Tabled paper
QUALITY REPORT
A monthly report presenting an update on Patient Safety,
Clinical Effectiveness and Patient Experience in the Trust
November 2012
Tabled paper
CONTENTS
Section
1
2
3
4
5
6
7
8
9
9.1
9.2
9.3
9.4
9.5
9.6
9.7 new
9.8
9.9
9.10
9.11
9.12
9.13
9.14
10
10.1
10.2
10.3
10.4
10.5
10.6
10.7
11
11.1 new
11.2
11.3
12
13
2|Page
Item
INTRODUCTION
KEY POINTS TO NOTE
TARGETED AREAS OF SUPPORT
EMERGING TRENDS/NOTICEABLE PATTERNS
OF SPECIFIC NOTE
KEY CLINICAL RISKS
CARE QUALITY COMMISSION’S QUALITY & RISK PROFILE
CQuINS
PATIENT SAFETY
Safety Thermometer
a) Falls
b) Pressure damage
c) VTE assessment
Nutrition/fluids
Infection Control
Maternity
Emergency Department highlights
Safeguarding
Health Visiting
Medicines management
Never Events
National Patient Safety Agency (NPSA) alerts
Lessons Learned
Significant risks
‘Listening into Action’
Nurse Staffing Levels
CLINICAL EFFECTIVENESS
Mortality
Patient Related Outcome Measures (PROMs)
Clinical Audit
Compliance with the ‘Five Steps to Safer Surgery’
Stroke care
Treatment of fractured Neck of Femur within 48 hours
Ward reviews
PATIENT EXPERIENCE
Net Promoter
Complaints/PALS
a) Complaints data
b) PALS data
End of Life
WORKFORCE QUALITY
RECOMMENDATION
Page No.
3
3
5
5
5
6
7
8
9
9
11
11
12
12
13
15
16
16
16
17
20
20
21
21
21
21
23
23
26
26
27
28
28
28
29
29
30
30
31
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Tabled paper
QUALITY REPORT
1
INTRODUCTION
This report presents a composite picture of the performance against the various key Quality metrics to
which the Trust works, both in terms of those mandated at a national or regional level and those set by
the organisation.
The report has been populated with latest performance information for the period up until this Board
meeting, across a range of areas within three domains: patient safety, clinical effectiveness and patient
experience.
2
KEY POINTS TO NOTE
The Trust Board’s attention is drawn to the following this month:
PATIENT SAFETY
 Safety Thermometer for October 91.52% - a further decrease on the previous month.
The decrease in performance is mainly around an increase in pressure damage
recorded. The Board should note that all pressure sores i.e. hospital acquired and non
hospital acquired are recorded; avoidable and non-avoidable and all sores on District
Nursing caseloads on the day of the audit. For detail of hospital acquired see pressure
damage section of the report. Whilst the number of pressure sores has increased the
numbers of patients experiencing multiple harm events remains very low.
 Pressure damage – the number of hospital/health acquired, avoidable pressure damage
reduced in August. Data is not yet available for Sept/Oct but we believe that there is a
slight increase in incidents associated with medical wards at Sandwell. Accountability
meetings with the Chief Nurse are now established and we hope to see the impact of
this, plus the ‘Happy Feet’ campaign over the coming weeks. The Trust pressure
damage rates remain favourable compared to other similar Trusts.
 Falls – overall numbers remain largely the same. Analysis of the upwards trend at
Sandwell suggests that more falls are happening in side rooms and on medical wards
that had been due for closure within the bed reduction plan.
 Nutrition – audits continue to show a slight downward trend. These are due to
underperformance on a small number of wards and the issue is being addressed via
accountability meetings. The issue is predominantly around accurate ‘charting’ and the
declining performance on a few wards is thought to be due to staffing issues.
 Infection control – The Trust is achieving all mandatory standards/targets with the
exception of MRSA screening. The MRSA screening data has been left out of this report
as we now know that there are issues with counting the number of screens against the
number of eligible patients.
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Tabled paper
A full report plus plan will go to Quality & Safety Committee.
 There has been a number of D&V outbreaks predominantly of a Norovirus nature.
These are not linked in any way to each other demonstrating effective infection
control procedures. There is a considerable amount of Norovirus in the Community
currently, leading to an increase in hospitals
 Safeguarding – no internal issues for Trust Board to be aware of. There are some
concerns regarding support posts within the LA/Community.
 Nurse bank/agency rates – rates are now at the highest level for the past 4 years. This
is as a result of paused bed closure plan and early opening of winter capacity in
Medicine. These levels represent a risk to standards of care on some wards and some
early signs of deterioration have been identified via our early warning processes.
Acute recruitment is in process with approximately 50 nurses recruited in the past few
weeks. A further 50 is still required for the main in patient wards. We are also
recruiting for a number of nurses to support changes in stroke services and to meet
identified requirements in EAU and the two EDs. It has not been possible to produce
ratio reports because of the state of change in Medicines ward establishments.
 Health Visiting – information re progress with HV services are included in the report.
 Dementia – A Steering Group has now been established chaired by the Chief Nurse
with multiprofessional user and external agency representation. A full report and
plan is due to go to Q&S in December/January.
CLINICAL EFFECTIVENESS
 Fractured Neck of Femur operated on within 24 hours has increased to 85.7% a
sustained improvement on previous performance and exceeding our local target of
70%
 Compliance with the use of the World Health Organisation (WHO) checklist is 99.5%
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Tabled paper
PATIENT EXPERIENCE
 Net Promoter Score – This has improved to 63 (target 65)
 74 complaints were received in October and 116 final responses sent out. As at week
ending 23 November 2012, 27 complaints were in breach of the Trust’s failsafe target.
Clearance of the complaints backlog is on track to be achieved in the last week in
November 2012.
 End of Life – Number of appropriate patients on a supportive care pathway is now at
77% and 60% of patients on a SCP achieved their preferred place of death –
representing an improvement of 24% since April.
3
TARGETED AREAS OF SUPPORT
The areas of the Trust being provided with targeted support this month are:
 EAU Sandwell – continues in special measures – will be taken off following completion of
closure report this month and incorporation of outstanding actions in ED plans.
 ED, City
Special measures
 ED, Sandwell
 Imaging division – areas for improvement identified as a result of external reviews
 P4, P5 and L4 wards – all are struggling as a result of paused bed closures and therefore
have staffing issues. Active support is being provided and close monitoring of standards.
4
EMERGING TRENDS/NOTICEABLE PATTERNS
 Increase nursing vacancies/gaps as a result of slippage in bed closure plan and winter
capacity open early
5
OF SPECIFIC NOTE

Reports from CQC visits now received and action plans in development.
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Tabled paper
6
KEY CLINICAL RISKS




Variable standards/leadership EDs
Staffing levels as a result of ‘paused’ bed closure plan
Variable standards of Medicine storage
Currently undertaking an extensive piece of working looking at apparent issues around
antenatal screening
6|Page
Tabled paper
7
CARE QUALITY COMMISSION’S QUALITY AND RISK PROFILE
looking at apparent is
Care Quality Commission (CQC): Quality and Risk Profile (QRP)
The Care Quality Commission (CQC) publishes a QRP for each registered provider which is used to
support the day to day work of CQC inspectors. The QRP provides the Trust with a risk estimate for each
outcome of the 16 Essential Standards of Quality and Safety. These risk estimates are produced by the
CQC using a statistical model that aggregates individual pieces of information which the CQC holds
about the Trust. The risk estimates are displayed as dials as shown below:
The current risk estimates for the essential standards for quality and safety for the Trust are:
Risk estimate
No Data
Insufficient data
Low Green
High Green
Low Yellow
High Yellow
Low Amber
High Amber
Low Red
High Red
Frequency
0
2
3
10
1
-
Outcomes
21 and 11
6, 14 and 17
1, 2, 5, 7, 8, 9, 10, 12, 13 and 16
4
-
There are currently no outcome risk estimates in Amber or Red. This shows the Trust as being at a low
risk of non-compliance with the CQC’s 16 essential standards of quality and safety. The overall position
has remained the same since December 2010, with the exception of a few changes which have not been
significant enough to have an effect on the overall RAG status for the Outcomes. It is important to state
that low risk estimates in a QRP do not guarantee compliance. On-going monitoring of compliance will
take place to ensure that this position is maintained and improved.
7|Page
8
Tabled paper
CQuINs
SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST CORPORATE DASHBOARD - OCTOBER 2012
Exec
Lead
RS
June
July
August
Trust
Trust
Trust
September
October
TARGET
To Date (*=most
recent month)
PATIENT SAFETY
A
3
VTE Risk Assessment (Adult IP)
396
%
RB
K
20
Appropriate Use of Warfarin
372
RO
H
8
Safety Thermometer
396
%
RB
H
20
Antibiotic Use
743
Score
RO
D
8
RO
H
8
Acute CQUIN
Reducing Avoidable Pressure Ulcers
372
Nutrition and Weight Management
743
No.
▼
91.0
▲
91.4
S'well
■
87.5
City
→
Compliant
→
→
→
Data Submitted
Data Submitted
Data Submitted
→
→
→
→
60
Base
Trust
S'well
■
91.0
City
→
Trust
▲
91.4
→
Data Submitted
▲
83
91.4*
Compliant
→
Data Submitted
Data Submitted
→
→
83
THRESHOLDS
12/13 Forward
Projection
Note
YTD
12/13
90
90
=>90
<90
Comply with audit
No
variation
Any
variation
Monthly data
collection
No
variation
Any
variation
70
No
variation
Any
variation
No
variation
Any
variation
No
variation
Any
variation
Any
variation
80
Compliant
Compliant
Compliant
→
Compliant
→
Compliant
Compliant
Comply with audit
Q1 Base Audit
Complete
Compliant
Compliant
→
Compliant
→
Compliant
Compliant
Comply with audit
b
RS
H
9
Safe Surgery - Operating Theatres
%
→
→
99.7
■
→
99.8
■
→
99.8
■
99.8
99
100
No
variation
%
→
→
99.6
■
→
100
▲
→
99.8
▼
99.8
98
98
No
variation
Any
variation
Any
variation
743
RS
H
RS
H
RO
H
RO
D
RO
H
9
Safe Surgery - Other Areas
10
Stroke Care
Safety Thermometer
11
Community
CQUIN
743
%
Met Q1 req's
→
→
→
Met Q2 req's
→
88
%
Data Submitted
Data Submitted
Data Submitted
→
Data Submitted
→
→
Met Q2 req's
Comply Comply
No
variation
Data Submitted
Monthly data
collection
No
variation
Any
variation
Any
variation
Reducing Avoidable Pressure Ulcers
176
Compliant
Compliant
Compliant
→
Compliant
→
Compliant
Comply with audit
No
variation
Nutrition and Weight Management
176
Q1 Base Audit
Complete
Compliant
Compliant
→
Compliant
→
Compliant
Comply with audit
No
variation
Any
variation
%
Met Q1 req's
Met Q2 req's
Met Q2 req's
→
Met Q2 req's
→
90
No
variation
Any
variation
%
68.2
▲
▼
▲
→
66.4
▲
→
66.4
80
No
variation
Any
variation
44
%
Met Q1 req's
Met Q2 req's
Met Q2 req's
→
Met Q2 req's
→
Met Q2 req's
70
90
No
variation
Any
variation
396
%
67.9
▲
→
→
→
→
→
67.9
67.6
71.6
No
variation
Any
variation
Any
variation
•
•
•
•
•
•
•
•
•
•
•
•
10/11
Outturn
11/12
Outturn
92.3
92.4
EFFECTIVENESS OF CARE
RO
H
8
Dementia
396
Meeting Q3 req's Meeting Q3 req's
70
Acute CQUIN
RS
RO
H
H
3
11
Mortality Review
Community
CQUIN
Dementia
743
63.6
64.9
66
b
•
•
•
PATIENT EXPERIENCE
RO
H
8
Net Promoter
372
No.
58
▲
58
■
60
▲
→
63
▲
→
63
60
65
End of Life Care
372
%
47
▼
55
▲
57
▲
→
60
▲
→
60
48
53
No
variation
Any
variation
10
Every Contact Counts - Alcohol
372
%
55
Base
12
Every Contact Counts - Smoking
372
%
→
11
Pt. (Community) Exp'ce - Personal Needs
44
Score
→
No
variation
Any
variation
No
variation
Any
variation
H
8
RO
H
8
RS
H
RO
H
RO
H
H
→
No
variation
RO
RO
Personal Needs
Acute CQUIN
11
Net Promoter
Community
CQUIN
88
No
75
→
→
Base
91 (H'son) & 80
(L'wes)
55
Base
→
→
91.5
▼
→
91.5
90
90
71
■
→
81
■
75
75
81
RO
H
11
Every Contact Counts
132
%
→
→
Baseline
established
→
Baseline
established
RO
H
11
Smoking Cessation
132
%
→
Base data being
captured
Base data being
captured
→
Baseline
established
→
Baseline
established
RS
H
49
Q1 Data
Submitted
→
→
→
Q2 Return
Submitted
→
73
%
Q1 Data
Submitted
→
→
→
Q2 Return
Submitted
122
%
Q1 Data
Submitted
→
→
→
Q2 Return
Submitted
%
Q1 Data
Submitted
→
Q2 Return
Submitted
RS
H
13
RS
H
13
RS
H
12
Neonatal - Hypothermia Treatment
Specialised
Commissioners Neonatal - Discharge Planning / Family
Experience and Confidence
HIV - Optmum Therapy
147
→
Base data being
captured
→
Base data being
captured
Clinical Quality Dashboards
80
▲
→
Baseline
established
→
95.5
→
■
→
Baseline
established
→
91
→
→
b
→
Q2 Return
Submitted
Submit Submit
Data
Data
No
variation
Any
variation
→
→
Q2 Return
Submitted
Derive
Base
Derive
Base
No
variation
Any
variation
→
→
Q2 Return
Submitted
Derive
Base
Derive
Base
Met
Not Met
→
Q2 Return
Submitted
Submit Submit
Data
Data
No
variation
Any
variation
→
•
•
•
•
•
•
•
•
•
•
•
•
•
66.9
Tabled paper
9
PATIENT SAFETY
9.1
Safety Thermometer
CQUiN for 2012/13 – requires introduction of the tool in acute and community in patient areas. CQUiN
Conducting monthly whole Trust census of patients for 4 harm events (falls, pressure damage, CAUTI
and VTE) continues to go well with good engagement of nursing staff. Work has commenced to add
other harm measures to the tool, eg avoidable weight loss.
The SHA ambition is for Trusts to achieve 95% harm free care.
Mar-12
90.48%
Apr-12
91.12%
May-12
94.75%
Figure 1: Harm free care trend
Jun-12
93.74%
Jul-12
93.55%
Aug-12
93.79%
Sep-12
93.43%
Oct-12
91.52% 
Nov-12
Dec-13
Tabled paper
Figures 2 & 3: Number of patients by type and number of harm incidents
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Acute Divisions
18 patients experienced 1 harm. No patients experienced 2, 3 or 4 harms
Community Division 6 patients experienced 1 harm and 0 patients experienced 2, 3 or 4 harms
a)
Falls
There are no formal targets set for falls for 2012/13 other than the safety thermometer but we will
continue to aim to reduce avoidable falls across the Trust by a further 10%. Our audits will continue to
monitor risk assessment compliance, appropriate use of care bundles and numbers of falls. Falls with
injury continue to be reported as adverse incidents and TTRs conducted.
6.00
4.00
2.00
0.00
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Sandwell Hospital
Feb-12
Mar-12
City Hospital
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Trust Total
Figure 4: Incidence of falls per 1000 bed days across Acute Inpatient Divisions
Sandwell continues to have a higher number of falls compared to City.
b)
Pressure Damage
Target 2012/13:
Eradication of all avoidable pressure damage SHA Priority and CQUiN.
Target to assess patients for risk, introduce appropriate care bundle and conduct
TTRs on all grade 3 and 4 sores.
75
50
25
0
Apr
May
Jun
Jul
2009-2010
Aug
Sep
2010-2011
Oct
2011-2012
Nov
Dec
Jan
Feb
Mar
2012-2013
Figure 5: Number of hospital acquired pressure damage Grade 2, 3 & 4, April 2009 - July 2012
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Tabled paper
New avoidable pressure ulcers (reported on ST):
October – 9 (7 grade 2, 2 grade 3, 0 grade 4).
Heel sores continue to account for the largest number of hospital acquired sores associated with TeD
stockings, slipper socks and plaster casts. A ‘Happy Feet’ campaign has now launched.
Accountability meetings have been established with the Chief Nurse where Matrons and Ward
Managers are called to account for every grade 3/4 hospital acquired avoidable sore.
c)
VTE Risk Assessment
The VTE Risk Assessment CQUIN target continued from 2011/12. Performance of at least 90% each
month is required to trigger payment. Early data for October indicates performance of 91.4%, just
above the required threshold of 90% CQUiN
9.2
Nutrition/Fluids
Target 2012/13:
Reduction of avoidable weight loss in patients on 8 Trust wards where vulnerable
adults are nursed. CQUiN
90% patients MUST assessed within 12 hours admission Internal Priority
Summary of Nutrition Audits (Sept 2011-Oct 2012)
105%
Percentage
100%
95%
90%
85%
80%
75%
11
pSe
O
11
ct-
11
vNo
11
cDe
12
na
J
12
bFe
2
-1
ar
M
2
r-1
Ap
ay
M
12
12
nu
J
2
l-1
Ju
12
gu
A
12
pSe
O
12
ct-
Month
MUST @ 12hrs
MUST @ 7 days
Figure 6: Nutrition Audit Results
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`R@R’ onBed Plan
Food Diary
Fluid Bal Chart
Tabled paper
9.3
Infection Control
Targets 2012/13:
(National Priority
Local contract)
C difficile – 57 cases (post 48 hours, using SHA testing methodology)
MRSA – 2 cases (post 48 hours)
MRSA Screening – 85% eligible patients
Blood culture contaminants – 3% or less
E Coli and MSSA – Continue to record and TTR device related
infections
National cleanliness standards – 95%
MRSA
There were no post 48 hour cases of MRSA reported in October.
MRSA Screening
Target:
85% eligible patients by March 2013.
The MRSA screening data has been excluded from reporting until clarification has been achieved.
Clostridium difficile
60
50
40
30
20
10
0
Apr-12
May-12
Jun-12
Jul-12
Sandwell
Aug-12
City
Sep-12
Oct-12
Nov-12
Threshold (cumulative)
Dec-12
Jan-13
Feb-13
Mar-13
Trust Total (cumulative)
2012-2013
Sandwell
City
Trust
Intermediate Care
DoH Trajectory
Trust Total (cumulative)
Threshold (cumulative)
Apr-12 May-12 Jun-12
1
0
1
2
1
1
3
1
2
0
0
0
5
5
5
3
4
6
5
10
15
Figure 7: SHA Reportable CDI
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Jul-12
0
2
2
0
5
8
20
Aug-12 Sep-12
2
1
4
1
6
2
0
0
5
5
14
16
25
30
Oct-12 Nov-12 Dec-12
2
3
5
0
0
0
5
5
5
21
21
21
35
40
45
Jan-13
Feb-13 Mar-13
0
0
0
4
21
49
4
21
53
4
21
57
Total
7
14
21
0
57
-
Tabled paper
10
8
6
4
2
0
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Sandwell
City
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
2012-2013
Sandwell
City
Trust
Intermediate Care
Trust Total (cumulative)
Apr-12 May-12 Jun-12
3
2
2
4
4
4
7
6
6
0
0
0
7
13
19
Jul-12
5
2
7
0
26
Aug-12 Sep-12
4
2
8
2
12
4
0
0
38
42
Oct-12 Nov-12 Dec-12
5
4
9
0
0
0
51
51
51
Jan-13
Feb-13 Mar-13
0
0
0
51
51
51
Total
23
28
51
0
-
Figure 8: Trust Best Practice Data
Blood Contaminants
Percentage Possibly Contaminated
12.0%
10.0%
Model Data City
Model Data Sandwell
8.0%
6.0%
4.0%
2.0%
0.0%
01/2009 04/2009 07/2009 10/2009 01/2010 04/2010 07/2010 10/2010 01/2011 04/2011 07/2011 10/2011 01/2012 04/2012 07/2012 10/2012
Figure 9: Blood Contaminants
E Coli Bacteraemia
30
25
20
15
10
5
0
Apr-12
May-12
Jun-12
Jul-12
Sandwell
Figure 10: E Coli Bacteraemia
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Aug-12
Sep-12
City
Oct-12
Nov-12
Dec-12
Trust Total (cumulative)
Jan-13
Feb-13
Mar-13
Tabled paper
MSSA
20
15
10
5
0
Apr-12
May-12
Jun-12
Jul-12
Sandwell
Aug-12
City
Sep-12
Oct-12
Threshold (cumulative)
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Trust Total (cumulative)
Figure 11: MSSA
Outbreak and Other Infection Control Activity

Newton 4 was closed on 29th September because of diarrhoea and vomiting. A cause for this
outbreak has not been identified. The ward re-opened on 24.10.12 following a decant to
Newton 2 to allow a full deep clean and application of hydrogen peroxide vapour.

D11 was closed on 22nd October because of 5 patients with diarrhoea and/or vomiting. No
infectious cause has been identified for this outbreak and the ward has now re-opened
following a decant to D20 to allow deep clean and application of hydrogen peroxide vapour.

D17 was closed on 20th October because of diarrhoea and vomiting. The cause for the outbreak
has been confirmed as norovirus. The ward decanted to D20 to enable a full deep clean and
application of hydrogen peroxide vapour and D17 re-opened on 12th November.

Leasowes was temporarily closed 20th-25th October because of symptoms of diarrhoea and
vomiting. No infectious cause has been detected for the majority of patients; however, one
patient was found to have CDI. This strain has been identified as identical to another patient
idenitified with CDI at Leasowes, making this a CDI outbreak by definition. An outbreak meeting
has been organised for 16th November.
PEAT
National Standards of Cleanliness average scores 96%.
9.4
Maternity
The Obstetric Dashboard is produced on a monthly basis. Of note:
Post Partum Haemorrhage (PPH)(>2000ml): there were 3 patients recorded to have had a PPH of
>2000ml in September.
Adjusted Perinatal Mortality Rate (per 1000 babies): the adjusted perinatal mortality rate for
September was 7.9 which was just under the trajectory (8) but was slightly higher than the previous
15 | P a g e
Tabled paper
month. Perinatal mortality rates must be considered as a 3 year rolling average due to the small
numbers involved and the significant variances from month to month.
Caesarean Section Rate: the number of caesarean sections carried out in September was 21.4%, which
is below the trajectory of 25% over the year and lower than the previous month.
Delivery Decision Interval (Grade I, CS) >30 mins: the delivery decision interval rate for September was
15% which is on trajectory (15).
Community Midwife Caseload (bi-monthly): The community midwife caseload in September decreased
to 139 from 142 in the previous month, which is just below the trajectory of 140.
Vacancies: Vacancy rates remained high in September (11.6).
9.5
Emergency Department highlights
A separate report is provided for the Trust Board this month.
9.6
Safeguarding
Safeguarding adults and children is managed via a Trust Committee structure chaired by the Chief
Nurse. Key points reported at the September Committee:
 70% of Trust staff have now had a CRB within the last 3years
 Mandatory Training is broadly on track
 Learning Disability Project Plan agreed. PMR issues now resolved.
 Project plan for ‘Refusal of Treatment’ presented but requires wider consultation.
 Domestic Homicide plan presented and agreed. The Board should note that every DH
investigation that is now required by the Safeguarding Boards is very resource intensive and as a
Trust we are likely to see approx. 6 – 12 every year.
 The Committee noted the removal of the domestic violence advisor post (Sandwell) from the
Community Safeguarding Team (non Trust staff). This will impact on training capacity and
advise within HV, Maternity and the ED’s. Concerns have been formally raised with the
CCG/LA/Safeguarding Board.
 The Trust has served notice to the CCG for the SLA for the Community Safeguarding Children
team and intends to bring into the Trust.
9.7
Health Visiting
The recent review of the Health Visiting Service by Sustain on behalf of NHS West Midlands recognised
several areas of strengths. In particular:
 Level of integration with other services in the 18 months of being part of the Trust

The workforce plan is the best scoping document in the Black Country in relation to the actions
required in ‘a call to action’

Staff ambassadors providing an extra dimension to engagement
16 | P a g e
Tabled paper

Listening into action as a method of staff engagement

Restorative supervision being rolled out to the whole team by November 2012

Leadership Development across all band 7s and now offered to band 6’s

Professional leadership and professional forums in place
The priority recommendations from the review included further deliverables around:
1. Staff & Workforce – Communication and Engagement Staff Communication Systems
2. Staff & Workforce – CPT & Student Wellbeing & Support CPT Capacity
3. Users & Partners – Commissioning Framework & Outcomes Service Specification
4. Defining the Service Offering – Universal & Universal Partnership Plus Development
of the Service Offer
The review was beneficial to get an external objective measure of progress and it complements the
planned activity in the Directorate IDP and the Health Visiting Workforce Plan.
To ensure that the service continues on its planned trajectory for delivering the Sandwell and West
Birmingham Health Visiting Model, we have taken the opportunity to develop an all inclusive project
plan as a pragmatic operational tool to inform our future activities. This also identifies key
interdependencies and potential barriers to success and creates plans to overcome these.
The Health Visiting plan for increasing HV numbers is on track within the Trust. We are fully established
and training numbers are in excess of our requirements for the next year.
9.8
Medicine Management
Target
% of patients with documented drug
allergy status on chart
% of patients with documented
stop/review date
% of patients with documented
indication on drug chart
% of patients compliant with abx
guidelines
Baseline
June
August
September
October
97%
91.7%
94.6%
95.0%
95.4%
92.80%
95%
73.7%
77.1%
74.7%
78.9%
81.80%
95%
8.8%
13.1%
51.6%
49.2%
66.90%
90%
86.0%
87.5%
96.2%
94.7%
96.10%
Figure 12: Results of drugs storage audits
Drug storage audits have been carried out in September for general drugs and controlled drugs.
For general drug audits a lower level of compliance has been seen compared to the August results.
For controlled drugs an improvement has been seen.
General Drugs
 Compliance of 90-100% was seen across 65% of standards (37% in September)
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Tabled paper

Compliance of over 70% was seen across 95% of standards (70% in September)
Controlled Drugs
 Compliance of 90-100% was seen across 67% standards (57% in September)
 Compliance of over 70% was seen across 81% of standards (81% in September)
Use of antibiotics – Antimicrobial Stewardship
The CQUIN target relating to antimicrobial prescribing has three elements – improving our score for
antimicrobial stewardship using the Department of Health Self-Assessment Toolkit, performing
quarterly audits of antimicrobial prophylaxis in general surgery and trauma & orthopaedic patients, and
a two monthly point prevalence survey of antimicrobial prescribing in all inpatients.
This report relates to the point prevalence survey, which gathers data on:







Percentage of patients with allergy status recorded on the drug chart;
Rationale: allergy status recording and documentation is a key patient safety initiative. A blank
allergy status box on the drug chart should be the exception, rather than the rule.
Percentage on antibiotics;
Rationale: There will always be patients on antibiotics, but limiting unnecessary prescribing will
help to maintain this percentage to the minimum.
Percentage on IV antibiotics;
Rationale: while this can be influenced by case mix and severity of infection, Trust guidelines
recommend oral antibiotics for the majority of infections, so this percentage should remain
stable, or decline over the course of the year.
Percentage on IV antibiotics for greater than 48 hours;
Rationale: a high proportion of patients on IV antibiotics for more than 48 hours may indicated
a delay in reviewing the need for and appropriateness of IV antibiotics, which are inconvenient
for the patient, require additional nursing time to prepare and administer and can cost up to 20
times more than an equivalent oral dose.
Percentage on antibiotics for more than 5 days;
Rationale: Trust guidelines on duration of therapy should be followed, and a high proportion of
patients on antibiotics for more than 5 days may indicate inappropriate durations of therapy
and failure to review patients.
Percentage with stop/review date documented on drug chart;
Rationale: The trust ‘Management of Antimicrobial Therapy’ policy and guidance from the
Department of Health specify that all antibiotic prescriptions must have a stop or review date
documented on the drug chart, to limit unnecessary antibiotic consumption.
Percentage with indication documented on drug chart.
Rationale: The trust ‘Management of Antimicrobial Therapy’ policy and guidance from the
Department of Health specify that all antibiotic prescriptions must have the indication
documented on the drug chart, so that all members of the healthcare team are clear why the
patient is taking antibiotics so there is no barrier to discontinuing them if they are not required.
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Tabled paper
Figure 13: Results of point prevalence survey
Data is collected by ward pharmacists on all inpatient wards at City and Sandwell hospitals, using a
standardised data collection form, and information from the drug chart and the medical notes. A
baseline assessment was undertaken in March and April 2012, and will be repeated monthly thereafter.
The data presented below represent the average of the two data points and form the baseline results
from which performance over the remainder of the financial year will be assessed. The October position
is summarised in the table below.
Indicator
SWBH
City
Sandwell
558
282
276
Number of patients
92.8%
89.5%
96%
% with allergy status
documented
27.6%
29.8%
25.4%
% on antibiotics
14.5%
14.5%
14.5%
% on IV antibiotics
60.5%
63.4%
57.5%
% on IV antibiotics for
more than 48 hours
9.7%
11.7%
7.6%
% on antibiotics for >5
days
81.8%
83.3%
80.0%
% with stop/review
date documented on
drug chart
66.9%
64.3%
70.0%
% with indication
documented on drug
chart
96.1%
95.2%
97.1%
% with antibiotics in
line with guidelines
*excluding neonatal unit
Figure 14: Baseline results from medicines management audit
19 | P a g e
Baseline
91.7%
30.8%
14.6%
61.4%
CQUIN
target
>97%
Maintain at
baseline level
9.7%
77.1%
>95%
8.8%
>95%
87.5%
>90%
Tabled paper
Agreement was reached with Sandwell PCT with regard to the acceptable thresholds for these point
prevalence surveys. It was agreed that 97% of patients (excluding neonates) should have their allergy
status documented on the drug chart. As a trust, this is not being achieved, and the position in
September (92.8%) has worsened August (95.4%), and is only marginally better than the baseline of
91.7%. This decline in performance was mainly driven by poor results at City, where the percentage of
allergy status recording dropped below 90%.
The percentage of patients on antibiotics (27.6%) is well below the baseline, which was the same as the
result in September (30.8%%), while the percentage of patients on intravenous antibiotics almost the
same as baseline (14.5% versus 14.6%). There has been a slight increase in the percentage of patients
on IV antibiotics for more than 48 hours compared to September (60.5% versus 58.9%), but it is
marginally below the baseline figure of 61.4%. The percentage of patients having more than 5 days of
antibiotics has declined compared to September (9.7% versus 10.9%), and remains the same as
baseline.
Compliance with recording of stop or review dates continues to improve, with the data for October
(81.8%) showing improvement over September (78.9%%) and also the baseline assessment (77.1%).
Recording of the indication for antibiotics on the drug chart is almost at 67% for the trust, which
continues to improve since the baseline assessment of 8.8%.
Compliance with the trust guideline needs to be achieved in ≥90% of antibiotic prescriptions; this was
achieved both at City and Sandwell.
9.9
Never Events
There were no Never Events reported in October 2012.
9.10
National Patient Safety Agency (NPSA) alerts
1. Overdue alerts: NPSA 2011/PSA001 – Safer spinal (intrathecal) epidural and regional devices. This
alert will continue to remain as “ongoing” on the Central Alert System until all of the components we
require to safely convert to the new neuraxial devices are available. We have been advised that the
manufacturer will not have these ready until June 2013 at the earliest.
2. New alerts: No new alerts have been received.
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Tabled paper
9.11
Lessons Learned
The key to a positive safety culture within the organisation is to learn from incidents through
sustainable actions. Below are some of these actions taken or being taken following serious incident
investigations.
Incident
Missed opportunity to
rescue a deteriorating
patient.
9.12
Extract from Action Plan
 Sepsis trolley available on assessment unit
 Specific shift leader identified for each shift
 Further work reinforcing escalation triggers for medical review or
EMRT
 Increased out of hours consultant cover
Significant Risks
Significant risks are presented on a monthly basis at the Risk Management Group (RMG). These risks
are being proposed for inclusion onto the corporate risk register.
Existing risks on the Corporate Risk Register are currently being reviewed and presented to the Quality
& Safety Committee in October and November 2012.
One risk was presented for inclusion on the Corporate Risk register from Critical Care Services regarding
risks related to unit capacity.
9.13
‘Listening into Action’
To ensure a smooth transition from Datix to the Safeguard Incident reporting system, for community
staff, work is progressing to ensure that all of the departments and reporting lines are correct.
9.14
Nurse Staffing Levels
The data for nurse staffing ratios is not available this month.
Bank & Agency
The Trust’s nurse bank/agency rates are detailed in the tables below and show year on year comparison
from 2008/9 to date. Notably we are now using more nurse bank/agency than we have for the past 4
years.
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Tabled paper
8000
7000
6000
2008 - 2009
5000
2009 - 2010
4000
2010 - 2011
2011-2012
3000
2012-2013
2000
1000
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Figure 15: Total Bank & Agency Use Nursing April 2008 –date.
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Jan
Feb
Mar
Tabled paper
6
10
10.1
CLINICAL EFFECTIVENESS
Mortality
CQUIN Target
As part of the Trust’s annual contract agreement with the commissioners the Trust has agreed a CQUIN scheme
with an end year target to review 80% of hospital deaths within 42 working days.
During the most recent month for which data is available (September) the Trust reviewed 66.4% of deaths
compared with a trajectory for the period of 66.0%.
The value of this CQUIN for 2012 / 2013 is approximately £743K.
Figure 16: Mortality review results
HSMR (Source: Dr Foster)
The Hospital Standardised Mortality Ratio (HSMR) is a standardised measure of hospital mortality and is
an expression of the relative risk of mortality. It is the observed number of in- hospital spells resulting in
death divided by an expected figure.
The Trusts 12-month cumulative HSMR (95.5) remains below 100, and remains lower than that of the
SHA Peer (100.2), with both Trust and SHA (Peer) HSMR within 95% statistical confidence limits. The inmonth (July) HSMR for the Trust has reduced to 85.5 and remains within statistical confidence limits
(See Mortality table and graph below).
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Tabled paper
HSMR (Source: Healthcare Evaluation Data (HED))
For comparison the Trust HSMR for corresponding 12-month cumulative periods, derived from the
UHBT Healthcare Evaluation Data (HED) Tool is included. The HSMR for the most recent 12-month
cumulative period remains stable at 96.5. HED data is subject to continued rebasing.
Summary Hospital – Level Mortality Indicator (SHMI)
The SHMI is a national mortality indicator launched at the end of October 2011. The intention is that it
will complement the HSMR in the monitoring and assessment of Hospital Mortality. One SHMI value is
calculated for each trust. The baseline value is 1. A trust would only get a SHMI value of 1 if the number
of patients who die following treatment was exactly the same as the number expected using the SHMI
methodology. SHMI values have also been categorised into the following bandings.
1
2
3
where the Trust’s mortality rate is ‘higher than expected’
where the trust’s mortality rate is ‘as expected’
where the trust’s mortality rate is ‘lower than expected’
Further SHMI data was published on 23/10/12 for the period April 11 – March 12. For this period the
Trust has a SHMI value of 0.97 and was categorised in band 2.
 10 trusts had a SHMI value categorised as ‘higher than expected'
 16 trusts had a SHMI value categorised as ‘lower than expected'
 116 trusts had a SHMI value categorised as ‘as expected'
May
June
July
Internal Data:
Hospital Deaths
146
126
121
Dr Foster 56 HSMR Groups:
Deaths
129
111
100
HSMR (Month)
89.2
89.7
85.5
HSMR (12 month cumulative)
88.3
96.4
95.5
HSMR (Peer SHA 12 month cumulative)
93.3
101.3
100.2
Healthcare Evaluation Data - HSMR (12 month cumulative)
96.8
Figure 17: Mortality statistics
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97.0
96.5
Tabled paper
Figure 18: HSMR/Readmission rate
Note In the graph above it should be noted that last month there was a sharp rise shown both for our
Trust and also for our SHA peers. This is because the scores have been rebased and does not indicate a
deterioration in performance.
CQC Mortality Alerts received in 2012/13
No new alerts have been received.
Dr Foster generated alerts (RTM)
A new diagnoses group is alerting with significant variation in terms of mortality when the data period
September 2011 – August 2012 is considered (see table below). The alert concerns the primary
diagnosis grouping of ‘Pulmonary Heart Disease’. The alert has been discussed at the Mortality &
Quality Alerts Committee (MQuAC). The majority of cases have already been reviewed under the
Mortality Review System (MRS). The remaining cases will be reviewed and a report discussed at the
next meeting of MQuAC.
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Tabled paper
Figure 19: Mortality in hospital diagnoses
National Clinical Audit Supplier – Potential Outlier Alerts
The Trust has not been notified of any new outlier alerts.
10.2
Patient Related Outcome Measures (PROMs)
Further provisional data in the form of experimental statistics was published on 13/11/12 for the
2011/12 financial year and also for the period April 12 to June 12 for the current financial year. Details
of the Trust’s performance will be presented to the Governance Board in December and further
information will be provided in the next Quality Report.
10.3
Clinical Audit
Clinical Audit Forward Plan 2012/13
The Clinical Audit Forward Plan for 2012/13 contains 83 audits that cover the key areas recognised as
priorities for clinical audit. These include both the ‘external must do’ audits such as those included in
the National Clinical Audit Patient Outcomes Programme (NCAPOP), as well as locally identified
priorities or ‘internal must do’ audits.
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Tabled paper
Status
Total
0 - Information requested
3
1 - Audit not yet due to start
9
2- Significant delay
2
3- Some delay - expected to be completed as planned
9
4- On track - Audit proceeding as planned
44
5- Data collection complete
10
6- Finding presented and action plan being developed
7- Action plan developed
A - Abandoned
Grand Total
1
2
3
83
The status of the audits that have been included in the plan as at the end of October is shown in the
table above. A further 2 audits have been indicated as having been abandoned. These audits are not
being run nationally in 2012/13 (National COPD Audit & Multiple Sclerosis Sentinel Audit).
10.4
Compliance with the ‘Five Steps for safer surgery’
Compliance with the “Five Steps to Safer Surgery” process is reported using the Clinical Systems
Reporting Tool (CSRT).
The reported compliance with the 3 sections in the checklist for October 2012 is shown in the table
below.
Trust performance (source QMF Dashboard- CDA)
“Five Steps to Safer Surgery”
Completion of the 3 sections of the checklist only
Reported compliance
October 2012
99.5%
All checklist sections and brief
93.5%
All checklist sections completed and brief & debrief
81.7%
The WHO Checklist Steering Group continues to meet monthly. Work is in progress to carry out
qualitative reviews focussing on the culture of patient safety in areas where interventions take place. A
communication plan has been drawn up and in under constant updating. Focus is on improving
completion of the debrief section of the 5 steps. The group also looks at if there are lessons to be
learned where any incidents have occurred where a WHOCL could be used.
A communications plan has been developed and is monitored by the group monthly.
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Tabled paper
10.5
Stroke care
Performance against the principal stroke care targets to which the Trust is working in 2012/13 is
outlined in the table below.
Indicator
July
Aug
Sept
Target
Pts spending >90% stay on Acute Stroke Unit
85.1
▼
88.9
▲
87.2
▼
83%
Pts admitted to Acute Stroke Unit within 4 hrs
64.0
▼
68.7
▲
65.1
▼
90%
Pts receiving CT Scan within 24 hrs of arrival
94.0
▲
93.8
▼
100
■
100%
Pts receiving CT Scan within 1 hr of arrival
51.3
▼
53.1
▲
61.5
▲
50%
TIA (High Risk) Treatment <24 h from initial presentation
57.1
■
80.0
■
71.4
▼
60%
TIA (Low Risk) Treatment <7 days from initial presentation
58.3
■
82.5
■
84.2
▲
60%
KEY TO PERFORMANCE ASSESSMENT SYMBOLS
▲
Fully Met - Performance continues to improve
■
Fully Met - Performance Maintained
▼
Met, but performance has deteriorated
▲
Not quite met - performance has improved
■
Not quite met
▼
Not quite met - performance has deteriorated
▲
Not met - performance has improved
■
Not met - performance showing no sign of improvement
▼
Not met – performance shows further deterioration
10.6
Treatment of Fractured Neck of Femur within 48 hours
The Trust has an internal Clinical Quality target whereby 70% of patients with a Fracture Neck of Femur
receive an operation within 24 hours of admission. Provisional data for October indicates 85.7% of
patients with a Fractured Neck of Femur received an operation within 24 hours of admission, resulting
in a year to date performance of 72.7% Internal Priority
10.7
Ward Reviews
The ward reviews will be reported in December.
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Tabled paper
10.1
11
Patient
Survey
Results
PATIENT
EXPERIENCE
11.1
Net Promoter
The Trust overall Net Promoter Score (NPS) increased by 3 to 63 making progress towards the SHA
target of 65 - the CQuIN requires a 10 point improvement on the baseline of 55 by March 2013. CQUiN
% returns have increased with the use of iPADS – weekly reports to the SHA has commenced.
SHA ambition requires both the improvement on score plus weekly reporting.
FFT 1
Friends and Family Test Survey (Net Promoter)
Summary Results Dashboard – September 2012
SWBH - Net Promoter Scores
Comparison of Net Promoter Scores from Neighbouring Trusts - September 2012
(This comparison does not take into account local patient diff erences, e.g. demographics)
70
60
50
58
57
55
60
58
63
100
80
40
60
30
40
20
20
Apr-12
May-12
Jun-12
Jul-12
SWBH - Net Promoter Scores (NPS)
Aug-12
Sep-12
63
63
UHB NHS
SWBH NHS
77
76
70
64
68
Dudley NHS
Wolverhampton
NHS
Walsall NHS
Heartlands NHS
Combined
Cluster Region
0
March 2013 Target NPS: 65
The Trust is making steady progress towards its target.
(Note: Other Trusts have different target levels).
The Trust NPS has shown steady improvement to reach 63 (+3) in Sept 2012
SWBH September 2012: Breakdown of Net Promter Responses
Trust Net Promoter Scores and Survey Returns %
6%
70
60
55
58
57
58
60
19
18
Jul-12
Aug-12
50
40
30
20
63
26%
12
11
10
Apr-12
May-12
Jun-12
24
10
0
68%
NPS
Sep-12
Survey returns
The Trust maintained a good survey response rate attributed to use of Ipads on
the wards for feedback collection.
Promoters
Passives
Detractors
Ward Action Plans to target the ‘Passive’ group to convert into ‘Promoters’
which can improve NPS dramatically.
Figure 20: Net Promoter position
Resources have now been identified to expand the Patient Experience Team which will enable a more
robust and co-ordinated approach to improvements in patient experience and bringing patient
experience to the Trust Board.
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Tabled paper
11.2
Complaints/PALS
a)
Complaints and PALS data
i) Complaints: Table A sets out the complaints data for October 2012 with reference to previous
months where relevant.
A)
Table A: number of complaints received and sent
MONTH
July 2012
Aug 2012
Sept 2012
Oct 2012
First
contact*
62
77
55
62
Complaint type:
RECEIVED
Link*2
4
10
5
12
TOTAL
66
87
60
74
First
contact*
42
58
81
97
Complaint type:
SENT
Link*2
3
3
11
19
TOTAL
45
61
92
116
*First Contact complaint: where the Trust’s substantive (i.e. initial) response has not yet been made.
*2Link complaint: the complainant has received the substantive response to their complaint but has returned as they
remain dissatisfied/or require additional clarification.
Failsafe parameters
The failsafe parameters identify those complaints which breach a prescribed period of days considered
the maximum acceptable time for the Trust to respond in the context of the risk grade of the complaint
(see Risk Grade2 above). These complaints comprise the ‘complaints backlog’.
The failsafe parameters for 1 April 2012 onwards comprise: 60 days for red; 70 days for amber and 20
days (fast track) or 90 days for yellow and green grade complaints.
There is a commitment to ensure that all cases currently over their “failsafe” date have been
investigated and a final response sent to the complainant.
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Tabled paper
At the time of this report the position is as follows:
Week ending
Total
Total backlog Total Backlog
Friday….
responses
responses
count
sent
sent
(failsafe target
breaches)
09/11/12
16/11/12
23/11/12
24
45
26
12
27
19
52
47
27
Figure 21: Progress with completing backlog complaints
b)
Complaints and PALS data
ii) PALS

Contacts and general enquiries: In October 2012 PALS recorded 188 PALS enquiry contacts and
189 general enquiry contacts, in comparison to September 2012 where PALS recorded 148 PALS
enquiry contacts, and 194 general enquiry contacts. The general informal enquiries are not
captured on the PALS database but relate to enquiries taken at the PALS reception desk.

Chart A provides a breakdown of the themes identified via PALS contacts in October 2012. The
main categories reported during the month of October 2012, were issues relating to Clinical
Treatment. PALS received 40 enquiries this month in comparison to 35 reported during
September 2012. These relate to queries, comprising the categories of clinical care, low staffing
levels, and medicines. In addition, issues relating to a delay in the following: investigations,
results, surgery, treatment and x-ray/scan.

During October 2012, there has been a slight increase in the number of appointment enquiries
where 21 enquiries were received during September 2012, and 25 during October 2012.
Appointment enquires relate to appointments cancelled, delay, notification and time.

There has been an increase in the number of formal complaint issues which comprise the
categories of handling, advice, process, referral and response time from 34 enquiries reported
during this month, in comparison to 26 enquiries during September 2012.
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Tabled paper
CHART A – Breakdown of top 10 issues
PALS Enquiries September/October 2012
250
200
150
September
100
50
October
0
Ad Ap At Cl Co Ge Pe Pr Fo PA
mi po titu inic m ne rs op rm LS
ss int de al mu ra on ert al i
ion m o tr n l e al y co nfo
/D ent f st eat icat nq rec and mp rm
isc s aff me ion uir or e la al
y ds xp int en
ha
nt
en s qu
rge
se
irie
/Tr
s
s
a..
.
a) Parliamentary and Health Service Ombudsman (PHSO) cases

The NHS Complaints Procedure comprises 2 stages. The first or ‘local resolution’ stage involves the
Trust investigating the complaint and providing a substantive response to the complainant. Where
the complainant remains dissatisfied with the Trust’s response given at the local resolution stage,
the complainant can progress their complaint to the second stage, that is, referral to the
Parliamentary and Health Service Ombudsman (PHSO). The PHSO provides a service to the public
by undertaking independent investigations into complaints that the NHS has not acted properly
fairly or has provided a poor service.

The Trust currently has 6 active cases with the PHSO.
11.3
End of Life
End of Life Report
Targets/Metrics:
32 | P a g e
CQuIN 10% increase in number of patients achieving preferred place of death
who are on a supportive care pathway – Acute and Community. This is also a
national nursing high impact action and nurse sensitive indicator. The target for
this year is 53%.
Tabled paper
% of Patients on SCP
Preferred Place of Care/Death of Patients on SCP (Joint
CQUIN)
70%
60%
50%
40%
30%
20%
10%
0%
60%
48%
36%
April
55%
May
June
July
Aug
Sept
Month
Figure 22: Preferred place of death/death of patients on SCP
33 | P a g e
Target
53%
57%
47%
Oct
Nov
Dec
Tabled paper
WORKFORCE QUALITY
12
The Board is asked to note key headlines from the workforce dashboard for October 2012.
% Trust
Mandatory Training
PDR
Turnover (leavers)
Sickness absence
85.06% (85%)
68.2% (85%)
8.57%
4.31% (3.5%)
RECOMMENDATION
13
The Trust Board is asked to:

NOTE in particular the key points highlighted in Section 2 of the report and DISCUSS the
contents of the remainder of the report.
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Tabled paper
APPENDIX 1
Glossary of Acronyms
Acronym
CAUTI
C Diff
CRB
CSRT
CQC
CQuIN
ED
DH
HED
HSMR
HV
ID
LOS
MRSA
MUST
NPSA
OP
PALS
PHSO
RAID
RTM
SHA
SHMI
TIA
TTR
UTI
VTE
Wards:
EAU
MAU
D
L
N
P
A&E
ITU
NNU
WHO
WTE
YTD
35 | P a g e
Explanation
Catheter Associated Urinary Tract Infection
Clostridium Difficile
Criminal Records Bureau
Clinical Systems Reporting Tool
Care Quality Commission
Commissioning for Quality and Innovation
Emergency Department
Department of Health
Healthcare Evaluation Data
Hospital Standardised Mortality Ratio
Health Visitor
Identification
Length of Stay
Methicillin-Resistant Staphylococcus Aureus
Malnutrition Universal Screening Tool
National Patient Safety Agency
Outpatients
Patient Advice and Liaison Service
Parliamentary and Health Service Ombudsman
Rapid Assessment Interface and Discharge
Real Time Monitoring
Strategic Health Authority
Summary Hospital-level Mortality Indicator
Transient Ischaemic Attack (‘mini’ stroke)
Table top review
Urinary tract infection
Venous thromboembolism
Emergency Assessment Unit
Medical Assessment Unit
Dudley
Lyndon
Newton
Priory
Accident & Emergency
Intensive Therapy Unity
Neonatal Unit
World Health Organisation
Whole time equivalent
Year to date