SAFE Presented to NHS Fife Board on 29th

SAFE Presented to NHS Fife Board on 29th

SAFE Presented to NHS Fife Board on 29th April 2014 989 973 80% 600 60% 400 200 Apr-14 Mar-14 Feb-14 Jan-14 Dec-13 Nov-13 Oct-13 Sep-13 Jul-13 Apr-14 Apr-14 Feb-14 Jan-14 Dec-13 Nov-13 Oct-13 Sep-13 Aug-13 7.0% 6.0% Apr-14 Mar-14 Jan-14 Feb-14 4.0% 3.0% 1.2 Feb-14 Jan-14 Apr-14 Mar-14 Jan-14 Feb-14 Dec-13 Oct-13 Nov-13 Sep-13 Dec-13 0.0% Nov-13 2.0% 1.0% 0.0 Oct-13 1.4 Aug-13 Mar-14 2.6 0.0 Jul-13 Apr-14 Mar-14 Feb-14 Jan-14 Dec-13 9.0% 8.0% 5.0% 3.0 1.0 Nov-13 Mar-14 4.3 1.3 MSSA bacteraemia Oct-Dec 13 0.0 Oct-13 Dec-13 12.0% 11.0% 10.0% Emergency Readmissions w ith 28 days 11.8% 11.3%11.2% 10.3% 10.1% 10.0% 9.5% 9.7% Sep-13 2.0 1.8 0.0 Sep-13 Oct-13 by Dec 15 Number of CAUTIs Jan = 6 Feb = 3 Rate 3.0 2.0 Aug-13 Nov-13 Target Aug-13 2.8 Sep-13 Fife mean rate 5.0 4.0 7.0 0% Mean rate based on NPSA guidance Mean rate based on NPSA guidance 5.5 20% 6.7 NHS Fife Reported CAUTIs per 1,000 catheter days Number of pressure ulcers Jan = 27 Feb =22 40% Jul-13 2.1 Jul-13 Rate Jul-13 7.9 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Apr-14 Feb-14 Mar-14 Jan-14 Dec-13 Oct-13 Nov-13 Sep-13 Aug-13 Jul-13 1.8 Aug-13 MRSA bacteraemia Oct-Dec 13 9.2 8.1 0.0 6.0 Jun-13 60% 10.3 4.0 NHS Fife Reported Pressure Ulcers (Grades 2-4) per 10,000 Occupied Bed Days 4.0 7.4 7.8 8.0 0.0 Target (90%) 92.9% 92.3% 91.7% 91.5% 91.8% 92.2% 91.1% 91.4% 80% 6.0 7.8 Apr-13 Jan-13 May-14 Apr-14 Feb-14 Mar-14 10.0 0.5 6.3 0% 100% 2.0 8.0 20% Combined target 9.4 Target by Dec 15 by Dec 15 0.9 10.0 May-13 40% 0 NHS Fife Reported Falls per 1,000 Occupied Bed Days 1.0 Rate 97.6% 97.5% 96.2% 95.3% 99.3% 98.5% 97.4% 96.0% 18 Weeks Referral to Treatment Combined Performance 1.5 1.2 1.3 1.2 1.2 National target (98%) 100% NO DATA Jan-14 1.5 Fife 971

C difficile (over 65) Oct-Dec 13 Cardiac Arrest Rate per 1,000 discharges Acute Services Division Only 1.8 986 Target 100% 80% 60% 40% 20% 0% 1.5 1045 937 945 800 95% Harm Free Care Acute Services Division Only 2.0 931 1130 1024 1000 J an-Mar Apr-J un Jul-Sep Oct-Dec J an-Mar Apr-J un Jul-Sep Oc t-Dec Jan-Mar Apr-Jun J ul-Sep 2011 2011 2011 2011 2012 2012 2012 2012 2013 2013 2013 Rate per 1,000 discharges 1136 1105 1046 1033 Mar-13 No. of reported incidents 0.50 Jul-13 Standardised Mortality Rate 1.00 1200 Feb-13 Activity was 82,314 patient episodes which included 8,365 overnight stays 1.50 0.00 4 hour Emergency Access Performance Reported Incidents for NHS Fife Scotland Aug-13 Hospital Standardised Mortality Rate Jan 2011 - Sep 2013 Fife EFFECTIVE NHS Fife HealthCheck January-February 2014 PERSON-CENTRED Activity Activity for the period January 2014 to February 2014 was 82, 314 patient episodes. This included 8,365 overnight stays and 4,626 day cases. There were 24,386 new and 44,487 review Outpatient attendances. Complaints, Concerns, Comments, Compliments Compliments Complaints Comments Hospital Standardised Mortality Rate (HSMR) The last quarterly data to September 2013 was published in February 2014. This shows a HSMR of 0.99 for Fife. It should be noted that this is a provisional figure. The majority of hospital admission data will be complete for that latest quarter, however it should still be considered provisional on the basis that the source data are dynamic and additional hospital returns will come in and be reflected in future calculations of the HSMR for that quarter. Concerns 95% Harm Free Care One of the aims of the SPSP is that 95% of people in acute adult health care are free from the four harms of the Scottish Patient Safety Indicator (SPSI). The four harms are Cardiac Arrests; Catheter Associated Urinary Tract Infection (CAUTI); Pressure Ulcers and Falls. 160 140 120 Cardiac Arrests The target is a 50% reduction in CPR attempts by the end of December 2015. Figures from last months HealthCheck have been adjusted in line with the SPSI definition of cardiac arrest and now excludes cardiac arrests that occurred in the following areas: A&E, SHDU, MHDU, CCU, outpatients and day cases. Improvement work around the deteriorating patient continues with PatientTrack being spread out to wards, weekly reporting on compliance with DNACPR and training by Resuscitation Officers. CAUTIs There were 6 CAUTIs in January (all Acute Services Division) and 3 in February (1 Acute Services Division, 2 Glenrothes & North East Fife CHP). It is the aim to reduce CAUTIs by 30 % by the end of December 2015. It is hoped to achieve this by the implementation of the urinary catheter insertion bundle , urinary catheter maintenance bundle, to raise awareness of issues with clinical staff and to implement interventions to improve antimicrobial prescribing. Pressure Ulcers It is thought that the increase in reporting of grade 2-4 pressure ulcers is due to an increased awareness that this is a required element of the SPSI. The aim is to achieve 300 days between hospital acquired avoidable pressure ulcers per ward by the end of December 2015. It is hoped that this will be achieved by implementing the NHS Scotland SSKIN bundle, risk identification and risk assessment of pressure ulcers and education and training in pressure area care. Falls The target is a 25% reduction in all falls by the end of December 2015. Given the current rate for falls the variation appears to be normal for NHS Fife. An extensive falls programme in the CHPs and the Acute Services Division is being undertaken in order to reduce the number of falls and to raise awareness of issues with clinical staff. 100 80 152 60 40 20 66 56 35 0 -20 30 33 -40 8 4 -60 37 42 64 36 34 17 5 31 44 11 5 68 23 17 6 1 53 36 65 49 53 -80 27 2 37 Significant Adverse Events (SAE) Review There were a total of 1995 incidents reported from January 2014 to February 2014. Of these 1.0% (18/1995) reported were graded as major/extreme and 44% of those (8/18) have been commissioned for an internal SAE Review. These were categorised as patient falls (2); tissue viability (2); endoscopy incident (1); personal accident (1); access/appointments/admission/transfers/discharge (1); and overpopulated emergency care services in Accident & Emergency and Admissions Unit 1 (1). One of the tissue viability incidents has now been downgraded to a local investigation after the initial Leadership Oversight Group (LOG) meeting. Feb-14 Jan-14 Dec-13 Nov-13 Oct-13 Sep-13 Jul-13 -120 Aug-13 -100 Staff Sickness Staff Sickness 6.00% 4.97%4.65% 4.64% 4.90% Complaints There were 64 formal complaints (with multiple issues) reported in January 2014 & February 2014. The 3 key themes from these formal complaints were: clinical treatment 44% (114/258); attitude and behaviour 19% (49/258); and communication (oral) 9% (24/258). Target (4.00%) 5.34% 4.64% 4.71% Patient/Staff Experience Baseline results are now available for five wards who have used the Your Care Experience questionnaire to seek feedback. This will be rolled out to a further two wards during the month of May. Tablet devices (n=32) have been purchased and an app developed which will link to the dashboard. The Board should expect to see patient experience data in the June report. 4.82% 5.00% 4.00% Scottish Public Services Ombudsman (SPSO) Four decisions were reached by the SPSO during January and February: Case 1 - the SPSO did not uphold a complaint about the treatment of a child who developed pneumonia; however they did highlight the fact that the documentation was not as detailed as it could have been and provided the Practice with Guidance. Case 2 the SPSO did not uphold a complaint about the delay in reaching the diagnosis of cleft palate, concluding that all aspects of treatment were reasonable. Case 3 and 4 the SPSO did not uphold a complaint about the treatment of a breathless patient who subsequently died as a result of a pulmonary embolus. The SPSO did however uphold aspects of the same patients hospital care and made a number of recommendations which have been acted upon and included in NHS Fifes reducing harm action plan and reported via Clinical Governance. 3.00% 2.00% 1.00% Patient Experience Staff Experience Theme for Person Stories at todays Board is dementia. The Board will hear the story of Mrs A whos mother suffers from dementia and a story from Mrs W from a staff perspective. 10 8 Dec-13 Dec-13 Oct-13 Nov-13 Sep-13 0 Jul-13 2 0 Oct-13 4 2 Aug-13 NO DATA 6 Nov-13 4 Sep-13 NO DATA 6 Jul-13 8 Aug-13 10 Apr-14 Mar-14 Feb-14 Jan-14 Dec-13 Nov-13 Oct-13 Sep-13 Aug-13 Jul-13 0.00% Data The source of data contained within this document varies and can be derived from validated published sources, official government returns and databases, and local activity data and management information from a variety of internal sources. The frequency of data updating also varies, with some data being updated monthly and others quarterly. Data correct as at 15/04/2014

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