Trust Board Committee – 28th April 2011
Presented By:
Gwen Nuttall – Chief Operating Officer, Nichole Day Executive Chief Nurse
Prepared By:
Information Team
Date Prepared:
15th April 2011
Subject:
Integrated Quality and Performance Report - March 2011
Purpose:
For Information
Strategic Objective:
To Achieve Performance Levels in accordance with the CQC “Standards for Better Health”
Executive Summary:
The paper focuses on the key core targets, identified by the Department of Health and the Care Quality Commission,
summarising performance to the end of March 2011.
It also provides the board with information to assess the Trust’s performance against quality indicators, including patient
experience, clinical outcome and effectiveness and patient safety.
Matters resulting from recommendations
made in this report
Financial Implications
Present
Considered
Yes / No
Yes / No
Workforce Implications
Yes / No
Yes / No
Impact on Equality and Diversity impact
Yes / No
Yes / No
Legislation, Regulations and other external directives
Yes / No
Yes / No
Internal policy or procedural issues
Yes / No
Yes / No
Risk Implications for West Suffolk Hospital (including
any clinical and financial consequences):
- Failure to deliver the 4 hour core access target for the year.
- Failure to achieve C-Difficile target for the year.
Mitigating Actions (Controls):
• Robust Action Plan developed.
• Performance Management and Monitoring.
• Improved Escalation
• Review of Cohort Unit
Level of Assurance that can be given to the Committee from the report based on the
evidence
[significant, sufficient, limited, none]:
SUFFICIENT
Recommendation to the Committee:
Note the Trust Performance to March 2011
Contents
1. Introduction
2. Emergency Care A&E
3. Cancelled Operations
4. LOS
5. Outcomes & Effectiveness – Clostridium Difficile
6. Patient Safety
7. Risk Assessment
8. Patient Experience
9. Conclusion
1.& 2. Introduction & Emergency Care
1. Introduction:
This report provides a briefing to the Board members on the
performance against key targets up to March 2011.
The paper focuses on the main targets, identified by the Department of
Health and the Care Quality Commission.
2. Emergency Care – A&E
Target: 95% of patients seen/treated/discharged
within 4 hours
The Trust did meet the 95% Target for the month of March
2011 (99.7%).
Key actions:Interviews for A&E and EAU consultant posts to be held in May
2011
Integrated Action Plan agreed and monitored weekly, via
weekly A&E departmental meetings.
Review of medical commitments in morning and afternoon
commenced. Job Plans are being updated.
Bed Meetings reviewed and enhanced. Standard operating
procedures commenced.
The pilot of the discharge lounge recommenced in April and its
impact will be reviewed on a daily basis.
The trust is developing a recording mechanism for the new A&E
quality indicators
Page 4
The updated detailed A&E 4 hour performance action plan is attached as a separate paper.
3. Cancelled Operations
The target was not met for March at 1.11%
A deterioration in performance from February to March.
Out of theatre time remains the predominant reason with
an increase in the number of emergencies impacting on
elective theatre time.
Target 0.8%
Actual 0.87% (YTD)
The first “Visioning Workshop” for the Productive Theatre
has taken place and an outline of the project given to the
Trust Board. Further TPOT workshops are scheduled.
Theatre scheduling issues are being addressed by the
Clinical Director of Theatres in conjunction with
Governance.
.
Page 5
4. Length of Stay (Spells)
The targets are from Dr Foster ‘Expected’ positions using 09/10
as a benchmark.
• Non Elective LOS for Medicine is above target – Actions to
improve this performance is linked to discharge action plans
and implementation of EAU model and short stay beds.
•Non Elective LOS for Surgery remains below the expected level,
but has seen an increase in 2010/11. There has been a small
increase in the length of stay for complex elderly patients over
the year. However the new Geriatrician now has scheduled ward
rounds on orthopaedic ward.
•Elective LOS for Surgery is similar to last year. Review of day
case and day of surgery activity continues, especially in
urology. The productive theatre will also focus on Urology.
Page 6
5. Outcomes and Effectiveness
Hospital Standardised Mortality Ratio
HSMR has been fairly consistent over recent months and is below the
expected level as can be seen by the overall mortality shown in the
graphs and the table giving a mortality rate for the five Dr Foster How Safe is Your Hospital indicators. These tables provide
information on relative risk, with red, blue and green traffic lighting.
Blue indicates that the score is within the standard deviation.
We continue to monitor the overall HSMR and we also monitor the
HSMR for emergency patients and identify any individual diagnoses
that trigger any alerts. These are all investigated and reported to the
Quality and Risk Committee and Patient Outcomes Implementation
Group.
National
Rate from
last
reporting
period
Rolling 12 Month HSMR-All
Admissions
Rolling 12 Month HSMR-Non
Elective
SMR Stroke (Acute Cerebrovascular
Disease)
SMR - Heart Attack (AMI)
SMR - FNOF
Mortality from Low Risk Conditions
Page 7
Jul Aug
08- 08Aug Sep
09
09
Sep
08Oct
09
Oct
Dec Jan Feb Mar Apr May Jun
08 - Nov 08 08 - 09 – 09
09 0909
09
Nov - Dec- Jan Feb -Mar -Apr May -Jun -Jul
09
09
10
10
10
10
10
10
10
Jul Aug
09- 09Aug Sep
10
10
Sep
09Oct
10
Oct
09Nov
10
Nov
09Dec
10
Dec
09Jan
11
87.8 86.3 84.6
84.1
80.3
81
-
86.4 85.2 84.5 84.6
82.8
-
86.2 84.9 84.6 84.5
83
80.1 80.8 80.4 80.3 79.6 89.1 89.1 88.1 86.7 84.8
84.2
80.3 81.1
86.2
85.9 82.6 86.4 82.8
83.3
83.1 82.9 80.9 81.1 79.4 87.8 86.8 88.7 88.6 84.2
84.4
79.7 80.5
90
81.6
0.84
100.4 105.1 106.1 94.1
70 65.4 64.9 65
91.8 100.6 96.6 95 92.4 92.1 93.7 94.5 89.4 82.4 78.5
69.4 61.3 64.2 69.5 68.4 64.7 73.3 69.2 60.7 62.9 66.2
0.65 0.57 0.57 0.44 0.49 0.67 0.62 0.62 0.53 0.49 0.44
77.9
66.9
0.49
81.8 94.1
67.4 65.9
0.45
-
80
80.7 80.2 80.1 76.5
89
89
7
5. Outcomes and Effectiveness
Infection Prevention
The C. difficile target for 2010/11 was 29 hospital cases
although due to the recent C. difficile outbreak the PCT
recognised that we would not hit our trajectory and
agreed that they would accept no further preventable C.
difficile cases. In March there were a further 3 hospital
attributed cases, bringing the total to 37. All cases were
considered unavoidable and all patients were transferred
to the F9 cohort unit within the time frame specified.
The Trust continues to achieve excellent results in other
infection control KPIs. There were no hospital associated
MRSA bacteraemia and High Impact Intervention
performance has improved with scores ranging from 93100%:
•HII 2b: Peripheral cannula ongoing scored 93% due to
VIP scores not recorded in the surgical directorate.
•HII 6b: Urinary catheter insertion scored 98%
•All other HII scored 100% compliance.
Antibiotic Prescribing
As part of the rolling programme of quarterly audit of
antibiotic prescribing, G4 scored 93% compliance in
March.
Page 8
8
6. Patient Safety
Pressure Ulcers
The number of patients with ward acquired pressure ulcers decreased this month to 11 with no Grade 3 or Grade 4 pressure ulcers reported. This is
calculated in bed days for CQUIN and March result = 0.92 pressure ulcers/1000 bed days. The target was 0.42 for Q.4 which equates to 5 pressure ulcers.
Themes from RCAs:
• 55% (6) of the hospital acquired pressure ulcers occurred on G4. A combination of vacancy, sickness absence and high patient dependency were issues
for this ward this month. These are being addressed by managers
• Poor documentation of risk assessment, management plans and scoring discrepancies between risk assessors is a recurring theme in patients that
develop pressure ulcers.
•Limited availability of the Tissue Viability Nurse team to support staff in training and risk management.
• At weekends there can be significant delays in acquiring pressure relieving mattresses.
• There is an identified need for more training of staff in classification of pressure ulcers on admission.
Actions:
•Equipment resources and timeliness of delivery into the clinical areas is a workstream identified by the pressure ulcer action plan.
•Training needs analysis for every member of nursing staff will be completed by the ward managers before developing a ward-based training programme.
Page 9
9
6. Patient Safety
Patient Falls
The total number of falls in March was 65 and 25 of these falls resulted in harm to the patient.
The majority of falls are within the medical directorate (n= 48). These are mainly on F8, G5 and G8- 10,10 and 13 falls respectively. The majority of all
patients on these three wards are at high risk of falling.
17 falls occurred within the surgical directorate, with a significant number on F3 (8 falls). F3 have 20-24 high risk of falls patients on the ward at any time.
Themes from RCAs:
•20 patients that sustained harm after falling were confused (dementia/delirium).
•Clinical areas are unable to access enough ultra low beds (4 in use in Trust currently) and wanderguards (20 in Trust) to manage high-risk patients
proactively. We currently have approximately 100 patients in the Trust at high risk of falling.
•Two patients fell out of bed
• Improvement needs to be made regarding routine documentation of risk assessments and management plans.
Actions:
• The Falls Prevention Group will be developing an action plan to reduce falls taking the above themes into consideration.
Page 9
1
0
6. Patient Safety
Venous Thrombo-Embolism (VTE)
Verbal update to be provided at the meeting by Dermot O’Riordan.
Page 10
11
8. Patient Experience
Patient Satisfaction (Patient Experience Tracker)
Overall satisfaction was 95%. 432 patients completed the survey. No
questions scored a red performance rating.
Patient Satisfaction Questionnaires (PSQ) (paper)
Overall satisfaction increased to 90%. 143 patients completed the
questionnaire
All question responses were green apart from “Were you ever bothered
by noise at night from patients or hospital staff?”
Themes:
• Confused patients calling out at night
•Patient transfers onto ward
CQUIN
2% target questionnaire completion was achieved by maternity and adult inpatient
services.
Outpatients surveyed 1.56% (364 patients)
Paediatrics surveyed 1.07% (7 patients out of 655 admissions)
Adult inpatient, maternity and paediatrics all achieved the overall Q4. CQUIN target
of 2% survey completion.
Paediatrics did not meet the 2% target due to poor performance this month.
Page 12
12
8. Patient Experience
Same Sex Accommodation
Same Sex Accommodation
There were no breaches of same sex accommodation
criteria during March.
Environment and Cleanliness
Environment and Cleanliness
All clinical areas scored above 80% apart from A&E
who scored 71%. This is due to:
• Current benching, storage and sink facilities not fit
for purpose
•Limited hand washing facilities available
Page 13
9. Conclusion
The action plan with regard to A&E and discharges remains in place and performance
was again excellent in March.
One of the major challenges for the Trust, was in adherence to same sex
accommodation , the re-configuration in December has improved performance.
Performance with regard to C-Difficile, full RCA’s have been carried out and actions
implemented specifically with regard to anti biotic prescribing and monitoring.
Progress on other KPI’s is being made.
Page 14