CoG (01/16) Item 9.3.2 - nlg.nhs.uk · PDF fileBACKGROUND DOCUMENT (IF ANY) ... r essu Ulc s( ad 2, 3 & 4) ( nom re tha 2 G PS7 Nu trion c ae p h wy s ... Re-opened complaints to not

CoG (01/16) Item 9.3.2.1

DATE 14 January 2016

REPORT FOR Council of Governors

REPORT FROM Tara Filby, Chief Nurse Wendy Booth, Director of Performance Assurance/Trust Secretary

CONTACT OFFICER Jeremy Daws, Head of Quality Assurance

SUBJECT

Monthly Quality Report

BACKGROUND DOCUMENT (IF ANY)

2014/15 Annual Quality Account

EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN THAT THE COG NEED TO BE MADE AWARE OF)

From this month’s Quality Report, the Board are asked to note the following key points:

Page 7: Latest SHMI released, 111, “higher than expected” range,

Page 9: NEWS compliance at 100% this month,

Page 10: Progress with dementia position, but still under 90% target,

Page 16: As requested at last month’s QPEC, a focus on discharge letters is included,

Page 19: Community Safety Thermometer 94%,

Page 20: Absence of ‘new’ harms is identified in 96.9% of patients,

Page 22: Lowest number of pressure ulcers reported,

Page 27: Food record chart is deteriorating,

Page 39: Latest morale barometer results reported.

COUNCIL ACTION REQUIRED

The Council of Governors is asked to note the report

Directorate of Performance Assurance

Quality Report

November 2015

Directorate of Performance Assurance, November 2015 Page 3 of 52

Board Report – Quality Summary

November 2015

Contents

1.0 Introduction 4

2.0 Board Action 4

3.0 Recommendations 4

4.0 At a Glance 5

5.0 Clinical Effectiveness Indicators 6

6.0 Patient Safety Indicators 17

7.0 Patient Experience Indicators 29

8.0 Glossary 42

9.0 Appendix 1 – Focus on VTE as reported in the 46 Safety Thermometer

10.1 Appendix 2 - Friends and Family Target Table 50


1.0 INTRODUCTION This, the latest monthly edition of the Trust’s Quality Report, outlines performance against the quality priorities agreed for 2015/16 and reports on these indicators to the Quality & Patient Experience Committee (QPEC) and ultimately the Trust Board. For the 2015/16 indicators wherever possible data is provided outlining the Trust position for the previous year to allow for comparison.

2.0 BOARD ACTION The Board is asked to:

Review the performance against the range of targets/indicators included within the report.

3.0 RECOMMENDATIONS

No new recommendations are contained in this report.


3.1) Screened for Dementi a DPoW 4.0% 92.0% G 88.0%

SGH 10.0% 93.0% G 83.0%

3.2) Dementi a - screened, DPoW 0.0% 100.0% G 100.0%

appropri ate assessment SGH 0.0% 100.0% G 100.0%

3.3) Dementi a - appropri ate DPoW 0.0% 100.0% G 100.0%

referral to speci al i st servi ces SGH 0.0% 100.0% G 100.0%

Indicator Change Oct-15 Previous

DPoW 0.0% 100.0% G 100.0%

CE2 NEWS - Appropri ate acti on taken SGH -3.2% 96.8% G 100.0%

GDH 0.0% 100.0% G 100.0%

st recent data Previous Trends

111.0 R 109.8 95

108.0 R 112.5 95

4.0

A

t a

Gla

nc

e

QUALITY INDICATORS AT A GLANCE: Nov-15

2015/16 Indi cators

Indicator Time period / RAG

CLINICAL EFFECTIVENESS Mo

Comparator

Target

CE1

Del i ver mortal i ty performance

wi thi n 'expected range' and

i mprovi ng quarter on quarter,

unti l reported SHMI i s 95 or

better

Offi ci al ' SHMI (Apr 14-

Mar 15) HED data (Aug 14 - Jul 15)

Posi ti on vs peers

Higher than expected

R

Higher than

expected

Wi thi n expected

range

Trends Target

95.0%

Oct-15 Previous Trends Target

CE3

CE3

90.0%

90.0%

CE3 90.0%

CE4

CE4

NICE - Compl i ance wi th Al l NICE Gui dance

NICE - Compl i ance wi th ALL NICE TAGs

assessed

-0.7% 79.0% R 79.7%

-3.0% 88.9% R 91.9%

90% by March

2015

CE5 Transfer of pati ents for non-cl i ni cal reasons

(capaci ty) to not exceed 10% of the total -1.0% 11.0% R 12.0% 10.0%

Indicator

PATIENT SAFETY

Change

Time period / RAG

Oct-15

Comparator

Previous

Trends

Target

PS1 MRSA Bacteraemi a Inci dence (YTD: 0) 0 0 G 0 0

C Di ffi ci l e Inci dence (ALL cases) (YTD: 16) -2 0 G 2 PS2

C Di ffi ci l e ('Lapses i n care') (YTD: 5) 0 0 G 0 No more than 21

PS3 Safety Thermometer (Communi ty) 3.0% 97.0% G 94.0% 95%

Open and Honest Ini ti ati ve - Harm DPoW -2.7% 88.2% R 90.9%

PS4 Free Care - Safety Thermometer ('New' and 'Ol d')

SGH 2.7% 93.5% R 90.8%

GDH 11.0% 95.0% G 84.0%

95%

Oct-15 Previous Trends Target

PS5

El i mi nati on of Avoi dabl e Repeat

Fal l ers

DPoW 0 0 G 0

SGH 0 0 G 0

GDH 0 0 G 0

DPoW 3 3 R 0

El i mi nate Al l

avoi dabl e repeat

fal l s

50% reducti on

PS6 Reducti on i n Number of Avoi dabl e SGH 1 1 G 0 Pressure Ul cers (Grades 2, 3 & 4)

(no more than 2

PS7

Nutri ti on care pathway was

GDH 0 0 G 0

DPoW 4.0% 99.0% R 95.0% SGH -2.0% 96.0% R 98.0%

per month)

fol l owed 100%

GDH 0.0% 100.0% G 100.0%

PS7

PS8

The food record chart compl eted

accuratel y and ful l y i n l i ne wi th

care pathway

The fl ui d management chart was

compl eted accuratel y and ful l y i n

l i ne wi th care pathway

DPoW 6.0% 98.0% R 92.0%

SGH -1.0% 88.0% R 89.0%

GDH 0.0% 100.0% G 100.0%

DPoW 0.0% 97.0% R 97.0%

SGH -10.0% 82.0% R 92.0%

GDH 0.0% 100.0% G 100.0%

100%

100%

Indicator

PATIENT EXPERIENCE

Change

Time period / RAG

Oct-15

Prev 12 mths

Previous Trends

Target

PE1 Response rate to fri ends and fami l y test wi thi n the top 50%

Inpati ent Medi an A Bottom 50%

A&E Bottom 50% R Bottom 50%

Top 50%

Re-opened compl ai nts to not exceed 20% of

Oct-15 Previous Target

PE2 total cl osed compl ai nts

10.3% 25.7% R 15.4% 20%


PE3

Compl ai nts - acti on pl ans drafted

Compl ai nts - acti on pl ans i mpl emented

0.0% 100.0% G 100.0% 90%

0.0% 100.0% G 100.0% 90%

Compl ai nts - 50% reducti on i n compl ai nts

Q1 15/16 Q4 14/15 Target

PE4 rel ati ng to communi cati on

No data to report as yet To be establ i shed

Pati ents shoul d not have any

DPoW


PE5

unpl anned omi ssi ons i n

provi di ng pati ent medi cati ons

Pati ents shoul d not have a del ay

of more than 30 mi nutes i n

provi di ng pai n rel i ef.

SGH

GDH

DPoW

SGH

GDH

No data to report as yet 90%

No data to report as yet 90%

Sep-15 May-15 Target

PE6 Staff sati sfacti on - i ncrease i n moral e/staff

sati sfacti on -0.1% 5.5% R 5.6%

2.5% i ncrease

(mi n. 6.65)

4.0 At A Glance

This Section…

5.0 CLINICAL EFFECTIVENESS (CE)

CE1 Mortality

CE2 National Early Warning Scores (NEWS)

CE3 Dementia

CE4 Evidence Based Practice (NICE)

CE5 Transfer and Discharge

6.0 Patient Safety

7.0 Patient Experience

8.0 Glossary

9.0 Appendix 1 – Focus on VTE as reported in the Safety Thermometer

10.1 Appendix 2 - Friends and Family Target Table



Cli

nic

al

Eff

ec

tiv

en

es

s

5.0 CLINICAL EFFECTIVENESS

CE1 – Mortality SHMI: Deliver Mortality Performance within ‘expected range’ and improving quarter on quarter, on a Moving Annual Total (MAT) basis at each quarterly publication date until our reported SHMI is 95 or better

Key points - context:

SHMI (Summary Hospital Level Mortality Indicator) is the ‘official’ NHS mortality

measure. It is reported quarterly. It measures in and out of hospital mortality (deaths within 30 days of hospital discharge).

The indicator uses data that is normally around six months out of date, for example the October 2015 release covered the period April 2014 – March 2015.

The Trust uses HED ‘provisional’ SHMI, purchased from the University Hospitals Birmingham NHS Foundation Trust. Enables a more recent timeframe in the interim of the ‘official’ quarterly publication.

The following information is an excerpt from this month’s Mortality report which contains more detail on this and the other work underway within the Trust regarding mortality.

Key points – performance:

Most recent Summary Hospital Level Mortality Indicator (SHMI) was published in October 2015 and covers the April 2014 – March 2015 time period.

The Trust’s SHMI score is 111 – ranking 124 out of the 137 NHS provider organisations included in data set.

This is now officially in the “higher than expected” range.

Previous quarter’s SHMI NLAG was ranked 121 out of 137, with a score of 110.

NLAG’s SHMI in National Context

The following chart illustrates the Trust’s most recent SHMI score in relation to those of all Trusts nationally.

Source: Information Services / Information Centre


NLAG’s Provisional SHMI in National Context

Using the HED (Healthcare Evaluation Data) ‘provisional’ SHMI we can now report on more up to date information.

HED SHMI currently shows data to the end of July 2015. Data in this analysis should

be treated as provisional. Whilst from reconciliation work, we know that this data source reflects the ‘official’ SHMI publications, the numerical value of the HED SHMI can be subject to change. This is due to a number of reasons (1) the quarterly publication of the ‘official’ indicator provides the HED model with rebased data (representing the national picture/changes) and (2) more complete data is available from hospital episode statistics (HES) data and Office for National Statistics (ONS) each successive month, therefore, both local and national changes (including deaths post hospital discharge) are an emerging picture and become more complete the further away we move from the months covered within the data release.

Using the provisional data for the twelve months to July 2015, the Trust is ranked as

111 out of the 136 NHS provider organisations included within the mortality data set, with a score of 108.0.

The Trust is within the ‘as expected range” banding. The following funnel plot

graphically represents this.

Source: Information Services based on the Healthcare Evaluation Data (HED)

Greater detail, including trend performance, for this indicator and full details regarding the Trust’s work on Mortality is reported on in the monthly mortality report.


Per

cen

tage

(%

) C

om

ple

ted

CE2 – National Early Warning Score (NEWS)

CE2: In 95% of cases with a NEWs score, appropriate clinical response was actioned

Key points – context:

NEWS (National Early Warning Score) is designed to help identify the deteriorating patient.

Once a patient is identified as deteriorating using NEWS, this should trigger appropriate escalation action, in line with local policy.

The following chart summarises the number of cases where appropriate action was taken as a result of the NEWS score assessment. The appropriateness of this assessment is judged by nursing staff undertaking this audit on a monthly basis.

Key points – performance:

In 95% of cases with a NEWS score, appropriate clinical response actioned

100%

98%

96%

94%

92%

90% Apr 14

May 14

Jun 14

Jul 14

Aug 14

Sep 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Trustwide 99% 99% 100% 100% 99.7% 99.7% 100% 96% 98% 100% 100% 99% 99.7% 99.7% 99.7% 99.1% 99.7% 100% 98.5%

DPoW 100% 99% 99% 100% 100% 100% 100% 100% 99% 100% 100% 98% 100% 100% 100% 100% 100% 100% 100%

SGH 97% 99% 100% 100% 100% 99.4% 100% 94% 97% 100% 100% 100% 99.3% 99.4% 99.4% 98.1% 99.4% 100% 96.8%

GDH 100% 100% 100% 100% 93.8% 100% 100% 94% 100% 100% 100% 95% 100% 100% 100% 100% 100% 100% 100%

Threshold 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Source: Information Services, Nursing Dashboard

NB: As Trust performance with this indicator has been consistently high, for optimal viewing

of this information at individual site level, the above charts axis starts at 90%.

Comments:

During October compliance was above 95% at all three sites. DPOW and Goole achieved 100% compliance. At Scunthorpe, compliance was 96.8%. This was from one specific ward area where patients with very low risk had not had their observations recorded in line with the NEWS local policy. This was escalated at the time of the Quality Matron visit.

This example has identified some residual improvements that can be made to the implementation of the NEWS policy on the Trust’s Web V system. Work is now underway with the developers to enable greater ability for clinical judgement to be used alongside the scoring framework to decide appropriate action needed and how the timescales for observations are flagged on the system.

The NEWS policy itself is being reviewed by the Trust’s lead nurse for deterioration to ensure the current scores are working as effectively as possible in triggering escalation.


Pe

rce

nta

ge (

%)

Co

mp

lian

ce

CE3 – Dementia

Target – 90% of patients aged 75 and over admitted as an emergency for more than 72 hours who have been screened for dementia and where patients are identified as potentially having dementia ensuring that at least 90% are appropriately assessed and where appropriate referred on to specialist services.

To measure this indicator, it has been broken down into 3 component parts, detailed over the next few pages:

CE3.1 – 90% of patients aged 75 and over admitted as an emergency to be asked the dementia case finding question.

The following chart summarises performance over time with this indicator.

100%

281

80%

60%

268

40%

20%

0% Apr 14

May 14

Jun 14

Jul 14

Aug 14

Sep 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

90% Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

DPoW 99% 96% 94% 93% 91% 88% 93% 88% 92% 94% 95% 94% 95% 83% 89% 89% 85% 88% 92%

SGH 96% 95% 96% 98% 95% 95% 94% 97% 94% 94% 96% 95% 95% 81% 80% 83% 88% 83% 93%

Source: NLAG CQUINS Data, Intranet, Information Services Team

NB: The above charts data labels refer the number of patients, not the percentage of patients, as illustrated in the chart axis.

For full details as to how compliance with this indicator is measured, see glossary.

Comments:

Dementia screening has once again achieved the target of 90%, the first month since April 2015, when compliance was first noted to have deteriorated.

Much effort has been employed to improve dementia screening to above 90%, a

summary of the key actions taken are listed as follows:

o A daily report is provided to the lead Quality Matron outlining in ‘real time’ the

number of patients eligible for a dementia screening. This is then passed on to operational colleagues for information and action.

o Work is underway to add this to the daily operations centre meetings to

provide further assurance that this necessary information is being disseminated to all operational areas.


Per

cen

tage

(%

) C

om

plia

nce

P

erce

nta

ge (

%)

Co

mp

lian

ce

CE3.2 – 90% of the above patients scoring positive on the case finding question to have a further risk assessment.

29

100% 26

90%

80%

70% Apr 14

May 14

Jun 14

Jul 14

Aug 14

Sep 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

90% Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

DPoW 100% 100% 100% 100% 92% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

SGH 100% 100% 100% 90% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%


NB: The above charts data labels refer the number of patients, not the percentage number of patients. Also, the axis starts at 70%.

For full details as to how compliance with this indicator is measured, see glossary. CE3.3 – 90% of the patients identified as requiring referral following risk assessment to be referred in line with local pathway.

20

100%

11

90%

80%

70% Apr 14

May 14

Jun 14

Jul 14

Aug 14

Sep 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

90% Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

DPoW 100% 100% 100% 100% 100% 100% 100% 100% 100% 90% 100% 100% 100% 100% 100% 100% 100% 100% 100%

SGH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%


NB: The above charts data labels refer the number of patients, not the percentage number of patients.

For full details as to how compliance with this indicator is measured, see glossary.

Comments:

The Trust continues to consistently meet these indicators for all patients


CE4 – Evidence Based Practice Target – To increase compliance with NICE guidance with 90% compliance achieved by the end of March 2015.

Overall Trust Compliance – NICE Technology Appraisal Guidance (TAGs)

As at the 23 November 2015, Trust compliance with those NICE Technology Appraisal Guidelines (TAGs) that had been assessed using the Trust’s Gap Analysis toolkit is as follows:

COLOUR

COMPLIANCE STATUS

COMPLIANCE NUMBERS

COMPLIANCE (%)

GREEN

FULL COMPLIANCE

185

88.9%

AMBER

Partial compliance

3

1.4%

BLUE

Not yet assessed – OVERDUE

20

9.6%

RED

Non-Compliant

0

0.0%

TOTAL

208

100.0%

Overall Trust Compliance – All NICE Guidance As at the 23 November 2015, overall Trust compliance is as follows:

COLOUR

COMPLIANCE STATUS

COMPLIANCE NUMBERS

COMPLIANCE (%)

GREEN

FULL COMPLIANCE

357

79.0%

AMBER

Partial compliance

33

7.3%

BLUE

Not yet assessed – OVERDUE

60

13.3%

RED

Non-Compliant

2

0.4%

TOTAL

452

100.0%


CE5 Transfer and Discharge **Revised target – reduction from 20% to 10%**

Transfer of patients for non-clinical reasons (capacity) to not exceed 10% of the total transfers.

The transfer and discharge group continue to focus on this important area. This month, the most recent version of the group’s action plan is included. It sets out the work being done across the Trust in regard to patient flow:

Refining the data compendium to provide information to drive clinical change

Securing clinical leadership to drive the changes

Recognising the impact of multi- agency action on realizing discharges

Opportunities to learn from best practice elsewhere

No. Required Outcome

Action

Lead

Update at December 2015

1 Clinicians and service managers have the data which provides a coherent and compelling description of the position within this Trust

To complete the

data

compendium

which collates

data on key

indicators. This

compendium will

include

comparisons

between the two

main sites and

against national

benchmarks

where these exist

Karen

Fanthorpe

A working version of the compendium has been produced. Key points are:

A&E attendances appear to have remained steady at about 170 people per day (and are comparable between the 2 main sites).

The conversion rate of A&E attendances to admissions is similar to the national average.

The number of discharges and admissions per day are virtually the same which means there is little room for spikes in activity – the figures we have also include day cases and elective inpatients so a single daily figure may be misleading .

Approx. 75% of admissions to CDU & AMU occur between the hours of 4pm and 8am.

The number of ambulances arriving at A&E is not dissimilar between the two sites (average of 55 per day @ DPOW and 49 @ SGH) but the percentage of people going on to be admitted is different. The other thing to note is the range of ambulances – for DPOW, for example, the minimum was 35 ambulances on a given day and a maximum of 81 on one day.

Nationally, the expected rate of discharge at a weekend is 80% of the typical number discharged on a weekday. Our figures suggest that we are only discharging c 50% of people.

Discharges by midday are lower than the national guidance is promoting.

Readmissions are different between the two sites with SGH having a higher percentage.

Length of stay for medicine is longer than the national or peer average – compared to our peers at 5.7 days, our LOS at DPOW is 7.5 days and at SGH is 6.3 days.

Further analysis of data is being undertaken to look at:

The typical number of patients who present at A&E by day of the week.

The length of stay by medical specialty comparing across sites and with national benchmarks if available.

Discharge percentages from AMU/CDU.


No.

Required Outcome

Action

Lead

Update at December 2015

2 Clinical engagement drives forward changes in practice based on the outcomes of the data compendium review

Secure clinical

engagement to

work with service

managers

Karen

Fanthorpe

Pete

Bowke

r

1) Consultant leadership secured for both sites:

Dr Luxy John –initial focus on Expected Date of Discharge (EDD).

Dr Gupta – initial focus at SGH on maximising the use of the Discharge Lounge and improving weekend discharges.

2) Medicine Group has established a “Discharge Planning Group” to drive & review changes in practice. Initiatives which are being implemented include:

additional clinician hours at weekend with a focus on increasing discharges. At SGH this is also linked to a Virtual Discharge Team which will commence

12th

December

Care Navigator proof of concept pilot on both sites

3 Improve the multi- agency support to ensure discharges are not delayed

Establish pilot

project in DPOW

led by Focus

(adult social

care) to deliver a

Hospital Inreach

Team to create

pace in

discharging

patients who are

medically fit

Pam

Clipson &

team

Ops

Centre

team

(DPOW)

3.1 Pilot commenced 5th

October – will involve an increased presence by the social care team on the wards and a daily review of patients admitted in the preceding 24 hours to identify case management arrangements more proactively.

Strategy & Planning Team providing daily information.

Outcome will be demonstrated through reduction in DTOCs. Evaluation of pilot awaited

3.2 Early discussions underway with Focus to consider discharges to community beds to reduce number of patients delayed due to awaiting intermediate care

4

Learn from best practice from across the country

Identify

opportunities to

learn from other

NHS Trusts as

part of existing

networks and ad

hoc events

Karen

Fanthorpe

1) data compendium shared with neighbouring Doncaster & Bassetlaw Trust – opportunities for joint learning being pursued

2) Patient Flow conference (Oct) and Improvement Academy conference (Oct) – outcomes and results disseminated to Transfer & Discharge Group (Oct)

3) to consider a locally based conference for NLaG clinicians and partner agencies


Source: Transfer and Discharge Working Group Report, Trust Information Services


Transfer and Discharge: Focus on discharge communication

From previous discussions at the Quality and Patient Experience Committee, an important element of the transfer and discharge agenda has been the process to support and ensure colleagues outside of hospital are well communicated with. Much work is currently been undertaken in this area and can be broadly broken down into 8 distinct work streams. The following diagram provides a high-level overview of these:


4.0 At A Glance

5.0 Clinical Effectiveness

This Section…

6.0 PATIENT SAFETY (PS)

PS1 MRSA Bacteremia Incidence

PS2 C Difficile

PS3 Safety Thermometer (Community)

PS4 Safety Thermometer (Acute)

PS5 Falls

PS6 Pressure Ulcers

PS7 Nutrition

PS8 Hydration


8.0 Glossary




2

1 1 1 0 0 0

Nu

mb

er

of

C D

iff

infe

cti

on

s (

n=

) N

um

be

r o

f M

RSA

B

acte

rae

mia

s (n

=)

Ap

r-1

2

May

-12

Ju

n-1

2 Ju

l-1

2

Au

g-1

2

Sep

-12

O

ct-1

2 N

ov-

12

Dec

-12

Ja

n-1

3

Feb

-13

Mar

-13

A

pr-

13

M

ay-1

3

Jun

-13

Jul-

13

A

ug-

13

Se

p-1

3 O

ct-1

3 N

ov-

13

Dec

-13

Ja

n-1

4

Feb

-14

Mar

-14

A

pr-

14

M

ay-1

4

Jun

-14

Jul-

14

A

ug-

14

Se

p-1

4 O

ct-1

4 N

ov-

14

Dec

-14

Ja

n-1

5

Feb

-15

Mar

-15

A

pr-

15

M

ay-1

5

Jun

-15

Jul-

15

A

ug-

15

Se

p-1

5 O

ct-1

5

Ap

r-1

5

Ma

y-1

5

Jun

-15

Jul-

15

Au

g-1

5

Se

p-1

5

Oct-

15

No

v-1

5

De

c-1

5

Jan

-16

Fe

b-1

6

Ma

r-1

6

Pa

tie

nt

Sa

fety

6.0 PATIENT SAFETY

PS1 – MRSA Bacteraemia Incidence

Target – 0 MRSA Bacteraemia developing after 48 hours into the inpatient stay (hospital acquired).

Trust Performance (April 2015 to date): 0 cases

October 2015: 0 cases reported at Diana Princess of Wales Hospital

October 2015: 0 cases reported at Scunthorpe General Hospital

3 Hospital Acquired MRSA Bacteraemias (post 48 Hours)

2

1 1 1

1

0 0 0 0 0 0 0 0 0 0

0

0 0 0

1 1 1

0 0 0

1

0 0 0 0 0 0 0 0 0 0 0

1

0 0 0 0 0 0 0 0

Source: Trust Infection Control Database, Information Services Team

Key points – previous performance: Hospital acquired MRSA (post 48hrs)

2010/11 2011/12 2012/13 2013/14 2014/15

MRSA Incidence

8

4

2

5

1

PS2 – C. Difficile Incidence (Lapses in care) Target – Achieve a level of no more than 21 hospital acquired C. Difficile cases linked with a lapse in the quality of care, over the financial year 2015/16.

Trust Performance (April 2015 to date): 5 cases

October 2015: 0 cases reported at Diana Princess of Wales Hospital (review pending)

October 2015: 0 cases reported at Scunthorpe General Hospital (review pending)

October 2015: 0 cases reported at Goole District Hospital

Hospital Acquired Clostridium Difficile Infections (Lapses in care)

10

8

6

4

2

0



5 5

4 4 4 4 4 2 2 2 2

1 2 1 1 1 1 1 1 1

1 1 01 1

0 0 0

Nu

mb

er

of

C D

iff

infe

cti

on

s (

n=

)

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

A

ug

-12

S

ep

-12

O

ct-

12

N

ov-1

2

De

c-1

2

Jan

-13

F

eb

-13

M

ar-

13

A

pr-

13

M

ay-1

3

Jun

-13

Jul-

13

A

ug

-13

S

ep

-13

O

ct-

13

N

ov-1

3

De

c-1

3

Jan

-14

F

eb

-14

M

ar-

14

A

pr-

14

M

ay-1

4

Jun

-14

Jul-

14

A

ug

-14

S

ep

-14

O

ct-

14

N

ov-1

4

De

c-1

4

Jan

-15

F

eb

-15

M

ar-

15

A

pr-

15

M

ay-1

5

Jun

-15

Jul-

15

A

ug

-15

S

ep

-15

O

ct-

15

For completeness: ALL cases of hospital acquired C. Difficile over the financial year 2015/16. Trust Performance (April 2015 to date): 16 cases (ALL cases)

October 2015: 0 cases reported at Diana Princess of Wales Hospital

October 2015: 0 cases reported at Goole District Hospital

October 2015: 0 cases reported at Scunthorpe General Hospital

ALL Hospital Acquired Clostridium Difficile Infections

10

8

6

4 3 2 3 3

2

0

4 4 3 3 2 3 3 3 3 3 3


Key points – previous performance: Hospital acquired C Diff (post 48hrs, ALL cases)

2010/11 2011/12 2012/13 2013/14 2014/15

C Diff Incidence

43

41

37

24

20

PS3 – Safety Thermometer – Increase in harm free care (Community)

Key Points: Context

The NHS Safety Thermometer methodology is used to monitor the incidence of harm as a result of acute and community care (Community care in North Lincolnshire area only, which became a part of the Trust from April 2011).

For details and methodology used by the Safety Thermometer, see the glossary.

Key Points: Performance against target – Provide harm free community care to 95% or more patients – as measured by the Safety Thermometer

The following table illustrates the overall percentage of harm free care within Community & Therapy Services provided by the Trust in North Lincolnshire since April 2013.

Overall % of harm free care – INCLUDING ‘old’ harms

Cumulative % of Harm Free Care

Site Year

13/14 Q1

14/15 Q2

14/15 Q3

14/15 Jan 15

Feb 15

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Community Care Total

93%

94%

95%

95%

97%

96%

96%

94%

96%

92%

94%

95%

94%

97%

Source: NLAG Safety Thermometer Data, Intranet, Information Services Team

Comments:

For the month of October, performance has increased to 97% which is above the target set.

PS4 – Increase in harm free care (Acute)

Target – Provide harm free acute care to 95% or more patients – as measured by the Open and Honest Initiative

Key Points: Context

The NHS Safety Thermometer is based on a point prevalence analysis of the care provided to patients on a given date each month. This point prevalence audit provides a ‘snapshot’ view of harm on that given day each month. It focusses on harm in four key areas. For details and methodology used by the Safety Thermometer, see the glossary.

Key Points: Performance to date – Safety Thermometer:

The charts below show the percentage of patients not experiencing harms.

Source: NLAG NHS Safety Thermometer, as reported within the open and honest initiative, NHS England

Comments:

The charts above illustrate that whilst 90.8% of patients did not experience any harms (new and old), a proportion of those patients presented to the acute hospital setting with a pre-existing harm i.e. an ‘old’ pressure ulcer, or in other words, a pre-existing pressure ulcer already afflicting them prior to hospital admission.

The chart on the right hand side illustrates those patients with ‘new’ harms only – those developing at least 72 hours after admission. For October, 96.6% of patients had harm free care. The trend illustrates an improving one.

The proportion of patients receiving harm free care therefore should be interpreted with caution, recognising that some harm is not preventable by the Trust.


Per

cen

tage

(%

)

Headline figures – Performance at site level (‘new’ and ‘old’ harms included):

The following chart breaks down the overall ‘headline’ figure to site specific detail. This information is for ‘new’ and ‘old’ harms, reported since October 2013.

Site Breakdown: Percentage who did not experience any harms 100%

95%

90%

85%

DPOW 88.2% SGH 93.5% GDH 95.0%

80%

75%

70% Oct Nov Dec Jan

Feb Mar Apr May Jun

Jul

Aug Sep Oct Nov Dec Jan

Feb Mar Apr May Jun

Jul

Aug Sep Oct

13 13 13 14 14 14 14 14 14 14 14 14 14 14 14 15 15 15 15 15 15 15 15 15 15

DPoW 89.1 91.2 96.1 95.6 86.9 95.9 94.8 95.6 94.6 93.7 92.6 88.2 85.4 93.8 87.1 90.2 90.7 90.6 87.7 89.9 86.7 89.9 92.0 90.9 88.2

SGH 90.4 93.3 97.2 93.1 91.5 96.6 92.0 94.7 91.9 93.8 87.1 89.8 92.9 85.4 86.5 92.5 86.5 91.3 88.9 94.3 91.9 92.2 92.2 90.8 93.5

Goole 91.3 76.5 96.0 91.3 96.4 100. 83.0 96.3 88.9 100. 100. 100. 91.7 72.2 91.3 95.8 100. 92.3 87.9 95.8 87.0 100. 95.8 84.0 95.0

Target 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0 95.0

Source: NLAG Safety Thermometer Data, as reported within the open and honest initiative, Information Services

Comments:

Contributing to overall performance in October were the following harms identified:

DPoW:

Pressure Ulcers: 96.3% (-3.7%) had no ‘new’, 91.0% (-9.0%) had no ‘old’,

UTI free: 98.3% (-1.7%) were UTI free,

No falls: 99.7% (-0.3%) had no falls,

‘New’ VTE: 98.6% (-1.4%) did not have any ‘new’ VTEs requiring treatment.

SGH:

Pressure Ulcers: 99.7% (-0.3%) had no ‘new’, 94.8% (-5.2%) had no ‘old’,

UTI free: 99.0% (-1.0%) were UTI free,

No falls: 99.7% (-0.3%) had no falls,

‘New’ VTE: 100.0% (0.0%) did not have any ‘new’ VTEs requiring treatment.

Goole: Pressure Ulcers: 95.0% (-5.0%) had no ‘new’, 95.0% (-5.0%) patients had no ‘old’.

Comments:

At Goole, 5% equated to 3 patients. All were known to the Tissue Viability Nursing team. One had end of life skin changes, the remaining 2 patients were cared for in Scunthorpe and were transferred to Goole.

Action now being taken:

VTE performance is focussed on in more detail within Appendix 1 of this report.

For ease of reference regarding the work underway to improve the quality of care for patients with pressure ulcers, please see section PS6 within this report.


Open and Honest Initiative: Falls & Pressure Ulcers Key Points: Headline figures – Performance as a Trust (NEW harm only):

The following charts illustrate the number of falls and pressure ulcers, identified from all reported incidents, since October 2013, including the level of harm and the falls rate per 1000 bed days. The chart also illustrates the trend over time.

Source: NLAG Specific Findings from Open and Honest Initiative, NHS England

Comments:

The above chart reports the harm classifications following falls, specified by the Open and Honest Initiative, specifically resulting in moderate, severe harm, or harm leading to death.

From those falls identified as causing harm, once work to understand individual root

causes is completed, a meeting will be organised to assess all the incidents. However, to date, from each reviewed, all were deemed to be accidents with no common themes arising.

There were no falls during October 2015 that met the above classifications of harm.


Comments:

The pressure ulcer rate per 1000 bed days demonstrates a continuously improving performance with a decreasing trend for harm from pressure ulcers.

In October the overall number of pressure ulcers was 20 in total. This was

comprised of 3 grade 3 and 17 grade 2 pressure ulcers.

There were no grade 4 pressure ulcers reported.

For ease of reference regarding the work underway to improve the quality of care for these patients, please see sections PS5 and PS6 of this report.



PS5 – Patient Falls – Eliminate all avoidable repeat falls (as measured via the Root Cause Analysis undertaken for every repeat faller) – From April 2014

Key points: Repeat Fallers – RCA Outcomes – Eliminate all avoidable repeat fallers

For every repeat fall a Root Cause Analysis (RCA) is performed to identify lessons that can be learnt to prevent future patients falling.

Each fall is determined to have been either avoidable or unavoidable.

The following table provides a summary of performance per month against this target.

2013 /14

Q1 2014 /15

Q2 2014 /15

Q3 2014 /15

Q4 2014 /15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Number of Repeat Fallers

362

56

59

62

48

19

12

18

16

13

19

10

Avoidable

41

4

1

2

1

2

2

0

0

1

0

0

11%

7%

2%

3%

2%

11%

17%

0%

0%

8%

0%

0%

Unavoidable

321

52

58

60

47

17

10

18

16

12

19

10

89%

93%

98%

97%

98%

89%

83%

100%

100%

92%

100%

100%

Data Source: RCA Records kept by lead Quality Matron

Comments:

There were no avoidable repeat falls during October. Action now being taken:

Various methods of obtaining training are now available for staff to access,

The findings from the national audit of inpatient falls, undertaken in 2015 will be fed into

the Trust’s falls action plan,

The substance misuse team will be looking at offering training to staff in relation to falls

and dealing with patients who have alcohol issues,

Hot spot areas are able to be identified through the trending data which is now available

on the quality wall boards. Action will be taken in relation to the findings.


October’s breakdown

Grade 2

Grade 3

Grade 4

17

3

0

PS6 – Pressure Ulcers – a 50% reduction in avoidable grade 2, 3 & 4 pressure ulcers (as measured via the Root Cause Analysis undertaken for every grade 2, 3 & 4 pressure ulcer)

Avoidable grade 2, 3 and 4 hospital acquired pressure ulcers – RCA outcomes – 50% reduction in avoidable grade 2, 3 and 4 pressure ulcers

The following table focusses on the number of potentially avoidable grade 2, 3 and 4 pressure ulcers from records kept by the lead Quality Matron as a result of the RCA work taking place.

In total for Quarter 1 14/15, of the 87 grade 2, 3 and 4 pressure ulcers, 12 were deemed to be avoidable following the root cause analysis work undertaken. Based on this, setting a 50% reduction target, equates to no more than 6 pressure ulcers per quarter. 6 per quarter, divided by 3 months, equates to no more than 2 avoidable pressure ulcers per reported month.

Q1

14/15 Q2

14/15 Q3

14/15 Jan 15

Feb 15

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Number of Grades 2, 3 & 4 Pressure Ulcers

87

85

98

50

30

40

24

35

22

23

25

16

20

Avoidable

12

24

14

3

1

4

1

0

0

1

1

0

4

14%

28%

14%

9%

5%

14%

4%

0%

0%

4%

4%

0%

20%

Unavoidable

75

61

69

33

21

24

23

35

22

22

24

16

16

86%

72%

70%

91%

95%

86%

96%

100%

100%

96%

96%

100%

80%

Source: RCA Records kept by lead Quality Matron

Comments:

There were four avoidable pressure ulcers in October, comprising 3 avoidable grade 2 (2 at DPOW and 1 at SGH) and an avoidable grade 3 pressure ulcer at DPOW.

The number of avoidable pressure ulcers this month is above the

target set. Some of this relates to the increased training and the resultant staff knowledge which has enabled earlier detection of pressure damage. As a result the number of reported pressure ulcers is likely to increase.

This has also been the focus over the last year working to reduce the number of grade 3

and 4 pressure ulcers and because of this more resource is now available and invested into understanding root causes for patients with grade 2 pressure ulcers. This again has resulted in a higher incidence of reporting of preventability. This greater understanding therefore enables more focus on the root causes for further improvement for all grades of pressure ulcer.

One RCA meeting held during November was for a patient with a pressure ulcer during

August. From the review of the case it was determined that the pressure ulcer was avoidable. This has been escalated as a Serious Incident (SI) following discussion with the Chief Nurse. This has retrospectively been added to the above table outlining performance in August 2015.



The Pressure Ulcer Grading (PUG) wheel has been printed and is in use with good

effect within the Trust.

A consultation paper is being written to explore the options around delivery of the

Tissue Viability Service across the Trust including the hospital and community teams. This is following a recent business case approval.

Pip, a Pug dog (relating to the branding of the Dragon’s Den successful bid to

develop the aforementioned PUG wheel and inspection mirrors) has made a debut on children’s wards for those at high risk, in the form of a fun interactive workbook for children to raise the importance of pressure ulcer prevention. Feedback from this to date has been very positive.

All dynamic mattresses have to be cleaned off site following use by individual

patients. The current contract cannot cope with the demand for mattress cleaning. As the Trust has invested in additional dynamic mattresses, the effects of this additional investment is not being felt by our patients due to the necessary waiting times for transportation, cleaning and return which can put a mattress out of action for up to 1 week. A business case is currently being developed by medical engineering to enable them to process and clean mattresses; this would require relocation of the Medical Engineering Team/Department to give them the needed space. This is still ongoing but is been reviewed on an on-going basis by Infection Control Team. An update on progress with this is being sought.

The Trust has commissioned a review to provide additional challenge from an

external expert in pressure ulcer care working elsewhere as a Tissue Viability Nurse (TVN). It is hoped this external scrutiny will help aid the focus on improving this area still further. This review has now been completed and the findings are expected by the end of January 2016.

From previous versions of this report and the data presented, ‘old’ pressure ulcers

remain an area of concern. Previous attempts have been made to explore the context within North Lincolnshire as part of the Trust’s community services. On the back of the development of the Tissue Viability Service closer links between the Trust and community services will be considered, using some increased capacity to look at a different model of care.


Per

cen

tage

(%

) C

om

ple

ted

PS7 Nutrition

PS7.1 Nutrition – for 100% of patients the Nutrition care pathway was followed


In September 2013 the Trust adopted a nationally validated tool – the Malnutrition Universal Screening Tool (MUST).

The MUST screening Tool is used to identify those patients who are at risk of malnutrition – depending on the MUST score – a management plan is then followed for the duration of the patients stay.

Key points – performance to date:

The following chart illustrates current levels of compliance with using the care pathway following roll-out of the MUST scoring system in September 2013.

100%

In 100% of patients the Nutrition care pathway was followed

95%

90%

85%

80% Apr 14

May 14

Jun 14

Jul 14

Aug 14

Sep 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Trustwide 88% 93% 95% 94% 90% 94% 93% 93% 95% 97% 97% 96% 96% 98% 97% 97% 96% 96% 97%

DPoW 87% 91% 95% 94% 90% 93% 93% 90% 92% 96% 95% 93% 94% 98% 96% 94% 95% 95% 99%

SGH 88% 95% 95% 94% 90% 94% 93% 94% 98% 98% 98% 98% 97% 97% 97% 99% 97% 98% 96%

GDH 100% 100% 100% 100% 94% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Threshold 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%


NB: The above charts axis starts at 80%.

Comments:

Performance against this indicator at all DPOW and SGH has not yet achieved the 100% target set. However as can be seen from the trend line, this is generally improving and so is a positive trend.


Focussed work to be undertaken on ensuring protected mealtimes are adhered to and improved use of the salmon pink tray for those patients identified as requiring assistance with eating or drinking or who require monitoring of their nutritional intake.

Also in support of this is the introduction of a mealtime standard, outlining what is

expected of staff at mealtimes. Promotion of this will commence during January 2016.


Per

cen

tage

(%

) C

om

ple

ted

PS7.2 Nutrition – for 100% of patients the food record chart was completed accurately and fully in the line with the care pathway

Key points – context:.

Those patients who are identified as moderate to high risk (MUST score >1) need to have a food record chart commenced and completed fully in line with the management plan.


The following chart illustrates the current compliance with ensuring the food record chart was used fully and appropriately.

In 100% of patients the food record chart was completed accurately and fully in line with the care pathway

100%

95%

90%

85%

80% Apr 14

May 14

Jun 14

Jul 14

Aug 14

Sep 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Trustwide 88% 97% 94% 96% 93% 94% 96% 94% 90% 88% 92% 89% 95% 93% 94% 90% 94% 91% 93%

DPoW 87% 96% 95% 97% 94% 93% 96% 97% 86% 89% 90% 86% 95% 94% 93% 92% 93% 92% 98%

SGH 88% 98% 93% 95% 92% 96% 94% 91% 93% 86% 93% 92% 94% 92% 94% 86% 95% 89% 88%

GDH 100% 100% 100% 100% 100% 100% 100% 100% 100% 95% 100% 100% 100% 100% 100% 100% 89% 100% 100%

Threshold 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%



Comments:

During October, overall compliance has increased to 93%, but the trend line shows a deteriorating trend.

Compliance reported above is ascertained from examining the documentation completed for those patients at risk who have been commenced on the food record chart. Therefore, not every patient on the ward will be on a food record chart, rather the numbers of patients needing this are very small. The figures presented above, therefore, should be interpreted with caution due to the small numbers represented.

Whilst the above chart illustrates that the documented evidence is not always available, the feedback from patients at the time the audits are completed provides assurance that patients are being well cared for from a nutrition and hydration point of view.


The Quality Matrons continue to undertake a more detailed focussed review of nutrition and hydration indicators. This work has included a wider scoping of patients deemed to be at risk and assessment of these patients to determine if the food record chart has been commenced and completed appropriately. Where improvements were felt to be possible, this supportive action has been taken at the time of the Quality Matron visit.

A pilot project was undertaken on wards 16 and 23 to aid staff awareness and support of patients with nutritional needs by using laminated symbol cards. The results of this pilot


have proved its success.


Per

cen

tage

(%

) C

om

ple

ted

PS8 Hydration

PS8 Hydration – for 100% of patients the fluid management chart was completed accurately and fully in line with the care pathway.


Effective and consistent fluid management is recognised nationally as being an area

of weak practice as demonstrated in the National Patient Safety Agency (NPSA) (2008) and the National Reporting and Learning System (NRLS) (2008) evidence.

Accurate fluid balance monitoring is an essential tool in the early identification of a patient whose condition is deteriorating.

Monitoring the hydration status of patients by using fluid management charts is imperative to reducing the risks of dehydration and the associated complications it can bring.


In 100% of patients the fluid management chart was completed accurately and fully in line with the care pathway

100%

95%

90%

85%

80% Apr 14

May 14

Jun 14

Jul 14

Aug 14

Sep 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Trustwide 88% 88% 89% 91% 88% 89% 86% 87% 96% 95% 96% 96% 96% 94% 96% 93% 96% 95% 90%

DPoW 87% 84% 89% 88% 83% 83% 85% 89% 96% 97% 97% 97% 97% 100% 95% 92% 97% 97% 97%

SGH 88% 90% 88% 94% 91% 94% 84% 83% 95% 92% 96% 96% 94% 88% 96% 93% 94% 92% 82%

GDH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Threshold 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%



Comments:

Evidence of compliance at SGH had dropped to 82%. A similar trend to the documented completion of the food record chart is seen here.

This is one of the indicators used to identify ward areas needing support meetings with the Deputy Chief Nurse to understand the context and agree actions for improvement. This work continues.


Fluid charts are an area that has been included on the electronic nursing document. A roll-out date for this is currently being agreed as a matter of priority.


4.0 At A Glance


6.0 Patient Safety

This Section…

7.0 PATIENT EXPERIENCE (PE 1-6)

PE1 Friends & Family Test

PE2 Reduction in Re-Opened Complaints

PE3 Complaints Action Plans Implemented

PE4 Complaints Themes Reduction in Incidence

PE5 Pain Management

PE6 Staff Satisfaction

8.0 Glossary




Pa

tie

nt

Ex

pe

rie

nc

e

7.0 PATIENT EXPERIENCE

PE1 – Friends and Family Test

Target – To have a response rate that achieves a response rate in the top 50% which also improves on the Quarter 1 response rate.

Response Rate: A&E Friends and Family – broken down by site

80%

NLAG A&E Friends & Family Response Rate in national context by Sites - Oct 15

70%

60%

50%

National Average - 13.6%

NLAG TRUST - 12.4%

40%

30%

20%

DPOW - 15.4%

SGH - 11.3%

GDH - 7.6%

10%

0%

Source: NHS England, Friends and Family Test Data

Comments:

The Trust ranks 82 out of 141, placed in the bottom 50% of responding organisations.

Goole MIU has only recently become eligible for inclusion in this indicator. This has been

impacted on further by a change of management in the unit.

Response Rate: Inpatient Friends and Family – broken down by site

100%

90%

NLAG Inpatients Friends & Family Response Rate in national context by Sites - Oct 15

NLAG TRUST - 26.3%

80%

70%

60%

50%

40%

30%

20%

10%

0%

National Average - 25.1% GDH - 26.8% SGH 26.5%

DPOW - 26.0%


Comments:

The Trust ranks 86 out of 172 Trusts which places the Trust in the middle of the responding organisations.


Greater clarity and action to support Friends & Family test response rate:

To bring further clarity to individual ward level performance, with a view to identifying

exemplar wards, a new addition to the monthly quality report, is the league table for ward areas, presented in appendix 2 of this document.

For a further summary of action being taken, see the end of this section for a full

summary.

Key Points – performance:

Feedback from the F&F Test: A&E – broken down by site

NHS England present this information in a comparable way defining the percentage of patients who recommend Trust against other UK comparators.

NLAG A&E Percentage Recomended in national context by Sites - Oct 15

100%

90%

National Average - 87.2%

GDH - 91%

NLAG Trust - 85% DPOW - 85%

SGH - 85%

80%

70%

60%

50%


Comments:

A&E feedback for the Trust is 85% which is lower than the national average of 87.2%.

Feedback from the F&F Test: Inpatient Percentage Recommended – broken down by site

NLAG Inpatients Percentage Recommended in national context by Sites - Oct 15

National Average - 95.5

100%

GDH - 100

NLAG Trust - 97

SGH - 96

DPOW - 95

90%

80%

70%

60%

50%


Comments:

97% recommended the Trust compared to the UK average of 95.5%.


For more information regarding the Friends & Family Test, please follow this link to the NHS England site: http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family- test/friends-and-family-test-data/

Action now being taken to improve:

A number of initiaves are being taken to focus on this area including:

o A weekly FFT dashboard,

o Flowchart design for the the processes involved,

o Brighter, more visible FFT boxes on clinical areas,

o Ward, department leads continuing to display the results,

o Identifying staff names within FFT in respect of recognising great patient care –

initially just touching base to say thank you but eventually formalising this approach,

o Sharing positive responses with staff for re validation purposes,

o Looking at ways to enhance the sharing of FFT results – with regards to

dashboard creations for groups,

o Breaking down responses, especially in community and rehab to help teams use data at local level – this involves looking at cards and how we enter data,

o Increased FFT awareness by attending group meetings to raise profile – monthly

link to matrons forum,

o Trial of new FFT card in A&E SGH,

o Re launch of support from volunteers in progress.

http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/

http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/


Per

cen

tage

of

re-o

pen

ed c

om

pla

ints

(%

) (R

e-o

pen

ed /

nu

mb

er c

lose

d)

PE2 – Reduction in Re-opened Complaints

Target – Re-opened complaints to not exceed 20% of total closed complaints


Since May 2014, the number of reopened complaints had been on average 12 per month which exceeded the target being aimed for – a 50% reduction, equating to no more than 2.5 per month. The number of closed complaints had continued to increase. As a significant proportion of these related to older complaints which made up the ‘backlog’, it is to be expected therefore that a proportion of those complaints closed will always be re-opened, as a result of the complainant requiring further assurance.

To set a numerically based reduction was therefore deemed unrealistic. Instead of a

numerical target, a proportional or a percentage target would seem more realistic. Accordingly the following chart illustrates the percentage of re-opened complaints.

50.0%

40.0%

Percentage of re-opened complaints

38.1%

37.5%

34.5% 31.6%

30.0% 26.7%

22.8%

27.8% 25.5%

22.9%

21.1%

25.7%

18.9% 16.9% 16.2% 19.3% 17.3% 20.0%

10.0%

14.9%

12.7%

5.8%

8.0%

15.9% 15.4%

0.0%

Jan

Feb Mar Apr May Jun

Jul

Aug Sep

Oct

Nov Dec

Jan

Feb Mar Apr May Jun

Jul

Aug

Sep

Oct

14

Percentage

14 14 14 14 14 14 14 14 14 14 14 15 15 15 15 15 15 15 15 15 15

re-opened 14.9 18.9 12.7 16.9 26.7 22.8 38.1 37.5 27.8 16.2 25.5 19.3 5.8% 17.3 22.9 8.0% 21.1 15.9 31.6 34.5 15.4 25.7

Re-opened 7 10 8 11 16 13 16 12 15 12 12 11 3 9 11 4 8 10 12 10 6 9

Data Source: DATIX, Performance Assurance Team

Comments:

The percentage of re-opened complaints is above the 20% target at 25.7%.

It is worth noting that in an attempt to improve complainants’ satisfaction and improve their feeling of assurance, at the end of each response letter, the complainant is offered the opportunity of a meeting to discuss the findings. More and more complainants are taking up this opportunity, this has an impact on the numbers of reopened complaints reported in this section of the monthly quality report. As a result of this impact, work is to be invested by the Trust in understanding from peer Trusts how soon they close their complaints. From this benchmarking exercise, the Trust will make a decision as to its own timescales to ensure we are in line with other organisations. Currently complaints are closed as soon as the final response letter is sent. This work is underway and is being discussed by the Trust’s Executive Team.


Key points: Complaints – contextual information – as at the 13 November 2015:

The following chart contains data extracted from DATIX as at 13 November 2015.


Comments:

The above chart illustrates the significant progress made in reducing the net open number of complaints. However whilst the numbers of new and closed complaints remain relatively static over the last 3 months, compared with previous months and this time last year, a small increase is seen in the number of net open complaints. This seeming disparity infers that some complaints are staying open for longer, resulting in a cumulative increase.

As a result of some recent changes in staff within the central team, there has been a

period of transition. This period is now ending and with the team fully allocated a caseload now an increasing number of closed complaints are being seen during November 2015. This will be reported in next month’s report.


PE3 – Complaints Target – 90% of action plans following a complaint to be implemented within agreed timescales.


An action plan, which records timescales and responsibilities, will be prepared by the relevant Directorate / Operational Group on the closure of a concern or no later than 3 months after closure of the complaint and will be monitored regularly by the Operational Group until fully implemented.

The following table illustrates part one of the process, that of drafting an action plan,

for those complaints requiring action, since April 2013.

2013 /14

Q1 2014 /15

Q2 2014 /15

Q2 2014 /15

Q4 2014 /15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct

15

Total number of complaints closed

Total number of complaints requiring action plan

Number of action plans drafted by Complaints Team

% action plans drafted by Complaints Team

968 182 128 178 152 50 38 63 38 29 39 35

394 41 39 53 48 25 14 25 11 10 10 10

392 41 39 53 48 25 14 25 11 10 10 10

99% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%


Step two of the process is implementation by the relevant Directorate / Operational Group of the actions within the agreed 3 month timeframe following closure of a complaint.

The following table illustrates the number of action plans that required implementation during each month and then illustrates the number of these actually implemented in practice. Due to the aforementioned 3 month timescale, the number eligible for completion each month differs from the number drafted in the same month.

2013 /14

Q1 2014 /15

Q2 2014 /15

Q2 2014 /15

Q4 2014 /15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Number of complaints action plans requiring implementation within month

254

43

14

40

32

14

14

22

16

20

23

14

Number of complaint action plans fully implemented

64

4

0

31

30

12

14

22

16

20

23

14

% of action plans fully implemented

25%

9%

0%

78%

94%

86%

100%

100%

100%

100%

100%

100%



Comments:

A more robust process for monitoring and implementing the complaint action plans has been introduced. These strengthened arrangements have resulted in significant improvements seen since October 2014.

The Complaints Team have implemented further monitoring mechanisms within the team,

this has involved the implementation of an action plan tracker report which is monitored weekly by the Complaints Manager to ensure escalation within groups is concluded at an earlier stage. Ownership of the action plans within the directorates to ensure actions and nominated leads are identified at the creation stage of the plans will be undertaken. The Complaints Team are working on changing the culture of the trust in relation to action plans and learning the lessons as more complainants are requesting evidence and assurance that lessons are being learnt. This has supported continued levels of compliance in this area.

This remains a priority and as well as being monitored within this monthly report, this also

features as a performance indicator overseen by the Trust’s Chief Executive during the routine quarterly performance framework.

PE4 – Complaints

Target – To achieve a 50% reduction in complaints relating to the specific theme of communication (Reported quarterly)

Key points – context to the target being set:

From an analysis of themes present in complaints, communication was identified as one of the most predominant reasons (55-60% of formal complaints analysed).

As a result of this, the Trust has set an improvement trajectory for complaints relating

to communication.

Based upon Q2 2013/14 data as a baseline identified 65 formal complaints over a 3

month (1 quarter) period related to this theme of communication.

Projecting this over the remainder of the year (3 remaining quarters) would equate to

260 complaints per year.

A 50% improvement trajectory based on this would be a maximum of 130 complaints

per year. This breaks down to a quarterly target of no more than 32.5, rounded up equals 33.

Mid-year review of target:

This target was designed to aid an improved understanding. However from reviewing

the themes to date and reporting these in this report, it has been difficult to ascertain the number of complaints made for the specific reason of poor communication. During the mid-year review of quality priorities the decision was taken to review this target.

As a result the DATIX system has been refreshed to include additional and more

specific categories for complaint themes to be logged at the time the complaint is received. These additional, more specific codes will enable the central complaints handlers to accurately code the exact nature of the communication issue and with which discipline of staff. The full list is included as follows for greater understanding and will be combined with existing fields in DATIX to result in more specific querying of the system:


COMMUNICATIONS

7 Access to Interpreting Service

07O Appointment sent to deceased patient

7.1 Bereavement Support Issues

7.3 Breakdown in communication between staff

7.4 Breakdown in communication re appointments

7.2 Breaking bad news

7.1 Communication between medical teams

7.5 Communication failure between departments

07JA Communication failure re Choose & Book

7.6 Communication failure within department

7.9 Communication with GP

7.7 Communication with patient

7.8 Communication with relatives/carers

7.11 Conflicting information

07FA Copying Letters

7.12 Delay in giving information/results

7.13 Delay in reporting results

7.14 Delay or failure to receive scans/x-rays

07H Failure to adhere to Duty of Candour Policy

07N Failure to liaise with patient following incident (not Duty of Candour)

7.23 Failure to listen to patient

07D Failure to listen to relatives

7.15 Failure to notify to community

7.17 Inadequate information provided

7.16 Inadequate record keeping

07HA Inadequate/inaccurate information provided for FOI request

07I Inconsistent clinical advice given

7.18 Incorrect entry on healthcare records

7.19 Incorrect/inaccurate interpretation

7.2 Incorrect/no information given

07DC Information on Condition & Treatment

07GA Information on non-clinical issues

7.21 Insufficient information provided

7.22 Method/style of communication

07DA Quality/Content of letters

07DB Unable to contact NLAG staff

07P Unavailability of death certificate

This increased specificity will enable the Trust to understand this area in much more detail.

As a result and to ensure that any target setting is accurate, it is planned that the

themes arising from this revised process are monitored and reported within the monthly quality report and using this as a baseline, set a reduction target for the 2016/17 quality priorities and monitoring of these in this monthly report.


PE5 – Pain Management


Following reflections within the ‘patient stories’ presented to QPEC and the Trust Board, management of pain and administration of pain relief were areas felt to require additional scrutiny.

Recent guidelines issued by NICE on nursing staffing levels included a number of

nursing ‘red flags’ to help trigger areas for greater nursing scrutiny/management. Two of these ‘red flags’ related to this area, specifically:

o Unplanned omission in providing patient medications, o Delay of more than 30 minutes in providing pain relief.

The nursing dashboard process by which levels of nursing quality are measured on a

monthly basis, evaluating 10 patients on every ward within the Trust, has been refocused and is likely to go live during January 2016. The core nursing dashboard will be supported by other dashboards focussing on patient experience, community adult and community children.

To ensure the Chief Nurse directorate are focussed on pain management, this

overhaul includes 4 specific new questions that relate to pain management, these are as follows:

o Patient Experience Dashboard:

o Did you feel that the medical and nursing staff did everything they could to

help control your pain?

o Did you receive pain relief when you needed it, in a timely way by staff?

o Acute Adult Nursing Dashboard:

o Are there >2 omitted doses of 1 or more medications?

o Was the appropriate action taken in relation to the medication omission?

The findings from these new dashboard questions will be included as soon as they are available in early 2016.


PE6 – Staff Satisfaction – 2.5% increase in morale / staff satisfaction per 6-months

Key points – context Culture Change measured via the Morale Barometer:

The work streams to operationally weave the Vision and Values (V&V) into Trust policies and procedures continue, but in many cases have been completed. From this work of particular note is as follows:

Renewed investment in staff engagement

Line manager support and visibility for all staff

Staff benefits and reward/recognition

Greater workforce support concerning organisational change and staff voice

With the V&V now falling into the Deputy CEO Strategy a revision of the V&V is presently underway with the view to simplifying the vision; drilling into and therefore emphasising its core components with presentation to Trust Board in November for Trust wide launch thereafter. The launch will importantly seek the participation from all staff to bolster the impact of the V&V on trust activities and standards of service delivery.

Key Points – Performance to date:

Morale Barometer incorporating the Friends and Family test

The ninth Morale Barometer survey took place in September 2015.

All 6,500 staff were invited to take part and participate in this quarterly survey. Response rates to date are illustrated in the following table:

Nov

2011 May 2013

Sept 2013

Jan 2014

Apr 2014

July 2014

Oct 2014

May 2015

Sept 2015

Response rate

87

340

545

356

330

496

286

321

288

Source: Morale Barometer Findings, Directorate of Organisation Development and Workforce

The Trust workforce (all sites, all staff) continue to report a morale score of 5/10; often referred to as morale neutral. This has remained the position since October 2014.

This MB survey is the 9th survey in its current format. The dashboard reveals that the mood of the workforce remains more or less constant since the instatement of the survey, less when the Trust launched its Vision and Values and during the period of time it was in special measures - a period where the 'blitz spirit' was previously evidenced by the survey and through discussions with staff.

Of particular note from the surveys is:

Staffs sense of 'value' both at departmental and Trust level is on the decline and of particular concern,

Staffs sense of 'voice', or their ability to suggest/influence service changes remains low,

Staff report that they continue to receive a PADR; however, staff question the worth of their PADR, reporting PDPs largely (for them) have no meaning nor do they receive the time to complete the objectives that have been set and agreed,

The Staff Friends and Family test questions again reveal that staff are moving towards not recommending the Trust as a place to work; this has been the stance for the second consecutive survey,

Finally staff report a 10% reduction in the number of staff receiving at least a monthly team meeting and only 6/10 report feeling engaged in Trust developments

To identify which respective staff group(s) faired better or worse the 8 individual staff groups returns were evaluated separately. From this it can be seen the AHPs typically report higher levels of engagement and satisfaction than other groups. It is therefore intended that the OD


team conduct some semi structured interviews and staff focus groups, to extract and share best practice across the other groups.

Actions (all actions link to agreed QPEC MB May 2015 action plan):

1. OD Team to conduct evaluate of engagement, value, staff voice etc within AHP staff group and share best practice,

2. OD Team to conduct some all staff Friends and Family Test focus groups to review

findings and provide steer to reverse the growing 'unlikely' to recommend the trust as a place to work concerns,

3. Comms and marketing to review and adapt communication channels for 'all staff' not

just those with PC access,

4. ETD to continue to work regarding improving the PADR experience and effectiveness

of PDPs. Summary: Measurement of the Quality improvement target around this area

To measure this quality improvement target, the key question highlighted on the next

page, is used to measure progress in this area. The question asks:

“How much personal satisfaction do you get from coming to work?”

The following contains the results of the most recently run morale barometer in Sept 2015 and presents this compared to previous surveys recorded in May.

Northern Lincolnshire and Goole fliiij Morale Barometer Survey Dashboard - Sept 2015

NHS Foundation Trust

Total

Between survey

Scoring Matrix

Scores prioduced are the mean of a ll staff groups for each survey

PAOR scores are based on those with Hmonths+ service

Directorate of Performa nee Assurance. November 2015 Page 41 of 52


Glo

ss

ary

8.1 Glossary

Benchmark Peer Group: Calderdale and Huddersfield NHS Foundation Trust, Chesterfield & North Derbyshire Royal Hospital NHS Trust, Countess of Chester NHS Foundation Trust, County Durham and Darlington NHS Foundation Trust, Doncaster and Bassetlaw Hospitals NHS Trust, North Cumbria University Hospitals NHS Trust, North Tees & Hartlepool NHS Trust, Rotherham NHS Foundation Trust, Royal Bolton Hospital NHS Foundation Trust, The Pennine Acute Hospitals NHS Trust, University Hospitals of Morecambe Bay NHS Trust

Clostridium Difficile – Guidance from Monitor, received during 2015: As part of the Trust’s obligations to Monitor, we are performance managed against this target of “no more than 21 hospital acquired cases”. However, when understanding their guidance to Trusts, this is no more than 21 cases “due to a lapse in care” or in other words, potentially preventable cases. An extract from Monitor’s guidance is reported as follows:

“For 2014/15, organisations will be encouraged to assess each CDI case they identify to determine whether the case was linked with a lapse in the quality of care provided to patients. This will increase the organisation’s understanding of the quality of the care they are providing and highlight areas where care could be improved. Where CDI cases are not linked with identifiable lapses in care, it is proposed that those cases are not considered when contractual sanctions are being calculated.”

As a result of this, the Quality report now contains an analysis of both ALL cases of hospital acquired C Diff alongside those classed as ‘preventable’ (or in other words lapses in care).

Commissioning for Quality & Innovation Framework (CQUIN): The CQUIN payment framework enables commissioners to reward excellence, by linking a proportion of English healthcare providers' income to the achievement of local quality improvement goals. Since the first year of the CQUIN framework (2009/10), many CQUIN schemes have been developed and agreed. This is a developmental process for everyone and you are encouraged to share your schemes (and any supporting information on the process you used) to meet the requirement for transparency and support improvement in schemes over time.

Common Cause Variation: an inherent part of the process, stable and “in control”. We can make predictions about the future behaviour of the process within limits. When a system is stable, displaying only common cause variation, only a change in the system will have an impact.

Complaints: The NHS Complaints Regulations (England) 2009 require that an offer to discuss the complaint with the complainant is made on receipt of all complaints; the discussion to include the response period (the period within which the investigation is likely to be completed and when the response is likely to be sent to the complainant). The requirement is to investigate the complaint in an appropriate manner, to resolve it speedily and efficiently and to keep the complainant inform ed as to progress. The response should be within 6 months or a longer period if agreed with the complainant before the expiry of that period.

The Complaints Regulations permit extensions to the agreed timescale where this becomes necessary and in agreement with the complainant. The Trust (as outlined within the Policy for the Management of Complaints) expects that any delay to the agreed response time is communicated to the complainant, the reasons explained and an extension agreed.

In respect of monitoring, the Regulations require (amongst other points) that the Trust maintain a record of the response periods and any amendment of that period and whether the response was sent to the complainant within the period or any amendment of that period.

KEY DEFINITIONS TO INTERPRET COMPLAINTS DATA:

NEW: The number of new complaints received in a month regardless of whether or not they were resolved within that

month.

CLOSED: The number of complaints that were resolved within a month regardless of whether they were received within the month or resolved within agreed timescale.

NET OPEN: The total number of complaints currently open; includes new complaints and those unresolved from previous month(s). This includes open ‘on hold’. This includes re-opened complaints.

RE-OPENED: Complaints that have been resolved which for any number of reasons require further review.

Control Limits: indicate the range of plausible variation within a process. They provide an additional tool for detecting special cause variation. A stable process will operate within the range set by the upper and lower control limits which are determined mathematically (3 standard deviations above and below the mean). These consist of an upper control limit, a lower control limit and a mean (average).

Crude Mortality Rate: The crude mortality rate is based on actual numbers. Unlike Standardised Mortality Ratios (SMRS) i.e. SHMI and HSMR which features adjustment based on population demographics and related mortality expectations. Crude mortality is calculated by using as the numerator the number of patients who have died divided by the denominator which in this case is the total population. Times this figure by 100, equals the crude mortality percentage (%).

Dementia – methodology for determining compliance with Quality Target:

CE3.1 – Dementia Screening: All patients who are admitted to the Trust as an emergency admission who are aged 75 or over

should have an initial screening for dementia. The screening consists of the patient being asked:

“Have you been more forgetful in the last 12 months to the extent that it has significantly affected your daily life?”

Patients who already have a diagnosis of dementia or who have a clinical diagnosis of delirium do not require screening. In the national guidance regarding calculating compliance, these two groups of patients are included in the numerator as patients who are determined to have had a dementia screening.

CE3.2 – Further risk assessment.

All patients admitted aged 75 and above, who have scored positively on the case finding question, or who have a clinical diagnosis of delirium and who do not fall into exemption categories should then receive a more detailed diagnostic assessment using the 6 item Cognitive Impairment Test (6CIT).


CE3.3 – Referred in line with local pathway.

Following the roll out of the national CQUIN for dementia, it was agreed locally with Rotherham Doncaster & South Humber NHS Foundation Trust in North Lincolnshire and NAVIGO Health & Social Care Community Interest Company in North East Lincolnshire that in patients with a positive diagnostic assessment (6CIT score of 8 or above) or inconclusive should be referred to them for a specialist Mental Health Liaison Team review.

Fall: A sudden, unintended, uncontrolled downward displacement of a patient’s body to the ground or other object. This includes situations where a patient falls while being assisted by another person, but excludes falls resulting from a purposeful action or violent blow.

Unavoidable Fall: Impossible to avoid the fall(s) from happening. Describes an event that could have been anticipated and prepared for, but that occurs because of an error or other system failure

Avoidable Fall: The fall(s) could have been avoided. Recognises that some of these events are not always avoidable, given the complexity of healthcare; therefore, the presence of an event on the list is not an a priori judgment either of a systems failure or of a lack of due care

Friends and Family Test – Methodology: The Trust introduced the new friends and family test in April 2014, when it was launched across the country. Within 48 hours of receiving care or treatment as an inpatient or visitor to A&E, patients are given the opportunity to answer the following question:

“How likely are you to recommend our ward/A&E department to friends and family if they needed similar care or treatment?”

Service users are then asked to answer how likely or unlikely along a six-point scale they would answer the above question.

There is also an opportunity to elaborate on the reasons for their answer and all feedback will be encouraged whether positive or negative.

‘Positive feedback’ defined as the percentage of patients/service users answering ‘extremely likely’ and ‘likely’

H.E.D. – Health Evaluation Data: The official national data publications are released quarterly, six months after the event. The Trust therefore reports its performance to its Board every month using provisional data published by the University of Birmingham through its Hospital Evaluation Data system (HED). This is normally three months behind the current position, and has been validated as virtually identical to the official published data.

HED SHMI – Numerical value – interpret with caution: HED SHMI is referred to within this report as a ‘provisional’ indicator and should be interpreted with caution. Sometimes within this report, the numerical value of the HED SHMI is sometimes observed as changing over subsequent months reports, for the same time frame. The reason for this is mult-faceted and is explained as follows:

1. SHMI modelling information is released on a quarterly basis, alongside the ‘official’ SHMI publication. The official SHMI essentially readjusts the HED ‘provisional’ indicator so it’s in line with the ‘official’ data/statistical modelling. This modelling data when available following the publication of the ‘official’ SHMI will readjust the HED data so it is line with the official statistic. It could be reasoned from this therefore, that the further away from the quarterly release of the official data, the more scope there is for HED to be different to the next/future ‘official’ SHMI publication. When we say different, the actual difference is usually small, less than a point.

2. Hospital Episode Statistics (HES) and Office for National Statistics (ONS) data is being added to as more and more data (data completeness) becomes available. Simply put each monthly HED data includes more complete information from Trust data sources and community data (the 30 day deaths, post discharge) than the information available for the previous month. Not all deaths are reported in a timely manner, so the monthly data going into HED for the month of February, let’s say as an example, could be added to – in terms of completeness – in future monthly releases. That means that the HED data for the Trust – but most importantly – the Trust’s peers, the rest of the UK, is always being added to. HED is vulnerable to these changes as it reports a period in time much sooner to that reported by the ‘official’ SHMI. The ‘official’ SHMI looks at data 6-18 months old, so in terms of data completeness is more stable and therefore reliable.

3. All Trusts can resubmit data for previous months (during a specified window of opportunity). This can be for small data corrections or specific pieces of work to cleanse/validate data.

HED SHMI is still a useful indicator, these factors need to be borne in mind when using the information for comparing progress made with the improvement agenda.

MUST – Malnutrition Universal Screening Tool: The total MUST score for a patient is worked out from their BMI, the amount of unplanned weight loss they may have and the ‘acute disease effect’ (if the patient is acutely ill and there has been or likely to be no nutritional intake for >5 days). The MUST score triggers appropriate action, as described below:

MUST score of 0: Low risk and require screening weekly,

MUST score of 1: Moderate risk and require screening weekly, commencement and completion of a food record chart, to be encouraged to have fortified meals from the food menu, offered snacks from the Trust wide snack list.

MUST score of 2 or more: High risk and require the same management as those patients scoring 1 plus a referral to the dietician for a dietetic review.

Patient Experience: This Trust has set the goal of being the hospital of choice for our local patients. Being the hospital of choice is a far different thing than being the hospital of convenience, proximity or default. We measure patient experience using methodologies employed by the NHS National Patient Experience Survey against two key indicators to help us determine that our hospitals are the ones our patients would choose if the practical factors were removed.

The Trust uses The Menu Card Survey which asks five questions relating to patient experience and is attached to inpatients’ menu cards. It measures the patients’ experience in real time. The questions asked are all derived from questions that feature in all National Patient Surveys.

The scores depicted in the graphs reflect an absolute figure generated by this methodology (in short – high score is good, 100% would be the maximum achievable score).

Pressure Ulcer: Definition of Avoidable and Unavoidable Pressure Ulcer


The Department of Health (DH) has been asked to clarify what an avoidable pressure ulcer is in regards the nurse sensitive outcome indicators. The DH researched the availability of definitions, finding that there are a limited number of definitions in existence to draw from.

The Wound, Ostomy and Continence Nurses Society of the US have produced a position paper which points to a clear definition of “avoidable” pressure ulcer (WOCNS) March 2009. However, the DH are using a modified version of the Avoidable d Unavoidable pressure ulcers definitions from the Centre for Medicare and Medicaide (CMS) 2004, to keep with the UK policy Terminology.

The modified definitions are:

AVOIDABLE PRESSURE ULCER:

“Avoidable” means that the person receiving care developed a pressure ulcer and the provider of care did not do ONE of the following:

Evaluate the person’s clinical condition and pressure ulcer risk factors

Plan and implement interventions that are consistent with the persons needs and goals and recognised standards of practice within the Trust

Monitor and evaluate the impact of the interventions

Revised the interventions as appropriate

UNAVOIDABLE PRESSURE ULCER:

“Unavoidable” means that the person receiving care developed a pressure ulcer even though the provider of the care had done ALL of the following

Evaluated the persons clinical condition and pressure ulcer risk factors

Planned and implemented interventions that are consistent with the persons needs and goals and recognised standards of practice within the Trust

Monitored and evaluated the impact of the interventions

Revised the interventions as appropriate

The individual person refused to adhere to prevention strategies in spite of education of the consequences of non- adherence and this was documented.

Pressure ulcer gradings from the European Pressure Ulcer Advisory Panel (EPUAP): Category/Grade 1: Non-blanchable redness of intact skin Intact skin with non-blanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.

Category/Grade 2: Partial thickness skin loss or blister Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This category/stage should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.

Category/Grade 3: Full thickness skin loss (fat visible) Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. May include undermining and tunnelling. Further description: The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Category/Grade 4: Full thickness tissue loss (muscle/bone visible)

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunnelling.

Further description: The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.

Rate per 1000 bed days: So we can know if we are improving even if the number of patients we are caring for goes up or down, we also calculate an average called 'rate per 1,000 occupied bed days'. This allows us to compare our improvement over time, but cannot be used to compare us with other hospitals, as their staff may report in different ways, and their patients may be more or less vulnerable than our patients.

Readmission Rate (RA): This measure shows the percentage of patients who were readmitted to hospital as an emergency within one month of being discharged. It can serve as an indicator of the quality of care provided and post-discharge follow up. A low readmission rate is an indicator of the quality of care in that it reflects a healthy care balance. Where rates are low, patients are not having to come back to the Trust for care of the same complaint. Conversely, a high readmission rate potentially signals that an organisation is releasing patients home too soon or otherwise not addressing all elements of their clinical condition.

Safety Thermometer methodology:

The NHS Safety Thermometer provides the ability for ‘a temperature check’ of harm to be recorded. It did this by auditing on a point prevalence basis the care provided to patients on a given date each month. This point prevalence audit provided a ‘snapshot’ view of harm on that given day each month. It focusses on harm in four key areas:

Pressure ulcers grades 2,3 & 4

Falls – all falls reported, even if no harm occurred


Catheter associated UTIs – those treated with antibiotics

VTE – risk assessment, prophylaxis and treatment of DVT or PE

Harm:

Catastrophic harm: Any patient safety incident that directly resulted in the death of one or more persons receiving NHS funded care.

Severe harm: Any patient safety incident that appears to have resulted in permanent harm to one or more persons receiving NHS-funded care.

Moderate harm: Any patient safety incident that resulted in a moderate increase in treatment and which caused significant but not permanent harm, to one or more persons receiving NHS-funded care. Locally defined as extending stay or care requirements by more than 15 days; Short-term harm requiring further treatment or procedure extending stay or care requirements by 8 - 15 days

Low harm: Any patient safety incident that required extra observation or minor treatment and caused minimal harm, to one or more persons receiving NHS-funded care. Locally defined as requiring observation or minor treatment, with an extended stay or care requirement ranging from 1 – 7 days

None/ ’Near Miss’ (Harm): No obvious harm/injury, Minimal impact/no service disruption.

Harm Free Care:

Safety Thermometer enables the calculation of the proportion of patients who received harm free care. This is calculated by dividing the number of patients receiving harm free care (as the numerator) by the total number of patients surveyed (the denominator).

Patients with more than one of the harms listed, will not be classified as harm free care and are thus not counted in the numerator. Patients recorded as having multiple harms are removed from the numerator in the same way as those with only one harm.

Proportion of patients with ‘harm free’ care:

Those patients without any documented evidence of a pressure ulcer (any origin, category 2-4), harm from a fall in care in the last 72 hours, a urinary infection (in patients with a urinary catheter) or a new VTE (treatment started after admission).

Proportion of patients with ‘harm free’ care – new harms only:

Those patients without any documented evidence of a new pressure ulcer (developed at least 72 hours after admission to this care setting, category 2-4), harm from a fall in care in the last 72 hours, a new urinary infection in patients with a urinary catheter which has developed since admission to this care setting, or a new VTE (treatment started after admission).

Community Safety Thermometer: VTE is not relevant as an indicator. In community practice, patients are not routinely risk assessed for VTE and any concerns regarding a patient in this matter would be referred to the patient’s GP or to the acute Trust via A&E attendance. In the same way, prophylaxis, unless prescribed by a doctor, would not routinely be commenced by community staff. Due to these differences, the individual elements of this indicator have been classed as not applicable to the community care safety thermometer results. As a result, VTE is not included in the following section pertaining to community care Safety Thermometer results.

Sigma: A sigma value is a description of how far a sample or point of data is away from its mean, expressed in standard deviations usually with the Greek letter σ or lower case s. A data point with a higher sigma value will have a higher standard deviation, meaning it is further away from the mean.

Summary Hospital Mortality Indicator (SHMI): The SHMI is the NHS ‘official’ Standardised Mortality Ratio (SMR). It is a method of comparing mortality levels in different years, or between different hospitals. As a result, the SHMI is used as a performance tool to rank NHS organisations within a league table. The ratio is calculated by using as a numerator the number of deaths divided by the denominator, in this case, the number of ‘expected’ deaths, multiplied conventionally by 100. Thus, if mortality levels are higher in the population being studied than would be expected, the SHMI will be greater than 100. This methodology allows comparison between outcomes achieved in different trusts, and facilitates benchmarking. The outcomes of the SHMI are reported in three bandings: (1) higher than expected, (2) as expected and (3) lower than expected. The SHMI includes not only in-hospital deaths, but also includes deaths within the community, occurring within 30 days of hospital discharge. As a result, it is dependant not only on in-hospital coded information, but also on Public Health data, this results in a delay in reporting. As a consequence, the quarterly data published by the Health and Social Care Information Centre reports on historic information ranging from 18 months to 6 months. To illustrate this point, the SHMI information release in April 2015 reports performance from October 2013 – September 2014.

Special Cause Variation: the pattern of variation is due to irregular or unnatural causes. Unexpected or unplanned events (such as extreme weather) can result in special cause variation. Systems which display special cause variation are said to be unstable and unpredictable. When systems display special cause variation, the process needs sorting out to stabilise it. This is most commonly reported using two types of special cause variation, trends and outliers. If a trend, the process has changed in someway and we need to understand and adopt if the change is beneficial or act if the change is a deterioration. The outlier is a one-off condition which should not result in a process change. These must be understood and dealt with on their own (i.e. response to a major incident).

Identifying Special Cause Variation – agreed rules:

Any point outside of the control limits,

A run of 7 points all above or below the central line, or all increasing / decreasing,

Any unusual patterns or trends within the control limits,

The proportion of points within the middle 1/3 of the region between the control limits differs from 2/3.

Standard Deviation: Standard deviation is a widely used measurement of variability or diversity used in statistics and probability theory. It shows how much variation or "dispersion" there is from the "average" (mean, or expected/budgeted value). A low standard deviation indicates that the data points tend to be very close to the mean, whereas high standard deviation indicates that the data are spread out over a large range of values.


4.0 At A Glance


6.0 Patient Safety


8.0 Glossary

This Section…

9.0 APPENDIX 1

Focus on VTE as reported in the Safety Thermometer



Per

cen

tage

co

mp

lian

ce (

%)

Focus on VTE – as reported in Safety Thermometer Performance with additional indicators relating to Venous Thromboembolism (VTE) are also captured by the Safety Thermometer, these are illustrated below for the month of October and also performance trends over time.

Month of October:

DPoW:

93.7% VTE risk assessment completed, 90.0% VTE prophylaxis given.

SGH:

100.0% VTE risk assessment completed, 97.2% VTE prophylaxis given.

Trend over time – VTE risk assessment completion:

100%

90%

100.0%

93.7%

80%

70%

DPoW

SGH

60%

May Jun

Jul

Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Jul

Aug Sep Oct

14 14 14 14 14 14 14 14 15 15 15 15 15 15 15 15 15 15 Month / time frame

Source: NLAG NHS Safety Thermometer, VTE risk assessment completion as reported within the open and

honest initiative, NHS England


The following outlines point prevalence snapshot information relating to VTE from the Safety Thermometer data:

Key to RAG Ratings: Green = > 90% Amber = 80 – 90% Red = < 80%

Site and Ward

Total VTE % Assessment

Done VTE % Prophylaxis

Given

DPOW

356

93.7%

90.0%

Amethyst

22

100.0%

100.0%

AMUAssess

24

75.0%

71.4%

AMUSS

12

75.0%

72.7%

B2

31

77.4%

79.2%

B3

21

100.0%

100.0%

B4

22

90.9%

90.9%

B6

20

100.0%

100.0%

B7

20

100.0%

100.0%

BlueBerry Ward

5

100.0%

100.0%

C1 Holles

25

100.0%

70.0%

C1 Kendall

27

96.3%

100.0%

C5

24

100.0%

100.0%

C6

24

100.0%

100.0%

CCU

8

100.0%

100.0%

HDU

6

100.0%

100.0%

Holly Ward

5

100.0%

100.0%

HoneySuckle Ward

5

100.0%

50.0%

ITU

5

100.0%

100.0%

Jasmine Ward

5

100.0%

100.0%

Laurel

15

80.0%

60.0%

NeoNatal Unit

8

NaN

NaN


Stroke Unit

22

100.0%

100.0%

GDH

20

100.0%

100.0%

Ward 3

13

100.0%

100.0%

Ward 6

7

100.0%

100.0%

SGH

306

100.0%

97.2%

CDU

15

100.0%

100.0%

ICU

7

100.0%

100.0%

SCCU

13

100.0%

100.0%

SNICU

7

NaN

NaN

Stroke Unit SGH

17

100.0%

100.0%

Ward 10

13

100.0%

100.0%

Ward 11

11

100.0%

100.0%

Ward 16

21

100.0%

76.2%

Ward 17

21

100.0%

100.0%

Ward 18

14

100.0%

100.0%

Ward 19

10

100.0%

100.0%

Ward 2

10

100.0%

100.0%

Ward 22

27

100.0%

100.0%

Ward 23

29

100.0%

100.0%

Ward 24

30

100.0%

100.0%

Ward 25

21

100.0%

100.0%

Ward 26

14

100.0%

100.0%

Ward 28

26

100.0%

92.3%

Total

1084

96.7%

93.5%


4.0 At A Glance


6.0 Patient Safety


8.0 Glossary

9.1 Appendix 1 – Focus on VTE as reported in the Safety

Thermometer

This Section…

10.0 APPENDIX 2

PE1 Friends & Family Target by Ward


Friends and Family Target Table end of October

This table shows you the number of eligible people who could respond to FFT and the number of cards collected.

Due to difficulties in monitoring this information, internally on an ongoing basis, an effective work around was developed in order to provide a mix of ‘live’ information from discharge data daily, and based on this, a target number of Friends and Family Test (FFT) responses needed from ward areas to achieve the internally set target of 40%. It should be stressed that this is internal performance data only used to help ward sisters/charge nurses monitor progress against their wards FFT response rate.

To introduce the specifics of this data, the following key illustrates definitions for the following presentation of this data:

Key:

Column A

This column is the number of people eligible for the FFT test based on discharge data from CAMIS. This is a live feed daily and updates overnight. Importantly the table fluctuates considerably over the month due to the live feed factor.

Column B This is the minimum number of cards a ward would need to get to reach 40% target based on its eligibility numbers for ward inpatient areas and 20% target for A&E.

Column C The number of cards collected by the mid-month point turned into a % of the total number of cards needed to reach 40%

Column D

The final % total at the month end, which is RAG rated.

>40% = green

30-40% = amber

<30% = red

This is a visual tool to help ward sister/charges to monitor their FFT progress as it is sent out weekly. It is used internally only.

A worked example:

A typical ward, i.e. C1 Holles:-

They had 40 patients in August who were eligible for FFT on discharge,

They would have to collect 16 cards to meet their 40%,

By the mid-month they had collected 7.5% = 3 cards,

By the end of the month they had exceeded their 40% and actually collected 18 cards


Column A Column B Column C Column D

Business group and Ward

Eligibility

Minimum Number Of

Cards

Mid Month Rate

Month Rate

A&E 7,418 1,484 7.4% 13.1%

AED DPOW 3,658 732 9.9% 16.0%

AED SGH 3,760 752 4.9% 10.3%

Medicine DPW 510 187 43.6% 52.5%

AMETHYST WARD 52 21 19.2% 19.2%

AMU 105 42 93.3% 93.3%

C1 HOLLES 57 23 24.6% 24.6%

C1 KENDALL 74 30 31.1% 31.1%

CORONARY CARE UNIT 42 0 45.2% 116.7%

STROKE UNIT 52 21 21.2% 21.2%

WARD C5 69 28 75.4% 75.4%

WARD C6 59 24 39.0% 39.0%

Medicine GDH 16 6 81.3% 81.3%

WARD 3 GDH 16 6 81.3% 81.3%

Medicine SGH 719 269 49.2% 49.2%

CCU 63 25 39.7% 39.7%

CDU 68 27 22.1% 22.1%

Planned Investigations Unit 65 26 41.5% 41.5%

SSRU 71 28 26.8% 26.8%

WARD 16 49 20 49.0% 49.0%

WARD 17 51 20 76.5% 76.5%

WARD 18 47 0 10.6% 10.6%

WARD 2 88 35 69.3% 69.3%

WARD 22 67 27 62.7% 62.7%

WARD 23 90 36 71.1% 71.1%

WARD 24 60 24 71.7% 71.7%

Surgery + Critical Care DPW 479 192 39.1% 39.1%

WARD B2 (SAU) 187 75 56.1% 56.1%

WARD B3 42 17 45.2% 45.2%

WARD B4 84 34 59.5% 59.5%

WARD B6 86 34 4.7% 4.7%

WARD B7 80 32 30.0% 30.0%

Surgery + Critical Care GDH 55 22 56.4% 56.4%

WARD 6 GDH 55 22 56.4% 56.4%

Surgery + Critical Care SGH 446 178 27.0% 50.2%

WARD 10 49 20 22.4% 61.2%

WARD 11 68 27 14.7% 44.1%

WARD 25 166 66 53.0% 53.0%

WARD 28 163 65 17.8% 42.3%

Women + Childrens DPW 137 55 46.7% 46.7%

LAUREL WARD 137 55 46.7% 46.7%

Women + Childrens SGH 96 38 76.0% 76.0%

Ward 19 (Gynae) 96 38 76.0% 76.0%

Grand Total 9,876 2,431 43.2% 48.4%

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