TB2012.13
Trust Board Meeting: Thursday 1 March 2012
TB2012.13
Title
Quality Report
Status
A paper for information
History
A regular monthly report to the Board
Board Lead(s)
Professor Edward Baker, Medical Director
Mrs Elaine Strachan-Hall, Chief Nurse
Key purpose
TB2012.13_Quality Report
Strategy
Assurance
Policy
Performance
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Oxford University Hospitals
TB2012.13
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
An Acute Trust Quality Dashboard is being provided to the trust quarterly via
NHS South of England (produced by the East Midlands Quality Observatory).
2
A total of one Never Event and five SIRIs were called during January 2012
3
The hospital standardised mortality ratio (HSMR) and summary hospital
mortality index (SHMI) are both within expected limits
4
Updated risk estimates are shown for the Trust in the CQC Quality & Risk
Profile
5
One hundred and two new complaints were received in January and this
represents a 79% increase compared to the previous month. This increase also
correlates to the increased number of calls to the PALS service.
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Introduction
1.
The East Midlands Quality Observatory produces a quarterly Acute Trust Quality
Dashboard. The data provided within this report as yet does not include the
Musculoskeletal and Rehabilitation Division.
2.
The Acute Quality Dashboard provides an assessment of quality across the domains
of the NHS Outcomes Framework. An extract of the report is provided in appendix
1. The most recent quarterly report covering data predominantly from quarter 4 of
2010/11 was received in February and is subject to further internal verification.
3.
A total of 104 indicators are included across the section headings which reflect the
NHS Outcomes Framework:
3.1.
3.2.
3.3.
3.4.
3.5.
preventing people from dying prematurely
enhancing quality of life for people with long term conditions
helping people to recover from episodes of ill health following injury
ensuring that people have a positive experience of care
treating and caring for people in a safe environment and protecting them from
avoidable harm and organisational context
4.
The Trust performed “better” than expected by chance for 17 indicators (99.8% or 3
standard deviations). The Trust performed “worse” than expected for in the 11
indicators. Internal monitoring shows that these findings are not unexpected and
were reflected in the contemporaneous Board reports. These are detailed in appendix
1. A full report will be provided to the Quality Committee on 20th March.
5.
Progress continues in developing and implementing an Integrated Performance
Framework for the Trust. The data warehouse envisaged for the Trust will be able to
report on key quality indicators such as those identified in the Acute Quality
Dashboard.
Safety, Quality and Risk
6.
This section covers a number of areas that are included in the attached safety, quality
and risk scorecard.
7.
One never event and 5 new Serious Incidents Requiring Investigation (SIRI) were
called in January 2012.
Key category/theme
SIRI
Level 3 Information Governance Incident
Category 3 pressure ulcer
Category 3 pressure ulcer
Category 3 pressure ulcer
Infection Control Cluster
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Never
Event
8.
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Retained foreign object post-operation (official classification)
All SIRIs and never events are investigated in accordance with the Incident
Reporting and Investigation Policy.
Outcomes (Dr Foster and Summary Hospital Mortality Indicator)
9.
The hospital standardised mortality ratio (HSMR) and summary hospital mortality
indicator (SHMI) are both within expected limits. The HSMR for the financial year to
date is 99.4 (note this figure is rebased annually) and the SHMI, based on a rolling 12
months from July 2010 to June 2011, is 1.02. The Figure below highlights both
measurements.
10.
The latest release of the Summary Hospital-level Mortality Indicator (SHMI) splits
diagnoses into 108 collections and, within these collections, compares the observed
number of deaths in the Trust (July 2010-June 2011) against the expected number
(Observed/Expected × 100). Of the 108 collections examined for the Trust, 98 had
mortality rates similar to those expected, five diagnosis collections had mortality
rates significantly below expected values and 5 had mortality rates higher than
expected.
11.
On-going work within the Trust to bring about a prospective reduction in HSMR and
SHMI going forward includes:
11.1. Continuous review of outcomes (mortality, length of stay, readmission rate) in
all specialities through the Dr Foster benchmarking process, with investigation
of all outcome related alerts. The SHMI diagnosis based mortality data will
now be reviewed using the same approach.
11.2. Introduction of a falls care pathway in geratology.
11.3. Continued focus on care bundles for line insertion and aftercare of lines.
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11.4. Updated programme to support the prevention of surgical site infections.
11.5. Rolling out of the national “Safety Thermometer” project to four wards.
11.6. Embedding a standardised review process of deaths occurring in all specialties
to identify areas for improvement in clinical care (likely to include the
introduction of care bundles for high volume conditions associated with
significant risk of mortality).
11.7. A review of acute medicine to examine the availability of a senior clinical
presence seven days a week and rapid access, where necessary to specialist
opinion. This will report in April.
11.8. Introduction of consultant of the week rotas in key specialties to ensure daily
consultant review of inpatients.
11.9. Reduction in pre-operative waiting time for patients with fractured neck of
femur.
11.10. Making improvements in documentation to facilitate accurate clinical coding
to deliver a reduction in the HSMR for 2011/12 which will be reported in
autumn 2012.
National Patient Safety Alerts
12.
The following number of alerts remain open, 2 medical devices Alerts (MDA), 5
National Patient Safety Alerts (NPSA) and 2 estates and facilities Alerts (EFA) remain
open.
13.
Of the total open alerts no alerts have breached their closure dates.
NICE Guidance
14.
NICE guidelines covering clinical (CGs), interventional procedure (IPGs), technology
appraisal (TA), public health (PHG), „Diagnostics Technology Guideline‟ (DTG) and
medical devices (MTGs) are issued each month. These are sent to the appropriate
Clinical Director within the Division to review for relevance, applicability and
compliance. The Clinical Director is responsible for returning the compliance
statement and for delivering implementation of recommendations and for the audit
of implementation. A Clinical Implementation Lead (CIL) may be assigned within
the Directorate.
15.
If partial compliance has been declared, the CIL is responsible for undertaking the
gap analysis and preparing an action plan for full compliance. A declaration of
partial compliance confirms that the guidance is relevant and that work is underway
to achieve full compliance. Delivery against the actions will be monitored through
Divisions‟ reports to the Clinical Audit Committee. Recommendations for any noncompliance must be reported via the Division‟s monthly quality reports to the
Clinical Governance Committee and then to the Trust Board for ratification.
16.
A summary of compliance for December 2011 is provided as follows.
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New Guideline
December 2011
CG- Anaphylaxis, organ donation, self harm
(longer term management)
Three issued- One not relevant as service not
provided. Two declared partial compliance
working towards full compliance. Gap
analyses/action plans due April 2012
IPGs-Epiretinal brachytherapy for wet age
related macular degeneration
One issued. Awaiting response.
TA-Arthritis –tocilizumab, breast cancerfulvestrant, colorectal cancer- panitumumab
Three issued.
PHG
None issued
MTG
None issued
DTG-Elucigene FH20 and LIPO chip for the
diagnosis of familial hypercholesterolemia
One issued – under review
Full compliance
Quality Walk Rounds
17.
During January 2012, five programmed walk rounds were completed in the
following areas:
Trust Site
Ward/ Department
Churchill Hospital
Geoffrey Harris Ward
Churchill Hospital
Sobell House
Churchill Hospital
Sleep Studies
John Radcliffe
TSSU
Wallingford Community Hospital
18.
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
Staff raised the possibility of SME training being available on
the Churchill site
Environment
Lack of storage space
Concern raised relating to the lack of an internal lock
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Poor Physical fabric of department
Communication
Potential for greater integration of patient care across acute
and community services
Transport
Delays in timely transfers of patients across sites
Areas of good
practice
International reputation of sleep unit, one stop service, well
established system for accreditation.
Summary of Care Quality Commission Quality and Risk Profile (QRP)
19.
Separate Quality and Risk Profiles for the Oxford Radcliffe and Nuffield Orthopaedic
Hospital Trusts were published in October 2011. Since the integration of the two
organisations in November, the CQC has published the QRP for February 2012
showing combined updated organisational data. A QRP was published in December,
however there were problems with the data and this was withdrawn. The table
below shows the ORH and NOC October risk estimates and the OUH February
rating.
Outcome
ORH QRP
Risk Estimate
October 2011
Involvement and information
Outcome 1:
Respecting and
involving people
who use services
Outcome 2:
Consent to care
and treatment
Personalised care
Outcome 4: Care
and welfare of
people who use
service
Outcome 5:
Meeting
nutritional needs
NOC QRP
Risk Estimate
October 2011
OUH QRP
Risk Estimate
February 2012
Outcome 6:
Cooperating with
other providers
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Outcome
ORH QRP
Risk Estimate
October 2011
Safeguarding and safety
Outcome 7:
Safeguarding
people who use
services from
abuse
Outcome 8:
Cleanliness and
infection control
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NOC QRP
Risk Estimate
October 2011
OUH QRP
Risk Estimate
February 2012
Outcome 9:
Management of
medicines
Outcome 10:
Safety and
suitability of
premises
Outcome 11:
Safety,
availability and
suitability of
equipment
Suitability of staffing
Outcome 12:
Requirements
relating to
workers
Outcome 13:
Staffing
Outcome 14:
Supporting staff
Quality and management
Outcome 16:
Assessing and
monitoring the
quality of service
provision
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Outcome
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ORH QRP
Risk Estimate
October 2011
NOC QRP
Risk Estimate
October 2011
OUH QRP
Risk Estimate
February 2012
Outcome 17:
Complaints
Outcome 21:
Records
Summary of risk estimates
20.
Outcome 13 - Staffing, is a high red due to two negative qualitative data items from
CQC Compliance Reviews from February 2011. Other quantitative data sources
contributing to the negative risk estimate are carried forward from the NOC, four of
which show much worse than expected three month vacancy rates (Source: Information
Centre for Health & Social Care (IC), Vacancy Survey, March 2010). There are seven
low or high greens. These are Outcomes 2, 6, 8, 9, 12, 17 and 21.
21.
The five neutral ratings are for Outcomes 1, 5, 7, 10 and 11.
22.
There are three outcomes which are rated as insufficient data – 4, 14 and 16. This
means that some data are available, but it is not sufficient to calculate a risk estimate.
23.
In future QRP summaries, further comparison will be made between past and
current ratings. The combining of data for the two organisations means that direct
comparison with previous risk estimates is not possible due to the merging of the
two datasets. A full analysis of the data will be presented to the March Quality
Committee.
Infection Control matters
MRSA Bacteraemia 2011/12
Apr
11
May
11
Jun
11
July
11
Aug
11
Sep
11
Oct
11
Nov
11
Dec
11
Jan
12
Total per
month
0
1
0
0
0
1
2
0
0
0
Monthly
limit
0
1
0
1
0
1
0
1
0
1
Cum total
0
1
1
1
1
2
4
4
4
4
Cum limit
0
1
2
2
3
3
4
4
5
5
24.
Feb
12
Mar
12
0
1
6
6
The annual ORH Trust objective for MRSA bacteraemia for 2011/2012 is, 6 MRSA
positive blood cultures taken 48hrs after admission. The NOC is monitored
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separately until March 2012. The NOC has an annual limit of 1 and have had one
MRSA bacteraemia since April 2012.
20
15
10
5
cumulative total
Fe
b
M
ar
ch
Ja
n
D
ec
N
ov
O
ct
t
Se
p
A
ug
Ju
ly
Ju
ne
ay
M
A
pr
il
0
cumulative limit
Clostridium difficile
25.
The table below includes the number of patients who tested positive after 72hrs of
admission. This is the method for monitoring Clostridium difficile against target for
secondary care. It does inform the Trust of the overall burden of Clostridium
difficile, as it excludes positive cases from samples taken within 72hrs of admission.
26.
The NOC has an annual limit of 4 cases of C. diff and they have had five cases to date
from April 2011 to present day. The December case will be discussed at their clinical
service improvement group and findings fed back in next month‟s report.
Div
Apr
11
May
11
Jun
11
Jul
11
Aug
11
Sep
11
Oct
11
Nov
11
Dec
11
Jan
12
Total
5
5
8
7
14
9
14
8
8
7
Monthly
limit
12
12
12
12
12
11
11
11
11
11
Cum total
5
10
18
25
39
48
62
70
78
85
Cum limit
12
24
36
48
60
71
82
93
104
115
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Feb
12
Mar
12
11
11
126
137
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300
250
200
150
100
50
cumulative total
M
ar
ch
b
Fe
n
Ja
ec
D
ov
N
O
ct
pt
Se
A
ug
ly
Ju
ne
Ju
ay
M
A
pr
il
0
cumulative limit
Antimicrobial documentation
27.
The Department of Health Advisory Committee on Antimicrobial Resistance and
Healthcare Associated Infection (ARHAI) have advised that all antibiotic
prescriptions have the indication and duration documented on the drug chart.
28.
To assess compliance with this, a monthly audit is carried out in every inpatient area
within the trust. Data collection commences on the first week of the month and is
extended for up to five working days until there is a minimum of ten antimicrobial
prescriptions reviewed for each ward. Data from areas that have fewer than ten
antimicrobial prescriptions is held and added to the following month‟s audit.
Safer Care and Nursing Quality Metrics Score Card
29.
When mapped on to the previous „safer care three by three matrix‟ the position with
the number of safe wards is largely unchanged and, despite lower levels of
permanent staff in some areas (supplemented by temporary staff), there are no
indication that patient safety is being compromised.
All Wards (January 2012)
Safe Staffing >
85%
Staffing 70 85%
Staffing below
70%
34
36
16
Intensive Support (More than 3 Red)
Supportive measures (3 Red)
Safe Care (fewer than 3 Red)
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30.
The Nursing Quality Metrics (see Appendix) have been further revised to reflect the
key nursing indicators for the patient care experience. This includes the removal of
the safer care boxes and the increased focus on the monitoring of the three categories
of shifts identified as agreed, minimum and at risk.
31.
It should be noted that for some clinical areas, e.g. day units and dialysis satellite
units will have patients not require the interventions being monitored, for example,
those relating to catheter care, and hence there will be a nil return.
32.
Where scores are reported to fall below the indicated threshold these are currently
highlighted as amber or red and actions are identified and reported by the Divisional
Nurse.
Patient Experience
33.
The Let Us Know Your Views leaflets ask the question „would you recommend the
hospital?‟. The response rate to the questions continues to be over 88% but the
number of returned leaflets remains low (averaging 65 pcm). Positive feedback
about care continues to be the highest single recorded theme and analysis of the
leaflet confirms that even when negative feedback is made the respondents are still
likely to recommend the hospital concerned.
34.
The table below provides a summary of the top five feedback issues:
Top 3 patient feedback issues
December
January
Care & service positive feedback
261
481
Concerns about aspects of care offered
111
191
Appointment, treatment and discharge delays
182
144
Source of patient experience reports
January 2012
Telephone calls (to PALS)
35.
333
Comments & Suggestion Forms
57
Letters and Web feedback
21
E-mails (via PALS)
62
In person (to PALS)
44
Let Us Know Your Views (Questionnaires)
56
Total feedback score for October, November and December are shown below:
November
December
January
Positive
1182
68.1%
386
51.0%
615
48.9%
Neutral
409
23.6%
196
25.9%
329
26.2%
Negative
145
8.4%
175
23.1%
313
24.9%
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36.
Throughout January the PALS service received up to 50 calls per day, this represents
an approximate increase of 50% compared to the previous month. The main issues
which caused frustration, was not being able to contact departments by telephone
and not being able to leave a voice message. This may have coincided with the
introduction of the new electronic patient administration system.
37.
A theme of communication between doctors and nurses and their communication to
patients and relatives accounted for 23% of the concerns raised in January. The data
are made available to the Divisions for actions to be taken to address the concerns.
These are then reported on through the Divisional Quality Reports.
38.
There has been a reduction in the trend of complaints about cancellations in
appointments and treatments. Similarly the reduction in complaints relating to
outpatient clinics now represents less than 2% of all patient care concerns.
Complaints and Organisational Learning
2011/
2012
Apr
11
May
11
Jun
11
July
11
Aug
11
Sep
11
Oct
11
Nov
11
Dec
11
Jan
12
Feb
12
Mar
12
Compl
aints
56
61
51
47
71
60
59
67
52
102
Cumul.
56
117
168
215
286
346
405
472
524
626
2010/
2011
67
63
88
61
50
75
62
62
72
68
68
56
Cumul.
67
130
218
279
329
391
453
515
587
655
723
779
39.
102 new complaints were received in January and this represents a 79% increase
compared to the previous month. This increase also correlates to the increased
number of calls to the PALS service.
40.
The key themes identified in the complaints received in the Trust in January were
patient care/experience, delays/waiting times, communication and behaviour.
41.
The main theme in the seven clinical Divisions continues to be patient care /
experience.
42.
The Divisions are using the feedback from complaints to respond to individual issues
which can be complex and multi-faceted and to introduce changes and these have
begun to be reported in the monthly Divisional reports to the Clinical Governance
Committee.
43.
In January there were three breaches in responding to complaints within the agreed
timescale of twenty five working days.
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Ombudsman Investigations and updates
44.
In January the Ombudsman‟s Office wrote to the Trust requesting details of one
complaint for detailed consideration. This relates to a complaint received by the
Trust in November 2010 regarding surgery and treatment received for gall stones.
45.
The Ombudsman‟s Office has written to the Trust to confirm one complaint has been
upheld and recommendations have been made. This relates to a complaint made to
the Trust in January 2010 regarding the treatment received by a patient suffering
from Alzheimer‟s disease.
Conclusions and recommendation
46.
The Board is asked to receive the report which highlights the wide range of activity
across the organisation.
47.
The Board is asked to note the actions being taken across the Trust.
Professor Edward Baker, Medical Director
Mrs Elaine Strachan–Hall, Chief Nurse
Appendices attached
Acute Trust Quality Dashboard
Safety, Quality and Risk Score Card
Nursing Quality Metrics Scorecards
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Appendix 1 - Acute Trust Quality Dashboard
Outlying indicators
PD03
PD31
IH33
PE02
PE03
PE23
PE21
PE22
SC03
SC02
SC17
PE08
SC06
SC08
SC11
SC19
OQ01
OQ02
OQ03
OQ21
OQ07
OQ08
Age / Sex standardised hospital mortality in hospital
mortality in low risk HRGs
Cancer waits – % waiting less than 62 days from GP
referral to first treatment (HQU15)
Emergency readmission - % within 2 days following nonelective admission (Same Specialty)
Diagnostic Waits - % of patients waiting over 5 weeks
Cancer waits – % seen within 14 days of GP referral to first
out-patient appointment (HQU14)
A&E - % of patients admitted, transferred or discharged
within 4 hours of arrival
Delayed Transfers of Care per 1,000 occupied beds - NHS
Responsibility
Delayed Transfers of Care per 1,000 occupied beds Social Care Responsibility
% of all admissions who have VTE risk assessment
Rate of "serious harm" patient incidents reported per 100
admissions
Medication errors per 1,000 bed days
A&E re-attendance - % within 7 days (HQU09)
HCAI - C. diff bacteria rate per 100,000 bed days (HQU02)
% of planned day case procedures that are converted to
inpatients on the day
% Admission of full-term babies to neonatal care
Incidence of pressure ulcers per 1000 admissions
Admitted Patient Care - % Valid data (Average for all fields)
Out Patient - % Valid data (Average for all fields)
Accident and Emergency - % Valid data (Average all fields)
Admitted Patient Care - % Records submitted with valid
HRG on first submission
Rate of written complaints per 1,000 episodes
NHSLA Claims per 10,000 bed days
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Q4 1011
155.2
100.0
Q4 1011
76.7%
86.5
Q4 1011
1.74%
1.35
Q4 1011
Q4 1011
9.06%
78.8%
5.33%
96.0%
Q4 1011
89.8%
94.8%
Q2 1112
52.4
21.6
Q2 1112
14.6
7.
Sep-11
Oct 10-Mar
11
Oct 10-Mar
11
Q4 1011
Q4 1011
Q4 1011
85.7%
0.84
89.3%
0.38
8.18
6.59
5.0%
2.76
3.7%
7.0%
8.04
4.4%
Q4 1011
Mar-11
Sep-11
Sep-11
Sep-11
Aug-11
0.80%
0.81
98.1%
94.4%
99.4%
100.0
7.95%
1.84
97.68%
92.96%
93.70%
97.1
0910
1011
2.98
0.12
4.31
1.43
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17
4 & 20
13
% shifts 'at risk
staffing'
4
% shifts
'minimum
staffing'
1
% shifts 'agreed
staffing'
Compliance with
Track and Trigger /
EWS
Pressure Ulcers
Grade 3/4 / Skin
Integrity
Compliance with
Nutritional
Assessments
5
SIRIs Not Incl
Pressure Ulcers
93%
100%
100%
100%
0%
4
Complaints
100%
100%
94%
80%
0%
4
Compliments
100%
100%
94%
95%
0%
4&9
Single Sex
Breaches
CTCC / CCU**
CTW *
6A *
5D*
Theatres**
4
Total No of
medication errors
100%
8
Total No of Falls
97%
100%
8
% End date
included
60%
100%
8
% Correct
presciption
100%
Cardiology *
8
National Cleaning
Overall Score
CAS **
8
Saving Lives
Catheter Care
C-Diff
Post 72 hrs
Non Nursing
Nursing
Division
Directorate
Medicine
PP
Surg &
Vasc
Cardiac, Vascular
and Thoracic (3)
Ward
8
MRSA / MSSA
post 48 hrs
8
Catheter on
going care
8
Hand Hygiene
Catheter
Insertion
CQC Outcomes
C, V & T Quality Metrics Scorecard
ANTT Injectables
January
0
0
93%
0
0
100%
0
0
18
0
0
70%
30%
0%
100%
100%
0
0
92%
N/A
N/A
3
3
60%
0
100%
0
18
1
0
55%
39%
6%
90%
100%
0%
100%
100%
90%
100%
0%
0
0
0
0
0
0
0
1
0
0
93%
93%
86%
92%
0%
100%
100%
100%
N/A
100%
92%
90%
N/A
2
3
3
0
0
1
1
1
2
0
93%
100%
100%
0%
0
0
0
0
0
100%
100%
100%
98%
0%
1
0
0
0
0
27
32
15
10
0
0
0
1
0
0
0
0
1
0
0
82%
97%
25%
62%
0%
18%
3%
60%
38%
0%
0%
0%
19%
0%
0%
Hand hygiene: weekly audits being undertaken
SIRI: - C Diff.transmission of C Diff occurred. Training given to staff, action plan
implemented and monitored to improve cleaning standards.
Reduction in cleaning standards: remedial action plan implemented on 6A. Enhanced
clean completed throughout the ward. Individuals given responsibility for specific areas
on wards.
Tract & Trigger: PDN undertaking observational shifts to ensure compliance and weekly
ward sister governance rounds. Implement track and trigger link nurse.
At risk staffing; although some shifts have been identified as 'at risk', none of wards
were deemed to be unsafe as staff were moved around the division to manage the
risks.
Antimicrobial
C & W Quality Metrics Scorecard
94%
95%
98%
92%
100%
98%
100%
98%
100%
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
86%
96%
88%
91%
89%
92%
92%
92%
93%
Actions
Handy Hygiene and Cleaning Scores - matrons attending twice weekly to raise
awareness of these issues.
Anti microbial - Clinical Director undertaken an audit, discussed at the
Consultant meeting and they have agreed to take a lead in monitoring this w
ith their junior medical staff. Divisional Nurses attending next Consultant
meeting to re enforce the messages
Staffing in Neonatal Unit – risks managed through use of temporary staffing
Neonatal medication errors - 13 near mises and 2 adverse events, no harm
resulted. Gentamycin prescription errors (near misses) are monitored and
reported monthly by the Matrons
Pharmacy undertaking spot audits of prescriptions to identify themes and
training needs.
60%
N/A
N/A
100%
50%
N/A
N/A
100%
4 & 20
13
% shifts 'at risk
staffing'
100%
100%
70%
95%
100%
100%
92%
100%
95%
17
% shifts
'minimum
staffing'
Childrens Ambulatory Care 100%
HGH Childrens W * 100%
Bel / Dray *
100%
Kamrans **
100%
Melanies *
100%
NNU**
100%
SCBU**
92%
PHDU**
100%
PICU**
95%
4
% shifts 'agreed
staffing'
N/A
100%
1
SIRIs Not Incl
Pressure Ulcers
N/A
100%
5
Complaints
90%
97%
4
Compliments
0
0
4
Single Sex
Breaches
0
0
4&9
Compliance with
Track and Trigger /
EWS
Pressure Ulcers
Grade 3/4 / Skin
Integrity
Compliance with
Nutritional
Assessments
91%
87%
4
Total No of
medication errors
95%
88%
Toms *
Robins *
Catheter on
going care
100%
100%
Ward
Catheter
Insertion
% End date
included
8
Antimicrobial
% Correct
presciption
8
National Cleaning
Overall Score
8
C-Diff post 72 hrs
8
MRSA / MSSA
post 48 hrs
8
Saving Lives
Catheter Care
ANTT Injectables
8
Non Nursing
8
Hand Hygiene
Nursing
Directorate
Paediatrics
Paediatric
Critical Care
Children's
Division
CQC Outcomes
Total No of
Accidents
January
0
1
1
0
100%
100%
0
0
100%
100%
0
0
6
0
0
0
0
0
88%
83%
12%
17%
0%
0%
0
0
0
0
0
0
0
0
0
0
0
1
0
1
15
0
0
0
na
98%
100%
100%
100%
n/a
n/a
n/a
100%
0
0
0
0
0
0
0
0
0
NA
100%
100%
96%
90%
0
0
0
0
0
0
n/a
0
0
2
6
0
0
0
0
2
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
73%
92%
38%
60%
87%
67%
100%
70%
90%
23%
8%
62%
40%
13%
44%
0%
29%
10%
0%
0%
0%
0%
0%
10%
0%
0%
0%
84%
50%
0%
100%
90%
100%
0%
0%
0%
0
0
92%
95%
96%
0%
88%
89%
94%
100%
100%
75%
100%
100%
81%
0
0
0
0
0
0
0
3
2
0
0
0
0
0
0
0
0
0
0
0
0
AICU/CICU/CCU
Cleaning Scores
The Matron has met with Carillion and Denise Pawley to discuss issues around inconsistency in cleaning
personnel and number of cleaners Action- Carillion have agreed that there will now be regular cleaners.
The re - audit was successful.
Catheter Care
Key points from the Catheter care bundle had not been documented which caused the score to be reduced
Action-. Email sent to all staff stressing the importance of documentation
Handy Hygiene
Scores for the nursing staff continues to rise. Non nursing scores remain low Action - The matron has spent
time on the units challenging non nursing staff re handy hygiene
Theatres
ANTT
1
13
4
17
4 & 20
% shifts 'at risk
staffing'
0
0
0
5
% shifts
'minimum
staffing'
0
0
0
4
% shifts 'agreed
staffing'
70%
100%
100%
4
SIRIs Not Incl
Pressure Ulcers
0%
0%
0%
4&9
Complaints
100%
100%
0%
% Correct % End date
presciption
included
4
Compliments
8
Antimicrobial
Single Sex
Breaches
8
Compliance with
Track and Trigger /
EWS
Pressure Ulcers
Grade 3/4 / Skin
Integrity
Compliance with
Nutritional
Assessments
8
National Cleaning
Overall Score
8
C-Diff post 72 hrs
70%
65%
67%
%
95%
88%
75%
Saving Lives
Catheter Care
MRSA / MSSA
post 48 hrs
87%
89%
89%
0%
100%
100%
100%
ANTT
Injectables
Non Nursing
AICU **
CICU **
HGH CICU **
HGH DCU *
Th West Wing **
Th JR **
Th HGH **
Nursing
Directorate
Anaes / CC / Th
Division
Critical Care,
Theatres,
Diagnostics &
Ward
8
8
Hand Hygiene
Total No of
medication errors
8
Catheter on
going care
CQC Outcomes
Total No of Falls
CCTDP Quality Metrics Scorecard
Catheter
Insertion
January
23
2
10
0
0
0
0
10
7
11
0
1
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100%
100%
100%
100%
100%
100%
100%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
Hand hygiene – low scores being highlighted at clinical unit meetings for actions
including spot checks by matrons. Cleaning issues being addressed across the
Division with re–audits being undertaken and where necessary action plans put in
place for staff and Carillion.
RCA for C Diff undertaken; no link to other patients and infection control team
have been consulted re antibiotics prescribing
Pressure ulcers: all under review and action plans underway.
Staffing issues being managed through continued recruitment and the
management of long term sickness
93%
80%
10
8
5
5
18
4
1
1
0
1
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
82%
80%
100%
100%
100%
95%
100%
100%
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
100%
100%
0%
100%
90%
0%
80%
100%
100%
94%
90%
100%
100%
100%
93%
86%
100%
13
% shifts 'at risk
staffing'
♠
♠
82%
100%
67%
73%
0
0
0
2
0
0
0
0
1
1
0
4 & 20
% shifts 'minimum
staffing'
93%
87%
♠
100%
100%
100%
100%
0%
100%
95%
0%
0%
100%
0%
17
% shifts 'agreed
staffing'
♠
♠
91%
100%
87%
73%
0
5
1
0
0
0
2
0
0
0
0
4
SIRIs Not Incl
Pressure Unlcers
♠
0
3
0
4
0
4
5
3
4
6
0
1
Complaints
92%
89%
92%
89%
91%
88%
93%
93%
N/A
92%
88%
NA
NA
NA
NA
NA
79%
82%
73%
92%
73%
na
5
Compliments
0
0
0
0
1
0
0
0
0
0
♠
100%
82%
100%
92%
82%
na
4
Single Sex
Breaches
0
0
0
0
0
0
0
0
0
0
♠
80%
4
Compliance with
Track and Trigger /
EWS
Pressure Ulcers
Grade 3/4 / Skin
Integrity
Compliance with
Nutritional
Assessments
0
0
70%
4&9
Total No of
medication errors
0
0
88%
88%
91%
93%
89%
90%
93%
86%
86%
89%
92%
4
Total No of Falls
100%
100%
100%
100%
0%
100%
100%
0%
0%
0%
100%
100%
75%
100%
100%
0%
0%
0
0
0
0
0
0
2
0
8
This infomration is collated by speciality
0%
100%
100%
100%
100%
100%
100%
100%
0%
100%
0%
100%
0%
0%
0%
0%
0%
0
0
0
0
0
0
0
0
% End date
included
100%
100%
100%
100%
80%
100%
94%
100%
95%
100%
100%
100%
100%
NA
100%
N/A
100%
8
Antimicrobial
% Correct
presciption
100%
100%
100%
100%
93%
100%
95%
100%
100%
100%
100%
100%
100%
NA
100%
N/A
100%
8
National Cleaning
Overall Score
PAU *
Oak *
Laburnam *
Juniper *
Level 4 *
ASU *
John Warin **
Geoffrey Harris *
Treatment Centre
Dermatology
Immunology
OCDEM Endocrine
OCDEM Diabetes
Sleep Physiology
GUM
Genetics
100%
8
C Diff post 72 hrs
100%
100%
100%
100%
0%
100%
95%
0%
0%
0%
0%
8
MRSA / MSSA
Post 48 hrs
100%
100%
100%
100%
60%
75%
100%
100%
100%
100%
100%
Catheter on
going care
89%
100%
100%
100%
90%
100%
100%
100%
100%
100%
100%
Ward
Catheter
Insertion
ANTT Injectables
Saving Lives
Catheter Care
Non Nursing
Directorate
Emergency Medicine
Ambulatory, Chest, ID
Division
8
JR ED **
JR EAU *
HGH ED **
HGH EAU *
7A *
7B *
7C *
7D *
7F*
5A *
5C Escalation
Hand Hygiene
Emergency Medicine, Therapies & Ambulatory (7)
8
Nursing
8
VTE
EMTA Quality Metrics Scorecard
January Data
CQC Outcomes
0
4
0
1
0
0
0
0
0
0
0
5
0
5
2
0
3
0
0
4
0
0
8
1
4
1
1
1
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
97%
40%
91%
85%
52%
62%
44%
48%
61%
17%
5%
3%
53%
9%
10%
41%
21%
49%
35%
33%
66%
77%
0%
7%
0%
5%
8%
16%
7%
16%
4%
17%
17%
0
0
0
0
0
2
0
0
0
5
12
7
10
6
12
4
18
0
1
5
2
4
1
10
0
0
0
0
0
1
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
60%
92%
56%
86%
41%
77%
55%
19%
0%
0%
0%
0%
0%
0%
0%
0%
23%
7%
44%
14%
56%
20%
45%
74%
0%
0%
0%
0%
0%
0%
0%
0%
6%
1%
0%
0%
3%
3%
0%
7%
0%
0%
0%
0%
0%
0%
0%
0%
A
g
e
n
c
y
i
NTSS Quality Metrics Scorecard
90%
80%
0
0
0
0
88%
91%
93%
0%
0%
0%
Increase in falls on SSIP, this was due to one patient falling a number of times.
Staffing increased to be able to observe more closely, falls assessment, care plan
and post falls care plan in use.
3A Pressure ulcer - patient admitted from home with this. NICU Pressure ulcer to
nose, currently being investigated as appears to be potentially unavoidable due
to medical care required at that time. RCA currently with Risk Management.
Low compliance with nutrition assesments on F ward, partly due to being unable
to weigh pre-operative #NOF pateints and increased use of agency/bank staff
due to increased sickness absence. Divisional Nurse visited F ward on 2/2/12 and
undertook an inspection with ward sister which found compliance had
improved.
All cleaning audits amber across the Division in January. There have been a
number of reinspections and communication with Carillion and the
Housekeepers. Action plans introduced where required. Continue to closely
monitor.
Medical staff hand hygiene Trauma OPD. Out patient sister continues to address
with the staff. Clinical Lead has been informed.
Antimicrobial– lead consultants to take actions and speak with teams; pharmacy
to provide individual consultant information for discussion with individuals
Yellow notice placed on neuro health records as reminder for correct prescribing
Staffing issues being managed through the use of temporary staff
0%
90%
1
0
100%
100%
0
0
100%
100%
100%
100%
2
4
1
0
100%
100%
0
1
100%
90%
0
4
0%
63%
0%
56%
5
6
0
0
80%
100%
0
0
75%
0%
5
0
% shifts 'at risk
staffing'
80%
100%
n/a
1
3
% shifts
'minimum
staffing'
0
0
0
1
4 & 20
% shifts 'agreed
staffing'
0
0
65%
17
SIRIs Not Incl
Pressure Ulcers
100%
100%
0%
82%
13
4
Complaints
100%
n/a
1
Compliments
100%
100%
5
Single Sex
Breaches
92%
90%
90%
88%
88%
4
Compliance with
Track and Trigger /
EWS
Pressure Ulcers
Grade 3/4 / Skin
Integrity
Compliance with
Nutritional
Assessments
0
0
4
Total No of
medication errors
0
0
4&9
Total No of Falls
100%
4
% End date
included
8
Antimicrobial
% Correct
presciption
8
National Cleaning
Overall Score
100%
100%
8
C-Diff post 72 hrs
0%
0%
0%
0%
0%
70%
94%
0%
0%
0%
0%
0%
8
MRSA / MSSA
post 48 hrs
95%
98%
100%
100%
100%
92%
100%
90%
90%
100%
90%
90%
Catheter on
going care
NICU **
Neurosciences IP *
Neurosciences OPD
2A *
3A *
Trauma OPD
F Ward *
SSIP *
Lichfield *
SSOPD
OPD Eye
OMFS OPD
8
Saving Lives
Catheter Care
Catheter
Insertion
Ward
Non Nursing
8
Nursing
Directorate
Neuro
Trauma
Specialist
Surgery
Division
CQC Outcomes
Neuro, Trauma, Specialist
Surgery (3)
8
Hand Hygiene
ANTT Injectables
January Data
12
25
10
28
20
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
6
0
0
0
0
0
0
0
0
0
0
0
0
0
82%
61%
0%
84%
82%
0%
80%
94%
27%
10%
0%
0%
16%
27%
0%
14%
16%
0%
18%
6%
74%
76%
0%
0%
2%
12%
0%
2%
3%
0%
1%
0%
0%
14%
0%
0%
70%
93%
N/A
N/A
55%
90%
80%
1
2
0
2
7
1
0
2
5
0
0
0
2
2
3
3
0
3
1
0
0
0
1
2
0
0
2
1
0
1
1
0
0
0
1
1
1
0
2
1
0
0
0
0
0
0
0
0
1
0
0
0
90%
na
100%
100%
90%
90%
100%
100%
100%
100%
100%
100%
100%
70%
100%
0
0
0
0
0
0
1
100%
80%
100%
60%
90%
70%
60%
Nutrition & Hydration Patient safety Week raised profile for nutritional screening, accurate fluid balance charts and provision of meal service. This work being
continued in focused observation in ward areas with less than 90% compliance for all admissions.
Pressure Ulcers - RCA undertaken and identified as avoidable; complex patient needs and compliance identified as a contributing factor
Cleaning scores: it is now the matrons' responsibility to organise re-audits when wards fail the cleaning audit and coordinate the services present at re-audit.
This has empowered the matrons to own the issues that fail the audit. Nursing scores have improved and there is improved evidence log of outstanding
cleaning requests made as these are encouraged to be made via the helpdesks.
Antimicrobial results: The Division is committed to raising compliance with documentation of antibiotic prescribing. All junior doctors have been reminded of
their responsibility to accurately document both the indication for use and the duration before review. Any non-compliant prescriptions will be recorded and
discussed with the individual eduactional supervisor. Consultants will review and remind on their daily ward rounds.
Division continues to focus on reducing the number of falls.
C.Diff investigated and no link to ANTT or antimicrobials was
identified in either case
Staffing issues being managed through redeployments between
ward areas and use temporary staff
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
6
0
3
21
7
6
7
5
3
6
12
14
20
20
4
7
8
0
0
0
0
0
0
0
0
0
1
0
0
0
2
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
13
% shifts 'at
risk staffing'
80%
100%
N/A
N/A
73%
90%
80%
5
% shifts
'minimum
staffing'
92%
92%
83%
100%
92%
N/A
4
% shifts
'agreed
staffing'
100%
100%
86%
100%
100%
92%
92%
83%
100%
92%
N/A
4
90%
N/A
70%
N/A
100%
100%
100%
100%
SIRIs Not Incl
Pressure Ulcers
0
0
0
1
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
79%
4 & 20
Complaints
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
57%
17
Compliments
N/A
100%
100%
N/A
86%
100%
91%
93%
91%
89%
88%
79%
89%
87%
87%
95%
94%
86%
84%
97%
94%
89%
87%
92%
4
Single Sex
Breaches
0
4&9
Compliance with
Nutritional
Assessments
0
%
% End
Correct
date
prescipti included
on
4
Pressure Ulcers
Grade 3/4 / Skin
Integrity
100%
Antimicrobial
Compliance with
Track and
Trigger / EWS
100%
N/A
80%
100%
N/A
100% 100%
95%
N/A
100% N/A
100% N/A
100%
NA
100%
100%
98% 100%
86%
N/A
100% N/A
100% N/A
86% 100%
90%
100%
100%
100%
100%
100%
100%
8
8
Total No of
medication
errors
80%
100%
100%
100%
100%
100%
100%
100%
90%
95%
92%
86%
67%
100%
60%
80%
80%
n/a
n/a
n/a
n/a
n/a
8
C-Diff post 72
hrs
National
Cleaning
Overall Score
100%
70%
100%
100%
100%
100%
100%
100%
100%
100%
100%
90%
100%
100%
100%
100%
100%
92%
100%
100%
100%
100%
8
MRSA / MSSA
post 48 hrs
Non
Nursing
Oncology Ward **
Oncology Treatment
Haematology **
Sobell *
SEU D & Triage*
SEU E
SEU F *
5F *
JR Endoscopy **
HGH Endoscopy **
HGH E Ward *
UGI *
Colorectal *
Jane Ashley *
Urology *
Transplant **
Renal Ward **
ORH Dialysis *
Stoke Mandeville *
Milton Keynes *
Swindon *
Wycombe *
8
Saving Lives
Catheter Care
Catheter
on going
care
Ward
ANTT
Injectables
8
Catheter
Insertion
8
Hand
Hygiene
Nursing
Directorate
Surgery - JR, HGH, Churchill &
Endoscopy
Renal, Transplant &
Urology
Surgery & Oncology (6)
Oncology
Division
CQC Outcomes
Total No of Falls
S & O Quality Metrics Scorecard
January Data
74%
25%
1%
43%
62%
90%
87%
46%
49%
97%
80%
97%
80%
86%
78%
33%
45%
54%
50%
35%
0%
10%
42%
26%
3%
10%
3%
17%
9%
21%
61%
50%
43%
7%
3%
10%
3%
12%
25%
0%
10%
0%
3%
5%
1%
6%
5%
3%
Falls reported in Maternity - Woman fainted in shower after delivery; she was
uninjured. Patient fell after trying to stand in room post epidural (alone) but no injury
sustained after medical review. Visitor's father collapsed whilst visiting daughter on
Level 6 - transferred to ED, no injury was sustained
Five drug errors: 2 documentation errors:
There was poor documentation noted on 2 drug charts. The date and time of when
the drug was administered was clearly documented but there was no evidence of a
signature by a health professional. There was no way to follow this up with the
individuals concerned.
5 vials of BCG were destroyed after being left out of the fridge overnight. The ward
managers and bleep holders were reminded about correct storage of the BCG
vaccine.
There was a delay in obtaining medication for a woman who arrived needing a
prescription of Lorazepam; this particular drug is not stocked in Women's centre. This
issue was discussed with the clinical midwifery manager and pharmacy re stocking
this drug in future. The Pharmacist has agreed to have a stock within the Woman's
centre. [Woman received alternative drug but alternative not optimum].
Pharmacy incorrectly dispensed drug from pharmacy (Flucloxacillin) the dosage in mls
and milligrams was incorrect, the drug was not administered to the baby and the
drug was returned to pharmacy.
Red handwashing score: new rotation of medical staff received handwashing as part
of their induction. Audits continue. Anaesthetists not washing hands in between
patients in Recovery; nursing staff wearing gloves inappropriately - individuals will
now be challenged. Low cleaning score in Theatres: Matron, scrub and recovery
sisters met and went through audit esults, Action plan in place to be completed by
end of week.
Gynae Ward:reaudited following failed cleaning score. Matron and Sister to review
cleaning manual and complete assurance checks.
1
4
17
4 & 20
% shifts 'minimum
staffing'
% shifts 'at risk
staffing'
No data
5
% shifts 'agreed
staffing'
60%
4
SIRIs Not Incl
Pressure Ulcers
70%
4
Complaints
46%
4&9
Compliments
88%
92%
88%
93%
91%
90%
92%
92%
85%
95%
%
% End
VTE
Correct
date
prescipti included
on
13
4
Single Sex
Breaches
0%
0
0
0
0
0
0
0
0
0
0
8
Compliance with
Nutritional
Assessments
0%
0
0
0
0
0
0
0
0
0
0
8
Antimicrobial
Pressure Ulcers
Grade 3/4 / Skin
Integrity
90%
100%
8
Compliance with
Track and Trigger
/ EWS
100%
100%
100%
8
Total No of
medication errors
78%
100%
50%
100%
8
Total No of Falls
96%
89%
90%
100%
ANTT
Injectables
Non Nursing
JR Gynae*
HGH Gynae*
Women's Theatres
Delivery Suite / Obs
Spires Midwifery Led
Level 5
Level 6
Level 7
HGH Delivery Suite
HGH Post Natal Ward
Nursing
Directorate
Gynae
Maternity
Division
Gynae and Maternity
Ward
8
Saving Lives
Catheter Care
National Cleaning
Overall Score
8
C-Diff post 72 hrs
8
Hand Hygiene
Catheter on
going care
CQC Outcomes
MRSA / MSSA
post 48 hrs
Gynae and Maternity Quality Scorecard Board
Catheter
Insertion
January
0
0
2
2
0
0
1
0
0
0
0
0
2
2
0
2
1
0
0
0
0
0
0
0
0
0
0
0
0
0
100%
100%
100%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0
0
0
0
0
0
0
0
0
0
0
0
0
6
4
1