1. EFFECTIVE C difficile (over 65) Oct-Dec 13 MRSA bacteraemia Oct-Dec 13 MSSA bacteraemia Oct-Dec 13 Activity was 82,314 patient episodes which included 8,365 overnight stays NO DATA Higher is better Lower is better by Dec 15 SAFE Lower is better Higher is better Lower is better NHS Fife HealthCheck January-February 2014 Presented to NHS Fife Board on 29 th April 2014 Number of CAUTIs Jan = 6 Feb = 3 Number of pressure ulcers Jan = 27 Feb =22 by Dec 15

2. Activity Activity for the period January 2014 to February 2014 was 82, 314 patient episodes. This included 8,365 overnight stays and 4,626 day cases. There were 24,386 new and 44,487 review Outpatient attendances. Hospital Standardised Mortality Rate (HSMR) The last quarterly data to September 2013 was published in February 2014. This shows a HSMR of 0.99 for Fife. It should be noted that this is a provisional figure. The majority of hospital admission data will be complete for that latest quarter, however it should still be considered provisional on the basis that the source data are dynamic and additional hospital returns will come in and be reflected in future calculations of the HSMR for that quarter. 95% Harm Free Care One of the aims of the SPSP is that 95% of people in acute adult health care are free from the four harms of the Scottish Patient Safety Indicator (SPSI). The four harms are Cardiac Arrests; Catheter Associated Urinary Tract Infection (CAUTI); Pressure Ulcers and Falls. Cardiac Arrests – The target is a 50% reduction in CPR attempts by the end of December 2015. Figures from last month’s HealthCheck have been adjusted in line with the SPSI definition of cardiac arrest and now excludes cardiac arrests that occurred in the following areas: A&E, SHDU, MHDU, CCU, outpatients and day cases. Improvement work around the deteriorating patient continues with PatientTrack being spread out to wards, weekly reporting on compliance with DNACPR and training by Resuscitation Officers. CAUTIs – There were 6 CAUTIs in January (all Acute Services Division) and 3 in February (1 Acute Services Division, 2 Glenrothes & North East Fife CHP). It is the aim to reduce CAUTIs by 30 % by the end of December 2015. It is hoped to achieve this by the implementation of the urinary catheter insertion bundle, urinary catheter maintenance bundle, to raise awareness of issues with clinical staff and to implement interventions to improve antimicrobial prescribing. Pressure Ulcers – It is thought that the increase in reporting of grade 2-4 pressure ulcers is due to an increased awareness that this is a required element of the SPSI. The aim is to achieve 300 days between hospital acquired avoidable pressure ulcers per ward by the end of December 2015. It is hoped that this will be achieved by implementing the NHS Scotland SSKIN bundle, risk identification and risk assessment of pressure ulcers and education and training in pressure area care. Falls – The target is a 25% reduction in all falls by the end of December 2015. Given the current rate for falls the variation appears to be normal for NHS Fife. An extensive falls programme in the CHPs and the Acute Services Division is being undertaken in order to reduce the number of falls and to raise awareness of issues with clinical staff. Significant Adverse Events (SAE) Review There were a total of 1995 incidents reported from January 2014 to February 2014. Of these 1.0% (18/1995) reported were graded as major/extreme and 44% of those (8/18) have been commissioned for an internal SAE Review. These were categorised as patient falls (2); tissue viability (2); endoscopy incident (1); personal accident (1); access/appointments/admission/transfers/discharge (1); and overpopulated emergency care services in Accident & Emergency and Admissions Unit 1 (1). One of the tissue viability incidents has now been downgraded to a local investigation after the initial Leadership Oversight Group (LOG) meeting. Complaints There were 64 formal complaints (with multiple issues) reported in January 2014 & February 2014. The 3 key themes from these formal complaints were: clinical treatment 44% (114/258); attitude and behaviour 19% (49/258); and communication (oral) 9% (24/258). Patient/Staff Experience Baseline results are now available for five wards who have used the “Your Care Experience” questionnaire to seek feedback. This will be rolled out to a further two wards during the month of May. Tablet devices (n=32) have been purchased and an app developed which will link to the dashboard. The Board should expect to see patient experience data in the June report. Scottish Public Services Ombudsman (SPSO) Four decisions were reached by the SPSO during January and February: Case 1 - the SPSO did not uphold a complaint about the treatment of a child who developed pneumonia; however they did highlight the fact that the documentation was not as detailed as it could have been and provided the Practice with Guidance. Case 2 – the SPSO did not uphold a complaint about the delay in reaching the diagnosis of cleft palate, concluding that all aspects of treatment were reasonable. Case 3 and 4 – the SPSO did not uphold a complaint about the treatment of a breathless patient who subsequently died as a result of a pulmonary embolus. The SPSO did however uphold aspects of the same patient’s hospital care and made a number of recommendations which have been acted upon and included in NHS Fife’s reducing harm action plan and reported via Clinical Governance. Theme for Person Stories at today’s Board is dementia. The Board will hear the story of Mrs A who’s mother suffers from dementia and a story from Mrs W from a staff perspective. 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 15/04/2014 PERSON-CENTRED NO DATA Lower is better NO DATA