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Enclosure F
Report to:
Council of Governors
Date of meeting:
15 November 2012
Title of paper:
Quarterly Quality Report
Executive Summary:
Complaints performance has deteriorated during this quarter due to low staffing levels and the
replacement of this workforce with new members who are developing the skills to support the
service. Training has been instigated, but this will be supported by an external source. A renewed
focus will be given via the divisions in terms of timeliness and quality of responses.
A large number of contacts are being logged via the PAL’s service in relation to patient’s inability to
reach the trust via telephone. This is particular evident within the partial booking centre where a
diagnostic review identified that ‘Only 49% of calls into the Partial Booking office were classed as
answered with a high number of unanswered phone calls between 7.00 am to 8.30 am and 5.00 pm
to 7.00 pm during weekdays and on weekends when no staff are scheduled to work ‘ . An action
plan has been developed and is currently being reviewed and signed off by Operations.
The most recent report from the National Learning Reporting System at the NPSA dated October
2011 to March 2012, shows that we have improved our level of reporting from an average of 6 per
100 admissions to 7.8 per 100 admissions, which places us in the top quarter percentile of 4
medium acute trusts. In comparing us with our peer group we appear to have fewer severe
incidents and deaths as outcomes of the incidents reported.
It has been over 960 days since we experienced a Trust acquired MRSA bacteraemia. Hospital
Acquired C Difficile performance has seen a significant improvement with 9 reported cases against a
trajectory of 18 year to date.
All CQUIN’s apart from ‘Think Glucose’ and ‘Improving the experience of patients with Learning
Disabilities (LD)’ have been delivered for Quarter 2 (confirmation is still required from the PCT)
‘Think Glucose’ CQUIN, has been reported previously as requiring radical improvements across the
Trust. Actions to improve are in progress, being led by senior clinicians, but changes to reducing
length of stay will take time to develop and embed due to large education programme and cultural
change required in treating these patients. A steering group and the division are giving this CQUIN
attention
The learning disabilities CQUIN will be escalated to the PCT within the next week, as the Trust
through regular audits are unable to demonstrate these patients have an extended length of stay.
They are not medically fit to be discharged, i.e. their learning disabilities needs are being addressed
but are not the cause of their stay
Recommendation:
The Council of Governors are asked to note the contents of this report.
Enclosure F
COUNCIL OF GOVERNORS MEETING : 15th November 2012
Quarterly Quality Report – 2nd Quarter (2012/13)
Quality Dashboard
Patient Experience
Patient experience personal needs
Improving Patient Experience
PALS Themes
Staff Experience
Food Quality
Cleanliness
Patient Safety
Serious Untoward Incidents
Implementation of NICE Guidance for acutely ill
patients
Midwife to birth ratio
Slip, Trips and Falls
Infection, Prevention and Control
Nutrition
Pressure Ulcer Prevention
Clinical Effectiveness
Summary Hospital Mortality Index (SHMI) (see
separate report)
Heart attack secondary prevention
PROMs
Stroke sentinel audit
CQUIN
Improving Dementia Care & Training
Failure to Rescue
Improving the experience of patients with Learning
Disabilities
NET Promoter Score & Patient Experience
Improving Choice of End of Life
VTE
Emergency Department Streaming
Think Glucose (Length of Stay & Medication)
Safety Thermometer
1
Q2
2012/13
Q1
2012/13
This report provides 2nd quarter information regarding patient experience, patient safety, clinical
effectiveness and CQUIN performance.
Enclosure F
Recommendations
Directors are asked to consider each section of the Quality Report and the highlights and issues
raised by individual Directors.
Susan Bowler
Executive Director of Nursing & Quality
Nabeel Ali
Executive Medical Director
Green
Yellow
Amber
Red
Achieved
On plan to
achieve
target
Further work
required to
achieve target
Significantly behind
target – urgent action
required
Key
2
Enclosure F
Q2 RAG
Title : Quarterly Quality Report
-
Patient Experience Personal Needs
Q3 RAG
Date period : Quarter 2 July – September 2012
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?
Key Aims for Q2
Progress against Quarter 2 Key Aims
Quarter 1 results = 97%
Quarter 2 results= 95%
The key aims are to maintain above the 80% target.
Individual questions are assessed to ensure they consistently achieve 80%
All questions for quarter 2 have been consistently achieving above 80%.
Question 4 and 5 results are starting to tail off. The results have been
shared and pharmacy has 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.
In relation to question 5 a discharge leaflet is being produced which
explains what to do when you leave hospital.
Actions to Deliver Quarter 3 Key Aims
Key Aims for Q3
To maintain 80% or above for the quarter. To monitor monthly results and act on
any questions that seem to be tailing off.
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.
To analyses question 4 and 5. To roll out the discharge leaflet.
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
3
Enclosure F
Title : Quarterly Quality Report - Improving Patient Experience (Complaints)
Q2 RAG
Q3 RAG
Date period : Quarter 2 July – September 2012
Aims / Objectives for 2012/13: To maintain a high quality IPE department
Key Aims for Q2
Progress against Quarter 2 Key Aims
Complainants should receive acknowledgement within 3 days of the complaint being
received by the department. During quarter 2 this performance dropped from 98% in
quarter 1 to 87% in quarter 2. This was due to low staffing levels and the commencement
of a replacement workforce who have never worked in complaints before.
Month
April
May
June
July
Aug
Sept
Complaints
48
45
53
46
46
44
3 days acknowledge
100%
93%
100%
89%
88%
83%
Performance
77%
60%
100%
91%
91%
80%
Quarter
Training has been put in place for the new IPE staff and the importance of
acknowledgements re-iterated. The department is still 1 staff member down due
to sickness.
Performance is monitored weekly and reports sent to divisions every week.
Systems have improved in the IPE department ensuring chasing of responses is
clearer and more timely.
YTD
79%
79%
Re-opened complaints have increased during quarter 2 and this seems to be
due to the complaint not being fully answered by the investigator.
87%
83%
Free training has been sourced from a solicitors firm and is planned for early
January. The IPE team have begun calling patients to ascertain the questions
they want answering from the outset.
Divisional performance dropped off in September partly due to new staff in the
department and their lack of capacity to chase responses with divisions.
The main themes for quarter 2 were clinical treatment, attitude of the doctor, clinical
diagnosis, communication-admin, nursing care and treatment. It is to be noted that if all
communication was linked together it would be the highest followed by all attitude.
Reopened complaints have increased in quarter 2 to 37. In quarter 1 there were 29.
Key Aims for Q3
Actions to Deliver Quarter 3 Key Aims
To aim for 100% acknowledgement and to increase response performance to above
90%
To reduce the amount of reopened complaints
Lessons learnt have been collated over the past 2 quarters and will be presented in the
CLIP report due in November.
Risks
The long term sickness is a risk to IPE performance
The actions above will continue
Controls and Mitigation
The Director of Customer Experience is taking on more operational work at
present to cover any urgent issues.
Lead: Sally Dore, Director of Customer Experience and Engagement
4
Enclosure F
Customer Experience – Patient Advice & Liaison Service (PALS)
Quarterly Progress Report -
Status
July to September 2012, Quarter 2
Risks and Issues
1. 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 not managed in other services.
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.
During this quarter the PALS team have logged 1975 contacts onto Datix, some contacts raise more than
one subject.
The themes and trends identified below continue to add pressure to the service and whilst we respond to the
enquiries we are not always able to log all of these contacts due to the volume, particularly with regards to
the Partial Booking Call Centre (please see 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.
Breakdown of primary subjects:
Comments – 926, Compliments – 144, Concerns – 858, Complaints (first stage) - 47
Themes
1. Telephone Communication – 89 Contacts logged, calls not logged (logged on tick sheet = 493)
Continuing from the previous 3 quarters patients are 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. Contact has also been received from
GPs.
2. Out Patient Capacity – 23 Contacts
Cardiology Patient Experience
Patient was informed there were no available appointments for cardiology at Newark Hospital but could be
seen at King’s Mill Hospital. The patient received an appointment letter, then received a telephone call
bringing forward the appointment, no confirmation letter was sent. The patient arrived for the appointment
she was informed the appointment was actually for Newark Hospital. The patient travelled to Newark, paid
for more parking, and was informed that the consultant had left for the day.
Dermatology Patient Experience
Patient saw GP who advised needed a referral to Dermatology, the Choose and Book system offered an
appointment at Chesterfield Hospital. The patient (who works for SFHT) advised that they wanted an
appointment at KMH. The GP advised this was unlikely as there were ‘never any appointments’. The patient
advised that as she worked at King’s Mill and she wanted to take as little time off work as possible & wanted
to support our services, to please try and get her at appointment at her chosen hospital. The GP tried to
secure an appointment during her visit but was unable to do so. He advised that he would contact her once
he had secured an appointment, she was informed of her appointment date the following week. The patient
was very concerned that GPs are not considering KMH as an option as they can not obtain choose and book
appointments.
This patient booked her appointment on 29 August, a letter from ‘The Appointments Line’ at Milton Keynes
dated 30 August arrived at her house on 27 September asking her to call and make an appointment.
3. CQC have raised individual concerns regarding patients inability to speak to the partial booking
office and the constant ringing
4C’s
breakdown
PC&S
Division
EC&M
Division
D&R
Division
Corporate
Development
Other
Total
Comments
225
182
376
33
110
926
Concerns
148
150
443
24
93
858
Compliments
92
34
14
1
3
144
Complaints
6
13
16
0
12
47
Lead :
2. Out Patient Capacity
a. Loss of business
b. Loss of reputation
Added value
The Customer Services teams are managing the following projects to enhance the customer
environment and experience.
Main activities for next quarter – Newark
1. Support improvements in the delivery of patient administration services.
Main activities for next quarter – King’s Mill
1. Review the main reception services and patient flow in preparation for the introduction of the
new main entrance doors.
2. Refurbishment of A&E, EAU relative’s rooms and review of further provision for care of
visitors.
3. Continue to monitor ‘The Friends and Family Test’ national agenda.
4. Support the introduction of SFH patient experience agenda at Mansfield Community Hospital.
Recruitment of volunteers has commenced to conduct out patient surveys and team member
receiving training to undertake in patient surveys.
4. Develop a protocol for implementing a PALS helpline with the support of the Communication
Director. (The PALS team have provided the Breast Service Helpline which requires evaluation)
5. Provide patient experience evidence to Support Service Line Managers to make the required
changes to the patient administration services to retain and develop business. A diagnostic
report related to the partial booking centre has been written by the ABC team. This report has
been reviewed with Director of Operations, with an action plan being developed.
Tracey Brassington – Customer Services Manager
5
Enclosure F
Title : Quarterly Quality Report
:
Staff Experience
Q2 RAG
Q3 RAG
Date period : Quarter 2,
July – September 2012
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 Q2
Progress against Quarter 2 Key Aims
Continue to increase the number of staff who have received an appraisal to 79%.
Continue to roll out the Stress Education Programme to managers and extend by
delivering to teams within work areas.
The Staff Survey Action Plan and Communication Plan to be implemented.
Implement the Staff Health & Well-being Action Plan and the Stress & Mental Health
Strategy in order to support the work to reduce sickness absence to 3.4%.
Training, Education & Development will deliver training to support managers in
managing change.
The Leadership and Management Development Programme will be delivered to a
second cohort and work will start on identifying individuals for the third and fourth
cohort.
Ensure efficient management of the junior doctors’ rotation in August and induction
to the Trust.
A PING sub group has been established to drive forward a programme of
work designed to increase appraisal rates.
The Stress Education Programme has been delivered to a number of work
areas. The evaluation has been very positive.
Committees and working groups continue to work on the achievement of the
2011 Staff Survey Action Plan. Progress reports have been given to JSPF,
the Workforce Committee and September’s Board.
Training, Education & Development continue to deliver training to support
managers in managing change in partnership with staff side colleagues.
The Leadership and Management Development Programme is being
delivered to a second cohort and individuals for the third and fourth cohort
have been identified and are fully subscribed.
The junior doctors’ rotation and induction to the Trust went smoothly
receiving positive feedback from junior doctors. For the first time the F1s
were inducted separately and given the opportunity to shadow thereby
improving their induction experience and increasing their knowledge and
confidence.
Key Aims for Q3
Actions to Deliver Quarter 3 Key Aims
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.
6
Divisional directors confirm 30 November completion date to increase
appraisal rates.
Regional appraisal framework assessed for adoption.
Managers to focus on meeting with staff who have attendance issues and
Enclosure F
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.
resolving matters.
Improved resilience confidence and skills for those managing workforce
change.
Improved staff resilience to health related issues, particularly with regard to
stress and mental health and steps to reduce the impact.
Continue to deliver and promote the Stress and Mental Health Strategy to
increase manager awareness and confidence in recognising and supporting
staff in their work area.
Effective promotion of the 2012 seasonal flu vaccination programme to
ensure maximum take up of vaccination particularly by frontline staff.
Promote the 2012 staff survey and make progress in addressing the key
findings from the 2011 Staff Survey to increase response rates and engage
staff.
Promote the Trust’s Equality workshop fostering staff engagement.
Risks
Controls and Mitigation
•
•
•
•
Low staff morale and disengagement.
Increased stress and/or sickness absence due to workforce change, winter
pressures and broader economic climate issues.
•
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 Nicola Awni, Deputy Director of Human Resources
7
Enclosure F
Title : Quarterly Quality Report
-
Food Quality
Q2 RAG
Q3 RAG
Date period : Quarter 2 July – September 2012
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 MiniPEAT audits as well as an on going programme of ward catering audits.
Key Aims for Q2
Progress against Quarter 2 Key Aims
Introduce Steamplicity individual plated meal system to Mansfield Community
Hospital Wards.
This system is now live at Mansfield.
MiniPEAT audits have demonstrated an on going high level of patient
satisfaction with the quality of the catering service at all 3 sites.
Key Aims for Q3
Actions to Deliver Quarter 3 Key Aims
Implement Ward Hostess Role and Steamplicity individual plated meal system to
Newark Wards .Undertake MiniPEAT audits at all 3 sites to demonstrate on
going high level of satisfaction with food service standard.
Rollout date scheduled for 0ctober 8th at Newark 2012 to coincide with
New Steamplicity Menu launch for all sites.
Additional Medirest management support at Newark to support ensure a
smooth transition to the new system.
Mini PEAT audits scheduled for October & November.
On going programme of catering audits.
Risks
No risks for this quarter identified
Controls and Mitigation
Lead: Liz Nicholas FM services Manager
8
Enclosure F
Title : Quarterly Quality Report
-
Cleanliness
Q2 RAG
Q3 RAG
Date period : Quarter 2,
July – September 2012
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 Trust and jointly with Project co.
Key Aims for Q2
Progress against Quarter 2 Key Aims
Mini PEAT audits to be undertaken at King’s Mill Hospital, Newark Hospital and
Mansfield Community Hospital.
Ongoing schedule for monitoring cleanliness standards across all areas.
Mini PEATS were undertaken, with the scores achieved following a
consistent trend from the main PEAT in February 2012.
Cleanliness audits undertaken by Medirest under the frequencies
required under National Standards of cleanliness provided consistent
high scores. Cleanliness audits undertaken by the Trust solely and as
part of a joint team, which includes Infection Control, provides validation.
Patient satisfaction surveys for cleanliness undertaken by Medirest for all
three sites has shown that patients are reporting the cleanliness of all
three hospitals to be a high standard.
Actions to Deliver Quarter 3 Key Aims
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.
Medirest staff have attended CQC awareness training, and have been
provided with additional ongoing support by the Trust
Risks
No risks identified in this quarter
Controls and Mitigation
Lead: Julie Horrobin FM Performance and Quality Manager
9
Enclosure F
Title : Quarterly Quality Report - Serious Untoward Incidents / Never Events / Incidents
Q2 RAG
Q3 RAG
Date period : Quarter 2 July – September 2012
Aims / Objectives for 2012/13: To reduce serious incidents resulting in harm (including never events)
Key Aims for Q2
Progress against Quarter 2 Key Aims
Support ‘Handlers/Investigators’ in their efforts
to reduce the numbers of overdue incidents.
Reinforce the importance of reporting all types
of incidents and how this is proven to improve
overall patient safety.
Quarterly Progress Report:
Zero Never Events reported for this quarter.
Serious Incidents reported on STEIS this quarter Q2 12/13 was 20 compared to 15 for Q2 11/12 and 12 reported
on STEIS for Q1 12/13.
Continue to upload patient safety incidents to
the NPSA in a timely manner.
To complete investigations and conclude the
reporting mechanism on outstanding SI
reports
To complete investigations and close
outstanding incidents that are currently open
on the reporting database.
To share lessons learn and ensure robust
action plans are implemented and monitored
within the Trust and divisional governance
structures.
Quarter 2 produced 2044 incidents compared to 2063 the previous quarter with Falls, Pressure Ulcers and Medication,
continuing to be the top 3 sub-categories.
There are 21 open Serious Incidents past the reporting deadline (7 of which have been requested to be closed by the
PCT) compared with 27 still open past the deadline in qtr 1.
The numbers of long dated open incidents has shown a continued improvement over this quarter, reducing from 603 in
Q1/12/13 down to 565 at time of writing this report.
Falls:
• Patient falls continue a downward trend in both absolute numbers and relative to Trust’s increased activity: 486
patient falls Q1/12/13, 442 Q2/12/13.
Hospital Acquired Pressure Ulcers:
• 71 Hospital acquired pressure ulcers in Q2 12/13 compared to 76 in Q1 12/13 (72 HAPU in Q2 11/12)
• 11 grade 3 and Zero grade 4 Hospital Acquired Pressure Ulcers (HAPU) reported for Q2/12/13.
Medication:
• 250 Medication related incidents this quarter compared to 279 for Q1.
• The top ‘Adverse event’ was ‘Medication not administered, with Emergency Admissions Unit (EAU) having the
highest incidence.
Key Aims for Q3
Actions to Deliver Quarter 3 Key Aims
•
•
•
•
To continue to be a high reporting trust
To continue to investigate and close the SI
reports within the target response time.
To continue to work on investigating and
closing open lower level incidents within the
•
•
To complete the review of the incident reporting policy with the update Serious Incident policy from NHS Midlands
and East.
To drive the closure of long dated open incidents further
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.
10
Enclosure F
timescales.
•
To undertake the Manchester Safety Framework audit to measure where we are as a trust on the safety culture
matrix
Risks
Controls and Mitigation
Level of knowledge and skill in investigation and
report writing in order to close incidents within the
allotted timescale.
The most recent report from the National Learning Reporting System at the NPSA dated Oct 2011 to March 2012,
shows that we have improved our level of reporting from an average of 6 per 100 admissions to 7.8 per 100
admissions, which places us in the top quarter percentile of 4 medium acute trusts. In comparing us with our peer group
we appear to have fewer severe incidents and deaths as outcomes of the incidents reported.
Lead:
Lesley White, Patient Safety Manager
11
Enclosure F
Title : Quarterly Quality Report - Care of the Acutely Ill Adult Patient
Q2 RAG
Q3 RAG
Date period : Quarter 2 July – September 2012
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 Q2
Progress against Quarter 2 Key Aims
Overall compliance with all elements of the Observation and ACAT audit was 93%. This
To improve overall compliance with documentation of :
represents an improvement.
Five of the six mandatory signs were recorded in 100% of cases.
All 6 mandatory vital signs every 12 hours as a minimum
There was an improvement in recording AVPU (89% compliance) and ACAT was recorded
Monitoring plans
Carry out a ‘deep dive’ audit of the Observations and the
correctly in 86% of cases.
93% had 12 hourly observations as a minimum, and where abnormalities were present, this was
Augmented Care assessment Tool (ACAT) which complements
increased in 83% of cases. 96% of patients had monitoring plans, 82% of which were
ongoing audit via the metrics audit in ‘Test Your Care’.
contemporaneous.
To improve care of the hypoxic and/or hypovolaemic / hypo AIMS national training for all members of the multi-disciplinary team continues (and now includes
perfusional patient.
Healthcare Support Workers).
All nursing staff have been informed of their responsibilities regarding oxygen administration in
acute situations (with no requirement for a PGD) and supplementary oxygen training has
commenced at Newark with a view to sharing this Trust wide, starting with Emergency Admission
Unit (EAU).
A Patient Group Directive has been ratified to facilitate rapid administration of fluid resuscitation
to hypovolaemic or hypo-perfusional patients and implementation will commence in Q4.
Key Aims for Q3
To raise the profile of physiological track and trigger scoring and
continue to increase compliance with the Rapid Response Systems
currently in operation at Trust. The outcome of this will be to
increase vigilance around the deteriorating, acutely ill patient
potentially enhancing patient safety.
Implementation of the PGD for intravenous 0.9% sodium chloride.
Continue Acute Illness Management (AIMS) training for all members
of the multi-disciplinary team.
Risks
Members of the multi-disciplinary team do not comply with the
observation and ACAT policy
Lead:
Actions to Deliver Quarter 3 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.
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.
Michele Platt, Critical Care Nurse Consultant
12
Enclosure F
Title : Quarterly Quality Report - Maternity Care including Midwife to Birth Ratio
Q2 RAG
Q3 RAG
Date period : Quarter 2 July – September 2012
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 Q2
Progress against Quarter 2 Key Aims
All emergency caesareans are reviewed by a senior midwife and consultant to identify learning and feedback
to staff involved current rate averaging 19-21%. A prospective audit undertaken with the current rate
averaging 28-30%
•
Review Caesarean Section rates
•
Review Induction of Labour rates
•
Midwife to birth Ratio at 1:28
Current ratio 1:32 working with regional colleagues on a work force tool to reflect local variations. Visit from
SHA maternity lead to review service.
•
Reduce Smoking during pregnancy rates
Smoking at time of delivery audit completed, well received by staff and results are expected in Nov.
•
Monitor women’s experience of the service and their
perception of 1:1 care in labour
•
Participate in the BirthRate plus tool data collection
to ascertain current staffing levels against national
recommendations
100% of women who responded to the survey highlighted that they felt they had received 1:1 care in labour.
Of the 68 women surveyed, there was a low return rate of 28. Results are based on how attentive the women
feel their midwife has been during labour. This is carried out solely within the labour suite and does not
extend to other areas of the service.
Key Aims for Q3
•
•
•
Reduce Caesarean Section rates
Reduce Induction of labour rates
Improve Midwife to Birth Ratio
The unit has closed to admissions on two occasions during this quarter. On one occasion we had to admit
women as the neighbouring trusts could not offer respite due to their own pressure. We have also supported
other Trusts through their closures. This is notified by the local supervising authority database and it is
evident that especially during September many units have experienced significant capacity problems.
Actions to Deliver Quarter 3 Key Aims
Continue the work described above. Also, awaiting formal feedback from the service review and explore
staffing options to meet the gaps. A paper will be produced outlining the findings and recommendations of
BirthRate Plus.
Risks
Controls and Mitigation
A concern has been identified with the administration of
midwifery led referrals, following the reconfiguration of PPC.
There is also a storage issue and insufficient preparation of
notes prior to admission.
Andrew May is leading to identify a notes accommodation solution.
The concerns regarding referrals have been escalated through Business Strategy Units who now manage
PPC, who are identifying corrective actions. This is being discussed at clinical Governance Committee and
Divisional meetings.
Lead: Alison Whitham
13
Enclosure F
Title : Quarterly Quality Report - Incidents/Trends Slips, Trips and Falls
Q2 RAG
Q3 RAG
Date period : Quarter 2 July – September 2012
Aims / Objectives for 2012:
1. To reduce the number of falls resulting in harm to patients
2. To integrate the Trust falls service into community falls service
3. To improve the knowledge and skills of staff to prevent falls and manage patients at risk of falls
Key Aims for Q2
A. To ensure Trust wide protocols and guidelines are updated and in line
with national guidelines.
• 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
• Night time elderly and frail people safe transfer policy
• Footwear project
• Improving equipment availability: walking aids, alarm system
C. To identify areas for improvement by Datix data analysis and review of
serious incidents related to in-patient falls
Key Aims for Q3
•
•
To complete the Quarter 2 project related actions
To review training and ensure it is appropriate for all categories of
staff
Risks
•
•
•
Failure to identify patients at risk and appropriately manage
various individual risk factors
Inadequate resource availability and location
Inconsistent management of patients at risk of falling
Progress against Quarter 2 Key Aims
•
•
•
•
•
•
The falls policy and bed rail policy have been reviewed and circulated for consultation.
To be submitted for approval in November 2012
Work is in progress to change falls risk assessment and care plan. The nursing
th
documentation group is to agree and approve the new documentation by 15 of
November 2012
A working group has been established to review the escalation and usage of
‘specialing’ across the Trust.
A paper is being written outlining the potential cost and care benefits of initiating an
outreach falls team who could work flexibly across areas of greatest need. This would
potentially reduce agency use and ensure the appropriate patients have the required
special input.
A Trust action plan for falls is under development and will be discussed at the Falls
Steering Group meeting in November 2012.
The system for feeding back falls data is currently being reviewed to ensure it is
accessible to ward leaders and Heads of Nursing, alongside other data sets which
indicate care standards across clinical areas.
Actions to Deliver Quarter 3 Key Aims
•
•
To review and update training sessions
Undertake a training needs analysis
Controls and Mitigation
• Work is underway to update the falls risk assessment and care plan to give clearer
•
•
signposts to staff and improve the quality of assessment and documentation.
A scoping exercise is in progress to assess resource availability.
The work to increase and improve the training will reduce inconsistencies.
Leads: Dr Anne-Louise Schokker, Consultant Geriatrician & Elena Caraman, Advanced Nurse Practitioner
14
Enclosure F
Title : Quarterly Quality Report - Infection Prevention & Control (IPC)
Q2 RAG
Date period : Quarter 2 July – September 2012
Q3 RAG
Aims / Objectives for 2012/13:
•
To maintain surveillance and infection control and prevention targets: MRSA bacteraemia: Trajectory 0, C. difficile infection: Trajectory 36, MSSA
bacteraemia: No national set trajectory, E. coil bacteraemia: No national set trajectory
•
Review of all IPC policies and guidelines before the end of Q4 in line with the Infection Prevention & Control Team (IPCT) programme.
Key Aims for Q2
• To remain within the MRSA bacteraemia trajectory for Q2
•
To remain within the C. difficile infection trajectory for Q2
•
To achieve < 5 MSSA bacteraemia for Q2
•
To achieve < 1 E. coil bacteraemia for Q2
•
To develop the Norovirus toolkit
•
To review the Norovirus policy
•
To proactively manage outbreaks
•
To ensure that damaged flooring on WD 33 is replaced
•
To ensure capacity and flow is maintained
•
To ensure policies and reviewed and updated within the
timescales required
•
To establish the Care Quality Commission (CQC)
Outcome Guardian role for Outcome 8 (Infection
Prevention and Control)
Key Aims for Q3
Progress against Quarter 2 Key Aims
• The IPCT has identified that further clarity is required on how surveillance is reported across
the Trust. It was agreed at the September Infection, prevention and Control Committee (IPCC)
that all surveillance reporting will be standardised and report ‘year to end surveillance’.
• During quarter 2 there were no hospital acquired cases of MRSA bacteraemia.
• To date there has been 9 cases of hospital acquired C. difficile infection (trajectory 18).
• To date there has been 4 cases of MSSA bacteraemia.
• To date there has been 24 cases of E. coil bacteraemia; of which 1 was a urine catheter
related which was in Q1.
• To date there has been 5 separate norovirus outbreaks, affecting a total of 33 patients and 20
members of staff with 77 bed days lost.
• A Norovirus Toolkit has been designed and issued to all clinical areas throughout the Trust.
• A Norovirus policy developed, consultation period complete and was ratified at the clinical
th
policy group on 17 September 2012. Now available on the Trust Infection and prevention (IP)
web page.
• The damaged flooring on Ward 33 has been replaced, along with the bed head buffers and the
area received Hydrogen Peroxide Vapour decontamination prior to reopening.
• IPCN attendance at the Capacity and Flow meeting during winter pressure was discussed at
the September IPCC meeting. It has been agreed that an IPCN will attend the 10am Capacity
st
th
and Flow meeting from the 1 October until 30 April. During outbreaks if required the IPN’s
will attend this meeting more frequently.
• During this quarter several policies have been reviewed including: Hand Hygiene, Infectious
outbreak/incident policy including major outbreak, Policy regarding safe linen disposal, Policy
for the management of scabies in a healthcare setting and Management for the deceased with
a suspected known infection – these policies will be forwarded to the Clinical Policy and
Guideline Group for ratification.
• The Nurse Consultant has set up 4 (red, green, blue, yellow) teams with a lead infection control
nurse within each team to do outcome guardian visits. 10 of these have been undertaken.
Actions to Deliver Quarter 3 Key Aims
15
Enclosure F
To remain within trajectory for surveillance
To develop assessment tools, patient’s information letter and
set up database
To develop audit tools to be ‘form’ based – electronically
completed, database
To review policies and review risk assessment frameworks for
IPC
Review the RCA’s for bacteraemia
Include Group A strep surveillance for maternity unit
Development of SSI surveillance tool
Development of SSI database
To undertake a Clinell trial
Perform the risk assessment/risk plans for IPCT
To continue the Outcome Guardian visits and put actions in place to address the 2 key themes that
have already been identified
Clinell wipe trials:
Two products are being trialled (commenced end of September), which will run into Q3. If successful
there is a significant cost saving by implementing both wipes, which would require a cost comparison:
a) Clorox Wipes for the cleaning of commodes and C.difficile positive bed spaces
b) Continence Care Wipes for the cleaning of patients skin following incontinence
Risks
ICNet Version 5
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.
Lead:
Controls and Mitigation
•
•
This was discussed briefly at the September IPCC and a demonstration has been arranged for
November 2012 to assess the benefits.
A recommendation will be made to the IPCC following the demonstration and next steps
identified.
Suzanne Morris, Nurse Consultant, Infection Prevention and Control
16
Enclosure F
Title : Quarterly Quality Report
- Nutrition
Q2 RAG
Date period : Quarter 2, July – September 2012
Q3 RAG
Aims / Objectives for 2012/13:
To provide a high standard of nutritional care to patients within the Trust:
All adult in patients 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 Q2
Progress against Quarter 2 Key Aims
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
Actions to Deliver Quarter 3 Key Aims
Key Aims for Q3
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.
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 visits undertaken in 3 areas and feedback given to ward leaders.
Ward metrics scores for nutrition during August reduced significantly
To ensure protected mealtimes is embedded throughout the Trust.
Continue to meet with nutrition board and sub groups.
Central line audit on going
Continue to monitor correct completion of MUST screens
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
th
Plans are underway for promoting Nutritional Day on 8 November
Risks
Controls and Mitigation
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.
Lead: Angela Hill, Nutrition Nurse Specialist
17
The nursing metrics are undertaken monthly and identify any areas of
concern. These are discussed with the ward leader to put actions in place.
Training on MUST tool will take place via registered nurse time outs and
nursing induction.
Enclosure F
Title : Quarterly Quality Report – Pressure Ulcer Prevention
Q2 RAG
Q3 RAG
Date period : Quarter 2 July – September 2012
Aims / Objectives for 2012:
Pressure ulcers are no longer a specific CQUIN target this year but are part of the Quality Schedule. The contractual requirement is to reach Zero Tolerance of Avoidable
Pressure Ulcers by the end of March 2013, with incremental reduction targets through each quarter.
Key Aims for Q2
Performance against Quarter 2 Key Aims
Continue the “No Pressure” communication campaign across the Trust
th
Raise awareness during national Pressure Ulcer week commencing 17 September
Training the Link Nurses to roll out the S.K.I.N.S. tool in their areas
Continued targeting of all pressure damage within the Trust by the TV team
Development of a culture of Zero Tolerance to avoidable pressure damage
To attend the Pressure Ulcer Prevention Collaborative Programme, which is a national
venture where teams gain leadership development and training tools.
Audit pressure relieving equipment and provide a gap analysis of any deficit
requirements for all hospitals within the Trust.
Complete all Route Cause Analysis presentations on grade 3 pressure ulcers so that
lessons and themes can be shared amongst nurse leaders and clinical staff to prevent
repetition of similar issues.
Key Aims for Q3
Review all Trust Guidance and documents relating to Pressure Ulcer care to reflect
strategy and best practice.
Develop an education programme for patient’s carers and staff to promote
prevention of pressure ulcer development.
Continue the implementation of the S.K.I.N.S tool to embed the new
documentation
Actions to Deliver Quarter 3 Key Aims
Promotion of the “No Pressure” Campaign and the S.K.I.N.S Tool
Auditing compliance of the S.K.I.N.S Tool
Continued targeting of all pressure damage within the Trust by the TV
team
Development of a culture of Zero Tolerance to avoidable pressure
damage
Engaging patients/carers in pressure ulcer prevention
18
Monthly communications delivered on I care 2 site to. Pressure ulcer
TH
week 17 September celebrated in “the street” supported by a
focused key pressure ulcer prevention messages and PU logo badges
distributed to staff. Stand was manned by staff raising awareness to
both staff and public.
TV team continue to review all reported grade 2,3,4 pressure ulcers
delivering patient and staff education at the bedside driving a no
tolerance approach.
Training for all Link Staff has been delivered to support the
Introduction of the S.K.I.N.S tool. A rolling programme of ad hoc
training has been delivered across all hospitals sites and clinical areas
by the TV team.
S.K.I.N.S tool has been implemented in all areas throughout the trust.
A tool has been developed and used
by the TV team to test S.K.I.N.S compliance formal and written
feedback is given to Ward leaders HON.
A Multidisciplinary Pressure Ulcer Collaborative team has been
established to attend regional collaborative work streams. This team
feeds into the Pressure Ulcer steering group and has helped to inform
the PU work programme for 2012/13
Full trust wide mattress audit undertaken in September
Grade 3 Pressure Ulcers presented at monthly PU Steering group and
lessons learnt are shared.
Enclosure F
Risks
Controls and Mitigation
Unable to recruit to Nurse Consultant Tissue Viability which is leaving a gap
around clinical expertise.
nd
Community Specialist TV Nurse employed by CHP was withdrawn on 2 July, with
no prior notice.
Leads: Sandra Hopkinson, Head of Nursing
19
This post is being re-submitted via the vacancy approval process so it
can be re-advertised
Discussions have taken place over the past few months between CHP
and commissioners who have agreed to fund 6 months of Band 7.
Enclosure F
Clinical Effectiveness
Heart attack secondary prevention. July 2012 to Sept 2012. Quarter 2.
Percentage of heart attack patients prescribed an anti-platelet, statin or beta blocker. National standard identified in the NSF for CHD.
Quarterly progress highlights
Risks & Issues
•
Taken from MINAP (Myocardial Ischaemia National Audit Project) data.
Period of July, 2012 – Sept, 2012. Data includes all patients discharged
alive with a discharge diagnosis of MI.
Aspirin
B Blocker
Ace
Clopidogrel
Statin (all
admissions)
Number of patients
KMH
100.0%
98%
98%
100.0%
100%
•
None.
Added value
•
National
99.4%
97.0%
95.7%
Main activities for next quarter
98.5%
•
81
•
To note: contractually the trust is required to have 90% of patients
discharged on secondary prevention medication
•
King’s Mill has maintained a strong performance across all categories.
•
Single audit clerk now collecting data enables more consistency in data
collection.
Continue to collect data on all ACS patients admitted rather than only
NSTEMI patients.
Validation of audit is due over the next quarter.
Author: Joanne Davies, Clinical Audit Assistant in Cardiac and Stroke Services
20
Enclosure F
Clinical Effectiveness
Status
PROMS – QUARTERLY PARTICIPATION RATE REPORT
Quarterly Progress Report
Risks and Issues
The PROMs pre-operative questionnaire participation and linkage rates for Sherwood
Forest Hospitals Trust for the period April 2011 to March 2012 are shown below.
PROMs pre-operative questionnaire participation and linkage
rates
All Procedures
Groin Hernia
Hip Replacement
Knee
Replacement
Varicose Vein
Total
eligible
episodes
1,390
436
355
Q1s
completed
1,172
352
290
Participatio
n rate
84.3%
80.7%
81.7%
Q1s
linked
831
271
193
Linkage
rate
70.9%
77.0%
66.6%
433
166
429
101
99.1%
60.8%
278
89
64.8%
88.1%
All procedures
Groin Hernia
Hip replacement
Knee replacement
Varicose Vein
•
•
•
•
Q1s
completed
827
314
180
251
82
Participatio
n rate
70.6%
89.2%
62.1%
58.5%
81.2%
Q1s
linked
529
191
136
168
34
Linkage
rate
64.0%
60.8%
75.6%
66.9%
41.5%
Provisional PROMs data for 12/13 for the period April 2012 to May 2012 has been
published but this is currently not available at a provider level.
Author: Julie Jan – Deputy Divisional Director – Planned Care & Surgery
21
None identified this quarter
Main activities for next quarter
•
The PROMs post-operative questionnaire participation and linkage
rates for Sherwood Forest Hospitals Trust for the period April 2011 to
March 2012 are shown below.
Total
eligible
episodes
1,172
352
290
429
101
•
Continue to encourage and collate PROM related data for
submissions to HES
Need to investigate why the participation rate for Varicose
vein procedures are much lower than the other
procedures. Pre and post op pathway to be reviewed.
Continue to interrogate National database at provider and
consultant level to determine variance in participation rates
New questionnaire forms received and will be in use from
17th Oct 2012 at both King’s Mill and Newark hospitals
Review the questionnaire process for all procedures post
operatively to ensure patients are getting the forms.
Enclosure F
Clinical effectiveness
To improve outcomes for stroke patients using the 9 SENTINEL indicators as a measure.
NICE, NSF, National Stroke Strategy: July to September- Quarter 2, 2012.
Quarterly progress highlights
Risks & Issues
•
•
Thrombolysis rates improving- 8% of stroke cases this quarter vs
National target of 10%.
Increasing recruitment to stroke research trials- 9th out of 23 in
East Mids league tables
Indicator
Qtr 3 Qtr 4 Qtr 1 Qtr 2
11/12 11/12 12/13 12/13
95%
96%
85%
95%
•
•
•
•
•
•
Dr Foster reporting rising stroke mortality
Lack of weekend therapy staff on Acute Stroke Unit.
Bed capacity pressures.
Lack of Community Stroke Team may lead to capacity issues if
inpatient bed base decreases
Still dependent on locum consultant staff (2 out of 4)
Decrease in Trust’s SALT contract may adversely impact on stroke
service
Patients spend at least 90% of
their stay on a stroke unit
Screening for swallowing
100% 99%
97%
99%
Added value
disorders <24hrs after
admission
• Role out of RCP SSNAP real time stroke audit will allow closer
Brain scan within 24hrs of
100% 100% 100% 96%
scrutiny of service.
stroke
Anti-platelet medication by
100% 100% 99%
100%
Main activities for next quarter
48hrs after stroke
Physiotherapist assessment
95%
98%
99%
100%
• Develop cross-site working with NCH to allow progress towards
within 72hrs of admission
24/7 thrombolysis service.
OT assessment within 4
91%
94%
99%
99%
• Enhance nursing expertise to support telemedicine projectworking days of admission
establish 24/7 Band 6 cover in line with peer stroke services
Patient weight during admission 100% 100% 98%
100%
throughout Region
Rehabilitation goals by the multi 100% 100% 96%
99%
• Relocation of Rehabilitation from ACH to KMH.
disciplinary team within 5 days
• Establish 6/52, 6/12 and annual stroke F/U in accordance with
Patients mood assessed by
100% 99%
95%
100%
National Stroke Improvement Programme
discharge
% patients who achieve all 9
83%
87%
96%
99%
indicators
The results from Quarter 2 from the ongoing measurement against the
9 Sentinel Audit KPIs are shown in the table above and show
maintained/continuing improvement.
Author: Martin Cooper, Stroke Physician & Joanne Davies, Clinical Audit Assistant in Cardiac & Stroke Services
22
Enclosure F
QUARTERLY UPDATE ON PROGRESS AGAINST THE COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN) TARGETS
QUARTER 2
1 JULY TO 30 SEPTEMBER 2012
The highlight reports that follow give an indication to the Board of progress to date, against the Nottinghamshire County CQUIN schemes with a total value of circa
£4.5m..
23
Enclosure F
Title : Quarterly Quality Report – CQUIN A) Improving Dementia Care B) Dementia Training
CQUIN Annual Value: £720k
Date period : Quarter 2 July – September 2012
Q1 Rating
Q2 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 Q2
• Production of a risk assessment tool
• Education of clinicians and nursing staff across Trust
• Safeguarding nurses and lead medic will focus upon Assessment
Units to increase awareness and compliance to documentation
• Agreement of structure to ensure successful implementation within
these areas
• Produce and consolidate action plan in Quarter 2
• Prepare for Q3/4 requirements
• Programme of Clinician education
• Continuation of Dementia & MCA training at Induction and
Mandatory sessions
• Possible fixed term recruitment of a fixed term data clerk to support
the CQUIN delivery
Progress against Quarter 2 Key Aims
• Dementia Screening Assessment & Diagnosis (DSAD) tool finalised and in place
• Education programmes rolled out across trust.
• Safeguarding nurse making daily visits to admission areas and wards
• Dementia and Mental Capacity Act (MCA) training continued
• A system has been implemented for data collection and national submission of data
• Recruitment of nurse (fixed term) to lead dementia strategy and CQUIN
Key Aims for Q3
• Aim for percentage targets for DSAD completion (as above)
• Raise awareness trust-wide
• Continue programme of education and training
• Re-invigorate dementia as a key agenda for clinicians and wards.
Actions to Deliver Quarter 3 Key Aims
• Clarify DSAD placement and filing for ward receptionists
• Investigate possibilities of IT for referral data (Orion question)
• Raise awareness –
- F1 teaching and grand rounds, nursing bulletin/posters
- Raise public profile of dementia screening
• Push trust dementia strategy forward
• Restructuring and reinstatement of Trust Dementia Working Group
• Support data collection/ maintain vigilance
Controls and Mitigation
• Re-engagement of clinicians and ward staff
• Dedicated nurse lead for dementia CQUIN
• Support data clerks and ensure regular feedback of current processes (weekly meetings)
th
th
Summary 13 August – 30 September
• Criteria 1 – 26% (Q2 no target, Q3 Target 95%)
• Criteria 2 – 30% (Q2 no target, Q3 Target 100%)
• Criteria 3 – 97% (Q2 no target, Q4 Target 100%)
• Dementia training compliance - 83% (Q2 target 70%)
Risks
• Reliant on engagement of clinicians trust-wide
• Current low percentage rate of completed assessments
• Level of change involved
• Labour intensiveness of data collection
Lead: Dr Steve Rutter, Consultant Geriatrician & Adam Hayward, Service Improvement Nurse - Dementia
24
Enclosure F
Title : Quarterly Quality Report – Failure to Rescue CQUIN
Annual CQUIN Value: £511k
Date period : Quarter 2 July – September 2012
Q1 Rating
Q2 Forecast
CQUIN Target: To reduce avoidable cardiac arrests by 50% by Quarter 4
Key Aims for Q2
1. Collection of data for “avoidable” cardiac arrests – feedback to wards & Consultants
2. Review all “avoidable” cardiac arrests and provide feedback to parent teams
3. Communications drive to highlight avoidable cardiac arrests and plans to reduce
them
4. Education – targeted ward-based Augmented Care Assessment Tool (ACAT)
training, AIM courses, junior doctor induction
5. Observation charts (re-design)
6. Acute Response Team: further publicity (especially for August hand-over) & audit
7. Develop Patient Group Directive (PGD) for Oxygen and Fluids
8. Engage senior medical staff: Consultant review of deteriorating patients, plus Allow
Natural Death (AND) and Ceiling of Therapy decisions
Key Aims for Q3
1. Continue to collect data for “avoidable” cardiac arrests & feedback to wards &
Consultants
2. Continue to review “avoidable” cardiac arrests, feedback to parent teams – ensure
response and chase up action plans.
3. Implementation of NEWS (National Early Warning Score) and development of
NEWS observation charts
4. Education – publicity & training on NEWS and escalation policy, training on Fluids
PGD
5. Re-write observations policy incorporating NEWS and NEWS escalation policy
6. VitalPAC – consider introduction of electronic monitoring of observations
7. Introduction of ceiling of therapy/treatment escalation plan document
8. Link into other key groups in Trust – Sepsis, Acute Kidney Injury
Risks
1. Staffing levels – ability of CCOT and NTLs to respond to increased volume of calls
generated by adoption of NEWS
Lead: Dr Lisa Milligan, Consultant in Anaesthetics and Intensive Care Medicine
Progress against Quarter 2 Key Aims
1. Data for Q2 will be sent to wards and consultants within the next 2 weeks.
By the end of quarter 2 a 52% reduction in avoidable cardiac arrests
has been achieved. This meets the Q2 CQUIN.
2. All “avoidable” cardiac arrests during Q2 have been reviewed by CQUIN
team and feedback sent to parent team Consultants.
3. Junior doctor induction training completed. On-going ward-based targeted
ACAT training, and monthly AIM courses, including courses for HCA’s.
4. Observation chart redesign – on going. Decision to change to National Early
Warning Score (NEWS).
5. Further publicity re Acute Response Team (ART) in early August, including
pop-ups. ART audit on-going.
6. PGD fluids approved by DTC – roll out and training to commence.
7. Medical Grand Round presentation on resuscitation decision making in early
August. Patient info leaflets redesigned. Formation of Consultant group to
discuss AND & ceiling of therapy decisions (due to meet 27 November)
Actions to Deliver Quarter 3 Key Aims
1. Agree the new version of the observation chart, based on NEWS
2. Agree the rollout and training plan for the NEWS chart across the Trust
3. Scope the impact on the Critical Care Outreach Team (CCOT) team in terms
of additional calls
4. The 12/13 action plan will be reviewed at the Failure to Rescue project group
meeting and specific actions allocated.
Controls and Mitigation
1. On-going discussions about staffing levels with Trust management, on-going
CCOT audit of calls
25
Enclosure F
Title : Improving the experience of patients with Learning Disabilities (LD)
Annual CQUIN Value £340k
Date period : Quarter 2 July – September 2012
Q1 Rating
Q2 Forecast
CQUIN Targets for 2012/13:
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 Q2
• Ongoing audit to find out whether patients with learning disabilities have a
longer length of stay at SFHFT and the reasons for this.
•
Review LOS data for Q2 with an associated audit to be undertaken on any
patients with longer LOS.
•
To continue to meet at the Learning Disabilities Steering Group 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 2 Key Aims
• Flagging system – Ongoing flags added as patients are seen by the learning
disability nurse specialist. The number of patients flagged so far is 258
•
During Quarter 1, the data supplied did not show a longer mean Length of Stay
for learning disabilities patients. The audit enabled patients with a higher than
average LoS to be identified and any Audit results showed that patients were
receiving active treatment and therefore were not a medically fit for discharge.
This has remained the case in the monthly audits undertaken.
•
Patient & Carers involvement – The August learning disability steering group
was cancelled due to low attendance, next meeting in November 2012. Patient
feedback has continued to be collated from inpatients on a monthly basis
•
The trust went to the Learning Disabilities Partnership Board on 6 September
to report on the CQUIN and inform interested parties of ongoing work.
th
Key Aims for Q3
• 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 3 Key Aims
th
• Learning disability steering group scheduled for Wednesday 28 November
2012.
• Continue to audit LOS for LD patients.
• Attend learning disability Partnership board meetings
• Continue to collect patient experience feedback
• Continue to Flag new patients to the electronic system
Risks
• Data for Q2 Length of Stay for Learning Disabilities against Trust average
is currently being collated
Controls and Mitigation
• Learning Disabilities nurse is proactively auditing the notes of patients who
have previously been admitted so any themes or issues of concern relating to
extended LOS can be addressed.
Lead: Claire Henley – Learning Disability Nurse Specialist
26
Enclosure F
Title : Quarterly Quality Report - Net Promoter Score (NPS)
ANNUAL CQUIN VALUE £340K
Date period : Quarter 2 July – September 2012
Q2 RAG
Q3 RAG
Aims / Objectives for 2012/13: To maintain a NPS of 71 or above per month
Key Aims for Q2
Results:
July:88
Aug:75
Sept:83
The aims are:
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 wards staffs general awareness of care, dignity and compassion
To ensure other teams visiting wards take action if they identify any areas of
concern
Key Aims for Q3
Ensure monthly scores remain above 71
Risks
The risk is that if one person chooses not to recommend us the overall score can
become very low.
Lead: Sally Dore, Director of Customer Experience and Engagement
27
Progress against Quarter 2 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
Customer services now collate the feedback from patients when
asking these questions and will log on datix, identifying if the patient
was a promoter, passive or detractor. This will enable a greater
understanding of the reasons for the scores. This is also being
compared to the inpatient survey results
All registered nurses have been invited to a Care, Dignity and
Compassion all day training event. Many have already attended
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.
There are thoughts that the Doctors handover in August may have
adversely affected the results.
Actions to Deliver Quarter 3 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
Controls and Mitigation
The above actions are in place to ensure patients do get a good
experience and would recommend our service.
Enclosure F
Title : Quarterly Quality Report + Improving choice at End of Life
Annual CQUIN Value: £340k
Date period : Quarter 2 July – September 2012
Q1 Rating
Q2 Forecast
CQUIN Aims / Objectives for 2012/13:
•
•
Improve identification of patients in the last year of life, communication with primary care and expedition of patients preferred place of care.
Primary care notification for at least 80% of patients on the Liverpool Care Pathway (LCP), within 24 hours
Key Aims for Q2
•
•
•
•
•
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 collaboratively 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.
On-going monthly audit to assess the compliance with
the implementation of the Liverpool Care Pathway and
Preferred Place of Death.
Key Aims for Q3
•
•
Continue to work collaboratively with primary care 24
RE: 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.
Progress against Quarter 2 Key Aims
1a: Identification of patients in the last year of life.
• Data shows 31 patients were placed on the End of Life register during July to September 2012.
This met the CQUIN requirements.
• End of Life Care covered in a Grand round presentation, to inform all medical staff of the
importance of early identification of patients approaching End of Life.
• 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.
1b: Primary Care notified of patients being placed on the Liverpool Care Pathway within 24 hours.
• 75 patients were coded as commenced on the Liverpool Care Pathway between 01.07.201230.09.2012, Primary Care were informed of 81% of these patients.
• End of Life Care Coordinator continue to notify Primary Care within 24 hours of patients
commencing on the Liverpool Care Pathway.
• Improvement in ward staff informing Primary care and End of Life Care Coordinator
Actions to Deliver Quarter 3 Key Aims
•
•
•
•
On-going monthly audit to assess compliance with the implementation of the Liverpool Care
Pathway and PPD.
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 patient on the Liverpool Care Pathway to Primary Care
28
Enclosure F
•
•
•
Risks
•
•
•
On- going monthly audit to assess the compliance
with the implementation of the Liverpool Care
Pathway and Preferred Place of Death (PPD).
Continue to deliver education on Induction
programmes, Registered Nurse Development Days,
Workshops, Medical Grand Rounds & Face to Face
teaching on the Wards
Continue to monitor progress being made on actions
within Trust Action Plans produced as a result of
participating in the National Cancer Network, local
audits and CQUINS
•
•
and End of Life Care Coordinator.
Establish discharge process to include questions surrounding identifying patients approaching end
of life.
Deliver on a number of education programmes
Update Trust Action Plans to reflect progress being made in improving EOLC
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.
•
•
Promote Primary Care 24 contact number (24 hour day/ 7 day week)
Limit number of professionals involved in referral process, i.e. Discharge Team and End of Life
Care Coordinator.
Lead: Dr Mark Roberts, Consultant & Lead for End of Life Care
29
Enclosure F
Title : Quarterly Quality Report Venous Thrombo-prophylaxis (VTE)
Annual CQUIN Value: £340k
Date period : Quarter 2 July – September 2012
Q1 Rating
Q2 Forecast
Aims / Objectives for 2012/13:
To improve the assessment and treatment of patients with VTE.
Key Aims for Q2
• To achieve 93% Compliance for VTE risk assessment. This is based on the
monthly compliance below
• To achieve 93% compliance in re-assessing patients their condition changes
significantly i.e. taken to theatre/ITU/CCU – currently 91.90% ( still collecting
data )
• To achieve 100% -patients requiring prophylaxis receive it in an appropriate and
timely manner.
Progress against Quarter 2 Key Aims
• July 93.04%, August 93.05%, September 93.15%
• To achieve 93% compliance in re-assessing patients their condition
changes significantly i.e. taken to theatre/ITU/CCU – currently 91.90% (
still collecting data )
• To achieve 100% -patients requiring prophylaxis receive it in an
appropriate and timely manner. 100% achieved.
Key Aims for Q3
• Increase in level of compliance needed to achieve is 95% for VTE Risk
Assessment.
• Undertake case reviews of hospital acquired thrombus to learn lessons
Actions to Deliver Quarter 3 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
Risks
• CQUIN requirements not met resulting in a loss of payment
• Patient safety issues if not Risk Assessed for VTE
• Data collection clerk has tendered her resignation and this will be a risk to
collecting the data if the vacancy is frozen
Controls and Mitigation
• Monitoring system in place to identify any specific issues within areas
• Alternative ways for working in place to cover data collection process
while considering the need to re-appoint to the post.
Lead: Dr Samuel Kemp, Consultant & Clinical Lead for VTE
30
Enclosure F
Title : Quarterly Quality Report + Emergency Department (ED)Streaming
Q1 Rating
Date period : Quarter 2 July – September 2012
Q2 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 Q2
Progress against Quarter 2 Key Aims
•
A minimum of 8% of ED attendances 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.
7% of all presentations were streamed to primary care, however 11% of patients
who could be streamed were streamed, which reflects the current rise in activity
through majors and resus. This meets the CQUIN requirements.
•
Q2 CDU partly operational by 1 July 2012
Appropriate patient pathways and operational policy all developed within quarter.
Key Aims for Q3
Actions to Deliver Quarter 3 Key Aims
For Q3 – 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.
Sustain current performance in streaming all appropriate patients to primary care,
review clinical criteria post audit.
Q3&4 – Fully functioning CDU by 1 October
The CDU is now in operation and a review of clinical pathways has commenced
Risks
Controls and Mitigation
Primary Care Streaming – opening of PC24 “front door” may reduce the number of
patients attending the ED with minor illness.
Discussion during ED/PC management meeting regarding review of percentage
required to meet target and increase focus on audit. This is being monitored via
the Trust contract meetings.
CDU – Trust overall capacity could impact on the ability to utilise beds on EAU for CDU
patients
CDU – Mitigation, highlight and identify patients suitable for CDU tariff.
Lead: Julie Dixon, Head of Nursing
31
Enclosure F
Title : Quarterly Quality Report – Think Glucose
CQUIN Annual Value: £511k
Date period : Quarter 2 July – September 2012
Q1 Rating
Q2 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. 80% reduction of insulin medication errors by Quarter 4.
Key Aims for Q2
Progress against Quarter 2 Key Aims
1. Develop and prepare for a trust wide pilot of new
blood sugar monitoring form
2. Meet with IT representative to implement ‘flagging’
system for diabetes patients
3. Work with Pharmacy to reduce insulin errors.
4. Identify clinical leads for each element of the CQUIN
to drive delivery.
Key Aims for Q3
1. Standardised referral process for specialist diabetes
intervention to be discussed at Steering Group
Meeting
2. Think Glucose information will be available at point of
use
3. Work towards reducing insulin errors
1. Form has been developed and approved by nursing documentation group and rolled out
2. A Think Glucose training session has been introduced to the Registered nurse time out days, which
features a patient story to reinforce key messages.
3. Training of ward based nurses and doctors is underway using Think Glucose criteria.
4. Training in use of Think Glucose criteria will follow the Admission to Discharge, incorporating the
Diabetes Inpatient Care Teaching Framework.
5. Work is in progress to develop a separate insulin prescription sheet and sliding scale sheet and promote
insulin safety on e-learning.
6. Insulin safety on line training is now mandatory and is assessed at junior doctor induction.
7. 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.
8. An in-patient diabetes service has been introduced.
Actions to Deliver Quarter 3 Key Aims
1. Diabetes team to work with divisional management team to review implications of service redesign to
orientate the diabetes and endocrinology service towards delivering a specialist in patient service.
2. The clinical team have undertaken the National In patient diabetes audit questionnaire. The use of this
structure is a part of the inpatient proposal. This measures the number of incident errors.
3. The National in patient diabetes audit data for October 2012 will be published on line in February 2012
were we are benchmarked against other trusts and I suggest we use that for the next quarterly report in
addition to January data.
4. Training will be conducted by a dedicated Diabetes support nurse with supervision by the Diabetes
Specialist nurses.
Risks
Controls and Mitigation
1. At present, there is no standardised referral process.
1. Plans for the review and redesign of the referral process is being discussed at the next steering group
This is being reviewed by the diabetes team.
meeting
2. Potential lack of clinical buy-in and awareness to
2. Opportunities to target senior medical staff are currently being scoped and awareness is being raised
achieve the LOS reduction
across nursing teams via the time out days and ward leader meetings.
3. Loss of income resulting in failure to deliver CQUIN
(£116)
LEAD: Dr Devaka Fernando, Consultant in Endocrinology and Diabetes
32
Enclosure F
Title : Quarterly Quality Report – Safety Thermometer
Annual CQUIN value £340K
Q2 RAG
Date period : Quarter 2 July – September 2012
Q3 RAG
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 and Q2 submitted to date.
2) To have 95% “harms free” care by December 2012 (stretch/ aspirational target)
Key Aims for Q2
Progress against Quarter 2 Key Aims
1) To ensure data is collected monthly
2) To report on the data to the NHS Information
Centre
3) ST information to be reviewed at Professional
Advisory Group to ensure it is being acted
upon effectively
4) Reports to be made available to Pressure
Ulcer and Falls Steering Groups
5) To continue to communicate to the ward staff
the designated day for data collection to
prevent any none collection of data.
1) Achieved: All Wards submitted data for July, August & Sept 2012.
Key Aims for Q3
1) To ensure data is collected monthly on ALL
wards
2) To report on the data to the NHS Information
Centre
3) ST information to be reviewed at PAG to
ensure it is being acted upon effectively
4) 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.
Lead:
Harms Free Care old (pre admission)+ new harms
Harm Free Care new harms(on or during admission)
Q1 90% (1625/1810),
Q1 96% (1735/1810),
Q2 91% (1647/1808)
Q2 97% (1743/1808)
2) Achieved: Data cleansed and then submitted to NHSIC within required deadline. During Q2, the NHSIC commenced
a data quality check process and SFH is one of the few Trusts that was reported as having no data quality issues for
Aug and Sept 2012.
th
3) Pending: PAG to review information on Wednesday 24 October. However in addition to a PAG review the
Divisional Governance Advisors have been introduced to the Safety Thermometer tool and Divisional Safety
Thermometers are now being created monthly and forwarded to the Division for review and appropriate action (as of
Oct 2012).
4) Achieved: Safety Thermometer PU data used by the Pressure Ulcer Collaborative group and falls data has been
included within the Monthly report to the Trust Falls and Safety group.
5) Achieved: Reminder send via Nursing Bulletin in August (Alison Clarke).
Actions to Deliver Quarter 3 Key Aims
1) Email reminders send for Safety Thermometer Co-ordinator to HoN and wards leaders 5 days before, 2 days before
and on the data collection day. This allows HoN, Ward leaders to nominate alternative staff to collect data in the
event of illness/ leave etc.
2) An additional member of Staff within E.A.R has been trained in data validation and procedures to upload data to
NHSIC ensure continuity of data submission in case of sickness.
th
3) Awaiting response from PAG review which is scheduled for 24 Oct 2012. Any required actions will be implemented
4) 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.
Controls and Mitigation
1) 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.
2) Additional member of Staff trained in EAR to submit data
3) Additional and on-going 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
33