Trust Quality and Performance Report

1. Trust Quality and Performance Report December 2012

2. Contents 2

3. This Corporate Trust Dashboard provides narrative for performance in five key areas: Clinical Quality Priorities, CQUIN Performance, Local Priorities, Monitor Compliance and Contract Priorities. Introduction 3

4. Clinical Quality Priorities • Summary • The number of falls reduced to 46 this month and no-one with serious harm • No MRSA bacteraemias or cases of C. difficile were reported • The inpatient satisfaction score increased to 93% • Noise at night and timely call bell response continue to be issues and board/subcommittee actions have been agreed on both of these indicators 4

5. Ward dashboard – A3 5-8

6. Quality Priority: Ward Performance Issues Infection prevention Critical Care Services reported a drop in performance against the HII 1a central venous catheter insertion (90%) and HII 2a peripheral cannula insertion (80%). HII 1a performance related to one CVC insertion safe disposal of sharps: no appropriate sharps bin was available. HII 2a performance related to no documentation at all for 2 patients who had peripheral cannulae inserted. This appears to be related to new medical staff not completing the documentation accurately rather than poor practice within CCS. F1’s performance in peripheral cannula care insertion and ongoing care has been discussed with the ward manager and the infection prevention team and actions allocated accordingly to improve performance. The insertion score for November was 80% due to the audit being completed on only 5 patient details and one of those not recording a cannula insertion date. The ongoing score was 0 as only one patient was audited and this audit failed as the VIP score was not completed. Fluid management Improved performance in fluid management is encouraging, although some areas still need to improve performance significantly. The low score on G4 is due to the target intake remaining at 1,500 mls for every patient which has not been achieved. The clinicians can make a clinical decision to change the target intake to an achievable, appropriate intake for each patient and this practice needs to be reinforced. EAU Last month’s report identified a fall in patient satisfaction on EAU. This month overall satisfaction improved significantly, despite the capacity issues faced by the Trust and the preparation for relocation of the unit. 54 responses to the survey were obtained. There was one complaint attributed to EAU and this was not related to staff behaviour, attitude or privacy and dignity issues. The first of the staff training days has taken place with the priority given to the Band 6 sisters as role models for the unit. This covered Patients First standards, managing challenging behaviour and dementia care. The Ward Manager has now returned from sick leave and a multi-disciplinary team is being convened to provide ongoing support to EAU during the transition. 9

7. Quality Priority: Infection Control • There were no cases of MRSA bacteraemia, MSSA bacteraemia or C. difficile infections during November. • Antibiotic audits carried out in November. • The full results and RAG report will be available as usual at the end of the quarter. The wards audited this month were F3, F6, G3, G5 and G8. • G3, G5 and G8 were 100% compliant with all six elements of antibiotic prescribing. Areas of non-compliance related to 3 patients on F3 • and 5 patients on F6 and involved similar elements of antibiotic prescribing: blood cultures not taken, indication for antibiotic treatment not • documented and discussions with microbiologists not documented regarding appropriate antibiotic prescribing in complex patients. • Current ongoing projects to aid compliance • ‘Indication – stating the source of infection’ poster campaign. • Antibiotic team to meet with the lead for the yellow weekend review stickers and potentially add an antibiotic review section, to prevent • prolonged courses of antibiotics being given. • Consider and plan 2013 locum, agency and bank staff training so errors in antibiotic prescribing and administration are avoided. • Hand Hygiene • Two wards had lower scores for hand hygiene compliance: F10 and F11. These wards had made a particular effort to measure compliance through covert audit rather than a more overt audit of practice by staff who only visit the clinical area to audit hand hygiene compliance. This change in results will be discussed at the DIPC meeting and will inform future audit practice. 10

8. Quality Priority: Falls 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 performance There were 46 falls across the Trust during November; 13 of these falls resulted in harm, none with serious harm. Themes 2 clear reasons for reduction were noted during November in two clinical areas: • F3 were temporarily on G9 during the deep clean for 3 weeks. During this time, no patients fell at all. One fall occurred when they returned to F3. The staff attribute this to the increased visibility of all patients on G9 as it is an open “Nightingale” style environment. There are not enough nursing staff per shift to maintain this visibility within the usual 5 bay environment on the ward. • F7 have seen a reduction in falls at night as they have been working differently during the night shifts to ensure patient visibility is as high as possible. This practice will be presented by the ward manager at the next ward manager meeting to encourage adoption in other areas as appropriate. 11

9. The performance target is to have no avoidable Grade 3/4 pressure ulcers in 2012-13 with a penalty of £5,000 for each incidence. The performance target regarding avoidable Grade 2 pressure ulcers is a ceiling of 4 for Quarter 3 with a penalty of £500 for each incidence above the ceiling. November performance 7 patients developed Grade 2 hospital acquired pressure ulcers this month, of which 4 were considered avoidable following concise root cause analysis. The Grade 2 pressure ulcers developed on F3, F5, F9, G5, G4, F7, F10 1 patient on G4 developed a Grade 3 sacral pressure ulcer. The RCA has not yet been held. Avoidable pressure ulcers • 1 patient developed a pressure ulcer on F3 due to a long period wearing a hard collar to support a spinal instability. Skin checks were not done frequently enough and therefore this has been considered avoidable. • 1 patient developed a sacral pressure ulcer which appeared to be due to friction caused by manual handling technique. The manual handling lead has been advised and is working with wards to strengthen the ward-based teaching. • 1 patient developed a sacral pressure ulcer on F10. There was a delay in getting the right pressure relieving mattress to this patient and therefore is potentially avoidable. The results of the mattress timeline audit (patient admitted, risk assessment completion, mattress request, mattress delivery, patient on mattress) are being collated and will be reported next month. • 1 patient developed a sacral pressure sore on F7. As a pressure relieving cushion was not in place within 2 hours of admission, this has to be considered avoidable. Quality Priority: Pressure Ulcers 12

10. Safety thermometer results CQUIN 2012-13 target is to survey all adult inpatients on the survey date and submit the data to the NHS Information Centre on time. Our quality priority is to achieve 95% harm-free care, current performance is 93.77%. The national amalgamated figure in November for all organisations is 92.3%. 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 care 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’ and with this new parameter, our Trust score is 98.85%. The national amalgamated figure in November for all organisations is 96.66%. ‘New harm’ is defined as harm in hospital occurring since the start of current admission. 13

11. 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 93% indicating a high level of satisfaction with most of the areas covered in the survey. Response rates were higher this month, but there is still variability between wards. Ward F12 was the only ward with particularly low responses and only obtained 2 responses. This is being raised again with the ward manager who is being asked to provide assurance as to how numbers will be increased. Requirements associated with the ‘Friends and Family’ (or net promoter question) which is administered with the survey, are that patients are surveyed within 24 hours of discharge and that staff do not administer the survey to patients themselves. This, therefore places some constraints on the numbers of responses obtained. However, we will shortly be adding a line on the ward dashboard to report on the number of responses by ward to ensure greater transparency. A&E National Patient Survey The Trust has received the results of the 2012 National Accident and Emergency Survey. This survey looked at 850 patients who attended A&E during March 2012. A response rate of 52% was achieved against a national response rate of 38%.The Trust was categorised as having scores that were broadly similar to other Trust in all of the questions except three, where we were classified as scoring “better” than other Trusts. These were: • Overall how long did your visit to A&E last? • Did doctors or nurses talk in front of you as if you weren’t there? • As far as you know, was your GP given all the necessary information about the treatment or advice that you received in A&E? The detailed results from this survey will be presented to the Patient Experience Committee and any actions identified and monitored. 14

12. 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 89 for inpatients during November with a 20% response rate. The low net promoter score for Ward G8 that was identified last month has reverted to a good level this month with a score of 94. The results for the other areas for the net promoter score are provided below: DSU obtained a very small number of responses in November, but this follows high numbers of returns in October and meets the requirements for the quarter for CQUIN. 15

13. Quality Priority: Mortality 16

14. 17

15. Q2 CQUIN performance report has been submitted to NHS Suffolk and the PCT’s response is awaited. It is understood that most measures are confirmed as met in line with expectations. VTE screening target continues to be met and is expected to rank very highly nationally. The new A&E Assessment of Falls target was also met. EPRO has been upgraded to meet Dementia screening requirements. A trial target list of patients for weekend discharge is in place to develop 7 day working. CQUIN Summary & Exceptions report 18

16. CQUIN dashboard – A3 19 – 20

17. Local Priorities Summary & Exceptions report 21

18. Local Priorities - Governance Dashboard 22

19. Upper quartile, median and lower quartile rebased from Sept 12 Harm (peer group average) rebased from Sept 12 There were 374 incidents reported in November including 311 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 was rebased in September to take into account the new dataset from the Oct 11 - Mar 12 NRLS report). The reporting rate fell in October from the number in October but still remained higher than any previous month. The number of harm incidents remains below the peer group average. 23

20. 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. This has remained relatively static over the previous six months. In October there were six ‘Red’ patient safety incidents reported. Two have been confirmed through RCA as serious harm; Surgical site “never event” and Grade 3 pressure ulcer. Another four are awaiting confirmation of grade through RCA: Missed fracture (1), Delay in treatment (3) 24

21. Local PrioritiesComplaintsComplaint response within agreed timescale with the complainant: 100% of responses due in November were responded to within the agreed timescale (target 90%). Of the 22 complaints received in November, the breakdown by Primary Directorate is as follows: Medical (11), Surgical (3), Clinical Support (3), Facilities (2) and Women & Child Health (3).Trust-wide the most common problem areas are as follows: Admission, discharge, transfer arrangements 3 All aspects of clinical treatment 6 Appointments, delay / cancellation (outpatient) 1 Attitude of staff 1 Communication / information to patients (written and oral) 2 Other 2 PCT commissioning (including waiting lists) 1 Personal records (including medical and / or complaints) 1 There was one complaint received for EAU in November and this was a medical expected patient who was required to wait in A&E.  Complaints received were spread across many areas of the Trust and relate to concerns about care given, communication and attitude of staff in the main. 25

22. Local PrioritiesPALS (Patient Advice & Liaison Service) In November 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 which is recorded as 173 for this month. A breakdown of contacts by Directorate from November 11 to November 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: From the information above, November has been a particularly busy month and there has been a considerable increase in general enquiries and patients/visitors seeking advice. An analysis of these enquiries does not indicate any trend – just the general public wishing to be signposted to the correct service in the hospital and in the community. There is however little change in the nature of overall issues raised with the PALS Manager for further investigation and the most detailed enquiries relate to aspects of clinical treatment. Attitude of staff remains about the same and this is often not the primary issue but associated with other concerns and relates to how the member of staff may have dealt with the initial enquiry or concern. Not listening has been quoted on a number of occasions. The PALS Manager 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. Analysis of contacts with PALS The five month from Jun ’12 to Oct ’12 has seen a steady increase in PALs enquiries relating to patients/users from the Medical Directorate. The number of enquiries has reduced for the month of November to 35. Analysis of this five month period shows that there is no specific trend in enquiries either in terms of the nature or the area/specialty it concerns. For the sample reviewed more than a quarter of enquiries related to requests for information or advice. The majority of these coming from A&E, which given the level of activity in the area this is unsurprising. The second most common enquiry related to discharge arrangements, however no individual department/ward was an outlier in terms of the number enquiries. With regard to the gradual increase in number of medical complaints since June 2012, a review of the issues raised does not highlight any trends. The chart above does in fact highlight peaks and troughs and an increase in PALS involvement will often link with increased activity in A&E and on the wards. 26

23. Local Priorities –Workforce Performance 27

24. Monitor Compliance Summary & Exceptions report Performance against the four hour target improved dramatically in late November and early December, achieving the best in England by a considerable margin for two consecutive weeks. However, winter pressures, including Norovirus, in December mean that it is not possible to recover performance for the quarter. All actions have been undertaken according to plan including opening additional escalation beds, trialling a GP expected bay and moving TIA patients to the Stroke Unit. 28

25. A&E CQI’s – National Benchmarking • This data is from the Department of Health based on July 2012. • Left Department - The Trust is under the National Average of 3% at 2% - WSFT is 4th in the East of England. • Re-Attendance Rate – WSFH is under the National Average of 7.3% at 5.7% - 7th in East of England. • Time to Initial Assessment – WSFT is over the National Median of 3 minutes at 5 minutes. Of 10 Trusts reporting this measure WSFT is 6th. 29

26. A&E CQI’s – National Benchmarking • Time to Treatment - WSFT is marginally under the National Median of 54 minutes at 51 minutes. The Trust is 4th in the East of England. • Total Time in A&E– The Trust is slightly under the National Median of 126 minutes at 122 minutes. WSFT is 3rd in the East of England. 30

27. Monitor Compliance Framework A3 printout Dashboard - screenprint 31

28. Contract Priorities Summary & Exceptions report Performance against a number of Stroke indicators improved in November through management action and improved patient flow. 32

29. Contract Priorities Dashboard + Other A3 printout Comes from dashboard - screenprint 33-34