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One example was identifying a higher number of made available by NHS Digital, a comparison of the
unstable neonates being transferred from one of our numbers, percentages, values, scores or rates of each
referring hospitals and concluding that some transfers indicator is made, with:
did not benefit the patient, who could have remained
• The national average for the same
in the local hospital with the family support network
readily available. We communicated this to the regional • Those NHS Trusts with the highest and lowest for the
neonatal network and to the surgical team to ensure all same
relevant questions are asked so that the family receives
the best care in the right place, which might be in the PART 3: OTHER
local hospital.
INFORMATION –
We have ensured that our major focus on sepsis QUALITY PERFORMANCE
continued into the mortality reviews and that
information was available to inform our quality IN 2017/18
improvement programme for sepsis. The early
identification and treatment of sepsis is a Trust priority 3.1 QUALITY PERFORMANCE
and we have established a sepsis working group to
oversee the rollout of an electronic sepsis pathway
This section provides an update on the Trust’s quality
across the Trust with associated teaching. The sepsis
performance during 2017/18, including progress against
pathway is continually being reviewed and adapted
the priorities identified in the previous quality report,
to fulfill its aims. There are multiple prompts on the plus an update on specific indicators under patient
electronic system used in the Trust to ensure that
safety, clinical effectiveness and patient experience.
sepsis is considered. The use of the sepsis pathway
is audited monthly and any children that have been
The Medical Director and Chief Nurse are jointly
identified with sepsis with the pathway not completed
responsible at Board level for leading the quality
are highlighted. Following feedback, the electronic agenda within the Trust, supported by the Director of
system now ensures that all the vital signs must be
Nursing, Deputy Director of Nursing and Associate
recorded so the PEWS is automatically calculated
Director of Risk and Governance. In addition, the Board
identifying the more unwell children. This should result
appointed two Directors of Transformation and Clinical
in a more rapid response to changes in the child’s
Effectiveness from among the consultant body during
condition. There is clear guidance for escalating the year to strengthen the team leading the Trust’s
concerns and the nursing team is empowered to raise
Quality Improvement agenda.
their concerns further if not receiving the required
response from more junior members of the medical
The Trust continues to maintain a strong focus on the
team.
delivery of the highest quality care with outstanding
examples of clinical and non-clinical excellence. In
We were also able to bolster senior clinical leadership
2017/18 we reviewed our overall Trust strategy and
on the High Dependency Unit for longer hours each
captured the outputs in a clear, simplified, eye-catching
day. The HDU clinical leadership is now clearly defined
way, which is now extensively displayed throughout
with the HDU consultant accepting and reviewing
the Trust and is widely recognised by staff, thereby
referrals between 0900 and1700 and the General ensuring clarity of the Trust vision to deliver ‘a healthier
Paediatric consultant between 1700-2200. Overnight,
future for children and young people’ (see Appendix
the senior medical doctor on site provides cover, with
2). In addition, whilst maintaining the underpinning
readily accessible phone advice from the consultant on
principles of the quality strategy that ‘patients will not
call.
suffer harm in our care’, ‘patients will receive the most
effective evidence based care’, and ‘patients will have
We also ensured that the early warning (PEWS) system
the best possible experience’, we have re-appraised
was adapted more precisely for cardiac patients.
our quality strategy and developed an updated draft
2.3 REPORTING AGAINST quality improvement plan which forms the focus of the
quality priorities for the coming year and will be the
CORE INDICATORS focus of a Quality Summit in May 2018, where teams of
staff and parents / patients will work together to finalise
The Trust is required to report performance against a our quality improvement plans for 2018/19.
core set of indicators using data made available to the
Trust by NHS Digital 2017/18 has been a strong year in terms of quality
performance with the strengthening of governance
For each indicator the number, percentage, value, arrangements, including a further embedding of
score or rate (as applicable) is presented in the table the model of devolved governance giving greater
at Appendix 1. In addition, where the required data is ownership of local quality related matters and resulting

Alder Hey Children’s NHS Foundation Trust 103 Annual Report & Accounts 2017/18