Agenda A meeting of the Aneurin Bevan University Health Board Quality and Patient Safety Committee will be held on Wednesday 13th September 2017, commencing at 9:30am in Conference Room 2, Conference Centre, Headquarters, St Cadoc’s Hospital, Caerleon AGENDA Preliminary Matters Attachment 9:30 1.1 Welcome and Introductions Chair 5 mins 1.2 Apologies for Absence Chair 1.3 Declarations of Interest Chair Presentations 9:35 2.1 Stroke Redesign Programme Presentation Dr Yaqoob Bhat/ 30 Performance Richard Griffiths mins 2.2 Improving Ambulatory Care Presentation Jeremy Griffith 20 and Discharge in Nevill Hall mins Hospital For Consideration 10.25 3.1 Quality, Safety and Attachment Dr Paul Buss 20 Performance Overview mins Risk Assessment Overview Risk Register – issues arising Chair for action Attachments Alison Shakeshaft QPSOG Assurance Report from Meeting held on 18th August 2017 Break 10.45 3.2 C-Difficile - progress against Attachment Moira Bevan 10 the action plan mins 3.3 Putting Things Right Annual Attachment Martine Price/ 15 Report Jane Dale mins 3.4 Health and Safety Annual Attachment Alison Shakeshaft 15 Report mins 3.5 Developing Our Approach to Attachment Kate Hooton 15 Clinical Audit mins 1 Quality & Patient Safety Committee - 13th September 2017-13/09/17 1 of 175 Agenda Final Matters 11.50 4.1 Draft Minutes of the Committee Attachment Chair 10 – Monday 12th June 2017 mins 4.2 Action Sheet Attachment Chair 4.3 Items for Board Consideration Chair To agree agenda items for Board consideration and decision 12.00 Date of Next Meeting Wednesday 1st November 2017, 9:30am Conference Room 2, Conference Chair Centre, Headquarters, St Cadoc’s Hospital, Caerleon 2 2 of 175 Quality & Patient Safety Committee - 13th September 2017-13/09/17 Tab 3.1 Quality, Safety and Performance Overview Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 3.1 Quality and Patient Safety Report September 2017 Purpose of the Report: The Quality and Patient Safety Report for the Quality and Patient Safety Committee provides information on the ABUHB main priorities in this area, as set out in the Integrated Medium Term Plan, the Annual Quality Statement and the Patient Safety Improvement Plan. Recommendation: The Quality and Patient Safety Committee is asked to review the report, note the progress being made in many areas and highlight any issues where further information is required for assurance. The Quality and Patient Safety Committee is asked to: (please tick as appropriate) Approve the Report Discuss and Provide Views Receive the Report for Assurance/Compliance X Note the Report for Information Only Executive Sponsor: Dr Paul Buss, Medical Director Report Author: Kate Hooton, Assistant Director Report Received consideration and supported by : Executive Committee of the Board Quality and Team [Committee Name] Patient Safety Operational Group Date of the Report: 11.08.17. Supplementary Papers Attached: Summary of Key Points The mortality run charts have been produced in excel so they are easier to read. Some charts contain more data, which aids comparison, but means they are quite “busy”. Feedback on whether they need to be separated out to improve clarity would be helpful. 1 Quality & Patient Safety Committee - 13th September 2017-13/09/17 3 of 175 Tab 3.1 Quality, Safety and Performance Overview Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 A lower RAMI in comparison to other health boards in Wales has generally been maintained for ABUHB through 2016 to date. RAMI has decreased since the winter and settled at an expected level for the months with 3.1 reasonable coding levels. (p3). Coding completeness is reliable through to October 2016 and for April 17 (p5). Data is given for RAMI for November 16-March 17, but the values shown should reduce as coding completeness increases. Coding completeness does not affect the number of deaths (crude mortality) or the mortality rate. Results from the National Diabetes In-patient Audit Report are reported. The prevalence of diabetes in the population has increased. In summary, the staffing levels for specialist diabetes staff are low, particularly at RGH. NHH has changed its model of care, using its specialist staff to see all diabetic patients on admission. RGH has been unable to adopt this model of care because of the staffing levels. NHH performs well, with lower numbers of insulin related incidents, whereas RGH has some areas where it can improve. Patients also report a good experience at NHH, whereas the patient experience is rated less well at RGH. (p9). ABC Sepsis has rolled out the sepsis screening tool to all wards, and is now working with the wards to improve the early identification of deterioration, supported by the Divisional Nurses and using data from the Outreach Databases. The A and E department performance is being generally maintained at RGH and NHH. MAU at RGH have increased the number of cases identified and the percentage treated with the sepsis 6 in 1 hour. The data reported is limited because a new spread sheet for recording and reporting the data is being introduced. (p17). ABUHB was successful in meeting the Welsh Government target set for reduction of C diff. to March 17. The numbers of C. diff. cases increased from February to April 17. However, actions to reverse this were put in place and the number of hospital acquired cases has now reduced, in all probability due to the programme of deep cleans for wards. (p21). 2 4 of 175 Quality & Patient Safety Committee - 13th September 2017-13/09/17 Tab 3.1 Quality, Safety and Performance Overview Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 1. High Level Outcomes 1.1 Risk Adjusted Mortality Index 3.1 Our aim in the IMTP is to reduce RAMI to 90 (2013 rebase) by March 2017 and to sustain this reduction through subsequent rebasing and to reduce/eliminate variation across our hospital sites. RAMI (2016) ABUHB and Welsh Peer and Top Peer July 15-July 17 Risk Adjusted Mortality Index 2016 - ABUHB v Peer Groups ABUHB Welsh Peer Top Peer 250 225 200 175 150 125 100 75 50 25 0 RAMI (2016) ABUHB Hospitals against ABUHB July 15-July 17 Risk Adjusted Mortality Index 2016 - ABUHB Hospitals ABUHB RGH NHH YYF 250 225 200 175 150 125 100 75 50 25 0 3 Quality & Patient Safety Committee - 13th September 2017-13/09/17 5 of 175 Tab 3.1 Quality, Safety and Performance Overview Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 1.2 Crude Mortality and Mortality Rate 3.1 ABUHB and Hospital Crude Mortality July 15 – July 17 Number of Deaths ABUHB RGH 400 NHH YYF 350 300 250 200 150 100 50 0 Jul-15 Jul-16 Jul-17 Jan-16 Jan-17 Jun-16 Jun-17 Oct-15 Oct-16 Apr-16 Apr-17 Sep-15 Feb-16 Sep-16 Feb-17 Dec-15 Dec-16 Aug-15 Aug-16 Nov-15 Nov-16 Mar-16 Mar-17 May-17 May-16 ABUHB Mortality Rate against Welsh Peer and Top Peer July 15- July 17 Mortality Rates % ABUHB % Welsh Peer % Top Peer 3.0 2.5 2.0 1.5 Percentages 1.0 0.5 0.0 Hospital Mortality Rates with Welsh Peer and Top Peer July 15- July 17 Mortality Rates - ABUHB Hospitals v Peer Groups % RGH % NHH % YYF % Welsh Peer % Top Peer 3.5 3.0 2.5 2.0 1.5 Percentages 1.0 0.5 0.0 4 6 of 175 Quality & Patient Safety Committee - 13th September 2017-13/09/17 Tab 3.1 Quality, Safety and Performance Overview Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 1.3. Narrative on Mortality Data CHKS is using the RAMI rebased in 2016, and the charts shown therefore 3.1 use RAMI 2016. The line in the run charts, which is ABUHB or an ABUHB hospital, shows more variation than the line for Welsh Peer or Top Peer. This is to be expected as the Peers include much greater numbers of patients and therefore the overall variation is reduced. Current coding completeness means the RAMI is reliable through to October 2016, and April 17 is also reliable. The RAMI levels for November 16 onwards should decrease, but are shown to give an indication of the value. Since January 2017, when the RAMI, number of deaths and mortality rate were high, the levels of these indicators have all decreased and remained at the levels that are normal for the time of year. The Palmer Review says that the RAMI can be used over time for the same hospital and we are therefore continuing to report RAMI. The RAMI for Welsh Hospitals and for the Top Peer is also shown, even though it is not a meaningful measure of quality when comparing with other hospitals. This is done because it is not a comparison with a single health board or hospital, but in both cases the average for a group of health boards or hospitals, and it gives general picture of what is happening over time for those hospitals. In ABUHB, the RAMI is generally lower than the Welsh average. The RAMI for the Top Peer is therefore shown in order to provide a goal to aim for, even though the top peer contains hospitals in England, where the coding is different because of Payment by Results and some differences in the coding guidance. 2. Completeness of Coding 2.1 ABUHB Coding Completeness: Oct 16 95.3% Nov 16 91.4% Dec 16 86.9% Jan 17 89.0% Feb 17 86.2% March 17 82.8% April 17 96.3% May 17 90.7% 5 Quality & Patient Safety Committee - 13th September 2017-13/09/17 7 of 175 Tab 3.1 Quality, Safety and Performance Overview Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 2.2 Uncoded Finished Consultant Episodes 3.1 3.