trust quality and performance report october 2012
TRANSCRIPT
Trust Quality and Performance Report
October 2012
Contents
Slide numbers
Clinical Quality Priorities inc Ward Dashboard 4 - 17
CQUIN 18 - 19
Local Priorities 20 - 26
Monitor Compliance 27 - 29
Contract Priorities 29 – 34
Pain Management Benchmarked Data 35 - 36
2
Introduction
This Corporate Trust Dashboard provides narrative for performance in five key areas: Clinical Quality Priorities, CQUIN Performance, Local Priorities, Monitor Compliance and Contract Priorities.
3
Clinical Quality Priorities Summary
• The number of patient falls increased during September. An assessment of bathroom and toilet facilities has been undertaken to identify action that could be taken to reduce falls in these areas.
• There were 4 Clostridium difficile infections this month. Where RCAs have been completed, they have been classified as unavoidable. This means that the target for the quarter has also been exceeded thereby attracting 1.0 penalty point in Monitors Compliance Framework. The position for the Year to Date is 18 cases against a ceiling of 14.
4
Ward dashboard
5-8
Quality Priority: Ward Performance Issues
9
Ward F3Ward F3 had an unusually low rating for patient satisfaction this month with five questions rated red. Two of these relate to noise at night (from patients and from staff) and this may be due to a particularly disruptive patient issue for a lengthy period during September.
Call bell response times were also rated particularly poorly by patients and it can be seen from the actual response times, that the percentage of responses in less than 2 minutes has fallen in comparison with normal levels for that ward, although given the response times, the impact on patient satisfaction would not be expected to be as great as it was. There does not appear to be an explanation for the lower than normal scores in other questions, therefore the Ward Manager and Matron, who are aware of the results, are monitoring the situation.
62%
26%
9%
3%
Aidcall response timings
0-2 Mins2-5 Mins5-10 Mins10 + Mins
Quality Priority: Infection Control
10
There were no cases of MRSA bacteraemia or MSSA bacteraemia during September There were 4 C. difficile infections this month. Three of the four have been classified as unavoidable and specimens were taken appropriately. The fourth case is awaiting classification at the RCA scheduled for later this month. Antibiotic Audit
Isolation AuditThe isolation audit has been increased to assess the use of side rooms and the isolation of patients every week day. This has identified that from a total of 580 isolation patient bed days, 501 took place in side rooms, leaving 79 bed days where patients were within bays. The majority of these were within the medical wards. The additional capacity of 8 single rooms as planned for the conversion of F12, would have addressed this need.
The quarterly results of the antibiotic audit are provided right. The overall compliance was 96% against all of the criteria examined within the audit, The Table right provides a breakdown of compliance against the individual audit criteria. As can be seen, the aspect of practice that requires further improvement is the documentation of the indication for the antibiotics when prescribed.
Quality Priority: Falls
11
The contract target for falls during 2012-13 is to reduce serious harm/ death from falls and to complete a risk assessment for patients who attend A&E as a result of a fall.
Falls performanceThere were 57 falls across the Trust during September an increase on last month:
Themes/preventable falls noted are:
There has been a decrease in bank staff availability to “special” cohorts of high risk patients as bank staff have been working in the escalation areas or backfilling substantive staff to work in escalation areas. This has led to an increase again in patients with dementia falling.
A number of mechanical falls occurred which have no common theme and are difficult to prevent.
Falls resulting in serious harm.1 fall occurred on G5, causing severe harm, a fractured neck of femur. This lady had been assessed by the physiotherapists as independent with her frame and was due to be discharged the following day. She fell in the toilet and it is unclear exactly why she fell as the patient has given different versions of the reasons she fell but the fall definitely occurred as she was leaving the toilet. The patient was transferred to F3 and has now been discharged home. This fall was not preventable.
Quality Priority: Pressure Ulcers
12
The performance target is to have no avoidable Grade 3/4 pressure ulcers 2012-13 with a penalty of £5,000 for each incidence.The performance target re: avoidable Grade 2 pressure ulcers is a ceiling of 4 for Quarter 3 with a penalty of £500 for each incidence above the ceiling.
September performance2 patients developed Grade 2 hospital acquired pressure ulcers this month, of which 1 was avoidable following concise root cause analysis. 1 patient developed a Grade 3 pressure ulcer which has initially been classified as unavoidable.
The Grade 2 pressure ulcers developed on G1 and G5:
G1- This oncology patient developed a sacral sore that was considered unavoidable as all preventative care was in place and delivered appropriately.
G5- A patient developed a sacral sore which the Matron considered to be avoidable. The ward staff could have been more proactive with upgrading the pressure relieving cushion to a higher specification brand which may have prevented the pressure ulcer.
The Grade 3 pressure ulcer developed on Critical Care Unit. This patient was admitted with sepsis & multi organ failure. His skin integrity was very poor with a lot of oedema and serous fluid leaks. He developed a pressure ulcer on the back of his head which developed as he was frequently agitated and was often shaking his head causing friction. As the ulcer was underneath his hair, no damage was noted until an exudate became apparent. The risk assessment was completed on time and he was nursed on a total care bed , regular 2-4 hourly turns carried out and skin assessment checks completed daily, therefore it has been initially categorised as unavoidable by the Tissue Viability team but this will be ratified at RCA.
Quality Priority: Patient Experience – Achievement of 85% satisfaction
13
‘Achieve at least 85% satisfaction in internal patient satisfaction surveys’ is a Quality Priority for the Trust.
The overall score for the inpatient survey was 91% indicating a high level of satisfaction with most of the areas covered in the survey. A satisfaction score of over 90% has now been achieved for 5 consecutive months . From the graph below it can be seen that over the last 3 months patient perception of call bell response times has improved as compared to the first quarter of 2012/13. As a result of continuing issues with call bell response times and noise at night, the Head of Nursing has incorporated the issues into Mandatory Training and the Matrons and Ward Managers continue to be vigilant in regard to these issues. At a meeting with the Patient Association at the beginning of October a collaborative project to explore call bell response times and better understand the issues, was agreed. The Patients Association are to put forward a proposal for the project for the Trust to approve. In relation to noise at night, it is felt that we should wait until full implementation of both the Dementia Project and Improving Patient Flow, to assess the impact on noise at night.
Quality Priority: Patient Experience – Achievement of 85% satisfaction
14
‘Achieve at least 85% satisfaction in internal patient satisfaction surveys’ is a Quality Priority for the Trust
The Outpatients Survey overall score was 86% and is in line with scores in previous months. Provision of information to patients about delays to their appointment, increased to 70% during August following a large dip to 44%in July but fell back to 50% this month. This issue continues to be progressed by the Health Records Manager, and a number of different approaches have been taken to provide the patient with more information. However, it is felt that the current question wording is ambiguous and a change of wording may allow us to better understanding the issue for patients, thus providing more accurate information through which to target improvement activity. It is therefore proposed that when the questionnaire is next reviewed, the wording of this question is changed.
The overall satisfaction reported in the short stay survey was 99%.
The A&E survey indicated good levels of satisfaction with an overall score of 90% for adults. The only issues that score low in relation to A&E are in relation to the provision of activities for children in the children’s survey. As reported last month the potential to supply alternative activities for children is being explored.
Quality Priority: Patient Experience – Recommend the service
15
‘Patients would recommend the service to their family and friends’ is a Quality Priority for the Trust
The Trust achieved a net promoter score of 87 for inpatients during September. The number of responses fell this month but achieved 11% thus meeting the 10% required by the SHA.
The results for the other areas for the net promoter score are provided below:
Department No of responses Net promoter score
OPD 139 84
DSU 188 100
A&E 95 94
Quality Priority: Mortality
16
17
• VTE: it is notable that the Trust achieved 99.27% VTE performance for September and the target has been met for consecutive months in the quarter. The VTE prophylaxis audit is also reported at 100%.
• Discharge summaries: Target 95%. Outpatients achieved 92%, inpatients 87% and A&E 95%. The discharge summary project group has improved the scope and regularity of performance reporting, and has arranged a pilot scheme of highly visible (to staff) screens with a rolling discharge summary, TTO and VTE performance reports.
• Falls: reduction of serious injury & harm from falls – The Trust has reached the early contractual limit of 7 falls resulting in harm for the year. Actions are as detailed under ‘falls’ in this report.
CQUINSummary & Exceptions report
18
CQUIN dashboard
19
Local PrioritiesSummary & Exceptions report
20
There are two reds in the governance dashboard: o actions from SIRIs beyond deadline (4) – targeted action being taken to complete by
the end of September; and o second letters for complaints (5) – detailed provided in report regarding themes and
areas Patient safety incident (PSI) reporting has dropped since July, but remains higher than
previous levels and within the peer group median. Extrapolation of data for September predicts an increase from August (271), but below July (302). The projected number of incidents in September is 289
PSIs resulting in harm remains below the peer group benchmark. PSIs resulting in serious harm remains below 1% (against a peer group average of 1.2%)
There was an increase in complaints during August (34 compared with 27 for the same period last year). Detail is provided in report regarding themes and areas.
• There were 18 complaints in September 2012. This is down from 34 in August 2012 and 24 in September 2011.
Local Priorities - Governance Dashboard
21
22
There were 394 incidents reported in September including 297 patient safety incidents (PSIs).
The rate of PSIs is a nationally mandated item for inclusion in the 2012/13 Quality Accounts. The NRLS target lines shows how many patient safety incidents WSH would have to report to fall into the median / upper and lower quartiles for small acute trusts reporting per 100 admissions. This has been rebased from September to take into account the new dataset from the Oct 11 - Mar 12 NRLS report).
The median has risen considerably as a consequence of improvement of reporting rates across all Trusts in the peer group but particularly those in the middle 50th centile. The upper and lower quartile benchmarks have remained relatively static.
After a fall in reported incidents in August the reporting rate has improved again and, using the new benchmark, the Trust falls into the lower half of the middle 50% of Trusts for the whole six month period. This is a considerable improvement on the previous six months as is demonstrated in the NRLS benchmark analysis on the next slide.
The number of harm incidents rose to its highest level since March as a consequence of an increase in Minor harm incidents. There was no corresponding rise in Moderate or Serious harm.
23
The percentage of PSIs resulting in severe harm or death is a nationally mandated item for inclusion in the 2012/13 Quality Accounts. The peer group average (serious PSIs as a percentage of total PSIs) has been rebased to 1.0% from the NPSA October 11 – March 12 report and now sits below the Trust’s average.
The number of serious PSIs (confirmed grade) are plotted as a column on the secondary axis.
The WSH data is plotted as a line which shows the rolling average over a 12 month period. August had four ‘Red’ incidents reported: Fall with fracture, VTE inquest, Deteriorating patient and Delayed diagnosis all awaiting confirmation of grade through RCA.
There are a small number of incidents newly included for previous months that were reported some time after the original incident date: One “Complication following surgery” (in June), reported on Datix in September after case discussion in General Surgery is awaiting an RCA. Two “management of deteriorating patients” cases in April identified following concise RCA of all cardiac arrests, were not reported on Datix until after the concise RCA took place. Action to ensure deteriorating patient incidents are identified in a more timely manner is being addressed as an action from one of the RCAs.
Sep
-11
Oct
-11
Nov
-11
Dec
-11
Jan-
12
Feb
-12
Mar
-12
Apr
-12
May
-12
Jun-
12
Jul-1
2
Aug
-12
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.6%
0
1
2
3
4
5
6
7
8
5
1
2
1 1
2 2
4
7
3 1
1
4
Serious Patient Safety Incidents reported to NRLS
(2ary axis) WSH serious harm PSIs pending final grade
(1ary axis) Benchmark NRLS Serious harm average (1.2%) (1ary axis) WSH serious harm - 12 month rolling average WSH%
1ary
axi
s (s
erio
us
har
m P
SIs
as
a %
of
tota
l P
SIs
)
2ary
ax
is (
nu
mb
er o
f co
nfi
rmed
PS
Is)
May 12: Delayed diagnosis (1), C. difficile (1), Pressure ulcer (2) , Delay in referral (1), Inquest (1)
24
Admission, discharge, transfer arrangements 1All aspects of clinical treatment 11Appointments, delay / cancellation (outpatients) 3Attitude of staff 2Communication / information to patients (written and oral) 7Patients property and expenses 1
It is unusual to see a significantly higher number of complaints allocated to the surgical directorate. However, there were a number of medical outliers on surgical wards during this time and it is possible that this impacted on the surgical patients experience. (Please note that more than one category can be allocated to each complaint so the total number of problem areas does not correlate with the total number of complaints) .
There was a significant reduction in the number of complaints received from patients who attended Accident and Emergency, with only 2 complaints in this period. There was only one complaint received for EAU and this related to the wait a medical-expected patient experienced. The Eye Treatment Centre received three complaints in this period but there was no commonality with the concerns raised.
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Complaints 2012/13
19 22 26 18 34 18 NaN NaN NaN NaN NaN NaN
Complaints 2011/12
22 26 27 19 27 24 24 22 15 32 23 22
2.5
12.5
22.5
32.5
Num
ber
of c
ompl
aint
s
Local Priorities
Complaints
Complaint response within agreed timescale with the complainant: 96% of responses due in September were responded to within the agreed timescale (target 90%). Of the 18 complaints received in September, the breakdown by Primary Directorate is as follows: Medical (4), Surgical (11), Clinical Support (2) and Women & Child Health (1).Trust-wide the most common problem areas are as follows:
25
Local Priorities
PALS (Patient Advice & Liaison Service)
In September 2012 there were 103 recorded PALS contacts. This number denotes initial contacts and not the number of actual communications between the patient/visitor and PALS.
A breakdown of contacts by Directorate from September 11 to September 12 is given in the chart and a synopsis of enquiries received for the same period is given below. Total for each month is shown as a line on a second axis. Trust-wide the most common five reasons for contacts are as follows:
Oct
-11
Nov
-11
Dec
-11
Jan-
12
Feb
-12
Mar
-12
Apr
-12
May
-12
Jun-
12
Jul-1
2
Aug
-12
Sep
-12
0
5
10
15
20
25
30
35
40
45
50
0
20
40
60
80
100
120
8388
84
100
81
63
96
80 79 77 79
103
Medical Surgical Clinical support Women and Child Health
Facilities Other / Not categorised Total
All aspects of clinical treatment
38 Admissions, Discharge and transfer arrangements
10 Attitude of staff 5
Information (advice) 22 Other (relating to outside organisations and some contacts not yet categorised) 20
From the information above, there has been a considerable increase in queries and concerns raised during September. There is however little change in the nature of issues raised with the PALS Manager and the most detailed enquiries relate to aspects of clinical treatment. It is however pleasing to note that the number of issues relating to staff attitude have reduced this month.
The PALS Manager therefore continues to deal with concerns about hospital procedures and clarification of treatment given, which can include attending meetings with patients and their clinicians. She also deals with clarification of future care plans; length of time waiting for results of tests and discrepancies about diagnosis and/or discharge arrangements.
Any issues which are not able to be dealt with by PALS are directed, if appropriate, to the formal complaints process.
The very nature of the PALS service requires responses to queries, concerns or complaints to be dealt with expediently. A Target of 80% for responding fully (completing the enquiry) within 48 hours has been set or within a timeframe agreed with the enquirer. The Manager consistently exceeds this target.
Local Priorities – Workforce Performance
• Recruitment Timescales – the Suffolk Redeployment Clearing House requires the Trust to place all appropriate vacancies with them for a period of 1 week prior to opening up the vacancy to outside competition. This has had the effect of adding 1 week to our usual recruitment timescales and therefore the target has been amended to include the additional week.
26
Monitor ComplianceSummary & Exceptions report
27
1. Please see slide 4 for Clostridium Difficile report.
2. Whilst the Trust achieved the 4 hour A&E target for the quarter, performance in month was 94.6% and conditions remain challenging. A Director led project group is in place to review the urgent care pathway. This will report to the Trust Executive at the end of October. Changes have been made with senior managers arrangements to ensure more consistent support to bed management and winter escalation plans are in place. Non elective demand for the year to end of September has increased as follows compared to the same period in 2011/12
3. The Trust achieved the 31 day wait for second/subsequent treatment target for the quarter but did not achieve this for Surgery in September. This is because of a planned delay of 6 days in booking treatment for 1 patient following chemotherapy and radiotherapy. As the quarter target was achieved, no financial or compliance penalties are attributed.
Activity % Increase
A&E + 2339 8.3%
Non Elective Admissions + 342 2.5%
Monitor Compliance FrameworkA3 printout
28
Contract PrioritiesSummary & Exceptions report
29
Actions relevant to A&E are described on slide 27
Key issues on Stroke performance are:• Identification of Stroke at triage• Availability of specialised staff 24 hours per day• Access to specialised diagnostic procedures at weekends
The Trust continues to actively participates in the SHA led Regional Stroke Review.
A business case is being developed to address the issues identified above.
3030
Contract Priorities Dashboard + OtherA3 printout
31 - 34
Pain Management - BenchmarkedThe data presented in this slide and the next is from Dr Foster Intelligence. One issue to note on the data is that Pain Management is coded differently across Trusts and can sometimes be coded as “Anaesthetics”. Therefore this may not be an accurate representation of activity. The actual number of attendances as our marker. This does not reflect either size of hospital or population size.
First Appointments
It can be concluded that for WSFT OP First Attendances we have the lowest number of Attendances on the rankings.
This may be due to the change in referral criteria that patients have to meet before being seen by the specialty. This change was implemented two years ago.
35
Pain Management - Benchmarked
Follow Up Attendances
WFT is ranked 11/14 Trusts for follow up attendances. The First to Follow up Ratio for WSH is 4.95 based on the data below. This is higher than the national rate which is 2.4 however, the restrictive criteria on first appointments compared to peers is likely to be a factor that affects this. Also there is no specific end of treatment criteria, this will also impact the follow up ratio. The WSFT cancellation rate is higher than peer group (3/14).
36
Day Cases