1. EFFECTIVE C difficile (over 65) Jul-Sep 15 MRSA bacteraemia Jul-Sep 15 MSSA bacteraemia Jul-Sep 15 For the 2 month period Jan-Feb 2016, there were 10,813 admissions to NHS Fife Hospitals. Of which 5,652 were unplanned, 1,762 planned and 3,339 day cases. In addition there were 17,498 new outpatient attendances and 43,558 reviews. REDUCE HARM Lower is better NHS Fife HealthCheck January-February 2016 Presented to NHS Fife Board on 26 th April 2016 SAFE Lower is better Higher is better Lower is better Higher is better

2. Activity Total activity for the period January- February 2016 was 71,869. This included 10,813 admissions to NHS Fife Hospitals, 17,498 new out-patient attendances and 43,558 reviews. Hospital Standardised Mortality Rate (HSMR) The long term trend in HSMR for NHS Scotland continues downwards with NHS Fife performance matching or exceeding this trend. Most recent data release cover period up to end Sep 2015. Weekly monitoring of crude mortality continues. HSMR in the third quarter (Jul-Sep 2015) was 0.91, slightly lower than the previous 2 quarters. The next update for Oct-Dec 2015 is due for release on 17 th May 2016. 95% Harm Free Care Under the Scottish Patient Safety Programme the aim is to further improve the safety of people in Acute Adult Healthcare by ensuring that 95% of people are free from the following harms: CAUTI – The NHS Fife CAUTI Prevention, Insertion and Maintenance bundles have been developed for use across inpatient areas in both Acute and Community hospitals. Cardiac Arrests /Deteriorating Patient - The use of the Scottish Structured Response is embedded in practice and has actions in relation to patients with a FEWs score of 4+ discussed at the daily safety huddle. The Deteriorating Patient Short Life Working Group with support from relevant clinical teams has developed a Hospital Anticipatory Care Plan to support the appropriate care of deteriorating patients, and in particular offer specific guidance for patients who are not appropriate for cardio pulmonary resuscitation. The document had been approved for pilot in 2 clinical areas within VHK. In addition the VHK hospice is keen to pilot its applicability within this care setting also. Pressure Ulcers – A new national pressure ulcer grading tool was introduced in December 2015 across NHS Fife. Discussions held with the University of Dundee re Undergraduate training. The Cluster review process is embedded in practice and from January 2016 meetings will happen monthly to review incidents of major harm “real time” to improve opportunity for learning and clinical improvement. The introduction of the “Tissue Viability Times” to provide a forum for Fife wide communication in relation to pressure ulcer prevention and management, and shared learning /actions following cluster reviews. Leading Better Care event planned for January 2016 focussing on pressure ulcer prevention and management for nurses across NHS Fife. The “Be aware of pressure area care” poster was introduced across NHS Fie to illustrate the process of pressure ulcer risk assessment and appropriate action and management, identifying key learning points identified from cluster review meeting outcomes. Falls -A “Falls Call to Action” Update and Review took place on 11 th December. The Inpatient Falls Prevention Group delivered a revised Falls Pathway across the Organisation and a new Falls Toolkit was launched at this event. Going forward, any new change ideas relating to falls will be tested on Ward 15 as part of the Older People’s Collaborative, led by Dr Aylene Kelman. Inpatient wards across Fife should implement the toolkit in their respective areas. As part of the improvement work, ward 15 is testing a revised process measure to simplify recording. The staff are also improving learning opportunities for all of the staff by ensuring that the outcome of “falls investigations” are shared with staff. Incidents For the period January to February 2016 there were 1989 reported incidents affecting patients. Of these 60% (1188/1989) were graded as no harm, 23% (460/1989) as minor harm, 13% (250/1989) as moderate harm, 4% (86/1989) as major harm and 0.3% (5/1989) as extreme harm. 10% (9/91) of those categorised as major/extreme have been commissioned for an internal Significant Adverse Events Review. These were categorised as: Patient fall (3); HAI (1); clinical (1); tissue viability (1); access/appointment/admission/transfer or discharge (1); endoscopy (1) and unwanted behaviours, violence & aggression (1). Readmissions Navigator from ISD is currently on hold while they develop the new NSS Discovery visualisation tool which is due to go live soon. Readmissions will be in the first phase of indicators. Indicators will drill from Board level data through Location/Consultant/CHP/GP Practice to the patient episodes contributing to a specific indicator. Our locally derived data shows normal variation month on month with a median of 11.6%. 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 57 formal complaints (with multiple issues) reported in January and February 2016.The 3 key themes from these formal complaints remain under the headings of clinical treatment, communication and staff attitude. Further analysis of the data around these themes has began. Your Care Experience In January 2016, 79% (68/86) patients from 8 patient areas at Victoria Hospital and Queen Margaret Hospital completed the “Your Care Experience”, a patient experience survey and rated their overall experience as the “best possible”. In February 2016,100 %(1/1) patients from 1 patient area at Victoria Hospital rated their overall experience as the “best possible”. Responses have been gathered using iPad technology. We are working towards a 90% target that patients will rate their overall experience as positive. Comments received from patients included the following: “All the staff were kind and very professional in the way they performed their duties.they made my stay very comfortable and enjoyable considering my circumstances” (Ward 33 - Jan) “Staff were all kind and friendly which helps when you are a bit afraid.” (Cataract Unit, QMH – Jan) “First class treatment throughout from initial consultation with specialist nurse to procedural team and post-op nursing.” (Ward 53 – Jan) “Patient feels sometimes duplication of appointment and unnecessary journeys being made to hospital” (Ward 54 – Jan) The number of respondents and areas included in the sample from the “Your Care Experience” survey fluctuates every month. In addition, another mechanism to gather patient/carer experience feedback is through Patient Opinion which appears to be utilised well. Scottish Public Services Ombudsman (SPSO) The SPSO upheld the case concerning a GP Practice who failed to reach a diagnosis of diabetes despite Practice attendances over a period of two years. The SPSO recommended that the Practice review their protocols for the management of abnormal diabetic results to ensure they are in line with WHO Guidance. The GP was also been asked to consider the WHO Guidance and identify any learning as part of an Appraisals process. The Practice are required to confirm compliance with the recommendations by 18 April 2016. 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 04/04/16. PERSON-CENTRED Lower is better Higher is better