Mortality: HSMR Performance improved in August 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 August. Mortality: SHMI (quarterly) A decline in performance is noted in Q4 2016/17. 1
Ward-based cardiac arrests (coded as preventable calls) There were 4 Ward Based cardiac arrests during November, of which 3 were coded as preventable, 1 each on Creaton (pre ward move), Holcot and Victoria. Peri-arrest calls - wards only There were 20 peri-arrest calls during November 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 1.92% during November. The percentage of Critical Risk Patients with a Care Plan in place declined during November to 54.55%. % of overdue observations The % of overdue observations improved during November to 7.5%, however remain above the Trust target of 7% for the fourth 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 approved.. Vitalpac upgrade now estimated to go live in Feb 2018. 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% November update not available at the time of reporting. Monthly Executive Safety Rounds by Trust Board Members 56 Executive Safety Visits have taken place so far this year. Current trajectory above the stretch target of 72 visits in the year. 122 Beat the Bug Executive visits have also taken place from April to November 2017 inclusive. 4
There have been 94 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 increased from 1.04 in October to 1.78 in November, this equates to 38 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 November. 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 for November 2017 remained at 99.7%. The improvement in compliance has been sustained for 5 consecutive months. Patient risk assessment completed for out of hours transfers 27 OOH transfers during November, 27 (100%) had a patient risk assessment completed prior to transfer. 7
As at the end of November 17 POC Sims have taken place within Urgent Care and a further 22 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. Documented risk assessment for VTE EDN Data The % of patients with documented risk assessment for VTE decreased to 95.3% in October, following validation. 8
Vitalpac Data Documented risk assessment for VTE September October November Ward % Patients Assessed Ward % Patients Assessed Ward % Patients Assessed Spencer 46% Spencer 38% Althorp 50% Althorp 49% Abington 58% Spencer 57% Hawthorn 59% Hawthorn 62% Willow 57% Rowan 64% Rowan 63% Hawthorn 58% Finedon 66% Cedar 64% Cedar 61% September October November Ward % Patients Assessed Ward % Patients Assessed Ward % Patients Assessed Spencer 41% Spencer 33% Spencer 31% Althorp 60% Abington 48% Holcot 40% Hawthorn 65% Talbot Butler 55% Hawthorn 43% Knightley 67% Rowan 60% Rowan 47% Finedon 73% Hawthorn 61% Becket 50% The % of patients discharged in the month that had a VTE assessment recorded on Vitalpac during their time in the Trust declined to 40% in November. Compliance declined in Medicine and Surgery during November. The 5 wards with the lowest compliance for the last three months are listed. The % of patients admitted receiving a VTE assessment was 48% in November. As of November this is no longer adjusted for Low Risk Cohort, Paediatrics and Maternity. The 5 Wards with the lowest compliance for the previous three months are listed. 9
Number of Hospital Acquired Thrombosis following RCA There were 5 HATs during March 2017 following root cause analysis. No updated data has been received. 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 declined to 54% during November. 10
11 Participants in leadership programmes As at the end of November there have been 516 participants in the LOVE programme, 193 staff trained by the QI Team and 60 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 November the percentage of women that had a CO measurement taken at their booking appointment declined to 75.3% however remains 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 Improvement during November to 88% for dementia carers that took the survey, that said they feel supported. % that answered yes to three questions regarding care rounds Decline in staff asking care round questions every 1-2 hours to 93%. Care rounds in place on the ward remained at 100%. Improvement in care rounds documented according to guidelines to 96%. Number of patients discharged with primary diagnosis of heart failure Vs. Referrals to Heart Failure During October the number of patients discharged with Heart Failure increased to 71 and the number referred to the Heart failure team increased to 79. 12
The % of stroke patients reaching a stroke bed within 4 hours declined to 67% during November, 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 93% during November. It is aimed that 85% of stroke patients spend at least 90% of their time on the stroke unit, performance declined during November 83% 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. November data is not yet available. 13
Friends and Family Test % that would recommend the Trust During November 93.0% 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 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 increase in on the day cancellations for non-clinical reasons is noted during November. There were 20 cancellations due to delays or over-running during November. No. cancelled operations due to bed availability There were 22 operations cancelled due to the lack of bed availability during November. 15
Theatre productivity reduced to 82% during November and remains below target. Utilised Theatre Time and time lost due to late starts % of time lost due to late starts reduced during November to 6%. 16
Outpatient DNA rates improved further in November to 6.91%, but remain above the internal target of 5%. Outpatient DNA rates DNA rates in Medicine have increased during November. In Surgery DNA rate improved, but remain above the target of 5%. WCOHC remain just above target at 5.3%. 17
Complaints relating to Outpatients Formal complaints reduced during November. Complaints relating to outpatients also reduced. Rescheduled Outpatient Appointments The Changing Care project in Outpatients aimed to improve the administration processes and reduce % of rescheduled appointments. The % of rescheduled appointments improved to 8.5% during November, further focus is required to reach the target of 5%. 18
The total Daycase percentage remained above target at 87.8% during November Total Daycase rate (%) Vs. Failed daycases (%) The Failed Daycase rate improved to 4.19% during November. 19
Patients cared for outside of specialty The percentage of patients cared for outside of specialty reduced to 16.1% during November Divisional breakdown of patients cared for outside of specialty M&UC 13.8% Surgery 22.1% WC&O 16.0% Early discharges during November declined to 19% and 6% below the 25% internal target. Discharges before midday Divisional breakdown discharges before midday M&UC 18.9% Surgery 16.2% WC&O 19.8% Early discharges at the weekend remain above the internal target during November. Early weekday discharges declined to >8% below target. 20
Productivity Medical notes available for clinics Performance improved to 99.6% during November. Divisional breakdown of medical notes available for clinics M&UC 99.6% Surgery 99.7% WC&O 99.8% Productivity Complaints responded to within agreed timescales The MQC project aimed to increase the percentage of complaints responded to within agreed timescales. During November 93.1% 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 go to triage has remained at 6 minutes for 8 consecutive months. Professional Standards Specialty doctors will assess emergency patients within 30 minutes of referral. The average time for patients in the emergency department to be seen by a specialty doctor following referral remains above the target of 30 minutes at 72 minutes during November. The average time to doctor by each Division is also shown for the last 6 months. 22
Nursing attrition and sickness rates Staff attrition remained at 6.6% in November and remains below the national benchmark. Sickness reduced during November to 4.7%, which is below the National Benchmark. The % of shifts covered by substantive RNs increased to 85% in November. Agency, Bank and Substantive Supply % for RNs Bank remained at 12%. Agency reduced to 3%. 23
Agency, Bank and Substantive Supply % for HCAs In November our HCA substantive supply rate increased to 71%. Bank supply reduced to 24%. Agency supply rates remained at 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. No data received for November 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. No data received for November. 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. No update available this month. 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. No update available this month. Environmental Measures Carbon Emissions Carbon Emissions remain below target this year. No update available this month. 26
Quality Improvement Ongoing Projects The Quality Improvement team are currently supporting 85 projects and a further 13 have sustainability checks ongoing. 31 QI abstracts have been submitted and accepted to the international Quality improvement forum. Quality Improvement Project of the Month Postpartum Haemorrhage rates in NGH The QI project of the month for December is: Postpartum Haemorrhage rates in NGH. This project was developed as NGH were identified as a national outlier for Postpartum Haemorrhage. Syntometrine injections to control postpartum haemorrhage after vaginal delivery and Carbetocin following caesarean section are being introduced in December. Training on measuring blood loss is also taking place in the coming weeks and work is on going to introduce a PPH care bundle. 27
Quality Improvement QI Projects Quality Impact Projection The Quality Improvement team have supported 129 projects during 2017/18. The expected quality impact of these is as follows: 108 improving staff experience 76 improving patient experience 49 with a positive financial impact 35 with a positive environmental impact 34 reducing LOS 17 Admission Avoidance 31 impacting Urgent Care 18 impacting Flow/ Discharge 10 impacting Outpatient Efficiency 127 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