NLG(18)341. DATE OF MEETING September Trust Board of Directors Public REPORT FOR. Dr Kate Wood, Acting Medical Director REPORT FROM

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1 NLG(18)341 DATE OF MEETING September 2018 REPORT FOR Trust Board of Directors Public REPORT FROM Dr Kate Wood, Acting Medical Director CONTACT OFFICER Dr Kate Wood, Acting Medical Director SUBJECT Mortality Briefing BACKGROUND DOCUMENT (IF ANY) N/A PURPOSE OF THE REPORT: For assurance EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE) The attached paper outlines the progress made and the current risks identified in respect of the Quality and Safety Mortality Workstream. The paper draws the board s attention to the 3 principle strands of addressing mortality. TRUST BOARD ACTION REQUIRED The Board is asked to note the progress in deteriorating patient and sepsis, and that there needs to be renewed focus on Learning from Deaths. The Board will receive an update soon re: the progress on the medical model from the medical division.

2 Mortality Highlight Report Mortality, as measured by SHMI, within NLAG has been persistently high for a number of years, and has had a number of different approaches to try and address the issue. The purpose of this brief highlight paper is to provide a brief overview and explain the current strategy being used to address the mortality position. The approach to mortality since early 2018 has been refreshed with the appointment of 2 new clinical leads Dr Kamath and Miss Balchandra. Mortality is now viewed as having a number of separate components, all of which can contribute to mortality and to view one in isolation (to the detriment of others) would not lead to sustained improvement in the figures. Mortality figures do not on their own signify poor care delivery, but the case note reviews can help identify where improvements can be made as well as identify and reinforce good practice. The calculation of the SHMI is reliant on depth of coding, which in turn relies on documentation by the medical staff, with initial early diagnosis and clear note of any co-morbidities. The issue of coding is crucially important to the organisation, not just for mortality, but also for income into the organisation and work has been undertaken with Grant Thornton to view this in more detail, so will not be further addressed within this document. There are essentially 3 key themes picked up through the Mortality Strategy (which should hopefully be ratified through the Mortality Improvement Group this month). The outline of the Strategy has already been discussed with NHSI who have agreed it is a fair approach, but obviously each area needs to be able to show how it is influencing care delivery. 1. Deteriorating Patient and Sepsis: the focus of this work stream has been on early identification and escalation of patients if they deteriorate in our hospital, allowing earlier focussed treatment. It is absolutely crucial to be able to identify patients early when they become unwell, and this work stream has led to the improved embedding of NEWS (and other early warning scores) across the Trust, as well as the early roll out of the hand held devices for timely recording of observations. This work is monitored through the IPR on a monthly basis, and will be monitored at ward level by the ward managers and matrons with development of the ward dashboards. 2. Learning From Deaths: The Learning from Deaths document launched in March 2017 provides the benchmark used for mortality reviews and is the process by which case notes are reviewed following a patient s death to understand if there is any learning that can be implemented to improve care delivery for other patients as well as identify if there are any avoidable deaths. NLAG was an original pilot site for the development of this process, so was originally ahead of other Trust s when the document was launched. However, this has not been sustained, and poor clinical engagement and lack of feedback and opportunities for sharing learning has led to our patients and the Trust not reaping the potential benefits. The process for case note review is not as robust as it needs to be for adequate learning, and the original approach by the mortality clinical leads (to influence colleagues) has not been successful in achieving the number of reviews that we would like.

3 The Learning from Deaths document gives a minimum data-set of notes to be reviewed, and we tend to achieve this minimum but more reviews will facilitate deeper analysis, as well as potentially engage more clinicians in the process. To achieve this, the Mortality Improvement Group will be receiving a paper this month to discuss different options to enable more reviews to be undertaken some of the options have a cost implication, but it may be that there is a selection of different options implemented to gain the most learning from reviews. Further discussion will be held through Trust Management Board as appropriate. The opportunities for individual reflection and team (as well as organisational learning) from case note reviews cannot be under-estimated, but this links in to the piece of work being started about threading governance through the organisation and making it everyone s responsibility. Community mortality reviews continue, with attendance at NE Lincs by both providers and commissioners allowing for multi-disciplinary review of care delivery and identification of potential areas for improvement. It is clear from both hospital as well as community reviews that more work needs to be done to identify patients approaching the End of Life, and have early discussions about what best can be done to support their continued care in the community if this is the right place for care delivery. This is an opportunity for reinvigorating the partnership working with our colleagues outside the acute Trust, and needs to be worked through with some urgency. 3. Medical Model: Mortality rates in hospital are known to be closely linked with length of stay, both in ECC as well as through the hospital. By reviewing the way that care is delivered the medical model will have potential benefits from a mortality perspective. Over the last year, the length of stay has reduced from 9.4 days to 6.5 days, and the 4 hour performance in A&E has improved. During this same period of time, our mortality position has improved slightly with a reduction in SHMI form 119 to 117. Crude mortality on the DPOW site has reduced, which possibly reflects some of the changes at enabling earlier discharge of patients approaching the End of Life who are being discharged faster to enable them to die in their preferred place (not in the hospital). There is still work to be done, and particular focus (through the medical division, and project management support through Improving Together) is the continued work on flow through the Trust, which includes increased use of ambulatory care where appropriate, introduction of a frail elderly service in DPOW (already in place in SGH), and embed use of SAFER across all the wards which includes daily senior review of patients. This work is being facilitated by ECIP and supported by NHSI. The Improving Together mortality highlight report will highlight progress against the pillars of work identified above, will be a standing item on the public agenda of Trust Board. The Monthly Mortality Report, which contains the performance figures, will continue to be a regular feature on the Board agenda as an item for information.

4 Next RAG Current RAG Previou s RAG Workstream: Quality and Safety - Mortality Senior Responsible Officer: Kate Wood Month: September 2018 Improving Together Board Update Project Risk Rating Blue Green Amber Red Project Title Complete and embedded. Completed. Not yet fully embedded/evidenced. In progress/ on track. Not yet completed/ significantly behind agreed timescales. Comments (explanation of RAG, progress update etc.) QS5 Mortality Deteriorating Patients and Sepsis and Critical Care Outreach Learning from Deaths Medical Model A A A A A A This includes the Deteriorating Patient and Learning Lessons project, End of Life (EoL) and Medical model will feed into this workstream for information purposes only to ensure joined up approach across the organisation Agreed will still feature as part of the new improving together programme under Quality and Safety. Proposed work to be undertaken and reported through Q&S: Work with the wards on action plans following deteriorating patient score cards Continue supporting PEWs to become electronic Devising method of escalation for Deteriorating patients Work with Critical care infection rates, specialist training Get Sepsis assessment on handhelds Incorporate work around Acute Kidney Injury CQUIN 2 Current % of patients being assessed with a 30 min grace: August (reporting month) % NEWs score (30 min Grace) % usage of Mobile Devices (NEWS) % MOEWs Score (30 min grace) GDH 66.4% 80.1% SGH 83% 46.7% 78.4% 59.4% DPOW 69% 46.3% 83.8% 64.3% Trust Wide 76% 46.3% 82% 62.7% % usage of Mobile Devices (MOEWs) % has slipped in the month of August with no ward achieving 95% and above therefore needing support with action plans Three Wards have consistently remained at 90% and above for 3 months: Ward 19 Ward 28 CCU Agreed will still feature as part of the new Improving Together programme under Quality and Safety. Proposed work to be undertaken and reported through Q&S: Development of and agreement of the Mortality Strategy Learning lessons from deaths with increase in reviews done and clear themes and actions plans identified See Access and Flow workstream 1

5 Workstream: Quality and Safety - Mortality Senior Responsible Officer: Kate Wood Month: September 2018 Issues for Escalation Handheld usage is not universal and not all observations are being completed in the set period Lack of Mortality Case note reviews Financial Delivery No financial target associated with this workstream. Level 1 KPIs 2

6 Workstream: Quality and Safety - Mortality Senior Responsible Officer: Kate Wood Month: September 2018 Ref Date Risk Added December 2017 December 2017 January 2018 Risk Description RAG Mitigation/Controls Date Mitigation Occurred Data quality and/or audit methodology of level 1 and level 2 KPIs is not robust R (20) 1. Review all level 1 KPIs for effectiveness 2. Data collection method identified for each KPI 3. Data validation method agree for each KPI 4. Develop data dictionary for all KPIs 13/03/18 KPIs still not being published 12/04/18 KPIs still not being published for level 2 Sepsis 6 - Need to ensure that Sepsis 6 bundle is compliant in all areas (within 1 hour receive all 6 elements) Progress is being potentially hampered by operational pressures/opel 3 which is focussing key staff members time on managing operational issues R (16) A (12) Both Accident & Emergencies to have discussions regarding process and also look at what we are auditing when looking at sepsis screening need to ensure that staff understand national standards. 12/04/18 Escalated the urgency of uploading the sepsis bundle onto the handheld devices. Divisional nurse leads and project managers asked to prioritise key meetings or use other opportunities to engage/feedback 13/03/18 current pressures still not allowing this to happen 10/05/18 - although pressures reduced this remains a potential risk RAG A (12) A (12) G (3) Risk Rating Matrix None/Near Miss (1) Severity / Impact /Consequence Low (2) Moderate (3) Severe (4) Catastrophic (5) Likelihood of recurrence Rare (1) Unlike (2) Possible (3) Likely (4) Certain (5)