NHS LANARKSHIRE QUALITY DASHBOARD Board Report October 2011 (Data available as at end August 2011) INTRODUCTION This paper provides a monthly quality dashboard for NHS Lanarkshire. This is in line with the Healthcare Quality Strategy for NHS Scotland in focussing on quality ambitions of person centred, safe and effective care. The data used in the report has been extrapolated from the LanQIP system, information from audits, Datix and ISD. For this month s report it was not possible to get figures on Occupied Bed Days from the new TrakCare system hence estimates are used based on this time last year. SUMMARY Quality Measure Trend Compliant Comment Complaints Number of complaints in line with previous year except in Women s, Cancer & Diagnostics where the level is higher Not Applicable Person centred Safe Effective Local patient experience survey Quarterly Hospital Standardised Mortality Ratios Unadjusted Inpatient Mortality (NHSL Acute Hospital) Reducing unnecessary harm Risk management KPIs Pending data Regression line shows reduction across three acute hospitals In line with the goal the unadjusted mortality is below the baseline Not Applicable This is being monitored by the Head of Patient Affairs and the Acute Division Data is available for wards and a Board level report is being developed The implementation of TrakCare has impacted on the ability of ISD to provide updated information on HSMR. In line with the goal the adverse event rate is below the line Less than 100% of incidents are Detailed commentary below closed in target timeframes with performance on high rated incidents improving In line with the goal the compliance is above the line In line with the goal the compliance is on the line Slightly under the goal line Have had sustained compliance, slight Compliance with hand hygiene Compliance with PVC bundle Compliance with CVC bundle dip this month. CQI compliance Performance is at goal or improving towards goal Admission to Stroke Heat target for admission to a Unit stroke unit is being achieved Stroke Care Performance below goals Detailed commentary below Medicine Performance improving towards reconciliation goal Cost effective Performance close to goal prescribing in primary care Compliant for pressure ulcers, almost compliant for falls and improving for FFN The Board requested a more detailed narrative of the areas where the goals are not being achieved. In response to this request a narrative is provided on two areas. These are the Risk Management KPIs and Stroke Care. A narrative will be provided on Medicine Reconciliation in the November Board Report as part of the quarterly update on the Scottish Patient Safety Programme. 1
Risk Management KPIs To improve achievement against the Risk Management Incident Key Performance Indicators, the Corporate Risk Manager has set out a revised Standing Operating Procedure which has been agreed with the Acute, CHP and Mental Health / Learning Disability Divisional Medical and Nursing Directors. This has also been endorsed by the Risk Management Steering Group. The revised procedure will be effective from 1 October 2011, and involves the Risk Management Service providing monthly reports to the Divisional Medical and Nursing Directors (including Associate Medical Directors for Primary Care and Associate Nursing Director for Mental Health) on incidents rated as High and Very High. This will enable them to: Audit of the completeness of the record Check that SBAR s and Critical Incident Reviews have been completed appropriately Review and where appropriately pursue improved KPI performance for High and Very High incidents The performance of KPIs for incidents rated as Low, Medium, High and Very High are also monitored by the Divisions through the Divisional Partnership arrangements. This is undertaken through quarterly reports which are provided by the Corporate Risk Manager. Divisional management discuss and agree actions to improve performance. The overall performance and management actions are overseen by the Risk Management Steering Group through quarterly reports provided by the Corporate Risk Manager. Within this reporting period, there has been a considerable improvement in the reporting, verifying, investigating and closing of the incidents graded as High within 27 days. Stoke Care Admission to a Stroke Unit The admission to a stoke unit goal (and the Heat target) has been met. The Heat target is for 90% of all patients admitted with a diagnosis of stroke will be admitted to a stroke unit on the day of admission, or the day following presentation by March 2013. In August 2011, 96% of stroke patients were admitted to a stroke unit on the day of or day after admission. There is also a trend of improvement for admission to a stroke unit on the day of admission. Stroke Care The dashboard also considers the stroke care standards of: Percentage of stroke patients receiving a swallow screened on day of admission (goal 100%) Percentage of stroke patients receiving CT scan on day of admission (goal 80%) Percentage of stroke patients receiving aspirin within one day of admission (goal 100%) These goals have not been achieved however, the Heat target and improvement in the stroke care standards has been a major focus for the MCN and the operational service and an action plan is in place covering: Swallow Screen Stroke Senior Charge Nurses visit accident and emergency and medical receiving wards twice a day to ensure swallow screening is performed and documented in the afternoon and late evening between 9-10pm in all three sites Monitoring of training and education of all staff involved in swallow screening is ongoing (e.g. core competency course, STAT training and onsite training sessions by Speech and Language Therapy) in emergency care and stroke unit using the agreed NHS Lanarkshire wide approach to deliver Senior Charge Nurses reinforce the need for nursing to clearly document whether a patient is safe or unsafe to swallow; and where the patient is unconscious to document that this status therefore makes them unsafe to swallow CT Scan Mapped ideal patient pathway for CT scanning using clinical audit data to inform Stroke Senior Charge Nurses visit accident and emergency and medical receiving wards twice a day to advise about CT scan request, performance and reporting National work on available evidence around benefits of early CT scanning has been used; and amendment of the KPI to 24 hours instead of day of admission (NHSL achieves this for all 3 sites) Local audit of the required timings of CT scans especially out of hours Business case being developed for the DMT for resource to run a pilot of immediate CT scanning on one acute hospital site to assess the impact Aspirin Stroke Senior Charge Nurses visit accident and emergency and medical receiving wards twice a day to advise about aspirin prescribing and administration Stroke unit nurses check aspirin has been prescribed and administrated 2
1. Quality Ambition: Person centred Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrates compassion, continuity, clear communication and shared decisionmaking. Progress on this ambition is measured through complaints quarterly reports, the Better Together national survey and ward patient experience survey information which is now available and is being developed into a Board level report. Complaints Top Issues Raised in Complaints in Year to 30 June 2011 Acute Care Issues Year to 30 June 2011 Total 2010/11 Clinical treatment 71 282 Staff attitude and behaviour 36 146 Communication oral 31 126 Family Health Services Year to 30 June 2011 Total 2010/11 Clinical 9 31 Communication / attitude 2 11 Other 5 32 Primary Care Hospital & Community Year to 30 June 2011 Total 2010/11 Health Treatment 15 50 Attitude/Behaviour 6 41 Date of appointment 5 7 Complaints by Area Acute Clinical Division Year to 30 June 2011 Total 2010/11 Emergency Medicine 55 228 Surgical and Critical Care 67 225 Women s, Cancer & Diagnostic 25 79 Other (Medical Records, PSSD, AHPs) 8 45 Primary Care H&CH and FHS Year to 30 June 2011 Total 2010/11 North CHP 27 106 South CHP 22 85 3
2. Quality Ambition: Safety There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times. Progress on this ambition is measured through standardised hospital mortality ratios, SPSP unadjusted patient mortality rates, key performance indicators for incidents and critical incident reviews and HAI indicators. 2.1 Improve mortality by reducing the mortality rate for NHS Lanarkshire by 15% by 31 March 2013 (from a baseline of November 2007) Quarterly Hospital Standardised Mortality Ratios Data source: From December 2009 Information Services Division (ISD) has produced quarterly hospital standardised mortality ratios (HSMR) for hospitals participating in the SPSP. The baseline quarters are those from October 2006 to September 2007. The data used was linked SMR01 Acute inpatient and day case records and GRO death records. The outcome of interest was mortality within 30 days from admission. For case mix adjustment, ISD adapted an approach used by Dr Foster for England. This enabled ISD to make use of the availability of linked data in Scotland, so that the analysis could be patient-based (as opposed to spell-based) and could include deaths following discharge. Two charts for the HSMR data are provided for each hospital. The first chart show the hospital s HSMR against the Scottish average. The second chart is new and shows any underlying trend in the data using a regression line. The regression line shows a reduction in the HSMR across all three acute hospitals. The Board should look for NHS Lanarkshire to be at or below Scottish SMR by quarter line which is the Scottish average. 4
The HSMR tables identify that Hairmyres Hospital HSMR rate has been consistently around the baseline Scottish SMR level. Both Monklands and Wishaw Hospitals have been higher however have been decreasing slowly. This in part may reflect the different services which are concentrated at the hospitals. One of the overall outcome measures of the SPSP is to demonstrate reduction in HSMR for each Board against its own HSMR baseline from November 2007. The charts below show the baseline period before the Scottish Patient Safety Programme commenced before the red line. The blue line after this is the regression line for the data. The Board should look for the regression line to be going down. The regression line shows a reduction in the HSMR across all three acute hospitals. 5
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Percentage Unadjusted Inpatient Mortality (NHSL Acute Hospital) A complementary outcome measure to the HSMR produced through the SPSP is percentage unadjusted inpatient mortality. This is unadjusted for the NHS Lanarkshire population however it provides an indicator of trend. The Board should look for NHS Lanarkshire s unadjusted mortality to be decreasing and to be consistently below the red line by 31 March 2013. 7
2.2 Improve patient safety by reducing unnecessary harm by 30% for NHS Lanarkshire by 31 March 2013 (from a baseline of November 2007) SPSP case note reviews are undertaken monthly at each of the Acute Hospitals to identify adverse events occurring during admissions using the Global Trigger Tool. A compliance level has been set of a 30% reduction in adverse events based on a 2007 baseline. The table show the adverse event rate has consistently been below this compliance level since October 2009. Comparison with the baseline may, however, be compromised as this was set by a separate group of clinicians using the tool for the first time. There has been a delay in the production of the data due to the implementation of Trakcare. The Board should look for NHS Lanarkshire s adverse event rate to be reducing and below the red line. 2.3 Improve performance on NHS Lanarkshire incident key performance indicators Through the Risk Management Steering Group a set of key performance indicators (KPI s) have been agreed. They relate to incident grading, closure and investigation. Incidents are rated as low, medium, high or very high based on their impact / consequence and their likelihood to reoccur using the NHS QIS Risk Matrices. The KPIs sets out to inform the Board of the effectiveness of a component part of incident management at operational level in relation to incidents being verified, investigated and closed within a number of working days. The Board should look for the KPIs to be met. 8
The Risk Management team is working with operational services to improve performance in relation to undertaking critical incident reviews for high and very high incidences, as appropriate, and the issue has been raised through the Risk Management Steering Group. Incidents graded as very high are exceptional and are considered on an individual basis. 9
2.4 Prevent healthcare associated infections Compliance with hand hygiene This shows ongoing good performance across Lanarkshire with the compliance level of 95%. The Board should look for the percentage compliance to be at or above the red line. Compliance with Peripheral Vascular Bundles (PVC) The use and compliance with PVC bundles is a means to prevent healthcare associated infections. The PVC bundle involves staff: Checking to ensure the PVCs in situ are still required Removing PVCs where there is extravasation or inflammation Checking PVC dressings are intact Considering removal of PVCs in situ longer than 72 hours Performing hand hygiene before and after all PVC procedures The Board should look for the percentage compliance to be at or above the red line. 10
Compliance with Central Venous Catheter Maintenance Bundle (CVC) The use and compliance with CVC bundles is a means to reduce complications and has been applied initially for patients cared for in the intensive care units. The CVC bundle involves staff: Daily checking and recording of the need for a CVC Ensuring CVC dressing is intact and was changed within last 7 days Ensuring CVC hub decontamination is performed Performing hand hygiene prior to line maintenance and access Using chlorhexidine gluconate for cleaning site during dressing changes Using line carts and dressing change kits to standardise processes The Board should look for the percentage compliance to be at or above the red line. 3. Quality Ambition: Clinical Effectiveness The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. Progress on this ambition is measured through clinical quality indicators, stroke care, medicine reconciliation and cost effective prescribing in primary care. 3.1 Clinical Quality Indicators (CQI s) Nationally three nursing clinical quality indicators (CQI s) have been developed as a result of Leading Better Care; Falls, Food Fluid and nutrition and Pressure Area Care. These CQI s are process indicators which measure aspects of nursing care such as assessment and interventions, the aim of which being to improve the quality of nursing care and promote patient safety. Acute inpatient wards report CQI data through the Lanarkshire Quality Improvement Portal (LanQIP). Discussions continue with Mental Health services regarding the applicability and implementation of the CQI s in inpatient mental health settings. The Board should look for the percentage compliance to be at or above the red line. 11
3.2 Stoke Care (Admission to Stroke Unit, Swallow Screen, CT Scan and Aspirin) Stroke is the third commonest cause of death in Scotland and the most common cause of severe physical disability amongst adults. The Scottish Stroke Care Audit includes all hospitals managing acute stroke in Scotland and measures care against NHS QIS standards. The Heat target 2011/12 is to improve stroke care, 90% of all patients admitted with a diagnosis of stroke will be admitted to a stroke unit on the day of admission, or the day following presentation by March 2013. The Board should look for the percentage compliance to be at or above the target lines. Admission to Stroke Unit % 100 90 80 70 60 50 40 30 20 10 0 Aug-11 Jul-11 Jun-11 May-11 Apr-11 Mar-11 Feb-11 Jan-11 Dec-10 Nov-10 Oct-10 Sep-10 On Day of Admission On Day or Day After On Day of Admisson Target On Day or Day After Target Month 12
Swallow Screen, CT and Aspirin % 100 90 80 70 60 50 40 30 20 10 0 Aug-11 Jul-11 Jun-11 May-11 Apr-11 Mar-11 Feb-11 Jan-11 Dec-10 Nov-10 Oct-10 Sep-10 Swallow Screen on day of admission CT scan on day of admission Aspirin on day of asmission or day after Swallow Screen& Aspirin Target CT Target Month 3.3 Percentage of patients with medication reconciliation performed One of the outcomes of the Scottish Patient Safety Programme is to provide safe and effective medicines management (reduce adverse drug events). This is supported by establishing a clear reconciliation process at the interface between primary and hospital care. The Scottish Patient Safety Programme monitors patient s charts 24 hours after admission to determine if a list of the patient s home medicines is present and if changes to those medicines are documented. The Board should look for the percentage compliance to be at or above the red line. 13
3.4 Compliance with cost effective prescribing in primary care Primary care clinical effectiveness is supported through the promotion of safe, effective, and economic prescribing in general practice. Progress on this is measured through compliance with prescribing of cost effective statins as a percentage of all statins prescribing and percentage of antidepressants prescribed complying with the formulary. NHS Lanarkshire s prescribing formulary supports cost effective prescribing in primary care with the aim of ensuring value for money in the use of NHS resources. The Board should look for the percentage compliance to be at or above the red lines. 14