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QUALITY REPORT FOR NORTH ESSEX CLUSTER

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					QUALITY REPORT FOR NORTH ESSEX CLUSTER – APPENDIX A

SEPTEMBER
This report provides an overview of performance across the cluster relating to a range of patient safety and patient experience.

Key areas to note include:

Green     MRSA performance there have been no cases of MRSA in the cluster this month

Green     VTE – all Trusts continue to perform above threshold

Red       HSMR - continues to be a concern at CHUFT. Details of updated actions from the Trust are included within the report.

Red       C.Diff – whilst this reporting period shows an improvement on performance the indicator overall is still rated as red as we are still at
          significant risk to not achieving year end target requirements.
QUALITY REPORT TO NORTH ESSEX PCT CLUSTER BOARD MEETINGS –
Hospital Standardised Mortality Ratio (HSMR) (Quality Intelligence East - QIE)

Contents

Patient Safety
Item                                                                             Page      Frequency
Hospital Standardised Mortality Ratio (HSMR)                                     3         Monthly (Standing Item)
Venous Thromboembolism (VTE) Risk Assessments                                    4         Monthly (Standing Item)
Healthcare Associated Infection (HCAI)                                           5–6       Monthly (Standing Item)
Never Events                                                                     7         Monthly (Standing Item)
Serious Incidents                                                                8         Monthly (Standing Item)
Community Provider Indicators                                                    9         Quarterly

Patient Experience
Item                                                                                       Frequency
Complaints and PALS contacts                                                     11 - 12   Monthly (Standing Item)
Patient stories                                                                  13        Ad hoc
Patient Experience Eliminating Mixed Sex Accommodation                           14        Monthly (Standing Item)




                                                                                                                     2
Trust Name                                     Q2        Q3        Q4        Rolling      CHUFT
                                               10/11     10/11     10/11     Average      The Board have already discussed in detail the actions that CHUFT
Mid Essex Hospital Services NHS Trust          111 (R)   114 (R)   101 (R)   107 (R)      are taking to address the on-going HSMR concerns which included a
Colchester Hospital University NHS FT          114 (R)   111 (R)   112 (R)   111 (R)      further refresh of their action plan with strengthening of clinical
The Princess Alexandra Hospital NHS Trust      104 (R)   108 (R)   104 (R)   104 (R)      leadership and with targeted focus on outlying areas. As noted at the
                                                                                          last meeting the refreshed and rebased figures for Q1 will not be
Addenbrookes                                   68 (G)    70 (G)    67 (G)    69 (G)
                                                                                          available until October 2011. However the Trusts own monitoring of
East of England average                        99        97        N/A                    the monthly non-rebased Dr Foster figures are showing an
Benchmarking (for information)                                                            improvement for Q1 and we anticipate that the rebased figures from
Basildon and Thurrock                          97        112       93        100          QIE will reflect this. In addition the external review group will be
E&N Herts                                      102       104       102       103          revisiting the Trust on 14th/15th September and a verbal update as to
                                                                                          the outcomes of this visit will be provided at the meeting.
Ipswich                                        100       97        95        97
West Herts                                     104       103       104       104
West Suffolk Hospital                          88        78        95        88

PLEASE NOTE THE ABOVE FIGURES ARE AS REPORTED IN AUGUST REPORT TO
BOARD. QIE WILL PRODUCE SUMMARY FOR Q1 2011/12 IN OCTOBER.

These figures represent rebased figures. Quality Intelligence East take the national Dr
Foster data set for HSMR and rebase this to take account of improvements that have
taken place over time. We are monitored by the SHA against this rebased figure and
therefore this is in turn is how we monitor the Trusts.

London SHA does not rebase its figures and therefore direct comparison between Whipps
Cross and East of England Trusts is not possible. However for information Whipps Cross
report their HSMR as 95.5.




                                                                                                                                                             3
Venous-thromboembolism (VTE)

% of all adult inpatients who have had a VTE risk assessment on admission to hospital using the clinical criteria of the national tool

Trust Name                                      Apr 2011     May 2011     June 2011     July 2011    Aug 2011      Sep 2011
Mid Essex Hospital Services NHS Trust           94.2% (G)    95.2% (G)    93.6% (G)     95.8% (G)
Colchester Hospital University NHS FT           92.0% (G)    93.7% (G)    93.7% (G)     93.0% (G)
The Princess Alexandra Hospital NHS Trust       90.2% (G)    90.6% (G)    90.8% (G)     90.4% (G)
Addenbrookes                                    96.7% (G)    97.0% (G)    97.1% (G)     Not a/v
Whipps Cross                                    22.6% (R)    44.2% (R)    44.8% (R)     77.83% (R)
Benchmarking (for information)                  91.6%        92.4%        94.2%         94.3%
Basildon and Thurrock                           71.2%        71.6%        91.9%         Not a/v
E&N Herts                                       90.6%        92.8%        91.6%         Not a/v
Ipswich                                         88.8%        94.6%        96.0%         Not a/v
West Herts                                      94.1%        93.2%        94.1%         Not a/v
West Suffolk Hospital                           99.4%        97.1%        95.9%         Not a/v




Please note the VTE data is published 2 months after reporting by Trusts following a validation process. The July data presented within this report for MEHT,
CHUFT and PAH has been obtained from the SHA in advance of formal publication and is therefore un-validated at this stage. The three Trusts within our
cluster continue to perform well and are meeting the 90% target for assessments. The cluster Medical Director is also leading work that will look at what
interventions were offered as a result of these risk assessments which will provide an even greater indicator of quality in relation to VTE. The outcomes of this
work are anticipated later this year.

We are able to report on Whipps Cross Hospital for the first time in this report and the data obtained confirms that the Trust has been performing very poorly
against this measure since the beginning of this year. However, actions reported to their Board at the end of July seem to be working well with the most recent
result for July showing 77.8%. We will continue to work closely with the lead commissioners for Whipps Cross in monitoring their performance to ensure the
target of 90% is reached as soon as possible.




                                                                                                                                                               4
PATIENT SAFETY
Healthcare Associated Infection (HCAI)                                                                                             MRSA Bacteraemia

                                  Apr-11   May-11    Jun-11   Jul-11   Aug-11   General HCAI Commentary
Cluster                           1 (R)    1 (R)     0 (G)    0 (G)    0 (G)    The Cluster continues to have excellent performance in relation to
Mid Essex                         0 (G)    0 (G)     0 (G)    0 (G)    0 (G)    MRSA Bacteraemia, the third consecutive month with no cases.
Mid Essex Hospital                0 (G)    0 (G)     0 (G)    0 (G)    0 (G)    However our performance for Cdiff remains below requirements and
Non-Mid Essex Hospital            0 (G)    0 (G)     0 (G)    0 (G)    0 (G)    further commentary on this is provided overleaf.
North East Essex                  0 (G)    0 (G)     0 (G)    0 (G)    0 (G)
Colchester Hospital               0 (G)    0 (G)     0 (G)    0 (G)    0 (G)    We reported in our last report that the cluster overall is carrying a
                                                                                significant number of vacancies for infection control and therefore
Non-Colchester Hospital           0 (G)    0 (G)     0 (G)    0 (G)    0 (G)
                                                                                internal capacity is a high risk area. We continue to try to recruit to these
West Essex                        1 R)     1 (R)     0 (G)    0 (G)    0 (G)
                                                                                vacancies and the Director of Nursing is exploring the potential for an
Princess Alexandra Hospital       0 (G)    0 (G)     0 (G)    0 (G)    0 (G)    Essex hub for Infection Control.        The capacity issues have been
Non-Princess Alexandra Hospital   1 (R)    1 (R)     0 (G)    0 (G)    0 (G)    highlighted to the Strategic Health Authority.

                                                                                Despite this we have made good progress in addressing the key issues
                                  YTD      Ceiling                              as identified within the Root Cause Analysis. We continue to work with
Cluster                           2 (G)    14                                   GP’s and providers to address antibiotic prescribing and we are actively
Mid Essex                         0 (G)    5                                    monitoring PAH to ensure that they have implemented previously agreed
Mid Essex Hospital                0 (G)    1                                    actions around stool sampling and environmental cleanliness.          A
Non-Mid Essex Hospital            0 (G)    4                                    challenge session between the Director of Nursing, Medical Directors
North East Essex                  0 (G)    7                                    and pharmacy leads for the cluster and PAH has been arranged for
Colchester Hospital               0 (G)    1
                                                                                October. We have also agreed a dedicated programme of HCAI
                                                                                walkrounds for PAH over the next four weeks with particular focus on
Non-Colchester Hospital           0 (G)    6
                                                                                environmental cleanliness. The outcomes of these visits will inform the
West Essex                        2 (R)    9
                                                                                challenge session between the cluster and Trust.
Princess Alexandra Hospital       0 (G)    2
Non-Princess Alexandra Hospital   2(R)     7                                    The current performance for HCAI has been discussed with each of the
                                                                                emerging Clinical Commissioning Groups that are giving consideration
                                                                                as to the specific actions that they could implement to support this
                                                                                agenda.

                                                                                Finally the Director of Nursing is looking to export the good practice from
                                                                                the North Essex PCT health economy HCAI meeting to the cluster and
                                                                                the first cluster meeting is planned for November.

                                                                                                                                                           5
Healthcare Associated Infection (HCAI)                                                                                          Clostridium Difficile (C-Diff)

                                   Apr-11   May-11     Jun-11   Jul-11   Aug-11    There has been a significant reduction in cases for Aug For the Mid Essex health
 Cluster                           13 (R)   17 (R)     24 (R)   31 (R)   12 (R)    economy overall, however MEHT remain over trajectory. Analysis of August cases
 Mid Essex                         3        5          9        13       5         shows a common theme of inappropriate stool sampling. One MEHT case related
                                                                                   to a patient following a transfer from out of area and the other showed appropriate
 Mid Essex Hospital                0        1          2        7        2         antibiotic therapy.    To improve sample taking, MEHT is identifying lead nurses
 Non-Mid Essex Hospital            3        4          7        6        3         with the responsibility of infection prevention, launching a stool sample flow chart
 North East Essex                  3        2          13       9        4         and the PCT continues with weekly walk rounds. The Root Cause Analysis (RCA)
 Colchester Hospital               0        0          6        4        4         for community also identified an on-going issue with inappropriate sample taking
 Non-Colchester Hospital           3        2          7        5        0         i.e. one of the samples was for a patient with known Clostridium difficile.
 West Essex                        6        7          2        9        3
                                                                                   At our last meeting we noted that the RCA for CHUFT cases in June and July
 Princess Alexandra Hospital       4        3          2        2        0         showed an issue around environmental cleanliness. These issues were discussed
 Non-Princess Alexandra Hospital   2        4          0        7        3         in the NEE infection control committee and in the CHUFT contract quality review
                                                                                   meeting and CHUFT have given assurances around new 2 person checking
                                                                                   procedures in place now and assurance checks moving forward into the new in
                                                                                   house cleaning arrangements due to start in October 2011. At this stage the RCA
                                   YTD       Ceiling                               for community cases is not showing any common themes. They have highlighted a
 Cluster                           97 (R)    177                                   repeat test on a May positive patient; due to moving into a new GP practice, a
 Mid Essex                         35        61                                    patient on multiple antibiotics due to post operative complications and a patient
 Mid Essex Hospital                12        22                                    who has not had any anti-biotics or C.diff associated drugs prescribed. We are
 Non-Mid Essex Hospital            23        39                                    awaiting outcomes of August C.diff Root Cause Analysis from CHUFT.
 North East Essex                  31        58
                                                                                   For West Essex, there has been no cases of Clostridium Difficle identified in PAH
 Colchester Hospital               14        25                                    for August which is excellent performance for the Trust. However PAH remain over
 Non-Colchester Hospital           17        33                                    trajectory. Recent RCA of previous cases highlighted a concern in relation to
 West Essex                        31        58                                    antibiotic prescribing, and sample taking. PAH are in the process of reviewing their
 Princess Alexandra Hospital       11        14                                    Antibiotic prescribing Policy, as well as introducing a stool sample protocol. The
                                                                                   root cause analysis for the community cases identified an on-going inappropriate
 Non-Princess Alexandra Hospital   20        44
                                                                                   sampling at Epping community Hospital and by GPs. Both patients had been
                                                                                   identified with Clostridium difficile in July. This has been addressed with the GP
Across the cluster we continue to see an increase in numbers of CDiff and we are   and provider directly.
55% towards our overall ceiling for the whole year at the end of the month 5.
                                                                                   Overall, as a result of the deterioration of stool sampling in Primary Care, the North
                                                                                   Cluster has sourced specific training for Primary Care across North Essex, this will
                                                                                   be led by EQUIP and cover sample taking, prevalence and antibiotic prescribing.
                                                                                   This will commence in October 2011. The Board will also not an anomaly in the
                                                                                   figures reported last month in July. There has been an out of area case reported
                                                                                   following the submission of Board papers.

                                                                                                                                                                       6
PATIENT SAFETY
Never Events


 Cluster                                             Apr-11    May-11    Jun-11     Jul-11   Aug-11     Sep-11   Oct-11   Nov-11   Dec-11   Jan-12   Feb-12
 Never Events
 WEST                                                                      1         2          0
 MID                                                                       1         0          0
 NORTH                                                                     0         0          0

We are now reporting Never Events based on month declared to SHA and not by incident date.

Mid Essex

1. Incorrect diagnostic procedure – MEHT (June) – No harm to patient

West Essex
2. Retained foreign object - arterial catheter – PAH (June) Serious harm - patient outcome/full recovery.
3. Misidentification of patient - CT Scan - PAH (July) Moderate harm – patient outcome/radiation level below acceptable level.
4. Retained foreign object - vaginal pack – PAH (July) Moderate harm – patient outcome/full recovery.




                                                                                                                                                              7
RISK MANAGEMENT
Serious Incidents (SI’s) including Pressure Ulcers (Grade 3 and 4)- JULY/AUG COMPARABLE

                                      Mid Essex                    North East Essex                     West Essex

                         May    June        July   August   May    June       July    August   May    June     July   August
                         2011   2011        2011    2011    2011   2011       2011     2011    2011   2011     2011    2011
New SI’s (non
pressure ulcer)
                         16      10          16      12      4      4          4        8       3      10       6       8
declared to the SHA in
month
New Pressure Ulcer
SI’s declared to SHA      6      19          6       5      14      6          13       6      13      14       24      9
in month
Open SI’s (non
pressure ulcer)                             125     126                        34       33                      65      63

Open Pressure Ulcer
SI’s declared to the                         24      25                        43       37                      63      67
SHA




                                                                                                                               8
The scope of this table demonstrates the following:

All trusts report serious incidents for Acute and Community Services, Out of Hours and independent Contractors.

Mid Essex reports serious incidents for Mental Health Acute and Community Services and Prisons Services.

North East reports serious incidents as host contractor for Ramsey Healthcare Private across 5 sites covering Essex and 2 sites outside of Cluster.

West Essex report serious incidents for Children and Adolescent Mental Health Services.

Mid Essex
Following a meeting with the SHA and MEHT a number of open serious incidents have been agreed as closed, with action plans being monitored in existing
quality monitoring processes. However, formal closure from the SHA has not been received and therefore the PCT continues to report a significant number of
open SI’s (non pressure ulcer). Of the 126 serious incidents 70 are attributed to NEPFT and18 to the Prison Service.

North East Essex
In August ten non pressure ulcer SI’s were closed by the SHA and PCT. Despite this the number of open non pressure ulcer SI’s remains constant. The number
of open pressure ulcer SI’s has decreased as twelve were closed by the SHA. Over the last few months the promptness of SI closures by the SHA has improved
and there is presently no longer a considerable delay in the PCT requesting closure and the SHA agreeing to close.

West Essex
There has been significant activity and review regarding the backlog of SI’s at West Essex PCT. Many SI’s have been closed down by the PCT and now require
confirmation from the SHA that this has been actioned. It is expected that once reflected these closures will have a significant impact on the open SI’s for West
Essex. Clinical resource continues to be accessed from NEE to review all serious incidents within West Essex. A meeting with PAH, the SHA and PCT has been
arranged in September to discuss the closing of SIs and the aggregating of common themes for future monitoring by the PCT.




                                                                                                                                                               9
PATIENT SAFETY
Community Provider Indicators

                                                      Mid Essex                           North East Essex                             West Essex
                                          Quarter 1        July      August      Quarter 1        July       August        Quarter 1        July        August
1. Hand Hygiene compliance               100%         100%                      99.7%        100%                      100%            100%
2. Methicillin Resistant                 0            0                         0            0                         0               0
Staphylococcus Aureus (MRSA)
Cases
3. Clostridium Difficile (Cdiff) Cases   0            0                         0            0                         0               1
4. Falls in Community Hospitals          21           11                        88           38                        50              24
5. Mixed Sex accommodation               0            0                         0            0                         0               0
breaches
6. Never Events                          0            0                         0            0                         0               0
.
General
This is the first report to the Board detailing quality indicators in relation to Community Providers. The Board will note there is a specific variance in
numbers of reporting falls. We are currently investigating the variance for Quarter 1; anomalies will be addressed within existing quality contracting
processes.

In preparing this report it became apparent across the North Cluster, whilst all the key performance indicators for Community Providers are broadly
similar, the methodology is quite different. It is therefore not possible to provide the Board with like for like data within the current contracting year.
However going forward we will develop a locality based report for each of the PCT areas.




                                                                                                                                                                 10
PATIENT EXPERIENCE – COMPLAINTS AND PALS MONITORING

The Board will recall that we reported in July and August that it currently not possible to present comparative data from across the cluster in relation to complaints
or PALS as each PCT is recording, triaging and grading using completely different systems. This position remains for September. The team however have met
to identify the differences and commenced work on a single cluster reporting methodology which will be progressed in the coming months. It is anticipated that
this will take some time to implement these changes. For this report therefore we are presenting information for each PCT based on their own current systems but
would suggest caution in drawing comparisons for this reason.

Mid Essex

                      Total contacts          Enquiry Lines                PALS contacts                           Formal complaints level 2        Compliments
                                                                           (24 hours – level 1)                    and above
  August 2011         178                     104                          60                                      12                               2

  Of the 31 complaints received 30 were graded at level 2 and 1 was graded at level 3. Complaints are graded against the risk register and reflect the
  relative risk to the organisation. They are graded by consequence from negligible to extreme and likelihood of recurrence from rare to certain. The
  combination of these two factors determines the grading given from level 2 to level 5 for the most serious. All complaints receive a formal response.

  These can be broken down as follows:

         Central Essex Community Services (CECS) 2
         GPs 2
         Opticians 1
         Prison Healthcare 1
         MEHT 4 (including 1 complaint graded at level 3)
         Mid Essex PCT 2



NORTH EAST ESSEX

          Total        24 hrs        Low (up to 5   Med (up to 20   High (up to 1   High up to       CEO letters   Concern       Compliment   Forwarded      Logged         Shared with
          contacts                   working        working         month)          2 months)                                                 to another     for info       other
                                     days)          days)                                                                                     organisation                  organisation
  Aug
  2011           69             15             1                4               7                1             8             1           13              7              1            127



                                                                                                                                                                                       11
Of the total contacts 14 were regarding ACE, and 9 regarding CHUFT.

There have been 2 major changes in local service delivery, Neurology and DRSS. This has resulted in ongoing contacts to PALS since June / July
2011. A new provider has taken over the DRSS contract which has resulted in a change of contact telephone numbers which were initially poorly
advertised. In highlighting patients difficulties in contacting them this resulted in increased publicity to assist more patients to contact the service.

WEST ESSEX

               Total         PALS       24 hours/concern           Low (up to 10 days)        Medium (up to 25          High (up to 45 days)       Top (3 – 6 months)
               contacts                                                                       days)
 Aug 2011      83            23         18                         16                         15                        11                         0

 Of the 15 medium level complaints – 11 related to independent contractors and/or out of hours, 2 to the PCT, 1 to PAH (local acute Trust) and 1 to WECHS (community health
 services).

 Of the 11 High level complaints – 8 related to independent contractors and/or out of hours, 2 to WECHS and 1 to PAH,




                                                                                                                                                                          12
PATIENT EXPERIENCE – “AND SO WHAT HAPPENED”
The following provides the PCT Boards with case studies of complaints and/or PALS queries that have been addressed by the PCTs and Trusts across the
cluster to demonstrate that real change is occurring as a result. This month we have focussed on commissioning interventions.

Summary of complaint                                               Response and lessons learned
Complaint regarding maternity services and continuity of care      The matter was raised with the relevant Associate Commissioning Director. As a result of this, the
relating to individuals opting to access maternity services ‘out   complaint and the issues it outlined will be discussed at the East of England Maternity
of area’. An example of this is that results are not easily        commissioners/Heads of Midwifery meeting with a view to agreeing more robust processes
shared between organisations (Hospital 1, Hospital 2 and           across the East of England.
GP) and this can affect the quality of monitoring, follow-up
and care.
Complainant raised issues relating to refusal to be allowed toThe investigation into incident showed that a lack of common understanding regarding the
be referred to requested cardiology consultant. Referral was  processes for patients that were requesting referral to specific consultant.        This included
processed by the Central Referral Service.                    incorrect understanding within the local GP community as to how the process should work. The
                                                              processes were immediately reinstated and communicated. In addition monthly CRS meetings
                                                              have been arranged where, among other things, details of complaints will be discussed. This will
                                                              allow us to identify and address any training needs and enable us to maintain and develop robust
                                                              and effective referral systems.
A contact to the PALS service highlighted part of the budget This issue was raised with East of England SCG and PCT Commissioners. It has now been
for referrals for patients with HIV was managed by East of agreed that responsibility for the entire budget will sit with PCT and in future all requests will go
England Specialised Commissioning Group requiring through Exceptional Cases Panel to ensure a faster and streamlined process.
approval from the PCT. The person responsible for sign off in
the PCT had left and so this link had broken down and a
situation arose where referral to a specialist unit was
delayed.


Follow up on previous reporting:

In our August report we provided information relating to the outcomes of the national survey on GP services and in particular the Board asked for information
relating to the poor performance for questions relating to out of hours. Donald McGeachy, Medical Director and lead for Out of Hours for the cluster confirms
that the National Patient Survey is undertaken on a random sample of the population, many of whom may not have used Out of Hours(OOH) services personally
and the scores are generally disappointing. This may be because of adverse media publicity surrounding OOH rather than personal knowledge. On the other
hand our OOH providers are obliged by their contracts to survey patients who have used their services and the results of these are generally very good but
obviously not immune to bias. In order to give us better information we have commissioned EQUIP to carry out an independent survey of OOH users in Mid
Essex. Should this prove useful we will do the same in the other two localities. The outcomes of these surveys will be provided in future Quality Reports.

                                                                                                                                                                  13
PATIENT EXPERIENCE                                                                                                    Eliminating Mixed Sex Accommodation (EMSA)

                                               Acute                               Community                       Mental Health                         Out of Area
PCT Locality
                                  Jun             Jul       Aug          Jun          Jul       Aug         Jun           Jul        Aug          Jun          Jul        Aug
Cluster                           18               6          0           0            0          0           0            0           0           7            10          3
Mid Essex                         4                0          0           0            0          0           0            0           0            1            2          1
West Essex                        14               6          0           0            0          0           0             0           0          3            5           1
NE Essex                          0                0          0           0            0          0            0           0            0          3            3            1

                                                                                        The Board will note there has been a significant reduction in the breaches reported at PAH
                               EMSA Breaches                                            and the hospital continue to implement their action plan in relation to the patient pathway
                                                                                        from the High Dependency Unit to the ward. We are continuing our scrutiny and on-going
 30                                                                                     monitoring to ensure this performance is sustained.
 25                                                                     Mid Essex
 20                                                                                     The organisations out of area that have had EMSA breaches relating to North Cluster
                                                                        West Essex      patients are identified on an on-going basis. For each provider, the lead commissioning PCT
 15
 10
                                                                        NE Essex        has been contacted, and asked to provide assurance of their management of these
  5                                                                     Cluster         breaches, cause of the breaches, action taken to remedy/reduce recurrence, and application
  0                                                                                     of financial penalties against that provider.
      Apr May    Jun Apr May   Jun Apr May        Jun Apr May     Jun
                                                                                        We have partial assurance from a number of PCTs at this stage, and are continuing to seek
         Acute        Community         Mental Health   Learning                        assurances from others regarding their management of EMSA on behalf of our patients.
                                                        Disability
                                                                                        In addition Whipps Cross University Hospital NHS Trust have declared 6 Eliminating Mixed
                                                                                        Sex Accommodation breaches for August, none however involved patients from the North
                                                                                        Cluster.




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