Transcript Slide 1

Trust Quality and Performance Report
November 2012
Contents
Slide numbers
Clinical Quality Priorities inc Ward Dashboard
4 - 19
CQUIN
20 - 22
Local Priorities
23 - 29
Monitor Compliance
30 - 32
Contract Priorities
33 - 36
2
Introduction
This Corporate Trust Dashboard provides narrative for performance in
five key areas: Clinical Quality Priorities, CQUIN Performance, Local
Priorities, Monitor Compliance and Contract Priorities.
3
Clinical Quality Priorities
Summary
•C. Difficile
There were 4 C.difficile infections this month against a trajectory of 2 for the month
and 7 for the quarter. This brings the total to 23 from April to October this year
against a ceiling of 27 for the year.
•Pressure Ulcers
there were 9 grade 2 ulcers this month and 1 grade 3 pressure ulcer. The detail of
this is described on page 13.
• Falls
There were 59 falls across the Trust during October. 17 of these resulted in harm
and one in serious harm. Detail is set out on pages 11 & 12.
4
Ward dashboard
5-8
Quality Priority: Ward Performance Issues
EAU
EAU was the only area with more than 3 red scores for patient satisfaction. These related to
noise at night from both patients and staff, involvement in decisions about your care and
treatment, privacy when discussing care and treatment, doctors talking in front of you as if you
weren’t there and call bell response times. The plans for the re-location of EAU trolleys and
the action plan already in place will address some of these issues. The issues of doctors
talking in front of patients and involvement in decisions about care and treatment are being
raised with senior medical staff on the unit.
Ward G8
Scored 33% on the Patient Experience score relating to friends and family. There were 12
responses in total, 8 of which scored 9, 2 scored 6 and 2 scored 4. As 4 of the 12 responses
were classed as detractors this had a large impact on the score. This is an unusually low
score for G8 and unfortunately none of the respondents indicated what had prevented them
from scoring the ward more highly. The responses to the other questions in the survey were
all very positive. Therefore the situation will be monitored.
9
Quality Priority: Infection Control
There were no cases of MRSA bacteraemia or MSSA bacteraemia during October. There were 4 C. Difficile infections this month. These
have been classified as unavoidable.
At the time of writing 21 of the 23 cases this had been subject to an RCA. Of the 15 were clinically significant. At the end of October
2011/12 there had been 23 cases, the same number as this year. Only 15 were reported because last years criteria was clinically
significant cases only. Therefore we are currently mirroring last years position.
Isolation Audit
The isolation audit has been increased to assess the use of side rooms and the isolation of patients every week day. This has identified
that from a total of 580 isolation patient bed days, 501 took place in side rooms, leaving 25 bed days where patients were within bays, a
significant reduction in comparison to other months The additional capacity of 8 single rooms as planned for the conversion of F12, would
have addressed this need.
10
Quality Priority: Falls
The contract target for falls during 2012-13 is to reduce serious harm/ death from falls and to complete a risk assessment for patients
who attend A&E as a result of a fall.
Falls performance
There were 59 falls across the Trust during October and 17 of these falls resulted in harm, one with serious harm. The serious harm
occurred to a patient on G5 who fell and fractured her neck of femur, she has since been discharged home. The RCA concluded that
this was not preventable.
Themes
A datix report was reviewed at Falls Group which detailed the time falls occurred. There was a peak in falls demonstrated between
midnight and 06.00hrs which potentially occurs due to lower staffing numbers, less patient visibility from staff and a dark environment.
Actions from falls group
• Clarity around patient visibility and expectations at nightime to be communicated to ward staff:
–Patients need to remain visible to staff as much as possible. One member of staff, at all times, to “patrol” the ward areas or be
seated at the end of the bays. F3, during the deep clean, are installing drop down tables throughout the ward corridor which will
be used at night.
– All bays should have enough dim lighting to ensure that patients are able to see if they try to get up.
– Only one member of staff to be at break at any one time to ensure enough staff remain on the ward.
• Preventable/unpreventable fall definition and care components to be further defined so that we can start to understand themes in
preventable falls and focus our work accordingly.
• Lying and standing blood pressure needs to be systematically managed, the falls group are considering ways to implement this.
11
Quality Priority: Falls environment review
As a significant number of falls occur in toilets, the occupational therapy team reviewed our ward toilet environment and made the
following observations and recommendations: These recommendations were discussed at Falls Group and will be escalated to PEAG.
• Opening and closing of the toilet door is difficult if using walking aids, and/or patient has limited grip/upper limb movement
• Patient may not be aware of how to use toilet aids if fitted, or alternatively – may need toilet equipment, as toilet too low and
therefore struggle to get off
• Patient not always aware of red pull cord, or if they use it, may have to wait for assistance and therefore try to sort themselves out,
and fall
• Patient may feel faint/low blood pressure on standing up and turning to wash-basin
• Standing at wash basin to wash hands – many patients need both hands and may become unsteady
• Leaning to get paper towels – patients may become unsteady
• Operating pedal bins with one foot – patient may become unsteady and fall
Recommendations:
• Nursing staff to accompany all patients who are unsteady mobilising and STAY by toilet door until patient has finished – assist with
hand washing as appropriate
• Consider removing bin lids to prevent operating with foot – or look at alternative method
• Ensure toilet equipment in place and at correct height etc as required. Ensure every ward has access to toilet aids (Raised toilet
seat/Mowbray frame)
• Staff to assist with door opening/closing
• Staff need to respond to patients who pull Red pull cord immediately
• Regular toileting of patients – ask hourly if possible to prevent patients attempting to go to the toilet themselves.
• Improved documentation within the DATIX system to ascertain reasons for fall in toilet – e.g. attempting to open door/attempting to
use pedal bin/feeling faint etc.
12
Quality Priority: Pressure Ulcers
The performance target is to have no avoidable Grade 3/4 pressure ulcers 2012-13 with a penalty of £5,000 for each incidence.
The performance target re: avoidable Grade 2 pressure ulcers is a ceiling of 4 for Quarter 3 with a penalty of £500 for each incidence above
the ceiling.
October performance
9 patients developed Grade 2 hospital acquired pressure ulcers this month, of which 3 were considered avoidable following concise root
cause analysis. The Grade 2 pressure ulcers developed on G4, G5, F6, F9, F10 and Critical Care Unit.
1 patient on G3 developed a Grade 3 pressure ulcer which has initially been classified as unavoidable but the RCA will determine outcome.
Avoidable pressure ulcers
•2 patients developed Grade 2 pressure ulcers on G4 which were considered avoidable as pressure relieving cushions were not provided to
each patient quickly enough. The cushions were available but the nurses did not access them. The process of obtaining cushions has been
reinforced to the ward staff.
•1 pressure ulcer developed on Critical Care Unit which was considered avoidable. This developed from the pressure of a naso-gastric tube
and routine skin inspection should prevent this. Critical Care has a high focus on improving their pressure ulcer prevention care and the
tissue viability team are offering education and training support.
13
Safety thermometer
• The NHS Safety Thermometer is a point estimate survey instrument developed by the
QIPP Safe Care team for measuring, monitoring and analysing patient harm and 'harm
free' care.
• It requires monthly surveying on one day of all adult inpatients to collect data on the
four outcomes and is a snap shot of the harm in time, a ‘temperature check’ on the
system.
• The data is collected at ward level on paper audit forms, screened by the Nursing
Directorate, inputted and sent to the NHS Information Centre. Our results are available
to us immediately. NHS Suffolk and NHS Midlands and East are able to access the
results via the Information Centre.
14
Safety thermometer results
CQUIN 2012-13 target is to survey all adult
inpatients on the survey date and submit the
data to the NHS Information Centre on time.
Our quality priority is to achieve 95% harm-free
care, current performance is 92.35%.
The National ‘harm free’ care composite
measure is defined as the proportion of patients
without a pressure ulcer (ANY origin, category IIIV), harm from a fall in care in the last 72 hours,
a urinary tract infection (in
patients with a urethral urinary catheter)
or new VTE treatment.
Therefore patients admitted with a pressure
ulcer will be considered as having “a harm”.
The data can be manipulated to just look at “new
harm” and with this new parameter, our Trust
score is 96.99%.
15
Quality Priority: Patient Experience – Achievement of 85% satisfaction
‘Achieve at least 85% satisfaction in internal patient satisfaction surveys’
is a Quality Priority for the Trust.
The overall score for the inpatient survey was % indicating a high level of satisfaction with most of the areas covered in the survey
with very high scores for privacy and dignity (98%) and staff being professional, approachable and friendly (98%). Noise at night will
be addressed through implementation of the dementia strategy and the patients flow work that is being carried out and the impact
assessed as these progress A project has been agreed with the Patients Association to examine the issue of call bell response
times. This is being scheduled by the Patients Association to take place early in the new year.
13
16
Quality Priority: Patient Experience – Recommend the service
‘Patients would recommend the service to their family and friends’
is a Quality Priority for the Trust
The Trust achieved a net promoter score of 89 for inpatients during October. With a 12% response rate.
The results for the other areas for the net promoter score are provided below:
Department
No of responses
Net promoter score
OPD
336
87
DSU
396
95
A&E
81
86
17
Quality Priority: Mortality
18
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CQUIN
Summary & Exceptions report
Q2 CQUIN performance report has been submitted to NHS Suffolk and the PCT’s response is awaited.
VTE screening performance continues at a very high level.
The new A&E Assessment of Falls target was also met.
Good progress is being made on implementation of Dementia screening.
A PMO led workshop on 7 Day Working is planned for 10 December.
Further work will need to be undertaken in General Surgery and ENT to meet Digital By Default targets.
20
CQUIN dashboard
21
Local Priorities
Summary & Exceptions report
There are three reds in the governance dashboard:
•RCA Actions beyond deadline for completion
•Incidents (Amber / Green) with investigation overdue (over 12 days)
•TA (Technology appraisal) business case beyond agreed deadline timeframe
RCA Actions beyond deadline for completion
Of the 18 overdue actions only two (from a deteriorating patient RCA) have been overdue for more than a month. A concerted effort to contact all leads
has been undertaken by Governance however there are 13 actions awaiting final clarification from the leads. A further five have been acknowledged as
being overdue by the lead and work is in progress to achieve completion
Incidents (Amber / Green) with investigation overdue (over 12 days)
A reduction in the number of overdue investigations has been achieved since the previous month’s result (305) as a result of targeted follow-up from
General Managers however this is still considerably higher than the KPI green threshold. 111/288 relate to patient safety incidents in Apr-Sept which
have a deadline of 30th November for submission to NRLS.
Please note the final figure includes movement in month with actions becoming overdue since the last report. Action to address this new indicator will be
monitored through Directorate Performance Meetings and at the next Board meeting we will be better placed to give an indication of timescale to
improve performance.
NICE Technology Appraisals (TA)
Of the current 11 outstanding TA past timescale for implementation, 8 are currently being developed by the Trust and are within our control to address.
Three further appraisals have already been to the Clinical Priorities Group who have requested additional work beyond the original template.
We have carried out a full review of TA implementation with Executive support and designed a new process that uses NICE Horizon scanning at the
consultation stage prior to publishing to increase the timeframe for work up of the business case. This will be formally agreed at the next Operational
Steering Group.
The role of the General Managers in this process will be strengthened.
The proposed date for the closure of the eight outstanding TA guidance is now planned for March 2013.
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Local Priorities - Governance Dashboard
Indicator
Performance target
National
safety
alerts
Number of NPSA alerts beyond national
implementation deadline
Timely
completion
of incident
investigatio
ns and
actions
RCAs (non SIRI) completed more than 45 days after
incident reported
Timely
reporting of
SIRIs
SIRI notification to NHS Suffolk beyond timeframe
Risk
assessment
R
A
Oct1
2
Commentary
1-4
0
0
1
0
0
1-4
0
18
Of the 18 overdue only two have been overdue for more than a
month.
<50
288
A reduction has been achieved since the previous month’s
result (305). Further action is required to achieve this target.
111/288 relate to patient safety incidents in Apr-Sept which
have a deadline of 30th November for submission to NRLS.
>=1
0
0
SIRI 45 day reports sent to NHS Suffolk beyond
timeframe
>=1
0
0
Active risk assessments in date
<75
%
75 –
94%
>=95
%
100%
Outstanding actions in date for Red / Amber entries
on Datix risk register
<75
%
75 –
94%
>=95
%
-
TA (Technology appraisal) business case beyond
agreed deadline timeframe
>9
4-9
0-3
11
IPG (Interventional procedure guideline) baseline
assessments beyond agreed deadline timeframe
>9
4-9
0-3
7
CG (Clinical guideline) baseline assessments beyond
agreed deadline timeframe
>9
4-9
0-3
8
A proposal to address the timeframes for achieving compliance
with TA deadlines is due to be submitted for approval at OPS
group . This will address timely compliance with future TAs.
Clinical
Audit
Trust participation in relevant ongoing National audits
(reported by Quarter)
<75
%
75 –
89%
>=90
%
-
100% at the end of Q2
Complaints
Response within 25 days or negotiated timescale with
the complainant
<75
%
75 –
89%
>=90
%
96%
Number of second letters received
>=5
1-4
0
0
Health Service Referrals accepted by Ombudsmen
>=2
1
0
0
Red complaints actions beyond deadline for
completion
>=5
1-4
0
0
Number of PALS contacts becoming formal
complaints
>=10
6-9
<=5
4
NICE
RCA Actions beyond deadline for completion
Incidents (Amber / Green) with investigation overdue
(over 12 days)
RAG rating has been set initially subject to approval
>=5
G
>1
>=5
>100
50-100
This KPI will be provided from December 2012 on completion of
the migration of all risks onto Datix
Overdue TAs would have been 8 but 3 business cases were
not agreed at CPG needing further clarification taking total
back to 11.
Response within 25 days or negotiated timescale with the
complainant
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There were 465 incidents reported in October including 366 patient safety incidents (PSIs).
The rate of PSIs is a nationally mandated item for inclusion in the 2012/13 Quality Accounts. The NRLS target lines shows how many
patient safety incidents WSH would have to report to fall into the median / upper and lower quartiles for small acute trusts reporting per
100 admissions. This was rebased in September to take into account the new dataset from the Oct 11 - Mar 12 NRLS report. The
reporting rate improved again on October and, using the new benchmark, the Trust falls just above the NRLS upper quartile.
The main categories leading to the increase over the last quarter are: Slips, trips & falls; Pressure ulcers (including community
acquired) and Obstetric incidents. Clinical care & treatment incidents have risen in the last two months but had been falling prior to
September. The majority of these incidents in all categories was near miss, no harm or minor harm. There has not been a noticeable
rise in Moderate or Serious harm incidents.
25
The percentage of PSIs resulting in severe harm or death is a nationally mandated item for inclusion in the 2012/13 Quality Accounts.
The peer group average (serious PSIs as a percentage of total PSIs) has been rebased to 1.0% from the NPSA October 11 – March 12
report and now sits below the Trust’s average.
The number of serious PSIs (confirmed grade) are plotted as a column on the secondary axis.
The WSH data is plotted as a line which shows the rolling average over a 12 month period. This has remained relatively static over the
last four months.
In September there were six ‘Red’ patient safety incidents reported. Two have been confirmed through RCA as serious harm: fractured
shoulder and patient fall. Another four are awaiting confirmation of grade through RCA: deteriorating patient, septic patient, grade 3
pressure ulcer and medication incident.
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Local Priorities
Complaints
Complaint response within agreed timescale with
the complainant: 96% of responses due in
October were responded to within the agreed
timescale (target 90%).
Of the 28 complaints received in October, the
breakdown by Primary Directorate is as
follows: Medical (13), Surgical (8), Clinical
Support (2), Facilities (2) and Women & Child
Health (3).
Trust-wide the most common problem areas are
as follows:
27
Local Priorities
PALS (Patient Advice & Liaison Service)
In October 2012 there were 88 recorded PALS
contacts. This number denotes initial contacts
and not the number of actual communications
between the patient/visitor and PALS which is
recorded as 118 for this month.
A breakdown of contacts by Directorate from
November 11 to October 12 is given in the chart
and a synopsis of enquiries received for the
same period is given below. Total for each month
is shown as a line on a second axis.
Trust-wide the most common five reasons for
contacts are as follows:
All aspects of clinical
treatment
20
Appointments, delays, cancellations (outpatients)
13
Attitude of staff
Information (advice)
14
Other (relating to outside organisations and some contacts not yet categorised)
10
12
From the information above, there has been a slight decrease in queries and concerns raised during October. There is however little
change in the nature of issues raised with the PALS Manager and the most detailed enquiries relate to aspects of clinical treatment.
Attitude of staff has again risen but this is often not the primary issue but associated with other concerns and relates to how the member of
staff may have dealt with the initial enquiry or concern.
The PALS Manager continues to deal with concerns about hospital procedures and clarification of treatment given, which can include
attending meetings with patients and their clinicians. She also deals with clarification of future care plans; length of time waiting for results
of tests and discrepancies about diagnosis and/or discharge arrangements.
Any issues which are not able to be dealt with by PALS are directed, if appropriate, to the formal complaints process.
The very nature of the PALS service requires responses to queries, concerns or complaints to be dealt with expediently. A Target of 80%
for responding fully (completing the enquiry) within 48 hours has been set or within a timeframe agreed with the enquirer. The Manager
28
consistently exceeds this target.
Local Priorities – Workforce Performance
•
Recruitment Timescales – the Suffolk Redeployment Clearing House requires the Trust to place all appropriate vacancies with them for a period of
1 week prior to opening up the vacancy to outside competition. This has had the effect of adding 1 week to our usual recruitment timescales and
therefore the target has been amended to include the additional week.
29
Monitor Compliance
Summary & Exceptions report
Performance against the 4 hour A&E target has been poor. This has been due to a sustained rise in attendances together with the
implementation of a new IT system leading to problems in data and operational control. Performance is as follows:
Intensive action is in place to recover the position in the short term and lead to sustainable performance. Changes to the configuration of
services to ensure that patients get the best possible experience are set out in the following slide. These include:
• A dedicated GP referral assessment area outside of A&E (MAU).
• Additional winter escalation beds.
• Transfer of DVT and TIA patients to more appropriate locations.
• Establishment of a Surgical Assessment Unit.
• Dedicated facilities for patients attending A&E with Fractured Neck of Femur.
Management arrangements have also been strengthened to ensure a more consistent and robust approach.
The number of cases of C. Diff also continue to be above the target for the month and increasingly close to the year. This is set out in detail in
slide 10.
30
Impact on
beds
Change in accommodation
Time
Patient Flow -Programme for inpatient capacity
03/11/12
22/11/12
25/11/12
26/11/12
01/02/12
G9 available for
Acute Medical
Unit
F3 move to
G9 whilst
maintenance/
deep clean
takes place
F3 move
from G9
back to F3
F8 remains high
turnover EAU
Gynae move from F12 to
F14
F14 closes for
refurbishment
works
8 single rooms available
for IP use
Space available
for trolley
assessment
area
SAU established
•
•
•
10 escalation beds (F14)
•
25 escalation beds (G9 19 beds, F8
6 beds)
12 trolleys (G9)
•
•
•
25 escalation beds
(G9 19 beds, F8 6 beds)
12 trolleys (G9)
8 IP beds (F12)
Less 6 -12 surgical beds
31
Monitor Compliance Framework
A3 printout
Dashboard - screenprint
32
Contract Priorities
Summary & Exceptions report
Stroke performance continues to be challenging.
A separate paper is presented to the Board to fully cover Stroke performance.
33
Contract Priorities Dashboard + Other
A3 printout
Comes from dashboard - screenprint
34-37