NHS LANARKSHIRE QUALITY DASHBOARD Board Report June 2011 (Data available as at end April 2011)

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1 NHS LANARKSHIRE QUALITY DASHBOARD Board Report June 2011 (Data available as at end April 2011) INTRODUCTION This paper provides a monthly quality dashboard for NHS Lanarkshire. This is in line with the Healthcare Quality Strategy for NHS Scotland in focussing on quality ambitions of person centred, safe and effective care. The data used in the report has been extrapolated from the SPSP systems, information from audits, Datix, NHS Lanarkshire prescribing data and ISD. NARRATIVE SUMMARY For this month s report it was not possible to get figures on Occupied Bed Days from the new TrakCare system hence the Occupied Beds Days figure are estimates based on this time last year. Primary Care Measures New measures for cost effective prescribing are provided under the clinical effectiveness heading for primary care. These measures are available quarterly and show that currently NHS Lanarkshire is close to but does not meet the goals set for prescribing of low cost statins and antidepressants prescribed complying with the formulary. Hospital Standard Mortality Rates The data for Hospital Standard Mortality Rates up to December 2010 has been released. This shows a reduction over the period October 2006 to December 2010 in HSMR for Lanarkshire s acute hospitals of: Hairmyres -6.6% Monklands -10.7% Wishaw -11.7% Overall average (mean) reduction in HSMR for NHS Lanarkshire is -9.6%. Over the same period the reduction in HSMR for Scotland as a whole has been -6.0%. NHS Lanarkshire welcomes the reduction in HSMR to date but is ambitious to reduce HSMR further. Areas of work currently being progressed in NHS Lanarkshire are: Established a mortality review group led by the Medical Director Ongoing case note reviews to identify adverse events Work in relation to the identification of sick and deteriorating patients using the Modified Early Warning Score (MEWS) and testing key questions to identify patients who require additional interventions and support As part of the reduction of SABS, focused work has begun on improving central line management out with the traditional intensive / critical care areas Review existing HSMR data to identify unexpected deaths and undertake case note reviews Work in relation to sepsis and visits to other areas of best practice will be undertaken, with consideration also being given to a sepsis assessment tool as part of our early warning score Board Members should note performance against the quality measures is either in line with the compliance target or in the preferred direction of travel with the exception of: Risk Management Incidents Key Performance Indicators This continues to be a priority for the Risk Management team working in conjunction with operational units and some improvements are being made. Stroke Treatment Indicators The Stroke MCN has developed an action plan to coordinate action to address the new Heat Target of to improve stroke care, 90% of all patients admitted with a diagnosis of stroke will be admitted to a stroke unit on the day of admission, or the day following presentation by March This is monitored quarterly at MCN s Clinical Quality meetings and progress reports will be provided to the Acute Division s performance review. Medication Reconciliation Performed Improvements are being made in a pilot area where there has been a refocus in the improvement methodology used. 1

2 1. Quality Ambition: Person centred Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrates compassion, continuity, clear communication and shared decisionmaking. Progress on this ambition is measured through complaints quarterly reports, the Better Together national survey and ward patient experience survey information once this becomes available. These figures are subject to final checks and that any changes will be reflected in the 2010/11 annual complaints reports. Complaints Top Issues Raised in Complaints in Year to March 2011 Acute Care Issues Total 2010/11 Total 2009/10 Clinical treatment Staff attitude and behaviour Communication oral Family Health Services Year to date Total 2009/10 Clinical Communication / attitude Practice / surgery management Primary Care Hospital & Community Year to date Total 2009/10 Health Treatment Staffing Waiting Times 7 12 Complaints by Area Acute Clinical Division Total 2010/11 Total 2009/10 Emergency Medicine Surgical and Critical Care Women s, Cancer & Diagnostic Other (Medical Records, PSSD, AHPs) Primary Care H&CH and FHS Year to date Total 2009/10 North CHP South CHP Patient Stories May 2011 patient focussed care From attending the GP, I was referred to WGH radiology department for a bladder and kidney scan and received my appointment very quickly. The appointment came with clear information on what would be happening to me and instructions that I should follow. On arrival at the radiology department the staff at reception were very patient orientated. I waited no longer than 10 minutes when a WRVS lady called me and escorted me to the area that I was expected for the scan. Without this, I might have been lost in the very large department. My escort was extremely pleasant and avoided any anxiety or confusion for me in getting to the right place within the department. The clinical staff in the department all introduced themselves to me and again explained the procedure. When I asked questions they were honest and were able to advise me that further investigations would be necessary and again they explained what this would involve. A scope followed the following week again at WGH and the reception and clinical staff all identified themselves and explained each stage of the procedure fully. At the end of the procedure I felt that I had been involved in my investigations with a full report from the Consultant with all findings confirmed with my GP and made the next stages of investigation much clearer to me. At each stage, I found the environment clean and was confident about the clinical staff s infection control practice. Outside ward x it says 100% infection control, this is not the case and shouldn t be displayed. My relative has been infected by someone in this ward and I want this sign removed 2

3 during my time waiting in the changing cubicle I noticed that the floor was not clean at all..i explained about the cubicle and its condition to a lady from the office. She asked if I would take a seat and she would speak to someone.. someone arrived and apologised and the area was cleaned. Can you please pass my thanks and gratitude to the very helpful staff in your X-ray department. 2. Quality Ambition: Safety There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times. Progress on this ambition is measured through standardised hospital mortality ratios, SPSP unadjusted patient mortality rates, key performance indicators for incidents and critical incident reviews and HAI indicators. 2.1 Improve mortality by reducing the mortality rate for NHS Lanarkshire by 15% by 31 March 2013 (from a baseline of November 2007) Quarterly Hospital Standardised Mortality Ratios Data source: From December 2009 Information Services Division (ISD) has produced quarterly hospital standardised mortality ratios (HSMR) for hospitals participating in the SPSP. The baseline quarters are those from October 2006 to September The data used was linked SMR01 Acute inpatient and day case records and GRO death records. The outcome of interest was mortality within 30 days from admission. For case mix adjustment, ISD adapted an approach used by Dr Foster for England. This enabled ISD to make use of the availability of linked data in Scotland, so that the analysis could be patient-based (as opposed to spell-based) and could include deaths following discharge. Two charts for the HSMR data are provided for each hospital. The first chart show the hospital s HSMR against the Scottish average. The second chart is new and shows any underlying trend in the data using a regression line. The regression line shows a reduction in the HSMR across all three acute hospitals. The Board should look for NHS Lanarkshire to be at or below the blue line which is the Scottish average. 3

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6 The HSMR tables identify that Hairmyres Hospital HSMR rate has been consistently around the baseline Scottish SMR level. Both Monklands and Wishaw Hospitals have been higher however have been decreasing slowly. This in part may reflect the different services which are concentrated at the hospitals. One of the overall outcome measures of the SPSP is to demonstrate reduction in HSMR for each Board against its own HSMR baseline from November The charts below show the baseline period before the Scottish Patient Safety Programme commenced before the red line. The blue line after this is the regression line for the data. There has been a reduction over the period October 2006 to December 2010 in HSMR for Lanarkshire s acute hospitals of: Hairmyres -6.6% Monklands -10.7% Wishaw -11.7% Overall average (mean) reduction in HSMR for NHS Lanarkshire is -9.6%. Over the same period the reduction in HSMR for Scotland as a whole has been -6.0%. 6

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8 Percentage Unadjusted Inpatient Mortality (NHSL Acute Hospital) A complementary outcome measure to the HSMR produced through the SPSP is percentage unadjusted inpatient mortality. This is unadjusted for the NHS Lanarkshire population however it provides an indicator of trend. The table shows a compliance level of 1.87% based on the mortality rate baseline from November The Board should look for NHS Lanarkshire s unadjusted mortality to be decreasing and to be consistently below the red line by 31 March Improve patient safety by reducing unnecessary harm by 30% for NHS Lanarkshire by 31 March 2013 (from a baseline of November 2007) SPSP case note reviews are undertaken monthly at each of the Acute Hospitals to identify adverse events occurring during admissions using the Global Trigger Tool. A compliance level has been set of a 30% reduction in adverse events based on a 2007 baseline. The table show the adverse event rate has consistently been below this compliance level since October Comparison with the baseline may, however, be compromised as this was set by a separate group of clinicians using the tool for the first time. The Board should look for NHS Lanarkshire s adverse event rate to be reducing and below the red line. 8

9 2.3 Improve performance on NHS Lanarkshire incident key performance indicators Through the Risk Management Steering Group a set of key performance indicators (KPI s) have been agreed. They relate to incident grading, closure and investigation. Incidents are rated as low, medium, high or very high based on their impact / consequence and their likelihood to reoccur using the NHS QIS Risk Matrices. The KPIs sets out to inform the Board of the effectiveness of a component part of incident management at operational level in relation to incidents being verified, investigated and closed within a number of working days. The Board should look for the KPIs to be met. 9

10 The Risk Management team is working with operational services to improve performance in relation to undertaking critical incident reviews for high and very high incidences, as appropriate. Incidents graded as very high are exceptional and are considered on an individual basis. 2.4 Prevent healthcare associated infections Progress on this is measured by the reduction in the rate of Clostridium Difficile infections in patients aged 65, reduction all Staphylococcus Aureus Bacteraemia (including MRSA) cases as the related process measure of hand hygiene compliance and compliance with the peripheral vascular catheter and central venous catheter bundles. CDI rate per 1000 bed days The C Difficile Heat target for 2011/12 is to further reduce the rate of Clostridium Difficile infections in patients aged 65 and over so that by March 2013 NHS Board s rate is 0.39 cases or less per 1000 total occupied bed days. The yellow line show the target for 2010/11 which was met at the end of March The red line shows the new target rate. The Board should look for the rate to be below the red line. 10

11 SABs compliance against Heat target The SABs Heat target has changed in 2011/12 to be measured by a rate. The Heat target is to further reduce SABs so that by March 2013 NHS Board s SABs cases are 0.26 or less per 1000 acute occupied bed days. The Board should look for the rate to be at or below the red line. Compliance with hand hygiene This shows ongoing good performance across Lanarkshire with the compliance level of 95%. The Board should look for the percentage compliance to be at or above the red line. Compliance with Peripheral Vascular Bundles (PVC) The use and compliance with PVC bundles is a means to prevent healthcare associated infections. The PVC bundle involves staff: Checking to ensure the PVCs in situ are still required Removing PVCs where there is extravasation or inflammation Checking PVC dressings are intact 11

12 Considering removal of PVCs in situ longer than 72 hours Performing hand hygiene before and after all PVC procedures The Board should look for the percentage compliance to be at or above the red line. Compliance with Central Venous Catheter Maintenance Bundle (CVC) The use and compliance with CVC bundles is a means to reduce complications and has been applied initially for patients cared for in the intensive care units. The CVC bundle involves staff: Daily checking and recording of the need for a CVC Ensuring CVC dressing is intact and was changed within last 7 days Ensuring CVC hub decontamination is performed Performing hand hygiene prior to line maintenance and access Using chlorhexidine gluconate for cleaning site during dressing changes Using line carts and dressing change kits to standardise processes The Board should look for the percentage compliance to be at or above the red line. 12

13 3. Quality Ambition: Clinical Effectiveness The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. Progress on this ambition is measured through clinical quality indicators, stroke care and medicine reconciliation. 3.1 Clinical Quality Indicators (CQI s) Nationally three nursing clinical quality indicators (CQI s) have been developed as a result of Leading Better Care; Falls, Food Fluid and nutrition and Pressure Area Care. These CQI s are process indicators which measure aspects of nursing care such as assessment and interventions, the aim of which being to improve the quality of nursing care and promote patient safety. Acute inpatient wards report CQI data through the Lanarkshire Quality Improvement Portal (LanQIP). The Board should look for the percentage compliance to be at or above the red line. 3.2 Stoke Care (Admission to Stroke Unit, Swallow Screen, CT Scan and Aspirin) Stroke is the third commonest cause of death in Scotland and the most common cause of severe physical disability amongst adults. The Scottish Stroke Care Audit includes all hospitals managing acute stroke in Scotland and measures care against NHS QIS standards. The Heat target 2011/12 is to improve stroke care, 90% of all patients admitted with a diagnosis of stroke will be admitted to a stroke unit on the day of admission, or the day following presentation by March The Board should look for the percentage compliance to be at or above the dotted target lines. 13

14 3.3 Percentage of patients with medication reconciliation performed One of the outcomes of the Scottish Patient Safety Programme is to provide safe and effective medicines management (reduce adverse drug events). This is supported by establishing a clear reconciliation process at the interface between primary and hospital care. The Scottish Patient Safety Programme monitors patient s charts 24 hours after admission to determine if a list of the patient s home medicines is present and if changes to those medicines are documented. There are currently ongoing challenges with meeting the compliance level of 95%. The Board should look for the percentage compliance to be at or above the red line. 14

15 3.4 Compliance with cost effective prescribing in primary care chart label is wrong in the box (denominator and numerators I am getting this changed) Primary care clinical effectiveness is supported through the promotion of safe, effective, and economic prescribing in general practice. Progress on this is measured through compliance with prescribing of cost effective statins as a percentage of all statins prescribing and percentage of antidepressants prescribed complying with the formulary. NHS Lanarkshire s prescribing formulary supports cost effective prescribing in primary care with the aim of ensuring value for money in the use of NHS resources. The Board should look for the percentage compliance to be at or above the red lines. 15

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