Quality Improvement Scorecard June 2017

Transcription

1 Mortality: HSMR Nat NB: Each month is a 12 month rolling value. I.e. Mar-16 reports the monthly average of Apr-15 to Mar-16. Performance remained below target in February. Mortality: HSMR (weekday) vs. HSMR (weekend) Mortality: HSMR Performance remained in the expected range in February. Mortality: SHMI (quarterly) An improvement in performance can be seen in Q2 2016/17. 1

2 Cardiac Arrests Ward-based cardiac arrests (coded as preventable calls) There were 7 cardiac arrests coded as preventable during May 2017: 1 each in Becket, Creaton, Eleanor, Victoria and Willow, and 2 on EAU. The theme for all 7 was DNACPR. Peri-arrests Peri-arrest calls wards only There were 36 peri-arrest calls during May 2017 for patients triggering EWS >5 or patients identified as code red. 2

3 Early Warning Score Patients scoring >7 (critical risk) Vs. % of critical risk patients with a management plan in place The percentage of Critical Risk patients increased to 3.53% in May. The percentage of Critical Risk Patients with a Care Plan in place declined further in May to 66.67%. Early Warning Score % of overdue observations Overdue observations remain below the Trust target at 6.75% for May. 3

4 Sepsis Treatment Sepsis screening, time to administration of antibiotics and antibiotic review Q1 : 2 of 4 CQUIN targets met. ED & Inpatient ABX treatment <60 mins compliance reduced due to EPMA go live in ED and medical wards. ABX stat doses being prescribed & given at next drug round (this can be circa 5-6 hours later). Doctors reminded to ask nurses to administer stat doses appears to be assumption that EPMA will alert nurses they tend not to use system until drugs rounds. Awareness campaign June/July including onward awareness posters, computer stick-on reminders, screensavers, targeted s and SMS messages to junior doctors and importantly, discussion with doctors & nurses during notes audits and ward visits. Trial screening tools are still used inconsistently. Paed tools updated to reflect the new per-age PEWS charts, Sepsis team supporting Labour wards with the sepsis screening tools. Trial tools will be formally reviewed with ward staff at the end of Q2. Board to Ward Monthly Executive Safety Rounds by Trust Board Members 11 Executive Safety Visits have taken place so far this year. On target to achieve the stretch target of 72 visits in the year. 4

5 There have been 17 grade 2 pressure ulcers so far this year. This is below the revised Sign up to Safety target. Pressure Ulcers Reduce hospital acquired pressure ulcers There have been 3 grade 3 pressure ulcers so far this year. This is below the revised Sign up to Safety target. Four learning sessions for the Pressure Ulcer Collaborative have taken place as well as the Cultural Web in July. Following this an improvement can be seen. In May there were 0.49 pressure ulcers/1000 bed days. 5

6 Harmful Falls Reduce harm from patient falls Number of falls per 1000 bed days reduced from 1.97 in April to 1.37 in May, this equates to 31 harmful falls in the month. Pain Management Patients receiving appropriate pain management All three measures of pain management have remained above the 95% target during May. Decline in Overall Pain Score and improvement in other two measures. Omitted Medicines Reduce percentage of omitted medicines (not documented) February s audit shows 5% of omitted doses, a decline from the last audit, however still below the 7% target. No audits have taken place since February due to lack of capacity, however they will recommence next month. 6

7 WHO Checklist Percentage of operations where WHO safer surgery checklist is being completed From October 2016 data collated from Nexus. Compliance for May is 94.99%. Improving transfers/handover of care Patient risk assessment completed for out of hours transfers 46 OOH transfers in May, 45 (98%) had a patient risk assessment completed. LFE for Clinical Teams Learning from Errors training The percentage of staff attending LFE sessions decreased during May to 22.13% for Nursing staff and 7.77% for Medical Staff. 7

8 VTE Risk Assessment EDN Data % of patients with documented risk assessment for VTE declined to 93.3% in May, however has not yet been validated. Documented risk assessment for VTE Vitalpac Data From 7 th December VTE assessments should be completed on Vitalpac. Improvement in overall compliance in May to 41%. Hospital Acquired Thrombosis Number of HATs following RCA There were 2 HATs during February 2017 following root cause analysis. 8

9 Time to Consultant Review Time to First Consultant Review All emergency admissions should be reviewed by a Consultant within 14 hours from the time of decision to admit. Compliance improved to 55% in May. Leadership Training & Development Participants in leadership programmes As at the end of May there have been 131 participants in the LOVE programme. The latest cohort of the Francis Crick programme started in February and MQC started their latest cohort in March, therefore there are no new participants for 2017/18 as yet. Reduce stillbirths & undiagnosed small for gestational age babies Carbon monoxide measurements taken In May 74% of women had a CO measurement taken at their booking appointment. 9

10 Dementia Carers Survey Dementia carers that feel supported Improvement in May to 88% of dementia carers that took the survey, that said they feel supported. Intentional Rounding % that answered yes to three questions regarding care rounds In May, decline in compliance for whether staff ask the care round questions every 1-2 hours and whether the car rounds are documented according to correct guidance. Heart Failure Number of patients discharged with primary diagnosis of heart failure Vs. Referrals to Heart Failure In April there was a reduction in patients discharged with Heart Failure and in the number referred to the Heart failure team. 10

11 The % of stroke patients reaching a stroke bed within 4 hours increased to 97% in May. Stroke Care The % of patients scanned within 1 hour of arrival is consistently above the target of 50% and increased to 100% in May. Caring for Stroke patients It is aimed that 85% of stroke patients spend at least 90% of their time on the stroke unit, in May 94% was achieved. 100% of patients in AF are discharged on anti-coagulation. 40% of patients should be discharged with ESD. Compliance improved to 40% in May. 11

12 Friends and Family Test % that would recommend the Trust In May 92.9% of patients that completed the Friends and Family Test said that they would recommend the Trust. National CQC Patient Survey An improvement in scores can be seen in most sections in the last survey compared with the previous year. The results for 2016 are expected in the summer of National annual patient survey The Right Time survey began in quarter 3 which asks some of the same questions as the CQC survey. Comparing the results of these questions we can see an improvement in the majority of section scores from the annual survey to the Right Time Q3 scores and a further improvement in Q4. 12

13 Productivity No. of patients per month cancelled on the day of surgery (all nonclinical reasons) Vs. No. of patients per month cancelled on the day of surgery due to delays or over-running A increase in on the day cancellations for non-clinical reasons is noted in May. There were 15 cancellations due to delays or over-running in May. Productivity No. cancelled operations due to bed availability There were 7 operations cancelled due to the lack of bed availability in May. Directorate breakdown of cancellations due to bed availability Surgery 3 Womens 3 Inpatients 1 13

14 Theatre productivity declined in May and remains below target. % of time lost due to late starts increased during May. Productivity Utilised Theatre Time and time lost due to late starts Within DSU, where the first phase of the Changing Care programme has been focused, the mean Theatre Utilisation and late starts have improved. In May Utilisation in DSU improved and a reduction in late starts is also noted. 14

15 Outpatient DNA rates remained above the target of <7.5% in May at 7.72%. Productivity Outpatient DNA rates DNA rates in Medicine and WCOHC are below the target of 7.5% in May. Surgery and Clinical Support remain above target. ENT and Urology have been working with Changing Care as part of the Outpatient Productivity programme. DNA rates in ENT have reduced in May, but remain above target. Urology DNA rates have increased, however remain below target. 15

16 Productivity Complaints relating to Outpatients Formal complaints increased in May. Complaints relating to outpatients reduced. Productivity Rescheduled Outpatient Appointments The Changing Care project in Outpatients aimed to improve the administration processes and reduce % of rescheduled appointments. The % of rescheduled appointments has improved to 8% in May. 16

17 Productivity The total Daycase percentage reduced in May to 88.3%. Total Daycase rate (%) Vs. Failed daycases (%) The Failed Daycase rate decreased in May to 3.27%. 17

18 Efficiency Patients cared for outside of specialty The percentage of patients cared for outside of specialty increased to 17.9% in May Divisional breakdown of patients cared for outside of specialty M&UC 13.1% Surgery 28.8% WC&O 39.5% Decline in early discharges in May to >6% lower than the 25% internal target. Productivity Discharges before midday Divisional breakdown discharges before midday M&UC 19.0% Surgery 16.3% WC&O 19.4% Decline in early discharges at the weekend to below the internal target in May. Early weekday discharges remain 7% below target. 18

19 Productivity Medical notes available for clinics Performance improved to 97.9% in May. Divisional breakdown of medical notes available for clinics M&UC 96.7% Surgery 98.6% WC&O 97.6% Productivity Complaints responded to within agreed timescales The MQC project aims to increase the percentage of complaints responded to within agreed timescales. An improvement was seen in May, but remains below target at 83%. 19

20 Nursing Productivity Staff attrition and sickness rates Staff attrition increased to 7.11% in May, but remains below the national benchmark. Sickness also increased during May to 3.7%, however remains below the National Benchmark. Nursing Productivity Agency, Bank and Substantive Supply % for RNs The % of substantive RNs has declined to 81.22% in May. This has led to an increase in Bank to 14.12% and a reduction in Agency to 4.65% in May. Nursing Productivity Agency, Bank and Substantive Supply % for HCAs In May our HCA substantive supply rate decreased to 62.15%. Bank supply increased from 23% to 28% and Agency supply rates reduced from 9% to 6%. 20

21 Report suspended, awaiting substantive and budgeted WTE for Medical Staffing validation. Medical Productivity Shift Fill Rate In May: 7.31 WTE increase in Agency No requested shifts were filled by Bank or internally. Medical Productivity Reason for Agency, Bank and Overtime In May 93.8% of shifts where agency was requested was due to vacancies, 3.5% to cover maternity and 2.6% to cover sickness. 21

22 Quality Improvement Ongoing Projects The Quality Improvement team are currently supporting 49 projects and a further 6 have been sustained. Quality Improvement Project of the Month 10 minute conversation The QI project of the month for June is: 10 minute conversation The aim of this project was to improve communication for members of the Adult emergency team to ensure all staff always know their roles in the event of a cardiac arrest. A 10 minute meeting is held every morning, which has led to better coordination within the team and ensures there is always a well-defined team leader. This is an ongoing project and was presented the International Forum on Quality & Safety in Healthcare. It has also been shortlisted at the Patient Safety Congress in July

23 Nat CC SU2S Key National Target Changing Sign up to safety Metrics in Development Target - Further metrics for MQC projects to be added Quarter Q1 MQC Making Quality Count Quality Improvement Environmental Measures to be added Q1 Carter Carter Recommendations QP Quality Priority Environmental Measures 23