Trust Board Meeting: Wednesday 13 May 2015
TB2015.48
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
TB2015.48 Quality Report
Strategy
Assurance
Policy
Performance
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Oxford University Hospitals
TB2015.48
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 10 of the 53 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:
• 13 Serious Incidents Requiring Investigation (SIRI) were reported in April
2015.
• One of the reported incidents is identified as a Never Event as per the NHS
England Framework. This is of particular concern to the Trust given five prior
Never Events where the index event occurred in 2014/15, and a further event
from prior years which was detected in 2014/15. Action being taken by the
Trust is outlined on Page 19 of the report.
4. In relation to Quality Walk Rounds:
• There have been 6 quality walk rounds in April 2015.
5. Patient Experience:
• Patient experience information is presented in a dashboard format at
Appendix 4, including Family and Friends Test data, complaints, activity,
PALS and compliments.
6. National Reporting of Nurse and Midwifery staffing levels:
• In March 2015, the fill rates were
92.4% Registered Nurses/Midwives
94.46% Care Support Workers (unregistered)
Recommendation
Trust Board is asked to receive this report.
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TB2015.48
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
Quality Committee.
2.
Key Quality Metrics
2.1. A suite of fifty three key quality metrics linked to the quality of clinical care
provided across the organisation are listed in dashboard format.
2.2 Quality indicators are validated by the indicator owner before release by the
ORBIT information system.
2.3
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).
2.4
Due to the reporting timeframe for the Committee, the detailed sections of the
Board Quality Report describe April information, however the Quality Metrics
section of the report relates to validated data for March as available.
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Table 1
BQR Rating Rating Descriptor
ID
Last
Period
Period
Threshold
Source
Red Amber
Safety Thermometer (%
Mar 15 Internal
97.89%
patients receiving care free of
PS01
Green
Green
any newly acquired harm)
[one month in arrears]
95%
97%
91%
93%
PS02
Safety Thermometer (%
Mar 15 Internal
patients receiving care free of
94.8%
Amber any harm - irrespective of
Green
acquisition) [one month in
arrears]
VTE Risk Assessment (%
96.97%
Green admitted patients receiving
Green
risk assessment)
Mar 15 National
N/A
N/A
PS03
Mar 15
N/A
N/A
Mar 15 National
70
N/A
PS05
Number of cases of
61
Clostridium Difficile > 72
Green
Green
hours (cumulative year to
date)
Number of cases of MRSA
7
Green bacteraemia > 48 hours
Green
(cumulative year to date)
Mar 15 National
1
N/A
PS06
% patients receiving stage 2
76.34%
Amber medicines reconciliation
Amber
within 24h of admission
Mar 15 Internal
75%
85%
PS09
Mar 15 Internal
94%
96%
PS10
100%
Green
PS11
2228
N/A
Mar 15
N/A
N/A
6.5%
5%
N/A
N/A
N/A
N/A
8
7
PS04
PS12
PS13
Serious Incidents Requiring
Investigation (SIRI) reported
via STEIS
17
N/A
% patients receiving allergy
Red reconciliation within 24h of
admission
% of incidents associated
2.15%
Green with moderate harm or
Green
greater
69
N/A
Total number of newly
acquired pressure ulcers
(category 2,3 and 4) reported
via Datix
Mar 15 Internal
Feb
15
Percentage of Falls with
moderate harm or greater as
a percentage of total harms
PS133
PS14
Total number of incidents
reported via Datix
4
Falls leading to moderate
Green
Green
harm or greater
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Mar 15 Internal
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PS15
Number of hospital acquired
Dec
1
thromboses identified and
14
Green
Amber
judged avoidable [two months
in arrears]
Cleaning Score - % of
inpatient areas with initial
score > 92%
60.98%
PS16
N/A
Internal
1
0
N/A
N/A
5%
N/A
Commissioner 95%
98%
N/A
N/A
1
N/A
N/A
N/A
Mar 15
N/A
N/A
80%
90%
Mar 15 Internal
85%
95%
Mar 15
PS17
4.02%
% 3rd and 4th degree tears in Mar 15 Internal
Green
Green
obstetrics [C&W Division]
PS18
% radiological investigations
98.23%
Amber achieving 5 day reporting
Green
standard [CSS Division]
PS19
PS20
9
N/A
Number of CAS alerts
received
CAS alerts breaching
0
deadlines at end of month
Green
and/or closed during month
Green
beyond deadline
Feb
15
Mar 15
Mar 15 Internal
CE01
1
N/A
Standardised Hospital
May
Mortality Ratio (SHMI) [most
13 recently published figure,
Jun 14
quarterly reported as a rolling
year ending in month]
CE02
190
N/A
Crude Mortality
Dementia - % patients aged > Mar 15 National
70.79%
75 admitted as an emergency
CE03
Red
Red
who are screened [one month
in arrears]
CE04a
83%
Red
Statutory and Mandatory
Red Training - % required
modules completed
ED - % patients seen,
84.88%
Amber assessed and discharged /
Red
admitted within 4h of arrival
Mar 15 National
85%
95%
CE05
Stroke - % patients spending Mar 15 National
76.81%
Green > 90% of admission in
Amber
specialist stroke environment
70%
80%
CE06
Stroke - % patients accessing Mar 15 National
71.88%
CE07
Amber specialist stroke environment
Red
within 4h of arrival
75%
85%
N/A
N/A
70%
75%
CE08
CE09
508
N/A
Transfer Lounge Usage
% of elective paediatric day
96.65%
Green cases managed as such (Did
Green
not result in an overnight
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Mar 15
Feb
15
Internal
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Oxford University Hospitals
stay) [C&W Division]
Feb
15
Internal
8
5
CE10
Vascular - Mean length of
stay for patients undergoing
6
Green elective AAA repair (3 month
Green
rolling period) [NOTSS
Division]
Feb
15
Internal
5%
3%
CE11
Vascular - % mortality
0%
Green following elective AAA repair
Green
[NOTSS Division]
Cardiology - % patients
94.44%
receiving primary angioplasty
CE12
Green
within 60 minutes of arrival at
Green
hospital [MRC Division]
Feb
15
Internal
85%
90%
Feb
15
Internal
3
2
CE13
Cardiology - Mean number of
2.4
days from referral to
Green
Green
admission to cardiology at
tertiary centre [MRC Division]
1%
0.5%
CE14
Cardiac surgery-% rate of
patients with organ space
0%
Green infections following cardiac
Green
surgery via the sternum
[MRC Division]
Cardiac Surgery - % mortality
0%
Green following elective primary
Green
CABG [MRC Division]
6%
4%
CE15
Mar 15 Internal
2
1
CE16
Number of unscheduled
1
Green returns to theatre within 48
Green
hours [NOTSS Division]
Rheumatology - % relevant
98.15%
patients who have their
CE17
Green
Green
DAS28 score documented
[NOTSS Division]
Oct 14 Internal
95%
98%
Mar 15 Internal
2
1
Mar 15
N/A
N/A
Mar 15 Internal
4%
2%
% fractured NOF patients
Mar 15 Commissioner 70%
who receive surgery within 36
Red
hours of admission [NOTSS
Division]
72%
CE18
CE19
CE21
CE22
Number of unscheduled
1
Green returns to theatre in
Green
gynaecology [C&W Division]
Number of patients admitted
to SEU wards from SEU
triage [S&O Division]
343
N/A
Neuroscience Intensive
Therapy Unit (NITU)
1.68%
Green readmission rate within 48
Green
hours of discharge [NOTSS
Division]
81.6%
Green
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Mar 15 Internal
Feb
15
Internal
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Oxford University Hospitals
CE23
19.65%
% deliveries by C-Section
Green
Green
[C&W Division]
CE24
7 day admission rate
Mar 15 Internal
2.25%
following assessment on (and
Amber
Amber
discharge from) paediatric
CDU [C&W Division]
PE01
72
Red
Friends & Family - Net
Red Promoter Score [one month
in arrears]
Mar 15 Commissioner 33%
Mar 15 Internal
Friends & Family - proportion Mar 15 Internal
94.92%
extremely likely or likely to
PE02
Green
recommend [one month in
Green
arrears]
23%
4%
2%
63
70
90%
94%
PE03
89
Green Complaints Received
Green
Mar 15 Internal
90
80
Mar 15 Internal
2
1
PE04
Number of complaints
0
Green received initially graded as
Green
RED
N/A
N/A
3
2
65%
70%
N/A
N/A
2
N/A
45%
60%
N/A
N/A
PE05
293
N/A
PALS contacts made
Mar 15
PE06
0
Green Single sex breaches
Green
PE07
55.48%
% patients EAU length of stay Mar 15 Internal
Red
Red
< 12h
75.31%
PE08
N/A
PE09
% Complaints upheld or
partially upheld [Quarterly in
arrears]
Number of legal claims
0
Green received / inquests opened
Green
initially graded as RED
Mar 15 National
Dec
14
Mar 14 Internal
% patients returning feedback Mar 15 Internal
86.67%
PE10
Green forms in specialist surgery
Green
outpatients [NOTSS Division]
PE11
12
N/A
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Number of reopened
complaints
Mar 15
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ORBIT
Reporting
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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Ch t D
i ti
Patient Safety
PS09 % patients receiving stage 2 medicines reconciliation
within 24h of admission
Narrative
The results
presented within
this metric rely
on paper charts
and are
restricted to
areas that
haven’t gone
live with ePMA.
At this point in
time this is
restricted to the
Childrens and
Womens
Division.
It is planned that
by the end of
Q1, all areas will
be able to be
reported through
this indicator
reflecting a Trust
wide view.
The chart shows the proportion of inpatients for whom second stage pharmacy-led
medicines reconciliation is completed within 24 hours of admission. Spot check audit by
pharmacy staff once per month. Approximately 600 patients are included in the audit
Trust-wide.
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Patient Safety
PS10 % patients receiving allergy reconciliation within 24h of
admission
Narrative
The results
presented within
this metric rely
on paper charts
and are
restricted to
areas that
haven’t gone
live with ePMA.
At this point in
time this is
restricted to the
Childrens and
Womens
Division.
With the
introduction of
ePMA
prescribers are
unable to
prescribe any
medications until
a reconciliation
of allergies has
been
completed.
The chart shows the proportion of inpatients within the Division for whom allergy status
has been documented at the time of a spot check audit by pharmacy staff once per
month. In August 2012, the criteria changed to allergy status documented prior to
pharmacy intervention.
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Patient Safety
PS16 Cleaning Score - % of inpatient areas with initial score >
92%
Narrative
This is a newly
reported
indicator through
the ORBIT
system. Futher
detail regarding
the results is
provided in
section 4.
This percentage reflects the cleaning score achievements for the wards audited by the quality
assurance team only.
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Clinical Effectiveness
CE03 Dementia - % patients aged > 75 admitted as an emergency Narrative
who are screened [one month in arrears]
As a National
CQUIN for
2014/15,
performance
against this
indicator has been
formally reported
to the OCCG
quarterly. A
number of actions
have been taken
in recent months
to improve results
against this
indicator,
including:
The formation of a
Dementia
Steering group,
Divisonal level
results are
disseminated
locally to foster
improvement and
awareness,
increased use of
the Electronic
record
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
Compliance
against this
Trust wide
indicator is
monitored
through
Divisional
Performance
Reporting
processes.
Each Division
has local action
plans in place
to improve
performance
and/or
compliance
against this
indicator.
Results indicate
a gradual
increase in
compliance
over the last 6
reporting
cycles.
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Clinical Effectiveness
CE05 ED - % patients seen, assessed and discharged / admitted
within 4h of arrival
Narrative
Performance
around this
target remains
poor; below the
95% target.
Some
improvement
has been seen
in February. The
department
continues to
focus on
admission
avoidance, rapid
turn-around and
ambulatory care.
The main issue
is capacity and
flow. Capacity
has been
impacted on by
delayed
transfers of
care. The
Emergency
Department
continues to
prioritise patient
safety but
patient
satisfaction and
maintaining
privacy and
dignity can be
negatively
affected.
% 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
These results
are reflective of
demand vs
capacity within
this services.
The Division
are taking
measures to
improve the
patient
pathway.
This is an
organisational
result and
includes the
Horton hospital
which requires
patient transfer
to JRH for
specialist
treatment.
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.
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Clinical Effectiveness
CE07 Stroke - % patients accessing specialist stroke environment Narrative
within 4h of arrival
These results
are reflective of
demand vs
capacity within
this services.
The Division
are taking
measures to
improve the
patient
pathway.
This is an
organisational
result and
includes the
Horton hospital
which requires
patient transfer
to JRH for
specialist
treatment.
Clinical Effectiveness
CE24 7 day admission rate following assessment on (and
discharge from) paediatric CDU [C&W Division]
Narrative
Each of the
individual cases
has been
reviewed
against the
clinical impact
on the patient.
Each case was
clinically
justified.
Number of patients discharged from CDU and number who are readmitted as emergency inpatients within
7 days to a ward other than CDU.
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Patient Experience
PE01 Friends & Family - Net Promoter Score [one month in
arrears]
Narrative
Further detail
and discussion
regarding
actions taken to
improve this
result are
included in
section 8.
The Net Promoter Score (NPS) is defined as % extremely likely to recommend minus
those who are neutral or negative in propensity to recommend. Those who 'don't know'
are excluded from the NPS calculation.
Patient Experience
PE02 Friends & Family - proportion extremely likely or likely to
recommend [one month in arrears]
Further detail
and discussion
regarding
actions taken to
improve this
result are
included in
section 8.
This metric was refreshed in August 2014 to include maternity data retrospectively from
October 2013. This indicator therefore now includes all responses from Inpatients, A&E
and Maternity. NB The total number of responses excludes responses of 'don't know'.
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2.
Patient Safety and Clinical Risk
2.1. Clinical Risk
2.1.1. 13 SIRIs have been notified to the OCCG in April 2015. SIRI reference
number 2015/040 is noted as a Never Event as per the NHS England Never
Event Framework.
2.1.2. Five of the 13 reported SIRIs have been subsequently downgraded as with
further information they do not meet NHS England SIRI criteria. A full Root
Cause Analysis is to be conducted for these incidents. The findings of these
investigations is monitored through the Patient Safety & Clinical Risk
Committee (a sub-committee of the Clinical Governance Committee).
Table 1 – Reported SIRIs
SIRI ref
2015/039
Division
NOTSS
Description
Retroperitoneal haemorrhage
2015/040
NOTSS
2015/041
S&O
2015/042
NOTSS
Cardiac Arrest in Radiology
2015/043
C&W
Transfusion of Un-crossmatched blood
2015/044
C&W
Maternal Death
2015/045
C&W
Ectopic Pregnancy leading to Laparotomy
2015/046
C&W
Baby Death
**2015/017
NOTSS
Delayed Biopsy
**2015/018
C&W
Retained placental pieces after caesarean section
**2015/019
S&O
Sepsis and Neutropenia
**2015/021
CSS
Missed Lung cancer
**2015/020
S&O
Arm Haematoma following administration of Fragmin
Wrong level Spinal Surgery (Never Event)
Death following pancytopaenia
Note: ** and italics denotes incidents initially reported as a SIRI, however
further investigations have identified that they do not meet SIRI reporting
criteria as per NHS England Serious Incident requiring Investigation
Framework.
2.1.3. SIRI investigations are categorised as a level 1 or level 2 investigation
dependant 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.
2.1.4. 12 Serious Incidents Requiring Investigation (SIRI) reports were
recommended to Oxfordshire Clinical Commissioning Group (OCCG) for
closure during April 2015. 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.
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2.1.5. One of the SIRIs reported this month is a Never Event related to wrong level
spinal surgery in a patient who required repeat surgery as a result, and was
having an orthopaedic procedure at the NOC. This is of particular concern to
the Trust given five prior Never Events where the index event occurred in
2014/15, and a further event from prior years which was detected in 2014/15.
Oxford University Hospitals
Date of event
13/09/2013
Never Event type
02/11/2014
Retained foreign object post procedure -Coronary
guide wire
Misplaced NG tube
03/10/2014
Wrong site surgery- wrong tooth removed
14/11/2014
Retained foreign object post procedure –guide wire
from a midline
Wrong site surgery- wrong tooth removed
09/01/2015
18/03/2015
07/04/15
Retained foreign object post procedure – retained
swab
Wrong site surgery - wrong level spinal surgery
2.1.6. The Trust takes these events very seriously and each has been investigated
or is the subject of an investigation, and an action plan to prevent repetition
has been drawn up and is being monitored. Two investigations are in
progress in relation to the retained swab reported to the Board in March 2015,
and the wrong level spinal surgery notified in this report.
2.1.7. In addition to the individual action plans, a further overarching Never Event
action plan is in place to improve safety across the Trust.
2.1.8. A Board seminar on quality, including a review of the root causes of each
Never Event from the past year was held in March 2015.
2.1.9. A further internal review of themes, risk and progress with actions in relation to
the Never Events is in progress in the Medical Director’s office and Clinical
Governance team, and will report to the Trust Management Executive at its
meeting on 14 May 2015.
2.1.10. The Medical Director has been in discussions with the executive and the
TDA with respect to commissioning an external review of all the events, and a
reviewer has been provisionally identified.
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2.1.11. Table 2 SIRI reports for closure with OCCG.
Due to the timeframe for closure meetings with the OCCG, not all reports will
have been discussed within the closure month.
Table 2.
SIRI Ref
Division Description
OUH
Date
Closure Status
2015/005 NOTSS
Incorrect teeth removal 27/04/2015
2015/007 MRC
Delay in diagnosis of a
Fractured Hip
Inpatient Fall resulting
in Fractured Hip
Missed Lung Cancer
Death
following
blocked tracheostomy
Death
following
insertion
of
a
gastrostomy tube
Hospital
acquired
thromboembolism
Neonatal Death
02/04/2015
Never Event
Not Closed
Closed
19/03/2015
Closed
24/03/2015
07/04/2015
Closed
Closed
17/04/2015
Not Closed
21/04/2015
Unreported Fractured
pelvis
2015/014 CSS
Misinterpretation
of
bowel ischaemia
2015/015 MRC
Unexpected
patient
deterioration
2015/016 CSS & Incorrect Insulin after
S&O
discharge
30/04/2015
To be discussed
in May 2015
To be discussed
in May 2015
To be discussed
in May 2015
To be discussed
in May 2015
To be discussed
in May 2015
To be discussed
in May 2015
2015/006 MRC
2015/008 MRC
2015/009 MRC
2015/010 CSS&
MRC
2015/011 S & O
2015/012 C & W
2015/013 CSS
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21/04/2015
28/04/2015
28/04/2015
30/04/2015
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2.2
Quality Walk Rounds
2.2.1
There were 6 Executive Quality Walk Rounds in April 2015. These are
detailed in figure 3 below.
Figure 3
Hospital Site
John Radcliffe Hospital
Churchill Hospital
Areas Visited
Bellhouse-Drayson Ward, CHOX
Neuropathology
Short Stay Ward
Churchill Mortuary
CRUK Clinical Trials Unit
Immunology Labs
2.2.2
Key issues with the potential to affect quality or patient experience identified
during the Quality Walk Rounds included challenges surrounding recruitment,
retention and reliance on agency staff, and the environment; particularly in
relation to the old estate (heating, maintenance, security).
2.2.3
All issues have actions associated with them and these will be monitored
through Divisional governance processes.
2.2.4 An update on actions arising from Executive Quality Walk Rounds is provided
to Quality Committee.
2.3
National Reporting and Learning System (NRLS)
2.3.1 The table below shows a summary overview of how the Trust compares to
the rest of the group of acute trusts for the period (Apr-14 to Sep-14).
Figure 4.
OXFORD UNIVERSITY
HOSPITALS NHS TRUST
Degree of harm
Days between incidents
occurring and being
reported to the NRLS
Number of that occurred
between Apr-14 to Sep-14
reported to NRLS
Apr 14 - Sep 14 Rate per
1,000 bed days
N
None
%
N
Low
%
N
Moderate
%
N
Severe
%
N
Death
%
TB2015.48 Quality Report
All Acute (non
specialist) trusts
Median: 15
Mean: 36.2
8,873
587,483
39.43
6,688
75.4
1,822
20.5
338
3.8
15
0.2
10
0.1
Mean: 35.9
432,815
73.7
128,067
21.8
23,750
4.0
2168
0.4
683
0.1
Page 21 of 42
Oxford University Hospitals
TB2015.48
OUH is the 7th highest reporting Trust out of the 140 Trusts within the Acute
(non specialist) cluster – as shown in the figure below:
2.3.2
Figure 5.
3. Clinical Effectiveness
3.1
Clinical Outcomes
3.1.1
Hospital Standardised Mortality Ratio (HSMR) and Summary Hospitallevel Mortality Indicator (SHMI)
The most recent Dr Foster data updates were released on 31st March 2015.
The Trust HSMR for latest available 12-month data period January 2014 to
December 2014 is 101.8. This is an increase from 97.4 reported in the last
update. This increase is partially due to the change to more frequent rebasing
of risks by Dr Foster to which now includes the most recent data (in this
update for discharges of 10 years until the end of September 2014). This is
reflected in the reduction in the Trust’s ‘expected’ values compared to the
previous update from approximately 2,083.2 down to 2,019.8; increasing the
ratio of observed to expected cases and therefore the HSMR.
3.1.2
The HSMR is a relative performance measure which benchmarks the
performance of a trust against all national providers. The HSMR is likely to
indicate an improvement against the benchmark previously set due to national
mortality performance tending to improve over time. Therefore, Dr Foster
periodically resets the national average against the current national
benchmark to ascertain each trust’s relative position; this process is referred to
as rebasing of risks. This could mean that a trust’s mortality rates may be
improving in absolute terms, but if the improvement is significantly slower than
that which is observed nationally then the HSMR for the trust may not show
improvement.
3.1.3
The Dr Foster risk methodology involves applying a risk assignment to every
patient and then comparing this to national outcomes. The risk assignment is
calculated from the national dataset and case mix adjusted for :
TB2015.48 Quality Report
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Oxford University Hospitals
•
•
•
•
•
•
•
•
•
•
•
•
TB2015.48
Age
Sex
Method of admission (Elective or Non-Elective)
Socio-economic deprivation
Diagnosis Clinical Classification System (CCS) subgroup
Co-morbidity – Charlson index
Improved Charlson weightings for interaction
Source of admission- 7 categories
Number of emergency admissions in last 12 months
Palliative care
Year
Month of admission
3.1.4
The expected number of deaths is calculated from accumulating the patient’s
risks. The HSMR is calculated as the ratio of observed deaths to expected
deaths for a basket of 56 diagnoses that represent approximately 80% of inhospital deaths.’
3.1.5
There are five new Dr Foster mortality alerts:
 Cancer of kidney and renal pelvis, this is a CUSUM (cumulative sum)
signal with 11 observed compared to 7.8 expected cases
 Cancer of other GI organs, peritoneum, has a higher than expected
relative risk of mortality, with 19 observed compared to 11 expected
cases
 Coronary atherosclerosis and other heart disease, has a higher than
expected relative risk of mortality, with 32 observed compared to 21.5
expected cases
 Deficiency and other anaemia, has a higher than expected relative risk
of mortality, with 12 observed compared to 5.9 expected
 Secondary malignancies, has a higher than expected relative risk of
mortality, with 86 observed compared to 65.8 expected
3.1.6 An initial analysis of the new Dr Foster mortality alerts has been completed by
the Trust Clinical Governance team and details have been distributed to the
respective specialties for investigation.
3.1.7 The next SHMI is due to be published on the 29th April 2015.
3.1.8
The Clinical Effectiveness Committee (CEC) met on the 9th April 2015. The
key points of discussion and presentations related to outcomes are
summarised below.
I.
Report to the Care Quality Commission (CQC) on maternity outlier for
puerperal sepsis and/or other puerperal infections
The conclusions of the report was that the rise in the number of patients
with the ICD-10 diagnosis code O85 (‘puerperal sepsis’) over the period
was due to a number of patients with an incorrect diagnosis made by
junior medical staff who did not adhere to the Trust guidance which in
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turn led to incorrect clinical coding and a reported rise in the number of
cases. The rise in the number of patients coded as ICD-10 diagnosis
code O86.4 (`pyrexia of unknown origin following delivery`) was due to
incorrect clinical coding. An action plan has been compiled to improve
the diagnosis, investigation and clinical coding of puerperal sepsis.
Oxford University Hospitals
The Committee noted that there were no deaths or intensive care
admissions of patients with this diagnosis. The Committee commended
the Unit on the thorough investigation and report.
II.
Requirements assessment for a data validation process before external
submission
The findings of the requirements assessment undertaken in the
Cardiology, Cardiac and Thoracic Surgery and Trauma Directorates were
presented. It was noted that both Directorates had in-house Information
teams who undertake the collection, submission and validation of data.
This was not reflective of the resources available to other Directorates.
Further the volume of data submissions and existence of an electronic
data collection system was not indicative of other Directorates.
It was noted that the implementation of central Trust process for the
validation of data before external submission would necessitate the
creation of a team of Information Analysts. The Information Analysts
would require the support of designated clinicians from the specialties for
which the data is related and there would need to be allocation of
clinicians’ time for the data validation.
III.
Mortality Reduction Strategy
The Mortality Reduction Strategy had been circulated to the Divisions for
feedback and was approved by the Committee. The strategy was ratified
by the Clinical Governance Committee at the 15th April 2015 meeting.
IV.
Consultant Outcomes Publications
Neurosurgery Consultant Outcomes, (Neurosurgery National Audit
Programme), were published 1st December 2014
The Committee were advised that this publication is referencing old data.
The performance of all surgeons and units was within the expected
range.
V.
Urological Surgery Consultant Outcomes (Nephrectomies), (BAUS
cancer registry), published 9th October 2014
The Committee were advised that this publication is referencing old data.
The performance of the surgeons was within the defined acceptable
parameters. The Committee noted the mortality rate was 0.05% (one
death in 2013).
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Oxford University Hospitals
3.1.8a
I.
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Review of Outcomes from National Clinical Audits
CEM Severe Sepsis & Septic Shock, October 2013 to March 2014 data,
published 5th September 2014
The Committee were advised that the John Radcliffe Hospital had
achieved 98% for timely blood cultures. This is due to the Rapid Nurse
Assessment (RNA) processes which are in place. Since the audit RNA
but has been introduced at the Horton General Hospital. Staff has been
encouraged to use the sepsis proforma. The Committee noted that the
service had achieved good results for this audit.
II.
CEM Paracetamol overdose, October 2013 to March 2014 data,
published 19th January 2015
The Committee were advised of a marginal decrease in overall
compliance with the MHRA (Medicines and Healthcare products
Regulatory Agency) guidance. It was commented that EPR should make
data collection easier. Feedback has been given to CEM (College of
Emergency Medicine) by the Unit about this audit not being particularly
useful.
The performance improvements highlighted by the audit and have been
put into practice by the Unit.
III.
CEM Asthma in children, October 2013 to March 2014 data, published 9th
January 2015
The audit identified that the Units do not routinely use peak flow meters
as part of the patients’ assessment. The action for the units was to
purchase additional peak flow monitors for both Emergency Departments
and encourage and re-enforce the use of monitors
IV.
Sentinel Stroke National Audit Programme (SSNAP): site specific report
for Horton General Hospital, Organisational Report: data as at 1st July
2014, published 8th October 2014 and public report 2nd December 2014
The Horton General Hospital performed well in four out of seven domains
and had attained a band ‘C’ rating overall. The Committee commended
the service on the improvements.
V.
Sentinel Stroke National Audit Programme (SSNAP): site specific report
for John Radcliffe Hospital, Organisational Report: data as at 1st July
2014, published 8th October 2014 and public report 2nd December 2014
The John Radcliffe Hospital attained a band ‘B’ rating which places the
site in the top third of teams nationally.
VI.
National clinical audit of rheumatoid & early inflammatory arthritis, 1st
February 2014 to 29th September 2014 data, published November 2014
A potential delay was identified between receiving the referral letter from
the GP and processing through MSK triage before the letter was received
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by the Rheumatology department. As a result of this a system was set
up whereby any patient whose letter indicated suspected rheumatoid
arthritis was fast tracked by email communication to the Early Arthritis
Clinic. The mean time from receipt of letter by the Rheumatology service
to first appointment was 6 weeks with 25% of patients seen within 3
weeks.
Oxford University Hospitals
VII.
National Bowel Cancer Audit NBOCAP, Patients diagnosed 1st April 2012
to 31st March 2013
The Committee were advised of an improvement in data quality following
Trust investment in data collection. The Trust reported favourable
mortality rates (adjusted 90 day mortality 2.4% compared with 4.6%
average for England). The results indicated that improvements could be
made in the CT scan reporting (it was considered that is an issue with
data recording rather than actual practice), the percentage of patients
having major surgery (consultants are wary of undertaking surgery on
high risk patients because of the publication of consultant mortality rates)
and the 18 month stoma rate which should be a little lower.
The high percentage of patients with a length of stay beyond 5 days
(64%) was noted in the context that the laparoscopic surgery rate was
reported to be above national average (77%). This may reflect the Trust’s
case mix with more complicated cases being referred from other centres.
VIII.
National Cardiac Rhythm Management (CRM), 2013/14 FY data,
published 19th December 2014
It was reported that the Trust’s implantable cardioverter defibrillators
(ICDs) implant rates have been low and that this has been discussed
with the CCG. The pacemaker rates were reported to be good and are
increasing.
4.
Quality Items rasied by the Oxfordshire Clinical Commission Group
4.1.1
The OCCG and Oxford University Hospital Quality/Clinical Governance
Management teams meet monthly to discuss and plan action against areas
of service provision where informaiton suggests a potential clinical
governance/quality related concern. Due to conflicting diary commitments a
meeting has not been possible in April 2015.
4.1.2
Items identified through Quality and Contract review meetings between the
OUH and the OCCG, along with the current status of actions are outlined
below.
 General Practitioner Feedback and reported SIRI’s have identied the
need for a Quality Assurance system for managing Test results.
 Emergency surgery cancellations.
Efforts continue to identify a method to measure this metric. The
Deputy Director of Clinical Services is working with the information
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TB2015.48
team to identify a sustainable and validated method of reporting and
monitoring.
Oxford University Hospitals
 Delays for patients to access outpatient appointments
The roll out of the Directly Bookable Service will improve access for
patients. The roll out of this service is on schedule.
 Ensuring outpatient letters are sent to General Practitioners within 10
working days.
The roll out of electronic outpatient letters is on track, and expected to
be completed by the end of May 2015.
 Management of acutely unwell oncology patients and associated
communication with General Practitioners.
 A review of the Datix feedback received is being reviewed by Mr Tony
Summersgill from OCCG and shared with Dr Clare Blessing.
 Concens regarding the results of the annual Nutrition Audit
Data to be reviewed, and a remedial action plan developed by the
Chief Nurse.
 Joint SIRI investigation process to be developed
The new National Guidance was released on 27 March 2015.
round table meeting of the key stakeholders is to be arranged.
4.1.3
A
In April 2015, 304 pieces of GP feedback were received in relation to
Oxford University Hospitals. The table below sets out a thematic review of
the types of feedback received.
Figure 6.
Area of Concern
% of Total
feedback received
General Clinical Communication/Documentation
9%
Discharge summaires – delayed or absent
38%
Clinical Decision Making
3%
Medication issues/prescribing concerns from
14%
Primary care
Appointment/referral processes/delays
25%
Follow up of Test Results
10%
Completion of Sickness Certificates
1%
Total
100%
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Page 27 of 42
TB2015.48
Oxford University Hospitals
5.
Infection Control
5.1
5.2
Clostridium difficile (C.diff) - The objective for 2014/2015 was an upper
limit of 67 cases.
The table below sets out the numbers of reported C.Diff each month.
Figure 7.
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sep
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Mar
15
Total
Monthly limit
1
5
6
5
7
5
6
6
3
6
6
6
6
6
8
6
3
6
4
6
3
5
8
5
Cum total
Cum limit
1
5
7
10
14
15
20
21
23
27
29
33
35
39
43
45
46
51
50
57
53
62
61
67
5.3
8 cases of C.diff were reported for March 2015, against a monthly limit set
at 5 for the month.
5.4
All 8 cases were discussed at the monthly Health Economy meeting with
the Oxford Clinical Commissioning Group, Oxford Health and Public
Health England held on 13th April 2015 and were deemed unavoidable.
However, the following patient management issues were identified as
requiring action:
 Delays in the commencement of oral antibiotics (Vancomycin) on
suspicion of C.diff infection.
 Improvements in the communication between Nursing and Medical
staff when samples have been sent for C.diff testing.
 Prompt isolation of patients on suspicion of a C.diff infection.
 ensuring that Enhanced cleans (cleans with a combined detergent
and bleach product) are requested as per OUH protocol.
5.5
5.6
MRSA bacteraemia - The OUH was set an objective of 0 Avoidable MRSA
Bacteraemia (Blood Stream Infection) for 2014 – 2015.
There were no MRSA Bacteraemia apportioned to the OUH in March
2015. The table reflects MRSA bacteraemia to date by speciality for 2014
/ 2015.
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Page 28 of 42
TB2015.48
Oxford University Hospitals
Figure 8.
Month Speciality
Avoidable/
unavoidabl
e
April
2014
Medicine
Unavoidable
June
2014
Medicine
Unavoidable
July
2014
Renal
Unavoidable
Sept
2014
Cardiothoracic
Surgery
Unavoidable
Lessons learned
Blood cultures should be taken on all patient
admitted with signs of sepsis.
Records provided by the Ambulance service
should be taken note of, as these may affect the
care decisions taken in A&E.
These practice points will be taken forward with
their teams by the Medical Consultant.
PIR undertaken with OCCG 19/08/14. It was
agreed that the positive blood culture was a likely
contaminant and that no actions were identified.
Following the case review meeting it was agreed
that the Post 48 hour bacteraemia was hospital
acquired but unavoidable due to co-morbidities
(end stage renal failure, hypertension) and a long
and complicated post-surgical recovery with
recurrent episodes of sepsis and pneumonia.
Multiple potential sources of the bacteraemia were
explored including respiratory, deep incisional
wound and lines, however it was agreed the
source was unknown.
Oct
2014
Haematology
TB2015.48 Quality Report
Avoidable
The case was well managed in accordance with
Trust guidelines and protocols i.e. Ventilator
Associated Pneumonia care bundle, Antibiotic
guidelines and there were no further learning
outcomes identified.
The PIR identified issues around some elements
of cannula insertion and VIP scoring
documentation and this was recorded as an action
that required addressing on the ward with the
Clinical service and this will be taken forward by
the Clinical service and Infection Control.
Page 29 of 42
Oxford University Hospitals
Dec
2014
Cardiolog
y
Avoidable
TB2015.48
The risk of infection was increased due to the
patient’s lengthy hospital stay. However this was
unavoidable because the patient became acutely
unwell before the intended earlier cardiac
intervention of a balloon Valvuloplasty.
Prior to subsequent cardiac intervention of a
pacemaker insertion the patient was given the
routine antimicrobial prophylaxis of Flucloxacillin
and Gentamicin. This was sub-optimal because
MRSA is not sensitive to Flucloxacillin. The
prescribing doctor should have followed OUH trust
guidelines and sought further advice from a
microbiologist.
Jan
2015
Medicine
Avoidable
Due to lack of documentation it was unclear if
adequate skin preparation was given prior to
insertion of the permanent pacemaker. It was
agreed that this will be followed up with the Sister
managing the cardiac angiography suite.
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.
5.7
The OUH was set an objective of 0 avoidable MRSA Bacteraemia by the
OCCG for 2014 -2015. There were 7 MRSA Bacteraemia apportioned to
the OUH (i.e. taken 48 hours after admission) of which 3 were deemed
avoidable : therefore this objective was not met.
TB2015.48 Quality Report
Page 30 of 42
TB2015.48
Oxford University Hospitals
5.2
5.2.1
Cleaning audits
The table below details the average reported cleaning scores by division
and the internal auditing team.
Figure 9.
Division
Neurosciences, Orthopaedics,
Trauma & Specialist Surgery
Medicine, Rehabilitation &
Cardiac
Children’s and Women’s
Surgery & Oncology
Clinical Support Services
OUH total
5.2.2
March 2015
Quality
Assurance
Team audits
Domestic audit
scores
Nursing audit
scores
89%
97%
99%
93%
94%
94%
92%
92%
93%
92%
94%
95%
96%
95%
88%
92%
93%
93%
The chart below details the distribution of National Cleaning scores from
the Clinical areas audited in March 2015.
Figure 10.
5.2.3 The clinical areas rated red in the chart above are as follows:
 6A
 NOC Ward D
5.3
Norovirus outbreak, Oak and Laburnum Wards, Horton March 2015
5.3.1
On the 21/03/15, Oak and Laburnum Wards at the Horton reported a
number of patients and staff members with symptoms indicative of a
Norovirus type illness (Diarrhoea and Vomiting). Oak ward had
TB2015.48 Quality Report
Page 31 of 42
TB2015.48
previously experienced a minor outbreak in February 2015 affecting a
total of 5 patients and 2 staff.
Oxford University Hospitals
5.3.2
Following a review by Infection Control on the 23/03/15, restrictions on
patient transfer and movement were put in place on the wards as per
OUH Outbreak policy.
5.3.3
A positive Norovirus sample was reported by OUH Microbiology (no
further testing is undertaken once a positive sample has been reported)
and the following total numbers of patient and staff affected by ward was
as follows :
 Oak ward: 7 patients, 0 staff
 Laburnum ward: 12 patients, 3 staff.
5.3.4
6
Restrictions on both wards were formally removed on the 26/03/15. A
total of 4 beds were closed during the period of the outbreak, though it
must be noted that these were opened as soon as it was appropriate to
do so.
Quality Account
6.1 The annual Trust Quality Account is being prepared in line with regulations,
and guidance issued by the Department of Health.
6.2
A programme of internal and external consultation has been proposed to
ensure the publication date of 30th June 2015 is met. Key milestones are
shown in the table below.
Picture 11.
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Page 32 of 42
TB2015.48
6.3 The priorities below are proposed for the forthcoming year. They have been
aligned with goals in the Trust Quality Strategy, Trust Annual Report,
National Audit Reports and feedback from our service users and Health
Watch Oxfordshire.
Oxford University Hospitals
Table 12.
Domains
Annual Priorities for the Trust
PATIENT
SAFETY
Preventing avoidable patient deterioration and harm in hospital:
Sign up for Safety
Partnership working to improve urgent and emergency care
Improving recognition, prevention and management of acute
kidney injury
CLINCIAL
Learning from deaths and harms to improve patient care
EFFECTIVENESS
Management of patients presenting with sepsis
PATIENT
EXPERIENCE
End of life: improving peoples care in the last few days and hours
of life
Improving
communication,
feedback,
engagement
and
complaints management: with patients, carers, health care staff
and social care providers
6.4
An early draft of the Quality Account was circulated to the Executive and
Non-Executive Directors on 24 March 2015 for comments, particularly with
regard to the priorities proposed for 2015/16. A second full draft was
presented to the 15 April 2015 Quality Committee (QC) to approve before it
is released for external review. The 27 April 2015 Audit Committee also
received a draft for information.
6.5
The Quality Account was presented to the Hospital Overview and Scrutiny
Committee (HOSC) on 23 April 2015 and was sent to the Oxfordshire
Clinical Commissioning Group and Healthwatch Oxfordshire on 28 April
2015.
6.7
Feedback received is listed below. These are being incorporated into the
next version.
Table 13.
Plain English edit throughout the document
Quality priorities to contain 2 or 3 SMART objectives
CQC good rating to be included
Patient voice to be more visible
Table to show how we have collected all patient experience data
Clearly state when targets are missed e.g. cancer access
Executive summary to be produced alongside full version
TB2015.48 Quality Report
QC
QC
QC
QC
QC
HOSC
HOSC
HOSC
Page 33 of 42
TB2015.48
6.8
An engagement event is being organised for May to present progress in
relation to the priorities in last year’s Quality Account and to discuss quality
plans for the forthcoming year. The patient experience team held a number
of events during 2014/15 to gather feedback from the public in relation to
quality improvement for the year ahead. In addition Healthwatch
Oxfordshire has also provided the patient experience team with a report
based on the feedback they have received. This information has informed
number of priorities in the Quality Account.
Oxford University Hospitals
6.9
There have been no changes to the regulations regarding the external audit
process for this document. This work will be carried out by Ernst and Young
as in previous years. A disclosure list was provided by Ernst and Young to
assist with the collection of prescribed information. The external audit
process entails:
 Review the content of the Quality Account for its compliance with
relevant regulations
 Review the content of the Quality Account to ensure that it is
consistent with other specified information
 Undertake substantive sample testing on two indicators
I.
Percentage of patient safety incidents resulting in severe
harm or death
II.
Rate of Clostridium difficile per 100,000 bed days
 Provide the Trust with a Limited Assurance Report
6.10 The final draft of the Quality Account will be presented for Trust sign-off to
the Quality Committee on 10 June 2015.
7.
CQUIN
7.1
The full CQUIN position for Q4 is being agreed with the Oxfordshire Clinical
Commissioning Group. It is anticipated that our performance will be as
listed overleaf.
7.2
The no of eligible patients on which to base the FFT calculation was
submitted twice to Unify as the original figures extracted on 2 April 2015
appeared not to include all discharges from Critical Care. The increased
number of eligible patients on which the calculations are based has reduced
the rate to just below the target 40% for March and 30% for Q4.
7.3
There have been very low responses to the dementia carers surveys during
2014/15 and none received in 2015/16. The patient experience team have
set up a carers project group to co-produce a new mechanism to collect
feedback. Face to face meetings as part of this project have highlighted the
issues below. Actions are in place to address these. Carers would like to:
 feel more welcome on the wards
 be more physically comfortable, such as improved tea and coffee
facilities and being offered a drink during tea round
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TB2015.48
 see communication improve between carers, nurses and clinical
support workers
Oxford University Hospitals
 know what we do with their feedback.
7.4
It has not been possible to measure the % of discharge summaries sent
within 24 hrs and the % of TTOs completed within 2 hours within ePMA.
KPIs have been suggested in relation to TTOs but require agreement.
7.5
Due to staff vacancies it has not been possible to introduce a five day
physician care into vascular surgery and neurosurgery.
Table 14.
FFT
Dementia
Timeliness and
communication
around
discharge
Care 24/7
Physician input
into the care of
surgical
patients
TB2015.48 Quality Report
Increased Response Rate ED Q4
Increased Response Rate: inpatient Q4 (Target
30%)
Increased Response Rate: inpatient March (Target
40%)
Safety Thermometer
Dementia: Find, Assess, Investigate and Refer
(Target 90%)
Dementia: assess
Achieved
Dementia referred
Achieved
Dementia: Clinical Leadership
Achieved
Dementia: confirm training programme
Achieved
Dementia: Supporting Carers
% of discharge summaries sent within 24 hours
(Target 98%)
Investigate all GP reported TTO and discharge
summary Datix issues within 10 days
% of TTOs completed within 2 hours of agreed
discharge in acute medicine and EAU (Target 95%)
Add KPIs to contract schedule for 2015/16
Number of ward rounds on weekends and evenings
Amount of consultant cover on weekends and
evenings
Diagnostic cover and pharmacy provision on
weekends and evenings
Provision of therapists on weekends and evenings
Number of diagnostic tests on weekends and
evenings
Introduce 5 day physician care into care of vascular
surgery and neurosurgery patients
(Target Monday – Friday 0800 – 1800)
Length of stay compared to equivalent quarter in
2013/14
Failed
Failed
Achieved
Failed
Achieved
TBC
Failed
Achieved
Failed
TBC
Achieved
Achieved
Achieved
Achieved
Achieved
Failed
Achieved
Page 35 of 42
TB2015.48
Oxford University Hospitals
Integrated
Psychological
Support for
Patients
8.
Report of patients seen by service by specialty
Report of % and number seen within urgent and
routine timescales
Quarterly meeting with commissioners
Achieved
Achieved
Achieved
Safe Staffing
8.1
Nursing and Midwifery Staffing
8.1.1 The Trust is required to comply with The National Quality Board (November
2013) and the NICE guidance (July 2014) for Safe Staffing for Adult Inpatient
Wards in Acute Hospitals. This includes, providing reports to the Trust
Board/Quality Committee on the levels of nursing and midwifery staffing on a
ward by ward/shift by shift basis. They also include ensuring that there are
procedures for systematic on-going monitoring of Nurse Sensitive Indicators
and formal review of nursing staff establishments for individual wards at least
twice a year.
8.1.2 This report includes the Safe staffing data for March 2015 and the metrics
against each of the 5 divisions (Appendices 1 a, b, c, d & e), which
incorporates Nurse Sensitive and Indicators (NSI), for the months of January
– March 2015, by division against the Trust metrics. The overall Trust safe
staffing report including individual wards and shifts is highlighted in appendix
(appendix 1f).
8.1.3
The detailed reporting related to each division can be found in the narrative
on the dashboard. This report also includes the acuity and dependency nurse
establishment review which was undertaken in January 2015, this process is
a national requirement at least 6 monthly, to be reported to the Trust Board
and the detail related to each division and ward can be found on the
appendix (appendix 2)
8.1.4 It should be noted that these metrics only apply to the in-patient clinical
areas that the Trust is required to report on staffing and so are likely to be
different, as they maybe a proportion of other metrics reported within the
Board Quality Report.
8.2
National reporting
8.2.1
The summary of the figures submitted to NHS Choices via the Unify platform
for March 2015 are included below but can be accessed via the Trust website
on (http://www.ouh.nhs.uk/about/saferstaffinglevels.aspx).
8.2.2 This report incorporates the actual hours worked against the planned rostered
hours for nursing and midwifery staff, for day and night shifts, separating
Registered Nurses and Care Support Workers.
8.2.3 In March 2015 the fill rates were:
92.94%
94.46%
TB2015.48 Quality Report
Registered Nurses/Midwives
Care Support Workers (unregistered)
Page 36 of 42
Oxford University Hospitals
TB2015.48
8.3
Update on national imperatives for Safe Staffing
8.3.1
Care Contact Time is a national requirement from spring 2015, and requires
the measurement of the proportion of time Registered Nurses and Care
Support Workers on wards spend in direct and indirect patient contact care
activities. This means of measuring the amount of time within a shift that
patients’ receive direct care. The Trust is currently piloting the Manchester
Clock system which requires nurses and CSWs to record their activities at 5
minute intervals for a shift in the week as well as at a weekend. This will be
collated to report on the percentage of time staff spend with patients in direct
and indirect care i.e. speaking with families and planning discharges. All wards
will undertake this process each year or if there is a change in the patient
group or services.
http://www.england.nhs.uk/wp-content/uploads/2014/11/safer-staffing-guidecare-contact-time.pdf
8.3.2
A national review of the implications of 12 hour shifts is being commissioned
through the National Nursing Research Unit currently, although no timeline
has been identified for publication.
8.3.4
Safe Staffing NICE guidance for paediatrics, A&E, Midwifery and Mental
Health are in various stages of development and consultation, with A&E due
for publication in May 2015.
8.4
Update on developments within the Trust
8.4.1
Acuity and Dependency Review -The Acuity and Dependency review of
staffing establishment levels was undertaken in January 2015 for two weeks.
This demonstrates that the vast majority of clinical in-patient areas have
appropriate staff establishments, although there are three areas highlighted
that require further reconfiguration and investment in order to address the
quality of care issues and changes in service activity. This business case has
been presented to the Business Strategy Group in mid-April 2015 and will be
presented to the Trust Management Executive in May 2015.
8.4.2
A permanent electronic acuity and safe staffing measurement tool, which
meets the specifications, set by the NICE guidance and National Quality Board
has been procured and is currently in the initial stages of roll out across the
Trust. This will replace the temporary system currently in place, and provide a
more comprehensive daily reporting system of safe staffing against
establishments, as well as daily acuity levels for every patient. It has the
capability to escalate automatically to senior nursing staff, providing a more
reliable monitoring and reporting system.
8.4.3
Theatre safe staffing – a local tool is being developed to measure the safe
staffing within theatres per theatre session according to The Association of
Peri-operative Practitioners’ (AFPP) guidance on safe staffing. This is being
trailed in the cardiac theatres currently.
http://www.afpp.org.uk/news/NICE-staffing-guidance
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TB2015.48
Review of the configuration of shift hours on e-rostering has included a review
of wards across the divisions and the use and efficiency of the e-rostering
system. This has been instigated following the shift pattern changes that
occurred in the summer of 2012 related to a Cost Improvement Programme to
shorten the overlap period between short shifts, which has contributed on the
impact on the appraisal rates for nurses and midwives.
Oxford University Hospitals
8.4.4
8.4.5
Some wards have and are continuing to consult on the option to move to 12
hour shifts as this provides a more efficient shift system that many staff prefer
to adopt, but also does not result in as many ‘unused hours’ that do not
conveniently fit into a 150 hour month, which often results in staff having to
work a six day week in order to utilise the hours.
8.4.6
The Lead for Safe Staffing has configured a shift system that provides a
number of options that are interchangeable and fit into 150/hours/month. This
is being trailed currently on Juniper ward at the Horton Hospital and will be
reviewed for efficiency and staff experience in early May.
8.5
Current status of nursing and midwifery staffing within the Trust
8.5.1
The Trust continues to have a high percentage of nursing vacancies throughout
the Trust and as a result utilises high levels of temporary staffing.. The overall
levels of minimal staffing remain a challenge particularly on day shifts and a
proportion of beds in key areas of risk have remained closed since January
2015, although other areas within the Medicine, Rehabilitation and Cardiac
division have escalation beds open to manage the winter pressures.
8.5.2
The nursing levels are monitored constantly and mitigation addressed through
the almost constant movement of staff and use of non-ward based staff for
whole or part shifts.
8.5.3
The Nurse Sensitive Indicators are being closely monitored to understand the
impact on quality and safety.
8.5.4
A coordinated overseas recruitment program is well established with over 250
confirmed offers of employment to EU nurses, and the implementation of two
weekly induction programmes that started in late February 2015. The benefits
and impact of these staff being in post will be realised from July onwards as
they require a period of adaptation and supernumery working. This is
monitored through the Workforce Optimisation Group.
9.
Friends and Family Test
9.1
Inpatient, ED and Maternity response rates:
9.1.1 National comparison:
 The national comparator FFT results for March 2015 were not available at
the time of writing this report. The dashboard includes national
benchmarking and the comparison with the national average for February
2015.
 The percentage of inpatients that would recommend their care in
February (96%) and March (95%) remains slightly higher than the
January national average (94%). The national average was between 94%
and 95% in the last 6 months, while the Trust achieved between 95% and
TB2015.48 Quality Report
Page 38 of 42
TB2015.48
98%. The best performing Trust in the country achieved 100% of patients
recommending their care, and the lowest was 78%.
Oxford University Hospitals
 The percentage of women using the Trust’s maternity services who would
recommend their care was 96% in March. Comparison with national
scores in February shows the Trust score (96%) was higher than the
national average (95%). The national range for maternity scores in
February was between 100% and 74%.
 The percentage of patients who would recommend the Trust’s
Emergency Departments was 92% in February and 82% in March. The
national average was 88% in February, and the range was between 98%
and 53%.
9.1.2 Inpatients:
 The Trust’s inpatient response rate in March was 39.3%, and therefore
very similar to the national response rate in February of 40%.
 The response rates for all divisions increased in March, except for
Children’s and Women’s (C&W) Division. The division’s response rates
were the highest for Trust and stayed the same during February and
March (54% to 52%).
 The percentage of inpatients who recommended their care in the
Medicine, Rehabilitation and Cardiac (MRC) Division was 95% in March,
with 1.2% not recommending their care, and a response rate of 47%.
 The percentage of inpatients who recommended their care in the Surgery
and Oncology (S&O) division was 96%, with 2.2% not recommending,
and a response rate of 34%.
 The percentage of inpatients who recommended their care in the
Neurosciences, Orthopaedics, Trauma and Specialist Surgery (NOTSS)
Division was 95%, with 0.7% not recommending their care, and a
response rate of 36%.
 The percentage of inpatients who recommended their care in the
Children’s and Womens (C&W) Division was 96%, with 2.1% not
recommending, and a response rate of 52%.
9.1.3 Emergency Departments (EDs):
 The response rate was 45% in March. This is an increase from the
response rate in February, 9%, and was due to implementing text
messaging and automated phone calls.
 The percentage of patients who were likely to recommend their care was
82% in January with 8% not recommending their care. This is a decrease,
from 92%, but may be due to implementing the new system, which has
increased response rates, and lower response rates mean the data are
less reliable.
TB2015.48 Quality Report
Page 39 of 42
Oxford University Hospitals
9.1.4
TB2015.48
Maternity:
 The percentage of women who recommended their care from maternity
services was 96% in March, with 0.8% not recommending their care.
 The response rate decreased from 17% in February to 9% in March.
9.1.5 Outpatients and Day Case:
 The percentage of patients who would recommend the Trust’s
Outpatients and Day Case were 92% and 96% respectively in March.
9.1.6 FFT CQUIN status:
 The CQUIN targets for FFT this year were as follows:
• Quarter 1:15% for ED and 20% for Inpatients. This was
achieved.
• Quarter 3: Commence the early implementation of outpatient
and day case FFT for all patients. This was achieved.
• Quarter 4: 20% for ED. This was achieved. The Trust
attained 20.37% for the quarter. The majority of this was
achieved in March (45%) with the implementation of texting.
This was a significant improvement and significantly reduced
the input of front line staff.
• Quarter 4:30% for adult inpatients and specifically for March
2015; 40%. The Trust submitted a response rate of 29.1%
for Quarter 4 and 39.3% for March 2015.
9.1.7
The number of eligible patients is usually calculated on 3rd day of the month.
This year 3 April was a bank holiday and therefore the number of eligible
patients during March was calculated on 2 April. The response rates achieved
using the number of eligible patients taken on 2 April, was 30% for Q4; and 43%
for March.
9.1.8
This calculation showed that the Trust had met the 30% target and the 40%
target, However, the accuracy of the number of eligible patients was questioned
because of a higher than expected number of patients shown as being
discharged from Critical Care during March.
9.1.9
Given the concern about the potential inaccuracy of the number of patients
discharged from Critical Care, the number of eligible patients was calculated
again on the 13 April. This showed the number of eligible patients had risen by
380. Therefore this meant that the CQUIN inpatient targets of 30% and 40%
were not achieved.
9.1.10 The response rates achieved using the number of eligible patients taken on 13
April is 29.1% for Q4; and 39.3% for March. The Trust required an additional 29
responses to meet the 40% target, and 98 responses for the 30% target.
TB2015.48 Quality Report
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TB2015.48
9.1.11 The increase in the response rates represented a significant and systematic
effort by the patient experience team and ward staff. NHS England requested
feedback in relation to the increase in response rates.
Oxford University Hospitals
9.1.12 The increased response rates in ED were attributable to:
•
Implementing text messaging and interactive voice messaging with an
external provider.
•
Increased communication by volunteers and reception staff, to raise
patient awareness about the text messaging and interactive voice
messaging, encourage patients to respond, opt-out patients who do not
wish to receive a text message, and offering paper questionnaires to
those patients.
9.1.13 The increased inpatient response rates were attributable to implementing a new
process from the last two weeks of February and the month of March. The
patient experience team visited all adult inpatient wards on a weekly basis to
collect comment cards, distribute weekly reports, to monitor response rates
more frequently with the ward team, and provide encouragement and support to
increase or maintain response rates. The team also took the opportunity to
discuss the feedback with ward staff, highlighting salient comments (both good
and critical), and discussing the next steps.
9.2
Complaints
9.2.1
The number of new complaints has increased from 82 in February to 89 in
March. This also shows an increase in the number of formal complaints
received in March 2014 (75).
9.2.2
NOTSS have experienced a continued increase in the number of formal
complaints received in March (38) compared with the number received in
February 2015 (29). C&W have also seen a marked increase in March 2015
(14) compared to February 2015 (6). MRC have also seen a similar increase
with 20 received in March 2015 compared to 14 in February 2015. However,
S&O, CSS and Corporate have all reported decreases in the number of
formal complaints received in March 2015 compared to February 2015.
9.2.3
Care/Nursing Care continues to be reported as a significant theme for the
clinical Divisions. During January to March, the proportion of complaints
relating to care/nursing care are as follows:
•
68% of all complaints received by C&W division
•
46% of complaints received by MRC division
•
35% of complaints received by NOTSS division
•
39% of complaints received by S&O division
•
32% of complaints received by CSS division.
9.2.4 NOTSS continue to report an increasing percentage (49%) of their complaints
relating to Access. This is predominantly in relation to patients contacting
outpatient services or making appointments between January 2015 and
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TB2015.48
March 2015. Access is also a theme reported by CSS (41%), S&O (34%)
and MRC (29%) Quarter 4 2015.
Oxford University Hospitals
9.2.5 The complaints received by corporate services included car parking and hotel
services.
9.2.6 There were no red graded complaints received in March 2015.
9.2.7
The annual complaints submission (KO41a) for NHS England and the
Department of Health is currently being collated and will be submitted on 7
May 2015. This information will be reported to Trust Board on 8 July 2015.
9.3
Managing complaints
9.3.1
The Trust continues to meet the target of 95% for acknowledgement of
complaints, with 100% (n= 89) acknowledged within the required timescale.
9.3.2
9.3.3
Five complainants requested their complaints to be reopened within S&O in
March 2015, compared with six reopened complaints for the Division in
February 2015. At the time of writing this report, four of the reopened
complaints were closed following further investigations. The remaining one
remains under further investigation. NOTSS reported that four complainants
requested their complaint be reopened in March 2015. At the time of writing
this report, three of the reopened complaints have been reinvestigated and
responded to in writing. The remaining one complaint is to be reviewed in a
resolution meeting with the complainant. Three complainants asked MRC to
reopen their complaint in March 2015. At the time of writing this report one of
the three complaints has been further investigated and responded to in
writing, the remaining two remain under further investigation.
No
complainant asked for their complaint to be reopened within Corporate, C&W
or CSS.
Two programs of complaints investigation training was held in January and
February this year. This training was delivered by lawyers from an external
provider. The Health Education Thames Valley (HETV) Compassionate Care
award funded this training. This will be repeated in Quarter 2 2015. In addition,
members of the Complaints and PALS teams participated in the successful pilot
of the of the Trust’s Delivering Compassionate Care course. Training has also
been commissioned for the Complaints, PALS, matrons and clinical directors in
mediation, facilitation and conflict resolution. This will better prepare them to
facilitate challenging complaint resolution meetings with complainants and staff.
This training will be held in July 2015 although
Tony Berendt
Medical Director
Catherine Stoddart
Chief Nurse
April 2015
TB2015.48 Quality Report
Page 42 of 42
Children’s and Women’s Division, (C&W), Trust Board Quality Report May 2015
Safe Staffing Dashboard Inpatient Areas Only
Appendix 1A
C&W
Total Funded WTE
January 15
769.5
February 15
769.5
March 15
769.5
Trust
January 15
2948.4
February 15
2948.41
March 15
2946.55
Vacancy %
8.6%
8.43%
8.6%
13.8%
13.06%
12%
Sickness %
6.39%
4.09%
3.8%
5.44%
4.5%
4.2%
Maternity/Adoption Leave %
2.88%
4.10%
4.4%
3.1%
3.6%
3.4%
Agreed Staffing Levels %
77.8%
73%
77.6%
67%
65%
62.7%
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
11
18
12
53
78
62
1
3
6
98
92
94
0
0
0
3
7
1
2
4
2
5
5
4
March 2015 Safe Staffing by INPATIENT wards 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 January and February due to the reduced 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% for March. 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 development, and expected to commence soon. 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. The high levels of minimum shifts at night in children’s services could be due to a lack of available bank staff due to the Easter holidays.
.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 20th 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.
Clinical Support Services Division, (CSS),Safe
Appendix 1B
CSS
Staffing Dashboard Inpatient Areas only Trust Board Quality Report May 2015
Total Funded WTE
January 15
170.57
February 15
170.57
March 15
168.71
Trust
January 15
2948.4
Vacancy %
13.8%
16.41%
11.3%
13.8%
13.06%
12%
Sickness %
6.29%
3.88%
3.4%
5.44%
4.5%
4.2%
Maternity/Adoption Leave %
4.92%
5.71%
5.5%
3.1%
3.6%
3.4%
Agreed Staffing Levels %
81.2%
79%
87.6%
67%
65%
62.7%
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
1
3
3
53
78
62
3
0
2
98
92
94
0
0
0
3
7
1
0
2
1
234
197
215
Falls with moderate, major or
catastrophic harm
0
0
0
5
1
3
February 15
2948.41
March 15
2946.55
March 2015 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 , intakes of band 5 nurses have started in February and March 2015, although are still undergoing the induction process. 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 leave, all of which are being managed proactively in conjunction with HR. In spite of the staffing issues, the quality indicators are stable, and agreed levels of staff
on shifts Is consistently higher than the Trust average.
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 20th 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.
Medicine, Rehabilitation & Cardiac Division, (MRC),Safe Staffing Dashboard Inpatient Areas Only
Trust Board Quality Report May 2015
Appendix 1C
MRC
January 15
899.54
February 15
899.54
March 15
Total Funded WTE
899.54
Trust
January 15
2948.4
Vacancy %
15.3%
15.05%
12.4%
13.8%
13.06%
12%
Sickness %
4.96%
4.89%
4.8%
5.44%
4.5%
4.2%
Maternity/Adoption Leave %
2.77%
3.07%
2.7%
3.1%
3.6%
3.4%
Agreed Staffing Levels %
67.7%
63%
58.7%
67%
65%
62.7%
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
22
29
16
53
78
62
38
51
44
98
92
94
1
0
3
7
1
Total Numbers of Falls
129
6 (Unconfirmed at time of
reporting)
114
135
234
197
215
Falls with moderate, major or
catastrophic harm
3
1
1
5
1
3
February 15
2948.41
March 15
2946.55
March 2015 Safe Staffing by Inpatient ward for MRC division.
EARLY SHIFT
LATE SHIFT
NIGHT SHIFT
Agreed
Establishment
Escalation
Minimum
Surplus
Narrative
The number of nursing vacancies means that safe staffing is maintained using a combination of NHSP bank and agency. However the divisional turnover rate (averages at mid-20% ) continues to be a challenge especially band 5 staff nurses. The decrease in the percentage of
shifts at agreed levels is attributed to this during January-March. The division continues to run on high levels of minimum staffing. 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 which including the SSKIN care bundle, and a focused approach by the Tissue Viability Team working with clinical staff on a joint action plan
in the division with regard to decreasing the levels of hospital acquired pressure ulcers. This is partially due to an increased level of reporting, but also a significant increase in dependency and acuity during January and February across Acute General Medicine. The ‘Fallsafe care
bundle’ is in the process of being rolled out and being implemented across the division. The escalated shifts have been addressed through moving staff from shift to shift between wards and divisions in order to achieve safe cover.
h
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 20t 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 May 2015
Appendix 1D
NOTSS
620.27
Trust
January 15
2948.4
February 15
2948.41
March 15
2946.55
16.66%
14.9%
13.8%
13.06%
12%
5.52%
4.94%
4.5%
5.44%
4.5%
4.2%
Maternity/Adoption Leave %
3.06%
2.95%
2.5%
3.1%
3.6%
3.4%
Agreed Staffing Levels %
66.2%
67%
60.3%
67%
65%
62.7%
Total number of Medication Nursing
Administration Errors or Concerns.
Total numbers of Hospital Acquired Pressure
Ulcers
8
18
8
53
78
62
31
15
21
98
92
94
Total number of avoidable grade 3-4 hospital
acquired Pressure Ulcers
Total Numbers of Falls
1
0
0
3
7
1
63
38
35
234
197
215
Falls with moderate, major or catastrophic
harm
1
0
1
5
1
3
February 15
620.27
March 15
Total Funded WTE
January 15
620.27
Vacancy %
16.7%
Sickness %
March 2015 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 at 60% in March. 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. The division has completed its 6 month implementation of the Fall Safe Bundle across all inpatient areas. Fall numbers will continue to be high within NOTSS due to the high risk patient groups found in the majority of its specialties, and
indicators are demonstrating that falls are being reported more accurately. The increase in the number of medication incidents is one if NOTSS’s quality priorities for 2015/16 there is increased reporting as a result of electronic medication prescribing and
administration. The escalated shifts have been addressed through moving staff from shift to shift between wards and divisions in order to achieve safe cover. There appears to have been surplus staff on the Trauma wards at night in particular. This is because the
night establishment is due to increase following the acuity and dependency review. Some beds on neurosciences were closed due to reduced staffing levels throughout January and February, including on the neurosciences and Trauma wards also in February. This
allows for higher numbers of shifts at agreed staffing levels. High levels of minimum staffing in SSIP reflect their particularly high vacancy rate within the division, posts have been recruited to, but start dates are awaited.
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 20th 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 May 2015
Appendix 1E
Staffing Dashboard Inpatient Areas Only
S&O
Total Funded WTE
January 15
488.53
February 15
488.53
March 15
488.53
Trust
January 15
2948.4
February 15
2948.41
March 15
2946.55
Vacancy %
16.2%
15.08%
13.7%
13.8%
13.06%
12%
Sickness %
4.29%
4.12%
3.6%
5.44%
4.5%
4.2%
Maternity/Adoption Leave %
3.5%
3.79%
3.5%
3.1%
3.6%
3.4%
Agreed Staffing Levels %
55.3%
57%
53%
67%
65%
62.7%
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
11
10
23
53
78
62
25
23
21
98
92
94
1
1
0
3
7
1
41
41
41
234
197
215
Falls with moderate, major or
catastrophic harm
1
0
1
5
1
3
March 2015 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 the majority of daytime shifts, with 53% Agreed staffing levels in March. 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, reducing clinical risk and ensuring safe staffing levels. 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 which may be due to reduced temporary staff availability during the Easter holidays, although fill rates are better at night. The highly specialist nature of oncology and haematology areas makes it very difficult to ensure a specialist
skill mix when utilising bank and agency staff.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 20th 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
Appendix 1F
Areas Only Safe Staffing Dashboard Trust Board Quality Report May
March 2015 Safe Staffing by Inpatient ward: Trust
Total Funded WTE
Trust
January 15
2948.4
February 15
2948.41
March 15
2946.55
Vacancy %
13.8%
13.06%
12%
Sickness %
5.44%
4.5%
4.2%
Maternity/Adoption Leave %
3.1%
3.6%
3.4%
67%
65%
62.7%
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
53
78
62
98
92
94
3
7
1
234
197
215
Falls with harm
5
1
3
Agreed Staffing Levels %
2015
Early Shift
Late Shift
March 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 20th 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.
APPENDIX 2
Acuity and dependency review of nursing establishments January 2015 - including nurse sensitive
indicators Medicine, Rehabilitation & Cardiac Division
Ward
Professional Judgement considerations
The acuity and dependency
outcomes
OCE
This ward has a patient group with a high enablement requirement, acuity in the Radical change in skill mix
management of tracheostomies and PEG feeds, and a complexity of care including undertaken.
psychological support and discharge arrangements, and high contact with families.
Increased numbers of beds have been opened in past 3-4 months which has capacity for
34/5 patients. The skill mix has been radically reviewed owing to the persistent numbers of
vacancies and increasing acuity and dependency of the patients. The establishment now
constitutes 72%:28% ratio of registered nurses to Care Support Workers, but including
those with learning disability and mental health qualifications as well as general nurses, in
order to address the cognitive behaviour component of care. .There is on-going work to
develop a rotational junior therapist role that forms part of the skill mix.
There has been support from the OCE staff in the evolvement of this staff skill mix, and it is
gradually addressing the issues related to vacancies. The sister leadership has also been
altered and strengthened, with an experienced charge nurse supporting the expansion of
beds and changes in culture and workforce on a temporary basis. The Multi-disciplinary
team is largely nurse led.
January 15 Quality Metrics.
Vacancy Rates: 19.5% Maternity Rates: 3.73% Sickness Rates: 3.58%
All Falls: 11 Falls with moderate or major harm: 1
All Hospital acquired pressure ulcers: 1 which was at grade 3/4 and found to have been
avoidable.
Gerontology
This is a unit with 39 beds, all as side rooms.
The skill mix is 58%:42%, and includes much 1:1 care, a complexity of care including end of
life, re-enablement, and high levels of medications, with some patients who are on the
stroke pathway. Feeding, hydration and the management of new onset delirium, forms a
large part of the care requirement, increasing the dependency demand. There is a high level
The skill mix is being reviewed
currently.
of contact with families.
The skill mix requirement of this specialty is currently being reviewed, specifically with
regard to a higher level of therapy, palliation and mental health components. Consideration
is being given to rotational posts.
Senior staff, including Practice Development Nurses are working with the Care Support
Worker (CSW) Academy to develop therapy competencies in the CSW workforce.
January 15 Quality Metrics
Vacancy Rates: 15.3% Maternity Rates: 0% Sickness Rates: 7.18%
All Falls: 15 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 0
Stroke ward
This unit has 19 beds and a fast turnover of highly dependent patients requiring level 2 The stroke pathway is undergoing
nursing at times.
a review and a business case will
be developed by the MRC division.
The skill mix is 67%:33%, and is currently under review along with the stroke pathway which
includes beds at the Horton and on OCE. This will include rapid triage through the
emergency department to the hyper acute unit, and will encompass a review of the rapid
rehabilitation at home, the dietetic and SALT components.
The sister leadership is changing and senior management is provided by the matron who is
supporting the nursing team.
The educational stroke development through the Bucks New University programme is being
accessed as well as the development of an in-house accredited stroke care programme for
the staff. This will include the capacity to develop stroke specialist nurses.
January 15 Quality Metrics
Vacancy Rates: 30.5% Maternity Rates: 0% Sickness Rates:1.8%
All Falls: 8 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 0
7A
This ward has 23 beds and has a 65%:35% split of Registered Nurses (RNs) to CSWs.
The skill mixes on these wards
were reviewed and increased last
There are a high proportion of patients requiring psychological care requiring 1:1 care year. Staff feedback has been
including those held under the Mental Health Act, many requiring Registered Mental Health positive, but there is a constant
Nurses (RMN), with increasing numbers of these patients during the winter months.
challenge to manage the turnover
of junior staff. The Nurse Sensitive
7A January 15 Quality Metrics Vacancy Rates 1.2% Maternity Rates: 0% Sickness Rates:
Indicators are monitored closely.
1.27%
All Falls: 7 Falls with moderate or major harm 1
All Hospital acquired pressure ulcers: 4 which were either grade 1/2 and found to have been
avoidable.
This ward has 21 beds with a skill mix of 69%:31%, due to the patient group having a higher
level of acuity including the need for vital sign monitoring.
7B
7B January 15 Quality Metrics
Vacancy Rates: 4.4% Maternity Rates: 0% Sickness Rates: 0.63%
All Falls: 7 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 6, which were at grade 1/2 and found to have been
avoidable.
This ward has 22 beds and has a 69%:31% skill mix and a high acuity of patients similar to
7B.
7C
7C January 15 Quality Metrics
Vacancy Rates: 1% Maternity Rates: 5.75% Sickness Rates: 6.54%
All Falls: 3 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 2 which were at grade 1/2 and found to have been
avoidable.
This ward is 20 beds and has a high level of elderly care and acuity and skill mix of
65%:35%.
7D
7D January 15 Quality Metrics
Vacancy Rates:-0.6% Maternity Rates: 0% Sickness Rates:2.98%
All Falls: 6 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 4, which were at grade 1/2 and found to have been
avoidable.
This ward has 22 beds and has a 65%:35%, and has a patient group with increasing levels
of dementia that have a higher level of dependency.
5A
5A January 15 Quality Metrics
Vacancy Rates: 8% Maternity Rates: 0% Sickness Rates: 5%
All Falls: 9. Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 4 which were at grade 1/2 and found to have been
avoidable.
This ward has 38 beds and a skill mix of 65%:35% and has opened 2 additional beds during
the winter. The acuity levels are lower but there is a high turnover of patients. The skill mix
and patient group is being monitored and reviewed currently
Short stay ward
Short Stay Ward January 15 Quality Metrics
Vacancy Rates:7.9% Maternity Rates: 3.8% Sickness Rates: 3.68%
All Falls: 4 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 4, which were at grade 1/2 and found to have been
avoidable.
All the level 7 wards, 5A and Short Stay Ward all have a level of low impact falls, low grade
pressure ulcers and medication incidents there have been low level of vacancies but these
are beginning to increase, and the challenge is the constant turnover of band 5 staff. There
are band 6 staff who provide night staff supervision and Practice Development Nurses to
support new staff nurses, provide training to CSWs and orientation to EU recruited nurses.
PAU (7F)
This ward receives patients awaiting discharge, many with cognitive disabilities/dementia The skill mix is being reviewed
and complicated discharge planning needs, including high contact with families. The skill within the division.
mix is 50%:50% but this needs to be reviewed in respect of the complex needs of this
patient group.
January 15 Quality Metrics
Vacancy Rates: -1.8% Maternity Rates:6.7% Sickness Rates: 2.16%
All Falls: 12 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 0
Laburnham
The skill mix is 65%:35% on this 28 bedded ward. The patient group on this ward has a level No change required to the
of acuity that includes patients with respiratory and cardiac conditions as well as general establishment
medical patients.
There are a number of low impact falls without harm and low grade pressure ulcers. There is
a Nurse Educator appointed and in post at the Horton site, who provides the education and
orientation for new staff.
January 15 Quality Metrics
Vacancy Rates: 8.1% Maternity Rates:1.88% Sickness Rates: 8.16%
All Falls:8 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 1, which was at grade 3/4 and has been unconfirmed
at the time of reporting as to whether it is avoidable or unavoidable.
Juniper
The skill mix is 65:35% on this 30 bedded ward. The patient group includes those with No change required to
gastroenterology, liver and Cohn’s diseases. There are a number of patients who have establishment
delayed discharges due to being from out of area.
January 15 Quality Metrics
Vacancy Rates: 26% Maternity rates: 3.41% Sickness Rates: 8.53%
All Falls:5 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 3, which were at grade 1/2 and found to have been
avoidable.
Oak
The skill mix is 65%:35% on this 36 bedded ward that includes 12 patients on the stroke No change required to
pathway as well as general medical patients.
establishment, although the stroke
patient pathway is being reviewed
This ward’s stroke pathway is being reviewed, along with the Stroke ward at the JR and the
OCE.
There are a number of low impact falls without harm due to the patient group.
Staff with long standing sickness are being addressed
January 15 Quality Metrics
Vacancy Rates: 13% Maternity rates: 2.45% Sickness Rates:5.24%
All Falls 13 Falls with moderate or major harm: 1
All Hospital acquired pressure ulcers: 0
Geoffrey Harris
This is a 24 bedded ward that specialises in acute respiratory patients and has a skill mix of
67%:33%, including 2 high care beds.
No change required to
establishment currently
The ward is to move to the JR site (7E) and the acuity will be further monitored and
reviewed on that site.
There are a level of clinical incidents due to the acuity of this patient group, including
weaning off ventilation, and acute deterioration of patients.
January 15 Quality Metrics
Vacancy Rates: 30.2% Maternity rates: 4.36% Sickness Rates: 12.89%
All Falls: 4 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 1,
avoidable.
John Warin
which were at grade 1/2 and found to have been
This ward is funded for 20 beds but open to 23 bed for escalation during winter months. No change required to
Currently using 20 beds. The patient group includes infectious diseases, TB and patients establishment
who are homeless and have associated conditions to living rough. This is the designated
ward should patients be admitted with suspected Ebola.
The skill mix is 68%:32.1%, with some vacancies although additional temporary staff have
been accessed to support the additional escalation beds during the winter months
January 15 Quality Metrics
Vacancy Rates: 24.6% Maternity rates: 2.53% Sickness Rates:6.21%
All Falls: 4 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 1, which were at grade 1/2 and found to have been
avoidable.
Cardiology ward This ward is large with 41 beds including a high dependency unit, and rapid assessment No change required to
unit, and 25 side rooms. The skill mix ratio is 72%:28% in order to accommodate to the establishment
acuity levels of this patient group.
The indicators include low grade pressure ulcers and falls, which are being addressed
although the reporting culture is good.
Vacancies are managed within the Cardiac Centre as a whole, and staff moved between
units on a daily basis
January 15 Quality Metrics
Vacancy Rates: 11.1% Maternity Rates: 0% Sickness Rates: 6.38%
All Falls: 2 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 4, which were at grade 1/2 and found to have been
avoidable.
Cardiothoracic
ward
This ward is made up entirely of 25 single rooms and has a high level of acuity for patients No change required to
who are received from the Cardio Thoracic Critical Care Unit in the immediate phase of step establishment
down. The skill mix is 70%:30%. Thoracic trauma patients are often out lied as the ward is
often full.
There are high levels of vacancies, although the Cardiac Centre moves staff around daily to
address the acuity and to mitigate short notice staff deficits.
January 15 Quality Metrics
Vacancy Rates: 35.3% Maternity Rates: 6.44% Sickness Rates: 2.27%
All Falls: 5 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 1, which were at grade 1/2 and found to have been
avoidable.
EAU JR & HH
The EAUs will be assessed using a
modified multiplier that accounts for
The skill mix at the JR site will be reviewed again following the recent opening of the new
the acuity but also the high
ambulatory section of EAU in late January 2015.
turnover of patients.
Additional support is being put into place to support junior nursing staff and to improve
clinical education through Practice Educator posts
The use of the electronic acuity tool
EAU JR January 15 Quality Metrics
which is shortly to be implemented
Vacancy Rates: 17.3% Maternity Rates: 3.42% Sickness Rates: 5.89%
will facilitate the trends and levels
of acuity on a continuous basis.
All Falls: 2 Falls with moderate or major harm: 0
The skill mixes are 76%:24% at the JR and 74.8%:25.2% HH.
All Hospital acquired pressure ulcers: 2, which were at grade 1/2 and found to have been
avoidable.
EAU HH January 15.Quality Metrics
Vacancy Rates: 5.6% Maternity Rates: 4% Sickness Rates: 11.16%
All Falls: 2 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 1, which was at grade 1/2 and found to have been
avoidable.
Surgery & Oncology Division
Ward
Professional Judgement considerations
Variations to the establishment
Sobell House
This is a partially funded by a charity and provides hospice facilities for palliative care. The No further change required to the
skill mix is 60%:40% and this reflects the patient group who require a level of acute care establishment
related to their symptom control and medication but remain high in their dependency of care.
The strengthening of leadership has been effective with a highly visible deputy matron. The
skill mix review in 2014 has proved effective and appropriate, optimising staff to an
appropriate skill mix.
January 15 Quality Metrics
Vacancy Rates: 26.8% Maternity Rates: 0% Sickness Rates:6.53%
All Falls: 5 Falls with moderate or major harm : 0
All Hospital acquired pressure ulcers: 7, 1 of which was at grade 3/4 and the other 6 at
grade 1/2 and found to have been avoidable.
Haematology
The specialist nature of this ward requires a high level of registered nurse to unqualified skill
mix related to cancer care and the administration of chemotherapy as well as the care of
other patients with other haematology conditions. This skill mix is 82%:18%. The level of
acuity is high in these patients especially on deterioration, and in the cases of Neutropenia
sepsis. As a result of vacancies (some which have been filled by staff who have not yet
undertaken the 6 month chemotherapy course) there has been a need to close 5 beds
temporarily during January & February 2015.The ratio for the number of Bone Marrow
Transplants has been capped, and five beds closed until long line agency nurses with
chemotherapy skills have been identified and commenced working on the ward to stabilise
the workforce.
Agency staff in general do not have the specialist competencies in the technical
requirements for this patient group as they require the National Chemotherapy course and
so the wards own staff undertake NHSP work coupled with long line specialist agency
workers in order to provide an optimal level of temporary staffing. This patient group require
skilled staff in the management of syringe drivers and complex medication requirements. 8%
of patients are audited to be at level 2 (high dependency) and the majority are high acuity.
The acuity tool identifies some
minor adjustments to the
establishment but this is being
monitored over time especially in
relation to out of hours.
Benchmarking with the Shelford Group demonstrates that OUH compared to other Trusts
has a higher level of band 5 and lower level of skilled band 6 staff in specialist posts. These
posts support, train and supervise the more junior workforce.as well as providing a career
structure..
The acuity of patients varies and the level of registered nurse cover is being monitored for
trends to ensure adequate support for patients especially out of hours.
The quality indicators however are well managed.
January 15 Quality Metrics
Vacancy Rates:9.7% Maternity rates:2.76% Sickness Rates:7.26%
All Falls: 5 Falls with moderate or major harm: 1
All Hospital acquired pressure ulcers: 0
Oncology
This ward cares for patients with cancer of many different tumour sites. There is a wide
range of care requirements that includes in-patients with high acuity needs and others who
are very high dependency (patients with spinal cord compression), The advancement of
specialised treatments such as brachytherapy has resulted in an increasing acuity of
patients over the last 2 years. The skill mix is 74%:26%.
This is the second priority ward
in terms of revision of
establishment The acuity tool
registers a higher requirement of
nursing staff.
However, through making a
Professional Judgement against
activity and layout of the ward, the
staffing could be optimised through
increased levels of non-nursing
The ward receives direct admissions from the Triage Unit which has consistently expanded
duties cover from:
the service due to its increased activity over the past 3 years, enabling patients to be
assessed and treated, many avoiding admission. However the haematology and oncology A housekeeper = 1.6WTE for
weekend cover
wards cover this service overnight and at weekends.
The ward requires additional staffing to release nurses to provide specialist care (prostate
brachytherapy and chemotherapy), palliative care, communication with families, and
specifically the administration of medications. Many patients are cared for through to end of
life on this ward, and there can be a higher dependency related to palliative care.
Increased ward clerk hours =
January 15 Quality Metrics
1.4 WTE for out of hours cover
Vacancy Rates: 23.7% Maternity Rates:0% Sickness Rates: 0.96%
A case of need has been
All Falls: 6 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 8, which were at grade 1/2 and found to have been
avoidable.The metrics include an increase in the number of category 2 hospital acquired
pressure ulcers and these are being managed and monitored closely
5F & 5E
This ward covers Gastroenterology and the Day Case unit with patients scheduled for
interventional radiology treatments. Many patients are complex cases requiring
psychological care, and patients sectioned under the Mental Health Act, as well as those
with eating disorders, cyclic vomiting and long term feeding therapy. There are a high
number of ward attenders.
There are multiple teams of medical staff (11) who attend this ward, and it has a skill mix of
75%:25%.
The ward establishment is funded to cover the ward, but also extends to the Day Case Unit.
developed and is being presented
to TME in May.
This is the 1st priority ward in
terms of skill mix review.
The acuity tool registers 4.48 WTE
RNs, which would provide one RN
per shift
– A case of need has been
developed and is being presented
to TME in May
Peer review highlighted some quality issues and additional staff were moved to the ward to
support the service improvements, which have been effective but not sustainable in the long
term.
The leadership has been strengthened through high visibility of the matron to support staff;
however there isn’t a co-ordinator between 5F and E.
The skill mix and levels of staff do require additional support in relation to ensuring that the
establishment of staff is sustainable and to cover 5E as well as the ward.
5F January 15 Quality Metrics
Vacancy Rates:3.3% Maternity rates: 6.2% Sickness Rates:1.99%
All Falls: 7 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 3, which were at grade 1/2 and found to have been
avoidable.
Surgical
This unit is very complex and has multiple levels of in-patient facilities, and a triage area for The acuity tool is registering that
Emergency
surgical emergency cases. It includes wards 5 C/D, 6D.
Unit (SEU)
5CD has side rooms and requires a high level of patient escorts to diagnostic investigations
5CD
6D
6E
6F
combined the SEU requires overall
9.6 WTE.
However, with Professional
Judgement and understanding the
5CD January 15 Quality Metrics
complexity of the geography of the
wards; the most effective
Vacancy Rates:24% Maternity Rates:6.49% Sickness Rates:3.37%
optimisation of the nurse ratios can
All Falls: 0
be achieved through inputting nonAll Hospital acquired pressure ulcers: 1, which was at grade 1/2 and found to have been clinical support
avoidable.
This will be presented through a
6D includes a Triage area and 10 beds, with a high turnover of patients and an average of business case being developed by
25 ward attenders a day, and on average 8.93 nurse escorts a day. The skill mix ratio is the Divisional Nurse and will
include:
80%:20%
The skill mix ratio is 66%:34%
There is a supernumery Emergency Nurse Practitioner (ENP) who provides emergency Phlebotomists
assessment expertise to the team.
Sisters Assistants
The consultants have changed their ways of working and include both surgeons and a Extended ward clerk hours to out of
physician based on SEU providing cover for triage and ED. This is in order to provide a hours cover.
more senior level of decision making. On average 74% of patients referred by their GP do
not require surgery
6D January 15 Quality Metrics
Vacancy Rates: 8.5% Maternity Rates:2.32% Sickness Rates: 2.29%
All Falls: 0
All Hospital acquired pressure ulcers: 0
6E has a skill mix ratio of 72%:28% and requires 6.29 nurse escorts per day on average.
6E January Quality Metrics
Vacancy Rates:24.4% Maternity Rates:0% Sickness Rates:2.34%
All Falls: 2 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 3, which were at grade 1/2 and found to have been
avoidable.
6F is a female ward which has on average 1-5 level 2 patients per day (high dependency)
and 4.9 nurse escorts. This patient group has a high level of acuity, clinical deterioration,
and cardiac arrests. It has a skill mix ratio of 72%:28%
The non- nursing ward support is minimal and only covers 8-4pm.
6F January 15 Quality Metrics
Vacancy Rates:8.1% Maternity Rates: 10.15% Sickness Rates:2.69%
All Falls: 3 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 0
Jane
Ashley/LGI
This ward has a complex patient group which includes all aspects of Lower GI Surgery
There is no change to this ward
establishment but it will be
The skill mix is 68%:32% which is appropriate for this clinical area and it has an effective
reviewed at the next acuity
experienced ward sister providing leadership.
assessment
The acuity includes a number of patients on parenteral feeding i.e. 14 at any one time,
therefore requiring a high skill mix of RNs. However it should be noted that during the time
period for this audit of acuity and dependency there were beds closed due to the high levels
of nurses vacancies and therefore this was not a typical period of assessment
January 15 Quality Metrics
Vacancy Rates: 29.6% Maternity Rates: 2.72% Sickness Rates:4.01%
All Falls: 0
All Hospital acquired pressure ulcers: 0
The indicators demonstrate low levels of incidents and the quality indicators are well
managed.
UGI
This ward undertakes highly complex surgery with high acuity levels post operatively, There is no change to this ward
establishment but it will be
including bariatric patients referred from Reading.
reviewed at the next acuity
The skill mix is 77%:23% and this relates to the specialist levels of care required by this
assessment indicators.
patient group, many of whom ‘step down’ from the Intensive Therapy Unit.
The levels of quality indicators are low except for low impact falls, and there is strong
leadership provided from a very experienced sister.
However it should be noted that during the time period for this audit of acuity and
dependency there were beds closed due to the high levels of nurses vacancies and
therefore this was not a typical period of assessment
January 15 Quality Metrics
Vacancy Rates:15.7% Maternity Rates:2.92% Sickness Rates:8.66%
All Falls: 3 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 1, which were at grade 1/2 and found to have been
avoidable.
Urology
This 20 bedded urology ward undertakes major complex surgery including specialist This ward is the third priority in
referrals from other areas in the region; this includes a significant increase in cystectomies terms of the revision to the
establishment
and radical prostatectomies.
There is a high turnover of patients and consistently high acuity and dependency levels of The acuity tool is registering an
care. Two new consultants have commenced in post and the referral rate has increased increase to the RN WTE.
significantly.
The indicators with the
Professional Judgement of the
There are on average 3.5 nurse escorts per day and 10 ward attendees per day.
senior nursing team, recommends
.There are usually 4 – 8 urology outliers on the CH site on any given day, and therefore the
that there is an investment of:
ward has retained the more acutely unwell patients with higher dependency and highly
specialised treatment requirement. Whilst outlying their less acute and less dependent 3.5 WTE RNs
patients to wards unfamiliar with urology care. This has resulted in a higher dependency
2.8WTE Care Support Workers,
and acuity on the ward and the current staffing establishment no longer meets requirements.
A case of need has been
January 15 Quality Metrics
developed and is being presented
Vacancy Rates:-10.2% Maternity Rates:7.31% Sickness Rates:4.2%
to TME in May
All Falls: 4 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 1, which was at grade 1/2 and found to have been
avoidable.
Renal
The renal ward provides care for a range of conditions, including those requiring dialysis and This ward is reviewing its trained
end of life care.
staff skill mix over time and
monitoring the trends, However
The skill mix is 72%:28% and this reflects the technical nature of the care for this patient
due to the vacancies and need to
group, although these do not include specialist staff.
close beds, this has not been a
There are some low grade pressure ulcers and low impact falls without harm.
typical period of assessment.
However it should be noted that during the time period for this audit of acuity and
dependency, there were beds intermittently closed due to the high levels of nurses
vacancies and therefore this was not a typical period of assessment
January 15 Quality Metrics
Vacancy Rates:13.6% Maternity Rates: 0% Sickness Rates:7.56%
All Falls: 1 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 0
Wytham
This is a ward with variable levels of acuity due to the nature of variation in activity related to No change required to
transplant surgery, which cannot be predicted. However during this time period due to lack establishment
of ITU beds, cases had to be cancelled and this was not typical of normal activity
There is an enhanced monitoring unit that provides level 2 step down of patients from ITU.
The patient group includes bowel, kidney and pancreas transplants and so the ratio is
81%:19%. The indicators demonstrate some low impact falls without harm.
January 15 Quality Metrics
Vacancy Rates:27.7% Maternity Rates:3.73% Sickness Rates:5.36%
All Falls: 2 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 0
E Ward
Horton Hospital
This 23 bedded ward which also includes a day case area managed by another division.
No change required to
establishment due to the review of
Although a surgical ward, it is currently providing care for medical patients with an average
this ward’s specialty and
length of stay of 7 days +, throughout the year.
winter/summer changes in case
However the ward specialties are currently under review.
mix.
The indicators are general good and it is not an outlier in this respect, and there is very
strong sister leadership, and the senior nursing team have adapted well to managing
The acuity assessment did
patients admitted through the medical emergency care pathway.
however highlight and increase in
January 15 Quality Metrics
RNs & CSWs due to the level of
dependency of the medical
Vacancy Rates: 27.9% Maternity Rates: 4.83% Sickness Rates: 2.4%
patients. It is not appropriate to
All Falls: 3 Falls with moderate or major harm: 0
address this at this time of review.
All Hospital acquired pressure ulcers: 1, which was at grade 1/2 and found to have been
avoidable.
Neurosciences, Orthopaedics, Trauma & Specialist Surgery Division
Ward
Professional Judgement considerations
Variations to the establishment
Neurosciences
The acuity data suggests that
although the ward is operating
within its current structure. There
are issues related to visible
leadership and managing staff
The ward is undergoing some re-organisation and being split by specialty i.e. neurology and
within a complex configuration of a
neurosurgery to facilitate more effective ward management. The split into 4 separate wards
74 bedded area of mixed specialty.
st
will be effective from 1 April 2015, and this will strengthen local leadership, with sisters for
The ward has been reconfigured
each section, although all working co-operatively to cover staffing.
into four separate sections to
The quality indicators demonstrate a number of low impact falls without harm in a patient
improve the leadership, and a
group where this is not an uncommon symptom, and for which strategies are put in place to
review of the skill mix will be
reduce the level of harm. There are also a number of low grade pressure ulcers.
required in June/July 2015.
Neuroscience ward January 15 Quality Metrics
This large ward has a skill mix split of 69%:31% and is made up of 5 areas including one for
high care. It has 89 bed spaces, with the current use of 69 in-patient beds and 12 day
case/theatre same day admissions, and 5 beds that open for escalation. There were
variable numbers of beds closed during this period of acuity assessment
Vacancy Rates:33.1% Maternity Rates:1.98% Sickness Rates:5.61%
All Falls: 11 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 3, which are at grade 1/2 and found to have been
avoidable.
SSIP
The skill mix is 68%:32.1%.
No necessity to alter the
establishments from the acuity
This ward has a variety of plastics and specialist surgery. The senior sister has left recently
review.
and the senior leadership structure has been under review and consultation with a view to
appointing senior sisters to oversee the ward and day unit, meanwhile the matron has been
overseeing the ward’s management.
January 15 Quality Metrics
Vacancy Rates: 21.3% Maternity Rates: 4.52% Sickness Rates:4.1%
All Falls: 6 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 6, 1 of which was at grade 3 and the other 5 at grade
1/2 and found to have been avoidable.
6A
This ward, which includes a triage area, has patients with vascular conditions; and the staff No necessity to alter the
undertake thrombolysis treatment which requires level 2 (high dependency care) and 1:1 establishments from the acuity
ratio of RN to patients during the treatment to provide continuity of care.
review.
These are a high risk group of patients for pressure ulcers, however none have been
reported for this time period and there have been few low impact falls with no harm.
January 15 Quality Metrics
Vacancy Rates:15.6% Maternity Rates: 3.2% Sickness Rates: 5.88%
All Falls: 4 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 1, which was at grade 1/2 and found to have been
avoidable.
Trauma
2A - JR
These wards have 26 beds and include a high acuity patient group, with a staff skill mix of The acuity tool indicates that the
skill mix should be altered on 2A
62%:38%.
and 3A, to increase the levels of
2A has acuity levels that are increasing as the patient group changes from moderate trauma
RNs at night and reduce the
i.e. fractures of the neck of femur, to a major trauma case mix.
CSWs, this will be undertaken
The quality indicators suggest that for this patient group there are a few low grade pressure within the establishment
ulcers and low impact falls for this time period, although there are preventative strategies in
However, this has not been a
place.
typical time period for assessment
2A January 15 Quality Metrics
of acuity on 3A due to closed beds,
although the ratios at night would
Vacancy Rates: 8.4% Maternity Rates: 2.76% Sickness Rates:2.18%
indicate a need for change
All Falls: 10 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 5, which were at grade 1/2 and found to have been
avoidable.
3A - JR
JR
3A has a similar case mix of trauma and skill mix of staff, however due to high vacancy
levels, 6 beds have been closed during this period of time.
F ward skill mix to remain the same
and will be funded and established
The night ratios are fragile for this level of acuity at 1:8.66 with 3RNs and 3 CSWs at night.
to 28 beds to stabilise the
3A January 15 Quality Metrics
workforce and reduce agency cost.
Vacancy Rates: 14.4% Maternity Rates: 2.88% Sickness Rates: 5.58%
All Falls: 4 Falls with moderate or major harm: 1
All Hospital acquired pressure ulcers: 3, of which 0 were at grade 3 or above and found to
have been avoidable.
F Ward Horton Hospital
F ward is a 28 bedded ward with 3 unfunded beds that open for escalation and a skill mix
ratio of 63%:37%. 50% of the patient mix includes other specialties other than trauma,
during the winter months, and the dependency level rises owing to the levels of medical
patients admitted.
One extra nurse per shift has been added to the skill mix during the winter months with the
winter pressure monies. This is reliant on short term bank/agency staff in order to support
this increase in capacity and acuity. The quality indicators are stable and are not outliers.
F Ward January 15 Quality Metrics
Vacancy Rates: 13.9% Maternity Rates: 3.43% Sickness Rates: 8.29%
All Falls: 12 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 4, which were at grade 1/2 and found to have been
avoidable.
Blenheim
This ward has 15 beds with 3 used for day cases, and as such the patient mix is being No necessity to alter the
reviewed over time with the acuity tool measurement. The skill mix ratio of 72%:28% is due establishments from the acuity
to difficult airway management and patients undergoing major complex head and neck review.
surgery. The quality indicators do not flag any specific issues, with a low level of low impact
falls.
January 15 Quality Metrics
Vacancy Rates: 7.8% Maternity Rates: 2.72% Sickness Rates: 5.86%
All Falls: 3 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 0
NOC wards
These wards have a skill mix of 66%: 34%, and have a stable workforce managing largely No necessity to alter the
elective surgery and treatment. However they all have the lowest uplift of the Trust at 18%
establishments from the acuity
review, although there is some
(for study, sick and annual leave) others are 20% or 21%
consideration for a twilight shift on
Ward C opens and closes dependent upon patient activity levels, and these beds will the BIU when vacancies are filled..
probably be annexed to F ward in the near future.
NOC C January 15 Quality Metrics
Vacancy Rates: 37.4% Maternity Rates: 0% Sickness Rates: 19.16%
All Falls:0
Wards D, E and F are relatively stable with some vacancies.
NOC D January 15 Quality Metrics
Vacancy Rates: 15.2% Maternity Rates: 2.5% Sickness Rates: 6.8%
All Falls: 6 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 1, which was at grade 1/2 and found to have been
avoidable.
NOC E January 15 Quality Metrics
Vacancy Rates: 14.2% Maternity Rates: 3.47% Sickness Rates:2.55%
All Falls: 2 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 0
NOC F January 15 Quality Metrics
Vacancy rates: 13.9% Maternity Rates: 3.43% Sickness Rates: 8.29%
All Falls: 4 Falls with moderate or major harm: 0
All Hospital acquired pressure ulcers: 0
The Bone Infection Unit (BIU) has 26 beds with 40% as side room beds. It is more fragile in
terms of levels of vacancies against agency/NHSP fill rates, with less resilience due to the
level of acuity of the patients, and a high level of intravenous antibiotics administered.
BIU January 15 Quality Metrics
Vacancy Rates: 20.6% Maternity Rates: 8.65% Sickness Rates: 3.74%
All Falls: 0
All Hospital acquired pressure ulcers: 1, which was at grade 1/2 and found to have been
avoidable.
Extravasation incidents are a sensitive indicator on BIU however there have not been any
incidents reported in this month.
Children’s & Women’s Division
Ward
Professional Judgement considerations
Childrens’
Services
Childrens’ in-patient wards have a national acuity tool that is currently out to national No necessity to alter the
establishments.
consultation and OUH were contributors to the data collection.
The current staffing model reflects the RCN staffing guidance.
Critical care staffing model reflects the Paediatric Intensive Care Standards
The New Born Care Unit is aspiring to meet the British Association of Perinatal Medicine
(BAPM), OUH isn’t an outlier as a benchmark nationally.
There are levels of extravasation incidents which are being monitored across the children’s’
wards, as this forms a specific quality indicator for children’s in-patient services.
Bellhouse Drayson Ward January 15 Quality Metrics
Vacancy Rates: 26.4% Maternity Rates: 0% Sickness Rates: 8.63%
Extravasation Incidents: 0
All Hospital acquired pressure ulcers: 0
Robins Ward January 15 Quality Metrics
Vacancy Rates:9% Maternity Rates: 0% Sickness Rates: 1.66%
Extravasation Incidents: 0
All Hospital acquired pressure ulcers: 0
Kamran’s Ward January 15 Quality Metrics
Vacancy Rates: 15.7% Maternity Rates:8.9% Sickness Rates: 6.89%
Variations to the establishment
Extravasation Incidents: 0
All Hospital acquired pressure ulcers: 0
Toms Ward January 15 Quality Metrics
Vacancy Rates: 3.9% Maternity Rates: 0% Sickness Rates: 6.3%
Extravasation Incidents: 0
All Hospital acquired pressure ulcers: 0
Melanie’s Ward January 15 Quality Metrics
Vacancy Rates: 5% Maternity Rates: 5.26% Sickness Rates: 3.76%
Extravasation Incidents: 0
All Hospital acquired pressure ulcers: 0
Neonatal Unit January 15 Quality Metrics
Vacancy Rates: 27.6% Maternity Rates: 6.3% Sickness Rates: 8.46%
Extravasation Incidents: 1
All Hospital acquired pressure ulcers: 0
PITU January 15 Quality Metrics
Vacancy Rates: 13% Maternity Rates: 6.61% Sickness Rates:2.18%
Extravasation Incidents: 0
All Hospital acquired pressure ulcers: 1, which was at grade 1/2 and found to have been
avoidable.
HH SCBU January 15 Quality Metrics
Vacancy Rates: 21.9% Maternity Rates: 8% Sickness Rates: 2.53%
Extravasation Incidents: 0
All Hospital acquired pressure ulcers: 0
HH Childrens Ward January 15 Quality Metrics
Vacancy Rates:7.3% Maternity Rates: 5.13% Sickness Rates: 0.41%
Extravasation Incidents: 0
All Hospital acquired pressure ulcers: 0
Midwifery
Services
OUHT Midwifery staffing establishments have been developed using the Birth Rate acuity
tool for ratios of the community midwifery service and clinical requirements for the inpatient
service, which are managed as one service.
Currently across the whole service there are:
• 8.64 wte midwifery vacancies or which
• 3.33 wte vacancies have been filled
• 5.31 wte vacancies still to be filled – and will be advertised shortly
The ratio of Midwives to birth fluctuates between 1:30.2 – 1:31
The NICE Midwifery Staffing Guidelines were published on 27 February 2015. The Senior
midwifery team will be reviewing the establishments in line with the recommendations.
JR Maternity January 15 Quality Metrics
Vacancy Rates: -0.2% Maternity Rates: 0% Sickness Rates: 6.57%
Extravasation Incidents: 0
HH Maternity January 15 Quality Metrics
Vacancy Rates: -8.7% Maternity Rates: 7.7% Sickness Rates: 6.77%
Extravasation Incidents: 0
Gynaecology JR
This ward has a skill mix of 65%:35%. This ward is made up of 20 beds with an emergency No necessity to alter the
direct access service for GP referrals, suspected ectopic pregnancies and high levels of establishments from the acuity
ward attenders. Otherwise this group of patients do not tend to have co-morbidities and are review.
generally well.
There is a ratio at night of 1 RN:10 patients, and this is justified through Professional
Judgement due to the wellness of this patient group and that major surgery is undertaken
early in the day. The matron has put in place twilight shifts to support days of high levels of
surgery, although the acuity later in the night does not warrant an additional RN all night as
the care is judged to be safe.
January 15 Quality Metrics
Vacancy Rates: 1.7% Maternity Rates: 5.21% Sickness Rates: 15.10%
All Falls: 0
All Hospital acquired pressure ulcers: 0
Clinical Support Services
Ward
Professional Judgement considerations
The areas of ITU and theatres are not measured against acuity or dependency as all
patients are either level 2 or 3 and the skill mix is determined by the Intensive Care Society
guidelines
Variations to the establishment
Appendix 3 Patient experience dashboard
FFT outpatients and day cases
OUH and National FFT % recommend
95%
Jan-15
Feb-15 Mar-15
100%
96%
96%
95%
95%
95%
90%
6%
Nov-14 Dec-14
Jan-15
FFT Inpatient % not recommend by
division
80%
98%
82%
100% 96%
92%
2.2%
2.1%
3%
1.2%
0.7%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
Feb-15 FFT % Not Recommend: National
Best and Worst
60%
40%
10%
8%
worst
OUH
best
0%
Inpatients
ED
Maternity
Only NHS Trusts with more than 100 responses have been
included.
Nurse was excellent, but all the staff were superb, including
the night staff. Thank you all so very much for your courtesy
and respect. Horton, E ward (S&O)
0% 1%
0%
3%
39%
35%
20%
9%
10%
0%
Oct-14
Nov-14
Dec-14
0% 0%
IP IP IP ED ED ED Mat Mat Mat
Only NHS Trusts with more than 100 responses have been
included.
Ward staff extremely helpful, cooperative, patient and
understanding. They created a ward peaceful, relaxing
atmosphere and were most cooperative to meeting my
particular needs. Yes, full marks and a very big thank you.
Jan-15
Feb-15
Mar-15
Feb-15 FFT Response Rates: National Best
and Worst
71%
60%
20%
20%
OUH and National FFT response rates
30%
80%
29%
74%
53%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
40%
4%
40%
0%
45%
worst
100% 96%
10%
50%
0%
Feb-15 FFT % Recommend: National Best
and Worst
20%
Feb-15 Mar-15
OUH
Kind, caring, highly professional, effective staff who made
me feel safe and incredibly well looked after at a time
when I was very vulnerable. And made me better!
Infectious Diseases Outpatients, Churchill (MRC)
0%
Oct-14
5%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
The kindness and dedication by the staff was
overwhelming. I felt my daughter was in safe hands
throughout our entire visit and subsequent follow up visits.
We received Outstanding care that should be recognised.
Thank you so very much. Child CDU, JR (C&W)
0.8%
1%
80%
120%
1.4%
2.0%
0.0%
36%
34%
30%
2%
85%
52%
47%
40%
4.0%
FFT Inpatient % recommend by division
100%
Staff understood my health needs, they were not
judgemental of me. Listened at 3am when I needed an ear.
Communication and consistency of care was helpful with
long shifts. Upper GI ward, Churchill Hospital (S&O)
Nov-14 Dec-14
best
I was treated like a person, not a number. The nurse
explained everything in-depth and put me at ease. The
hospital is very pleasant. Plastic Surgery Outpatients,
Horton (NOTSS)
Oct-14
worst
I am always happy with my treatment at the Churchill both
medically and with administration and I feel that I could
not be better treated anywhere else. Thank you. Urology
Day case, Churchill (S&O)
75%
OUH
I can’t praise enough all the staff in the department I had
to attend while having an investigation procedure
requiring sedation. Everyone was so caring, patient and
reassuring and answering questions in a clear manner. So
yes, I will definitely talk about my experience in a positive
way to anyone having to go through the same procedure.
Endoscopy Day Case, JR (S&O)
80%
best
Comments
82%
worst
Day cases
OUH
Outpatients
88%
85%
60%
50%
6.0%
90%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
8.0%
8.0%
best
93%
92%
96%
95%
worst
94%
Higher response rates mean data are more reliable: we can be
more confident that the scores are representative of the
population.
FFT Inpatient response rates by division
100%
OUH
96%
FFT: Response rates
OUH and national FFT % not recommend
best
96%
90%
It is now a requirement for the Trust to report the percentage
of unlikely and extremely unlikely responses.
best
98%
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.
worst
100%
FFT: % not recommend
OUH
Outpatient and Day Cases % recommend
FFT: % recommend
47%
40%
27%
20%
9%
4%
0%
best
OUH
Inpatients
worst
best
OUH
2%
worst
ED
Only NHS Trusts with more than 100 responses have been
included.
Very good, professional staff, very good care and I felt really
safe. Treated with respect and all procedures have been
prepared from the beginning of my staying in ward E, to the
end. I wish success to all of you. Ward E, Nuffield
Ward 7A, John Radcliffe (MRC)
Orthopaedic Centre (NOTSS)
Complaints
New complaints
New PALS enquiries
% Complaints against Finished Consultant Episodes (FCE)
0.40%
0.14%
0.12%
0.10%
0.08%
0.11%
0.30%
0.09%
0.07%
0.20%
Closed complaints
% PALS against FCE
0.29%
0.22%
0.19%
0.13%
0.13%
0.06%
0.04%
0.04%
0.02%
0.02%
0.00%
Oct-14
50
Nov-14
Dec-14
Jan-15
Feb-15
0.10%
38
40
10
0
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Complaints by severity grading, January - March 2015
100
2
98%
Jan-15
Feb-15
Mar-15
96%
NOTSS
S&O
CSS
Corporate
Top 3 complaints themes by division, January - March 2015
100
1
0
Quarter 1
(2014/15)
Quarter 2
(2014/15)
82%
81%
99%
80%
98%
79%
97%
78%
Target 95%
access
parking/environment
hotel services
S&O
CSS
care/nursing care
other
Corporate
communication
NOTSS
S&O
0
CSS
Corporate
81%
79%
77%
76%
75%
73%
92%
NOTSS
MRC
0
74%
93%
MRC
attitude
0
75%
94%
C&W
3
% Complaints upheld or partially upheld
100%
95%
0
4
C&W
Quarter 3
(2014/15)
96%
50
5
2
% complaints acknowledged within 3 days
MRC
6
3
93%
20
Q3 2014/15
7
4
Quarter 4
(2013/14)
Q2 2014/15
Reopened complaints: March 2015
5
95%
94%
Q1 2014/15
8
96%
96%
40
C&W
0
0
9
91%
0
2
2
10
92%
60
6
4
4
6
Q4 2013/14
97%
97%
93%
80
Dec-14
% complaints investigations completed within agreed
timescales
20
14
11
4
8
Managing complaints
30
20
Nov-14
This includes all PALS enquiries and issues: positive, negative, or mixed
feedback; issues for resolution; and advice or information requests.
New Complaints Opened
10
10
4
0.00%
Oct-14
Mar-15
Reopened complaints
12
72%
Quarter 1 (2014/15)
91%
90%
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Quarter 2 (2014/15)
Quarter 3 (2014/15)