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Nursing, Deputy Director of Nursing and Associate review to ensure that content remains responsive to
Director of Risk and Governance. In addition, the Board
appointed two Directors of Transformation and Clinical
Effectiveness from among the consultant body during
the year to strengthen the team leading the Trust’s
Quality Improvement agenda.
The Trust’s Quality Strategy was refreshed following
the move to the new hospital and the revised version
approved by the Board in April 2016. It has been
refreshed further on an iterative basis as the new
Divisional management model developed and new
roles embedded. The key elements of the strategy
include:
• Strong clinical leadership driving quality improvement
• Engaging our workforce to get involved
• Improved culture of risk management and quality
improvement through a devolved quality and
governance structure
• Improvements in workforce health and wellbeing
based on the principle of ‘happy staff = happy
patients’
• Greater patient and carer involvement: ‘giving patients
a voice.’
Underpinning each of these elements is a range of
projects and initiatives which in turn are designed to
deliver the fundamental building blocks of the Quality
Strategy which remain:
• Patients will not suffer harm in our care
• Patients will receive the most effective evidence
based care
• Patients will have the best possible experience
It is these fundamentals and their associated Quality
Aims that have been consistently at the core of the
Trust’s approach to quality since 2012/13 and which
enable a coherent and authentic narrative for staff.
The Quality Account is a core element of measuring
the delivery of the Quality Strategy. The quality
outcome measures identified in the Trust’s Quality
Account are identified and reviewed on an annual
basis in consultation with our Governors and other
stakeholders.
In support of this, during the year the Trust’s internal
Quality Report, which is embedded within the
Corporate Report, was reviewed to ensure consistency
of information tracking against the Quality Aims, a
range of sixteen safety, effectiveness and experience
measures that also allow for comparison with other
providers and can be used as assurance for regulators.
The Quality Report is reviewed in detail by the Clinical
Quality Assurance Committee and by the Board of
Directors on a monthly basis. The Report is kept under
Alder Hey Children’s NHS Foundation Trust 78
key national drivers, such as the change to the metrics
set out by NHS Improvement in the Single Oversight
Framework and that actions taken to achieve the aims
incorporate learning from elsewhere in the NHS.
Significant work has been undertaken during the year
to assure the accuracy of the quality data contained
within the report. Our data quality team undertakes
regular audit across a series of metrics, indicators
and measures and this work is reported to the Data
Quality Steering Group which meets monthly to review
data quality in the Trust. The Trust Audit programme
for 2017/18 included audit to assess the data quality
to recording patient demographics, of A&E waiting
times, referral to treatment (RTT) referral and pathway
information. MIAA also carried out audits focusing on
referral and waiting list management and performance
management and monitoring. Performance information
is validated by the service and reviewed at the weekly
performance meeting prior to sign off for reporting.
Information procedures are maintained to ensure they
reflect changes in reporting processes. There have
been improvements made to recording of patient
demographics and recording of patient outcomes in
clinic this year with more oversight and monitoring of
these processes supported by standard processes and
procedures.
At Alder Hey we have undertaken a range of measures
to ensure we have accurate and robust waiting times
data. We have a Data Quality Steering group that meets
monthly to review recording and reporting of patient
information including waiting times information. Our
Patient Access Policy, although not due for review is
currently being reviewed and relaunched in May 2018.
Our Patient Access Policy was reviewed and updated
to reflect current processes and reporting requirements
and a weekly performance group is in place to monitor
all aspects of RTT performance and identify and
resolve issues with the clinical divisions. We have also
focused improvement work on patient pathways in
outpatients, with the establishment of an Outpatient
Improvement project with work streams including
a booking and scheduling workstream which has
undertaken work to improve pathways and processes.
The improvement programme at the Trust for 2018/19
continues to focus on further improving our booking
and scheduling process with a ‘Brilliant Booking and
Scheduling’ project that will fundamentally change the
way we book our patients ensuring we have the right
capacity in place to book our patients into. It is also an
aspiration of the group to review the use of technology
to improve access to book an appointment and
improve user satisfaction.
The Trust regularly validates patients on pathways
which in turn feeds into our Data Quality Steering
group which meets on a monthly basis. The Outpatient
Department task and finish group highlighted the
Annual Report & Accounts 2017/18