Date of Meeting: 27 October 2016 / Agenda Item: 6
Title
Quality Report – Month 6
Responsible Executive Director
Dr George Findlay, Medical Director
Amanda Parker, Director of Nursing and Patient Safety
Prepared by
Dr George Findlay, Medical Director
Amanda Parker, Director of Nursing and Patient Safety
Status
Disclosable
Summary of Proposal
N/A
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 report.
Communication and Consultation
N/A
Appendices
Appendix I: Quality Scorecard
Appendix II: Ward Staffing Scorecard
1 INTRODUCTION
1.1 This 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).
1.2 The 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.
2 2016/17 REFRESH
2.1 As part of the refresh of the Quality Strategy for 2016/17 that outline key quality objectives for the next years, this report will be refreshed and redesigned in line with the strategy objectives and to align to the Trust’s True North objectives.
2.2 There 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.
3 KEY QUALITY OBJECTIVES
3.1 Dashboard Definitions
3.1.1 The full Clinical Quality Dashboard is presented as Appendix I. Figures are in-month figures (e.g. the number of falls reported in October) 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.
3.1.2 Exception reports are included under the relevant section of this report (i.e. under the broad headings Effectiveness, Safety and Experience).
3.1.3 Only 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.
3.2 Domain scores
3.2.1 The 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.
3.2.2 Year to date domain scores are calculated 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.
3.2.3 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.
3.3 Overview of Key Quality Objectives
3.3.1 The following table shows performance against key, top level quality objectives.
Indicator / July2016 / August
2016 / Sept
2016 / 2016/17 to date / 2016/17 Target / limit
Effectiveness Domain Score / 2.58 / 2.71 / 2.64 / 2.56 / 2.5
Safety Domain Score / 2.5 / 2.22 / 2.06 / 1.96 / 2.5
Experience Domain Score / 2.07 / 2.13 / 2.15 / 2.13 / 2.5
E01 Trust crude mortality rate (non-elective) / 2.88% / 2.63% / 2.57 / 2.91% / 3.13%
E03 Hospital Standardised Mortality Ratio for top 56 diagnoses (Dr Foster, based on rolling 12 months) / 89.8 (12m to Jne / <92
S06 Number of Serious Incidents Requiring Investigation (number reported in month) / 6 / 7 / 6 / 48 / 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 / 1 / 1 / 10 / 16 (national target = 39)
X38 The Friends and Family Test: Percentage Recommending Inpatients / 95.8% / 96% / 96% / 95.7%
X39 The Friends and Family Test: Percentage Recommending A&E / 89.2% / 87.9% / 86.7% / 89.9%
X13 Mixed Sex Accommodation breaches (number of breaches) / 0 / 0 / 0 / 6 / 0
X18 Number of complaints / 58 / 47 / 46 / 323 / 570
4 EFFECTIVENESS
4.1 Crude Trust Mortality
4.1.1 Due 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.
4.1.2 Crude non-elective mortality fell from 2.63% in August to 2.57% in September. This is lower than the equivalent month in 2015 (September 2015 = 2.70%). The number of nonelective patients who died in September was 146 (from 5472 discharges). The year to date mortality rate is 2.91% and the rolling 12 month mortality rate is 3.12%. The limit for both measures is 3.13%
4.2 Hospital Standardised Mortality Ratio (HSMR)
4.2.1 There 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 June 2016.
4.2.2 The Trust’s HSMR for the twelve months to May 2016 is 89.8 (where 100 is the level predicted by the Dr Foster model using the April 2015 benchmark).
4.2.3 The twelve month HSMR to January 2016 split by site is lower for St Richards (85.5) than for Worthing (93.2), however both are lower than 100.
4.2.4 This data is now rebased using the latest available benchmark (April 2015), this accounts for the observable increase at April 2015.
4.2.5 A 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.
4.2.6 The Trust has set the goal of achieving a position within the top 20% of Trusts as measured by HSMR. For the twelve months to June 2016 performance using this measure places us in the top 16% of Trusts
4.3 Summary Hospital-Level Mortality Indicator (SHMI)
4.3.1 The latest data made available by the Health and Social Care Information Centre is for the period to March 2016. The Trust value is 1.00 (where 1.00 is the national average), with the Trust banded as ‘as expected’.
4.4 Exception Reports Relating to Effectiveness
4.4.1 E11. Emergency readmissions. An audit of emergency readmissions is underway to fully understand the data, the true position and the opportunities for improvement.
4.4.2 E13. C-Section rate. C-Section rate has shown an in month increase to 31.3%. Each case undergoes a RCA process to look for learning opportunities. No systemic causes or trends have been identified and practice is very much in line with national recommendations and NICE guidance. This continues to be an area of focus for the division and is closely managed via monthly divisional performance reviews.
5 SAFETY
5.1 Central Alert System (CAS) Safety Alerts
5.1.1 There are no outstanding alerts for the Trust relating to September 2016 or earlier.
5.2 Serious Incidents Requiring Investigation (SIRIs)
There were 6 incidents which were reported in September that have initially 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.
5.2.1 The 6 incidents related to 2 unstageable pressure ulcers, 3 falls resulting in a fracture neck of femur and surgery/death, I maternity incident and a never event around wrong medication route.
5.2.2 Recent actions undertaken/planned following SIRIs include a review of the escalation process in A&E when their capacity is full. Trust wide sharing of information on devices that support preventing heel damage and sharing of the method for SWARM introduction in regard to pressure damage. This a process currently used around falls.
5.3 Infection control
5.3.1 There was 1 case of hospital attributable Clostridium difficile during September. This occurring at the Worthing site.
5.3.2 This case number for September equates to a rate of 3.6 cases of C diff per 100,000 bed days compared the national average for 2014/15 of 15.1 cases per 100,000 bed days (interquartile range 10.3 to 17.6) (source: https://www.gov.uk/government/statistics/clostridium-difficile-infection-annual-data).
5.3.3 Of the 1 case in September, root cause analysis identified there was a lapse in care due to a dirty commode. Within this clinical area all staff have been requested to view the commode cleaning video that is readily available.
5.3.4 The allocated trust target limit for 2016/17 remains at 39. A stretch target limit of 33 has been agreed for the trust as we aspire to improve on last year. We have currently reached a total of 20 cases and are currently above trajectory.
5.3.5 A total of 10 lapse of care incidents have occurred against a stretch target of 16 cases.
5.4.1 Influenza Vaccination
5.4.2 Activity has commenced to ensure that the organisation is prepared for winter and that staff have received the flu vaccine in order to to protect patients, themselves and their families. Nationally a target of 75% uptake for front line workers has been set with this linked to CQUIN funding.
5.4.3 After 3 weeks of vaccination the trust has achieved an uptake rate of 26.7% of frontline staff. In addition a significant number of non-front line staff have been vaccinated as a part of supporting staff health and well-being.
6.1.1 Falls
6.1.2 In September there were 41 falls resulting in harm against a benchmark of 43.
6.1.3 There were 2 falls resulting in a fracture neck of femur and surgery and resulted in moderate harm to patients.
6.1.4 Ten wards are currently within a falls break through project, these wards continue to show significant improvement in their patient fall numbers and have been sharing their learning with other wards.
6.2 Tissue Viability
6.2.1 As described previously, changes in the way the Trust reports pressure ulcers means that more grade 2 and grade 3 ulcers were reported in 2015/16 than previous years. This pattern of reporting will change from October as grade 3 plus will not be required to reported as serious incidents.
6.2.2 Based upon these reporting arrangements, during September the Trust reported 17 cases of grade 2 hospital acquired pressure ulcers.
6.2.3 In addition to this there were 3 hospital acquired pressure ulcers that were grade 3. None related to medical devices and all were considered to have had a lapse in care related to either assessment, documentation or use of equipment.
6.2.4 The incidence of pressure ulcers, Grade 2 and above (including those developing within 72 hours after admission) per 1000 bed days in September was 0.71. This compares to a national rate of 0.9 as recorded through the Safety thermometer nationally in March 2016.
6.2.5 There were 134 patients admitted to the Trust from the Community with pressure damage.
6.3 NHS Patient Safety Thermometer
6.3.1 The NHS Patient Safety Thermometer is 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.