AH ANNUAL REPORT 2018

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PART 2: PRIORITIES FOR IMPROVEMENT AND STATEMENTS OF ASSURANCE FROM THE BOARD 2.1 PRIORITIES FOR IMPROVEMENT This section of the report describes an overview of the Trust’s plans for continuous quality improvement and specifically details the key quality improvement priorities for 2018/19, including the rationale for selection of the priorities. 2.1.1 Priorities for Improvement in 2018/19 The Trust’s five year quality strategy, ‘Inspiring Quality’, maintains a strong focus on patient safety, patient experience and clinical effectiveness, plus recognises the significance of staff health and wellbeing and our environment in supporting the delivery of a high quality service. The past year has included a refresh of the quality strategy with a view to further strengthening our approach to quality improvement. In doing so we have examined our performance over the past three years in which we adopted the Sign up to Safety pledge and delivered significant improvements in incident reporting, medication errors and hospital acquired infections. We will maintain a strong focus on these areas for further improvement in 2018/19. We have also consulted with our key stakeholders to gain their views on where our quality improvement efforts should lie in the coming year. This included discussions within the Trust through the Clinical Quality Assurance Committee (CQAC), Operational Delivery Group (ODG) and Divisional teams, as well as discussions with the Children & Young People’s Forum, Parents’ Forum, Council of Governors and Healthwatch organisations. A draft Quality Improvement Plan was constructed and this will be further developed in May 2018 through a Quality Summit, where we will invite staff from all departments and services to come together with patients and families to refine our Quality Improvement plan and strive to create a culture of quality improvement every day. Details of the specific priorities for 2018/19, as identified in the draft Quality Improvement Plan are provided in the following tables. It should be noted that the fine detail of these priorities may be modified following further consultation with a wider group of staff and with patients and families at the Quality Summit in May 2018. Priority 1 Rationale Measuring Monitoring & Reporting Children and Families First, Every Time The vast majority of patient feedback we receive is extremely positive, however there are some areas of dissatisfaction identified through engagement with children and families and through patient surveys. As an organisation we strive to ensure that we always put the children and families at the centre of everything we do, ensuring they are involved in decisions about the care they receive. We will seek to create more opportunities for children, young people and families to work in partnership with Trust staff in collaborative teams to co-design service improvements. In particular we plan to further improve our outpatient care and booking systems, ensuring we put children and families first, every time. The Trust Board agree that there should be specific focus on: • Improving outpatient care • Improving access to services through brilliant booking systems Successful delivery of this priority will be measured through patient survey feedback, including a focus on satisfaction with outpatient care and satisfaction with the booking system when given an appointment. Final metrics will be agreed following the Quality Summit in May 2018. Once metrics are confirmed, they will be monitored through the corporate report, which is available through the Trust’s electronic information channel, Infofox, and is formally presented to Clinical Quality Steering Group, with exception reports being shared with Clinical Quality Assurance Committee and ultimately Trust Board. Alder Hey Children’s NHS Foundation Trust 82 Annual Report & Accounts 2017/18
Priority 2 Rationale Measuring Monitoring & Reporting No Preventable Harms or Deaths The Trust has made significant improvements in reducing the amount of harm being caused to patients, with medication errors causing harm being reduced by 75% and hospital acquired infections being reduced by over 45%. Patient safety remains a top priority for the Trust with the acknowledgement that there is always room for further improvement. Specific focus will be given to early intervention when patients begin to deteriorate unexpectedly, and to reducing the number of hospital acquired pressure ulcers. The Trust Board agree that there should be specific focus on: • Achieving zero preventable deaths in hospital • Early intervention for the deteriorating patient • Reduction in preventable pressure ulcers The number of preventable deaths will be taken as a high level proxy for this measure. Compliance with the national sepsis standards and the number of Grade 3 and 4 pressure ulcers will also be measured. The monthly corporate report will be used to monitor and report progress against these measures. This is reported through to Clinical Quality Assurance Committee and Trust Board. Sepsis standards are also reported nationally and form part of the quality contract with commissioners. Priority 3 Rationale Measuring Monitoring & Reporting Outstanding Clinical Outcomes for Children The Trust is proud to be world leading in many areas of developing paediatric outcome measures and recognises there are further opportunities to develop and improve our monitoring of clinical outcomes. Part of this commitment links to the Trust’s desire to reduce variation and to strengthen standardisation of clinical pathways, thereby ensuring the best evidence based pratice is embedded and spread across the organisation. As a Global Digital Exemplar, the Trust is already committed to digitising clinical pathways and standardising documentation, using best practice as evidenced in NICE guidance and National Standards. This will form part of our priority to deliver outstanding clinical outcomes for children. Specific focus will also be given to further reducing hospital acquired infections as a key measure of improved clinical outcome. The Trust Board agree that there should be specific focus on: • Developing digitised clinical pathways • Developing and improving outcomes in each specialty • Reduction in hospital acquired infections The Trust will track the number of standardised / digitised pathways, plus bespoke outcome measures in each specialty. The number of hospital infections will also be used to demonstrate improvement in clinical outcomes. Evidence based, digitised care pathways will continue to be monitored through the bespoke Global Digital Excellence Steering Group and reported to the Trust’s Programme Board. Hospital Acquired Infections will be closely monitored by the Trust’s Infection Prevention and Control team and tracked monthly through the Trust’s corporate report, reporting ultimately to Clinical Quality Assurance Committee and Trust Board. Alder Hey Children’s NHS Foundation Trust 83 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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Page 36 and 37: All complainants are offered the op
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Page 44 and 45: accordance with Non-Executive remun
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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
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Page 66 and 67: External Audit In April 2017 new re
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Page 70 and 71: STATEMENT OF THE CHIEF EXECUTIVE’
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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
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• To complete and roll out the ne
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3.3.8 Peri-operative Care The focus
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3.3.9 Best in Operative Care The Be
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Improvements: • Increased the Bla
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and continues to work towards findi
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In November 2017, the National Qual
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3.3.14 Management of Complaints and
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Target or Indicator (per 2013/14 Ri
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I would recommend the Trust’s app
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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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