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Excel format v1 Nov-14 JW
Excel format v2 Jan-15 JW
Excel format v3 Apr-15 JW
Quality Report Alan Sheward - Director of Nursing & Workforce
April 2015 - Month 1
Version control
Target YTD
TargetPrevious Year
2015/162014/15
p13 National 0 0 Apr-15 0 0 0 2 1
p13 National 7 1.05 Apr-15 2 0 2 23 14
No N/A N/A N/A Apr-15 0 0 0 1 3
No N/A N/A N/A Apr-15 1 0 1 1 17
p14 N/A N/A N/A Apr-15 38 - 38 670 548
p15 N/A N/A N/A Apr-15 1.0557 - - - - -
p32 N/A N/A N/A Apr-15 3 - 3 10 90
Local 10% 0 Apr-15 5 10 5 152 129
N/A N/A - Apr-15 19 0 19 429 425
N/A N/A - Apr-15 18 0 18 294 100
Local 10% 64 Apr-15 83 64 83 1402 859
Local 10% 4 Apr-15 3 4 3 47 50
Local 10% 0 Apr-15 1 0 1 13 3
No N/A N/A - Apr-15 29 - 29 162 60
Local 10% 16 Apr-15 13 16 13 270 217
Local 10% 0 Apr-15 0 0 0 6 4
p19 Local 10 Apr-15 20 10 20 328 162
20 Local 11 Apr-15 33 11 33 425 254
No Local 50% 1 Apr-15 2 1 2 38 22
Local 10% 16 Apr-15 17 16 17 286 216
Local 69 Apr-15 92 69 92 1205 920
N/A - - Apr-15 234 - 234 3551 3713
N/A - - Apr-15 26 - 26 569 -
p12 National 0 0 Apr-15 6 0 6 59 1
p25 N/A Apr-15 7 - 0 112 - -
No National 95% 95% Apr-15 99% 95% 99.2% 98.3%
Consultant lead Outpatient appts p35 Local 10% 1618 Apr-15 2314 1871 2314 30919 24945
p36 Local 10% 334 Apr-15 425 392 425 4750 5223
p33 N/A - - Apr-15 809 - 809 10648 9701
p37 Local 0 0 Apr-15 10 - 10 218 297
p38 N/A 0 0 Apr-15 5 - 5 35 119
No N/A ↑10% 343 Apr-15 269 - 269 3311 3742
Cancelled appointments
Patient satisfaction
Complaints
Concerns
Compliments
Service Group Outpatient appts
Mixed sex accommodation breaches
Chaplaincy visits
Patient discharges recorded as after 23:00 and before 06:00
Venous-Thromboembolism (VTE) Acute contract service users only
Patient moves (Numbers of patients involved) without clinical justification - unvalidated
Contacts (neither complaints nor concerns)
DoLS (Deprivation of Liberty safeguards
National SHMI update (qrtly)
Resulting in Harm (Catastrophic confirmed after investigation)
Pressure UlcersHospital setting (newly developed)
Community setting (newly developed)
Clinical Incidents
Resulting in any harm
Resulting in Harm (Major)
Slips, Trips & FallsResulting in any injury
Resulting in Serious injury
Duty of Candour (Potential and actual incidents reported)
Measure Description Detail page
included
Trustwide
p16
p17
Clostridium difficile cases (Healthcare acquired)
MRSA bacteraemia (Healthcare acquired)
MSSA bacteraemia (Healthcare acquired)
E.Coli bacteraemia (Healthcare acquired)
Mortality
Number of Healthcare cases going to inquest (inquests held)
SIRIs in Month
New SIRIs reported
Number of Ongoing SIRIs
Number of SIRIs closed in month
Number of Inpatient deaths
Deteriorated (grades 2-4) Trustwide
Patient discharges recorded as after 06:00 and before 12:00 (noon)
Isle of Wight NHS Trust Quality ReportApr-15
Main Summary - Trustwide
Monthly
TargetDate
Latest
Data
Performance
trend in
month
Projected
performance if
current trends
continue
p18
p25-28
Curent
YTD
2015/16
Year End
Forecast
2015/16
Local or
National target
Page 2 of 38
Target YTD
Target
Previous
Year
2015/16 2014/15
Community & Mental Health
p31 Local 4 Apr-15 3 4 3 42 31
MRSA bacteraemia (healthcare acquired) No National 0 Apr-15 0 0 0 0 0
Clostridium Difficile (healthcare acquired) No National tbc Apr-15 0 tbc 0 0 1
E Coli (healthcare acquired) No N/A N/A N/A Apr-15 0 N/A 0 0 4
No National ≥90% 90% Apr-15 78% 90% 78% 84%
No National ≥90% 90% Apr-15 50% 90% 50% 29%
No National ≥100% 100% Apr-15 100% 100% 100% 100%
No National ≤2% 99% Apr-15 11% 2% 11% 7%
Local 10% - Apr-15 3 - 3 80 -
N/A N/A N/A Apr-15 11 N/A 11 189 N/A
Local 10% Apr-15 47 - 47 1058 -
Local 10% Apr-15 0 - 0 25 -
All reported incidents Local 10% Apr-15 100 - 100 1440 -
Local 10% Apr-15 4 - 4 77 -
Local 10% Apr-15 0 - 0 3 -
Local 10% Apr-15 16 - 16 299 -
Pressure ulcers no National Apr-15 34 - 34 463 -
Local 10% - Apr-15 2 - 2 58 51
Local - Apr-15 12 - 12 95 125
N/A - - Apr-15 23 - 23 949 1286
Concerns
Compliments
Slips, Trips & Falls
HCAI
Clinical Incidents
Resulting in any harm
p16Resulting in Harm (Major)
Isle of Wight NHS Trust Quality ReportApr-15
Directorate SummariesMeasure Description Detail
page
included
Local or
National
target
Monthly
TargetDate
Latest
Data
Performance
trend in month
Curent
YTD
2015/16
Year End
Forecast
2015/16
Projected
performance if
current trends
continue
Emergency Readmissions within 30 days (MH areas)
SIRIs in MonthNew SIRIs reported
All grades reported
All slips, trips & falls reported
Resulting in any injury
Patient satisfaction
Complaints
p15
Number of SIRIs closed in month
p17Resulting in Serious injury
p24-27
Antimicrobial Stewardship
Overall HAPPI compliance
Prescription to Protocol (DIPPI)
Allergy Status (NAPPI)
Missed doses (NAPPI)
Page 3 of 38
Target YTD
Target
Previous
Year
2015/16 2014/15
Hospital & Ambulance
p31 Local 75 Apr-15 72 75 72 855 895
MRSA bacteraemia (healthcare acquired) No National 0 0 Apr-15 0 0 0 2
Clostridium Difficile (healthcare acquired) No National tbc Apr-15 2 tbc 2 20
No N/A N/A N/A Apr-15 1 N/A 1 2
No National >99% 99% Apr-15 100% 99% 99.0% 99.9% 99.9%
No
No
No National 95% 95% Apr-15 99% 95% 99.2% 98% 99%
National ≥24% 24% Apr-15 22% >24% 22% 23% 20%
National ≥70% 70% Apr-15 63% 70% 63% 66% 68%
National ≥80% 80% Apr-15 56% >73% 56% 54% 72%
N/A N/A N/A Apr-15 14% N/A N/A 21% 18%
Local 90% 90% Apr-15 94% N/A N/A 90% 91%
N/A N/A N/A Apr-15 44% N/A N/A 60% N/A
Local 90% 90% Apr-15 97% N/A N/A 97% N/A
N/A N/A N/A Apr-15 14% N/A N/A 23% 14%
Local 90% 90% Apr-15 100% N/A N/A 98% -
No National ≥90% 90% Apr-15 89% 90% 89% 91%
No National ≥90% 90% Apr-15 60% 90% 60% 35%
No National ≥100% 100% Apr-15 100% 100% 100% 100%
No National ≤2% 2% Apr-15 4% 2% 4% 3%
Local 10% - Apr-15 2 - 2 74 - -
N/A N/A Apr-15 7 - 7 105 - -
Local 10% Apr-15 35 - 35 941 - -
Local 10% Apr-15 3 - 3 22 - -
All reported incidents N/A N/A Apr-15 307 - 192 2930 - -
Local 10% Apr-15 9 - 9 191 - -
Resulting in Serious injury N/A N/A Apr-15 0 - 0 2 - -
Local 10% Apr-15 36 - 36 124 - -
Pressure ulcers no N/A N/A Apr-15 19 19 290
Local 10% - Apr-15 15 0 15 226 161
- Apr-15 78 - 78 1099 764
N/A - - Apr-15 202 - 202 2477 2332
Patient satisfaction
Complaints
p24-27Concerns
Compliments
p17
All Slips, trips & falls reported
p15
p16
Family & Friends Test
Emergency Dept response rate
No
% who would recommend
Inpatient response rate
%who would recommend
Maternity services response rate
All grades reported
% who would recommend
SIRIs in Month
New SIRIs reported
Number of SIRIs closed in month
Clinical Incidents
Resulting in any harm
Resulting in Harm (Major)
Slips, Trips & FallsResulting in any injury
Antimicrobial Stewardship
Overall HAPPI compliance
Prescription to Protocol (DIPPI)
Allergy Status (NAPPI)
Missed doses (NAPPI)
Caesarean section rate
p21/22Spontaneous delivery rate
Breast feeding at delivery rate
Emergency Readmissions within 30 days (PBR mix)
Diagnostic waits less than 6 weeks
MRSA Screening Elective admissions
Venous-Thromboembolism (VTE)
Maternity activity
HCAI
MRSA screening policy has changed nationally and previous reporting is no longer applicable.
Reporting under new regulations will commence quarterly at the end of Q1Non-elective admissions
Curent
YTD
2015/16
Year End
Forecast
2015/16
Projected
performance if
current trends
continue
E Coli (healthcare acquired)
Isle of Wight NHS Trust Quality ReportApr-15
Directorate SummariesMeasure Description Detail
page
included
Local or
National
target
Monthly
TargetDate
Latest
Data
Performance
trend in month
Page 4 of 38
Target YTD
Target
Previous
Year
2014/15 2014/15
Community
N/A N/A N/A Apr-15 33% 30% 33% 42% N/A
Local 90% 90% Apr-15 94% 90% 94% 90% N/A
N/A N/A N/A Apr-15 N/A new report 90%
Local 90% 90% Apr-15 95% new report 90% 95%
Local 10% - Apr-15 3 - 3 71 - -
Local 10% - Apr-15 46 - 46 675 -
Local 10% - Apr-15 0 - 0 21 -
All reported incidents N/A N/A - Apr-15 80 - 80 1150 -
Local 10% - Apr-15 4 - 4 64 -
Local 10% - Apr-15 0 - 0 0 -
All reported slips, trips & falls N/A N/A - Apr-15 14 - 14 271 -
- Apr-15 12 - 12 144 -
- Apr-15 15 - 15 180 -
- Apr-15 0 - 0 37 -
- Apr-15 7 - 7 94 -
Local 10% - Apr-15 1 - 1 22 -
- Apr-15 9 - 9 45 -
N/A - - Apr-15 18 - 18 764 -
Slips, Trips & Falls
Resulting in any injury
Resulting in Serious injury
Patient satisfaction
Complaints
Concerns
Compliments
Pressure ulcers (includes community wards & external
community)
Grade 1
Grade 2
Grade 3
Grade 4
Clinical Incidents
Resulting in any harm
Resulting in Harm (Major)
SIRIs in Month New SIRIs reported
Inpatient response rate (Community wards)
% would recommendFamily & Friends Test
All Community Services
% would recommend
Isle of Wight NHS Trust Quality ReportApr-15
Directorate SummariesMeasure Description Local or
National
target
Monthly
TargetDate
Latest
Data
Performance
trend in month
Curent
YTD
2014/15
Year End
Forecast
2014/15
Projected
performance if
current trends
continue
Page 5 of 38
Target YTD
Target
Previous
Year
2014/15 2014/15
Mental Health
Local 4 Apr-15 3 4 3 42 82
N/A N/A N/A Mar-15 0.6% new report
Local 90% 90% Mar-15 96% new report
Local 10% - Apr-15 0 - 0 9 -
N/A N/A Apr-15 0 - 0 5 -
Local 10% Apr-15 1 - 1 51 -
Local 10% Apr-15 0 - 0 4 -
All reported incidents N/A N/A Apr-15 20 - 20 290 -
Local 10% Apr-15 0 - 0 15 -
Resulting in Serious injury Local 10% Apr-15 0 - 0 3 -
Local 10% Apr-15 2 - 2 28 -
Local 10% - Apr-15 1 - 1 36 27
- Apr-15 3 - 3 50 43
N/A - - Apr-15 5 - 5 185 207
Isle of Wight NHS Trust Quality ReportApr-15
Directorate SummariesMeasure Description Local or
National
target
Monthly
TargetDate
Latest
Data
Performance
trend in month
Curent
YTD
2014/15
Year End
Forecast
2014/15
Projected
performance if
current trends
continue
Number of SIRIs closed in month
Complaints
Concerns
Compliments
Resulting in any harm
All reported slips, trips & falls
Resulting in Harm (Major)
Slips, Trips & Falls
Resulting in any injury
Emergency Readmissions within 30 days (MH areas)
Patient satisfaction
SIRIs in MonthNew SIRIs reported
Clinical Incidents
Family & Friends testMental Health Services response rate
% would recommend
Page 6 of 38
Target YTD Target Previous Year
2014/15 2014/15
Hospital
Local 75 Apr-15 72 75 72 855 895
National >99% 99% Apr-15 99.9% 99% 100.0% 99.9% 99.9%
National ≥24% 24% Apr-15 22% >24% 22% 23% 20%
National ≥70% 70% Apr-15 63% 70% 63% 66% 68%
National ≥80% 80% Apr-15 56% >73% 56% 54% 72%
Local 10% - Apr-15 2 3.75 2 74 50
N/A N/A - Apr-15 7 2.625 7 101 35
Local 10% - Apr-15 35 31.725 35 910 423
Local 10% - Apr-15 3 1.2 3 22 16
All reported incidents N/A N/A - Apr-15 186 233.025 186 2880 3107
Local 10% - Apr-15 9 11.25 9 191 150
Local 10% - Apr-15 0 0.15 0 2 2
All slips, trips & falls reported N/A N/A - Apr-15 36 44.175 36 531 589
- Apr-15 6 0 6 83 36
- Apr-15 8 0 8 135 68
- Apr-15 1 0 1 5 10
- Apr-15 4 0 4 54 11
Local 10% - Apr-15 15 - 15 225 158
- Apr-15 75 - 75 1067 739
N/A - - Apr-15 191 - 191 2382 2256
Isle of Wight NHS Trust Quality ReportApr-15
Directorate SummariesMeasure Description
Local or
National
target
Monthly
TargetDate Latest Data
Performance
trend in month
Curent YTD
2014/15
Year End
Forecast
2014/15
Projected
performance if
current trends
continue
Emergency Readmissions within 30 days (PBR mix)
Diagnostic waits less than 6 weeks
Maternity activity
Caesarean section rate
Spontaneous delivery rate
Breast feeding at delivery rate
Patient satisfaction
SIRIs in MonthNew SIRIs reported
Number of SIRIs closed in month
Complaints
Concerns
Compliments
Clinical Incidents
Resulting in any harm
Resulting in Harm (Major)
Slips, Trips & Falls
Resulting in any injury
Resulting in Serious injury
Pressure ulcers (excludes community wards)
Grade 1
Grade 2
Grade 3
Grade 4
Page 7 of 38
Target YTD
Target
Previous
Year
2015/16 2014/15
Ambulance
Local 10% - Apr-15 0 - 0 0 2
Local 10% Apr-15 0 - 0 31 5
Local 10% Mar-15 0 - 0 0 0
All reported incidents N/A N/A Apr-15 6 - 6 51 69
Local 10% Apr-15 0 - 0 0 0
Resulting in Serious harm Local 10% Apr-15 0 - 0 0 0
N/A N/A Apr-15 0 - 0 0 0
Local 10% - Apr-15 0 - 0 1 3
- Apr-15 3 - 3 32 25
N/A - - Apr-15 11 - 11 95 76
Slips, Trips & Falls
Resulting in any harm
All Slips, trips & falls reported
Patient satisfaction
Complaints
Concerns
Compliments
Clinical Incidents
Resulting in any harm
Resulting in Harm (Major)
SIRIs in Month New SIRIs reported
Isle of Wight NHS Trust Quality ReportApr-15
Directorate SummariesMeasure Description Local or
National
target
Monthly
TargetDate
Latest
Data
Performance
trend in month
Curent
YTD
2015/16
Year End
Forecast
2015/16
Projected
performance if
current trends
continue
Page 8 of 38
Improvement in SIRIs, Incidents & Falls with harm reported during month
Isle of Wight NHS Trust Quality ReportApr-15
Successes this month
Standardised Hospital Mortality Index continues within expected limits
Continue to show well against nationally published Safety Thermometer indicators
Page 9 of 38
Pressure injury development levels remain challenging both internally & externally
Isle of Wight NHS Trust Quality ReportApr-15
Challenges this month
2 cases of Healthcare acquired Clostridium Difficile identified during April
Mixed sex accommodation breach event affected 6 patients during April
Page 10 of 38
Isle of Wight NHS Trust Quality ReportApr-15
Ward dashboard summaryOur inpatient wards and various other departments now have their key indicators displayed publically (as a dashboard screen print) in preparation for interactive screens to
be rolled out later in the year. This is a summary for the month of APRIL that has been aligned to reflect service performance. Further work is continuing to aggregate
totals and some sections (such as Ambulance & District Nursing) do not yet have data contributing to this system. N.B. Activity levels for individual areas are not in this summary although further detail is available on the interactive dashboard to authorised staff. The main FFT returns are now required
for the 12th of each month with Community & Mental Health submissions for the 18th. This means that not all data is available at the time this report is collated. Safer staffing has now
replaced the HR staffing budgets in the leading columns. Gaps are present where Safer Staffing is not yet applied.
Location
Average fill rate -
registered
nurses/midwives
(%)
Average
fill rate -
care staff
(%)
Average fill
rate -
registered
nurses/
midwives (%)
Average
fill rate -
care staff
(%)
Staff
Sickness
Mandatory
Training
Falls with
harm
Pressure
Ulcers
VTE Risk
Assmt
C.
Diff. MRSA
FFT
Survey
Likely to
Recommend
Formal
Complaints Concerns
Community & Mental Health
Mental Health
Afton ward 97% 121% 103% 130% 8% 91% 0 0 n/a 0 0 n/a n/a 0 0
Osborne Ward 106% 143% 125% 132% 1% 88% 0 0 n/a 0 0 n/a n/a 0 0
Seagrove Ward 80% 104% 98% 96% 4% 88% 0 0 n/a 0 0 n/a n/a 0 0
Shackleton Ward 80% 85% 103% 104% 12% 93% 0 0 n/a 0 0 n/a n/a 0 0
Woodlands 101% 100% 105% 88% 9% 83% 0 0 n/a 0 0 n/a n/a 0 0
Community
Community Stroke Rehabilitation Team #N/A #N/A #N/A #N/A 1% 95% 0 0 n/a 0 0 n/a n/a 0 0
Stroke Neuro Rehab 92% 100% 108% 113% 11% 90% 1 0 100% 0 0 n/a n/a 0 3
General Rehab and Step Down Unit 114% 81% 177% 98% 5% 92% 1 0 100% 0 0 n/a n/a 1 1
Poppy Unit 75% 101% 77% 102% - - 0 0 100% 0 0 n/a n/a 0 0
District Nursing #N/A #N/A #N/A #N/A 7% 78% 0 0 n/a 0 0 n/a n/a 0 1
Hospital & Ambulance
Medical
Cardiac Investigation Unit #N/A #N/A #N/A #N/A 0% 82% 0 0 n/a 0 0 n/a n/a 0 0
Chemotherapy Unit #N/A #N/A #N/A #N/A 1% 91% 0 0 n/a 0 0 n/a n/a 0 0
Colwell Ward 115% 86% 103% 100% 2% 80% 2 3 100% 1 0 n/a n/a 1 1
Emergency Department #N/A #N/A #N/A #N/A 3% 81% 0 2 n/a 0 0 n/a n/a 3 6
MAAU 82% 67% 103% 92% 1% 89% 1 2 99% 0 0 n/a n/a 1 1
Respiratory Department #N/A #N/A #N/A #N/A 1% 86% 0 0 n/a 0 0 n/a n/a 0 1
Surgical
ENT #N/A #N/A #N/A #N/A 0% 72% 0 0 n/a 0 0 n/a n/a 0 0
Mottistone Ward 94% 101% 102% - 17% 85% 1 0 100% 0 0 n/a n/a 0 0
St Helens Ward 108% 111% 105% 100% 2% 85% 2 2 99% 0 0 n/a n/a 0 1
Whippingham Ward 101% 92% 108% 102% 3% 70% 1 3 97% 0 0 n/a n/a 0 4
Crititcal care
Intensive Care Unit 78% 108% 86% 83% 4% 91% 0 2 100% 0 0 n/a n/a 0 0
Coronary Care Unit 76% 94% 91% 130% 5% 84% 0 0 100% 1 0 n/a n/a 0 0
Endoscopy
Endoscopy Unit #N/A #N/A #N/A #N/A 6% 87% 0 0 n/a 0 0 n/a n/a 0 0
Theatres
Main Theatres #N/A #N/A #N/A #N/A 7% 74% 0 0 n/a 0 0 n/a n/a 0 0
Day Surgery Unit #N/A #N/A #N/A #N/A 9% 75% 0 1 100% 0 0 n/a n/a 0 0
Maternity Services 96% 102% 101% 100% 3% 83% 0 0 95% 0 0 n/a n/a 0 3
Neonatal Intensive Care Unit 88% 89% 100% 96% 4% 88% 0 0 n/a 0 0 n/a n/a 0 0
Orthopaedic Unit
Orthopaedic Unit 108% 99% 100% 97% 4% 71% 2 1 100% 0 0 n/a n/a 2 7
Childrens
Paediatric Ward 86% 100% 82% 112% 3% 79% 0 0 n/a 0 0 n/a n/a 0 0
Pathology
Phlebotomy #N/A #N/A #N/A #N/A 6% 94% 0 0 n/a 0 0 n/a n/a 0 0
Maternity
0
Page 11 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
2014/15 0 0 0 0 0 0 4 0 0 6 0 0 10 10
2015/16 6
Isle of Wight NHS Trust Quality ReportApr-15
Mixed Sex Accommodation
Measure
Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position
Mixed sex accommodation breaches 0
Reconfiguration and upgrade to MAAU area on ground floor is continuing as planned Director of Nursing & Workforce May-15 In progress
Root cause analysis and review has been completed Director of Nursing & Workforce CompletedMay-15
Commentary
During April there was a single event of mixed sex accommodation on Day 8 of the Black Alert status period which was made to avoid 12 hours breaches during the high
pressure on admission beds. Day surgery unit was actually being used as a ward at this time and the Black Alert continued for a further day.
A total of 6 patients were involved as the accommodation was a 6-bedded bay. The staff continued to support the principles of single sex accommodation which is to ensure
privacy and dignity for all patients affected with use of curtains and support to use toilets in single sex areas. Actions were put in place to ensure privacy and dignity was
maintained and the patients were moved as soon as possible but the breach did continue over 24 hours.
There is a direct financial penalty for each breach of £250 and the total penalty for the Trust will be £1500.
There is a continued risk of recurrence whilst we maintain our current bed management practices until such time as the MAAU rebuild is completed (August 2015),
reconfiguration work is completed and more single rooms are available for use.
Actions Responsible job title Date Progress
Page 12 of 38
Isle of Wight NHS Trust
MRSA Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD
Acute Target 0 0 0 0 0 0 0 0 0 0 0 0 0
Actual 0 0
Highlighted awareness campaign including intranet, posters & automatic screensavers Infection control team &
Communications teamMay-15 Continuing
Increased auditing of commode cleaning on individual wards Ward managers May-15 Continuing
Isle of Wight NHS Trust Quality ReportApr-15
Methicillin-resistant Staphylococcus Aureus (MRSA):
There have been no further cases of Healthcare acquired MRSA identified in the Trust since November 2014.
Healthcare acquired Infections - Trustwide within the hospital environment
Increasing education regarding timely sampling of loose stool events and isolation Infection control team May-15 Continuing
Responsible job title Date Progress Actions
Red = 1 or more MRSA or 2 or more C Diff in rolling 3/12
Amber = No MRSA and 1 C Diff in rolling 3/12
Green = No MRSA and No C Diff in rolling 3/12
Clostridium Difficile (C Diff):
There have been 2 cases of Healthcare acquired Clostridium Difficile identified in the Trust during
April.
Work continues to raise awareness and highlight actions, including intranet and poster campaigns
regarding bowel management with action plans for rapid isolation of suspected cases.
Reconfiguration of ward to facilitate further isolation facilities is ongoing.
It should be noted that patients are admitted with known Clostridium Difficile or MRSA developed in
the community (or in some cases transferred from other Trusts). So far this year there has been 1
patient admission with Clostridium Difficile identified as contracted externally. Apr
May
Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Total 2
National Target 1 1 2 2 3 3 4 4 5 6 6 7
0
1
2
3
4
5
6
7
8
Isle of Wight NHS Trust C.Difficile Performance (Cumulative)
All Hospital
April 2015
Page 13 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
2014/15 36 44 47 39 34 42 37 50 48 68 53 50 36 548
2015/16 38 38 38
2014/15 1.9% 2.2% 2.5% 1.8% 1.7% 2.0% 1.6% 2.3% 2.3% 3.4% 2.7% 2.5% 1.9% 2.2%
2015/16 2.1% 2.1% 2.1%
Commentary
The table above shows the raw numbers for Inpatient deaths at St Marys and is a basic indicator of activity. The graph below demonstrates the rate of deaths per 1000
discharges and demonstrates improvement since 2012 when coding changes were implemented. Nationally, there is concern over high numbers of deaths at weekends when
there has been traditionally less staff available and our weekday numbers are now demonstrated below.
The NHS collates hospital data nationally and uses standardised methodology to compare all organisations across the country using the Standardised Hospital Mortality Index
(SHMI) which is published quarterly for retrospective periods. (Included in this report each quarter). Using this system we compare favourably with our local/similar peer group
and are have been graded within the 'Amber' (as expected) rating. The most recent (April 2015) update gives us a current score of 1.056 as detailed on the following page. The
overall number of deaths is lower than last year for this time of year but there is a recent peak in January which is within normal expectations. This peak occurred in October last
year and follows a mild winter with less influenza in the community.
Ongoing audit is starting to demonstrate the percentage of deaths where a Do Not Resucitate decision is recorded on admission and whether an Amber Care Bundle** is in
place. This data is only available retrospectively and currently demonstrates 98% of deaths had DNR during March with 8% on existing Amber care.
** The Amber Care Bundle is an agreed plan of action between patient, carers and healthcare staff when it is recognised that future health improvement is unlikely or uncertain and can extend
for considerable time across periods of deterioration during management of a long term condition. It is not an end-of-life pathway.
The Executive Medical Director recieves monthly reports on Inpatient deaths and investigates any cases of concern. Executive Medical Director May-15 Ongoing
Actions Responsible job title Date Progress
n/aNumber of Inpatient deaths
N.B. These figures refer to admitted patients only and as such do not include stillbirths or patients brought in to A&E who do not survive to admission.
Isle of Wight NHS Trust Quality ReportApr-15
Mortality - (1) Deaths at St Mary's of Admitted Patients
Measure
n/aInpatient Deaths as % of all discharges
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD
00 - 04 yrs 0
05 - 15 yrs 0
16 - 44 yrs 0
45 - 64 yrs 2 2
65 - 74 yrs 5 5
75 - 84 yrs 16 16
85+ yrs 15 15
Sum: 38 0 0 0 0 0 0 0 0 0 0 0 38
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD
Monday 5 5
Tuesday 3 3
Wednesday 6 6
Thursday 9 9
Friday 8 8
Saturday 2 2
Sunday 5 5
Sum: 38 0 0 0 0 0 0 0 0 0 0 0 38
Deaths by weekday YTD
Deaths by age band YTD
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD
00 - 04 yrs 0
05 - 15 yrs 0
16 - 44 yrs 0
45 - 64 yrs 2 2
65 - 74 yrs 5 5
75 - 84 yrs 16 16
85+ yrs 15 15
Sum: 38 0 0 0 0 0 0 0 0 0 0 0 38
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD
Monday 5 5
Tuesday 3 3
Wednesday 6 6
Thursday 9 9
Friday 8 8
Saturday 2 2
Sunday 5 5
Sum: 38 0 0 0 0 0 0 0 0 0 0 0 38
Deaths by weekday YTD
Deaths by age band YTD
Page 14 of 38
Isle of Wight NHS Trust Quality ReportApr-15
Mortality (2) Standardised Hospital Mortality Index -Quarterly update
Commentary
Most recently published data covers October 2013 to September
2014 and was published at the end of April 2015. The SHMI for
this period is 1.0557, maintaining an amber ‘as expected’ rating of
band 2.
Actions taken such as the 24/7 critical care outreach and The
Prepip project were taken in the second half of 2013 and their
effect is starting to feature in the current data. Another factor is
that the coding of community deaths from patient notes since
January 2014 contributes to a more accurate calculation.
The graph below shows benchmarking against the other NHS
organisations measured with IOW NHS Trust shown in red.
The Executive Medical Director continues to have oversight of mortality figures on a regular basis
and investigates any deemed to be cause for concern.
Actions Responsible job title Date Progress
Executive Medical Director May-15 Continuing
0.7
0.8
0.9
1
1.1
1.2
1.3
Value Upper Control Limit Lower Control Limit
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
RP
AR
XL
RM
PR
P5
RB
DR
GP
RJR
RL
NR
XR
RT
ER
RF
RX
CR
HU
RM
CR
TG
RW
AR
TF
R1
FR
FR
RA
JR
JER
TX
RK
5R
A4
RN
ZR
N7
RF
FR
NA
RB
NR
WE
RT
RR
JCR
Q8
RY
RR
N5
RD
ZR
R7
RC
DR
BT
RG
NR
A9
RN
SR
FS
RV
RR
NQ
RM
1R
D1
RN
LR
JFR
A7
RX
1R
F4
RD
8R
XH
RJN
RD
UR
H8
RG
RR
AP
RH
QR
WJ
RT
KR
XF
RA
XR
1K
RA
2R
QM
RR
VR
KE
IW NHS Trust VALUE
Page 15 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
2014/15 5 11 9 8 3 9 21 14 10 19 15 5 129 129
2015/16 5 0 0 0 0 0 0 0 0 0 0 0 5 5
Total 18 0 0 0 0 0 0 0 0 0 0 0 18 18
In time 8 0 0 0 0 0 0 0 0 0 0 0 8 8
N/A 2015/16 19 19 19
Hospital Ambulance Community MH Corp Total
0
2 2
0
1 1
0
0
C Diff & Healthcare Acquired Infection (death) 0
Safeguarding Vulnerable Adult/Child 0
1 1 20
0
2 0 3 0 0 5
Actions - embedded in policy
Ongoing
Trust Management of SIRIs will be overseen by external monitors at the Trust Development Authority (previously
under SHIP jurisdiction). External monitors May-15 Ongoing
Directorate and Quality Team
leadsMay-15 Ongoing
All reported SIRIs will be assessed on their individual merits to determine whether a full incident review panel is
required to carry out a detailed root cause analysis within 3 days of notification. External monitors May-15
The SIRI will be graded in accordance with the SIRI policy. Initial grading may be changed on investigation.
All Serious Incidents Requiring Investigation follow a set procedure for route cause
analysis and the numbers form part of Clinical Incident reporting.
The Trust SIRI policy document is available here:- http://nww.iow.nhs.uk/guidelines/SIRI%20Procedure%20V2%20FINAL.pdf (not linked)
Isle of Wight NHS Trust Quality ReportApr-15
Serious Incidents Requiring Investigation (SIRIs)Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position
Measure
Total NEW SIRIs reported
Pressure ulcers - Healthcare acquired
Pressure ulcers - Community acquired
Unexpected deaths
Information Governance
Delayed Diagnosis
SIRI type (list not exhaustive)
Responsible job title Date Progress
Number of NEW SIRIs opened during month
Medication issues
10%
? mthly
Number of CLOSED SIRIs during month N/A
Total number of ongoing SIRIs in month (snapshot)
Slips, Trips & FallsVenous Thromboembolism
Other 8
0 0 0 0 0 0 0 0 0 0 0
10
0 0 0 0 0 0 0 0 0 0 0 0
2
4
6
8
10
12
0
2
4
6
8
10
12
14
16
18
20
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
Nu
mb
er
of
ne
w S
IRIs
op
en
ed
Nu
mb
ers
Month
SIRI Analysis Closed in time Out of time
New SIRIs Target new in month
Page 16 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
2014/15 57 55 49 58 57 72 70 71 81 101 82 106 57 859
2015/16 83 83 83
2013/14 4 3 4 4 0 7 2 5 4 6 3 3 4 45
2014/15 3 3 3
2014/15 311 345 337 354 350 375 363 345 358 441 365 377 311 4321
2015/16 307 307 307
12015/16 1
May-15
A regular publication is circulated specifically for Learning Lessons from incidents (both potential and actual)
The winter issue is now available and can be accessed through the internal intranet here:- Clinical Risk & Claims Manager
Completed
monthly
QuarterlyMay-15
PLEASE NOTE:
All incidents with an unverified* grading of Major/Catastrophic are investigated via the 48 hour report/SIRI**
process and final grading is confirmed at the completion of the investigation. No unverified catastrophic
incidents will be included in data above until completion of investigation
Actions Responsible job title
All reported incidents are automatically cascaded via due process to relevant managers and investigated according
to potential and actual severity of event. If applicable, the 48 hour report/SIRI process is instigated.
Lead for Patient Safety, Experience & Clinical
Effectiveness
Commentary
During April 2015 there were a total of 307 clinical incidents reported, of which 83 resulted in harm. 3 of
these incidents met the severity criteria of Major resulting in harm. Incident numbers include cases of falls,
pressure ulcer development, and SIRIs, all of which are reported separately. The Catastrophic incident
referred to above relates to an incident dated November 2014 and has been signed off by the Commissioners
in April 15.
Incidents with harm are also reported via the National Safety Thermometer and results for all contributing
organisations are available nationally on the website :- http://www.safetythermometer.nhs.uk
The National Safety Thermometer is a snapshot audit for benchmarking nationally and currently shows that the Trust
performs well with an average of 96% harm free care against the national average of 93%.
The Trust has an internal 'Incidents' dashboard available to authorised members of staff which gives details of
numbers and types of incident with potential/actual severity score down to service level to facilitate internal
management. This is updated on a daily basis and includes both clinical and non-clinical incidents.
** Serious Incident Requiring Investigation
Date Progress
Isle of Wight NHS Trust Quality ReportApr-15
Clinical Incidents resulting in HarmIndividual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position
Measure
10%
<64 mthly
10%
<3 mthly
n/a
Clinical Incidents Resulting in Harm (All)
Clinical Incidents Resulting in Harm (Major)
Clinical Incidents reported (Total)
Clinical Incidents resulting in Harm(Catastrophic-confirmed after investigation only)
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
5.0%
0
50
100
150
200
250
300
350
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
Nu
mb
er
of
rep
ort
ed
clin
ical
inci
de
nts
Month
Incidents resulting in Harm from April 2014
No harm Minor harm Major harm % of discharges with harm
Page 17 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
2014/15 18 9 19 11 14 24 17 18 23 22 18 24 18 217
2015/16 13 13 13
2014/15 0 0 1 0 0 1 0 0 0 1 0 1 3 4
2015/16 0 0 0 0 0 0 0 0 0 0 0 0 0
2014/15 66 51 63 53 58 63 67 72 60 62 68 80 683 763
2015/16 52 0 0 0 0 0 0 0 0 0 0 52 52
A dedicated falls co-ordinator is supporting work toward falls prevention across the Trust in the wider community.
There is currently no dedicated falls co-ordinator working within the acute Trust. Fall Co-ordinator May-15 In post
Responsible job title Date Progress Actions
Commentary
All patient slips, trips and falls within acute, intermediate care and outpatients across the sites are reported and appear on the
Datix reporting system as incidents and are investigated. All patients admitted to St Mary’s are screened for falls risk using a 5
question tool and may be placed on a Falls Care Plan (as per Falls Policy) if appropriate. This screening is repeated weekly, at
ward transfer or if conditions change. Following a fall, whether previous deemed at risk or not, a patient is fully re-assessed and
measures put in place to reduce risk as appropriate. Falls numbers also contribute to the incidents dashboard and, depending
upon severity, could also contribute to the Serious Incident Requiring Investigation (SIRI) numbers. The numbers also contribute
to the National Safety Thermometer snapshot audit for patient harm, which is reported nationally. Numbers of individual incidents
are recorded and a single patient may have multiple falls events during an admission.
During April 15 there were 52 slips/trips/falls reported. Although 13 resulted in Harm, there were no cases (0) where the
harm met the severity criteria of 4 or 5 indicating serious injury.
Work is continuing to relate the number of falls to the occupied bed days to give a better understanding of incidence across the
hospital for reporting. (Currently showing against discharges). Work to understand the relationship between admissions due to
known falls events and falls during admission is underway and will be expanded to look at 'unexpected' falls events. (i.e. to include
patients with no previous falls history).
10%
<16 mthly
10%
<0.3 mthly
All slips/ trips & falls with harm
All slips, trips & falls with serious injury
All reported slips, trips & falls10%
<57 mthly
Isle of Wight NHS Trust Quality ReportApr-15
Falls Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position
Measure
0.0%
0.1%
0.2%
0.3%
0.4%
0.5%
0.6%
0.7%
0.8%
0
10
20
30
40
50
60
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
% o
f d
isch
arge
s in
mo
nth
Nu
mb
er
of
rep
ort
ed
slip
s, t
rip
s &
fal
ls
Month
Degree of harm by falls from April 2014
No harm Minor harm Significant harm % of discharges with harm from falls
Page 18 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
20% 2014/15 1 4 4 1 2 0 9 4 7 1 5 4 1 42
(3 mthly) 2015/16 6 6
30% 2014/15 6 2 5 5 5 12 4 9 9 10 10 9 6 86
(5 mthly) 2015/16 9 9
50% 2014/15 1 1 0 1 2 2 1 0 1 1 2 0 1 12
(0.5 mthly) 2015/16 1 1
2014/15 1 0 0 3 1 1 0 2 1 1 3 4 1 17
2015/16 4 4
2014/15 12 12 12 23 0 46 23 23 34 0 47 20 254 254
2015/16 NYA NYA NYA NYA NYA NYA NYA NYA NYA NYA NYA NYA 0
The Tissue Viability Nurse continues to support ward staff with recognition and management of patients at risk. Tissue Viability Nurse Specialist May-15 Ongoing
Actions Responsible job title Date Progress
Grade 1 Pressure Ulcer developing in Hospital
Commentary
N.B. Figures for previous months will continue to change as validation occurs during the process of investigation.
Pressure ulcer development contributes to clinical incident numbers and the higher grades contribute to the numbers of Serious Incidents Requiring Investigation. (SIRIs). They also form part of the National
Safety Thermometer snapshot audit scheme which is reported nationally. Further details of the Safety Thermometer are available here. http://www.safetythermometer.nhs.uk
During April there was a slight decrease in reported pressure ulcers in the hospital setting from the previous month across all grades. The Tissue Viability Nurse continues to support ward staff with recognition
and management of patients at risk but higher numbers of patients staying longer is challenging. Validation of avoidable pressure injury continues and deterioration of existing pressure injury is now being
reported separately so that reduction can be monitored but this is not currently split.
Isle of Wight NHS Trust Quality ReportApr-15
Pressure Ulcers - in hospital setting (includes community wards in set targets)Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position
Measure
Grade 2 Pressure Ulcer developing in Hospital
Grade 3 Pressure Ulcer developing in Hospital
Grade 4 Pressure Ulcer developing in Hospital 0
Overall Rate per 100,000 occupied bed days. (updated
retrospectively as data available)
0
2
4
6
8
10
Nu
mb
er
rep
ort
ed
Month
G1 Hospital Acquired Pressure ulcer incidence
2014/15 2015/16 target
0
2
4
6
8
10
12
14
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Nu
mb
er
rep
ort
ed
Month
G2 Hospital Acquired Pressure ulcer incidence
2014/15 2015/16 target
0
0.5
1
1.5
2
2.5
Nu
mb
er
rep
ort
ed
Month
G3 Hospital Acquired Pressure ulcer incidence
2014/15 2015/16 target
0
1
2
3
4
5
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Nu
mb
er
rep
ort
ed
Month
G4 Hospital Acquired Pressure ulcer incidence
2014/15 2015/16 target
Red=Any G4 or 2 G3 or 5 any in rolling 3 month period
Amber=1G3 or increase/no change in G2 in rolling 3 month period
Green=No G3 or G4 and decrease in G2 or 2 or less of any grade (1&2) in rolling 3 month period
Page 19 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
20% 2014/15 4 3 1 6 5 3 6 5 3 9 5 9 4 59
(4 mthly) 2015/16 12 12
30% 2014/15 9 17 8 11 13 7 11 6 9 12 11 16 9 130
(8 mthly) 2015/16 14 14
50% 2014/15 1 1 1 3 1 1 4 2 2 2 2 4 1 24
(1 mthly) 2015/16 0 0
50% 2014/15 4 3 1 4 1 1 2 2 6 7 5 5 4 41
(2 mthly) 2015/16 7 7
Grade 2 Pressure Ulcer developing in the community
Grade 3 Pressure Ulcer developing in the community
Grade 4 Pressure Ulcer developing in community
Commentary
N.B. Figures for previous months will continue to change as validation occurs during the process of investigation.
Pressure ulcer development contributes to clinical incident numbers and the higher grades contribute to the numbers of Serious Incidents Requiring Investigation. (SIRIs).
Incidence of pressure ulcer development continues to cause concern and remain challenging with District Nurses continuing to experience increasing caseloads within the community. The numbers remain
similar to last month and this may be due to the effectiveness of the recent awareness campaign activity, particularly over the lower grades. Overall incidence as a percentage of the number of contacts over
the month remains low. The public awareness campaign across local press and venues has resulted in increased referrals as awareness of pressure injury is raised.
Isle of Wight NHS Trust Quality ReportApr-15
Pressure Ulcers - in community setting (external to hospital for set targets - yet to be confirmed)Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position
Measure
Grade 1 Pressure Ulcer developing in the community
Actions Responsible job title Date Progress
Tissue Viability Nurse Specialist/
Communications teamMar-15
The Tissue Viability Nurse Specialist continues to work with the Communications team on a public awareness campaign
to encourage prevention and self help in the community. (Further awareness week scheduled in March 15 with ongoing
training and support for care homes available)
The public awareness event 'I feel good' was taken to locations across that island and was well attended by
patients/carers and non-trust staff involved in patient care as well as a delegation from Southampton CCG who are
looking to hold a similar campaign in their area
Ongoing
Completed
0
2
4
6
8
10
12
14
Ap
r
May
Jun
Jul
Au
g
Sep
t
Oct
No
v
Dec
Jan
Feb
Mar
Nu
mb
er
rep
ort
ed
Month
G1 Community Acquired Pressure ulcer incidence
2014/15 2015/16 target
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Ap
r
May
Jun
Jul
Au
g
Sep
t
Oct
No
v
Dec
Jan
Feb
Mar
Nu
mb
er
rep
ort
ed
Month
G3 Community Acquired Pressure ulcer incidence
2014/15 2015/16 target
0
2
4
6
8
10
12
14
16
18
Ap
r
May
Jun
Jul
Au
g
Sep
t
Oct
No
v
Dec
Jan
Feb
Mar
Nu
mb
er
rep
ort
ed
Month
G2 Community Acquired Pressure ulcer incidence
2014/15 2015/16 target
0
1
2
3
4
5
6
7
8
Nu
mb
er
rep
ort
ed
Month
G4 Community Acquired Pressure ulcer incidence
2014/15 2015/16 target
Red=Any G4 or 2 G3 or 5 any in rolling 3 month period
Amber=1G3 or increase/no change in G2 in rolling 3 month period
Green=No G3 or G4 and decrease in G2 or 2 or less of any grade (1&2) in rolling 3 month period
Page 20 of 38
Pressure Ulcers
The latest submitted data (April
15) indicates that the IOW NHS
Trust is below the all England
average for new pressure ulcers
and demonstrates a progressive
decrease over time.
Falls
The latest submitted data (April
15) indicates that the IOW NHS
Trust is below the all England
average for harm by falls in
care and demonstrates a
progressive decrease over
time.
Harm Free Care
The latest submitted data (April
15) indicates that the IOW NHS
Trust remains above the all
England average for care
without harm. (98.59%)
Harms can include falls,
pressure ulcers, infection or
any other clinical event
producing an adverse effect on
the individual.
Catheters & UTIs
The latest submitted data (April
15) indicates that the IOW NHS
Trust remains above average in
the level of urinary catheters used.
However, the Island also has a
higher proportion of over 75s than
most areas in England and
catheterisation for urinary retention
is more common in this
demographic.
The data also demonstrates a
lower level of Urinary Tract
Infections in our patients and this
may indicate good management.
Isle of Wight NHS Trust Quality ReportApr-15
NHS Safety Thermometer (from http://www.safetythermometer.nhs.uk)
"It is not just counting, it's caring"The NHS Safety Thermometer provides a point of care survey instrument to provide local areas with a progress measure toward harm free care. This is a publically available website showing data
submissions from a variety of organisations from multisite trusts to individual care homes. It should not be used for benchmarking against individual sites. Over future months this will be expanded as
Mental Health will be joining and submitting other indicators.
Page 21 of 38
Target Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total
99 99
≥90% 82%
≥90% 71%
≥90% 97%
≥90% 100%
≥90% 100%
≥90% 89%
- 62
≥90% 60%
≥100% 100%
246
≤2% 4%
Target Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total
10
≥90% 60%
≥90% 70%
≥90% 90%
≥90% N/A
≥90% 90%
≥90% 78%
- 2
≥90% 50%
≥100% 100%
18
≤2% 11%
Appropriate IV duration (if applicable)
Appropriate total duration
NAPPI
Allergy status documented
Prescribed according to protocol
NAPPI
Allergy status documented
Missed doses* (% of doses available)
Doses available
* Each missed dose is recorded separately even if a single patient repeatedly refuses medication.
DIPPI
Possible protocols
Measure
Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position
Isle of Wight NHS Trust Quality ReportApr-15
Antimicrobial stewardship (HAPPI, DIPPI, NAPPI snapshot audits)Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position
Measure
Number of patients prescribed antimicrobials
Review date
Indication documentation
Appropriate antimicrobial
Prescribed according to protocol
Missed doses* (% of doses available)
Over all compliance
HAPPI
The Antimicrobial stewardship audits are undertaken monthly by pharmacy staff and the results returned to the individual wards both in a regular newsletter and via the PIDS dashboards.
Problems are highlighted and shared across the hospital so that learning can take place. There is an ongoing problem relating to DIPPI recording as the electronic prescribing system records whether the protocol is
queried and not whether the drug/dosage matches the guidance within the protocol. For common usage, protocols are well known by the prescribers and therefore not specifically queried.
Hospital & Ambulance Directorate
Community & Mental Health Directorate
Number of patients prescribed antimicrobials
HAPPI
Review date
Indication documentation
Appropriate antimicrobial
Appropriate IV duration (if applicable)
Appropriate total duration
Over all compliance
Doses available
* Each missed dose is recorded separately even if a single patient repeatedly refuses medication.
DIPPI
Possible protocols
Page 22 of 38
Figures for Breast feeding initiation this month are being checked as it is likely to be a miscount and is subject to local audit to verify.
The Labour ward dashboard is updated monthly and discussed at a regular meeting where developing trends can be highlighted and managed. A red flag is an indicator to be aware of possible trends as
our comparatively small numbers give rise to exaggerated percentage differences and a single incident may not be significant. Figures are rounded to nearest %. An appendix logs further local indicators
and is available to relevant staff on the intranet, as shown below.
Isle of Wight NHS Trust Quality ReportApr-15
Maternity Labour ward dashboard of indicators
The non-RCOG monitoring section has not been included this month as the data has not yet been made available.
≤ ≥ Prev Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 YTD
Women delivered 80-100 101-110 ≥111 1301 84 84
Babies born 1318 86 86
In utero transfer 6 1 1
Antenatal bookings (inc transfers in) 100-125 126-150 ≥151 1476 0
Induction of labour rate ≤24% 25-26% ≥27% 28% 31% 31%
Spontaneous vaginal delivery rate ≥70% 60-69% ≤60% 68% 63% 63%
Ventouse/Forceps rate (Instrumental) ≤16% 17-19% ≥20% 11% 12% 12%
Caesarean section rate ≤22% 22-25% ≥25% 20% 22% 22%
Elective Caesarean section rate ≤10% 11% ≥12% 8% 9% 9%
Emergency Caesarean section rate ≤12% 13-14% ≥15% 12% 13% 13%
ITU admissions 0 1 ≥2 1 0 0
PPH> 1.5L ≤3 4-5 ≥6 12 3 3
3rd/4th degree tear ≤2 3-4 ≥5 12 0 0
% failed instrumental delivery ≤3.5% 3.6-4.9% ≥5% 0.8% 0.0% 0.0%
% Readmissions within 30 days of delivery ≤2% 2.1-3.4% ≥3.5% 0.0% 0.0% 0.0%
Undiagnosed term breech in labour 0 n/a ≥1 10 0 0
Days of NICU closure 0 n/a ≥1 0 0 0
% Babies admitted to NICU rate ≤10% n/a >10% 10% 9% 9%
%NICU admissions >37 weeks rate ≤50% n/a >50% 39% 13%
Babies born with pH<7 0 n/a ≥1 7 0
Shoulder Dystocia ≤3 4 >5 15 1 1
% attempting VBAC after 1 CS ≥80% 71-79% ≤70% 72% 63% 63%
% attempting VBAC successfully rate ≥70% 66-69% ≤65% 76% 40% 40%
Booking before 12 weeks rate ≥90% 81-89% ≤80% 93%
Breast feeding at delivery rate (new target2015/16) ≥73% 66-72% ≤65% 73% 56% 56%
Total homebirths 28 3 3
Babies born before arrival 0 ≥1 9 0 0
Homebirth rate 2% 2% 2%
Number of SUIs 0 ≥1 0 0 0
Targets
Home
births
Maternal
Morbidity
Maternity activity dashboard 2015/16
Activity
VBAC
Latest update 13/05/2015
Mode of
delivery
Neonatal
Morbidity
2014-
15
Page 23 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
2014/15 18% 16% 26% 15% 17% 26% 18% 14% 27% 21% 24% 15% 18% 20%
2015/16 22% 22%
2014/15 69% 70% 66% 69% 67% 66% 71% 76% 62% 69% 63% 71% 69% 68%
2015/16 63% 63%
2014/15 22% 32% 28% 21% 33% 25% 29% 31% 27% 33% 27% 33% 22% 28%
2015/16 31% 31%
2014/15 74% 79% 74% 80% 69% 75% 77% 72% 66% 71% 69% 67% 74% 73%
2015/16 56% 56%
Q1 Q2 Q3 Q4
307 318 362 305
31% 39% 33% 36%
13% 11% 12% 9%
2014/156-8 wk checks done
100% Breast fed
Mixed breast/bottle
=>70%
=<24%
>73%
Commentary Small numbers and the particular cohort of patients can influence the data considerably and one red month is a marker to observe for trend
Caesarean Sections - We have seen 86 deliveries this month with 22% by caesarean section again, both emergencies (13%) and electives (9%) at the similar levels as last month. All Consultants
follow NICE and levels of opportunity achieved at VBAC (vaginal birth after previous caesarean section) are at low at 40% this month. Small numbers and the particular cohort of patients can influence
the data significantly and one red month is a marker to observe for trend.
Normal Vaginal Deliveries - There is a consistent rate of spontaneous normal deliveries across the year compared to number of women delivered, which can be challenging giving the changing
population with changing levels of obesity and complex medical problems. This was maintained at 63% this month, as although the section numbers were down the induction level was again high at
31%.
Inductions of Labour - There was another high month for inductions during April, although down slightly from March. Induction levels continue to exceed the target of 24% and are being monitored to
identify if there are common factors. However, induction may not always be done for medical necessity and maternal choice plays an important role.
Breast Feeding Figures (at delivery) – Following recognition of the difficulties, breastfeeding targets have been reduced nationally to 73%. Emphasis will be on maintaining the initialised rate.
Breast feeding initiation is at exceptionally low at 56% this month, despite the introduction of breast feeding champions and may be affected by the higher level of inductions. However, no single reason
can account for the mothers' personal choice. Since the figure is outside the normal range for the Trust, Maternity teams are rechecking and auditing to ensure a validated figure is submitted and this
may be subject to change. The Trust is aiming to become recognised as 'Baby Friendly' and an in- house multi disciplinary training package is continuing alongside a joint Breast feeding policy between
Health and the local authority. The Head of Midwifery has been liaising with NHS England through Public health and we compare well with the rate of 72% covering mainland trusts in this area.
Continued education continues for staff across the localities. Breast feeding champions have been identified and are in place on each shift from both NICU and Maternity. Our overall breast feeding
initiation rate at year end was satisfactory at 73%. Breast feeding figures for 5 days are now being collected and will be included in future reporting.
Breast Feeding Figures (at 6 weeks) This is part of the Health Visitors’ areas of responsibility and data is recorded at the 6-8 week check. Q4 data has now been collated for 2014/15.
Isle of Wight NHS Trust Quality ReportApr-15
Maternity activity Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position. Figures are rounded and slight cumulative differences may exist within totals.
Measure
Inductions of Labour
Normal vaginal deliveries (spontaneous)
Caesarean section rates
Breast feeding at delivery
=<24%
Page 24 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
2014/15 0 0 1 0 0 2 1 0 1 7 12 15 0 39
2015/16 7 7 7
N/A 0 0
N/A 0 0
N/A 1 1
N/A 6 6
2015/16
Commentary
Deprivation of Liberty Safeguards (DoLS) are part of the Mental Capacity Act 2005 (MCA). They aim to make sure that people in care homes and hospitals are looked after
in a way that does not restrict their freedom inappropriately. The safeguards should ensure that all deprivations of liberty in care homes and hospitals are in the best
interests of the person, necessary to protect them from harm and there is no less restrictive way to do so. They provide a legal framework for authorising detention in
hospitals and care homes, including an appeals process and other legal safeguards.
There has been a heightened interest in the DoLS in recent months, following a Supreme Court ruling that extends the scope of the Safeguards to include anyone who is
'under continuous supervision and control and not free to leave'. An application for Authorisation must be made by the Managing Authority (the hospital or care home) to the
Supervisory Body (the Local Authority) in respect of anyone who meets that test. The Supervisory Body will then arrange for two independent assessors to assess whether
the person meets the 6 criteria for an Authorisation to be issued.
Due to the big increase in applications following the Supreme Court ruling, DoLS services in all areas are currently unable to process applications within the legal time limits.
Supervisory Bodies are being asked to identify and refer priority cases in the first instance. Difficulties also arise where the patient is discharged prior to the process being
completed.
Deprivation of Liberty in the Isle of Wight NHS Trust is currently under-reported, although the number of applications has begun to increase. The major training package
recently delivered to ensure that all ward staff of band 6 and above understand their responsibilities under the MCA and DoLS has resulted in higher levels of applications
from January. Further sessions have been held (3) and more are planned. It is anticipated that applications will rise as awareness increases. 136 band 6 staff have now
taken the course and are cascading down across the teams.
Isle of Wight NHS Trust Quality ReportApr-15
Deprivation of Liberty Safeguards (DoLS)RAG rating is not appropriate as the number of Safeguarding orders will be affected by the number of vulnerable individuals admitted
Measure
Approved and granted
Applications made for DoLS orders
Withdrawn prior to assessment
Outstanding (waiting for assessment)
n/a
Not granted
May-15 In progress
Actions Responsible job title Date Progress
A Training package was delivered to ensure all ward staff of band 6 and above understand their
responsibilities under the MCA and DoLS. At the time of report 8 sessions have been completed
with 3 more sessions scheduled.
Deputy Director of Nursing & Workforce has been working with Matrons, highlighting patients at
risk and undertaking ward audits.
MCA & MH Lead May-15 Completed
Director of Nursing & Workforce
Page 25 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
Trustwide
2014/15 20 14 15 17 13 16 21 14 16 15 26 187 187
2015/16 17 0 0 0 0 0 0 0 0 0 0 17 17
10 10
12 12
2 2
In Time 4 4
Out of Time 0 0
number/closed 24% 10%
2014/15 48 62 69 74 102 91 76 86 81 67 76 832 832
2015/16 92 0 0 0 0 0 0 0 0 0 0 92 92
number 63 63
number/closed 74% 74%
0 0
0 0
Commentary
The percentage of complaints
managed within their agreed timescale
is subject to retrospective revision as
this report gives a snapshot available
at the time and cases may continue
across several months if agreed with
the principal. Therefore, the numbers
may differ from previous reports for the
same month.
The graphs at the left demonstrate
complaints, concerns and compliments
received Year to Date for the various
directorate services.
% concerns resolved within 3 working days
*Parliamentary & Health Service Ombudsman
2014/15
Percentage of complaints managed within timescale negotiated
with complainant
(retrospectively updated at closure, figures in italics will change)N/A
Number of concerns resolved within 3 working days
Number of cases reported upheld/partially upheld
Number of cases referred to PHSO* in month
Complaints logged within NHS formal procedure%
14 mthly
Number of Concerns received within month10%
62 mthly
Complaints process
compliance
(closed within month)
0-20 days
21-45 days
>45 days
N/A
Isle of Wight NHS Trust Quality ReportApr-15
Complaints & Concerns - Management Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position
Measure
Hospital 15
Ambulance 0
Community 1
Mental Health
1 Others
0
Complaints YTD
Hospital 75
Ambulance 3
Community 9
Mental Health
3
Others 2
Concerns YTD
Hospital 191
Ambulance 11
Community 18
Mental Health 5 Others
9
Compliments YTD
Page 26 of 38
Complaints & Concerns - Categories & Areas
0
4
0902000
0
0001100
0
000
Oct-14Primary Subject
Categories of complaints have been realigned to the new National requirements and quarterly reports will be submitted under the following headings.
Comparison with previous year would require complete reassessment of all complaints to realign and is not feasible.
Progess against previous month will be resumed once futher data is available.
Access to treatment or drugs
Apr-14 May-14 Jun-14 Jul-14 Sep-14
Restraint
Staff numbers
Values and Behaviours (Staff)
Waiting Times
Commentary
The graph to the right
demonstrates the highest
recurring themes of the
complaint or concern
The graph at the left
demonstrates the area or
department involved in
the highest number of
complaints or concerns.
Over time, correlation
between the graphs will
show areas with specific
problems to help address
the issues.
Trust admin/Policies/Procedures (including patient record management)
Transport (Ambulances)
Mortuary
Other (Use with Caution)
Privacy, Dignity and Wellbeing
Mar-15Nov-14 Dec-14 Jan-15 Feb-15Aug-14
Prescribing
Patient Care
Admissions and discharges (excluding delayed discharge due to absence of care package)
Appointments
Clinical Treatment
Commissioning
Isle of Wight NHS Trust Quality ReportApr-15
Facilities
Integrated Care (Including Delayed Discharge due to absence of care package)
Communication
Consent
End of Life Care
0
2
4
6
8
10
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Top categories of complaint or concern since April 2015
Clinical Treatment
Admissions and discharges
Communication 0
10
20 Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Top areas subject of complaint or concern since April 2015
OPARU
Emergency Department
Orthopaedics
Medical Services
Page 27 of 38
Other contacts*
Total contacts** 575
Formal complaints (number) 15 0 1 1
(%) 0.08%
Concerns addressed (number) 75 3 9 3
(%) 0.39%
* Other contacts:- This figure is not definitive and may not include peripheral services if access to records is not centralised.
** Total contacts: Community & MH figures are available a month in arrears so an average has been used to facilitate perspective.
23007
New and Re-opened complaints.
Following the initial closure of a complaint investigation, the complainant may wish to
go further if they are unsatisfied by the response from the Trust. Options open include
referral to the Ombudsman and re-opening the case for further investigation, if
appropriate.
This can occur some time after the initial case was closed and may be dependent upon
progressive medical findings after an event.
It should be noted that the number of cases needing to be re-opened has apparently
reduced over the previous financial year, which may be an indication of greater
thoroughness and subsequent satisfaction with the complaints handling process.
0.17%
2,133
Commentary
This table demonstrates the levels of activity both within
the hospital and the wider community in order to provide
perpective to the number of complaints received by the
Directorates during the month.
It is important to note that the formal complaints received
are from across the services' total areas of responsibility,
including Nurse Lead and Allied Health Professional
services, not just the consultant OP and A&E services.
(There are too many variables to separate complaints
relating to individual areas in this report).
19,445 1872 23,779
0.00% 0.00%
CommunityHospital Mental Health
0.16% 0.04% 0.52%
1872
Consultant OP attendances
A&E attendances
- 43
11,545 - 749 532
3,680 -
Inpatient episodes (FCEs) 232,087
Isle of Wight NHS Trust Quality ReportApr-15
Complaints & concerns - Activity
Activity Type
(February 2015)Ambulance
157
15 3
25 1
27
1
28
1
7 7
0
20
40
60
80
100
120
140
160
180
200
Hospital(Prev yr) Hospital YTD Ambulance (Prev yr Ambulance YTD Community (Prev yr) Community YTD Mental Health (Prev yr)
Mental Health YTD
Nu
mb
ers
Directorate/service (2013/14, 2014/15)
New and Reopened complaints 2015/16 YTD
New complaints Re-opened
Page 28 of 38
Hospital
“...I just wanted to record my thanks to you – you and your nurses were just so kind and really reassured me ….Sometimes we take these things for
granted but believe me they mean such a lot…”
"I was impressed to receive an appointment … just a couple of weeks after being referred …… Throughout the process; the initial data collection, the
actual procedure, recovery and report; I was called by my first name and introduced to each member of staff by their first names….. Every step of the
procedure was fully explained and time was taken to answer any questions before beginning. All this ensured that any anxiety I felt initially was
allayed..."
Ambulance
“You were very kind and skilled when you took me to A&E ….. You were most caring, considerate and professional”
"I would like to say a massive thank you to you both for your support and guidance ….. You guys do a fantastic job and the NHS should be proud to
have you on their team "
Community
“To all who have had any contact with (patient)…. our sincere thanks for all your help and kindness. We’re sorry we didn’t get to say good-bye to many
of you to express our thanks in person but each and everyone of you will be missed…”
Mental Health
“To all the wonderful dedicated nursing staff and support workers ….. You are all a credit to your professions. Thank you for saving my life, making me
well again. Your care and attention to my illness, your compassion and understanding are a credit to you all. ….. Now begins the hardest fight of my life,
with your help, I know I will succeed. Thank you."
“… For the whole of my time in Sevenacres I saw complete dedication, care, understanding and wonderful treatment from all staff, whether on the
nursing side, administration or cleaning staff. Everyone I encountered gave such thought and care to those of us trying to find our way back to coping at
home and within the outside community. A huge thank you to all involved … for their support, care and understanding.”
Isle of Wight NHS Trust Quality ReportApr-15
Compliments- Extracts from Patient letters
Page 29 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
N/A 44% 44%
90% 97% 97%
N/A 33% 33%
90% 94% 94%
N/A 14% 14%
90% 94% 94%
N/A 14% 14%
90% 100% 100%
N/A N/A
90% 95% 95%
2014/15
2014/15
2014/15
% Recommended
% Recommended
Reponse rate
Inpatient areas
(Community wards, ex MH)*
Response rate
Isle of Wight NHS Trust Quality ReportApr-15
Friends & Family Test - Local targetsIndividual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position
Measure
Inpatient areas
(Acute hospital wards)
Response rate
% Recommended
Response rate
2014/15
Continuing
Completed
Improve response rates by utilising other methodologies to capture FFT feedback including use of tablet devices
Roll FFT out to other settings in line with national guidance i.e. Outpatient, Community and Mental Health
Ward Managers / Patient Experience Leads
Patient Experience / Service Leads
Mar-15
Mar-15
Actions Responsible job title Date Progress
% Recommended
The Friends & Family Test (FFT) is a single question asking 'How likely are you to recommend our ward/department to friends & family' asked nationally to benchmark perception of services by service users.
National targets were set for response rates and, from October 2014, the percentage that would recommend was recorded and benchmarked in line with a more user-friendly approach on the website. With effect
from April 2015, the FFT is not related to a CQUIN target for response or recommendation as it is felt nationally that the system should be sufficiently embedded within organisations to continue without. Our local
targets for recommendations remain at 90% and individual areas are expected to improve their client uptake. The most important element is that the feedback system should be available to all service users
whenever they wish to use it. it is patient choice whether they comment at the end of a course of treatment or at every attendance as long as the opportunity is available.
The percentage measures is calculated as follows:
Recommend (%)=(extremely likely+likely)
(extremely likely+likely+neither+unlikely+extremely unlikely+don't know) ×100
Results are published nationally and are available at: http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/
Locally, the FFT results are presented as part of the Ward Dashboard and are publically available on individual area boards around the hospital. This is summarised in the ward summary dashboard snapshot
elsewhere in this report. Outpatient areas are now included in the FFT survey and display their results on local area boards similar to those on the wards.
There are national challenges with regard to achieving sufficiently high response rates to have confidence that the results are representative and work is ongoing as the FFT is rolled out to include more
departments across the year. The island overall has a particular challenge as the test question asks 'how likely are you to recommend the service' which is difficult to respond to objectively when there is no
alternative facility to measure against. We also have times when there is a large visiting population and these have previously stated that they would not recommend to friends as they don't live in the catchment
area. s.
* With effect from January 2015, national reporting of Community Services was instigated (see summaries) and these figures have been extracted to provide continuity of ward only results.
Due to reporting requirements, data for the Friends & Family Test ' Community' and 'Mental Health' may be reported retrospectively as data is not always available in time to publish.
Community (Overall)
(response rate not applicable)
Reponse rate2014/15
% Recommended
Accident & Emergency
Maternity (birth point)
Page 30 of 38
CQC published the 5th Intelligent Monitoring reports for Acute trusts on 21 April, with publication due 28 May 2015:
The intelligent monitoring of trusts that provide acute services considers 95 different types of evidence, based on many sources e.g. Hospital Episode statistics, National Reporting Learning System data, national
inpatient surveys and Electronic Staff Records. These are titled Indicators and the total number of risks increased from 6 in December 2014 to 7, including 3 new risks
Of the 7 Risks listed on 21 April the following were Elevated Risks, both having been previously listed as Risks:
i) In-hospital mortality - Endocrinological conditions - Fluid and electrolyte disorders (case status as at 14.04.15); and
ii) Safeguarding concerns (25.12.14 to 24.02.15)
Our priority banding would have remained at Band 3 of 6 (Band 6 having the lowest Risk Level) but as a recently inspected Trust this is not officially recorded but provided by the CQC for benchmarking purposes.
The second Intelligent Monitoring reports for Mental Health trusts were published on 28 April, with publication due 11 June 2015:
The intelligent monitoring of trusts that provide mental health services considers 59 different types of evidence, based on sources that include the NHS staff survey, bed occupancy rates, the national health outpatient
survey and concerns raised by trust staff. The total number of risks has reduced from 11 in December 2014 to 8, however the number of indicators was previously 57.
Of the 8 Risks listed on 28 April two were on the previous report, with three new Elevated Risks:
i) Proportion of discharges from hospital followed up within 7 days (1.12.13 to 30.11.14)
ii) Service users who had five individual cardio metabolic health risk factors monitored in the past 12 months (1.08.13 to 30.11.13)
iii) Monitoring of alcohol intake in the past 12 months (1.08.13 to 30.11.13)
Our priority banding would have been at Band 1 of 4 (Band 4 having the lowest Risk level) but as a recently inspected Trust this is not officially recorded but provided by the CQC for benchmarking purposes.
CQC were asked to justify how data for two Acute indicators where CQC and Trust data did not match, with their feedback subsequently added to the action plan. The Action Plan for every listed Risk is attributed by
Lead Directors to senior staff for every listed indicator. The designated managers provided updates to the action plan schedule, including RAG ratings to reflect the ability of the action plan to address the criteria
within every indicator. The action plan is scheduled to be presented to SEE Committee on 20 May 2015.
Isle of Wight NHS Trust Quality ReportApr-15
CQC Quarterly Intelligent Monitoring Report - DRAFT REPORTS of April 2015
Page 31 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
2014/15 11 14 6 15 0 9 6 8 5 6 10 1 11 91
2015/16 3 3 3n/aNumber of Cases going to Inquest
Commentary
Of the inquests held in April 2015, the following conclusions were reported:
Narrative Conclusion - refer below
Road Traffic Collision
Suicide
Narrative detail: ‘The deceased sustained a substantial head injury previously which caused serious brain injury. The deceased failed to inform authorities of this pre-existing
condition. He was referred to Neurology but due to operational reasons he was not seen prior to his death or prescribed any anti-seizure medication. He suffered 5 fits prior to
his death and died of status epilepticus.’
NB The inquests registered for January 2015 total has increased by one due to the late notification by the Coroner of an inquest being held that month.
The conclusion was Death by accident‘
Isle of Wight NHS Trust Quality ReportApr-15
Cases going to Inquest during previous month
Measure
Page 32 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
2014/15 690 827 792 886 660 794 987 711 710 939 808 690 8804
2015/16 809 809 809Number of chaplaincy visits N/A
Commentary
For the month of April 2015 Chaplaincy’s Significant Patient Encounters amounted to 809. We achieved a 17% increase on the equivalent month in April 2014 (690).
These encounters lasted a total of 135 hours which averages out at 10 minutes per visit.
To substantiate the quality of our pastoral encounters, chaplaincy received 8 letters, cards and emails of appreciation during the month.
Some quotations:
“I wanted to thank you on behalf of us all for your wonderful support over the past couple of months, we know 'X' took great comfort and enjoyment from your visits and
prayers.”
“Just a quick thank you for spending time chatting to myself and family on the ward… your [words] touched my heart…so a big thank you once again”
“Thank you for coming to see her….it’s a great comfort to know that [she] will be fully prepared to meet her creator. Thank you for all you have done”
We are currently looking ahead to the Children’s Memorial Service on 28th June and our Chaplaincy Conference on 16th May when our guest speaker will be Rev. Karen
Mackinnon, the Lead Chaplain at University Hospital Southampton.
Isle of Wight NHS Trust Quality ReportApr-15
Chaplaincy activity
Measure
Page 33 of 38
Measure Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
2014/15 72 64 76 99 74 68 87 74 63 67 62 83 72 858
2015/16 72 72 72
2014/15 4.99% 4.19% 5.20% 5.97% 4.97% 4.34% 5.03% 4.55% 4.28% 4.34% 4.28% 5.43% 4.99% 4.39%
2015/16 5.01% 5.01% 5.01%
2014/15 2 3 0 5 2 2 3 1 5 4 2 0 2 29
2015/16 3 3 3
2014/15 3.70% 7.50% 0.00% 8.77% 5.13% 4.65% 6.82% 1.85% 10.64% 6.35% 4.35% 0.00% 3.70% 5.11%
2015/16 6.25% 6.25% 6.25%
2014/15 120 115 117 139 106 36 119 131 114 108 107 97 120 1309
2015/16 115 115 115
2014/15 13.23% 11.84% 12.68% 12.93% 11.17% 3.77% 12.21% 12.76% 11.23% 10.34% 11.69% 9.39% 13.23% 11.10%
2015/16 11.78% 11.78% 11.78%
↓ Reduction
on 2014/15
baseline (<? monthly)
TBA
Emergency readmissions within 30
days. Acute Hospital only(Payment by results(PBR) authorised national bundle
excluding maternity, children under 3 yrs, cancer
diagnosis and specified trauma)
Emergency readmissions within 30
days. Mental Health wards only (with same primary diagnosis code)
This was previously 28 days and previous year
has been rerun to align to new parameters.
↓ Reduction
on 2014/15
baseline(<? mthly)
TBA
admission %
admission %
Trustwide Emergency Readmissions
within 30 days(All emergency readmissions to all areas
regardless of diagnosis & speciality - includes
Mental Health)
↓ % reduction
on 2014/15
baseline
TBA
emergency
admission %
number
Commentary:
Emergency readmission following discharge is a raw indicator of the care received and can only be truly relevant if the second admission is for the same diagnosis. Many patients have co-existing
conditions and only case note analysis is able to state that the second admission is directly related to the first. However, the national PBR (payment by results) bundle addresses this by excluding
various categories and using a standardised methodology to facilitate national benchmarking. This is shown at the top in the table above. Readmissions for paediatrics provides a significant
contribution to the numbers at an individual level of 13.9% during April.
The Mental Health emergency readmission figures have been calculated for the same diagnosis but treatment regimes differ to other medical conditions and it could mean that home leave was
unexpectedly curtailed. In all cases, the percentage has been calculated against the comparable admission numbers for that month.
Regular audit of readmissions from various areas is carried out and shows that the majority of readmissions are unavoidable and frequently due to multiple co-morbidities on patients with
progressive health issues. Where other issues are identified (such as discharge home and subsequent admission due to failure of home care package) this is followed up individually.
Isle of Wight NHS Trust Quality ReportApr-15
Emergency Readmissions Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position
number
number
Page 34 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
↓10% 2014/15 1846 1804 2879 1886 1649 1763 1617 1869 2129 2460 2637 2406 1846 249451871 monthly 2015/16 2314 0 0 0 0 0 0 0 0 0 0 0 2314 2314
2014/15 57 76 72 102 75 161 165 84 106 103 115 117 57 1233
2015/16 43 43 43
Isle of Wight NHS Trust Quality ReportApr-15
Cancellations by hospital (1) Consultant lead appointmentsIndividual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position
Responsible job title Date Progress
Measure
Reduction on hospital lead cancellations(from 2014/15 baseline)
Appointments brought forward (Patient benefit)
Commentary:
Appointments for Consultant clinics are recorded on the Patient System Outpatient clinic diary and includes some Nurse Specialists in the data available. All
reasons related to the patient have been excluded. It should be noted that cancellations citing clinician on sick leave have been retrospectively included so
that the impact of this category can be assessed even thought it cannot be planned for in advance. However, all calculations have been made on the same
basis to enable comparison with the previous year.
A major problem affecting cancellations is the current system of issuing follow up appointments long periods in advance, although not doing this would cause
other operational problems. Clinician rotas, including annual & study leave requests, require 6 weeks notice and this obviously impacts on pre-existing
appointments as can be seen from the table below. There is also an increased requirement for clinicians to be included in management meetings nationally
which also impinges on previously booked clinic time.
Rebooking of re-existing appointments continues. Changes are underway to
improve recording and 'transfer to another clinician' is now available. All will take time
to work through and are not retrospective, unspecified reasons continue to appear.
Discussions are being held with PAS system administrators to reduce system limitations on recording in order to
produce more accurate reporting:-
a) Cancelled and rebooked clinics not affecting patient attendance
(e.g. change of room to be used)
b) Removing free text field from cancellation reason fields.
(Reduce unspecified cancellations).
General Manager, Medical, Emergency &
Diagnostic ServicesMay-15 In progress
0
500
1000
1500
2000
2500
3000
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
Hospital Outpatient Cancellations Consultant lead only
2014/15 2015/16 Target
Recorded cancellation reason on systemOn day or
retrospectively
Within
1 week
1-6
weeks
Over 6
weeks
Month
Total
CHOOSE AND BOOK 1 1 5 4 11
CLINIC CANCELLED OTHER REASON 29 199 167 29 424
CLINIC MOVED TO ANOTHER DATE 1 24 9 34
CLINICIAN ATTENDING MEETING 3 44 36 83
CLINICIAN ON ANNUAL LEAVE 14 9 99 109 231
CLINICIAN ON CALL 13 15 28
CLINICIAN ON SICK LEAVE 22 72 45 1 140
CLINICIAN ON STUDY LEAVE 3 15 42 22 82
EXPEDITE TO REINSTATED CLINIC 2 3 1 6
HOSPITAL CANCELLED APPT 46 291 543 257 1137
MORE URGENT CASE 10 16 1
REDUCE CLINIC SLOTS 1 1
TIMESLOT CANCELLED 5 5
TIMESLOT DELETED (SYS DEF) 1 5 52 58
Z C&B USE ONLY - BY PROVIDER 13 31 3 47
Grand Total 115 623 1037 539 2314
Local Specialty Name Apr 2015
OPHTHALMOLOGY 370
UROLOGY 212
GYNAECOLOGY 160
TRAUMA & ORTHOPAEDIC SURGERY 143
GENERAL SURGERY 131
ENT 133
RHEUMATOLOGY 124
PODIATRY 102
PAEDIATRICS 112
MAXILLO-FACIAL SURGERY 94
GASTROENTEROLOGY 90
ADULT MENTAL HEALTH 89
COLORECTAL SURGERY 60
MIDWIFE MATERNITY EVENT 60
RESPIRATORY & THORACIC MED 38
CLINICAL IMMUNOLOGY & ALLERGY 45
ORAL SURGERY 36
MATERNITY ANTE NATAL 31
CARDIOLOGY 30
HAEMATOLOGY - CLINICAL 30
CLINICAL ONCOLOGY 28
BREAST SURGERY 27
DERMATOLOGY 27
ELDERLY MENTAL HEALTH 25
CHEMICAL PATHOLOGY 23
PAIN MANAGEMENT 15
FRACTURE (OUTPATIENTS) 10
MEDICAL ONCOLOGY 13
LEARNING DISABILITIES 13
ENDOCRINOLOGY 10
ORTHODONTICS 9
TRANSIENT ISCHEMIC ATTACK 6
GENERAL MEDICINE 6
GERIATRIC MEDICINE 5
DIABETIC CLINIC 3
REHABILITATION 2
ANAESTHETICS 1
NEUROLOGY 1
Grand Total 2314
Page 35 of 38
Measure Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
↓10% 2014/15 613 467 335 473 420 511 465 426 353 552 699 1104 613 6418target 481 481 481 481 481 481 481 481 481 481 481 481 481 5776.2
(392 Monthly) 2015/16 425 425 425
2014/15 13 25 11 14 18 26 40 16 21 22 32 33 13 271
2015/16 8 8
Discussions are being held with PAS system administrators to reduce system limitations on
recording in order to produce more accurate reporting:-
a) Cancelled and rebooked clinics not affecting patient attendance
(e.g. change of room to be used)
b) Removing free text field from cancellation reason fields.
(Reduce unspecified cancellations).
General Manager, Medical, Emergency
& Diagnostic ServicesMar-15 In progress
Commentary:
Appointments for Allied Health Professional clinics are recorded on the Patient System Service Group Diary and those departments that use this
system are available for retrieval. Notable exceptions are Physio- and Occupational Therapies as well as Othotics & Prosthetics and others that
use a separate part of the system and further work is required to include these other areas. All reasons related to the patient have been excluded,
and cancellations citing clinician on sick leave have been retrospectively included although this cannot be planned for in advance. It should be
noted that all calculations have been reworked on the same basis for the previous year to enable comparison.
Allied Health Professionals and Nurses have very low levels of multiple
cancellations during an episode. This may be due to their methods of
working or a reduced need for the patient to be followed up.
The table to the top left illustrates the types of reasons given for cancellations
and demonstrates the level of unspecified reasons cited. This will start to
be addressed by the planned review of the recording system as previously
stated.
The table at the lower left illustrates the top areas that the appointments have
been cancelled for this month. This does not take account of the various
levels of associated activity.
Actions Responsible job title Date Progress
Appointments brought forward
(Patient benefit)
Reduction on hospital lead cancellations
(from 2014/15 baseline)
Isle of Wight NHS Trust Quality ReportApr-15
Cancellations by hospital (2) Allied Health Professional and Nurse lead appointmentsIndividual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position
-50
50
150
250
350
450
550
650
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
Hospital Outpatient Cancellations Allied Health Professionals & Nurses
2014/15 2015/16 target Clinic Service Group Desc Total
IW CARDIOLOGY 516
IW PODIATRY 252
IW EYE ORTHOPTIST 51
IW CHRON PAIN PSYCHL 47
IW EYE FIELD 46
IW PREASSESSMENT 16
IW MPTT - SPINAL 15
IW CHEST INVEST'TION 14
IW ENDOSCOPY 10
IW EYE NS 7
IW MPTT - LOWER LIMB 7
IW ALLERGY 4
IW CHILDRENS WARD 3
IW EYE OPTOMETRIST 3
IW ALLERGY DIETITIAN 2
IW OHPIT 2
IW CONTINENCE NS 1
IW DIETITIANS 1
Appt Cancel Reason Description total
CANCELLED APPT BROUGHT FORWARD 8
CLINIC CANCELLED OTHER REASON 46
CLINICIAN ATTENDING MEETING 4
CLINICIAN ON ANNUAL LEAVE 30
CLINICIAN ON SICK LEAVE 69
CLINICIAN ON STUDY LEAVE 3
HOSPITAL CANCELLED APPT 189
MORE URGENT CASE 1
NO NURSE AVAILABLE 1
TIMESLOT CANCELLED 134
TIMESLOT DELETED (SYS DEF) 512
Page 36 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
2014/15 42 43 35 47 26 28 22 15 35 35 50 50 428 428
2015/16 31 31 31
2014/15 29 29 23 32 20 19 18 10 25 26 33 33 297
2015/16 10 10
The bed manager has oversight of the patient moves on a monthly basis and is reviewing
clinically to exclude justified transfers and provide validated figures for this measure. Bed Manager Mar-15 Planned
Actions Responsible job title Date Progress
Isle of Wight NHS Trust Quality ReportApr-15
Patient moves within stay
Measure
Patient moves 3 or more times
(excluding clinically justified moves)
Commentary
Patient moves within an episode or spell may be clinically appropriate but it is important that moves are justified and do not affect patient care adversely. In order to
calculate the base figures shown above, all admissions for the year were retrieved and filtered for any internal transfers during the admission. The number of transfers was
calculated and those that were deemed likely to have been clinically justified excluded. These included moves from MAAU to a specific ward, moves to and from ITU,
cardiac care or stroke care. It is not possible to be completely accurate for each patient without individual case note review by a clinician but the figures above are
comparable for each month and are valid for identifying a basic trend. Future reporting may be a month further retrospectively to enable time for this clinical review to take
place and for validated figures to be presented. Work is underway to develop this aspect of reporting and numbers may change retrospectively as the process is refined.
This will also demonstrate the degree of variance with and without clinical validation.
The figures above show the number (sum) of moves experienced by patients moved more than twice within their stay. As different patients experience different numbers of
moves, the number of patients experiencing 3 or more moves is also shown. For the year to date, both the numbers of moves and the numbers of patient experiencing those
moves have reduced since the beginning of the year.
April figures continue to demonstrate efforts to reduce unnecessary moves with
10 patients experiencing a maximum of 3 moves that may not have been clinically
justified. A single patient was moved 4 times. These figures have not been clinically
validated and are subject to change.
The CQC visit highlighted patient moves as an area of particular interest with
respect to end of life care and early identification of patients for whom the
Amber Care Bundle is appropriate has already resulted in a reduction in
unjustified transfers since implementation.
It should be noted that the Trust admits approximately 2500 patients a month and only
a small percentage are affected by these moves, which may be made to avoid
mixed sex accommodation breaches whilst the building is being reconfigured.
Number of patients involved in these moves
0
2
4
6
8
10
12
0
5
10
15
20
25
30
35
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
Nu
mb
er
of
pat
ien
ts a
ffe
cte
d
Nu
mb
er
of
un
just
ifie
d m
ove
s
Month
Clinically unjustified moves within stay Moves recorded Patients affected
Page 37 of 38
Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Total Total
2014/15 7 18 5 13 17 12 9 12 7 7 4 8 7 119
2015/16 5 5 5
The bed manager continues to receive monthly reports for investigation. Bed Manager May-15 Ongoing
Isle of Wight NHS Trust Quality ReportApr-15
Discharges recorded as Overnight (re-aligned to be after 23:00 & before 06:00)
CommentaryN.B. Numbers will change retrospectively as coding completes for preceding months.
These figures are for admitted patients only and do not include non-admitted attendees that leave A&E following examination and/or treatment.
Discharges outside of 'normal working hours' have hit national headlines and work has been underway to identify any local problems. Initial
analysis demonstrated considerable data validation errors due to historical ways of working within the recording system used. (see notes at right).
These are reducing but further work is needed to increase the accuracy of the data available. Alignment of times for the definition of 'overnight
discharge' with other organisations is hoped to enable benchmarking.
Regular scrutiny and monitoring of these figures by the Bed Manager confirms that cases remaining after transfers to other facilities and
recognised day admissions have been excluded, are patient choice once medical clearance had been recieved. Children's and Maternity
wards are excluded from this report for this reason. The Bed Manager continues to recieve monthly reports and cascades information down to
individual areas as necessary. 60% of the recorded overnight discharges this month are of patients 75 years or over but it is not possible
to say whether these patients had home back up without individual case note investigation. There is however, a noticeable decrease in
late discharges recorded since the start of the 2014/15.
Reporting is being expanded to include monitoring of discharges between 06:00 and noon
which we aim to increase in line with the new Key Performance Indicator requested for 2015/16.
Actions Responsible job title Date Progress
Measure
Discharges recorded as overnight (all LOS)
DATA VALIDATION KNOWN DATA ERRORS
1. Numbers reported for the previous month will change as discharge summaries are entered and coding is completed.
2. Data errors involving incorrect 12/24
hour clock formats have been confirmed by case note audit. This has reduced considerably through training but is ongoing and may affect over 60% of past records.
This human error will never be totally eliminated but is improving now that ward clerks check details for previous 24 hours.
3. Post-discharge system entries default to the time the entry is completed if no specific time is entered. This occurs when the discharge is not completed electronically at the same time as the physical discharge and is finished at a later time.
This error is being addressed by ward clerks checking discharge details for the previous 24 hours and is reducing over time.
Discharge Ward Name 23:0
0 -
23:5
9
00:0
0 -
01:5
9
02:0
0 -
03:5
9
04:0
0 -
05:5
9
Gra
nd T
ota
l
Monday
Tuesday
Wednesday
Thurs
day
Friday
Satu
rday
Sunday
MAAU 1 4 5 1 2 2 10
Grand Total 1 4 0 0 5 0 0 0 1 2 2 10
Page 38 of 38