Trust Board Committee – 28th January 2011
Presented By:
Gwen Nuttall – Chief Operating Officer, Nichole Day Executive Chief Nurse
Prepared By:
Information Team
Date Prepared:
18th January 2011
Subject:
Integrated Quality and Performance Report - December 2010
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 December 2010.
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 December 2010
Contents
1. Introduction
2. Emergency Care A&E
3. Cancelled Operations
4. LOS
5. Outcomes & Effectiveness – Clostridium Difficile
6. Patient Safety
7. Patient Experience
8. 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 December 2010.
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
December (97.6%).
Key actions:EAU Locum Consultants commenced in November.
Posts to be advertised substantively in February.
Daily (08.00) debrief to review previous day/night -identifying
any issues.
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.
Meetings with ward sister commenced December to review
Discharge Plans.
Short stay beds introduced on ward G5.
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The updated detailed A&E 4 hour performance action plan is attached as a separate paper.
3. Cancelled Operations
The target was not met for December at 0.85%
Unavoidable cancellations (Surgeon sickness absence and
bad weather) accounted for 45% of the cancelled
operations. Equipment issues 10% and out of theatre time
/other for the remaining 45%.
Target 0.8%
Actual 0.91% (YTD)
The Productive Operating Theatre project (TPOT) is in
progress, and will be reported to the Board in March 2011.
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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 now below target – Actions
to improve this performance is linked to discharge action plans
and implementation of EAU model.
•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.
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5. Outcomes and Effectiveness
Clostridium difficile
The Clostridium. Difficile target
The C. difficile target for 2010/11 for the Trust is
29 hospital cases. However, in December there were
a further 2 hospital attributed cases. Patients were
transferred to the F9 cohort unit within the time frame
specified.
Due to the increase of CDT cases over the past
months the PCT have agreed to increase our annual
trajectory.
Other Infection Control indicators
The Trust continues to achieve excellent results in
other infection control KPIs. There was no hospital
associated MRSA bacteraemia. Overall compliance
with hand hygiene and the dress code requirements
for all directorates remained at 100% .
Five of the High Impact Intervention audits carried
out achieved 100%.
Five however scored 80-97%:
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6. Patient Safety
Pressure Ulcers
The number of patients with ward acquired pressure ulcers decreased this month to 7 including one Grade 3 and one Grade 4 ulcer.
Actions:
•As part of the “No avoidable pressure ulcers at WSHT” campaign, pressure ulcer education is now incorporated in the nursing and midwifery mandatory training day to ensure effective
risk assessment and improved knowledge by all staff.
•A pressure ulcer development group has been established to develop, facilitate and review an annual pressure ulcer prevention strategy
Patient Falls
The number of falls resulting in harm increased this month to 25, all harm was minor except one patient who fractured their neck of femur on F6.
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6. Patient Safety
Venous Thrombo-Embolism (VTE)
Verbal update to be provided at the meeting by Dermot O’Riordan.
Antibiotic Prescribing
Compliance with the antibiotic prescribing policy has improved this month to 90%.
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6. Patient Safety
SIRI Information
In December 2010 there were three SIRIs reported to NHS Suffolk.
All were reported to the PCT within the time frame for the initial 2 day report and the 7 day report.
Five reports were due in December. All were submitted within due date.
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Patient Satisfaction (Patient Experience Tracker)
Overall satisfaction was 88% (see Table 1 for breakdown of clinical areas).
A&E/EAU/F4 scored 80%+ in all questions.
Patient Satisfaction Questionnaires (paper)
All remaining clinical areas use this method for reporting and overall
satisfaction scored 85%.
Questions that scored lower in nearly every clinical area are:
• Were you bothered by noise at night? (overall 66%). The noise
disturbance is often related to patients being moved/ admitted onto the ward
at night or confused patients shouting.
• 23% of patients across the Trust answered that it took more than 3
minutes for the callbell to be answered.
• Although the scores have increased, most clinical areas still score below
80% in discharge issues: have you been told who to contact if you are
worried when you leave hospital (overall 76%)/ medication side-effects to
watch for when you go home (overall 74%).
Main OPD
173 returns
Diabetic Clinic
95
Eye Clinic
9
PAU
21
A&E
306
EAU
5
F4
26
93% satisfaction
91%
63%
82%
96%
94%
99%
Table 1.
The patient experience implementation group workplan addresses all these
issues and action points include: discharge information leaflets, ear plugs
offered routinely and new call bell systems which allows data analysis of
time to answer callbells.
CQUIN
Achievement of 2% patients surveyed for Q3 was achieved by adult
inpatient, children’s services and maternity services. Outpatients (main
OPD, diabetic/eye clinic/PAU) surveyed 1.4% patients against a target of
1.5%.
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8. Patient Experience
Same Sex Accommodation
The number of breaches on EAU
decreased in December to 1 breach with
8 patients affected.
The male/female configuration in EAU
was undertaken on 24th December. To
date no same sex breaches have been
reported.
Environment and Cleanliness
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9. Conclusion
The action plan remains in place and performance has improved in December with
regard to the 4hr standard.
One of the major challenges for the Trust, is in adherence to same sex accommodation
in the Emergency Assessment Unit. This was reconfigured in December.
Performance with regard to C-Difficile deteriorated in November however full RCA’s
have been carried out and actions implemented specifically with regard to anti biotic
prescribing and monitoring.
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