1. Presented By: Gwen Nuttall – Chief Operating Officer, Nichole Day Executive Chief Nurse Prepared By: Information Team Date Prepared: 18 th January 2011 Subject: Integrated Quality and Performance Report - December 2010 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 December 2010. 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 January 2011

2. SUFFICIENT Note the Trust Performance to December 2010 - 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

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

4. 1.& 2. Introduction & Emergency Care 1. Introduction: This report provides a briefing to the Board members on the performance against key targets up to December 2010. 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 December (97.6%). Key actions:- EAU Locum Consultants commenced in November. Posts to be advertised substantively in February. Daily (08.00) debrief to review previous day/night -identifying any issues. 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. Meetings with ward sister commenced December to review Discharge Plans. Short stay beds introduced on ward G5. The updated detailed A&E 4 hour performance action plan is attached as a separate paper. Page 4

5. 3. Cancelled Operations The target was not met for December at 0.85% Unavoidable cancellations (Surgeon sickness absence and bad weather) accounted for 45% of the cancelled operations. Equipment issues 10% and out of theatre time /other for the remaining 45%. Target 0.8% Actual 0.91% (YTD) The Productive Operating Theatre project (TPOT) is in progress, and will be reported to the Board in March 2011. Page 5

6. 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 now below target – Actions to improve this performance is linked to discharge action plans and implementation of EAU model. Non Elective LOS for Surgery remains below the expected level, but has seen an increase in 2010/11. This is related to complex elderly patients. Elective LOS for Surgery is similar to last year. Review of day case and day of surgery activity continues, especially in urology.

7. 7 Clostridium difficile 5. Outcomes and Effectiveness Page 7 The Clostridium. Difficile target The C. difficile target for 2010/11 for the Trust is 29 hospital cases. However, in December there were a further 2 hospital attributed cases. Patients were transferred to the F9 cohort unit within the time frame specified. Due to the increase of CDT cases over the past months the PCT have agreed to increase our annual trajectory. Other Infection Control indicators The Trust continues to achieve excellent results in other infection control KPIs. There was no hospital associated MRSA bacteraemia. Overall compliance with hand hygiene and the dress code requirements for all directorates remained at 100%. Five of the High Impact Intervention audits carried out achieved 100%. Five however scored 80-97%:

8. 8 6. Patient Safety Page 8 Pressure Ulcers The number of patients with ward acquired pressure ulcers decreased this month to 7 including one Grade 3 and one Grade 4 ulcer. Actions: As part of the “No avoidable pressure ulcers at WSHT” campaign, pressure ulcer education is now incorporated in the nursing and midwifery mandatory training day to ensure effective risk assessment and improved knowledge by all staff. A pressure ulcer development group has been established to develop, facilitate and review an annual pressure ulcer prevention strategy Patient Falls The number of falls resulting in harm increased this month to 25, all harm was minor except one patient who fractured their neck of femur on F6.

9. 9 6. Patient Safety Venous Thrombo-Embolism (VTE) Verbal update to be provided at the meeting by Dermot O’Riordan. Antibiotic Prescribing Compliance with the antibiotic prescribing policy has improved this month to 90%. Page 9

10. 10 6. Patient Safety Page 10 SIRI Information In December 2010 there were three SIRIs reported to NHS Suffolk. All were reported to the PCT within the time frame for the initial 2 day report and the 7 day report. Five reports were due in December. All were submitted within due date.

11. 11 Page 11 Overall satisfaction was 88% (see Table 1 for breakdown of clinical areas). A&E/EAU/F4 scored 80%+ in all questions. Patient Satisfaction Questionnaires (paper) All remaining clinical areas use this method for reporting and overall satisfaction scored 85%. Questions that scored lower in nearly every clinical area are: Were you bothered by noise at night? (overall 66%). The noise disturbance is often related to patients being moved/ admitted onto the ward at night or confused patients shouting. 23% of patients across the Trust answered that it took more than 3 minutes for the callbell to be answered. Although the scores have increased, most clinical areas still score below 80% in discharge issues: have you been told who to contact if you are worried when you leave hospital (overall 76%)/ medication side-effects to watch for when you go home (overall 74%). The patient experience implementation group workplan addresses all these issues and action points include: discharge information leaflets, ear plugs offered routinely and new call bell systems which allows data analysis of time to answer callbells. CQUIN Achievement of 2% patients surveyed for Q3 was achieved by adult inpatient, children’s services and maternity services. Outpatients (main OPD, diabetic/eye clinic/PAU) surveyed 1.4% patients against a target of 1.5%. Patient Satisfaction (Patient Experience Tracker) Main OPD 173 returns93% satisfaction Diabetic Clinic 9591% Eye Clinic 963% PAU 2182% A&E 306 96% EAU 594% F4 2699% Table 1.

12. 8. Patient Experience Page 12 Same Sex Accommodation The number of breaches on EAU decreased in December to 1 breach with 8 patients affected. The male/female configuration in EAU was undertaken on 24 th December. To date no same sex breaches have been reported. Environment and Cleanliness

13. 9. Conclusion The action plan remains in place and performance has improved in December with regard to the 4hr standard. One of the major challenges for the Trust, is in adherence to same sex accommodation in the Emergency Assessment Unit. This was reconfigured in December. Performance with regard to C-Difficile deteriorated in November however full RCA’s have been carried out and actions implemented specifically with regard to anti biotic prescribing and monitoring. Page 13