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Quality Report Alan Sheward - Director of Nursing & Workforce

April 2015 - Month 1

Version control

Target YTD

TargetPrevious Year

2015/162014/15

p13 National 0 0 Apr-15 0 0 0 2 1

p13 National 7 1.05 Apr-15 2 0 2 23 14

No N/A N/A N/A Apr-15 0 0 0 1 3

No N/A N/A N/A Apr-15 1 0 1 1 17

p14 N/A N/A N/A Apr-15 38 - 38 670 548

p15 N/A N/A N/A Apr-15 1.0557 - - - - -

p32 N/A N/A N/A Apr-15 3 - 3 10 90

Local 10% 0 Apr-15 5 10 5 152 129

N/A N/A - Apr-15 19 0 19 429 425

N/A N/A - Apr-15 18 0 18 294 100

Local 10% 64 Apr-15 83 64 83 1402 859

Local 10% 4 Apr-15 3 4 3 47 50

Local 10% 0 Apr-15 1 0 1 13 3

No N/A N/A - Apr-15 29 - 29 162 60

Local 10% 16 Apr-15 13 16 13 270 217

Local 10% 0 Apr-15 0 0 0 6 4

p19 Local 10 Apr-15 20 10 20 328 162

20 Local 11 Apr-15 33 11 33 425 254

No Local 50% 1 Apr-15 2 1 2 38 22

Local 10% 16 Apr-15 17 16 17 286 216

Local 69 Apr-15 92 69 92 1205 920

N/A - - Apr-15 234 - 234 3551 3713

N/A - - Apr-15 26 - 26 569 -

p12 National 0 0 Apr-15 6 0 6 59 1

p25 N/A Apr-15 7 - 0 112 - -

No National 95% 95% Apr-15 99% 95% 99.2% 98.3%

Consultant lead Outpatient appts p35 Local 10% 1618 Apr-15 2314 1871 2314 30919 24945

p36 Local 10% 334 Apr-15 425 392 425 4750 5223

p33 N/A - - Apr-15 809 - 809 10648 9701

p37 Local 0 0 Apr-15 10 - 10 218 297

p38 N/A 0 0 Apr-15 5 - 5 35 119

No N/A ↑10% 343 Apr-15 269 - 269 3311 3742

Cancelled appointments

Patient satisfaction

Complaints

Concerns

Compliments

Service Group Outpatient appts

Mixed sex accommodation breaches

Chaplaincy visits

Patient discharges recorded as after 23:00 and before 06:00

Venous-Thromboembolism (VTE) Acute contract service users only

Patient moves (Numbers of patients involved) without clinical justification - unvalidated

Contacts (neither complaints nor concerns)

DoLS (Deprivation of Liberty safeguards

National SHMI update (qrtly)

Resulting in Harm (Catastrophic confirmed after investigation)

Pressure UlcersHospital setting (newly developed)

Community setting (newly developed)

Clinical Incidents

Resulting in any harm

Resulting in Harm (Major)

Slips, Trips & FallsResulting in any injury

Resulting in Serious injury

Duty of Candour (Potential and actual incidents reported)

Measure Description Detail page

included

Trustwide

p16

p17

Clostridium difficile cases (Healthcare acquired)

MRSA bacteraemia (Healthcare acquired)

MSSA bacteraemia (Healthcare acquired)

E.Coli bacteraemia (Healthcare acquired)

Mortality

Number of Healthcare cases going to inquest (inquests held)

SIRIs in Month

New SIRIs reported

Number of Ongoing SIRIs

Number of SIRIs closed in month

Number of Inpatient deaths

Deteriorated (grades 2-4) Trustwide

Patient discharges recorded as after 06:00 and before 12:00 (noon)

Isle of Wight NHS Trust Quality ReportApr-15

Main Summary - Trustwide

Monthly

TargetDate

Latest

Data

Performance

trend in

month

Projected

performance if

current trends

continue

p18

p25-28

Curent

YTD

2015/16

Year End

Forecast

2015/16

Local or

National target

of 38

Target YTD

Target

Previous

Year

2015/16 2014/15

Community & Mental Health

p31 Local 4 Apr-15 3 4 3 42 31

MRSA bacteraemia (healthcare acquired) No National 0 Apr-15 0 0 0 0 0

Clostridium Difficile (healthcare acquired) No National tbc Apr-15 0 tbc 0 0 1

E Coli (healthcare acquired) No N/A N/A N/A Apr-15 0 N/A 0 0 4

No National ≥90% 90% Apr-15 78% 90% 78% 84%

No National ≥90% 90% Apr-15 50% 90% 50% 29%

No National ≥100% 100% Apr-15 100% 100% 100% 100%

No National ≤2% 99% Apr-15 11% 2% 11% 7%

Local 10% - Apr-15 3 - 3 80 -

N/A N/A N/A Apr-15 11 N/A 11 189 N/A

Local 10% Apr-15 47 - 47 1058 -

Local 10% Apr-15 0 - 0 25 -

All reported incidents Local 10% Apr-15 100 - 100 1440 -

Local 10% Apr-15 4 - 4 77 -

Local 10% Apr-15 0 - 0 3 -

Local 10% Apr-15 16 - 16 299 -

Pressure ulcers no National Apr-15 34 - 34 463 -

Local 10% - Apr-15 2 - 2 58 51

Local - Apr-15 12 - 12 95 125

N/A - - Apr-15 23 - 23 949 1286

Concerns

Compliments

Slips, Trips & Falls

HCAI

Clinical Incidents


p16Resulting in Harm (Major)


Directorate SummariesMeasure Description Detail

page

included

Local or

National

target

Monthly

TargetDate

Latest

Data

Performance

trend in month

Curent

YTD

2015/16

Year End

Forecast

2015/16

Projected

performance if

current trends

continue

Emergency Readmissions within 30 days (MH areas)

SIRIs in MonthNew SIRIs reported

All grades reported

All slips, trips & falls reported

Resulting in any injury


Complaints

p15


p17Resulting in Serious injury

p24-27

Antimicrobial Stewardship

Overall HAPPI compliance

Prescription to Protocol (DIPPI)

Allergy Status (NAPPI)

Missed doses (NAPPI)

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Target YTD

Target

Previous

Year

2015/16 2014/15

Hospital & Ambulance

p31 Local 75 Apr-15 72 75 72 855 895

MRSA bacteraemia (healthcare acquired) No National 0 0 Apr-15 0 0 0 2

Clostridium Difficile (healthcare acquired) No National tbc Apr-15 2 tbc 2 20

No N/A N/A N/A Apr-15 1 N/A 1 2

No National >99% 99% Apr-15 100% 99% 99.0% 99.9% 99.9%

No

No

No National 95% 95% Apr-15 99% 95% 99.2% 98% 99%

National ≥24% 24% Apr-15 22% >24% 22% 23% 20%

National ≥70% 70% Apr-15 63% 70% 63% 66% 68%

National ≥80% 80% Apr-15 56% >73% 56% 54% 72%

N/A N/A N/A Apr-15 14% N/A N/A 21% 18%

Local 90% 90% Apr-15 94% N/A N/A 90% 91%

N/A N/A N/A Apr-15 44% N/A N/A 60% N/A

Local 90% 90% Apr-15 97% N/A N/A 97% N/A

N/A N/A N/A Apr-15 14% N/A N/A 23% 14%

Local 90% 90% Apr-15 100% N/A N/A 98% -

No National ≥90% 90% Apr-15 89% 90% 89% 91%

No National ≥90% 90% Apr-15 60% 90% 60% 35%

No National ≥100% 100% Apr-15 100% 100% 100% 100%

No National ≤2% 2% Apr-15 4% 2% 4% 3%

Local 10% - Apr-15 2 - 2 74 - -

N/A N/A Apr-15 7 - 7 105 - -

Local 10% Apr-15 35 - 35 941 - -

Local 10% Apr-15 3 - 3 22 - -

All reported incidents N/A N/A Apr-15 307 - 192 2930 - -

Local 10% Apr-15 9 - 9 191 - -

Resulting in Serious injury N/A N/A Apr-15 0 - 0 2 - -

Local 10% Apr-15 36 - 36 124 - -

Pressure ulcers no N/A N/A Apr-15 19 19 290

Local 10% - Apr-15 15 0 15 226 161

- Apr-15 78 - 78 1099 764

N/A - - Apr-15 202 - 202 2477 2332


Complaints

p24-27Concerns

Compliments

p17

All Slips, trips & falls reported

p15

p16

Family & Friends Test

Emergency Dept response rate

No

% who would recommend

Inpatient response rate

%who would recommend

Maternity services response rate

All grades reported

% who would recommend

SIRIs in Month

New SIRIs reported


Clinical Incidents



Slips, Trips & FallsResulting in any injury

Antimicrobial Stewardship

Overall HAPPI compliance

Prescription to Protocol (DIPPI)

Allergy Status (NAPPI)

Missed doses (NAPPI)

Caesarean section rate

p21/22Spontaneous delivery rate

Breast feeding at delivery rate

Emergency Readmissions within 30 days (PBR mix)

Diagnostic waits less than 6 weeks

MRSA Screening Elective admissions

Venous-Thromboembolism (VTE)

Maternity activity

HCAI

MRSA screening policy has changed nationally and previous reporting is no longer applicable.

Reporting under new regulations will commence quarterly at the end of Q1Non-elective admissions

Curent

YTD

2015/16

Year End

Forecast

2015/16

Projected

performance if

current trends

continue

E Coli (healthcare acquired)


Directorate SummariesMeasure Description Detail

page

included

Local or

National

target

Monthly

TargetDate

Latest

Data

Performance

trend in month

of 38

Target YTD

Target

Previous

Year

2014/15 2014/15

Community

N/A N/A N/A Apr-15 33% 30% 33% 42% N/A

Local 90% 90% Apr-15 94% 90% 94% 90% N/A

N/A N/A N/A Apr-15 N/A new report 90%

Local 90% 90% Apr-15 95% new report 90% 95%

Local 10% - Apr-15 3 - 3 71 - -

Local 10% - Apr-15 46 - 46 675 -

Local 10% - Apr-15 0 - 0 21 -

All reported incidents N/A N/A - Apr-15 80 - 80 1150 -

Local 10% - Apr-15 4 - 4 64 -

Local 10% - Apr-15 0 - 0 0 -

All reported slips, trips & falls N/A N/A - Apr-15 14 - 14 271 -

- Apr-15 12 - 12 144 -

- Apr-15 15 - 15 180 -

- Apr-15 0 - 0 37 -

- Apr-15 7 - 7 94 -

Local 10% - Apr-15 1 - 1 22 -

- Apr-15 9 - 9 45 -

N/A - - Apr-15 18 - 18 764 -





Complaints

Concerns

Compliments

Pressure ulcers (includes community wards & external

community)

Grade 1

Grade 2

Grade 3

Grade 4

Clinical Incidents



SIRIs in Month New SIRIs reported

Inpatient response rate (Community wards)

% would recommendFamily & Friends Test

All Community Services

% would recommend


Directorate SummariesMeasure Description Local or

National

target

Monthly

TargetDate

Latest

Data

Performance

trend in month

Curent

YTD

2014/15

Year End

Forecast

2014/15

Projected

performance if

current trends

continue

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Target YTD

Target

Previous

Year

2014/15 2014/15

Mental Health

Local 4 Apr-15 3 4 3 42 82

N/A N/A N/A Mar-15 0.6% new report

Local 90% 90% Mar-15 96% new report

Local 10% - Apr-15 0 - 0 9 -

N/A N/A Apr-15 0 - 0 5 -

Local 10% Apr-15 1 - 1 51 -

Local 10% Apr-15 0 - 0 4 -

All reported incidents N/A N/A Apr-15 20 - 20 290 -

Local 10% Apr-15 0 - 0 15 -

Resulting in Serious injury Local 10% Apr-15 0 - 0 3 -

Local 10% Apr-15 2 - 2 28 -

Local 10% - Apr-15 1 - 1 36 27

- Apr-15 3 - 3 50 43

N/A - - Apr-15 5 - 5 185 207



National

target

Monthly

TargetDate

Latest

Data

Performance

trend in month

Curent

YTD

2014/15

Year End

Forecast

2014/15

Projected

performance if

current trends

continue


Complaints

Concerns

Compliments


All reported slips, trips & falls




Emergency Readmissions within 30 days (MH areas)



Clinical Incidents

Family & Friends testMental Health Services response rate

% would recommend

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Target YTD Target Previous Year

2014/15 2014/15

Hospital

Local 75 Apr-15 72 75 72 855 895

National >99% 99% Apr-15 99.9% 99% 100.0% 99.9% 99.9%

National ≥24% 24% Apr-15 22% >24% 22% 23% 20%

National ≥70% 70% Apr-15 63% 70% 63% 66% 68%

National ≥80% 80% Apr-15 56% >73% 56% 54% 72%

Local 10% - Apr-15 2 3.75 2 74 50

N/A N/A - Apr-15 7 2.625 7 101 35

Local 10% - Apr-15 35 31.725 35 910 423

Local 10% - Apr-15 3 1.2 3 22 16

All reported incidents N/A N/A - Apr-15 186 233.025 186 2880 3107

Local 10% - Apr-15 9 11.25 9 191 150

Local 10% - Apr-15 0 0.15 0 2 2

All slips, trips & falls reported N/A N/A - Apr-15 36 44.175 36 531 589

- Apr-15 6 0 6 83 36

- Apr-15 8 0 8 135 68

- Apr-15 1 0 1 5 10

- Apr-15 4 0 4 54 11

Local 10% - Apr-15 15 - 15 225 158

- Apr-15 75 - 75 1067 739

N/A - - Apr-15 191 - 191 2382 2256


Directorate SummariesMeasure Description

Local or

National

target

Monthly

TargetDate Latest Data

Performance

trend in month

Curent YTD

2014/15

Year End

Forecast

2014/15

Projected

performance if

current trends

continue

Emergency Readmissions within 30 days (PBR mix)

Diagnostic waits less than 6 weeks

Maternity activity

Caesarean section rate

Spontaneous delivery rate

Breast feeding at delivery rate




Complaints

Concerns

Compliments

Clinical Incidents






Pressure ulcers (excludes community wards)

Grade 1

Grade 2

Grade 3

Grade 4

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Target YTD

Target

Previous

Year

2015/16 2014/15

Ambulance

Local 10% - Apr-15 0 - 0 0 2

Local 10% Apr-15 0 - 0 31 5

Local 10% Mar-15 0 - 0 0 0

All reported incidents N/A N/A Apr-15 6 - 6 51 69

Local 10% Apr-15 0 - 0 0 0

Resulting in Serious harm Local 10% Apr-15 0 - 0 0 0

N/A N/A Apr-15 0 - 0 0 0

Local 10% - Apr-15 0 - 0 1 3

- Apr-15 3 - 3 32 25

N/A - - Apr-15 11 - 11 95 76



All Slips, trips & falls reported


Complaints

Concerns

Compliments

Clinical Incidents



SIRIs in Month New SIRIs reported



National

target

Monthly

TargetDate

Latest

Data

Performance

trend in month

Curent

YTD

2015/16

Year End

Forecast

2015/16

Projected

performance if

current trends

continue

of 38

Improvement in SIRIs, Incidents & Falls with harm reported during month


Successes this month

Standardised Hospital Mortality Index continues within expected limits

Continue to show well against nationally published Safety Thermometer indicators

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Pressure injury development levels remain challenging both internally & externally


Challenges this month

2 cases of Healthcare acquired Clostridium Difficile identified during April

Mixed sex accommodation breach event affected 6 patients during April

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Ward dashboard summaryOur inpatient wards and various other departments now have their key indicators displayed publically (as a dashboard screen print) in preparation for interactive screens to

be rolled out later in the year. This is a summary for the month of APRIL that has been aligned to reflect service performance. Further work is continuing to aggregate

totals and some sections (such as Ambulance & District Nursing) do not yet have data contributing to this system. N.B. Activity levels for individual areas are not in this summary although further detail is available on the interactive dashboard to authorised staff. The main FFT returns are now required

for the 12th of each month with Community & Mental Health submissions for the 18th. This means that not all data is available at the time this report is collated. Safer staffing has now

replaced the HR staffing budgets in the leading columns. Gaps are present where Safer Staffing is not yet applied.

Location

Average fill rate -

registered

nurses/midwives

(%)

Average

fill rate -

care staff

(%)

Average fill

rate -

registered

nurses/

midwives (%)

Average

fill rate -

care staff

(%)

Staff

Sickness

Mandatory

Training

Falls with

harm

Pressure

Ulcers

VTE Risk

Assmt

C.

Diff. MRSA

FFT

Survey

Likely to

Recommend

Formal

Complaints Concerns

Community & Mental Health

Mental Health

Afton ward 97% 121% 103% 130% 8% 91% 0 0 n/a 0 0 n/a n/a 0 0

Osborne Ward 106% 143% 125% 132% 1% 88% 0 0 n/a 0 0 n/a n/a 0 0

Seagrove Ward 80% 104% 98% 96% 4% 88% 0 0 n/a 0 0 n/a n/a 0 0

Shackleton Ward 80% 85% 103% 104% 12% 93% 0 0 n/a 0 0 n/a n/a 0 0

Woodlands 101% 100% 105% 88% 9% 83% 0 0 n/a 0 0 n/a n/a 0 0

Community

Community Stroke Rehabilitation Team #N/A #N/A #N/A #N/A 1% 95% 0 0 n/a 0 0 n/a n/a 0 0

Stroke Neuro Rehab 92% 100% 108% 113% 11% 90% 1 0 100% 0 0 n/a n/a 0 3

General Rehab and Step Down Unit 114% 81% 177% 98% 5% 92% 1 0 100% 0 0 n/a n/a 1 1

Poppy Unit 75% 101% 77% 102% - - 0 0 100% 0 0 n/a n/a 0 0

District Nursing #N/A #N/A #N/A #N/A 7% 78% 0 0 n/a 0 0 n/a n/a 0 1

Hospital & Ambulance

Medical

Cardiac Investigation Unit #N/A #N/A #N/A #N/A 0% 82% 0 0 n/a 0 0 n/a n/a 0 0

Chemotherapy Unit #N/A #N/A #N/A #N/A 1% 91% 0 0 n/a 0 0 n/a n/a 0 0

Colwell Ward 115% 86% 103% 100% 2% 80% 2 3 100% 1 0 n/a n/a 1 1

Emergency Department #N/A #N/A #N/A #N/A 3% 81% 0 2 n/a 0 0 n/a n/a 3 6

MAAU 82% 67% 103% 92% 1% 89% 1 2 99% 0 0 n/a n/a 1 1

Respiratory Department #N/A #N/A #N/A #N/A 1% 86% 0 0 n/a 0 0 n/a n/a 0 1

Surgical

ENT #N/A #N/A #N/A #N/A 0% 72% 0 0 n/a 0 0 n/a n/a 0 0

Mottistone Ward 94% 101% 102% - 17% 85% 1 0 100% 0 0 n/a n/a 0 0

St Helens Ward 108% 111% 105% 100% 2% 85% 2 2 99% 0 0 n/a n/a 0 1

Whippingham Ward 101% 92% 108% 102% 3% 70% 1 3 97% 0 0 n/a n/a 0 4

Crititcal care

Intensive Care Unit 78% 108% 86% 83% 4% 91% 0 2 100% 0 0 n/a n/a 0 0

Coronary Care Unit 76% 94% 91% 130% 5% 84% 0 0 100% 1 0 n/a n/a 0 0

Endoscopy

Endoscopy Unit #N/A #N/A #N/A #N/A 6% 87% 0 0 n/a 0 0 n/a n/a 0 0

Theatres

Main Theatres #N/A #N/A #N/A #N/A 7% 74% 0 0 n/a 0 0 n/a n/a 0 0

Day Surgery Unit #N/A #N/A #N/A #N/A 9% 75% 0 1 100% 0 0 n/a n/a 0 0

Maternity Services 96% 102% 101% 100% 3% 83% 0 0 95% 0 0 n/a n/a 0 3

Neonatal Intensive Care Unit 88% 89% 100% 96% 4% 88% 0 0 n/a 0 0 n/a n/a 0 0

Orthopaedic Unit

Orthopaedic Unit 108% 99% 100% 97% 4% 71% 2 1 100% 0 0 n/a n/a 2 7

Childrens

Paediatric Ward 86% 100% 82% 112% 3% 79% 0 0 n/a 0 0 n/a n/a 0 0

Pathology

Phlebotomy #N/A #N/A #N/A #N/A 6% 94% 0 0 n/a 0 0 n/a n/a 0 0

Maternity

0

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Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total

2014/15 0 0 0 0 0 0 4 0 0 6 0 0 10 10

2015/16 6


Mixed Sex Accommodation

Measure

Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position

Mixed sex accommodation breaches 0

Reconfiguration and upgrade to MAAU area on ground floor is continuing as planned Director of Nursing & Workforce May-15 In progress

Root cause analysis and review has been completed Director of Nursing & Workforce CompletedMay-15

Commentary

During April there was a single event of mixed sex accommodation on Day 8 of the Black Alert status period which was made to avoid 12 hours breaches during the high

pressure on admission beds. Day surgery unit was actually being used as a ward at this time and the Black Alert continued for a further day.

A total of 6 patients were involved as the accommodation was a 6-bedded bay. The staff continued to support the principles of single sex accommodation which is to ensure

privacy and dignity for all patients affected with use of curtains and support to use toilets in single sex areas. Actions were put in place to ensure privacy and dignity was

maintained and the patients were moved as soon as possible but the breach did continue over 24 hours.

There is a direct financial penalty for each breach of £250 and the total penalty for the Trust will be £1500.

There is a continued risk of recurrence whilst we maintain our current bed management practices until such time as the MAAU rebuild is completed (August 2015),

reconfiguration work is completed and more single rooms are available for use.

Actions Responsible job title Date Progress

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Isle of Wight NHS Trust

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

Acute Target 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual 0 0

Highlighted awareness campaign including intranet, posters & automatic screensavers Infection control team &

Communications teamMay-15 Continuing

Increased auditing of commode cleaning on individual wards Ward managers May-15 Continuing


Methicillin-resistant Staphylococcus Aureus (MRSA):

There have been no further cases of Healthcare acquired MRSA identified in the Trust since November 2014.

Healthcare acquired Infections - Trustwide within the hospital environment

Increasing education regarding timely sampling of loose stool events and isolation Infection control team May-15 Continuing

Responsible job title Date Progress Actions

Red = 1 or more MRSA or 2 or more C Diff in rolling 3/12

Amber = No MRSA and 1 C Diff in rolling 3/12

Green = No MRSA and No C Diff in rolling 3/12

Clostridium Difficile (C Diff):

There have been 2 cases of Healthcare acquired Clostridium Difficile identified in the Trust during

April.

Work continues to raise awareness and highlight actions, including intranet and poster campaigns

regarding bowel management with action plans for rapid isolation of suspected cases.

Reconfiguration of ward to facilitate further isolation facilities is ongoing.

It should be noted that patients are admitted with known Clostridium Difficile or MRSA developed in

the community (or in some cases transferred from other Trusts). So far this year there has been 1

patient admission with Clostridium Difficile identified as contracted externally. Apr

May

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Total 2

National Target 1 1 2 2 3 3 4 4 5 6 6 7

0

1

2

3

4

5

6

7

8

Isle of Wight NHS Trust C.Difficile Performance (Cumulative)

All Hospital

April 2015

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2014/15 36 44 47 39 34 42 37 50 48 68 53 50 36 548

2015/16 38 38 38

2014/15 1.9% 2.2% 2.5% 1.8% 1.7% 2.0% 1.6% 2.3% 2.3% 3.4% 2.7% 2.5% 1.9% 2.2%

2015/16 2.1% 2.1% 2.1%

Commentary

The table above shows the raw numbers for Inpatient deaths at St Marys and is a basic indicator of activity. The graph below demonstrates the rate of deaths per 1000

discharges and demonstrates improvement since 2012 when coding changes were implemented. Nationally, there is concern over high numbers of deaths at weekends when

there has been traditionally less staff available and our weekday numbers are now demonstrated below.

The NHS collates hospital data nationally and uses standardised methodology to compare all organisations across the country using the Standardised Hospital Mortality Index

(SHMI) which is published quarterly for retrospective periods. (Included in this report each quarter). Using this system we compare favourably with our local/similar peer group

and are have been graded within the 'Amber' (as expected) rating. The most recent (April 2015) update gives us a current score of 1.056 as detailed on the following page. The

overall number of deaths is lower than last year for this time of year but there is a recent peak in January which is within normal expectations. This peak occurred in October last

year and follows a mild winter with less influenza in the community.

Ongoing audit is starting to demonstrate the percentage of deaths where a Do Not Resucitate decision is recorded on admission and whether an Amber Care Bundle** is in

place. This data is only available retrospectively and currently demonstrates 98% of deaths had DNR during March with 8% on existing Amber care.

** The Amber Care Bundle is an agreed plan of action between patient, carers and healthcare staff when it is recognised that future health improvement is unlikely or uncertain and can extend

for considerable time across periods of deterioration during management of a long term condition. It is not an end-of-life pathway.

The Executive Medical Director recieves monthly reports on Inpatient deaths and investigates any cases of concern. Executive Medical Director May-15 Ongoing


n/aNumber of Inpatient deaths

N.B. These figures refer to admitted patients only and as such do not include stillbirths or patients brought in to A&E who do not survive to admission.


Mortality - (1) Deaths at St Mary's of Admitted Patients

Measure

n/aInpatient Deaths as % of all discharges

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD

00 - 04 yrs 0

05 - 15 yrs 0

16 - 44 yrs 0

45 - 64 yrs 2 2

65 - 74 yrs 5 5

75 - 84 yrs 16 16

85+ yrs 15 15

Sum: 38 0 0 0 0 0 0 0 0 0 0 0 38


Monday 5 5

Tuesday 3 3

Wednesday 6 6

Thursday 9 9

Friday 8 8

Saturday 2 2

Sunday 5 5

Sum: 38 0 0 0 0 0 0 0 0 0 0 0 38

Deaths by weekday YTD

Deaths by age band YTD


00 - 04 yrs 0

05 - 15 yrs 0

16 - 44 yrs 0

45 - 64 yrs 2 2

65 - 74 yrs 5 5

75 - 84 yrs 16 16

85+ yrs 15 15

Sum: 38 0 0 0 0 0 0 0 0 0 0 0 38


Monday 5 5

Tuesday 3 3

Wednesday 6 6

Thursday 9 9

Friday 8 8

Saturday 2 2

Sunday 5 5

Sum: 38 0 0 0 0 0 0 0 0 0 0 0 38

Deaths by weekday YTD

Deaths by age band YTD

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Mortality (2) Standardised Hospital Mortality Index -Quarterly update

Commentary

Most recently published data covers October 2013 to September

2014 and was published at the end of April 2015. The SHMI for

this period is 1.0557, maintaining an amber ‘as expected’ rating of

band 2.

Actions taken such as the 24/7 critical care outreach and The

Prepip project were taken in the second half of 2013 and their

effect is starting to feature in the current data. Another factor is

that the coding of community deaths from patient notes since

January 2014 contributes to a more accurate calculation.

The graph below shows benchmarking against the other NHS

organisations measured with IOW NHS Trust shown in red.

The Executive Medical Director continues to have oversight of mortality figures on a regular basis

and investigates any deemed to be cause for concern.


Executive Medical Director May-15 Continuing

0.7

0.8

0.9

1

1.1

1.2

1.3

Value Upper Control Limit Lower Control Limit

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

RP

AR

XL

RM

PR

P5

RB

DR

GP

RJR

RL

NR

XR

RT

ER

RF

RX

CR

HU

RM

CR

TG

RW

AR

TF

R1

FR

FR

RA

JR

JER

TX

RK

5R

A4

RN

ZR

N7

RF

FR

NA

RB

NR

WE

RT

RR

JCR

Q8

RY

RR

N5

RD

ZR

R7

RC

DR

BT

RG

NR

A9

RN

SR

FS

RV

RR

NQ

RM

1R

D1

RN

LR

JFR

A7

RX

1R

F4

RD

8R

XH

RJN

RD

UR

H8

RG

RR

AP

RH

QR

WJ

RT

KR

XF

RA

XR

1K

RA

2R

QM

RR

VR

KE

IW NHS Trust VALUE

of 38


2014/15 5 11 9 8 3 9 21 14 10 19 15 5 129 129

2015/16 5 0 0 0 0 0 0 0 0 0 0 0 5 5

Total 18 0 0 0 0 0 0 0 0 0 0 0 18 18

In time 8 0 0 0 0 0 0 0 0 0 0 0 8 8

N/A 2015/16 19 19 19

Hospital Ambulance Community MH Corp Total

0

2 2

0

1 1

0

0

C Diff & Healthcare Acquired Infection (death) 0

Safeguarding Vulnerable Adult/Child 0

1 1 20

0

2 0 3 0 0 5

Actions - embedded in policy

Ongoing

Trust Management of SIRIs will be overseen by external monitors at the Trust Development Authority (previously

under SHIP jurisdiction). External monitors May-15 Ongoing

Directorate and Quality Team

leadsMay-15 Ongoing

All reported SIRIs will be assessed on their individual merits to determine whether a full incident review panel is

required to carry out a detailed root cause analysis within 3 days of notification. External monitors May-15

The SIRI will be graded in accordance with the SIRI policy. Initial grading may be changed on investigation.

All Serious Incidents Requiring Investigation follow a set procedure for route cause

analysis and the numbers form part of Clinical Incident reporting.

The Trust SIRI policy document is available here:- http://nww.iow.nhs.uk/guidelines/SIRI%20Procedure%20V2%20FINAL.pdf (not linked)


Serious Incidents Requiring Investigation (SIRIs)Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position

Measure

Total NEW SIRIs reported

Pressure ulcers - Healthcare acquired

Pressure ulcers - Community acquired

Unexpected deaths

Information Governance

Delayed Diagnosis

SIRI type (list not exhaustive)

Responsible job title Date Progress

Number of NEW SIRIs opened during month

Medication issues

10%

? mthly

Number of CLOSED SIRIs during month N/A

Total number of ongoing SIRIs in month (snapshot)

Slips, Trips & FallsVenous Thromboembolism

Other 8

0 0 0 0 0 0 0 0 0 0 0

10

0 0 0 0 0 0 0 0 0 0 0 0

2

4

6

8

10

12

0

2

4

6

8

10

12

14

16

18

20

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

Nu

mb

er

of

ne

w S

IRIs

op

en

ed

Nu

mb

ers

Month

SIRI Analysis Closed in time Out of time

New SIRIs Target new in month

of 38


2014/15 57 55 49 58 57 72 70 71 81 101 82 106 57 859

2015/16 83 83 83

2013/14 4 3 4 4 0 7 2 5 4 6 3 3 4 45

2014/15 3 3 3

2014/15 311 345 337 354 350 375 363 345 358 441 365 377 311 4321

2015/16 307 307 307

12015/16 1

May-15

A regular publication is circulated specifically for Learning Lessons from incidents (both potential and actual)

The winter issue is now available and can be accessed through the internal intranet here:- Clinical Risk & Claims Manager

Completed

monthly

QuarterlyMay-15

PLEASE NOTE:

All incidents with an unverified* grading of Major/Catastrophic are investigated via the 48 hour report/SIRI**

process and final grading is confirmed at the completion of the investigation. No unverified catastrophic

incidents will be included in data above until completion of investigation

Actions Responsible job title

All reported incidents are automatically cascaded via due process to relevant managers and investigated according

to potential and actual severity of event. If applicable, the 48 hour report/SIRI process is instigated.

Lead for Patient Safety, Experience & Clinical

Effectiveness

Commentary

During April 2015 there were a total of 307 clinical incidents reported, of which 83 resulted in harm. 3 of

these incidents met the severity criteria of Major resulting in harm. Incident numbers include cases of falls,

pressure ulcer development, and SIRIs, all of which are reported separately. The Catastrophic incident

referred to above relates to an incident dated November 2014 and has been signed off by the Commissioners

in April 15.

Incidents with harm are also reported via the National Safety Thermometer and results for all contributing

organisations are available nationally on the website :- http://www.safetythermometer.nhs.uk

The National Safety Thermometer is a snapshot audit for benchmarking nationally and currently shows that the Trust

performs well with an average of 96% harm free care against the national average of 93%.

The Trust has an internal 'Incidents' dashboard available to authorised members of staff which gives details of

numbers and types of incident with potential/actual severity score down to service level to facilitate internal

management. This is updated on a daily basis and includes both clinical and non-clinical incidents.

** Serious Incident Requiring Investigation

Date Progress


Clinical Incidents resulting in HarmIndividual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position

Measure

10%

<64 mthly

10%

<3 mthly

n/a

Clinical Incidents Resulting in Harm (All)

Clinical Incidents Resulting in Harm (Major)

Clinical Incidents reported (Total)

Clinical Incidents resulting in Harm(Catastrophic-confirmed after investigation only)

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

0

50

100

150

200

250

300

350


Nu

mb

er

of

rep

ort

ed

clin

ical

inci

de

nts

Month

Incidents resulting in Harm from April 2014

No harm Minor harm Major harm % of discharges with harm

of 38


2014/15 18 9 19 11 14 24 17 18 23 22 18 24 18 217

2015/16 13 13 13

2014/15 0 0 1 0 0 1 0 0 0 1 0 1 3 4

2015/16 0 0 0 0 0 0 0 0 0 0 0 0 0

2014/15 66 51 63 53 58 63 67 72 60 62 68 80 683 763

2015/16 52 0 0 0 0 0 0 0 0 0 0 52 52

A dedicated falls co-ordinator is supporting work toward falls prevention across the Trust in the wider community.

There is currently no dedicated falls co-ordinator working within the acute Trust. Fall Co-ordinator May-15 In post

Responsible job title Date Progress Actions

Commentary

All patient slips, trips and falls within acute, intermediate care and outpatients across the sites are reported and appear on the

Datix reporting system as incidents and are investigated. All patients admitted to St Mary’s are screened for falls risk using a 5

question tool and may be placed on a Falls Care Plan (as per Falls Policy) if appropriate. This screening is repeated weekly, at

ward transfer or if conditions change. Following a fall, whether previous deemed at risk or not, a patient is fully re-assessed and

measures put in place to reduce risk as appropriate. Falls numbers also contribute to the incidents dashboard and, depending

upon severity, could also contribute to the Serious Incident Requiring Investigation (SIRI) numbers. The numbers also contribute

to the National Safety Thermometer snapshot audit for patient harm, which is reported nationally. Numbers of individual incidents

are recorded and a single patient may have multiple falls events during an admission.

During April 15 there were 52 slips/trips/falls reported. Although 13 resulted in Harm, there were no cases (0) where the

harm met the severity criteria of 4 or 5 indicating serious injury.

Work is continuing to relate the number of falls to the occupied bed days to give a better understanding of incidence across the

hospital for reporting. (Currently showing against discharges). Work to understand the relationship between admissions due to

known falls events and falls during admission is underway and will be expanded to look at 'unexpected' falls events. (i.e. to include

patients with no previous falls history).

10%

<16 mthly

10%

<0.3 mthly

All slips/ trips & falls with harm

All slips, trips & falls with serious injury

All reported slips, trips & falls10%

<57 mthly


Falls Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position

Measure

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

0.7%

0.8%

0

10

20

30

40

50

60


% o

f d

isch

arge

s in

mo

nth

Nu

mb

er

of

rep

ort

ed

slip

s, t

rip

s &

fal

ls

Month

Degree of harm by falls from April 2014

No harm Minor harm Significant harm % of discharges with harm from falls

of 38


20% 2014/15 1 4 4 1 2 0 9 4 7 1 5 4 1 42

(3 mthly) 2015/16 6 6

30% 2014/15 6 2 5 5 5 12 4 9 9 10 10 9 6 86

(5 mthly) 2015/16 9 9

50% 2014/15 1 1 0 1 2 2 1 0 1 1 2 0 1 12

(0.5 mthly) 2015/16 1 1

2014/15 1 0 0 3 1 1 0 2 1 1 3 4 1 17

2015/16 4 4

2014/15 12 12 12 23 0 46 23 23 34 0 47 20 254 254

2015/16 NYA NYA NYA NYA NYA NYA NYA NYA NYA NYA NYA NYA 0

The Tissue Viability Nurse continues to support ward staff with recognition and management of patients at risk. Tissue Viability Nurse Specialist May-15 Ongoing


Grade 1 Pressure Ulcer developing in Hospital

Commentary

N.B. Figures for previous months will continue to change as validation occurs during the process of investigation.

Pressure ulcer development contributes to clinical incident numbers and the higher grades contribute to the numbers of Serious Incidents Requiring Investigation. (SIRIs). They also form part of the National

Safety Thermometer snapshot audit scheme which is reported nationally. Further details of the Safety Thermometer are available here. http://www.safetythermometer.nhs.uk

During April there was a slight decrease in reported pressure ulcers in the hospital setting from the previous month across all grades. The Tissue Viability Nurse continues to support ward staff with recognition

and management of patients at risk but higher numbers of patients staying longer is challenging. Validation of avoidable pressure injury continues and deterioration of existing pressure injury is now being

reported separately so that reduction can be monitored but this is not currently split.


Pressure Ulcers - in hospital setting (includes community wards in set targets)Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position

Measure



Grade 4 Pressure Ulcer developing in Hospital 0

Overall Rate per 100,000 occupied bed days. (updated

retrospectively as data available)

0

2

4

6

8

10

Nu

mb

er

rep

ort

ed

Month

G1 Hospital Acquired Pressure ulcer incidence

2014/15 2015/16 target

0

2

4

6

8

10

12

14

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

Nu

mb

er

rep

ort

ed

Month


2014/15 2015/16 target

0

0.5

1

1.5

2

2.5

Nu

mb

er

rep

ort

ed

Month


2014/15 2015/16 target

0

1

2

3

4

5

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

Nu

mb

er

rep

ort

ed

Month


2014/15 2015/16 target

Red=Any G4 or 2 G3 or 5 any in rolling 3 month period

Amber=1G3 or increase/no change in G2 in rolling 3 month period

Green=No G3 or G4 and decrease in G2 or 2 or less of any grade (1&2) in rolling 3 month period

of 38


20% 2014/15 4 3 1 6 5 3 6 5 3 9 5 9 4 59

(4 mthly) 2015/16 12 12

30% 2014/15 9 17 8 11 13 7 11 6 9 12 11 16 9 130

(8 mthly) 2015/16 14 14

50% 2014/15 1 1 1 3 1 1 4 2 2 2 2 4 1 24

(1 mthly) 2015/16 0 0

50% 2014/15 4 3 1 4 1 1 2 2 6 7 5 5 4 41

(2 mthly) 2015/16 7 7

Grade 2 Pressure Ulcer developing in the community


Grade 4 Pressure Ulcer developing in community

Commentary

N.B. Figures for previous months will continue to change as validation occurs during the process of investigation.

Pressure ulcer development contributes to clinical incident numbers and the higher grades contribute to the numbers of Serious Incidents Requiring Investigation. (SIRIs).

Incidence of pressure ulcer development continues to cause concern and remain challenging with District Nurses continuing to experience increasing caseloads within the community. The numbers remain

similar to last month and this may be due to the effectiveness of the recent awareness campaign activity, particularly over the lower grades. Overall incidence as a percentage of the number of contacts over

the month remains low. The public awareness campaign across local press and venues has resulted in increased referrals as awareness of pressure injury is raised.


Pressure Ulcers - in community setting (external to hospital for set targets - yet to be confirmed)Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position

Measure



Tissue Viability Nurse Specialist/

Communications teamMar-15

The Tissue Viability Nurse Specialist continues to work with the Communications team on a public awareness campaign

to encourage prevention and self help in the community. (Further awareness week scheduled in March 15 with ongoing

training and support for care homes available)

The public awareness event 'I feel good' was taken to locations across that island and was well attended by

patients/carers and non-trust staff involved in patient care as well as a delegation from Southampton CCG who are

looking to hold a similar campaign in their area

Ongoing

Completed

0

2

4

6

8

10

12

14

Ap

r

May

Jun

Jul

Au

g

Sep

t

Oct

No

v

Dec

Jan

Feb

Mar

Nu

mb

er

rep

ort

ed

Month

G1 Community Acquired Pressure ulcer incidence

2014/15 2015/16 target

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Ap

r

May

Jun

Jul

Au

g

Sep

t

Oct

No

v

Dec

Jan

Feb

Mar

Nu

mb

er

rep

ort

ed

Month


2014/15 2015/16 target

0

2

4

6

8

10

12

14

16

18

Ap

r

May

Jun

Jul

Au

g

Sep

t

Oct

No

v

Dec

Jan

Feb

Mar

Nu

mb

er

rep

ort

ed

Month


2014/15 2015/16 target

0

1

2

3

4

5

6

7

8

Nu

mb

er

rep

ort

ed

Month


2014/15 2015/16 target

Red=Any G4 or 2 G3 or 5 any in rolling 3 month period

Amber=1G3 or increase/no change in G2 in rolling 3 month period

Green=No G3 or G4 and decrease in G2 or 2 or less of any grade (1&2) in rolling 3 month period

of 38

Pressure Ulcers

The latest submitted data (April

15) indicates that the IOW NHS

Trust is below the all England

average for new pressure ulcers

and demonstrates a progressive

decrease over time.

Falls



Trust is below the all England

average for harm by falls in

care and demonstrates a

progressive decrease over

time.

Harm Free Care



Trust remains above the all

England average for care

without harm. (98.59%)

Harms can include falls,

pressure ulcers, infection or

any other clinical event

producing an adverse effect on

the individual.

Catheters & UTIs



Trust remains above average in

the level of urinary catheters used.

However, the Island also has a

higher proportion of over 75s than

most areas in England and

catheterisation for urinary retention

is more common in this

demographic.

The data also demonstrates a

lower level of Urinary Tract

Infections in our patients and this

may indicate good management.


NHS Safety Thermometer (from http://www.safetythermometer.nhs.uk)

"It is not just counting, it's caring"The NHS Safety Thermometer provides a point of care survey instrument to provide local areas with a progress measure toward harm free care. This is a publically available website showing data

submissions from a variety of organisations from multisite trusts to individual care homes. It should not be used for benchmarking against individual sites. Over future months this will be expanded as

Mental Health will be joining and submitting other indicators.

of 38

Target Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total

99 99

≥90% 82%

≥90% 71%

≥90% 97%

≥90% 100%

≥90% 100%

≥90% 89%

- 62

≥90% 60%

≥100% 100%

246

≤2% 4%

Target Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total

10

≥90% 60%

≥90% 70%

≥90% 90%

≥90% N/A

≥90% 90%

≥90% 78%

- 2

≥90% 50%

≥100% 100%

18

≤2% 11%

Appropriate IV duration (if applicable)

Appropriate total duration

NAPPI

Allergy status documented

Prescribed according to protocol

NAPPI

Allergy status documented

Missed doses* (% of doses available)

Doses available

* Each missed dose is recorded separately even if a single patient repeatedly refuses medication.

DIPPI

Possible protocols

Measure

Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position


Antimicrobial stewardship (HAPPI, DIPPI, NAPPI snapshot audits)Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position

Measure

Number of patients prescribed antimicrobials

Review date

Indication documentation

Appropriate antimicrobial

Prescribed according to protocol

Missed doses* (% of doses available)

Over all compliance

HAPPI

The Antimicrobial stewardship audits are undertaken monthly by pharmacy staff and the results returned to the individual wards both in a regular newsletter and via the PIDS dashboards.

Problems are highlighted and shared across the hospital so that learning can take place. There is an ongoing problem relating to DIPPI recording as the electronic prescribing system records whether the protocol is

queried and not whether the drug/dosage matches the guidance within the protocol. For common usage, protocols are well known by the prescribers and therefore not specifically queried.

Hospital & Ambulance Directorate

Community & Mental Health Directorate

Number of patients prescribed antimicrobials

HAPPI

Review date

Indication documentation

Appropriate antimicrobial

Appropriate IV duration (if applicable)

Appropriate total duration

Over all compliance

Doses available

* Each missed dose is recorded separately even if a single patient repeatedly refuses medication.

DIPPI

Possible protocols

of 38

Figures for Breast feeding initiation this month are being checked as it is likely to be a miscount and is subject to local audit to verify.

The Labour ward dashboard is updated monthly and discussed at a regular meeting where developing trends can be highlighted and managed. A red flag is an indicator to be aware of possible trends as

our comparatively small numbers give rise to exaggerated percentage differences and a single incident may not be significant. Figures are rounded to nearest %. An appendix logs further local indicators

and is available to relevant staff on the intranet, as shown below.


Maternity Labour ward dashboard of indicators

The non-RCOG monitoring section has not been included this month as the data has not yet been made available.

≤ ≥ Prev Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 YTD

Women delivered 80-100 101-110 ≥111 1301 84 84

Babies born 1318 86 86

In utero transfer 6 1 1

Antenatal bookings (inc transfers in) 100-125 126-150 ≥151 1476 0

Induction of labour rate ≤24% 25-26% ≥27% 28% 31% 31%

Spontaneous vaginal delivery rate ≥70% 60-69% ≤60% 68% 63% 63%

Ventouse/Forceps rate (Instrumental) ≤16% 17-19% ≥20% 11% 12% 12%

Caesarean section rate ≤22% 22-25% ≥25% 20% 22% 22%

Elective Caesarean section rate ≤10% 11% ≥12% 8% 9% 9%

Emergency Caesarean section rate ≤12% 13-14% ≥15% 12% 13% 13%

ITU admissions 0 1 ≥2 1 0 0

PPH> 1.5L ≤3 4-5 ≥6 12 3 3

3rd/4th degree tear ≤2 3-4 ≥5 12 0 0

% failed instrumental delivery ≤3.5% 3.6-4.9% ≥5% 0.8% 0.0% 0.0%

% Readmissions within 30 days of delivery ≤2% 2.1-3.4% ≥3.5% 0.0% 0.0% 0.0%

Undiagnosed term breech in labour 0 n/a ≥1 10 0 0

Days of NICU closure 0 n/a ≥1 0 0 0

% Babies admitted to NICU rate ≤10% n/a >10% 10% 9% 9%

%NICU admissions >37 weeks rate ≤50% n/a >50% 39% 13%

Babies born with pH<7 0 n/a ≥1 7 0

Shoulder Dystocia ≤3 4 >5 15 1 1

% attempting VBAC after 1 CS ≥80% 71-79% ≤70% 72% 63% 63%

% attempting VBAC successfully rate ≥70% 66-69% ≤65% 76% 40% 40%

Booking before 12 weeks rate ≥90% 81-89% ≤80% 93%

Breast feeding at delivery rate (new target2015/16) ≥73% 66-72% ≤65% 73% 56% 56%

Total homebirths 28 3 3

Babies born before arrival 0 ≥1 9 0 0

Homebirth rate 2% 2% 2%

Number of SUIs 0 ≥1 0 0 0

Targets

Home

births

Maternal

Morbidity

Maternity activity dashboard 2015/16

Activity

VBAC

Latest update 13/05/2015

Mode of

delivery

Neonatal

Morbidity

2014-

15

of 38


2014/15 18% 16% 26% 15% 17% 26% 18% 14% 27% 21% 24% 15% 18% 20%

2015/16 22% 22%

2014/15 69% 70% 66% 69% 67% 66% 71% 76% 62% 69% 63% 71% 69% 68%

2015/16 63% 63%

2014/15 22% 32% 28% 21% 33% 25% 29% 31% 27% 33% 27% 33% 22% 28%

2015/16 31% 31%

2014/15 74% 79% 74% 80% 69% 75% 77% 72% 66% 71% 69% 67% 74% 73%

2015/16 56% 56%

Q1 Q2 Q3 Q4

307 318 362 305

31% 39% 33% 36%

13% 11% 12% 9%

2014/156-8 wk checks done

100% Breast fed

Mixed breast/bottle

=>70%

=<24%

>73%

Commentary Small numbers and the particular cohort of patients can influence the data considerably and one red month is a marker to observe for trend

Caesarean Sections - We have seen 86 deliveries this month with 22% by caesarean section again, both emergencies (13%) and electives (9%) at the similar levels as last month. All Consultants

follow NICE and levels of opportunity achieved at VBAC (vaginal birth after previous caesarean section) are at low at 40% this month. Small numbers and the particular cohort of patients can influence

the data significantly and one red month is a marker to observe for trend.

Normal Vaginal Deliveries - There is a consistent rate of spontaneous normal deliveries across the year compared to number of women delivered, which can be challenging giving the changing

population with changing levels of obesity and complex medical problems. This was maintained at 63% this month, as although the section numbers were down the induction level was again high at

31%.

Inductions of Labour - There was another high month for inductions during April, although down slightly from March. Induction levels continue to exceed the target of 24% and are being monitored to

identify if there are common factors. However, induction may not always be done for medical necessity and maternal choice plays an important role.

Breast Feeding Figures (at delivery) – Following recognition of the difficulties, breastfeeding targets have been reduced nationally to 73%. Emphasis will be on maintaining the initialised rate.

Breast feeding initiation is at exceptionally low at 56% this month, despite the introduction of breast feeding champions and may be affected by the higher level of inductions. However, no single reason

can account for the mothers' personal choice. Since the figure is outside the normal range for the Trust, Maternity teams are rechecking and auditing to ensure a validated figure is submitted and this

may be subject to change. The Trust is aiming to become recognised as 'Baby Friendly' and an in- house multi disciplinary training package is continuing alongside a joint Breast feeding policy between

Health and the local authority. The Head of Midwifery has been liaising with NHS England through Public health and we compare well with the rate of 72% covering mainland trusts in this area.

Continued education continues for staff across the localities. Breast feeding champions have been identified and are in place on each shift from both NICU and Maternity. Our overall breast feeding

initiation rate at year end was satisfactory at 73%. Breast feeding figures for 5 days are now being collected and will be included in future reporting.

Breast Feeding Figures (at 6 weeks) This is part of the Health Visitors’ areas of responsibility and data is recorded at the 6-8 week check. Q4 data has now been collated for 2014/15.


Maternity activity Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position. Figures are rounded and slight cumulative differences may exist within totals.

Measure

Inductions of Labour

Normal vaginal deliveries (spontaneous)

Caesarean section rates

Breast feeding at delivery

=<24%

of 38


2014/15 0 0 1 0 0 2 1 0 1 7 12 15 0 39

2015/16 7 7 7

N/A 0 0

N/A 0 0

N/A 1 1

N/A 6 6

2015/16

Commentary

Deprivation of Liberty Safeguards (DoLS) are part of the Mental Capacity Act 2005 (MCA). They aim to make sure that people in care homes and hospitals are looked after

in a way that does not restrict their freedom inappropriately. The safeguards should ensure that all deprivations of liberty in care homes and hospitals are in the best

interests of the person, necessary to protect them from harm and there is no less restrictive way to do so. They provide a legal framework for authorising detention in

hospitals and care homes, including an appeals process and other legal safeguards.

There has been a heightened interest in the DoLS in recent months, following a Supreme Court ruling that extends the scope of the Safeguards to include anyone who is

'under continuous supervision and control and not free to leave'. An application for Authorisation must be made by the Managing Authority (the hospital or care home) to the

Supervisory Body (the Local Authority) in respect of anyone who meets that test. The Supervisory Body will then arrange for two independent assessors to assess whether

the person meets the 6 criteria for an Authorisation to be issued.

Due to the big increase in applications following the Supreme Court ruling, DoLS services in all areas are currently unable to process applications within the legal time limits.

Supervisory Bodies are being asked to identify and refer priority cases in the first instance. Difficulties also arise where the patient is discharged prior to the process being

completed.

Deprivation of Liberty in the Isle of Wight NHS Trust is currently under-reported, although the number of applications has begun to increase. The major training package

recently delivered to ensure that all ward staff of band 6 and above understand their responsibilities under the MCA and DoLS has resulted in higher levels of applications

from January. Further sessions have been held (3) and more are planned. It is anticipated that applications will rise as awareness increases. 136 band 6 staff have now

taken the course and are cascading down across the teams.


Deprivation of Liberty Safeguards (DoLS)RAG rating is not appropriate as the number of Safeguarding orders will be affected by the number of vulnerable individuals admitted

Measure

Approved and granted

Applications made for DoLS orders

Withdrawn prior to assessment

Outstanding (waiting for assessment)

n/a

Not granted

May-15 In progress


A Training package was delivered to ensure all ward staff of band 6 and above understand their

responsibilities under the MCA and DoLS. At the time of report 8 sessions have been completed

with 3 more sessions scheduled.

Deputy Director of Nursing & Workforce has been working with Matrons, highlighting patients at

risk and undertaking ward audits.

MCA & MH Lead May-15 Completed

Director of Nursing & Workforce

of 38


Trustwide

2014/15 20 14 15 17 13 16 21 14 16 15 26 187 187

2015/16 17 0 0 0 0 0 0 0 0 0 0 17 17

10 10

12 12

2 2

In Time 4 4

Out of Time 0 0

number/closed 24% 10%

2014/15 48 62 69 74 102 91 76 86 81 67 76 832 832

2015/16 92 0 0 0 0 0 0 0 0 0 0 92 92

number 63 63

number/closed 74% 74%

0 0

0 0

Commentary

The percentage of complaints

managed within their agreed timescale

is subject to retrospective revision as

this report gives a snapshot available

at the time and cases may continue

across several months if agreed with

the principal. Therefore, the numbers

may differ from previous reports for the

same month.

The graphs at the left demonstrate

complaints, concerns and compliments

received Year to Date for the various

directorate services.

% concerns resolved within 3 working days

*Parliamentary & Health Service Ombudsman

2014/15

Percentage of complaints managed within timescale negotiated

with complainant

(retrospectively updated at closure, figures in italics will change)N/A

Number of concerns resolved within 3 working days

Number of cases reported upheld/partially upheld

Number of cases referred to PHSO* in month

Complaints logged within NHS formal procedure%

14 mthly

Number of Concerns received within month10%

62 mthly

Complaints process

compliance

(closed within month)

0-20 days

21-45 days

>45 days

N/A


Complaints & Concerns - Management Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position

Measure

Hospital 15

Ambulance 0

Community 1

Mental Health

1 Others

0

Complaints YTD

Hospital 75

Ambulance 3

Community 9

Mental Health

3

Others 2

Concerns YTD

Hospital 191

Ambulance 11

Community 18

Mental Health 5 Others

9

Compliments YTD

of 38

Complaints & Concerns - Categories & Areas

0

4

0902000

0

0001100

0

000

Oct-14Primary Subject

Categories of complaints have been realigned to the new National requirements and quarterly reports will be submitted under the following headings.

Comparison with previous year would require complete reassessment of all complaints to realign and is not feasible.

Progess against previous month will be resumed once futher data is available.

Access to treatment or drugs

Apr-14 May-14 Jun-14 Jul-14 Sep-14

Restraint

Staff numbers

Values and Behaviours (Staff)

Waiting Times

Commentary

The graph to the right

demonstrates the highest

recurring themes of the

complaint or concern

The graph at the left

demonstrates the area or

department involved in

the highest number of

complaints or concerns.

Over time, correlation

between the graphs will

show areas with specific

problems to help address

the issues.

Trust admin/Policies/Procedures (including patient record management)

Transport (Ambulances)

Mortuary

Other (Use with Caution)

Privacy, Dignity and Wellbeing

Mar-15Nov-14 Dec-14 Jan-15 Feb-15Aug-14

Prescribing

Patient Care

Admissions and discharges (excluding delayed discharge due to absence of care package)

Appointments

Clinical Treatment

Commissioning


Facilities

Integrated Care (Including Delayed Discharge due to absence of care package)

Communication

Consent

End of Life Care

0

2

4

6

8

10

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Top categories of complaint or concern since April 2015

Clinical Treatment

Admissions and discharges

Communication 0

10

20 Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Top areas subject of complaint or concern since April 2015

OPARU

Emergency Department

Orthopaedics

Medical Services

of 38

Other contacts*

Total contacts** 575

Formal complaints (number) 15 0 1 1

(%) 0.08%

Concerns addressed (number) 75 3 9 3

(%) 0.39%

* Other contacts:- This figure is not definitive and may not include peripheral services if access to records is not centralised.

** Total contacts: Community & MH figures are available a month in arrears so an average has been used to facilitate perspective.

23007

New and Re-opened complaints.

Following the initial closure of a complaint investigation, the complainant may wish to

go further if they are unsatisfied by the response from the Trust. Options open include

referral to the Ombudsman and re-opening the case for further investigation, if

appropriate.

This can occur some time after the initial case was closed and may be dependent upon

progressive medical findings after an event.

It should be noted that the number of cases needing to be re-opened has apparently

reduced over the previous financial year, which may be an indication of greater

thoroughness and subsequent satisfaction with the complaints handling process.

0.17%

2,133

Commentary

This table demonstrates the levels of activity both within

the hospital and the wider community in order to provide

perpective to the number of complaints received by the

Directorates during the month.

It is important to note that the formal complaints received

are from across the services' total areas of responsibility,

including Nurse Lead and Allied Health Professional

services, not just the consultant OP and A&E services.

(There are too many variables to separate complaints

relating to individual areas in this report).

19,445 1872 23,779

0.00% 0.00%

CommunityHospital Mental Health

0.16% 0.04% 0.52%

1872

Consultant OP attendances

A&E attendances

- 43

11,545 - 749 532

3,680 -

Inpatient episodes (FCEs) 232,087


Complaints & concerns - Activity

Activity Type

(February 2015)Ambulance

157

15 3

25 1

27

1

28

1

7 7

0

20

40

60

80

100

120

140

160

180

200

Hospital(Prev yr) Hospital YTD Ambulance (Prev yr Ambulance YTD Community (Prev yr) Community YTD Mental Health (Prev yr)

Mental Health YTD

Nu

mb

ers

Directorate/service (2013/14, 2014/15)

New and Reopened complaints 2015/16 YTD

New complaints Re-opened

of 38

Hospital

“...I just wanted to record my thanks to you – you and your nurses were just so kind and really reassured me ….Sometimes we take these things for

granted but believe me they mean such a lot…”

"I was impressed to receive an appointment … just a couple of weeks after being referred …… Throughout the process; the initial data collection, the

actual procedure, recovery and report; I was called by my first name and introduced to each member of staff by their first names….. Every step of the

procedure was fully explained and time was taken to answer any questions before beginning. All this ensured that any anxiety I felt initially was

allayed..."

Ambulance

“You were very kind and skilled when you took me to A&E ….. You were most caring, considerate and professional”

"I would like to say a massive thank you to you both for your support and guidance ….. You guys do a fantastic job and the NHS should be proud to

have you on their team "

Community

“To all who have had any contact with (patient)…. our sincere thanks for all your help and kindness. We’re sorry we didn’t get to say good-bye to many

of you to express our thanks in person but each and everyone of you will be missed…”

Mental Health

“To all the wonderful dedicated nursing staff and support workers ….. You are all a credit to your professions. Thank you for saving my life, making me

well again. Your care and attention to my illness, your compassion and understanding are a credit to you all. ….. Now begins the hardest fight of my life,

with your help, I know I will succeed. Thank you."

“… For the whole of my time in Sevenacres I saw complete dedication, care, understanding and wonderful treatment from all staff, whether on the

nursing side, administration or cleaning staff. Everyone I encountered gave such thought and care to those of us trying to find our way back to coping at

home and within the outside community. A huge thank you to all involved … for their support, care and understanding.”


Compliments- Extracts from Patient letters

of 38


N/A 44% 44%

90% 97% 97%

N/A 33% 33%

90% 94% 94%

N/A 14% 14%

90% 94% 94%

N/A 14% 14%

90% 100% 100%

N/A N/A

90% 95% 95%

2014/15

2014/15

2014/15

% Recommended

% Recommended

Reponse rate

Inpatient areas

(Community wards, ex MH)*

Response rate


Friends & Family Test - Local targetsIndividual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position

Measure

Inpatient areas

(Acute hospital wards)

Response rate

% Recommended

Response rate

2014/15

Continuing

Completed

Improve response rates by utilising other methodologies to capture FFT feedback including use of tablet devices

Roll FFT out to other settings in line with national guidance i.e. Outpatient, Community and Mental Health

Ward Managers / Patient Experience Leads

Patient Experience / Service Leads

Mar-15

Mar-15


% Recommended

The Friends & Family Test (FFT) is a single question asking 'How likely are you to recommend our ward/department to friends & family' asked nationally to benchmark perception of services by service users.

National targets were set for response rates and, from October 2014, the percentage that would recommend was recorded and benchmarked in line with a more user-friendly approach on the website. With effect

from April 2015, the FFT is not related to a CQUIN target for response or recommendation as it is felt nationally that the system should be sufficiently embedded within organisations to continue without. Our local

targets for recommendations remain at 90% and individual areas are expected to improve their client uptake. The most important element is that the feedback system should be available to all service users

whenever they wish to use it. it is patient choice whether they comment at the end of a course of treatment or at every attendance as long as the opportunity is available.

The percentage measures is calculated as follows:

Recommend (%)=(extremely likely+likely)

(extremely likely+likely+neither+unlikely+extremely unlikely+don't know) ×100

Results are published nationally and are available at: http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/

Locally, the FFT results are presented as part of the Ward Dashboard and are publically available on individual area boards around the hospital. This is summarised in the ward summary dashboard snapshot

elsewhere in this report. Outpatient areas are now included in the FFT survey and display their results on local area boards similar to those on the wards.

There are national challenges with regard to achieving sufficiently high response rates to have confidence that the results are representative and work is ongoing as the FFT is rolled out to include more

departments across the year. The island overall has a particular challenge as the test question asks 'how likely are you to recommend the service' which is difficult to respond to objectively when there is no

alternative facility to measure against. We also have times when there is a large visiting population and these have previously stated that they would not recommend to friends as they don't live in the catchment

area. s.

* With effect from January 2015, national reporting of Community Services was instigated (see summaries) and these figures have been extracted to provide continuity of ward only results.

Due to reporting requirements, data for the Friends & Family Test ' Community' and 'Mental Health' may be reported retrospectively as data is not always available in time to publish.

Community (Overall)

(response rate not applicable)

Reponse rate2014/15

% Recommended

Accident & Emergency

Maternity (birth point)

of 38

CQC published the 5th Intelligent Monitoring reports for Acute trusts on 21 April, with publication due 28 May 2015:

The intelligent monitoring of trusts that provide acute services considers 95 different types of evidence, based on many sources e.g. Hospital Episode statistics, National Reporting Learning System data, national

inpatient surveys and Electronic Staff Records. These are titled Indicators and the total number of risks increased from 6 in December 2014 to 7, including 3 new risks

Of the 7 Risks listed on 21 April the following were Elevated Risks, both having been previously listed as Risks:

i) In-hospital mortality - Endocrinological conditions - Fluid and electrolyte disorders (case status as at 14.04.15); and

ii) Safeguarding concerns (25.12.14 to 24.02.15)

Our priority banding would have remained at Band 3 of 6 (Band 6 having the lowest Risk Level) but as a recently inspected Trust this is not officially recorded but provided by the CQC for benchmarking purposes.

The second Intelligent Monitoring reports for Mental Health trusts were published on 28 April, with publication due 11 June 2015:

The intelligent monitoring of trusts that provide mental health services considers 59 different types of evidence, based on sources that include the NHS staff survey, bed occupancy rates, the national health outpatient

survey and concerns raised by trust staff. The total number of risks has reduced from 11 in December 2014 to 8, however the number of indicators was previously 57.

Of the 8 Risks listed on 28 April two were on the previous report, with three new Elevated Risks:

i) Proportion of discharges from hospital followed up within 7 days (1.12.13 to 30.11.14)

ii) Service users who had five individual cardio metabolic health risk factors monitored in the past 12 months (1.08.13 to 30.11.13)

iii) Monitoring of alcohol intake in the past 12 months (1.08.13 to 30.11.13)

Our priority banding would have been at Band 1 of 4 (Band 4 having the lowest Risk level) but as a recently inspected Trust this is not officially recorded but provided by the CQC for benchmarking purposes.

CQC were asked to justify how data for two Acute indicators where CQC and Trust data did not match, with their feedback subsequently added to the action plan. The Action Plan for every listed Risk is attributed by

Lead Directors to senior staff for every listed indicator. The designated managers provided updates to the action plan schedule, including RAG ratings to reflect the ability of the action plan to address the criteria

within every indicator. The action plan is scheduled to be presented to SEE Committee on 20 May 2015.


CQC Quarterly Intelligent Monitoring Report - DRAFT REPORTS of April 2015

of 38


2014/15 11 14 6 15 0 9 6 8 5 6 10 1 11 91

2015/16 3 3 3n/aNumber of Cases going to Inquest

Commentary

Of the inquests held in April 2015, the following conclusions were reported:

Narrative Conclusion - refer below

Road Traffic Collision

Suicide

Narrative detail: ‘The deceased sustained a substantial head injury previously which caused serious brain injury. The deceased failed to inform authorities of this pre-existing

condition. He was referred to Neurology but due to operational reasons he was not seen prior to his death or prescribed any anti-seizure medication. He suffered 5 fits prior to

his death and died of status epilepticus.’

NB The inquests registered for January 2015 total has increased by one due to the late notification by the Coroner of an inquest being held that month.

The conclusion was Death by accident‘


Cases going to Inquest during previous month

Measure

of 38


2014/15 690 827 792 886 660 794 987 711 710 939 808 690 8804

2015/16 809 809 809Number of chaplaincy visits N/A

Commentary

For the month of April 2015 Chaplaincy’s Significant Patient Encounters amounted to 809. We achieved a 17% increase on the equivalent month in April 2014 (690).

These encounters lasted a total of 135 hours which averages out at 10 minutes per visit.

To substantiate the quality of our pastoral encounters, chaplaincy received 8 letters, cards and emails of appreciation during the month.

Some quotations:

“I wanted to thank you on behalf of us all for your wonderful support over the past couple of months, we know 'X' took great comfort and enjoyment from your visits and

prayers.”

“Just a quick thank you for spending time chatting to myself and family on the ward… your [words] touched my heart…so a big thank you once again”

“Thank you for coming to see her….it’s a great comfort to know that [she] will be fully prepared to meet her creator. Thank you for all you have done”

We are currently looking ahead to the Children’s Memorial Service on 28th June and our Chaplaincy Conference on 16th May when our guest speaker will be Rev. Karen

Mackinnon, the Lead Chaplain at University Hospital Southampton.


Chaplaincy activity

Measure

of 38

Measure Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total

2014/15 72 64 76 99 74 68 87 74 63 67 62 83 72 858

2015/16 72 72 72

2014/15 4.99% 4.19% 5.20% 5.97% 4.97% 4.34% 5.03% 4.55% 4.28% 4.34% 4.28% 5.43% 4.99% 4.39%

2015/16 5.01% 5.01% 5.01%

2014/15 2 3 0 5 2 2 3 1 5 4 2 0 2 29

2015/16 3 3 3

2014/15 3.70% 7.50% 0.00% 8.77% 5.13% 4.65% 6.82% 1.85% 10.64% 6.35% 4.35% 0.00% 3.70% 5.11%

2015/16 6.25% 6.25% 6.25%

2014/15 120 115 117 139 106 36 119 131 114 108 107 97 120 1309

2015/16 115 115 115

2014/15 13.23% 11.84% 12.68% 12.93% 11.17% 3.77% 12.21% 12.76% 11.23% 10.34% 11.69% 9.39% 13.23% 11.10%

2015/16 11.78% 11.78% 11.78%

↓ Reduction

on 2014/15

baseline (<? monthly)

TBA

Emergency readmissions within 30

days. Acute Hospital only(Payment by results(PBR) authorised national bundle

excluding maternity, children under 3 yrs, cancer

diagnosis and specified trauma)

Emergency readmissions within 30

days. Mental Health wards only (with same primary diagnosis code)

This was previously 28 days and previous year

has been rerun to align to new parameters.

↓ Reduction

on 2014/15

baseline(<? mthly)

TBA

admission %

admission %

Trustwide Emergency Readmissions

within 30 days(All emergency readmissions to all areas

regardless of diagnosis & speciality - includes

Mental Health)

↓ % reduction

on 2014/15

baseline

TBA

emergency

admission %

number

Commentary:

Emergency readmission following discharge is a raw indicator of the care received and can only be truly relevant if the second admission is for the same diagnosis. Many patients have co-existing

conditions and only case note analysis is able to state that the second admission is directly related to the first. However, the national PBR (payment by results) bundle addresses this by excluding

various categories and using a standardised methodology to facilitate national benchmarking. This is shown at the top in the table above. Readmissions for paediatrics provides a significant

contribution to the numbers at an individual level of 13.9% during April.

The Mental Health emergency readmission figures have been calculated for the same diagnosis but treatment regimes differ to other medical conditions and it could mean that home leave was

unexpectedly curtailed. In all cases, the percentage has been calculated against the comparable admission numbers for that month.

Regular audit of readmissions from various areas is carried out and shows that the majority of readmissions are unavoidable and frequently due to multiple co-morbidities on patients with

progressive health issues. Where other issues are identified (such as discharge home and subsequent admission due to failure of home care package) this is followed up individually.


Emergency Readmissions Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position

number

number

of 38


↓10% 2014/15 1846 1804 2879 1886 1649 1763 1617 1869 2129 2460 2637 2406 1846 249451871 monthly 2015/16 2314 0 0 0 0 0 0 0 0 0 0 0 2314 2314

2014/15 57 76 72 102 75 161 165 84 106 103 115 117 57 1233

2015/16 43 43 43


Cancellations by hospital (1) Consultant lead appointmentsIndividual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position

Responsible job title Date Progress

Measure

Reduction on hospital lead cancellations(from 2014/15 baseline)

Appointments brought forward (Patient benefit)

Commentary:

Appointments for Consultant clinics are recorded on the Patient System Outpatient clinic diary and includes some Nurse Specialists in the data available. All

reasons related to the patient have been excluded. It should be noted that cancellations citing clinician on sick leave have been retrospectively included so

that the impact of this category can be assessed even thought it cannot be planned for in advance. However, all calculations have been made on the same

basis to enable comparison with the previous year.

A major problem affecting cancellations is the current system of issuing follow up appointments long periods in advance, although not doing this would cause

other operational problems. Clinician rotas, including annual & study leave requests, require 6 weeks notice and this obviously impacts on pre-existing

appointments as can be seen from the table below. There is also an increased requirement for clinicians to be included in management meetings nationally

which also impinges on previously booked clinic time.

Rebooking of re-existing appointments continues. Changes are underway to

improve recording and 'transfer to another clinician' is now available. All will take time

to work through and are not retrospective, unspecified reasons continue to appear.

Discussions are being held with PAS system administrators to reduce system limitations on recording in order to

produce more accurate reporting:-

a) Cancelled and rebooked clinics not affecting patient attendance

(e.g. change of room to be used)

b) Removing free text field from cancellation reason fields.

(Reduce unspecified cancellations).

General Manager, Medical, Emergency &

Diagnostic ServicesMay-15 In progress

0

500

1000

1500

2000

2500

3000


Hospital Outpatient Cancellations Consultant lead only

2014/15 2015/16 Target

Recorded cancellation reason on systemOn day or

retrospectively

Within

1 week

1-6

weeks

Over 6

weeks

Month

Total

CHOOSE AND BOOK 1 1 5 4 11

CLINIC CANCELLED OTHER REASON 29 199 167 29 424

CLINIC MOVED TO ANOTHER DATE 1 24 9 34

CLINICIAN ATTENDING MEETING 3 44 36 83

CLINICIAN ON ANNUAL LEAVE 14 9 99 109 231

CLINICIAN ON CALL 13 15 28

CLINICIAN ON SICK LEAVE 22 72 45 1 140

CLINICIAN ON STUDY LEAVE 3 15 42 22 82

EXPEDITE TO REINSTATED CLINIC 2 3 1 6

HOSPITAL CANCELLED APPT 46 291 543 257 1137

MORE URGENT CASE 10 16 1

REDUCE CLINIC SLOTS 1 1

TIMESLOT CANCELLED 5 5

TIMESLOT DELETED (SYS DEF) 1 5 52 58

Z C&B USE ONLY - BY PROVIDER 13 31 3 47

Grand Total 115 623 1037 539 2314

Local Specialty Name Apr 2015

OPHTHALMOLOGY 370

UROLOGY 212

GYNAECOLOGY 160

TRAUMA & ORTHOPAEDIC SURGERY 143

GENERAL SURGERY 131

ENT 133

RHEUMATOLOGY 124

PODIATRY 102

PAEDIATRICS 112

MAXILLO-FACIAL SURGERY 94

GASTROENTEROLOGY 90

ADULT MENTAL HEALTH 89

COLORECTAL SURGERY 60

MIDWIFE MATERNITY EVENT 60

RESPIRATORY & THORACIC MED 38

CLINICAL IMMUNOLOGY & ALLERGY 45

ORAL SURGERY 36

MATERNITY ANTE NATAL 31

CARDIOLOGY 30

HAEMATOLOGY - CLINICAL 30

CLINICAL ONCOLOGY 28

BREAST SURGERY 27

DERMATOLOGY 27

ELDERLY MENTAL HEALTH 25

CHEMICAL PATHOLOGY 23

PAIN MANAGEMENT 15

FRACTURE (OUTPATIENTS) 10

MEDICAL ONCOLOGY 13

LEARNING DISABILITIES 13

ENDOCRINOLOGY 10

ORTHODONTICS 9

TRANSIENT ISCHEMIC ATTACK 6

GENERAL MEDICINE 6

GERIATRIC MEDICINE 5

DIABETIC CLINIC 3

REHABILITATION 2

ANAESTHETICS 1

NEUROLOGY 1

Grand Total 2314

of 38

Measure Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total

↓10% 2014/15 613 467 335 473 420 511 465 426 353 552 699 1104 613 6418target 481 481 481 481 481 481 481 481 481 481 481 481 481 5776.2

(392 Monthly) 2015/16 425 425 425

2014/15 13 25 11 14 18 26 40 16 21 22 32 33 13 271

2015/16 8 8

Discussions are being held with PAS system administrators to reduce system limitations on

recording in order to produce more accurate reporting:-

a) Cancelled and rebooked clinics not affecting patient attendance

(e.g. change of room to be used)

b) Removing free text field from cancellation reason fields.

(Reduce unspecified cancellations).

General Manager, Medical, Emergency

& Diagnostic ServicesMar-15 In progress

Commentary:

Appointments for Allied Health Professional clinics are recorded on the Patient System Service Group Diary and those departments that use this

system are available for retrieval. Notable exceptions are Physio- and Occupational Therapies as well as Othotics & Prosthetics and others that

use a separate part of the system and further work is required to include these other areas. All reasons related to the patient have been excluded,

and cancellations citing clinician on sick leave have been retrospectively included although this cannot be planned for in advance. It should be

noted that all calculations have been reworked on the same basis for the previous year to enable comparison.

Allied Health Professionals and Nurses have very low levels of multiple

cancellations during an episode. This may be due to their methods of

working or a reduced need for the patient to be followed up.

The table to the top left illustrates the types of reasons given for cancellations

and demonstrates the level of unspecified reasons cited. This will start to

be addressed by the planned review of the recording system as previously

stated.

The table at the lower left illustrates the top areas that the appointments have

been cancelled for this month. This does not take account of the various

levels of associated activity.


Appointments brought forward

(Patient benefit)

Reduction on hospital lead cancellations

(from 2014/15 baseline)


Cancellations by hospital (2) Allied Health Professional and Nurse lead appointmentsIndividual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position

-50

50

150

250

350

450

550

650


Hospital Outpatient Cancellations Allied Health Professionals & Nurses

2014/15 2015/16 target Clinic Service Group Desc Total

IW CARDIOLOGY 516

IW PODIATRY 252

IW EYE ORTHOPTIST 51

IW CHRON PAIN PSYCHL 47

IW EYE FIELD 46

IW PREASSESSMENT 16

IW MPTT - SPINAL 15

IW CHEST INVEST'TION 14

IW ENDOSCOPY 10

IW EYE NS 7

IW MPTT - LOWER LIMB 7

IW ALLERGY 4

IW CHILDRENS WARD 3

IW EYE OPTOMETRIST 3

IW ALLERGY DIETITIAN 2

IW OHPIT 2

IW CONTINENCE NS 1

IW DIETITIANS 1

Appt Cancel Reason Description total

CANCELLED APPT BROUGHT FORWARD 8

CLINIC CANCELLED OTHER REASON 46

CLINICIAN ATTENDING MEETING 4

CLINICIAN ON ANNUAL LEAVE 30

CLINICIAN ON SICK LEAVE 69

CLINICIAN ON STUDY LEAVE 3

HOSPITAL CANCELLED APPT 189

MORE URGENT CASE 1

NO NURSE AVAILABLE 1

TIMESLOT CANCELLED 134

TIMESLOT DELETED (SYS DEF) 512

of 38


2014/15 42 43 35 47 26 28 22 15 35 35 50 50 428 428

2015/16 31 31 31

2014/15 29 29 23 32 20 19 18 10 25 26 33 33 297

2015/16 10 10

The bed manager has oversight of the patient moves on a monthly basis and is reviewing

clinically to exclude justified transfers and provide validated figures for this measure. Bed Manager Mar-15 Planned



Patient moves within stay

Measure

Patient moves 3 or more times

(excluding clinically justified moves)

Commentary

Patient moves within an episode or spell may be clinically appropriate but it is important that moves are justified and do not affect patient care adversely. In order to

calculate the base figures shown above, all admissions for the year were retrieved and filtered for any internal transfers during the admission. The number of transfers was

calculated and those that were deemed likely to have been clinically justified excluded. These included moves from MAAU to a specific ward, moves to and from ITU,

cardiac care or stroke care. It is not possible to be completely accurate for each patient without individual case note review by a clinician but the figures above are

comparable for each month and are valid for identifying a basic trend. Future reporting may be a month further retrospectively to enable time for this clinical review to take

place and for validated figures to be presented. Work is underway to develop this aspect of reporting and numbers may change retrospectively as the process is refined.

This will also demonstrate the degree of variance with and without clinical validation.

The figures above show the number (sum) of moves experienced by patients moved more than twice within their stay. As different patients experience different numbers of

moves, the number of patients experiencing 3 or more moves is also shown. For the year to date, both the numbers of moves and the numbers of patient experiencing those

moves have reduced since the beginning of the year.

April figures continue to demonstrate efforts to reduce unnecessary moves with

10 patients experiencing a maximum of 3 moves that may not have been clinically

justified. A single patient was moved 4 times. These figures have not been clinically

validated and are subject to change.

The CQC visit highlighted patient moves as an area of particular interest with

respect to end of life care and early identification of patients for whom the

Amber Care Bundle is appropriate has already resulted in a reduction in

unjustified transfers since implementation.

It should be noted that the Trust admits approximately 2500 patients a month and only

a small percentage are affected by these moves, which may be made to avoid

mixed sex accommodation breaches whilst the building is being reconfigured.

Number of patients involved in these moves

0

2

4

6

8

10

12

0

5

10

15

20

25

30

35


Nu

mb

er

of

pat

ien

ts a

ffe

cte

d

Nu

mb

er

of

un

just

ifie

d m

ove

s

Month

Clinically unjustified moves within stay Moves recorded Patients affected

of 38


2014/15 7 18 5 13 17 12 9 12 7 7 4 8 7 119

2015/16 5 5 5

The bed manager continues to receive monthly reports for investigation. Bed Manager May-15 Ongoing


Discharges recorded as Overnight (re-aligned to be after 23:00 & before 06:00)

CommentaryN.B. Numbers will change retrospectively as coding completes for preceding months.

These figures are for admitted patients only and do not include non-admitted attendees that leave A&E following examination and/or treatment.

Discharges outside of 'normal working hours' have hit national headlines and work has been underway to identify any local problems. Initial

analysis demonstrated considerable data validation errors due to historical ways of working within the recording system used. (see notes at right).

These are reducing but further work is needed to increase the accuracy of the data available. Alignment of times for the definition of 'overnight

discharge' with other organisations is hoped to enable benchmarking.

Regular scrutiny and monitoring of these figures by the Bed Manager confirms that cases remaining after transfers to other facilities and

recognised day admissions have been excluded, are patient choice once medical clearance had been recieved. Children's and Maternity

wards are excluded from this report for this reason. The Bed Manager continues to recieve monthly reports and cascades information down to

individual areas as necessary. 60% of the recorded overnight discharges this month are of patients 75 years or over but it is not possible

to say whether these patients had home back up without individual case note investigation. There is however, a noticeable decrease in

late discharges recorded since the start of the 2014/15.

Reporting is being expanded to include monitoring of discharges between 06:00 and noon

which we aim to increase in line with the new Key Performance Indicator requested for 2015/16.


Measure

Discharges recorded as overnight (all LOS)

DATA VALIDATION KNOWN DATA ERRORS

1. Numbers reported for the previous month will change as discharge summaries are entered and coding is completed.

2. Data errors involving incorrect 12/24

hour clock formats have been confirmed by case note audit. This has reduced considerably through training but is ongoing and may affect over 60% of past records.

This human error will never be totally eliminated but is improving now that ward clerks check details for previous 24 hours.

3. Post-discharge system entries default to the time the entry is completed if no specific time is entered. This occurs when the discharge is not completed electronically at the same time as the physical discharge and is finished at a later time.

This error is being addressed by ward clerks checking discharge details for the previous 24 hours and is reducing over time.

Discharge Ward Name 23:0

0 -

23:5

9

00:0

0 -

01:5

9

02:0

0 -

03:5

9

04:0

0 -

05:5

9

Gra

nd T

ota

l

Monday

Tuesday

Wednesday

Thurs

day

Friday

Satu

rday

Sunday

MAAU 1 4 5 1 2 2 10

Grand Total 1 4 0 0 5 0 0 0 1 2 2 10

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alan sheward - director of nursing & workforce monthly... · excel format v2 jan-15 jw excel...

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