TRUST BOARD SAFETY AND QUALITY MONTHLY REPORT SEPTEMBER 2013 1. EXECUTIVE SUMMARY As reported to the Board last month, the reporting on safety and quality to the Trust Board has changed. Each month a summary safety and quality report will be presented to the Board which will focus on: Serious incidents declared year to date as at 31 August 2013 Complaints performance as at 31 August 2013 Summary on the key items reviewed at the Safety Panels in July and August Safety Thermometer Performance The report will also updates the Board on other items relating to safety and quality, for this month this specifically includes: Establishing Quality Panels Everyone Counts Consultant Level Data Patient Safety Day Safety Culture Assessment The first revised quarterly Excellence in Safety and Quality report will be presented to the Board in October for the quarter two period and will provide detailed analysis in key areas: Mortality statistics and trends Outcomes from the Harm reviews Ward clinical indicators Incident reporting trends in levels of harm Complaint trends Clinical audit and effectiveness Delivery of the Trust s safety and quality priorities and associated improvement programmes 1
Cancer And Clinical Support Services Business Unit Emergency Care & Medicine Business Unit Emergency Surgical & Elective Care Business Unit Paediatric Business Unit 2. SERIOUS INCIDENTS DECLARED YEAR TO DATE (AS AT END OF AUGUST 2013) The Trust declared 21 serious incidents since the last reporting period to the Board (June 2013). The graph below summarises the serious incidents declared across both hospital sites and clinical business units for 2013/14 as at the end of August 2013. Pressure Area Care Infection Control Falls System failures / Equipment / Information Governance Clinical Treatment / Diagnosis / Death / Medication Errors / Suicide Never Events Pressure Area Care Infection Control Falls System failures / Equipment / Information Governance Maternity & Paediatric Related Clinical Treatment / Diagnosis / Death / Medication Errors / Suicide Never Events Pressure Area Care Infection Control Falls System failures / Equipment / Information Governance Clinical Treatment / Diagnosis / Death / Medication Errors / Suicide Never Events Pressure Area Care Infection Control Falls System failures / Equipment / Information Governance Clinical Treatment / Diagnosis / Death / Medication Errors / Suicide Never Events 0 2 4 6 8 10 12 Cumberland Infirmary West Cumberland Hospital 2
An analysis on the themes and contributory factors of the incidents has been completed and reviewed by the Safety and Quality Committee in September 2013. The improvement priorities from this analysis are included in the serious incident report to the Board in September 2013. 3. SAFETY PANELS JULY AND AUGUST The Safety Panel meetings are fundamental to the weekly review of serious incidents, complaints and mortality alerts. The Safety Panels meet every week and have a set programme of work. 3.1 Mortality Review Group The Mortality Review Group has met twice as part of the Safety Panel schedule. The first meetings have predominantly focussed on agreeing the inputs/data which will be reviewed each month. This will include the alerts which are generated from the Dr Foster system. The Trust is adopting the investigatory method set out by Dr Foster, which will include a monthly report looking at mortality alerts in the following key areas: Diagnoses Groups with a Relative Risk of over 90 Mortality dashboards for the two hospital sites Mortality by day of admission Top Ten Diagnoses associated with Mortality Deaths in Low-Risk Diagnosis Groups The outputs of the above analysis will be reported to the Safety and Quality Committee in November 2013. 3.2 Review of Serious Incidents The Safety Panel has reviewed eight new serious incident reports from 2012/13 and three new serious incidents from 2013/14. The Safety Panel also carried out a follow up review on the action plan following the indirect maternal death in 2012/13. The Safety Panels throughout July and August also focussed on the performance monitoring of completing the backlog of serious incidents declared in 2012/13, which was achieved. The Safety Panel have agreed that all grade 3 and 4 pressure ulcers would be declared as serious incidents, irrespective of whether they are avoidable or unavoidable. 3.3 Review of Serious Complaints The Safety Panel has met twice to review the serious complaints received and closed for July and August 2013. The Trust has closed six complaints for 2013/14 to date that have maintained their risk grading as serious upon closure. A report on the key themes and action plans from these complaints will be included in the report to the Safety and Quality Committee in October 2013. 3
No. Open Complaints at 1st of Month No. Open Complaints at 1st of Month 3.3.1 Complaints Performance The Safety and Quality committee received a report on the current performance on complaints in September 2013. Progress continues to be made on addressing the backlog of complaints which is summarised in the charts below. 120 Open New Complaints 100 80 60 40 Backlog Current < 25 Days Current > 25 Days 20 0 May June July August September 60 Open Further Local Resolution (re-openedcomplaints) 40 Backlog Current < 25 Days 20 Current > 25 Days 0 May June July August September The focus is now on implementing the new complaints process as well as capturing the themes from complaints. A detailed report will be presented to the Safety and Quality Committee in October 2013 on the themes from serious complaints closed this year to date. From initial review at the Safety Panels, the key themes do cross over with the analysis on the serious incidents regarding delay in diagnosis, clinical treatment and communication. 4. SAFETY CULTURE ASSESSMENT The Manchester Patient Safety Framework (MaPSaF) endorsed by the NPSA is a tool to help NHS organisations and healthcare teams assess their progress in developing a safety culture. It is recognised best practice for organisations (and teams) to regularly undertake a safety culture assessment. 4
The MaPSaF identifies five levels of culture: Level A Pathological B Reactive C Bureaucratic D - Proactive E Generative Description Why do we need to waste our time on patient safety issues? We take patient safety seriously and do something when we have an incident. We have systems in place to manage patient safety. We are always on the alert/thinking about patient safety issues that might emerge. Managing patient safety is an integral part of everything we do. As part of the 2013 Patient Safety days a safety culture assessment was undertaken. The results from the survey were presented and reviewed by the Safety and Quality Committee in September 2013. The results of the survey placed the two sites broadly at level B. The safety culture assessment will be repeated at the next Patient Safety days. Our new approach to patient safety is intended to transform the organisation to a level D in two to three years. 5. QUALITY PANELS From November 2013, quality panels will be established across the Trust. The purpose of the quality panels is to review individual services in terms of how safe the service is, how effective it is in terms of good clinical outcomes and what the experience is of patients who use the service. The membership of the Quality Panel will include: Medical Director Director of Nursing Director of Operations Director of Governance The panels will meet every month and will review the safety, quality and patient experience data relating to individual services with the Clinical Director, Operational Services Manager and Matron or Senior Nurse. The data will include: SAFETY EFFECTIVENESS PATIENT EXPERIENCE Mortality Morbidity Infection prevention Patient Safety Incidents Safety Thermometer National benchmarks Everyone counts / consultant level outcomes Compliance with NICE Clinical audit activity Waiting times / RTT access Length of Stay Payment by Results Patient feedback / surveys / real time Complaints The aim will be to target two services per month. The outputs of the reviews will be reported to the Safety and Quality Committee with an exception report to the Trust Board as part of the quarterly excellence in quality and safety report. The services to be reviewed will be prioritised by the Safety Panel and Executive Management Team. 5
6. CONSULTANT LEVEL OUTCOMES - EVERYONE COUNTS As previously reported to the Board, the data published as part of the Everyone Counts framework commenced over the summer period. On behalf of NHS England, the Healthcare Quality Improvement Partnership (HQIP) has worked with specialty associations to develop the data using selected national clinical and medical audits for consultants practising in these areas. The table below summarises the Trust / consultant level data published to date: SPECIALTY PUBLICATION DATE OUTCOME Adult cardiac surgery (heart) Vascular (veins and arteries) Endocrine and Thyroid Interventional cardiology The data is currently being reviewed by the clinical teams for the reports published to date. A full report on all the data published against the eight specialties applicable to the Trust will be prepared following the data for the last two specialties being published as highlighted above. This information will also form part of the Quality Panels described in section five of this report. 7. SAFETY THERMOMETER The summary below highlights to the Board the current performance in the national NHS Safety Thermometer. The individual ward safety thermometer results are included in the Ward Assurance Report (Enc 8) and confirm that in July 13 wards out of 28 did not meet the required 95% in July and 14 out of 28 wards in August. All wards not achieving the required levels have been met with by their Chief Matron and Deputy Director of Nursing. The key area of focus relates to pressure area care. Investment in two tissue viability nurses has been approved to support training and specialist advice. Ward manager are clear on the expectation that staff must adhere to best practice. 7.1 July position Not applicable to NCUHT Published Published Published 497 patient s audits were completed on 17 July 2013 to assess patients on the four harms included in safety thermometer point prevalence audit. This audit is completed monthly on a set day for all NHS Trusts. N/A No outliers or concerns. No outliers or concerns, however low volume identified which is being addressed by the Clinical Business Unit. No outliers or concerns. Orthopaedics Published No outliers or concerns, however low volume by some consultants and certain procedure type identified which is being addressed by the Clinical Business Unit. Bariatric Not applicable to NCUHT Urology Now published Insufficient numbers for meaningful analysis. Head and neck Published No outliers or concerns. Bowel cancer Autumn 2013 Data yet to be reviewed. Upper GI Autumn 2013 Data yet to be reviewed. 6
Harm free care in July was overall 94% of which there was a reduction in harms from June of 49 patient harms across the Trust to 41 patient harms in July. Of the 497 patients in July; 38 patients suffered 1 harm & 3 patients suffered 2 harms. Of the 41 harms, 20 pressure ulcers, 9 catheter related, 7 VTE and 8 patient falls. VTE assessment reported at 95%. 7.2 August Position 474 patient audits were completed on 14 August 2013. Again there was a reduction in harms from July to 39 reported harms in August. Harm free care in August was 96%. Of the 39 harms, 20 pressure areas, 13 catheter related, 5 VTE, 3 falls. Thirty seven patients suffered one harm and two patients suffered two harms. VTE assessment reported at 95 %. 8. PRESSURE ULCERS ON ADMISSION AND FOLLOWING ADMISSION All grade 3 and 4 pressure ulcers are reported and investigated as serious incidents (SI s). The investigation report will categorised whether these ulcers were avoidable or unavoidable pressure damage. The tables below show all grades of pressure ulcer damage; table 1 relates to those patients who have pressure damage on admission to hospital and table 2 relates to patients who have developed pressure ulcers following admission to hospital. Table 1: Admitted with pressure Ulcers Admitted with pressure ulcers (2013) Grade 1 Grade 2 Grade 3 Grade 4 Total no. ulcers Total no. pts. April 2 27 6 0 35 28 May 6 24 3 2 35 31 June 7 26 8 2 43 35 July 2 27 9 6 44 35 Aug 7 31 7 7 52 44 There is a significant increase in July and August with patients admitted to hospital with grade 3 and 4 pressure damage. The Director of Nursing has arranged a meeting to review this with Cumbria Partnership Trust and how we can address pressure area care across the health economy. The outputs following that meeting due to be held in September will be reported to board in October 2013. Table 2: Pressure Ulcers Developed following admission to NCUH Pressure ulcers developed following admission (2013) Grade 1 Grade 2 Grade 3 Grade 4 Total no. ulcers Total no. pts. April 3 15 5 3 26 19 May 6 17 6 1 29 23 June 7 11 4 1** 0 23 19 July 2 16 1 0 19 17 Aug 2 8 0 1 11 10 ** Patient admitted with Grade 2 pressure damage not grade 4, graded incorrectly on admission and pressure damage in place on admission. 7
Month Grade Ward Immediate Actions July 13 3 - heel Jenkin WCH RCA presented to TV, further information requested by group and to be represented August 13 4 - sacrum Maple C CIC RCA presented to Tissue Viability Group. The TV group deemed that this damage was avoidable. Documentation and care were reviewed by the TV group with the ward manager. Team meeting has been held to discuss this case and lessons learnt. The sacral area initially was a moisture lesion but developed into a pressure lesion. All staff have completed Tissue Viability training refresher and review of documentation and pressure care audit. 9. FALLS AND HARM FOLLOWING FALLS In July there were 119 reported slips trips and falls and 87 reported in August with no harm. The two SI s reported in July, relate to two fractures that occurred in June following a fall and reported to Board. These are all reported as Serious Incidents and investigations have commenced. Reducing falls and harm from falls is a key safety priority for the Trust. The Trust is currently establishing links with the Clinical lead in Northumbria through Dr Richardson who will present to CPG the Northumbria falls strategy and implementation. This is one of the improvement priorities identified following the review of the themes from our serious incidents. 10. RECOMMENDATION The Board are asked to approve the report. Dr Jeremy Rushmer Chris Platton Ramona Duguid Medical Director Acting Director of Nursing Acting Director of Governance 8