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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
4 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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
5QUALITY ACCOUNT 2015/16
• 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
6 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
• 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
7QUALITY ACCOUNT 2015/16
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
8 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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.
9QUALITY ACCOUNT 2015/16
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)
Aim Rationale Monitored Measured
Usingthegovernorstoestablishapeerreviewprocesstoreviewcomplaintresponses
Toensurethatresponsesareempatheticandresponsivetopatientconcerns
Patient Experience OperationalGroup Bythereturnrate
Attendanumberofestablishedserviceuserssupportgroups
Gainabetterunderstandingoftheviewsofourserviceusers
Patient Experience OperationalGroup
Obtainfeedbackandfactorintoproposedservicedevelopments
Reviewthecarerstrategymeasures
Toensurethestrategyiseffective
Patient Experience OperationalGroup Satisfactionaudit
Effectiveness- (#Effective)
Aim Rationale Monitored Measured
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
11QUALITY ACCOUNT 2015/16
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
12 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
> 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
13QUALITY ACCOUNT 2015/16
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
14 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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.
15QUALITY ACCOUNT 2015/16
> 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
16 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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.
17QUALITY ACCOUNT 2015/16
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
18 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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
19QUALITY ACCOUNT 2015/16
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
20 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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
22 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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.
23QUALITY ACCOUNT 2015/16
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.
24 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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.
25QUALITY ACCOUNT 2015/16
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.
26 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
> 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.
27QUALITY ACCOUNT 2015/16
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
28 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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
29QUALITY ACCOUNT 2015/16
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.
30 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
> 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)
31QUALITY ACCOUNT 2015/16
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
32 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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.
33QUALITY ACCOUNT 2015/16
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.
34 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
> 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.
35QUALITY ACCOUNT 2015/16 35QUALITYACCOUNT2015/16
36 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
> 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.
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> 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.
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> 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.
39QUALITY ACCOUNT 2015/16
• 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
40 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
> 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:
41QUALITY ACCOUNT 2015/16
> MATERNITY SURVEYIn2014,thehospitalparticipatedinthenationalmaternitysurvey.Theresultsaredisplayedbelow.Thematernityservicehasanumberofactionstheyareprogressingtocontinuallyimprovetheserviceitprovidestowomen.
How do we compare to other Trusts?
The survey showed that our Trust is:
SignificantlyBETTERon 2questions
SignificantlyWORSEon 0question
Thescoresshownosignificantdifferenceon42questions
SignificantlyBETTERon 12questions
SignificantlyWORSEon 1question
Thescoresshownosignificantdifferenceon38questions
Have we improved since the 2013 survey?
Atotalof44questionswereusedinboththe2013and2015surveys.Compared to the 2013 survey, our Trust is:
42 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
> 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.
43QUALITY ACCOUNT 2015/16
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.
44 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
> 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
45QUALITY ACCOUNT 2015/16
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
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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
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> 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
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49QUALITY ACCOUNT 2015/16
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.
50 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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.
51QUALITY ACCOUNT 2015/16
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
52 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
WenotethecommentsfromHealthwatchandhavemadesomechanges.However,someofthetextandindicatorpresentationsarenationallymandatedsothereforeweareunabletochangetheformat.Inlightofthecommentsmade,wehavealsoreviewedtheglossaryofterms.
Countess of Chester Hospital NHS Foundation TrustMay 2016
53QUALITY ACCOUNT 2015/16
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
54 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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%
55QUALITY ACCOUNT 2015/16
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%
56 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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
57QUALITY ACCOUNT 2015/16
100%
0%10%20%30%40%50%60%70%80%90%
EQVAS EQ-5DIndex
Same
Increase
Decrease
Groin Hernia
58 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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.
59QUALITY ACCOUNT 2015/16
Term Abbreviation Description
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.
60 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
Term Abbreviation Description
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.
61QUALITY ACCOUNT 2015/16
Term Abbreviation Description
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
62 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
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
63QUALITY ACCOUNT 2015/16
• 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.
64 COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST
> 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
65QUALITY ACCOUNT 2015/16 65QUALITYACCOUNT2015/16
Safe | Kind | Effective
Countess of Chester Hospital NHS Foundation Trust
LiverpoolRoad,Chester,CH21UL
www.coch.nhs.uk