1. business and industrial
2. company
3. annual report

ENC H1
Report to meeting of:
Council of Governors
Date of meeting:
14th February 2013
Title of paper
Quarterly Quality Report
Time required on
agenda:
20 mins
Executive Summary:
The concerns raised previously regarding the number of PALS contacts in relation
to our administrative processes have reduced.
Staff experience is scoring amber due to the need to improve appraisals and
improve our Trust Sickness and Absence rates.
A focused drive to close outstanding Serious Incidents (SIs) has been successful
with only two SIs now open beyond their closure date (agreed due to complexity of
investigation). It has been over 12 months since the Trust reported a never event.
STEIS reported incidents are static in numbers. The Trust Governance Action Plan
will strengthen the management of harm and potential harm events going forward.
Overall the Trust is compliant with physiological observations and caring for acutely
ill patients. It has successfully delivered the ‘failure to rescue’ CQUIN for Q1-Q3
leading to a reduction in avoidable Cardiac Arrest Events. We are adopting the
national observation chart and altering our track and trigger system to the nationally
recognised NEWS in February 2013. The Trust is also assessing the possibility of
introducing an electronic monitoring system. This will have capital and revenue
implications for the Trust (which is being assessed) but could massively improve
patient safety and support a reduction in the Trust HSMR.
Three CQUIN Targets are at risk of none delivery for Quarter 3 and Quarter 4
(Dementia, End of Life and Think Glucose). The targets were always identified as a
risk due to the need for whole organisation change and new ways of working. The
financial implications are noted within the report. Much progress has been made
since the beginning of 2012/13. Actions will continue in Q4 to drive the delivery of
all CQUIN’s. Negotiations with commissioners have commenced for 2013/14
CQUIN’s.
Submitting Director:
Susan Bowler, Executive Director of Nursing and Quality
Action required:
The Council of Governors are asked to note the contents of
this report.
COUNCIL of GOVERNORS MEETING - 14 FEBRUARY 2013
Quarterly Quality Report – 3rd Quarter (2012/13)
This report provides 3rd Quarter information regarding patient experience, patient safety, clinical
effectiveness and CQUIN performance. The targets are subjective and based upon the opinion of
the author in terms of what they consider the risk to the Trust is in relation to the area reported.
Green
Yellow
Amber
Red
Achieving
goals
On plan to
achieve goals
Further work
required
Urgent action
required
Projected
Q4
2012/13
Q3
2012/13
Quality Dashboard
Q2
2012/13
Key
Patient Experience
Personal Needs
PALS Themes
Staff Experience
Food Quality
Cleanliness
Patient Safety
Serious Untoward Incidents
Care of the Acutely Ill Patient
Maternity Care including Midwife to Birth Ratio
Slips, Trips and Falls
Infection, Prevention and Control
Nutrition
Pressure Ulcer Prevention
Clinical Effectiveness
PROMs
Stroke Sentinel Audit
CQUIN
Improving Dementia Care
Delivering Dementia Training
Failure to Rescue
Improving the Experience of Patients with Learning
Disabilities
NET Promoter Score
Patient Experience
Improving Choice at End of Life
VTE (Venous Thrombo-Prophylaxis)
Emergency Department Streaming
Think Glucose (Length of Stay & Medication)
Safety Thermometer
SB - CoG January 2013 - Q3 Quarterly Quality Report
1
Recommendations
Directors are asked to consider each section of the Quality Report and the highlights and issues
raised by individual authors.
Susan Bowler
Executive Director of Nursing & Quality
Nabeel Ali
Executive Medical Director
January 2013
SB - CoG January 2013 - Q3 Quarterly Quality Report
2
Quarterly Quality Report
Date period : Quarter 3
-
Patient Experience -
Patient Experience Personal Needs
Q3 RAG
October-December 2012
Q4 RAG
Predicted
Aims / Objectives for 2012/13: For the composite score for all indicators to achieve 80% per quarter. Questions asked at discharge are:
1.
2.
3.
4.
5.
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 enough privacy when discussing your condition or treatment?
Were you told about medication side effects to watch for went you went home?
Were you told who to contact if you were worried about your condition after you left hospital?
Results for Quarter 3
Quarter 1 results = 97%
Quarter 2 results = 95%
Quarter 3 results = 96%
The key aim is to maintain above the 80% target. Individual questions are
assessed to ensure they consistently achieve 80%.
Key Aims for Quarter 4
To maintain 80% or above for the quarter.
To continue the established data collection methods
To continue to share the monthly results with ward staff, broken down by
question.
To ask staff for ideas to improve the scores if they are tailing off.
Patient Experience Questions 2012/13
100
Overall number per question
Progress against Quarter 3 Key Aims
All questions for quarter 3 have been consistently achieving above 80%.
Question 4 and 5 results showed some deterioration in quarter 2. The results have
been shared with Pharmacy and they have introduced a card for every patient in
relation to question 4. They are ensuring that all Pharmacists and ward staff continue
to distribute it to patients. The results for these questions in quarter 3 have now
improved.
Actions to Deliver Quarter 4 Key Aims
90
80
70
60
Quarter1
50
40
Quarter 3
Quarter 2
Quarter 4
30
20
10
0
Question 1 Question 2 Question 3 Question 4 Question 5
Risks
Controls and Mitigation
Not Applicable
There are currently no risks to the CQUIN target
Lead: Sally Dore, Director of Customer Experience and Engagement
SB - CoG January 2013 - Q3 Quarterly Quality Report
3
Quarterly Quality Report
Date period : Quarter 3
-
Patient Experience -
Patient Advice & Liaison Service (PALS)
October-December 2012
Q4 RAG
Quarter 3 Update
During this quarter the PALS team have logged 2141 contacts onto Datix, some
contacts result in more than one subject being raised.
The themes and trends identified below
Monthly reports are despatched to service line and divisional management teams
collating the concerns, comments and compliments received. Possible service
improvements are highlighted and feedback requested.
Key Themes
4C’s
breakdown
Comments
Concerns
Compliments
Complaints
(first stage)
Q3 RAG
PC&S
Division
188
182
111
EC&M
Division
134
184
49
D&R
Division
305
557
53
Corporate
Development
39
38
16
Other
122
91
17
Total
788
1052
246
12
14
12
0
17
55
1. Breast Services / Pathology Oestrogen Receptor Results
The SFHT PALS team promptly responded to provide a helpline for patients and family
members affected by the Oestrogen Receptor results issue. 98 customers received
support, information and assistance with their pathway from the team. The service was
provided 8am to 8pm, Monday to Sunday inclusive.
2. Telephone Communication (199 contacts logged on Datix plus 571 contacts
not logged)
The service continued to receive a high volume of calls in the first two months of the
quarter from patients experiencing severe difficulties in contacting the hospital with
regards to appointment bookings and general enquiries. Patients report that they have
been trying to contact services at KMH and Newark for a number of days or weeks.
During December the number of enquiries significantly decreased following changes to
working practices and increase in staffing in the appointments office.
SB - CoG January 2013 - Q3 Quarterly Quality Report
Predicted
Main Activities For Quarter 4
1.
Develop a customer services helpline operational policy in partnership with
the operational teams for future use.
2 & 3. Continue to support the operational teams to improve our patient
administrative service by providing timely patient experience feedback to
assist with service improvements.
4.
Ensure reporting feedback is received from divisional teams where lost
property issues have been identified and to support service improvement
initiatives in these areas.
Risks and Issues
1. Breast Services / Pathology ER Results
a. Following evaluation of the recent helpline we require an operational policy and
telephony technology to enable improvements for future use of in-house helplines.
Mitigation: An operational policy is currently being developed
2. Telephone Communication
a. Poor customer service resulting in loss of business and poor reputation.
b. The Customer Services team are failing to deliver their key service areas –
PALS concerns, Charitable Funds, Voluntary Sector and Patient Experience whilst
handling excessive volume of calls.
c. Increase in DNA rate as patients are unable to advise us of their availability and
problems.
d. Increase in Complaints.
e. Increase in demand for compensation for loss of earnings and out of pocket
expenses.
Mitigation: The ABC team are supporting the Patient Services Manager to
review and implement service changes to improve delivery
3. Missing Case Notes
a. Poor patient experience and impact on patient care
b. Damage to reputation and loss of business
c. Increase in Complaints.
4
3. Missing Case Notes
22 patients have reported to PALS that they have attended both hospitals for
appointments and have been informed their case notes are either missing or have not
arrived in time for their appointments. A significant increase in the Trust’s Datix entries
in Q3 relating to missing case notes and documentation from the case notes is evident
and supports the PALS intelligence.
4. Patients Missing Property
21 patients or their carers have reported the loss of property whilst receiving inpatient
care resulting in unnecessary upset to the patient, financial claims and poor use of
time for PALS team searching for items.
Mitigation: The Patient Services Manager has identified extra note storage
facilities to address the lack of storage capacity and awaits final approval for the
release of funds.
4. Patients Missing Property
a. Increased patient anxiety and distress.
b. Financial loss.
Mitigation: A new sealable bag for property has been ordered for use across the
Trust. This will give staff a designated bag for property and should improve the
situation.
Lead : Tracey Brassington, Customer Services Manager
SB - CoG January 2013 - Q3 Quarterly Quality Report
5
Quarterly Quality Report
Date period : Quarter 3
- Patient Experience
-
Staff Experience
Q3 RAG
October – December 2012
Q4 RAG
Predicted
Aims / Objectives for 2012/13:
Review and improve recruitment and selection process developing key quality indicators.
Work with divisions and corporate services to ensure that the appraisal process is integrated and aligned to strategic objectives and priorities and performance improves
to 79%.
o Implement the health and wellbeing action plan and stress and mental health strategy to support; managers and staff, to achieve a reduction in sickness
absence.
o Incorporate the principles and delivery of effective change management in leadership and management development programmes. Ensure all management
involved in implementing change management have received appropriate development and support.
o Embed the Trust’s Equality objectives.
o Improve Staff Survey results and staff engagement.
o Continue the implementation of the leadership and management development programme which seeks to embed core behaviours into management practice.
Key Aims for Q3
Continue to increase the number of staff who have received an appraisal and secure
improved levels of performance and productivity.
Review the new appraisal documentation following the pilot in 4 work areas and if
appropriate agree and commence roll-out plan.
Continue to roll-out the Stress Education Programme to managers and extend by
delivering to teams within work areas.
Implement the Staff Survey Action Plan and Communication Plan and facilitate
delivery of the 2012 Staff Survey questionnaires.
Implement the Sickness Absence Action Plan.
Training, Education & Development, will deliver training to support managers in
managing change.
The Leadership and Management Development Programme will be delivered to
further cohorts.
SB - CoG January 2013 - Q3 Quarterly Quality Report
Progress against Quarter 3 Key Aims
Appraisal pilot completed and evaluated. Feedback has been incorporated`
into the new appraisal framework launched in October 2012.
The Director of Operations and the Deputy Director of Human Resources
met with managers to identify issues influencing the effective management
of sickness absence and the appraisal rate, a number of actions have been
implemented as a result of these meetings.
In order to support the wider staff well being agenda – a Health & Wellbeing
event (39 stands) for staff was held in the KTC at King’s Mill Hospital.
The Stress Education Programme continues to be rolled-out to managers
and work areas and continues to receive positive feedback.
Training, Education and Development (TED) continue to deliver training to
support managers including:
th
1. Leadership & Management training programme (5 cohort being
pulled together)
2. Managing sickness absence
3. Effective Occupational Health Referral/Reporting
4. Managing Change.
TED training for managers makes reference to the Trust’s Stress & Mental
Health Strategy in order to embed this and help managers recognise the
signs of stress and better manage/ offer support as appropriate within their
work area.
To mark National Stress Awareness Day in November 2012, the Staff Health
& Wellbeing Group sent a ‘Tips for Managing Stress’ poster out to all work
areas.
The Sickness Absence Action Plan was developed and implementation of
6
Key Aims for Q4
Continue to embed the new appraisal framework to increase the number of staff
appraised to achieve the 79% target and secure improved levels of performance and
productivity.
Continue to roll-out the Stress Education Programme to managers and work areas.
Improve staff resilience to health related issues, particularly with regard to stress and
mental health in order to support a reduction in sickness absence.
Training, Education and Development, to continue to deliver training to support
managers in managing change and sickness absence.
Review the Sickness Absence Action Plan and consult with relevant stakeholders to
identify actions to support a reduction in sickness absence.
Commence analysis of the Trust’s raw 2012 NHS Staff Survey results against those
for 2011 to identify trends/changes.
Ongoing review of HR Recruitment & Selection with relevant stakeholders, including
evaluation of the new electronic welcome packs for Agenda for Change and Medical
Staff.
Delivery of specialist clinical holding and disengagement training for staff working in
identified high risk areas.
Risks
Low staff morale and disengagement.
Increased stress and/or sickness absence due to workforce change, winter
pressures and broader economic climate issues.
actions continue in order to facilitate a reduction in sickness absence.
The Staff Flu Vaccination Programme successfully vaccinated 51.2% of
frontline 40% of non-clinical staff.
On 12 October 2012 the Trust’s Equality Workshop saw representatives
from various staff groups actively involved in discussing and scoring the
Trust’s progress towards implementing its Equality Objectives. The Health &
Wellbeing event on 17 October provided a further opportunity to promote,
discuss and allow staff to score the progress in implementing the Equality
Objectives.
Progress in implementing the Staff Survey Action Plan and Communication
Plan continued throughout quarter 3, culminating in a 50% response rate for
the 2012 NHS Staff Survey.
The HR Advisors received additional training to better support managers in
order to facilitate improved management of workforce change and sickness
absence.
Actions to Deliver Quarter 4 Key Aims
Appraisal Action Plan to facilitate increased appraisal rates.
Managers to focus on meeting with staff who have attendance issues and
resolving matters.
Review of the Sickness Absence Action Plan.
Strengthening the team of HR Advisors to provide support to managers to
enable improved management of workforce change and sickness absence.
Continue to deliver the Leadership and Management Development
Programme.
Continue to deliver the Stress & Mental Health Strategy and the Stress
Education Programme to increase manager awareness and confidence in
recognising and supporting staff in their work area.
Staff health awareness to be supported through health promotion activity
(the Health & Wellbeing section of the Trust’s intranet and a calendar of
topics/events) to encourage healthy lifestyle choices.
Controls and Mitigation
Sickness Absence Action Plan.
Increased training and support for HR Advisors and managers to enable
improved management of workforce change and sickness absence.
Flu immunisation programme.
Lead: Anne Burton, Staff Support & Benefits Co-ordinator and Karen Fisher, Executive Director of Human Resources
SB - CoG January 2013 - Q3 Quarterly Quality Report
7
Quarterly Quality Report
Date period : Quarter 3
-
Patient Experience -
Food Quality
Q3 RAG
October – December 2012
Q4 RAG
Predicted
Aims / Objectives for 2012/13:
To deliver a high quality catering service that meets the Nutritional needs of all patients as well as offering sufficient variety to suit different tastes and preferences. This is
measured during annual PEAT and mini PEAT audits, as well as an ongoing programme of ward catering audits.
Key Aims for Q3
Implement Ward Hostess Role and Steamplicity individual plated meal system
to Newark Wards.
Undertake mini PEAT audits at all 3 sites to demonstrate ongoing high level of
satisfaction with food service standard.
Key Aims for Q4
Review the current catering service provision in line with the new standards set
out for hospital food as announced by Health Secretary, Jeremy Hunt, on
15/10/12. This set of basic principles covering the quality of food, nutritional
content and choice for patients, will be backed by new inspections led by
patients to be introduced in 2013.
Demonstrate compliance with CQC outcome 5-meeting nutritional needs.
Risks
No risks for this quarter identified.
Progress against Quarter 3 Key Aims
Hostess service introduced at ward level at Newark Hospital along with
Steamplicity catering service. New menu also launched at King’s Mill and
Mansfield sites to include jacket potatoes following customer feedback.
Mini PEAT audits took place between October & December 2012, demonstrating a
high level of patient satisfaction with the food service.
Enhanced contingency arrangements were put in place to ensure 3 day stock of
st
meals available on site, following an issue identified on 31 December where
limited hot meal choices were available temporarily.
Actions to Deliver Quarter 4 Key Aims
Review the current patient food provision with the Dietician and Nutritional link
nurse to ensure that compliance with the new standards is achieved.
Continue to undertake CQC Nutritional compliance audits in relation to Outcome 5
and undertake any remedial actions where non-compliances are identified.
Undertake National Patient Environment Audits on all sites in February and
demonstrate that the previous “excellent” score is being maintained. Validated
PEAT scores will not be available until mid-2013.
For information, official PEAT audits are being replaced this year with new PLACE
audits (Patient Led Assessments of the Care Environment). The Trust will be
notified of further details in due course.
Controls and Mitigation
Lead: Liz Nicholas, FM Services Manager
SB - CoG January 2013 - Q3 Quarterly Quality Report
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Quarterly Quality Report Date period : Quarter 3
Patient Experience
-
Cleanliness
Q3 RAG
October – December 2012
Q4 RAG
Predicted
Aims / Objectives for 2012/13:
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. This benchmark is viewed as a performance parameter for the cleaning services as provided by Medirest and this is validated
through monitoring of the service by the Trust and jointly with Project Co.
Key Aims for Q3
The integration of the ’15 steps’ into the auditing methodology by Medirest. The
audit tool is being developed for use by Domestic Supervisors and will form part
of their ongoing monitoring.
Review of the hydrogen peroxide fogging protocol.
Ongoing schedule for monitoring cleanliness standards across all areas.
Progress against Quarter 3 Key Aims
Medirest have developed an audit methodology based on the 15 steps, which
covers cleanliness as well as other services on the audit. The audits will be
further developed over the coming months for staff engagement. The results of
the audits will be presented within the monthly performance report, and shared
to allow inclusion in the CQC newsletter.
Initial review of hydrogen peroxide protocol has been undertaken in conjunction
with infection control.
Joint monitoring between the Trust and the Project partners has been
undertaken monthly on all three Trust sites.
Key Aims for Q4
Review of RAG rating for individual clean requests with infection control,
Medirest, CNH and Commercial Services.
Actions to Deliver Quarter 4 Key Aims
This is to remove the ambiguity for Trust and Medirest staff in relation to what
type of clean is required for each clinical need. The inclusion of hydrogen
peroxide fogging within this process will lead to further development of the
hydrogen peroxide fogging protocol.
PEAT auditing across the three sites
Hydrogen peroxide fogging equipment to be reviewed.
Dates to be reviewed.
Further investigation into other companies providing hydrogen peroxide fogging
equipment with a faster cycle to reduce impact on capacity, will be undertaken
with Infection Control and the Project partners. A cost versus capacity report to
be provided.
Risks
No risks identified in this quarter
Controls and Mitigation
Lead: Julie Horrobin, FM Performance and Quality Manager
SB - CoG January 2013 - Q3 Quarterly Quality Report
9
Quarterly Quality Report - Patient Safety
-
Serious Untoward Incidents / Never Events / Incidents
Q3 RAG
Date period : Quarter 3 October – December 2012
Q4 RAG
Predicted
Key Objective for 2012/13: To reduce serious incidents resulting in harm (including never events)
Key Aims for Q3
Progress against Quarter 3 Key Aims
Update on Key Aims from Quarter 3
Reinforce the importance of reporting all types
of incidents and how this is proven to improve
overall patient safety.
To monitor investigations of Serious Incidents
and close outstanding incidents within the
deadlines. The Trust is under intense scrutiny
from the CCG and SHA on this.
To share lessons learned and ensure robust
action plans are implemented and monitored
within the Trust and divisional governance
structures.
1. An ‘icare2’ communication about never events was sent out in December 2012 to help to heighten awareness of
the need to report. Internal Assurance Team visits in progress to reinforce importance of incident reporting.
2. A focused drive to close all overdue incidents was successful within Q3. All SI’s were closed within the timescale of
45/60 days, apart from 2 requiring complex investigation and extensions have been agreed by the CCG.
3. Trust and divisional governance structures/meetings are currently being reviewed to enable more robust sharing of
lessons learnt.
4. The SHA incident reporting policy has been discussed with commissioners via the Quality & Scrutiny meetings and
further work is needed to amend the policy to reflect our desired internal working practices.
5. Further work on RCA training will be carried out during Quarter 4 (as below)
6. The need to undertake the Manchester Safety Framework audit has been identified as key to our patient safety
strategy and timescales for completing this will be defined in Quarter 4.
Quarterly Performance Update:
To complete the review of the incident
reporting policy with the update Serious
Incident policy from NHS Midlands and East.
To arrange investigation and Root Cause
Analysis (RCA) training to key individuals who
are requested to undertake RCA
investigations. The ward leaders will be a
specific target group.
To undertake the Manchester Safety
Framework audit to measure where we are as
a Trust on the safety culture matrix.
Zero Never Events reported for this quarter. In October 2012 there was a media release from the DH suggesting
that more transparency on ‘never events’ was needed to drive up NHS safety. Sir Bruce Keogh stated that NHS
leaders should examine the figures and the guidance to focus on driving never events out of the NHS. There have
been no never events reported in the Trust for 377days (22/11/2011).
Serious Incidents reported on STEIS this quarter Q3 12/13 was 31 compared to 28 for Q3 11/12 and 20 reported
on STEIS for Q2 12/13. In December an additional SI was reported retrospectively from June 12. The dashboard
has been amended accordingly.
In Quarter 3 there were 2426 incidents compared to 2044 the previous quarter with Falls, Pressure Ulcers and
Medication, continuing to be the top 3 sub-categories.
Of the 31 Serious Incidents, 23 remain ‘Open’ and 2 are past the reporting deadline compared with 21 past the
deadline in Q 2. This is a key achievement for Quarter 3.
The numbers of long dated open incidents has shown a continued improvement over this quarter, reducing from
565 in Q2/12/13 down to 422 at time of writing this report.
Falls:
Patient falls increased in number during quarter 3 to 514 compared to 442 Q2/12/13. However, the trend is still
downward when taking into account increased occupied bed days.
SB - CoG January 2013 - Q3 Quarterly Quality Report
10
Hospital Acquired Pressure Ulcers:
74 Hospital acquired pressure ulcers in Q3 12/13 compared to 71 in Q2 12/13.
11 grade 3 and 1 grade 4 Hospital Acquired Pressure Ulcers (HAPU) reported for Q3 12/13.
Looking at last 5 quarters and taking into account occupied bed days the trend continues to be downwards overall.
Medication:
247 Medication related incidents this quarter compared to 250 for Q2.
Emergency Admissions Unit (EAU) having the highest numbers of incidents.
Harm to Patients:
Incidents reported on Datix coded for ‘Severity of Harm’ including ‘Low’, ‘Moderate’, Severe’ & ‘Catastrophic’
demonstrates there is a clear downward trend in patient harm at this Trust.
Key Aims for Q4
To continue to be a high reporting Trust.
To continue to monitor and close the SI
reports within the target response time.
To continue to work on monitoring and closing
open lower level incidents within the
timescales.
Risks
Controls and Mitigation
Serious Incident investigations are not
standardised or consistently robust due to
training not being available.
Lead:
To complete the review of the incident reporting policy with the update Serious Incident policy from NHS Midlands
and East.
To arrange investigation and Root Cause Analysis (RCA) training to key individuals who are requested to
undertake RCA investigations. The ward leaders will be a specific target group.
A process has been put in place to continue to drive the closure of reported incidents within the target timescale.
To plan an initial Patient Safety Improvement Study Day to senior clinicians to raise awareness and initiate a series
of training sessions and improvement projects.
To advertise a Trust Patient Safety Lead post to drive the patient safety strategy with the Associate Director for
Patient Safety.
To undertake the Manchester Safety Framework audit to measure where we are as a trust on the safety culture
matrix.
A Route Cause Analysis and investigation training programme is currently being developed jointly between the
Governance and Training and Education Departments. The aim is to introduce this within the next 3-6 months.
Ward leader development day in March 2013 will focus upon raising the profile of quality and safety and instilling
tools for undertaking effective investigations.
3 key aims repeated from quarter 3 as not completed due to time constraints and are repeated in qtr 4
Lesley White, Patient Safety Manager
SB - CoG January 2013 - Q3 Quarterly Quality Report
11
Quarterly Quality Report -
Patient Safety
-
Care of the Acutely Ill Adult Patient
Q3
Date period : Quarter 3 October – December 2012
Q4
Predicted
Aims / Objectives for 2012/13:
To improve compliance with physiological track and trigger scoring in order to identify patients early in the course of their deterioration, obtain help and appropriate treatment
sooner and help to prevent further decline.
Key Aims for Q3
To improve overall compliance with documentation of :
All 6 mandatory vital signs every 12 hours as a minimum – This
will change to 4 hourly in the next quarter.
Monitoring plans to be recorded in all patients notes.
To raise the profile of physiological track and trigger scoring and
continue to increase compliance with the Rapid Response
Systems currently in operation at the Trust. The outcome of this
will be to increase vigilance around the deteriorating, acutely ill
patient potentially enhancing patient safety.
Progress against Quarter 3 Key Aims
Overall compliance with all elements of the Observation and ACAT audit for all wards was 88%.
This represents deterioration in compliance from last quarter. Compliance varies from month to
month and across the different divisions. Work is not consistently bad or good.
AIMS national training for all members of the multi-disciplinary team continues (and now includes
Healthcare Support Workers).
Completion of Plan, Do, Study, Act (PDSA) projects on ward 21 where all Healthcare support
workers now complete observations and the ACAT score. This has not, as yet, demonstrated an
improvement in the Nursing Metrics scores but continues to be monitored.
Key Aims for Q4
Implementation of National Early Warning Score in February
2013 with standardised observation chart
Actions to Deliver Quarter 4 Key Aims
Commence implementation of the National Early Warning Scoring System on an incremental
basis across the Trust. This will help to re-engage staff with the rapid response system and the
training required will re-energise teams in this very vital area of practice.
Existing data already collected on calls to Critical Care Outreach Team, unexpected admissions
to Intensive Care Unit and cardiac arrest calls will be used to monitor the organisational effects of
the new score and subsequently review potential resources required to maintain our Rapid
Response System
Review metrics data for compliance with observations and the track and trigger tool in Q3 and
repeat the ‘deep dive’ audit in Q4.
To re-write the observations and physiological track and trigger score policy to allow for
implementation of NEWS and share this widely.
To increase baseline observation frequency to 4 hourly from
12hrly.
Expansion of healthcare support worker role to include all
observations and early warning score recording across the
trust.
Risks
Members of the multi-disciplinary team do not comply with the
observation and ACAT/NEWS policy
Increased sensitivity of NEWS score will increase the number of
calls to the outreach team and this will need to be managed.
Lead:
Controls and Mitigation
A number of audits are currently in place to identify when this does not happen, e.g. Global Trigger
Tool audits across the Trust and in Intensive Care through which ‘missed opportunities’ are fed back
to the teams concerned for further investigation and training.
This will be monitored following the introduction of NEWS in February 2013 and as a contingency a
business case is being prepared in case Outreach team require additional resources to facilitate an
appropriate level of response. New ways of working are being reviewed also.
Michele Platt, Nurse Consultant / Lecturer Critical Care
SB - CoG January 2013 - Q3 Quarterly Quality Report
12
Quarterly Quality Report Date period : Quarter 3
Patient Safety
-
Maternity Care including Midwife to Birth Ratio
Q3 RAG
October to December 2012
Q4 RAG
Predicted
Aims / Objectives for 2012/13:
Work with regional colleagues on a maternity workforce tool and monitoring.
Work with regional colleagues to establish a maternity network.
Maintain midwife to birth ratios and proactively monitor local outcomes.
Key Aims for Q3
Progress against Quarter 3 Key Aims
Monitor Caesarean Section rates
We have seen a sustained improvement in caesarean section rates during this quarter. Current
rate 17.65%. One incident suggested that the culture on labour ward needs reviewing regarding
Review Induction of Labour rates
Midwife to Birth Ratio at 1:28
expectation to achieve vaginal births and work is being done around this.
Reduce Smoking during pregnancy rates
Induction of labour rates continue to be a challenge and individual practice is being reviewed.
Monitor women’s experience of the service and their perception of
Significant work is being undertaken using aromatherapy to support low risk inductions.
Current midwife to birth ratio is 1:33, with 882 births in the quarter.
1:1 care in labour
Smoking at time of delivery audit completed and has been well received by staff. The results are
th
expected any time soon and will be reviewed at the working group on 18 January 2013.
100% of women who completed the form within the audit period felt that there was a Midwife
available to them, once they were in labour, when they wanted one. This was on a 53%
completion rate. The intention is to change the audit process to increase compliance and
participate in the net promoter work.
Key Aims for Q4
Monitor Caesarean Section rates
Reduce Induction of labour rates
Improve Midwife to Birth Ratio
Recruit to current posts
Participate in the first meeting of the maternity network
Risks
A concern remains with the administration of midwifery led
referrals, following the reconfiguration of Patient Pathway
coordinator role. There is also a storage issue and insufficient
preparation of notes prior to admission.
Recent recruitment has had poor responses.
Changes to reporting requirements will see an increase in the
number of STEIS submitted from the maternity department. All
parties aware of reporting changes.
Lead: Alison Whitham, Head of Midwifery
SB - CoG January 2013 - Q3 Quarterly Quality Report
Actions to Deliver Quarter Key Aims
Continue to progress the work described above.
Still awaiting formal feedback from the service reviews and proposed staffing options to meet the
gaps identified. A staffing plan that addressed any gaps highlighted by benchmarking exercise
will be developed during Quarter 4.
Andrew May is leading to identify a trust-wide notes accommodation solution.
Review recruitment materials, the regional position and continue to monitor on current
recruitment.
Continue to monitor to assess level of risk, and respond within the required time frames.
13
Quarterly Quality Report
-
Patient Safety
-
Date period : Quarter 3
October - December 2012
Slips, Trips and Falls
Q3
Q4
Predicted
Key Objectives for 2012 / 2013:
1. To reduce the number of falls related incidents.
2. To reduce the number of harmful falls on a background of possible increased reporting.
3. To provide training for employees about falls prevention.
4. To integrate the Trust falls service into community falls service.
Key Aims for Q3
A. To ensure Trust wide protocols and guidelines are updated and in line with national
guidance.
Review and update falls policy and bed rail policy
Review and update nursing documentation (falls risk assessment, falls care
plan, post fall management plan)
B. To ensure appropriate process and allocation of resources (i.e. one to one
observation, equipment) is available and accurately allocated for the management of
patients with temporary and permanent cognitive impairment.
One to one/Zone observation assessment process
Zero tolerance for nonclinical transfers of older people after 10pm.
Foot wear project
Bed sensor usage to be reviewed
C. Data collection
To continue to collect falls per 1000 occupied bed days in line with NPSA
recommended practice.
To identify areas for improvement by Datix data analysis and review of serious
incidents related to in-patient falls
Progress against Quarter 3 Key Aims
A1. Falls policy and bed rail policy reviewed and submitted for consultation.
Achieved.
A2. Work in progress to change the falls risk assessment and care plan. Achieved.
B.1. Working group nominated/ review of resources allocation undertaken/feed
back and discussions due at the next Falls steering group meeting January 2013.
Ongoing.
B.2. The group suggests this is a CQUIN for 2013
B.3. Safer footwear pilot is under way – reporting April 2013
B.4. Bed sensor pilot to be revisited in Q4.
C. Data collection is ongoing. Noted downward trends on ward 52 and 41. Both
areas asked to provide a report with insight into any interventions on those wards
to reduce falls.
D. here is work to be done about how lessons are shared from a number of
groups and likely to be addressed through the safety thermometer work.
D. Ongoing RCAs for serious falls done through the serious falls group and learning
from these to be shared cross divisionally and via nursing/governance forums.
Key Aims for Q4
Continue to reduce the number of patient falls resulting in harm
To identify areas for improvement by Datix data analysis and review of serious
incidents related to in-patient falls
To ensure appropriate training for all categories of staff
Pilot the ‘reducing patient harms team’ across medicine and surgery wards
Risks
Failure to identify patients at risk and appropriately manage various individual risk
factors
Failure to follow policy appropriately
SB - CoG January 2013 - Q3 Quarterly Quality Report
Actions to Deliver Quarter 4 Key Aims
Continue and complete Q3 documentation and policy work regarding post fall
management plan. Pilot to commence utilising a post fall protocol sticker.
Bed sensor pilot to be about to commence in Q4.
Training needs analysis
Training PP/sessions
Implement a PDSA pilot of a reducing harms team, funded by transformational
monies. The impact of this pilot will be assessed against quality measures.
Controls and Mitigation
The Lead clinician and Executive Nurse are currently developing a falls action
plan which will identify the key priorities and work plan for 2013. This is being
done alongside the development of a falls CQUIN for 13/14.
14
Inappropriate resource allocation –e.g. additional support for patients needing
additional supervision
Inconsistent medical management of patients at risk of falling
Lack of dedicated Falls Nurse Specialist time
Lead:
A procedure for the enhanced support of patients is currently under
development.
Dr A-L Schokker, Consultant Geriatrician
SB - CoG January 2013 - Q3 Quarterly Quality Report
15
Quarterly Quality Report –
Date period : Quarter 3
Patient Safety
-
Infection Prevention and Control (IPC)
Q3 RAG
October – December 2012
Q4 RAG
Predicted
Aims / Objectives for 2012/13:
To maintain surveillance and infection prevention and control targets:
o MRSA bacteraemia: trajectory 0
o C. difficile infection: trajectory 36
o MSSA bacteraemia: no national set trajectory
o E.coli bacteraemia: no national set trajectory
Review of all IPC policies and guidelines before the end of Q4 in line with the Infection Prevention and Control Team (IPCT) programme
Key Aims for Q3
To remain within the MRSA bacteraemia trajectory for Q3
To remain within the C. difficile infection trajectory for Q3
To achieve < 5 MSSA bacteraemia for Q3
To achieve < 5 E.coil bacteraemia
To achieve < 1 catheter associated bacteraemia for Q3
Review the RCA’s for bacteraemia
Include Group A strep surveillance for maternity unit
Development of SSI surveillance tool/database
Undertake a Clinell trial
Perform the risk assessment/risk plans for Infection Prevention & Control Team
(IPCT)
To continue the Outcome Guardian visits and put actions in place to address the key
themes that have already been identified
Key Aims for Q4
To remain within trajectory for surveillance
To investigate Q3 raise in MSSA Bacteraemia and E Coli Bacteraemia and report to
Infection Control Committee
To develop audit tools to be ‘form’ based – electronically completed, database
To review remaining IPC policies
To review IPC nursing care plans
To manage norovirus outbreaks, aim for mean averaged duration of 10 days
To develop IPC dashboard for divisions – to feed back results at the IPCC
SB - CoG January 2013 - Q3 Quarterly Quality Report
Progress against Quarter 3 Key Aims
To date there has been zero cases of MRSA bacteraemia (1021 days)
To date there has been 17 cases of hospital acquired C. difficile. We are
within year to end trajectory and quarterly trajectory
To date there has been 10 cases of hospital acquired MSSA bacteraemia, of
which 6 of these were acquired in Q3
To date there has 43 cases of hospital acquired E.coli bacteraemia, of
which 19 of these were acquired in Q3
There has been no hospital acquired catheter associated bacteraemias
RCA tool is in first draft and sent for consultation. Nottinghamshire
Commissioners have requested a copy of the RCA tool used by the Trust for
C.difficile RCA investigations as an example of good practice.
Group A strep surveillance implemented to cover all aspect of the Trust
Surveillance tool is in first draft, awaiting confirmation from the HPA to
potential increase of mandatory surveillance from April 2013
Clinell trial was extended and finial review/report to be provided next Qtr
Health and Safety risk assessment for IPCT completed, actions taken to
remove risk, where this was not possible actions implemented to reduce risk
Due to recent norovirus outbreaks (9 this quarter ) the outcome guardian
visits have been temporarily postponed
Actions to Deliver Quarter 4 Key Aims
Maintain target surveillance as previous quarters
Development of audit forms – available from the intranet
Continue to review policies and circulate for consultant
Development of a IPC dashboard
Work with FM and Medirest in the development of a RAG cleaning scheme
Work with FM in reviewing hydrogen peroxide decontamination
Discussions with CCG regarding 13/14 trajectory
16
To develop RAG cleaning scheme – to standardise cleaning levels
Review Hydrogen Peroxide decontamination system
Risks
ICNet Version 5
This tool was installed in 2008. It is the IT software used by the IPCT to monitor active
infections and target surveillance. The system has never been updated, and it has now
reached a critical point. The system is limited and in the event that the system should fail
it will not be possible for it to be repaired. ICNet NG: is the latest version of ICNet, it has
the capability to receive data from various hospital systems already in place, in real time.
By having an up to date system with additional availability will reduce the administration
time for the IPCT, allowing more time for them to focus on delivering IPC at the point of
care, thereby improving infection prevention practices.
Controls and Mitigation
The ICNet demonstration took place in November 2012. At present ICNet is in
discussion with the Trust and Pathology IT personnel to establish if the new
version of ICNet is compatible with the software already in use within the
laboratory. Suzanne Morris is in the process of completing a risk assessment
and placing the risk on the Trust Risk Register.
Lead: Suzanne Morris, Nurse Consultant Infection Prevention and Control
SB - CoG January 2013 - Q3 Quarterly Quality Report
17
Quarterly Quality Report
Date period : Quarter 3
-
Patient Safety
-
Nutrition
Q3 RAG
October - December 2012
Q4 RAG
Predicted
Aims / Objectives for 2012/13:
To provide a high standard of nutritional care to patients within the Trust:
All adult inpatients to be screened for the risk of malnutrition within 24 hours of admission to the ward, re-assessed appropriately and action taken.
Raise staff awareness on the importance of embedding protected mealtimes and effective nutritional care planning into the ward culture.
Reduction of central line infections in relation to parenteral nutrition
Key Aims for Q3
To ensure correct completion and calculation of Malnutrition Universal
Screen Tool (MUST) scores
Implementation of MUST e-learning programme.
Geriatric wards to drive protected mealtimes.
Meet with nutrition board and parenteral and enteral sub group to review all
aspects of nutritional care.
Commence the drill down visits to wards as part of the Trusts Care Quality
Commission (CQC) implementation strategy (outcome 5, meeting nutritional
needs).
Central line audit commenced on all patients receiving Parenteral Nutrition.
SB - CoG January 2013 - Q3 Quarterly Quality Report
Progress against Quarter 3 Key Aims
Nursing metrics scores during Quarter 3 have shown some deterioration. Overall for the
quarter the Trust wide total against a number of nutrition metrics stands at 87%. At the
last Nutrition Board, members identified a number of key actions to address some of the
hotspots and issues identified. Some of these have been initiated during Q3 (below) and
further actions are highlighted within the aims for Quarter 4.
The MUST screening tool has been revised to ensure correct completion. This is
being incorporated into the new nursing risk assessment booklet.
On going analysis of MUST datix incidents and development and review of actions.
Ward metrics scores for nutrition have improved since the dip in August 2012, with
on average 87% of patients receiving a MUST assessment within 24 hrs of
admission. This requires further improvement
Nutrition scores on the nursing metrics are now being monitored by Nutritional Board
and any areas of concern identified.
Liaising with training and development and British Association Parenteral Enteral
Nutrition with regards to implementation of MUST e-learning programme.
Initial meeting with geriatric ward leaders regarding protected mealtimes. Mealtime
service audited. Awaiting results.
Relevant updates in nutritional care fed into Nutrition board and sub groups (e.g
National Patient Safety Agency (NPSA) alerts).
Drill down internal assurance visits undertaken in 3 areas and feedback given to
ward leaders.
th
A Trust Nutritional Day was held on 8 November 2012.
18
Key Aims for Q4
To develop the campaign to re-launch protected mealtimes.
To review the criteria for protected mealtimes
Strengthen the Nutrition Board meetings so the Trust action plan can be
driven with increased momentum
Continue to monitor correct completion of MUST screens
Undertake the Essence of Care benchmark scoring across the Trust during
February to assess quality of nutritional care
Risks
Patients at risk of malnutrition may not be identified
Completing and calculating of MUST scores may be sub- optimal
Non-adherence to protected mealtimes may compromise patient recovery.
Overall these factors are contributing to a deterioration in nutrition metrics
scores.
Actions to Deliver Quarter 4 Key Aims
Review results of initial protected mealtime audit. Identify examples of good practice
to share and disseminate with wards. Identify areas where improvement needed.
Continue to audit central lines in relation to Parenteral Nutrition
Continual audit of MUST through the Trust wide quality metrics project.
Analysis of datix incidents that identify issues relating to MUST
Plans are underway to organise quarterly Nutritional Days during 2013
Increase frequency of meetings and review membership, ensuring key links with
PEAT, outcome guardian visits and new Nursing Care Forum.
Controls and Mitigation
The nursing metrics are undertaken monthly and identify any areas of concern.
These are discussed with the ward leader and senior nurses to put actions in place.
Training on MUST tool will take place via registered nurse time outs and nursing
induction.
Specific actions to improve the nursing metrics scores highlighted above and a
separate Trust-wide action plan is being completed.
Lead: Angela Hill, Nutrition Nurse Specialist
SB - CoG January 2013 - Q3 Quarterly Quality Report
19
Quarterly Quality Report –
Date period : Quarter 3
Patient Safety
-
Pressure Ulcer Prevention (Tissue Viability)
Q3 RAG
October – December 2012
Q4 RAG
Predicted
Aims / Objectives for 2012/13:
To improve the prevention and management of pressure ulcers and achieve zero tolerance of avoidable pressure ulcers throughout 2013
Key Aims for Q3
Documentation – Updating SKINS chart, pressure area management guideline, 8
core care plans and initial assessment of pressure ulcer risk sites chart
Share learning from the Midlands and East Pressure Ulcer Prevention Collaborative
Programme
Undertake the Essence of Care Pressure Ulcer Benchmark Trust wide
Redesign the pressure ulcer audit tool to ensure the SKINS chart is captured
Conduct a static mattress audit to ensure mattresses comply with National
Standards and Trust infection control standards
Identify pressure ulcer prevention/management trends and themes via the RCA
process and those identified at the bed side when assessing patients
SKINS compliance audit on the pressure ulcer ambition pilot sites (5 Wards)
Continued targeting of all pressure damage with the Trust by the tissue viability team
Continue to report key pressure ulcer prevention/management trends and themes
through the icare2 site and directly to ward leaders
Key Aims for Q4
Develop a competency based training programme that relates to evidence based
pressure ulcer prevention and treatment
Review the nursing metrics questions on pressure ulcer care to align and reflect trust
guidance
Development of a new SKINS compliance audit tool and auditing to be undertaken in
other ward/clinical areas
To identify a patient representative to help raise awareness of pressure ulcer
prevention throughout the Trust
Monitor the tissue viability input to community hospitals
Risks
Inability to meet target of zero avoidable grade 2, 3 and 4 pressure ulcers during
2013
The tissue viability team have been without designated senior leadership for 6
months due to inability to recruit Consultant Nurse.
Increased levels of Emergency admissions
Increase in alerts from other providers regarding inherited pressure ulcers
Progress against Quarter 3 Key Aims
There has been an avoidable grade 4 pressure ulcer reported
Pressure area management guideline awaiting consultation and approval.
Remainder of documentation completed and approved
Initiatives from the ambition developed which have yet to be implemented
trust wide e.g. Safety Cross data Pressure Ulcer Prevention Posters
Pressure ulcer benchmark undertaken – overall score of 93%
Updated audit tool incorporating SKINS documentation is now being used
Trust-wide
Mattress audit completed and findings actioned
SKINS compliance audits completed and finding reported back to ward
leaders
Project group established to review incidences of pressure damage relating
to Plaster of Paris.
Actions to Deliver Quarter 4 Key Aims
Auditing compliance of the SKINS chart
Continued targeting of all pressure damage with the Trust by the tissue
viability team
Engaging patients/carers in pressure ulcer prevention
Embedding the culture of zero tolerance to pressure ulcers with the
introduction of competency based training
Support the implementation of ‘care rounding’
Complete the detailed investigation of the grade 4 pressure ulcer and initiate
a robust action plan which ensures shared learning
Controls and Mitigation
A clear action plan is being implemented and monitored via the Pressure
Ulcer Steering Group. National adviser visiting Trust during January 2013.
Nurse consultant recruited and due to start within next 3 months.
The team are looking at streamlining working practices to cope with the
increased level of admissions.
Lead: Sue Yates, Tissue Viability Nurse Specialist / Sandra Hopkinson, Head of Nursing
SB - CoG January 2013 - Q3 Quarterly Quality Report
20
Quarterly Quality Report
-
Clinical Effectiveness
-
PROMS
Status
Date period : Quarter 3, October-December 2012
Status
Quarterly Progress Report
Risks and Issues
The Sherwood Forest Hospitals NHS Foundation Trust PROMs performance for August
2012 is shown below.
Participation
Rate Hernia
Participation
Rate Hip
Participation
Rate Knee
Participation
Rate Vein
73%
132%
79%
37%
The PROMS 2012/2013 data is available via a new National reporting system. This will allow more
real-time reporting of performance. At present there is insufficient data nationally to report on
provisional data for 12/13 for all of the procedures.
2011/2012 Provisional England/SFHT PROMS data is shown in the tables below
Provider
ENGLAND
SFHT
Provider
ENGLAND
SFHT
Provider
ENGLAND
SFHT
All Procedures
- Total HES
Episodes
247,213
1,394
Groin Hernia Total HES
Episodes
70790
436
Hip
Replacement Total HES
Episodes
72344
355
Predicted
All Procedures
- Total Pre-Op
Qs
184,958
1,171
Groin Hernia Total Pre-Op
Qs
42884
350
Hip
Replacement Total Pre-Op
Qs
59595
289
SB - CoG January 2013 - Q3 Quarterly Quality Report
All Procedures
- Participation
Rate
74.80%
84.00%
Groin Hernia Participation
Rate
60.60%
80.30%
Hip
Replacement Participation
Rate
82.40%
81.40%
Groin
Hernia Total
Linked
31648
275
Hip
Replaceme
nt - Total
Linked
49536
201
Groin
Hernia Linkage
rate
73.80%
78.60%
Hip
Replaceme
nt - Linkage
rate
83.10%
69.60%
None identified this quarter
Main activities for next quarter
Continue to encourage and collate PROM related data for
submissions to HES.
A review of post-operative returns showed that patients are sent
the questionnaire’s by post by the PROMs company, 6 months
after surgery. The Trust needs to look at promoting the
completion of these during the patients pre-operative
assessment visit.
Continue to interrogate national database at provider and
consultant level to determine variance in participation rates.
Agree actions to improve returns as appropriate.
New questionnaire forms introduced in Oct 12 are now in use at
both King’s Mill and Newark hospitals.
A review of the Vein patient pathways and PROMs
communication is in progress.
21
Provider
ENGLAND
SFHT
Knee
Replacement Total HES
Episodes
77464
437
Knee
Replacement Total Pre-Op
Qs
69198
430
Knee
Replacement Participation
Rate
89.30%
98.40%
Knee
Replaceme
nt - Total
Linked
51884
288
Knee
Replaceme
nt - Linkage
rate
75.00%
67.00%
Provider
ENGLAND
SFHT
Varicose Vein
- Total HES
Episodes
26615
166
Varicose Vein
- Total Pre-Op
Qs
13281
102
Varicose Vein
- Participation
Rate
49.90%
61.40%
Varicose
Vein - Total
Linked
11055
90
Varicose
Vein Linkage
rate
83.20%
88.20%
Lead : Julie Jan, Deputy Divisional Director – Planned Care & Surgery
SB - CoG January 2013 - Q3 Quarterly Quality Report
22
Title : Quarterly Quality Report
Date period : Quarter 3
:
Clinical Effectiveness
-
Stroke Sentinel Audit
Q3 RAG
October – December 2012
Q4 RAG
Predicted
Aims / Objectives for 2012/13:
Ensure that SFH Hyperacute and Acute Stroke service remains commissioned
Establish 24/7 thrombolysis service
Key Aims for Q3
Develop cross-site working with Nottingham City Hospital to allow
progress towards 24/7 thrombolysis service.
Enhance nursing expertise to support telemedicine project establish 24/7 Band 6 cover in line with peer stroke services
throughout Region.
Relocation of Rehabilitation from ACH to KMH.
Establish 6/52, 6/12 and annual stroke F/U in accordance with
National Stroke Improvement Programme.
Progress against Quarter 3 Key Aims
Engagement with NUH has continued. Shadowing at KMH by NUH stroke physicians due for
w/c 14.01.13
Band 6 stroke nurse appointments in progress. Will have sufficient senior staff in place to
allow 24/7 cover by senior nurses for telemedicine by mid-January 2013.
Project management group in place to co-ordinate Rehabilitation move from ACH to KMH
but will not be in Quarter 4.
Stroke F/U visits with SFH stroke service being arranged for 6/52 and 6/12 (6/12 visits are a
“CQUIN” replacement for CCG reporting). Unclear how these visits are funded. Annual F/U is
responsibility of CCG but SFH could be well-placed to deliver.
Key Aims for Q4
Establish 24/7 thrombolysis rota KMH
Establish 7 day TIA service
Establish 7/7 therapy working
Relocate rehabilitation from ACH to KMH (see above)
Actions to Deliver Quarter 4 Key Aims
Need to secure availability of stroke physicians to staff rota.
TIA - Need to explore models for weekend carotid imaging. Doppler service unavailable
(unless “purchase” external private service). Need discussion with Imaging to explore MR
angiography for these patients
7/7 Therapy - Need update from therapy services. Rehabilitation move from ACH to KMH will
help deliver on this.
Controls and Mitigation
Ensure we continue to provide high quality service, as evidenced by our Sentinel KPI’s, East
Midlands “dashboard”, thrombolysis figures - all of these 3 show delivery of high quality
service.
Working with NUH to promote model of dual site Hyper-acute service rather than single site.
Meeting between CEOs with Stroke leads from SFH & NUH to clarify concerns and agree
joint response to SHA.
Continue work on consultant recruitment.
Risks
SHA stroke services review looking to have single Nottinghamshire
Hyperacute stroke service- based in Nottingham with SFH service
being changed to potentially a subsidiary service (yet to be defined).
Lead:
Dr Martin Cooper- Head of Service for Stroke
SB - CoG January 2013 - Q3 Quarterly Quality Report
23
CQUIN UPDATE 2012/13
This section gives an update on our CQUIN position for Q3. The commissioners have not signed off
the Q3 performance, hence the forecast RAG rating
CQUIN Opportunity for 2012/13
Planning Assumption
:
:
£4.548 million
£3.548 million (ie, will not achieve £1 million of possible payments)
Period
Planned payment for each Quarter
Actual Payment
Quarter 1
£1.137 million
£1.137 million
confirmed
Quarter 2
£1.137 million
£1.137 million
confirmed
Quarter 3
£1.137 million
£877k TBC
Quarter 4
£1.137 million
£574k forecast
Under-delivery
SB - CoG January 2013 - Q3 Quarterly Quality Report
24
:
£822.9k
Title : Quarterly Quality Report – CQUIN A) Improving Dementia Care B) Dementia Training
CQUIN Annual Value: £720k
Date period : Quarter 3 October – December 2012
Q2 Actual
Achieved
Q3 Forecast
CQUIN Target:
1. 95% of all emergency patients aged >75 years have been screened using dementia screening tool
2. 95% patients aged > 75 years who have been positively screened have had a dementia risk assessment undertaken
3. 100% patients aged > 75 years who are identified at risk have been referred for specialist diagnosis
4. 90% of all relevant staff are trained in Dementia Care & Mental Capacity Act every 2 years
Key Aims for Quarter 3
To achieve the targets as stated above
Re-invigorate dementia as a key agenda for clinicians and
wards
Continue programme of education and training
Raise awareness trust-wide
Investigate possibilities of IT for referral data (Orion question)
Progress against Quarter 3 Key Aims
The dementia CQUIN target for 12/13 posed a significant challenge from the outset and this has been
flagged since April 2012. The target set for SFH has a higher target set than the national CQUIN, with a
portion more income attached. The target of achieving 95% was not incremental and was expected
from Q1. During Q1, following discussions with commissioners, the CQUIN targets were altered and
the Trust has met the requirements for Quarter 1 and 2. The target for Q3 and Q4 carry a high risk of
delivery to the organisation, given the level of change to working practices and clinical engagement
required within a short timescale. A clear plan is being implemented to drive the improvements but
given the level of compliance required (95% for all patients over 75) there is a high risk. The financial
implication of this for Q3 and Q4 is £250k. The dementia training element is low risk and expected to
deliver £140k in Q3 & Q4.
The dementia strategy work has been accelerated during the last quarter, with the Lead Clinician for
Dementia and Dementia nurse driving the following actions:
Dementia awareness training of F1 and F2 doctors by Dementia Nurse.
Dementia Lead Nurse making daily visits to admission areas and wards.
Dementia Strategy Development Group in place with monthly meetings.
Trust representation on regional groups (Dementia Action Alliance, Dementia Strategic Initiative
Group, Dementia Workforce Development Group, NUH Dementia Steering Group).
Trust sign-up to the Dementia Action Alliance.
Review and ongoing redesign of Trust Dementia Pathway.
Development of patient information leaflets.
Early stages of funding bid for environmental changes to wards.
Existing dementia education programmes ongoing across Trust, with good feedback from
attendees.
Participation in development of regional and national training packages for all grades of staff.
Engagement with charities and carer support groups locally (currently sit on the Dementia Strategy
Development Group).
Incorporation of Dementia agenda in ‘Quality Metrics’ programme.
Ongoing data collection and national submission of data.
SB - CoG January 2013 - Q3 Quarterly Quality Report
25
Securing of funding to purchase activities equipment for people with dementia.
Changes to the electronic discharge system to ensure improved communication with primary care.
Employment’ of volunteers to befriend and support patients with dementia on inpatient wards.
Visits and reporting back from Trusts identified as providing best practice in dementia care.
st
st
Summary 1 October – 31 December.
Key Aims for Quarter 4
Increase dementia screening rates
Ensure dementia agenda is sustainably integrated into
practice and strategic Trust planning.
Review effectiveness of 2011/12 Dementia CQUIN plans
Formulate and negotiate 2013/14 Dementia CQUIN targets
Continue programme of education and training
Continue to raise awareness, Trust-wide
Actions to Deliver Quarter 4 Key Aims
Support data collection/ maintain vigilance
Maintain pressure on front-line clinicians re: dementia screening
Creative planning for 2013/14 dementia CQUIN
Develop practical steps for care of people with dementia
Push trust dementia strategy forward
Develop carer support survey tool
Submit bid from national funds to support improvements for dementia patients
Risks
Reliant on engagement of clinicians trust-wide
Current low percentage rate of completed assessments
Level of change involved
Labour intensiveness of data collection
Controls and Mitigation
Ongoing engagement of clinicians and ward staff
Dedicated nurse lead for dementia CQUIN
Support data clerks and ensure regular feedback of current processes (weekly reporting)
Lead: Dr Steve Rutter, Consultant Geriatrician & Adam Hayward, Practice Development Nurse – Dementia
SB - CoG January 2013 - Q3 Quarterly Quality Report
26
Title : Quarterly Quality Report – Failure to Rescue CQUIN
Annual CQUIN Value £511k
Date period : Quarter 3 October – December 2012
Q2 Rating
Achieved
Q3 Forecast
CQUIN Target :
To reduce avoidable cardiac arrests by 50% by Quarter 4
Key Aims for Quarter 3
Continue to collect data for “avoidable” cardiac arrests and feedback to wards &
Consultants.
Continue to review “avoidable” cardiac arrests, feedback to parent teams –
ensure response & chase up action plans.
Implementation of NEWS (National Early Warning Score) and development of
new observation charts.
Education – publicity & training on NEWS & escalation policy, training on fluids
PGD.
Re-write observations policy incorporating NEWS & NEWS escalation policy.
VitalPAC – consider introduction of electronic monitoring of observations.
Introduction of ceiling of therapy/treatment escalation plan document.
Link into other key groups in Trust – Sepsis, Acute Kidney Injury (AKI).
Key Aims for Quarter 4
Continue to collect data for “avoidable” cardiac arrests and feedback to wards &
Consultants.
Continue to review “avoidable” cardiac arrests, feedback to parent teams –
ensure response and chase up action plans.
Implementation of new observation chart incorporating NEWS on 12/02/13.
Increase staff training in recognition of the sick patient.
Re-write observations policy incorporating NEWS & NEWS escalation policy.
VitalPAC – consider introduction of electronic monitoring of observations.
Introduction of ceiling of therapy/treatment escalation plan document.
• Continue to link into other key groups in Trust – Sepsis, AKI.
Risks
Ability of CCOT to respond to increased volume of calls generated by adoption of
NEWS
Progress against Quarter 3 Key Aims
To date avoidable cardiac arrests have reduced by 52% during 2012.
Data has continued to be collected during Q3. Indicative data shows the
Q3 CQUIN has been achieved.
All “avoidable” cardiac arrests during Q3 have been reviewed by CQUIN
team and feedback sent to parent team Consultants.
Ongoing monthly AIM courses, including for HCAs continue.
Observation chart has been redesigned and launch date identified.
Publicity and training has commenced.
Observations policy currently under review.
Options for electronic monitoring are now being explored.
Format of the ceiling of therapy/treatment document is currently under
review.
Links with sepsis / AKI group ongoing.
Actions to Deliver Quarter 4 Key Aims
Roll out for new observation chart on 12/02/13.
Scope the impact on the Critical Care Outreach team (CCOT) in terms of
additional calls.
Additional AIM courses planned for both trained staff and HCAs during Q4.
The 2012/13 action plan will be reviewed at the Failure to Rescue project
group meeting & specific actions allocated.
Controls and Mitigation
Ongoing discussions about staffing levels with Trust management, ongoing
CCOT audit of calls
Lead : Dr Lisa Milligan, Consultant in Anaesthetics and Intensive Care Medicine
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Title : Improving the Experience of Patients with Learning Disabilities (LD)
Annual CQUIN Value £340k
Date period : Quarter 3 October – December 2012
Q2 Actual
Achieved
Q3 Forecast
CQUIN Targets for 2012/13:
To ensure a flagging system in place for identification of patients with Learning Disabilities
Patients with Learning Disabilities to have a mean length of stay (LOS) of no longer than patients without Learning Disabilities
Demonstrate involvement of users with learning disabilities and their carers in surveys
Report to the Learning Disabilities Partnership Board 6 monthly
Key Aims for Quarter 3
Ongoing audit of records to find out whether patients with Learning Disabilities
have a longer length of stay at SFHFT for any reason other than medical
instability and the reason for this.
To continue the learning disability steering group meetings quarterly.
To continue to raise awareness to staff of the flagging system to prevent any
patients not being recognised with a LD.
Progress against Quarter 3 Key Aims
The Learning Disabilities CQUIN targets have been met for Quarter 1 & 2.
Quarter 3 data is currently being collated regarding Length of Stay but the other 3
elements have been achieved.
Quarterly audits on LD patient Length of stay continue to inform the work
programme going forward and enable any issues to be identified and addressed.
Patient & Carer feedback – changes have been made to the questionnaires by the
LD steering group (in November 2012) to enable a full picture of the hospital stay
to be established. A template has been developed to show any emerging themes.
This will ensure that feedback is acted on by ward leaders/heads of departments
and changes can be implemented.
Key Aims for Quarter 4
To ensure Learning Disabilities patients are flagged up immediately on
admission to the Trust so that reasonable adjustments/care needs can be
met.
To engage LD patients and carers to ensure improvements are introduced
within the system.
Actions to Deliver Quarter 4 Key Aims
To provide a progress report on the CQUIN for Learning Disability Partnership
Board In March 2013 to outline the work we have been doing at the Trust.
Continue to audit Length of Stay for LD patients.
Continue to collect patient and carer experience feedback.
Continue to flag new patients to the electronic system.
Easy read volunteer project – getting feedback from patients.
Risks
Ensuring pathway for learning disabilities patients is consistently followed and
staff are adequately consulting with carers and relatives
Controls and Mitigation
Use of patient held hospital traffic light assessment to guide staff on individual
patient preferences.
Prompts for staff within the nursing documentation booklet.
Learning Disabilities training is provided at Induction within the mandatory booklet
and on vulnerable adults study days.
A collection of resources is available to staff on the intranet.
Lead: Claire Henley – Learning Disability Nurse Specialist
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Title : Quarterly Quality Report - Net Promoter Score (NPS)
ANNUAL CQUIN VALUE £340K
Date period : Quarter 3 October – December 2012
Q2 Actual
Achieved
Q3 Forecast
Aims / Objectives for 2012/13:
To establish a system to gain feedback from patients on whether they would recommend this service to friends and family
Maintain a Trust Net Promoter Score of 71 or above per month
Results for Quarter 3
Results:
October 76
November 83
December 88
Therefore the CQUIN has been achieved to date. The aims are constant with the last
quarter:
To increase awareness with the ward teams about their individual ward scores.
To ask ward leaders to produce action plans if their results are less than 75.
To ensure the reasons for not recommending us are captured on Datix to enable
feedback to the wards.
To increase ward staffs general awareness of care, dignity and compassion.
To ensure other teams visiting wards take action if they identify any areas of
concern.
Progress against Quarter 3 Key Aims
The raw results are fed back to the Ward Leaders and Heads of Nursing and
they have taken a great interest in them. They are:
discussing the results and implications at ward meetings
asking patients the question themselves and digging deeper to fully
understand the reasons for the scores
explaining to all staff the importance of enabling the patients to be able to
say they are highly likely to recommend our service
The Guardians of Care are surveying wards every week and will identify any
areas of concern and feed it back to the ward leaders on the same day.
The nursing metrics are carried out on the wards every month and will
identify any issues.
The results have improved over the past 3 months.
Key Aims for Quarter 4
Ensure monthly scores remain above 71.
Net promoter will be a national CQUIN for 13/14. To trial a new data collection
method ready for reporting in April 2013. New areas included will be the Emergency
Department, Emergency Assessment Unit and Maternity Ward. This will involve
national reporting via a central database.
There is discussion underway as to whether this question will be asked of staff in the
future.
Actions to Deliver Quarter 4 Key Aims
Director of Customer Experience to ensure the above actions are
maintained.
SHA conference calls are participated in every month to enable learning
from other organisations.
New methods of data collection to be introduced and roll out plan for 13/14
data collection method to be trialled.
The nursing metrics is being revised so that staff will be asked the question
in future months, prior to any national directive.
Risks
The way that the national scoring criterion is set up, there is a risk that if one person
chooses not to recommend us the overall score will be compromised.
Controls and Mitigation
The above actions are in place to ensure patients get a positive experience
and would recommend our service.
Lead: Sally Dore, Director of Customer Experience and Engagement
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Title : Quarterly Quality Report
-
Patient Experience Personal Needs
ANNUAL CQUIN VALUE £340K
Date period : Quarter 3 October-December
Q2 Actual
Achieved
Q3 Forecast
Aims / Objectives for 2012/13: For the composite score for all indicators to achieve 80% per quarter. Questions asked at discharge are:
1. Were you as involved as you wanted to be in decisions about your care and treatment?
2. Did you find someone to talk to about worries and fears?
3. Were you given enough privacy when discussing your condition or treatment?
4. Were you told about medication side effects to watch for went you went home?
5. Were you told who to contact if you were worried about your condition after you left hospital?
Key Aims for Quarter 3
Quarter 1 results = 97%
Quarter 2 results= 95%
Quarter 3 results= 96%
Progress against Quarter 3 Key Aims
The key aims are to maintain above the 80% target. Individual questions are assessed to
ensure they consistently achieve 80%
Key Aims for Quarter 4
To maintain 80% or above for the quarter.
All questions for quarter 3 have been consistently achieving above 80%.
Question 4 and 5 results were starting to tail off in quarter 2. The results
have been shared with pharmacy and they have introduced a card for every
patient in relation to question 4. They are going to ensure all pharmacists
and ward staff continue to distribute it to patients.
The results for these questions in quarter 3 have improved
Actions to Deliver Quarter 4 Key Aims
To share the monthly results with ward staff broken down by question and to
ask staff for ideas to improve the scores if they are tailing off.
Patient Experience Questions 2012/13
Overall number per question
100
90
80
70
60
Quarter1
50
40
Quarter 3
Quarter 2
Quarter 4
30
20
10
0
Question 1 Question 2 Question 3 Question 4 Question 5
Risks
There are no risks to the CQUIN target. Results are consistently high.
Controls and Mitigation
Lead: Sally Dore, Director of Customer Experience and Engagement
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Q2 Actual
Title : Quarterly Quality Report - Improving Choice at End of Life
Achieved
ANNUAL CQUIN VALUE £340K
Date period : Quarter 3 October- December 2012
Q3 Forecast
Aims / Objectives for 2012/13:
To improve the identification of patients in the last year of life and communication to Primary Care for those patients on the Liverpool Care Pathway.
Key Aims for Quarter 3
Continue to raise awareness of ward staff/medics in identifying patients
approaching End of Life.
Raise awareness of the multi-professional team in identifying patients
needs and planning care through the process of Advanced Care Planning.
Continue to work with Primary Care 24 re: notifying Primary Care of
patients approaching End of Life and the End of Life Care Register.
Continue to support ward staff to inform GP, within 24 hours of
commencement of the Liverpool Care Pathway.
Ongoing monthly audit to assess the compliance with the implementation
of the Liverpool Care Pathway.
Progress against Quarter 3 Key Aims
This CQUIN has been delivered for Q1 and Q2. This has been RAG rated as amber for
Q3, as indicative data is showing that part 1b of this target may not have been met but this
is yet to be confirmed. There was a significant increase in the number of referrals to the
End of Life Co-ordinator during December 2012 and also a change in personnel, which
may have contributed to the position. This issue has been resolved for Q4. The Board of
Directors is asked to note the moderate risk of non-delivery within Quarter 3 which would
have a financial implication of £85k.
Target 1a: Identification of patients in the last year of life.
Data shows 81 patients were placed on the End of Life register during October to
December 2012. In April 2012 this was zero so this shows a marked improvement.
Continue to use established referral process to primary care, for patients identified as
approaching their last year of life.
A process has been developed for the discharge team to refer all identified fast track
patients to the End of Life register.
Mandatory questions have been developed, as part of the discharge process to
become a mechanism for identifying patients approaching End of Life. This has been
delayed due to problems with the electronic data base. (ORION)
Target 1b: Primary Care notified of patients being placed on the Liverpool Care Pathway
within 24 hours.
77 patients were identified to the End of Life Co-ordinator and Integrated Discharge
st
Team as being commenced on the Liverpool Care Pathway between 1 October &
st
31 December 2012. Quarter 3 data is currently being collated to establish the % of
patients for whom we informed Primary Care.
Improvement in ward staff informing Primary Care and End of Life Care Co-ordinator,
within 24 hours of commencement of the Liverpool Care Pathway.
End of Life Care Co-ordinator continues to notify Primary Care within 24 hours of
patients commencing on the Liverpool Care Pathway.
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Key Aims for Quarter 4
Continue to work collaboratively with Primary Care 24 regarding notifying
Primary Care of patients approaching End of Life, in order to maintain the
End of Life register.
Continue to support ward staff to inform primary care, within 24 hours of
commencement of the Liverpool Care Pathway.
Ongoing monthly audit to assess the compliance with the implementation
of the Liverpool Care Pathway.
Produce a potential End of Life CQUIN for 2013/14 for discussion with
commissioners.
Risks
Actions to Deliver Quarter 4 Key Aims
Ongoing monthly audit to assess compliance with the implementation of the Liverpool
Care Pathway.
Continue to work with Primary Care 24 re: notifying primary care of patients
approaching End of Life.
Continue to work collaboratively with the Discharge Team with referrals to the End of
Life Care register.
Continue to support ward staff to refer all patients on the Liverpool Care Pathway to
Primary Care and End of Life Care Co-ordinator.
Establish discharge process to include questions surrounding identifying patients
approaching end of life.
Undertake a renewed communications drive to promote key messages around end of
life care to staff members, this includes clinicians and also support staff such as
receptionists.
Controls and Mitigation
Failure to notify primary care of all patients implemented on the Liverpool
Care Pathway.
Process and mechanism for effective communication with primary care,
and implementing the End of Life register.
Sustainability of new processes being introduced particularly due to
instability in End of Life Co-ordinator post.
Promote Primary Care 24 contact number (24 hour day / 7 day week)
Increase capability of staff to notify primary care of end of life patients, through training
(both practice based and via formal teaching sessions)
Review the End of Life Co-ordinator role and undertake a quality impact assessment
of the role going forward to identify the value to the organisation
Lead: Dr Mark Roberts, Consultant & Clinical Lead for End of Life Care
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Title : Quarterly Quality Report
Venous Thrombo-prophylaxis (VTE)
Annual CQUIN Value: £340k
Date period : Quarter 3 October – December 2012
Q2 Actual
Achieved
Q3 Forecast
Aims / Objectives for 2012/13:
To improve the assessment and treatment of patients with VTE
Key Aims for Quarter 3
To achieve 95% Compliance for VTE risk assessment. This is based on the monthly
compliance below.
To achieve 95% compliance in re-assessing patients if their condition changes
significantly i.e. taken to theatre/ITU/CCU – (still collecting data ).
To achieve 100% - patients requiring prophylaxis receive it in an appropriate and
timely manner.
Key Aims for Quarter 4
Increase in level of compliance needed to achieve is 95% for VTE Risk Assessment.
Undertake case reviews of hospital acquired thrombus to learn lessons.
th
Data collection clerk appointed – due start date January 7 2013.
Risks
CQUIN requirements not met resulting in a loss of payment
Patient safety issues if not Risk Assessed for VTE
Progress against Quarter 3 Key Aims
October - 95.00% achieved
November - 95.00% achieved
December – data collection currently in progress
To achieve 95% compliance in re-assessing patients their condition changes
significantly i.e. taken to theatre/ITU/CCU. Data collection currently in
progress – achieved for Q1 & Q2.
To achieve 100% - patients requiring prophylaxis receive it in an appropriate
and timely manner. Data collection currently in progress – achieved for Q1
and Q2.
Actions to Deliver Quarter 4 Key Aims
Continue to maximise data collection methods for VTE.
Continue to influence electronic solution
Influence the paper prescription chart to enable easier completion of the risk
assessment until electronic solution is available
Encourage the checks on post take wards rounds by consultants to ensure
increase in compliance
Weekly meetings with service leads
Controls and Mitigation
Monitoring system in place to identify any specific issues within areas
Weekly meetings with clinicians to ensure compliance
Lead: Dr Samuel Kemp, Consultant & Clinical Lead for VTE
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Title : Quarterly Quality Report + Emergency Department (ED)Streaming
Annual CQUIN Value: £511k
Date period : Quarter 3 October – December 2012
Q2 Rating
Achieved
Q3 Forecast
Aims / Objectives for 2012/13:
Achievement of quarterly percentages of patients streamed (as highlighted in in-year milestones) and/or all patients who could be streamed were streamed. Suitability
agreed via clinical audit with PCT lead.
Fully functioning Clinical Decision Unit (CDU) by 1 October 2012.
Key Aims for Quarter 3
Progress against Quarter 2 Key Aims
A minimum of 8% and/or all patients who could be streamed were streamed.
Suitability agreed via clinical audit with PCT Clinical Lead with 1% leeway either side
of “all patients who could be streamed were streamed” for cases where the clinical
audit does not reach agreement on the appropriateness of said cases for primary
care.
Fully functioning CDU by 1 October
Key Aims for Quarter 4
A minimum of 8% and/or all patients who could be streamed were streamed.
Suitability agreed via clinical audit with PCT Clinical Lead with 1% leeway either
side of “all patients who could be streamed were streamed” for cases where the
clinical audit does not reach agreement on the appropriateness of said cases for
primary care.
Operational Clinical Decisions Unit
Risks
Primary Care Streaming – opening of PC24 “front door” may reduce the number
of patients attending the ED with minor illness.
CDU – Trust overall capacity could impact on the ability to utilise beds on EAU
for CDU patients
Performance for Q3 shows that 6% of ALL ED patients have been referred to
PC24, however taking out the major and resus category patients. This totals
11%.
Since the opening of PC24 front door, the number of patients streamed has
reduced slightly, however the % remains consistent. This reduction in numbers
is consistent with the number of patients (walk-ins) attending PC24 having
increased dramatically during December.
Appropriate patient pathways and an operational policy for CDU have all been
developed within quarter.
Actions to Deliver Quarter 3 Key Aims
Sustain current performance in streaming all appropriate patients to primary
care, review clinical criteria post audit.
The CDU is now in operation and a review of appropriate clinical pathways
has been completed to optimise patient care.
The ED and PC24 teams meet on a fortnightly basis to review pathways and
ensure that flow is driven by clinical decision making.
Controls and Mitigation
Discussion during ED/PC management meeting regarding review of %
required to meet target and increase focus on audit. This is being
monitored via the Trust contract meetings.
CDU – Mitigation, highlight and identify patients suitable for CDU tariff and
manage clinical pathways are safely and effectively as possible.
Lead: Julie Dixon, Head of Nursing
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Title : Quarterly Quality Report – Think Glucose
CQUIN Annual Value: £511k
Date period : Quarter 2 July – September 2012
Q2 Rating
Achieved
Q3 Forecast
Aims / Objectives for 2012/13:
1. Mean length of stay for patients with diabetes admitted for any reason to be no more than 1 day longer than patients without diabetes (admitted for any reason).
2. Reduction of insulin medication errors resulting in harm by Quarter 4.
Key Aims for Quarter 3
Progress against Quarter 3 Key Aims
From the outset this CQUIN has been flagged as high risk of delivery in Q1-Q4. A clinically led project group
was established from the outset and focused work has enabled the achievement of Q1 and Q2 improvement
Standardised referral process for specialist diabetes
intervention to be discussed at Steering Group Meeting. targets, with a reduction in the number of insulin errors resulting in harm and a reduction in diabetic length of
stay of >0.5 days within 1 quarter. Due to the level of reduction in LOS expected (0.5 day per quarter), delivery
Think Glucose information will be available at point of
use.
of Quarter 3 and 4 are high risk. This would have a financial implication of £250k.
Work towards reducing insulin errors.
There has been a small increase in the number of insulin incidents reported which is anticipated when
Work with pharmacy colleagues to understand the
undertaking focused work. However, there has been a small reduction in the number of insulin errors
pattern of insulin incident reporting and rates of harm.
resulting in harm to patients.
Training in use of Think Glucose criteria to follow the Admission to Discharge, incorporating the Diabetes
Inpatient Care Teaching Framework has been implemented.
The clinical team have identified areas within the Trust where length of stay for diabetic patients (outside of
diabetes wards) is higher than average and education and training is being targeted to these areas.
An inpatient diabetes service has been introduced.
The clinical team has undertaken the National Inpatient Diabetes Audit Questionnaire. The use of this structure
is a part of the inpatient proposal. This measures the number of incident errors.
Key Aims for Quarter 4
To further reduce the number of insulin errors resulting
in patient harm.
To reduce LOS for diabetic patients by a further 0.5
days during Q4 to meet the CQUIN requirement.
Actions to Deliver Quarter 4 Key Aims
Training of ward based nurses and doctors will continue using Think Glucose criteria.
The National Inpatient Diabetes Audit Data for October 2012 will be published on line in February 2013 and
will give an updated position of how we perform against peers.
Diabetes team are working with the divisional management team to review implications of service redesign
to orientate the Diabetes and Endocrinology service towards delivering a specialist inpatient service.
Training will continue to be conducted by a dedicated Diabetes support nurse with supervision by
the Diabetes Specialist nurses.
Risks
Potential lack of clinical buy-in and awareness to
achieve the dramatic LOS reduction, within the
timescales.
Loss of income resulting in failure to deliver CQUIN.
Controls and Mitigation
Plans for the review and redesign of the referral process is being discussed at the next steering group
meeting.
Opportunities to target senior medical staff are currently being maximised and awareness is being raised
across nursing teams via the time out days and ward leader meetings.
Lead: Professor Devaka Fernando, Consultant in Endocrinology and Diabetes
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Title : Quarterly Quality Report – Safety Thermometer
Annual CQUIN value £340K
Date period : Quarter 3 October – December 2012
Q2 Actual
Achieved
Q3 Forecast
Aims / Objectives for 2012/13:
1) To ensure Safety Thermometer data is collected on ALL WARDS monthly and submitted to NHS information centre (NHSIC) by required deadline (mandatory) Target - 3 consecutive quarterly submissions of monthly survey data - Q1, Q2 and Q3 submitted to date.
2) To have 95% “harms free” care by December 2012 (stretch / aspirational target)
Key Aims for Q3
To ensure data is collected monthly.
To report on the data to the NHS Information
Centre.
ST information to be reviewed at PAG to
ensure it is being acted upon effectively.
To continue to communicate to the ward staff
the designated day for data collection and to
ensure accurate data reporting.
Progress against Quarter 3 Key Aims
Achieved: All Wards submitted data for October, November & December 2012.
Key Aims for Q4
To ensure data is collected monthly on ALL
wards.
To report on the data to the NHS Information
Centre.
ST information to be reviewed at PAG to
ensure it is being acted upon effectively.
To continue to communicate to the ward staff
the designated day for data collection and to
ensure accurate data reporting.
Risks
Non-submission of data from 1 or more wards.
Non-submission of data to NHSIC.
Inaccurate data collected.
Actions to Deliver Quarter 3 Key Aims
Email reminders send from Safety Thermometer Co-ordinator to Heads of Nursing and Ward Leaders 5 days before,
2 days before and on the data collection day. This allows Heads of Nursing and Ward Leaders to nominate
alternative staff to collect data in the event of illness/leave etc.
An additional member of staff within EAR has been trained in data validation and procedures to upload data to
NHSIC ensure continuity of data submission in case of sickness.
Presentation of a full year’s update to PAG.
To work with Divisional Clinical Governance Advisors to produce support information to be distributed via Nursing
Bulletin to ensure all Safety Thermometer data collectors understand and collect accurate data.
Lead:
Harms Free Care old (pre admission)+ new
harms
Harm Free Care new harms (on or during
admission)
Q1 90%
Q2 91%
Q3 92%
Q1 96%
Q2 97%
Q3 98%
Achieved: Data cleansed and then submitted to NHSIC within required deadline
Achieved: Update presentation and national comparisons to PAG 14/11/12
Achieved: Regular emails to Ward Leaders and Heads of Nursing. Ward Leader Time Out Day 12/11/12 – Safety
Thermometer stand and poster presentation (Michelle Cowdrey).
Controls and Mitigation
Reminder system as described above, more than 2 staff per ward trained to collect data, support from Ward
Leaders/Safety Thermometer Leads on other wards in the event of no availability of all trained staff.
Additional member of staff trained in EAR to submit data.
Additional and ongoing training in use of Safety Thermometer plus production of support information and
continuation of data validation by Trust’s Safety Thermometer Co-ordinator before submission to NHSIC.
Sonia Gill, Clinical Audit Support Officer / Safety Thermometer Co-ordinator
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