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TRUST BOARD26 October 2017
AGENDA ITEMNUMBER
5.2
TITLE OF PAPER Quality Report
Confidential NO
Suitable for publicaccess
YES
PLEASE DETAIL BELOW THE OTHER SUB-COMMITTEE(S), MEETINGS THIS PAPER HAS BEENVIEWED
None
STRATEGIC OBJECTIVE(S):
Best outcomes
Excellent experience
Skilled & motivatedteams
Safety is improved when teams actively engage with care qualityimprovement.
Top productivity Performance is improved with effective pathways and safe care.
EXECUTIVE SUMMARY
This report summarises clinical quality data for September 20171.
The report format and content has been refreshed this month, although thisprocess will be iterative across the next few months and some data fields arestill pending information. The key changes are:
Main monthly Quality Scorecard has been modified to show internaltolerance limits (where possible statistically guided) which are inaddition to the targets for in-year achievement set at the start of theyear. This will aid improvement targeting so that minor variations withinlimit may not necessarily require intervention. An associated changehas been designating many measures as for improvement orsurveillance – so that improvement can also be more targeted to thoseareas needing it most. The Trust scorecard remains unchanged.
Performance history on the monthly Quality Scorecard now showsperformance back several years where possible, and a separatesection focussing on performance currently.
New clinical effectiveness measures have been added for stroke andcardiology in national audit priority areas.
Run charts were added with external benchmarked performance shown
2
alongside, along with learning and next steps.
Patient experience complaints performance against timescale agreedwith the complainant (using the current methodology) is not includedbecause the data produced for the current month upon validationrequires significant re-work. A verbal update on this item will beavailable to trust Board on the day. Performance against timescale bygrade is shown in Section 3.2. Of grades 1 and 2 48% were issued in25 days and of grades 3 and 4 22% were issued in 35 days. A pathwayand improvement programme will take place from Q3.
Within the QEWS Dashboard a deep dive into significant trends is underwayand the outcome will be reported to QPC.
Performance against the Quality Account and Business Plan 2017/18 prioritiesis shown in Section 6. There has been slippage in a number of areas owing tocapacity constraints and this will be an area of focus in Q3.
RECOMMENDATION: Review the paper and seek additional assurance as necessary.
SPECIFIC ISSUES CHECKLIST:
Quality and safety Y
Patient impact Y
Employee Y
Other stakeholder Quality priorities are set following consultation with internal and externalstakeholders.
Equality & diversity All of our services give consideration to equality of access, taking intoconsideration disability and age and all matters are dealt with in a fair andequitable way regardless of the ethnicity or religion of patients.
Finance Not applicable.
Legal Poor quality care for patients can lead to potential litigation, non-compliance
with the Health and Social Care Act 2008 (Regulated Activities) Regulations
2014 and could affect the Care Quality Commission registration and NHS
Improvement licences.
Link to BAF principal risk Vulnerable groups care is part of Board Assurance Framework (BAF) risk 2.2.
AUTHOR NAME/ROLE Dr Erica Heppleston, Associate Director of Quality
PRESENTED BY Dr David Fluck, Medical Director and Mrs Sue Tranka, Chief Nurse
DATE 26 October 2017
BOARD ACTION The Board is asked to please consider formally approving the Non-ExecutiveDirector who kindly attended the first Mortality Committee in October and whowill oversee mortality and be a member of the Mortality Committee goingforward as per national guidance on Learning from Deaths.
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4
Quality scorecard September 2017
Key: Validation mechanism - assurance process over the underlying data. Assurance category (AC): Imp (monitoring for improvement), Sur (monitoring for surveillane). Data reliability rating (DRR): H (high), M (moderate), L (low)
Area Safety - Mortality Performance History YTD This
Month
Narrative Monthly
Target 17-
18
Tolerance Range Validation
mechanism
AC DRR
INPUTS
Mortality reviews %completed -
[1 month in arrears].68.2 68.8
Mortality completion rates were 79% for MES, 31% for
TASCC and 0% for DTTO and WH&P. There was 1 death
each in DTTO and WH&P in August. The WH&P death is
due for review on the 20 October.
>90%<80% needs
intervention
100% manual
validation
Imp H
In-hospital SHMI - ratio of
observed to expected deaths.
Monthly is rolling 6 month
position, 1 month in arrears.
YTD is rolling 12 months, 1
month in arrears.
Increasing trend since April 2015. 2 years
ended March 2017 averaged 64 with range of
58 to 71 (2 SDs).
66.4 58.5
The SHMI has returned to the lower level of baseline.
Benchmarking data is in Section 1.1.
<72 <72
None - external
data from CHKS
Sur H
In-hospital RAMI - CHKS
measure for risk of death for
patients with similar
characteristics. Data reported 1
month in arrears.
The RAMI briefly spiked in winter 2016/17 for
2 months but then returned to range.
64.88 55.3
The RAMI is in line with expectations.
<70 <70
Performance
Reports
Sur H
In-hospital deaths - Crude
mortality. Absolute number of
deaths in the month. Excludes
children, maternity, and trauma
cases. A 5 year crude mortality analysis in May 2017
showed Trust July-January 102% increase
exceeded peers' 47-63% rise, but Trust Dec
to Jan 17% increase is more favourable than
peers' 26-30% rise. Most recently Trust
crude mortality for 2016 versus 2015 was an
increase of 15% compared to national,
regional, or local peers recorded at 4-6%
increase. Multi-variate analysis for
correlation or causation including age,
residence location, condition, ward, clinician,
day/time of admission showed no
correlation.
560 95
Crude mortality winter rise can start as early as
September. A new tolerance range is set 1 standard
deviation from average crude mortality for the 2 years
ending March 2017, after adjustment removing 2 high
outlier months (December 2016 and January 2017). The
key learning and improvement will be from the Learning
From Deaths programme case reviews from Q3 onwards.
90 80 - 111 (1 SD)
Case reviews Imp H
AREA Safety - Falls Performance History Target 17-
18
Tolerance Range Validation
Mechanism
AC DRR
Falls per 1000 bed days
2.48 2.28
The odds of an individual inpatient suffering a fall is
steadily reducing across time. 2.46 To be set
Manual validation Imp H
Falls (total)
217 32
The falls Sign up to Safety Plan cumulative reduction in
falls of 50% will be unattainable because total falls has
risen 3.3% at end September, so to reduce falls by 109
cases (51.8%) in the next 6 months is too much of a
stretch. Whilst ward mandatory training was recently
refreshed to be more integrated, frontline support from the
Corporate Falls Team is not at capacity.
319 To be set
Manual validation Imp H
AREA Safety - Pressure Ulcers stage
2 and above (hospital acquired)
Performance History Target 17-
18
Tolerance Range Validation
Mechanism
AC DRR
OUTCOMES
Pressure ulcers per 1000 bed
days1.50 0.57
Cumulatively this measure is improving indicating that the
likelihood of an individual patient receiving an ulcer as an
inpatient is getting less over time.1.98 To be set
Manual validation Imp H
Pressure ulcers (total)
77 7
Pressure ulcers (stage 2 and above) have reduced 32% in
6 months which is slightly below the 41% trajectory
needed to achieve the Sign up to Safety 50% reduction
across the 3 years ending March 2018.
140 To be set
Manual validation Imp H
OUTCOMES
OUTCOMES
14/15 15/16 16/17
3.30 2.59 2.36
14/15 15/16 16/17
638 457 421
14/15 15/16 16/17
2.04 2.08 2.24
14/15 15/16 16/17
281 207 225
14/15 15/16 16/17
1111 1139 1319
14/15 15/16 16/17
60 62 69
14/15 15/16 16/17
58 64 70
14/15 15/16 16/17
38% 56% 56%
5
Area Safety - Cardiac arrests in
areas outside critical care
Performance History YTD This
Month
Narrative Monthly
Target 17-
18
Tolerance Range Validation
Mechanism
AC DRR
OUTCOMES Number of cardiac arrests not
in critical care areas
In 2016/17 62 events occurred in the year, on
average 5 per month. 16 1
The low number is favourable. Trustwide rollout of the
Treatment Escalation Plan (TEP) document is scheduled
for early December 2017.None set <4
Manual validation Sur H
Area Safety - infection control Performance History YTD This
Month
Narrative Monthly
Target 17-
18
Tolerance Range Validation
Mechanism
AC DRR
OUTCOMES Hospital acquired MRSA
0 0
No cases to date.
0 nil
Manual validation Sur H
OUTCOMES Hospital acquired C.difficile
9 1
9 cases in 6 months (11 to mid October) exceeds the
Department of Health’s annual target of 17. Of the 11
cases, 1 case had no lapses in care. Validated outcomes
of the other 10 cases is underway.
1 1
Manual validation Sur H
Area Safety - medication errors Performance History YTD This
Month
Narrative Monthly
Target 17-
18
Tolerance Range Validation
Mechanism
AC DRR
OUTCOMES Medication errors per 1000
beddays 2.90 2.93
this measure has oscillated over the past 3 years and is complex to analyse due to the many campaigns over the past 2 years to encourage staff to report incidents generally
_ To be set
Analytic review Sur M
Area Safety - Dementia Performance History YTD This
Month
Narrative Monthly
Target 17-
18
Tolerance Range Validation
Mechanism
AC DRR
Dementia screening - asked
case finding question within 72
hours of admission36.90%
Data not yet available.
90% TBC
None Imp L
Dementia screening - scored
positively to case finding
question99.10%
Data not yet available.
90% TBC
None Imp L
Dementia screening -
diagnostic assessment100.00%
Data not yet available.
90% TBC
None Imp L
INPUTS
14/15 15/16 16/17
1 0 0
14/15 15/16 16/17
18 15 20
14/15 15/16 16/17
2.92 3
14/15 15/16 16/17
42.80%
14/15 15/16 16/17
99.40%
14/15 15/16 16/17
96.00%
6
Area Effectiveness - Stroke Performance History YTD This
Month
Narrative Monthly
Target 17-
18
Tolerance Range Validation
Mechanism
AC DRR
INPUTS
Stroke unit admission in 4
hours (%)58.7 58.3
4 hour Stroke Unit admission of 58.3% is below target of
90%. The largest contributing factors were disruptions in
the stroke pathway or clinical condition complexities which
delayed admission.
90%<90% needs
intervention
Manual validation Imp M
OUTCOMES
Sentinel Stroke National Audit
Programme (SSNAP) level
Trust’s overall national domain ranking the
top 16% of providers based on our national
audit performance at March 2017.
A A
4 out of 10 measures are below a full score (where A is
highest, E lowest) – stroke unit admission time (B),
timeliness of thrombolysis (B), speech and language
therapy provision (D), and multidisciplinary working (D)
covering therapy and rehabilitation goal setting.
A Not applicable TBC Imp M
Area Effectiveness - non-elective
readmissions
Performance History YTD This
Month
Narrative Monthly
Target 17-
18
Tolerance Range Validation
Mechanism
AC DRR
OUTCOMES
30 day non-elective
(emergency) readmissions
14.5 13.7
30 day readmissions at 13.7% remains above target but
lower than last month. MES is undertaking a deep dive
into this area and in Surgery Urology (20%) is to be
reviewed to determine if any further pathway improvements
can reduce this.
12.5 To be set
Externally audited
recently
Sur H
Area Patient Experience - FFT Performance History YTD This
Month
Narrative Monthly
Target 17-
18
Tolerance Range Validation
Mechanism
AC DRR
Friends and Family Satisfaction
Score - Inpatients (including
daycase)96.40% 96.10%
Satisfaction rates reamin constant with similar response
rates to last month. Of note are wards that received 100%
satisfaction and high response rates; Dickens had 40.7%
response rate, May 36.6%, NICU 30.4% and Ambulatory
Pleural Unit 23.8%. SDU received a lower satisfaction
level of 92.9% but a high response rate of 46.7%.
95% To be set
Manual Imp M
Friends and Family Satisfaction
Score - A&E (including
paediatrics)83.20% 83.90%
Satisfaction rates have slightly increased and response
rates remain similar to previous months at 1.4% which is
very low. Improvement options are being considered.87% To be set
Manual Imp M
Friends and Family Satisfaction
Score - Maternity (touchpoint 2) 83.50% 79.40%
Response rates remain high at 48%.
97% To be set
Manual Sur M
Friends and Family Satisfaction
Score - Outpatients
95.40% 96.60%
Outpatients response rates remain low at 2.2%. A
significant decline in response rate occurred at the start of
April 2017 from 25% to 5% when surveying changed from
being limited areas via text message to all areas using
paper and online surveys.
92% To be set
Manual Sur M
Area Patient Experience - complaints Performance History YTD This
Month
Narrative Monthly
Target 17-
18
Tolerance Range Validation
Mechanism
AC DRR
OUTCOMES Complaints follow up rate
5.80% 0.00%
There were zero follow-up complaints received in
September. 28 new complaints were received comprising
7 grade 1, 14 grade 2, 7 grade 3 and zero grade 4.<10% <10%
Manual Sur M
OUTCOMES
14/15 15/16 16/17
53% 65% 58%
14/15 15/16 16/17
13.1% 14.1% 14.0%
14/15 15/16 16/17
75.00% 96.20% 94.90%
14/15 15/16 16/17
48.40% 84.30% 86.40%
14/15 15/16 16/17
81.40% 96.30% 96.80%
14/15 15/16 16/17
94.70% 95.80%
14/15 15/16 16/17
6.50%
7
1. SAFETY
1.1 Mortality indices
SHMI2
50
55
60
65
70
75
80
Mon
th
Nov-13
Jan-14
Mar-14
May
-14
Jul-1
4
Sep-14
Nov-14
Jan-15
Mar-15
May
-15
Jul-1
5
Sep-15
Nov-15
Jan-16
Mar-16
May
-16
Jul-1
6
Sep-16
Nov-16
Jan-17
Mar-17
May
-17
Jul-1
7
Sep-17
Crude mortality (in-hospital deaths)
50
70
90
110
130
150
170
190
Oct-13 Jan-14
Apr-14 Jul-14
Oct-14 Jan-15
Apr-15 Jul-15
Oct-15 Jan-16
Apr-16 Jul-16
Oct-16 Jan-17
Apr-17 Jul-17
2The CHKS benchmarking Peer Group is ASPH, Royal Surrey County Hospital, Frimley Park Hospital, Royal Berkshire Hospital, St George’s Hospital, Portsmouth Hospital and Brighton and
Sussex Hospitals.
Learning from Deaths Programme from Q3
2017/18 - QI tool is case review
Q1 Q2 Q3 Q4
In-patient deaths 300 260
In-patient deaths subject to case review –
number and %
Hospital mortality indices demonstrate the Trust is generally a good performer.
CHKS SHMI data from September 2016 to August 2017 benchmarks the Trustagainst a peer group of 7 Trusts, which would place ASPH as 5
thout of 7 Trusts in
that peer group. Nationally, ASPH had the 52nd lowest SHMI out of 135 Trusts,placing us in the top 39% in England based on April 2016 to March 2017 data
A crude mortality peak occurred in winter 2016/17 period which was extensivelyanalysed. No correlation with underlying variables was identified.
National Guidance on Learning from Deaths is being implemented led by the MedicalDirector. A Mortality Surveillance Group was established in October as the keymortality governance forum reporting to QPC. A key challenge is finding bothcapacity and funding for clinicians to perform the new Structured Case Reviews, andthe plan for this is still underway. The Trust intends to report mortality indicators byQ3 as nationally mandated.
The Trust will receive a Coroner’s Regulation 28 Report on an Action to PreventFuture Deaths in September 2017 and the details of actions are pending. The Trusthas no further Regulation 28 Reports with action plans still open.
8
1.2 Falls
Falls per 1000 bed days
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
5.00
Oct-13
Jan-14
Apr-14 Jul-14
Oct-14
Jan-15
Apr-15 Jul-15
Oct-15
Jan-16
Apr-16 Jul-16
Oct-16
Jan-17
Apr-17 Jul-17
Total falls
Deaths per case reviews likely to be due to
care problems - number and %
Lessons learned and outcomes
When the new mortality reviews are implemented from Q3 onwards, lessons learned will be included in this
section.
Lessons learned and next steps
Falls indices demonstrate that the chance of an individual patient stayresulting in a fall is decreasing, as evidenced by the declining falls per1000 bed days. However, total falls is rising cumulatively this year.
The Trust’s approach to reducing falls is outlined in the Falls Strategy andCorporate Action Plan, which are due for refresh this year, and the 3 YearSign up to Safety 3 Plan which ends in March 2018.
To achieve the 3 yearly cumulative 50% reduction in total falls by March2018 a reduction of 102 falls (24.2%) was needed this year, an averagereduction of 8.5 falls per month. This will almost certainly be unattainableas total falls has risen 3.3% for the six months ended September 2017.
Key process changes over the past year were incorporating a falls riskassessment in the Adult Nursing Assessment in April 2016 and the rolloutof a medical assessment and falls intervention tool around June 2016.
The Falls Corporate Nursing Team has not been fully filled on the frontlinesince June 2016 resulting in reduced clinical service hours and a lessspecialised staff group mix providing support to wards.
9
20
30
40
50
60
70
80
Apr-14
Jun-14
Aug-14
Oct-14
Dec-14
Feb-15
Apr-15
Jun-15
Aug-15
Oct-15
Dec-15
Feb-16
Apr-16
Jun-16
Aug-16
Oct-16
Dec-16
Feb-17
Apr-17
Jun-17
Aug-17
1.3 Pressure ulcers (PUs) (all data is hospital acquired stage2 and above)
Pressure ulcers per 1000 bed days
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
Oct-13 Jan-14
Apr-14 Jul-14
Oct-14 Jan-15
Apr-15 Jul-15
Oct-15 Jan-16
Apr-16 Jul-16
Oct-16 Jan-17
Apr-17 Jul-17
Nationally, total falls is not part of a benchmarked dataset.
Next steps – in order to achieve the Sign up to Safety target falls would need to reduce by
109 cases (51.8%) in the next 6 months which will be unattainable. Ward mandatory falls
training has been refreshed to be more integrated this year. Potentially given increased
patient bed days the absolute level of falls may be reaching a new plateau.
Sign up to Safety Plan 50% reduction in falls
cumulatively for 3 years ending 31 March 2018
14/15 15/16 16/17 17/18
YTD
17/18
Target
Total falls 638 457 421 217 319
Falls (reduction) / increase in-year (181) (36) 7 (102)
Percentage falls (reduction) / increase (28.3%) (7.8%) 3.3% (24.2%)
Falls with harm – defined as grade 3 18 13 15 11 0
Lessons learned and next steps
10
Pressure ulcers stage 2 and above
1.4 Medications management
Medication errors – rate per 1000 bed days
1.00
2.00
3.00
4.00
Oct
-14
Jan-
15
Apr-
15
Jul-1
5
Oct
-15
Jan-
16
Apr-
16
Jul-1
6
Oct
-16
Jan-
17
Apr-
17
Jul-1
7
Medication safety thermometer
Data is not currently available from the national data provider.
Nationally total pressure ulcers is not part of a composite dataset.
In June 2016 a PU SIRI resulting in death occurred with failings in pressure ulcer body
mapping, daily assessment, escalation to specialist Tissue Viability Team, and treatment
planning. Combined failings including medical management and nutrition resulted in an
upcoming Coroners’ Regulation 28 Report being notified at inquest in September 2017. Issue
of the report is pending and an improvement action plan will be due to the Coroner 56 working
days later.
Next steps are to continue the Heel SOS “strictly off surface” campaign started in April 2017.
A heel wedge has been introduced and 3000 pocket mirrors to check heels are on order
following generous funding by the League of Friends. Since 1 April 2017 seven wards been
commended for achieving 100 days without a stage 2 or greater pressure ulcer.
Sign up to Safety Plan 50% reduction in stage 2
and above PU cumulatively for 3 years ending 31
March 2018
14/15 15/16 16/17 17/18
YTD
17/18
Target
Total PUs – 2,3,4 281 207 225 76 140
PU (reduction) / increase in-year (65) 24 (36) (99)
Percentage PU (reduction) / increase in year (23.1%) 11.1% (32%) (41%)
Stage 3 and above 17 9 15 7 zero
11
Lessons learned and next steps
In Medicine 3 incidents have occurred regarding patients not getting insulin administered
appropriately and 1 patient needed an Intensive Care Unit admission.
MES Divisional Governance Team is currently investigating these incidents for learning.
12
1.5 Infection control report
Meticillin-resistant Staphylococcus aureus (MRSA) bacteraemias
There have been zero trust apportioned MRSA bacteraemias since February 2015.
Clostridium Difficile (C. difficile)
9 cases have occurred in 6 months (11 to mid October) against the Department of Health’s annual target of 17. Of the 11 cases, 1 case had no lapses in care. Validated
outcomes of 10 cases is underway.
Meticillin Sensitive Staphylococcus Aureus (MSSA) Bacteraemias
22 MSSA bacteraemias occurred of which 7 are healthcare associated (defined as taken at least 48 hours after admission)
MSSA bacteria in the bloodstream E coli bacteria in the bloodstream
E. coli bacteraemia Department of
Health annual Trust limitYTD
Performance - Community and hospital
acquiredcases
243 cases (10% fewer than last year)140 19 cases above trajectory by end of Q2.
Lessons learned and next steps
A common cause of infection is sepsis in the urinary tract so root causes analyses for
Trust acquired cases is needed if the infection was device related.
13
Next steps – the Trust is working with CCG to determine risk factors and how a means of
reducing these community infections might be practicable.
14
1.6 Learning disability update
Establishment
The Trust continues to work with Surrey and Borders NHS Foundation Trust (SABP) to provide learning disability (LD) nursing services. The current provision is a 0.6 working
time equivalent (WTE) band 6 nurse with onsite presence on Tuesdays and Thursdays with Friday offsite. A new 0.6 WTE nurse is to commence to maximise cover over
both sites.
Patient pathway
The LD Team is currently working on changing the patient pathway to make it easier to understand and action from a staff perspective, this is still being reviewed. We have
now progressed ward champions who have had further training and development.
Training and developing staff
Our ward champions have attended a training and development workshop run by the LD team from SABP. A very successful LD training day was held in the Post Graduate
Education Centre.
Partnership working
The Trust’s Safeguarding Team continues to be represented on SABP committees for LD.
15
2.CLINICAL EFFECTIVENESS
2.1 Non-elective (emergency) 30 day readmissions
Percentage of non-elective (emergency) 30 day readmissions by month
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
Oct-13
Jan-14
Apr-14
Jul-14
Oct-14
Jan-15
Apr-15
Jul-15
Oct-15
Jan-16
Apr-16
Jul-16
Oct-16
Jan-17
Apr-17
Jul-17
Percentage of non-elective (emergency) 30 day readmissions by specialty area
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
General Surgery
Urology
Colorectal Surgery
Upper GI Surgery
A&E
General Medicine
Next steps
Next steps - by volume the largest patient cohorts are A&E and General Medicine and
the Divisional Director of MES is performing a deep dive into readmissions currently.
Urology with a rate of around 20% has the most consistently elevated emergency
readmission rate in Surgery and the Governance Teams have been asked to ascertain
whether there is any improvement opportunity in this patient pathway.
30 day non-elective readmissions for September of 13.7%(YTD14.5%) exceeds internal target of 12.5% and ranged from13% to 16% over the past 18 months. The year-to-date rate is14.7%. National data on this measure used to be available viathe HSCIC however this has not been available to the sector forseveral years now.
The current approach to readmissions reduction is Divisional
surveillance following a 2 year Trustwide reduction programme
targeting pathway level interventions.
September Divisional readmission rates were WH&P 6.9%,
DTTO 9.4%, TASCC 14.3% and MES 17.2%. Using
September data as a guide a monthly reduction in readmissions
of 32 patients (around 1 patient per day) would be needed to
achieve the internal target.
By specialty area the larger volume or percentage rate
specialties across 2017/18 have been identified on the adjacent
run chart and next steps are outlined below.
16
17
2.2 Percutaneous coronary interventions (PCIs)
The percutaneous coronary intervention (PCI) procedure involves opening narrowed coronary arteries using methods such as a catheter and may involve stenting to keep
the vessel open. Benchmarked data is from the 2015 year national audit3 issued in September 2017. Data is national average unless marked with an asterisk* in which case
it is a national target.
3(refer https://www.hqip.org.uk/resources/national-audit-of-percutaneous-coronary-intervention-annual-public-report/
Benchmarked performance against the
year ended 31 December 2015 UK
dataset (issued Sept. 2017)
2015
(validated)
2016
(provisional)
NationalAverage ‘15orbenchmark
Volume above 400 PCIs per year 692 684 >400*
Volume above 100 for primary PCIs 74 124 >100*
STEMI patients treated within 90
minutes by urgent/emergency PCI
96% 96% 91%
NSTEMI and unstable angina treated
within 72 hours by urgent/emergency
PCI
84% 83% 57%
PCI access route is via radial access 33% 51% 78%
Lessons learned and next steps
Learning – the radial access rate is an area for improvement, however, it is not possible
in all cases as the measure does have some downsides such as vessel clots, especially
with repeat procedures.
Next steps - By volume the largest patient cohorts are A&E and General Medicine and
the Divisional Director of MES is performing a deep dive into readmissions currently.
Urology with a rate of around 20% has the most consistently elevated emergency
readmission rate in Surgery and the Governance Teams have been asked to ascertain
whether there is any improvement opportunity in this patient pathway.
National data demonstrates the Trust is above average for overall PCI
performance in most areas. The Trust is below average for rates of
obtaining access via the arm (radial route) rather than via the thigh
(femoral route) with 51% radial access compared with a benchmark of
78%. Although evidence is equivocal in some studies, it is generally
agreed that the trans-radial route (particularly in less urgent cases) has
fewer vascular complications with less bleeding at the access site and
patients may be discharged earlier after their procedure. The Trust’s
lower radial access rate is due mainly to operator preference.
18
2.3 Stroke
Percentage of patients admitted to Stroke Unit within 4 hours
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-13
Jan-14
Apr-14
Jul-14
Oct-14
Jan-15
Apr-15
Jul-15
Oct-15
Jan-16
Apr-16
Jul-16
Oct-16
Jan-17
Apr-17
Jul-17
SSNAP nationally benchmarked strokeperformance
Dec 16toMar 17
Apr to
July 17
17/18NationalDomainRanking
SSNAP level – overall audit benchmarked level A Top 16%
Patient centred key indicator level A Top 23%
4 out of 10 audit domains scored less than ‘A’ on a scale of A (best) toE (lowest)Domain 2 stroke unit covers 4 hour stroke unitadmission, time to stroke unit admission, and whethera patient stays more than 90% of their time on a strokeunit.
C 30% - 51%range
Domain 3 thrombolysis improved from a D score inDecember 2016 to C in March 2017. The domainmeasures assessment and timely administration ofthrombolysis for eligible stroke patients.
C↑ 41% - 69%range
Domain 7 speech and language therapy (SALT)covers timeliness of therapy provision.
B 17% - 38%range
Domain 8 multidisciplinary team working includesPhysiotherapy, Occupational Therapy, andrehabilitation goal setting.
B↓ 12% - 40%range
Lessons learned and outcomes
Next steps – Domain 7(SALT) - Stroke patients often suffer from dysphagia (trouble
swallowing). Dysphagia incidents from April 2017 were reviewed and issues included
timeliness of referral to SALT, swallow screen accuracy, adherence to guidelines and
identification of patients already on modified diets upon admission. The MES improvement
action plan includes drop-in training including housekeeping staff and better signposting of
dietary needs.
Stroke indices demonstrate the Trust’s overall national domain rankingis to be in the top 16% of providers based on our national auditperformance at March 2017.
The national stroke dataset is the Sentinel Stroke National AuditProgramme (SSNAP) of the Royal College of Physicians.Benchmarked data is released 4-monthly with latest data to March2017. The SSNAP programme states their standards are the moststringent in the world https://www.strokeaudit.org/. Data for the 4months ending July 2017 is due for release in November 2017.
The Trust’s approach to improving stroke is at the system level throughincreased rehabilitation provision and at the inpatient pathway level.
Domain 2 - Stroke unit admission is being monitored on a case-by-case basis and the reasons for all breaches are analysed to guideimprovement actions. Most delays this month were referral delaysfollowed by specific patient needs requiring an alternative bed location.The key improvement action is continuing communication amongclinicians to prioritise maintaining the specified stroke pathway.
Domain 3 - Thrombolysis door to needle time was met for September
patients in-hours but the Surrey standard of less than 60 minutes was
not met out of hours averaging 84 minutes.
19
20
3. PATIENT EXPERIENCE
3.1 Friends and Family Test (FFT)
FFT satisfaction percent FFT response rate
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
Ap
r-1
5
Jun
-15
Au
g-1
5
Oc
t-1
5
De
c-1
5
Fe
b-1
6
Ap
r-1
6
Jun
-16
Au
g-1
6
Oc
t-1
6
De
c-1
6
Fe
b-1
7
Ap
r-1
7
Jun
-17
Au
g-1
7
Series1
Series2
Series3
Series4
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Ap
r-1
5
Jun
-15
Au
g-1
5
Oct
-15
De
c-1
5
Feb
-16
Ap
r-1
6
Jun
-16
Au
g-1
6
Oct
-16
De
c-1
6
Feb
-17
Ap
r-1
7
Jun
-17
Au
g-1
7
Series1
Series2
Series3
Series4
Lessons learned and outcomes
Learning from patient feedback is at a combination of ward level and individual
clinician level. The current feedback tool is being reviewed to determine whether
the types of information reported back from patients is optimal in terms of showing
both detailed feedback and high level outcomes. This will considerably aid the
setting of improvement work in all areas.
Stroke indices demonstrate the Trust’s overall national domain ranking isto be in the top 16% of providers based on our national audit performanceat March 2017.
The national stroke dataset is the Sentinel Stroke National AuditProgramme (SSNAP) of the Royal College of Physicians. Benchmarkeddata is released 4-monthly with latest data to March 2017. The SSNAPprogramme states their standards are the most stringent in the worldhttps://www.strokeaudit.org/. Data for the 4 months ending July 2017 isdue for release in November 2017.
The Trust’s approach to improving stroke is at the system level throughincreased rehabilitation provision and at the inpatient pathway level.
Key
Inpatients with daycase
A&E includingPaediatric
Maternity touchpoint 2
Outpatients
21
22
3.2 Learning from complaints
Percentage of grade 1 and 2 complaints issued within 25 days
On average 48% of patients received responses within 25 days on this time series.
Percentage of grade 3 and 4 complaints issued within 35 days
On average 22% of patients received responses within 35 days on this time series.
0%
10%
20%
30%
40%
50%
60%
70%
80%
Apr-1
6
May
-16
Jun-
16
Jul-1
6
Aug-16
Sep-
16
Oct-16
Nov-16
Dec-16
Jan-17
Feb-
17
Mar
-17
Apr-1
7
May
-17
Jun-
17
Jul-1
7
Aug-17
Sep-
17
Grade 3 and 4 responses in 35 days
Complaints Learning
The themes of complaints responded to in September were reviewed. Problems with adherence to discharge protocols occurred on several occasions and the Trust is
already working on a way of improving patient experience and safety around discharge. Concerns about non-adherence to the stroke pathway and admitting patients in a
timely manner was noted and that broad area is addressed in Section 2.3 as a known improvement pathway. There were multiple instances of patients hearing clinical team
members disagreeing within the hearing of the public. A behavioural piece was undertaken on this area in 2016/17 but it is clear more work is needed to continually promote
this. There was also raised that information may be being shared with external care providers without patient consent and this is still actively under review as to our
processes and what is needed to ensure consistent Trustwide behaviour.
23
24
4. Nursing and midwifery safer staffing
Nursing and midwifery safer staffing table September 2017
Safer staffing indices trends of high vacancy rates and
under-filled day and night shifts of registered nurses (RNs)
continued in September.
Shift fill - review of red rated ward shifts showed 1 in 3 shifts
had more than a 2 person shortfall. Four wards had 1 staff
member short on most shifts. To mitigate senior nurses
review staffing shortfalls twice daily and move nurses among
wards to maintain safety and care.
By site - registered nurse shift fill for Ashford is 92.5% by day
and 99% at night, with St Peter’s site filling 85% by day and
86.2% at night. Shift fill is reflected in total care hours at
Ashford of 3.8 (RNs) and 3.1 Health Care Assistants (HCAs)
and St Peter’s of 4.9 (RNs) and 3.1 (HCAs).
25
Division Wards Total shifts Red Amber Green % Green
% Green
shif ts
sparkline
Apr 16- Sep
17
Ward SIs
Ward SIs
Sparkline
Apr 16 -
Sep 2017
Ward Red
Flags
Ward Red
Flags
Sparkline
Apr 16 -
Sep 17
QEWS
LEVEL
AandE 248 53 15 202 82% 0 1 1
Aspen 90 8 15 67 74% 1 2 2
CCU & Birch 90 7 16 67 74% 0 0 2
Cedar 90 0 14 76 84% 1 2 2
Holly 90 0 10 80 89% 0 0 2
May 90 0 16 74 82% 1 0 2
ACU 60 2 22 36 60% 0 0 -
AMU 90 8 9 73 81% 1 1 1
Cherry 90 0 2 88 98% 0 0 2
Maple 0 0 3
Sw if t 90 0 4 86 96% 0 0 2
Wordsw orth 90 8 0 82 91% 0 0 2
Dickens 90 11 22 57 63% 0 0 2
Sw an 90 30 13 47 52% 0 0 1
Kingfisher 90 31 21 38 42% 0 0 2
Falcon 90 0 2 88 98% 0 2 3
SDU 90 4 0 86 96% 0 2 3
Heron 90 3 20 67 74% 0 1 3
SAU 90 23 26 41 46% 0 0 2
ITU 90 42 22 26 29% 0 0 2
Abbey BC 60 2 0 58 97% 0 0 -
Ash 60 0 1 59 98% 0 0 3
NICU 240 32 70 138 58% 0 5 3
Labour Ward 120 12 31 77 64% 1 1 2
Joan Booker 120 1 16 103 86% 0 3 3
SAFESTAFFING LEVELS DATA – Sep 2017
T&
OA
cu
tea
nd
Em
erg
en
cy
Me
dic
ine
Wo
me
n’s
He
alt
ha
nd
Pa
ed
iatr
ics
TA
SC
C
5. Regulation
26
5.1 Care Quality Commission (CQC)
A focussed CQC unannounced inspection of Medical Wards took place in September 2017. The CQC is yet to issue the formal inspection report, however, a
change in ratings is not expected. On the inspection day an immediate item requiring rectification was clearing objects from ward fire exit doors and ensuring
doors were working properly and that has been resolved. The Trust has an ongoing fire safety assurance programme and evidence of this was supplied to
the CQC. Other regulatory improvement areas subject to priority work are learning from incidents, Coroners’ cases, and medicines management safety. A
multidisciplinary approach to identifying and tackling the most serious aspects of medications safety, such as those which can be potentially life threatening, is
currently being formulated by the Chief Pharmacist, Head of Regulation and Patient Safety Improvement, and Divisional Chief Nurses.
5.2 NHS Improvement (NHSI) ratings
The Trust’s current rating from NHS Improvement is segment 2 which is the second highest segment out of four categories. The rating reflects our ongoingissue areas of both Accident and Emergency Department 4 hour waiting times and 62 day cancer targets.
5.3 Deprivation of Liberty Safeguards (DOLS)
Seven DOLS applications were made in September with 1 on the Acute Medical Unit and 6 on Swift Ward. None were assessed by the local authority.
5.4 Deloitte Well-Led Review
A separate paper on this action plan will be presented by the Chief Nurse to Trust Board during the meeting.
27
6. QEWS
28
Quality, Experience, Workforce and Safety Monthly Triangulation & Predictor Dashboard (QEWS)
QEW
SLe
vel
CMR
Sep-1
7
Patient ExperienceO O P P P P P
Co
mp
lain
ts
PA
LS
Frie
nd
s&
Fam
ilyTe
st-
Res
po
nse
Rat
e
Frie
nd
s&
Fam
ilyTe
st
Sati
sfac
tio
nSc
ore
-%
Rec
om
men
d
%P
atie
nts
dis
char
ged
on
or
bef
ore
3p
m
%P
atie
nts
dis
char
ged
on
or
bef
ore
4p
m
Len
gth
of
Stay
on
war
d(h
rs)
Do
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ns
inC
linic
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ract
ice
aud
it-
May
20
17
resu
lts
Ap
pra
isal
%
%G
reen
Safe
Staf
fin
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%o
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bse
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ion
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me
%o
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bse
rvat
ion
sat
Nig
ht
New
Har
mFr
eeca
re-
fro
m
Safe
tyTh
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om
eter
aud
it
Tren
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SIR
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d
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tco
me:
Nu
mb
ero
fFa
lls
NO
HA
RM
Tren
d
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tco
me:
Nu
mb
ero
fFa
lls
resu
ltin
gin
MO
DER
ATE
and
AB
OV
EH
AR
M
Ou
tco
me:
No
of
Ho
spit
al
Acq
uir
ed P
U ≥
gra
de
2
Tren
d
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tco
me:
Nu
mb
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gra
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d
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Han
dH
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me:
No
of
Cat
het
ers
1-2
8
Day
s-
fro
mSa
fety
Ther
mo
met
er
aud
it
Ou
tco
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New
CA
UTI
(ho
spit
al
acq
uir
ed)
-fr
om
Safe
ty
ther
mo
met
erau
dit
QEW
SLe
vel
CMR
Crude Mortality Data Divisional
report. The data displayed will
be in the following descending
order
1. Actual Number of Deaths
2. Total Discharges All
3. Mortality Rate AllSep-1
7
AuditNursing
Workforce
VitalPAC
obs NHS Harm Falls Pressure Ulcers Infection ControlPatient Experience
AMU 1 3 16.2% 97.4% 31.5% 59.6% 32.6 60% 57.1% 81% 82% 26% 100% 1 1 0 3 24 100% 2 0 1
Med
icin
e&
Emer
gen
cySe
rvic
es
Aspen 0 0 44.8% 97.4% 31.1% 55.3% 70.5 87% 46.5% 74% 81% 24% 96% 1 1 1 0 1 100% 7 0 2
BACU 0 0 31.2% 94.1% 27.6% 54.3% 62.9 83% 50.0% 74% 94% 19% 100% 0 0 0 0 6 100% 1 0 2
Bradley Unit 0 0 0.0% NA NA NA NA NA 97.1% 99% NA NA 95% 0 0 0 0 0 86% 0 0 3
Cedar 1 1 15.5% 100.0% 41.3% 53.8% 66.1 80% 77.4% 84% 81% 24% 100% 1 1 1 0 0 100% 4 0 2 81
Cherry 1 1 5.9% 100.0% 41.3% 66.3% 67.0 85% 87.0% 98% 88% 18% 100% 0 3 0 0 0 100% 4 0 2
Holly 0 0 48.3% 100.0% 62.2% 74.3% 177.1 93% 86.1% 89% 92% 23% 100% 0 3 1 0 0 100% 4 0 2
May 0 0 36.6% 100.0% 35.9% 59.4% 116.7 87% 47.6% 82% 88% 24% 100% 1 2 0 1 0 100% 3 0 2 2592
Maple 0 0 NA NA 0.0% 0.0% 0.0 83% 91.9% NA 81% 0% NA 0 0 0 0 0 NA NA NA 3
Swift 0 4 25.5% 78.6% 29.0% 56.5% 154.5 92% 77.1% 96% 90% 23% 100% 0 5 0 0 3 100% 4 0 2 3.13%
Heron Annexe 0 0 NA NA 44.4% 74.1% 54.4 NA NA NA 91% 20% NA NA 0 0 0 0 0 NA NA NA 3
Wordsworth 0 0 4.2% 100.0% 57.7% 69.2% 442.5 72% 83.3% 91% 89% 5% 100% 0 0 0 0 0 100% 4 0 2
ED 2 4 1.3% 87.7% 56.2% 70.8% 17.9 83% 83.1% 82% NA NA 80% 0 2 0 0 150 97% 0 0 1
Endoscopy 1 2 2.5% 95.2% 66.7% 66.7% 2.9 96% 59.5% NA NA NA NA NA 0 1 0 0 0 100% NA NA 3
Dickens 0 1 40.7% 100.0% 35.2% 68.5% 61.1 85% 76.9% 63% 93% 18% 100% 0 2 0 0 0 100% 1 0 2 3
Swan 2 2 11.0% 81.8% 28.9% 43.3% 147.6 89% 69.2% 52% 86% 23% 94% 0 1 0 1 0 81% 5 0 1 438
0.68%
Kingfisher 0 1 28.4% 95.1% 39.4% 66.1% 66.4 82% 86.2% 42% 94% 22% 96% 0 3 0 1 0 100% 4 0 2
Falcon 0 1 33.1% 97.4% 32.8% 57.1% 86.7 98% 85.0% 98% 89% 24% 100% 0 2 0 0 0 100% 8 0 3
SDU & Wren 0 1 46.7% 92.9% 25.8% 51.6% 62.1 83% 41.7% 96% 95% 26% 100% 0 0 0 0 0 100% 2 0 3
Heron 0 0 52.7% 92.3% 38.9% 66.7% 69.3 94% 95.0% 74% 94% 20% 100% 0 0 0 0 4 100% 1 0 3 11
SAU 2 0 19.8% 100.0% 55.0% 72.1% 13.1 90% 89.3% 46% 92% 21% 100% 0 0 0 0 4 100% 2 0 2
Urology 0 1 1.0% 75.0% 0.0% 0.0% 2.5 NA 78.6% NA NA NA NA NA 0 0 0 0 0 94% NA NA 3
ITU 0 0 NA NA 44.4% 88.9% 56.7 88% 68.3% 29% NA NA 100% 0 1 0 1 3 100% 6 0 2 2140
DSU ASH 0 0 30.7% 95.8% 50.0% 100.0% 5.5 NA 83.8% NA NA NA NA NA 0 0 0 0 0 100% NA NA 3 0.51%
Theatres ASH 0 0 NA NA 0.0% 0.0% 3.6 NA 83.3% NA NA NA 100% 0 0 0 0 0 100% 0 0 3
Theatres SPH 0 0 NA NA 0.0% 0.0% 3.6 NA 62.8% NA NA NA 100% 0 0 0 0 0 100% 1 0 3
Oak 0 0 45.6% 97.3% 100.0% 100.0% 6.8 90% NA NA NA NA NA 0 0 0 0 0 100% NA NA 3
Ash 0 2 42.9% 95.6% 46.7% 63.2% 30.8 83% 98% NA NA 100% 0 1 0 0 0 100% 0 0 3 0
NICU 0 0 30.4% 100.0% 52.0% 76.0% 270.1 98% 92.7% 58% NA NA 100% 0 0 0 0 0 98% 0 0 3
Paeds ED 0 3 1.7% 76.7% 0.0% 0.0% 5.9 91% 81.3% NA NA NA NA NA 0 0 0 0 0 100% NA NA 2 1326
Labour Ward 0 2 48.0% 79.4% 50.0% 50.0% 13.2 82% 64% NA NA 100% 1 0 0 0 0 0% 3 0 2
Joan Booker 0 2 NA NA 43.0% 61.2% 39.8 88% 86% NA NA 100% 0 0 0 0 0 94% 8 0 3 0.00%
Green 93 - 100%
Yellow 82 - 92%
Amber 71 - 81%
Red ≤ 70%
Key: NA = Not applicable, NS = Non submission
Wo
men
's&
Ch
ildre
n
Actual No. of
Deaths
Actual No. of
DeathsTotal Discha rges
Al l
Mortal i ty Rate Al l
Actual No. of
Deaths
Total Discharges
Total Discharges
All
Mortality Rate All
RAYG ratings ED - Monthly 4 HR Percentile
Observa
tions at
night93.7%
Actual No. of
Deaths
Total Discharges
Mortality Rate All
Mortality Rate All
28/08-01/10/17
81.7%
78.6%
This month
Med
icin
e&
Emer
gen
cySe
rvic
esTh
eatr
es,A
nae
sth
etic
s,Su
rger
y
and
Cri
tica
lCar
eTO
DT
RAYG
ratings
QEWS VitalPAC
% of observations
on time
Appraisal target:
90%
Domains in
Clinical Practice
Workforce August
92.2%
The indicators highlighted in dark blue are the indicators used to calculate QEWS levels
Where data is marked NA, the indicator was not applicable e.g. ITU Friends & Family Test; where data is marked NS the data was not submitted
Note that Maple closed from 13/08/17 for 6 weeks
> 20%93 - 100%
85 - 92%
71 - 84%
≤ 70%
≥ 90%
15 - 20%
> 90%
85 - 90%
10 - 15%
≤10%
80 - 85%
≤ 80%
81 - 90
≤ 81%
No immediateaction required
Level 29 – 12 Greenindicators in
total
Review currentactions and
completecheckpoint plan
Level 15 – 8 Greenindicators in
total
Level 00 – 4 Green
indicators intotal
Action plan to be
formulated andreviewed in 1month
Immediateaction plan
Level 3
13 – 16Green
indicators in
29
Quality Priority Dashboard 2017-18
REF 2017/18 Quality Account Measure Q2 Quarter 2 Narrative
Priority 1 - Safety - Improving harm free care
1.1 Strengthen governance of medication errors and
learning from these by improving year on year
Medication Safety Thermometer performance.
The national Medication Safety Thermometer data is not available currently owing to supplier side factors.
No data can be reported for this measure.
1.2 Maternity Safety Thermometer performance to be
better than the national average.
Data is not currently available for this national tool as explained for measure 1.1.
1.3 Continue the Sign up to Safety falls trajectory with the
reduction of falls to be set to achieve a 50%
cumulative reduction by end of 2017/18 (Plan Year
3). Reduce falls by 102 per annum in 2017-18, with
no more than 319 total falls in 2017-18.
Total falls has risen 3.3% for the six months ended September 2017. This measure will almost certainly not
be achieved by year end as with 6 months left to achieve a full year's reduction falls in 6 months would need
to reduce more than 48% which is not sustainable.
1.4 Continue the Sign up to Safety hospital acquired
stage 2 and above pressure ulcer reduction trajectory
with the reduction to be set to achieve a 50%
cumulative reduction by end of 2017/18 (Plan Year
3). Reduce PU stage 2 and above hospital acquired
by 99.5 per annum in 2017-18, with no more than
140.5 total stage 2 and above hospital acquired PUs
in 2017-18.
To achieve the 3 yearly cumulative 50% reduction in total grade 2 and above hospital acquired PUs by
March 2018 a reduction of 140 ulcers (41%) is needed this year, an average reduction of 11.6 ulcers per
month. Performance for the first 6 months is slightly below trajectory with a 32% reduction.
1.5 Risk assess 97% of adult inpatients for VTE on
admission.
July 99.15%, August 99.18% and September to be confirmed.
1.6 Root cause analysis (RCA) of 100% of identified
cases of hospital associated thrombus (HAT) in 2
months.
All diagnostic screening for Q2 is up to date; this is completed on a weekly basis with all HATs identified and
notified on the same day. In Q2 there were 26 HATs identified; of these 9 have had RCAs completed. Of
these HATs there are still 17 RCAs to be completed all of which are still within the 2 month time scales. All
RCAs for HATs identified in Q1 have had their RCAs completed.
1.7 Audited documentation of the prescription of
appropriate chemical thromboprophylaxis with the
aim of achieving 85%.
July 80%, August 80% and September to be confirmed. The review of the audit tool is still to be actioned. It
is expected to be reviewed during Q4 when the VTE Prevention Nurse Specialist returns to post. It is
important to note that this measure is looking at whether the prescription of chemical thromboprophylaxis is
appropriate according to the outcome of the risk assessment tool. It does not measure whether patients
have received thromboprophylaxis or whether thromboprophylaxis has been prescribed in general.
1.8 Work towards the national target limits for E. Coli
bacteraemia infection, with trajectories to reduce
these in 2017.
The target of 243 applies to all E.coli bacteraemias, most of which are community cases. To date there
have been 138 and we are 17 over the target trajectory. A Surrey-wide workshop to discuss E.coli
infections agreed focus around risk factors would be key as most patients have not seen a GP and are
admitted from their own homes. Work around infection control practices and catheter care within the
hospital continues.
1.9 Trustwide rollout of the National Aseptic Non Touch
Technique (ANTT) protocol as part of the overall drive
to reduce hospital acquired infection and thus length
of stay.
There have been 2 aseptic non touch technique (ANTT) implementation meetings with relevant clinical
individuals. Resources have been reviewed and a “train the trainer” process agreed for implementation.
There is a National ANTT conference in November and it is hoped funding can be secured to send key
leads.
6. Quarterly Quality Account 2017/18 Priorities and Business Plan 2017/18 Quality Measures Dashboard
Quality Account Q2 Priorities Update
30
Priority 2 - Caring for patients in a safe way,
without delay
2.1 Implement a process to improve early diagnosis of
cancer through sharing upfront learning with clinical
teams quarterly as new claims arise (with focus on
missed/delayed diagnosis).
Owing to capacity gaps in the Claims and Coroners' Team this measure has not progressed.
2.2 Increase completion rates and improvement
opportunities for learning from mortality reviews
within the Clinical Divisions, in line with national
guidance documents. Target to be set in Q2 once
guidance has been assimilated, with improvement
trajectory for achievement by Q4.
A programme to implement national framework for Learning from Deaths is progressing. A key meeting of
the Mortality Committee is on 20 October 2017 at which the Terms of Reference for this programme will be
reviewed. The target is yet to be set therefore and the measure is amber rated because completion rates in
the year to date (albeit under the soon to be superceded methodology) are not sustainably increasing.
Priority 3 - Safety standards and our clinical
workforce
3.1 Progress the Reducing Variation Programme
including participating in the external data collection
exercise. This programme will continue throughout
2017/18.
This programme is progressing and on track.
3.2 Formulate a Clinical Workforce Strategy and develop
demand/capacity modelling for the medical workforce
by Q4.
A review into this measure will be undertaken in Q3 and the measure rated then.
3.3 Commence a nursing associate test pilot in
conjunction with Health Education England and the
Nursing Associate Implementation Programme.
The pilot continues and we remain a lead member of the consortium. The students are now entering their
second placements and have been regularly reviewed by the university.
3.4 Communication campaign to promote staff
awareness of the Freedom to Speak up Guardian
(FTSUG) role by Q2.
An awareness campaign continues with a freedom to speak up question bow being monitored in wards who
are piloting the Perfect Ward App audit and quality improvement tool. All ward areas included in the pilot are
now aware of the FTSUG. The plan is to write a business case to seek to purchase the Perfect Ward App
and test awareness on an ongoing basis in a wider group of wards.
Priority 4 - Clinical effectiveness: work to
improve diagnosis for patients with diabetes
4.1 The population of eligible admitted patients to be
screened for diabetes will continue to be audited on a
spot day each month, with target performance to be
set at 98% which is consistent with the target set
from 2014/15 onwards.
The percentage of patients undergoing capillary blood glucose testing within 24 hours of admission was
93% in Q2 and is the same result as Q1. This measure has not been achieving the target for some time
despite various improvement initiatives.
Priority 5 - Clinical effectiveness: improve
dissemination and learning
5.1 Implementation of relevant NICE Clinical Guidelines –
monthly status report on progress including a gap
analysis with reasons for non-compliance identified.
Updates to the Formulary for NICE guidance July and August are pending. There has been reduced
Pharmacy resource and recruitment is underway. Responses from clinicians have been delayed due to the
recent holiday season. Similarly, there have been some delays within divisions to update their NICE
guidance monitoring plans.
5.2 Set up an extranet site to share learning openly to
both staff and the wider public learning from a range
of areas including external reviews, audits, serious
incidents and complaints.
This measure has not been addressed but will be prioritised in Q3 to retrieve this slippage.
5.3 Participate in all applicable mandatory national audits
and implement action plans based on key
recommendations from the national bodies.
Recent review at CENARG included recommendations from NCEPOD studies on tracheostomy care and
non-invasive ventilation. Members discussed plans for closer working with Quality Improvement to support
implementation of recommendations from national reports. It was acknowledged that there might be
supportable reasons for not participating in some of the mandatory audits.
31
Priority 6 - Patient experience: work to
improve the experience of vulnerable groups
6.1 Feasibility test and develop specialty volunteers to
support named areas, with first pilot in dementia.
Four new volunteers have been recruited and are now supporting the wards. Their experience as dementia
volunteers is being monitored. Recruitment continues.
6.2 Either adopt or locally adapt the principles of the
NHS England Quality Checkers Programme for
Patients with Learning Disability and Autism.
This work programme is not yet believed to be implemented.
Priority 7 - Promote patient empowerment
7.1 Pilot a patient awareness empowerment initiative as
part of planned care pre-admission to promote,
where appropriate, patient ‘self care’ and encourage
challenging poor care.
The Patient Panel have discussed this and would like to be involved further when work commences.
7.2 Develop in-house a Trustwide #InvolveMe
programme encompassing involving patients in
planning their care incorporating service level
consideration of patient equality characteristics.
Whilst this programme is not yet underway this will be commenced as priority in the next quarter.
Priority 8 - Improve patient experience
8.1 Continue to develop a means of communicating to
inpatients the potential for transfers between wards
as part of their expected care pathway and
implement this communication process by Q2.
The status of this measure has not been established.
8.2 Further embed Always Events by introducing 2 new
always events covering the areas of (1) medications
safety and (2) patient involvement (including shared
decision making) and understanding of care planning.
Hope Parents and the Carers Group attended Always Event Training with NHS England. The CCG
Partnership Manager has pledged support for an Always Event with Young Carers. With current capacity it
will be very challenging now to implement 2 new programmes by year end hence this is red rated.
8.3 A minimum of 95% of patients in the Urgent Care
Centre to achieve the 4 hour wait target.
The 95% target was achieved in Q2.
Priority 9 - opportunities for patient
involvement in research
9.1 Continue to meet the Department of Health
requirements to increase our recruitment of patients
to clinical research studies by 20% year on year.
Updates on this measure are yet to be obtained.
9.2 Enhance Trustwide communication to staff
promoting research publications and studies, to
include signposting to the Knowledge and Research
Hub.
Whilst updates on this measure are yet to be obtained there is opportunity to achieve this objective by year
end so it is green rated.
Priority 10 - Transformational cross-
boundary working
10.1 Actively participate in the Surrey Heartlands
Sustainability and Transformation Programme (STP).
Specific objectives to be set 6 monthly as the STP
progresses.
The Trust continues to be an active participant in Surrey Heartlands Sustainability and Transformation
Programme (STP). The Executive Director attend the Transformation Programme Board and recently took
part in the STP three day leadership event. ASPH provides three strategy leads to the STP work
programme and one clinical lead. Progress on specific workstreams is reviewed regularly at the
Transformation Programme Board.
32
REF Business Plan Measure Quarter 2 Narrative
1 Actively participate in the Surrey Heartlands
Sustainability and Transformation Programme (STP).
specific objectives to be set 6 monthly as STP
progresses
Achieved as outlined in measure 10.1 above.
2 Further embed Aways Events by introducing 2 new
always events covering the areas of (1) medications
safety and (2) patient involvement (including shared
decision making) and understanding of care planning.
This is red rated as described in measure 8.2 above.
3 Continue Adopt a Grandparent programme with
rollout to selected new wards in 2017/18. Measure
impact via feedback from service users.
There has been slippage, however, promotional activity with staff is planned for October and November to
mitigate.
4 Develop an in-house Commitment to Carers patient
engagement and information programme.
Planned rollout via a task and finish group lead by the Deputy Chief Nurse continues. A Carers Lead
continues to build working relationships with clinical staff.
5 Clinical strategy rollout emphasising working
practices and behaviours by clinicians which
promote our philosophy of care.
This measure will be reviewed in Q3 so is not currently rag rated.
6 Continue iWant Great Care rollout of clinician level
data; uptake and impact assessment mechanism to
be developed to guide improvement action plan.
Clinician Review information is now included in corporate induction linking to appraisal and revalidation.
7 Continue to meet the Department of Health
requirements to increase our recruitment of patients
to clinical research studies by 20% year on year.
As per measure 9.1 above this measure's performance requires determination.
8 Refresh Quality, Safety, and Risk Management
Strategy and supporting strategies where applicable
(e.g., Patient Experience Strategy).
Paused whilst the review of Trust strategy is undertaken. This measure is anticipated to be achieved by
year end so is green rated. Patient Experience Strategy will be outlined within the Trust Strategy and action
plans will be developed from that.
9 Formulate Clinical Workforce Strategy with demand /
capacity modelling for the medical workforce.
Not yet rated see measure 3.2 above.
10 Adapt the principles of the NHS England Open and
Honest Care Driving Improvements Programme
(OHCP) to share key elements of monthly Quality
Report or other applicable safety, experience, and
effectiveness information more widely among staff
and the public.
This measure has slipped but will be progressed by the end of Q4.
11 Either adopt or locally adapt the principles of the NHS
England Quality Checkers Programme for Patients
with Learning Disability and Autism.
This work programme is not yet believed to be implemented.
12 Develop in-house Trustwide #InvolveMe programme
encompassing involving patients in planning their
care incorporating service level consideration of
patient equality characteristics.
Whilst this programme is not yet underway this will be commenced as priority in the next quarter.
Business Plan Quality Q2 Priorities Update
33
13 Feasibility test and develop specialty volunteers to
support named areas, with first pilot in dementia.
Four new volunteers have been recruited and are now supporting the wards. Their experience as dementia
volunteers is being monitored. Recruitment continues.
14 Pilot a patient awareness empowerment initiative as
part of planned care pre-admission to promote,
where appropriate, patient ‘self care’ and encourage
challenging poor care.
The Patient Panel have discussed this and would like to be involved further when work commences.
15 Develop a long term integrated Chaplaincy strategy
with Royal Surrey County Hospital based on the
model of a Spiritual Health and Wellbeing Centre.
There has been no further work/discussion with Royal Surrey County Hospital on an Integrated Chaplaincy
Strategy. The Lead Chaplain’s priority has been to build up and develop the Chaplaincy department in-
house.
16 Improve early diagnosis of cancer through sharing
upfront learning with clinical teams quarterly as new
claims arise (with focus on missed/delayed
diagnosis).
Owing to capacity gaps in the Claims and Coroners' Team this measure has not progressed.
17 Build on the work of the Mortality Review Group to
increase completion rates and improvement
opportunities regarding learning from mortality
reviews within the Clinical Divisions.
Completion rates under the soon to be superceded methodology have not sustainably improved by end Q2.
Going forward this work will be progressed with oversight by a new committee to monitor mortality under the
Learning from Deaths national programme.
18 Work towards the national target limits for E. coli
bacteraemia infection, with trajectories to reduce
these in 2017/18.
Not achieving target see measure 1.8 above.
19 Trustwide rollout of the National Aseptic Non Touch
Technique (ANTT) protocol as part of the overall drive
to reduce hospital acquired infection and thus length
of stay.
Amber rated as explained in measure 1.9 above.
20 Refresh Sign up to Safety Plan Year 3 – falls
trajectory to determine a revised target reduction of
falls in 2017/18.
Total falls has risen 3.3% for the six months ended September 2017. This measure will almost certainly not
be achieved by year end as with 6 months left to achieve a full year's reduction falls in 6 months would need
to reduce more than 48% which is not sustainable.
21 Refresh Sign up to Safety Plan Year 3 – stage 2 (and
above hospital acquired) pressure ulcers trajectory to
determine a revised target reduction of stage 2
pressure ulcers in 2017/18.
To achieve the 3 yearly cumulative 50% reduction in total grade 2 and above hospital acquired PUs by
March 2018 a reduction of 140 ulcers (41%) is needed this year, an average reduction of 11.6 ulcers per
month. Performance for the first 6 months is slightly below trajectory with a 32% reduction.
22 Set up an extranet site to share learning openly to
both staff and the wider public learning from a range
of areas including external reviews, audits, serious
incidents and complaints.
This measure has not been addressed but will be prioritised in Q3 to retrieve this slippage.
23 Commence a nursing associate test pilot in
conjunction with Health Education England(HEE) and
the Nursing Associate Implementation Programme.
The pilot continues and the Trust remains a lead member of the consortium. The students are now
entering their second placements and have been regularly reviewed by the participating university.
34
24 Explore learning and training opportunities such as
through the apprenticeship scheme.
The Apprenticeship Scheme for clinical staff is developing. We have now looked at the training courses
available and the bidding process to commence these. The Trust is continuing to looking at a model to
recruit HCAs into 18 month training posts.
25 Rollout multiprofessional integrated Education
Strategy for all staff.
No update received.
26 Develop additional training courses or events with a
view to both improving our staff’s development
opportunities whilst simultaneously promoting the
Trust and gaining revenue from external attendees.
This measure has slipped owing to lack of capacity in the Corporate Quality Team to progress this.
27 Quality Department learning needs analysis and
training programme formulation.
This is pending development.
28 Communication campaign to promote staff
awareness of the Freedom to Speak up Guardian
role.
Ongoing and on track as per measure 3.4 above.
29 Expand use of a variety of quality improvement tools
(such as run charts) thereby improving or expanding
data presentation to improve the quality of care.
Ongoing with review pending from wards and departments. IHI have also fed-back on this and and our ward
based audits were considered favourable.
30 Develop a personalised solution to providing relatives
with patients’ personal possessions following a
bereavement.
There have been no further developments this quarter. There are plans to review Bereavement Office
Operational Policy and engage directly with Clinical Nurse Leaders.
31 Enhance Trustwide communication to staff
promoting research publications and studies, to
include signposting to the Knowledge and Research
Hub.
Whilst updates on this measure are yet to be obtained there is opportunity to achieve this objective by year
end so it is green rated.
32 In November 2016 the CQC issued the results of its
review into its NHS National Patient Survey
Programme - 1 annual Inpatient Survey plus rolling 2
yearly surveys in Urgent and Emergency Care,
Maternity, and Children and Young People.
Implement new survey regime as per national
timescales when released.
The National Patient Surveys have been implemented according to timescales, including the inpatient
surveys. Data for the cancer survey is also now supplied.
33 Strengthen governance of medication errors and
learning from these; improve year on year Medication
Safety Thermometer performance.
The national Medication Safety Thermometer data is not available currently owing to supplier side factors.
No data can be reported for this measure.
35
36
Abbreviations
CENARG Clinical Effectiveness and National Audit Review Group (CENARG) which reports to Quality and Performance Committee
CHKS The external service contractor who provides the Trust with statistical information including mortality data.
CCG Clinical Commissioning Group
CQC Care Quality Commission
DTTO Division of Diagnostics, Therapies, Trauma, and Orthopaedics
ED / A&E Accident and Emergency Department
DNACPR Do Not Attempt Cardio-pulmonary Resuscitation
FFT Friends and Family Test
KPI Key Performance Indicators
PU Pressure ulcer
MES Division of Medicine and Emergency Services
MRSA Meticillin Resistant Staphlococcus Aureus
NCEPOD National confidential enquiries into patient outcomes and deaths – targeted audits into cases in national priority areas.
QPC Quality and Performance Committee
RAMI Risk adjusted mortality index
SD Standard deviation(s)
SALT Speech and language therapy
37
SHMI Summary hospital-level mortality indicator
SIRI / SI Serious incident requiring investigation
STEMI ST elevation myocardial infarction (heart attack)
TASCC Division of Theatres, Anaesthetics, Surgery and Critical Care
VTE Venous thromboembolism
WH&P Division of Women’s Health and Paediatrics
YTD Year to date
