Welcome to The Princess Alexandra Hospital’s

Local Healthcare Event and Annual General Meeting

September 2010

IntroductionGerald Coteman, Chairman

An Insight into Quality ImprovementsClare Burns, Associate Director for Quality and Efficiency

Innovations in Cardiac DevelopmentsDr El-Gendi, Consultant Cardiologist

Now and in the FutureJane 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 BurnsAssociate Director Quality & Efficiency

Mortality Ratios (SMR)Why it matters: • SMR is a key performance indicator and quality measureWhat 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 AccommodationWhy 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 InfectionsWhy it matters: • HCAI is a key performance indicator, a grave public concern

and a major reason for delayed discharge/ patient mortalityWhat 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 ViewsWhy 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 groupFigures: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 ReportsWhy 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

The amount of time directly spent with patients has increased from 48% to 59% on Fleming Ward.

Releasing Time to Care

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 CareStress 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.

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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

• Achieve at least six METS for diagnostic accuracy

© Continuing Medical Implementation …...bridging the care gap

Exercise Test LimitationNot suitable in 30-50% of patients, for exampleabnormal ECG at baseline, poor mobility, functionalcapacity

Low sensitivity and specificity

False positive middle age women

In seeking an imaging solution to the limitations ofstandard exercise stress testing, echocardiography isattractive on practical grounds. It is the most widelydisseminated and inexpensive technique for noninvasive imaging of the heart. It is “patient friendly”because it is rapidly performed, echocardiographyprovides a means of identifying myocardial ischemiaby detection of stress induced wall motionabnormalities.

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

© Continuing Medical Implementation …...bridging the care gap

In recent guidelines, the advantages of stressechocardiography over myocardial perfusion scaninclude higher specificity, greater versatility, greaterconvenience, and lower cost. Myocardial perfusionscan will have relatively higher sensitivity (especiallyfor single-vessel disease involving the left circumflex),better accuracy when multiple resting LV wall motionabnormalities are present.

The ESC Guidelines on stable angina conclude that: ‘Onthe whole, stress echo and myocardial perfusionscintigraphy, whether using exercise orpharmacological stress (inotropic or vasodilator), havevery similar applications’. The choice as to which isemployed depends largely on local facilities andexpertise.

Decision MakingProbability Investigation & Management

> 90% Manage as angina61-90% Offer angiography30-60% Offer functional imaging10-29% 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 SAdmitted with chest Pain, Angio 3 vs diseaseTrop+, cath 3 vs disease, surgical candidate ifviability proven, patient very anxious,Myocardial perfusion as IP w/l 10 days, DSE formedical treatment explained plan for patientdischarged on the same day.

Mrs M

Sever AS, very symptomatic poor EF, declinedsurgery, but only if reversible myocardialdamage, DSE, normal LVF at peak. Acceptedfor surgery.

• Chest Pain (71)• Assessment of valvular disease (3)• Post-catheter viability (7)• Shortness of Breath (13)• Other (8)

DSE Outcomes

Of the 102 DSEs, 36 were positive for underlying ischaemia

Three were inconclusive

3%

62%

35%

Safety

So far no reported complication in 300 patientswho had DSE since the start of the service.

Follow-up After a Positive DSESo far, a total of 8 patients with a positive DSEhave had follow-up coronary angiogram. Seven have had coronary angiograms displayingischaemic 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”

• Quality: patient safety, outcomes and patient satisfaction

• Capacity and demand

• Money

• Compliance and access target

• Strategy and strategic relationships

Findings and Priorities

Foundation Trust Application

Quality• Patient safety and

outcomes: clinical working groups in place helping to deliver safe care and best practice

• Patient perceptions: big improvement but A&E still an issue

• Board focus: new assurance systems being refined

• Patient experience - more action needed in some areas

Capacity and Demand

0

500

1,000

1,500

2,000

2,500

3,000

Sept

embe

r

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

Apr

il

May

June July

Aug

ust

2009/10 2010/11

Spel

ls

Activity - Emergency - Actual v PlanActual

Plan (I)

0

500

1,000

1,500

2,000

2,500

3,000

3,500

Sept

embe

r

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

Apr

il

May

June July

Aug

ust

2009/10 2010/11

Spel

ls

Activity - Elective - Actual v PlanActual

Plan (I)

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 ResultsSteady delivery of surpluses since deficit in 2005/06

-8000

-6000

-4000

-2000

0

2000

4000

6000

2005/06 2006/07 2007/08 2008/09 2009/10 2010/11

Income & ExpenditureSurplus / -Deficit

Planned Actual

Growth Now Decreasing

125.0 136.8

149.2 161.3

172.6 168.4

2005/06 2006/07 2007/08 2008/09 2009/10 2010/11

TurnoverTurnover

7,500 6,714

9,848

5,816

8,781 8,474

4,200 4,470 5,266 5,392

7,133 7,290

2005/06 2006/07 2007/08 2008/09 2009/10 2010/11

Capital Cashflow & DepreciationCapital Depreciation

Capital Investment

Where We Spent Our Money

Medical£36,080

21%

Nursing£37,119

22%

Other staff£31,855

19%Domestics

£6,4224%

Operating expenses£48,887

28%

Depreciation£7,133

4%

Financing£4,163

2%

Expenses

0

500

1,000

1,500

2,000

2,500

3,000

2005/06 2006/07 2007/08 2008/09 2009/10 2010/11

Staff (WTE)

Medical Nursing Other Clinical Scientific & Technical Non Clinical

The Auditors Local Evaluation (ALE)

2 2

1

2 2

1

2 2 2 2 2 2

3 3 3

2

3 3

2

3

4

2

3 3

2

3

4

2

3 3

Financial Reporting

Financial Management

Financial Standing

Internal Control

Value for Money

Overall

Auditors Local Evaluation"Use of Resources"

2005/06 2006/07 2007/08 2008/09 2009/10

Excellent (4)Good (3)Adequate (2)Inadequate (1)

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

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