Board of Director s Meeting Meeting Date: 15 November 212 Agenda item: 6.1 Title: Purpose: Summary: Recommendation: Author: Presented by: QUALITY AND PATIENT SAFETY ASSURANCE COMMITTEE To provide an exception report from the Quality and Patient Safety Committee Meeting held on 5 November 212 This papers highlights the key items from the Committee meeting To receive and discuss the report Mrs Julie Firth, Director of Nursing and Patient Experience Mrs Julie Firth, Director of Nursing and Patient Experience & Dr Sean MacDonnell, Medical Director Page - 1 -of 7
Quality and Patient Safety Assurance Committee Report 1. Infection Control There were no Methicillin-resistant Staphylococcus aureus (MRSA) cases in quarter 2. There have been a total of 13 cases of clostridium difficile (Cdiff) which places the Trust exactly on trajectory for the end of quarter 2. The Committee noted that the cleanliness levels within the hospital continues to be variable and this was discussed with Paul Theocleous and his actions and increased vigilance and follow up approved. There is a clean and safe water supply at Essex County Hospital, however the aged system makes this challenging. A formal risk assessment is being completed and will report back recommendations. The Committee also received the Annual Infection Control report prior to its publication on the Trusts website. 2. Mortality and ECRIT The 211/12 rebased Hospital Standardised Mortality Rate (HSMR) is 1.8. The end of year figure for last year was 2. Summary Hospital-level Mortality Indicator (SHMI) for the period April 211 to March 212 is 117.59. The Trust and Primary Care will be working collaboratively to review the issues surrounding the SHMI indicator. A Programme Manager has been appointed for the ECRIT Project. Project Managers/Matrons have also been appointed along with Clinical Champions for each of the work streams. 3. Patient Experience The Committee noted the Netpromoter (Family and Friends Test) scores for quarter 2. Q2 Net Promoter Scores (Specialty) 9 94.7 8 86.5 83.5 85. 82.8 84.8 7 77.3 6 68.3 69.1 5 4 3 2 6% 5% 4% 3% 2% % % The overall score for Q2 is 79.9 %. and the Trust remains in the upper quartile for Midlands and East. At our Best training is back on schedule and 77% of staff have completed training. Specialist Medicine (Care of the Elderly) will revert back to mixed wards, however single sex compliance will still be met with single sex bays and separate single sex toilet/bathrooms on each ward. The final behaviour for the At our Best initiative, Be the Difference is to be launched in November. Page - 2 -of 7
4. Estates and Facilities Division Facilities were asked to report on the variable standards of cleaning in general across the Trust. They confirmed that they have a new hand held tool which flags up a poor audit in an area within a few hours. They are also re training staff and appointing team leaders in high risk areas. It was agreed that this Assurance Committee would continue to monitor and review the indicators. 5. Quality Indicators There were 238 total falls recorded during quarter two. There have been 9 (17%) fewer falls recorded from April September 212/13 compared to the same period in 211/212. 14 12 All Falls 5% Reduction 212/13 based on 211/12 No. of Falls 8 6 4 2 612 535 39 461 297 2 115 Trajectory Cumulative Falls 12/13 There was 1 serious harm fall in September bringing the year to date total to 11; two fewer than the same period in 211/12. This represents a further 8% reduction. 73% of serious harm falls have been classified as unavoidable following a MDT panel review process. 3 25 Serious Harm Falls 211/12 to 212/13 No. of Falls 2 15 5 12 11 7 4 5 2 5% Reduction Target Cumulative Falls 12/13 Page - 3 -of 7
The Pressure Ulcer CQUIN performance for April to September reflects a 46% reduction in grades 2-4 pressure ulcers in comparison to 211/12. It is anticipated that CHUFT, along with other NHS hospitals, will shortly be visited by the Pressure Ulcer Intensive Support Team in order to audit our internal processes. 14 12 Zero Tolerance to Avoidable Hospital Pressure Ulcers Grades 2/3/4 212/13 8 6 4 2 Gd 3/4 Gd 3/4 Gd 2 Gd 2 Gd 2 Awaiting Gd 3/4 Gd 3/4 Gd 2 Awaiting Awaiting Gd 2 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Avoidable/Awaiting Review G2 Target The Safety Thermometer audit process continues to meet CQUIN criteria. Safety Thermometer 212/213 6% 212/13 Data for September identifies a harm free rate of inpatient care of 96%. Safety Thermometer Inpatients receiving harm free care 212/213.% % of patients with harm free care 9.% 8.% 7.% 6.% 98.2% 97.8% 95.8% 95.4% 94.% 96.% Harm Free Care Page - 4 -of 7
Performance for the quarter 2 VTE CQUIN milestone was not met, however local manual audits indicate that performance is now moving towards the 95% target VTE Risk Assessments 211 /13 CQUIN Performance Risk Assessments Target % May 212,change in measurement methodology Rounding has dipped below the target, therefore, during November there will be a focussed piece of work to re-launch the programme. Patient Rounding 212/213 6% 91% 74% 81% 76% 71% 212/13 Target % 212/13 There were 23 ward cardiac arrest incidents in quarter two. 7 6 Cumulative Ward Cardiac Arrests with 2% Reduction Trajectory Cumulative arrests 5 4 3 2 Cumulative ward cardiac arrests 212/13 Target 2% reduction based on 11/12 arrests Page - 5 -of 7
Patient At Risk (PAR) Compliance for September was 97% PAR Compliance (%) 211/12 to 212/13 9 8 7 6 5 211/12 Target % 212/13 Malnutrition University Screening Tool (MUST) assessment compliance for quarter two remain above the target of MUST Compliance (%) 211/12 to 212/13 9 8 7 6 5 211/12 Target 212/13% 212/13 In response to the Care Quality Commission (CQC) Remedial Action plan, safeguarding training compliance (Child Protection and Safeguarding Adult) for September was 85%. The CQC have now confirmed that CHUFT is fully compliant with this outcome. Page - 6 -of 7
CHUFT Total Safeguarding Compliance 6% 5% 4% 3% 2% % % There have been 2 reported incidences of ventilator associated pneumonia this financial year, however the work stream remains on target to deliver a 5% reduction Cumulative VAP Incidence for Patients Ventilated >48hrs 2% Data recommences % % Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 % of Ventilated Patients Acquiring VAP YTD Target 5% Page - 7 -of 7