Trust Quality and Performance Report

1. Trust Quality and Performance Report 25 April 2014 (March Performance Pack)

2. Contents 1

3. Executive Summary This commentary provides an overview of key issues during the month and highlights where performance fell short of the target valuesas well as areas of improvement and noticeable good performance. A&E Performance for March was 95.5%, the tenth month in a row that the Trust has achieved the target. The Trust has also achieved Q4 (95.6%) and the A&E 95% target for the year (95.3%). There were two cases of C.Diff in March against the threshold of two. This is covered within the quality report. The YTD position is 23 cases against a year end ceiling of 19. The Trust failed two Stroke targets in March, access to brain scan in 24 hours and low risk TIA access in scan within 7 days. See page 3. 4. Performance on outpatient and inpatient discharge summaries remains below target, although this has improved since February. See page 3. 5. Performance on MRSA screening of emergency admissions was 96.17% against the 100% target. This is covered on page 3 & 7 of this report. The Trust achieved all access targets including the six-week diagnostic test target for February. 7. The Trust failed the patients treated within 28 days of cancelled operation target. See page 3. 2

4. Executive Summary 3

5. 4

6. Appraisal monitoring – 89.62% (1.31%) The Trust Board has set a target of 90% of staff having had an appraisal meeting in any year, and this is reported to and monitored each month by the Board of Directors, General Managers and individual managers. Compliance within the Trust is currently reported at 89.62% for March 2014 (this is measured by returned personal development plans (PDP’s) to the HR Directorate, and is recorded on ESR) against a figure of 40.71% in December 2011. This figure differs from that reported by the staff survey. Those with up to date PDP’s are as follows; Surgery - 90.27% Medicine - 90.85% Clinical support - 86.88% Women and Children - 89.33% Corporate - 87.24% Estates and Facilities - 92.12% The latest staff survey response (2013) which surveyed approximately 450 staff (the Trust headcount is currently around 2,955), suggests that we are in the bottom 20% of acute trusts for staff being appraised in the last 12 months, with our score being 75%, against a national average of 84%. This represents a 4% decrease on the 2012 survey. We are also slightly below average for staff feeling that their appraisal meetings are well structured. (3.62 against an acute average score of 3.64) Monitoring is undertaken at various levels within the organisation; Monthly board reporting Monthly reporting at directorate level, as part of performance management meetings. In depth reporting each month by individual budget code. Encouraging appraisal take up Appraisal completion forms part of the management role and responsibility for all staff with people management in their job description. Managers attend training in the undertaking of appraisal, during which they learn about the skills, process and paperwork etc. Appraisal is identified as a mandatory requirement for all staff. Failure to meet this requirement could be met as follows; Managers who fail will be met informally in the first instance to be tasked with improving their performance in this area. Disciplinary rules then allow the Trust to take action under “failure to undertake a reasonable management instruction”. Incremental progression could be withheld for those managers who have not reached the top of their Pay band (currently 45% of those in Bands 7 and above, 192 managers out of 428 in total). However national Terms & Conditions do not allow for increments to be withdrawn for those managers who have reached the top of their scale (currently 55% of those on band 7 and above). In order to withhold increments a systematic approach would need to be introduced, (to avoid a legal challenge from a contractual basis) A business case was produced to introduce this, but was not approved due to current financial constraints. 5

7. Clinical Quality Priorities: Summary • 57 patients fell during March; an increase of 7 compared to February. 1 fall resulted in a neck of femur fracture. • There were 2 hospital associated C. difficile infections in March against a trajectory of 19 for the year. 6

8. Quality Priority: Infection Control MRSA Bacteraemia There were no cases of hospital attributable MRSA bacteraemia in March. MSSA Bacteraemia There were 2 cases of hospital attributable MSSA bacteraemia in March. C. Difficile 2 cases of C. Difficile were confirmed in March. 1 on G3 and 1 on G8. There were 23 cases of C. Difficile during 2013/14; 10 less than during 2012/13. MRSA Screening Elective 96.2% compared to 97% in February Emergency 96.2% compared to 96.8% in February Trust Antibiotic Audit For Quarter 4 the Trust overall achieved 95% compliance against a target of 98%. A detailed breakdown of results have been distributed to all clinical areas & teams for action. Sepsis 6 audit A low score this month (55%) has prompted a review of the data collection tool to ensure that it meets audit outcome requirements. 7

9. Quality Priority: Infection ControlQuarter 4 Infection Prevention Audit Results show an overall compliance of 91% against a target of 90%.Action plans are in place on F9 & G9 to increase compliance with VIP (Visual Infusion Phlebitis) score and a re-audit is planned for April.A cannula care newsletter has been developed by the Infection Prevention team for ward areas to remind them of the importance of cannula care and VIP score documentation. 8

10. Quality Priority: Ward Performance Issues • Ward G4 has reported a number of red and amber indicators this month. A focus on documentation in March has improved the score for MEWS & escalation. Nutrition assessment and monitoring has scored lower than February. Work continues to improve documentation in all areas. A lower score for patient satisfaction overall (78 compared to 90 in January & February) was reported with a score of 33 for the Friends & Family test (recommender question). Identified areas for focus from the surveys are noise at night, help with meals and being able to discuss worries or fears with staff. • Ward F8 have had a challenging month with beds used for escalation for most of the month. Monitoring of staffing levels has shown that 77.4% of shifts over the month were staffed with less than planned numbers. Reduced staffing per shift is reflected in the poorer performance against patient safety & quality indicators this month. Plans are in place to improve performance at ward level with increased monitoring & support from the Nursing Directorate. 9

11. Quality Priority: Falls Falls Performance There were 57 falls this month, 1 of which resulted in serious harm, this patient was normally independent around his side room and to the bathroom, on this occasion he fell and sustained a fractured hip. 45 falls resulted in no harm and the remaining 12 were recorded as negligible or minor harm. The rate per 1,000 occupied bed days is 4.8 (Feb 4.61). WSNHSFT falls with harm March: 0%, National falls with harm March: 0.7% (Safety Thermometer). Themes There were 5 falls in the toilet this month, this is 8.77% of all falls down from 10% last month. Work to install safety rails in toilets is now complete. F7/F8 had 11 falls this month, 9 of which occurred at night none of which occured in the toilet. 10

12. Quality Priority: Pressure Ulcers . The performance target is to have no avoidable Hospital Acquired Pressure Ulcers (HAPU) Grade 2, 3 or 4 during 2013-14. Grade 2 Pressure Ulcers There were six grade 2 HAPU again this month, four of which we believe to have been unavoidable, the CCG have yet to confirm this. The CCG have now confirmed 3 of last months HAPU to be unavoidable. Grade 3 pressure Ulcers No grade 3 HAPU, last grade 3 HAPU was in January We have had no grade 4 HAPU during 2013/14. 11

13. Safety Thermometer results The National ‘harm free’ care composite measure is defined as the proportion of patients without a pressure ulcer (ANY origin, category II-IV), harm from a fall in the last 72 hours, a urinary tract infection (in patients with a urethral urinary catheter) or new VTE treatment. New harm (harm that occurred within our care) is 0.53% therefore, our new harm free care is 99. 47%. The National new harm for March is 2.6% and national harm free is 93.6%. The data for March shows we had 0% of falls with harm and the national performance for March 2014 was 0.7%. The data also shows we had 0.27% of new pressure ulcers recorded in March 2014 against the national performance of 1%. It should be noted that the Safety Thermometer is a spot audit and data is collected on a specific day each month. 12

14. Safety Thermometer Rolling Programme CQUIN Target started April 2012. 13

15. Quality Priority: Patient Experience – Achievement of 85% satisfaction ‘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 90%, in line with previous months. Privacy during examinations is the highest scoring question. Noise at night from other patients and timeliness of call bell response are the lowest scoring questions and remain the areas of focus. Call bell response times are able to be recorded electronically (across 5 wards). Plans are in place to roll out this method of data capture across all wards. Due to a technical problem this data is not available this month but will be included on next months report. Analysis of patient satisfaction questionnaire responses on “timeliness of call bell responses” reveals that 24% of patients stated that their call bell was answered immediately and 42% stated their call bell was answered within 1-2 minutes. 66% of call bells were answered within 2 minutes. 11% of call bells were answered between 3-5 minutes. 14

16. Quality Priority: Patient Experience – Achievement of 85% satisfaction ‘Achieve at least 85% satisfaction in internal patient satisfaction surveys’ is a Quality Priority for the Trust. Overall satisfaction scores for the OPD, A&E, and short stay were maintained at a high level. The lowest scoring question in the A&E survey was “Were you given enough privacy when discussing your condition at reception” at 84%. 2013 National In-Patient Survey • The results of the National In-patient Survey were publicised in April which highlight many positive aspects of the patient experience. • Overall: 80% rated care 7+ out of 10. • Overall: treated with respect and dignity 81%. • Doctors: always had confidence and trust 81%. • Hospital: room or ward was very/fairly clean 97%. • Hospital: toilets and bathrooms were very/fairly clean 96%. • Care: always enough privacy when being examined or treated 90%. • WSFT scored worst than other Trusts in questions about discharge planning and information, being bothered by noise at night, knowing how to complain and not being asked about quality of care. Further analysis will be conducted and a summary of results and an action plan will be presented to Patient Experience Committee in June. 15

17. Quality Priority: Patient Experience – recommend the service ‘Patients would recommend the service to their family and friends’ is a Quality Priority for the Trust. The Trust achieved a Friends and Family test score of 89 for inpatients during March, maintaining the high scores of previous months. G4 scored 33 for the Friends and Family test. This reflects the overall low scoring for patient experience indicators. The Ward Manager has been tasked to improve scores for next month. The recommender score for A&E has declined to 56 for March. 92% of patients’ surveyed were either Extremely Likely or Likely to recommend the service. Maternity recommender scores are high for all stages of the pathway as indicated below: This shows an improvement for the postnatal ward from a score of 70 for February to 86 in March. 16

18. Local Priorities: Exception report Incidents (Amber / Green) with investigation overdue (over 12 days) • The next NRLS cut off for incidents from OCT13 to APR14 is the 31st May. All patient safety incidents will need to have been investigated and finally approved prior to the cut off date to allow upload to the NRLS. There are (as at 14/04/14) 231 green and amber incidents overdue an investigation and an additional 51 which have been investigated but are still awaiting final approval. • The General Managers have received details of the non-medical individuals who have overdue incident investigations and the Medical Director has circulated the medical staff overdue incidents for follow up. In addition the Operational Steering group on the 14/04/14 received the details of individual and locations with high numbers of overdue investigations and a list of all the overdue amber incidents with identified handlers. 17

19. Local Priorities: Exception report • RCA actions overdue • Governance provide the General Managers with a regular report on the first working day of the month listing all overdue and upcoming RCA actions. Progress with closing these actions will then be monitored through the Directorate performance meetings. • There are currently 20 overdue actions including 7which have completion dates before March 2014. Complaints - Response within 25 working days or negotiated timescale with the complainant There were six complaints sent out late this month due to volume of work. Complaints - Number of second letters received There were five second letters received in March which related to requirement for further information and/or disagreement with the content of the initial response. Increased numbers of complaints will result in increased numbers of second letters. However, in the year the Trust has resolved 92% of complaints at first response. 18

20. Local Priorities - Governance Dashboard 19

21. Local Priorities - Governance Dashboard (cont.) 20

22. Local Priorities - Governance Dashboard (cont.) 21

23. Patient Safety Incidents reported The rate of PSIs is a nationally mandated item for inclusion in the 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. The Oct12 – Mar13 NRLS report was issued in December and the benchmark in the graph above was updated. This shows a increase in reporting across the peer group. The Trust reporting rate has risen in March following the dip in the shorter month of February and is now just below the upper quartile threshold for the peer group. There were 474 incidents reported in March including 389 patient safety incidents (PSIs). The Trust reporting rate has risen in March following the dip in the shorter month of February and is now just below the upper quartile threshold for the peer group. The number of harm incidents in March remained below the peer group average. 22

24. Patient Safety Incidents (Severe harm or death) The percentage of PSIs resulting in severe harm or death is a nationally mandated item for inclusion in the Quality Accounts. The peer group average (serious PSIs as a percentage of total PSIs) from the NPSA Oct ’12 – Mar ‘13 report and sits below the Trust’s average. The WSH percentage data is plotted as a line which shows the rolling average over a twelve month period. The number of serious PSIs (confirmed and unconfirmed) are plotted as a column on the secondary axis with avoidable hospital acquired pressure ulcers indentified separately. The benchmark line applies the peer group percentage serious harm to the peer group median total PSIs to give a comparison with the Trust’s monthly figures. In January there were three confirmed patient safety incidents: one pressure ulcer one fall and one delay in diagnosis and two awaiting confirmation through RCA: one delay in patient management and one inquest. 23

25. Local Priorities: Complaints There was a significant increase in the number of complaints received compared with the previous three months but this high number is consistent with the other months of the year, although this is the single highest number received on any given month of this financial year. Complaint response within agreed timescale with the complainant: 74% in March. This is due to increased workload. Of the 41 complaints received in February, the breakdown by Primary Directorate is as follows: Medical (21), Surgical (7), Clinical Support (9), Facilities (1), and Women & Child Health (3). Trust-wide the top 5 most common problem areas are as follows: 24

26. Local Priorities: PALS (Patient Advice & Liaison Service) In March 2014 there were 88 recorded PALS contacts. This number denotes initial contacts and not the number of actual communications between the patient/visitor which can, in some particular cases, be multiple. A breakdown of contacts by Directorate from April 13 to March 2014 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 shown below. The numbers per Ward/Department remain small and consistent when spread across all areas of care provided, although the PALS Manager continues to receive complaints about cancellations for pain treatment. It is evident that the PALS Manager, in addition to assisting with genuine concerns from patients and relatives, frequently signposts enquirers to other services including the formal complaints process. She is also actively involved in dealing with specific in-patients and their families’ concerns during the total admission period. This last month has been particularly busy with patient families raising queries with the PALS Manager. 25

27. Local Priorities – Workforce Performance 26

28. Monitor Compliance Framework 27

29. Contract Priorities Dashboard 28

30. Contract Priorities Dashboard 29

31. Clinical Quality Priorities: Ward Dashboard A3 Printout of Ward Analysis Quality Report From Trust Dashboard 30-35