Trust Quality and Performance Report

1. Trust Quality and Performance Report 31 January 2014 (December Performance Pack)

2. Contents 1

3. Executive Summary • This commentary provides an overview of key issues during the month and highlights where performance fell short of the target valuesas well as areas of improvement and noticeable good performance. • A&E Performance for December was 96.78%, quarterly performance was 96.9%; the highest in the Region and second quarter in a row that the Trust has achieved the target. Year to date performance is now also above 95%. • There were three cases of C.Diff in December against the threshold of two. This is covered within the quality report. The Trust met the Q3 ceiling with five cases in the quarter (ceiling of five). The YTD position is 21 cases against a year end ceiling of 19. • The Trust failed one Stroke performance measure in December. See page 4. • Performance on outpatient and inpatient discharge summaries remains below target. In addition to previous actions, further PMO support to this target has been introduced. Further details on page 3. • Performance on MRSA screening of emergency admissions was 97% against the 100% target. This is covered on page 12 of this report. • The Trust failed the 28 day re-booking target with one patient not offered a new date for surgery • within 28 days of being cancelled on the day. See page 4. 2

4. Executive Summary 3

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6. Clinical Quality Priorities: Summary • Falls and pressure ulcers reduced in December, giving our lowest totals in a month for this year. • MRSA screening continues to improve and reached over 95% for emergency screening. However, the target from the CCG is for 100% compliance. 5

7. Quality Priority: Ward Performance Issues • Ward F9 continues be monitored closely and monthly meetings held between the Head of Nursing, Matron, Ward Manager and Service Manager. Overall the quality indicators have improved over the last two months with 100% compliance this month in nutrition and MEWS audits and 80% compliance with hydration. There was one fall that did not result in harm but no pressure ulcers were recorded for the ward in December. However, vacancies remain a challenge as the ward is losing staff to the newly opening F12 ward and although sickness is being robustly managed, it remains at 14%. • Ward F3 has seen increases in bed capacity at intervals during December in response to pressures on bed capacity within the Trust. This was done with the agreement that temporary staff would be utilised to manage this, however, there has been an impact on the consistency of care. This is reflected in a number of quality indicators triggering red or amber during the month. The recommender score for the ward remains lower than most other wards. However, the comments from patients in response to the patient experience survey were generally very positive with a number of comments from patients about the nurses’ sensitive management of patients with challenging behaviour. The two negative comments related to the perception that the ward was understaffed. • Ward G4 continues to have a relatively low recommender score, with a score this month of 53. The high number of patients with confusion and dementia on this ward, impacts on the experience of other patients and the view is frequently expressed by patients that they should be cared for separately. In addition, there is no bedside entertainment system on the ward and this has an impact on their experience. However, given the particularly dependent patient groups cared for on this ward, the number of falls are low and the quality indicators are generally good. There have been no avoidableward acquired pressure ulcers since May 2013. An action plan for G4 is being presented to the Board separately. • Ward G5 has a number of amber and red indicators this month. Actions are being taken by the Ward Manager and Matron to improve compliance with MRSA screening and Matron’s patient ward rounds will focus on call bell response times to identify whether there are any issues specific to G5 that are influencing response times. However, the noise at night score improved in December and the amber scores for the survey are not felt to signify an on-going problem, but more a result of normal variations. 6

8. Quality Priority: Infection Control • MRSA Bacteraemia • There were no hospital associated MRSA bacteraemia’s during December. • C. difficile • There were three hospital acquired C.difficile infections during December. These are awaiting RCA and occurred in three different wards (F3, F6 and G1). Initial examination suggests that there may be grounds for appeal in two of these cases. We have appealed eight cases of which four have been rejected. All four remaining cases are pending results of the appeal. • F12 is due to open on 30 January 2014 providing an eight bedded isolation facility. • High Impact interventions • All High Impact Intervention audit results were 100%. • MRSA screening • Emergency screening reached almost 97% in December has been over 95% for the last three months. Further improvements should be seen following the implementation of daily reports for the Matrons and Ward Managers. • Elective screening compliance was 93.5% for December. In relation to elective screening: • Coding and categorisation continue to be addressed to ensure that procedures that do not require screening are not included in the figures. • Day case procedures where the interval between pre-assessment and surgery is outside the screening window continues to cause some problems. • A small number of oncology day case patients who attend on an on-going basis are still not being screened as frequently as necessary. For example two patients who attended six times in December without a screen account for12 failures in screening. • VIP Score audits • The VIP score audits carried out by the Infection Prevention Team have identified variations in compliance with daily recording of VIP score between different wards. Those wards such as F5, F9 and F10 have implemented spot checks by the Matron and peer reviews by other members of the ward team. • . 7

9. Quality Priority: Falls Falls Performance There were 40 falls this month, 27of which resulted in negligible or minor harm, one incurred serious harm. One was due to a collapse for medical reasons and would not have been counted in our old definition. The rate per 1,000 occupied bed days is 3.41 (November 4.86) giving an overall downward trend. In November we reported 50 falls. However on investigation, one was incorrectly categorised, therefore 49 falls for November. Themes We continue to monitor the number of falls occurring in toilets: there were 5 this month, 12.8% of our total number, which was up from 3 falls (or 6%) in November. Detailed intelligence continues to be collected to reveal what the patient was actually doing at the time of the fall. Work is about to start to fit hand rails in all toilets this was delayed due to materials availability. We have investigated falls by day of week, fall numbers have not been higher at weekends. 8

10. Quality Priority: Pressure Ulcers The performance target is to have no avoidable Hospital Acquired Pressure Ulcers (HAPU) Grade 2, 3 or 4 pressure ulcers 2013-14. Grade 2 Pressure Ulcers There was one grade 2 HAPU this month which the CCG have confirmed was unavoidable. This PU occurred on the bridge of the nose of a Critical Care patient. The patient required continuous ventilator support via a tight face mask. The damage occurred due to the frailty of the patients skin, which despite protection, could not be avoided. Grade 3 pressure Ulcers There were no grade 3 HAPU The improvement in the data may be attributed to the increase in availability of pressure relieving equipment , and increased education from the Tissue Viability Team. Ward managers have received a Masterclass in Preserving Skin Integrity this month. Matrons continue to check patient equipment needs and risk assessments on daily rounds. 9

11. Safety thermometer results The National ‘harm free’ care composite measure is defined as the proportion of patients without a pressure ulcer (ANY origin, category II-IV), harm from a fall in the last 72 hours, a urinary tract infection (in patients with a urethral urinary catheter) or new VTE treatment. The data can be manipulated to just look at “new harm” (harm that occurred within our care) and with this parameter, our Trust score is 97.75%. National December performance is 97.5%. The data for December shows we had 0.50% of falls with harm and the national performance for December was 0.8%. The data also shows we had 0.25% of new pressure ulcers recorded in December against the national performance of 1.0% It should be noted that the Safety Thermometer is a spot audit and data is collected on a specific day each month. 10

12. Nutrition Compliance with nutritional screening and assessment is being maintained consistently this year at levels over 95%. Hydration The action taken to improve fluid management is starting to have an impact. Some wards improved more quickly and the actions they had taken to improve were discussed at length at the Matron’s performance meeting at the beginning of December and cascaded to the poorer performing wards. This month no ward scored lower than 70% in the audits and the overall compliance increased to over 85%. Quality Priority: Nutrition and Hydration 11

13. 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 89, in line with previous months. Overall satisfaction scores for the OPD, A&E, and short stay were maintained at a high level with each scoring at least 90% overall. Call Bell Project • A review meeting was held with the surgical ward managers in January. There has been a particular focus on prompt response to patients using the toilet. Clocks have been purchased for all of the wards and will be installed during February 2014. • A project plan for the rollout of the upgraded call bell system, allowing monitoring of actual response times, is being developed and will be presented to the next meeting of the Board. • The ward managers are ensuring that there is meticulous attention to intentional rounding in order to reduce the need for the call bells to be pressed. 12

14. Quality Priority: Patient Experience – recommend the service ‘Patients would recommend the service to their family and friends’ is a Quality Priority for the Trust. Inpatient The Trust achieved a net promoter score of 82 for inpatients during December, maintaining the high scores of previous months. Currently those wards with lower recommender scores tend to have a greater percentage of patients who score “likely” and are therefore classified as passive rather than a higher percentage of patients who are detractors. The two wards that had low scores last month were wards F3 and G4. These have had similar scores this month. As with last month there were few comments, but comments received for G4 indicated that patients without dementia feel that they should not be on a ward with predominantly dementia patients and for F3 there were several comments regarding perceived low staffing levels. A&E The recommender score for A&E has remained fairly static over the last few months with the scores being between 58 and 61. The score for December 2013 was 59. Maternity Maternity recommender scores are good at all stages of the pathway as indicated below: 13

15. Local Priorities: Exception report Incidents (Amber / Green) with investigation overdue (over 12 days) The Trust met the deadline for submission of all PSIs in Apr-September NRLS of the 30th November. This has resulted in a reduction in the total overdue for investigation and final approval. Medicine in particular have demonstrated a noticeable improvement. Duty of Candour (DoC) non-compliance Case one: A patient on critical care sustained a grade 2 pressure ulcer following essential treatment to assist his breathing . The patient was in a poor state of health and prior to admission resided in a residential home with 24 hour care in place  as the result of a long term debilitating illness. It was judged inappropriate to discuss with the family as the patient was dying and the PU was unavoidable and did not impact on the outcome Case two: A patient with C. difficile. Whilst the clinical management was discussed and documented, DoC was not undertaken - the impact of the infection on the patient was not clinically significant. The case was review at the Operational Steering Group and actions agreed to strengthen medical staff awareness of the requirement of DoC with regard to cases of C difficile. The RAG rating for the KPIs has been adjusted to use actual numbers rather than percentages. This is considered more meaningful given the relatively small number of incidents involved. 14

16. Local Priorities - Governance Dashboard 15

17. Local Priorities - Governance Dashboard (cont.) 16

18. Patient Safety Incidents reported The rate of PSIs is a nationally mandated item for inclusion in the 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. The Oct12 – Mar13 NRLS report was issued in December and the benchmark in the graph above has been backdated to September. This shows a increase in reporting across the peer group and the Trust reporting rate has now fall in the last two months and sits approximately on the median for the peer group. There were 385 incidents reported in December including 318 patient safety incidents (PSIs). The reporting rate in November and December is at its lowest since September 2012. Analysis of the data shows a reduction in reporting of “equipment availability”, This has been addressed by the purchase of additional pressure relieving equipment in October 2013). There is also a drop in the number of falls reported. Other perceived drops in reporting by area need to be reviewed in more detail and followed up locally. The reporting culture within the Trust remains positive as measured in the annual staff survey. The number of harm incidents in December was below the peer group average (also backdated to September for the latest NRLS benchmark) 17

19. Patient Safety Incidents (Severe harm or death) The percentage of PSIs resulting in severe harm or death is a nationally mandated item for inclusion in the Quality Accounts. The peer group average (serious PSIs as a percentage of total PSIs) from the NPSA Oct ’12 – Mar ‘13 report and sits below the Trust’s average (NRLS benchmark updated from September ‘13). The WSH data is plotted as a line which shows the rolling average over a six month period. This has been changed from the previous reported 12 month period as six months matches the NRLS reporting period. The number of serious PSIs (confirmed and unconfirmed) are plotted as a column on the secondary axis with avoidable hospital acquired pressure ulcers (HAPU) indentified separately. In October there were three ‘Red’ patient safety incidents: a deteriorating patient, one inquest awaiting confirmation through RCA and one pressure ulcer judged as unavoidable awaiting confirmation from the CCG before downgrade. 18

20. Local Priorities: Complaints After the large number of complaints received in November (40), December saw a significant reduction (15). Complaint response within agreed timescale with the complainant: 100% of responded to in December. Of the 15 complaints received in December, the breakdown by Primary Directorate is as follows: Medical (9), Surgical (3), Clinical Support (2), Facilities (1), and Women & Child Health (0). Trust-wide the top 3* most common problem areas are as follows: *all other problem areas had a count of one 19

21. Local Priorities: PALS (Patient Advice & Liaison Service) In December 2013 there were 63 recorded PALS contacts. This number denotes initial contacts and not the number of actual communications between the patient/visitor which can, in some particular cases, be multiple. Although the overall number of initial contacts is much less for November, the length of time dealing with families has been prolonged. A breakdown of contacts by Directorate from April’12 to December‘13 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 shown below It is evident that the PALS Manager, in addition to assisting with genuine concerns from patients and relatives, frequently signposts enquirers to other services including the formal complaints process. She is also actively involved in dealing with specific in-patients and their families’ concerns during the total admission period. This last month has been particularly busy with patient families raising queries with the PALS Manager. No trends within specific departments/wards identified this month. 20

22. Local Priorities – Workforce Performance 21

23. Monitor Compliance Framework 22

24. Contract Priorities Dashboard 23

25. Contract Priorities Dashboard 24

26. Clinical Quality Priorities: Ward Dashboard A3 Printout of Ward Analysis Quality Report From Trust Dashboard 25-28