Quality
Strategy
2014 - 2017
AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
Contents
Foreword ...................................................................................................... 3
Definitions .................................................................................................... 4
What are we trying to accomplish? ............................................................ 4
Care that is safe ........................................................................................... 5
Quality Goal: Reducing harm ........................................................................................... 5
Quality Goal: Reducing avoidable mortality...................................................................... 6
Care that is clinically effective .................................................................... 8
Quality Goal: Deliver reliable care .................................................................................... 8
Care that provides a positive experience for patients and their families 9
Quality Goal: Improve patient and family centred care ..................................................... 9
What will drive change? ............................................................................ 10
Quality Improvement Methodology .......................................................... 10
Measurement and Assurance ................................................................... 12
Communicating Strategy & Improvement Plans ..................................... 12
Enabling Principles ................................................................................... 12
Building Capacity and Capability .................................................................................... 12
Learning with and from other organisations ................................................................... 13
Leadership for Quality .................................................................................................... 13
Developing a Safety Culture........................................................................................... 13
Comprehensive Unit Safety Programmes (CUSP) ......................................................... 14
Patient Safety Officers.................................................................................................... 14
Patient Safety Champions .............................................................................................. 14
Human Factors – Developing Expertise ......................................................................... 15
Engaging with our Staff .................................................................................................. 15
Patient and public involvement ....................................................................................... 15
Summary .................................................................................................... 16
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AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
Foreword
Our vision is to provide world class services for all our patients. We are committed to achieving this
through a collaborative effort from staff, who are in everyday contact with patients, to the Board
and by getting it right for every patient, every time. We recognise that it is important to aim for
excellence and that quality must be the cornerstone of our values. This strategy describes how we
will achieve the aspirations we have for our services.
As a starting point for developing the strategy, we asked our patients and their families for their
views. They told us what they need from the services provided by us and we have developed this
strategy with these priorities in mind:
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Caring and compassionate staff
Being involved in decisions about their care and treatment
Clear communication and timely information about their conditions and treatment
A clean and safe environment
Continuity of care
Clinical excellence
We asked our staff for their views and they told us that above all, being able to deliver high quality,
safe and effective services as a team is important to them. Providing this care in a caring and
compassionate environment is at the heart of their clinical values.
Our success as a Trust in delivering this strategy will mean that patients and families receiving
care at Aintree University Hospital will always have:
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Confidence that we will use feedback from patients and relatives to improve our services
Access to high quality, effective clinical services
Care provided in a clean and safe environment
A guarantee that the Trust Board, senior clinical and managerial leaders and Governors will
make quality their top priority
We need to recognise that quality is not only about the care and treatment provided by clinical staff
but also about ensuring that every member of staff in the hospital can fully play their part.
Catherine Beardshaw
Chief Executive
Aintree University Hospital NHS Foundation Trust
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AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
Definitions
Quality
Our single common definition of Quality encompasses three equally important elements:
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Care that is safe - working with patients and their families to reduce avoidable harm and
improve outcomes
Care that is clinically effective - not just in the eyes of clinicians but in the eyes of
patients and their families
Care that provides a positive experience for patients and their families
Quality Governance
Quality Governance is the combination of structures and processes at and below board level and
these include:
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A focus on ensuring that required standards are achieved
Investigating and taking action on sub-optimal performance
Planning and driving continuous improvement
Identifying, sharing and ensuring the delivery of best practice
Identifying and managing risks to quality of care
What are we trying to accomplish?
Our vision is to provide world class services for all our patients, with the common purpose of
‘getting it right for every patient, every time’.
The Quality Strategy will help us to achieve improvements in the quality of our clinical services
over three years. We will agree a portfolio of projects that address internal and external priorities to
ensure that we deliver the three elements of our definition of quality:
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Care that is safe - working with patients and their families to reduce avoidable harm and
improve outcomes. We will focus on reducing harm and avoidable mortality
Care that is clinically effective - not just in the eyes of clinicians but in the eyes of
patients and their families. We will focus on the delivery of reliable care
Care that provides a positive experience for patients and their families. We will focus
on improving the delivery of patient and family centred care
The delivery of improvements will be supported by a number of enabling principles which we have
outlined within our strategy and which relate to building capability and creating an optimal
environment for improvement.
We will focus our work on projects that will have a significant impact on the delivery of our quality
goals. These projects are outlined in the strategy, as are the measurements we will use to
determine their success.
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AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
We aim to create a culture of continuous quality improvement. Our aim is to become a learning
organisation in which every member of staff understands their role in delivering this strategy and
works towards that aim every day.
Care that is safe
Quality Goal: Reducing harm
Harm is unintended injury resulting from sub-optimal clinical care which results in additional
monitoring, treatment or extended stay in hospital.
Our goal is to achieve at least 98% of patients receiving harm free care, consistent across every
ward, as measured by the Department of Health tool, ‘Safety Thermometer’:
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Hospital Acquired Pressure Ulcers
Catheter Associated Urinary Tract Infections
Venous thrombo-embolism
Patient falls
In addition to the harms under the umbrella of Safety Thermometer our ambition is to achieve a
50% reduction in hospital acquired infections within 12 months as measured by:
- Methicillin Sensitive Staphylococcus Aureus (MSSA) Bloodstream Infections
- Hospital Acquired Clostridium difficile
We will aim to have zero avoidable MRSA Bloodstream Infections
We will also establish baseline measurements for:
- Ventilator Acquired Pneumonias
- Wound Infections (including surgical site infections and high risk areas)
Following a baseline evaluation, we will achieve a similar reduction within an 18 month period.
We will develop a medication related workstream for harms linked to the omission of critical
medicines and missed doses of all prescribed medication. There are plans to introduce a National
Medication Safety Thermometer, and consideration will be given to this when establishing
performance measures. We will also aim to achieve zero ‘never events’.
Measuring harm
Despite the hard work and good intentions of healthcare professionals, patients are harmed in
hospitals every day. It is our duty and responsibility to protect patients and Aintree University
Hospital is committed to providing harm free care.
Traditionally there has been a reliance on voluntary reporting of patient safety incidents in order to
track harm. However, research has shown that only 10 to 20 percent of errors are reported through
voluntary reporting systems and, of those, 90 to 95 percent cause no harm to patients.
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AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
We will continue to monitor harm through the reporting of all patient safety incidents, but we will
also focus on detecting and measuring harm using the Safety Thermometer, thereby enabling us to
take remedial action and learn from sub-optimal care.
Quality Goal: Reducing avoidable mortality
Our goal is to reduce the number of avoidable deaths in Aintree, by reducing the number of
patients who die as a result of avoidable harm. This will be measured by Aintree consistently
remaining in the ‘statistically as expected’ range for our Standardised Hospital Mortality Index
(SHMI) and Hospital Standardised Mortality Ratio (HSMR).
Defining mortality measures
Overall mortality at Aintree is measured in three ways across all specialties; two are a risk adjusted
ratio/index: the SHMI and the HSMR. The third is a crude death count of all inpatient discharges.
Our aim is to maintain scores consistently in the ‘statistically as expected’ range, or better, for both
the ratio/index measures and to reduce actual numbers of crude deaths. These measures will be
reported monthly via the Mortality Report to the Trust Board and its relevant Sub-Committees.
Crude death count relates to the percentage of patients who die in hospital as a proportion of all
patients who are discharged; this measure excludes day cases (Figure 1).
The HSMR is a risk adjusted indicator which has been in use for several years and is produced by
Dr Foster Intelligence. It is a similar risk adjusted indicator to SHMI, but has been in use for longer
and is constructed slightly differently (Figure 2). The calculations take account of more factors than
the SHMI. Both these measures compare an organisation’s actual number of deaths with their
expected (or predicted) number of deaths.
The SHMI, produced by the NHS Information Centre, is risk adjusted for age, sex, diagnosis and
co-morbidities. It does not include weighting for palliative care input. It includes deaths up to 30
days following discharge from hospital (Figure 3).
If the Trust has a HSMR (or SHMI) of 100 it means that the number of patients who died is exactly
as expected taking into account the standardisation factors. We have reported an HSMR of
predominantly below 100 over the time it has been reported. These two standard ratios/indices
allow comparison between different hospitals serving different communities. Since the more recent
introduction of the SHMI, where Aintree’s performance was worse than the desired level, we have
been working hard to tackle specific areas where avoidable mortality could be improved.
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AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
Figure 1 – Monthly crude mortality rates
Figure 2 – HSMR 2010-2014 by Quarter
HSMR trend for all activity across the last available 3 years of data
Figure 3 – SHMI 2010-2014 by Quarter
SHMI Trend for all activity across the last available 3 years of data
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AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
Amongst a range of measures, we have initiated a number of clinical work streams to tackle key
priorities and risks:
• Improving the prevention, early detection and treatment of Acute Kidney Injury (AKI)
• Identification and management of pneumonia
• Identification and management of sepsis
• Early recognition and management of the deteriorating patient
• End of life care
The outputs from these work streams will be delivered and embedded across all areas of clinical
practice. Over time, we will continue to review key mortality indicators and develop new streams of
work to improve clinical quality and reduce avoidable mortality.
Care that is clinically effective
Quality Goal: Deliver reliable care
There is evidence of inconsistencies in the delivery of high quality care with some patients not
receiving all the care that is recommended as best practice; this applies to both inpatient and
outpatient services. The Institute for Healthcare Improvement has developed the concept of
“bundles” to help health care providers to reliably deliver the best possible care for patients
undergoing particular treatments with inherent risks. A bundle is a structured way of improving the
process of care and patient outcomes: a small, straightforward set of evidence-based practices
that, when performed together and reliably, have been proven to improve patient outcomes.
Our goal is to achieve at least 95% delivery of reliable care, 7 days a week in the following areas:
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Advancing Quality Care Bundles for:
- Community acquired pneumonia
- Heart failure
- Hip and knee care
- Myocardial infarction
- Stroke care
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Intentional Rounding (Comfort Rounds – a systematic and regular review and
assessment of basic patient needs)
Structured Ward Rounds
Ventilator Associated Pneumonia
Peripheral Intravenous Cannula care
‘Sepsis 6’
Surgical outcomes
Nutrition and hydration
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Over the next three years we will use the principles of reliability science to maintain high
performance and improve care. We will engage staff in the development of care bundles, train
them in their use and audit them to make sure they are being consistently applied. We recognise
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AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
that there will be occasions when clinical judgement, based on the requirements of individual
patients, will override guidelines. This will be documented on the occasions when this occurs.
Reliability science can help healthcare providers redesign systems to ensure patients receive all
the elements of care they need. Healthcare systems are organised differently at the weekends
compared to weekdays where there is a lack of access to certain services over the 7 day period.
This can result in delays to treatment that can contribute to less favourable outcomes for patients.
Aintree has committed to developing safe and effective clinical services across 7 days in alignment
with plans for the wider NHS.
Care that provides a positive experience for
patients and their families
Quality Goal: Improve patient and family centred care
A positive patient and family experience is of great importance to us. We understand that many of
our patients often experience life changing diagnoses and treatments, and it is our ambition to
make their experience the best that it can possibly be. In order to do this we recognise the need for
our staff to feel valued and supported.
There is much more that we need to do to improve patient and family care and we asked our
patients and their families for their views. They told us what was important to them and we have
developed this strategy with these priorities in mind:
Measuring patient and family centred care
Currently we are 62nd in the Picker Institute national survey across 143 organisations (excluding
specialist Trusts). We aim to be ranked in 36th position or above, by the end of three years.
Our current ‘Friends and Family Test’ Net Promoter Score (FFTNPS) position is higher than the
national average for inpatients and lower than the national average for the Accident and
Emergency Department. Further clinical services will be incorporated into the national FFT survey
over the next three years.
We aim to be in the top 25% for patient and staff experience national surveys, and achieve a
FFTNPS consistently higher than the NHS England average in all measures.
To achieve our aims we will deliver a programme of work which will ensure our patients and
families describe Aintree as their provider of choice based on the quality of their experience. The
work we focus on will be based on the guiding principle that all care will be viewed through the
eyes of patients and their families; additional information on the programme of activities is provided
in the portfolio plans supporting this strategy.
Staff experience
Our ambition is, at the end of three years, to be in the top 25% of organisations ranked in the
Picker Institute national staff experience survey. Currently, not all organisations participate but we
rank 25th out of the 44 organisations which do.
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AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
What will drive change?
The improvements we aspire to will not happen in isolation and we will manage the change
programme based on an understanding of what will drive and influence change. We have used a
driver diagram to conceptualize the strategy and determine its components and the impact our
work will have on our patients and staff. This diagram identifies the connections and
interdependencies that will need to be managed to improve our services.
“Getting it right for every
patient, every time”
Care that is:
Leadership
Measurement
Safe
Patient investment at every level
Optimise team working
Effective communication
(Internal/ external)
Develop a fair and just culture
Clinical engagement
Mortality SHMI
Patient and staff satisfaction
Harm free care (Safety Thermometer)
Readmission rates
Adverse events
(SUIs/Never Events/ PSIs)
Clinically effective
Portfolio of projects (Falls/High risk
medication/IPC/VTE/CAUTI/HAPUs)
Provides a positive
experience for
patients and their
families
Clean environment
Advancing Quality projects
(CAP/HIP/Stroke/Heart Failure)
End of Life Care
Structured ward rounds
Reducing avoidable mortality
Quality Initiatives
(AKI/Sepsis/Pneumonia/
Deteriorating patient)
Intentional rounding
Surgical outcomes
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Nutrition and hydration
Capability
Patient involvement at every level
Improved methodology at every level
Awareness of human factors
Quality Drivers
Primary Drivers
Secondary Drivers
The Driver Diagram illustrates the four interdependent system components which will drive the change
required to deliver our aims
This strategy will be delivered through a portfolio of projects linked to current evidence and national
standards. Each project will be coordinated through the Project Management Office and supported
by a delivery team using Quality Improvement Methodologies. A Driver Diagram will be developed
for each project incorporating measureable indicators, a timeframe for delivery and standardised
data and monitoring requirements.
Quality Improvement Methodology
We will use the Institute for Healthcare Improvement’s (IHI) Model for Improvement and the
Breakthrough Series collaborative model to provide a framework for improvement efforts:
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AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
The IHI Improvement Model
The Breakthrough Series collaborative model is a proven intervention through which wards and
departments learn from each other and from recognized experts around a focussed set of
objectives.
The key to success is engagement, alignment and collaboration. Subject matter experts work with
clinical teams to select, test and implement changes on the front line of care and systems are
redesigned from the bottom up using small tests of change. The use of a collaborative model will
provide a framework to optimise the likelihood of success for the organisation. It is most effective
when there is a deficit in quality which can be identified by teams as ‘unacceptable’ and where
there are pockets of excellence which can be used to promote learning.
Breakthrough Series collaborative model
Teams commit to working together over a fixed period and attend three 1 day learning sessions. In
between learning sessions there are ‘action periods’ where teams test changes using a
Plan/Do/Study/Act model for improvement. Learning sessions provide instruction in improvement
theory and guidance on best clinical practice, focusing the organisation’s learning. Each team
reports on their methods and results, lessons learned and provide social support and
encouragement for making further changes. The fixed period of testing and learning culminates in
rapid spread of a safety improvement change package.
Critical success factors include leadership support, patients being placed at the heart of what we
do, a clear aim, a focus on measurement, an agreed time frame and clinical engagement. This
approach has already successfully been applied within Aintree to reduce the incidence of pressure
ulcers.
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AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
Measurement and Assurance
Robust and ambitious targets will be set for each of our quality goals to indicate progress and
success in achieving this strategy. An important element of our training programme will be teaching
‘measurement for improvement’ skills and knowledge.
There will be a portfolio of projects for which key performance indicators will be agreed in
consultation with clinical leaders. These will be linked to our quality goals. A dashboard will be
developed to enable monitoring at operational level and provide assurance to the Trust Board
through the Quality Advisory Group.
Communicating Strategy & Improvement Plans
We believe that at the cornerstone of delivering a successful strategy is a clear vision for the
future. Preparatory work will focus on building a common quality improvement vocabulary for every
member of the Trust.
To start this process we held engagement events which have allowed us to share our strategic
direction and articulate the challenges we face. These events highlighted our intention to develop a
common quality improvement language; more importantly, they gave us the opportunity to hear
staff views, enabling them to contribute to our quality improvement plans.
We will build a system of accreditation, recognition and personal achievement awards with the
intention of celebrating success.
Enabling Principles
Building Capacity and Capability
This strategy will only be successful if we focus on developing continuous improvement capability
in our workforce. We will build on existing organisational structures and expertise to develop skills,
build capacity and create opportunities for shared learning across the wider multi-disciplinary team.
We will deliver this strategy by ensuring that our staff are supported to have the capability,
enthusiasm and motivation to make, sustain and spread quality improvements. We will build on our
membership of the Advancing Quality Alliance (AQuA) making use of the opportunities it provides,
and work with a range of other improvement organisations including NHS Improving Quality.
We will provide consistent and sustainable improvement methodologies, developing a network of
staff across Aintree who possess the knowledge, skills and commitment to deliver
ongoing transformational change.
In addition to building capacity and capability within front-line teams, our leaders need the skills to
enable and drive improvement. We will develop a curriculum which will be tailored according to
identified needs and priorities. This curriculum will cover:
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AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
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Models for Improvement and small-scale rapid tests of change
A coherent improvement strategy
Concepts and practices of high-reliability organisations
Concepts of flow management
Concepts and practices of scale-up and spread of improvements
Concepts and practices of safety systems
Understanding human factors
The NHS faces challenging times requiring resilient and creative leadership together with a
determination to learn and develop.
Learning with and from other organisations
We will maximise the opportunities to learn with and from other NHS provider Trusts and
international organisations to bring about measurable improvement. We will actively promote good
practice across the Trust by learning from high performing organisations.
Leadership for Quality
The drive for continuous quality and safety improvement requires exceptional leadership at every
level of the organisation. We recognise the power and value of having clinicians leading the quality
agenda, and we aim to have clinical leaders at the forefront of delivery. The importance of
leadership has been recently highlighted by the Patient Safety First Campaign which promotes the
requirement for a commitment to patient safety not only by clinical leaders, but also at Board of
Director level.
There is strong commitment from the Aintree’s Board of Directors to lead the quality improvement
agenda. This will be done by:
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Keeping the patient and their family at the centre of all we do
Creating an environment where staff feel empowered to lead change
Promoting patient involvement in the quality improvement activities of the Trust
Ensuring transparency of quality performance and improvement activities
Providing support for quality improvement training programmes for staff
Ensuring that senior meetings have a focus on quality and safety improvement
A commitment to quality will be at the heart of clinical and managerial leadership at all levels of the
Trust. We will ensure that continuous quality improvement is a key element underpinning our
leadership development programmes for all groups of staff.
Developing a Safety Culture
A positive safety culture in healthcare organisations can have a significant impact on patient safety.
We want to create a culture within the Trust where patient safety and reliable high quality care is
central to everyday practice. This includes the development of an environment where there are
optimal systems and processes for reporting and learning from patient safety incidents and serious
untoward incidents (SUIs). We will achieve this by ensuring staff understand what their
responsibilities are and what is expected of them. We will also create an environment where staff
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AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
know that we will listen to their concerns and support them in delivering safe care. This will ensure
that patient safety is recognised as our foremost priority and everyone’s responsibility.
Just
Culture
Informed
Culture
Learning
Culture
Principles
of a
Safety
Culture
Open
Culture
Reporting
Culture
Our safety culture approach will influence behaviours by having a positive effect on beliefs, values,
and attitudes. Culture is difficult to measure directly but indications can be gained from surveys of
staff attitudes and opinions, or the use of safety culture assessment tools to evaluate whether our
safety culture is improving. The development of a positive safety culture will be closely linked to our
programme to build human factors knowledge and expertise.
Safety culture forms part of the broader organisational culture and we will ensure that we embed
and strengthen the values and behaviours which promote the delivery of high quality care focussed
on the needs and wishes of our patients.
Comprehensive Unit Safety Programmes (CUSP)
The Comprehensive Unit Safety Programme (CUSP) initiative was originally developed in
partnership with Johns Hopkins Hospitals and brings teams together to develop local programmes
to improve patient safety. A key component of this strategy will be the wider introduction of CUSPs
at specialty and department level.
Patient Safety Officers
Each clinical ward and department will have a designated Patient Safety Officer to take a lead role
in implementing a culture of safety on their individual wards and departments. The role of the
Patient Safety Officer will be reviewed and developed to support the delivery of quality
improvements.
Patient Safety Champions
The Trust has appointed three Patient Safety Champions at Consultant level to provide leadership
for quality improvement projects, promoting a culture where patient safety is a first priority at all
times.
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AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
Human Factors – Developing Expertise
Human Factors are the interrelationships between humans, the tools they use, and the
environment in which they live and work.
In the healthcare setting this has two main components:
The first is a review of organisational systems and processes to eliminate or reduce latent
conditions which can lead to harmful or potentially harmful incidents. This aspect includes incident
reporting and learning from mistakes in a way that improves the system and reduces the chances
of recurrence of the same mistake. The second, “Team Resource Management”, helps clinical
teams to work together safely and effectively. This includes training teams to improve:
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Leadership, followership and team roles
Effective teamwork
Communication
Situational awareness
Workload management
Problem solving and decision making
There is overwhelming evidence that the integration of Human Factors into clinical care is a vital
aspect of improving patient safety, and we are committed to eliminating error prone systems and
processes by developing human factors awareness within Aintree’s workforce.
Engaging with our Staff
Listening into Action
Meaningful engagement is essential to create a culture where safety and high quality care is
embedded in every day practice. Listening into Action (LiA) is one vehicle for staff engagement
within the organisation. LiA takes a conversation approach to engaging staff at all levels for
positive and effective change. It helps make connections between people, services and functions
and fosters collaboration to ensure collective ownership. This approach will support delivery of the
Quality Strategy by engaging staff to design quality improvement schemes.
Harm Free Care Events
We will take an innovative approach to raising staff awareness of patient harm by the delivery of
regular ‘Harm Free Care Events’. This structured approach will demonstrate the collaborative work
being delivered, and engage the hearts and minds of staff by sharing real patient stories and
encouraging individual ownership of harm free care.
Patient and public involvement
Our record of involving patients, families and the public in quality improvement has been
inconsistent; however, we recognise the value that this involvement can bring to service
improvement. We are totally committed to increasing the opportunities to engage our patients, their
families and the public to help us to understand the different perspectives of our service users. This
feedback will be used to inform our quality improvement work.
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AINTREE HOSPITAL QUALITY STRATEGY 2014-2017
Summary
Aintree is committed to developing a robust and sustainable process for the improvement of the
services and care that we provide. We recognise that this can only be achieved with input from our
patients, their families and our staff.
This strategy aims to draw together the different components which are key to delivering safe,
effective care and a positive experience for patients and their families. It also provides a clear set
of goals which are challenging but crucial for the successful delivery of our vision of providing world
class services and getting it right for every patient, every time.
Aintree Hospital NHS Foundation Trust
Lower Lane
Fazakerley, Liverpool
L9 7AL
Telephone 0151 525 5980
You can visit our Trust website
www.aintreehospitals.nhs.uk
if you need any further information about the hospital
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