Trust Board Meeting: Wednesday 11 September 2013
TB2013.99
Title
Quality Report
Status
A paper for information
History
This is a regular report to the Board
Board Lead(s)
Professor Edward Baker, Medical Director
Key purpose
Strategy
TB2013.99 Monthly Quality Report - September
Assurance
Policy
Performance
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Oxford University Hospitals
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Summary
1.
Mortality – Current mortality measures are all within the expected range.
2.
HSMR/SHMI – The re-based HSMR will be released by Dr Foster during
September. This will appear in the 2013 Hospital Guide, published in November.
The Trust’s mortality reduction programme will be reviewed at the Clinical
Outcomes Committee in September 2013. This will be reported to the Quality
Committee in October 2013.
3.
Reported Incidents – The total number of incidents reported continued to
increase. The top six incident categories are highlighted; these categories
account for 53% of the total number reported in the 12 months to July 2013.
5.
Serious Incidents Requiring Investigation (SIRIs) – 5 SIRI’s were reported in
July 2013.
7.
Executive walk rounds – Eight walk rounds were completed in July 2013.
8.
Patient Safety – The NHS Patient Safety Thermometer indicated a ‘harm free’
rate of 92.8% This is an improvement from the previous month (89.8%).
9.
Central Alerting System – 14 new Medical Device Alerts (MDAs) and 23
Estates and Facilities notifications were issued in July 2013.
10.
Complaints – A total of 75 complaints received in July 2013, three of which were
graded as red.
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Mortality & HSMR/SHMI
1.
The latest SHMI is 0.96 (January 2012 – December 2012).
2.
Dr Foster data quality issues have been resolved enabling data from May and June
discharges to be uploaded into their tool. All mortality measures continue to be within the
expected range for 2013/14:
3.
HSMR results for the first quarter of the financial year (April 2013 – June 2013) have now
been released. For this period overall HSMR for the OUH is 89.9. This fall compared to
2012/13 is principally due to a marked reduction in non-elective weekday HSMR (85.9).
Weekend HSMR (102.8) remains at a similar level as 2012/13. This is being evaluated.
HSMR for elective surgery is within expected range for each day of the week.
4.
The underlying Dr Foster risk model has been recalculated to give a new, recalibrated
view of relative performance. The rebased annual HSMR for 2012/13 at the OUH will be
published during September and will be included in the 2013 Hospital Guide due
November 2013.
5.
Figure 1 below shows OUH SHMI in comparison to the Shelford Group of Trusts for
January to December 2012.
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6.
Figure 2 below shows OUH HSMR in comparison to the Shelford Group of Trusts for the
period April – June 2013.
7.
A mortality reduction work plan for 2013/14 will be presented to the September Clinical
Outcomes Review Committee. This will include review of the a) OUH Standardised
Mortality Review Process b) identification of high risk deaths c) out-of-hours mortality c)
actions to improve risk calculation informed by the HSMR coding audit. This will presented
to the Quality Committee in October.
8.
Two risk summits will occur in the next month reviewing pneumonia and inpatient care for
diabetes. These will examine outcomes and identify improvement for care pathways for
these conditions.
Incident Reporting
9.
Figure 3 shows the total number of incidents reported per month. This continues to
increase.
Total incidents reported per month
(Mean & limits set for rolling 7 Months)
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Oxford University Hospitals
10.
Table 1 shows the top six categories of incidents from Jun 2012 to May 2013.
Slips Trips and Falls
Medication Incidents/
Events
Pressure Ulcers and Skin
Integrity
Documentation and
Records (including EPR)
Appointment, Admission,
Discharge & Patient
Transport
Communication
11.
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Oct12
Nov12
Dec12
Jan13
Feb13
Mar13
Apr13
May13
Jun13
Jul13
Total
213
237
237
227
239
221
218
227
223
239
2281
242
200
152
181
186
186
240
244
235
218
2084
135
131
132
202
168
208
264
236
268
305
2049
143
125
96
79
103
89
107
119
103
145
1109
89
103
93
107
111
95
126
103
93
137
1057
45
63
52
65
56
59
68
87
53
89
637
Figure 4 below reflects the comparison of harm vs. no harm incidents on a month
by month basis, in total figures.
Reported incidents
12.
This shows that the overall increase in reported incidents is due increased
reporting of those with minor or no-harm; evidence of a strong reporting and safety
aware culture.
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SIRIs for June and July 2013
13.
Five new Serious Incidents Requiring Investigation (SIRI’s) have been declared in
July 2013. These are shown in table 2 below.
Table 2
SIRI Ref
Division
Dept
Date of
Incident
JULY 2013
Date SIRI
called
2013/025
CVT/CCTADP
Cardiology/Radiology
10/11/2011
04/07/2013
2013/026
EMTA
Respiratory Day
Case Unit
10/07/2013
12/07/2013
2013/027
S&O
JAU
22/02/2011
15/07/2013
2013/028
S&O
5F
31/12/2012
18/07/2013
2013/029
NTSS
SSIP
15/06/2013
18/07/2013
Description
Tumour found on
chest X-ray no further
treatment or referral
Diagnostic
thoracoscopy carried
out on wrong side –
Never Event
Missed Lung tumour
– CT scan not
undertaken
Cat 3 Sacral Pressure
Injury
Fall with Fracture
Sustained
14.
All SIRIs are now being investigated according to Trust policy.
15.
There has been no increase in SIRIs despite the rising total number of incident
reports and the rate of SIRIs remains low (Figure 5).
SIRI investigations launched Sept 2012 – July 2013
Figure 5
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Quality Concerns Raised by Staff
16.
There have been no new quality concerns raised. These are reported through the
Clinical Governance Committee.
Executive Walk rounds
17.
There were 8 executive walk rounds in July 2013. These were: Neurology
inpatients ward, Emergency Department (JR), Trauma outpatients (JR), Estates
Department (JR), Cardiac Angiography Suite, Women's Centre outpatients,
Radiology and TSSU (HGH) and Lionel Cosin Day Hospital.
18.
The key issues with the potential to affect quality or patient experience included
concerns regarding patient confidentiality (unlocked and unattended notes trolleys
and inappropriate disposal of confidential waste), security issues (theft of patient
and staff belongings) the standard of cleaning provided, and upkeep of the fabric
of the patient surroundings. All issues have actions associated with them and
these will be monitored through divisional governance processes.
Patient Safety Thermometer
19.
The Safety Thermometer is a survey tool intended to identify trends in harm
related incidents. It does not measure the overall incidence of new harm related
incidents and is not intended as a benchmarking tool. The survey is undertaken
monthly. In July there was a ‘harm free’ rate of 92.8%. This is an improvement
from the previous month (89.8%). When identifiable ‘old’ harms are removed from
the data, the ‘harm free’ rate is 97.9%, also an improvement from the previous
month (95.3%).
20.
Detail of the ‘harm free’ care rate for the past 3 months within the OUH is provided
in table below:
Table 3
Number of Patients
‘Harm Free’ Care
%*
May
1103
96.8
June
1079
95.3
July
1065
97.9
*’Harm free’ rate when ‘old harms’ are removed from the data.
21.
Pressure ulcers continue to account for the largest percentage of ‘new’ harms
identified (Table 4).
Table 4
Category 2
Category 3
Category4
22.
May
1.09% (n12)
0.36% (n4)
0
June
1.30 (n14)
0.19 (n2)
0
July
0.75% (n 8)
0
0
Figures 6 to 9 show the percentage of patients each month who were assessed as
suffering new harm for each of the harms surveyed.
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Figure 6
%New Harms – Pressure Ulcers
Figure 7
% New Harms – Falls
Figure 8
Figure 9
% New Harms – Catheter Associated Urinary Tract Infection
% New Harms – VTE
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Central Alerting System (CAS)
23.
14 new Medical Device Alerts and 23 Estates and Facilities notifications were
issued in July 2013.
24.
As of 31st July 2013 there was one alert currently open and breaching the
required deadline. NPSA/2009/PSA004B “Safer spinal (intrathecal), epidural and
regional devices - Part B” breached the deadline on 1st April 2013 and remains
open. This is a national issue and arises from a lack of non-luer connectable
devices on the market, especially for epidural infusions. A risk assessment for
non-compliance with this safety alert has been agreed and added to the Trust’s
Corporate Risk Register.
25.
In addition, 3 Medical Device Alerts and 4 Estates and Facilities alerts remain
open at month end in July 2013. Each of these has been risk assessed as low risk
to the Organisation.
Complaints
26.
The number of formal complaints received in July (75) presented as a decrease
compared to June (80). Table 5 illustrates the complaints trend for a three-year
period against total OUH activity.
Table 5
27.
OUH Complaints for 2010/11 – 2012/13 (FY) in context of activity
Financial Year
Total OUH activity
% of activity
2010-11
1101845
0.075%
2011-12
1135868
0.076%
2012-13
1145846
0.075%
The table below shows the number of Finished Consultant Episodes (FCEs),
including outpatient appointments attended, ED attendances and inpatients, per
Division, for the period July 2012 to July 2013, together with the corresponding
number of complaints received and the corresponding percentages.
Table 6
Complaints and Finished Consultant Episodes (FCEs)
Division
Activity Jul
2012 to Jul
2013
Complaints Jul
2012 to Jul
2013
%
Cardiac Thoracic & Vascular
61398
43
0.07%
Critical Care Theatres Pharmacy &
Diagnostics
317440
69
0.02%
Children & Women’s
161829
130
0.08%
Emergency Medicine & Therapies
334692
147
0.04%
Musculoskeletal & Rehabilitation
136655
84
0.06%
Neurosciences, Trauma & Specialist
Surgery
258892
209
0.08%
Surgery & Oncology
293924
215
0.07%
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Figure 10
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Complaints Themes 2013 - YTD
New Complaints – July 2013
28.
Of the 75 new complaints, 3 have been graded initially as red as follows:
28.1. Patient died while waiting for cardiac surgery.
28.2. Un-empathetic care provided for patient following miscarriage.
28.3. Lack of engagement and communication with family during patient’s
admission and subsequent death.
Management of complaints
29.
In July, all complaints were acknowledged within the statutory 3 working days.
Ombudsman Investigations
30.
There were two review requests for information from the Parliamentary and Health
Service Ombudsman in July.
31.
The requests related to:31.1. Lack of communication regarding options to surgery.
31.2. Delays and miscommunication regarding treatment and lack of on-going pain
management.
Patient Experience
32.
Patient feedback data has been collated from 2023 items of feedback; this
includes Friends and Family Test.
33.
The majority of PALS feedback (n = excludes Friends and Family Test) relates to
issues that require resolution (n=239; 54%). 10% of the feedback comments were
positive and 17% were constructively critical (without an issue to resolve).
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Table 8
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Types of comments received March – May 2013
Type
May
Issues that required resolution
201
53%
227
67%
239
54%
Positive Feedback
79
21%
45
13%
43
10%
Constructively critical Feedback
56
15%
36
11%
76
17%
Advice/ information request
23
6%
17
5%
73
16%
Mixed positive and negative
8
2%
8
2%
9
2%
Other
9
2%
6
2%
3
1%
34.
June
July
Table 9 below provides a summary of the top four feedback topics from the above
data.
Table 9
Top four patient feedback issues
Top four patient feedback issues
May
June
July
Appointment, treatment and discharge delays
91
120
107
Communication/Consent/Confidentiality
36
41
50
Caring, friendly and helpful attitude/high quality care
37
38
41
Negative staff attitude
11
11
19
35.
There were 1,580 Friends and Family Test responses from patients in July, 1,614
in June and 924 in May. The response rate for July was 17%, lower than June
(19%). The Trust needs to work towards the target of 20% response rate by
quarter 4. The patient experience and involvement manager will work with wards
which need to improve response rates to help find solutions. Some wards
experience lower response rates due to unavoidable factors such as a high
incidence of dementia or cognitive impairment. Where possible, measures will be
put in place to maximise response rates (i.e. use of volunteers, or a different
comment card design). It is recognised that some wards are able to achieve a
higher response rate and this brings up the overall Trust average.
36.
The Friends and Family score (net promoter score) was 69 for July, 64 for June
and 67 for May (presented in figure 25; below). The percentage of patients who
said they would be extremely likely or likely to recommend their ward/ED was
91%.
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Oxford University Hospitals
Figures 11 & 12
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Friends and Family Test Results and Score
Figure 11: Responses (n=1566, there
were a further 14 “don’t know” responses
which are excluded from NPS calculations
Figure 12: The Friends and Family Test Score
(net promoter score *, NPS = extremely likely
minus [unlikely + neutral + extremely unlikely])
Recommendations
37.
The Board is asked to receive the report and note the actions being taken.
Professor Edward Baker, Medical Director
4 September 2013
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