West Suffolk Hospital NHS Trust

1. West Suffolk Hospital NHS Trust Report To: Trust Board Date: April 2012 Title: Quality 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. Executive Summary This report presents the completed year end quality data April 2011- April 2012. The following CQUIN targets were achieved in Q4: 35% reduction in falls No avoidable Grade 3 or 4 pressure ulcers Patient risk assessment for hydration Smoking cessation referrals (590 referrals in Q4) and 2 staff from each clinical area trained in brief intervention therapy 5 cardiac arrest RCAs completed each month and action plans developed VTE risk assessment Achievement of EAU phone calls Achievement of roll out of clinical management system ( CMS)

4. 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 bacteraemia or MSSA bacteraemia during March.There were 2 cases of clinically significant hospital acquired C. difficile during March (giving a total of 23 this year).In respect of compliance with the High Impact Interventions (HII), all interventions scored 100%. During the sideroom audit, of the 33 siderooms in the Trust, 24 were used for IC purposes. There were 7 high risk patients who should have been isolated and were not due to lack of capacity. The F9c cohort became operational again as of 15 March 2012 (having been used since January 2012 as additional bed capacity) and there were 4 patients in the cohort on the day. ( 1 already in the side room)

5. 1. To further reduce hospital acquired infections Aim: To improve the management of antibiotics by achieving 100% compliance with antibiotic policy The compliance with the antibiotic prescribing policy was 98% in March.

6. 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 Compliance with risk assessment was 96.69% for March. The overall result for Q4 was 98.17% VTE prophylaxis compliance for March was 98%.

7. The CQUIN ceiling is 126 falls in Quarter 4 and the payment associated with Quarter 4 is £41,250. The total number of falls in March was 30 giving a Quarter 4 total of 116 falls, therefore meeting the reduction required for this quarter. The ward areas with red scores from fall incidents are F4, G4, G3, G1 and CCU: One patient fell on CCU: • This gentleman fell out of bed while sleeping. G1 reported three falls by two patients: • One patient with Parkinson’s disease fell twice. This lady was at very high risk of falling and had a wanderguard in situ to alert staff when she was getting up but she frequently unclipped the device. • One patient fell while transferring from bed to chair. One patient fell on G3: • This patient was sitting on the edge of the bed and slipped to the floor as the overlay mattress had not been re-fastened to the bed mattress following cleaning and slid off the bed. G4 reported 6 falls involving 4 patients. During March, G4 had a significant number of confused patients (approx 50% of total patients). All the patients who fell had dementia/delirium: • 5 falls occurred at night which is a high risk time for confused patients. Although G4 increased their staff numbers at night by 2 health care assistants, they are unable to constantly observe and supervise 16 confused patients. • 1 fall occurred during the daytime, this was a lady with Parkinson’s disease who stood unaided and fell on the floor. F4 had 3 patient falls during March: • One lady slipped and fell on the wetroom floor following her shower. • One gentleman slipped and fell when getting out of bed wearing anti-embolic stockings and no slippers. It is felt that the stockings were the causative factor. • A patient, following a knee replacement, walked across to the toilet without her sticks and fell. Actions All ward areas have taken individual actions relating to their fall causes. The Business Case for the 3 month Safina grip anti-embolic stocking trial on F3,4,5 and 6 is being presented at a TEG in May. 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

8. 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 1 patient developed a Grade 3 hospital acquired pressure ulcer during March on G4. This lady had all care provided but had significant medical problems which were risk factors for tissue damage. The RCA has not yet been held to determine if it was avoidable or unavoidable. 4 patients developed Grade 2 hospital acquired pressure ulcers this month, 2 of which were avoidable: F9: 1 patient developed a Grade 2 unavoidable sacral pressure ulcer. All preventative care was in place. G1: a patient on the Liverpool care pathway developed a Grade 2 pressure ulcer which was reported the day before she died. This was classified as unavoidable. G3: a gentleman developed a Grade 2 pressure ulcer which subsequently healed while he was still an inpatient. We have classified this as avoidable as the moisture damage which led to the pressure ulcer developing could have been managed better with low pH skin cleansers. G8: a lady developed a Grade 2 pressure ulcer on her spine. As we have no documentation to support that her pressure areas were checked for two days, we are considering this an avoidable pressure ulcer. Actions The pressure ulcer intensive support team commissioned by the East and Midlands SHA to support the launch of the Ambition “ No avoidable pressure ulcers” will be visiting Suffolk on the 30th April, hosted by Ipswich hospital. They will be critically reviewing all Trust’s processes and pathways and making suggestions for improved practice to achieve further reductions in avoidable pressure ulcers. The CQUIN target for 2011/12 is to have no more than 2 hospital-acquired avoidable Grade 3/4 pressure ulcers in each of Quarters 1,2 and 3 and 1 hospital-acquired avoidable Grade 3/4 pressure ulcer in Quarter 4 with a quarterly payment of £41,250. We have met all these CQUIN quarterly targets.

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 • Overall percentage scores for the surveys for March are provided in the table (left). From next month the new recommender question will be used with associated scoring system. • adult inpatient, stroke and midwifery survey responses were obtained as compared to 169 responses during February. This was 18% of inpatient discharges (excludes all day cases). • The number of surveys completed for Outpatients and DSU also increased but higher numbers will be required for DSU and A&E in future in order to meet next years CQUIN targets. Over the year improvements have been seen in doctors and nurses not talking in front of patients as if they were not there. The national inpatient survey results that surveyed inpatients from August 2011 showed a two point increase in these questions, but if the more recent results are maintained a further increase should be seen in this years survey.

10. 3a/b) To continuously improve the experience of patients using our services CQUIN patient experience targets Patient experience goals for CQUIN during 2011/12 centred on the national patient survey and internal surveys for specific patient groups: maternity, paediatrics, stroke, dementia and learning disability. Internal Surveys CQUIN required the development of feedback mechanisms during Quarter 1 for each group, the collection of baseline data and development of an improvement plan in Quarter 2, and the delivery of improvement during Quarters 3 and 4. The results of the baseline surveys and improvement plans were presented to the Patient Experience Committee. In fact the results of the baseline surveys was very positive and left little room for increasing the scores. Despite this improvement actions were identified and these have been implemented. National Patient Survey A report on the results from the national inpatient survey of inpatients in August 2011 will be reported separately to the Board. The CQUIN target focused on five questions with an overarching theme of “responsiveness to personal needs of patients”. CQUIN required the Trust to achieve a 5.5 point increase in the composite score for these questions and a 15.5 point increase in the question relating to being informed of the side effects of medication on discharge. As can be seen in the table below, an increase was seen in some of the questions but the CQUIN targets were not achieved.

11. 3c) To continuously improve the experience of patients using our services • Environment and Cleanliness • All wards achieved at least 85% except Theatres (83%), F14 (76%) and F3 (80%) • Theatres score was comprised of 87 % cleaning, 86% nursing and 67% estates. • F14 score was comprised of 76% cleaning, 80% nursing and 67% estates. The nursing issues related to stains under the drug trolley and a dusty base on the blood pressure monitoring equipment that were rectified when they were identified to staff. • F3 score was 83% cleaning, 75% nursing and 71% estates. This score has improved in April’s audit to 86%.

12. 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.

13. We are publishing the Number of Deaths as a trial to see if it is useful to be used alongside the HSMR and the SHMI data. It does NOT allow meaningful comparisons to be made with other providers or national averages as its solely the crude number of deaths in hospital. What it should allow us to see trends at West Suffolk over prolonged periods of time. Month to month figures will fluctuate but generally we should be wary of over interpretation. The dataset used to calculate the SHMI includes all deaths in hospital, plus those deaths occurring within 30 days after discharge from hospital. The expected number of deaths is calculated from a risk-adjustment model developed for each diagnosis grouping that accounts for age, gender, admission method and co-morbidity . There isn’t much variation month on month. Unlike HSMR, it is "rebased" every quarter so the trend is smoothed out unlike HSMR.

14. Local issues requiring escalation Patient surveys All wards have improved their number of patient surveys completed during March. No ward had a significant number of red scores although F7’s performance still requires close monitoring by the Matron. The ward manager returns to work in May. G8 however does have a deterioration in patient satisfaction which will be discussed at the ward governance meeting. The stroke care plan is routinely given to the patients by the Emergency Stroke Outreach team at discharge so this process will be reviewed to ensure that patients have the care plan prior to completing the patient experience survey. Wards Nurse staffing in the medical directorate continues to be of concern due to the continued requirement to provide staff from each area to the escalation area, F14 and the escalation beds open on F9c and G8. As the escalation area has been open for five months this is having a noticeable impact on ward establishments. It should be noted that the directorate put forward for the model for opening of F14. Additional beds on F9C and G8 were not included in the original capacity plan. G5 currently have significant registered nurse staffing challenges as they have 3 vacancies which is 10% of their workforce establishment. They are interviewing at the end of April but this is a difficult ward to recruit to due to as there is no assigned speciality. Complaints A&E have had an increase in complaints during March- 8 complaints. These have been related to dissatisfaction with escalation area, misdiagnosis on initial attendance, attitude of nursing and medical staff, medication errors on discharge, and transport home. All complaints will be reviewed at the department’s governance meeting.

15. Other CQUIN Targets (not reported elsewhere) Nutrition • Nutrition screening, assessment, and action for 95% of patients with nutritional requirements At least 97% compliance was achieved in each quarter of 2011/12 thus meeting the target. • Review of nutritional supplements prior to discharge Procedures were put into place in the first quarter of 2011/12 to ensure that dietitians are notified of all patients to be discharged with nutritional supplements to allow review to take place. This has enabled the Trust to achieve the target therefore this will be maintained throughout the coming year. Hydration • Identification of patients at risk from dehydration A risk assessment tool was developed and implemented in Quarter 1 and audits of compliance undertaken in Quarters 2, 3, and 4. Improvement targets were met and an average compliance of 97% was achieved in Quarter 4. Deteriorating Patient • RCAs to be carried out in a sample of 5 patients per month who have a cardiac arrest outside critical care RCAs were carried out on all patients suffering a cardiac arrest outside critical care throughout the year and an action plan was developed and monitored through the Deteriorating Patient Group to address issues identified for learning/improvement thus meeting the CQUIN target. Smoking Cessation • Number of referrals to the NHS Suffolk Smoking Cessation Service The numbers of referrals increased during the year in line with the targets set. Therapy for stroke patients • Eligible patients to receive a minimum of 45mins of therapy for a minimum of 5 days per week. 30% Q2, 45% Q3, 60% Q4. The improvement targets were met for each quarter.

16. Local Priorities - Governance Dashboard 15

17. Local Priorities Patient Safety Incidents (PSIs) resulting in harm (including Serious harm), Serious Incidents requiring investigation (SIRIs) and reporting PSIs to the National Reporting and Learning Service (NRLS) There were 197 patient safety incidents reported in March of which 96 resulted in harm. The number of serious incidents in March was eight. Following receipt of a report from the PCT it has been agreed that all Neonatal, Intrapartum and Intra-uterine deaths will be submitted (as catastrophic) initially for review by the PCT but it is expected that a number of these will be reclassified as ‘not an incident / not a SIRI’ after the 2-day or 7-day report. In March there were seven SIRIs reported initially but in two cases the 7-day report provided evidence to allow the PCT to downgrade (1 controlled drug incident and 1 obstetric incident). The remaining five were: Grade 3 Pressure ulcer (1), Deteriorating patient (1 Feb incident), Confidentiality issue (1 no harm incident) and Neonatal death / Intrauterine death (2 incidents requiring comprehensive RCA to decide status). The eight serious incidents in March included three (3) Neonatal / Intrapartum / Intra-uterine deaths and one (1) SUDIC. The other four were: Grade 3 Pressure ulcer (1 reported as SIRI in March), Deteriorating patients (2 not SIRIs), 4th degree perineal tear (1 not a SIRI).  The top graph shows how many harm incidents have been reported in total, how many were serious harm and how many were reported as a SIRI by month over the last 12 months. The number of SIRIs do not directly correlate to the number of serious harm in the same month because some SIRIs did not cause actual major harm (e.g. a breach of confidentiality) or the SIRI was not reported until the following month. The bottom graph shows all incidents (including Near miss and No harm) reported to the NRLS against a benchmark of the median Trust for incidents per 100 admissions in the small acute Trust category (6.2 based on the Oct 10 – Mar 11 dataset). NPSA data to be rebased in the next report. The second (red) line on the bottom graph shows what percentage of the incidents reported in total are categorised as serious (Red: actual major / catastrophic harm). This is high in March as a consequence of a slight reduction in the total number of incidents reported and the additional reporting of Neonatal / Intrapartum / Intra-uterine deaths. This figure is expected to reduce after the review of these cases.

18. Local PrioritiesComplaintsComplaint response within agreed timescale with the complainant: 95% of responses due in March were responded to within the agreed timescale (target 90). Of the 22 complaints received in March, the breakdown by Primary Directorate is as follows: Medical (14), Surgical (7), Clinical Support (0), Women & Child Health (1) and Facilities (0). Trust-wide the most common problem areas are as follows: - All Aspects of Clinical Treatment 9- Communication 6- Attitude of Staff 6- Admission, Discharge & Transfer 3 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) . The data in the graph above demonstrates that there has been an increase in the number of complaints received in 2011/12 compared to 2010/11. Themes from Red complaints 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 Apr11 to Mar 12 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 there is now evidence that the Manager consistently meets this target.