Tabled paper

QUALITY REPORT

CONTENTS

A monthly report presenting an update on Patient Safety, Clinical Effectiveness and Patient Experience in the Trust

November 2012

Tabled paperSection Item Page No.

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Tabled paper1 INTRODUCTION 32 KEY POINTS TO NOTE 33 TARGETED AREAS OF SUPPORT 54 EMERGING TRENDS/NOTICEABLE PATTERNS 55 OF SPECIFIC NOTE 56 KEY CLINICAL RISKS 67 CARE QUALITY COMMISSION’S QUALITY & RISK PROFILE 78 CQuINS 89 PATIENT SAFETY 99.1 Safety Thermometer

a) Fallsb) Pressure damagec) VTE assessment

9111112

9.2 Nutrition/fluids 129.3 Infection Control 139.4 Maternity 159.5 Emergency Department highlights 169.6 Safeguarding 169.7 new Health Visiting 169.8 Medicines management 179.9 Never Events 209.10 National Patient Safety Agency (NPSA) alerts 209.11 Lessons Learned 219.12 Significant risks 219.13 ‘Listening into Action’ 219.14 Nurse Staffing Levels 2110 CLINICAL EFFECTIVENESS 2310.1 Mortality 2310.2 Patient Related Outcome Measures (PROMs) 2610.3 Clinical Audit 2610.4 Compliance with the ‘Five Steps to Safer Surgery’ 2710.5 Stroke care 2810.6 Treatment of fractured Neck of Femur within 48 hours 2810.7 Ward reviews 2811 PATIENT EXPERIENCE 2911.1 new Net Promoter 2911.2 Complaints/PALS

a) Complaints datab) PALS data

303031

11.3 End of Life 3212 WORKFORCE QUALITY 3413 RECOMMENDATION 34

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Tabled paper QUALITY REPORT

This report presents a composite picture of the performance against the various key Quality metrics to which the Trust works, both in terms of those mandated at a national or regional level and those set by the organisation.

The report has been populated with latest performance information for the period up until this Board meeting, across a range of areas within three domains: patient safety, clinical effectiveness and patient experience.

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The Trust Board’s attention is drawn to the following this month:

Safety Thermometer for October 91.52% - a further decrease on the previous month. The decrease in performance is mainly around an increase in pressure damage recorded. The Board should note that all pressure sores i.e. hospital acquired and non hospital acquired are recorded; avoidable and non-avoidable and all sores on District Nursing caseloads on the day of the audit. For detail of hospital acquired see pressure damage section of the report. Whilst the number of pressure sores has increased the numbers of patients experiencing multiple harm events remains very low.

Pressure damage – the number of hospital/health acquired, avoidable pressure damage reduced in August. Data is not yet available for Sept/Oct but we believe that there is a slight increase in incidents associated with medical wards at Sandwell. Accountability meetings with the Chief Nurse are now established and we hope to see the impact of this, plus the ‘Happy Feet’ campaign over the coming weeks. The Trust pressure damage rates remain favourable compared to other similar Trusts.

Falls – overall numbers remain largely the same. Analysis of the upwards trend at Sandwell suggests that more falls are happening in side rooms and on medical wards that had been due for closure within the bed reduction plan.

Nutrition – audits continue to show a slight downward trend. These are due to underperformance on a small number of wards and the issue is being addressed via accountability meetings. The issue is predominantly around accurate ‘charting’ and the declining performance on a few wards is thought to be due to staffing issues.

Infection control – The Trust is achieving all mandatory standards/targets with the exception of MRSA screening. The MRSA screening data has been left out of this report as we now know that there are issues with counting the number of screens against the number of eligible patients.

PATIENT SAFETY

2 KEY POINTS TO NOTE

1 INTRODUCTION

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A full report plus plan will go to Quality & Safety Committee. There has been a number of D&V outbreaks predominantly of a Norovirus nature.

These are not linked in any way to each other demonstrating effective infection control procedures. There is a considerable amount of Norovirus in the Community currently, leading to an increase in hospitals

Safeguarding – no internal issues for Trust Board to be aware of. There are some concerns regarding support posts within the LA/Community.

Nurse bank/agency rates – rates are now at the highest level for the past 4 years. This is as a result of paused bed closure plan and early opening of winter capacity in Medicine. These levels represent a risk to standards of care on some wards and some early signs of deterioration have been identified via our early warning processes. Acute recruitment is in process with approximately 50 nurses recruited in the past few weeks. A further 50 is still required for the main in patient wards. We are also recruiting for a number of nurses to support changes in stroke services and to meet identified requirements in EAU and the two EDs. It has not been possible to produce ratio reports because of the state of change in Medicines ward establishments.

Health Visiting – information re progress with HV services are included in the report. Dementia – A Steering Group has now been established chaired by the Chief Nurse

with multiprofessional user and external agency representation. A full report and plan is due to go to Q&S in December/January.

CLINICAL EFFECTIVENESS

Fractured Neck of Femur operated on within 24 hours has increased to 85.7% a sustained improvement on previous performance and exceeding our local target of 70%

Compliance with the use of the World Health Organisation (WHO) checklist is 99.5%

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3 TARGETED AREAS OF SUPPORT

The areas of the Trust being provided with targeted support this month are: EAU Sandwell – continues in special measures – will be taken off following completion of

closure report this month and incorporation of outstanding actions in ED plans. ED, City Special measures ED, Sandwell Imaging division – areas for improvement identified as a result of external reviews P4, P5 and L4 wards – all are struggling as a result of paused bed closures and therefore have

staffing issues. Active support is being provided and close monitoring of standards.

4 EMERGING TRENDS/NOTICEABLE PATTERNS

Increase nursing vacancies/gaps as a result of slippage in bed closure plan and winter capacity open early

5 OF SPECIFIC NOTE

Reports from CQC visits now received and action plans in development.

PATIENT EXPERIENCE

Net Promoter Score – This has improved to 63 (target 65) 74 complaints were received in October and 116 final responses sent out. As at week

ending 23 November 2012, 27 complaints were in breach of the Trust’s failsafe target. Clearance of the complaints backlog is on track to be achieved in the last week in November 2012.

End of Life – Number of appropriate patients on a supportive care pathway is now at 77% and 60% of patients on a SCP achieved their preferred place of death – representing an improvement of 24% since April.

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6 KEY CLINICAL RISKS

Variable standards/leadership EDs Staffing levels as a result of ‘paused’ bed closure plan Variable standards of Medicine storage Currently undertaking an extensive piece of working looking at apparent issues around

antenatal screening

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[Type text]

Care Quality Commission (CQC): Quality and Risk Profile (QRP) The Care Quality Commission (CQC) publishes a QRP for each registered provider which is used to support the day to day work of CQC inspectors. The QRP provides the Trust with a risk estimate for each outcome of the 16 Essential Standards of Quality and Safety. These risk estimates are produced by the CQC using a statistical model that aggregates individual pieces of information which the CQC holds about the Trust. The risk estimates are displayed as dials as shown below:

The current risk estimates for the essential standards for quality and safety for the Trust are:

Risk estimate Frequency Outcomes No Data - - Insufficient data 0 Low Green 2 21 and 11 High Green 3 6, 14 and 17 Low Yellow 10 1, 2, 5, 7, 8, 9, 10, 12, 13 and 16 High Yellow 1 4 Low Amber - - High Amber - - Low Red - - High Red - -

There are currently no outcome risk estimates in Amber or Red. This shows the Trust as being at a low risk of non-compliance with the CQC’s 16 essential standards of quality and safety. The overall position has remained the same since December 2010, with the exception of a few changes which have not been significant enough to have an effect on the overall RAG status for the Outcomes. It is important to state that low risk estimates in a QRP do not guarantee compliance. On-going monitoring of compliance will take place to ensure that this position is maintained and improved.

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7 CARE QUALITY COMMISSION’S QUALITY AND RISK PROFILE

looking at apparent is

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YTD 12/13

RS A 3 396 % 91.0 ▼ 91.4 ▲ 87.5 ■ 91.0 ■ 91.4 ▲ 90 90 =>90 <90

RB K 20 372 No variation

Any variation

RO H 8 396 %No

variationAny

variation

RB H 20 743 Score 60 Base 83 ▲ 70 80No

variationAny

variation

RO D 8 372 No.No

variationAny

variation

RO H 8 743 No variation

Any variation

RS H 9 % 99.7 ■ 99.8 ■ 99.8 ■ 99 100No

variationAny

variation

RS H 9 % 99.6 ■ 100 ▲ 99.8 ▼ 98 98No

variationAny

variation

RS H 10 743 % Comply ComplyNo

variationAny

variation

RO H 88 %No

variationAny

variation

RO D 176 No variation

Any variation

RO H 176 No variation

Any variation

RO H 8 396 % 70 90No

variationAny

variation

RS H 3 743 % 68.2 ▲ 63.6 ▼ 64.9 ▲ 66.4 ▲ 66 80No

variationAny

variation

RO H 11 44 % 70 90No

variationAny

variation

RO H 8 396 % 67.9 ▲ 67.6 71.6No

variationAny

variation

RO H 8 372 No. 58 ▲ 58 ■ 60 ▲ 63 ▲ 60 65No

variationAny

variation

RO H 8 372 % 47 ▼ 55 ▲ 57 ▲ 60 ▲ 48 53No

variationAny

variation

RS H 10 372 % 55 Base 55 Base 80

RO H 12 372 %

RO H 11 44 Score 91 ■ 95.5 ▲ 91.5 ▼ 90 90No

variationAny

variation

RO H 11 88 No 75 Base 71 ■ 81 ■ 75 75No

variationAny

variation

RO H 11 132 %

RO H 11 132 %

RS H 49 Submit Data

Submit Data

No variation

Any variation

RS H 13 73 % Derive Base

Derive Base

No variation

Any variation

RS H 13 122 % Derive Base

Derive Base Met Not Met

RS H 12 147 % Submit Data

Submit Data

No variation

Any variation

92.3

•

Comply with audit •

•→

→

→

→

Trust

→

→

→ Data Submitted

Data Submitted

Q1 Base Audit Complete

EFFECTIVENESS OF CARE

Acute CQUIN

Mortality Review

Met Q2 req'sMet Q1 req'sDementia

→Met Q1 req'sDementia Met Q2 req's

Met Q2 req's

Met Q2 req's

Met Q2 req's

→ Met Q2 req's

→

→

→

91.4*

••→Compliant

Compliant

•

→

Comply with audit

→

→

Trust

→

SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST CORPORATE DASHBOARD - OCTOBER 2012

Exec Lead PATIENT SAFETY

Trust

To Date (*=most recent month)

TARGET

Community CQUIN

October

City

June AugustJuly

Compliant

Compliant

Safety Thermometer

Reducing Avoidable Pressure Ulcers

Data Submitted

Met Q1 req's

Reducing Avoidable Pressure Ulcers

Data Submitted

→

Compliant

Trust Trust

11/12 Outturn

10/11 OutturnNote

THRESHOLDS12/13 Forward

Projection

September

City S'wellS'well

92.4

Compliant

→

Compliant

→

→ Data Submitted

99.8

→

→

→

→

•→

Comply with audit

Compliant

Compliant

•Compliant

Meeting Q3 req's

66.4

→

••

Compliant

11

Nutrition and Weight Management

→

→ 99.8

•

Compliant

83

Comply with audit

•

Data Submitted

Comply with audit

•

→

Safe Surgery - Operating Theatres

Compliant

Data Submitted

Community CQUIN

66.9

Compliant

Met Q2 req's

Data Submitted

Compliant •

743

Acute CQUIN

Safety Thermometer → Monthly data collection

Monthly data collection

→

→ →

Meeting Q3 req's •

Met Q2 req's

→

•

Baseline established

•

Q2 Return Submitted

81

Baseline established

63

→

→→

→

→

→

Q2 Return Submitted

Q2 Return Submitted

Q2 Return Submitted

→

→

→

→

→

→

•

•

Q2 Return Submitted

91 (H'son) & 80 (L'wes)

Base data being captured

Base data being captured

Base data being captured

Base data being captured

→ →

→

→

→

Q2 Return Submitted •

→ Baseline established

→ Baseline established

Baseline established

•

•

Q2 Return Submitted

→

Acute CQUIN End of Life Care

→→

Q1 Data Submitted

→

→

→

→

Net Promoter

Personal Needs

→

→

→

→

•

Q2 Return Submitted

Neonatal - Discharge Planning / Family Experience and Confidence

Every Contact Counts - Smoking

•

Net Promoter

67.9

→

Pt. (Community) Exp'ce - Personal Needs

Every Contact Counts - Alcohol

Clinical Quality Dashboards

Neonatal - Hypothermia Treatment

91.5

Q1 Data Submitted

→

→

•60→

→

•

••

Stroke Care →

Data Submitted

Appropriate Use of Warfarin

VTE Risk Assessment (Adult IP)

→

→ Compliant

→ Compliant

→

→

→ Met Q2 req's

CompliantQ1 Base Audit Complete

Compliant

→

Specialised Commissioners

Q1 Data Submitted

Q1 Data Submitted

→ →

→

→

→ Baseline established

→

→

Community CQUIN

→

→

b

b

b

Smoking Cessation

HIV - Optmum Therapy

→

→

→

→

Every Contact Counts

PATIENT EXPERIENCE

→

Data Submitted

Compliant

Compliant

Nutrition and Weight Management

Antibiotic Use

Data Submitted

→

Compliant

Safe Surgery - Other Areas

8 CQuINs

Tabled paper

9.1 Safety Thermometer

CQUiN for 2012/13 – requires introduction of the tool in acute and community in patient areas. CQUiN

Conducting monthly whole Trust census of patients for 4 harm events (falls, pressure damage, CAUTI and VTE) continues to go well with good engagement of nursing staff. Work has commenced to add other harm measures to the tool, eg avoidable weight loss.

The SHA ambition is for Trusts to achieve 95% harm free care.

Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-13 90.48% 91.12% 94.75% 93.74% 93.55% 93.79% 93.43% 91.52%

Figure 1: Harm free care trend

9 PATIENT SAFETY

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Figures 2 & 3: Number of patients by type and number of harm incidents11 | P a g e

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Acute Divisions 18 patients experienced 1 harm. No patients experienced 2, 3 or 4 harmsCommunity Division 6 patients experienced 1 harm and 0 patients experienced 2, 3 or 4 harms

a) Falls

There are no formal targets set for falls for 2012/13 other than the safety thermometer but we will continue to aim to reduce avoidable falls across the Trust by a further 10%. Our audits will continue to monitor risk assessment compliance, appropriate use of care bundles and numbers of falls. Falls with injury continue to be reported as adverse incidents and TTRs conducted.

0.00

2.00

4.00

6.00

Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12

Sandwell Hospital City Hospital Trust Total

Figure 4: Incidence of falls per 1000 bed days across Acute Inpatient Divisions

Sandwell continues to have a higher number of falls compared to City.

b) Pressure Damage

Target 2012/13: Eradication of all avoidable pressure damage SHA Priority and CQUiN.Target to assess patients for risk, introduce appropriate care bundle and conduct TTRs on all grade 3 and 4 sores.

0

25

50

75

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2009-2010 2010-2011 2011-2012 2012-2013

Figure 5: Number of hospital acquired pressure damage Grade 2, 3 & 4, April 2009 - July 2012

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New avoidable pressure ulcers (reported on ST): October – 9 (7 grade 2, 2 grade 3, 0 grade 4).

Heel sores continue to account for the largest number of hospital acquired sores associated with TeD stockings, slipper socks and plaster casts. A ‘Happy Feet’ campaign has now launched.

Accountability meetings have been established with the Chief Nurse where Matrons and Ward Managers are called to account for every grade 3/4 hospital acquired avoidable sore.

c) VTE Risk Assessment

The VTE Risk Assessment CQUIN target continued from 2011/12. Performance of at least 90% each month is required to trigger payment. Early data for October indicates performance of 91.4%, just above the required threshold of 90% CQUiN

9.2 Nutrition/Fluids

Target 2012/13: Reduction of avoidable weight loss in patients on 8 Trust wards where vulnerable adults are nursed. CQUiN90% patients MUST assessed within 12 hours admission Internal Priority

Summary of Nutrition Audits (Sept 2011-Oct 2012)

75%

80%

85%

90%

95%

100%

105%

Sep-11

Oct-11

Nov-11

Dec-11

Jan-1

2

Feb-12

Mar-12

Apr-12

May-12

Jun-1

2Ju

l-12

Aug-12

Sep-12

Oct-12

Month

Perc

enta

ge

MUST @ 12hrs MUST @ 7 days `R@R’ onBed Plan Food Diary Fluid Bal Chart

Figure 6: Nutrition Audit Results

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Tabled paper9.3 Infection Control

Targets 2012/13: C difficile – 57 cases (post 48 hours, using SHA testing methodology)(National Priority MRSA – 2 cases (post 48 hours)Local contract) MRSA Screening – 85% eligible patients

Blood culture contaminants – 3% or lessE Coli and MSSA – Continue to record and TTR device related infectionsNational cleanliness standards – 95%

MRSA

There were no post 48 hour cases of MRSA reported in October.

MRSA Screening

Target: 85% eligible patients by March 2013. The MRSA screening data has been excluded from reporting until clarification has been achieved.

Clostridium difficile

0

10

20

30

40

50

60

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Sandwell City Threshold (cumulative) Trust Total (cumulative)

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 TotalSandwell 1 0 1 0 2 1 2 7City 2 1 1 2 4 1 3 14Trust 3 1 2 2 6 2 5 0 0 0 0 0 21Intermediate Care 0 0 0 0 0 0 0 0DoH Trajectory 5 5 5 5 5 5 5 5 5 4 4 4 57Trust Total (cumulative) 3 4 6 8 14 16 21 21 21 21 21 21 -Threshold (cumulative) 5 10 15 20 25 30 35 40 45 49 53 57 -

2012-2013

Figure 7: SHA Reportable CDI

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0

2

4

6

8

10

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Sandwell City

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 TotalSandwell 3 2 2 5 4 2 5 23City 4 4 4 2 8 2 4 28Trust 7 6 6 7 12 4 9 0 0 0 0 0 51Intermediate Care 0 0 0 0 0 0 0 0Trust Total (cumulative) 7 13 19 26 38 42 51 51 51 51 51 51 -

2012-2013

Figure 8: Trust Best Practice Data

Blood Contaminants

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

01/2009 04/2009 07/2009 10/2009 01/2010 04/2010 07/2010 10/2010 01/2011 04/2011 07/2011 10/2011 01/2012 04/2012 07/2012 10/2012

Percentage Possibly Contaminated

Model Data City Model Data Sandwell

Figure 9: Blood Contaminants

E Coli Bacteraemia

0

5

10

15

20

25

30

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Sandwell City Trust Total (cumulative)

Figure 10: E Coli Bacteraemia

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Tabled paperMSSA

0

5

10

15

20

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Sandwell City Threshold (cumulative) Trust Total (cumulative)

Figure 11: MSSA

Outbreak and Other Infection Control Activity

Newton 4 was closed on 29th September because of diarrhoea and vomiting. A cause for this outbreak has not been identified. The ward re-opened on 24.10.12 following a decant to Newton 2 to allow a full deep clean and application of hydrogen peroxide vapour.

D11 was closed on 22nd October because of 5 patients with diarrhoea and/or vomiting. No infectious cause has been identified for this outbreak and the ward has now re-opened following a decant to D20 to allow deep clean and application of hydrogen peroxide vapour.

D17 was closed on 20th October because of diarrhoea and vomiting. The cause for the outbreak has been confirmed as norovirus. The ward decanted to D20 to enable a full deep clean and application of hydrogen peroxide vapour and D17 re-opened on 12th November.

Leasowes was temporarily closed 20th-25th October because of symptoms of diarrhoea and vomiting. No infectious cause has been detected for the majority of patients; however, one patient was found to have CDI. This strain has been identified as identical to another patient idenitified with CDI at Leasowes, making this a CDI outbreak by definition. An outbreak meeting has been organised for 16th November.

PEAT

National Standards of Cleanliness average scores 96%.

9.4 Maternity

The Obstetric Dashboard is produced on a monthly basis. Of note:

Post Partum Haemorrhage (PPH)(>2000ml): there were 3 patients recorded to have had a PPH of >2000ml in September.

Adjusted Perinatal Mortality Rate (per 1000 babies): the adjusted perinatal mortality rate for September was 7.9 which was just under the trajectory (8) but was slightly higher than the previous

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Tabled papermonth. Perinatal mortality rates must be considered as a 3 year rolling average due to the small numbers involved and the significant variances from month to month.  

Caesarean Section Rate: the number of caesarean sections carried out in September was 21.4%, which is below the trajectory of 25% over the year and lower than the previous month.

Delivery Decision Interval (Grade I, CS) >30 mins: the delivery decision interval rate for September was 15% which is on trajectory (15).

Community Midwife Caseload (bi-monthly): The community midwife caseload in September decreased to 139 from 142 in the previous month, which is just below the trajectory of 140.

Vacancies: Vacancy rates remained high in September (11.6).

9.5 Emergency Department highlights

A separate report is provided for the Trust Board this month.

9.6 Safeguarding

Safeguarding adults and children is managed via a Trust Committee structure chaired by the Chief Nurse. Key points reported at the September Committee:

70% of Trust staff have now had a CRB within the last 3years Mandatory Training is broadly on track Learning Disability Project Plan agreed. PMR issues now resolved. Project plan for ‘Refusal of Treatment’ presented but requires wider consultation. Domestic Homicide plan presented and agreed. The Board should note that every DH

investigation that is now required by the Safeguarding Boards is very resource intensive and as a Trust we are likely to see approx. 6 – 12 every year.

The Committee noted the removal of the domestic violence advisor post (Sandwell) from the Community Safeguarding Team (non Trust staff). This will impact on training capacity and advise within HV, Maternity and the ED’s. Concerns have been formally raised with the CCG/LA/Safeguarding Board.

The Trust has served notice to the CCG for the SLA for the Community Safeguarding Children team and intends to bring into the Trust.

9.7 Health Visiting

The recent review of the Health Visiting Service by Sustain on behalf of NHS West Midlands recognised several areas of strengths. In particular:

Level of integration with other services in the 18 months of being part of the Trust

The workforce plan is the best scoping document in the Black Country in relation to the actions required in ‘a call to action’

Staff ambassadors providing an extra dimension to engagement

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Tabled paper Listening into action as a method of staff engagement

Restorative supervision being rolled out to the whole team by November 2012

Leadership Development across all band 7s and now offered to band 6’s

Professional leadership and professional forums in place

The priority recommendations from the review included further deliverables around:1. Staff & Workforce – Communication and Engagement Staff Communication Systems2. Staff & Workforce – CPT & Student Wellbeing & Support CPT Capacity3. Users & Partners – Commissioning Framework & Outcomes Service Specification4. Defining the Service Offering – Universal & Universal Partnership Plus Development

of the Service Offer

The review was beneficial to get an external objective measure of progress and it complements the planned activity in the Directorate IDP and the Health Visiting Workforce Plan.

To ensure that the service continues on its planned trajectory for delivering the Sandwell and West Birmingham Health Visiting Model, we have taken the opportunity to develop an all inclusive project plan as a pragmatic operational tool to inform our future activities. This also identifies key interdependencies and potential barriers to success and creates plans to overcome these.

The Health Visiting plan for increasing HV numbers is on track within the Trust. We are fully established and training numbers are in excess of our requirements for the next year.

9.8 Medicine Management Target Baseline June August September October

% of patients with documented drug allergy status on chart 97% 91.7% 94.6% 95.0% 95.4% 92.80%

% of patients with documented stop/review date 95% 73.7% 77.1% 74.7% 78.9% 81.80%

% of patients with documented indication on drug chart 95% 8.8% 13.1% 51.6% 49.2% 66.90%

% of patients compliant with abx guidelines 90% 86.0% 87.5% 96.2% 94.7% 96.10%

Figure 12: Results of drugs storage audits

Drug storage audits have been carried out in September for general drugs and controlled drugs. For general drug audits a lower level of compliance has been seen compared to the August results.For controlled drugs an improvement has been seen. General Drugs

Compliance of 90-100% was seen across 65% of standards (37% in September) Compliance of over 70% was seen across 95% of standards (70% in September)

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Tabled paper Controlled Drugs

Compliance of 90-100% was seen across 67% standards (57% in September) Compliance of over 70% was seen across 81% of standards (81% in September)

Use of antibiotics – Antimicrobial Stewardship

The CQUIN target relating to antimicrobial prescribing has three elements – improving our score for antimicrobial stewardship using the Department of Health Self-Assessment Toolkit, performing quarterly audits of antimicrobial prophylaxis in general surgery and trauma & orthopaedic patients, and a two monthly point prevalence survey of antimicrobial prescribing in all inpatients.

This report relates to the point prevalence survey, which gathers data on:

Percentage of patients with allergy status recorded on the drug chart;Rationale: allergy status recording and documentation is a key patient safety initiative. A blank allergy status box on the drug chart should be the exception, rather than the rule.

Percentage on antibiotics;Rationale: There will always be patients on antibiotics, but limiting unnecessary prescribing will help to maintain this percentage to the minimum.

Percentage on IV antibiotics;Rationale: while this can be influenced by case mix and severity of infection, Trust guidelines recommend oral antibiotics for the majority of infections, so this percentage should remain stable, or decline over the course of the year.

Percentage on IV antibiotics for greater than 48 hours;Rationale: a high proportion of patients on IV antibiotics for more than 48 hours may indicated a delay in reviewing the need for and appropriateness of IV antibiotics, which are inconvenient for the patient, require additional nursing time to prepare and administer and can cost up to 20 times more than an equivalent oral dose.

Percentage on antibiotics for more than 5 days;Rationale: Trust guidelines on duration of therapy should be followed, and a high proportion of patients on antibiotics for more than 5 days may indicate inappropriate durations of therapy and failure to review patients.

Percentage with stop/review date documented on drug chart;Rationale: The trust ‘Management of Antimicrobial Therapy’ policy and guidance from the Department of Health specify that all antibiotic prescriptions must have a stop or review date documented on the drug chart, to limit unnecessary antibiotic consumption.

Percentage with indication documented on drug chart.Rationale: The trust ‘Management of Antimicrobial Therapy’ policy and guidance from the Department of Health specify that all antibiotic prescriptions must have the indication documented on the drug chart, so that all members of the healthcare team are clear why the patient is taking antibiotics so there is no barrier to discontinuing them if they are not required.

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Figure 13: Results of point prevalence survey

Data is collected by ward pharmacists on all inpatient wards at City and Sandwell hospitals, using a standardised data collection form, and information from the drug chart and the medical notes. A baseline assessment was undertaken in March and April 2012, and will be repeated monthly thereafter. The data presented below represent the average of the two data points and form the baseline results from which performance over the remainder of the financial year will be assessed. The October position is summarised in the table below.

Indicator SWBH City Sandwell Baseline CQUIN target

Number of patients 558 282 276 -% with allergy status documented

92.8% 89.5% 96% 91.7% >97%

% on antibiotics 27.6% 29.8% 25.4% 30.8%% on IV antibiotics 14.5% 14.5% 14.5% 14.6%% on IV antibiotics for more than 48 hours

60.5% 63.4% 57.5% 61.4% Maintain at baseline level

% on antibiotics for >5 days

9.7% 11.7% 7.6% 9.7%

% with stop/review date documented on drug chart

81.8% 83.3% 80.0% 77.1% >95%

% with indication documented on drug chart

66.9% 64.3% 70.0% 8.8% >95%

% with antibiotics in line with guidelines

96.1% 95.2% 97.1% 87.5% >90%

*excluding neonatal unitFigure 14: Baseline results from medicines management audit

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Tabled paper

Agreement was reached with Sandwell PCT with regard to the acceptable thresholds for these point prevalence surveys. It was agreed that 97% of patients (excluding neonates) should have their allergy status documented on the drug chart. As a trust, this is not being achieved, and the position in September (92.8%) has worsened August (95.4%), and is only marginally better than the baseline of 91.7%. This decline in performance was mainly driven by poor results at City, where the percentage of allergy status recording dropped below 90%.

The percentage of patients on antibiotics (27.6%) is well below the baseline, which was the same as the result in September (30.8%%), while the percentage of patients on intravenous antibiotics almost the same as baseline (14.5% versus 14.6%). There has been a slight increase in the percentage of patients on IV antibiotics for more than 48 hours compared to September (60.5% versus 58.9%), but it is marginally below the baseline figure of 61.4%. The percentage of patients having more than 5 days of antibiotics has declined compared to September (9.7% versus 10.9%), and remains the same as baseline.

Compliance with recording of stop or review dates continues to improve, with the data for October (81.8%) showing improvement over September (78.9%%) and also the baseline assessment (77.1%).

Recording of the indication for antibiotics on the drug chart is almost at 67% for the trust, which continues to improve since the baseline assessment of 8.8%.

Compliance with the trust guideline needs to be achieved in ≥90% of antibiotic prescriptions; this was achieved both at City and Sandwell.

9.9 Never Events

There were no Never Events reported in October 2012.

9.10 National Patient Safety Agency (NPSA) alerts

1. Overdue alerts: NPSA 2011/PSA001 – Safer spinal (intrathecal) epidural and regional devices. This alert will continue to remain as “ongoing” on the Central Alert System until all of the components we require to safely convert to the new neuraxial devices are available. We have been advised that the manufacturer will not have these ready until June 2013 at the earliest.

2. New alerts: No new alerts have been received.

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Tabled paper

9.11 Lessons Learned

The key to a positive safety culture within the organisation is to learn from incidents through sustainable actions. Below are some of these actions taken or being taken following serious incident investigations.

Incident Extract from Action PlanMissed opportunity to rescue a deteriorating patient.

Sepsis trolley available on assessment unit Specific shift leader identified for each shift Further work reinforcing escalation triggers for medical review or

EMRT Increased out of hours consultant cover

9.12 Significant Risks

Significant risks are presented on a monthly basis at the Risk Management Group (RMG). These risks are being proposed for inclusion onto the corporate risk register.Existing risks on the Corporate Risk Register are currently being reviewed and presented to the Quality & Safety Committee in October and November 2012.One risk was presented for inclusion on the Corporate Risk register from Critical Care Services regarding risks related to unit capacity.

9.13 ‘Listening into Action’

To ensure a smooth transition from Datix to the Safeguard Incident reporting system, for community staff, work is progressing to ensure that all of the departments and reporting lines are correct.

9.14 Nurse Staffing Levels

The data for nurse staffing ratios is not available this month.

Bank & AgencyThe Trust’s nurse bank/agency rates are detailed in the tables below and show year on year comparison from 2008/9 to date. Notably we are now using more nurse bank/agency than we have for the past 4 years.

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Tabled paper

0

1000

2000

3000

4000

5000

6000

7000

8000

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2008 - 2009

2009 - 2010

2010 - 2011

2011-2012

2012-2013

Figure 15: Total Bank & Agency Use Nursing April 2008 –date.

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Tabled paper

10.1 Mortality

CQUIN TargetAs part of the Trust’s annual contract agreement with the commissioners the Trust has agreed a CQUIN scheme with an end year target to review 80% of hospital deaths within 42 working days.

During the most recent month for which data is available (September) the Trust reviewed 66.4% of deaths compared with a trajectory for the period of 66.0%.

The value of this CQUIN for 2012 / 2013 is approximately £743K.

Figure 16: Mortality review results

HSMR (Source: Dr Foster)The Hospital Standardised Mortality Ratio (HSMR) is a standardised measure of hospital mortality and is an expression of the relative risk of mortality. It is the observed number of in- hospital spells resulting in death divided by an expected figure.

The Trusts 12-month cumulative HSMR (95.5) remains below 100, and remains lower than that of the SHA Peer (100.2), with both Trust and SHA (Peer) HSMR within 95% statistical confidence limits. The in-month (July) HSMR for the Trust has reduced to 85.5 and remains within statistical confidence limits (See Mortality table and graph below).

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10 CLINICAL EFFECTIVENESS

Tabled paperHSMR (Source: Healthcare Evaluation Data (HED))For comparison the Trust HSMR for corresponding 12-month cumulative periods, derived from the UHBT Healthcare Evaluation Data (HED) Tool is included. The HSMR for the most recent 12-month cumulative period remains stable at 96.5. HED data is subject to continued rebasing.

Summary Hospital – Level Mortality Indicator (SHMI)The SHMI is a national mortality indicator launched at the end of October 2011. The intention is that it will complement the HSMR in the monitoring and assessment of Hospital Mortality. One SHMI value is calculated for each trust. The baseline value is 1. A trust would only get a SHMI value of 1 if the number of patients who die following treatment was exactly the same as the number expected using the SHMI methodology. SHMI values have also been categorised into the following bandings.

1 where the Trust’s mortality rate is ‘higher than expected’2 where the trust’s mortality rate is ‘as expected’3 where the trust’s mortality rate is ‘lower than expected’

Further SHMI data was published on 23/10/12 for the period April 11 – March 12. For this period the Trust has a SHMI value of 0.97 and was categorised in band 2.

10 trusts had a SHMI value categorised as ‘higher than expected' 16 trusts had a SHMI value categorised as ‘lower than expected' 116 trusts had a SHMI value categorised as ‘as expected'

May June July

Internal Data:

Hospital Deaths 146 126 121

Dr Foster 56 HSMR Groups:

Deaths 129 111 100

HSMR (Month) 89.2 89.7 85.5

HSMR (12 month cumulative) 88.3 96.4 95.5

HSMR (Peer SHA 12 month cumulative) 93.3 101.3 100.2

Healthcare Evaluation Data - HSMR (12 month cumulative) 96.8 97.0 96.5

Figure 17: Mortality statistics

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Tabled paper

Figure 18: HSMR/Readmission rate

Note In the graph above it should be noted that last month there was a sharp rise shown both for our Trust and also for our SHA peers. This is because the scores have been rebased and does not indicate a deterioration in performance.

CQC Mortality Alerts received in 2012/13No new alerts have been received.

Dr Foster generated alerts (RTM)A new diagnoses group is alerting with significant variation in terms of mortality when the data period September 2011 – August 2012 is considered (see table below). The alert concerns the primary diagnosis grouping of ‘Pulmonary Heart Disease’. The alert has been discussed at the Mortality & Quality Alerts Committee (MQuAC). The majority of cases have already been reviewed under the Mortality Review System (MRS). The remaining cases will be reviewed and a report discussed at the next meeting of MQuAC.

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Tabled paper

Figure 19: Mortality in hospital diagnoses

National Clinical Audit Supplier – Potential Outlier AlertsThe Trust has not been notified of any new outlier alerts.

10.2 Patient Related Outcome Measures (PROMs)

Further provisional data in the form of experimental statistics was published on 13/11/12 for the 2011/12 financial year and also for the period April 12 to June 12 for the current financial year. Details of the Trust’s performance will be presented to the Governance Board in December and further information will be provided in the next Quality Report.

10.3 Clinical Audit

Clinical Audit Forward Plan 2012/13The Clinical Audit Forward Plan for 2012/13 contains 83 audits that cover the key areas recognised as priorities for clinical audit. These include both the ‘external must do’ audits such as those included in the National Clinical Audit Patient Outcomes Programme (NCAPOP), as well as locally identified priorities or ‘internal must do’ audits.

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Tabled paper

Status Total0 - Information requested 3

1 - Audit not yet due to start 92- Significant delay 2

3- Some delay - expected to be completed as planned 94- On track - Audit proceeding as planned 44

5- Data collection complete 106- Finding presented and action plan being developed 17- Action plan developedA - Abandoned

23

Grand Total 83

The status of the audits that have been included in the plan as at the end of October is shown in the table above. A further 2 audits have been indicated as having been abandoned. These audits are not being run nationally in 2012/13 (National COPD Audit & Multiple Sclerosis Sentinel Audit).

10.4 Compliance with the ‘Five Steps for safer surgery’

Compliance with the “Five Steps to Safer Surgery” process is reported using the Clinical Systems Reporting Tool (CSRT).

The reported compliance with the 3 sections in the checklist for October 2012 is shown in the table below.

Trust performance (source QMF Dashboard- CDA)

“Five Steps to Safer Surgery” Reported complianceOctober 2012

Completion of the 3 sections of the checklist only 99.5%

All checklist sections and brief 93.5%

All checklist sections completed and brief & debrief 81.7%

The WHO Checklist Steering Group continues to meet monthly. Work is in progress to carry out qualitative reviews focussing on the culture of patient safety in areas where interventions take place. A communication plan has been drawn up and in under constant updating. Focus is on improving completion of the debrief section of the 5 steps. The group also looks at if there are lessons to be learned where any incidents have occurred where a WHOCL could be used.

A communications plan has been developed and is monitored by the group monthly.

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Tabled paper

10.5 Stroke care

Performance against the principal stroke care targets to which the Trust is working in 2012/13 is outlined in the table below.

Indicator July Aug Sept Target

Pts spending >90% stay on Acute Stroke Unit 85.1 ▼ 88.9 ▲ 87.2 ▼ 83%

Pts admitted to Acute Stroke Unit within 4 hrs 64.0 ▼ 68.7 ▲ 65.1 ▼ 90%

Pts receiving CT Scan within 24 hrs of arrival 94.0 ▲ 93.8 ▼ 100 ■ 100%

Pts receiving CT Scan within 1 hr of arrival 51.3 ▼ 53.1 ▲ 61.5 ▲ 50%

TIA (High Risk) Treatment <24 h from initial presentation 57.1 ■ 80.0 ■ 71.4 ▼ 60%

TIA (Low Risk) Treatment <7 days from initial presentation 58.3 ■ 82.5 ■ 84.2 ▲ 60%

KEY TO PERFORMANCE ASSESSMENT SYMBOLS

▲ Fully Met - Performance continues to improve

■ Fully Met - Performance Maintained

▼ Met, but performance has deteriorated

▲ Not quite met - performance has improved

■ Not quite met

▼ Not quite met - performance has deteriorated

▲ Not met - performance has improved

■ Not met - performance showing no sign of improvement

▼ Not met – performance shows further deterioration

10.6 Treatment of Fractured Neck of Femur within 48 hours

The Trust has an internal Clinical Quality target whereby 70% of patients with a Fracture Neck of Femur receive an operation within 24 hours of admission. Provisional data for October indicates 85.7% of patients with a Fractured Neck of Femur received an operation within 24 hours of admission, resulting in a year to date performance of 72.7% Internal Priority

10.7 Ward Reviews

The ward reviews will be reported in December.

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Tabled paper

10.1 Patient Survey Results

11.1 Net Promoter

The Trust overall Net Promoter Score (NPS) increased by 3 to 63 making progress towards the SHA target of 65 - the CQuIN requires a 10 point improvement on the baseline of 55 by March 2013. CQUiN % returns have increased with the use of iPADS – weekly reports to the SHA has commenced.

SHA ambition requires both the improvement on score plus weekly reporting.

Friends and Family Test Survey (Net Promoter) Summary Results Dashboard – September 2012

FFT 1

SW BH - Net Promoter Scores

70

60

50 55 57 58 58

40

30

20

60 63

1 0 0

8 0

6 0

4 0

2 0

Com parison of Ne t Promoter Scores from Ne ighbouring Trusts - Septem ber 2012 (Th is comparison does not take into acc ount loc al patient d if f erenc es , e.g. demographic s )

63 63 77 76 70 64 68

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12

SWBH - Net Promoter Scores (NPS) March 2013 Target NPS: 65

0 UHB NHS SWBH NHS Dudley NHS Wolv erhampton

NHS

W alsa ll NHS Hear tlands NHS Combined

Cluster Region

The Trust NPS has shown steady improvement to reach 63 (+3) in Sept 2012

The Trust is making steady progress towards its target. (Note: Other Trusts have different target levels).

Trust Net Promoter Scores and Survey Returns % SWBH September 2012: Breakdown of Net Promter Responses

6% 70 60 55

50 40

57 58 58 60 63

24

26 %

30 20 12 11 10

10 0

19 18 68%

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12

NPS Survey re tu rn s

The Trust maintained a good survey response rate attributed to use of Ipads on the wards for feedback collection.

Promoters Passives Detracto rs Ward Action Plans to target the ‘Passive’ group to convert into ‘Promoters’ which can improve NPS dramatically.

Figure 20: Net Promoter position

Resources have now been identified to expand the Patient Experience Team which will enable a more robust and co-ordinated approach to improvements in patient experience and bringing patient experience to the Trust Board.

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11 PATIENT EXPERIENCE

Tabled paper

11.2 Complaints/PALS

a) Complaints and PALS data

i) Complaints: Table A sets out the complaints data for October 2012 with reference to previous months where relevant.

A) Table A: number of complaints received and sent

MONTHComplaint type:

RECEIVEDComplaint type:

SENTFirst

contact*Link*2 TOTAL First

contact*Link*2 TOTAL

July 2012 62 4 66 42 3 45Aug 2012 77 10 87 58 3 61Sept 2012 55 5 60 81 11 92Oct 2012 62 12 74 97 19 116

*First Contact complaint: where the Trust’s substantive (i.e. initial) response has not yet been made.

*2Link complaint: the complainant has received the substantive response to their complaint but has returned as they remain dissatisfied/or require additional clarification.

Failsafe parameters

The failsafe parameters identify those complaints which breach a prescribed period of days considered the maximum acceptable time for the Trust to respond in the context of the risk grade of the complaint (see Risk Grade2 above). These complaints comprise the ‘complaints backlog’.

The failsafe parameters for 1 April 2012 onwards comprise: 60 days for red; 70 days for amber and 20 days (fast track) or 90 days for yellow and green grade complaints.

There is a commitment to ensure that all cases currently over their “failsafe” date have been investigated and a final response sent to the complainant.

At the time of this report the position is as follows:

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Tabled paperWeek ending

Friday….Total

responses sent

Total backlog responses

sent

Total Backlog count

(failsafe target breaches)

09/11/12 24 12 5216/11/12 45 27 4723/11/12 26 19 27

Figure 21: Progress with completing backlog complaints

b) Complaints and PALS data

ii) PALS

Contacts and general enquiries: In October 2012 PALS recorded 188 PALS enquiry contacts and 189 general enquiry contacts, in comparison to September 2012 where PALS recorded 148 PALS enquiry contacts, and 194 general enquiry contacts. The general informal enquiries are not captured on the PALS database but relate to enquiries taken at the PALS reception desk.

Chart A provides a breakdown of the themes identified via PALS contacts in October 2012. The main categories reported during the month of October 2012, were issues relating to Clinical Treatment. PALS received 40 enquiries this month in comparison to 35 reported during September 2012. These relate to queries, comprising the categories of clinical care, low staffing levels, and medicines. In addition, issues relating to a delay in the following: investigations, results, surgery, treatment and x-ray/scan.

During October 2012, there has been a slight increase in the number of appointment enquiries where 21 enquiries were received during September 2012, and 25 during October 2012. Appointment enquires relate to appointments cancelled, delay, notification and time.

There has been an increase in the number of formal complaint issues which comprise the categories of handling, advice, process, referral and response time from 34 enquiries reported during this month, in comparison to 26 enquiries during September 2012.

CHART A – Breakdown of top 10 issues

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Tabled paper

a) Parliamentary and Health Service Ombudsman (PHSO) cases

The NHS Complaints Procedure comprises 2 stages. The first or ‘local resolution’ stage involves the Trust investigating the complaint and providing a substantive response to the complainant. Where the complainant remains dissatisfied with the Trust’s response given at the local resolution stage, the complainant can progress their complaint to the second stage, that is, referral to the Parliamentary and Health Service Ombudsman (PHSO). The PHSO provides a service to the public by undertaking independent investigations into complaints that the NHS has not acted properly fairly or has provided a poor service.

The Trust currently has 6 active cases with the PHSO.

11.3 End of Life

End of Life Report

Targets/Metrics: CQuIN 10% increase in number of patients achieving preferred place of death who are on a supportive care pathway – Acute and Community. This is also a national nursing high impact action and nurse sensitive indicator. The target for this year is 53%.

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PALS Enquiries September/October 2012

050

100150200250

Admission/Discharge/Tra...

Appointments

Attitude of staff

Clinical treatment

Communication

General enquiry

Personal records

Property and expenses

Formal complaints

PALS informal enquiries

SeptemberOctober

Tabled paper

Preferred Place of Care/Death of Patients on SCP (Joint CQUIN)

36%48% 47%

60%57%

55%

0%10%20%30%40%50%60%70%

April May June July Aug Sept Oct Nov Dec

Month

% o

f Pat

ient

s on

SC

P

Figure 22: Preferred place of death/death of patients on SCP

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Target 53%

Tabled paper

The Board is asked to note key headlines from the workforce dashboard for October 2012.% Trust

Mandatory Training 85.06% (85%)PDR 68.2% (85%)Turnover (leavers) 8.57%Sickness absence 4.31% (3.5%)

The Trust Board is asked to:

NOTE in particular the key points highlighted in Section 2 of the report and DISCUSS the contents of the remainder of the report.

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13 RECOMMENDATION

12 WORKFORCE QUALITY

Tabled paperAPPENDIX 1

Glossary of AcronymsAcronym Explanation

CAUTI Catheter Associated Urinary Tract InfectionC Diff Clostridium DifficileCRB Criminal Records BureauCSRT Clinical Systems Reporting ToolCQC Care Quality CommissionCQuIN Commissioning for Quality and InnovationED Emergency DepartmentDH Department of HealthHED Healthcare Evaluation DataHSMR Hospital Standardised Mortality RatioHV Health VisitorID IdentificationLOS Length of StayMRSA Methicillin-Resistant Staphylococcus AureusMUST Malnutrition Universal Screening ToolNPSA National Patient Safety AgencyOP OutpatientsPALS Patient Advice and Liaison ServicePHSO Parliamentary and Health Service OmbudsmanRAID Rapid Assessment Interface and DischargeRTM Real Time MonitoringSHA Strategic Health AuthoritySHMI Summary Hospital-level Mortality IndicatorTIA Transient Ischaemic Attack (‘mini’ stroke)TTR Table top reviewUTI Urinary tract infectionVTE Venous thromboembolismWards:

EAUMAUDLNPA&EITUNNU

Emergency Assessment UnitMedical Assessment UnitDudleyLyndonNewtonPrioryAccident & EmergencyIntensive Therapy UnityNeonatal Unit

WHO World Health OrganisationWTE Whole time equivalentYTD Year to date

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