Trust Board Meeting: Thursday 1 March 2012 TB2012 · 2012. 2. 27. · TB2012.13 TB2012.13_Quality...

TB2012.13

TB2012.13_Quality Report 1

Trust Board Meeting: Thursday 1 March 2012

TB2012.13

Title Quality Report

Status A paper for information

History A regular monthly report to the Board

Board Lead(s) Professor Edward Baker, Medical Director

Mrs Elaine Strachan-Hall, Chief Nurse

Key purpose Strategy Assurance Policy Performance

Oxford University Hospitals TB2012.13 paper number


Summary

This report updates the Trust Board on the quality of care drawn from a variety of clinical governance and nursing indicators.

The report includes updates on activity taking place across the OUH aimed at delivering quality improvement.

The following items are highlighted as key changes compared to the previous Quality Report:

1 An Acute Trust Quality Dashboard is being provided to the trust quarterly via NHS South of England (produced by the East Midlands Quality Observatory).

2 A total of one Never Event and five SIRIs were called during January 2012

3 The hospital standardised mortality ratio (HSMR) and summary hospital mortality index (SHMI) are both within expected limits

4 Updated risk estimates are shown for the Trust in the CQC Quality & Risk Profile

5 One hundred and two new complaints were received in January and this represents a 79% increase compared to the previous month. This increase also correlates to the increased number of calls to the PALS service.



Introduction

1. The East Midlands Quality Observatory produces a quarterly Acute Trust Quality Dashboard. The data provided within this report as yet does not include the Musculoskeletal and Rehabilitation Division.

2. The Acute Quality Dashboard provides an assessment of quality across the domains of the NHS Outcomes Framework. An extract of the report is provided in appendix 1. The most recent quarterly report covering data predominantly from quarter 4 of 2010/11 was received in February and is subject to further internal verification.

3. A total of 104 indicators are included across the section headings which reflect the NHS Outcomes Framework:

3.1. preventing people from dying prematurely

3.2. enhancing quality of life for people with long term conditions

3.3. helping people to recover from episodes of ill health following injury

3.4. ensuring that people have a positive experience of care

3.5. treating and caring for people in a safe environment and protecting them from avoidable harm and organisational context

4. The Trust performed “better” than expected by chance for 17 indicators (99.8% or 3 standard deviations). The Trust performed “worse” than expected for in the 11 indicators. Internal monitoring shows that these findings are not unexpected and were reflected in the contemporaneous Board reports. These are detailed in appendix 1. A full report will be provided to the Quality Committee on 20th March.

5. Progress continues in developing and implementing an Integrated Performance Framework for the Trust. The data warehouse envisaged for the Trust will be able to report on key quality indicators such as those identified in the Acute Quality Dashboard.

Safety, Quality and Risk

6. This section covers a number of areas that are included in the attached safety, quality and risk scorecard.

7. One never event and 5 new Serious Incidents Requiring Investigation (SIRI) were called in January 2012.

Key category/theme

SIRI

Level 3 Information Governance Incident

Category 3 pressure ulcer



Infection Control Cluster



Never

Event

Retained foreign object post-operation (official classification)

8. All SIRIs and never events are investigated in accordance with the Incident Reporting and Investigation Policy.

Outcomes (Dr Foster and Summary Hospital Mortality Indicator)

9. The hospital standardised mortality ratio (HSMR) and summary hospital mortality indicator (SHMI) are both within expected limits. The HSMR for the financial year to date is 99.4 (note this figure is rebased annually) and the SHMI, based on a rolling 12 months from July 2010 to June 2011, is 1.02. The Figure below highlights both measurements.

10. The latest release of the Summary Hospital-level Mortality Indicator (SHMI) splits diagnoses into 108 collections and, within these collections, compares the observed number of deaths in the Trust (July 2010-June 2011) against the expected number (Observed/Expected × 100). Of the 108 collections examined for the Trust, 98 had mortality rates similar to those expected, five diagnosis collections had mortality rates significantly below expected values and 5 had mortality rates higher than expected.

11. On-going work within the Trust to bring about a prospective reduction in HSMR and SHMI going forward includes:

11.1. Continuous review of outcomes (mortality, length of stay, readmission rate) in all specialities through the Dr Foster benchmarking process, with investigation of all outcome related alerts. The SHMI diagnosis based mortality data will now be reviewed using the same approach.

11.2. Introduction of a falls care pathway in geratology.

11.3. Continued focus on care bundles for line insertion and aftercare of lines.



11.4. Updated programme to support the prevention of surgical site infections.

11.5. Rolling out of the national “Safety Thermometer” project to four wards.

11.6. Embedding a standardised review process of deaths occurring in all specialties to identify areas for improvement in clinical care (likely to include the introduction of care bundles for high volume conditions associated with significant risk of mortality).

11.7. A review of acute medicine to examine the availability of a senior clinical presence seven days a week and rapid access, where necessary to specialist opinion. This will report in April.

11.8. Introduction of consultant of the week rotas in key specialties to ensure daily consultant review of inpatients.

11.9. Reduction in pre-operative waiting time for patients with fractured neck of femur.

11.10. Making improvements in documentation to facilitate accurate clinical coding to deliver a reduction in the HSMR for 2011/12 which will be reported in autumn 2012.

National Patient Safety Alerts

12. The following number of alerts remain open, 2 medical devices Alerts (MDA), 5 National Patient Safety Alerts (NPSA) and 2 estates and facilities Alerts (EFA) remain open.

13. Of the total open alerts no alerts have breached their closure dates.

NICE Guidance

14. NICE guidelines covering clinical (CGs), interventional procedure (IPGs), technology appraisal (TA), public health (PHG), „Diagnostics Technology Guideline‟ (DTG) and medical devices (MTGs) are issued each month. These are sent to the appropriate Clinical Director within the Division to review for relevance, applicability and compliance. The Clinical Director is responsible for returning the compliance statement and for delivering implementation of recommendations and for the audit of implementation. A Clinical Implementation Lead (CIL) may be assigned within the Directorate.

15. If partial compliance has been declared, the CIL is responsible for undertaking the gap analysis and preparing an action plan for full compliance. A declaration of partial compliance confirms that the guidance is relevant and that work is underway to achieve full compliance. Delivery against the actions will be monitored through Divisions‟ reports to the Clinical Audit Committee. Recommendations for any non-compliance must be reported via the Division‟s monthly quality reports to the Clinical Governance Committee and then to the Trust Board for ratification.

16. A summary of compliance for December 2011 is provided as follows.



New Guideline December 2011

CG- Anaphylaxis, organ donation, self harm

(longer term management)

Three issued- One not relevant as service not

provided. Two declared partial compliance

working towards full compliance. Gap

analyses/action plans due April 2012

IPGs-Epiretinal brachytherapy for wet age

related macular degeneration

One issued. Awaiting response.

TA-Arthritis –tocilizumab, breast cancer-

fulvestrant, colorectal cancer- panitumumab

Three issued.

Full compliance

PHG None issued

MTG None issued

DTG-Elucigene FH20 and LIPO chip for the

diagnosis of familial hypercholesterolemia

One issued – under review

Quality Walk Rounds

17. During January 2012, five programmed walk rounds were completed in the following areas:

Trust Site Ward/ Department

Churchill Hospital Geoffrey Harris Ward

Churchill Hospital Sobell House

Churchill Hospital Sleep Studies

John Radcliffe TSSU

Wallingford Community Hospital

18. Key headings are used to summarise the issues discussed and identified from the walk rounds. Specific issues are highlighted and fed back to the service and the Division. The following issues were raised:

Topic Theme

Staffing Staff raised the possibility of SME training being available on

the Churchill site

Environment Lack of storage space

Concern raised relating to the lack of an internal lock



Poor Physical fabric of department

Communication Potential for greater integration of patient care across acute

and community services

Transport Delays in timely transfers of patients across sites

Areas of good

practice

International reputation of sleep unit, one stop service, well

established system for accreditation.

Summary of Care Quality Commission Quality and Risk Profile (QRP)

19. Separate Quality and Risk Profiles for the Oxford Radcliffe and Nuffield Orthopaedic Hospital Trusts were published in October 2011. Since the integration of the two organisations in November, the CQC has published the QRP for February 2012 showing combined updated organisational data. A QRP was published in December, however there were problems with the data and this was withdrawn. The table below shows the ORH and NOC October risk estimates and the OUH February rating.

Outcome ORH QRP Risk Estimate October 2011

NOC QRP Risk Estimate October 2011

OUH QRP Risk Estimate February 2012

Involvement and information

Outcome 1: Respecting and involving people who use services

Outcome 2: Consent to care and treatment Personalised care

Outcome 4: Care and welfare of people who use service

Outcome 5: Meeting nutritional needs

Outcome 6: Cooperating with other providers






Safeguarding and safety

Outcome 7: Safeguarding people who use services from abuse

Outcome 8: Cleanliness and infection control

Outcome 9: Management of medicines

Outcome 10: Safety and suitability of premises

Outcome 11: Safety, availability and suitability of equipment

Suitability of staffing

Outcome 12: Requirements relating to workers

Outcome 13: Staffing

Outcome 14: Supporting staff

Quality and management

Outcome 16: Assessing and monitoring the quality of service provision






Outcome 17: Complaints

Outcome 21: Records

Summary of risk estimates

20. Outcome 13 - Staffing, is a high red due to two negative qualitative data items from CQC Compliance Reviews from February 2011. Other quantitative data sources contributing to the negative risk estimate are carried forward from the NOC, four of which show much worse than expected three month vacancy rates (Source: Information Centre for Health & Social Care (IC), Vacancy Survey, March 2010). There are seven low or high greens. These are Outcomes 2, 6, 8, 9, 12, 17 and 21.

21. The five neutral ratings are for Outcomes 1, 5, 7, 10 and 11.

22. There are three outcomes which are rated as insufficient data – 4, 14 and 16. This means that some data are available, but it is not sufficient to calculate a risk estimate.

23. In future QRP summaries, further comparison will be made between past and current ratings. The combining of data for the two organisations means that direct comparison with previous risk estimates is not possible due to the merging of the two datasets. A full analysis of the data will be presented to the March Quality Committee.

Infection Control matters

MRSA Bacteraemia 2011/12

Apr

11

May

11

Jun

11

July

11

Aug

11

Sep

11

Oct

11

Nov

11

Dec

11

Jan

12

Feb

12

Mar

12

Total per

month

0 1 0 0 0 1 2 0 0 0

Monthly

limit

0 1 0 1 0 1 0 1 0 1 0 1

Cum total 0 1 1 1 1 2 4 4 4 4

Cum limit 0 1 2 2 3 3 4 4 5 5 6 6

24. The annual ORH Trust objective for MRSA bacteraemia for 2011/2012 is, 6 MRSA positive blood cultures taken 48hrs after admission. The NOC is monitored



separately until March 2012. The NOC has an annual limit of 1 and have had one MRSA bacteraemia since April 2012.

0

5

10

15

20

April

May

June

July

Aug

Sep

tOct

Nov

Dec Ja

nFeb

Mar

ch

cumulative total cumulative limit

Clostridium difficile

25. The table below includes the number of patients who tested positive after 72hrs of admission. This is the method for monitoring Clostridium difficile against target for secondary care. It does inform the Trust of the overall burden of Clostridium difficile, as it excludes positive cases from samples taken within 72hrs of admission.

26. The NOC has an annual limit of 4 cases of C. diff and they have had five cases to date from April 2011 to present day. The December case will be discussed at their clinical service improvement group and findings fed back in next month‟s report.

Div Apr

11

May

11

Jun

11

Jul

11

Aug

11

Sep

11

Oct

11

Nov

11

Dec

11

Jan

12

Feb

12

Mar

12

Total 5 5 8 7 14 9 14 8 8 7

Monthly

limit

12 12 12 12 12 11 11 11 11 11 11 11

Cum total 5 10 18 25 39 48 62 70 78 85

Cum limit 12 24 36 48 60 71 82 93 104 115 126 137



0

50

100

150

200

250

300

Apri

lM

ay

June

July

Aug

Sep

tOct

Nov

Dec Ja

nFeb

Mar

ch

cumulative total cumulative limit

Antimicrobial documentation

27. The Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) have advised that all antibiotic prescriptions have the indication and duration documented on the drug chart.

28. To assess compliance with this, a monthly audit is carried out in every inpatient area within the trust. Data collection commences on the first week of the month and is extended for up to five working days until there is a minimum of ten antimicrobial prescriptions reviewed for each ward. Data from areas that have fewer than ten antimicrobial prescriptions is held and added to the following month‟s audit.

Safer Care and Nursing Quality Metrics Score Card

29. When mapped on to the previous „safer care three by three matrix‟ the position with the number of safe wards is largely unchanged and, despite lower levels of permanent staff in some areas (supplemented by temporary staff), there are no indication that patient safety is being compromised.

All Wards (January 2012) Safe Staffing >

85%

Staffing 70 -

85%

Staffing below

70%

Intensive Support (More than 3 Red)

Supportive measures (3 Red)

Safe Care (fewer than 3 Red) 34 36 16



30. The Nursing Quality Metrics (see Appendix) have been further revised to reflect the key nursing indicators for the patient care experience. This includes the removal of the safer care boxes and the increased focus on the monitoring of the three categories of shifts identified as agreed, minimum and at risk.

31. It should be noted that for some clinical areas, e.g. day units and dialysis satellite units will have patients not require the interventions being monitored, for example, those relating to catheter care, and hence there will be a nil return.

32. Where scores are reported to fall below the indicated threshold these are currently highlighted as amber or red and actions are identified and reported by the Divisional Nurse.

Patient Experience

33. The Let Us Know Your Views leaflets ask the question „would you recommend the hospital?‟. The response rate to the questions continues to be over 88% but the number of returned leaflets remains low (averaging 65 pcm). Positive feedback about care continues to be the highest single recorded theme and analysis of the leaflet confirms that even when negative feedback is made the respondents are still likely to recommend the hospital concerned.

34. The table below provides a summary of the top five feedback issues:

Top 3 patient feedback issues December January

Care & service positive feedback 261 481

Concerns about aspects of care offered 111 191

Appointment, treatment and discharge delays 182 144

Source of patient experience reports January 2012

Telephone calls (to PALS) 333

Comments & Suggestion Forms 57

Letters and Web feedback 21

E-mails (via PALS) 62

In person (to PALS) 44

Let Us Know Your Views (Questionnaires) 56

35. Total feedback score for October, November and December are shown below:

November December January

Positive 1182 68.1% 386 51.0% 615 48.9%

Neutral 409 23.6% 196 25.9% 329 26.2%

Negative 145 8.4% 175 23.1% 313 24.9%



36. Throughout January the PALS service received up to 50 calls per day, this represents an approximate increase of 50% compared to the previous month. The main issues which caused frustration, was not being able to contact departments by telephone and not being able to leave a voice message. This may have coincided with the introduction of the new electronic patient administration system.

37. A theme of communication between doctors and nurses and their communication to patients and relatives accounted for 23% of the concerns raised in January. The data are made available to the Divisions for actions to be taken to address the concerns. These are then reported on through the Divisional Quality Reports.

38. There has been a reduction in the trend of complaints about cancellations in appointments and treatments. Similarly the reduction in complaints relating to outpatient clinics now represents less than 2% of all patient care concerns.

Complaints and Organisational Learning

2011/

2012

Apr

11

May

11

Jun

11

July

11

Aug

11

Sep

11

Oct

11

Nov

11

Dec

11

Jan

12

Feb

12

Mar

12

Compl

aints

56 61 51 47 71 60 59 67 52 102

Cumul. 56 117 168 215 286 346 405 472 524 626

2010/

2011 67 63 88 61 50 75 62 62 72 68 68 56

Cumul. 67 130 218 279 329 391 453 515 587 655 723 779

39. 102 new complaints were received in January and this represents a 79% increase compared to the previous month. This increase also correlates to the increased number of calls to the PALS service.

40. The key themes identified in the complaints received in the Trust in January were patient care/experience, delays/waiting times, communication and behaviour.

41. The main theme in the seven clinical Divisions continues to be patient care / experience.

42. The Divisions are using the feedback from complaints to respond to individual issues which can be complex and multi-faceted and to introduce changes and these have begun to be reported in the monthly Divisional reports to the Clinical Governance Committee.

43. In January there were three breaches in responding to complaints within the agreed timescale of twenty five working days.



Ombudsman Investigations and updates

44. In January the Ombudsman‟s Office wrote to the Trust requesting details of one complaint for detailed consideration. This relates to a complaint received by the Trust in November 2010 regarding surgery and treatment received for gall stones.

45. The Ombudsman‟s Office has written to the Trust to confirm one complaint has been upheld and recommendations have been made. This relates to a complaint made to the Trust in January 2010 regarding the treatment received by a patient suffering from Alzheimer‟s disease.

Conclusions and recommendation

46. The Board is asked to receive the report which highlights the wide range of activity across the organisation.

47. The Board is asked to note the actions being taken across the Trust.

Professor Edward Baker, Medical Director Mrs Elaine Strachan–Hall, Chief Nurse Appendices attached Acute Trust Quality Dashboard Safety, Quality and Risk Score Card Nursing Quality Metrics Scorecards



Appendix 1 - Acute Trust Quality Dashboard

Outlying indicators

PD03 Age / Sex standardised hospital mortality in hospital mortality in low risk HRGs

Q4 1011 155.2 100.0

PD31 Cancer waits – % waiting less than 62 days from GP referral to first treatment (HQU15)

Q4 1011 76.7% 86.5

IH33 Emergency readmission - % within 2 days following non-elective admission (Same Specialty)

Q4 1011 1.74% 1.35

PE02 Diagnostic Waits - % of patients waiting over 5 weeks Q4 1011 9.06% 5.33% PE03 Cancer waits – % seen within 14 days of GP referral to first

out-patient appointment (HQU14) Q4 1011 78.8% 96.0%

PE23 A&E - % of patients admitted, transferred or discharged within 4 hours of arrival

Q4 1011 89.8% 94.8%

PE21 Delayed Transfers of Care per 1,000 occupied beds - NHS Responsibility

Q2 1112 52.4 21.6

PE22 Delayed Transfers of Care per 1,000 occupied beds - Social Care Responsibility

Q2 1112 14.6 7.

SC03 % of all admissions who have VTE risk assessment Sep-11 85.7% 89.3% SC02 Rate of "serious harm" patient incidents reported per 100

admissions Oct 10-Mar 11

0.84 0.38

SC17 Medication errors per 1,000 bed days Oct 10-Mar 11

8.18 6.59

PE08 A&E re-attendance - % within 7 days (HQU09) Q4 1011 5.0% 7.0% SC06 HCAI - C. diff bacteria rate per 100,000 bed days (HQU02) Q4 1011 2.76 8.04 SC08 % of planned day case procedures that are converted to

inpatients on the day Q4 1011 3.7% 4.4%

SC11 % Admission of full-term babies to neonatal care Q4 1011 0.80% 7.95% SC19 Incidence of pressure ulcers per 1000 admissions Mar-11 0.81 1.84 OQ01 Admitted Patient Care - % Valid data (Average for all fields) Sep-11 98.1% 97.68% OQ02 Out Patient - % Valid data (Average for all fields) Sep-11 94.4% 92.96% OQ03 Accident and Emergency - % Valid data (Average all fields) Sep-11 99.4% 93.70% OQ21 Admitted Patient Care - % Records submitted with valid

HRG on first submission Aug-11 100.0 97.1

OQ07 Rate of written complaints per 1,000 episodes 0910 2.98 4.31 OQ08 NHSLA Claims per 10,000 bed days 1011 0.12 1.43

Oxford University Hospitals

January

8 8 8 8 8 8 4 4 & 9 4 4 5 1 4 17 4 & 20

Nur

sing

Non

Nur

sing

Cat

hete

r In

serti

on

Cat

hete

r on

goin

g ca

re

% C

orre

ct

pres

cipt

ion

% E

nd d

ate

incl

uded

CAS ** 100% 60% 97% 0 0 93% 0 0 100% 0 0 18 0 0 70% 30% 0%

Cardiology * 100% 100% 100% 100% 100% 0 0 92% N/A N/A 3 3 60% 0 100% 0 18 1 0 55% 39% 6%

CTCC / CCU** 100% 100% 93% 100% 0 0 93% 100% 100% 2 1 0 100% 1 27 0 0 82% 18% 0%CTW * 100% 100% 100% 100% 0 0 93% 100% 92% 3 1 93% 0 100% 0 32 0 0 97% 3% 0%6A * 94% 94% 100% 90% 90% 0 1 86% 100% 90% 3 1 100% 0 100% 0 15 1 1 25% 60% 19%

PP 5D* 95% 80% 100% 100% 100% 0 0 92% N/A N/A 0 2 100% 0 98% 0 10 0 0 62% 38% 0%Theatres** 0% 0% 0% 0% 0% 0 0 0% 0 0 0% 0 0% 0 0 0 0 0% 0% 0%

C, V & T Quality Metrics ScorecardCQC Outcomes 8 8

Car

diac

, Vas

cula

r

and

Thor

acic

(3)

Med

icin

eSu

rg &

Va

sc

13

Div

isio

n

Dire

ctor

ate

Ward

Hand Hygiene

AN

TT I

njec

tabl

es Saving Lives Catheter Care

MR

SA

/ M

SS

A

post

48

hrs

C-D

iff

P

ost 7

2 hr

s

Nat

iona

l Cle

anin

g O

vera

ll S

core

Com

plim

ents

Com

plai

nts

SIR

Is

Not

Incl

P

ress

ure

Ulc

ers

Tract & Trigger: PDN undertaking observational shifts to ensure compliance and weekly ward sister governance rounds. Implement track and trigger link nurse.

At risk staffing; although some shifts have been identified as 'at risk', none of wards were deemed to be unsafe as staff were moved around the division to manage the risks.

Com

plia

nce

with

N

utrit

iona

l A

sses

smen

ts

Sin

gle

Sex

B

reac

hes

Tota

l No

of F

alls

Tota

l No

of

med

icat

ion

erro

rs

Com

plia

nce

with

Tr

ack

and

Trig

ger /

E

WS

Pre

ssur

e U

lcer

s G

rade

3/4

/ S

kin

Inte

grity

Antimicrobial

Hand hygiene: weekly audits being undertaken

SIRI: - C Diff.transmission of C Diff occurred. Training given to staff, action plan implemented and monitored to improve cleaning standards.

Reduction in cleaning standards: remedial action plan implemented on 6A. Enhanced clean completed throughout the ward. Individuals given responsibility for specific areas on wards.

% s

hifts

'm

inim

um

staf

fing'

% s

hifts

'at r

isk

staf

fing'

% s

hifts

'agr

eed

staf

fing'

January8 8 8 8 4 4 & 9 4 4 5 1 4 17 4 & 20

Nur

sing

Non

Nur

sing

Cat

hete

r In

serti

on

Cat

hete

r on

goin

g ca

re

% C

orre

ct

pres

cipt

ion

% E

nd d

ate

incl

uded

Toms * 100% 95% 91% 0 0 90% N/A N/A 0 1 100% 0 100% 0 6 0 0 88% 12% 0%Robins * 100% 88% 87% 0 0 97% 100% 100% 1 0 100% 0 100% 0 0 0 0 83% 17% 0%Childrens Ambulatory Care 100% 100% 94% 0 0 86% 0 0 na 0 NA 0 2 1 0 73% 23% 0%HGH Childrens W * 100% 100% 95% 0 0 96% 0 0 98% 0 100% 0 6 0 0 92% 8% 0%Bel / Dray * 100% 70% 98% 1 0 88% 60% 50% 0 1 100% 0 100% 0 0 0 0 38% 62% 0%Kamrans ** 100% 95% 92% 0 0 91% N/A N/A 0 0 100% 0 96% 0 0 0 0 60% 40% 0%Melanies * 100% 100% 100% 0 0 89% N/A N/A 0 1 100% 0 90% 0 0 0 0 87% 13% 0%NNU** 100% 100% 98% 0 0 92% 100% 100% 0 15 n/a 0 0 0 0 0 67% 44% 10%SCBU** 92% 92% 100% 0 0 92% 0 0 n/a 0 n/a 2 0 0 100% 0% 0%PHDU** 100% 100% 98% 0 0 92% 0 0 n/a 0 0 0 0 0 70% 29% 0%PICU** 95% 95% 100% 0 0 93% 0 0 100% 0 0 0 0 0 90% 10% 0%

Actions

C & W Quality Metrics ScorecardCQC Outcomes 8 8 8 13

Div

isio

n

Dire

ctor

ate

Ward

Hand Hygiene

AN

TT I

njec

tabl


MR

SA

/ M

SS

A

post

48

hrs

C-D

iff p

ost 7

2 hr

s

Nat

iona

l Cle

anin

g O

vera

ll S

core

% s

hifts

'm

inim

um

staf

fing'

% s

hifts

'at r

isk

staf

fing'

Pharmacy undertaking spot audits of prescriptions to identify themes and training needs.

Chi

ldre

n's

Pae

diat

rics

Pae

diat

ric

Crit

ical

Car

e

Com

plia

nce

with

N

utrit

iona

l A

sses

smen

ts

Sin

gle

Sex

B

reac

hes

Com

plim

ents

Com

plai

nts

SIR

Is

Not

Incl

P

ress

ure

Ulc

ers

% s

hifts

'agr

eed

staf

fing'

Antimicrobial

Tota

l No

of

Acc

iden

ts

Tota

l No

of

med

icat

ion

erro

rs

Neonatal medication errors - 13 near mises and 2 adverse events, no harm resulted. Gentamycin prescription errors (near misses) are monitored and reported monthly by the Matrons

Handy Hygiene and Cleaning Scores - matrons attending twice weekly to raise awareness of these issues.

Anti microbial - Clinical Director undertaken an audit, discussed at the Consultant meeting and they have agreed to take a lead in monitoring this w ith their junior medical staff. Divisional Nurses attending next Consultant meeting to re enforce the messages

Staffing in Neonatal Unit – risks managed through use of temporary staffing

Com

plia

nce

with

Tr

ack

and

Trig

ger /

E

WS

Pre

ssur

e U

lcer

s G

rade

3/4

/ S

kin

Inte

grity

January

8 8 8 8 4 4 & 9 4 4 5 1 4 17 4 & 20

Nur

sing

Non

Nur

sing

Cat

hete

r In

serti

on

Cat

hete

r on

goin

g ca

re

% Correct presciption

% End date included

AICU ** 87% 70% 100% 0% 70% 0 0 92% 100% 100% 0 3 0 23 10 0 0 100% 0% 0%CICU ** 89% 65% 100% 0% 100% 0 0 95% 100% 100% 0 2 0 2 7 0 0 100% 0% 0%HGH CICU ** 89% 67% 0% 0% 100% 0 0 96% 75% 81% 0 0 0 10 11 0 0 100% 0% 0%HGH DCU * 0% % 0% 0 0 0 0 0 0 0 100% 0% 0%Th West Wing ** 100% 95% 84% 100% 0% 88% 0 0 0 0 1 0 0 100% 0% 0%Th JR ** 100% 88% 50% 90% 0% 89% 0 0 0 0 0 0 0 100% 0% 0%Th HGH ** 100% 75% 0% 100% 0% 0 0 94% 0 0 0 0 1 0 0 100% 0% 0%

CCTDP Quality Metrics ScorecardCQC Outcomes 8 8 8 13

Div

isio

n

Dire

ctor

ate

Ward

Hand Hygiene

AN

TT

Inje

ctab

les

Saving Lives Catheter Care

MR

SA

/ M

SS

A

post

48

hrs

C-D

iff p

ost 7

2 hr

s

Nat

iona

l Cle

anin

g O

vera

ll S

core

Crit

ical

Car

e,

Thea

tres,

D

iagn

ostic

s &

Ana

es /

CC

/ Th

Com

plia

nce

with

N

utrit

iona

l A

sses

smen

ts

Sin

gle

Sex

B

reac

hes

Com

plim

ents

Antimicrobial

Tota

l No

of F

alls

Tota

l No

of

med

icat

ion

erro

rs

Com

plia

nce

with

Tr

ack

and

Trig

ger /

E

WS

Pre

ssur

e U

lcer

s G

rade

3/4

/ S

kin

Inte

grity

Com

plai

nts

SIR

Is

Not

Incl

P

ress

ure

Ulc

ers

% s

hifts

'agr

eed

staf

fing'

% s

hifts

'm

inim

um

staf

fing'

% s

hifts

'at r

isk

staf

fing'

AICU/CICU/CCU Cleaning Scores The Matron has met with Carillion and Denise Pawley to discuss issues around inconsistency in cleaning personnel and number of cleaners Action- Carillion have agreed that there will now be regular cleaners. The re - audit was successful. Catheter Care Key points from the Catheter care bundle had not been documented which caused the score to be reduced Action-. Email sent to all staff stressing the importance of documentation Handy Hygiene Scores for the nursing staff continues to rise. Non nursing scores remain low Action - The matron has spent time on the units challenging non nursing staff re handy hygiene Theatres ANTT

January Data8 8 8 8 8 4 4 & 9 4 4 5 1 4 17 4 & 20

Nur

sing

Non

Nur

sing

Cat

hete

r In

serti

on

Cat

hete

r on

goin

g ca

re

% C

orre

ct

pres

cipt

ion

% E

nd d

ate

incl

uded

JR ED ** 89% 100% 100% 0 0 88% 0 0 100% 0 0 5 8 0 97% 3% 0% JR EAU * 100% 100% 100% 100% 100% 0 0 88% 70% 80% 3 5 100% 0 100% 4 0 1 0 40% 53% 7%HGH ED ** 100% 100% 100% 0 0 91% 0 1 100% 0 0 5 4 0 91% 9% 0%HGH EAU * 100% 100% 100% 100% 100% 0 0 93% ♠ ♠ 4 0 100% 2 100% 1 2 1 0 85% 10% 5%7A * 90% 60% 0% 0% 0 0 89% 100% 79% 0 0 0% 0 0% 0 0 1 0 52% 41% 8%7B * 100% 75% 100% 100% 0 0 90% 82% 82% 4 0 100% 0 100% 0 3 1 0 62% 21% 16%7C * 100% 100% 95% 0% 0 2 93% 100% 73% 5 2 95% 0 90% 0 0 3 0 44% 49% 7%7D * 100% 100% 0% 0% 0 0 86% 92% 92% 3 0 0% 0 0% 0 0 0 0 48% 35% 16%7F* 100% 100% 0% 0% 86% 82% 73% 4 0 0% 1 80% 0 4 0 0 61% 33% 4% 5A * 100% 100% 0% 0% 0 0 89% na na 6 0 100% 1 100% 0 0 0 0 17% 66% 17%5C Escalation 100% 100% 0% 0% 0 0 92% ♠ ♠ 0 0 0% 0 100% 0 0 0 0 5% 77% 17%PAU * 100% 100% 0% 0% 0 0 92% 91% 82% 10 0 82% 0 94% 0 5 0 0 60% 23% 6%Oak * 100% 100% 100% 100% 100% 0 0 89% 100% 100% 8 0 80% 0 90% 0 12 0 0 92% 7% 1%Laburnam * 100% 100% 100% 100% 100% 0 0 92% 87% 67% 5 0 100% 0 100% 0 7 0 0 56% 44% 0%Juniper * 100% 100% 100% 0% 75% 0 0 89% 73% 73% 5 0 100% 0 100% 0 10 0 0 86% 14% 0%Level 4 * 93% 80% 100% 100% 100% 0 1 91% ♠ ♠ 18 1 100% 1 100% 0 6 1 0 41% 56% 3%ASU * 100% 100% 100% 100% 100% 0 0 88% ♠ ♠ 4 0 95% 0 93% 2 12 0 0 77% 20% 3%John Warin ** 95% 94% 100% 0% 0% 0 0 93% 93% 93% 1 0 100% 0 86% 0 4 0 0 55% 45% 0%Geoffrey Harris * 100% 100% 100% 0% 0% 0 0 93% 87% 80% 1 0 100% 0 100% 0 18 1 0 19% 74% 7%Treatment Centre 100% 95% 0% 0 0 N/A 0 0 0 0 0 0 0 0% 0% 0%Dermatology 100% 100% 0 0 92% 1 0 0 1 0 0 0% 0% 0%Immunology 100% 100% 100% 88% 0 0 0 5 0 0 0% 0% 0%OCDEM Endocrine 100% 100% 100% NA 0 0 0 2 0 0 0% 0% 0%OCDEM Diabetes 100% 100% NA 0 0 0 4 0 0 0% 0% 0%Sleep Physiology NA NA NA 0 0 0 1 0 0 0% 0% 0%GUM 100% 100% NA 0 0 0 10 0 0 0% 0% 0%Genetics N/A N/A NA 0 0 0 0 0 0 0% 0% 0%

EMTA Quality Metrics ScorecardCQC Outcomes 8 8 8 13

Div

isio

n

Dire

ctor

ate

Ward

Hand Hygiene

AN

TT In

ject

able

s Saving Lives Catheter Care

MR

SA

/ M

SS

A

Pos

t 48

hrs

C D

iff p

ost 7

2 hr

s

Nat

iona

l Cle

anin

g O

vera

ll S

core

Sin

gle

Sex

B

reac

hes

Com

plim

ents

Com

plai

nts

SIR

Is

Not

Incl

P

ress

ure

Unl

cers

% s

hifts

'agr

eed

staf

fing'

% s

hifts

'min

imum

st

affin

g'

Hand hygiene – low scores being highlighted at clinical unit meetings for actions including spot checks by matrons. Cleaning issues being addressed across the Division with re–audits being undertaken and where necessary action plans put in place for staff and Carillion.RCA for C Diff undertaken; no link to other patients and infection control team have been consulted re antibiotics prescribingPressure ulcers: all under review and action plans underway. Staffing issues being managed through continued recruitment and the management of long term sickness

Em

erge

ncy

Med

icin

e, T

hera

pies

& A

mbu

lato

ry (7

)

Em

erge

ncy

Med

icin

e

Th

is in

fom

ratio

n is

col

late

d by

spe

cial

ity

Am

bula

tory

, Che

st, I

D

Com

plia

nce

with

N

utrit

iona

l A

sses

smen

tsAntimicrobial

VTE

Tota

l No

of F

alls

Tota

l No

of

med

icat

ion

erro

rs

Com

plia

nce

with

Tr

ack

and

Trig

ger /

E

WS

Pre

ssur

e U

lcer

s G

rade

3/4

/ S

kin

Inte

grity

% s

hifts

'at r

isk

staf

fing'

Agency

i

January Data

8 8 8 8 4 4 & 9 4 4 5 1 4 17 4 & 20

Nur

sing

Non

Nur

sing

Cat

hete

r In

serti

on

Cat

hete

r on

goin

g ca

re

% C

orre

ct

pres

cipt

ion

% E

nd d

ate

incl

uded

NICU ** 95% 0% 100% 0 0 92% 0% 0 1 0% 1 100% 0 12 0 0 82% 16% 2%Neurosciences IP * 98% 0% 100% 100% 0 0 90% 82% 65% 1 3 90% 0 100% 0 25 1 0 61% 27% 12%Neurosciences OPD 100% 0% 90% 10 0 0 0% 0% 0%2A * 100% 0% 100% 100% 100% 0 0 88% 100% 100% 2 1 100% 0 100% 0 28 0 0 84% 14% 2%3A * 100% 0% 100% n/a 100% 0 0 88% 100% 100% 4 0 100% 1 90% 4 20 0 0 82% 16% 3%Trauma OPD 92% 70% 0 0 0 0% 0% 0%F Ward * 100% 94% 80% 90% 80% 0 0 88% 0% 0% 5 0 80% 0 75% 5 0 0 0 80% 18% 1%SSIP * 90% 0% 100% 0 0 91% 63% 56% 6 0 100% 0 0% 0 0 0 0 94% 6% 0%Lichfield * 90% 0% n/a 93% 0 0 0 27% 74% 0%SSOPD 100% 0% 0% 0 0 0 10% 76% 14%OPD Eye 90% 0% 0% 0 6 0 0% 0% 0%OMFS OPD 90% 0% 0% 0 0 0 0% 0% 0%

NTSS Quality Metrics ScorecardCQC Outcomes 8 8 8 13

Div

isio

n

Dire

ctor

ate

Ward

Hand Hygiene

AN

TT I

njec

tabl


MR

SA

/ M

SS

A

post

48

hrs

C-D

iff p

ost 7

2 hr

s

Nat

iona

l Cle

anin

g O

vera

ll S

core

Sin

gle

Sex

B

reac

hes

Com

plim

ents

Com

plai

nts

SIR

Is

Not

Incl

P

ress

ure

Ulc

ers

% s

hifts

'agr

eed

staf

fing'

% s

hifts

'm

inim

um

staf

fing'

% s

hifts

'at r

isk

staf

fing'

Neu

ro, T

raum

a, S

peci

alis

t

Sur

gery

(3)

Neu

roTr

aum

aS

peci

alis

t S

urge

ry

Com

plia

nce

with

N

utrit

iona

l A

sses

smen

tsAntimicrobial

Tota

l No

of F

alls

Tota

l No

of

med

icat

ion

erro

rs

Com

plia

nce

with

Tr

ack

and

Trig

ger /

E

WS

Pre

ssur

e U

lcer

s G

rade

3/4

/ S

kin

Inte

grity

Antimicrobial– lead consultants to take actions and speak with teams; pharmacy to provide individual consultant information for discussion with individuals Yellow notice placed on neuro health records as reminder for correct prescribingStaffing issues being managed through the use of temporary staff

Increase in falls on SSIP, this was due to one patient falling a number of times. Staffing increased to be able to observe more closely, falls assessment, care plan and post falls care plan in use.

3A Pressure ulcer - patient admitted from home with this. NICU Pressure ulcer to nose, currently being investigated as appears to be potentially unavoidable due to medical care required at that time. RCA currently with Risk Management.

Low compliance with nutrition assesments on F ward, partly due to being unable to weigh pre-operative #NOF pateints and increased use of agency/bank staff due to increased sickness absence. Divisional Nurse visited F ward on 2/2/12 and undertook an inspection with ward sister which found compliance had improved.

All cleaning audits amber across the Division in January. There have been a number of reinspections and communication with Carillion and the Housekeepers. Action plans introduced where required. Continue to closely monitor. Medical staff hand hygiene Trauma OPD. Out patient sister continues to address with the staff. Clinical Lead has been informed.

January Data8 8 8 8 4 4 & 9 4 4 5 1 4 17 4 & 20

Nur

sing

Non

N

ursi

ng

Cat

hete

r In

serti

on

Cat

hete

r on

goi

ng

care

% Correct prescipti

on

% End date

included

Oncology Ward ** 100% 80% 100% N/A 100% 0 0 91% 57% 79% 2 2 90% 0 90% 0 6 0 0 74% 25% 1%Oncology Treatment 70% 100% 80% 93% 0 0 N/A 0 na 0 0 0 0Haematology ** 100% 100% 100% N/A N/A 0 0 91% 92% 92% 2 0 70% 100% 0 3 0 0 43% 50% 7%Sobell * 100% 100% 100% 100% 100% 0 0 89% 92% 92% 7 2 N/A 0 100% 0 21 0 0 62% 35% 3%SEU D & Triage* 100% 100% 95% N/A 100% 0 0 88% 83% 83% 1 1 100% 1 90% 0 7 1 0 90% 0% 10%SEU E 100% 100% 100% N/A N/A 0 1 79% 100% 100% 0 0 100% 0 90% 0 6 0 0 87% 10% 3%SEU F * 100% 100% 100% N/A 86% 0 0 89% 92% 92% 2 1 100% 0 100% 0 7 0 0 46% 42% 12%5F * 100% 100% 100% NA 100% 0 0 87% N/A N/A 5 1 100% 0 100% 0 5 0 0 49% 26% 25%JR Endoscopy ** 100% 90% 100% 0 0 87% 0 0 0 3 2 0 97% 3% 0%HGH Endoscopy ** 100% 95% 100% 0 0 95% 0 0 0 6 0 0 80% 10% 10%HGH E Ward * 100% 92% 98% 100% 100% 0 0 94% 80% 70% 0 0 100% 0 100% 0 12 0 0 97% 3% 0%UGI * 90% 86% 86% N/A 100% 0 0 86% 100% 93% 2 1 100% 0 80% 0 14 0 0 80% 17% 3%Colorectal * 100% 67% 100% N/A 86% 0 0 84% N/A N/A 2 1 100% 0 100% 0 20 0 0 86% 9% 5%Jane Ashley * 100% 100% 100% N/A 100% 0 0 97% N/A N/A 3 1 100% 0 60% 0 20 0 0 78% 21% 1%Urology * 100% 60% 86% 100% 100% 0 0 94% 73% 55% 3 0 100% 0 90% 0 4 1 0 33% 61% 6%Transplant ** 100% 80% 90% 0 1 89% 90% 90% 0 2 70% 0 70% 0 7 0 0 45% 50% 5%Renal Ward ** 100% 80% 100% 0 0 87% 80% 80% 3 1 100% 1 60% 0 8 0 0 54% 43% 3%ORH Dialysis * 92% n/a 100% 1 0 92% 1 0 0 0 0 0Stoke Mandeville * 100% n/a 100% 0 0 0 0 0 0 0 0Milton Keynes * 100% n/a 100% 0 0 0 0 0 0 0 0Swindon * 100% n/a 100% 0 0 0 0 0 0 0 0Wycombe * 100% n/a 100% 0 0 1 0 0 0 0 0

S & O Quality Metrics ScorecardCQC Outcomes 8 8 8 13

Div

isio

n

Dire

ctor

ate

Ward

Hand Hygiene

ANTT

In

ject

able

s


MR

SA /

MSS

A po

st 4

8 hr

s

C-D

iff p

ost 7

2 hr

sN

atio

nal

Cle

anin

g O

vera

ll Sc

ore

Sing

le S

ex

Brea

ches

Com

plim

ents

Com

plai

nts

SIR

Is

Not

Incl

Pr

essu

re U

lcer

s

% s

hifts

'a

gree

d st

affin

g'

% s

hifts

'm

inim

um

staf

fing'

Nutrition & Hydration Patient safety Week raised profile for nutritional screening, accurate fluid balance charts and provision of meal service. This work being continued in focused observation in ward areas with less than 90% compliance for all admissions.Pressure Ulcers - RCA undertaken and identified as avoidable; complex patient needs and compliance identified as a contributing factor

Surg

ery

& O

ncol

ogy

(6)

Onc

olog

ySu

rger

y - J

R, H

GH

, Chu

rchi

ll &

Endo

scop

yR

enal

, Tra

nspl

ant &

U

rolo

gy

Com

plia

nce

with

N

utrit

iona

l As

sess

men

tsAntimicrobial

Tota

l No

of F

alls

Tota

l No

of

med

icat

ion

erro

rs

Com

plia

nce

with

Tr

ack

and

Trig

ger /

EW

S

Pres

sure

Ulc

ers

Gra

de 3

/4 /

Skin

In

tegr

ity

Cleaning scores: it is now the matrons' responsibility to organise re-audits when wards fail the cleaning audit and coordinate the services present at re-audit. This has empowered the matrons to own the issues that fail the audit. Nursing scores have improved and there is improved evidence log of outstanding cleaning requests made as these are encouraged to be made via the helpdesks.

Antimicrobial results: The Division is committed to raising compliance with documentation of antibiotic prescribing. All junior doctors have been reminded of their responsibility to accurately document both the indication for use and the duration before review. Any non-compliant prescriptions will be recorded and discussed with the individual eduactional supervisor. Consultants will review and remind on their daily ward rounds.

Division continues to focus on reducing the number of falls.

C.Diff investigated and no link to ANTT or antimicrobials was identified in either caseStaffing issues being managed through redeployments between ward areas and use temporary staff

% s

hifts

'at

risk

staf

fing'

January

8 8 8 8 8 4 4 & 9 4 4 5 1 4 17 4 & 20

Nur

sing

Non

Nur

sing

Cat

hete

r In

serti

on

Cat

hete

r on

goin

g ca

re

% Correct prescipti

on

% End date

included

JR Gynae* 96% 78% 100% 0 0 88% 0 0 0 0 6 0 100% 0% 0%HGH Gynae* 89% 100% 0 0 92% 0 0 0 0 0 100% 0% 0%Women's Theatres 90% 50% 0 0 88% 2 2 0 0 0 100% 0% 0%Delivery Suite / Obs 100% 100% 0 0 93% 2 2 0 4 0 0% 0% 0%Spires Midwifery Led 0 0 91% 0 0 0 0 0% 0% 0%Level 5 100% 90% 0 0 90% 0 2 0 0 0% 0% 0%Level 6 100% 100% 0 0 92% 70% 60% 1 1 0 0 0% 0% 0%Level 7 0 0 92% 0 0 0 0 0% 0% 0%HGH Delivery Suite 0 0 85% 0 0 0 0 0% 0% 0%HGH Post Natal Ward 0% 0% 0 0 95% 0 0 0 0 0% 0% 0%

Falls reported in Maternity - Woman fainted in shower after delivery; she was uninjured. Patient fell after trying to stand in room post epidural (alone) but no injury sustained after medical review. Visitor's father collapsed whilst visiting daughter on Level 6 - transferred to ED, no injury was sustained

Five drug errors: 2 documentation errors:There was poor documentation noted on 2 drug charts. The date and time of when the drug was administered was clearly documented but there was no evidence of a signature by a health professional. There was no way to follow this up with the individuals concerned. 5 vials of BCG were destroyed after being left out of the fridge overnight. The ward managers and bleep holders were reminded about correct storage of the BCG vaccine. There was a delay in obtaining medication for a woman who arrived needing a prescription of Lorazepam; this particular drug is not stocked in Women's centre. This issue was discussed with the clinical midwifery manager and pharmacy re stocking this drug in future. The Pharmacist has agreed to have a stock within the Woman's centre. [Woman received alternative drug but alternative not optimum].Pharmacy incorrectly dispensed drug from pharmacy (Flucloxacillin) the dosage in mls and milligrams was incorrect, the drug was not administered to the baby and the drug was returned to pharmacy.


MR

SA

/ M

SS

A

post

48

hrs

Gynae and Maternity Quality Scorecard Board8 8

Red handwashing score: new rotation of medical staff received handwashing as part of their induction. Audits continue. Anaesthetists not washing hands in between patients in Recovery; nursing staff wearing gloves inappropriately - individuals will now be challenged. Low cleaning score in Theatres: Matron, scrub and recovery sisters met and went through audit esults, Action plan in place to be completed by end of week.Gynae Ward:reaudited following failed cleaning score. Matron and Sister to review cleaning manual and complete assurance checks.

VTE

Hand Hygiene

8

Gyn

ae

46%

No data

Antimicrobial

Tota

l No

of

med

icat

ion

erro

rs

Com

plia

nce

with

Tr

ack

and

Trig

ger

/ EW

S

SIR

Is

Not

Incl

P

ress

ure

Ulc

ers

Div

isio

n

Dire

ctor

ate

Ward

Nat

iona

l Cle

anin

g O

vera

ll S

core

CQC Outcomes

AN

TT

Inje

ctab

les

C-D

iff p

ost 7

2 hr

s

Gyn

ae a

nd M

ater

nity

Mat

erni

ty

Com

plim

ents

Tota

l No

of F

alls

13

% s

hifts

'agr

eed

staf

fing'

% s

hifts

'min

imum

st

affin

g'

% s

hifts

'at r

isk

staf

fing'

Pre

ssur

e U

lcer

s G

rade

3/4

/ S

kin

Inte

grity

Com

plia

nce

with

N

utrit

iona

l A

sses

smen

ts

Sin

gle

Sex

B

reac

hes

Com

plai

nts

Trust Board Meeting: Thursday 1 March 2012 TB2012 · 2012. 2. 27. · TB2012.13 TB2012.13_Quality...

Documents

Transcript of Trust Board Meeting: Thursday 1 March 2012 TB2012 · 2012. 2. 27. · TB2012.13 TB2012.13_Quality...