June 20161
Included this month: Pages: 4-9 Incident Repor ng Rates Pressure Ulcers Pa ent Falls Safety Thermometer Medica on Safety Radia on Incidents DNA CPR Audit 10-12 Mortality Rates Na onal Audits 13-14 Local Friends and Family Test Results Friends and Family Analysis 15-16 Complaints Dashboard Complaints Panel feedback 17 2016/17 Na onal CQUIN indicators 2
The Quality Report Execu ve Summary: Safe Four SI s were reported in June 2016. Full details can be found on page 5. The number of pa ent falls reported in June is under both the Trust target and the na onal target. The number of pressure ulcers has increased slightly when compared to the same month 12 months previously. The repor ng of medica on incidents has increased slightly this month. Work con nues to ensure that these incidents are inves gated in a mely manner. Effec ve The most recent SHMI mortality data shows that the Trust is performing as expected. Crude number of deaths for June 2016 was 143. HSMR is within expected limits. The results for the Na onal Care of the Dying and Sen nel Stroke Na onal Audit programme have been released and the Trust has performed well. An overview summary can be found on page 11. Caring The Trust con nues to perform well in regards to the na onal Friends and Family Test. Responsive Pa ents con nue to receive a response to either complaints or claims in a mely fashion. Well-led The Na onal CQUIN indicators for 2016/17 have been agreed and outlined on page 17. Further indicators will be added to the list as and when the details is agreed with the commissioners. 3
Safe Incident Repor ng Again there has been an increase in the total number of pa ent incidents reported this month. The Sign up To Safety Campaign aims to increase incident repor ng rates within the Trust and therefore this should be celebrated. NOTE : Apr 2015 to Apr 2016 totals have been revised to represent 'date reported' rather than date of incident to bring this report in line with na onal repor ng criteria. The number of incidents reported per 1000 bed days in June 2016 is higher than the number of incidents reported in the same month during 2015. Higher rates of incidents suggest a posi ve pa ent safety culture and so this increase is to be seen in a posi ve light. The percentage of incidents that result in severe harm or death in June is lower that to that reported in the same month during 2015/16. 4
Safe Serious Incidents and Never Events Serious Incidents (SIs) There were 4 SIs reported during June 2016: General One fall causing serious harm One Category 3 pressure ulcer One death of a pa ent following an aor c aneurysm One incomplete excision of tumour Never events There have been no Never Events reported in June 2016. 5
Safe Harm Free Care There has been an increase in the number of pressure ulcers reported this month when compared to the same spell last year. The incidence of pressure ulcers and moisture lesions con nue to vary across the year, whilst this last month sees an increase compared to 15/16 there is an overall slight reduc on in Category III pressure ulcers and Moisture Lesions. During the last 12 months, we have had no Category IV pressure ulcers, which is encouraging. The number of pa ent falls reported per 1000 beds days in June 2016 is below the na onal and local target which is excellent. The most recent data available from the Safety Thermometer shows that the Trust has achieved the 95% harm free care target. 6
Safe Medica on Repor ng A total of 176 pa ent related medica on incidents have been reported in June 2016 which is 29 more than the same month of the preceding year. A total of 2257 incidents have been reported between 1 April 15-30 June 16. Of those 1794 had been fully inves gated at the me of the produc on of this report. The graph to the le shows that, all medica on incidents reported in June 2016 have been graded as either insignificant or minor. The grading of incidents can change between being first inves gated and fully inves gated. For this reason only incidents which have been fully inves gated and given their final severity grading are depicted in this graph. However the data captured in this graph will be updated throughout the year as the number of incidents fully inves gated increases. 7
Safe Radia on Incident Repor ng For April 16 to June 16 there were 39 radia on incidents reported, an increase of 9 from the same me period of the preceding year. The number of incidents reported to the CQC in this me period has increased by two. The most frequently reported type of radia on incident reported since April 16 relates to overexposure, (n=14), followed by (n=12) incidents rela ng to equipment failure. There have been 5 near miss incidents reported, four reported incidents rela ng to geographical miss or wrong anatomy and on four occasions pa ents received an unintended exposure to radia on. 8
Safe Do Not A empt Cardiopulmonary Resuscita on Audit This reaudit of Do Not Attempt Cardiopulmonary Resuscitation documentation, in May 2016, followed three previous audits undertaken in January, May and December 2015. The reaudit u lised the same methodology as for the previous audits, involving the Clinical Governance and Risk Department (CGARD) and the Resuscita on Training Team. Wards were contacted on the morning of the audit to establish the total number of inpa ents in the Trust and how many of those pa ents had a DNACPR in place. Once the numbers of inpa ents with a DNACPR in place had been established, CGARD and the Resuscita on Training Officers a ended the appropriate wards and audited the medical notes and nursing documenta on for the respec ve pa ents. A second key area of focus was on documenta on to show that on all appropriate occasions, DNACPR decisions are made in conjunc on with the pa ent s partner / family. The graph below again demonstrates a slight improvement although clearly more improvement is needed in this area. One of the key areas iden fied for improvement from the previous audits was that all DNACPRs ini ated by Junior Doctors should be countersigned by the appropriate senior responsible clinician. The graph below shows that steady progress is con nuing to be made although there is s ll room for improvement. Further Ac on Discussion took place at the Resuscita on Commi ee in June 2016 and whilst con nued progress was being made, some concern was expressed at the pace of change. It was agreed that the results should be presented to the Clinical Risk Group and to seek the Group s advice on poten al methods to improve compliance moving forwards. 9
Effec ve Mortality Indicators In total there were 143 deaths reported in June 2016 which is slightly lower than the numbers reported 12 months previously (n=168). Summary-level Hospital Mortality Indicator (SHMI) The most recent SHMI results show that the Trust has scored 99 for a fourth consecu ve quarter. This remains lower that the na onal average and within the as expected category. Whilst the increase in deaths at the start of the year (highlighted in the graph above) will con nue to effect the SHMI score for some me, it is hoped that the reduc on in the crude number of deaths may bring the SHMI score down over the next 6 months. 10
Effec ve Mortality Indicators Hospital Standardised Mortality Ra o (HSMR) The most recent HSMR results show there has been a slight increase in HSMR for the month of February. However this increase is s ll within expected limits and is not sta s cally significant. Please note: HSMR results are based on clinical coding data. A pa ent s record is coded following either discharge from hospital or death. Therefore the HSMR score for each month will change slightly as more pa ents are discharged or die and the coding is completed. All fields in this graph are checked each month and updated to ensure the most accurate informa on is displayed each month. The bar chart to the right shows the overall HSMR score from April 15- February 16. The Trust has a score of 102 which indicators the same number of deaths as expected. A score of 102 places the Trust approximately in the middle of the Shelford group, with 4 Trusts scoring higher and 5 Trusts having a lower score. Historically the London Trusts have always performed well on the HSMR measure it is believed that this can be explained by their case mix (i.e. the number of elderly people in their popula on compared to other loca ons in the UK). 11
Effec ve Na onal Audits Na onal Audit/NCEPOD results released: 12
Caring Friends and Family Test The above graphs show that the percentage of pa ents who would recommend the Trust to their friends and family, (and the response rates) are similar to those reported in the same month last year. The tables below show the results of recent analysis undertaken by NEQOS. In the 12 month period April 15 March 16, NUTH s collec ons have mainly been via paper/postcard at the point of discharge (see table 1). The NEQOS analysis also shows that online ra ngs for the inpa ent FFT are, on average, 22 points lower (using the former net promoter scoring methods) than those ra ngs submi ed on postcards. Interes ngly na onally those organisa ons with the most responses collected at discharge scored 7% higher than all others (74 vs. 67). Na onally 70% of responses came from paper/postcard used at point of discharge, with three other modes accoun ng for a further 25%. Table 1: Mode of Newcastle Hospitals NHS FT FFT data collec on Table 2: Mode of Na onal FFT data collec on 13
Caring Friends and Family Test FFT: % Recommending inpa ent services FFT: % NOT recommending inpa ent services Friends & Family Test Results For the period April 2015-March 2015, the propor on of respondents at Newcastle who would recommend inpa ent services (98%) is be er than reported both across England( 95%), and the NHS England Cumbria and North East region (96%). The propor on of respondents at Newcastle who would Not recommend inpa ent services ( 1%) is be er than reported across England (1.5%) and the same as that reported for the NHS Cumbria and North East region ( April 2015-March 2016). 14
Responsive Complaints Management April 2015 to March 2016 15
Responsive The following innova ve tool for sharing key themes from complaints across the Trust : Complaints Management Source: Complaints Department, Pa ent Services 16
Well-led CQUIN CQUIN Indicators - CCG Origin Service Staff Health & Well-being Introduc on of health and well-being ini a ves Healthy food for NHS staff, visitors and pa ents Improving the uptake of vaccina ons for front line staff within providers Sepsis Screening Timely iden fica on and treatment for sepsis in ED Timely iden fica on and treatment for sepsis in Acute inpa ent se ngs An microbial resistance and an microbial stewardship Reduc on in an bio c consump on per 1000 admissions Empiric review of an bio c prescribing Na onal Na onal Na onal Acute & community Acute Acute CQUIN Indicators - Specialised Origin Service Op mal Devices (cardiac) Use of the right specifica on of device appropriate to pa ents clinical needs Enhanced Suppor ve Care access for Advanced Cancer Pa ents To improve access to Enhanced Suppor ve Care for pa ents with a diagnosis of incurable cancer. Adult Cri cal Care Timely Discharge Discharge from Adult Cri cal Care within 4h/24h of clinical decision to discharge Na onal Na onal Na onal Acute Acute Acute During 2016/2017 the Trust will be par cipa ng in the Commissioning for Quality and Innova on (CQUIN) ini a ve. The CQUIN payment framework enables commissioners to reward excellence, by linking a propor on of English healthcare providers' income to the achievement of local quality improvement goals. The tables to the le detail the na onal CQUINs in which the Trust will be par cipa ng. In addi on to those listed the Trust is also in the process of refining the details of several other locally derived CQUINS and a selec on of CQUINS linked to our Specialised Commissioners/ services. The detail of these, once finalised, will be included in future reports. CAMHS Screening for Paediatric Pa ents with Long Term Condi ons Improve screening for children with relevant long term condi ons Na onal Acute 17