Trust Board Meeting in Public: Wednesday 11 May 2016
TB2016.42
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 and Ms Catherine
Stoddart, Chief Nurse
Key purpose
Strategy
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Assurance
Policy
Performance
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Executive Summary
1.
This paper briefs the Board on National developments on Quality related topics and
commentary on the progress against the Trust’s Quality Strategy and quality
assurance and improvement work underway.
2.
A section on National Quality Strategy Updates and Trust Quality priorities is
included in this report to inform the Board of the national context and progress
against our objectives.
3.
Key quality metrics:
For nine of the 32 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 is presented in dashboard format within Appendix One.
4.
Matters for attention of the Board:
WHO checklist compliance of regular audits is reported to the Trust Board three
Divisions have areas where compliance is less than 100% each area has actions in
place to improve compliance.
5.
Issues raised by OCCG:
Test results and discharge summaries timeliness have been an area of significant
work this year. In March 71.9% of discharge summaries were sent before or within 24
hours of discharge and 66.2% of results endorsed on EPR within 7 days
GP feedback collated from the OCCG DATIX system is reported.
6.
Patient Safety and Clinical Risk:
Two Never Events were reported in March.
25 Serious Incidents Requiring Investigations (SIRIs) were reported in March.
17 SIRIs were recommended for closure to Oxfordshire Clinical Commissioning
Group (OCCG) in March.
7.
Clinical Effectiveness:
There have been no mortality outliers reported for OUHFT by the CQC or the Dr
Foster Unit at Imperial College.
The most recent OUHFT HSMR is 100.0 and the most recent SHMI is 1.0.
8.
Infection Control:
3 cases of C.diff apportioned to the OUHFT were reported for March 2016, against a
monthly limit set at five. 57 cases have been identified year to date against a ceiling
of 64.
There was one case of MRSA bacteraemia apportioned to the OUHFT in March
2016, the ceiling for the year was zero avoidable MRSA bacteraemias and 4 have
occurred in total for the financial year 2015/16.
9.
Patient Experience:
The number of respondents who would not recommend their care has risen to 11.5%
in March; this is above the February national average 8.4%.
Overall the percentage remains at 96% recommend and 1% not recommend.
The carer’s survey is being piloted within the Trust; this will inform the development
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of a carer’s policy.
There were 107 complaints received in March. Two of these are being investigated
as SIRIs.
10. Safe Staffing:
This report provides the Trust Board with an update on the current status of nursing
and midwifery staffing across the Trust by ward as well as by shifts. Including:
• The summary of the March 2016 Unify submission of staffing.
• Current status of nursing & midwifery Nurse Sensitive Indicators (6
appendices as dashboards)
Updates on:
• The implementation of the Integrated Patient Acuity Monitoring System
• The proposal to utilise a validated national SNCT for children’s inpatient
services in order to measure acuity against staffing establishments
• The implementation of the bespoke NMC Revalidation tool in the Trust, in
readiness for the national revalidation of nurses and midwives which
commenced 1st April 2016
• The plans nationally to implement Care Hours Per Patient Day (CHPPD) for
nursing & midwifery by May 2016, and AHPs and Medical Staff by 2017
11. Recommendation
The Board is asked to receive this Quality Report as information provided from within the
organisation on the measures being taken in relation to quality assurance and
improvement.
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Board Quality Report
1.
Purpose
1.1. This paper briefs the Board on National developments on Quality related topics
and commentary on the progress against the Trust’s quality Strategy and quality
assurance and improvement work underway.
1.2. An update is provided on progress against the quality priorities described in the
Trust quality account presented to the Board as a separate document for
approval.
1.3. This Quality Report will be received for information by relevant Trust Committees
(Clinical Governance Committee) following the meeting of the Trust Board.
2.
National Quality Strategy Updates
2.1. April 2016 NICE issued a new quality standard on antimicrobial resistance.
2.2. Dame Sally Davis, Chief Medical Officer, has described the threat of antimicrobial
resistance as ‘catastrophic’.
2.3. The following schematic shows the location of antibiotic prescriptions in England.
Although the majority of prescriptions take place in general practice, hospitals
also have an important role to play.
Chart 1
2.4. Aspects of the new quality standards which apply to secondary care providers
are
2.4.1.
People prescribed an antimicrobial have the clinical indication, dose
and duration of treatment documented in their clinical record.
2.4.2.
People in hospital who are prescribed an antimicrobial have a
microbiological sample taken and their treatment reviewed when the
results are available.
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2.4.3.
Individuals and teams responsible for antimicrobial stewardship monitor
data and provide feedback on prescribing practice at prescriber, team,
organisation and commissioner level.
2.4.4.
Prescribers in secondary and dental care use electronic prescribing
systems that link the indication with the antimicrobial prescription.
2.5. The Trust has an established antimicrobial stewardship committee which is
working on the commissioning for quality and innovation (CQUIN) target for
antimicrobial stewardship and the new guidance.
3.
Update on progress against the Trust Quality priorities
3.1. Our quality priorities for 2016/17 are as follows:
3.1.1.
Preventing harm and deterioration including programmes for
•
Medication safety (in response to audits in 2015/16 and including
antibiotic stewardship- a national Commissioning for Quality
Improvement and Innovation (CQUIN)
• Acute kidney injury, AKI, (an alert affecting 30 patients per day)
• Recognition and treatment of sepsis (National CQUIN)
• Care 24/7 (NHS national priority)
• Nationally recognised iPad based track and trigger SEND project
3.1.2. Following an expert external review of our investigations of Never
Events that occurred in the Trust in 2014/15 we are committed to:
•
Further Human factors training to enhance the lessons learned from
adverse events.
• Improving our systems for sharing learning within and between
teams across the Trust.
• Improving our systems for ensuring knowledge of and compliance
with essential policies.
3.1.3. More effective care with better patient experience including
programmes for
•
•
•
3.1.4.
End of life care (proposed local CQUIN)
Dementia care
Our Compassionate Care programme to improve patient experience
throughout the Trust.
Stakeholder engagement and partnership working (including work
across the system such as the DTOC project, endorsing of test results,
prompt and accurate discharge documentation and a better patient
experience of discharge).
3.2. The place of our priorities in the domains of patient safety, clinical effectiveness
and patient experience is shown in Chart 2.
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Chart 2
3.3. Updates on the priorities are shown in Table 1.
Table 1
Priority
Medicines safety
Progress
The medicines safety team has been working with and
supporting existing specialist multidisciplinary teams to
improve medicines safety for anticoagulants, insulins and
antimicrobials. A ‘deep dive’ into delayed and omitted
doses has confirmed the importance of this issue and a
new work stream is being established to drive
improvement. The overlap between these first three and
the omission or delay of essential medicines has not been
lost and is essential in managing sepsis.
The team has been supporting the Divisions with Trust
investigations and learning from where more serious
patient harm has been associated with medicines use.
This has included reviewing all ‘Serious Incidents’ reports
to identify themes, share learning, develop and inform
action plans to reduce the potential and actual patient
harm associated with these prioritised work streams.
Improved recognition,
An AKI e-alert was launched in the Trust on Monday 18th
prevention, and management April 2016. There will be 30-40 e-alerts daily, so all clinical
of Acute Kidney Injury (AKI)
areas (with the exception of Paediatrics and Maternity) will
expect to see alerts. The e-alert will be a test result in
EPR, together with a suggested AKI care bundle as an
EPR PowerPlan. This PowerPlan is a tool to both improve
the standard management of AKI and its documentation.
The AKI group have prepared two short videos which
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Priority
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Progress
provide: the background to the e-alert and care bundle;
and instructions on how to use the EPR AKI PowerPlan.
Recognition and treatment of OUHFT is an active participant in the newly formed
sepsis
OxAHSN sepsis group. The QI Nurse Educator has
benchmarked with other hospitals and has visited Great
Western Hospital in Swindon with some information
sharing and network opportunities.
The filming of a patient story related to this subject has
taken place with the aim of using the film for educational
purposes, and include e-learning as part of the education
programme
Care 24/7
The new out of hours handover process is fully embedded
on one of our four sites (the Horton hospital) and is being
implemented across our three remaining hospitals starting
with the Churchill hospital and Nuffield Orthopaedic
Centre.
Positive feedback has been reported by the out of hours
team and compliance visits have noted improved
communication at handover meetings underpinned by the
Situation, Background, Assessment and Recommendation
(SBAR) tool and adherence to the new handover
guidance. The SBAR tool and video showing best practice
is now part of the junior doctor’s induction programme and
all resources are available on our intranet.
Extended skills training revisions for managing a
deteriorating patient and advance life support have been
provided to fully equip the out of hours team across the
Churchill site.
SEND project
The roll out of send electronic track and trigger project is
on target and is fully implemented in all acute areas across
the trust and in all areas at the NOC and the Churchill.
One of the quality improvement nurse educators has
scoped where all the relevant training is being delivered in
the divisions and a resultant education strategy has been
signed off at the RAID committee.
Human factors training
A review of the training records shows that there has been
multi-disciplinary attendance to the training, not only from
those areas involved in Never Events, but the wider Trust.
A plan to increase human factors training this year and
double the number of ambassadors is in place.
46 human factors ambassadors have been trained to
deliver human factors training at the clinical front line.
End of life care
One of the Trust’s consultants, has been reappointed as
National Clinical Director for end of life care.
Dementia care
An educational strategy has been drafted and approved
through the Dementia Steering Group (March 2016).
The tier two dementia simulation training that is currently in
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Priority
Compassionate Care
Stake holder engagement
and partnership working
(health systems interface)
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Progress
place continues until May 2016 with five events in total,
this includes peer discussion and facilitation.
The Dementia Information Café has proved successful
with carers’ attendance, but this is being benchmarked
with a highly effective Dementia Café in Bristol, in order to
maximise its user friendliness before roll out to other
hospital sites in the Trust.
The Dementia Leads who were trained through Worcester
University are ensuring parity of education provision
across the Trust and are supporting Leads and
Champions.
Provision of the Delivering Compassionate Care (DCC)
programme continues on a weekly basis. The training,
which was initially funded as part of the HETV
Compassionate Care bid, is delivered as a one-day
development workshop aimed at providing participants
with an appreciation of the impact of behaviour and
attitudes on the patient, and an understanding of effective
communication styles with those who are vulnerable (i.e.
anyone receiving treatment within our hospitals).
Since December 2015 more than 280 patients waiting for
rehabilitation and social care in either OUHFT or
community hospital beds have been moved to
intermediate care beds in one of 17 care homes across the
county. The delayed transfer of care (DTOC) project
involved significant cross system working at all levels, was
well implemented and delivered on time, with patients
being transferred as agreed.
This programme of work has enabled more effective cross
system identification and resolution of issues affecting
patient delays. The key focus by system partners is now
on:
• The continued use of beds in care homes for
intermediate care
• A continued role for the liaison hub in supporting patients
in care home beds and ensuring their onward transfer
• The implementation of a single system across health and
social care for the management of all post-acute patients
• A focus on increasing home care capacity to enable
patients to return home when they are medically fit to be
discharged.
Further information about discharge summaries and test
results endorsement is covered elsewhere in this report.
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4.
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The Quality Account
4.1. The draft Annual Quality Account is presented to the May Trust Board as a
separate document for discussion and final approval and submission by the end
of May 2016 as part of the Trust’s Annual Report.
4.2. The draft Quality Account has been consulted on at the following forums:
• Clinical Governance Committee
• Quality Committee
• Patient, Public and Staff engagement event
• Health and Scrutiny Overview Committee
• Council of Governors
• Audit Committee
• Trust Management Executive
4.3. The feedback has demonstrated satisfaction around the progress achieved
against the 2015/16 quality priorities and broad agreement with the proposed
quality priorities for 2016/17. The draft will also be shared and discussed with the
External Auditors, Oxfordshire CCG, NHS England, and Healthwatch, before
being approved by the Trust Board and laid before parliament on 27th May 2016
as a chapter in the Annual Report.
4.4. The Council of Governors have agreed to adopt end of life care as their priority
for 2016/17.
5.
Key Quality Metrics
5.1. 32 key quality metrics linked to the quality of clinical care provided across the
organisation are listed in Table 2.
5.2. Quality indicators are validated by the indicator owner before release by the
ORBIT information system.
5.3. Where specified thresholds have not been met (‘red-rated’) or have declined from
green to amber trend graphs and exception reports are included. Thresholds are
drawn from a mixture of sources (national, commissioner and internal).
5.4. A brief explanation on how to interpret exception charts is also provided in the
appendices.
Indicators deteriorating or red rated
5.5. 9 indicators have deteriorated against target since the last reporting cycle or are
red rated due to breeching of an annual threshold:
5.5.1. PS01 – Safety Thermometer (% patients receiving care free of any
newly acquired harm)
5.5.2. PS02 - Safety Thermometer (% patients receiving care free of any harm
- irrespective of acquisition)
5.5.3. PS06 – Number of cases of MRSA bacteraemia > 48 hours (cumulative
year to date)
5.5.4. PS08 – % patients receiving stage 2 medicines reconciliation within 24h
of admission
5.5.5. PS16 – CAS alerts breaching deadlines at end of month and/or closed
during month beyond deadline
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5.5.6.
5.5.7.
5.5.8.
5.5.9.
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PS17 – Number of hospital acquired thromboses identified and judged
avoidable
CE03 – Dementia - % patients aged > 75 admitted as an emergency
who are screened [one month in arrears]
CE06 – ED - % patients seen, assessed and discharged / admitted
within 4h of arrival
PE15 – % patients EAU length of stay < 12h
Indicators improving
5.6. No indicators have an improved rating since the previous reported period,
however the following have been noted:
5.6.1.
There were no falls leading to moderate harm or greater
5.6.2.
There was a small improvement in the friends and family test (FFT)
feedback in maternity, with an increase in % for respondents likely to
recommend the Trust from 93.54% the service in February to 95.87% in
March.
Table 2
BQR
ID
Rating
Rating
Last
Period
Descriptor
Period
Threshold
Source
Red
Amber
PS01
95.92%
Amber
Green
Safety Thermometer (% patients receiving care free of
any newly acquired harm)
Mar 16
Internal
95%
97%
PS02
90.7%
Red
Amber
Safety Thermometer (% patients receiving care free of
any harm - irrespective of acquisition)
Mar 16
Internal
91%
93%
PS03
95.62%
Green
Green
VTE Risk Assessment (% admitted patients receiving risk
assessment)
Feb 16
National
95%
95.25%
Serious Incidents Requiring Investigation (SIRI) reported
via STEIS
Number of cases of Clostridium Difficile > 72 hours
(cumulative year to date)
Number of cases of MRSA bacteraemia > 48 hours
(cumulative year to date)
Antibiotic prescribing - % compliance with antimicrobial
guidelines [most recently available figure, undertaken
quarterly]
% patients receiving stage 2 medicines reconciliation
within 24h of admission
Mar 16
N/A
N/A
25
N/A
57
Green
4
Red
Green
PS07
94.42%
Amber
Red
PS08
62.68%
Red
Red
PS09
100%
Green
Green
% patients receiving allergy reconciliation within 24h of
admission
PS10
1.17%
Green
Green
% of incidents associated with moderate harm or greater
PS11
69
N/A
PS04
PS05
PS06
PS12
PS13
PS14
PS16
0
Green
42.55%
N/A
99.13%
Green
1
Red
Red
Total number of newly acquired pressure ulcers
(category 2,3 and 4) reported via Datix
Green
Green
Green
Falls leading to moderate harm or greater
Mar 16
National
69
N/A
Mar 16
National
1
N/A
Jan 16
Internal
93%
95%
Mar 16
Internal
75%
85%
Mar 16
Internal
94%
96%
Mar 16
Internal
6.5%
5%
N/A
N/A
8
7
N/A
N/A
95%
98%
1
N/A
Feb 16
Mar 16
Internal
Cleaning Score - % of inpatient areas with initial score >
92%
% radiological investigations achieving 5 day reporting
standard [CSS Division]
Mar 16
Feb 16
Commissioner
CAS alerts breaching deadlines at end of month and/or
closed during month beyond deadline
Mar 16
Internal
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PS17
7
Red
CE01
1
N/A
CE02
221
N/A
CE03
56.93%
Red
Red
CE04
81.9%
Amber
Amber
CE06
78.91%
Red
Red
PE01
PE02
PE03
Red
Number of hospital acquired thromboses identified and
judged avoidable
Standardised Hospital Mortality Ratio (SHMI) [most
recently published figure, quarterly reported as a rolling
year ending in month]
Crude Mortality
80.71%
N/A
11.54%
N/A
95.87%
N/A
N/A
90%
ED - % patients seen, assessed and discharged / admitted
within 4h of arrival
Mar 16
National
85%
95%
Mar 16
N/A
N/A
Mar 16
N/A
N/A
Mar 16
N/A
N/A
Mar 16
N/A
N/A
Mar 16
N/A
N/A
Mar 16
N/A
N/A
Mar 16
N/A
N/A
Mar 16
N/A
N/A
Friends & Family test % likely to recommend - Mat
1.95%
N/A
Friends & Family test % not likely to recommend - IP
53.61%
N/A
N/A
80%
PE06
PE16
Mar 16
Internal
Friends & Family test % not likely to recommend - ED
Friends & Family test % likely to recommend - OP
Friends & Family test % not likely to recommend - OP
Red
N/A
Feb 16
Friends & Family test % likely to recommend - IP
55.4%
Red
N/A
Dementia diagnostic assessment and investigation [one
month in arrears]
95.58%
N/A
PE15
Sep 15
90%
Friends & Family test % likely to recommend - ED
Green
0
80%
PE05
PE14
1
National
Friends & Family test % not likely to recommend - Mat
PE08
Internal
Feb 16
1.27%
N/A
93.24%
N/A
3.8%
N/A
0
Green
Mar 16
Dementia - % patients aged > 75 admitted as an
emergency who are screened [one month in arrears]
PE04
PE07
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Single sex breaches
% patients EAU length of stay < 12h
% Complaints upheld or partially upheld [Quarterly in
arrears]
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Mar 16
National
3
2
Mar 16
Internal
65%
70%
N/A
N/A
Dec 15
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Exception charts
Chart 3 – PS01 – Safety Thermometer (% patients receiving care free of any newly
acquired harm)
There was an increase in
the number of new
pressure ulcers (PU)
reported in the Safety
Thermometer compared to
previous months (n=21
compared to an average
of 8 in the preceding 11
months) which accounts
for the deterioration in the
harm free care rates. The
new PUs were spread
across many clinical areas
with no one area being a
significant outlier. The
Tissue Viability Team are
delivering training and
pressure ulcer prevention
e-learning is promoted.
The proportion of patients without any documented evidence of a new pressure ulcer (developed at least 72 hours after admission
to this care setting, category II-IV), harm from a fall in care in the last 72 hours, a new urinary infection in patients with urinary
catheter (which has developed since admission to this care setting) or new VTE (developed since admission to this organisation).
Chart 4 – PS02 - Safety Thermometer (% patients receiving care free of any harm irrespective of acquisition)
There was an increase in
the number of new
pressure ulcers (PU)
reported in the Safety
Thermometer compared to
previous months (n=21
compared to an average
of 8 in the preceding 11
months) which accounts
for the deterioration in the
harm free care rates. The
new PUs were spread
across many clinical areas
with no one area being a
significant outlier. The
Tissue Viability Team is
delivering training and
pressure ulcer prevention
e-learning is promoted.
The proportion of patients without any documented evidence of a pressure ulcer, (ANY origin, category II-IV), harm from a fall in
care in the last 72 hours, a urinary infection (in patients with urinary catheter) or new VTE (developed since admission to this
organisation).
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Chart 5 – PS06 – Number of cases of MRSA bacteraemia > 48 hours (cumulative year to
date)
There was one MRSA
bacteraemia apportioned
to the OUHFT in March
2016. The blood culture
which grew MRSA, though
taken within 48 hours of
admission to the OUHFT,
was
seen
as
a
contaminant and therefore
the apportioned to the
OUHFT.
Training
in
correct technique for blood
culture samples continues.
The nationally set Trust
ceiling set for this metric in
2015/16 was zero and the
final number for the year
was four, two of which
relate to contaminated
blood cultures.
The chart shows the number of cases of MRSA bacteraemia reported via UNIFY (external IT system). If a case is subsequently
removed in following consultation with CCG (for example, attributed to a referring hospital), the figure will be modified in future
graphs. [Owner: S Wells].
Chart 6 – PS08 – % patients receiving stage 2 medicines reconciliation within 24h of
admission
Pharmacy provides a full
ward based clinical service 5
out of 7 days in most areas.
The current target is based
on all inpatient admissions
for the month having a
medicines reconciliation
completed within 24 hours of
admission. Based on current
5 day ward based clinical
pharmacy services 87% of
patients have medicines
reconciliation completed
within 24 hours of admission
Recent investment in ward
based pharmacy services
over a 7 day period on most
medical wards at the JR, all
wards at the Horton and
limited wards at the Churchill
will improve compliance in
these areas.
The chart shows the percentage of inpatients for whom second stage pharmacy-led medicines reconciliation is
completed within 24 hours of admission. Audit is based on ePMA fired medicines reconciliation tasks Trust wide and
includes approximately 2500 patients [Owner: P Devenish].
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Chart 7 – PS16 – CAS alerts breaching deadlines at end of month and/or closed during
month beyond deadline
An alert related to a stage
one warning of risk of
severe harm or death
when desmopressin is
omitted or delayed in
patients with cranial
diabetes insipidus breached by one working
day which is regrettable.
An action plan was in
place however the alert
was not closed on time.
Central clinical
governance actions have
been strengthened to
ensure this does not
happen again.
The Trust should acknowledge and, where required, respond to alerts in a timely manner.
Chart 8 – PS17 – Number of hospital acquired thromboses identified and judged
avoidable
The Trust VTE lead has
met with the NOTSS
Divisional lead – to
discuss 6 potentially
preventable HATs in order
to formulate a local action
plan. The latest Trust wide
VTE audit was reported to
CEC in April;
recommendations arising
from this include work with
the Divisional nurses to
improve safety and
prescribing around TED
stockings; work with the
EPR team to link eVTE
risk assessment to eprescribing; and improved
patient information on
admission and discharge.
When a hospital-associated thrombosis occurs, screening +/- root cause analysis is triggered. This graph shown the number of
hospital acquired thromboses in month that were felt to have been avoidable [Owner: S Shapiro].
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Chart 9 – CE03 – Dementia - % patients aged > 75 admitted as an emergency who are
screened [one month in arrears]
NOTSS have improved
their month on month
performance at the
Divisional level up to 79%
from 72%. Similarly S&O
have also improved
slightly compared to last
month to 54%, up from
50%. MRC’s Divisional
performance has fallen in
percentage terms.
Actions going forward will
involve training more staff
to complete cognitive
screening – mainly non
medical staff. This will
empower nurses and in
turn increase cognitive
test data.
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.
Chart 10 – CE06 – ED - % patients seen, assessed and discharged / admitted within 4h of
arrival
There was a marginal
improvement in ED 4 hour
target performance in
March, though
performance remained
well below the national
target. This is attributed to
significant problems
relating to patient flow,
delays in the accepting of
referrals and capacity
issues within other
specialties and the
Emergency Assessment
Unit.
% Patients attending ED who are discharged or admitted within 4 hours of arrival. [Owner: EMT]
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Chart 11 – PE15 – % patients EAU length of stay < 12h
The EAU has moved
successfully to an
'ambulatory by default'
(same-day discharge)
model, but achievement of
the 12 hour standard is
compromised when patients
who do require overnight
care cannot move from
EAU to an inpatient bed.
Achievement of this
standard is therefore highly
dependent on moderate
levels of delayed transfers
of care and bed occupancy.
Within those constraints, a
comprehensive range of
actions is in place to
optimise patient flow,
including proactive inreach
by ambulatory medical and
nursing teams, and support
services such as portering.
EAU is an assessment area and the majority of patients should either be admitted or discharged promptly following assessment.
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6.
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Matters for attention of the Board
WHO Compliance
6.1. Table 3 shows the compliance with the WHO checklist by Division and in specific
divisional areas. These audits were paper-based. An explanation is given for
areas that are not at 100%.
Table 3 – WHO Checklist March 2016
Division
NOTSS
C&W
Area
Orthopaedics
Division
Compliance
100%
90%
CSS
Division
97.5%
MRC
Cardiology
98%
100%
S&O
Cardiothoracic
Surgery
Respiratory
Intervention
Churchill Theatres
TB2016.42 Board Quality Report
Comment
42 audits were carried out in C&W
3 maternity forms were partially complete; 2
time out; I sign in.
Letters will be sent to non-compliant
clinicians.
All relevant areas have been asked to
ensure this is discussed and raised within
the teams.
There were no non-compliances but 9
partial compliance results in theatres and
radiology. These have been followed up
with the respective teams.
There were 2 partially completed checklists
where the sign out sections were
incomplete; both were missing a nurse sign
out at the end of the case. These have
been followed up with the respective teams
and action plans to prevent further failures
have been identified.
A formal handover section will be added
onto the care pathways for the Cardiac
Angiography Suite. This will act as an extra
safety check and will ensure nurses on the
ward do not accept patients into their care
until they are satisfied that the process in
the Cath Labs has been correctly followed.
These new care pathways will be updated
and published as soon as possible. The
team are also going to create a video
demonstrating a perfect WHO procedure.
All staff will be asked to watch this and it
will be used as a training tool for new staff.
100%
100%
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Oxford University Hospitals NHS Foundation Trust
7.
TB2016.42
Issues raised by OCCG
7.1. The Trust is reporting performance to the OCCG against trajectories agreed for
discharge summaries e-messaged within 24 hours of discharge and
endorsement of results on EPR within 7 days.
7.2. Current data for March 2016 show 71.9% of discharge summaries were sent
before or within 24 hours of discharge and 66.2% of results endorsed on EPR
within 7 days (note it is possible to review a result and not endorse it). This is a
slight improvement for discharge summaries (up from 71% reported for February)
and Clinical results endorsed (up from 64.9% reported last month).
7.3. Feedback for March 2016 received by the OCCG from GPs is summarised in the
tables below. These have been provided alongside data for January and
February 2016 in order to contextualise and highlight trends in themes identified
by GPs.
7.4. There were 355 separate items of feedback received by the OCCG regarding the
Trust’s services in March. This is a significant rise on the total feedback received
in February (189).
7.5. Feedback related to ‘Delay in GP receiving clinical docs (i.e. OPD/Discharge
letters)’ continues to be the most frequently reported type of feedback for the
third consecutive month accounting for 15% of all feedback received in March.
The top 5 themes combined account for 49% of all feedback received over the
month (Table 4).
7.6. Of the top 5 themes, feedback related to ‘Duplicate information sent to practice’
and ‘Communication failure between GP and Hospital/PCT‘ have risen
considerably compared to last month (from 2 to 29 and 27 respectively) in the
number of separate items of feedback received from GPs.
Table 4 – GP Feedback – Top 5 thematic areas
Theme
Delay in GP receiving clinical docs (i.e. OPD/Discharge
letters)
Jan-16
39
Feb-16
40
Mar-16
55
Delay / difficulty in obtaining clinical assistance
20
8
36
Duplicate information sent to practice
12
2
29
Failure to note relevant information in patient's record
13
11
28
Communication failure between GP and Hospital / PCT
10
2
27
7.7. Table 5 shows GP feedback by stage of care – with ‘Patient Information (records,
documents, test results, scans)’ accounting for 39% of the feedback received in
March (this is up from 33% reported for February). When all feedback received is
ordered by stage of care, the top 5 account for 88% of all feedback received.
TB2016.42 Board Quality Report
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Oxford University Hospitals NHS Foundation Trust
Table 5 – GP Feedback - Top 5 stage of care
Stage of care
Patient Information (records, documents, test results,
scans)
Access, Appointment, Admission, Transfer, Discharge
TB2016.42
Jan-16
73
Feb-16
61
Mar-16
140
41
46
66
Consent, Confidentiality or Communication
23
21
42
Medication
17
21
34
Clinical assessment (investigations, images and lab tests)
18
22
32
8.
Patient Safety and Clinical Risk
8.1. In relation to Patient Safety and Clinical Risk:
•
•
•
2 Never Events were reported in March and declared at the April Quality
Committee meeting.
25 Serious Incidents Requiring Investigations (SIRIs) were reported in March.
17 SIRIs were recommended for closure to Oxfordshire Clinical Commissioning
Group (OCCG) in March.
Clinical Risk
8.2. The following graphs provide an update on SIRIs which increased in March
particularly in NOTSS and MRC and at the JR and Horton sites.
Chart 12 – SIRIs declared and investigations completed in this financial YTD
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Oxford University Hospitals NHS Foundation Trust
TB2016.42
Chart 13 – SIRIs declared during the 2015/16 financial year by Division.
Chart 14 – SIRI Investigations completed
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Oxford University Hospitals NHS Foundation Trust
TB2016.42
Chart 15 – SIRIs declared by hospital site.
8.3. Table 6 provides more details of those SIRIs declared to NHS England via the
STEIS reporting system in March 2016, including the time in (working) days from
the incident occurrence to being reported on Datix, and from Datix reporting to
being reported on STEIS.
TB2016.42 Board Quality Report
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Oxford University Hospitals NHS Foundation Trust
TB2016.42
Table 6
SIRI Ref
Division
2016/024
Corporate
2016/025
Never
Event
CSS
2016/026
CSS
2016/027
MRC
2016/028
Never
Event
CSS
2016/029
MRC
Description
Since October 2015
approximately 2000 letters
which have been dictated to an
external dictation company
have not been sent to the
planned recipients; these
include GP letters. No patient
harm has yet been identified
from this incident and a project
group is in place ensuring that
all letters are recovered and
sent.
A wrong side iliac nerve block
was performed on a patient
undergoing a trauma related
orthopaedic operation. This falls
under the criteria of a never
event, wrong site surgery as it
relates to the ‘Stop before you
block’ guidance from 2011.
A patient had an ascitic drain
sited. The patient deteriorated
which was thought to be related
to a possible intraabdominal
bleed (which is a known
complication of
paracentesis).There was delay
in performing a CT scan. An
interventional radiology
procedure to embolise the
bleeding point was planned
however the patient suffered a
cardiac arrest as this was being
commenced. The patient was
successfully resuscitated but
subsequently died.
A man was treated for
pneumonia on an ambulatory
pathway with antibiotics. He
deteriorated in the community
which resulted in him being
unable to attend a follow up
appointment. The patient
represented approximately two
weeks later with an empyema
which required an inpatient
procedure.
A patient undergoing an
elective orthopaedic operation
had a femoral nerve block on
the incorrect side. This meets
the criteria for a Never Event.
A patient being conservatively
managed on a medical ward
following traumatic fractures
had a fine bore nasogastric
tube inserted. The patient was
subsequently identified as
having a large
pneumothorax. The cause of
the pneumothorax is not
certain.
TB2016.42 Board Quality Report
Incident
Date
Datix
Date
STEIS
Date
01/03/16
IncidentDatix
Interval
10
01/03/16
DatixSTEIS
Interval
1
17/02/16
29/02/16
29/03/16
0
02/03/16
4
06/01/16
26/02/16
38
03/03/16
5
06/01/16
26/02/16
38
03/03/16
5
08/03/16
08/03/16
0
09/03/16
1
29/02/16
01/03/16
1
14/03/16
10
Page 22 of 44
Oxford University Hospitals NHS Foundation Trust
SIRI Ref
Division
2016/030
NOTSS
2016/031
S&O
2016/032
MRC
2016/033
MRC
2016/034
MRC
2016/035
NOTSS
Description
A patient with type one diabetes
was outlying on a trauma
ward. The patient had an
elevated blood glucose on
morning reading but insulin was
omitted in error until the
afternoon when the patient had
a blood glucose of >27mmol/l
and raised ketones.
A patient underwent a pancreas
transplant. Both the donor and
the patient were known to be
CMV negative. The patient had
a CMV test three weeks later
which gave a mildly positive
result. This test result was
electronically endorsed but it’s
significance was not
appreciated. The patient
represented three weeks later
with symptoms of a primary
CMV infection which was
confirmed on laboratory testing.
A patient having palliative
treatment for metastatic cancer
had a chest drain sited. The
drain quickly drained 1800mls
fluid. The patient developed
hypoxia and chest pain and
died despite escalation to
critical care.
A patient on the surgical
emergency unit had chest pain
with ischemic changes on their
ECG and a raised troponin
level. The surgical team
encountered difficulty in
obtaining a medical
review. The patient was taken
to the cath lab for primary
angioplasty approximately 4
hours after concerns were first
highlighted.
A lady who had newly
diagnosed Type 1 diabetes was
managed as an ambulatory
patient with instructions to
return the following day. The
patient returned with
ketoacidosis. Whilst ambulatory
pathways are encouraged this
particular pathway for newly
diagnosed type 1 diabetes has
not been fully discussed and
consequently lessons can be
learned from this near miss.
A patient who was having
seizures was prescribed
intravenous anticonvulsants.
Cannulation was requested
several times by the Nursing
staff but was not achieved due
to a number of issues with both
establishing access and the
TB2016.42 Board Quality Report
TB2016.42
Incident
Date
Datix
Date
STEIS
Date
03/03/16
IncidentDatix
Interval
1
14/03/16
DatixSTEIS
Interval
8
03/03/16
20/01/16
07/03/16
34
14/03/16
6
03/03/16
08/03/16
4
14/04/16
5
08/03/16
08/03/16
0
14/03/16
5
11/03/16
14/03/16
2
21/03/16
6
01/03/16
11/03/16
9
18/03/16
6
Page 23 of 44
Oxford University Hospitals NHS Foundation Trust
SIRI Ref
Division
2016/036
MRC
2016/037
MRC
2016/038
MRC
2016/039
NOTSS
2016/040
MRC
2016/041
MRC
2016/042
NOTSS
2016/043
NOTSS
2016/044
C&W
Description
prescription; the patient had
further fits and received her
medication 19 hours after it had
been prescribed.
A young person attended ED at
the HGH after being involved in
a collision during sports event.
The patient complained of acute
pain and was discharged home
with instructions to return if the
pain continues. The patient represented to their local hospital
the following day with a
significant trauma related injury
A post-operative patient who
had undergone cardiac surgery
had a cardiac arrest seven days
after surgery. The resuscitation
attempts were unsuccessful
and the patient died.
A patient with learning
difficulties was admitted and
subsequently suffered a cardiac
arrest and despite prolonged
resuscitation efforts the patient
died. In retrospect a review of
his ECG’s show cardiac
abnormalities which had not
been recognised.
An elderly patient underwent
surgery for a fractured neck of
femur elsewhere and was
transferred to the OUH for a
closure of a left leg laceration;
Whilst an inpatient at the OUH
she developed a pulmonary
embolus. This is a possibly
preventable hospital acquired
thrombosis.
A patient who was admitted for
a fracture developed a category
3 hospital acquired pressure
ulcer to the sacrum.
A patient who was admitted
with confusion and diabetes
developed a category 3 hospital
acquired pressure ulcer
An elderly patient admitted for
spinal surgery developed a
category 3 hospital acquired
pressure ulcer.
A patient admitted with critical
limb ischemia developed a
category 3 hospital acquired
pressure ulcer.
A baby born in 2013 was
investigated a week after birth
for a sacral dimple. Imaging
was undertaken and reviewed
by a consultant neurologist. The
images were thought to be
reassuring and the baby was
discharged. The child
represented at two years of age
TB2016.42 Board Quality Report
TB2016.42
Incident
Date
Datix
Date
IncidentDatix
Interval
STEIS
Date
DatixSTEIS
Interval
04/11/15
16/03/16
92
18/03/16
3
25/10/15
14/03/16
98
18/03/16
4
12/03/16
12/03/16
0
18/03/16
5
16/01/16
09/02/16
17
21/03/16
30
23/02/16
23/02/16
1
18/03/16
19
03/03/16
03/03/16
1
18/03/16
12
10/03/16
11/03/16
2
21/03/16
7
10/03/16
10/03/16
1
21/03/16
8
07/07/13
16/03/16
634
24/03/16
7
Page 24 of 44
Oxford University Hospitals NHS Foundation Trust
SIRI Ref
Division
2016/045
MRC
2016/046
MRC
2016/047
C&W
2016/048
NOTSS
Description
with an infection and a clinical
review showed an undiagnosed
spinal abnormality potentially
amenable to surgical correction
had it been identified at birth.
An elderly patient with a brain
tumour was admitted and
developed a pulmonary
embolus whilst an
inpatient. This is a potentially
preventable hospital acquired
thrombosis.
A patient with cancer was
admitted for a procedure. Due
to an incorrect risk assessment
on admission the patient was
not given dalteparin during the
admission. The patient
developed a pulmonary
embolus after discharge which
is potentially preventable
A patient with suspected cancer
was booked for an outpatient
CT scan. Follow up for this
patient after the CT scan was
not arranged as planned and
the patient presented to her GP
two weeks after the scan to
enquire about her next
appointment. The patient was
immediately referred back to
the oncology service.
A patient admitted with vascular
disease and sepsis developed a
hospital acquired grade 3
pressure ulcer.
TB2016.42
Incident
Date
Datix
Date
IncidentDatix
Interval
STEIS
Date
DatixSTEIS
Interval
12/02/16
22/02/16
7
24/03/16
24
18/02/16
03/03/16
11
24/03/16
16
18/03/16
21/03/16
2
24/03/16
4
04/03/16
04/03/16
1
29/03/16
16
8.4. A number of SIRI reporting timescales were not reached in March 2016 over 10
(working) days; details of these delays are as follows:
8.5. Delays in reporting on Datix:
8.5.1.
2016/026 – This was discussed at an M&M and then brought to the
attention of the CGRP at a clinical governance meeting where it was
requested that a Datix be put in for this patient.
8.5.2.
2016/027 – The reported incident date relates to when the patient had a
procedure which gave information that was not fully acted on. The
clinical incident was not identified until the patient had been re-admitted.
8.5.3.
2016/031 - The results of a CMV test wasn’t acted on appropriately and
this was put down as the date of incident. However the significance of
this only became apparent much later when a second CMV PCR came
back very high, hence what appears to be a delay reporting.
8.5.4.
2016/036 – was brought to the attention of the Trust following a
complaint.
8.5.5.
2016/037 - there was a delay in review of the case at the cardiac
surgery M&M.
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Oxford University Hospitals NHS Foundation Trust
TB2016.42
8.5.6.
2016/039 and 2016/046 – the Thromboprophylaxis Nurses are
dependent on services sending the clinical information to them. Each
Venous Thromboembolism (VTE) is screened to see whether they meet
the Hospital Acquired Thrombosis (HAT) criteria. These cases are often
complex and need to be discussed with our consultant to confirm if they
meet the HAT criteria. This incident was identified via radiology.
Reports are usually sent to the Thromboprophylaxis Nurses two to three
times a week and reflect data that has been collected in the previous
week.
8.5.7.
2016/044 - the incident was highlighted following receipt of a Solicitors
letter on 23/02/16. Following review of the case the incident was
reported on Datix on 16/03/16 and the incident discussed at SIRI Forum
and declared as a SIRI.
8.6. Delays in reporting on STEIS:
8.6.1.
2016/039, 2016/045 and 2016/046 – HAT screening process and the
timing of the SIRI Forum used for decision making.
8.6.2.
2016/040, 2016/041 and 2016/048 – delay in reporting on STEIS due to
process of establishing whether the Hospital Acquired Pressure ulcer
(HAPU) was unavoidable.
8.7. The time to notification to DATIX of some incidents remains over 48 hours with a
mean of 76 working days and a median of 2 days. These figures have been
greatly affected by the length of time taken to report 2016/044, for which there is
an explanation above. The mean time from DATIX report to entry onto STEIS is
currently 7 working days with a median of 6 days.
8.8. Twelve SIRI reports were recommended to OCCG for approval during March
2016.
8.9. No SIRI closure meetings were held between the Trust and OCCG in March.
Further OCCG closure meetings were planned in April.
8.10. One SIRI was downgraded in March as following further investigation it did not
meet the criteria of a Serious Incident.
8.11. 2016/009 - a community midwife lost her diary whilst performing home visits.
8.12. Two Never Events were declared in March and raised as an exception to the
April 2016 Quality Committee meeting:
8.12.1. SIRI 2016/025
Date of incident: 29 February 2016
A wrong side iliac block was performed on a patient undergoing a
trauma orthopaedic procedure. This falls under the criteria of a Never
Event, wrong site surgery as it relates to the ‘Stop before you block’
guidance from 2011.
Following the confirmation of this incident the Medical Director sent out
a communication to all medical staff notifying them that important and
Urgent action was needed. Copies of a “Stop Before You Block” poster
were put up in all the anaesthetic rooms across the Trust.
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Oxford University Hospitals NHS Foundation Trust
TB2016.42
8.12.2. SIRI 2016/028
Date of Incident: 08 March 2016
A patient undergoing an elective orthopaedic operation had a femoral
nerve block on the incorrect side. This was noted prior to surgery and a
second nerve block was given into the correct leg. This meets the
criteria for a Never Event.
Following this subsequent incident further communication was
disseminated to the Operating Department Practitioners and
Anaesthetic Nurses from the Lead Anaesthetist to encourage them to
support anaesthetic colleagues regarding checking that “Stop Before
You Block” has been undertaken and final checks made.
Executive Quality Walk Rounds
8.13. There were 4 Executive Quality Walk Rounds that took place in April 2016
detailed in table 7.
Table 7 – Quality Walk Rounds
Hospital Site
John Radcliffe Hospital
Horton Hospital
Areas to visit
Theatres
Emergency Department
Radiology
Juniper ward
8.14. Key issues arising during the Quality Walk Rounds with the potential to affect
quality or patient experience either positively or negatively included:
•
•
•
•
Continued higher levels of staff turnover rates and vacancies, mainly within the
theatres scrub team, which is driving a continuous need to recruit, induct and
train new staff. This is impacting on team morale and the ability to develop
services.
The positive impact of the ‘perfect week’ was discussed, with a key benefit
relating to the accepting of patient referrals in a timely way. A new document
had been created by the Emergency Department (ED) team and shared with
other clinical areas to help assist the department in ensuring patient flow.
Some difficulties were noted around the recruitment of middle grade and
Consultant level staff to ED, though significant benefits had been obtained
following investment in the RAF medical training team and by offering places for
the armed forces deanery. It was discussed whether more placements could be
facilitated.
The use of the atrium area in ED as an additional bay area was discussed, with
processes in place to ensure patient safety including the use of a dedicated
nurse to ensure monitoring. Some work was still required by the Estates team
to ensure the area was not overlooked and to improve patient privacy and
dignity.
TB2016.42 Board Quality Report
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Oxford University Hospitals NHS Foundation Trust
TB2016.42
•
Discussion with staff on Juniper ward identified a happy, positive team with
pride in the quality of care and patient safety delivered.
• SEND was having a positive impact on identifying sick patients. Used at
Hospital at Night handover meeting as a way of prioritising patients for review.
8.15. All issues that have actions associated with them will be monitored through
Divisional governance processes.
9.
Clinical Effectiveness
9.1. The Mortality Review Group (MRG) held the inaugural meeting on 21st March
2016 chaired by the Deputy Medical Director. The following investigation reports
were presented and reviewed by MRG.
9.2. A report on the CABG (other) outlier gave no cause for concern and has been
sent to the CQC. A review of seven maternal deaths also showed diverse causes
some many months after birth. The report has been shared with MBRACE.
Clinical Outcomes – Summary Hospital-level Mortality Indicator (SHMI) and Hospital
Standardised Mortality Ratio (HSMR)
9.3. There have been no mortality outliers reported for OUHFT by the CQC or the Dr
Foster Unit at Imperial College.
9.4. The SHMI for the data period October 2014 to September 2015 is 1.00. This is
rated ‘as expected’. The SHMI trend is depicted in Chart 16. The SHMI remains
within the ‘as expected’ range.
120
12%
110
10%
100
8%
90
6%
80
4%
70
2%
60
Oct-13 to Sep-14 Jan-14 to Dec-14
Apr-14 - Mar-15
Jul-14 - Jun-15
Oct-14 to Sep-15
Crude mortality (%)
Relative risk
Chart 16 – SHMI trend
0%
SHMI period
9.5. The SHMI identifies the following diagnoses (Table 8) to be the leading causes of
patient mortality at OUHFT. These are the same diagnoses identified in the
previous SHMI publication (for the data period July 2014 to June 2015).
TB2016.42 Board Quality Report
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Oxford University Hospitals NHS Foundation Trust
TB2016.42
Table 8 – SHMI Diagnoses with highest number of deaths
SHMI Diagnosis Groupings
Secondary malignancies
Acute cerebrovascular disease
Pneumonia (except that caused by tuberculosis or sexually
transmitted disease)
Observed
153
194
Expected
134.2
192.8
446
449.5
9.6. The Trust’s HSMR is 100 (for the latest 12-month period February 2015 to
January 2016). The value is ‘within the expected’ range (95% CI 95.6 -104.5).
The HSMR has decreased from 100.7 (for the data period January to December
2015). The number of observed deaths within the HSMR 56-diagnosis groups is
1944. The HSMR trend is depicted in Chart 17. The HSMR remains ‘within the
expected’ range.
120
12%
110
10%
100
8%
90
6%
80
4%
70
2%
60
Oct-14 to Sep-15 Nov-14 to Oct-15 Dec-14 to Nov-15 Jan-15 to Dec-15 Feb-15 to Jan-16
Crude mortality (%)
Relative risk
Chart 17 – HSMR trend
0%
HSMR period
Crude Mortality
9.7. The OUHFT crude mortality by month, site and division for the 2015/2016
financial year to date is displayed in the graphs below. Crude mortality gives a
contemporaneous but not risk adjusted view of mortality across OUHFT. Some
seasonal increase in winter months is usual due to the seasonal nature of some
diseases such as influenza and some respiratory conditions. Chart 18 and 19
reflect an unchanging crude mortality as a percentage of patient attendances
when looked at over 12 months.
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Chart 18 – Crude Mortality
OUH Crude Mortality
250
Number of Deaths
200
150
100
50
0
Apr-15 May-15 Jun-15
Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
Chart 19 – Crude Mortality by Division
Crude Mortality by Division
250
225
Number of deaths
200
175
150
125
100
NOTSS
CSS
MRC
75
C&W
50
S&O
25
0
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Chart 20 – Crude Mortality by Site
Crude Mortality by Hospital Site
250
Number of deaths
225
Sobell House
200
NOC
175
150
CH
125
HGH
100
75
JR
50
25
0
Clinical Audit
9.8. The following audits were presented at the Clinical Effectiveness Committee key
areas for improvement are highlighted:
9.8.1. National Hip Fracture Database mortality report
9.8.2.
National Bowel Cancer Audit
9.8.3.
Interventional Cardiology consultant outcomes
9.8.4.
British Thoracic Society (BTS) Emergency Use of Oxygen
9.8.4.1.
The audit found that administered oxygen was signed for in
none of the cases reviewed. There is EPR development work in
progress to create a task for oxygen prescription. There is work
underway to embed an online training tool from BTS into the
essential training program.
9.8.5.
NICE technology appraisal guidance TA260 Botulinum toxin type A for
the prevention of headaches in adults with chronic migraine
9.8.6.
NICE quality standard QS17 Lung Cancer
9.8.7.
National Lung Cancer Audit (LUCADA)
9.8.7.1.
The service reported high resection rates and advised that if
the rest of the UK had equivalent resection rates an additional 5000
lives would be saved from lung cancer.
9.8.8.
National Lung Cancer Audit of Mesothelioma
9.8.9.
Intensive Care National Audit (ICNARC)
9.8.10. Groin Hernia Patient Reported Outcomes Measures (PROMs)
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10. Infection Control
Clostridium difficile (C.diff)
10.1. The upper ceiling limit for OUHFT apportioned cases of C.diff for 2015/2016 was
69.
10.2. The OUHFT had a total of 57 apportioned cases for 2015/2016 and are therefore
below the upper ceiling for cases.
10.3. Table 9 lists OUHFT apportioned C.diff cases per month for the financial year
2015/2016.
Table 9
Total
Apr-
May-
Jun-
Jul-
Aug-
Sep-
Oct-
Nov-
Dec-
Jan-
Feb-
Mar-
15
15
15
15
15
15
15
15
15
16
16
16
3
4
8
8
3
4
7
6
3
3
5
3
5
6
6
6
6
6
6
6
6
6
5
5
Cum total
3
7
15
23
26
30
37
43
46
49
54
57
Cum limit
5
11
17
23
29
35
41
47
53
59
64
69
1
1
3
1
1
0
0
2
1
0
1
0
Monthly
limit
*30 Day
Mortality
10.4. 3 cases of C.diff apportioned to the OUHFT were reported for March 2016,
against a monthly limit set at 5. These cases were reviewed at the April Health
Economy meeting with the OUHFT, OCCG, Oxford Health and PHE in
attendance.
10.5. Of the 3 cases, it was determined that 2 were unavoidable and 1 case avoidable
due to the prescribing of Ciprofloxacin in a non-penicillin allergic patient.
30 day C.diff Mortality review
10.6. As per Department of Health guidance (2008), the OUHFT undertakes a monthly
review to identify deaths within 30 days of diagnosis of CDI to ensure that a
common standard of assessment is being applied in terms of the cause of death
or contribution to death. To date there have been no deaths in March with meet
these criteria.
MRSA bacteraemia
10.7. There was one MRSA Bacteraemia apportioned to the OUHFT in March 2016,
the patient’s blood culture, though taken within 48 hours of admission to the
OUHFT, was seen as a contaminant and therefore apportioned to the OUHFT.
10.8. The ceiling for 2015/2016 is 0 avoidable MRSA bacteraemia. To date, 4 MRSA
bacteraemias apportioned to the OUHFT have been reported (April 2015, June
2015, December 2015 and March 2016); with 3 cases in June and December
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2015 and March 2016 deemed avoidable. Two related to contaminated blood
cultures and two to clinical infections.
10.9. The OUHFT has therefore failed to meet this objective for 2015/2016.
Table 10
Apr
2015
May
2015
Jun
2015
July
2015
Aug
2015
Sep
2015
Oct
2015
Nov
2015
Dec
2015
Jan
2016
Feb
2016
Mar
2016
Total
1
0
1
0
0
0
0
0
1
0
0
1
Avoidable
N
-
Y
-
-
-
-
-
Y
-
-
Y
*Contaminant
N
-
N
-
-
-
-
-
Y
-
-
Y
Cum total
1
1
2
2
2
2
2
2
3
3
3
4
Cleaning audits
10.10. Table 11 details the average reported cleaning scores by Division
undertaken by the OUHFT Facilities Monitoring Team from April 2015 to March
2016.
Table 11 – Average reported cleaning scores by Division
Division
Apr
May
Jun
84%
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
NOTSS
87%
82%
84%
86%
84%
87%
87%
NC
85%
89%
87%
MRC
89%
89%
88%
87%
90%
88%
91%
89%
88%
95%
91%
92%
C&W
90%
89%
89%
88%
90%
90%
89%
92%
92%
89%
92%
91%
S&O
91%
90%
87%
88%
89%
89%
91%
89%
89%
91%
90%
89%
CSS
Total
94%
90%
83%
87%
87%
87%
88%
87%
86%
88%
91%
88%
86%
89%
90%
89%
89%
90%
91%
90%
95%
91%
92%
90%
Cleaning Audit Performance and Process
10.11. As a consequence of poor cleaning audit score reporting and a lack of
consistent auditing across the Divisions due to the small size of the auditing
team, the Infection Control service have co-ordinated meetings with key staff
members to review the following:
•
How the cleaning audits are currently undertaken and how this process can be
improved to ensure a consistent approach.
• Strategies to improve cleaning score performance.
10.12. An initial meeting with the Interim Head of Estates, the Deputy Chief Nurse
and Senior Infection Control Nurse was held on the 8th March 2016 to discuss
the issues as outlined above and to devise a plan moving forward. The meeting
identified that at present there is work being undertaken by the Contracts team
with an aim to standardise the contracts that are currently in place for the 3 PFI
providers (G4S Churchill, G4S NOC and Carillion) and the in-house Domestic
team at the Horton and this will therefore allow for comparable data when the
audits are undertaken by the Facilities Performance Monitoring Team.
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MRSA Screening Compliance
10.13. The OUHFT achieved 54.9% (2706/4932) overall compliance with MRSA
screening, 74% (790/1067) for elective admissions and 49.6% (1916/3865) for
emergency admissions. Clinical areas with high turnover of patients have lower
compliance with screening emergency admissions. Table 12 below details the
compliance with emergency and elective MRSA screening by Division.
Table 12 – Compliance with emergency and elective MRSA screening, March 2016
Percentage
Screened Electives
Percentage screened
emergencies
Percentage of
Patients screened
Neurosciences, Orthopaedics,
Trauma & Specialist Surgery
76%
62%
69%
Medicine, Rehabilitation & Cardiac
94%
47%
49%
Surgery & Oncology
65%
47%
51%
Clinical Support Services
61%
94%
72%
OUHFT total
74%
50%
55%
Division
10.14. As a consequence of a low level of MRSA Screening compliance, the
Infection Control service will be co-ordinating a meeting with key staff members
in order to improve screening compliance. An initial meeting with the OUHFT
Chief Clinical Information Officer held on the 23/03/16 has identified the potential
to use the EPR system as a means of collating and reporting screening
compliance.
Norovirus Outbreaks 5AU John Radcliffe Hospital and Juniper Ward, Horton
Hospital, March 2016
Ward 5AU
10.15. From 06/03/16 a total of 5 patients and 0 staff members reported symptoms.
A positive Norovirus sample was reported by OUHFT Microbiology (no further
testing is undertaken once a positive sample has been reported). Restrictions on
the ward were formally removed on the 12/03/16.
Juniper Ward, Horton
10.16. From 02/03/16, a total of 11 Patients and 1 staff member reported
symptoms. A positive Norovirus sample was reported by OUHFT Microbiology.
Restrictions on the ward were formally removed on the 10/03/16.
Measles Incident Paediatric Emergency Department, March 2016
10.17. A child with suspected measles was admitted to the Paediatric Emergency
Department in early March and transferred to the Paediatric Ward in the
Children’s Hospital.
10.18. Contact tracing of patients and staff in Paediatric ED was undertaken by
infection control and it was arranged for those who required Immunoglobulin (as
per PHE guidelines) to receive this under the care of the Paediatric team.
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11. Patient Experience
Friends and Family Test (FFT) feedback 1
Emergency Department (ED) FFT Feedback:
11.1. The percentage of respondents who would not recommend their care has risen
from 10.8% in February to 11.5% in March; this is above the February national
average (8.4%). The percentage to recommend remains constant at 81%.
Nationally, EDs are experiencing unprecedented pressure in terms of number of
patients presenting at departments. It is the view of the Division that the number
of patients who would not recommend their care is related to the increased
activity pressure within ED and is monitoring the impact regularly.
11.2. The response rate has fallen slightly to 23% in March, but it remains above the
February national average (13%). The Trust has been approached by regional
colleagues to learn about the Trust’s approach to and methodology for FFT as
response rates are considerably higher.
Chart 21 – OUH and national FFT percentage not recommend - ED
OUH and national FFT % not recommend
14%
12%
11.5%
10%
8%
6%
4%
2%
0%
1
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
The most recently available national data are from February 2016.
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Chart 22 – OUH and national FFT response rates - ED
OUH and National FFT response rates
30%
25%
23%
20%
15%
10%
5%
0%
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Inpatient and Day case FFT Feedback by division:
11.3. The percentage to recommend has fallen in C&W, S&O and CSS, and the
percentage not recommend has increased.
11.4. The percentage to recommend has increased for NOTSS but the percentage not
recommend is approximately the same.
11.5. Overall rates remain at 96% recommend and 1% not recommend.
Chart 23 – OUH FFT inpatient % recommend by division
FFT Inpatient % recommend by division
100%
98%
98%
97%
96%
96%
94%
94%
94%
92%
90%
Oct-15
Nov-15
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Chart 24 – OUH FFT inpatient % not recommend by division
FFT Inpatient % not recommend by division
4%
3%
3.1%
2.7%
2%
1.6%
1.6%
1.2%
1%
0%
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Maternity FFT feedback:
11.6. The response rate for the birth question has increased to 27% in March.
Chart 25 – OUH and national FFT response rates (Maternity - labour and birth
questionnaire)
OUH and National FFT response rates
30%
27%
25%
20%
15%
10%
5%
0%
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Carers’ Project
11.7. The Patient Experience team have designed a survey for staff, currently being
piloted within the Trust. The survey incorporates input from Carers Voice, Carers
Oxfordshire, the Trust’s Lead Nurse for Learning Disabilities and the Young
Carers team at Oxfordshire County Council.
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11.8. The planned objective for this survey is to receive responses from at least 1% of
the total workforce, with representation from all divisions, by 30 June 2016.
Feedback from the survey will be presented at a future public and staff
engagement event where the Patient Experience and Engagement Team will ask
for input on how the results can inform and shape the Carers Policy 2016.
Children's patient experience update
11.9. The percentage of children/parents who are extremely likely and likely to
recommend their care remained about the same at 98% in February and 97% in
March. However, the percentage of children/parents who are extremely likely to
recommend their care went from 87% in February 2016 to 91% in March 2016.
11.10. Chart 26 and 27 show the recommendation rates from children’s patient
feedback for February and March 2016.
Chart 26 – February 2016 percentage of children/parents who would recommend their
care.
February 2016 Children's Patient Feedback
0.6%
0.6%
0.6%
0.6%
Extremely Likely
11.0%
Likely
Neither likely nor unlikely
Unlikely
Extremely unlikely
86.5%
Don't Know
Chart 27 – March 2016 percentage of children/parents who would recommend their care
March 2016 Children's Patient Feedback
1.1% 0.4%
1.1%
0.0%
Extremely Likely
6.2%
Likely
Neither likely nor unlikely
Unlikely
Extremely unlikely
91.3%
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Young People’s Executive (YiPpEe)
11.11. YiPpEe has grown from 20 members in February 2016 to 24 members in
March 2016.
12. PALS and Complaints
12.1. The number of new complaints received during March was 107. This is an
increase against the numbers of formal complaints received in February (n=83).
This continues the recent trend showing a higher number of formal complaints
being received each month.
12.2. There were two extreme (previously coded red) graded complaints received in
March 2016. One is for MRC, and is being investigated as a SIRI, with the
findings due in May 2016. The second complaint graded extreme (previously
coded red) was for NOTSS. The issues are already being investigated as a SIRI
with the findings due in May 2016.
Divisional Overview
12.3. NOTSS received the highest number of complaints across the Trust in March
(n=34, 32% 2). This is the same as the previous month but still remains
considerably higher than the number received in January (n=23). The Division’s
complaints are related to Neurosciences (n=12), Specialist Surgery (n=10),
Trauma (n=3) and Orthopaedics (n=9). Activity in February and March was
0.10% in comparison to 0.6% in January which may account for the increase in
complaints. However, the same increase in activity was also seen in MRC and
C&W. The Divisional Nurse responded that there is no correlation in the grading
or themes that can be attributed to the increase.
12.4. S&O received 11 complaints this month (10.3%) of the overall number received
Trust-wide, which concerned Clinical Oncology (n=2), Surgery (n=4), Renal,
Transplant and Urology (n=1) and Gastro, Endoscopy and Theatres (n=4). This
number represents a decrease in the number of complaints received by the
Division in December (n=15).
12.5. CSS received seven complaints this month (6.5%) of the overall number of
complaints received by the Trust. Of the seven received in March, the areas of
concerns related to Critical Care, Pre-op Assessment, Pain Relief and
Resuscitation (n=2), Radiology and Imaging Services (n=3) and Pharmacy (n=2).
12.6. MRC received 30 complaints this month (28% of the overall number of
complaints received by the Trust) which is a significant increase compared to 20
received in February. The complaints related to Ambulatory Medicine (n=6),
Acute Medicine and Rehabilitation (n=22) and Cardiology, Cardiac and Thoracic
Surgery (n=2). 10 complaints that fall under Acute Medicine and Rehabilitation
were related to the Trust’s Emergency Departments/Emergency Assessment
Units. There has been an increase in complaints in Acute Medicine and
Rehabilitation. It is the view of the Division that the number of complaints
received is as a result of increased patient activity throughout the patient
pathway.
1.
The percentage is of the total number of complaints.
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12.7. C&W received 21 complaints this month (19.6% of the overall number of
complaints received by the Trust) and compares to 7 received in February. This
is a significant increase. 15 of the complaints received in March related to
Women’s Services, whereas 6 of the complaints related to Children’s Services.
We did not receive any complaints about Children’s Services last month and the
fluctuation in complaints is being monitored.
12.8. The Corporate division received four complaints this month (3.7%). This was a
decrease on the number received in February (n=5). We are slowly seeing a
decrease in the number of complaints relating to the Corporate Division, but Car
Parking (which was an increasing concern within the last 4 four months) is still
being monitored by the Complaints Team and by the Trust.
Clinical Treatment
12.9. There were 31 complaints (28.9%) across five of the clinical divisions (C&W,
CSS, MRC, NOTSS and S&O) in relation to clinical treatment compared to 25
complaints for the previous month. The concerns raised were around delay in
the induction of labour, delay in obtaining clinical assistance, delay/failure in
treatment or procedure, delay/failure to diagnose, delay/failure in ordering tests,
delay/failure to undertake scan/x-ray, inappropriate procedure, inadequate pain
management, inadequate frequency of observations and failure to follow up on
observations/recognise deteriorating patient, delay/failure in treatment of for
infection and post-treatment complications.
Patient Care
12.10. There were five (4.6%) complaints in relation to patient care. The complaints
spanned three of the clinical divisions – C&W, MRC and NOTSS. Issues raised
included failure to provide adequate care, care needs not adequately met, failure
to adopt infection control measures and slips, trips and falls.
Future Patient Experience reports
12.11. The Patient Experience Team will produce two dashboards for the June
Board Quality Report. This will enable Quality Committee to decide the preferred
format for visually reviewing Patient Experience Data.
13. Safe Staffing – Nursing and Midwifery
13.1. The Trust is required to comply with The National Quality Board (November
2013) and NICE guidance (July 2014) for Safe Staffing for Adult Inpatient Wards
in Acute Hospitals. This report therefore includes the safe staffing data for
December 2015 and the metrics against each of the 5 divisions (appendices 4 a,
b, c, d & e).
13.2. It also incorporates Nurse Sensitive Indicators (NSI), for the months of January March 2015/16, by division, against the Trust metrics. The overall Trust wide safe
staffing report including individual wards and shifts is highlighted in appendix
(appendix 4f)
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National reporting for Safe Staffing March 2016
13.3. The summary of the figures submitted to NHS Choices via the Unify platform for
March 2016 are included below but can be accessed via the Trust website on
(http://www.ouh.nhs.uk/about/saferstaffinglevels.aspx).
13.4. 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 Nursing Assistants.
13.5. These figures include all staff both permanent and temporary staff.
13.6. The Trust has been striving to meet the national standards set for the national
‘Agency Cap’, of agency usage below 6% of the overall nursing workforce, and
reduced the use of Non-Framework nursing agency very significantly.
Unify data – March 2016
13.7. The fill rates of actual shifts against those planned (including temporary staff) are:
•
•
96.41% for Registered Nurses/Midwives
91.45% for Nursing Assistants (unregistered)
Current status of nursing and midwifery staffing within the Trust
13.8. The Trust continues to have a significant percentage of nursing vacancies in key
areas such as Paediatric and Neonatal ICU and Adult ITU.
13.9. The EU recruitment campaign has continued throughout the winter with 40 new
starters every month, reducing to 20 per month from 1st April 2016. This
recruitment is continuing through until the summer with a review of the turnover
of junior staff and the requirement for specialist staff.
13.10. The Associate Chief Nurse for Workforce is working with the lead nurse for
recruitment based in HR to review with the Divisional Nurses their key
recruitment needs and turnover. The intention is to recruit outside of the EU for
specialist staff i.e. theatres and ITU.
Integrated Patient Acuity Monitoring Tool System (IPAMS)
13.11. The Integrated Patient Acuity Monitoring Tool System (IPAMS) has been
rolled out and implemented since December 2015 with support on the wards from
the Lead Nurse for Safe Staffing & Nursing/Midwifery Regulation.
13.12. Compliance is much improved and the tool is used on all sites as part of the
staff and bed capacity meetings.
13.13. Reports are developed using the ‘Tableau’ reporting tool that the Trust has
procured with a view to reporting in this format from June.
13.14. The bi-annual acuity & dependency review has been deferred due to the
implementation of IPAMS and acuity measurements taken in April are currently
being validated by the Divisional Nurses.
13.15. IPAMS currently only utilises the Safer Nursing Care Tool (SNCT) that has
been validated nationally for adult areas including Intensive care areas. This
does not include Emergency Departments (ED) or Childrens’ inpatient areas.
13.16. The ED safe staffing tool although previously withdrawn nationally following
initial testing by NHS England is due to be reintroduced shortly.
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13.17. There is a SNCT for children’s’ in patient services, to which the Trust has
contributed development data. The Safe Staffing Team and matrons is children’s’
services are currently discussing its implementation.
NMC Revalidation
13.18. The bespoke Trust revalidation tool was launched in December 2015 and
has been well received by registered nurses and midwifery staff. Reports are
being extracted from the data to monitor the compliance, as the first 60 staff
revalidated on the 1st April 2016. Some staff have chosen to use alternative tools
i.e. RCN tool, and the Trust is working with the matrons to ensure the Trust tool is
completed in order to enable accurate reporting, audit and assurance.
13.19. Less than 5 staff have been identified as having chosen alternative options
i.e. retirement, or have elected to lapse their registration, and two revalidated
through their organisation of the military.
13.20. A Quality Assurance panel has been established to ensure standardisation of
‘confirmation processes’ and monitoring of the process.
13.21. The communications strategy is well established and ongoing with hard to
reach staff being contacted i.e. long term sickness, or those on maternity leave.
Divisional Nurses are monitoring the compliance within their divisions in
conjunction with the Lead Nurse for Safe Staffing and & Nursing/Midwifery
Regulation.
Care Hours Per Patient Day (CHPPD) Guidance
13.22. This process for consistent national reporting on staff hours was highlighted
in Lord Carter’s Review 3, following work undertaken in Australia (Twigg et al.,
2011) 4. This will apply to nursing and midwifery staffing from May 2016 (reporting
in June 2016) and will gradually include Nurse Sensitive Indicators within the
templates, such as those presented in the monthly Trust safe staffing
dashboards.
13.23. The Trust is currently working with the IPAMS provider and the Operational
Team to facilitate this reporting. It will require the patient numbers at 23.59 each
night on each ward to be validated, and integrated into the monthly Unify staffing
reports. The Registered Nursing/Midwifery and Nursing Assistant actual work
hours will be divided by the number of patients per month by ward to determine
the number of Care Hours Per Patient Day.
13.24. This process will also apply to Allied Health Professionals and Medical staff
from April 2017.
13.25. The purpose of this process is to eliminate variation, optimise the
deployment of staff and have a means of benchmarking across organisations
nationally.
13.26. The Trust will report on progress to the Quality Committee in June 2016 with
the first Unify report including CHPPD.
3
Lord Carter Review https://www.gov.uk/government/publications/productivity-in-nhs-hospitals
Twigg, D. (2011) The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: A
retrospective analysis of patient and staffing data; International Journal of Nursing Studies. Vol: 48, Issue 5, P 540-548
4
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14. Recommendations
14.1. The Board is asked to receive this Quality Report as information provided from
within the organisation on the measures being taken in relation to quality
assurance and improvement.
Dr Tony Berendt
Medical Director
Catherine Stoddart
Chief Nurse
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Appendices
How to interpret charts
Data are presented in this report in a number of different ways – including statistical
For 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)
TB2016.42 Board Quality Report
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Board Quality Report Dashboard
PS01 - Safety Thermometer (% patients receiving care free of any newly
acquired harm)
CE02 - Crude Mortality
CE03 - Dementia - % patients aged > 75 admitted as an emergency who are
screened [one month in arrears]
100%
250
100%
96%
200
80%
150
92%
60%
100
88%
40%
50
84%
0
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
RAG threshold
Red
Division
Children's & Women's
Clinical Support Services
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
OUH
Apr-15 May-15 Jun-15
Jul-15
Aug-15 Sep-15 Oct-15
Nov-15 Dec-15 Jan-16
Feb-16 Mar-16 Trend to date
100.00% 100.00% 100.00% 100.00% 100.00% 98.82% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
100.00% 100.00% 90.91% 100.00% 91.67% 95.45% 88.00% 86.67% 100.00% 86.96% 100.00% 90.00%
94.92% 97.12% 97.97% 98.44% 97.20% 95.83% 95.54% 97.52% 95.99% 99.08% 97.61% 96.53%
97.43% 99.69% 98.44% 98.72% 99.31% 97.90% 98.14% 96.54% 97.51% 96.83% 96.52% 96.85%
97.00% 97.00% 95.90% 98.55% 96.18% 95.60% 95.80% 96.88% 94.90% 96.58% 95.47% 92.64%
96.56% 98.07% 97.63% 98.68% 97.58% 96.58% 96.51% 97.15% 96.63% 97.69% 97.08% 95.92%
95% Amber
Apr-15 May-15 Jun-15
97%
PS02 - Safety Thermometer (% patients receiving care free of any harm irrespective of acquisition)
Division
Children's & Women's
Clinical Support Services
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
OUH
Apr-15
May-15
3
1
138
13
43
198
6
0
140
19
46
211
Jun-15
4
0
118
15
44
181
Jul-15
Aug-15
2
0
108
16
31
157
2
0
118
16
48
184
Sep-15
6
0
117
21
57
201
Oct-15
6
1
118
12
51
188
Nov-15
3
0
97
17
53
170
Dec-15
2
0
116
21
42
181
Jan-16
Feb-16
9
2
133
24
51
219
4
1
141
15
42
203
Mar-16
Trend to date
1
0
155
14
51
221
PS03 - VTE Risk Assessment (% admitted patients receiving risk
assessment) [one month in arrears]
100%
100%
94%
98%
88%
96%
20%
Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
RAG threshold (Trust)
Red
Division
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
OUH
Mar-15 Apr-15 May-15 Jun-15
Jul-15
Aug-15 Sep-15 Oct-15
Nov-15 Dec-15 Jan-16
Feb-16 Trend to date
77.76% 69.35% 73.77% 77.84% 77.08% 84.03% 44.67% 51.05% 52.75% 55.40% 59.89% 53.01%
56.47% 21.92% 76.53% 74.78% 81.93% 77.01% 21.43% 35.82% 33.98% 73.23% 71.93% 79.17%
38.04% 64.63% 50.57% 42.55% 46.58% 83.54% 52.17% 47.96% 55.56% 55.91% 50.00% 53.93%
70.79% 63.09% 71.17% 72.92% 74.08% 83.09% 42.74% 48.32% 50.49% 58.40% 60.44% 56.93%
92%
5
Red
91% Amber
93%
Division
Children's & Women's
Clinical Support Services
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
OUH
Apr-15 May-15 Jun-15
Jul-15
Aug-15 Sep-15 Oct-15
Nov-15 Dec-15 Jan-16
Feb-16 Mar-16 Trend to date
100.00% 100.00% 100.00% 100.00% 100.00% 98.82% 100.00% 100.00% 100.00% 98.65% 100.00% 100.00%
100.00% 100.00% 81.82% 95.24% 91.67% 86.36% 88.00% 73.33% 100.00% 86.96% 96.00% 85.00%
91.61% 90.71% 91.20% 91.54% 90.54% 90.13% 88.84% 90.32% 88.68% 93.12% 89.23% 87.59%
95.18% 96.88% 97.19% 98.08% 97.59% 95.51% 95.96% 94.97% 95.02% 95.87% 93.35% 94.64%
92.13% 92.00% 93.52% 95.27% 92.37% 90.11% 90.76% 95.31% 92.94% 96.90% 91.77% 87.88%
93.48% 93.63% 93.99% 94.90% 93.46% 92.22% 92.12% 93.33% 92.72% 94.97% 92.05% 90.70%
PS10 - % of incidents associated with moderate harm or greater
RAG threshold
Red
95% Amber
Division
Children's & Women's
Clinical Support Services
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
OUH
Mar-15 Apr-15 May-15 Jun-15
Jul-15
Aug-15 Sep-15 Oct-15
Nov-15 Dec-15 Jan-16
Feb-16 Trend to date
94.83% 95.37% 95.60% 96.43% 95.11% 95.95% 93.14% 95.69% 94.96% 97.02% 96.65% 96.21%
97.37% 99.31% 97.44% 97.66% 98.02% 95.92% 93.16% 95.86% 99.53% 96.67% 96.49% 94.67%
96.11% 92.54% 96.52% 97.27% 95.44% 96.67% 94.36% 97.78% 97.50% 95.49% 95.97% 92.86%
96.21% 96.83% 95.59% 96.80% 93.27% 93.58% 94.86% 95.38% 94.66% 95.55% 93.23% 90.67%
97.83% 98.08% 98.44% 98.17% 98.15% 98.06% 98.27% 98.67% 98.85% 99.01% 98.52% 98.02%
96.97% 96.47% 97.36% 97.63% 96.60% 96.91% 96.47% 97.75% 97.64% 97.57% 97.02% 95.62%
Children's & Women's
95.25%
PS11 - Total number of newly acquired pressure ulcers (category 2,3 and 4)
reported via Datix [one month in arrears]
Division
Children's & Women's
Clinical Support Services
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
Corporate Services
OUH
8
4%
60
6
40
4
20
2
1%
0%
Apr-15 May-15 Jun-15
Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
RAG threshold (Trust)
Red
Division
Children's & Women's
Clinical Support Services
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
OUH
Apr-15 May-15 Jun-15
Jul-15
Aug-15 Sep-15 Oct-15
Nov-15 Dec-15 Jan-16
Feb-16 Mar-16 Trend to date
2.32%
0.67%
0.67%
0.66%
0.38%
0.36%
2.46%
0.31%
0.00%
0.73%
0.00%
1.20%
2.51%
1.43%
1.84%
0.61%
2.29%
0.75%
1.29%
1.48%
1.95%
0.41%
1.00%
0.34%
1.88%
2.15%
1.17%
1.38%
2.15%
1.10%
1.93%
0.92%
1.57%
0.26%
0.40%
1.11%
2.24%
2.16%
3.49%
3.82%
4.05%
4.86%
2.96%
1.51%
2.43%
1.42%
0.56%
2.45%
3.40%
2.37%
2.16%
2.46%
3.27%
3.00%
3.49%
1.89%
1.89%
2.44%
1.29%
0.97%
2.45%
1.99%
2.13%
1.77%
2.40%
1.90%
2.37%
1.19%
1.59%
0.93%
0.61%
1.17%
6.5% Amber
0
Mar-15 Apr-15 May-15 Jun-15
Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16
5%
Division
Children's & Women's
Clinical Support Services
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
OUH
Mar-15
2
2
34
16
14
68
Apr-15
1
1
19
12
14
47
May-15
1
2
34
11
23
71
Jun-15
1
5
30
13
17
66
Jul-15
Aug-15
0
3
29
15
24
71
0
1
34
13
19
67
Sep-15
1
3
34
12
25
75
Oct-15
2
1
36
15
23
77
Nov-15
4
1
29
14
24
72
Dec-15
0
4
39
17
11
71
Jan-16
Feb-16
2
2
34
11
26
75
1
0
27
13
28
69
Trend to date
Apr-15
May-15
4
0
0
3
1
0
8
Jun-15
1
2
5
1
2.5
0.5
12
Jul-15
1
2
4
4
3
0
14
Aug-15
2
3
6
5
2
1
19
Sep-15
1
1
8
3
2
0
15
Oct-15
0
2
3
3
5
0
13
Nov-15
1
0
4
4
5
0
14
Dec-15
0
2
4
4
5
1
16
Jan-16
2
1
7
3
3
0
16
Feb-16
3
0
2
4
4
0
13
Mar-16
1
1
1
4
3
0
10
Trend to date
2
3
12
6
1
1
25
PS12 - Falls leading to moderate harm or greater
80
2%
Neuroscience, Orthopaedics,
Trauma & Specialist Surgery
Medicine, Rehabilitation &
Cardiac
Clinical Support Services
0
Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16
5%
3%
Surgery & Oncology
15
76%
RAG threshold
Corporate Services
20
94%
90%
90%
25
82%
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
80% Amber
PS04 - Serious Incidents Requiring Investigation (SIRI) reported via STEIS
10
70%
Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16
0
Apr-15 May-15 Jun-15
Jul-15
RAG threshold (Trust)
Red
Division
Children's & Women's
Clinical Support Services
Medicine, Rehabilitation & Cardiac
Neuroscience, Orthopaedics, Trauma & Specialist Surgery
Surgery & Oncology
Corporate Services
OUH
Apr-15
Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
8 Amber
May-15
0
0
3
0
1
0
4
7
Jun-15
0
0
0
1
1
0
2
Jul-15
0
0
3
0
0
0
3
Aug-15
0
0
5
0
0
1
6
Sep-15
0
0
2
0
2
0
4
Oct-15
0
0
0
2
3
0
5
Nov-15
0
0
3
1
2
0
6
Dec-15
0
0
0
0
1
0
1
Jan-16
0
0
0
0
1
1
2
Feb-16
0
0
1
0
0
0
1
Mar-16
0
0
0
0
0
0
0
Trend to date
0
0
0
0
0
0
0
Appendix 2 Patient experience dashboard:
Comments
95%
6%
2%
1.9%
1.3%
4%
98%
98%
97%
96%
96%
94%
94%
94%
92%
FFT Inpatient % not recommend by
division
3%
2%
1.6%
1.6%
1.2%
2%
1%
Inpatients
ED
Maternity
Only NHS Trusts with more than 100 responses have
been included.
0%
Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
FFT Inpatient and day case response
rates by division
30%
25%
Feb-16 FFT % Not Recommend: National
Best and Worst
37.2%
16%
13%
7%
15%
10%
40.0%
35.0%
30.0%
25.0%
20.0%
10.8%
15.0%
8.1%
10.0%
0.0%
5.0% 0.0% 1.5%
0.0%
IP
ED
8.0%
worst
OUH
best
worst
0.0% 1.5%
Mat
Only NHS Trusts with more than 100 responses
have been included.
70%
60%
50%
40%
30%
20%
10%
0%
31%
26%
20%
0%
OUH
worst
OUH
120% 100%
100% 94%
98%
96%
100%
84%
81%
74%
80%
46%
60%
40%
20%
0%
5%
Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
best
Feb-16 FFT % Recommend: National Best
and Worst
0%
16%
5%
worst
Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
23%
10%
35%
3.1%
2.7%
3%
best
90%
Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
1%
best
The staff were very willing to help, no matter how
small the problem (like helping to put me on the right
path when I was lost) the consultant was on time and
pleasant to talk to and I didn’t feel rushed, he was
also eager to help when I asked if I could have the
results of the test he had just performed so I could
take them to my next appointment which was only
two hours after that appointment. Also I didn’t have
to wait long to get the appointment after the initial
referral and it was helpful to receive a reminder text.
Neurophysiology Outpatients, JR (NOTSS)
100%
27%
25%
15%
3.8%
0%
OUH and National FFT response rates
20%
4%
FFT Inpatient % recommend by division
worst
From the moment I entered the department the
service was excellent. Booking in assistant, to the
nurse, to the consultant was a warm and friendly
experience. The consultant took his time explaining
and made me feel like an equal. Blenheim
outpatients, Churchill (NOTSS)
Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
30%
11.5%
OUH
75%
OUH
The service I received was excellent by all members
of staff I met and was treated by. They were very
kind, compassionate and understanding throughout,
given my general ill health and frailty with the injury I
went to A+E with. Horton ED (MRC)
81%
OUH and national FFT % not
recommend
10%
85%
80%
FFT: Response rates
12%
8%
best
The care, help, communication of what is happening
to you and why has been excellent from surgeon to
nurses, to carers, and domestics. Your questions are
answered in a language you can understand and
your choices explained to you. Cannot fault any part
of the process or staff. They should all be
congratulated on their professionalism. Jane Ashley
& Colorectal Centre, Churchill (S&O)
14%
90%
Excellent, patient and kind care. First class medical
care, efficient and helpful aftercare and liaison with
other agencies. Food very good and excellent
choice. Short Stay Unit (Ward 6B/C), JR (MRC)
Absolutely brilliant care from GP, operation and post
operation.
Excellent
communication.
Great
hospitality throughout the whole experience. Thank
you to the whole team. Ward C, NOC (NOTSS)
96%
96%
93%
best
Wonderful care by every member of staff‐ midwives,
care workers, consultants ‐ everyone! I have been so
well looked after and so well supported during this
hugely new experience. Breastfeeding support
especially appreciated. Delivery Suite, JR (C&W)
100%
worst
Consultants and Doctors take time to listen to our
needs and concerns. Clear plan of treatment is
explained but discussed with parents. Nurses seem
to be under pressure but endeavour to do their best.
Bellhouse-Drayson Children’s Ward, JR (C&W)
FFT: % not recommend
OUH and National FFT % recommend
OUH
We were made to feel at home as soon as we came
in. Nothing was too much trouble. The parent's room
and playroom are a god send as well as all the
fabulous staff. Children’s ward, Horton (C&W)
FFT: % recommend
Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
Feb-16 FFT Response Rates: National Best
and Worst
63%
46%
24%
19%
6%
best
OUH worst
Inpatients
0.2%
best
OUH worst
ED
Only NHS Trusts with more than 100 eligible patients
have been included.
Complaints
New complaints
0.15%
New PALS enquiries
% Complaints against Finished Consultant Episodes (FCE)
0.14%
0.50%
Closed complaints
% PALS against FCE
0.39%
0.40%
0.10%
0.10%
0.10%
0.04%
0.04%
Oct-15
0.10%
Nov-15
Dec-15
Jan-16
Feb-16
New Complaints Opened
20
21
10
11
7
4
100%
Mar-16
95%
0
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Complaints by severity grading January 2016 - March 2016
100
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
This includes all PALS enquiries and issues: positive, negative, or mixed
feedback; issues for resolution; and advice or information requests.
30
14
12
10
10
8
6
Oct-15
Mar-16
34
30
Managing complaints
4
96%
0
Q4 2014/15
95%
2
3
2
2
1
1
60
80%
40
Q2 2015/16
Reopened complaints: March 16
90%
85%
Q1 2015/16
3
92%
4
3
2
1
0
Q3 2015/16
2
4
% complaints investigations completed within agreed
timescales
80
1
82%
0
0
C&W
MRC
NOTSS
S&O
CSS
Corporate
75%
Quarter 4
(2014/15)
20
0
C&W
150
0.28%
0.24%
0.20%
0.17%
0.00%
0.00%
40
0.30%
0.20%
0.05%
Reopened complaints
16
MRC
NOTSS
S&O
CSS
Corporate
Top complaints themes by division, January 2016- March
2016
100
Quarter 1
(2015/16)
Quarter 2
(2015/16)
Quarter 3
(2015/16)
% complaints acknowledged within 3 days
C&W
Clinical treatment
Appointments
80%
100%
70%
99%
60%
98%
50%
Target 95%
Communication
CSS
Corporate
Admission and Discharge
Other
50%
54%
20%
10%
94%
NOTSS
S&O
Access to treatment
78%
30%
95%
MRC
81%
40%
96%
0
90%
97%
50
% Complaints upheld or partially upheld
0%
Quarter 4
(2014/15)
93%
92%
91%
90%
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Quarter 1
(2015/16)
Quarter 2
(2015/16)
Quarter 3
(2015/16)
Children’s and Women’s Division, (C&W),
Safe Staffing Dashboard (In-patient Areas only) May 2016
Appendix 4A
C&W
Total Funded WTE
Vacancy %
Sickness %
Maternity/Adoption Leave %
Agreed Staffing Levels %
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
January 2016
February 2016
March 2016
January 2016
Trust
February 2016
767.2
767.2
767.2
2963.3
2963.7
2963.7
6.5%
6.7%
6.1%
6.4%
5.3%
5.1%
5.3%
5.2%
5.6%
4.6%
4.6%
4.6%
4.5%
4.6%
4.5%
3.2%
3.2%
3.1%
69%
57%
51%
76%
69%
69%
10
14
16
61
67
59
2
1
3
73
68
94
1
0
0
4
2
3
5
1
0
9
1
0
March 2016
March 2016 Safe Staffing by inpatient wards for C&W division
EARLY SHIFT
LATE SHIFT
NIGHT SHIFT
Agreed
Establishment
Escalation
Minimum
Surplus
Narrative: Childrens Directorate: mitigation of at risk shifts has included the use of bed closures through the official sign off process, staff have also been moved between areas and appropriate use of temporary bank and agency staff in order to mitigate
escalation shifts. The levels of ‘agreed staffing’ have reduced to 51%, however the system of reporting has been refined with the new deputy matrons in childrens’ services and although there have been consistent bed closures due to the levels of staffing, there
are greater % of minimum staffing ratios this can be attributed to higher than average sickness rates including long term and short notice sickness. All escalation shifts have been mitigated by the bed closures.
The national Safer Nursing Care Tool for Children’s acuity and dependency has been developed and provides a greater level of evidence than the current RCN guidance which is non-specific to specialist areas and differing acuity levels, and has been in place for a
number of years. The SNCT is planning to be tested and utilised from June 2016, to assist in identifying the specific evidence base for each specialist area and the required establishments. Horton Childrens Ward: The situation is unchanged and is usually on
minimum staffing, due to high levels of long term sickness which has decreased the nurse to patient ratio, requiring 4 bed closures to mitigate the safe staffing levels. This is on the Divisional Risk Register. Beds were closed and elective patients cancelled to
mitigate risk
Incidents: All reported medication errors and pressure ulcers are being monitored closely and learning generated through the SIRI process.
Maternity – an escalation process is in place to cover periods of high activity/staffing issues. If there are available staff in the individual maternity units they are moved to cover the areas with reduced staffing or higher acuity. At night there are on call midwives
available and as clinically indicated community midwives are called to cover alongside the Midwifery Lead or Consultant led units. Women can be asked to move to either the JR or HH if the activity is high on a particular site.
Clinical Support Services Division, (CSS), Safe Staffing Dashboard Inpatient Areas only
May 2016 Appendix 4B
CSS
Total Funded WTE
Vacancy %
Sickness %
Maternity/Adoption Leave %
Agreed Staffing Levels %
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
Falls with moderate, major or
catastrophic harm
January 2016
February 2016
March 2016
187.6
187.6
21.9%
Trust
January 2016
February 2016
March 2016
187.6
2963.3
2963.7
2963.7
16.8%
18.2%
6.4%
5.3%
5.1%
3.9%
3.9%
3.9%
4.6%
4.6%
4.6%
6.0%
7.3%
6.1%
3.2%
3.2%
3.1%
92%
74%
80%
76%
69%
69%
3
0
5
61
67
59
1
0
0
73
68
94
0
0
0
4
2
3
4
1
1
231
188
182
0
0
0
1
0
0
March 2016 Safe Staffing by Inpatient ward for CSS division
EARLY SHIFT
LATE SHIFT
NIGHT SHIFT
Agreed
Establishment
Escalation
Minimum
Surplus
Narrative
Recruitment campaign plans continue within adult critical care services, with an increase in the levels of agreed staffing.
Long term agency staff are utilised to ensure optimal levels that comply with level 3 and level 2 patient requirements, and operate across all three sites where there is an ITU/CCU facility. The Adult Critical Care Units experience the highest levels of maternity leave in the Trust, which leads
to issues related to senior staff cover and supervision. At risk shifts are mitigated by careful bed management and movement of staff across units and sites, and the at risk shifts mitigated through agency staff booking and senior supernumery staff being included in the numbers i.e. matron.
There has been a very slight increase in medication errors in March, and this is being closely monitored.
Medicine, Rehabilitation & Cardiac Division, (MRC), Safe Staffing Dashboard (In-patient Areas Only)
May 2016
Appendix 1C
MRC
January 2016
February 2016
March 2016
Total Funded WTE
895.6
895.7
Vacancy %
3.0%
Sickness %
Trust
January 2016
February 2016
March 2016
895.7
2963.3
2963.7
2963.7
2.3%
1.7%
6.4%
5.3%
5.1%
4.5%
5.0%
4.6%
4.6%
4.6%
4.6%
Maternity/Adoption Leave %
2.7%
2.6%
2.4%
3.2%
3.2%
3.1%
Agreed Staffing Levels %
79%
74%
73%
76%
69%
69%
19
25
22
61
67
59
34
30
45
73
68
94
0
0
3
4
2
3
122
108
97
231
188
182
1
0
0
1
0
0
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
Falls with moderate, major or
catastrophic harm
March 2016 Safe Staffing by Inpatient ward for MRC division
EARLY SHIFT
LATE SHIFT
NIGHT SHIFT
Agreed
Establishment
Escalation
Minimum
Surplus
Narrative:
There is monitoring of the Nurse Sensitive Indicators in alignment with the quality of the staffing levels and there has been a significant reduction in the number of patients with pressure ulcers overall with a slight increase again in
March. This is supported by a proactive approach within the division towards prevention, through undertaking early assessment including the early use of pressure relieving equipment. All SIRIs are scrutinised, learning gained and
shared locally and across the division through the Pressure Ulcer Prevention and Clinical Improvement Group (PUPCIG).
MRC has had a few shifts within the medical wards at the John Radcliffe recorded as At Risk and escalated, this was mitigated appropriately and no harm occurred to patients as a result. Agreed levels of staffing increases at night
due to a higher temporary staff fill rate. Sickness, maternity/adoption leave and the vacancy rates remain consistent and well managed.
There have been high levels of falls, however no high impact falls, this is monitored, and the Falls Safe programme is being implemented with close monitoring of trends and the impact of the interventions. The levels of category 3
pressure ulcers are being monitored closely and staff receive training in early assessment and prevention, this is monitored through the PUPCIG.
Neurosciences, Orthopaedics, Trauma & Specialist Surgery, (NOTSS), Safe Staffing Dashboard (Inpatient Areas Only)
May 2016
Appendix 4D
NOTSS
Trust
January 2016
February 2016
Total Funded WTE
635.0
635.0
Vacancy %
6.1%
Sickness %
Maternity/Adoption Leave %
Agreed Staffing Levels %
January 2016
February 2016
March 2016
635.0
2963.3
2963.7
2963.7
4.4%
3.5%
6.4%
5.3%
5.1%
3.4%
3.5%
4.0%
4.6%
4.6%
4.6%
2.5%
1.6%
1.5%
3.2%
3.2%
3.1%
78%
86%
73%
76%
69%
69%
14
16
9
61
67
59
11
11
17
73
68
94
2
1
0
4
2
3
63
41
39
231
188
182
0
0
0
1
0
0
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
Falls with moderate, major or catastrophic
harm
March 2016 Safe Staffing by Inpatient ward for NOTSS division
EARLY SHIFT
LATE SHIFT
NIGHT SHIFT
Agreed
Establishment
Escalation
Minimum
Surplus
Divisional Nurse Narrative:
Escalation shifts remain at a minimum and continue to be managed proactively by the directorates, reviewing acuity and activity on a shift by shift basis, and implementing mitigation; no harm resulted from the levels of staffing.
Quality indicators continue to be monitored closely to ensure that impact of minimal and escalation shifts remains manageable and without harm.
Surgery & Oncology Division, (S&O), Safe Staffing Dashboard (In-patient Areas Only)
May 2016
Appendix 4E
Total Funded WTE
Vacancy %
Sickness %
Maternity/Adoption Leave %
Agreed Staffing Levels %
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
Falls with moderate, major or
catastrophic harm
February 2016
March 2016
January 2016
Trust
February 2016
478.2
478.2
478.2
2963.3
2963.7
2963.7
6.9%
5.6%
7.0%
6.4%
5.3%
5.1%
5.4%
4.3%
4.0%
4.6%
4.6%
4.6%
2.2%
2.7%
3.2%
3.2%
3.2%
3.1%
72%
73%
77%
76%
69%
69%
15
12
7
61
67
59
25
26
29
73
68
94
1
1
0
4
2
3
38
37
44
231
188
182
0
0
0
1
0
0
January 2016
S&O
March 16
March 2016 Safe Staffing by Inpatient ward for S&O division
Early Shift
Late Shift
Night Shift
Agreed
Establishment
Escalation
Minimum
Surplus
Narrative :
The Division continues to embed learning from the monitoring of the Nurse Sensitive Indicators including previous HAPU, high impact falls and medication incident investigations. There have been no category 3 pressure ulcers or high impact falls in March.
The recruitment and retention strategies within the division continue and the vacancy rate has increased in March. There are significant numbers of nurses remaining supernumerary until competent to take a case load of patients – usually between 6-8 weeks
after commencing employment and staffing levels have fluctuated during this time period. This time period is necessary to build their confidence and competence in order to avoid incidents and ensure safety.
Higher agreed staffing levels at night reflect higher fill rates of temporary staff at night.
Trust Safe Staffing Dashboard (In-patients only) May 2016
Appendix 4F
Trust
Jan 2016
Total Funded WTE
Vacancy %
Sickness %
Maternity/Adoption Leave %
Agreed Staffing Levels %
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
Falls with harm
Feb 2016
Mar 2016
2963.6
2963.7
2963.7
6.4%
5.3%
5.1%
4.6%
4.6%
4.6%
3.2%
3.2%
3.1%
76%
69%
69%
61
67
59
73
68
94
4
2
3
231
188
182
1
0
0
March 2016 Safe Staffing by Inpatient ward: Trust
Early Shift
Late Shift
March 2016 Safe Staffing by Shift: (Inpatient only): Trust
Agreed
Establishment
Early Shift
Night Shift
Escalation
Minimum
Late Shift
Surplus
Night Shift
Narrative These diagrams demonstrate the shift by shift staffing across the Trust ward by ward as required by the National Quality Board guidance.