Agenda Item: Board of Directors Meeting Subject: Date: Authors: Lead Director: Executive Summary Report Monthly Quality & Safety Report Thursday 19th December 2013 Susan Bowler / Amanda Callow Susan Bowler – Executive Director of Nursing & Quality This monthly report provides the Board with a summary of important quality and safety items and our key quality priorities. In summary, the paper highlights the following key points: • Pressure ulcers – We continue to see a significant reduction in avoidable grade 2 and 3 pressure ulcers and have had zero grade 4’s for 11 months. This good performance is also shown in our monthly safety thermometer audit figures. • Patient flow – Average length of stay continues to be around 6.2 days against a Trust target of 6 days. There has been a reduction in 30 day re-admissions rates during October and November. Focused work continues to reduce the number of patients with four or more ward movements during their hospital stay. • Complaints – Of the 491 complaints received since 2013, 3 remain open past their agreed timeframe. The numbers of complaints received has fallen to less than 50 during November. Clinical treatment and diagnosis remain the top themes for complaints, followed by doctors attitude. The key recommendations from the Clwyd/Hart review are summarised within the report and being factored into the redesign of the complaints service. • National Maternity Survey - The indicative results were received in November 2013. Overall the Trust performed within the middle of the range. Out of 42 questions we performed in the top 20% of Trusts for 14 and in the bottom 20% for 6 questions. The results are being interrogated in further detail and an improvement plan is being developed to target key areas. • CNST – maternity services have been successful in achieving level 2 during our recent assessment. • Infection control – In terms of C Diff performance, as of 10th December there have been 27 C Diff cases against a total year trajectory of 25. To date, there has been 3 Trust acquired MRSA cases during 2013/14. An external review undertaken by Professor Duerden identified some specific recommendations which are being implemented across the Trust. • Vitalpac – this project is now underway and has the support of a designated project manager. Implementation of the system is currently planned for Spring 2014 and the specific timescales and milestones are being discussed at the Vitalpac Programme Board. • Summary of Discussions from Clinical Governance & Quality Committee Recommendation To note the content of the report and progress / position to date Relevant Strategic Objectives (please mark in bold) Achieve the best patient experience Improve patient safety and provide high quality care Attract, develop and motivate effective teams Links to the BAF and Corporate Risk Register Details of additional risks associated with this paper (may include CQC Essential Standards, NHSLA, NHS Constitution) Links to NHS Constitution Achieve financial sustainability Build successful relationships with external organisations and regulators BAF 1.3, 2.1, 2.2 2.3, 5.3, 5.5 Mortality, C Diff & Complaints on corporate risk register Failure to meet the Monitor regulatory requirements for governance - remain in significant breach. Risk of being assessed as non-compliant against the CQC essential standards of Quality and Safety Failure to meet 2013/14 infection control trajectories – impacts on governance risk rating Principle 2, 3, 4 & 7 Financial Implications/Impact Potential contractual penalties for C Difficile, Pressure Ulcers, Never Event and MRSA Legal Implications/Impact Reputational implications of delivering sub-standard safety and care Partnership working & Public This paper will be shared with the CCG Performance Engagement Implications/Impact and Quality Group. Committees/groups where this item has been presented before Monitoring and Review Is a QIA required/been completed? If yes provide brief details A number of specific items have been discussed at Infection Prevention & Control Committee, Pressure Ulcer Strategy Group, Nursing Care Forum, Clinical Management Team and Clinical Governance & Quality Committee Monitoring via the quality contract, CCG Performance and Quality Committee & internal processes, e.g. Clinical management Team & relevant committees/forums No TRUST BOARD OF DIRECTORS - DECEMBER 2013 MONTHLY QUALITY & SAFETY REPORT 1. Introduction This monthly report highlights to the Board of Directors key areas in relation to quality and safety. It complements the quarterly quality report, which gives a more comprehensive review of progress against all of the Trust’s quality and safety priorities. The monthly report will include updates on 2 of the Trust’s top 3 quality priorities for 2013/14, which are: • Priority 2 – Delivering Harm Free Care by reducing hospital acquired pressure ulcers • Priority 3 - To reduce length of stay and readmissions by improving patient flows (i.e. reducing the number of bed movements during the patients inpatient stay) Priority 1 – Improving the effectiveness of care we deliver by achieving a reduction in mortality (HSMR, SHMI and crude mortality) will be presented in a separate report. 2. Pressure Ulcer Reduction (Priority 2) The organisation has clear targets for pressure ulcer reduction during 2013/14. We are currently making good progress towards the goal of eliminating avoidable pressure ulcers by 2014. The table below demonstrates actual numbers of avoidable pressure ulcers (by grade) in comparison to the contractual targets. • In October the target for Grade 3 Pressure Ulcers was achieved, but unfortunately there were 9 Grade 2 Pressure Ulcers. • In November we achieved our targets. There have been no avoidable grade 4 pressure ulcers for 11 months Table1: 2013/14 SFH Avoidable Pressure Ulcer Reduction Trajectory Target No Grade 4 Actual No. Target No. Grade 3 Actual No. Target No. Grade 2 Actual No. Apr 13 0 May 13 0 Jun 13 0 Jul 13 0 Aug 13 0 Sept Oct 13 13 0 0 Nov 13 0 Dec 13 0 Jan 14 0 Feb 14 0 Mar April 14 14 0 0 0 3 0 3 0 2 0 2 0 2 0 2 0 2 0 1 1 1 1 0 0 5 15 4 20 2 10 0 7 1 7 0 6 2 6 1 7 7 4 3 3 0 14 13 16 8 7 5 9 6 1 We discuss performance at the monthly quality review meetings with commissioners and no contractual penalties have been applied during this financial year. They remain satisfied with our progress to date in reducing avoidable pressure ulcers. There has been 101 avoidable pressures ulcer against a target of 115 The number of avoidable pressure ulcers against patient admissions for the last 12 months gives the incidence rates demonstrated below. The safety thermometer data, which is the point prevalence census undertaken once a month across all inpatients areas correlates with the incidence data, showing an improved performance over recent months/ The Pressure Ulcer Strategic Group are currently reviewing the Pressure Ulcer Strategy, including the key priorities and the action plan for Quarter 4 to put additional measures in place, given that during winter last year the number of patients with pressure ulcers increased due to case mix and acuity. This was a national picture. In Quarter 4 there will be continued emphasis upon competence based training in practice, embedding mattress selection and availability and heel management. Focusing on these areas should enable us to sustain the good performance through winter. 2 3. Improved Patient Flow (Priority 3) The urgent care workstream have continued to progress actions to improve length of stay overall, the length of time patients remain on the emergency assessment unit and ensure there is real focus on risk assessing patient moves. Length of stay in November was 6.27 days against a Trust target of 6 days. Given that November is the technical start of winter it is encouraging that we have been able to bring back the likely impact of half term performance in October. We are however flat lining at an average 6.5 days and not achieving the 6 days target set this year. The Clinical Director has established a specific task and finish group to further support this agenda, particularly focusing on processes around shorter stay patients which can be directly influenced. 4 hour target performance in November was 96.87% with Q3 to date at 96.43% and year to date 96.62%. In November, the key issue impacting on performance was medical manpower, not patient flow and remedial action has been taken to improve streaming at peak times within the department. Readmissions information is not fully reliable until all coding has concluded. The November data is therefore not fully accurate until January. This therefore shows that readmissions was sustained at below 10% since August and there is confidence that this is being sustained as winter pressures take hold and innovative practices take place because of capacity. We are also monitoring the length of stay and number of patients who remain on EAU longer than 48 hours. There is a cohort of short stay patients who we expect to remain on EAU longer than 48 hours however our aim is for right patient, right ward, right specialty to ensure that all patients are receiving care in the right place. The graphs below show the significant improvement made during the early part of the financial year to ensure patients are treated in the right environment. This started to deteriorate again as flow became more difficult in July and September. However further progress is being made in relation to 3 turnaround. The group will be concentrating on how we ensure we sustain the timely and safe movement of patients during high demand. The number of ward moves is continuing in the right direction following an increase late summer. Changes made to the risk assessment and outlier process should continue to positively impact on patient experience and ensure moves are minimised and only when clinically appropriate. 4 4.0 Patient Experience & Complaints 4.1 Complaints Performance - Current Position The numbers of complaints received by the organisation are shown in the diagram below: Please note the above table slightly differs to the report given in September (April 2013 onwards) as the pending (without consent to act) complaints have now been included. This shows that the organisation has seen a decrease in the numbers of complaints received in November 2013. As of the 4th December 2013, the position is as follows: • • There is no backlog of complaints Of the 491 complaints received since 1 April 2013 there are only 3 that remain open past their timeframe. This is due to the complexity of the complaints and the fact that other hospitals are involved. All of the complainants are kept fully informed at every stage and are aware of the situation. Planned Care and Surgery: • 47 complaints are open, 7 reopened complaints and 4 new complaints are awaiting consent to act. • Of the 47 complaints – 2 have passed their deadline dates Emergency Care and Medicine: • 31 complaints are open, 8 reopened complaints and 6 new complaints are waiting consent to act. • Of the 47 complaints - 1 has passed its deadline date. Diagnostics and Rehabilitation: • 11 complaints are open, 2 reopened complaints and 1 new complaint is waiting for consent to act. • There are no complaints open beyond their deadline date. Corporate / Central Services: • 2 complaints are open. • There are no complaints open beyond their deadline date. 5 4.3 Parliamentary Health Service Ombudsman We currently have 3 active Ombudsman cases plus 1 case which was upheld by the Parliamentary Health Service Ombudsman whereby all work required has now been concluded including an action plan. There are a further 8 complainants that have contacted the Ombudsman however we are awaiting feedback as to whether these will be put forward for investigation. 4.4 Themes and Learning We are currently collating information to enable us to analyse what the most common issues identified by complainants are and the areas highlighted. Discussions are underway with divisional teams in order to create a suite of information that can be usefully reviewed at divisional governance forums, the Clinical Management Team and Clinical Governance Committee. This is a key action within the complaints sustainability work outlined below so that learning and changes can be enacted in response to these themes. The graph below illustrates complaints which were received for November 2013 by the subject that the complaint related to. The most common themes for complaints received in November 2013 were clinical treatment, for which a total of 11 complaints were received and clinical diagnosis for which 7 complaints were received. 4.4.1 The following table gives an understanding of what complainants are complaining about in relation Complaint Theme Clinical Treatment Specific Concerns as specified by complainant • • • • • Clinical – Diagnosis • • • • • 3 attempts to find an artery during angiogram, left patient with pain and discomfort groin, left and right wrist. Care and treatment whilst on the maternity ward Inadequate pain relief given Patient referred to another clinic without being examined Cannula blocked resulting in delay in treatment Delay in diagnosis Misdiagnoses of fracture to foot Misinformed diagnosis Misinterpretation of consultants letter resulting in delay in treatment Patient diagnosed with fractured elbow then x-ray revealed it was fractured collar bone 6 4.4.2 Complaints relating to Doctors Attitude From August to November 2013 there have been 36 complaints received regarding doctors attitude. It is difficult to distinguish in detail which doctors these refer to as very often there in no name attached to the complaint. The divisional management teams are currently undertaking some detailed analysis to investigate this further. The complaints received relate to doctors attitude both within clinic and on the wards and are mainly about the way in which the doctor spoke to the patient or their carers i.e. abrupt or dismissive. When a doctor has been identified they have been spoken to about their attitude and this is relayed back to the complainant within the response letter. The graph below represents the number of doctor attitude complaints by month from August to November 2013. : 4.5 Complaints received 2012/13 We are currently assessing how the number of complaints we receive benchmarks against other Trusts. The table below details how many complaints have been received by other Trusts throughout the local area for 2012/13. The figures represent how many actual complaints have been received as a whole, rather than the different subjects of concern within each complaint. Trust Chesterfield Royal Hospital NHS Foundation Trust Complaints Received 2012/13 771 Derby Hospitals NHS Foundation Trust 595 Sherwood Forest Hospitals NHS Foundation Trust 785 Kettering General Hospital NHS Foundation Trust 498 Northampton General Hospital NHS Trust 538 United Lincolnshire Hospitals NHS Trust 710 7 University Hospitals Of Leicester NHS Trust 1,527 Nottingham University Hospitals NHS Trust 819 Lincolnshire Partnership NHS Foundation Trust 202 Leicestershire Partnership NHS Trust 228 Northamptonshire Healthcare NHS Foundation Trust 286 East Midlands Ambulance Service NHS Trust 229 Derbyshire Healthcare NHS Foundation Trust 114 Lincolnshire Community Health Services NHS Trust 182 Derbyshire Community Health Services NHS Trust 214 Nottinghamshire Healthcare NHS Trust 825 4.6 Sustainability of Complaints Performance During September, a senior consultant was commissioned to undertake a review of current service provision. The review has utilised the Guiding Principles of NHS Complaints Procedures in England 2012 as a basis upon which to identify a clear way forward. The new process will closely align the PAL’s and complaints function, whilst also creating more local management through the divisions. This process is now well underway. The workforce change application is going to the Workforce Change Committee on 17 December and it is anticipated that there will be a 45 day consultation with staff. For these reasons the specifics of the new process have not been included within this paper as the staff affected need to be sighted of the change in the first instance. It is envisaged that once the proposal is accepted the changes can be implemented swiftly to ensure complaints performance is sustained and the service is improved for patients. The Divisions have requested we stay with the current process whilst the change process is implemented to ensure quality and performance is retained during 4.7 The Clwyd/Hart Review This report outlines the Clywyd/Hart review that has taken place around the complaints process within health as a result of the Francis report. It is envisaged that the Department of Health (DOH) will focus on: • Communications between complainants and Trusts • Patient communication in the first place • Getting things put right at front line level • Possibly a position to oversee patient interaction at DOH level Although it is felt that the current complaint procedure was adequate the document does contain many references to CCG’s and their services which would need renewing and might lead to a new document or a large number of amendments to the current one. The current NHS England process is not covered at all in the current document and therefore it is more likely that a new document would be forthcoming, although with much the same process for Trust’s just more emphasis on communications and training staff. 8 Communication feedback is that patients feel alienated by the process and there are some strong views by some complainants as to the accuracy of their responses. Healthwatch England Healthwatch England welcomes the recognition of the problems individuals face when thinking about, or trying to make a complaint. Their comments are: • • • Recognises the issues outlined in the report in relation to complaints advocacy services and PALS. Calls for consolidated advocacy services and agrees with the need to review PALS so it is clear what the service offers to patients. Wants to work with the Department of Health and others to design and promote standards for health and social care complaints handling alongside a consolidated PALS and complaints advocacy offer. Healthwatch England welcomes the recognition in the report that providers need to meet their existing statutory obligations and that the existing regulations need revising to bring in additional duties. Healthwatch England believe that the Regulations should be changed so that ‘worried bystanders’ can also register concerns or complaints and be directed to local Healthwatch. The report which gives recommendations on how to make improvements focuses on four key areas of change including: • • • • Making improvements in the quality of care in the NHS hospitals so fewer people have to complain; Making improvements in the way complaints are handled; Giving the complaints process independence; and Avoiding the need for whistle-blowing in the future, and protection for those who speak out. Key Recommendations 1. Chief Executives need to take responsibility for signing off complaints. The Trust board should also scrutinise all complaints and evaluate what action has been taken. A board member with responsibility for whistleblowing should also be accessible to staff on a regular basis. 2. Trusts must publish an annual complaints report in plain English which should state complaints made and changes that have taken place. 3. Trusts should ensure that there is a range of basic information and support on the ward for patients, such as a description of who is who on the ward and what time visiting and meals take place. 4. Patients and communities should be involved in designing and monitoring the complaints system in hospitals. 5. Trusts should provide patients with a way of feeding back comments and concerns about their care on a ward, including by putting a pen and paper by the bedside and making sure patients know who they can speak to, to raise a concern. 6. The Patient Advice and Liaison Service should be rebranded and reviewed so its offer to patients is clearer and it should be adequately resourced in every hospital. The Independent Advocacy Services should also be rebranded and reorganised. 7. Staff need adequate support and training in listening to and acting on feedback, with appraisals linked to their communication skills. Our Response 1. The Chief Executive of Sherwood Forest Hospitals NHS Foundation Trust does currently sign off all complaints unless he is unable to do so due to leave and then it is delegated to another Executive i.e. Director of Nursing, however this is rare. 9 2. All complaints data is recorded and reported to the Trust Board on both a quarterly and monthly basis. We are continually to enhance this data month by month and presented our first patient experience report at the end of October. We are mindful we have further work to develop this aspect of the recommendation. Further reports are also regularly undertaken including the net promoter, ward reports and a weekly update. Staff within the complaints department are always available for any member of staff or patient to contact from 8.30 - 5pm daily. The Interim Complaints Manager is available 24/7 via mobile. 3. Previously annual reports have been undertaken, but due to the major difficulties in our complaints service we did not publish an annual complaints report for 2012/13, but we will definitely publish a report for 2013/14. 4. Patient information is available on all wards however this is being emphasized by the inception of the new ‘Communication Boards’ located in all wards, which tells the patients and public; who is the ward sister, nurse : patient ratios, improvement initiatives based upon feedback and grade of staff on duty. All ward entrances now have the same published information which includes uniform descriptors, visiting times, cleanliness standards, infection control expectations and ‘making mealtime matters’ information 5. At present patients are not directly involved in the complaints process however patients are invited to the Trust Board to tell their story and every complainant is asked whether they would like a meeting to discuss their complaint and are invited to join the membership scheme at the Trust. The Trust is exploring the opportunity to create a Trust Wide Patient Experience and Engagement Group, following the ‘In Our Shoes’ co creation events. 6. The current interim complaints manager has discussed with two of the Divisional Matrons the possibly of starting ‘complaints focus groups’ with both staff and pass complainants to allow for reflective learning. This will enable all involved with complaints to talk through what went wrong and how assurance can be given that it won’t happen again. 7. The Trust currently uses comment cards and these are available throughout the hospital. All comments are reported and acted on appropriately including being sent through to the complaints department if there are issues that cannot be resolved within PALS. We are reviewing the pen and paper proposal 8. PALS will be rebranded within the new structure. The complaints Advocacy service (ICAS) has now been taken over by POhWER. (People of Hartford want equal rights) 9. The interim complaints manager has undertaken some training within the Trust around complaints however once the new structures have been implemented further training will be rolled out. At present only doctors have complaints against them brought up at their revalidations/appraisals but with nursing revalidation being progressed the opportunity to expand this to nursing will be explored in 2014/15. 10 5.0 Family and Friends October and November 2013 Family and Friends Test Results are as below: Response Rate Month Net Promoter Score Acute Inpatient A&E Overall Acute Inpatient A&E Overall October 33.1% 19.1% 23.3% 73 54 64 November 24.6% 20.3% 21.6% 74 53 62 England (including Independent Sector Providers) 27.8% 10.4% 16.1% 71 54 64 During October, of the 23 acute inpatient wards taking part in the survey, 11 scored below the Trust wide average of 73. The three lowest scoring wards were wards 52, 35 and 31. During November, of the 23 inpatient wards taking part in the survey, 7 scored below the Trust wide average of 74. The three lowest scoring wards were wards 34, 35 and Sconce Ward. 5.1 Further Sources Comments and reviews posted by Patient Opinion and NHS Choices were largely positive but there are some negative comments. Our current rating on NHS Choices is 3.5 stars out of a possible 5 stars (172 ratings) Of the last 24 comments on Patient Opinion (posted over 4 weeks): • There are a large number of comments which spoke of the professionalism of doctors and nurses. • A&E, Maternity, Day Case (mentioned on a number of occasions), Orthotic Service and Ward 52 are mentioned positively • SAU/ Ward 21 were mentioned both positively and negatively – SAU staff were outstanding, Ward 21 ‘rude, failure to discuss with relatives. • Discharge processes, waiting for tests and staff attitude were negative comments. This included rudeness, lack of respect and failure to keep relatives informed • ‘Presently surprised at some of the improvements made’ – mentioned care and comfort rounding • Exceptional second visit – diagnosis of breast lump 11 6.0 National Maternity Survey The 2013 National Maternity survey has been undertaken by Quality Health for our Trust. The maternity survey was last undertaken in 2010 and seeks opinions on various aspects of maternity care, including, antenatal care, check-ups, baby’s birth, the staff, post-natal hospital care and care at home after birth. The full Management Report was received on 22nd November, which outlines the Trust’s score across a range of questions. There are 42 questions, 50% of which are new/amended to the survey this year so no comparison with previous score can be made. Of the remaining questions, there were 14 where we scored higher this year than previous and 4 where we received lower scores. Areas where we improved included: • • • Given a choice of where antenatal appointments will take place Was able to move around and change position during labour Treated with kindness and understanding Areas where we showed some deterioration since the last survey include: • • Saw midwife as much as they wanted to Given advice about contraception The results also show how the Trust performed against the national average. Sherwood Forest Hospitals is in the top 20% of the country in 13 criteria and bottom 20% in 6 criteria. For the remaining 23 questions we performed in the amber category, which is the remaining 60% of Trusts. The top 20% include areas such as: • • • • • Midwives listened to women’s thoughts and personal circumstances Involvement in decision making during ante natal care Cleanliness of bathrooms for their labour care Had trust and confidence in the midwives they saw after going home Given information explaining how to recover and emotional impact after the birth In addition, we scored in the highest percentage for length of stay and cleanliness of rooms during the post natal stay. We are in the lowest 20% for: • • • Taking concerns seriously in labour (the threshold was 77% and we scored 76%) Response times to patient call buttons Had telephone number of midwife to call when they were home There are a number of new questions this year around breast feeding which we appear to have achieved in the upper amber range compared to the national picture. The National Document is due to be released on the 12th December 2013, which will offer a fuller picture to enable us to undertake our ongoing improvement work. The senior midwives and obstetricians are currently interrogating these results in more detail and developing an action plan to address the key areas where progress is needed. The action plan will be presented at the Maternity specialty meeting and CMT in February 2014. 12 7.0 CNST Maternity services at the trust were successful at achieving CNST level 2 at our recent assessment. We were one of the last trusts to be assessed using the current standards and method. As yet we are unsure of what will replace this assessment, but it is thought that it will become more outcome focussed and services will have to demonstrate learning. We achieved a score of 48/50 obtaining 10/10 in four of the five criterions and 8/10 in the other criterion. During the verbal feedback we were commended for our organisational structure and governance/risk arrangements and training programmes. In the criterion we scored 8/10 for clinical care, we were praised for some aspects of good practice, in particular our follow up of screening investigations. However we have identified we are required to improve on our use of maternity early warning charts and ensuring we fully complete all documentation including dating and timing entries especially in regard to entering test results. We await with interest the changes to Maternity CNST assessment but in order to maintain the momentum we have set ourselves some projects to address the above. We are expecting a full report within the next 14 days. 8.0 Never Events As stated in the government’s response to the Francis inquiry, NHS England will begin publishing data on never events in greater detail, including number and type of never event by reporting organisation. This will initially cover data reported between April and September 2013, as well as less detailed data for the whole of 2012/13. This will continue to published quarterly, and then on a monthly basis from April 2014. As reported to our Clinical Governance and Quality Committee (August 2013) and the Trust Board, we have experienced 1 never event during 2013. This was our first never event within a 3 year reporting period and has been stated as 1 under the category (Other NE Types 4-25). 9.0 Healthcare Associated Infection Sherwood Forest Trust is working very hard to tackle Healthcare associated infections (HCAI), but Hospitalacquired infections (HAI) still present us with a great challenge. 9.1 C.difficile Infection As of 10th December 2013, the Trust has identified 27 cases of Trust acquired C. difficile infection against a total year trajectory of 25. Root cause analysis has indicated that the majority of these cases are sporadic. Since April 2013, there have been two periods of increased incidence, which were upgraded to outbreaks when the ribotyping indicated the same strain of C. difficile, which is highly suggestive of cross infection. Outbreak meetings were convened, action plans implemented, and to-date there has been no further cases in relation to the outbreak (September Ward 24, 2 symptomatic patients, October Ward 51, 2 symptomatic patients). Review of the Hospital Antibiotic Prudent Prescribing Indicators (HAPPI) audit has not highlighted any concerning issues regarding the inappropriate antibiotic usage of antibiotics. Actions instigated: • Implementation of SIGHT poster in clinical areas across all divisions • Infection Prevention and Control Team worked closely with staff especially Ward 24 and Ward 51 • Implementation of ‘RAG’ infection clean level regime (including posters, training) • Aerosol hydrogen peroxide environment decontamination system is used at present by the Trust – plan to review the appropriateness of moving to a hydrogen peroxide vapour environment decontamination system 13 C. difficile infection cases against average reduction target April – November 2013 Number of C. difficile infection processed across East Midlands from April 2010 to October 2013 Incidence of C. difficile Trust apportioned cases per 100,000 bed days across the East Midlands Chesterfield Sherwood Royal Derby Forest University Hospital Hospitals Nottingham Hospitals United Hospitals NHS NHS University NHS Lincolnshire of Foundation Foundation Hospitals Foundation Hospitals Leicester East Year Month Trust Trust NHS Trust Trust NHS Trust NHS Trust Midlands 2013 April 25.1 26.5 19.0 9.9 19.6 13.8 18.5 2013 May 18.2 18.4 9.2 19.2 15.8 15.6 15.2 2013 June 12.6 22.8 40.3 9.9 26.1 4.6 20.7 2013 July 12.2 33.0 13.8 9.6 9.5 13.3 15.2 2013 August 24.3 29.4 20.7 19.2 25.3 11.1 20.6 2013 September 25.1 15.2 26.1 19.9 22.9 20.7 21.8 2013 October 12.2 33.0 18.4 24.1 9.5 13.3 17.9 14 9.2 MRSA Bacteraemia As of 10th December 2013, there has been three cases of Trust apportioned MRSA bacteraemia (May, July and September 2013), and one case of Non-Trust apportioned MRSA bacteraemia (October 2013) since April 2013. The post infection review for the three cases has already been completed. The third case that was sent to Public Health England for arbitration was allocated to the Trust. Actions: • Monthly audits continue to be undertaken by the Infection Prevention and Control Team on key themes, reports and actions plans and represented at the HCAI Forum • Review and update the Clinical Assessment packs for Naseptin-Bactroban-Chlorhexidine • Reviewing the use of Chor-Prep® for skin preparation prior to venous cannulation continues • Regular unannounced visits to various clinical areas by the Infection Prevention and Control continues Monthly counts of MRSA bacteraemia ‘Trust’ and ‘Non- Trust’ apportioned processed by SFH Trust laboratory since April 2010 Following the second Trust apportioned MRSA bacteraemia, Professor Brian Duerden, retired Microbiology Inspector for DH, visited the Trust on the 15th October 2013, to carry a thorough external review the infection prevention and control practices from ward to board. 9.3 Professor Brian Duerden External Visit The review was commissioned by the Trust to provide an external view of the functioning and effectiveness of the infection prevention and control arrangement within the Trust, with particular reference to the recent occurrence of MRSA bacteraemia. Although Professor Duerden did not have any specific recommendations to make about the leadership, management, governance and assurance arrangements, he made some recommendations which are summarised below: • Policies: although the content of these policies is entirely appropriate and reflect the needs of current clinical practice, they were a good source document and as such provided good training material and a good point of reference, Professor Duerden recommended that the policies contained a short summary or abstract of the policy o Actions: this recommendation is in the process of being implemented • VIP audit: procedures for all IV access to be reinforced with added training on insertion and monitoring, to redesigned the VIP chart to promote good practice, and VIP observation should be done every 4 hours (we had already agreed this action prior to his visit) 15 o Action: the VIP chart has been redesigned taking into account 4 hourly observation, the chart has been agreed by the document group, and is in the process of being printed. • Isolation practices audit: should be reinforced, in particular the need to keep the door closed and the correct use of personal protective equipment. Poster and signage. o Action: the Infection Prevention and Control Team, conducts quarterly isolation audits, as well as spot checks during their daily ward visits. Emphasise the important of door closure and use of PPE at Trust mandatory training (clinical and medical staff). As part of the isolation policy review the isolation posters were also redesigned to make them more striking, less cluttered and providing clear instructions, Professor Durden strongly supported this approach and commended the draft poster he was shown. Once the policy and isolation resource package has been ‘signed off’ the posters will be printed and implemented across the Trust • Urinary catheter monitoring audit: procedures for monitoring urinary catheters should be reinforced and the need for regular observations and decision on whether the catheter is still need emphasised. o Action: Vital Pak will be implemented across the Trust early 2014, indwelling devices is part of this package, which will • Hand hygiene audit: There is alcohol gel available in dispensers at the entrance to each ward and at the bedside. Generally the dispensers were available and were being used; one entrance the alcohol gel was empty. Recommend enhanced training and audit to raise compliance, which should be maintained at over 90%. o Action: The back plates for the alcohol dispensers have been installed, with the remaining plates being installed week commencing the 2nd December 2013. Ward staff have been requested to monitor and replaced any empty alcohol gel o Glow and tell audit conducted by the Infection Prevention and Control Links during October and November o Development of a hand hygiene DVD for training, to incorporate staff from across the Trust in music and dance activities o To review the use of electronic version of the ‘Lewisham hand hygiene’ tool • Antimicrobial stewardship: consider including junior medical staff in the audit and monitoring of antimicrobial stewardship, to review the design of the prescription chart, with view to putting the antimicrobial prescriptions into a separate section that incorporates the key indicators, ensure that junior staff have easy access to a simple form of the antimicrobial prescribing guidelines, and to establish links with primary care on antimicrobial prescribing so that common policies can be adopted o Action: Junior medical staff are conducting an audit into the usage of Tazocine. A summary sheet is in the process of being developed by the DIT committee, for inclusion into the antimicrobial policies. • RCA: the findings of the RCA for the three MRSA cases to be combined into one action plan to address the issues raised o Action: the individual actions plans required for each of the Post Infection Reviews has been brought into the generic bacteraemia reduction Trust action plan 9.4 Norovirus Overall activity is beginning to show signs of seasonal increase in the number of norovirus and rotovirus cases in the local population, although there have been no outbreaks of norovirus within the Trust since May 2013. The norovirus posters have been placed across the Trust and the DH YouTube video suit is available for the public to access on the Trust Facebook page, and a Norovirus awareness day was held on the 15th November 2013. 16 10.0 VitalPAC The Trust has now committed to purchase the VitalPAC system by The Learning Clinic. This is a revolutionary software system which allows nurses and doctors to capture clinical information, such as vital signs, on portable electronic devices (iPods and iPads) at the patient’s bedside. Using this data the system calculates the NEWS (National Early Warning Score) and then automatically alerts staff to signs of deterioration. Evidence from hospitals already using VitalPAC shows that mortality rates are reduced, cardiac arrest rates decline and fewer patients require admission to intensive care. There are other potential benefits such, as reduced length of hospital stay, less infections and earlier detection of problems such as sepsis, acute kidney injury, dementia, alcohol-related problems and poor nutrition. . A Project Board has been convened which is chaired by Dr Nabeel Ali/Dr Lisa Milligan. The Board comprises of key individuals from clinical and IT backgrounds and representatives from The Learning Clinic. The Project Board has met on two occasions now. A project manager has been appointed The proposal is to complete “localisation” this quarter, then The Learning Clinic will build our software, and it should be delivered for testing at the beginning of January 2014. Testing of the software will then take place from January to March, with the start of ward roll-out and the “go-live” date proposed for the end of March 2014. These are indicative timescales at this stage and will be agreed at the next Project Board meeting. The Learning Clinic has suggested a 9 week roll-out across the wards of VitalPAC Core. Some of the other modules we have purchased, such as VTE, Nutrition, Indwelling Devices, will be included in the software that is rolled out at this time, but we can decide which of these to turn on nearer the time depending upon how training with the core system is going. Other modules, such as Paediatrics and Maternity, require additional customisation and will be rolled out later in 2014, along with Infection Prevention and Control (IPC) Manager and the Fluid Balance module. A Communications plan has been developed and the Communications Department have already begun to promote the new system by all-user emails and there will be an item in the next edition of Best Magazine. An article featuring the acquisition of VitalPAC by the Trust was in printed ‘The Chad’ on 23 October. A VitalPAC website will be set upon the Trust intranet to act as an information resource and news update site for all Trust staff. Familiarisation sessions for Trust staff have begun, with a presentation given to Ward Leaders on 12 November. The training approach is to train a number of ‘Super-Users’ in the first instance, and then to use them to disseminate training to all ward staff. Discussions are on-going regarding the details of training, and training for other groups of staff, including nursing, medical staff, locum staff and other healthcare practitioners who will use the system. A group will be convened in the next few weeks to review the Risk Management issues relating to the introduction of VitalPAC and a Business Continuity Plan (for use in the event of system failure) will be developed and approved by the Trust’s Clinical Management Team prior to the roll-out and “go-live” date on the wards. A representative from the Finance Department is on the Project Board (Fran Steele/Michael Powell) to ensure financial control of the project, and a meeting with an accountant from the Finance Department has been arranged to discuss projected expenditure on VitalPAC for 2013/14. The Project Board will report progress with the introduction of VitalPAC to the Trust Board on a regular basis. 17 11.0 Summary of Discussions at Clinical Governance and Quality Committee This report summarises the discussions and decisions made, and the assurances received at the Clinical Governance and Quality Committee (CGQC) held on November 27th2013. Present Peter Marks Susan Bowler Gerry McSorley Claire Ward - Non-Executive Director (Chair) Executive Director of Nursing and Quality Non-Executive Director Non-Executive Director In Attendance Tim Reddish Nigel Nice Karen Fisher Fran Steele Jacqui Tufnell Anne-Louise Schokker Denise Berry Jane Jones Lynn Smart Ann Gray Stephanie Sheppard Dr Kumar - Non-Executive Director Public Governor Director of Human Resources Chief Finance Officer Executive Director of Operations Clinical Director Clinical Governance Lead PwC Clinical Lead Diagnostics and Rehabilitation Patient Services Manger Tissue Viability Consultant Nurse Consultant Microbiologist. Serious Incident Log The serious incident log was discussed. The Committee were informed that the Serious Falls group had reviewed 4 of the 6 Serious Falls that were reported between the 15th October and the 12th November 2013. There was a delay in reporting 3 of the 6 incidents to the Commissioners via the STEIS data base therefore it appeared that there had been an increased incidence of Serious Falls in a month’s period. This was because serious harm had not been diagnosed until tests had been performed but all incidents were reported on the Trust incident reporting system (Datix) timely. The format of the report was discussed by the Committee and it was agreed that work was required to provide assurances about the themes and lessons learnt. It was noted that Trends and Themes are being collated for the Quarterly Quality report. Report on open incidents by the handler on Datix A paper was presented to the Committee summarising the Trust position in relation to the investigation and closure of incidents on Datix, within a 3 month period. Closure within 3 months is a Trust standard set by the previous Risk Management Committee. On the 21st November 833 incidents were open and of these 111 were open beyond the standard: 16 in July and 95 in August. The Committee were informed that Trustwide actions have been agreed to improve compliance and this will be monitored through the Divisional Governance Forums and by the Clinical Management Team. The Committee requested an update for the January meeting. The Mid Nottinghamshire Mortality review The Committee was provided with a personal interpretation of the review findings and requested a copy of the Executive Summary. It was acknowledged that this would be discussed at the next Trust Board meeting. The Management of Hard Copy Patient Investigation Reports. The Committee received a report on the backlog of loose documentation/reports not filed and available in patients notes for admission and clinic appointments. This risk is on the Diagnostics and Rehabilitation 18 divisional risk register and has been escalated to the Committee by the Clinical Management Team. The Committee considered the contents of the report and requested that this risk is monitored by the Clinical Management Team. The plan to go live with the electronic reporting on ICE in December was also discussed Decontamination of Pressure Relieving Mattresses. A paper was presented to the Committee summarising the concern raised at the Risk Committee that the Trust was not compliant with alert MDA/2010/002. The alert relates to the Inspection of the exterior surface of each mattress cover for signs of damage and removal of the cover to inspect the mattress core. This alert related to static mattresses and the Trust has a rolling programme of inspection therefore deemed to be compliant. The process for decontamination of Dynamic mattresses was not robust and the report outlined the actions taken to address the mattress decontamination issues and provide assurances that decontamination is being undertaken appropriately. Update on Breakaway and Physical Intervention Skills Training. An update was provided to the Committee on the delivery of training agreed as part of a HSE action plan. As of the 8 October 2013, a total of 19 courses have now been delivered and 128 out of 408 identified staff have been trained in breakaway and physical intervention skills training since the courses began in February 2013. A further 7 courses are planned until the end of December 2013 with 79 staff currently booked onto them which overall equates to 51% of the risk assessed staff group receiving training since these courses started. The Committee supported the importance of this training and it was agreed that this is to be included in the ward dashboard as a separate compliance metric for the 10 areas identified in this paper in order to drive full compliance. An update will be provided in 3 months time. Early Warning Dash Boards and Ward Assurance Matrix The Committee were asked to note the contents of Trust wide Early Warning Dashboard which has developed over the last 6 months to enable clinicians and managers to monitor Trust performance against a number of key quality and safety metrics. It is collated monthly and will become a standard agenda item. Alongside this will be the updated version of the ward assurance matrix. This matrix has been supplemented with additional metrics, following a visit to Norwich and Norfolk NHS Trust and discussions at the Nursing Care Forum. A number of additional metrics (including training compliance and ward based audits) will be added over the next few weeks. The committee welcomed the progress on this work. The incidence in falls had been noted by CMT and had requested an understanding of this concern and actions required from the serious falls group (refer to section on serious incident log) Infection Prevention and Control Dr Kumar gave an update to the Committee on the Trust’s performance with Infection Prevention and Control. Clostridium Difficile targets were discussed and Dr Kumar reported positive feedback following an external review by Professor Dearden. Although this feedback was encouraging the Committee were assured that a review of our action plans against other high performing Trusts would be initiated through the CCG. Susan Bowler Executive Director of Nursing & Quality 19
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