QUALITY REPORT PART A Patient Experience 1
Number of complaints Complaints and Patient Advice and Liaison Report 40 35 30 25 20 15 10 Total number of complaints received Number of complaints received Trendline 17 formal complaints were received in November. This compares to 28 in the same month last year. 7 related to outpatient areas and 7 related to ward areas. 2 related to the Emergency Department; 1 related to central appointment administration. 5 complaints were received for Medicine, 8 for Surgery and 4 for Women and Children. The 5 reasons for complaints were 9 (53%) clinical care and concerns, 3 (18%) staff attitude and behaviour, 2 (12%) admissions / transfers / discharge procedures, 2 (12%) appointments and 1 (5%) communication and information. Of those staff involved in the complaints, 10 (59%) related to medical staff. There were 15 further contacts received by the Complaints Team. These were resolved quickly to the complainant s satisfaction. The complainants then decided that a formal complaint was not required. These were logged as PALS contacts. There were 214 contacts with the PALS service at the RUH site: 128 required resolution; 74 requested information or advice; 8 provided feedback and 4 were compliments We are encouraging wards and outpatient departments to report the number of compliments they receive to PALS each month. This will enable us to provide a more balanced report on patient and carer experience. The top three subjects requiring resolution were: Communication and Information of the 45 contacts (35%) there were 11 contacts regarding difficulties in accessing outpatient services by telephone - this was across 8 departments in the Trust. There are no trends or themes in relation to the remaining 34 enquiries. Appointments of the 34 contacts (26.5%) were queries regarding outpatient appointments across 11 departments, for example waiting times and changes to appointment date. Clinical care and treatment of the 23 contacts (18%) none were attributed to a particular hospital service. 2
Nursing Quality Indicators Triangulation Chart - Exception Report (November data) Areas of focus - The full Triangulation Report is in Appendix A. wards have flagged this month: Two Respiratory ward This ward has flagged for the second consecutive month with day and night staffing Registered Nurse (RN) fill rate <90% due to RN vacancies, however HCA hours were increased to cover, particularly at night. Quality matrices to note are: Pressure ulcer x 1 Grade 2 (x 1 Grade 2 last month) Staff sickness RN 17.3% HCA 9.1% (12.2% and 10.8% last mth) Appraisal rates RN 50% HCA 77.8% (61.5% and 66.7% last mth) FFT score improved to 82 and 1 negative PALs (63 and negative PALS x 2 last month) Action being taken Long term sickness is being managed and staff are starting to return to work. Staff are deployed from other wards to cover and the ward has been allocated EU nurses which commence in January 2016. Cardiac ward This ward has flagged for the first time due to <90% RN fill rate on both day and night shifts although increased HCA hours at night to cover. The ward has RN vacancies and high RN sickness. Quality matrices to note are: FFT score 75, formal complaint x 1 Staff sickness RN 11.3% Appraisal rates RN 63.6% and HCA 54.5% Action being taken Long term sickness is being managed. Recruitment is active and 6 RNs recruited although not in post. Agency nurses are being block booked Staff are deployed from other wards to cover as required. HCA hours have been increased to cover, particularly at night. The Directorate has placed Cardiac nurse staffing on the Risk Register with these mitigating plans. Note: These 3 wards flagged the previous month, however their quality matrices have improved this month. Medical Assessment Unit (MAU) RN vacancies are still high (around 15.0wte) however staff have been deployed from other areas to cover. ACE and Combe ward (OPU) Both of these wards patient quality matrices have improved, however it is important to note that both these wards were closed for 2 weeks in November due to Norovirus. Ward quality matrices to overall: Nursing quality matrices have improved this month however it is important to note that up to 7 wards were closed due to Norovirus in this month starting from 11 th November onwards. Complaints and negative PALs (wards only) have gone down slightly this month Clostridium difficile x 4 cases (7 cases last month) Grade 2 Pressure Ulcers x 2 (5 last month) Nurse staffing Datix reports reduced this month from 29 ( 41 last month) The number of Falls are fairly consistent with last month, but note the change of interpretation/definition regarding moderate harms to major harms this month to comply with NPSA guidance. Recruitment update RN vacancies are around 80wte and recruitment remains very active with new starters in the pipeline and EU nurses starting Jan/Feb 2016. Trainee Assistant Practitioner applications exceeded expected numbers (48) with interviews being held 22 nd and 23 rd December for 15 posts on the wards. 3 5
QUALITY REPORT PART B Patient Safety and Quality Improvement Medicine Reducing length of stay Medical ambulatory care Stroke sentinel audit performance Venous Thromboembolism (VTE) 6 Patient Safety Priorities Deteriorating Patient including National Early Warning Score (NEWS) Sepsis Acute Kidney Injury (AKI) Venous Thromboembolism (VTE) Falls, Clostridium difficile 10 Executive sponsored projects of must-do s informed by business unit priorities, CQUIN or as a response to stakeholders Pressure ulcers, Discharge, Ward and outpatient accreditation, Medicines management, Critical Care, Diabetes, Dementia, Maternity (still birth and breastfeeding), Urgent Care (Ambulatory Care), Peri-operative 15 Divisional Safety Priorities Surgery Reducing length of stay Surgical ambulatory care (ESAC) Critical Care Integration with RNHRD specialties Women and Children Increased consultant obstetric cover - labour ward Gynaecology emergency pathway Acute paediatric flow Reducing neonatal readmissions to maternity Reducing full term admissions to NICU 4
Patient Safety - Acute Kidney Injury (AKI) Background Acute Kidney Injury has been established nationally as an area for improvement with National drivers such as National Think Kidneys campaign, NICE guidelines, National patient safety alert in June 2014, National CQUIN 2015/6. RUH has agreed a local CQUIN target with the CCGs. Current Status The CQUIN report for the second quarter has been submitted and awaiting response but expecting full achievement as compliant with all targets Project Support Manager appointed for 6 months to support the AKI work and started in November Baseline numbers for incidence of AKI at RUH have been established from the e alert average 64 patients a week, 250 patient a month 2/3 of patients with AKI were triggered from ED majors i.e. were admitted with AKI (similar to national data) Next commonest areas MAU, ICU, respiratory and cardiac wards Baseline data from July September 2015 (709 patients) demonstrates that 65% of these patients had AKI grade 1, 20% grade 2 and 15% grade 3 CCG representative joined steering group to link with care in the community Next Steps Test improvement ideas on cardiac and respiratory wards Awaiting IT linking E alert to discharge summary for patients with AKI. Mandatory information on AKI then included in discharge summary Outcome data from BIU to be obtained Developing patient information stickers linking with NBT as regional renal centre and national resources Awareness and Training Awareness campaign UR INE Trouble has been launched in November with cascade training of a simple 10 minute teaching tool and launch of U.R.I.N.E. bundle November training target was met of 100 staff since the beginning of November Bundle compliance Details of measures to demonstrate bundle compliance have been established Focused work now starting on pilot wards (cardiac and respiratory) Baseline measures being collected on these wards in November and December Improvement ideas to improve bundle compliance to be tested in January Work planned with radiology to standardise process for reducing AKI following contrast medium for imaging 5
Patient Safety - Acute Kidney Bundle 6
Patient Safety - Clostridium difficile Background The RUH target for Trust apportioned Clostridium difficile in 2015/16 is 22 cases. Clostridium difficile toxin positive stool samples taken 3 or more days after admission are Trust apportioned. Current Performance Analysis of the last 10 RCAs (September and October) Delay in sending stool samples in 7 cases Delay in isolation in 5 cases Missing stop/review dates for antibiotics in 4 cases Stool chart not commenced on admission in 1 case Cleaning scores below standard (2 amber, 2 red) Dirty commodes noted on two wards where the C diff infections occurred Actions Stool rules circulated to staff Posters on toilet doors to prompt patients to report diarrhoea Side room tool in use and regular contact between IP&C Team and Site Team Ward Pharmacists to check that stop/review dates are documented Stool charts to be completed from admission to MAU and SAU Cleaning issues to be addressed by the Cleaning Working Group Matrons and Ward sisters reviewing commode cleanliness regularly Trial of sporicidal wipes for commode cleaning Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actions: The C diff peer review took place on 19 November and was chaired by the Director of Nursing and Quality, B&NES CCG. Final report has not yet been received. Actions for improvement following the review include: Improved antimicrobial stewardship Timely stool sampling Improving cleaning of the environment and equipment by reviewing cleaning staff roles and providing effective materials for decontamination of equipment and environment Actual no cases CDI appeals (no lapse of care) Proposed trajectory 4 4 5 6 7 6 7 4 1 1 3 1 0 1 1 0 4 3 3 2 2 7
Accreditation Pressure Ulcers Programme Update Background The Accreditation Programme has been developed to recognise and incentivise high standards of care and reduce variation in practice at ward and department level. It also provides assurance that regulatory requirements including the Care Quality Commission (CQC) fundamental standards are being met and identify where any improvements in practice are required. Wards and departments are assessed against Key Performance Indicators (KPI) under the CQC domains (safe, caring, effective, responsive, well-led) over a period of 6 months. The assessment takes a tiered approach with wards initially being reviewed against performance indicators for Foundation level. These are minimum standards of quality and safety that wards are expected to achieve. The indicators for Foundation level include information on the number of incidents, safety briefings and handover, white board rounds, written complaints, the Friends and Family Test, compliance with Millennium assessments, compliance with key documentation and infection control audits, mandatory training and staffing standards. Next steps Outpatients Accreditation Outpatient departments are being mapped against KPIs Foundation level. An observational audit has also been undertaken in each outpatient area. The findings from the assessment will be presented at the Outpatient Steering Group in January 2016. Maternity and Paediatrics Accreditation KPIs for Foundation level have been agreed with Maternity and Paediatrics. Assessment to be completed in January 2016. Ward Accreditation: Bronze level The KPIs for Bronze level have been agreed. The assessment includes further indicators including observations of care and unannounced visits. An observational audit tool has been developed which is currently being tested. This is an extensive assessment and it will require a team of staff to undertake the observations of care. It is proposed that the Bronze level assessment will be undertaken as part of the planning for the CQC inspection of the Trust. It is anticipated that this will be completed by February 2016. Current Performance To date 19 adult wards have achieved accreditation at Foundation level. There are 4 adult wards that have not yet achieved Foundation level. The senior sisters of these wards have been given support with developing an improvement plan and will be reassessed between December 2015 and March 2016. The Emergency Department have also achieved accreditation at Foundation level. 8
Number of falls per 1,000 bed days Number of falls Number of falls Patient Safety Falls Background Reduction in falls is one of the Trust s safety priorities. All ward areas, including the RNHRD site, have an identified ward falls lead, with evidence of embedding of active falls prevention and management strategies. The targets for this workstream are a 10% reduction in the number of repeat falls (the same patient falls more than once) and a 25% reduction in falls resulting in moderate or severe harm. 350 300 250 200 150 100 50 0 2015 (falls) 2015 (cumulative) 2015 Target The Trust is above the trajectory for repeat fallers. There were 17 repeat falls in November 2015. However, this is within the monthly target of 19.7. Repeat Falls continue to be a high priority for reduction and are being addressed through the ward falls leads and individual ward action plans. Falls per 1,000 bed days 8 6 4 2 0 Repeat Falls 2015 Falls per 1,000 bed days HQIP 35 30 25 20 15 10 5 0 Falls resulting in moderate or severe harm (cumulative) 2015 (falls) 2015 (cumulative) 2015 Target The Trust is above the trajectory for moderate or major harms from falls. The Trust had a rate of 0.16 falls per 1000 bed days resulting in moderate/major/death. This is below the HQIP benchmark of 0.19 moderate/severe/death per 1000 bed days The Patient Safety Steering Group and the Falls Steering Group endorsed a decision to change the harm level arising from falls with serious injury, in line with National Guidance. Falls that were classified as resulting in moderate harm are now major harm. From November this will be reflected in all reporting. A Falls Leads study morning is planned for December 2015 to include national falls audit action plan, and development of falls training matrix Achievement of Falls CQUIN for Q2. There continues to be concentrated support to identified clinical areas to facilitate achievement of Q3. A quarterly report is produced which details progress to the work plan. The data from the falls care bundle audit is included to provide ward level data Presentation to Innovation Panel planned for December on use of slippers. Results suggest qualitative and anecdotal benefit. However data does not show a reduction in falls The Healthcare Quality Improvement Partnership (HQIP) proposed a benchmark of 6.63 falls/1000 bed days in October 2015. This replaces the previous NPSA benchmark of 5.6 falls/1000 bed days. 9
Patient Safety National Falls Audit Background The National Falls audit is funded through the Healthcare Quality Improvement Partnership (HQIP). The audit criteria are based on NICE guidance on falls assessment and prevention (2013) and delirium (2010) and National Patient Safety Agency (NPSA) guidance. Method A team of clinicians carried out the audit in May 2015, submitted the results electronically, and the national results were published in September 2015 Sample size was 30 patients who were admitted consecutively over 2 days. Results Organisational audit - the Trust was compliant with 23/35 standards. Clinical audit - The Trust achieved amber or green compliance with 13/22 standards. The results identified a number of areas of good practice and compliance. Low compliance and areas below the national percentage have been analysed. All results have been discussed at the Falls Steering Group and actions incorporated into the Falls work plan. Areas of low compliance and actions are summarised in the tables below. Organisational Standard Use of a delirium assessment and management plan Assessment of fear of falling Medication review and modification Evaluation of vision Provision of appropriate walking aids 7 days a week and access to safe footwear Bed Rail Audit Non-exec director with responsibility for leading falls prevention Action Addressed in conjunction with senior nurse quality improvement and CQUIN facilitator Action complete. Question now included in electronic assessment. Electronic application in pharmacy and ward level information being developed On Falls Care Plan. Included in training and emphasised to ward falls leads Admission areas have access. Trust-wide 7 day access is being reviewed by therapy lead. Access to safe footwear to be discussed at Falls Steering Group On Falls Work plan as planned action Currently not identified. Falls Steering Group to scope requirements Clinical Standard Cognitive assessment Continence care plan Lying/ standing BP recorded Falls Care Plan Written information provided Mobility aid within reach Call bell in sight/reach of the patient National % RUH % Action 57.9% 44% Admission documentation updated to include AMT 69.4% 30.8% Plan to review this care plan as part of wider review of RUH Care plans 16.1% 25%. Included in training sessions, included in root cause analysis recommendations, included in audits, intranet links with NEWS, and ward falls leads. 63.6% 51.7% The Falls Steering Group has agreed that all patients receive an initial electronic assessment. Following this a Falls Care Plan is not always required. In the sample, 83% of appropriate patients had a care plan present. The steering group is satisfied that no action is required and clinical staff are adhering to RUH guidelines and policy. 11.4% 0% Ensure all wards have supply of information leaflets via ward falls leads. Importance of documenting these actions emphasised in training, falls leads study morning, and individual ward meetings. 67.6% 53% Importance emphasised to therapists, ward falls leads and clinical teams through ward meetings and training. To be included in falls care bundle audit. 82.3% 79.3% Currently measured on comfort form audit. To be incorporated as part of falls care bundle audit The HQIP is planning a second audit in September 2016 after organisations have introduced interventions to improve services. An internal preliminary audit will take place prior to this to test the quality improvement measures that are in place or planned. 10
Serious Incident (SI) summary Current Performance During November, five Serious Incidents were reported. Four of these remain under investigation. The incidents have been discussed with the patient and/or their family and they are aware of the investigation, in line with the Duty of Candour framework. Date of Datix ID Summary Incident 09.11.15 37452 Fall resulting in a fracture 10.11.15 37603 Unexpectedly unwell at birth 03.11.15 37260 Fall resulting in a fracture 26.11.15 37988 Fall resulting in a fracture 27.11.15 38100 7 wards affected due to an outbreak of Norovirus 11
Serious Incident reports approved by the November Operational Governance Committee (OGC) Date of Incident Datix ID Summary Learning/ Recommendations 28.03.15 30694 Omission of medical alert Clinical staff need to be aware of how to obtain information on red drugs, which are drugs not included on the GP list, because they don t prescribe them; Clinical teams should make the consultant team aware of the admission of any patients. 06.06.15 32730 Patient fall resulting in an injury To review the use of over-bed tables without brakes in MAU; Encourage patients not to use over-bed tables as a means of support; Falls risk assessments to be undertaken within the agreed timeframe. 09.06.15 32783 Patient fall resulting in a fracture To comply with the falls care plan requirement for lying and standing blood pressure assessments; To review the delirium, pathway with the use of the falls care plan; To utilise the mental health liaison team for patients with delirium, for a standardised approach across the Trust. 17.07.15 34053 Patient fall resulting in a fracture The process for HCA s undertaking and documenting admission assessments requires review; Reinforcement of the falls care bundle within the RNHRD environment. 09.08.15 34768 Collapse following diabetic ketoacidosis For the Diabetes team to provide education to relevant clinical staff on the management of type 1 Diabetes in the elderly; To include Diabetes e-learning in the mandatory training matrix. 15.08.15 34914 Patient fall resulting in a fracture To share the report findings with the patient's GP and the CCG, to highlight admission criteria To review the criteria for moving staff when balancing staffing levels. 03.09.15 35574 Patient fall resulting in a fracture To consider the discharge of patients to their pre-admission place of residence, if awaiting long term plans for alternative accommodation/placement; To identify a lead in complex discharges, to ensure that issues that require action are not overlooked. 12
Number of overdue SIs Overdue Serious Incident Reports Summary 15 10 5 0 Apr May Jun Jul Aug Sep Oct Nov As of 30 November, there are 19 open Serious Incidents (SIs); of these, one is overdue. From September 2015, the timescale for completion of the investigation moved to 60 days, as per the NHSE SI framework, therefore some SIs are still measured against the previous timeframe of 45 days. The investigation has been concluded for ten of the open incidents and the reports will be submitted to the Operational Governance Committee for approval at the December meeting. A target of minimal overdue SIs by the end of the financial year (with the exception of HR investigations) has been agreed, supported by the post of Duty of Candour and Serious Incident Advisor, achieving this has proved difficult for the past few months, due to the competing commitments of the investigating managers. However, progress has been made in providing completed investigation reports, that are of a good quality, more rapidly. Trajectory Apr May Jun Jul Aug Sep Oct Nov Dev Jan Feb Mar Actual 12 11 13 4 6 9 8 1 Target 12 10 9 8 7 6 5 4 3 13