0 West Suffolk Hospital NHS Trust Report To:Trust Board Date: March 2012 Title:Quality Report Report of:Nichole Day, Executive Chief Nurse

1 Introduction This Quality Report provides the narrative for performance in three key areas: Quality priorities, CQUIN performance and local issues requiring escalation. It should be read in conjunction with the Ward and Trust 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.

2 Executive Summary There are a number of wards that have demonstrated exceptional performance during February particularly F3. The SIRI incidents look very high for February, this is due to individual occurrences of norovirus being identified on several individual wards that were then closed. They were reported externally as one SIRI. There were 9 Grade 2 hospital acquired pressure ulcers identified during February which is a high incidence rate, however 5 were attributed to end of life care. We have commenced a priority piece of work reviewing our slide sheet availability as lack of availability was identified as a theme from 2 avoidable pressure ulcers. The total number of falls in February was 42 which leaves us just above the CQUIN trajectory for month 2 in Q.4 (ceiling = 84 falls, current total = 86 falls). Reduction of falls remains a priority for clinical staff during March and the current incident count for March looks optimistic.

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 There were no cases of MRSA bacteraemia or MSSA bacteraemia during February. There was 1 case of clinically significant hospital acquired C. difficile during February (giving a total of 21 year to date). In respect of compliance with the High Impact Interventions (HII), all interventions scored 100% except peripheral cannula ongoing care (95%). This lower score is mainly attributed to F10 where some cannulae were not changed after 72hrs and G1 where documentation was an issue. An additional audit programme has been developed by the IPT and they will ensure that there is a renewed emphasis on compliance, including ensuring that there is a set time for the patient checks and a standard place where this information is documented. On the audit day, of the 32 side rooms available (capacity increased by 1 side room as F7 operating at 4 following refurbishment), 19 were used for infection prevention purposes and additionally there was 1 infectious patient in a side room on Critical Care. There were 4 high risk patients who should have been isolated and were not. These were patients who needed to stay within the specialty ward, and other side rooms on the ward contained patients with infections.

4 1. To further reduce hospital acquired infections Aim: To improve the management of antibiotics by achieving 100% compliance with antibiotic policy The compliance with the antibiotic prescribing policy was 97% in February. It was reported last month that a revised rolling programme of audits will be initiated this year. Therefore a rolling quarterly compliance graph is displayed but the historic data may not be completely accurate as the wards audited within a quarter may not be consistent. From April 2012 the new programme will have taken full effect.

5 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 Compliance with risk assessment was 98.16% for February. Prophylaxis data is reported quarterly and is due in April’s report.

6 The CQUIN ceiling is 126 falls in Quarter 4 and the payment associated with Quarter 4 is £41,250. The total number of falls in February was 42. This leaves a ceiling of 40 falls for March which we have placed a high priority on achieving. The benchmarking data provided in last month’s report should read that 13 falls per week would be average for a Trust this size. We are currently reporting approximately 10 falls per week. The falls in February occurred in 19 confused patients, 5 patients who refused all help in mobilising, 7 independent patients and 7 patients who had a sudden onset of dizziness/ condition deteriorated. To demonstrate the types of falls, examples are provided below: Independent patients who fell: Gentleman on EAU spilt a little tea on the floor, tried to mop it up himself and slipped in the tea. Lady with plaster cast on her leg, decided not to put a slipper on the affected leg to dash to the toilet, slipped over. Confused patients Gentleman on G5 got up and fell. He was unsupervised as staff were responding to an emergency buzzer. Gentleman isolated in side room because of Clostridium difficile fell out of bed while unsupervised. The cohort unit was closed and he was isolated in a ward side room with the door closed. 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 Sudden deterioration Independent patient, stood, felt dizzy and fell. Independent patient, in toilet alone, her blood pressure dropped when she stood up and she fell. Actions Pharmacy to audit the medication review process. They currently identify “offending medications” but we have no data re: whether the medications are reviewed by medical staff. Sub-group to consider standing and lying blood pressure guidelines. The pilot to provide patients with non-slip anti-embolus stockings is being commenced. Environmental assessments are to be carried out on the ward toilets to identify any modifications that could be made to mitigate falls.

No patients developed a Grade 3/4 hospital acquired pressure ulcer during February. 9 patients developed Grade 2 hospital acquired pressure ulcers this month: A 102 yr old patient with a # shoulder who was on the Liverpool Care Pathway developed a Grade 2 sacral ulcer. This was considered unavoidable as the patient had all equipment in place but did not want to be re-positioned. A patient on G1 developed a Grade 2 pressure ulcer. He was also on the Liverpool Care Pathway and the pressure ulcer was unavoidable. A patient on G4 developed Grade 2 heel and sacral ulcers. Although all care was in place, the pressure ulcers appear to have resulted from friction which have been attributed to poor manual handling techniques. We therefore consider these patient’s ulcers to be avoidable. A patient on F5 developed a Grade 2 Kennedy pressure ulcer (a pre-cursor to end of life). This was unavoidable. Two patients on G8 developed Grade 2 pressure ulcers from friction. One appeared to be due to manual handling technique and was considered avoidable. One was due to the patient’s constant agitation in bed and was considered unavoidable. Three patients developed Grade 2 pressure ulcers on F7 during February. One patient was on the Liverpool Care Pathway and one patient had bone metastases and refused to be repositioned due to the pain or have an alternating pressure mattress. These were both considered unavoidable. One patient developed a Grade 2 pressure ulcer which we considered to be avoidable. Although she had everything in place when reviewed, there was a delay in acquiring the repose cushion, which could have led to the development of the ulcer. Actions 2 avoidable pressure ulcers were attributed to manual handling technique. On investigation, there is a problem with the supply of slide sheets which is causing considerable problems for nursing staff. This has been escalated to the manual handling advisor, estates and facilities manager and will be discussed at the pressure ulcer prevention group. We are reviewing some parafrictor products which may prevent pressure ulcer damage from friction caused by continuous patient movement in the future. The CQUIN target is to have no more than 2 hospital-acquired Grade 3/4 pressure ulcers in each of Quarters 1,2 and 3 and 1 hospital-acquired Grade 3/4 pressure ulcer in Quarter 4 with a quarterly payment of £41,250. We have met all these CQUIN quarterly targets so far and are confident in achieving Quarter 4. We now aim to eradicate avoidable Grade 2 pressure ulcers. 7 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

8 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. Survey results SurveyOverall satisfaction Recommender question Inpatients9099 Outpatients94 Short stay97100 A&E97100 Overall percentage scores for the surveys for February are provided in the table (left). As can be seen from the graph below, the issue that impacts on the overall experience score for Outpatients is the question relating to information provided about delays and the score has reduced over the last 2 months. A group is being convened to identify the best way to address this as in some outpatients areas, the reception where the patient books in may not be aware of delays, due to the separation of the areas. 169 inpatient survey responses were obtained during February. This needs to be increased if we are to achieve feedback from 10% of inpatients. The wards with low numbers of responses are being targeted to ensure that numbers are increased. Already in March, the numbers have dramatically increased on the two surgical wards with low response rates.

9 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 Survey results The inpatient survey results show slight variation from month to month on most of the high scoring aspects of care. There has been a small increase month on month in respect of doctors and nurses not talking in front of patients. Awareness of this issue has been heightened with both doctors and nurses. Nurses have been carrying out a review of handover as part of the Productive Ward initiative and it is felt that this will have a significant impact when it is fully implemented. Several of the wards were impacted during February by sub-optimal staffing levels due to norovirus and this may explain the slight dip this month in issues such as timely response to call bells and patient being able to find someone to talk to about their worries and fears.

10 Environment and Cleanliness All wards achieved over 85% except Recovery (82%), A&E (84%) and F7 (84%). F7 score was comprised of 82% cleaning, 85% estates and 89.4% nursing. Theatre’s score was comprised of 86% cleaning, 69% estates and 75% nursing. A&E’s score was comprised of 89% cleaning, 73% estates and 63% nursing. The low nursing score related to several things including dust on the nurse’s station and tape on walls. The nursing score has improved to 90% in the March maximiser assessment. 3c) To continuously improve the experience of patients using our services

11 Aim: To consistently achieve a Hospital Standardised Mortality Ratio that is below the expected rate HSMR remains 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 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 Apr 10- May 11 May 10- June 11 June 10- July 11 July 10- Aug 11 Aug 10- Sep 11 Sep 10-Oct 11 Oct 10- Nov 11 Nov 10- Dec 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

12 Patient surveys G5 had very low scores for their patient experience surveys this month which was immediately considered during an emergency senior nurse meeting. The following actions have been taken: Enforce compliance with trust policy on nurse handover to ensure patients are involved in their care and do not feel that staff are talking in front of them. Reinforce standards of behaviour regarding professional discussion in front of patients. Proactively seeking real-time patient experience feedback by asking patients and visitors daily about their experience, introduction of real-time patient experience feedback cards for patients and visitors to use and monitoring of responses with feedback displayed for staff, patients and visitors to see. Recruit into vacant posts: 3.4 wte RN posts. The results of the survey will also be shared with the medical staff and cleaning staff as some of the responses are directly attributed to them. Wards The majority of emergency clinical areas have had high sickness rates during February (6-12%) which has undoubtedly had an impact on the quality of care delivered in some areas, G1 in particular has had a number of senior nursing staff absent during February and senior medical matron cover has been implemented to ensure quality standards are maintained. Nutrition Several wards had lower than normal nutritional audit scores. This was mainly due to a lack of regular weighing of patients. Staff have been asked to ensure that there is a system for completing weights weekly. An issue with availability of functional scales has been identified and new scales ordered. Local issues requiring escalation

Local Priorities - Governance Dashboard 13 IndicatorPerformance targetRAGFeb12Commentary National safety alerts Number of NPSA alerts beyond national implementation deadline >= Two NPSA alerts remain overdue and on the Risk register: PSG/2007/001 Medicines reconciliation and SPN/2008/014Right Patient Right Blood Timely completion of Red incident investigations and action RCAs (non SIRI) completed more than 45 days after incident reported >= (Trimethoprin) and /155040/ both delayed due to clinical availability of staff. Actions beyond deadline for completion >= Timely reporting of SIRIs to NHS Suffolk SIRIs 2 day report beyond timeframe >=10 0The 4 SIRIs reported in February all had the relevant reports submitted within the required timescale. SIRIs 7 day report beyond timeframe >=10 0 SIRIs 45 day reports beyond timeframe >=10 0The 1 SIRI 45-day report due in February was submitted within the agreed timescales Risk assessments Active risk assessments in date <75%75 – 94%>=95% 95% Outstanding actions in date <75%75 – 94%>=95% 96% NICETA (Technology appraisal) business case beyond agreed deadline timeframe > TA Business case process was discussed in depth at NICE Coordination Group. Issue is a combination of the increasing levels of information requested by the PCT for each case which delays date to CPG and trust process. Several actions identified. 1. Maintain extra 7.5hr pharmacy time. 2,Utilise the Directorate Performance Meetings to notify new TA cases needed and outstanding cases, allocate actions from the meeting to the relevant staff. This should cut down the time before submission to D&T then CPG. 3.Take out baseline assessment process for TAs and go straight to business case. 4. Working with PCT to review business case template to reduce to 2 sides, should be agreed by the end of Feb. Discussed at Clinical Safety & Effectiveness group on 9 th March. 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% 97% in Quarter 3 Complaints Response within 25 days or negotiated timescale with the complainant <75%75 – 89%>=90% 96% Number of second letters received >= Health Service Referrals accepted by Ombudsmen >=210 0 Red complaints actions beyond deadline for completion >= Number of PALS contacts that became formal complaints > <=5 7

14 Local Priorities Care Quality Commission (CQC) Quality & Risk Profile Background The CQC publish a monthly Quality & Risk Profile (QRP) outlining the external sources of data which can be used to assess a Trust’s level of compliance using a statistical assessment to identify if a Trust’s performance is Much worse than expected; Worse than expected; Tending towards worse than expected; Similar to expected; Tending towards better than expected; Better than expected or Much better than expected. The expectation is that each Trust will study this QRP and use it to provide evidence of compliance and/or act upon those areas highlighted as below expected. In addition, this report contains Negative Comments or Positive Comments taken from local engagement, external inspectors’ reports and a range of other sources. The Operational Steering Group allocate actions to individuals to address the areas highlighted as a concern and monitor the completion of these actions and the Quality & Risk Committee review in details progress to address areas of concern. QRP issued February 2012 (Jan12 data) – new items in the Negative categories with narrative from Operational Steering Group ItemScore No. of items Narrative Comparison of observed to expected number of elective hip replacement admissions with an emergency readmission within 28 days of discharge [Dr Foster Intelligence, Hospital Guide 2011] Much worse than expected 1 This item has been flagged up by Dr Foster reports regularly. Review has identified that patients sent back into hospital with a suspected DVT were being “admitted” instead of being managed as “ward attenders”. This has followed up and future reports from Dr Foster will be monitored to ensure the issue has been successfully addressed. QRP issued February 2012 (Jan12 data) – new items in the Positive categories. There were also 17 items graded as “Similar to expected” ItemScore No. of items Multiple indicators [Dr Foster Intelligence, Hospital Guide 2011]Much better than expected5 Proportion of unplanned re-attendance at A&E within 7 days of original attendance AUG 2011 [Information Centre for Health & Social Care, Accident and Emergency Clinical Quality Indicators] Much better than expected1 Proportion of alerts acknowledged within deadline out of total number of alerts issued to the organisation. (Report 2) JAN-DEC 2011 [Medicines and Healthcare products Regulatory Agency (MHRA), Central Alerting System] Better than expected1 Multiple indicators [Information Centre for Health & Social Care, Accident and Emergency Clinical Quality Indicators]Tending towards better than expected3 The proportion of unjustified mixed sex accommodation breaches DEC 2011 [Department of Health, Eliminating Mixed Sex Accommodation] Tending towards better than expected1 Proportion of alerts completed out of total number of alerts issued and due for completion within the time-period AUG 2009 – JAN 2012 [Medicines and Healthcare products Regulatory Agency (MHRA), Central Alerting System] Tending towards better than expected1

Local Priorities Patient Safety Incidents (PSIs) resulting in harm (including Serious harm), Serious Incidents requiring investigation (SIRIs) and reporting PSIs to the National Reporting and Learning Service (NRLS) There were 220 patient safety incidents reported in February of which 91 resulted in harm. The number of serious incidents in February was 9 and there were 4 SIRIs reported: Norovirus outbreak (multiple outbreaks reported as one combined SIRI); compliance with cardiac arrest policy (1); failure to follow neutropenic sepsis policy (1) and fall resulting in fractured clavicle (1). The 9 serious incidents in February were: Norovirus outbreaks (6 reported as one SIRI in February); fall resulting in fractured clavicle (1 reported as SIRI in February); deteriorating patient (1 reported as SIRI in March) and one awaiting confirmation of grade.  The top graph shows how many harm incidents have been reported in total, how many were serious harm and how many were reported as a SIRI by month over the last 12 months. The number of SIRIs do not directly correlate to the number of serious harm in the same month because some SIRIs did not cause actual major harm (eg a breach of confidentiality) or the SIRI was not reported until the following month.  The bottom graph shows all incidents (including near miss and no harm) reported to the NRLS against a benchmark of the median Trust for incidents per 100 admissions in the small acute Trust category (6.2 based on the Oct 10 – Mar 11 dataset). The second (red) line on the bottom graph shows what percentage of the incidents reported in total are categorised as serious (Red: actual major/catastrophic harm). This showed a marked increase in February as a consequence of a slight reduction in the total number of incidents reported and an increase in the serious harm incidents reported in the month mainly due to the 6 instances of Norovirus outbreak.

16 Local Priorities Complaints Complaint response within agreed timescale with the complainant: 96% of responses due in February were responded to within the agreed timescale (target 90). Of the 21 complaints received in February, the breakdown by Primary Directorate is as follows: Medical (9), Surgical (9), Clinical Support (1), Women & Child Health (2) and Facilities (0). Trust-wide the most common problem areas are as follows: - Communication 9 - Admission, Discharge & Transfer 7 - Attitude of Staff6 - Patients Privacy & Dignity6 This breakdown reflects an expected distribution across the categories. (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). The data in the graph above demonstrates that there has been an increase in the number of complaints received in 2011/12 compared to 2010/11. Themes from Red complaints All actions identified from Red complaints are currently within the deadlines for completion.

Local Priorities PALS (Patient Advice & Liaison Service) The revised PALS database is now functional and, together with prompt recording of contacts and enquiry details, accurate and meaningful information is now readily available. As previously reported, categories are being collated to correspond with the categories for formal complaints but additional information is being recorded on primary and secondary concerns. A comparison of the number of enquiries dealt with Communication, concerns about aspects of clinical treatment and general enquiries remain the most prominent reasons for contacting PALS. However, there are no trends identified for specific groups of staff, speciality or discipline. The PALS Manager continues to deal with requests for information which can vary from clarification of hospital procedure to specific details about treatment given, future care plans, outcome or length of time waiting for results of tests and discrepancies about diagnosis and/or discharge arrangements. A number of queries also relate to appointment dates and length of time waiting for these; the length of time waiting in clinics; and general enquiries about services not directly managed by West Suffolk Hospital. The PALS Manager frequently helps to improve communication between the Trust and patients’ family members both in this country and abroad. Any issues which are not able to be dealt with by PALS are directed, if appropriate, to the formal complaints process. The very nature of the PALS service requires responses to queries, concerns or complaints to be dealt with expediently. A Target of 80% for responding fully (completing the enquiry) within 48 hours has been set or within a timeframe agreed with the enquirer. This target is currently being monitored and evidence of compliance will be submitted in the new year, after three months data has been collected. Communication/Information (oral or written)21Other (relating to queries about other organisations11Attitude of staff8 All aspects of clinical treatment14Appointments (delays / cancellations)8 from Mar11 to Feb12 is given in the chart and a synopsis of enquiries received for the same period is given below. Trust-wide the most common five reasons for contacts are as follows: