West Suffolk Hospitals NHS Trust

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West Suffolk Hospitals NHS Trust

• Report To Trust Board
• Date October 2009
• Title Quality Report
• Report of Nichole Day, Executive Chief Nurse

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Summary This report provides the Board with
information to assess the Trusts performance
against quality indicators, including patient
experience, clinical outcomes and effectiveness,
and patient safety. The report has been revised
and is presented in a new format with new
indicators/measures that take into account the
requirements of CQUIN, priorities identified in
the Quality Accounts, and workstreams within the
Trust such as the Patient Safety First
Initiative. Some of the new indicators are in the
development stage, with targets and data
collection processes currently being agreed, the
detail for these will therefore be added into the
report in due course.

Background
Recommendation The Board is asked to receive
and note the contents of this report.
Controls Assurance ReferenceTo Achieve
performance levels in accordance with the CQC
Standards for Better Health
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Contents

• Key Performance Indicator Dashboard
• Introduction
• Outcomes and Effectiveness
• Patient Safety
• Patient Experience
• Conclusion

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1. Key Performance Indicators
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2. Introduction
Introduction This report provides the
Board with information on our performance in
relation to the key quality indicators. Detail is
provided on those indicators that are traffic
lighted amber or red or require a fuller
explanation. Detail has not been provided on the
of patients in the stroke unit. as the
target of 74 is the CQUIN year end target, and
an interim quarter 2 target has been set at 69
(this has been achieved).
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3. Outcomes and Effectiveness

• Hospital Standardised Mortality Ratio
• Dr Foster has updated the benchmark data year,
  therefore this months figures are based on
  2008/09 benchmarks whereas the previous months
  figures are based on 2007/2008 benchmarks. Data
  for the year up to and including June is
  therefore not directly comparable with this
  months data in the top graph.
• The graphs demonstrate that overall HSMR for the
  West Suffolk Hospital is below that which would
  be expected given our patient mix.

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3. Outcomes and Effectiveness
Clostridium difficile The graph demonstrates that
we are well below trajectory for the first six
months of the year.
MRSA bacteraemias No new MRSA bacteraemias this
month. We remain on trajectory for the year to
date. Compliance with peripheral cannula and
urinary catheter procedures has also improved.
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4. Patient Safety

• Patient Falls
• Although the number of preventable falls remains
  low, one ward had a higher than average number of
  falls this month. Most of these falls occurred on
  the late or night shift when staffing numbers are
  lower and they were in-patients with
  confusion/dementia. This ward was below core
  staffing levels on 60 of the shifts due to
  vacancy / sickness levels. Having undertaken a
  Trust wide staffing review, we are working on
  individual recruitment plans for those wards that
  have particular problems. The wanderguard sensor
  system is proving useful for some patients with
  confusion to alert staff to their movement. A
  small number of falls also occurred in patients
  with alcohol problems who were undergoing
  detoxification.

Assessment of VTE This indicator is to be
reported quarterly and is based on the NPSA
requirement that all patients should be assessed
for the risk of developing venous
thrombo-embolism. New documentation has recently
been introduced to facilitate recording of
assessments and an audit tool developed. The
audit tool was piloted in September and the graph
shows the result of the first baseline audit. The
audit included 324 medical and surgical patients.
Whilst compliance with recording of assessment is
low, the audit results indicate that an
additional 40 of those who did not have a
recorded risk assessment did have appropriate
prophylaxis prescribed indicating that an
informal risk assessment had been carried out.
Awareness raising of junior doctors will help to
address the issues.
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4. Patient Safety
4.5 Patient Safety walkabouts
Since the end of May 2009, the Walkabout
component of the Leadership module of the Patient
Safety First Campaign has covered 13 areas in
seven seperate walkabouts. This has included
seven wards, EAU, Critical Care, Outreach Team
and matrons, and the Physio, Occupational and
Speech and Language Therapies. Safety discussions
have taken place with variable numbers of staff
from a broad spectrum of disciplines and themes
are now emerging, categroised as follows
From the themes that are raised within the
walkabout session, actions are identified. These
are implemented at different levels including
individual, ward/area and at corporate level.
Additionally, the time scales which are
attributed to each action are dependent on
different variables.

• Actions to date have included
• Individual
• The placement of notices on all oxygen cylinders
  to indicate how long each cylinder will run for
  and when replacement cylinders will be required.
• The purchasing and distribution of underwire bed
  ties across the Trust to prevent falls.
• Ward/Area
• The purchasing of ward equipment such as drip
  stands and catheter stands.
• The development of systems to promptly remove
  empty cylinders from ward corridors.
• Improvements in the hand over system in use for
  patients being transfered from ward to ward.
• The renovation of the childrens roof-top play
  area.
• The review of patients mobility throughout the
  hospital when requiring oxygen.
• Corporate
• A review of the reporting of nurse staffing
  across the Trust to be included in Performance
  Review meetings. This report will undergo a
  revised template and include for the first time a
  balanced scorecard demonstrating the quality
  indicators matched to staffing taking into
  account nurse staffing levels as a result of long
  and short term sick, bank staffing and maternity
  leave.
• To consider making available funds for small
  scale ward alterations to improve safety, storage
  and security.
• The ongoing roll out of the Productive Ward and
  the developments in Simpler Process.

As a number of the walkabouts have taken place
within the medical directorate, it is now
proposed to visit the surgical ward areas and to
meet with non clinical support staff including
the portering and domestic staff.
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4. Patient Safety

• Global Trigger Tool
• Since the beginning of June 2009, 50 sets of
  notes have been audited using the Global Trigger
  tool. Results indicate that the average length of
  stay was 9 days 30 had no adverse event
  triggers and episodes of care were uneventful.
  The adverse events linked to the remaining
  audited case notes indicated that these fell into
  Category F Contributed to or resulted in
  temporary harm to patients and required initial
  or prolonged hospitalization. Other categories
  are listed below.
• Using the formula Total number of adverse
  events/total length of stay for all records
  reviewed x 1000 adverse events per 1000 patient
  days, from the NHS Institute, comparisons can be
  made with other organisations.
• The results of the audits to date have indicated
  that there were twenty seven adverse events per
  1000 days. Case notes were taken randomly from
  the past two years this has now been changed and
  the sample will be based on a set of discharges
  six months prior to the audit date. The
  amalgamated report of all UK Trusts on the
  National Safety Patient First indicates an
  average of 38 adverse incidents per 1000 days.
  Due to the small sample size required,
  variability in results are expected from month to
  month. Therefore, the target has been set at the
  national average until six months of data for
  this Trust is available, when the target will be
  reviewed.
• Of the adverse events, falls, hospital acquired
  infections and pressure sores are already being
  addressed within the Trusts Quality agenda. The
  overriding area of concern is considered to be
  the robustness of clinical documentation of
  medical reviews, timeliness of reviews and
  adequate information within reviews for handover.
  In the next 50 notes audited, it is proposed that
  this aspect will be considered in greater detail,
  alongside the existing triggers indicated in the
  Global Trigger Tool.

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5. Patient Experience
5.1 Patient Satisfaction (Near patient
TV) Satisfaction increased this month to just
above target. However, perception of there being
enough staff on duty to care for patients was low
on one ward. Although staffing was at core levels
for the majority of shifts, patient acuity was
particularly high. 5.2 Patient
Satisfaction (PET) Feedback was obtained from
over 800 patients during September attending AE,
EAU, OPD, PAU and Ward F4. There is an issue with
the weighting of answers to the questions, that
produces a lower satisfaction rating than is
appropriate this is being addressed with the
company. General satisfaction is high, however,
improvement is needed in the information provided
to patients in AE regarding their waiting time
for treatment. This is being raised with the AE
Manager to identify actions needed.
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5. Patient Experience
5.3 Environment and cleanliness A score of 89
was achieved this month. Two surgical wards were
identified as having reduced scores and as a
result, housekeeper input to these have increased
and retraining of existing staff is being carried
out. Recruitment to the additional housekeeper
posts is continuing, but has been slower than
expected. However, half of the posts have now
been appointed to. 5.4 Hand Hygiene 100
achieved this month.
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6. Conclusion

• Due to a continued focus and drive to improve
  documentation in parallel with practice, further
  improvements have been seen this month in
  compliance with best practice in infection
  control procedures such as peripheral cannula and
  urinary catheter care.
• Hand hygiene performance was 100 this month
  demonstrating the continued emphasis and high
  profile of infection control.
• The baseline scores against some of the new
  indicators show that a focus on these areas of
  practice is needed to ensure that staff are fully
  aware of best practice. We are taking the
  necessary actions to ensure adherence to the new
  standards.