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 32 34 34 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. 3|Page 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% 4|Page 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. 5|Page 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 10 | P a g e Tabled paper 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 11 | P a g e 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 12 | P a g e `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 13 | P a g e 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 14 | P a g e 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) 17 | P a g e 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. 18 | P a g e 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. 20 | P a g e 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. 21 | P a g e 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. 22 | P a g e 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). 23 | P a g e 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 24 | P a g e 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. 25 | P a g e 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. 26 | P a g e 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. 27 | P a g e 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. 28 | P a g e 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. 29 | P a g e 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. 30 | P a g e 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. 31 | P a g e 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. 34 | P a g e 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