1. EFFECTIVE C difficile (over 65) Apr-Jun 14 MRSA bacteraemia Apr-Jun 14 MSSA bacteraemia Apr-Jun 14 For the 2 month period Sep-Oct 2014, there were 10,413 admissions to NHS Fife Hospitals. Of which 5,398 were unplanned, 1,504 planned and 3,511 day cases. In addition there were 17,871 new outpatient attendances and 43,492 reviews. REDUCE HARM SAFE Lower is better Higher is better Lower is better NHS Fife HealthCheck September-October 2014 Presented to NHS Fife Board on 16 th December 2014 Higher is better

2. Activity Total activity for the period July-August 2014 was 71,766. This included 10,413 admissions to NHS Fife Hospitals and 17,971 new out-patient attendances and 43,492 reviews. Hospital Standardised Mortality Rate (HSMR) The last quarterly data to June 2014 was published in November 2014. This shows a HSMR of 0.78 for Fife. The HSMR data shows an improvement 95% Harm Free Care Cardiac Arrests – The Resuscitation Department has funded membership to the National Database for In-Hospital Cardiac Arrests and data for this will be collated from January 2015, reported on a quarterly basis and will for the first time be able to compare how we are doing nationally. From the National Database annual report it is apparent that cardiac arrest incidence does increase in the winter months in hospitals across the UK, with the highest peak being in Dec, Jan & Feb, so the increase in Oct may not be unexpected. Work is continuing in identifying the deteriorating patient within the Acute Services Division. For the period Sep-Oct 2014 97% of patients who were expected to die had a documented DNACPR decision. However, only 55% of the DNACPR forms were completed correctly. Ward audits are being carried out on a regular basis and where a form has been completed incorrectly a slip is left asking for this to be rectified as soon as possible. DNACPR continues to be included as a topic in nurse education and mandatory doctors induction. Pressure Ulcers – There is an exercise underway to cleanse this data as it has been highlighted through Significant Adverse Events Reviews that one pressure sore may be reported multiple times. In Kirkcaldy & Levenmouth CHP there has been a cluster review which looks at more than one incident of pressure ulcers. This has generated an improvement plan which shows what needs to be put in place in terms of change. Falls – following the NHS Fife Falls Summit and the Healthcare Scotland Improvement event with NHS Fife “frailty is everyone's business” the falls bundle was launched. Delivery units across NHS Fife have been starting to implement the new bundle process and measurement plan. An update to the Call to Action will be circulated in December with a further Summit planned for early Spring by which time the anticipated outcome of a reduction in falls, and falls with harm will be realised and shared. Significant Adverse Events Review (SAER) There were a total of 2276 incidents reported from September 2014 to October 2014. Of these 3% (70/2276) reported were graded as major/extreme and 9% (6/70) of those have been commissioned for an internal SAER. These were categorised as falls (2); endoscopy incident (1); clinical (2); and tissue viability (1). Readmissions The readmissions data presented is the national validated data from ISD. In the main, the information presented in this indicator is derived from the last episode in the spell of the original admission (e.g. specialty, consultant, hospital, condition) except in those instances where a procedure occurred in an earlier episode. The vast majority of spells consist of single episodes. Readmission rates are standardised to take account of differences in age, sex and type of admission (elective/non-elective). Readmissions data is reported on an annual basis from ISD. However, locally derived data will be used to monitor any changes in readmission rates. 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 69 formal complaints (with multiple issues) reported in September and October 2014. The 3 key themes from these formal complaints were: clinical treatment 46% (130/282); attitude and behaviour 20% (55/282); and communication (oral) 11% (30/282). Staff Experience A national tool, i-Matter, is being developed. Work is in progress to determine whether this would be an appropriately sensitive measure to capture staff experience. Your Care Experience Your Care Experience has been rolled out to 13 areas within the Acute Services Division. However, there is no data for this period as there has been technical issues with the software. IT are working on a solution and it hoped that this will be resolved soon. Scottish Public Services Ombudsman (SPSO) One SPSO report was published in September 2014. The SPSO upheld the complaint that there was an avoidable delay in making a diagnosis of liver cancer. The Board were asked to review processes for communicating abnormal results and to apologise for the failures identified. The review has resulted in a systems change which is underway. A further four decisions were reached by the SPSO The SPSO upheld a complaint about unreasonable treatment of a patient by psychiatric staff whilst in Stratheden Hospital. The Board was asked to issue a written apology for the failings identified in relation to seclusion which has been completed. The SPSO upheld a complaint relating to a Practice where there was failure to diagnose the cause of thigh pain. The Practice was asked to apologise and to carry out a Significant Event meeting to discuss the incident. In addition the GPs were asked to familiarise themselves with the diagnosis and management of hip fracture, paying particular reference to need for re assessment in situation where x ray negative to fracture. All actions have been completed by the Practice. The SPSO upheld one of two complaints relating to a medical practice, concerning failure to provide appropriate medical care (not upheld) and failure to respond to the formal complaint (upheld). The Practice was asked to make an apology and to update their complaint handling procedure which has happened. In a final decision the SPSO did not uphold a complaint concerning the Board’s management of a patient in relation to stiffness and contractures. The Medical Advised considered that the overall treatment of the patient was reasonable. The theme for Person Stories at today’s Board is the importance of a person centred approach. 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 26/11/2014. PERSON-CENTRED Lower is better Higher is better