Quality Improvement Scorecard December 2016

Transcription

1 Mortality: HSMR Nat The improvement in performance has been maintained in year. NB: Each month is a 12 month rolling value. I.e. Mar-16 reports the average of Apr-15 to Mar-16. Mortality: HSMR (weekday) vs. HSMR (weekend) Mortality: HSMR Performance remained in the expected range going into Q2 2016/17. Mortality: SHMI (quarterly) An improvement in performance since 2014/15 (Q4) is acknowledged. Q3 2015/16 noted a further improvement and remains below expected levels. 1

2 Cardiac Arrests Ward-based cardiac arrests (coded as preventable calls) There was 1 cardiac arrest coded as preventable during November 2016: in Willow ward. The MET trial took place between 14 th and 25 th November Monday to Friday During this time there were no cardiac arrests. Peri-arrests Peri-arrest calls wards only There were 35 peri-arrest calls during November 2016 for patients triggering EWS >5 or patients identified as code red. The MET trial took place between 14 th and 25 th November Monday to Friday During this time there were 4 peri arrests, of these 3 would not have triggered (non Vitalpac areas) and 1 patient had just been admitted. 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 decreased to 3.16% in November. The percentage of Critical Risk Patents with a Care Plan in place improved in November to 73.68% Early Warning Score % of overdue observations Overdue observations for the Trust improved in November to 7.16%. 3

4 The CQUIN was extended for 2016/17 to include inpatients as well as those in A&E. Sepsis Treatment Sepsis screening, time to administration of antibiotics and antibiotic review Audit monitors (1) the % of patients with EWS 3+ & who meet SIRS criteria, that are screened, then (2) the % patients with red flag sepsis given antibiotics within 60 minutes (A&E) / 90 minutes (Inpatients) AND having an antibiotic review within 3 days. Note: Compliance for antibiotic administration and review is higher when reviewed separately. Combining them, as we are required to for the CQUIN, pulls the % down. Board to Ward Monthly Executive Safety Rounds by Trust Board Members No Executive Safety Visits were completed in November, therefore the total remains at 56 for the year. 4

5 14 Grade 2 pressure ulcers in November an increase of 7 from last month. Pressure Ulcers Reduce hospital acquired pressure ulcers No Grade 3 pressure ulcers in November. Four learning sessions for the Pressure Ulcer Collaborative have taken place. Pressure Ulcers reduced each month following the Cultural Web in July, until the increase in November. 5

6 Harmful Falls Reduce harm from patient falls Number of falls per 1000 bed days reduced from 1.21 in October to 1.18 in November, this equates to 26 harmful falls in the month. Pain Management Patients receiving appropriate pain management Reduction in Pain evaluated and documented to 97%. Increase in Overall Pain Score to 99%. Omitted Medicines Reduce percentage of omitted medicines (not documented) Omitted medicines improved to 3.23% in November, below the target of 7% 6

7 WHO Checklist Percentage of operations where WHO safer surgery checklist is being completed Monthly audit taken from Nexus from October. Compliance declined further in November to 80%. Improving transfers/handover of care Patient risk assessment completed for out of transfers 70 OOH transfers in November, 61 (87%) had a patient risk assessment completed. LFE for Clinical Teams Learning from Errors training The percentage of Nursing and staff attending LFE sessions continued to improve in November. 7

8 Reduce stillbirths & undiagnosed small for gestational age babies Carbon monoxide measurements taken In November 58% of women had a CO measurement taken at their booking appointment. VTE Risk Assessment Documented risk assessment for VTE % of patients with documented risk assessment for VTE dropped further below the National Quality Requirement to 94.0% in November. Hospital Acquired Thrombosis Number of HATs following RCA There was 1 HAT in September 2016 following root cause analysis. 8

9 Time to Consultant Review EAU & Benham Time to First Consultant Review All emergency admissions should be reviewed by a Consultant within 14. On EAU & Benham average of 37% at night being seen within 14 and 28% during the day seen within 8. Improvement in performance in November is noted. Leadership Training & Development Participants in leadership programmes During 2016/17 there have been 63 MCQ participants, 7 MQC projects and 350 participants in the LOVE programme. The second cohort for the Francis Crick programme is due to start in January. 9

10 Dementia Carers Survey Dementia carers that feel supported The % of dementia carers that took the survey and said they feel supported increased to 88% in November Intentional Rounding % that answered yes to three questions regarding care rounds Increase in care rounds documented according to current guidance and staff asking care round questions every 1-2 in November. Heart Failure Number of patients discharged with primary diagnosis of heart failure Vs. Referrals to Heart Failure Data shows a gap between the number of patients discharged with Heart Failure and those being referred to the Heart Failure Team. 10

11 The % of stroke patients reaching a stroke bed within 4 dropped below target in November to 74%. Stroke Care The % of patients scanned within 1 hour of arrival is consistently above the target of 50%. Caring for Stroke patients It is aimed that 85% of stroke patients spend at least 90% of their time on the stroke unit, in November 88% was achieved. 100% of patients in AF are discharged on anti-coagulation. 40% of patients should be discharged with ESD, compliance improved to 46% in November. 11

12 Friends and Family Test % that would recommend the Trust In November 92.3% of patients that completed the Friends and Family Test said that they would recommend the Trust. National CQC Patient Survey National annual 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

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 An increase in on the day cancellations for non-clinical reasons can be seen in November. There were 16 cancellations due to delays or over-running in November. Productivity No. cancelled operations due to bed availability There were 20 operations cancelled due to the lack of bed availability in November. Directorate breakdown of cancellations due to bed availability O&G 12 Surgery 7 H&N 1 Productivity TTOs sent by Taxi There were zero TTO s sent by taxi in November. 13

14 Productivity Utilised Theatre Time and time lost due to late starts Theatre productivity declined in November. % of time lost due to late starts improved in the month. Productivity Outpatient DNA rates Outpatient DNA rates remained the same in November and are above the target of <7.5% for the fifth consecutive month. Productivity Daycase rate (%) Vs. Failed daycases (%) The total Daycase percentage increased to 88.7% in November. The Failed Daycase rate reduced from 4.20% to 4.13% in November. 14

15 Productivity Complaints relating to Outpatients Formal complaints stayed at the same level in October. Complaints relating to outpatients increased. 15

16 Efficiency Patients cared for outside of specialty Reduction in month for patients cared for outside of speciality is noted. Divisional breakdown of patients cared for outside of specialty M&UC 14.4% Surgery 25.6% WC&O 11.4% Productivity Discharges before midday Overall decline in early discharges in November, >6% lower than the 25% internal target. Divisional breakdown discharges before midday M&UC 18.4% Surgery 19.6% WC&O 18.4% Productivity Medical notes available for clinics Improvement in performance in November to 97.5%. Divisional breakdown of medical notes available for clinics M&UC 97.0% Surgery 97.9% WC&O 97.3% 16

17 Nursing Productivity Staff attrition and sickness rates Staff attrition increased to 9.68% in November, above the national benchmark. Sickness remains below the National Benchmark. Nursing Productivity Agency, Bank and Substantive Supply % for RNs In November 87% of our RNs were substantive members of staff, an improvement from October. This led to a reduction in agency to 4% and bank remained at 10%. Nursing Productivity Agency, Bank and Substantive Supply % for HCAs In November 72% of our HCAs are substantive staff, an increase from October. This led to a reduction in Bank and Agency supply rates. 17

18 Safe Staffing Levels Ward name Registered midwives/nurses planned staff Day actual staff planned staff Care Staff actual staff Registered midwives/nurses planned staff Night actual staff planned staff Care Staff actual staff Day Average fill rate - registered nurses /midwives (%) Average fill rate - care staff (%) Night Average fill rate - registered nurses / midwives (%) Average fill rate - care staff (%) Key: Below 80% Shift Fill Rate Target 80% and Above Shift Fill Rate Target Care Hours Per Patient Day (CHPPD) Cumulative count over the month of patients at 23:59 each day Registered midwives/ nurses Care Staff Overall Actions/Comments Red Flag Abington 1, , , , , , , , % 103.4% 100.2% 113.1% x Shortfall of 25% or more of planned RN on shift Last minute sickness, escalated when notified - care prioritised no harms highlighted Allebone 1, , , , , , , % 138.8% 99.2% 158.8% Althorp % 97.5% 95.1% 116.3% Becket 1, , , , , , % 97.7% 95.3% 105.0% Benham 1, , , , , , % 158.4% 100.6% 197.0% MATERNITY COMBINED UNIT: Sturtridge, MOW, Balmoral & Birth Centre 6, , , , , , , , % 83.7% 96.3% 82.7% Brampton 1, , , , , , , % 108.3% 100.0% 168.1% x Other Staffing issues Patient care prioritised, escalated appropriately, no harm to patients Cedar 1, , , , , , , , % 109.9% 100.0% 123.3% x Unplanned omission in providing patient medications Patient care prioritised, escalated appropriately, no harm to patients highlighted Collingtree 2, , , , , , , % 107.8% 99.4% 148.3% Compton 1, , , % 143.2% 100.1% 210.9% Creaton 1, , , , , , , % 115.2% 98.9% 166.1% CHILD HEALTH COMBINED: Disney, Gosset & Paddington 7, , , , , , , , % 87.9% 92.1% 95.7% Dryden 2, , , , % 100.0% 102.0% 106.4% x Other Staffing issues please provide narrative within the description Patient care prioritised, escalated appropriately, no harm to patients 18

19 Safe Staffing Levels Ward name Registered midwives/nurses planned staff actual staff Day planned staff Care Staff actual staff Registered midwives/nurses planned staff actual staff Night planned staff Care Staff actual staff Day Average fill rate - registered nurses /midwives (%) Average fill rate - care staff (%) Night Average fill rate - registered nurses / midwives (%) Key: Below 80% Shift Fill Rate Target 80% and Above Shift Fill Rate Target Average fill rate - care staff (%) Care Hours Per Patient Day (CHPPD) Cumulative count over the month of patients at 23:59 each day Registered midwives/ nurses Care Staff Overall Actions/Comments Red Flag EAU 2, , , , , , , , % 164.3% 100.8% 133.9% Eleanor 1, , % 106.4% 100.0% 113.3% Finedon 2, , , , % 87.9% 100.0% 113.3% Hawthorn 1, , , , , , , % 99.3% 100.1% 109.2% Head & Neck 1, , % 95.9% 96.7% 138.4% Holcot 1, , , , , , , % 121.2% 100.0% 251.3% ITU 6, , , , % 98.8% 97.3% 115.6% Knightley , % 107.1% 91.7% 166.8% Rowan 1, , , , , , % 100.9% 100.1% 131.7% Spencer % 126.0% 102.5% 155.5% Talbot Butler 2, , , , , , , % 82.0% 74.9% 151.2% The numbers of HCA increased on night duty increased to support patient care due to RN ongoing recruitment. Staffing monitored daily by the Matron and reallocation as required. Victoria 1, , % 130.3% 99.9% 213.3% Willow 2, , , , , , % 110.6% 96.8% 130.1% x1 Other Staffing issues please provide narrative within the description Investigated internally. Escalated appropriately at time, support sent and further problems occurred. care prioritised no harms occurred. 19

20 Report suspended, awaiting substantive and budgeted WTE for Medical Staffing validation. Medical Productivity Shift Fill Rate In November: 4.77 WTE reduction in Agency 0.03 WTE increase in Internal Overtime 3.05 WTE increase in Bank staff Medical Productivity Reason for Agency, Bank and Overtime In November 96.9% of Medical Agency, Bank and Internal overtime was due to vacancies, 3.1% was to cover sickness and 0.70% to cover holidays. 20

21 3 rd Party Outpatient Dispensing Dispensing prescription waiting times 30 mins : performance has remained above the required performance level of 95% over the last 12 months. 15 mins: There was an increase in performance in November to 76.5% 3 rd Party Out Patient Dispensing Dispensing errors related to the number of dispensed items There was 1 dispensing error during November. 21

22 3 rd Party Outpatient Dispensing Number of genuine complaints received by the supplier during quarterly period There were zero complaints received in November There have been zero complaints over the last 12 months. If the supplier fails to meet this service level of 2 or less complaints per quarter, the instalment of the Operational Service Charge shall reduce by 5%. 3 rd Party Out Patient Dispensing Monthly availability of medicines to patients in full at the time of presentation of prescription. Monthly availability of medicines was 99.5% in November. 22

23 Nat CC SU2S Key National Target Changing Sign up to safety Metrics in Development Target QP - Deliver Reliable and Effective Care Ventilated acquired pneumonia Quarter Q3 IQET Improving Quality & Efficiency Team MQC Making Quality Count QI Quality Improvement Carter Carter Recommendations QP Quality Priority 23