Agenda item

Quality Report

Hilary Walker, Chief Nurse


The Board received and considered a monthly report which provided commentary and progress on activity associated with key safety and quality indicators. The key points to note for November 2017 were as follows: -


·         Most recent Hospital Standardised Mortality Rate (HSMR) was 98.9 (12 month period September 2016 to August 2017)

·         There were no cases of Clostridium difficile during November 2017 with a current rate of 9.4 per 100,000 bed days.

·         1 Serious Incident was reported during November 2017.

·         There had been a decrease in overdue clinical incident investigations during November 2017.

·         There was a slight increase in complaints in November 2017.


Hospital Standardised Mortality Rate (HSMR) 

HSMR remained below 100 but was expected to change when the data was next rebased. 


It was highlighted that the septicaemia diagnosis group was alerting again which was being investigated.  Previously coding and reporting as well as the way Dr Foster captured data had been the issue.  GR commented on the recording being undertaken by junior doctors which was being reviewed with Dr Foster.


GR reported that there was new guidance on learning from deaths which included publication requirements.  GR advised that the Trust’s focus was on the quality of mortality reviews with an emphasis on learning.   There was an aim to achieve 50% reviews.  GR reported that the good news was that the Trust was not reporting more than 50% avoidable deaths.   GR highlighted that the Trust would always be reporting a quarter late.


Infection Prevention and Control

GR was pleased to advise that there had been no cases of C.diff in November. GR advised that cases of norovirus, flu and influenza were being seen.


GR advised that the flu vaccination campaign had been successful but there were variations in the strain of flu and outbreaks had been seen nationally.


Operational pressures

HW referred to the operational pressures advising that the Patient Quality Committee had been cancelled in November due to the Trust’s OPEL 4 escalation status, which was the highest level that could be declared.  Membership of the Committee was comprised of senior clinical staff who were needed to provide direct patient care.  Cancellation had been mitigated by making sure key messages were sent via email.  HW anticipated that the meeting of the Committee next week would proceed.


Complaints, Concerns and Compliments

HW reported that the Patient Advice Liaison Service (PALS) and the Clinical Risk Team were supporting Divisions to continue investigation and learning from incidents and complaints. Complaint responses were being prioritised, such as those in maternity.



The report included the 6 monthly update for adult safeguarding.  There was an increasing understanding of safeguarding requirements.  HW commented that there was variable compliance with mandatory training, but good compliance with level 2 adult safeguarding training.


National Audit of Inpatient Falls 2017

HW highlighted that there had been considerable improvement in results noting that the Trust was the only hospital in the South West to achieve 80-100% compliance in 4 key areas and the Trust had achieved above national average in 5 out of 7 key areas.  Staff were very proud of the progress made and there was ongoing commitment to make the improvements identified.


Patient Stories

HW referred to the patient feedback noting that extracts from NHS Choices were included in the report.  It was explained that responses were provided and individuals were invited to contact the Trust about their concerns.


Freedom to Speak Up

There were two cases during November which were being investigated.  Since April a pattern of internal escalation was being seen rather than external notifications, which was desirable.




(a)   that the quality matters and exceptions contained within the report be noted;


(b)   that it be agreed that the Quality Report provides assurance of progress towards quality improvements and quality indicators; and


(c)   that the report be noted.

Supporting documents: