Report to: Board of Directors Agenda item: 7 Date of Meeting: 27 July 2016

Report to: Board of Directors Agenda item: 7 Date of Meeting: 27 July 2016 Title of Report: Status: Board Sponsor: Author: Appendices Quality Report For discussion Helen Blanchard, Director of Nursing and Midwifery Tim Craft, Medical Director Jan Lynn, Lead Nurse Workforce Development and Education Appendix A - Nursing Quality Indicators Chart (June data) 1. Executive Summary of the Report This report provides an update on quality with a focus on patient experience and key patient safety and quality improvement priorities reviewing June 2016 data. The Quality Report this month includes a quarterly update on the improvement priorities as highlighted in the 2016/17 Patient Safety and Quality Improvement Triangle. Other items will be reported on an exception basis. This month the report focuses on: Part A - Patient Experience: o Complaints and PALS monthly activity data Part B - Quality Improvement Priorities: o Patient Safety Acute Kidney Injury (AKI) o Patient Safety National Early Warning Score (NEWS) o Patient Safety Insulin Safety o Patient Safety Movement of Patients Location Exception reports: o Nursing Quality Indicators Exception Report o Serious Incidents monthly summary o Serious Incident reports approved in June o Overdue serious incidents summary 2. Recommendations (Note, Approve, Discuss) To note progress to improve quality, patient safety and patient experience at the RUH. 3. Legal / Regulatory Implications It is a legal requirement to comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3). Author : Jan Lynn, Lead Nurse Workforce Development and Education Document Approved by: Helen Blanchard, Director of Nursing and Midwifery and Tim Craft, Medical Director Date 11 th July 2016 Version: 1 Agenda Item: 7 Page 1 of 2

4. Risk (Threats or opportunities, link to a risk on the Risk Register, Board Assurance Framework etc.) A failure to demonstrate sustained quality improvement could risk the Trust s registration with the Care Quality Commission (CQC) and the reputation of the Trust. 5. Resources Implications (Financial / staffing) Delivery of the priorities is dependent on the continuation of the agreed resources for each project. 6. Equality and Diversity Ensures compliance with the Equality Delivery System (EDS). 7. References to previous reports Monthly Quality Reports to Management Board and Board of Directors 8. Freedom of Information Public. Author : Jan Lynn, Lead Nurse, Workforce Development and Education Document Approved by: Helen Blanchard, Director of Nursing and Midwifery and Tim Craft, Medical Director Date: 11th July 2016 Version: 1 Agenda Item: 7 Page 2 of 2

QUALITY REPORT PART A Patient Experience 1

Complaints and Patient Advice and Liaison Report Number of complaints 40 30 20 10 Total number of complaints received Number of complaints received Trendline There were 21 formal complaints in June 2016: 9 were regarding Medicine services 8 were in relation to Surgical services 4 were related to Women and Children s services 14 of the complaints related to care in 2016, 6 related to care given in 2015 and 1 to care given between 2009 to the present date 11(52%) complaints were received regarding Clinical care and treatment. 7 of these related to inappropriate care and treatment Of the 7 relating to inappropriate care and treatment, 2 relate to overall care received, 2 relate to patients expectations not being met, 1 relates to an alleged delay in medication, 1 to a patient s preparation for surgery and 1 to a misdiagnosis 10 (48%) of the complaints were split between 6 themes, the most prevalent being outpatient appointment delay/cancellation (3) and staff attitude (2) There were 359 contacts with the PALS service: 157 requested information or advice (44%) 131 required resolution (36%) 31 provided feedback (9%) 40 were compliments (11%) This is a notable increase on previous months and further analysis will be provided in the Q2 Patient Experience report. The top three subjects requiring resolution were: Communication and Information there were 33 contacts (25%) with requests for communication and information regarding the services provided by the Trust, there are no trends or themes in relation to these contacts Appointments of the 30 contacts (23%) regarding appointments, 12 patients had concerns about waiting for outpatient appointments across medicine and surgical divisions Clinical care and treatment of the 33 contacts (25%) none were attributed to a particular hospital service 2

QUALITY REPORT PART B Patient Safety and Quality Improvement Safer 6 Patient Safety Priorities Acute Kidney Injury (AKI), Improving Insulin Safety, Movement of Patient s Location National Early Warning Score (NEWS) Sepsis, Clostridium difficile 10 Executive sponsored projects of must-do s informed by business unit priorities, CQUIN or as a response to stakeholders Pressure ulcers, Anti Coagulation/Missed Doses, VTE, Falls, Emergency Laparotomy/NatSsips, Harm & MFFD Patients, Frailty, SSIS 15 Divisional Safety Priorities Medicine Surgery Women and Children 3

Patient Safety - Acute Kidney Injury (AKI) Background National CQUIN for 2015/6 completed and achieved in full AKI has been agreed as a quality indicator for 2016/17, and reports to include evidence of continuation of training programme, identification and management of AKI, including compliance with the AKI care bundle and information in the discharge summary Current Status Awareness and Training 636 staff have been trained since November which equates to 31% of clinical staff (adult inpatient staff only) MAU have trained 68% of staff Cascade training continues in particular on MAU, ED and maternity but cascade training needs to increase to achieve 90% all staff trained by December 2016. Cascade trainers identified and trained but struggling to deliver training and support is required from departmental and ward leads (Percentage of staff trained by ward is shown in next slide fig 1) AKI Bundle compliance Improvement work has continued on Cardiac, Respiratory ward and MAU Current bundle compliance for Cardiac and Respiratory wards can be seen in the run charts (overleaf). Work is on going to sustain improvements, including adaptation of the bundle sticker Plans to roll out the sticker for more widespread use will be following the new doctors arriving in August Discharge Summary Information The improvement of information in the discharge summary for cardiac and respiratory patients has been sustained (see run chart) and this data is planned to be collected Trust wide by the end of Q2 The automatic link of AKI alert to the discharge summary followed by key mandatory questions is part of the larger project on discharge summaries and should be live in August Update on patients receiving IV contrast An F1 quality improvement project with the radiologists to increase awareness/management of patients following IV contrast (risk of AKI) has commenced on SAU before rolling out more widely. This project won first prize at the F1 Quality improvement presentations in June Update on fluid balance and hydration work Work has started with Nutrition and Hydration group regarding increasing awareness of urine output for all patients, particularly those on hydration charts. Baseline data is currently being collected Links with Community The RUH AKI steering group has representation from the community AKI group and has established good links to ensure the AKI work is integrated across the sector An educational session at the GP cluster forum has been organised for September and it is planned to switch on the AKI e-alert for GPs and community teams in the near future Patient Information Patient Information leaflets have been developed and are due to be launched Next Steps Increase training from AKI cascade trainers across all wards Spread improvement work hospital wide The specific incidence of AKI per division and speciality is currently communicated at divisional governance level, and future plans will be for ownership of compliance with bundle delivery and discharge summary information at speciality and divisional level 4

Patient Safety - Acute Kidney Injury (AKI) fig 1.0 Bundle Compliance for Cardiac and Respiratory ward Discharge summary compliance for Cardiac and Respiratory ward fig 3.0 fig 3.0 5

Patient Safety - National Early Warning Score (NEWS) work stream report Work stream update The aim of the National Early Warning Score (NEWS) work stream is to ensure that NEWS is reliably and accurately used to monitor adult patients vital signs, that care is appropriately and reliably escalated and that correct actions are taken to ensure optimal care for the patient Progress to work plan: 1.0 Documentation and Policy First draft of revised NEWS chart at printers; to include section for recording escalation and flowchart for management of Deteriorating patient Task and finish group established to review and establish option for electronic system to record vital signs 2.0 Education and Training Total of 86 nursing and AHPs have been trained as cascade trainers which means 100% of wards have at least two Cascade trainers Total of 922 nursing staff and AHPs have been trained at ward level by Cascade trainers (66% of our target group of Nursing and therapists) Cascade trainers Celebration event planned for July 20th 2016 Shortlisted in Nursing Times Patient Safety Improvement category ED Department: Focused Improvement work launched in ED department 2nd May - Improvement team (NEWS Squad) led by Band 5 and 6 ED nurse supported by Consultant/Clinical Governance lead and NEWS work stream Standard agreed for recording of NEWS in ED 6 Cascade trainers have trained 68 staff at level 2 to date, in addition delivering short teaching bullet sessions and developed NEWS notice board Developed teaching sessions for doctors (includes prescribing of oxygen saturation ranges) and adjusting frequency Improvement measured by regular measurements (Figure 1) Figure 1 3.0 Measurement and communication of compliance In wards where cascade trainers have trained at least 75% of staff, additional audits are carried out to review the impact of the training on the completion of NEWS example of SAU (Figure 2) Figure 2 6

Patient Safety - National Early Warning Score (NEWS) work stream report Monthly audits continue to measure NEWS compliance and accuracy. Feedback of audit results via Senior Sister meetings for Medicine and Surgery and data submitted to dashboard (Tables 1 and 2) Table of Current Performance of NEWS score recorded The percentage score shown in Table 1 is the percentage of observations performed where a NEWS score is recorded. It should be noted that this is the third month that all areas are reported as green for NEWS recorded, over 90%. Table of Current Performance of NEWS accuracy recorded The percentage score shown in Table 2 is the percentage of observations performed where a NEWS score is accurate. For May the overall scores have shown improvement with 11 areas achieving over 80%. Key: Adherence > 90% Adherence 80% 89% Adherence < 80% Table 1 Key: Adherence Adherence Adherence Table 2 > 90% 80% 89% < 80% 7

Patient Safety Insulin Safety Background A national diabetes audit carried out in 2015 highlighted a number of areas in the management of diabetes that require improvement in the Trust. A key part of this involves prescribing and administration of insulin. Currently a team at the RUH is participating in improvement work with NHS Quest, a national collaborative to improve safety in this area. In addition, there is also input into the West of England Academic Health Science Network as the work is complementary and there are specific resource tools that may be shared. The Trust recognises the importance of this safety work and it is now part of the Safer 6 safety programme AIM of the project: is to reduce adverse incidents involving insulin to adult patients with diabetes by 75% by May 2017 Driver Diagram for the NHS Quest Haelo Quality Systems project Progress A team including a specialist diabetes clinician, nurses, pharmacists and a manager have developed a draft driver diagram (opposite) following a process mapping exercise to identify key areas to focus on. Diabetes management is complex and development of the measures has been challenging to ensure that there is a robust way of capturing the benefits of any interventions. The current KPIs include: a) incidence of hypoglycaemia b) number and type of insulin prescribing errors c) number and type of insulin administration errors, which may be refined further The initial PDSA cycles will focus on wards with a higher incidence of diabetes (cardiac, CCU, ASU, RSW and SAU). Baseline measures were captured daily in 2014 over a 2 month period. They showed 0.53 hypoglycaemic events per admission and 1.25 medication errors per admission Next Steps The baseline measures captured in 2014 will be revisited to ensure that they are suitable for continuous data collection in the selected wards to ensure that the interventions can be monitored. 8

Patient Safety Movement of Patients Location Aims of the project The project aims to reduce patient ward transfers and reduce moves at night Background A review of 27 patients was undertaken focusing on inpatients recorded on Millennium (Patient Administration System) as having overnight ward moves over a three month period from September to November 2015. The review compared the time of the patient move recorded on Millennium, to the time documented in the patient s medical notes. The review also compared the time of the patient s discharge on Millennium and the patient s notes Results The total number of ward moves for the 27 patients was 90 moves. 11% of patients were moved five times during their stay, 33% were moved four times and 55% were moved three times The time recorded on Millennium compared to the time documented in the patients medical notes is detailed in Figure 1. 69% of patients were moved within a 30 minutes of the time documented in the medical records and the time recorded on millennium. 24% of patients were recorded as being moved on a different day, either on Millennium or in the medical records, and 6.7% of these patients wrongly recorded as moving after 20.00hrs Figure 2 illustrates the number of variances to the actual time of discharge. 63% of patients had a different time recorded either on millennium or in their medical records for their actual time of discharge. 4% of patients were discharged on millennium on the incorrect day, and 9% were incorrectly recorded as being discharged overnight Next Steps Further ongoing reviews of patient moves and time of discharge compared to time recorded on Millennium will be undertaken Head of Nursing set up Project group reporting to Discharge Project Board Set KPI s and develop work plan by August (next Discharge Project Board) Figure 1 Figure 2 9

Serious Incident (SI) summary Current Performance During June, 7 Serious Incidents were reported and these remain under investigation. The incidents have been discussed with the patient and/or their family and they are aware of the investigation, in line with the Duty of Candour framework. Date of Incident Datix ID Summary 03.06.16 43570 A patient fall resulting in a fracture 03.06.16 43566 Admission to ITU for level 3 care following a recognised maternity complication 06.06.16 43643 A patient fall resulting in a Head injury 11.06.16 43792 Delayed diagnosis 13.06.16 43844 Infection reported as cause of death 24.06.16 44174 A patient fall resulting in a fracture 30.06.16 44334 A patient fall resulting in a fracture 10

Serious Incident reports approved in June Date of Incident 26.01.16 (reported 08.03.16) Datix Summary ID 41062 Wound dressings discovered in cavity wound not documented. Learning/ Recommendations Inadequate segregation of absorbent antimicrobial dressings and haemostatic agents within Theatres. Poor documentation in the patient s records. Recommended that these dressings must be clearly labelled and segregated. Intentional dressings/packing of cavity wounds must be clearly documented including plans for removal 24.04.16 42440 A baby suffered a fracture after fall from the mother s bed. The Safer Sleep/bed-sharing information given to new parents will include falls prevention and a robust process for providing this information to new parents will be developed 11

Overdue Serious Incident reports summary Trajectory April May June Actual 1 1 2 Target 0 0 0 3 2 1 0 April May June The drive to reduce the number of overdue SI reports will continue this year, working to a target of zero overdue reports As of 4 th July, there are 19 open Serious Incidents; of these, two are overdue for submission to the Clinical Commissioning Group, but the investigations have been completed and draft reports are written. Any delay in providing a final report is escalated to the relevant Divisional Management team for them to identify what further support can be provided to the investigator to assist them in completing the report. The investigation has been concluded for a further five of the open incidents and the reports will be submitted to the July Operational Governance Committee for approval. The Operational Governance Committee (OGC) monitors the progress against the action plans developed following the investigation; at the June OGC meeting the status at the end of May was: 12

Nursing Quality Indicators - Exception Report (June data) Areas of focus The Nursing Quality Indicators chart is attached as Appendix A. Two wards flagged this month as having nursing quality indicators of note (below). One of these wards also flagged last month Mary ward (Maternity) This is the second subsequent month this ward has flagged. The MCA fill rate during the day and night shifts was around 77% fill rate and this was due to vacancies and sickness. The staffing hours fill rate has improved from last month as staff are returning from sick and starting in post Quality matrices to note are: 6 negative PALs all due to care issues FFT response rate 29% RM and MCA sickness above 5% (April data) Appraisal rates for RMs 80% and MCAs 33% The Matron states that the staffing for Mary Ward also includes the Bath Birthing Centre as staff rotate between the 2 areas. Presently there are 3 Band 7 vacancies across these areas which has impacted on the 4 existing Band 7 midwives and their ability to undertake appraisals and support staff management. Recruitment is active with staff recruited and due to start in post therefore it is expected that the staffing issues will improve within the next few months To support staff to remain at work and reduce the sickness rate the HR Business partner and Matrons have recently met with EAP to find out what services they can offer staff e.g. mindfulness taster sessions Note: Last month both Respiratory Ward and Forrester Brown Ward flagged however their quality matrices have improved this month Acute Stroke Unit This ward has flagged previously last year (Oct 2015) but not since. The HCA fill rate in the day shift was 83.5% and this was predominately due to sickness. The RN day shift hours were 108.9% and this would have supported patient care needs Quality matrices to note are: FFT response rate 32% 2 Patients acquired C.Difficle 5 Datix incident reports for poor nurse staffing levels Appraisal rates for RNs 76.5% This ward does not have a permanent Senior Sister at present although the 2 Junior Sisters are covering in the interim. The Matron is supporting this ward and the Sisters closely and the post of Senior Sister is being advertised Other quality matrices of note: Clostridium Difficle (C.Diff) This month there were 7 cases of C.Diff and this remains a high priority and there is continued robust monitoring and infection control surveillance in place. A detailed thematic case review of patients who have been reported to have died of C.Diff will be undertaken within the next month to determine any lessons learnt form these cases Pressure Ulcers (PUs) There were 3 hospital acquired category 2 PUs this month. A Trust-wide quality improvement event is planned on 26 th July to generate an action plan enabling further improvements and reduction in hospital acquired PUs Falls The total number of falls this month were 79 and this is a significant reduction from last month (109). There were two falls resulting in major harm (fracture and head injury) and root cause analysis investigations are being undertaken. Recently (non-slip) slipper socks have been provided for patients who are 1. 1 admitted without appropriate footwear 1 The Falls Group are presently reviewing their work plan for this year 13 1 3

Nursing Quality Indicators - June 2016 APPENDIX A Report for June 2016 by ward/area triangulating FFT Score; PALS; Complaints; Cdiff; Falls; Pressure Ulcers; HR Ward Group Ward Name FFT % Recommending FFT Response Rate % Number of complaints received Number of PALS contacts Positive Negative Number of patients with CDiff Negligible harm Number of patients who fell Minor harm Moderate harm Major harm Number of patients with pressure ulcers Grade 2 Grade 3 Grade 4 Human Resources Safer Staffing % Fill rate Sickness % Appraisal % Nurse Staffing Datix Reports Day Night R/N HCA R/N HCA Registered Nurses/ Midwives Care Staff Registered Nurses/ Midwives Care Staff No: Emergency Department Inpatient Wards SAU 100 23% 4 1 1 1.8 6.6 78.3 64.7 102.6% 106.1% 96.5% 117.6% 3 MAU 96 19% 1 3 3 2 3.5 3.4 87.5 85.7 81.3% 99.8% 88.7% 106.9% 2 A&E 92 22% 1 5.3 9.8 95.1 78.3 - - - - 3 Mary Ward* 100 29% 6 1 5.1 7.9 80.0 33.3 104.7% 77.8% 99.8% 77.0% 8 Parry 100 67% 1 1 2 1 5.7 1.5 76.9 86.7 1 106.7% 94.5% 82.6% 140.0% 3 Combe 100 50% 1 1 3.9 7.4 88.2 85.7 10 82.1% 107.1% 90.9% 136.3% 2 Violet Prince (RNHRD) 100 40% 2 4.9 3.2 93.3 87.5 92.2% 86.7% 99.3% 95.2% 1 Respiratory 100 39% 5 2 1 2.2 14.8 82.4 82.4 1 70.9% 105.9% 72.2% 104.4% 4 Charlotte 100 35% 2 1 1 4 0.0 15.5 60.0 70.0 3 107.3% 74.4% 100.0% 103.3% 5 Surgical Short Stay Unit 100 32% 2 1 1 7.3 0.9 68.4 81.8 2 92.3% 113.7% 100.6% 125.0% 3 Waterhouse 100 27% 3 5 1.3 9.4 94.1 100.0 80.9% 111.4% 70.3% 104.3% 5 Phillip Yeoman 100 22% 1 1 4.8 1.9 86.7 100.0 75.7% 115.0% 96.6% 88.7% 3 ACE OPU 99 41% 1 2 8.5 9.2 91.3 93.3 2 76.7% 97.5% 100.0% 98.6% 4 NICU 99 14% 3.0 0.0 76.7 63.6 2 66.3% 113.3% 102.1% 90.1% 4 Pulteney 98 47% 2 1 1 1 2 1 6.4 5.8 81.8 90.5 2 95.5% 111.1% 100.6% 202.0% 4 Cheselden 98 42% 2 1 0.0 0.8 88.9 100.0 1 89.1% 121.0% 99.9% 125.0% 1 Helena 98 33% 1 2 1.5 8.9 94.1 83.3 104.1% 95.4% 68.5% 118.3% 5 Medical Short Stay Unit 98 18% 1 4.7 11.8 86.7 71.4 1 85.6% 130.9% 86.5% 136.5% 5 ITU 97 65% 5.7 11.7 88.9 83.3 96.5% 84.9% 101.0% 43.3% 4 Haygarth 97 34% 1 1 1 2 8.1 3.8 87.5 84.6 88.3% 107.3% 74.4% 100.0% 4 Forrester Brown 96 51% 1 2 2 9 1 1 1.0 7.6 88.9 100.0 2 86.8% 110.0% 95.7% 107.3% 3 Robin Smith 95 46% 2 1 1 3.1 1.9 81.0 68.8 2 84.7% 87.4% 94.9% 97.8% 3 Children 95 40% 1 2 1 0.0 1.9 71.1 84.6 2 78.7% 132.3% 89.4% 61.2% 5 Acute Stroke Unit 95 32% 2 2 3 4.7 4.0 76.5 100.0 5 108.9% 83.5% 111.5% 111.3% 6 William Budd 94 47% 2 3 2 1.6 2.1 82.4 100.0 2 96.4% 103.9% 92.5% 115.0% 2 Cardiac 93 42% 2 2.1 5.8 90.5 81.8 1 82.5% 107.5% 80.0% 144.6% 3 CCU 91 35% 2.4 2.2 64.7 100.0 84.3% 123.9% 102.2% 93.3% 2 Midford 85 57% 1 1 0.0 1.9 100.0 88.9 1 67.0% 114.1% 76.4% 105.6% 3 * FFT data taken from Maternity FFT touchpoint 2 - Labour Ward 80% or less < 35% (< 15% Nursing / Midwifery ED, MAU & SAU) related N/M related C. Diff (per patient) 10 Falls or more or major harms HA PUs 5% or more 80% or less 5 or more < 90% More than 5

1.8 6.6 78.3 64.7 5.3 9.8 95.1 78.3 3.5 3.4 87.5 85.7 0.3 6.6 88.9 83.3 5.7 1.5 88.2 85.7 3.9 7.4 64.7 100.0 8.1 3.8 87.5 84.6 1.3 9.4 94.1 100.0 4.9 3.2 93.3 87.5 4.7 11.8 86.7 71.4 1.6 2.1 82.4 100.0 4.8 1.9 76.7 63.6 8.5 9.2 86.7 100.0 3.0 0.0 71.1 84.6 6.4 5.8 88.9 100.0 2.1 5.8 90.5 81.8 0.0 15.5 60.0 70.0 5.1 7.9 80.0 33.3 5.7 11.7 91.3 93.3 7.3 0.9 68.4 81.8 1.0 7.6 81.0 68.8 3.1 1.9 76.9 86.7 0.0 1.9 100.0 88.9 4.7 4.0 81.8 90.5 1.5 8.9 94.1 83.3 2.2 14.8 82.4 82.4 2.4 2.2 76.5 100.0 0.0 0.8 88.9 100.0