1. Trust Quality and Performance Report February 2013

2. Contents Slide numbers Clinical Quality Priorities inc Ward Dashboard 4 - 17 CQUIN18 - 20 Local Priorities21 - 27 Monitor Compliance28 - 29 Contract Priorities30 - 35 2

3. Introduction This Corporate Trust Dashboard provides narrative for performance in five key areas: Clinical Quality Priorities, CQUIN Performance, Local Priorities, Monitor Compliance and Contract Priorities. 3

4. Clinical Quality Priorities Summary The overall wards’ performance in January relating to quality indicators continues to require improvement. Although there has been progress in some areas of patient experience and safety, the number of falls increased again in January whilst the patients’ call bell perception and the number of avoidable pressure ulcers also remain unsatisfactory. There has undoubtedly been extra pressures on ward staffing during the winter months which has impacted on appropriate supervision of patients but some patient safety incidents relate to non-compliance by a range of staff with processes and guidelines. This non-compliance needs to be understood in order for it to be addressed appropriately and a proposal for a new scheme to think differently about the way wards function and deliver care will be discussed at an extraordinary senior nurse meeting this month. 4

5. Ward dashboard – A3 5-8

6. Quality Priority: Ward Performance Issues As highlighted on the Safety Thermometer report page of this document, a number of ward areas have not achieved 95% harm-free care as measured by the Safety Thermometer. In all cases, this is due to the large number of patients we admit with community pressure ulcers. Accurate fluid management continues to prove challenging in some ward areas, particularly F6 and AMU (F8) which is a concern as these are the two ward areas that manage the most acutely ill patients. These clinical areas have been asked to develop action plans to improve their position with this quality indicator. 9.

7. Quality Priority: Infection Control 10 There were no cases of hospital associated MRSA bacteraemia during January, however there has been 1 incidence during February on F5. There was 1 case of C. difficile during January on ward F9. The RCA meeting has been held but further information is needed from medical staff who are on leave prior to conclusions being drawn on avoidability. Hand Hygiene Hand hygiene and dress code audit results returned to 100% this month. The Infection Prevention Team will undertake some validation audits during February. Isolation data results During February there were 587 inpatient days for patients requiring isolation and 50 inpatient days when isolation was not achieved giving a 92% compliance rate with isolation.

8. Quality Priority: Falls The contract target for falls during 2012-13 is to reduce serious harm/death from falls and to complete a risk assessment for patients who attend A&E as a result of a fall. Falls performance There were 71 falls across the Trust during January; 26 of these falls resulted in harm, 1 with serious harm. The fall with serious harm occurred on G9. The RCA has been held and demonstrated that one contributory factor was that the gentleman, who was confused, was moved late at night against clinician advice and subsequently fell. The incidence rate has increased and the rate of falls per 1,000 bed days has also increased (6.1 falls per 1,000 occupied bed days), The national average cited by the NPSA in 2009 was a mean rate of 5.6 falls per 1,000 bed days. This is a concern and is an increasing upward trend. Actions An urgent senior nurse meeting has been called to consider three nurse sensitive indicators- increased incidence of falls, increased incidence of pressure ulcers and call bell response times. The actions that relate to preventing all of these incidences rely on pro-active care especially relating to toileting. Different ways of working will be considered and literature searches,/visits to other Trusts/ best practice is currently being reviewed to ensure some external ideas are considered. 11

9. Quality Priority: Pressure Ulcers 12 The performance target is to have no avoidable Grade 3/4 pressure ulcers 2012-13 with a penalty of £5,000 for each incidence. The performance target regarding avoidable Grade 2 pressure ulcers is a ceiling of 4 for Quarter 3 with a penalty of £500 for each incidence above the ceiling. Grade 2 pressure ulcers 5 patients developed Grade 2 hospital acquired pressure ulcers in January on F6, G5 and F7. Following concise root cause analysis, 4 were considered unavoidable as all care was delivered as prescribed by the pressure ulcer prevention pathway. The patient’s pressure ulcer on F7 was considered to be avoidable as the patient’s risk of developing pressure ulcers was not assessed weekly. This has been subsequently improved with the introduction of the integrated risk assessment. Grade 3 pressure ulcers 2 patients developed Grade 3 pressure ulcers, one on F10 and one on F7. RCAs have not yet been held but initial investigations have defined the patient’s pressure ulcer as unavoidable on F10 and avoidable on F7. The gentleman on F7 developed a Grade 3 heel sore which is considered avoidable as he did not have heel protectors in place.

10. Safety thermometer results CQUIN 2012-13 target is to survey all adult inpatients on the survey date and submit the data to the NHS Information Centre on time. Our quality priority is to achieve 95% harm- free care, current performance is 93.02%. This is due to the large numbers of patients admitted with community –acquired pressure ulcers. The data can be manipulated to just look at “new harm” and with this new parameter, our Trust score is 98.19%, an improvement on last month. Some ward areas have low harm-free care scores and this is due to high numbers of community-acquired pressure ulcers. F10, F9 and G3 all have 88% harm-free care but > 96% for new harm-free care. F10 reported 2 community-acquired pressure ulcers, 1 community acquired CAUTI and one hospital fall with low harm. F9 and G3 reported similar data. 13

11. Quality Priority: Patient Experience – Achievement of 85% satisfaction 14 ‘Achieve at least 85% satisfaction in internal patient satisfaction surveys’ is a Quality Priority for the Trust. The overall score for the inpatient survey was 88% indicating a high level of satisfaction with most of the areas covered in the survey. The Patients Association have indicated that the Call Bell Project should start in March 2013 provided they are able to identify a Project Manager. If this is the case the project report should be available by the end of June. Scores for the other monthly surveys continue to be positive. As can be seen from the graph below, the main variability in the A&E survey is the length of time taken to speak to a doctor or nurse. This reflects the increased pressure on A&E during January.

12. Quality Priority: Patient Experience – Recommend the service 15 ‘Patients would recommend the service to their family and friends’ is a Quality Priority for the Trust The Trust achieved a net promoter score of 85 for inpatients during December with a 12% response rate. The recommender score for each ward shows more consistency this month and the low score for G5 last month has reverted back to a normal level. Following the discussion at the Board last month, the Matron and Ward Manager have spoken to patients and relatives over the last two weeks to try to identify any factors which may have led to a low score last month but have not identified any issues. The number of responses by ward has been added to the Ward Dashboard this month. All wards have been informed of the need to achieve a 15% response rate from April. Response rates for Ward F12 have improved this month but are still lower than would be expected for this area. The results for the other areas for the net promoter score are provided below: DepartmentNo of responsesNet promoter score OPD35289 DSU33100 A&E6172

13. Quality Priority: Mortality 16

14. 17

15. The Quarter 3 CQUIN assessment was submitted to NHS Suffolk at the end of January 2013. At the time of writing no feedback has been received. CQUIN Summary & Exceptions report 18

16. CQUIN dashboard – A3 19 – 20

17. Summary & Exceptions report 21 Local Priorities

18. Local Priorities - Governance Dashboard IndicatorPerformance targetRAGJan13Commentary National safety alerts Number of NPSA alerts beyond national implementation deadline>=51-400 Timely completion of incident investigations and actions RCAs (non SIRI) completed more than 45 days after incident reported >1100 RCA Actions beyond deadline for completion>=51-403Actions relating to timely reporting of ‘unexpected’ deaths, documentation of EAU Consultants advice to GPs and HCSW competencies relating to monitoring and escalation are still open. Incidents (Amber / Green) with investigation overdue (over 12 days) >15050-150<50327Each Directorate has been set a ‘Red’ threshold (weighted for total incidents reported Apr-Dec). Only Clinical Support have managed to achieve the target this month. Timely reporting of SIRIs SIRI notification to NHS Suffolk beyond timeframe>=100The seven SIRIs reported in January were submitted within the required timescale. SIRI 45 day reports sent to NHS Suffolk beyond timeframe>=100The three 45-day reports due in January were all submitted within the agreed timescales Risk assessment Active risk assessments in date<75%75 – 94%>=95%100% Outstanding actions in date for Red / Amber entries on Datix risk register <75%75 – 94%>=95%96% NICETA (Technology appraisal) business case beyond agreed deadline timeframe >94 - 90 - 35 The NICE TA business cases outstanding have be reduced to five from nine last month. Four outstanding business cases were signed off at the PCT CPG this month. The new TA process is progressing and addressing issues and improving communication for complex cases. This will reduce the timescale it takes to complete these cases. IPG (Interventional procedure guideline) baseline assessments beyond agreed deadline timeframe >94 - 90 - 36 CG (Clinical guideline) baseline assessments beyond agreed deadline timeframe >94 - 90 - 35 Clinical AuditTrust participation in relevant ongoing National audits (reported by Quarter) <75%75 – 89%>=90%-100% at the end of Q3 ComplaintsResponse within 25 days or negotiated timescale with the complainant <75%75 – 89%>=90%95% Number of second letters received>=51-403Two of the three second letters relate to Eye Treatment Centre complaints. The complainants are unhappy with explanations given for treatment plans in both cases. The remaining one relates to the length of time waiting to receive surgery; the complainant is unhappy with the apology given for this. Health Service Referrals accepted by Ombudsman >=2100 The Trust has recently received an ombudsmen report from a specific complaint and will be reviewing its arrangements for investigation of complaints Red complaints actions beyond deadline for completion>=51-400 Number of PALS contacts becoming formal complaints>=106 - 9<=52 22

19. There were 442 incidents reported in January including 368 patient safety incidents (PSIs). The rate of PSIs is a nationally mandated item for inclusion in the 2012/13 Quality Accounts. The NRLS target lines shows how many patient safety incidents WSH would have to report to fall into the median / upper and lower quartiles for small acute trusts reporting per 100 admissions. This was rebased in September to take into account the new dataset from the Oct 11 - Mar 12 NRLS report). The reporting rate in January has risen again and is just above the median line. The number of harm incidents rose in January to approximately the peer group average. This is due to an increase in the number of Minor harm incidents. There is no corresponding rise in the number of serious harm incidents. Upper quartile, median and lower quartile rebased from Sept 12 Harm (peer group average) rebased from Sept 12 23

20. The percentage of Patient Safety Incidents (PSIs) resulting in severe harm or death is a nationally mandated item for inclusion in the 2012/13 Quality Accounts. The peer group average (serious PSIs as a percentage of total PSIs) has been rebased to 1.0% from the NPSA October 11 – March 12 report and now sits below the Trust’s average. The WSH data is plotted as a line which shows the rolling average over a 12 month period. The number of serious PSIs (confirmed grade) are plotted as a column on the secondary axis. In December there were four ‘Red’ patient safety incidents reported. One fall and three awaiting confirmation of grade through RCA: Fall (2) and Delay in diagnosis (1). Four incidents in the period Oct-Dec were either reported late or upgraded after initial investigation. Since rebasing the peer group average in Aug ’12, the Trust’s percentage of severe harm incidents has been above average in four of the last five months. The number of reported severe harm incidents in January and February 2013 is also expected to be above the average. 24

21. Local Priorities Complaints Complaint response within agreed timescale with the complainant: 95% of responses due in January were responded to within the agreed timescale (target 90%). Of the 24 complaints received in January, the breakdown by Primary Directorate is as follows: Medical (11), Surgical (9), Clinical Support (1), Facilities (1) and Women & Child Health (2). Trust-wide the most common problem areas are as follows: Admissions, discharge and transfer arrangements 5 All aspects of clinical treatment 11 Communication / information to patients (written or oral) 5 Attitude of staff 5 The 24 complaints received are spread over 16 wards / departments. They express dissatisfaction with delays, communication and staff attitude. The Trust has recently received an ombudsmen report from a specific complaint and will be reviewing its arrangements for investigation of complaints, with a focus on engaging with the complainant regarding the investigation process to be followed and clinical input to support this process. 25

22. Local Priorities PALS (Patient Advice & Liaison Service) In January 2013 there were 92 recorded PALS contacts. This number denotes initial contacts and not the number of actual communications between the patient/visitor and PALS which is recorded as 166 for this month. A breakdown of contacts by Directorate from February ’12 to January ‘13 is given in the chart and a synopsis of enquiries received for the same period is given below. Total for each month is shown as a line on a second axis. Trust-wide the most common five reasons for contacts are as follows: There is a considerable increase this month compared to December 2012 but it is not unusual to see an increase at this time of year. The number of complaints relating to attitude of staff has risen again this month (from one last month). However, the largest increase has been in requests for information and advice, which has in fact doubled this month. The PALS Manager continues to deal with concerns about hospital procedures and often assists with clarification of a patient’s treatment plan. This will include attending meetings with patients and/or family and their respective clinicians. The nature of the PALS service requires an expedient response to concerns or queries. A target of 80% for completing an enquiry within 48 hours, or a timeframe agreed with the enquirer, is consistently exceeded by the PALS Manager. Information/Advice request 3232 All aspects of clinical treatment 20Other (relating to other organisations/not classified) 13 Attitude of staff 6Appointments delay/cancellation 5 26

23. Local Priorities – Workforce Performance 27

24. Monitor Compliance Summary & Exceptions report 28 A separate paper is presented to the Board on A&E performance. C Diff is reported on page 10 of this report.

25. Monitor Compliance Framework A3 printout Dashboard - screenprint 29

26. Contract Priorities Summary & Exceptions report 30 The number of cancelled operations was above the 1% target in January. This was because of emergency bed pressures, overrunning theatre lists and operating staff sickness.

27. Stroke The Trust achieved the key target of 100% Stroke patients requiring an urgent scan, scanned within 60 minutes of arrival. The Trust achieved the 50% target of all Strokes scanned within 60 minutes of arrival. The Trust did not achieve the all Strokes scanned within 24 hours of arrival. Two of the patients breaching this standard had a Stroke after admission. The Trust achieved the key target of patients spending 90% of their stay on a Stroke Unit. The Trust achieved low risk TIA from referral targets. The Trust did not achieve the low risk TIA from onset target. All breaches were late presentation by the patient (9 days – 3 months) following onset. The Trust did not achieve the 90% target of patients admitted directly to a Stroke Unit within 4 hours of hospital arrival. Three of the patients breaching the target were admitted via EAU. The Trust achieved care planning and thrombolysis targets. In summary, focussed attention will be on direct admission to the Stroke Unit and identifying and addressing Stroke post admission as well as maintaining performance against other Stroke targets. 31

28. Contract Priorities Dashboard + Other A3 printout Comes from dashboard 32-35