clinical quality & patient safety report - surrey scrutiny... · 2012-10-19 · enclosure d...

Enclosure D

CLINICAL QUALITY & PATIENT SAFETY REPORT

Trust Board Meeting Item: 7.2

29th February 2012 Enclosure: D

Purpose of the Report: To report and provide assurance on the Trust’s clinical quality and patient safety performance for January 2012. For information

For Decision

Sponsor (Executive Lead):

Jane Wilson, Medical Director

Author:

Jane Wilson, Medical Director Jenny Parr, Director of Nursing and Patient Experience and Director of Infection Prevention and Control

Author Contact Details:

[email protected] 8934 2723 [email protected] 8934 3855

Financial/Resource Implications: None

Quality Governance Implications:

Evidence of the approach to Quality and Safety and how Quality Governance is addressed, including Board awareness and oversight of risk and performance management.

Risk Implications – Link to Assurance Framework or Corporate Risk Register:

Quality and Safety KPIs in relation to risks identified in the Board Assurance Framework and the Corporate Risk Register.

Legal / Regulatory / Reputation Implications:

None

Link to Relevant CQC Standard:

Outcome 1 – Respecting and involving people who use services; Outcome 5 – Meeting nutritional needs; Outcome 9 – Management of medicines; Outcome 10 – Safety and suitability of premises; Outcome 11 – Safety, availability and suitability of equipment; Outcome 17 – Complaints; Outcome 21 – Records.

Link to Relevant Corporate Objective:

Strategic objective 1: To deliver quality patient centred healthcare services with an excellent reputation.

Impact on Patients and Carers:

The delivery of safe, effective services which provide an excellent patient experience.

Document Previously Considered By:

Executive Management Team – 13th February 2012

Recommendations: Note current performance actions proposed to improve and confirm agreement with them.

Kingston Hospital NHS Trust - Trust Board – Part I - February 2012 1

mailto:[email protected]

mailto:[email protected]

Enclosure D

Kingston Hospital NHS Trust -Trust Board – Part I - February 2012

Enclosure D

CLINICAL QUALITY & PATIENT SAFETY REPORT

(Trust Board February 2012)

Kingston Hospital NHS Trust -Trust Board – Part I - February 2012

Enclosure D


Enclosure D

CONTENTS EXECUTIVE SUMMARY .................................................................................................................................... 4

SECTION 1: OUTCOMES/EFFECTIVENESS AND PATIENT SAFETY ........................................................... 5

SECTION 2: PATIENT EXPERIENCE.............................................................................................................. 10SECTION 3: QUALITY ACCOUNT PRIORITIES SUMMARY……………………………………………………...13 SECTION 4: CARE QUALITY COMMISSION ESSENTIAL STANDARDS OF QUALITY AND SAFETY ...... 15

SECTION 5: JANUARY 2012 DETAILED KPIS .............................................................................................. 16 APPENDIX A: CARE QUALITY COMMISSION ESSENTIAL STANDARDS OF QUALITY AND SAFETY

(DECEMBER 2012)……………………………………………………………………………………..18


Enclosure D

EXECUTIVE SUMMARY 1. The purpose of this report is to provide the Board with an overview of clinical quality and safety. The metrics should be considered in the context

of the overall performance of the Trust and in particular to determine if there are any changes in quality that might be due to the Productivity Programme. To date there is no evidence that quality is being adversely affected by the Productivity Programme.

2. Quality and Safety performance overall remains good. Achievements 3. HSMR (82)) for the Trust remains low. 4. The incidence of falls and pressure ulcers remain low. 5. Length of stay throughout the Trust is good. 1. VTE risk assessments are now being undertaken above the required rate 5. All Serious Incident investigation reports have been submitted within expected date 6. There are no new Grade 2 SIs 7. The Trust is compliant with single sex accommodation requirements,

Concerns Actions • There have been two cases of C.difficile and this takes the Trust

very close to our year end target. • The importance of infection control measures are being

reinforced throughout the Trust and in particular through Frontline Focus Fridays.

• Achieving a caesarean section within our SLA contract rate (26%) remains challenging

• The maternity unit have initiated several actions to reduce the section rate further and the rate in primiparas has shown some improvement

• The results of the Picker Outpatients Survey 2011 demonstrate that patient experience in Outpatients is worse than in the 2009 survey.

• The data is being analysed and an action plan is in development. It will be approved at the Patient Experience Committee in March.

Recommendations & Action required by the Trust Board 8. Note current performance actions proposed to improve and confirm agreement with them. . .


Enclosure D

SECTION 1: OUTCOMES/EFFECTIVENESS AND PATIENT SAFETY

COMMENTARY Hospital Standardised Mortality Ratio (HSMR) DFI 1. The trend data and Trust position nationally show good

performance with the HSMR at 82 year to date. ForOct 2010 – Nov 2011 this represents 185 less deathsthan expected (747 vs 932)

SHMI 2. SHMI is now published for all Trusts by NHS Choices

and is reported quarterly, the latest value (Jan 2012) is85 (much better than expected.) There is no trend datayet available.

Mortality Alerts (DFI) 3. There are no new mortality alerts this month. Patient Safety Indicators (PSI) 4. As reported to the Board previously there are 3 Patient

Safety Indictors for which there is a higher reportedincidence than expected. These are for perinealtrauma with both normal and operative vaginal birthsand for accidental puncture and laceration. Full detailsrelating to these alerts have been reported to the Boardpreviously (January 2012). As the alerts are influencedby external data it is likely that they will remain.

Mortality: Chart showing in month position HSMR (DFI)

Relative Risk of Mortality (All HSMR Diagnoses)Source: Dr Foster

0

20

40

60

80

100

120

Apr

May Ju

n

Jul

Aug

Sep Oct

Nov

Dec Ja

n

Feb

Mar

Month

Rel

ativ

e R

isk

2011-12 2010-11 Target

GOOD

Funnel plot KHT position HSMR DFI (Apr-Nov 2011)


Enclosure D

Number of Patient Safety Incident Falls

0

2

4

6

8

10

12

Apr

May Ju

n

Jul

Aug

Sep Oct

Nov

Dec Ja

n

Feb

Mar

Month

Num

ber o

f Fal

lsFalls per 1000 bed days 2011-12Falls per 1000 bed days 2010-11NPSA Benchmark falls/1000

GOOD

COMMENTARY Falls Quality Account Priority 1: 5. The incidence of falls remains low at 3.4/100 beds days

(NPSA benchmark 4.8/100 bed days). Continuingactions to maintain this level are monitoring of the fallsKPI on the ward score cards and as a topic for frontlineFocus Fridays. An audit of completed fallsassessments in December showed an improvement ofcorrect assessment being completed from 72% into89%

Venous Thrombo-embolism (VTE) Quality Account Priority 3: 6. The reported rate of completion of VTE risk

assessments is currently 92.8%. This is above the nationally required rate of 90%. Providing this rate continues we will achieve the Q4 CQUIN target.

Length of Stay (LoS) 7. Trust wide LoS remains below expected by DFI

benchmark. There was a slight increase in LoS for January 2012 in Emergency Surgery.

Prevention of Hospital Acquired VTE - % of Patients Risk Assessed

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr

-11

May

-11

Jun-

11

Jul-1

1

Aug

-11

Sep

-11

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Feb-

12

Mar

-12

Month

% o

f Pat

ient

s R

isk

Ass

esse

d fo

r VTE

Prevention of Hospital Acquired VTE - %patients risk assessedTarget

GOOD

POOR


Enclosure D

Kin

COMMENTARY Pressure Ulcers Quality Account Priority 2:

8. The incidence of pressure ulcers remains lower than last year.The frequency of occurrence of grade 2 pressure ulcers isunchanged for the past 3 months. There were no grade 3 or 4pressure ulcers in January 2012. Root cause analysis of thegrade 3s December has been completed and an action planapproved at the Executive Management Committee. Thisincludes specific individual performance actions, the introductionof an enhanced training programme with a particular focus oninitial assessments in the Emergency Department and checkingof the assessment by senior staff on the admission ward.

Infection Control

9. There were no MRSA bacteraemias in January 2012. The yearto date incidence is 2 hospital acquired MRSA bacteriaemias(year end target is no more than 3). The Trust will be expected tohave no more than 1 MRSA for 2012/13.

10. Two cases of C.difficile occurred in January 2012. This takes thetotal for the year to 16. The target for the year is 17 and there isa risk that this will be breached. It will be very challenging for theTrust to meet next year’s more stringent target of 15 cases.

11. In December 2011 there was a new case of the outbreak strain

Number of Patients with Grade 2 Pressure Ulcers

0

5

10

15

20

25

Apr

May Ju

n

Jul

Aug

Sep Oct

Nov

Dec Ja

n

Feb

Mar

Month

Num

ber o

f Pat

ient

s w

ith P

ress

ure

Ulc

ers

Grade 2 Pressure Ulcers 2011-12Grade 2 Pressure Ulcers 2010-11Target for 2011-12

GOOD

Number of Patients with Grade 3&4 Pressure Ulcers

1

2

3

4

5

6

7

umbe

r of P

atie

nts

with

Pre

ssur

e U

lcer

s

Grade 3-4 Pressure Ulcers 2011-12Grade 3-4 Pressure Ulcers 2010-11Target for 2011-12

GOOD

of vancomycin resistant enterococci (VRE) reported previously. The patient had been on ITU and Astor and the infection control team carried out environmental audits and raised hand hygiene awareness in both areas. Management was appropriate.

12. In January 2012 there were two confirmed cases of Norovirus in Derwent ward; there were no other confirmed cases and the outbreak was contained to one bay.

0

Apr

May Ju

n

Jul

Aug

Sep Oct

Nov

Dec Ja

n

Feb

Mar

Month

N

gston Hospital NHS Trust - Trust Board – Part I - February 2012 7

Clinical Incident Reporting: Serious Incidents January 2012

STEIS ID REPORTING CRITERIA DIVISION NPSA

GRADE

(0, 1, 2)

INCIDENT DATE

DUE DATE

2012/1447

Unexpected admission to neonatal intensive care

Women and Children’s Services 1 18-Jan-12

23 Mar 12

2012/1487 Information Governance Surgery and Critical care 1 20-Jan-12

23 Mar 12

2012/1490 Delay in treatment Surgery and Critical care 1 20-Jan-12

23 Mar 12

2012/2178 Head injury post fall in hospital

Medicine and emergency care 1 06-Jan-12

30 Mar 12

2012/2378 Ambulance handover breach Medicine and emergency care 1 24-Jan-12 02 Apr 12

2012/2383 Unexpected death –GI bleed Medicine and emergency care 1 21-Jan-12 02 Apr 12

COMMENTARY 11. There were 6 incidents in January 2012 that met

the criteria for management under the SIprocess. All are Grade 1 SIs and their details areshown in the table (left). .

Grade 2 Investigation Reports and Action Planprogress 12. There are no new Grade 2 serious incidents and

no outstanding actions beyond agreed timeline. Grade 1 Action Plan progress 13. Action plans for Grade 1 investigations are

monitored at Divisional Risk/Governance Boardsand overseen by the Patient Safety Committee.All actions due for completion by 31 January2012 for Grade 1 investigations have beencompleted.


Serious Incident Performance

Key

January 2012 Division

Incident reports due and completed in January 1

Serious incidents currently overdue2

Serious Incident performance in 3 months NHSL RAG3

Forecast progress4

Ambulatory Care 1 0 1 0

Women's & Childrens 1 0 2 1

Surgery & Critical Care 0 0 0 2 2 1

Medicine & Emergency Care 0 0 1

2

Corporate 0 0 1 1

3 1

Trust Total

2

0 5 5

1The number of SIs that were due back to NHS London in December 2011

3 Serious incidents that were due in the last 3 months where green indicates no overdue reports, amber indicates 1-49% overdue and red indicates 50% or more overdue

2The number of SIs that are currently overdue to be submitted to NHS London

4 The number of current serious incidents where green indicates the number on schedule, amber indicates the number at risk of breaching the final date due for completion of Trust approval and red indicates the number at risk of being overdue to NHS London.

COMMENTARY 14. Performance in completing SI reports has

improved.

15. Performance is now managed to a timeline withset date milestones instigated as soon as the SIis declared by the Head of Risk. This ismonitored weekly by the ExecutiveManagement Team.

16. The table demonstrates that no reports wereoverdue in January 2012. Progress with ongoing investigations is on target to have nofurther overdue reports.


SECTION 2: PATIENT EXPERIENCE

Mixed Sex Accommodation 1. There have been no breaches of mixed sex

accommodation or complaints relating to mixed sexaccommodation relating to this period.

Patient Experience Tracker (PET) 2. As previously reported to the Trust Board, PETs are

used throughout the hospital to gain real time feedbackfrom patients about their experience.

3. Performance has remained similar over the period.

Work is required to improve the patient’s perception ofnurses involving them in discussions about their care.Frontline Focus is a mechanism for this.

Outpatient Experience 4. The results of the Picker outpatient survey 2011 has

been received by the Trust. The survey suggests thatpatient experience in outpatients is worse that it was inthe previous survey in 2009. A Trust Board walkaboutto oupatients was held on January 26th 2012. Theresults of the survey are currently being analysed. Anaction plan addressing the concerns raised in thesurvey and walkabout is being developed and will beapproved at the Patient Experinece Committee inMarch 2012.

Patient Experience Tracker – April 2011 to January 2012

Patient Experience Tracker Responses to Trust Two Core QuestionsApril 2011 to January 2012

0

2000

4000

6000

8000

10000

12000

14000

16000

Do staff respect your privacy and dignity? Do you feel that nurses include you with discussionsabout your care?

Question

Num

ber o

f Res

pons

es

Alw ays Most of the timeSometimes Seldom


Co

Kin

mplaints and PALS

COMMENTARY Formal Complaints The Trust received 87 formal complaints in the periodNovember 2011 to January 2012 compared to 106 for thesame period in 2010. The Accident and EmergencyDepartment received the highest number of complaints at22% of the total. The most frequent complaints were about poorcommunication (24%), clinical treatment (15%) and failedor delayed diagnosis (6%). Examples of actions taken as a result of these complaintsare:- Delayed or failed diagnosis

• A rapid assessment of patient (RAP) streamingprocess has been developed in the Majors area.

• The ER Consultant has highlighted the need for alldoctors to undertake a comprehensive examinationof all patients presenting with trauma, howeverseemingly minor. He has instructed that all patientspresenting with chest pain following trauma have anabdominal examination.

• The Orthopaedic Matron is to review the currentthrombo-prophylaxis guidelines for Orthopaedicsand the pathway for diagnostics re MRI scanning

gston Hospital NHS Trust - Trust Board – Part I - February 2012 11

COMMENTARY PALS 5. The Trust received 365 concerns during the period

November 2011 to January 2012, compared to 570 forthe same period in 2010. This number will increaseonce all the data entry is completed.

6. The charts opposite show the top five most commonly

raised concerns and the subjects by the top threelocations.

7. This period has shown an increase in concerns relating

to the Royal Eye Unit, and a sustained volume ofconcerns about the work carried out by Administrativeand secretarial office staff.


SECTION 3: QUALITY ACCOUNT PRIORITIES SUMMARY Publication of an Annual Quality Account is a statutory responsibility. This table gives an update of performance in the 7 quality account priorities identified in this year’s account and the likely end of year achievement. Priority Aim Current Position Actions Month Year

End rating

Falls To reduce patient falls to less than 4.8/1000 bed days NPSA benchmark by March 2012

January 2012 – Falls 3.4/1000 bed days April to January 2012, there was a 46.7% reduction in falls, compared to the same period last year.

• Implement post falls pathway • Continue to implement Falls

Action plan and monitor performance and risk assessments (documentation audit)

Pressure ulcers To reduce hospital acquired grade 3 and 4 pressure ulcers by 70% by 30th March 2012

April to January 2012 data shows Grade 3 and 4s reduced by 56.5% compared to the same period last year

To reduce the number of hospital acquired grade 2 pressure ulcers from the baseline 10/11 figure by 30% by 30th March 2012.

April to January 2012 Grade 2 reduced by 38% compared to the same period last year

• Develop and implement PU skin care bundle

• Monitor assessment through documentation audit

• Implement mini grade 2 PU RCA

VTE To meet the 95% risk assessment target set last year by 30th March 2012

January 2011 = 92.8% Weekly monitoring Divisional actions

Pain Better pain control for all patients by 30th March 2012.

No progress since the last report. Audit currently being analysed. Standardisation of documentation. Establishment of Pain Link Nurse programme. Vulnerable groups invited to trial form.

• Obtain final results of audit. • Vulnerable groups to trial

form. • Obtain feedback on Trust-

wide pain management guidelines from group and submit to D&T Group & Clinical Effectiveness.


Priority Aim Current Position Actions Month Year End rating

Administration process (nursing practicalities). Trust-wide pain management guidelines feedback awaited. Patient Information Booklet agreed.

• Obtain input from Patient

Liaison Group on Patient Information Booklet.

To eliminate emergency readmissions (0%) occurring within 30 days of discharge following an elective admission.

Emergency post elective readmissions have reduced from 2.2% to 1.3%.

Divisional investigation of readmissions Actions taken through contract monitoring group Readmissions group

Readmissions

Reduce all other admissions within 30 days of discharge (to 6.2%).

Emergency post emergency readmissions are at 10.2%

Divisional investigation of readmissions and assessment of whether related to original admission

Dementia To improve the care to our patients who suffer from dementia.

81% of patients aged 65 and over had memory assessment. (no new data since December 2011)

Increase education of junior doctors (induction) Care plan for personalised care to be implemented Re-audit early brief cognitive assessment (March 2012)

Communication To ensure that we listen to you and address your concerns and improve the way we communicate with you.

Defined values Implemented Living our values everyday project Communication complaints has reduced again in this period. The Team Development Sessions have been delayed but are in the process of being scheduled.

Implement outputs from “in your shoes” sessions Pilot team development sessions initially planned for Q3 are being scheduled for Q4. Implement Net Promoter Score (Q4)


SECTION 4: CARE QUALITY COMMISSION ESSENTIAL STANDARDS OF QUALITY AND SAFETY Summary of Current Position The Care quality Commission have not issued a Quality Risk Profile for January at the time of writing this paper. The previous QRP (December 2011) is presented as Appendix A, for reference.


SECTION 5: JANUARY 2012 DETAILED KPIS


APPENDIX A: CARE QUALITY COMMISSION ESSENTIAL STANDARDS OF QUALITY AND SAFETY (DECEMBER 2012) 1. There are 16 core outcomes for which Kingston Hospital Trust is scored by the CQC. Each Outcome has an Executive Director Lead who

undertakes a self assessment of compliance with the standards described in the outcome. The assessments are validated by a challenge process.

2. The CQC visited the Trust on 16th and 17th November 2011 to review compliance with the 16 Essential Standards of Quality and Safety.

The draft report has been received and is being checked for factual accuracy. On receipt of the final report from the CQC the Trust Board will receive a more detailed report.

3. The CQC give the Trust a compliance score based largely on external evidence derived from a number of sources. These scores form a Quality and Risk Profile. The QRP is used by the CQC as a broad indicator and useful comparator tool, it should be considered in this context. It does, however, help us identify and focus on areas where there may be concerns. The most recent QRP (December 2011) showed changes in 4 outcomes as shown below.

December Quality and Risk Profile (QRP) 4. The table below shows the changes in regard to the CQC compliance score trend from October 2011to December 2011. When Comparing

the November 2011 QRP with the December 2011 QRP; three outcomes have an increasing risk score, one has a decreasing risk score and nine outcomes are unchanged.

5. The Trust’s lowest score is Low amber for 1 out of the 16 Outcomes (Outcome 12 ‘Staffing’), whilst the highest score is Low Green (the best score within the CQC ratings) for 1 Outcome (Outcome 21 ‘Records’).

6. The table shows the QRP ratings for all the Essential Standards; those highlighted indicate where there has been a change from the

November 2011 QRP.


Outcome Description Oct QRP Nov QRP Dec QRP Change in

risk score Nov – Dec ‘11

Reasons for changes in risk score

1 Respecting &involving people who use services

Low neutral Low neutral Low neutral

2 Consent to care & treatment

High green Low neutral Low neutral

4 Care & welfare of people who use services

Low green Low green High green Increased There are no new red or amber ratings within this outcome but data has been added and there have been shifts in the rating of existing data resulting in a slight increase in risk.

5 Meetingnutritional needs

Low green Low green Low neutral Increased The risk of non compliance has slightly increased. The data is exactly the same, both qualitatively and quantitatively as that contained within the November QRP. The reason for this revised rating is believed to be due to a changed statistical weighting given to the data.

6 Cooperating withother providers

High green High green High green

7 Safeguardingpeople who use services from abuse

Insufficient data

Not enough data

Not enough data

8 Cleanliness &infection control

Low neutral Low neutral Low neutral

9 Management ofmedicines

Insufficient data

Not enough data

Low neutral

10 Safety andsuitability of premises

High green High green Low neutral Increased The risk of non compliance has slightly increased, due to additional new data. This data is rated as ‘similar to expected’ but the shift in overall rating must be due to changes in statistical weighting given to the data. There are no new red or amber ratings within this outcome.


Outcome Description Oct QRP Nov QRP Dec QRP Change in risk score Nov – Dec ‘11

Reasons for changes in risk score

11 Safety,availability and suitability of equipment

High neutral High neutral Not enough data

12 Requirementsrelating to workers

Insufficient data

Low amber Low amber This outcome had been reported as insufficient data from the first QRP in September 2010. The new item in the November 2011 QRP is associated with the Endoscopy Global Rating Scale Self Assessment Census, in particular Skill mix and recruitment. The Division is developing an action plan to address this.

13 Staffing Low neutral Not enough data

Not enough data

14 Supporting staff Low neutral High neutral Low neutral Decreased The risk of non compliance has slightly decreased. The data is exactly the same, both qualitatively and quantitatively as that contained within the November QRP. The reason for this revised rating is believed to be a changed statistical weighting given to the data.

16 Assessing &monitoring the quality of service provision

Low neutral Not enough data

Low neutral

17 Complaints Low neutral Not enough data

Not enough data

21 Records High green Low green Low green


Elements which are rated “worse” and “much worse than expected”

Actions:

• The last results of the adult inpatient and outpatient national survey results.

• Number of patients not treated within 28 days of last minute cancellation

• The emergency readmission ratio for 2 specific Healthcare

Resource Groups (HRG). • VTE is currently rated red as we are working to achieve the DH

target of 90%. • Elements of the most recent staff survey.

• Some workforce areas which are derived from a 2010 vacancy

survey looking at three month vacancies. • Participation in Patient Reported Outcome Measures (PROMs) is

low. • Response to the Bliss Baby Report survey of neonatal units – Data

for Kingston Hospital. • Data quality of data provided to Secondary User service (SUS).

• The Patient Experience action plan and the RTT action plan are addressing these.

• Reviewed weekly, no apparent trends. Capacity issues being addressed in all specialties so that patients can be rebooked very quickly.

• Reducing readmission rates is a Quality Account priority and the focus of the Contract Monitoring group and a specific readmissions group has been set up.

• VTE is currently rated red as we are working to achieve the DH target of 90%.

• Addressed by the Staff Survey Action plan and the Patient Experience Action plan.

• Since this time we have taken steps to address these which are covered more fully in the workforce report.

• Low participation is being investigated.

• The Trust choose not participate in this survey. We are discussing with the CQC whether non participation warrants a ‘worse than expected’ score.

• Investigating causes of score as KHT has good reputation for data quality.


clinical quality & patient safety report - surrey scrutiny... · 2012-10-19 · enclosure d...

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