SAFE
Presented to NHS Fife Board on 29th April 2014
989 973
Higher is better
1.2
0.0
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Mar-14
Jan-14
Feb-14
Apr-14
Jul-13
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
4.0%
3.0%
2.0%
Apr-14
Mar-14
Jan-14
Feb-14
Dec-13
Oct-13
Nov-13
Sep-13
Aug-13
Feb-14
0.0%
Jan-14
1.0%
Dec-13
0.0
1.0
Jul-13
Apr-14
Mar-14
Jan-14
0.0
Feb-14
Apr-14
1.4
1.3
5.0%
Nov-13
2.0
2.6
6.0%
Oct-13
3.0
7.0%
Sep-13
3.0
4.0
0.0
Dec-13
Apr-14
4.3
5.0
8.0%
Aug-13
2.0
Number of CAUTIs
Jan = 6
Feb = 3
Rate
Jul-13
7.0
5.5
1.8
Nov-13
Emergency Readmissions with 28 days
11.8%
11.3%11.2%
10.3%
10.1%
10.0%
9.5% 9.7%
9.0%
MSSA bacteraemia Oct-Dec 13
Lower is better
Number of pressure ulcers
Jan = 27
Feb =22
2.8
Oct-13
Dec-13
12.0%
Mar-14
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
by Dec 15
10.0%
6.0
Sep-13
0%
Target
NHS Fife Reported
CAUTIs per 1,000 catheter days
Lower is better
7.8
20%
11.0%
Mean rate based on NPSA guidance
10.0
40%
Fife mean
rate
2.0
Apr-14
Feb-14
Mar-14
Jan-14
Dec-13
Oct-13
Nov-13
Sep-13
Jul-13
Aug-13
Oct-13
Mean rate
based on
NPSA
guidance
4.0
NHS Fife Reported Pressure Ulcers
(Grades 2-4) per 10,000 Occupied Bed Days
Aug-13
Nov-13
6.7
0.0
Jul-13
Sep-13
Rate
Higher is better
7.9
6.0
0.0
2.1
Jul-13
MRSA bacteraemia Oct-Dec 13
9.2
8.1
Mar-14
0.5
7.4 7.8
60%
Jul-13
1.2 1.3
Target (90%)
92.9% 92.3% 91.7% 91.5% 91.8% 92.2% 91.1% 91.4%
80%
8.0
Lower is better
Lower is better
1.5
0.9
1.8
Apr-13
May-14
Apr-14
Feb-14
Jan-14
100%
9.4
10.0
1.0
4.0
0%
Combined target
NHS Fife Reported Falls
per 1,000 Occupied Bed Days
Target
by Dec 15 by Dec 15
1.8
1.5
6.3
20%
NO
DATA
Mar-14
Higher is better
Rate per 1,000 discharges
8.0
40%
18 Weeks Referral to Treatment
Combined Performance
10.3
Rate
Mar-13
Jan-13
Feb-13
0
Aug-13
200
60%
Oct-13
400
97.6% 97.5% 96.2% 95.3% 99.3% 98.5% 97.4% 96.0%
Sep-13
600
80%
Target
100%
80%
60%
40%
20%
0%
National target (98%)
100%
C difficile (over 65) Oct-Dec 13
Cardiac Arrest Rate per 1,000 discharges
Acute Services Division Only
1.2 1.2
Fife
971
800
95% Harm Free Care Acute Services Division Only
1.5
1130
1045
1024
986
1000
Jan-Mar Apr-J un Jul-Sep Oct-Dec Jan-Mar Apr-J un Jul-Sep Oct-Dec Jan-Mar Apr-J un Jul-Sep
2011
2011
2011
2011
2012
2012
2012
2012
2013
2013
2013
2.0
937 945
931
Jun-13
No. of reported incidents
0.50
Lower is better
Standardised Mortality Rate
1.00
1200
1136
1105
1046
1033
May-13
Activity was
82,314
patient
episodes
which
included
8,365
overnight
stays
1.50
0.00
4 hour Emergency Access Performance
Reported Incidents for NHS Fife
Scotland
Aug-13
Hospital Standardised Mortality Rate Jan 2011 - Sep 2013
Fife
EFFECTIVE
NHS Fife HealthCheck January-February 2014
PERSON-CENTRED
Activity
Activity for the period January 2014 to February 2014 was 82, 314 patient episodes. This included 8,365 overnight stays and 4,626 day
cases. There were 24,386 new and 44,487 review Outpatient attendances.
Complaints, Concerns, Comments, Compliments
Compliments
Complaints
Comments
Hospital Standardised Mortality Rate (HSMR)
The last quarterly data to September 2013 was published in February 2014. This shows a HSMR of 0.99 for Fife. It should be noted that
this is a provisional figure. The majority of hospital admission data will be complete for that latest quarter, however it should still be
considered provisional on the basis that the source data are dynamic and additional hospital returns will come in and be refl ected in
future calculations of the HSMR for that quarter.
Concerns
95% Harm Free Care
One of the aims of the SPSP is that 95% of people in acute adult health care are free from the four harms of the Scottish Patient Safety
Indicator (SPSI). The four harms are Cardiac Arrests; Catheter Associated Urinary Tract Infection (CAUTI); Pressure Ulcers and Falls.
160
140
120
• Cardiac Arrests – The target is a 50% reduction in CPR attempts by the end of December 2015. Figures from last month’s
HealthCheck have been adjusted in line with the SPSI definition of cardiac arrest and now excludes cardiac arrests that occurred
in the following areas: A&E, SHDU, MHDU, CCU, outpatients and day cases. Improvement work around the deteriorating patient
continues with PatientTrack being spread out to wards, weekly reporting on compliance with DNACPR and training by
Resuscitation Officers.
• CAUTIs – There were 6 CAUTIs in January (all Acute Services Division) and 3 in February (1 Acute Services Division, 2
Glenrothes & North East Fife CHP). It is the aim to reduce CAUTIs by 30 % by the end of December 2015. It is hoped to achieve
this by the implementation of the urinary catheter insertion bundle , urinary catheter maintenance bundle, to raise awareness of
issues with clinical staff and to implement interventions to improve antimicrobial prescribing.
• Pressure Ulcers – It is thought that the increase in reporting of grade 2-4 pressure ulcers is due to an increased awareness that
this is a required element of the SPSI. The aim is to achieve 300 days between hospital acquired avoidable pressure ulcers per
ward by the end of December 2015. It is hoped that this will be achieved by implementing the NHS Scotland SSKIN bundle, risk
identification and risk assessment of pressure ulcers and education and training in pressure area care.
• Falls – The target is a 25% reduction in all falls by the end of December 2015. Given the current rate for falls the variation
appears to be normal for NHS Fife. An extensive falls programme in the CHPs and the Acute Services Division is being
undertaken in order to reduce the number of falls and to raise awareness of issues with clinical staff.
100
80
152
60
40
66
0
-20
30
33
-40
8
4
-60
37
42
64
36
34
17
5
31
44
27
2
37
11
5
68
23
17
6
1
53
36
49
65
Feb-14
56
35
Jan-14
20
53
-80
Dec-13
Oct-13
Sep-13
Aug-13
Jul-13
-120
Nov-13
-100
Significant Adverse Events (SAE) Review
There were a total of 1995 incidents reported from January 2014 to February 2014. Of these 1.0% (18/1995) reported were graded as
major/extreme and 44% of those (8/18) have been commissioned for an internal SAE Review. These were categorised as patient falls
(2); tissue viability (2); endoscopy incident (1); personal accident (1); access/appointments/admission/transfers/discharge (1); and
overpopulated emergency care services in Accident & Emergency and Admissions Unit 1 (1). One of the tissue viability incidents has
now been downgraded to a local investigation after the initial Leadership Oversight Group (LOG) meeting.
Staff Sickness
Staff Sickness
6.00%
4.97%4.65%
Complaints
There were 64 formal complaints (with multiple issues) reported in January 2014 & February 2014. The 3 key themes from these formal
complaints were: clinical treatment 44% (114/258); attitude and behaviour 19% (49/258); and communication (oral) 9% (24/258).
Target (4.00%)
5.34%
4.64%
4.90%
4.82%
4.64% 4.71%
Patient/Staff Experience
Baseline results are now available for five wards who have used the “Your Care Experience” questionnaire to seek feedback. This will be
rolled out to a further two wards during the month of May. Tablet devices (n=32) have been purchased and an app developed which will
link to the dashboard. The Board should expect to see patient experience data in the June report.
Lower is better
5.00%
4.00%
3.00%
Scottish Public Services Ombudsman (SPSO)
Four decisions were reached by the SPSO during January and February:
Case 1 - the SPSO did not uphold a complaint about the treatment of a child who developed pneumonia; however they did highlight the
fact that the documentation was not as detailed as it could have been and provided the Practice with Guidance.
Case 2 – the SPSO did not uphold a complaint about the delay in reaching the diagnosis of cleft palate, concluding that all aspects of
treatment were reasonable.
Case 3 and 4 – the SPSO did not uphold a complaint about the treatment of a breathless patient who subsequently died as a result of a
pulmonary embolus. The SPSO did however uphold aspects of the same patient’s hospital care and made a number of
recommendations which have been acted upon and included in NHS Fife’s reducing harm action plan and reported via Clinical
Governance.
2.00%
1.00%
Staff Experience
NO
DATA
4
4
Dec-13
Oct-13
Nov-13
0
Sep-13
2
0
Jul-13
2
Aug-13
NO
DATA
6
Jul-13
6
Theme for Person Stories at today’s Board is dementia.
The Board will hear the story of Mrs A who’s mother suffers from dementia and a story from Mrs W from a staff perspective.
Dec-13
8
Oct-13
8
Nov-13
10
Sep-13
10
Aug-13
Patient Experience
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
0.00%
Data
The source of data contained within this document varies and can be derived from validated published sources, official government
returns and databases, and local activity data and management information from a variety of internal sources.
The frequency of data updating also varies, with some data being updated monthly and others quarterly.
Data correct as at 15/04/2014