Presented By: Gwen Nuttall – Chief Operating Officer, Nichole Day Executive Chief Nurse Prepared By: Information Team Date Prepared: 15 th April 2011 Subject: Integrated Quality and Performance Report - March 2011 Purpose: For Information Strategic Objective: To Achieve Performance Levels in accordance with the CQC “Standards for Better Health” Executive Summary: The paper focuses on the key core targets, identified by the Department of Health and the Care Quality Commission, summarising performance to the end of March It also provides the board with information to assess the Trust’s performance against quality indicators, including patient experience, clinical outcome and effectiveness and patient safety. Trust Board Committee – 28 th April 2011

SUFFICIENT Note the Trust Performance to March Failure to deliver the 4 hour core access target for the year. - Failure to achieve C-Difficile target for the year. Robust Action Plan developed. Performance Management and Monitoring. Improved Escalation Review of Cohort Unit

Contents 1. Introduction 2. Emergency Care A&E 3. Cancelled Operations 4. LOS 5. Outcomes & Effectiveness – Clostridium Difficile 6. Patient Safety 7. Risk Assessment 8. Patient Experience 9. Conclusion

1.& 2. Introduction & Emergency Care 1. Introduction: This report provides a briefing to the Board members on the performance against key targets up to March The paper focuses on the main targets, identified by the Department of Health and the Care Quality Commission. 2. Emergency Care – A&E Target: 95% of patients seen/treated/discharged within 4 hours The Trust did meet the 95% Target for the month of March 2011 (99.7%). Key actions:- Interviews for A&E and EAU consultant posts to be held in May 2011 Integrated Action Plan agreed and monitored weekly, via weekly A&E departmental meetings. Review of medical commitments in morning and afternoon commenced. Job Plans are being updated. Bed Meetings reviewed and enhanced. Standard operating procedures commenced. The pilot of the discharge lounge recommenced in April and its impact will be reviewed on a daily basis. The trust is developing a recording mechanism for the new A&E quality indicators The updated detailed A&E 4 hour performance action plan is attached as a separate paper. Page 4

3. Cancelled Operations The target was not met for March at 1.11% A deterioration in performance from February to March. Out of theatre time remains the predominant reason with an increase in the number of emergencies impacting on elective theatre time. Target 0.8% Actual 0.87% (YTD) The first “Visioning Workshop” for the Productive Theatre has taken place and an outline of the project given to the Trust Board. Further TPOT workshops are scheduled. Theatre scheduling issues are being addressed by the Clinical Director of Theatres in conjunction with Governance.. Page 5

4. Length of Stay (Spells) Page 6 The targets are from Dr Foster ‘Expected’ positions using 09/10 as a benchmark. Non Elective LOS for Medicine is above target – Actions to improve this performance is linked to discharge action plans and implementation of EAU model and short stay beds. Non Elective LOS for Surgery remains below the expected level, but has seen an increase in 2010/11. There has been a small increase in the length of stay for complex elderly patients over the year. However the new Geriatrician now has scheduled ward rounds on orthopaedic ward. Elective LOS for Surgery is similar to last year. Review of day case and day of surgery activity continues, especially in urology. The productive theatre will also focus on Urology.

7 Hospital Standardised Mortality Ratio HSMR has been fairly consistent over recent months and is below the expected level as can be seen by the overall mortality shown in the graphs and the table giving a mortality rate for the five Dr Foster - How Safe is Your Hospital indicators. These tables provide information on relative risk, with red, blue and green traffic lighting. Blue indicates that the score is within the standard deviation. We continue to monitor the overall HSMR and we also monitor the HSMR for emergency patients and identify any individual diagnoses that trigger any alerts. These are all investigated and reported to the Quality and Risk Committee and Patient Outcomes Implementation Group. 5. Outcomes and Effectiveness Page 7 National Rate from last reporting period Jul 08- Aug 09 Aug 08- Sep 09 Sep 08- Oct 09 Oct 08 - Nov 09 Nov 08 - Dec- 09 Dec 08 - Jan 10 Jan 09 – Feb 10 Feb 09 -Mar 10 Mar 09 -Apr 10 Apr 09- May 10 May 09 -Jun 10 Jun 09 -Jul 10 Jul 09- Aug 10 Aug 09- Sep 10 Sep 09- Oct 10 Oct 09- Nov 10 Nov 09- Dec 10 Dec 09- Jan 11 Rolling 12 Month HSMR-All Admissions Rolling 12 Month HSMR-Non Elective SMR Stroke (Acute Cerebrovascular Disease) SMR - Heart Attack (AMI) SMR - FNOF Mortality from Low Risk Conditions

8 5. Outcomes and Effectiveness Page 8 Infection Prevention The C. difficile target for 2010/11 was 29 hospital cases although due to the recent C. difficile outbreak the PCT recognised that we would not hit our trajectory and agreed that they would accept no further preventable C. difficile cases. In March there were a further 3 hospital attributed cases, bringing the total to 37. All cases were considered unavoidable and all patients were transferred to the F9 cohort unit within the time frame specified. The Trust continues to achieve excellent results in other infection control KPIs. There were no hospital associated MRSA bacteraemia and High Impact Intervention performance has improved with scores ranging from %: HII 2b: Peripheral cannula ongoing scored 93% due to VIP scores not recorded in the surgical directorate. HII 6b: Urinary catheter insertion scored 98% All other HII scored 100% compliance. Antibiotic Prescribing As part of the rolling programme of quarterly audit of antibiotic prescribing, G4 scored 93% compliance in March.

9 6. Patient Safety Page 9 Pressure Ulcers The number of patients with ward acquired pressure ulcers decreased this month to 11 with no Grade 3 or Grade 4 pressure ulcers reported. This is calculated in bed days for CQUIN and March result = 0.92 pressure ulcers/1000 bed days. The target was 0.42 for Q.4 which equates to 5 pressure ulcers. Themes from RCAs: 55% (6) of the hospital acquired pressure ulcers occurred on G4. A combination of vacancy, sickness absence and high patient dependency were issues for this ward this month. These are being addressed by managers Poor documentation of risk assessment, management plans and scoring discrepancies between risk assessors is a recurring theme in patients that develop pressure ulcers. Limited availability of the Tissue Viability Nurse team to support staff in training and risk management. At weekends there can be significant delays in acquiring pressure relieving mattresses. There is an identified need for more training of staff in classification of pressure ulcers on admission. Actions: Equipment resources and timeliness of delivery into the clinical areas is a workstream identified by the pressure ulcer action plan. Training needs analysis for every member of nursing staff will be completed by the ward managers before developing a ward-based training programme.

6. Patient Safety Page 9 Patient Falls The total number of falls in March was 65 and 25 of these falls resulted in harm to the patient. The majority of falls are within the medical directorate (n= 48). These are mainly on F8, G5 and G8- 10,10 and 13 falls respectively. The majority of all patients on these three wards are at high risk of falling. 17 falls occurred within the surgical directorate, with a significant number on F3 (8 falls). F3 have high risk of falls patients on the ward at any time. Themes from RCAs : 20 patients that sustained harm after falling were confused (dementia/delirium). Clinical areas are unable to access enough ultra low beds (4 in use in Trust currently) and wanderguards (20 in Trust) to manage high-risk patients proactively. We currently have approximately 100 patients in the Trust at high risk of falling. Two patients fell out of bed Improvement needs to be made regarding routine documentation of risk assessments and management plans. Actions: The Falls Prevention Group will be developing an action plan to reduce falls taking the above themes into consideration. 10

11 6. Patient Safety Venous Thrombo-Embolism (VTE) Verbal update to be provided at the meeting by Dermot O’Riordan. Page 10

12 Page 12 Patient Satisfaction (Patient Experience Tracker) Overall satisfaction was 95%. 432 patients completed the survey. No questions scored a red performance rating. Patient Satisfaction Questionnaires (PSQ) (paper) Overall satisfaction increased to 90%. 143 patients completed the questionnaire All question responses were green apart from “Were you ever bothered by noise at night from patients or hospital staff?” Themes: Confused patients calling out at night Patient transfers onto ward 8. Patient Experience CQUIN 2% target questionnaire completion was achieved by maternity and adult inpatient services. Outpatients surveyed 1.56% (364 patients) Paediatrics surveyed 1.07% (7 patients out of 655 admissions) Adult inpatient, maternity and paediatrics all achieved the overall Q4. CQUIN target of 2% survey completion. Paediatrics did not meet the 2% target due to poor performance this month.

8. Patient Experience Page 13 Same Sex Accommodation There were no breaches of same sex accommodation criteria during March. Environment and Cleanliness All clinical areas scored above 80% apart from A&E who scored 71%. This is due to: Current benching, storage and sink facilities not fit for purpose Limited hand washing facilities available

9. Conclusion The action plan with regard to A&E and discharges remains in place and performance was again excellent in March. One of the major challenges for the Trust, was in adherence to same sex accommodation, the re-configuration in December has improved performance. Performance with regard to C-Difficile, full RCA’s have been carried out and actions implemented specifically with regard to anti biotic prescribing and monitoring. Progress on other KPI’s is being made. Page 14