1. health and fitness
2. disease

Agenda Item:
Board of Directors
Meeting
Subject:
Date:
Author:
Lead Director:
Report
Quarterly Quality Report
Thursday 1st August 2013
Susan Bowler / Amanda Callow
Susan Bowler – Executive Director of Nursing & Quality
Executive Summary
This is a new style Quarterly Quality Report. It is an iterative process and further information
will be added in future reports; e.g. more detailed complaints themes and trends. It reports
on the three key quality priorities, CQUIN’s and other priorities that are featured within the
Quality Account.
Mortality has been reported in depth in previous monthly reports, with a comprehensive
summary of the current figures and progress against the action plan reported to July’s
Clinical Governance and Quality Committee. The latest information demonstrates that for the
first quarter of 2013, HSMR was 105 and crude mortality for May has fallen to 2.49%. These
are both extremely positive figures for the Trust.
The Quarter 1 CQUIN position is reported. Evidence for Quarter 1 is currently being
collected and performance against the targets will be reviewed by the commissioners on the
9th September 2013. The Trust is predicting it has met the majority of Q1 CQUIN’s apart
from dementia screening. The Trust will pilot the support of a specialist nurse in EAU to
drive this.
Complaints management is improving, but remains challenging. The total number of
complaints during Quarter 1 was 169 plus 11 reopened complaints. Between 1st January
2010 and 30th April 2013, there were 204 complaints requiring a response. As of the 23rd
July this number had reduced to 72. None of this 72 is dated before 31st December 2012.
The Trust is planning to respond and close the outstanding 72 by the end of July 2013. A
new complaints process is being redesigned for implementation in September 2013.
Recommendation
To note the content of the report and progress / position to date
Relevant Strategic Objectives (please mark in bold)
Achieve the best patient experience
Improve patient safety and provide high
quality care
Attract, develop and motivate effective teams
Links to the BAF and Corporate
Risk Register
Details of additional risks
associated with this paper (may
Achieve financial sustainability
Build successful relationships with external
organisations and regulators
BAF 1.3, 2.1, 2.2 2.3, 5.3, 5.5
Mortality, C Diff & Complaints on corporate risk register
Failure to meet the Monitor regulatory requirements for
governance- remain in significant breach.
include CQC Essential Standards,
NHSLA, NHS Constitution)
Links to NHS Constitution
Financial Implications/Impact
Risk of being assessed as non-compliant against the
CQC essential standards of Quality and Safety
Failure to meet 2013/14 infection control trajectories –
impacts on governance risk rating
Principle 2, 3, 4 & 7
The failure to deliver the CQUIN – monetary value
£4.5M
Contractual penalties for C Difficile, Pressure Ulcers
and MRSA
Legal Implications/Impact
Reputational implications of delivering sub-standard
safety and care
Partnership working & Public
This paper will be shared with the CCG Performance
Engagement Implications/Impact and Quality Group and the Patient Quality and
Experience Committee
Committees/groups where this
A number of specific items have been discussed at
item has been presented before
Safeguarding Adults Board, Safeguarding Children’s
Board, Clinical Management Team and Clinical
Governance & Quality Committee
Monitoring and Review
Monitoring via the quality contract and CQUIN (CCG
Performance and Quality Committee). & internal
processes, e.g. Safeguarding Adults Board
Is a QIA required/been
No
completed? If yes provide brief
details
Patient Safety & Experience Report
Trust Board of Directors Meeting
August 2013
Quarter 1 April, May & June 2013
Contents – Patient Safety & Experience Report Quarter 1
Introduction & Summary
3
Maternity Summary
19
National Picture
4
Falls Summary
20
Mortality Summary
(Quality Priority 1)
6
Patient Advice Liaison Service (PALs)
Summary
22
Pressure Ulcer Summary
(Quality Priority 2)
7
Complaints Summary
23
Patient Flow Summary
(Quality Priority 3)
8
Voluntary Services Summary
25
2013/14 CQUIN Indicators
10 Serious Incidents & Never Events Summary
26
2013/14 Specialist CQUIN Indicators
11 Infection Prevention & Control Summary
31
Dementia Summary
12 Medicines Safety Summary
34
Patient Experience – Friends & Family Test
14 Nutrition & Hydration Summary
36
Patient Experience – Feedback from Inpatients
15
Safeguarding Adults Summary
37
Patient Experience: Acting on Feedback
16
Safeguarding Children & Young People
Summary
38
Reducing Mortality - Sepsis & Cardiac Arrests
17
Learning Disability Summary
40
Safety Thermometer - Harms
18
2
Q1 – Introduction & Summary
This report is presented by the Executive Director of Nursing & Quality and Executive Medical Director and has been prepared with the support
of the Deputy Director of Nursing & Quality and the relevant clinical and staff leads.
This first ‘new look’ report covers the
period quarter 1; specifically April,
May, June 2013.
This report should be viewed as a
summary report aimed at updating
the Board of Directors and the public
on the Trust’s progress against its
key quality and safety priorities.
It should be read in conjunction with
the Integrated Performance
Scorecard which shows, at a glance,
performance against a range of
quality and safety indicators.
The report contains information on
our 3 top quality priorities, our
CQUIN schemes and other quality,
safety and patient experience
indicators.
3
Q1 – National Picture
Improving Quality of Care for Patient with Long Term Conditions
The health secretary has announced he is seeking views on a set of proposals to
radically improve care for vulnerable older people. The proposals set out
improvements in primary care and urgent and emergency care. They look at
establishing ways for NHS and social care services to work together more
effectively for the benefit of patients, both in and out of hospital.
The proposals include every vulnerable older person having a named clinician
responsible for their care outside of hospital, ensuring accountability is clear and
care packages are personalised and tailored around individual needs. The other
proposals include:
•
•
•
•
•
better early diagnosis and support to stay healthy by improving the role
GPs play in supporting people to stay healthy
improving access to primary care through new types of services and
technology
providing consistent and safe out-of-hours services
enhancing choice and control by rolling out the friends and family test to
general practice by December 2014, giving more choice about location and
type of service such as seeing a preferred GP or nurse and the option of
doing this face-to-face or by email and telephone
better sharing of information and joining up services so care can be
provided in a coordinated way
Comments are currently being sought from NHS, social care and public health
staff, carers and patients. The final plan will be published in October and will be
reflected in the refreshed Mandate to NHS England for 2014 to 2015.
4
The Cavendish Review
This independent review by Camilla Cavendish makes a number of recommendations on how the training and support of both healthcare assistants who
work in hospitals, and social care support workers who are employed in care homes and people’s own homes, can be improved to ensure they provide care
to the highest standard. The review proposes that all healthcare assistants and social care support workers should undergo the same basic training, based
on the best practice that already exists in the system, and must get a standard ‘certificate of fundamental care’ before they can care for people
unsupervised.
The Practice Development Forum has discussed these initial recommendations and has commissioned some internal work to be done ready for the next
forum in September. By this time, the Department of Health response should also have been publicized. Themes are:
1. Common training standards – all healthcare assistants should complete a certificate in ‘fundamental’ care before they can look after patients
unsupervised
2. Career progression – talented care workers will be able to progress into nursing and social care through the creation of a ‘Higher Certificate of
Fundamental Care’. This will ensure they have a route to progress in their careers and an opportunity to use their vocational experience of working as
healthcare assistant to enter the nursing profession
3. New job title – Healthcare assistants who completed the certificate should be allowed to use the term ‘nursing assistant’ in a bid to reduce the number
of current job titles held by support workers
4. Caring experience – the Nursing and Midwifery Council should make caring experience a prerequisite to starting a nursing degree and review the
contribution
of vocational
experience towards degrees
Q1
– Quality
Scorecard
5. Recruitment – directors of nursing should take back responsibility for the Healthcare assistant workforce from human resources departments.
Employers should also be supported to test the values, attitudes and aptitude of future staff for caring at the recruitment stage
6. Quality assurance – Health Education England, with Skills for Health and Skills for Care, should develop proposals for a rigorous system of quality
assurance for training and qualifications, which links to funding outcomes, so that money is not wasted on ineffective courses
7. Poor performance – the legal processes for challenging poor performance should be reviewed so that employers can be more effective in identifying
and removing any unsatisfactory staff
Review of End of Life Care
The Government is to replace the Liverpool Care Pathway (LCP) and will ask senior clinicians to sign off all end of life care plans, as part of its The Review,
headed by Baroness Julia Neuberger, was established by Norman Lamb after concerns were raised by patients, families, carers and a number of clinicians
that the system for providing care in the last days and hours of people’s lives was flawed. The Review found that in the right hands and when operated by
well-trained, well-resourced and sensitive clinical teams the LCP does help patients have a dignified and pain-free death. But its findings included too many
cases of poor practice, poor quality care of the individual, with families and carers not being properly engaged in the patient’s care. Because of these
failings in its use, the Review has recommended it should be phased out.
Every patient is different, and at SFH we always cared for patients as individuals. The LCP was only ever a tool to encourage best practice in managing
death in the most appropriate way for individual patients and families. It encourages clinicians to think about particular issues around patient care unique to
death. Patients dying at SFH will continue to receive the best care possible, and we will develop alternative ways to provide guidance to clinicians to help
them to manage dying patients in the most appropriate way (Mark Roberts Consultant- End of Life Lead).
5
Q1 – Mortality Summary
The Trust’s adjusted mortality rate (HSMR) for the past 12 months
is 115, which is above the expected range and the highest in the
East Midlands
For the past 4 months that we have reliable figures for (up to March
2013) HSMR has dropped into the expected range
Mortality by AcuteTrust in the East Midlands
120
115
HSMR
110
105
April 2012-March 2013
100
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The biggest improvement has been in the management of sepsis,
following the implementation of the sepsis action plan in December.
This involved the development of a new sepsis policy and a sepsis
audit tool, implementation of sepsis boxes, training of the nursing
and medical workforce and the appointment of a sepsis nurse
The Trust’s mortality reduction plan was launched in December
2012 to improve care of patients with the diagnoses most
commonly identified as a cause of death
Mortality by Diagnosis Group
Pneumonia
Acute cerebrovascular
disease
Septicemia (except in
labour)
Congestive heart failure,
nonhypertensive
Urinary tract infections
Acute and unspecified
renal failure
Chronic obstructive
pulmonary disease and
bronchiectasis
Improvement groups have been established for each of these
diagnoses to develop new care bundles, audit tools and training
programmes and implement other relevant improvements.
6
Q1 – Pressure Ulcer Summary
During Quarter 1, avoidable pressure ulcer rates have reduced and there has been zero avoidable grade 4 pressure ulcers. Performance
against our contract pressure ulcer reduction plan is highlighted in the table below:
Target No. Grade 3
Actual No. Grade 3
Target No. Grade 2
Actual No. Grade 2
Apr
3
5
15
14
May
3
4
20
13
Jun
2
2
10
16
Total Q1
8
11
45
43
Although the number of grade 3 pressure ulcers reduced significantly in June,
we have breached our target trajectory but have achieved our reduction plan
for grade 2’s. We have had zero grade 4 pressure ulcers during quarter 1. The
CQUIN safety thermometer has incremental improvement targets upon which
payments will be made. We look set to achieve this but data is currently being analysed.
The pressure ulcer prevention action plan is focusing on key elements, including, training and education, equipment, documentation and joint
working with community colleagues. Our investigations are showing a trend around heel damage and a number of devices are being trialled
across clinical areas to target this, with associated ward based training.
Spotlight on the Front Door
There has been considerable work undertaken during Q1 to prevent
pressure ulcers developing from the moment the patient arrives at ED.
Actions include:
•
•
•
Pilot of emergency department pressure ulcer prevention plan with
daily teaching at 8am to support staff
Pressure reducing mattress and off- loading devices ordered for ED
Immediate access to profiling bed and therapy mattress for patients
admitted with deep pressure ulcers to ED
For Quarter 1 we have met the contractual target for grade 2 & 4 pressure ulcers
7
Q1 – Patient Flow Summary
The Trust has set a target of 6 days for Average Length of Stay and 8% for
readmissions. Length of stay improved in June as detailed in the information below
however quarterly performance of 6.72 days is worse than 2012/13 outturn
performance of 6.36 days . Readmissions are also starting to reduce however the
quarterly data of 9.43% is worse than 2012/13 full year outturn of 9.25%. The key
achievements in the last three months were:
- New Clinical Decisions Unit (CDU) opened with additional ambulatory
pathways to increase the number of patients who can be streamed to this
area. To date, the unit is managing approximately 30 patients per day
through this area.
- Daily geriatrician input to the emergency assessment unit (EAU).
- Significant progress with reducing the number of patients remaining on EAU
post 24 hours.
- CDU/EAU operational policy drafted and circulated for comment.
- EAU observational beds in place.
- Process for capturing constraints at ward level created and providing clarity in
relation to internal delays to enable appropriate action.
- Nurse led discharges implemented on CDU.
- Patient flow action cards drafted and circulated for comment.
- Escalation policy revised.
- Medical staffing on call responsibilities/handover reviewed and
implementation of revised arrangements ongoing.
- Specialty level bed capacity plan.
- On plan to transfer Ward 22 from orthopaedics to medicine on 22 July 2013.
- Progress made in relation to day before discharge preparation of TTOs
- Cascade of escalation cards defining roles and responsibilities
- Human factors training for ED & EAU team
- Trial of new on-call arrangements
- Refinement of the Jonah live process
8
Q1 4hour target performance was 96.73% with
performance sustained in Q1 when activity has peaked
at ‘normal’ winter levels. Support has increased to
ensure the Trust position in relation to delayed transfers
of care does not deteriorate. All additional winter
capacity has now closed however 10 beds on EAU
are having to be flexed during July to cope with the
impact of additional attendances. Recruitment is on
track for the reopening of additional capacity in October
2013 and the bed modelling arrangements have been
agreed by the Executive Team. A bed modelling and
capacity paper is being prepared for the September
Trust Board Meeting.
Q1 – Patient Flow Summary
Following increases in April and May, readmissions have
reduced and the information team are reviewing with
medicine to establish if this is an impact of the new CDU
pathway implementation. The target for 2013/14 is
8%.There is a correlation of increase and implementation.
Work is on-going with commissioners to not include this
cohort of patients as admissions as this distorts the Trust
readmission data.
9
2013/14 CQUIN Indicators
The Commissioning for Quality and Innovation (CQUIN) payment framework was introduced in 2009 to make a proportion of providers’ income
conditional on demonstrating improvements in quality and innovation in specified areas of care. The framework helps make quality part of the
commissioner-provider discussion everywhere. The table below gives an overview of the schemes within the acute contract and a forecast of
delivery. Evidence for Quarter 1 is currently being collected and performance against the targets will be reviewed by the commissioners on the
9th September 2013.
CQUIN Scheme
1
VTE assessment
2.1 Dementia Screening
(Find, Assess, Investigate &
Refer)
2.2 Dementia – clinical
leadership
2.3 Dementia – supporting
carers
3
Friends and Family Test
4.1 Safety Thermometer
4.2 Safety Thermometer
5.1 Think Glucose
5.2 Think Glucose
6.1 Reducing mortality
6.2 Reducing mortality
7
End of Life (joint with
CHP)
8 Smoking at Time of
Delivery
9 Falls
Summary of Acute Schemes
Requirement
Q 1 Forecast & Q’s 2-4 Risk Assessment
Q1
Q2
Q3
Q4
95% of patients screened for venous thromboembolism (VTE) &
100% root cause analyses carried out on cases of hospital
£112,000 £112,000 £112,000
associated thrombosis (HAT)
95% of emergency admission patients aged 75 & over screened,
assessed and referred on to specialist services (during 3
£242,190 £242,190 £242,190
consecutive months)
Named lead clinician for dementia and appropriate training for
£13.455
£13.455
£13.455
staff
Improve the support available for carers
£13,455
£13.455
£13.455
Phased expansion to ED & maternity, increased response rate &
improved performance
Submit monthly harms data for Safety thermometer
Reduction in the prevalence of pressure ulcers
Maintaining reduced Length of Stay for Patients with Diabetes
Reduction of errors resulting in harm relating to insulin
prescribing and / or administration
Implementation of sepsis bundle
Failure to Rescue – reduce the number of cardiac arrests
Local action plan to improve care for end of life patients
3 year target. 3% reduction in smoking at time of delivery by Q4
13/14
Reduction in the number of falls resulting in harm
10
£112,000
£242,190
£13.455
£13.455
£168,187 £168,187 £168,187
£168,187
£56,063
£56,063
£56,063
£56,063
£56,063
£44,850
£56,063
£44,850
£56,063
£44,850
£56,063
£44,850
£44,850
£44,850
£44,850
£44,850
£56,063
£56,063
£56,063
£56,063
£56,063
£56,063
£56,063
£56,063
£100,913 £100,913 £100,913
£100,913
£56,063
£56,063
£56,063
£100,913 £100,913 £100,913
£100,913
£56,063
2013/14 Specialist CQUIN Indicators
There are 4 additional schemes set by East Midlands Specialist Commissioning Group. As above, the table highlights the forecast position for
Quarter 1 and the risk assessment of delivery for Quarters 2-4.
Summary of Specialist CQUIN Schemes
Q 1 Forecast & Q’s 2-4 Risk Assessment
CQUIN Scheme
Requirement
Q1
Q2
Q3
1 Clinical Dashboards
To embed and demonstrate routine use of specialised services
clinical dashboards (Cystic Fibrosis, Cardiology, Trauma,
Immunoglobulin, HIV, Neonates)
£18,825
£18,825
£18,825
£18,825
£12,550
£12,550
£12,550
£12,550
£12,500
£12,550
£12,550
£12,550
£6,275
£6,275
£6,275
£6,275
2 Paediatric High
Dependency
To prevent and reduce the number of patients re-admitted onto
PHDU on an unplanned basis within 48hrs of original discharge
3 Neonatal Care
Improved access to breast milk in preterm infants
4 Neonatal Care
Timely simple discharge for neonates
Q4
Each of the CQUIN schemes has a clinical sponsor and a project lead. Each of the sponsors submit progress reports quarterly and these are
evaluated by the lead commissioners for Nottinghamshire County Clinical Commissioning Group. Progress against those schemes that are
currently deemed high (red) risk of delivery is described within their respective reports.
There are a number of schemes that are currently RAG rated as amber. These are as follows:
• Safety Thermometer pressure ulcer improvement target – initial data shows we are likely to achieve Q1 but there is a moderate risk
• Reduced length of stay for diabetic patients – significant reduction was achieved during 2012/13 so the challenge is sustaining this.
Data is awaited for Q1 so this is assessed as amber risk.
• Reduction in the number of insulin errors resulting in harm – although we look likely to achieve this for Q1, there is a moderate risk for
subsequent quarters
• Reduction in the number of falls – although we estimate we will achieve Q1 and Q2 targets there is a risk in achieving the level of
reduction required within the CQUIN.
11
Q1 – Dementia Summary
This year’s Dementia CQUIN is one of the most
challenging initiatives that the Trust has. There is a
requirement to:
•
Screen, assess and refer 90% patients emergency
admitted over the age of 75 (the graph shows our
performance against this target) X
•
Have a designated dementia clinical lead√
•
Improve carer support √
Staff training rates for dementia continue to be excellent
with 2198 (84%) staff having received dementia
awareness training in Quarter 1.
Improvements have been made to the care environment
on ward 52 as well as implementing more support for
carers of people living with dementia.
! This graph shows that currently the % of patients screened for dementia within
72 hours = 27.97% (target 90%). We are achieving part 2 & 3 for assessment
and referral. The divisional nurses and clinical directors are currently assessing
options to improve this performance, which includes strengthening senior
nursing expertise within the admission areas to work closely with the medical
staff to ensure all patients are screened. This is being followed up at Clinical
Management Team, where it has been decided to pilot the support of a specialist
nurse in EAU to drive C1.
Working in close partnership with our colleagues in the Acute Care Liaison
Team, we are able to offer clinical expertise and support across the Trust. June
2013 saw the greatest number of referrals in a single month (133) since the
service commenced.
New dementia friendly signage on Ward 52
For Quarter 1 we are predicting that we have only partially met the CQUIN requirements
12
Q1 – Dementia Summary cnt
Dementia Carers Survey Q1
12
11
10
9
8
7
6
5
4
3
2
10
Carer Support
Initial results from our carers survey show 48% of carers for patients with
dementia at the Trust feel either supported or very well supported. 23%
stated that they felt unsupported to some degree. The survey is conducted
by the Trust’s Dementia Practice Development Nurse to ensure that any lack
of support is addresses at source and any lessons learned cycled back into
practice as quickly as possible.
Carers Said….
Our Actions….
“My wife has been very well looked after here. I’m very
happy with the care.”
The Trust intranet page is being developed to enable staff
to signpost to resources & support services.
“The staff are always too busy and there aren’t enough of
them.”
Partnership working with ‘third sector’ organisations, such
as Alzheimer’s Society to enable support in clinical areas
for carers of people living with dementia.
“There hasn’t been any Dr’s to speak with. I work full time,
so can’t be here during afternoon visiting.”
Dementia friendly signage installed on three wards to be
extended to other clinical environments.
“The nurses and carers are lovely.”
Engagement, support and training for volunteers who want
to come and spend time with patients with dementia.
“I haven’t been spoken to by anyone about what’s
happening during this whole stay.”
Better recognition of staff excellence in dementia care
planned for this year…..
“The Ward Sister has been very supportive. Everyone is so
busy.”
13
Q1 – Patient Experience – Friends and Family Test
Monthly Friends and Family Test Score
The Trust’s response rates have increased by 60% since April for
the inpatient wards and by 140% in A & E. We are required to
ensure 15% of our patients respond, which we are meeting.
Maternity are currently preparing to survey their patients from
October 2013.
From April 2013 all acute hospital inpatients and emergency
department patients are given the opportunity to rate and review the
service provided. On discharge a questionnaire and on-line facility
are available for patients to leave a review. From July 2013 the
Friends and Family Test results will also be available on the NHS
Choices website.
The scoring system for this year has changed. Trusts are marked
on a star rating system, out of 5. On this scoring system we score
4.6 out of 5.
800
The other way of scoring is on a range from - 100 to + 100 (which is
shown in the graph below). During quarter 2 we expect to receive
information that demonstrates how we are performing against other
organisations. From initial reports, we continue to do well compared
with other organisations.
400
600
In Patient
200
0
April
Overall Scores for Quarter 1
April
61
May
63
May
June
Response rate
Every ward receives a breakdown of their scores each month and
their ranking. The top 5 wards are shown below. Scores are out of
100.
100
50
A&E
June
61
0
The Top 3 Wards – Q1 2013/14
April
May
June
Ward 51 100
Ward 53 100
Ward 21 92
Ward 23
90
Ward 31
94
Ward 41 89
Ward 44
90
Ward 23
89
Ward 14 89
-50
-100
For Quarter 1, we are predicting that we have achieved this CQUIN target
14
Q1 – Patient Experience – Feedback from our Inpatients
‘All staff are very
kind and caring.
Make you feel at
ease. Pleasant
atmosphere and
clean.’
Ward 14 – May 2013
‘The nurses were brilliant,
Nothing was too much
trouble. Food was good also.’
Ward 32 – June 2013
‘Professional
support with a
smile.’
EAU – June
2013
‘All the staff here have
been very kind and
helpful, including the
doctors and ancillary
staff. Many thanks.’
Ward 51 – May 2013
‘Excellent care and
consideration from all
staff despite being under
pressure 24/7. Need more
staff and the level of care
would be even higher’
Ward 11 – May 2013
‘Waiting far too long,
but I suppose it’s to be
expected.’
A&E – May 2013
‘Nurses very efficient.
Five and a half hours
waiting around for
tablets when going
home.’
EAU – June 2013
15
‘Nothing too much trouble.
Everything from cleaning
to meals and to general
staff was good.’
Ward 33 – June 2013
Q1 - Patient Experience: Acting on Feedback
Issue raised
Action Taken
A urology patient with a long term condition waited in the
Emergency Department to be seen prior to admission for a
prolonged period of time after recently being discharged from
Ward 21 and under the care of urology outreach
Patients were concerned about the number of times dressings
were taken down by junior doctors for ward round reviews
when the wound was not due to be redressed
Patient on Ward 25 phoned to say her son had lost his mobile
phone charger
Specialist urology nurses now have direct admission
permissions to the Surgical Assessment Unit to prevent this
happening again.
Dressing change date and times are now placed on laminated
signs above the bed head with the date and time of next
dressing change
The Ward Receptionist found the charger and returned to the
her son
NHS Choices Website
Ward 53 Stroke Team
‘Having just experienced the faultless care provided by this hospital I cannot praise it enough. From the moment my frail mom (who only last
year had a triple heart by pass following a heart attack) was admitted to A&E with a stroke to the day she left - everyone was polite, dignified,
courteous and informative - and I have never had such an uplifting experience from a hospital. Luckily my mom was admitted and treated
extremely quickly after the initial stroke and was fortunate to be given thrombolysis immediately - which has had a massive impact on her
miraculous recovery. From being completely paralysed down her right side and unable to move or speak - within 24 hours she regained full
movement and speech and was able to walk to the loo. Having been in hospital only 3 days she is now having an early discharge with ongoing
care from the Occupational and Speech Therapist at home. Visually you would not know mom had had a stroke. But her recognition and
memory recall of words and items along with the blurred sight in one eye are all that seem to remain.
I couldn't recommend this hospital, especially all the team on ward 53 involved in moms care, highly enough. They have informed all the family
(including grandchildren) of what has happened and what the next course of action was going to be completely throughout her treatment. and
encouraged us all to ask any questions we needed to know. We never felt rushed or in the way or an inconvenience.
Well done Ward 53 you are a credit to the NHS and thank you from the bottom of my heart.’
16
Q1 – Reducing Mortality – Sepsis & Cardiac Arrests
There are 2 CQUIN schemes this year that form part of the Trust’s mortality reduction programme. These are reducing cardiac arrests and
implementing the sepsis bundle (refer to mortality section). The aim to reduce cardiac arrests builds on the work undertaken last year to
significantly reduce ‘avoidable’ cardiac arrests, for which the Trust achieved a 50% reduction overall. Cardiac arrests is an important outcome
measure for the assessment of the effectiveness of the deteriorating patient work programme.
Targets:
Q2 = 2.47 cardiac arrests per 1000 admissions (5% reduction)
BASELINE: Overall in Quarter 1, we counted a total of 2.6
cardiac arrests per 1000 of our inpatient admissions
Q3 = 2.34 cardiac arrests per 1000 admissions (10%
reduction)
Q4 = 2.21 cardiac arrests per 1000 admissions (15%
reduction)
The clinical lead for the cardiac arrest work is Dr Lisa Milligan who has a project
team of clinicians and experts working alongside her to drive this initiative. The
main areas to be targeted are summarised in the diagram below:
Due to the challenging reduction targets by quarter 3 and 4, these
have been risk (RAG) rated as red. This is based on comparison
with other Trusts who have attempted this improvement work.
The cardiac arrest and sepsis action plans are based
on the “Chain of Prevention” and continue much of
the work from the previous year, along with a number
of new initiatives which include Trust wide education
and training on the deteriorating patient and a pilot of
‘call for concern’ whereby relatives/patients have a
contact number for the Critical Care Outreach Team
who they can contact if they are worried about their
relative’s condition.
For Quarter 1, the Trust is predicting both parts of this CQUIN will be met
17
Q1 – Safety Thermometer Summary
The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and ‘harm free’ care. It is a
point prevalence survey undertaken on an agreed date each month. The collection of this data is a national CQUIN and there is an
improvement target around pressure ulcer reduction.
•
•
Trust Lead:: Amanda Callow Staff Groups Involved: Nursing Teams – all in-patients wards (excluding paediatrics)
Description: Monthly data collected on pressure ulcers, venous thrombo-embolism (VTE), falls and urinary tract infection (UTI) and
indwelling urinary catheters and reduction in the prevalence of pressure ulcers (PU).
All Harms
Jun-12
Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12
Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13
National results ( all acute Trusts)
9.80%
9.00%
8.80%
8.30%
8.00%
7.70%
7.60%
7.70%
7.80%
7.50%
7.80%
7.60%
7.30%
SFH
9.95%
7.11% 10.60%
7.99%
7.10%
7.79%
8.99%
8.59%
7.36%
8.72%
7.47%
6.95%
7.20%
SFH better than national?
No
YES
No
YES
YES
No
No
No
YES
No
YES
YES
YES
New Harms
Jun-12
Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12
Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13
National results ( all acute Trusts)
4.30%
4.00%
3.90%
3.60%
3.50%
3.30%
3.20%
3.30%
3.30%
3.20%
3.30%
3.20%
3.00%
SFH
2.61%
1.09%
2.81%
2.12%
3.06%
2.34%
2.79%
2.86%
2.25%
2.91%
1.98%
3.07%
1.84%
SFH better than national?
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
Summary Results
For the last 13 months SFH has had 7 months where our reported “harms” rate was less than the national reported rate – this includes pre-hospital as well
as hospital acquired harms. When you review NEW harms only (hospital acquired harms) then we have 13/13 months when we have reported fewer
harms when compared to the national results.
When broken down by type of harms, the highest reported cause of “harm” is pre and post hospital pressure ulcers (between 4-7%). The biggest
proportion of which are pre-hospital pressure ulcers. The remaining types of harm (falls, VTEs, UTI + catheter) account for approx. 0.5-1% of the reported
harms each month. The only type of harm that SFH is reporting a higher rate than national for in 10/13 months is “catheter associated UTI”. This drops to
7/13 months when you only looked at “New” UTI (New UTI = treatment started post admission). It should be noted that this is not the official definition of a
true catheter associated UTI and that figures are reported elsewhere.
18
Q1 – Maternity Summary
Midwife to Birth Ratios
In recent years there has been increasing need to produce some basis for recommending ratios of births
per whole time equivalent (WTE) to midwife to enable large-scale workforce planning based upon projected
annual hospital and home births. Birthrate Plus® has made a number of contributions to large scale
planning by drawing on its data gathered from detailed workforce planning studies in maternity services
across the United Kingdom. (DOH 2003, Ball et al 2003, Ball 2004, 2005)
The ratios provided in the reports cited above was focussed on national planning and quoted a figure of 28
births per whole time equivalent (WTE.) midwife for hospital births (including all aspects of midwifery care in
hospital and community) and 35 births per WTE midwife for home births.
At Sherwood Forest Hospitals we saw a drop of 7% births on the same period of last year with a total of
793. With the investment in establishments this gives us a ratio of 1:28 against funded establishment.
However recruitment is becoming difficult especially for experienced band 6 posts, so ratios against staff in
post is 1:31. Interviews for Band 6 community midwives are arranged for July13. Band 5 midwives
interviews are arranged for mid August 13.
National Maternity Survey
CNST – Maternity standards
The survey is well underway on the women who used our Services
in February 2013. At the moment our response rate is at 42%
which is favourable to other trusts. The survey closes in 8 weeks
on 6th September and we are expecting initial results on the 12th
September and a management report by mid October.
Maternity Services had a pre assessment Visit for CNST level 2
on the 18th of June and whilst we still have some work to do the
assessor was very complimentary of our progress and has
recommended we progress to full assessment in October.
Smoking @ Time of Delivery Audit
The Birthing Unit participated in a management audit undertaken by the Tobacco Control Collaborating Centre in Aug /Sept 2012. It ran over a
7 week period; the purpose was to determine the accuracy of data (are women truthful regarding their smoking habits) that is used to measure
the prevalence of smoking in pregnancy at both a local & national level. Women were sampled as to whether or not they give their smoking
status as smoking or non smoking. Saliva cotinine testing results were recorded along with the answers to questions re smoking status; the
responses then used to determine smoking status at delivery. Data was compared to the previous months smoking prevalence, determined
using existing data retrieval systems. The full report is anticipated this summer.
For Quarter 1 – This CQUIN target is being discussed due to data complexities
19
Q1 – Falls Summary
Hospital Falls
The quarter 1 incidence of falls in the Trust is lower than the previous 2 quarters, with 471 recorded in total. 395 of these resulted in no harm.
Acute medicine and Newark overall has seen a higher incidence over the winter months. The graphs below show overall performance with falls
over the past few quarters. The rate of harmful falls was 82 compared to 121 during quarter 4 of 12/13, which shows an improvement. There
were zero falls resulting in fractures. We also review the number of falls per 1000 bed days which is indicated in the performance report.
Falls recorded by Severity (No Harm/Low-Minimal/Moderate/Severe)
Total Count of All Falls by Severity
500
408
400
Total Count of falls recorded by Quarter from April 2012 – June 2013
373
438
395
300
200
100
10
478
91
8
102
Q2 2012/13
4 1
Q3 2012/13
559
9
6 1
Severe - Permenant or
long term harm
All falls causing fracture from April 23012/13 – June 2013/14
All Falls Causing Fracture by Quarter
5
Low - Minimal Harm
Patient required extra
obs or minor treatment
Moderate - Short term
harm pt required further
treatment procedure
Severe - Permenant or
long term harm
4
Q1 2012/13
5
3
5
2
0
Q1
2013/1
4Q4
2012/1
3Q3
2012/1
3Q2
2012/1
3Q1
2012/1
3
0
Q1 2013/14
515
All Falls with HARM by Quarter
50
Q4 2012/13
76
All falls from Apr 2012/13 – June 2013/14 with Harm by Quarter
100
443
112
0
150
Q1 2012/13
487
344
Moderate - Short term
harm pt required
further treatment
procedure
No Harm
102
Total Count of All Falls by Quarter
Low - Minimal Harm
Patient required extra
obs or minor treatment
Fracture
20
Q2 2012/13
Q3 2012/13
Q4 2012/13
Q1 2013/14
Q1 – Falls Summary
Falls Risk Assessment Audit
Reducing Harms Team Pilot
The Trust falls risk assessment audit is undertaken
monthly and results are discussed at the Falls Strategy
Group. Overall, the Trust continues to have good
compliance in ensuring that patients have had a falls risk
assessment undertaken. This consistently achieves over
95%, in line with the Trusts CQUIN requirement. The
methods for feeding this information back to ward and
divisional teams are currently being reviewed and
improved following suggestions from ward sisters/charge
nurses.
This pilot scheme was introduced in May 2013 with the
aim of providing additional care to patients at a higher risk
of harm. These are patients who may be frail or
vulnerable and need enhanced observation and support
to maintain their safety.
A number of care assistants employed through our
internal nurse bank have received specific training and
are allocated to areas each day where there is a need for
1 to 1 care. This pilot will be evaluated during September
to assess the impact on care delivery and outcomes.
There are currently two projects underway that underpin
our falls prevention strategy. These are:
•
•
The roll out of ‘care and comfort rounds’ (hourly
nursing rounds)
The pilot of the Reducing Harms Team
For Quarter 1 we are predicting we will meet the Falls CQUIN
21
Q1 –Patient Advice Liaison Service (PALs) Summary
The PALS team received 1841 contacts during Quarter 1 2013/4. This is a slight decrease when compared with Q4 2012/3 (n=82 contacts). .
.
PALS – Contact Method
700
600
500
400
300
200
100
0
PALS Contacts – Top 3
April
Divisions
Planned Care & Surgery (n=588)
Emergency Care & Medicine (n=517)
Diagnostics & Rehabilitation (n=466)
Top 3 Areas
Patient Administration (n=277)
Emergency Care (n=110)
Trauma & Orthopaedics (n=109)
Top 3 Subjects
Communication (n=617)
Compliments (n =325)
Appointment Queries (n=258)
May
June
Patient Story
Peters Story
Peter contacted the PALS team to report how concerned he was about his wife, June, who was an in-patient. June had been moved around the
ward four times in six days. The fourth move was due to another patient being suspected of having Norovirus and therefore he/she needed a
single room. Tests later confirmed that the patient did have the virus. Peter felt that even if it was suspected the virus was present that it was
not safe to move June (or any patient) into that bay. The move went ahead and Peter could not see his wife for 72 hrs. This distressed Peter
and June. Peter was happy to discuss his concerns with the ward leader in the first instance. The ward leader advised that although all
Infection Control policies had been followed she did understand his concerns and arranged for the Infection Control consultant to speak to
Peter. Peter was advised by the consultant that in light of his and his wife’s experience she would review the policy with regards to patients
being moved to area’s where a patient may have suspected infection of this type.
Divisional teams continue to receive monthly PALS/Patient Experience reports highlighting possible service improvements and themes
identified.
22
Q1 – Complaints Summary
Activity
The total number of complaints during Quarter 1 was 169 plus 11 reopened complaints. Working on the figure of 180 complaints, this total
represents a 10% decrease when compared to Q1 in 2012/13, in which there were 174 complaints plus 26 reopened complaints.
During Q1 2013/14, 121,913 patients received episodes of care either as an Emergency Department Attendee, Day Case, Elective, Non
Elective or Outpatient attendee (new and follow-up). This indicates that 0.15 % of our patients formally complained.
Total Number of Complaints Received in Divisions
in Q1 (April-June 2013)
COMPLAINTS by MONTH
57
80
APR 13
MAY 13
64
50
40
30
20
22
1
0
CENT
CORDEV
D&R
ECAMS
PLANCS
EMCAM
JUN 13
10
3
DANDR
MAY 13
60
JUN 13
60
CENT
CORDEV
APR 13
52
79
70
COMPLAINTS by MONTH
35
30
25
20
15
10
5
0
PLANCS
Response Times
When the Trust receives a complaint, the complainant should receive an acknowledgement within 3 working days. Performance severely
dipped during May, but performance has radically improved during July: April 94%, May 33%, June 79%, July currently 100%.
Response Backlog
Between 1st January 2010 and 30th April 2013, there were 204 complaints requiring a response. As of the 23rd July this number had reduced to
72. None of these 72 is dated before 31st December 2012. The Trust is planning to respond and close the outstanding 72 by the end of July
2013. A new complaints process is being redesigned for implementation in September 2013.
23
Q1 – Complaints Summary
Themes
Complaints about clinical treatment is the predominant cause of concern
ATTITUDE
SUBJECTS by MONTH
Breach of Confidentiality
Cancellation appointment
Cancellation - Surgery
31
2
Clinical Treatment
1
Attitude
•
Painful procedure
•
Attitude of Doctor in ED
•
Treatment received in ED
•
•
Delay in buzzer being answered
and attitude of nurse
Assessment and treatment by
too junior medical staff
•
No communication following fall
•
Food and medication
•
Delay in diagnosis
•
Insufficient advice following
consultation
•
Attitude of clinical staff
CLINICAL
2
COMMUNICATION
Control of Infection
ENVIROMENT
Liverpool Care Pathway
18
14
11 1 2 1
Not allowing more than
one bag in Ambulance
NURSING
Pain Management
PROCEDURE
WAITING TIME
Number of complaints reviewed by the
Parliamentary and Health Service
Ombudsman
In Quarter 1 the Parliamentary and Health
Service Ombudsman notified the Trust of
two cases that had been referred to them
for consideration.
Division
Complaint
Received
PHSO
Interest
Received
Datix
No
Current Position
Currently being assessed – Patients belongings missing
Ward 42 and attitude of nurses Ward 43
Currently being assessed – Pain management and
communication – Doctors in clinic 7 and Ward 21
EMCAM
June 2012
June 2013
8553
PLANCS
May 2012
May 2013
8477
24
Q1 – Voluntary Services Summary
The Voluntary Services Department continues to develop new roles
in addition to the valued established volunteer roles that 644
volunteers currently provide across the four hospital sites.
National Volunteers Week 1 – 7 June 2013
During National Volunteers Week events were organised across the
four hospital sites to recognise the contribution, commitment and
dedication our volunteers provide to the Trust.
In Quarter 1 Volunteers contributed 19,608 hours
• Newark Hospital
5,508 hours
• King’s Mill Hospital
11,172 hours
• Ashfield Health Village
1,308 hours
• Mansfield Hospital
1,620 hours
Voluntary Services Fund Raising:
The volunteers concluded their fund raising activities in support of
the King’s Mill Hospital MRI Appeal. A total of £539,000 donated.
New Initiatives:
Volunteers continue to fund raise across the four sites for the
general accounts or the Friends Associations. Their enthusiasm
and energy in the present difficult financial climate is to be
commended.
Fernwood Community Unit - Ward Volunteers recruited to
provide a meet and greet service to enhance the customer
service
Extension of befriending and patient support on Health Care
of the Older Person Wards
Duke of Edinburgh Awards:
4 students were supported by the voluntary services to complete
their bronze awards.
Surveys:
25 trained volunteers continue to assist the PALS team to collect
Out Patient Experience Surveys to inform our service improvement
plans.
During August trained volunteers will be available to support
patients who require assistance to complete the Friends and Family
test and additional questions to gain insight into patients
perceptions of the care we provide.
April 2013 £5,000 donated by ward trolley volunteers to MRI Appeal
25
Q1 – Serious Incidents and Never Events
There were no Never Events recorded during Quarter 1. It has been 2 years and 7 months since the Trust experienced a Never Event
Serious Incident Summary
Serious Incidents by Division
There were 38 Serious Incident Uploaded onto STEIS
Strategic Executive Information System) during Quarter 1.
As of 19th July 2013 there are 21 Serious Incidents open on STEIS,
of which 5 have been submitted for closure. All Serious Incidents
during
Q1 were closed within the specified timescales
April
No of Serious
Incidents
May
13
June
18
ECM
PC&S
D&R
7
April
5
4
4
May
12
3
3
June
4
1
2
Serious Incident By Category
Key recommendations from the SI Unexpected Death:
April Serious Incidents by
1
1
Maternity
Changes in practice :
2
Grade 3 Pressure Ulcers
In May 2013 the case was presented at the specialty and
divisional mortality meeting to share findings and changes in
practice
2
Slip/Trip/Fall
5
2
Ward Closure
Additional staff have been placed on our wards to support
‘out of hours’ care.
Unexpected Death
The doctor in training has received help and support from the
educational supervisor.
26
Q1 – Serious Incidents and Never Events
Key recommendations from the SI MRSA Bacteraemia:
Maternity
May Serious Incidents by
Changes in practice:
1
1 1
Grade 3 Pressure Ulcers
To promote use of bionectors for all peripheral venous
cannula (PVC) throughout the Trust and review new large
bore bionectors for use with CT Contrast.
4
8
3
Slip/Trip/Fall
Ward Closure
Re-energise communication campaign to promote the
benefits of hand hygiene to staff and patients.
MRSA Bacteraemia
Review use of the monitoring form used for patients with
intravenous cannulae
June Serious Incidents By Catagory
Initial findings for SI Unexpected Death:
Changes in practice:
Grade 3 Presuure
Ulcers
1
Slip/Trip/Fall
1
The CT result was not phoned through to the ward or the
requester. The individual has been made aware of current
policy for reporting the findings of this nature (re-education).
Unexpected Death
2
Other
3
27
Q1 – Serious Incidents and Never Events
Incident Reporting
Top 10 Incidents April 2012 to March 2013 by Datix Sub-category
There has been no significant increase of reported incidents over the year April 2012 to March 2013.
Patient incident numbers resulting in harm also remains static.
28
Q1 – Serious Incidents and Never Events
Over the period April to June 2013 the category of the top ten incidents remains unchanged.
100
80
60
40
20
0
Low - Minimal Harm Patient required
Moderate - Short term harm pt
Severe - Permenant or long term harm
extra obs or minor treatment
required further treatment procedure
2013 04
2013 05
29
2013 06
Catastrophic - Death
Q1 – Serious Incidents and Never Events
Management of Serious Incidents
Management of Serious Incidents cont
Training for Ward Leaders on the principles for managing an
investigation including the development of an action was provided at
the Ward Leaders Development Day in March 2013.
The management of serious incidents is one aspect of the review of
governance processes within the Trust.
The initial focus of the review of the management of serious incidents
was to ensure that the investigation and reports were completed in a
time critical manner to ensure that lessons learnt were recognised and
acted upon quickly and the reports submitted for closure on STEIS by
the Clinical Commissioning Groups (CCG’s) within the agreed time
frame.
To monitor the progress of the Serious Incident (with the exception of
pressure ulcers and falls that do not result in death) a template was
developed for reporting to the Executive Lead and the CCG’s
Governance Team within 24hrs hours of the incident being recognised
and a 7 day update report. The 24hr and /or the 7 day report includes
the terms of reference for the investigation (the pertinent questions
that will need to be answered in order to determine the root cause)
and any lessons learnt and immediate actions taken to mitigate the
risk.
The Quality Team of the Governance Support Unit (GSU) now reviews
all Datix Incidents. In recognising that an incident is potentially a
Serious Incident (SI) the appropriate Divisional Management Team is
notified to scope the incident and escalate as required.
On recognising a Serious Incident the GSU has provided mentorship
for the investigator to help with the development of the terms of
reference and to embed the reporting requirements. Depending on the
experience of the investigator advice is available to support the
investigation and writing the report. A list of potential investigators has
been collated and training is being arranged for September 2013.
30
The Trusts incident reporting policy has been reviewed to ensure it is
aligned to the requirements for the ‘Policy for the Reporting and
Management of Serious Incidents in the East Midlands’. A Framework
for the management of a Serious Incident has been produced which
identified the responsible officer for each aspect of the process and
the time frame for completion. This framework once ratified will be
incorporated as an appendix within the Trusts Incident Reporting
Policy.
Throughout Quarter 1 cooperative working with the Clinical
Commissioning Groups governance teams has been further
developed and regular meetings have taken place.
As part of the validation process for the information that was provided
for the Trust’s Quality report on serious incidents an internal audit was
undertaken by East Midlands Internal Audit Services (EMIAS) which
identified that there had been misclassification of a serious incident.
The Trust has commissioned EMIAS to review all incidents classified
as moderate from April 2012 to the end of May 2013 to ensure these
incidents have been correctly classified.
WHO checklist
The Trust’s Clinical Management Team initiated a review of the
WHO checklist -how and where this works in practice. Planned
Care and Surgery have taken the lead on this review. The division
are currently scoping the use of the WHO checklist within other
Trusts and have reviewed the working documents that are currently
being used within Theatres to support the management of the
patient.
Q1 – Infection, Prevention & Control Summary
Healthcare associated infection rates
When comparing Quarter 1 from 2012-13 with this year’s Quarter 1, the rate of infection for both Quarters are very similar, except that
there has been a significant reduction in the number of E. coli bacteraemia.
As from the 1st April 2013, a Root Cause Analysis for all bacteraemia (not just for line related) is being undertaken; Heads of Nursing are
working closely with their ward teams to identify the root cause, any contributory factors, and subsequent actions arising.
A hospital acquired bacteraemia action plan (irrespective of their causative agent) is being implemented and monitored. Actions
implemented include : a rapid investigation within 48 hrs of diagnosis, an invasive device audit, an increase in the monitoring of venous
invasive lines to 4 hrly and a review of cleaning solutions used for the insertion of vascular devices
MRSA bacteraemia: There has been 1 case of hospital acquired
(trajectory 0), and zero community acquired MRSA bacteraemia for
Q1.
MSSA bacteraemia: There has been 7 cases of hospital acquired
MSSA bacteraemia (quarter internal target of 1.8 cases) and 6
community acquired MSSA bacteraemia for Q1
MSSA trend April 2012 - March 2014
MRSA trend April 2012 - March 2014
2012-13 MRSA
2013-14 MRSA
2012-13 Rate per 100.000 bed days
2013-14 Rate per 100.000 bed days
25
4
20
Number of cases
Number of cases
5
3
2
1
2012-13 MSSA
2013-14 MSSA
2012-13 Rate per 100.000 bed days
2013-14 Rate per 100.000 bed days
15
10
5
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
0
Mar
Apr
Month
May
Jun
Jul
Aug
Sep
Oct
Month
31
Nov
Dec
Jan
Feb
Mar
Q1 – Infection, Prevention & Control Summary
C. difficile: There have been 8 cases of hospital acquired (quarter E. coli bacteraemia: There have been 10 cases of hospital acquired
E. coli bacteraemia, (quarter internal target of 12 cases) and 20
trajectory 6), and 6 community acquired C.difficile infections for Q1.
community acquired E. coli bacteraemia for Q1
E. coli trend April 2012 - March 2014
Clostridium difficle trend April 2012 - March 2014
2012-13 E. coli
2012-13 Rate per 100.000 bed days
2013-14 CDI
2013-14 E. Coli
2013-14 Rate per 100.000 bed days
40
20
18
16
14
12
10
8
6
4
2
0
35
Number of cases
Number of cases
2012-13 CDI
30
25
20
15
10
5
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
0
Mar
Apr
Month
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Month
Catheter associated bacteraemia: there have been 6 cases of
catheter associated bacteraemia that were hospital acquired,
against an internal target of 1 for Q1. Each bacteraemia has
been reviewed by the Infection Prevention and Control Team
(IPCT) and a RCA has been completed. G-straps have been
implemented, and the IPCT are reviewing the potential of using a
closed catheter system at the point of catheterisation to reduce
the risk of colonisation and infection.
Estates and infection control: Various small wards have been
undertaken as required. There was an aspergillus outbreak in
ICCU affecting 4 patients, although the source of the air
contamination was thought to be from the demolition of the
Dukeries, this is now questionable as the number of cases was
small, and the time frame was small considering the length of
time the demolition work took. No further cases have been
reported.
32
Q1 – Infection, Prevention & Control Summary
Outbreaks: Norovirus has still been active during April and May
both in the community and within the Trust. This has had a
direct impact of capacity and flow during these periods.
Norovirus outbreaks remain primarily a seasonal risk to the
Trust operations and efficiency. Plans are in place to ensure
early identification of patients and optimum management of
patients with symptoms to prevent spread at any time.
Norovirus
Total number of symptomatic
patients
Total number of symptomatic
staff
Duration of outbreak
Total bed lost days
Delayed discharges
Number of wards affected
Number of wards closed
Number of wards were bays
closed
Apr
13
5
15
23
7
3
1
2
May
33
16
7
77
0
4
2
2
Policy review/development: the C. difficile policy has been
reviewed and was ratified at the July IPCC meeting. In light of
the aspergillus a policy and risk assessment tool has been
developed, which is at present being peered reviewed. The
isolation policy is being reviewed and will be circulated for peer
review during July 2013
MRSA colonisation: 53 patient during Q1 were identified as
new MRSA colonisation across the health economy.
Jun
0
0
New MRSA colonisation - post 48hrs
New MRSA colonisation - pre 48hrs
TOTAL
0
0
0
0
0
0
Surgical site infections: No THR/TKR surgical site infections
have been reported for Q1. However there has been 4 reported
surgical site infections post C-section. However these figures
may change as orthopaedic is reviewed for a year, and Csection data for 30 days post discharge.
33
Apr13
3
14
17
May13
3
14
17
Jun13
2
17
19
Q1 – Medicines Safety Summary
Executive Summary
The total number of medication-related incidents reported on Datix has remained remarkably consistent since 2011, with a total of 1998
reported in both 2011/12 and 2012/13 (see Graph 1). Of these, most relate to medicine administration (44%), prescribing (23%), monitoring and
follow-up (19%), and pharmacy (12%). The most commonly reported adverse event over this period is in relation to medication nonadministration (18%) (see Graph 2). Over 96% of reported medication incidents result in no directly attributable reported harm.
Graph 1:
Graph 2:
Total Medication Incidents
120
Medication Incidents Sub-Categories
Administration or supply of a medicine from a clinical area
Medication error during the prescription process
110
60
100
50
90
40
80
Monitoring or follow up of medicine use
Preparation of medicines / dispensing in pharmacy
30
70
20
60
10
50
Medication Incidents this quarter
The number of medication incidents reported in 2013/13 Q1 is consistent with quarterly totals over the last 2 years, and demonstrates a higher
level of reporting with Datix compared to the final year of paper reporting in 2005/6 (which produced approximately 550 medication-related
incidents in the full year). Incidents relating to medicine administration and particularly to non-administration continue to be the top reported
category. These trends are consistent with a greater awareness of the need to report all medicines-related incidents, and in particular the
importance of highlighting when ‘critical’ medicines have been omitted (as highlighted by the NPSA Alert on Omitted and Delayed Medicines
(2010)).
34
J un 2013
May 2013
Apr 2013
Mar 2013
F eb 2013
J an 2013
D ec 2012
N ov 2012
O c t 2012
Sep 2012
Aug 2012
J ul 2012
J un 2012
May 2012
Apr 2012
Mar 2012
F eb 2012
J an 2012
D ec 2011
N ov 2011
O c t 2011
Sep 2011
Aug 2011
J ul 2011
J un 2011
May 2011
Apr 2011
J un 2013
Apr 2013
F eb 2013
D ec 2012
O c t 2012
Aug 2012
J un 2012
Apr 2012
F eb 2012
D ec 2011
O c t 2011
Aug 2011
J un 2011
Apr 2011
0
Q1 – Medicines Safety Summary
Medication-related harm events this quarter
Graph 3 indicates that the number of medication incidents resulting in harm events remains very low since 2011. Less than 2% of medicinesrelated incidents reported in Q1 of 2013/14 (5/264) were reported as resulting in patient harm (‘low-minimal harm requiring extra observations
or minor treatment’); there were no ‘moderate’, ‘severe’ or ‘catastrophic’ harm outcomes reported. There were no medication ‘Never-Events’.
Graph 4 shows that overall numbers of medication incidents per 1000 bed days is reducing.
Graphs 3 & 4:
Medicines Safety Messages
•
The Trust Medicines Safety Group is being reestablished in September 2013 in order to provide a
focal point for the review, analysis and learning from
medicines safety incidents and near-misses.
•
This group will lead the development of a Medicines
Safety Strategy, which will form part of a broader
Medicines Management Strategy being developed by
the Chief Pharmacist.
•
All Trust staff (including medical staff) need to be
encouraged and supported to report medicines-related
incidents and near-misses (especially those relating to
medication ‘Never Events’ and other high-risk
medicines).
•
A key principle of medicines optimisation (helping
patients to make the most of medicines) is ensuring
that medicines use is as safe as possible.
•
Improving the safe use of medicines and minimising the
potential for harm is the responsibility of all Trust staff.
The 5 Rights: RIGHT medicine, RIGHT dose, RIGHT time, RIGHT route, RIGHT patient, every time
35
Q1- Nutrition & Hydration Summary
Meeting our patient’s nutritional and hydration needs is a fundamental priority at the Trust and an area that is carefully monitored through
monthly nursing metrics, observational visits and the recent PLACE assessment. Whilst good nutritional care is reported through our audits and
patient feedback there are areas for improvement and further consistency. The PLACE assessment reported that overall the audits were very
good, and all patients spoken to provided positive feedback and comments in regard to the choice of food available and the meal service
received. However, in some areas it was noted that food temperature and presentation were not satisfactory.
The recent external reviews undertaken by the
Keogh team and the Care Quality Commission
reinforced the need to strengthen nutrition and
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
hydration. A number of actions have already been
2012 2012 2012 2012 2012 2012 2013 2013 2013 2013 2013 2013 implemented and are outlined below. There are a
number of further actions being introduced
92% 93% 73% 92% 86% 82% 84% 82% 86% 92% 82% 91%
imminently and this will be a key focus within
Nursing and Midwifery over the next 2 months.
Summary of Nutritional Nursing Metrics over the last 12 Months
All locations
Nutritional
Assessment
Spotlight on Ward 44
Key Action Summary
As part of Nutrition week, areas of
good practice were showcased. Ward
44 staff have worked exceptionally
hard by making mealtimes a priority
in terms of importance and dedication
of staff time. All non essential ward
activity is halted at mealtimes and all
grades of staff are on hand to deliver
meals and give assistance to patients
who require it.
National Outreach Study day incorporating principles of good fluid
The nursing staff work closely with
the ward Hostess in promoting and
maintaining good nutritional care.
management √
Guardians of care model introduced with a programme of internal
review visits to assess hydration and nutritional standards √
Nutrition week held to raise the profile and showcase our work √
Development of a ‘MUST’ eLearning programme – October 2013
The previous Chairman, Chris Mellor is
photographed with Sister Helen Barker,
our nutritional nurse specialist, dietician
and a ward 44 patient.
Re-launch protected mealtimes and red tray/jug protocols –
September 2013
Assemble a fluid management task group – August 2013
36
Q1 – Safeguarding Adults Summary
Safeguarding Training Percentages Per Quarter Staff
Referrals to the Trusts Safeguarding Adults Team in Q1 remain approximately the
same amount as Q4; there have been 117 referrals 22 of which necessitated a
referral to the Nottinghamshire Multiagency Safeguarding Team (MASH). The
other 95 referrals were dealt with by the Trust’s Safeguarding Team. In Q1 there
have been 9 safeguarding referrals where there were concerns regarding the
Trust’s care; in 4 cases no abuse took place and in 1 case the outcome was
‘there had been acts of omission by the Trust around a patient’s discharge, as
pressure relieving equipment had not been arranged for discharge and discharge
information regarding patient had not been sent to the care home’. The other 4
are still being investigated.
2500
91% 93%
1500
Concerns
regarding the
Trust
self neglect
22
40%
500
Q1 2013/14
Total
20
8
vulnerable
patients
tissue viability
18
20
15
15
10
46
investigation
work for
MASH/SOCIAL
SERVICES
0
4
1
4 4
1 1 2 2 2 2
2
3 2
1
4
2 2 1
11
12
14
21
22
23
24
32
33
34
35
36
41
42
44
51
52
53
EAU
ED
ITU
MIU
SCONCE
Social…
TV Nurse
5
deprivation of
liberty
6 7 5
6
5
37
Q4 2012/13
Plans for quarter 2
Total count of referrals to the Trust
Safeguarding Team
25
Sum of Consent
Mental
Capacity Act
Training
0
9
11
16
61%
1000
During Q1 an electronic data base has been developed to record referrals to the
Trusts Safeguarding Team and has the ability to generate data for reporting.
Themes of Referrals to the
Trusts Safeguarding Team
Sum of
Safeguarding
Training
91% 92%
2000
An audit to ascertain how effective
the full day Consent and Mental
capacity Act (MCA) training the
Safeguarding Team delivers will take
place. All wards which have a high
number of staff who have received
this training will be audited and
measured against the wards that
have not received the training. This
should give an indication of the effect
the training is having on practice.
Domestic violence will be reported in
Q2.
Q1 – Safeguarding Children & Young People Summary
Safeguarding Children and Young people Summary
Referrals/ reasons for referral to Children’s Social Care remain comparable with previous quarters. Maternity safeguarding activity has
remained stable. There has been a slight increase in paediatric non-safeguarding admissions of children who are already have a social
worker [this mirrors increased activity within local Children’s Social Care].
The Safeguarding Children Work Plan is progressing although the development of an ED alert system in conjunction with TPP continues to
remain problematic – this has been escalated. One audit was undertaken in Q1 “Completion of the Safeguarding Children information on the
Paediatric Triage form and use of the Paediatric Referral Criteria within ED & MIU&UCC”, paediatric liaison referral rates were unacceptable
in ED; the department has taken immediate corrective action.
An action plan is in place to increase overall training compliance however it should be noted that midwifery compliance continues to remain
high [Q1 97%]. A report [providing supplementary information] was submitted to the Nottinghamshire Safeguarding Children Board as part
of a Serious Case Review; the Trust was not required to undertake a full individual management review.
Referrals to Children's Social Care 2013/14 [Q1] 0 - 17 years
Other
Child Sexual Abuse
Suspected Non Accidental Injury
Negelct
Substance Misuse [Child]
Substance Misuse [Adult]
Deliberate Self Harm [Child]
Deliberate Self Harm [Adult]
Domestic Violence
Referrals to Children's Social Care 2013/14 [Q1]
Unborn children
8
Drug/alcohol misuse
3
3
2
Not accessing antenatal care
1
Mental health issues
1
Previous children removed
1
1
5
4
44
9
0
10
0
20
30
40
50
0.5
1
1.5
2
2.5
Number/categories of referrals to Children's Social Care 2013/14
Q1
Number/categories of referrals to Children's Social Care 2013/14 Q1
38
Q1 – Safeguarding Children & Young People Summary
Paediatric Admissions
[comparative numbers]
Trust Referral [comparative numbers]
6
Q1 2013/14
Q1 2013/14
5
Q4
4
Q3
3
Q2
5
Q1 2012/13
5
Q4 2011/12
4
0
18
6
Q2
72
21
5
Q4 2011/12
68
18
7
Q1 2012/13
74
22
4
Q3
83
6
5
4
3
2
1
0
25
5
Q4
77
Maternity Activity for Q1
0
18
10
20
30
88
20
40
Unborn children
60
80
3
2
1
2
1
100
90%
89%
79%
63%
55%
60%
40%
Domestic Drug /
Violence Alcohol
Misuse
Neglect
Other
No. home with targeted services
62%
89%
Level 2 non-medical staff]
62%
60%
45%
35%
Q2
level 2 [Permanent medical
staff]
Level 3 [all other staff]
0%
Q1 2012/13
1 1
No. home on CP Plan
Non-safeguarding admission [but has social
worker]
87%
20%
1
0
Training Compliance
80%
1
No. removed at birth
Safeguarding admission
0-17yr olds
100%
5
5
Q3
Q4
Q1 2013/14
39
Q1 Learning Disability Summary
•
•
•
During Q1 there have been 53 referrals to the Learning Disability nurse to support with complex patients.
SFHFT Learning Disability Steering Group is held quarterly. The next meeting is on August 14th.
The LD Nurse specialist and a service user addressed the Nottinghamshire Healthcare Trust End of Life Care conference to promote the
‘Improving End of Life care for people with learning disability project’. The work was shared as a Best Practice example.
Patient Feedback
3.5
3
2.5
2
1.5
1
0.5
0
Happy
Yes
No
NA
Unhappy
FEEDBACK:
Patient
Carer
Professionals
What patients were happy about
100% of patients that gave feedback were given a
hospital traffic light assessment to tell ward staff
about their needs/wants/dislikes.
100% of patients felt that they had been given
information in a way they understood .
What Patients were unhappy about?
Patient A was unhappy about noise from another
patient – when he told the nurse he was moved into
another room which solved the problem.
Patient B was unhappy/anxious about the wait for
a procedure – this was discussed with the nurse on
duty and the patient was reassured.
The Big Health Days The Learning Disability ‘Big Health days’ took Place on 5th June for Mansfield & Ashfield and for the 7th June
for Newark and Sherwood. These days were led by the appropriate CCG’S and gave people with learning disabilities, family carers
and other professionals the opportunity to give feedback about local services. This information is used to inform the LD self
assessment Framework which will be submitted by end of Q2 by the CCG lead for Quality. SFHFT went along to both days with a
stand of easy read information about our services:
Including; coming to Emergency Care Centre, staying in hospital, having a pre-operative assessment, having an outpatient
appointment. Both days had good attendance and feedback for Kings Mill and Newark Hospitals was good.
40