TRUST BOARD Document Title: Presenter: Quality Report Jo Hunter, Deputy Chief Nurse Authors: Contact details for further information: Jo Furley, Interim Chief Nurse Dr Ben Lobo, Medical Director Jo Hunter, Deputy Chief Nurse Mary Heritage, Assistant Director of Quality Jo.hunter@dchs.nhs.uk Date of Meeting: 25 July 2013 Agenda Item No: 214/13 No of pages inc. this one: 9 The Quality Report for July includes: 1) Safe Care 2) Patient Experience 3) Clinical Effectiveness 4) Risk and Assurance 5) Francis Report update Document is for: (indicate with an x) Assurance x Information x Decision Executive Summary Section 1 Safe Care provides an outline of DCHS data regarding Safety Thermometer, Falls, Pressure Ulcers and Health Care Associated Infections. Section 2 Patient Experience gives a breakdown of the Friends and Family Test along with scores for June and across the Trust as the initiative is expanded across more services within DCHS. Section 3 Clinical Effectiveness provides evidence of the Clinical Audit regarding Clinical Records and highlights the new Clinical Records Audit Tool and how this will be used to audit Consent to Treatment. Section 4 Risk and Assurance offers an update on the CQC action plans and Welbeck Ward. Section 5 gives and update on the Francis Working Group which still meets monthly and provides reports to QSC.
There is no direct financial impact declared. Financial Impact Links to DCHS Strategy DCHS Quality (and supporting) Strategies; Risk Management Strategy, Integrated Business Plan and Annual Plan. Patient Experience and Involvement Strategy: keeping patients safe whilst in our care, to get the basics right and patients at the centre of care delivery. Recommendations To accept the report as providing information and assurance relating to actions and performance against key quality issues within the organisation Monitoring Information Brief Summary CQC Compliance Compliance with CQC Essential Standards Monitor Compliance n/a NHSLA Compliance Assurance Framework Ref: Other Are there Equality & Diversity implications? Are there Patient and Public Involvement implications? 1.1 (safe care); 1.2 (effective care) ; 1.3 (positive patient experience) (If no, why) Contributes to the Trust approach to Equality & Diversity Supports Trust approach in listening & involving patients
Section 1: Safe Care 1.1 Safety Thermometer (Prevalence data is taken from Safety Thermometer and this includes Falls, Venous Thromboembolism (VTE), Catheter Acquired Urinary Tract Infections (CAUTI and Pressure Ulceration) The DCHS target increased from 87% to 90% in April of this year, quarter 1 s cumulative performance is 90.25%. Table 1: A gap has been identified between the Safety Thermometer data and the number of incidents reported on the Datix system. These anomalies are currently being investigated, it appears that some may be due to a delay in reporting incidents on datix, but this is yet to be verified. The issue has been raised and discussed at the ICBS Governance meeting. Team leaders, matrons and managers have been requested to check data accuracy for each safety thermometer monthly return against the number of incidents on Datix. This is now a standard agenda item and monitored monthly at the ICBS Governance meeting in order to identify and eliminate the variance, a detailed report will be presented to QSC. 1.2 Falls (Incident data taken from DATIX aligned with bed occupancy data from PAS) June 2013 Harm Free Care scores: All Trust: 91.12% Rehab Wards 90.81% Older Peoples Mental 98.33% Health Wards District Nursing 90.62% Learning Disability 100% Services Intermediate Care 100% Graph 2 benchmarks our position in relation to falls compared with our peers during 2012/2013. The blue line represents the DCHS position in relation to injurious falls. The Improvement Plan following the falls deep dive is being developed at present and once completed will be presented to QSC. The Falls Strategy is also being developed between the Quality and Operations Directorates and will encompass all related findings and
recommendations, including clarification upon the definition of falls whilst identifying a consistent reporting process. 1.3 Zero Tolerance To Avoidable Pressure Ulcers Pressure Ulcer data for June 2013 is detailed in the table below: (DATIX Activity Data for June 2013 Data locked 15.07.13 at 12.00hrs. Safety Thermometer Data for June 2013 Data locked 28.06.13) Measure Source DCHS June Performance DCHS Previous month (May 2013) National Benchmark Number of Avoidable PU's (Quality Schedule) DATIX 3 0 N/A Total G3/4 PU developed/deteriorated in DCHS care DATIX 12 11 11 (May) All PU Prevalence (2,3&4) Safety Thermometer 6.9% 7.53% 5.21% NEW PU Prevalence (2,3&4) Safety Thermometer 1.53% 1.19% 1.19% Total PUs Developed/Deteriorated in DCHS care (G1-4) DATIX 102 102 n/a Total PUs Admitted/Referred into DCHS care (G1-4) DATIX 119 132 n/a Avoidable Pressure Ulcers (Ambition One Grade 2, 3, 4 & multiples) During June 2013, there have been 3 verified incidents of avoidable pressure damage either developing or deteriorating to patients in DCHS care. A further 2 cases are yet to be verified through the RCA process (1 case is due to not being able to access the patient s clinical record and 1 case was due to the late reporting of the incident). If either of these incidents are found to be avoidable, they will be included in the report for the July incidents. Patient 1: Avoidable Grade 3 Pressure Ulcer W25164 Rowsley Ward, Newholme Hospital The patient s clinical record did not provide the detail required to indicate that adequate assessment and preventative strategies were put in place to reduce the risk of pressure damage developing or deteriorating. Patient 2: Avoidable Grade 2 Pressure Ulcer W25180 North East & Bolsover Community Nursing In relation to pressure ulcer prevention and management documentation, there were significant deficits. It is because of these shortfalls in the community nursing record that this Grade 2 pressure ulcer has been verified as avoidable. Patient 3: Grade 3 Pressure Ulcer W25222 - North East & Bolsover Community Nursing The community nursing record does not evidence a holistic assessment of patient need or care planning to detail the care required to meet the patients increasing needs. Neither does it evidence a consistent and effective approach to reducing the risk and severity of pressure damage.
Key Learning and Actions Taken An initial action plan has been put in place in all areas, led by the senior nurse. The ICBS management team, led by the Assistant Director, is meeting all three teams separately during July. The purpose of meeting is to review findings, identify wider lessons learnt, to share at the ICBS Governance meeting, and to investigate individual performance issues, taking appropriate action as required. The Clinical Summit, held on the 4 July 2013, provided a wealth of information, opinion and suggestions on how to sustain the overall reduction in occasions, when it was shown that DCHS staff could have done more to reduce the risk of pressure damage developing or deteriorating. One work stream already in the development phase will look at ways to improve the transfer of patient care from community hospitals to community nursing services. An educational debate is to be held and led by all team leaders and matrons throughout ICBS services commencing in August, supported by the Interim Chief Nurse and Deputy Chief Nurse. This will use information obtained from the incidents that have occurred, where care fell short of expected standards, with the aim to identify and articulate what good looks like in relation to prevention and treatment of patients who are at risk of pressure damage. A review of the process for identification, reporting, completion of the RCA and verification of pressure ulcers is planned for August. This will be mapped with the aim to provide a speedier response rate for the whole process from start to finish, supporting a more timely understanding of the cause or deficit in care, resulting in a more rapid change in practice as required. It is proposed a whole system approach will be adopted led by the Assistant Directors North and South ICBS. Unavoidable Pressure Ulcers A total of 97 unavoidable pressure ulcers occurred within DCHS services during June, and 3 verified avoidable pressure ulcers as detailed above, with 2 only verified. STEIS reportable pressure ulcers (Avoidable and Unavoidable Grade 3&4) The table demonstrates pressure ulcers of Grade 3&4 that were recorded onto STEIS in June. These have been investigated and 4 in total were removed as they did not meet the criteria for STEIS reporting. Cases Reported on STEIS in June that Occurred Prior to June DCHS DATA June STEIS Reportable Cases All Cases Reported on STEIS in June Total STEIS Cases Closed Total Total Reported Removed PU Grade Unavoidable Avoidable Unavoidable Avoidable on STEIS from STEIS 3 1 (Mar) 7 2 4 1 (Apr) 1 TOTALS 2 0 8 2 16 4 12 The information detailed in the table above relates to cases reported on STEIS during June that were investigated by the Tissue Viability Team during that month. This is a slightly lower figure
than in the DCHS Performance Report, which includes cases investigated and closed in May but were not reported on STEIS until June. The delay in reporting was because pressure ulcers were only reported onto STEIS once they had been verified by the Tissue Viability Team. This delay not only caused data accuracy concerns, because there were 2 sets of monthly figures reported on different reports, albeit correct, the delay was also raised as a concern by the commissioners in view of timeliness of reporting. The process was changed during the month of June and now all grade 3 and 4 pressure ulcers are reported onto STEIS as soon as the datix form is submitted, any that do not meet the STEIS criteria once verification has been completed are then removed. The June data is the last month where this variation in figures occurs. 1.4 Health Care Associated Infections: (Incident data taken from DATIX and ICNet) There have been no incidences of norovirus duirng the month of June. The HPA benchmarking data that used to be recorded within Graph 5 is now excluded. Following the transfer of the HPA to NHS England, the Derbyshire Health Organisation Data is no longer provided separately and therefore to benchmark against national data become less statistically relevant. Section 2: Patient Experience 2.1 The Friends and Family Test The Friends & Family Test (FFT) this is a national measurement of patient experience and asks patients if they would recommend DCHS for treatment and care. (Graph 6 represents our performance)
June 2013 Promoters Detractors Non Scorers Total number of comment card responses New Comment Card Friends and Family Test Scores ICBS Inpatients 158 2 9 169 92 ICBS Community Services & MIU Health and Wellbeing 326 10 11 347 91 168 6 26 200 81 Planned Care Leicestershire 524 7 16 148 12 11 547 95 171 80 Overall Derbyshire CCG F&F Score Overall DCHS F&F Score (inc Leics) 1176 25 62 1263 91 1324 37 73 Friends and Family Test Scores - Summary June 2013 Phased expansion of FFT across DCHS in 2013/2014 progress 1434 90 April May June Total Number of Services 78 78 78 Total Number of Services participating in FFT 14 40 51 Total Number of Services Returning Cards (Year To Date) 14 40 59 TOTAL NUMBER OF COMMENT CARDS RESPONSES 248 1088 1263 The number of services participating in FFT has increased this month, and the number of cards received continues to increase. The Patient Experience team is monitoring the return rates for each ward and service, in order to identify any areas where the number of returns is decreasing. There has been a decrease in the number of complaints received for 4 consecutive months. If this decrease is sustained we could attribute this to a more proactive approach to seeking
patient experience feedback through the roll out of FFT since August 2012. 12 complaints were received requiring investigation and formal response in June (17 in April 2013, 13 in May 2013). 2.2 Dignity in Care Since the roll out in 2011 to June 2013 there has been 24 services awarded the Bronze Dignity Award with 10 being awarded in April/June 2013. An initial training session for the Silver award was held on 13 June 2013 and was well attended. We currently have an additional 37 services who are working towards their Bronze. Section 3: Clinical Effectiveness 3.1 Clinical Audit Clinical Records DCHS services have submitted clinical records audit data during April and May using 2012/2013 audit tool. The first report of 2013/2014 is now available and has been circulated to services. Detailed analysis will identify services where improvements need to be made, and any specific standards which require overall improvement. Below is the summary for all services showing increased participation and a marked improvement in submission rate and slight improvement in compliance against national records standards. November 2012 April-May 2013 Submission rate 59% 84% Questions with a positive response 595 610 3.2 Consent To Treatment Consent to treatment will be audited by the new Clinical Records Audit Tool, which was rolled out in July. This will screen documentation for correct consent procedures for patients using every service in every month. A more in depth consent audit tool has been developed to follow on from the Clinical Records Audit and will be implemented in services and patient groups that represent the highest risk, or where scores on the Clinical Records Audit Tool are low. Patients will be asked whether they understood the proposed procedure and how it might affect them and whether they had enough information to make a choice. The in-depth clinical record review will run alongside the patient survey. Work has commenced with the Safeguarding team to audit improvements in staff knowledge as a result of training on consent, which is now incorporated into Safeguarding training. Section 4: Risk and Assurance 4.1 CQC update on action plans A detailed file has been collated to evidence the implementation of the 3 CQC unannounced visits in January/February 2013. The Quality compliance team is ensuring that this evidence is maintained in order to ensure once requested the CQC have the most up to date position. Ongoing monitoring will be through the CQC compliance report to QSC on a monthly basis. To gain further external assurance regarding the implementation of the CQC action plan on Derwent Ward EMIAS were commissioned to undertake a Mock CQC Inspection. This took place on 27 June 2013 and the final report is now under agreement with relevant DCHS officers.
Despite positive internal visits and significant work by the ward against the action plan the EMIAS visitor observed what appeared to be delays in response time to a call bell which was felt could lead to the CQC reporting further moderate impact non-compliance concerns. Immediate action was taken on receipt of the draft report. Further investigation by the Matron showed that staff reported a number of interactions with the patient throughout the time period for a number of different reasons. The apparent delay highlighted a wider environmental issue with the call bells as they have a two tier system and only ring audibly in the toilet areas and are silent in the patient rooms, with just a light to attract attention, unless constantly depressed. This is a design feature and is being rectified 17 July 2013. There is a conference call 17 July 2013 to ensure that any actions from the EMIAS report are captured within the on-going compliance work on the ward. The CQC made a further unannounced inspection 15 July 2013 and the results of this visit are not available at the time of reporting. 4.2 Welbeck ward QSC (3 July 2013) received a report from William Jones on progress against the Welbeck Ward development plan. Monthly monitoring of progress against the agreed KPI s will be made to QSC until all development work is satisfactorily completed and consistency maintained. See QSC summary report for further detail. In June the Harm Free Care Score for Welbeck Ward was 100% which has been maintained from May 2013. On 25 June 2013 EMIAS conducted a Mock CQC Inspection on the ward; staff reported very positive outcomes from the development programme to the EMIAS visitor. The findings of the visit were overall positive however the visitor felt that the challenge to the ward will be maintaining positive progress once the ward is operating at full capacity with less staff time available per patient. Based on this EMIAS felt that the CQC may report minor impact non-compliance concerns if they were to visit the ward. There is a conference call 17 July 2013 to ensure that any actions from the EMIAS report are captured within the on-going compliance work on the ward. Section 5: Francis 5.1 Francis Working Group The working group continues to meet monthly with high levels of operational engagement and provides a summary report to QSC. The June meeting received a detailed progress report on individual service priority areas. Feedback on staff engagement sessions held over the past 4 months have been collated and the group used the workshop approach to sense check contributions from these sessions. The same exercise will be undertaken at the Leadership Forum (16 July 2013), Board development session (25 July 2013) and the Front Line Care Council (29 July 2013). The outcomes of this work will inform the forward plan against the 5 priority areas taken from the 290 recommendations of the Francis report. The priority areas being: Record Keeping(documentation/clinical access to IT) Workforce profiling (staffing verses acuity verses dependency and flexibility) Privacy and Dignity (patient communications/timely intervention) Staff confidence around whistleblowing and raising concerns Clinical Leadership