This report is based on information from December 2016. The information is presented in three key categories: safety, experience and improvement. This report will also signpost you towards additional information about Tameside and Glossop Integrated Care NHS Foundation Trust's performance..
On one day each month we check to see how many of our patients suffered certain types of harm whilst in our care. We call this the Safety Thermometer. The Safety Thermometer looks at four harms: pressure ulcers, falls, blood clots and urine infections for those patients who have a urinary catheter in place. This helps us to understand where we need to make improvements. The score below shows the percentage of patients who did not experience any new harms.
99.0% of patients did not experience any of the four harms.
For more information, including a breakdown by category, please visit:
HCAIs are infections acquired as a result of healthcare interventions. Clostridium difficile (C.difficile) and methicillin-resistant staphylococcus aureus (MRSA) bacteremia are the most common. C.difficile is a type of bacterial infection that can affect the digestive system, causing diarrhoea, fever and painful abdominal cramps - and sometimes more serious complications. The bacteria does not normally affect healthy people, but because some antibiotics remove the 'good bacteria' in the gut that protect against C.difficile, people on these antibiotics are at greater risk.
The MRSA bacteria is often carried on the skin and inside the nose and throat. It is a particular problem in hospitals because if it gets into a break in the skin it can cause serious infections and blood poisoning. It is also more difficult to treat than other bacterial infections as it is resistant to a number of widely-used antibiotics.
We have a zero tolerance policy to infections and are working towards eradicating them. If the number of actual cases is greater than the target then we have not improved enough. The table below shows the number of infections we have had this month and results for the year to date.
The rigorous Root Cause Analysis is in place to determine whether a ‘ lapse in care’ occurred for the 12 Cdifficile cases during the month of October and as a result this number may be subject to change.
|Improvement target (year to date)||97||0|
|Actual to date||49||3|
Pressure ulcers are localised injuries to the skin and/or underlying tissue as a result of pressure. They are sometimes known as bedsores. They can be classified into four grades, with one being the least severe and four being the most severe.
This month 16 pressure ulcers were acquired during hospital stays.
|Severity||Number of pressure ulcers|
The pressure ulcer numbers include all pressure ulcers that occured from 72 hours after admission to this Trust
So we can know if we are improving even if the number of patients we are caring for goes up or down, we also calculate an average called 'rate per 1,000 occupied bed days'. This allows us to compare our improvement over time, but cannot be used to compare us with other hospitals, as their staff may report pressure ulcers in different ways, and their patients may be more or less vulnerable to developing pressure ulcers than our patients. For example, other hospitals may have younger or older patient populations, who are more or less mobile, or are undergoing treatment for different illnesses.
|Rate per 1000 bed days: 1.51|
This measure includes all falls in the hospital that resulted in injury, categorised as moderate, severe or death, regardless of cause. This includes avoidable and unavoidable falls sustained at any time during the hospital admission.
This month we reported 0 falls that caused at least 'moderate' harm.
|Severity||Number of falls|
So we can know if we are improving even if the number of patients we are caring for goes up or down, we also calculate an average called 'rate per 1,000 occupied bed days'. This allows us to compare our improvement over time, but cannot be used to compare us with other hospitals, as their staff may report falls in different ways, and their patients may be more or less vulnerable to falling than our patients. For example, other hospitals may have younger or older patient populations, who are more or less mobile, or are undergoing treatment for different illnesses.
|Rate per 1,000 bed days: 0.00|
To measure patient and staff experience we ask a number of questions.The idea is simple: if you like using a certain product or doing business with a particular company you like to share this experience with others.
The answers given are used to give a score which is the percentage of patients who responded that they would recommend our service to their friends and family.
The Friends and Family Test requires all patients, after discharge, to be asked: How likely are you to recommend our ward to friends and family if they needed similar care or treatment? We ask this question to patients who have been an in-patient or attended A&E (if applicable) in our Trust.
The In-patient FFT score: 96.29% for the Friends and Family test*. This is based on 949 responses
A&E FFT score: 79.2%for the Friends and Family test*. This is based on 1122 responses
*This result may have changed since publication, for the latest score please visit:
This month our FFT score relates to both inpatient wards and A&E. In previous months we have published the inpatient score only.
We asked 49 patients the following questions about their care:
|Were you involved as much as you wanted to be in the decisions about your care and treatment?||86|
|If you were concerned or anxious about anything while you were in hospital, did you find a member of staff to talk to?||91|
|Were you given enough privacy when discussing your condition or treatment?||86|
|During your stay were you treated with compassion by hospital staff?||89|
|Did you always have access to the call bell when you needed it?||89|
|Did you get the care you felt you required when you needed it most?||89|
|How likely are you to recommend our ward/unit to friends and family if they needed similar care or treatment?||75|
Our patient stories are important to us and we believe that feedback - both positive and negative - is essential to improving the care received by the patients and their families.
We asked 54 staff the following questions:
|Net Promoter Scores|
|I would recommend this ward/unit as a place to work||91|
|I would recommend the standard of care on this ward/unit to a friend or relative if they needed treatment||91|
|I am satisfied with the quality of care I give to the patients, carers and their families||73|
Guidelines produced by the National Institute for Health & Care Excellence (NICE) make recommendations to ensure safe staffing levels on adult wards in acute hospitals and maternity settings. In-line with this guidance we are required to publish monthly reports showing the number of Registered Nurses/Midwives and Health Care Assistants (Care Staff) working on our in- patient wards.
Each month the data compares the number of staff hours ‘Planned’ against the number of staff hours used ‘Actual’. This is collected by ward, by shift, and is reported by calendar month as a % fill rate by day and by night.
An overview of Tameside hospitals current position is given below:
To view our detailed reports, which provide a breakdown by ward and to access the monthly Trust Board Reports relating to Safer Staffing information at Tameside, please use the link below:
Improvement story: We are listening to our patients and making changes
Improving patient experience through timely and responsive communication
Administration – Our Improvement Journey
Brief Outline of Problems:
Staff in our main administration building raised concerns regarding the timeliness of our administration of clinical letters to GPs and patients. Their concerns included:
The working environment
Delays in dispatching clinical letters
Length of time answering telephone calls as a result of workload pressures.
Difficulty achieving contractual turnaround times for clinical letters
An improvement programme was established to look at the issues raised. The priorities were:
Removal of any safety hazards and clearing case notes from corridors
Provide additional resources to clear the backlog of typing
Undertake a staffing analysis (capacity and demand) to ensure we had the right people, with the right skills, in the right place
Improvements and achievements:
A working group was established and in just over 5 weeks the backlog had been cleared and we hit our turnaround times for urgent and routine clinical letters.
A staffing review was undertaken and the Trust invested in additional administrative support.
We reviewed and realigned existing resources to ensure we had equity across all specialties. This included our staff working more flexibly across a number of specialties.
We introduced monthly team meetings to improve communication and encourage staff to speak openly about any concerns they had.
Establishing an extended centralised team using a phased approach to centralisation to bring together the Booking, Scheduling and Admin Team under one management structure.
Implementation of an Office Standards Policy and standard operating procedures to demonstrate how we work and the standards we work to.
Development of standard protocols for managing patients who are awaiting test results which allows us to inform patients and their GPs in a timely manner. This also acts as a safety check to provide assurance that patient pathways are being monitored and patients are not missing results and appointments.
There is now clear ownership and accountability within each specialty area.
Flexibility to share administrative resources across the trust to meet peaks in demand in different areas.
Delivery of appropriate training for our staff.
Established processes in place to monitor the completeness of clinical letters in a timely manner.
Achievement of our turnaround times for clinical letters (2 days for urgent letters; 5 days for routine letters), which is monitored in a timely manner.
The improvements made have a positive impact on the experience of our service users, staff and partners in care and assist in ensuring the Trust delivers information in a timely manner.