West Suffolk Hospital NHS Trust

1. West Suffolk Hospital NHS Trust Report To: Trust Board Date: January 2012 Title: Quality and Performance Report Report of: Nichole Day, Executive Chief Nurse

2. Introduction This Quality Report provides the narrative for performance in three key areas: Quality priorities, CQUIN performance and local issues requiring escalation. It should be read in conjunction with the Ward and Trust dashboards. The layout of this report identifies performance data followed by themes identified during the analysis process and actions being taken. The ward quality report summary has been used to highlight wards that have a number of red scores and these are discussed within the report.

3. 1. To further reduce hospital acquired infections Aim: To reduce hospital acquired MRSA bacteraemia to no more than 2 cases and C. difficile infection to no more than 29 cases between April 2011 and April 2012 There were no cases of MRSA or MSSA bacteraemia during December.There was 1 case of clinically significant hospital acquired C. difficile during December (giving a total of 17 year to date).In respect of compliance with the High Impact Interventions (HII), all interventions scored 100% except peripheral cannula ongoing care (96%) and urinary catheter ongoing care (92%). This was related to documentation and has been discussed at the Matron’s performance meeting and will be addressed by the Matrons. The sideroom audit during December demonstrated that of the 32 siderooms available: 21 were used for Infection control purposes. 1 sideroom was empty and available for isolation. No high risk patients were not isolated at that time.

4. 1. To further reduce hospital acquired infections Aim: To improve the management of antibiotics by achieving 100% compliance with antibiotic policy The compliance with antibiotic prescribing policy was 97% in December. 1 out of 31 patients (3%) received non-guideline/unauthorised antibiotic treatment: This patient was treated with Co-Amoxiclav for a urinary tract infection; the guideline treatment is Trimethroprim or Nitrofurantoin. The patient had not had a urine sample sent to microbiology this admission to indicate the use of Co-Amoxiclav, nor were there any contraindications for the use of the guideline antibiotics. Co-amoxiclav usage has improved compared with previous months and this is reflected in the improved overall results. A report on the proposed changes to antibiotic audits is provided in Appendix 1 of this report. Actions taken/proposed: The results have been fed back to the individual ward Consultants, Ward Managers and Pharmacists via email. On 13th December the Antibiotic Audit Nurse presented the recent antibiotic audit results at the Medical Clinical Governance afternoon and gave a presentation on correct antimicrobial prescribing. The possibility of the Antibiotic Audit Nurse attending individual ward governance meetings to enable face-to-face reporting and action plans was discussed and it was agreed that details of these meetings will be provided to facilitate this. A copy of the abbreviated antibiotic guidelines was included in the junior doctor induction packs, to try to minimise the effect that the junior doctor change-over may have on antibiotic prescribing. Gemma Kerridge, Antimicrobial Pharmacist, presented the correct use of the antimicrobial page on the drug chart at the junior doctor’s induction on Friday 9th December 2011.

5. 2a) To achieve the highest levels of patient safetyAimsi) To assess at least 98% of admissions for risk of VTE ii) Provide prophylaxis to 100% patients at risk VTE assessment performance/ issues and actions Compliance with risk assessment was 95.6% for December. Prophylaxis compliance was 98%.

6. Patient Falls The CQUIN ceiling is 147 falls in Quarter 3. The total number of falls in December was 44 which brings us to a Q3 total of 140 falls, meeting the CQUIN target. Q4 ceiling will be 126 falls across the quarter. The wards with significantly increased fall rates against their normal performance were F6 and G1. F6 had a very difficult, aggressive patient who had all interventions in place (low bed, 1:1 nursing) but fell 3 times as he refused assistance to mobilise. The number of falls have now been reduced to a level where it is difficult to identify themes and different issues are identified each month. These are very difficult to reduce further when balancing the need for rehabilitation with patient safety, therefore it is felt that the only way to make further progress is to ensure that the expertise of other professional groups is fully utilised and a joint approach to problem solving further developed. Actions The Head of Nursing met with AHP leads to discuss falls and joint actions that could be developed. As a significant number of falls happen in our patient toilets, the OT lead will review toilet facilities for grab rail availability, toilet raiser seats etc. The AHP leads are now sent 10 falls concise RCAs/ month to review and consider further preventative actions that could provide benefits to a wider group of patients. 2b) To achieve the highest levels of patient safety Aim: To reduce the number of patients who fall in hospital by 35% in the last quarter of 2011/12

7. : 2c) To achieve the highest levels of patient safety Aim: To reduce the number of avoidable Grade 3 and 4 pressure ulcers by 80% in the last quarter of 2011/12 Pressure Ulcers 5 patients developed ward acquired pressure ulcers this month: • A #NOF patient developed a Grade 2 heel pressure ulcer on F3. This was considered avoidable as the leg trough was putting pressure onto the heel and should have been noticed. • Two patients on G5 developed pressure ulcers. One was considered unavoidable as the patient refused all preventative care and one patient developed an avoidable pressure ulcer - there was no evidence of risk assessment or preventative care. • A patient on the Coronary Care Unit was admitted with a Grade 1 pressure ulcer which deteriorated to a Grade 2 pressure ulcer due to his poor physical condition. This was considered unavoidable as the patient was on the Liverpool Care Pathway and refused care. • A patient on F7 developed Grade 2 sacral pressure ulcers. A pressure relieving mattress was unavailable for this patient, therefore this is classified as avoidable.

8. 3a/b) To continuously improve the experience of patients using our services Aims: At least 90% of patients would choose to use the hospital again. To achieve at least an 85% satisfaction rating in our internal patient experience surveys Survey results Overall percentage scores for the surveys for December are provided in the table (left). Individual question scores were high for all questions in the Outpatients, A&E, and short stay surveys. A breakdown of the scores for the questions in the inpatient survey are provided below and overleaf. Following feedback from the last Board meetings the graphs have been presented differently this month and broken down into 3 graphs to aid clarity. The recommender question and overall satisfaction with the care provided have been removed from the graphs as these are reported in the table and are consistently high. The question on noise at night was changed in September and broken down into 2 questions, one relating to noise from patients and the other noise from staff.

9. 3a/b) To continuously improve the experience of patients using our services Aims: At least 90% of patients would choose to use the hospital again. To achieve at least an 85% satisfaction rating in our internal patient experience surveys Survey results As reported last month, the scoring related to the question on call bell response times was changed in September to reflect the scoring within the national patient survey, hence the reduction in scores. The average call bell response times in December on the wards with the new call bell system are displayed below. The two questions in the graph on the right are mainly relevant to surgical patients.

10. 3c) To continuously improve the experience of patients using our services Environment and Cleanliness The overall Trust score was 91% and all clinical areas scored greater than 85% except F7 who scored 67%. A number of issues have resulted in a low score for Ward F7 this month. Refurbishment of the neighbouring ward has led to unacceptable increases in dust levels that have been addressed with the contractor. Issues have also arisen since the ward move related to poor ward practices and problems with team working between housekeeping and nursing staff. A meeting has been held with all parties and an action plan agreed. Formal monitoring by the housekeeping supervisor has been initiated to ensure that improvement is maintained..

11. 4a) To achieve optimal clinical outcomes and effectiveness Aim: To consistently achieve a Hospital Standardised Mortality Ratio that is below the expected rate HSMR remains well below the expected level as can be seen by the overall mortality shown in the graph and the table giving a mortality rate for the five Dr Foster - How Safe is Your Hospital indicators. This table provides information on relative risk, with red, blue and green traffic lighting. Blue indicates that the score is within the standard deviation.

12. Local issues requiring escalation Patient Experience Ward surveys CCU and G4 had 4 red scores on their patient experience relating to noise at night, call bell response times and staff talking in front of them, These areas experienced pressures created by increased patient throughput and patient dependency during December, compounded in the case of G4 by staffing pressures as a result of Norovirus. These patient experience results will be escalated to the ward governance meetings and actions developed.

13. Other OTHER PERFORMANCE STANDARDS • Overall, performance against other performance standards remains good. • The area’s for exception reporting this month are:- • Cancer 62 day. Performance was below standard for December, however did achieve for the quarter. Performance was affected in December due to the holiday period and less elective operating • Stroke TIA. This was below standard for December, this was due to late referrals from GP’s to the Trust, combined with annual leave. Regional stroke performance for quarters 1and 2 is attached to this report for information. It show that WSH performance overall is good, although there is always scope to improve. • A&E. There was a significant wait for one patient of over 11 hours in December. This was a patient who was referred to the mental health services and there was a delay in attendance to the A&E department. The Trust and the PCT are in discussion with the Mental Health Trust for a new service level agreement for response times from April 2012. • The ambulance handover times for A&E have been static for several months, although it should be noted have improved significantly from this time last year. One of the key challenges relates to the arrival of GP expected patients in the department. The new EAU is scheduled to open at the end of January, and whilst this in itself will not solve all the issues with regard to handover times, it is anticipated that the additional assessment capacity in EAU will enable more patients to be seen directly in that department and not attend A&E. • 18 week performance remains good. There are challenges with diagnostic waiting times for endoscopy, but performance is within the tolerance allowed 1% of patients waiting over 6 weeks.

14. Local Priorities - Governance Dashboard 13

15. Local Priorities Care Quality Commission (CQC) Quality & Risk Profile Background The CQC publish a monthly Quality & Risk Profile (QRP) outlining the external sources of data which can be used to assess a Trust’s level of compliance using a statistical assessment to identify if a Trust’s performance is much worse than expected; worse than expected; tending towards worse than expected; similar to expected; tending towards better than expected; better than expected or much better than expected. The expectation is that each Trust will study this QRP and use it to provide evidence of compliance and/or act upon those areas highlighted as below expected. In addition, this report contains Negative Comments or Positive Comments taken from local engagement, external inspectors’ reports and a range of other sources. The Quality and Risk Committee review in detail progress to address areas of concern.

16. Local Priorities Patient Safety Incidents resulting in harm (including serious harm) and Serious Incidents Requiring Investigation (SIRIs) The overall rate of incidents resulting in harm has shown a decrease in the last month to 76. The number of serious incidents is three. The number of SIRIs reported in December was one (an outbreak of Norovirus). NRLS analysis shows that WSH has a reporting rate of 4.4 per 100 admissions, which is at the lower end of reporting rates for our small acute peer group and this has been highlighted as “tending towards worse than expected” by the CQC on the Trust Quality & Risk Profile. More detailed analysis of NPSA data is provided on the next slide. The three serious incidents in December were: the Norovirus outbreak (SIRI), a worsening of infection due to missed doses of antibiotics and a third which relates to the care of a patient with an ectopic pregnancy which is still awaiting confirmation of final grading and so remains Red until confirmed otherwise. Themes from 2011 SIRIs The number of reported SIRIs over the last year (excluding May) has fallen slightly. There is evidence to suggest that SIRIs relating to pressure ulcers, falls and information governance have reduced. In addition there have been no nasogastric tube incidents and only one maternity incident, both of which are reductions compared to 2010. Incidents of infectious outbreaks (eg C difficile and Norovirus) still occur at sporadic intervals. No theme is identifiable from the remaining SIRI.

17. Local Priorities Patient Safety Incidents reporting to NPSA National Reporting and Learning Service (NRLS) The first axis of the graph shows the number of patient safety incidents (including near miss and no harm) for the period Jan – Dec 11. The ‘Median’ line shows the number of incidents required to be reported (to the NRLS) to be the median Trust for incidents per 100 admissions in the small acute Trust category (6.2 based on the Oct 10 – Mar 11 dataset). There is a downward trend in the reporting of incidents overall from April onwards which appears to be based mainly on a reduction in the number of reported falls with no/minor harm. The Datix implementation project recognises the need to ensure that staff are encouraged to report through the new system but this needs to consider what the causes of low reporting are due to. A plan has been agreed to ensure effective communication of reporting arrangements and sharing of learning from incidents. This is linked to the implementation of the new electronic incident reporting procedure. The second axis of the graph shows the percentage of incidents leading to serious harm (as a % of all reported incidents including ‘no harm’ and ‘near miss’). The axis is set from 0% to 10% to clearly demonstrate fluctuations month on month. The percentage of incidents leading to serious harm (major or catastrophic) was identified as a concern in the Trust NRLS benchmark reports. Since April, a senior review of all incidents in these categories (and those categorised as moderate) is being undertaken weekly to ensure accuracy of level of harm grading. This led to a drop in this category from April to August but then this rises again from September. The Trust proforma for completion at the end of the RCA asks (amongst other things) whether the outcome to the patient occurred directly as a result of failings in care, coincidental to any failings in care (or unable to conclude either way). This has allowed the downgrade of a small number of incidents originally graded as Major or Catastrophic before submission to the NRLS when the RCA review identified that the outcome to the patient was not affected by any care issues. This is reflected by updating the previous months’ data on the graph every month. Incidents in the most recent period Nov/Dec that have not completed the RCA process may be subject to this downgrade after the investigation but this assumption should not be made prematurely and (based on the experience of Apr-Sept) it is likely that most will remain unchanged.

18. Local PrioritiesComplaintsComplaints response within agreed timescale with the complainant: 100% of responses due in December were responded to within the agreed timescale (target 90). Of the 16 complaints received in December , the breakdown by Primary Directorate is as follows: Medical (7), Surgical (4), Clinical Support (2), Women & Child Health (2) and Facilities (1).Trust-wide the most common problem areas are as follows: Aspects of clinical care 11 Attitude of staff 8 Communication & information 2 This breakdown reflects an expected distribution across the categories. (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). Themes from red complaints There have been no red complaint investigations completed since the last report.  However, there are five on going red investigations that are expected to have been completed prior to the next report. All actions identified from Red complaints are currently within deadline for completion. 17

19. Local PrioritiesPALS (Patient Advice & Liaison Service) The revised PALS database is now functional and, together with prompt recording of contacts and enquiry details, accurate and meaningful information is now readily available. As previously reported, categories are being collated to correspond with the categories for formal complaints but additional information is being recorded on primary and secondary concerns. A comparison of the number of enquiries dealt with from January to December 2011 is given in the chart and a synopsis of enquiries received for the same period is given below. Trust-wide, the most common five reasons for contacts are as follows:   Communication, concerns about aspects of clinical treatment and general enquiries remain the most prominent reasons for contacting PALS. However, there are no trends identified for specific groups of staff, speciality or discipline. The PALS Manager continues to deal with requests for information which can vary from clarification of hospital procedure to specific details about treatment given; future care plans; outcome or length of time waiting for results of tests and discrepancies about diagnosis and/or discharge arrangements. A number of queries also relate to appointment dates and length of time waiting for these; the length of time waiting in clinics; and general enquiries about services not directly managed by West Suffolk Hospital. The PALS Manager frequently helps to improve communication between the Trust and patients’ family members both in this country and abroad. 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. This target is currently being monitored and evidence of compliance will be submitted in the new year, after three months data has been collected.

20. Appendix 1 Antibiotic Audit Programme The rolling antibiotic audit programme identifies current antibiotic prescribing practice within the West Suffolk Hospital and areas for improvement. 14 ward areas across Medical and Surgical Directorates are audited quarterly. Exceptions are: • Critical Care - as they have a daily Microbiology ward round. • Women’s and Children’s Directorate (Wards F1, F11 and F12) have been excluded until their updated drug chart, including the antimicrobial section, is in use. If any antibiotic prescribing issues arise on F1, F11 or F12 then auditing can be performed, separate from the programme.  Additional audits are carried out in wards where there is a period of increased incidence of Clostridium difficile. Methodology Audits are carried out monthly on approximately a third of wards. All patients on antibiotic treatment on those wards are included, by reviewing all of the drug charts for the patients on the ward at the time of the study. For those identified to be receiving antibiotics, further data is collected using medical notes, observation charts and IT pathology systems. Six standards from the Trust Antibiotic Guidelines are audited: All drug allergies must be specified on the drug chart. The clinical indication for antibiotics must be stated on the drug chart. Course length must be stated on the drug chart. Patients will receive IV antibiotics for a maximum of 72 hours unless there is a valid clinical reason. All patients will be prescribed antibiotics as per the Trust Antibiotic Guidelines or on advice from a Consultant Microbiologist. Appropriate samples will be sent to microbiology (to enable narrower spectrum antibiotics to be used at earliest opportunity).

21. Following each ward’s audit, results are emailed to the ward Consultants, Ward Manager, Senior Matron and Pharmacist. Overall results were produced quarterly, with a ‘RAG’ spreadsheet distributed to all wards and for inclusion in the quality reports and for discussion at the Antimicrobial Management Group, Drugs and Therapeutics Committee and the Infection Prevention Implementation Group. More recently, monthly reporting has been required by NHS Suffolk and therefore the results for those wards audited have been reported and the results included in the Trust quality report. This means that the data cannot be compared on a ‘like-for-like’ basis each month. It is therefore planned that the following wards are to be audited in the same month each quarter to allow for some continuity. National recommendations (Department of Health) 2011) are that organisations develop their own audit programmes, targeting specific components of best practice antibiotic prescribing, with at least annual point prevalence studies. Whilst we audit against all elements of practice identified in the recommendation, other Trusts identified in the above report, audit a selection of the elements. Our audit programme is therefore more comprehensive in comparison and the infection prevention team feel that it is more useful in changing practice than a less detailed monthly audit. Whilst we audit six criteria, the figure that is reported to NHS Suffolk and included in the Trust quality report is compliance with criterion 5; “all patients will be prescribed antibiotics as per the Trust Antibiotic Guidelines or on advice from a Consultant Microbiologist.” The following graph shows the overall compliance achieved encompassing the six audit standards, against the compliance with the antibiotic prescribed as the guidelines.

22. Antibiotic choice as per Trust guideline vs overall audit complinace 120% 100% 80% All patients will be prescribed antibiotics as per the Trust Antibiotic Guidelines or on advice from Consultant Microbiologist 60% Overall compliance 40% 20% 0% Q1, 2010- Q2, 2010- Q3, 2010- Q4, 2010- Q1, 2011- Q2, 2011- Q3, 2011- 11 11 11 11 12 12 12 Despite all of these changes to practice and educational sessions, we are still failing to achieve the 100% target. With the number of individual patient factors to be taken into consideration when prescribing antibiotics, such as allergies, microbiology sensitivities, renal and hepatic function etc, a more realistic target would be 98%. This still represents a challenging measure, still sets a high standard to achieve and the additional prescribing information that is collected in the audit process but not reported, such as sending of microbiology samples and de-escalating intravenous treatment to oral, would ensure that the patients are not being put at risk. The graph demonstrates the improvements that have been made in antibiotic prescribing practice since the audit programme began in January 2010. In that time a number of initiatives have been implemented to help improve prescribing practice, including the addition of a new antimicrobial prescribing page on the hospital drug chart, abbreviated copies of the antibiotic guidelines provided to medical staff and an antibiotic awareness session on the nurse mandatory training.