AH ANNUAL REPORT 2018

Recommendations

Info

3.3.9 Best in Operative Care The Best in Operative Care (BIOC) group set out the below aims for 2017/18. Improvements have been achieved in all areas with some ongoing work which will continue to be tracked and supported throughout 2018/19. Comprehensive Pre-Operative Assessment Service • Develop comprehensive pre-assessment service for all patients undergoing a general anaesthetic • Review processes at other centres to provide a benchmark of pre-assessment service nationally Improving Patient Access and Flow • Simple, accurate single process booking system • Good communication throughout all phases of patient journey from clinic to theatre • Reduce inpatient bed requirements • Theatre staff involved in list planning for all specialities • Formula 1 theatre teams • Private practice Patient Safety First • Recognition and accreditation • Completion of overarching policy and risk assessment • Electronic dashboard development to provide oversight and assurance • Surgical site surveillance for all specialities • Updated approach to paediatric life support/resus training • Embed and audit use of NatSSIPs Staff Development and Well Being • 95% compliance with mandatory training and CPD requirements • Plan in place for all staff to have a qualification for the role they perform • Human factors training in place • Development of a Band 6 leadership programme and first cohert trained • Clear development plan for all staff • Improved staff survey results • Communication strategy • Staff recognition • Reduction in sickness Emergency Surgery • Senior leadership across six days • Electronic booking system • Development of a set of Emergency Surgery standards • Robust training and development plan in place for all emergency staff • Review of early bird pathway • Coordinate the line list Materials Management • Enhanced Materials Management Team • New contract for decontamination of surgical instruments • Theatre non-pay spend in line with budget • Capital replacement programme with budget • STP and HTE procurement projects Notable achievements included: • Implementation of ELIS (Emergency List Information System) across all specialties, winning the Game Changing Innovation award at the staff awards in January 2018. • Delivering human factors training to over 55% of theatre and surgical staff (from 0% in April 2017). • Pre-operative assessment delivered to 4,344 children in 17/18 (an increase of 600 patients compared to the previous year). • Reduction in never events relating to theatres. Alder Hey Children’s NHS Foundation Trust 136 Annual Report & Accounts 2017/18
When planning the workstreams for 2018/19 the focus has been on “doing the basics brilliantly” with the team wanting to lead change not just for the surgical division but with workstreams which will be far reaching and impact upon care for all patients and families attending the Trust. The metrics for improvement have been defined and presented as part of the annual plan and monitoring of these improvements will take place via the BIOC group. Pre-Operative Assessment Service • Improve safety, quality and patient experience • Reduce cancellations Incident Reporting and Management • Use of Ulysses within Theatres • Safety Culture Workforce Development • NatSips • Recruitment and Retention • CPD, Training, Career progression • Human Factors Emergency Surgery • Consolidate and further improve Emergency pathways Materials Management • Reduced incidents/ cancellations due to stock • Reduce expired stock/wastage • Reduce cost • Theatre Scheduling and Planning • Re-allocated sessions • Review under-utilised lists • Realignment of sessions 3.3.10 Equality and Diversity Alder Hey continues with its commitment to try to ensure that its services offer equal access for all communities who need to use them and that all employees experience equal opportunity in employment. This means that we actively seek to engage with patients, parents and carers, as well as members of staff, to ensure that we do not discriminate against any individual and that the diversity of each individual is valued. The principles of equality and diversity are core elements of the Trust’s stated Values, which are reinforced through the Trust’s induction programme and personal development review for all staff. We are able to monitor our performance in meeting our public sector equality duties (PSED) as required by the Equality Act 2010, the NHS Constitution, CQC inspection questions and NHS commissioners through: 1. Equality Delivery System (EDS2) that has eighteen outcomes and four goals: 1. Better Health Outcomes 2. Improved Patient Access and Experience 3. A Representative and supported workforce 4. Inclusive Leadership 2. Workforce Race Equality Standard (WRES) that has 9 indicators comparing the data for white and black & minority ethnic (BME) staff. Four are based on workforce profile data, four on data from the NHS staff survey questions and one on BME representation at board level. Aim: For Alder Hey to be an inclusive and accessible place for all to visit and work, to meet our duties and in so doing to provide the best patient care possible. Targets: From the 2016/17 Equality Objectives Plan: • To increase the representation of black and minority (BME) ethnic staff • To improve the experience of families with learning disability/autism that visit Alder Hey • To improve the involvement of patient and staff stakeholders in decision making • To improve the quality of staff data • To improve the quality of patient data • To ensure equality is embedded through the quality strategy • To broaden equality training opportunities for staff Alder Hey Children’s NHS Foundation Trust 137 Annual Report & Accounts 2017/18
Page 1:
A E H E LD Y R ANNUAL REPORT & ACCO
Page 4 and 5:
©2018 Alder Hey Children’s NHS F
Page 6 and 7:
A MESSAGE FROM OUR CHAIR AND CHIEF
Page 8 and 9:
PERFORMANCE REPORT OVERVIEW The fol
Page 10 and 11:
Teenage Cancer Trust Honorary Patro
Page 12 and 13:
OUR CQC RATINGS The Trust’s curre
Page 14 and 15:
• Applied clinical research perfo
Page 16 and 17:
The Trust’s performance against n
Page 18 and 19:
‘Alder Play’ A new approach to
Page 20 and 21:
KEY RISKS TO DELIVERY IN 2017/18 Th
Page 22 and 23:
Regulatory Ratings NHS Improvement
Page 24 and 25:
Expenditure Operating expenses tota
Page 26 and 27:
ALDER HEY USES MRI/ CT DATA TO CREA
Page 28 and 29:
Louise Shepherd CBE - Chief Executi
Page 30 and 31:
Mags Barnaby - Interim Chief Operat
Page 32 and 33:
NHS IMPROVEMENT’S WELL LED FRAMEW
Page 34 and 35:
Clinical Educators The Trust has ag
Page 36 and 37:
All complainants are offered the op
Page 38 and 39:
have resulted in Memoranda of Under
Page 40 and 41:
The Community Cluster Developed wit
Page 42 and 43:
Alder Hey’s collaborative campaig
Page 44 and 45:
accordance with Non-Executive remun
Page 46 and 47:
(R) Indicates that the individual i
Page 48 and 49:
SALARY AND PENSION ENTITLEMENTS OF
Page 50 and 51:
STAFF REPORT Analysis of Trust staf
Page 52 and 53:
approach to internal materials and
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
Page 68 and 69:
Segmentation Alder Hey has been pla
Page 70 and 71:
STATEMENT OF THE CHIEF EXECUTIVE’
Page 72 and 73:
During the year the Trust sustained
Page 74 and 75:
The Divisions report against CQC Fu
Page 76 and 77:
organisation’s ability to continu
Page 78 and 79:
Nursing, Deputy Director of Nursing
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/
Page 86 and 87: National Confidential Enquiries Par
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 102 and 103: • A Data Quality dashboard is emb
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
Page 114 and 115: • Improved the quality of room bo
Page 116 and 117: When a child has an asthma attack t
Page 118 and 119: The awards and review schedule is h
Page 120 and 121: F. The Alder Play App Aims: • To
Page 122 and 123: Developing a System of 7 Day Workin
Page 124 and 125: of staff and governors, assess each
Page 126 and 127: • Working with external organisat
Page 128 and 129: the Tate Exchange programme during
Page 130 and 131: experience. Medication errors are t
Page 132 and 133: • To complete and roll out the ne
Page 134 and 135: 3.3.8 Peri-operative Care The focus
Page 138 and 139: Improvements: • Increased the Bla
Page 140 and 141: and continues to work towards findi
Page 142 and 143: In November 2017, the National Qual
Page 144 and 145: 3.3.14 Management of Complaints and
Page 146 and 147: Target or Indicator (per 2013/14 Ri
Page 148 and 149: I would recommend the Trust’s app
Page 150 and 151: Commentary from Clinical Commission
Page 152 and 153: STATEMENT OF DIRECTORS’ RESPONSIB
Page 154 and 155: • feedback from local Healthwatch
Page 156 and 157: AN EVENING CELEBRATING THE PASSION,
Page 158 and 159: STATEMENT OF COMPREHENSIVE INCOME N
Page 160 and 161: STATEMENT OF CHANGES IN EQUITY FOR
Page 162 and 163: NOTES TO THE ACCOUNTS 1. ACCOUNTING
Page 164 and 165: 1.6 Expenditure on Other Goods and
Page 166 and 167: of Financial Position’ by the tru
Page 168 and 169: through the expected life of the fi
Page 170 and 171: Exchange gains or losses on monetar
Page 172 and 173: 3.3 Overseas Visitors (Relating to
Page 174 and 175: 5.1 Operating Expenses 2017/18 £00
Page 176 and 177: 7.1 Retirements Due to Ill-Health D
Page 178 and 179: 11. FINANCE EXPENDITURE Finance exp
Page 180 and 181: 15. PROPERTY, PLANT AND EQUIPMENT 1
Page 182 and 183: 15.3 Property, Plant and Equipment
Page 184 and 185: 20. TRADE RECEIVABLES AND OTHER REC
Page 186 and 187:
24. OTHER LIABILITIES 26. FINANCE L
Page 188 and 189:
30. OTHER FINANCIAL COMMITMENTS The
Page 190 and 191:
32.2 Carrying Values of Financial A
Page 192 and 193:
32.5 Maturity of Financial Liabilit
Page 194 and 195:
34. RELATED PARTIES (CONT’D) In a
Page 196 and 197:
KEY AUDIT MATTERS Key audit matters
Page 198 and 199:
AN OVERVIEW OF THE SCOPE OF OUR AUD
Page 200 and 201:
“A matter is significant if, in t
Page 202:
Alder Hey received visits from both
show all

AH ANNUAL REPORT 2018

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?