Mortality: HSMR Nat NB: Each month is a 12 month rolling value. I.e. Mar-16 reports the monthly average of Apr-15 to Mar-16. Performance further improved in October. November data not yet available. Mortality: HSMR (weekday) vs. HSMR (weekend) Mortality: HSMR Performance remained in the expected range in October. November data not yet available. Mortality: SHMI (quarterly) An improvement in performance is noted in Q1 2017/18. 1
Ward-based cardiac arrests (coded as preventable calls) There were 6 Ward Based cardiac arrests during February, of which 4 were coded as preventable, 2 on Becket and 1 each on EAU and Victoria. Peri-arrest calls - wards only There were 46 peri-arrest calls during February 2018 for patients triggering EWS >5 or patients identified as code red. 2
Patients with an early warning score >7 (critical risk) Vs. % of critical risk patients with a management plan in place The percentage of Critical Risk patients increased to 4.62% during February. The percentage of Critical Risk Patients with a Care Plan in place declined during February to 74.1%. % of overdue observations The % of overdue observations increased during February to 8.85% and remains above the Trust target of 7% for the seventh consecutive month. December and January s data has now been validated by ICT. 3
Sepsis screening, time to administration of antibiotics and antibiotic review Q3 : Achievement of 2 out of 4 CQUIN targets: Confident that both ED and inpatient sepsis screening will achieve Q4 targets. Compliance with antibiotics <60 minutes is improving in both areas however the Q4 target will be challenging to achieve continued education and engagement initiatives with support from Antimicrobial Pharmacists and Resus training team continues. Action February/March: Awareness campaign - FY1 teaching session, screensavers to be published and Ward managers will be sent Sepsis updates at the end of the year and expectations for 2018/19 CQUIN Guidelines Latest update to be reviewed by clinical guidelines committee in March. Distribution to wards as soon as validated. Sepsis Nurse role being reviewed in context of the wider CQUIN requirements. VitalPac upgrade being validated in test system. Go live date planned March. Demonstrations to Nursing management will be organised for March/April. New functionality is vital to enable the Trust to be 100% compliant with inpatient early screening targets as well as guaranteeing improvement for early treatment to achieve CQUIN target. Monthly Executive Safety Rounds by Trust Board Members 232 Executive Safety Visits have taken place so far this year, this is above the stretch target of 72 visits in the year. 149 Beat the Bug Executive visits have also taken place from April to February inclusive. 4
There have been 110 grade 2 pressure ulcers so far this year. This is below the revised Sign up to Safety target for 2017/18 of less than 195 grade 2 pressure ulcers in the year. Reduce hospital acquired pressure ulcers There have been 14 grade 3 pressure ulcers so far this year. This is below the revised Sign up to Safety target for 2017/18 of less than 53 grade 3 pressure ulcers in the year. Four learning sessions for the Pressure Ulcer Collaborative have taken place as well as the Cultural Web in July. Following this an improvement can be seen. Two rapid Improvement Challenges and a Stop the Pressure Day have also taken place. In February there were 0.35 pressure ulcers/1000 bed days. 5
Reduce harm from patient falls Number of falls per 1000 bed days reduced from 1.90 in January to 1.44 in February, this equates to 29 harmful falls in the month. Patients receiving appropriate pain management All three pain management key performance indicators have remained above the 95% target during February. Reduce percentage of omitted medicines (not documented) EPMA data for omitted medicines (not documented) from July-November 2017 remains not validated. EPMA have been asked to modify reports. A point prevalence audit of 4 wards completed in June 2017 is being used as baseline data. 6
Percentage of operations where WHO safer surgery checklist is being completed From October 2016 data collated from Nexus. Compliance during February 2018 was 99.7%. The improvement in compliance has been sustained for 8 consecutive months. Patient risk assessment completed for out of hours transfers 83 OOH transfers during February, 80 (96%) had a patient risk assessment completed prior to transfer. 7
As at the end of February 22 PoC Sims have taken place within Urgent Care and a further 29 have taken place in wards across the rest of the hospital. Point of Care Simulation Reactive Sims arising from concerns from the ROHG agenda commenced in July. A total of 63 sims have tested 5 areas of best practice, the number where best practice was adhered to is shown in the chart. No Reactive Sims have taken place during February. 8
Vitalpac Data The % of patients recorded on vitalpac as admitted during February receiving a VTE assessment within 24hours declined to 70%. Documented risk assessment for VTE A decline in compliance was seen in the Surgery Division during February. Compliance in WC&O improved and compliance in Medicine remained at 57% December January February Ward % Patients Assessed Ward % Patients Assessed Ward % Patients Assessed Spencer 34% Abington 30% Collingtree 0% Abington 40% Hawthorn 33% Hawthorn 0% Willow 41% Compton 33% Compton 0% Rowan 44% Collingtree 40% Rowan 13% Finedon 44% Head and Neck 41% Head and Neck 21% The 5 wards with the lowest compliance for the last three months are listed. 9
Number of Hospital Acquired Thrombosis following RCA There were 9 HATs during August and September 2017 following root cause analysis. A breakdown of VTE s by quarter, showing the number that were preventable and the number that were not preventable is shown. Time to First Consultant Review All emergency admissions should be reviewed by a Consultant within 14 hours from the time of decision to admit. Compliance further improved to 73% during February. 10
11 Participants in leadership programmes As at the end of February there have been 734 participants in the LOVE programme, 193 staff trained by the QI Team and 74 new QI projects. The latest cohort of the Francis Crick programme started in February 17 and MQC started their latest cohort in March 17, therefore there are no new participants for 2017/18 as yet. Carbon monoxide measurements taken at booking appointment During February the percentage of women that had a CO measurement taken at their booking appointment continued to improve to 80.4% and remains above the 50% sign up to safety target. Harm Index The Harm Index is a cumulative view of 6 harm measures. The cumulative cases of harm for 2017/18 are now above the total number for 2016/17. This is due to higher numbers of Harmful Falls, HATs and medication errors.
Dementia carers that feel supported Improvement during February to 77% for dementia carers that took the survey, that said they feel supported. % that answered yes to three questions regarding care rounds Care rounds in place on the ward remained at 100%. Decline in care rounds documented according to guidelines to 94%. Decline in staff asking care round questions every 1-2 hours to 95%. Number of patients discharged with primary diagnosis of heart failure Vs. Referrals to Heart Failure During January the number of patients discharged with Heart Failure reduced to 42 and the number referred to the Heart failure team reduced to 59. 12
The % of stroke patients reaching a stroke bed within 4 hours declined to 60% during February and remains below the 75% target. Caring for Stroke patients The % of patients scanned within 1 hour of arrival is consistently above the target of 50% and compliance was 85% during February. It is aimed that 85% of stroke patients spend at least 90% of their time on the stroke unit, performance further declined during February and 75% was achieved. 100% of patients in AF are discharged on anti-coagulation. 40% of patients should be discharged with ESD. Compliance in February was 30%, this was appropriate for the case mix. 13
Friends and Family Test % that would recommend the Trust During February 92.15% of patients that completed the Friends and Family Test said that they would recommend the Trust. National CQC Patient Survey National annual patient survey The results of the 2016 National CQC patient survey have now been received. Following an improvement in 2015 in all sections the results show a decline in scores in all sections. The Right Time survey began 2016/17and 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 each quarter this year, from the latest CQC Survey results. 14
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 to 169 is noted during February. There were 24 cancellations due to delays or over-running during February. No. cancelled operations due to bed availability There were 23 operations cancelled due to the lack of bed availability during February. 15
Utilised Theatre Time and time lost due to late starts Theatre productivity increased to 79% during February and remains below target. % of time lost due to late starts reduced during February to 7.7%. 16
Outpatient DNA rates improved in February to 6.49% however remain above the internal target of 5%. Outpatient DNA rates DNA rates in Medicine and Surgery have reduced during February and WCOH have increased. All Divisions remain above the target of 5%. 17
Complaints relating to Outpatients Formal complaints increased during February. Complaints relating to outpatients also increased, however remain below average. Rescheduled Outpatient Appointments The Changing Care project in Outpatients aimed to improve the administration processes and reduce % of rescheduled appointments. The % of rescheduled appointments increased to 10.51% during February, further focus is required to reach the target of 5%. 18
Total Daycase rate (%) Vs. Failed daycases (%) The total Daycase percentage remained above target however reduced to 90% during February. The Failed Daycase rate reduced to 4.02% during February. 19
Patients cared for outside of specialty The percentage of patients cared for outside of specialty reduced to 17.9% during February Divisional breakdown of patients cared for outside of specialty M&UC 17.0% Surgery 20.2% WC&O 17.7% Early discharges during February improved to 19% however remains 6% below the 25% internal target. Discharges before midday Divisional breakdown discharges before midday M&UC 17.8% Surgery 16.3% WC&O 22.0% Early discharges at the weekend remained below the internal target during February at 24.7%. Early weekday discharges improved, however remain 7% below target. 20
Productivity Medical notes available for clinics Performance was 99.7% during February. Divisional breakdown of medical notes available for clinics M&UC 99.7% Surgery 99.8% WC&O 99.6% Productivity Complaints responded to within agreed timescales The MQC project aimed to increase the percentage of complaints responded to within agreed timescales. During February 100% were responded to within the agreed timescales. 21
Professional Standards An emergency department decision making clinician will see new patients on or as close to arrival as possible in the ED. The average time for patients in the emergency department to be seen by a doctor has declined during February to 76 minutes. 22
Nursing attrition and sickness rates Nursing staff attrition during February was 6.43% and remains below the national benchmark. Sickness reduced during February to 5.1%, however remains above the National Benchmark. The % of shifts covered by substantive RNs reduced to 83% in February. Agency, Bank and Substantive Supply % for RNs Bank increased to 14%. Agency remained at 3%. 23
Agency, Bank and Substantive Supply % for HCAs In February our HCA substantive supply rate reduced to 67%. Bank supply increased to 28%. Agency supply rates reduced to 5%. 24
Report suspended, awaiting substantive and budgeted WTE for Medical Staffing validation. Medical Staff Shift Fill Rate In February: 14.99 WTE increase in Agency No requested shifts were filled by Bank or internally. Reason for Agency, Bank and Overtime In February 82.5% of shifts where agency was requested was due to vacancies, 7.9% to cover maternity, 6.1% to cover sickness and 3.5% for the medical in-reach service. 25
Environmental Measures Recycled Waste The percentage of waste recycled by the Trust increased in 2016/17 and has increased further during 2017/18. Environmental Measures Water usage A leak increased water usage in 16/17. Despite increasing numbers of patients, overall usage has reduced so far this year. Environmental Measures Carbon Emissions Carbon Emissions have reduced in 2017/18 and remain below target. 26
Quality Improvement Ongoing Projects The Quality Improvement team are currently supporting 63 projects and a further 10 have sustainability checks ongoing. 32 QI abstracts were submitted and accepted to the International Forum on Quality and Safety in Healthcare in May 2018, of these 10 will be presented at the conference. Quality Improvement Project of the Month Improving Topical Prophylaxis Compliance on Surgical Wards in NGH The QI project of the month for February is: Improving Topical Prophylaxis Compliance. Surgical site infection (SSI) accounts for 20% of all healthcare-associated infections and approximately 5% of patients undergoing surgery develop SSI. This can result in wounds failing to heal and a prolonged hospital stay. The aim of this project was to improve the administration of topical skin prophylaxis, which minimises SSI. As well as delivering training and producing prompt stickers the IPC team gained approval for nurses to administer the prophylaxis without it needing to be prescribed. This project and the changes introduced have led to a significant improvement in compliance. This project will be presented at the International Forum on Quality & Safety in Healthcare in May 2018. 27
Quality Improvement QI Projects Quality Impact Projection The Quality Improvement team have supported 143 projects during 2017/18. The expected quality impact of these is as follows: 122 improving staff experience 88 improving patient experience 56 with a positive financial impact 42 with a positive environmental impact 42 reducing LOS 17 Admission Avoidance 35 impacting Urgent Care 28 impacting Flow/ Discharge 10 impacting Outpatient Efficiency 138 improving patient safety Quality Improvement QI Projects Benefits Realisation At the end of Q3 2017/18 QI projects have had a positive financial impact of 405k. 28
Nat Key National Target Changing Care@NGH Sign up to safety Quality Improvement IQET Carter QP Improving Quality & Efficiency Team Carter Recommendations Quality Priority Environmental Measures 29