Agenda item

Tracey McErlain-Burns, Chief Nurse to present

Tracey McErlain-Burns, Chief Nurse, gave the following powerpoint presentation:-

 

Quality Ambitions 2014-16

-          SAFE Mortality – Reduction in HSMR (Hospital Standardised Mortality Ratio) year on year

-          SAFE Achieve 96% Harm Free Care (HFC) with zero avoidable grade 2-4 pressure ulcers and zero avoidable falls with harm

-          CARING & RELIABLE Achieve improvements in all Friends and Family responses

-          RELIABLE Achieve all national waiting times targets i.e. 18 weeks, cancer and A&E

 

Quality Improvements 2015/16

-          100% of unpredicted deaths will be subject to review

-          From a baseline of 120 we will reduce the number of patients with a LOS>14/7 (length of stay greater than 14 days)

-          Improved reporting of the deteriorating patients

-          Reduce noise at night

-          Increase the number of colleagues trained in Dementia care and reduce complaints

-          Improve complaints response times

-          Meet stroke targets

 

So how have we done?

Mortality

-          Rolling 12 months HSMR

December 2014 = 99.28

November 2015 = 108.06

(March 2015 – 112.48)

-          SHMI (Standardised Hospital Mortality Index) July 2014 to June 2015

111.64

 

Harm Free Care

-          Achieve minimum 96% Harm Free Care with the following percentage reduction on the 2014/15 baseline (No.  Trending at 94.85%; a 0.5% improvement on the previous year):-

-          70% reduction in avoidable pressure ulcers grade 2-4 (yes – 74% achieved)

-          50% reduction in avoidable falls with significant harm (yes – 57% achieved)

 

Family and Friends Test (FFT)

-          Achieve and maintain a minimum 95% positive (FFT) score – in-patients (yes – 97% achieved)

-          Achieve and maintain a minimum 86% positive FFT score – A&E (yes 88% achieved)

-          Achieve a 40% FFT response rate – in-patient areas (yes 41% achieved)

 

4 Hour Access – National Comparison

Period	TRFT Performance	TRFT Rank (of 140)	England Avg (Type 1)	No of Trusts >95% (Type 1)
April	93.3%	53	89.8%	31
May	97.3%	9	92.5%	45
June	97.1%	16	91.5%	53
Q1	95.7%	23	91.1%	44
July	93.7%	73	92.5%	55
August	88.6%	113	91.5%	44
September	93.9%	46	90.1%	34
Q2	92.1%	79	91.45	43
October	92.5%	44	88.6%	21
November	93.7%	29	87.1%	14
December	85.5%	82	86.6%	14
Q3	90.5%	58	87.4%	12

 

Other Improvement Priorities

-          100% of unpredicted death reviews – yes

-          Reporting of the deteriorating patient – yes

-          Noise at night - ?

-          Dementia training – yes (61% of TRFT colleagues have had first level dementia training)

-          Complaints performance – no

-          Stroke targets – yes (improved proportion with AF anti-coagulated on discharge; proportion admitted directly to Stroke Unit and spending 90% of their time on the Stroke Unit; proportion scanned within an hour.  Business case for allied health professional ESD team supported)

 

Other items to be covered in the Quality Account/Report

-          Staff and patient survey results

-          Listening into Action work

-          Environmental improvements

-          Community transformation

-          Progression from the CQC action plan to a Quality Improvement Plan

-          Serious incidents and Never Events

-          Data quality

-          Workforce

 

Discussion ensued with the following issues raised/clarified:-

 

·           4 hour access - performance had deteriorated from Q1 to Q3 and was an area of concern for the Trust

 

·           There were a number of reasons for not meeting the A&E national target the majority of which had related to workforce matters within the Emergency Department and more recently delays in waiting for access to beds.  There had been recruitment of consultants, middle grade Doctors and nursing colleagues and the use of a number of locums in the Emergency Department

 

·           The Trust Board received an Operational Performance report and Integrated Performance report (available on the Trust’s website) which provided the detail about how long patients were waiting; it did not give a number for those waiting but an indication could be provided outside of the meeting  

 

·           Those patients whose hospital stays were longer than 14 days were often elderly who were admitted during the Winter period and took longer to recover from their conditions.  There was the chance that some, as it got nearer to their expected discharge date, might get a hospital acquired pneumonia due to their long length stay, or not being able to achieve a discharge plan for that patient which required multi-agency responses

 

·           At the time of the 2015/16 Quality Account, a baseline had been set of 120 patients with a long length of stay.  As of August, 2015, the Hospital had been below that baseline.  An ideal target of 70 had been set which enabled the Trust to manage its bed base effectively.  There had been no reduction in the number of beds across the particular time period; the figure of 70 had been calculated on the reduction of bed places previously.  The reduction had been achieved with no more than 70 patients in hospital with a long length of stay and it had been planned to open beds over the winter period.  That Ward remained open at the moment

 

·           The steady increase in November had been a combination of factors.  There had been pressure on A&E and work was taking place with colleagues to change the systems of working and in doing so recognised that more work was required to improve the internal systems particularly in recognising what the expected day of discharge was and how that was communicated to other agencies

 

·           When talking about planning a patient discharge, the Hospital would often refer to the EDD (Expected Date of Discharge) which was one measure when the patient was considered, usually by the medical clinician, as being medically fit for discharge.  What the Trust was trying to do currently was identify a date at which point a patient was:

 

(a) considered medically fit for discharge

(b) socially ready for discharge and may well include readiness of other partners to support the patient and family, and

(c) therapeutically ready for discharge particularly if Physiotherapy and Occupational Therapy colleagues might be involved

 

·           The Trust did not have any trained psychologists; the only areas where there was some active psychological intervention was within some of the Cancer pathways.  However, a number of the community-based colleagues had extensive communication skill training which took account of some psychological therapies but no training in psychological therapy techniques

 

·           The Trust had the benefit of a Community Unit on the Hospital site should a patient require ongoing rehabilitation of a non-acute nature.  There was also access to intermediate care beds through work with Social Care colleagues.  If the Trust had particular pressures and had a number of patients that no longer needed to be in hospital, then work would take place with Social Care and the Clinical Commissioning Group for spot purchase where a bed was purchased for a period of time in an alternative but suitable accommodation for the patient.  This would be discussed with the patient’s family.  If families strongly disagreed with the proposal it may lead to a slightly longer delay in that patient’s transfer

 

·           Internally the Trust’s target was to have no more than 20 patients in hospital who had a long length of stay and were medically fit for discharge.  The presentation showed that the Trust had been having around 30-40 patients in hospital who were medically fit for discharge with an average length of stay beyond being medically fit of about 10 days.  However, in the last couple of months there had been no significant increase in those numbers

 

·           A range of mechanisms had been used to gain the patient’s opinion.  Trust Governors held surgeries and had spoken to many patients, families and visitors to the Hospital.  The report was submitted to the Council of Governors with a management response.  Further information about the Governors surgeries would be forwarded

 

·           Friends and Family Test – still difficult to obtain responses in the Emergency Department despite trying various means.  The dip in response rates and scores in C&F services was in relation to the School Nursing Service but had improved since the survey was changed from a four point to a six point scale.

 

·           The Trust worked with a company, Dr. Foster, and through the use of Dr. Foster data sets were able to analyse mortality by diagnosis, by weekend, by day of the week and also looked at crude mortality and compared its mortality rates with other Trusts.  There was a depth of data which the Quality Alerts and Mortality Group analysed on a monthly basis and more recently the Medical Director had presented a report to the Board which was available on the Trust’s website

 

·           The Health Care Support Workers in the community were working on pressure ulcer avoidance

 

·           The Trust measured data outliers on a daily basis by speciality; the Executive Team knew how many the Trust had.  Currently there were approximately 20 patients who had been moved from 1 area to another

 

·           There were currently 29 consultant vacancies within the Trust, many of which were being filled by locum colleagues.  5 consultants had successfully been recruited recently.  The newly recruited Head of Medical Workforce would assist with the plans to make the Trust attractive to new recruitment.  In some areas there were particular national shortages and district general hospitals of Rotherham’s size would always struggle to compete when there was a large teaching hospital not too far away

 

·           There were currently approximately 30 registered nursing vacancies, 22 at Band 6, and 8 at Band 5.  The overseas recruitment programme had been suspended with the Trust investing in the development of the colleagues already recruited

 

·           Additional Health Care Support Workers had been recruited together with a further 20 apprentices.  There was a workforce improvement programme taking place but inevitably the use of locum and agency colleagues did not give the sense of loyalty to the organisation as that of its own workforce

 

·           Universities still had more potential nurses apply for places than there were training places available.  It was not yet understood what the impact of the changed bursary system for potential nursing students would be

 

·           Currently there were 140 student nurses on placement at the Trust together with 50 allied professional students.  Previously placement students had reported a positive experience and Tracey actively engaged with them from the beginning to help them see the benefits of working at Rotherham Hospital 

 

·           Agency nurses were currently still used where there were vacancies and, where there was long term sickness combined in a particular area with perhaps maternity leave.   The Trust was currently investing in its own workforce even if that meant the opportunity to recruit over its establishment as it gave the benefit of continuity of care for the patient, commitment from a substantive colleague  and a reduction in the financial burden of using agencies

 

·           The annual staff survey changed slightly each year.  The Trust had the option to survey all colleagues or only a sample of 850.  Last year it had chosen to sample all colleagues and received a mid-40% response rate. It included staff morale in a number of different ways including support for line manager, whether the individual was considering leaving the Trust, whether they had reported an incident and whether they felt they had received feedback etc.

 

·           At the moment data quality with regard to the length of time it took before a Ward requested medication for a patient to be discharged was received was not formally reported

Following the meeting the information below was provided for HSC

The target was to turn the script around in under 120 minutes.  The average turnaround once the prescription arrived in pharmacy was 98 minutes. This was monitored monthly and reported to the division of support services.

 

·           There were a number of things that enabled colleagues to progress their career.  There were opportunities for Health Care Support Workers to become Registered Nurses by going to university, however, the numbers were very small.  There may be an opportunity for Health Care Support Workers with regard to assistant practitioner roles

 

·           The intent, whether medical or nursing colleagues, was to recruit the Trust’s own workforce and reduce agency costs.  It was becoming increasingly difficult to attract some agencies as a consequence of the implementation in agency caps and therefore the reduction of the hourly rate that was paid to individuals.  The Trust projected that it would continue to recruit nursing colleagues, vdrive out the use of agency combined with increasing its internal bank.  Similarly for medical colleagues, the strategy was again to recruit substantively and avoid the need for agency colleagues.  It could be difficult to recruit Doctors in certain areas due to national shortages and, therefore, anticipated that there would still be some reliance on agency and locum doctors.  In terms of working together and savings, as a Working Together Partnership, the Trust would be looking to circa £30M savings through procurement given the amount of budget the Working Together Partnership had

 

·           The Trust currently did not utilise self-medication in the Hospital.  The majority of patients who were admitted to Hospital had their medication administered by nursing colleagues.  A few patients would self-medicate whilst in hospital but it was a question as to whether there should be an increasing opportunity to self-medicate.  The benefit of a patient being involved in self-medication was that when they went home they knew more about their medication.  However, not many patients would be able to self-medicate when they went into hospital.  Work was taking place with the new Chief Pharmacist to try and have more technical pharmacy input to help patients understand their medications for when they returned home.  There were some instances when patients were ready to go home but were waiting for their take home drugs to come back to the Ward.  This could be a cause for concern

 

·           There were some patients who had sufficient medication at home who had had no changes to their medication and would have been able leave the hospital sooner.  The new Chief Pharmacist, Medical Director and Chief Nurse were currently putting together an improvement plan for medicines management.  It would focus not only on medicine safety whilst in hospital but also increasing patient understanding of medication when in hospital and shortening the period they waited for medication once told they could go home.  The aim would be to seek to try and achieve increased numbers of patients having an understanding of their expected date of discharge sooner in their hospital stay and, once clinicians had agreed with the patient and family the date to work towards, an obligation to prepare a prescription that could be taken to the Ward before the patient was in the position of having a long wait

 

Resolved:-  (1)  That the information presented be noted.

 

(2)  That the draft Quality Account document be submitted to members of the Health Select Commission for their consideration.

 

(3)  That the Select Commission provide feedback to the Foundation Trust in accordance with their timescales.