Date of Meeting / 24th March 2016 / Confirm Part One or Two / Part One /
Title of Paper / Quality and Safety Report
Responsible Director / Cath Byford, Director of Commissioning & Quality
Author / Quality and Safety Team
Action required / Approval / ☐ / Decision / ☐ / Discussion / / Information / /
Purpose of the report: / For Governing Body to receive detailed information regarding performance and issues relating to patient safety and quality from providers
Executive Summary (maximum 500 word limit) / This report provides comprehensive information with regard to quality and patient safety performance across providers. Items of particular note are as follows:
James Paget University Hospitals NHS Foundation Trust(page 6)
- CQC report published on 12 November 2015 judged JPUH as ‘Good’ overall.
- Mixed Sex Accommodation breaches continue due to lack of bed availability.
- Quality Issue Reports still being received for patient discharge concerns.
- The Tissue Viability Team continues to work collaboratively with JPUH and to deliver training and education to care homes regarding pressure ulcers.
- CQC report published on 28 September 2015 judged Beccles Hospital to be meeting the required standards following re-assessment.
- Staffing continues to be problematic across the organisation due to a combination of staff absence and resignations.
- CQC report published on 16 March 2016 judged the NNUH as ‘Requires Improvement’ overall.
- Three Never Events reported since April 2015, one involving a GYW patient.
- Delayed responses to Quality Issue Reports raised at CQRM, new process being implemented as a result.
- CQC report published on 3 February 2015 judged NSFT as ‘Inadequate’ overall.
- CQC inspection scheduled for 11th July 2016.
- Comprehensive improvement plan in place being managed by Monitor.
- See full report.
- Call response times being closely monitored.
(page 24)
- CQC inspection report published
- CQC inspection scheduled for 4th April 2016.
- EEAST performance is below both the national standards and agreed recovery trajectories.
- C. Difficile Infection (CDI) trajectory for 2015/16 is 70 cases.
- From 1 April 2015 to 15March 2016 there have been 83 reported cases.
- Approximately 50% cases continue to be successfully appealed.
- See full report.
- See full report.
- Two GP practices recently rated as “Outstanding” by the CQC in recognition of the excellence of care being offered to patients - Sole Bay Health Centre and Park Surgery.
The recommendation is to:
Links to the CCG strategic objectives: / Effectiveness / /
Quality / /
Improved experience / /
Make a difference for local people / /
Reduce inequalities and delivery / ☐ /
Sustainable financing / ☐ /
Links to strategic risk register:
Risk scoring and description:
Consequence
(impact) / Rare / Unlikely / Possible / Likely / Almost
Certain
1 / 2 / 3 / 4 / 5
1 Negligible / 1 / 2 / 3 / 4 / 5
2 Minor / 2 / 4 / 6 / 8 / 10
3 Moderate / 3 / 6 / 9 / 12 / 15
4 Major / 4 / 8 / 12 / 16 / 20
5 Catastrophic / 5 / 10 / 15 / 20 / 25
The CCG Quality and Safety Directorate continue to locally monitor performance,challenge issues and report on good practice relating to patient safety and quality. This is achieved by support of the commissioning and contracting teams and through Clinical Quality Review Meetings with providers. Quality schedules are detailed within contracts and providers are required to report on key performance indicators. Where concerns are raised providers are required to provide detail including but not limited to; root-cause analysis, action plans to address poor performance, recovery action plans and information detailing lessons learned and corrective measures following complaints and incidents.
This risk has been assessed as follows
- Without controls - on the basis of failure to effectively monitor providers with regard to Quality and Patient safety
- With controls - effective monitoring of quality and patient safety to support early identification of performance issues and contractual requirement for remedial action
4x4 =16
(Red)
With controls
3x3 = 9
(Amber)
Primary Care Conflict of Interest / Conflict of Interest Exists (Y/N) / No /
Potential Conflict of Interest Exists (Y/N) / No /
Impact
Quality and Safety / Positive / / Negative / ☐ / Neutral / ☐ /Enables monitoring and early identification of possible issues allowing a collaborative approach with providers to review, learn lessons and improve services for Great Yarmouth and Waveney patients
Patient Experience / Positive / / Negative / ☐ / Neutral / ☐ /
An effective locally delivered Quality and Patient Safety service will positively impact on patient experience for Great Yarmouth and Waveney residents.
Clinical/Operational Effectiveness / The provision of an effective Quality and Patient Safety service supports effective commissioning of safe, clinical effective services and allows for monitoring of performance against quality outcomes
Financial/Performance
(see business case template attached where applicable) / N/A
QIPP/Better Care Fund / N/A
Statute/Compliance/
Governance Issues / Quality and Patient safety monitoring supports effective governance with regard to authority, accountability and decision making.
NHS Constitution
Equality Impact / Positive / ☐ / Negative / ☐ / Neutral / /
Human Resources / N/A
Patient Engagement / N/A
System incl. primary care,NHS providers, local authority, voluntary sector etc. / The Quality and Safety Directorate work collaboratively with providers, local authorities, other commissioning organisations, and the independent sector.
Supporting documents
(List all appendices or further attachments)
Communications Strategy
(How this initiative will be disseminated)
Acronyms used in the report
(List alphabetically and list in full within the report) / A&E – Accident and Emergency
CCG – Clinical Commissioning Group
C.Diff – Clostridium Difficile
CHC – Continuing Health care
CQC – Care Quality Commission
CQRM – Clinical Quality Review Meeting
CQUIN – Commissioning for Quality and Innovation
EEAST - East of England Ambulance Service NHS Trust
ECCH – East Coast Community Healthcare
FFT – Friends and Family Test
GYW – Great Yarmouth and Waveney
HCAIs – Healthcare Associated Infections
HR – Human Resources
IC24 – Integrated Care 24
INR – International Normalised Ratio
JPUH – James Paget University Hospital NHS Foundation Trust
KLOEs – Key Lines of Enquiry
LAC – Looked After Children
MDT – Multi-disciplinary Team
MRSA – Methicillin Resistant Staphylococcus Aureus
MSA – Mixed sex Accommodation
NCHC – Norfolk Community Health and Care
NICE – National Institute for Clinical Excellence
NNUH – Norfolk and Norwich University Hospital NHS Foundation Trust
NSFT – Norfolk and Suffolk Foundation Trust
OOH – Out of Hours
PIRs – Post Infection Reviews
QIPP – Quality, Innovation, Productivity and Prevention
QIR – Quality Incident Report
RCA – Root Cause Analysis
RTT – Referral to Treatment
SHMI – Standard Hospital Mortality Index
SI – Serious Incident
SSNAP – Sentinel Stroke National Audit Programme
WHO – World Health Organisation
Directorate involvement and sign off prior to submission to committee / board. Please state role titles or state N/A if appropriate.
Finance / N/ACommissioning / N/A
QIPP and Delivery / N/A
Information / N/A
Contracting / N/A
Engagement / N/A
Governance / N/A
Quality and Safety / Rebecca Hulme – Deputy Chief Nurse
1.0James Paget University Hospital (JPUH)
1.1Friends and Family Test (FFT) for Inpatients, A&E and Maternity Services:
December 2015Area / Total Responses / Total Eligible / Response Rate / % Recommended / % Not Recommended
A&E / 503 / 4498 / 11.2% / 91% / 2%
Inpatients / 1003 / 5855 / 17.1% / 97% / 1%
Maternity –
Antenatal Care / 42 / Not Available / Not
Available / 100% / 0%
Maternity –
Birth / 60 / 168 / 35.7% / 100% / 0%
Maternity –
Postnatal Ward / 34 / Not Available / Not
Available / 94% / 0%
Maternity –
Postnatal Community Provision / 23 / Not Available / Not
Available / 100% / 0%
January 2016
Area / Total Responses / Total Eligible / Response Rate / % Recommended / % Not Recommended
A&E / 437 / 4478 / 9.8% / 92% / 3%
Inpatients / 889 / 5707 / 15.6% / 97% / 1%
Maternity –
Antenatal Care / 80 / Not
Available / Not
Available / 99% / 0%
Maternity –
Birth / 57 / 177 / 32.2% / 98% / 2%
Maternity –
Postnatal Ward / 44 / Not
Available / Not
Available / 93% / 2%
Maternity –
Postnatal Community Provision / 78 / Not
Available / Not
Available / 99% / 1%
For further information, the following link shows the full range of results for FFT by region, Trust, Site and Ward:
Note: FFT data for February 2016 will be published by NHS England on 7 April 2016 (post report publication) and the FFT data for March 2016 will be published by NHS England on 12 May 2016.
1.2Care Quality Commission (CQC)
The CQC undertook a planned inspection at JPUH week commencing 10 August ‘15. The inspection report was published on 12 November ‘15 where the CQC overall judged JPUH to be Good.
CQC Inspection Area RatingsSafe? / Requires improvement
Effective? / Good
Caring? / Good
Responsive? / Good
Well-led? / Good
The Trust has developed an action plan to address the improvements identified which is being monitored at the Clinical Quality Review Meetings.
1.3Patient Safety Indicators Published on NHS Choices
From June 2014, all NHS providers are expected to upload and publish data about their nurse staffing levels on their public website. In addition you can also see howhospitals perform on patient safety on NHS Choices.These include how hospitals recognise and report problems with safety, how well they are fulfilling their nurse staffing requirements or if the staff would recommend the hospital to their own family or friends.
The February 2016 position for JPUH is below. The nurse staffing metrics continue to report that only 91% of planned nursing staff was in place; however this is an improved position and the Trust continues to actively recruit locally, nationally and internationally. It should be noted that the Trust is reporting against their enhanced established levels which surpass NICE guidance.
CQC Rating / A&E Performance / Safe Staffing / Recommended by Staff / Infection Control and Cleanliness / Percentage of patients waiting less than 18 weeks from referral / Patients assessed for blood clots / Open and honest reportingGood / 95.7%
Patients seen within 4 hours / 93%
Of planned level / Within expected range with a value of 65% / Among the best / 93%
of patients waiting less than 18 weeks / 97%
Of patients assessed / As expected
1.4Mixed Sex Accommodation (MSA)
During January the Trust experienced a number of periods of significant operational pressure where it was not possible to comply with mixed sex requirements on two occasions. 12 patients were affected on the Acute Coronary Unit and Hyper Acute Stroke Unit over a period of seven days resulting in 45 breaches.
On two occasions during February the Trust reported MSA breaches due to bed pressures and lack of bed availability to resolve both breaches. This affected 5 patients on the Acute Coronary Unit and Hyper Acute Stroke Unit.
The CCG has received both full investigation reports.
1.5Serious Incidents (SIs) / Never Events
Serious Incidents reported:
Apr2015 / May
2015 / Jun
2015 / Jul 2015 / Aug 2015 / Sept
2015 / Oct
2015 / Nov 2015 / Dec 2015 / Jan 2016 / Feb 2016
8 / 5 / 6 / 4 / 4 / 3 / 7 / 5 / 3 / 3 / 3
No new Never Events have been reported by the Trust since July ’14.
SIs that currently remain open (as at 29.02.16) pendinginvestigation are noted within the following table:
SI number / Category / Incident Date / Reported Date / Current Status2015/34682 / Treatment / Procedure / 20/09/15 / 03/11/15 / RCA received for review
2015/36021 / Breast Screening / Radiology / 16/11/15 / 18/11/15 / RCA received for review
2015/37324 / Breast Screening / Radiology / 02/12/15 / 02/12/15 / RCA received for review
2016/167 / Obstetric Delay / 25/12/15 / 05/01/15 / Currently under investigation
2016/195 / Business Continuity / 04/01/16 / 05/01/16 / Currently under investigation
2016/5097 / Fall / 20/02/16 / 23/02/16 / Currently under investigation
2016/5113 / Grade 3 Pressure Ulcer / 07/02/16 / 23/02/16 / Currently under investigation
2016/5115 / Grade 3 Pressure Ulcer / 20/02/16 / 23/02/16 / Currently under investigation
The GY&W CCG Patient Safety and Clinical Quality Committee continue to identify SIs to be reviewed in more detail. This focuses on completed RCAs and details behind any delays in submission.
1.6 World Health Organisation (WHO) Surgical Checklist
The Trust continues to audit compliance in operating theatre settings with the WHO Surgical Checklist on a monthly basis and results are received on a 6 monthly basis at the Quality Meetings.As previously reported, the October ‘15 results showed an overall figure of 99.7% compliance.
1.7 Quality Issue Reporting (QIR)
QIRs reported:
Apr2015 / May 2015 / Jun 2015 / Jul
2015 / Aug 2015 / Sept 2015 / Oct 2015 / Nov 2015 / Dec 2015 / Jan 2016 / Feb 2016
15 / 4 / 10 / 7 / 8 / 7 / 2 / 7 / 4 / 6 / 9
1.7.1Open / Closed / Void
From 1st October2014to 29th February 2016, 16 QIR remain open pending investigation, 149QIR have been closed, 9 QIR have been voided and 2 are pending closure.
1.7.2Open QIR reported in 2014/15/16:
QIR Ref / Date / Source of QIR / Description of Concern / Status / Date reminder sentJPUH/316 / 20/04/2015 / Park Surgery / No discharge summary or instruction for care. / Under investigation / 15/03/16
JPUH/352 / 15/09/2015 / Beccles Medical Centre / Anti-coagulation communication. / Under investigation / 15/03/16
JPUH/355 / 23/09/2015 / Alexandra Road Surgery / Anti-coagulation issue. / Under investigation / 15/03/16
JPUH/356 / 23/09/2015 / Alexandra Road Surgery / Communication failure. / Under investigation / 15/03/16
JPUH/360 / 09/11/2015 / Cutlers Hill Surgery / Lack of information on discharge summary. / Under investigation / 15/03/16
JPUH/368 / 08/12/2015 / Park Surgery / Incorrect discharge summary. / Under investigation / 15/03/16
JPUH/370 / 31/12/2015 / Beccles Medical Centre / Report received for wrong patient. / Under investigation / 15/03/16
JPUH/371 / 04/01/2016 / ECCH / Inappropriate discharge. / Under investigation
JPUH/372 / 05/01/2016 / ECCH / Inappropriate discharge. / Under investigation
JPUH/373 / 08/01/2016 / Norfolk County Council / Inappropriate discharge. / Under investigation
JPUH/375 / 26/01/2016 / ECCH / Medicines reconciliation error. / Under investigation
JPUH/376 / 01/02/2016 / Andaman Surgery / Incorrect patient’s details. / Under investigation
JPUH/377 / 28/01/16 / Chet Valley Medical Practice / Inappropriate discharge. / Pending Closure
JPUH/378 / 30/01/2016 / IC24 / Medicines availability. / Under investigation
JPUH/380 / 19/01/16 / ECCH / Information Governance / Pending Closure
JPUH/381 / 12/02/2016 / EEAST / Inappropriate discharge. / Under investigation
JPUH/382 / 12/02/2016 / Norfolk County Council / Inappropriate discharge. / Under investigation
JPUH/384 / 24/02/2016 / EEAST / Ambulance crew delay. / Under investigation
The CCG continues to monitor trends and themes arising from reported QIRs at the monthly CQRM. This includes inappropriate discharges, medicines on discharge and equipment concerns.
1.8Infection Prevention & Control
The ceiling of maximum c-difficile cases within JPUH for 2015/16 has nationally been determined as no more than 17 avoidable cases.
1.9Stroke Performance (July – September2015)
The Sentinel Stroke National Audit Programme (SSNAP) data is the agreed source of data for stroke measures within the Clinical Commissioning Group (CCG) Outcomes Indicators Set and reports against these measures for the population of each CCG in England.Included in SSNAP’s reporting suite are high level summaries of hospitals’ performance across 10 key aspects of stroke care, a more detailed analysis of every hospitals' performance across each of these key indicators, and an overall SSNAP score. The reporting cycle is three months in arrears.
Domain (D): / Oct – Dec ‘14 / Jan – Mar ‘15 / Apr – Jun ‘15 / Jul – Sep ‘15D1 Scanning / B / B / B / B
D2 Stroke Unit / B / B / B / B
D3 Thrombolysis / C / C / C / D
D4 Specialist Assessments / C / B / B / B
D5 Occupational Therapy / A / B / A / A
D6 Physiotherapy / B / B / C / B
D7 Speech & Language Therapy / D / D / D / C
D8 MDT Working / D / C / D / D
D9 Standards by Discharge / D / B / B / B
D10 Discharge Process / C / B / B / B
Patient-Centred SSNAP Level / C / B / B / B
1.10Cancer Target Performance (January 2015– December2015)
Preventing people from dying prematurely:
Breast symptoms urgent referral to first outpatient appointment (Target – 93%)Target is to achieve a 14 day maximum wait from GP referral to first outpatient appointment with patients with any breast symptoms except suspected cancer.
Jan / Feb / Mar / Apr / May / Jun / Jul / Aug / Sep / Oct / Nov / Dec
100 / 96.77 / 100 / 95.8 / 96.8 / 100 / 93.3 / 100 / 91.3 / 100 / 92.31 / 93
Cancer urgent referral to first outpatient appointment (Target – 93%)
Target is to maintain a 14 day maximum wait from urgent GP referral to first outpatient appointment for all urgent suspected cancer referrals.
Jan / Feb / Mar / Apr / May / Jun / Jul / Aug / Sep / Oct / Nov / Dec
97.9 / 97.9 / 97.4 / 96.9 / 97.2 / 97.3 / 96.7 / 97.46 / 96.13 / 97.1 / 96.31 / 97.8
Cancer 2 week wait - Monitor combined Breast and urgent referral target (Target – 93%)
Performance
Target is to achieve a 14 day maximum wait from GP referral to first outpatient appointment for both patients with any breast symptoms and also urgent suspected cancer referrals.
Q4 (14/15) / Q1 (15/16) / Q2 (15/16) / Q3 (15/16) / Q4 (15/16)
Met / Met / Met / Met
Cancer urgent referral to treatment 62 day target (Target – 85%)
Performance
Target is to achieve a maximum waiting time of 62 days from urgent referral to treatment for all cancers.
Jan / Feb / Mar / Apr / May / Jun / Jul / Aug / Sep / Oct / Nov / Dec
85.7 / 93.42 / 78.5 / 80 / 75 / 85.29 / 83.8 / 83.76 / 81.89 / 86.6 / 88.54 / 90
Cancer urgent referral to treatment from cancer screening services 62 day target (Target – 90%)
Target is to achieve a maximum time of 62 days from screening services referral to treatment.
Jan / Feb / Mar / Apr / May / Jun / Jul / Aug / Sep / Oct / Nov / Dec
90 / 96.67 / 90.9 / 94.7 / 100 / 91.3 / 100 / 100 / 85.71 / 100 / 94.74 / 100
Cancer urgent referral to treatment – Consultant upgrade (Target – 85%)
Target is to achieve a maximum waiting time of 62 days from Consultant upgrade to treatment.
Jan / Feb / Mar / Apr / May / Jun / Jul / Aug / Sep / Oct / Nov / Dec
80 / 100 / 72.7 / 100 / 85.7 / 100 / 100 / 57.14 / 81.82 / 94.1 / 96.55 / 93.3
Cancer urgent referral to treatment all 62 day pathways - Monitor target (Target – 85%)
Performance
Target is to achieve a maximum waiting time of 62 days from urgent referral to treatment for all cancers across all 62 day pathways combined.
Q4 (14/15) / Q1 (15/16) / Q2 (15/16) / Q3 (15/16) / Q4 (15/16)
Met / Failed / Failed / Met
Cancer diagnosis to treatment waiting times – 31 day target (Target – 96%)
Target is to ensure a maximum waiting time of 31 days from diagnosis to treatment for all cancers.
Jan / Feb / Mar / Apr / May / Jun / Jul / Aug / Sep / Oct / Nov / Dec
98.8 / 100 / 100 / 97.1 / 97.1 / 100 / 100 / 100 / 100 / 100 / 99.14 / 100
Cancer diagnosis to subsequent treatment waiting times – Surgery (Target – 94%)
Target is to ensure a maximum waiting time of 31 days from diagnosis to subsequent surgical treatmenty.
Jan / Feb / Mar / Apr / May / Jun / Jul / Aug / Sep / Oct / Nov / Dec
100 / 100 / 100 / 100 / 100 / 100 / 100 / 100 / 100 / 100 / 100 / 100
Cancer diagnosis to treatment anti-cancer drug regimen (Target – 98%)
Target is to ensure a maximum waiting time of 31 days from diagnosis to subsequent treatment or anti-cancer drug regimen.
Jan / Feb / Mar / Apr / May / Jun / Jul / Aug / Sep / Oct / Nov / Dec
100 / 100 / 100 / 100 / 100 / 100 / 100 / 100 / 100 / 100 / 100 / 100
Cancer diagnosis to treatment all 31 day pathways - Monitor pathway (Target – 98%)
Performance
Target is to achieve a maximum waiting time of 31 days from diagnosis to treatment for cancer across all 31 day pathways combined.
Q4 (14/15) / Q1 (15/16) / Q2 (15/16) / Q3 (15/16) / Q4 (15/16)
Met / Met / Met / Met
Cancer is a priority quality standard for the CCG and enhanced scrutiny is being placed on the acute providers to ensure delivery of these key safety standards.
1.11Pressure Ulcers
Both JPUH and ECCH continue theirlocal CQUIN Indicator in 2015/16 which requires both organisations to track patients with pressure ulcers within the Great Yarmouth and Waveney locality. Progress against theseCQUIN local indicators is monitored by the CCG and at relevant monthly meetings with both organisations.