0 West Suffolk Hospital NHS Trust Report To:Trust Board Date: July 2011 Title:Quality and Performance Report Report of:Nichole Day, Executive Chief Nurse; Dermot O’Riordan, Medical Director and Gwen Nuttall, Executive Chief Operating Officer

Introductionpage 2 Quality Sectionpages CQUINpage 10 Local Issuespages Local Prioritiespages Other Performance Commentarypages

2 Introduction This Quality Report provides the narrative for performance in the key areas of: Quality priorities, CQUIN performance and other performance issues requiring escalation. It should be read in conjunction with the Trust and Ward and dashboards. The layout of this report identifies performance data followed by themes identified during the analysis process and actions being taken. The ward quality report summary has been used to highlight wards that have a number of red scores and these are discussed within the report. We are exploring the potential value of early warning scores that might allow a more robust approach to escalation. The areas to highlight where we are doing well are: The number of patient falls have reduced for the quarter and the reduction seen last month has been maintained There have been no avoidable hospital acquired grade 3 or 4 pressure ulcers this quarter The number of patients referred to the smoking cessation service have increased dramatically A& E performance continues to improve Stroke Performance has improved The areas where we need to improve are: Noise at night (despite an improvement this month) Review of nutritional supplements prior to discharge The actions we are taking are covered in the appropriate sections of the report.

3 1. To further reduce hospital acquired infections Aim: To reduce hospital acquired MRSA bacteraemia to no more than 2 cases and C. difficile infection to no more than 29 cases between April 2011 and April 2012 i ) There were no incidences of MRSA bacteraemia in the Trust during June. ii) There were 3 cases of hospital acquired C. difficile. All cases were categorised as unavoidable. No ‘new’ issues were identified. Action is focused on reinforcement of good practice following existing protocols where necessary. In respect of compliance with the High Impact Interventions (HII), all scored above 95% except peripheral cannula insertion (91%). This was due to failures in documenting cannula changes in one area and is being directly addressed with the individuals concerned. Aim: To improve the management of antibiotics by achieving 100% compliance with antibiotic policy. Qtr 1 target = 90% We have achieved 91.5% compliance for the first quarter of 2011/12, meeting the target.

4 CQUIN performance iii) RCA for all deep vein thromboses and pulmonary emboli occurring 72 hours after admission RCAs were carried out on all patients developing deep vein thrombosis or pulmonary embolism. iv) Patient Information leaflets A Standard Operating Practice has been developed to ensure that all patients are provided with a information leaflet on admission. 2a) To achieve the highest levels of patient safety Aims i) To assess at least 98% of admissions for risk of VTE ii) Provide prophylaxis to 100% patients at risk. Although compliance with risk assessment fell slightly this month it remained above the target for the quarter. VTE prophylaxis increased to 98% this month.

5 Patient Falls The CQUIN target is no more than 177 falls in Quarter 1 with further reductions in Quarters 2, 3 and 4. The total number of falls in June was 40; 7 of these falls were considered avoidable. 14 falls resulted in harm to patients none of which were classified as serious harm. Themes Several of the falls this month occurred in low risk patients who were independent but either overbalanced or over-reached. G4 and G5 had the highest number of falls but they also have the greatest number of patients at high risk of falling. Prevalence studies of patients at risk of pressure ulcers and falls during June indicated that 32 of the 34 patients were classified as at high risk on G4. All the falls occurred in patients with dementia or delirium and on a number of occasions, additional staff to cohort the patients were unavailable. Actions based on themes and actions agreed at previous Board presentation The Falls Group have incorporated an action into their work plan to ask GPs, to identify patients with dementia when they are referred by them for admission to hospital. An audit to monitor the number of patient moves at night with reasons for the move is being undertaken (RCA theme). The purchase of 10 additional low profile beds has been agreed. Ward staffing levels across the Trust have been reviewed, and adjustments are being recommended for Wards G4 and G5. This would decrease reliance on temporary staffing and allow closer observation of patients with confusion and dementia. 2b) To achieve the highest levels of patient safety Aim: To reduce the number of patients who fall in hospital by 35% in the last quarter of 2011/12

Pressure Ulcers 7 patients developed ward acquired pressure ulcers this month with no hospital acquired Grade 3/4 pressure ulcers reported. No ward had significantly high numbers, although unusually two pressure ulcers occurred on the critical care unit. So far to date we have had no avoidable hospital acquired grade 3 or 4 pressure ulcers. Themes from concise RCAs One of the pressure ulcers was felt to be avoidable as the patient had not had regular risk assessments, the remaining pressure ulcers were considered unavoidable. The pressure ulcers associated with critical care were in patients with multi-organ failure for whom all preventative measures had been put into place. Update on pressure ulcer action plan A number of actions from the pressure ulcer action plan have been completed. In particular: Patient pathway completed with associated documentation, to improve recording and RCA process Heel protectors and pressure relieving mattresses are being purchased for all A&E trolleys A camera has been purchased and the team trained in it’s use to ensure prompt photography The key remaining risk issues are: Provision of education and training to staff – a bid against CQUIN is needed to justify the appointment of an additional Tissue Viability resource Reducing the time taken for delivery of equipment to one hour. This is dependent on staffing and equipment availability (to be approached through a bid for CQUIN funding. 6 2c) To achieve the highest levels of patient safety Aim: To reduce the number of avoidable grade 3 and 4 pressure ulcers by 80% in the last quarter of 2011/12

7 3a/b) To continuously improve the experience of patients using our services Aims: At least 90% of patients would choose to use the hospital again. To achieve at least an 85% satisfaction rating in our internal patient experience surveys Data review Each ward’s data is reviewed at the Matron’s performance meeting and individual action plans set for any areas scoring red/amber. Any ward that has >3 red scores will be escalated through this report. Overall, Trust wide, 98% patients would choose to use the hospital again. Patient Satisfaction (Patient Experience Tracker) 98% of patients would choose to use the hospital again. Overall satisfaction was 93% (equal to last month). No themes emerged from the analysis. Patient Satisfaction (paper questionnaires) The overall result stayed at 89% but a small improvement was seen for the second month with regards to noise at night. A further analysis of noise at night is provided in the local issues section of this report.

8 Environment and Cleanliness Overall Trust score was 91%. Individual areas scoring below 90% were Ward G3 (88%) and Ward F12 (87%) Ward G3 improved their score slightly from 86% last month due to estates work on the flooring and some painting. However, major refurbishment work is required to address damaged plaster and decoration particularly in the bathrooms and showers. Ward F12: Housekeeping and nursing scored well within this audit, however, the ward has a number of environmental issues that would be addressed within a refurbishment programme. 3c) To continuously improve the experience of patients using our services

9 Aim: To consistently achieve a Hospital Standardised Mortality Ratio that is below the expected rate HSMR has fallen again this month and is well below the expected level as can be seen by the overall mortality shown in the graph and the table giving a mortality rate for the five Dr Foster - How Safe is Your Hospital indicators. This table provides information on relative risk, with red, blue and green traffic lighting. Blue indicates that the score is within the standard deviation. 4a) To achieve optimal clinical outcomes and effectiveness National Rate from last reporting period Apr 09-May 10 May 09-Jun 10 Jun 09-Jul 10 Jul 09-Aug 10 Aug 09-Sep 10 Sep 09-Oct 10 Oct 09- Nov 10 Nov 09-Dec 10 Dec 09-Jan 11 Jan 10-Feb 11 Feb 10-Mar 11 Mar 10-Apr 11 Rolling 12 Month HSMR-All Admissions Rolling 12 Month HSMR-Non Elective SMR Stroke (Acute Cerebrovascular Disease) SMR - Heart Attack (AMI) SMR - FNOF Mortality from Low Risk Conditions

10 Smoking cessation i) The target of achieving 250 referrals to smoking cessation was achieved through a focus on referrals, primarily of A&E attenders, during June. It is important that this focus continues and that all areas of the Trust contribute towards the referrals if the targets are to be achieved in future months, when the numbers of referrals required increase. ii)The Trust already has a number of Level 1 smoking cessation advisors able to deliver brief intervention training. Discussions have taken place with LiveWell regarding delivery of a training programme but definite dates for these have not been achieved at the date of this report. This has been raised as an issue with NHS Suffolk. Hydration A risk assessment tool to identify patients at risk of dehydration has been developed in line with the EoE Intelligent Fluid Bundle recommendations. This is being piloted on two wards and training initiated for staff, with the intention to roll out to the remaining wards during July. Baseline audits of risk assessment will be carried out in July and August. Nutrition For 2011/12 there are two CQUIN indicators for nutrition: risk assessment and monitoring of patients, and review of all patients on supplements prior to discharge. Despite introducing a more comprehensive audit for assessment and monitoring of patients, 100% was achieved this month in relation to the first indicator. In order to examine compliance with the review of supplements prior to discharge, all patients discharged with nutritional supplements were audited in June. Compliance was found to be 43%. A business case has been put forward to increase administrative resources within dietetics to free up dietetic time to undertake a review of all these patients. CQUIN : Other key performance indicators

11 Patient Experience Noise at Night Noise at night is an issue that remains a concern for the Trust as it is an area where despite a number of initiatives to reduce noise, it continues to produce low scores in the internal patient surveys and in the national survey. It was reported last month that the Matrons would be looking in depth at the issues surrounding noise at night. The issues identified below are a result of their discussions with patients and the observations made during an unannounced night visit carried out by the Head of Nursing Development. Many patients said that they expect a certain level of noise at night whilst in hospital and that it had been no greater than expected. Several said that they had been offered ear plugs but had refused them. However, they stated that if they were asked if they had ever been disturbed by noise at night they would probably answer yes. That aside the issues can be categorised into three groups: Noise from other patients ie confused patients causing a disturbance, shouting out, getting out of bed etc, other patients snoring, and patients being admitted during the night. Noise from equipment: IV pumps alarming, the bedpan macerator, telephones ringing, changing oxygen cylinders, noisy waste bins, drug trolleys, air mattresses. Staff: Doctor and staff bleeps and pagers going off. Some staff visiting the ward talking loudly however, ward staff generally speak quietly. Action The results will be reported in full to the Patient Experience Committee and actions identified to address the issues. However, immediate action has been taken to reduce noise from bleeps and pagers by putting laminated reminder cards on the ward entrance doors, asking staff to remember that patients are sleeping and that bleeps should be placed on the vibrate only setting. staff who visit all wards at night have been reminded of the need to speak quietly and have been asked to carry out an audit of patient transfers after 10pm including reasons for the move. Local issues requiring escalation

12 Ward dashboard (Full ward dashboard can be seen in Item 8b Monthly Performance Dashboard pages 7-13 entitled ‘Ward Analysis Quality Report June 2011’) Wards F9, G3 and G4 had 3 red indicators in respect of patient satisfaction. Ward F9 alerted in relation to noise at night, call bell response times and being told who to contact if worried after leaving hospital. A meeting has been held with the ward manager and these issues raised with her. As a result, increased monitoring of the issues will be undertaken by the Ward Manager and Matron. Issues of concern relating to ward G3 were, involvement in decisions about care and treatment, information about medication side effects, and being informed of who to contact if worried after leaving hospital. Emphasis will be placed on ensuring that patients are provided with discharge information leaflets prior to discharge. Ward G4 alerted in relation to call bell response times, noise at night and information on who to contact after leaving hospital. This was discussed at the action plan update meeting for G4. Particularly high numbers of patients with dementia or delirium were present on the ward during June, affecting noise at night and call bell response times. Reductions in the number of temporary staff used by the ward in June may also have had an impact on performance. In response to the issues identified in relation to information on discharge, the discharge team are working to develop a personalised discharge plan to take home for patients with ongoing needs. Local issues requiring escalation

13 Local Priorities - Governance Dashboard IndicatorPerformance targetRAGJune 11 Commentary National safety alerts Number of NPSA alerts beyond national implementation deadline >= Reviewed at Ops group on 11/07/11. Will be subject to detailed review in August and September Timely completion of Red incident investigations and action RCAs (non SIRI) completed more than 45 days after incident reported >=10 214/16 non-SIRI RCAs were undertaken within the required 45 working day period. 2/16 were not. For one a meeting took place within the required timeframe but identified the need for further information. The other incident relates to a medication error and the process for follow-up is being reviewed. Actions beyond deadline for completion >= Timely reporting of SIRIs to NHS Suffolk SIRIs 2 day report beyond timeframe >=10 0Both (2) SIRIs reported in June had the 2-day and 7-day reports submitted within the required timescale SIRIs 7 day report beyond timeframe >=10 0 SIRIs 45 day reports beyond timeframe >=10 0The three SIRI 45-day reports due in June were all submitted within the agreed timescales Risk assessmentsActive risk assessments in date <75%75 – 94%>=95% 98% Outstanding actions in date <75%75 – 94%>=95% 98% NICETA (Technology appraisal) business case beyond agreed deadline timeframe > Targeted meetings have been set up to include Pharmacy, Governance, Finance and NICE guidance leads to complete the remaining outstanding TA business cases. The Deputy Medical Director has stated that any cases still outstanding by the end of July will result in not being able to use the treatment specified. IPG (Interventional procedure guideline) baseline assessments beyond agreed deadline timeframe > CG (Clinical guideline) baseline assessments beyond agreed deadline timeframe > Clinical AuditTrust participation in relevant ongoing National audits (reported by Quarter) <75%75 – 89%>=90% 100% ComplaintsResponse within 25 days or negotiated timescale with the complainant <75%75 – 89%>=90% 96% Complaints resolved with first written response <75%75 – 84%>=85% 92% Number of PALS contacts that became formal complaints > <=5 3

14 Local Priorities Patient Safety Incidents resulting in harm (including Serious harm) and Serious Incidents requiring investigation (SIRIs) The overall rate of incidents resulting in harm has remained stable over the last quarter. The number of serious incidents fell slightly and the number of incidents reported as SIRIs also fell. One of June’s SIRIs relates to an incident that occurred in late May. NRLS analysis shows that WSH has a reporting rate of 4.72 per 100 admissions, which is at the lower end of reporting rates for our small acute peer group. In June there were 97 Patient Safety Incidents resulting in harm of which six were Serious harm (Major / Catastrophic). None of these six incidents were reported as SIRIs. They were in brief: Patient Deterioration (1), Delayed Diagnosis (2) and Intra-uterine Death (4). A new enhanced process for multidisciplinary clinical review of IUDs is due to begin in Maternity in July with an aim to provide a greater level of information to parents following the loss of their baby. There were 2 SIRIs reported in June. This included a Breach in Confidentiality (no actual harm to patient) and a Delayed Diagnosis which was an April incident. The Clinical Safety & Effectiveness Committee receive an aggregated analysis of incidents to ensure that themes from incident reporting are being effectively identified and addressed.

15 Local Priorities Complaints Complaints response within agreed timescale with the complainant: 96% of responses in June were responded to within the agreed timescale (target 90%). Of the 27 complaints received in June, the breakdown by Primary Directorate is as follows: Medical (11), Surgical (10), Clinical Support (2), Women & Child Health (3) and Facilities (1). This breakdown reflects an expected distribution across the directorates. There were a reduced number of complaints in A& in June Trustwide the top four problem areas are as follows: Communication & information11 Aspects of clinical care8 This breakdown reflects an expected distribution Attitude of staff4 across the categories.Admission, discharge & transfer arrangements2 (Please note that more than one category can be allocated to each complaint so the total number of problem areas does not correlate with the total number of complaints). All complaints received are reviewed by the Patient Experience Committee to ensure that effective action is being taken and emerging themes identified. Also Directorate / ward complaints are discussed at monthly Directorate meetings to identify actions required and actions taken.

16 Local Priorities PALS (Patient Advice & Liaison Service) The PALS database is currently being reviewed to enable more meaningful reports to be extracted. It is hoped the revised system will be available by September In the meantime, a synopsis of enquiries received during June 2011 are outlined below. The numbers recorded do not necessarily indicate the number of contacts or time spent on each individual issue raised. Of the 61 enquiries received in June, the breakdown by Primary Directorate is as follows: Medical (24), Surgical (26), Clinical Support (9), Women & Child Health (2). A breakdown at location level is as follows: MEDICAL A&E (2) Cardiology (4) Critical care (1) EAU (1) Gastroenterology (1) General Medicine (3) Haematology (1) Radiology (1) Rheumatology (2) Wards (5) Transport (1) Nursing care (2) SURGICAL Waiting list (1) Audiology (2) ENT (1) General Surgery (5) Orthopaedic (7) Urology (4) Discharge arrangements (2) Patient enquiry (1) DSU (1) Oncology (1) Plastic surgery (1) WOMEN AND CHILD HEALTH Information (2) CLINICAL SUPPORT Out-patient (1) Pharmacy (2) Radiology (2) Transport (3) Phlebotomy (1) Issues raised with the PALS Manager include: clarification of advice given for discharge arrangements and medication; queries about proposed treatment plan and care suggested; length of time waiting for an appointment or admission; help with cancelling or postponing admissions; length of time waiting for results; waiting time in clinics; request to deal with concerns about patient care on the ward; and assistance with general administrative queries/redirection to the correct department.

Commentary on Performance Metrics The following charts detail the performance for the key stroke and A&E metrics. Overall performance is good and improving, however there are still some area’s for improvement. There are robust action plans in place for each area that are monitored on a daily basis in order the ensure that performance continues to improve and that the actions are sustainable. The key area for A&E related to the new CQI’s and that of ambulance turnover. There is a detailed action plan in place to improve performance in this area, however key to this is the removal of medical expected patients from the A&E department, directly to the EAU. This piece of work is directly related to the new PMO project with regard to managing Discharge Planning in the organisation. Choose and book performance was red in June 8% slot availability instead of 5%. This was linked to consultant leave and availability in August. ( Slot availability is about slots in future weeks and months, hence August is an issue). Performance in July has improved to back below the target. Breast Feeding initiation rates are static just below the 80% target. The Midwives are having a concerted push to see if more new mothers will agree to commence breast feeding in order to achieve this standard Follow Up to New Ratio’s are monitored at a specialty level, there is further work required in ENT and Diabetes Workforce Performance Performance has been above target on: Sickness absence Turnover Disciplinary Investigations completed within 8 weeks It should be noted that: Recruitment timescales are below target. This is an agreed change following the introduction of a Vacancy Approval process An action plan is in place to ensure that all staff have an up to date Appraisal and PDP 17

Stroke Indicators 18

A&E Clinical Quality Indicators 19

A&E Clinical Quality Indicators 20