Mortality: HSMR Performance remained below target in July Nat 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 in July. Mortality: SHMI (quarterly) A decline in performance can be seen in Q4 2016/17. 1
Ward-based cardiac arrests (coded as preventable calls) There were 5 cardiac arrest coded as preventable during October 2017, 1 each on Dryden, EAU, Finedon, Hawthorn and Willow. Peri-arrest calls - wards only There were 31 peri-arrest calls during October 2017 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 reduced to 2.81% in October. The percentage of Critical Risk Patients with a Care Plan in place improved in October to 68.75%. % of overdue observations Overdue observations increased in October to 8.15%, above the Trust target of 7% for the third consecutive month. 3
Sepsis screening, time to administration of antibiotics and antibiotic review Q2 : 2 out of 4 CQUIN targets achieved: ED & Inpatient sepsis screening exceeded 90% target. Compliance with antibiotics <60 mins below target in both areas. Action October/November: Sepsis educational overview created for inclusion in BLS training sessions Business case being developed for Sepsis Nurse role. To be reviewed by Director of Strategy & Partnerships Guidelines await committee validation at the end of November. New Sepsis Boxes are in the process of being signed off. Vitalpac upgrade now estimated to go live in Feb 18. It will include ability to link individual PINs to sepsis screening and action functionality, allowing only registered nurses to be able to see the screening function. Nurses will receive alerts when EWS scores trigger sepsis. This will support delivery of the antibiotic target of 90% Monthly Executive Safety Rounds by Trust Board Members 44 Executive Safety Visits have taken place so far this year. Current trajectory now above the stretch target of 72 visits in the year. There were 10 visits during September. 109 Beat the Bug Executive visits have also taken from April to October 2017 inclusive. 4
There have been 84 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 12 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 have also taken place. In October there were 0.68 pressure ulcers/1000 bed days. 5
Reduce harm from patient falls Number of falls per 1000 bed days reduced from 1.53 in September to 1.04 in October, this equates to 23 harmful falls in the month. Patients receiving appropriate pain management All three measures of pain management key performance indicators have remained above the 95% target during October. Reduce percentage of omitted medicines (not documented) EPMA data related omitted medicines (not documented) from July-October 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 for October 2017 improved to 99.7%. The improvement in compliance has been sustained for 4 consecutive months. Patient risk assessment completed for out of hours transfers 16 OOH transfers during October, 16 (100%) had a patient risk assessment completed prior to transfer. 7
As at the end of October there have been 34 thematic sims across all wards. Point of Care Simulation Reactive sims arising from concerns from the ROHG agenda commenced in July. A total of 49 sims have tested 3 areas of best practice, the number where best practice was adhered to is shown in the chart. 8
EDN Data The % of patients with documented risk assessment for VTE decreased to 96.7% in September, following validation. Documented risk assessment for VTE Vitalpac Data The % of patients discharged in the month that had a VTE assessment recorded on Vitalpac during their time in the Trust declined to 43% in October. Compliance declined in all divisions during October. August September October Ward % Patients Assessed Ward % Patients Assessed Ward % Patients Assessed Spencer 40% Spencer 46% Spencer 38% Hawthorn 57% Althorp 49% Abington 58% Althorp 64% Hawthorn 59% Hawthorn 62% Eleanor 65% Rowan 64% Rowan 63% Rowan 65% Finedon 66% Cedar 64% The 5 wards with the lowest compliance for the last three months are listed. 9
Documented risk assessment for VTE Number of Hospital Acquired Thrombosis following RCA August September October Ward % Patients Assessed Ward % Patients Assessed Ward % Patients Assessed Spencer 34% Spencer 41% Spencer 33% Talbot Butler 60% Althorp 60% Abington 48% Hawthorn 60% Hawthorn 65% Talbot Butler 55% Holcot 67% Knightley 67% Rowan 60% Eleanor 68% Finedon 73% Hawthorn 61% Vitalpac Data Patients admitted, (excluding Paediatrics and Maternity and adjusted for Low Risk Cohort), the % receiving a VTE assessment within 24 hours was 83.5% in October. The 5 Wards with the lowest compliance for the previous three months are listed. There were 5 HATs during March 2017 following root cause analysis. 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 improved to 58% during October. 10
11 Participants in leadership programmes As at the end of October there have been 468 participants in the LOVE programme, 216 staff trained by the QI Team and 48 new QI projects. The latest cohort of the Francis Crick programme started in February and MQC started their latest cohort in March, therefore there are no new participants for 2017/18 as yet. Carbon monoxide measurements taken at booking appointment During October the percentage of women that had a CO measurement taken at their booking appointment increased to 76.8% which is above the 50% sign up to safety target. Harm Index There is a consistent reduction in harm year on year, as demonstrated in the cumulative view of the 6 harm measures.
Dementia carers that feel supported Decline during October to 83% for dementia carers that took the survey, that said they feel supported. % that answered yes to three questions regarding care rounds Improvement in staff asking care round questions every 1-2 hours to 97%. Care rounds in place on the ward remained at 100%. Decline in care rounds documented according to guidelines to 92%. Number of patients discharged with primary diagnosis of heart failure Vs. Referrals to Heart Failure During September the number of patients discharged with Heart Failure increased to 55 and the number referred to the Heart failure team increased to 67. 12
The % of stroke patients reaching a stroke bed within 4 hours improved to 90% in October, above 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 91% in October. It is aimed that 85% of stroke patients spend at least 90% of their time on the stroke unit, in October 98% was achieved. 100% of patients in AF are discharged on anti-coagulation. 40% of patients should be discharged with ESD. Compliance in October was 29%, this was appropriate for the case mix. 13
Friends and Family Test % that would recommend the Trust During September 92.6% of patients that completed the Friends and Family Test said that they would recommend the Trust. October data not validated for this report. 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 in quarter 3 and 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 to the quarterly results. A decline in scores is seen in Q1, however remain higher than the national 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 improvement in on the day cancellations for non-clinical reasons is noted during October. There were 15 cancellations due to delays or over-running during October. No. cancelled operations due to bed availability There were 4 operations cancelled due to the lack of bed availability during October. 15
Theatre productivity increased to 84% during October, however remains below target. Utilised Theatre Time and time lost due to late starts % of time lost due to late starts reduced during October. 16
Outpatient DNA rates improved further in October to 7.03%, but remain above the internal target of 5%. Outpatient DNA rates DNA rates in Medicine have increased during October. In Surgery DNA rate improved, but remain above the target of 5%. WCOHC remain just above target at 5.2%. 17
Complaints relating to Outpatients Formal complaints increased during October. Complaints relating to outpatients also increased. 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 9.5% during October further focus is required to reach the target of 5%. 18
The total Daycase percentage remained above target at 87.6% during October Total Daycase rate (%) Vs. Failed daycases (%) The Failed Daycase rate increased to 4.29% during October. 19
Patients cared for outside of specialty The percentage of patients cared for outside of specialty increased to 16.4% during October Divisional breakdown of patients cared for outside of specialty M&UC 15.3% Surgery 18.0% WC&O 20.2% Early discharges in October remained at 20% and 5% below the 25% internal target. Discharges before midday Divisional breakdown discharges before midday M&UC 20.2% Surgery 17.6% WC&O 20.6% Early discharges at the weekend remain above the internal target in October. Early weekday discharges remain >7% below target. 20
Productivity Medical notes available for clinics Performance improved to 99.4% in October. Divisional breakdown of medical notes available for clinics M&UC 99.1% Surgery 99.7% WC&O 99.3% Productivity Complaints responded to within agreed timescales The MQC project aimed to increase the percentage of complaints responded to within agreed timescales. In October 100% were responded to within the agreed timescales. 21
Professional Standards Time for Resus patients to be seen by specialty SpR or Consultant following referral The average time for resus patients to be seen by a specialty doctor following referral declined to 45 minutes in October. The average time to Triage was 8 minutes. The average time to doctor, by Division is also show, for patients that have been referred to a specialty within the hospital. Decline in all divisions in October and all remain above the target of 20 minutes. Professional Standards Specialty patients reattending with the same problem within 1 week The percentage of re-attenders that returned with the same problem within a week was below target in October at 1.9%. 22
Nursing attrition and sickness rates Staff attrition increased to 6.63% in October however remains below the national benchmark. Sickness increased during October to 4.8%, which is equal to the National Benchmark. The % of shifts covered by substantive RNs reduced to 84.0% in October. Agency, Bank and Substantive Supply % for RNs Bank remained at 12%. Agency remained at 4%. 23
Agency, Bank and Substantive Supply % for HCAs In October our HCA substantive supply rate increased to 69%. Bank supply remained at 26%. Agency supply rates reduced from 6% to 5%. 24
Report suspended, awaiting substantive and budgeted WTE for Medical Staffing validation. Medical Staff Shift Fill Rate In October: 24.61 WTE increase in Agency No requested shifts were filled by Bank or internally. Reason for Agency, Bank and Overtime In October 61.7% of shifts where agency was requested was due to vacancies, 19.8% for the new medical in-reach service, 12.7% to cover maternity, 4.4% to cover sabbatical, 1.4% to cover sickness and 0.1% to cover holiday. 25
Environmental Measures Recycled Waste The percentage of waste recycled by the Trust increased in 16/17 and has increased further so far overall this year. 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 remain below target this year. 26
Quality Improvement Ongoing Projects The Quality Improvement team are currently supporting 76 projects and a further 13 have sustainability checks ongoing. The QI project of the month for November is: Go Fast Go Home: Managing Atrial Fibrillation in ED Quality Improvement Project of the Month Go Fast Go Home: Managing Atrial Fibrillation in ED The aim of this project was to reduce the number of admissions for patients presenting to ED with isolated atrial fibrillation, when no further inpatient treatment is needed. To improve the management of these patients a new pathway, specific to patients with AF, was developed. The pathway contains guidance on rhythm and rate control and a strict discharge plan including medication and follow up in the Ambulatory Care Centre (ACC). The implementation of the pathway has shown a significant reduction in the admission rate, reducing costs and improving patient care. 27
Quality Improvement QI Projects Quality Impact Projection The Quality Improvement team have supported 117 projects during 2017/18. The expected quality impact of these is as follows: 100 improving staff experience 65 improving patient experience 42 with a positive financial impact 30 with a positive environmental impact 27 reducing LOS 12 Admission Avoidance 24 impacting Urgent Care 12 impacting Flow/ Discharge 8 impacting Outpatient Efficiency 115 improving patient safety Quality Improvement QI Projects Benefits Realisation At the end of Q2 2017/18 QI projects have had a positive financial impact of 269k. 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