Lancashire Teaching Hospitals NHS Foundation Trust. Quality Account Excellent care with compassion

Transcription

1 Lancashire Teaching Hospitas NHS Foundation Trust Lancashire Teaching Hospitas NHS Foundation Trust Quaity Account Exceent care with compassion 1 Exceent care with compassion

2 Annua report and accounts Contents Chief Executive s Statement... 4 Priorities for Improvement... 5 Statements of Assurance... 7 from the Board Participation in Cinica Audits... 8 Research Goas Agreed with Commissioners Registration with the Care Quaity Commission Quaity of Data...21 Review of Quaity Performance Safe Care Effective Care Experience of Care Performance Against Key Nationa Priorities Care Quaity Commission Compiance Annexes Independent Auditor s Report to the Counci of Governors of Lancashire Teaching Hospitas NHS Foundation Trust on the Quaity Report Contact Detais Exceent care with compassion 2

3 Lancashire Teaching Hospitas NHS Foundation Trust The Estates Directorate has been awarded the government s Customer Service Exceence Standard Award for our hote services 3 Exceent care with compassion

4 Annua report and accounts Chief Executive s Statement This report provides an overview of the quaity of services provided at Lancashire Teaching Hospitas NHS Foundation Trust for the period Apri 2013 to March Our Safety and Quaity Strategy - Safe, Reiabe and Compassionate has been revised during and sets out our ambitions and intention to deiver quaity improvements in a transparent and measurabe way. This strategy seeks to buid on the important work undertaken in recent years and describes the means through which we wi achieve our goas. We recognise that we must continue to focus on those areas of improvement that remain fundamentay crucia to the deivery of safe, reiabe and compassionate care. We recognise that the heathcare andscape continues to evove and that our strategy needs to be sensitive to and earn from the experiences of staff, patients and their famiies both here at Lancashire Teaching Hospitas and esewhere. I remain, as aways, gratefu for the continuing commitment and contribution of patients, staff, governors and members in supporting quaity improvement activities at the trust, especiay during these chaenging times. There were 4 cases of MRSA bacteraemia during against a nationay set target of zero. We remain committed to achieving zero MRSA bacteraemias in In doing so we wi continue to focus on achieving and maintaining best practice around management of infusions, appropriate antimicrobia treatment, safe care of patients with urinary catheters and screening and treatment of patients with MRSA. Athough we did not achieve our objective for the reduction in Costridium difficie infection during , we continue to achieve year-on-year reductions. However, we recognise the need for sustained effort in ensuring that the rate continues to fa during , and continue to find areas for improvement wherever we can. Costridium difficie performance, aong with issues reated to achievement of referra to treatment targets has triggered an investigation by Monitor. Whist this process is not yet compete we have introduced a programme of measures that we are confident wi ead to improvement. The resuts of the 2013 nationa inpatient survey show some improvement when compared to 2012 resuts. The introduction of the friends and famiy test has provided some highy positive feedback with 93% of patients stating they woud recommend the ward or emergency department to friends and reatives who needed simiar treatment. Our net promoter scores for our emergency department are higher than the nationa median with inpatient scores on a par. It is aso peasing to note the improvements highighted in this year s staff survey, incuding the responses to the friends and famiy question. For the second time, the quaity of cinica coding data was recognised and our coding team received a nationay recognised award for data quaity. In addition, our research and deveopment team won the Cinica Innovation category at the North West Exceence in Suppy Awards 2013, for the deveopment of a new disposabe femae urina. The Estates Directorate has been awarded the government s Customer Service Exceence Standard Award for our hote services. The award is in recognition of the high standard of services the team provides across a range of our hote services, incuding domestic services, catering, porters, transport, security, and inen services. The Adut Oxygen Assessment Team was awarded the tite of team of the year at the North West Respiratory Awards. The team were assessed on how we their work deivered the QIPP agenda for Quaity, Innovation, Productivity and Prevention. Dr Martin Myers, Consutant Heathcare Scientist in Biochemistry and Cinica Director of Pathoogy Services was awarded an MBE for services to heathcare. A nationa award for improving treatment for breast cancer patients was presented by NHS Improvement to our breast care speciaist nurses for the impementation of a 23 hour breast service, which has reduced the ength of hospita stay for breast cancer patients from five days to one day foowing surgery. In addition to the teams and individuas mentioned here, I am proud to share within this account some exceent exampes of the innovation, commitment and achievements of our staff who have demonstrated that they isten and respond to the needs of our patients and their famiies. That commitment is refected in the engagement of staff year-on-year in our quaity awards, where this year we saw 53 innovative quaity improvement projects submitted by staff, a fantastic achievement. In summary, I am peased to present the Quaity Accounts. The information provided represents an accurate account of progress and highights achievements as we as areas that need to improve. More importanty it is an opportunity to reaffirm the trust commitment to improving the patient experience and outcomes of care as a priority for a staff. I am confident that the information contained within this report is accurate. The trust s interna auditors wi review the processes and mechanisms through which data is extracted and reported in the Quaity Account Report to provide further assurance. Karen Partington Chief Executive Exceent care with compassion 4

5 Lancashire Teaching Hospitas NHS Foundation Trust Priorities for Improvement Our Safety and Quaity Strategy; Safe, Reiabe and Compassionate was deveoped in conjunction with staff, patients, the pubic and governors. This strategy set out a number of ambitious, measurabe, patient-centred safety and quaity improvement goas. The key strategic goas to be achieved were: 15% reduction in inpatient mortaity 15% improvement in patient safety Year-on-year improvement in the patient experience This account provides detais of performance in reation to these goas over the ife of the strategy and specificay during The Hospita Standardised Mortaity Ratio reduced by a further 1.2% in , cuminating in a 18.2% improvement against the strategy baseine figure from , with a further 2.6 point improvement during (subject to competion of the dataset and nationa rebasing). During , there was significant reduction in harm events associated with fas (37% reduction), medication administration errors (20% reduction) and hospita acquired pressure ucers where incidence reduced by 57%. During , the number of inpatient fas and harm associated with fas increased ony sighty compared to performance and may be refective of an increase in activity and patient risk, with (with 5.48 fas per 1000 bed days and 1.19 harm events per 1000 bed days). Further reductions have been demonstrated in respect of avoidabe pressure ucers (there were a tota of 120 patients with hospita acquired pressure ucers, compared to 125 during ) and medication administration errors (the trust reduced harm associated with medicine administration errors by 32%, with 17 recorded harm events against a trajectory of 24). Athough we faied to achieve its nationa objective of 41 during 2013/14, the 55 cases of Costridium difficie represent a 15% reduction in rates compared to Performance in respect of MRSA bacteraemia is consistent with with a tota of 4 cases. In addition, we maintained high eves of engagement and performance with a eements of the Safety Thermometer programme with a year-end performance eve of 97.13% harm-free hospita care, comparing very favouraby with the nationa performance rate. Comprehensive detai reating to a aspects of infection prevention and contro is provided in the Infection Prevention and Contro Annua Report which is pubished separatey. Patient feedback generated through our Empowering Quaity Improvement for Patients (EQIP) programme has demonstrated high eves of positive feedback across the majority of services, whist patient surveys and cancer surveys have aso shown areas of improvement. The strategy has now been reviewed and revised during , with the principes of safe, effective care and a positive experience remaining fundamentay centra. However, the key indicators have evoved in response to changing oca and nationa priorities and performance against these wi be incuded in the Quaity Accounts. These themes and indicators were again seected foowing a period of consutation and engagement with trust membership, cinica staff, the governingcounci, managers and commissioning coeagues, and wi continue to define the focus of our quaity priorities over the next three years. Within the previous strategy, the organisation of care focused primariy on access to services, efficient deivery of care and management of discharge process. We recognise that the consistent deivery of safe, reiabe and compassionate care reies on more than process. Safe, reiabe and compassionate describes the means by which we wi deveop and sustain the necessary cuture to support deivery of the highest standards of care and treatment. This wi be achieved through: 5 Exceent care with compassion

6 Annua report and accounts Safe, reiabe and compassionate describes the means by which we wi deveop and sustain the necessary cuture to support deivery of the highest standards of care and treatment The strengthening of shared purpose and vaues Further investment in effective eadership at a eves The estabishment and embedding of cear principes and systems supporting accountabiity The ongoing deveopment of a skied and knowedgeabe workforce A strong organisationa focus on improvement The key strategic objectives for the revised strategy are as foows: - Achievement of 98% harm-free hospita care and sustained performance as it reates to: Inpatient fas Pressure ucers Venous thromboemboism, and Catheter associated urinary tract infection - A reduction in the trust inpatient mortaity ratio of 15% over the ife of the strategy - Achieving and sustaining 90% positive patient feedback reating to the overa experience of care and treatment within the trust Deivery of these objectives wi be achieved by a programme of improvement activity deveoped and progress and performance monitored and reported via the three trust improvement groups estabished for this purpose. The groups wi periodicay report on performance and progression of the improvement programmes to our Safety and Quaity Committee. Performance against the three strategic objectives wi aso be pubished in the monthy trust performance dashboard that is avaiabe to the pubic via the trust website. Exceent care with compassion 6

7 Lancashire Teaching Hospitas NHS Foundation Trust Statements of Assurance from The Board During the Lancashire Teaching Hospitas NHS Foundation Trust provided and/or sub-contracted 40 reevant heath services. Lancashire Teaching Hospitas NHS Foundation Trust has reviewed a the data avaiabe to them on the quaity of care in a of these reevant heath services. generated from the provision of reevant heath services by the Lancashire Teaching Hospitas NHS FoundationTrust for The income generated by the reevant heath services reviewed in represents 100 per cent of the tota income 7 Exceent care with compassion

8 Annua report and accounts Participation in Cinica Audits During nationa cinica audits 1 and 3 nationa confidentia enquiries covered reevant heath services that Lancashire Teaching Hospitas NHS Foundation Trust provides. During Lancashire Teaching Hospitas NHS Foundation Trust participated in 97% nationa cinica audits and 100% nationa confidentia enquiries of the nationa cinica audits and nationa confidentia enquiries which it was eigibe to participate in. The nationa cinica audits and nationa confidentia enquiries that Lancashire Teaching Hospitas NHS Foundation Trust was eigibe to participate in during are as foows: Cinica Audit Nationa cinica audit Acute coronary syndrome or Acute myocardia infarction (MINAP) Adut community acquired pneumonia Adut critica care (ICNARC) Bowe cancer (NBOCAP) Bronchiectasis Chronic obstruction pumonary disease Diabetes (Adut) ND(A), incudes nationa diabetes inpatient audit (NADIA) Diabetes (Paediatric) Eective surgery PROMS Emergency use of oxygen Epiepsy 12 (chidhood epiepsy) Round 2 Fas and fragiity fractures audit programme, incudes nationa hip fracture database Head and neck oncoogy (DAHNO) Heart faiure Infammatory bowe disease Lung cancer (NLCA) Moderate or severe asthma in chidren (care provided in emergency departments) Nationa audit of dementia audit Nationa audit of seizure management (NASH) Nationa cardiac arrest audit (NCCA) Nationa comparative audit of bood transfusion Nationa emergency aparotomy audit (NELA) Nationa joint registry (NJR) Nationa vascuar registry, incuding CIA and eements of NVD (NVR) Neonata intensive and specia care (NNAP) Non-invasive ventiation - aduts Oesophago-gastric cancer (NAOGC) Exceent care with compassion 8

9 Lancashire Teaching Hospitas NHS Foundation Trust Nationa cinica audit Paediatric asthma Paracetamo overdose (care provided in emergency departments) Prostate cancer Rena repacement therapy (Rena Registry) Stroke nationa audit programme (combined Sentine and SINAP) Severe sepsis & septic shock Trauma (TARN) 1 List of nationa cinica audits as per specification provided by the DH cited on the HQIP website ( Nationa Confidentia Enquiries Cinica outcome review programmes/nationa confidentia enquiries Chid heath programme CHR-UK Materna, infant and new-born cinica outcome review programme MBRRACE-UK Medica and surgica programme: Nationa Confidentia Enquiry into Patient Outcome and Death NCEPOD: Tracheostomy care study Lower imb amputation study Gasterointestina haemorrhage study 9 Exceent care with compassion

10 Annua report and accounts The nationa cinica audits and nationa confidentia enquiries that Lancashire Teaching Hospitas NHS Foundation Trust participated in during are as foows: Cinica Audit Nationa cinica audit Acute coronary syndrome or Acute myocardia infarction (MINAP) Adut community acquired pneumonia Adut critica care (ICNARC) Bowe cancer (NBOCAP) Bronchiectasis Chronic obstruction pumonary disease Diabetes (Adut) ND(A), incudes nationa diabetes inpatient audit (NADIA) Diabetes (Paediatric) Eective surgery PROMS Emergency use of oxygen Epiepsy 12 (chidhood epiepsy) Round 2 Fas and fragiity fractures audit programme, incudes nationa hip fracture database Head and neck oncoogy (DAHNO) Heart faiure Infammatory bowe disease Lung cancer (NLCA) Moderate or severe asthma in chidren (care provided in emergency departments) Nationa audit of dementia audit Nationa audit of seizure management (NASH) Nationa cardiac arrest audit (NCCA) Nationa comparative audit of bood transfusion Nationa emergency aparotomy audit (NELA) Nationa joint registry (NJR) Nationa vascuar registry, incuding CIA and eements of NVD (NVR) Neonata intensive and specia care (NNAP) Non-invasive ventiation aduts Oesophago-gastric cancer (NAOGC) Paediatric asthma Paracetamo overdose (care provided in emergency departments) Prostate cancer Rena repacement therapy (Rena Registry) Stroke nationa audit programme (combined Sentine and SINAP) Severe sepsis & septic shock Trauma (TARN) Trust participation? - study not coecting data - study not coecting data No to ND(A) to NADIA - study not coecting data - study not coecting data Note: pease see Gossary for an expanation of the abbreviations. Exceent care with compassion 10

11 Lancashire Teaching Hospitas NHS Foundation Trust Nationa Confidentia Enquiries Cinica outcome review programmes/nationa confidentia enquiries Chid heath programme CHR-UK Materna, infant and new born cinica outcome review programme MBRRACE-UK Medica and surgica programme: Nationa Confidentia Enquiry into Patient Outcome and Death NCEPOD: Tracheostomy care study Lower imb amputation study Gasterointestina haemorrhage study Trust participation? but no patient identified who compy with incusion criteria The nationa cinica audits and nationa confidentia enquiries that Lancashire Teaching Hospitas NHS Foundation Trust participated in, and for which data coection was competed during 2013/14, are isted beow aongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Tite Cinica cases required Actua number submitted Acute coronary syndrome or Acute myocardia infarction Roing no sampe size specified RPH submissions to date CDH - 76 submissions to date Bowe cancer Roing no sampe size specified 236 submissions to 2013 annua report (pubished Juy 2013) COPD COPD admissions between 1st February and 30th Apri Deadine for submission 31st May 2014 Data coection in progress Nationa Diabetes Inpatient Audit (NaDIA) Inpatient diabetes patients between 16th - 20th Sept 2013 CDH - 37 patients RPH - 92 patients Diabetes (Paediatric) A appicabe cases 188 Nationa Eective Surgery (PROMS) No set number of questionnaires for competion, as patients met criteria Apri - Sept 2013 atest quartery pubications (Feb 2014) 48 Emergency use of oxygen Min of 1 ward Submitted data from 10 wards 100% Epiepsy 12 (chidhood epiepsy) Round 2 No set number 10 (up to October 2013) Hip fracture database Roing - no set number, as met criteria 399 submitted to 6th March 2014 Head and neck oncoogy Roing no sampe size specified 128 submitted to 8th annua report (pubished Juy 2013) Heart faiure Roing - at east 20 cases per month RPH patients (189%) CDH patients (101%) Infammatory bowe disease Admissions between 1st January and Submitted 45 admissions (67%) 31st December 2013 Lung cancer Roing no sampe size specified 244 submitted to annua report pubished December 2013 Moderate or severe asthma in chidren (care provided in emergency departments) 50 cases between 1st August 2013 and 31st March 2014 Nationa audit of seizure management (NASH) 30 admissions 30 (100%) Working towards submitting 50 cases by 31st March 2014 not enough cases yet 11 Exceent care with compassion

12 Annua report and accounts Tite Cinica cases required Actua number submitted Cardiac arrest No set number, as met criteria RPH - 79 CDH - 36 Nationa emergency aparotomy audit (NELA) No set number, as met criteria 55 Nationa joint registry (NJR) 768 reevant procedures undertaken 671 forms submitted (87.4%) Nationa vascuar registry, incuding CIA and eements of NVD (NVR) No set number, as met criteria The 2 atest reports we pubished were on carotid endarterectomy in October 2013 and on abdomina aortic aneurysm (AAA) in November Submissions as foows: 50/52 (96%) of carotid cases. 152/157 (97%) of eective infra-rena AAA Neonata intensive and specia care (NNAP) A babies during the period audited 534 (100%) Non-invasive ventiation Minimum of 1 17 (1700%) Oesophago-gastric cancer Ongoing 52 submitted to 2013 report Paediatric asthma 3 8 (267%) Paracetamo overdose (care provided in emergency departments) 50 cases between 1st August 2013 and 31st March cases coected wi be submitted by 31st March (100%) Rena registry Roing October 2012 October patients (100% of new patients) Stroke nationa audit programme (combined Sentine and SINAP) A stroke admissions 678 cases up to 10th March 2014 Severe sepsis and septic shock 50 cases between 1st August 2013 and 31st March cases coected wi be submitted by 31st March (100%) Trauma Roing TARN (RPH ony) Tota No of submitted cases through (117%) Exceent care with compassion 12

13 Lancashire Teaching Hospitas NHS Foundation Trust The reports of a nationa cinica audits were reviewed by the provider in and Lancashire Teaching Hospitas NHS Foundation Trust intends to take the foowing actions to improve the quaity of heathcare provided. Tite of audit Audit of Nationa Neonata Audit Programme (Chid Heath) Nationa Paediatric Diabetes Patient & Parent Reported Experience Measures (PREM) ( Chid Heath) Intended actions The data coection method wi be reviewed. Ongoing extended staff training to be provided to band 5, 6 & 7 nurses and tier 1, 2 & 3 doctors. Reguar scrutiny of data by domain ead, neonata ead, matron and administration staff. Rea time data insertion on Retinopathy of prematurity by ophthamoogist. More nursing staff have been added to the team and a business pan has been deveoped to add dedicated psychoogica support (0.6 WTE) to the team. The duration of cinic appointment time has been increased from 15 minutes to 30 minutes per patient. Annua 1:1 dietician review is avaiabe for a patients to provide information regarding carbohydrate counting. Nationa Audit of Seizure Management in Hospitas (NASH) Trauma Improved patient information through pump awareness evening hed in January 2014 and new etters sent to a patients. The Emergency Department (ED) has set up a first fit service for patients who present to the ED having had a first fit. Suitabe patients are referred directy from the ED for an outpatient appointment with the Neuroogy Team. Patients are then discharged from the ED with advice regarding their condition and sent an appointment to the speciaist cinic within 2 weeks of the referra being made. The trust has consistenty been above the nationa average for the quaity of data input to TARN and this is due to a vast improvement in the documentation of trauma cases and the introduction of a dedicated data manager working cosey with consutants. A deaths with a percentage surviva chance of over 75% are reviewed in the trauma cinica reference group aongside a the acute speciaty eads that are invoved in trauma. As we as numerous earning points and changes in practice, this has provided insight into the points at which the department interacts with others, and how this can be done seamessy in the future. 13 Exceent care with compassion

14 Annua report and accounts NCEPOD Studies Study tite Study period Report pubication date Subarachnoid Haemorrhage Acoho Reated Liver Disease A review of the care of adut (>16 years od) patients who were admitted to hospita with a diagnosis of subarachnoid haemorrhage during the period 30th June 2011 and 30th September 2011 Patients wi be seected from a incuded cases if the patient died during 1st January and the 30th June 2011 Autumn 2013 Spring 2013 Feedback action to date Currenty benchmarking services against the report recommendations. The trust is compiant with a number of the recommendations foowing the estabishment of the Hospita Acoho Liaison Service (HALS). A baseine assessment concuded that: There had been significant improvement in speciaist input for acoho addiction after the introduction of Hospita Acoho Liaison Service. 100% of patients who required thiamine prescribing received it correcty. However, the assessment aso identified that: 41% of patients with decompensated iver disease were not seen by gastroenteroogist within 24 hours. 19% of patients with ongoing acoho intake had a nutrition review within 24 hours. 58% of patients with ongoing acoho intake had no nutrition review at a. In response to the poor performance reating to nutrition, members of the Hospita Acoho Liaison team have joined the trust Integrated Nutrition and Communication Service and are working cosey with the nutrition nurses and dieticians to improve performance. Nationa report not yet pubished. Tracheostomy Care Study A patients who undergo the insertion of a new tracheostomy or a aryngectomy between the 25th February 24th June 2013 wi be incuded in the study Spring 2014 Exceent care with compassion 14

15 Lancashire Teaching Hospitas NHS Foundation Trust The reports of over 300 oca cinica audits were reviewed by the provider in 2013/14 and Lancashire Teaching Hospitas NHS Foundation Trust intends to take the foowing actions to improve the quaity of heathcare provided. Tite of audit Re-audit of Identification of patients ost to foow up (Orthopaedics) Re-audit of Consent for Pastic Procedures (Pastics) Frozen Sections (Pathoogy) Resuting actions More uniform system across the orthopaedic wards, with eimination of non-approved forms. Staff to ceary indicate whether patient needs foow up on IHDS even if it is on the operation note. Action: Increase awareness at induction. Staff information about foow up for common operations at induction. Action: Increase awareness at induction, hand-out or emai. Improved confirmation of consent when a period of time has passed since initia consent. Action: If more than 48hours has passed since the initia consent it shoud be reconfirmed on the day of surgery by medic prior to surgery. Ensure histopathoogy consutants at LTHTR are aware of the importance of recording time and person when giving a verba frozen section report. Deveop a more detaied frozen section request form to ensure not ony that the histopathoogist has sufficient cinica information for reporting a frozen section, but aso to provide a record of when and to whom the report is given, and to aid future audits. Incude in the above form a section to be competed if there are difficuties in preparing a frozen section or artefact which affected accuracy of report given, for exampe in the first fase negative where the specimen was fatty and difficut to cut. This coud hep identify the cause of fase negative rates and where improvements can be made. Continue to ensure no high risk specimens are sent for frozen section. Breech ECV (Women s Heath) Re-audit of operative vagina deivery (OVD) (Women s Heath) Perinea wound infection (Women s Heath) Botox audit (Chid Heath) Educate surgeons regarding the optimum size of specimens. Portabe utra sound scans introduced in antenata unit to reduce percentage of undiag nosed breech. Expected standard of documentation of OVD incuded in the departmenta induction programme. Birth case notes amended to incude documentation of badder care and verba/written consent for OVD. Audit findings and recommendations incuded in red day for practice (training day). Infection prevention and contro discussed with new doctors on induction day. New suture packs introduced on the deivery suite to minimise infection. Tone management assessment forms reviewed with regards to Gross Motor Function Cassification System (GMFCS) eve and contraindication for Botox toxin. Botox toxin admission/check ist designed. More invovement of occupationa therapist in pre-assessment. 15 Exceent care with compassion

16 Annua report and accounts Tite of audit Audit of Rapid Assessment Unit (RAU) Referra Paperwork (Medicine) Resuting actions The referra form is to be amended to incude detais required by the Roya Coege approved generic record keeping standards cinician, grade and consutant on ca. The findings are to be presented at the medicine audit meeting in May. A simpe teaching package is to be designed for junior doctors to re-enforce the importance of good record keeping. Audit of Costridium difficie prophyaxis using probiotics (Medicine) Confirmation of NG tube position: staff awareness (Medicine) Patient satisfaction with the voca cord dysfunction (VCD) cinic (Medicine) Audit of Eary Neonata sepsis (Chid Heath) Re-Audit of investigation of hypogycaemia in chidren over 1 week age (Chid Heath) Audit of Neonata jaundice (Chid Heath & Women s Heath) Functiona Visua Loss (Ophthamoogy) Occupationa Therapy goa setting in acute stroke rehabiitation (Occupationa Therapy) Re-audit foowing presentation at the audit meeting. Foowing an initia audit, a poster was designed and dispayed on medica wards to remind junior doctors to prescribe Actime when patients were prescribed antibiotics. Re-audit showed the prescribing of Actime had increased sighty and there was more use of the pre-printed prescribing stickers in the prescription chart. E-earning programme for a doctors in/entering the trust to provide education and assess competence wi be deveoped in conjunction with Consutant Interventiona Radioogist. The Nutritiona Nurse Consutant is iaising with the undergraduate team to estabish an NG day for theoretica and practica earning for medica students. A more forma VCD patient information eafet is to be produced. This wi expain each of the MDT member s roes in the patient s treatment. Loca guideines amended to refect NICE guideines with regards to Benzy Peniciin and Gentamycin doses. Avaiabiity of bood cuture resuts within 36 hours through Teepath system. Loca protoco amended. Amendments made in 1. Changes to BM threshod (<2.6). 2. Urine reducing substances removed from the protoco. Agreed mode of referra pathway for babies who need serum biirubin from the community to ward 8 impemented. Re-audit panned to evauate impementation of referra pathway. A new care pathway has been deveoped and impemented. Liaison with the chid psychoogy department to organise training for imparting the news of a chid s FVL and of the best way to reassure chidren and parents. Questionnaires have been deveoped; a questionnaire for patients to compete prior to being seen and a patient satisfaction questionnaire to be competed post discharge. Training and further experientia practice with the team re setting SMART goas. Action: Compete training session. Ensure that ong term goas are considered and forwarded to the community therapy teams on discharge. Action: Highight to the whoe team to document goas on the goa setting proforma. Adapting stye of goa setting as the integrated therapy team joint with physiotherapy becomes more estabished foowing our service restructure. Action: Triaing new goa setting form jointy with physiotherapy. Re-audit specificay to review that SMART goas are being set consistenty. Exceent care with compassion 16

17 Lancashire Teaching Hospitas NHS Foundation Trust Tite of audit Point prevaence audit of competion of aergy status on in-patient prescription charts (Surgery) Audit of Rena Transpantation in the Edery (Rena) Audit of CT Head & Cervica Spine foowing NICE Guidance (Imaging) Adequacy of Orbit X-rays performed to detect metaic intraocuar foreign bodies pre-mr scan (Imaging) Resuting actions Information to be disseminated via notices on the wards, intranet buetin, screensaver info and emai, reminding everyone invoved in the prescription and administration of medications that the aergy status section is mandatory. Induction and refresher training for every heathcare staff member/student, not ony prescribers, on the importance of correct and compete documentation, not ony regarding the aergy status but throughout the prescription chart. A group of edery patients experienced positive outcomes foowing rena transpantation - this is keeping with rena registry outcomes for transpantation and simiar smaer trias from the UK. In the rena department another project has been aready competed to ook at whether a the patients appropriate for rena transpantation had been referred and isted for transpantation in a timey fashion. Pan for Emergency Department CT instaation Onsite radiographers for Preston. Re-audit Re-write oca guideines. Increase education for awareness. Do not repeat exposure uness true intraocuar foreign bodies (IOFB) detected. Method for forma reporting to be discussed. Audit of ens excusion in Computerized Tomography (CT) examinations of brain (Imaging) PEG Remova Times in Head and Neck Cancer Patients (Speech and Language Therapy) Use of Adjuvant Herceptin in HER2-Positive Breast Cancer Patients (Oncoogy) Pan to re-audit in 12 months. Deveop a protoco for CT brain examinations to excude the eye ens. Identify excusions to this protoco (e.g. examination for dipopia, exophthamos, orbita fractures or orbita infections). Re-audit after impementing changes. Deveop a Nutritiona poicy to inform practice on PEG pacement and remova. Coect quaity of ife (QOL) data to support changes in practice. A head and neck cancer patients treated at LTHTR to be referred to pre and post treatment cinics. Deveopment of guideines for management of fas in EF whist on Herceptin. Raise awareness of potentia issues with patients with EF <55% at the start of Herceptin treatment. Compare resuts to ongoing audits at other hospitas within the network. Continue to encourage cear documentation about why Herceptin/chemotherapy is not offered to some patients. Note: pease see Gossary for an expanation of the abbreviations. Reaudit with specific attention to cardiac scanning and compications foowing deveopment of oca guidance for monitoring and management. 17 Exceent care with compassion

18 Annua report and accounts Research Participation in cinica research. The number of patients receiving reevant heath services provided or sub-contracted by Lancashire Teaching Hospitas NHS Foundation Trust in Apri - March that were recruited during that period to participate in research approved by a research ethics committee was Recruitment We recruited 1554 patients to NIHR portfoio adopted studies in We granted NHS Permission for 57 new portfoio studies to commence during that time and had a median time to issue NHS Permission of 8 days against a nationa benchmark of 30 days. We recruited a further 472 to non-portfoio studies. In tota there are currenty 212 active research studies recruiting patients in our hospitas. Research governance We competed our first year of the new monitoring and audit programme for research. The programme has competed 10 panned audits across 5 speciaties with no triggered audits. Themes of good practice and areas for improvement have been identified and are in the process of being deveoped into training packages for research staff. New deveopments in The Innovation Pathway designed in the previous year has competed its first year in piot form. The success of the piot has resuted in 2 nationa awards and the team are now working directy with NICE to refine the pathway ready for a forma aunch in The success of the piot has resuted in 2 nationa awards saw an increase in the number of trias avaiabe to acutey unwe patients with a strong year of recruitment in the Trauma and Acute Care research theme. Neurosciences has been the best performing research theme at the trust recruiting to a mixture of genetics studies and earier phase compex cinica trias of investigationa medicina products. Exceent care with compassion 18

19 Lancashire Teaching Hospitas NHS Foundation Trust Goas Agreed with Commissioners Use of the CQUIN payment framework. A proportion of Lancashire Teaching Hospitas NHS Foundation Trust s income in was conditiona upon achieving quaity improvement and innovation goas agreed between Lancashire Teaching Hospitas NHS Foundation Trust and Greater Preston and Chorey and South Ribbe CCG s and any person or body they entered into a contract, agreement or arrangement with for the provision of reevant heath services, through the Commissioning for Quaity and Innovation payment framework. Further detais of the agreed goas for and for the foowing 12 month period Further detais of the agreed goas for 2013/14 and for the foowing 12 month period are avaiabe onine at: The CQUIN goas are divided into three categories: Nationa goas that are mandated as part of the Nationa Standard Acute Contract for Hospita Services of which there are two. Speciaist Commissioner Goas set out by NHS Engand that are consistent across a acute providers. Loca Indicators that are subject to agreement and discussion between commissioners and providers. We received income from the achievement of CQUIN of 8.4 miion in conditiona upon achieving quaity improvement and innovation goas, and a monetary tota for the associated payment in of 8.4 miion. Exampes of improvements achieved through the CQUIN programme incude: Estabishment of GP direct access diagnostic services for specific pathways. Reduction in Out-Patient DNA Rates and Out-Patient short notice canceed cinics. Reductions in waits for dispensing medicines in outpatients. Improved standards for timeiness of discharge communications to GPs supported by eectronic maiing systems. High standards of dementia screening, risk assessment and referra. Achievement of VTE risk assessment performance objectives. Impementation of the Friends and Famiy Test across admitted care, A&E and maternity services. Roya Coege of Psychiatrists Quaity Mark accreditation for Edery Friendy Wards within the trust. Deveopment of service quaity dashboards for specific speciaist services such as neonata intensive care and radiotherapy services. Outpatient Parentera Antimicrobia Therapy (OPAT) An audit of ength of stay for inpatients on antibiotics demonstrated that there were a significant number of patients in hospita who were there ony because they needed intravenous antibiotics. Microbioogists now attend wards daiy to visit these patients to try and reduce their ength of stay by suggesting ora antibiotic switches or outpatient parentera antimicrobia therapy (OPAT). The OPAT patients visit hospita once a day for the intravenous antibiotics, which has had extremey favourabe feedback. Over a 2 year period, 271 patients were treated as part of the OPAT service. 19 Exceent care with compassion

20 Annua report and accounts Registration with the Care Quaity Commission Lancashire Teaching Hospitas NHS Foundation Trust is required to register with the Care Quaity Commission (CQC) and its current registration status is that the Care Quaity Commission has registered and icensed Lancashire Teaching Hospitas NHS Foundation Trust to provide the foowing services; Fas Prevention Diagnostic and/or screening services Maternity and midwifery services Surgica procedures Assessment or medica treatment for persons detained under the Menta Heath Act 1983 Termination of pregnancies Treatment of disease, disorder or injury Management of suppy of bood and bood derived products There are no conditions to this registration. The Care Quaity Commission has not taken enforcement action against Lancashire Teaching Hospitas NHS Foundation Trust during Our Fas and Fracture Prevention Service work in cose coaboration with heath, socia and vountary care stakehoders to improve the fas patient journey. They have made key deveopments and contribution towards the safe care of patients at risk of fas incuding: The deveopment of speciaist fas cinics at Lancashire Teaching Hospitas The introduction of a fas user carer forum A Centra Lancashire Fas pathway These deveopments are underpinned by a unique vision for fas prevention in Centra Lancashire aigned to the various nationa poicies and strategies. Exceent care with compassion 20

21 Lancashire Teaching Hospitas NHS Foundation Trust Quaity of Data It is generay accepted that good quaity data is at the heart of identifying the need to improve. It aso provides the evidence that there has been improvement in the quaity of care deivered by the trust as a resut of changes that it has made. Lancashire Teaching Hospitas NHS Foundation Trust submitted records during to the Secondary Uses Service for incusion in the Hospita Episode Statistics which are incuded in the atest pubished data. The percentage of records in the pubished data, which incuded the patient s vaid NHS number, was: 99.6% for admitted patient care 99.7% for outpatient care 97.8% for accident and emergency care The percentage of records in the pubished data, which incuded the patient s vaid Genera Medica Practice code, was: 97.6% for admitted patient care 99.1% for outpatient care 98.1% for accident and emergency care Our Information Governance (IG) Assessment Report overa score for was 78% and was graded green. This demonstrates achievement of the minimum eve two compiance in 29 out of 45 requirements and achievement of eve three compiance in a further 15, with one requirement not reevant to the trust. Interna auditors reported significant assurance for the trust. They confirmed the trust has a strong organisationa structure with associated processes for identifying, improving and embedding Information Governance issues and improvements. Lancashire Teaching Hospitas NHS Foundation Trust wi be taking the foowing actions to improve data quaity: Continuation of the roing audit programme to raise awareness of good data management and quaity assurance, with targeted improvements within specific areas. Continuation of Data Quaity Assurance workshops aimed at a staff groups (incuded within the Nursing Interns and Junior Doctors induction programmes). Cose working with departments/ directorates and IT training to ensure that improvements to data quaity and underying processes are fuy supported and sustained. Enhanced working with cinica governance team to support the consistent data coection processes in pace across cinica areas of the organisation. During 2013/14 we sustained the high eve of performance achieved in 2012/13 in reation to the Audit Commission s reference costs data quaity audit and the Advancing Quaity Programme. The trust has competed on-going work in reation to a number of audits competed by Mersey Interna Audit Agency regarding quaity assurance of specific board reporting areas. We worked with externa partners to compete audits of the quaity of data reating to mortaity and co-morbidity. Lancashire Teaching Hospitas NHS Foundation Trust was not subject to the Payment by Resuts cinica coding audit during by the Audit Commission. In the absence of a Payment by Resuts cinica coding audit commissioned by the Audit Commission, Lancashire Teaching Hospitas NHS Foundation Trust commissioned an interna Payment by Resuts audit and the error rates reported in the atest audit for the period for diagnoses and treatment coding (cinica coding) were as foows: Primary diagnosis - 5% Secondary diagnosis - 9% Primary procedure - 5% Secondary procedure - 10% The audit was based on a random seection of records from the genera surgery, neurosurgery, cardioogy and chid heath speciaties. Improvement actions have been identified in respect of quaity of case notes, staff training and accreditation, and staffing eves. Note: These resuts shoud not be extrapoated further than the actua sampe audited in the identified speciaties. 21 Exceent care with compassion

22 Annua report and accounts Review of Quaity Performance Our safety and quaity strategy; Safe, reiabe and compassionate was deveoped in conjunction with staff, patients the pubic, and governors. This strategy set out a number of ambitious, measurabe, patient-centred safety and quaity improvement goas. The improvement focus that described the cornerstones of the our Safety and Quaity strategy during are as defined beow but, in respect of safe care, have evoved during the ife of the strategy to focus on reduction of avoidabe harm and cassification of eves of harm associated with adverse incidents: Safe care As defined and measured by a reduction in harm associated with patient fas, medication error and heathcare associated infections. In addition to this, the reiabiity of care processes wi aso be monitored in reation to the eary recognition of the sick patient and peri-operative care. Effective care As defined by deivery of optimised patient care processes and outcomes of care in reation to stroke care, end of ife care, dementia care and those identified through the Advancing Quaity programme. In addition, there is focus on nutritiona care, pain management, prevention of venous thromboemboism and tissue viabiity care and eements of care that impact on the wider patient popuation. Experience of care As defined by patients and the pubic in reation to privacy and dignity, compassion and respect, information giving and invovement in decisions about care and treatment. The key strategic goas to be achieved during the ife of the strategy were: 15% improvement in patient safety 15% reduction in mortaity Year-on-year improvement in the patient experience Over the ife of the previous safety and quaity strategy, up to , there was significant reduction in harm events associated with fas (37% reduction), medication administration errors (20% reduction). Incidence of hospita acquired pressure ucers reduced by 57% but this may have been due to some extent to actions taken to strengthen the depth and accuracy of reporting. During further reductions have been demonstrated in respect of pressure ucers and medication administration errors as detaied in the safe care section of the report. Athough we faied to achieve our nationa objective of 41 during , the 55 cases of Costridium difficie represent a 15% reduction in rates compared to Harm associated with medication administration errors and hospita acquired pressure ucers aso showed improvement. Despite the introduction of a range of improvement measures incuding enhanced risk assessment and supervision, environmenta improvements and use of monitoring devices, harm associated with inpatient fas has increased sighty, athough this may be refective of a change in case mix. Performance in respect of MRSA bacteraemia is consistent with with a tota of 4 cases. In addition, we maintained high eves of engagement and performance with a eements of the Safety Thermometer programme with a year-end performance eve of 97.13% harm-free hospita care, comparing very favouraby with the nationa performance rate. Comprehensive detai reating to a aspects of infection prevention and contro is provided in the IPC annua report which is pubished separatey. During we reported 2 never events both were in reation to surgica procedures; a detaied action pan and improvement programme is in pace and progress is monitored via the Safety & Quaity Sub Committee. We pace importance on openness and transparency when reporting incidents and never events; anaysis of the never events reported does not show any patterns regarding causation factors. Exceent care with compassion 22

23 Lancashire Teaching Hospitas NHS Foundation Trust Never events are serious, argey preventabe patient safety incidents that shoud not occur if the avaiabe preventative measures have been impemented. They can ead to serious adverse outcomes, and can damage patients confidence and trust. They incude incidents such as: Wrong site surgery Retained instrument post operation Wrong route administration of chemotherapy Incidents are considered to be never events if: There is evidence that the never event has occurred in the past and is a known source of risk (for exampe, through reports to the Nationa Reporting and Learning System or other serious incident reporting system). The Hospita Standardised Mortaity Ratio reduced by a further 1.2% in 2012/13, cuminating in a 18.2% improvement against the strategy baseine figure from , with a further 2.6 point improvement during (subject to competion of the dataset and nationa rebasing). Patient feedback generated through the trust Empowering Quaity Improvement for Patients (EQIP) programme has demonstrated high eves of positive feedback across the majority of services, whist patient surveys and cancer surveys have aso shown areas of improvement. Consistent with our commitment to improve the quaity of reporting and information, we continue to refine incident reporting poicies, processes and systems to ensure systems remain fit for purpose and that the timeiness and competeness of vaidated data accuratey and objectivey informs accurate reporting and the identification of meaning improvement actions. Cinica effectiveness has been strengthened through embedding of systems and processes to support impementation of the growing ibrary of NICE quaity standards, and the trusts responses to them. In addition there has been further strengthening of trust and divisiona governance arrangements in respect of cinica audit, ensuring that the baance between nationa, corporate and oca priorities is maintained, that audit cyces are competed and that focus is maintained on the improvement of cinica outcomes. Cinica Governance arrangements have been subject to significant review and improvement throughout A board eve Safety and Quaity Subcommittee has been introduced whose primary functions are to: Promote and ead a safety and quaity cuture in which staff are supported and empowered to improve services and care; There is existing nationa guidance or safety recommendations, which if foowed, woud have prevented this type of never event from occurring (for exampe, for Retained foreign object post procedure the referenced nationa guidance is reated to the peri-operative counting and checking processes that woud be expected to occur at the time of the procedure, incuding suturing after a vagina birth). Occurrence of the never event can be easiy identified, defined and measured on an ongoing basis. Throughout this account there are numerous exampes of staff demonstrating innovation and commitment to improving safety, cinica outcomes and experience, working coaborativey with each other and with others to deiver high quaity care and treatment. Lead and co-ordinate the deveopment and deivery of our Safety and Quaity strategy, and; Provide the Board of Directors with assurance that patient safety, patient experience and outcomes of care are optimised. Three improvement groups, who ead and coordinate quaity improvement programmes associated with safe, effective care and patient experience, serve the subcommittee. 23 Exceent care with compassion

24 Annua report and accounts Assuring Quaity The avaiabiity of meaningfu, reevant and timey information in reation to safety and quaity is essentia to monitor a range of cinica indicators that provide assurance and direction in the anaysis of cinica outcomes and the identification of earning. We use a range of processes in order to monitor and assess safety and quaity. We synthesising information from a range of sources incuding oca and nationa audit, benchmarking, and feedback from patients (via surveys, our EQIP programme, friends and famiy tests and compaints/ compiments). We undertake systematic interna inspections of a ward areas, utiising the Care Quaity Commission s standards. Where significant concerns are identified, a we-estabished process of rapid response is initiated which incudes a requirement to identify and impement corrective action and to monitor the effectiveness of this. Senior divisiona and corporate teams oversee this process. During 2013 we commissioned interna audits in respect of a range of services and received significant assurances in respect of a number of these. We utiise nationay benchmarked data where possibe e.g. Dr Foster Inteigence cinica benchmarking toos, and have participated in peer review exercises e.g. in respect of infection prevention and contro and cancer services. Patient feedback generated through the trust Empowering Quaity Improvement for Patients (EQIP) programme has demonstrated high eves of positive feedback across the majority of services Exceent care with compassion 24

25 Lancashire Teaching Hospitas NHS Foundation Trust Safe Care MRSA bacteraemia Staphyococcus aureus is a bacterium that commony coonises human skin and mucosa. Most strains of S. aureus are sensitive to the more commony used antibiotics, and infections can be effectivey treated. Some S. aureus bacteria are more resistant. Those resistant to the antibiotic meticiin are termed meticiinresistant Staphyococcus aureus (MRSA). Bacteraemia occurs when bacteria get into the boodstream. Safeguarding Chidren Infection prevention and contro remains a key priority and the focus on MRSA bacteraemia (and Costridium difficie infection) has been maintained throughout the ife of the safety and quaity strategy and has been reported in previous Quaity Accounts. During , our performance for MRSA bacteraemia was 4 against a nationa objective of 0. The focus for preventing further avoidabe MRSA bacteraemia cases remains on best practice around periphera and centra ine management, antimicrobia stewardship, urinary catheter care, MRSA screening and decoonisation. We remain committed to a zero toerance on avoidabe cases Apr 11 May 11 Jun 11 Ju 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Ju 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Ju 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Our Emergency Departments Chidren s Safeguarding Group adopted a mutidiscipinary/ mutiagency approach to safeguarding a chidren and adoescents who attend the emergency departments. Performance (rem exd) Pan Utiising the avaiabe expertise the group has deveoped a ceary defined, easy to use, robust structure for referra of chidren where there are safeguarding concerns. Each case is aocated a unique og number and an eectronic aert system aows staff to see immediatey if a chid is known aready to have safeguarding. 25 Exceent care with compassion

26 Annua report and accounts Costridium difficie Infection Costridium difficie infection is the most important cause of hospita-acquired diarrhoea. Costridium difficie is an anaerobic bacterium that is present in the gut of up to 3% of heathy aduts and 66% of infants. As stated above, infection prevention and contro remains a key priority and the focus on the prevention of Costridium difficie infection has been maintained throughout the ife of the Safety and Quaity Strategy and has been reported in previous Quaity Accounts. During our performance for Costridium difficie cases was 55 against a nationa objective of 41. This performance sti represents a 15% reduction in the number of cases when compared to the previous year s tota of 65 cases. We have a we-estabished annuaised improvement pan in pace, suppemented by an in-year responsive pan to performance data findings. Our focus for preventing Costridium difficie cases remains on best practice around antimicrobia stewardship, hand and environmenta hygiene. We have increased domestic service support and recruited staff for out-of-hours housekeeping roes. We have aso introduced the use of actime across the trust as part of the trusts ongoing commitment to reducing a avoidabe cases of Costridium difficie infection. As part of our assurance processes we commissioned a peer review of our Costridium difficie prevention programme by experts from another trust. The review highighted numerous exampes of good practice and recommended minor refinements to support progression of our improvement pans. Research and Deveopment Our research and deveopment taskforce, in conjunction with a oca manufacturer have deveoped a femae urina Apr 11 May 11 Jun 11 Ju 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Ju 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Ju 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Performance (rem exd) Source: LTHTR ECAP programme Pan It was estabished that whist women were in hospita, it was chaenging to remain independent when using a bed pan or commode. Foowing a number of design iterations based on focus group feedback the disposabe femae urina (VernaFem) was deveoped, offering a practica soution to continence probems and improving safety and independence. It increases patient privacy and dignity, reduces bed pan reated pressure ucers, reduces deay in toieting and has been found to reduce patient anxiety. Exceent care with compassion 26

27 Lancashire Teaching Hospitas NHS Foundation Trust Fas prevention Preventing patients from faing is a particuar chaenge in acute hospita settings. There wi aways be a risk of fas in hospita given the nature of the patients that are admitted, and the injuries that may be sustained are not trivia. However, there is a ot that can be done to reduce the risk of fas and minimise harm, whist at the same time aowing patient freedom and mobiisation during their stay. Dementia Care The reasons why patients fa are compex and infuenced by contributing factors such as physica iness, menta heath, medication and age, as we as other environmenta factors. Our we-estabished programme of improvement activities that incudes: Awareness-raising of the importance of the reporting of fas, resuting in year-on-year increased reporting since Ongoing education of ward staff regarding use of the fas assessment too and corresponding actions to be taken to reduce fas. Sustained strong performance across the trust in respect of risk assessment and response to risk, incuding enhanced supervision of at risk patients. Embedding of intentiona rounding with improved anticipation of patient s needs and provision of support. Our monitoring continues to focus on the number of fas, on harm events associated with fas, and on staff compiance with expected standards of assessment and response, as evidenced through the Essentias of Care Audit Programme (ECAP), which directy measures the eve of staff compiance with procedures for assessment of risk, responsive panning and intervention against the agreed audit too. The audit of cinica records is undertaken on 50% of ward patients on a monthy basis. Resuts are shown beow: % 90.00% 80.00% 70.00% 60.00% 50.00% Fas ECAP scores The oder person steering group have deveoped and introduced a range of resources for patients with dementia, which incude activity boxes containing a wide range of dementia specific activities to occupy and stimuate and activity bankets. These bankets, produced by our inen department are designed to provide a range of sensory stimui and opportunities to address the common probem of restess hands % 30.00% 20.00% 10.00% 0.00% Mar Feb Jan Dec Nov Oct Sep Aug Ju Jun May Apr Exceent care with compassion

28 Annua report and accounts During , the number of inpatient fas and harm associated with fas remained consistent with with 5.48 fas per 1000 bed days and 1.19 fas per 1000 bed days (to February 2014) where patients experienced harm. It shoud however be noted that this sustained performance occurred despite the significant increase seen in the number of patients over the age of 80 admitted to hospita with a corresponding increase in risk and acuity. Neurosurgica ibooks LTHTR in-patient fas Apr 11 May 11 Jun 11 Ju 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Ju 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Ju 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Harm Fas Trajectory Adjusted Fas Source: Datix The Neurosurgery Preoperative Information Team and Medica Iustration have deveoped a series of pre-operative neurosurgica patient information ibooks containing videos, 3D animations, interactive diagrams and 3D modes which can currenty be downoaded by patients to their ipad or Appe computer. The ibook is shared with a patients attending pre-operative assessment. The team are deveoping a series of Women s Heath ibooks and ooking to transfer the ibooks to an Android patform to increase the avaiabiity for other tabet users. The ibooks are on our website. Exceent care with compassion 28

29 Lancashire Teaching Hospitas NHS Foundation Trust Medication errors The Essentias of Care Audit Programme (ECAP) continues to provide the most reiabe method for monitoring safe practice in respect of medicines prescribing and administration. We have continued to coect data through ECAP on a number of indices which provide further detai on specific aspects of performance that coud be infuentia on reducing harm. Specia Care Dentistry The associated criteria are; A patient prescription documentation wi provide detais of ward, patient name, date of birth, hospita/nhs number and aergy status. Omission codes wi be evident for a medication not administered as prescribed. The status of patients with a potentia/actua medication aergy wi be identified. Patients requiring intravenous antibiotics wi be a) cinicay reviewed on a daiy basis and b) have a defined stop date. ECAP performance - Medicines During , there has been continued strong performance in respect of the medication ECAP audit, which foows the same methodoogy as the fas ECAP process described above. Overa performance from this audit of 50% of patients in participating wards, undertaken by wards on a monthy basis, was amost 96.7% during the year. As ECAP data monitors safe practice, so incident reporting is the vehice for monitoring incidence and outcomes of errors. During 2013/14, the trust reduced harm associated with medicine administration errors by 32%, with 17 recorded harm events against a trajectory of % 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Apr 13 May 13 Jun 13 Ju 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Source: LTHTR ECAP programme LTHTR Medication Administration Errors Feb 14 Mar 14 The Department of Specia Care Dentistry has deveoped and impemented a simpe and user friendy cinica hoding framework to hep peope with earning disabiities and menta i heath. Cinica hoding is the use of physica hods to assist or support a patient to receive cinica denta care or treatment in situations where their behaviour may imit the abiity of the denta team to effectivey deiver treatment, or where the patient s behaviour may present a safety risk to themseves, members of the denta team or other accompanying persons. Patients who woud otherwise have been isted for an ora examination and denta treatment under genera anaesthesia may now not require it. 5 0 Apr 11 May 11 Jun 11 Ju 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Ju 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Ju 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Harm events Medication administration errors Harm Trajectory Source: Datix 29 Exceent care with compassion

30 Annua report and accounts Effective Care Mortaity The Hospita Standardised Mortaity Rate (HSMR) is derived from routiney coected data based on 56 diagnostic groups that account for 80% of a hospita deaths. The data is adjusted to take into account a range of factors that can affect surviva rates but that may be outside of the direct contro of the hospita such as age, gender, associated medica conditions and socia deprivation. The HSMR is defined as the ratio of observed deaths to expected deaths (based on the sum of the estimated risks of death) mutipied by 100. Thus, a rate greater than 100 indicates a higher than expected mortaity rate whist a rate ower than 100 indicates a ower rate. We recognise the importance of mortaity rates as a key factor in promoting confidence in trust services. As such, it has been and remains a key strategic objective. HSMR is monitored on a monthy basis. Where adverse mortaity aerts are triggered: an initia anaysis of data is undertaken to determine whether a more detaied case note review is required. This is then undertaken by cinica staff and the findings are formay reported to the cinica governance subcommittee and the board of directors. Mortaity rates are reported to the board of directors on a monthy basis and quartery performance reports are aso submitted to the cinica governance subcommittee. The graph beow depicts our annua HSMR rate since The chart demonstrates year-on-year reduction in HSMR despite increased activity across the trust, with a 2.6 point improvement during 2013/14 (subject to competion of the dataset and nationa rebasing). The trust has identified further reduction in patient mortaity as a strategic objective with an ambition to reduce mortaity by 15% over the next three years Comparative Hospita Standardised Mortaity Ratio Lancashire Teaching Hospitas NHS Foundation Trust (v benchmark) Lancashire Teaching Hospitas NHS Foundation Trust (rebased) Engand (rebased) HSMR Q Q Q Q Q Q Q Q Q1 Source: Dr Foster Inteigence Rea Time Monitoring. (2013/14 data not rebased) Exceent care with compassion 30

31 Lancashire Teaching Hospitas NHS Foundation Trust However, rebased HSMRs, as demonstrated beow have remained sighty higher than the nationa rebased benchmark of 100. During 2012/13, foowing rebasing of the data, overa performance was higher than expected. A number of case note reviews undertaken during have not identified any patterns of suboptima care or treatment that impacted on the patient outcomes. In acknowedgement of the need for timey and detaied information about patient mortaity, a mortaity and morbidity review process was initiated in January Approximatey 50% of a cases are reviewed by a cinica mutidiscipinary team ed by a consutant. The review process confirms diagnoses and associated medica conditions and seeks evidence of substandard care. Learning from these reviews is shared on a reguar basis with cinica teams against the nationa benchmark. During 2012, the summary hospita mortaity indicator (SHMI) was introduced nationay. SHMI differs from HSMR in that it incudes deaths within 30 days of discharge from hospita, does not account for socia deprivation, does not excude patients receiving paiative care, and incudes zero ength of stay emergencies, materna deaths and babies. Unfortunatey, SHMI data is not as readiy avaiabe as HSMR data and as of Apri 2014, SHMI data is ony avaiabe to June In view of this, and as HSMR was the mortaity indicator of choice at the time the trust quaity strategy was aunched, HSMR continues to be the primary mortaity measure utiised by the trust. As can be seen from the chart beow our Summary Hospita Mortaity Indicator has been within expected range for quarter 1 of and a but one quarter since its introduction. Q1 performance is improved from Q with a rate of During , it is anticipated that the HSMR wi be around 95 (based on Apri - December data). Assuming performance is sustained and does not improve or deteriorate further this figure wi rise to 105 once rebasing of the nationa benchmark has taken pace. Sustaining improvement in the face of increased case compexity continues to provide a rea chaenge for the trust. The trust however maintains the beief that focussing attention on improved safety, effectiveness and cose monitoring of patient outcomes wi continue to contribute to a reduction in mortaity in the trust. The revised safety and quaity strategy for wi continue to focus attention on cinica pathways and improvement programmes underpinned by Roya Coege and NICE guidance and inked to commissioning strategies associated with urgent and eective care, ong term conditions, and dementia. With continuing engagement from cinica eaders within the Trust and partners outside of it, we wi ensure the deivery of these pathways to patients in need. Reative Risk FY Q2 FY Q3 SHMI trend for a activity across the ast avaiabe 3 years of data FY Q4 FY Q1 FY Q2 FY Q3 Source: Dr Foster Inteigence mortaity Comparator. Weekend mortaity rates were highighted in the atest CQC Inteigent monitoring report as an area of risk. The eevated risk appied to this measure reated to weekend mortaity rates during the period Juy 2012 to June Current performance data for the 12 months to date has demonstrated month on month improvement with the mortaity ratio now within the expected range and no onger aerting as a risk. FY Q4 Financia Quarter FY Q1 FY Q2 FY Q3 FY Q4 FY Q Crude mortaity rate (%) 31 Exceent care with compassion

32 Annua report and accounts Tissue Viabiity - Pressure Ucer Incidence Nationa and trust focus on the eimination of avoidabe pressure ucers in NHS provided care continues, with pressure ucers one of the four indicators measured within the safety thermometer. The prevention of pressure ucers has been a key priority throughout the ife of the trust Safety and Quaity Strategy and has been incuded in the Quaity Accounts in recent years. Pressure ucers can occur in any patient but are more ikey to occur in patients with underying medica conditions, the edery, the manourished and obese. Pressure ucers may be acquired in the community or in hospita, measurement systems therefore need to take account of the incidence or the number acquired in hospita and the prevaence which reate to the tota number of patients with a pressure ucer (a proportion of which wi reate to acquisition in the community). Our estabished programme focuses on prevention and management of pressure uceration, which has in previous years incuded key features such as: Mattress, bed frame and seat cushion management. The contract with a commercia suppier aows for immediate avaiabiity of pressure reieving devices such as aternating pressure mattresses, for a patients are as the assessment of their risk dictates. The contract aso aows for a yeary repacement programme for norma ward mattresses ensuring that mattress quaity is maintained. There has been an increase in usage of speciaist bariatric equipment; these patients are invariaby at high risk of tissue damage due to pressure. The avaiabiity of an eectric bed frame for every patient enhancing the abiity of patients to assist in pressure redistribution. The use of a tissue viabiity risk assessment on admission and instigation of an appropriate care pan to prevent pressure ucer formation. Strengthening of vaidation processes, ensuring accurate cassification, cause, and avoidabiity. A Grade 3 and 4 pressure ucers are subject to root cause anaysis. This vaidation exercise undertaken by senior nurses provides assurance of the accuracy of reporting. Grade 3 and 4 pressure ucer root cause anayses are subject to executive reviews by the nursing director in the same way that MRSA bacteraemia reviews occur. The practice of eary and reguar skin inspection practices and risk assessment of a patients is embedded across our hospitas. An e-earning package is avaiabe to a staff. In addition, during : Reported hospita acquired pressure ucers of grade 2 and above are investigated by Divisiona Heads of Nursing foowed by executive review by the Director of Nursing. The Medica Iustration Department photograph a hospita acquired pressure ucers which further informs and strengthens the investigation process. A staff are informed of the outcomes, earning and key actions from pressure ucer review meetings through quartery distribution of posters in cinica areas. Pressure Ucer grading posters have aso been distributed to a cinica areas to ensure cear, consistent definitions and to improve the reiabiity of grading. There has been a focus on reducing equipment reated pressure ucers resuting in the introduction of pressure reducing oxygen products, ge sheets and change in practice within critica care to use different techniques to retain endotrachea tubes. There are now a range of options avaiabe for pressure ucer prevention training to suit a staff earning styes monthy taught sessions, an e-earning package and a recenty deveoped pressure ucer workbook. We participated in the Word Wide Stop the Pressure Ucer day in November. Exceent care with compassion 32

33 Lancashire Teaching Hospitas NHS Foundation Trust The measures described above have contributed to the reducing trend in acquired pressure ucers. We monitor ans report pressure ucer incidence and prevaence in three ways: As an annua point-prevaence audit which is a spot check of a patients who have acquired a pressure ucer in hospita and as an incidence report detaiing a pressure ucers reported over the course of the year. The prevaence audit, which was conducted by an externa organisation, indicated a sight increase compared to with a rate of 2.51% hospita acquired pressure ucers. Stereotactic Radiotherapy Acquired pressure ucer prevaence % 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 2005 Source: Pressure Ucer Prevaence Report LTH 2013 Arjo Hunteigh 2013 Via the safety thermometer a monthy point prevaence audit of a pressure ucers, incuding hospita acquired ucers. The resuts indicate a very ow eve of new pressure ucers with performance better than the nationa average. 1.80% 1.60% 1.40% 1.20% 1.00% Stereotactic Radiosurgery is a speciaised type of Radiotherapy which uses speciaist equipment to deiver high dose x-rays very precisey at sma brain tumours. It is fast becoming the treatment of choice for patients with sma brain metastases, ow grade maignant brain tumours and benign brain conditions. The Rosemere Cancer Centre is a European Reference Site for this equipment and has hosted internationa visitors to demonstrate and share good practice. 0.80% 0.60% 0.40% 0.20% 0.00% Apr 13 May 13 Jun 13 Ju 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Lancashire Teaching Hospitas NHS Foundation Trust Engand Source: NHS safety Thermometer 33 Exceent care with compassion

34 Annua report and accounts Via incident reporting - There has been a sight reduction in the tota number of avoidabe pressure ucers across the organisation. In , (there were a tota of 120 patients with hospita acquired pressure ucers, compared to 125 during ). The chart beow suggests a significant reduction in the tota number of avoidabe pressure ucers across the organisation since June 2012 compared to the period up to May It shoud be noted, however that some changes in reporting were made during this time, which incuded the identification of avoidabe/ unavoidabe ucers and excusion of those deemed unavoidabe foowing vaidation. As a consequence, the two periods may not be directy comparabe. Assuming no further changes direct year-on-year comparison wi be more reiabe in the report. Dementia Care Avoidabe Hospita aquired pressure ucers by grade Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Ju 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Ju 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Source: Datix The Essentias of Care Audit Programme (ECAP) continues to focus attention on the importance of the tissue viabiity risk assessment and resuts show that 98.4% of patients have risk assessments for tissue viabiity competed within 6 hours of admission or transfer to a ward, representing a 0.4% improvement on performance % 90.00% 2 10 Grade 2 Grade 3 Grade ECAP performance - Tissue viabiity Our award winning Oder Persons Steering Group, consisting of medica, nursing, therapy and estates and faciities staff are committed to deveop the trust to be among the best dementia friendy hospitas. In consutation with patients, carers and support organisations a programme of dementia friendy ward refurbishments was commenced to ensure that the environment meets the needs of patients with dementia. Patients now have greater freedom of movement and comfort within safe and secure ward areas. In addition, a programme of staff training was introduced and 6 wards are currenty seeking accreditation with the Roya Coege of Psychiatrists Quaity Mark for care of the oder person % 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Apr 2013/14 May 2013/14 Jun 2013/14 Ju 2013/14 Aug 2013/14 Sep 2013/14 Oct 2013/14 Nov 2013/14 Dec 2013/14 Jan 2013/14 Feb 2013/14 Mar 2013/14 Source: LTHTR ECAP programme Exceent care with compassion 34

35 Lancashire Teaching Hospitas NHS Foundation Trust Nutrition One of our aims continues to be to ensure that patients admitted and who remain for more than 48 hours (excuding maternity and day case patients) have a nutritiona screening assessment on admission. The assessment is carried out using the Manutrition Universa Screening Too (MUST) deveoped by the British Association for Parentera and Entera Nutrition. The screening too highights patients who are aready manourished or at risk of manourishment and determines the need for referra for a more detaied nutrition assessment by a dietician. Audit resuts indicate that over 96% of patients are assessed within 48 hours of admission. Overa performance in assessment, panning and intervention in respect of nutritiona support, as measured through the trusts Essentias of Care Audit programme, has been strong throughout the year. Overa resuts are described in the foowing chart: % 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Apr 2013/14 ECAP performance - Nutrition May 2013/14 Jun 2013/14 Ju 2013/14 Aug 2013/14 Sep 2013/14 Oct 2013/14 Nov 2013/14 Dec 2013/14 Jan 2013/14 Feb 2013/14 Mar 2013/14 Source: LTHTR ECAP programme An integrated nutrition and communication service has been deveoped to improve response times and access to expertise incorporating members of the speech and anguage therapy department, dieticians, nutrition speciaist nurses, members of the Hospita Acoho Liaison team and members of the Centra Venous Access team. In addition, a tota parentera nutrition outpatient cinic has been initiated to monitor and provide medica review of patients with compex nutritiona needs, thereby avoiding the need for hospita admission. The avaiabiity of nutrition nurse has been increased. Nutrition nurses are now avaiabe at weekends and bank hoiday to provide advice and support. Foowing pubic consutation and a review of catering provision, the hot mea option at suppertime was re-introduced. Other options such as modified textured which incudes iquidised, puree and finger food menus are aso avaiabe. In addition, a muti-cutura, rena, and guten free menu are avaiabe too. Work is underway to review the nutritiona content of the current hospita meas (both puree diet and norma texture), comparing this to nationa recommendations. 35 Exceent care with compassion

36 Annua report and accounts Experience of Care Improving patient experience was and remains a key priority, and the focus on respect and dignity, patient invovement and effective communication has been maintained throughout the ife of the safety and quaity strategy and has been described and reported in previous Quaity Accounts. We participated in the two nationa patient surveys that were undertaken in The nationa inpatient survey resuts demonstrated sustained performance in respect of around a quarter of the questions asked, with improvement in respect of amost haf. There was significant improvement in respect of GP etters shared with patients, but a significant drop was noted in respect of change of admission date. This change may have been affected by emergency activity eves at the time of the survey. Overa performance was as expected across a sections. The nationa maternity survey resuts demonstrated that performance was aso within the expected range for a questions. Performance improved significanty when compared to the 2010 survey in respect of: Support and encouragement with feeding Information about mothers recovery after the birth, and Information about emotiona changes that may be experienced Performance deteriorated in respect of not seeing the same midwife in antenata cinic. This issue has been addressed through a review of staff aocation processes. As stated a key objective of the Safety and Quaity Strategy is to improve the patient experience. Patient feedback is obtained via a range of sources incuding compaints PALS activity, NHS choices and other websites, nationa surveys and friends and famiy tests. Feedback obtained using the trust patient feedback devices (Empowering Quaity Improvement for Patients or EQIP) is utiised to monitor progress in respect of overa patient experience and specificay, experience reated to dignity and respect, communication, invovement and responsiveness of care. Performance data suggests consistenty high eves of positive responses during , with performance improved when compared to performance in respect of overa feedback ( %, %), invovement ( %, 2012/ %), and communication (2013/ %, 2012/ %). Performance reating to respect and dignity reduced very sighty from 92.65% in 2012/13 to 92.5% in Competency Score Overa Respect and Dignity Communication Invovement in care Responsive, prompt care Privacy Feeing safe Assurance of pain contro 92.1 Meeting nutritiona needs Promotion of continence Rest and seep The trust s ambition to be the best dementia friendy hospita has seen the introduction of highy significant improvements during Exceent care with compassion 36

37 Lancashire Teaching Hospitas NHS Foundation Trust We have been coecting rea-time data from patients since During 2011, we invested in new devices in order to obtain richer and more detaied feedback from patients. These devices aow the patients the opportunity to respond to a wider range of questions but aso to provide free text feedback about their experiences that may not be covered by the survey questions. Overa patient experience feedback 100.0% 95.0% 90.0% 85.0% 80.0% 75.0% 70.0% Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Ju 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Ju 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Overa satisfaction Respect & Dignity Communication Invovement Responsive, prompt care Patient feedback resuts and patient comments are avaiabe to wards and departments on a near rea-time basis. Each ward area has a performance board dispaying the feedback resuts and other quaity indicators, and together, they are used to inform areas for improvement within wards and across directorates. Use of the devices and feedback obtained through bedside handovers continue to hep to focus staff attention on issues that are important to patients. It aso provides a foundation for more detaied engagement with patients. Within a context of significant response voumes, the resuts provide a robust indicator of patient perception and experience. They can aso provide assurance around standards of care when anaysed aong with other data sources such as compaints and PALS activity. The board of directors reviews reguar reports capturing a these indicators. During patients have provided responses to questions providing feedback on the quaity of services that are over 86% positive across a responses. Adut inpatient responses were 88% positive, outpatients 83%, day case patients 91% and chidren and parents 85%. A review of feedback provided by patients aged 65 and over was consistent with the overa scores. Mixed sex accommodation has been virtuay eiminated, with no reported breaches during A new buids and panned refurbishment are reviewed from a privacy and dignity perspective and do not proceed uness same sex compiant. Once again, the nationa dementia CQUIN has been achieved, argey through the efforts of the trust s proactive Edery Care Team who support the deivery of high quaity care and treatment for oder patients irrespective of where they are in the trust. This mutidiscipinary team, consisting of consutant physicians, nurses and therapists undertake fraity assessments on patients over 75, supporting coeagues in panning and deivering safe, effective treatment and the panning of eary supported discharge. As described esewhere in this account, the trust s ambition to be the best dementia friendy hospita has seen the introduction of highy significant improvements during Major ward refurbishments undertaken during have been informed by consutation with dementia patients and their carers, aong with best practice evidence. Wards catering for patients with dementia are now we equipped to provide safe patient focused care and treatment, a warm wecoming and stimuating environment, improved security, cear signage and are purpose designed to maintain safety, and promote respect and protect dignity. Having competed work in two of our wards we pan to introduce these improvements to other wards during The Friends and Famiy Test was introduced in March Foowing successfu impementation of the test within maternity, we achieved the nationa CQUIN target of a 20% combined response rate in the wards and emergency departments. During March 2014, 93% of patients who expressed a view stated that they woud be extremey ikey or ikey to recommend the ward or department. The net promoter scores 37 Exceent care with compassion

38 Annua report and accounts Mixed sex accommodation has been virtuay eiminated for the emergency departments was 59 compared to the most recent NHS Engand score of 55, and the score for the wards was equa to the most recent NHS Engand score of 72. During , we received 582 compaints, a reduction of 11 compared to figures, foowing two years of increased numbers between % of compainants who contacted we were contacted within 3 working days of receipt of the compaint. Just over 50% of compaints reated to inpatient care, 36% to outpatient care, and 11% inked to visits to the accident and emergency departments. 15 compaints were raised either by reatives or visitors to the hospita We defended 253 of the 596 compaints, with the remainder found to be fuy or party justified. Approximatey 19% reated to cinica treatment or procedure, 16% to issues about admission discharge or transfer, 13% reated to dissatisfaction with staff attitudes and 13% to communication as the primary reason for compaint patients or visitors raised concerns through the Patient Advice and Liaison Service (PALS) who were abe to resove their concerns prompty without the need to submit a forma compaint in writing. 23 compaints were reviewed by the Pariamentary Heath Services Ombudsman (PHSO) during , where compainants had reported that we had not resoved their compaints to their satisfaction by the trust. Of these, 18 were either not investigated, required no further action or were not uphed by the PHSO. 2 were referred back to the trust for further resoution, 2 were partiay uphed, and 1 other uphed. Action pans were identified in respect of the 3 compaints uphed or partiay uphed and shared with the compainant. In addition we received a tota of 5088 compiments and thank you cards during During we undertook a review of its compaints handing procedures and introduced a range of improvements incuding: Enhanced triage processes to identify opportunities for prompt review and response to compaints. Introduction of a PALS outreach service to promote greater access to the team, supporting oca resoution of concerns. Introduction of a peer review process underpinned by Patient Association standards. Sampe compaints are reviewed by a pane whose members incude executive and non-executive directors and governors, who consider the quaity of investigations and response etters. The introduction of a feedback survey. A compainants are provided with opportunity to feedback on their experiences with the compaints process and satisfaction with the response received. Revised information incuding eafets and posters with detais on the ways in which patients, reatives and the pubic can provide feedback and make a compaint. Exceent care with compassion 38

39 Lancashire Teaching Hospitas NHS Foundation Trust Performance Against Key Nationa Priorities As a foundation trust our performance is measured against a range of patient safety, access and experience indicators identified in the Monitor Compiance Framework and the Acute Services Contract. We achieved compiance against a range of measures within the Monitor Compiance Framework incuding access standards such as A&E waiting times, non -admittance and incompete 18 week referra to treatment and access to cancer treatment. In addition we maintained performance against a range of other measures identified in the Acute Services Contract. However, we faied to achieve our objectives in reation to 18 week admission access target, 62 day cancer treatment, and operations canceed for non-cinica reasons and patients readmitted within 28 days foowing canceation. This was argey due to significant emergency demand during quarter 4 of and Q1 of 2013/14 that adversey impacted on the Eective Care Programme. Particuary evident were an increase in non-eective admissions of edery, frai patients and an increase in arrivas by ambuance suggestive of greater acuity. We introduced a number of initiatives during to identify and utiise additiona capacity to move back into a position of compiance by the end of Q Foowing the pressures experienced in Q a heath economy wide Urgent Care Review was commissioned in The review focussed on the deveopment of a whoe system Urgent Care Transformation Programme. The core themes of the programme are service integration, system wide capacity panning and A&E access points. The summary position detaiing performance against key nationa and oca targets and priorities for is shown in the tabe opposite. 39 Exceent care with compassion

40 Annua report and accounts Indicator Target % Cumuative performance Achieved Current period A&E - 4 hour standard N % - Cumuative to End Feb 2014 A&E - Troey waits greater than 12 hours 0 0 Y % - Cumuative to End Feb 2014 Cancer - 2 week rue (A Referras) - New method Y % - Cumuative to End Feb 2014 Cancer - 2 week rue - Referras with breast symptoms Y % - Cumuative to End Feb 2014 Cancer - 31 day target Y % - Cumuative to End Feb 2014 Cancer - 31 Day Target Y % - Cumuative to End Feb 2014 Subsequent treatment - Surgery Cancer - 31 Day Target - Subsequent treatment - Drug Y % - Cumuative to End Feb 2014 Cancer - 31 Day Target Y % - Cumuative to End Feb 2014 Subsequent treatment - Radiotherapy Cancer - 62 day target - tota N % - Cumuative to End Feb 2014 Cancer - 62 Day Target - Referras from NSS (Summary) Y % - Cumuative to End Feb 2014 MRSA 0 4 Y No of Patients - Cumuative to End March 2014 Costridium difficie - Monitor Pan N No of Patients - Cumuative to End March 2014 Canceed Operations - Non Cinica N % - Cumuative to End Feb 2014 (% of Eective FFCE s) Canceed Operations - Not Readmitted Within 28 Days N % - Cumuative to End Feb 2014 Deayed Discharges - Acute Y % - Average to End Feb 2014 Medica Outiers Y % - Singe month of Feb 2014 Stroke Care - Admission to a designated stroke ward within N % - Cumuative to End Jan hours of presentation Stroke Care - 90% of stay within designated stroke ward Y % - Cumuative to End Jan 2014 TIA - Commencement of treatment within 24 hours Y % - Cumuative to End Feb weeks - Referra to Treatment - Admitted Patients N % - Singe month of Feb weeks - Referra to Treatment Y % - Singe month of Feb 2014 Non-admitted patients 18 weeks - Referra to Treatment - Incompete Pathways Y % - Singe month of Feb weeks - Number of patients that have waited over N % - Cumuative to End Feb 14 weeks for treatment % direct access audioogy within 18 weeks in month Y % - Cumuative to End Feb 14 % patients waiting greater than 6 weeks for diagnostics < N % - Cumuative to End Feb 2014 Same Sex Accommodation Breaches 0 0 Y Number of Patients - Cumuative to End Feb 2014 Heath & Socia Care Needs Assessment within Y % - Singe month of Feb weeks and 6 days of pregnancy Infant Heath: Smoking During Pregnancy Y % - Cumuative to End Feb 2014 Infant Heath: Breastfeeding Initiation N % - Cumuative to End Feb 2014 Certification against compiance with requirements regarding access to heathcare for peope with a earning disabiity NA 100% Y Compiance with a objective * Position is incusive of Q1-3 reaocations. Does not take account of any potentia Q4 reaocations ** Absoute Figures (i.e. number of patients) Note fu year threshod incuded *** Target was 0 with a deminimus of 6 aowed Exceent care with compassion 40

41 Lancashire Teaching Hospitas NHS Foundation Trust Summary tabe of performance against core indicators 12. Summary Hospita-Leve Mortaity Indicator (SMHI) (a) the vaue of banding of the summary hospita-eve mortaity indicator ( SHMI ) for the trust for the reporting period (b) the percentage of patient deaths with paiative care coded at either diagnosis or speciaity eve for the trust for the reporting period Apr Mar 2012 Trust = 1.02 Nationa average:1.0 Low = 0.89 High=1.12 Trust = 15.39% Nationa = NA High = 44.2% Low = 0 Apr Mar 2013 Trust = 1.02 Nationa average:1.0 Low = 0.65 High = 1.17 Trust =16% Nationa = NA High = 43.9% Low = 0.1% Lancashire Teaching Hospitas NHS Foundation Trust considers that this data is as described for the foowing reasons: It represents performance that is within the expected range, refecting the effectiveness of cinica treatment within the trust. Oct Sept 2013 Trust = Nationa average:1.0 Low = 0.63 High=1.18 Trust = 19.4% Nationa = NA High = 44.8% Low = 0 Athough there has been an increase in reation to paiative care coding, it has been recognised that historica trust rates were ower than expected and the current rate is in response to actions to improve the coding rate and is not inconsistent with the hospita case-mix. Lancashire Teaching Hospitas NHS Foundation Trust has taken the foowing actions to improve this score, and so the quaity of its services, by: Introducing patient eve review of inpatient deaths, with a focus on accuracy of cinica documentation and coding, assessment of standards of care and treatment, and assessment of the impact of deivered care and treatment on the patient outcome. Shared earning of findings. Improvements in access to the hospita speciaist paiative care team (HSPCT) and accurate identification and documentation of HSPCT activity. 41 Exceent care with compassion

42 Annua report and accounts PROMS; The Trust s patient reported outcome measure scores for: (i)groin hernia repair (ii)varicose vein surgery EQ5D (Heath gain) Trust = Nationa = Trust = Nationa = Apri 2011 March 2012 Apri 2011 March 2012 Apri-Dec 2013 Oxford score Aberdeen score EQ5D (Heath gain) NA NA Trust = NA NA Nationa = NA Trust = NA Nationa = Trust = Nationa = Oxford score Aberdeen score EQ5D (Heath gain) Oxford score Aberdeen score NA NA Heath gain = 0.04 NA NA NA NA Nationa = High = Low = NA Trust = NA Nationa = Heath gain = NA Heath gain = Nationa = High = Low = 0.02 NA NA NA Nationa = High = Low = (iii)hip repacement surgery (iv) knee repacement surgery Trust = Nationa = Trust = Nationa = NA NA Trust = NA NA Nationa = Trust = Nationa = NA Trust = NA Nationa = NA NA Heath gain = NA NA Nationa = High = Low =.301 Trust = Nationa = NA Heath gain = NA Nationa = High = Low = NA NA Heath gain = Nationa = High = Low = Patient Reported Outcome Measures (PROMS) is a survey through which patients are asked about their heath and quaity of ife before they have an operation, and about their heath and the effectiveness of the operation afterwards. In this way the impact of treatment on an individua patient can be measure. The higher the score, the greater the impact on the patient. The PROMS programme uses three measures: The EQ5D too provides a generic measure of quaity of ife The Oxford specificay measures the impact of knee repacement surgery on quaity of ife and is ony used for patients undergoing knee surgery, whist The Aberdeen score measures the impact of varicose vein surgery on quaity of ife and is ony used for patients undergoing varicose vein surgery Lancashire Teaching Hospitas NHS Foundation Trust considers that this data is as described for the foowing reasons PROMS performance was positive and broady in ine with nationa performance and positive in respect of groin hernia repair but ower than the nationa score in respect of hip repacement. This may be a refection of referra practices or patient expectations. Non-adjusted heath gain for knee repacement is ower than the nationa figure in respect of EQ5D but better in respect of the Oxford score. This appears to refect a better condition and treatment specific outcome. For varicose vein surgery, whist performance was negative in respect of heath gain this was consistent with nationa performance and consistent with evidence suggesting imited cinica vaue of the procedure. Knee repacement PROMS performance has been highighted in the CQC Inteigent monitoring report as a risk. Patient eve data is currenty being reviewed to identify possibe reasons for variance in performance and wi inform deveopment of improvement actions. In addition, compiance with 9 standards of care reated to fractured hip was aso identified in the same report as a risk and may impact on the perceived heath gain for patients Lancashire Teaching Hospitas NHS Foundation Trust intends to take the foowing actions to improve this score, and so the quaity of its services, by reviewing and responding to patient eve data. The appointment of an Orthogeriatrician has aready improved compiance with hip fracture standards significanty and removed this issue as a risk. It is hoped that this wi aso impact positivey on the PROMS hip repacement score. NA NA NA NA Exceent care with compassion 42

43 Lancashire Teaching Hospitas NHS Foundation Trust 19. Readmission rate within 28 days of discharge 0-14 years Trust = spit under and over 16 years Trust = Trust = Nationa = Nationa = Nationa = High/ow performing trusts - NA 15 years and over Trust= Trust = Trust = Nationa = Nationa = Nationa = High/ow performing trusts - NA Lancashire Teaching Hospitas NHS Foundation Trust considers that this data is as described for the foowing reasons; Readmission rates for over 15 year od patients remains consistenty ower than the nationa average but sighty higher for 0-14 year od patients and may be refective of case compexity in respect of neonata services. Lancashire Teaching Hospitas NHS Foundation Trust intends to take the foowing actions to improve this score, and so the quaity of its services, by reviewing the impact of any significant shift in case mix on readmission rates and responding where areas of improvement are identified 20. Responsiveness to patients persona needs Trust = 69.4 Trust = 62.9 Trust = 67 Nationa = 67.3 Nationa = 67.4 Nationa = 68.1 High = 79.5 Low = 57.4 Lancashire Teaching Hospitas NHS Foundation Trust considers that this data is as described for the foowing reasons; Trust scores show a significant improvement on performance. Unfortunatey improvement measures had not been fuy embedded by the time of the survey and as such, performance had not at that time returned to eves. Lancashire Teaching Hospitas NHS Foundation Trust intends to take the foowing actions to improve this score, and so the quaity of its services, by the deveopment and impementation of quaity improvement programmes which wi incude the introduction of aways events. It is anticipated that these wi positivey enhance responsiveness to patient need. Readmission rates for over 15 year od patients remains consistenty ower than the nationa average 43 Exceent care with compassion

44 Annua report and accounts The combined response rates and net promoter score for inpatients who woud recommend the hospita to friends and famiy who needed simiar treatment The combined response rates and net promoter score for emergency department (ED) who woud recommend the hospita to friends and famiy who needed simiar treatment Jan 2014 Feb 2014 Mar 2014 Inpatient response rate = 15.7% Nationa response rate = 31% High = 100% Low = 10.9% Inpatient net promoter score = 76 Nationa net promoter median score = 72 High = 100 Low = 27 ED response rate = 12.3% Nationa response rate = 17.4% High = 52.4% Low = 1.7% ED net promoter score = 59 Nationa net promoter median score = 57 High = 92 Low = 0 Inpatient response rate = 23.4% Nationa response rate = 34% High = 100% Low = 16.2% Inpatient net promoter score = 73 Nationa net promoter median score = 72 High = 100 Low = 18 ED response rate = 17.6% Nationa response rate = 18% High = 66.1% Low = 1.5% ED net promoter score = 58 Nationa net promoter median score = 55 High = 90 Low = -5 Inpatient response rate = 41.5% Nationa response rate = 34.8% High = 100% Low = 10.9% Inpatient net promoter score = 73 Nationa net promoter median score = 72 High = 100 Low = 28 ED response rate = 21.2% Nationa response rate = 18.5% High = 53.5% Low = 1.6% ED net promoter score = 58 Nationa net promoter median score = 55 High = 90 Low = 1 Lancashire Teaching Hospitas NHS Foundation Trust considers that this data is as described for the foowing reasons; As a resut of improvements undertaken in response to compaints and other feedback Lancashire Teaching Hospitas NHS Foundation Trust intends to take the foowing actions to improve this score, and so the quaity of its services, by: Increasing response voumes through a review of data coection processes Impementation of aways events promoting positive staff/patient interaction and experience 21. %age of staff who woud recommend the trust to their famiy and friends Trust = 62 Trust = 56 Trust = 64 Nationa = 60 Nationa = 63 Nationa = 65 High/Low score - NA Lancashire Teaching Hospitas NHS Foundation Trust considers that this data is as described for the foowing reasons; The staff survey friends and famiy score improved significanty in 2013 and is now consistent with the nationa median. Lancashire Teaching Hospitas NHS Foundation Trust has taken the foowing actions to improve this score, and so the quaity of its services, by: Increased focus on staff deveopment and appraisa Positive regard, recognition and feedback of good practice and high standards Promotion of positive corporate vaues, attitudes and behaviour in the workpace increased board visibiity and engagement Exceent care with compassion 44

45 Lancashire Teaching Hospitas NHS Foundation Trust 23. %age of patients admitted who were risk assessed for Venous thromboemboism (VTE) Q Q Q Trust = 95.7% Trust = 96.0% Trust = 96.4% Nationa = 95.5% Nationa = 95.7% Nationa = 95.8% High = 100% Low = 74.1% Lancashire Teaching Hospitas NHS Foundation Trust considers that this data is as described for the foowing reasons; Compiance with VTE assessment remains above the nationa median. Performance in respect of root cause anaysis has improved significanty during 2013/14 and by year-end a root cause anaysis have been competed within the prescribed period. Lancashire Teaching Hospitas NHS Foundation Trust intends to take the foowing actions to improve this score, and so the quaity of its services, by: Continued root cause anaysis of a patients with VTE Shared earning and dissemination of good practice via patient safety champions in the workpace 24. C Difficie rates (/ bed days) amongst patients aged 2 or over Trust = 22.7 Trust = 21.7 Trust = 18.0 (based on popuation pending confirmation of popuation figures) Nationa = 21.7 High = 57.4 Low = 0 Nationa = 17.3 High = 30.8 Low = 0 Nationa = NA High/Low = NA Lancashire Teaching Hospitas NHS Foundation Trust considers that this data is as described for the foowing reasons; Custers of increased incidence during Q3 and Q4 Figures incude a number of cases that are subject to appea and may, if successfu, ead to a reduction in rate Lancashire Teaching Hospitas NHS Foundation Trust has taken the foowing actions to improve this score, and so the quaity of its services, by: Ensuring that focus for preventing Costridium difficie cases remains on best practice around antimicrobia stewardship, hand and environmenta hygiene. Increasing domestic service support and recruiting staff for out-of-hours housekeeping roes. Introducing the use of actime across the trust as part of the trusts ongoing commitment to reducing a avoidabe cases of Costridium difficie infection. 45 Exceent care with compassion

46 Annua report and accounts Patient safety incidents and the percentage that resuts in severe harm or death (i)rate of Patient Safety Incidents per 100 Admissions Apr 2010 March 2011 Apri 2011 March 2012 Apri 2012 March 2013 Number = 3723 Rate/100 admissions = 2.96 Nationa rate/ pop = 603 Number = 3902 Rate/100 admissions = 3.1 Nationa rate/ pop = 643 (does not incude Q4) Severe harm or death Number =11 Rate/100 admissions = 0 Number = 9867 Rate/100 admissions = 7.6 Nationa rate/ pop = NA High/Low - NA Severe harm or death Number = 57 Rate/100 admissions = 0 (ii) % of Above Patient Safety Incidents = Severe/Death Severe harm or death Number = 16 Rate/100 admissions = 0 Nationa rate/ pop = 5.07 Nationa rate/ pop = 5.22 (does not incude Q3 and Q4) Nationa = NA High/ow - NA Lancashire Teaching Hospitas NHS Foundation Trust considers that this data is as described for the foowing reasons; The increase in reporting of incidents and corresponding increase in those cases reported as severe harm or death is as a resut of improvements made to trust structures, processes and utiisation of the Datix incident reporting system to support increased reporting. Ongoing organisationa focus on the importance of incident reporting and deveopment of a positive safety cuture with improved staff engagement in incident reporting has aso contributed to this increase. Lancashire Teaching Hospitas NHS Foundation Trust intends to take the foowing actions to improve this score, and so the quaity of its services, by: Ongoing recruitment of patient safety champions to provide oca and speciaist advice on management of risks and to support incident reporting. Source: Heath and Socia Care Information Centre (HSCIC) Exceent care with compassion 46

47 Lancashire Teaching Hospitas NHS Foundation Trust Care Quaity Commission Compiance 4 Lancashire Teaching Hospitas NHS Foundation Trust has decared compiance against 16 of the 16 Core Outcomes. 4 Lancashire Teaching Hospitas NHS Foundation Trust has not participated in any specia reviews or investigations by the CQC during the reporting period. 4 The Care Quaity Commission has not taken enforcement action against Lancashire Teaching Hospitas NHS Foundation Trust during However an unannounced inspection of Roya Preston Hospita was conducted, an overview of the inspection and findings is provided beow. Date Review Findings 14-18th November 2013 Emergency Pathway invoving the Emergency Department. Media Assessment Unit, Rapid Assessment Unit and two medica wards 26th - 27th November 2013 Emergency Pathway invoving the Emergency Department. Media Assessment Unit, and one medica wards Met the standards: Ceaniness and Infection Contro Assessing and Monitoring and the Quaity of service provision Action needed (Minor): Care and wefare of peope who use services Staffing Compaints Met the standards: Ceaniness and Infection Contro Assessing and Monitoring and the Quaity of service provision Care and wefare of peope who use services Staffing Compaints An action pan to address concerns was agreed with the CQC and impemented within the required timescaes, foowing which a foow up inspection wi take pace. Quaity Risk Profies have ceased to be pubished by the CQC during and have been repaced by the Inteigent Monitoring reports which are reviewed on pubication and presented to the Risk Management Committee and Board. 47 Exceent care with compassion

48 Annua report and accounts Annexes Annex 1: Statements from Externa Stakehoders Greater Preston/Chorey and South Ribbe Cinica Commissioning Group. We have received an initia response from the Cinica Commissioning Groups as foows: NHS Greater Preston CCG wecomes the opportunity to comment on the Lancashire Teaching Hospitas NHS Foundation trust s annua quaity account. The process that we have undertaken has been to forward the account to the Joint Quaity and Performance Committee, which is a sub-committee of the CCG s Governing Body, for review and comments. Throughout the year the trust and CCG, in partnership, have reviewed and discussed quaity on a monthy basis. Through these discussions and the review of supporting evidence, it is our beief that the information contained within the trust s quaity account gives an overarching view of the quaity of services provided over the ast year. We are peased to note the number of awards that Lancashire Teaching Hospitas NHS Foundation Trust has achieved over the past 12 months: Customer Services Exceence Standard Award for hote services The Adut Oxygen Assessment Team Award for Quaity, Innovation, Productivity and Prevention Nationa Award for improvement in Breast Care Services These awards aign themseves to the overa vision of the NHS to promote an improved standard of care that not ony improves point of care standards but aso takes into consideration the importance of the environment in which we care for patients and services users. We fee the trust has missed an opportunity to document their success by not discussing the two nationa awards that have been achieved through participation in the Innovation Pathway piot. The CCG has noted the high number of Cinica Audits, the trust contributed to during , which demonstrates a commitment to improve standards and cinica pathways through research participation. We woud have iked the trust to provide evidence of the progress on the actions and recommendations of the nationa and oca Cinica Audits documented in the pubished quaity account for This woud aow the CCG to share the findings with our associates across the network. Research and Deveopment is key to improving services and products that are avaiabe to assist in the deivery of high quaity care for patients. We are peased to see that the trust has recruited over 2000 patients to take part in the 212 active research studies at the trust. Further information on the themes of good practice identified and the training packages being deveoped woud give an opportunity to share good practice across the network and for the trust to present its own success. We note the quaity performance data detaied within the quaity account and are encouraged to note the improved performance in the key strategic goas. The strategic focus on Safe Care, Effective Care and Experience of Care is ceary demonstrated and has been proved to increase the standards of cinica effectiveness within the trust. Whist we note the improvement in the overa Hospita Standardised Mortaity Rate reduction of 1.2%, we woud ike to see further detai on the Hospita Standardised Mortaity Rate at the weekends. We assume our coeagues in Speciaist Commissioning wi respond to the trust s quaity account reating to other key areas, for exampe around cancer targets. The CCG is mindfu of the chaenges the trust has faced during the ast 12 months. The partnership arrangements to address these have resuted we wi hope to maintain throughout the new financia year. The CCG is encouraged by the goas agreed for and woud ike to see these more ceary documented within the quaity account, in particuar the 7 Day Access CQUN as this aigns itsef to the recommendations highighted in the Keogh Report. There has been a variation of resuts throughout the year, associated to the Friends and Famiy Test; however we note that the trust has significanty improved its systems and processes within the A&E Department which has had a positive impact. We woud ike to recommend that the trust pubishes more detai on the resuts of the staff survey carried out, aong with detais on the current workforce and the actions in pace to address the concerns raised by staff members. Exceent care with compassion 48

49 Lancashire Teaching Hospitas NHS Foundation Trust The CCG was aware of the actions required within the trust foowing the CQC unannounced visit. We fee that the quaity account woud benefit from further detai of these aong with the improvements made. NHS Greater Preston CCG vaues the coaborative reationship estabished with coeagues at Lancashire Teaching Hospitas NHS Foundation Trust and ooks forward to continuing to work cosey on the quaity agenda in order to further improve the safety, effectiveness and experience for patients over the coming year. Heathwatch We have received apoogies from Heathwatch and been advised that they wi respond as soon as possibe. Governors Governors have not provided further comment, aside from some observations reating to formatting and grammar that have been addressed. Our response to Statements Lancashire Teaching Hospitas NHS Foundation Trust acknowedges the feedback provided by coeagues and partners. Specificay, feedback provided by commissioners as it reates to weekend mortaity rates and awards have been considered and revisions made to the narrative within the quaity report. In fact, the fina version provides a higher eve and depth of detai than that covered by the initia draft. Much of the information requested as it reates to the Trust workforce and detai reated to CQUIN programmes is provided through other forums and reporting mechanisms, but we wi expore with commissioner coeagues ways in which we can share earning from audit and research more widey and effectivey to mutua benefit. We aso ook forward to continuing to work cosey with commissioning coeagues to the benefits of patients and the pubic over the coming year. 49 Exceent care with compassion

50 Annua report and accounts Annex 2: Statement of Directors responsibiities for the Quaity report. The directors are required under the Heath Act 2009 and the Nationa Heath Service Quaity Accounts Reguations to prepare quaity accounts for each financia year. Monitor has issued guidance to NHS Foundation Trust Boards on the form and content of annua quaity reports (which incorporate the above ega requirements) and on the arrangements that NHS foundation Trust Boards shoud put in pace to support data quaity for the preparation of the quaity report. In preparing the quaity report, directors are required to take steps to satisfy themseves that: - The atest nationa patient survey 17/04/2014; - The atest nationa staff survey 25/02/2014; - The Head of Interna Audit s annua opinion over the trust s contro environment dated 21 May 2014; and - Care Quaity Commission quaity and risk profies pubished through ; The quaity report presents a baanced picture of the NHS Foundation Trust s performance over the period covered; The performance information reported in the quaity report is reiabe and accurate; The data underpinning the measures of performance reported in the quaity report is robust and reiabe, conforms to specified data quaity standards and prescribed definitions, is subject to appropriate scrutiny and review; and The quaity report has been prepared in accordance with Monitor s annua reporting guidance (which incorporates the Quaity Accounts reguations) as we as the standards to support data quaity for the preparation of the quaity report. The directors confirm to the best of their knowedge and beief they have compied with the above requirements in preparing the quaity report. The content of the quaity report meets the requirements set out in the NHS Foundation Trust Annua Reporting Manua ; The content of the quaity report is not inconsistent with interna and externa sources of information incuding: - board minutes and papers for the period Apri 2013 to March 2014; There are proper interna contros over the coection and reporting of the measures of performance incuded in the quaity report, and these contros are subject to review to confirm that they are working effectivey in practice; - Papers reating to Quaity reported to the Board over the period Apri 2013 to March 2014; - Feedback from commissioners dated 09/05/2014; - Feedback from governors dated 14/05/2014; By order of the Board - Feedback from oca Heathwatch organisations dated 13/05/ The trust s compaints report pubished under reguation 18 of the Loca Authority Socia Services and NHS Compaints Reguations 2009, dated 28/05/2014; Stuart Heys Karen Partington Chairman Chief Executive 28 May May 2013 Exceent care with compassion 50

51 Lancashire Teaching Hospitas NHS Foundation Trust Independent Auditor s Report to the Counci of Governors of Lancashire Teaching Hospitas NHS Foundation Trust on the Quaity Report We have been engaged by the Counci of Governors of Lancashire Teaching Hospitas NHS Foundation Trust to perform an independent assurance engagement in respect of Lancashire Teaching Hospitas NHS Foundation Trust s Quaity Report for the year ended 31 March 2014 (the Quaity Report ) and certain performance indicators contained therein. Scope and subject matter The indicators for the year ended 31 March 2014 subject to imited assurance consist of two of the three nationa priority indicators as mandated by Monitor: For acute NHS foundation trusts: Emergency readmissions within 28 days of discharge from hospita. 62 Day cancer waits - Percentage of patients receiving first definitive treatment for cancer within 62 days of an urgent GP referra for suspected cancer. We refer to these nationa priority indicators coectivey as the indicators. Respective responsibiities of the Directors and auditors The Directors are responsibe for the content and the preparation of the Quaity Report in accordance with the criteria set out in the NHS Foundation Trust Annua Reporting Manua issued by Monitor. Our responsibiity is to form a concusion, based on imited assurance procedures, on whether anything has come to our attention that causes us to beieve that: the Quaity Report is not prepared in a materia respects in ine with the criteria set out in the NHS Foundation Trust Annua Reporting Manua; the Quaity Report is not consistent in a materia respects with the sources - specified in the Detaied Guidance for Externa Assurance on Quaity Reports; and. the indicators in the Quaity Report identified as having been the subject of imited assurance in the Quaity Report are not reasonaby stated in a materia respects in accordance with the NHS Foundation Trust Annua Reporting Manua and the six dimensions of data quaity set out in the Detaied Guidance for Externa Assurance on Quaity Reports. We read the Quaity Report and consider whether it addresses the content requirements of the NHS Foundation Trust Annua Reporting Manua, and consider the impications for our report if we become aware of any materia omissions. We read the other information contained in the Quaity Report and consider whether it is materiay inconsistent with: Board minutes for the period Apri 2013 to May 2014; Papers reating to Quaity reported to the Board over the period Apri 2013 to May 2014; Feedback from the Commissioners dated May 2014; Feedback from oca Heathwatch organisations dated May 2014; The trust s compaints report pubished under reguation 18 of the Loca Authority Socia Services and NHS Compaints Reguations 2009, ; The nationa patient survey; The nationa staff survey; Care Quaity Commission quaity and risk profies-inteigent monitoring reports ; and The Head of Interna Audit s annua opinion over the Trust s contro environment. We consider the impications for our report if we become aware of any apparent misstatements or materia inconsistencies with those documents (coectivey, the documents ). Our responsibiities do not extend to any other information. We are in compiance with the appicabe independence and competency requirements of the Institute of Chartered Accountants in Engand and Waes (ICAEW) Code of Ethics. Our team comprised assurance practitioners and reevant subject matter experts. This report, incuding the concusion, has been prepared soey for the Counci 51 Exceent care with compassion

52 Annua report and accounts of Governors of Lancashire Teaching Hospitas NHS Foundation Trust as a body, to assist the Counci of Governors in reporting Lancashire Teaching Hospitas NHS Foundation Trust s quaity agenda, performance and activities. We permit the discosure of this report within the Annua Report for the year ended 31 March 2014, to enabe the Counci of Governors to demonstrate they have discharged their governance responsibiities by commissioning an independent assurance report in connection with the indicators. To the fuest extent permitted by aw, we do not accept or assume responsibiity to anyone other than the Counci of Governors as a body and Lancashire Teaching Hospitas NHS Foundation Trust for our work or this report save where terms are expressy agreed and with our prior consent in writing. Assurance work performed We conducted this imited assurance engagement in accordance with Internationa Standard on Assurance Engagements 3000 (Revised) - Assurance Engagements other than Audits or Reviews of Historica Financia Information issued by the Internationa Auditing and Assurance Standards Board ( ISAE 3000 ). Our imited assurance procedures incuded: Evauating the design and impementation of the key processes and contros for managing and reporting the indicators. Making enquiries of management. Testing key management contros. Limited testing, on a seective basis, of the data used to cacuate the indicator back to supporting documentation. Comparing the content requirements of the NHS Foundation Trust Annua Reporting Manua to the categories reported in the Quaity Report. Reading the documents. A imited assurance engagement is smaer in scope than a reasonabe assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deiberatey imited reative to a reasonabe assurance engagement. Limitations Non-financia performance information is subject to more inherent imitations than financia information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of estabished practice on which to draw aows for the seection of different but acceptabe measurement techniques which can resut in materiay different measurements and can impact comparabiity. The precision of different measurement techniques may aso vary. Furthermore, the nature and methods used to determine such information, as we as the measurement criteria and the precision thereof, may change over time. It is important to read the Quaity Report in the context of the criteria set out in the NHS Foundation Trust Annua Reporting Manua. The scope of our assurance work has not incuded governance over quaity or nonmandated indicators which have been determined ocay by Lancashire Teaching Hospitas NHS Foundation Trust. Concusion Based on the resuts of our procedures, nothing has come to our attention that causes us to beieve that, for the year ended 31 March 2014: the Quaity Report is not prepared in a materia respects in ine with the criteria set out in the NHS Foundation Trust Annua Reporting Manua; the Quaity Report is not consistent in a materia respects with the sources specified above; and the indicators in the Quaity Report subject to imited assurance have not been reasonaby stated in a materia respects in accordance with the NHS Foundation Trust Annua Reporting Manua. KPMG LLP St James Square Manchester M26DS 28 May 2014 Exceent care with compassion 52

53 Lancashire Teaching Hospitas NHS Foundation Trust Lancashire Teaching Hospitas NHS Foundation Trust If you have any queries regarding this report, or wish to make contact with any of the directors or governors, pease contact: Pau Howard Trust Secretary Lancashire Teaching Hospitas NHS Foundation Trust Roya Preston Hospita Sharoe Green Lane Fuwood Preston PR2 9HT Additiona information on our work is avaiabe at: 53 Exceent care with compassion