Quality Dashboard October 2013 Legend/Key: Forecasts: raph Legend: Target Type: N National R Underachieving C CQUIN Standard L Local Shows whether next month's position will meet standard Performance Mean Control Limits 0
NUH at a lance (1/2) Clinical Effectiveness Patient Safety 2013/14 National Clinical Audit Participation (1) (Numerator: Eligible National audits. Denominator: NUH participating). 2013/14 Participation in External Best Practice Reviews (Numerator: External best-practice reviews in which NUH is participating. Denominator: External best-practice reviews for which NUH is eligible) 2013/14 Response to External Best Practice (Numerator: Number of external best practice reports NUH has responded to. Denominator: Number of external best practice reports NUH should respond to 2013/14). Summary Hospital-level Mortality Indicator (SHMI)- October 2011 - September 2012 HSMR [basket of 56 diagnosis] HSMR [all diagnoses] Eligible patients having Venous Thromboembolism (VTE) risk assessment No patients acquire MRSA bloodstream infection caused by our care Fewer than 74 patients acquire C. Diff in our care (<6 per month) (2) Patients screened for MRSA (Elective, Emergency and Daycase) Rate of falls per 1000 occupied bed days (3) Rate of falls per 1000 occupied bed days resulting in harm Target Set 95% Jul 48% 48% N 100% Sep 100% 100% L 100% Sep 100% 100% L 100 Jul 0.93 0.93 N 100 Jul 100.7 104.3 L 100 Jul 104.3 105.5 L 95% Sep 94.9% 94.9% N & C 0 Sep 1 2 N & L 6 Sep 11 55 N & L 98% Jun 100% 100% N 6.2 Sep 5.69 6.05 C 2.1 Sep 2.03 2.41 C Ratio of falls per faller per 1000 occupied bed days 1.26 Sep 1.25 1.27 C Harm event rate /1000 occupied bed days (4) TBA Sep 21.1 21.1 L Patient Safety Conversations CLINICAL OUTCOMES Unvalidated Stage 2 Total Pressure Ulcers (5) Validated Stage 2 Avoidable Pressure Ulcers Unvalidated Stage 3 Total Pressure Ulcers Validated Stage 3 Avoidable Pressure Ulcers 4 Sep 4 23 L 50 Sep 83 390 C 50 Sep 20 142 C 0 Sep 11 64 C 0 Sep 0 33 C Unvalidated Stage 4 Total Pressure Ulcers 0 Sep 0 2 C Validated Stage 4 Avoidable Pressure Ulcers 0 Sep 0 2 C Medication errors per 1000 bed days (6) Standard Standard not defined Current data month Month Actual YTD (April- March) Sep 4.93 4.68 - Trend LEEND 1- DoH Quality Accounts List for 2013/14 published. Monitoring to begin in October against eligible audits- 48 for NUH. 2- The C diff testing methodology changed in August 2011 and again from 1st April 2012 3- Quarterly report on falls presented to Trust Board 4- Harm event rate - Trust wide case note review during September. Suggest bi annual case note review, to support other intelligence in identifying areas of focus for patient safety work programme. 5- Quarterly report on pressure ulcers presented to Trust Board. 6- Standard under review with Chair of Medicines Safety roup. Annual Medicines Safety report to November QUAC. To agree measure and standard following presentation of report. 7- The proportion of harm free patients with no new Safety Thermometer defined harm events whilst under our care at NUH. 8- Target of 75 to be implemented January 2014. 9- Target to be set in line with national guidance when available Harm-free care (Safety Thermometer) (7) 90% Sep 94% 94% C Clinical and Organisational Risk 100% Sep 100% 99% L SI investigations completed within given timeframe (60/45 days or as agreed with commissioners) 0 Sep 0 0 L Never Events CAS alerts on target with delivery timescales 100% Sep 93% 88% N 1
NUH at a lance (2/2) CLINICAL OUTCOMES PROMS: Hip and Knee replacement patients reporting better general health after surgery How likely are you to recommend our ward to friends and family if they needed similar care or treatment? Sample size: How likely are you to recommend our ward to friends and family if they needed similar care or treatment? How likely are you to recommend our A&E department if they needed similar care or treatment? Sample size: How likely are you to recommend our A&E department if they needed similar care or treatment? Standard Current data month Month Actual YTD (April- March) Target Set 54% Sep 96% 86% L 68.0 Sep 79.0 77.0 L 38% Sep 40.6% 37.7% C 68.0 Sep 70.2 70.0 L 20% Sep 22.6% 16.6% C Trend Patient Experience Did you feel safe during your stay in hospital? How likely are you to recommend the support our ward gave to you as a Carer (of patients with dementia) to friends and family if they needed similar support? How likely are you to recommend the support our ward gave to you as a Carer to friends and family if they needed similar support? Did doctors talk in front of you as if you weren t there? (High score is good-weighted score based on No and Yes sometimes responses) Were you involved as much as you wanted in decision about your care and treatment? Did you feel you had enough emotional support from hospital staff during your stay? 95.2 Sep 95.9 95.8 L 57.0 Sep 78.6 65.6 L 63.0 Sep 74.3 65.6 L 93.0 Sep 91.3 90.8 L 90 Sep 88.1 86.9 N 92.0 Sep 93.4 92.5 L Were you ever bothered by noise at night? (score reflects No responses) TBC Sep 67.0 72.8 L (8) In your opinion, how clean was the hospital room or ward that you were in? 93.2 Sep 93.4 93.6 L How clean were the toilets and bathrooms that you used in hospitals? 89.6 Sep 90.1 90.5 L 90% Sep 95.0% 93.3% L The staff were always friendly, caring and polite towards me? On the day you left hospital, was your discharge delayed for any reason?(score reflects No responses) 70.5 Sep 67.6 70.1 L Number of Involvement events demonstrating engagement, partnership working 30 Sep 43 424 L How likely are you to recommend the Outpatient Department to friends and family if they needed similar care or treatment? (9) TBC Sep 59.4 58.4 L How likely are you to recommend the Outpatient Department to friends 50 per and family if they needed similar care or treatment? Sample size Dept Sep 441 2417 L Outpatients: In the reception area, could other patients overhear what you talked about with the receptionist? (Score reflects No responses) 44.8 Sep 44.1 45.4 L Outpatients: Were you told how long you would have to wait? 53.6 Sep 48.2 49.8 L Outpatients: Were you told why you had to wait? Outpatients: Did someone apologise for the delay? Outpatients: Did doctors talk in front of you as if you weren t there? (High score is good-weighted score based on No and Yes sometimes responses) 55.9 Sep 56.2 56.4 L 69.3 Sep 72.2 70.8 L 96.0 Sep 93.2 95.1 L Information overnance Other Research and Development 100% Sep 89.8% 92.2% N Freedom of Information requests processed within 20 working days Subject Access Requests processed within 40 days 100% Sep 99.7% 95.6% N I incidents at or above Level 2 severity (target 2 per quarter) 2 Sep 5 13 L Mixed sex accommodation breaches Recruit 10,000 patients into high quality clinical trials in year 0 Sep 0 0 N 834 per month Sep 668 2617 N 2
Performance Escalation (1/14) VTE (2013-14) Numerator: Number patients assessed for VTE. Denominator: Number of eligible patients 100 95 90 85 80 75 70 65 60 55 50 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 Issues causing underperformance The two main clinical areas of non compliance are general surgery and trauma and orthopaedics. This has likely been contributed to by the commencement of new junior doctors. There has been a slight improvement on August data. CQUIN Target Overall Compliance Individually Assessed Latest performance 2013-14 94.94% Agreed corrective actions 1. MSKN/DDT Clinical Director monitors directorate speciality compliance/ actions via speciality performance meetings. Distribution of monthly VTE patient level data figures will increase to weekly to each consultant from September 23 rd. League table of speciality performance established to create competition to drive improvement. 2. DDT/ MSKN Clinical Director will identify the need for discussion of VTE at consultant ward rounds via Heads of Service. 3. VTE performance continues to be discussed at performance meetings with DMT and at October Directors roup. DCD s charged with continued work with their specialties to increase individual compliance 4. Patient Safety Newsletter (Sept) highlighted 1. requirement for assessment and 2. learning from RCAs around contributory factors to VTE events. 5. Contact being made nationally to seek further suggestions for driving improvement and sustaining compliance. Forecast 2013-14 reen Signed off by: Stephen Fowlie to meet standard: November 2013 Plan for next Board report: Monthly 3
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 Escalation Pages (2/14) No patients acquire MRSA bloodstream infection caused by our care Multi-discipliniary review of case led by Infection Control Doctor/ Microbiologist. Patient admitted with pneumonia. Known to be colonised with MRSA (recently an in patient in another hospital). Non adherence to screening and decolonisation protocol in relation to screening all wounds and commencing decolonisation treatment on admission for patients admitted from other healthcare facilities. Admission screen was negative, but positive from leg wound taken at day 4 of admission. Leg ulcer did not appear to be clinically infected and had not changed appearance during admission. Decolonisation treatment commenced but not all doses signed for by staff. Post Infection Review discussed at ICO in order to share learning across all directorates ( September 27 th 2013). Clinical Leads identifying whether prescription charts ( and administration of medications) are reviewed as part of Accountability around the Clock nursing handover. Clinical Leads identifying whether ward teams are aware that Nursing Assistants ( under supervision of Registered Nurse) can sign prescription charts when decolonisation treatment given and reinforcing this is appropriate practice. R Standard 93% Sep YTD Forecast 3 2 1 0 0 1 2 This target will not be met by year end Stephen Fowlie Tissue viability team involved with wound care and advice on dressings during patient stay. Some delay in obtaining specialised wound decolonisation dressings for leg wound as not stocked routinely in pharmacy. Microbiology identify that MRSA extremely difficult to clear from leg ulcers. No obvious source for the bacteraemia. The panel concluded that there were 2 possibilities 1) aspiration pneumonia or 2) from long standing leg ulcer. Specialised antibacterial wound dressings are now stocked at both campuses ( 14/09/2013). A Standard Operating Procedure is in development for dressing leg ulcers and leg ulcer infection ( which will include MRSA) with anticipated rollout in November 2013. eneral reminder to staff with regard to admission Screening and Decolonisation protocol ( version 9) Trust wide MRSA Bacteraemia Reduction Action Plan in place and actions on-going. Plan on track. 4
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 Escalation Pages (3/14) Fewer than 74 patients acquire C. Diff in our care (<6 per month) Weekly clinical case reviews by the Infection Prevention and Control doctor have identified no delays in diagnosis or specialist referrals Neither have any incomplete treatments or significant shortcomings in antibiotic use been evident. None of the cases have been secondary, linked, clustered or in outbreaks i.e. from cross infection ( one C Diff ribotyping result is outstanding for September) and there have been no C.difficile deaths. We have made substantial reduction in C. Difficile over the past 5 years. We have demonstrated that we now have a healthcare environment which is near-free from C. Difficile contamination, and that cross-infection with C. Difficile has been virtually eliminated. We have wiped out completely the 3 hospital outbreaks strains (ribotypes 027, 001 and 106), and the pattern of C. Difficile infection we now see is virtually identical to that seen in community onset cases. Our antibiotic stewardship is of high standard and continuing to improve, and we design our antibiotic guidelines around antibiotics that minimise C. Difficile risks. We have agreed with CC to focus on drivers for improvement for any potential further reductions (rather than solely target numbers). C diff cases lower year to date than in 2012/13 ( 55 v 70) There is a highly active C. Difficile programme at NUH which aims to reduce C. Difficile infection to the absolute minimum, including 2 separate weekly meetings looking in detail at each case in terms of epidemiology, risk factors, clustering, antibiotic use, treatment, and overall management. This is backed up by a comprehensive C. Difficile action plan New targets (quarterly increase in compliance level from Q2) for hand hygiene have been agreed and this has been rolled out and is monitored through ICO. We have agreed with commissioner colleagues a more sophisticated approach to measurement of our performance which focuses on the drivers for improvement namely an enhanced root cause analysis process, a rigorous approach to hand hygiene compliance and a limit to the number of cases caused by cross infection. We have demonstrated the achievement of all these criteria for quarter one performance. The trust and Clinical Commissioning roup colleagues have developed an approach to ensure the automatic reinvestment of 80% of potential financial penalties, on the provision that the criteria mentioned above are met. This will be transacted on a quarterly basis, with intentions for investing the remaining 20% to be discussed following the published Q3 performance. The Trust is in discussions with NHS England area team colleagues to replicate this approach across our specialised services contract. R Standard 93% Sep YTD Forecast 25 20 15 10 5 0 6 11 55 This target will not be met by year end Stephen Fowlie 5
Apr-13 Apr-13 Escalation Pages (4/14) Unvalidated Stage 2 Total Pressure Ulcers Investigation into the number of stage 2 unvalidated pressure ulcers has shown that staff appear to be over-reporting in that they are reporting skin issues that are not ulcers and will be later removed from the numbers. There is also a degree of duplication in the reports. Unvalidated Stage 3 Total Pressure Ulcers Work in being undertaken to review reporting and to help staff differentiate between stage 2 ulcers and other skin issues. Work continues to focus on skin assessments and repositioning of patients. The 'react to red' campaign continues. The sskin bundle continues to embed. Standard 93% Sep YTD Forecast 100 80 60 40 20 0 50 83 390 R This target will not be met by year end Jenny Leggott Standard 93% Sep YTD Forecast 0 11 64 R There are 11 RCAs outstanding. From the validated reports of stage 3 pressure ulcers, 4 have been removed as they were not stage 3 pressure damage, following RCA 3 are unavoidable, 2 pressure ulcers were avoidable 3 incidents reported during September have been raised by the community after the patients were discharged from NUH and date back to June / July RCAs show that avoidable pressure ulcers continue to be due to missed steps in care plans; skin assessments and repositioning of patients not having been performed in a timely manner. The new sskin bundle is in place and continues to embed. RCAs are reviewed at the weekly Pressure Ulcer roup. In addition subsequent RCA action plans now require formal discussion and sign off at the PUO chaired by the CEO or Deputy Director of Nursing. All actions plan are managed to tight timescales. Wards where there is no evidence of learning or improvement will be asked to attend PUO so that the group can understand any issues and help with resolutions. 20 15 10 5 0 This target will not be met by year end Jenny Leggott 6
Escalation Pages (5/14) % of CAS alerts on target with delivery timescales NUH process for managing alerts;- All alerts are robustly logged and reviewed at either ORC or CRC on a monthly basis. Where there are any gaps in delivery to fully meet the requirements of the alert, these are highlighted and actions agreed ( with timescales) to rectify. Where sufficient assurance is not received, key leads report to either committee for further discussions and as necessary support with actions to meet compliance and recorded in the minutes of the meetings. To further strengthen the arrangements any alerts which are likely to go over the due dates will be formally escalated to Directors roup (D) as part of the update reports from the Sub-committees of D. In September 14 alerts were due for completion, 13 of which were actioned within agreed timeframes. One alert is outstanding (NPSA/2009/PSA004 Part B All epidural, spinal (intrathecal) and regional infusions and boluses are performed with devices that use safer connectors that will not connect with intravenous luer connectors or IV infusion spikes. Deadline 1st April 2013 (as previously reported). There are a number of aspects to this alert, i)administration of medicine by epidurals- there are no non luer giving sets available for the type of infusion devices currently used at NUH. This necessitates NUH changing its infusion devices. ii) Caudal needles used to inject into the lower epidural space must have a non luer fitting. Currently there are no non luer caudle needles available nationally, iii) Luer locks for nerve block injections. Equipment to meet this aspect not yet available for procurement ( anticipate in next 6 months). iv) No non luer fittings available nationally for extra- ventricular drains. The Trust continues to progress this alert (as far as possible) led by a consultant anaesthetist The Trust Lead is discussing progress on national solutions with Professor David Cousins, National Lead NHS Commissioning Board The alert has been broken down into key parts and NUH aim to adopt each part when equipment and resources for implementation become available. Procurement tender process underway for infusion pumps ( 2-3 month process) to meet epidural requirement. Staff training will be required (around 6 months) NUH is dedicated to adopting the NPSA Alert in its entirety, but are currently hampered as some of the equipment is not yet available (example caudal needles, luer locks for nerve block injections and ventricular drains). Robust competency assessment in place for consultants and SPR administrating via ventricular route. CRC continues to monitor progress carefully against a detailed action plan. Current Risk assessment score of 10 agreed at the Clinical Risk Committee. The open alert is a national issue. Lack of available equipment prevents full closure of this alert Standard 93% Sep YTD Forecast 100% 93% 88% April 2014 in part Stephen Fowlie 7
Apr-13 Escalation Pages (6/14) Inpatients: Did doctors talk in front of you as if you weren t there? Standard 93% Sep YTD Forecast 93 91.3 90.8 This is an improvement target based on performance from Q1 Various actions by Directorates to include: This has been discussed at speciality and directorate governance meetings. The heads of service are now questioned on the at speciality performance meetings. We are asking the specialties to have these themes as a focus of the week so the junior doctors are engaged in changing practice. Consultants are to promote good practice within their teams during all consultations with patients. CD to inform Consultants of this requirement. 100 95 90 85 80 75 70 Variable by Directorate - Jenny Leggott 8
Apr-13 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 Escalation Pages (7/14) Were you involved as much as you wanted in decision about your care and treatment? Standard 93% Sep YTD Forecast 90 88.1 86.9 Directorate teams continue to examine root causes and develop action plans. Various actions by Directorates to include: As above and also ensuring staff in all areas have consent training/are up to date. Action plan into place which will include structuring ward rounds, nursing staff to perform follow-up discussions with patients to ascertain level of understanding. A trial of using a document by the bedside with key points from the nursing and medical plan of care to be conducted. 100 95 90 85 80 75 70 Variable by Directorate - On the day you left hospital, was your discharge delayed for any reason?(score reflects No responses) Jenny Leggott Standard 93% Sep YTD Forecast 70.5 67.6 70.1 This is an improvement target based on performance from Q1 Various actions by Directorates to include: Common reasons for delay are actively monitored e.g. TTOs, transport. These are feedback at a weekly capacity meeting and AHP have actions to address these issues 100 90 80 70 60 50 40 Variable by Directorate - Jenny Leggott 9
Apr-13 Apr-13 Escalation Pages (8/14) Outpatients: In the reception area, could other patients overhear what you talked about with the receptionist? This is an improvement target based on performance from Q1 We are reminding staff to use the private areas that are available when interviewing patients Standard 93% Sep YTD Forecast 70 60 50 40 30 20 44.8 44.1 45.4 March 2014 - Outpatients: Were you told how long you would have to wait? Jenny Leggott Standard 93% Sep YTD Forecast 53.6 48.2 49.8 This is an improvement target based on performance from Q1. In a number of out-patient areas patients are not attending just for a consultation. Many patients are attending for a scheduled treatment or procedure of some description which can present challenges in terms of managing a patient s pathway through the department as it can synchronising hospital transport. For many patients there can be a number of unforeseen preparatory and diagnostic tests. ED expected time to be seen displayed. We are looking into the best way to update patients in clinic 1 area H&N: In all of the out-patient areas staff are instructed to update patients and apologise for delays at 15 minute intervals. The nursing staff know to keep the reception staff aware of delays so that patients are told as they book in an attempt to manage expectations. 100 80 60 40 20 0 March 2014 - Jenny Leggott 10
Apr-13 Escalation Pages (9/14) Outpatients: Did doctors talk in front of you as if you weren t there? Standard 93% Sep YTD Forecast 96 93.2 95.1 This is an improvement target based on performance from Q1 Various actions by Directorates to include: Discussion at speciality and directorate governance meetings. The Heads of Service are now questioned on this at speciality performance meetings. We are asking the specialties to have these themes as a focus of the week so the junior doctors are engaged in changing practice. 100 98 96 94 92 90 Variable by Directorate - Jenny Leggott 11
Escalation Pages (10/14) % of Freedom of Information Act (FOIA) requests processed with 20 working days Standard 93% Sep YTD Forecast Background information Anyone has a right to request information from a public authority using the FOIA. The FOIA places 2 separate duties on NUH as a public authority to respond to requests: 1. To inform the applicant whether NUH holds the information falling within the scope of their request; 2. To respond by providing information normally within 20 working days The FOI Act is enforced by the Information Commissioner who can, where authorities repeatedly or seriously fail to meet the requirements of the legislation (or codes of practice), can take the following action: conduct assessments to check organisations are complying with the Act; serve information notices requiring organisations to provide the ICO with specified information within a certain time period; issue undertakings committing an authority to a particular course of action to improve its compliance; serve enforcement notices where there has been a breach of the Act, requiring organisations to take (or refrain from taking) specified steps in order to ensure they comply with the law; issue practice recommendations specifying steps the public authority should take to ensure conformity to the codes; issue decision notices detailing the outcome of the ICO s investigation to publically highlight particular issues with an authority s handling of a specific request; prosecute those who commit criminal offences under the Act. Description of Processes FOI requests are received centrally and allocated to the nominated FOI Lead for the Directorate or Department. FOI leads are advised of an internal deadline date which is 7 days in advance of the 20-day deadline. Continuous progress chasing emails and telephone calls commence a few days before the internal deadline until the signed off information is made available and approved by the Records Manager and or the Associate Director of Communications as appropriate. A further escalation procedure has been put in place from 7 th October 2013 (see standard escalation page overleaf). 100% 89.8% 92.2% R 12
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 Escalation Pages (11/14) % of Freedom of Information Act (FOIA) requests processed with 20 working days (cont.) There were 5 underperformances for September 2013: Reference No: (NUH 14895) (NUH 14905) Reason: Delay in response from FOI Lead. Delay in response from FOI Lead. A more substantial process for monitoring delays to FOI requests has been introduced from 7 th October 2013. Breaches of the 20 day deadline will be immediately brought to the attention of individual Executive Directors /Clinical Directors and the Director of ICT as Senior Information Risk Owner (SIRO). Parties will receive an email warning every 3 days once the 20 day deadline has been breached and until disclosure is made. Performance will continue to be monitored by the Information overnance Committee. Additional FOI training is in the process of being scheduled for FOI Leads who have not attended any formal training to date. No of working days delay (i.e. >20) Still outstanding (was due 24/9/13) Still outstanding (was due 25/9/13) Relevant Directorate: DIRC HEAD AND NECK (Ophthalmology) (NUH 297) Delay in response from FOI Lead 7 FINANCE Finance referring to Human Resources FOI Lead. (NUH 296) Delay in response from FOI Lead. 1 FINANCE (NUH 14737) Delay in response from FOI Lead. 6 CORPORATE (ICT Services) Standard 93% Sep YTD Forecast 100% 100% 95% 90% 85% 80% 75% 70% 89.8% 92.2% Immediate Immediate R Andrew Fearn 13
Escalation Pages (12/14) % of Data Protection Act (DPA) Subject Access Requests (SARS) processed within 40 days Standard 93% Sep YTD Forecast Background information SARs are requests for photocopies usually of patient s paper-based health records or copies of computer data made within the terms of the DPA. The DPA places a legal duty on NUH to process and disclose records for such requests with 40 days of receipt of a request. The vast majority of NUH SARs are submitted by solicitors acting for patients in 3 rd party litigation and relate to accidents, e.g. actions against employers, drivers etc. Numbers of SAR s received are subject to fluctuations and an unexpected temporary large increase as seen earlier this year in an action being taken by a large quantity of individuals all requiring SAR from NUH has a potential to cause a delay in processing. The DPA is enforced by the Information Commissioner who has available the following options to change the behaviour of organisations and individuals that collect, use and keep personal information: serve information notices requiring organisations to provide the Information Commissioner s Office with specified information within a certain time period; issue undertakings committing an organisation to a particular course of action in order to improve its compliance; serve enforcement notices and stop now orders where there has been a breach, requiring organisations to take (or refrain from taking) specified steps in order to ensure they comply with the law; conduct consensual assessments (audits) to check organisations are complying; serve assessment notices to conduct compulsory audits to assess whether organisations processing of personal data follows good practice (data protection only); issue monetary penalty notices, requiring organisations to pay up to 500,000 for serious breaches of the Data Protection Act prosecute those who commit criminal offences under the Act. Description of Processes 89.8% 92.2% Written requests are received by the Data Protection Administration Office (ICT Services), receipt is acknowledged by return letter, information requirements are researched, records retrieved, fees are requested and record are then copied and disclosed. All processes are administrated using Datix system. 100% 14
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 Escalation Pages (13/14) % of Data Protection Act (DPA) Subject Access Requests (SARS) processed within 40 days (cont.) Standard 93% Sep YTD Forecast 100% 99.7% 95.6% There was 1 underperformance for September 2013 which was as a result of a delay from the Treatment Centre to authorise a disclosure of TC records being processed on their behalf (under SLA). Arrangements initiated for alternative authorisations when main contact is on leave. 99% 94% 89% 84% Immediate Immediate Andrew Fearn 15
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 Escalation Pages (14/14) Recruit 10,000 patients into high quality clinical trials in year During the period April 2010-March 2013 NUH recruited a total of 26,592 patients in research studies. Some of these studies require labour intensive follow up (ranging from 2 to 10 years in some rare cancer studies). At the same time, there has not been a review of the resource allocated in directorates to support both existing and new studies. Poor recruitment is most likely the result of finite research resources and it appears that the majority of research time is taken up supporting patients already recruited in clinical trials rather than screening for new patients. The workforce change in pharmacy is impacting substantially on delays with cancer and clinical haematology trials recruiting patients. Radiology and medical physics remain a substantial cause of delays: Scheduled R&I meetings with DCS management were cancelled due to the change in CD therefore R&I currently have no escalation route within DCS. Performance management: R&I did not have access to Trent CLRN data prior to June 2013 in order to conduct meaningful performance management across the entire NUH research portfolio. We have now completed a detailed analysis of the data and are contacting clinicians who are not recruiting to target to investigate the reasons in detail and discuss a corrective plan of action. Action by 20 October 2013. Maria Koufali Escalation of performance issue to DCS CD Action by October 2013. Brian Thomson Directorate engagement: CDs and Ms are provided with monthly performance scorecards and with the support of R&I are developing improvement plans for recruitment. Action by 5 th Nov 2013 Maria Koufali Review of Trent CLRN resource allocation: in partnership with the CDs and Ms we will develop a reviewed bid to Trent CLRN for resource allocation for 2014/15 with the objective to support both existing studies and recruit to new ones. Action by January 2014 Brian Thomson These measures will take effect medium to long term. R Standard 93% Sep YTD Forecast 1200 1000 800 600 400 200 0 834 668 2617 Target unlikely to be met this year Stephen Fowlie 16
Appendix 1: National Quality Dashboard (1/1) Indicator Description Reporting Period National Average NUH Lowest 25% Highest 25% Summary Hospital-level Mortality As Mar-10- Dec-12 Indicator (SHMI) Expected Amenable Mortality ICD Codes Number of deaths as a proportion of all from ONS definition admissions 1.40% 1.70% 0.98% 1.81% Quality of Life for Adults with a Emergency admissions for patients with a LTC as a Long Term Condition proportion of all unplanned admissions 6.03% 6.04% 4.86% 6.84% Emergency admissions for under 19s due to Quality of Life for Under 19s with asthma, diabetes or epilepsy as a proportion of all a Long Term Condition unplanned admissions for under 19s 5.79% 4.30% 4.30% 7.34% Net Promoter Score [from NHS choices] Feb-13 25.30 23.73 A&E > 4Hrs [Type 1] Proportion of people waiting more than 4hrs in A&E w/e 15/09/13 3.07% 4.14% RTT> 18 weeks Proportion of patients on an admitted pathway waiting over 18 weeks 7.54% 5.09% Suspected Cancer Waits > 2 Weeks Readmissions within 30 days of discharge from index elective or emergency admission Emergency admissions for acute condition not usually requiring admission Proportion of patients who have suspected cancer who are seen by a professional more than 2 weeks after referral Number of readmissions to hospital within 30 days of discharge as a proportion of all admissions Patients with an emergency admission and with any of selected primary diagnoses as a proportion of all unplanned admissions Mar-13 5.66% 6.39% 17.34% 16.46% 9.05% 8.32% 7.82% 10.29% Infections Notified (MRSA, MSSA, C Diff & E Coli) per 1,000 beds Number of infections notified in a month as a proportion of inpatient bed days Mar-13 1.76 1.85 Serious Incidents (per 1,000 beds) Never Events (per 1,000 beds) Harm Free Care [No pressure ulcer, VTE, Catheter UTI, fall on safety thermometer ] Staff Sickness Bed Occupancy Nurses to Bed Ratio Doctor to Patient Ratio * National Quality Dashboard figures taken 04/10/13 Number of serious incidents notified in a month as a proportion of inpatient bed days Number of Never Events notified in a month as a proportion of inpatient bed days Proportion of patients surveyed not experiencing apressure ulcer, VTE, UTI in patients with a catheter or a fall Total number of days taken sick as a proportion of total days Average beds occupied overnigh' as a proportion of beds available overnight Number of nurses (Full Time Equivalent) as a proportion of number of beds available Number of qualified doctors (headcount) as a proportion of inpatient stays Mar-13 0.52 0.44 Mar-13 0.04 0.03 93.15% 92.87% Mar-13 4.15% 3.26% 3.61% 4.67% Apr-13 85.54% 82.42% 1.99 1.97 0.18 0.17 17
May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 Appendix 2: Friends and Family Test (1/2) The Friends & Family Test score has been obtained by asking patients a single question, How likely is it that you would recommend this service to friends and family? Based in their responses, patients have been categorised into one of three groups: Promoters (Extremely likely), Passives (Likely), and Detractors (Neither Likely nor Unlikely, Unlikely, Not at all, Don t Know). The number of Detractors is then subtracted from the number of Promoters and divided by the number of responses. Chart 1: Inpatient Friends & Family Test per Month Chart 2: Inpatient Friends & Family Test per Month 90 80 70 60 50 40 30 20 10 0 100% 80% 60% 40% 20% 0% 100 80 60 40 20 0 Detractors Passives Promoters Friends & Family Test score Table 1: Directorate Inpatient Friends & Family Test per Month and YTD May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 NUH 54.6 58.9 64 59.7 64 61 64 66 63 66 63 72.9 77.7 77.8 77.1 77.2 79 Acute Medicine 52 46 51 53 60 51 54 59 57 61 58 57 75 68 74 73 78.2 Cancer & Associated Specialties 87 84 93 84 78 88 84 77 81 89 84 87 87 86 88 89 82 Diabetic, Renal & Cardiovascular 74 75 75 77 81 73 80 80 79 83 77 73 72 84 77 86 84.8 Digestive Diseases & Thoracic 29 64 60 62 58 60 65 59 36 50 47 72 74 74 73 61 70 Family Health 53 51 53 43 55 47 51 51 56 48 58 81 82 85 64 71 85.4 Head & Neck 24 11 50 58 31 66 58 65 66 91 98 81 90 90 91 83 86.4 Musculoskeletal & Neurosciences 69 76 74 61 71 69 79 79 70 71 75 75 77 77 78 72 73.8 Unknown / Other 46 54 58 66 64 61 44 64 72 69 56 87.5 93 55 100 92 95.2 18
Appendix 2: Friends and Family Test (2/2) Chart 1: A&E Friends & Family Test per Month Chart 2: A&E Friends & Family Test per Month 74 100% 75 72 80% 70 68 60% 70 66 64 40% 20% 65 62 60 Apr-13 0% Apr-13 Detractors Passives Promoters Friends & Family Test score 60 Table 1: A&E Friends & Family Test by ED/Eye Cas per Month and YTD Apr-13 Total 65.1 67.4 71.2 72.1 71.6 70.2 ED 64.3 66.2 69.8 70.5 70.1 68.43 Eye Cas 80.4 87.5 75.3 77.3 80.1 79.69 19
Appendix 3: CQUINs (1/2) POD Ref Title Brief outline description Baseline Q1 Q2 Q3 Q4 Overview of progress as at end September 2013 Value Impact CQ001 1.1 Expansion of FFT to maternity services- reported Oct 2013 and Mar 2014. 1.2 Increased response rate- Mar 2014 greater than Q1 and greater than 20%. 1.2 Increased response rate- Mar 2014 greater than Q1 and greater than 20%. Mar 2014 above baseline Q1 36.50% 38.91% Apr-13 Q1 Baseline Number of promoters 1502 1423 1827 4752 1742 1552 1719 Number of detractors 71 43 70 184 61 62 54 Number of reponses 1994 1802 2309 6105 2213 1956 2144 Number of discharges 5792 5679 5263 16734 5586 5363 5275 Number of Don't Knows 32 27 52 111 32 27 37 1.1 Friends & Family Score 72.9% 77.7% 77.8% 76.2% 77.1% 77.2% 79.0% 1.2 Response rate 34.4% 31.7% 43.9% 36.5% 39.6% 36.5% 40.6% 290,725 387,633 290,725 CQ002 CQ003 CQ004 NHS Safety Thermometer - Harm Free Care - data collection on pressure ulcers, falls & catheter associated tract infections. 2.1 Data collection- reported every month and submitted quarterly. Dementia - screening for emergency admissions aged 75 and over, including finding risk assessment, investigation and referral to specialist servcies (FAIR). 3.1 Achieve an average of 90% or greater in each of the elements of the indicator each month for any three consecutive months Dementia - clinical leadership - named lead for dementia and appropriate training for staff. 3.2 Trust has a named lead clinician for the dementia training programme for the entire financial year Complete data submitted monthly 90% Dementia - supporting carers of people with dementia. 3.3 Undertake a monthly audit of carers of people with dementia Monthly audit of carers to test whether they feel supported- results to be reported to the reported to board Board Theatre safety: #1. Pre-list briefing - Q2 70%, Q3 80%, Q4 90% compliance across all elective lists. #2. Cultural survey - Q1 action plan, Q2 repeat survey, Q3 feedback results, Q4 evidence delivery programme of work. Named lead clinican Met Met 90% compliance with pre-list briefing by end of Q4 Q1 pre-list baseline Apr-13 Harm-Free patients 1472 1363 1400 1315 1330 1373 95.10% 93.28% 1,162,900 Sample size 1498 1451 1504 1416 1427 1464 Harm-Free Care rate 98.3% 93.9% 93.1% 92.9% 93.2% 93.8% Met Met Pre list compl. 70% >90% Not met. Will not be met in Q1 & Q2 2013-14, on track to be met from Q3. Proposed dementia screening roll out programme is as follows (based on where majority of emergency admissions nursed), to achieve 90% compliance: Oct Nov Dec Final system checks and w/c 14 equipment checks w/c 4 C31 w/c 2 C25 & E16 w/c 21 D57 w/c 11 RAU & SRU w/c 9 CCU, ACU & SSU Berman, Harvey 2 & w/c 28 B3 & LJU w/c 18 illies w/c 16 Fleming & Southwell w/c 25 C4, 5 &6 Dr Aamer Ali HCOP/ED liaison Prof Rowan Harwood HCOP/admission wards/medical education (alongside other HCOP consultants) Dr Rob Morris HCOP/dementia strategy Mrs Maria Bentley Clinical Lead (nursing) Ms Sara Deakin Practice Development Matron (nurse/ahp education) Audit in place (agreed with commissioners) Audit results reported monthly on Trust Board Report Integrated Performance Report for question - How likely are you to recommend the support our ward gave you as a Carer to friends and family if they needed similar support? Summary of results for quarter 2 available Training programme being rolled out and on track. Pre list briefing compliance over 90%. August 2013. 350 responses received. Feedback to theatre team leaders scheduled for 16th Oct. 465,160-348,870 77,527 232,580 484,542 484,542 CQ005 Patient s perceptions of safety in a hospital setting. Q1 Baseline, Q2 action plan, Q3 & 4 re-audit to assess progress with action plan Understanding patient perception of safety in hospital Q1 95.20% 96.13% Action plan in place. Q1 Baseline Did you feel safe during your stay in hospital? 95.2 96.5 96.7 95.9 775,267 20
Appendix 3: CQUINs (2/2) CQ006 Diabetes - Reducing the difference in length of stay between patients with and without diabetes (DIABETES) by one day. 6.1 For the financial year 2013/14 there should be a difference in LoS of 1.98 days or less Diabetes - reduction in insulin medication errors - audit March 2014. 6.2 Q4 performance should be at 80% error-free or above Apr-13 Mean LoS for diabetes patients 7.47 7.26 7.21 7.31 7.14 6.94 Mean LoS for non-diabetes 1.98 2.98 2.4 2.25 patients 5.37 5.02 4.81 4.61 4.91 5.13 387,633 Key 6.1 Actions: Difference in LoS 2.1 2.24 2.4 2.7 2.23 1.81 Insulin chart pilot completed 31/08/13, Insulin chart launched 30/09/2013 uidelines and protocols: Surgical guidelines ratified and uploaded on intranet 15/08/13 Practical insulin safety pen device training completed across both hospitals 16/07/13 Diabetes Specialist Nurse to support ward based training in post 15/09/13 Ward based education and training package launched Sept 13 roll out across 21 priority wards completed 31/03/14 Q4-80% error free E.learning safe use of insulin competency package launched for registered nurses in priority areas Audit 01/09/13 Nov Patient Focus group for people with diabetes held 31/08/13 387,633 Self-administration revised documentation launched 30/09/13 Linked up with NUH Mealtimes Matter initiative - guidelines to give insulin with meals 31/7/13 CQ007 Deteriorating patient (SEPSIS) - increase in proportion of patinets receiving all elements of steps 1-5 of the surviving spesis resucitation bundle (of all patients admitted to critcial care). 7.1 60% of patients to be receiving whole of sepsis resuscitation bundle by Mar 2014 End Q4-60% 62.69% 54.70% Quarter 2 has seen a disappointing drop in compliance with the requirements of the CQUIN, confirming our previous concerns that this year was about reliability and sustainability. The reason for the drop in compliance is not entirely clear but seems to coincide with the new trainee medic cohort starting in August. The Sepsis CQUIN team have now completed a number of improvement projects which we hope will get us back to where we were (and beyond): 1. A new sepsis website is now available on the intranet, offering educational information and links to other helpful sites. 2. The sepsis e-learning package is now live on NUH Learning. This will be used initially as a remedial training tool for areas that are under-performing or where an individual case is poorly managed. This package is also being made available to nursing and medical students through our sepsis education programme. 1,162,900 Number of X-Rays reported on within Timely X-Ray results to Ps 3 days. by Q4-90% 60% 70% 3 days 3232 3753 3679 2875 Number of X-Rays reported on within CQ008 5 days 3472 3949 3679 3291 Number of X-Rays requested 3485 3965 3679 3376 969,084 3 day compliance 92.7% 94.7% 100.0% 85% Timely X-Ray results to Ps 5 days. By Q4-95% 85% 90% 5 day compliance 99.6% 99.6% 100.0% 97% Milestones- reported within 3 days 60% 70% Milestones- reported within 5 days 85% 90% CQ009 Reducing harm - (focus in 6 ward / admission areas) EWS / Pediatric EWS adherence to policy. Were observations done at End Q4-75% 66.00% 69.60% 69.87% least 4 hourly? Reducing harm - was the EWS correctly scored and added up, based on the recorded observations? Reducing harm - where frequency of observations should have been increased based on EWS score, was this done appropriately? Reducing harm - were the nursing escalation interventions carried out where mandated by the EWS score? Reducing harm - were the medical escalation interventions carried out where mandated by the EWS? End Q4-95% 90.00% 82.00% 92.77% End Q4-35% 26.00% 42.60% 35.59% End Q4-35% 20.00% 22.00% 23.37% End Q4-35% 24.00% 21.00% 26.26% No. of patients audited 35 36 48 1. Were observations done at least 4 hourly? 25 22 37 Score 1 71.4% 61.1% 77.1% 2. Was the EWS correctly scored and added up based on the recorded observations? 33 34 43 Score 2 94.3% 94.4% 89.6% 3. Where frequency of observations should have been increased based on EWS score, was this done appropriately? 28.7% 44.5% 33.5% 4. Were the NURSIN escalation interventions carried out where mandated by the EWS score? 25.2% 32.6% 12.3% 5. Were the MEDICAL escalation interventions carried out where mandated by the EWS score? 37.8% 18.3% 22.7% Key Improvement Aims for Quarter 3: One further Nurse Educator post due to commence in October. Completion of comprehensive ward level consultation exercise by EWS Nurse Educators. Formulation of EWS Nurse Educator developed individualised ward area change strategy. Improved junior doctor project engagement through both educational strategies and new junior doctors patient safety group Improved Trust wide communication strategy 1,162,900 Total 8,721,753-348,870 To be redistributed from ambulance turnaround CQUIN 10 = 969,084 9,690,837 21