TRUST BOARD PUBLIC JULY 2013 Agenda Item Number: 128/13 Enclosure Number: (4) Subject: Quarterly Quality Report Quarter /2014 Prepared by:

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1 TRUST BOARD PUBLIC JULY 213 Agenda Item Number: 128/13 Enclosure Number: (4) Subject: Quarterly Quality Report Quarter 1 213/214 Prepared by: Lorna Wilkinson, Deputy Director of Nursing / Head of Patient Safety Derek Williams, Clinical Audit and Assurance Manager Tracey Stenning, Governance Compliance Manager Sponsored by: Presented by: Purpose of paper Key points for Trust Board members Briefly summarise in bullet point format the main points and key issues that the Trust Board members should focus on including conclusions and proposals Julie Dawes, Director of Nursing Simon Holmes, Medical Director Julie Dawes, Director of Nursing Simon Holmes, Medical Director Discussion requested by Trust Board Regular Reporting For Information / Awareness There is a summary sheet at the beginning of each section of the report providing an overview of compliance with each indicator. All CQUIN, Contract, Quality Account and internal quality indicators have achieved compliance with the following exceptions: Patient Safety exceptions Dementia CQUIN Partially achieved - The dementia screening compliance remains a challenge with screening not achieving the 9% required in Q1. Daily meetings are now being held and the vitalpac solution is expected in July 213. Safety Thermometer CQUIN Partially achieved - 35% reduction in the prevalence of new grade 2, 3 and 4 pressure ulcers; 1.6 by the end of quarter 4. The definitions to be used during data collection have been clarified with the Health and Social Care Information Centre and the Trust is working even closer with those responsible for collecting the data to ensure the correct definition is used during data collection. This will help to ensure more accurate reporting and improve compliance. Pressure Ulcer reduction 1% (Quality Contract) Not achieved - The Trust is over trajectory in Q1 with 12 grade 3 or 4 pressure ulcers reported against a trajectory of 7. Implementation of the SKIN bundle and weekly monitoring of compliance within wards is being rolled out urgently as a result. This also links to the safety thermometer CQUIN which requires a reduction in prevalence of pressure ulcers which is currently not being achieved. Clinical Effectiveness NICE (Contract) Partial compliance - Overall compliant, however, 1 NICE Technology Appraisal Guidance regarding the use of Macular Oedema (diabetic) is PHT Quarterly Quality Report - Quarter 1 213/214 Page 1 of 59

2 declared as non-compliant. This will be discussed at the Clinical Effectiveness Steering Group. Patient Experience exceptions Friends and Family Test (CQUIN) - Following a baseline response rate in April, the Trust is required to achieved an 15% average response rate in May and June and in quarters 2 and 3 and an average of a 2%. The Trust achieved a total response rate of 17.25% in May and June and has therefore achieved the quarter 1 target. Options and decisions required Clearly identify options that are to be considered and any decisions required Next steps / future actions: Clearly identify what will follow the Trust Board s discussion Consideration of legal issues (including Equality Impact Assessment)? Consideration of Public and Patient Involvement and Communications Implications? Governance Compliance Care Quality Commission - Quarter 1 internal self-assessment showing full compliance with all outcomes, with the exception of Clinical Support who are declaring non-compliance with a moderate impact for outcome 21 (records). For discussion None Considered none None Links to Portsmouth Hospitals NHS Trust Board Strategic Aims, Assurance Framework/Corporate Risk Register Strategic Aim BAF/Corporate Risk Register Reference (if applicable) Strategic Aim 1: To deliver safe, high quality patient centred care 1.1, 1.2, 1.3, 1.4 Risk Description CQC Reference All Committees/Meetings at which paper has been approved: Date PHT Quarterly Quality Report - Quarter 1 213/214 Page 2 of 59

3 Table of contents 1. INTRODUCTION PATIENT SAFETY Patient safety compliance summary VTE (CQUIN and Contract)... 5 Risk Assessment Initiation of thromboprophylaxis... 5 Hospital Associated Thrombosis... 6 Root Cause Analysis Dementia (CQUIN) Partially achieved... 6 Find, Assess, Investigate and Refer Not achieved... 6 Clinical Leadership and training Supporting Carers of People with Dementia Safety Thermometer (CQUIN and Quality Contract) Partially achieved Serious Incidents Requiring Investigation (SIRIs) (Contract) Reporting only Patient Safety Incidents (Contract) Reporting only Claims (NHSLA) Reporting only Inquests Reporting only Rule 43 Reporting only Safety alerts (Contract) Reporting only Pressure Ulcers (Contract) Not Falls (Contract) HCAI (National target and Contract) Catheter Acquired Urinary Tract Infections (CAUTI) (Contract) Medication Safey (Contract) Monitor/No increase based on 12/13 outturn medication incidents that result in moderate/severe harm/death Month on month increase in number of stage 1 medicines reconciliations completed by trained pharmacy staff until target of 8% (of achievable med reconciliations) reached for 3 consecutive months Quarterly increase in proportion of ibuprofen/naproxen vs diclofenac prescribed against 212/213 outturn Safeguarding Adults (Contract) Safeguarding Children (Contract) CLINICAL EFFECTIVENESS Clinical effectiveness compliance summary High Impact Innovations (CQUIN)... 2 Intra-operative Fluid Management (IOFM) Cardiac Telemetry (3 million lives) Electronic pre-operative assessment pilot (Digital First) Patient self check-in (Digital First) Digital Appointment Reminders (Digital First) Dr Foster Hospital Standardised Mortality Ratios (HSMR) (Contract and Quality Account) Summary Hospital Level Mortality Indicator (Contract and Quality Account) Improving clinical effectiveness and patient outcomes (Contract) Enhanced Recovery Programme (Contract) To be confirmed Re-admissions (Contract) Fragility fractures (Contract) End of Life Care (Contract) Amber Care Bundle Liverpool Care of the Dying Pathway (LCDP) Discharge summaries (Contract) Reporting only National Clinical Audit Benchmarking Clinical Outcomes (Contract) Patient Reported Outcome Measures (PROMs) (Contract) COPD Discharge Care Bundle (Contract) Emergency Care Pathway (Quality Account) PHT Quarterly Quality Report - Quarter 1 213/214 Page 3 of 59

4 Submission of data in line with national requirements Reduce the number of patient moves Reduce the number of patients outlied from their required speciality ward National Institute for Health and Clinical Excellence (NICE) Partial compliance PATIENT EXPERIENCE Patient experience compliance summary Friends and Family Test (CQUIN) National In-patient Survey and Improving patient reported outcomes (Contract) Real time patient feedback (Contract) Mixed Sex Accommodation (Contract) Enhancing quality of life for carers (Contract) Improving care for patients with learning disabilities (Contract) Improving care of people with cancer (Quality Account) Complaints, PALS and Plaudits (Contract) Parliamentary Health Service Ombudsman (PHSO) Reporting only PALS Contacts Reporting only Plaudit examples Reporting only GOVERNANCE COMPLIANCE Governance compliance summary Care Quality Commission Unannounced inspection Compliant Care Quality Commission Quarter 1 self-assessment Reporting only Care Quality Commission Quality and Risk Profile (QRP) (June 213) Reporting only Quality Improvement Framework 213/14 Reporting only APPENDIX 1: LESSONS LEARNT FROM PATIENT SAFETY INCIDENTS APPENDIX 2: POTENTIAL CLAIMS RECEIVED IN QUARTER APPENDIX 3: CLAIMS CLOSED IN QUARTER APPENDIX 4 SMALL CLAIMS PHT Quarterly Quality Report - Quarter 1 213/214 Page 4 of 59

5 1. INTRODUCTION This quarterly quality report covers contractual, Quality Account and national and local requirements to provide a comprehensive overview of quality performance for quarter 1 213/ PATIENT SAFETY 2.1. Patient safety compliance summary Patient safety compliance summary Indicator VTE Risk Assessment (CQUIN and Contract) VTE Initiation of thromboprophylaxis (Contract) VTE Hospital Associated Thromobosis (Contract) VTE Root Cause Analysis (CQUIN) Dementia (CQUIN) Safety Thermometer (CQUIN) Serious Incidents Requiring Investigation (SIRIs) (Contract) Patient Safety Incidents (Contract) Claims (NHSLA) Inquests Rule 43 Safety alerts Pressure Ulcers (Contract) Falls (Contract) HCAI (National target and Contract) Monitor Catheter Acquired Urinary Tract Infections (CAUTI) (Contract) Medication Incidents (Contract) Medicines reconciliation (Contract) Non-steroidal anti-inflammatory drugs (NSAID) (Contract) Safeguarding Adults (Contract) Safeguarding Children (Contract) Compliance Partially achieved Partially achieved Reporting only Reporting only Reporting only Reporting only Reporting only Reporting only Not 2.2. VTE (CQUIN and Contract) Risk Assessment - The following table demonstrates the Trust performance against the CQUIN requirement to achieve 95% of all adult in-patients having had a VTE risk assessment on admission to hospital per month. VTE risk assessment screening Quarter 4 212/13 Quarter 1 213/14 Year to date Jan Feb Mar Total Apr May Jun Total 213/ % 92.81% 92.8% 92.9% 94.59% 95.8% 95.88% 95.16% 95.16% (provisional) Initiation of thromboprophylaxis The Trust is required to achieve the prescription and administration of appropriate (NICE compliant) thromboprophylaxis for 92% of those patients identified as being at risk of VTE. The provisional figure, subject to final confirmation, for quarter 1 is 93.5%; therefore achieving the CQUIN requirement. PHT Quarterly Quality Report - Quarter 1 213/214 Page 5 of 59

6 Hospital Associated Thrombosis The Trust is required to report on and investigate all cases of Hospital Associated Thrombosis (HAT). That is any deep vein thrombosis (DVT) or pulmonary embolism (PE) that is diagnosed for an inpatient or for a patient that has been discharged from hospital within the previous 9 days. The number of VTE events reported in quarter 1 (213/14) was 235, of these, 167 were community acquired and 68 were hospital associated, of which 4 have been graded as red or avoidable to date. This compares to 193 VTE events reported in quarter 4 (212/13) of these 98 were community acquired and 95 were hospital associated, with 11 being graded as red or avoidable. VTE SIRIs Reported Quarters /13 & Quarter 1 213/14 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 3 1 Root Cause Analysis There were 68 hospital associated VTE events in Q1, of those 68, 66 have had RCA s completed. The remaining 2 are on track to have their RCA completed over the next 3 weeks. PHT will therefore achieve 1% compliance with RCA s Dementia (CQUIN) Partially achieved This CQUIN indicator has three components Find, Assess, Investigate and Refer Not achieved There are three stages to this first part of the Dementia CQUIN: 1. Dementia case finding. 2. Dementia diagnostic assessment and investigation. 3. Referral for specialist diagnosis. The Trust is required to achieve 9% compliance for each of the stages for three consecutive months. The table below shows quarter 1: Element April 213 May 213 June 213 To be validated Step 1: Case Finding 46.3% 49.7% 6.4% Step 2: Assessment 76.% 71.1% 79.2% Step 3: On-ward referral 1% 94.4% 95.7% Clinical Leadership and training - Gill Gould (Head of Nursing for Surgery and Cancer) has been identified as the clinical lead for the Trust Training programme for dementia has been submitted to commissioners as per requirement in Q1 and we are awaiting their comments Supporting Carers of People with Dementia - Audit tool to survey how well carers feel supported in hospital has been drafted and agreed through the Dementia Steering Group. Pilots start in July 213 with results reported monthly. PHT Quarterly Quality Report - Quarter 1 213/214 Page 6 of 59

7 2.4. Safety Thermometer (CQUIN and Quality Contract) Partially achieved This CQUIN indicator has three parts: Monthly surveying of all appropriate patients using the NHS Safety Thermometer tool on a single day per month and is submitted to the NHS Information Centre. - The Trust has submitted 1% data each month in quarter 1. Delivery of an agreed whole health system improvement plan. - The Trust has participated in a healthcare wide partnership group looking at pressure ulcer prevalence reduction. The event was hosted by the CCG and included NHS and non-nhs providers in care. This group is working across organisational boundaries for the benefit of patient safety. 35% reduction in the prevalence of new grade 2, 3 and 4 pressure ulcers; 1.6 by the end of quarter 4. - The definitions to be used during data collection have been clarified with the Health and Social Care Information Centre and the Trust is working even closer with those responsible for collecting the data to ensure the correct definition is used during data collection. This will help to ensure more accurate reporting and improve compliance. Safety Thermometer Pressure ulcer prevalence Quarter 1 213/214 Year to date April May June Total 213/ Serious Incidents Requiring Investigation (SIRIs) (Contract) Reporting only A total of 24 SIRIs (including HCAIs) reported in quarter 1 213/14 compared to 19 SIRIs in quarter 4 212/ SIRIs were initially reported in quarter 4 but following investigation 6 SIRIs were downgraded. SIRIs 212/13 213/14 Quarter (plus 11 unavoidable Pressure ulcers) Quarter 2 27 Quarter 3 16 Quarter 4 19 TOTAL 94 There were 12 avoidable pressure ulcers in quarter 1 213/14. This compares to 6 avoidable pressure ulcers in quarter 4 212/ unavoidable pressure ulcers were also reported onto STEIS in Q1. Unavoidable pressure ulcers have not previously been included in PHT SIRI figures but following discussion with the Commissioners future reports will include unavoidable pressure ulcers. 1 were initially reported in Q4 but 4 were deemed as unavoidable following investigation and were downgraded. 5 Hospital Acquired Venous Thromboembolism (VTE) events in quarter 1, compared to 9 in quarter 4 212/ were initially reported in Q4 but 2 were found to be unavoidable and subsequently downgraded 7 clinical SIRIs in quarter 1, compared to 4 in quarter 4 212/13; there is no theme to these. PHT Quarterly Quality Report - Quarter 1 213/214 Page 7 of 59

8 HCAI SIRIs reported in quarter 1 comparable with in quarter 4 212/13. Zero Never Events were reported in quarter 1. Status of SIRIs at the end of Quarter 1 Closed in Quarter Open at the end of the Quarter Q1 42 (including unavoidable PU) 23 TOTALS Of the 23 open SIRI s 18 remain under investigation; 5 have been submitted and are awaiting review and closure by the Commissioners. 3 have exceeded their target date for submission. This is due to the complexity of some of the investigations and further information being requested following the review panels. Training is being reviewed to ensure that Root Cause Analysis (RCA) are carried out thoroughly before panels are held. The SPC chart below shows the total number of SIRIs including pressure ulcers and VTE events. Appendix 1 details some of the lessons learnt and changes to practice following incidents including SIRIs. Total SIRIs July 11 - June July 11 Aug 11 Sept 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 June 12 July 11 Aug 12 Sept 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May-13 June 13 Value Mean UCL LCL Linear (Value) As can be seen from the chart below, when removing pressure ulcers and VTE events from the figures, the Trust continues to maintain SIRI numbers between -3 per month. Total SIRIs Excluding PUs, VTEs, or HCAI July 11 - June July 11 Aug 11 Sept 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 June 12 July 11 Aug 12 Sept 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 June 13 Value Mean UCL LCL Linear (Value) PHT Quarterly Quality Report - Quarter 1 213/214 Page 8 of 59

9 2.6. Patient Safety Incidents (Contract) Reporting only The SPC chart below shows the total patient safety incidents excluding SIRI s which have been reported. As can be seen, there has been a reduction in reported incidents in quarter 1, (June data not complete at time of reporting), this coincides with the continued roll out of Datix web and an initial drop in reporting was anticipated. This is being monitored closely and a task and finish group has been set up to ensure that the system is fully embedded and to overcome issues raised regarding usage. CSC level data and recovery of numbers in the months post implementation is being monitored through the Patient Safety Steering Group Total Incidents Excluding SIRIs July 11 - June July 11 Aug 11 Sept 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 June 12 July 11 Aug 12 Sept 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 June 13 Value Mean UCL LCL Top 6 Incidents by Detail Quarter Slips, trips, falls and collisions Pressure sore / decubitus ulcer Administration or supply of a medicine from a clinical area Implementation of care or ongoing monitoring - other Other Medication error during the prescription process 1 Slips/trips/falls, pressure ulcers and administration or supply of a medicine from a clinical area remain the top three reported incidents. Other remains the fifth reported incident for quarter 1. Roll-out of Datix-web means that coding of incidents is now completed at a local level which is resulting in variances of coding. The category other is being used instead of specific codes. This is being addressed through training as well as a reminder on Datix to staff regarding accuracy of coding, and continues to also be picked up through the task and finish group Claims (NHSLA) Reporting only The reporting of claims together with SIRIs, adverse incidents and complaints provides the Board with a comprehensive overview of quality and any emerging themes within the organisation. Summary of number of clinical negligence claims received in quarter 1 CSC Number CSC Number Emergency Medicine 4 MSK 12 Head and Neck 2 Surgery/Cancer 14 Medicine 2 Women and Children 15 PHT Quarterly Quality Report - Quarter 1 213/214 Page 9 of 59

10 Summary of number of clinical negligence claims received in quarter 1 CSC Number CSC Number MOPRS CSS 1 Theatres TOTAL: 5 It should be noted that the above are potential clinical claims only at this stage, no breach of duty of care or causation has been determined and, therefore, the final outcome with regards to any liability is yet to be determined. The 5 new potential claims for the 1st quarter as detailed in Appendix 2, have been coded as per NHSLA codes as follows:- Intraoperative problems - 12 Failure to diagnose 9 Inappropriate discharge 1 Inappropriate treatment 3 Birth defects 1 Medication errors 1 Not specified 1 Failure to perform tests 1 Failure/delay treatment 6 Failure to recognise complication of treatment 1 Performance of operation that is not indicated 1 Delay in performing operation 1 Inappropriate use of forceps-ventouse 2 Intubation problems 1 Appendix 2 details claims received and claims closed during quarter Inquests Reporting only April June 212 April June 213 Coroner request for report Staff required to attend inquest 2 21 Please note that the inquests which staff have attended in this quarter will be cases notified to the Trust before this quarter. The numbers of staff attending inquests, above, do not therefore relate to the number of requests received from the Coroner in this quarter. Summary of Verdicts for Inquests held in April to June 213 There were 46 Inquests held in Portsmouth in this quarter relating to Trust hospital deaths. 24 were held without Trust staff having to attend to give evidence in person, although reports were provided. Summary of Verdicts for Inquests held in Quarter 1 Verdict No. Comments Natural causes 19 One of these cases initiated the SIRI process in respect of a fall in hospital. Accidental death (out of hospital accident) 12 One of these cases involved a patient who also fell in hospital for which there was a SIRI investigation carried out. However, the Coroner felt that on the balance of probabilities, the fall he had at home prior to admission was more likely to have caused the death, although the fall in hospital could possibly have contributed. This was also one of the three cases included in the Coroner s Rule 43 letter which is reported in the Rule 43 section at 1.3 below. PHT Quarterly Quality Report - Quarter 1 213/214 Page 1 of 59

11 Summary of Verdicts for Inquests held in Quarter 1 Verdict No. Comments Industrial disease 9 (asbestosis) Death due to complication of necessary medical/surgical treatment: 5 Treatments involved were cardiac pacing wire (2 cases), oesophagectomy, Hartmann s procedure, hemicolectomy Took their own life 1 The above data illustrates that the SIRI process has been implemented proactively at the Trust and is sensitive in identifying cases where there are lessons to be learned. Monitoring will continue to ensure that the two processes are linked through the risk and legal services departments Rule 43 Reporting only As expected, the Trust received a Rule 43 letter on 9 th May 213 which covered three cases where patients had fallen in Queen Alexandra Hospital. The Coroner accepted that the Trust is carrying out a lot of work to reduce the number of falls but due to the similarities across the cases within a short time period he felt it necessary to formalise his concerns. The letter indicated that he had particular concern that where falls did occur, proper neurological and other monitoring should take place. The three cases involved had highlighted the fact that falls prevention protocols had not been followed and that appropriate post-fall monitoring had been deficient. The Trust s response was sent to the Coroner on 2 nd July 213. Attached to the letter was a Falls Prevention Report which detailed all initiatives being undertaken in the Trust and nationally, to prevent falls and to ensure that all staff are appropriately trained in falls prevention and post fall monitoring. The Coroner was also offered the opportunity to meet with the Head of Nursing, Medical Director and our Clinical Nurse Specialist for Falls and Bone Health to discuss the falls report if he would find it helpful Safety alerts (Contract) Reporting only A total of 3 alerts were received by the Trust in Quarter 1. Of the 13 that were applicable to the Trust, 2 remain open at the close of Quarter 1 neither of which are overdue. There are 3 Alerts which are being assessed to see if there are applicable to PHT, these alerts have been sent to Carillion for investigation. Title of Alert Due Date Safety blood collection and infusion sets. Various item and lot numbers. 29 th July 213 Implantable screw: MatrixMANDIBLE, MatrixNEURO, MatrixMlDFACE and MatrixORTHOGNATHlCS High Voltage Equipment Defect NATIONAL EQUIPMENT DEFECT REPORT (NEDeR)SIEMENS - ARGUS 1 RELAY High Voltage Hazard Alert DANGEROUS INCIDENT NOTIFICATION (DIN)Long & Crawford GF3T Fuse Switch High Voltage Hazard AlertSUSPENSION OF OPERATIONAL PRACTICE (SOP)Long & Crawford GF3T Fuse Switch 11 th July st August th July th July Pressure Ulcers (Contract) Not A new reduced target of 25 has been agreed internally for 213/14, this represents a 1% decrease on last years outturn figure of 28. The number of reported grade 3 and 4 pressure ulcers has increased with 12 being reported for the quarter. This compares to 1 in quarter 4, 3 in quarter 3 and 8 in quarter 2 and 1 in quarter 1 last year PHT Quarterly Quality Report - Quarter 1 213/214 Page 11 of 59

12 The Trust is reporting 12 grade 3 and 4 pressure ulcers against a trajectory of 7, therefore placing the Trust 5 over trajectory at the time of reporting. Total Grade 3 and 4 Avoidable Pressure Ulcer Incidents July 11 - June July 11 Aug 11 Sept 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 June 12 July 11 Aug 12 Sept 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 June 13 Value Mean UCL LCL Linear (Value) TOTAL TRUST - PRESSURE ULCER INCIDENTS Number of Pressure Ulcer Number of Incidents by Severity 13/14 incidents mth 13/14 12/13 Near Miss Green Yellow Amber Red Amber Red April May June Quarter 1 Total The number of reported grade 1 and 2 pressure ulcers has reduced further over quarter 1, as can be seen from the chart below. It should be noted that the Trust has seen a general downward trend with incident reporting since the implementation of DatixWeb; this needs to be considered when reviewing the data. Total Grade 1 and 2 Pressure Ulcer Incidents July 11 - June July 11 Aug 11 Sept 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 June 12 July 11 Aug 12 Sept 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 June 13 Value Mean UCL LCL Linear (Value) Key Developments: Braden has been fully implemented across PHT. PDSA testing in MSK for pressure ulcer prevention strategies, has resulted an a reduction in grade 3 and 4 pressure ulcers within the CSC. Refreshing of all CSC and Trust-wide pressure ulcer prevention reduction action plans, which are reviewed at the pressure ulcer working group. Trust wide implementation of the SKIN bundle and weekly auditing of practice at ward level is being taken forward urgently in response to the above trajectory position at Q Falls (Contract) The requirement for 213/14 is to achieve a 1% reduction in moderate and severe harm (amber and red incidents) based on 212/13 outturn giving a target of 34. PHT Quarterly Quality Report - Quarter 1 213/214 Page 12 of 59

13 4 events have been reported in Q1 leaving the Trust under trajectory. It is important to note that following coroners instructions and post mortem results there is a further 1 potential red event pending investigation. The event occurred in May 212 and the investigation is to conclude on the 15 th July. The leads for falls and safeguarding have compared data and there are no cases in Q1 of patients who fell sustaining a moderate or serious injury who are the subject of a safeguarding concern or require a safeguarding alert. Total Patient Fall Incidents July 11 - June July 11 Aug 11 Sept 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 June 12 July 11 Aug 12 Sept 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 June 13 Value Mean UCL LCL Linear (Value) TOTAL TRUST FALLS INCIDENTS (Quarter 1) Number of Falls Number of Incidents by Severity 212/13 month 13/14 12/13 Near Miss Green Yellow Amber Red Amber Red April May June Quarter 1 Total Falls per 1, bed days The chart below show the Trust falls rate per 1, occupied bed days. Our mean falls rate (Q1) is currently 5.7 (national average 5.6). The dramatic drop off for June 213 is representative of incomplete data however the general trajectory of reduction in falls rate remains. Rule 43 report The Trust received a Rule 43 letter from the Portsmouth Coroner dated 8th May; regarding three cases where patients had fallen in hospital. The Coroner concluded that two of these patients died as a result of the injuries they sustained in the fall in PHT Quarterly Quality Report - Quarter 1 213/214 Page 13 of 59

14 hospital. The third most likely died from injuries sustained in a fall prior to admission to hospital but that a subsequent fall in hospital could have contributed to the death. A full response and report has been provided plus a covering letter from the CEO inviting the coroner for a meeting with key staff. The report back to the coroner details the falls and harm prevention interventions being implemented across the Trust Key Developments Introduction of the FallSafe Care Bundle to 15 wards started in December 212 and is now concluded. This is a series of evidence-based interventions proven to improve the quality of assessment and management and reduce falls. Excellent progress is being made with some bundle elements seeing a 29% improvement in compliance. A celebration event was held in June and attracted representation from the Royal College of Physicians and NHS England Thematic analysis of all amber incidents has produced a list of priority areas to be agreed by the Falls Prevention Strategy Group in April 213. Specific areas of focus are: working with medical and nursing staff to raise awareness of the recognition of the increased risk of falls associated with clinical deterioration, improving staff skills levels around assessment of neurological function post fall and assessment of blood pressure for orthostatic hypotension. Safeguarding prompts have been incorporated into the DatixWeb reporting processes for injurious falls HCAI (National target and Contract) There were cases of MRSA Bacteraemia reported in the quarter. The Trust MRSA objective for 213/14 is zero avoidable cases. Failure to meet this objective will result in loss of the tariff payment for the episode of care. A turnaround programme, led by the MRSA action group, continues to be implemented. There were 4 cases of C.Difficile reported in quarter 1, giving a year to date total of 4 cases against a trajectory of 11. The Trust continues to report all MSSA and E. coli bacteraemias via the national mandatory surveillance programme (MESS). Internal reviews of all the cases are undertaken by the clinical teams with the findings disseminated via the Trust s governance leads. MSSA bacteraemia Month < 48 hrs > 48 hrs April May June Total Objective - avoidable cases Actual MRSA Bacteraemias > 48 hours from admission Cumulative Totals Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Catheter Acquired Urinary Tract Infections (CAUTI) (Contract) The Trust is required to monitor catheter acquired urinary tract infections based on the 211/12 outturn and improve compliance with appropriate catheterisation Actual Objective C difficile cases > 72 hours from admission Cumulative Totals Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar PHT Quarterly Quality Report - Quarter 1 213/214 Page 14 of 59

15 In quarter 1, a point prevalence survey of urinary catheter care was conducted in 5 wards/specialities across the Trust. A total of 141 patients were audited of whom 24 patients had a urinary catheter in place on the day of the survey. The urinary catheter prevalence was 17% of patients (21% in quarter 4). Ward Number of occupied beds Number of pts with a catheter Catheter prevalence Number of pts on treatment for CA-UTI G % 1 A % E % D % C % 1 The survey looked at a number of key indicators for catheter insertion, management and care. Overall key findings include: Insertion details: 92% of catheters had documentation to support an aseptic insertion of the device in keeping with Trust policy. This is an improvement compared to quarter 4 where 83% of catheters had documentation of insertion. 88% (21 patients) of catheters had an appropriate reason for insertion documented. Of these, 33% (7 patients) of catheters were inserted for acute retention, a further 33% (7 patients) for fluid monitoring, 29% (6 patients) for chronic retention and 5% (1 patient) intra operatively. Out of the 24 patients with catheters 12% (3 patients) did not have a documented reason for insertion and therefore it was not possible to determine whether in these 3 patients there was an appropriate reason for catheterisation. This data is an improvement compared to quarter 4 where 75% catheters had a documented reason for insertion. 29% (7 patients) of catheters audited had on-going care documented in the 24 hours prior to audit. 8% (2 patients), with urinary catheters in-situ, were receiving treatment for a CA- UTI. This information is reported weekly to the CSCs through an infection control dashboard for improvement actions to be implemented Medication Safey (Contract) Monitor/No increase based on 12/13 outturn medication incidents that result in moderate/severe harm/death There has been one confirmed amber medication related incident in Quarter 1. This incident related to an issue during the ordering process, this has been investigated and internal processes are under review. There is also one incident currently under investigation which occurred in June. Month on month increase in number of stage 1 medicines reconciliations completed by trained pharmacy staff until target of 8% (of achievable med reconciliations) reached for 3 consecutive months Indicator Baseline April 213 May 213 June 213 PHT Quarterly Quality Report - Quarter 1 213/214 Page 15 of 59

16 Medicines reconciliation 86% 89% 92% 9% Quarterly increase in proportion of ibuprofen/naproxen vs diclofenac prescribed against 212/213 outturn The above data shows compliance with this metric across the whole of PHT. A continued improvement is expected to be seen with this metric as ongoing actions are completed Safeguarding Adults (Contract) The Trust continues to declare full compliance with CQC outcome 7 (Safeguarding adults). Areas for further work include: Trust specific Restraint Policy (physical), which is currently being finalised. Update of Mental Capacity Act, DOLS and Safeguarding policies Domestic Abuse agenda Mental Capacity Act and DOLS training Safeguarding Alerts - The numbers of adult safeguarding alerts has increased considerably over the last quarter. The rising numbers has been attributed to: The effective implementation of e-reporting of adverse incidents which has a compulsory prompt related to safeguarding. Continued focus on safeguarding awareness and training. Heightened staff awareness related to national reports and media focus e.g. Winterbourne View, The Francis Report. April 213 safeguarding audit showed compliance of 75% or above for 33/34 questions. The Trust continues to raise the majority of alerts with very few coming in from our external partners. However we have seen an increasing number of concerns coming into safeguarding from the CQC this quarter. This change in alerting patterns could be due to increased public awareness, both of the CQC and adult safeguarding resulting from recent reports within the NHS, social care and the media. Quarter Total number Safeguarding alerts Internally Alerts raised by Portsmouth Hampshire City Council County Council Quarter Quarter * 5 PHT Quarterly Quality Report - Quarter 1 213/214 Page 16 of 59

17 * includes 7 received from the CQC Quarter 4 saw a rise in the proportion of safeguarding concerns relating to Trust provided care (29%). This figure remains static in quarter 1. Themes of the safeguarding allegations relating to Trust provided care can be seen below. PHT Safeguarding themes and trends - The Trust is required to evidence practice changes through analysis of safeguarding incidents. In Quarter 1, 65 safeguarding alerts relating to hospital provided care and treatment were reported. It should be noted that this information relates to the initial reason given for the alert and that following investigation not all allegations are proven or indeed turn out be related to Trust provided care and treatment. Theme Number of alerts Alerts relating to patient with LD/MH problem Hospital associated Pressure Ulcers 3 Discharge arrangements / communication 5 Not safeguarding 1 Alleged professional behaviour of staff 6 General care and treatment 7 1 Capacity Issues 5 1 Abscondment of vulnerable patient 2 1 Financial abuse / theft Potential hospital associated pressure ulcers remain the highest category of internal care concerns. These are investigated as per Trust policy with the outcome and learning fed back to external safeguarding partners. Our safeguarding training includes reference to the Whistle-blowing Policy, but also emphasises professional codes of conduct, and whilst any allegation about unprofessional / inappropriate staff behaviour is disappointing, it is encouraging that in the majority of cases it is our own staff who are raising the alert. This provides evidence that staff feel confident to raise concerns about practice issues or colleagues. Actions An overarching Safeguarding Committee was established in Quarter 4. The committees purpose is to ensure that the Trust is fulfilling its responsibilities for the safeguarding of adults and children. Terms of reference have now been finalised. Direct feedback mechanisms to the staff member who raises a safeguarding alert was introduced in quarter 4 and initial feedback is that this is viewed very positively by staff. It is hoped this will contribute to an increase in the quality of alerts and reduce the number of inappropriate alerts raised. Formalisation of the Safeguarding Operational Leads (SOL s) Group and role. Terms of reference have been drawn up along with an SOL role descriptor. All CSC s / SOL s have signed up to the role descriptor. In April 213 SOL s began to produce monthly reports on safeguarding activity within their own CSC, focussing on trends and learning / practice changes resulting from safeguarding cases. Reports are shared with the SOL group and CSC governance meetings. Mental Capacity Act and Deprivation of Liberty Safeguards awareness sessions are being delivered within CSC development days / sessions. The Safeguarding Lead has also scoped out alternative external providers for additional training. PHT Quarterly Quality Report - Quarter 1 213/214 Page 17 of 59

18 Outcomes Care concerns that are not related to the Trust are closed as not PHT if we do not receive a request for information or assistance from the Local Authority within 2 weeks of sending the alert externally. The table below shows the status of cases relating to Trust provided care. Closed case Outcomes (PHT care concerns only) Quarter 1 Not Safeguarding 1 Undetermined (not proven) 8 Partially Determined (some elements raised were proven) 1 Fully Determined (all elements were substantiated) 2 No Further Safeguarding Action / Alert only 3 Outcome not known (awaiting feedback from councils) 1 Not PHT* 1 Case remains open 39 * Investigation found the care concerns were not related to Trust provided care. Organisational Learning from Safeguarding Incidents Many safeguarding concerns are also deemed an internal incident or SIRI and as such are investigated within the Trusts already well-established policies and procedures. One of the two cases found determined related to a hospital related pressure ulcer deemed avoidable. A summary of the root cause analysis, learning and actions were fedback to our external safeguarding partners. The other related to an allegation of unprofessional behaviour. In this case appropriate action was taken following Trust HR policies, along with support for the staff member and guided reflection on the events Deprivation of Liberty Safeguards (DOLS) - In April 213 responsibility for DOLS passed from the PCT to Local Authorities and we have been working with our external partners to not only effect a smooth transition of responsibility but also to improve our own internal processes for DOLS applications. Our MCA and DOLS policy is currently under review and should be ratified in quarter 2, along with a DOLS decision making and guidance tool. There have been 5 applications for DOLS authorisation in quarter 1 compared to 4 in quarter 4. There have been no known occurrences of unauthorised DOLS. All of these have been reported to the CQC as required. Counter terrorism A Prevent Policy has been developed and ratified. A key task in quarter 1 was to identify and agree with our commissioners key staff groups for training and develop a HealthWRAP delivery plan. Currently there is only 1 HealthWRAP facilitator in the Trust and there has been no delivery of HealthWRAP in quarter 1. There are plans to a train an additional facilitator in July 213, following which workshops will re-commence. The last Prevent forum reported on progress across the region and the Trust achieved a green RAG rating following the self-assessment process. PHT Quarterly Quality Report - Quarter 1 213/214 Page 18 of 59

19 Approximately 52 senior staff within the Emergency Department are required to attend HealthWRAP awareness training to meet Trust contractual requirements. A programme of 12 sessions were scheduled between September 212 and March 213. In addition to the staff groups specified within the contract other key staff were invited to attend. By the end of Quarter 4 a total of 5 staff have attended the training, of which 15 were from the contract specified staff group. Domestic Abuse Domestic Abuse advisors / leads have long been established within Women s and Childrens services and the Emergency Department. There is however a requirement for wider awareness and leadership within the Trust in this field, therefore the Adult Safeguarding Lead is now taking coordination of the overall domestic abuse agenda. Staff awareness of domestic abuse and violence is a key requirement. Safeguarding training sessions have been updated to include information on domestic abuse and violence. SOL s are commencing a programme of attending multiagency safeguarding training which incorporates an e-learning module on this subject. Contact has also been made with local domestic abuse organisations (both local authority and independent sector) with a view to obtaining additional information resources within the Trust and delivering additional training to key staff groups e.g. staff within the Emergency Department and Occupational Health Safeguarding Children (Contract) The Safeguarding Children Assurance Framework Self-assessment tool was selfassessed on the 2 th June 213 and reported an overall rating of 2, with minor concerns. The tool was discussed and agreed at the Safeguarding meeting on the 2 nd July. Areas where action is required are: Updating of the Safeguarding Children strategy. Review of training compliance. Review of supervision and monitor, complete a wider audit as appropriate. Domestic abuse policy to be discussed, written and HR policy reviewed if appropriate. 1WTE Vacancy within the Safeguarding Children team from June 213. Review of the notification forms to Health Visitors, GP, looked after nurse. PHT Quarterly Quality Report - Quarter 1 213/214 Page 19 of 59

20 3. CLINICAL EFFECTIVENESS 3.1. Clinical effectiveness compliance summary Clinical effectiveness compliance summary Indicator High Impact Innovations (CQUIN) Hospital Standardised Mortality Ratio (HSMR) (Contract and Quality Account) Summary Hospital Level Mortality Indicator (SHMI) Contract and Quality Account) Improving clinical effectiveness and patient outcomes (Contract) Enhanced Recovery Programme (Contract) Re-admissions (Contract) Fragility fractures (Contract) End of Life Care: Amber Care Bundle (Contract) Discharge summaries National Clinical Audit benchmarking clinical outcomes (Contract) Patient Reported Outcome Measures (PROMs) (Contract) COPD Discharge Care Bundle (Contract) Emergency Care Pathway (Quality Account) National Institute for Health and Clinical Excellence (NICE) (Contract) Compliance To be confirmed Reporting only Partial compliance 3.2. High Impact Innovations (CQUIN) Intra-operative Fluid Management (IOFM) - Maintaining optimal fluid status during and immediately after surgery is a vital component of high quality surgical care and can contribute to achieving enhanced recovery. There are a variety of technologies available that enable surgical teams to more accurately assess and manage a patient's fluid status, therefore minimising the risks of complications due to a patient having too much or too little fluid in their tissues. The Trust is required to undertake a full baseline assessment in quarter 1 followed by maintenance of uptake above 8%, or reaching 8% averaged across all included procedures in quarter 4. The agreed techniques are: oesophageal doppler techniques, transthoracic impedance methods, Lidco; and IV tranexamic acid in conjunction with fluid restriction. (other techniques for IOFM may also be utilised as they become available) The Trust has undertaken the baseline assessment of utilisation of the agreed procedures in the agreed case range. Audit results can be seen below. PHT Quarterly Quality Report - Quarter 1 213/214 Page 2 of 59

21 Cardiac Telemetry (3 million lives) - This initiative aims to rapidly accelerate the use of assistive technologies in the NHS such as telehealth and telecare, aiming to benefit 3 million lives over the next five years. The plans and trajectories agreed with the Commissioners in 212/213 for delivery by July 213 have been completed. The target for 213/214 is to extend the scope of the current cardiac telemetry applications to incorporate routine pacemaker patients. The quarter 1 requirements to scope feasibility of remote follow-up of patients with pacemakers and to complete financial modelling have been met. Electronic pre-operative assessment pilot (Digital First) - In 213/214 the Trust is required to commence an electronic pre-operative assessment pilot within the Head and Neck speciality and if fit for purpose, roll-out to other specialities. The quarter 1 requirements to commence the pilot and complete training of the preoperative assessment nurses have been met. The pilot has identified some IT issues which have been escalated to the software company and are being addressed. Training of the Pre-operative assessment nurses in Max Fax and ENT has been completed. Patient self check-in (Digital First) - In 213/214 the Trust is required to introduce a patient self check-in service. All quarter 1 requirements have been completed as outlined below: Analysis of system requirements. Hardware installation. Creation of a test training environment. Benchmarking of key patient experience indicators: - Current patient waiting times audited for the pilot go-live area on 15 th July. - Multi-language system set up and to be further audited using the patient survey as part of go-live. - Patients knowledge of waiting times to be audited as part of go-live. Digital Appointment Reminders (Digital First) - In 213/214 the Trust is required to roll-out a digital appointment reminder system across diagnostics. All quarter 1 requirements have been met as outlined below: Data analysis complete (included in improvement plan below). Small scale audits complete. A full Quality Impact Assessment (QIA) has been completed. The installation of the new PACS/RIS into the Trust and the region as a whole has prevented the Trust testing how the new PACS/RIS will be able to deliver digital reminders, however, there is an alternative solution should this not be possible. Improvement plans submitted to the Commissioners. Improvement plan The Imaging department have completed a full analysis of DNA s across 3 modalities, CT, MRI and Ultrasound. The breakdown is outlined below: PHT Quarterly Quality Report - Quarter 1 213/214 Page 21 of 59

22 <> <> <> Ultrasound Age Group DNA % -18 9% % % 6+ 4% MRI Age Group DNA % -18 5% % % 6+ 4% CT Age Group DNA % -18 1% % % 6+ 3% The Imaging department is keen to reduce DNA s in the age range as this is where the most DNA s are recorded. This, it is hoped will be the patient group that is most likely to respond to digital reminders. The Trust would aim to reduce DNA rates within the age group by 15% by the end of quarter 4. The milestones for achieving this will be the introduction of digital reminders in quarter 2. In quarter 3, examine the feasibility of introducing a pilot call centre for a specific modality to assess the cost benefit analysis for introducing across Imaging as a whole. This will attempt to reduce all DNA s within the Department Dr Foster Hospital Standardised Mortality Ratios (HSMR) (Contract and Quality Account) The chart below gives a comparison of the Trust s Dr Foster HSMR for the previous 3 financial years. For 212/13 the Trust HSMR using the model for 211/212 was 1; equal to the national average for that year. Rebasing the model using provisional national data for 212/213 indicates a Trust HSMR of 16 which is above the national average. PHT Quarterly Quality Report - Quarter 1 213/214 Page 22 of 59

23 Trend in HSMR The funnel plot below demonstrates a rebased value for 212/13 for all Acute Trusts, along with the control limits. As can be seen the Trust was below the upper control limit. Current HSMR The Trust HSMR for the period May 212 to April 213 using the model for 211/212 is 99, below the national average. This compares with a rate of 12 for the period April 212 to January 213. A rebased figure is currently not available for this period. The table below shows 3 diagnoses groups and 5 procedure groups that have higher than average relative risk (RR) of mortality using the 211/212 model (shown as red in the RR column). There is an on-going clinical audit into stroke care by non-specialists. Analysis identified that the urethral catheterisation deaths were spread across numerous high risk diagnoses groups. A coding investigation of a sample of the contrast radiology or catheterisation of heart deaths didn t highlight any concerns; the patients had had seizures or arrests. One spell was missing comorbidity codes and this has been amended. PHT Quarterly Quality Report - Quarter 1 213/214 Page 23 of 59

24 There have been 11 diagnoses groups with positive cumulative summary (CUSUM) alerts (lower than expected mortality) and none with negative alerts. Negative alerts identify sequences of adverse outcomes over shorter intervals than a yearly RR analysis. There have been 7 procedure groups with negative alerts. An alert is reset after triggering so that it can re-alert in the following months. Only urethral catheterisation has retriggered in the 12 month period Summary Hospital Level Mortality Indicator (Contract and Quality Account) The SHMI is published quarterly for the preceding 12 months of activity. There is a delay of approximately 6 months before publication, partly to allow for the inclusion of deaths occurring up to 3 days after discharge unlike the HSMR. Other differences are that the SHMI includes all deaths and makes no adjustment for palliative care. For 211/212 the Trust SHMI was and HSMR was 99. The latest SHMI publication, for the period October 211 to September 212, shows the Trust to have a SHMI of 1.63 against an estimated HSMR of for the same period. The chart below displays the Trust SHMI and estimated HSMR for the same period relative to other acute Trusts. Both the SHMI and HSMR were at approximately the level of the national average of 1 and both within control limits. (NB: time period is different to that reported in the HSMR section above). PHT Quarterly Quality Report - Quarter 1 213/214 Page 24 of 59

25 The table below shows the SHMI diagnostic groups with higher than expected deaths, along with the HSMR for the same diagnoses and for the same time period: Collection SHMI Observed Expected HSMR Observed Expected (113) Other connective tissue disease (59) Nonspecific chest pain (98) Other gastrointestinal disorders (25) Cancer of brain and nervous system The higher number of deaths shown in the SHMI are as a consequence of including post-discharge deaths; clarification regarding this is being sought from Dr Foster. Sample coding investigations of the in-hospital deaths for the first 3 of the 4 groups, identified that almost all patients were on the Liverpool Care Pathway (LCP) or had a terminal illness. This too would help to explain why the SHMI values are significantly higher than the HSMR values Improving clinical effectiveness and patient outcomes (Contract) The Clinical Effectiveness Steering Group (CESG) has appointed clinical leads to review the recommendations from each of the named studies. The leads ensure a gap analysis is completed and highlight areas where the Trust can improve practice by learning from the reports. The CESG continue to regularly monitor the progress of actions against the recommendations within these studies. NCEPOD Alcohol Related Liver Disease (213) Measuring the units This NCEPOD report, published in June 213, highlights the process of care for patients who died with a diagnosis of alcohol-related liver disease, to identify the remediable factors in the quality of care provided. The study highlights hospitals are missing opportunities to save the lives of people with alcohol-related liver disease by failing to provide early intervention and specialist consultant input. A clinical lead has been appointed in the Trust to review the recommendations from this study and to ensure a gap analysis is completed to highlight areas where the Trust can improve practice by learning from these reports Enhanced Recovery Programme (Contract) To be confirmed The Trust has agreed the following targets associated with the Enhanced Recovery Programme. Due to reporting processes and data validation the results will be reported one month in arrears. Procedure LoS Same Day Admission Hip replacement 3.5 days not less than 93.5% Knee replacement 4.5 days - Q1, 2, 3 to allow Maintain current performance for physiotherapy interventions 4. days at end of Q4 Colectomy 5. days Maintain current performance Excision of Rectum 7. days Maintain current performance Abdominal Hysterectomy 3. days (cancer LoS to be shown separately) 97% Vaginal Hysterectomy 1.8 days 99% Cystectomy 1.5 days 6% Prostatectomy 2. days 9% (excluding patients being admitted from the Isle of Wight and the Channel Islands) PHT Quarterly Quality Report - Quarter 1 213/214 Page 25 of 59

26 3.7. Re-admissions (Contract) The contract requires the Trust to analyse re-admissions to identify any quality and safety themes. A Commissioner led audit, as part of Payment by Results (PBR), in 212/213 demonstrated that most of the re-admissions were out of the control of the Trust, and it has been agreed with the Commissioners that this audit will not be repeated in 213/214. The identification of quality and safety themes would be identified through this audit, and as this is not to be repeated in 213/214 there is no mechanism for the information to be provided; the Trust will however continue to monitor re-admissions to reduce where they are deemed avoidable Fragility fractures (Contract) The contract requires the Trust to provide a leaflet to patients aged 45 years and over, who have sustained a fracture. The leaflet informs the patient of the need to prevent future fractures and recommends that patients arrange to see their GP to consider bone protection medication. All patients attending the fracture clinic in quarter 1 received a copy of the broken bones leaflet End of Life Care (Contract) Amber Care Bundle - The AMBER care bundle was developed at Guy's and St Thomas' NHS Foundation Trust. It was developed to improve the quality of care of patients who are at risk of dying in the next one to two months but may still be receiving active treatment. The bundle is a tool which combines identification questions, four clinical interventions and systematic monitoring that can be applied in adult ward settings. The first pilot of the use of the AMBER Care Bundle has commenced in June 213 on Ward F4 for patients under the care of Dr Kate Hardy. To enable the pilot to commence a process of education for staff, as well as the production of the necessary documentation was necessary. Given the limitations of current resources, it is planned that the use of the tool will be extended, ward by ward to other clinical areas expressing a wish to participate. An initial audit has been carried out, against which the advantages of the use of AMBER will be measured. It is acknowledged that the success of AMBER in the Trust will be measured by the benefits it is seen to produce for patients, especially in terms of reduced unnecessary readmissions, and ultimately, reduced hospital deaths: this may take some time to evaluate. The objective for 213/214 is to steadily increase the use of the tool, both in terms of patient numbers, and wards using it. Anecdotal feedback of the benefits of its use may also be possible. Liverpool Care of the Dying Pathway (LCDP) Although no longer a contractual requirement, the Trust monitors the usage of the LCDP. The use of the LCDP has reduced since the adverse publicity last Autumn; the figure has dropped by 5% to 1%. In itself this may not be a large variation, but the implications for individual patients, of professional uncertainty around the delivery of end-of-life care may be considerable in those cases. PHT Quarterly Quality Report - Quarter 1 213/214 Page 26 of 59

27 End of Life Care - LCDP Month % ward deaths on LCDP Quarter 1 212/ /214 April 58% 43% May 44% 41% June 48% 38% Q1 Total 5% 41% Quarter 2 July 55% August 55% September 6% Q2 Total 57% Quarter 3 October 55% November 4% December 46% Q3 Total 47% Quarter 4 January 38% February 34% March 4% Q4 Total 37% Year-end total 48% A circular letter to all senior clinical staff from the Medical Director, and Director of Nursing made it clear that the Trust supports the use of a framework for care for a patient who may be dying (currently the tool used being the LCDP), when no reversible causes are present. The Hospital Palliative Care Team has also adopted a proactive approach, to address the concerns of clinical teams, and once the national Neuberger Report is published, it is hoped that these elements will reinforce the importance in the Hospital, of demonstrating quality in provision of care around the end of life, by the appropriate use of such a Framework of Care Discharge summaries (Contract) Reporting only The Trust is required to undertake an audit of discharge summaries in quarters 2 and 4 to ensure compliance with the appropriate contractual schedule. Associated with this the Trust has submitted to the Commissioners an improvement plan regarding the roll-out of the Electronic Discharge Summaries. This will be monitored by the Clinical Effectiveness Steering Group National Clinical Audit Benchmarking Clinical Outcomes (Contract) Everyone counts - Consultant level data In December 212 NHS England (formerly NHS Commissioning Board) published its planning guidance for 212/213, entitled Everyone counts: Planning for patients 213/14. This stated: "The Healthcare Quality Improvement Partnership (HQIP) will develop methodologies for casemix comparison and, in conjunction with NHS Choices, publish activity, clinical quality measures and survival rates from national clinical audits for every consultant practising by summer 213". PHT Quarterly Quality Report - Quarter 1 213/214 Page 27 of 59

28 In accordance with contractual requirements, a link to the published data can be found on the Trust Internet site at the following link: Those specialties, along with the associated societies and the audit/registry from which the data will primarily derive from, which are relevant to the Trust, are listed below: Specialty Clinical audit/registry title Specialist Society Publication date Bariatric surgery National Bariatric Surgery Register BOMSS 3/6/213 Colorectal surgery National Bowel Cancer Audit Programme ACPGBI Autumn 213 Head and Neck surgery National Head and Neck Cancer Audit BAHNO Autumn 213 Interventional cardiology Adult Coronary Interventions BCIS 1/7/213 Orthopaedic surgery National Joint Registry BOA 1/7/213 Thyroid and endocrine surgery Upper gastro-intestinal surgery BAETS national audit BAETS 3/6/213 National Oesophago-Gastric Cancer Audit AUGIS Autumn 213 Urological surgery BAUS cancer registry BAUS 5/7/213 Vascular surgery UK Audit of Vascular Surgical Services & Carotid Endarterectomy VSGBI 28/6/213 Consultant level data is due to be published on the NHS Choices website from the 28 th June 213; this data will be reviewed by the CESG to ensure any concerns are addressed. Vascular Surgery The information contained in this report has been drawn from data collected by the National Vascular Database and the UK Carotid Interventions Audit. Elective Abdominal Aortic Aneurysm (AAA) For elective abdominal aortic aneurysm (AAA) repairs, the report provides the number of procedures performed by NHS organisations and consenting surgeons, and the proportion of patients who died before discharge after their surgery (postoperative mortality). The figures are based on five years of data from patients who had their operation between 1 January 28 and 31 December 212. The national average rate of risk-adjusted in-hospital mortality after elective AAA repair is 2.2%; the Trust rate is 4.2% Elective Abdominal Aortic Aneurysm (AAA) South Central Trust AAA Open EVAR Mortality Status Buckinghamshire Healthcare NHS Trust % Heatherwood and Wexham Park Hospitals NHS Foundation Trust % Milton Keynes Hospital NHS Foundation Trust % Oxford University Hospitals NHS Trust % University Hospital Southampton NHS Foundation Trust % Portsmouth Hospitals NHS Trust % Mr Paul Gibbs % 1 Mr Simon Payne % 1 indicates whether the surgeon had outcomes in the expected range given their level of activity. PHT Quarterly Quality Report - Quarter 1 213/214 Page 28 of 59

29 Elective Abdominal Aortic Aneurysm (AAA) South Central Trust AAA Open EVAR Mortality Status Mr Mark Pemberton % Ms Sabine Sonnenberg % Wing Commander Timothy Whitbread 1 1.% Mr Simon Payne should not be on the Vascular Registry for this operation as he has not undertaken this form of surgery since 211. The registry states that only surgeons actively performing this operation are reported, and the surgeon has himself informed the Vascular Society that he no longer undertook aneurysm repairs. As a consequence of major shoulder surgery, he was no longer able perform this type of surgery. This surgeon s data for the five year period has been reviewed by the Vascular Society and it was found that his outcomes fell within the acceptable limit. Carotid Endarterectomy (CEA) For carotid endarterectomy, the report describes the number of procedures, the median delay from symptom to surgery, and the proportion of patients who died or had a stroke within 3 days of the operation. The outcome information was derived from three years of data, on patients who underwent surgery between 1 st October 29 and 3 th September 212. The median delay was based on one year of data, and relates to patients treated between 1 st October 211 and 3 th September 212. The national average rate of risk-adjusted stroke/death within 3 days of a carotid endarterectomy is 2.4%; the Trust rate is 1.9% Trust CEAs Total CEAs with outcomes % Stroke and/or Death Status Median (IQR) Buckinghamshire Healthcare NHS Trust % 11(8, 16) Milton Keynes Hospital NHS Foundation Trust % * Oxford University Hospitals NHS Trust % 19(8,41) University Hospital Southampton NHS Foundation Trust % 16(11, 26) Portsmouth Hospitals NHS Trust % 22(12, 65) Mr Andras Palffy % 2 Mr Simon Payne % Mr Mark Pemberton % Ms Sabine Sonnenberg 3 3.% Wing Commander Timothy Whitbread 7 7.% Current Outcome Data The Trust outcomes for the two specific operations reported in the Vascular Registry over the last 12 months are % mortality for aneurysm repair and 1% mortality for Carotid Endarterectomy which are amongst the best in the country. Endocrine & Thyroid Surgery The national report found: Mortality of thyroid surgery is low, at.1%. Early re-operation to control bleeding in the neck is infrequent, at 1% on average. 2 indicates whether the surgeon had outcomes in the expected range given their level of activity. PHT Quarterly Quality Report - Quarter 1 213/214 Page 29 of 59

30 Hospital stay after thyroid surgery is short. After lobectomy, most patients are discharged within 24 hours; after total thyroidectomy, most require only 1-3 days in hospital. Following discharge home, only around 2% require re-admission for reasons related to their surgery. Late hypocalcaemia after total thyroidectomy is the commonest reported complication, at about 9%, with much greater variation between surgeons than with other outcomes. Given that submission of data to the audit has until recently been essentially voluntary, the level of data completeness is reassuringly high, with almost 9% of the relevant data fields being complete. There is more variability between surgeons with respect to this issue than in any clinical outcome. The data sample relates to patients having thyroidectomy surgery between 1 st July 29 and 3 th June 212. Only one surgeon is identified as undertaking this surgery at Queen Alexandra Hospital Portsmouth; Mr.Constantinos Yiangou. Mr Yiangou reported no postoperative in-hospital deaths out of a total of 15 first-time thyroid surgery procedures recorded in the registry. This equates to a mortality rate of.% (95% Confidence Interval: %). Bariatric Surgery Nationally bariatric surgery is safe in the UK with 3 deaths out of 4,389 (.7%) operations; there have been no deaths at the Trust despite some high risk patients. The data sample in the report relates to patients having Bariatric surgery between April 212 and March 213. Four consultants are listed: Shaw Somers: Reported no post-operative in-hospital deaths out of a total of 3 primary bariatric surgery procedures where the outcome was recorded in the registry. Simon Toh: Reported no post-operative in-hospital deaths out of a total of 1 primary bariatric surgery procedures where the outcome was recorded in the registry. Zoltan Szucs (although reported in the report as Zoltan Somers): Reported no post-operative in-hospital deaths out of a total of 2 primary bariatric surgery procedures where the outcome was recorded in the registry. Stuart Mercer: Although listed within the report Mr Mercer undertook too few procedures, and no longer carries out bariatric surgery. Of these four consultants 42 patients are recorded with no mortalities and a hospital stay of 1-2 days, which is as per the national average. This was the first year of the service and the Trust has since increased the number of operations to approximately 2 per year. Revision operations were not included as there was no facility for this in the national database; this is now entered for future audits. The full details of consultant outcomes will be reported and discussed at the Clinical Effectiveness Steering Group. National Joint Registry (NJR) The NJR provides information about surgeons and hospitals where hip and knee replacements are undertaken. The data sample relates to hip or knee procedures carried out between 1 st January 212 and 31 st December 212 and includes data on mortality rates between April 23 and March 213. In the future, this online information service will include other surgical procedures. PHT Quarterly Quality Report - Quarter 1 213/214 Page 3 of 59

31 Age (%) Sex (%) Medical History (%) Shock (%) Urgency (%) Vessels attempted (%) Stable ACS (not STEMI) Primary PCI Other Unknown Per 1 procedures No. of PCI performed Self reported observed MACCE 3 Upper 95% Confidence Limit The national average 9 day mortality rate following primary hip replacement surgery is approximately.6%. The national average 9 day mortality rate following primary knee replacement surgery is approximately.4%. The NJR report does not give a total mortality for the Trust. None of the 16 consultants listed in the report are identified as outliers and are performing within the expected levels. Adult Coronary Interventions The analyses within the report and shown below is for Percutaneous Coronary Intervention (PCI) procedures performed in the calendar year 212. Adult Coronary Interventions Portsmouth Hospitals NHS Trust Extent of missing data No. of procedures by Clinical Syndrome Consultant Mark Connaughton 144 Ali Dana 31 Huw Griffiths 185 Alex Hobson 244 Philip Strike 262 () 3 (1) () () 1 (.38) 1 (.69) () () () () () () () () () () () () () () () () () () () 3 (2.8) 1 (.33) () 2 (.82) () BAUS Nephrectomy Audit This audit was chosen to be used by BAUS as there is no single operation which all urologists undertake but nephrectomies are routinely performed by about 4% of the 7 consultant urologists practicing in England. Data collection covers the period 1 st January to 31 st December 212. None of the 4 consultants listed in the report are identified as outliers and are performing within the expected levels. National Audits National Joint Registry Hip and Knee procedure data is submitted to this national registry on a continuous basis. The latest report covers the data collection period from January to December MACCE = Major Adverse Cardiac and Cerebrovascular Event Rate PHT Quarterly Quality Report - Quarter 1 213/214 Page 31 of 59

32 The Trust submitted 458 cases to the registry which was 36% of the records required; this has since been corrected and improved up to 98% of required data submission. The revision rate for knee and hip replacements from 23 to 211 and the 9 day mortality rates were within the expected normal range. The types of hip and knee prostheses used at the Trust have been shown to have comparable early revision rates to other types of prostheses. British Thoracic Society - Emergency Use of Oxygen Data collection for this audit took place between August and November 212. The Trust submitted 33 cases; 1% of the records required. Results: 45 (13.6%) patients were using oxygen on the day of audit. 38 (84%) patients were using oxygen with no bedside prescription chart. Of the 7 patients who had a prescription chart 5 (71%) had oxygen saturations within the prescribed target range. Since the 211 national audit a new oxygen chart had been designed and piloted successfully on the respiratory wards within the Trust. The new chart however, had not been deployed prior to this 212 audit. Training of nursing staff to level 2 oxygen prescribing competency to be able to prescribe oxygen has delayed roll out of the new chart. Since the 212 audit the new chart has been added to the Trust oxygen policy and rolled out on MAU and in Medicine. The Combined Haematology Oncology Centre (CHOC) plan a roll out with Surgery to follow. Compliance with prescribing will inevitably improve when the oxygen chart is integrated into the new combined prescribing chart in 213. Discussion is ongoing with the VitalPAC design group to incorporate oxygen prescribing into the vital signs recording process. British Thoracic Society Adult Asthma Data collection for this audit took place between September and October 212. The Trust submitted 45 cases; more than the 1% of the records required. Results: 37.7% of patients had been previously admitted in the preceding 12 months. Less than a third 31% received systemic corticosteroids within the first hour with a further 29% receiving them within 4 hours. Poor inhaler compliance was noted in 2% of patients although only 6% were checked and of those none had their compliance addressed. 4 week follow up was booked for 42.6% and only 15.5% had evidence of advice to see their GP within 1 week. Self management plans were given to only 2.2% of patients. All patients requiring arterial blood gases did receive the test (however 27 patients not meeting the criteria for the test also received it). All areas of this audit require improvement in order to meet the national guidance on the treatment of this patient group. The Trust has had declining adherence to best practice guidelines for the care of adult asthma patients admitted to the hospital. This has occurred since the dedicated PHT Quarterly Quality Report - Quarter 1 213/214 Page 32 of 59

33 respiratory nurse specialist post was removed and despite attempts to increase ward based knowledge to fill the gaps. An asthma pathway has been introduced but has been poorly taken up within areas admitting patients, where a large part of this patient group's care takes place. Actions: The audit results have been highlighted at the weekly respiratory education meeting and the MAU junior doctor education sessions. The Asthma Care Pathway is to be re-launched. Results have been highlighted at the Medicine CSC governance group and added to the specialties risk register. The results are to be presented to the Consultants Governance meeting. British Thoracic Society Paediatric Pneumonia Data collection for this audit took place between November 212 and January 213. The Trust submitted 25 cases; 1% of the records required. Results: The Trust had similar gender and age distribution compared to national figures. Higher admission temperatures recorded. 1% of patients length of stay </= 6 days compared with 91% nationally. The Trust demonstrated better microbiological surveillance than the national figures (Blood Cultures drawn 8% vs. 5%, other micro 5% vs. 29%). Less positive results for causative organism (1% vs. 18%). Significant drop in the use of physiotherapy from last year (83% down to 52%), although this remains higher than national figure (13%). The results were good compared to the national figures except for the use of physiotherapy which is improving. Actions: Continue to educate staff in regard to the appropriate use of physiotherapy in Pneumonia including on-going support of physiotherapist's to empower them to refuse requests for physio. Excellent microbiological surveillance but yield is poor so need to consider alternative techniques to increase yield. Discussed at the departmental grand round. British Thoracic Society Bronchiectasis Data collection for this audit took place between October and November 212. The Trust submitted 77 cases; more than 1% of the records required. Audit Standard Target National Trust (%) result (%) result (%) Chest CT Self management plan CVID excluded ABPA investigated Exacerbation sputum culture Stable sputum culture Pseudomonas/ MRSA/ NTM n/a Long term oral Antibiotics n/a 3 35 Needed iv antibiotics last year n/a 18 3 Offered home iv antibiotics n/a 4 74 Objective evaluation iv result Nebulised antibiotics n/a 1 2 Chest physio Pulmonary rehab n/a PHT Quarterly Quality Report - Quarter 1 213/214 Page 33 of 59

34 All patients Number of cases reported Case ascertainment (number reported as proportion of HESrecorded cases) Discussed at MDT meeting Recorded seen by CNS Overall the results are better than the national average. The results have demonstrated an improvement in the use of pulmonary rehabilitation (4% 211) and chest physio (68% 211) which were recommendations from the 21 and 211 national audits respectively. Pulmonary rehabilitation referral rate needs to improve but it is still not available for bronchiectasis patients in Fareham and Gosport or SE Hants (limited to COPD patients only). National Bowel Cancer Audit Project (NBOCAP) 212 The NBOCAP report for 212 included data from all Trusts in the UK analysing data on 29,26 cases submitted between August 21 and July 211. The data as collected suggest that compared with national figures Trust processes could be improved but outcomes are good. Postoperative length of stay, mortality rates, permanent stoma rates and % of cases performed laparoscopically are excellent. Improvements have been seen in emergency outcomes such that total mortality at 3 days for electives and emergency resections combined is now 2.1%, whereas in the 21 audit it was 5.4%. The cause of this improvement is probably multifactorial. UK / England NBOCAP 212 Portsmouth , Comment / action needed 87% 15% 12% 14% The Trust has had consistently high and reliable data reporting with an independent data coordinator retrieving and loading data. We are grateful she is now on a permanent contract 97% 1% 99.7% 1% Patients not discussed may be those who die after acute admission with new diagnosis e.g. disseminated disease on medical ward patients where no management was indicated. 87% 99% 5% % Poor recording rather than poor compliance. Need a process that ensures that data coordinator is notified reliably of CNS involvement CT scan recorded 88% 99% 97% 88% Same as above Operated patients Major surgery/ resection 17, % 66% Among operated patients, % completed laparoscopically % Dukes D at surgery Urgent / emergency surgery 37% 8% 79% 8% 12 % (7-2% ) acc to network 16% 18% 19% 12 3% 17% 15% 22% Figures reflect emergency as well as elective presentations hence relatively low national and local figure for major surgery CSCCN audit by D.O Leary showed approx 59% completed laparoscopically across this network. This network has a relatively high uptake of laparoscopic resections and Portsmouth s uptake is highest Better cancer care should lead to a fall in emergency operations. Portsmouth s data have varied with time, sometimes as many as 1/4 emergency operations. PHT Quarterly Quality Report - Quarter 1 213/214 Page 34 of 59

35 LOS Risk adjusted mortality 3 days UK / England NBOCAP days colon, 9 days rectal. 65 % stay > 5 days after colon resection and 8% after rectal resection, i.e. beyond expected for enhanced recovery Portsmouth Not reported by Trust within audit 5 days 3.3% 2.1% 1.3% 5.4% Risk adjusted mortality 5.% 2.5% 2.7% 9 days Rectal cancer operated patients Rectal Cancer Not calculated MRI scan 84% 72% 86% 81% Pre op radiotherapy 39% 35% 25% 24% APER (AP resection with permanent colostomy) 24% 19% 11.3% 13% Comment / action needed LOS is 5 days (4 days laparoscopic, 9 days open). Important to appreciate that we are approaching the limit of what can be done laparoscopically. Patients operated open increasingly likely to be unsuitable for laparoscopic op on account of extensive cancer and will have more complications and longer stay because of the nature of their disease as well as open surgery. 21 figures included to show how results vary between years. 21 report (29) 52 patients had emergency operations of whom 46% died. (Audit presented to Board 211). All patients having rectal cancer treatment should have an MRI scan. In a few the cancer, staged on CT will be incurable and MRI not needed. In others the patient cannot have an MRI: metalwork/ claustrophobia. This is a controversial and interesting area. Who should get preoperative radiotherapy? The answer in terms of practice indicates a huge variation in interpretation of the evidence which, for patients, becomes a postcode lottery. Low rates of radiotherapy are good in units with low rates of local recurrence without it (as Portsmouth) Several hospitals in Wessex have low rates of APER largely down to the influence of Bill Heald in B stoke. Rates of APR vary between networks from 1% to > 4 %. This is unlikely to be due to varying stage of disease and is a postcode lottery. Our rates of permanent colostomy / AP resection indicate a unit that is pretty good at managing rectal cancer. Our AP rates are lower than those in SUHT Gains: Colorectal ward restored on E3 a great move to support the service. Decision to run the colorectal service as a single service rather than a split one. Losses: Reduced CNS numbers. The Trust Clinical Nurse Specialists (CNS) are not all fully trained and manage an average of 15% caseload of other hospitals in the Network. The Trust has lost one of our CNS personnel since then. Not replaced. Inadequate input from CNS is reflected in patient information, perceived continuity of care and patient experience and in lack of a proactive approach to target management, all of which featured in Peer Review assessment 212. Reduced stoma therapy numbers: PHT Quarterly Quality Report - Quarter 1 213/214 Page 35 of 59

36 National Pain Audit Data collection for this national audit took place between 21 and 212 in 3 stages. Stage 1 identification of services Stage 2 Patient experience Stage 3 Follow up patient experience General results: Age 72% of patients working age (middle age). Female:Male 2:1 but chronic pain equal among sexes. 2% attended A & E in the last 6 months. 66% had more than three visits to a Health Care Professional in the last 6 months. Patients indicated it was moderately difficult to access Pain management. The majority of patients indicated their condition had a high impact on work. A large proportion of patients were Musculo-skeletal (75%) but recommended that Clinical commissioning Groups (CCGs) must recognise other areas. Trust results demonstrated positive outcomes for all three measurements of pain improvement and quality of life. 83% of patients reported receiving advice on managing their pain (8% standard). Only 5% of Trusts complied with the multidisciplinary standard of having access to a psychologist, pain physician and physiotherapist. The Trust does not currently have a multidisciplinary team, however does have access to psychology within Portsmouth City. This is currently not available for Hampshire. The national audit recommends Commissioners ensure that there is access to physiotherapy and psychology services and that these are incorporated into local care pathways. Medical consultants should underpin every specialist service to manage risk and provide expert advice on diagnosis and treatment. Commissioning groups should ensure procurement of an integrated multidisciplinary care model rather than a fragmented provision that confuses patients and referrers. Action: To continue to engage with CCGs. Consider if a multidisciplinary care group can be developed Patient Reported Outcome Measures (PROMs) (Contract) - The Trust continues to participate in the national PROMs programme which currently comprises patients who have undergone hip or knee replacement, groin hernia repair and varicose vein repair. Validated PROMS outcome data is reported annually. There are only provisional results for the period April 212 to December 212 which were published in May 213. In the charts below, the red dot denotes Trust performance. The contract requirement is to achieve on or above the national average patient reported outcomes in regard to Hip and knee replacement and as can be seen for each procedure, the trust outcome performance is above the national average for these. Groin hernias are below the national average and varicose vein figures are suppressed due to the small number of procedures. PHT Quarterly Quality Report - Quarter 1 213/214 Page 36 of 59

37 Hip replacement (Oxford hip score) Knee replacement (Oxford knee score) Groin Hernia Repair (EQ5D) PHT Quarterly Quality Report - Quarter 1 213/214 Page 37 of 59

38 3.13. COPD Discharge Care Bundle (Contract) A COPD Discharge Care Bundle has been developed to deliver a set of evidence based interventions to Trust in-patients with a primary COPD diagnosis; this is a one year pilot. In quarter 1 the Trust is required to submit a plan showing trajectories of usage of the discharge care bundle. The care bundle is delivered by a specialist nurse funded through an unconditional medical education grant. The funding for this work is not currently available beyond April 214. Progress to date: Specialist nurse appointed in June 213. Roll out of Care Bundle due 15 th July 213. Usage trajectory: Quarter 2: 2% Trust inpatient admissions with primary diagnosis of COPD exacerbation to receive the Care Bundle. Quarter 3: 33% Quarter 4: 33% A response target of 25% has been set for the patient reported experience element of the care bundle. This will be reported in quarters 2 and Emergency Care Pathway (Quality Account) Submission of data in line with national requirements The Trust submits data in line with national reporting requirements, quarter 1 data can be found below: Indicator Quarter 1 Trolley wait >12 hours Zero Wait >4 hours 88.92% Indicators to ensure patients who receive care and treatment through the emergency pathway do so in a safe, caring and efficient way are included as part of the national Emergency Department clinical quality indicators. Time from start to full initial assessment, includes a pain score for all patients arriving by ambulance, this aims to reduce the clinical risk associated with the time the patient spends un-assessed in the Emergency Department. The Department has seen a general improvement in this during the past three months and is currently achieving above 8%. A senior nurse or doctor takes the ambulance handover and within the hours of 1-18 there is a designated decision making clinician who is able to define a management plan, at this point or very shortly afterwards, which can identify if a patient may require admission or discharge. The Acute Physicians are actively involved in the process, ensuring that patients that can be managed via an ambulatory route are identified and moved out of the Emergency Corridor. Since the beginning of June the Rapid Assessment and Treatment process has been working in a designated area which has enabled the process to be more effective. A senior clinician is working within the hours of 1-18hrs in this area to enable patients to have a management plan started; this has improved the patient experience and reduced the clinical risk. The Department are not making a significant impact at present with being seen within the hour according, however a piece of work around coding is being undertaken to see if coding is sufficient to capture what is required. PHT Quarterly Quality Report - Quarter 1 213/214 Page 38 of 59

39 95th percentile wait arrival to assessment >15 mins < 15 mins < 15 mins April May.39.3 April May Median time arrival to treatment >6 mins <6 mins <6 mins Reduce the number of patient moves The Trust is monitoring the number of inpatient moves that are greater than 2 moves per inpatient. Performance in 213/214 is being measured against a monthly target of 658* patients with moves greater than 2. In 212/213 there were 78,92 inpatient admissions to the Trust (elective and nonelective), of which there were 7,246 inpatient moves greater than 2. Therefore the percentage of patients affected was 9.18% of all inpatient admissions. The total number of inpatient admissions in 212/213 is 78,92 The total number of inpatient admissions in Quarter 1, 213/214 is 19,154 PHT Quarterly Quality Report - Quarter 1 213/214 Page 39 of 59

40 The total number of inpatient admissions in Quarter 1, 212/213 is 19,934 In Quarter 1, 212/213, 9.5% of inpatient admissions had a move greater than 2 In Quarter 1, 213/214, 9.5% of inpatient admissions had a move greater than 2 However, whilst the percentage of inpatients affected by moves greater than 2 has not changed, Quarter 1, 213/214 has shown a small improvement of 57 less moves than in Quarter 1, 212/213. The table below describes out turn for 212/213 and Quarter 1, 213/214. Patient moves Target >2 >2 3-4 >4 >2 212/13 Movement April May June Quarter July August September Quarter October November December Quarter January February March Quarter Forecast 213/ Average per Month The reasons that patients move are multi-factorial, as such further analysis is being carried out to understand the number of patient moves that are to be expected on clinical grounds (clinical pathway related) and the number that have happened in response to the need to create acute capacity. The outcome of this analysis will be reported at the end of Quarter 2. PHT Quarterly Quality Report - Quarter 1 213/214 Page 4 of 59

41 Reduce the number of patients outlied from their required speciality ward Since 31 st May 213 the Trust has been monitoring on a daily basis the number of patients that are recorded as having been outlied from both the Medicine CSC and MOPRS CSC. Similarly the number of patients that have been discharged from outlying capacity has been monitored. The monitoring has identified that on average there are 2.85 Medicine CSC patients being managed as an outlier each day (31 st May th July 213). During this same period there is an average of 4.14 Medicine CSC discharges from outlier capacity. On average MOPRS CSC has outliers daily (31 st May th July 213), with a lower average daily outlier discharge of The main reason for outlying is the need to create capacity to meet acute demand. A number of schemes are currently being developed that will assist the reduction of the Length of Stay (LOS) and thereby reduce bed numbers. Medicine and MOPRS both expect the LOS reduction plans for both CSC s will result in the reduction of a sufficient number of beds to enable both CSC s to manage this within their respective bed footprints. Renewed focus at the Integrated Discharge Bureau meetings has also seen an improvement in discharges that will contribute to the overall reduction in LOS. Further analysis is being undertaken to establish the differential in LOS of those patients that are outlied compared with those that remain within the appropriate specialty bed throughout the duration of admission. This data will be reported at end of Quarter 2. PHT Quarterly Quality Report - Quarter 1 213/214 Page 41 of 59

42 3.15. National Institute for Health and Clinical Excellence (NICE) Partial compliance Technology Appraisal Guidance (TAG): Provide recommendations on the use of new and existing health technologies within the NHS. Each TAG focuses on a particular technology, which may be a drug, medical device, diagnostic technique, surgical procedure, or other intervention. Approximately a third of TAGs refer to technologies other than drugs. There is a statutory obligation to meet the funding implications of the recommendations of all NICE TAGs within three months of the date of issue (unless where specifically exempted). As can be seen from the tables below, despite increasing numbers of published guidance, the Trust compliance remains high. Technology Appraisal Guidance Compliance Fully compliant Total Published Dec 11 Mar 12 Jun 12 Sep 12 Dec 12 Mar 13 Jun (98%) 131 (97%) 142 (97%) 151 (99%) 156 (97%) 157 (96%) 158 (95%) NICE TAG 26 - Migraine (chronic) - botulinum toxin type A Not achieved The clinical lead reviewing this guidance has indicated there are no plans to use botulinum toxin in the management of headache at the Wessex Neurological Centre (WNC) or in district clinics. The clinical view is that the evidence does not support the treatment. The evidence is based on two large studies in the USA which have shown an average reduction of headache from 19 days to 17 days a month, and there was believed to be a placebo effect. Further research is awaited. This decision was further reviewed by the CESG and as the Neurology Service is not part of the Trust and the WNC is not within the jurisdiction of the Trust, this TAG has been declared not relevant rather than non-compliant. NICE TAG 274 Macular Oedema (diabetic) Not achieved A business case has been submitted to enable this service to be provided by the Ophthalmology Service, but the Trust has not yet been given the go-ahead from the commissioners. Therefore, the Trust is currently not using this treatment at present. Interventional Procedure Guidance (IPG) Evaluates the safety and efficacy of such procedures where they are used for diagnosis or treatment. PHT Quarterly Quality Report - Quarter 1 213/214 Page 42 of 59

43 Fully compliant Total Published Interventional Procedure Guidance - Compliance Dec 11 Mar 12 Jun 12 Sep 12 Dec 12 Mar 13 Jun (89%) 59 (94%) 62 (95%) 63 (95%) 63 (95%) 63 (93%) 63 (8%) Clinical and Cancer Services Guidelines (CG) Provide recommendations based on the best available evidence, on the appropriate treatment and care of people with specific diseases and conditions and may focus on any aspect such as prevention, self-care, or management in primary and secondary care. These are usually based on much larger pathways of care and full implementation should be evidenced within 3-4 years of publication. Clinical and Cancer Services Guidelines - Compliance Fully compliant Total Published Dec 11 Mar 12 Jun 12 Sep 12 Dec 12 Mar 13 Jun (7%) 58 (72%) 61 (73%) 62 (69%) 6 (67%) 61 (67%) 61 (68%) NICE Quality Standards NICE Quality Standards are markers of high-quality, cost-effective patient care, covering the treatment and prevention of different diseases and conditions. Derived from the best available evidence such as NICE guidance and other evidence sources accredited by NHS Evidence, they are developed independently by NICE, in collaboration with NHS and social care professionals, their partners and service users, and address three dimensions of quality: clinical effectiveness, patient safety and patient experience. They are intended to be used as commissioning guides for commissioners to drive and measure priority quality improvements. NICE Quality Standards - Compliance Jun 12 Sep 12 Dec 12 Mar 13 Jun 13 Partially compliant New Standard Awaiting response Not applicable Fully compliant 5 (31%) 6 (37%) 8 (38%) 8 (38%) 8 (33%) Total Published PHT Quarterly Quality Report - Quarter 1 213/214 Page 43 of 59

44 4. PATIENT EXPERIENCE Portsmouth Hospitals NHS Trust Quarterly Quality Report Quarter 1 213/ Patient experience compliance summary Patient experience compliance summary Indicator Friends and Family Test (CQUIN) National In-patient survey and Improving patient reported outcomes (Contract) Real-time patient feedback (Contract) Mixed Sex Accommodation (Contract and National Priority) Enhancing quality of life for carers (Contract) Improving care for patients with learning disabilities (Contract) Improving care for people with cancer (Quality Account) Complaints, PALS and Plaudits (Contract) Parliamentary Health Service Ombudsman (PHSO) PALS contacts Compliance Reporting only Reporting only 4.2. Friends and Family Test (CQUIN) The Friends and Family Test is aimed to improve patient care and identify the best performing hospitals in England. This CQUIN indicator has three elements: Phased expansion From April 213 all acute in-patient and Emergency Department areas are to be included. From October 213 maternity services are to be included. - The use of the Friends and Family test has been fully rolled out to in-patient and ED areas. - For Maternity, the Wessex trusts, represented by the Midwifery Network are looking at how to collect Friends and Family data in a consistent way. The Midwifery Network is keen to develop an app, an approach they recently developed for Birthplace Choices. If the Wessex approach is unwieldy the Trust will implement a separate approach based on our experiences during the DH pilot. Following a baseline response rate in April, the Trust is required to achieved an 15% average response rate in May and June and in quarters 2 and 3 and an average of a 2%. o The Trust achieved a total response rate of 17.25% in May and June and has therefore achieved the quarter 1 requirement. The Trust achieves Friends and Family Test response rate Quarter 1 213/214 April May June Total Year to date 213/214 In-patient areas 8.4% 24.1% 41.3% 24.4% 24.4% Emergency Department 1.2% 2.1% 7.9% 3.7% 3.7% Total 4.5% 11.8% 22.7% 17.25% 17.25% An increase in the score from the 213 National Staff Survey related question result in 214 (3%). - This is monitored through the staff pulse survey and reported to the Board as part of the workforce performance report. At the time of writing this quality report, data analysis is underway.

45 4.3. National In-patient Survey and Improving patient reported outcomes (Contract) - The key areas from the 212 survey where a deterioration was seen have been taken forward through other action plans and work streams. A summary of actions are: Discharge experience: ECIST action plan incorporated improvement in discharge; this is monitored through the Discharge improvement group. Deliverables through the group include the improvement of discharge planning using PDD (planned discharge date) with the transition to the Vital Pac pilot of EDD (expected date of discharge) rolled out across the Trust. In addition the use of the discharge leaflet helps the patient have a reference for discharge. Finally, improvements with near-patient dispensing of TTO (to take out) medication have improved any delays for TTO s and patient awareness of their medication and its side-effects. The ECIST action plan work stream 2 reviewed the prescribing timeliness of TTO s, led by the Medical Director. Noise at night: The Matron for the Hospital at night team undertook a review and identified key areas for changes with some wards not following lights dim processes and some wards requiring ordering of soft close bins to reduce noise. All these have been taken forward within the CSC s. Communication: The involvement and engagement of the patient in their care plan, including discharge plan, has been taken forward through the documentation group. Waiting time to access a bed: Specifically a focus in the emergency corridor and forms part of the whole system ECIST action plan of improvements in whole system emergency demand and discharge of patients needing social or stepdown care. A whole system meeting monitors actions, which while improvement have been made this is still identified as an issue Real time patient feedback (Contract) - This indicator links into the results of the Friends and Family Test CQUIN requirements. Feedback from patient comments have identified the following themes: Vast majority of responses are positive in relation to staffing levels (all staff groups), caring, friendly, attentive and helpful staff, good communication, food, the environment, professionalism of staff, privacy, treatment, pain control. There has been minimal negative responses in relation to the time patients wait to be seen/have surgery, staffing levels, pain relief, food, pre-surgery information. Response outcomes: Emergency Department: 87.59% would extremely likely/likely recommend the service In-patient areas: 82.45% would extremely likely/likely recommend the ward 4.5. Mixed Sex Accommodation (Contract) - There have been no breaches in quarter Enhancing quality of life for carers (Contract) - The action plan associated with the implementation of the carers strategy and carer s support has been refreshed and sent to the Trust Carer s forum and Public and Patient Involvement Group for comments with a plan to share with partners once ratified. Some aspects of the action plan have already been completed such as: - Carer s support at the Health Information Centre with carer s break support in conjunction with Portsmouth City Council (PCC). - Meeting held with PCC and members of the Carer s association to review a further spread of information across the Trust to increase awareness of carer s support. - Review in progress with PCC regarding Trust membership on external network groups. PHT Quarterly Quality Report - Quarter 1 213/214 Page 45 of 59

46 4.7. Improving care for patients with learning disabilities (Contract) - The Learning Disabilities Liaison nurses continue to provide a high standard of service within the Trust and were commended at the recent CQC inspection. All patients admitted with a learning disability have nursing risk assessments carried out as per PHT nursing documentation standards; these include falls risk, pressure ulcer risk, and nutritional risk. All patients referred to the Learning Disabilities liaison service are seen by one of the nursing team who will assess and work with ward teams to identify what reasonable adjustments are required as part of the plan of care whilst in hospital. The team also work closely with colleagues around discharge planning. The Learning Disability Liaison nurses will additionally carry out (where appropriate) a choking screen as per the Hampshire tool and as required in the quality contract for 213/14. During Q1 the team have reviewed the tool and the pathway for onward referral to speech and language therapy if required. The screening has commenced on 1 st July 213 with data being collected to allow for prospective audit and reporting in subsequent quarterly reports Improving care of people with cancer (Quality Account) - The following actions have been taken to improve the care of people with cancer: Access to clinical nurse specialists: Posters are displayed in all outpatient/diagnostic settings; anecdotal evidence reveals patients now asking for Clinical Nurse Specialists (CNS) details. Audit of voic messages for CNS; results reveal clear messages and setting expectation for return of call All cancer CNS have business cards which are routinely given to patients at point of diagnosis. Local patient survey demonstrates high levels of awareness of CNS and ability to contact (9% of respondents knew who their CNS was). Pain control: Audit of staff confidence/knowledge regarding cancer pain control. Pain management group formed. Development of pain management guidelines. Introduction of oramorph on drug trollies. Teaching programmes delivered by acute pain team and specialist palliative care team. Vitalpac scoring for pain. Local patient feedback exercise revealed 9.91% of respondents felt pain was managed all or some of the time. Participation in new pain management research study with Southampton. Emotional support Meeting with patient representative group. Implementation of holistic assessment. Sage & Thyme training to assist with communication skills. Assessment of psychological distress level II training. Macmillan Band 4 support role to assist work around health and well being. Lylac workshop to assist people with cancer. Stress & relaxation workshops/complementary therapies/counselling. Written information Macmillan coordinator role appointed to progress information project aim to progress use of information prescriptions but also to standardize information pathway to ensure consistency of availability but also to meet individual needs. Review of information available in Macmillan Information Centre and outpatient departments. PHT Quarterly Quality Report - Quarter 1 213/214 Page 46 of 59

47 Awareness workshops around Trust regarding access to cancer related information. Demystifying chemotherapy workshops Complaints, PALS and Plaudits (Contract) - Complaints in quarter 1 decreased in comparison to quarter 4, and increased by 24 against the same period in 212/213. The top 5 themes remain unchanged and there was a decrease of 6 in relation to complaints about admission/discharge and transfer compared to quarter 4. First column 212/13 Second column 213/14 The Trust is compliant with the required complaints indicators. Indicator Number of complaints acknowledged in 3 working days Percentage of complaints acknowledged in 3 working days Number of complaints by category, CSC/Specialty & outcome Number of complaints resolved within the timescale agreed with the complainant Percentage of complaints resolved within the timescale agreed with the complainant Q1 212/13 Q2 212/13 Q3 212/13 Q4 212/13 Q1 213/ % 1% 1% 1% 1% % 1% 1% 1% 1% Number of complaints referred to Ombudsman (%) *Number of complaints upheld by the Ombudsman 2 Number of complaints not resolved with the complainants within the agreed timescale *Subject to final validation from the Ombudsman 4.1. Parliamentary Health Service Ombudsman (PHSO) Reporting only In the event that all avenues for complaint resolution have been exhausted and the complainant is still not satisfied with the Trust response, the complainant can take their complaint to the PHSO. The Trust is aware of no referrals to the Parliamentary Ombudsman in June 213. PHT Quarterly Quality Report - Quarter 1 213/214 Page 47 of 59

48 4.2. PALS Contacts Reporting only There were 274 PALS contacts in Quarter 1 which is an increase of 22 contacts compared to Quarter 4. Work with ward and departmental teams to attempt to resolve concerns locally have supported this continued reduction Plaudit examples Reporting only There were 1581 plaudits received in Quarter 1 compared to 178 in Quarter 4. Written Plaudits End of Life Team Since my dad passed away on the 1 April, Mum and I have talked about the care that we received at the hospital by you and the other teams. We feel that everything that could have been done to help dad and ourselves was done. The fact that we were able to stay with him around the clock in a private room was the best outcome for us. Dad had made it perfectly clear to us that he wished to die at home (when the time came) because he did not want to be alone in hospital. Mum and I felt that with him being in a private room in the hospital it allowed us the best of both worlds in the fact that we were able to be with him and spend as much time with him as we wanted but that he had all the necessary healthcare and medical assistance on hand if and when required which would have been difficult at home. The staff from your team were very helpful answering any questions which we had and keeping a check on dad s progress. The staff from F2 were also very caring and attentive when we needed assistance and so at no time did mum and I feel alone in trying to deal with the situation. From the time that dad was placed on the Pathway we feel that we were looked after and supported completely. We are just so grateful that you were all there for us and made a difficult time for us as easy and as positive as it could be. We have both said that in a strange way it was a very special time for us and this is due to the help and support that you gave us throughout. With very best wishes and lots of thanks. PHT Quarterly Quality Report - Quarter 1 213/214 Page 48 of 59

49 5. GOVERNANCE COMPLIANCE Portsmouth Hospitals NHS Trust Quarterly Quality Report Quarter 1 213/ Governance compliance summary Governance compliance summary Indicator Care Quality Commission unannounced inspection Care Quality Commission Quarter 1 self-assessment Care Quality Commission Quality and Risk Profile (QRP) April 213 Quality Improvement Framework Compliance Compliant Reporting only Reporting only Reporting only 5.2. Care Quality Commission Unannounced inspection Compliant On 16 th May 213 the CQC undertook an unannounced inspection in response to concerns that one or more of the essential standards of quality and safety were not being met. This was particularly focused around the discharge process as concerns had been raised by the public. The CQC looked at the personal care or treatment records of people using the service and observed how people were cared for at each stage of their treatment and care. The CQC talked to people who used the service, carers and or family members, staff and reviewed information the Trust provided. During the visit the CQC were accompanied by a pharmacist and a specialist advisor, they were also supported by an expert-byexperience (this is a person who has personal experience of using or caring for someone who uses this type of care service). In order to assess the discharge process the CQC spent time in the discharge lounge, on ward F4, the pharmacy and the various wards within the Medical Assessment Unit (MAU). One member of the inspection team spent the day with the hospital's lead in the Integrated Discharge Bureau. This included spending time with other professional's from external organisations and attending a multidisciplinary meeting where discharges were discussed and arranged. Over the course of the day 33 patients, five relatives/friends of patients, three doctors, twenty two nurses, eleven support workers, three pharmacists, a pharmacy technician, a ward clerk and at least nine professionals from other organisations were spoken to. The CQC met and observed a variety of other staff such as porters and physiotherapists. On the wards and units they observed that people were spoken to in a friendly manner and their wishes were respected. The majority of people they spoke to were happy with their treatment and their plans for discharge. Records showed they were consulted on the decision making and their relatives and other professionals were also consulted if necessary. The CQC found that the Trust had robust systems for discharge and worked well with other providers to ensure safe and successful discharges took place; however, it was found that sometimes the systems fell short of ensuring this for every patient in particular those admitted for short periods. Overall the Trust was found to be compliant with the four outcomes inspected. PHT Quarterly Quality Report - Quarter 1 213/214 Page 49 of 59

50 5.3. Care Quality Commission Quarter 1 self-assessment Reporting only The Trust is declaring compliance with all CQC outcomes, with the exception of Clinical Support who are declaring non-compliance with a moderate impact on patients for outcome 21 (records management). Outcome 21 (Records): Clinical Support have declared non-compliance, with a moderate impact on patients, within Queen Alexandra Hospital. The main concerns noted on the risk assessment include: There is insufficient staff within the culling team to adequately perform a culling function. This will lead to unwieldy notes and a continued lack of space within the library. Large volumes of patient records are not marrying up with the main patient record and are being stored outside the record library. Further investigation is required to determine the full extent of the problem. Lack of roller racking in medical records will mean that the Trust will run out of storage space. The roof at the main record library is prone to leaking which could cause damage to records. This risk is being monitored through the CSC and Risk Assurance Committee and is due to be included in the Trust-wide Risk Register Care Quality Commission Quality and Risk Profile (QRP) (June 213) Reporting only The chart below shows the CQC risk estimates for each outcome from October 212 to April May 213. Risk Estimates PHT Quarterly Quality Report - Quarter 1 213/214 Page 5 of 59

51 As can be seen there has been very little movement with the risk of non-compliance for each of the outcomes, with all outcomes currently indicating a low risk of noncompliance Quality Improvement Framework 213/14 Reporting only Following the agreement of the Quality Account; CQUIN and Quality Contract indicators for 213/214, the Quality Improvement Framework has been updated and distributed to all Chiefs of Service, General Managers, Heads of Nursing, Corporate Nursing Team and Modern Matrons for dissemination and display within departments and clinical areas. PHT Quarterly Quality Report - Quarter 1 213/214 Page 51 of 59