Patient Experience. Month Reported November 2010

Transcription

1 Patient Experience Report Month Reported November Section Section Section Section 4 Section 5 Section 6 Section 7 Patient Experience Deaths Incidents Pressure Sores Drug Errors Litigation Infection Control Section - Patient Experience a. Cumulative Complaints Figure illustrates the percentage rate of complaints in relations to activity, received by the Trust from November 8: Figure : Complaints Rate Rate (number of complaints/activity).4%.5%.%.5%.%.5%.%.5%.% Nov-8 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan- Mar- May- Jul- Sep- Nov- Complaints Rate Mean Lower Expected Limit Upper Expected Limit Page of

2 b. Complaints Response Times Figure illustrates the actual number of complaints activity for September to November for each division. The overdue responses are for those complaints falling in the illustrated month. Figure DIRECT CARE September October November Number of Complaints 8 Responses 8 4 Overdue 4 6 overdue ( not yet due) SUPPORT SERVICES September October November Number of Complaints 4 5 Responses Overdue due 4// Page of

3 c. Complaints by Category Figure illustrates the categories of complaints received by the Trust during 9/ (whole year) and / (year to date): Figure : Complaints Categories Number of Complaints Category Appointment - Delay (OP) Operation - Adverse Outcome Appointment - Delay (IP) Appointment - Cancellation(IP) Nursing Care Transport Communication/Info to Patients Diagnosis Problems Appointment - Cancellation(OP) Premises - Access to Equipment Discharge Arrangements Attitide of Staff - Combined Allied Professionals Patient's Privacy & Dignity Admission Arrangements Patient Status Discrimination Transfer Arrangements Personal Records Operation (IP) Cancellation Loss of Personal Property Hotel Services - Food Choice Failure to Follow Procedures Condition Building Appointment - Time Aids & Appliances Consent to Treatment / / Page of

4 d. Patient Feedback Data / Patient Satisfaction Figure 4 illustrates the rate of PALS enquiries received by the Trust from November 8: Figure 4: PALS Rate Rate (PALS enquiries/activity).5%.%.5%.%.5%.% Nov-8 Dec-8 Jan-9 Feb-9 Mar-9 Apr-9 May-9 Jun-9 Jul-9 Aug-9 Sep-9 O ct-9 Nov-9 Dec-9 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- O ct- Nov- PALS Rate Mean Low er Expected Limit Upper Expected Limit Page 4 of

5 e. Real-time Patient feedback The tables below show the percentage of real time feedback from patients, this is collected on discharge by patients completing a computerised survey. There is no collection of data from several areas which record some attenders as inpatients/day cases. REALTIME PATIENT FEEDBACK Month August September October November Ward Discharges Feedback Discharges Feedback Discharges Feedback Discharges Feedback AMU Duke of Gloucester Jackson Burrows Margaret Hart Rehabilitation Spinal Injuries Unit 4 5 The Coleman Unit Combined Childrens Ward Ward Total % % % 45% 44% Not currently collecting feedback August September October November External Capacity FARs Lab Imaging Stanmore Imaging Bol Street Metabolic Unit Private Wards Total % of overall discharges 6.8% 4% 4% % Trust Total Reported Discharges Page 5 of

6 The following table shows the real time patient feedback given since June : Key: Target achieved Within % of target More than % from achieving target Jun- Jul- Aug- Sep- Oct- Nov- Number of surveys carried out % of discharges (target = 8%) (excluding interventional radiology) 8.% (.7%).8% (7.5%) 8.6% (.%) 8.5% (4.%) 45% 44% How organised was the admission process? (target = 9% very organised ) 8.% 77.% 84.% 8.% % Were you involved as much as you wanted to be in decisions about your care and treatment? (target = 9% yes ) 94.9% 89.4% 95.8% 9.% 9.8% 95% Did you have enough time to discuss your operation or procedure with the Consultant? (target = 9% yes, definitely ) When you were first admitted to a bed on a ward did you share a sleeping area, for example, a room, or a bay, with patients of the opposite sex? (target = % yes ) Did you find someone on the hospital staff to talk to about your worries and fears? (target = 9% yes ) Were you given enough privacy when discussing your condition or treatment? (target = 9% yes, all of the time ) If moved to another ward (or wards) did you ever share a sleeping area, for example a room, or a bay, with patients of the opposite sex? (target = % yes ) While staying in hospital, did you ever use the same bathroom or shower area as patients of the opposite sex? (target = % yes ) Did a member of staff tell you about medication side effects to watch for when you went home? (target = 9% yes ) 8.% 7.5% 79.8% 75.9% 8.6% 77.4%.8% 8.9% 8.5%.%.8%.% 94.8% 89.9% 9.8% 76.% 74.% 9.% 8.% 76.7% 78.7% 85.9% 74.9.% 85.9% 9.% 7.5% 7.7% 5.4% 9.4%.9% 7.7% 8.9% 8.% 9.% 6.7% 4.% 86.% 78.% 8.8% 85.7% 79.6% 84.5% How would you rate the courtesy of your doctors? (target = 9% very good or excellent ) 9.% 88.9% 87.4% 9.8% 94.5% 9.9% How would you rate the courtesy of your (target = 9% very good or excellent )nurses? Would you recommend this hospital to your family and friends? (target = 9% yes ) 9.% 87.% 9.% 9.% 9.6% 9.% 9.% 86.6% 86.9% 89.% 9.7% 9.9% Page 6 of

7 f. Nutrition Assessments Figure 5 illustrates the percentage of nutrition assessments carried out, since August 9: The CQUIN target is for patients over 65 years; however the Trust has opted to report on all patients. Data is collected manually and reported back to the ward managers on a monthly basis. Figure 5: Nutritional Assessments % 9% 8% 7% % of areas 6% 5% 4% % % % % Aug- 9 Sep- 9 Oct- 9 Nov- 9 Dec- 9 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- % of nutrition assessments carried out Target Page 7 of

8 g. Monitoring of Mixed Sex Breeches Figure 6 illustrates number of patients affected by mixed sex breeches each day, from April : Figure 6: Mixed Sex Breeches 8 6 Number of patients affeced by a breech Apr May Jun Jul Aug Sep Oct Nov Number of Patients Affected by Mixed Sex Breech Mean Lower Expected Limit Upper Expected Limit The number of mixed sex breeches exceeded the expected limit several times during November. Section Deaths Figure 7 illustrates the mortality rate at the Trust from November 8: Figure 7: Mortality Rate Rate (deaths/activity).%.5%.%.5%.% Nov-8 Dec-8 Jan-9 Feb-9 Mar-9 Apr-9 May-9 Jun-9 Jul-9 Aug-9 Sep-9 Oct-9 Nov-9 Dec-9 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Mortality Rate Mean Low er Expected Limit Upper Expected Limit Page 8 of

9 Section Incidents a. Cumulative Incidents Figure 8 illustrates the rate of incidents at the Trust from November 8: Figure 8: Incident Rate.% Rate (incidents/activity).5%.%.5%.%.5%.% b. Serious Untoward Incidents None to report. Section 4 Pressure Sores Figure 9 illustrates the rate of pressure sores at the Trust from November 8: Figure 9: Pressure Sore Rate Rate (pressure sores/inpatient activity).5%.%.5%.%.5%.% Nov-8 Dec-8 Jan-9 Feb-9 Mar-9 Apr-9 May-9 Jun-9 Jul-9 Aug-9 Nov-8 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Sep-9 Jan- Mar- May- Jul- Sep- Nov- Incident Rate Mean Lower Expected Limit Upper Expected Limit F Oct-9 Nov-9 Dec-9 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Incident Rate Mean Low er Expected Limit Upper Expected Limit Page 9 of

10 Figure illustrates the grades of pressure sores at the Trust during /: Figure : Pressure Sores by Grade 4 Number of PRessure Sores Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Grade Grade Grade Grade 4 Section 5 Medication Errors Figure illustrates the medication error rate at the Trust from November 8: Figure : Medication Error Rate Rate (errors/inpatient activity).4%.%.%.8%.6%.4%.%.% Nov-8 Dec-8 Jan-9 Feb-9 Mar-9 Apr-9 May-9 Jun-9 Jul-9 Aug-9 Sep-9 Oct-9 Nov-9 Dec-9 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Medication Error Rate Mean Low er Expected Limit Upper Expected Limit Page of

11 Section 6 Litigation / Legal Issues Figure illustrates the percentage litigation rate in relation to activity at the Trust from August 8: Figure : Litigation Rate.9% Rate (litigation/activity).8%.7%.6%.5%.4%.%.%.%.% Aug-8 Oct-8 Dec-8 Feb-9 Apr-9 Jun-9 Aug-9 Oct-9 Dec-9 Feb- Apr- Jun- Aug- Oct- Litigation Rate Mean Lower Expected Limit Upper Expected Limit.%.8% Page of

12 Section 7 Infection Control a. Surgical Site Infections Figure illustrates the rate of surgical site infections in hips, knees and spines since data collection began in December 9: Figure : Rate of Surgical Site Infections Rate (number of infections/relevent activity) 6.% 5.% 4.%.%.%.%.% Dec- 9 Jan- Feb- Mar- Apr- M ay- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Hip Rate Knee Rate Spine Rate b. MRSA Bacteraemia and Clostridium Difficile Figure 4 illustrates the number of cases of MRSA Bacteraemia and Clostridium Difficile acquired at the Trust during /: Figure 4: MRSA Bacteraemia and C Dif Cases Aquired at the Trust 5 4 Number of cases Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- MRSA Bacteraemia C Dif Page of

13 d. Cleaning Audit Within clinical areas deemed to have a very high infection risk, such as Theatres and ITU, the Trust aims to achieve a 95% score each month. Figure 5 details our results during 9/ and / against this target: Figure 5: Cleaning Audit Scores for Very High Risk Areas Score % 9% 8% 7% 6% 5% 4% % % % % Apr-9 May-9 Jun-9 Jul-9 Aug-9 Sep-9 Oct-9 Nov-9 Dec-9 Jan- Feb- Actual % Target % Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Within all other clinical areas, the Trust aims to achieve a 9% score each month. Figure 6 details our results during 9/ against this target: Figure 6: Cleaning Audit Scores for High Risk Areas Score % 9% 8% 7% 6% 5% 4% % % % % Apr-9 May-9 Jun-9 Jul-9 Aug-9 Sep-9 Oct-9 Nov-9 Dec-9 Jan- Feb- Actual % Target % Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Page of