Agenda item

-        Tracey McErlain-Burns, Chief Nurse and Hilary Fawcett, Quality Governance Lead

Tracey McErlain-Burns, Chief Nurse, and Hilary Fawcett, Quality Governance Lead, gave the following powerpoint presentation:-

Quality Account

-     The focus of the Quality Account is on how we take assurance that the services we provide are safe, effective and enabling our patients, their families and carers to have a positive experience of care

Looking Back – our quality improvement for 2013/13

-          Priority 1 – Patient Safety – Intraoperative Fluid management (CQUIN) - Achieved

-          Priority 2 – Improving Data Quality - Improved

-          Priority 3 – Review of Death Certificates - Achieved

-          Priority 4 – Patient Experience – Dementia – Not achieved

Looking Forward – TRFT Quality Objectives 2014/15

-          1 – SAFE – Mortality – Deliver a 4 point reduction in HSMR

-          2 – SAFE – Harm free Care (HFC)

2.1  Minimum 96% HFC

2.2  Zero avoidable pressure ulcers grade 2-4

2.3  Zero avoidable falls with harm

-          3 – RELIABLE – Achieve all national waiting time targets

3.1  Cancer

       3.1.1 2 week waits

       3.1.2 31 days

       3.1.3 62 days

3.2  A&E

3.3  18 weeks

-          4 – CARING AND RELIABLE – Friends and Family (FFT)

4.1  Achieve an A&E net promoter score (NPS) of 75

4.2  Achieve an IP NPS of 83

4.3  Achieve a maternity NPS of 83

4.4  Achieve a 40% response rate for A&E, maternity and in-patients combined

CQC Inspection – all standards met

-          Consent to treatment

-          Care and welfare of people who use the service

-          Cleanliness and inflection control

-          Requirements relating to workers

-          Supporting workers

-          Assessing and monitoring the quality of service provision

Information Governance

-          Information Governance Management – 66% (satisfactory)

-          Confidentiality and Data Protection Assurance - 66% (satisfactory)

-          Information Security Assurance – 66% (satisfactory)

-          Clinical Information Assurance – 66% (satisfactory)

-          Secondary Use Assurance – 66% (satisfactory)

-          Corporate Information Assurance – 66% (satisfactory)

-          Overall 66% (satisfactory)

Discussion ensued on the presentation with the following issues raised/clarified:-

·           The mortality rates covered 3 principle measures:- Hospital Standardised Mortality Ratio (covered all deaths in hospital), SHMI (Summary Hospital Level Mortality Indicator) (covered all patients in the community if they died within 30 days of discharge from hospital) and RAMI (Risk Adjusted Mortality Index) (a different way of comparing hospital death rates within the service).  A further area to be implemented in 2014 was Chronic Obstructive Pulmonary Disease and Respiratory Disorders especially Acute Pneumonia  and the introduction of respiratory bundles

·           Infection Control – there had been 7 cases reported of Clostridium Difficile in September-October, 2013, with the precise cause not identified.   Since then cleaning, cleanliness standards, cleaning of wheelchairs, changing of curtains and all practices in relation to infection prevention had been looked at.  When the outbreak had occurred, the Trust had reverted to the very old fashioned process of isolation and converted a 14 bed into closed door isolation environment and prevented any further spread

·           A NEVER event involved factors that the Department of Health described as ones that should never occur if a Trust had implemented all the safety bulletins that have been issued over the previous year.  Details of the event could not be given for possible identification of the patient but assurance targets set

·           The CQC had highlighted earlier in the year, the risk that there might be underreporting on patient safety (this was the national picture that gave assurance that Trusts were reporting).  It was thought that the CQC may be identifying that Rotherham had a different threshold in reporting compared to other Trusts

·           Staffing levels had been monitored i.e. every shift and whether or not the staffing levels were correct.  The Quality Account was reporting that on 8% of occasions the Trust had not met the plan for nursing staff levels despite bank nurses and agency staff.  122 applicants were being interviewed for 35 Band 5 nursing vacancies with permission to over-recruit due to the expected loss of approximately 10 nurses a month for natural reasons/retirement/promotion.  If unsuccessful, consideration would be given to overseas recruitment because of the demand on Registered Nurses across England.  The health and wellbeing offer was being strengthened and sickness management arrangements tightened up

·           There was a full establishment of nurses in Community Services and Maternity. A review of the nursing establishment would be considered by the Trust Board shortly.  There were some vacancies in the Health Support posts  

·           As services transferred out to Community Services, the workforce would have to transfer and recognition of the requirements in advance in order to develop competencies of staff but also more importantly confidence of the staff.  It was very different working in the hospital to being in a patient’s home

·           The Accounts contained a number of targets some of which were national.  There were potential penalties in that some of the targets were CQUIN targets or contracting for quality improvement.  If the targets described did not improve, the CCG could financially penalise the Trust and 1 of the areas where that could be applied was in instances of infection.  The £10M cost improvement proposals had to be quality impact assessed and signed off as not having an adverse effect on quality by the medical director and that was being managed.  It was not known at this stage whether the CCG would impose any financial penalty.  There was a process that if a CCG believed there was a risk to the target they would serve a Contact Enquiry in order to understand whether there were suitable plans in place to prevent the risk maturing.  It was felt that the relationship between the CCG and Trust was such that they would be looking to re-invest in order to drive the improvement

Resolved:-  That the report be noted.