Trust Quality and Performance Report

1. Trust Quality and Performance Report June 2013 1

2. Contents 2

3. Executive Summary This commentary provides an overview of key issues during the month and highlights where performance fell short of the target values as well as areas of improvement and noticeable good performance. The pattern of increased A&E activity continued in May with 2.71% more attendances (4.32% YTD) compared with the same period in 2012/13. It is also notable that elective activity increased by 9.15% whilst non-elective admissions reduced by 4.3% on the previous year. 3

4. Whilst there was 1 case of C Diff in the month against a threshold of 2, the Trust had 6 cases at the end of May against a quarter target of 3 There was also 1 MRSA bacteraemia. This is covered on page 10 of the quality report. A&E performance was 93.49% against the 95% target. At the time of writing the Trust is on track to achieve 95% for June in line with the objectives agreed with Monitor and WSCCG. It is anticipated that the ECIST programme will continue to impact incrementally on this indicator. 4

5. 6 of the 9 stroke targets have been achieved. The three that were not achieved are as follows 5

6. The following measures are being implemented to positively impact on stroke performance • 24 hour specialised stroke team anticipated to be in place by end of September. • Improvements in emergency care. Anticipated completion of ECIST programme by end of September. • Rapid assessment of patients arriving by emergency ambulance and ‘FAST’ assessment of all patients attending A&E is being developed. • Intensive performance management to be in place from July 2013. The Trust achieved 92.36% against the 93% target. The patients not seen within 2 weeks were all patient not available for some or all of the 2 week period and some patients were not aware of the urgency of this appointment. This has been discussed with WSCCG and action is in place including a revised referral form advising GP’s to inform the patient of the urgency of the appointment and indicating date the patient was not available. At the time of writing the Trust is on track to achieve this measure for June and for the quarter. 6

7. Clinical Quality Priorities 7

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11. Clinical Quality Priorities: Summary • New questions added to the internal patient survey scored very highly by patients including patients’ satisfaction with the provision of compassionate care. • Response rates for the Friends and Family test have been maintained. • There was only 1 case of C. difficile this month, however, there was one MRSA bacteraemia. • Actions taken in relation to staffing challenges reported last month: • Utilisation and scrutinisation of electronic rostering data within the Directorate Performance meetings • Control mechanism for signing additional duties put into place • An external review of ward staffing • Further recruitment plan including the introduction of a staff pool 11

12. Quality Priority: Ward Performance Issues • Although on G4 there has been a decrease in performance in some of the KPIs this month, the ward does not give us cause for concern. A number of unrelated events have coincided to flag some indicators. However, the two complaints received in May relate to the attitude of one member of staff and this is being addressed by the ward manager with the nurse concerned. • A number of different issues have been identified in relation to F9 over the last two months. As a result an action plan has been agreed by the Matron with the Ward Manager. This covers falls, pressure ulcers, cleanliness, High Impact Interventions and drug errors. For example, actions being taken relating to falls are given in the falls section of this report. In relation to environmental/ cleanliness issues, identified areas of suboptimal practice have been addressed and subsequent audits have shown improved performance. The Matron is also carrying out formal quality assurance rounds on a weekly basis to focus on all areas of the action plan. • F6 appears to flag on the dashboard but the drug errors identified are not major errors (and practice issues have been highlighted to staff). The recommender question score is not reflective of the scores for other questions or the comments on the surveys. It is therefore felt that scores for next month will revert to normal. • Ward F3 had an unusually high number of falls, two pressure ulcers and a decrease in some of the other KPIs in May. There are currently 4 WTE vacancies, and there was an increase in sickness levels in May, which coincided with an increase in patient dependency. Two long term agency nurses have been secured to boost staffing levels until recruitment has taken place. • Feedback in respect of G9 is provided in the patient experience section of this report. . 12

13. Quality Priority: Infection Control MRSA Bacteraemia There was one hospital associated MRSA bacteraemia during May on Ward F10. The RCA identified deficiencies in the screening processes and an action plan has been agreed. C. Difficile The Trust has had one C. difficile case during May 2013.  This originated in the critical care unit but the specimen was sent from F9; this does not result in a period of increased incidence for F9. The RCA is awaited at the time of writing this report. This brings the total number of cases to six to date in 2013/14. Hand Hygiene Hand hygiene and dress code overall audit results were 100% this month against a target of 95%. High Impact Interventions All results for these audits were above 90%. Failures in compliance relate to: documentation of care and one failure to record VIP scores on the ward and in theatre, and a failure to wear gloves when undertaking cannulation. Some practitioners still find it easier to site a cannula without gloves when a patient has veins that are difficult to palpate. MRSA screening These are being reported for the first time this month and are split into elective admissions and emergency admissions. The compliance for emergency admissions is 90% and the compliance for elective admissions is 79.6% for May 2013. The deficit in elective screening has been investigated and it appears that this is related to the Oncology Day Unit and has been escalated to the service manager for investigation. A number of temporary staff have been working in the unit recently and therefore screening procedures are being highlighted with them. 13

14. Quality Priority: Falls Falls performance There were 63 falls across the Trust during May;16 of these falls resulted in harm but not serious harm. The rate per 1,000 occupied bed days is 6.0, which is approximately the same as for the last four months (6.1 per thousand bed days in April, 6.00 per 1,000 bed days in March, 6.39 per 1,000 bed days in February and 6.1 per 1,000 bed days in January). • Ward F3 had 12 falls, an unusually high number for the ward; 2 patients fell twice despite increased frequency of observations (every 15 minutes and a Wanderguard being used). The majority of the falls occurred when the ward were at least one nurse below core level on the shift. This ward is highlighted in the ward summary section of this report • G9 had 10 falls, 3 of which occurred in patients who were independent and one occurred whilst the patient was walking with a frame and accompanied by a member of staff (patient’s legs suddenly gave way and nurse could not prevent the fall); 3 falls occurred in patients with confusion/dementia and at high risk of falls and staffing levels on occasions did not enable the level of supervision required. • G5 had 7 falls in May, most of which occurred at night. One of the falls occurred in a patient who had been assessed by the OT as safe to mobilise independently. The Matron has asked the Ward Manager to look at the distribution of staff across the 24hrs and increase the number of staff on duty at night. Other actions include placing a table in the ward corridor at night to increase staff observation of patients and a focus on falls at each handover with discussion of fall free days. • Falls on Ward F9 reduced compared to last month but remain higher than normal. An action plan has been put into place and this includes actions to reduce falls, including identifying a Band 6 Sister as the falls champion, improving risk assessment, identifying all patients at high risk of falls at Board Rounds and ensuring compliance with intentional rounding. Further analysis is provided in the ward performance section of this report. In addition to the Trust falls action plan, wards with high numbers of falls have been asked to identify individual actions pertinent to their area. 14

15. The performance target is to have no avoidable Grade 2, 3 or 4 pressure ulcers 2013-14 Grade 2 pressure ulcers There were 10 grade 2 pressure ulcers this month; two were considered to be avoidable: • A pressure ulcer developed in a patient on critical care on the patient’s toe. It was classified as avoidable as there was insufficient evidence that the TED stockings had been removed and the skin in this area checked each day. • A patient developed a pressure ulcer on the back of his ankle. The patient was tall and his ankle rested on the edge of the mattress. The unavoidable pressure ulcers mostly occurred in patients who refused pressure relieving equipment, despite being advised that it was necessary, or all care had been put into place; but patients were extremely poorly. Grade 3 and 4 pressure ulcers There were no hospital associated grade 3 or 4 pressure ulcers this month. Quality Priority: Pressure Ulcers 15

16. Quality Priority: Nutrition and Hydration Hydration Hydration audits were introduced in 2012/13 and examine whether patients who are identified as at risk of dehydration have fluid targets set, whether those targets are met and whether documentation is completed accurately to monitor the patient’s intake and output. As with the high impact intervention audits, 10 patients are surveyed each month and compliance is only considered to have been achieved for each patient if all elements of the audit are achieved. Over 2012/13 there has been considerable improvement in the scores for these audits, however, there is still variability between wards and month-on-month. A drop in compliance was seen in May due to very low compliance (below 25%) on three wards. Further examination identified that the failures in compliance were mainly related to failure to total intake and output daily and failure to transfer the totals to the observation chart. There were a few instances where fluid targets had not been set by the medical staff. Fluid targets were met in approximately 70% of patients on the wards where documentation was poor. Ward Managers have been asked to check all fluid charts daily on the three wards where compliance was below 25% and the Matrons are also carrying out further checks. Initial indications are that the results for May should have improved. 16

17. Safety thermometer results Current performance for harm-free care is 93.2%. National May performance is 92.4%. 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 new parameter, our Trust score is 98.24%. National May performance is 96.8% 17

18. 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% indicating a high level of satisfaction with most of the areas covered in the survey. The internal survey questions were reviewed in the context of the feedback from the Trust membership, the national survey results and the Trust priorities and some changes made which took effect from 1 May 2013. The three new questions added this month all scored 99%. These are: • Were staff caring and compassionate in their approach? • Were you treated with dignity and respect? • Did you get enough help with your meals? Overall satisfaction for the other internal surveys (OPD, short stay, A&E, Maternity, Children and stroke) have remained stable. Patient story A patient story was discussed in May relating to an adverse experience on Ward G9 (Winter escalation ward). The following actions have been agreed following this story: • Aim to close the ward at the earliest opportunity • Review of processes to escalate and discuss complaints. • Enhance performance management of patient experience issues and manage action plans. • Matrons undertaking ward rounds at visiting time to seek feedback on current inpatient stay. • Deputy Chief Nurse and Chief Nurse to accompany Matrons on ward rounds. • Progress hot line for staff to report issues of concern relating to patient care. Any issues logged will be addressed by the Duty Manager and any further escalation agreed. 18

19. 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 85 for inpatients during May with a 36% response rate. The score for A&E was 71 with a 15% response rate. Comments from the inpatient surveys in relation to the score given included: • 4 comments related to perception that there were not enough staff/busyness of ward eg staff lovely but they can’t be everywhere at once …some patients need their constant care • 2 comments regarding delays in the discharge process • Long wait for scan then long wait for results • Numerous ward moves There were only 5 comments regarding the score for A&E; 4 related to long waiting times and the other said not from this area. 19

20. New Quality Priorities Deteriorating Patient Early identification of any deterioration in a patient’s condition is vital to ensure optimal outcomes for the patient and can impact on mortality rates. The Trust has implemented an early warning score (MEWS) which is calculated with every set of vital sign observations to aid identification of deterioration and ensure objective assessment and escalation of a patient’s condition where necessary. Recent RCAs carried out on patients who have had a cardiac arrest outside the critical care unit, have suggested that delays in escalation or response to escalation have occurred in a small number of cases. Therefore a decision has been made to increase the monitoring of the use of the MEWS and resulting escalation through a monthly audit by ward managers. The audits commenced in May on some wards and will be carried out on all wards in June. The results of the audits will be reported monthly on the Ward Dashboard from July 2013. Sepsis Six Sepsis six is a set of actions to be taken when a patient presents with potential sepsis. Evidence shows that timely identification and treatment can have a significant impact on the patients chances of survival. The Patient Safety Implementation Group have identified that this is an area that would benefit from a focused improvement programme. One of the key targets is the provision of antibiotics within one hour of arrival in the A&E department and this aspect of sepsis six will be reported within the Trust dashboard. The details of data collection are currently being developed and it is expected that reporting to the Board will be able to start at the beginning of the second quarter of 2013/14 . 20

21. Quality Priority: Mortality 21

22. Quality Priority: Mortality cont 22

23. Local Priorities: Summary and exception report (Red indicators) RCA Actions beyond deadline for completion The Datix system now has an automated process for follow up of overdue actions on a fortnightly basis. Incidents (Amber / Green) with investigation overdue (over 12 days) ~ 100 incidents were closed off centrally to achieve the 31st May external deadline for NRLS submission. This has meant that the total number overdue has dropped, however it has not addressed the underlying reason why some areas are not closing incidents off in a timely manner. It has been agreed that any ‘problem areas’ would be escalated directly to the relevant GM to follow up and that areas with low numbers of staff undertaking incidents would be encouraged to increase the pool of staff able to undertake this role. SIRI notification beyond timeframe. There were three SIRIs which were notified to the CCG beyond the two working day timeframe. One incident involving the administration of insulin was delayed while confirming the outcome to the patient (5763). SIRI final reports beyond timeframe Three SIRIs were sent to the commissioners outside of the 45 working day timeframe. A remedial action plan has been submitted to the CCG with a trajectory to address the outstanding SIRI reports. 23

24. Local Priorities - Governance Dashboard 24

25. Local Priorities - Governance Dashboard (cont.) 25

26. Patient Safety Incidents reported 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 March to take into account the new dataset from the Apr12 - Sept 12 NRLS report showed a fall in the peer group median but upper and lower quartiles remained similar to previous reports. There were 459 incidents reported in May including 390 patient safety incidents (PSIs). The reporting rate fell in May but remained above the upper quartile for peer group. The number of harm incidents in May remained at the peer group average level. 26

27. 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) has been rebased to 0.9% from the NPSA Apr ’12 – Sept ‘12 report and sits above the Trust’s average. 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. In April there were six ‘Red’ patient safety incidents: Deteriorating patient (1), Pressure ulcer (2), Fall (2) and Ophthalmology (1) all awaiting confirmation of grade through RCA. 27

28. Local Priorities: Complaints The Trust continued to receive a high number of complaints in May compared to 2012/13. Complaint response within agreed timescale with the complainant: 100% of responses due in May were responded to within the agreed timescale (target 90%). Of the 31 complaints received in May, the breakdown by Primary Directorate is as follows: Medical (16), Surgical (9), Clinical Support (1), Facilities (0), Other (0) and Women & Child Health (5). Trust-wide the most common problem areas are as follows: 28

29. Local Priorities: PALS (Patient Advice & Liaison Service) In May 2013 there were 72 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 85 for this month. A breakdown of contacts by Directorate from Jun’12 to May‘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. The number of contacts has reduced which is possibly due to two bank holiday periods during the month. Trust-wide the most common five reasons for contacts are shown below. The most common reasons for contacts have only changed slightly since the last report. Although the number of concerns relating to staff attitude had reduced last month this has risen again. There is no individual person, ward or department identified and the contact with PALS frequently relates to inadequate communication and relatives perception of urgency. There are no particular themes that the PALS Manager has identified this month. The contacts with PALS during May have covered all services with an even distribution across most wards and departments, with the exception of the Emergency Assessment Unit (7) and Accident and Emergency Department (8). These continue to relate to queries about relatives that may have been admitted and delays in diagnosis and/or being transferred to wards. 29

30. Local Priorities – Workforce Performance 30

31. CQUIN: Summary & Exceptions report Good progress is being made in implementing CQUIN schemes and evidence of Q1 performance will be presented to West Suffolk CCG in early July. One target is rated ‘red’ and this relates to closing EAU beds at night. The target was negotiated before the Trust had agreed the Emergency Care Plan (ECP) with WSCCG. The model agreed through ECP supersedes the CQUIN target agreed and the Trust has proposed to the CCG that the assessment is based on opening the surgical assessment unit (SAU) and improvement to the pathway for patients with a fractured neck of femur. 31

32. A4 printout of CQUIN

33. Monitor Compliance Framework 40

34. Contract Priorities Dashboard A4 printout