Trust Quality and Performance Report

1. Trust Quality and Performance Report 29 November 2013 (October 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 October was 97.08%, exceeding the 95% target for the fifth consecutive month and placing the Trust in the top quartile nationally and remains the best performance in the Region. 2. There were two cases of C.Diff in October against the threshold of two. This is covered on page 12 of this report. 3. Performance on outpatient and inpatient discharge summaries remains below target. A number of new steps have been introduced through the month. Further detail is on page 3. 4. Performance on MRSA screening of emergency admissions was 95% against the 100% target, and 92% for elective admissions. This is covered on page 12 of this report. All Stroke targets were achieved for the month. 6. The Trust had 2 single sex breaches during October. All 2 occurred within a short timescale. See page 3. 2

4. Executive Summary Clinical staff and the project team have been exploring options. In agreement with the CCG  a number of non-critical areas have been removed as part of the performance framework while data collection has been extended beyond just EPRO. TEG have agreed a number of initiatives to address the key issues, including performance discussion at consultant  appraisal, targeting the underperforming specialities in directorates, where the Ops Groups have agreed a new process. Looking at automating the process further by sending letters sooner In order to support Discharge Summaries and Letters the project team have been working with clinicians to explore a range of options in order to resolve the current performance. In agreement with the CCG  a number of non-critical areas have been removed as part of the performance framework while data collection has been extended beyond just EPRO. In addition TEG have agreed a number of initiatives to address the key issues, including performance discussion at consultant  appraisal, targeting the underperforming specialities in directorates including a new process agreed by the Ops Group. In addition looking at automating the process further by sending letters sooner . All 3 breaches were associated with ITU step-down and occurred over a 48 hour period. High levels of level 3 occupancy and limited ward beds meant these patients could be neither safely partioned or stepped-down to wards. 3

5. Executive Summary Appraisals are monitored through the Trust’s Electronic Staff Record system (ESR), when a completed Personal Development Plan (PDP) is submitted to the HR Department (this can be done electronically or by using a paper based system). Reporting then takes place on a monthly basis, through the directorate performance management process. Managers can also request individual reports on their own staff from HR at any time. The Trust Board receive appraisal take up information monthly. The target is 90% and as at end October the Trust compliance figure is at 85.47%. • Performance on MRSA screening of emergency admissions was 95.09% against the 100% target. This is covered on page 12 of this report. 4

6. Clinical Quality Priorities: Ward Dashboard A3 Printout of Ward Analysis Quality Report From Trust Dashboard 5-9

7. Clinical Quality Priorities: Summary • The Friends and Family score was commenced at four points of maternity care in September. Scores for all of these are good and lie between 82 and 90. • There were two same sex accommodation breaches this month involving a total of five patients. Both were in critical care where patients who had recovered enough for transfer to the ward were delayed in moving to general wards due to capacity issues within the Trust. Discussions have been held with the Bed Managers and Critical Care to identify ways to prioritise patient movement from Critical care onto the main wards. • Falls with harm are lower this month and there were no falls with serious harm. 10

8. Quality Priority: Ward Performance Issues • No ward had more than 3 red scores in patient satisfaction. • The newly opened F7/8 scored poorly in some of the quality audits in September. Although the ward is still not up to a full complement of permanent staff, the quality indicators have improved with an increase in MEWS compliance from 50% in September to100% this month. • Quality indicators for ward F9 continue to give some concern: there was a grade 3 pressure ulcer during October; concerns regarding infection prevention issues and compliance with the hydration audits was only 30%. However other indicators are improving. An increase in staffing has been agreed for the ward and four new nursing assistants have been appointed, along with two new Portuguese nurses. Interviews for 2 more nursing assistants are planned. When these are in post, this should have a considerable impact. 11

9. Quality Priority: Infection Control MRSA Bacteraemia There were no hospital associated MRSA bacteraemia during October. C. difficile There were two hospital acquired C. difficile infections this monthboth of which occurred on Ward G4. Both patients were female patients identified 3 days apart. These formed part of a period of increased incidence and was investigated accordingly. Ribotyping demonstrated they were different types. The first case was not thought to be clinically significant and is being appealed. The second case was clinically significant but a mild infection; the patient had had antibiotics (appropriately), but the case was not deemed suitable for appeal. The RCA documentation has been slightly modified to streamline the process and clarify grounds for appeal. The C. difficileaction plan has been updated to incorporate recommendations from the external review and has been discussed at TEG and CSEC and will be reported to the Board separately. Hand Hygiene Hand hygiene compliance was 100%. There was one failure in compliance on ward G5, in respect of a student nurse. This was addressed with the nurse at the time of the audit. MRSA screening Elective: 92% Non Elective: 95% Compliance in elective screening has improved slightly and non-elective screening has increased by 3% this month but further improvements are needed if we are to achieve 100% compliance as required by the Commissioners. This will impact on the closure of the Remedial Action Plan. 12

10. Quality Priority: Falls Falls performance Despite changing the definition of falls last month to include patients who faint or collapse due to medical reasons, the total number of falls in October was 50, none of which were faints or collapse. Twelve of these falls resulted in harm but none resulted in serious harm. The rate per 1,000 occupied bed days is 5 (September 5.31) giving an overall downward trend. Themes We continue to monitor the number of falls in toilets: this month 8% of our falls occurred in the toilet, down from 11.7 in September. Detailed intelligence continues to be collected to reveal what the patient was actually doing at the time of the fall. A detailed survey of all inpatient toilets was completed this week, to highlight where extra hand rail support is required. The results will be analysed and reported to the Board next month. Several patients slipped from their chair this month (6), four of these patients had an alternating air cushion in place which makes the chair significantly higher, this may have contributed to their fall and for that reason, all patients using chairs fitted with an air cushion will now be risk assessed by occupational therapy, physiotherapy or a registered nurse to ensure safety. . . 13

11. Quality Priority: Pressure Ulcers The performance target is to have no avoidable Grade 2, 3 or 4 pressure ulcers 2013-14. Grade 2 pressure ulcers There were four HAPU grade 2 this month, all of which the Trust believes to be unavoidable, due to compliance and or morbidity. Grade 3 and 4 pressure ulcers There was one HAPU grade 3, which may have been avoidable as risk assessments and other documentation had not been fully and accurately completed. Our 29 new mattresses are in place and relevant training is underway on all wards. 14

12. 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. The data can be manipulated to just look at “new harm” (harm that occurred within our care) and with this parameter, our Trust score is 99.42%. National October performance is 97.3%. • Current performance for harm-free care is 92.46%. National October performance is 93.4%. 15

13. 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 91%, in line with previous months. Overall satisfaction scores for the OPD, A&E, short stay and maternity services were maintained at a high level. There was a significant increase in the number of surveys completed by both patients and parents in paediatrics this month and good scores were achieved for all questions. The number of responses to the surveys have increased since the appointment (part time) of a Patient Feedback Coordinator and her continued input to all areas. Unfortunately the focus on maintaining the numbers of responses has reduced her ability to carry out more in-depth pieces of work and introducing new sources of feedback. However, the post holder played a vital role in the call bell project. An update on the implementation of the call bell action plan will be provided next month. It is hoped that the data on the call bell response times and the number of calls for the six wards with the wireless call bell system will be provided within this report from next month. 16

14. 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 net promoter score of 87 for inpatients during October, maintaining the high scores of previous months. The score for A&E was 59, this score has been fairly stable over recent months. Analysis of the very few comments on the reasons for not giving a promoter response has not led to any conclusions as to themes/issues other than waiting times. Maternity services introduced the Friends and Family test at 4 points of the care pathway last month and the scores this month are good. These are provided in the table below. 17

15. CQC Action Plan Update The education and training activities identified in the action plan continue to progress well, except on F7/8 where there have been significant challenges in ensuring all new staff achieve the competencies and training required for all elements of their role . All wards now have an MCA and DOLS resource folder on the ward and folders have been prepared for all departments. This ensures that all staff have easy access to guidance and documentation in hard copy. Additional questions were added to the internal CQC assurance audits and incorporated into the peer review audits last month. These demonstrate, whilst consent is sought for treatments and procedures, documentation on capacity and completion of DNACPR documentation to indicate involvement of patients, families and capacity assessment is not consistent. Full implementation of the action plan will address this issue. The process for CQC assurance audits will be changed from Quarter 4. The audits will focus on half of the outcomes in more depth rather than carrying out assessments against all of the outcomes. However, Outcomes 4 and 11 will be included in all the audits. 18

16. Local Priorities: Exception Reporting • KPI-3 SIRIs open more than 45 days after submission on STEIS • This measures all SIRIs that remain open on STEIS beyond the final report submission deadline. This includes three sub-sets: • SIRI final report overdue submission (n = 0) • SIRI final reports for which WSFT response to CCG queries is pending (n = 7) • SIRI final reports submitted for which feedback / closure by the CCG is pending (n = 4) • RAG rating* RED (n >10) Amber (n = 6 - 10) Green (0 - 5) • As @ 15/11/13n = 10 (Amber) • RAG rating based on local benchmark data for 22 Trusts provided by CCG • The number of open reports has fallen considerably from 24 in September to18 in October to 10 in November. One of the 10 SIRIs has had a “stop the clock” pending the findings of an external review of CTG tracing. Incidents (Amber / Green) with investigation overdue (over 12 days) The next deadline for NRLS submission is the 30th November. The Operational Steering Group have agreed a pathway to complete sign off of the Apr-September incidents within the timeframe which has resulted in a reduction in the total overdue for investigation and final approval. Ops group also identified a need to consider a robust method for ensuring timeliness of future investigation and sign off. RCA actions overdue • Seven of the actions are from Maternity RCAs and have only just become overdue in November. These will be actively followed up to ensure completion. Two relate to others policies currently being drafted. 19

17. Local Priorities - Governance Dashboard 20

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

19. 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 but then withdrawn for technical reasons therefore it has not been updated on the graph above.. There were 447 incidents reported in October including 358 patient safety incidents (PSIs). The reporting rate has remained relatively static over the last six months. The number of harm incidents in October was below the peer group average (updated benchmark not yet available from NRLS). 22

20. 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 ‘12 report and sits above the Trust’s average (updated benchmark not yet available from NRLS for Oct ‘12 – Mar ‘ 13). The WSH data is plotted as a line which shows the rolling average over a 12 month period. The number of confirmed serious PSIs are plotted as a column on the secondary axis. The unconfirmed incident in October 2012 was identified via a complaint and reported retrospectively in September 2013. In August there were four ‘Red’ patient safety incidents: Pressure ulcer (1), Retained tampon (1), DNACPR (1), and one awaiting confirmation through RCA: Fall (1) 23

21. Local Priorities: Complaints There was a slight reduction in the number of complaints received in October 2013 compared to other months this year and compared to October 2012. Complaint response within agreed timescale with the complainant: 88% of responded to in October. This represents 4 of the 32 complaint responses going out late. Of the 26 complaints received in October, the breakdown by Primary Directorate is as follows: Medical (12), Surgical (11), Clinical Support (2), Facilities (0), and Women & Child Health (1). There was a higher than average number of complaints about the Orthopaedic Department and this has been highlighted to the Clinical Lead. Trust-wide the top 6 most common problem areas are as follows: 24

22. Local Priorities: PALS (Patient Advice & Liaison Service) In October 2013 there were 102 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’12 to October ‘13 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 across the different areas of concern remain constant and there are no particular themes that the PALS Manager has identified this month. The number of comments about staff attitude has risen slightly again, which the PALS Manager has personally noticed a problem in the out-patients area. However, the main area where concerns are raised about care and waiting times is A/E (8) with other issues following such as care of the elderly (6); orthopaedic surgery (5); ophthalmology (6); emergency assessment, cardiology and general medicine (5). It is evident that the PALS Manager, in addition to assisting with genuine concerns from patients and relatives, frequently signposts enquirers to other services. She is also actively involved in dealing with specific in-patients and their families concerns during the total admission period. 25

23. Local Priorities – Workforce Performance 26

24. CQUIN – November 2013 • NOVEMBER 2013 – CQUIN • Report By PMO: This provides an update on CQUIN progress supported by the Trusts Programme Management Office (PMO) working with Target Owners. • Q2 Report – CCG acceptance/ final feedback due 25 November. • 3i – Unify data used for Q2 accepted. Use EPRO new data for Unify Q3 onwards shows 100% met. • Q2 remaining issues: • 7 – Psychiatric Liaison. Launch November/ final recruitment on-going (external influence) – % income deferred to Q3 tbc 25/11. Team on site w/e 15/11. • 8 – Pain Pathway – (external influence) more complex than when set up so work on-going into Q3 in conjunction with CCG. % income deferred tbc 25/11. • 14 – GP Assessment area - finalise delivery Q3 onwards. • 11 - 7 day - Diagnostic Test higher trajectory set at CCG request – part not met Q2. CCG to advise outcome 25/11. Review of what is possible electronically for other 7 day evidence for Q4 (versus manual audit evidence for Q2, Q3). • Q3 - Dispute re: 2i – CCG to agree not set % for falls in toilets. Dispute re: 3iii – dementia carers – CCG agree not set target. • 2014-5 targets setting – involve relevant staff, ensure data collection available or allowances made, ensure responsibilities allocated – collaborative working. • If felt appropriate – own Trust ideas were to be submitted 14 November 2013 / however, Trust work with CCG on integrated way forward. • PMO support colour coding: 27

25. CQUIN – November 2013 28

26. CQUIN – November 2013 29

27. CQUIN – November 2013 30

28. Monitor Compliance Framework 31

29. Contract Priorities Dashboard 32

30. Contract Priorities Dashboard 33

31. Contract Priorities Dashboard 34