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Welcome to The Princess Alexandra Hospital’s Local Healthcare Event and Annual General Meeting September 2010 Introduction Gerald Coteman, Chairman An Insight into Quality Improvements Clare Burns, Associate Director for Quality and Efficiency Innovations in Cardiac Developments Dr El-Gendi, Consultant Cardiologist Now and in the Future Jane Herbert, Chief Executive Questions to the Speakers Close Gerald Coteman, Chairman Taking Control • Foundation Trust • Clinical and Patient Empowerment (inc. commissioning) • Health versus Hospitals Health • Long term Conditions • Long term Conditions • Long term Conditions • Biggest global disease burden facing the modern world • PAH - reinforcing our role in both managing and preventing ill-health • Deep and sustainable reform of commissioning and Local Health Economy What Else is Important? • Stronger and more visible Board • Higher priority for patient quality and safety • Engagement with staff and patients has improved • Dialogue with our partners and stakeholders has increased and improved Other Things that Matter • To you – – Dementia • To me – – Carers Thank You • Our Staff • The Board • You Improving Quality 2009/10 Clare Burns Associate Director Quality & Efficiency Mortality Ratios (SMR) Why it matters: • SMR is a key performance indicator and quality measure What we did: • Set up a project team to examine and improve mortality ratios across PAHT through root cause analysis Figures: • Overall, PAHT is currently equal to the average rating of all hospitals both locally and nationally. PAHT has made improvements in the SMR rate for acute cerebrovascular disease and for congestive heart failure, non-hypertensive. Single Sex Accommodation Why it matters: • Top concern for patients • Patient dignity What we did: • Spent £500,000 on improving the accomodation • Audited what was happening • Made it a must do for all staff • Some building works Figures: • Patient survey – sharing bathrooms or toilets – PAH 85.4 England average 70.3 Healthcare Associated Infections Why it matters: • HCAI is a key performance indicator, a grave public concern and a major reason for delayed discharge/ patient mortality What we did: • Changed screening process for MRSA (inpatients). Hand hygiene audits. New cleaning protocols. Figures: • PAH has significantly better rates of HCAI than the local and national average and is comfortably within the top 25% of hospitals for all HCAI indicators including C-Diff & MRSA. Patient Views Why it matters: • Central to achieving a patient centred approach and understanding our customers needs What we did: • Launched project groups to tackle all aspects of patient views and survey results e.g. outpatients project group Figures: PAHT is significantly better than both the local and national average for, • hospital room cleanliness/single sex use of bathrooms • Asking patients their views on quality/complaints process • Post op/ discharge advice and guidance Incident Reports Why it matters: • The reporting of incidents is paramount to identifying, understanding and overcoming the challenges facing the Trust What we did: • Introduction of the DATIX electronic incident reporting system. • Restructuring of the clinical governance department (Patient Safety & Risk) Figures: • PAHT is better than the national average for consistently reporting patient safety events and in a timely manner • PAHT is equal to the national average for the rate of patient safety events Releasing Time to Care • Ward specific ‘activity follow’ • Well organised ward • Activity follow • Patient status at a glance Releasing Time to Care The amount of time directly spent with patients has increased from 48% to 59% on Fleming Ward. Observations • Audited weekly • Displayed on the ward • Micro teaching • Results are shared The recording of patient observation in case notes has increased from 72% to 95% on Fleming Ward, and from 0% to 94% on Harvey Ward (all 14 productive wards have improved between 23% and 100%). Falls • Audit number of falls • Display data on knowing how we are doing board • Falls assessments of patients Falls The number of falls has decreased on Harvey Ward from an average of seven to three per month. Summary • PAH has achieved real and significant improvements across a wide range of performance indicators in 2009/10. • There remains significant challenges ahead, both in terms of quality and efficiency, the PMO are dedicated to meeting these challenges and achieving further improvements in 2011. Improvements in Cardiac Care Stress ECHO Service Dr Hossam El-Gendi, Consultant Cardiologist Introduction Patients with coronary artery blockages may have minimal or no symptoms during rest. However symptoms and signs of heart disease may be unmasked by exposing the heart to the stress of exercise. Exercise Stress Testing • Treadmill or bicycle ergo meter • Protocols vary - symptom limited • Bruce most popular – Eight stages – Incline and speed increment every three minutes • Target 85-100% maximum age predicted HR © Continuing Medical Implementation …...bridging the care gap • Achieve at least six METS for diagnostic accuracy Exercise Test Limitation Not suitable in 30-50% of patients, for example abnormal ECG at baseline, poor mobility, functional capacity Low sensitivity and specificity False positive middle age women In seeking an imaging solution to the limitations of standard exercise stress testing, echocardiography is attractive on practical grounds. It is the most widely disseminated and inexpensive technique for non invasive imaging of the heart. It is “patient friendly” because it is rapidly performed, echocardiography provides a means of identifying myocardial ischemia by detection of stress induced wall motion abnormalities. What We Used To Do? • Refer patients to UCH for Thalium Scan • Total Number 500+ per year • Cost Implication • Patient Satisfaction/ management issues Functional Imaging • Myocardial Perfusion Scanning • Stress Echo Global Ischaemia © Continuing Medical Implementation …...bridging the care gap In recent guidelines, the advantages of stress echocardiography over myocardial perfusion scan include higher specificity, greater versatility, greater convenience, and lower cost. Myocardial perfusion scan will have relatively higher sensitivity (especially for single-vessel disease involving the left circumflex), better accuracy when multiple resting LV wall motion abnormalities are present. The ESC Guidelines on stable angina conclude that: ‘On the whole, stress echo and myocardial perfusion scintigraphy, whether using exercise or pharmacological stress (inotropic or vasodilator), have very similar applications’. The choice as to which is employed depends largely on local facilities and expertise. Decision Making Probability > 90% 61-90% 30-60% 10-29% Investigation & Management Manage as angina Offer angiography Offer functional imaging Offer CT Calcium Scoring “Do not use exercise ECG to diagnose or exclude stable angina for people without known CAD” Stress Echo • Based on principle that ischaemic myocardium becomes hypokinetic • Baseline echo to identify regional LV function • Exercise or pharmacologic stress • Immediate echo to look for changes in wall motion © Continuing Medical Implementation …...bridging the care gap Prognostic Value of Stress Echo Compared with Stress Thallium in Patients Evaluated for CAD © Continuing Medical Implementation …...bridging the care gap The following impact is expected: • A locally provided service for patients • Reduction in the need and cost (to the patient & Trust) of travel to the UCLH. • Improved continuity of care • Diagnosis and treatment plan agreed by local teams • Reduced level of inappropriate referrals • Reduced length of stay for inpatients • Reduced waiting times for outpatients referrals from six weeks • Training and development opportunities for staff • Financial savings Note: based on current referral patterns PAH would absorb the vast majority of patients that would normally be referred to UCLH, with only a few patients requiring Myocardial Perfusion Imaging. The criteria for referral would have to be agreed with the Consultants. Mr K • • • • • Admitted with chest pain (IP) Strong RF for CAD/ Trop (-), Renal impair Unable to exercise Thalium Await 7-10d DSE + for LAD isch, Angio confirm tight LAD disease, referred for revasc Mr S Admitted with chest Pain, Angio 3 vs disease Trop+, cath 3 vs disease, surgical candidate if viability proven, patient very anxious, Myocardial perfusion as IP w/l 10 days, DSE for medical treatment explained plan for patient discharged on the same day. Mrs M Sever AS, very symptomatic poor EF, declined surgery, but only if reversible myocardial damage, DSE, normal LVF at peak. Accepted for surgery. • • • • • Chest Pain (71) Assessment of valvular disease (3) Post-catheter viability (7) Shortness of Breath (13) Other (8) DSE Outcomes 3% Of the 102 DSEs, 36 were positive for underlying ischaemia Three were inconclusive 35% 62% Safety So far no reported complication in 300 patients who had DSE since the start of the service. Follow-up After a Positive DSE So far, a total of 8 patients with a positive DSE have had follow-up coronary angiogram. Seven have had coronary angiograms displaying ischaemic lesion. One patient had a false positive because of intra-muscular bridging This equates with a 87.5%- 100% specificity Jane Herbert, Chief Executive The Princess Alexandra Hospital NHS Trust Now and In the Future Our Five Year Vision and Mission “To become the best general hospital in the East of England” “To deliver the best possible care in a safe, reliable, effective and respectful environment” Findings and Priorities • Quality: patient safety, outcomes and patient satisfaction • Capacity and demand • Money • Compliance and access target • Strategy and strategic relationships Foundation Trust Application Quality • Patient safety and outcomes: clinical working groups in place helping to deliver safe care and best practice • Board focus: new assurance systems being refined • Patient perceptions: big improvement but A&E still an issue • Patient experience more action needed in some areas Capacity and Demand Activity - Emergency - Actual v Plan Actual 3,000 Plan (I) 2,500 1,500 1,000 500 2009/10 2010/11 August July June May April March February January December November October 0 September Spells 2,000 Activity - Elective - Actual v Plan Actual 3,500 Plan (I) 3,000 2,000 1,500 1,000 500 2009/10 2010/11 August July June May April March February January December November October 0 September Spells 2,500 Capacity and Demand Management • Significant mismatch between demand and capacity • Drives financial problems • Jeopardises access targets • Poorer patient experience • Workforce issues • Threatens the Foundation Trust application • Change in strategy needed • More support for Care Closer to Home • Internal work to reduce demand • Refresh bed strategy Finance – Headline Results Steady delivery of surpluses since deficit in 2005/06 Income & Expenditure 6000 Surplus / -Deficit Planned Actual 4000 2000 0 2005/06 -2000 -4000 -6000 -8000 2006/07 2007/08 2008/09 2009/10 2010/11 Growth Now Decreasing Turnover Turnover 172.6 168.4 2009/10 2010/11 161.3 149.2 136.8 125.0 2005/06 2006/07 2007/08 2008/09 Capital Investment Capital Cashflow & Depreciation Capital Depreciation 9,848 8,781 8,474 7,500 6,714 7,133 7,290 5,816 5,266 4,200 2005/06 5,392 4,470 2006/07 2007/08 2008/09 2009/10 2010/11 Financing £4,163 2% Expenses Depreciation £7,133 4% Medical £36,080 21% Where We Spent Our Money Operating expenses £48,887 28% Nursing £37,119 22% Domestics £6,422 4% Other staff £31,855 19% Staff (WTE) 3,000 2,500 2,000 1,500 1,000 500 0 2005/06 Medical 2006/07 Nursing 2007/08 Other Clinical 2008/09 Scientific & Technical 2009/10 Non Clinical 2010/11 The Auditors Local Evaluation (ALE) Auditors Local Evaluation "Use of Resources" 2005/06 2006/07 2007/08 2008/09 Excellent (4) Good (3) Adequate (2) Inadequate (1) 2009/10 4 4 3 2 2 3 3 3 2 2 2 2 2 Financial Reporting 3 Financial Management 3 3 3 2 2 2 2 2 3 3 3 2 2 1 2 1 Financial Standing Internal Control Value for Money Overall Compliance and Access Targets • Delivery is varied • Problems from increased demand • Focus on underlying capacity/demand mismatch • Prioritise • Ensure milestones for key targets with tight performance management systems Strategy and Strategic Relationships • Networking important for patient care, service planning and saving money • White paper maintains drive to FT for acute hospitals by 12/13 • GPs to become commissioners • New FT application with less not more activity in the future • Continue to build links with GPs, community services, local acute hospitals What does this mean for our Foundation Trust Application? Summary • Top priority: work with primary care on “Care Closer to Home” to address capacity and demand imbalance to underpin other key issues • Strategy therefore based on doing less, not more • Continue to drive quality agenda and refine assurance/governance • Focus on finance and cost improvement • Build performance management culture • Lots to be proud of! Any Questions Please do hand your badges and feedback forms back.