Cluster Board Quality Safeguarding and Safety Report January 2012

Transcription

1 Quality/Safety Excellence CQC essential standards of quality and safety Cluster Board Quality Safeguarding and Safety Report January Introduction This report is presented to the Cluster Board to indentify the key aspects of Clinical Quality Assurance including patient safety; patient experience and safeguarding in relation to NHS funded care across NHS Milton Keynes and Northamptonshire. The report provides assurance on red rated areas and identifies other quality/safeguarding issues for the board to be aware of. 2. Quality Dashboard The quality dashboard presents information relating to CQC registration, patient safety and patient experience. AREA MEASURES Period Reported NGH KGH MK CQC Registrations Registered with no conditions Sep-11 CQC Quality & Risk Profiles CQC Mortality Outlier Alerts Involvement and information Jul-11 Personalised care Jul-11 Safeguarding and safety Jul-11 Suitability of staffing Jul-11 Quality and management Jul-11 No. of active outliers Dec No. of closed outliers () Dec Serious Incidents Serious Incidents Reported Summary Hospital Level Mortality Indicator (SHMI) Elective & Emergency Oct Safety Thermometer Pressure Ulcers (grade 3-4 ) Dec Catheter Acquired UTIs Dec Serious Injury from falls Dec Cluster Board 31 January 2012 Page 1 of 9

2 Patient Experience AREA MEASURES Period Reported NGH KGH MK VTE screening Nov % 93% 91% 90% 92% 92% 90.00% 93% 76% Complaints Complaints in Quarter Sep-11 0 Q2= Q2= Q1+2= NHS Choices Staff Survey Patients who would recommend this hospital to a friend Dec-11 47% 72% 41% Total Responses Dec KF34 Staff recommendation of the trust as a place to work or receive treatment (NHS Staff Dec Survey 2010) Q16. Were you involved as much as you wanted to be in decisions about your care and Jul-11 71% 85% 72% 74% treatment? Q18. Did you find someone on the hospital staff to talk to about your worries and fears? Jul-11 63% 81% 61% 70% East Midlands Patient Experience Project Q19. Were you given enough privacy when discussing your condition or treatment? Q27. Did a member of staff tell you about medication side effects to watch for when you went home? Q30. Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital? Jul-11 82% 97% 81% 85% Jul-11 49% 75% 47% 52% Jul-11 74% 86% 78% 86% Patient Opinion Stories Told Dec Changes Made Dec What Could be improved? Dec-11 None A&E None 3. CQC Issues Trust Assurance MKFT MKFT was found to be compliant with Outcome 8 Infection Prevention and Control following an unannounced CQC visit in November NHfT The Trust was visited in November 2011 as part of the CQC review of Learning Disability services. The report published in January Cluster Board 31 January 2012 Page 2 of 9

3 identified that improvements were required in relation to care planning and weekend activities. The trust have an action plan in place to address these concerns. 4. Patient Safety 4.1 Serious incidents The cluster reviews all serious incident investigations and monitors the implementation of recommendations and action plans through the SI assurance meetings and clinical quality meetings. In addition learning will be shared across the wider health economy through the Medical and Nurse Directors forum. Midlands and East SHA are reviewing the regional policy for Serious Incidents Requiring Investigation. This will enable us to update our local policy and harmonise reporting across the cluster. Trust MKFT KGH NGH NHFT Assurance MKFT have a year to date performance of 76% of patient being assessed for VTE against a target of 90%. The trust has implemented actions to improve performance in this area and have reported over assessment rates of over 90% since August KGH have reported 30 grade 3 and 4 pressure ulcers since April An intensive work programme is in place and had delivered a reduction in the numbers of pressure ulcers reported in October, November and December. NGH have reported 11 falls resulting in serious injury since April 2011 and have commenced an internal review of falls which will be shared with the Cluster. NHFT have reported 2 homicides since April 2011 involving service users. Internal investigations have been submitted and neither report identifies any significant failings in care delivery 4.2 MRSA and C-Difficile Trust Assurance KGH KGH reported their 1 st MRSA bacteraemia in over 500 days in December MKCHS Performance currently is over trajectory for C-Difficle. A remedial action plan has been requested and will be managed through the clinical quality meetings The trajectory for MRSA and C-Difficile remains tight and it will be challenging to maintain performance for the remainder of The SHA met with the cluster Nurse Director in November 2011 to review the actions being taken by the cluster in relation to HCAI targets, to ensure continued performance and delivery of year end targets. The SHA confirmed that the health economy actions are appropriate and no additional actions are required Cluster Board 31 January 2012 Page 3 of 9

4 12-03 Cluster Board 31 January 2012 Page 4 of 9

5 4.3 Mortality Mortality at NGH remains of concern. The trust has presented to their board a range of actions being taken to reduce mortality including working with Dr Foster and CHKS. NGH have met with the SHA Medical Director and the Cluster Medical and Nurse Directors to review these actions. A detailed action plan has been requested. 4.4 PIP Breast Implants Following concerns relating to the safety of PIP breast implants the cluster has sought assurance from both NHS and Private providers relating to the numbers of women who received PIP implants on the NHS. All Providers have confirmed that no women have received PIP breast implants on the NHS within the cluster area. Clear advice for woman with breast implants has been published on the clusters website and with PALs. We are working with general practice through the Local Medical Committees to ensure a consistent message is available and appropriate clinical actions taken. 4.5 Further Developments: Safety thermometer Safety Thermometer (ST) is an important tool in the improvement of patient safety and the reduction of avoidable harm to patient. It provides a point prevalence measurement for Pressure Ulcers (Grades 2, 3 and 4), Falls, Cather Associated Urinary Tract Infections and Venous Thromboebolism (VTE) across acute trusts, district nursing teams and elderly care settings in Mental Health Services. The tool will enable benchmarking across the whole Midlands and East region and will drive improvements in reducing avoidable harm. All NHS providers in the cluster area have committed to the implementation of ST for 100% of all patients by April 2012 with a pilot data collection in March. ST data will be reported to the Board from May Patient Experience The improvement of patient experience across a range of care setting is a cluster priority for All providers have systems to monitor patient experience such as patient surveys, telephone follow-up, hand held patient trackers and improvement plans in place. Contract levers and incentives are currently being developed for the contracts to drive further improvements Cluster Board 31 January 2012 Page 5 of 9

6 Trust MKFT Assurance Formal complaints have reduced in the first 2 quarters of compared with (107 compared to 158). This is due to improved local resolution of concerns avoiding escalation to formal complaint. KGH There has been a slight reduction in complaints between Q1 and Q (134 to 122). The trust is demonstrating a consistent and sustained improvement in patient experience reported as part of the East Midlands Patient Experience Survey (EMPES 1 ). The results for KGH are in line with the scores for other acute trusts in the East Midlands. NGH Complaints remain static for Q1 and Q2 (129 and 128). NGH is demonstrating a sustained improvement in patient experience as part of EMPES scoring slightly higher than other acute hospitals in the East Midlands. NHfT Complaints remain static in Q1 and Q2 (47 and 47) for Mental Health services which is in line with complaints for the same period for There was an increase in overall complaints in Q2 due to the inclusion of community services in the totals for the first time. MKCHS Complaints management performance is monitored within the service on a monthly basis. Across the combined Community and Mental Health service fewer complaints were received in Q2 than Q Net Promoter Score A core element of improving patient experience is to understand whether the patient would recommend the service they have received to friends and family. This is known as the Net Promoter Score (NPS). The SHA, as part of their ambition regarding the implementation of the patient revolution, have requested that all providers ask the NPS question within their current patient experience systems and that commissioner set improvement trajectories. The NPS will be in place from April 2012 and will be reported as part of the quality dashboard from May. 6. Clinical Visits 1 EMPES is an important tool that provides the ability to benchmark patient experience within 4 groups of elective patients receiving primary hip and knee replacements, varicose vein surgery and hernia repair. The survey is sent to all patients who have had one of the procedures. The response rate for the cluster area is currently 60% - 70% Cluster Board 31 January 2012 Page 6 of 9

7 Clinical visits are an important aspect of provider quality assurance and enable commissioners to see patient care directly and to hear first hand patient experience. Clinical visits are now included in every monthly clinical quality meeting with providers. The focus for January with acute trusts will be patient safety in operating theatres. Trust MKFT NGH NHft Assurance The PCT conducted a visit to A&E on 1st December, which identified improvements were required in A&E in relation to the maintenance of privacy and dignity for patients within the trolley waiting area. The trust has redesigned the layout of A&E and has created 2 patient observation cubicles and a new seating area for patients waiting for X-rays. A further visit on the 23rd December 2011 confirmed that all works had been completed. An action plan has been received from the trust to address the other areas for improvement identified at the visit. A clinical visit was undertaken to NGH A&E in December 2011 to review the performance in relation to transit time, managing patient flow and delays in ambulance turnaround. The visit highlighted a number of further areas of improvement and the trust has been asked for an action plan to address these concerns. A joint safeguarding and quality visit was undertaken in December 2011 to the Berrywood and St Mary s older persons in-patient areas following an increase in the number of falls reported. The visit identified that information on falls assessment and the actions to be taken to minimise the risks of falls were easily available and that staff had received appropriate training. The cluster found no further actions were required by the Trust and the situation will be closely monitored via the clinical quality meetings Action plans are monitored through the contract and clinical quality meetings. 7. CQUIN CQUIN schemes for were developed to incentivise quality improvements that support the QIPP agenda, such as improving prescribing, reducing Caesarian Sections and reducing avoidable harm from VTE. All trusts have achieved end of Q2 targets except those identified below. Failure to achieve targets will result in recovery of pre-paid finances. MKFT NGH NHFT Further information has been requested in relation to 2 indicators to determine whether these have been fully achieved. Has not achieved in respect to a two indicators in relation to reducing Caesarian sections and improving statin prescribing in secondary care. Has not achieved in respect of one mental health indicator. The Trust missed the target of 80% seen within 6/18 weeks of referral for Cluster Board 31 January 2012 Page 7 of 9

8 dementia assessment Cluster Board 31 January 2012 Page 8 of 9

9 8. Care Homes Quality The Care Home Quality team are currently completing quality schedules as part of the DoH Care Homes Contract. This will required care homes to provide similar data on patient experience, patient safety and patient outcomes as acute providers and will ensure a consistent approach to quality assurance across the range of NHS funded provision. 30 Providers throughout Northamptonshire and Leicestershire have been identified to take part in the Improving and Sustaining Nursing Home Quality & Safeguarding through the implementation of an Educational Toolkit training following a successful bid for East Midlands Health Innovation and Education Cluster funding. Each provider has identified a lead nurse to undertake the training; the first two stages have been completed within Northamptonshire and are now being rolled out into Leicestershire. Stages three and four will be completed by the summer. It is envisaged that this work will led to a reduction in avoidable hospital admissions. A further report will be available in Q Cluster Board 31 January 2012 Page 9 of 9