TRUST BOARD PART I APRIL 2012 Agenda Item Number: 54/12 Enclosure Number: (1)

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1 TRUST BOARD PART I APRIL 2012 Agenda Item Number: 54/12 Enclosure Number: (1) Subject: Prepared by: Sponsored by: Presented by: Purpose of paper Why is this paper going to the Trust Board Workshop? 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 Quality Performance Report (March 2012 position) Fiona McNeight, Head of Governance and Patient Safety Tracey Stenning, Governance Compliance Manager Julie Dawes, Director of Nursing Julie Dawes, Director of Nursing Discussion requested Regular Reporting For Information / Awareness HCAI (National target and Quality Contract) - MRSA: 0 cases in March. Year to date position: 5 against a trajectory of 4. - C.Diff: 3 cases in March against a trajectory of 6. Year to date position: 67 against a trajectory of 78. Year ended 14% under trajectory. VTE (National CQUIN target and Quality Account) % compliance in March (subject to validation) compared to 92.9% February. Quarter 4 target of 90% achieved. - Year end position of 90.1%. Single Sex Accommodation (National target and Quality Contract) - There have been 5 mixed sex accommodation breaches reported in March. (Please note that this is currently subject to external validation and may be classed as clinically justified). Patient Experience 5 key questions (CQUIN and Quality Accounts) - In March, the Trust scored 83% against the 5 key questions compared to 90.5% in February. SIRIs (Quality Contract) - 5 confirmed SIRIs reported in March. 2 of which were VTE events (compared to 4 in February) and 3 pressure ulcers (compared to 9 in February). Never Events (Quality Contract) - No reported Never Events. Falls (Quality Contract and Quality Account) - Zero red incidents and 3 amber incidents reported in March. - A year to date total of 35 incidents (5 red and 30 amber) reported against a trajectory of 39, therefore the Trust has achieved the 10% reduction target; reducing the total red and amber incidents by 18%. - Currently reporting a total of 5 red incidents, compared to 4 in total in 2010/11. Pressure Ulcers (Quality Contract) - 3 grade 3 and 4 hospital acquired pressure ulcers reported in March. - Total 50 against a trajectory of 57.

2 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? - Achieved the target of a 25% reduction. Complaints (Quality Contract) - Total of 39 complaints received in March, compared to 43 in February. - The overall Trust monthly target is 42 therefore; target achieved in March. Patient Moves (Quality Contract) - Increase in patient moves seen in March, which is reflective of demand across the Trust. Medication (Quality Contract and Quality Account) - Zero incidents reported in March. - Allergy status: 94% achieved in March, compared to 97% in February. - A year end total of 78% achieved, against a target of 71.5%, therefore, the target has been achieved. - Medicines reconciliation: 75% in March, compared to 73% in February. - A year end total of 69% achieved against a target of 77%, therefore the target has not been achieved. Comparison of results across the South Central region demonstrates the Trust position is broadly in line with results from other Trusts in the South Central region. End of Life Care (Liverpool Care of the Dying Pathway (LCDP)) (Quality Contract) - Excluding patients suffering a cardiac arrest and who died immediately despite CPR gives a year end total percentage of patients who died being place on the LCDP as 52.5%. Safeguarding adults - 8 Adult Safeguarding alerts were raised in March, compared to 26 in February. 1 of these alerts was raised by external organisations, the remaining 7 were raised by the Trust, relating to care prior to admission. Safeguarding children - 63 referrals were made to Children Social Care copied to the Safeguarding Children Team (comparable to previous months). - The Safeguarding Children Team have raised 6 Adverse Incident Report forms during March, compared to 4 in February. Nil decisions required. Ongoing monitoring of all metrics and regular Board reporting. Considered None. MRSA over trajectory.

3 Quality Heatmap Page 3 of 21

4 National Targets and National CQUIN Healthcare Associated Infections (HCAIs) Incidence of MRSA bacteraemia more than 48 hours after admission (PCT/SHA trajectory for 2011/2012 is 4). There were no cases of hospital acquired MRSA bacteraemias for March against a monthly trajectory of 0. Thus, the year-to-date position at the end of March is 5 cases against a trajectory of 4. The annual output trajectory for 2011/12 is 4 cases and the Trust is therefore over its annual trajectory. Incidence of C.Difficile more than 72 hours from admission (PCT/SHA trajectory for 2011/2012 is 78). There were 3 cases of hospital acquired C.Difficile recorded in March 2012 against a monthly trajectory of 6. The Trust ends the year 14% under trajectory. The Trust C.Difficile action plan is complete. The bi-weekly performance dashboards for March show an overall improvement in performance for patient isolation of 80% (weeks 9,10) and 78% (weeks 11,12) across the Trust. A centralised bed cleaning service has been set up to ensure effective cleaning of beds. Venous Thromboembolism (VTE) The VTE risk assessment figure for March is 93.42% (subject to validation) compared to 92.9% in February. The Trust has achieved a quarter 4 figure of 93.01%, therefore, achieving the 90% target. A year end position of 90.08% has been achieved. Page 4 of 21

5 Single Sex Accommodation There was a mixed sex accommodation breach within the Medicine for Older People Rehabilitation and Stroke Clinical Service Centre. 4 patients were affected by the breach. These 5 breaches are currently subject to PCT validation and may be classed as clinically justified. Patient Experience (5 key questions) In March, the Trust scored 83% against the 5 key questions compared to 90.5% in February. Additional information can be found in the Quarter 4 Quality Board report. Trust and Quality Contract targets Serious Incidents Requiring Investigation (SIRIs) (excluding HCAIs and as reported on STEIS) In March the Trust had a total of 5 confirmed SIRIs: 2 VTE incidents and 3 pressure ulcers: SIRIs March 2012 SIRI Clinical Service Centre (CSC) 1 x Grade 3 pressure ulcer Medicine 1 x Grade 3 pressure ulcer MOPRS 1 x Grade 3 pressure ulcer MSK 2 x PE/DVT Surgery and Cancer In March the Trust had a total of 5 confirmed SIRIs, 2 of which were VTE incidents and 3 grade 3 pressure ulcers. This compares to 16 confirmed SIRIs in February, 4 of which were VTE incidents, 9 confirmed pressure ulcers and 1 grade zero pressure ulcer incident 1. Never Events Zero Never Events were reported in March Incidents Incidents March 2012 (as at 10 th April 2012) Incidents Month Adjusted to include receipt of late reports Previously reported March 543 February January December November An incident is reported as a grade zero if it is unclear if an actual SIRI has occurred or if a pressure ulcer has been sustained from a plaster cast. Page 5 of 21

6 At the time of reporting, the top three reported incidents for March 2012 were: Slips, trips and falls, Pressure ulcers Adverse events that affect staffing levels. It should be noted that at the time of preparing this report 543 incidents have been inputted for March: inputting of additional reports may lead to a change in the top three. Falls 3 amber and zero red falls incidents have been reported in March, a total of 3 against a trajectory of 2. To date, the Trust has had a total of 35 incidents (5 red and 30 amber) reported against a trajectory of 39, therefore the Trust has achieved the 10% reduction target by reducing the total red and amber incidents by 18%. The Trust is currently reporting a total of 5 red incidents against last year s total of 4, which could possibly be an artefact of improved investigation procedures, however, the overall total of injurious falls (red and amber incidents combined) remain lower than last year. Pressure Ulcers A total of 3 grade 3 and 4 pressure ulcers were reported in March. The Trust is reporting 50 grade 3 and 4 pressure ulcers against a trajectory of 57 and has therefore achieved the 25% reduction target. The rise in the number of hospital acquired pressure ulcers reported in January and February has now reduced. Complaints and PALS A total of 39 complaints were received in March, compared to 43 in February and 58 in January. The overall Trust monthly target is 42 therefore; the target was achieved in March. In comparison the target was exceeded in February by 1, and 16 in January. Month Complaints Received Variance on previous month Page 6 of 21

7 Month Complaints Received Variance on previous month April 32 - May June July 52 9 August 53 1 September 45 8 October 43 2 November December January February March 39 4 The following table illustrates the target for each CSC in relation to the actual number of complaints received in March 2012: CSC Target Actual Plaudits Corporate FM CHAT CSS MOPRS Page 7 of 21

8 CSC Target Actual Plaudits Emergency Head and Neck Medicine MSK Renal 1 per ¼ 0 11 Cancer Surgery Women and Children 5 0 1,061 Total ,262 On/Under target Over target Category of Complaints Top 5 March 2012 All Clinical Service Centres Severity of Complaints March 2012 All Clinical Service Centres Comparison of themes for complaints Complaint theme February March 2012 total 2012 total Variance All Aspects of Clinical Treatment Communication to Patients Admission, Discharge and Transfer Arrangements Attitude of Staff Decrease compared to previous month Increase compared to previous month The same compared to previous month Page 8 of 21

9 Parliamentary Ombudsman The Trust is aware of one complainant referring their complaint to the Parliamentary Ombudsman in March Complaint Acknowledgement Rate 100% of all 39 complaints were acknowledged within the 3 day target in March Page 9 of 21

10 PALS Contacts There were 129 PALS contacts in March This is a decrease of 24 compared to February where 153 contacts were made. 39 of the contacts were requesting information or advice, compared to 38 in February. Comparison of themes for PALS contacts PALS theme/reasons for contact February 2012 March total 2012 total Variance Contacts Received Communication to Patients Appointment Delay/Cancellation Outpatients Appointment Delay/Cancellation Inpatients Decrease compared to previous month Increase compared to previous month The same compared to previous month Reported Plaudits A total of 1,222 plaudits were received in March compared to 1,542 in February and 1730 in January. Patient Moves March has seen an increase in the number of time patients have moved. 776 patients were moved more than twice in March, compared to 739 in February. 725 patients were moved more than 3-4 times in March compared to 692 in February. There has also been a slight increase in the number of patients moved greater than 4 times moved, 51 in March compared to 47 in February. The overall increases are reflective of the overall demand within the Trust. Medication Errors Zero serious medication incidents were reported in March. One amber incident was reported during February, following investigation and a review of notes the initial grading has been downgraded as there was no actual harm to the patient and treatment was not affected. Patient Safety Federation Data The Trust has achieved the allergy status target. The Trust has not achieved the target relating to medicines reconciliation, however, an improvement has been seen during January March 2012 with the further roll-out of the nearpatient pharmacy service. In comparison of results across the South Central region, the Trust s broadly in line with other Trusts in the South Central region. Indicator Baseline January 2012 February 2012 March 2012 Min. target 2011/12 Allergy status 65% 98% 97% 94% 71.5% Medicines Reconciliation (within 24 hours) 70% 66% 73% 75% 77% Year end compliance 78% (Achieved) 69% (Not achieved) End of Life Care It has been agreed that those patients suffering a cardiac arrest and who died immediately despite Cardiopulmonary resuscitation (CPR) should be excluded from the figures as they are classed as non-anticipated deaths and would not have been placed on the LCDP. When excluding these patients the total percentage of patients who died being place on the LCDP is 52.5%. This amended calculation gives a more accurate picture of compliance and indicates that the Trust has achieved the year end target. Unfortunately it is not possible to provide a month by month breakdown for this financial year, but it is anticipated that this will be included in the reported figures from April Page 10 of 21

11 Quality Indicators Safeguarding adults 8 Adult Safeguarding Cases were raised in March compared to 26 in February and 9 in January. Only one alert was raised externally and related to care provided within the Trust, the allegation was regarding a discharge which deemed to have failed. The remaining 7 cases were raised by hospital staff and related to care prior to admission, the majority of which were community acquired grade 3 and 4 pressure ulcers. The Trusts revised process maps for raising a Safeguarding Alert and making a referral are in place. Several Department specific training sessions are planned for the next couple of months, including off site areas. The implementation of an agreed single system of referral for Hampshire and Portsmouth City Councils is still awaited. Safeguarding children 63 referrals were made to Children Social Care copied to the Safeguarding Children Team (SCT). This number is comparable to previous months. The highest number of referrals, 46 in total were from Maternity, the majority of which relating to concerns 2 and domestic violence. The SCT have raised 6 Adverse Incident Report forms during March, compared to 4 in February. These involved communication, documentation and procedural issues within maternity and paediatrics. All issues have been dealt with through the relevant Clinical Service Centres. Releasing Time To Care Bundle Programme (Productive ward) The Releasing Time to care (RTtC) Bundle programme continues to move forward and this can be demonstrated in the SHA report (see below) 2 Multiple factors include: Housing problems, Asylum seekers no recourse to funds, Previous child death, Previous harm to a child, Previous children known to Children Services, Living with a sex offender, Mother a sex offender, Substance abuse, Invite to Child Protection Conference -concern not know until conference, Late booking, Child moved from foster care to new accommodation pregnant again, Failure to attend antenatal care, Aggressive behaviour, Poor parenting post birth, Head injury post delivery, Unknown. Page 11 of 21

12 Work has also been undertaken on additional modules as part of the Trust programme including Fit and Well to Care, Documentation, and Infection Control. The programme is showing a continued sustained improvement in direct care time (DCT), this is currently an average of 52.78% for a registered nurse and 61.20% for a health care support worker (see diagrams below) Average RN DCT at the start and at the repeat Activity Follow Average HCSW DCT at the start and at the repeat Activity Follow 60.0% 50.0% 40.0% 70.0% 60.0% 50.0% 30.0% 20.0% 10.0% 0.0% Total 40.0% 30.0% 20.0% 10.0% 0.0% Total National average RN DCT at start Repeat DCT RN National average HCSW DCT at start Repeat DCT HCSW Trust average for an RN: At start % Currently 52.78% An increase of 9%. Trust average for the HCSW: At start % Currently % An increase of 9.68% The Productive Operating Theatre (TPOT) TPOT continues as planned, see SHA report below. TPOT has contributed to the increase utilisation and efficiency in theatres. Despite the increased demand from the surgical backlog activity, utilisation has increased from 85% in 2010/2011 to 86.25% for 2011/2012. This takes into account the move to more complex cases in managing the backlog, with day-cases decreasing from 2.65 cases per list to 2.53 cases per list. TPOT is being applied to the day surgical unit reconfiguration that is due to commence shortly, to provide a sustained solution for single sex accommodation. Facilities Management (FM) Due to the timings of receipt of monthly reports from Carillion Services Limited (CSL) it is only possible to include information for February During the month of February 2012 all of the FM Services provided by CSL operated within the parameters laid down by the PFI Contract. Page 12 of 21

13 Portering Service The service performance maintained performance within the boundary of the Service Failure Points (SFP) threshold of 235 SFPs at 137 SFPs from 11,999 reactive tasks logged via the FM Helpdesk. The focus continues to be the implementation by CSL of Portertrack, the new computerised management system for Portering services, which remains on course for introduction by late spring. The instigation of the bed-washing facility on ward G1 by Infection Control has resulted in a marked increase of requests for bed movements during February. It was agreed with CSL senior management that the Portering Service would facilitate bed-washing bed movements on a short-term trial basis. However, the resulting heavy volume of bed movement requests was shown to adversely affect patient-focused moves, therefore the management of bed moves to and from G1 has returned to the Infection Control bed-washing team. Estates Service Following the independent audit undertaken by The Hospital Company (THC), CSL have produced and shared with the Trust and THC an action plan. CSL are working with these parties to implement and effect changes identified as required. The (CSL) Estates service continues to deliver below threshold for the month, although failings previously identified and applied retrospectively impacted upon the 6 month threshold. CSL have set an internal threshold of 300 SFPs against a contracted limit of 360 to improve the performance as part of the measures from the action plan mentioned above. One of the recommendations in the submitted action plan is the introduction to staff of Personal Digital Assistants (PDA) to improve the flow of task information. Work on this progresses for a planned (currently) introduction date of November From previous months, of particular concern was a blockage and resulting flood in A8 (Shipwreck ward). This followed CSL, The Hospital Company (THC) and Carillion Construction (CCL) presenting at the Trust Audit Committee in January with regards to previous floods in the Paediatric department in October 2009 and August CSL and THC again went to an Audit committee meeting on the 8 th March. A full design survey is being undertaken which, to date, has identified a number of minor design issues with the drains. The survey works have now been extended and are expected to be completed by March 31 st. A report of the findings is to be published by 6 th April 2012 and all resulting remedial actions required completed by 6 th June CSL and THC are expected to present the findings and actions taken to a further meeting of the Audit Committee on the 7 th June Discussions are ongoing relating to the programme of life cycle works for financial year 2012/13 with the full programme to be confirmed, although targeted for a start at the beginning of April. The painting programme for 2011/12 continues with wall protection added where areas are subject to heavy wear or damage. Planned works are for both F and G levels although there are concerns about the ability of the Trust to release a decant ward by the necessary start date due to the high patient activity and acuity. With respect to the renal flooding affecting the Hospital Sterilization and Disinfection Unit (HSDU) department, CSL have received the summary costs for the insurance claim for Renal and have requested supporting timesheets and cost backup for the loss adjuster as part of the joint claim process. This issue has still to be resolved. The CSL Estates team produced an in month service performance of 348 SFPs just below the monthly threshold of 360 from 2644 reactive tasks logged via the FM Helpdesk. Planned Preventative Maintenance (PPM) completion stands at 88.3% for January (reported 1 month in arrears). The Trust team continues to review those not completed. Page 13 of 21

14 Security and Car Parking At the beginning of February there were some problems experienced relating to the issue of tickets by the pay and display machines. It is thought that these arose as a result of the sudden cold snap, with reports being received of machines being affected country-wide The car parks on the hospital site have been assessed and awarded a Safer Parking Award under the Parkmark Safer Parking Scheme. The scheme is an initiative of the Association of Chief Police Officers and is managed by the British Parking Association on their behalf. The Award is granted for a period of three years. Domestic Service 54 domestic cleaning audits, spot checks and re-checks were carried out in February, with 3 failures and 3 areas passing overall but requiring re-checking of certain rooms or areas which had failed individually to meet the required standard. The team have continued to work jointly with Infection Control, with the introduction by the latter of an alternative chemical (Difficil S) for use by Patient Services as an enhanced infection control cleaner in trial areas. A decision will be made shortly as to whether this will be rolled out site-wide. Waste management February saw the successful implementation of a recycling waste stream to a small number of office areas, being Trust HQ, De La Court House, the Development Team offices and the FM offices. The lessons to be learned are currently being evaluated before introducing the recycling waste stream Trust-wide. At the end of the month the pilot commenced to introduce both recycling and offensive waste streams in Wards F5, F6 & F7. Again, lessons will be learnt from this to assist the phased roll-out of these streams throughout the organisation. Telephone Service Following the successful data recovery required as a result of the failure of the Tiger call logging system at the end of December, an upgrade has been made to the system by Tiger and as a consequence the data is being modified A problem with the switchboard at St James Hospital occurred during the month which resulted in a number of calls being made in error from St Mary s to the Carillion Helpdesk. Helipad During the month a total of 8 helicopter flights were received, two of which were training exercises undertaken by the CHC Coastguards. A mechanical pump failure in the fire suppression system resulted in the Helipad being closed for 3 days whilst this was rectified. Flights were diverted to Horsea Island during this period, with no loss of service experienced. An investigation into the fault has been conducted to minimise the risk of a repeat of this type of mechanical failure. Page 14 of 21

15 Summary of Audits undertaken in the last 12 months Analysis of FM Audits for the last 12 months Number of Audits Total audits Total Pass Total Fail Mar 2011 Apr 2011 May 2011 Jun 2011 Jul 2011 Aug 2011 Month Sep 2011 Oct 2011 Nov 2011 Dec 2011 Jan 2012 Feb 2012 There have been 57 Soft FM audits carried out in the month with 3 domestic cleaning failures, which were: PALS office (Remedial) The remedial audit failed to find any improvement made there was still dust on most surfaces and furniture items in the PALS area of the Main Entrance. A 2 nd remedial has been carried out and an improvement was seen. Ward E6 The domestic cleaning in this very high risk area was found to be below standard in several areas, including the open bed area. Dust on most high surfaces and scale on sinks were the most prevalent issues. Following rectification work a successful remedial audit has been carried out with a big improvement very evident C Level Pharmacy Dispensary and Offices Whilst the Dispensary met the required standard, some of the associated rooms did not, causing this area to fail the spot check. Issues included low and high dusting, including chairs and desks, and scale on some sinks and hand basins. A remedial audit will be undertaken in early March In addition to domestic audits, the other Soft FM services inspected include patient food tasting, Security, Grounds and Portering. The Client Team have been enhancing the format of the nondomestics Soft Services audits, making them more probing and introducing an observation element. This is proving to be informative and useful to all parties. The Captain s Rounds continue to be carried out each month and are found to be beneficial to the FM services as well as to the overall environment of the hospital. The main findings from the Captains Round continue to be aesthetic issues and are being addressed. Formal Complaints received via the CSL Help Desk in the last 12 months The table below shows only the formal complaints received as reported using the Project Agreement payment mechanism. The Development Team continue to work with the Trust Complaints Team on any formal Facilities Management related complaints received through them. Page 15 of 21

16 The total numbers of complaints received has shown a decrease overall from the previous month. This is partly due to small decreases in complaints relating to Domestics, Patient Catering and Security. It is noted that the number of complaints relating to Portering increased slightly to a total of 7 in February, and those for Estates totalled 3. The users are encouraged to report both compliments and complaints. Formal complaints received via the CSL Help Desk in the last 12 months Service Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Catering Car parking Domestic Estates Helpdesk Housekeeping Linen Pest and Grounds Portering R&D Security Telecomms Post Waste Totals There were no car parking complaints declared for February. Page 16 of 21

17 Appendix 1: Business Intelligence Pack Page 17 of 21

18 Appendix 1: Business Intelligence Pack Page 18 of 21

19 Appendix 2: Statistical Process Control (SPC) format Page 19 of 21

20 Appendix 2: Statistical Process Control (SPC) format Page 20 of 21

21 Appendix 2: Statistical Process Control (SPC) format Page 21 of 21