Date of Meeting: 29 September 2016 / Agenda Item: 6
Title
Quality Report – Month 5
Responsible Executive Director
Dr George Findlay, Medical Director
Amanda Parker, Director of Nursing and Patient Safety
Prepared by
Dr George Findlay, Medical Director
Amanda Parker, Director of Nursing and Patient Safety
Status
Disclosable
Summary of Proposal
N/A
Implications for Quality of Care
Describes performance against quality outcome KPIs, including safety, infection control, experience, effectiveness and mortality.
Link to Strategic Objectives/Board Assurance Framework
This report pulls together key national, regional and local quality indicators relating to quality and safety providing assurance for the board and (if necessary) highlighting issues.
Financial Implications
Describes KPIs that have potential financial impact (e.g. CQUIN).
Human Resource Implications
Describes KPIs linked to workforce.
Recommendation
The Board is asked to NOTE the report.
Communication and Consultation
N/A
Appendices
Appendix 1: Quality Scorecard
Appendix 2: Ward Staffing Scorecard
1INTRODUCTION
1.1This report brings together key national, regional and local quality indicators relating to quality and safety. The purpose of the report is to bring to the attention of the Trust Board quality performance within Western Sussex Hospitals Foundation Trust (WSHFT).
1.2The paper describes performance on an exceptional basis determined by RAG (red/amber/green) ratings based on national, regional or local targets. Further quality items are shown as dashboards in the appendices.
22016/17 REFRESH
2.1As part of the refresh of the Quality Strategy for 2016/17 that outline key quality objectives for the next years, this report will be refreshed and redesigned in line with the strategy objectives and to align to the Trust’s True North objectives.
2.2There are revised targets for 2016/17 these have been calculated based on a similar logic to that applied for 2015/16:-
- If 2015/16 Performance exceeded target, then 2015/16 actuals used as 2016/17 target
- If 2015/16 Performance did not meet target then 2015/16 target remains for 2016/17
- If national or set target then follow or continue
- If no target for 2015/16 this also continues for 2016/17
The only new target for 2016/17 Scorecard is ‘Repeat Falls’ and this has been included with the target ‘tbc’.
3KEY QUALITY OBJECTIVES
3.1Dashboard Definitions
3.1.1The full Clinical Quality Dashboard is presented as Appendix I. Figures are in-month figures (e.g. the number of falls reported in October) unless otherwise stated. The dashboard shows 13 months to allow trends to be identified, although some data items are reported retrospectively. Year to date actuals/targets are based on financial years unless otherwise stated (e.g. standardised mortality ratios are recorded as 12 month positions).A subset of the key measures from the report is presented at 3.3.
3.1.2Exception reports are included under the relevant section of this report (i.e. under the broad headings Effectiveness, Safety and Experience).
3.1.3Only the current financial year and year to date values are RAG rated, with the exception of those metrics reported in arrears with no data in the current financial year where the most recent data-point of last year is RAG rated.
3.2Domain scores
3.2.1The domain score is an overall indication of the performance in relation to each of the three areas. The score is calculated as follows: Each RAG rated indicator for a month is scored as follows: reds score 1, ambers score 2, greens score 3. These scores are then totalled and divided by the total number of indicators with RAG ratings to give a score for the domain as a whole between 1 and 3. This final score can then itself be RAG rated with >2.5 giving an overall green, 1.5 to 2.5 amber and <1.5 an overall red score for the domain as a whole. For example if a domain had two greens and a red the calculation would be as follows:
3 (green) + 3 (green) + 1 (red) = 7
7 / 3 (i.e. the total number of metrics) = 2.33 i.e. amber overall.
3.2.2Year to date domain scores arecalculated based on the year to date RAG ratings for each metric. Previous months are retrospectively updated to take account of any measures reported in arrears.
3.2.3As with any aggregate indicator, it remains essential that the board retains sight of the individual elements as well as the domain score as a whole.
3.3Overview of Key Quality Objectives
3.3.1The following table shows performance against key, top level quality objectives.
Indicator / June2016 / July
2016 / August
2016 / 2016/17 to date / 2016/17 Target / limit
Effectiveness Domain Score / 2.40 / 2.58 / 2.71 / 2.78 / 2.5
Safety Domain Score / 2.44 / 2.5 / 2.22 / 2.22 / 2.5
Experience Domain Score / 2.0 / 2.07 / 2.13 / 2.07 / 2.5
E01 Trust crude mortality rate (non-elective) / 2.57% / 2.88% / 2.63% / 2.98% / 3.13%
E03 Hospital Standardised Mortality Ratio for top 56 diagnoses (Dr Foster, based on rolling 12 months) / 91.5 (12m to May / <92
S06 Number of Serious Incidents Requiring Investigation (number reported in month) / 11 / 6 / 7 / 42 / 60
S14 Numbers of hospital attributable MRSA / 1 / 0 / 0 / 1 / 0
S28 Numbers of hospital C. diff where a lapse in the quality of care was noted / 2 / 2 / 1 / 9 / 18 (national target = 39)
X38 The Friends and Family Test: Percentage Recommending Inpatients / 95.5% / 95.8% / 96% / 95.6%
X39 The Friends and Family Test: Percentage Recommending A&E / 90.9% / 89.2% / 87.9% / 90.4%
X13 Mixed Sex Accommodation breaches (number of breaches) / 0 / 0 / 0 / 6 / 0
X18 Number of complaints / 58 / 58 / 47 / 277 / 570
4EFFECTIVENESS
4.1Crude Trust Mortality
4.1.1Due to the low level of mortality experienced in elective care, the Trust measures mortality in relation to non-elective activity. The Trust uses the previous year as a benchmark.
4.1.2Crude non-elective mortality fellfrom 2.88% in July to 2.63% in August. This is lower than the equivalent month in 2015 (August2015 = 3.15%).The number of nonelective patients who died in August was 148 (from 5622 discharges). The year to date mortality rate is 2.98% and the rolling 12 month mortality rate is 3.13%. Thelimit for both measures is 3.13%
4.2Hospital Standardised Mortality Ratio (HSMR)
4.2.1There is a delay in data being available in Dr Foster tools to allow for coding and processing by the Health and Social Care Information Centre and Dr Foster. The most recent data available is May2016.
4.2.2The Trust’s HSMR for the twelve months to May2016is 91.5 (where 100 is the level predicted by the Dr Foster model using the April 2015 benchmark).HSMR has been relatively stable at around 90 for the last 10 months, indicating that the significant improvements have been sustained.
4.2.3The twelve month HSMR to January2016split by site is lower for St Richards (88.0) than for Worthing (94.2), however both are lower than 100.
4.2.4This data is now rebased using the latest available benchmark (April 2015), this accounts for the observable increase at April 2015.
4.2.5A further report is available to clinical leaders in the Trust showing the clinical diagnostic areas with high actual versus expected mortality and any mortality CuSum alerts.
4.2.6The Trust has set the goal of achieving a position within the top 20% of Trusts as measured by HSMR. For the twelve months to May 2016 performance using this measure places us in the top 22% of Trusts
4.3Summary Hospital-Level Mortality Indicator (SHMI)
4.3.1The latest data made available by the Health and Social Care Information Centre is for the period to March 2016. The Trust value is 1.00 (where 1.00 is the national average), with the Trust banded as ‘as expected’.
4.4Exception Reports Relating to Effectiveness
None to report
5SAFETY
5.1Central Alert System (CAS) Safety Alerts
5.1.1There are no outstanding alerts for the Trust relating toAugust2016 or earlier.
5.2Serious Incidents Requiring Investigation (SIRIs)
There were 7 incidents which were reported in August that have initially been graded as serious incidents requiring investigation. A detailed SIRI report is provided to the Committee section of the Trust Board. The Board should note there is a slight variation in the month by month numbers between the SIRI report and the scorecard as the scorecard assigns incidents to the month in which they occur whereas the latter assigns them to the month in which the SIRI was raised.
5.2.1 The 7 incidents related to 2unstageable pressure ulcers, 4 falls resulting in a fracture neck of femur and surgery and I neonatal death.
5.2.2 Recent actions undertaken/planned following SIRIs include continuing education and training of staff particularly falls and pressure damage prevention.
5.3Infection control
5.3.1There were 2cases of hospital attributable Clostridium difficile during August. One case occurred at the Worthing site and one at St Richards.
5.3.2The 2 cases in Julyequate to a rate of7.21cases of C diff per 100,000 bed days compared the national average for 2014/15 of 15.1 cases per 100,000 bed days (interquartile range 10.3 to 17.6) (source:
5.3.3Of the 2cases in August, root cause analysis identifiedone case related to lapses in care, relating to a dusty environment.
5.3.4The allocated trust target limit for 2016/17 remains at 39. A stretch target limit of 33 has been agreed for the trust as we aspire to improve on last year. We have currently reached a total of 19cases andare above trajectory.
5.3.5A total of 9 lapse of care incidents have occurred against a stretch target of 16 cases.
5.3.6Further assurance on how the trust manages the risk of patients contracting MRSA bacteraemia. In order to prevent a hospital acquired infection best practice is required in a number of areas. The infection control team meets monthly and reviews ward audits on hand hygiene, peripheral and central line management. Decontamination of high risk equipment and undertake a monthly audits of whether patients received an MRSA screen on admission and as per policy during their hospital stay. In addition audits on blood cultures and antibiotic use are seen.
5.3.7All areas where audits demonstrate underachievement are requested to provide action updates on what is occurring to improve standards.
5.3.8Surgical Site Infections
5.3.9SSI are overseen by the SSI group chaired by an orthopaedic surgeon. The group reports into the trust infection control committee. Quarterly reports are received on surgical site infection in relation to hip and knee surgery, bowel surgery and breast surgery. There is focused activity by clinical specialties looking at standardisation of care across the patients pathway and learning events are held for specialties to learn from each other. We recognize that within our SSI rates are higher than the national benchmark.
5.3.10SSI Report for Total Hip Replacements January – March 2016.
The overall SSI rate for Total Hip Replacements are 5.1% with an average of 3.2% for last 4 quarters. The National benchmark is 1.1%. There were 5 re admissions of Total Hip replacements of these 3 were organ space infections. Our inpatient infection rate is 3.2%. The national benchmark is 0.5%.
5.3.11SSI Report for Total Knee replacements January – March 2016.
The overall SSI rate for Total Knee Replacements are 4.5% with an average of 2.7% for last 4 quarters. The National benchmark is 1.5%. There were no deep infections or re admissions of Total Knee Replacements, there were 8 superficial incisional infections. Our inpatient infection rate is 0%. The national benchmark is 0.5%.
5.3.12 For hips and knees there is a recognized pathway that is in place and all infections are assessed against that best practice path.
5.3.13SI Report for Larger BowelSurgery January – March 2016.
The overall SSI rate for Large Bowel surgery is20% with an average of 17% for last 4 quarters. The National benchmark is 12.4%. Our inpatient infection rate was16.7%. The national benchmark is 9.9%.
5.3.14SSI Report for Breast Surgery January – March 2016.
The overall SSI rate for Breast surgery is 6.8% with an average of 5.7% for last 4 quarters. The National benchmark is 3.9%. Our inpatient infection rate was 0%. The national benchmark is 0.8%.
5.4.1 Streptococcus A
5.4.2 Ten cases of Group A Streptoccus infection have occurred across sites in August. Of these 2 cases were Invasive Group A Streptococcal Disease(iGAS) and notified to PHE.All the cases were reviewed and a meeting with PHE was held to ascertain if any were linked and should be classed as an outbreak.3 of the cases were confirmed as community acquired, 3 of the cases were post breast surgery in Worthing and of these two were of the same strain and had been operated on in the same theatre. Therefore these cases were considered linked.
5.4.3 Immediate action were taken and included; Staff screening of staff in the breast theatres and 1 surgical ward was advised and initiated by Occupational Health.Deep cleans of the theatres (undertaken) and ward.
5.4.4 A further surgical case in SRH (circumcision) was not linked but screening of the theatre staff involved advised and initiated.
5.4.5 There have been no further cases and the cases occurred at a time of increased community Strep A.
5.4.1 Influenza Vaccination
5.4.2 Activity has commenced to ensure that the organisation is prepared for winter and that staff have received the flu vaccine in order to to protect patients, themselves and their families. Nationally a target of 75% uptake for front line workers has been set with this linked to CQUIN funding.
6
6.3Falls
6.3.13In August there were 40falls resulting in harm against a benchmark of 43.
6.3.14There were 4 falls resulting in a fracture neck of femur and surgery and resulted in moderate harm to patients.
6.3.15Ten wards are currently within a falls break through project, these wards continue to show significant improvement in their patient fall numbers and have been sharing their learning with other wards.
6.4Tissue Viability
6.4.13As described previously, changes in the way the Trust reports pressure ulcers means that more grade 2 and grade 3 ulcers were reported in 2015/16 than previous years. This pattern of reporting will continue during 2016/17.
6.4.14Based upon these reporting arrangements, during August the Trust reported 17 cases of grade 2 hospital acquired pressure ulcers.
6.4.15In addition to this there were2hospital acquired pressure ulcersthat weregrade 3. One related to a medical device and there was no lapse of care and for the second a lapse of care was noted in the assessment of the patient and subsequent allocation of pressure relieving equipment.
6.4.16The incidence of pressure ulcers, Grade 2 and above (including those developing within 72 hours after admission) per 1000 bed days in Julywas 0.72.This compares to a national rate of 0.9 as recorded through the Safety thermometer nationally in March 2016.
6.4.17There were 137 patients admitted to the Trust from the Community with pressure damage.
6.5NHS Patient Safety Thermometer
6.5.13The NHS Patient Safety Thermometeris used across all relevant acute wards. This tool looks at point prevalence of four key harms(falls, pressure ulcers, urinary tract infections and deep vein thrombosis (DVT) and pulmonary embolism (PE)) in all patients on a specific day in the month. A dashboard is available to each ward showing Trust-wide and ward-level data for each individual harm as well as the harm-free care score. These numbers are also shared via the new ward screens.
6.5.14The harm-free care score for the Trust in August was 96.3% (indicator S02), better than the target of 93.8% (target based on national average for 2014/15).
6.5.15The Safety Thermometer includes harms suffered by the patient in healthcare settings prior to admission. The actual number of patients with no new harms during their inpatient stay at WSHFT (indicator S03) was98.7%. A new target of 99% of patients suffering no new harms following admission for 2015/16 has been set within the Trust Quality Account. This will prove a stretching target as it is considerably higher than the national average of 97.7%.
6.5.16National data relating to the NHS safety thermometer is available here:
7PATIENT EXPERIENCE
7.3PALS andComplaints
7.3.13All complaints are responded to by the Trust Office. The process is administered by the Customer Relations Team. The Quarterly Complaints Report provides an in-depth analysis of trends and lessons learned. This is reviewed by the Patient Experience and Feedback Committee and is presented to the Trust Board.
7.3.14During August2016 the Trust received 47 complaints, these will all be responded to and the trust is working on improving its response time to complaints received.
7.4Friends and Family Test (FFT)
7.4.13Patients who access hospital services are asked whether they would recommend WSHFT to their friends or family if they needed similar treatment. Patients who access inpatient, outpatient, day-case, A&E and maternity are all offered the opportunity to respond to the question (plus a number of other areas outside the scope of the official friends and family data collection).
7.4.14Immediate feedback is provided to wards and departments on a continuous basis to ensure staff can address problems or get positive feedback as quickly as possible. In addition to this a dashboard is available giving wards access to their individual scores and a poster printed with ward performance to display to the public. Ward recommend rates are also shown on the new screens installed on wards.
7.4.15Friends and Family Test Response Rates:As described previously the criteria for inclusion in Friends and Family changed significantly for 2015/16 to include paediatric patients, day-cases and short-stay non-electives. As such the response rate fell considerably at the beginning of that year. Work continues to improve response rates and for the first quarter of 2016/17 we have seen the inpatient and daycase response rate achieve above 30%, and nearing our target this year of 40%.
7.4.16Friends and Family Test Recommend Rates:In line with national guidance the Friend and Family test is now reported as a ‘percentage recommending’ score (calculated as the percentage of respondents indicating they were either ‘highly likely’ or ‘likely’ to recommend the service divided by the total respondents including ‘don’t knows’). National performance is published on the NHS England website:
7.4.17The table below shows the latest local scores against national benchmarks:
Percentage recommending WSHFT in May(year to date in brackets) / National median (April 2014 to March 2015)*Inpatient care / 96.0% (95.6%) / 94.1%
A&E / 87.9% (90.4%) / 86.8%
Maternity: Delivery care / 95.5% (95.8%) / 95.4%
Outpatient care / 95.2% (93.6%) / No benchmark
Maternity: Antenatal care / 100% (96.1%) / 94.6%
Maternity: Postnatal ward / 95.5% (95.8%) / 92.2%
Maternity: Postnatal community care / 98% (99.3%) / 96.6%
* Some caution should be undertaken using this benchmark due to the changes to the eligible patients noted above.
8CARE QUALITY COMMISSION (CQC)
8.3CQC Inspection
8.3.13The CQC undertook inspection of the Trust on 8th to 11th December.A summary of actionson areas identified for improvement has been provided to the CQC. These actions are monitored through the CQC steering group and updates provided to the Trust Executive Committee each month and the action plan is overseen by the Quality and Risk Committee.
9Freedom to Speak Up Guardian
9.1 The board has previously been up dated on the trust requirement to appoint a Freedom to Speak Up Guardian by October 1st 2016. The Amanda Parker, Director of Nursing is appointed as the executive lead and Joanna Crane as the Non-executive lead for Freedom to Speak Up.