TB2012.59
Trust Board Meeting: Thursday 5 July 2012
TB2012.59
Title
Monthly Quality Report
Status
A paper for information
History
A regular monthly report
Board Lead(s)
Professor Edward Baker, Medical Director
Mrs Elaine Strachan-Hall, Chief Nurse
Key purpose
TB2012.59(i)_Monthly Quality Report
Strategy
Assurance
Policy
Performance
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Oxford University Hospitals
TB2012.59(i)
Summary
This report updates the Trust Board on the quality of care drawn from a variety of clinical
governance and nursing indicators.
The report includes updates on activity taking place across the OUH aimed at delivering
quality improvement.
The following items are highlighted as key changes compared to the previous Quality
Report:
1
2
3
4
5
A total of 92 complaints were received during May 2012, 2 of which were graded
as red.
The patient feedback received indicates that a high level of patients would
recommend the OUH
Nine serious incidents requiring investigation were reported to the Primary Care
Trust and Strategic Health Authority in May 2012.
A standardised mortality review process is being implemented across the Trust.
The Quality Account has now been approved by the Trust Board Quality
Committee and assurance has been received from the Audit Commission. The
Quality Account has been submitted to the Department of Health for publication,
in accordance with the published timetable and regulations.
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Complaints
1.
The number of complaints received in May (92) remains above the previous
average. This increase was reflected in: Cardiac, Thoracic and Vascular together
with Critical Care, Theatres, Diagnostics and Pharmacy. The number of complaints
for the last three years is illustrated in the table below.
Oxford University Hospitals NHS Trust
Complaints Trends for 2009 ‐ 2012 (Financial year)
120
100
80
60
40
20
0
April May
June
July
August
January
February
March
2009‐10 ‐ 679
52
41
57
66
59
September October
50
47
November December
62
44
46
76
79
2010‐11 ‐ 837
67
63
88
63
53
74
62
66
74
73
72
82
2011‐12 ‐ 866
57
64
57
50
73
60
74
73
58
101
103
96
2012‐13 ‐ 165
73
92
2.
The four key themes identified remain patient care/experience, delays/waiting
times (appointments, admissions discharge and transport), communication and
behaviour. All Divisions have received complaints in one or more of these
categories. The Emergency Medicine, Therapies and Ambulatory Medicine
(EMTA) received a complaint related to bereavement.
3.
Organisational learning is shared across Divisions so that changes in practice can be
embedded within the Trust and the changes are reported at the monthly Clinical
Risk Management Committee.
New Complaints – May 2012
4.
Of the 92 new complaints, there were 2 graded red, 30 orange, 52 yellow and 8
green across all Divisions. Complaints are initially graded using the Department of
Health grading matrix which ranges from red (most serious) through orange and
yellow to green (least serious). Grading is reviewed on completion of the
investigation.
5.
The two red complaints were received by the Children’s and Women’s Division
and EMTA related to diagnostic process in ED and the management of a patient fall
in medicine.
6.
All of these red complaints remain open and are being managed through the
complaints process.
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Management of complaints
7.
Complaints received within the Trust are managed in accordance with the OUH
Complaints Policy. In May 97% of complaints were acknowledged within the
statutory 3 workings days.
8.
In May there were 7 breaches in responding to complaints within the agreed
timescale of 25 working days relating to complaints received in February and
March 2012. To date there have been no breaches recorded for complaints received
in May, although some complaints for this period are still open.
Ombudsman Investigations
9.
In May the Trust did not receive any communication from the Ombudsman’s Office
requesting information.
Divisional updates on key themes and trends received in May 2012
10.
The table below indicates the number of complaints received by Division in May
and the themes of these complaints.
Division
Complaints
received
May 2012
Cardiac, Thoracic
& Vascular
10
Increase/
decrease
on
previous
month
+6
0
3
6
1
Children &
Women’s
13
-4
0
6
6
1
Corporate
3
+3
0
1
2
0
Critical Care,
Theatres,
Diagnostics &
Pharmacy
Emergency
Medicine,
Therapies &
Ambulatory
8
+4
0
1
6
1
12
-2
2
4
3
3
Musculoskeletal &
Rehabilitation
Services
Neurosciences,
Trauma &
Specialist Surgery
5
+1
0
2
3
0
26
+8
0
7
19
0
Surgery &
Oncology
15
+2
0
6
7
2
TB2012.59(i)_Monthly Quality Report
Themes:
Please note that themes are
listed by number as one
complaint may have more
than one theme
5 Patient Care/Experience
4 Delays/waiting time
1 Communication
6 Patient Care/Experience
3 Behaviour
3 Communication
1 Delays/Waiting Time
2 Communication
1 Behaviour
3 Patient Care/Experience
5 Communication
6 Patient Care/Experience
2 Delays/Waiting time
2 Behaviour
1 Communication
1 Bereavement
2 Delays/Waiting time
2 Patient Care/Experience
1 Behaviour
12 Delays/Waiting time
9 Communication
5 Patient Care/Experience
7 Patient Care/Experience
4 Delays/Waiting time
4 Communication
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Oxford University Hospitals
11.
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The table below illustrates the number of complaints by Division for the last three
years and does illustrate that overall complaint numbers have not risen significantly.
Oxford University Hospitals NHS Trust
Breakdown of Complaints for Financial Year 2011 ‐2012 by Division
350
300
250
200
150
100
50
0
Not specified
Division A
Division B
Division C
197
292
165
25
2010-11
4
132
196
117
43
2011-12
6
0
33
4
2009-10
2012-13
Corporate
Neurosciences,
Trauma &
Specialist
Children's &
Women's
Critical Care,
Theatres, Diagn
Emergency
Medicine,
Therapies
13
53
23
82
103
71
34
13
108
30
41
12
181
26
228
44
169
28
Cardiac,
Thoracic &
Vascular
Surgery &
Oncology
Musculoskeletal
& Rehabilitation
38
9
Divisional Action following complaints
12.
Neurosciences, Specialist Surgery and Trauma Division, offers complainants
whenever possible a local resolution meeting and routinely contact complainants to
discuss their concerns in the initial stages of complaint investigations.
13.
Similarly, Emergency Medicine, Therapies and Ambulatory are proactively
suggesting patient meetings and this is considered to have improved the resolution
and has reduced the number of further letters.
14.
As a result of complaints received, Cardiac Thoracic & Vascular Division have
initiated teaching sessions for staff to address administrative errors and are seeking
external supply of customer care training to aid with improving communication
and delivering compassionate care. 15.
As a result of complaints received the Women’s and Children’s Directorate are
reviewing the fasting guidelines for children prior to surgery. The Division is also
liaising with the Radiology Department at the Horton General Hospital to ensure
that training for clinical staff on child specific issues during procedures. TB2012.59(i)_Monthly Quality Report
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Patient Experience
16.
Patient experience feedback for May is compiled solely from the ‘Let Us Know Your
Views’ leaflets and the Comments and Suggestions Forms. As a consequence of the
implementation of the Datix software for the PALS, the capability for categorising
and reporting of patient experience has been temporarily lost: Software development
will be necessary to enable patient experience reports from the PALS, chaplaincy and
bereavement databases to be collated and reported. A transitional solution is being
sought to capture and report this information.
The table below provides a summary of the top four feedback issues.
Top 4 patient feedback issues
April
Care & service positive feedback
May
982
786
Concerns about aspects of care offered
54
128
Environmental concerns
31
10
Appointment, treatment and discharge delays
30
31
Source of patient experience reports
May
Let Us Know Your Views (Questionnaires)
17.
164
Telephone calls (to PALS)
82
Comments & Suggestions Forms
39
E-mails (via PALS)
8
Letters and Web feedback
8
In person (to PALS)
7
Total feedback score for March, April and May 2012 are shown below:
March
April
May
Positive
184
50.7%
995
71.9%
1589
78.7%
Neutral
10+6
27.8
283
20.5%
365
18.1%
Negative
76
21.5%
103
7.6%
66
3.2%
18.
The return of the ‘Let Us Know Your Views’ leaflets continues to increase as a
consequence of wards and clinical areas being encouraged to promote the
availability and use of these leaflets by members of the Patient Services team. These
leaflets are now providing a rich source of qualitative information with 2019 issues
reported during May.
19.
Almost all of the 184 patients who responded to the question “would you
recommend this hospital” responded positively (182).
20.
Communication and delays in appointments are the principle causes of concern for
patients, representing 63% of all concerns reported in May.
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Nursing and Midwifery Quality Dashboards 21.
The seven quality dashboards are provided as an appendix showing data for each of
the Divisions and key points covering all Divisional activities are highlighted on the
accompanying sheets. The indicators on these dashboards largely relate to the
indicators which are sensitive to nursing interventions such as pressure tissue
damage, and harm from medication errors and falls.
22.
In terms of nursing staffing, intervention continues to be needed to provide
additional support by ward basing senior staff, moving staff from other areas and
reducing beds or activity in order to provide safe care. . The correlation with nurse
sensitive indicators indicates that in a number of areas intervention has been
required and this is effective in that there is little correlation with harm events.
23.
In relation to staffing and indicators of harm, the position in May is largely the same
as that of previous months. The reporting and management of pressure ulcers
continue to feature in the monthly reports, particularly with EMTA which has a
predominantly high level of patients predisposed to the risk of pressure ulcers.
24.
Several wards are working with Carillion to improve cleaning standards and in staff
are being reminded of the content and requirements of the cleaning guidelines. Daily
checks on the cleaning of equipment have been enhanced in some areas where audits
have picked up issues.
25.
The children’s wards have recently introduced nutritional assessment champions
which have begun to deliver improvements with the audit of nutritional
assessments.
26.
The trust commitment to delivering same sex accommodation continues with no
breaches, excepting those that are clinically appropriate, reported in May.
Safety, Quality and Risk
27.
This section covers a number of areas that are included in the attached safety, quality
and risk scorecard.
Outcomes (Summary Hospital Mortality Index and Dr Foster)
28.
Both the Summary Hospital Mortality Index (SHMI) and Hospital Standardised
Mortality Ratio (HSMR) are within expected limits.
29.
The current SHMI published in April is 1.01; this relates to the time period October
2010-September 2011. The next SHMI will be published by the NHS Information
Centre on 1 July 2012. The HSMR for financial year to date at the OUH is 98.1
30.
Dr Foster is able to produce trend data for both the SHMI and HSMR over a 3 year
period. The graph below shows some evidence of a downward SHMI trend.
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31.
Three diagnosis groups have higher than average SHMI. An analysis using the Dr
Foster tool shows that two of the three diagnosis groups exhibit the expected number
of in-patient deaths. This suggests that the high SHMI is related to out of hospital
deaths however it is not currently possible to identify the precise cause of this
variance. Surveillance is in place to note any increase in in-patient mortality rates
within these two categories.
32.
The category ‘Secondary malignancies’ has both a higher than average SHMI and inpatient mortality rate and has also had a mortality alert on the Dr Foster early
warning system. An internal investigation has highlighted incorrect coding of both
primary and secondary tumours. Meetings to review notes within the Palliative Care
specialty have focussed on accurate clinical coding and ensuring a complete record
of co-morbidities is captured to improve risk rating of expected outcomes. A review
of case records has not identified any clinical concerns with the care of these patients.
33.
The notes audit to ensure accurate coding of Charlson Index co-morbidities in order
to reduce the reported HSMR for 2011/12 is well advanced. The greatest number of
notes to review is within the cancer specialities. Processes are also being put in place
to collect complete co-morbidity information with each admission prospectively. The
project is on target to re-submit amended data to the secondary user service (SUS)
before the 2011/12 HSMR figures are finalised.
34.
A standardised mortality review process is being implemented across the Trust. The
goal is for all deaths that occur in the Trust to be formally reviewed such that any
issues with the quality of care can be identified in order to improve services.
Individual departments are devising forms to assist them in undertaking such
reviews and this paperwork is being reviewed to ensure that there is consistency
across the organisation. Variations to the data collection forms by Clinical Specialties
have been received by the Safety Quality and Risk (SQR) Department.
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Serious Incidents Requiring Investigation (SIRIs)
35.
All Serious Incidents Requiring Investigation are investigated in accordance with the
Incident Reporting and Investigation Policy
36.
There were nine serious incidents requiring investigation that were reported to the
Primary Care Trust and Strategic Health Authority in April/May 2012. These are
listed in the table below.
Key category/theme
SIRI
1. Intrauterine death in early labour
2. Category 3 pressure ulcer to sacral area
3. Death following failure of medical device
4. Category 3 pressure ulcer to right heel
5. Category 4 pressure ulcer on patient’s right foot
6. Failure to follow up fracture in a child followed by re-admission with further
fractures
7. Category 3 pressure to sacral area
8. Category 4 pressure ulcer to heel
9. Death from Clostridium difficile in part one of patient’s death certificate
National Patient Safety Alerts
37.
Between April and May 2012 14 Medical Device Alerts (MDA) and 1 Estates and
Facilities Alert (EFA) were issued. During this time period 1 EFA and 4 MDAs were
closed within the given time frame and 9 breached their closure date (2 in April and
7 in May). These MDA breaches have been reported to the Clinical Risk Management
Committee. No incidents have been reported in relation to these MDA notices. The
process for managing MDAs takes place within the department of clinical
engineering and there are some short term staffing challenges within this
department. The issue has been escalated within the relevant division such that the
work of the department is prioritised using a risk-based approach.
38.
In April 3 National Patient Safety Alerts (NPSA) were closed within the given time
frame. Action plans for NPSA alerts are monitored each month at the Clinical Risk
Management Committee; these relate to:

RRR NPSA/2012/RRR001: ‘Harm from flushing nasogastric tubes before
confirmation of placement’. Procedures for insertion, use and care of
nasogastric tubes have been amended in line with this alert and new
manufactures guidelines have been disseminated across the Trust.

NPSA: PSA/2011/001 and RRR/2011/003 both refer to Safer spinal
(intrathecal), epidural and regional devices and relate to the sourcing of
equipment to ensure the correct connectors are used with devices.
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
39.
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RRR 018: Preventing fatalities from medication loading doses. Processes are being
established to ensure all medication loaded doses are reviewed by pharmacy
on a risk priority basis.
As of the 31st May 2012, 8 MDA, 3 NPSA and 1 EFA Alerts remain open. These alerts
are due for closure in the future have been distributed within the Trust in line with
current policies and procedures.
Quality Account 2011/2012
40.
The Quality Account has now been approved by the Quality Committee. The Trust
has received assurance from the Audit Commission. The Audit Commission stated
that
‘Based on the results of my procedures, nothing has come to my attention that causes me to
believe that the Quality Account for the year ended 31 March 2012 is not consistent with the
requirements set out in the Regulations’.
The Quality Account also sets out the key quality improvements for 2012/2013.

Patient Safety

Clinical Effectiveness
o
o

Safe Medicines delivered on time
Innovation to support better care
Patient Experience
o
o
Improving end of life care
Delivering compassionate excellence
The Quality Account has now been submitted to the Department of Health in
accordance with the published timetable and regulations.
Executive Quality Walk Rounds
41.
Feedback from staff and patients who are involved in 'Quality Walk Rounds' has
been positive. During April to May 2012, 14 Executive Quality Walk rounds were
completed in the following areas:
Trust Site
Ward/ Department
Horton Hospital (HH)
Women’s Day Case
Horton Hospital
Estates and Facilities
John Radcliffe Hospital (JR)
Neuroradiology
Horton Hospital
Cardiac Physiology / ECG
Horton Hospital
Emergency Assessment Unit (EAU)
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April
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John Radcliffe Hospital
Mortuary
Nuffield Orthopaedic Centre (NOC)
Neuron Rehabilitation Service
John Radcliffe Hospital
Immunology Day Case Service
John Radcliffe Hospital
Gastroenterology, Ward 5F
Churchill Hospital (CH)
Theatres and Day Case
Churchill Hospital
Cytogenetic and Molecular Genetics Laboratory
Churchill Hospital
Haemophilia and Thrombosis Centre
May
Wantage Community Midwifery Unit
Nuffield Orthopaedic Centre
42.
Sarcoma and Orthopaedic Ward (F Ward)
Key headings are used to summarise the issues discussed and identified from the
walk rounds. Specific issues are highlighted and fed back to the service and the
Division. The following issues were raised:
Topic
Theme
Staffing
Week end lists and extended days to be reviewed (Neuroradiology)
Staff Recruitment in the mortuary
Improvements to out of hours medical cover in place to ensure safe management
and cover across all 4 sites. Effective handover at night of high risk patients,
appropriate training and inclusion at junior doctors induction of configuration of 4
hospital sites
Matron liaising with Chief Nurse to support morale of staff following clinical
incident (Theatres, CH)
Environment
Improvements to staff changing facilities planned (Estates and Facilities)
Patient waiting area reconfigured (Cardiac Physiology)
Bathroom belonging to Ward 5F but outside ward area to be redesigned as office
/storage (Gastroenterology)
Redesign of shelving and storage to meet to meet infection control standards
(Theatres – CH)
Lighting levels at exits being assessed by Health and Safety (Molecular Genetics)
Signage to Department will be improved (EAU, HH)
Electronic
Patient
Record (EPR)
A contingency plan is being negotiated with BT Cerner by the Director of Planning
and Information (Ward F, NOC)
Difficulties interfacing EPR between NOC and JR, CH and HH being examined by
Director of Planning and Information (Ward F, NOC)
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Difficulties recording clinic activity being addressed by EPR team (Haemophilia
and Thrombosis Centre)
Equipment
Flooring to be replaced (Cardiac Physiology and Mortuary)
Maintenance and storage of bariatric concealment trolleys to be confirmed
(Mortuary)
Additional suction and oxygen points required to improve bay usage
(Gastroenterology)
Replacement of delivery bed is being assessed (Wantage Community Midwifery
Unit)
Damaged fire doors require repair (Theatres, CH)
Medical records
A Standard Operating Procedure is in development for the availability of notes
cross-site describing transport arrangements (Neuro Rehabilitation Service, NOC)
Extending service
Examination of service requirements and provision at Horton and NOC
(Haemophilia and Thrombosis Centre, CH)
Patient information
and feedback
Improved processes in place to ensure patient information is up to date and to
collect patient feedback (Neuroradiology, JR)
Areas of good
practice include
A graduate programme within Radiology and Nuclear medicine has had a positive
effect on recruitment
Positive patient feedback within Radiology and Nuclear medicine
Completion of Root Cause Analysis for all categories of pressure ulcers within the
Bone Infection Unit
43.
Completed actions since April 2012 include:

Improvements are underway for staff changing facilities for
porters and housekeepers as identified in April.

Two ultrasound machines with improved design have been purchased for
the Radiology Department (JR), to reduce the risk of upper limb disorders
amongst staff.

Improved staffing on F ward (HH) with improved induction to ward area for
agency staff in place.

85% of staff on F ward (HH) have received manual handling training to
reduce the risk of muscular skeletal injuries associated with physically
dependent patients

A contingency plan is in place to repair an unreliable lift with in Theatre
Sterile Services Unit (CH).

Improvements have been made to recruitment process of band 7 staff. This
has provided clarity to the physiotherapy Department who are awaiting
workforce plans to be signed off.
Executive Quality Walk Rounds - Next Steps.
44.
A review of quality walk rounds was presented to the Board in May 2012. The
report noted the importance of walk rounds and a need to avoid cancellations and
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recommended that refinements are made to the programme to provide a greater
focus on Patient Experience and ensure improvements take place in a timely manner,
with measurable outcomes and dissemination of lessons learnt throughout the
organisation. The Quality Committee considered and approved a proposed revised
methodology in June 2012 to address these improvements.
45.
The revised walk round methodology includes changes to the responsibilities of
individuals, the scheduling, leader team membership, reporting of learning and
actions and sharing of lessons learned. The changes in methodology will provide a
greater focus on Patient Experience and ensure safety improvements take place in a
timely manner, with measurable outcomes and dissemination of lessons learnt
throughout the organisation.
46.
Quality Walk Rounds are also replicated at Senior Nurse and Divisional level to
ensure the leadership of the Trust are aware, assured and take actions as indicated.

A night inspection at F ward (HH) by the Divisional Nurse revealed a calm
environment with no unanswered call bells. In addition the Chief Nurse
observed on inspection demonstrable improvements in patient care and
delivery (from NTSS Quality Report, June CGC)

The need to improve communication between specialist teams was raised by
a patient in OCDEM.

A ’15 Steps challenge’ took place on E Ward (NOC) with patient
representatives and members of the multidisciplinary team. Positive
feedback was received relating to the organised and clean environment.
Areas identified for review were the information displayed, location of
noticeboards and signage. These are being addressed by the Ward Manager
and progress reported via the monthly Quality Report. (Mars Quality Report,
June CGC)
Infection Control
MRSA
47.
There have been no cases of MRSA bacteraemia in the Trust so far this financial year.
Clostridium difficile
48.
In March 2012, the Department of Health (DH) published updated guidance on the
diagnosis and reporting of Clostridium difficile (C. diff). The remit of this guidance
was to outline who should be tested the type of tests that should be used to detect C.
diff infection and what healthcare providers should do depending on the outcome of
the tests.
Testing for Clostridium Difficile
49.
All Microbiology laboratories in England were requested by the DH to change over
to the two stage new testing regime from 1st April 2012. The OUH Trust
implemented this on 30th March 2012.
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50.
The new testing system is more sensitive for detecting C. diff disease. Therefore more
patients with the disease will be detected however it can also detects C. diff in
patients who have the germ in their bowel but do not have active disease.
51.
The long term effect of the new testing regime on the number of reported cases of C.
diff is unclear. However, since the introduction of the new testing regime, the OUH
Trust has seen an increase in the number of cases identified in the lab during April
and May 2012. However, since the beginning of June, the number of cases identified
in the lab has reduced.
Review of Clostridium difficile cases
52.
All cases of Clostridium difficile identified from samples taken after admission to the
OUH Trust are investigated with the clinical area.
Actions in addition to current programme to reduce Clostridium difficile
53.
54.
55.
An intensive programme in addition to the present monitoring programme of
antimicrobial prescribing will be introduced by September 2012.
Review the evidence regarding cleaning products to check that there are no relevant
new publications to support the need to change.
Explore the potential impact of new antibiotic treatment for C. diff
Conclusions and recommendations
56.
57.
The Board is asked to receive the report which highlights the range of activity across
the organisation.
The Board is asked to note the actions being taken.
Professor Edward Baker, Medical Director
Elaine Strachan-Hall, Chief Nurse
Appendices attached
Appendix 1 Nursing Dashboard
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