TRUST BOARD PART I NOVEMBER 2011 Agenda Item Number: 179/11 Enclosure Number: (1) Subject: Prepared by: Sponsored by: Presented by: Purpose of paper Why is this paper going to the Trust Board? Key points for Trust Board members Briefly summarise in bullet point format the main points and key issues that the Trust Board members should focus on including conclusions and proposals Quality Performance Report (September position) Fiona McNeight, Head of Governance and Patient Safety Tracey Stenning, Governance Compliance Manager Julie Dawes, Director of Nursing Julie Dawes, Director of Nursing Discussion requested by Trust Board Regular Reporting For Information / Awareness HCAI (National target and Quality Contract) - MRSA: 0 (zero) cases in September. Year to date position: 1 against a trajectory of 2. - C.Diff: 10 cases in September. Year to date position: 49 against a trajectory of 43. Action plan in place to address. VTE (National CQUIN target and Quality Account) - 91.4% compliance in September (subject to validation) compared to 88.9% compliance in August. Single Sex Accommodation (National target and Quality Contract) - Nil mixed sex breaches in September. SIRIs (Quality Contract) - 3 SIRIs reported in September of which one was a pressure ulcer. Never Events (Quality Contract) - No reported Never Events. Falls (Quality Contract and Quality Account) - Zero amber and red reported incidents in September, against 2 amber incidents in August. Total of 14 against a year to date trajectory of 23. Pressure Ulcers (Quality Contract) - 1 grade 3 and 4 hospital acquired pressure ulcer reported in September (2 reported in August). Total 17 against an upper trajectory of 30. On trajectory to achieve 25% reduction. Complaints (Quality Contract) - Total of 45 complaints in September compared to 53 in August 2011. - The overall trust monthly target is 42 therefore; August exceeded the target by 3 complaints. Patient Experience (Quality Contract) - Increased patient experience with the discharge process. Medication (Quality Contract and Quality Account) - Allergy status year end target of 71.5%, currently 71%. - Medicines reconciliation year end target of 77%, currently 71%.
Options and decisions required Clearly identify options that are to be considered and any decisions required Next steps / future actions: Clearly identify what will follow the Trust Board s discussion Consideration of legal issues (including Equality Impact Assessment)? Consideration of Public and Patient Involvement and Communications Implications? End of Life Care Patients placed on LCP (Quality Contract) - % of ward deaths on LCP is 49% (target 50%) Unplanned returns to theatre (Quality Contract) - Reduction in the number of unplanned returns to theatre of 0.17% in quarter 1 to 0.03% in quarter 2. Safeguarding adults - 11 safeguarding alerts raised in September. - 8 were raised by Trust staff, 3 from external partners (2 of those to advise the Trust of patients already known to safeguarding with protection plans in place). Nil decisions required. Ongoing monitoring of all metrics and regular Board reporting. Considered None. VTE is now in line with the national target. C.Difficile over trajectory. 2
Quality Heatmap
National and National CQUIN Targets Healthcare Associated Infections (HCAIs) Incidence of MRSA bacteraemia more than 48 hours after admission (PCT/SHA trajectory for 2011/2012 is 4). There were no cases in September. The trajectory for September was 0 cases. Thus, the yearto-date position at the end of September is 1 case against a trajectory of 2. Incidence of C.Difficile more than 72 hours from admission (PCT/SHA trajectory for 2011/2012 is 78). 1 There were 10 cases recorded in September. The trajectory for the month was 8 cases. Thus the year-to-date position at end of September is 49 cases against a trajectory of 43. The Trust C.Difficile action plan continues to be implemented in full. An external visit from the HPA infection lead concluded that the action plan was comprehensive, and that a huge amount of intervention on a Trust-wide basis had started to pay dividends albeit slowly. However, it is to be noted that the Trust has not been identified as a Trust of concern by the Department of Health or HPA. New or enhanced interventions introduced in September include: 1. Focus on cleaning at the patient bedside. This is nurse led cleaning of equipment and soft furnishing (e.g. bed, armchair etc) in the near patient environment which is monitored robustly, with on the spot reporting and feedback made to the ward staff concerned. 2. All diarrhoeal swabs are screened daily to prevent inappropriate testing for C.Difficile. 3. Increased emphasis on timely patient isolation with a four hour window for isolation. 4. Education and feedback. Drop in days on wards, formal feedback sessions to Clinical Service Centres (CSCs). Venous Thromboembolism (VTE) Risk assessment figures for September is 91.4%, this data is currently being validated and may be subject to slight change. This figure demonstrates a month on month improvement since July. Day Surgery undertakes manual data collection rather than using VitalPAC. There is a process in place whereby patients will not be collected from recovery unless a risk assessment has been completed; therefore, 100% of patients have a risk assessment recorded within the Day Surgical Unit. Meetings are underway between the Head of Professions and Nursing for Clinical Support, surgeons, theatre staff and the VTE and VitalPAC leads to introduce a similar system for all elective surgery. Risk assessments would be completed in theatres manually. It is proposed that the risk assessment could then be entered onto VitalPAC by the recovery staff; this would ensure that no patient would leave theatres without a documented risk assessment. The Head of Nursing for theatres has agreed that this is the way forward provided that appropriate hardware is installed and adequate training is provided. Single Sex Accommodation There were nil mixed sex occurrences within MAU or the general wards in September. Patient Experience Currently on target with 5 key questions (internal monitoring). 1 Please note the change to the C.difficile terminology from 48 hours from admission to 72 hours from admission. The way these are counted has not changed, the Trust has been using the incorrect terminology.
Trust and Quality Contract targets Serious Incidents Requiring Investigation (SIRIs) (excluding HCAIs and as reported on STEIS) Of the five reports presented to the Serious Incident Review Group (SIRG) in September, four were signed off with further work being required on the fifth. Three SIRIs were reported in September. Six SIRIs were reported in August however, one grade 4 plaster sore was subsequently down graded by the Commissioners. There is one SIRI that has exceeded the target date for completion (a joint investigation with the PCT). The Trust section of the report is complete and agreed with the PCT, however, the full final report is awaited from the PCT, upon receipt this will be submitted to SIRG. SIRIs September 2011 SIRI 1 x Grade 3 pressure ulcer MSK Patient Identifiable Information Missed diagnosis Clinical Service Centre (CSC) Corporate/L&D Emergency Medicine Never Events Zero Never Events were reported in September 2011. Incidents Incidents September 2011 Incidents Month Adjusted to include receipt of late reports September 114 Previously reported August 2011 661 169 July 2011 680 659 June 2011 688 678 May 2011 643 635 Number of Reported Incidents not including SIRIs Aug 11 - Sept 11 200 150 100 50 0 Cancer Corp CSS M OPRS Emerg M edicine FM H & N M edicine M SK R & T Surgical Theatres Aug 37 0 40 148 66 0 22 101 72 13 54 25 83 Sept 7 0 9 7 7 1 2 22 11 2 5 1 39 Women & Childrens The top three reported incidents in September 2011 at the time of reporting: slips, trips and falls, pressure ulcers and the administration or supply of a medicine from a clinical area. Pressure ulcers have replaced patient case notes and adverse events that affect staffing levels which were in the top 3 reported incidents in August. 5
Falls The Trust has been under the monthly falls trajectory since April and is on target to achieve compliance with the year end target of 39 red and amber events, based on 10% reduction from 2010/2011. There were 0 amber or red falls against a monthly trajectory of 3 in September. Previously 1 amber fall was reported in August; however, due to late reporting this has now increased to 2. Pressure Ulcers A total of 1 grade 3 and 4 hospital acquired pressure ulcers (HAPUs) were reported in September. This brings the total to seventeen HAPUs against an upper trajectory of thirty. Therefore, the Trust is currently on trajectory to achieve the 25% reduction target. Complaints and PALS September 2011 saw a decrease of 8 complaints compared to August. The Trust overall target for the month is 42; therefore September exceeded the target by 3 (exceeded by 11 in August and 10 in July). Month Complaints Variance on 2011-2012 Received previous month April 32 - May 43 11 June 61 18 July 52 9 August 53 1 September 45 8 Comparison of themes for complaints Complaint theme August 2011 September total 2011 total Variance All Aspects of Clinical Treatment 24 24 Communication to Patients 10 4 6 Admission, Discharge & Transfer Arrangements 5 9 4 Attitude of Staff 5 2 3 Decrease compared to previous month Increase compared to previous month The same compared to previous month Parliamentary Ombudsman The Trust is aware of one reported case which was referred to the Parliamentary Ombudsman in September 2011. This is an on-going complaint relating to several years ago. Complaint Acknowledgement Rate 100% of all 45 complaints were acknowledged within the 3 day target in September 2011. 6
PALS Contacts There were 118 PALS contacts in September 2011 regarding the Trust. This is a decrease of 5 compared to August where 123 contacts were made (150 contacts in July). Comparison of themes for PALS contacts PALS theme/reasons for contact August 2011 September total 2011 total Variance Contacts Received 1123 118 5 Communication to Patients 37 535 2 Appointment Delay/Cancellation Outpatients 34 26 8 Appointment Delay/Cancellation Inpatients 4 10 6 Decrease compared to previous month Increase compared to previous month The same compared to previous month Reported Plaudits A total of 1,551 plaudits were received in September compared to 1,376 in August. Patient Experience Discharge Survey for Quarter 2 Improvement was reported in 23/30 of the questions. Of those, 18 showed a significant improvement of 5% or more. The range of improvement was 5 38% with a mean improvement of 18%. Areas of greatest improvement at 20% or higher, include: Provision of predicted date for discharge within 24 hours of admission. Appropriateness of area whilst waiting for discharge. Danger signals relating to illness to watch for. How to feedback to the Trust including complaints procedures, comments and compliments and PALS. Six questions however, showed deterioration. The range of deterioration was 3 to -8 %, with a mean of -4%. These responses were related to: Information for families and carers. Knowing when care would start if required. Information about contacting care agencies. One response remained the same. The Discharge Improvement Group is responsible for the development of corporate and CSC specific action plans. The implementation will be monitored by the Patient Experience Steering Group. Patient Moves While no statistically significant variation was evident in the total number of patient moves between quarters 1 and 2, the Trust remains focussed on the priority of reducing the number of patients who move 3 or more times. Some of these patients will move this number of times for clinically appropriate reasons (e.g. transfers to and from critical care), but in many instances the statistics bear relation to the practice of 'outlying'. As part of the 2011 winter plan, the Medicine for Older People, Rehabilitation and Stroke CSC is working in partnership with Southern Health NHS Foundation Trust to establish an OIder Persons' Assessment Service in the Emergency Corridor at the Trust. This will extend daily consultant geriatrician cover at the front door of the hospital from 4 hours to 12 hours. This will provide a multidisciplinary team of hospital and community professionals with the aim of safely discharging patients who otherwise would have spent at least one, and frequently more, nights 7
in hospital. It is anticipated that initiatives such as this will ease the pressure on hospital beds, and support the Trust's aim of reducing multiple patient moves. In October the Trust's Senior Nurse for Discharge delivered a project to streamline referrals to external agencies for discharge assessment and support. In place of four existing referrals, one request for support is now sent within 48 hours of the patient arriving in hospital, enabling far better coordination and communication of discharge arrangements. Such major initiatives to continue the Trusts impressive track record of minimising delayed transfers of care will also have a positive impact on the need to outlie patients. Medication Errors During quarter 2, there were two amber medication-related incidents compared to five amber and one red for the same quarter in 2010/11. As a result of these incidents and review of compliance with outcome 9 of the CQC Essential Standards, targeted intensive medicines management training and insulin safety training at ward level are to be rolled out to CSCs. Following the appointment of a new Director of Pharmacy and Medicines Management the role of Accountable Officer is to transfer in November 2011. Missed dose incidents continue to be a focus and a CSC led audit has been conducted, the results are to be analysed and an action plan generated. Patient Safety Federation Data Indicator Baseline August 2011 September Minimum target 2011 2011/2012 Allergy status 65% 76% 71% 71.5% Medicines Reconciliation 70% 71% 71% 77% The Trust is currently on target to achieve both indicators. End of Life Care The Trust has a contractual target for 50% of patients that are identified as dying being placed on the Liverpool Care of the Dying Pathway (LCP). As can be seen from the table below, improvement against compliance has been noted since July. Indicator July 2011 August 2011 September 2011 % ward deaths on LCP 28% 46% 49% Actions listed in last months report continue to be progressed. Unplanned returns to theatre This metric is reported quarterly. A reduction has been seen in the number of unplanned returns to theatre of 0.17% in quarter 1 to 0.03% in quarter 2. Quality Indicators Safeguarding adults An appointment has been made to the post of Patient Safety Clinical Coordinator for Adult Safeguarding and VTE. The post holder has operational responsibility for the further development and management of adult safeguarding cases working closely with the local Safeguarding Teams in the county and city council. 8
In September, 11 safeguarding cases were raised compared to 13 in August. Two cases were communications to the hospital from Council Safeguarding Teams to alert the hospital team to the fact that a patient was known to safeguarding and protection plans were in place. Three were related to patients admitted from a care environment with grade 3 or 4 pressure ulcers, reported in line with commissioner s requirements. Three concerns were raised about care prior to admission and two were allegations of assault. One safeguarding case was raised related to the discharge of a patient to a care home. Safeguarding children Nil to report. Releasing Time To Care Bundle Programme (Productive ward) Productive Care The Trust received positive feedback following participation at the South England SHA celebratory productive care conference. The Trust provided presentations from the Hospital at Night (H@N) handover project and Releasing time to care Bundle (RTtCB) programme. In addition there were representatives from the various teams at the event. Releasing Time to Care Bundle Programme (Productive ward) The Releasing Time to Care Bundle (RTtCB) programme continues to progress with a further increase in the direct care time (DCT) for the RN and HCSW (see below). Along with DCT reduced motion and reduced interruptions can also be seen. Average RN DCT at the start and at the repeat Activity Follow Trust average for an RN: 60.0% 40.0% At start - 41.70% At repeat activity follow - 52.0% An increase of 10.3% 20.0% 0.0% Total National average RN DCT at start Repeat DCT RN Average HCSW DCT at the start and at the repeat Activity Follow Trust average for a HCSW: 80.0% 60.0% 40.0% 20.0% At start - 56.12% At repeat activity follow - 62.0% An increase of 5.88% 0.0% Total National average HCSW DCT at start Repeat DCT HCSW 9
The graph shows an average throughout the Trust with many wards being at different levels of the plan. Along with the direct care time the motion has decreased for the RN by 5.74% and 5.53% for the HCSW. Interruptions have also been seen to decrease by 59% for the RN and by 75% for the HCSW. This time saved is reinvested into patient care. The Productive Operating Theatre (TPOT) TPOT team have continued with Ear Nose and Throat (ENT) to develop agreed outcomes following a patient turnaround session. In addition, MSK clinicians have been involved in a TPOT briefing identifying key barriers to tackle first, in partnership with the four clinical champions. Orthopaedic theatre staff have completed an overview of TPOT and the foundation modules. TPOT is planned to be implemented in the Radiology Intervention suite, with theatre support. This will replace RTtCB, as TPOT is more suited to this clinical environment. Progress to date, as reported to the SHA is below. Facilities Management During the month of September 2011 all of the FM Services provided by Carillion Services Limited (CSL) operated within the parameters laid down by the PFI Contract. Portering Service September saw continued intense activity requiring additional CSL Portering staff on several days within the month. As a result of the increased resource, the service performance stabilised within the boundary of the Service Failure Point (SFP) threshold of 235 SFPs at 118 SFPs from 11,428 reactive tasks logged via the FM Helpdesk. With the hospital under immense pressure latterly during the month, the backlogs caused as a result in ED and MAU created high volumes of patient moves, especially for the Discharge Lounge as wards attempted to free up beds. Estates Service The Estates service in September continues to see further improvement and control with the team producing an in month service performance of 227 SFPs, below the monthly 10
threshold of 360 SFPs, from 2,783 reactive tasks logged via the FM helpdesk. A new process to improve the process for small works (improvements/adaptations) is being implemented on the 17 th October 2011. During this month as part of the life cycle works for 2011/12 F2 ward has been worked upon following the decant of that service to G2. The ward has been rewired, new lights installed, new ceiling fitted, various fire works completed, a new nurse call system fitted and the whole ward redecorated. There was a sewage flood in Starfish ward at the end of August/beginning of September which required the ward to be vacated to an adjacent ward. The cause was attributed to a defect relating to the construction of the drains network. Outstanding actions related to this are being pursed via the contractual mechanisms. Security Following the previous positive audit by an external consultant, the Security Service was audited during September by the Security Industry Authority (SIA) in order to gain SIA Approved Contractor Scheme accreditation. The official report has yet to be received, but initial feedback has been very positive. Domestic Service 46 domestic cleaning audits, spot checks and re-checks were carried out in September, with one failure and 5 areas passing overall but requiring re-checking of certain rooms or areas which had failed individually to meet the required standard. Significant challenges have been experienced by the service as a direct result of the increased patient admissions pressures experienced in ED and MAU. Team Leaders worked with ward staff to ensure that the increased number of infectious cleans were completed promptly and facilities were ready to accept new admissions as required. Telephone Service The roll-out of the Trust s new mobile phone contract with O² was successfully undertaken during September, with over 200 replacement mobiles collected during a 4 day period. Helipad During September 8 helicopter flights were received, with one landing requiring the assistance of the Resuscitation Team to assist in the stabilisation of the patient before transfer to the Emergency Department. The application made to Portsmouth City Council to remove existing time restrictions on flights was successfully approved during September. This will now be taken to the Civil Aviation Authority for their approval. The 2011 PEAT results were officially released, with confirmation of the improvements from good to excellent for patient food and from acceptable to good for hospital environment. 11
Summary of Audits undertaken in the last 12 months Analysis of FM Audits for the last 12 months 80 70 60 Number of Audits 50 40 30 Total audits Total Pass Total Fail 20 10 0 Oct 2010 Nov 2010 Dec 2010 Jan 2011 Feb 2011 Mar 2011 Month Apr 2011 May 2011 Jun 2011 Jul 2011 Aug 2011 Sep 2011 There have been 51 Soft FM audits carried out in the month with just one domestic cleaning failure, which was in Ward C6. CSL have acted immediately to rectify the areas of concern; the ward has since been re-audited and passed successfully, with improvements seen. In addition to domestic audits, the other Soft FM services inspected include Patient Food Tasting, Pest Control, Waste, Helpdesk and Telecoms The Captain s Rounds continue to be carried out each month and are found to be beneficial to the FM services as well as to the overall environment of the hospital. The main findings from the Captains Round continue to be aesthetic issues and are being addressed. It is proposed that for 2012 the allocation of floors to Captains will change. Formal Complaints received via the CSL Help Desk in the last 12 months The table below, shows only the formal complaints received as reported using the Project Agreement payment mechanism. The Development Team continue to work with the Trust Complaints Team on any formal Facilities Management related complaints received through them. The total numbers of complaints received has shown a decrease overall from the previous month. This is due to small decrease in complaints relating to Car Parking, Catering, Security and Portering. Also, the number of complaints relating to Estates decreased from 11 in August to 5 in September. The users are encouraged to report both compliments and complaints. 12
Formal complaints received via the CSL Help Desk in the last 12 months Service Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Catering 2 1 5 1 3 1 3 2 2 0 3 1 Car parking 0 0 0 0 0 1 1 1 13 9 3 0 Domestic 3 2 2 1 5 9 7 2 6 4 1 1 Estates 9 10 9 8 6 10 5 5 2 3 11 5 Helpdesk 2 2 0 0 0 0 0 0 0 0 0 0 Housekeeping 4 2 2 0 1 3 1 3 2 1 0 1 Linen 2 1 3 4 1 1 0 0 0 0 0 0 Pest 1 0 0 0 1 0 0 0 0 0 0 2 Portering 7 10 4 7 7 6 7 1 2 7 7 5 R&D 0 0 0 0 0 1 0 0 0 0 0 0 Security 0 1 0 0 1 1 0 1 0 1 1 0 Telecomms 0 1 2 2 2 0 0 1 0 0 1 0 Post 0 0 0 0 0 0 0 0 0 0 0 0 Waste 0 0 0 0 0 0 0 0 0 0 0 0 Totals 30 30 27 23 27 33 24 16 27 25 27 15 There were no car parking complaints declared for September. 13
Appendix 1: Business Intelligence Pack
Appendix 1: Business Intelligence Pack
Appendix 2: Statistical Process Control (SPC) format
Appendix 2: Statistical Process Control (SPC) format
Appendix 2: Statistical Process Control (SPC) format