1. EFFECTIVE C difficile (over 65) Jul-Sep 15 MRSA bacteraemia Jul-Sep 15 MSSA bacteraemia Jul-Sep 15 For the 2 month period Nov-Dec 2015, there were 10,897 admissions to NHS Fife Hospitals. Of which 5,616 were unplanned, 1,694 planned and 3,587 day cases. In addition there were 19,143 new outpatient attendances and 43,845 reviews. REDUCE HARM Lower is better NHS Fife HealthCheck November-December 2015 Presented to NHS Fife Board on 23 rd February 2016 SAFE Lower is better Higher is better Lower is better Higher is better

2. Activity Total activity for the period November-December 2015 was 73,885. This included 10,987admissions to NHS Fife Hospitals, 19,143 new out-patient attendances and 43,845 reviews. Hospital Standardised Mortality Rate (HSMR) The long term trend in HSMR for NHS Scotland continues downwards with NHS Fife performance matching or exceeding this trend. Most recent data release cover period up to end Jun 2015. Weekly monitoring of crude mortality over 2015 identifies seasonal variability but not to a level where the median should be adjusted according to statistical controls. HSMR in the second quarter (Apr-Jun 2015) remained the same as the first quarter at 0.93. The next update for Jul-Sep 2015 is due for release on 16 th February 2016. 95% Harm Free Care Under the Scottish Patient Safety Programme the aim is to further improve the safety of people in Acute Adult Healthcare by ensuring that 95% of people are free from the following harms: CAUTI – The NHS Fife CAUTI Prevention, Insertion and Maintenance bundles have been developed for use across inpatient areas in both Acute and Community hospitals. Cardiac Arrests /Deteriorating Patient - The use of the Scottish Structured Response is embedded in practice and has actions in relation to patients with a FEWs score of 4+ discussed at the daily safety huddle. The Deteriorating Patient Short Life Working Group with support from relevant clinical teams has developed a Hospital Anticipatory Care Plan to support the appropriate care of deteriorating patients, and in particular offer specific guidance for patients who are not appropriate for cardio pulmonary resuscitation. The document had been approved for pilot in 2 clinical areas within VHK. In addition the VHK hospice is keen to pilot its applicability within this care setting also. Pressure Ulcers – A new national pressure ulcer grading tool was introduced in December 2015 across NHS Fife. Discussions held with the University of Dundee re Undergraduate training. The Cluster review process is embedded in practice and from January 2016 meetings will happen monthly to review incidents of major harm “real time” to improve opportunity for learning and clinical improvement. The introduction of the “Tissue Viability Times” to provide a forum for Fife wide communication in relation to pressure ulcer prevention and management, and shared learning /actions following cluster reviews. Leading Better Care event planned for January 2016 focussing on pressure ulcer prevention and management for nurses across NHS Fife. The “Be aware of pressure area care” poster was introduced across NHS Fie to illustrate the process of pressure ulcer risk assessment and appropriate action and management, identifying key learning points identified from cluster review meeting outcomes. Falls -A “Falls Call to Action” Update and Review took place on 11 th December. The Inpatient Falls Prevention Group delivered a revised Falls Pathway across the Organisation and a new Falls Toolkit was launched at this event. Going forward, any new change ideas relating to falls will be tested on Ward 15 as part of the Older People’s Collaborative, led by Dr Aylene Kelman. Inpatient wards across Fife should implement the toolkit in their respective areas. As part of the improvement work, ward 15 is testing a revised process measure to simplify recording. The staff are also improving learning opportunities for all of the staff by ensuring that the outcome of “falls investigations” are shared with staff. Incidents For the period November to December 2015 there were 1816 reported incidents affecting patients. Of these 54% (977/1816) were graded as no harm, 26% (476/1816) as minor harm, 15% (275/1816) as moderate harm, 5% (86/1816) as major harm and 0.1% (2/1816) as extreme harm. 8% (7/88) of those categorised as major/extreme have been commissioned for an internal Significant Adverse Events Review. These were categorised as: HAI (2); clinical (1); medication (controlled drugs) (1); medication (non-controlled drugs) (1); tissue viability (1); and patient fall (1) Readmissions Navigator from ISD is currently on hold while they develop the new NSS Discovery visualisation tool which is due to go live soon. Readmissions will be in the first phase of indicators. Indicators will drill from Board level data through Location/Consultant/CHP/GP Practice to the patient episodes contributing to a specific indicator. Our locally derived data shows normal variation month on month with a median of 11.6%. Complaints The formal definition of complaint is ‘an expression of dissatisfaction about an action or lack of action or standard of care provided’. In Fife our approach is to make direct contact with the individual raising the complaint or concern, to be clear about any issue and to distinguish how this is coded on the system. Our policy in Fife is to seriously consider all forms of feedback and to act on and learn from them. There were 53 formal complaints (with multiple issues) reported in November and December 2015.The 3 key themes from these formal complaints remain under the headings of clinical treatment, communication and staff attitude. Further analysis of the data around these themes has began. Your Care Experience In November 2015, 79% (69/87) patients from 13 patient areas at Victoria Hospital and Queen Margaret Hospital completed the “Your Care Experience”, a patient experience survey and rated their overall experience as the “best possible”. In December 2015, 89%(57/64) patients from 11 patient areas at Victoria Hospital and Queen Margaret Hospital rated their overall experience as the “best possible”. Responses have been gathered using iPad technology. We are working towards a 90% target that patients will rate their overall experience as positive. Comments received from patients included the following: “First class service since my phone call 3 weeks ago until day of discharge. Very appreciative of my care.” (Ward 10 - Nov) “I was moved from A/E to AU1 then AU2 and finally Ward 41. It has been very confusing as my consultant is from another ward. My condition is medical and I am in a surgical ward. The nursing care was good.” (Ward 41 – Nov)) “My only suggestion would be the time you wait for discharge drugs.” (Ward 54 – Nov) “The delay waiting on pharmacy is the only complaint.” (Ward 54 – Dec) “This is my first time in hospital. My experience from admission to discharge has been very good. It has been a really good experience.” (Ward 33 – Dec) The number of respondents and areas included in the sample from the “Your Care Experience” survey fluctuates every month. In addition, another mechanism to gather patient/carer experience feedback is through Patient Opinion which appears to be utilised well. Scottish Public Services Ombudsman (SPSO) The SPSO published one report during the quarter concerning the standard of care provided by mental health services in the Community and in Stratheden Hospital. The Ombudsman made a number of recommendations, all of which have been actioned to the satisfaction of the SPSO. The SPSO reached decisions on the following cases during the quarter: The SPSO considered a case about unreasonable care and treatment when a patient was being cared for by the Hospital at Home Team. In considering the case the SPSO recognised that the Board had identified failings in relation to processing a blood sample and apologised appropriately for the failing. Following the complaint the Service developed a Standing Operating Procedure for obtaining blood samples and actioning results which was viewed as acceptable by the SPSO advisor. The SPSO did not uphold a complaint about an avoidable delay by clinicians at the Victoria Hospital in diagnosing hypersensitivity to a medication used to treat urinary tract infections. The SPSO concurred with the Board’s view that the reaction to the medication was extremely rare and that the care and treatment provided was in accordance with appropriate clinical guidance. The SPSO did not uphold a complaint about inappropriately discharging a patient following gall bladder surgery and failing to provide appropriate treatment following a further referral from the GP. The SPSO did however make a recommendation in relation to the provision of information to patients at the point of discharge. As a result of this the Unit concerned is reviewing all written patient information leaflets. The SPSO upheld a complaint that staff at the Victoria Hospital failed to adequately monitor a patient following surgery and asked the Board to ensure the case was discussed in a multi disciplinary setting and to offer an apology to the patient. All recommendations by the SPSO have been completed and the SPSO have confirmed their satisfaction with the actions taken by the Board. The SPSO considered a complaint concerning the standard of nursing care, communication about the patient’s condition, an issue in relation to dressing a wound and the amount of time taken to respond to the complaint. The SPSO upheld the complaints about the standard of nursing care and complaint handling; noting that appropriate action had been taken by the Board in offering an apology and identifying improvements in relation to complaint handling performance. The SPSO upheld a complaint about an avoidable delay in a GP Practice diagnosing toxicity to a medication used in the treatment of urinary tract infections. As the Practice had already undertaken a Significant Review and apologised to the patient and reviewed other patients in the Practice; the SPSO had no recommendations to make. The SPSO upheld a complaint about a GP Practice failing to appropriately assess a patient at a consultation and failing to appropriately manage a telephone request. Despite the Practice having undertaken a Significant Review the SPSO recommended an apology and made specific recommendations to the GP in relation to managing patients with Chronic Obstructive Airways Disease. The GP was also asked to discuss the case at next appraisal. All recommendations have been actioned and the SPSO have confirmed their satisfaction with this. The final decision reached by the SPSO concerned a GP practice and a number of complaints including, failure to diagnose a damaged bowel prior to hospital admission, failure to provide appropriate medication following development of a urinary tract infection, failure in the transfer of information between primary and secondary care, inappropriate advice by GP and refusal to prescribe a medication. One of the five complaints was upheld; failure to diagnose damage to bowel. The Practice was asked to offer an apology and provide an assurance that the GP would discuss the case at their next appraisal. All; actions have been completed by the Practice and the SPSO have confirmed their satisfaction with this. Data The source of data contained within this document varies and can be derived from validated published sources, official government returns and databases, and local activity data and management information from a variety of internal sources. The frequency of data updating also varies, with some data being updated monthly and others quarterly. Data correct as at 26/01/16. PERSON-CENTRED Lower is better Higher is better