Oxford University Hospitals
TB2012.28
Trust Board Meeting: Thursday 3 May 2012
TB2012.28
Title
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
TB2012.28_Monthly Quality Report
Strategy
Assurance
Policy
Performance
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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
One new SIRI was called during March 2012 and one new Never Event was
called on 21st March.
The Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital
Mortality index (SHMI) are both within expected limits.
3
A total of 96 complaints were received during March 2012 and included one
graded as red.
4
The patient feedback indicates that 96% of patients would recommend the OUH
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Safety, Quality and Risk
1.
This section covers a number of areas that are included in the attached safety, quality
and risk scorecard (appendix 1).
2.
One new Serious Incident Requiring Investigation (SIRI) and One Never Event were
called in March 2012.
Key category/theme
SIRI
C-DIFF part 1A death certificate
Never Event
Retained foreign object post operation
3.
All SIRIs are investigated in accordance with the Incident Reporting and
Investigation Policy. The investigations into the Never Events are on going.
4.
The profile of the WHO Surgical Safety Checklist and other safety critical standard
operating procedures has increased over recent months following the occurrence of
two separate „Never Events‟ within the Trust during 2012.
National Patient Safety Lead Investigator Root Cause Analysis Training
5.
Root Cause Analysis is a key component to incident investigation.
6.
Two lead investigators courses run by the National Patient Safety Agency on Root
Cause Analysis training have been organised for key staff in April and May.
Organisation Patient Safety Incident Report
7.
An organisational Patient Safety Incident Report providing an overview of incidents
reported by the Oxford Radcliffe Hospitals NHS Trust and the Nuffield Orthopaedic
Centre NHS Trust was received in March 2012.
8.
The report provides an overview of incidents reported by the two organisations to
the National Reporting and Learning System (NRLS) between 01 April 2011 and 30
September 2011.
9.
The report provides a benchmark for incidents reported to the NRLS. The data is
presented in two organisational clusters, ORH within the Acute Teaching Hospitals
organisations cluster of 27 organisations, and the NOC within the Acute Specialist
Organisations cluster of 21 organisations.
10.
For the number of reported incidents the ORH was in the best 50% of Trusts within
their cluster and the NOC was in the best 25% of their cluster.
11.
The ORH has successfully increased the reporting rate from 5.7 incidents reported
per 100 admissions to 6.7 which has taken the Trust from the middle of the 25-50% of
reporters to the middle 50-75 % of reporters in their cluster.
12.
The NOC has fallen slightly within their cluster but remain within the best 25% by
reporting 10.8% of incidents per 100 admissions.
13.
The introduction of an electronic incident reporting system commencing in May 2012
should ensure that incidents from the ORH are submitted to the NRLS in a more
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timely way. Currently 50% of incidents are submitted in more than 60 days after the
incident occurred.
14.
The ORH was noted to have reported fewer incidents as causing no harm than
nationally or those within the cluster. Training sessions will be reviewed to ensure
that those completing the incident forms are recording actual harm to patients rather
than the potential degree of harm.
Staff Incidents Resulting in Harm
15.
During the month of January there were a total of 60 incidents which resulted in
harm to staff. This was below the monthly threshold target of 72.
16.
The two highest incidence rates by cause type which resulted in harm comprised of
manual handling (12%) and Needlestick (26%). Investigations have been undertaken
which has resulted in interventions being identified and implemented in order to
further reduce the number of incidents. In addition the MSD/ULD Group and
Needlestick safety action group are reviewing the root causes of the incidents in
order to identify additional precautions in order to reverse the trend.
Outcomes (Dr Foster and Summary Hospital Mortality Index)
17.
Both mortality measures are within expected limits although both measures are near
to the upper control limits.
18.
The current SHMI published in April is 1.01, this relates to the time period October
2010-September 2011. The HSMR for financial year to date at the OUH is 99.2.
19.
It is not currently possible to identify patient level information using the data from
the NHS IC or the SHMI data within the Dr Foster tools. Thus interrogation of
mortality data for the time being is reliant on the RTM tool within Dr Foster
intelligence that measures HSMR and HMR.
20.
The NHS Information centre SHMI diagnosis groups with the largest difference
between observed and expected deaths for October 2010 to September 2011 are
broadly comparable to those being audited as part of the HSMR project. Three
diagnosis groups have better clinical outcomes when analysing using the Doctor
Foster Intelligence Tools and will be the subject of further analysis over the next
month.
National Patient Safety Alerts
21.
In March 2012 7 Medical Device Alerts (MDA) and 1 National Patient Safety (NPSA)
Rapid Response Report (RRR) were issued. The NPSA/RRR/001 ‘Harm from flushing
of nasogastric tubes before confirmation of placement’ was released following an earlier
related NPSA alert (NPSA/2011/PSA002) which related to reducing the harm
caused by misplaced nasogastric feeding tubes in adults, children and infants. This
has been circulated with immediate actions specified to all Divisional Nurses and the
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on-going leadership of work associated with this is being examined. Monitoring of
this and all CAS alerts occurs at the monthly Clinical Risk Management Committee.
22.
2 of the 3 MDAs alerts due for closure in March were completed within the given
time frame and MDA alert MDA/2012/006 breached the closure date by 24 hours;
this related to histology laboratory reagents. No incident has been received relating
to the advice contained within this alert.
23.
The following number of alerts remain open, 11 MDAs, 3 NPSAs and 2 EFAs. These
alerts due for closure in the future have been distributed within the Trust in line with
current policies and procedures.
Quality Walk Rounds
24.
25.
During March 2012, five of the seven programmed walk rounds were completed in
the following areas:
Trust Site
Ward/ Department
John Radcliffe
Radiology and Nuclear medicine
John Radcliffe
Physiotherapy OPD
Nuffield Orthopaedic Centre
Bone Infection Unit
Churchill
Tarver Unit
Churchill
TSSU
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
Delays with VCF process (Physiotherapy OPD)
Concern that statutory and mandatory training not available
on NOC site (plan in place to resolve)
Potential for staff injuries highlighted
Environment
Poor physical environment for wheelchair users (Radiology and
Nuclear medicine)
Inadequate air-conditioning (TSSU)
Flooring in need of replacement (Physiotherapy OPD)
EPR
Patients not being discharged from ED on EPR and hence
cannot be admitted (Bone Infection Unit)
Patients being missed on return to reception area
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Equipment
Replacement chairs needed within TSSU.
Shuttle
A request for the shuttle to include the NOC site ( completed)
Areas of good
practice include
A graduate programme within Radiology and Nuclear medicine
has had a positive effect on recruitment
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Positive patient feedback within Radiology and Nuclear
medicine
Completion of Root Cause Analysis for all categories of
pressure ulcers within the Bone Infection Unit
26.
Completed actions since January 2012 include:
The addition of a security lock on an internal door at Wallingford Community
Hospital
A solution for the main door at Sobell House has been agreed and ordered with
Estates.
Transport SLA policies are being updated.
The site provision of SME training has been reviewed. The shuttle transport now
incorporates the NOC site.
Executive Quality Walk Rounds and Inspection Visits
27.
The Quality Committee received two papers reviewing the Quality Walk Round
Programme and the Serious about Safety Inspections Programme for the last year.
28.
Quality Walk Rounds are undertaken by Board members throughout the year. They
provide a formal process for m e e t i n g w i t h frontline staff about quality and
safety issues providing opportunity to discuss areas of concern with staff and
demonstrate support for reporting errors and near misses.
29.
The Inspection Programme was introduced as a series of activities to promote
understanding of the clinical standards that are expected, to check compliance and
support staff to deliver the standards. These visits were launched as the next phase
of the “Serious about Standards Programme” in two phases: firstly a fast roll out
phase followed by a „business as usual‟ phase.
30.
The aim of the Quality Walk Rounds is to promote two way communication, and
the Inspection Programme was introduced to promote visibility and build capability
in compliance with standards.
Activity during 2011/12
31.
Eighty two Quality Walk Rounds took place during the reporting period of the
2011/2012 with an out turn of 7 per month. This is a decrease on the previous
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year (98 walk rounds). However both non-executive and executive directors are
involved in a number of other informal departmental visits. Of the formal walk
rounds, 39 have been at the John Radcliffe site, 24 at the Churchill, 11 at the Horton,
4 at satellites and 4 at the Nuffield Orthopaedic Centre. Ninety-four per cent of the
walk rounds have been undertaken within clinical areas.
3 2 . In excess of 150 inspection visits were completed as part of the two phased approach
and continue now as business as usual. Visits covered three areas of focus covering
the sixteen CQC “Essential Standards of Safety and Quality.
Patient orientated outcomes covered CQC standards on respect and involving
patients, consent, nutrition, co-operating with partners, record keeping and
complaints;
S taff or people orientated outcomes covered CQC standards on recruitment and
staffing, supporting workers, safeguarding and medicines; and
Performance related outcomes covered premises, governance and monitoring.
33.
All wards and departments were inspected at least once and many (particularly in
medicine and gerontology) received multiple visits at different times of day to
assess compliance with different aspects of the sixteen essential standards.
Themes and findings
34.
The main themes and issues from the Executive Walk Rounds have remained
consistent around staffing, equipment and estates issues. Findings from the
Inspections included good levels of patient satisfaction and improvement areas,
particularly in risk assessments for malnutrition.
35.
From October 2011 onwards the Divisions led the inspections and aimed to embed
the process and expand the Divisional ownership. The templates for capturing the
findings were also simplified.
The findings illustrated improvements particularly
with:
Engagement at mealtimes, availability and prompt answering of call bells
Cleaning of equipment and ownership and pride in making improvements and
highlighting good practice
A stronger focus on nursing assessments a n d also on the required plans of
care.
Improvements in documentation and evidence of medical engagement.
36.
However documentation remained an improvement area and the extent of this was
better understood following executive director visits where shortfalls required
intensive executive and divisional action to address.
Impact and Evaluation
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37.
Both walk rounds programme and the inspection programme have been well
received and evaluated by staff. Feedback from staff and patients on the Walk
Round programme is positive, areas welcome the visits, and they have been
effective in establishing lines of communication and identifying opportunities to
improve quality and safety in the Trust. Staff appreciated directors taking the
time to hear their concerns and reported that they value having the Trust‟s broader
context explained to them. Directors valued meeting a broad cross section of staff –
on several occasions staff have steered visitors to a particular problem that has been
frustrating them. Impact can, however be affected by cancellations and director
availability was the most common reason for cancellation.
38.
Divisional Nurses evaluated the Inspection Programme has increased the visibility
of leadership and the awareness of CGC standards. They have also familiarised
staff with inspection and developed an appetite to use inspection as a mechanism of
assurance.
39.
Staff conducting the inspections have found it most beneficial to spend the first 20-30
minutes observing the ward environment (rather than immediately talking to
patients or staff) as often environments were tidied during the duration of the visit.
(This is advocated in the 15 steps initiative).
40.
Executive
director
involvement
also
identified
weaknesses
in
the
methodology due to variable understanding of assurance, and historic variation in
approach to Trust wide initiatives compounded by the overlaying of initiatives to
address specific issues. This confirmed the need for formal validation and
assessment of the effectiveness of the inspections and a programme of training and
development in assurance, in order that inspections can form a valid assurance
mechanism.
41.
Whilst the methodology and purpose of the walk rounds and inspections differ
there is potential to cause confusion when the timing of the visits co-insides, which
will be addressed in future scheduling. In summary both programmes have been
welcomed and both form important components of the trust assurance and
compliance mechanisms.
Next Steps for the Walk Round and Inspection Programmes
42.
The walk round programme will be refreshed to enable wider coverage across a 24
hour period and focus on the patient experience, taking account of learning from
the 15 Steps Challenge methodology. This will be re-launched by the end of June
with simplified follow-up arrangements and capture (reporting) of the informal
visits.
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43.
The 2012 programme of Serious about Standards inspections will continue to
focus on divisional ownership to embed the programme. Executive involvement in
the programme is an essential component and will continue using a risk based
approach
44.
The programme methodology is to be formally reviewed and the feedback
mechanisms strengthened to enable the programme to form part of an
assurance framework. A programme of training in conducting inspections
and validation of inspections will also be introduced as part of the methodology
review.
Infection Control
45.
The MRSA and Clostridium difficile objectives for 2011/2012 were monitored
separately for the ORH and NOC trust until 31st Match 2012. However, in the
forthcoming year the infection control objectives will be monitored as a single trust.
46.
The Oxford Radcliffe Hospitals (ORH) NHS Trust has met both its MRSA and
Clostridium difficile objectives for 2011/2012. The MRSA objective was 7 for the year
and the trust had 4 cases of MRSA bacteraemia. The Clostridium difficile objective was
137 cases and the ORH trust had 103 cases.
47.
The Nuffield Orthopaedic Centre (NOC) met it MRSA objective of one case of MRSA
bacteraemia. The NOC had a reduction in cases of Clostridium difficile from previous
years but were one case over their Clostridium difficile objective for 2011/2012.
48.
The Department of Health have set the MRSA and Clostridium difficile objectives for
the OUH Trust for 2011/2012.
49.
The MRSA objective 2012/2013 for the OUH Trust is 7 MRSA bacteraemia identified
from blood cultures taken after two days of admission. The DH has combined last
years ORH and NOC MRSA objectives there is no change from 2011/2012.
50.
The objective for Clostridium difficile will be 88 cases identified from stool specimens
taken after three days of admission. This is a reduction of 49 cases from the previous
year‟s objective.
Nursing and Midwifery Quality Dashboards
51.
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.
52.
In terms of nursing staffing, each ward has completed a staffing profile for each shift
and identified the optimum or agreed staffing for safe, quality nursing and
midwifery care, the minimum staffing required to deliver safe care and the at risk
level of staffing where specific risk assessment and intervention takes place such as
providing additional support by ward basing senior staff, moving staff from other
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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 such intervention is
required and that this is successful in that there is little correlation with harm events.
53.
In relation to staffing and indicators of harm, the March position is largely the same
as that of previous months. Key factors reported this month, which influence the
management of staff, include staff vacancies, long term sickness and maternity leave.
Each of the Divisions has a plan in place to manage these factors.
Complaints
54. The number of complaints received in March (96) remains above the previous
average. This increase was reflected in: Cardiac Thoracic & Vascular, Critical Care,
Theatres, Diagnostics and Pharmacy, Emergency Medicine, Therapies & Ambulatory
and Musculoskeletal & Rehabilitation Service divisions. The number of complaints
for the last three years is illustrated in the table below.
55.
The four key themes identified remain patient care/experience, delays/waiting
times, communication and behaviour. All Divisions have received complaints in
one or more of these categories. EMTA, Surgery and Oncology have all received
complaints relating to end of life care. Both Corporate Services and CTD&P have
received complaints relating to the environment.
56.
Organisational learning is shared across Divisions so that changes in practice can be
embedded within the Trust at the monthly Clinical Risk Management Committee.
New Complaints – March 2012
57.
Of the 96 new complaints, one Division received a complaint graded Red and there
were 51 orange, 40 yellow and 4 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.
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58.
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The red complaint has been received by the Children‟s and Women‟s Division and
relates to concern over the standard of care when giving birth in November 2011.
The complaint remains open and is being managed through the complaints process.
Management of complaints
59.
Complaints received within the Trust are managed in accordance with the ORH
Complaints Policy, 98% of complaints were responded to within 25 working days,
or extended if complex, with the consent of the complainant for this time period.
60.
In March there was 1 breach in responding to complaints within the agreed
timescale of 25 working days.
Ombudsman Investigations
61.
In March the Ombudsman‟s Office wrote to the Trust confirming that they will not
be undertaking a statutory investigation on one complaint.
62.
The Ombudsman‟s Office also wrote to confirm that they considered that their
recommendations had been fully complied with by the Trust on another complaint
and this case was now closed.
Divisional updates on key themes and trends received in March 2012
The table below indicates the number of complaints received by Division in March and the
themes of these complaints.
Division
Complaints
received
March 2012
Increase/
decrease
on previous
month
Cardiac, Thoracic
& Vascular
6
+4
0
3
3
0
Children &
Women’s
12
-3
1
8
3
0
Corporate
2
0
1
1
0
Critical Care,
Theatres,
Diagnostics &
Pharmacy
6
+5
0
2
2
2
Emergency
Medicine,
Therapies &
Ambulatory
23
+2
0
12
11
0
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Themes:
Please note that themes
are listed by number as
one complaint may have
more than one theme
4 (66%) Patient Care/Experience
3 (50%) Communication
1 (17%) Delays/Waiting Time
11 (92%) Patient Care/Experience
5 (42%) Communication
4 (3%) Delays/Waiting Time
3 (25%) Behaviour
1 (50%) Behaviour
1 (50%) Environment
5 (83%) Communication
2 (33%) Delays/Waiting Time
2 (33%) Patient Care/Experience
1 (17%) Behaviour
1 (17%) Environment
22 (96%) Patient Care/Experience
12 (52%) Communication
7 (30%) Behaviour
2 9%) Comment
1 (4%) Delays /Waiting Time
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Musculoskeletal &
Rehabilitation
Services
10
+2
0
3
7
0
Neurosciences,
Trauma &
Specialist Surgery
20
-14
0
10
9
1
Surgery & Oncology
17
-3
0
12
4
1
63.
1 (4%) End of life
7 (70%) Delays/Waiting Time
5 (50%) Communication
3 (30%) Patient Care/Experience
1 (10%) Behaviour
14 (70%) Communication
10 (50%) Patient Care/Experience
8 (40%) Delays/Waiting Time
4 (20%) Behaviour
13 (76%) Communication
11 (59%) Patient Care/Experience
7 (41%) Delays/Waiting Time
3 (18%)Behaviour
2 (12%) End of Life Care
1 (6%) Comment
The table below illustrates the number of complaints by Division for the last three
years and does illustrate that overall complaint numbers has not risen significantly.
Divisional Action following complaints
64.
The Women & Children‟s Division have implemented additional administration
resources and staff training to improve reception facilities and telephone call
answering. Appointment letters have been revised to advise parents and patients
of delays that may arise as a result of EPR.
65.
Following the complaints received as a consequence of delays caused by the
implementation of EPR, the Surgery & Oncology Division have instigated
additional staff training sessions for EPR and now have a member of the A&C staff
available to answer telephone calls about appointment bookings.
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The Cardiac Thoracic & Vascular Division has amended their administration
procedures as a result of feedback from complaints related to the implementation of
EPR.
Patient Experience
67.
Analysis of March patient experience data is still in progress. However 46 of the 48
respondents indicated that they would recommend the Trust hospitals, a
recommendation rate of 96% regardless of any negative comments made.
68.
The table below provides a summary of the top five feedback issues:
Top 5 patient feedback issues
February
March
Care & service positive feedback
310
163
Concerns about aspects of care offered
119
71
Appointment, treatment and discharge delays
95
56
Complaints about contacting the hospital/wards
85
51
Environmental concerns
26
21
Source of patient experience reports
March
Telephone calls (to PALS)
112
Let Us Know Your Views (Questionnaires)
18*
E-mails (via PALS)
63
In person (to PALS)
16
Letters and Web feedback
7
*48 Leaflets received in March. Data from 18 processed in detail
69.
Total feedback scores for January, February and March are shown below:
January
February
March
Positive
615
48.9%
352
51.5%
184
50.7%
Neutral
329
26.2%
204
29.8%
106
27.8%
Negative
313
24.9%
128
18.7%
76
21.5%
70.
Clinical areas that have used their own survey questions such as cardiac, ENT and
Trauma will, from the beginning of May, be expected to include the standard
question about recommending the Trust hospitals and then forward their collated
data to Patient Services for inclusion in their monthly Board reports.
71.
Complaints about cancelled operations in March are the highest in percentage terms
for 15 months and account for 49% of negative feedback about treatment and
appointment delays. Of particular concern to patients are the frequently cancelled
neurosurgery lists, the reason for this appears to be the demands of emergency
admissions and the impact this has on elective cases.
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72.
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Evaluation of the Datix software is underway to assess its suitability to integrate
local and Trust wide patient experience data and to provide comprehensive
graphical presentation of patient experience data direct to clinical services.
Conclusions and recommendations
73.
The Board is asked to receive the report which highlights the range of activity across
the organisation.
74.
The Board is asked to note the actions being taken.
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Professor Edward Baker, Medical Director
Elaine Strachan-Hall, Chief Nurse
Appendices attached
Safety, Quality and Risk Scorecard
Divisional Quality Matrices
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