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West Suffolk Hospital NHS Trust

Item 8a Monthly Quality & Performance Report. West Suffolk Hospital NHS Trust. Report To: Trust Board Date: August 2011 Title: Quality and Performance Report Report of: Nichole Day, Executive Chief Nurse Dermot O’Riordan, Medical Director

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West Suffolk Hospital NHS Trust

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  1. Item 8a Monthly Quality & Performance Report West Suffolk Hospital NHS Trust Report To: Trust Board Date: August 2011 Title: Quality and Performance Report Report of: Nichole Day, Executive Chief Nurse Dermot O’Riordan, Medical Director Gwen Nuttall, Executive Chief Operating Officer

  2. Introduction This report provides the narrative for performance in three key areas: Quality priorities, CQUIN performance and local issues requiring escalation. It should be read in conjunction with the Ward and Trust dashboards. The layout of this report identifies performance data followed by themes identified during the analysis process and actions being taken. The ward quality report summary has been used to highlight wards that have a number of red scores and these are discussed within the report. We are exploring the potential value of early warning scores that might allow a more robust approach to escalation. The areas to highlight where we are doing well are: Nutrition assessment and monitoring Falls reduction Reduction in pressure ulcers Generally, performance against the quality priorities is improving and we are on trajectory to meet the targets set at the beginning of the year. With regard to performance, stroke performance continues to improve overall, along with performance on the new A&E targets. However there are potential financial impact on not fully achieving some aspects of standards in stroke and A&E. Performance management of follow up: new ratio’s and consultant to consultant referrals has been escalated within directorates at specialty level. Financial penalties are applicable at year end, however there are some area’s that flag red at the moment and early intervention is required. There is a separate paper on re-admissions

  3. 1. To further reduce hospital acquired infections Aim: To reduce hospital acquired MRSA bacteraemia to no more than 2 cases and C. difficile infection to no more than 29 cases between April 2011 and April 2012i) There was 1 case of MRSA bacteraemia. This was not felt to be clinically significant for the patient and all aspects of IV line care were appropriately documented. However, standard follow-up MRSA screening was inconsistent during the patients admission. This was identified and addressed through the RCA process.ii) There were 2 cases of hospital acquired C. difficile. Both cases were categorised as unavoidable and no ‘new’ issues were identified. We have invited the Consultant Microbiologist from Southend NHS Trust to undertake a review of C. difficile issues to identify any additional action or changes to practice to bring about further reductions in numbers of infections.In respect of compliance with the High Impact Interventions (HII), all scored above 98% except peri-operative care in relation to surgical site infection. There were two occasions when an element of preventative care was not recorded for this intervention resulting in an overall compliance rating of 80%. The reasons for this are being investigated with the staff concerned. Aim: To improve the management of antibiotics by achieving 100% compliance with antibiotic policy100% compliance was achieved for the wards audited in July.

  4. 2a) To achieve the highest levels of patient safetyAimsi) To assess at least 98% of admissions for risk of VTE ii) Provide prophylaxis to 100% patients at risk Compliance with VTE assessment increased to 97% this month and is above the target but further improvement is needed if the targets later in the year are to be achieved. The Medical Director has identified areas with low compliance and the clinical lead and ward manager for those areas have been contacted to highlight the improvements needed. VTE prophylaxis is assessed through quarterly audit and will be reported in October.

  5. Patient Falls The CQUIN target is no more than 159 falls in Quarter 2 with further reductions in Quarters 3 and 4. The ward RAG rating for falls is now calculated by taking a reduction against last year’s baseline for that individual ward. The total number of falls in July was 37, which provides a good platform for achieving the quarter 2 target. 14 falls resulted in harm to patients, none of which were classified as serious harm. Themes • There was a change this month in themes from falls. Only a small number of the falls occurred in patients who were suffering from dementia or confusion, although the total number of inpatients with these diagnoses was also slightly reduced this month. A proportion of falls occurred in patients who had been advised to ask for assistance when mobilising but who tried to mobilise independently. Several falls occurred in low risk patients who were independent but either overbalanced or over-reached. • The number of falls on Ward G4 and G5 reduced this month but there were 5 falls on Ward F3; an unusually high number of falls for this ward. The high number of falls coincided with a high number of patients admitted with fractured femurs resulting in high patient dependency. One of the falls occurred in an independent patient who was wearing anti-embolus stockings and no footwear, whilst the remaining 4 falls occurred in patients who required assistance to mobilise and did not ask for help. Actions based on themes The overall reduction in falls and particularly falls in patients with confusion and dementia, may be due to the roll out of intentional rounding across the medical directorate. It will be interesting to see if the reduction is maintained over the next few months. 2b) To achieve the highest levels of patient safety Aim: To reduce the number of patients who fall in hospital by 35% in the last quarter of 2011/12

  6. 2c) To achieve the highest levels of patient safety Aim: To reduce the number of avoidable grade 3 and 4 pressure ulcers by 80% in the last quarter of 2011/12 Pressure Ulcers 4 patients developed ward acquired pressure ulcers this month however no hospital acquired Grade 3/4 pressure ulcers reported. 2 of the 4 patients with pressure ulcers were on Ward G1 (Oncology) and the patients had all preventative care in place that was appropriate for their condition. . Update on pressure ulcer action plan A number of actions from the pressure ulcer action plan have been progressed further, in particular: • Heel protectors and pressure relieving mattresses have been ordered for all A&E trolleys • All ward link nurses have been asked to produce an action plan to address the training needs identified in the recent training needs analysis process. • The cleaning service for pressure relieving mattresses is to be moved to the housekeeping department and will become a seven day a week service following the staff consultation process. • A trial on Ward F3 (Orthopaedics) of an alternative preventative mattress is to be undertaken. This is a static mattress rather than alternating pressure and may be more comfortable for patients and more cost effective. If successful, these mattresses will be standard supply for all patients on the ward except those with existing pressure damage.

  7. 3a/b) To continuously improve the experience of patients using our services Aims: At least 90% of patients would choose to use the hospital again. To achieve at least an 85% satisfaction rating in our internal patient experience surveys Data review Each ward’s data is reviewed at the Matron’s performance meeting and individual action plans set for any areas scoring red/amber. Any ward that has >3 red scores will be escalated through this report. Overall, Trust wide, 99% of patients would choose to use the hospital again. Patient Satisfaction (Patient Experience Tracker) Use of the Patient Experience Tracker ceased at the end of June and therefore there are no results this month. The system is being replaced by a new system that will be available in all wards and departments. However the question set will be tailored to the area in which it is being used. Patient Satisfaction (paper questionnaires) The overall result stayed at 89% but there were significant improvements in the scores for some of the questions for some wards. For example, patients’ perception of call bell response times improved on Wards F8, F9, F10, G1, G3, and G4; noise at night improved on Wards F10, G1,G3 and F3 and being informed of who to contact if worried or concerned after leaving hospital improved on Wards F8, F9, G1, G3, F3, and F6.

  8. 3c) To continuously improve the experience of patients using our services Environment and Cleanliness Overall Trust score was 90%. All areas scored greater than 85% except critical care where the score was 84%. In Critical Care the three elements of the overall score were broken down as follows: Nursing 84%, Housekeeping 85%, and Estates 76%. The Housekeeping Supervisor and the Matron for critical care are reviewing the cleaning schedules for the department with a view to increasing frequency and the division between nursing and housekeeping responsibilities.

  9. Aim: To consistently achieve a Hospital Standardised Mortality Ratio that is below the expected rate HSMR has fallen slightly again this month and is well below the expected level as can be seen by the overall mortality shown in the graph and the table giving a mortality rate for the five Dr Foster - How Safe is Your Hospital indicators. This table provides information on relative risk, with red, blue and green traffic lighting. Blue indicates that the score is within the standard deviation. 4a) To achieve optimal clinical outcomes and effectiveness

  10. Nutrition The Audit Committee asked for more detailed information to be included in this month’s Board report in relation to the content of the nutrition KPI. This indicator started to be reported to the Board in January 2010 when a full explanation of the development of the indicator was provided. In summary, the Trust felt it important to measure the quality of nutritional care provided to patients, but there was, and still is, no nationally agreed quality indicator. The Trust took the opportunity to develop a nutritional indicator in collaboration with the Royal College of Nursing as part of the national “Nutrition Now” initiative in which the Trust participated as a pilot site. The indicator measures compliance with a number of elements of care in much the same way as the infection control HII indicators have been developed. Audits are carried out on 10 vulnerable patients from each ward on a day per month and the audit examines whether specific elements of nutritional care have been completed for each patient. Compliance is only recorded for each patient if all elements of care have been completed. Initially the elements examined were as follows: • Nutritional screening within 24 hours of admission • Full nutritional assessment for those patients identified as “at risk” within 24 hours of admission to the ward • Patient weighed on admission • Patient re-weighed every seven days Compliance was initially recorded as 31% in January 2010 and had increased to 86% by March 2011. As part of the CQUIN targets, the indicator was expanded from April/May 2011 to include measures of additional action taken based on the assessment results i.e. food diary initiated and repeated assessments completed. Over the last 3 months compliance with the expanded indicator has been between 99% and 100%. CQUIN : Other key performance indicators

  11. Local issues requiring escalation Patient Experience Noise at Night As reported in the previous section of this report, noise at night has improved in several wards this month. The telemetry sets have been changed in the Coronary Care Unit and this had had a positive impact, however, other changes that have been introduced appear to have had a limited impact so far and further action continues to be taken to address the issues. Individual discussions have been held with the Hospital at Night Team and they have been asked to develop an action plan to monitor and improve noise at night. Ward dashboard (Full ward dashboard can be seen in Item 8B Monthly Performance Dashboard pages 8-11 entitled ‘Ward Analysis Quality Report 2011-2012 July 2011’) Ward Staffing indicators have been added this month for sickness. The other staffing indicators being developed and validated. G8 had four red indicators in respect of patient satisfaction this month leading to an overall score of red. G5 had three red indicators in respect of patient satisfaction this month. The scores for Ward G8 fell significantly for the following indicators: noise at night, call bell response times, information about medication side effects, and information who to contact about worries and concerns after leaving hospital. The Matron and ward staff were unable to identify a reason for the fall in patient experience and an action plan is to be developed. Ward G5 alerted on 3 questions: call bell response times, information about medication side effects and information about who to contact about worries and concerns after leaving hospital. Scores for the survey reduced generally for this ward this month and the Matron is exploring the reasons for this with the acting Ward Manager.

  12. Local issues requiring escalation Ward dashboard continued Improvements from last month’s data. Ward F9 improved considerably (59% to 89%) in respect of patient perception of call bell response times. Ward G3 improved considerably in relation to a number of questions in the experience survey compared to last month, including information on medication side effects prior to discharge, information of who to contact if worried after leaving hospital, noise at night and call bell response times. Following a meeting with ward staff regarding the issues last month, one of the Band 6 sisters is taking the lead on patient experience survey results. Ward G4 improved it’s scores this month in respect of call bell response times and information provided to patients on who to contact if worried after leaving hospital. Falls also reduced following an increase last month and although flagging red on the dashboard is within acceptable limits for this ward (as the number of patients at high risk of falls is high). Nutrition assessment was 100%. The ward staffing establishment has been adjusted to allow for the high patient dependency and recruitment is taking place. Two nursing assistants have been recruited in the last month and further interviews are taking place.

  13. Local Priorities - Governance Dashboard Local Priorities - Governance Dashboard

  14. Local Priorities Patient Safety Incidents resulting in harm(including serious harm) and Serious Incidents Requiring Investigation (SIRIs)The overall rate of incidents resulting in harm has shown a reduction in the last month with figures down to 88 (from 95 in June). The number of serious incidents is six (pending confirmation) the same as in June. The number of new SIRIs in July fell to one. NRLS analysis shows that WSH has a reporting rate of 4.72 per 100 admissions, which is at the lower end of reporting rates for our small acute peer group. In July there were 88 Patient Safety Incidents resulting in harm of which six were categorised as serious harm (Major/Catastrophic). One incident has been reported as a SIRI. This related to: Incorrectly labelled blood sample leading to unnecessary investigation (1). The non-SIRI reds (5) were: missed fractured NOF (2); Intra-Uterine Death (1); mortality photos requested for parents (1); staff fractured ankle (1). The Clinical Safety & Effectiveness Committee receive an aggregated analysis of incidents to ensure that themes from incident reporting are being effectively identified and addressed.

  15. Local Priorities Patient Advice & Liaison Service (PALS) Review of the PALS database to enable reporting will be complete by the end of September 2011. In the meantime, a synopsis of enquiries received during July 2011 are outlined below. The numbers recorded do not necessarily indicate the number of contacts or time spent on each individual issue raised. MEDICAL A&E (2) Cardiology (2) General Medicine (1) Haematology (1) Rheumatology (1) Pain (2) Ward F9 (2) Ward G1 (1) Ward G5 (3) Ward G8 (2) SURGICAL Waiting list (2) Audiology (1) Ophthalmology (1) General Surgery (4) Surgery (OP) (1) Orthopaedic (10) Urology (6) DSU (1) Colorectal (2) Ward F3 (1) Ward F4 (2) Ward F6 (5) WOMEN AND CHILD HEALTH (0) - CLINICAL SUPPORT (6) Out-patient (1) Waiting list (2) Health records (2) Transport (1) Issues raised with the PALS Manager include: clarification of advice given for discharge arrangements and medication; queries about proposed treatment plan and care suggested; length of time waiting for an appointment or admission; help with cancelling or postponing admissions; length of time waiting for results; waiting time in clinics; request to deal with concerns about patient care on the ward; and assistance with general administrative queries/redirection to the correct department. There are no obvious themes or trends identified from the 59 contacts recorded above. There are also no outstanding issues as the PALS Manager endeavours to deal with all queries in a timely manner. Any issues which are not able to be dealt with by PALS are directed, if appropriate, to the formal complaints process.

  16. Local PrioritiesComplaintsComplaints response within agreed timescale with the complainant: : 94% of responses in July were responded to within the agreed timescale (target 90%). Of the 19 complaints received in July, the breakdown by Primary Directorate is as follows: Medical (4), Surgical (10), Clinical Support (3), Women & Child Health (0) and Facilities (2).It is normal to see a more even distribution between the Medical and Surgical Directorate. However, there is no common theme or ward/department within the ten complaints attributed to the Surgical Directorate. Trust-wide the most common problem areas are as follows: - Communication & information 6  - Aspects of clinical care 7 - Attitude of staff 3 - Appointment delay/cancelation (outpatients) 3 - Patient privacy & dignity 3 This breakdown reflects an expected distribution across the categories. (Please note that more than one category can be allocated to each complaint so the total number of problem areas does not correlate with the total number of complaints).  All complaints received are reviewed by the Patient Experience Committee to ensure that effective action is being taken and emerging themes identified. Also, directorate/ward complaints are discussed at monthly directorate meetings to identify actions required and actions taken.

  17. Workforce Performance Performance has been above target on: Sickness absence Turnover Disciplinary Investigations completed within 8 weeks The following change is recommended to the Board: It is proposed that the target for CRB checks is reduced from 100% as the Trust has a turnover rate of 9.9% to a more realistic but challenging target of 95% It should be noted that: Recruitment timescales are below target. This is an agreed change following the introduction of a Vacancy Approval process All staff have an up to date PDP – an action plan is in place

  18. Performance Measures (1) • Stroke Performance • Overall performance on the Acute Stroke Indicators (ASI) and the locally agreed SHA or PCT measures continues to improve. The Trust overall performance on stroke is above average for the East of England. However there are still area’s for improvement. • Key issues to resolve are the out of hours pathway for suspected stroke patients. During evenings, nights and weekends if a definitive diagnosis of a stroke is not made then patients are directed for admission via the emergency assessment unit. Further education and training of A&E doctors and Medical Registrars is being provided to enable them to make a more definitive decision with regard to stroke patients, This is also required to ensure stroke thrombolysis can occur 24/7. • Ringfencing of 24 stroke beds occurred in July and the impact of this has been demonstrated in an improvement of patients admitted directly to the stroke unit. This is linked to the above issue. • All patients who breach any of the stroke targets are reviewed as a concise RCA by the stroke team so that lessons can be learnt and escalation to other departments or individuals can happen as quickly as possible after the breach. • It should be noted that sometimes the failure of 1 patient along a pathway can cause a significant impact on the target achieved.

  19. Performance Measures (2) ACCIDENT AND EMERGENCY • There is improvement on the majority of the new A&E measures. Attendances in the A&E department have continued to be above expected, especially at weekends. This can have an impact on the length of time some patients wait in the department, especially for minor injury or illness. However the Trust remains in the top quartile nationally in terms of performance against the 95% of patients being seen, treated and discharged from the department in 4 hours. • The department is working hard, constantly reviewing the handover and assessment model when patients arrive, in order to improve the times to initial assessment and also the activation of the ‘button submit’ and the clinical handover. (NB, these are the triggers for handover from the ambulance crew when patients arrive and also time for triage/ assessment for all patients) • The production of discharge summaries has commenced, although there is significant amount of work to be undertaken to ensure that 95% of these are produced in 1 day. There are some exceptions to the production of discharges, which is why the dashboard says that the 53% in July is provisional FOLLOW UP TO NEW REFERRALS The specialties that are being reviewed and monitored in terms of performance above the expected ratio, with the largest potential financial impact are:- • Ophthalmology; General medicine; Cardiology; Dermatology; Rheumatology and Paediatrics

  20. Performance Measures (3) • CONSULTANT TO CONSULTANT REFERRALS • There has been an increase in some specialties in consultant to consultant referrals. This measurement is based on no increase above the number of consultant to consultant referrals undertaken in 2010. • The specialties where the increases have occurred and where there is the highest financial risk are:- medical oncology, gynaecology, vascular surgery and neurology. All the increases are being investigated down to consultant level to see if there are acceptable clinical reasons, such increase in referrals to the above specialties or changes to clinical pathways. • The financial impact will be determined at the end of the financial year, so there is the opportunity to change practice and affect the potential risk to the Trust.

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