Presented By: Gwen Nuttall – Chief Operating Officer, Nichole Day Executive Chief Nurse

Prepared By: Information Team

Date Prepared: 15th March 2011

Subject: Integrated Quality and Performance Report - February 2011

Purpose: For Information

Strategic Objective: To Achieve Performance Levels in accordance with the CQC “Standards for Better Health”

Executive Summary:

The paper focuses on the key core targets, identified by the Department of Health and the Care Quality Commission, summarising performance to the end of February 2011.

It also provides the board with information to assess the Trust’s performance against quality indicators, including patient experience, clinical outcome and effectiveness and patient safety.

Trust Board Committee – 25th March 2011

Matters resulting from recommendations made in this report

Present Considered

Financial Implications Yes / No

Yes / No

Workforce Implications Yes / No

Yes / No

Impact on Equality and Diversity impact Yes / No Yes / No

Legislation, Regulations and other external directives Yes / No Yes / No

Internal policy or procedural issues Yes / No Yes / No

Risk Implications for West Suffolk Hospital (including any clinical and financial consequences):

Mitigating Actions (Controls):

Level of Assurance that can be given to the Committee from the report based on the evidence [significant, sufficient, limited, none]: Recommendation to the Committee:

SUFFICIENT

Note the Trust Performance to February 2011

- Failure to deliver the 4 hour core access target for the year.

- Failure to achieve C-Difficile target for the year.

• Robust Action Plan developed.

• Performance Management and Monitoring.

• Improved Escalation

• Review of Cohort Unit

Contents

1. Introduction

2. Emergency Care A&E

3. Cancelled Operations

4. LOS

5. Outcomes & Effectiveness – Clostridium Difficile

6. Patient Safety

7. Risk Assessment

8. Patient Experience

9. Conclusion

1.& 2. Introduction & Emergency Care

1. Introduction: This report provides a briefing to the Board members on the performance against key targets up to February 2011. The paper focuses on the main targets, identified by the Department of Health and the Care Quality Commission.

2. Emergency Care – A&E

Target: 95% of patients seen/treated/discharged within 4 hoursThe Trust did meet the 95% Target for the month of February 2011 (98.59%).

Key actions:- EAU posts to be advertised in February.

Integrated Action Plan agreed and monitored weekly, via weekly A&E departmental meetings.

Review of medical commitments in morning and afternoon commenced. Job Plans are being updated.

Bed Meetings reviewed and enhanced. Standard operating procedures commenced.

Short stay beds introduced on ward G5.

Trust will pilot Discharge/Transfer Lounge in March to assist with flow of patients and discharge planning.

The updated detailed A&E 4 hour performance action plan is attached as a separate paper.

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3. Cancelled Operations

The target was not met for February at 0.85%

A decrease in performance from last month.  Out of Theatre time (41%) and Lack of theatre time (29%) are the highest reasons for cancellation. Urgent Patients (18%) and Equipment issues (12%) follow.

Target 0.8%Actual 0.85% (YTD)

The Productive Operating Theatre project (TPOT) is in progress, and will be reported to the Board in March 2011.

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4. Length of Stay (Spells)

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The targets are from Dr Foster ‘Expected’ positions using 09/10 as a benchmark.

• Non Elective LOS for Medicine is above target – Actions to improve this performance is linked to discharge action plans and implementation of EAU model and short stay beds.

• Non Elective LOS for Surgery remains below the expected level, but has seen an increase in 2010/11. This is related to complex elderly patients.

• Elective LOS for Surgery is similar to last year. Review of day case and day of surgery activity continues, especially in urology. The productive theatre will also focus on Urology.

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Hospital Standardised Mortality Ratio

HSMR has been fairly consistent over recent months and is below the expected level as can be seen by the overall mortality shown in the graphs and the table giving a mortality rate for the five Dr Foster - How Safe is Your Hospital indicators. These tables provide information on relative risk, with red, blue and green traffic lighting. Blue indicates that the score is within the standard deviation.

We continue to monitor the overall HSMR at the Patient Outcomes Group. We also monitor the HSMR for emergency patients and identify any individual  diagnoses that trigger any alerts. These are all investigated and reported to the Quality and Risk Committee and Patient Outcomes Implementation Group.

5. Outcomes and Effectiveness

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Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

0

20

4060

80

100120

Mortality

Mortality: standard-ised rate

Series2

 

National Rate from

last reporting

period

Jul 08-Aug 09

Aug 08-Sep 09

Sep 08-Oct 09

Oct 08 - Nov 09

Nov 08 - Dec-

09

Dec 08 - Jan 10

Jan 09 – Feb 10

Feb 09

-Mar 10

Mar 09

-Apr 10

Apr 09-May 10

May 09

-Jun 10

Jun 09

-Jul 10

Jul 09-Aug 10

Aug 09-Sep 10

Sep 09-Oct 10

Oct 09-Nov 10

Nov 09-Dec 10

Rolling 12 Month HSMR-All Admissions - 86.4 85.2 84.5 84.6 82.8 80 80.7 80.2 80.1 76.5 89 89 87.8 86.3 84.6 84.1 80.3

Rolling 12 Month HSMR-Non Elective - 86.2 84.9 84.6 84.5 83 80.1 80.8 80.4 80.3 79.6 89.1 89.1 88.1 86.7 84.8 84.2 80.3

SMR Stroke (Acute Cerebrovascular Disease)

86.2 85.9 82.6 86.4 82.8 83.3 83.1 82.9 80.9 81.1 79.4 87.8 86.8 88.7 88.6 84.2 84.4 79.7

SMR - Heart Attack (AMI) 90 100.4 105.1 106.1 94.1 91.8 100.6 96.6 95 92.4 92.1 93.7 94.5 89.4 82.4 78.5 77.9 81.8

SMR - FNOF 81.6 70 65.4 64.9 65 69.4 61.3 64.2 69.5 68.4 64.7 73.3 69.2 60.7 62.9 66.2 66.9 67.4

Mortality from Low Risk Conditions 0.84         0.65 0.57 0.57 0.44 0.49 0.67 0.62 0.62 0.53 0.49 0.44 0.49 0.45

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5. Outcomes and Effectiveness

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Infection PreventionThe C. difficile stretch target for 2010/11 is 29 hospital cases. The PCT contract is 42 cases. In February there were a further 2 hospital attributed cases, bringing the total to 34. All patients were transferred to the F9 cohort unit within the time frame specified.

The Trust continues to achieve excellent results in other infection control KPIs. There were no hospital associated MRSA bacteraemia and High Impact Intervention performance has improved with scores ranging from 93-100%:• HII 1a: CVC Insertion scored 93% in the Critical Care

Unit due to a documentation issue. This is being addressed by the Matron.

• HII 2b: Peripheral cannula ongoing scored 97% due to VIP scores not recorded.

• All other HII scored 100% compliance.

Antibiotic PrescribingThere was an improvement in performance to 95% in January. The revised drug chart which includes a specific antibiotic prescribing section requiring a medical review signature every 3 days has been implemented from the 1st March.

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6. Patient Safety

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Pressure Ulcers

The number of patients with ward acquired pressure ulcers decreased this month to 12 with 1 Grade 3 and 1 Grade 4 pressure ulcer reported

Themes from RCAs:

• Four pressure ulcers were considered avoidable and root causes were identified as infrequent assessment of patients and a lack of proactive pressure ulcer prevention plan.

•Eight pressure ulcers were classed as unavoidable as all aspects of the pressure ulcer management bundle were implemented

Actions:

•The pressure ulcer prevention group will be driving improvement through the development of a strategy and workstreams focusing on identified problems from RCAs.

•To ensure that appropriate action is taken from the risk assessment, the matrons will be moving their focus from incident management to risk management with an early warning system from the Ward to Matron..

•Pressure ulcer incidence will be reviewed at Directorate Performance Meetings.

6. Patient Safety

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Patient Falls

The total number of falls in February was 51.

16 of these falls resulted in harm to the patient.

Themes from RCAs:

• Only minor harm was caused.

• Of the falls with harm, all were elderly patients and 75% of these patients had delirium/dementia.

• Five of the sixteen falls were considered preventable as 1:1 nursing staff were requested to “special” but were unavailable and one patient was inappropriately left alone on the commode by a physiotherapist.

Actions:• Driving forward the dementia strategy may decrease falls in this patient group. A SWIFT bid has just been approved which will provide two trainers

delivering dementia/delirium knowledge and practice development as well as a County project lead who will embed the change process and develop pathways of care, policies and guidelines in order to ensure that the practice development is embedded and sustained.

• The Falls Group has updated the documentation as part of their action plan reported recently at the Operational Group meeting.

• All completed parts of the documentation form our falls management plan: screening, risk assessment, medical review, high risk care plan and post-fall protocol. The Matrons audit 10 patients/ward area/month with a random sampling strategy to ensure that our falls management plan is adhered to.

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6. Patient SafetyVenous Thrombo-Embolism (VTE)Verbal update to be provided at the meeting by Dermot O’Riordan.

 

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12

6. Patient Safety

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Root Cause Analysis (RCA)

Performance data: A total of 11 RCAs were undertaken in February: 6 SIRIs and 5 reds. These related to: 3 unexpected deaths, 2 Pressure Ulcers, 2 falls and 1 regarding discharge planning. 2/11 have an associated complaint letter.

2/5 of the RCAs (non SIRI) were late (both) by seven working days. No SIRI RCAs were late. A delay in receipt of the chronologies meant that the meetings attendees were not identified early enough to set the meetings up within the deadlines. The process has now been amended to ensure that the initial chronology request includes an "attendees required" question to ensure that delays in receipt of final chronology do not impact on meeting dates .

In March all eight RCAs due have dates set within the 45 working day limit.

All the 10 actions outstanding in last month's dashboard have now been completed. An additional 10 became due at the end of February all from one RCA. Of these 6 are still outstanding. The action plan from this RCA was the subject of in depth discussion at the Operation Steering group on the 28th February. As a result it was agreed to take an organisational approach to the issues raised rather than locally to the area. This has led to a review of the timeascales for implementation. The key issues identified include;a)The induction of Locums across the Trust, b) Consultation with the Consultant before all invasive procedures, however minor, andc) An update to the aspiration policy.

Patient Safety Incidents resulting in harm:Please refer to SIRI report for details. 

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7. Risk Assessments

 

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Risk Assessments in dateThere are currently 112 (as of 9th March) active risks on the Risk Register. Of these, 99 (88%) are in date, while 13 (12%) are late for review.This is a significant improvement from last month’s performance.The number of risk assessments beyond their review per Directorate are listed below:1) Medical = 52)Trust-Wide = 3

Additional controls in dateEach active risk should identify additional controls which are required to reduce the risk rating to a tolerable level. Currently there are 155 additional controls identified by the active risk assessments. Of these, 124 (80%) are within the agreed timescale, while 31 (20%) have passed their agreed implementation date. This is a significant improvement, as at the start of the year only 51% of the additional controls were in date.The number of additional actions beyond their review date per Directorate are listed below:1) Medical = 92) Trust-Wide = 73) Facilities = 64) Surgical = 55) Finance and Information = 36) Human Resources = 1

The Directorate Governance Performance Meetings and Operational Steering Group reports also detail the actions and status required so that this can be managed/progressed at the Directorate level, and where necessary considered at the Operational Steering Group.

Active risk assessments in date(according to grading Red-3 mths, Amber-6 mths)

In date Beyond review date

88%

12%

In date Beyond implementation date

21%

79%

Additional Controls in Place

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Patient Satisfaction (Patient Experience Tracker)

Overall satisfaction was 95%. No questions scored a red performance rating.

Patient Satisfaction Questionnaires (PSQ) (paper)

All remaining clinical areas use this method for reporting and overall satisfaction remained at 82% although only 173 patients completed the paper questionnaire.The questions with red performance ratings relate to noise at night and discharge advice re: who to contact/medication side effects. The noise at night is particularly an issue in the midwifery areas and also medical wards due to confused patients.

The low score re: discharge advice is related to the timing of the questionnaire rather than lack of advice as patients wait for TTOs and complete the questionnaire prior to being given side-effect advice. A number of wards also use volunteers to complete the questionnaires with patients prior to side-effect information being given.

Actions:• Increase the number of patient respondents.• Continue to advise ward areas to ask patients to complete the patient

satisfaction questionnaires at discharge. • Advise the patient discharge lounge staff to ensure questionnaires

have been completed.• Proactive management of sleep routines for patients with dementia.

CQUIN

Achievement of 2% patients surveyed this month was achieved by all CQUIN reportable areas.

8. Patient Experience

8. Patient Experience

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Same Sex Accommodation Same Sex AccommodationThere were no breaches of same sex accommodation criteria during February.

Environment and Cleanliness

9. Conclusion The action plan remains in place and performance has improved in January with

regard to the 4hr standard.

One of the major challenges for the Trust, was in adherence to same sex accommodation , the re-configuration in December has improved performance.

Performance with regard to C-Difficile, full RCA’s have been carried out and actions implemented specifically with regard to anti biotic prescribing and monitoring.

Progress on other KPI’s is being made.

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