QUALITY REPORT
CONTENTS
Section / Item / Page No.1 / INTRODUCTION / 3
2 / KEY POINTS TO NOTE / 3
3 / TARGETED AREAS OF SUPPORT / 5
4 / EMERGING TRENDS/NOTICEABLE PATTERNS / 5
5 / PATIENT SAFETY / 6
5.1 / Safety Thermometer
a)Falls
b)Pressure damage
c)VTE assessment / 6
6
7
8
5.2 / Nutrition/fluids / 8
5.3 / Infection Control / 9
5.4 / Maternity / 13
5.5 / Emergency Department highlights / 13
5.6 / Safeguarding / 14
5.7 / Medicines management / 14
5.8 / Never Events / 14
5.9 / National Patient Safety Agency (NPSA) alerts / 14
5.10 / Lessons Learned / 15
5.11 / Significant risks / 15
5.12 / ‘Listening into Action’ / 15
5.13 / Nurse Staffing Levels / 15
6 / CLINICAL EFFECTIVENESS / 18
6.1 / Mortality / 18
6.2 / Patient Related Outcome Measures (PROMs) / 20
6.3 / Clinical Audit / 21
6.4 / Compliance with the ‘Five Steps to Safer Surgery’ / 21
6.5 / Stroke care / 22
6.6 / Treatment of fractured Neck of Femur within 48 hours / 23
6.7 / Ward reviews / 23
7 / PATIENT EXPERIENCE / 24
7.1 / Patient survey results / 24
7.2 / Complaints/PALS
a)Complaints and PALS data
b)PHSO cases / 24
24
27
8 / RECOMMENDATION / 27
APPENDIX 1 / Glossary of Acronyms / 28
QUALITY REPORT
This report presents a composite picture of the performance against the various key Quality metrics to which the Trust works, both in terms of those mandated at a national or regional level and those set by the organisation.
The report has been populated with latest performance information for the period up until this Board meeting, across a range of areas within three domains: patient safety, clinical effectiveness and patient experience.
5.1Safety Thermometer
CQUiN for 2012/13 – requires introduction of the tool.CQUiN
Conducting monthly whole Trust census of patients for 4 harm events (falls, pressure damage, CAUTI and VTE) continues to go well with good engagement of nursing staff. Although an inability to give any ward based data back to teams may start to affect compliance if not sorted soon.
Overall Trust harm free care in: - April = 91%
-May = 94.75%
-June = 93.74%
The target is to achieve 95% harm free care.
a)Falls
There are no formal targets set for falls for 2012/13 but we will continue to aim to reduce avoidable falls across the Trust. Our audits will continue to monitor risk assessment compliance, appropriate use of care bundles and numbers of falls. Falls with injury continue to be reported as adverse incidents and TTRs conducted.
Figure 1:Trend of falls
Figure 2: Incidence of falls per 1000 bed days across Acute Inpatient Divisions
There were 3 falls reported on the safety thermometer in May and again in June. All were low harms.
Figure 3: Community Risk Assessment
b)Pressure Damage
Target 2012/13:Reduction in pressure damage from baseline (to be agreed) CQUiN
Eradication of all avoidable pressure damage SHA Priority
Figure 4: Number of hospital acquired pressure damage Grade 1, 2, 3 & 4, April2009 - March 2012
New avoidable pressure ulcers (reported on ST):
May – 12
June – 13
(10 grade 2, 3 grade 3 community acquired).
c)VTE Risk Assessment
The VTE Risk Assessment CQUIN target continued from 2011/12. Performance of at least 90% each month is required to trigger payment. Performance in May remains in excess of the minimum 90% threshold.CQUiN
5.2Nutrition/Fluids
Target 2012/13:Reduction of avoidable weight loss in patients on 8 Trust wards where vulnerable adults are nursed.CQUiN
95% patients MUST assessed within 12 hours admission Internal Priority
Figure 5: Nutrition Audit Results
The majority of our wards now consistently meet nutrition and fluid balance standards on audit. We are changing the audit methodology to include peer audit and also to monitor all patients on the 8 selected wards for avoidable weight loss.
The baseline of avoidable weight loss will be reported in July and a reduction target agreed with commissioners.
5.3Infection Control
Targets 2012/13:C difficile – 57 cases (post 48 hours, using SHA testing methodology)
(National PriorityMRSA – 2 cases (post 48 hours)
Local contract)MRSA Screening – 85% eligible patients
Blood culture contaminants – 3% or less
E Coli and MSSA – Continue to record and TTR device related infections
National cleanliness standards – 95%
MRSA
There were no post 48 hour cases of MRSA reported in May.
MRSA Screening
Target :85% eligible patients by March 2013.
Figure 6:Percentage of eligible spells screened
Clostridium difficile
We now report C Diff numbers in two ways; the Department of Health target and our own internal best practice numbers. The SWBH best practice numbers are determined by a combination of clinical assessment and a recognised testing algorithm. By using this reporting mechanism we can ensure that all patients with clinical signs of C diff infections are identified and managed appropriately.
Figure 7: SHA Reportable CDI
Figure 8:Trust Best Practice Data
Blood Contaminants
We have been monitoring trends for several years (see graph below) and generally the trend is downward. The area with the greatest number of contaminants is EAU at Sandwell and therefore targeted action is happening.
Figure 9:Blood Contaminants
E Coli Bacteraemia
Figure 10:E Coli Bacteraemia
MSSA
Figure 11: MSSA
Surgical Site Surveillance
The Trust continues to participate in surveillance of hip and knee surgical site infection. No concerns have been identified with our practice.
Outbreak and Other Infection Control Activity
Norovirus
Priory 5 was closed due to confirmed Noroviruson 23April and re-openedon 5thMay. 22 patients and 4 members of staff were affected during the 12 days that the ward was closed.
Priory 4 was closed due to confirmed Norovirus on 23May and re-opened on 3rd June. A total of 18 patients and 6 members of staff were affected during the 11 days that the ward was closed.
Newton 4 was closed on 28th May and re-opened on 29th May. A total of 7 patients and 0 members of staff were affected; the cause of the symptoms of diarrhoea and vomiting is unknown.
PEAT
National Standards of Cleanliness average scores 96 – 97% throughout the year.
5.4Maternity
The Obstetric Dashboard is produced on a monthly basis. Of note:
Post Partum Haemorrhage (PPH)(>2000ml): there were no patients recorded to have had a PPH of >2000ml in May.
Adjusted Perinatal Mortality Rate (per 1000 babies):the adjusted perinatal mortality rate for Aprilwas 4.1 which wasnot over trajectory (8)and showed adecrease from the previous month (11.9). Perinatal mortality rates must be considered as a 3 year rolling average due to the small numbers involved and the significant variances from month to month.
Caesarean Section Rate: the number of caesarean sections carried out in May was 24.1%, which is within the trajectory of 25% over the year.
Delivery Decision Interval (Grade I, CS) >30 mins: the delivery decision interval rate for March was 6% which waswithin trajectory (15).
Community Midwife Caseload (bi-monthly): The community midwife caseload in April was 138 which wasjust within the trajectory of 140.
Vacancies: Vacancy rates remain high, but there was an improvement in April (10) down from 15 in March. The position is anticipated to continue to improve by May/June.
5.5Emergency Department highlights
Performance against a number of key measures is reviewed on monthly basis by the Emergency Department (ED) Action Team. Quality Account
Of note:
- For the first time the Emergency Departments have recorded 100% compliance with the three safety proformas
- Further investment has been agreed to improve consultant cover and to strengthen the medical middle grade (registrars)
- There has been a number of serious incidents. Whilst very small in number in comparison to the number of patients seen by the Emergency Departments, these incidents are of concern in themselves and because they appear to be above benchmark rates
- An in-depth review of incident trends is underway in order to identify themes and thus improvement actions.
- In order to provide more intensive support, the Emergency Departments have been placed in Special Measures. This is similar to the approach that is used for wards that require focused attention.
- An external Quality Assurance visit has been organized for 23 July which will provide further assistance.
5.6Safeguarding
Target 2012/13:Improve awareness and diagnosis of dementia in acute setting and on District Nurse caseload CQUiN
Currently undertaking baseline and developing assessment and audit process
Safeguarding is not due for reporting this month – the next update is due in August.
5.7Medicine Management
Target 2012/13:Use of antibiotics – Antimicrobial Stewardship – reduce the incidence of healthcare associated infectionsCQUiN
The baseline work is currently being undertaken and will be reported in June/July.
5.8Never Events
No further never events have been reported in May.
5.9National Patient Safety Agency (NPSA) alerts
1. Overdue alerts: NPSA 2011/PSA001 – Safer spinal (intrathecal) epidural and regional devices. This alert will continue to remain as “ongoing” on the Central Alert System until all of the components we require to safely convert to the new neuraxial devices are available.
2. New alerts: No new alerts have been received.
3. Completed alerts:No alerts are due to be completed or have been completed and signed off.
5.10Lessons Learned
The key to a positive safety culture within the organisation is to learn from incidents through sustainable actions. Below are some of these actions taken or being taken following serious incident investigations.
Incident / Extract from Action PlanFalse positive blood result communicated incorrectly leading to an unnecessary caesarean section /
- Review of fast track testing of bloods policy
- Initiate training on fast track procedures
- Review how fast tracked blood results are tracked and amend as necessary
Failure to apply APLS techniques in a timely manner /
- Review and amend children’s direct access protocols
- Formalise the ED triage process and escalation requirements for when delays occur
- Review and reinforcement of paediatric escalation process for calling senior medical staff
Retained guide wire following varicose veins surgery /
- Policy amendment to ensure guide wires now counted as part of theatre swab and instrument count.
Figure 12:Lessons learned from incidents
5.11Significant Risks
Significant risks are presented on a monthly basis at the Risk Management Group (RMG). These risks are being proposed for inclusion onto the corporate risk register.
There were no significant risks presented at RMG in May 2012.
5.12Listening into Action
Following the listening into action event for Patient and Staff safety an action plan has been developed and will be made available on the Risk Management and Health and Safety intranet pages. Feedback is now a mandatory field on the Safeguard system which is used by staff within the hospital setting to report incidents.
5.13Nurse Staffing Levels
The Trust aims to have staffing ratios at around 1 WTE:1 bed (unless guidance specifically states otherwise) and a qualified to unqualified ratio of 60:40.
Figure 13:Medicine Nurse Staffing Ratios
Figure 14: Surgery Nurse Staffing Ratios
We are currently holding around 80 nursing vacancies across the main bed holding divisions, pending the bed closure programme. This situation is becoming difficult to maintain as the bed closure plan has ‘slipped’ and will be discussed at Exec Team.
Bank & Agency
The Trust’s nurse bank/agency rates are detailed in the tables below and show year on year comparison from 2008/9 to date.
Figure 15: Total Bank & Agency Use Nursing April 2008 –date.
6.1Mortality
HSMR (Source: Dr Foster)
The Hospital Standardised Mortality Ratio (HSMR) is a standardised measure of hospital mortality and is an expression of the relative risk of mortality. It is the observed number of in- hospital spells resulting in death divided by an expected figure. For the most recent period the 12-month cumulative the HSMR for the Trust (92.3) continues to follow a downward trend, similar, but lower than that of the SHA Peer (97.4), with both Trust and SHA (Peer) HSMR beneath the lower (95% statistical confidence) limits. The in-month (February) HSMR for the Trust has increased slightly to 91.3. (See Mortality table and graph below)
HSMR (Source: Healthcare Evaluation Data (HED))
For the most recent12 month cumulative period, the HSMR for the Trust stands at 97.7 and although subject to continuous rebasing also demonstrates a downward trend.
SummaryHospital – Level Mortality Indicator (SHMI)
The SHMI is a national mortality indicator launched at the end of October 2011. The intention is that it will complement the HSMR in the monitoring and assessment of Hospital Mortality. One SHMI value is calculated for each trust. The baseline value is 1. A trust would only get a SHMI value of 1 if the number of patients who die following treatment was exactly the same as the number expected using the SHMI methodology. SHMI values have been categorised into the following bandings.
1 / where the Trust’s mortality rate is ‘higher than expected’2 / where the trust’s mortality rate is ‘as expected’
3 / where the trust’s mortality rate is ‘lower than expected’
Further SHMI data was published on 24/04/12 for the data period October 10 – September 11. For this period the Trust has a SHMI value of 0.99 and was categorised in band 2.
Mortality table 2011/12
Apr / May / Jun / Jul / Aug / Sep / Oct / Nov / Dec / Jan / FebInternal Data:
Hospital Deaths / 140 / 158 / 118 / 130 / 131 / 132 / 146 / 140 / 171 / 172 / 171
Dr Foster 56 HSMR Groups:
Deaths / 121 / 133 / 102 / 110 / 112 / 116 / 125 / 125 / 152 / 146 / 150
HSMR (Month) / 90.1 / 100.8 / 81.3 / 90.7 / 90.5 / 92.3 / 91.1 / 81.6 / 89.3 / 86.6 / 91.3
HSMR (12 month cumulative) / 98.4 / 98.1 / 103.4 / 102.9 / 102.9 / 101.9 / 100.6 / 97.7 / 95.7 / 93.1 / 92.3
HSMR (Peer SHA 12 month cumulative) / 96.7 / 97.0 / 106.4 / 106.2 / 105.5 / 104.5 / 104.0 / 102.5 / 100.7 / 98.3 / 97.4
HSMR (Peer National 12 month cumulative) / → / → / 93.8 / → / → / 95.7 / → / → / 92.2 / → / →
Healthcare Evaluation Data - HSMR (12 month cumulative) / 103.6 / 103.5 / 103.9 / 103.5 / 104.3 / 104.2 / 103.3 / 102.1 / 101.4 / 99.6 / 97.7
Figure 16:Mortality position
Figure 17:HSMR/readmission rate
CQC Mortality Alerts received in 2012/13
The Trust received notification in April 12 from the Care Quality Commission (CQC) of being an outlier for mortality in the period from Nov10 – Nov11 for patients with a primary diagnosis of biliary tract disease. The review into the deaths that occurred in this period has been completed. It was considered that although none of the deaths were preventable, some aspects of care could be improved. The majority of these are being addressed through existing work streams. The investigation report has been submitted to the Commission and their response is awaited.
.
Dr Foster generated alerts (RTM)
There were no new diagnoses or procedures alerting with significant variation in terms of mortality when the data period April 2011 – March 2012 is considered (see table below).
Figure 18:Dr Foster RTM alerts information
6.2Patient Related Outcome Measures (PROMs)
Further provisional data in the form of experimental statistics were published on 10th May 2012. The provisional data included updated outcome scores for the periods April 10 – March 11 and April 11- December 2011. Previously, provisional data for 2010/11 showed that patient reported outcomes needed to be improved with regard to hip and knee replacement in particular. The latest provisional data shows an improvement in the procedure specific measure scores (Oxford Knee Score) following knee replacement. A number of steps arebeing taken to better understand the potential reasons for patients not reporting better outcomes and to enhance the service provided. The Directorate of Trauma & Orthopaedics is due to present a further update on progress to the Governance Board at the meeting to be held in July.
6.3Clinical Audit
Clinical Audit Forward Plan 2012/13
The Clinical Audit Forward Plan for 2012/13 contains 83 audits that cover the key areas recognised as priorities for clinical audit. These include both the ‘external must do’ audits such as those included in the National Clinical Audit Patient Outcomes Programme (NCAPOP), as well as locally identified priorities or ‘internal must do’ audits. The position reached with the audits included in the plan as at the end of May is summarised in the table below.
Status / Total0 - Information requested / 3
1- Audit not yet due to start / 25
2- Significant delay / 0
3- Some delay - expected to be completed as planned / 1
4- On track - Audit proceeding as planned / 54
5- Data collection complete / 0
6- Finding presented and action plan being developed / 0
7- Action plan developed / 0
Grand Total / 83
Figure 19:Progress with Clinical Audit forward plan 2012/13
6.4Compliance with the ‘Five Steps for Safer Surgery’
The collection of data on the compliance with the “Five Steps to Safer Surgery” processusing the Clinical Systems Reporting Tool (CSRT) commenced on 06/02/12. Compliance data is shown in the table and graph below.
Trust performance from 06/02/12 – 10/06/12 (source CDA)Number of list entered / 4226
Number of cases / 16055
“Five Steps to Safer Surgery” / Reported compliance
Completion of the 3 sections of the checklist only / 98.%
All checklist sections and brief / 94.%
All checklist sections completed and brief & debrief / 85.%
Figure 20:Position statement of compliance with the Five Steps for Safer Surgery
Figure 21:WHO checklist compliance
The above graph indicates that performance with the checklist process itself is high at 98% overall (3 sections only). The performance with the brief and debrief aspects is less good.Compliance will continue to be monitored and feedback on performance provided to areas where this needs to be improved.
6.5Stroke Care
Performance against the principal stroke care targets to which the Trust is working in 2012/13 is outlined in the table below.
1 | Page
Indicator / April / May / TargetPts spending >90% stay on Acute Stroke Unit / 91.2. / ▼ / 88.2 / ▼ / 83%
Pts admitted to Acute Stroke Unit within 4 hrs / 82.1 / ▲ / 64.7 / ▼ / 90%
Pts receiving CT Scan within 24 hrs of arrival / 100 / ■ / 100 / ■ / 100%
Pts receiving CT Scan within 1 hr of arrival / 71.4 / ▲ / 52.9 / ▼ / 50%
TIA (High Risk) Treatment <24 h from initial presentation / 61.5 / ▼ / 56.3 / ■ / 60%
TIA (Low Risk) Treatment <7 days from initial presentation / 53.6 / ■ / 51.9 / ▼ / 60%
1 | Page
Tabled paper
KEY TO PERFORMANCE ASSESSMENT SYMBOLS▲ / Fully Met - Performance continues to improve
■ / Fully Met - Performance Maintained
▼ / Met, but performance has deteriorated
▲ / Not quite met - performance has improved
■ / Not quite met
▼ / Not quite met - performance has deteriorated
▲ / Not met - performance has improved
■ / Not met - performance showing no sign of improvement
Figure 22:Performance against stroke care targets