Trust Board Committee – 25th February 2011
Presented By:
Gwen Nuttall – Chief Operating Officer, Nichole Day Executive Chief Nurse
Prepared By:
Information Team
Date Prepared:
15th February 2011
Subject:
Integrated Quality and Performance Report - January 2011
Purpose:
For Information
Strategic Objective:
To Achieve Performance Levels in accordance with the CQC “Standards for Better Health”
Executive Summary:
The paper focuses on the key core targets, identified by the Department of Health and the Care Quality Commission,
summarising performance to the end of January 2011.
It also provides the board with information to assess the Trust’s performance against quality indicators, including patient
experience, clinical outcome and effectiveness and patient safety.
Matters resulting from recommendations
made in this report
Financial Implications
Present
Considered
Yes / No
Yes / No
Workforce Implications
Yes / No
Yes / No
Impact on Equality and Diversity impact
Yes / No
Yes / No
Legislation, Regulations and other external directives
Yes / No
Yes / No
Internal policy or procedural issues
Yes / No
Yes / No
Risk Implications for West Suffolk Hospital (including
any clinical and financial consequences):
- Failure to deliver the 4 hour core access target for the year.
- Failure to achieve C-Difficile target for the year.
Mitigating Actions (Controls):
• Robust Action Plan developed.
• Performance Management and Monitoring.
• Improved Escalation
• Review of Cohort Unit
Level of Assurance that can be given to the Committee from the report based on the
evidence
[significant, sufficient, limited, none]:
SUFFICIENT
Recommendation to the Committee:
Note the Trust Performance to January 2011
Contents
1. Introduction
2. Emergency Care A&E
3. Cancelled Operations
4. LOS
5. Outcomes & Effectiveness – Clostridium Difficile
6. Patient Safety
7. Risk Assessment
8. Patient Experience
9. Conclusion
1.& 2. Introduction & Emergency Care
1. Introduction:
This report provides a briefing to the Board members on the
performance against key targets up to January 2011.
The paper focuses on the main targets, identified by the Department of
Health and the Care Quality Commission.
2. Emergency Care – A&E
Target: 95% of patients seen/treated/discharged
within 4 hours
The Trust did meet the 95% Target for the month of
January 2011 (96.14%).
Key actions:EAU posts to be advertised in February.
Integrated Action Plan agreed and monitored weekly, via
weekly A&E departmental meetings.
Review of medical commitments in morning and afternoon
commenced. Job Plans are being updated.
Bed Meetings reviewed and enhanced. Standard operating
procedures commenced.
Short stay beds introduced on ward G5.
Trust will pilot Discharge/Transfer Lounge in March to assist
with flow of patients and discharge planning.
The updated detailed A&E 4 hour performance action plan is attached as a separate paper.
Page 4
3. Cancelled Operations
The target was met for January at 0.30%
An improvement from last month. Out of theatre time
remained the highest reason for cancellation (50%). Bed
unavailable (33%). Equipment issues (17%).
Target 0.8%
Actual 0.85% (YTD)
The Productive Operating Theatre project (TPOT) is in
progress, and will be reported to the Board in March 2011.
Page 5
4. Length of Stay (Spells)
The targets are from Dr Foster ‘Expected’ positions using 09/10
as a benchmark.
• Non Elective LOS for Medicine is above target – Actions to
improve this performance is linked to discharge action plans
and implementation of EAU model and short stay beds.
•Non Elective LOS for Surgery remains below the expected level,
but has seen an increase in 2010/11. This is related to complex
elderly patients.
•Elective LOS for Surgery is similar to last year. Review of day
case and day of surgery activity continues, especially in
urology. The productive theatre will also focus on Urology.
Page 6
5. Outcomes and Effectiveness
Mortality
120
100
80
60
40
20
0
Hospital Standardised Mortality Ratio
HSMR has been fairly consistent over recent months and is
below the expected level as can be seen by the overall mortality
shown in the graphs and the table giving a mortality rate for the
five Dr Foster - How Safe is Your Hospital indicators. These
tables provide information on relative risk, with red, blue and
green traffic lighting. Blue indicates that the score is within the
standard deviation.
We monitor the HSMR for emergency patients and identify any
individual diagnoses that trigger any safety and effectiveness
alerts. These are all investigated and reported to the Quality
and Risk Committee.
Mortality:
standardised rate
Apr May Jun
Rolling 12 Month HSMR-All Admissions
90
85
80
Feb
09
-Mar
10
Mar
09
-Apr
10
Apr
09May
10
May
09
-Jun
10
Oct 09Nov 10
Sep 09Oct 10
Aug 09Sep 10
Jul 09Aug 10
Jun 09Jul 10
May 09Jun 10
Apr 09May 10
Mar 09Apr 10
Feb 09Mar 10
Jan 09 Feb 10
Dec 08
- Jan 10
Oct 08 Nov 09
Sep 08Oct 09
Aug 08Sep 09
Jul 08Aug 09
70
Nov 08
- Dec-…
75
Jan
National Rate
Jul
08Aug
Sep
Oct
08
Dec
08
09
–
from last
Aug
08- 08-Oct - Nov Nov 08 - - Jan Feb
reporting
09 Sep 09 09
09 Dec-09 10
10
period
Jun
09
-Jul
10
Jul
09Aug
10
Aug
09Sep
10
Sep
09Oct
10
Oct
09Nov
10
-
86.4
85.2
84.5
84.6
82.8
80
80.7
80.2
80.1
76.5
89
89
87.8
86.3
84.6
84.1
86.2
84.9
84.6
84.5
83
80.1
80.8
80.4
80.3
79.6
89.1
89.1
88.1
86.7
84.8
84.2
SMR Stroke (Acute Cerebrovascular
Disease)
86.2
85.9
82.6
86.4
82.8
83.3
83.1
82.9
80.9
81.1
79.4
87.8
86.8
88.7
88.6
84.2
84.4
SMR - Heart Attack (AMI)
90
81.6
0.84
100.4 105.1 106.1
94.1
91.8
100.6
96.6
95
92.4
92.1
93.7
94.5
89.4
82.4
78.5
77.9
65
69.4
61.3
64.2
69.5
68.4
64.7
73.3
69.2
60.7
62.9
66.2
66.9
0.65
0.57
0.57
0.44
0.49
0.67
0.62
0.62
0.53
0.49
0.44
0.49
Rolling 12 Month HSMR-All Admissions
Rolling 12 Month HSMR-Non Elective
SMR - FNOF
Mortality from Low Risk Conditions
Page 7
Jul Aug Sep Oct Nov Dec Jan Feb Mar
70
65.4
64.9
7
5. Outcomes and Effectiveness
Infection Prevention
The C. difficile target for 2010/11 is 29 hospital cases
although due to the recent C. difficile outbreak the PCT
recognised that we would not hit our trajectory and
agreed that they would accept no further preventable C.
difficile cases. In January there were a further 4 hospital
attributed cases, bringing the total to 32 non of which
were avoidable. All patients were transferred to the F9
cohort unit within the time frame specified. There have
been a further 2 cases in February (as at 17/2/2011),
bringing the total to 34.
The Trust continues to achieve excellent results in other
infection control KPIs. There were no hospital associated
MRSA bacteraemia and High Impact Intervention
performance has improved. Overall compliance with
hand hygiene and the dress code requirements for all
directorates in January dropped slightly to 99% and the
affected areas are being addressed.
Antibiotic Prescribing
There has been an improvement in performance to 95%.
The revised drug chart which includes a specific
antibiotic prescribing section requiring a medical review
signature every 3 days is due to be used from the 1st
March.
Page 8
8
6. Patient Safety
Number
20
Pressure Ulcers
No of patients with
ward acquired
pressure sores
15
10
No of patients with
ward acquired Grade
3 or 4 pressure sores
5
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Falls
Number
35
30
25
20
15
10
5
0
Apr
No of short RCAs
completed for
patient falls
No of patient falls
resulting in harm
May
Jun
Jul
Aug Sep
Oct
Nov Dec
Jan
Feb
Mar
Pressure Ulcers
The number of patients with ward acquired pressure ulcers increased this month to 16 however with no Grade 3 or 4 reported.
Themes from RCAs:
• Lack of continuity of care when patients have been moved around the hospital.
• Patient situations that create unavoidable pressure ulcers: patients who choose not to participate in their own pressure ulcer prevention or patients on the Liverpool Care
Pathway.
Actions:
• A pressure ulcer development group has been established to develop, facilitate and review an annual pressure ulcer prevention strategy.
• Clinical areas with significant/increased pressure ulcer incidence have been asked to develop action plans concentrating on preventing Grade 2 ulcers, next month
themes from Grade 2s will be reported.
Patient Falls
The number of falls resulting in harm decreased this month to 22, no severe harm was caused.
• 16 of these patients had delirium/dementia. Driving forward the dementia strategy by ensuring that patients are more meaningfully occupied may decrease falls in this
patient group. The Patient Falls Specialist Group/ Dementia Steering Group have been asked to focus their actions in these areas.
• 2 Wards with significant nurse recruitment problems had the highest rates of falls: 41% of total incidences. There are recruitment action plans in place to address these
staffing issues.
Page 9
9
6. Patient Safety
Venous Thrombo-Embolism (VTE)
Verbal update to be provided at the meeting by Dermot O’Riordan.
Page 10
10
6. Patient Safety
Root Cause Analysis (RCA)
There were 6 outstanding medical actions and 4 outstanding surgical actions at the month end. The total number of actions
demonstrates an on going reduction since September.. Five of the actions reported as outstanding at the last Board have
now been completed.
4/6 outstanding actions within Medical Directorate RCAs and 2/4 outstanding actions within Surgical Directorate RCAs have
updates indicating progress to achieve completion and evidence is pending.
The targeted follow up continues through individual contact with leads as well as presentation of the “outstanding RCA
actions” report to the Directorate Performance meetings, Directorate steering groups and the Operational Steering group.
Patient Safety Incidents resulting in harm
Detail is provided within the SIRI report.
Page 12
11
7. Risk Assessments
Risk Assessments in date
There are currently 108 (as of 15th February)
active risks on the Risk Register. Of these, 85
(79%) are in date, while 23 (21%) are late for
review.
This is a significant improvement as at the start
of the year 52% of risk assessments were
beyond their review date.
The number of risk assessments beyond their
review per Directorate are listed below:
1) Medical = 7
2)Trust-Wide = 7
3) Surgical = 6
4) Finance and Information = 2
5) Human Resources = 1
Each directorate receives a monthly report which
is discussed at the Directorate Governance
Steering Groups. This report details the
Directorate’s risk management performance and
enables actions to be set on individuals to
review/progress risk assessments as necessary.
There is also the option to escalate issues where
the progression of implementing additional
controls is not satisfactory.
The Operational Steering Group will be receiving
a themed monthly report based on different
issues to be addressed from the Risk Register.
The Operational Steering Group will deliberate
concerns and determine required action with risk
management performance accordingly.
Page 11
Active risk assessments in date
(according to grading Red-3 mths, Amber-6 mths)
Additional controls in date
Each active risk should identify additional
controls which are required to reduce the risk
rating to a tolerable level. Currently there are
155 additional controls identified by the active
risk assessments. Of these, 124 (80%) are
within the agreed timescale, while 31 (20%)
have passed their agreed implementation date.
This is a significant improvement, as at the start
of the year only 51% of the additional controls
were in date.
The number of additional actions beyond their
review date per Directorate are listed below:
1) Medical = 9
2) Trust-Wide = 7
3) Facilities = 6
4) Surgical = 5
5) Finance and Information = 3
6) Human Resources = 1
21%
79%
In date
Beyond review date
20%
The Directorate Governance Performance
Meetings and Operational Steering Group
reports also detail the actions and status
required
so
that
this
can
be
managed/progressed at the Directorate level,
and where necessary considered at the
Operational Steering Group.
80%
In date
Beyond im plem entation date
12
8. Patient Experience
Patient Satisfaction (Patient Experience Tracker)
Overall satisfaction was 95% (see Table 1 for breakdown of
clinical areas). (A&E scored 95%+ in all questions with a
returns rate of 1350). EAU/ Eye Clinic are developing action
plans to increase the volume of patients surveyed. Eye clinic
have introduced a volunteer to undertake additional surveys.
Main OPD
Diabetic Clinic
Eye Clinic
PAU
A&E
EAU
F4
DSU
1175 returns
650
45
105
1350
5
95
185
93% satisfaction
91%
98%
96%
98%
100%
89%
99%
Table 1.
Patient Satisfaction Questionnaires (PSQ) (paper)
All remaining clinical areas use this method for reporting and
overall satisfaction scored 82%.
%
100
Patient Satisfaction Questionnaire
Enough privacy
Call button
response time
80
60
The two questions with a red performance rating response
was “Has a member of staff told you about medication side
effects to watch for when going home?” and “Were you told
who to contact if you were worried about your condition after
you left hospital?”.
Actions:
• Matrons to advise ward areas to give PSQ to patients at
discharge as patients only receive this information with
TTOs.
• Discharge leaflets now being used on wards which provide
side-effect advice.
Page 13
Side effects
information
40
20
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Contact for
worries after
discharge
Choose hospital
again
CQUIN
Achievement of 2% patients surveyed this month was
achieved by all CQUIN reportable areas.
13
8. Patient Experience
Same Sex Accommodation
Number
300
Same Sex Accommodation
250
200
Same sex accommodation:
total breaches
150
100
50
Same sex accommodation:
total patients
0
Apr
May Jun
Jul
Aug Sep
Oct
Nov Dec
Jan
Feb
Mar
Environment and Cleanliness
%
100
Environmental Audit
Environment
and
Cleanliness
Target
80
60
40
20
0
Apr May Jun
Page 14
Jul
Aug Sep Oct Nov Dec Jan Feb Mar
Same Sex Accommodation
Same sex accommodation criteria were breached on one
occasion during January. This occurred in the
assessment area of EAU when two male patients had to
be placed in the female assessment bay which contained
three female patients. At the time there were no male
beds available in the hospital; bed availability and patient
movement was being affected by ward closures due to
norovirus. Staff apologised to patients and worked with
the H@N team to move the female patients to surgical
wards as soon as possible.
9. Conclusion
The action plan remains in place and performance has improved in January with regard
to the 4hr standard.
One of the major challenges for the Trust, was in adherence to same sex
accommodation , the re-configuration in December has improved performance.
Performance with regard to C-Difficile, full RCA’s have been carried out and actions
implemented specifically with regard to anti biotic prescribing and monitoring.
Progress on other KPI’s is being made.
Page 15