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GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST

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Meeting and date :

Trust Board – 24 November 2011

Title:

Patient Safety and Quality Report – (Great Western Hospital and Wiltshire Community Health Services)

Executive s ummary:

This report comprises: • A summary of the Trust’s performance against key

Patient Safety and Quality Indicators Section A and Appendix A

• A briefing from the Patient Safety and Quality Committee (PSQC) comprising:

1. Patient Safety and Clinical Risk Section B 2. Summary of the NHSLA informal assessment

recommendations Appendix B 3. Clinical Effectiveness – Section C 4. Regulation – Section D and Appendix C

Key Achievements These are described on page 3 Key areas for focus These are described on pages 3 – 8

Recommendations/ decisions required:

• To note the exceptions. To acknowledge improvements where indicated

• To receive assurances that actions are being progressed where planned improvements are required

• To note the actions required to progress compliance with NHSLA Level 1 standards following an informal assessment during October 2011 (Appendix B).

• To receive assurances that the actions arising from the NHSLA Level 1 have informed the Executive Committee and will be progressed according to the planned timescales. (Appendix B)

Link to strategic objectives:

To deliver consistently high quality, safe services which deliver desired patient outcomes and we will perform in the top 25% (upper quartile) of comparable Trusts in delivering HSMR, Patient Satisfaction and Staff Satisfaction. To improve the patient and carer experience of every aspect of the service and care that we deliver. To ensure that staff are proud to work for the Trust and would recommend the Trust as a place to work, and to receive treatment.


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Financial implications:

Financial implications will be associated with CQUIN

Legal implications:

Regulatory implications for some indicators – Monitor and CQC (see Dashboard [Appendices A & C)

Impact upon patients:

Improved communications, and faster access to services, promotes patient choice. Assurances of the quality of care provided.

Impact upon carers:

Improved communications, and faster access to services, promotes patient choice. Assurances of the quality of care provided.

Consultation/Communication:

• Monthly Directorate Performance Meetings • Patient Safety and Quality Committee (PSQ) • Executive Committee

Risk issues:

Contractual Financial – CQUIN Regulatory – Monitor and CQC

Confidentiality: This report does not contain any confidential information.

Name of Lead Executive Director: Dr Alf Troughton, Medical Director Name of Author: Ruth Lockwood, Associated Director of Patient Safety

and Quality Hilary Shand, Director of Operations


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A - Patient Safety and Quality Dashboard October 2011 (Appendix A) October - Patient Safety and Quality Dashboard The October 2011/12 dashboard provides the month seven (some month six where reporting is in arrears) data for key performance targets required for Monitor, PCT Contract and Quality Account and identifies those linked to CQUIN payment – Appendix A. Key Achievements Indicator 1J – MRSA bacteraemia (Combined) Target – 2 October - 0 YTD actual 1 Indictor 2J - Clostridium difficile (Combined) Target – 69 September –2 YTD actual – 9 Indicators 3G to 9G – Cancer Targets GWH All Cancer targets for Q2 were successfully achieved Key Areas for Focus Indicator 11G – % of patients who stay max of 4 hou rs in A&E GWH Target – >95% October – 94.2% YTD actual – 96.0% There were 358 x 4 hour patient breaches against 6,297 attendances in October. Attendance at A&E in October was high with averages from April this year at around 5,800 attendances per month (July also high). 170 of the breaches were due to unavailability of a bed for the admission of patients and 110 breaches were due to delayed 1st assessment. 28 breaches were for minors patients not admitted. 43 breaches were clinical exceptions for patients too unstable or with significant clinical reason to remain in A&E past 4 hours. Availability of beds has been a significant issue in October, particularly medical beds; this is clearly linked to the increasing volumes of delays to discharges. There are also internal processes that need to be improved to ensure timely and effective discharge and this is being managed through the internal work around length of stay. Weekend discharges remain a challenge and Mondays continue to be a particular pressure day for emergency admissions through A&E. A new Project Lead is in post for the Length of Stay Project and they will focus efforts in November on improving timely discharge. Discussions are also underway on looking at potential solutions for better managing delays to 1st assessment and breaches for minors not admitted as these tend to occur where A&E becomes ‘backed-up’ due to patients being unable to be admitted with no beds available. The implementation of the new ambulatory care service will be monitored to understand the impact on patient flow from A&E. This is a high priority target to be achieved by the Trust and will be a focus of activity in the Unscheduled Care Directorate.


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Indicator 21G - Reduction in harm from falls GWH Target - <22 October – 3 YTD - 13 Overall we are on target for the year but unfortunately 3 severe harm falls occurred in October. Investigations into these incidents are ongoing. Learning has shown some environmental areas of concern in the wards where the floor design can hinder someone’s visual judgement. Staff in this area have been reminded to raise awareness for patients regarding potential environmental hazards. The new falls tool trial remains in progress and we have responded to learning as a result of previous serious incidents and new national guidance by modifying the tool appropriately. Once this is ratified it will be rolled out across the trust in place of the current falls tools. Indicator 22G – Never Events GWH Target – 0 incidents September – 1 incident YTD actual – 2 incidents On the 23rd September 2011 the Trust reported a wrong strength ophthalmology lens implant as a serious incident. This type of incident is included in the Department of Health’s ‘Never Event’ list 2011/12. A Lead Investigator and Executive have been identified for the investigation of this incident; a full root cause analysis is now underway. The investigation report is due with our lead commissioners by the 16th December 2011. The NPSA, CQC, lead commissioners and Monitor have been informed. A peer group from Plymouth Hospitals NHS Trust is visiting GWH on 18th October 2011 to offer support and advice on the implementation of the safer surgical checklist. Following a number of never events the CQC carried out an unannounced inspection at Plymouth leading to a robust action plan and enforcement of the safer surgical checklist, the team have kindly agreed to visit our Trust to share learning and experience. On the 22nd November 2011 the Trust is sending a team of staff to attend the Peri-operative work stream event which is focusing the prevention of ‘Never events’ within the theatre setting. Indicator 26G – Nutritional assessments GWH Target – 95% by September 2011 October – 90.1% YTD – 88.1% There continues to be improvement in the number of patients receiving nutritional assessments although the target of 95% has not been achieved. The action plan to improve compliance with nutritional assessments continues. The PSQC has also requested some insight into how we compare with other organisations with regard to this target and if the target has been set locally or nationally. . A report will inform the PSQC in December 2011. Indicator 33G – Delayed transfer of care – number o f patient GWH Target – >3.5% October – 7.3% YTD actual – 4.8%


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Indicator 33G – Delayed transfer of care – number o f patient WCHS Target – >1% October – 14.1% YTD actual – 12.4% Delayed transfer of care continues to impact on bed availability for both GWH beds and Community Hospital beds. Formal notification to charge for delays from 1st November 2011 has been sent to all relevant agencies. Internal process are being established to support the new charging arrangements and the reducing delays action plan is being further enhanced to ensure internal Trust processes are robust. A number of meetings are taking place in November with both Swindon and Wiltshire health and social care to develop better processes and timings to assure effective and timely discharge. This is a high priority activity as bed availability impacts on a number of other critical patient safety and quality indicators and targets and will be a focus of activity in the Unscheduled Care Directorate. Indicator 39G – Inpatient discharge summaries to be with GP within 1 working day of discharge – EDS - GWH Target – 90% October – 58.4% YTD actual – 66.7% Indicator 40G – Clinic letters to be typed and with GP within 2 working days - GWH Target – 90% September – 50.8% (p) YTD actual – 50.8% (p) A new Project Manager has recently been appointed for the project who will start to review the different areas and practices across the patch to try to get a more standardised approach. Regular weekly meetings will be up and running from 10th November. Each DGM has been asked to provide an action plan of how to bring their typing times back on track. GWH are also looking to trial the ‘Weston’ template (proposed by the PCT) across the Trust – with modifications for each service, in order to make a more structured approach to our correspondence with GP’s, professionals and parents/patients.’ Indicator 41J (Combined) - Number of patients who a re not placed in a single sex bay during their hospital stay GWH Target – 0 October 34 YTD - 101 The Trust reported 34 mixed sex breeches during October 2011. These were all within the Acute Assessment Unit due to a lack of suitable beds being available, and the high demand for beds. In line with the bed reconfiguration plans, capacity on AAU has now been increased to 36 beds. At the time of reporting, no breeches have been occurred since the increased capacity on AAU. Indicator 45W Patients could not always find staff to discuss concerns with WCHS Target <3% Q2 – 6.2% YTD – 7.6%


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Indicator 47W Side effects of medication not always fully explained WCHS Target - <10% Q2 – 21.5% YTD – 23.6% Indicator 48W – Patients not always told who to con tact after discharge if worried WCHS Target<20% Q2 – 23.7% YTD – 26.4% The above WCHS patient survey results are shared with ward staff by Matrons to ensure staff are aware of targets and the requirements to achieve. The increase in Yes responses and the decrease in No responses show that by sharing information with wards and discussion at ward meetings, standards are improving. This will continue. Although not meeting some of the patient experience targets, the trend shows an improvement in performance. This is in line with the steps reported above. Ward Managers will meet to ensure that best practice can be shared to further drive improvement. The GWH Q2 Picker Survey results are not available at the time of reporting Indicator 57J – % of women seen by a midwife by 12 weeks and 6 days of pregnancy - Combined Target – 90% (Quarterly) September – 86.1% Q2 actual – 87.9% YTD actual – 89.2% There continue to be problems with data being collected manually and at times late submission of data does not give an accurate reflection of activity. The importance of correct data collection and timely submission has been raised with the Community midwifery team. New computer system will enable correct and timely data collection. All late booking reasons are captured in a monthly audit by the screening coordinator. Indicator 58J – Elective c-sections Combined Target – 8% September – 10.3% YTD actual – 9.7% Decision for elective c-section is only made by the Consultant Obstetrician following a thorough consultation with the mother. Review of VBAC clinics in place with a view to midwives running such clinics. Elective rate is being reviewed by the CMM lead and the VBAC midwives should be in post from the end of November. Audits have shown that the demographics of our users we have seen an increase in those with raised BMIs and more mature in age group. Indicator 62J – Breastfeeding Initiation Combined Target – >=85% (quarterly) October – 79.0% YTD actual – 79.8%


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Non compliance in achieving standard of > 85% has been raised with staff in delivery suite via handover briefings .Staff urged to ensure correct data collection .The next step is to further analyse the data and see if there are trends related to individual midwives. Indicator 189 – Reduce short stay emergency admissi ons (0-1day) GWH Target – >20% October – 7.8% YTD actual – 7.8% This performance area is currently being reviewed and an action plan developed. The impact of the implementation of Ambulatory Care is also being assessed against this target. An update will be provided with November data. Indicator 190W – Average Length of stay WCHS Target – <17 days October – 19.6 days YTD actual – 21.4 days There has been a reduction in the LOS from 22.4 days to 19.6 days but the target of 17 days is still not being achieved. Throughput on wards continues to be managed by Patient Flow Co-ordinator who will support the wards in this area. It should be noted that the rise in DTOCs linked to Wiltshire Social Care will affect achievement of this target. Indicator 192W – Increase the total number of peopl e who are discharged from a community hospital to their original residence WCHS Target – >=75% October – 72% YTD actual – 75.8% This is the first time that this indicator has flagged Red. Further investigation is underway. Indicator 198W – RTM 13 weeks (Community led servic es) WCHS Target – >=95% October – 89% YTD actual – 95% Remedial action will be taken with services that are underperforming specifically podiatry and MSK physiotherapy. Podiatry administration team is undergoing a reorganisation. An action plan is being developed for MSK to shorten waiting times. This will include the roll out of Medway across the service to facilitate appointment booking processes. Indicator 200W – Urgent Dental Access % seen in und er 48 hours WCHS Target – 100% September – 98% YTD actual – 99% Further investigation is required but it is likely that non-achievement of target will be linked to patient choice. Where possible patients are offered an appointment at their local clinic but this is not always possible so alternatives are offered as this will then involve travel patients decline and choose to wait for the next available appointment locally.


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Indicator 202W – CHC 1 st Review seen within 12 weeks - WCHS Target – >=90% October – 0% YTD actual – 13% Indicator 203W – CHC Fast Track 6 week review - WCH S Target – >=90% October – 0% YTD actual – 9% Indicator 204W – CHC Annual Review completed within 12 months - WCHS Target – >=90% October – 35% YTD actual – 28% Work continues to improve performance. Clear processes for information flow and data quality matters were established and commenced in November 2011. Further details will be provided in the November report.


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B – Patient Safety Clinical Risk and Patient Safety Serious Incidents (SIs)

• 10 new serious incidents were reported in October 2011:

IR1 and STEIS Incident details

Ward/Department

Exec Lead/Lead

investigator SI grade Immediate Actions

41431 2011/20063

Community Acquired Grade 3 Pressure Ulcer

Devizes NT Sue Rowley/Cate Judd

1 Appropriate pressure relieving devices supplied.

40994 2011/18652

Patient Fall open fracture

Kingfisher Helen Jones/Em Taylor

1 The surgeon discussed the treatment options with the patient and the patient's son.

41102 2011/19166

Patient Fall - # NOF

Radiology Guy Rooney/Gail Powell

1 The patient was made comfortable and assessed for any injury. The patient was admitted to the hospital via the emergency department

41184 2011/19046


Longleat ward

Sue Rowley/Heather Kuhler

2 Referral to Tissue Viability Nurse Specialist

41288 2011/19679


Amesbury NT

Guy Rooney/Di Green

1 Referral to Tissue Viability Nurse Specialist

41286 2011/19687


Melksham NT

Sue Rowley/Beth Palmer

1 Currently admitted to acute hospital setting. Neighbourhood team to liaise with acute ward for pressure ulcer care post discharge

41287 2011/19690


Devizes NT Sue Rowley/Cate Judd

2 Referral to Tissue Viability Nurse Specialist. Appropriate pressure relieving devices supplied.

41280 2011/20231

Hospital Acquired Grade 3 Pressure Ulcer

Mercury Elizabeth Price/Rosemary Barefield

1 GP informed, Referral to Tissue Viability Nurse Specialist. Appropriate pressure relieving devices supplied.

41543 2011/20574

Patient Fall - # NOF

CCU Elizabeth Price/Wendy Johnson

1 Immediate attendance by nursing and medical staff. Hemodynamic status assessed. Risk assessed for use of hoist to get off floor - not


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IR1 and STEIS Incident details

Ward/Department

Exec Lead/Lead

investigator SI grade Immediate Actions

appropriate. Scoop used. Patient placed back on bed. Hip xray and CT performed for diagnosis. Pain relief administered. Falls nurse contacted.

41489 2011/20442

Patient Fall - Head Injury

Mercury Elizabeth Price/Rosemary Barefield

1 Seen by medical team, management plan in place.

41088 2011/18921

Ward Closure

Saturn Elizabeth Price/JO Hutt

1 All relevant Trust staff informed of bay and ward closure. Twice daily chlorine cleaning commenced. All bay doors remain closed with nursing notes outside the bays. Medical and temporary staff movement limited. Strict hand washing procedures and personal protective equipment used throughout the ward. Symptoms monitored every shift. Samples sent to laboratory and tested for C.difficile and Norovirus but no aetiology found. Outbreak meetings and symptomatic patients isolated.

Investigation leads have been identified and progress against investigations will be monitored by PSQC. Two serious incident reports were presented at the November 2011 PSQC:

Incident number Recommendations 37780 - Delayed follow up of positive diagnosis of Cancer

• If a patient with lump is to undergo surgery, MDT case must remain open until final histology reviewed

• Formalise sign-off by MDT coordinators of WinPath reports

• Written confirmation of OPAs booked to r/v histology should be handed to patients while still in the hospital

• Written flag to be placed on OPA list where histology review is required (to prevent inadvertent clinic cancellation


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SI 38628 – Diabetic retinopathy. Delayed follow up

• All Booking Centre and reception staff who cancel patients’ appointments following a telephone call will rebook them immediately themselves, or refer the patient to the relevant supervisor of the department if there is no appropriate capacity.

• Validation of the hold file on a weekly basis to ensure that no patient appointments are outstanding.

SW SHA Quality and Patient Safety Improvement Progr amme

A peer group from Plymouth Hospitals NHS Trust visited GWH on 18th October 2011 to offer support and advice on the implementation of the safer surgical checklist. Following a number of never events the CQC carried out an unannounced inspection at Plymouth leading to a robust action plan and enforcement of the safer surgical checklist. Recommendations from peer review:

• Consider development of Theatre Safety Strategy in consultation with senior management, governance and front line staff.

• Define standards for completion of checklist, associate accountability and develop reliable metrics that can then be fed back to staff regularly.

• Develop robust communication channels through team meetings, newsletters, email etc. Use these to provide meaningful feedback that encourages and informs staff rather than punishing or criticising. Ensure communication across all staff groups.

• Appoint a surgical lead to help drive cultural change. • Suggest setting a fixed timeframe with clear targets and milestones – 30 days may be

a realistic timeframe.

An action plan, incorporating the recommendations from the peer review, is now in place within the department to mitigate the risk of reoccurrence of surgical never events. On the 22nd November 2011 the Trust is sending a team of staff to attend the Peri-operative work stream event which is focusing on the prevention of ‘Never events’ within the theatre setting. NPSA organisational feedback report September 2011 - Summary NPSA Organisation Patient Safety Incident Report A patient safety incident is any unintended or unexpected incident which could have or did lead to harm to one or more patients receiving NHS care (NPSA) The Trust reports all incidents which relate to patient safety to the National Patient Safety Agency (NPSA) via the Reporting and Learning System (NRLS) on a weekly basis. The NPSA is now required to send all incidents resulting in moderate harm, severe harm or death to the Care Quality Commission (CQC). Incidents reported to the NPSA between 1 st October 2010 and 31 st March 2011 The NPSA encourages reporting of incidents and recognises that high reporting organisations usually have a better and more effective safety culture. The NPSA reports clusters Trusts to enable some comparison between organisations. The Great Western Hospitals NHS Foundation Trust is placed in the medium acute Trust cluster group along with 49 other Trusts.


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The number of patient safety incidents reported by the Trust to the NPSA has increased from 3759 incidents reported during 2009/10 to 4613 during 2010/11. The Trust’s organisational report received from the NPSA for the period October 2010 to March 2011 confirmed this improvement. The Trust’s reporting rate had increased to 5.8 per 100 admissions compared to 5.4 per 100 admissions for the period between April to September 2010. The median reporting rate within our cluster group is 5.8 incidents reported per 100 admissions, placing the Trust in the middle 50% of reporters. The CQC staff survey results revealed that the Trust scored better than average for the percentage of staff who said they had witnessed a harmful error in the last month (fewer staff had witnessed a harmful error). Table 1 demonstrates that although incident reporting to the NPSA increased during the period October 2010 to March 2011, (a higher percentage of incidents reported than in the preceding period), these were either a near miss incident or resulted in no harm to a patient. This indicates that although more incidents were reported this did not equate to higher numbers of incidents resulting in harm. Table 1 Actual harm resulting from patient safety incidents

Actual harm April – September 2010

% of incidents

October 2010 -March 2011

% of incidents

All medium acute organisations

No harm 1,449 67.7% 1,561 68.7% 71.9% Low harm 597 27.9% 650 28.6% 22.2% Moderate harm

80 3.7% 50 2.2% 5.1%

Severe harm 14 0.7% 6 0.3% 0.6% Death 1 0.05% 5 0.2% 0.2% Total 2141 100% 2272 100% 100%

Although incident reporting has increased, this has not resulted in an increased number of incidents resulting in serious harm. Of the 2272 incidents reported during the period October to April 2011 97.3% resulted in low or no harm to a patient, which is a similar pattern to other Trust’s within our cluster group where 94.1% of incidents resulted in low or no harm. During the report period six incidents resulted in severe harm and five incidents resulted in death. Each incident was reported as serious and managed in line with the Incident Management Policy. These incidents were each subject to a robust root cause analysis investigation each resulting in the implementation of action plans to reduce the risk of reoccurrence. Timeliness of reporting The time between an incident occurring and being reported to the NPSA is important for the information to be useful for identifying and acting upon quickly. During the period October 2010 to April 2011 Trusts within our cluster group submitted fifty percent of all incidents to the NRLS more than 37 days after the incident occurred, whilst in our organisation, 50% of incidents were submitted more than 16 days after the incident occurred.


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Type of incident reported

Cause Group

April

2010-Sept

2010

GWH % of

incidents

Oct

2010-

Mar

2011

GWH %

of

incidents

Oct 2010-Mar

2011 all

medium acute

Trusts % of

incidents

Patient accident 28.1 28.0 28.6

Treatment, procedure 12.6 10.9 13.4

Medication 12.3 9.9 11.6

Implementation of care and ongoing

monitoring/review 7.2 10.9 8.9

Access, admission, transfer, discharge 8.0 4.7 7.3

Documentation(including records,

identification) 6.2 6.3 6.4

Infrastructure (including staffing,

facilities, environment) 2.4 3.9 5.8

Clinical Assessment 5.4 3.7 4.8

Consent, communication,

confidentiality 2.0 2.3 3.9

Medical device/equipment 5.2 8.8 3.5

All other categories 10.6 10.6 5.8

If a Trusts reporting profile looks different from similar organisations, this could reflect differences in reporting culture, the type of services provided or patients cared for, or pointing towards high risk areas. The Trusts reporting profile is similar to Trusts in our cluster group and does not indicate any specific areas of concern during the report period. During 2011/12 analysis of themes, cause groups and learning will form part of developing trust wide aggregated analysis of incidents, claims and complaints data required for NHSLA assessment. Wiltshire Community Health Services Reports for Primary Care Organisations were also published by the NPSA this month. The report for Wiltshire Community Health Services demonstrated that the organisation reported 41.8 incidents per 1,000 bed days (community reporting measure). The organisation compared favourably with other Trusts in the cluster and has been grouped in the highest 25% of reporters. However, incidents on average were submitted to the NPSA more than 74 days after the incident occurred, whilst more than 50% of incidents from all other Trusts in the cluster were submitted more than 37 days after the incident occurred. Since transfer of services, management of the Incident reporting process for Wiltshire community services has been passed to the Clinical Risk Team and Health and Safety Teams at Great Western Hospital. The teams will be focusing on maintaining the good reporting culture within the community, whilst improving incident submission deadlines to the NPSA.


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NHSLA Acute On 25th October 2011 the NHSLA attended the Trust to undertake an informal Level 1 assessment. The assessor reviewed a number of criteria identified by the NHSLA Project Coordinator: 1.1.2 Policy on Procedural documents 1.1.8 Health Records 1.3.1 Secure Environment 1.3.3 Slips, Trips and Falls 1.3.4 Moving and Handling 1.4.5 Medicines Management 1.5.1 Clinical Audit 1.5.3 Concerns and complaints 1.4.9 Transfer 1.4.10 Discharge A gap analysis has now been completed based on feedback received from the assessor. These priorities for action are shown at Appendix B and Executive Committee is requested to progress the action plan in accordance with the timescales indicated. This will support the Level 1 in formal assessment in February 20012. Mortality Trust HSMR for the period April – August 2011 is 100.0 The Trust Mortality Group continues to monitor trends in mortality at its monthly meetings and drills down to diagnosis or operative procedure group to target areas for further investigation and possible audit. The Trust mortality group is reviewing the performance to date and key elements of its action plan include:

• Reviewing the clinical coding of diagnosis groups where HSMR appears high • Clinical reviews of the same high HSMR diagnosis groups where appropriate • Ensuring accurate recording of co-morbidities in the Trust’s data • Continuing the enhancement and support of Mortality and Morbidity review groups • Targeting the areas where analysis suggests review of coding and clinical care are

needed. This includes a procedure red bell for drainage of peritoneal cavity. • The Mortality Clinical Lead gave a presentation to medical staff this month and

included the need for improved coding information in the notes (Charlson Codes), improved death certification and the areas we have identified through previous audit that could be improved.

• The Mortality Group are also going to look at Plymouth as an example to see if we can learn from the best performing trust in the region.

Graph 1 shows the SHA and GWH HSMR performance for the most recent 13 month period. The SHA trend line is smoother due to the number of Trusts being included in the average performance. The peaks at GWH represent individual month’s data and it can be seen that three of the five months since April 11 have exceeded 100. The Trust data includes the former WCHS data from June onwards when the Trust’s merged.


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Graph 1 Hospital Mortality HSMR GWH and South Wes t SHA

Graph 2 shows the HSMR performance for Acute Trusts in the South West SHA for the first five months of the year, April – August 2011. Graph 2: SHA Acute Trust HSMR April – August 2011

60.0

70.0

80.0

90.0

100.0

110.0

120.0

130.0A

ug

-10

Se

p-1

0

Oct

-10

No

v-1

0

De

c-1

0

Jan

-11

Fe

b-1

1

Ma

r-1

1

Ap

r-1

1

Ma

y-1

1

Jun

-11

Jul-

11

Au

g-1

1

HSMR Mortality GWH and SHA - Most Recent 13 Months

GWH

SHA

Nat Expected

0

20

40

60

80

100

120Relative Risk SW Acutes April 2011 to August 2011


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Summary Hospital Level Mortality Indicator (SHMI) The SHMI measure of mortality was published at the end of October and covered the year April 10 to March 11. The Trust value was 100.01 which meant the expected number of deaths almost exactly matched the expected level. The SHMI was published for 147 Trusts and the Trust was ranked 69th over all. The SHMI differs from the HSMR measure in that it includes deaths in hospital and non-hospital deaths for patients who have been discharged from hospital. The SHMI will be updated each quarter by the Department of Health. Infection Prevention and Control (IP&C)

Limit Trajectory GWH WCHS Non-Acute Trust October Total October Total October Total MRSA Bacteraemia

2 – GWH

0 - WCHS

0.19 below

on target

0 1 0 0 0 4

MSSA Bacteraemia

NA NA 1 8 0 0 2 15

E coli Bacteraemia

NA NA 0 12 0 2 8 75

Clostridium difficile

39 – GWH 30 - WCHS

13.75 below 17.5 below

2 9 0 0 0 15

GRE Bacteraemia

NA NA 0 0 0 0 0 0

Mortalities NA NA 0 1 (GWH)

0 0 NA NA

MRSA Bacteraemia There were no MRSA bacteraemias reported during October for GWH, WCHS or the Non-Acute Trust. The combined PCT/Acute Trust limit of no more than 4 cases has been exceeded. For the most recent quarter (July to September 2011) the rate per 100,000 bed days for Acute Trust apportioned cases was 2.0 compared to a regional rate of 0.3 and the national rate of 1.1. Clostridium difficile Infection There were 2 cases of Clostridium difficile reported during October for GWH. No cases were reported for WCHS or the Non-Acute Trust during this period. For the most recent quarter (July to September 2011) the rate of acute trust apportioned cases per 100,000 bed days for Great Western was 8.2, compared to the South West region which was 24.4 and the national rate of 22.5.

Outbreak Reports Saturn ward was closed for 2 days during October, with a bay closed for a further 3 days. A bay was closed on Teal ward for 2 days. A bay was closed on Beech ward Chippenham Community Hospital for 4 days. All closures were due to diarrhoea and vomiting of unknown aetiology. Learning outcomes will be shared with relevant staff groups and findings presented at the Patient Safety and Quality Committee/Infection Control Forum.


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E coli Bacteraemia From the 2nd of November 2011 the Health Protection Agency will publish E coli bacteraemia surveillance data on their website. Please note that unlike MRSA bacteraemia, MSSA bacteraemia and Clostridium difficile, the E coli bacteraemia tables will not be split into Acute Trust and Non-Acute Trust cases, only total figures will be published. Of note, there have been 8 cases since 1st of June when data collection commenced (12 YTD). There have been 51 Non acute cases since June (74 YTD), therefore the public will view a combined total of 59 cases against Great Western Hospital.


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C - Clinical Effectiveness (CA&E) NICE Summary Reporting - The NICE Report covers both GWH and WCHS services. There are no exceptions to report. NICE compliance against NICE guidance for the organisation remains 100%. NICE Quality Standards- The recently published NICE Quality Standards Statements are currently being reviewed by the Clinical Leads with necessary action plans in place, where appropriate. Quality Standards for WCHS are still in the process of being collated and the status will be reported by next month.

Dr Foster Red Bells Dr Foster Report covers both GWH and WCHS services. New Alerts – The monthly reports published on 15th Oct 2011 alerted the following areas:

• Patient Safety Indicator- Obstetric Trauma • Mortality Review- Resection of Bladder Tumour • Mortality Review- Drainage of Peritoneal Cavity

These areas will be investigated to identify areas for improvement and explain the reason for deviation beyond apparent.

Ongoing Investigations - The following investigations instigated following publication of previous Dr Foster Red Bells are underway:

• Length of Stay Review - Non-Hodgkin’s Lymphoma • Mortality Review –Cancer of Colon • Day Case Rates- Extraction of Cataract

These alerts are being investigated to identify areas for improvement and any reason for deviation in clinical care or processes.

Completed Investigations- The following reviews were reported as complete this month:

Type of Alert

Area of Alert Directorate Learning from the Review

Length of Stay

Angioplasty Coronary Atherosclerosis Acute Myocardial Infarction

Unscheduled Care

There was no evidence of clinical care being compromised and the updated reports reflect improvement in performance.

Readmission

Delivery W & C Review did not reveal any areas of concerns. Further input into coding of these episodes will help reflect local practice more appropriately.

Mortality Peptic Ulcer Planned Care Review did not reveal any areas of clinical/coding concerns.


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Other Dr Foster Updates-

• The trust reviewed Mortality in Acute Renal Failure in Jan 2011 and it was an area of concern. Further input into coding of these episodes has helped reflect our practice more appropriately and the current performance is being reported as better than expected.

• Service Line Indicators – These are designed to monitor performance across the care pathway for specific conditions or procedures. Trust performance is in line/better than expected for both of the indicators currently reported:

• Stroke • Orthopaedics • Dr Foster Hospital Guide- The public report is due on 28th Nov 2011. To date we

have been notified of 1 outlier measure:

1. Extended length of stay on patients who underwent Knee Replacement in Oct-Nov 2010 has been reported as an outlier. This is currently being investigated

This is currently being investigated. A media briefing is being prepared ready for when the Dr Foster Hospital Guide is published

Clinical Audits Compliance with the Trust Clinical Audit Plan remains at 100%. This includes compliance with the Audit Plan from WCHS. 73 % of audits completed to date have resulted in learning and a change in clinical practice. Key learning/recommendations from the completed audits this month are as follows:

Audit Title Directorate Learning from the Project

SALT (Speech and Language Therapy) - Service Evaluation of the interface between agencies supporting children with ASD.

Women’s and Children’s (Wilts Children)

Actions include improved sharing of information using Communication Assessment Form and better communication between the SALT Service and other multi-agencies.

Venous Thromboembolism (VTE)

Women’s and Children’s (Wilts Maternity)

The results demonstrated that overall compliance was very high. Actions include possibility of using a sticker stating the VTE assessment at each ante natal admission.

Induction of Labour

Women’s and Children’s (Wilts Maternity)

There was low compliance with documentation of the discussion with the mother about induction of labour in the maternal records. Actions include- Remind all midwives of the importance of discussion of prolonged pregnancy and induction of labour and giving leaflet to supplement these discussions.


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VTE Assessment of Screening Prophylaxis

Community Services

The results reflected very high compliance with the majority of criterion.

Delayed and Omitted Medicines Audit

Community Services

Actions include all blank missed doses to be reported to the Ward Manager and investigated.

Death Certificate Completion

Planned Care

Areas for improvement identified were recording of Doctor’s grade and name, training and education and guidance notes that include clarification on confirmation and certifying deaths.

End of Life

Trustwide

Base line audit results demonstrate that the Trust performance is better that the nationally published data. Actions include- discussion of results with the Commissioners to agree a CQUIN target.

NCEPOD (National Confidential Enquiries into Patien t Outcomes and Deaths).

Trust participation for NCEPOD studies, remains at 100%. Updates on NCEOP studies-

• Surgery in Children - Report was published on 28/10/11. The report will be reviewed for relevance and updated next month.

• Peri-operative Care - The report is due to be published in Dec 2011. • Alcoholic Liver Disease -The Trust is awaiting further details from the project

organisers. • Subarachnoid Haemorrhage - To commence in early 2012.

Other updates -

• Latest HQIP announcement - 11 new topics for national clinical audit are to join the 29 projects already forming the National Clinical Audit and Patient Outcomes Programme (NCAPOP). Further details will be provided in due course.

• CA & E Plan for 2011-12 -CA & E Manager will e-mail all the AMD’s & GM’s to commence working on Clinical Audit Plan for next financial year.


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D – Regulation

1 External reviews – Details shown at Appendix B

New Reviews October and November 2011 to date a) Chippenham CQC - Unannounced Visit – 08/11/11

An unannounced focused inspection was completed by the CQC on 08/11/11 due to 3 complaints that had been reported directly to them. Complaint themes were (as advised by the inspector) around call bells availability, patient’s inability to reach drinks and staff attitude Inspection Outcome : Draft report and compliance status awaited Verbal feedback : Verbal feedback post inspection-no major concerns/compliance actions,

improvement actions only.

b) GWH Hospital Standards Dementia Peer Review 01/1 1/11 Review outcome-- Positive verbal feedback with some areas for further development identified in the verbal feedback. Report anticipated for the end of December 2011. c) Savernake CQC Inspection October 2011

Inspection Outcome -- Compliant with improvement actions. Current status -Draft report received 27th October 2011 and factual accuracy response sent to the CQC on the 10th November 2011. An action plan is under development to address improvements required.

Particular improvements documented in the draft report (compared directly against the last inspection in November 2010) include patient risk assessments, patient feedback, staff training/supervision/appraisal and record keeping. All previous external review action plans are progressing as per plans and monitored through the Clinical Standards Group and PSQC. 2 CQC Registration

A review meeting was undertaken with our CQC inspectors in October, with the aim of simplifying community based CQC registration. A draft Trust registration variation has since been completed and work is underway to progress this. 3 CQC Quality Risk profile (QRP) The latest QRP risk status is shown on the ‘Current Compliance’ excel sheet (in red under the current QRP column). Outcome 9-Management of Medicines remains as a risk against compliance’, and our information to date shows that the risk was escalated due the PICKER survey results 2010-11(patient medication information dissatisfaction) and also late submission of the Local Security Management work plan and report (which will improve the risk rating if submitted on


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time in 2012). The risk of non compliance with this outcome has however been reduced from a high red to a high amber this month on the QRP. 4 Site Compliance A meeting has been arranged with the General Managers on 16th November to formally agree the future process for site compliance with all outcomes and evidence collation and responsibilities. More information will follow once agreed. 5 Notifications of other incidents to the CQC

Clarity has been requested to our CQC inspector regarding notification of specific incidents (such as abuse, police investigations and injury to a patient). Once received, a Trust flow chart for the process will be created and shared for information. 6 Quality Account

The PSQC received an update on progress with the Quality Account in October 2011. All improvement measures are included within the Patient Safety and Quality Dashboard. The key exception noted by the PSQC was compliance with nutritional assessments. The 95% target had not been achieved although improvements are noted. An action includes reviewing the target measure to determine best practice and to ascertain some comparative data from similar Trusts.. More detailed actions are described under Section A. Updates on the Quality Account are being presented to Swindon and Wiltshire LINks, HOSC’s and the Council of Governors. Engagement is being progressed with these key stake holders to ensure opportunity is given to contribution to the Quality Account for 2012/13. This will be driven and monitored through the PSQC.

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