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QUALITY REPORT - MARCH 2016
1
Title: Quality Performance Report To: Quality Governance Committee From: Suneil Kapadia, Medical Director Michelle Rhodes, Director of Nursing Author: Bernadine Gallen Quality & Safety Manager Date: 18TH March 2016 Purpose of the Report: To update the Board on the performance of the Trust for the period ending 29th February 2016, and set out the plans and trajectories for performance improvement.
The Report is provided to the Board for:
Recommendations: The Trust Board is asked to note the current performance and future projections for improvement. This is an evolving report and the Board are invited to make suggestions as we continue to develop it.
Strategic Risk Register Performance KPIs year to date As detailed in the report
Resource Implications (e.g. Financial, HR) None
Assurance Implications: The report is a central element of the Board Assurance Framework
Patient and Public Involvement (PPI) Implications
Equality Impact None
Information exempt from Disclosure None
Requirement for further review? The report will be updated in April 2016 reflecting performance to 31st March 2016.
Version: Integrated performance report May 2013 FINAL Issued 27th June 2013
Decision Discussion
Assurance x Endorsement
Document management
2
CONTENT PAGE PERFORMANCE AT A GLANCE 0 MORTALITY 1 PATIENT SAFETY – SAFETY THERMOMETER 5 PATIENT SAFETY – FALLS 6 PATIENT SAFETY – PRESSURE ULCERS 7 PATIENT SAFETY – MEDICATION 8 PATIENT SAFETY – INFECTION CONTROL 9 PATIENT EXPERIENCE – COMPLAINTS 10 PATIENT EXPERIENCE – PALS 12 PATIENT EXPERIENCE – FRIENDS & FAMILY TEST 13
CONTENTS
0
METRIC STANDARD YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 MOVEMENT
Hospital Standardised Mortality Ratio (DFI) (Latest data December 14 - November 15 this is
a rolling figure reported in the month specified)100 N/A 105.83 108.21 107.50 107.63 104.93 105.46 103.33 102.54 101.69 101.69 101.35
Summary Hospital-level Mortality Indicator (Latest data July 2014 to June 2015) 100 N/A 107.31 101.1 111.1 111.86
Clostrium Difficile (post 3 days) 59 51 2 3 4 3 5 8 5 2 9 4 6
MRSA bactaraemias (post 3 days) 0 1 1 0 0 0 0 0 0 0 0 0 0
MSSA 24 1 1 0 3 3 1 2 5 3 3 2
ECOLI 61 5 5 6 7 2 8 5 12 3 5 3
Never Events (may change when reviewed) 0 2 0 0 0 0 0 0 2 0 0 0 0
Serious Incidents reported (may change when reviewed) 76 11 4 8 11 8 5 7 9 8 3 2
Harm Free Care % (Safety Thermometer) 95% 93.01% 92% 93.77% 93.88% 94.57% 90.41% 92.83% 93.94% 93.20% 92.57% 93.57% 92.41%
New Harm Free Care % (Safety Thermometer) 97.57% 97.51% 97.15% 97.40% 98.30% 95.43% 98.70% 97.60% 97.84% 97.60% 97.53% 98.16%
Catheter & New UTIs (Safety Thermometer) 0.30% 0.31% 0.32% 0.33% 0.57% 0.91% 0.11% 0.46% 0.11% 0.0% 0.0% 0.2%
Falls (DATIX) 1746 150 150 152 143 141 137 169 164 194 159 187
Medication errors (DATIX) 1239 126 122 106 130 103 86 104 108 106 128 120
Medication errors (mod, severe or death) (DATIX) 61 4 (M) 5 8 7 4 8 4 4 5 7 9
Pressure Ulcers (PUNT) 3/4 0 42 2 2 1 3 4 1 2 3 9 10 5
VTE Risk Assessment (Monthly figures only available quarterly) 95% 94.69% 97.07% 98.23% 98.28% 98.08% 88.92% 89.72% 89.94% 94.10% 95.10% 97.50% MB
Overdue CAS alerts (PD = past deadline) (NC = not completed) 0 0 0 0 0 0 0 0 0 0 0 0 0
SQD % 90% 86.47% 85.72% 87.91% 83.33% 86.26% 89.30% 86.63% 86.89% 85.08% 87.66% 85.09% 87.30%
METRIC STANDARD YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 MOVEMENT
#NOF 24 hrs 70% 69.91% 76.9% 69.70% 64.29% 65.88% 54.05% 75.61% 83.54% 72.73% 65.28% 64.29% 76.67%
#NOF 48 hrs 95% 94.71% 100% 93.94% 98.21% 90.59% 90.54% 93.90% 97.47% 90.91% 95.83% 97.14% 93.33%
PPCI - 90 minute door to balloon Q1 Data April - June 15 Quarterly Quarterly 97.30% Quarterly Quarterly 97.20% Quarterly Quarterly 95.50% Quarterly Quarterly
PPCI - 150 minute call to balloon Q1 April - June 15 Quarterly Quarterly 85.30% Quarterly Quarterly 91.30% Quarterly Quarterly 85.80% Quarterly Quarterly
Dementia Screening 90% 85.29% 87.53% 88.50% 88.36% 83.21% 77.20% 80.46% 82.71% 84.28% 87.13% 91.76% 87.02%
Dementia Risk Assessment 90% 90.58% 97.54% 95.63% 96.25% 91.10% 88% 91.05% 92.58% 84.95% 84.64% 82.30% 92.78%
Dementia Referral for Specialist Treatment 90% 69.64% 70.79% 86.42% 84.62% 78.67% 88% 80.82% 68.29% 60.76% 57.63% 23.46% 66.13%
Patients who have had a stroke who spend at least 90% of their time in hospital on a
stroke unit 85.10% 72.19%65% 71% 71% 71% Not avail Not avail 75.95% Quarterly Quarterly 79.20% Quarterly
Scanned within 1 hour 47.40% 52.12% 50% 50% 44% 65% Not avail Not avail 53.20% Quarterly Quarterly 50.50% Quarterly
Scanned within 24 hours 95.90% 96.52% 97% 97% 95% 96% Not avail Not avail 96.90% Quarterly Quarterly 97.20% Quarterly
Death following stroke inpatients stay 13.50% 16.65% 23% 14% 14% 14% Not avail Not avail 15.70% Quarterly Quarterly 19.20% Quarterly
Admitted to a stroke unit within 4 hours 61.80% 53.90% 46% 49% 52% 59% Not avail Not avail 56.60% Quarterly Quarterly 60.80% Quarterly
eDD (Figures taken 7th March 2016) 98% 77.24% 75.48% 77.20% 76.60% 79.01% 78.66% 78.45% 78.66% 78.21% 76.89% 75.83% 74.65%
*MB = Month Behind
METRIC STANDARD YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 MOVEMENT
IP response rate from FFT (November Onwards Includes Day Case) >30% 30.64% 34% 30% 30% 24% 31% 33% 32% 31% 30% 30% 32%A&E response rate from FFT >20% 23.00% 26% 26% 25% 17% 23% 23% 24% 22% 23% 22% 22%
METRIC STANDARD YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 MOVEMENT
Inpatient' recommend' scores from FFT (November onwards includes Day Case) 88.91% 90% 91% 89% 90% 88% 88% 89% 90% 88% 87% 88%
A&E 'recommend' scores from FFT 83.09% 83% 84% 84% 81% 83% 83% 83% 84% 83% 83% 83%
Compaints received 772 57 51 74 74 88 94 71 57 60 74 72
Complaints open 4855 520 529 456 489 406 427 443 384 382 407 412
Complaints on-going 82 7 3 5 8 16 6 6 3 10 6 12
Mixed sex accommodation breaches (To be confirmed, investigation pending) 0 77 5 8 0 1 4 9 3 1 15 19 12
RESPONSIVE DOMAIN
SEE INTEGRATED PERFORMANCE REPORT
WELL - LED DOMAIN
EFFECTIVENESS DOMAIN
SAFE DOMAIN
PERFORMANCE AT A GLANCE
1 | P a g e
HSMR Diagnosis Groups alerting YTD:
Diagnosis group Observed Expected Obs. - Exp. Crude (%) Exp. (%) HSMR Low High
Septicemia (except in labour) 127 97.1 29.82 27.02 20.68 130.69 108.95 155.5
Other perinatal conditions 15 5.08 9.91 3.46 1.17 294.93 164.95 486.47
85.00
90.00
95.00
100.00
105.00
110.00
115.00
120.00
Jul 10-Jun11
Oct 10-Sep11
Jan 11-Dec11
Apr 11-Mar12
Jul 11-Jun12
Oct 11-Sep12
Jan 12-Dec12
Apr 12-Mar13
Jul 12-Jun13
Oct 12-Sep13
Jan 13-Dec13
Apr 13-Mar14
Jul 13-Jun14
Oct 13-Sep14
Jan 14-Dec14
Apr 14-Mar15
Jun 14 -Jul15
SHMI vs HSMR Rolling Year June 2010 to July 2015
SHMI All deaths SHMI in Hospital Deaths HSMR Rolling Year Linear (HSMR Rolling Year)
ULHT HSMR Dec 14-Nov 15
HSMR Apr 15-Nov 15
ULHT HSMR Nov-15
HSMR National Avg
Nov 15
ULHT SHMI Jul 14-Jun 15
SHMI National Avg
July 14-June 15
ULHT Crude Mortality %
Nov 15
Crude Mortality % National Avg
Nov 15
101.35 99. 59 95.49 98.09 111.86 100.44 1.62% 1.32%
PATIENT SAFETY - MORTALITY
2 | P a g e
HSMR
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
HSMR
HSMR 15/16 HSMR 14/15
National Avg HSMR 15/16 Benchmark
0
20
40
60
80
100
120
140
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15
HSMR by Site
Grantham & District Hospital Lincoln County Hospital
Pilgrim Hospital Linear (Grantham & District Hospital )
Linear (Lincoln County Hospital ) Linear (Pilgrim Hospital )
Performance Data Overview: United Lincolnshire Hospitals NHS Trust:
The current year to date HSMR (April 15 to November 15) is 98.9 which is in line with the Trust and National Benchmark.
Rolling year HSMR (December 15 to November 15) stands at 101.35; which is within expected range.
In November 2015 HSMR has decreased to 95.49. Lincoln County Hospital:
In November 2015 has decreased to 104.06 which is within expected range.
HSMR YTD mean trend is currently showing a downward trajectory overall. Pilgrim Hospital:
In November 2015 HSMR has decreased to 86.58 which is well below expected range. HSMR YTD mean trend is currently showing a downward trajectory for Pilgrim.
Grantham Hospital:
In November 2015 HSMR has decreased to 91.47 which is below expected range.
HSMR YTD mean trend is currently showing a slight upward trajectory for Grantham; this is due to a rise in October 2015 to 105.18.
3 | P a g e
SHMI
96
98
100
102
104
106
108
110
112
114
116
118
Jul 10-Jun11
Oct 10-Sep 11
Jan 11-Dec 11
Apr 11-Mar 12
Jul 11-Jun12
Oct 11-Sep 12
Jan 12-Dec 12
Apr 12-Mar 13
Jul 12-Jun13
Oct 12-Sep 13
Jan 13-Dec 13
Apr 13-Mar 14
Jul 13-Jun14
Oct 13-Sep 14
Jan 14-Dec 14
Apr 14-Mar 15
Jun 14 -Jul15
SHMI ALL vs SHMI in Hospital
SHMI SHMI In Hospital Linear (SHMI) Linear (SHMI In Hospital)
Performance Data Overview:
Current SHMI reporting period (Jul 14-Jun 15) show that ULHT have increased to 111.86 for all deaths and higher than the National average.
Recording 393 more deaths that expected within the current reporting period.
In hospital deaths are alerting at 107.72; however this is in line with our HSMR at this time 106.78.
ULHT have the 10th
highest SHMI out of the 137 non-acute trusts reported within Dr Foster.
Alerting Diagnosis at this time are; Pneumonia, Sepsis, UTI and intestinal obstruction without hernia- Reviews have been carried out for the alerts.
Both all deaths and In hospital deaths are showing a downward trajectory in a 5 year time span (please see graph below).
NB: SHMI has a time lapse in the data.
Site SHMI Jul 14-Jun15
Actual Deaths
Expected Deaths
Lincoln County Hospital 116.76 1905 1631.62
Pilgrim Hospital 107.55 1427 1326.87
Grantham & District Hospital
105.02 365 347.55
4 | P a g e
CRUDE MORTALITY
0.70%
0.90%
1.10%
1.30%
1.50%
1.70%
1.90%
2.10%
2.30%
Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16
Crude Mortality Trust and Site Rolling Year
GDH LCH PHB ULHT Linear (GDH) Linear (LCH) Linear (ULHT)
1.00%1.10%1.20%1.30%1.40%1.50%1.60%1.70%1.80%1.90%
Jan
12
-Dec
13
Feb
12
-Jan
13
Mar
12
-Feb
13
Ap
r 1
2-M
ar 1
3
May
12
-Ap
r 1
3
Jun
12-
May
13
Jul 1
2-J
un
13
Au
g 1
2-Ju
l 13
Sep
12
-au
g 1
3
Oct
12-
Sep
13
No
v 1
2-O
ct 1
3
Dec
12
-No
v 13
Jan
13
-Dec
13
Feb
13
-Jan
14
Mar
13
-Feb
14
Ap
r 1
3-M
ar 1
4
May
13
-Ap
r14
Jun
13-
May
14
Jul 1
3-J
un
14
Au
g 1
3-Ju
l 14
Sep
13
-Au
g 14
Oct
13-
Sep
14
No
v 1
3-O
ct 1
4
Dec
13
-No
v 14
Jan
14
-Dec
14
Feb
14
-Jan
15
Mar
14
-Feb
15
Ap
r 1
4-M
ar 1
5
May
14
-Ap
r15
Jun
14-
May
15
Jul 1
4-J
un
15
Au
g 1
4-Ju
l 15
Sep
14
-au
g 1
5
Oct
14-
Sep
15
No
v 1
4-O
ct 1
5
Dec
14
-No
v 15
Jan
15
-Dec
15
Feb
15
-Jan
16
Mar
15
-Feb
16
Crude Mortality Rolling Year Average Jan 12 to Feb 16
Crude Death Avg Dr Foster Crude Avg
Linear (Crude Death Avg) Linear (Dr Foster Crude Avg)
Performance Data Overview:
Crude mortality rolling average year shows a downward trajectory.
Against National average (Dec 14-Nov 15) ULHT is higher by 0.27%. ULHT’s average is 1.72%.
In month Feb 2016; crude has decreased to 1.91% an increase of 0.12%. However in comparison to Feb 15 Crude has decreased.
ULHT’s crude mortality for the rolling year is 1.63%.
In rolling year ULHT has a slight upward trajectory.
February crude mortality by hospital:
Grantham: 1.80%
Lincoln: 1.78%
Pilgrim: 2.13%
Action Plan: Quality governance are holding sepsis awareness month; with sepsis champions going round the hospitals. In line with the Sepsis task
and finish group action plan. Quality Governance are undertaking an interrogation into the Dr Foster high volume diagnosis groups. UTI Dr Foster interrogation has been undertaken as part of the PSC action log. Working with the CCG all deaths within 48 hours over the age of 75 are being sent to CCG for review regarding avoidable admissions.
5 | P a g e
Table 1 – Harm Free and New Harm Free Care across ULHT February 2016
Table 2 – National Comparison of Harm Free Care (Old & New) January 15-16
Table 3 - National Comparison of New Harm Free Care January 15-16
The Key Harms that ULHT are alerting on are Catheters, Catheter associated UTI and Falls. The other Kay Harms are all within national expectations.
Overview All key harms have a committee working on improving compliance.
ULHT % GDH % LCH % PBH %
Harm Free 92.41 97.83 92.86 90.27
New Harm Free 98.16 98.91 98.66 97.26
Jan 15
Feb 15 Mar 15 Apr 15
May 15 June 15
July 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15 Jan 16
NHS England
94% 93.7% 94% 93.8% 94% 94.1% 94.1% 94.1% 94.3% 94.3% 94.2% 94.2% 94.1%
ULHT 94.5% 93.17% 92.1% 92% 93.9% 93.4% 94.6% 90.4% 92.8% 93.9% 93.2% 92.2% 93.6%
Jan 15 Feb 15 Mar 15 Apr 15 May 15 June 15
July 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15 Jan 16
NHS England
97.7% 97.6% 97.7% 97.6% 97.8% 97.8% 97.8% 97.7% 97.9% 97.9% 97.8% 97.9% 97.9%
ULHT 97.54% 97.33% 97% 97.5% 97.1% 97.4% 98.3% 95.4% 98.7% 97.6% 97.8% 97.3% 97.5%
PATIENT SAFETY – SAFETY THERMOMETER
6 | P a g e
PATIENT SAFETY – FALLS
Performance Data Overview 2015/16 April to January Average Rate Harmful Ward Falls is 0.97 Falls with Harm Review Panels are now in place on all three sites which are being led by the Deputy Director of Nursing Newsletter formulated to share lessons learnt from review panels across organisation Risk Summit held for Pilgrim Hospital on 7th March 2016 in terms of quality performance Work progresses on workbook and intranet site Positive feedback from CCG regarding improved quality of SI investigations Risk team requested to report safety data on a weekly basis so that information can be triangulated against staffing data and reliance of temporary staffing
Action Plan An annual work plan is place for the falls group Lying and Standing Blood Pressure Video about to be launched as a recurring theme in review panels MEAU to pilot Falls Workbook Falls Study Day planned for the 21st September 2016 as part of the Sign up to Safety Heads of Nursing have been asked to submit local improvement plans for increased compliance with Falls Assessment for SQD
7 | P a g e
PATIENT SAFETY – PRESSURE ULCERS
Performance Data Overview
• Trust has reported a total of 364 HA pressure ulcers YTD 2015/2016 compared to 462 for the same period in the previous year • Year to date there has been a 4% reduction in Category 3, 17% reduction in Category 2 and 24% reduction in Category 1 pressure ulcers reported on PUNT. No
reduction is reported for category 4 PU - though further work is required to explore whether avoidable grade 4 PU has reduced. • In February 2016, four category 3 (one of which was a deterioration from a previously reported category 2 due to the patients deteriorating medical condition) and
one category 4 hospital acquired pressure ulcer – likely to be deemed unavoidable post SUI investigation
• Pressure Ulcer Review Panels for all grade 3 and 4 are now in place in all sites led by the Deputy Director of Nursing
Action Plan Further skill mix will be introduced to the team with a Band 5 to focus on Pressure Ulcer Prevention Two research projects are being supported which focus on pressure ulcer prevention Documentation to be reviewed to capture the timing of the implemented interventions Focused training on using Heel protection
8 | P a g e
26 (79%) of the incidents relating to priority/high risk drugs were due to the medication being omitted. 68 (57%) of all the events recorded were associated with priority/high risk drugs.
Overview This report is reviewed at the Medication Safety Committee and all incidents are reviewed on a monthly basis to identify trends. All Heads of Nursing receive
the errors by ward area and disseminate to their matrons who in turn disseminate to their ward leaders. These all must be looked into regardless of the
severity rating.
020406080
100
Number of incidents over the year by site
County Hospital, Louth Grantham & District Hospital
Lincoln County Hospital Pilgrim Hospital, Boston
020406080
100120140160180
ULHT total number of medication incidents over the year
02468
101214
Omitted medicine/ingredient
Omitted high risk medicines
Anticoagulant Antiepileptics Antimicrobials Insulin Opiate/CD Parkinsons
9% 3%
35%
18%
31%
3% 1% Priority/high risk drugs
Anticoagulant
Antiepileptics
Antimicrobials
Insulin
Opiate/CD
Parkinsons
Potassium
PATIENT SAFETY – MEDICATION
9 | P a g e
There have been six (6) cases of hospital attributable (trajectory 5), bringing the total of hospital attributable cases to fifty two (52). There was also one (1) community acquired cases reported or February 2016.
There has been zero cases of hospital attributable (trajectory 0). The Trust reported zero (0) cases of community acquired cases for February 2016. This brings the total of hospital attributable MRSA bacteraemia to one (1) case, which breaches the Trust trajectory of zero (0) cases.
0
1
2
3
4
5
6
7
8
9
10
11
12
Nu
mb
er
of
cases
Trust acquired C difficile positives April 2015-March 2016
CDI - Acute acquired (>72) CDI - Trust monthly reduction target
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Louth 0 0 0 0 0 0 0 0 0 0 0
LCH 1 0 0 0 0 0 0 0 0 0 0
PH 0 0 0 0 0 0 0 0 0 0 0
GDH 0 0 0 0 0 0 0 0 0 0 0
Total 1 0 0 0 0 0 0 0 0 0 0
Cum
1 1 1 1 1 1 1 1 1 1 1
PATIENT SAFETY – INFECTION CONTROL
10 | P a g e
The graph below shows the number of complaints received by month and the number that have been ‘reopened’ (this refers to complaints responses that have bounced back
from complainants because they are dissatisfied with the response. This term has now been replaced with ‘ongoing’.
0
10
20
30
40
50
60
70
80
90Complaints Received 2015/16
Trust Pilgrim Lincoln Grantham
0
10
20
30
40
50
60
70
80
90
20
13
09
20
13
10
20
13
11
20
13
12
20
14
01
20
14
02
20
14
03
20
14
04
20
14
05
20
14
06
20
14
07
20
14
08
20
14
09
20
14
10
20
14
11
20
14
12
20
15
01
20
15
02
20
15
03
20
15
04
20
15
05
20
15
06
20
15
07
20
15
08
20
15
09
20
15
10
20
15
11
20
15
12
20
16
01
20
16
Complaints Monthly Trend 2013/2015
Received
Ongoing
Overdue complaints January 2016 February 2016
Business Unit LCG PHB GDH LCH PHB GDH
Surgical 32 3 0 33 4 0
Medicine 35 8 0 37 9 0
Grantham 0 0 1 0 0 6
Women and Children’s 11 1 1 15 2 1
Corporate Services 4 0 0 4 0 0
Path Links 0 0 0 0 0 0
TACC 2 0 0 2 0 0
Clinical Support Services 2 0 1 3 0 1
Totals 86 12 3 94 15 8
PATIENT EXPERIENCE – COMPLAINTS
11 | P a g e
Percentage of complaint responses sent within agreed timescales 2015/2016
Overview We have changed the process in which we commence new complaints that are received so that we can respond within the timescales given. Once the complaint is received and acknowledged we would send an email asking the Senior Site Lead contact. Previously the complaint investigation would not commence until we are advised that this call has been made and of a case manager who will be co-ordinating the investigation.
The process we are following now is that once the complaint has been received and acknowledged it will be sent to the Senior Site Lead and followed up for with a call to enquire who they have allocated as case manager. It is stated in the email that we will now follow the SSL email with a call to ask who has been allocated as case manager We then commence the investigation within the first few days and we have requested that the call is made within 7 working days. The acknowledgment that is sent to the complainant has been amended to reflect these changes. This has started to make a difference in the volume of complaints that have been responded to within timescale and this should continue to increase which will in turn reduce the amount of cases that go overdue.
We are in the final stages of completing some new case manager training which will look at the quality of investigations and written responses. This too will hopefully increase the responses that go out from trust first time without requiring any amendments any prevent unnecessary delays.
May 2015
June 2015
July 2015
Aug 2015
Sep 2015
Oct 2015
Nov 2015
Dec 2015
Jan 2016
Feb 2016
Lincoln
25%
38%
15%
17%
25%
0%
18%
32%
41%
26%
Pilgrim
30%
31%
24%
20%
7%
20%
40%
42%
41%
40%
Grantham
0%
34%
23%
50%
50%
22%
50%
36%
40%
33%
12 | P a g e
233 277 253
391 326
354 360 334 281
380 341
294 256 274 297 290 264
339 306 298
244 304
391
20
14
04
20
14
05
20
14
06
20
14
07
20
14
08
20
14
09
20
14
10
20
14
11
20
14
12
20
15
01
20
15
02
20
15
03
20
15
04
20
15
05
20
15
06
20
15
07
20
15
08
20
15
09
20
15
10
20
15
11
20
15
12
20
16
01
20
16
02
Total of PALS concerns 2015-2016
117 57
40 35
31 25 25
22 9
7 7
5 5 5 5
0 50 100 150
Waiting times
Communication - Verbal
Communication - Written
Medical care
Cancellation and change
Not Given
Attitude
Discharge
Nursing or Midwifery care
Medical records
Security
Car parking
Care other - not nursing or medical
Environment issues
Medication
PALS February 2016 Subject >5 concerns
PATIENT EXPERIENCE – PALS
13 | P a g e
FFT Sentiment Analysis Sentiment analysis breaks down each comment received by from patient into phrases, using punctuation and scored according to the sentiment within in the phrase – positive or negative. A score is given to every phrase and then an average score is applied to the whole comment. The charts below show the overall number of positive and negative based on all FFT comments by theme.
Overview and actions
Following the national publication of FFT data for January, the Trust remains in the lowest 20% quartile for FFT would recommendation rates for Inpatients and Emergency
Care whilst achieving above the national average for response rates. The patient experience team will continue to provide support and advice to wards and departments to
encourage them to seek ways of improving recommendation rates.
Patient Opinion 65 stories were posted to Patient Opinion during February and were viewed 12,918 times. This equates to each story being read 198 times. The three most read stories were all positive and are shown below. The significant increase the number of views is due to positive stories being posted on the ULHT Nurse Together Facebook site and via Twitter which commenced in January 2016. NHS England have expressed interest in how the Trust shares positive feedback with staff and a meeting with the NHS England Head of Staff Experience is scheduled for April.
23%
37%
23%
27%
24%
16%
28%
15%
33%
35%
6%
9%
7%
8%
22%
9%
10%
8%
17%
10%
71%
54%
69%
65%
54%
74%
62%
77%
50%
55%
A D M I S S I O N
C A T E R I N G
C L I N I C A L T R E A T M E N T
C O M M U N I C A T I O N
E N V I R O N M E N T
I M P L E M E N T A T I O N O F C A R E
P A T I E N T M O O D F E E L I N G
S T A F F A T T I T U D E
S T A F F I N G L E V E L S
W A I T I N G T I M E
TRUST THEMES
Negative Percentage Neutral Percentage Positive Percentage
PATIENT EXPERIENCE – FRIENDS & FAMILY