AH ANNUAL REPORT 2018

Recommendations

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• A Data Quality dashboard is embedded within our Data Quality Process which includes key data items from throughout the patient pathway, to monitor data quality and facilitate improvement • Workshops and refresher training sessions arranged to ensure staff are fully aware of the importance of Data Quality and the integrity of the data is accurate at source • The annual audit plan has covered a number of patient checks including - A&E waiting times - Demographic changes - Missing NHS numbers - 18 weeks Referral to Treatment (RTT) & Outcomes - Duplicate registrations - Ethnicity monitoring - Pathway starts - GP checks 2.2.9 Information Governance (IG) Toolkit Attainment Levels Alder Hey’s Information Governance Assessment Report overall score for 2017/18 was 76% and was graded as ‘satisfactory’ (green). Additionally, the Trust’s internal auditors assessed compliance with the IG Toolkit and reported ‘significant assurance’. 2.2.10 Clinical Coding Error Rate Alder Hey Children’s NHS Foundation Trust was required to undertake an Information Governance Toolkit audit during the reporting period; the error rates reported in the latest published audit for that period for diagnoses and treatment coding, i.e. clinical coding, were: • Primary Diagnoses Incorrect 4.5% • Secondary Diagnoses Incorrect 19% • Primary Procedures Incorrect 7% • Secondary Procedures Incorrect 10% The results should not be extrapolated further than the actual sample audited and the services audited during this period included: • 200 Random Finished consultant episodes 2.2.11 Learning from Deaths During the period 1st April 2017 to 31st March 2018, 65 inpatients died. This comprised the following number of deaths which occurred in each quarter of that reporting period: • 18 in the first quarter; • 16 in the second quarter; • 17 in the third quarter; • 14 in the fourth quarter. By 1st April 2018, 39 case record reviews and two investigations have been carried out in relation to the 65 deaths included in the previous paragraph. Whilst many adult trusts only conduct mortality reviews on cases where deaths are unexpected or flagged through an incident, it is the policy of Alder Hey that all inpatient deaths are reviewed. In two cases a death was subject to both a case record review and an investigation. The number of deaths in each quarter for which a case record review or an investigation was carried out was: • 18 in the first quarter; • 14 in the second quarter; • 7 in the third quarter; • 0 in the fourth quarter (due to be completed in the coming period) None (representing 0%) of the patient deaths during the reporting period are judged to be more likely than not to have been due to problems in the care provided to the patient. These numbers have been estimated using the mortality review process established in Alder Hey Children’s NHS Foundation Trust. Every child that dies in the Trust has a Hospital Mortality Group review (a group consisting of professionals from across the Trust and specialties) and usually at least one departmental review prior to this. Although there were no avoidable deaths in the reporting period over this time, that have been reviewed so far, the Trust has continued to learn from our mortality process and instituted appropriate changes (even though the issue addressed by the change was not thought to have contributed to the patient’s death). In our process, we also identify external factors impacting on the children who then die in the Trust. As part of its process, the Hospital Mortality Review Group identifies children who, with early intervention or education, may not have died. Of course, such factors are also examined by multi-agency Child Death Overview Panels (CDOP). External factors impacting on children that then die at Alder Hey include external traumatic incidents which could have been avoided (in which circumstances the conclusion of HMRG is that death could have been prevented). This is classed as an example of a ‘potentially modifiable factor’. This is also highlighted by co–sleeping resulting in a SUDI (sudden unexplained death of an infant). There is currently a campaign ongoing in Merseyside highlighting the risks of co-sleeping that should impact on the SUDI presentations Alder Hey Children’s NHS Foundation Trust 102 Annual Report & Accounts 2017/18
One example was identifying a higher number of unstable neonates being transferred from one of our referring hospitals and concluding that some transfers did not benefit the patient, who could have remained in the local hospital with the family support network readily available. We communicated this to the regional neonatal network and to the surgical team to ensure all relevant questions are asked so that the family receives the best care in the right place, which might be in the local hospital. We have ensured that our major focus on sepsis continued into the mortality reviews and that information was available to inform our quality improvement programme for sepsis. The early identification and treatment of sepsis is a Trust priority and we have established a sepsis working group to oversee the rollout of an electronic sepsis pathway across the Trust with associated teaching. The sepsis pathway is continually being reviewed and adapted to fulfill its aims. There are multiple prompts on the electronic system used in the Trust to ensure that sepsis is considered. The use of the sepsis pathway is audited monthly and any children that have been identified with sepsis with the pathway not completed are highlighted. Following feedback, the electronic system now ensures that all the vital signs must be recorded so the PEWS is automatically calculated identifying the more unwell children. This should result in a more rapid response to changes in the child’s condition. There is clear guidance for escalating concerns and the nursing team is empowered to raise their concerns further if not receiving the required response from more junior members of the medical team. We were also able to bolster senior clinical leadership on the High Dependency Unit for longer hours each day. The HDU clinical leadership is now clearly defined with the HDU consultant accepting and reviewing referrals between 0900 and1700 and the General Paediatric consultant between 1700-2200. Overnight, the senior medical doctor on site provides cover, with readily accessible phone advice from the consultant on call. We also ensured that the early warning (PEWS) system was adapted more precisely for cardiac patients. 2.3 REPORTING AGAINST CORE INDICATORS The Trust is required to report performance against a core set of indicators using data made available to the Trust by NHS Digital For each indicator the number, percentage, value, score or rate (as applicable) is presented in the table at Appendix 1. In addition, where the required data is made available by NHS Digital, a comparison of the numbers, percentages, values, scores or rates of each indicator is made, with: • The national average for the same • Those NHS Trusts with the highest and lowest for the same PART 3: OTHER INFORMATION – QUALITY PERFORMANCE IN 2017/18 3.1 QUALITY PERFORMANCE This section provides an update on the Trust’s quality performance during 2017/18, including progress against the priorities identified in the previous quality report, plus an update on specific indicators under patient safety, clinical effectiveness and patient experience. The Medical Director and Chief Nurse are jointly responsible at Board level for leading the quality agenda within the Trust, supported by the Director of Nursing, Deputy Director of Nursing and Associate Director of Risk and Governance. In addition, the Board appointed two Directors of Transformation and Clinical Effectiveness from among the consultant body during the year to strengthen the team leading the Trust’s Quality Improvement agenda. The Trust continues to maintain a strong focus on the delivery of the highest quality care with outstanding examples of clinical and non-clinical excellence. In 2017/18 we reviewed our overall Trust strategy and captured the outputs in a clear, simplified, eye-catching way, which is now extensively displayed throughout the Trust and is widely recognised by staff, thereby ensuring clarity of the Trust vision to deliver ‘a healthier future for children and young people’ (see Appendix 2). In addition, whilst maintaining the underpinning principles of the quality strategy that ‘patients will not suffer harm in our care’, ‘patients will receive the most effective evidence based care’, and ‘patients will have the best possible experience’, we have re-appraised our quality strategy and developed an updated draft quality improvement plan which forms the focus of the quality priorities for the coming year and will be the focus of a Quality Summit in May 2018, where teams of staff and parents / patients will work together to finalise our quality improvement plans for 2018/19. 2017/18 has been a strong year in terms of quality performance with the strengthening of governance arrangements, including a further embedding of the model of devolved governance giving greater ownership of local quality related matters and resulting Alder Hey Children’s NHS Foundation Trust 103 Annual Report & Accounts 2017/18
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A E H E LD Y R ANNUAL REPORT & ACCO
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©2018 Alder Hey Children’s NHS F
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A MESSAGE FROM OUR CHAIR AND CHIEF
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PERFORMANCE REPORT OVERVIEW The fol
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Teenage Cancer Trust Honorary Patro
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OUR CQC RATINGS The Trust’s curre
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• Applied clinical research perfo
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The Trust’s performance against n
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‘Alder Play’ A new approach to
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KEY RISKS TO DELIVERY IN 2017/18 Th
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Regulatory Ratings NHS Improvement
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Expenditure Operating expenses tota
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ALDER HEY USES MRI/ CT DATA TO CREA
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Louise Shepherd CBE - Chief Executi
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Mags Barnaby - Interim Chief Operat
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NHS IMPROVEMENT’S WELL LED FRAMEW
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Clinical Educators The Trust has ag
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All complainants are offered the op
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have resulted in Memoranda of Under
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The Community Cluster Developed wit
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Alder Hey’s collaborative campaig
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accordance with Non-Executive remun
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(R) Indicates that the individual i
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SALARY AND PENSION ENTITLEMENTS OF
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STAFF REPORT Analysis of Trust staf
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Page 54 and 55: EXIT PACKAGES 2016/17 Exit Package
Page 56 and 57: As in 2016, we surveyed all staff i
Page 58 and 59: NHS FOUNDATION TRUST CODE OF GOVERN
Page 60 and 61: Governor Constituency Class Term of
Page 62 and 63: Throughout our membership activitie
Page 64 and 65: Attendance at Board of Directors an
Page 66 and 67: External Audit In April 2017 new re
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Page 70 and 71: STATEMENT OF THE CHIEF EXECUTIVE’
Page 72 and 73: During the year the Trust sustained
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Page 80 and 81: THE YOUNG PEOPLE’S CANCER UNIT RE
Page 82 and 83: PART 2: PRIORITIES FOR IMPROVEMENT
Page 84 and 85: 2.1.2 Quality Improvements in 2017/
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Page 88 and 89: 2.2.4 Actions arising from Local Cl
Page 90 and 91: Local Audit Retrospective Audit of
Page 92 and 93: Local Audit How often are high ferr
Page 94 and 95: Local Audit Emollient and bath pack
Page 96 and 97: Local Audit Has the introduction of
Page 98 and 99: The Quality Account deals with rese
Page 100 and 101: Indicator Indicator Description Tar
Page 104 and 105: in improved ward to board reporting
Page 106 and 107: Clinical Incidents Reported 2013/14
Page 108 and 109: Reducing Hospital Acquired Infectio
Page 110 and 111: 3.3.2 PRIORITY 2 - Increase Engagem
Page 112 and 113: Are you: 95 17% 8 1% Parent/Carer P
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Page 120 and 121: F. The Alder Play App Aims: • To
Page 122 and 123: Developing a System of 7 Day Workin
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Page 134 and 135: 3.3.8 Peri-operative Care The focus
Page 136 and 137: 3.3.9 Best in Operative Care The Be
Page 138 and 139: Improvements: • Increased the Bla
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Page 142 and 143: In November 2017, the National Qual
Page 144 and 145: 3.3.14 Management of Complaints and
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Page 150 and 151: Commentary from Clinical Commission
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STATEMENT OF DIRECTORS’ RESPONSIB
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• feedback from local Healthwatch
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AN EVENING CELEBRATING THE PASSION,
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STATEMENT OF COMPREHENSIVE INCOME N
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STATEMENT OF CHANGES IN EQUITY FOR
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NOTES TO THE ACCOUNTS 1. ACCOUNTING
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1.6 Expenditure on Other Goods and
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of Financial Position’ by the tru
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through the expected life of the fi
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Exchange gains or losses on monetar
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3.3 Overseas Visitors (Relating to
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5.1 Operating Expenses 2017/18 £00
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7.1 Retirements Due to Ill-Health D
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11. FINANCE EXPENDITURE Finance exp
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15. PROPERTY, PLANT AND EQUIPMENT 1
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15.3 Property, Plant and Equipment
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20. TRADE RECEIVABLES AND OTHER REC
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24. OTHER LIABILITIES 26. FINANCE L
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30. OTHER FINANCIAL COMMITMENTS The
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32.2 Carrying Values of Financial A
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32.5 Maturity of Financial Liabilit
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34. RELATED PARTIES (CONT’D) In a
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KEY AUDIT MATTERS Key audit matters
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AN OVERVIEW OF THE SCOPE OF OUR AUD
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“A matter is significant if, in t
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Alder Hey received visits from both
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AH ANNUAL REPORT 2018

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