QUALITY REPORT Part A Patient Experience 1
Number of complaints Complaints and Patient Advice and Liaison Report 40 Total number of complaints received 30 20 10 Number of complaints received Trendline There were 21 formal complaints in May 2016: 10 related to Medicine 5 related to Surgery 5 related to Women and Children 1 related to Corporate Division 17 of the complaints related to care in 2016, 3 relate to care given in 2015 and 1 to care given in 2014. 11 (52%) complaints received were regarding Clinical care and treatment. 7 of these related to Inappropriate care and treatment. Of the 7 relating to inappropriate care and treatment, 2 relate to long term care pathways, 2 relate to not meeting expectations and the overall standard of care, 2 relate to pain management and care whilst waiting investigation, and 1 to a missed diagnosis of a fracture. 10 (48%) of the complaints were split between 4 themes: 5 about communication and information; 2 regarding staff attitude; 2 about appointments and 1 regarding transport arrangements. There were 230 contacts with the PALS service at the RUH site: 158 required resolution (69%) 37 requested information or advice (16%) 10 provided feedback (4%) 25 were compliments (11%) The top three subjects requiring information and advice were: Communication and Information there were 78 contacts (49%) with requests for communication and information regarding the services provided by the Trust, there are no trends or themes in relation to these contacts. Appointments of the 24 contacts (15%) regarding appointments, 13 patients had concerns about delays in outpatient follow-up appointments across 9 specialties. 6 patients reported cancellations of appointments - of these 5 were related to the Surgical Division. Clinical care and treatment of the 31 contacts (20%) none were attributed to a particular hospital service. 2
QUALITY REPORT PART B Patient Safety and Quality Improvement Safer 6 Patient Safety Priorities Sepsis, Acute Kidney Injury (AKI) NEWS, Movement of patients location, Clostridium difficile, Improving Insulin Safety 10 Executive sponsored projects of must-do s informed by business unit priorities, CQUIN or as a response to stakeholders Emergency Laparotomy, SSIS, Harm & MFFD Patients, Frailty, Venous Thromboembolism (VTE), Anti Coagulation, Missed Doses, Falls, Pressure Ulcers, NatSSips 15 Divisional Safety Priorities Medicine Surgery Women and Children 3
Perioperative Patient Safety Update National Safety Standards for Invasive Procedures (NATSIP) The National Safety Standards for Invasive Procedures requires that local standards are developed for all invasive procedures, with regard to development of safety checklists, briefings and debriefings. This includes the work currently well embedded in theatres with the WHO Surgical Safety Checklist and now involves spreading that work to all other invasive procedures Trust wide. A list of the extra procedures to which this is applicable is being developed by each division. Draft checklists have been developed for several procedures such as chest drain insertion, pleural taps and lumbar puncture as well as a standard checklist for outpatient procedures and these are being tested. As with the WHO checklist, these will be monitored for compliance and quality assurance, using the same methodology as for the WHO checklist. The WHO checklist compliance in theatres will be continued to be monitored but alongside that will be compliance for other procedures outside of theatres as these are developed. Monitoring of compliance with these will be the responsibility of the Speciality Governance Leads and the Divisional Governance Committees. C KPIs to be monitored going forward 1. Local policy for safety standards for all invasive procedures to be in place by September 2016 2. Approved checklists in place for all procedures with standardised approach by December 2016 3. Compliance with WHO Surgical Safety Checklist in theatres to be over 90% complete each month 4. Compliance with Prelist briefing in theatres to be over 95% for elective patients Monthly monitor of compliance with checklists for procedures outside theatres once established (responsibility Divisional Governance Committees). Monthly quality assessment compliance for standards for all invasive procedures once developed. Compliance with the WHO Surgical Safety Checklist in theatres remains high with 99.8% of all patients undergoing surgery having the checklist fully completed in Q4 (1300-1600 patients per month), and 99.9% in April and May 2016 (see run chart). The work on the WHO checklist and Prelist briefing has been shortlisted as a finalist in the Changing Culture section of the national Patient Safety Awards 2016. 4
Perioperative Patient Safety Update Emergency Laparotomy Collaborative Since re-launching the Emergency Laparotomy work there has been an improvement in a number of areas. 1. Increase in percentage of patients receiving postoperative management on critical care 2. Increase in the use of goal directed fluid therapy in theatre 3. Increase in consultant presence in theatre 4. Increase in risk assessment preoperatively Data collection for emergency laparotomy work is still a challenge and retrospective reviews are still required occasionally. Data for February in particular at the moment is incomplete but will be added once the notes have been reviewed. There are ongoing challenges to the collection of data using IT systems at the time of surgery and this has been escalated. As a result there has been a decrease in the mortality rate at the Trust over the last 6 months. The results have been fed back to all staff and at the bi-monthly safer surgery meetings and theatre governance meetings. A newsletter update for theatres is being developed.. Work is now focussing on improving the preoperative management, in particular sepsis. Concern over possible increased trend in time to theatre is also being reviewed. Baseline data for the Academic Health Science Network (AHSN) Care of the Elderly project is now complete and the involvement of the Care of the Elderly consultant team for patients over 70 years old is due to commence on June 1 st 2016. 5
Data for all patients undergoing emergency laparotomy 6
2016/17 CQUIN Frailty (Q1 April-May 2016 summary) Background The CQUIN for Frailty 2016/17 is based on the National recommendation to develop a local CQUIN to promote a system of timely identification and proactive management of frailty The indicator has been divided into three parts to achieve the following: Part 1: 85% of patients aged 75 and over who are frail admitted under Medicine are screened for frailty Part 2: A summary of the outcome of the Comprehensive Geriatric Assessment should be included in the discharge summary to the patient s GP for 85% of patients discharged aged 75 and over. This includes patients who are referred to the Discharge Assessment Team (DAT) and/or admitted to the ACE short stay frailty ward where a Comprehensive Geriatric Assessment has been completed and, for those with a Clinical Frailty Score (CFS) of 5 or above Part 3: Roll out the discharge passport to patients discharged from ACE Ward, building on the work completed in 2015/16 to improve the information provided to patients on discharge Progress On track to achieve all Q1 milestones which include: Development of a Medical Assessment Proforma for Adult patients over the age of 75 to include the Rockwood Clinical Frailty Score and Comprehensive Geriatric Assessment tool Launch of an education programme to underpin the implementation of the Medical Assessment Proforma Initiate implementation of the discharge passport on ACE Delivery and Governance The CQUIN will be delivered through the Frailty FLOW programme which reports to the Trust s Front Door Group and Urgent Care Collaborative Board. Next Steps Launch of the Medical Assessment Proforma Weekly review of progress of the Medical Assessment Proforma implementation following an agreed PDSA methodology. Plan to have structured interviews with users of the proforma in the first 3 weeks of launch Review education and training needs to ensure full coverage of all staff and following outcomes of ongoing review of the implementation Complete required audits to demonstrate compliance with the CQUIN requirements for Q1 including baseline measurements Roll out of the discharge passport on ACE Community and Primary Care to join a Frailty FLOW meeting date being arranged for June 2016 and to agree ongoing involvement in the programme 7
Surgical Site Infection Surveillance (SSIS) The Orthopaedic Directorate continues to submit data of all surgical site infections following Total Knee Replacement (TKR), Total Hip Replacement (THR) and Repair of Femur Surgery. The Trust submits data on a quarterly basis rather than the mandated 1 quarter as set out by Public Health England (PHE) in order to provide more robust collection of surgical site infections. Table 1 shows a variable numbers of reported infections and at present no common theme has been identified. The information shows all infections including those that are patient reported and have not necessarily been seen or confirmed as an infection by a doctor. The number of infections reported have increased for TKR and Repair of Femur as per Table 1. Table 1 Year TKR* Repair of Femur* THR* 2014 2.6% 1.7% 3.4% 2015 4.9% 2.1% 2.7% * All SSIS included in this % including patient reported Graph 1 Graph 1 for PHE data shows an increase in infection rates overall for TKR and Repair of Femur but a reduction in the infection rates for THR. During the previous 4 quarters, the Trust has received alert notifications from PHE showing the Trust as an outlier for Hip and Knee Arthroplasty infections. In order to reduce infection rates, changes in practice have included the standardisation of skin preparation in theatre with 2% Chlorhexidine, external review of air sampling in theatres and improvements to the laminar flow system and introduction of a theatre cleaning standard and environment audit. In October 2015, the Trust set up a nurse advice line for patients with wound concerns in order for them to have access to specialist advice and review if required. Next Steps Introduction of skin de-colonisation for 5 days prior to admission/surgery for elective major joints Theatre etiquette standards to be introduced and audited by Orthopaedic clinical lead Review of wound care products for those wounds that are requiring increased dressing due to exudate (a fluid that oozes out of blood vessels due to inflammation) post operatively 8
Number of wards Ward and Outpatient Accreditation report Background The Ward and Outpatient 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 are scored against each of the performance indicators based on their levels of performance over the last 6 months on a sliding scale. Foundation level is achieved with a score of 75% or more for each of the CQC domains assessed. 14 12 10 8 6 4 2 0 Nov-14 (1st assess) May-15 (2nd assess) Jul-15 (ED) Foundation assessment specialities Mar-16 (3rd assess) Apr-16 (4th assess) Achieved Not achieved May-16 (Violet Prince) All 23 Wards originally assessed including the Emergency Department (ED) have now achieved Foundation level. Violet Prince have been assessed in May 2016 and did not achieve Effective (61%) Paediatric Ward Foundation level May 2016: assessed for the period November to April 2016, not achieved in Effective (74%) and Well led (73%) domain Maternity - Mary Ward including Central Delivery suite May 2016: assessed for the period November to April 2016, not achieved in Effective (50%) and Well led (56%) domain Outpatient Foundation level update February 2016: 18 Outpatient areas and 4 departments assessed for the period July to December 2015. In addition to data routinely collected the process also included observations of practice completed over a 3 day period in August and September 2015 11 areas have achieved Foundation level: Outpatients: Breast unit, Diabetes Clinic, Fracture Clinic, Gynaecology, Respiratory, Sexual ealth, Urology, Vascular Studies Departments: Medical Therapy Unit, Pre-Operative Assessment, Ambulatory Care Next Steps The results are being discussed with the Matrons and Heads of Nursing. Individual meetings are being arranged with respective Sisters, Charge Nurses and Department leads. An Outpatient focused lunch will take place on 17 th June, where teams will be presented with their certificates and learn more about the 15 Steps Challenge in preparation for reassessment and Bronze level. Reassessment will take place later in 2016. Ward Bronze level update Assessment for Ward Bronze level has commenced. Bronze level includes all elements of Foundation level with the addition of further data and observations of practice such as quality of safety briefings, handover and whiteboard rounds. The observation tool developed also includes interviews with patients and staff. A team of observers has been identified which includes clinical staff Matrons, Sisters, Charge Nurses and non clinical staff including Non- Executive Directors. Observation in all wards will be completed by end of June 2016 Next Steps Assessment of all 70 indicators for Bronze level is aimed to be completed by the end of August 2016 9
Nursing Quality Indicators - Exception Report (May data) Areas of focus The Nursing Quality Indicators chart is attached as Appendix A. Three wards flagged this month as having nursing quality indicators of note (below). Two of these wards also flagged last month Respiratory ward This ward also flagged in May, although the nursing quality indicators have improved slightly this month. The RN fill rate for both day and night was <80% due to vacancies and sickness, although there are new staff coming into post over the next few months. To support ward staffing during the day the Supervisory Sister supported care delivery and HCA hours were increased at night to compensate to planned staffing hours overall. Quality matrices to note are: FFT response rate 35% although 91% recommending One pressure ulcer Grade 2 (none last month) RN and HCA sickness above 5% (April data) Falls reduced (3) from last month where there were 8 falls Nil recorded complaints or negative PALS (2 nursing related formal complaints last month) Forrester Brown ward This ward also flagged last month. The RN fill rate during the day was <90% due to vacancies and sickness, although the HCA fill rate was increased to achieve planned staffing hours overall. Quality matrices to note are: FFT response rate 31% although 95% recommending One negative nursing related PALS comment One patient acquired Clostridium Difficile RN and HCA sickness above 5% (April data) although slightly improved from March Mary ward (Maternity) This is the first time this ward has flagged. The MCA fill rate during the day was 75% due to vacancies and sickness and the RM fill rate at night 87.6% due mainly to vacancies. Maternity have a good recruitment plan in place and have recruited new starters who will commence over the next few months. Quality matrices to note are: FFT response rate 24% although 98% recommending One formal complaint that was midwife related MCA sickness above 5% (April data) Appraisal rates for both RMs and MCAs below 80% Other quality matrices of note: Clostridium Difficle This month there was one hospital attributable Clostridium Difficile case and this is continued improvement over the last few months. However Clostridium Difficile remains a high priority and therefore there is continued robust monitoring and infection control surveillance in place Pressure Ulcers (PUs) There were five category 2 PUs this month of which three related to one patient (Cardiac ward). This is the same number as last month. A Trust-wide quality improvement event is planned in July to generate an action plan enabling further improvements and reduction in hospital acquired PUs Falls The total number of falls remains fairly consistent with an increase of two from last month. There were two falls resulting in major harm (fractures) and root cause analysis investigations are being undertaken. The falls group work plan is presently in development for this financial year and will take into account the findings from the thematic review which took place in April 5 6 10
Serious Incident (SI) summary Current Performance During May, eight Serious Incidents were reported and 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 Incident Datix ID Summary 04.05.16 42721 A patient fall resulting in a fracture 05.05.16 42747 Unexpected death 05.05.16 42761 A patient fall resulting in a fracture 06.05.16 42792 Unexpected death from Clostridium Difficile 19.05.16 43193 Unexpected death from Clostridium Difficile 20.05.16 43220 Shoulder dystocia resulting in harm 23.05.16 43300 Missed diagnosis during pregnancy 27.05.16 43433 A patient fall resulting in a fracture 11
Serious Incident Root Cause Analysis reports approved in May Date of Datix Summary Incident ID 13.12.15 38462 A patient fall resulting a fracture 17.12.15 38565 A patient fall resulting a fracture 09.01.16 39164 Unexpected admission of a baby to NICU 15.02.16 40408 Shoulder dystocia resulting in harm 05.03.16 40967 A patient fall resulting a fracture Learning/ Recommendations While the outcome for this patient was significant, there was no evidence that any actions or omissions by the teams involved contributed to the occurrence of the fall The falls care bundle in full has been implemented in all ward areas. To notify patients of the risks associated with inflatable pressure relieving mattresses There was no evidence that any actions or omissions by the staff involved contributed to the events There was no evidence that any actions or omissions by the staff involved contributed to the event The need to reduce delays in performing an x-ray to identify fractures 12
Overdue Serious Incident reports summary The drive to reduce the number of overdue SI reports will continue this year, working to a target of zero overdue reports. As of 3 rd May, there are 19 open Serious Incidents (SIs); of these, one is overdue, for submission, but the investigation has been completed and the report is in draft. Any delay in providing a final report is escalated to the relevant Divisional Management team, for them to identify what further support can be provided to the investigator to assist them in completing the report. The investigation has been concluded for eight of the open incidents and the reports will be submitted to the June Operational Governance Committee for approval. The Operational Governance Committee monitors the progress against the action plans developed following the investigation; at the May OGC meeting the status was: 13