Trust Quality and Performance Report

1. Trust Quality and Performance Report 20 December 2013 (November 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 November was 96.06%, exceeding the 95% target for the sixth consecutive month and continues at a rate well above both the regional and national averages. There were zero cases of C.Diff in November against the threshold of two. This is covered on page 12 of this report. All Stroke targets were achieved for the second consecutive month. Performance on outpatient and inpatient discharge summaries remains below target. In addition to previous actions, further PMO support to this target has been introduced. Further details on page 3. Performance on MRSA screening of emergency admissions was 96% against the 100% target. This is covered on page 12 of this report. NOTE – due to the early board reports the Trust is unable to confirm final 18 week performance for November. A verbal update will be given at the board. 2

4. Executive Summary Additional work is now being taken forward with new performance information to look at individual department and consultants - led by Medical Director. Has now increased to its highest level with support at ward level and further performance information being provided via whiteboards . The A&E letters are down because of a technical fault with the letter template that stopped the sending on 20th Nov – these letters were subsequently re-sent manually. 3

5. Executive Summary The Trusts cumulative sickness absence rate is currently 3.90% (over 12 month period). The highest % being in Estates and Facilities (4.97%) and the lowest in Corporate Services (2.39%). A number of initiatives are currently in place to further address this issue; The Trust’s solicitors are undertaking a review of our policy/process to see if further changes can be introduced. The Well Managed Ward Manager Programme will address managing sickness absence, and a specific KPI added. Medical staff absence has been investigated as part of the regional quality benchmark, for the Quality & Risk Committee. Monthly reports are provided to all General Managers and cascaded to all managers, regular training for managers is offered through the skills+ programme  and HR & Occupational Health continue to review all long term sickness absence.  Trust compliance has increased very slightly this month. The highest area being the Medical Directorate (90.20%) and the lowest being the Surgical Directorate (82.83%). Senior medical staff appraisal is at 82%. The following initiatives are in place; A new electronic appraisal/ revalidation system for doctors has been purchased and will be implemented in January 2014. The Strengthening Appraisal & Revalidation Database (SARD) will go live from 1st January 2014. Monthly reports are produced for general managers listing those staff that are due to expire, and training is available to all new and existing appraisers through the skills+ programme.  • Performance on MRSA screening of emergency admissions was 95.97% 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 • There has been an increase in grade 3 pressure ulcers this month. • There were no C. difficile infections during November. • Analysis of the Trust’s incident reporting shows a reduction in reporting for November ’13. This is in the context of a national increase in reporting for our peer  (source National Reporting & Learning System (NRLS)). This indicator will be kept under review and the reporting rate for December ’13 will be reviewed in greater detail if the trend continues. 10

8. Quality Priority: Ward Performance Issues • No ward had more than 3 red scores in patient satisfaction. • Ward F9 continues to experience vacancy issues and this is being managed through regular meetings between the Head of Nursing and the management team for the ward. Compliance with the hydration audits increased to 90% this month from 30% last month, MEWS escalation audits achieved 100% and there were no pressure ulcers or falls during November. • Ward F3 decreased its bed capacity due to staffing issues but on occasions this was increased during November due to Trust wide bed capacity issues. The recommender score for this ward was lower than average for the Trust and there were amber scores for the questions in the patient experience survey relating to opportunity to talk about worries and fears, involvement in decision making and help with meals. Although the ward is meeting its core staffing levels for the reduced bed capacity, when bed numbers were increased this caused additional pressure. Approval to recruit to the numbers required for the six additional beds has been put forward. 11

9. Quality Priority: Infection Control MRSA Bacteraemia There were no hospital associated MRSA bacteraemia’s during November. C. difficile There were no hospital acquired C.difficile infections during November. High Impact interventions All High Impact Intervention audit results were 100% except for peripheral cannula on-going care which scored 93% overall. Failures in compliance in relation to this indicator were related to documentation of VIP scores. This has been highlighted with the wards concerned and the Matron is undertaking additional spot checks. MRSA screening Elective: 87.60% Non Elective: 92.84% . 12

10. Quality Priority: Falls There were 50 falls this month 15 of which resulted in negligible or minor harm, none incurred serious harm. Two were due to collapse for medical reasons and would not have been counted in our old definition. The rate per 1,000 occupied bed days is 5 (October 5) which is below National average of 5.6 (NPSA 2010) Themes We continue to monitor the number of falls in toilets: this month 8% of our falls occurred in the toilet, the same number as in October Detailed intelligence continues to be collected to reveal what the patient was actually doing at the time of the fall. Only one patient slipped from their chair this month. Down from 6 last month. This patient did not have an alternating air cushion in place. Several patient fell while attending to their own hygiene needs after using the toilet, hand rails may have prevented these falls, and work is about to start to fit safety rails in all patient toilets. It should be noted that since publishing last month’s data one more fall has been recorded and we are now reporting 52 falls for October. The quality report and Datix records have been amended. Falls performance 13

11. Quality Priority: Pressure Ulcers The performance target is to have no avoidable Hospital Acquired Pressure Ulcers (HAPU) Grade 2, 3 or 4 pressure ulcers 2013-14. Grade 2 Pressure Ulcers There was one grade 2 HAPU this month which we believe was unavoidable. All four grade 2 HAPU from last month have been deemed UNAVOIDABLE by the CCG. Grade 3 pressure Ulcers There were five grade 3 HAPU in November, at least two of these are thought to be UNAVOIDABLE but we are still awaiting CCG confirmation. Three may have been avoidable as risk assessments and other documentation could have been improved,. Two of the pressure ulcers were on the ears of palliative patients receiving oxygen therapy. It has been highlighted to ward staff to check patients ears when checking other pressure points. We have also obtained pressure relieving gel tape to protect wars ate risk We are looking into ways of improving and streamlining our service to provide pressure relieving mattresses to the wards. We plan to steam clean electric beds, fit them with an electric alternating mattresses and deliver the whole package to the ward requesting the mattress. This will provide improved systems to ensure mattresses are fitted correctly, safely and ready for use. 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 96.39%. National November performance is 97.4%. It should be noted that the Safety Thermometer is a spot audit and data is collected on a specific day each month. The number of falls were higher than normal, in November, on the day of the audit however the Trust total for the month remain constant. 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 90%, in line with previous months. Overall satisfaction scores for the OPD, A&E, short stay and maternity services were maintained at a high level with each scoring over 90% overall. Call Bell Project A meeting was held on 29th November with the ward managers to review the action plan. • The ward managers are disseminating the results of the project at their team meetings. Unfortunately there have been problems with the CD provided by the Patients Association and therefore it has not been possible to use the video clips with the ward staff to date. However, a hand out for staff has been produced. • The ward managers are ensuring that there is meticulous attention to intentional rounding in order to reduce the need for the call bells to be pressed. • The use of tables in bays for documentation tasks by staff is being encouraged where these are available. • Clocks are available in the bay areas of most wards. • A project to consider alternative methods of organising care to enable call bells to be answered more quickly is being focused on the early adopter wards where ‘supervisory status’ is being piloted. • As an example the response times for F5 and F6 are shown in the graph below. 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 84 for inpatients during November, maintaining the high scores of previous months. Two wards had noticeably lower scores, these were wards F3 and G4. There was only one comment regarding G4 and this indicated that the patient felt that they should not be mixed with dementia patients. In relation to F3 there were 5 comments as follows: • Two indicated that they felt that there was not enough staff on duty to meet the needs of the patients • One said that they were kept waiting too long to go to the toilet • 2 said the ward was chaotic and noisy The score for A&E was 61. There were five comments from patients relating to the score, these were as follows: • Doctors good, nurses less so • After care ‘virtually non existent’ • Long wait and not kept informed • Slow service, not very helpful • Stupid question. 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 only outstanding actions within the CQC Action Plan are as follows: • A presentation and discussion at the Surgical Clinical Governance Audit session on Consent, MCA and DNACPR in January • MCA and DoLS updates provided in conjunction with the County MCA/DoLS Facilitator will continue into 2014 to maximise attendance • MCA and DOLS awareness information to be included in the Greensheet scheduled for week of 16th December. • Dedicated webpages on the staff intranet in January • Displays in ‘Time Out Staff Restaurant re: MCA / DoLS / IMCA / Consent planned to follow Greensheet publication It is anticipated that all actions will be complete by the end of January 2013. 18

16. Local Priorities: Exception report Incidents (Amber / Green) with investigation overdue (over 12 days) The Trust met the deadline for submission of all PSIs in Apr-September NRLS of the 30th November. This has resulted in a reduction in the total overdue for investigation and final approval. Ops group identified a need to consider a robust method for ensuring timeliness of future investigation and sign off to ensure the levels do not start to creep up again now the submission deadline has passed. RCA actions overdue n = 8 • Six actions became overdue in November and are being actively followed up to ensure completion. Two others due in October relate to 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 the Apr ’12 – Sept ’12 rate is still shown as the benchmark in the graph above. There were 385 incidents reported in November including 316 patient safety incidents (PSIs). The reporting rate fell to its lowest rate since September 2012 but still remains above the benchmark median. The number of harm incidents in November was below the peer group average (Apr ’12 – Sept ’12 benchmark). 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 Apr ’12 – Sept ‘12 report and sits below 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 serious PSIs (confirmed and unconfirmed) are plotted as a column on the secondary axis with avoidable hospital acquired pressure ulcers (HAPU) indentified separately. In September there were six ‘Red’ patient safety incidents: cardiac arrest (1), AKI (1), pressure ulcer (1), deteriorating patient (1), delayed admission to CCS (1), and one awaiting confirmation through RCA Cardiac arrest (1). 23

21. Local Priorities: Complaints There was a large increase in complaints received in November 2013 compared to November 2012. Complaint response within agreed timescale with the complainant: 96% of responded to in November. This represents 1 of the 23 complaint responses going out late. Of the 40 complaints received in November, the breakdown by Primary Directorate is as follows: Medical (19), Surgical (14), Clinical Support (4), Facilities (1), and Women & Child Health (2). Trust-wide the top 6 most common problem areas are as follows: 24

22. Local Priorities: PALS (Patient Advice & Liaison Service) In November 2013 there were 71 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. Although the overall number of initial contacts is much less for November, the length of time dealing with families has been prolonged. A breakdown of contacts by Directorate from Nov’12 to Nov‘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 are quite small and consistent when spread across the different areas although the PALS Manager has noticed a definite trend in the patient’s dissatisfaction with cancelled clinics (particularly surgical). The other main areas where concerns were raised in November 2013 are Ward G9 (5); Emergency Department (4); and Ward G5 (4) 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

23. Local Priorities – Workforce Performance 26

24. Monitor Compliance Framework 27

25. Contract Priorities Dashboard 28

26. Contract Priorities Dashboard 29