Mortality: HSMR Nat Performance continued to improve into Q3 2016/17. NB: Each month is a 12 month rolling value. I.e. Mar-16 reports the monthly average of Apr-15 to Mar-16. Mortality: HSMR (weekday) vs. HSMR (weekend) Mortality: HSMR Performance remained in the expected range going into Q3 2016/17. Mortality: SHMI (quarterly) An improvement in performance since 2014/15 (Q4) is acknowledged. Q3 2015/16 noted a further improvement and remains below expected levels. 1
Cardiac Arrests Ward-based cardiac arrests (coded as preventable calls) There were 4 cardiac arrest coded as preventable during January 2017: 2 in Creaton, 1 in EAU and 1 in Collingtree. Peri-arrests Peri-arrest calls wards only There were 26 peri-arrest calls during January 2017 for patients triggering EWS >5 or patients identified as code red. 2
Early Warning Score Patients scoring >7 (critical Risk) Vs. % of critical risk patients with a management plan in place The percentage of Critical Risk patients increased to 5.58% in January. The percentage of Critical Risk Patients with a Care Plan in place declined in January to 66.67% Early Warning Score % of overdue observations Overdue observations for the Trust reduced in January, however remain above the Trust target at 7.28%. 3
Sepsis Treatment Sepsis screening, time to administration of antibiotics and antibiotic review Q3 targets achieved. Upward trend in ABX review <3 days, reflecting work with Pharmacy promoting timely review and ward poster campaign, ward conversation and Junior doctor promotions. Mixed trend in ABX administration <60 mins: 50% target easily exceeded, but evidence of screening rose in November and degraded in December. Dr Dyer (ED Sepsis lead) continues to encourage staff to complete FIT form screening. Trial screening and action tools launched on adult wards in December with a view to help with rapid treatment. Q4 some targets at risk. ED screening and ABX review target should be achieved. Inpatient screening could be met if trial screening tools are used. ABX/review target at risk due to inconsistent evidence. Trail screening tools now in adult & maternity wards, Paeds relaunch in February. Promotion continues including screening of Starfish film in February. Board to Ward Monthly Executive Safety Rounds by Trust Board Members 11 Executive Safety Visits were completed in January, bringing the total to 174 for the year. 4
14 Grade 2 pressure ulcers during January. Pressure Ulcers Reduce hospital acquired pressure ulcers No Grade 3 pressure ulcers during January. Four learning sessions for the Pressure Ulcer Collaborative have taken place as well as the Cultural Web in July. An improvement was initially seen until the increase in November and December. An improvement can be seen in January. 5
Harmful Falls Reduce harm from patient falls Number of falls per 1000 bed days increased from 1.57 in December to 1.60 in January, this equates to 36 harmful falls in the month. Pain Management Patients receiving appropriate pain management All three measures of pain management have remained above the 95% target during 2016/17. Omitted Medicines Reduce percentage of omitted medicines (not documented) No audit in December or January due to lack of capacity. July to November s figures revised following review. 6
WHO Checklist Percentage of operations where WHO safer surgery checklist is being completed Monthly audit taken from Nexus from October. Audit compliance improvement during January to 81%. Improving transfers/handover of care Patient risk assessment completed for out of hours transfers 94 OOH transfers in December, 91 (97%) had a patient risk assessment completed. January data not available for this report. LFE for Clinical Teams Learning from Errors training The percentage of Nursing and Medical staff attending LFE sessions increased during January. 7
VTE Risk Assessment % of patients with documented risk assessment for VTE (from EDN) remained at 94% in January. Documented risk assessment for VTE From 7 th December VTE assessments should be completed on Vitalpac. Decline in overall compliance on Vitalpac in January to 22%. Hospital Acquired Thrombosis Number of HATs following RCA There were 3 HAT s validated during October 2016 following root cause analysis. No update was available this month. 8
Time to Consultant Review EAU & Benham Time to First Consultant Review All emergency admissions should be reviewed by a Consultant within 14 hours. This is now calculated from the time of decision to admit rather than registration. On average 54% are seen within 14 hours, a decline to 43% has been seen in January. Leadership Training & Development Participants in leadership programmes During 2016/17 there have been 63 MCQ participants, 7 MQC projects and 526 participants in the LOVE programme. The second cohort for the Francis Crick programme is now due to start in February. Reduce stillbirths & undiagnosed small for gestational age babies Carbon monoxide measurements taken In January 66% of women had a CO measurement taken at their booking appointment. The decline this month is due to faulty monitors which have had to be returned to the manufacturer. 9
Dementia Carers Survey Dementia carers that feel supported 100% of dementia carers that took the survey in January, said that they feel supported. Intentional Rounding % that answered yes to three questions regarding care rounds Improvement in compliance for all three questions in January. Heart Failure Number of patients discharged with primary diagnosis of heart failure Vs. Referrals to Heart Failure Data shows a gap between the number of patients discharged with Heart Failure and those being referred to the Heart Failure Team. 10
The % of stroke patients reaching a stroke bed within 4 hours improved in January but remains below target 67%. Stroke Care The % of patients scanned within 1 hour of arrival is consistently above the target of 50%. Caring for Stroke patients It is aimed that 85% of stroke patients spend at least 90% of their time on the stroke unit, in January 79% was achieved. 100% of patients in AF are discharged on anti-coagulation. 40% of patients should be discharged with ESD, compliance improved in January to 41%. 11
Friends and Family Test % that would recommend the Trust In December 92.7% of patients that completed the Friends and Family Test said that they would recommend the Trust. January data not available for this report. National CQC Patient Survey An improvement in scores can be seen in most sections in the last survey compared with the previous year. The results for 2016 are expected in the summer of 2017. National annual patient survey The Right time survey began in quarter 3 which asks some of the same questions as the CQC survey. Comparing the results of these questions we can see an improvement in the majority of section scores from the annual survey. 12
Productivity No. of patients per month cancelled on the day of surgery (all nonclinical reasons) Vs. No. of patients per month cancelled on the day of surgery due to delays or over-running An increase in on the day cancellations for non-clinical reasons can be seen in January. There were 12 cancellations due to delays or over-running in January. Productivity No. cancelled operations due to bed availability There were 10 operations cancelled due to the lack of bed availability in January. Directorate breakdown of cancellations due to bed availability Surgery 9 Head & Neck 1 13
Theatre productivity declined in January. % of time lost due to late starts also declined during January. Productivity Utilised Theatre Time and time lost due to late starts Within DSU, where the first phase of the Changing Care programme has been focused, the mean Theatre Utilisation has improved but late starts have declined. Both have declined in January. 14
Outpatient DNA rates improved in January, however remain above the target of <7.5%. Productivity Outpatient DNA rates All four divisions are above the target of 7.5% in January. ENT and Urology have been working with Changing Care as part of the Outpatient Productivity programme. 15
Productivity Complaints relating to Outpatients Formal complaints increased in January. Complaints relating to outpatients also increased. Productivity The total Daycase percentage improved to 92.0% in January. Total Daycase rate (%) Vs. Failed daycases (%) The Failed Daycase rate remained at 3.60% in January. 16
Efficiency Patients cared for outside of specialty Increase in month for patients cared for outside of speciality is noted. Divisional breakdown of patients cared for outside of specialty M&UC 22.4% Surgery 35.4% WC&O 9.9% Overall improvement in early discharges in January, however remains >5% lower than the 25% internal target. Productivity Discharges before midday Divisional breakdown discharges before midday M&UC 17.3% Surgery 20.5% WC&O 20.6% During the weekends the 25% target is generally met. On week days on average 18% of discharges are before midday. 17
Productivity Medical notes available for clinics Improvement in performance in January to 98.4%. Divisional breakdown of medical notes available for clinics M&UC 97.1% Surgery 99.4% WC&O 97.6% 18
Nursing Productivity Staff attrition and sickness rates Staff attrition remained at 6.6% in January, below the national benchmark. Sickness increased during January, but remains below the National Benchmark. Nursing Productivity Agency, Bank and Substantive Supply % for RNs In January 85.76% of our RNs were substantive members of staff, a decline from December. This led to a increase in Bank to 10% and Agency remained at 4%. Nursing Productivity Agency, Bank and Substantive Supply % for HCAs In January 69% of our HCAs are substantive staff, a reduction from December. This led to an increase in both Bank and Agency supply rates. 19
Report suspended, awaiting substantive and budgeted WTE for Medical Staffing validation. Medical Productivity Shift Fill Rate In December: 13.30 WTE increase in Agency No requested shifts were filled internally or with bank in December. January data not available for this report. Medical Productivity Reason for Agency, Bank and Overtime In December 91.7% of Medical Agency, Bank and Internal overtime was due to vacancies, 3.8% was to cover sickness, 2.4% due to other reasons and 2.1% to cover holidays. January data not available for this report. 20
Nat CC SU2S Key National Target Changing Care@NGH Sign up to safety Metrics in Development Target - Metrics for MQC projects to be added Quarter Q4 MQC Making Quality Count QI Quality Improvement Carter Carter Recommendations QP Quality Priority 21