Patient Experience Report August 2011
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1 Patient Experience Report August 2011 Section Page number 1. Patient Experience 2 a) Cumulative Complaints & PALS 2 b) Complaints response times 2 c) Complaints by category 3 d) Litigation 3 e) Inpatient Real-Time Patient Feedback 4 f) Outpatient Real-Time Patient Feedback 5 g) Say So Feedback 6 2. Incidents 7 3. Medication Errors 9 4. DVT & PE Pressure Sores Deaths Mix Sex Breaches Nutrition Infection Control 14 a) Surgical Site Infections 14 b) Acquired HPA reportable Bacteraemia 14 c) Cleaning Audit 15 New additions to the report: Outpatient Real-Time Patient feedback Say So Summary Acquired HPA Reportable Bacteraemia MSSA & E-coli DVT & PE rate Page 1 of 15
2 1. Patient Experience a) Cumulative Complaints & PALS Figure 1 illustrates the percentage rate of complaints and PALS enquires in relation to activity received by the Trust: The total number of complaints received during August: 9 and total number of PALS enquiries received: 89 Figure 1: Complaints and PALS Rate 1.00% 0.90% Rate (Complaints & PALS/Activity) 0.80% 0.70% 0.60% 0.50% 0.40% 0.30% 0.20% 0.10% 0.00% PALS Rate Complaints Rate Complaints Summary: Key themes for complaints received within the Trust include: Communication / information to patients PALS Summary: Key themes for PALs received within the Trust include: The key issues were communication and providing information to patients/carers b) Complaints Response Times Figure 2 illustrates the actual number of complaints activity received for both Divisions. The overall total is the number of overdue responses currently still outstanding within the Trust. August 2011 Direct Care Support Services Number new complaints received in August Responses 0 0 Overdue 4 1 Overall total number of all complaints outstanding 7 4 The current longest outstanding complaint is Nugent received on 14/03/2011 Claire Levermore is leading. Page 2 of 15
3 c) Complaints by Category Figure 3 illustrates the categories of running complaints received by the Trust 2011/12: Figure 3: Complaints Categories /12 0% 7% 14% 11% Non Clinical Process Nursing related Doctor related Allied Health Professionals Facilities 68% d) Litigation / Legal Issues There were two litigation claims received within the Trust during August ` Page 3 of 15
4 e) Inpatient Real-time Patient feedback Figure 4: show the percentage of real time feedback from patients, this is collected on discharge by patients completing a computerised survey. Please note the figures exclude External Capacity/MediHome, FARS Lab, Imaging Stanmore, Imaging Bolsover Street, Metabolic Unit and Private Wards. REALTIME PATIENT FEEDBACK 2010/11 Month May June July August Ward Discharges Feedback Discharges Feedback Discharges Feedback Discharges Feedback AMU Duke of Gloucester Jackson Burrows Margaret Hart Rehabilitation Spinal Injuries Unit The Coleman Unit Combined Childrens Ward Ward Total % 44% 48% 48% 51% Figure 5: The following table shows the real time patient feedback breakdown of questions: Key: Target achieved Within 10% of target More than 10% from achieving target Number of surveys carried out % of discharges (target = 80%) (excluding interventional radiology) 48% 48% 51% 1 How organised was the admission process? (target = 90% very organised ) 83.0% 72.1% 82.2% Were you involved as much as you wanted to be in decisions about your care and treatment? (target = 90% yes ) Did you have enough time to discuss your operation or procedure with the Consultant? (target = 90% 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 = 0% yes ) 94.9% 96.3% 96.1% 79.1% 74.7% 78.8% 8.6% 5.2% 7.6% Page 4 of 15
5 Did you find someone on the hospital staff to talk to about your worries and fears? (target = 90% yes ) Were you given enough privacy when discussing your condition or treatment? (target = 90% 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 = 0% yes ) While staying in hospital, did you ever use the same bathroom or shower area as patients of the opposite sex? (target = 0% yes ) Did a member of staff tell you about medication side effects to watch for when you went home? (target = 90% yes ) 92.9% 95..0% 93.9% 88.2% 84.9% 83.5% 4.6% 4.4% 4.8% 5.0% 6.9% 7.8% 84.8% 83.9% 84.2% 10 How would you rate the courtesy of your doctors? (target = 90% very good or excellent ) 93.4% 91.4% 93.7% 11 How would you rate the courtesy of your (target = 90% very good or excellent )nurses? 92.1% 93.3% 94.4% Would you recommend this hospital to your family and friends? (target = 90% yes ) 90.7% 90.9% 92.9% Have you been told who to contact if you are worried about your condition after laving the hospital? (target = 90% yes ) 87.2% 86.4% 88.1% 14 Were you happy to complete the questionnaire? (target = 90% yes ) 98.9% 98.7% 94.5% f) Outpatient Real-time Patient feedback The tables below show the percentage of real time feedback from patients, this is collected in the outpatients department by completing a computerised survey. % Yes Question August Number of surveys carried out 114 Was you privacy and dignity respected during your consultation? 99% Did I you feel that we tried adequately to inform you of your condition and its treatment? Did I you received any written information to take away to support what was discussed with you? Were you seen within 15minutes of your appointment? 42% Were the people who dealt with you friendly and helpful? 97% Did you feel safe during your visit to the hospital? 97% Would you recommend this hospital to a member of your family or to a friend? Overall how would you rate your experience as a patient? (Excellent) 57% 97% 34% 95% Page 5 of 15
6 g) Say So Summary Say So Summary July 2011 Total Total number of responses 7 Total number of patient queries via completed Say So form 2 Total number of staff queries via completed Say So form 0 Total number of patient queries received via 0 Total number of positive comments received via 0 Total number of positive comments received via Say So form 2 Number of enquiries passed to Estella Cotton 3 Page 6 of 15
7 2. Incidents Figure 6 illustrates the rate of incidents occurring in the Trust. The number of clinical incidents received in August 2011: 140 Figure 6: Incident Rate 2.50% Rate (incidents/activity) 2.00% 1.50% 1.00% 0.50% 0.00% Incident Rate Trend line incident rate Figure 7 illustrates the total number of incidents occurring within the Trust grouped by category/risk rating: Figure 7: Incident Rate by Category/Risk Rating Number of Incidences Very Low Low Medium High There were no Serious Untoward Incidents received within August Page 7 of 15
8 Figure 8: illustrates the breakdown of incidents occurring within the Trust during August. Overall clinical assessment was the highest due to over booked clinics. Figure 8: Incident Type 1% 0% 13% 5% 7% 16% 10% 3% 0% 0% 1% 1% 24% 7% 6% 1% 0% 1% 2% Abuse Access, Admission, Xfer, Disch Blood transfusion Clinical Assessment Consent, Communication Documentation Environment Harm/injuries Implementation of care Infection control Information Governance Infrastructure Manual Handling Medical Device, Equipment Medication Pressure sore Slips, Trips and Falls Staffing Issues Treatment/procedure Page 8 of 15
9 3. Medication Errors Figure 9: illustrates the medication error rate at the Trust: *Please note overall drug errors have risen because pharmacists have started incident reporting corrections to prescription dosage errors. The number of medication errors received in August 2011: 14 Figure 9: Medication Errors 1.60% 1.40% 1.20% 1.00% 0.80% 0.60% 0.40% 0.20% 0.00% Rate (medication errors / activity) Medication Error Rate Trend line medication error rate Figure 10: breakdown of medication errors by risk rating: Figure 10: Medication Risk Rating Number of Medication Errors Very Low Low Medium High Page 9 of 15
10 4. DVT & PE Figure 11: illustrates the DVT & PE rate within the Trust. There were none received within the Trust during August Figure 11 : DVT & PE Rate 1.00% 0.90% Rate (DVT & PE/inpatient activity) 0.80% 0.70% 0.60% 0.50% 0.40% 0.30% 0.20% 0.10% 0.00% Sep-11 Oct-11 Nov-11 Dec-11 Incident Rate Page 10 of 15
11 5. Pressure Sores Figure 12: illustrates the rate of acquired pressure sores occurring with Trust: Pressure sores are part of the Trusts CQUIN for 2011/12. The number of pressure sores received in August 2011: 1 Figure 12 : Pressure Sore Rate 0.90% 0.80% 0.70% 0.60% 0.50% 0.40% 0.30% 0.20% 0.10% 0.00% Rate (pressure sore/inpatient activity) Incident Rate Figure 13: illustrates the grades of acquired pressure sores occurring at the Trust: Figure 13: Pressure Sores by Grade 10 9 Number of PRessure Sores Grade 1 Grade 2 Grade 3 Grade 4 Page 11 of 15
12 6. Deaths Figure 14: illustrates the mortality rate at the Trust: There were no deaths occurring in the Trust during August Figure 14: Mortality 0.20% 0.18% 0.16% Rate (mortality/activity) 0.14% 0.12% 0.10% 0.08% 0.06% 0.04% 0.02% 0.00% Mortality Rate 7. Monitoring of Mixed Sex Breaches There were no mixed sex breaches occurring in August Page 12 of 15
13 8. Nutrition Figure 15: illustrates the percentage of nutrition assessments. Data is collected manually and reported back to the ward managers on a monthly basis. Figure 15: Nutritional Assessments 100% 90% 80% 70% Percentage 60% 50% 40% 30% 20% 10% 0% % of nutrition assessments carried out Target over 65's Trend Line Figure 16: illustrates the average completed nutritional assessments across all wards/units for patients over 65 years: Figure 16: Nutritional Assessments for over 65's 100% 90% 80% 70% Percentage 60% 50% 40% 30% 20% 10% 0% % of nutrition assessments carried out for over 65's Target over 65's Trend Line Page 13 of 15
14 9. Infection Control a) Surgical Site infections Figure 17: illustrates the number of inpatient surgical site infections for hips, knees and spines occurring within the Trust: Figure 17: Rate of Surgical Site Infections Rate (number of infections/relevent activity) 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% Hip Rate Knee Rate Spine Rate b) Acquired HPA reportable Bacteraemia Figure 18: illustrates the number of cases of MRSA, MSSA and E-coli and Clostridium Difficile Bacteraemia acquired at the Trust: Figure 18: Acquired HPA Reportable Bacteraemia Rate (total bacteraemia / activity) Number of bacteraemia Month MSSA MRSA Bacteraemia C-Dif E-coli Infection rate Page 14 of 15
15 c) Cleaning Audit Figure 19: 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 19: Cleaning Audit Scores for Very High Risk Areas 100% 90% 80% Percentage Score 70% 60% 50% 40% 30% 20% 10% 0% Actual % Target 95% Figure 20: the Trust aims to achieve a 90% score each month within all other clinical areas Figure 20: Cleaning Audit Scores for High Risk Areas 100% 90% 80% Percentage Score 70% 60% 50% 40% 30% 20% 10% 0% Actual % Target 90% Page 15 of 15
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