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West Suffolk Hospitals NHS Trust. Report To: Trust Board Date: February 2010 Title: Quality Report Report of: Nichole Day, Executive Chief Nurse. Summary:
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West Suffolk Hospitals NHS Trust Report To: Trust Board Date: February 2010 Title: Quality Report Report of: Nichole Day, Executive Chief Nurse
Summary: This report provides the Board with information to assess the Trust’s performance against quality indicators, including patient experience, clinical outcomes and effectiveness, and patient safety. Background: The report has been revised and has presented in a new format since October 2009 with new indicators/measures that take into account the requirements of CQUIN, priorities identified in the Quality Accounts, and workstreams within the Trust such as the Patient Safety First Initiative. Some of the new indicators are in the development stage, with targets and data collection processes currently being agreed, the detail for these will therefore be added into the report in due course. Recommendation: The Board is asked to receive and note the contents of this report. Controls Assurance Reference:To Achieve performance levels in accordance with the CQC “Standards for Better Health”
Contents • Key Performance Indicator Dashboard • Introduction • Outcomes and Effectiveness • Patient Safety • Patient Experience • Conclusion
2. Introduction This report provides the Board with information on our performance in relation to the key quality indicators. Detail is provided on those indicators that are traffic lighted amber or red or require a fuller explanation.
3. Outcomes and Effectiveness Hospital Standardised Mortality Ratio HSMR remains at well below the expected level. % Stroke Patients in a Stroke Unit for 90% of Stay This data is not available until at least six weeks after the quarter end and will therefore be reported with the February data.
3. Outcomes and Effectiveness Clostridium difficile The Trust remains on target for C. difficile. The peak expected in January due to norovirus was not as great as anticipated. MRSA bacteraemias There were two additional MRSA bacteraemias reported in January. One of these, although classified as hospital acquired, appears to be an ongoing sepsis whilst on antibiotic treatment that was first reported as community acquired in December. Cannula and Catheter High Impact Interventions Compliance with ongoing care procedures fell this month. This is due, in the main, to lack of documentation and is disappointing as this element had shown improvement over recent months. However, the pressures created by norovirus and capacity issues are felt to be the reason for this.
4. Patient Safety Pressure Ulcers One grade 3 and one grade 4 ward acquired pressure ulcer were reported this month. RCAs are being carried out for these patients.There has been an increase in grade 2 ulcers this month due to individual issues, some of which are patient related and unavoidable. However, one ward has seen an increase in pressure ulcers recently and a specific action plan including education of nurses, and provision of equipment has been put into place by the ward manager and matron. Patient Falls A decision was made to discontinue the division of falls into preventable and non-preventable due to the subjectivity of this criteria. Therefore total falls are now shown. The total number of falls increased this month. The ward that showed an increase previously and reported improvement last month has shown sustained improvement this month, due to prioritising the provision of “specials” for confused patients on this ward. Unfortunately other wards have shown as increase this month. One ward had 18 confused patients at one stage this month and this impacts on patient dependency. In addition, due to capacity issues confused patients were placed on wards that do not normally care for such patients and this is felt to have been a contributory factor.
4. Patient Safety 8 Nutrition This indicator was added last month when baseline data was collected. To achieve compliance all of the following assessments need to be completed for the patients audited: Nutritional screening on admission Full nutritional assessment if indicated by screening Patient weighed on admission Patient weighed weekly If any of these are missing a non compliance is recorded. Five patients are assessed on each ward for the purpose of the audit. Compliance rose from 13% last month to 31% this month. Whilst a full range of assessments are not being completed for each patient, the compliance figure mask improvements in individual elements of assessments such as admission weights. However, considerable further improvement is needed. The actions to improve performance identified last month will continue.
4. Patient Safety Walkabouts Walkabouts have continued throughout January and have included site visits to theatres, to the Central Delivery Suite and F12. No specific safety issues were identified in CDS and F12. Actions to be taken forward this month includethe implementation of the the Acuity and Dependancy tool across ward areas to determine further valuable information regarding patients who have complex needs . Global Trigger Tool A further five sets of notes have been audited using the Global Trigger Tool. These notes were taken from a random set of medical notes of admissions from the last six months. The average length of stay was 5.4 days. 80% of patients experienced no adverse event triggers with episodes of care categorised as uneventful. The adverse event linked to the remaining case notes fell into Category E i.e ‘Contributed to or resulted in temporary harm to patients and required intervention’. No other triggers led to any of the other adverse event categories, Triggers this month (excluding those already being addressed within the Trusts’ Quality Report such a s falls, ulcers ) included a minor complication to an operation. Using the formula : Total number of adverse events per 1000 patient days, from the NHS Institute, comparisons can be made with other organisations and this audit indicated that there were 35 adverse events per 1000 days with the previous national average recorded at 38. The number of events is being monitored over time and a specific Trust target will be set in three months time once more data is available. In addition to using the Global Trigger tool for adverse event audit, an audit of the completion of the MEWS scores, VTE assessments and completion of the surgical checklist will be incorporated simultaneously.
5. Patient Experience 5.1 Patient Satisfaction (Near patient TV) Satisfaction was 80% this month. Three additional questions were added last month relating to single sex accommodation and call bell response time. An action plan has been developed to address the main issues emerging from this survey and the PET and progress will be monitored through the Patient Experience Implementation Group. 5.2 Patient Satisfaction (PET) 85% achieved this month. A TV screen was installed in A&E this month and this displays waiting times. Improvements should therefore be seen next month in relation to patients being informed of waiting times.
5. Patient Experience 5.3 Environment and cleanliness A score of 90% was achieved this month. These scores are now being monitored through the Patient Environment Action Group along with the environmental audits carried out by the Matrons. 5.4 Hand Hygiene 100% achieved this month in both hand hygiene and bare below the elbows.
Conclusion • This month’s results have been affected by the staffing and capacity issues experienced by the Trust as a result of norovirus and the severe weather conditions. • Continued emphasis needs to be placed on the new indicators to be able to demonstrate further improvement in the coming months. • Hand hygiene performance was 100% along with 100% compliance with the bare below the elbows policy demonstrating the continued emphasis and high profile of infection control.
