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Tabled paper

QUALITY REPORT

CONTENTS

A monthly report presenting an update on Patient Safety, Clinical Effectiveness and Patient Experience in the Trust

October 2012

Tabled paperSection Item Page No.

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Tabled paper1 INTRODUCTION 32 KEY POINTS TO NOTE 33 TARGETED AREAS OF SUPPORT 54 EMERGING TRENDS/NOTICEABLE PATTERNS 55 OF SPECIFIC NOTE 56 KEY CLINICAL RISKS 57 CARE QUALITY COMMISSION’S QUALITY & RISK PROFILE 68 new CQuINS 79 PATIENT SAFETY 79.1 Safety Thermometer

a) Fallsb) Pressure damagec) VTE assessment

8101111

9.2 Nutrition/fluids 119.3 Infection Control 129.4 Maternity 159.5 Emergency Department highlights 169.6 Safeguarding 169.7 Medicines management 169.8 Never Events 169.9 National Patient Safety Agency (NPSA) alerts 179.10 Lessons Learned 179.11 Significant risks 179.12 ‘Listening into Action’ 179.13 Nurse Staffing Levels 189.14 new Resuscitation 1810 CLINICAL EFFECTIVENESS 2010.1 Mortality 2010.2 Patient Related Outcome Measures (PROMs) 2210.3 Clinical Audit 2210.4 Compliance with the ‘Five Steps to Safer Surgery’ 2310.5 Stroke care 2410.6 Treatment of fractured Neck of Femur within 48 hours 2410.7 Ward reviews 2411 PATIENT EXPERIENCE 2511.1 Patient survey results 2511.2 Complaints/PALS

a) Complaints datab) PALS data

252527

11.3 End of Life 2712 new WORKFORCE QUALITY 2813 RECOMMENDATION 28

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Tabled paper QUALITY REPORT

This report presents a composite picture of the performance against the various key Quality metrics to which the Trust works, both in terms of those mandated at a national or regional level and those set by the organisation.

The report has been populated with latest performance information for the period up until this Board meeting, across a range of areas within three domains: patient safety, clinical effectiveness and patient experience.

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The Trust Board’s attention is drawn to the following this month:

Safety Thermometer for September 93.13% - a small decrease on last month Pressure damage – continues to show downward trend – performing well compared to

rest of region Falls numbers remained largely the same Nutrition standards maintained Infection control – within target trajectories. Elective MRSA screening remains a

concern. ESBL contamination in neonatal unit has identified the need for additional isolation capacity.

Maternity staffing/caseloads remains an issue but is resolving Antenatal screening review currently being undertaken as a result of concerns identified Mortality figures remain on an improving trajectory overall, with targeted action taking

place in specific areas of concern – Stroke and Fractured Neck of Femur Resuscitation headlines are included for the first time in this report. To note is the good

survival rate post cardiac arrest and progress with training access. Medicines management – standards continue to be audited but results are variable.

PATIENT SAFETY

2 KEY POINTS TO NOTE

1 INTRODUCTION

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CLINICAL EFFECTIVENESS

Fractured Neck of Femur operated on within 24 hours has increased to 80.0% a sustained improvement on previous performance and exceeding our local target of 70%

Compliance with the use of the World Health Organisation (WHO) checklist is 99.8%

PATIENT EXPERIENCE

Net Promoter Score – This has improved but as a Trust we are not improving at the same rate as the rest of the region.

A total of 60 complaints was received in September and 92 responses sent. As at the week ending 19 October, the backlog count was 38 complaints from 127 at the beginning of September. This reflects a continuing improvement trend. A trajectory has been agreed to achieve clearance of the complaints backlog by the end of November 2012.

End of Life – baseline audits complete and action plans in place to achieve CQuIN and improve patient end of life care

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3 TARGETED AREAS OF SUPPORT

The areas of the Trust being provided with targeted support this month are: EAU Sandwell – continues in special measures - improving ED, City Special measures ED, Sandwell Imaging division – areas for improvement identified as a result of external reviews

4 EMERGING TRENDS/NOTICEABLE PATTERNS

Increase nursing vacancies/gaps as a result of slippage in bed closure plan and winter capacity open early

Maternity antenatal screening concerns

5 OF SPECIFIC NOTE

CQC general standards visit 27th September – awaiting report. Launched work with ‘Kissing it Better’ re patient experience/volunteers

6 KEY CLINICAL RISKS

Variable standards/leadership EDs – plan in place Staffing levels as a result of ‘paused’ bed closure plan – recruitment programme will resolve Variable standards of Medicine storage – plan in place Currently undertaking an extensive piece of working looking at apparent issues around

antenatal screening Stroke performance – benefits of reconfiguration yet to be realised Variable reporting standards imaging

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[Type text]

The Care Quality Commission (CQC) publishes a QRP for each registered provider which is used to support the day to day work of CQC inspectors. The QRP provides the Trust with a risk estimate for each outcome of the 16 Essential Standards of Quality and Safety. These risk estimates are produced by the CQC using a statistical model that aggregates individual pieces of information which the CQC holds about the Trust. The risk estimates are displayed as dials as shown below:

The current risk estimates for the essential standards for quality and safety for the Trust are:

Risk estimate Frequency Outcomes No Data - - Insufficient data 2 4 and 7 Low Green 3 21 and 11 High Green 1 6, 14 and 16 Low Yellow 9 1, 2, 5, 7, 8, 9, 10, 13 and 17 High Yellow 2 4 and 12 Low Amber - - High Amber - - Low Red - - High Red - -

There are currently no outcome risk estimates in Amber or Red. This shows the Trust as being at a low risk of non-compliance with the CQC’s 16 essential standards of quality and safety. The overall position has remained the same since December 2010, with the exception of a few changes which have not been significant enough to have an effect on the overall RAG status for the Outcomes. It is important to state that low risk estimates in a QRP do not guarantee compliance. On-going monitoring of compliance will take place to ensure that this position is maintained and improved.

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7 CARE QUALITY COMMISSION’S QUALITY AND RISK PROFILE

looking at apparent issues around antenatal screening

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YTD 12/13

RS A 3 396 % 92.9 ▲ 91.0 ▼ 90.3 ▼ 87.2 ■ 90.1 ■ 90 90 =>90 <90

RB K 20 372 No variation

Any variation

RO H 8 396 %No

variationAny

variation

RB H 20 743 Score 60 Base 80No

variationAny

variation

RO D 8 372 No.No

variationAny

variation

RO H 8 743 No variation

Any variation

RS H 9 % 99.7 ■ 99.8 ■ 99 100No

variationAny

variation

% 99.6 ■ 100 ▲ 98 98No

variationAny

variation

RS H 10 743 % Comply ComplyNo

variationAny

variation

RO H 88 %No

variationAny

variation

RO D 176 No variation

Any variation

RO H 176 No variation

Any variation

RO H 8 396 % 70 90No

variationAny

variation

RS H 3 743 % 69.0 ▼ 70.6 ▲ 61.1 ■ 58.7 ▼ 64 80No

variationAny

variation

RO H 11 44 % 70 90No

variationAny

variation

RO H 8 396 % 69.4 ▲ 67.9 ▲ 67.6 71.6No

variationAny

variation

RO H 8 372 No. 57 ■ 58 ▲ 58 ■ 60 ▲ 59 65No

variationAny

variation

RO H 8 372 % 48 ▲ 47 ▼ 55 ▲ 57 ▲ 47 53No

variationAny

variation

RB H 10 372 % 55 Base 55 Base 80

RO H 12 372 %

RO H 11 44 Score 91 ■ 95.5 ▲ 90 90No

variationAny

variation

RO H 11 88 No 75 Base 71 ■ 75 75No

variationAny

variation

RO H 11 132 %

RO H 11 132 %

RS H 49 Submit Data

Submit Data

No variation

Any variation

RS H 13 73 % Derive Base

Derive Base

No variation

Any variation

RS H 13 122 % Derive Base

Derive Base Met Not Met

RS H 12 147 % Submit Data

Submit Data

No variation

Any variation

July

→

Meeing Q2 req's

91 (H'son) & 80 (L'wes)

Base data being captured→

Base data being captured→

HIV - Optmum Therapy

→

→Community CQUIN

Specialised Commissioners

Q1 Data Submitted

Q1 Data Submitted •→

••

Q1 Data Submitted

Q1 Data Submitted

→

PATIENT EXPERIENCE

→ Base data being captured

Every Contact Counts

→

→

→

Clinical Quality Dashboards

Neonatal - Hypothermia Treatment

95.5

→

71

Base data being captured

Every Contact Counts - Smoking

→

→

→

→

Acute CQUIN

Net Promoter

Personal Needs

→

→

→

Compliant

f

f

g

→

→

→

→

Quarterly Audit

→

→

→

→

→ →

Data Submitted

→

Reducing Avoidable Pressure Ulcers Compliant

→

Compliant

→ Compliant

→

→ →

→

Compliant •

Acute CQUIN

Safety Thermometer → Data Submitted

→

→ →

→ Data Submitted

Stroke Care Met Q1 req's→

Data Submitted

→ →

→ Data Submitted

→

Nutrition and Weight Management

Appropriate Use of Warfarin

End of Life Care

→

60

•

•

→

Net Promoter

67.9

→Neonatal - Discharge Planning / Family Experience and Confidence

Quarterly Assessment / Data Submission

Quarterly Assessment / Data Submission

Quarterly Assessment / Data Submission

Smoking Cessation

Pt. (Community) Exp'ce - Personal Needs

Every Contact Counts - Alcohol

→

→

Base data being captured

Base data being captured

Q1 Data Submitted •→

→

→

→

Q1 Data Submitted

→

•

→

→

→ Quarterly Assessment / Data Submission

o

•

•

•57→

Q1 Data Submitted

→ •

Q1 Data Submitted

•

EFFECTIVENESS OF CARE

Met Q1 req's

Acute CQUIN

Dementia

Met Q1 req's

66.9Mortality Review

Meeing Q2 req'sMet Q1 req's

→

Dementia

58.7*

Community CQUIN

→

••

Meeing Q2 req's •Meeing Q2 req's

11 Community CQUIN

Data Submitted

Nutrition and Weight Management

→

→

→

Compliant

743Safe Surgery - Other Areas

92.3

•

Comply with audit •

Compliant

Compliant ••

Compliant

100

•

60 Base

Comply with audit

•

d

Monthly data collection

Monthly data collection

92.4

Compliant

Quarterly Audit

→

→

Compliant

→

Comply with audit

→

→ Data Submitted

99.7

→

→

→

•→

Comply with audit

•

SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST CORPORATE DASHBOARD - SEPTEMBER 2012

Exec Lead PATIENT SAFETY

Data Submitted

→

→

Trust

Compliant

Data Submitted

Trust

To Date (*=most recent month)

TARGET11/12

Outturn

June10/11

OutturnTrustS'well

Exec Summary Note

THRESHOLDS12/13 Forward

Projection

August

S'well City Trust

SeptemberMay

Trust City

Compliant

Compliant

Safety Thermometer

Reducing Avoidable Pressure Ulcers

Data Submitted

Met Q1 req's

→

Data Submitted

→

Compliant

Compliant

Q1 Base Audit Complete

Compliant

VTE Risk Assessment (Adult IP)

Safe Surgery - Operating Theatres

Compliant

→

Antibiotic Use

→

→

Compliant

Compliant

Met Q1 req's

90.1*

Q1 Base Audit Complete

•

••

→

→

→

→ → Comply with audit

Meeing Q2 req's

Meeing Q2 req's

→

Meeing Q2 req's

→

n

n

8 CQuINs

Tabled paper

9.1 Safety Thermometer

CQUiN for 2012/13 – requires introduction of the tool in acute and community in patient areas. CQUiN

Conducting monthly whole Trust census of patients for 4 harm events (falls, pressure damage, CAUTI and VTE) continues to go well with good engagement of nursing staff. Work has commenced to add other harm measures to the tool, eg avoidable weight loss.

The SHA ambition is for Trusts to achieve 95% harm free care.

Mar-12

Apr-12 May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-13

jan-13

Feb-13

Mar-12

90.48%

91.12%

94.75%

93.74%

93.55%

93.79%

93.43%

Figure 1: Harm free care trend

9 PATIENT SAFETY

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Figures 2 & 3: Number of patients by type and number of harm incidents

Acute Divisions 14 patients experienced 1 harm. No patients experienced 2, 3 or 4 harms

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Community Division 8 patients experienced 1 harm and 0 patients experienced 2, 3 or 4 harms.

a) Falls

There are no formal targets set for falls for 2012/13 other than the safety thermometer but we will continue to aim to reduce avoidable falls across the Trust by a further 10%. Our audits will continue to monitor risk assessment compliance, appropriate use of care bundles and numbers of falls. Falls with injury continue to be reported as adverse incidents and TTRs conducted.

Figure 4: Trend of falls

Figure 5: Incidence of falls per 1000 bed days across Acute Inpatient Divisions

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Tabled paperSandwell continues to have a higher number of falls compared to City.

b) Pressure Damage

Target 2012/13: Eradication of all avoidable pressure damage SHA Priority and CQUiN.Target to assess patients for risk, introduce appropriate care bundle and conduct TTRs on all grade 3 and 4 sores.

0

25

50

75

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2009-2010 2010-2011 2011-2012 2012-2013

Figure 6: Number of hospital acquired pressure damage Grade 2, 3 & 4, April 2009 - July 2012

New avoidable pressure ulcers (reported on ST): August – 12 (5 grade 2, 4 grade 3, 3 grade 4).

Heel sores continue to account for the largest number of hospital acquired sores associated with TeD stockings, slipper socks and plaster casts. A ‘Happy Feet’ campaign has now launched.

Accountability meetings have been established with the Chief Nurse where Matrons and Ward Managers are called to account for every grade 3/4 hospital acquired avoidable sore.

c) VTE Risk Assessment

The VTE Risk Assessment CQUIN target continued from 2011/12. Performance of at least 90% each month is required to trigger payment. Early data for September indicates performance of 90.1%, just above the required threshold of 90% CQUiN

9.2 Nutrition/Fluids

Target 2012/13: Reduction of avoidable weight loss in patients on 8 Trust wards where vulnerable adults are nursed. CQUiN90% patients MUST assessed within 12 hours admission Internal Priority

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Tabled paper

Summary of Nutrition Audits, June 2011-Sept 2012

75%

80%

85%90%

95%

100%

105%

Month

Perc

enta

ge

MUST @ 12hrs MUST @ 7 days `R@R’ onBed Plan Food Diary Fluid Bal Chart

Figure 7: Nutrition Audit Results

9.3 Infection Control

Targets 2012/13: C difficile – 57 cases (post 48 hours, using SHA testing methodology)(National Priority MRSA – 2 cases (post 48 hours)Local contract) MRSA Screening – 85% eligible patients

Blood culture contaminants – 3% or lessE Coli and MSSA – Continue to record and TTR device related infectionsNational cleanliness standards – 95%

MRSA

There were no post 48 hour cases of MRSA reported in September. MRSA Screening

Target : 85% eligible patients by March 2013.

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Tabled paper

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12

Pre-Admission (elective)

Admission (emergency)

All MRSA Screens

Figure 8: Percentage of eligible spells screened

Clostridium difficile

0

10

20

30

40

50

60

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Sandwell City Threshold (cumulative) Trust Total (cumulative)

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 TotalSandwell 1 0 1 0 2 1 5City 2 1 1 2 4 1 11Trust 3 1 2 2 6 2 0 0 0 0 0 0 16Intermediate Care 0 0 0 0 0 0 0DoH Trajectory 5 5 5 5 5 5 5 5 5 4 4 4 57Trust Total (cumulative) 3 4 6 8 14 16 16 16 16 16 16 16 -Threshold (cumulative) 5 10 15 20 25 30 35 40 45 49 53 57 -

2012-2013

Figure 9: SHA Reportable CDI

0

2

4

6

8

10

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Sandwell City

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Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 TotalSandwell 3 2 2 5 4 2 18City 4 4 4 2 8 2 24Trust 7 6 6 7 12 4 0 0 0 0 0 0 42Intermediate Care 0 0 0 0 0 0 0Trust Total (cumulative) 7 13 19 26 38 42 42 42 42 42 42 42 -

2012-2013

Figure 10: Trust Best Practice Data

Blood Contaminants

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

01/2009 04/2009 07/2009 10/2009 01/2010 04/2010 07/2010 10/2010 01/2011 04/2011 07/2011 10/2011 01/2012 04/2012 07/2012

Percentage Possibly Contaminated

Model Data City Model Data Sandwell

Figure 11: Blood Contaminants

E Coli Bacteraemia

0

5

10

15

20

25

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Sandwell City Trust Total (cumulative)

Figure 12: E Coli Bacteraemia

MSSA

0

5

10

15

20

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Sandwell City Threshold (cumulative) Trust Total (cumulative)

Figure 13: MSSA15 | P a g e

Tabled paper

Outbreak and Other Infection Control Activity

There have been a total of 10 babies affected by ESBL-producing E coli found on faecal screens since August on the NNU. No babies have shown any signs of infection. Outbreak meetings have been held and a review of infection control and decontamination practices been undertaken and practices optimised. There have been no further cases identified on screening for over a week. The unit remains open.

Newton 4 was closed on 29th September because of diarrhoea and vomiting. A cause for this outbreak has not been identified but two patients have subsequently been diagnosed with CDI. A total of 13 patients and 2 members of staff have been affected so far. The ward remains closed to admissions although has been reopened to visitors.

Lyndon 3 was closed on 29th September because of 4 patients with vomiting. A cause for this outbreak has not been identified. No staff members were affected. the ward was deep cleaned and re-opened on 7th October.

The Board should note that other Trusts do not routinely screen for ESBL and therefore we are operating best practice which gives us early warning of issues.

PEAT

National Standards of Cleanliness average scores 96%.

9.4 Maternity

The Obstetric Dashboard is produced on a monthly basis. Of note:

Post Partum Haemorrhage (PPH)(>2000ml): there was 1 patient recorded to have had a PPH of >2000ml in August.

Adjusted Perinatal Mortality Rate (per 1000 babies): the adjusted perinatal mortality rate for August was 7.1 which was not over trajectory (8) and was slightly lower than the previous month. Perinatal mortality rates must be considered as a 3 year rolling average due to the small numbers involved and the significant variances from month to month.  

Caesarean Section Rate: the number of caesarean sections carried out in August was 27.1%, which is above the trajectory of 25% over the year.

Delivery Decision Interval (Grade I, CS) >30 mins: the delivery decision interval rate for July was 16% which was just above trajectory (15). The data for August was not available at the time of writing the report.

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Tabled paperCommunity Midwife Caseload (bi-monthly): The community midwife caseload in July increased to 146 from 135 in the previous month, which is above the trajectory of 140. The data for August was not available at the time of writing the report.

Vacancies: Vacancy rates remained high in August (9). A mitigation plan is in place reducing the risk and it is anticipated that by September the situation will have improved.

We are currently undertaking an extensive piece of working looking at apparent issues around antenatal screening. A report has been taken to Q&S Committee for wider discussion.

9.5 Emergency Department highlights

A separate report is provided for the Trust Board this month.

9.6 Safeguarding

Safeguarding is not due for reporting this month – the next update is due in November.

9.7 Medicine Management

Target Baseline June August September % of patients with drug allergy status documented on chart 97% 91.7% 94.6% 95.0% 95.4% % of patients where stop or review date documented on drug chart? 95% 73.7% 77.1% 74.7% 78.9% % of patients where indication documented on drug chart? 95% 8.8% 13.1% 51.6% 49.2% % of patients whose antibiotics are in line with guidance? 90% 86.0% 87.5% 96.2% 94.7%

Drug storage audits have been carried out in September for general drugs and controlled drugs. For general drug audits a lower level of compliance has been seen compared to the August results.For controlled drugs an improvement has been seen. General Drugs Compliance of 90-100% was seen across 37% of standards (48% in August) Compliance of over 70% was seen across 81% of standards (85% in August) Controlled Drugs Compliance of 90-100% was seen across 57% standards (same as in August) Compliance of over 70% was seen across 81% of standards (67% in August)

9.8 Never Events

During September one ‘Never Event’ was reported. An incorrect tooth was removed despite all staff and the patient checking and agreeing the tooth to be extracted. The WHO surgical checklist was used.

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Tabled paper9.9 National Patient Safety Agency (NPSA) alerts

1. Overdue alerts: NPSA 2011/PSA001 – Safer spinal (intrathecal) epidural and regional devices. This alert will continue to remain as “ongoing” on the Central Alert System until all of the components we require to safely convert to the new neuraxial devices are available. Evaluation of the manometers is about to commence and a meeting with the representative for the needles is scheduled.

2. New alerts: No new alerts have been received.

3. Completed alerts: Flushing of naso-gastric tubes was ‘signed off’ during early October after agreement from Governance Board.

9.10 Lessons Learned

The key to a positive safety culture within the organisation is to learn from incidents through sustainable actions. Below are some of these actions taken or being taken following serious incident investigations.

Incident Extract from Action PlanOver capacity in Critical Care resulting in sub-optimal care.

Escalation policy to be reviewed to include cross site transfer of patients

Local escalation procedure for concerns to be implemented Documentation audit against RCP standards Gap analysis on staffing and safe model for staffing to be

undertaken.Missed opportunity to diagnose cancer

Audit of abnormal investigations for 4 month period (2009) Accountability system for abnormal tests within MDT to be put in

place. ED manual system for following up “missed findings” to be

developed electronically. 9.11 Significant Risks

Significant risks are presented on a monthly basis at the Risk Management Group (RMG). These risks are being proposed for inclusion onto the corporate risk register.

There were no risks presented to Governance Board in October. A review of the risks presently on the Corporate Risk Register has been taking place over the past couple of months. A refreshed Corporate Risk Register will be presented to the Trust Board in October.

9.12 Listening into Action Work continues to ensure that all staff currently using the Datix incident reporting system

have the necessary tools to convert to the Safeguard system by 31 March 2013.

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Tabled paper The first new Risk Forum took place and although only one person attended they had there

questions answered and some training took place on risk assessments.

The recently revised Incident Reporting, Managing and Investigating policy and the Risk Management Policy (for risk assessments and risk registers) are now available on CONNECT.

9.13 Nurse Staffing Levels

The data for nurse staffing levels is not available this month.

Bank & AgencyThe Trust’s nurse bank/agency rates are detailed in the tables below and show year on year comparison from 2008/9 to date.

0

1000

2000

3000

4000

5000

6000

7000

8000

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2008 - 2009

2009 - 2010

2010 - 2011

2011-2012

2012-2013

Figure 16: Total Bank & Agency Use Nursing April 2008 –date.

The Trust Board is asked to note that there are some risks associated with nurse staffing levels relating to slippage on the bed closure plans. Acute recruitment has commenced to address this deficit plus the additional requirement of 75 WTE nursing staff for winter beds. Deficits are showing in the amount of nurse bank/agency being used.

9.14 Resuscitation

Q2 report – will now be included in future reports

There were 21 cardiac arrests (compared to 51 in Q1), 2 survived to discharge (9.5%) - down 4.2% from Q1. (National survival to discharge rates in hospital is 12-15%).

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Tabled paper Mandatory Training is at 65.24% - there are now over 5000 places available per year for training

following team reconfiguration and investment to provide Intermediate Life Support Training. There is more training for Paediatrics and Newborn available. A current review of equipment is needed to provide trolleys on all wards and fund up- to-date

Defibrillator replacement programme. A business plan will go to SIRG in due course. Production of NCEPOD 'time to intervene' report - looks at events over a 2 week period in 2012

of which we participated. Any action will be via the Resuscitation Committee (scoping/action plan due to go to next meeting) but will look at consultant review of patients and key focus on the 48hr pre deterioration/call.

A decision has been made to include DNACPR on the Safety Thermometer audit from Q4/Q1.

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Tabled paper

10.1 Mortality

HSMR (Source: Dr Foster)The Hospital Standardised Mortality Ratio (HSMR) is a standardised measure of hospital mortality and is an expression of the relative risk of mortality. It is the observed number of in- hospital spells resulting in death divided by an expected figure.

Each year Dr Foster rebases its calculation of the relative risk of mortality, the impact of which is seen in the most recent 12-month cumulative mortality data. As a consequence the HSMR of the Trust, and the HSMR of a number of specialities has increased, the impact of the rebasing is also seen in SHA Peer derived data.

Following rebasing the 12-month cumulative HSMR (96.4) remains below 100, and remains lower than that of the SHA Peer (101.3), with both Trust and SHA (Peer) HSMR within 95% statistical confidence limits. The in-month (June) HSMR for the Trust has increased marginally to 89.7, but remains within statistical confidence limits (See Mortality table and graph below).

HSMR (Source: Healthcare Evaluation Data (HED))For comparison the Trust HSMR for corresponding 12-month cumulative periods, derived from the UHBT Healthcare Evaluation Data (HED) Tool is included. The HSMR for the most recent 12-month cumulative period remains stable at 97.0. HED data is subject to continued rebasing.

Summary Hospital – Level Mortality Indicator (SHMI)The SHMI is a national mortality indicator launched at the end of October 2011. The intention is that it will complement the HSMR in the monitoring and assessment of Hospital Mortality. One SHMI value is calculated for each trust. The baseline value is 1. A trust would only get a SHMI value of 1 if the number of patients who die following treatment was exactly the same as the number expected using the SHMI methodology. SHMI values have also been categorised into the following bandings.

1 where the Trust’s mortality rate is ‘higher than expected’2 where the trust’s mortality rate is ‘as expected’3 where the trust’s mortality rate is ‘lower than expected’

Further SHMI data was published on 25/07/12 for the period January 11 – December 11. For this period the Trust has a SHMI value of 0.99 and was categorised in band 2.

10 trusts had a SHMI value categorised as ‘higher than expected' 16 trusts had a SHMI value categorised as ‘lower than expected' 117 trusts had a SHMI value categorised as ‘as expected'

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10 CLINICAL EFFECTIVENESS

Tabled paperMortality table 2012/13

Apr May June

Internal Data:

Hospital Deaths 133 146 126

Dr Foster 56 HSMR Groups:

Deaths 110 129 111

HSMR (Month) 84.6 89.2 89.7

HSMR (12 month cumulative) 89.7 88.3 96.4

HSMR (Peer SHA 12 month cumulative) 94.9 93.3 101.3

Healthcare Evaluation Data - HSMR (12 month cumulative) 94.0 96.8 97.0

CQC Mortality Alerts received in 2012/13No new alerts have been received.

Dr Foster generated alerts (RTM)There were no new diagnoses or procedures alerting with significant variation in terms of mortality when the data period August 2011 – July 2012 is considered (see table below).

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Tabled paper

National Clinical Audit Supplier – Potential Outlier AlertsThe Trust has not been notified of any new outlier alerts.The National Diabetes Inpatient Audit 2011 report was published in May 2012. The findings have highlighted a number of areas where the performance of the Trust was below the National average. The findings are currently being assessed and an action plan is being developed to address areas identified for improvement.

10.2 Patient Related Outcome Measures (PROMs)

Provisional data in the form of experimental statistics were published on 11/10/12 for the 2011/12 financial year and for the first two months of 2012/13.Trust data tables are only being updated on a quarterly basis and are due to be published in November 12. Further details will be included in a subsequent report.

10.3 Clinical Audit

Clinical Audit Forward Plan 2012/13The Clinical Audit Forward Plan for 2012/13 contains 83 audits that cover the key areas recognised as priorities for clinical audit. These include both the ‘external must do’ audits such as those included in the National Clinical Audit Patient Outcomes Programme (NCAPOP), as well as locally identified priorities or ‘internal must do’ audits.

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Status Total0 - Information requested 3

1 - Audit not yet due to start 122- Significant delay 2

3- Some delay - expected to be completed as planned 54- On track - Audit proceeding as planned 51

5- Data collection complete 76- Finding presented and action plan being developed 07- Action plan developedA - Abandoned

21

Grand Total 83

The National Health Promotion Audit has been indicated as ‘Abandoned’ due to the inability of the supplier to secure funding from Trusts to conduct the audit.

The Consent for Chemotherapy local audit has been indicated as ‘significant delay’ due the possibility of a Network audit of the same subject being undertaken. The audit of the Compliance with the Trust guidelines for prescribing specific antibiotics for adults has also been marked as ‘significant delay’ as the data has been collected but the findings are yet to be presented.

Some delay has also been indicated with the submission of data to a national audit. The Trust is required to submit data on major trauma activity to TARN (Trauma Audit & Research Network) At the recent external Trauma Unit validation visit to review how services for major trauma patients work against the Regional Trauma Network standards, it was identified that the Trust is behind in submitting TARN data for 2012/13 (one of the Network standards relates to completeness and timing of TARN submissions). In order to increase the volume of cases submitted in 2012/13 there is a plan to increase clinical support in order to provide validation and to address other data queries.

10.4 Compliance with the ‘Five Steps for Safer Surgery’

Compliance with the “Five Steps to Safer Surgery” process is reported using the Clinical Systems Reporting Tool (CSRT).

The reported compliance with the 3 sections in the checklist for September 2012 is shown in the table below.

Trust performance (source QMF Dashboard- CDA)

“Five Steps to Safer Surgery” Reported compliance September 2012

Completion of the 3 sections of the checklist only 99.8%

All checklist sections and brief 93.5%

All checklist sections completed and brief & debrief 76.3%

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10.5 Stroke Care

Performance against the principal stroke care targets to which the Trust is working in 2012/13 is outlined in the table below.

Indicator June July Aug Target

Pts spending >90% stay on Acute Stroke Unit 94.1 ▲ 85.1 ▼ 88.9 ▲ 83%

Pts admitted to Acute Stroke Unit within 4 hrs 71.2 ▼ 64.0 ▼ 68.7 ▲ 90%

Pts receiving CT Scan within 24 hrs of arrival 92.3 ■ 94.0 ▲ 93.8 ▼ 100%

Pts receiving CT Scan within 1 hr of arrival 58.3 ▼ 51.3 ▼ 53.1 ▲ 50%

TIA (High Risk) Treatment <24 h from initial presentation 100% ■ 57.1 ■ 80.0 ■ 60%

TIA (Low Risk) Treatment <7 days from initial presentation 47.4 ▼ 58.3 ■ 82.5 ■ 60%

KEY TO PERFORMANCE ASSESSMENT SYMBOLS

▲ Fully Met - Performance continues to improve

■ Fully Met - Performance Maintained

▼ Met, but performance has deteriorated

▲ Not quite met - performance has improved

■ Not quite met

▼ Not quite met - performance has deteriorated

▲ Not met - performance has improved

■ Not met - performance showing no sign of improvement

▼ Not met – performance shows further deterioration

Figure 22: Performance against stroke care targets

10.6 Treatment of Fractured Neck of Femur within 48 hours

The Trust has an internal Clinical Quality target whereby 70% of patients with a Fracture Neck of Femur receive an operation within 24 hours of admission. Provisional data for September indicates 80% of patients with a Fractured Neck of Femur received an operation within 24 hours of admission, resulting in a year to date performance of 71.7% Internal Priority

10.7 Ward Reviews

The ward reviews are next due to reported in November.

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10.1 Patient Survey Results

11.1 Net Promoter

The Trust overall Net Promoter Score (NPS) increased by 2 to 60 making progress towards the SHA target - the CQuIN requires a 10 point improvement on the baseline of 55 by March 2013. CQUiN % returns have increased with the use of iPADS – weekly reports to the SHA has commenced.

SHA ambition requires both the improvement on score plus weekly reporting.

The Trust NPS target is minimum 65 by March 2013

The Trust is making steady progress towards its target. (Note: Other Trusts have different target levels).

Ward Action Plans to target the ‘Passive’ group to convert into ‘Promoters’ which can improve NPS dramatically.

The Trust maintained a good survey response rate attributed to use of Ipads on the wards for feedback collection.

Friends and Family Test Survey (Net Promoter) Summary Results Dashboard – August 2012

FFT 1

SWBH - Surveys returns % per total discharges.

12 11 1019 18

0

10

20

30

40

50

Apr-12 May-12 Jun-12 Jul-12 Aug-12

NPS

SWBH August 2012: Breakdown of Net Promter Responses

67%

26%

7%

Promoters Passives Detractors

Comparison of Net Promoter Scores from Neighbouring Trusts - August 2012 (This comparison does not take into account local patient dif ferences, e.g. demographics)

67 6077 78 71 61 67

0

20

4060

80

100

UHB NHS SWBH NHS Dudley NHS WolverhamptonNHS

Walsall NHS Heartlands NHS CombinedCluster Region

SWBH - Net Promoter Scores

55 57 58 58 60

20

30

40

50

60

70

Apr-12 May-12 Jun-12 Jul-12 Aug-12

SWBH - Net Promoter Scores (NPS) March 2013 Target NPS: 65

Figure 23: Net Promoter position

11.2 Complaints/PALS

a) Complaints and PALS data

i) Complaints: Tables A and B set out the complaints data for September 2012 with reference to previous months where relevant.

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11 PATIENT EXPERIENCE

Tabled paperA) Table A: number of complaints received and sent

MONTHComplaint type:

RECEIVEDComplaint type:

SENTFirst

contact*Link*2 TOTAL First

contact*Link*2 TOTAL

July 2012 62 4 66 42 3 45Aug 2012 77 10 87 58 3 61Sept 2012 55 5 60 81 11 92

*First Contact complaint: where the Trust’s substantive (i.e. initial) response has not yet been made.

*2Link complaint: the complainant has received the substantive response to their complaint but has returned as they remain dissatisfied/or require additional clarification.

Failsafe parameters

The failsafe parameters identify those complaints which breach a prescribed period of days considered the maximum acceptable time for the Trust to respond in the context of the risk grade of the complaint (see Risk Grade2 above). These complaints comprise the ‘complaints backlog’.

The failsafe parameters for 1 April 2012 onwards comprise: 60 days for red; 70 days for amber and 20 days (fast track) or 90 days for yellow and green grade complaints.

Backlog Trajectory

The number of cases completed and variance against the trajectory is being reported weekly to the Director of Governance and Chief Executive.

At the time of this report the position is as follows:Week ending

Friday….Total

responsessent

Total backlog

responses sent

Backlog trajectory

Backlogcount

Variance

02/09/12 ----- ----- 127 ----- ----- 07/09/12 27 18 105 109 4 14/09/12 30 9 99 125 26 21/09/12 29 29 86 96 10 28/09/12 20 18 70 78 805/10/12 16 11 55 67 1212/10/12 30 18 39 49 1019/10/12 23 11 34 38 4

Variance key

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Tabled paperBetter than planWorse than planOn plan

 Figure 24:Progress with clearance of complaints backlog

b) Complaints and PALS data

ii) PALS

Contacts and general enquiries: In September 2012 PALS recorded 148 PALS enquiry contacts, and 194 general enquiry contacts, in comparison to August 2012 where PALS recorded 129 PALS Enquiry contacts and 246 General Enquiries. The general informal enquiries are not captured on the PALS database but relate to enquiries taken at the PALS reception desk.

Chart A provides a breakdown of the themes identified via PALS contacts in September 2012. The main categories reported during the month of September 2012, were issues relating to Clinical Treatment. These relate to queries, comprising the categories of clinical care, low staffing levels, and medicines. In addition, issues relating to a delay in the following: investigations, results, surgery, treatment and xray/scan.

During September 2012, there has been a slight increase in the number of appointment enquiries where 21 enquiries were received during September 2012, and 18 during August 2012. Appointment enquires relate to appointments cancelled, delay, notification and time.

There has been a slight reduction in the number of formal complaint issues which comprise the categories of handling, advice, process, referral and response time from 26 enquiries reported during this month, in comparison to 32 enquiries during August 2012.

11.3 End of Life

End of Life Report

Targets/Metrics: CQuIN 10% increase in number of patients achieving preferred place of death who are on a supportive care pathway – Acute and Community. This is also a national nursing high impact action and nurse sensitive indicator.

Achieved 75% - target 81% Patients on Supportive Care Pathway = 88%

This data represents a steady and sustained improvement.

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The Board is asked to note key headlines from the workforce dashboard% Trust

Mandatory Training 83.24% (85%)PDR 65.60% (85%)Turnover (leavers) 9.03%Sickness absence 4.32% (3.5%)

The Trust Board is asked to:

NOTE in particular the key points highlighted in Section 2 of the report and DISCUSS the contents of the remainder of the report.

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13 RECOMMENDATION

12 WORKFORCE QUALITY

Tabled paperAPPENDIX 1

Glossary of AcronymsAcronym Explanation

CAUTI Catheter Associated Urinary Tract InfectionC Diff Clostridium DifficileCRB Criminal Records BureauCSRT Clinical Systems Reporting ToolCQC Care Quality CommissionCQuIN Commissioning for Quality and InnovationED Emergency DepartmentDH Department of HealthHED Healthcare Evaluation DataHSMR Hospital Standardised Mortality RatioHV Health VisitorID IdentificationLOS Length of StayMRSA Methicillin-Resistant Staphylococcus AureusMUST Malnutrition Universal Screening ToolNPSA National Patient Safety AgencyOP OutpatientsPALS Patient Advice and Liaison ServicePHSO Parliamentary and Health Service OmbudsmanRAID Rapid Assessment Interface and DischargeRTM Real Time MonitoringSHA Strategic Health AuthoritySHMI Summary Hospital-level Mortality IndicatorTIA Transient Ischaemic Attack (‘mini’ stroke)TTR Table top reviewUTI Urinary tract infectionVTE Venous thromboembolismWards:

EAUMAUDLNPA&EITUNNU

Emergency Assessment UnitMedical Assessment UnitDudleyLyndonNewtonPrioryAccident & EmergencyIntensive Therapy UnityNeonatal Unit

WHO World Health OrganisationWTE Whole time equivalentYTD Year to date

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