Airedale NHS Foundation Trust Board of Directors:23 rd January 213 Title: Quarter 2 212/13 Quality Account (Quality and Safety) Author: Alison Fuller, Assistant Director Healthcare Quarter 2 212/13 Quality Account (Quality and Safety) The attached report is the 212/13 Quarter 2 Quality Account (Quality and Safety) report. It is intended to provide assurance that identified risks are being managed appropriately and raise areas of. Recommendation The Executive Board of Directors is asked to receive and discuss. 1
Quality Account: Airedale NHS Foundation Trust 212/13 212/13 Quality & Safety Indicator data type 21/11 211/12 Qtr1 Qtr2 Qtr3 Qtr4 R A G Target REGULATORS: Care Quality Commission & Monitor CQC Registration: Bridget Fletcher (accountable officer) categorical CQC Inspection - planned review: Castleberg - - CQC/Ofsted inspection and review: safegurading and care May 212 CQC inspection - responsive review: TOP services March 212 CQC inspection - planned review: dignity and nutrition for older people CQC Healthcare Associated Infection: inspection 29/1 - In-patient survey ( 21, 211) Q74 overall, how would you rate the care you received - Out-patient Survey (29, 211) Q48 Overall, how would you rate the care you received at the OPDept? - Emergency Department (28) Q4 overall, how would you rate the care you received in the A&E Dept - Maternity Services Survey ( 21) C17 Overall, how would you rate the care received during labour & birth NHS Staff Survey ( 21, 211) KF34: Staff recommendation as a place to work or receive treatment NHS Staff Survey ( 21, 211) KF1: % staff feeling satisfied with the quality of work & patient care they are able to deliver Quality and Risk Profile Monitor: Governance Rating worse/same/ better minor s - - - - no s - - - - no s - - - - no s - - - - - no s - - - - - no s 79 7.9 - - - 86 86 - - - 82 - - - 7.8/1 84 - - - - - % score 3. 3.46 - - % score 6 69 - - signpost link Current rating LInk to QRP QRP - Jun 12 QRP - Oct 12 range 2% L=6.6 H=9.2 2% L=82 H=86 better than most other trusts 2% L=79 H=87 - Nat Ave 3. - Nat Ave 74 - - Link to Green Green Green Green - - Green Infection Control Methicilin Resistant Staphylococcus Aureus (MRSA) n 3 1 1 - - Clostridium Difficile n 16 21 4 - - target = (de minimis=2) target=9 (de minimis=12) SPC chart for C.difficile cases developing more than 72 hours after admission to Airedale Hospital site SPC chart for all MRSA bacteraemia cases Count of C. difficile 1 UCL=.86 Mean=26.93 LCL=2.992 Count of MRSA bacteraemia 8 7 6 4 3 2 1 UCL=.877 Mean=2.4 LCL=. 1 2 3 Period: Q3 2/6 - Q2 212/13 1 2 Period: Q3 2/6 - Q2 212/13 3 NHS Complaints n (formal) 8 72 26 13 - - reduce C-PALS Complaints referred and upheld to Parliamentary and Health Services Ombudsman (PHSO) (upheld/referred) n upheld / n referred upheld / 8 referred upheld / 4 referred 1 referred 2 referred n upheld / n referred 1 referred suggest= PALS n 1742 1963 494 46 - -? increase/reduce SPC chart for complaints Airedale NHS Foundation Trust SPC chart PALS contacts [Airedale NHS Foundation Trust & other healthcare organisations] 6 Count of complaints 4 3 2 1 UCL=43.98 Mean=27.7 LCL=11.1 Count of PALS contacts 4 3 2 1 UCL=464.3 Mean=31.2 LCL=238. 1 2 3 Period: Q1 2/6 - Q2 212/13 1 2 3 Perod: Q1 2/6 - Q2 212/13 1 of 4
Quality Account: Airedale NHS Foundation Trust 212/13 212/13 Quality & Safety Indicator data type 21/11 211/12 Qtr1 Qtr2 Qtr3 Qtr4 R A G Target Inquiries open n Inquiry report pub: June 21 - - - - threshold= Inquests - rule 43 n - - threshold= Patient Safety: SIRIs, incidents, NHSLA risk management standards and PEAT Serious Incidents (open on STEIS) n 4 - - reduce Never event cases: (7 in 21/11, expanded to 2 211/12) n - - threshold= Rate of reported incidents (reported to the NRLS per 1 admissions) bi-annual 1.4 / 3.8 6.9 / 6.3 7.9 increase Degree of harm - no harm n 119 [Apr-Sep 11] 1141 [Oct 11-Mar 12] increase low harm n 649 [Apr-Sep 11] 947 [Oct 11-Mar 12] moderate harm n 34 [Apr-Sep 11] 43 [Oct 11-Mar 12] severe harm n 1 [Apr-Sep 11] 3 [Oct 11-Mar 12] death n [ [Apr-Sep 11] 2 [Oct 11-Mar 12] suggest= NHSLA Risk Management Standards for Acute Trusts:(26th Aug 29) Clinical Negligence Scheme for Trusts (CNST): maternity standards (7th Dec 21) Level 1-3 Level 1-3 Level 2 (41/) Level 1 (46/) - - - - - - Claims: total matters (CNST & RPST) n tbc tbc - - - Payments made (CNST, ELS & RPST) 1,772,478 tbc - - - Obstetric claims: total matters n tbc - - - Obstetric payments made 18,64 tbc - - - Inspection planned NHSLA Contributions 2,632,329 3,37,66 - - - - PEAT: E-Environment; F-Food; PD-Privacy & Dignity (21, 211) categorical selfassessed E-Good F-Excellent PD-Excellent E-Good F-Excellent PD-Excellent - - - Inspection planned maintain level 2 - maintain level 1 Results reduce claims reduce costs reduce claims reduce costs reduce contributions Excellent SPC chart for reported clinical incidents Airedale NHS Foundation Trust 2 SPC chart for all reported moderate harm clinical risks 6 UCL=6.78 Special cause v ariation: 2 out of 3 points more than 2x SD f rom the centre line [same side] 1 UCL=1317 4 Count of incidents 1 Mean=13 LCL=689.2 Count 3 2 1 Mean=28.2 LCL=. 1 2 3 Period Q1 2/6 - Q2 212/13 Period: Q3 9/1 to Q2 12/13 1 Patient Safety Incidents - breakdown Rate of reported medication errors Rate of reported medication errors, which resulted in harm n / 1 bed n / 1 bed 69 (4%) 74/(4.9%) n=163 n=132 increase 238 (1.%) 97 (.6%) n=38 n=31 reduce - number of medication errors resulting in severe harm n 2 maintain Rate of in-patients [AGH] where a fall was recorded [AGH] Rate of in-patients [AGH] where fall resulted in a fracture Rate of in-patients where a fall resulted in significant harm Number of in-patient pressure ulcers: Grade 3 & 4 - developed in hospital Number of in-patient pressure ulcers: Grade 3 & 4 - developed in community care n / 1 bed n / 1 bed n / 1 bed 9.7 1.9 n=26 n=28 reduce.2.3 n=1 n=7 reduce n=1 reduce n 2 32 6 3 reduce n 18 3 3 reduce 2 of 4
Quality Account: Airedale NHS Foundation Trust 212/13 212/13 Quality & Safety Indicator data type 21/11 211/12 Qtr1 Qtr2 Qtr3 Qtr4 R A G Target 1 SPC chart for reported fractures from falls UCL=13.66 SPC chart for reported hospital-acquired grade 3 & 4 pressures ulcers UCL=12.29 Count of fractures from falls 1 Mean=.83 LCL=. Count 1 Mean=6.36 LCL=.42 1 2 Period: Q1 28/9 to Q2 212/13 1 1 Period: Q1 29/1 to Q4 212/13 Summary Hospital-level Mortality Indicator (SHMI) - emergency & elective 211 / 12.93.89 1. or less SHMI risk adjusted banding 2 2 2 or less Summary Hospital Mortality Indicator (SHMI) SHMI diagnosis group - pneumonia 211 / 12.66 awaited - - - - 1. or less SHMI diagnosis group - acute cerebrovascular disease 211 / 12.83 awaited - - - - 1. or less SHMI diagnosis group - COPD 211 / 12 1.4 awaited - - - - 1. or less SHMI diagnosis group - urinary tract infections 211 / 12.77 awaited - - - - 1. or less SHMI diagnosis group - congestive heart failure, 211 / 12.77 awaited - - - - 1. or less nonhypertensive - - - SHMI diagnosis group - acute bronchitis 211 / 12.71 awaited - - - - 1. or less SHMI diagnosis group - cancer of bronchus lung 211 / 12.72 awaited - - - - 1. or less SHMI diagnosis group - fracture neck of femur 211 / 12.71 awaited - - - - 1. or less SHMI diagnosis group - septicemia (except in labour) 211 / 12.77 awaited - - - - 1. or less SHMI diagnosis group - acute and unspecified renal failure 211 / 12.48 awaited - - - - 1. or less 21/11 211/12 Relative SHMI risk to average % of patients admitted within the Trust whose treatment includes palliative care % of patients admitted within the Trust included in the SHMI whose treatment included palliative care not avail 1.22 not avail 21.6 1. Relative risk.9.93.9.89.92.9.89 Apr1-Mar11 Apr11-Mar12 Jan11-Dec11 Jul1-Jun11 Oct1-Sept11 3 of 4
Quality Account: Airedale NHS Foundation Trust 212/13 212/13 Quality & Safety Indicator data type 21/11 211/12 Qtr1 Qtr2 Qtr3 Qtr4 R A G Target Clinical effectiveness: PROMs, clinical audit and NICE gudiance Rate of eligible patients taking part in PROMs - eligible finished consultant episodes PROMs -Patients reporting an improvement following Hip Replacement - EQ--D index PROMs -Patients reporting an improvement following Knee Replacement - EQ-D index PROMs -Patients reporting an improvement following Varicose Vein Procedure - EQ D index PROMs -Patients reporting an improvement following Groin Hernia Procedure - EQ - D index VTE incidence rate Emergency re-admissions to hospital within 28 of discharge Particiption 89.4% 86.% - - - - Nat Mean=79.8% % risk assessed % admitted 28 Rate of adults who are dying whilst being cared for on LCP incidence - 9% by Q4 CAS alerts (outstanding / ongoing) NICE Quality Standards - baseline assessment within 3 mths NICE Guidance Compliance TAGs within 9 Participation in relevant clinical audits/outlier data Developed by Caroline Booton - 287 n complete / n relevant alerts 9./86.7% 81.1/87.3% - - - - 8.1/77.9% 83//78.6% - - - - 61.7/1.6% 4/3.3% - - - - 42./.% 39.6/49.9% - - - - 9% 9% 97.7% 98.3% target = 9% 6.1%.7% - - Results - - average increase rate to 9% by Q4 11/12 1% compliance within timeframe n / relevant 6/7 7/8 1/2 target=1% n / relevant - - 1/11 1/4 - - target=1% n / relevant 3 / 49 (72%) 29 / 37 (78.3%) x / x (x%) x / x (x%) - 3/37 - - target=1% 4 of 4