Trust Board Meeting: Wednesday 11 March 2015
TB2015.28
Title
Board Quality Report
Status
For information
History
This is a monthly report, presented alternately to the Trust Board
or to the Quality Committee
Board Lead(s)
Dr Tony Berendt, Medical Director
Key purpose
TB2015.28 Quality Report
Strategy
Assurance
Policy
Performance
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Executive Summary
1. The Board Quality Report (BQR) presents validated information that is as
contemporary as possible, where possible this may include the last calendar
month.
2. In relation to key quality metrics:
• For 17 of the 52 quality metrics, pre-specified targets were not fully achieved
in the last relevant data period. For selected metrics, trend data are provided
along with brief exception reports.
• For a selection of the quality metrics Divisional specific information that
contributes to organisational results are presented in dashboard format at
Appendix 1.
3. In relation to Patient Safety and Clinical Risk:
• 11 Serious Incidents Requiring Investigation (SIRI) were reported in February
2015.
4. In relation to Quality Walk Rounds:
• There have been seven quality walk rounds in February 2015.
5. In relation to Clinical Effectiveness and Outcomes
• The Standardised Hospital Mortality Indicator (SHMI) for the period July 2013
to June 2014 is 1.00. This is ‘as expected’ using the Health and Social Care
Information Centre (HSCIC) 95% confidence interval, adjusted for overdispersion.
6. Patient Experience:
• Patient experience information is presented in a dashboard format, including
Family and Friends Test data, complaints, activity, PALS and compliments.
7. Nurse staffing levels for December 2014 and January 2015
• This provides a clear picture as to the high levels of ‘minimal shifts’, and the
numbers of shifts that required escalation to ensure that the staffing levels
were mitigated.
• It should be noted that during this period a number of wards had beds closed
for the reason of preserving safe staffing levels. However in other areas
during the winter period there were a number of escalation beds open.
Recommendation
Trust Board is asked to receive this report.
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TB2015.28
Board Quality Report
1.
Purpose
1.1. This paper aims to provide the Board with information on the quality of care
provided within the organisation, and on the measures being taken in relation to
quality assurance and improvement.
1.2. This Board Quality Report will be received for information by relevant Trust
Committees (Clinical Governance Committee) following the meeting of the Trust
Board.
2.
Key Quality Metrics
2.1. A suite of fifty three key quality metrics has been identified for consideration by
the Committee, these are listed in dashboard format.
2.2. These metrics have been chosen as they are considered to be linked to the
quality of clinical care provided across the organisation and data quality is felt to
be satisfactory.
2.3 Quality indicators are validated by the indicator owner before release by the
ORBIT information system.
2.4
Trend graphs and exception reports in relation to selected metrics where
specified thresholds have not been met (‘red-rated’) or those that are amberrated having been green-rated in the previous period are included. Thresholds
are drawn from a mixture of sources (national, commissioner and internal).
2.5
Due to the reporting timeframe for the Committee, the detailed sections of the
Board Quality Report outline February information, however validated February
information is not available for the Quality Metrics section of the report .
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Table 1
BQR
ID
Rating
Rating
Last
Period
Descriptor
Period
Threshold
Source
Red
Amber
PS01
98.03%
Green
Green
Safety Thermometer (% patients receiving care free of any
newly acquired harm) [one month in arrears]
Jan 15 Internal
95%
97%
PS02
94.53%
Green
Amber
Safety Thermometer (% patients receiving care free of any
harm - irrespective of acquisition) [one month in arrears]
Jan 15 Internal
91%
93%
PS03
95.86%
Green
Green
VTE Risk Assessment (% admitted patients receiving risk
assessment)
Jan 15 National
95% 95.25%
PS04
7
N/A
Serious Incidents Requiring Investigation (SIRI) reported via
STEIS
Jan 15
N/A
N/A
PS05
50
Green
Green
Number of cases of Clostridium Difficile > 72 hours (cumulative
year to date)
Jul 14
National
23
N/A
PS06
7
Red
Red
Number of cases of MRSA bacteraemia > 48 hours (cumulative
year to date)
Jan 15 National
1
N/A
PS07
83.4%
Red
Antibiotic prescribing - % prescriptions where indication and
Amber duration specified [most recently available figure, undertaken
quarterly]
Oct 14 Internal
85%
88%
PS08
92.6%
Red
Antibiotic prescribing - % compliance with antimicrobial
Green guidelines [most recently available figure, undertaken
quarterly]
Jan 15 Internal
93%
95%
PS09
81.58%
Amber
Amber
% patients receiving stage 2 medicines reconciliation within
24h of admission
Jan 15 Internal
75%
85%
PS10
96.99%
Green
Green
% patients receiving allergy reconciliation within 24h of
admission
Jan 15 Internal
94%
96%
PS11
2050
N/A
Total number of incidents reported via Datix
Jan 15
N/A
N/A
PS13
67
N/A
Total number of newly acquired pressure ulcers (category 2,3
and 4) reported via Datix
Dec 14
N/A
N/A
PS14
2
Green
Jan 15 Internal
8
7
PS15
1
Red
Dec 14 Internal
1
0
PS17
3.44%
Green
Green % 3rd and 4th degree tears in obstetrics [C&W Division]
Jan 15 Internal
5%
N/A
PS18
95.36%
Amber
Green
Dec 14 Commissioner 95%
98%
PS19
13
N/A
Jan 15
N/A
N/A
PS20
0
Green
1
N/A
CE02
262
N/A
Jan 15
N/A
N/A
CE03
71.12%
Red
Red
Dementia - % patients aged > 75 admitted as an emergency
who are screened [one month in arrears]
Dec 14 National
80%
90%
CE04a
80.8%
Red
Red
Statutory and Mandatory Training - % required modules
completed
Jan 15 Internal
85%
95%
CE05
83.45%
Red
Red
ED - % patients seen, assessed and discharged / admitted
within 4h of arrival
Jan 15 National
85%
95%
CE06
73.44%
Amber
Green
Stroke - % patients spending > 90% of admission in specialist
stroke environment
Jan 15 National
70%
80%
Green Falls leading to moderate harm or greater
Green
Number of hospital acquired thromboses identified and judged
avoidable [two months in arrears]
% radiological investigations achieving 5 day reporting
standard [CSS Division]
Number of CAS alerts received
Green
CAS alerts breaching deadlines at end of month and/or closed
during month beyond deadline
Crude Mortality
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Jan 15 Internal
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CE07
67.24%
Red
Jan 15 National
75%
85%
CE08
573
N/A
Jan 15
N/A
N/A
CE09
95.42%
Green
Green
% of elective paediatric day cases managed as such (Did not
result in an overnight stay) [C&W Division]
Dec 14 Internal
70%
75%
CE10
4.9
Green
Amber
Vascular - Mean length of stay for patients undergoing elective
AAA repair (3 month rolling period) [NOTSS Division]
Dec 14 Internal
8
5
CE11
4%
Amber
Amber
Vascular - % mortality following elective AAA repair [NOTSS
Division]
Dec 14 Internal
5%
3%
CE12
81.82%
Red
Green
Cardiology - % patients receiving primary angioplasty within 60
minutes of arrival at hospital [MRC Division]
Jan 15 Internal
85%
90%
CE13
1.8
Green
Amber
Cardiology - Mean number of days from referral to admission
to cardiology at tertiary centre [MRC Division]
Jan 15 Internal
3
2
CE14
0%
Green
Green
Cardiac surgery-% rate of patients with organ space infections
following cardiac surgery via the sternum [MRC Division]
Jan 15 Internal
1%
0.5%
CE15
0%
Green
Green
Cardiac Surgery - % mortality following elective primary CABG
[MRC Division]
Dec 14 Internal
6%
4%
CE16
0
Green
Green
Number of unscheduled returns to theatre within 48 hours
[NOTSS Division]
Jan 15 Internal
2
1
CE17
98.15%
Green
Green
Rheumatology - % relevant patients who have their DAS28
score documented [NOTSS Division]
Oct 14 Internal
95%
98%
CE18
0
Green
Red
Number of unscheduled returns to theatre in gynaecology
[C&W Division]
Jan 15 Internal
2
1
CE19
452
N/A
Number of patients admitted to SEU wards from SEU triage
[S&O Division]
Jan 15
N/A
N/A
CE21
2.44%
Amber
Red
Neuroscience Intensive Therapy Unit (NITU) readmission rate
within 48 hours of discharge [NOTSS Division]
Jan 15 Internal
4%
2%
CE22
63.08%
Red
Green
% fractured NOF patients who receive surgery within 36 hours
of admission [NOTSS Division]
Dec 14 Commissioner 70%
72%
CE23
20.27%
Green
Green % deliveries by C-Section [C&W Division]
Jan 15 Commissioner 33%
23%
CE24
0.45%
Green
Green
Jan 15 Internal
4%
2%
PE01
78
Green
Green Friends & Family - Net Promoter Score [one month in arrears]
Jan 15 Internal
63
70
Jan 15 Internal
90%
94%
Jan 15 Internal
90
80
Jan 15 Internal
2
1
N/A
N/A
Jan 15 National
3
2
Jan 15 Internal
65%
70%
Dec 14
N/A
N/A
PE02
Red
Stroke - % patients accessing specialist stroke environment
within 4h of arrival
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Transfer Lounge Usage
7 day admission rate following assessment on (and discharge
from) paediatric CDU [C&W Division]
173.18%
Friends & Family - proportion extremely likely or likely to
Green
Green
recommend [one month in arrears]
PE03
72
Green
PE04
2
Red
PE05
193
N/A
PALS contacts made
PE06
4
Red
Green Single sex breaches
PE07
59.63%
Red
PE08
75.31%
N/A
Green Complaints Received
Amber Number of complaints received initially graded as RED
Amber % patients EAU length of stay < 12h
% Complaints upheld or partially upheld [Quarterly in arrears]
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ORBIT Reporting
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Board Quality Report
How to interpret charts
Data are presented in this report in a number of different ways – including statistical process control (SPC)
charts, line charts (without confidence intervals / control limits), histograms and cumulative histograms.
Graphics have been selected in order to encourage the analysis of trends and to identify when a change in
relation to the historical position is likely to be ‘real’ or statistically significant.
SPC charts show a trend line and allow easy reference to the historical mean for that metric at a time at which
it was stable and ‘within control’. Where shown, the mean is displayed as a horizontal orange line. In addition,
warning limits and control limits are shown where appropriate, above and below the mean. Warning limits are
placed at two standard deviations (2SD – dashed black line) and control limits at three standard deviations
(3SD – solid black line). If a data point is found beyond the control limit (3SD from the mean) in either direction,
the change is statistically significant and is very unlikely to have occurred simply by chance.
There are other patterns within the data that are likely to reflect real change as opposed to random fluctuation
– these patterns are known as special cause variations. They include:
2 consecutive points lying beyond the warning limits (unlikely to occur by chance)
7 or more consecutive points lying on the same side of the mean (implies a change in the mean of the process)
5 or more consecutive points going in the same direction (implies a trend)
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Patient Safety
PS06 Number of cases of MRSA bacteraemia > 48 hours (cumulative year to date)
Narrative
Each case of MRSA
Bacteraemia are
reviewed via a
systematic review
program with
involvement of the CCG.
Of these cases, 3 have
been deemed
“avoidable”
The chart shows the number of cases of MRSA bacteraemia reported via UNIFY (external IT system). If a case is
subsequently removed in following consultation with CCG (for example, attributed to a referring hospital), the figure will
be modified in future graphs.
Patient Safety
PS07 Antibiotic prescribing - % prescriptions where indication and duration
specified [most recently available figure, undertaken quarterly]
Narrative
This data is quarterly so
the next audit result will
be available in January
2015, however currently
no report available on
Orbit.
Each antimicrobial prescription has to have a clinical reason as to why it is prescribed along with the length of the course
written in days/doses.
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Patient Safety
PS08 Antibiotic prescribing - % compliance with antimicrobial guidelines [most
recently available figure, undertaken quarterly]
Narrative
Monitored through
Divisional performance
processes.
This is a ‘snap shot survey’ of all inpatient medication charts across the trust. The audit measures compliance with
antimicrobial guidelines. There is a rolling programme of anti-microbial audits across the Trust. Different audits are
completed and reported each month. The frequency of data points differs and is not monthly.
Patient Safety
PS15 Number of hospital acquired thromboses identified and judged avoidable
[two months in arrears]
Narrative
Each Hospital Acquired
Thrombosis that is
judged to be avoidable
undergoes a full Root
Cause Analaysis review.
When a hospital-associated thrombosis occurs, screening +/- root cause analysis is triggered. This graph shown the number
of hospital acquired thromboses in month that were felt to have been avoidable
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Patient Safety
PS18 % radiological investigations achieving 5 day reporting standard [CSS
Division]
Narrative
No new data entered for
January 2015, however
the decrease in
performance is related
to cyclical pressures
Data is available a month
in arrears. In December
2014 compliance was
within target at 95.5%.
Radiology has identified
risks around RTT in
ultrasound and put
measures in place to
improve.
95% of routine examinations should have a verified report within 5 working days of the examination date. Contractual
requirement for primary care. Quality goal in other elements of service
Clinical Effectiveness
CE03 Dementia - % patients aged > 75 admitted as an emergency who are screened
[one month in arrears]
Narrative
Further detail
regarding the actions
in progress to improve
performance against
this indicator are
outlined in section 6 of
the Board Quality
report. Divisional level
compliance is
monitored through
Divisional performance
reporting processes.
Elderly patients admitted on a non-elective basis should be screened for dementia using a screening question and / or a
simple cognitive test. Performance shown in this graph reflects figures submitted monthly to NHS England. These figures
are derived from both EPR and local paper-based systems.
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Clinical Effectiveness
CE04a Statutory and Mandatory Training - % required modules completed
Narrative
Divisional Level
Statutory and
Mandatory Training
compliance rates is
monitored through
Divisional Performance
processes.
Clinical Effectiveness
CE05 ED - % patients seen, assessed and discharged / admitted within 4h of arrival Narrative
Performance is noted to
have decreased within
January 2015. This is
reflective of on-going
winter pressures.
% Patients attending ED who are discharged or admitted within 4 hours of arrival.
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Clinical Effectiveness
CE06 Stroke - % patients spending > 90% of admission in specialist stroke
environment
Narrative
At the JR Hospital 71.4%
of eligible patients
within January 2014
spent greater than 90%
of their admission within
a stroke unit. At Horton
this figure was 87.5 %. In
both sites performance
was noted to have
decreased between
December 2014 and
January 2015.
Being assessed and treated following stroke in a specialised environment is a quality marker. A target of 80% is applied in
schedule 3, part 4. It also contributes towards best practice tariff. Following discussion with commissioners, acute
geratology is defined as a specialised environment for stroke care if patients are transferred here from 5B
Clinical Effectiveness
CE07 Stroke - % patients accessing specialist stroke environment within 4h of
arrival
Narrative
This indicator is
monitored through
Divisional performance
monitoring processes.
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Clinical Effectiveness
CE11 Vascular - % mortality following elective AAA repair [NOTSS Division]
Narrative
No new data entered for
January 2015.
Performance is
monitored via Divisional
performance reporting
processes.
Information collected from ORBIT and based on the primary procedure coded and elective admission method.
Clinical Effectiveness
CE12 Cardiology - % patients receiving primary angioplasty within 60 minutes of
arrival at hospital [MRC Division]
Narrative
Performance against
this indicator to be
referred to the
Divisional
Management
Executive Team to
investigate these
results.
Information reported through Datacam/Solus and calculated by CTV information team. In 12/13 target was door to balloon
(DTB) time <60 minutes for 85% of patients. Data are 2 months in arrears.
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Clinical Effectiveness
CE22 % fractured NOF patients who receive surgery within 36 hours of admission
[NOTSS Division]
Narrative
No new data available
for January 2015 via
the ORBIT System,
however the results
associated with this
indicator are
monitored via
Divisional performance
processes.
70% of patients admitted with a fractured neck of femur that requires surgical intervention, should be operated upon
within 36 hours of being medically fit for surgery. These data are reported quarterly, as per CCG contract, as a percentage
of all eligible patients.
Patient Experience
PE04 Number of complaints received initially graded as RED
Narrative
Further detail
regarding complaints
received in January
2015, is provided in
section 8 of the Board
Quality report. The
Patient Experience
Dashboard also details
to location of each of
these “Red” rated
compliants.
The chart shows the number of new complaints received and initially rated as ‘RED’ by the corporate complaints
department
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Patient Experience
PE06 Single sex breaches
Narrative
Four patients involved. It
was justifiable for 1
patient who was
admitted to the stroke
unit and needed to be
assessed and cared for
by Stroke Physicians and
specialist nursing staff
within four hours. The
three patients already in
the bay were recovering
from a stroke however
they did not need to be
cared for in a mixed sex
accommodation.
The chart shows the number of single sex breaches reported via UNIFY. Those cases judged to be clinically justifiable are
not reported here.
Patient Experience
PE07 % patients EAU length of stay < 12h
Narrative
Performance is noted to
have decreased within
January 2015. This is
reflective of on-going
winter pressures.
EAU is an assessment area and the majority of patients should either be admitted or discharged promptly following
assessment.
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3.
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Patient Safety and Clinical Risk
3.1. Information relating to patient safety and clinical risk is provided within the key
quality metrics.
3.2. 10 Serious Incidents Requiring Investigation (SIRI) reports were recommended
to Oxfordshire Clinical Commissioning Group (OCCG) for closure during
February 2015.
3.3. Following internal closure of a SIRI report, the report is presented to the OCCG
for agreement and endorsement of both the level and quality of the investigation
and the appropriateness of the recommendations to prevent a re-occurrence.
3.4. SIRI investigations are categorised as a level 1 or level 2 investigaiton
dependent on the type of event. All Never Event investigations are category 2
investigations, and therefore are kept open by the Commissioning groups until
such time as all the actions and recommendations are implemented.
3.5. Table 1 below outlines the SIRI investigation reports that have been provided to
the OCCG for closure in Feburary 2015. Further detail regarding the themes
from all closed SIRI reports is provided to the Quality Committee bi-monthly.
Table 1.
SIRI Ref
Division
Description
Closure Date
2014/036
MRC
Retained Guidewire – Never Event
20/02/2015
2014/048
MRC
Misplaced Naso Gastric Tube – Never Event
13/02/2015
2014/049
MRC
Category 3 Hospital Acquired Pressure Ulcer
10/02/2015
2014/050
MRC/S&O
Spinal Cord Compression
09/02/2015
2014/052
S&O
Category 4 Hospital Acquired Pressure Ulcer
04/02/2015
2014/053
NTOSS
Wrong teeth removed – Never Event
27/02/2015
2014/054
MRC
Retained Guidewire – Never Event
27/02/2015
2014/056
CSS
Missed Lung Cancer
18/02/2015
2014/057
S&O
Category 3 Hospital Acquired Pressure Ulcer
09/02/2015
2015/010
CSS
Complications of a Gastromy Tube insertion
19/02/2015
3.6
In February 2015, four of the closed SIRI reports related to Never Event
investigations. An example of the key findings of these investigations (in
summary) are:

The need to have standardised and robust protocols and procedures for the
management of guide wires used during procedures;

The importance of human factors training to support safe patient care;

The development and implementation of documentation to support high
standards of clinical record keeping;
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
A review of the education and the associated competency framework to
ensure the necessary competency levels to perform the index
procedure/task;

Use of a bespoke WHO Surgical Safety checklist to support practice in the
speciality area;

Development of a standard operating protocol to ensure visible marking of a
patient prior to surgery;

A highlighted importance of a second check methodology to prevent errors;

Further improvements in the management of inpatient diabetes,

The introduction of a standard operating procedure to ensure formal review
and reporting of chest x- rays;

Dissemination of relevant safety alerts/notices to staff to advise of a
requirement of increased attention/dillegence when performing high risk
tasks/procedures;
3.7
The actions listed above are in response to a combination of Root Causes,
Contributory Factors and Lessons Learnt findings from each of the four
investigations.
3.8
The action plans for each of the closed SIRI reports Table 2 below provides a
list of the 11 SIRI’s that have been notified to the OCCG in February 2015.
Table 2.
SIRI ref
Division
Description
2015/010
CSS
Death following insertion of a Gastromy Tube
2015/011
S&O
Hospital Acquired Thrombosis
2015/013
CSS
Unreported pelvic fracture resulting in delayed treatment
2015/014
CSS
Misinterpretation of CT results
2015/015
MRC
Unexpected deterioration of patient
2015/016
CSS/S&O
Patient discharged with incorrect insulin
2015/017
NTOSS
Delayed biopsy
2015/018
C&W
Retained products following Ceasarean Section
2015/019
S&O
Un-managed Sepsis and Neutropenia
2015/020
S&O
Medication administration incident
2015/021
CSS
Missed Lung Cancer
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4.
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Quality Walk Rounds
4.1 There were 7 Executive Quality Walk Rounds in February 2015. These are
detailed in figure 2 below.
Figure 3
Hospital Site
Areas Visited
John Radcliffe Hospital
Maternity Ward Level 6 and Silver Star Unit
Neuroradiology
Ward 5A
Adult Intensive Care Unit
Clinical Engineering
Ward 6A
Vascular Studies Unit
4.2 Key issues with the potential to affect quality or patient experience identified
during the Quality Walk Rounds included the environment (namely storage),
retention of Band 6 staff, and capacity of services impacting on the patient
pathway and meeting diagnostic targets.
5.
4.3
All issues have actions associated with them and these will be monitored
through Divisional governance processes.
4.4
An update on actions arising from Executive quality Walk Rounds is provided
to Quality Committee.
Clinical Effectiveness
Divisional Mortality Reports (Quarter 2 2014/2015)
5.1
The Quarter 2 Divisional Mortality Reports were due to be submitted to the
Clinical Governance Committee (CGC) in November 2014. However, there
were delays in submission by the Surgery and Oncology Division and
Children’s and Women’s Division.
5.2
There were 7 deaths reported to be avoidable. The Medicine Rehabilitation
and Cardiac (MRC) Division has since informed CGC that, following further
investigation, 5 of these deaths were now deemed unavoidable. The MRC
Divisional Nurse will provide further details to CGC.
5.3
There were 2 avoidable cases reported by Surgery and Oncology Division.
one, on investigation and review, was deemed unavoidable, and the second is
the subject of a SIRI investigation.
During Quarter 2, there were varying degrees of compliance with the Trust
Standardised Mortality Review policy reported by the Divisions.
5.4
5.5
The Divisions will be reporting on continuing compliance with the Trust
Standardised Mortality Review policy in the monthly Divisional Quality
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Reports. The issues presented in the quarterly Divisional Mortality Reports
were diverse.
5.6
The recurrent issues noted in the Divisional Mortality Reports related to:
• Communication with clinical teams
• Documentation
5.7
At the December 2014 Mortality Review Group meeting, the Group requested
that each Division include in the quarterly reports the issues identified and
actions that they recommend to be shared across the Trust. Each Division will
provide this information for Quarter 3 Divisional Mortality reports.
5.8
The Clinical Effectiveness Committee (CEC) met on the 12th February 2015.
The key points of discussion and presentations related to outcomes, including
mortality indicators, are summarised below.
Outcomes External Data Submissions
5.9
5.10
5.11
At the request of the Committee, a paper was presented to inform discussions
on the implementation of a process for the central validation of clinical data
prior to submission external to the Trust.
The findings were:
• There are 84 national audits currently registered on Datix for which data
are submitted externally. The validation of clinical data occurs at a local
level and does not appear to occur at Directorate or Divisional level.
• The Trust submits data for four mandatory Patient Reported Outcomes
Measures (PROMs). There is no validation of the data prior to
submission. The Orthopaedics Directorate completes a review of the
provisional data before the final version is published.
• The Infection Control team submits data to Public Health England (PHE)
for Methicillin Resistant Staphylococcus Aureus, Methicillin Sensitive
Staphylococcus Aureus and Clostridium Difficile infections. The data are
validated by the Infection Control team and signed off by the Medical
Director before submission.
• The Oxford Simulation, Teaching and Research centre (OxSTaR) has
overseen 53 quality improvement projects involving Foundation Year 2
doctors during 2014. These have been presented to Divisions but not
registered on Datix. Doctors can publish the results externally without the
permission or knowledge of the Trust.
The Committee were asked to consider the implementation of a process for the
validation of data before it is submitted externally. The Committee requested
that an assessment of the requirements for a data validation process (before
external submission) be completed in one Directorate, to assist the Committee
in gaining insight into what this process entails.
Review of Mortality Indicators
5.12
The Standardised Hospital Mortality Indicator (SHMI) for the period July 2013
to June 2014 is 1.00. This is ‘as expected’ using the Health and Social Care
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dispersion. This is an increase of 0.01 when compared to the previous
release (data period April 2013 to March 2013) which had a value of 0.99.
5.13
For the equivalent period to the latest SHMI release, the Trust’s Hospital
Standardised Mortality Ratio (HSMR) was 99.54. This is within the ‘expected’
range using Dr Foster’s 95% confidence intervals. Based on the latest Dr
Foster update, the HSMR for the rolling 12-months to date (November 2013 to
October 2014) is 98.07.
5.14
Feedback from Monitor indicated an over-reliance on benchmarking against the
Shelford Group. Dr Foster has provided a list of ten Trusts which may be used
for peer comparison based on volume and case mix. The suggested list was
rejected by the Committee. The Committee members will discuss and advise
on a list of peers which may be used as appropriate comparators for mortality
indicators.
Consultant Outcomes Publications
 Interventional Cardiology Consultant Outcomes (Adult Coronary
Interventions, BCIS)
This is the first publication of these data. The publication included all
percutaneous coronary interventions (PCI) procedures performed in the
calendar years 2012 and 2013. It was highlighted that activity increased
from 1360 procedures in 2012 to 1621 procedures in 2013. Major
Adverse Cardiovascular and Cerebrovascular Event (MACCE) rates were
reported to be less than predicted for the Trust. It was highlighted that
there is error in the number of operators reported in the analysis as there
are some clinicians included who do not preform PCIs. This is being
addressed by the Directorate. It was noted that there has been an
adverse event relating to a guide wire reported at the Trust.

Thyroid and Endocrine Surgery Consultant Outcomes (BAETS
National Audit)
It was highlighted that there was a 0% mortality rate and that mortality
was a rare occurrence following Thyroid surgery. The Committee were
advised that the data are not all validated but an independent clinician
validates five cases as a sample.
•
Bariatric Surgery Consultant Outcomes (National Bariatric Surgery
Register)
This report includes outcomes during the period 2012 – 2013. It was
highlighted that the mortality rate was 0%. The Trust performs mainly
gastric bypasses and very few gastric bands. The Trust undertakes
bariatric surgery on patients who are sicker and/or have a slightly higher
BMI when compared to other Trusts.
Review of Outcomes from National Clinical Audits
• National Lung Cancer Audit (BTS/SCTS) Annual Report 2013
The results indicate that the Trust generally performs well. There have
been improvements noted in relation to the proportion of patients having
a CT prior to bronchoscopy. A high proportion of patients have surgery,
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with the Trust being one of the highest performing in the country. There
has been a decrease in the proportion of patients seen by a nurse
specialist. This is due to maternity leave and nurse cover not being
available. The 2 week-wait clinics have had to be changed to meet
targets which meant that nurses are not always available during new
clinic times.
5.15
•
MINAP Acute Coronary Syndrome or Acute Myocardial Infarction,
National Clinical Audit Report, 2013/2014 Financial Year
The audit includes the John Radcliffe and Horton General Hospital sites.
It was highlighted that in relation to the door to balloon time the Trust is
rated second to Newcastle. The Trust is above the national standard for
the call to balloon time. The results are not as good for the management
of inpatients. There have been improvements at the Horton site due to
the efforts of the team and the appointment of two consultants. The
Advanced Nurse Practitioners (ANPs) were noted to be critical in
achieving a difference and the service is currently trying to secure
funding for additional ANPs.
•
Sentinel Stroke National Audit Programme (SSNAP): site specific
report for Horton General Hospital, Inpatient Care Report: July September 2014
The overall SSNAP score for the Horton General Hospital is level E. The
Horton stroke service is above the national standard for 16 criteria.
There have been improvements over the last quarter in the proportion of
patients treated by a stroke skilled Early Supported Discharge team and
therapists achieving the national standard.
There are continuing
difficulties relating to the recruitment of speech and language therapists.
•
Sentinel Stroke National Audit Programme (SSNAP): site specific
report for John Radcliffe Hospital, Inpatient Care Report: July September 2014
The John Radcliffe Hospital achieved the highest overall SSNAP score,
since involvement with the programme, with a band of level C. This
score places the site in the top third nationally. The Committee were
advised that there are plans to appoint a new speech and language
therapist, to address a data entry issue relating to applicable patients
being thrombolysed, for larger scale pathway changes (to establish a one
point of entry at the John Radcliffe for all acute strokes, rather than
patients also being taken to the Horton) and an attempt is being made to
increase the number of community beds. It was noted that there was a
decrease in the results for early supported discharge and that the current
commissioning pathway is limited which will apply constraints on the
Trust.
Care Quality Commission (CQC) notification of maternity outlier for
puerperal sepsis and/or other puerperal infections within 42 days of
delivery
The Committee were advised that the CQC had informed the Trust of
significantly high rates of puerperal sepsis. It was identified that there were
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four times as many events for the size of the Trust. The Directorate advised
that there had not been any previous concerns relating to puerperal sepsis.
The CQC had requested that the Trust review 58 sets of health records
including a check on the accuracy of the clinical coding. All 58 sets of health
records, 14 from the Horton General Hospital and the remaining from the John
Radcliffe, have been reviewed by the Directorate. There were 2 cases of
incorrect clinical coding identified and 24 cases did not meet the criteria for
sepsis. The Committee were advised that there was a change in guidance for
the diagnosis of puerperal sepsis in December 2013 which may have led to
over diagnosis. It was acknowledged that the rate is higher than average and
an action plan will be compiled to address this. The Directorate are due to
submit the complete case review report to the CQC in February 2015.[Note at
time of writing of paper: the report has been submitted to CQC by the agreed
deadline]
CE 20 - Percentage of patients having their operation within the time specified
according to clinical categorisation [CSS Division]
5.16 For January to December 14 the mean percentage of patients having their
operations within the time specified according to their clinical categorisation
was around 80% (range 66-92%) for JR emergency theatres.
5.17 This has been on the Directorate risk register since the closure and
decommissioning of John Radcliffe (JR) theatres 9 and 10 and since August
2014 on the Divisional risk register. The reduction of theatre capacity with the
closure of these two theatres impacted on the responsiveness to operate on
emergency patients. In December 2014 JR Theatre User group planned for
change of use of JR/WW sessions to accommodate all the vascular lists at JR
and improve access for emergency patients. The detail of the changes were
that WW vascular list moved to JR, a general surgical list moved to WW,
spinal surgeons offered a half-day list to general surgeons on Friday morning
to increase emergency capacity. This has been in place since January 2015.
The impact of the change will be monitored through indicator “percentage of
patients having their operations within the time specified according to their
clinical categorisation”.
6.
CQUINS
6.1
This section sets out performance against the 2014/15 CQUINS as defined in
the Trust Quality Account.
6.2.
Progress against the applicable milestones for Quarter 3 as set with the
Oxfordshire Clinical Commissioning group are in table 4
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Table 4.
CQUIN Title
Milestone
RAG
Family and Frients Test
Demonstrate impementation of FFT across all staff groups
N/A Q3
Full delivery across all clinical services
Maintained response Rates for A&E, and acute inpatient services
N/A Q3
Safety thermometer –
Hosptial
Acquired
Pressure Ulcers
Dementia:
% of patients with a new Category 2 – 4 pressure ulcer (5 month
Median.
Target 0.88%
90% of patients aged 75+
0.63%
Find, Assess, Investigate
and Refer (FAIR)
90% identified as potentially having dementia are assessed
92%
90% identified as positive or inconclusive are referred to specialist
services.
98 % of discharge summaries sent within 24 hours.
98%
Timeliness
Communication
discarge
&
around
Responses to GP reported Datix within 10 days
96% of TTO’s completed within 2 hours of agreed discharge in
acute medicine and EAU
Baseline Assessment – No milestones Quarter 3
Care 24/7
Physician input into the
care of surgical patients
71%
N/A Q3
Introduce 7 day physician care into care of SEU patients
Introduce 5 day physician care into care of vascular surgery and
neurosurgery patients
Length of stay compared to equivalent quarter in 2013/14
Integrated psychological
support for Patients
Report of patients seen by service by specialty
Report of % and number seen within urgent and routine
timescales
Quarterly meeting with commissioners
6.3 Based on the information provided by the individual CQUIN owners Dementia,
Timeliness & Communication around discharge, and Physician input into the
care of surgical patients have not met the agreed milestones agreed with the
OCCG.
6.4 The following actions are being taken to address the deficits in each of the
CQUINS that are considered to have failed to meet the agreed milestones:
•
Dementia: Data are now reported via the Trust-wide Dementia Steering
Group, Divisional Level data are now being disseminated to aid
engagement with clinical teams. In Q4 this will be embedded within
Divisional Quality Reports.
•
Timliness & Communication around Discharge: The roll out of ePMA will
inprove the Trusts ability to measure this indicator effectively. At present
the Trust is unable conclusively to measure the elapsed time frames
between discharge and the production of an associated discharge
summary.
•
Physician input into the care of surgical patients: The extension of the
Consultant Medical input into surgical patients has been limited by the
Acute Medicine / Geratology vacancy rates, combined with high levels of
demand within non-elective services. Extension of services into Vascular
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Surgery will begin in month 12 of 2014-15 with full implementation in the
next financial year Extension into Neurosurgery is not currently feasible
due to the limited Consultant numbers. This will continue to be
reassessed within service development plans.
7.
Infection Control
7.1
This section provides an update regarding cases of Clostridium Difficile (c.Diff)
and Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia.
7.2
The objective for 2014-2015 is 67 cases. Table 5 below sets out the cases of
C.diff per month with cumulative numbers also reported.
Table 5
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sep
14
Oct
14
Nov
14
Dec
14
Jan
15
Total
1
6
7
6
3
6
6
8
3
4
Monthly limit
5
5
5
6
6
6
6
6
6
6
Cumulative total
1
7
14
20
23
29
35
43
46
50
Cumulative limit
5
10
15
21
27
33
39
45
51
57
Feb
15
Mar
15
5
5
62
67
7.3
Four cases of C.diff were reported for January 2015, against a monthly limit set
at 6 for the month. All 4 cases were discussed at the monthly Health Economy
meeting held on 9th February. Two of the four cases reviewed were deemed
unavoidable.
7.4
One of the four cases was deemed avoidable, though it must be highlighted that
this was because a sample had been sent inappropriately from a patient with a
previous C.diff positive history who did not meet the criteria for C.diff testing,
rather than due to any lapse in patient. The patient did not have active C.
difficile infection.
7.5
A further review by the Infection Control Service is required on one remaining
case before agreement can be met as to whether it can be deemed avoidable
or unavoidable. This will be reported in next month’s Clinical Governance
Infection Control report.
7.6
An OUH apportioned C.diff positive case (Infection Control RCA No. 498) from
September 2014 was also discussed at the February Health Economy meeting,
as a final decision was required as to whether this case was deemed avoidable
or unavoidable.
7.7
Following discussion with the representative from Public Health England, it was
agreed that the case was avoidable, though, it must also be highlighted that this
was because a sample had been sent inappropriately from a patient with a
previous C.diff positive history who did not meet the criteria for C.diff testing,
rather than due to any lapse in patient. The patient did not have active C.
difficile infection.
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7.8 Oxford University Hospitals remains on track to meet the C.diff objective for
2014-2015.
MRSA bacteraemia
7.9 There was 1 MRSA Bacteraemia apportioned to the OUH in January 2015. The
Post Infection review process has been commenced and a Case review with the
OCCG in attendance was undertaken in early February. The learnings from this
review are detailed in table 6 below.
Table 6
Speciality
Avoidable/
unavoidable
Details of case/Lessons learned
Medicine
JR2
Avoidable
A Post Infection Review (PIR) meeting was held on the 12/02/15 and it
was agreed that the MRSA Bacteraemia was avoidable.
The likely source of this MRSA bacteraemia was agreed to be chronic
leg ulcers.The patient had multiple co-morbidities including chronic
peripheral vascular disease, STEMI Feb 2014, chronic MRSA
osteomyelitis on long term oral clindamycin suppression as
recommended by the Bone Infection Unit, paraplegia secondary to a
T12 spinal cord infarct and pressure sores to buttocks present on
admission.
The following learning points were identified:
•
Prior to bilateral Angioplasty procedure undertaken in
interventional radiology, skin preparation was performed using
povidone iodine aqueous.This is not in line with Trust
guidelines which recommends the use of Chlorhexidine 2% in
alcohol for skin preparation.(povidone iodine alcohol is
recommended as an alternative to Chlorhexidine 2% for
patients allergic/contraindicated)
•
The scheduled Angioplasty was cancelled on > 3 occasions,
delaying treatment of chronic MRSA colonised leg ulcers.
•
The patient was receiving long term oral Clindamycin
suppression therapy for chronic MRSA osteomyelitis. However
the MRSA was confirmed to be resistant to Clindamycin,
microbiology advised the medical team no change in
antibiotics was necessary.
Agreed Action plan
Awaiting the final agreed action plan from the OCCG following the PIR
meeting held on 12/02/15.This will be reported in next month’s clinical
governance infection control report.
January 2015
Month
8.
Patient Experience Dashboard
8.1 The Patient Experience Team have produced a dashboard for Quality Committee
(Appendix 2). This includes the Friends and Family Test (FFT) data, complaints
activity, management of complaints, PALS activity and compliments. The intention
of the dashboard is to provide a Trust wide overview to support divisional
analysis. In summary:
Friends and Family Test
Inpatient, ED and Maternity response rates:
8.2 NHS England no longer publishes FFT net promoter scores. Instead the
percentage who would recommend their care (extremely likely/likely) and the
percentage who would not recommend their care (extremely unlikely and unlikely)
are reported.
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8.3 National comparison:
8.3.1
The national comparator FFT results for January 2015 were not
available at the time of writing this report. The dashboard includes
national benchmarking and the comparison with the national average
for December 2014.
8.3.2
The percentage of inpatients that would recommend their care (96%)
remains slightly higher than the national average (95%). The national
average was between 93% and 95% in the last 6 months, while the
Trust achieved between 95% and 97%. The national range for inpatient
scores in December was between 100% and 78% and the Trust’s score
was 97%.
8.3.3
The percentage of women using the Trust’s maternity services who
would recommend their care (97%) was higher than the national
average (95%). The national range for maternity scores in December
was between 100% and 83%.
8.3.4
The percentage of patients who would recommend the Trust’s
Emergency Departments rose to 98% in January. The national average
was 86% in December, and the range was between 99% and 54%.
8.4 Inpatients:
8.4.1
Response rates for MRC and NOTSS remained the same in January,
while the C&W response rate increased to 30% and the S&O response
rate increased to 22%. The most common reason for low response
rates was staff absence and a subsequent breakdown in processes.
The patient experience team have offered wards specific advice and are
increasing contact with wards to support them on a weekly basis.
8.4.2
The percentage of inpatients who would recommend their care in the
Medicine, Rehabilitation and Cardiac (MRC) Division is 96% in January,
with 1.7% not recommending their care, and a response rate of 19%.
8.4.3
The percentage of inpatients who would recommend their care in the
Surgery and Oncology (S&O) division is 97%, with 0.4% not
recommending, and a response rate of 22%.
8.4.4
The percentage of inpatients who would recommend their care in the
Neurosciences, Orthopaedics, Trauma and Specialist Surgery (NOTSS)
Division is 97%, with 1.1% not recommending their care, and a
response rate of 18%.
8.4.5
The percentage of inpatients who would recommend their care in the
Children’s and Womens (C&W) Division is 93%, with 1.6% not
recommending, and a response rate of 30%.
8.5 Emergency Departments (EDs):
8.5.1
The percentage of patients who were likely to recommend their care
was 98% in January with 0.5% not recommending their care. This is an
increase (from 77%) and higher than the national average (86%).
8.5.2
The response rate was 8%. The department remains busy due to
winter pressures and outflow issues, which means patients are
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waiting longer and they are less likely to want to give any feedback
when they are able to leave. In addition, there is a higher than usual
proportion of majors admissions to minors attendances. It is more
difficult to seek feedback from majors patients as the admissions
process is more urgent which removes that opportunity to provide a
comment card or voting token. In addition, these patients are more
likely to be too unwell to want to provide feedback.
8.6 Maternity:
8.6.1
The percentage of women who would recommend their care from
maternity services was 97% in December, with 0% not
recommending their care.
8.6.2
The response rate remained at the lower rate of 12% in January.
8.7 Outpatients and Day Case:
8.7.1
The percentage of patients who would recommend the Trust’s
Outpatients and Day Case were 98% and 100% respectively in
January.
FFT CQUIN status:
8.8 All FFT CQUIN targets have been met to date.
8.9 The patient experience team have implemented a new system to support
inpatient wards to meet the target of 30% for the quarter and 40% in March
2015. The patient experience team will visit wards on a weekly basis, collect
comment cards, and bring a report from the previous week. The team will
highlight comments that provide useful detail about why care was particularly
good or issues that need addressing. The team will support ward sisters to
implement solutions to issues that can be solved simply and escalate issues
that need addressing at a higher level. The majority of feedback is very
positive and it is an effective way of rewarding staff for their hard work. It is
expected that more regular feedback to wards will provide an additional
incentive to encourage patients to provide more feedback. The team also
offer advice and support on methods to improve response rates. In addition
to the patient experience star of the month, one team per site will be selected
as ‘team of the week’.
8.10 Text messaging and interactive voice messaging for the Emergency
Departments commenced for patients who visited the Emergency
Departments on Thursday 26 February. In addition to this, a volunteer has
been placed in the John Radcliffe emergency department for 2 days per
week. The volunteer continues to have an important role after the
commencement of text messaging, to inform patients that they will be
contacted and encourage them to respond, to opt out patients who do not
wish to be contacted, and to offer comment cards to patients who would
prefer to provide feedback before they leave the hospital.
9.
Complaints
9.1 The number of new complaints has increased from 67 in December to 72 in
January. This shows a decrease in the number of formal complaints received
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in January 2014 (81). It is important to compare this with 117 complaints in
October. The Annual Complaints Report published by Health and Social Care
Information Centre (HSCIC) earlier this year has noted that the national trend
is increasing. The Trust is only currently able to benchmark against other
NHS Trusts nationally on an annual basis. However from 1 April 2015, the
Trust will submit complaints data and information to the HSCIC on a quarterly
basis. It is anticipated that the national information will also be published
every quarter, thus enabling the Quality Committee and Trust Board to
nationally benchmark against the best and worst practice using more current
information.
9.2 Access to services, particularly Outpatient appointments by telephone
continues to be a recurrent theme for complaints received by most Divisions
and particularly for NOTSS, though no access issues were reported for C&W
Division.
9.3 NOTSS, MRC, S&O and CSS have all seen a slight increase in the number
of formal complaints received in January in comparison to December 2014.
However, both C&W and Corporate have reported a slight decrease in the
number of formal complaints received compared to December 2014.
9.4 Care/Nursing Care continues to be reported as a significant theme for all
clinical Divisions, with 40% of complaints received by NOTSS during
November – January relating to Care/Nursing Care, 38% for S&O, 49% for
C&W, 42% for MRC and 33% for CSS.
9.5 The complaints received by Corporate services included car parking and
hotel services.
9.6 In total there were five red graded complaints received by the Trust from
November 2014 to January 2015. Three were received by NOTSS, one was
received by MRC and one was received by CSS. Three of the red graded
complaints remain open at investigation stage at the time of writing this report
(one for NOTSS, one for MRC and one for CSS). The Chief Nurse has been
briefed in relation to these investigations; however the details are not
included in this report. The remaining two complaints for NOTSS were
investigated and closed in December 2014 and February 2015.
9.6.1
The complaint related to delays for urgent vascular surgery, poor
communication and compassionate care, poor nursing care, timely
pain relief, lack of dignity and infection control. It was partially upheld
by Trust. The outcome of investigation and learning was to improve
administrative and clinical communication between teams including
the review of concerns at consultants meetings, develop options to
avoid transfer delays caused by lack of beds and maintain vascular
scans at 6 weeks or less. The issues in relation to communication,
safety, quality and dignity were discussed with the ward‘s nursing
staff.
9.6.2
The complaint related to the change in surgeon, the delay in the CT
scan, the delay in considering a pseudo-obstruction, poor
communication poor, and the delay in transferring patient to the JR.
The patient’s death was investigated as a serious incident requiring
investigation (SIRI). The Trust partially upheld the complaint. The
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SIRI report has made a number of recommendations to improve
communication between Orthopaedic and on call surgical teams in
an endeavour to learn from the experience of the patient.
Managing complaints
9.7 The Trust continues to meet the target of 95% for acknowledgement of
complaints, with 99% (n= 71) acknowledged within the required timescale.
This is an increase in the number acknowledged within the required
timescale.
9.8 Two complainants requested their complaints to be reopened within S&O and
NOTSS, compared to one in CSS and Corporate. No complainant asked for
their complaint to be reopened within MRC and C&W Divisions. The requests
for complaints to be reopened is increasing for C&W and S&O and reducing
for MRC, NOTSS, CSS and Corporate.
9.9 The Chief Nurse has proposed the implementation of quarterly divisional
patients’ experience and complaints dashboards. This information will enable
the divisions to use a comparable format to report the good practice and
concerns to Clinical Governance Committee, Patient Safety and Clinical Risk
Committee, the divisions Performance reviews, Quality Committee and Trust
Board.
9.10 Five national complaints reports have been published in recent months by the
Parliamentary and Health Service Ombudsman (PHSO), the Parliamentary
Health Select Committee and the Care Quality Commission (CQC). The Chief
Nurse briefed the Executive Directors in relation to these reports on 3
February 2015.
9.11 Trust Board is asked to note one of these reports, entitled ‘My expectations
for raising concerns and complaints’ was published on 18 November 2014 by
the PHSO, Health Watch and the Local Government Ombudsman; in
consultation with patients, service users and over 40 organisations. It aims to
help improve the way complaints are handled across the NHS and in social
care by describing people's expectations for good complaint handling. This
includes, knowing they have a right to complain and where to complain, being
kept informed and feeling their complaint made a difference so the same
thing does not happen to anyone else, and feeling confident to complain
again. ‘My expectations’ is presented in Appendix 2.These five steps will form
the basis of the six monthly feedback meetings with the Chief Nurse and
complainants.
9.12 The first and second complaints investigation training was held on in January
and February. This training was delivered by lawyers from Bond Solon Ltd.
The Health Education Thames Valley (HETV) Compassionate Care award
funded this training. This will be repeated in April 2015. In addition, members
of the Complaints and PALS teams are participating in the Trust pilot of the
Delivering Compassionate Care training.
The first complaints satisfaction data and analysis from the Patients Association
and NHS Benchmarking Network has been received. In summary, the
questionnaires were sent to 80 Trust’s complainants; the response rate was
13% (n = 11). The questionnaire asks 19 questions and is administered on a
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quarterly basis by the Trust and analysed by the NHS Benchmarking Network.
This follows national feedback from complainants that they were reluctant to
complete Trusts in house surveys. Nine people (81%) reported that they had
complained about their care or a relatives care. The results varied and although
most respondents understood the explanation in their response letter, six
people felt they had been told the complete or partial truth and five people felt
they had not been told the truth or were unsure. Some complainants described
the process as stressful, and felt ill informed whilst others described feeling
comfortable and well informed.
10. Nursing Safe Staffing
10.1 This is a presentation of the staffing levels within the Trust for December 2014
and January 2015, and the Nurse Sensitive Indicators for November 2014 –
January 2015.
10.2 The Trust is committed to ensuring that there is the appropriate level and skill
mix of nursing and midwifery staff, and is compliant with the national guidance
provided via the National Quality Board in 2013 (‘How to ensure the right
people, with the right skills, are in the right place at the right time’ National
Quality Board November 2013), in reviewing the capability and capacity of
these staffing levels.
Background
10.3 The assessment of acuity and dependency was undertaken in January 2015, as
the trust is required to review staffing establishments with an evidence based
tool six monthly. This data will be presented to the Quality Committee in April
and the Trust Board in May 2015.
10.4 The nurse staffing levels have been provided for January 2015. They are
presented on the attached appendices (all labelled appendices No 3) against a
suite of Nurse Sensitive Indicators (November 2014– January 2015).
Explanation is provided in the annotated notes regarding key issues during that
time period.
10.5 The levels of staffing by ward and by shift are demonstrated graphically in the
appendices. These show the levels of staff according to the RAG rated (RedAmber-Green) Safe Staffing system the Trust utilises to identify when shifts
have a deficit of staff. These are then mitigated either by moving staff to areas
of higher acuity, including non-ward based staff, reducing the activity, or
considering a suite of actions to support the staff during fluctuations in activity or
increases in the acuity of patients.
Conclusion
10.6 In most areas there are nurse vacancies levels, which are filled to to some
extent by temporary staff, however short notice absence provides a challenge
and has required constant review on a shift by shift basis to ensure that all
actions are taken mitigate risk. This has included escalation to the appropriate
executive to review bed numbers on a shift by shift basis and consideration of
all alternatives.
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10.7 An electronic tool for the measurement of patient acuity daily, using the Safer
Nursing care Tool is being implemented from March 2015. This will incorporate
the site templates that illustrate the staffing levels at staff and bed capacity
meetings, escalate shift deficits and provide acuity and dependency reporting
over time against establishment. This will eventually replace the in-house tool.
11. Recommendation:
11.1 The Trust Board is asked to receive this report.
Report prepared by:
Annette Anderson
Head of Clinical Governance
On behalf of:
Tony Berendt
Medical Director
Catherine Stoddart
Chief Nurse
March 2015
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Board Quality Report Dashboard
APPENDIX 1
PS01 - Safety Thermometer (% patients receiving care free of any newly
acquired harm) [one month in arrears]
100%
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
CE03 - Dementia - % patients aged > 75 admitted as an emergency who are
screened [one month in arrears] (CQUIN, Trust-wide only)
300
250
200
150
100
50
0
74%
72%
70%
68%
66%
64%
62%
60%
Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14
Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15
RAG threshold
Red
Division
Children's & Women's
Clinical Support Services
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
OUH
Apr-14 May-14 Jun-14
Jul-14
Aug-14 Sep-14 Oct-14
Nov-14 Dec-14 Jan-15
Trend to date
100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
100.00% 95.65% 95.83% 100.00% 90.48% 95.00% 90.48% 100.00% 100.00% 95.00%
96.90% 96.06% 95.57% 96.00% 96.96% 97.26% 95.17% 97.09% 97.54% 98.05%
97.35% 97.67% 97.25% 98.99% 98.37% 98.99% 97.74% 98.09% 98.32% 97.77%
96.06% 97.48% 96.93% 96.55% 95.05% 96.88% 97.17% 97.56% 97.06% 97.95%
97.15% 97.08% 96.73% 97.29% 96.98% 97.78% 96.66% 97.74% 97.89% 98.03%
95% Amber
97%
PS02 - Safety Thermometer (% patients receiving care free of any harm irrespective of acquisition) [one month in arrears]
100%
95%
90%
85%
80%
75%
70%
CE02 - Crude Mortality
Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15
RAG threshold
Red
91% Amber
93%
Division
Children's & Women's
Clinical Support Services
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
OUH
Apr-14 May-14 Jun-14
Jul-14
Aug-14 Sep-14 Oct-14
Nov-14 Dec-14 Jan-15
Trend to date
100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
100.00% 86.96% 91.67% 95.83% 76.19% 90.00% 80.95% 95.65% 95.45% 90.00%
89.26% 88.43% 89.58% 89.78% 90.40% 90.55% 90.11% 89.91% 89.66% 92.41%
95.03% 94.67% 95.05% 96.96% 94.44% 96.98% 97.42% 95.22% 96.30% 96.18%
93.70% 95.68% 94.54% 94.14% 93.29% 93.75% 93.29% 94.43% 90.44% 94.88%
93.01% 92.60% 93.21% 93.63% 92.70% 93.80% 93.50% 93.32% 92.65% 94.53%
PS12 - % of incidents associated with moderate harm or greater (Trust-wide
only)
8%
6%
4%
2%
0%
Division
Children's & Women's
Clinical Support Services
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
Unknown
OUH
Apr-14
May-14
9
1
128
19
57
0
214
Jun-14
3
0
126
15
49
0
193
Jul-14
8
0
108
20
51
2
189
Aug-14
5
0
100
10
61
0
176
Sep-14
2
1
105
16
51
1
176
Oct-14
6
0
110
22
51
0
189
Nov-14
6
0
130
19
50
0
205
Dec-14
6
0
131
16
42
0
195
Jan-15
6
0
156
19
46
0
227
Trend to date
6
1
171
24
60
0
262
Red
80% Amber
90%
Division
OUH
Apr-14 May-14 Jun-14
Jul-14
Aug-14 Sep-14 Oct-14
Nov-14 Dec-14 Trend to date
62.23% 63.36% 67.88% 63.27% 63.09% 67.20% 71.71% 64.66% 71.12%
This indicator reports electronic and paper reporting combined at Trust-wide level
only. Plans are underway to report at Divisional level.
PS03 - VTE Risk Assessment (% admitted patients receiving risk
assessment)
100%
98%
96%
94%
92%
90%
88%
86%
84%
82%
80%
RAG threshold (Trust)
PS04 - Serious Incidents Requiring Investigation (SIRI) reported via STEIS
8
Surgery & Oncology
6
Neuroscience, Orthopaedics,
Trauma & Specialist Surgery
4
Medicine, Rehabilitation &
Cardiac
2
Apr-14 May-14 Jun-14
Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14
RAG threshold
Red
95% Amber
Division
Children's & Women's
Clinical Support Services
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
Unknown
OUH
Apr-14 May-14 Jun-14
Jul-14
Aug-14 Sep-14 Oct-14
Nov-14 Dec-14 Trend to date
94.37% 93.11% 92.77% 94.06% 92.52% 95.52% 95.12% 91.98% 94.90%
97.44% 97.33% 96.69% 97.13% 95.00% 94.71% 98.40% 97.18% 98.61%
84.37% 81.17% 88.74% 89.88% 91.23% 91.69% 93.08% 89.98% 91.32%
91.55% 90.65% 92.70% 91.61% 90.31% 91.57% 93.05% 94.70% 95.01%
96.71% 95.54% 95.70% 96.05% 96.88% 96.62% 95.76% 96.54% 97.93%
100.00% 100.00% 100.00% 93.75% 85.71% 95.31% 100.00% 100.00% n/a
93.09% 91.54% 93.50% 93.92% 94.31% 94.67% 94.73% 94.49% 95.82%
Clinical Support Services
0
Children's & Women's
95.25%
PS13 - Total number of newly acquired pressure ulcers (category 2,3 and 4)
reported via Datix
Division
Children's & Women's
Clinical Support Services
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
OUH
Apr-14
May-14
0
0
2
1
3
6
Jun-14
0
0
2
0
2
4
Jul-14
0
1
1
1
0
3
Aug-14
0
0
0
1
1
2
Sep-14
1
1
3
0
1
6
Oct-14
0
0
0
0
2
2
Nov-14
0
0
3
1
0
4
Dec-14
0
0
2
2
3
7
Jan-15
2
1
0
0
2
5
Trend to date
0
0
2
2
3
7
PS14 - Falls leading to moderate harm or greater (Trust-wide only)
10
8
6
4
2
0
70
60
50
40
30
20
10
0
Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14
RAG threshold (Trust)
Red
Division
OUH
Apr-14 May-14 Jun-14
Jul-14
Aug-14 Sep-14 Oct-14
Nov-14 Dec-14 Jan-15
Trend to date
4.97%
6.01%
4.94%
3.81%
4.65%
3.87%
4.32%
4.56%
4.14%
7.02%
6.5% Amber
5%
Currently this information is not broken down by division to the Board. It is
proposed to include this indicator within ORBIT. Plans are underway to report at
Divisional level, to commence in the new financial year.
Division
Children's & Women's
Clinical Support Services
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
OUH
Apr-14
1
5
30
14
7
57
May-14
2
2
26
8
11
49
Jun-14
1
5
36
15
10
67
Jul-14
Aug-14
2
7
36
6
11
62
2
5
23
8
9
47
Sep-14
0
1
17
13
11
42
Oct-14
2
3
22
9
16
52
Nov-14
0
2
30
6
19
57
Dec-14
3
1
25
14
14
57
Trend to date
RAG threshold (Trust)
Red
Division
OUH
Apr-14
8 Amber
May-14
5
7
Jun-14
9
Jul-14
3
Aug-14
3
Sep-14
2
Oct-14
1
Nov-14
2
Dec-14
5
Jan-15
3
Trend to date
2
It is proposed to include falls with harm within ORBIT from the new financial year
at a Divisional level to promote analysis and learning at all levels
Appendix 2 Patient experience dashboard
FFT outpatients and day cases
FFT: Response rates
NHS England now reports the percentage of extremely likely and
likely responses as the FFT indicator of quality of patient
experience: the net promoter score is no longer used.
It is now a requirement for the Trust to report the percentage
of unlikely and extremely unlikely responses.
Higher response rates mean data are more reliable: we can be
more confident that the scores are representative of the
population.
98%
OUH and National FFT % recommend
Took great care of my son, making sure he was ok & knew what
to expect. It was a huge weight taken off out shoulders, having
fantastic and friendly nurses and doctors, looking out for us. I
don’t feel you could have done anything better with our stay.
Thank you to everyone that looked after us today. Children’s
Day Ward (C&W)
Great care and kindness was shown to me by the team. Thank
you very much.
Pain Relief Clinic , Churchill Hospital (CSS)
20%
22%
19%
18%
2.0%
1.1%
1.0%
0.5%
0.7%
0.0%
0.0%
Aug-14
Sep-14
Oct-14
Nov-14 Dec-14
Jan-15
FFT Inpatient % recommend by division
97%
97%
100%
95%
96%
93%
90%
14%
Aug-14
Sep-14
Oct-14
Nov-14 Dec-14
Jan-15
FFT Inpatient % not recommend by
division
12%
8%
120%
100%
1.7%
1.1%
1.6%
0.4%
0%
Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15
Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15
December FFT % Recommend: National Best
and Worst
100% 97%
78%
80%
100% 96%
99%
77%
40%
0%
Inpatients
ED
Maternity
Only NHS Trusts with more than 100 responses have been
included
My mother was dealt with efficiently and kindly. All procedures were
explained carefully and thoroughly.
Pre-Op JR - CSS
OUH and National FFT response rates
20%
13%
12%
8%
20%
10%
0%
Aug-14
Sep-14
Oct-14
14%
8%
0% 1%
0%
20%
0%
IP IP IP ED ED ED Mat Mat Mat
Only NHS Trusts with more than 100 responses have been
included.
The treatment I received from the ambulance crew, A&E,
surgeons/consultants, and post-operative care in Trauma Ward 2
was nothing short of inspirational.
JR ED (MRC) & Trauma 2a (NOTSS)
Dec-14
Jan-15
71%
42%
40%
0% 1%
Nov-14
December FFT Response Rates: National
Best and Worst
60%
6%
0%
Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15
80%
32%
20%
20%
0%
December FFT % Not Recommend: National
Best and Worst
83%
54%
60%
40%
5%
30%
6%
2%
80%
10%
40%
10%
4%
85%
15%
50%
worst
Seen very quick, almost as soon as I sat down. Staff lovely, put
me at ease. Problem explained well. Great service relaxed.
Gynaecology outpatients, JR (C&W)
25%
4.0%
OUH
Positive consultations with recommended exercise routines
leading to a vast improvement in physical condition. Easy
/confident two way verbal exchange with physiotherapist.
Physiotherapy Outpatients, East Oxford Health Centre (MRC)
30%
5.0%
best
The ward is clean, tidy and efficient. The staff are both capable
and courteous. It’s a nice environment to receive treatment in,
Rowan Day Hospital, Horton (?MRC)
30%
worst
All the staff very friendly and very professional that always helps
put patients at ease. It can be rather daunting to attend a
hospital appointment Endoscopy day case, Horton (S&O)
6.0%
OUH
Kind, explained everything well. Reassuring and very polite. Not
rushed. Blenheim Outpatients, Churchill (NOTSS)
35%
best
Comments:
I was impressed by the shortness of waiting times, the very
pleasant manner of both nurses and the efficiency of the
treatment and helpful advice I was given. Ears, Nose and
Throat/Aural care Outpatients, JR (NOTSS)
75%
7.0%
worst
Response rates are not monitored as many patients attend
multiple appointments and it is not expected that they would
provide feedback on every occasion.
80%
worst
Day cases
FFT Inpatient response rates by division
8.0%
3.0%
85%
OUH
Jan-15
best
Outpatients
Dec-14
worst
Nov-14
96%
OUH
Oct-14
90%
best
90%
95%
97%
97%
worst
92%
98%
OUH
94%
100%
best
96%
OUH and national FFT % not recommend
OUH
100%
FFT: % not recommend
best
Outpatient and Day Cases % recommend
FFT: % recommend
18%
6%
best
OUH
Inpatients
worst
best
6%
2%
OUH
worst
ED
Only NHS Trusts with more than 100 responses have been
included
Very attentive, responded quickly to buzzer for toilets. Cannot fault
it. Explained everything very well.
E Ward, Horton (S&O)
Complaints
New complaints
New PALS enquiries
% PALS against FCE
% Complaints against Finished Consultant Episodes (FCE)
0.14%
0.12%
0.10%
0.08%
0.07%
0.06%
0.05%
0.05%
0.06%
0.04%
0.03%
0.02%
0.50%
12
0.40%
10
0.30%
0.22%
0.17%
0.11%
0.08%
0.06%
0.20%
0.10%
0.00%
0.00%
Aug-14
50
Sep-14
Oct-14
Nov-14
Dec-14
Aug-14 Sep-14
Oct-14 Nov-14 Dec-14
Jan-15
This includes all PALS enquiries and issues: positive, negative, or mixed
feedback; issues for resolution; and advice or information requests.
Jan-15
New Complaints Opened
30
19
18
20
16
10
0
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Complaints by severity grading, Nov 2014 - Jan 2015
100
10
8
6
4
4
6
4
2
2
0
0
Q4 2013/14
8
8
3
% complaints investigations completed within agreed
timescales
98%
93%
0
Quarter 4
(2013/14)
20
Quarter 1
(2014/15)
Quarter 2
(2014/15)
Quarter 3
(2014/15)
C&W
MRC
NOTSS
S&O
CSS
Corporate
Top 3 complaints themes by division, Nov 2014 - Jan 2015
50
82%
100%
81%
99%
80%
98%
79%
97%
78%
96%
77%
Target 95%
95%
access
parking/environment
hotel services
S&O
CSS
care/nursing care
other
Corporate
communication
MRC
NOTSS
S&O
CSS
Corporate
81%
79%
76%
75%
73%
92%
NOTSS
C&W
1
74%
93%
MRC
attitude
0
75%
94%
C&W
0
1
% Complaints upheld or partially upheld
% complaints acknowledged within agreed timescales
0
2
1
91%
40
2
2
92%
60
Q3 2014/15
96%
95%
94%
Q2 2014/15
3
96%
96%
Q1 2014/15
Reopened complaints: January 2015
4
97%
97%
93%
80
0
Reopened complaints
Managing complaints
40
100
Closed complaints
72%
Quarter 1 (2014/15)
91%
90%
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Quarter 2 (2014/15)
Quarter 3 (2014/15)
Appendix 2: My expectations for raising concerns and complaint.
Children’s and Women’s Division, (C&W), Trust Board Quality Report March 2015
Safe Staffing Dashboard Inpatient Areas Only
C&W
Total Funded WTE
November 14
768.5
December 14
769.5
January 15
769.5
Trust
November 14
2948.4
Vacancy %
7.9%
9.4%
8.6%
11.9%
13.1%
13.8%
Sickness %
4.9%
5.7%
6.39%
4.6%
5.58%
5.44%
Maternity/Adoption Leave %
4.6%
4.5%
2.88%
3.7%
3.7%
3.1%
Agreed Staffing Levels %
81.3%
80.8%
77.8%
71%
67.5%
67%
Total number of Medication
Nursing Administration Errors
or Concerns.
Total numbers of Hospital
Acquired Pressure Ulcers
Total Number of Avoidable
Grade 3-4 Hospital Acquired
Pressure Ulcers.
Extravasation incidents
12
23
11
68
73
53
2
3
1
98
94
98
0
0
0
9
3
3
1
3
2
5
5
5
December 14
2949.4
January 15
2948.4
January 2015 Safe Staffing by INPATIENTward for C&W division.
EARLY SHIFT
LATE SHIFT
NIGHT SHIFT
Agreed
Establishment
Escalation
Minimum
Surplus
Narrative Staff within children’s’ services have been moved between clinical areas in order to ensure safe staffing cover, although a number of beds were closed during December and January due to the low levels and skill mix of staffing.
In maternity services, there is a flexible approach to covering the high acuity areas, which are determined through the use of the Birthrate plus tool. Staff are moved from within the acute sites to cover the delivery suites when activity
increases, and the midwives from the community services are moved onto the acute sites to support as required. Gynaecology move staff from the day case area to mitigate at risk staffing on the ward placing both areas at minimum,
however the day case areas are not captured here. There remains a high vacancy rate of 8.6% and sickness at 6.39% for January. Gynaecology are the only area in the division who have undergone acuity measurement, however the
National tool for measuring this for children is currently under consultation. The quality indicators for extravasation incidents have a good reporting culture in children’s’ services as they serve as a sensitive indicator against staffing levels
and skill mix .NB: These figures relate to selected inpatient areas against specific indicators that are being monitored as nursing sensitive. The figures presented are accurate as of the date the information was retrieved from Datix (on 8th
of the month). Any changes to the record after these dates as a result of on-going review or investigation may not be reflected in figures retrieved after the Safe Staffing cut-off or elsewhere (i.e. Divisional Quality reports). Please note the
data represents the total count of incidents observed that meet the indicator criteria for the given period, similar indicators that are constructed/reported differently will not match the figures reported here.
Medicine,Rehabilitation & Cardiac Division, (MRC),Safe StaffingDashboard Inpatient Areas Only
Trust Board Quality Report March2015
MRC
899.54
Trust
November 14
2948.4
December 14
2949.41
January 15
2948.4
14.5%
15.3%
11.9%
13%
13.8%
5%
5.8%
4.96%
4.6%
5.6%
5.44%
Maternity/Adoption Leave %
2.8%
3.4%
2.77%
3.7%
3.7%
3.1%
Agreed Staffing Levels %
73.8%
67.7%
67.7%
71%
67.5%
67%
Total number of Medication Nursing
Administration Errors or Concerns.
Total numbers of Hospital Acquired
Pressure Ulcers
Total Number of Avoidable Grade 3-4
Hospital Acquired Pressure Ulcers
Total Numbers of Falls
26
20
22
68
73
53
50
39
38
98
94
98
3
1
1
9
3
3
124
131
129
206
223
234
Falls with moderate, major or
catastrophic harm
1
1
3
1
1
5
December 14
900.54
January 15
Total Funded WTE
November 14
900.54
Vacancy %
14%
Sickness %
January 15 Safe Staffing by Inpatient ward for MRC division.
EARLY SHIFT
LATE SHIFT
NIGHT SHIFT
Agreed
Establishment
Escalation
Minimum
Surplus
Narrative
Safe staffing is maintained using a combination of NHSP and high cost agency. However the divisional turnover rate (averages at mid-20% ) continues to be a challenge especially band 5 and below. The Turnover rate has decreased at the Horton
Hospital since the business case for an increase in the nursing establishment, but not as yet at the John Radcliffe site, and this is being closely monitored. The decrease in the percentage of shifts at agreed levels in December and January could be
attributed to the increase in maternity and adoption leave, sickness levels and vacancy rates. The division continues to run on high levels of minimum staffing which can impact on morale and can lead to staff being unable to attend educational
programmes. The division is encouraging staff to increase their culture of reporting medication incidents, however in recent months there has been a notable improvement in reporting and a decrease in the number of medication incidents with harm.
There is an on-going educational programme and focused approach by the Tissue Viability Team with regard to hospital acquired pressure ulcers. The escalated shifts have been addressed through moving staff throughout each shift between wards
and divisions in order to achieve cover.NB: These figures relate to selected inpatient areas against specific indicators that are being monitored as nursing sensitive. The figures presented are accurate as of the date the information
was retrieved from Datix (on 8th of the month). Any changes to the record after these dates as a result of ongoing review or investigation may not be reflected in figures retrieved after the Safe Staffing cut-off or elsewhere (i.e.
Divisional Quality reports). Please note the data represents the total count of incidents observed that meet the indicator criteria for the given period, similar indicators that are constructed/reported differently will not match the
figures reported here. Full specification details are included with the Safe Staffing reports.
Clinical Support Services Division, (CSS),Safe
CSS
Staffing Dashboard Inpatient Areas only Trust Board Quality Report March2015
Total Funded WTE
November 14
170.57
December 14
170.57
January 15
170.57
Trust
November 14
2948.4
Vacancy %
9.5%
10%
13.8%
11.9%
13%
13.8%
Sickness %
6.1%
6.5%
6.29%
4.6%
5.6%
5.44%
Maternity/Adoption Leave %
4.7%
5.5%
4.92%
3.7%
3.7%
3.1%
Agreed Staffing Levels %
77.7%
72.5%
81.2%
71%
67.5%
67%
Total number of Medication
Nursing Administration Errors
or Concerns.
Total numbers of Hospital
Acquired Pressure Ulcers
Total Number of Avoidable
Grade 3-4 Hospital Acquired
Pressure Ulcers.
Total Numbers of Falls
4
3
1
68
73
53
2
1
3
98
94
98
0
0
0
9
3
3
0
2
0
206
223
234
Falls with moderate, major or
catastrophic harm
0
0
0
1
1
5
December 14
2949.41
January 15
2948.4
January 15 Safe Staffing by Inpatient ward for CSS division.
EARLY SHIFT
LATE SHIFT
NIGHT SHIFT
Agreed
Establishment
Escalation
Minimum
Surplus
Narrative
Robust recruitment plans are in place across adult critical care areas to reduce the shortfall in nursing numbers (vacancy 13.8%), intakes of band 5 EU nurses are due to start in February and March 2015. Sickness levels are above the trust KPI and team leaders are undertaking return to
work interviews as per the First Care and Trust policy, there are a number of staff on long term sick, all of which are being managed proactively in conjunction with HR as necessary. AICU/CICU have operated above 100% capacity in adult critical care services for the previous 9 months,
these levels of activity could be contributing to sickness levels, low morale and retention. The agreed levels of staffing have increased to 81.2% in January, and escalated shifts are managed by moving staff between different divisional ITUs or across sites to ensure cover. Inspite of the
staffing issues, the quality indicators are stable
th
NB:These figures relate to selected inpatient areas against specific indicators that are being monitored as nursing sensitive. The figures presented are accurate as of the date the information was retrieved from Datix (on 8 of the month). Any changes to the record after these dates as a
result of ongoing review or investigation may not be reflected in figures retrieved after the Safe Staffing cut-off or elsewhere (i.e. Divisional Quality reports). Please note the data represents the total count of incidents observed that meet the indicator criteria for the given period, similar
indicators that are constructed/reported differently will not match the figures reported here. Full specification details are included with the Safe Staffing reports.
Neurosciences, Orthopaedics, Trauma & Specialist Surgery, (NOTSS), Division
Safe Staffing Dashboard Inpatient Areas Only Trust Board Quality Report March 2015
NOTSS
620.27
Trust
November 14
2948.4
December 14
2949.41
January 15
2948.4
13.8%
16.7%
11.9%
13%
13.8%
4%
5.6%
5.52%
4.6%
5.6%
5.44%
Maternity/Adoption Leave %
2.3%
2.7%
3.06%
3.7%
3.7%
3.1%
Agreed Staffing Levels %
65%
68%
66.2%
71%
67.5%
67%
Total number of Medication Nursing
Administration Errors or Concerns.
Total numbers of Hospital Acquired Pressure
Ulcers
10
9
8
68
73
53
15
23
31
98
94
98
Total number of avoidable grade 3-4 hospital
acquired Pressure Ulcers
Total Numbers of Falls
2
0
1
9
3
3
36
32
63
206
223
234
Falls with moderate, major or catastrophic
harm
0
0
1
1
1
5
December 14
620.27
January 15
Total Funded WTE
November 14
620.27
Vacancy %
12.3%
Sickness %
January 15 Safe Staffing by Inpatient ward for NOTSS division.
EARLY SHIFT
LATE SHIFT
NIGHT SHIFT
Agreed
Establishment
Escalation
Minimum
Surplus
Narrative
Maintaining staffing levels at minimum or above continues to be a challenge within the NOTSS Division. Agreed staffing levels were 66.2% in January. Recruitment remains the key focus within the division; there is a drive to ensure the success of the EU recruitment
initiative as numbers applying to local registered nurse adverts remains low. In spite of the staffing challenge, quality indicators assure the division that care is continues to safely delivered. i.e. high number of falls, mainly within neurosciences, but numbers of high
impact falls remain low. Electronic prescribing has been rolled out across Neurosciences, and Orthopaedics and has presented some significant challenges, mainly attributed to the high use of temporary workers from nurse agencies that require training and access to
be able to administer medication safely. Access to training is being addressed within the Trust, and the Division remains positive to this challenge to ensure that the training is successfully rolled out. Reducing the number of medication incidents is one if NOTSS’s
quality priorities for 2014/15. The escalated shifts have been addressed through moving staff throughout each shift between wards and divisions in order to achieve cover. Some beds on neurosciences were closed due to staffing levels throughout December and
January. This allows for higher numbers of shifts at agreed staffing levels than there would be with the beds open. 6 beds on 3A Trauma have been closed in January 2015 due to staffing levels
th
NB: These figures relate to selected inpatient areas against specific indicators that are being monitored as nursing sensitive. The figures presented are accurate as of the date the information was retrieved from Datix (on 8 of the month). Any changes to the record
after these dates as a result of ongoing review or investigation may not be reflected in figures retrieved after the Safe Staffing cut-off or elsewhere (i.e. Divisional Quality reports). Please note the data represents the total count of incidents observed that meet the
indicator criteria for the given period, similar indicators that are constructed/reported differently will not match the figures reported here. Full specification details are included with the Safe Staffing reports.
Surgery & Oncology Division, (S&O), Safe
Trust Board Report March 2015
S&O
Staffing Dashboard Inpatient Areas Only
Total Funded WTE
November 14
488.53
December 14
488.53
January 15
488.53
Trust
November 14
2948.4
December 14
2949.41
January 15
2948.4
Vacancy %
12.3%
16.3%
16.2%
11.9%
13%
13.8%
Sickness %
4%
4.5%
4.29%
4.6%
5.6%
5.44%
Maternity/Adoption Leave %
3%
3.8%
3.5%
3.7%
3.7%
3.1%
Agreed Staffing Levels %
64%
58%
55.3%
71%
67.5%
67%
Total number of Medication
Nursing Administration Errors
or Concerns.
Total numbers of Hospital
Acquired Pressure Ulcers
Total Number of Avoidable
Grade 3-4 Hospital Acquired
Pressure Ulcers.
Total Numbers of Falls
16
10
11
68
73
53
29
28
25
98
94
98
4
2
1
9
3
3
43
55
41
206
223
234
Falls with moderate, major or
catastrophic harm
0
0
1
1
1
5
January 15 Safe Staffing by Inpatient ward for S&O division.
EARLY SHIFT
LATE SHIFT
NIGHT SHIFT
Agreed
Establishment
Escalation
Minimum
Surplus
Narrative
S&O wards continue to run on minimum staffing for long periods, in particular on the day shifts with 55.3% Agreed staffing levels in January. The Churchill site continues to work effectively by moving nursing staff to mitigate at risk areas
at the twice daily safe staffing meetings. This continues to be challenging in terms of staff cover, and reducing clinical risk and ensuring patient safety. The division has seen an increase in hospital acquired pressure ulcers, although these
are low grade. This is of particular concern to the division alongside the low agreed staffing levels, and the division continues to monitor closely. The division will continue to use agency staff on long term placements to provide continuity
of care in areas of either high vacancy or where substantive staff are unable to work additional hours to support the clinical teams. Temporary staff shifts are requested as early as possible however there has been poor bank and agency
fill rates The Trust is working with the Nurse Bank and agencies to enable maximum fill rates, including increasing the bank rates for band 5 staff. Beds on the transplant ward were periodically closed during December and January, as
well as beds on haematology, as well as the Upper and Lower GI wards.. The highly specialist nature of oncology and haematology areas makes it very difficult to ensure a specialist skill mix when utilising generally skilled temporary staff.
th
NB:These figures relate to selected inpatient areas against specific indicators that are being monitored as nursing sensitive. The figures presented are accurate as of the date the information was retrieved from Datix (on 8 of the month). Any changes to the
record after these dates as a result of ongoing review or investigation may not be reflected in figures retrieved after the Safe Staffing cut-off or elsewhere (i.e. Divisional Quality reports). Please note the data represents the total count of incidents observed that
meet the indicator criteria for the given period, similar indicators that are constructed/reported differently will not match the figures reported here. Full specification details are included with the Safe Staffing reports.
Trust Inpatient
Areas Only Safe Staffing Dashboard Trust Board Quality Report March 2015
January 2015 Safe Staffing by Inpatient ward: Trust
Total Funded WTE
Trust
November 14
2948.4
December 14
2949.41
January 15
2948.4
Vacancy %
11.9%
13%
13.8%
Sickness %
4.6%
5.6%
Maternity/Adoption Leave %
3.7%
3.7%
3.1%
Agreed Staffing Levels %
71%
67.5%
67%
Total number of Medication Nursing
Administration Errors or Concerns.
Total numbers of Hospital Acquired
Pressure Ulcers
Total Number of Avoidable Grade 3-4
Hospital Acquired Pressure Ulcers
Total Numbers of Falls
68
68
53
98
98
98
11
9
3
206
206
234
Falls with harm
1
1
5
Early Shift
Late Shift
January 2015 Safe Staffing by Shift: Inpatient only: Trust.
Early Shift
Night Shift
Late Shift
Agreed
Establishment
Escalation
Night Shift
Minimum
Surplus
Narrative.
These diagrams demonstrate the shift by shift staffing across the Trust ward by ward as required by the National Quality Board guidance. NB: figures relating selected inpatient areas against specific indicators that are being monitored as nursing
sensitive. The figures presented are accurate as of the date the information was retrieved from Datix (on 8th of the month). Any changes to the record after these dates as a result of ongoing review or investigation may not be reflected
in figures retrieved after the Safe Staffing cut-off or elsewhere (i.e. Divisional Quality reports). Please note the data represents the total count of incidents observed that meet the indicator criteria for the given period, similar indicators
that are constructed/reported differently will not match the figures reported here. Full specification details are included with the Safe Staffing reports.
Trust Inpatient
Areas Only Safe Staffing Dashboard Trust Board Quality Report March 2015