Item 9a 16-02 Quality report - FEB16

AGENDA ITEM:
9a
PRESENTED BY:
JON GREEN, CHIEF OPERATING OFFICER AND
ROWAN PROCTER, DIRECTOR OF NURSING
PREPARED BY:
JON GREEN, CHIEF OPERATING OFFICER AND
ROWAN PROCTER, DIRECTOR OF NURSING
DATE PREPARED:
17 FEBRUARY 2016
SUBJECT:
TRUST QUALITY & PERFORMANCE REPORT
PURPOSE:
TO UPDATE THE BOARD ON CURRENT QUALITY
ISSUES AND CURRENT PERFORMANCE AGAINST
TARGETS
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 Trust missed the A&E 4-hour target with monthly performance of 93.48%
against the 95% target. This reflected national challenges relating to activity
(page 19).
The Trust failed the 4-hour and low risk TIA scan in 7 days Stroke targets.
Performance against SSNAP remains strong (pages 21/22).
Whilst the Trust missed the Cancer Screening target, all other access and
Cancer targets were achieved (page 19)
The Trust had four c.Diff cases in January, 56 falls (56 in December) and ten
pressure ulcers (9 in December) (pages 4/5/6).
Three new indicators have been agreed to measure outstanding amber/green
incidents. Outstanding RCA’s are much improved and non-compliance with
Duty of Candour has also improved (page 7-10).
The Trust failed the 28-day rebooking target with eight patients missing the
target (page 22).
Work against performance standards for Community Services in a similar format to
acute performance report is in progress and is planned for presentation to the March
Trust Board.
Recommendation:
The Board is asked to note the Trust Quality & Performance Report and agree the
implementation of actions as outlined.
1
1.
CLINICAL QUALITY
This section identifies those areas that are breaching or at risk of breaching the Clinical Quality
Indicators, with the main reasons and mitigating actions.
Patient Safety Dashboard
Indicator
Target
Red
Amber
Green
Nov
Dec
Jan
HII compliance 1a: Central venous catheter insertion
= 100%
<85
85-99
= 100
100
100
100
HII compliance 1b: Central venous catheter ongoing care
= 100%
<85
85-99
= 100
100
93
100
HII compliance 2a: Peripheral cannula insertion
= 100%
<85
85-99
= 100
100
100
100
HII compliance 2b: Peripheral cannula ongoing
= 100%
<85
85-99
= 100
98
97
99
HII compliance 4a: Preventing surgical site infection preoperative
= 100%
<85
85-99
= 100
100
100
100
HII compliance 4b: Preventing surgical site infection perioperative
= 100%
<85
85-99
= 100
100
100
100
HII compliance 5: Ventilator associated pneumonia
= 100%
<85
85-99
= 100
100
100
100
HII compliance 6a: Urinary catheter insertion
= 100%
<85
85-99
= 100
100
100
100
HII compliance 6b: Urinary catheter on-going care
= 100%
<85
85-99
= 100
100
99
100
Total no of MRSA bacteraemias: Hospital
= 0 per yr
>0
No Target
=0
0
0
0
Total no of MRSA bacteraemias: Community acquired (Trust level only)
No Target
No Target
No Target
No Target
0
0
1
= 90%
<80
80-89
90-100
NA
93
NA
MRSA decolonisation (treatment and post screening) (Trust Level only)
= 90%
<80
80-94
95-100
94
93
83
MRSA Elective screening (Trust level only)
= 100%
<80
80-99
= 100
97.98
ND
ND
MRSA Emergency screening (Trust level only)
= 100%
<80
80-99
= 100
97.03
ND
ND
Hand hygiene compliance
= 95%
<85
85-99
= 100
100
100
99
Total no of MSSA bacteraemias: Hospital
No Target
No Target
No Target
No Target
2
1
0
Quarterly Standard principle compliance
90%
<80
80-90%
90-100
NA
89
NA
Total no of C. diff infections: Hospital
= 16 per yr
No Target
No Target
No Target
3
2
4
Total no of C.diff infections: Community acquired (Trust Level only)
No Target
No Target
No Target
No Target
3
3
1
= 98%
<85
85-97
98-100
NA
94
NA
16
Quarterly MRSA (including admission and length of stay screens)
Quarterly Antibiotic Audit
No Target
No Target
No Target
No Target
21
16
Isolation data (Trust level only)
= 95%
<85
85-94
95-100
90
ND
95
Quarterly Environment/Isolation
= 90%
<80
80-89
90-100
NA
92
NA
Quarterly VIP score documentation
= 90%
<80
80-89
90-100
NA
90
NA
MEWS documentation and escalation compliance
= 100%
<80
80-99
= 100
95
96
95
PEWS documentation and escalation compliance
100
Total no of E Coli (Trust level only)
= 100%
<80
80-99
= 100
100
80
No of patient falls
= 48
>=48
No Target
<48
33
57
56
Falls per 1,000 bed days (Trust and Divisional levels only)
= 5.6
>5.8
5.6-5.8
<5.6
2.74
4.54
4.34
No Target
No Target
No Target
No Target
11
24
14
=0
>0
No Target
=0
0
NA
NA
= <0.19
>0.19
No Target
= <0.19
0.08
0.25
0.08
No of patients with ward acquired pressure ulcers
<5
>=5
No Target
<5
7
9
10
No of patients with avoidable ward acquired pressure ulcers
=0
>0
No Target
=0
0
2
3
= 95%
<85
85-94
95-100
98.70
97.40
97.01
92.48
No of patient falls resulting in harm
No of avoidable serious injuries or deaths resulting from falls
Falls with moderate/severe harm/death per 1000 bed days (Trust and Divisional
levels only)
Nutrition: Assessment and monitoring
Hydration: Patients with appropriate fluid balance management
= 95%
<85
85-94
95-100
92.14
92.31
No of SIRIs
No Target
No Target
No Target
No Target
3
7
4
No of medication errors
No Target
No Target
No Target
No Target
62
76
85
Cardiac arrests
No Target
No Target
No Target
No Target
2
5
4
=0
>0
No Target
=0
0
1
1
= 80%
<70
70-79
80-100
NA
NA
90
VTE: Completed risk assessment (monthly Unify audit)
> 98%
< 98
No Target
> 98
99.45
99.63
100
Quarterly VTE: Prophylaxis compliance
= 100%
<95
95-99
= 100
NA
99
NA
Safety Thermometer: % of patients experiencing new harm-free care
= 95%
<95
95-99
= 100
98.61
97.96
97.48
Grade 1 Caesarean Section (Decision to Delivery Time met)
Grade 2 Caesarean Section (Decision to delivery time met)
Babies transferred to tertiary centres for therapeutic cooling
Non-SIRI Trust-led RCA investigation not complete > 60 days after incident
reported
RCA Actions beyond deadline for completion
100%
<95%
95 - 99%
100%
100
100
100
80%
<75%
75 - 79%
80%
75
70
100
0
>0
No Target
0
0
1
0
0
>3
1-3
0
0
0
0
0
>=10
5-9
0-4
13
12
1
Cardiac arrests identified as a SIRI
Pain Management: Quarterly internal report
2
Target
Indicator
[NEW] % of ‘Green’ PSI incidents investigated
SIRIs reported > 2 working days from identification as red
SIRI final reports due in month submitted beyond 60 working days
Number of SIRI reports open on STEIS more than 60 days after initial
notification - Total
Number of SIRI reports open on STEIS more than 60 days after initial
notification– Sitting with WSFT (excludes ‘stop the clock’)
Active risk assessments in date
Outstanding actions in date for Red / Amber entries on Datix risk register
Non-compliance with Duty of Candour requirements
80%
Red
TBC
Amber
TBC
Green
TBC
Nov
Dec
Jan
NA
NA
0
>1
1
67
0
0
1
0
>1
0
1
0
0
0
0
No Target
No Target
No Target
No Target
0
0
0
0
>6
4-6
0-3
0
0
0
100%
<75%
75 – 94%
>=95%
100
100
100
100%
<75%
75 – 94%
>=95%
100
100
100
0
>3
1-3
0
0
2
2
Exception reporting for indicators in the Patient Safety Dashboard
All indicators in the Patient Safety dashboard which are red, amber for two consecutive months or
are an amber quarterly indicator will have narrative below.
1.1
HII compliance 2b: Peripheral cannula ongoing
a)
Current Position
A score of 99.15% this month is an improvement on last month.
b)
Recommended action
To continue to monitor compliance with all elements of peripheral cannula ongoing care.
1.2
MRSA decolonization
a)
Current Position
The Trust target for compliance with MRSA decolonization regimens is 95 %. In January only 83%
compliance was achieved, however the figure was significantly affected by one case on ward F3.
This case has been recorded as an incident for investigation by the ward team.
b)
Recommended action
A review of monitoring the decolonization regimen is underway and it is anticipated that an
improvement will be seen next month.
1.3
MEWS documentation and escalation compliance
a)
Current Position
A score of 95.10% this month with 4 wards scoring less than 100%. These were F7 Keats ward,
F10 Kipling ward, F14 Bronte ward & G4 Culford ward with a total of 5 sets of observations not
recorded correctly. The target oxygen saturation were not recorded on 3 sets of observations.
b)
Recommended action
Matrons to maintain focus on ensuring MEWS documentation is consistent and accurate.
1.4
Hydration: Patients with appropriate fluid balance management
a)
Current Position
A score of 92.48% is in line with previous months. 5 wards were noted to score less than 100%,
these were F10 Kipling ward, F14 Bronte ward, G3 Beyton ward, G5 Denham ward and G9
Fornham ward. For F10 & G3 this is the second consecutive month of not meeting 100% score.
b)
Recommended action
This audit will continue to be the focus for the Matrons peer audit next month with ward areas
being audited by the senior nursing team.
3
1.5
Total no of C. difficile infections: Hospital
a) Current Position
Performance against trajectory is as follows:
There were four cases of Clostridium difficile in January 2016.
At the end of January the Trust CDT trajectory, to date, was 21 reported cases against a final total
of no more than 16 trajectory cases for 2015-2016.
Of the 21 cases 10 have been deemed non trajectory by our commissioners (no lapses of care)
whereby they will not accrue a penalty, there are six trajectory cases and five cases are under
investigation and will be submitted for arbitration to our commissioners.
The graph below has been updated to demonstrate the Trust performance against the trajectory
target set by the CCG.
b) Recommended Action
To continue with vigilance to identify symptoms of C difficile for early identification and testing.
1.6
No of Patient Falls & No of Patient Falls Resulting In Harm or Serious Injury
4
There were 56 falls this month (56 in December, although 57 were reported last month as one
incident was reported twice by two different areas) one patient sustained major harm on G1, this
lady attempted to go to the en suite bathroom unassisted.
No patients sustained moderate harm (two in December).
F7 reported 8 falls (13 in December), 4 occurred during the night and 4 during the day; we
continue to experience a high number of night admissions.
Two patients were assisted to the floor by staff, saving them from falling (6 in December).
There were 4.26 falls per 1000 bed days, (4.45 in December). National average - 6.63 (Royal
College of Physicians 2015).
2 falls occurred in the toilet, 1 lady fainted in the shower on F11; (10 WC or shower in December).
One patient fell whilst using the commode (0 in December) this lady sustained a fracture to her
femur.
None of the falls that occurred in WC/showers occurred in F7 who have, at the beginning of
January, had patient motion sensors fitted in each WC /shower room.
Two patients fell more than twice in their inpatient stay this month on F7, one in December.
There were 196 patients who fell more than three times in the last three months in their normal
place of residence and prior to their admission.
Three falls occurred at Davers Court, seven at Newmarket Hospital one patient sustained a
fractured femur, and these falls are reported separately
5
1.7
No of Patient with Ward Acquired Grade 2/3/4 Pressure Ulcers
Grade 2 Pressure Ulcers
There were nine HAPU-2 in January. G3, G4 and G5 had two ulcers, G1, F14 and F12 one each.
Three have been confirmed as unavoidable (on G5 (2) and F10) and the other six await
investigation to confirm avoidability status.
There are six HAPU-2 from 2015; Nov (2) and Dec (4) still pending confirmation of avoidability
status.
Grade 3 Pressure Ulcers
One HAPU-3 (G5) which is pending RCA to confirm avoidability status
Grade 4 Pressure Ulcers
No grade four pressure ulcers were reported.
1.8
Safety Thermometer: % of patients experiencing harm-free care
a) Current Position
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.
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sept-15
Oct-15
Nov-15
Dec-15
Jan-16
Harm Free
95.25
96.44
94.95
94.12
94.59
94.92
95.10
93.59
93.38
91.94
Pressure Ulcers – All
2.50
2.54
3.46
3.07
2.97
2.79
3.09
4.46
4.07
4.28
Pressure Ulcers - New
0.25
0.25
0.00
0.26
1.08
0.76
0.77
0.56
1.02
1.01
Falls with Harm
0.50
0.00
0.00
0.26
0.27
0.51
0.00
0.28
0.00
0.50
Catheters & UTIs
1.75
1.53
1.60
2.81
2.43
1.78
1.80
2.23
2.54
3.53
Catheters & New UTIs
0.00
0.00
0.00
0.000
0.00
0.25
0.52
0.56
1.02
0.76
New VTEs
0.00
0.00
0.27
0.00
0.00
0.00
0.00
0.28
0.00
0.25
All Harms
4.75
3.56
5.05
5.88
5.41
5.08
4.90
6.41
6.62
8.06
New Harms
0.75
0.25
0.27
0.51
1.35
1.52
1.29
1.39
2.04
2.52
Sample
400
393
376
391
370
394
388
359
393
397
Surveys
18
18
18
18
17
18
17
18
18
6
18
The data can be manipulated to just look at “new harm” (harm that occurred within our care) and
with this parameter, our Trust score for January 2016 is 2.52 % therefore, our new harm free care
is 97.48% The National new harm for January 2016 is 2.1% or (97.9%).
It should be noted that the Safety Thermometer is a spot audit and data is collected on a specific
day each month.
The SPC chart below shows the Trust Harm free care compared to the national benchmark for the
period April 2012 to December 2015. The Trust dipped below the National average in January for
the first time since December 2013.
b) Recommended Actions
To continue to monitor actual harm against national benchmarks
1.9
Incidents with investigation overdue
a) Current Position
The Scrutiny Committee and Executive Directors agreed three new indicators for the Board
dashboard. These will replace the current indicator Incidents (Amber / Green) with investigation
overdue in future.
The indicator % of ‘Green’ PSI incidents investigated in month provides a more accurate measure
against the national benchmark of 50% of incidents uploaded to the NRLS (National Reporting &
Learning System) within ‘x’ days.
A RAG rating of Red (<25%) Amber (25-75%) Green (>=75%) is proposed as this applies the peer
group benchmark quartiles (see graph overleaf).
7
Graph: Report regularity (Count of days for 50% of incidents to be submitted to the NRLS)
WSFT
The second indicator Amber incidents greater than 30 days overdue provides a measure of the
recently agreed Amber investigation pathway. The Clinical Directors meeting receives a monthly
update on overdue Amber incident investigations to ensure follow up of the relevant leads.
The majority of overdue incident investigations fall within the month of January but there is a
smaller tail of overdue investigations from previous months (see graph below).
Graph: Overdue Green and Amber investigations
In addition a third indicator has been agreed to measure the actual timeliness of 50% of patient
safety incidents (PSIs) uploaded to the NRLS. The latest NRLS data indicates the Trust’s
performance of 89 days is significantly below the peer group average of 26 days. Action is being
taken to address this and establish a baseline position for KPI reporting.
b) Recommended Action
In order to improve the timeliness of green incident investigations the Executive Directors meeting
agreed the following actions:

The current two stage approach in place for completion of Green incident investigations is
simplified and the handler and final approver are the same person and they complete and
finally approve the investigation at the same time. This would require the ward manager to
review all green incident investigations to ensure there are aware of current themes within their
area of responsibility.

An initial review of the areas where the highest number of outstanding investigations / final
approval are required to be completed. Approach the ward managers for each of these areas
with a paper report for them to initially review and identify incidents they feel could be closed
8
by the Datix administrator. Therefore reducing the time they spend doing administration within
Datix. This should be considered a short term solution with the presentation of a long-term
solution that is agreed with the Clinical Directors, Heads of Nursing, Matrons and Ward
Managers.

Ensure timely upload to NRLS when incident investigation are approved.
1.10
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 the peer group.
The peer groups have been amended and WSFT is now in a much larger ‘acute non-specialist
trusts’ group. The reporting rate has also been changed to reporting per 1000 bed days (previously
per 100 admissions). The NRLS have provided backdated data to allow plotting the peer on the
graph back to 2013.
There were 555 incidents reported in January including 471 patient safety incidents (PSIs).
Data from October onwards has been extended to include Community incident reports which are
being manually uploaded in Datix pending the ‘go live’ of Datix e-reporting being piloted in Q4
2015/16. This has resulted in a small increase in total incidents reported (39 PSIs for the period
Oct15 – Jan16)
500
400
300
200
100
WSH (harm PSIs)
NRLS Lower quartile (all PSIs)
NRLS benchmark (harm PSIs)
NRLS Median (all PSIs)
Jan-16
Dec-15
Nov-15
Oct-15
Sep-15
Aug-15
Jul-15
Jun-15
May-15
Apr-15
Mar-15
Feb-15
Jan-15
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
Mar-14
Feb-14
0
Jan-14
Number of incidents reported
Graph: Patient Safety Incidents reported
600
WSH (all PSIs)
NRLS Upper quartile (all PSIs)
At the Clinical Safety & Effectiveness Committee it was requested that the Quality reported
included some SPC charts (similar to that provided for Falls). The chart below plots all PSIs
reported over a two year period.
Graph: Patient Safety Incidents reported over two years
9
1.11
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) is from the NRLS period Oct13 – Mar14. The benchmark line applies the peer group
percentage serious harm to the peer group median total PSIs to give a comparison with the Trust’s
monthly figures.
The WSH percentage data is plotted as a line which shows the rolling average over a twelve
month period. The Trust percentage sits below the NRLS average. The number of serious PSIs
(confirmed and unconfirmed) is plotted as a column on the secondary axis.
In January there were four cases reported as serious harm; one clinical care & treatment incident,
one Intrauterine death and two falls with fracture which are all awaiting an RCA to confirm harm
grading.
The four incidents from previous months still awaiting confirmation of harm include one case
identified retrospectively following inquest notification, one fall with fracture, and two cardiac arrest
cases identified retrospectively in February all awaiting RCA to confirm harm grading.
6
0.8%
5
4
0.6%
1
3
4
1
2
1
1
Jan-16
1
Nov-15
1
Oct-15
1
Jul-15
1
Jun-15
Apr-15
Mar-15
Feb-15
Jan-15
Dec-14
Nov-14
Oct-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
Mar-14
4
3
2
1
Sep-15
2
1
May-15
2
1
0.0%
2
3
Aug-15
3
Sep-14
0.2%
5
Dec-15
5
0.4%
0
2ary axis (number of confirmed PSIs)
1.0%
Feb-14
1ary axis (serious harm PSIs as a % of
total PSIs)
Graph: Patient Safety Incidents (Severe harm or death)
Pending final grade
Confirmed severe harm/death
(1ary axis) Benchmark NRLS Serious harm (%)
(1ary axis) WSH confirmed serious harm - 12 month rolling average WSH%
1.12
Non-compliance with Duty of Candour (DoC) requirements
a) Current Position
There are currently two DoC outstanding for cases in January with two pending for previous
months (November and December).
b) Recommended Action
Clinicians with outstanding DoC are regularly followed up by the Governance team. Cases that are
unable to be resolved locally are escalated to the Clinical Director with an expectation that they will
undertake the DoC conversation and correspondence to ensure its completion. A monthly report is
provided to the Clinical Directors meeting.
Cases where DoC is not appropriate to be carried out are agreed with the CCG on an individual
basis as described in the recently re-issued policy PP197 Being Open - The Duty of Candour. For
example when a patient has died and the death is not related to the incident. These cases would
potentially cause unnecessary additional distress to the bereaved family and are therefore
excluding in accordance with Doc guidance.
10
Patient Experience Dashboard
In line with national reporting (on NHS choices via UNIFY) the scoring for the Friends and Family
test changed from April 2015. It is now scored & reported as a % of patients recommending the
service i.e. answering extremely likely or likely to the question “How likely is it that you would
recommend the service to friends and family?”
A target of 90% of patients recommending the service has been set.
Indicator
Patient Satisfaction: In-patient overall result
(In-patient) How likely is it that you would recommend the service to friends and family?
Were you ever bothered by noise at night from other patients?
Patient Satisfaction: outpatient overall result
(Out-patient) How likely is it that you would recommend the service to friends and family?
Were you informed of any delays in being seen?
Patient Satisfaction: short-stay overall result
(Short-stay) How likely is it that you would recommend the service to friends and family?
Patient Satisfaction: A&E overall result
(A&E) How likely is it that you would recommend the service to friends and family?
Patient Satisfaction: Maternity overall result
How likely is it that you would recommend the post-natal ward to friends and family if they
needed similar care or treatment?
How likely are you to recommend our labour suite to friends and family if they needed
similar care or treatment?
How likely are you to recommend our antenatal department to friends and family?
How likely are you to recommend our post-natal care to friends and family?
How likely is it that you would recommend the birthing unit to friends and family if they
needed similar care or treatment?
Patient Satisfaction: F1 Parent overall result
(F1 Parent) How likely are you to recommend our ward to friends & family if they needed
similar care or treatment?
Patient Satisfaction: Stroke overall result
(Stroke) How likely is it that you would recommend the service to friends and family?
Target
= 85%
= 95%
= 85%
= 85%
= 95%
= 85%
= 85%
= 95%
= 85%
= 95%
= 85%
Red
<75
<80
<75
<75
<80
<75
<75
<80
<75
<80
<75
Amber
75-84
70-89
75-84
75-84
70-89
75-84
75-84
70-89
75-84
70-89
75-84
Green
85-100
90-100
85-100
85-100
90-100
85-100
85-100
90-100
85-100
90-100
85-100
Nov
93
98
71
94
97
80
99
99
93
93
92
Dec
93
98
68
92
96
66
98
99
90
91
96
Jan
93
99
67
90
97
85
99
99
91
92
93
= 95%
<80
70-89
90-100
97
97
96
= 75%
<70
70-74
75-100
100
100
100
= 75%
= 75%
<70
<70
70-74
70-74
75-100
75-100
100
100
100
100
96
96
= 95%
<80
70-89
90-100
100
100
100
= 85%
<75
75-84
85-100
99
97
97
= 95%
<80
70-89
90-100
99
99
100
= 85%
= 95%
<75
<80
75-84
70-89
85-100
90-100
95
100
98
92
100
100
Indicator
Target
Red
Amber
Green
Nov
Dec
Jan
Response within 25 working days or negotiated timescale with complainant
100%
<75%
75 – 89%
>=90%
87
92
58
Number of second letters received
0
>6
2-6
0-1
2
1
1
Health Service Referrals accepted by Ombudsman
0
>=2
1
0
1
0
0
Red complaints actions beyond deadline for completion
0
>=5
1-4
0
0
0
0
Number of PALS contacts becoming formal complaints
0
>=10
6-9
<=5
2
3
5
Additional Patient Experience indicators
Exception reporting for indicators in the Patient Experience Dashboard
All indicators in the Patient Experience dashboard which are red or amber for two consecutive
months will have narrative below.
1.13
Noise at night
a) Current Position
A score of 67 in January is similar to the previous month (December 68).
b) Recommended Action
To continue with interventions on pilot wards to help settle patients to sleep at night.
Data captured thus far on moves at night has been of some value in identifying wards with the
highest number of moves. However, it is considered that a more precise piece of data collection
can be identified to produce meaningful information to improve this aspect of patient experience.
11
Therefore, a meeting is being organised with representatives of the transformational teams across
the divisions to define how this can be achieved.
The performance against December 2015 data indicates a very slight increase in total moves by 4,
from 31 total moves in December 2015 to 35 total moves in January 2016. Trust is working hard to
move a higher proportion of patient’s moves before Midnight by identifying and facilitating the
required capacity earlier in the day. This will reduce the disturbance of patients at night.
1.14
Complaints
The number of complaints received in January was consistent with the previous month and
significantly lower with the same period last year. 12 complaints were responded to in January with
58% within agreed timeframe, meaning five were late.
The breakdown of the 20 complaints received in January is as follows by Primary Division: Medical
(9), Surgical (6), Women & Child health (4) Clinical Support (1)
Trust-wide the top 3 most common problem areas are as below:
Communications
Patient Care - including Nutrition/Hydration
Clinical Treatment - Surgical group
Number of complaints
40
35
30
25
20
15
10
5
0
1.15
7
5
5
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Complaints 2014/15
28
26
27
23
27
35
30
25
22
24
23
36
Complaints 2015/16
16
26
24
31
28
15
17
15
14
20
Second letters 2014/15
8
5
3
1
1
3
7
1
0
2
4
1
Second letters 2015/16
0
0
0
2
2
3
2
2
1
1
PALS
12
In January 2016 there were 185 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.
A breakdown of contacts by Directorate from Jan 15 – Jan 16 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.
Medical
Clinical support
Facilities
Total
80
Surgical
Women and Child Health
Other Trusts / Corporate Services
185
180
70
60
137
108
104
160
136
134
140
123
122
119
50
107
102
120
40
30
200
100
80
54
60
20
40
10
20
0
Jan-16
Dec
Jan
0–3
0
0
0
90 – 94
>=95
NA
97
NA
<75
75 – 89
>=90
NA
100
NA
No target
No target
No target
0
3
5
<50%
50-80%
>80%
94
94
88
100%
>100
90-100
<90
92.80
90.01
88.92
0
>=1
No target
0
0
0
0
Aug-15
Nov-15
Dec-15
Oct-15
Nov
Sep-15
Green
Jul-15
Jun-15
May-15
Apr-15
Mar-15
Feb-15
0
Trust-wide the most common reasons for contacts are shown as follows:
Queries, advice and requests for information
85
Appointments - including delays & cancellations
27
Communications
14
Clinical Effectiveness Dashboard
Indicator
Target
Red
Amber
TA (Technology appraisal) business case beyond agreed deadline
0
>9
4–9
WHO checklist (Quarterly)
100%
<90
Trust participation in relevant ongoing National audits (Quarterly)
100%
Gynaecology (F14) 30 day readmissions
No target
Babies admitted to NNU with normal temperature on arrival (term)
0
12 month Mortality standardised rate (Dr Foster)
CAS (central alerting system) alerts overdue
Exception reporting for red indicators in the Clinical Effectiveness Dashboard
No indicators are reported as red this month.
The Ward Analysis Report for all Clinical Quality Indicators is provided at Appendix 1.
13
2.
MORTALITY DATA
The latest SHMI has been released which
updates our national position.
14
15
West Suffolk NHS Foundation Trust v Other Acute providers in East of England
16
17
3.
MONITOR ASSURANCE FRAMEWORK
The Governance Rating table shows no failures of the governance rating against Monitor’s Risk
Assessment Framework.
Governance Rating
Rated Green if no issues are identified and Red where monitor are taking enforcement action.
Where Monitor have identified a concern at a trust but not yet taken action, they provide a
written description stating the issue at hand and the action they are considering.
3.1 Number of RTT waits over 52 weeks for incomplete pathways
a) Current Position
1 against a threshold of 0.
b) Recommended Action
This was due to a Gynaecology patient missed off list as the prescription for Surgery did not reach
the Admission Team and the patient was not on the Out Patient Waiting List (Other) tracking sheet
which would have enabled early identification.
3.2 A&E: Maximum waiting time of four hours from admission/transfer/discharge
18
a) Current Position
93.48% against a threshold of 95%.
b) Recommended Action
There have been several challenges in meeting the 4 hour standard culminating in our ability to
meet the 4-hour breach target. Issues impacting on performance are:
 Staffing challenges in department
 Increased Demand and at times Acuity
 Poor flow/available beds (note delays running at twice 14/15 levels)
 Ward closure due to Norovirus
ED continuously monitors staffing levels and the impact of all other factors impacting on breach
times. We will continue to make adjustments and assess new ways of working which we anticipate
will improve performance and more importantly patient care.
3.3 All cancers: 62-day wait for first treatment (5) from: NHS Cancer Screening Service
referral
a) Current Position
88.90% against a threshold of 90%
b) Recommended Action
It took time to heal an extensive haematoma developed post core biopsy excision which delayed
surgery. It was an unavoidable medical condition.
3.4 Clostridium (C.) difficile - meeting the C.difficile objective - MONTH
c) Current Position
4 cases against a threshold of 2
d) Recommended Action
Covered in page 3.
19
4.
CONTRACTUAL AND KEY PERFORMANCE INDICATORS
This section identifies those area that are breaching or at risk of breaching the Key Performance Indicators,
with the main reasons and mitigating actions.
Key:  performance improving, performing deteriorating,  performance remains the same.
20
4.1
A&E time to treatment in department (median) for patients arriving by ambulance CDM & Single longest total time spent by patients in the A&E department, for admitted and
non-admitted patients
e) Current Position
The Trust remained outside the contractual target for both these indicators.
f) Recommended Action
The Trust continues to work with the ECP pathway to improve performance. A number of issues
have been identified with high weekend activity. Staff levels are being consistently monitored to
address this.
4.2
Ambulance handovers above 30 minutes & 60 minutes
a) Current Position
The target continues to be missed.
b) Recommended Action
The Trust is working with the Ambulance Service and Commissioners to improve both data
validation and overall performance.
A whole system review is underway with partners across the healthcare system. It should be noted
that numbers shown within the report is ambulance raw data and is pre-hospital validation which has
shown to improve performance overall.
Validated data has significantly improved this raw data and has therefore reduced fines.
4.3
Maximum time of 18 weeks from point of referral to treatment in aggregate - admitted
a) Current Position
81.15% against a threshold of 90%
Data has been rebased to reflect recent changes to contractual requirements. Performance now
shows unadjusted performance, rather than taking in to account any pauses on a pathway.
b) Recommended Action
Specialties have improved the non-admitted tracking enabling pathways to be managed earlier.
Longest waiting patients continue to be booked to ensure waits are kept to a minimum.
4.4
Proportion of Stroke patients admitted to an acute stroke unit within 4 hours of
hospital arrival
a) Current Position
82%% against a threshold of 100%
b) Recommended Action
6 patients breached.
 1 patient long delay in medical clerking in ED – black bed state
 1 patient admitted to CDU as a quick turnaround – discharged next day but counted as
admission as in a bed
 1 end of life patient needed a Side room – none on G8
 1 diagnostic uncertainty
 1 self-referral to ED, late notification to ESOT who were in CT with another patient
 1 admitted to F8, not thought to be a stroke but later found to be one.
No common themes this month, target under review with CCG for new contract.
21
4.5
65% of patients with low risk TIA have access to MRI or carotid scan within 7 days
(seen, investigated and treated)
a) Current Position
57% against a threshold of 65%
b) Recommended Action
All breaches were beyond the control of the TIA service, as patients didn’t present to a Health Care
Professional within 7 days of onset of symptoms.
4.6
Discharge summaries - Inpatients
a) Current Position
92.37% against a threshold of 95% sent to GPs within 1 day
b) Recommended Action
In order to reduce the clinical risk from sending unchecked/signed letters a focus for contract
negotiation will be changing the target in the context of the WSFT's strong benchmark performance;
this has resulted in the following targets being proposed:
Discharge Summaries to be sent to GP’s from:
a) Emergency Non Elective (including ED) within 24 hours
b) Elective within 72 hours
c) Outpatients within 5 working days
All with a 95% target and no financial penalties if not achieved.
e-Care will support back office procedures once embedded.
4.7
Patients offered date within 28 days of cancelled operation
a) Current Position
72.00% against a threshold of 100%
b) Recommended Action
Eight patients have been identified as 28 day breaches; five of which are due to industrial action.
One was an unavoidable reported breach as the patient was admitted as an emergency. Two
breaches were due to theatre capacity as lists did not have the flexibility of an offer due to urgent
and Cancer cases already booked.
4.8
Access to Maternity Services (VSB06)
c) Current Position
89.35% against a threshold of 90%
d) Recommended Action
In December 2015, 251 women were booked for antenatal care. Of these 23 were not booked
before 12 completed weeks. On investigation of these reasons for this, the 23 women included a
group of 11 who were unaware that they were pregnant, and therefore did not seek antenatal care.
This is an unusually high number for which there is no obvious reason.
4.9
Breastfeeding initiation rates
e) Current Position
79.66% against a threshold of 80%
22
f) Recommended Action
Breastfeeding initiation rates for December 2015 have fallen just below 80% for the second
consecutive month. Review of the available information provides no immediate explanation for this
reduction in initiation rates following a number of months where the 80% target had been exceeded.
The maternity services are constantly striving to ensure that women make an informed decision to
breastfeed and have a number of new and on-going initiatives in place to support this. F11 ward is
now able to offer breast milk storage which will support an initiative to encourage a high risk group
of women, who may not be able to breastfeed initially after delivery, to express and store milk
antenatally. The service also continues to prepare for the external accreditation by Baby Friendly
Initiative (BFI) in May 2016.
5.
WORKFORCE
This section identifies those areas that are breaching or at risk of breaching the Workforce
Indicators, with the main reasons and mitigating actions.
5.1
Sickness Absence Rate
a) Current Position
3.73% against a threshold of <3.5%.
b) Recommended Action
September – March is always problematic re sickness absence, as we usually see an increase in
the cumulative absence rate due to issues such as bugs, colds/flu, norovirus etc.
HR are supporting the divisions as follows:
 Providing monthly Bradford factor reports to line managers
 Ensuring meetings are arranged to support staff and managers through the process.
 1/4rly reports to Service and General Managers for their areas.
 Staff with 4+ week’s sickness absence are referred to Occupational Health.
 A number of staff have resigned as a result of absence review meetings being held.
Further work is being undertaken in the following areas:
 Clarification on the recording of sickness absence reasons and communicating this to line
managers
 Correct recording generally.
 General communication to all staff about notifying the correct person if going off sick – staff still
do not seem to be adhering to policy.
5.2
All Staff to have an Appraisal
a) Current Position
89.07% against a threshold of 90%
b) Recommended Action
23
HR continues to monitor and support the appraisal monitoring process. The appraisal policy is being
reviewed in light of the forthcoming Nursing Revalidation requirements. This will involve a review of
policy, paperwork, reporting and the training programme, and will involve managers and users in
this review.
6.
RECOMMENDATION
The Board is asked to note the Trust Quality & Performance Report and agree the implementation
of actions as outlined.
24
Appendix A - Community Data
25
26
27
28
29
30
31
32
33
34
35
36
37
38