Agenda and supporting papers - Plymouth Hospitals NHS Trust

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Item 8 DETAILED REPORT Trust Board 5 July 2013 Subject Prepared by Approved by Presented by Safety & Quality Report Deputy Director of Nursing, Patient Experience Manager, Patient Safety & Effectiveness Manager Director of Nursing Director of Nursing 1. Purpose The purpose of this report is to provide the Trust Board with an update on Safety and Quality activities within the Trust. 2. Background The Trust recognises the importance of continually enhancing its healthcare governance arrangements for the benefit of our patients. Significant progress has been made in introducing a revised framework to support the delivery of safe, effective and personal care. The Trust has a dedicated Integrated Healthcare Governance Team which seeks to support clinical teams in the provision of safe, effective and personal care. 3. Clinical Effectiveness 3.1 Hospital Standardised Mortality Rate (HSMR) The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures and compares the expected rate of death in the Trust with the actual rate of death. The graph illustrates that the PHNT mean is consistently below the national average of 100 and that this position is stable. In addition, there are now 7 consecutive data points below the mean indicating that the mean could potentially be reset to a lower value. It should be noted that HSMR is just one quality marker amongst many and the drive for improvement must continue.
Item 8 3.2 Quarterly Summary Hospital-Level Mortality Indicator (SHMI) SHMI is a hospital-level indicator which reports mortality at trust level across the NHS in England using standard and transparent methodology. This indicator is being produced and published quarterly by the Health and Social Care Information Centre. As with the HSMR values, the Trust has now reported 7 consecutive data points below the mean and there is the option to reset the mean to drive continuous improvement. 4. Patient Safety 4.1 Monthly Incident Reporting Rate Incident Reporting Rate per 100 Admissions (May 11 - May 13) 12 Incident Reporting Rate per 100 Admissions 10 8 6 4 2 0 6.1 Jul-11 6.7 Aug-11 7 Sep-11 5.8 Oct-11 6.4 6.5 Nov-11 Dec-11 5.6 Jan-12 7.3 Feb-12 6.3 Mar-12 7.5 Apr-12 7.8 8.15 7.95 May-12 Jun-12 Jul-12 8.71 Aug-12 7.92 Sep-12 8.48 8.87 9.69 Oct-12 Nov-12 Dec-12 10.54 9.33 9.4 8.94 Jan-13 Feb-13 Mar-13 Apr-13 Month / Year Incident Reporting Rate per 100 Admissions UCL LCL Mean The Trust continues to improve the incident reporting rate reflecting an open culture of reporting and learning which is essential in the drive for continuous improvements in patient safety. The control limits have now been reset to encourage continuing improvement. The Safe Care Group are currently reviewing the detailed information within this data and are expected to set a revised definition and trajectory in order to maintain the focus on patient safety incidents. 4
Page 1 and 2: Trust Board Friday 5 July 2013, 9.0
Page 3 and 4: Members of Plymouth Hospitals NHS T
Page 5 and 6: Item 3 observer. The Chairman requi
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Page 11 and 12: Item 3 been involved and there was
Page 13 and 14: Item 3 continuing to build. Mr Babe
Page 15 and 16: Item 3 to Norovirus, Professor Lewi
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Page 21 and 22: Updated: prior to July Board Item 4
Page 23 and 24: Updated: prior to July Board Item 4
Page 25: Item 8 Quality Impact Assessment Pa
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Page 45 and 46: Item 8a SUMMARY REPORT Trust Board
Page 47 and 48: Annex 2 Item 8a Summary of Serious
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Page 57 and 58: Item 9 Summary of performance excep
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Page 63 and 64: Item 9 Update on previous actions C
Page 65 and 66: Contents EXECUTIVE SUMMARY D FINANC
Page 67 and 68: B1 Safe care Description Hospital S
Page 69 and 70: Response Rate Recommender Score B3
Page 71 and 72: B5 Other safety & quality metrics D
Page 73 and 74: C2 Non-Elective Activity Descriptio
Page 75 and 76: C4 Referral To Treatment (RTT) Desc
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C6 Other access & activity metrics
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D2 Cost improvement programme (CIP)
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D4 Cash Management Description Revi
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E1 Staffing numbers Description Est
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E3 Sickness absence PERFORMANCE IND
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Risk Rating F2 Monitor's Financial
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Item 10 DETAILED REPORT Trust Board
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Item 10 4. Key Issues for the Board
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Item 11 SUMMARY REPORT Trust Board
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Item 11 DETAILED REPORT Trust Board
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Item 11 • Challenge in respect of
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Item 11 Over the past two years, me
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Item 11 Getting it Right Charter An
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Item 11 Outcome of review with exte
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Item 11 Learning Disabilities Natio
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Item 11 Peer Review 2.5 Peer Review
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Item 12 Next Steps 1. Conversation
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Item 12 2. Board Inclusion Developm
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Item 12 EDS Grades and E & D Object
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Item 12 Plymouth Hospitals Trust -
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Item 12 3.6 The workforce is suppor
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Item 13 Key Recommendations The Tru
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Item 13 Telephone conversations.
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Item 13 19. The Medical Director ha
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Item 15 incident investigations to
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Item 15, Annex 1 3. Review of Actio
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Item 15, Annex 1 • Top three issu
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Item 15, Annex 1 The Chair asked SS
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Item 16 COMMITTEE MINUTES Finance,
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Item 16 pay and staffing, highlight
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Item 16 • PACS contract - likely
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Item 17 Terms and Conditions of Emp
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Item 17, Annex 1 29/2013 Minutes an
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Item 17, Annex 1 31/2013 Francis Re
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Item 18 Next Steps The Audit Commit
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Item 18, Annex 1 Matters arising 4/
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Item 18, Annex 1 time to embed and
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Item 18, Annex 1 Payroll & Expenses
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Item 18, Annex 1 The Committee note
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Item 18, Annex 1 Going Concern Revi
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Item 18, Annex 1 if Internal Audit
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Agenda and supporting papers - Plymouth Hospitals NHS Trust

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