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Quality Accounts 2011/12 Looking back, looking forward Dr Patricia Bain Director of Quality and Standards 12th September 2012 Quality Accounts 2011/12 • Legal requirement to produce quality account • Statement of assurance, Monitor, DH • Audited: KPMG – without conditions, green for all selected indicators • Chief Executive commentary: context • Looking back: Achievements, External Assurance • Looking forward: Improvement programmes, new indicators, supporting programmes Section 2: Looking Back • Between 2010 and 2011, for the National surveys, • more positive feedback from patients in 2 of the 5 questions • the same for one question • less positive feedback for 2 of the 5 questions Staff Survey Top 4 ranking scores 2011 (2011-12 vs 2010-11) 2011-12 TRFT Effective team working (KF6) Staff witnessing potentially harmful errors, near misses or incidents in the last month (KF20) Staff using flexible working options (KF9) Support from immediate managers (KF15) Bottom 4 ranking scores 2011 (2011-12 vs 2010-11) 3.84 29% 69% 3.78 Staff experiencing physical violence from staff in the last 12 months (KF24) Staff feeling valued by their work colleagues (KF3) Impact of health and well-being on ability to perform work or other daily actvities (KF28) Staff receiving job-relevant training, learning or development in the last 12 months (KF11) • In 2011-12 national survey, reduction in staff reporting good communication between senior management and staff, (33% to 24% ) • Staff satisfaction for 2011-12 is 3.55, above the national average for acute Trusts (3.47 in 2011-12) • Reduction in the number of harmful errors witnessed (5%) • Local survey highlighted training, job satisfaction as areas of concern , feeling valued higher National National TRFT average average 3.72 3.76 3.69 34% 34% 37% 61% 67% 63% 3.61 3.75 3.61 2011-12 TRFT 2% 74% 1.59 76% 2010-11 2010-11 National National TRFT average average 1% 2% 1% 76% 72% 76% 1.56 1.6 1.57 78% 80% 78% Local survey Subject area Feeling valued Learning and Development Performance Health and Wellbeing Communication from managers Job satisfaction Conflict resolution Overall score Trust improvement/ deterioration 2.1% -14.7% 3.0% 0.8% Trust improvement/ deterioration 0.0% 2.8% -0.6% -5.0% Average Score 7.2 6.0 6.1 7.3 6.6 5.7 7.0 6.5 Looking Back: Improvement programmes 2011-12 Liverpool Care Pathway Acute & Community Patient Experience Tracker High risk medication compliance Looking back: 2011/12 Quality Review Communication IR1s & RCA 30 day readmission rates Improvement Programme1i: High risk drugs - compliance Medication Opiate (Morphine PRN) Anti-coagulant (Tinzaparin subcutaneous) Anti-coagulant (Warfarin oral) Antibiotics (various) Category Prescription Administration Monitoring Prescription Administration Monitoring Prescription Administration Monitoring (<5 INR) Prescription Administration Monitoring Total for all medications/categories Target Qtr 1 Qtr 2 Qtr 2 Total 95% - 88.9% 95% - 96.8% 95% - 25.8% 95% - 98.1% 95% - 81.7% 95% - 73.6% 95% - 36.1% 95% - 36.4% 95% - 87.9% 95% - 54.0% 95% - 92.0% 95% - 92.0% 95% - 76.9% (n=42) Qtr 3 Qtr 3 Total Qtr 4 91.2% 94.6% 100.0% 77.6% (n=57) 100.0% 15.4% 100.0% 85.4% (n=107) 91.3% 88.9% (n=116) 75.0% (n=39) 50.0% (n=42) 73.0% 83.0% 64.4% (n=47) 16.1% 98.8% 99.0% 90.2% 89.1% (n=94) 41.9% 83.6% 88.0% 75.4% 35.9% 46.0% (n=93) 43.0% 79.4% 47.9% 73.6% (n=31) 96.4% 74.0% 99.0% 4.3% 57.3% 91.5% 74.0% (n=48) 78.6% 41.5% YTD 91.7% 81.8% 34.3% 48.7% 72.2% (n=50) Qtr change 77.8% 37.2% 48.6% Q4 Total 87.6% 91.8% 75.9% 74.6% • Improvements in the prescribing, administration and monitoring of opiates, antibiotics and the anticoagulation medicine Tinzaparin; prescription and administration of Warfarin are the key areas for on-going focus • Current actions: reviewing of anticoagulation service, training on anti-coagulants routinely included in junior doctor study day • Focus remains , expanded to all aspects of medicines management- Trust wide medicine management task finish group currently taking a comprehensive work programme forward Improvement Programme 1ii: Communications Incident reporting & Root Cause Analyses (RCA) Formal RCA of communications related incidents ensures that learning is captured, and proactive steps taken to minimise communication issues which may affect their care. • Incidents relating to ‘Communications between staff and teams ‘ showed 5% increase in reporting and 33% increase in completed RCAs • Incidents relating to communication with the patient showed a 3% increase in reporting and 31% increase in completed RCAs • Investigations into issue relating to patient case notes increased by 20% • A key theme incidents related to handover; progress noted by deanery, to be further progressed in 2012-13, linking to EPR Improvement Programme 2i: Reducing 30 day readmissions arising from elective admissions 2010-11 Elective Admissions Discharged in year Cardiology 2011-12 % of Discharges of which in period that returned as a returned as a non elective non-elective admission within admission within 30 days 30 days Elective Admissions Discharged in year % of Discharges of which in period that returned as a returned as a non elective non-elective admission within admission within 30 days 30 days 586 35 5.97% 521 33 6.33% - - - 1 0 0.00% Dermatology 689 12 1.74% 680 9 1.32% ENT 764 7 0.92% 712 4 0.56% Gastroenterology 2318 59 2.55% 2080 59 2.84% General Medicine 1782 105 5.89% 1742 82 4.71% General Surgery 5897 255 4.32% 6259 282 4.51% 39 4 10.26% 28 2 7.14% Gynaecology 4482 138 3.08% 4324 128 2.96% Haematology (Clinical) 1560 125 8.01% 2341 133 5.68% 171 3 1.75% 217 9 4.15% Ophthalmology 4132 70 1.69% 4174 71 1.70% Oral Surgery 3390 37 1.09% 3351 30 0.90% 85 2 2.35% 45 2 4.44% Photopheresis 559 10 1.79% 485 5 1.03% Rehabilitation 15 3 20.00% 9 2 22.22% Rheumatology 418 13 3.11% 486 11 2.26% Trauma & Orthopaedics 4343 143 3.29% 4126 132 3.20% Urology 4200 179 4.26% 4192 180 4.29% 35430 1200 3.39% 35773 1174 3.28% Clinical Oncology Geriatric Medicine Obstetrics* Paediatrics T otal: *for patients using a hospital bed or Delivery Facilities 2011-12 Vs 2010-11 - 30 day re-admissions: on-going actions Work continues to try and impact on the rate of readmission for all types of admission across the Trust, including: • Implementation of ‘open access’ to follow up appointments for selected specialties • A review of discharge information provided to patients • Scoping of the ‘virtual ward’ concept • Exploration of ‘telemedicine’ and a Single Point of Access call/contact centre to signpost patients appropriately to the care they need • Development of the Early Pregnancy Advisory Unit (EPAU) telephone triage service, introduction of urgent outpatient appointments • Accident and Emergency, piloting of a GP triage service, a Community Matron pilot, audit of admissions with a length of stay less than 48 hours and Multi Disciplinary Team meetings to review issues related to frequent attenders Improvement Programme 3i: Increasing our responsiveness to patient needs: volume Significant improvement in the volume of community surveys by Quarter 4, No improvement for Acute services. Both Adult and Universal Services Community Health achieved year end results in excess of their quarter 2 baseline. Increasing our responsiveness to patient needs: responses Acute inpatients (PET CQUIN template) Baseline period & value Qtr 1 Qtr 2 Qtr 3 Qtr 4 YTD Did a member of staff tell you about medication side effects to watch for when you went home? Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital? April 2011 April 2011 84.7 87.5 88.6 91.6 83.0 81.2 78.2 75.1 78.7 76.9 81.5 80.2 Did you find someone on the hospital staff to talk to about your worries and fears? Were you given enough privacy when discussing your condition and treatment? Were you involved as much as you wanted to be in decisions about your care and treatment? April 2011 April 2011 April 2011 87.5 93.8 87.5 90.1 94.1 89.7 88.0 86.5 82.4 81.7 80.7 76.9 83.8 80.3 79.9 85.5 84.0 81.8 Average score April 2011 88.5 91.0 84.1 78.4 79.8 82.6 Number of surveys completed April 2011 144 286 292 197 770 1545 Community Health - Adult (PET template data) Baseline period & value Qtr 1 Qtr 2 Qtr 3 Qtr 4 YTD Have you been involved as much as you wanted to be in decisions about your care and treatment? Were you given enough time to discuss your condition with healthcare professionals? Qtr2 2011-12 Qtr2 2011-12 89.3 87.3 - 89.3 87.3 87.7 89.8 90.7 89.8 89.2 88.8 Do you know what number/who to contact if you need support out of hours (after 5pm)? Overall, have staff treated you with dignity and respect? Overall, are you satisfied with the personal care and treatment you have received from community services? Average score Qtr2 2011-12 Qtr2 2011-12 Qtr2 2011-12 Qtr2 2011-12 90.8 96.0 94.2 91.5 - 90.8 96.0 94.2 91.5 92.3 96.8 97.1 92.7 95.8 95.6 93.4 93.0 92.6 96.2 94.9 92.3 Number of surveys completed Qtr2 2011-12 454 Community Health - Universal Services (PET template data) Baseline period & value - 454 353 313 1120 Qtr 1 Qtr 2 Qtr 3 Qtr 4 YTD Were you given enough time to discuss your child’s health with the healthcare professionals? Did staff clearly explain the purpose of their contact with you in a way that you could understand? Do you know what number/who to contact if you need support out of hours (after 5pm)? Qtr2 2011-12 Qtr2 2011-12 Qtr2 2011-12 92.2 93.9 86.1 - 92.2 93.9 86.1 96.6 98.0 85.4 91.3 94.4 87.1 93.7 95.7 86.2 Overall, have staff treated you and your family with dignity and respect?* Overall, are you satisfied with the service you have received from community services? Average score Qtr2 2011-12 Qtr2 2011-12 Qtr2 2011-12 0.0 94.8 73.1 - 0.0 94.8 73.1 57.3 97.6 87.0 97.9 96.3 93.5 54.0 96.4 85.2 Number of surveys completed Qtr2 2011-12 160 - 160 236 179 396 Qtr Change YTD Qtr Change YTD Qtr Change YTD - Focus on improving patient’s rating of their experience will be continued throughout 2012-13 in the acute setting. - Improvement Programme 3ii: Compliance with 5 key Liverpool Care Pathway measures Number of deceased (mortality Database) Proportion of those on LCP LCP question Qtr 1 Qtr 2 Qtr 3 Qtr 4 YTD Qtr Change 258 247 264 286 1,055 <1084 50.0% 45.7% 42.8% 49.3% 47.0% >41.3% Qtr 1 Qtr 2 Qtr 3 Qtr 4 YTD Qtr Change Target Target Q5 Has the patient had the opportunity to discuss what is important to them & their wishes 38.0% 47.8% 45.1% 41.1% 42.7% 95.0% Q6 Has the relative / carer had the opportunity to discuss what is important to them & their wishes 38.0% 48.7% 44.2% 41.1% 42.7% 95.0% The patient has medication prescribed on a PRN basis for the following: 29.3% 40.4% 36.8% 36.7% 35.6% 95.0% Pain 36.4% 46.0% 42.5% 39.7% 40.9% 95.0% Agitation 31.0% 44.2% 41.6% 39.0% 38.7% 95.0% Respiratory Tract Secretions 29.5% 38.9% 37.2% 39.0% 36.1% 95.0% Nausea / vomiting 24.0% 38.1% 33.6% 32.6% 31.9% 95.0% Dyspnoea Q7 25.6% 34.5% 29.2% 33.3% 29.6% 95.0% Q13 Is a full explanation of the current plan of care given to the relative / carer? 36.4% 46.9% 44.2% 41.1% 41.9% 95.0% Q14 Has the LCP Coping with death leaflet or equivalent been given to the relative / carer? 34.1% 46.0% 40.7% 38.3% 39.5% 95.0% 32.6% 43.5% 39.8% 38.4% 38.4% • Proportion of deceased on LCP increased from 41% to 47%, national average is 26% • 95% target for 5 elements was not achieved , although increase shown across all questions, continued target for 2012-13 • Governors indicator for this years quality accounts and extended to the community setting 95.0% YTD Target status ‘Quality at a glance’ Indicators: 2011-12 Zero local targets set for MRSA (with 23 months of zero MRSA infections) One occurrence impacted on zero achievement for the whole year; still achieves DoH targets C. Difficile performance achieved and improved by 30% against last year’s performance, falling from 50 (March 2011) to 35 for the year ending March 2012. Performance against National Peers incredibly strong – with the average rate for MRSA = 4.1 , C.Diff 82.7 Medication error rate, reduced year on year – from 1.6 to 1.5 (per 1,000 dispensed items). Attributed in part to focus on high risk medication protocol adherence Fluid Balance and Patient At Risk (PAR) scoring on wards have improved vastly – from 64.5% and 50% (2010-11) to 83.8% and 82.7% respectively- major contribution towards optimising conditions for patient recovery. First Never Event in 3 years – retained swab, zero target re-set for 2012/13 ‘Quality at a glance’ 2011-12 contd.. • Grade 2+ pressure ulcer occurrences for acute inpatients have reduced by 8% against performance in 2010-11. • Risk Adjusted Mortality Index (RAMI – CHKS Live) has decreased from 95 (2010-11) to 84 (2011-12). • Our Summary level Hospital Mortality Indicator also reflects some improvement, decreasing from 76.1 (2010-11) to 74.2 (2011-12), for in hospital deaths . • Falls from height increasing by 1.8/1000 bed days to 2.3/1000 bed days, however improvements already seen in Q1 this year. • National comparisons NHS Safety Thermometer lowest number of ‘harms’ from falls (1.2% national , 0.2% TRFT) Section 2b: Statement of Assurance • Service reviews: External reviews , NHSLA,CQC risk profile • CQUIN : For 2011-12 the baseline value of CQUIN was £2.5m, total estimated value payable to the Trust for CQUIN for 2011-12 is £2.32m • Clinical Audit activity, broadened and expanded include NICE Quality Standards (currently 15) • Research programmes, number of patients increased by 300 • Data Quality >98% on selected indicators • Information Governance: 5 of 6 categories satisfactory, IG training increased 30% to 80% , not satisfactory rating overall • National Priorities indicators 23 out of 28 targets met Quality Accounts 2012/13 Our overarching strategic objectives for the next 3 years as set out in our Quality Strategy and linked to the Quality Accounts programme, are: SAFE Reduce mortality: achieve a position in top 10% of organisations with lowest risk adjusted mortality Reduce Harm: 95% of patients are harm-free CARING Improve the patient/staff experience: achieve top 20% for patient and staff experience surveys RELIABLE Provide reliable care: ensuring that evidence based practice is followed by meeting 90% compliance with all NICE Quality Standards Specific Improvement Programmes 2012-13 • Never events (cont’d) • Medicines management (cont’d and expanded) • NHS Safety Thermometer (Falls, UTI,VTE,PU) • Health assessments for looked after children * NICE Quality Standards ongoing Reliable Safe Caring • End of Life Care Pathway, extended to community setting • Fast track discharges to CHC for Dementia patients • Dementia investigations Quality indicators for 2012-13 Domain Culture ID C_1 C_2 C_3 C_4 Patient Safety SAFE Rationale for monitoring Links to ‘caring’ objectives Reflects ‘no blame’ culture Links to supporting staff objectives Reflects morale of staff To ensure that we are meeting 90% compliance PS_1 against all of the standards set out in relation to safe and secure storage of medications High risk medications review to be reported as part of the Ward Nursing Accreditation Scheme (WNAS), which includes all wards – due to limited success attained in the four areas reviewed last year. The selected indicator for this year is a more comprehensive review of all medicines management processes PS_2a Have zero ‘Never Events’ Zero target not achieved for 2011/12-continue PS_2b Rate of patient safety incidents/1000 admissions New DoH/Trust indicator PS_2c Patient Experience CARING Indicator name All applicable staff to have in year PDR Increase in IRI reporting All staff to maintain compliance against MAST training Employee sickness rates Percentage of patient safety incidents resulting in severe harm or death New DoH/Trust indicator PS_3 Number of patients with CDiff/Rate of CDiff New DoH/Trust indicator PS_4 Number of patients with MRSA On-going Trust requirement PS_5 Increase in number of complaints On-going Patient Experience indicator Increasing our responsiveness to our patients PE_1 needs using a composite indicator of care, from April 2011 baseline Increasing compliance to 95% of 5 key measures PE_2 on the Liverpool Care of the Dying Pathway (LCP) by April 2012 Increase the proportion of community OT visits for PE_3 assessment within 28 days from April 2012/13 baseline to 95% by April 2013/14 Improvement on 2011/12 required, metric continues to be a CQUINs indicator for 12012-13 This is the Governor selected indicator for 2012-13, also continues to be a CQUINs indicator New programme - community focus Quality indicators for 2012-13 contd. Domain ID PE_4 Patient Experience PE_5 PE_6 CE_1 CE_2 Clinical CE_3 Effectiveness CE_4 RELIABLE CE_5 CE_6 Indicator name Increase the number of Health Visitor first visit within 10-14 days of birth from 90% to 97% Increase in the number of patients assessed using the MUST nutritional tool and completed fluid balance charts PROMS data Reducing the number of hospital re-admissions from care homes within 30 days from April 2012 baseline Reducing emergency re-admissions to hospital within 28 days of discharge Rationale for monitoring Reduction in Mortality: SHMI value and banding New DoH indicator % patients admitted treatment inc palliative care New DoH indicator % patients whose death inc in SHMI treatment palliative care Reducing weekend mortality rates as at April baseline 2012 New DoH indicator DQ_1 Data Quality index CHKS live (HRG4 based) Data Quality Blank or invalid or unacceptable primary diagnosis rates CHK live HRG4 based Depth of coding average diagnosis per coded DQ_3 episode CHKS live exclude Breathing Space DQ_2 New programme - community focus On-going Trust requirement New DoH indicator New programme - community focus New DoH indicator New Trust indicator mortality targets On-going Trust requirement On-going Trust requirement On-going Trust requirement Developments for 2012-13 • SDS3 and Quality Strategy implementation, monitored PMO • Strengthening of the Quality Governance Framework • Revised Patient Safety, Patient Experience and Clinical Effectiveness Strategies • Initiatives aligned with the Trust’s Business Intelligence strategy – currently being implemented Datix/CHKS/ Quality Dashboards: Service to Board – Supports end user ‘self service’ • Dashboards configured to suit end user requirements • Capability to ‘drill down’ to data detail as necessary • Data available for review as soon as it is entered Will provide ‘real time’ information to the Board and weekly Harm meetings Any Questions?