The Christie NHS FT Annual Report & Accounts 2019-20

The Christie NHS Foundation Trust Annual Report & Accounts 2019-20

Healthcare acquired infections - Clostridium Difficile There were 32 cases of Clostridium Difficile infections (CDI) – healthcare acquired in 2019/20 against an agreed threshold of no more than 31. There were community acquired 6 cases identified on admission and therefore not attributable. Upon full root cause analysis 2 of the healthcare acquired cases were deemed due to lapses in care by our commissioners. Each case of CDI is subjected to a rigorous review and multi-disciplinary root cause analysis. This has demonstrated that each attributable case of CDI was induced by the specialist treatment provided at The Christie. The treatments we provide make our patients more susceptible to CDI and this is balanced against the importance of delivering effective cancer treatments.

C-Difficile - Attributable - (Cumulative)

35

30

25

20

15

10

5

0

Apr

May Jun Jul

Aug Sep Oct

Nov Dec Jan Feb Mar

2018/19 Total 2019/20 Total

1 4

2 5 6

5 7 8

8 8

9

10 13 16

11 19 18

12 21 21

12 26 23

12 28 26

14 30 28

14 32 31

11 13

19/20 Reduction Trajectory 3

11

Incidents Management We have a strong system of incident reporting and review which enables us to identify underlying problems and to learn from events, thereby preventing recurrence. We upload patient safety incidents from our internal system to the National Reporting and Learning System (NRLS). Comparison of our reporting practices with those of trusts in the same cluster of specialist trusts shows that we have good levels of reporting and low levels of patient harm, indicating an appropriate culture of reporting and learning within the organisation. All reported incidents are investigated, with the level of investigation commensurate with the incident grade. All incidents with an impact grade of 3 (moderate) and above, out of a maximum of 5, are reported on a weekly basis to the executive team. These incidents are triaged by an executive review team consisting of the Chief Nurse and Executive Director of Quality, the Medical Director, the Associate Chief Nurse and Deputy Director of Quality, the Associate Medical Director. The

86