Quality Performance Detailed View March 2015 position

Page 1 Quality Performance Detailed View March 2015 position

Portsmouth Hospitals NHS Trust QAH Hospital Page 2 Quality of Care Key Exceptions to note Quality of Care Executive Summary March performance Safety: Pressure ulcers: The Trust reported 1 avoidable grade 3 pressure ulcer in March. The end of year position for grade 3 and 4 pressure ulcers was 24 against an in year target of 28. Falls: The Trust reported 2 cases resulting in severe harm in March. The end of year position is 43 patients suffered harm against an in year target of 32. Healthcare acquired infection: The Trust reported 1 case of MRSA Bacteraemia. The Root Cause Analysis, at the time of writing the report, was not completed. The end of year position is 2 confirmed unavoidable cases, with 2 cases currently under review against an in year limit of 0 (zero) avoidable. The Trust reported 1 case of C.Diff in March. The end of year position is 40 cases against a year end limit of 31 cases. Medication: There has been 1 patient suffering severe harm (red incident) and 1 patient suffering moderate harm (amber incident) as the result of a medication incident in March. The end of year position is 16 patients having suffered harm as a result of medication incidents. A full report is to be presented to the May Board. Effectiveness: Standardised Hospital Mortality Index (SHMI): The quarterly SHMI figure was published in February. The Trust SHMI for July 2013 to June 2014 is 107.9; which is an increase from the previous quarter s figures of 104.9. Whilst this figure is above the National Average of 100, it is within the official control limits.

Portsmouth Hospitals NHS Trust QAH Hospital Page 3 Quality of Care Executive Summary Quality of Care Key Exceptions to note March performance Caring: Dementia: The quarter 4 CQUIN requirements have been achieved. Responsive: Patient moves: There was a significant improvement in the number of patient moves after midnight to 54, during March. Friends and Family Test: Staff Implementation Achieved. Response rates Achieved. - In-patient areas: A response rate of 37.4% averaged over quarter 4 was achieved, therefore exceeding the CQUIN target of 30% average over quarter 4. - ED: At the end of quarter 4 the Trust achieved a response rate of 18.5%, therefore exceeding the CQUIN target of 15% CQUIN by the end of quarter 4. Improving positive responses Achieved. - ED: An average positive response rate of 95.3% was achieved in quarter 4, therefore exceeding the CQUIN target of 92% average in quarter 4. - In-patient areas: An average positive response rate of 96.5% was achieved in quarter 4, therefore exceeding the CQUIN target of 96% average in quarter 4. - Maternity: An average positive response rate of 99.3% was achieved in quarter 4, therefore exceeding the CQUIN target of 75% average in quarter 4.

4/23/2015 Page 4 Quality of Care Overview March 2015 Safety - Overview

Portsmouth Hospitals NHS Trust QAH Hospital Page 5 Local CQUIN March update Local and specialised CQUINs: used as an incentive to ensure providers of specialised services offer continuous improvement in line with best practice, benchmarked utilisation, appropriate care and quality indicators. Effectiveness - CQUIN Local CQUIN Medical Workforce Nursing Workforce Elective ED / Urgent Care Diagnostics Admission, Discharge, Transfer Details Q1 Status Q2 Status Q3 Status Q4 Status To develop appropriate, clinical productivity indicators to underpin service plans for Gastroenterology, Respiratory, Urology and Trauma & Orthopaedics. To realise an appropriate and sustainable increase in front line ward based nursing posts 7/7 and 24/7. Assist with the reduction of inappropriate General Practice referrals and reduce the incidence of inappropriate hospital attendances, repeat clinical work and/or missed follow ups (necessary to complete the care pathway). To support the UCC. Support training of triage nurses. Reducing attenders. Assist in the reduction of inappropriate medical imaging diagnostic tests by way of audits, guidelines and reporting. Minimising the risk of harm and preventing hospital readmissions through the provision of seamless care: improving admission, transfer and discharge (ADT) processes across the Portsmouth and South East Hampshire area. Met with the CCG on 11.12.14 to agree productivity proposal. Working with the CSC to achieve reports agreed with CCG Dec 2014. Collation of evidence and presentation being agreed. Q3 evidence to submitted w/c 16.03.15. Achieved. Achieved. Achieved. Q3 evidence submitted. Achieved. Achieved. Achieved. Q3 evidence submitted. Achieved. Achieved PHT actions. Working with the CCG to achieve joint actions. Achieved. Q3 evidence submitted. Achieved. Achieved. Achieved. Q3 evidence submitted. Achieved. Achieved. Achieved. Q3 evidence submitted. Awaiting date with CCG for presentation to be scheduled. Achieved. CSC awaiting internal approval before submission to the CCG. On track. Specialities compiling data for submission to CCG. On track. Speciality compiling data for submission to CCG. On track. Speciality compiling data for submission to CCG. Ready to submit to the CCG after Trust Board have approved.

Page 6 Local CQUIN March update Local and specialised CQUINs: used as an incentive to ensure providers of specialised services offer continuous improvement in line with best practice, benchmarked utilisation, appropriate care and quality indicators. Effectiveness - CQUIN Specialised CQUIN Details Target Current status February 2015 (M11 Q4) Local 1 Reduce cold ischaemic time for >18hours after brainstem death. Q4 achieved. Data to be sent to kidney transplants. 12hours after circulatory death. Commissioners. Local 2 Shared haemodialysis care. 1.>10% of patients participate in at least 5/14 tasks. Q4 data being gathered. No concerns 2.>95% patients asked if they would like to participate. noted. Local 3 Complete specialised services Quarterly monitoring targets with dashboard Specialities continue to complete and clinical dashboards. completed and submitted for the specialities of Cardiology, Neonatal, Ivig, Radiotherapy, Endocrinology, Critical Care, Renal and Hepatobillary & Pancreas to use the dashboard results to demonstrate improved practice. submit. No concerns noted. Local 4 Retinopathy of Prematurity 90% in babies of <1.5kg or <32 weeks (full year) Q4 on track to achieve. Screening (ROP). Local 5 Local 6 Improve access to breast milk in babies <34weeks. Support local implementation of Ivig demand management plan. 5% improvement (full year) Q1 to be agreed by NHS England pending agreement of target achievement with consideration given to exceptional neonatal cases. Q2, Q3 and Q4 target at risk due to exceptional circumstances of babies. Liaison with commissioners is ongoing. All patients on IVIG are approved by Ivig panel. Attendance at IVIG meetings. All patients to be recorded on the regional IVIG database. Local 7 Support Dental Network. Dental Network service with clinician involvement. Attendance at Dental Network meeting. Local 8 Breast Screening Not agreed at present, ongoing negotiations between specialty and commissioners. Partially achieved. Meetings attended in January and March. Q4 achieved. Data to be sent to Commissioners. 50% settlement agreed with Commissioners as resolution at year end.

Portsmouth Hospitals NHS Trust QAH Hospital Page 7 Exception Report: Pressure Ulcers (CQUIN & Quality Account) March position Target: 28 (Quality Account priority - 10% reduction in avoidable amber and red incidents (grade 3 and 4) based on 2013/14 outturn of 31. Safety Pressure Ulcers Pressure Ulcer SIRIs Avoidable hospital acquired The Trust reported 1 avoidable grade 3 pressure ulcer in March; this occurred in the MSK CSC. Organisational learning has taken place. Following a review cases of presented in January and February, the final outturn for these months has been amended. The end of year position for avoidable grade 3 and 4 pressure ulcers is 24 against a target of 28. The CQUIN was therefore achieved, reflecting a 22% reduction when compared to 2013/2014. Pressure Ulcer SIRIs Unavoidable hospital acquired The Trust reported 3 cases of unavoidable grade 3 pressure ulcers in March. Pressure Ulcers grade 1 and 2 The Trust reported 19 cases of grade 1 and 2 pressure ulcers in March compared to 46 reported in February. Actions and progress to date A full review of the Trust response to management of Tissue Viability is underway and will report to the Governance and Quality Committee in May. Pressure Ulcers Present on admission A total of 166 present on admission pressure ulcers were reported in March compared to 193 in February.

Page 8 Exception Report: Pressure ulcers Skin bundle compliance (CQUIN & Quality Account) Safety Pressure Ulcers March position Target: 92% compliance for both SKIN bundle and Braden by the end of quarter 3 increasing to 95% by the end of quarter 4. Compliance is now set against overall audit submission rates, which for March stands at 100% which is equal to the February submission rate. Compliance with the SKIN bundle for March is 98% which is an improvement on the 92% February figure; the Trust has achieved this element of the CQUIN requirement. Compliance with Braden has dropped to 91% for March compared to 93.84% in February; The Trust has not achieved this element of the CQUIN Actions and progress to date The TVN team are currently reviewing the Braden and skin bundle documentation to ensure all are using a validated tool and that it is as clear and simple as possible to work with, this will be completed at the end of April and will be added to the rollout of a new education programme to ensure a consistent level of education for all Nursing staff. Braden and SKIN Bundle compliance Month Braden SKIN Bundle Submission rate March 2015 91% 98% 100% February 2015 93.84% 92% 100% January 2015 92.3% 95.7% 100% CSC Audit compliance March 2015 CSC Submission Braden Skin Bundle CHOC 100% 75% 100.% Emergency Medicine 100% 80% 100% HNU 100% 95% 100% Renal 100% 93% 95% W & C 100% 100% 100% Surgery 100% 94% 99% MOPRS 100% 90% 93% MSK 100% 95% 99% Medicine 100% 93% 98% G5 CHAT 100% 100% 100% 100% 100% 100% Trust 100% 91% 98%

Page 9 Exception Report: Falls (CQUIN & Quality Account) March position Target: 32 ( Quality Account priority: 10% reduction in falls resulting in moderate/severe harm or death; based on the 2013/14 outturn of 36) The Trust reported 2 cases of falls resulting in severe harm in March The end of year position is 43 cases against an in year target of 32 cases. Actions and progress to date A full review of the Trust response to falls is underway and due to report to the Governance and Quality Committee in May. Safety - Falls

Page 10 Exception Report: Patient Safety Thermometer (Contract) March position Target: Submit data to the National Patient Safety Thermometer* The Trust achieved 100% data collection for March. To date the Trust has maintained high submission rates, with 100% being achieved each month. Actions and progress to date Sustain 100% audit submission. Percentage of harm free care* (contract) Target: Report percentage of harm free care. In March the Trust recorded in-patient harm free care of 97.18%, compared to 96.93% in February. All old and new pressure ulcers identified are now being fully validated (previous validation focussed on new pressure ulcers), which has resulted in an increase in identified new pressure ulcers. The total harm free care which, includes pre-hospital admission harm events, was recorded as 92.81% which is an increase to February s 90.60%. Data was collected on all 1,029 eligible patients. All harm events continue to be validated by specialist teams. Actions and progress to date The Clinical Commissioning Group (CCG) are leading co-ordinated work on community harms (i.e. the number of present on admission pressure ulcers in March this totalled 166). Harm free care Month March 2015 February 2015 January 2015 Total Harm Free Care (data collection from number of patients) 92.81% (1,029) 90.60% (1,075) 90.60% (1,053) Trust Harm Free Care 97.18% 96.93% 96.30% Safety * Methodology and purpose of measure The NHS Safety Thermometer allows teams to measure harm and the proportion of patients that are 'harm free' from pressure ulcers, falls, urine infections (in patients with a catheter) and venous thromboembolism. Information is collected on every inpatient on one day each month. The 'harm free care' measure is the proportion of in-patients who are free from any of the harm measured (as stated) at the point of the audit (a point prevalence snapshot audit). This includes harm events that have occurred within hospital and prior to admission.

Page 11 Healthcare Acquired Infection (National) March position MRSA (Incidence more than 48 hours after admission) Target: 0 In March, there was 1 patient with MRSA bacteraemia. The case involved a patient with an MRSA bacteraemia identified on day 9 of admission whilst on G6 (Renal). A Post Infection Review panel will be held in April to determine the root cause of the bacteraemia, and whether the case was deemed avoidable. The Trust s current year to date position is 2 unavoidable with 1 avoidable which has been submitted for consideration through the arbitration process; and 1 further case pending PIR panel, against a target of 0 (zero) avoidable cases. Safety Infection The target for 2015/16 remains at 0 (zero) avoidable cases.

Page 12 Healthcare Acquired Infection (National) March position healthcare acquired infection C.Difficile (Incidence more than 72 hours from admission) Target : 31 cases 1 patient with hospital acquired C.Difficile was reported in March against a monthly trajectory of 3. The case occurred within the Medicine CSC. The Trust s current year to date position is 40 patients with hospital acquired C.Difficile, against a trajectory of 31. 38% (n=15) of the cases attributed to the Trust involved samples taken within the first 10 days of admission. 15% (n=6) samples were delayed samples and a further 5% (n=2) were repeat samples. It is imperative that in 2015/16 these avoidable cases due to sampling and reporting anomalies are mitigated. The target for 2015/16 is 40 hospital attributable cases. Safety Infection Actions and progress to date (C. Difficile) Typing results received to date, from the Public Health England (PHE) C.Difficile reference laboratory indicate no predominance of a particular strain of C.Difficile, nor do the results indicate evidence of patient-to-patient cross-transmission of C.Difficile strains. The Infection Prevention and Control Team (IPCT) continue to carry out unannounced peer review audits to assess, rectify and improve the standard of clinical cleaning in the near patient environment. In March, 42% of clinical areas audited scored 95%+, compared to 36% in February (95% illustrates the target score for cleaning). A further 50% scored 85-95%. Audits that score below 90% receive a repeat audit by IPCT within 2 weeks of the initial audit, and will continue receiving fortnightly audits and intensive support until a satisfactory score is achieved. The main areas of non-compliance in relation to cleaning continue to be clinical equipment (hoists, observation machines, drip stands) found dusty, dirty kitchen equipment (microwaves, dishwashers) and general clutter throughout the wards. IPCT continues to work very closely with clinical staff to ensure compliance with cleaning standards. Several CSCs have participated in training sessions run by the IPCT to improve their ability to self-audit using the NPSA cleaning tool in a consistent and effective manner.

Page 13 Exception Report : Venous Thrombo-embolism Screening March performance VTE Screening Target: 95% per month The VTE risk assessment figure for March is 97.2% (subject to validation); compared to the February figure of 97.77%. VTE Serious Incidents Requiring Investigation (SIRIs) and Incidents There have been 0 (zero) reported VTE SIRIs in March which is comparable to February. 99 VTE events were reported in March compared to 84 in February. - Of these 33 were hospital associated events (HAT), compared to 30 in February and 66 were community associated events (CAT) compared with 54 in February. Safety - VTE Although there has been an increase in overall VTE events this is comparable to last year and is likely seasonal variation due to winter. The split between HAT and CAT events is comparable. Actions and progress to date Sustain performance and actions from investigations

Page 14 Safety Serious Incidents Exception Report: Serious Incidents Requiring Investigation (SIRIs) (Contract and National) March Performance SIRIs (including HCAIs and as reported on STEIS) 11 SIRIs were reported in March; (4 of the 11 SIRIs related to pressure ulcers, 3 reported as unavoidable), compared to 9 in February (4 of which related to pressure ulcers). SIRIs over 45 day deadline 6 SIRI s that were due to be submitted in March exceeded the 45/60 day target date, this is due to the complexity of the cases and the date of SIRG and the target date co-in-siding. 3 of the 6 have now been submitted to the Commissioner. 1 other SIRI remains overdue, as further work was requested following review at the Serious Incident Review Group. Extensions have been granted by the Commissioner for all 6 SIRIs. Never Events Target: 0 (zero) 0 (zero) Never Events reported in March. Revised Never Event guidance has been published in March by NHS England, the Never Event list has reduced from 25 to 14. The full list can be found on the NHS England website : http://www.england.nhs.uk/ourwork/patientsafety/never-events/. Duty of Candour The Trust is required to inform the patient and/or other relevant person within 10 operational days that the safety incident (SIRI) has occurred or is suspected to have occurred. 9 patients involved in SIRIs in March, were informed of the incident within the deadline and are aware of the on-going investigation. The SIRI screening incident is under NHS England review and the MRSA Bacteraemia is under review by the Infection Prevention Team. SIRI MRSA noted on part 1 of death certificate x1 (Unavoidable) Unavoidable grade 3 pressure ulcer x2 Deteriorating patient x1 Slip, trip, fall resulting in a fracture/death x2 Unavoidable grade 3 pressure ulcer x1 Avoidable grade 3 Pressure ulcer x1 Delay in Treatment x1 Screening programme incident x1 Medication x1 CSC Medicine MOPRS MOPRS MOPRS MSK MSK Emergency Department Clinical Support Medicine

Portsmouth Hospitals NHS Trust QAH Hospital Page 15 Exception Report: Patient safety incidents (excluding SIRIs) (Contract) March position At the time of reporting, the top three reported incidents for March were: Slips, trips and falls Implementation of care or on-going monitoring - other. Administration or supply of a medicine from a clinical area. This compares with slips trips and falls, Implementation of care or on-going monitoring - other and pressure sore/decubitus ulcer in February. This varies from that reported previously due to the receipt and confirmation of additional incidents. Safety Incidents Actions and progress to date Continue safety work streams to reduce avoidable harm. Sustain positive reporting and feedback culture. Feedback on incident outcomes is through corporate and CSC incident newsletters and governance committees Month Incidents Adjusted to include receipt of late reports Previously reported March 2015 470 - February 2015 659 469 January 2015 777 689

Page 16 Exception Report: Patient safety incidents (Contract) The first chart provides a comparison of finally approved incidents by severity Incident severity is coded by the reviewing manager at close of investigation, therefore it must be noted that some data is not yet complete due to reporting timeframes. This is always updated for each subsequent Board report. This should be considered when interpreting data. The Risk Management Department escalate all incidents awaiting final approval to the CSC Management Team. Safety - Incidents A specific task and finish group continues to address any system and process issues. The total PHT reported Patient Safety Incidents April 2013 March 2015 graph represents the total number of all patient safety incidents reported by Trust staff (including community incidents and incidents which have not been Finally Approved ). This graph demonstrates there has been a steady increase in total reported incidents.

Page 17 Coroner s recommendations and CAS alerts (Contract) March position Coroners recommendations Regulation 28 reports (previously referred to as Rule 43 letters to prevent future deaths) The Trust received no Regulation 28 reports in March. CAS Alerts over deadline 9 alerts were issued in March of which 3 were applicable to the Trust. 3 remain open at the time of producing this report; but within date. 1 alert was closed 5 days late in March due to late return from Medicine CSC. An automated system is in place sending weekly reminders of outstanding alerts to the Governance leads and e-mail reminders sent to Carillion. Actions and progress to date Sustain positive action of CAS alerts. Safety

4/23/2015 Page 18 Exception Report: Medication (Contract) Safety Medication errors March position Target: Monitor/no increase based on 2013/14 outturn of medication incidents which result in moderate/severe harm or death of 11 (subject to validation). There has been 1 patient suffering severe harm (red incident) and 1 patient suffering moderate harm (amber incident) as the result of a medication incident in March. This compares to 1 patient suffering severe harm in February. Following final panels and investigations there have been 2 further patient incidents confirmed as amber (in November and January). There are 4 further patient incidents currently being investigated or awaiting panel meetings to confirm grading. Trust year to date position is 16 patients having suffered harm as a result of medication incidents (3 patients suffering severe harm and 13 patients suffering moderate harm, of which 1 was a non-preventable adverse reaction); with 4 incidents awaiting final grading. The Trust has not achieved the target of no more than 11 incidents. There are discussions underway with the commissioners to downgrade the red incident in February to an amber incident, following the results of the investigation. Actions and progress to date Continue positive reporting and increase data report quality, feedback and learning. Medications to be one of the patient safety workstreams for 2015/16. A Gentamicin Working Group has been set up to address points raised in investigations concerning gentamicin prescribing, administration and monitoring. Oxygen chart to be reviewed / redesigned as a result of incidents concerning oxygen prescribing & administration. Vancomycin level pathology reporting information to be updated following investigation of therapeutic drug monitoring concerns.

Portsmouth Hospitals NHS Trust QAH Hospital Page 19 Safeguarding adults (Contract) March position - Safeguarding adults alerts A total of 87 alerts raised in March compared to 80 in February. 81 alerts were reported by the Trust. 6 alerts raised from an external organisation compared to 3 in February, 1* of which was a request for information to support external safeguarding activity. Of the 81 alerts reported by the Trust, 21 related to Trust provided care, compared to 18 in February: Safety - Safeguarding - 4 were determined not to cross the safeguarding threshold. - 2 (1*) allegations of physical abuse in hospital; both concerns relate to the actions and threats from visitors. - 8 allegations of omission of care; 1 fall related, 1* discharge concern, 3 (2*) concerns relating to general care issues, 1 abscondment of a patient under a Deprivation of Liberty Safeguard Authorisation, 2(1*) relating to concerns about mental capacity assessment, 1-7 potential hospital related pressure ulcers. The fall related allegation has been investigated and closed as not substantiated. The discharge concerns have been investigated. Although no actual patient harm occurred, poor communication on discharge has resulted in the allegation being partly substantiated. * externally raised alerts

Portsmouth Hospitals NHS Trust QAH Hospital Page 20 Safeguarding adults (Contract) March position - Deprivation of Liberty Safeguards (DoLS) There have been no confirmed unauthorised DoLS in March. Two investigations into potential unauthorised DoLS reported in January have found breaches of the legislation, largely due to failure or delays to apply for a DOLS Authorisation. There has been no adverse patient impact as a result of these breaches. The Department of Health have now issued new guidance in response to the DoLS Supreme Court ruling in March 2014; Trust Policy will be updated in line with this. Safety - Safeguarding Actions and progress to date The Care Act 2014 comes into force on 1 st April 2015 and brings with it significant changes for adult safeguarding. The Trust continues to work in partnership with the local Adult Safeguarding Boards to ensure compliance with the statutory requirements across local health and care sectors. Update on highlighted internal care concerns: - 2 serious allegations were raised in January. 1 investigation is ongoing. The other has been completed and found no evidence of inappropriate behaviour and is awaiting formal closure by external safeguarding. - Other allegations highlighted in February remain under investigation or are awaiting formal closure by external safeguarding. The Trust is currently contributing to 3 Adult Safeguarding reviews and 1 Domestic Homicide Review.

Portsmouth Hospitals NHS Trust QAH Hospital Page 21 Safeguarding Children (Contract) March position - Safeguarding children 59 referrals were made by hospital staff to Children s Social Care (CSC) in March compared to 50 in February - 26 referrals by midwives, - 16 by paediatrics/hospital staff; and - 17 from the Emergency Department. Safety - safeguarding In total the team were notified of 96 cases, the additional cases (x 37) were received from: - Children s Social Care, Police and the Multiagency Safeguarding Hub (x 35) notifications of concern were received - Enquiries from Community and other (x 2) - All referrals/notifications are triaged, responded too and supervision given where required by the Safeguarding Children Team (SCT). No complaints received. No adverse incidents graded red or amber, 1 adverse incident raised in relation to communication with either the Safeguarding Children Team or partner agencies. The SCT raised 70 Child Protection Alerts (maternity). No allegations were raised internally or externally to the Trust in February via the Safeguarding Children Team. Serious Case Reviews (SCR)/Reflective Practice for Portsmouth Safeguarding Children Board (PSCB) and Hampshire Safeguarding Children Board (HSCB) reported in the quarter 4 quality Board report. There were two child deaths reported in March; 1 relating to a child aged 4 months which was expected. The other relates to a child aged 16; unexpected death-child Death Procedures were followed.

Page 22 Mortality indicators: HSMR and SHMI (Contract and Quality Account) March position Hospital Standardised Mortality Ratio (HSMR) Target: On or below National Average of 100 The Current HSMR figure for January 2014 to December 2014 is within the expected range at 100.3 which is higher than the previous months reported figure of 95.2. This increase is mostly due to a new process which has been instigated by Dr Foster in that their data model is being updated every month. Current HSMR Dec13 Nov14 HSMR: 100.3 (within expected range) Effectiveness - Mortality Summary Hospital-level Mortality Indicator (SHMI) Target: On or below National Average of 100 The quarterly SHMI figure was published in February and is therefore unchanged from the previous report. The Trust SHMI for July 2013 to June 2014 is 107.9; which is an increase from the previous quarter s figures of 104.9. Whilst this figure is above the National Average of 100, it is within the official control limits. The Clinical Effectiveness Steering Group continues to investigate some of the issues surrounding this with the benchmarking provider, Dr Foster. Definitions: HSMR: The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower would be expected. The national average is 100 and a score of below this indicates less deaths than this average. HSMR covers 56 groups of diagnosis and only relates to patients that have died whilst in hospital. SHMI: The Summary Hospital-level Mortality Indicator (SHMI) is a high level mortality indicator that is published by the Department of Health on a quarterly basis. It follows a similar principal than HSMR, however SHMI covers all diagnosis groups and relates to all patients that have died (whether the patient died whilst in hospital or not). It does not take account of deprivation. Annual HSMR 2013/14 HSMR: 99.68 (within expected range) Weekday HSMR: 99.01 (within expected range) Weekend HSMR: 101.62 (within expected range) Current SHMI July 13 June 14 SHMI: 107.9 (within expected range)

Page 23 Dementia (CQUIN) March position : Element 1: Find, Assess, Investigate and refer Target: 90% or greater in each of the three steps each quarter. There has been a decrease in compliance with step 1 in March of 89.9% compared to 92.7% in February. There has been a different operational process put in place from March 11 th 2015 for admitting patients from the unscheduled care pathway. The majority of medical patients who will require a greater than 48 hour length of stay are transferred directly to the wards from the Emergency Department. This has led to a slight reduction in compliance with dementia screening; processes are being reviewed by the CSC s. Dementia CQUIN compliance January 2015 February 2015 March 2015 Step 1: Case finding 93.9% 92.7% 89.9% Step 2: Assessment 100% 100% 100% Step 3: Onward referral 100% 100% 100% The quarter 4 CQUIN requirements have been achieved. Caring - Dementia Actions and progress to date Daily e-mails highlighting patients not assessed continue to be sent to the CSCs to ensure focus is maintained. Definition of steps: Step 1 Case finding: The number of patients >75 admitted as an emergency who are reported as having a known diagnosis of dementia or clinical diagnosis of delirium, or who have been asked the dementia case finding question, excluding those for whom the case finding question cannot be completed for clinical reasons (e.g. coma). Step 2 - Assessment: Number of above patients reported as having had a diagnostic assessment including investigations. Step 3 Onward referral: Number of above patients referred for further diagnostic advice in line with local pathways agreed with commissioners.

Page 24 Mixed Sex Accommodation (National) Caring Mixed Sex Accommodation Non-clinically justified single sex accommodation breaches Target: 0 (zero) There have been 0 (zero) non-clinically justified Single Sex Accommodation breaches in March. Year to date total of 8 non-clinically justified Single Sex Accommodation beaches (1 breach affecting 8 patients) in May 2014. Facilities single sex accommodation breaches There have been 0 (zero) single sex accommodation breaches relating to facilities in March.

Page 25 Complaints (Contract and National) March position A total of 57 complaints were received In March compared to 60 in January (equating to 0.91 per 1,000 episodes compared to 1.03 in February). To date, 10 (18%) complaints received in March have been responded to within the agreed 30 working days. Of the 60 complaints received in February, 42 (70%) have so far been responded to within 30 working days. Please note: 6 complaints received in quarter 4 were subsequently withdrawn by the complainant as their concerns had been resolved by a conversation with staff or it later became clear issues related to a different trust. Month No. of Complaints Received 2013/14 2014/15 Variance year on year Variance month on month March 76 57 19 3 February 63 60 3 5 January 60 55 5 16 Caring 1-3 Low risk 8-12 High risk 4-6 Moderate risk 15-25 Extreme risk

Page 26 Complaints (Contract and National) March position Complaint acknowledgment rate (national requirement) 100% of complaints were acknowledged within the mandatory 3 day target in March which is comparable with February. Longest running case previously reported is now closed. The longest running case now is within the Women and Children s CSC and is from December 2014. Parliamentary Health Service Ombudsman (PHSO) (National requirement) The Trust has been made aware of 5 new referrals to the PHSO in March, 1 to be upheld; compared to 0 (zero) in February. There are 9 complaints still currently under review. Plaudits In total the Trust received 380 messages of thanks during March 2015. Caring

Page 27 Complaints, PALS and patient satisfaction (Contract) March position PALS contacts 201 PALS contacts were received in March, compared to 197 in February. This is a considerable increase from March 2014 when PALS received only 113 contacts. 178 (89%) of these cases have already been resolved to the satisfaction of the individual. 149 (84%) were resolved within 5 working days in March compared to 138 (70%) in February. Caring Complaints PALS conversion to complaints 1 case was converted to a formal complaint as PALS were unable to resolve compared to 3 in February. Patient Satisfaction Satisfaction rate is based on the surveys currently being used through the Elephant system. In March 613 patients participated in the surveys in comparison to 601 in February. The satisfaction rate was 90.96 in March in comparison to 89.76 in February. A small increase in respondent numbers and satisfaction rate was seen in March compared to February.

4/23/2015 Page 28 Responsive Patient Moves Patient Moves (Contract and Quality Account) March 2015 Performance Target: Quarter by quarter improvement in performance in relation to the number of patient moves Significant work has been undertaken during March to reduce the number of non-clinical moves experienced by patients. An administration error has been identified regarding a delay in the updating of the PAS system, especially out of hours. A double method of validation has been implemented by the Duty Hospital Managers. In March, despite increased activity the number of patient moves after midnight reduced to 54. The improvement trend is being sustained during April. *Based on revised March figures post PAS update QUARTER 4 January February March 2015 Quarter 4 Q3 to Q4 0700-1859 443 14.3 369 13.2 576 18.6 46.0 1900-2259 220 7.1 169 6.0 214 6.9 20.0 2300-0659 228 7.4 194 6.9 175 5.6 19.9 Total moves 891 28.7 732 26.1 965 31.1 86.0

Page 29 Well-Led Friends and Family Friends and Family Test: Increasing response rate in In-patient areas and ED (CQUIN) March position Target: In-patients: Q1, Q2 Q3: 25% over the quarter average. Q4: 30% over the quarter average. ED: Q1: 10% by end. Q2: 10% over the quarter average. Q3: 12% by end. Q4: 15% by end. There has been an increase in the number of eligible patients for both ED and in-patients in March; with an increase being seen in the response rates for both in-patients and ED. The Net Promoter Score (NPS) remains at 77. The percentage of friends and family who would recommend the Trust has remained at 96%. The number of don t know responses continues to decrease. The CQUIN target has been achieved for both in-patients and ED. Actions and progress to date Weekly monitoring reports continue. Each CSC display the additional satisfaction scoring alongside NPS. In-patient areas completing transparency boards locally, which are to be included in the CSC quality and governance reports. ED have been given a daily target for compliance. Comments: Friends and Family Response rates Total response rate (responses / eligible patients) Month In - Total ED Patient March 15 25.6% Friends and Family percentage to recommend rates Month 18.5% 1033/5580 February 15 23.6% 16.9% 853 / 5047 January 15 22.7% 16.6% 899 / 5408 Recommendation percentage % recommend 39.2% 1132/2887 36.5% 966 / 2647 36.6% 985 / 2691 % not recommend March 15 96% 1.5% February 15 96% 1.2% January 15 95.7% 1.6% Net Promoter Score (NPS) Month Score March 15 77 February 15 77 January 15 76

Page 30 Well-Led Friends and Family Friends and Family Test Improving positive responses in ED, In-patient areas and maternity(cquin) March performance Improving positive responses in ED Target: 92% average in quarter 4 (3% improvement on 2013/14 baseline of 89%) The CQUIN target has been achieved with an average across quarter 4 of 95.3% against a target of 92%. There has been a significant increase in the number of responses and continued improved positive responses. The number of Don t know responses remains lower than previously. The response themes are being identified locally by the clinical areas. Improving positive responses in In-patient areas Target: 96% average in quarter 4 (3% improvement on months 1, 2, 10, 11 and 14 2013/14 baseline of 93%) The CQUIN target has been achieved with an average across quarter 4 of 96.5% against a target of 96%. There has been an increase in the number of responses and high positive responses maintained. Improving positive responses in Maternity Target: 75% average in quarter 4 (3% improvement on October to March 2013/14 baseline of 72%) The CQUIN target has been achieved with an average across quarter 4 of 99.33% against a target of 75%. March has seen a significant decrease in the number of responses for all questions with an increase in satisfaction. There were no don t know responses in the month of March. Individual groups of staff have now been given responsibility for ensuring the numbers of responses increases. Improving positive responses Month Improving positive responses Month Total number likely and very likely Total number likely and very likely EMERGENCY DEPARTMENT (target: 92% average over quarter 4) Total number responses (including don t know ) MATERNITY (target: 75% average over quarter 4) Total number responses (including don t know ) Overall compliance March 2015 988 1033 95.6% February 2015 814 853 95.4% January 2015 853 899 94.9% Improving positive responses Month Total number likely and very likely INPATIENT AREAS (target: 96% average over quarter 4) Total number responses (including don t know ) Overall compliance March 2015 1092 1132 96.5% February 2015 934 966 96.6% January 2015 950 985 96.4% Overall compliance March 2015 288 288 100% February 2015 367 371 98.9% January 2015 490 494 99.1%

Page 31 Well-led Friends and Family Friends and Family Test Maternity (National and Contract) March performance Target: The Trust is required to report and improve upon response rates. Women are asked to complete a Friends and Family form at four points of contact and respond to four specific questions. There has been a significant reduction in the overall response rate seen in March of 15.1% compared to 20.3% in January. Actions and progress to date: The results have been circulated to all staff showing the significant reduction and requesting for proactive increase in encouraging women to complete the forms. Band 2 and Band 3 staff have now been given specific responsibility for ensuring question 1 and 4 forms are completed by women. Midwives working in Children Centres will ensure children centre teams support maternity services in the collection of the forms and participate in the collection of the antenatal question at 36 weeks gestation. The diabetic team and maternity outpatients team will be asked to circulate the antenatal forms to increase completion of forms. Response themes: The majority of responses are positive Positive comments: I knew I could ring someone and always get advice. Fantastic breast feeding support and options for home visit if I needed it. Very polite and friendly. Very happy with the service. Thank you. Everything was extremely through and felt very well cared for. Thank you so much to everyone. Special mention to the Consultant who delivered Jack, The anaesthetist the diabetic team and the midwives were all excellent. Negative comments: Discharge process could be improved as I was hoping for a speedy discharge - Midwives will be performing NIPE (newborn infant physical examination) for low risk babies which should improve the discharge process. More information required about early labour - Some women choose not to access parent education classes. Midwives to be reminded about the importance of discussing early labour particularly for first time mothers during the antenatal period. A new birth choice app is being used in maternity and early labour should be discussed when considering preference for place of birth. Maternity Friends and Family response rates Jan 15 Feb 15 March 15 1. 9.9% 8.1% 2.4% 2. 36.1% 30.5% 23.3% 3. 33.5% 31.9% 32% 4. 22.4% 14.8% 4.1% Response rate 25.3% 20.3% 15.1% Maternity Friends and Family questions 1. Antenatal care (community based care up to 36 weeks). 2. Intrapartum labour care. 3. Immediate postnatal care. 4. Postnatal care up to discharge to Health Visitors.

Portsmouth Hospitals NHS Trust QAH Hospital Page 32 Key