Pennine Acute Hospitals NHS Trust. Advancing Quality Results October 2008 to December 2016

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1 Pennine Acute Hospitals NHS Trust Advancing Quality Results October 2008 to December 2016

2 Pennine Acute Hospitals NHS Trust Participation Summary Y1 Y2 Y3 Y4 Y5 Y6 Acute Kidney Injury Alcohol Related Liver Disease Chronic Obstructive Pulmonary Disease Diabetes Heart Failure Hip or Knee Replacement Surgery Hip Fracture Pneumonia Sepsis ,691 patients treated on the Advancing Quality clinical pathways at Pennine Acute Hospitals NHS Trust 494,120 patients treated within the Advancing Quality programme Key Provider participated and was reported Did not Participate Provider participated but was not eligible for reporting Focus Area Not Available -

3 Glossary of Terms s set AQ periods ACS Score CPS Score Eligible for reporting Retired focus area Transitioned Focus Area For each focus area there are specified interventions that a patient should receive. These are defined and agreed by a clinical expert group and are based on national guidelines. Data is collected for each patient about each measure and this is collated and analysed. Each focus area consists of between 6 and 16 measures - the measure set. The measure set is reviewed regularly alongside new evidence and updated if required. The programme is split into defined periods in line with achievement targets and CQUINs. - the percentage of patients who received all the measures that they were eligible for. - the percentage of measures achieved. In order to be eligible for public reporting, providers must meet the following conditions: 95% ICD10 coding completeness. 95% measure completeness for the clinical focus area. Pass independent assurance audit for the clinical focus area (ended during Year 8). The AQ programme has retired some focus areas due to high achievement from all participants. The AQ programme has utilised national audits where data is available to provide benchmarking for participating organsiations.

4 Pennine Acute Hospitals NHS Trust Latest Results Overview (Jan to Dec 2016) Current Year ACS Score Acute Kidney Injury Alcohol Related Liver Disease 1% 1% Chronic Obstructive Pulmonary Disease Diabetes 1 16% Heart Failure 23% Hip Fracture 5% Hip or Knee Replacement Surgery 47% Pneumonia Sepsis 54% 59%

5 Acute Kidney Injury The AKI measure set was launched in July There are 6 clinical process measures and 1 data collection measure in the AKI measure set % 1% 21% 3 Y8 Y9 Y8 Y9

6 Alcohol Related Liver Disease The ARLD measure set was launched in April There are 8 clinical process measures and 3 data collection measures in the ARLD measure set % 1% 45% 37% Y8 Y9 Y8 Y9

7 Chronic Obstructive Pulmonary Disease The COPD measure set was launched in December 2014 and following the annual review, amendments were made from April There are currently 5 clinical process measures and 1 data collection measure in the COPD measure set % 4% 16% 43% 35% 44%

8 Diabetes The Diabetes measure set was launched in February 2015 and following the annual review, amendments were implemented from April There are currently 10 clinical process measures in the Diabetes measure set % % 47% 53%

9 Heart Failure The Heart Failure measure set was launched in October 2008 and following the annual review amendments were implemented from October There are currently 6 clinical process measures and 1 data collection measure in the Heart Failure measure set. Heart Failure was transitioned to the National Heart Failure audit in September Participating organisations can now submit national data for quarterly benchmark % 15% 17% 43% 54% 46% 24% 23% Oct 08- Sep 09 Oct 09- Mar 10 Apr 10- Mar 11 Apr 11- Mar 12 Apr 12- Mar 13 Apr 13- Mar 14 57% % 76% 74% 56% 49% Oct 08- Sep 09 Oct 09- Apr 10- Apr 11- Apr 12- Apr 13- Mar 10 Mar 11 Mar 12 Mar 13 Mar 14 Y1 Y2 Y3 Y4 Y5 Y6 Y1 Y2 Y3 Y4 Y5 Y6

10 Hip Fracture The Hip Fracture measure set was launched in January There are currently 6 clinical process measures and 2 data collection measures in the Hip Fracture measure set % 5% 65% 64% 65%

11 Hip and Knee Replacement The Hip or Knee Replacement measure set was launched in October 2008 and following the annual review, amendments were implemented from April There are currently 6 clinical process measures and 1 data completeness measure in this measure set % 51% 63% 89% 89% 85% 88% 83% 47% Oct 08- Oct 09- Apr 10- Apr 11- Apr 12- Apr 13- Sep 09 Mar 10 Mar 11 Mar 12 Mar 13 Mar 14 86% 82% 87% 97% 97% 96% 98% 97% 85% Oct 08- Sep 09 Oct 09- Mar 10 Apr 10- Mar 11 Apr 11- Mar 12 Apr 12- Mar 13 Apr 13- Mar 14 Y1 Y2 Y3 Y4 Y5 Y6 Y1 Y2 Y3 Y4 Y5 Y6

12 Pneumonia The Pneumonia measure set was launched in October 2008 and following the annual review, amendments were implemented from October There are currently 5 clinical process measures in the Pneumonia measure set % 63% 63% 53% 68% 57% 58% 56% 59% Oct 08- Sep 09 Oct 09- Apr 10- Apr 11- Apr 12- Apr 13- Mar 10 Mar 11 Mar 12 Mar 13 Mar 14 Y1 Y2 Y3 Y4 Y5 Y6 83% 83% 84% 82% 87% 81% 81% 81% 84% Oct 08- Sep 09 Oct 09- Mar 10 Apr 10- Mar 11 Apr 11- Mar 12 Apr 12- Mar 13 Apr 13- Mar 14 Y1 Y2 Y3 Y4 Y5 Y6

13 Score Sepsis The Sepsis measure set was launched in December 2014 and following the annual review, amendments were implemented from July % 53% 54% 67% 8 79%