Quality Report

Transcription

1 Quality Report

2 About Airedale NHS Foundation Trust Airedale NHS Foundation Trust provides acute and community services to a population of over 200,000 from an area covering West and North Yorkshire and East Lancashire. Care and treatment is provided from our main site at Airedale General Hospital. Until April 2017 we also had inpatient beds at Castleberg Hospital, but have subsequently withdrawn services pending a public consultation. Community services are provided from sites which include Coronation Hospital in Ilkley and Skipton Hospital as well as health centres and general practices. We employ over 2,600 staff, including a community based workforce and have approximately 400 volunteers. Contents Part 1: Statement on quality from the Chief Executive Introduction Signed declaration Current view of Airedale NHS Foundation Trust s position and status on quality... 5 Part 2: Priorities for improvement and statements of assurance from the Trust Board Priorities for improvement 2016/ Priority 1 patient experience: improving the quality of care for people in the last days of life in Airedale General Hospital Priority 2 patient safety: management of pressure area care Priority 3 clinical effectiveness: management of sepsis Statements of assurance from the Board Review of services Participation in clinica l audits and national confidential enquiries Participation in clinical research Use of Commissioning for Quality and Innovation framework Registration with the Care Quality Commission Information on the quality of data Sign up to Safety Duty of Candour Race Equality Standard Reporting against core national indicators Part 3 Other quality improvement information Patient experience Patient safety Clinical effectiveness Performance against key national priorities Part 4: Annex Airedale, Wharfedale and Craven Clinical Commissioning Group (CCG) Overview and Scrutiny Committee Healthwatch Statement of directors responsibilities in respect of the Quality Report NHS Improvement guidance for data quality assurance on Quality Reports Glossary... 77

3 Part 1: Statement on quality from the Chief Executive 1.1 Introduction I am pleased to introduce Airedale NHS Foundation Trust s annual Quality Report as part of our public commitment to the delivery of excellent services. Our aim is to provide high quality care that is safe, clinically effective, compassionate and responsive to the needs of individual patients and their families the Right Care as set out in our three year Quality Improvement Strategy. Our achievements and the challenges that we must overcome to deliver best practice are reflected in this report. In March 2016 the Care Quality Commission undertook a full inspection of our services, publishing its report in August. Under this scheme, each service is given a rating against five domains. The ratings for individual services are combined to give an overall rating for the Trust. Against the caring, effective and responsive domains we were rated as good. For the other domains of safe and well-led we were rated as requires improvement, giving an summary rating of requires improvement. Overall we received 43 good ratings, one outstanding and one inadequate rating out of a possible 54. It gives me satisfaction to be able to report that inspectors found our staff and volunteers to be caring, treating patients and their families with dignity. The community based care teams were praised for providing a valued service to help people remain in their homes whilst the Trust s end of life care was commended. Our electronic record sharing and the telemedicine services, including the Gold Line service were recognised for their tangible outcomes for patients. Where any immediate concerns were raised about services for example, that remote telemetry monitoring of patients is safe and effective immediate action has been taken with staff responding directly to make quality improvements. Recruitment of additional doctors and nurses, the creation of modern facilities to augment multi-disciplinary working and a renewed focus on quality and safety are underway. There are recognised national shortages within staffing groups and specialisms for example Urgent and Emergency Care and we are working with expert bodies as well as with colleagues across the region to address the issue. Steps are being taken to strengthen engagement with staff so we can be assured that we are responding to concerns raised by staff and that management supports the development of leadership, accountability and governance across all levels. I would personally like to thank our staff for rising to the challenge to make the changes needed and the shared determination to deliver the Right Care vision for our patients and community during times of financial constraint and enormous pressure on services, including high levels of demand in emergency services throughout the year. We have a lot to be proud of as demonstrated at our annual Pride of Airedale awards. More recently in March 2017, the Care Quality Commission carried out a further comprehensive inspection with a focus on the services with domains rated as requires improvement or inadequate to understand whether we have embedded the requisite quality improvement. The release of the findings is not timely enough for inclusion in this publication, but will be fully reported in the 2017/18 Quality Report. Over the last year and in addition to addressing the Care Quality Commission inspection findings, we have monitored our progress against our 2015/16 quality priorities. In partnership with local people, representative groups and other providers these priorities aim is to provide safe and effective services which result in a positive patient experience for patients and their families. The Quality Report showcases our services and some of these quality improvement initiatives.

4 Quality achievements over the last twelve months include: Development of partnership approaches with primary and secondary care around Urgent Care. We are a partner on the West Yorkshire Urgent and Emergency Care Vanguard with improved access to out of hours services. Plans to increase the number of ED consultants and the roll out of a partnership scheme with local GP groups. Approval of a capital plan to deliver an Acute Assessment Unit an integrated Emergency Department, Acute Medical, Surgical Assessment, and Ambulatory Care Unit. The aim is to improve clinical decision making, patient flow and the patient experience. Implementation of SystmOne e- prescribing and e-discharge across more wards. Adoption of John s campaign to support carers to stay with patients with dementia in hospital. Runners up in the Kate Granger Compassion in Care awards for the Gold Line Service run by the Palliative Care Team. Roll out of the Nursing Associate pilot programme with colleagues from Leeds and Bradford and introduction of a Health Care Support Worker apprenticeship scheme in partnership with Keighley College. Recognition by Unicef UK (United Nations Children s Fund) of the commitment of our Maternity Services to the achievement of breastfeeding best practice standards. Successful bids to become one of the sites in the new Maternity and Neonatal Safety Collaborative - focusing on high risk versus low risk antenatal pathways - and to pilot a new national model of midwifery supervision. Establishment of a unique service offering help to adults with a stammer using a video link via the Airedale Digital Hub following a collaborative project proposal made with the British Stammering Association in response to a national shortage of specialist speech and language services. 1.2 Signed declaration We seek to foster an open and transparent culture so we can understand where improvements are needed. It is important that our Quality Report is accurate and presents an honest picture of our care. I am pleased to confirm that the Board of Directors has reviewed the 2016/17 Quality Report. As Chief Executive of Airedale NHS Foundation Trust, I can confirm that the information used and published in the Quality Report is, to the best of my knowledge, accurate and complete. It is important this document is read in conjuction with the Trust s Annual Plan. 31st May 2017 Bridget Fletcher Chief Executive Airedale NHS Foundation Trust

5 1.3 Current view of Airedale NHS Foundation Trust s position and status on quality The Trust aspires to deliver harm free, high quality patient care and aims to accomplish this by putting our patients, families and carers first. Our Quality Improvement Strategy, launched in 2016, following consultation with patients, staff and wider stakeholder groups, is built on the Right Care Quality Temple and its four pillars of quality, people, service and innovation which collectively underpin safe patient care. The following provides a brief review of quality outcomes against our quality and safety aims and includes Care Quality Commission (CQC) inspection findings. Harm free care Harm occurs when care is sub-optimal either as the result of something we did or did not do for the patient. According to the NHS Safety Thermometer indicator, 94.2 per cent of our patients receive harm free care, a finding which compares favourably with national and regional values. The 2016 NHS National Staff Survey indicates that the percentage of staff witnessing potentially harmful errors, near misses or incidents is in the best performing quintile for all acute trusts. Regrettably this year the Trust reported one Never Event - wrong site surgery this is a preventable patient safety incident that should not occur. Nationally between April 2016 and January 2017, there were 351 Never Events. Whilst the Trust prides itself on an effective incident reporting culture as indicative of a willingness amongst staff to raise concerns and promote patient safety, the CQC reported that some staff described a less open and positive culture and tasked us with improving staff engagement and responding appropriately to concerns raised by staff. As part of The People Plan, the Trust has developed a Freedom to Speak Up guardian role to support staff raising concerns. The 2016 National Staff Survey shows the fairness and effectiveness of incident reporting and staff confidence and security in reporting unsafe clinical practice is in line with the average results of the benchmark group. Having the right number and mix of staff with the appropriate skills, at all times, is integral to providing safe, high-quality care. The CQC required that the Trust make improvements to ensure that during each shift there are a sufficient number of suitably qualified, competent, skilled and experienced staff, nursing and medical, deployed to meet the needs of patients. Areas identified by inspectors included the Emergency Department and Critical Care (where there was an insufficiency in post registration nursing qualifications and intensivists). The latest available national Intensive Care National Audit and Research Centre (ICNARC) data shows hospital mortality for patient admissions in the Critical Care Unit within the expected range. 1 Other areas for improvement related to safety highlighted by the CQC inspection where detailed action has been taken include: Remote telemetry monitoring and the timely response to arrhythmias. Introduction of a daily multi-disciplinary ward round on the Critical Care Unit. Greater scrutiny of the physiological early warning score (NEWS) to identify those patients whose condition may be deteriorating. Review of processes around the management storage, administration and reconciliation of medicines. Compliance with and auditing of the World Health Organisation safety checklist for safer surgery. 1 ICNARC (2016) Annual Quality Report 2015/16 for adult critical care. Availiable at: Audit/Audits/Cmp/Reports/Annual-Quality-Report [Accessed 13/02/17.]

6 Examination of the storage and completion of medical records in line with professional standards, including individualised care planning. Review of guidelines to ensure the currency of recommendations within national guidance. Monitoring of staff mandatory training compliance levels, including safeguarding training. Introduction of a two person equipment check on the Critical Care Unit following a serious incident in April In September 2016 the Care Quality Commission conducted an unannounced follow-up inspection on the Critical Care Unit and some of the medical wards to assess improvement in relation to the safe and wellled domains. No formal ratings were provided. Inspectors found evidence that the Critical Care Unit action plan is on track to be deliver the recommendations from its comprehensive review. Our focus across all services remains on ensuring appropriate monitoring of equipment and staffing levels is in place. Key inspection findings have been incorporated into the overarching action plan. Patient complaints offer insight into safety related problems which may not be identified by traditional systems of healthcare monitoring such as incident reporting or case note review. In the last year we reported 73 formal complaints compared to 86 in the preceding period. Through monitoring complaints, the Trust aims to support managers to make prompt improvements. A newsletter Quality and Safety Matters highlighting learning from complaints and incidents is circulated to staff each month to reinforce learning. 2 For example: You said Why are all elderly care appointments in the morning; this does not take into consideration the elderly person? Elderly people tend to have mobility issues upon rising, they may need carers to get them up, possibly require carers to feed them, and they need to be 2 Detailed analysis and learning from complaints can be found in the complementary annual Complaints and Concerns Report 2016/17 available in June 2017 at: [accessed 20/02/17]. ready for two hours prior to the appointment time for the ambulance transport We did... The department has commenced some afternoon clinics. The service is currently under review with further consideration being given to elderly clinics in the afternoon. You said Concerns regarding the cleanliness of the Emergency Department were raised. We did... Head of Facilities visited the department, cleaning input has been increased and additional training provided to domestic staff. Patient Advice and Liasion Service notice boards display resultant learning to the public. The Health Service Public Ombudsman upheld a complaint regarding the Trust not following MRSA colonisation suppression protocol. Actions have been taken to address compliance. Infections as a result of healthcare interventions for the fiscal year are: two cases of hospital acquired MRSA bacteraemia and 13 cases of C.difficile of which two cases were found upon investigation to be unavoidable. C.difficile infection per 100,000 bed days in Trust patients aged 2 or over is in line with the England average for the most currently available fiscal year. In May 2016 the Trust was named for the third consecutive year one of the top five hospitals for the CHKS national patient safety award by the independent provider of healthcare intelligence. No avoidable mortality Estimating preventable deaths is complex and the number of such deaths across England remains uncertain. Key mortality measures Summary Hospital-level Mortality Indicator and the Hospital Standardised Mortality Ratio show no evidence of risk with performance for the Trust with expected. Mortality cases are routinely reviewed by a Consultant-led Mortality Group to identify cases of potentially avoidable mortality, formulate action plans and highlight learning. As part of a regional group of trusts who have adopted structured case note review, this approach has led to

7 demonstrable quality improvement in, for example, antibiotic prescribing. We are currently participating in the Yorkshire and Humber Learning Disability Mortality Review Pilot which aims to capture best practice and provide a co-ordinated approach in the care of a potentially vulnerable patient group. Innovative real-time quality intelligence To drive forward and monitor improvement in care, meaningful patient information and clinical intelligence is required at all levels of the organisation. In recent years we have: Adopted electronic incident online reporting to provide more timely information and feedback so that action can be taken to prevent harm to others. Established accessible real time clinical audit, complaint, serious incident and claims and litigation trackers to allow appraisal of progress and cross referencing of information to identify emerging patient safety themes. Developed a performance dashboard for theatres. Switched to a new internal intranet Aireshare with improved governance of policy and clinical guidelines (in line with CQC recommendations). Upgraded the Real Time Patient Survey to improve sample size, breadth of areas included and allow bespoke topic review. Introduced capacity and demand modelling linked to the Patient Administration System to deliver front line service managers with near real time information on referrals and booking patterns. Through the use of SystmOne shared primary and secondary healthcare record access, information can be accessed securely across care settings to obtain a tailored view of an individual s health information. A flagging system of patient electronic records means that when patients with additional needs are admitted or attend outpatients for example patients living with dementia specialist staff can be alerted and a more responsive service provided. No avoidable delays in care NHS England has indicated that instances of delayed transfers of care from hospital to other care settings is increasing across the country. This has an impact on the flow of patients through the hospital. For example, the CQC inspection found that patients well enough to leave the Critical Care Unit experienced delays being transferred to a ward more conducive to their recovery. In response, the Unit s bed configuration has been reviewed to ensure the bed base is being used appropriately and efficiently. Patient Pathways and Flow Programme is part of our transformational work to integrate the contributions of district nurses, social workers, mental health professionals, GPs, care homes and voluntary organisations into a cohesive system to support the health and well-being of the community. The CQC reported that the community based collaborative care teams were an outstanding example of multi-disciplinary team working. Working across the acute and community services and with other agencies, these teams provide a responsive service for patients 24 hours a day, seven days a week, aiming to support those patients in crisis to remain in their own home as well as supporting early discharge from hospital. The work of the Intermediate Care Hub in using enabling technology to provide a single point of access to all aspects of specialist health and social care advice was also highlighted by inspectors. In the last year we have hosted a Multi- Agency Discharge Event (MADE) to facilitate the discharge of medically fit patients. Allied to this work is the adoption in recent months of the SAFER patient flow bundle from NHS Improvement, a set of simple rules for adult inpatient wards to improve patient flow and prevent unnecessary waiting for patients. In spite of these and other initiatives including seven day opening of the Ambulatory Care Unit, multiple pressures across the whole health and care system have affected the

8 delivery of services. In the last 12 months, we have exceeded national standards including: Emergency Department maximum waiting time of four hours from arrival to admission, transfer or discharge. Regrettably, one patient waited over 12 hours for admission. The maximum 18 week wait from referral to treatment. We apologise for not achieving these important quality standards. However, across the region, we are within the top third of providers for ED and ambulance handover standards with an incremental improvement in the average handover times. The Trust continues to work with the Local A&E Delivery Board and is part of the West Yorkshire Accelerator Zone. The planned new Acute Assessment Unit will re-design emergency and acute care services to allow rapid access to appropriate staff and diagnostic tests and clinical treatments, enhance clinical skills via enhanced multidisciplinary working. The aim is to reduce waiting and treatment time for some patients, reduce unnecessary admission and improve patient flow. The plan is for the Unit to be completed by Spring Part 2: Priorities for improvement and statements of assurance from the Trust Board 2.1 Priorities for improvement 2016/17 In last year s Quality Report, we identified our three key local quality priorities for this fiscal year. These are listed below with detailed information on how we performed are set out in this section of the Quality Report: Patient experience: improving the quality of care for people in the last days of life at Airedale General Hospital; Patient Safety: management of pressure area care; and, Clinical Effectiveness: the management of sepsis. We also committed to reporting on a number of aspects of improvement work within the three domains of quality. Our progress and performance over the last year for the following quality goals is reported in Part 3 of this report: 3.1 Patient experience: Improving care for patients living with dementia; Privacy and dignity: o Promotion of a customer services culture; and, o A patient-led care environment. 3.2 Patient safety: Infection prevention and control; Reduction of slips, trips and falls sustained by patients admitted to our hospital wards; and Frail Elderly Care Pathway Team initiative (to identify frailty and enhance care planning between health and social care). 3.3 Clinical effectiveness: Airedale Digital Care Hub and the overall quality of healthcare for people with longterm conditions; The monitoring of Caesarean section rates through the safe promotion of normality; and, Fractured neck of femur improvement project. Future priorities for 2017/18 How we engage with others in developing our quality goals The views of our patients and staff is important and we receive feedback via a number of methods, including: surveys, patient and staff stories, complaints and concerns, social media, Patient Safety and commissioner Quality Walk Rounds, listening events and Healthwatch enter and view visits. Our volunteers, the Patient and Carer Panel and the Council of Governors play an

9 invaluable role in representing the views and interests of the local community, including staff; their engagement work informs and guides our Right Care vision. According to the 2016 National NHS Staff Survey we compare favourably with other acute trusts in England for the second consecutive year for making effective use of patient and service user feedback. In recent years the following priorities have been judged to be embedded and monitored within clinical governance systems and, as such, will no longer be reported in future publications: Improving the quality of care for people in the last days of life at Airedale General Hospital; and, Management of pressure area care. Our 2017/18 key quality priorities are: 1 Patient experience: improving the quality of wound care for patients both in hospital and the community. The care we provide to patients who have or develop wounds can fundamentally improve the quality of their lives. There are approximately 79,500 people in England who have a complex wound at any one time; healing can take months, years or never happen at all. However, by the provision of standardised care based on research and best practice, patients will have the greatest opportunity for healing. In addition by working seamlessly between community, primary care and the hospital setting we will ensure there is an individualised programme of treatment to support this healing and the improvement in the quality of patients lives. This initiative will be monitored at the Nursing Midwifery Leaders Group and reported through all the Clinical Delivery Assurance Groups. 2 Patient Safety: improve the prevention, early identification and management of Acute Kidney Injury. As a significant source of harm, the early detection and effective management of Acute Kidney Injury is a key priority for the Trust. One in five emergency admissions to hospital in England and Wales has Acute Kidney Injury (AKI) 3 and of the estimated 100,000 deaths associated with AKI, approximately 30 per cent could have been prevented with the right care and treatment. 4 Building on existing quality improvement work and in recognition that early detection and management has a profound effect upon patient safety we seek in collaboration with our Right Care partners, Airedale Wharfedale Craven Clinical Commissioning Group and Bradford District Care NHS Foundation Trust, to raise awareness with the aim of reducing avoidable deaths whether in hospital and/or community care settings. Progress will be monitored by the Clinical Groups and reported at all the Clinical Delivery Assurance Groups. 3 Clinical Effectiveness: management of sepsis. Sepsis is a key national priority for NHS England and local commissioning groups with recent high profile reports highlighting issues in the its detection and treatment. Sepsis claims 37,000 lives each year in the United Kingdom. Research indicates that by continuing to improve, the Trust can save up to 100 extra lives each year in a hospital the size of Airedale. Other local quality improvement work identified for inclusion in the 2017/18 Quality Report remains unchanged and is as referenced on the preceding page (3.1 to 3.3): 3 Wang H, E, Muntner P, Chertow G, M, Warnock D, G, Acute Kidney Injury and Mortality in Hospitalized Patients. Am J Nephrol 2012;35: NCEPOD (2009) Adding insult to injury. A review of the care of patients who died in hospital with a primary diagnosis of acute kidney injury. Availabel at: df [Accessed 16/12/17].

10 2.1.1 Priority 1 patient experience: improving the quality of care for people in the last days of life at Airedale General Hospital The challenge and our aim The care we provide to patients who are dying and their relatives is fundamental to high quality, individualised and compassionate care. Our approach is based on One Chance to get in Right (NHS England 2014) and focuses on five principles: 1. Recognition that a person is likely to be in the last few days of life; 2. Sensitive communication between staff, the dying person and those important to them; 3. Involvement in treatment and care decisions to the extent desired; 4. The needs of families are understood and respected; and, 5. An individual plan of care is co-ordinated and delivered with compassion. How we monitor progress Meeting quarterly, quality improvement is monitored by the multi-disciplinary End of Life Operational Group via: Evaluation of staff training uptake, Staff assessment of its usefulness and patient outcomes; Feedback from the annual Bereaved Relatives Survey; and, On-going national and local clinical audit. The Trust s Caring for Patients in the Last Days of Life (Adults) Policy underpins this group s work. A key group member is a Patient and Carer Panel representative who ensures that the views of patients and wider public as well as healthcare professionals are taken into account. In recognition of the varying needs of the patient group across the locality, a Community Services End of Life Operational Group has been established. Current status In its inspection, the CQC rated end of life care as Good. It found staff were trained and demonstrated a consistently good knowledge of end of life care issues. Pain was well managed and patients were treated with compassion, dignity and respect. Bereaved family and friends were cared for in a sensitive and supportive way. However, the following was observed: A lack of engagement with black minority and ethnic communities, a finding also highlighted in the 2015 Royal College of Physician s End of Life Care Audit Dying in Hospital. Facilities for families and friends could be improved, particularly the mortuary environment ( stark and basic ) and the route bereaved families walked. It was difficult to determine responsiveness of services to a patient s preferred place of death as around two thirds of patients did not record a preference. 24 The National Survey of Bereaved People VOICES (Views of Informal Carers Evaluation of Services) collects information on bereaved peoples views on the quality of care provided. Participation allows benchmarking against national data. The 2012 national VOICES survey demonstrated that the majority of bereaved relatives felt their loved ones received good or excellent care at the end of life. Three areas were identified where we could improve: communication,

11 Standard 6 Privacy and dignity, spiritual care Standard 1 Communication privacy and dignity and variation in staffing levels and competency. With permission, the Trust used the questions from the VOICES questionnaire relating to experiences within the last days of life in the hospital setting and added additional questions to provide an annual assessment of the quality of our care. The following metrics have been selected from this local survey to measure improvement in our inpatients experience in respect of communication and privacy and dignity. The standards were agreed by the Bradford and Airedale Palliative Care Managed Clinical Network and take into account NICE quality standards and national recommendations. Table 1: Airedale General Hospital (AGH) Survey of Bereaved Relatives 2012 to 2016 Domain Standard Survey of Bereaved People AGH 2012 Overall sample [n]=55 AGH 2014 Overall n =92 AGH 2015 Overall n = 29 AGH 2016 Overall n = 46 Communication with the patient is honest, open and ensures involvement in decisions about care and treatment if the patient wishes. Relatives, important others and/or advocates are involved in discussions about the patient s plan of care and are given the opportunity to discuss their own concerns. Of those where discussion was possible, was this done sensitively? Was there adequate involvement in decision making? Did the patient have a preferred place of death? Were relatives involved in the decision making? 36.6% 66.5% 78.0% 68.0% 81.0% 93.0% 95.5% 100.0% 10.4% 26.5% 33.0% 15.2% 79.2% 76.6% 86.0% 82.0% Wherever possible the patient is cared for and offered a single room. Spiritual needs of patients assessed and a support referral made where appropriate. Cared for in side room 55.0% 68.0% 83.0% 55.3% Cared for on main ward 38.0% 22.0% 10.0% 27.6% Moved to another ward 7.0% 10.0% 7.0% 17.0% Spiritual support for patient was poor 27.3% 15.0% 0.0% 6.3% Data source: Airedale General Hospital End of Life Care Annual Report January 2017 This year s survey has had mixed results but overall there had been a reduction in standards of care as perceived by relatives and friends of the dying patient compared to last year. For example, fewer patients were cared for in a side room. This shows us that although we did well in the CQC inspection we still need to be vigilant in not letting our high standards slip. An action plan has subsequently been developed and includes: planned training sessions on difficult conversations for medical staff, awareness raising for all staff on the importance of addressing spiritual needs and continued training for Chaplaincy volunteers around care in the last days of life. Work is underway to identify quiet and private spaces within the Trust..

12 Initiatives and progress in 2016/17 In the previous year the following areas were identified as areas of development with the resulting progress made: Implement a competency framework and related mandatory sessions for all staff groups for care in the last days of life. The Specialist Palliative Care Team have run four sessions of four hour duration on the care of patients in the last days of life and communication. These have been attended by 64 nurses and healthcare professionals. There continues to be a palliative care session on the rolling education programme for registered nurses. Sessions on advance care planning and training for advance nurse practitioners to make Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions have also been organised. In addition, the End of Life Facilitator continues to support individual wards to use the main care tools adopted by the Trust, such as the Gold Standards Framework, the personalised end of life care plan and the Electronic Palliative Care Co-ordination System. Identify opportunities to enable difficult conversations training for senior medical staff. A programme of training in difficult conversations for senior clinicians across Airedale and Bradford was implemented in the 2016/17 with five sessions held at Airedale General Hospital. Local consultants and advanced nurse practitioners attended. The initiative has now finished, but remains an area where further developmental work is required. A Death Café was held in May 2016 to encourage staff, patients and carers to have conversations about end of life and raise awareness of this issue. Maximise learning from complaints, concerns and compliments related to end of life care. These are now discussed in the End of Life Operational Group with the intention that themes will be summarised biannually. One theme that has been noted is the importance of documenting the content of conversations in case notes. This is fed back to the individual on a case-by- case basis. When auditing DNACPR forms evidence of discussion with patient and family is one quality marker. Where this is not achieved this is relayed to the relevant ward. Link with Estates to ensure the needs of relatives and carers are taken into account in its on-going programme of work. Following feedback from the Care Quality Commission inspection, the route taken by families to the mortuary is being reviewed in collaboration with patients and carers. A plan to refurbish the view room environment is being taken forward. Women and Children s Services are agreeing actions required to improve transportation of deceased babies. In addition the Chaplaincy has undertaken a survey with patients and visitors to assess the provision of quiet space for reflection. Introduce ward level audit of documented care and feedback via ward governance meetings. Information on how staff use the last days of life personalised care plan is being collated via review of in- hospital deaths. Between 38 and 46 per cent of deaths indicate use of the plan. Results are disseminated to individual ward managers; where uptake is low, support is being offered by the Specialist Palliative Care Team and the End of Life Care Facilitator to ensure priorities for care are met. Pilot the use of Schwartz rounds 5 (or similar) to enhance staff support and reflection around end of life care. A Lottery funding application was unsuccessful. This initiative is seen as a means of maintaining staff resilience and compassion and is to be reconsidered later next year. 5 For more information: [Accessed 6/01/16]

13 Develop appropriate last days of life material for the Trust internet site. Whilst there is a palliative care site and an app for staff use, patient and public information on end of life care remains an area of intended development. Take part in engagement work to ensure we are meeting the needs of black minority ethnic groups around care in the last days of life. Following the CQC inspection, an action plan for this work is being implemented with this regarded as a key objective in the coming year. This includes: engagement with ethnic minority groups and community leaders; a training session on end of life issues with interpreters; a rolling programme to raise awareness of cultural and spiritual issues; and, a review of methods for obtaining feedback from ethnic minorities. Consider hospital wide Gold Standard Framework accreditation. The Specialist Palliative Care Team continues to support staff, patients and families with information, including the principles of the Gold Standard Framework. This is a nationally recognised and a systematic, evidence based approach to improve the quality of care for people considered to have a life expectancy of less than 12 months. Wards 6 and Ward 9 achieved full accreditation in March 2016, a recognised quality marker. Harden Ward, Castleberg, is working towards accreditation; other wards are considering it. Although the focus is on the care delivered within the hospital, there are strong crossboundary links in terms of services and strategic planning. In line with the National Palliative Care Strategy, the hospital has a seven day Clinical Nurse Specialist service enabled by partnership working with Sue Ryder Manorlands Hospice, who provide staffing and additional funding to employ an extra nurse in the hospital so that the Hospital Team and Manorlands Community Team can combine to cover weekend working. Longer term funding is currently being sought. Other associated work: Access to advice through the innovative Gold Line telephone service a central point of contact for terminally ill patients and carers offered 24 hours a day, seven days a week, via the Airedale Digital Care Hub is also available. The joint use of the electronic palliative care co-ordination systems across Airedale, Wharfedale, Craven and Bradford aims to enhance cross boundary working through a more complete picture of treatment and care decisions. Next steps In addition to the on-going work from last year, planned future work includes: Use of SystmOne to record and print DNACPR forms within the hospital (this already happens in the community). This means information is cannot be complete and legible. Improved end of life care for specific nonmalignant illnesses. e.g. end-stage cardiac disease, end-stage liver disease, end- stage Parkinson s disease, people with a learning disability near end of life; Support for staff in dealing with end of life issues and how it affects them; Joint working with Manorlands and community teams to look at patient flow in order to minimise hospital admissions and length of stay where appropriate.

14 2.1.2 Priority 2 patient safety: management of pressure area care The challenge and our aim Pressure ulcers are a type of injury that breaks down the skin and underlying tissue due to impaired blood supply caused by friction and/or pressure. Whilst all patients confined to bed or a chair are at risk of developing a pressure ulcer, particularly those sedated or unconscious, the risk is heightened in those with significant cognitive impairment, poor nutrition, impaired mobility or sensation, incontinence, or with a neurological condition. Pressure ulcers can become infected, painful and reduce quality of life and length of hospital stay. 6 Although some pressure ulcers are inevitable, many can be avoided. 7 Building on patient feedback on existing quality improvement work and in recognition that pressure ulcers originate across and outside of the health and social care system, we seek in collaboration with our Right Care partners, Airedale Wharfedale Craven Clinical Commissioning Group and Bradford District Care NHS Foundation Trust, to integrate tissue viability services and implement interventions that prevent and address the causes of pressure ulcers with the aim of reducing prevalence, whether in hospital and/or community care settings. How we monitor progress The initiative s project plan is monitored by the Nursing and Midwifery Leaders Group with oversight linked to the integrated tissue viability service specifications as monitored by the Integrated Tissue Viability Board. Current status The NHS Safety Thermometer, a national improvement tool used to monitor and analyse patient harm including that relating to pressure ulcers, has been embedded within the organisation. A point prevalence tool, it surveys 100 per cent of inpatients and a sample of community patients one day per month. Unlike incident reporting, the tool records only the most serious category rather than each single incident. The special process control chart (SPC) is based on a mean average over the last 25 months, and shows how the Trust compares to the Yorkshire and Humber and the England average in that period. The average monthly sample is 475 patients. Over the last 24 months, the percentage of patients with a pressure ulcer C2 to 4 (denoted by the blue line) has followed a downward trend across all sites. A shift below the regional and national average (green and orange line) is noted in July 2016, albeit with a slight elevation noted at the start of In March 2017 performance was significantly better than expected. The metric includes both those pressure ulcers that developed directly under our care and those that developed outside of our care domain. As such, it provides an indication of the effectiveness of this initiative as well as of our care. (In the last twelve months, 22 per cent of all C2 to 4 pressures ulcers developed under our sphere of care.) 6 The University of York (2014), Effectiveness Matters: Preventing Pressure Ulcers, Centre for Reviews and Dissemination October NHS Stop the Pressure Campaign. [Accessed 22/1/16].

15 Figure 1: Data source: Yorkshire and Humber Academic Health Sciences Improvement Academy. In addition to the above, all reported incidents are reviewed on a weekly basis to address learning from avoidable pressure ulcers and identify issues promptly. A serious incident cluster investigation of three pressure ulcers resulting in significant harm on the Orthopaedic Ward was undertaken in 2016 with learning identified, notably glide off-tilt principles, and disseminated across a range of forums. The National Hip Fracture Database managed by the Royal College of Physicians describes the variation in care for the frail older patient who typically suffers this injury. The prevention of pressure ulcers has huge implications for a patient s comfort, dignity, length of stay and long term dependency. In total in 2015, 94.9 per cent of inpatients across England, Wales and Northern Ireland presenting with a hip fracture were recorded as free of a pressure ulcer; the proportion for Airedale was 98.4 per cent, a value which also compares favourably with the regional average for Yorkshire and Humber. 8 Each year the Trust, in association with ArjoHuntleigh, undertakes a pressure ulcer prevalence audit to support understanding of our preventative care. Case mix adjusted data measures patient outcomes. Facility-acquired prevalence (excluding category one pressure ulcers) was 0.4 per cent for the 255 patients assessed, a rate lower than the observed national reference data. 8 Royal College of Physicians (2016), Falls and Fragility Fracture Audit Programme. The National Hip Fracture Database Extended Report Health Quality Improvement Partnership. Page 78.

16 Initiatives and progress in 2016/17 In the last year there has been continued focus on training for certain staff groups in pressure ulcer screening, identification and prevention through the implementation of: skin bundles, off-loading techniques and prioritising the availability of pressure relieving equipment in both the hospital and community setting. In the previous year the following areas were identified as areas of development with the following progress made: Fully operationalize the integrated tissue viability service to include a single point of referral to ensure uniformity of approach. The Trust continues to work with Airedale Wharfedale and Craven Clinical Commissioning Group (CCG) in support of integrated working with Bradford District Care NHS Foundation Care Trust with the overarching aim of establishing a tissue viability service model. (As we previously reported, the CCG has funded three Pressure Ulcer (Team) Nurses to provide additional training, education and support to the nursing and residential care homes across the district.) In July 2014, the Trust employed a further Tissue Viability Nurse. Due to manpower issues there has been a further delay in the start of the integrated service by providers. We anticipate full integration in 2017/18; recruitment is underway. Following the success of the 2015 November STOP Pressure Ulcer Day, the Trust has continued to promote awareness across the Airedale, Wharfedale and Craven locality. For example the React to Red national campaign which aims to educate not only staff but patients, carers and family about the signs and actions to manage pressure ulcers more effectively. An action and implementation plan has been developed to support the campaign s launch and longer term success. Next steps Progress against this priority will be monitored through clinical governance mechanisms. Scrutiny of all monitoring data will continue to ensure on-going effectiveness. Improving the care and treatment of wounds encompasses more than pressure ulcers which is why in the coming year, future key quality improvement work will focus on improving wound care for all our patients. Other work: A Joint Wound Care Formulary has been finalised. A joint Integrated Tissue Viability Policy has been implemented; a review of risk assessment tools has taken place.

17 2.1.3 Priority 3 clinical effectiveness: management of sepsis The challenge and our aim How we monitor progress Sepsis is a common and potentially life-threatening condition where the body s immune system overacts to an infection. Affecting all age groups, sepsis is recognised as a significant cause of mortality and morbidity in the NHS, with around 35,000 deaths attributed to sepsis annually. 9 Reports by the Parliamentary and Health Service Ombudsman have highlighted problems in the detection and treatment of sepsis. 10 Sepsis is a key national priority for NHS England and local commissioning groups. The Trust seeks to embed identification and treatment of sepsis in line with national guidance for the Commissioning for Quality and Innovation (CQUIN). Whilst there has not been any local patient engagement as such, patients have fed into the national toolkit which has been used as the basis for the recently updated Sepsis Clinical Pathway. Staff participated in the Healthcare Quality Improvement Partnership as part of the Clinical Outcome Review Programme s Sepsis Study. Progress is measured through the CQUIN indicator and monitored by the Clinical Groups and reported at all the Clinical Delivery Assurance Groups. Current Status A range of actions are recommended for rapid implementation when a patient presents with sepsis known as the Sepsis Six Bundle. The UK Sepsis Trust and others have developed the concept of the Sepsis Six a set of six tasks including oxygen, cultures, antibiotics, fluids, lactate measurement and urine output monitoring to be instituted within one hour by non-specialist practitioners at the front line. 11 It is the prompt administration of antibiotics which is regarded as the most crucial action in the prevention of morbidity and mortality. 1. Screening for sepsis (focus within Emergency Department). Each month a minimum of 50 case notes for those patients aged 18 and above who presented at the Emergency Department with symptoms associated with sepsis are reviewed, to assess the proportion that are screened. Screening performance has improved from an average of around 60 per cent in the previous equivalent period to over 95 per cent in the last fiscal year. 9 Royal College of Physicians (2014) Acute Care Toolkit 9: Sepsis [Accessed 25/11/16] 10 Parliamentary and Health Service Ombudsman, Time to Act. Severe sepsis: rapid diagnosis and treatment saves lives sepsis. Available at: data/assets/pdf_file/0004/22666/final_sepsis_report_web.pdf [Accessed 11/01/16] 11 [Accessed 11/01/16]

18 Table 2: 2016/17 national CQUIN goals physical health: sepsis Q1 2016/17 Q2 2016/17 Q3 2016/17 Q4 2016/17 The percentage of Emergency Department patients presenting with symptoms associated with sepsis that were screened according to local protocol. 97% 95% 95% 95% Data source: CQUIN 2016/17 submission. 2. Administration of antibiotics Retrospective case note review of a random sample of inpatients where clinical codes indicate sepsis has been undertaken over the last year to understand the level of compliance with the local protocol for the administration of intravenous antibiotics and where improvements can be made. It is acknowledged at national level that coding for sepsis and systemic inflammatory response syndrome (SIRS) is a challenge. There continues to be clinical discussion about the conditions and their definitions, and the Coding Department works closely with clinical leads to ensure information is reliable and complete. A new proforma is coming that will is designed to make coding simpler. Initiatives in 2016/17 to achieve progress Integration of the recommendations of the Clinical Outcome Review Programme, Sepsis Study. Published in November 2015, the aim of the study is to identify and explore avoidable and remediable factors in the process of care for patients with sepsis. Amongst its objectives are: the evaluation of systems and processes that are in place to facilitate timely identification, escalation and appropriate treatment of infection, including transfer to high dependency and intensive care units where appropriate, and examination of the recognition of sepsis and early signs of septic shock across the entire patient pathway from onset of acute illness recognisable as sepsis through to admission to a definitive clinical area (e.g. intensive care). Following its inspection, the Care Quality Commission required that the Trust ensure that physiological observations and the national early warning score (NEWS) are calculated, monitored and that all patients at risk of deterioration are escalated in line with Trust guidance. Consistent use of NEWS assesses how sick patients are and can improve the identification and treatment of sepsis. Training and documentation review has been undertaken in response to these findings to ensure a standardised approach across all services. Clinical audit is on-going to ensure compliance is maintained. Provision of regular training and updates in sepsis management to encourage staff to think sepsis continues. This includes medical staff tutorials and a rolling programme for nurses. As part of quality improvement work, emergency scenarios for example, recognising sepsis are regularly enacted in the clinical environment, utilising a high fidelity manikin and actual clinical teams to ensure the experience is as realistic as possible. The primary objective is the identification of latent risks staff knowledge which can then be addressed. Other related work: Education materials produced by Health Education England to increase awareness amongst healthcare professionals have been distributed. Sepsis boxes are available in clinical areas Acute Medical Unit, Intensive Care and Labour Ward to enable timely intervention. Embedding of new sepsis guidelines from February Availability for all staff of a sepsis pathway based on the national toolkit (revised in February 2016). Attendance of key nursing and medical clinical leads at a series of half-

19 day regional sepsis sessions, hosted by the Yorkshire Ambulance Service, looking at how to further develop the sepsis pathway in a way that gives the patient the best chance of rapid continuing treatment at the Emergency Department, by recognising the signs of sepsis in the community. Other related work: Embedding across the organisation a systematic approach to assessing risks and preventative treatment for venous thromboembolism; Ensuring the appropriate prescribing to safeguard against antibiotic resistance. Participation in the Severe Sepsis & Septic Shock in Adults Clinical Audit 2016/17. Next steps Continue to participate in and submission of healthcare intelligence to the Intensive Care National Audit and Research Centre (ICNARC) to support the availability of national data on the impact of sepsis. Improve consistency and transparency of reporting through participation in 2017 in the NHS England s sepsis specific indicator to help highlight those areas requiring improvement.

20 2.2 Statements of assurance from the Board The following statements serve to offer assurance that the Trust is measuring clinical outcomes and performance, is involved in national projects aimed at improving quality and is performing to essential standards Review of services During Airedale NHS Foundation Trust provided and/or sub-contracted 77 relevant health services [as per NHS Improvement s Provider License]. The Airedale NHS Foundation Trust has reviewed all the data available to them on the quality of care in 77of these relevant health services. The national clinical audits and national confidential enquiries that Airedale NHS Foundation Trust was eligible to participate in during 2016/17 are as follows: see tables 3 and 4. The national clinical audits and national confidential enquiries that Airedale NHS Foundation Trust participated in during 2016/17 are as follows: see table 3 and 4. The national clinical audits and national confidential enquiries that Airedale NHS Foundation Trust participated in, and for which data collection was completed during 2016/17, are listed below alongside 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. The income generated by the relevant health services reviewed in 2016/17 represents 91 per cent of the total income generated from the provision of relevant health services by the Airedale NHS Foundation Trust for 2016/ Participation in clinical audits and national confidential enquiries Clinical audit measures the quality of care and services against agreed national and local standards and recommends improvements where necessary. National confidential enquiries into patient outcomes and death are conducted by specialists with the aim of improving patient care and safety. During 2016/17, 35 national clinical audits and 8 national confidential enquiries covered relevant health services that Airedale NHS Foundation Trust provides. During that period Airedale NHS Foundation Trust participated in 92 per cent of national clinical audits and 100 per cent of national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.

21 Table 3: National clinical audits undertaken by Airedale NHS Foundation Trust Per cent eligible Ref Title Applicable Participation patients submitted 1 Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP) Adult Asthma Adult Cardiac Surgery N/A N/A 4 Asthma (paediatric and adult) care in emergency departments Bowel Cancer (NBOCAP) Cardiac Rhythm Management (CRM) Case Mix Programme (CMP) Chronic Kidney Disease in primary care N/A N/A 10 Congenital Heart Disease (CHD) N/A N/A 11 Coronary Angioplasty/National Audit of Percutaneous Coronary Interventions (PCI) N/A N/A 12 Diabetes (Paediatric) (NPDA) a) Elective Surgery (National PROMs Programme) knee replacement b) Elective Surgery (National PROMs Programme) groin hernia c) Elective Surgery (National PROMs Programme) varicose veins 29.5 d) Elective Surgery (National PROMs Programme) hip replacement Endocrine and Thyroid National Audit a) Falls and Fragility Fractures Audit programme (FFFAP) Hip Fracture Database 100 b) Falls and Fragility Fractures Audit programme (FFFAP) Falls Audit Awaiting May 2017 start N/A c) Falls and Fragility Fractures Audit programme (FFFAP) Fracture Liaison Database N/A N/A 16 Head and Neck Cancer Audit N/A N/A 17 Inflammatory Bowel Disease (IBD) programme NA 19 Major Trauma Audit National Audit of Dementia National Audit of Pulmonary Hypertension N/A 25 National Cardiac Arrest Audit (NCAA) N/A a) National Chronic Obstructive Pulmonary Disease (COPD) Audit programme Underway pulmonary rehab 26 b) National Chronic Obstructive Pulmonary Disease (COPD) Audit programme Continuous commenced secondary care Feb c) National Chronic Obstructive Pulmonary Disease (COPD) Audit programme primary N/A N/A 12 Ref 13 PROMS data covers 2015/16; the dataset remains provisional. There are known issues regarding participation rates including: patients refusing surgery, cancelled operations, coding issues and the timining of questionnaires.

22 Ref Title Applicable Participation care Per cent eligible patients submitted a) National Comparative Audit of Blood Transfusion - Audit of Patient Blood Management in Scheduled Surgery 100 a) National Diabetes Audit - Adults (Core) 100 b) National Diabetes Audit - Adults Foot care 100 c) National Diabetes Audit - Adults Diabetes in Pregnancy 100 d) National Diabetes Audit - Adults Inpatient Audit National Emergency Laparotomy Audit (NELA) National Heart Failure Audit National Joint Registry (NJR) National Lung Cancer Audit (NLCA) National Neurosurgery Audit Programme N/A N/A 34 National Ophthalmology Audit National Prostate Cancer Audit National Vascular Registry N/A N/A 37 Neonatal Intensive and Special Care (NNAP) Nephrectomy audit Oesophago-gastric Cancer (NAOGC) [ grouped] 40 Paediatric Intensive Care (PICANet) N/A N/A 41 Paediatric Pneumonia N/A 42 Percutaneous Nephrolithotomy (PCNL) Prescribing Observatory for Mental Health (POMH-UK) N/A N/A 44 Radical Prostatectomy Audit N/A N/A 45 Renal Replacement Therapy (Renal Registry) N/A N/A 46 Rheumatoid and Early Inflammatory Arthritis N/A New audit Sentinel Stroke National Audit programme (SSNAP) Severe Sepsis and Septic Shock care in emergency departments Specialist rehabilitation for patients with complex needs N/A N/A 50 Stress Urinary Incontinence Audit UK Cystic Fibrosis Registry N/A N/A

23 Table 4: National Confidential Enquiries (NCEPOD) undertaken by Airedale NHS Foundation Trust Ref Title Applicable Participation Per cent eligible patients submitted 8 a) Child Health Clinical Outcome Review Programme Chronic Neurodisability 80 b) Child Health Clinical Outcome Review Programme Young People s Mental Health Underway 18 Learning Disability Mortality Review Programme Awaiting roll N/A (LeDeR Programme) out 20 Maternal, Newborn and Infant Clinical Outcome Review Programme 100 Medical & Surgical Clinical Outcome Review Awaiting roll N/A Programme - Peri-operative diabetes out Medical & Surgical Clinical Outcome Review Programme - Cancer in children, teens and young adults Underway 21 Medical & Surgical Clinical Outcome Review Programme - Heart Failure Underway Medical & Surgical Clinical Outcome Review Programme - Acute pancreatitis 100 Medical & Surgical Clinical Outcome Review Programme - physical and mental health care of 100 mental health patients in acute hospitals Medical & Surgical Clinical Outcome Review Programme - Non-invasive ventilation Mental Health Clinical Outcome Review N/A N/A N/A Data source: Airedale NHS Foundation Trust Clinical Audit Department. The reports of 32 national clinical audits were reviewed by the provider in 2016/17 and Airedale NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided. The following is a sample. Procedural Sedation in Adults (Care in Emergency Departments) The clinical proforma has been updated to prompt improved care and documentation. The impact of this change will be assessed together with the development of a local safety standard for sedation. Sentinel Stroke National Audit Programme (SSNAP) Quarterly reports are received and discussed within the team. At the March 2017 meeting it was agreed to: i. Commence admission reviews for Occupational Therapy and Physiotherapy Services; and, ii. Produce a poster of current SSNAP grading and results to share with ward staff. National Neonatal Audit Programme (NNAP) We continue to maintain results above the national average in most areas. Support of breast feeding in the Neonatal Unit is ongoing. Electronic reminders for two year follow-ups are under consideration. Major Trauma Audit (TARN) A monthly TARN meeting monitors our results with the objective to further improve the Trauma Service. The following actions are currently in progress: i. The development of an icon on our electronic patient administration system to

24 identify trauma patients from point of admission; and, ii. The introduction of a Trauma and Resuscitation Team Skills course. Cancer Outcomes and Services Dataset (COSD) and national Cancer Audits (Bowel, Prostate, Oesophago-Gastric, Lung) The Trust continues to focus on data accuracy and has taken the following steps to augment progress, including: i. The availability of a national timetable for national uploads; ii. Monthly data validation; and, iii. Escalation of identified discrepancies to the appropriate national team. National Joint Registry The Trust continues to achieve excellent results. National Comparative Audit of Patient Blood Management in Scheduled Surgery We achieved good results as we preoperatively identify patients with anaemia and are able to offer an intravenous iron service. Tranexamic acid is routinely used in Orthopaedic surgery and cell salvage where appropriate. Transfusion triggers guide clinical staff when prescribing blood components with consent gained prior to transfusion. Patient information leaflets are offered. The reports of 141 local clinical audits were reviewed by the provider in 2016/17 and Airedale NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided. The following is a sample. Further actions planned and undertaken in response to audit findings are detailed in the Trust s annual clinical audit report. Annual Record Keeping by Community Therapy, Occupational Therapy and Physiotherapy Services Aim: To monitor compliance with both Trust and professional and chartered standards of record keeping and clinical decision making. Conclusions: Overall the standard of record keeping is high. However there are elements which can be improved upon. Actions include: i ii iii Ensure the abbreviation list is current and fit for purpose. Ensure electronic patient record is designed to meet. professional standards for record keeping. Adapt audit process to align with the electronic record The Safe Handling and Storage of Controlled Drugs Outcome Underway Underway Aim: To monitor compliance with the safe and secure handling of controlled drugs (CD). Conclusions: Quarterly audit demonstrates that most clinical areas have a high level of compliance with policy with no concerns about security. Areas of non-compliance relate to standards of documentation and monitoring of expiry date, particularly for those medicines which have a reduced expiry when opened. Actions include: i ii Include safety of medicines in monthly clinical spot checks by Matrons. Provision of an additional label on liquid CD medicines to prompt recording the date opened and the expiry date. Outcome Emergency Department (ED) Intentional Rounding Audit Aim: To assess compliance with intentional rounding which is designed to

25 enhance patient experience and care delivery, allowing patients to receive appropriate personal cares and nutritional requirements during an ED stay. Conclusions: A high percentage of staff are implementing this initiative and delivering fundamental care requirements. However, there are opportunities to further promote the project amongst staff. Actions include: i ii Raise the initiatives profile via Sisters Meeting, and mini-teaching handover. Include as part of the Safety Brief to staff starting shift. Outcome Planned Post-operative Pain Relief in Hip and Knee Replacement Surgery Aim: To ascertain the adequacy of pain relief using the enhanced recovery protocol (ERP). Conclusions: Many patients experienced moderate to severe pain following such a procedure. Most drugs were given late except for 10 pm doses which were invariably given early. The current ERP may be inadequate. Actions include: i ii Review of the ERP to include Oxycodone. ERP drug regimen to be added to the electronic prescribing and medicine administration. Outcome Planned Actions include: i ii Create a proforma for bladder care. Adopt proforma across the serviced. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Audit Outcome Planned Aim: To monitor against local standards as set out in Trust policy. Conclusions: The audit highlights issues around the completion of documentation. Actions include: i ii iii Develop an electronic system to record DNACPR forms on SystmOne. Communicate key findings across the Trust to targeted staffing groups including the availability of an e-learning package. Record DNACPR on standardised nursing handover sheets. Outcome Underway Underway Annual Standard Resuscitation Trolley Audit Aim: To monitor compliance with resuscitation trolley standards. Conclusions: A marginal decline in adherence with trolley standards from the 2015 audit is noted although the shortfalls were minor and did not pose a risk to patients. Bladder Care for the Obstetric Patient Aim: To establish whether current practice is compliant with NICE guidance and the Royal College of Obstetricians and Gynaecologists. Conclusions: Marginal improvement on 2015 results was noted but documentation of bladder scans and residual volumes requires improvement. Actions include: i ii iii Replace automated external defibrillators. Add stopwatches to time cardiac pulmonary resuscitation cycles. Issue guides for checking the trolleys. Outcome Planned Planned Planned

26 2.2.3 Participation in clinical research Clinical research and clinical trials are an everyday part of the NHS. The people who do research are mostly the same doctors and other health professionals who treat our patients. A clinical trial is a particular type of research that tests one treatment against another. Research is a core part of the NHS, enabling it to improve the current and future health of the people it serves. The number of patients receiving relevant health services provided or sub-contracted by Airedale NHS Foundation Trust in 2016/17 that were recruited during that period to participate in research approved by a research ethics committee was 850. Airedale NHS Foundation Trust was involved in conducting 108 clinical research studies across all specialties during 2016/17 of which 76 were on the National Portfolio. During 2016/17 Airedale has been commended by the Clinical Research Network for achieving national benchmarks for performance in initiating and delivering research and for exceeding patient recruitment targets. There were 31 senior clinical staff participating in research approved by a research ethics committee at Airedale NHS Foundation Trust during 2016/17. These staff participated in research across 18 different clinical specialties. The Trust has been committed to expanding research into new specialties to improve the quality of care for our patients. The primary motivation for conducting research within the Trust is for the advancement of knowledge and promotion of evidence-based practice within clinical care. We aim to offer every patient the opportunity to take part in a clinical trial. This is reflected in the number of non-commercial studies undertaken during 2016/17. As well, in the last three years, five publications have resulted from our involvement in National Institute for Health Research studies, which show our commitment to transparency and desire to improve patient outcomes and experience across the NHS. In addition to this, a further 33 papers arising from academic and own account research have been published in peer reviewed journals since April Participation in clinical research demonstrates the commitment of Airedale NHS Foundation Trust to improving the quality of care we offer and to making our contribution to wider health improvement. Our clinical staff stay abreast of the latest possible treatment possibilities and it has been demonstrated that active participation in research leads to better patient outcomes. Our engagement with clinical research also demonstrates the commitment of Airedale NHS Foundation Trust to testing and offering the latest medical treatments and techniques Use of Commissioning for Quality and Innovation framework Commissioners are responsible for ensuring that adequate services are available for their local population by assessing needs and purchasing services. A proportion of a provider s income is conditional on the achievement of quality and innovation as set out in the Commissioning for Quality and Innovation (CQUINS) payment framework. Use of CQUINS payment framework A proportion of Airedale NHS Foundation Trust s income in 2016/17 was conditional on achieving quality improvement and innovation goals agreed between Airedale NHS Foundation Trust, and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2016/17 and for the following 12 month period are available electronically at:

27 As part of the drive to improve quality, an amount of funding to be paid to the Trust during 2016/17 for the delivery of services to our patients was dependent upon achieving a range of quality markers. This scheme (CQUIN) linked 2,832,914 of our funding to the delivery of the agreed quality indicators. [This is based on the indicative outturn value for 2016/17.] During 2016/17 Airedale NHS Foundation Trust delivered CQUINs to the value of 2,777,942 to the satisfaction of our commissioners (to be confirmed). The monetary total of funding conditional to the delivery of agreed quality indicators in 2015/16 was 2,824, Registration with the Care Quality Commission CQC North Yorkshire Children Looked After Safeguarding Review March 2016 (report due May 2017) Ofsted, the CQC, Her Majesty s Inspectorate of Constabulary and Her Majesty s Inspectorate of Probation joint targeted area inspection: investigation on the response to children living with domestic abuse February 2017 The Trust underwent a CQC inspection in March 2016 in relation to its regulated services: Urgent and Emergency Services; Medical Care; Surgery; Critical Care; Maternity and Gynaecology; Services for Children and Young People; End of Life Care; Outpatients and Diagnostic Imaging; and, Community Health Inpatient Services. The final report was published on 10 August 2016 and concluded the overview of ratings as follows: The Care Quality Commission (CQC) is the independent regulator of health and social care in England. Statements from the Care Quality Commission Airedale NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is without conditions. Airedale NHS Foundation Trust has no conditions on registration. The Care Quality Commission has not taken enforcement action against Airedale NHS Foundation Trust during 2016/17. Airedale NHS Foundation Trust has participated in special reviews or investigations by the Care Quality Commission relating to the following areas during 2016/17: In 2015/16 the Trust participated in an Urgent and Emergency Care Review. CQC Inspection Programme for NHS Ambulance Trusts: Yorkshire Ambulance Service September 2016 In September 2016, the Care Quality Commission conducted an unannounced

28 follow-up inspection on the Critical Care Unit and on some of the medical wards to assess improvement in relation to the safe and wellled domains. As this was a focused inspection, no formal ratings were provided. A re-inspection was undertaken during March 2017 of the areas rated as requires improvement and inadequate. Release of the findings will not be timely enough for inclusion in this publication, but will be fully reported in the 2017/18 Quality Report. Care Unit action plan is on track to be deliver the recommendations from its comprehensive review. Findings have further informed the quality improvement action plan. All CQC inspection reports are available at: Airedale NHS Foundation Trust intends to take the following action to address the conclusions or requirements reported by the CQC: The Trust was rated good for effective, caring and responsive domains. For safety and well-led the rating was requires improvement, giving an overall rating of requires improvement. The report identified areas where the Trust was required to take compliance actions must do which related to safety and the leadership of services. The Trust developed and provided a detailed action plan in response to the inspection report, which was signed off by the CQC. The final report was shared with commissioners and the Bradford Health and Social Care Overview and Scrutiny Committee. Progress updates have been provided to both organisations throughout the year. Airedale NHS Foundation Trust has made the following progress by 31st March 2017 in taking such action: The CQC report provides the Trust with an opportunity to engage with and implemented required improvement across the organisation. A series of action plans were developed in response to the must do and the should do with significant progress against all actions. The CQC continues to scrutinise progress, making a further unannounced inspection in September Inspectors found evidence that the Critical

29 2.2.6 Information on the quality of data Good data quality information underpins the effective delivery of improvements to the quality of patient care. The Secondary Uses Service (SUS) is designed to provide anonymous patientbased data for purposes other than direct clinical care such as healthcare planning, commissioning, public health, clinical audit and governance, benchmarking, performance improvement, medical research and national policy development. NHS Number and General Medical Practice Code Validity Airedale NHS Foundation Trust submitted records during 2016/17 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data which included the patient s valid NHS number, was: 99.9 per cent for admitted patient care; 100 per cent for outpatient care; and 99.5 per cent for accident and emergency care. which included the patient s valid General Practitioner Registration Code was: 100 per cent for admitted patient care; 100 per cent for outpatient care; and 100 per cent for accident and emergency care. 13 Information Governance Assessment Report Information governance (IG) ensures necessary safeguards for, and appropriate use of, patient and personal information; the IG toolkit is a system which allows NHS organisations and partners to assess themselves against Department of Health information governance policies and standards. The assessment provides an overall measure of the quality data systems, standards and processes within an organisation. Airedale Foundation Trust Information Governance Assessment Report overall score for 2016/17 was 75 per cent and was graded satisfactory. [Findings are substantiated by a significant assurance rating from Internal Audit]. 13 The above is published data for the period April 2016 to March 2017.

30 Clinical Coding error rate Airedale NHS Foundation Trust was not subject to the Payment by Results clinical coding audit during 2016/17 by the Audit Commission. 14 However, the Trust was subject to an external Clinical Coding Audit for Information Governance (IG) in November 2016; the error rates reported in the audit for 2016/17 and 2015/16 for diagnoses and treatment coding (clinical coding) were as follows: Trust Reported Results National Standards 2016/ /16 Level 1 Level 2 Level 3 Primary Diagnosis 6.0% (Level 2) 5.0% (Level 3) >10% 10% 5% Secondary Diagnosis 4.3% (Level 3) 2.0% (Level 3) >20% 20% 10% Primary Procedures 5.2% (Level 2) 5.6% (Level 2) >10% 10% 5% Secondary Procedures 10.3% (Level 2) 3.2% (Level 3) >20% 20% 10% Overall Level 2 Level 2 The report stated that: The overall results of the audit were adequate. It should be noted that all areas that were at IG level 2 were 1 per cent or less away from the IG level 3 threshold. The audit was conducted by an accredited auditor as recommended by NHS Classifications Services. Two hundred episodes were selected at random, whose discharge date fell between May and September 2016, covering a range of specialties. It should be noted that results from clinical coding audits should not be extrapolated further than the actual sample audited. Airedale NHS Foundation Trust will be taking the following actions to improve data quality as recommended in the audit report: There were three recommendations in the audit report covering the following areas: 1. Feedback of audit findings to individual coders 2. Review of training and auditing practices 3. Consideration of the introduction of data validation reports The Trust has formulated an action plan to address each of these areas. Additionally, the staff resources available to the coding team have been increased; this action will enable the recommendations from the audit report to be implemented and also provide each coder with more time to complete their work to a high standard and within the required timescales. 14 NHS Improvement comment: References to the Audit Commission are now out of date because it has closed. From 2014 responsibility for coding and costing assurance transferred to Monitor and then NHS Improvement. From 2016/17 this programme has applied a new methodology and there is no longer a standalone costing audit with errors rates as envisaged by this line in the regulations. It is therefore likely that providers will be stating that they were not subject to the Payment by Results clinical coding audit referred to above.

31 2.2.7 Sign up to Safety The patient safety campaign, Sign up to Safety, is a national initiative to improve safety and reduce avoidable harm by 50 per cent. We signed up in October 2014 and are committed to creating the right conditions for safer care. Whilst the Trust signed up to the Sign up Safety Campaign, we did not submit a safety improvement plan as we wanted to use the campaign as an opportunity to learn from others and as we cascade a newsletter to relevant staff within the Trust. The following are examples of learning identified elsewhere that we have implemented locally: Fall free and pressure ulcer free awards to encourage a zero tolerance of harm whilst recognising the efforts of staff and the progress towards safer care. Collaboration with the Improvement Academy, Yorkshire and Humber to provide a sustained approach to improvement at a clinical front line level, for example, through safety huddles. A Surgical Servies rapid improvement event a week long intensive workshop of improvement Duty of Candour In 2014, in response to the inquiry into Mid Staffordshire NHS Foundation Trust, the CQC introduced the statutory duty of candour. The duty of candour explains what we should do to make sure we are open and honest with people when something goes wrong with their care and treatment. There is an organisational and professional requirement for healthcare providers and registered practitioners to be open with patients and apologise when things go wrong as detailed in the Trust s Being Open Policy. Candour requirements and that there was evidence the duty had been applied. Mandatory training is delivered to all clinical and non-clinical staff. Incident monitoring systems are aligned to ensure any incident resulting in moderate harm and above follows the necessary Duty of Candour steps. Annual audit is undertaken to provide assurance of on-going scrutiny Workforce Race Equality Standard The following measures are included as part of the Workforce Race Equality Standard and are sourced from the 2016 NHS Staff Survey: Key finding (KF) 26: The percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months is 25 per cent which is line with the the acute trust average. There is no significant change from The percentage of staff reporting a recent experience of harassment, bullying or abuse show the largest improvement over the last year although findings are in the worst quintile for acute trusts in England (KF 27). KF 21: The percentage of staff believing that the Trust provides equal opportunities for career progression or promotion is 88 per cent. Whilst there is no significant change from 2015, performance is better than the acute trust average. The Trust has agreed an Inclusion Strategy, with plans to become a more encompassing employer. The Care Quality Commission inspection found that most staff were aware of Duty of

32 2.3 Reporting against core national indicators To provide a better understanding of comparative performance, the Quality Report includes a core set of mandatory national quality indicators. These reflect data that providers report on nationally. The measures are robust, conforming to specified data quality standards and prescribed standard national definitions and are subject to appropriate scrutiny and review. 15 To understand whether a particular number represents good or poor performance, the national average, outlier intelligence and a supporting performance commentary is included (where available). Unless indicated, the data source for the following indicators is NHS Digital. In line with national guidance, information for (at least) the last two reporting periods is provided. 16 Domain 1 Preventing people from dying prematurely Domain 2 Enhancing the quality of life for people with long-term conditions Summary hospital-level mortality indicator (SHMI) The SHMI is not an absolute measure of quality but is a useful indicator for supporting organisations to ensure they properly understand their mortality rates across services. The SHMI is based on all primary diagnoses, with deaths measured which take place in or out of hospital for 30 days following discharge. The SHMI value is the ratio of observed deaths in the Trust over a period of time divided by the expected number given the characteristics of patients treated (where 1.0 represents the national average). Depending on the SHMI risk adjusted value, trusts are banded between 1 and 3 dependent on whether their SHMI is low (3), as expected (2) or high (1) compared to other trusts. Table 5: SHMI Jan15 Dec 15 Pub: Jun 16 Apr 15 Mar 16 Pub: Sep 16 Jul 15 Jun 16 Pub: Dec 16 Oct 15- Sep 16 Pub: Mar 17 Airedale NHS Foundation Trust SHMI value National average The highest value for any acute trust The lowest value for any acute trust Airedale NHS Foundation Trust SHMI banding The SHMI takes account of underlying illnesses such as diabetes and heart disease. By including a measurement of the potential impact of providing palliative care on hospital mortality, additional context to the SHMI value and banding is offered. 15 Definitions are based on Department of Health guidance, including the NHS Outcomes Framework 2016/17 Technical Appendix. 16 Data source:

33 Jan15 Dec 15 Apr 15 Mar 16 Jul 15 Jun 16 Oct 15- Sep 16 Pub: Jun 16 Pub: Sep 16 Pub: Dec 16 Pub: Mar 17 Percentage of patient deaths with palliative care coded at either diagnosis or speciality level for Airedale NHS Foundation Trust Percentage of patient deaths with palliative care coded at either diagnosis or speciality level average for England The highest value for any acute trust The lowest value for any acute trust The Airedale NHS Foundation Trust considers that this data is as described for the following reasons: Trust mortality data is submitted in accordance with established information reporting procedures. To date, the SHMI for the Trust has remained consistent and not subject to significant variation. The Trust continues to view this in line with internal scrutiny of data quality. SHMI data is provided through NHS Indicators and is formally signed off by the Medical Director. The Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this rate, and so the quality of its services, by: review process. This is essentially a more in depth and validated process: fewer sets of notes are reviewed, but the time spent by the reviewer is considerably longer. The aim is to identify cases of potentially avoidable death, tease out areas for improvement and share best practice. The eventual aim is for all trusts in the region to be engaged in exactly the same process of case note review. Data will be collected, centralised and shared for wider learning. Consideration of the recommendations made by the CQC in its review of the way NHS trusts investigate the deaths of patients in England Learning, candour, accountability and how these will be integrated into our local processes. Mortality cases are routinely reviewed by a Consultant-led Trust Mortality Group. The fundamental reason for undertaking reviews is to identify any cases of potentially avoidable mortality, formulate action plans and disseminate learning. Themes and trends are highlighted and have led to demonstrable quality improvements. Appraisal of mortality, morbidity and other correlative data at the Quality Improvement Assurance Committee and specialty clinical governance meetings to further support this work. Airedale NHS FT is part of a regional group of trusts who have adopted a standardised and structured case note

34 Health gain Health gain Domain 3 Helping people recover from episodes of ill health or following injury Patient Reported Outcome Measures (PROMs) PROMs indicate patients health status or health-related quality of life from their perspective, based on information gathered from a questionnaire that they complete before and after surgery. PROMs offer an important means of capturing the extent of patients improvement in health following ill health or injury. Airedale s adjusted average health gain is presented alongside the national average and 95 per cent control limits. An average adjusted health gain allows fair comparison as the characteristics of the patient and level of complexity is accounted for. It is a measure of outcomes in the sense of how much a patient has improved as a result of the surgery. A high health gain score is good. Datasets for 2015/16 are provisional and will not be finalised until August As in previous years, the 2016/17 dataset is not included as there is limited response data at this stage, particularly for hip and knee procedures where the post-operative questionnaires are not sent to Orthopaedic patients until six months after the procedure is carried out. The standardised EQ-5D measure is presented as this applies to all elective conditions. However, this is less sensitive than condition specific measures and for a more complete analysis, the Oxford Score is provided for hip and knee replacement and the Aberdeen score for varicose vein surgery. The following information relates to primary procedures as the records for revisions are insufficient to draw inference. Hip replacement EQ-5D / / /16 England Average Airedale NHS FT Upper Control Limit Lower Control Limit Hip replacement Oxford Score 2013/ / /16 England Average Lower Control Limit Airedale NHS FT Upper Control Limit Figure 2 Figure 3

35 Health gain Health gain Health gain Health gain Health gain Knee replacement EQ-5D Knee replacement Oxford Score / / / / / /16 England Average Airedale NHS FT England Average Airedale NHS FT Lower Control Limit Upper Control Limit Lower Control Limit Upper Control Limit Figure 4 Figure Varicose vein surgery EQ-5D 4 Varicose surgery Aberdeen Score / / / / / / England Average Airedale NHS FT England Average Airedale NHS FT Lower Control Limit Upper Control Limit Lower Control Limit Upper Control Limit Figure 6 Figure 7 Groin hernia surgery EQ-5D / / /16 England Average Lower control limit Airedale NHS FT Upper Control Limit Figure 8

36 The Airedale NHS Foundation Trust considers that this data is as described for the following reasons: The Trust is above the upper control limit for knee replacement EQ-5D score. It is unlikely that this is has occurred by chance (statistically significant) and indicates that the patient health gain is greater than anticipated. For procedures such as groin hernia patients may actually feel worse than before the surgery e.g. from pain, mobility. The five dimensions of the EQ-5D measure mobility, self-care, usual activities, pain/discomfort, and anxiety/depression may not really test for relatively minor conditions like groin hernia apart from perhaps pain and discomfort. Across England, over a quarter of pre-operative groin hernia patients are already at the top score, so cannot improve further. Review of Trust data showed a higher proportion scoring at the maximum pre-operatively in 2013/14 compared to 2014/15 which may partly explain the variation between years. The sample size for varicose vein surgery is currently too small to generate returns for 2015/16. A change in the process of care to day surgery for this patient group meant that not all patients were receiving a pre-operative questionnaire. This shortfall has now been rectified. In the Aberdeen Varicose Vein Surgery Score, the scale is reversed. A score is generated from the questionnaire whereby 0 is the best score (no evidence of varicose veins) and 100 is the worst possible. Therefore if the patient has improved following surgery, the health gain will be a minus number and the larger the minus number, the greater the health gain. Airedale is a positive outlier (outside of the upper control limit) for the last three available years. The Airedale NHS Foundation Trust intends to take /has taken the following actions to improve the score and so the quality of its services, by: Continuing to monitor our rate of participation for each procedure and, although we have less direct influence, response rates are similarly reviewed. The Trust continues to raise awareness of the importance of returning the questionnaires at pre-operative assessment and in the ward environment at discharge. Actively participate in review of its results and work with the NHS Digital and others to understand the data in order to inform understanding of patient outcomes.

37 2.3.3 Percentage emergency re-admissions to Airedale NHS Foundation Trust within 28 days of discharge The data for this section has not been published by Digital Health since December The section below and comments are historical, but are required to be included. Also provided is our own data on re-admissions to offer more recent information on performance. Whilst some emergency re-admissions following discharge from hospital are an unavoidable consequence of the original treatment, others could potentially be avoided through ensuring the delivery of optimal treatment according to each patient s needs, careful planning and support for self-care. The following is standardised to allow comparison with other organisations and is presented in age groups: 0 to 15 and 16 years and over. A low percentage score is good.readmissions Table 6: Emergency re-admissions 2010/ /12 Pub: Dec /13 Airedale NHS Foundation Trust percentage 0 to 15 years National percentage average [England] 0 to 15 years The highest* percentage return by small acute trust 0 to 15 years The lowest* percentage return by small acute trust: 0 to 15 years NHS Digital Health has not updated this metric since Airedale NHS Foundation Trust percentage 16 years or over National percentage average [England] 16 years or over The highest* percentage return by small acute trust 16 years or over The lowest* percentage return by small acute trust 16 years or over * The highest and lowest rates are taken from comparable trusts [small acute]. Indirectly age, sex, method of admission, diagnosis and procedure standardised per cent. The Airedale NHS Foundation Trust considers that this data is as described for the following reasons: The figures presented are from the NHS Digital portal and are derived from information provided by Airedale and other trusts. Elements of this information are subject to commissioner scrutiny and a variety of external audits. Datasets have not been updated since December No attempt is made by NHS Digital to assess whether the readmission is linked to the discharge in terms or diagnosis or procedure; nor does the return identify whether the emergency admission is avoidable. 0 to 15 years: the re-admission rate is above average, but has fallen in the last (available) year. As part of Trust strategy to get patients home as soon as possible, we frequently discharge and then offer families 24 hour open access for review on the unit. This allows the patient to be readmitted directly to the ward if the parent or carer feels there is any deterioration or if they are struggling with caring for the patient for any other reason. Clearly this will impact on the re-admission rate. 16 years or over: the re-admission rate is below average and has fallen in the last year. A number of actions have had an impact, including a target for urgent referrals to community of 95 per cent of patients being

38 seen within 24 hours of discharge from hospital. During the data collection period the Trust will have coded some of the patients attending the ambulatory care unit (ACU) as admissions. These would be patients who in the past would have been admitted to a hospital bed for treatment (for example, deep vein thrombosis, pulmonary embolism patients). The referrals (mainly from GPs) are now triaged by a Consultant who will assess suitability for ambulatory care instead of an admission. It is likely that in the data period 2011/12 and 2013/14 some of the patients attending ACU will have been classified as a re-admission if they had had an admitted spell within 28 days. Data collection changed in March The Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this percentage, and so the quality of its services, by: 16 years or over: Medical re-admissions by Consultant are incorporated into performance metrics, circulated to colleagues and discussed at the monthly General Internal Medicine meeting. A similar process is in place within Surgical Services and provides the opportunity to discuss, understand the rationale and accuracy of clinical coding and ensure readmissions are correctly captured on the Trust s patient administrations system. For the period April 2016 to March 2017 and using the methodology developed by the Health and Social Care Information Centre (now NHS Digital), the Trust s Information Service has calculated the percentage of emergency re-admissions occurring within 28 days of the last and previous discharge form the Trust for all ages as per cent Indicator construction: Numerator The number of finished and unfinished continuous inpatient spells that are emergency admissions within 0 to 27 days (inclusive) of the last, previous discharge from hospital (see denominator), including those where the patient dies, but excluding the following: those with a main speciality upon re-admission coded under obstetric; and those where the re-admitting spell has a diagnosis of cancer (other than benign or in situ) or chemotherapy for cancer coded anywhere in the spell. Denominator The number of finished continuous inpatient spells within selected medical and surgical specialities, with a discharge date up to 31 March within the year of analysis. Day cases, spells with a discharge coded as death, maternity spells (based on specialty, episode type, diagnosis), and those with mention of a diagnosis of cancer or chemotherapy for cancer anywhere in the spell are excluded. Patients with mention of a diagnosis of cancer or chemotherapy for cancer anywhere in the 365 days prior to admission are excluded.

39 Domain 4 Ensuring that people have a positive experience of care Responsiveness of Airedale NHS Foundation Trust to the personal needs of patients An organisation s responsiveness to patients needs is regarded as a key indication of the quality of patient experience and care. The score for the inpatient setting is part of the NHS Outcomes Framework (indicator 4b: Ensuring that people have a positive experience of care). Based on the annual CQC s annual Inpatient Survey, the measure is the overall average percentage score for answers covering five domains: access and waiting; safe, high quality, coordinated care; better information, more choice; building closer relationships; and clean, comfortable, friendly place to be. The scores are presented out of 100 with a high score indicating good performance. Table 7: Responsiveness to patient needs replies; 808 surveyed replies; 850 surveyed replies; 1250 surveyed Airedale NHS Foundation Trust overall percentage score National percentage score Highest percentage for any acute trust Lowest percentage for any acute trust The next update of the annual Inpatient Survey is due in August The Airedale NHS Foundation Trust considers that this data is as described for the following reasons: The Trust sample varies from year to year and difference in outcomes is to be expected unlike the national score which is, by definition, adjusted data. This should be considered when making comparison between years. Improvements or deterioration of patient experience continue to be monitored via our Real-time (inpatient) Survey and Friends and Family Test so that remedial actions can be introduced in a timely way. The 2015 NHS Staff Survey shows an improvement in the number of staff reporting the effective use of patient/ service user feedback with an increase from 3.7 out of 5 to 3.8 out of 5. We continue to work with partner organisations to ensure a holistic approach to patient engagement. The Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this score and so the quality of its services, by: Monitoring of local and national patient survey results by the Trust s Patient and Public Engagement and Experience Steering Group. Implementation of the Patient and Public Engagement and Experience Strategy for The implementation plan will follow a phased approach each year and align closely to the Inclusion Strategy and Right Care principles. Listening and learning from patient experiences via the Friends and Family Test (FFT) and the Real-time (inpatient) Survey and taking action where necessary. Friends and Family reports on the public facing website have been streamlined for simpler access and a link embedded for patients to complete the FFT after discharge.

40 2.3.5 The percentage of staff employed by, or under contract to the Trust during the reporting period, who would recommend Airedale NHS Foundation Trust as a provider of care to their family or friends How members of staff rate the care that their employer organisation provides can be a meaningful indication of the quality of care and a helpful measure of improvement over time. The following is the percentage of staff that agree or strongly agree with the statement If a friend or relative needed treatment, I would be happy with the standard of care provided by this Trust and is based on the annual NHS Staff Survey (question 21d). The scores are presented out of 100 with a high score indicating good performance. Table 8: Staff recommendation replies; 2504 surveyed replies; 2580 surveyed replies; 2699 surveyed Pub: Feb 2015 Pub: Feb: 2016 Pub: Mar 2017 Airedale NHS Foundation Trust percentage National average percentage acute trusts [England] Highest percentage for any acute trust Lowest percentage for any acute trust The Airedale NHS Foundation Trust considers that this data is as described for the following reasons: The response rate was 40 per cent with is below average for acute trusts and the same as that of The results of the 2016 NHS Staff Survey for this question are slightly below our locally conducted quarterly Staff Pulse Survey which randomly samples 10 per cent of our workforce across all staff groups on a quarterly basis, and the Staff Friends and Family Test census. Overall staff engagement has remained unchanged at 3.81 compared to 3.82 in 2015 and is average when compared with other trusts of a similar type. Possible scores range from one to five, with one indicating that staff are poorly engaged (with their work, team and organisation) and five indicating staff are highly engaged. The Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this score and so the quality of its services, by: The Trust s People Plan sets out the key priorities for people management across the Trust with the overall aim of improving staff experience. The People Plan has been refreshed to support the Trust s ambition over and to further improve employee engagement. Actions include: Improving the quality of leadership and line management through targeted learning and support; Improving staff health and well-being; Improving the quality of appraisals and non- mandatory training and education; Involving staff in quality improvement through engagement activities and the Quality Improvement Strategy and its associated framework; Embedding Trust values and behaviours in key people processes: recruitment, appraisal and learning and development; and, Continued engagement with staff around the Right Care portfolio.

41 2.3.6 Friends and Family Test (FFT) Patient The NHS Friends and Family Test (FFT) is a quick and anonymous way for those using services to give their views after receiving care or treatment. It was created to help service providers and commissioners understand satisfaction levels with a service and where improvements can be made. In recent years, the FFT test has expanded to cover Maternity Services, Community Services and most of late, Outpatients and Day Case Surgery. The percentage of the patient group who are either likely or extremely likely to recommend services is presented from a single question posed to patients, If a friend or relative needed treatment, I would be happy with the standard of care provided by the Trust. The higher the percentage scores the better. Although there is no statutory requirement to report on the patient element of the Friends and Family Test, we have included this information to support an open picture. No national benchmarks are provided below as, according to NHS England, results are not statistically comparable against other organisations because of the various data collection methods. 18 Table 9: Friends and Family Test Airedale NHS Foundation Trust - percentage recommendation score Jan 2017 Feb 2017 Mar 2017 Emergency Department Average 96% 96% 97% Inpatient Average 96% 96% 95% Community Services 99% 97% 97% Day Cases 99% 99% 98% Maternity Services 99% 100% 98% Outpatients 98% 98% 97% 18 NHS England Friends and Family Test data: [Accessed 5/02/16].

42 The Airedale NHS Foundation Trust considers that this data is as described for the following reasons: The Trust monitors its recommendation scores against the national average and is consistently above average across all services. The Trust monitors response rates against the national average for the Emergency Department, Inpatients and Maternity Services to ensure a sufficient and reliable sample size. Minimum response targets have been set of 15 per cent for the Emergency Department; and 25 per cent for Maternity Services (births) and Inpatients (which includes Day Cases). Performance is consistently above the target for most inpatient wards, and a clear focus on response rates in the Emergency Department, the Labour Ward and on Ward 17(Children s Unit) has resulted in a sustained improvement in these areas since December Planned actions: Creation of a child friendly web version of the FFT survey for use on the Children s Ward, to be used by staff on ipads during the discharge process. Pilot project to implement text messaging as a method of offering the FFT in the Emergency Department, Maternity services and on the Children s Ward. Relocation of the FFT kiosk to the postnatal ward to support increased response rates in that area. Implementation of new online system to enable real time access to FFT data. This will be accessible via AireShare and enable staff to search comments by keyword, including historical data, and to create word clouds on demand. Enable patients who complete the FFT online to choose from a range of different languages. The Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this score and so the quality of its services, by: Creating a new FFT site on the staff intranet (AireShare) designed to improve access to the data for managers. Redesigning the FFT reports to make the data more visual and accessible, enabling greater public understanding, easier benchmarking and monitoring of performance across services and wards, and improved access to free text comments. Relocating the FFT kiosk from the Emergency Department to the main landing outside the Patient Information Centre to test whether this improves use of the kiosk. Inclusion of FFT performance targets in ward improvement plans. Presence of FFT reports on new quality and safety noticeboards on all wards.

43 Domain 5 Treating and caring for people in a safe environment and protecting them from avoidable harm Percentage of patients admitted to hospital and were risk assessed for venous thromboembolism (VTE) VTE can cause death and long-term morbidity. According to NICE many cases of VTE acquired in healthcare settings are preventable through effective risk assessment and prophylaxis. A high percentage score is good. Table 10: Risk assessment for VTE Jan Mar 2016 Apr-Jun 2016 Jul-Sep 2016 Oct-Dec 2016 Pub: Jun 16 Pub: Sep 16 Pub: Dec 16 Pub: Mar 2017 Airedale NHS Foundation Trust percentage National percentage average [England] The highest percentage return for any acute trust The lowest percentage return for any acute trust Data Source: NHS England. The Airedale NHS Foundation Trust considers that this data is as described for the following reasons: The Trust has maintained compliance with the national VTE risk assessment priority. Data is provided weekly to all managers and lead clinicians. Broken down by clinical group, this allows those which are under reporting to be identified and supported with improvement and restorative actions. The VTE risk assessment tool is embedded in the clinical areas and features prominently in clinical decision making, ensuring vigilance in completing risk assessments. Thromboprophylaxis prescription rates are benchmarked against other NHS providers, using data from the NHS Safety Thermometer. These compare favourably and indicate that clinicians are completing VTE risk assessments with appropriate VTE prophylactic measures. The Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this percentage, and so the quality of its services, by: Continue to benchmark Airedale s performance against other providers in England and report on a monthly basis through the Trust dashboard. Regular discussion of VTE assessment data with clinical directors to educate and improve rates across groups. The Trust continues to embed the processes of root cause analysis for reported VTE with the dissemination of results to learn lessons and improve overall VTE care.

44 2.3.8 Rate of C. difficile infection per 100,000 bed days in Airedale NHS Foundation Trust patients aged 2 or over Hospital associated C. difficile can be preventable. There are issues around reporting cases of C. difficile, resulting from differences in the tests and algorithms used in the NHS for determining whether patients have a C. difficile infection. In March 2012, the Department of Health issued revised guidance on a new clinical testing protocol; this aims to bring about more consistent testing and reporting of cases of C. difficile infection. The rate provides a helpful measure for the purpose of making comparisons between organisations and tracking improvements over time. A low rate is good. Table 11: Rate of C. difficile 2013/ / /16 Airedale NHS Foundation Trust rate per 100,000 bed days National average rate [England] rate per 100,000 bed days The highest rate for any acute trust rate per 100,000 bed days The lowest rate for any acute trust rate per 100,000 bed days Figures based on Trust apportioned cases for specimens taken for patients aged 2 or over. Data Source: Public Health England. The Airedale NHS Foundation Trust considers that this data is as described for the following reasons: The Trust has a rigorous diagnostic testing protocol to identify cases. All confirmed cases are monitored through internal processes and reported to Public Health England, NHS Improvement and commissioners. Performance is reflective of: a robust antibiotic policy closely scrutinised by Pharmacy staff, high standards of staff and patient hand hygiene, environmental cleanliness and the continued vigilance and awareness of staff. Root cause analysis of all hospital acquired cases is undertaken to ensure opportunities to improve practice are identified and enacted. All cases are reviewed with Community Service staff to assess which are unavoidable. Receipt of the C.difficile risk assessment and action plan at the Executive Assurance Group. The Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this rate, and so the quality of its services, by: Implementing further strategies during the forthcoming year, including: Early detection of all cases; Environmental sampling; SystmOne antibiotic prescribing flag for those patients with a history of C.difficile infection/colonisation; Monitoring of the use of antibiotics in comparison with neighbouring and similar sized acute trusts; Discussion of anti-microbial prescribing in community at the District Wide Infection Prevention Team Meeting; Implementation of NICE guidance: Urinary tract infection in Adults; and, Consultant Microbiologist provision and succession planning.

45 Domain 5 - Treating and caring for people in a safe environment and protecting them from avoidable harm Reported number and rate of patient safety incidents per 1000 bed days reported within the Airedale NHS Foundation Trust and the number and percentage that resulted in severe harm or death Patient safety incidents are adverse events where either unintended or unexpected incidents could have led or did lead to harm for those receiving NHS healthcare. Based on national evidence about the frequency of adverse events in hospitals, it is likely that there is significant under reporting. An open, transparent culture is important to readily identify trends and take timely, preventative action. This indicator is designed to measure the willingness of an organisation to report incidents and learn from them and thereby reduce incidents that cause serious harm. The expectation is that the number of incidents reported should rise as a sign of a strong safety culture, whilst the number of incidents resulting in severe harm or death should reduce. (Severe signifies when a patient has been permanently harmed as a result of the incident.) Table 12: Patient safety incidents Apr 2016 Sep 2016 [Issue: Apr 2016] All reported patient safety incidents Severe harm Death Rate [per 1000 bed Number days] Number Percentage Number Percentage Airedale NHS Foundation Trust National position [acute non specialist n=136] The highest value [acute non specialist n=136] The lowest value [acute non specialist n=136] Oct 2015 Mar 2016 [Issue: September 2016] All reported patient safety incidents Severe harm Death Rate [per 1000 bed Number days] Number Percentage Number Percentage Airedale NHS Foundation Trust National position [acute non specialist n=136] The highest value [acute non specialist n=136] The lowest value [acute non specialist n=136]

46 The Airedale NHS Foundation Trust considers that this data is as described for the following reasons. The Trust has in place: Consistent reporting of all patient safety incidents to the National Reporting and Learning System (NRLS) against each of the required six month periods. The Trust is in the upper quartile of reporters for the last four reporting periods. According to the National Reporting and Learning System, organisations that report more incidents usually have a better and more effective safety culture. In order to improve, an understanding of the problems is essential. An open and engaged culture to learn from incidents and improve the quality and safety of services. The Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this rate, and so the quality of its services, by: Maintaining and improving an open and transparent reporting culture, one which encourages all healthcare staff to report all adverse events and near misses. Undertaken work to improve how quickly incidents are uploaded to the NRLS to ensure lessons can be learned and actions taken to prevent harm to others. Appointment of a Freedom to Speak Up Guardian to provide confidential, independent advice and support to staff in relation to concerns about patient safety, care and treatement.

47 Part 3 Other quality improvement information As well as the improvement projects detailed in section two, the Quality Report takes the opportunity to outline other local priority work in the three areas of quality: patient experience, safety and clinical effectiveness. A series of metrics or indicators are included to understand performance and where possible, historical and benchmarking data is provided to support interpretation. 3.1 Patient experience The Trust is committed to the principle that all patients and the public are treated as individuals with dignity and respect, that cultural and ethnic diversity are valued, and that vulnerable and seldom heard groups have equal opportunity to be fully involved in all aspects of their care Improving the care for patients living with dementia The challenge and our aim An estimated 25 per cent of hospital beds are occupied by people with dementia. People with dementia stay in hospital for longer, are more likely to be re-admitted and more likely to die than patients admitted for the same reason. 19 If patients living with dementia are diagnosed in a timely way, this patient group can receive treatment, care and support to improve their experience of the condition. Through focusing on developing the skills and expertise of our workforce in the recognition and the care of patients living with dementia, the Trust seeks to improve the prompt and appropriate referral to specialist services. This priority is part of the wider Right Care portfolio agreed by the Board of Directors in consultation with stakeholders. How we monitor progress The multi-disciplinary and agency Here to Care Group co-ordinates the key dementia priorities: training, enhancing the environment (wayfinding), patient flow and elective pathway. Membership includes Patient and Carer Panel and Dementia Friends Keighley representatives which provides independent insight on how we can improve care for this patient group. Current status It is estimated that less than half of people with dementia in England have a formal diagnosis or have contact with specialist services. 19 If diagnosed in a timely way, this patient group can receive the treatment, care and support social and psychological, as well as pharmacological to improve their experience of this condition. To ensure prompt and appropriate referral to specialist services, all patients aged 75 and over admitted as an emergency are screened for dementia or delirium. We have set ourselves a 90 per cent target of achievement: In 2015/16, 92 per cent of eligible patients were asked the screening question In 2016/17, 86 per cent of eligible patients were asked the screening question. 20 Work has commenced within the Surgical Services Group to improve compliance levels. 19 Department of Health (2014), Dementia. A state of the nation report on dementia care and support in England. William Lea. 20 Data source: methodology based on the 2015/16 CQUIN indicator improving dementia and delirium care.

48 Count of complaints According to the National Hip Fracture Database Annual Report 2016, of the 266 cases submitted in 2015, 99.5 per cent had a mental test score recorded on admission. Complaints provide valuable qualitative information which may not be identified by more traditional indicators. From a total of 73 formal complaints over the year, one complaint has been received in concerning a patient living with dementia. During hospital admission the patient fell and sustained an injury; investigation is currently underway. Figure 9: Bar chart of formal complaints received from patients living with dementia for the last three years / / / /17 Data source: Complaint and PALS Team Ulysses database Initiatives and progress in 2016/17 In May 2016 in collaboration with the Alzheimer s Society, Carers Resource and Dementia Friends Keighley, staff from Airedale participated in the National Dementia Awareness campaign. Activities included information sharing around John s Campaign, a national drive to promote flexible hospital visiting hours for those caring for people living with dementia. Airedale has established a dedicated task and finish group to oversee its adoption. A pilot on Wards 4, 6, 9, 13 and Harden Ward (Castleberg) has commenced. Hospital stays are generally damaging to people with dementia who can find the acute setting a difficult and disorientating environment. It is not uncommon for a person living with dementia to experience a loss of functioning level and independence following an acute episode of care. John s Campaign focuses on an open visiting culture, supporting carer access outside of normal visiting hours to minimise the stress and anxiety. This may include staying overnight. A carer can be better placed to help those living with dementia understand their surroundings, care and treatment. Through an improved experience, the overall discharge outcome for an individual can be enhanced. Working collaboratively with Carers Resource (Bradford, Airedale and Craven) and Carers Link (East Lancashire), we are encouraging

49 staff to refer carers for appropriate support. A staff leaflet for John s Campaign and a Stay with me information pack for carers have been developed. A guidance sheet about flexible visiting for carers is available. The Trust is an Ambassador Trust for the Butterfly Scheme which seeks to highlight the unique needs of those patients affected by dementia by displaying a butterfly icon on the bed management system to make staff aware of a Butterfly Care Plan. Mandatory training for clinical and non-clinical staff including volunteers and bank is provided to ensure all staff have knowledge and skills in caring for people with dementia. Wards have Butterfly Champions to promote the use of individualised care plans detailing personal preferences. By the end of March 2017, 91.3 per cent of the workforce had achieved competency in dementia awareness training (this incorporates privacy and dignity training). 21 A relaunch of this initiative is planned for 2017/18. Refusal to eat, loss of appetite, forgetting to chew and swallow and being distracted are all frequently observed in this vulnerable group. 22 A new menu is being designed for all patients and will be trialled on the Elderly and Stroke wards. The objective is to make it simpler for patients to read. Finger foods are also being piloted to encourage patients with less dexterity to maintain independence by feeding themselves at mealtimes. This may also be of benefit to those with smaller appetites, a common feedback theme. Completion of the Malnutrition Screening Tool (MUST) to establish nutritional risks continues to be monitored on a monthly basis. Research indicates that for those living with dementia, changes in the physical surroundings eyecatching colour contrasting schemes and signage can encourage greater independence, help patients find their way around and reduce distress. Dementia principles are embedded in the Estate s Capital Development Strategy reflected in the rolling refurbishment of wards programme. Dementia Friends Keighley have been involved in the planning stages of the new Acute Care Hub. It is predicted that the number of people with dementia from black, Asian and minority ethnic groups will rise significantly as this population ages. 19 People with learning disabilities have a heightened dementia risk and usually develop the condition at a younger age. This is particularly true of people with Down s syndrome. It is important that these patient groups have access to timely diagnosis and culturally sensitive support and treatment. A qualitative Dementia Carers Survey is undertaken to monitor carers perceptions of care. This work has been enhanced by feedback from Healthwatch Bradford and District s focus group s conversations with carers of people living with dementia. 23 Other work undertaken: The Trust has participated in the National Audit for Dementia 2016 with results expected in June Twiddlemuffs have been knitted by community groups to provide stimulation activity to reduce anxiety in those with dementia. Development of dementia-specific nutritional literature. Next steps An Enhanced Supervision Project has commenced; this is proposed work that aims to improve the patient experience by ensuring that observations of the patient are engaging, meaningful and patient centred. Four work streams have been identified: 21 Data source: Human Resources NHS Foundation Trust. 22 Watts, V.et al., (2007), Feeding Problems in dementia Geriatric Medicine 37:8 pp The full report is available from Healthwatch at the following link:- [Accessed 02/03/15].

50 1) Improving care initiatives; 2) Staff education and practice development; 3) Patient management and assessment; and, 4) The development of guidelines for practice Privacy and dignity The challenge and our aim In recent years, high profile reports and inquiries have shown a failure at individual and organisational level to deliver care with compassion privacy and dignity. It is important to continually reflect on and challenge the way in which we treat and care for patients, relatives, friends and carers and staff. We know there is a link between the well-being of staff and that of patients. Our priorities are to: 1) Embed our Fundamental Standards of Caring for People with Dignity and Respect. 2) Develop a patient-led a care environment that is clean, safe, accessible and equipped to underpin privacy and dignity. How we monitor progress Privacy and dignity are key principles within the Trust s Patient and Public Engagement and Experience Strategy as agreed by the Board of Directors in consultation with stakeholders. Implementation is monitored via the Patient Experience and Engagement Group established to ensure the experiences of those who use our services and carers are captured and acted upon to improve future care and treatment. Representation includes Estates, the Patient and Carer Panel, local Healthwatch organisations and voluntary groups and commissioners. Current status Creating a Customer Service Culture According to the CQC throughout its inspection, we observed staff providing compassionate care across the organisation staff demonstrated a sensitive and supportive manner to patients and families who came to the hospital, such as the Bereavement Officer. 24 Overall the Trust was rated Good for caring. The following metrics have been selected to measure improvement in our patients experience. Each year, as part of the annual Inpatient Survey, people are asked by the CQC about different aspects of their care and treatment. Based on these responses, health providers receive scores out of ten. A higher score is better. 24 Care Quality Commission (August 2016), Airedale NHS Foundation Trust Quality Report, p.25. Available at: [Accessed 31/1016]

51 Table 13: Care Quality Commission Inpatient Survey up to and including 2015/16 performance against selected metrics for Airedale NHS Foundation Trust [Q32] Were you involved as much as you wanted to be in decisions about your care and treatment? 2013/ / / [Q33] Did you have confidence in the decisions made about your condition or treatment? n/a [Q34] How much information about your condition or treatment was given to you? [Q50] Did you feel you were involved in decisions about your discharge from hospital? [Q62] Did the doctors or nurses give your family or someone close to you all the information they needed to care for you? [Q66] Did you feel you were treated with respect and dignity while you were in hospital? [Q67] During your time in hospital did you feel well looked after by hospital staff? n/a [Q68] Overall, how would you rate the care you received? Data source: Care Quality Commission National NHS Inpatient Survey 2015 (published June 2016). Benchmarks: GREEN = best 20 per cent performing trusts. AMBER = trusts within the middle 60 per cent; about the same RED = worst 20 per cent performing trusts. In addition to the annual Inpatient Survey, NHS England s Cancer Patient Experience Survey 2015 was published July 2016 with the following findings for privacy, dignity and compassionate care: For the overall care rating where zero is poor and 10 is very good, patients rated Airedale 8.8; the national average score was 8.7. Of the 177 respondents to the question, Were you always treated with dignity and respect? 87 per cent agreed. This is comparable with the national average. Of the 178 respondents to the question, Were you always given enough privacy when discussing your condition? 82 per cent agreed. The national average was 85 per cent. The annual anonymous National NHS Staff Survey 25 (published by NHS England) helps us to improve the working lives of all our staff. We know there is a clear relationship between the wellbeing of staff and that of patients. 26 This year s survey results indicates staff engagement is in line with the previous year. The percentage of staff reporting a recent experience of harassment, bullying or abuse shows the most improvement over the last year, although the Trust is in the worst quintile for all acute trusts. Deterioration is noted in the percentage of staff saying they would recommend the Trust as a place to work or receive treatment. Reported strengths include: making effective use of patient feedback and appraisal compliance. We scored less well (lowest 20 per cent of trusts) in relation to staff feeling satisfied with their quality of work or patient care and agreeing that their role makes a difference to patients. Organisation and management interest, effective team working and action on health and well being all scored better than the average. The Health and Well-being Programme aims to help staff eat well, exercise and take care of mental health with resilience training available to help staff deal with stress. A leadership and coaching 25 NHS Staff Survey 2016 is available from: [Accessed 07/03/17]. 26 Boorman S. (2009), NHS Health and well-being: final report. London: Department of Health. Available at: licyandguidance/dh_ [Accessed 6/03/16]

52 programme has been introduced as part of our wider People Plan. We seek to listen to staff via Quality Forums, rapid improvement events and our partners notably through feedback from Airedale Wharfedale and Craven Quality Walk rounds and enter and view visits by our local Healthwatch organisations. The latter s 2016 review of our Emergency Department precipitated a Your experience matters discussion forum for staff and patients using an experience based design approach facilitated by a Consultant in Emergency Medicine. Initiatives and progress in 2016/17 A series of training initiatives, including Customer care training Right Care, encourage staff to reflect on how compassionate care can be embedded into practice. To instil core values and challenge opposing attitudes and complacency, the Trust created its own customer care training module Right Care for clinical and non-clinical staff. The package refreshes key messages of who our customers (patients, carers, relatives) are and the importance of treating people as individuals. Training is aligned with line management standards, the NICE patient experience standard (QS15) and the NHS Constitution. 27 Drawing on the real experiences of patients and using good and inadequate customer care form its basis with the objective to reinforce four principles of patient experience: 1. Through your eyes. 2. Making every contact count. 3. No decision about me without me. 4. The patient at the heart of everything we do. Last year we reported that the Trust signed up to the official #hellomynameis campaign launched by Dr Kate Granger, a NHS consultant and terminally ill cancer patient. In August 2016 staff values were displayed across the Trust wall mounts on corridors, screensavers and staff booklets and promoted at the annual Staff Open Day. One of our key behaviours is always introduce yourself and your role and ask what the patient would like to be called. In September 2016 winners of the Kate Granger awards celebrating compassionate patient care were announced with recipients selected by Kate before her death in July We are proud that our Palliative Care Team were named runner-up in the making a difference to patient care category for the Gold Line Service. High quality care is dependent on a high quality workplace where staff are treated with respect at work and have the tools, training and support to deliver care and the opportunities to develop and progress. 27 Following last year s launch of core staff values and leadership behaviours, a Consistently Good Line Manager Conversations Toolkit has been developed offering practical guidance to managers with three questions seen as fundamental to any dialogue: 1. The well-being question 2. The work challenges question 3. The support question 27 Department of Health (2013), The NHS Constitution. Available from:- [Accessed 20/01/14].

53 The NHS Constitution recognises that staff have a right to healthy and safe working conditions and an environment free from harassment, bullying, aggression and violence. In response to a national shortage of nurses, we have an on-going international recruitment programme. Two nurses from Romania and Croatia shared their experience of working at Airedale and living in the United Kingdom with the Board of Directors in July Both spoke positively of the extensive induction training, mentoring and warmth of the welcome. The Trust has a zero tolerance approach to racism to any staff from colleagues or patients. Staff are urged to report any such instances. Next steps Continue the roll out of the People Plan and the Health and Well-being Programme, including the Lean on me initiative. International recruitment continue to review level of support and training provision. Promote the work of our Rightcare Champions A patient-led care environment The challenge and our aim There are a range of non clinical factors which can have an impact on the patient experience of care: cleanliness; the condition, appearance and maintenance of healthcare premises and the quality and availability of food and drink. The extent to which our environment supports the delivery of care with privacy and dignity is a key area of focus within the Right Care portfolio. In recent years, a number of estate refurbishment and development projects have been undertaken that serve to ensure that people are cared for in a modern hospital environment with privacy and dignity. We aspire to an environment that is pleasant, comfortable, calming, clean and safe in clinical and non-clinical areas. We want to make all our open spaces accessible, including courtyards. Current status The annual Patient-Led Assessment of the Care Environment (PLACE) provides a snapshot of how an organisation is performing against a range of areas which impact on the patient experience of care. A fundamental aspect of the assessment is the inclusion of a lay assessor. Assessments have been extended to include criteria on how well healthcare providers premises are equipped to meet the needs of caring for patients with dementia and disability. This does not represent a comprehensive assessment of these aspects, but rather focuses on a limited range of facets with strong environmental or building associated components. Our most recent PLACE assessment was carried out in April 2016 with results published in September 2016.

54 Table 14: Airedale General Hospital and Castleberg 2016 PLACE results AGH Castleberg National % average National IQR at site % score % score site level score level Cleanliness to 99.9 Food and hydration to 94.1 Organisation food (catering service) to 92.9 Ward food to 97.8 Privacy, dignity and well-being to 91.7 Condition, appearance and maintenance to 97.2 Dementia to 88.4 Disability to 90.0 Data source: NHS England 2016: NHS Digital. Assessments were undertaken across 287 organisations, of which 226 were NHS trusts. The assessment tool, the composition of the inspection team and the wards selected vary each year invalidating comparison with previous years. The above table provides the site level national average and, to support appraisal, the distribution of the middle (interquartile - IQR) fifty per cent of scores for the participating organisations. Ward food, Privacy, dignity and well-being are in the lower quartile for Airedale General Hospital and Castleberg against all participating sites. In addition, Airedale General Hospital site compares less favourably for: Cleanliness, Condition, appearance and maintenance, Dementia and Disability. Where issues are identified, these are included in the on-going PLACE Improvement Plan, which is monitored and progressed through the Patient Environment Action Group meetings. Mini-PLACE audits are carried out on a quarterly basis and include a comprehensive inspection of waste, linen, cleanliness, environment and food safety at ward level. The Infection Prevention and Estates and Facilities teams carry out these audits alongside Matrons. Since the 2016 inspection was undertaken, an increase in the frequency of building issues concerning Castleberg has been highlighted by the Trust s adverse event monitoring system. These incidents include heating, sewerage and the electrical infrastructure. Whilst there has been no harm to patients, these concerns are of sufficient seriousness in relation to the possible welfare of patients and staff. Therefore during April 2017, the Trust in consultation with the Commissioners has withdrawn the inpatient beds at Castleberg Hospital pending a public consultation. Initiatives and progress 2016/17 The CQC remarked in its inspection finds that the route to the Mortuary was cluttered, shabby and unpleasant The viewing room used for families to see deceased patients was stark and basic. 24 The route taken by families to the Mortuary has been improved whilst a plan to improve the viewing room is planned. The refurbished Elderly Ward has specific facilities to enable families to stay with distressed and/or end of life patients as does the Children s Ward and Labour Ward. Not all wards have this resource and a scoping exercise forms part of the John s Campaign work. Ward refurbishment continues on a rolling programme.

55 Remedial work on courtyards has been completed. Eight have been adopted by staff, suppliers, governors and volunteers with work to develop the sites underway. Our charities have committed to on-going funding support. A new Endoscopy Quiet Room George s Room was opened (thanks to donations) within the Endoscopy Unit in July A move to barrier controlled parking is part of a wider programme to improve access including, drop off zones and greater disabled parking. Signage has been overhauled in the last year with the aim of improving the patient experience of navigating the hospital site. Initial and on-going feedback has led to testing with a group of patients, visitors and new staff members with changes made including: notice boards outside ward areas and additional information points. Lifts are to be updated and the inclusion of maps in patient letters is to be trialled. Following a Healthwatch Enter and View visit in May 2016, the Emergency Department is working through recommendations to improve the environment for patients and visitors, including signage for the Breastfeeding Room. Across all wards signage has been changed on toilet and bathroom doors in line with PLACE dementia guidelines. Next steps A model ward will be completed based on the PLACE report findings. On completion, the cost and impact of replicating across the organisation will be evaluated. The Youth Forum are to be involved in the design of a Teen Room on Ward 17. Plans for a new Acute Assessment Unit have been passed and include provision for dementia and disability. It is hoped this work will be completed by the end of March Patient safety Together with the management of pressure area care, infection prevention, the reduction of inpatient falls and the identification of frailty remain as specific areas of focus identified by the Board of Directors in consultation with stakeholders Infection prevention and control The challenge and our aim Healthcare associated infections (HCAI) are infections that are acquired as a result of healthcare interventions. According to the National Institute for Health and Clinical Excellence, HCAI are a serious risk to patients, causing significant morbidity to those infected. Whilst there are a number of factors that can increase a patient s risk of acquiring an infection, high standards of infection control practice minimise the risk of occurrence. The Trust aims for sustained reduction in the incidence of avoidable harm from C. difficle and MRSA bacteraemia infection.

56 Count of cases How we monitor progress The Infection Control Committee monitors compliance with the standards of The Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance (Public Health England, 2015). The District Wide Infection Prevention Team continues to support an integrated approach to infection prevention and control work streams. Current status The CQC reported that the hospital was clean and observed that most staff adhered to infection control principles. This fiscal year the Trust reported two hospital acquired MRSA bacteraemia (one community acquired infection); 13 C. difficile cases developed in hospital. Root cause analysis showed that two of C.difficile cases were avoidable. Data is governed by standard national definitons. Figure 10: MRSA bacteraemia and C. difficile cases at Airedale General Hospital since 2008/ / / / / / / / / /17 1st April to 31st March MRSA C. difficile Data source: Airedale NHS Foundation Trust Infection Prevention. Initiatives and progress in 2016/17 To prevent HCAI, we continue to monitor closely the rates of infection; strengthen infection prevention and control measures; and learn from best practice. Key measures include: The Matron for Infection Prevention and Senior Sisters/Charge Nurses provide updates and assurance on measures implemented to reduce HCAI through the Infection Prevention Implementation Group. All hospital acquired MRSA bacteraemia and C. difficile infections are subject to Post Infection Reviews with learning points cascaded immediately to clinical teams. MSSA and E.coli cases are investigated if the Consultant Microbiologist requests a review. Infection alerts are in place on SystmOne to ensure staff are aware of patients with a history of MRSA, C.difficile and multi-resistant organisms. GPs using SystmOne can now access messages entered by the Infection Prevention Team regarding the infection status of patients. Anti-microbial selection and usage is reviewed by the Antibiotic Pharmacist and Director of Infection Prevention and Control; treatment choice is closely monitored as part of the analysis of C. difficile infection prevention. Environmental sampling for C. difficile continues.

57 The Health Service Public Ombudsman upheld a complaint regarding the Trust not following MRSA colonisation suppression protocol. An audit tool has been developed and compliance with MRSA Screening and Suppression Protocol is being monitored. Instructions for MRSA Screening / Re-screening and Colonisation Suppression have been reviewed and distributed to clinical areas. The monthly hand hygiene audit reports a Trust aggregated compliance average of 97 per cent since April This is part of a robust and on-going infection prevention clinical audit programme. Quarterly newsletters are issued to maintain the profile of infection prevention. Topics in the last year have included: C. difficile, Infection Risk Score, flu and Norovirus. Mandatory training and link worker programmes are on-going. External events such as Bradford and Airedale Infection Prevention Study Day promote infection prevention and control principles to a wider audience. Domestic Services, Matrons and the Infection Prevention Team have worked closely to monitor standards of cleanliness, including inspections of the care environment, spot audits and routine cleanliness audits. In response to the CQC inspection observation of inappropriate floor covering in an inpatient clinical area, the carpet on Ward 19 has been replace with vinyl. Routine cleanliness audits are undertaken whilst a work programme is maintained by the Enhanced Cleanliness Team. A peripherally inserted central catheter (PICC) has been introduced in Radiology Department to provide patients with more appropriate intravenous access. Staff are being trained to care for and manage these devices. Next steps A key factor in the spread of antibiotic resistance is the indiscriminate or inappropriate use of antibiotics. Through the CQUIN framework, work over the last year has focused on reducing antibiotic consumption and encouraging antimicrobial stewardship, including antibiotic review within 72 hours. The Trust is currently the second lowest user of antibiotics in the Yorkshire and Humber region and aims to further consolidate this work in the coming year Reduction of slips, trips and falls sustained by patients admitted to our hospital wards The challenge and our aim Falls are a cause of injury, pain, distress, delay in discharge and loss of independent living. Evidence suggests that the effect is particularly compounded for people over the age of The effective management to reduce the number of falls sustained by our inpatients is therefore a high priority. Focusing on the Elderly Ward (Ward 4) and working in collaboration with the Academic Health Sciences Improvement Academy, core safety improvement principles are being implemented, including providing support in the team s own clinical environment and recognising the clinical expertise and knowledge of front line health professionals. 28 Airedale NHS Foundation Trust Infection Prevention. 29 Department of Health (2009), Falls and Fractures: effective interventions in health and social care. Crown copyright: COI for DH.

58 How we monitor progress The multi-disciplinary Trust s Falls Steering Group co-ordinates an overarching Falls Care Plan detailing key areas of focus: falls risk assessment, care and management of patients following a fall, discharge, patient and family information, equipment, and training and education. The Trust is an active member of the district wide Falls Pathway Development Group. Current status Measurement over time is essential in quality improvement work with benchmark data necessary to demonstrate improvement. Figure 11: Special Process Control Chart number of falls on Ward 4 commencing 26/01/15 (Week 1) The special process control chart shows the number of fall incidents reported each week on Ward 4, commencing 26 th January 2015 (Week 1). A 64 week baseline period provides a reliable value against which progress can be evaluated. In the baseline period, there were on average 2.9 falls a week. Four points in this period show the number of falls above the expected range (upper control limit [UCL] denoted by the green line), a finding that cannot be explained by random variation or chance. Key intervention milestones are as follows: Week 63 weekly safety huddles commence. Week 66 The NHS Improvement Academy visits Ward 4. Week 75 Chair and mattress alarms are introduced. In the subsequent period (Week 65 onwards), the average number of weekly falls has improved to 1.7. Two out of three data points are more than two standard deviations below the average and three out of five points are more than one standard deviation below the average. These are statistical tests which indicate a positive step change in care. Besides an improvement in the number of falls, the data also indicates on closer inspection, a decline in the severity of harm.

59 Work to sustain the progress made is being supported by an initiative to measure the days between falls; Ward 4 recorded an episode of 26 consecutive fall free days in July and August This is a cultural shift away from accepting inpatient falls as normal and part of the initiative s proactive approach to prevention. In the 2015 RCP Falls Audit England and Wales, the Trust was the third highest reporter of falls with 11 falls per 1000 occupied bed days (OBD) against a national finding of 6.6 falls per 1000 OBD. The following table shows all inpatient falls across the Trust for the last three years and those which resulted in a fracture. The overall performance shows a decreasing year on year trend in the reported falls rate per 1000 OBD. A sign of a strong safety culture is a reduction in the number of incidents resulting in harm. Whilst underlying values in the last two years are the same, when adjusted for activity, improvement is noted over three years. Furthermore, the number of reported falls resulting in fracture neck of femur has fallen since 2013/14 from 16 to seven in the last year. Although the total number of fractures has not reduced significantly in this period, arguably the level of harm has. Table 15: Airedale NHS Foundation Trust rate of inpatient falls per 1000 bed days 30 Fiscal year Bed days [Y] Reported Falls [X] Reported falls per 1000 bed days *Reported falls resulting in fracture Reported falls resulting in fracture per 1000 bed days 2016/17 12, / / Data source: bed days Airedale NHS Foundation Trust Information Services; patient safety incidents Airedale Quality and Safety Team [Ulysses database]. Initiatives and progress in 2016/17 Current evidence 31 shows that multi-component interventions are effective in reducing falls, including chair and mattress alarms, advice on footwear and toileting schedules. A key intervention is a fall safety briefing (known as a falls huddle). These are led by a senior clinician with the objective of identifying those patients at high risk of falling and determining how to prevent such a fall. Continuous improvement is built on small incremental changes, using a systematic approach to test their impact and feasibility - Plan-Do-Study-Act. Work to scale up the described improvement work on Wards 6, 7 and 9 commenced in November Other key and on-going interventions to reduce risk and incidence of harm to the patient are: 30 A bed day is a day during which a person is confined to a bed and in which the patient stays overnight in a hospital (OECD Health Data June 2013). Methodology: Bed occupancy and inpatient falls are calculated from data from Wards: 1/2/4/5/6/7/9/13/14/17/18/19/21/HDU/ICU/CC/Harden Ward includes Wards 3/10 /15 when opened as temporary wards. Bed days supplied by the Trust s Information Services Department.. Falls comparable with National Reporting and Learning System [NRLS] calculation as follows: X= the total number of all patient falls reported in hospital/unit in the most recent year for which data are available. Y= the total number of occupied bed days in your hospital/unit in the most recent year for which data are available, multiplied by X divided by Y gives the number of falls per 1000 occupied bed days. Taken from: The Third Report from the Patient Safety Observatory, Slips, Trips and Falls in Hospital (NPSA, 2007). Data quality subject to third party review in 2015/16 31 Centre for Reviews and Dissemination (2014), Preventing Falls in the community, Effectiveness Matters October University of York.

60 Intentional rounding - a structured process where regular checks are carried out with individual patients at set intervals; Nursing specialling to enhance supervision of those patients at high risk of a fall. Next steps It is noted that the majority of falls that result in harm occur on the ground floor wards (including Ward 4). The University of Portsmouth has a proposed study into cushioned flooring for high risk areas in clinical wards. The Trust is considering participation. Research demonstrates that a focus on reducing multiple falls (by the same patient) can reduce falls by between 20 and 30 per cent with a concomitant reduction in overall level of harm. Work to assess data has commenced to understand how interventions can be tailored to an individual patient Frail Elderly Pathway Team initiative According to NHS England there has been a 65 per cent increase in the episodes of care in hospitals for those aged 75 and over. As we age and body systems decline, we can become more vulnerable to sudden events such as an infection or fall. Whilst there are times when a frail older person requires hospital admission, evidence suggests that if frail older people are supported to retain and/or recover independence after illness or injury they are less likely to reach crisis and require urgent care. 32 The Trust s Patient Pathways and Flow Programme is part of transformational work to integrate and coordinate the contributions of nursing, medical, allied healthcare professionals, social workers, mental health professionals, GPs, care homes and voluntary organisations into a cohesive system. One such initiative developed over the last two years is the Frail Elderly Pathway Team which aims to instigate proactive care models such as personalised care and support planning and the targeting of geriatric resources. Composed of Physiotherapists, Occupational Therapists, a Dietician and Senior Nurse, and with some social work input, the team is based on the Acute Medical Unit with Emergency Department in reach. The Frail Elderly Pathway Team s key objectives are: Reduce hospital admissions by early specialist integrated assessment and intervention; Facilitate early discharge by commencing rehabilitation at the earliest stage to optimise recovery; Reduce length of hospital stay by rapid signposting to Intermediate care and Community Services; Act as an interface with Community Advanced Nurse Practitioners from the Collaborative Care Teams and with voluntary and charitable services to avoid unnecessary admission; and, Provide integrated holistic care and treatment. 32 NHS England (2014), Safe, compassionate care for frail older people using an integrated care pathway. [Accessed: 16/11/16]

61 How we monitor progress Meeting monthly, the multi-disciplinary Frail Elderly Pathway Team aims to improve the active management of care for older people through review of outcome data for example length of stay, avoidable re-admissions and patient and staff feedback. The Patient Pathways and Flow Programme forms part of the Right Care portfolio and is monitored by the Board of Directors with progress reviewed on a quarterly basis. Current status A key performance indicator is length of stay, with the Frail Elderly Pathway Team aiming to reduce hospital stays for individual patients during each admission. The data below compares the period March to September 2016 (following merger of the Ambulatory Care Unit with the Acute Medical Unit and the extension of the Team) with August 2014 to February 2016 (when data collection commenced). It assesses whether the Team has been able to improve outcomes form the point at which it was able to work most effectively: Frail Elderly Pathway Team discharge from the Acute Medical Unit I. August February 2016: 3.80 days average II. March 2016 September 2016: 3.37 days average III. Reduction in average length of stay: 0.43 days per patient Frail Elderly Pathway Team discharge from base wards I. August February 2016: 17.3 days average II. March 2016 September 2016: 14.6 days average III. Reduction in average length of stay: 2.7 days per patient Data source: SystmOne. Results show that over the seven months where the Team has been at its most effective, it has achieved an 11.3 per cent reduction in the average length of stay for patients discharged from the Acute Medical Unit whilst more timely transfers from the Unit to base wards have led to a 16.2 per cent decrease in overall length of stay for those admitted to acute care. Other outcome findings: The Care Quality Commission s review of Urgent and Emergency services reported evidence of good multi-disciplinary working: the Frail Elderly Team attended the Emergency Department when bleeped ( Monday to Friday and on weekends) to review patients and support safe discharge, liaising with the community teams. Older people s care within Medical Services was judged as Good with audit demonstrating that the Frail Elderly Pathway (and other services) had reduced admissions. A readmission audit investigated whether patients discharged from the Frail Elderly Pathway Team who received dietetic intervention in the community experienced fewer subsequent admissions: in the six months follow up period admissions fell by 67 per cent (24 patients), a statistically significant result. This and other larger scale studies suggest that nutritional status can make a difference in the care of the frail elderly. Feedback on patient s experience is gathered by those healthcare professionals not directly involved in the patient s care. Responses are extremely positive in terms of communication, efficiency, support and caring attitudes. Telephone interviews regarding the Dietician s community intervention demonstrates improvement in functional measures (strength, mobility, energy) and psychological patient measures (mood, confidence) and improved ability to selfcare.

62 The Frail Elderly Pathway Team has been shortlisted for a prestigious Health Service Journal Value in Healthcare award. Initiatives and progress in 2016/17 The initial team has been extended and reviewed against Society of Acute Medicine guidance. The merger of the Ambulatory Care Unit with the Acute Admissions Unit has enabled greater team cohesion and efficiency, further supported by the adoption of the electronic patient record. From November 2016, the service provision was extended from six to seven days. To optimise efficiency and avoid the involvement of too many people in one person s care, team members have developed competencies beyond their own core areas. Knowledge and ideas to improve the process are shared across disciplines and locations. For example, evaluation of walking aid training with ward staff and nutrition training to community teams to manage malnutrition suggests a 50 to 90 per cent improvement in overall staff knowledge. The last year has seen a reduction in the falls incidence rate on the Acute Admissions Unit. Involvement of patients and carers in the drafting of patient information, selection of formulary products for the community malnutrition pathway and soliciting patient experience feedback. Next steps A Frailty Unit attached to the ED forms part of the plans for the development of the Acute Care Hub the integrated ED, Acute Medical, Surgical Assessment, and Ambulatory Care Unit. 3.3 Clinical effectiveness Quality of healthcare for people with long-term conditions Airedale Digital Care Hub The following projects reflect key local priorities and focus on the delivery of clinical excellence in care and treatment. The challenge and our aim There is evidence to suggest that people, particularly those with long-term conditions, want to have control over decisions about their care, desire to live a normal life and do not wish to spend time in hospital unnecessarily. 33 Assistive technologies, such as telemedicine, can allow patients to manage their conditions and avoid time-consuming and costly trips either to hospital or outpatient clinics. Airedale s Digital Care Hub aims to care for patients closer to home whenever it is safe to do so; people with chronic illness can avoid emergency treatment and admission if their condition is well-managed Department of Health (2011), Whole System Demonstrator Programme. Available from:- [Accessed 06/12/13]. 34 Dr Foster Intelligence (2013), Dr Foster Hospital Guide Dr Foster Limited. p.10.

63 How we monitor progress The multi-disciplinary and agency Digital Care Hub Business and Governance Group is responsible for the delivery of this priority. Qualitative and quantitative monitoring is on-going both internally and externally to support assessment of the impact of the innovation and inform future initiatives and strategy. Current status The CQC commented that telemedicine services provided at the Digital Care Hub were outstanding. There were some innovative examples of practice, such as telemedicine in combination with the Intermediate Care Hub, where nursing and care home residents and their carers benefitted from being able to access expert advice and support remotely 24 hours a day, seven days a week. The following figure illustrates patient outcomes for those registered with and accessing assistive technologies. Figure 12: Patient outcomes April to December 2016 Data source: Airedale NHS Foundation Trust Information Services. The Hub regularly receives in excess of 1700 video calls each month from nursing and residential home patients across England, an increase of around 30 per cent on the previous reporting period. Each month the Gold Line Service handles in excess of 950 telephone calls, an increase of almost 35 per cent on the previous reporting period. 35 Initiatives and progress in 2016/17 The Airedale Digital Care Hub offers teleconsultation by secure video link with nursing and residential homes. Staffed 24/7 by highly skilled Senior Nurses, the team has developed to include Acute Care, Urgent Care and District Nurses, Fall Practitioners and Occupational Therapists. If required, escalation to a Consultant is available. Via the Hub, the team can review on-going clinical observations. Access to the SystmOne GP record has made available care plans and patient medication information in support of clinical decision-making. It also means a patient s GP is kept 35 Data source: Airedale NHS Foundation Trust Information Services.

64 informed of consultations. If a patient needs to come to hospital, staff are able to communicate with the ambulance service to ensure a direct admission. Country-wide over 400 nursing and residential care homes are connected to the Hub, including 53 across the Airedale, Wharfedale and Craven district (this compares to a total of 17 for the locality in 2012/13). Other services delivered from the Digital Care Hub which support safe and clinically effective standards of care for those patients with long-term conditions include: The Intermediate Care Hub (IC_HUB) This is a joint health and social care approach, and the result of organisational and district wide integration work. The IC_Hub acts as a health and social care referral point for adults needing rehabilitation or recovery care after an illness, such as a stroke. It offers quick interventions to prevent major health problems developing should a patient s long-term condition deteriorate. The approach seeks to prevent unnecessary admissions into hospital where patients can be more effectively cared for in community settings and provide a supported and speedier discharge from hospital. The Gold Line Service This is an innovative approach created in partnership with patients, carers, GPs, commissioners and Manorlands Hospice, and made possible through a grant from the Health Foundation. The Gold Line service provides a single point of contact for patients at the end of life and their carers to be able to access seven day, around the clock help and advice via the Hub. The initial pilot commenced in 2013 across Airedale, Wharfedale and Craven and was extended to the remainder of the Bradford district and its metropolitan populations in The Airedale and Partners Enhanced Health in Care Homes Vanguard This is one of six collaborations across the country which aims to offer older people better joined up care and rehabilitation services. The Vanguard aims to use the Digital Care Hub as a single point of access to expert advice and support for example the Intermediate Care Hub to enhance the quality of care and treatment for nursing and care home residents living in Bradford, Airedale and Wharfedale, Craven and East Lancashire and thereby reduce inappropriate demand on GPs, ambulances and acute care. Next steps The Trust is a member of the West Yorkshire Urgent Care Network Vanguard. This is one of eight national sites with the ambition to improve the co-ordination of urgent and emergency care services and reduce the pressure on Emergency Departments. The Network has commissioned the use of our enabling technologies in 30 nursing homes across Leeds and Harrogate. Between 40 and 60 participants will be part of a pilot project to deliver an on-screen stammering therapy service from April 2017 for a year. This will offer help to adults who are unable to access therapy locally. Case Study: Mark s Story a patient s experience of receiving speech and language therapy At the May 2016 Board of Director s meeting, Mark, a 45 year old prisoner, shared his experience of using speech and language therapy via the Digital Care Hub. Addressing members on screen, he explained how seeking help to overcome his stammer had transformed his life. "One thing I always wanted to do was say happy birthday to my daughter over the phone which I'd struggled to manage," he said. "After speaking to my therapist about it, she told me to split the

65 words down. The day I said it over the phone to my daughter, it made me so happy I could not have done any of this without therapy and the excellent help and advice from my therapist After 40-plus years of stammering, I never thought I could ever stand in groups of people and join in conversations, or openly speak over the phone. With many thanks to my therapist, I now can." Stephanie Burgess, Mark s therapist was initially apprehensive about using telemedicine, thinking that it would be no substitute for personal contact. But after several sessions, she realised it was equally as effective as meeting Mark face to face. "I saw a complete transformation in him, from the first session when he was shaking and crying, looking down, covering his mouth and constantly switching his words to the last session, when he was laughing and joking and telling me how happy he was to have been able to join in with a discussion about football and to have wished his daughter a happy birthday." Stephanie said her approach is tailored to the individual and she encourages people to be open about their stammer. "By the end of the sessions, Mark no longer cared that he stammered and because he no longer worried, he didn't stammer as much." Source: Ilkley Gazette 31st May The monitoring of Caesarean section rates through the safe promotion of normality The challenge and our aim Whilst it is important to point out that a caesarean is in itself, not an adverse outcome and in many cases is the most appropriate action to take to ensure that there is no preventable loss or morbidity, there are a number of risks associated with this procedure for mother and baby. The Maternity Unit aims to optimise opportunities for normal birth and to reducing intervention rates. How we monitor progress To understand performance against this priority, the multidisciplinary Women s Integrated Governance Group receives monthly aggregated and disaggregated caesarean section rates. Case note review by senior staff against guidance and recommendations for best practice in respect of non-elective caesarean section is regularly undertaken and informs the group discussion. Current status The latest available England percentage of caesarean hospital deliveries has increased to 27.1 per cent for 2015/16 with a continuing national incremental trend in caesarean birth. The Trust s overall caesarean section rate of 25.6 compares favourably. Finer grained analysis for 2016/17 shows that the rate for electives is 10.6 percent compared to the national average of 11.5 per cent.

66 Percentage of all delivery episodes [confinements] Figure 13: Caesarean section rate for Airedale NHS Foundation Trust long term trend / / / / / / / / / / / /17 1st April to 31st March ANHST National average Data Source: Evolution Maternity System. Initiatives and progress in 2016/17 The bespoke Midwifery Led Unit provides a homely environment. With access to a private outdoor space and a less clinical labour room, it offers a relaxing place to give birth. The Unit s primary focus is on normality and active birth from the onset of labour. The aim is to promote normal birth and a reduction in the number of interventions, including caesarean section. Both Medical and Midwifery staff are fully committed to this philosophy of care. At the time of this report, six per cent of women gave birth in water which is the same as the previous year; rates for women labouring in water have decreased slightly to 10.2 per cent. Feedback from patient surveys and evaluations is positive saw the launch of the Lucinda Team of midwives offering a new approach which advocates normality (and normal birth). The Team work alongside the Labour Ward staff and aim to maintain the low risk environment of the Midwife Led Unit, promote normal labour and birth and support women requesting home birth. Although year to date caesarean levels are unaltered, an effect on vaginal birth after caesarean (VBAC) and water birth rates has been noted. Women who have had one previous caesarean section for a non-recurring reason and who are not at increased risk of uterine rupture in labour are actively encouraged to aim for vaginal birth in the subsequent pregnancy. The service s goal is to reduce the number of second caesarean sections and hence increase vaginal birth through the implementation of the following: I. The Patient Decision Aid (PDA), introduced in 2014, aims to ensure that all women eligible for VBAC receive and have the opportunity to discuss essential information upon which to base their decision about method of delivery. II. The Midwife led VBAC clinic, allowing those women who are undecided about VBAC following discussion with an Obstetrician, to have a further opportunity to discuss all options prior to a final decision. Those women with tocophobia or extreme anxiety can be referred to the Healthcare Psychology Service. III. Wireless cardiotocography CTG monitors allow women who have had a previous caesarean section to be monitored while remaining active in labour and even to labour in water. High risk antenatal care, low risk intrapartum care (HALO) care system permits women with antenatal risk factors, but no intrapartum risk factors, to be cared for in labour by a Midwife on

67 the Midwife Led Unit, reducing the risk of obstetric intervention and offering the best opportunity for a vaginal birth in a low risk setting. External Cephalic Version ECV is offered to women with a baby in the breech position and for whom it is safe. This may remove the need for caesarean section in those women for whom ECV is successful. Next steps The promotion of normality is set to continue in 2017/18. Following a successful bid to the Health Education England Maternity Training Fund, the Clinical Lead Obstetrician, Labour Ward Manager and one of the Labour Ward Coordinators are attending the four day Royal College of Obstetricians and Gynaecologists Management of Labour Ward Conference which is focused on developing leadership skills to further promote and maintain normality. Skills developed will include: advance effective team communication skills; confidence when discussing birth options/outcomes and ensuring that all have up to date knowledge underpinning practical obstetric skills. Following the conference a working group will be initiated to focus on increasing the normal birth rate Fractured neck of femur improvement project The challenge and our aim A broken hip, also known as a fractured neck of femur, is the most serious consequence of a fall, with the risk of occurrence increasing with age. According to NICE, the majority of fractured neck of femurs happen in elderly patients with osteoporosis; mortality is high although most deaths are from associated conditions and not the fracture itself. 36 For those who recover, there is a possibility of a loss in mobility and independence. Research suggests that organisational factors in a patient s treatment can affect outcomes. Our aim is to improve recovery from fractured neck of femur by focussing on such factors in a patient s treatment. How we monitor progress Orthopaedic multi-disciplinary audit governance meetings are held monthly to identify areas of improvement and understand outcomes for this group of patients. Current status The CQC reported that, The inspection team were impressed with the leadership and dedication from the manager and staff working on Ward 9 [Orthopaedic Ward] We saw evidence of effective multi-disciplinary team working within the orthopaedic department. In February 2016 the Senior Sister was awarded Leader of the Year at the Pride of Airedale Awards whilst Ward 9 staff received the Team of the Year award. Feedback from a Quality Walk-round on Ward 9 by commissioners in 2016 was similarly positive. Measurement over time is essential to understand progress and the group monitors best practice targets and participates in the Royal College of Physicians Falls and Fragility Fracture Audit 36 NICE (2011), Hip Fracture. The management of hip fracture in adults. NICE clinical guideline 124. NICE: Manchester.

68 Length of stay: days Programme. According to the National Hip Fracture Database Annual Report 2016, of the 266 cases submitted in 2015: 34.6 per cent were admitted to an Orthopaedic ward within four hours; 86.1 per cent had a perioperative medical assessment; 89.2 per cent were mobilised and out of bed on the day after surgery; 99.6 per cent received a falls assessment; 98.8 per cent received bone health assessment; 70.1 per cent had surgery on day of, or day after, admission. The above form part of best practice tariffs for the management of hip fracture. Where targets are not met, the reasons are investigated to understand if clinical care can be more effectively delivered. A further marker of the quality of care that patients receive, is the total length of NHS care following a fractured neck of femur with a shorter length of stay associated with less risk. Figure 14: Fractured neck of femur mean length of stay [day] for Airedale General Hospital patients / / / / / / / / /17 1st April to 31st March Length of Stay by fiscal year Airedale General Hospital overall mean Upper Control Limit Lower Control Limit Data source: Airedale NHS Foundation Trust Information Services. The figure describes our performance in the last eight years in the reporting period 1 st April to 31 st March: mean length of stay is 18.2 days with upper and lower confidence interval (of 95 per cent) ranging from 17 to 20.5 days. These intervals help to identify variation which falls outside the expected limits (an outlier) and supports understanding of whether length of stay is longer or shorter than expected. In the last three years performance has consistently been below the eight year mean. Between 1 st January and 31 st December 2015, the overall hospital mean length of stay for England was 21.1 days; for Yorkshire and Humber 18.7 days; and, 18.3 days for Airedale General Hospital Royal College of Physicians (2016), Falls and Fragility Fracture Audit Programme. The National Hip Fracture Database Extended Report Health Quality Improvement Partnership. Page 78.

69 Initiatives and progress in 2016/17 The Orthopaedic-Geriatric ward rounds remain on-going with specialist input from two consultants in Elderly Medicine. The multi-disciplinary team support all Orthopaedic patients with the appropriate advice, rehabilitation services, aids and adaptations to promote mobility and independence both in and outside of hospital. The CQC inspectors had concerns regarding senior doctor review of trauma and orthopaedic patients and the associated documented evidence. All Orthopaedic Consultant job plans have been reviewed and the Trust has set a 100 per cent compliance target via case note audit outcomes. The Enhanced Recovery Pathway (ERP) continues to be successfully utilised for elective patients. Exploratory discussions about a similar ERP pathway for trauma patients on Ward 9 are underway. It is intended to have a neck of femur designated bed on Ward 9 to enable a seamless transfer of acute patients from the Emergency Department. The ERP will also include carbohydrate loading pre-operatively and increased protein supplements as there is some evidence that these can be beneficial in this patient group. The Orthopaedic Nurse Practitioner period of training to become an Orthopaedic Advanced Nurse Practitioner has now commenced. A secondment to cover the original post holder s duties and responsibilities has ensured continuity, including with submissions to the National Hip Fracture Database and monthly reports to the Orthopaedic Audit Meeting. Over the last 24 months, fascia iliac blocks have been introduced in the Emergency Department for pre-operative pain relief. A clinical audit undertaken in 2015 showed that 100 per cent of patients in the Emergency Department with a fracture neck of femur were considered for a fascia iliac block on admission as recommended by NICE, and that of these, 91 per cent received the block. The audit demonstrated a significant improvement on an audit of practice conducted in This pain management technique has also been utilised on occasion post-operatively. The aim is to make fascia iliac blocks available to all appropriate patients. In support of this, an advanced level Orthopaedic Nurse Practitioner competency framework has been completed by the seconded Orthopaedic Specialist Nurse. This objective is to allow more effective post-operative physiotherapy, increased mobility, improved morbidity and a shorter length of stay. Next steps The Orthopaedic Specialist Nurse is seeking to develop a Fracture Liaison Service in line with Public Health England s system based approach to the design and planning of services across falls and fragility fractures. A stakeholder event garnered must interest from commissioners and a business case is in development.

70 3.4 Performance against key national priorities The following indicators support the national priorities as set out in the 2016/17 Risk Assessment Framework and the Single Oversight Framework. Returns conform to specified data quality standards and prescribed standard national definitions 15 and are subject to third party scrutiny and review. Indicator Threshold 2014/ / /17 Clostridium difficile meeting the Clostridium difficile objective All cancers: 62-day wait for first treatment, comprising either: from urgent GP referral to treatment from NHS Cancer screening service referral Maximum 18 week waits from referral to treatment in aggregate patients on an incomplete pathway 85% 90% 90.2% 95.7% 89.8% 96.7% 92.3% 93.8% 92% 92.4% 92.4% 91.5% A&E maximum waiting time of four hours from arrival to admission/ transfer/ discharge 95% 95.6% 95.7% 90.6% = subject to third party audit on behalf of NHS Improvement. See section 4.6 for detail of data testing in 2016/17. Data source: Airedale NHS Foundation Trust Information Services.

71 Part 4: Annex 4.1 Airedale, Wharfedale and Craven Clinical Commissioning Group (CCG) The draft Quality Report 2016/17 was circulated to the Airedale, Wharfedale and Craven Clinical Commissioning Group and the following feedback received from NHS Airedale, Wharfedale and Craven CCG, Bradford City CCG and Bradford Districts CCG: Airedale NHS Foundation Trust Quality Report 2016/17 On behalf of NHS Airedale, Wharfedale and Craven, NHS Bradford City and NHS Bradford Districts Clinical Commissioning Groups, I am delighted to provide feedback to Airedale NHS Foundation Trust (ANHSFT) on its Quality Report 2016/17. I would like to start by offering my congratulations on the number of accolades that the Trust has been recognised for during 2016/17, some of which are detailed in the report. They include: In May 2016 the Trust was named for the third consecutive year one of the top hospitals for the CHKS national patient safety award by the independent provider of healthcare intelligence. (CHKS is a leading provider of healthcare intelligence and quality improvement services) In August 2016 the CQC reported that the community based collaborative care teams were an outstanding example of multi-disciplinary team working. Recognition by Unicef UK (United Nations Children s Fund) of the commitment of Maternity Services for the achievement of breastfeeding best practice standards. Runners up in the Kate Granger Compassion in Care awards for the Gold Line Service run by the Palliative Care Team. The Frail Elderly Pathway Team has been shortlisted for a prestigious Health Service Journal Value in Healthcare award. Following the Care Quality Commission (CQC) inspection in March 2016 and their report published in August 2016, the Trust was rated overall as requires improvement. The Critical Care Unit received an overall rating of requires improvement but it was disappointing that the safe domain was rated as inadequate. The Trust was pleased that when the CQC conducted an unannounced follow up inspection in September 2016 the inspectors found that the Trust was on track with their action plan to deliver the recommendations. The Quality Report details the actions that the Trust has taken in relation to these recommendations and we look forward to the feedback from the recent CQC inspection to confirm progress. It is regrettable that this year the Trust has reported one Never Event of wrong site surgery and the Quality Report would benefit from further details of how learning will be translated into change and improvement in practice. It is reassuring that the Trust is above the national

72 position for reported safety incidents. This demonstrates that there is an open reporting culture which is promoted by the Trust. The Quality Report cites a number of initiatives and innovations, service developments, achievements and quality improvements to ensure delivery of the 2016/17 priorities. These include: Development of partnership approaches with Primary and Secondary Care around Urgent Care. The Trust is a partner on the West Yorkshire Urgent and Emergency Care Vanguard for improved access to out of hours services. Plans to increase the number of ED consultants and the roll out of a partnership scheme with local GP groups. Approval of a capital plan to deliver an Acute Care Hub an integrated Emergency Department, Acute Medical, Surgical Assessment, and Ambulatory Care Unit. The aim being to improve clinical decision making, patient flow and the patient experience. Implementation of SystmOne e-prescribing and e-discharge across more wards. Adoption of John s Campaign to support carers to stay with patients with dementia in hospital. Roll out of the Nursing Associate pilot programme with partners from Leeds and Bradford and introduction of a Health Care Support Worker apprenticeship scheme in partnership with Keighley College. Successful bid to become one of the sites in the new Maternity and Neonatal Safety Collaborative - focusing on high risk versus low risk antenatal pathways - and to pilot a new national model of midwifery supervision. Establishment of a unique service offering help to adults with a stammer using a video link via the Airedale Digital Hub. I welcome the launch of the Trust s Quality improvement Strategy in March 2016 following engagement with patients, staff and stakeholders and I commend the approach of the Trust in improving the quality of care in all services, building on the Right Care programme. A great example of this is Ward 6 and Ward 9 achieving full accreditation of the Gold Standards Framework in March 2016 and the Trusts ambition to have further wards accredited. Your Quality Report highlights the partnership working with other local Trusts and I am pleased that the Tissue Viability Service in conjunction with Bradford District Care Trust is expected to be fully integrated over the coming year. It also provides details of the transformational work that the Trust is engaged in to integrate the contributions of district nurses, social workers, mental health professionals, GPs, care homes and voluntary organisations into a cohesive system to support the health and well-being of the community. This is reflected by the CQC report that the community based collaborative care teams were an outstanding example of multi-disciplinary team working. The Intermediate Care Hub, providing a single point of access for health and social care services and advice was also highlighted by the inspectors. I am also delighted that the Trust is working in collaboration with the Academic Health Science Network to improve patient care and reduce harm with the introduction of safety huddles and embedding improvement principles in practice. The People Plan identifies the Trusts ambition for for people management across the Trust with the overall aim of improving staff experience and shows the Trust s ongoing commitment to improve engagement with staff. Actions include:

73 Improving the quality of leadership and line management through targeted learning and support. Improving staff health and well-being. Improving the quality of appraisals and non- mandatory training and education. Involving staff in quality improvement through engagement activities and the Quality Improvement Strategy and its associated framework. Embedding the Trusts values and behaviours in key people processes: recruitment, appraisal and learning and development. Continued engagement with staff around the Right Care portfolio. The Quality Report would benefit from more detail on the steps the Trust is taking to strengthen leadership and governance at all levels. The Trust has identified the key quality priorities for the forthcoming year (2017/18). The CCG s welcomes these priority areas and the approaches that the Trust is taking to ensure the progress and the assurance on delivery of these key areas; Improving the quality of wound care for patients both in hospital and community. Improving the prevention, early identification and management of acute kidney injury. Management of sepsis. Despite the significant workforce challenges for the Trust and the solutions and work with other partners to address this, workforce has not been explored in depth in this report and the Trust should consider that this is a priority area for 2017/18. The CCGs would like to thank the Trust for their engagement in supporting the CCGs strategic programmes to improve the health and well-being of the population of Airedale, Wharfedale and Craven and acknowledge the Trust s staffs continued hard work and endeavours, through a challenging year. I confirm compliance with the national and local requirements. The statements of assurance have been completed demonstrating achievements against the essential standards. Finally, I confirm that we believe this report to be a fair and accurate account of the Trust s achievements for 2016/2017 and demonstrates via the priorities for 2017/2018 a commitment to continuously strive to improve the quality and safety of patient care; we commend the Trust s achievements during 2016/17 and look forward to supporting the Trust to achieve their ambitions during 2017/ Overview and Scrutiny Committee The draft Quality Report 2016/17 was circulated to Bradford Metropolitan District Council Health Overview and Scrutiny Committee and North Yorkshire County Council Overview and Scrutiny Committee for comment. The following comment was received:

74 The North Yorkshire Scrutiny of Health Committee has worked with the Airedale NHS Foundation Trust over the past 12 months through formal committee meetings and ongoing liaison to maintain an open dialogue about the delivery of hospital based health services in the area. This has included discussions on proposed service changes, contributions to in-depth scrutiny of End of Life Care in the county and early engagement in consultations. The committee recognises the challenges faced by hospitals serving the population of North Yorkshire as they look to change the way in which key services are delivered, in response to rising demand, workforce shortages and financial pressures. In these circumstances, early and ongoing engagement is more important than ever. The Scrutiny of Health Committee remains committed to a system-wide view of services that helps to ensure that decisions on the planning and delivery of health care are not made in isolation and that the key role that a broad base of community services have to play is not overlooked. County Councillor Jim Clark North Yorkshire Scrutiny of Health Committee 27 April Healthwatch The draft Quality Report 2016/17 was circulated to Healthwatch Bradford and District and Healthwatch North Yorkshire and Healthwatch Lancashire for comment. No feedback was offered. 4.4 How to provide feedback on the Quality Report Hopefully the Quality Report has been informative. We welcome your feedback and suggestions you may have for next year s publication. The Annual report and Quality Report will be available on our website at: A annual summary of the Quality Report is available in The Airedale Annual Record 2016/17. If you need a copy in a different format, such as large print or in another language, then please contact our Interpreting Services on telephone: or interpreting at interpreting.services@anhst.nhs.uk

75 4.5 Statement of directors responsibilities in respect of the Quality Report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year. NHS Improvement has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report. In preparing the Quality Report, directors are required to take steps to satisfy themselves that: the content of the Quality Report meets the requirements set out in the NHS foundation trust annual reporting manual 2016/17 and supporting guidance the content of the Quality Report is not inconsistent with internal and external sources of information including: o board minutes and papers for the period April 2016 to the date of this statement] o papers relating to quality reported to the board over the period April 2016 to the date of this statement o feedback from commissioners dated 18/05/17 o feedback from governors dated 18/05/17 o feedback from local Healthwatch organisations dated : offer declined. o feedback from Overview and Scrutiny Committee dated 27/04/2017 o the trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated May 2017 o the latest national patient survey 08/06/2016 o the latest national staff survey 07/03/2017 o the Head of Internal Audit s annual opinion of the trust s control environment dated 31/05/2017 o CQC inspection report dated 10/08/2016 the Quality Report presents a balanced picture of the NHS foundation trust s performance over the period covered the performance information reported in the Quality Report is reliable and accurate there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review and

76 the Quality Report has been prepared in accordance with NHS Improvement s annual reporting manual and supporting guidance (which incorporates the Quality Accounts regulations) as well as the standards to support data quality for the preparation of the Quality Report. The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. By order of the board...date...chairman...date...chief Executive

77 4.6 NHS Improvement guidance for data quality assurance on Quality Reports NHS Improvement requires foundation trusts to obtain external assurance on its Quality Reports. Set out below is the detailed 2016/17 guidance for auditors to enable review and testing of data quality. To the best of our knowledge and belief the information used to calculate indicators is complete, accurate and relates to the reporting period Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways Source of indicator definition and detailed guidance The indicator is defined within the technical definitions that accompany Everyone counts: planning for patients 2015/ /19 and can be found at content/uploads/2014/01/ec-tech-def pdf Detailed rules and guidance for measuring referral to treatment (RTT) standards can be found at Detailed descriptor E.B.3: The percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the period Numerator The number of patients on an incomplete pathway at the end of the reporting period who have been waiting no more than 18 weeks Denominator The total number of patients on an incomplete pathway at the end of the reporting period Accountability Performance is to be sustained at or above the published operational standard. Details of current operational standards are available at: planning for patients 2014/ /19 and can be found at content/uploads/2014/01/ec-tech-def pdf Detailed rules and guidance for measuring A&E attendances and emergency admissions can be found at https: content/uploads/sites/2/2013/03/ae-attendances- Emergency-Definitions-v2.0-Final.pdf This indicator is as required to be reported by the Risk Assessment Framework: A&E four-hour wait: waiting time is assessed on a provider basis, aggregated across all sites: no activity from off-site partner organisations should be included. The four-hour waiting time indicator applies to minor injury units/walk-in centres. Numerator The total number of patients who have a total time in A&E of four hours or less from arrival to admission, transfer or discharge. Calculated as: (Total number of unplanned A&E attendances) (Total number of patients who have a total time in A&E over 4 hours from arrival to admission, transfer or discharge) Denominator The total number of unplanned A&E attendances Accountability Performance is to be sustained at or above the published operational standard. Details of current operational standards are available at: (see Annex B: NHS Constitution Measures). Indicator format Reported as a percentage Percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge Source of indicator definition and detailed guidance The indicator is defined within the technical definitions that accompany Everyone counts:

78 4.7 Glossary Acute trust An acute trust provides hospital services; mental health hospital services are provided by a mental health trust. Board of Directors The Board of Directors is responsible for the effective governance of the organisation by setting the corporate strategy, supervising the work of the executive directors, setting the organisation s culture, taking those decisions that the Board reserves to itself and being accountable to its stakeholders. Executive directors are responsible for the management of the foundation trust and are accountable to the Board of Directors, of which they are part, for the performance of the foundation trust. The Board of Directors is accountable to the Council of Governors via the non executive directors. Care Quality Commission (CQC) The independent regulator of health and social care in England. CHKS A provider of healthcare improvement services, including analytic tools. It is part of the Capita plc. group. Commissioning for Quality and Innovation (CQUIN scheme) A proportion of a healthcare provider s income is conditional on quality and innovation through the CQUIN payment framework. Clinical Commissioning Groups (CCG) The local NHS organisation responsible for making sure that appropriate health services are in place to meet local people s needs. Foundation Trust A type of NHS trust in England created to devolve decision-making from central government control to local organisations and communities to ensure they are responsive to the needs and wishes of their local people. NHS foundation trusts members are drawn from patients, the public and staff and are governed by a Board of Governors comprising people elected from and by the membership base. Gold Standard Framework A nationally recognised systematic, evidence-based approach to improve the quality of care for people considered to have a life expectancy of less than 12 months. The framework is widely used in primary care and nursing homes. Health Foundation An independent, charitable foundation working to improve the quality of healthcare in the UK and beyond. Healthwatch England An independent consumer champion for health and social care in England. Working with a network of 152 local Healthwatch, it ensures that the voices of consumers reach the ears of the decision makers. NHS Digital The national provider of information, data and IT systems for health and social care. NHS Constitution sets out the rights of NHS patients and staff. These rights cover how patients access health services, the quality of care, confidentiality, information and the right to complain if things go wrong. NHS England is empowered to make informed decisions, spend taxpayers money wisely and provide high quality services through the mechanism of the clinical commissioning groups (CCGs). NHS Improvement is responsible for overseeing foundation trusts and NHS trusts, as well as independent providers that provide NHS funded care. It aims to support the delivery of high quality, compassionate care within local health systems that are financially sustainable. The National Institute for Health and Clinical Excellence (NICE) An independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. NHS Outcomes Framework 2016/17 Sets out the national outcome goals and indicators that the Secretary of State uses to monitor progress of the NHS.

79 Overview and Scrutiny Committees (OSC) These are committees made up of locally elected lay members which provide a mechanism by which the local authority or population can scrutinise the NHS. Patient Advice and Liaison Service (PALS) PALS ensures that the NHS listens to patients, carers and friends, answers their questions and resolves concerns as quickly as possible. Parliamentary Health Service Ombudsman (PHSO) The role of the PHSO is to provide a service to the public by undertaking independent investigations into complaints where the NHS in England has not acted properly or fairly or has provided a poor service. Primary Care The first point of contact for most people, for example, services provided by local GPs and their teams. Providers The organisations that provide NHS services, for example NHS trusts and their private or voluntary sector equivalents. Registration From April 2009, every NHS trust that provides healthcare directly to patients has to be registered with the Care Quality Commission (CQC). Secondary Care A service provided by medical specialists who generally do not have first contact with patients. Special Review A review carried out by the CQC to look at themes in health and social care. Reviews focus on services, pathways of care or groups of people.

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