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Trust Quality and Performance Report. 23 May 2014 (April Performance Pack). Contents. 1. Executive Summary.
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Trust Quality and Performance Report 23 May 2014 (April Performance Pack)
Contents 1
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. The 4 hour performance target for April was 94.96%, failing the target by one patient. This is the first time the Trust has failed the target since May 2013. Full details are on page 3. There were zero cases of C.Diff in April against the threshold of two. This is covered within the quality report. 3. The Trust failed one Stroke target in April; patient being discharged with health and social care plan. See page 3. 4. Performance on outpatient and inpatient discharge summaries remains below target. See page 4. 5. Performance on MRSA screening of emergency admissions was 96.22% against the 100% target. This is covered on page 3 & 7 of this report. 6. The Trust missed the breastfeeding initiation rate with performance of 76.3% against an 80% target See page 4. 2
Clinical Quality Priorities: Summary • Norovirus affected F8 this month resulting in the closure of 2 bays for a total of 8 days. • 45 patients fell during April; a decrease of 12 compared to March. 1 fall resulted in a fractured neck of femur. • There were no cases of Clostridium Difficile in April against a yearly trajectory of 25. 6
Quality Priority: Infection Control MRSA Bacteraemia There were no cases of hospital attributable MRSA bacteraemia in April. MSSA Bacteraemia There were 2 cases of hospital attributable MSSA bacteraemia in April. C. Difficile There were no cases of Clostridium difficile in April. A case from December 2013 which went to appeal was upheld. Norovirus A patient was admitted to F8 from home on 1 April with vomiting. Norovirus was confirmed. A further 3 patients developed symptoms of Norovirus which resulted in the closure of 2 bays for a total of 8 days and the ward being closed to transfers throughout this period. MRSA Screening Elective 97.8% compared to 96.2% in March Emergency 96.2% compared to 96.2% in March 7
Quality Priority: Ward Performance Issues • Acute Medical Unit (AMU) – comprising of F7 & F8. There are a number of red and amber scores for AMU this month. These are mainly for documentation and patient experience. Actions to improve documentation and lower scoring aspects of the patient experience are being formulated into an action plan in conjunction with the ward manager, general manager and matron. • Ward G4 Improvements on scores for patient safety are seen this month. This is shown in documentation, especially MEWS & Nutrition assessment. A higher patient satisfaction score of 93 has been achieved compared to 78 in March. The Friends & Family test (recommender question) score was 73 compared to 33 for March. 8
Quality Priority: Falls Falls Performance There were 45 falls this month, 1 of which resulted in serious harm, the patient sustained a fractured hip on ward F7. 31 falls resulted in No Harm and the remaining 13 were recorded as Negligible or Minor Harm. The rate per 1,000 occupied bed days is 4.16 (March 4.8) WSNHSFT falls with harm April: 0.54%, National falls with harm April: 0.7% (Safety Thermometer). Themes There were 4 falls in the toilet this month, this is 8.8% of all falls compared to 8.7% last month. A trial has commenced on G3 to use patient movement sensors in bathrooms and commodes for at risk patients. There were 12 falls on G5, (10 last month) 9 falls were during the night, the staffing review is looking at staffing during the day and at night. 9
Quality Priority: Falls Investigation into WSH falls over the last two years has been carried out by a statistical analyst commissioned by the CCG. The following SPC chart shows a statistical improvement in the number of falls since March/April 2013.Further in-depth analysis to be carried out and reported later in the year. 10
Quality Priority: Pressure Ulcers . The performance target is to have no avoidable Hospital Acquired Pressure Ulcers (HAPU) Grade 2, 3 or 4 during 2013-14. Grade 2 Pressure Ulcers There were three grade 2 HAPU this month all three of which we believe to have been unavoidable, the CCG have yet to confirm this. Out of the six reported HAPU for March four have been confirmed by the CCG as Unavoidable Grade 3 pressure Ulcers No grade 3 HAPU this month, last grade 3 HAPU was in January. We have had no grade 4 HAPU since February 2010. 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 0.82% therefore, our new harm free care is 99. 18%. The National new harm for April is 2.5% or (97.5%) and national harm free is 93.6%. The data for April shows we had 0.54% of falls with harm and the national performance for April 2014 was 0.7%. The data also shows we had no new pressure ulcers recorded in April 2014 against the national performance of 1%. It should be noted that the Safety Thermometer is a spot audit and data is collected on a specific day each month. 12
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 91%, in line with previous months. Being treated with dignity & respect and Staff being compassionate in their approach are the highest scoring questions (both 99%). Getting enough help from staff at mealtimes scored lower this month with 4 wards with scores of less than 85%. Matrons will be conducting mealtime observations to monitor this and determine reasons for this response. 6 volunteers have completed training in April to assist with feeding patients and can be deployed once competency has been achieved. Noise at night from other patients and timeliness of call bell response are the lowest scoring questions and remain the areas of focus. 14
Call Bell Response Times Call bell response times are now captured electronically on 7 wards. A planned upgrade to install this technology across the Trust was not successful and a further attempt is planned for the end of May. Response time for April are shown below. 5 wards increased the percentage of call bells answered within 0-2 minutes compared to March data. 1 further ward maintained a score of 68% answered in 0-2 minutes. This will be a focus of Matrons rounds this month to obtain verbal feedback from patients or their perception of response timeliness. 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. Overall satisfaction scores for the OPD, A&E, and short stay were maintained at a high level with short stay achieving 100% from 313 responses. The lowest scoring question in the A&E survey was “Were you given enough privacy when discussing your condition at reception?” at 79%. Signs are in place in the reception area of the department offering patients a private space when discussing their condition. The lowest scoring question in the OPD survey was “Were you informed of any delays in being seen?” at 75%. 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 Friends and Family test score of 89for inpatients during April, maintaining the high scores of previous months. AMU scored 67 for the Friends and Family test. This reflects the overall low scoring for patient experience indicators. A ward action plan to address this has been formulated. The recommender score for A&E was 54 maintaining a similar score to previous months. The response rate to the Friends and Family test in A&E has improved with a total of 995 responses in April. Maternity recommender scores are high for all stages of the pathway as indicated below: 17
Local Priorities: Exception report Incidents (Amber / Green) with investigation overdue (over 12 days) • The next NRLS cut off for incidents between Oct13 to Apr14 is the 31st May. All patient safety incidents will need to have been investigated and finally approved prior to the cut off date to allow upload to the NRLS. There are (as at 12/05/14) 222 green and amber incidents overdue an investigation and an additional 55which have been investigated but are still awaiting final approval. • The General Managers and Clinical directors have received details of the individuals who have overdue incident investigations that pre-date the NRLS cut off and these are being actively followed up. In addition the Operational Steering group on the 12/05/14 received the details of individual with high numbers of overdue investigations. 18
Local Priorities: Exception report • RCA actions overdue • Governance provide the General Managers with a regular report on the first working day of the month listing all overdue and upcoming RCA actions. Progress with closing these actions is monitored through the Directorate performance meetings. • There are currently 17overdue actions including 3 which have completion dates before April 2014. • Complaint second letters • There were eight second letters received in April which related to requirement for further information and/or lack of agreement with the content of the initial response. Increased numbers of complaints will result in increased numbers of second letters. A total of 35 second letters were received in 2013-14 against 356 first responses therefore 90% of complaints were resolved at first response. There was a 22% increase in the total number of complaints received compared to the previous year. 19
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 Apr13 – Sept13 NRLS report was issued in April and the benchmark in the graph above was updated. This shows an increase in reporting across the peer group. There were 358 incidents reported in April including 286 patient safety incidents (PSIs). The Trust reporting rate fell in April to the lowest level since August 2012 to below the lower quartile threshold for the peer group. We are currently reviewing areas which have seen a significant reduction in reporting (AMU and A&E) and areas with consistent low levels of reporting (F14 and Theatres). The number of harm incidents in April remained below the peer group average which has also been updated for the Apr13 – Sept13 NRLS report release. 23
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 Apr13 – Sept13 report sits below the Trust’s average. The WSH percentage data is plotted as a line which shows the rolling average over a twelve month period. The number of serious PSIs (confirmed and unconfirmed) are plotted as a column on the secondary axis with avoidable hospital acquired pressure ulcers indentified separately. The benchmark line applies the peer group percentage serious harm to the peer group median total PSIs to give a comparison with the Trust’s monthly figures. In February there were two confirmed patient safety incidents: one delay in diagnosis and one intrauterine death. 24
Local Priorities: Complaints • Complaint response within agreed timescale with the complainant: 93% in April. This is due to increased workload. • Of the 27 complaints received in April, the breakdown by Primary Directorate is as follows: Medical (7), Surgical (7), Clinical Support (4), Facilities (2), and Women & Child Health (7). • There were 8 second letters received in April which related to requirement for further information and/or disagreement with the content of the initial response. Increased numbers of complaints will result in increased numbers of second letters. A total of 29 second letters were received in 2013-14 against 359 first responses therefore 92% of complaints were resolved at first response. There was a 22% increase in the total number of complaints received compared to the previous year. • Trust-wide the top 5 most common problem areas are as follows: 25
Local Priorities: PALS (Patient Advice & Liaison Service) In April 2014 there were 95recorded 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. A breakdown of contacts by Directorate from April 13 to April 2014 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. The numbers per Ward/Department remain small and consistent when spread across all areas of care provided, although the PALS Manager continues to receive complaints about cancellations for pain treatment. April has seen a reduction in the number of concerns around Admission/discharge and transfer arrangements. It is evident that the PALS Manager, in addition to assisting with genuine concerns from patients and relatives, often signposts enquirers from the community to other Trusts & external organisations to resolve their concerns. 26
Monitor Compliance FrameworkNote: 18 week performance data provisional information prior to final sign off 28
Clinical Quality Priorities: Ward Dashboard A3 Printout of Ward Analysis Quality Report From Trust Dashboard 31-36
