1.1This Report Brings Together Key National, Regional and Local Quality Indicators Relating

To: Trust Board
Date of Meeting: 2nd March2017 / Agenda Item: 7
Title
Month 10,2016/17Quality Report
Responsible Executive Director
Dr George Findlay(Medical Director) and Maggie Davies(Acting Director of Nursing and Patient Safety)
Prepared by
Lynn Woolley (Head of Clinical Governance)
Status
Disclosable
Summary of Proposal
Not applicable
Implications for Quality of Care
Describes performance against quality outcome KPIs, including safety, infection control, experience, effectiveness and mortality.
Link to Strategic Objectives/Board Assurance Framework
This report pulls together key national, regional and local quality indicators relating to quality and safety providing assurance for the board and (if necessary) highlighting issues.
Financial Implications
Describes KPIs that have potential financial impact (e.g. CQUIN)
Human Resource Implications
Describes KPIs linked to workforce
Recommendation
The Board is asked to: Note the contents of this report.
Communication and Consultation
Not applicable
Appendices
Appendix I: Quality Scorecard
Appendix II: Ward Staffing Scorecard

1INTRODUCTION

1.1This report brings together key national, regional and local quality indicators relating to quality and safety. The purpose of the report is to bring to the attention of the Trust Board quality performance within Western Sussex Hospitals Foundation Trust (WSHFT).

1.2The paper describes performance on an exceptional basis determined by RAG (red/amber/green) ratings based on national, regional or local targets. Further quality items are shown as dashboards in the appendices.

22016/17 REFRESH

2.1As part of the refresh of the Quality Strategy for 2016/17 that outline key quality objectives for the next year, this report will be refreshed and redesigned in line with the strategy objectives and to align to the Trust’s True North objectives.

2.2There are revised targets for 2016/17 these have been calculated based on a similar logic to that applied for 2015/16:-

• If 2015/16 Performance exceeded target, then 2015/16 actuals used as 2016/17 target
• If 2015/16 Performance did not meet target then 2015/16 target remains for 2016/17
• If national or set target then follow or continue
• If no target for 2015/16 this also continues for 2016/17

The only new target for 2016/17 Scorecard is ‘Repeat Falls’ and this has been included with the target ‘tbc’. Aspirational targets have been added in October 2016 against some of the metrics to indicate the goal for achievement.

3KEY QUALITY OBJECTIVES

3.1Dashboard Definitions

3.1.1The full Clinical Quality Dashboard is presented as Appendix I. Figures are in-month figures (e.g. the number of falls reported in January) unless otherwise stated. The dashboard shows 13 months to allow trends to be identified, although some data items are reported retrospectively. Year to date actuals/targets are based on financial years unless otherwise stated (e.g. standardised mortality ratios are recorded as 12 month positions).A subset of the key measures from the report is presented at 3.3.

3.1.2Exception reports are included under the relevant section of this report (i.e. under the broad headings Effectiveness, Safety and Experience).

3.1.3Only the current financial year and year to date values are RAG rated, with the exception of those metrics reported in arrears with no data in the current financial year where the most recent data-point of last year is RAG rated.

3.2Domain scores

3.2.1The domain score is an overall indication of the performance in relation to each of the three areas. The score is calculated as follows: Each RAG rated indicator for a month is scored as follows: reds score 1, ambers score 2, greens score 3. These scores are then totalled and divided by the total number of indicators with RAG ratings to give a score for the domain as a whole between 1 and 3. This final score can then itself be RAG rated with >2.5 giving an overall green, 1.5 to 2.5 amber and <1.5 an overall red score for the domain as a whole. For example if a domain had two greens and a red the calculation would be as follows:

3 (green) + 3 (green) + 1 (red) = 7

7 / 3 (i.e. the total number of metrics) = 2.33 i.e. amber overall.

3.2.2Domain scores arecalculated based on the year to date RAG ratings for each metric. Previous months are retrospectively updated to take account of any measures reported in arrears.As with any aggregate indicator, it remains essential that the board retains sight of the individual elements as well as the domain score as a whole.

3.3Overview of Key Quality Objectives

3.3.1The following table shows performance against key, top level quality objectives.

Indicator / Nov
2016 / Dec
2016 / Jan 2017 / 2016/17 to date / 2016/17 Target / limit
Effectiveness Domain Score / 2.35 / 2.58 / 2.42 / 2.36 / 2.5
Safety Domain Score / 2.40 / 2.12 / 2.32 / 2.24 / 2.5
Experience Domain Score / 2.25 / 2.06 / 2.13 / 2.04 / 2.5
E01 Trust crude mortality rate (non-elective) / 3.23% / 3.29% / 4.15% / 3.16% / 3.13%
E03 Hospital Standardised Mortality Ratio for top 56 diagnoses (Dr Foster, based on rolling 12 months) / 92.4 / <92
S06 Number of Serious Incidents Requiring Investigation (number reported in month) / 4 / 8 / 8 / 70 / 60
S14 Numbers of hospital attributable MRSA / 0 / 0 / 0 / 1 / 0
S28 Numbers of hospital C. diff where a lapse in the quality of care was noted / 2 / 0 / 1 / 19 / 16 (national target = 39)
X38 The Friends and Family Test: Percentage Recommending Inpatients / 96.1% / 96% / 97.0% / 95.9% / 97%
X39 The Friends and Family Test: Percentage Recommending A&E / 89.3% / 89.3% / 88.4% / 89.2% / 93%
X13 Mixed Sex Accommodation breaches (number of breaches) / 0 / 0 / 0 / 6 / 0
X18 Number of complaints / 47 / 40 / 38 / 495 / 570

4EFFECTIVENESS

4.1Crude Trust Mortality

4.1.1Due to the low level of mortality experienced in elective care, the Trust measures mortality in relation to non-elective activity. The Trust uses the previous year as a benchmark.

4.1.2Crude non-elective mortality rose from 3.29% in December to 4.15% in January. This is higher than the equivalent month in 2015 (January 2015 = 3.45%). The number of non-elective patients who died in January was 233 (from 5608 discharges). The year to date mortality rate is 3.16% and the rolling 12 month mortality rate is 3.19%. The limit for both measures is 3.13%.

4.2Hospital Standardised Mortality Ratio (HSMR)

4.2.1There is a delay in data being available in Dr Foster tools to allow for coding and processing by the Health and Social Care Information Centre and Dr Foster. The most recent data available is October 2016.

4.2.2The Trust’s HSMR for the twelve months to October 2016 is 92.37 (where 100 is the level predicted by the Dr Foster model using the June 2016 benchmark).

4.2.3The twelve month HSMR to October 2016 split by site continues to be lower for St Richard’s (84.75) than for Worthing (98.62), however both are lower than 100.

4.2.4A further report is available to clinical leaders in the Trust showing the clinical diagnostic areas with high actual versus expected mortality and any mortality CuSum alerts.

4.2.5The Trust has set the goal of achieving a position within the top 20% of Trusts as measured by HSMR. For the twelve months to October 2016 performance using this measure places us outside the top 20% of Trusts on the 23rd centile

4.3Summary Hospital-Level Mortality Indicator (SHMI)

4.3.1The latest data made available by the Health and Social Care Information Centre is for the period to March 2016. The Trust value is 0.99 (where 1.00 is the national average), with the Trust banded as ‘as expected’.

4.4Exception Reports Relating to Effectiveness

4.4.2 E13. C-Section rate. C-Section rate has continued to be higher than target. In January there was a slight increase in the rate to 28.2% against a target of 26%. Each case undergoes a review process to look for learning opportunities. No systemic causes or trends have been identified and practice is very much in line with national recommendations for safe practice and NICE guidance.Increasing normal birth continues to be an area of focus for the division and is closely managed via monthly divisional performance reviews.

4.4.3E42. Night time moves in patients with dementia. As well as the ongoing work tracking bed moves in patients with dementia, the matrons for dementia and for safer care are undertaking an audit triangulating those patients with dementia who experienced night moves and those who had subsequent falls. The care for each will be reviewed in detail to identify areas for improvement.

5SAFETY

5.1Central Alert System (CAS) Safety Alerts

5.1.1There are no outstanding alerts for the Trust up to January 2017.

5.2Serious Incidents Requiring Investigation (SIRIs)

There were 8 incidents which were reported in January that have been graded as serious incidents requiring investigation. A detailed serious incident report is provided to the Committee section of the Trust Board. The Board should note there is a slight variation in the month by month numbers between the SIRI report and the scorecard as the scorecard assigns incidents to the month in which they occur whereas the latter assigns them to the month in which the SIRI was raised.

5.2.1The incidents involved 2 inpatient falls (1 resulting in fracture and one resulted in a head injury). There was a Never Event categorised as ‘wrong implant of prosthesis’resulting in a moderate level of harm with no revision surgery. Two serious incidents were declared relating to errors in diagnostic reviews. The remaining three incidents related to a delay in treatment, suboptimal care of a deteriorating patient and a maternity incident meeting the serious incident criteria.

5.2.2Any incidents that are reported as causing significant harm (moderate, severe or resulting in the death of a patient) are notified immediately to the senior team in the trust including the Director of Nursing and Medical Director with at least weekly updates on progress.

5.2.3On a monthly basis there is triangulation of information arising out of complaints, claims, incidents and inquests to identify any areas of learning or for focus

5.3Infection control

5.3.1There were 2 cases of hospital-attributable Clostridium difficile at SRH during January. The organisation remains significantly over trajectory and has breached the control target. The allocated trust target limit for 2016/17 remains at 39. A stretch target limit of 33 had been agreed but has been exceeded with 37 cases to date.

5.3.2The patients affected for January equate to a rate of 6.4 cases of C diff per 100,000 bed days compared the national average for 2015/16 of 14.9 cases per 100,000 bed days (source:

5.3.3On review of the cases, root cause analysis identified there was one lapse in care identified. This was due to a delay in isolating the patient, some dusty areas found during an Infection Control audit and a low scoring hand hygiene audit. These have all been rectified through training and further audit. The areas that are reviewed as part of the RCA are cleaning, hand hygiene, timely isolation and antibiotic prescribing.

5.4.1 Influenza Vaccination

5.4.2Activity is ongoing to encourage staff to have the flu vaccine in order to protect themselves, our patients and their families. Nationally a target of 75% uptake for front line workers was set with a link to CQUIN funding.

5.4.33,079 (61.1%) of frontline staff have had the vaccine. This is more than a 25% improvement on last year’s uptake. In total, 78.5% of staff have been approached and offered the opportunity for vaccination.

5.4.4Work Place Vaccinators have been a key factor in the successful campaign and are being thanked at afternoon tea events.

6.1.1Falls

6.1.2In January there were 180 inpatient fallswith37falls resulting in harm against a benchmark of 38.

6.1.3There were 3falls causing significant (moderate) harm to patients– 2falls resulting in a fracture and 1 fall resulting in head injury.The difference in the falls data in this section and in the SIRI section where 2 falls are highlighted is due to the threshold for SIRI reporting that is dependent on the nature of the injury sustained. As with pressure damage, all falls that result in significant harm are subject to the same level of rigorous internal investigation regardless of whether they require reporting externally or not.

6.1.4Fourteen wards are currently taking part in a falls breakthrough project. In comparison to last year’s data, six wards have achieved a 40-50% reduction in falls and Botolphs Ward had no patient falls in the period.

6.1.5Trust performance overall on falls has plateaued but this is against a background of very high activity. There were clear links between activity and falls on days when business continuity was a factor.

6.2 Tissue Viability

6.2.1As described previously, changes in the way the Trust reports pressure ulcers meant that more grade 2 and grade 3 ulcers were reported in 2015/16 than in previous years. This pattern of reporting has changed from October and grade 3 or greater damage will not be routinely reported as a serious incident unless it meets the national threshold for SIRI reporting. Internal scrutiny of cases continues exactly as before with robust follow through of actions.

6.2.2During Januarythe Trust reported 18cases of grade 2 hospital acquired pressure ulcers. Damage to the sacrum, buttocks and heels remains the most common form of pressure damage.Lapses in care are identified in more than 50% of care reviews. Inadequate documentation of skin assessment and changes of position is a recurring theme. There are ongoing challenges with mattress availability with stock levels not meeting the rising demand resulting in the need for ad hoc hiring of mattresses. Kaizen is supporting with a piece of work to look at the process.

6.2.3There is intensive education and audit of SSKIN bundles and it is hoped that the launch of electronic Purpose T assessment on Patientrack at the end of February will enable better monitoring.

6.2.4In addition to this there werethreehospital acquired pressure ulcersthat weregrade 3 and one grade 4. None related to medical devices. The grade 4 pressure damage was probably secondary to existing deep-seated damage already present on admission and compounded by lapses in repositioning.

6.2.5The incidence of pressure ulcers, Grade 2 and aboveincluding those developing within 72 hours after admission per 1000 bed days in Januarywas 0.7.This is below the national rate of 0.9 (as per the Safety thermometer data).

6.2.6There were 147 patients admitted to the Trust from the Community with existing pressure damage.

6.3NHS Patient Safety Thermometer

6.3.1The NHS Patient Safety Thermometeris used across all relevant acute wards. This tool looks at point prevalence of four key harms- falls, pressure ulcers, urinary tract infections and deep vein thrombosis (DVT) and pulmonary embolism (PE) in all patients on a specific day in the month. A dashboard is available to each ward showing Trust-wide and ward-level data for each individual harm as well as the harm-free care score. These numbers are also shared via the new ward screens.

6.3.2The harm-free care score for the Trust in Januarywas 96.07% (indicator S02), comparing positively against the target of 95.7% (target based on national average for 2014/15).

6.3.3The Safety Thermometer includes harms suffered by the patient in healthcare settings prior to admission. The actual number of patients who sufferedno new harm during their inpatient stay at WSHFT (indicator S03)in Januarywas99.17%, again very positive against a national average of 97.7% and achieving for the first time the challenging target of 99% set within the Trust Quality Account.

6.3.4In January,5 patients suffered VTE. No themes are available at the time of writing this report and RCAs are being undertaken for all of the cases and the findings will be included next month.

6.3.5National data relating to the NHS safety thermometer is available here:

6.4 Exception Reports Relating to Safety

6.4.1S23 Falls assessment undertaken within 24 hours of admission has seen month-on-month improvement to 93.0%in January(86.5% year to date) against a target of 80%.

6.5 Safer StaffingScorecard

6.5.1There continues to be ongoing recruitment across Divisions in terms of Registered Nurses (RN) and Health Care Assistants (HCA) with the plan to over-recruit to HCAs to support direct patient care while recruitment continues to trained nursing. This is a particular priority in wards where patients have high care needs.

6.5.2Barrow and Boxgrove wards – additional HCA staffing is provided in acknowledgment of the needs of patients with frailty, dementia or delirium. Both wards have also had a skill mix review as part of the ward models for the year ahead.

6.5.3Burlington ward undertakes chemotherapy and additional trained nurse support is put in place when activity is high. Ford ward has low numbers of chemotherapy trained nurses and has 5 nurses undertaking training that is due for completion in the spring. In the meantime there is close liaison between Ford ward and the Fernhurst Centre to support provision of chemotherapy and staff training.

7PATIENT EXPERIENCE

7.1 PALS andComplaints

7.1.1All complaints are responded to by the Trust Office. The process is administered by the Customer Relations Team. The Quarterly Complaints Report provides an in-depth analysis of trends and lessons learned. This is reviewed by the Patient Experience and Feedback Committee and is presented to the Trust Board.

7.1.2During January 2017the Trust received 38 complaints, the lowest level to date this year and continuing the trend of a steady reduction over the last 6 months.These will all be responded to and the trust is working on improving response times for complaints.

7.2 Friends and Family Test (FFT)

7.2.1Patients who access hospital services are asked whether they would recommend WSHFT to their friends or family if they needed similar treatment. Patients who access inpatient, outpatient, day-case, A&E and maternity are all offered the opportunity to respond to the question (plus a number of other areas outside the scope of the official friends and family data collection).

7.2.2Immediate feedback is provided to wards and departments on a continuous basis to ensure staff can address problems or get positive feedback as quickly as possible. In addition to this a dashboard is available giving wards access to their individual scores and a poster printed with ward performance to display to the public. Ward ‘recommend’ rates are also shown on the screens installed on wards.

7.2.3Friends and Family Test Response Rates:

7.2.4Work continues to improve response ratestowards a target this year of 40%. The average response rate in 2015/16 for NHS acute trusts was 24.7%. Response rates across all domains – Inpatient, A&E and Maternity are below the trust target and inpatient rates in particular have seen significant deterioration in January.

7.2.5While acknowledging the reduction in response rates during January, the proportion of patients who would recommend our services to friends and family compares favourably with national median benchmark in all areas as per the table overleaf:

Percentage recommending WSHFT in January(year to date in brackets) / National median (April 2014 to March 2015)*
Inpatient care / 97.0% (95.9%) / 95.3% (April 2015-March 2016)
A&E / 88.4% (89.3%) / 86.8%
Maternity: Delivery care / 100% (97%) / 95.4%
Outpatient care / 96.6% (95.2%) / No benchmark
Maternity: Antenatal care / 100% (96.2%) / 94.6%
Maternity: Postnatal ward / 98.7% (97%) / 92.2%
Maternity: Postnatal community care / 100% (98.6%) / 96.6%

* Some caution should be undertaken using this benchmark due to the changes to the eligible patients noted above.