PAPER: SFT 3003 SALISBURY NHS FOUNDATION TRUST TITLE: Quality Indicator Report to 30 April 2010 PURPOSE OF PAPER: To inform the Board about performance against agreed quality indicators for Month 1. The report also includes the year on year comparators as this is the second full year of the indicator report (reference CQC outcome 16, monitoring the quality of care) EXECUTIVE SUMMARY: The following key issues are highlighted Year on Year comparators shows improvements across nearly all indicators from 2008/09 to 2009/10 with pressures reported at grade 3&4 showing the only deterioration. Although C Diff rates have increased this is due to an increase in community acquired rates. The best improvement has been shown for stroke patients having a CT scan within 24 hours of admission Month 1 The targets for 2010/11 have been reset based on improvements made last year. Parameters have been reset accordingly. The first month shows:- Mortality highest number of deaths per month compared to previous 12 months and compared to April 09 (57) but note the large decrease in total number of deaths during 09/10 against previous year with an increase in activity Falls resulting in serious harm high for one month Pressure Sores the first month since vember 2009 when there have been no reported grade 3 or 4 pressure sores. This will remain a high priority this year as highlighted in the quality account VTE compliance has increased to 89% which is a 17% improvement against the previous audit Readmission rate for April at 6.6% is higher than any month in the preceding 12 months Fracture Neck of Femur A deterioration in April to 57%. The last time it was this low was in September 2009. The reporting logic has been refined and is more accurate than previously with times of admission and actual time to theatre. % of stroke patients with 9 of their stay on Farley has deteriorated but likely to be due to impact of norovirus patients on Farley. Patient experience scores have also improved apart from the respect and dignity score. Quality of care scoring excellent has exceeded the target. Work is currently underway to develop the amount of benchmark data available and should be completed by end of Q1 ACTION REQUIRED BY THE BOARD: To note the report Sean O Kelly, Medical Director, May 2010
Quality Indicators - Year on Year Comparator Patient Safety 2008-09 2009-10 Trend Mortality - HSMR 94.4 88.8. Mortalities Elective Patient Mortalities n-elective Patient Mortalities MRSA tifications Clostridium Difficile tifications * Global Trigger Adverse Event - Rates Per 1000 Bed days Never Events Falls resulting in Fractures or Major Harm Clinical Effectiveness Pressure Sores developed in Hospital (grades 3 and 4 only) VTE Compliance with Risk Assessment Emergency Readmissions within 14 days of discharge % Having Surgery within 24 hours of Admission with Fractured Neck of Femur patients treated 1000 926 31 29 969 897 5 5 68 79 44 av 40 n/a 0 24 24 45 58 n/a 7.3% 5. 52% 6 Stroke & TIA CT within 24 hours of Admission for Stroke % of Stroke patients with 9 of their stay on Farley TIA (High risk patients seen < 24hrs) Patient Experience Use of Escalation Policy - Average additional Beds Opened per day % Discharges who changed ward more than 3 times during their time in hospital actual Do you feel you were treated with dignity and respect? (always) Overall how would you rate the quality of care you received? (excellent) Would you recommend this hospital to a family or friends? (definitely) 56% 89% 47% 6 17% 44% n/a 2 0.43% 0.33% n/a 89.5% n/a 48.3% n/a 87.6%
* C.Diff notification includes community cases
Patient Safety Mortality Quality Indicators Report April 2010 Benchmark Target 2009-10 Apr May Jun Qtr 1 YTD Status HSMR - by year (Quarterly) 10 9 88.8%. Mortalities 900 926 95 95 95 r Elective Patient Mortalities 28 29 2 2 2 g n-elective Patient Mortalities 872 897 93 93 93 r Infection Control MRSA tifications 0 5 0 0 0 g Clostridium Difficile tifications: Total 0 79 2 2 2 g Clostridium Difficile tifications: Hospital Acquired 0-2 2 2 g Global Trigger Adverse Event Rates Per 1000 Bed days (Quarterly & YTD figures are averages) < 40 40 Never Events 0 0 0 0 0 g Falls resulting in Fractures or Major Harm <20/yr 24 4 4 4 a Clinical Effectiveness Pressure Sores developed in Hospital (grades 3 and 4 only) 29 58 0 0 0 g VTE Compliance with Risk Assessment 10 72% 89% 89% 89% a Emergency Readmissions within 14 days of discharge 5. 5. 6.6% 6.6% 6.6% r % Having Surgery within 24 hours of Admission with Fractured Neck of Femur Patients Treated 68% 9 6 57% 57% 57% r Stroke & TIA Page 1 of 7
Quality Indicators Report April 2010 Benchmark Target 2009-10 Apr May Jun Qtr 1 YTD Status CT within 24 hours of Admission for Stroke 98% 10 89% 93% 93% 93% g % of Stroke patients with 9 of their stay on Farley 95% 10 6 5 5 5 r TIA (High risk patients seen < 24hrs) 44% 62% 62% 62% a Patient Experience Use of Escalation Policy Average Extra beds opened per day 0 2 % Discharges who changed ward more than 3 times during their time in hospital Actual 0.4% 0.33% 0.61% 0.61% 0.61% r Patient Feedback Do you feel you were treated with dignity and respect?, always 10 89.5% 73.4% 73.4% 73.4% r, sometimes 8.8% 23.4% 23.4% 23.4% 1.7% 3.1% 3.1% 3.1% Overall how would you rate the quality of care you received? Excellent 5 48.3% 55.7% 55.7% 55.7% g Very Good 4 40.2% 32.8% 32.8% 32.8% Good 1 9.6% 9.8% 9.8% 9.8% Fair 1.7% 1.6% 1.6% 1.6% Poor 0.3% 0. 0. 0. Would you recommend this hospital to a family or friends?, definitely 9 87.6% 86. 86. 86. a, probably 1 10.4% 12.3% 12.3% 12.3% 1.9% 1.8% 1.8% 1.8% Page 2 of 7
Real Time Feedback Charts N.B. Real-time Feedback Surveys were not completed during January 108% 1.) Do you ever use the same toilet as patients of the opposite sex? * 72% 36% I haven't used the toilet facilities September October vember December 10 2.) Do you ever use the same bathroom or shower as patients of the opposite sex? * 8 6 4, because it has specialist equipment I need I haven t used the bathroom/shower 2 September October vember December 106% 3.) Have you shared a sleeping area (room or bay) with patients of the opposite sex? * 71% 35% September October vember December
Real Time Feedback Charts N.B. Real-time Feedback Surveys were not completed during January 10 4.) As far as you know, do staff wash their hands between treating patients? 8 6 4, always, sometimes Don t know 2 September October vember December February March April 10 5.) In your opinion, how clean is your ward? 8 Very clean 6 Fairly clean 4 t very clean t at all clean 2 September October vember December February March April 101% 6.) Did you get enough help from staff to eat your meals? 67%, always, sometimes 34% I do not need help to eat my meals September October vember December February March April
Real Time Feedback Charts N.B. Real-time Feedback Surveys were not completed during January 10 7.) Do you know which nurse is looking after you today? 8 6 4 2 September October vember December February March April 10 8.) Do you know which doctors is looking after you today? 8 6 4 2 September October vember December February March April 10 9.) Overall, are you involved as much as you want to be, in decisions about your care and treatment? 8, always 6, to some extent 4 2 September October vember December February March April
Real Time Feedback Charts N.B. Real-time Feedback Surveys were not completed during January 10 10.) Do you feel you are treated with dignity and respect? 8, always 6, sometimes 4 2 September October vember December February March April 10 11.) Overall, how would you rate the quality of care you received? 8 Excellent 6 Very good Good Fair 4 Poor 2 September October vember December February March April 10 12.) Would you recommend this hospital to your family or friends? 8, definitely 6, probably 4 2 September October vember December February March April
Real Time Feedback Charts N.B. Real-time Feedback Surveys were not completed during January 10 13.) If you used the call bell, how long did you have to wait for a response? 8 6 Up to 5 minutes From 6-10 minutes Longer than 10 minutes 4 N/A 2 February March April 10 14.) Do you know how to raise a concern or make a complaint? 8 6 4 t sure 2 February March April * As of February 2010, patients are no longing being asked to respond to questions 1, 2 & 3. Questions 13 & 14 have been added for February 2010. April data up to 21st April.