1. Presented By: Gwen Nuttall – Chief Operating Officer, Nichole Day Executive Chief Nurse Prepared By: Information Team Date Prepared: 19 th May 2011 Subject: Integrated Quality and Performance Report - April 2011 Purpose: For Information Strategic Objective: To Achieve Performance Levels in accordance with the CQC “Standards for Better Health” Executive Summary: The paper focuses on the key core targets, identified by the Department of Health and the Care Quality Commission, summarising performance to the end of April 2011. It also provides the board with information to assess the Trust’s performance against quality indicators, including patient experience, clinical outcome and effectiveness and patient safety. Trust Board Committee – 27 th May 2011 Item 8a

2. SUFFICIENT Note the Trust Performance to April 2011 - Failure to deliver the 4 hour core access target for the year. - Failure to achieve C-Difficile target for the year. Robust Action Plan developed. Performance Management and Monitoring. Improved Escalation Review of Cohort Unit

3. 3 Introduction This Quality Report provides the narrative for performance in three key areas: Quality priorities, Key Operational Indicators (Stroke and A&E CQI’s), CQUIN performance and local issues requiring escalation. It should be read in conjunction with the Trust and Ward dashboards. As the format and content of this report is new, all quality priorities and CQUIN performance has been reported this month, from next month CQUIN reporting will be on an exception basis. The layout of this report identifies performance data followed by themes identified during the analysis process and actions to be taken. The ward quality report summary has been used to highlight wards that have a number of red scores. This month F3 has 7 red scores. Following review with the matron this is an exception to F3’s normal performance rather than an ongoing trend of quality. The red scores have been discussed within this report as appropriate and F3’s performance will be reviewed next month. Key issues identified this month to be noted are: Nutrition, specifically performance against CQUIN target Falls data and patients with dementia Noise at night indicator from patient experience survey.

4. 4 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 Apr 2011 and Apr 2012. i) There were no incidences of hospital acquired MRSA bacteraemia in the Trust during April. ii) There were 3 incidences of hospital acquired C. difficile during April, which were all unavoidable. There have been no incidences in May to date (19/5). All High Impact Interventions scored 100% except urinary catheter ongoing care (98%). This was due to a 75% score on F3 (4 catheters were audited and there was one documentation issue for one catheter). Aim: To improve the management of antibiotics by achieving 90% compliance with antibiotic policy. iii) Overall compliance with the antibiotic policy was 90% across the Trust.

5. 5 2a) To achieve the highest levels of patient safety. Aims: i) To assess at least 92% of admissions for risk of VTE and ii) provide prophylaxis to 100% patients at risk. i) 97% of patients received VTE risk assessment this month. Real time data is available on line for the UNIFY baseline assessment for VTE. Across the 4 quarters of 2010-11 performance was 74, 76 79 and 95% now exceeding the 90% CQUIN target. The quarterly CQUIN target for 20011-12 is 92, 94, 96 and 98% at the current rate of improvement this should be achieved provided the current focus on this target is maintained. ii) Further audit cycles of DVT prophylaxis has been completed across both the medical and surgical directorates in September and November 2010. Compliance with reassessment at 24 hours is improving overall, (62% and 45% for medicine and surgery respectively - target 80% - previous quarter 66% and 21%). Over 90% of eligible patients in both directorates are prescribed pharmacoprophylaxis but the administration rate for anti embolic stockings, whilst improving, requires further focused work. The next audit of compliance with prescribing and dispensing is happening in May iii) Concise RCAs are completed for patients who have a VTE within 3 months of discharge and inpatients experiencing VTE >72hours after admission. The main challenge is for clinical governance to identify the cases. This is currently done via clinical coding which identifies all patients with VTE. This is labour intensive as large numbers of patients are identified which need to be filtered. The possibility of identifying these patients at point of diagnostics is being considered. iv) The East of England VTE leaflets are available in all inpatient areas. A process to demonstrate that they are offered to patients is being confirmed. CQUIN performance iii) RCA for all deep vein thromboses and pulmonary emboli occurring 72 hours after admission. iv) Patient Information leaflets

6. 6 2b) To achieve the highest levels of patient safety. Aim: To reduce the number of patients who fall in hospital by 35% Patient Falls: The total number of falls in April was 51, a significant decrease from 65 in March. 15 of these falls resulted in harm (n=25 in March) and 1 was severe harm: a lady sustained a # humerus following a fall out of bed at night (F3). As would be expected, the majority of falls are within the medical directorate (n= 37). All wards had 1- 6 falls with the exception of G5 who had 12 falls (for analysis see below). The surgical directorate had 12 falls - F3: 5 falls; F6: 3 falls; F5: 3 falls and F4 had 1 fall. 2 falls occurred within the women and children's directorate. Themes: 44 falls across the Trust occurred in patients with dementia/confusion. The remainder were incidents that occurred in low-risk patients, and have no recurring themes and are difficult to predict. G5 had the highest number of falls. Of these 12 falls: 6 occurred at night, five during the late shift and one during the morning shift. All were patients with dementia. G4 has improved their falls rate performance this month, with 3 falls in total. Actions: A key theme is the number of dependent patients with dementia/confusion. Part of the solution to this issue is to drive the implementation of the dementia strategy through the three key elements - environment, staff training and staffing levels. These highly dependent patients put particular demands on nurse staffing- a review of nursing establishments has been completed and will be presented to the Board. The Dementia Strategy needs to be presented to TEG for agreement on the implementation plan. A meeting has taken place between Nursing Directorate, Matron and Ward Manager on G5 to develop an action plan to manage the high level of falls during the evening/night. Poor lighting and lower staffing levels have been identified as significant contributory factors. CQUIN: Falls assessment undertaken and onward referral to an appropriate service to address contributing factors number of patient identified as high risk. The Falls Group is currently developing a process to manage onward referral reporting.

7. 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%. Pressure Ulcers: The number of patients with ward acquired pressure ulcers in April was 11 - this is equal to March. There was 1 unavoidable hospital-acquired Grade 3 pressure ulcer reported. No ward had disproportionately high numbers. Themes from RCAs: 10 of the pressure ulcers were considered unavoidable as all care was given per pressure ulcer guidelines or the patient was non-compliant with care 1 Grade 2 pressure ulcer was considered avoidable as it took 48 hours for the patient to receive the pressure relieving mattress needed Reviewing possible over-reporting of pressure damage due to uncertainty from nursing staff in distinguishing between ulcers resulting from moisture damage and pressure. Actions: The pressure ulcer prevention group is redesigning the patient pathway and developing standards as part of the action plan to meet CQUIN requirements. This incorporates: 1 hour threshold for request of pressure relieving mattress to delivery onto ward Specific targets for moderation of assessment by senior nurses and photographs of all pressure point damage on admission Specific standards re: documentation of assessment, care provided and non-compliance of patients.

8. 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. 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. The overall Trust result is 99% patients would choose to use the hospital again and 90.5% overall satisfaction. Patient Satisfaction (Patient Experience Tracker) 100% of patients would choose to use the hospital again Overall satisfaction rate was 94%, all elements scored over 85%. Patient Satisfaction Questionnaires (paper) 96% of patients would choose to use the hospital again. Overall satisfaction was 87%. Overall all question responses were amber/green apart from “Were you ever bothered by noise at night?” Themes: Confused patients calling out during the night and patients admitted onto ward at night High acuity/dependency of patients requiring nursing observation/intervention during the night. Actions: Re-organisation of wards to ensure that elderly patients are in the same ward areas. CQUIN performance Methods are currently being developed to capture patient experience in the following client groups: maternity, paediatrics, stroke and patients with dementia.

9. 9 3c) To continuously improve the experience of patients using our services Aim: To achieve at least 90% compliance with environment and cleanliness standards. Environment and Cleanliness Overall Trust score was 91%. Individual areas scoring below 90% are: A&E - 85% (Cleaning 85%, Nursing 78%, Estates 89%). An action plan is in place to address the nursing/MDT issues. F10 - 89% (Cleaning 88%, Nursing 94%, Estates 94%). A meeting is arranged to discuss the cleaning score and set an action plan for improvement. F6 - 88% (Cleaning 87%, Nursing 90%, Estates 92%). Audit was performed just prior to ward move for deep clean programme. Critical care - 88% (Cleaning 90%, Nursing 92%, Estates 72%). All estates issues have been put through the helpdesk. Recovery - 82% (Cleaning 72%, Nursing 72%, Estates 86%). A robust action plan was put in place to improve the nursing and cleaning aspect and this month’s score is 93%. F12 - 89% (Cleaning service - 93%, Nursing - 95%, Estates - 76%). All estates issues have been escalated.

10. 10 4a) To achieve optimal clinical outcomes and effectiveness. Aim: To consistently achieve a Hospital Standardised Mortality Ratio that is below the expected rate. HSMR has been fairly consistent over recent months and is below the expected level as can be seen by the overall mortality shown in the graphs and the table giving a mortality rate for the five Dr Foster - How Safe is Your Hospital indicators. These tables provide information on relative risk, with red, blue and green traffic lighting. Blue indicates that the score is within the standard deviation. We continue to monitor the overall HSMR at the Clinical Safety and Effectiveness Committee. National Rate from last reporting period Jul 08- Aug 09 Aug 08- Sep 09 Sep 08- Oct 09 Oct 08 - Nov 09 Nov 08 - Dec- 09 Dec 08 - Jan 10 Jan 09 – Feb 10 Feb 09 -Mar 10 Mar 09 -Apr 10 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 Rolling 12 Month HSMR-All Admissions - 86.485.284.584.682.88080.780.280.176.589 87.886.384.684.180.38179 Rolling 12 Month HSMR-Non Elective - 86.284.984.684.58380.180.880.480.379.689.1 88.186.784.884.280.381.179.1 SMR Stroke (Acute Cerebrovascular Disease) 86.2 85.982.686.482.883.383.182.980.981.179.487.886.888.788.684.284.479.780.575 SMR - Heart Attack (AMI) 90 100.4105.1106.194.191.8100.696.69592.492.193.794.589.482.478.577.981.894.182.5 SMR - FNOF 81.6 7065.464.96569.461.364.269.568.464.773.369.260.762.966.266.967.465.964.2 Mortality from Low Risk Conditions 0.84 0.650.57 0.440.490.670.62 0.530.490.440.490.45- -

11. 11 4b-c) Improving Clinical Outcomes and Effectiveness Aim: To improve early identification and management of the deteriorating patient. The deteriorating patient working group is currently developing the RCA process for a randomised sample of 5 cardiac arrest patients per month and a process to disseminate and implement system wide actions based on learning from these. The key actions being implemented by this group to improve the identification and management of the deteriorating patient are: From the 1 st of May 2011 the critical outreach team have become a 24hr service enabling the hospital to provide a consistent approach for managing the deteriorating patient. Implementation and roll out of the transfer risk assessment tool which has been adapted for local use and trialled in two areas of the hospital. Aim: To reduce re-admissions of patients within 28 days of a hospital admission. The clinical safety and effectiveness group will identify the diagnoses/procedures where readmission rate is above the national average and these will be investigated in more detail and an action plan developed to address any key issues.

12. 12 CQUIN : Other key performance indicators Hydration: The fluid management group are currently in the process of developing a risk assessment tool to identify patients at risk of dehydration. An action plan has been developed to drive the performance required to be successful in this target. Smoking cessation: i) 49 patients have been referred to LiveWell during April, therefore 201 extra referrals during May/June are required to meet the CQUIN target. An action plan is being developed to provide this level of referrals focusing in all areas but particularly in OPD/ A&E and maternity services. ii) The Trust already has a number of Level1 smoking cessation advisors able to deliver brief intervention training. Discussions are taking place with LiveWell to determine a further training plan. EAU Consultants advice: Following discussion with Suffolk PCT, community services and our EAU team, a pilot will commence on Monday 23 May. This pilot includes a nurse from Suffolk Community Health working alongside our EAU Consultants to collect more detailed referral information and identify and re-direct patients to other more possibly appropriate services in the community, ideally preventing an acute admission. This pilot will run for 3 months. Measures collected will be straight forward and include the number of referrals, source, initial request and outcome. Establishment and engagement in this pilot will result CQUIN payment. Offer stroke patients active therapy: Current work is to identify the baseline and to work with the Stroke Network to agree the final definitions and confirm the trajectory for improvement from this.

13. 13 Local issues requiring escalation. Aim: The CQUIN target for nutrition is to achieve 95% compliance of all patients receiving assessment of nutritional needs. Performance against this indicator as seen in the ward dashboard requires some further attention, as this month we achieved 88% compliance. The data is collated from audit of five components for ten patients on each surgical and medical ward. The components audited are: weight on admission, nutrition screening, nutrition assessment (if appropriate), nutrition plan and patient re-weighed every 7 days. Areas achieving 80% or less are: G3, CCU, G8, CCS and F4 (see ward quality report summary). Themes: Lack of compliance at weekends on CCS with weighing patients and nutrition screening Patients not weighed on admission to cardiac wards Patients not weighed pre-operatively on F4. Actions: Matrons have a target of 99% to achieve in their nutritional audits during May and June. Each Matron has developed an action plan to ensure 99% compliance White boards behind beds used to remind staff of assessment dates Increased monitoring of weekend compliance. Patient experience: Three red scores were reported on the patient satisfaction responses for F3 and CCU (see ward quality report summary). F3: F3 had one very confused patient who called out most nights. Actions to reduce this were taken i.e, nursed in side-room and medication review. Call bell response times on F3 average 4 mins (from call bell system report). The Matron will spend extra time reviewing the time spent answering call bells. Volunteers assist staff with questionnaires on F3. This question typically scores red when the questionnaire is completed pre- discharge advice, therefore the matron will ensure volunteers advise patients to complete questionnaire just prior to being discharged. CCU: The discharge questions frequently score low on CCU as patients are not discharged home from CCU. Noise at night results from the high acuity of patients and need for close monitoring.

14. Local Priorities - Governance Dashboard NICE The ongoing targeting of Technology Appraisals continues however, there is no overall change from last month's figure as new TAs have also now become overdue. A series of targeted meetings with Trust Clinical leads has led to 11 Interventional Procedure Guidelines and 5 Clinical Guidelines being closed off that were late or due. Additional baseline assessments that were not late last month have now become overdue so the overall total remains red rated. A considerable number of those reported last month as late had in fact been addressed locally however, no feedback had been submitted centrally (as per Trust policy) until one-to-one meetings with the leads were set up. The remainder of these one-to-one meetings will take place in May. 14 IndicatorPerformance targetRAGApr 11Commentary National safety alertsNumber of NPSA alerts beyond national implementation deadline>=51-4041. Technical Patient Safety Solutions for Medicines Reconciliation on admission of adults to hospital (RR535) 2. Right Patient, Right Blood’ (RR457) 3. Early identification of failure to act on radiological imaging reports (RR558) 4. Oxygen safety in hospitals (RR670) All these alerts are regularly reviewed at the Trust operational group. The Trust is not able to fully implement numbers 1 and 3 at this moment and these will remain amber. There is a detailed plan for item 2 and 3 to be resolved. Timely completion of Red incident investigations and actions RCAs (non SIRI) completed more than 45 days after incident reported>=100All nine non-SIRI RCAs were undertaken within the required 45 working day period Actions beyond deadline for completion>=51-400 Timely reporting of SIRIs to NHS Suffolk SIRIs 2 day report beyond timeframe>=100All four SIRIs reported in April had the 2-day and 7-day reports submitted within the required timescale SIRIs 7 day report beyond timeframe>=100 SIRIs 45 day reports beyond timeframe>=100The five SIRI 45-day reports due in April 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%97% NICETA business case beyond agreed deadline timeframe>91 - 9016This month’s NICE Coordination group will be agreeing a short deadline for closing the outstanding guidance. (See below) IPG baseline assessments beyond agreed deadline timeframe>91 - 9012 CG baseline assessments beyond agreed deadline timeframe>91 - 9011 Clinical AuditTrust participation in relevant ongoing National audits (reported by Quarter) <75%75 – 89%>=90%-Previously reported as 89% at end of Q4 2010/11 ComplaintsResponse within 25 days or negotiated timescale with the complainant<75%75 – 89%>=90%88%See complaints analysis Complaints resolved with first written response<75%75 – 84%>=85%100% Number of PALS contacts that became formal complaints>106 - 9<=55

15. 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. There has been an increase since February in incidents classified as resulting in serious harm. This is consistent with benchmark data from the National Reporting & Learning System (NRLS) and requires further analysis and investigation. This will be undertaken by Governance and a report submitted to the Clinical Safety and Effectiveness Committee. 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. To ensure that the cause is not under reporting the Trust induction and all training sessions stress why it is important to report incidents and how this should be done. Further to this, promotion of incident reporting continues to ensure incidents are investigated and that staff are given feedback to ensure their confidence in the system and to encourage them to report in the future. The implementation of electronic incident reporting during 2011/12 is also expected to support increased reporting. The national staff survey reports above average staff confidence in the “Fairness and effectiveness of procedures “. It also indicates the Trust is at the average level for the percentage of staff reporting errors. In April there were 94 Patient Safety Incidents resulting in harm of which 10 were Serious harm (Major / Catastrophic). These were (in brief): 1 inappropriate transfer, 1 stillbirth, 1 fall with fractured humerus (a SIRI), 1 fractured hip not from a fall, 1 fall from bed,1 Norovirus outbreak (a SIRI), 1 delayed diagnosis (reported as a SIRI in May), 1 grade 3 pressure ulcer (a SIRI) and 2 inappropriate discharges (1 reported as a SIRI in May). There were 4 SIRIs reported in April. This included 3 serious harm incidents mentioned above and one breach of confidentiality with no actual harm to patient. The Clinical Safety & Effectiveness Committee will receive an aggregated analysis of incidents for 2010/11 to ensure that themes from incident reporting are being effectively identified and addressed. Patient safety incident analysis provided in this section of the report will focus on those issues not already addressed through the quality priorities e.g. pressure ulcers and falls. 15

16. Key issues arising on A&E performance A&E Performance against the existing 95% target of time of arrival to discharge, admission or transfer was the best or second best in England in every week in April. Targets CQI 1 (DVT and Cellulitis Admissions rates) remain under development nationally and is measured quarterly The Trust meets CQI 2 (unplanned re-attendance rate), CQI 3 (Total time spent in A&E), CQI 4 (Left without being seen) and CQI 7 (Time from arrival to clinical assessment) CQI 5 relates to service experience and remains under development The Trust does not yet me CQI 6 Time to initial Assessment - Patients arriving by emergency ambulance – The Trust achieved 80.9% for the month against a target of 95%. A positive trend or significant improvement is evident during May The A&E department has reviewed systems in place to meet this target and implemented improvement A trial of a majors triage nurse is taking place – this appears to be having a positive effect No regional or national comparator data is yet available on performance against these indicators since their April implementation date. WSH performed well compared to other Trusts regionally on the limited data available in Q2 o 2010/11.

17. A&E Clinical Quality Indicators

19. Key issues arising on Stroke performance The proportion of patients in atrial fibrillation presenting with stroke receiving anti-coagulation – target 60% - achieved 86%. The proportion of patients admitted to an acute stroke unit within 4 hrs of arrival target 90% - achieved 100%. The % of patients eligible for thrombolysis who are treated within 3 hours target 100% - achieved 100%. 80% of patients treated on a stroke unit for 90% of their stay – achieved 88%. Area’s requiring action Unusually the Trust did not achieve the standard relating to TIA and access to scanning; this was due to the late referrals from GP (escalated to PCT). The main focus of work related to scanning of inpatients within 1 hour of having a stroke, specifically out of hours identification of patients. All breaches are reviewed and discussed with the relevant ward clinical team by the stroke team. The stroke action plan is reviewed monthly and there are weekly meetings to review performance. The Trust attended the Suffolk Overview and Scrutiny Committee on Tuesday 17 th May where facilities for stroke patients following discharge were being reviewed. Suffolk LINk presented the results of a recent questionnaire they had undertaken which highlighted the need to improve:- Information and awareness to patients, relatives and careers about facilities and organisation available to assist post discharge. Overall, stroke performance continues to improve, with achievement of the following standards:-

20. Key issues arising on Stroke performance - continued The need to ensure early supported discharge programme is developed across the country. NB. A pilot for early supported discharge programme commenced in the West Suffolk Hospital in April. Overall the committee was please to see the progress made in acute Trust, however requested that all providers of care from primary, secondary, community, social care and voluntary charitable organisations work together to improve pathways.

21. Stroke Indicators

22. Cancelled Operations The revised target is for no more than 1% of elective admissions (including day surgery) to be cancelled on the day of admission. Trust performance improved in April to 0.33%. At the last meeting non executive directors asked for clarity around the cancellation reasons that the Trust could control and those that were more difficult, even though they still are included in the 1% target. Trust ControlDifficult to Predict Lack of bedOver-running theatre case Lack of equipmentUnscheduled emergency case Over-booked theatre listStaff sickness Patient not fit for surgery The productive theatre team continues to develop its work programme and presented to the Shadow Board of Governors in May 2011.