Trust Quality and Performance Report

January 2013

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Contents

Slide numbers

Clinical Quality Priorities inc Ward Dashboard 4 - 17

CQUIN 18 - 20

Local Priorities 21 - 27

Monitor Compliance 28 - 31

Contract Priorities 32 - 36

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Introduction

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

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Clinical Quality Priorities Summary

• The number of falls rose in December. Increased activity and increased capacity is felt to have had an impact. However, the Trust compares favourably with surrounding Trusts when benchmarking the number of falls.•There were 5 patients with C. difficile diarrhoea. This coincided with a norovirus outbreak.•Patient satisfaction was high and has been maintained at above 90% since May 2012.

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Ward dashboard – A3

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Quality Priority: Ward Performance Issues

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Patient satisfaction

Ward F3 was the only ward with more than 3 red scores in patient satisfaction this month. This is unusual for F3 and will be monitored. The only issue that has been identified for action is noise at night from staff. This specific issue has been brought to the attention of the Ward Manager who will cascade to staff and remind them of the importance of this issue.

Quality Priority: Infection Control

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There were no cases of MRSA bacteraemia, however, there was one case of MSSA bacteraemia which is in the process of investigation and may not have been clinically significant.

There were 5 cases of C. difficile during December, two of which occurred on ward F7 and coincided with a norovirus outbreak. This is regarded as a period of increased incidence of C. difficile and a meeting has been held to investigate. No additional actions have been identified as a result. 4 of the 5 cases were associated with norovirus outbreaks on the wards. A review of cases this year indicates that 29% of cases were detected in patient on wards that were closed or recently closed with norovirus. The remaining case was on another ward and the RCA has indicated that the C. difficile was clinically insignificant and unavoidable. NorovirusThree wards experienced norovirus during December (G4, G5, F7). A total of 55 patients and 14 members of staff were affected. However, prompt action was taken and the wards closed when more than one bay was affected. Each ward was closed for a period of 8 or 9 days and the spread was limited, resulting in a shorter outbreak and no spread to other wards.Hand HygieneHand hygiene and dress code audit results returned to 100% this month. The Infection Prevention Team will undertake some validation audits during February.Isolation data resultsDuring December there were 483 inpatient days for patients requiring isolation and 41 inpatient days when isolation was not achieved giving a 84% compliance rate with isolation.

Quality Priority: Infection Control

Antibiotic Compliance Audit Audit criteria TOTALNumber of patients audited 354Number of patients on Antibiotic treatment 127% of patients on Antibiotic Treatment 36%Overall compliance 95%

The Trust achieved 95% compliance overall for the antibiotic auditsfor Quarter 3 against a target of 95%.  The audits comprise 6 standards and the results for each of the standards is provided below with details of action being put into place to further improve compliance against individual standards. More general action against compliance reported last month continues.

Standard 1: The allergy box will be completed on all drug charts 99% :(126patients)Action: The pharmacy team will continue to highlight this deficit to the prescribers by completing this section in green pen on the drug charts and ongoing teaching and educational activities continue.Standard 2: The indication for the antibiotics will be documented on the drug charts:84% (107patients). Action: A poster campaign has commenced specifically raising awareness of the prescribing shortfall relating to the completion of the ‘indication’ box on the drug chart. These flyers have so far been displayed within the two doctors rooms within surgery. This is being rolled out further this month Focus areas: F4, F5, G4, EAU and CCU, then F3, F6, F7 and F9, as these areas are red and amber rated. Ongoing teaching and educational activities are also taking place.Standard 3: A stop or review date will be documented on the drug charts: 99% (126 patients)Action: Continue with the training session for NHS professional nurses during the trusts mandatory training day and to implement a form of training for temporary nursing and medical staff working within the trust. This will commence in the new year. Standard 4: Patients will receive intravenous antibiotics for a maximum of 72 hours unless there is a valid clinical reason: 100% (127 patients)Standard 5: Ensure adherence to the correct antibiotics as per trust guidelines or on advice from a consultant Microbiologist: 96% (122 patients)Actions: Small coloured cards to be clipped to the front of the drug charts to act as prescribing alerts for doctors. These will be laminated and in highly visible colours stating which element of antibiotic prescribing needs to be reviewed. Laminated A4 copies of the trust antibiotic guidance to be attached to the notes trolleys / computer on wheels to enable quick reference. IT have recently changed the antibiotic guideline access point on the pink book and this will reduce the time doctors spend searching for the guidance. Antibiotic review area to be allocated on the doctors yellow weekend review sticker. This would then encourage forward planning and the timely discontinuation of antibiotics (if appropriate).Standard 6: Ensure appropriate samples are sent to Microbiology: 93% (118 patients)Action: Ongoing teaching and educational activities continue. We will highlight the need for blood cultures to be taken when the patient demonstrates two vital sign ‘Sepsis 6’ triggers and are being treated with antibiotics for Sepsis of an unknown origin. 

 

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Quality Priority: Falls

The contract target for falls during 2012-13 is to reduce serious harm/death from falls and to complete a risk assessment for patients who attend A&E as a result of a fall.

Falls performanceThere were 63 falls across the Trust during December; 15 of these falls resulted in harm, 2 with serious harm. The falls with serious harm were as follows:• A patient on G5 suffered a fractured neck of femur . This was a patient with dementia who often refused to mobilise with physiotherapists and nurses despite encouragement, thus making it difficult to provide rehabilitation. However, on this occasion he got up without asking for assistance and fell when unobserved. •A patient on G9 fell and fractured both neck of femurs. The patient was confused and got out of bed without assistance. His confusion was such that he would have been moved to one of the high visibility beds if one had been available but capacity issues prevented this.

Themes from fallsDuring December increased activity and capacity issues were felt to be significant factors in the increase in falls. There was a huge demand for 1:1 come for confused patients and those with challenging behaviour that could not be filled, due to a high demand for staff to support core staffing levels. This was due to the increased bed capacity and sickness levels. Although the incidence rate appears to have increased significantly, when the incidence is considered per 1,000 bed days, November’s performance was 4.4 falls per 1,000 bed days and December’s performance was 5.8 falls per 1,000 bed days. In addition, there were a significant number of falls in independent patients who could not have been predicted to fall.

Benchmarking dataFalls data from James Paget NHS FT and Ipswich Hospital NHS Trust have been examined to understand our performance. Falls/1,000 bed days have been used to benchmark data against Ipswich due to different bed capacity. Incidence data has been used to compare JPH as they do not report per 1,000 bed days and have similar bed capacity. Kings Lynn only report falls with serious harm in their performance report.During 2012, Ipswich have reported a range of 7.52-10.94 falls/1,000 bed days. James Paget reported 67 falls during November, their data from Apr 2011 to Nov 2013 demonstrates performance only dropped below 60 falls/ month in 2 out of the 20 months and generally was in the range of 67-110 falls/month.

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Quality Priority: Pressure Ulcers

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The performance target is to have no avoidable Grade 3/4 pressure ulcers 2012-13 with a penalty of £5,000 for each incidence.The performance target regarding avoidable Grade 2 pressure ulcers is a ceiling of 4 for Quarter 3 with a penalty of £500 for each incidence

above the ceiling.

December performance2 patients developed Grade 2 hospital acquired pressure ulcers this month, all of which were considered avoidable following concise root cause

analysis. The Grade 2 pressure ulcers developed on G1 and G5.1 patient on F3 developed a Grade 3 heel pressure ulcer. The patient had cognitive impairment and was non compliant , repeatedly rubbing his

heel on the bedsheets. All preventative measures appear to have been implemented including the provision of heel protectors, high level mattress and red flag checks.. An RCA is due to take place and will assess whether it was unavoidable.

Safety thermometer results

CQUIN 2012-13 target is to survey all adult inpatients on the survey date and submit the data to the NHS Information Centre on time.

Our quality priority is to achieve 95% harm-free care, current performance is 95.66%. The national amalgamated figure in December for all organisations is 92.33%. .

The National ‘harm free’ care composite measure is defined as the proportion of patients without a pressure ulcer (ANY origin, category II-IV), harm from a fall in care in the last 72 hours, a urinary tract infection (in patients with a urethral urinary catheter) or new VTE treatment.

The data can be manipulated to just look at “new harm” and with this new parameter, our Trust score is 97.86%. The national amalgamated figure in December for all organisations is 96.68%.

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Quality Priority: Patient Experience – Achievement of 85% satisfaction

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‘Achieve at least 85% satisfaction in internal patient satisfaction surveys’ is a Quality Priority for the Trust.

The overall score for the inpatient survey was 91% indicating a high level of satisfaction with most of the areas covered in the survey.

Response rates were higher this month, but there is still variability between wards. The number of responses for Ward F12 remained unacceptably low and the Ward Manager has indicated that she is moving to paper questionnaires to try to increase responses. F7 and F9 also had low responses, possibly due in part to reduced volunteer activity in December. However, a problem with the survey system at the beginning of the month gave inflated response figures, which meant that Matrons were unaware of the low responses. This has been rectified by the company. Ward F5 achieved an increased number of responses in December following an initiative by the Ward Manager. The Ward Manager is allocating 2 members of staff each month to champion the survey and has indicated that there will be an annual prize for those achieving the highest number of responses.

The number of responses to the survey will be added to the ward dashboard from next month.

Outpatient survey results remain good with

an overall score of 96% and, as can be seen

by the graph (right), the provision of information

about delays has seen improvement

over the last two months.

Quality Priority: Patient Experience – Recommend the service

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‘Patients would recommend the service to their family and friends’ is a Quality Priority for the Trust

The Trust achieved a net promoter score of 87 for inpatients during December with a 17% response rate. Although the overall score was high there were low scores for several individual wards. The Matrons have been asked to look into this in more detail and talk to patients to discover if there is a reason for this. Matrons report that in their normal rounds when they speak to patients, the patients are very positive about their care on these wards. There are very few responses to the question asking for reasons for a low score and those that do comment, are not necessarily patients on the wards that have a low recommender score. This month there were a small number of useful comments for example:

• Limited continuity of care –never the same staff on duty (G5)• Woken at 6am but no cup of tea until 8.30 (EAU)• Operation delayed –not kept informed (F5)• More like a number not a person. Night staff noisy (F4)

However, some of the comments did not seem to correlate with the score:• “we think you are all great” (score 5, ward F3)• “very good” (score 8, ward G3)

The results for the other areas for the net promoter score are provided below:

Department No of responses Net promoter score

OPD 117 96

DSU 7 86

A&E 102 88

Quality Priority: Mortality

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Q2 CQUIN performance report has been submitted to NHS Suffolk and the PCT’s response is awaited. It is understood that most measures are confirmed as met in line with expectations. Performance on quarter 3 will be submitted at the end of January 2013.

Two patients did not receive the full range of VTE prophylaxis and therefore 99.3% score against 100% target

EPRO has been upgraded to meet Dementia screening requirements. The Trust is on track to achieve the target of 90% of eligible patients screened.

Conversion of number of alcohol assessments done to positive test requires substantial increase in Q4 as well as number of referrals to specialised agency.

CQUINSummary & Exceptions report

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CQUIN dashboard – A3

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Local PrioritiesSummary & Exceptions report

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There are three reds in the governance dashboard:•RCAs (non SIRI) completed more than 45 days after incident reported•Incidents (Amber / Green) with investigation overdue (over 12 days)•NICE Technology Appraisals (TA)•RCAs (non SIRI) completed more than 45 days after incident reportedOne was 3 days late to ensure multiple medical staff attendance. Two others due in December had RCAs in January due to delays in finalising chronologies and attendees•Incidents (Amber / Green) with investigation overdue (over 12 days)The following processes are in place to maintain and improve performance:•Email from Datix administrator to leads of overdue incident investigations (weekly)•Email to “handlers” with 5 or more overdue investigations (fortnightly) •Performance report to General Managers, including names of “handlers for all overdue incidents (monthly).•Governance lead (Medicine) / Clinical Directors (Surgery) following up individual Consultants with overdue investigations.A number of areas have been identified for targeted improvement and strategies suggested to improve performance e.g. train more users to undertake incident investigations.•NICE Technology Appraisals (TA)There are currently nine TAs beyond deadline for implementation. The Christmas period has negatively impacted on this both in terms of allowing internal review and sign-off by NHS Suffolk,. Review meetings for six of the overdue TAs are booked (16th and 17th Jan) and meetings for the remaining three TAs are being finalised. Review meetings are also being arranged for TA guidance within timescale, including those in the consultation period, this will ensure that we deliver future implementation to deadline. It is expected that by March ‘13 there will be a significant reduction in the number outstanding TAs.The Datix module to support NICE guidance administration has been developed and is currently being tested. Go live is expected by 1st April 2013.

Local Priorities - Governance Dashboard

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Indicator Performance target R A G Dec12 Commentary

National safety alerts

Number of NPSA alerts beyond national implementation deadline

>=5 1-4 0 0

Timely completion of incident investigations and actions

RCAs (non SIRI) completed more than 45 days after incident reported

>1 1 0 3 See local priorities summary report

RCA Actions beyond deadline for completion >=5 1-4 0 0

Incidents (Amber / Green) with investigation overdue (over 12 days)

>150 50-150 <50 283 See local priorities summary report

Timely reporting of SIRIs

SIRI notification to NHS Suffolk beyond timeframe >=1 0 0

SIRI 45 day reports sent to NHS Suffolk beyond timeframe

>=1 0 0

Risk assessment

Active risk assessments in date <75% 75 – 94%

>=95% 100%

Outstanding actions in date for Red / Amber entries on Datix risk register

<75% 75 – 94%

>=95%95%

NICE TA (Technology appraisal) business case beyond agreed deadline timeframe

>9 4 - 9 0 - 3 9 See local priorities summary report

IPG (Interventional procedure guideline) baseline assessments beyond agreed deadline timeframe

>9 4 - 9 0 - 3 6

CG (Clinical guideline) baseline assessments beyond agreed deadline timeframe

>9 4 - 9 0 - 3 6

Clinical Audit Trust participation in relevant ongoing National audits (reported by Quarter)

<75% 75 – 89%

>=90% 100%

Complaints Response within 25 days or negotiated timescale with the complainant

<75% 75 – 89%

>=90% 100%

Number of second letters received >=5 1-4 0 0

Health Service Referrals accepted by Ombudsman >=2 1 0 0

Red complaints actions beyond deadline for completion

>=5 1-4 0 0

Number of PALS contacts becoming formal complaints

>=10 6 - 9 <=5 2

There were 406 incidents reported in December including 328 patient safety incidents (PSIs).

The rate of PSIs is a nationally mandated item for inclusion in the 2012/13 Quality Accounts. The NRLS target lines shows how many patient safety incidents WSH would have to report to fall into the median / upper and lower quartiles for small acute trusts reporting per

100 admissions. This was rebased in September to take into account the new dataset from the Oct 11 - Mar 12 NRLS report). The reporting rate in December was similar to November. The number of harm incidents rose in December but remains below the peer group

average.

Upper quartile, median and lower quartile rebased from Sept 12

Harm (peer group average) rebased from Sept 12

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The percentage of PSIs resulting in severe harm or death is a nationally mandated item for inclusion in the 2012/13 Quality Accounts. The peer group average (serious PSIs as a percentage of total PSIs) has been rebased to 1.0% from the NPSA October 11 – March 12 report and now sits below the Trust’s average.

The number of serious PSIs (confirmed grade) are plotted as a column on the secondary axis.

The WSH data is plotted as a line which shows the rolling average over a 12 month period. This has remained relatively static over the previous six months.

In November there were two ‘Red’ patient safety incidents reported both awaiting confirmation of grade through RCA: Neonatal death (1), Delay in treatment (1)

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Local Priorities

Complaints

Complaint response within agreed timescale with the complainant: 100% of responses due in December were responded to within the agreed timescale (target 90%). Of the 20 complaints received in December , the breakdown by Primary Directorate is as follows: Medical (7), Surgical (8), Clinical Support (1), Facilities (2) and Women & Child Health (2).

Trust-wide the most common problem areas are as follows:

Admission, discharge, transfer arrangements 5All aspects of clinical treatment 11Attitude of staff 4Communication / information to patients (written and oral) 4

The most common theme being patients expressing dissatisfaction with care and treatment, but with no commonality between wards or directorates.

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Local PrioritiesPALS (Patient Advice & Liaison Service)

In December 2012 there were 81 recorded PALS contacts. This number denotes initial contacts and not the number of actual communications between the patient/visitor and PALS which is recorded as 119 for this month.

A breakdown of contacts by Directorate from December 11 to December 12 is given in the chart and a synopsis of enquiries received for the same period is given below. Total for each month is shown as a line on a second axis.

Trust-wide the most common five reasons for contacts are as follows:

Although the contacts have reduced slightly this month, this takes account of the Christmas and New Year holiday period. The numbers related to clinical care and general advice have reverted to the average number expected (after a notable increase in November). It is however pleasing to note that the contacts regarding attitude of staff have reduced to only one this month. Contacts from the medical

Directorate have again increased.

Analysis of the data for the Medical Directorate shows three areas with more than three contacts – ward G5 (6), ward F9 (5) and A&E (4). The level of contact for G5 has been highlighted to the relevant Matron for review.

The PALS Manager continues to deal with concerns about hospital procedures and often assists with clarification of a patient’s treatment plan. This will include attending meetings with patients and/or family and their respective clinicians.

The nature of the PALS service requires an expedient response to concerns or queries. A target of 80% for completing an enquiry within 48 hours, or a timeframe agreed with the enquirer, is consistently exceeded by the PALS Manager.

All aspects of clinical treatment

22 Information/Advice request 15 Other (relating to other organisations/not classified)

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Appointments delay/cancellation

6 Communication/information to patients

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Local Priorities – Workforce Performance

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Performance Indicator ThresholdDirect Financial

PenaltyIn Month

PerformanceYTD Comments

Sickness absence rate <4.39% (National Average) NO 4.02% 4.02% Jan BloomfieldTurnover <14.2% (National Average) NO 6.12% 6.12% Excluding Junior Doctors Jan Bloomfield

Reviews Grievance/Banding reviews NO1 1 One Employment Tribunal (postponed no judge available) Jan Bloomfield

Recruitment Timescales Average number of weeks to recruit = 7 NO5.5 5.5

This will continue to include any additional weeks for the Suffolk Redeployment Clearing House Jan Bloomfield

CRB Disclosures existing staff To complete 95% of required CRB checks NO 99.00% 99.00% Jan Bloomfield

All Staff to have an appraisal 90% of staff have had an appraisal within the previous 12 months NO

90.30% 90.30%

Directorates receive their monthly reports to monitor their own position. The Trust uses the performance directorate reporting process to tackle underperformance. Appraisal Workshops are in place to ensure Managers and staff are appropriately trained in using the appraisal process and its importance to the organisation. It is hoped that performance will be back on track next month Jan Bloomfield

Mandatory Training compliance (reported Quarterly) It has been agreed that the quarterly mandatory training figures will be reported for the February Board Jan Bloomfield

Lead Exec

Workforce

Monitor ComplianceSummary & Exceptions report

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Performance against the four hour target improved dramatically in late November and early December, achieving the best in England by a considerable margin for two consecutive weeks.

However, winter pressures, including Norovirus, in December mean that was not possible to recover performance for the quarter. All actions have been undertaken according to plan including opening additional escalation beds, trialling a GP expected bay and moving TIA patients to the Stroke Unit.

Monitor Compliance FrameworkA3 printout

Dashboard - screenprint

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Contract PrioritiesSummary & Exceptions report

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Performance on stroke targets and specifically more detailed analysis of the ‘60 minutes to urgent scan’ target is included in this section as discussed with the Board on 4 January 2013.

Detracted information on Falls and Pressure Ulcers is included in pages 12 and 13 of this report respectively..

Stroke

The above graph represents performance over 2012/13 on the ‘60 minute to urgent scan target. The board requested that the reason for breach was examined and that any adverse consequences for the patient were also considered. The circumstance in which a patient would be adversely affected is where the patient is suitable for thrombolysis and did not receive that treatment in a timely way. One patient breached the ’60 minute to urgent scan’ target in December. Under national rules, performance is calculated on discharge and the scan event therefore happened in September. The scan was delayed by 1 hour and 47 minutes as the patient arrives on a Sunday during early morning when no specialised stoke team is available and was not given suffi cient priority. The patient was clinically unsuitable for thrombolysis and there was no adverse impact on this patients treatment or outcome. Employing the 24 hour specialised stroke service as planned in response to the stroke business case is likely to have improved this patients pathway

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Contract Priorities Dashboard + OtherA3 printout

Comes from dashboard

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