeds.Theinformationismadeupofpatientresponsestofivequestionsaskedintheinpatientsurvey.

Year 2013/14 Countess of Chester Hospital Average from 211 Trusts Worst Best

Responsiveness% 69.2% 68.4% 58.8% 79.2%

Note: We are awaiting the next results

> MONITOR COMPLIANCE TARGETS

RAG Target Actual Comments

Infection Control Targets

R ClostridiumDifficile 24 25

R MRSA 0 3

Waiting Times

R %RTTincompletePathway 92% 90.2% Last6months

91.7%Fullyear15/16

R TotaltimeinA&E 95% 89.18%

Cancer Targets

G 14days–allcancers 93% 96.67%

G 14days-breastsymptomatic 93% 95.40%

G 31day–decisiontotreattotreatment 96% 99.30%

G 31days–subsequentsurgicaltreatment 94% 97.16%

G 31days-subsequentnon-surgicaltreatment 98% 100%

R 62days–firsttreatmentfromurgentGPreferral 85% 81.58%

G 62days–firsttreatmentfromscreeningreferral 90% 98.65%

G MonitorGovernancerating

Note: Cancer figures may change as the March figure is still un-validated

48 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST48 COUNTESSOFCHESTERHOSPITALNHSFOUNDATIONTRUST


Thishasbeenaverychallengingyearforthehospitalinmaintainingtheemergencystandardsaccessmeasureof4hours.Whilstperformancehasbeenachievedwithinthesummermonths(Quarter2),thelastsixmonthsoftheyearhaveprovenextremelydifficulttoachievethe95%standard.TheTrusthascontinuedtoworkinpartnershipwithotherhealthandsocialcareorganisationstosupporttheperformanceoftheemergencydepartmentandthetimelydischargeofpatientsintotheappropriatehealthandsocialcaresetting.Theperformancetomeetthe18weekwaitingtime(incompletepathway)standardhasbeenachallengeoverthelatermonthsoftheyear,duetoemergencypressuresandincreasingdemandonelectiveservicesaswellastheindustrialactionbythejuniordoctors.TheTrustAccessPolicyprovidestheoperationalframeworkforthemanagementofpatientswhoarewaitingforelectivetreatment.TheTrustcontinuestoproduceroutineelectivewaitingtimedata(bothinpatientandoutpatient),whichissubjecttoreviewandanalysisin-linewithgoodstandardsofcorporategovernance.

Within the final quarter of 2014/15, the Quality Account’s audit identified two issues: 1 ArequirementtoretainmonthlyvalidatedPatientTargetLists,whichwasactionedwithimmediateeffect;

2 Anissueofinterpretationrelatingto18week‘clockpauses’whichafterfurtherclarificationwasactionedandreflectedinthemanagementofthe18weekstandard.TheTrusthasclarifiedtheRTTincompletepathwayfollowingtheaudit,whichhaddemonstratedsomeerroneouslyreported‘pauses’inthepathway.Therefore,therearetwofiguresreported:-

• Thecurrentoneisthelast6monthsofdata2015/16.

• Thecommentandpercentagealongsideisthefullyearendposition,followingtheproblemnotbeingrectifiedtoasatisfactoryconclusionforthefirst6monthsof2015/16fromthepathwayasthesolutionandtrainingtoenablethisisapermanenthappenedinthefirst6monthsofthisyear.

Individualstaff,whowereinvolvedwiththecollectionandrecordingofthisdatahavebeenmadeawareoftheirresponsibilitiesandreceiveannualmandatorytraining.TheTrustcontinuedtoachieveallcancerstandardsexceptforthe62daystandardwhich,althoughthishasimprovedremainsapriority.Toimprovetheperformance,asignificantamountofworkandinvestmenthasbeenplacedintotheserviceandwhilethestandardcontinuestobedifficult,thenumberofpatientswaitingover62dayshascontinuedtoreduce.TheTrusthasmaintainedperformancewithregardtoclostridiumdifficile.Againstatargetof24casesfortheyear,theTrustendedtheyearwith25.TheTrustreported3casesofMRSAfortheyearandcontinuestoworktowardsatargetofnocasesfortheupcomingyear.


PART FOURWRITTEN STATEMENTS BY OTHER BODIES> GOVERNORS’ QUALITY ACCOUNT

STATEMENTGovernorscontinuetomonitorthequalityofsafetyandeffectivenessofthepatientandstaffexperienceattheTrust.TheyvaluetheopennessandqualityoftheinformationandpresentationsfromtheexecutiveteamandtakeeveryopportunitytochallengeandquestiontheBoardofDirectors.DuringthelastyeartheTrusthasfacedmanychallenges,withincreasingnumbersofsickandfrailpatientspresentingatthehospital,delaysindischargeof‘medicallyoptimised’patientsandfinancialconstraints,incommonwiththerestofthecountry.GovernorshavebeenkeptinformedthroughoutandarepleasedwiththesuccessoftheAmbulatoryCareUnitandthefurtherdevelopmentstoextendtheGPinvolvementwithhospitalclinicianstohelpreducethenumberofadmissions.TheestablishmentoftheCentreforHealthyAgeingbasedatEllesmerePorthospitalisalsoacknowledgedasawelcomedevelopmenttoimprovesafetyandreducethelengthofstayandneedforadmissionoffrailelderlypatients.Governorshavealsotakenaparticularinterestingatheringfeedbackfromtheexperienceofpatientsandarepleasedtonotetheconsiderableincreaseinresponsestothe‘FriendsandFamily’test.ItwasdisappointingthattheengagementeventswerenotwellattendedbuttheinputfromtheDeputyDirectorofNursingisvaluedanditispleasingthattheseeventswillcontinuewithlessonslearntforthefuture.

Theplantoestablishapeerreviewprocesstoreviewresponsestocomplaintstoensurethattheseareempathicandresponsivetotheconcernsofpatientsisaverywelcomeonewithwhichgovernorswillbepleasedtobeinvolved.GovernorsarehugelyimpressedbythegoodwillandhardworkputinbyeverymemberofstaffattheTrustandaredelightedwiththedevelopmentsinoccupationalhealth,fitnessclassesandinitiativestosupportstaffwellbeing.TheCarers’Strategywhichhasbeendevelopedtoinvolvecarersinthedeliveryofcareisimportant,particularlyasitisanopportunitytoidentifyandsupportmembersofstaffwhoarealsocarers.Itistobehopedthattheoutcomesofthesedevelopmentswillbereflectedinthenumbersandresponsestothestaffsurveyinfuture.Itwasdisappointingthattherehavebeentwo‘never’eventsduringtheyear;governorshavenotedthatthesehavebeenthoroughlyreviewedandlessonslearnedandmonitored.Whentherearesomanypressuresonstaffwhoareoften‘goingtheextramile’itisimportantthatsafetyisnotcompromisedandgovernorswillcontinuetonoteandchallengesignssuchasstaffsicknessandturnover.TheQualityAccounthighlightsthewiderangeofachievementsoftheTrustandgovernorscongratulatethoseawardedforsuccessandhardwork.ThesearechallengingtimesthroughouttheNHSandgovernorsaregratefulfortheopportunitytoreviewandcommentontheQualityAccount;theywillcontinuetomonitortheexperiencesofpatientstoimproveandensurethattheyreceivesafe,kindandeffectivecare.


Response to Quality Accounts Document – Countess of Chester Hospital (COCH)

HealthwatchCheshireWest(HWCW)valuestheopportunitytocommentonthesequalityaccounts.COCHcontinuestobethemainhospitalTrustsupportingresidentsofChester,RuralCheshireandEllesmerePort.In regard to the document Healthwatch Cheshire West would like to make the following comments:• Wefeelthattheexecutivesummariesatthebeginningofthedocumentformausefulprécis,however,wefeelthatwherepossiblehyperlinkscouldbeaddedsothatthoseindividualsreadingelectronicallyareabletofollowupawardnominationsetc.Inadditionwefeelthatmoreexplanationshouldbegiventocertainphrasese.g. ‘never event.’Whatisit?Whatlessonsaretobelearned?

• Inrelationtoawardnominations,whereappropriate,wefeelindividualsshouldbegivencredit.e.g. Craig Hough/Sue Miller (Catering Award Nomination).

• HWCWendorsestheprioritiesforimprovementsectionandinparticularthematrixexplanationfollowing;althoughwefeelaseparate“timescale”columnwouldgivegreaterstrengthtotheinformationaspresented.

• Clinical Audits –Wenotethesignificantnumberofthesedetailed;however,nodetailisgiventothereaderastoifthisisagoodthingorbadthingforthoseserviceusersusingthehospital?

• Wewouldliketoseeabriefsummaryonhowthisworkbenefitspatientoutcomesandfeelthebulletpointsofplannedactionsneedgreaterdetail–perhapssomethingsimilartothetablesusedinthe‘prioritiesforimprovement’sectionofthedocument.

• Commissioners’ goals (CQUIN) - HWCWarepleasedtoseethatsomeof

thesegoalshavebeenachievedinfull. InparticularwewouldcongratulatetheTrustonitsachievementsonidentificationdementia/delirium.

- Inrelationtothosetargetsthathaveonlybeenpartiallyachieved.Wefeelthatthisdocumentshouldincludealittlemoreinformation-toindicatetothereaderanybarriersthathavepreventedachievement.e.g. Resources and plans/actions put in place to improve this performance.

- Inrelationtothe‘appropriatesettingforneed’targetHWCWfeelthatgreaterexplanationisrequired.Wenotecommentsinrelationtotheabovemissedtargetsbutinrelationtofuturegoals,feelthatmoreinformationcouldbeincludedhere;toinformthereaderofspecificplansandactionstoimproveperformanceandadditionalinformationonwhatthechallengesareand;Whatspecificallyhascausedpatientstobe‘delayedinhospital’overtheperiod?

• From the delivery of priorities section: - WefeelthattheSkypesystemusedforsome

oftheclinicsisagoodideaandsomethingthatcouldbeexpandedanddevelopedfurther.

- Wefeelthatthissectioniscomprehensiveanddetailedbutinplaceshardtoreadwithsomeofthegraphshardtounderstand(evenwhenenlargedusingthecomputer).Somesectionshaveaclearsummaryatthebeginningofeachsection(good)othersnotsomuch.Wehopethismaybeeditedpriortopublication.

• Patient surveys: - HWCWexpressessomeconcernoverwording

choicesinrelationtosurveys.Howcantoiletsorwardsbefairly/veryclean?Wefeelthattheyarecleanornotandthattheterm‘fairlyclean’isunacceptable.

HealthwatchCheshireWestfeelsthatoverallthedocumentispositive,wellproducedandgivesagoodandfairaccountofservice.However,inordertoencouragemorepeopletoviewitscontents,wewouldliketoseelesstechnicallanguageusedinfuture;orifthiscannotbeavoided,duetosubjectmatter;asimplesummaryatendorbeginningofeachsectionandanappendixoftechnicalwordsandabbreviationsused.Inaddition,inordertogiveabroaderpictureofworkatthehospitalandsosetitsplaceinthecommunity,wewouldliketoseesomereferencetootherhospitalrelatedgoings-onincludingbuildingimprovementsandcommunityactivity,e.g. detail on the £25,000 Aviva Award November 2015.

Healthwatch Cheshire West - May 2016


WenotethecommentsfromHealthwatchandhavemadesomechanges.However,someofthetextandindicatorpresentationsarenationallymandatedsothereforeweareunabletochangetheformat.Inlightofthecommentsmade,wehavealsoreviewedtheglossaryofterms.

Countess of Chester Hospital NHS Foundation TrustMay 2016


AMI

Apr 15

40%

60%

80%

100%

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

ACS%Target

AMI

Heart Failure

Apr 15

40%

60%

80%

100%

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

ACS%Target

HF

Hip and Knee

Apr 15

40%

60%

80%

100%

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

ACS%Target

Hip and Knee Replacement

Pneumonia

Apr 15

40%

60%

80%

100%

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

ACS%Target

Pneumonia

> ADVANCING QUALITY MEASURES


COPD

Sepsis

Fractured Hip

Apr 15

Apr 15

Apr 15

20%10%0%

30%40%

60%50%

May 15

May 15

May 15

Jun 15

Jun 15

Jun 15

Jul 15

Jul 15

Jul 15

Aug 15

Aug 15

Aug 15

Sep 15

Sep 15

Sep 15

Oct 15

Oct 15

Oct 15

Nov 15

Nov 15

Nov 15

Dec 15

Dec 15

Dec 15

ACS%Target

ACS%Target

ACS%Target

COPD

Sepsis

FracturedHip

20%10%0%

30%40%

60%50%

20%10%0%

30%40%

60%50%


Diabetes

Alcohol Related Liver Disease

Acute Kidney Injury

Apr 15

Apr 15

Apr 15

May 15

May 15

May 15

Jun 15

Jun 15

Jun 15

Jul 15

Jul 15

Jul 15

Aug 15

Aug 15

Aug 15

Sep 15

Sep 15

Sep 15

Oct 15

Oct 15

Oct 15

Nov 15

Nov 15

Nov 15

Dec 15

Dec 15

Dec 15

ACS%Target

ACS%Target

ACS%Target

Diabetes

AlcoholRelatedLiverDisease

AcuteKidneyInjury

20%

20%

20%

10%

10%

10%

0%

0%

0%

30%

30%

30%

40%

40%

40%

60%

60%

60%

50%

50%

50%


20%10%0%

30%40%

60%70%80%90%

100%

EQVAS EQ-5DIndex OxfordKneescore

50%

Same

Increase

Decrease

Knee Replacement

100%

0%

20%

40%

60%

80%

EQVAS EQ-5DIndex OxfordHipscore

Same

Increase

Decrease

Hip Replacement

100%

0%

20%

40%

60%

80%

EQVAS EQ-5DIndex AberdeenVV Question

Same

Increase

Decrease

Varicose Vein

> PATIENT RECORDED OUTCOME MEASURES


100%

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

EQVAS EQ-5DIndex

Same

Increase

Decrease

Groin Hernia


APPENDIXAPPENDIX 1 - GLOSSARY & ABBREVIATIONS

Term Abbreviation Description

Accident and Emergency A&EorED TheEmergencyDepartment,usuallyatahospital.

Acute Oncology AOReferstothemanagementoftheunexpectedcareneedsofthepatientwithcancer,includingemergencysituationsandtheacutelyunwellpatient

Advancing Quality AQ

Aprogrammewhichrewardshospitalstoimprovecareonanumberofkeyareas–heartattacks,pneumonia,hipandkneereplacements,heartfailureandheartbypasssurgery–whencomparedtoresearchwhichidentifieswhatbestcareconstitutes.

Anti-microbial stewardship

Referstoasetofcoordinatedstrategiestoimprovetheuseofantimicrobialmedicationswiththegoalofenhancingpatienthealthoutcomes,reducingresistancetoantibiotics,anddecreasingunnecessarycosts.

Bacteraemia Thepresenceofbacteriaintheblood

Birthing Unit BUTheBirthingUnithasafocusonnormality,providesarelaxedenvironmenttosupportwomen’schoicesandimproveoutcomesforlowriskwomen.

Cardiac Arrhythmia CA

Alsoknownascardiacdysrhythmiaorirregularheartbeat,isagroupofconditionsinwhichtheheartbeatisirregular,toofast,ortooslow

Care Quality Commission CQC

TheindependentregulatorofhealthandsocialcareinEngland.It’saimistomakesurebettercareisprovidedforeveryone,whetherthat’sinhospital,incarehomes,inpeople’sownhomes,orelsewhere.TheCQCreplacestheHealthcareCommission.

Clostridium Difficile C-diff

Anaturallyoccurringbacteriumthatdoesnotcauseanyproblemsinhealthypeople.However,someantibioticsthatareusedtotreatotherhealthconditionscaninterferewiththebalanceof‘good’bacteriainthegut.Whenthishappens,C-diffbacteriacanmultiplyandcausesymptomssuchasdiarrhoeaandfever.

Clinical Commissioning Group

CCG ThisisthenewGPledcommissioningbodywhobuysservicesfromprovidersofcaresuchasthehospital.

Colorectal Relatingtooraffectingthecolonandtherectum.



Colposcopy Acolposcopyisaproceduretofindoutwhetherthereareabnormalcellsonorinawoman'scervixorvagina

Commissioner Apersonorbodywhobuyservices.

Commissioning for Quality and Innovations

CQUINs

CQUINisapaymentframeworkdevelopedtoensurethataproportionofaproviders’incomeisdeterminedbytheirworktowardsqualityandinnovation.Theschemewasintroducedindetail,fromimplementationtofunction,inHighQualityCareForAlltoencourageorganizationstoseequalityimprovementandinnovationasamotivatortowardsabetterservicefortheirpatients.

Criteria Led Discharge CLD

ThisisasystembywhichtheDoctorclearlydefinesthecarethatneedstobemet/treatmentdeliveredorresultsparameterstobeachievedbeforethenursecandischargethepatienthome.

Clinical Research Network CRN

TheNIHRClinicalResearchNetwork(CRN)makesitpossibleforallpatientsandhealthcareprofessionalsacrossEnglandtoparticipateinrelevantclinicaltrials.

COPD Chronicobstructivepulmonarydiseaseisthenameforacollectionoflungdiseases

Cystoscopy Thisisamedicalprocedureusedtoexaminetheinsideofthebladderusinganinstrumentcalledacystoscope

Early Supported Discharge ESD

Thisprocessisaboutputtingadditionalcareintothecommunitysettingtoenablepatientstospendashortertimeinhospitalandwherepossiblereturningtotheiroriginalplaceofresidence.

Enhanced Recovery Programme

ERP

Apathwayofcareappliedtoaprocedurerelatingtotypeofanaesthesia,typeofpost-operativepainrelief,earlierpatientmobilitypost-surgery,increasednutritionalintakepreoperativelyandassoonafterwakingaspossible,toreducerecoverytime.

Gastroenterology Thisdealswithdisordersofthestomachandintestines

Global Trigger Tool

Thisisatoolthatisusedtoreviewapatientmedicalrecordandestablishwhetheranyharmeventsoccurredduringthepatient’scareandtreatmentinhospital.Fromananalysisofalargenumberofrecordsthehospitalcanmeasureitsrateofharmandworktowardsreducingthis.

Haematology Thisisaspecialtycoveringthediagnosisandtreatmentofblooddisorders

Healthcare Associated Infections

HCAI AgenericnametocoverinfectionslikeMRSAandC-diff.



Hospital Episode Statistics HES

ThisisthenationalstatisticaldatawarehouseforEnglandofthecareprovidedbyNHShospitalsandforNHShospitalpatientstreatedelsewhere.HESarethedatasourceforawiderangeofhealthcareanalysisfortheNHS,governmentandmanyotherorganisationsandindividuals.

Intrauterine growth restriction IUGR

Referstoaconditioninwhichanunbornbabyissmallerthanitshouldbebecauseitisnotgrowingatanormalrateinsidethewomb

Laparoscopy Otherwiseknownaskeyholesurgery,isamedicalprocedureusedtoexaminetheinterioroftheabdominalorpelviccavities.

Laparotomy Thisisanymajorsurgicalprocedurethatinvolvesopeningtheabdomen

Methicillin-Resistant Staphylococcus Aureus

MRSA

Staphylococcusaureusisabacteriumwhichisoftenfoundontheskinandinthenoseofabout3in10healthypeople.Aninfectionoccurswhenthebacteriumentersthebodythroughabreakintheskin.AstrainofthisbacteriumhasbecomeresistanttoantibiotictreatmentandthisisoftenreferredtoasMRSA.

MonitorThisistheregulatorofNHSFoundationTrusts.ItisanindependentbodydetachedfromcentralgovernmentanddirectlyaccountabletoParliament.

Myocardial Infarction MI Knownmedicallyasaheartattack

National Patient Survey

Co-ordinatedbytheCareQualityCommission,itgathersfeedbackfrompatientsondifferentaspectsoftheirexperienceofcaretheyhaverecentlyreceived,acrossavarietyofservices/settings:Inpatients,Outpatients,Emergencycare,Maternitycare,Mentalhealthservices,primarycareservicesandAmbulanceservices.

National Reporting & Learning Service

NRLSThisistheNationalReportingandLearningServicewhichcollatesincidentdatafromallorganisationsnationallyandallowstrendstobeidentified.

Nephrectomy Nephrectomy(nephro=kidney,ectomy=removal)isthesurgicalremovalofakidney

NeonatologyThisisasubspecialtyofpaediatricsthatconsistsofthemedicalcareofnew-borninfants,especiallytheillorprematurenew-borninfant

Never Events Theseareserious,largelypreventablepatientsafetyincidentsthatshouldnotoccuriftheavailablepreventativemeasureshavebeenimplemented.

Obstetrics Concernedwithchildbirthandmidwifery.



Oesophago-gastro- duodenoscopy

OGDKnownmoresimplyasagastroscopyorendoscopy.Thisisanexaminationofyouroesophagus,stomachandthefirstpartofyoursmallbowelcalledtheduodenum.

Patient Recorded Outcome Measures

PROMs

Aprogrammeinwhichpatientscompleteaquestionnaireontheirhealthbeforeandaftertheiroperation.Theresultsofthetwoquestionnairescanbecomparedtoseeiftheoperationhasimprovedthehealthofthepatient.Anyimprovementismeasuredfromthepatient’sperspectiveasopposedtotheclinicians.

Percutaneous Nephrolithotomy PCNL Thisisaproceduretoremoveakidneystoneorstones.

Quality AccountThisisastatutoryannualreportofqualitywhichprovidesassurancetoexternalbodiesthattheTrustBoardhasassessedqualityacrossthetotalityofservicesandisdrivingcontinuousimprovement.

Safety Brief Thisisatoolofcommunicationusedbyclinicalstaffatwardleveltoensurerisksarehandedover

Secondary Users Service

ThisistheNHSdatasystemforrecordingallNHSpatientactivity.Itenablescorrectpaymentsbycommissioners,forcareprovidedbyallproviderservicesincludingacuteTrusts.

SepsisAlsoreferredtoasbloodpoisoningorsepticaemia, thisisapotentiallylife-threateningcondition,triggeredby aninfectionorinjury

Service Level Agreement SLA ThisisalocalcontractbetweenservicesexternaltotheTrustto

deliversharedorpartofthepatientpathway

Statement of Purpose

ThisisacareQualityCommissionrequirementofregistrationanddescribedtheaimsandobjectivesoftheserviceproviderincarryingontheregulatedactivity.Itdescribesthekindsofservicesprovidedforthepurposesofthecarryingonoftheregulatedactivityandtherangeofserviceusers’needswhichthoseservicesareintendedtomeet.

StomaAstomaisanopeningonthefrontofyourabdomen(tummy)whichismadeusingsurgery.Itdivertsyourfaecesorurineintoapouch(bag)ontheoutsideofyourbody

Venous Thrombo-embolism VTE

Thisisabloodclotdevelopingwhenapersonisinhospitalandmaynotbeasmobileastheyareusuallyorfollowingsurgery.Thebloodclotitselfisnotusuallylifethreatening,butifitcomeslooseitcanbecarriedinyourbloodtoanotherpartofyourbodywhereitcancauseproblems–thisiscalledaVenousThromboembolism(VTE).Iftheclottravelstothelungsitiscalledapulmonaryembolus(PE)anditcanbefatal.Evenifabloodclotdoesnotcomeloose,itcanstillcauselong-termdamagetoyourveins.

6Cs Care,Compassion,Competence,Communication,CourageandCommitment


INDEPENDENT AUDITOR’S REPORTTO THE COUNCIL OF GOVERNORS OF COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST ON THE QUALITY REPORT We have been engaged by the Council of Governors of Countess of Chester Hospital NHS Foundation Trust to perform an independent assurance engagement in respect of Countess of Chester Hospital NHS Foundation Trust’s Quality Report for the year ended 31 March 2016 (the ‘Quality Report’) and certain performance indicators contained therein.

> SCOPE AND SUBJECT MATTERThe indicators for the year ended 31 March 2016 subject to limited assurance consist of the following two national priority indicators (the indicators):• percentageofincompletepathwayswithin18weeksforpatientsonincompletepathwaysattheendofthereportingperiod;and

• A&E:maximumwaitingtimeoffourhoursfromarrivaltoadmission/transfer/discharge.

> RESPECTIVE RESPONSIBILITIES OF THE DIRECTORS AND AUDITORS

ThedirectorsareresponsibleforthecontentandthepreparationoftheQualityReportinaccordancewiththecriteriasetoutintheNHSFoundationTrustAnnualReportingManualandsupportingguidanceissuedbyMonitor.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:• theQualityReportisnotpreparedinallmaterialrespectsinlinewiththecriteriasetoutintheNHSFoundationTrustAnnualReportingManualandsupportingguidance;

• theQualityReportisnotconsistentinallmaterialrespectswiththesourcesspecifiedintheDetailedGuidanceforExternalAssuranceonQualityReports2015/16(‘theGuidance’);and

• theindicatorsintheQualityReportidentifiedashavingbeenthesubjectoflimitedassuranceintheQualityReportarenotreasonablystatedinallmaterialrespectsinaccordancewiththeNHSFoundationTrustAnnualReportingManualandsupportingguidanceandthesixdimensionsofdataqualitysetoutintheGuidance.

WereadtheQualityReportandconsiderwhetheritaddressesthecontentrequirementsoftheNHSFoundationTrustAnnualReportingManualandsupportingguidanceandconsidertheimplicationsforourreportifwebecomeawareofanymaterialomissions.We read the other information contained in the Quality Report and consider whether it is materially inconsistent with:• boardminutesandpapersfortheperiodApril2015to24May2016;

• papersrelatingtoqualityreportedtotheboardovertheperiodApril2015to24May2016;

• feedbackfromcommissionersMay2016:• feedbackfromgovernorsMay2016;• feedbackfromlocalHealthwatchorganisationsdatedMay2016;

• theTrust’scomplaintsreportpublishedunderregulation18oftheLocalAuthoritySocialServicesandNHSComplaintsRegulations2009;

• thelatestnationalpatientsurvey datedMay2015:

• thelatestnationalstaffsurveyreceived February2016;

• the2015/16HeadofInternalAudit’sannualopinionovertheTrust’scontrolenvironmentdatedApril2016;and


• thelatestCQCIntelligentMonitoringReportdatedMay2015.

FeedbackfromOverviewandScrutinyCommitteewasrequestedon13May2016butnotreceived.Weconsidertheimplicationsforourreportifwebecomeawareofanyapparentmisstatementsormaterialinconsistencieswiththosedocuments(collectively,the‘documents’).Ourresponsibilitiesdonotextendtoanyotherinformation.WeareincompliancewiththeapplicableindependenceandcompetencyrequirementsoftheInstituteofCharteredAccountantsinEnglandandWales(ICAEW)CodeofEthics.Ourteamcomprisedassurancepractitionersandrelevantsubjectmatterexperts.Thisreport,includingtheconclusion,hasbeenpreparedsolelyfortheCouncilofGovernorsofCountessofChesterHospitalNHSFoundationTrustasabody,toassisttheCouncilofGovernorsinreportingtheNHSFoundationTrust’squalityagenda,performanceandactivities.WepermitthedisclosureofthisreportwithintheAnnualReportfortheyearended31March2016,toenabletheCouncilofGovernorstodemonstratetheyhavedischargedtheirgovernanceresponsibilitiesbycommissioninganindependentassurancereportinconnectionwiththeindicators.Tothefullestextentpermittedbylaw,wedonotacceptorassumeresponsibilitytoanyoneotherthantheCouncilofGovernorsasabodyandCountessofChesterHospitalNHSFoundationTrustforourworkorthisreport,exceptwheretermsareexpresslyagreedandwithourpriorconsentinwriting.

> ASSURANCE WORK PERFORMED WeconductedthislimitedassuranceengagementinaccordancewithInternationalStandardonAssuranceEngagements3000(Revised)–‘AssuranceEngagementsotherthanAuditsorReviewsofHistoricalFinancialInformation’,issuedbytheInternationalAuditingandAssuranceStandardsBoard(‘ISAE3000’).Ourlimitedassuranceproceduresincluded:• evaluatingthedesignandimplementationofthekeyprocessesandcontrolsformanagingandreportingtheindicator;

• makingenquiriesofmanagement;• testingkeymanagementcontrols;

• limitedtesting,onaselectivebasis,ofthedatausedtocalculatetheindicatorsbacktosupportingdocumentation;

• comparingthecontentrequirementsoftheNHSFoundationTrustAnnualReportingManualandsupportingguidancetothecategoriesreportedintheQualityReport;and

• readingthedocuments.

Alimitedassuranceengagementissmallerinscopethanareasonableassuranceengagement.Thenature,timingandextentofproceduresforgatheringsufficientappropriateevidencearedeliberatelylimitedrelativetoareasonableassuranceengagement.Non-financialperformanceinformationissubjecttomoreinherentlimitationsthanfinancialinformation,giventhecharacteristicsofthesubjectmatterandthemethodsusedfordeterminingsuchinformation.Theabsenceofasignificantbodyofestablishedpracticeonwhichtodrawallowsfortheselectionofdifferent,butacceptablemeasurementtechniqueswhichcanresultinmateriallydifferentmeasurementsandcanaffectcomparability.Theprecisionofdifferentmeasurementtechniquesmayalsovary.Furthermore,thenatureandmethodsusedtodeterminesuchinformation,aswellasthemeasurementcriteriaandtheprecisionofthesecriteria,maychangeovertime.ItisimportanttoreadthequalityreportinthecontextofthecriteriasetoutintheNHSFoundationTrustAnnualReportingManualandsupportingguidance.Thescopeofourassuranceworkhasnot includedgovernanceoverqualityorthenon-mandatedindicator,whichwasdetermined locallybyCountessofChesterHospitalNHSFoundationTrust.


> BASIS FOR QUALIFIED CONCLUSIONAssetoutonpage47oftheTrust’sQualityReport,theTrustcurrentlyhasconcernswithaccuracyofthe“percentageofincompletepathwayswithin18weeksforpatientsonincompletepathwaysattheendofthereportingperiod”datapresentedinitsQualityReport.Forthefirstsixmonthsofthefinancialyear(April2015toSeptember2015),clockpauseswereerroneouslyincludedwithinthedataforthisindicator,whichisnotcompliantwiththeGuidance.Whilstforthesecondsixmonthsoftheyear(October2015toMarch2016)clockpauseswerecorrectlyexcluded,theGuidancerequiresthatthefigureincludedintheQualityReportisatwelve-montharithmeticaverage.Asaresultoftheseissues,weareunabletoconcludethatnothinghassometoourattentionthatcausesustobelievethatthe“percentageofincompletepathwayswithin18weeksforpatientsonincompletepathwaysattheendofthereportingperiod”indicatorfortheyearended31March2016hasbeenreasonablystatedinallmaterialrespectsinaccordancewiththeNHSFoundationTrustAnnualReportingManualandsupportingguidanceandthesixdimensionsofdataqualitysetoutintheGuidance.

> QUALIFIED CONCLUSIONBasedontheresultsofourprocedures,exceptfortheeffectsofthemattersdescribedinthe‘Basisforqualifiedconclusion’sectionabove,nothinghascometoourattentionthatcausesustobelievethat,fortheyearended31March2016:• theQualityReportisnotpreparedinallmaterialrespectsinlinewiththecriteriasetoutintheNHSFoundationTrustAnnualReportingManualandsupportingguidance;

• theQualityReportisnotconsistentinallmaterialrespectswiththesourcesspecifiedintheGuidance;and

• theindicatorintheQualityReportsubjecttolimitedassurancehasnotbeenreasonablystatedinallmaterialrespectsinaccordancewiththeNHSFoundationTrustAnnualReportingManualandsupportingguidanceandthesixdimensionsofdataqualitysetoutintheGuidance.

KPMG LLP

CharteredAccountants1StPeter’sSquare Manchester M23AE26May2016

Safe | Kind | Effective

Countess of Chester Hospital NHS Foundation Trust

LiverpoolRoad,Chester,CH21UL

www.coch.nhs.uk

quality account 2015/16 · quality account 2015/16 3 - safeguarding 34 - equality, diversity and...

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