1

West Suffolk Hospital NHS Trust

Report To: Trust Board

Date: November 2011

Title: Quality and Performance Report

Report of: Nichole Day, Executive Chief Nurse

Gwen Nuttall, Chief Operating Officer

2

Introduction

This Quality and Performance Report provides the narrative for performance in three key areas: Quality priorities, CQUIN performance and local issues requiring escalation. It should be read in conjunction with the Ward and Trust dashboards.

The layout of this report identifies performance data followed by themes identified during the analysis process and actions being taken. The ward quality report summary has been used to highlight wards that have a number of red scores and these are discussed within the report.

3

1. To further reduce hospital acquired infections

Aim: To reduce hospital acquired MRSA bacteraemia to no more than 2 cases and C. difficile infection to no more than 29 cases between April 2011 and April 2012

There were no cases of MRSA bacteraemia during October. There was one case of MSSA bacteraemia.There was 1 case of clinically significant hospital acquired C. difficile during October.In respect of compliance with the High Impact Interventions (HII), all interventions scored 100% except peripheral cannula ongoing care that scored 97%. This was due to 60% performance on G4 (2 x VIP scores not recorded) and 80% performance on F12 (1 x VIP score not recorded). This has been discussed with the ward managers and sample size will be increased from 5 patients to 10 patients this month. Hand hygiene compliance was 100%.

Isolation audit of the 32 siderooms available (capacity increased by 1 sideroom due to F7,following refurbishment, increasing from 3 to 4 siderooms) identified that 29 were used for Infection Control purposes and only 3 were not. This is a vast improvement on previous months and may reflect the introduction to the sideroom data collection tool of a final column which reflects the high risk patients requiring isolation, identifying this within IPT and to the bed management team. According to the criteria agreed at Implementation group, there was only 1 patient deemed high risk who was not isolated. The high risk patient had been previously isolated in a sideroom but on transfer to another ward was placed in a bay. This patient whilst MRSA positive on admission, subsequently had 3 negative MRSA screens which under national definitions would deem them to have low or nil carriage. 

4

1. To further reduce hospital acquired infections Aim: To improve the management of antibiotics by achieving 100% compliance with antibiotic policy

Compliance with antibiotic policy dropped to 83% in October. (7 out of 36 patients received non-guideline/unauthorised antibiotic treatment ,namely oral or intravenous Co-amoxiclav). Co-amoxiclav was used instead of the recommended Piperacillin/Tazobactam in a small number of patients with urinary sepsis or pneumonia and in two instances without microbiological indication

In terms of trend analysis, it is more helpful to review performance on a quarterly basis rather than monthly as the audits measure compliance in different areas each month.

Actions taken:•These results will be fed back to the individual ward Consultants, Ward Managers and Pharmacists. •The Antimicrobial Management Group discussed the issues relating to co-amoxiclav at its meeting on10 th November. It was agreed to review inclusion of the antibiotic for specific infections as part of the Formulary review and to provide further education to junior doctors who are on rotation from Trusts where this antibiotic is used as part of the formulary.•Dr Soliman (Antibiotic Lead) will meet with Mr O’Riordan to discuss further actions.•Friday 18th November was European Antibiotic Awareness Day; the Antibiotic Audit nurse had an information stand in Time Out promoting the antibiotic guidelines and offered guidance on how to use the new antimicrobial prescribing page on the drug chart correctly.

5

 

2a) To achieve the highest levels of patient safetyAimsi) To assess at least 98% of admissions for risk of VTE ii) Provide prophylaxis to 100% patients at risk

VTE assessment performance/ issues and actions

Compliance with risk assessment was 98.84% for October which was above the target of 96%.

The target for prophylaxis compliance was achieved.

6

Patient Falls The CQUIN ceiling is 147 falls in Quarter 3 with further reductions required in Quarter 4. The total number of falls in October was 51 which was just over the trajectory. The highest falls occurred on G1, G5 and G4 (7,8 and 8 respectively). Significant numbers of falls have been seen in clinical areas this month which do not normally have any patient falls- G1 (7), CCS (2), DSU (1) and F12 (2).

G1 had a high number of falls. This was due to a number of factors:•1 patient fell 3 times. This patient was aggressive as a result of his medical problem and difficult to prevent falling as he could walk independently and refused help.•2 independent patients fell while mobilising- one had been assessed as able to walk alone with a walking frame by the physiotherapist and then fell and one lady lost her balance.•1 patient, sitting on the edge of her bed, had a pain spasm and fell off the bed.•1 patient with confusion was found kneeling by her bed, it is unclear if she fell or knelt down.

Actions

The falls clinical leads met to analyse the data for October and develop an action plan:• A number of falls are related to toilet needs in confused patients. Although we offer the toilet to these patients every 2 hours, in consultation with Suffolk Community Health’s continence service, we are changing the “offer toilet” to “take to toilet” as patients with dementia may not recognise the questioning or concept of being offered the toilet. A visual reminder may be more effective and prevent them getting up to go to the toilet unaccompanied. The dementia team is working to develop more meaningful occupation during the day for patients with dementia so they are less likely to wander and fall.•MDT discussions with AHP leads to discuss how they can support improved performance.•Implementing a real-time falls “counter” so we understand our performance in real-time and can challenge clinical areas.•Training programme for falls prevention in specific ward areas relevant to patient group..

2b) To achieve the highest levels of patient safety Aim: To reduce the number of patients who fall in hospital by 35% in the last quarter of 2011/12

:

Pressure Ulcers

5 patients developed ward acquired pressure ulcers this month:

•1 patient developed a Grade 3 sacral pressure ulcer on G1. The RCA will take place on 22nd November and will determine whether this was avoidable/unavoidable according to the agreed definition.

•4 patients developed Grade 2 pressure ulcers, 1 on F6, G1, G3 and F7.

•The patient on F6 had a condition which prevented position changes. This was classified this as avoidable and discussions have taken place at ward level to learn from this.

•The patient on G3 was very high risk of developing pressure ulcers. All care was provided as planned, therefore this is considered unavoidable.

•The patient on F7 was very high risk of developing pressure ulcers. His position was not changed as frequently as prescribed therefore we have considered this avoidable.

•The patient on G1 was very high risk; emaciated with poor peripheral Perfusion and all care was given as planned. This was therefore classified as unavoidable

The nursing and medical directorate are currently reviewing the tissueviability team establishment and considering the potential of an SLA withSuffolk Community Healthcare to deliver pressure area support and advice.

7

2c) To achieve the highest levels of patient safety

Aim: To reduce the number of avoidable Grade 3 and 4 pressure ulcers by 80% in the last quarter of 2011/12

8

3a/b) To continuously improve the experience of patients using our servicesAims: At least 90% of patients would choose to use the hospital again. To achieve at least an 85% satisfaction rating in our internal patient experience surveys

Question sets

The new survey system is becoming established and the majority of wards have been given a target of achieving at least 20 responses per month initially. Generally, wards have achieved this number, apart from F7 where there were problems with the tablet device. As reported last month, the analysis of the question relating to call bell responses has changed and has resulted in lower scores for all wards this month and all wards are flagging red/amber for this question. This is discussed in more detail in the “Issues for Escalation” section of this report. Despite this, the overall inpatient satisfaction score is 88% and 95% of patients would choose to use the hospital again in similar circumstances. A breakdown by question is provided overleaf.

The results of the short stay and outpatients department questionnaire indicate that the overall level of satisfaction is 96% with 99% of patients choosing to use the hospital again.

Each ward’s data is reviewed at the Matron’s performance meeting and individual action plans set for any areas scoring red/amber. Any ward that has >4 red scores will be escalated through this report.

The SHA have indicated that they are planning to standardise the wording of the “recommender” question to facilitate direct comparisons across the East of England. This may result in the need for changes in our Trust recommender question in the future.

9

3a/b) To continuously improve the experience of patients using our servicesAims: At least 90% of patients would choose to use the hospital again. To achieve at least an 85% satisfaction rating in our internal patient experience surveys Survey results

10

Environment and Cleanliness

Overall Trust score was 92% and all clinical areas scored greater than 85% except recovery who scored 83%.

Recovery’s score was: Housekeeping 84%, Nursing 87.5% and Estates 75%. This will be addressed at the Patient Environment Action Group.

3c) To continuously improve the experience of patients using our services

11

Aim: To consistently achieve a Hospital Standardised Mortality Ratio that is below the expected rate

HSMR remains well below the expected level as can be seen by the overall mortality shown in the graph and the table giving a mortality rate for the five Dr Foster - How Safe is Your Hospital indicators. This table provides information on relative risk, with red, blue and green traffic lighting. Blue indicates that the score is within the standard deviation.

4a) To achieve optimal clinical outcomes and effectiveness

 

National Rate from last

reporting period

Jul 09-Aug 10

Aug 09-Sep 10

Sep 09-Oct 10

Oct 09-Nov 10

Nov 09-Dec 10

Dec 09-Jan 11

Jan 10-Feb 11

Feb 10-Mar 11

Mar 10-Apr 11

Apr 10-May 11

May 10-June 11

June 10-July 11

July 10-Aug 11

Rolling 12 Month HSMR-All Admissions - 87.8 86.3 84.6 84.1 80.3 81 79 79.3 76.9 76.3 76.3 84.8 83.6

Rolling 12 Month HSMR-Non Elective - 88.1 86.7 84.8 84.2 80.3 81.1 79.1 79.4 77.1 76.4 76.4 85 83.9

SMR Stroke (Acute Cerebrovascular Disease)

86.2 88.7 88.6 84.2 84.4 79.7 80.5 75 78.1 74.3 74.2 74.2 76.5 77.8

SMR - Heart Attack (AMI) 90 89.4 82.4 78.5 77.9 81.8 94.1 82.5 79.6 77.7 71.1 71.1 69.7 67.7

SMR - FNOF 81.6 60.7 62.9 66.2 66.9 67.4 65.9 64.2 64.3 64.1 62.4 62.4 88.7 76.4

Mortality from Low Risk Conditions 0.84 0.53 0.49 0.44 0.49 0.45 - - 0.55 0.6 0.51 0.51 0.52 0.57

12

4b) To achieve optimal clinical outcomes and effectiveness

Patient Reported Outcome Measures (PROMS)

There is a national requirement to collect PROMS information for four procedures currently and this is expected to expand to cover additional procedures in the coming year. Information is collected from patients through a health questionnaire before and after their procedure. This is analysed nationally. The results are provided in the form of funnel plots which indicate the position of the Trust’s patients in comparison to the national picture. Whilst there have been small variances both positively and negatively from the previous years scores, there are within the normal range expected and not statistically significant.

Knee Replacement Hip replacement

13

4b) To achieve optimal clinical outcomes and effectiveness

Patient Reported Outcomes Measures (PROMS) continued

Groin Hernia Varicose veins

14

4c) To achieve optimal clinical outcomes and effectivenessStroke Indicators

15

Performance TargetsStroke

Stroke performance was mixed in October, with the lowest proportion of patients admitted to a stroke ward in 4 hours since the beginning of April. This was due to the high volume of strokes in the hospital and admitted to the hospital in October. All stroke beds on ward G8 were full and patients had to be admitted to EAU for an initial period, until discharges occurred on the stroke ward.

The Trust did not achieve the access to urgent and 24 hr brain scan. All cases are reviewed with the clinical teams to ensure appropriate escalation in future cases.

Choose and BookThere has been a prolonged problem with the reporting on the % of patients who are referred for an outpatient appointment being able to choose a named consultant team.This has been due to the national reporting system not being able to identify the Department of Health Guidance ( DoH Gateway 15616) that there are clear exceptions. These include 2 week wait referrals, joint clinics, urgent referrals. The clinics which are exempt from the guidance have been agreed with NHS Suffolk and the Trust will not be subject to penalty clauses as they are content that the Trust has all appropriate services/ clinics indentified with a name clinician and therefore achieving the expected requirements.

16

Performance Targets contBreast Length of Stay

The Trust has reported below target performance for several months on Breast Length of stay. The clinicians involved in the delivery of service believe that they are achieving the 80% target for all breast patients staying less than 24 hours. An audit into the coding and correct use of admission method for breast surgery patients has identified that there are errors in what has been recorded for patients on the Trust’s PAS system. This has led the trust to show erroneous day case rates for Breast surgery patients. This should be correct by the November performance report.

Cancer 2 Week Waits

The recording of individual patients on cancer monitoring requires validation for national returns within 25 working days. This relates to GP rapid access referrals and other cancer standards. The validation involves completeness and accuracy checks against all data items, which include checks for armed services and prison referring details and other patient information, such as availability. There are clear guidance rules in the Cancer Waiting time guidance for GP deferrals for unavailable patients and the Trust always follows this information. This has previously been audit by the internal audit team within the access policy.

Workforce Performance

Performance has been above target on:-

Sickness absence

Turnover

Disciplinary investigations completed within 8 weeks

Recruitment timescales

CRB checks

Is should be noted that – All staff have an up to date PDP 0 on going action plan and there is a separate report for mandatory training

17

FallsThe number of falls across the Trust has increased significantly in October and this hasbeen addressed within the report.

Ward areasG1 has seen a significant drop in performance this month which will be addressed at the medical directorate performance meeting. This was related to a particularly challenging patient casemix during that period.

Patient ExperienceWard surveysG5 and F7 both have 4 or more red scores on their patient experience surveys this month. Both ward managers have been asked to ensure that they are undertaking walkabouts during visiting times, to proactively talk with patients and relatives alike to ensure they are having a positive experience whilst at WSHT.The senior matron/nursing directorate are also doing three times/week patient safety rounds on F7 to ensure that clinical performance is at the standard required.

Noise at Night

The data now demonstrates that the noise at night disturbances result from other patients. Some noise is generated from usual patient noise when sleeping in a room with 5 other patients i.e. snoring, getting up to use the toilet, oxygen, alternating pressure mattresses. However, the majority of noise results from patients with dementia or delirium and is represented by the lowest scores in the areas with the highest numbers of these patients (F3, G5, G4 and F7). The dementia trainer plans to spend some time on the wards at nighttime to understand the issues and make recommendations for improved practice. This will also be discussed at the next dementia standards meeting.

Local issues requiring escalation

18

FallsThe number of falls across the Trust has increased significantly in October and this hasbeen addressed within the report.

Ward areasG1 has seen a significant drop in performance this month which will be addressed at the medical directorate performance meeting. This was related to a particularly challenging patientGroup during that period.

Patient ExperienceWard surveysG5 and F7 both have 4 or more red scores on their patient experience surveys this month. Both ward managers have been asked to ensure that they are undertaking walkabouts during visiting times, to proactively talk with patients and relatives alike to ensure they are having a positive experience whilst at WSHT.The senior matron/nursing directorate are also doing three times/week patient safety rounds on F7 to ensure that clinical performance is at the standard required.

Noise at Night

The data now demonstrates that the noise at night disturbances result from other patients. Some noise is generated from usual patient noise when sleeping in a room with 5 other patients i.e. snoring, getting up to use the toilet, oxygen, alternating pressure mattresses. However, the majority of noise results from patients with dementia or delirium and is represented by the lowest scores in the areas with the highest numbers of these patients (F3, G5, G4 and F7). The dementia trainer plans to spend some time on the wards at nighttime to understand the issues and make recommendations for improved practice. This will also be discussed at the next dementia standards meeting.

Local issues requiring escalation

19

Patient Experience

Call Bell response time

The weighting of the responses to this question has been updated to reflect the weighting in the national patient survey. This only gives credit for full compliance if the call bell is responded to immediately, whilst the Trust standard has been response within 3 minutes. The issue of analysis of this question will be discussed at the Patient Experience Committee on 22 nd November, as there are options regarding the weighting of the different responses. The actual response times for call bells for the wards with the new call bell system is starting to become available through the IT department. This demonstrates that the average response time is under 3 minutes in the five wards where the system is used (F3, F4, F5, F6, and G3). However the breakdown, currently available only for F3 and F6, demonstrates a variation in the percentage of patients waiting over 3 minutes as can be seen by the pie charts below.

Local issues requiring escalation

Local Priorities - Governance Dashboard

20

Indicator Performance target R A G Oct 11 Commentary

National safety alerts

Number of NPSA alerts beyond national implementation deadline

>=5 1-4 0 3 See next slide

Timely completion of Red incident investigations and action

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

>=1 0 2 Two RCAs missed the 45 day deadline having been rescheduled a number of times to ensure all relevant parties could attend.

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

Timely reporting of SIRIs to NHS Suffolk

SIRIs 2 day report beyond timeframe >=1 0 0 The three SIRIs reported in October had the relevant reports submitted within the required timescale

SIRIs 7 day report beyond timeframe >=1 0 0

SIRIs 45 day reports beyond timeframe >=1 0 0 The two SIRI 45-day reports due in October were both submitted within the agreed timescales

Risk assessments

Active risk assessments in date <75% 75 – 94% >=95% 95%

Outstanding actions in date <75% 75 – 94% >=95% 96%

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

>9 4 - 9 0 - 3 4 There are four outstanding TA business cases waiting for clinicians input, this reduction follows improvement in clinicians engagement with pharmacy. Six TAs are waiting for final completion and sign off, including costing figures before submission to PCT. This has been escalated Executive level. IPGs have been reduced to four, but CGs are still at nine. The CE&A Manager will work with clinicians to produce self assessments and action plans against each outstanding CG.

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

>9 4 - 9 0 - 3 4

CG (Clinical guideline) baseline assessments beyond agreed deadline timeframe

>9 4 - 9 0 -3 9

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

<75% 75 – 89% >=90% - 99% at the end of Q2

Complaints Response within 25 days or negotiated timescale with the complainant

<75% 75 – 89% >=90% 86% Three complaints were responded to outside the agreed timescales. This is a reflection of the increased number of complaints received this financial year; as well as the complexity of some of the complaints that require input from more than one specialty.

Complaints resolved with first written response <75% 75 – 84% >=85% 88%

Red complaints actions beyond deadline for completion >=5 1-4 0 0

Number of PALS contacts that became formal complaints >10 6 - 9 <=5 2

Local Priorities NPSA alerts beyond national implementation deadline issued by the Central Alerting System (CAS)

There are three NPSA alerts beyond the deadline for implementation:

NICE/NPSA/PSG/2007/001 - Technical Patient Safety Solutions for Medicines Reconciliation on admission of adults to hospital

SPN/2008/014 - ‘Right Patient, Right Blood’

PSA/2009/004 - Early identification of failure to act on radiological imaging reports

A review of the status of other Trusts in the region on the CAS website found that all had signed off compliance with PSA004 and all but one with SPN014.

Medicines Reconciliation

PSG001 was jointly issued with NICE and the information on other Trusts’ compliance is not available on the CAS website, however at least two other Trusts in the Eastern region have not signed compliance with the wider remit of the CQC Outcome 9 – Medicines Management, in part due to their problems with implementation of Medicines reconciliation. A paper was presented to TEG in November providing a summary of the current medication reconciliation activity and a review of options available to increase this activity. Medication reconciliation is being considered in the Clinical Support Directorate business planning process for 2012/13.

Right Patient, Right Blood

This requires identified staff to have one or more of four competencies. There are a number of issues causing problems with implementation which are (in brief):

a)Identification of who needs the competencies and limitations of OLM in respect of this

b) Undertaking the competency assessments due to the huge number of assessments required and the availability of staff time for completion of these

c) Recording a) and b) on OLM and follow up of staff who are ‘out of date’. The reporting and follow up process has been hindered by inaccuracies of data and limited resources to up date OLM .

Radiological imaging

The Trust policy PP203 Results Validation has been updated from the 2008 version to document a process which will allow the Trust to declare compliance with the NPSA alert once the policy has been agreed and implemented (including audit). This will also provide compliance with the NHSLA criterion 4.4 Diagnostic Testing procedures. The policy has been issued for consultation but not finalised and approved yet.

Local Priorities Patient Safety Incidents resulting in harm

(including Serious harm) and Serious Incidents requiring investigation (SIRIs)

The overall rate of incidents resulting in harm has shown a decrease in the last month to 82. The number of serious incidents is 2. The number of SIRIs reported in October was 3.

Three incidents have been reported as a SIRI in October:

Themes from SIRIs:

The incident which involved a patient who fractured a neck of femur involved a senior staff nurse whose decision to leave the ward at this time is currently being reviewed within the HR process.

The second incident identified an underlying lack of understanding by a number of staff of when to put a patient on the pre-eclampsia toximia (PET) protocol even though the patient fitted the criteria with 3 consecutive raised BP readings.

The third incident involved a patient who was palliative, but who suffered a Grade 3 pressure ulcer. The concise RCA indicates that the patient required significant encouragement to both reposition and use the equipment available to her due to the terminal stage of her condition. A full RCA is being scheduled.

Local PrioritiesPatient Safety Incidents reporting to NPSA National Reporting and Learning Service (NRLS)NRLS analysis of the period October 2010 – March 2011 shows that WSH has a reporting rate of 4.4 per 100 admissions, which is in the bottom 25% of reporting rates for our small acute peer group. In the previous six months the rate was 4.7 per 100 admissions. A Trust with high reporting rates captures more of the lower grade incidents which can act as an alert for issues / problems prior to a more serious incident occurring.

The graph shows the number of patient safety incidents (including near miss and no harm) for the period Nov 10 – Oct 11. The ‘Median’ line shows the number of incidents required to be reported (to the NRLS) to be the median Trust for incidents per 100 admissions in the small acute Trust category (6.2 based on the Oct 10 – Mar 11 dataset).

There is a downward trend in reporting of incidents overall from April onwards with no discernable cause.

The second axis of the graph shows the percentage of incidents leading to serious harm (as a % of all reported incidents including ‘no harm’ and ‘near miss’). The axis is set from 0% to 10% to clearly demonstrate fluctuations month on month. The percentage of incidents leading to serious harm (major or catastrophic) was been identified as a concern. Since April a senior review of all incidents in these categories (and those categorised as moderate) is being undertaken weekly to ensure accuracy of level of harm grading. This has led to a drop in this category from April onwards with the exception of September.

The Trust is piloting a new proforma for completion at the end of the RCA to ask (amongst other things) whether the outcome to the patient occurred directly as a result of failings in care, coincidental to any failings in care (or unable to conclude either way). This will allow the downgrade of some ‘Red’ incidents before submission to the NRLS.

24

Local Priorities

Complaints

Complaints response within agreed timescale with the complainant: 86% of responses due in October were responded to within the agreed timescale (target 90%). Three complaints were responded to outside the agreed timescales. There is an increase in the number of complaints received this financial year; as well as the complexity of some of the complaints requiring input from more than one specialty.

Of the 24 complaints received in October , the breakdown by Primary Directorate is as follows: Medical (5), Surgical (11), Clinical Support (3), Women & Child Health (5) and Facilities (2).

Trust-wide the most common problem areas are as follows: - Communication & information 11- Aspects of clinical care 10

This breakdown reflects an expected distribution - Attitude of staff 6 across the categories. - Appointment delay/cancellation (outpatients) 4

- Admission / Discharge /Transfer arrangements 3

(Please note that more than one category can be allocated to each complaint so the total number of problem areas does not correlate with the total number of complaints). 

All actions identified from Red complaints are currently within deadline for completion. 

25

Local Priorities

PALS (Patient Advice & Liaison Service)

The revised PALS database system has now been commissioned and data will be collated to correspond with the categories for formal complaints.

A comparison of the number of enquiries dealt with for January to October 2011 is given in the chart and a synopsis of enquiries received for the same period is given below.

The PALS Manager continues to deal with requests for information which can vary from clarification of hospital procedure to specific details about treatment given; future care plans; outcome or length of time waiting for results of tests and discrepancies about diagnosis and/or discharge arrangements.  

A number of queries also relate to appointment dates and length of time waiting for these; as well as the length of time waiting in clinics. The PALS Manager has received a number of queries as a result of contractual changes between the PCT and Ambulance Service for patients transport arrangements. This is reflected in the numbers of contacts indicated below.  The PALS Manager frequently helps to improve communication between the Trust and patients’ family members both in this country and abroad.  Any issues which are not able to be dealt with by PALS are directed, if appropriate, to the formal complaints process. 

The very nature of the PALS service requires responses to queries, concerns or complaints to be dealt with expediently.  A Target of 80% for responding fully (completing the enquiry) within 48 hours has been set and will be monitored. with immediate effect. Evidence of compliance with this target will be submitted after three months data has been collected. 

Trust-wide, the most common five contacts with the PALS Manager are: Communication/Information (oral or written) 30All aspects of clinical treatment 18Attitude of staff 13Transport (ambulances and other) 11Appointments (delays / cancellations) 11