1. Presented By: Gwen Nuttall – Chief Operating Officer, Nichole Day Executive Chief Nurse Prepared By: Information Team Date Prepared: 20 th December 2010 Subject: Integrated Quality and Performance Report - November 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 November 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 – 7 th January 2011

2. SUFFICIENT Note the Trust Performance to November 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 November 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 November (97.7%). Key actions:- EAU Locum Consultants commence in November. 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. Winter plans submitted to PCT/SHA Bed Meetings reviewed and enhanced. 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 November at 0.87% A small improvement from previous months. Analysis demonstrates that the same cancellation reasons predominate. There was an increase in cancellations due to staff sickness in November compared to previous months. Target 0.8% Actual 0.91% (YTD) The Trust will commence on the ‘Productive Theatre’ project in January 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 still above target – predominantly in complex elderly patients. 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 For 2010/11 the Trust’s stretch target is 29 hospital cases. However, in November there were a further 5 hospital associated cases bringing this years total to date to 26. Two of the five cases this month were identified on one ward and was a continuation of the previous month’s Clostridium difficile outbreak; the other 3 cases were situated in other areas. All patients were transferred to the F9 cohort unit within the time frame specified. Due to the increase of Clostridium difficile cases in October and November a Trust Action Plan was agreed with the PCT and a visit to the Trust by the SHA and PCT supported the plan. Other Infection Control indicators The Trust continues to achieve excellent results in other infection control KPIs. There were no hospital associated MRSA bacteraemias. Overall compliance with hand hygiene and the dress code requirements for all directorates remained at 100%.The High Impact Interventions audits carried out achieved 100% with the exception of HII 4b Prevention of Surgical site infection where antibiotic prophylaxis was not given within a specified time. This is being addressed by the surgical matron.

8. 8 6. Patient Safety Page 8 Pressure Ulcers The number of patients with ward acquired pressure ulcers increased this month. All were grade 2 ulcers, there were no grade 3 or 4 ward acquired ulcers this month. A “No avoidable pressure ulcers at WSHT” campaign is being launched in January which focuses on education, training and support to reduce the number of patients who develop ward acquired pressure ulcers. Patient Falls The number of falls resulting in harm decreased this month, all harm was minor except one patient who fractured their wrist.

9. 9 6. Patient Safety Venous Thrombo-Embolism (VTE) The improved rate of completed VTE assessments has continued with the November figure of 62%. Further improvements are expected in the December figure with the introduction of nurse completed assessments (but doctor still responsible for treatment decisions) of the large number of patients going through DSU and the capturing of completed assessments completed in pre-admissions unit for elective in-patients. Live data on completion on ward patients is also being captured and reported. Antibiotic Prescribing Issues relating to antibiotic use impact on C. difficile numbers. The Trust has a CQUIN target related to adherence to the antibiotic policy. There was a significant improvement from the first audit in April 2010 and the second July 2010. A dedicated antibiotic section is being introduced into the West Suffolk prescription chart with an implementation date of 1-3-11. This will replace the checklist and ensure prescribing in accordance with policy. In addition, the Medical Director has written to all medical staff reminding them of the standards required for antibiotic prescribing, and the pharmacists and nursing staff have been asked to ensure that they query prescriptions that do not follow the policy with the medical staff concerned. Page 9

10. 10 6. Patient Safety Page 10 SIRI Information In November there were 5 incidents reported to Suffolk PCT Of the five incidents: All were reported to the PCT within the time frame for the initial report and the 7 day report. Of three final reports due in November one was late by 9 days. This was due to a delay in undertaking the RCA meant that the target date for the final report was also missed. No extension was applied for at the time.

11. 11 7. Patient Experience Page 11 Performance against all the indicators has improved with the exception of two questions which fell by 1%. Patient Satisfaction (Near Patient TV) Paper surveys continue to be used for this reporting. The results show a decrease in patient satisfaction in 7/10 of the questions which will be addressed in the clinical areas action plans. However 99% of patients would choose to use the hospital again for themselves, their family and friends. CQUIN Achievement of 2% patients surveyed was achieved by inpatient and children’s services. Maternity and outpatients have been set targets to achieve by the end of December to ensure Q3 compliance. Patient Satisfaction (Patient Experience Tracker)

12. 8. Patient Experience Page 12 Same Sex Accommodation The number of breaches on EAU increased in November and remains a concern for the Trust. Privacy and dignity issues are paramount and staff apologise when mixing occurs. EAU will be reconfigured to ensure compliance for same sex on December 24 th. AprilMayJuneJulyAugustSeptemberOctober No of patients No of breaches No of patients No of breaches No of patients No of breaches No of patients No of breaches No of patients No of breaches No of patients No of breaches No of patients No of breaches Endoscopy40142 31000000 EAU1681421133294562665753516018457 DSU1620000000000 0 0 November No of patients No of breaches 00 539 0 0 Environment and Cleanliness

13. 9. Conclusion The action plan remains in place and performance has improved in November with regard to the 4hr standard. Performance management of cancelled operations has been enhanced at the surgical directorate performance review meeting, focussing on reasons, specialty and individual if required. One of the major challenges for the Trust, is in adherence to same sex accommodation in the Emergency Assessment Unit. 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