1. society
2. welfare
3. healthcare
4. hospital

COVER SHEET
Report to:
Board of Directors
Date of meeting:
30 April 2012
Title of paper:
Quarterly Quality Report
Time required on agenda:
20 minutes
Executive Summary:

Our SHMI for the year up to September 2011 (latest figure available) is 101 and has reduced from
the July figure of 102. This period is before the introduction of weekend ward rounds in medicine.

We are pleased to report that there have been No Grade 4 pressure ulcers post admission to
hospital for 22 months.

The initial indication is that VTE risk assessment completion for the quarter is at 92%. A yearly audit
to measure prophylaxis rates has been completed in quarter 4 and the data is being analysed for
reporting.

Complaints handling performance has reduced during the period due to a number of factors. This is
being proactively managed.

There remain issues around appointment and results communication. A project continues to
address these issues on a daily basis and make service improvements.

It has been over 2 years since we experienced a Trust acquired MRSA bacteraemia. Hospital
Acquired C Difficile performance failed to meet its target in the last quarter and by year-end the Trust
had seen 45 cases against a trajectory of 43. C Difficile performance since December 2011 has
been the second best in the region.
Recommendation:
The Board of Directors is asked to note the contents of this report.
Next Steps / Action:


Continue to monitor performance
Address those areas where underperformance / a reduction in quality is evident e.g. discharge
communication.
Presenter/Sponsor
(name / title):
Susan Bowler, Executive Director of Nursing & Quality
Nabeel Ali, Executive Medical Director
Originator/Author
(name / title):
Susan Bowler, Executive Director of Nursing & Quality
Nabeel Ali, Executive Medical Director
BOARD OF DIRECTORS – MONDAY 30 APRIL 2012
Quarterly Quality Report
Patient Safety – Summary and Commentary
The provision of high quality patient care underpinned by excellence in patient safety is the Trust's
absolute priority. This paper reports on a number of key performance indicators which demonstrate
our ongoing commitment to continuous improvement in delivering the highest standards of patient
care across the organisation.
Specifically this report will cover:
1.
2.
3.
4.
5.
6.
7.
Serious Untoward Incidents / Never Events
Tissue Viability
Slips, Trips and Falls
Acutely Ill Adult Patient – ACAT (CQUIN)
Maternity Care including Midwife to Birth Ratios
Nutrition
Infection Prevention and Control
'Never Events' are defined as very serious, largely preventable patient safety incidents that should
not occur. There were zero never events during this quarter and the work to promote the culture
of incident reporting continues on an upward trajectory.
We are pleased to report that there have been No Grade 4 pressure ulcers post admission to
hospital for 22 months and that the incidences of hospital acquired pressure ulcers have reduced
by 23%. A pressure ulcer strategy is currently being finalised and will be overseen by the
Executive Director of Nursing, with the Pressure Ulcer Steering Group managing the clinical
improvement plan. This will help to ensure that the organisation meets its contractual requirement
to achieve zero hospital acquired grade 3 & 4 pressure ulcers by the last quarter of 12/13.
Falls continue to be our largest clinical risk followed by pressure ulcers and medication errors. The
focused work to reduce falls continues across the organisation and there has been a 7%
reduction since this work began. There have been zero same sex breaches within 2011/12. The
Nursing Metrics and Essence of Care Benchmarking Programme continue to enable the quality of
patient care being delivered within clinical areas to be monitored and scrutinised closely. This
allows the fundamentals of care, including falls, tissue viability, nutrition screening, privacy &
dignity and others, to be proactively measured and improved.
We can now report that it has been over 2 years since we experienced a Trust acquired MRSA
bacteraemia. Hospital Acquired C Difficile performance failed to meet its target in the last quarter
and by year end the Trust had seen 45 cases against a trajectory of 43. The robust implementation
and monitoring of the action plan continues, led by the Executive Director of Nursing and since
December performance has been the second best in the region. There were 7 outbreaks of
Norovirus during the last quarter, but the total number of bed days lost was minimised as a
consequence of swift action by the Infection Control Team, supported by the operational divisions.
Susan Bowler
Executive Director of Nursing & Quality
April 2012
Patient Safety
Status
Serious Untoward Incidents/Never Events : January - March 2012 Q4
Quarterly Progress Report:
Risks and Issues




Zero Never Events reported for this quarter.
18 Serious Incidents were reported on STEIS this quarter compared to 33 for Q3.
These are broken down into categories below:
8 x pressure ulcers grade 3
4 ward closures due to confirmed nor virus
1 ward closure due to unconfirmed nor virus
2 serious falls
1 x child abuse
1x maternity unplanned admission to Critical Care
1x neonatal death
5 are closed on STEIS with the rest still under investigation.
Incident reporting continues its upward trend (Q4: 2146, Q3: 1973) and is a good
measure of a developing internal safety culture. A recent staff survey showed key
positives including:
 67% of staff respondents thought the form was easy to access
 82% knew why it is important to report incidents.
 Between 60-90% said they always or sometimes received feedback from their ward
leaders/managers
 93% said they were aware of the Trust’s ‘Being Open Policy’.
On the negative side 52% of respondents thought the form was ‘time consuming and
53% would like the form to be simpler. The form design has to have enough complexity to
capture useful information whilst being user ‘friendly’.
Increased incident reporting means ‘Handlers’ need to stay on top of the process of
investigation and closing them.
Figures clearly identify a worsening problem with numbers of un-processed incidents
continuing to rise each quarter with currently 1091 still to be investigated and closed
compared to 773 for Q3. This appears to be as a consequence of clinicians working
within the clinical environments to support the current operational pressures
Top three types of incidents continue to be patient ‘Falls’, ‘Pressure Ulcers’ and
The time taken to investigate and close incidents is increasing
leading to a backlog in certain areas and by certain ‘Handlers’.
All Handlers are sent reminders each week informing them of their
over-due incidents.
A monthly report of overdue incidents by ‘Handler’ is sent to
Divisional Managers.
‘Medication’.
Falls:
The absolute numbers of patient falls has increased but as a proportion of increased
hospital activity and increased incident reporting there is a definite downward trend.
Hospital acquired Pressure Ulcers:
Reducing ‘Post admission’ pressure ulcers is proving more difficult though recent data
indicates a possible downward trend developing following determined efforts by the
Tissue Viability Team to respond proactively.
Medication:
Medication related incidents continue an upward trend both absolute and relative to
increased incident reporting and Hospital activity.
The main areas where these types of incidents are reported from are EAU and A/E. The
two predominant sub-categories within this Medication category relates to
‘Administration of medication’ and ‘Medication errors during prescription process’.
Author: John Ashmore on behalf of Lesley White, Patient Safety Manager
Main activities for next quarter
 Support ‘Handlers/Investigators’ in their efforts to reduce the
numbers of over-due incidents.
 Reinforce the importance of reporting of all types of incidents and
how this is proven to improve overall patient safety.
 Continue to upload patient safety incidents to the NPSA in a timely
manner to demonstrate our improving benchmarking against
similar sized Trusts as shown by the six monthly feedback reports
made public by the NPSA.
Patient Safety
Tissue Viability
: January – March 2012
Quarterly Progress Report
Status
Local CQUIN target
 There have been
Q1
Q2
Q3
Q4
168 pressure
ulcers during
Quarterly Total
69
69
66
52
quarter 4, of which
Quarterly Target
69
70
68
68
52 were hospital
acquired and 116
were attributed to pre-admission skin damage. This shows a 23.5% reduction in the numbers of
all pressure ulcers and means the Trust is compliant with the local CQUIN target of a 5%
reduction for this quarter.


Risk and Issues
Following the quarter 3 results, in January a more thorough interrogation of hospital acquired
pressure ulcers took place in relation to admission dates, and indicated a duplication of reporting
for the December figures. This reduced the numbers we had previously reported and brought the
organisation back in line with targets for the quarter.
Hospital Acquired Pressure Ulcers against CQUIN Target
80
70
60
50
40
30
20
10
0
Apr‐11 May‐11 Jun‐11
SFHFT Total
Jul‐11
Aug‐11 Sep‐11 Oct‐11 Nov‐11 Dec‐11 Jan‐12 Feb‐12 Mar‐12
Monthly Target
Quarterly Running Total
Quarterly Target

A meeting of senior nurses was held to determine the
investigation process for skin damage under Plaster of Paris
casts.
Having reviewed recommendation and associated literature,
the group agreed that this was not to be classified as
pressure damage and a working party would be set up to
establish the investigation and reporting process.
Main Activities for Next Quarter are:
 The challenge for 2012/13 is to achieve the national
target of “Zero Tolerance for Avoidable Pressure Ulcers”
by December.
 The drive towards this ambitious target must remain a
high priority for the trust as financial penalties will occur
if there is failure.
 Clarification and guidance of this will take place at the
launch of the East Midlands Pressure Ulcer Ambition on
th
April 25 2012.
 The pressure ulcer steering group will continue to meet
2 weekly and review all incidences of pressure damage
and route cause analyses for grade 3 and 4 ulcer.
 Plans will be put in place to begin monitoring incidents
where grade 1 pressure damage has occurred.
 The pressure ulcer reduction strategy will be finalised
following the East Midlands event
The key drivers for success have been identified as:
 Improved education and guidelines
 Improvements in direct clinical care,
 Regular audits, including nursing metrics which enables regular interrogation of performance
across the clinical areas
National CQUIN target
 The target for the national CQUIN is to ensure all patients are assessed for their risk of pressure
ulcer development, and other factors in the table below. We have managed to achieve a high
level of attainment but not quite the 100% required.
 It should also be noted that the numbers of patients admitted to this Trust at risk of pressure
ulceration remains high
No reviewed
Percentage identified at risk
% Reviewed with risk assessment
documented
No with core Care Plan
No with reassessment as per Core
Care Plan
Q2
562
Q3
674
Q4
607
73.30%
70.30%
74.60%
98.30%
99%
97.60%
99%
96.50%
98%
88.30%
95.30%
96.60%
Author: Pam Kirby, Lead Nurse, Vascular and Tissue Viability Team
Status
Patient Safety
Incidents/trends slips, trips and falls - January – March 2012
The Falls and Safety group will report on the number and trends of slips, trips and falls. National standards identified in NSF for older people (2001) standard 6(5). RCP
National Clinical Audit of Falls (2007). National Patient Safety Agency (2007). NICE CG 21.
Quarterly Progress Report
The Trust’s Falls group has continued to identify areas for improvement and audits
monthly the management of falls and their risk within SFHFT. Some of the actions
this quarter are:
 We are pleased to report that we have reduced our inpatient falls rates by
6.9% in 2011.
 SFHFT continues to have a LOWER rate of moderate harm than the national
average and slightly higher no harm, suggesting that falls care plans and
interventions are working to reduce the incidence of serious falls.
 Since introducing the bed rail audit 9 months ago, SFHFT has increased
compliance with assessments from 85% to 96%.
 Following the NPSA recommended HI audit of a small number of cases, we have
completed a large scale audit of our head injury policy and are awaiting results.
 Ongoing cross trust observational audit on the risk assessment tools and care
plans has been completed and results evaluated.
 Trends and high risk areas have been identified utilising incident reporting and
RIDDOR.
 Datix data has been reviewed to identify trends and hotspots and develop action
plans accordingly using calculated falls per occupied bed days as per NPSA,
RCP and NSF guide lines.
 The serious incident sub group continues to meet to review serious incidents
relating to in-patient falls and has populated the matrix.
 NHSLA ‘level 2’ depth review of policy and procedures has occurred, aiming to
improve our NHSLA rating from level 1 to 3
 We have arranged a joint Falls study day locally with the East Midlands Health
Innovation and Education Cluster for April 2012.
 We have undertaken a pilot of a rapid response team to provide specialist input
and assessment of inpatients that either have more than one fall or are found to
be at very high risk of falling on the wards.

Following the group’s escalation of concerns around the safety of frail, older
patients transferred late at night for nonclinical needs, we have been supported
and encouraged by the executive board to develop a policy around this.
Author:
Dr A-L Schokker, Consultant Geriatrician
Risks and Issues
1.
Failure to identify all patients at risk of falls.
2.
Inadequate assessment of patients experiencing falls.
3.
Inconsistent management of patient experiencing falls.
4.
Inadequate equipment for patients at risk.
Main activities for next quarter







Ongoing analysis of trust falls per OBD and comparison with other local trusts,
Monitoring of harmful v non harmful falls rates as per NPSA guidelines.
Ongoing monthly audit to assess the quality of falls risk assessments and care
plans and review of ward action plans.
Indepth review of ward action plans if audit results show non-compliance
Analysis of interventions to reduce falls done in the areas where the biggest
reductions were seen in order to replicate this success.
Ongoing work and data analysis as part of our pilot of a rapid response team to
provide specialist input and assessment of inpatients that either have more than
one fall or are found to be at very high risk of falling on the wards.
Develop a policy around the zero tolerance of transfers of frail older patients late
at night due to non-clinical need.
Patient Safety
Care of the Acutely Ill Adult Patient
Status
: January - March 2012
Quarterly Progress Report
1. Observations and ACAT audit
Trust-wide audits show that compliance with observations over the last quarter was
82% (average), improving to 84% for March 2012. This result for quarter 4 however
does not reflect that there are some areas of excellent practice achieving 99-100%. It
should also be noted that changes in how data is collected has negatively affected the
findings in this audit. A further ‘deep-dive’ audit will identify key areas for focus and
improvement.
2. Critical care skills training for ward staff
 AIMS courses continue to be delivered on a monthly basis
 Additional courses for HCSW are soon to be provided
 All nurses new to the Trust attend the in-house critical care skills course provided
by the ICCU team.
 A degree level HDU course is currently available from the University of
Nottingham, run from the Mansfield Centre by the Nurse Consultant Critical Care.
This provides local staff with the opportunity for further development. The next
course is planned for November 2012 and ward staff will be encouraged to apply.
3. LIPS safety strategy presented to the Trust Board (March 2012)
Care of the acutely ill patient has been agreed as a primary driver for a number of
improvement projects.
Author: Michele Platt, Nurse Consultant Critical Care
Risks and Issues
1. 84% compliance with observations across the Trust indicates there are
missed opportunities in some clinical areas to identify the deteriorating
patient. Work is currently underway by the Trust’s LIPS team on a
patient safety strategy within which care of the acutely ill patient is a key
element. The critical care team will be working closely with the LIPS
project leads over the next year to enhance this work
Main activities for next quarter
 LIPS strategy development and service improvement PDSA projects
 Focus on under-performing areas regarding compliance with observation
and ACAT policy to reduce missed opportunities.
 Further development of the Acute Care Team (ACT) to support the existing
Critical Care Outreach service. Audits are currently underway.
Patient Safety
Maternity Care including Midwife to Birth Ratio
Status
: January - March 2012 Quarter 4
Quarterly Progress Report
Risks and Issues
1:1 care in labour CQUIN Quarter 4
95.2% of women within the audit period felt that there was a Midwife available to them,
once they were in labour, when they wanted one.
 95.2% responded yes
 4.8 % responded no

Midwife to Birth Ratio
 The current indication is that the figure remains at 1:33.4, which is below the
national recommendation for midwife to birth ratio. Discussions are taking place
with commissioners regarding funding levels.

Caesarean Rates
Since December 2011 the rates are as follows:
 Dec 19.1%
 Jan 22.92%
 Feb 19.00%
As we are seeing a perceived increase in relation to the quality targets, we have
triggered an audit to identify trends and themes to inform an action plan. This will
identify whether the midwifery ratios is starting to impact on care outcomes.
Local Supervising Authority Audit visit 21st February 2012
Excellent feedback on the day with only minor areas of concern. Awaiting report to
develop action plan to address areas of concern.
Completed Intention of Notification to practice process.
Smoking Cessation
 SNAP trail published in which we were a key participant
 Exploring further areas of work with the research team
Author: Alison Whitham, Head of Midwifery and Gynaecological Nursing
Second Never event was reported in quarter 3. Within quarter 4, a Route
Cause Analysis has been completed and has been shared with PCT and
Closure of STEIS requested. SHA and PCT assurance visit on 5th April 2012
to review the events in detail – post note- the review has been facilitated,
many examples of lessons learnt and changes in practice noted. Changes to
practice to be shared across the region
Maternity Theatre staffing paper at Executive Management Committee for
consideration – further work being undertaken to mitigate clinical and
financial risk.
Main activities for next quarter





Royal College of Midwives General Secretary visit expected 11th April 2012
Workforce review
Continue to monitor quality outcomes
Baby Friendly Accreditation Visit 25th and 26th April 2012
Preparation for CNST level 2 accreditation to be continued
Status
Patient Safety
Nutritional Screening / Protected Mealtimes : January – March 2012
This key area of patient safety is part of the regional and local CQUIN target and quality schedule.
Quarterly Progress Report
Risks and Issues
Malnutrition Screening Tool (MUST)
Our requirement to screen all patients for risk of malnutrition continues to improve. The
local and regional CQUIN targets have been achieved quarter on quarter. During Q3
an audit of the case notes of all inpatients across all four hospitals showed that 93% of
patients had been screened using MUST. Compared to the previous quarter the same
audit showed 90% patients had been screened. Quarter 4 audit was undertaken during
February 2012. We are awaiting these results. A larger scale MUST audit will be
undertaken during April 2012.
Although significant improvements have been made there remain areas that require
further concentration. To ensure robustness and embedment of the MUST the
following actions have been implemented:
 Monthly training workshops and ward based teaching sessions to be held for
Nurses to focus on completing the MUST screen within 24 hours, ensuring that
screens are completed fully and that scores are calculated correctly.
 An analysis of Datix incidents has been implemented that identifies issues relating
to MUST. This has highlighted trends and has facilitated the development of action
plans accordingly. These trends are identified at the Nutrition Board and
Professional Advisory Group
Essence of Care Nutrition Benchmark
The audit was completed in December 2011. The overall score for the Trust was 93%
which is above the agreed minimal level of 70%. These results give an excellent
picture of the improved quality of patient care and work that has been carried out since
the previous benchmark. Those clinical areas that have failed to achieve 70% in any of
the factors will promptly devise a local action plan. They will re-audit within 6 months
with the focus being on these action points and the Head of Nursing will expedite
actions following spot checks.
Nutrition Operational Policy and Protected Mealtime Policy
A Patient Information Leaflet has been developed as part of the implementation of
protected mealtimes. A standardised ward poster will also be developed. The policy
has been presented at the grand round and ward leaders meetings to raise
awareness. The implementation of both policies demonstrates strong direction from the
Trust to move from guidance to policy.
Author:
Angela Hill, Nutritional Nurse Specialist
1. There is further work to ensure the consistency of MUST screening across
SFHFT to ensure that every patient with specific nutritional needs are
identified.
2. Non adherence of hospital staff to the Nutrition Operational policy and
Protected Mealtimes policy may compromise patient recovery.
Added Value
Good nutrition is essential to patient recovery and the reduction of pressure
ulcers in hospital. Patients at risk of malnutrition stay in hospital significantly
longer and are more likely to be discharged to healthcare destinations other than
home.
Main activities for next quarter
 On going monitoring to assess the quality of MUST screens - larger scale
MUST audit to be undertaken in April 2012
 Ongoing analysis of Datix incidents and development and review of action
plans.
 Review and triangulation of the above with the nursing metrics scores
relating to nutrition
 Continuation of monthly training workshops and ward based teaching
sessions for nursing staff which will further embed foundation knowledge and
target specific elements of the MUST screening process.
 Ongoing work to ensure that protected mealtimes is embedded into the ward
culture throughout the Trust.
 As part of the Protected Mealtimes implementation programme,
observational audits will be undertaken throughout the Trust. The aim is to
identify current practice in order to support wards with barriers to
implementation
Patient Safety
Infection Prevention and Control : January – March 2012 (Quarter 4)
Quarterly Progress Report
Status
Risks and Issues
MRSA 21 day screening:
To date the compliance score for the 21 day MRSA screening is 91%.
Communication is held between the MRSA co-ordination, the Heads of Nursing and
Ward Leaders, to establish a rationale for non-compliance.



Trust Acquired MRSA Bacteramia:
To date it has been 747 days since a Trust acquired MRSA bacteraemia (last case
18th March 2009).
Clostridium difficile trajectory: 43
Quarter 4 has seen 8 cases of Clostridium difficile infection (CDI) confirmed as
hospital acquired infections. Year to date there has been 45 Trust acquired infections,
which exceeds the overall 2011/12 trajectory of 43 cases. Since measures were put
in place via the independently scrutinised action plan and the commencement of
consultant microbiologists, it is looking like we will be one of the best performing
Trusts within the region for quarter 4 (Results due May2012)
January
February
March
> 48hrs C Diff
1
5
2
Monthly Ceiling
4
5
4
Cumulative
37
42
45

Progress Report



For October – December 2007/08 there were 78 community and trust acquired C
Difficile infections. For the same period, October – December 2011/12 there were 21
community and Trust acquired C Difficile infections – reduction of 74%.
There is no evidence of cross infection during 2011/12.
Antibiotic usage is a contributing factor to the acquisition of C Difficile in some patients.
A snap shot review of the antibiotic usage in the Trust on one day (5th March 2012)
showed that “high-risk” antibiotics accounted for 16% of the total antibiotic usage.
These results show a reduction in the proportion of patients on “high risk” antibiotics,
when compared to results of a similar point prevalence survey in July 2011 – 23% of
total antibiotic usage.
Breach of CDI target – action plan in place, trend analysis of all RCA to be
conducted.
Contamination of theatre 6 ventilation filter – which led to the theatre being
closed until new filter fitted and appropriate testing conducted.
Pseudomonas water risk in particular NNU/ITU – Department of Health alert.
Risk assessment and water testing being conducted, further meeting arranged
following results to discuss appropriate control measures.
5 patients admitted from care home (outbreak of possible influenza) – staff had
very little knowledge related to the required infection prevention and control
practices, influenza box, etc. These issues need to be addressed in preparation
for the 2012 influenza season.
Development of patient information leaflets for Norovirus and influenza.
Development of Norovirus tool kit – to be circulated to ward areas by the end of
April 2012.
Draft terms of reference for Infection Prevention and Control Committee to
strengthen their outputs
Main activities for next quarter
 Review policy for C. difficile, influenza, isolation, outbreak and Norovirus
 Development of route cause analysis form and guidance for C. Difficile. MRSA,
MSSA. E. coli bacteraemia
 Adapt the C difficile action plan to incorporate Kettering recommendations
 Continue to implement the C Difficile action plan
 Drive antibiotic audit results (HAPPI) to have improvements across all 5
measurable domains
MSSA bacteraemia:
No set trajectory. For 2011/12, there have been 18 cases of MSSA bacteraemia
confirmed as hospital acquired infection. In 2010/11 the Trust reported 57 cases of
MSSA bacteraemia, 20 of these were Trust acquired.
E.coli bacteraemia:
No set trajectory. For 2011/12, there have been 228 e.coli bacteraemia, of which 41
have been identified as hospital acquired infections. In 2010/11, the Trust reported
258 cases of E coli bacteraemia, 53 of these were Trust acquired.
CQUIN:
Urethra catheter associated bacteraemia –
To date for quarter 4, there have been 12 cases of urethra catheter associated
bacteraemia confirmed as hospital acquired infection. In 2010/11, the Trust reported
13 cases of urinary catheter associated bacteraemia which matched the CQUIN
target.
Norovirus outbreak:
January: The Norovirus outbreak continued for 17 days (07/01/2012 – 23/01/12),
affecting Sconce Ward. The ongoing transmission occurred by person to person
spread between staff and patients. Based on the line listing data, 25 cases, reported
symptoms which met the case definition for Norovirus, of which 12 cases were
inpatients and 13 cases staff members. With a total number of bed days lost as 71.
February: There were 5 Norovirus outbreaks during February, affecting WD 41
(08/02/12 – 15/02/11), WD 51 (16/02/12 – 26/02/12), WD 52 (16/02/12 – 01/03/12),
WD 24 (17/02/12 – 26/02/12) and WD 23 (21/02/12 – 25/02/12) (transmission same
as for January). Based on the line listing data, 67 cases, reported symptoms which
met the case definition for Norovirus, of which 53 cases were inpatients and 12 cases
staff members. With a total number of bed days lost as 100.
March: There were 3 single cases of Norovirus identified from 3 different clinical
areas, control measures where implemented, i.e. bay closure, there was no ongoing
transmission.
There was 1 Norovirus outbreak during March affecting Lindhurst Ward (transmission
same for January). Based on the line listing data, 14 cases reported symptoms which
met the case definition for Norovirus, of which 8 cases were inpatients and 6 cases
staff members, with a total number of bed days lost as 14.
Author: Suzanne Morris, Nurse Consultant, Infection Prevention and Control
BOARD OF DIRECTORS MEETING: 30 APRIL 2012
Quarterly Quality Report
Patient and Staff Experience – Summary and Commentary, April 2012
The areas that will be covered in this area of the Board of Directors Quality Report
are:
1.
Patient experience - outpatients
2.
Patient experience - inpatients
3.
Improving patient experience (complaints)
4.
Customer experience (PALS)
5.
Staff experience
6.
Food quality
7.
Cleanliness
8.
Same Sex Accommodation
I would like to highlight the following points from the report:









Although the amount of people who would recommend SFHFT is high it has
reduced slightly over the past three months. We will continue to look weekly
at the results to identify a trend.
The complaints performance has decreased this quarter due to competing
pressures and staff sickness within the divisions.
Telephone communication difficulties and lost property have been the main
issues in customer services this month. 360 compliments were also
received.
Staff survey key findings in relation to all acute trusts in England are: - 5
questions in the best 20%, 18 above average, 7 average, 7 below average
and 1 in the worst 20%.
The Trust’s Equality objectives have been communicated across the Trust
and feedback invited in order to ensure they represent the quality priorities.
Annual PEAT audits were undertaken on all 3 sites during February 2012.
We have received very positive comments from patients regarding the
quality and choice of the meals at King’s Mill, Mansfield and Newark
hospital sites.
An excellent score was awarded for the food service, which was observed
as part of the audit .The food was also sampled on the day.
Medirest now provide a service for Hydrogen Peroxide Fogging from 8am to
8pm every day.
The Trust can successfully report there have been no same sex breaches for
2011/12. The Department of Health guidance continues to be fully implemented
and this is a renewal of the declaration that was made in March 2011, in that we
are compliant with the national definition ‘to eliminate mixed sex accommodation
except where it is in overall best interests of the patient, or reflects their patient
choice’. It is recommended the Trust Board endorse the proposed
declaration for publication on our website.
Sally Dore
Director, Customer Experience and Engagement
Patient Experience
Patient experience data - Out Patient Questions
Status
Risk Summary
Quarterly Progress Report
Risks and Issues
There are no risks identified this quarter
: January – March 2012
During this quarter we have concentrated on asking patients if they would recommend us, but also asked them
more qualitative information in regards to what we do well and what we could do better. If patients have said they
would not recommend us we have asked why. Some patients have said they would not recommend us due to
problems they have previously had, not necessarily due to this visit. Others have cited things like long waits in the
outpatient department and lack of information. Others have commented on expensive parking and lack of spaces.
Other people felt that the doctor was not aware of their problems. Case notes not being available is also a theme.
The results of the survey are disseminated on a monthly basis to the clinical teams and the divisions for service
improvements.
Percentage
Would you recommend us to family or friends?
Jan-March 2012
What did we do well?

100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0


Jan Sample size 105
Feb sample size 141
March Sample size 219





Yes
Maybe
Very impressed all round for first visit.
Staff were so helpful.
On time, staff polite. Clean hospital,
decent parking.
Dr was polite and explained well. No
waiting.
Everything ran smoothly, excellent
service
Pleasant visit, polite staff, well informed.
Efficient and helpful staff. Clean hospital
Always excellent. Friendly and
knowledgeable. Seen on time.
Everything fine, exceptionally helpful.
No
Months
Some improvement identified during this quarter are:
A business case for electronic information boards in every waiting area has been written. These boards will
display information such as waiting times and the reasons for the wait and information regarding which doctors are
in clinic. Health information will be displayed relevant to that clinic and/or in relation to national awareness weeks.
BBC tickertape news will run along the bottom of each screen.
Missing notes is a recurring theme and work is underway to address the issues. A new workforce structure is
being put in place in case notes. This will ensure that only day staff file notes and each person will have a specific
area of responsibility to ensure ownership of the notes. X-rays are being relocated from case notes to free up
more space for case notes ensuring misfiles are reduced.
Author:
Sally Dore, Director of Customer Experience and Engagement
Progress Report
Each clinic receives reports for their areas to
enable service improvements to be made.
Results are also shared with Medirest
colleagues regarding perceptions of
cleanliness.
What could we have done better?
 No problems but suggest we could have
routine bloods & x-ray before seeing
consultant & results be available.
 Initially was phoned with appointment but
received no letter re confirmation of
appointment, had to phone to get
appointment confirmed.
 No cups for water, receptionist could not
help.
 Sat in clinic 11 for 40 mins before being told
I was in wrong clinic.
 Lives 23 miles away and had 2 appts in
same week. Why not combine the 2 and
save everyone's time.
Main activities for next quarter
During the next quarter a focused group of
operational and service improvement staff are
meeting to discuss the concept of a ‘patient
experience control centre’ this regular focused
centre will identify patient experience issues on
a weekly basis and generate ideas for service
improvement. They will receive the patient
experience information and be responsible for
improvement.
Patient Experience
InPatient Experience Commissioning for Quality and Innovation (CQUIN)
Quarterly Progress Report : January – March 2012
Status
Risk Summary
Risks and Issues
Every month the Patient Advice and Liaison (PALS) team at Newark distribute 200
questionnaires’ to patients who have experienced our inpatient service. The table below shows
the results. The Primary Care Trust CQUIN target is to achieve 75% total per quarter for all
questions.
Quarter 1 = 77%
Quarter 2 = 82%
Quarter 3 = 78%
Quarter 4= not yet available
Percentage
Patient Experience Questions
Quarter 1
Quarter 2
100
90
80
70
60
50
40
30
20
10
0
Quarter 3
There have been no risks identified during the past quarter
Main activities for next quarter
A carers policy will be launched during this next quarter to
ensure carers receive information they need as well as receiving
a leaflet to help them understand their rights to a carers
assessment.
CQUIN questions will continue. The nursing metrics patient
experience questions continue to ask about side effects to
medication and pharmacy staff are proactively asking patients if
they have any questions. To enable any patient issues to be
addressed immediately, it has been decided that this year the
CQUIN questions will be asked face to face to the patients on
discharge. They will be asked at the same time as the new
friends and family net promoter score (this asks if patients would
recommend us)
CQUIN target for 2011/12
The CQUIN questions will be asked on discharge alongside the
Net Promoter question.
Were you as
involved as you
wanted to be in
decisions about
your care and
treatment?
Did you find
someone to talk
to about worries
and fears?
Were you given
Were you told
Were you told
enough privacy about medication who to contact if
when discussing
you were worried
side effects to
your condition or
about your
watch for when
condition after
treatment?
you went home?
you left hospital?
During the last six months some of these questions have also been asked to patients whilst
they are currently an inpatient via the nursing metrics. This has enabled senior nurses to
address any issues the patient has whilst they are still in our hospital. Patients have been
encouraged by staff to ask questions. Pharmacy has developed a card encouraging patients to
ask if they do not understand their medication. Patients have been asked if doctors and nurses
answer all their questions. The results for nurses has averaged 95% and for doctors has
averaged 89% over the past 7 months. These results have been fed back to the ward teams.
Author:
Sally Dore, Director of Customer Experience and Engagement
The target for 2012 is to achieve a composite score for the 5
indicators at 80%. Payment is based on.
75% achievement in any quarter = ¼ payment of 0.125%
78% achievement in any quarter = ¼ payment of 0.15%
80% achievement in any quarter = ¼ payment of 0.2%
Patient Experience
Status
Patient Experience – Improving Patient Experience
Risk Summary
Quarterly Progress Report : January – March 2012
There is a risk that the workforce review is reliant on
the divisions being able to maintain the new process.
There has been a problem with performance in
February and March and no capacity to pick this up
within complaints. Operational pressures are
consistent and until these subside, performance
remains at risk.
Responding to complaints
The graph below shows the performance for the Trust in relation to the number of complaints
responded to within the time frame agreed.
Responses
due to
complainant
Complaint performance
100%
90%
M
onths
80%
70%
EC&M % answered on time
60%
PC&S % answered on time
50%
D&R % answered on time
40%
SFH total % answered on
time
30%
20%
Oct: 46
Nov 42
Dec 55
Jan 45
Feb 51
March 66
Reopened complaints. There were 48 reopened
complaints in 2010 and this reduced to 38 in 2011.
The aim is to answer the complainant’s points
thoroughly the first time.
Number of reopened complaints per month
10%
14
M
ar
ch
D
ec
Ja
n12
F
eb
ru
ar
y
N
ov
O
ct
S
ep
t
A
ug
Ju
ly
Ju
ne
M
ay
A
pr
-1
1
0%
12
10
The divisions have been made aware that the performance has dropped and have given a
commitment to improve.
Diagnostic and Rehab had 2 complaints in February and therefore their performance was 50%.
The PHSO has upheld one complaint this month. This has been reported to Clinical Governance
Committee (April 12). An action plan and response is being developed in accordance with PHSO
timescales. Learning points will be disseminated via Specialty Governance Forums.
2010
8
2011
6
2012
4
2
0
Ja
n
Fe
b
M
ar
ch
Ap
ril
M
ay
Ju
ne
Ju
ly
Au
g
Se
pt
O
ct
No
v
De
c
Over this quarter the performance within all divisions has deteriorated. This has been as a
consequence of:
 Exceptional operational pressures particularly at the ‘front door’. Divisional teams, particularly
emergency care, have been spending considerable time and focus on maintaining safety in
clinical environments.
 Sickness of a senior staff member whom co-ordinates planned care & surgery complaint
processes.
 Reduced number of senior consultants in ED to respond.
Month
Percentage answered on time
Number
It is expected that there will be more reopened
complaints in March 2012 as the number of
complainants responded to was higher than the
preceding months.
Customer Experience – Patient Advice & Liaison Service (PALS)
January to March 2012
Quarterly Progress Report
Status
Risks and Issues
During this fourth quarter the PALS team have logged 2451 contacts onto Datix.
The themes and trends identified below continue to add pressure to the service, and whilst we
respond to the enquiries we are not always able to log all of these contacts due to the volume.
Monthly reports are despatched to service line and divisional management teams collating the
concerns, comments and compliments received.
Evaluation of the monthly report summaries have taken place with the senior divisional teams to
ensure the information provided by the PALS team is in a useable format to inform service
improvement delivery.
1. Telephone Communication
a. Poor customer service resulting in loss of business and poor reputation.
b. Excessive demand on the Customer Services team to respond to telephone enquirers who
have been unable to contact the departments mentioned.
c. Increase in DNA rate as patients are unable to advise us of their availability and problems.
Comments – 969, Compliments – 360, Concerns – 1040, Complaints (first stage) - 82
2. Lost property
a. Financial loss as customers are making claims for compensation and losses.
b. Poor customer experience.
c. Poor reputation management.
d. Poor use of staff hours searching for and investigating loss of property.
Themes
Added value
1. Telephone Communication
Continuing from quarter 3, patients are experiencing severe difficulties in contacting the
hospitals with regards to appointment bookings and general enquiries. Patients report that they
have been trying to contact services at KMH for a number of days. Main areas of concern are
partial booking and Therapy Services. Similar problems are being encountered at Newark
Hospital.
Service Improvements
The Customer Services teams are managing the following projects to enhance the customer
environment and experience.
2. Lost property
Enquiries relating to lost patient property have increased in quarter 4. 32 customers have
contacted the PALS service distressed and concerned about the loss of valuable and
sentimental items.
Quarterly summary reports of this theme have been sent to the divisional nurse directors and
includes the loss of a 60 year old yellow coloured watch, £300 in cash, mobile phone, wallet,
orthotic items, dentures and spectacles.
3. 4Cs – Breakdown
PC&S
Division
EC&M
Division
D&R
Division
Corporate
Development
Other
Total
Comments
Compliments
Concerns
327
180
351
219
119
231
360
38
307
54
23
72
9
0
79
969
360
1040
Complaints
29
18
14
1
20
82
Author:
Tracey Brassington, Customer Liaison Manager
Main activities for next quarter - Newark
1. Hospital Open Day Planning.
2. Refurbishment of OutPatients.
Main activities for next quarter – King’s Mill
1. Introduction of smoking shelters.
2. Improvements to main reception services with an introduction of a new desk and a workforce
review.
3. Refurbishment of A&E, EAU relative’s rooms, and review of further provision for care of
visitors.
4. Manage the implementation of further car parking concessions improving publicity and
simplifying availability.
5. Implementation of ‘The Friends and Family Test’ national agenda.
Patient and Staff Experience – Staff Feedback March 2012
Staff Experience
Quarterly Progress Report – January 2011 – March 2012

The Care Quality Commission (CQC) Annual Staff Survey report was received in early March.
49% (below average) of randomly selected staff responded compared to a response rate of
52% in 2010. Overall staff engagement was 3.69 (where 1 is poorly engaged staff, 5 is highly
engaged), slightly above the national average for acute trusts in England (3.62) and last year’s
score of 3.66. Of the 38 key findings the Trusts score increased in 1 area, decreased in 1
area and remained the same in 36 when compared to last year. The Trust’s key findings in
relation to all acute trusts in England are: - 5 in the best 20%,18 above average, 7 average, 7
below average and 1 in the worst 20%

The Bus to Work salary sacrifice scheme was finalised with Stagecoach and as part of the
th
Trust’s Energy Awareness Event on 7 December a road show was held to launch the
scheme. Representatives from mycar also attended to promote this staff benefit.

The training session for managers to improve the effectiveness of OH referral and reporting
continued to be rolled out. This session is a key element of the development of managers and
to help in improved sickness absence management.

The Trust’s Equality objectives have been communicated across the Trust and feedback
invited in order to ensure they represent the quality priorities. These have now been approved
by the Board of Directors.

The Task & Finish group established to take forward the work on Stress & Mental Health in
support of positive employment practice in line with ‘Mindful Employer’, met throughout the
quarter and the group’s recommendations will inform the Trust’s Staff Health & Well-being
Strategy.

th
A Staff Health, Safety & Well-being Workshop was held on 29 February. Outcomes from the
session are being used to inform the Trust’s Staff Health & Well-being Strategy. The workshop
was well attended. A further workshop is planned for June to; crystallise objectives,
communicate these to key stakeholders, engage managers and achieve to buy in.

Parent Workshops continue to be well attended. Drop In Sessions are held on a bi-monthly
basis at Newark Hospital following the Joint Staff Partnership Forum (JSPF) meeting and all
new starters attending Orientation day are given a copy of the booklet ‘Introduction to Staff
Support & Benefits’.

The Stress Education Programme continues to be rolled out to managers and work areas
affected by workforce change. The feedback has been excellent.
The new mobile phone and computer salary sacrifice scheme launched in January. This was well
received by staff and the next window is planned for April.
Author – Karen Fisher, Executive Director of Human Resources
Status
Risk Summary
Risks and Issues

The level of appraisal completion has improved for medical staff, whilst
other staff group figures require improvement. The revision of
documentation is now drawing to a close and includes talent
management.
Roll out will begin with pilot areas.

The workshop on developing the Trust Equality objectives has been
followed up with two further group conversations to refine the detail.
There has been a public consultation on the draft Equality Objectives
and feedback has been received from 6 individuals. The objectives
published on the Trust website for 6 April 2012 to comply with the
Equality Act public duty. Progress on achievement will be monitored
through the Workforce Committee.

Attendance continues to be managed and monitored more closely and
the Sickness Absence policy is under review.

Work is moving forward to review break periods across the Trust and
conversations with staff have started in all areas to remain consistent.
Main activities for next quarter
 Support ward leaders to roll out the new shift patterns and revision to
break periods and support manager review of break periods in other
Trust areas
 Finalise and publish the Trust’s Equality objectives, seek to re-engage
and re- energise the Trust Equality group.
 Staff Survey action plan to be developed and staff engaged on the
actions required
 Continue to monitor the number of staff who have received an appraisal
and secure improved levels of performance and productivity.
 The Staff Well-being group will lead the work in response to the two
DH’s reports; ‘Healthy Staff, Better Care for Patients’ and ‘NHS Health
& Well-being Improvement Framework’ and develop a strategy and
action plan to support Staff Health and well-being.
 Continue the roll out of the Stress Education Programme
 Hold a Staff Benefits and Discount events at King’s Mill Hospital and
Newark Hospital to raise awareness of the various schemes and offers
available to staff.
Patient and staff experience – Food Quality – January- March 2012
Food Quality
Quarterly Progress Report









Risks and Issues
No risks identified in this quarter
Monitoring compliance with new Special Diet sheet
Work has continued to monitor compliance at ward level with
using the new special Diet sheets .The new sheets ensure
consistency when ordering and clarify where assistance with
feeding is required. This has improved communication regarding
Main activities for next quarter
special diets .
Positive patient feedback
 Quarterly Mini PEAT audits are scheduled to take place during
Annual PEAT audits were undertaken on all 3 sites during
May and June
February We have received very positive comments from patients
regarding the quality and choice of the meals at Kings Mill,
 Agreement has been reached for Steamplicity individual plated
Mansfield and Newark hospital sites.
meal service to be rolled out to wards at Newark Hospital. Date
An excellent score was awarded for the food service, which was
to be confirmed, subject to a site survey and any minor works
observed as part of the audit .The food was also sampled on the
that may be needed to facilitate this.
day.
 Rollout of Steamplicity meals at Mansfield Community Hospital.
Hostess service introduced at Mansfield Community
Minor works have commenced to undertake minor alterations to
Hospital
enable this to proceed.
In advance of rollout of Steamplicity individual patient meals at
MCH, the hostess service has already been introduced which has
 Ongoing Contract Management team programme of patient and
provided wards with a dedicated member of catering staff to
non-patient catering audits at Mansfield, Newark and King’s Mill
focus solely on the meal service.
Hospitals.
Steamplicity minor works at MCH
Minor works have commenced to provide additional electrical
sockets etc necessary for the rollout of the new individual plated
meal service.
Author:
Liz Nicholas- FM Services Manager, Corporate Development.
Quality Report – Cleanliness January - March 2012
Status
Standards of Cleanliness are measured against the National Specifications for Cleanliness; the current benchmarks are Significant Risk areas at 75% and
above, High Risk and Very High Risk areas at 85% and above.
Quarterly Progress Report
Medirest are reporting a consistently high aggregate score against the National
Specifications of Cleanliness requirements, detailed in the table below:
King's Mill Site
VHR
HR
SR
C
N
C
N
C
N
Dec
Jan
Feb






VHR
C
N
Newark Site
HR
C
N
SR
C
N
MCH
SR
C
N
97%
98%
94%
95% 94% 98% 97% 96%
98%
100% 92% 96% 95% 100%
97%
98%
95%
92% 93% 100% 96% 92%
95%
100% 90% 96% 97% 97%
96%
97%
96%
94% 93% 99% 97% 88%
94%
100% 92% 90% 96% 96%
Audits
The Corporate Development team undertake audits across the Trust to validate the
scores reported. The joint monitoring audits that are undertaken with the service
providers include clinical representatives. The audits cover the whole patient
environment rather than just looking at cleanliness.
Annual PEAT audits
Annual PEAT inspections were undertaken during February achieving a very high
standard. The Trust have to wait until later in the year for the validated scores but
the Trust expect to achieve a similar environment score to previous years.(4-good)
Most areas achieved top marks of 5 (excellent)The only area where equipment
scored less than 4 for cleanliness was the patient equipment in A&E. Significant
work has been done in this area to ensure that these standards have been brought
back up to the expected standard immediately and a programme of follow up audits
and a working group were established to ensure this was maintained permanently.
At Newark there were some dusty radiators and vents but apart from that they
achieved a good standard in all areas as did Mansfield community hospital.
Introduction of 7 day fogging service
Medirest now provide a service for Hydrogen Peroxide Fogging from 8am to 8pm
every day .This service was previously only Monday to Friday. In addition to this
Medirest have supported the Trust throughout the winter months providing fogging
services around the clock to enable wards to be reopened as quickly as possible,
following infectious outbreaks. Due to significant pressure on beds it was not
possible to decant wards for cleaning.
Risks and Issues
No risks identified in this quarter
Main activities for next quarter

Ongoing schedule monitoring cleanliness standards
across all areas.

Mini PEAT (Patient Environment Action Team) audits
scheduled to be undertaken during May, June, on all four
sites.
Patient & Staff Experience
Patient Experience – Same Sex Accommodation – 2012/13
Full Year Report
The NHS Operating Framework for 2012/13 requires all providers of
NHS funded care to confirm whether they are compliant with the
national definition ‘to eliminate mixed sex accommodation except
where it is in overall best interests of the patient, or reflects their
patient choice’. Those organisations that breach will attract
sanctions through the NHS Contract
The Trust can successfully report there have been no same sex
breaches for 2011/12. The Trust provides monthly reporting via the
integrated performance report, along with a quarterly update to the
commissioners via the quality and scrutiny group.
The Department of Health guidance continues to be fully
implemented and this is a renewal of the declaration that was made
in March 2011, in that we are compliant with the national definition
‘to eliminate mixed sex accommodation except where it is in overall
best interests of the patient, or reflects their patient choice’. It is
recommended the Trust Board endorse the proposed
declaration for publication on our website.
It is anticipated the Trust will remain compliant for 2012/13 and
regular self assessments will continue via the site management and
on call team to confirm continual compliance.
Author:
Susan Bowler – Executive Director of Nursing
Status
Risks and Issues


Risk of non compliance at times of high demand
Potential loss of income where breaches occur
Main activities for next quarter
Continue to monitor and report monthly via Unify 2 and the integrated
performance report.
Continue to identify patients experiences of DSSA through PET surveys.
Clinical Effectiveness
Heart attack secondary prevention. January 2012 to March 2012. Quarter 4.
Percentage of heart attack patients prescribed an anti-platelet, statin or beta blocker. National standard identified in the NSF for
CHD.
Quarterly progress highlights
Risks & Issues

Taken from MINAP (Myocardial Ischaemia National Audit
Project) data. Period of January, 2012 – March, 2012. Data
includes all patients discharged alive with a discharge
diagnosis of MI.

Added value

Aspirin
B Blocker
Ace
Clopidogrel
Statin (all
admissions)
Number of patients


KMH
100.0%
96.9%
95.0%
100.0%
98.6%
National
99.4%
97.5%
96.4%
98.6%
99
To note: contractually the trust is required to have 90% of
patients discharged on secondary prevention medication
None.
The cardiology database will provide robust audit data and
incorporate ACS requirements into the PRISM software.
There was a server upgrade in March, which has automated
the replication of data from the web portal to the main server
increasing efficiency.
Main activities for next quarter

Continuation of implementation of cardiology database with
specific focus centring on the efficiency and effectiveness of
the database.
King’s Mill has maintained a strong performance across all
categories.
Author: Greg Dickman, Business Support Officer, Emergency Care and Medicine
Patient Safety
To improve outcomes for stroke patients using the 9 SENTINEL indicators as a measure.
NICE, NSF, National Stroke Strategy: January 2012 to March 2012, Quarter 4.
Quarterly progress highlights
Risks & Issues


Weekend rota implemented, supported by consultant
geriatricians.
To ensure EMAS pre-alert the ED of new stroke admissions.
Indicator
Patients spend at least 90% of their stay
on a stroke unit
Screening for swallowing disorders
<24hrs after admission
Brain scan within 24hrs of stroke
Anti-platelet medication by 48hrs after
stroke
Physiotherapist assessment within 72hrs
of admission
OT assessment within 4 working days of
admission
Patient weight during admission
Rehabilitation goals by the multi
disciplinary team within 5 days
Patients mood assessed by discharge
% patients who achieve all 9 indicators
Qtr 1
95%
Qtr 2
90%
Qtr 3
95%
Qtr 4
96%
95%
98%
100%
99%
96%
98%
98%
97%
100%
100%
100%
100%
89%
87%
95%
98%
83%
100%
91%
94%
100%
100%
100%
100%
100%
100%
100%
100%
99%
67%
100%
74%
100%
83%
99%
87%

Imaging slot capacity.
Added value

Main activities for next quarter





To continue the development of the stroke thrombolysis
service, focusing on effectiveness and efficiency.
To review S&LT input to stroke service.
To investigate ring fencing daily imaging slots to support the
stroke service.
To advertise the new TIA service to GPs.
To recruit substantive stroke consultant.
The results from quarter 4 from the ongoing measurement
against the 9 SENTINEL audit KPIs are in the table above and
show continued improvement in all indicators.
Author: Greg Dickman, Business Support Officer, Emergency Care and Medicine
Clinical Effectiveness 4th Quarter
End of Life Care: January – March 2012
Quarterly Progress Report
Risks and Issues
End of Life Care (EOLC) strategy quality markers for Acute Hospitals consist of
14 identified measures.
1. Continuing education of the multi-professional teams in the end of life
care, remains a challenge
2. Process and mechanism for effective communication with GP’s and
HCP within Primary Care, and the implementing the Gold Standards
Framework register locally
3. EOLC does not remain a high priority if the EOLC Coordinator post is
not sustained.
Acute hospital providers have to demonstrate their compliance with these
measures.
The SFHFT General Palliative & End of Life Care Group have base-lined
against these measures and can demonstrate full compliance with 5
measures:
1. Hospital based Specialist Palliative Care MDT (3.2)
2. Full implementation of LCP across all Wards within the Trust (3.9)
3. Quiet spaces in wards for relatives and carers. (3.11)
4. Communication with patients GPs at end of life decisions and informing
GP when patient dies. (3.13)
5. Staff are aware of end of life training (inc LCP), enabling access for
relevant and all staff to attend (3.17)
Work completed in Quarter 4
1. The Trust participated in the National Care of the Dying Audit and has
developed an action plan in response to the results and findings.
2. EOL Co-ordinator post recruited to for a further 6 months secondment and
funding secured for a further 3 months to ensure post remains until
December 2012
3. Monitoring patient/carer experience through complaints.
4. Workbook ratified for use
5. Attendance on induction training ongoing
6. Re-established EOLC Link Nurse Forum within Ward/Department areas
7. Audit programme has been developed to monitor the use of LCP and % of
expected/unexpected deaths
Work that needs to be progressed:
1. Develop referral process to GPs for patients identified as approaching their
last year of life and a locality wide Gold Standards Framework register.
2. Raise awareness of multi-professional teams in identifying patients needs
and planning care through the process of advanced care planning
3. Business case to ensure End of Life Care Co-ordinator post is made
substantive
Author: Carolyn Bennett – Macmillan Lead Cancer Nurse
Main activities for next quarter
1. Continue to audit use of LCP and % of expected /unexpected deaths
2. Continue to work with Primary Care 24 re notifying Primary Care of
patients approaching EOLC and the Gold Standard Framework (GSF)
locality register process
3. Develop a business case for ongoing funding to make the EOL
Coordinator post substantive
4. LCP Operational policy to be ratified
5. Implement EOLC Workbook and continue to provide training to new
HCP and updates to existing HCP across the Trust. An EOLC section
also to be developed for the Trust Mandatory Training programme
6. Develop a reflective practice process for all HCP involved in using the
LCP after death.
7. Develop an EOLC site on the Trust Intranet to improve
communication
Clinical Effectiveness
Status
Summary Hospital Mortality Index: January – March 2012
Quarterly Progress Report
Risks and Issues
PART ONE
The SHMI (Summary Hospital Mortality Index) is the DoH preferred measure of mortality. It replaces the HSMR, which is unduly sensitive to variations in palliative care
coding. SHMI includes all admissions and deaths that occur within 30 days of discharge, Analysis of 2011/12 data indicates that our high HSMR was largely attributable
to relatively low levels of palliative care coding. Without it we would have an average HSMR. In this and future reports I will concentrate on the SHMI.
On the SHMI measure SFH has been just a little worse than average at 103 when last reported to the Board. Since then there has been a small but steady fall and the
most recent results for the year to September 2011 are 101. This is encouraging but not good enough. It should be added that this period is before the introduction of
weekend ward rounds in medicine. I would hope to see an impact from these changes from the November 2011 figures when these changes were introduced.
A more detailed mortality paper than usual is presented below. It focuses on specific diagnostic groups linked to service lines. This will become the basis for identifying
areas for work and monitoring progress in improving our SHMI.
The data presented is somewhat historical and covers the year to June 2011. Unfortunately this is the most up to date detailed SHMI data available
The first slide (SHA Non- Elective) shows our overall performance in non-elective activity. Although we are only average compared to English providers we compare well
to our SHA neighbours who with the exception of NUH are significantly worse than average.
In the subsequent slides I have chosen to highlight diseases that fall within the activity of the Gastroenterology, Cardiology, Orthopaedics/Geriatrics and Respiratory
Service lines. In addition Sepsis and UTI are shown. I have taken this approach because significant numbers of patients present with these diseases and we need to focus
on them for that reason. It will also allow these lines to focus on improving pathways and provide a baseline to measure progress. This will drive improvement in care and
thus SHMI.
Gastroenterology includes deaths from Upper GI bleeding and liver disease. Since the period covered in these data we have appointed a consultant with an interest in
hepatology and have instituted a daily gastroenterology specialist ward round to pick up the acute admissions on EAU and increased the provision of rapid endoscopic
intervention for GI bleeding. I would expect these changes to have an impact on our performance in the period from December 2011. To improve further we would need to
establish a 24/7 acute endoscopy service in line with NUH and Derby, both of which have a better performance than we do.
Cardiology. This includes acute MI, Congestive Cardiac Failure (CCF) and dysrhythmias. The performance here is generally very good and has been for some time.
Directing the majority of patients with CCF to the cardiology service will improve the care given to these patients and will improve the SHMI in this area.
Author: Nabeel Ali
Clinical Effectiveness
Status
Summary Hospital Mortality Index: January – March 2012
Quarterly Progress Report
Risks and Issues
PART TWO
Respiratory Medicine. This is an important area because it represents approximately 8% of non elective spells and has a high mortality rate. Performance is acceptable
but with the introduction of weekend working and daily specialist ward rounds I expect to see further improvement here in the next period.
Orthopaedics/ Geriatrics. Here the data concerns patients admitted with Fractured Neck of Femur. We have been aware of poor performance in this area. The introduction
of a partial Orthogeriatric service should begin to address some of the issues contributing to increased mortality.
Sepsis/UTI. No specific service line is concerned but mortality from SEPSIS/UTI reflects the effectiveness of our pathways in dealing with acutely ill patients and can be
considered a measure of these. Our performance has not been good and reviewing these data will focus attention on implementing the sepsis bundle.
We have appointed four Acute Physicians and will separate the on call rotas for Acute Medicine and the medical specialities from August 2012. This will have an
immediate effect of increasing the capacity to deliver daily specialist ward rounds as well as weekend working. This should have a measurable effect on the quality of care
our mortality data.
A question arose at the March Board about the age distribution of admissions to SFH and specifically whether we had an older population admitted as an emergency than
other SHA providers. We do not. Our patients are exactly average in age distribution.
Author: Nabeel Ali
Clinical Effectiveness
Status
Risk Assessments for VTE Prophylactic Anti-Thrombosis Treatment : January- March 2012
Quarterly Progress Report
Risks and Issues
Data collection continues.
1. CQUIN compliance rate for 2012 is due to increase to 95%. The
Quarter 4 data is not complete at time of writing report however the most up to date
change will be gradual and reach 95% by Q3, allowing us time to
data achieved as per the table below.
make changes to achieve it.
JANUARY
92.06%
2. E-prescribing to which the electronic VTE assessment will be
FEBRUARY
91.54%
attached has been piloted during this quarter on Ward 14 and
MARCH
91.13% *data collection not yet complete for reporting until
there are major issues with the data collection. These issues
27.4.2012
have been reported to the project steering board for resolution
A yearly audit to measure prophylaxis rates has been completed in quarter 4 and the
with the company Systemone. An investment may be required to
data is being analysed for reporting.
The Trust wide VTE group continues to meet regularly to drive improvements.
achieve this.
Daily data is available and is sent to the on call Consultants in order that they can
3. Risk of compliance % decreasing when Junior Doctors change
influence practice at the bedside.
over.
There is a patient safety improvement project being undertaken, on the re-assessment
4. Capacity to undertake case note reviews at risk due to vacancies
of the patient at 24 hours post admission on one respiratory ward which was presented
in the EAR department
at the patient safety afternoon held in March 2012.
 The aim of prophylaxis of course is to prevent hospital acquired VTE. We have
identified 318 cases of VTE for the year to April 2012 of whom 63 (20%) had
been admitted within 12 weeks and can be considered to be hospital acquired.
Work to investigate these cases is hampered by staffing shortages in EAR.
 Patient information leaflet on discharge is available and the compliance of this
standard will be part of the clinical audit which will be completed by the End o
January 2012.
 Training for junior doctors is available on an e- learning platform. However it is
clear that changeover will again present a challenge in maintaining
performance
 Work on reassessing the patient after 24 hours is being piloted on ward 44 as
part of a Patient Safety Project by junior doctors under the direction of the
patient safety AMD.
 Information on all of the above has been requested by the SHA lead and will
be shared
Main activities for next quarter
1. Continue to collect data
2. VTE group continue to meet to look at ways of increasing
compliance.
3. The process for identifying patients with positive results of
hospital acquired VTE has been agreed and cases are being
highlighted to the Consultants for them to undertake RCA
investigations, lessons to be learnt and feedback into service
lines/ Trust wide.
4. Presentation of case review of hospital associated VTE report to
VTE group.
5. Influence the electronic solution and issues to ensure that data
collection can continue.
Author: Prepared by Patient Safety Manager on behalf of Dr Nabeel Ali – Executive Medical Director
Clinical Effectiveness 4th Quarter
Status
PROMS – QUARTERLY PARTICIPATION RATE REPORT
Quarterly Progress Report
Risks and Issues
The Quarterly participation rates for PROMs with absolute numbers and percentages
for October 2011 to December 2011 participation rates for 2011/2012 are now
available on the HES online website.
The Trust’s PROMs quarterly participation rates for the period of Oct – Dec 2011 are
as follows:
Quarterly
Participation Rate
Hernia
Quarterly
Participation
Rate Hip
Quarterly
Participation
Rate Knee
Quarterly
Participation
Rate Vein
86%
63%
84%
44%
Notes:- It is also the case that low participation rates on some procedures may be the
result of decommissioning of some procedures by PCTs (especially veins)
Hernia, Knee and Vein rates continue to be in line with or above the National average
whilst the Hip participation rate is lower than expected.
Numertor used for this reported period:

Absolute numbers of scanned questionnaires over the 3 month period by
procedure.
Need to investigate why HIP participation rate has gone down.
Total Scanned HERNIA
92
Total Scanned HIP
50
Total Scanned KNEE
99
Total Scanned VEIN
25
Main activities for next quarter
 Continue to encourage and collate PROM related data for
submissions to HES
 Requested that Pre-Operative Assessment investigate the
reasons for a lower participation rate for hip procedures and
develop an action plan to resolve any issues.
Denominator used for this reported period

Average number of eligible PROMs operations performed by your
Trust/Provider per quarter (taken from the 12 month period June 2010 – May
2011).
Quarterly
HES Hernia
Quarterly
HES Hip
Quarterly
HES Knee
Quarterly
HES Vein
107
80
118
56
Author: Julie Jan – Deputy Divisional Director – Planned Care & Surgery