COUNCIL OF GOVERNORS 14 TH AUGUST 20 PATIENT EXPERIENCE & QUALITY HIGHLIGHT REPORT 1. Improving the Patient Experience & Net Promoter Score 1.1. Background From April 20 organisations across NHS Midlands and East have been set a regional CQUIN. It is referred to as the net promoter score or the family and friends test. 1.2. Method Indicator 1 = to establish the question and base line result. This has been achieved. Indicator 2 = patient experience and commissioner reporting. Monthly Trust Board minutes must clearly demonstrate reporting of patient experience including the net promoter score broken down to organisational, speciality and ward level. Board actions and challenge relating to improvement must be demonstrated. Indicator 3 = organisations collate and review net promoter score on a weekly basis commencing quarter 2. Indicator 4 = performance improvement. A 10 point improvement in the score or maintenance of the top quartile performance throughout 20/13 is required. We asked 10% of our patients at discharge the following question: How likely is it that you would recommend this service to friends and family? We use the scale of 0 to 10 The responses are then mapped to the following scoring system: SCORE QUESTION SCALE POINT SCALE Promoters Extremely likely 10 or 9 Passive Likely 8 or 7 Detractors Neither likely or unlikely Unlikely Not at all Don t know 0-6 The percentage of Detractors is then subtracted from the percentage of Promoters to obtain a Net Promoter Score. (The passive scores are ignored). The information is collected by the customer experience team. Approximately 60 patients per week are asked the question upon discharge. This gives patients the opportunity to discuss anything else with a member of the team prior to discharge. The survey question is SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 1
asked in the same way. Six customer service staff, including the supervisor and senior officer, individually ask the question on separate days, i.e. each staff member is allocated a day. The wards are phoned for any impending discharges and the customer service staff visits and asks the question. The supervisor and senior officer randomly shadow the assistants to ensure consistency of questioning. The data is analysed weekly, looking for trends. 1.3. Target The target for SFHFT was set following collection of baseline data during April 20 and this is to maintain performance in the top quartile. Top quartile has been set by the Strategic Health Authority at 71% or above. This needs to be achieved each month. 0.2% of the CQUIN income quota is attached to this question. 1.4. Results The results for Quarter 1 have been as follows: April 94% May - 83% June 89% The Strategic Health Authority are in the process of analysing data and comparing it to how the data is collected. This information will be useful to help discover if there is an alternative ways to collect the data. Graph 1 below shows the monthly results per ward for April - June 20 Net promoter score per ward 100 90 80 70 Score 60 50 40 30 20 10 0 11 22 21 31 32 23 24 42 43 44 41 51 52 53 33 34 14 35 36 DCU Apr- May- Jun- Ward SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 2
Overall, the results for SFHFT have remained consistently high. It should be noted that sample sizes have to be taken into account, as it is difficult to survey the same number of patients per ward or the same numbers of patients each month as discharges vary. Below is the sample size per ward during June 20: Ward Specialty April May June 11 Orthopaedics 17 33 13 Trauma 11 14 9 14 Gynaecology 18 28 16 22 Trauma & Orthopaedics 5 8 7 21 General Surgery 19 22 31 General Surgery 6 17 32 General Surgery 4 20 16 23 Cardiology/CCU 13 27 8 24 Cardiology/Haematology 5 6 10 41 HCOP 1 7 2 42 Gastroenterology 10 9 43 Respiratory 7 11 9 44 Respiratory 13 8 3 51 HCOP 10 4 8 52 HCOP 16 4 6 53 Acute Stroke Unit 10 33 Diabetes/Gastroenterology 8 9 16 34 Diabetes/Endocrinology 9 9 10 35 Winter ward 7 6 23 36 Winter ward 30 5 0 DCU Day Case 17 40 23 The data is also analysed per service line: April 20 May 20 June 20 Trauma and Orthopaedics 97% 76% 89% Surgery 100% 71% 91% Cardiorespiratory 98% 87% 92% Geriatrics 94% 85% 94% Gastroenterology/diabetes 94% 76% 92% endocrinology Gynaecology 83% 75% 86% Winter wards 98% 100% 87% Day case 82% 95% 100% SFH Total 95% 83% 89% SFHFT is currently performing exceptionally well on the net promoter scores and is amongst the top 5 Trusts nationally. Last month out of a total number of 240 patients only 2 gave a score of 6 or less making them detractors. 17 gave a score of 7 or 8 with the rest scoring 9 or 10. SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 3
Net Promoter Score - National Performance Table X = less than 10% of patients sampled SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 4
2. Infection, Prevention and Control During June I am pleased to report the Trust has recorded excellent infection control results for those indicators that are reported nationally: 1) No cases of Trust acquired MRSA 2) 1 case of Trust acquired C Difficile 3) No cases of MSSA Bacteraemia 4) No cases of urinary catheter associated Bacteraemia > 7 days after admission 5) 4 cases of E Coli bacteraemia cases (8 cases in May, 7 cases in April ) 2.1. Meticillin Resistant Staphylococcus Aureus (MRSA) The Department of Health mandatory MRSA bacteraemia surveillance scheme has been used to measure the effectiveness of infection prevention and control practices in all NHS Trusts. The rationale behind this scheme is that it is sometimes difficult to distinguish between colonisation and true infection caused by MRSA, but culture of the bacterium from blood almost always represents significant infection. As of July 20, the Trust is able to report that it has been 2 years and 4 months since any patient experienced a hospital acquired MRSA bacteraemia. This is a fantastic achievement and is the direct result of continuous high quality care delivered by our staff. The MRSA bacteraemia target of <3 was met for 2011/. To put this into context and demonstrate the scale of the improvements made, in 2006/07 there were 36 reported cases of hospital acquired MRSA bacteraemias in the Trust. We are the only Trust in the East Midlands to have zero hospital acquired MRSA. To give this a broader context, the 2011/ national results are as follows: East Midlands - we were the only Trust to have had no Trust acquired cases of MRSA bacteraemia in the last two years East of England - all Trusts reported Trust acquired cases of MRSA bacteraemia London - 2 Trusts reported no Trust acquired cases of MRSA bacteraemia North East - all Trusts reported Trust acquired cases of MRSA bacteraemia North West - 4 Trusts reported no Trust acquired cases of MRSA bacteraemia South Central - 1 Trust reported no Trust acquired cases of MRSA bacteraemia South East Coast - all Trusts reported Trust acquired cases of MRSA bacteraemia South West - 1 Trust reported no Trust acquired cases of MRSA bacteraemia West Midlands - 4 Trusts reported no Trust acquired cases of MRSA bacteraemia Yorkshire & the Humber - 2 Trusts reported no Trust acquired cases of MRSA bacteraemia This places Sherwood Forest Hospitals in the top 15 Trusts to report no Trust acquired cases of MRSA bacteraemia. SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 5
2.2. Clostridium Difficile The target trajectory for 20/13 has reduced to 36. There were 2 Trust acquired C Difficile cases for April 20, 3 for May and 1 for June. The Trust is currently on target. C difficile Cases April 20 - March 2013 Reduction target (based on Trust apportioned cases) Trust apportioned cases Apr May Jun Jul Aug Sep Oct Nov Dec Jan 13 Feb 13 Mar 13 TOTALS 3 3 3 3 3 3 3 3 3 3 3 3 36 2 3 1 6 2.3. Meticillin Sensitive Staphylococcus Aureus (MSSA) Bacteraemia The Trust has monitored MSSA bacteraemias detected from blood cultures since 2006/07. Since April 2008 the Trust has participated in the voluntary surveillance of MSSA bacteraemia and reported figures to the Department of Health via the HCAI Data Capture System. This became mandatory in January 2011. The graph below shows the annual number of MSSA bacteraemias in the Trust since 2006/07; this highlights that since 2009/10 there has been a year-on-year reduction in the number of MSSA bacteraemias. Trust apportioned MSSA bacteraemia 50 45 40 35 30 25 20 15 10 5 0 2006-7 2007-8 2008-9 2009-10 2010-11 2011- MSSA bacteraemia has the potential to become resistant and develop into MRSA bacteraemia; therefore the Trust treats these bacteraemias as near misses for an MRSA bacteraemia. A Root Cause Analysis (RCA) is carried out for each intravenous line related MSSA bacteraemia, with analyses of the RCA s from these incidents, resulting in action plans to enable further reduction in the numbers to be achieved. This process means that patients can be assured that as an organisation we actively investigate to help prevent them happening again. The infection control team analysed all 2011/ cases to identify themes and trends that informed the 20/13 Trust Wide action plan. SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 6
2.4. Escherichia Coli (E coli) Bacteraemia Escherichia coli (E coli) is one of the most frequent causes of many common bacterial infections such as urinary tract infections, food poisoning and bacteraemia (when the bacteria gets into the bloodstream). Since June 2011, as part of ongoing information gathering we have submitted data on E coli bacteraemia to the Health Protection Agency, in a similar way to MRSA. Most E. coli infections arise from patients own bowel flora and 100% of the population are colonised by E. coli. The Department of Health has announced provisional plans requiring Trusts to reduce hospital acquired UTI by 50%. Although the Trust peaked in the number of Trust apportioned E.coli bacteraemias in 2009/10, there has been a downward trend and the Trust is now back to the level of 2007/08. Trust apportioned E coli bacteramia 80 70 60 50 40 30 20 10 0 2007-8 2008-9 2009-10 2010-11 2011- The majority of these cases were related to urine infections, with 11 cases in catheterised patients and 10 in non-catheterised. Remaining sources were related to chest infection, surgical procedure/soft tissue infection, neonatal sepsis, with 17 cases having no obvious cause. In order to further reduce E.coli the following strategies have been implemented: Further analysis of the data to identify common themes Introduction of RCA in selected post 48 hour E.coli bacteraemias Continue to monitory urinary catheter use and management (previously done as part of 2011/ CQUIN) Scoping exercise to determine the use of silver and/or antibiotic coated catheters 2.5. Urethral Catheter Associated Infections Using the Commissioning for Quality and Innovation target (CQUIN) set in 2011/, the Trust s aim is to continue to reduce the incidence rate of Trust apportioned urethral catheter associated bacteraemias (blood borne infections). Although this is no longer a CQUIN, it is a High Impact Action for Nursing and work continues to drive this initiative this year. The Trust s 2010/11 surveillance highlighted that there were 40 hospital-acquired urethral catheter associated bacteraemias. The Trust prioritised; 1) reducing the number of catheterisations, 2) applying best practice to those with a urethral catheter and 3) monitoring patients with a catheter for episodes of urinary tract infection. This approach has seen a significant reduction in the number of Trust apportioned urethral catheter associated bacteraemias from 40 in 2010/11 to in 2011/ and further reductions so far in 20/13. The graph below shows the breakdown. SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 7
Urinary Catheter Associated Bacteraemia cases since Sep 2008 (CQUIN target) 6 5 Others E coli only 4 3 2 1 0 Mar- Jan- Nov-11 Sep-11 Jul-11 May-11 Mar-11 Jan-11 Nov-10 Sep-10 Jul-10 May-10 Mar-10 Jan-10 Nov-09 Sep-09 Jul-09 May-09 Mar-09 Jan-09 Nov-08 Sep-08 2.6. Norovirus Norovirus (winter vomiting disease) causes sporadic cases as well as outbreaks of gastroenteritis in people of all ages. Norovirus outbreaks are common and are predominantly, although not exclusively, a winter time pathogen, and Norovirus is highly contagious. During 2011/ the Trust had wards affected by Norovirus, with 139 patients and 86 staff affected overall. Several wards were closed during the outbreak, with an average closure of 11 days and a range of 9-17 days. Ward staff swiftly reported suspected cases, which led to prompt assessment and implementation of control measures. The kinds of measures undertaken on all wards include: Close ward or bay immediately to prevent the spread of infection Segregate nursing and medical teams to care for affected and non affected patients Ensure enhanced cleaning takes place immediately Decontaminate the area with hydrogen peroxide vapour once patients have recovered. Restriction of visitors 3. Pressure Ulcers The elimination of avoidable pressure ulcers has become a national and local must do as part of delivering the harm free care agenda. Sherwood Forest Hospitals commenced a focused reduction strategy at the beginning of 2011/ and as a consequence has placed itself in a favourable position to meet the expectations of this important goal. The information contained within this section has been incorporated to inform the Council of Governors of what has been achieved so far and the work that is planned for this year, to ensure we meet the 20/13 reduction targets. SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 8
3.1. Work to date In 2011/ there was a significant focus on the way we managed pressure ulcer prevention and reduction. The overall approach evolved into a more focused, strategic way of thinking and care delivery. The development of a steering group together with a full work programme led to some real positive changes for the safety of our patients at Sherwood Forest Hospitals. The main achievement and focus of the change for 2011/ was to deliver specialist education and care planning at the bedside, working together with the staff and patients in collaboration to reduce pressure ulcer incidence. All patients presenting with Grade 2 Pressure Ulcers are now reviewed by the Tissue Viability team providing clinical staff with a conduit to give advice on any specialist equipment and care requirements at the bedside, working together planning care with the patient and clinical staff. This focus also facilitated clinical education at the bedside giving the specialist nurses the opportunity to look at opportunities to improve care and give direct feedback and education to staff. Trends and themes during this process have been collated and lessons learnt have translated into actions, and formed the basis of the education programme delivered to the Pressure Ulcer Link Nurses Group. Introduction of clinical photography of pressure damage has supported the Tissue Viability team to grade ulcers and has also raised the awareness within the clinical teams. Routine photography of all Grade 2, 3 and 4 ulcers ensures pressure damage is clearly documented from first detection. This has in turn assisted with clinical management and grading of ulcers due to the ability to enhance and enlarge the image on a screen. Introduction of Root Cause Analysis on all Grade 3 and 4 pressure ulcers, together with the development of supporting RCA documentation and guidance, has enabled the root cause of pressure ulcer incidence to be monitored. This practice allows trends and themes to be identified and used to inform changes in practice and education programmes, and has influenced decision making regarding pressure ulcer prevention and management. Each Root Cause Analysis is presented on a monthly basis to the Pressure Ulcer Steering Group by the Ward Leader. Pressure ulcer audits are completed in all clinical areas monthly and results on pressure ulcer incidence and performance against key measures are reported back to ward leaders and service line clinical governance teams. This allows shared learning and support and has promoted ownership of the overall aim to reduce the incidence of pressure ulcers. 3.2. Pressure Ulcer Incidence & Key Drivers Real progress on Pressure Ulcer reduction at Sherwood Forest Hospitals has been reported. No patient has suffered grade 4 (full thickness) pressure damage in two years and a recent audit has shown that 99% of patients had received a pressure ulcer risk assessment and of those identified as at risk, 99% had an appropriate care plan in place. As a direct result of prompt risk assessment and appropriate care planning the Trust achieved the agreed CQUIN reduction of 5% in 2011/. SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 9
During Quarter 1, there have been 220 pressure ulcers reported (Grade 2, 3 and 4 s) of which 61 were hospital acquired. 34 of these were avoidable. The number of avoidable pressure ulcers in June has reduced in comparison to April and May. There have been no avoidable grade 3 pressure ulcers for 2 months and no hospital acquired grade 4 pressure ulcers for 2 years. The Trusts target is to achieve a zero tolerance to all hospital acquired avoidable pressure ulcers by the end of December 20. We are achieving our reduction target. The Tissue viability team are seeing all pressure ulcers (including grade 1) and assessing the post admission ulcers as avoidable or unavoidable. A combination of many factors is responsible for achieving the avoidable ambition reduction target for this quarter. Much of this is due to the tissue viability team s increased intervention and education at ward level. The Trusts No Pressure campaign was launched in June 20 to drive a further reduction All Hospital Aquired Avoidable Pressure Ulcers Grade 2,3 and 4 80 60 40 20 SFHFT Total Monthly Target Quarterly Running Total Quarterly Target 0 Apr- May- Jun- Updated documentation and pressure area guidance has supported our most venerable patients ensuring the right equipment is waiting for the patient on admission a fast track system for the most At Risk patients ensured the prompt provision of appropriate pressure relief equipment, e.g. high risk mattress. This was achieved by the successful development of a business case to purchase an additional 50 pressure relieving mattresses 3.3. The Challenges and Actions of 20/13 One of NHS Midlands and East's five ambitions is to "Eliminate avoidable grade 3 and 4 pressure ulcers by December 20. To achieve this, a full programme of activities has been developed through a formal collaborative engagement process with stakeholders. SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 10
Members of the Tissue Viability team and steering group have participated in launch events across the region. The Ambition is also linked to the Safety Express - the Department of Health QIPP Safe Care work stream, plus the Operating Framework for 20/13 includes a new national CQUIN goal that incentivises the use of the NHS Safety Thermometer. This is an improvement tool that allows NHS organisations to measure harm in four key areas including pressure ulcers. The Trust is already participating in the use of this tool and all data collected is reported through the Safety Thermometer. 3.4. Performance Performance will be benchmarked against the 20/13 Quality Schedule Your Skin Matters The Trust is required to ensure systems are in place to: Provide Monthly figures to be submitted to the Quality Scrutiny Panel Provide evidence of appropriate staff training at induction and ongoing quarterly review of staff attendance Implement systems to ensure Grade 1 pressure ulcers are identified and processes implemented to ensure that Grade 1 s do not deteriorate into Grade 2 ulcers. Note: The 20/13 Reduction targets have been based upon Pressure Ulcer Incidence for March 20. This was the Trust s best performing month for 2011/. 3.5. Communication Effective communication strategies have been developed (internally and in conjunction with the SHA and community based stakeholders) to launch the Ambition target, engaging all staff and raising awareness of the pressure ulcer agenda. A Pressure Ulcer Training Day is being held during August and a week of action will take place during September 20 to drive the agenda. 3.6. Care Delivery Introduction of the SSKIN pressure ulcer care bundle is to be launched at the Ward Leaders time out day in June. This approach is a new concept to managing the way we deliver care with supporting documentation. The focus is on pressure ulcer prevention and recording all aspects of care that effect the development of pressure ulcers. S S K I N - Surface is the patient nursed on the correct equipment - Skin Inspection - Keep the patient moving (turn charts) - Incontinence moisture (patient is kept dry) - Nutrition records / diet and fluid intake and requirements SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 11
3.7. Monitoring compliance The Tissue Viability Team will review all Grades of pressure ulcers reported via the Datix system and provide expert individual plans of care to patients whilst supporting and educating staff within the clinical areas. 3.8. Equipment Programme The Trust invested in 50 new pressure relieving mattresses during 2011/, with a view to increasing pressure relieving mattresses in 20/13. Mansfield and Ashfield Community Hospitals at the time of the previous audit were not part of our Trust and therefore require a focus in 20/13. This is a risk that has been identified in the Pressure Ulcer Reduction Strategy and a priority for this financial year. 4. Emergency Department Admission Avoidance Support Scheme (EDAASS) Since commencing the service in April 2011, EDAASS have become an integral part of the Emergency Care Centre. The performance has been consistent and the delivery of care to our patients excellent. The number of patients successfully taken home by EDAASS has improved monthly. The EDAASS team has been recently supported by the Geriatric Assessment Team and the End of Life Care Team to provide a comprehensive service. Patients accessing the service are taken home, followed up and supported during the first 48 hours of discharge and referred in a timely manner to the appropriate support service. Referrals to the Falls Prevention Service have improved by over 50% within the year. Positive feedback has been received from both patients and carers who say that they feel supported and highly satisfied with the service. Since February 20 we have also bridged care packages for inpatients supporting early discharge and have saved a total of 147 bed days. 5. Baby Friendly Assessment The Baby Friendly Initiative is a global programme of UNICEF and the World Health Organisation that works with health services to improve practice so that parents are enabled and supported to make informed choices on how they feed their babies. Healthcare services are encouraged to adopt practices so that they may work towards the prestigious Baby Friendly Award. This is an arduous process that is achieved in 3 stages over approximately 5 years. The first stage is ensuring all the policy and guidelines are in place, the second stage is assessment of staff knowledge of all those involved in the care of mothers and babies (paediatricians, midwives and health care support workers) and the third stage is assessment of care that mothers report they have received. Sherwood Forest Hospitals have recently passed stage 2 with flying colours! The assessors that came from Baby Friendly were most impressed at how cheerful and caring the 38 members of staff they randomly interviewed were. Published evidence: Mothers delivering in Baby Friendly accredited hospitals are 10% more likely to initiate breastfeeding. Data from the Millennium Cohort Study of 18,819 children born in the year 2000 found that mothers delivering in Baby Friendly accredited hospitals are 10% more SB - Quality & Safety Report - August 20 - FINAL-Board of Governors
likely to initiate breastfeeding (after adjustment for confounding variables) than those who deliver in non-accredited units. Bartington S, Griffiths L, Tate A, Dezateux C and the Millennium Cohort Study Child Health Group. Are breastfeeding rates higher among mothers delivering in Baby Friendly accredited maternity units in the UK (International Journal of Epidemiology. doi:10.1093/ije/dyl155). This increase in breastfeeding would have a huge impact on both long and short term health benefits of mothers and babies. Breastfeeding reduces the risk of breast cancer, ovarian cancer, osteoporosis and obesity for mothers. For babies the risk of sudden infant death is reduced by 50%. There is reduced gastroenteritis, insulin dependent diabetes, childhood leukaemias and cancers. Savings in healthcare costs to the country are enormous. Many mothers are aware of Baby Friendly and this will influence their decision to choose SFHFT as their preferred location. Midwives seeking employment may also select Baby Friendly units. By nature of the award it shows a unit has a strong commitment to improving care for all mothers and babies. The assessors awarded us 100% in all 8 categories. This is the first time the assessor has ever done this in 10 years. 6. NPSA Alerts During May 20 there were 7 new NPSA alerts of which: 4 have been acted upon and have been closed 3 are ongoing and require further action 6.1. Current Risk There remains 1 alert that is still open beyond its deadline for closure - NPSA/2011/PSA001 Safer spinal (intrathecal), epidural and regional devices Part A: update deadline 02-Apr-. This alert has passed the deadline as the devices, which are on the market to reduce the risk of connecting the wrong syringe, have not been evaluated from a safety point of view and the National Society of Anaesthetists have recommended that they should be not used until safety evaluations have been completed. A report is due in July/August 20 and the Clinical Governance Committee has agreed with this advice. In the peer SHA group of acute hospitals, there are 2 (NUH and CRH) which have closed the alert and 5 (including SFHFT) which still have this alert showing as open/ongoing. Work is underway to understand why some Trusts have closed this alert and why others have it open. 6.2. Risk and Mitigating Actions The current risk is that a mistake could be made as the wrong drug is attached to a spinal device which is not lock connected. The staff who undertake spinal procedures are the theatre anaesthetists. They have been made aware of this potential risk via the lead anaesthetist, Dr Andrew Taylor. Once the recommended devices have been evaluated and are available, they will be purchased to use with spinal devices. SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 13
6.3. Residual Risks There is a residual risk to the Trust s reputation as the alert is open past the deadline. Alerts are monitored by the Care Quality Commission and the Executive Director of Nursing has corresponded with the compliance inspector to explain why the alert remains open. 7. Care Quality Commission Review of Compliance for Termination of Pregnancy This review was undertaken on 20th and 21st March 20 as part of a targeted inspection programme to services that provide regulated activity of termination of pregnancy. The focus of the visit was to assess the use of the forms that are used to certify the grounds under which a termination of pregnancy may lawfully take place. The review identified that King s Mill Hospital was meeting the essential standards of quality and safety. 8. NHSLA Level 2 Assessment The NHSLA handles negligence claims (CNST) and works to improve risk management practices in the NHS. The Trust pays a premium to the NHSLA and set standards to determine if the Trust can be part of their scheme. The acute standards were assessed on 8th February 20 with a top score of 50/50, which means we successfully achieved Level 1 and our premiums will be discounted by 10% for two years. Level 1 means that the process for managing risks has been described and documented. The Level 1 assessment requires all minimum standards for each criterion to be described. However, the quality of the processes will not be rigorously tested until the Level 2 assessment takes place. It is important to note therefore that compliance at Level 1 i s n o t a n indication that the organisation will be able to demonstrate compliance at Level 2 or that it is effectively managing risks. Over the past months the Trust has been working hard to become a Level 2 organisation and if successful it will mean our premiums will be discounted by a further 10% for three years. 8.1. Preparation for Level 2 Previous informal assessments demonstrated that policies were of a high standard but they failed to reflect the practice within the organisation. A gap analysis was performed and an action plan implemented to address the concerns. A strategy group was developed to ensure there is development of documents that match practice and these are presentable as evidence for submission at the next assessment. NHSLA supported training was given to key individuals in May 2011 to facilitate achievement of the standards. To assess our progress the Trust was entitled to an informal assessment through the NHSLA assessor. This occurred on Tuesday 10 th July, 20. 8.2. Assessment Feedback The assessor spent a day with the Trust undertaking a mock assessment. This involved assessment of many criterions, including a practice visit which has become part of the assessment to ensure policies reflect everyday practice. The assessor reported: The Trust has made significant progress since her last visit months ago SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 14
There has been significant progress in policy development and policy amendments The appointment of an evidence collator has been instrumental in moving forward There has been significant progress in relation to evidence collection and the accuracy of evidence to reflect policy and practice Overall a few policies require some minor tweaks to reflect what happens in practice, but again these are much more aligned than where they were, a year ago The ward visit to review nursing, medical and pharmacy documentation was exemplary. As this is a significant part of the level 2 assessment she feels this is a real strength. 9. PEAT (Patient Environment Action Teams) Scores The PEAT Audit is an annual assessment of inpatient healthcare sites in England and is undertaken on all sites with more than 10 beds. It is self-assessed and measures standards across a range of services including food, cleanliness, infection control and patient environment (including bathroom areas, décor, lighting, floors in all patient areas). The assessment was established in 2000 and is a benchmarking tool to ensure improvements are made in the non-clinical aspects of a patient's healthcare experience. PEAT highlights areas for improvement and shares best practice across the NHS. NHS organisations are each given scores from 1 (unacceptable) to 5 (excellent) for standards of privacy and dignity, environment and food within their buildings. The NPSA (National Patient Safety Agency) publish these results every year to all NHS organisations, as well as stakeholders, the media and the general public. We inspect a wide range of clinical areas and assess against best practice standard national definitions. The team of assessors consisted of representatives from Infection Prevention and Control, Facilities Services, Head of Nursing and also included a patient representative. As the same team were involved in previous PEAT audits, they commented that this was one of the best outcomes of the past 7 years of PEAT auditing, with standards at a very good level across the board. The validated scores are awaited but indicative scores are below, based on the findings on the day. Excellent scores for environment, cleanliness and food service were recorded at all three sites. Patient feedback was also very positive. Performance Comparison (year on year) Site and Year Environment Food Privacy and Dignity 2010: King s Mill 4 (Good) 5 (Good) 4 (Good) 2010: Newark 4 (Good) 5 (Excellent) 5 (Excellent) 2011: King s Mill 4 (Good) 5 (Excellent) 4 (Good) 2011: Newark 4 (Good) 4 (Good) 5 (Excellent) 20: King s Mill 5 (Excellent) 5 (Excellent) 4 (Good) 20: Newark 5 (Excellent) 5 (Excellent) 5 (Excellent) 20: Mansfield 5 (Excellent) 5 (Excellent) 5 (Excellent) SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 15
10. Summary Hospital Mortality Index The SHMI (Summary Hospital Mortality Index) is the Department of Health preferred measure of mortality. SHMI includes all admissions and deaths that occur within 30 days of discharge. Analysis of 2011/ data indicates that our high HSMR was largely attributable to relatively low levels of palliative care coding. Without this, we would have an average HSMR in comparison to other organisations. On the SHMI measure, SFH has been a little worse that average at 103 when last reported to the Board. Since then there has been a small but steady fall and the most recent results from the year (which cover the end of last year) are 101. This is encouraging but further work needs to be done to improve this. In terms of overall performance in non-elective activity; although we are only average compared to English providers we compare well to our SHA neighbours who, with the exception of NUH, are significantly worse than average. Within Gastroenterology, Cardiology, Orthopaedics/Geriatrics and Respiratory Service lines, significant numbers of patients present with these diseases and we need to focus on them for that reason. Focusing on these areas will also allow these services to focus on improving patient pathways and provide a baseline to measure progress. This will drive improvement in care and thus SHMI. Respiratory Medicine is an important area because it represents approximately 8% of non elective spells and has a high mortality rate. Performance is acceptable but with the introduction of weekend working and daily specialist ward rounds I expect to see further improvement here in the next period. For Orthopaedics/ Geriatrics the data concerns patients admitted with Fractured Neck of Femur. This could be improved by the introduction of a partial Orthogeriatric service which would begin to address some of the issues contributing to increased mortality. No specific service line is concerned but mortality from SEPSIS/UTI reflects the effectiveness of our pathways in dealing with acutely ill patients and can be considered a measure of these. Our performance has been below average and reviewing data within these areas will focus attention on implementing the sepsis bundle. We have appointed four Acute Physicians and will separate the on call rotas for Acute Medicine and the medical specialities from August 20. This will have an immediate effect of increasing the capacity to deliver daily specialist ward rounds as well as weekend working. This should have a measurable effect on the quality of care our mortality data. A further review of the Data will take place and an update will be reported to the Board of Directors. Authors: Susan Bowler, Executive Director of Nursing and Quality Dr Nabeel Ali, Executive Medical Director SB - Quality & Safety Report - August 20 - FINAL-Board of Governors 16