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Quarter 3 2015/16
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Section Contents Page
1.0 Executive Summary
3.0 Patient Safety
3.1 Health Care Associated Infections
3.2 Serious Incidents
4.1 Transforming Care
4.2 Care Homes
4.3 Continuing Health Care Retrospective Reviews
5.0 Quality Visits to Providers
6.0 Patient Experience
6.1 Patient Advice and Liaison Service
6.3 Patient Experience Activity
6.4 Patient Stories
7.0 Primary Care Quality
7.1 CQC Inspections
7.2 Quality Monitoring
8.0 Nursing and Midwifery Council Revalidation
Appendix 1 Summary of Complaints and MP Letters Quarter 3 2015/16
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Quarter 3 2015/16 1.0 Executive Summary
This Quality Report provides an update on the activity of the Quality and Patient Safety Team, acting on behalf of Nottingham North and East (NNE), Nottingham West (NW) and Rushcliffe Clinical Commissioning Groups (CCGs), collectively known as the South Nottinghamshire CCGs, during the period Quarter 3 2015/16. The report also identifies any local or national initiatives or developments aimed at improving the quality of services. The following are included in this report: An update on Health Care Associated Infection position against limits up to the end of quarter
3, 2015/16. This shows that Nottingham University Hospitals (NUH) and NHS Rushcliffe CCG are currently over trajectory for Clostridium difficile and NUH has not achieved zero tolerance for Methicillin Resistant Staphylococcus Aureus Blood Stream Infection (MRSA BSI). Additional information has been included in this section to enable comparison of the CCGs and NUH with similar organisations which gives more context to organisational performance against nationally set trajectories.
An update on numbers and categories of Serious Incidents (SIs) reported to the end of quarter
3 2015/16. This shows that the overall number for Q3 is similar to Q1 and Q2 but there has been an increase in pressure ulcers and a reduction in falls, Health Care Acquired Infections (HCAI) and maternity related incidents.
An update on the Transforming Care Programme (the response to the Winterbourne View
investigation) including the requirement for a 10% reduction in inpatient cohort and transfer of a further 10% to a less restrictive setting. The status of the current South Nottinghamshire funded inpatients as at the end of Quarter 3 (0 NNE, 3 NW and 0 Rushcliffe) with learning disabilities and/or autism in locked rehabilitation and Assessment and Treatment Units is also provided.
An update on care homes of note identifying changes since the last report.
A progress report on retrospective Continuing Health Care review completion showing that all
three CCGs are currently meeting or exceeding the revised national trajectories for completion.
Details of Quality Visits undertaken to our providers during the first three quarters of 2015/16 including complaints,
PALS and patient stories. A summary of Quarter 3 complaints and MP letters is included at Appendix 1.
An update on CQC inspections in Primary Care.
An update on National plans to introduce Nursing and Midwifery Council revalidation from April 2016.
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The report is considered in detail at the South Nottinghamshire CCGs Quality and Risk Committee and presented to the Governing Bodies for information and assurance purposes. 2.0 Introduction Commissioning is a tool for ensuring high quality, costeffective care. Quality is a key thread that underpins the work undertaken by commissioning groups. The mission is to improve the health and wellbeing of people in Nottinghamshire with a specific aim to improve quality by delivering improvements across the three domains of quality:
Patient Safety Patient Experience Clinical Effectiveness
Quality is only achieved when all three domains are met; delivering on one or two is not enough. To achieve a good quality service the values and behaviours of those working in the NHS need to remain focussed on patients first. Our ambition is to commission excellent, safe and cost effective healthcare for Nottinghamshire. The Quality Strategy (20142019) sets out how we will ensure quality is at the heart of commissioning. The Quality Framework sets out our Governance processes for achieving this. These documents set the context for this Quality Report which provides an update on the activity of the Quality and Patient Safety Team, acting on behalf of Nottingham North and East (NNE), Nottingham West (NW) and Rushcliffe Clinical Commissioning Groups (CCGs) during the period Quarter 3 2015/16. The report also identifies any local or national initiatives or developments aimed at improving the quality of services. 3.0 Patient Safety
Patient Safety will be our highest priority (Quality Strategy 2014-2019).
3.1 Healthcare Associated Infections (HCAIs) The table below shows the position against HCAI limits as at end of Quarter 3 2015/16.
Organisation Clostridium difficile MRSA Blood Stream Infection (BSI)
Full Year Limit (Limit to
end Q3 2015/16)
Actual to end of Q3 2015/16
Pre/Post 72 hour
Full Year Limit
Actual to end of Q3 2015/16
NNE CCG 47 (31) 27 21 Pre 6 Post 0 0
NW CCG 21 (15) 13 4 Pre 9 Post 0 0
Rushcliffe CCG 24 (16) 18 10 Pre 8 Post 0 0
NUH 91 (66) 76 N/A 0 6
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Clostridium difficile All cases of Clostridium difficile (C diff) and MRSA Blood Stream Infections (BSI) are subject to a Root Cause Analysis (RCA) or Post Infection Review (PIR). Where lapses in care are identified appropriate action plans are developed to mitigate risk and learning is shared across the health community. CCG targets Targets for CCGs are set nationally and population based. Cases are designated as pre or post 72 hours, using the Public Health England definition, which is:
Pre 72 hour / Community Acquired = diagnosis confirmed by a stool sample taken within 72 hours of admission to hospital or diagnosis from a GP sample.
Post 72 hour / Hospital Acquired = diagnosis confirmed by a stool sample taken 72 hours after admission to hospital.
Regardless of pre or post 72 hour designation all cases are assigned to the CCG relevant to the GP that the patient is registered with. Analysis of the 13 community acquired cases in quarter three has identified that 5 cases were pre 72 hour admission samples and 8 were from GP samples. 11 of the cases had received recent antibiotics which were in line with current prescribing guidelines and 1 of those not receiving antibiotics was a relapse case whose initial disease was prompted by antibiotic treatment. Antibiotics are a known risk factor for developing C diff infection. No management issues were found, 1 patient was found to be self- medicating with loperamide highlighting the importance of gaining a full history from the patient as this may have masked the severity of their disease. Learning from the case reviews this quarter included advice to a GP on taking a wound swab when treating a patient with antibiotics to ensure that the patient received the appropriate treatment. There is no evidence of cross infection in any of the cases reviewed. Work continues to gain a greater understanding into the cases presenting locally, it is recognised that many of these cases have multiple co-morbidities and that this is a complex disease. One RCA investigation completed on behalf of Nottingham West CCG was led by Health Partnerships as the community nurses were managing this patients longstanding leg ulcers. It was apparent that the patient received multiple doses of antibiotics for frequent leg ulcer infections and the key learning was that had the patient commenced compression bandaging earlier following tissue viability assessment, this would have reduced the risk of subsequent C diff infection. There was also poor communication between secondary and primary care and a joint action plan has been developed across organisations and specialist areas to address the issues and ensure learning. Comparison with other similar organisations is helpful to gain contextual detail on trajectories against performance targets and this is supplied in the tables below for the 3 South Nottinghamshire CCGs. Whilst Rushcliffe CCG is the only CCG to be outside of its performance target, when compared with comparative CCGs it has the lowest incidence of C diff amongst its peers. The peer groups shown below reflect those used within RightCare and are based on number of factors including deprivation scores, age distribution, population density and ethnicity. Categorisation of CCGs by RightCare has been linked to the Office of National Statistics (ONS) clusters. NNE and NW are within the same peer group named manufacturing towns. Rushcliffe is located within the Prospering Smaller Towns group.
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Comparative data for Rushcliffe CCG for C diff:
Rating Peer Comparison to NHS Rushcliffe CCG
Clostridium difficile cases
Rating Peer Comparison to NHS Rushcliffe CCG
Clostridium difficile rates per 100,000 mid-year
1 NHS Rushcliffe CCG 18 1 NHS Rushcliffe CCG 10.43