TB2013.57
Trust Board: Wednesday 8th May 2013
TB2013.57
Title
Quality Report
Status
A paper for discussion.
History
This is a regular report to the Board
Board Lead(s)
Professor Edward Baker, Medical Director
Mrs Elaine Strachan-Hall, Chief Nurse
Key purpose
TB2013.57_Quality Report
Strategy
Assurance
Policy
Performance
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Summary
1.
Mortality HSMR/SHMI Risk adjusted mortality measures – Risk-adjusted
mortality measures for the OUH are currently within expected limits. Mortality
rates for non-elective admissions at weekends are rated by Dr Foster as ‘within
the expected range’.
2.
Incidents – The report includes an analysis of the six monthly review published
by the NHS Commissioning Board for the period April-Sept 2012. OUH has made
significant improvements in the proportion of incidents causing no harm. This is
now 76.6% (peer group 74%), compared to 38% previously.
3.
Serious Incidents Requiring Investigation (SIRIs) – Three SIRIs were reported
in March 2013.
4.
Quality Concerns raised by staff – Concerns have been raised by Consultant
Gynaecologists about out-of-hours theatre facilities. The Clinical Lead for ED has
expressed concern about the pressure that the emergency departments have
been working under since the New Year. Ophthalmologists have raised concerns
about the management of their clinics.
5.
Executive walk rounds – Seven walk rounds were completed in March 2013.
This brings the total to 78 since April 2012.
6.
Patient Safety – In March 2013 the ‘harm free’ rate was 92.51%. This is a small
decline from the previous month (93.19%). When identifiable ‘old’ harms are
removed from the data, the ‘harm free’ rate is 96.78%.
7.
Central Alerting System – As of 31st March 2013 no alerts were breaching the
required deadline. Eleven new Medical Device Alerts (MDAs) were issued in
March 2013. Seven MDAs were due for closure in March 2013 of which five were
closed within the given time frame. Two breached by one day and six days
respectively.
8.
Complaints – A total of 85 complaints were received during January 2013, none
of which were graded as red.
9.
Annual CQC inpatient survey – Responses in relation to overall experience was
“about the same” as other Trusts in the report.
10
Friends and Family Test – There were 635 responses from patients in March.
The estimated response rate was 4.9%. 93% of respondents said that they would
be extremely likely or likely to recommend the clinical area.
11
Infection Control – The OUH Trust had a further reduction (10%) in cases of
Clostridium difficile over the past year from 103 in 2011/2012 to 92 in 2012/2013.
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Mortality-HSMR/SHMI Risk adjusted mortality measures
1.
Risk adjusted mortality measures for the OUH are currently within expected limits.
2.
The latest Summary Hospital Mortality Index (SHMI) is unchanged at 0.96. This was
published on 11th April 2013 and relates to the twelve months ending September
2012. The rates for the last 4 reporting periods are shown in Figure 1.
Figure 1: Summary Hospital Mortality Index (SHMI)
3.
The majority of deaths accounted for by SHMI (within 30 days of admission) continue
to occur within the Trust (75.9%).
4.
The HSMR as measured by Dr Foster is 98.1 for April to December 2012 1.
Weekend mortality rates
5.
Mortality rates during both weekdays and weekends are currently within the expected
range. The weekend HSMR is 97.6 and the weekday HSMR is 97.9.
SIRIs for March 2013
6.
Three serious incidents (SIRIs) were reported in March 2013 as detailed in the table
below.
Date of
Incident
Date SIRI
called
SIRI Ref
Div
Department
SIRI Ref
2013/009
C&W
Women's
28/02/2013
15/03/2013
2013/8113
2013/010
EMTA
ED
13/03/2013
15/03/2013
2013/7970
2013/011
NTSS
2A
17/02/2013
25/03/2013
2013/8869
Detail
Neonatal death
Self-harm incident
in ED resulting in
subsequent death.
Cat 3 pressure
ulcer on heel
Table 1: Serious Incidents (SIRIs)
7.
Figure 2 below outlines the number of SIRIs reported in financial years 2011/12 and
2012/13. There were a total of 40 for 2012/13 compared to 54 for the previous year.
1
Dr Foster data is complete up to December 2012. The figure relates to the time period April to December
2012 but will be subject to the process of ‘rebasing’ prior to publication in the 2013 Hospital Guide.
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Figure 2: SIRIs for 2011/12 and 2012/13
Reported Incidents for 2012/13
8.
An analysis of the incidents reported in 2012/13 highlight that:
a) The total number of incidents being reported has significantly increased. This
increase has been associated with the introduction of Datix electronic incident
reporting (see Figure 3).
b) The top six incident categories (below) account for approximately 57% of all
incidents reported.
i.
Slips trips & falls.
ii.
Medication errors.
iii.
Pressure ulcers or skin integrity issues.
iv.
Appointment, administration.
v.
Documentation / records / EPR.
vi.
Equipment & medical devices.
Fig. 3 Incidents for 2011/12 & 2012/13
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NHS Commissioning Board – Organisational Report (Q1 and Q2, 2012/13)
9.
The National Patient Safety Agency publish organisational level reports every six
months, based on data submitted to the National Reporting Learning Service. The
functions of the NPSA have now been absorbed into the role of the NHS England
(formerly NHS Commissioning Board). The six monthly reports are based on a peer
group of 30 teaching organisations. The highlights are as follows:
a. The implementation of the Datix reporting system since April 2012 has had a
positive effect on the accuracy of incident reporting.
b. OUH has made improvements in the proportion of incidents reported as causing
no harm, 76.6% (peer group 74%). The previous figure was 38% (based on Q3
and Q4, 2011/12 data). This change is due to a review of the OUH grading system
for incidents to ensure that it came into line with NPSA guidance.
c. OUH incident reporting rate is 6.4 incidents per 100 admissions. Median for the
cohort of teaching hospitals is 6.8 per 100.
Quality Concerns raised by staff
10. The Clinical Lead for the Emergency Department has expressed concern in relation
to the significant pressure that the emergency departments have been working under
since the New Year. Specifically, there are concerns around sustainability for staff.
Concerns are being addressed with the Director of Clinical Services.
11. Concerns have been raised by Consultant Gynaecologists in relation to changes in
the theatre facilities that are available for out-of-hours emergency surgery. The
Director of Clinical Services has investigated these concerns and taken action to
address them.
12. Consultant Ophthalmologists have raised concerns about the organisation of and
plans for development of the ophthalmology clinics. The Director of Clinical Services
and Medical Director are meeting with them to discuss these issues.
13. An anonymous concern regarding nurse staffing and behaviours in a neuroscience
ward has been investigated with the report due shortly.
Central Alerting System (CAS)
14. As of 31st March 2013 there were no alerts currently breaching the required deadline.
Eleven new Medical Device Alerts (MDAs) were issued in March 2013. Seven MDAs
were due for closure in March 2013 of which five were closed within the given time
frame. One MDA was closed on 8th March 2013 after breaching the deadline by one
day and one closed on 27th March 2013 after breaching the deadline by 6 days
Infection control
15. For the year 2012/2013 the OUH Trust is currently reporting 92 cases of Clostridium
difficile identified from stool samples taken after the first three days of admission.
There continues to be a year on year reduction in cases. There were 150 cases in
2010/2011 and 103 cases in 2011/2012. The number of cases per month for
2012/2013 is illustrated at Figure 4.
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Figure 4: the number of Clostridium Difficile cases per month over 2012/2013
16. The infection control service with members of staff from Oxfordshire Clinical
Commissioning Group review all of the cases of Clostridium difficile from samples
taken after the first three days of admission from 2012/2013 and assess if cases
were avoidable or unavoidable. This process will continue in 2013/2014.
17. The MRSA Policy is being replaced with an updated MRSA guideline. The Trust is
moving from screening all elective and emergency admissions for MRSA to
screening patients within certain specialities. Patients not within these specialities
will be offered an MRSA screen if they fulfil the criteria for an MRSA screen outlined
in the guideline.
18. The decision to stop MRSA screening in some specialities was based on three years
of data where no MRSA positives were identified within these groups.
Executive Walk rounds
19. Seven walk rounds were completed in March 2013. A total of 78 since April 2012.
20. The key issues with the potential to affect quality or patient experience included:
difficulties of visitors accessing a ward; bed capacity affecting patient flow; and,
feedback regarding the need for healthier patient food options. An issue with regards
to clarifying whose responsibility it is to inform a patient’s next of kin when they move
from one ward to another was also raised. All issues have actions associated with
them that will be monitored through Divisional governance processes.
Patient Safety
21. The NHS Patient Safety Thermometer for March 2013 indicated a ‘harm free’ rate of
92.51%. When identifiable ‘old’ harms are removed from the data, the ‘harm free’ rate
is 96.78%.
22. The ‘harm free’ care rate for the past 3 months within the OUH is provided below:
f Patients
‘Harm Free’ Care % *
January
1073
97.48
February
1130
97.79
March
1148
96.78
Table 2: Harm Free Care rate
*’Harm free’ rate when ‘old harms’ are removed from the data.
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23. Charts 1, 2, 3 and 4 (below) provide a breakdown of the ‘new’ harms each month, by
category, since July 2012.
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24. Pressure ulcers continue to account for the largest percentage of ‘new’ harms in the
OUH. In March new pressure ulcers caused ‘harm’ to 1.83% (n=21) of the patients
surveyed. 1.66% (n=19) were category II, 0.17% (n=2) were category III.
25. The Trust is working in collaboration with Oxford Health to develop an improvement
strategy to deliver a reduction in pressure ulcers across the whole health economy.
The 2013/2014 NHS Patient Safety Thermometer CQUIN will require the Trust to
reduce ‘new’ pressure ulcers by 50%.
26. The strategy to reduce pressure ulcers across the health economy is outlined in a
separate paper for Trust Board.
27. Good progress is being made in the EMTA Division in relation to the training and
development of ward-based FallSafe leads. Lessons learned will be shared with the
MARS Division. It is too early in the implementation to be able to report on any
impact on the numbers or trend in falls.
28. Due to the definitions of the Safety Thermometer it is difficult to ascertain whether the
new VTEs were hospital acquired thromboses (HATs) or developed prior to
admission with diagnosis occurring within the Trust. The Trust Thrombo-prophylaxis
Team will review their data in relation to HATs for the quarter January to March 2013
and recommend whether continuing to collect Safety Thermometer data in relation to
VTE assessment, prophylaxis and VTE events is valuable since it is not mandatory
from April 2013.
29. The Trust Continence Service Team aims to reduce the incidence of Catheter
Associated Urinary Tract Infection by monitoring the prevalence of catheter use,
removing inappropriate urinary catheters, training nurses, midwives, clinical support
workers and medical students. The team provide regular reports to the Hospital
Infection Control Committee.
30. To date the audit demonstrated a 40% reduction between April 2012 and April 2013
and plan to reach the 50% reduction target by providing further training regarding
urinary catheter insertion in the Emergency Department and Emergency Assessment
Unit.
Complaints
31. The number of formal complaints received in March (85) is an increase in the number
of formal complaints received compared to February (67). Chart 5 illustrates the
complaints trends for the last four financial years. Table 3 illustrates the complaints
trends for the same period with total OUH activity.
120
100
Chart 5: Oxford University Hospitals NHS Trust
Complaints Trends for 2009/10 - 2012/13 (Financial year)
80
60
2009-10
40
2010-11
20
2011-12
0
2012-13
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Financial Year
Total OUH activity
% of activity
2009-10
1059623
0.064%
2010-11
1101845
0.075%
2011-12
1135868
0.076%
2012-13
1145846
0.075%
Table 3: Oxford University Hospitals NHS Trust Complaints Trends for 2009/10 - 2012/13
(Financial Year) with total OUH activity
31. Table 4 below shows the amount of Finished Consultant Episodes (FCEs), the
amount of Outpatient appointments attended and the A&E attendances, per Division
for the period March 2012 to March 2013, together with the corresponding number of
complaints received and the corresponding percentages.
Division
Cardiac Thoracic & Vascular
Critical Care Theatres Pharmacy & Diagnostics
Children & Women’s
Emergency Medicine & Therapies
Musculoskeletal & Rehabilitation
Neurosciences & Specialist Surgery
Surgery & Oncology
Activity
Mar 2012 to
Mar 2013
59529
24371
156958
325143
132039
254323
287655
Complaints
Mar 2012 to
Mar 2013
103
84
140
166
86
230
188
%
0.02%
0.03%
0.08%
0.05%
0.06%
0.09%
0.06%
Table 4: Finished Consultant Episodes (FCEs)
Fig. 5: Complaints by month for 2011/12 & 2012/13
32. 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.
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33. Two Divisions, Childrens & Womens and Neurosciences, Trauma & Specialist
Surgery have a higher percentage of complaints than others. The chart below
illustrates the complaints themes received 0.08% and above of total activity.
34. Both divisions are carrying out considerable activity to monitor, learn from and reduce
complaints. Actions include: communication training for neuroscience nurses;
introduction of value based interviewing techniques; and, more administrative support
in specialist surgery.
35. Figure 6 below show themes recorded for all Divisions for January, February and
March 2013.
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Complaints themes from January to
March 2011-12
Patient Care/Experience
5% 2%
4%
Complaints themes from January to
March 2012-13
Patient Care/Experience
7%
Delay/Waiting Time
Delay/Waiting Time
14%
49%
30%
15%
Communication
43%
31%
Behaviour
Communication
Behaviour
Food Parking & Med Recs
Food Parking & Med Recs
Figure 6: Themes of Complaints for Q4 2011/12
Figure 7: Thames of Complaints for Q4 2012/13
New Complaints – March 2013
36. Of the 86 new complaints, there were no complaints graded red, 14 were graded
orange, 49 yellow and 23 green.
Management of complaints
37. In March all complaints were acknowledged within the required 3 working days.
38. There was 99% compliance in responding to complaints within the agreed timescales
for February. There are some complaints for January and February that remain open
and within the complaint process.
Ombudsman Investigations
39. In March, the Trust received no requests from the Parliamentary and Health Service
Ombudsman for information for review.
Patient Experience
40. Patient experience data has been collected from 129 telephone calls, 30 ‘let us know
your views’ questionnaires, 2 comments/suggestions forms, 16 attendances to the
PALS office in person, 14 comments on NHS choices, and 69 instances of feedback
in written form.
41. The majority of comments received relate to issues that need resolving (65%).
Additionally, 12% of the feedback in January was negative (without an issue to
resolve). However, 14% of the comments received were positive.
Type
Issue for resolution
Positive Feedback
Negative Feedback
Advice/ information request
Mixed positive and negative
Interpreting requests
Other
January
February
185 65% 167 66%
45 16% 43 17%
30 11% 27 11%
16 6%
2
5%
8
3% 13
1%
0
0%
1 0.4%
0
0%
1 0.4%
March
169 65%
36 14%
31 12%
19
7%
6
2%
0
0%
0
0%
Table 5: Patient experience data
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42. Table 6 below provides a summary of the top four feedback issues.
Top 4 patient feedback issues
Appointment, treatment and discharge delays
89
Communication/Consent/Confidentiality
43
Caring, friendly and helpful attitude/high quality care
42
Negative attitude (disinterested/rude)
Table 6: Top 4 patient feedback issues
12
43. Appointment, treatment and discharge delays:
a. Appointments (45 comments): re-scheduled, cancelled, delayed, wait in clinic. The
division with the most comments is NTSS (16 comments) and there is on-going
work to improve, including running extra clinics at weekends.
b. Treatment delays (31 comments): including admission waiting list cancelled and
delayed operations and referrals. The MARS division had the most comments
(14), mainly relating to delayed operations in the spinal and joint reconstruction
services. Theatre capacity is being increased, but this is a long-term action. Until
this is achieved, teams are working with the admissions department to
communicate realistic timescales and schedules.
c. Discharge (13 comments): issues were not localised to a single division. The main
reason cited for delayed discharge was wait for medicines (6). This was also noted
as a common issue in the national inpatient survey: 39% said discharge was
delayed by more than 1 hour and the main reason for waiting was medicines.
44. Forty-three people commented on communication/consent/confidentiality: the most
comment problem was ‘difficulty contacting department’ (14), the majority of which
are from the NTSS division (10). The division has implemented weekly phone audits
and monitoring tool in services where this is a particular issue.
45. Twelve people commented on negative attitude: ‘disinterested/rude’. A trust-wide
customer care training course is being developed, which will be rolled out in 2013/14.
46. However, thirty-five comments mentioned ‘caring, friendly and helpful attitude/high
quality care’. These comments are fed back to staff and their managers.
47. Friends and Family Test:
a. There were 594 responses 2 from patients in February and 635 in March. The
estimated response rates are 4.6% and 4.9% respectively.
b. Most patients said they would be extremely likely or likely to recommend their
ward/ED: 93%.
2
This has increased since the last board report as there was data that was not available at the time but
relates to patients who used services in February.
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Figure 8: Friends and Family Test Results
c. The Friends and Family net promoter score 3 for March was 71, the previous score
was 65 in February.
d. Positive comments relate to staff doing “everything they can” to make the
experience as comfortable as possible; staff explaining their treatment and
condition; and all members of the team including domestic staff working together
to provide an excellent patient experience.
e. Comments for improvement relate to waiting for treatment, organisation, staffing
levels and the discharge process.
48. The national inpatient survey 2012 results showed that 85% of respondents rated
their overall experience between 7 and 10, on a scale of 0-10. This result was “about
the same” as other Trusts in the Care Quality Commission report.
a. A sample of 850 patients is used for the national inpatient survey. In 2012, 796
were eligible and 436 were returned, giving a response rate of 55%.
b. Positive results:
i. Risks and benefits of operations/procedures explained beforehand in a way
the patient can understand: 86% said this was explained fully. This Trust
scored in the top 20% of Trusts (CQC).
ii. Staff treating/examining the patient introduced themselves: 75% said this
happened all of the time. This was above the ‘Picker’ average 4.
iii. 100% of survey respondents who were moved to a second ward did not share
ward/bay with a patient of the opposite sex.
c. Areas for improvement include:
i. Discharge (delay, safety and involvement);
3
FFT score is a net promoter score which is calculated as follows:
Proportion of respondents who would be extremely likely to recommend (response category: “extremely
likely”) MINUS Proportion of respondents who would not recommend (response categories: “neither likely
nor unlikely”, “unlikely” & “extremely unlikely”).
4
The Picker report calculates whether the trust is significantly better than average using 95% confidence
intervals, based on data from trusts that use Picker as a survey contractor.
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ii. Admission waiting time,
iii. Accessibility of staff on the ward;
iv. Giving views on the quality of care
v. Being given enough information about hospital procedures.
49. These results will be discussed at the Trust Management Executive to agree action
plans or specific task and finish groups.
Nursing Metrics
50. The seven quality dashboards are provided at Appendix 1 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
issues which are sensitive to nursing interventions such as pressure tissue damage,
and harm from medication errors and falls.
51. The data relating to pressure ulcers and harm from falls differs from that reported via
the NHS Safety Thermometer as they are collected in different ways; the Safety
Thermometer being a point prevalence survey on a given day each month.
52. The key issues during March are those of pressure tissue damage, antimicrobial
prescribing and staffing.
53. The majority of pressure ulcers developed prior to admission or developed despite all
preventative measures being taken. In EMTA pressure relieving mattresses have
been purchased which enable a reduction in the length of time patients are waiting
for these. The Pressure Ulcer Link Group has been established where learning can
be shared.
54. Actions are being taken to address issues with antimicrobial prescribing, including
closer working between pharmacists and medical teams. In one area all junior
doctors are being written to highlighting the standards expected and nurses are to be
reminded of the pre-administration checks that must be undertaken.
55. March data highlights that increased levels of ‘minimum’ and ‘at risk’ staffing have
been an issue in two areas (different Divisions) for three consecutive months.
Difficulty in filling vacancies, the length of time of the recruitment process and lack of
available agency staff are all identified as contributory factors. The risks to delivering
safe, quality patient care are closely monitored through regular Matron visits, review
of patient safety indicators and patient feedback. Beds are closed or admissions held
in one area if patient safety is a concern. This may have an impact on patient flow
from the Emergency department and Acute General Medicine. Longer term solutions
include recruitment campaigns and attending job fairs at universities to capture
potential graduates. Neither area considers there to have been any detrimental
impact on patient safety or experience but recognise the impact on staff morale at
these times.
Recommendations
56. The Board is asked to receive the report and note the actions being taken.
Professor Edward Baker, Medical Director
Elaine Strachan-Hall, Chief Nurse
May 2013
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Appendix 1
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Appendix 1
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Appendix 1
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Appendix 1
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Appendix 1
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Appendix 1
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Appendix 1
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In Patient Wards
4
4
5
1
4 & 20
Compliance with
Nutritional
Assessments
Single Sex
Breaches
SIRIs Not Incl
Pressure Ulcers
National Cleaning
Overall Score
4
Hospital Acquired
Pressure Ulcers
/ Skin Integrity
ANTT Injectables
4&9
13
2
0
90%
11
5
93%
0
0
56%
43%
1%
67%
1
0
100%
0
0
80%
0
0
66%
30%
4%
3
0
94%
0
0
70%
30%
0%
100%
0
0
100%
0
0
45%
55%
0%
Sobell *
94%
100%
88%
3
67%
0
0
SEU D & Triage*
95%
100%
93%
8
100%
0
0
% shifts 'at risk
staffing'
92%
55
% shifts
'minimum
staffing'
13
100%
% shifts
'agreed
staffing'
99%
95%
Overall
percentage
of indications
& durations
100%
Number of
Prescriptions
All Pressure
Ulcers / Skin
Integrity
Hand Hygiene
4
Compliance with
Track and Trigger
/ EWS
8
Antimicrobial
Total No of
medication errors
that did harm
8
Oncology Ward **
Division
Clinical Areas
8
Haematology **
Ward
Surgery & Oncology (6)
8
Total No of Falls
that did harm
S & O Quality Scorecard Board
March Data
CQC Outcomes
Appendix 1
SEU E
100%
100%
88%
7
100%
0
0
100%
1
0
100%
0
0
58%
42%
0%
SEU F *
92%
93%
94%
7
100%
0
0
100%
1
0
100%
0
0
66%
34%
0%
5F *
100%
95%
92%
5
100%
0
0
90%
1
0
68%
0
0
83%
10%
7%
HGH E Ward *
96%
96%
95%
6
100%
0
0
99%
2
1
99%
0
0
75%
25%
0%
85%
15%
0%
UGI *
85%
90%
93%
10
70%
0
0
100%
0
0
85%
0
0
Colorectal *
100%
100%
0%
13
100%
0
0
100%
0
0
90%
0
0
Jane Ashley *
100%
100%
0%
5
100%
2
0
100%
1
1
90%
0
94%
6%
0%
Urology *
90%
90%
92%
10
90%
0
0
80%
2
2
90%
0
0
67%
33%
0%
Transplant **
Renal Ward **
95%
95%
97%
100%
90%
90%
23
10
91%
80%
0
0
0
0
90%
100%
0
0
0
0
88%
100%
0
0
0
0
63%
52%
31%
45%
6%
3%
Oxford Man Unit*
100%
100%
0%
0
0
0
0
82%
18%
0%
Oxford Tarver Dialysis*
100%
100%
88%
0
0
0
71%
29%
0%
Stoke Mandeville *
100%
96%
0
1
0
100%
0%
0%
0
Milton Keynes *
100%
100%
0
0
0
0
87%
13%
0%
Sw indon *
100%
100%
0
0
0
0
100%
0%
0%
Wycombe *
100%
100%
Th Churchill **
100%
92%
0%
91%
0
0
100%
88%
0
0
90%
0
0
0
0
0
Th TDA / DCU *
60%
Oncology Treatment
95%
0
0
0
0
90%
10%
0%
0
0
0
0
60%
40%
0%
0
0
85%
15%
0%
0
0
45%
78%
50%
15%
5%
7%
Brody Centre HGH
95%
100%
Triage
100%
100%
Research
100%
100%
94%
0
0
0
0
JR Endoscopy **
HGH Endoscopy **
77%
100%
97%
87%
0%
93%
0
0
0
0
0
0
0
0
0
0
Anti-microbial prescriptions
The Oncology Directorate pharmacists have been asked to w ork w ith the medical teams to ensure the results for haematology and Sobell House w ard
improve. All other results continue to improve.
Staffing levels
Several w ards have reported high vacancy levels again this month: This has been compounded by difficulties filling shifts w ith agency/bank. Mitigation
has been to move staff from areas of agreed staffing to other areas w hich w ould otherw ise have been at risk. This has increased the percentage of
shifts that w ere w orked at minimal staffing levels. The Division is progressing several initiatives to improve recruitment including attending jobs fairs at
various universities w ith graduating nurses and by offering overtime to staff.
Hand Hygiene results
New campaign of reminders started and prominent position of new posters to remind non-nursing team of the importance of complying w ith hand
hygiene opportunities.
Key
Poor
Fair
Good
National Cleaning Specification (%)
**
>95
V. High Risk
High Risk
Significant Risk
*
>92
>85
90-95
<90
Green
87-92
80-85
<87
<80
Amber
Red
Antimicrobial Prescribing
80% or more
70 - 79%
69% and below
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