Trust Quality and Performance Report

Trust Quality and Performance Report November 2012

Contents 2

This Corporate Trust Dashboard provides narrative for performance in five key areas: Clinical Quality Priorities, CQUIN Performance, Local Priorities, Monitor Compliance and Contract Priorities. Introduction 3

Clinical Quality Priorities Summary C. Difficile There were 4 C.difficileinfections 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

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. Quality Priority: Pressure Ulcers 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 II-IV), 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: 17

Quality Priority: Mortality 18

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. CQUIN Summary & Exceptions report 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. 23

Local Priorities - Governance Dashboard 24

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. 26

Local PrioritiesComplaintsComplaint 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 PrioritiesPALS (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: 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 consistently exceeds this target. 28

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

26/11/12 01/02/12 Time 03/11/12 22/11/12 25/11/12 F14 closes for refurbishment works Gynae move from F12 to F14 8 single rooms available for IP use SAU established F3 move to G9 whilst maintenance/deep clean takes place F3 move from G9 back to F3 G9 available for Acute Medical Unit F8 remains high turnover EAU Space available for trolley assessment area Change in accommodation Patient Flow -Programme for inpatient capacity • 25 escalation beds • (G9 19 beds, F8 6 beds) • 12 trolleys (G9) • 8 IP beds (F12) • Less 6 -12 surgical beds • 10 escalation beds (F14) • 25 escalation beds (G9 19 beds, F8 6 beds) • 12 trolleys (G9) Impact on 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

Trust Quality and Performance Report