board report template report201801.pdf · 2018. 1. 26. · page55 page 56 context for the...

Integrated Report

Quality,Performance & Workforce toend December 2017

Contents

Dec-17 Dec-17 01/10/2017 01/11/2017 01/12/2017

Current MthTrend on

prev mth

Previous

MthOct-17 Nov-17 Dec-17 FYTD

1 23 2 1

-573 Emergency Department Attendances 5656 5083 5438 5083 5656 49364

5826 Outpatient Attendances 19118 24944 24522 24944 19118 207276

56 Inpatient Admissions (Elective & Emergency) 4009 4065 3970 4065 4009 35744

685 Other (regular day patients, day cases etc) 2888 3573 3375 3573 2888 28746

Compliance Scorecard1

Quality & Risk2

Performance & Standards3

CQUINS4

Workforce5

Finance6

Appendices7

8

Page 3

Page 4

Page 32

Page 48

Page 49

Page 55

Page 56

Context for the Integrated Report

Produced by the Performance and Information Team, ext 3735 2 of 56

0 Qtr 1 2016/17Qtr 2 2016/17Qtr 3 2016/17Qtr 4 2016/172016/17

Indicators TargetCurrent

QTDOct Nov Dec Qtr 1 Qtr 2 Qtr 3 Qtr 4 *FYTD

Risk Assessment framework 2015/16 6 01/10/2017 01/11/2017 01/12/2017 Qtr 1 2017/18 Qtr 2 2017/18 Qtr 3 2017/18 Qtr 4 2017/18 2017/18

18 Wks - Adm (adjusted) Target18 Wks - Adm Perf (adjusted) 90.00% 75.91% 72.97% 74.75% 81.72% 77.51% 77.22% 75.91% 77.51%

18 Wks - Non Adm Target18 Wks - Non Adm Perf 95.00% 83.79% 85.28% 83.34% 82.84% 91.40% 84.61% 83.79% 86.73%

18 Wks - Incomp Target18 Wks - Incomp Perf 92.00% 84.75% 86.49% 86.45% 81.32% 92.02% 87.66% 84.75% 88.11%

A&E 4 Hr TargetA&E 4 Hour Performance 95.00% 87.15% 93.82% 86.90% 80.98% 88.64% 89.05% 87.15% 88.29%

Cancer-62 Days RTT TargetCancer-62 Days RTT 85.00% 85.58% 88.42% 83.33% n/a 79.37% 87.44% 85.58% 84.15%

Cancer-31 Days Sub Treat (Surg) TargetCancer - 31 Days Subsq Treatment - Surgery 94.00% 100.00% 100.00% 100.00% n/a 93.55% 98.33% 100.00% 96.67%

Cancer-31 Days Sub Treat (Drug) TargetCancer - 31 Days Subsq - Drug Treatments 98.00% 100.00% 100.00% 100.00% n/a 100.00% 99.47% 100.00% 99.77%

Cancer - 31 Days Subsq - Radiotherapy 94.00% n/a n/a n/a n/a n/a n/a n/a n/a n/a

31 Day Diag to Treat Target31 Day Diag to Treat 96.00% 99.52% 100.00% 98.94% n/a 98.39% 98.52% 99.52% 98.71%

Cancer-2ww TargetCan

cer-Cancer-2 Wk Waits - All urgent Referrals (cancer suspected) 93.00% 95.84% 95.93% 95.76% n/a 97.44% 96.21% 95.84% 96.55%

Cancer-2ww (Breast Symptomatic) TargetCan

cer-Cancer-2 Wk Waits - Symptomatic breast patients (cancer not initially suspected) 93.00% 99.33% 98.78% 100.00% n/a 97.13% 99.10% 99.33% 98.38%

Care Programme Approach (CPA) patients

Follow up contact within 7 days of discharge 95% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Having formal review within 12 months 95% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Admissions to inpatients services had access to crisis resolution / home treat teams 95% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Meeting commitment to serve new psychosis cases by early intervention teams 95% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Ambulance FTs-Category A call – emergency response within 8 minutes

Category A call – emergency response within 8 minutes - Red 1 calls 75% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Category A call – emergency response within 8 minutes - Red 2 calls 75% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Ambulance FTs-Category A call – emergency response within 19 minutes

Category A call – ambulance vehicle arrives within 19 minutes 95% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Clostridium Difficile

CDIFF (Target)CDIFFClostridium (C.) Difficile - meeting the C. difficile objective 5 12 7 4 1 9 13 12 0 34

Mental Health

Minimising Mental Health delayed transfer of care <7.5% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Mental Health data completeness: identifiers 97% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Mental Health data completeness: outcomes for patients on CPA 50% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Certification against compliance with requirement regarding access to health care for

people with a learning disabililtyN/A n/a n/a n/a n/a n/a n/a n/a n/a n/a

Monitor Compliance Framework Total ScoreScore 5 5 **

*FYTD denotes Financial Year to Date (Please note - Cancer Wait Times figures are always 1 month in arrears)

** Not appropriate with absence of key data items for Cancer

The FYTD position for Cancer is based on the QTR 1 & July performance combined

Acc

ess

Trust Risk Assessment frameworkO

utc

om

es

Compliance Scorecard

Quality & RiskPerf &

StandardsCQUINS Workforce Finance Appendices

Produced by the Performance and Information Team 3 of 56

01/10/2017 01/11/2017 01/12/2017

Indicators Var to prev mth Target Oct Nov Dec *FYTDCritical Incidents 01/10/2017 01/11/2017 01/12/2017 2017/18 2016/17

Total Never Events (Target)Total Never Events 0 0 0 0 0Total Falls Resulting in Serious Harm (Target)Total Falls Resulting in Serious Harm 0 0 1 1 5Pressure Ulcers - Grade 3 (Target)Pressure Ulcers - Grade 3 0 3 2 1 16Pressure Ulcers - Grade 4 (Target)Pressure Ulcers - Grade 4 0 0 0 0 0Total Other SIs (Target)Total Other Sis 0 3 4 1 18Pressure Ulcers - Grade 2 (Target)Pressure Ulcers - Grade 2 0 5 5 2 27Safety Thermometer - (new harm only) TargetSafety Thermometer - (New Harm Free) 95.00% 97.83% 97.47% 90.54% 95.72%VTE Assess TargetVTE Assessment Completeness 97.24% 97.51% 97.73% NA 97.53%

Infection ControlMRSA (Target)MRSA 0 0 0 0 0CDIFF (Target)CDIFF 5 7 4 1 34

Indicators Var to prev mth Target Oct Nov Dec *FYTDPatient experienceFFT % Recommended (IP & DC) 96.04% 94.85% 94.46% 95.45%FFT % Recommended (AE) 95.44% 93.61% 92.51% 93.02%

FFT Resp Rate (IP & DC) TargetFFT Response Rate (IP & DC) 30.00% 31.60% 29.72% 27.05% 31.30%FFT Resp Rate (AE) TargetFFT Response Rate (AE) 20.00% 16.73% 23.45% 15.18% 17.78%MSA Breaches TargetNo. of Mixed Sex Accommodation breaches 0 4 8 0 41

Number of Patient moves (over 2) 35 46 49 382Positive experienceCompliments 168 172 163 1428Complaints

Non-Clinical Complaints TargetNon-Clinical Complaints 6 2 6 30Clinical Complaints TargetClinical Complaints 15 25 20 236

Indicators Var to prev mth Target Oct Nov Dec *FYTDMortality

Crude Mortality (deaths per 1000 admissions) TargetDeaths per 1000 admsCrude Mortality (deaths per 1000 admissions) 19 11.0 12.0 18.6 13.6RAMI (Risk adjusted mortality) (National target)SHMI (Summary Hospital Level Mortality Indicator) Apr 16 - Mar 17 as expected 98.14

HSMR (Hospital Standardised Mortality Ratio) Oct 16 - Sep 17 as expected 101.39Outcome

Stroke - 90% of Stay on SU TargetStroke - 90% of Stay on a Stroke Unit 80.00% 85.71% 98.18% NA 84.83%TIA - HR TIA seen & treated <24hrs TargetTIA - High Risk,Non admitted TIA treated in 24 Hrs 60.00% 70.83% 64.29% NA 71.43%EL LOS TargetLength of stay - Elective 2.2 1.6 1.6 1.5 1.6EM LOS TargetLength of stay - Emergency 5.0 4.0 3.8 4.1 4.0Readm Rate (EL) TargetReadmission Rate - ElReadmission Rate - Elective 3.00% 3.91% 3.33% NA 3.63%Readm Rate (Em) TargetReadmission Rate - EmReadmission Rate - Emergency 10.00% 16.75% 17.52% NA 17.39%

Indicators Var to prev mth Target Oct Nov Dec Rolling 12 mthsWorkforce

Sickness Absence Rate (Target)Sickness Absence Rate 3.50% 5.36% 5.26% 5.81% 4.98%Staff Turnover Rate Complete Trust (Target)Staff Turnover Rate Complete Trust 10.00% 11.66% 11.64% 11.76% 11.39%Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) (Target)Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) 10.00% 8.75% 8.72% 10.37% 9.54%Staff Turnover Rate Registered Nursing & Midwifery (Target)Staff Turnover Rate Registered Nursing & Midwifery 10.00% 14.82% 14.37% 13.27% 14.06%Staff Turnover Rate Allied Health Professionals (Target)Staff Turnover Rate Allied Health Professionals 10.00% 15.38% 16.77% 16.20% 18.17%

*FYTD denotes Financial Year to Date (HSMR & SHMI will be at snapshot date specified) Stroke, TIA, VTE, Re-adm is 1 month in arrears.

Safe

care

Quality & Risk Scorecard

Pati

en

t exp

eri

en

ceW

ell l

ed

Tru

stSu

pp

ort

ing

o

ur

staff





Methodology used to derive the HSMR is freely available. Latest Dr Foster Mortality Summary shows QEH is 101.39 as expected

· Included in the new intelligence monitoring system used by the CQC and available to the public through the CQC website

· Widely reported (including as part of the Dr Foster Good Hospital Guide and in the press)

· Risk of death based on diagnosis at first episode of care

· Does not include deaths after discharge

· Can be adversely affected by low use of palliative care codes (QEH is historically a low user of these codes)

HSMR for the 12 month period Oct 16 - Sep 17 is 101.39 as expected

Weekday HSMR is 100.02 as expected

Weekend HSMR is 103.79 as expected

Latest Report shows QEH is 98.14 as expected

· Available to public on the NHS Choices website

· Risk of death based on diagnosis at first episode of care

· Includes deaths within 30 days of discharge.

· Rolling 12 month average, but only published 6 months in arrears

SHMI for the 12 month data period of Apr 16 - Mar 17 is 98.14 as expected

SHMI for Q4 of 16/17 is 99.45 which is as expected

Reporting to the Board - The mortality surveillance group continues to closely monitor both higher than expected areas of mortality and trends that suggest where future outliers may be. This informs audit and the work of that group. This report will show from January 2018,

in addition to the present metrics, the incidence of avoidable deaths as they are identified

Mortality- HSMR (Hospital Standardised Mortality Ratio)

SHMI - (Quarterly Trend)

HSMR - (Monthly Trend) Key Points/Operational Actions

Definitions

What does ‘as expected’ mean?SHMI: 95% control limits from a random effects model applying a 10% trim for over-dispersion are used to give a trust a banding of ‘as expected’, ‘higher than expected’ or ‘lower than expected’.

HSMR: 99.8% control limits are applicable.

Key Points/Operational Actions

Mortality- SHMI (Summary Hospital Mortality Indicator)

There were 128 deaths in the hospital in December 2017, this number is higher than last year (110) and equates to 18.6 deaths per 1000 admissions which is higher than our previous rate in December 2016 at 16.0.

The most number of deaths occurred on our respiratory ward (18) and medical assessment ward (18).

The highest number of deaths were recorded against a final diagnosis of pneumonia (27) and cancer (14)

Our HSMR is within expected at 101.4. Our SHMI is also within expected at 0.98. Both weekday and weekend HSMR are within the expected ranges with no statistical significant differences.





Crude rate within HSMR basket is 3.50% (based on Oct 16-Sep 17),East of England rate = 3.70%

Perinatal mortality - Death of the foetus or live born between 24 weeks gestational age to 7 days post natal

The Crude Mortality increased slightly in Sep to 3.59, from 3.39 (Aug). Again a similar increase to the same

period last year.

Mortality Rate for the Trust per 1000 Admissions, Calculation = Total Deaths/Total spells *1000.Perinatal mortality - Death of the foetus or live born between 24 weeks gestational age to 7 days post natal

Mortality - Crude Mortality Rate (per 1000 admissions)

Definitions

Mortality - HSMR Basket Crude Rate (Yearly Comparison)

Perinatal Mortality - QEH Relative Risk (Monthly) & Observed No'sPerinatal Mortality - QEH Benchmarked Vs East of England

Palliative Care Coding Rate

The Trust's 'Palliative Care Coding' rate of (1.58%) for 17/18, is low when compared to the National average (3.66%)





Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17

Observed 0 1 1 0 0 1 0 1 0 0 0 0


10 5

Details of the Serious Incidents are shown below (shown in order of the "Incident Date").

Data provided from DATIX and is a snapshot of data recorded on DATIX at the time.Incidents are assigned to a Service Group based on the Main Specialty of the consultant assigned to the patient in question.

Serious Incidents


Definitions

2Total Serious Incidents rrrr

0of which were "Never Events"

Serious Incidents (Rolling 12 months)

0123456789

Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17

Total Serious Incidents: rolling year (with trendline)

Total Never Events Total Falls Resulting in Serious Harm Total PU's as SI's Total Other Sis

0

1

0

1

Never Events Falls reported as SI's PU's reported as SI's Other SI's

Category of most recently Reported (SI's)

Compliance with SI Report submission dates




Ref Incident date SI/NE Inc: SI Reported Date Location Exact Division

WEB46415 09/12/2017 SI 14/12/2017 Medical Assessment Unit Medical Division

WEB46674 15/12/2017 SI 21/12/2017 Public Place Other

Serious Incidents during Dec 2017

Number of Open Serious Incidents

Adverse Event Number of open Si's

Unplanned admission / transfer to specialist care unit 2

Fall on level ground 1

Neonatal seizures 1

Suspected fall 1

Delay / difficulty in obtaining clinical assistance 1

Fall from a height, bed or chair 1

Delay or failure to monitor 1

Stillbirth 1

Breach of patient confidentiality 1

Healthcare associated cross infection 1

Apgars <6 at 5 mins 1

Other medication incident 1

Grand Total 13

Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17

7 14 16 20 17 12

Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17

12 12 10 9 11 13

No. of open SI's as at date of provision of data for Board Report


There were no "Serious Incidents" closed during December

Learning from incidents closed





10 5

Analysis of "Other Incidents"






Falls by Degree of Harm inc rate per 1000 beddays


There are a total of 73 validated falls reported in December 2017 which is 5.51 per 1000 beddays rate. From this report, one (1) is not fall, but a collision with an object resulting to minor harm. We have a slight decreased number of falls from previous month (November 5.94/1000 beddays). This month’s report remains high and above the Trusts benchmark standard of 5 falls per 1000 beddays and still below the national average of 6 falls per 1000 bed days. This month’s fall consequences: (0) Catastrophic, (1) Major, (0) Moderate, (23) Minor and (49) Negligible. There were 9 patients fell on more than one occasion:

• 1 patient had 3x falls on Shouldham ward• 1 patient had 2x falls on Shouldham ward• 3 patients had 2x falls on Windsor ward• 1 patient had 2x falls on Necton ward• 1 patient had 2x falls; 1 on Leverington Escalation and 1 on West Newton ward• 1 patient had 2x falls; 1 on Oxborough and 1 on West Newton ward• 1 patient had 2x falls on West Raynham ward

Clinical areas with increased number of falls this month:(12) Windsor, (9) MAU, (8) Windsor, (7) Oxborough and Terrington, (6) Shouldham, (5) Necton and West Newton

On-going and Recommended Actions:• ‘Prevention and Management of Patients Fall Policy’ and Post Fall Protocol has been ratified by Clinical Governance Committee on 19th December 2017, awaiting guide of medicines to be finalised by the

Pharmacist and incorporated in the falls policy.• Trial of post fall grab bag will commence in February 2018. This bag will contain post fall protocol, Neurological Observation Chart, pen torch, post fall stickers/checklist, Duty of Candour Sticker, red socks

and first aid kit. The first 6 wards to undertake the trial are Terrington SS, Oxborough, Windsor, Gayton, Necton and Tilney ward.• On-going/extended trial of Hi/Lo bed from Medstrom continues on West Newton ward. We are considering allocating some of these beds to other ward that could benefit this type of bed. • Falls Champion workshop was completed on 11th January 2018 attended by 10 ward champions.• “Falls Summit” is arranged on 28th February 2018 at the Inspire Centre, The QEH 2nd Falls Summit focuses on reducing in patient falls and harm from inpatient falls and learn key assessments that could

help identify risks.• The Falls Steering Group is still waiting for the summary of the Trust report following NAIF (National Audit of Inpatient Falls) held in May 2017 from the CoE (Care of the Elderly) Clinician.

Definitions

Total number Falls incidents per month (across all levels of Harm) Number of Falls incidents per 1000 beddays, per month (across all levels of Harm)






I am pleased to report there has again been a reduction on the previous month’s figures, 3 in total for December. Only 1 was avoidable, the remaining 2 were unavoidable meaning the ASKINS bundle was implemented appropriately and in a timely manner. This is particularly significant considering the challenges the trust continues to experience.

Avoidables;Oxborough – 1 x grade 2Due to failure to risk assess accurately and subsequently failure to provide appropriate equipment.

Unavoidables;Necton– 1 x grade 2 , ASKINS bundle was implemented appropriately and in a timely manner.Terrington – 1 x grade 3, ASKINS bundle was implemented appropriately and in a timely manner.

There has been a 42% reduction on HAPU’s during Jan-Dec 2017 compared to Jan-Dec 2016. Pressure ulcer prevention training continues on induction, NA training, mandatory training and adhoc where possible.

Hospital Acquired Pressure Ulcers inc rate per 1000 beddays ,and analysis of avoidable/unavoidable cases

Definitions

Total number Pressure Ulcers incidents per month / per 1000 beddays / proportion of avoidable and unavoidable Pressure Ulcer incidents each month





For Safety Thermometer the rate of new harms ( Developed by the QEH) for December 2017 was 9.46% an increase from 2.53% in November making the QEH 90.54%, new harm free. Harm free care relates to the % of patients on the day of the study December who were harm free from pressure ulcers, falls, VTE events and catheter associated urinary tract infections. The marked decrease in December we believe relates to the collection of data on Terrington ward and the Deputy Chief Nurse will review the data collected with the ward manager to ensure the collection processes are robust.

Safety Thermometer (Hospital Acquired Harm)CQUIN

Safety Thermometer


Definitions

90.54%

Safety Thermometer (Target 95%) rrrr

96.9

6%

97.8

2%

96.9

3%

96.5

5%

98.4

9%

91.2

5%

96.5

0%

96.1

2% 97.2

2%

97.8

3%

97.4

7%

90.5

4%


Safety Thermometer Performance - New Harm Free

Safety Thermometer - (New Harm Free) Target





The Trust has continued to achieve the target of 97.24 % with December data at 97.73%

VTE:Proportion of admissions that have been VTE assessed within the reporting month (1 month in arrears)

VTE Assessment


Definitions

97.73%VTE Assessments Completed (Target 97.24%) aaaa

97.5

7%

97.6

0%

97.4

3%

97.4

7%

97.5

1%

97.7

1%

97.4

1%

97.4

2%

97.2

8%

97.6

5%

97.5

1%

97.7

3%

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17

VTE Assessment Performance

VTE Assessment Completeness VTE Assess Target





Latest Month's Performance Financial YTD

MRSA - The objective aims to deliver a continuing reduction in MRSA bacteraemia by requiring acute trusts and PCOs to improve to the level of top performers.

MRSA

Definitions


0 case of MRSA BSI apportioned to the Trust this year.

MRSA screening across the trust (both weekly and admission) continues to remain high.

0MRSA

aaaa

0MRSA

aaaa

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

MRSA Weekly Screening Compliance Across Trust






Benchmarked figures will always be 1 month in arrears

CDIFF - The objective aims to deliver a continuing reduction in Clostridium difficile infections. Organisations with higher baseline rates will be required to deliver larger reductions.

Clostridium Difficile

C Diff Incidents

Definitions

C Diff Incidents VS Prev Years C Diff Benchmarking


To date (18th Jan 2018) 36 cases of Hospital acquired infection (April 2017 – March 2018), the trajectory for this year is 53 cases.

Following a CCG review 6 cases have been deemed non trajectory – all measures were taken in line with national and local polices.

1C Diff (All cases)

aaaa

34CDIFF (All cases) aaaa





Gram Negative BSI

Definitions


The IP&C Team are working with CCG and other Acute Trust at reducing numbers of BSI, a quality premium of a 10% reduction has been set for CCG for this year.

Data collection of themes and numbers are reported via the PHE Data Capture System.




0

5

10

15

20

25

E.coli Bacteraemia (Hospital & Community Apportioned Cases)

HAI CAI

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5Klebsiella Bacteraemia (Hospital & Community Apportioned Cases)

HAI CAI

0

0.5

1

1.5

2

2.5

3

3.5

Psuedomonas Bacteraemia (Hospital & Community Apportioned Cases)

HAI CAI


IPC Dashboard

Definitions


IP&C audits include Hand Hygiene standards, cleaning of commodes/bed pans and other audits of practice. All data is fed back to clinical areas.





Service line Clinical Indicators (by ward)

Definitions




The nursing indictors for December 2017 indicate deterioration in performance in relation to completion of body map, moving and handling assessments and bed rails assessments. This comes during a very challenging month with increased acuity and extra capacity in place.

Where there are white gaps on the indicators, clinical audit have indicated that this is due to non-receipt of data from these clinical areas in relation to fluid charts and care rounds. A revised process will be put into place to

ensure that data is received by the audit department in a timely manner with a longer term plan to collect this data using the “perfect Ward App”. It should be noted that the MUST assessment is only undertaken initially in MAU and SAU, which is why these two areas are the only places where this has been assessed


Indicator Description

Fluid Charts 100% 100% 100% 94% 100% 100% 97% 99% 100% 100% 100% 95% 96% 100%

MUST Assessment 100% 50%

Waterlow Assessment 100% 100% 100% 93% 100% 94% 75% 86% 100% 100% 100% 100% 50% 100% 100%

Waterlow Re-Scored 86% 100% 100% 75% 100% 70% 91% 80% 57% 67% 100% 92% 86% 100%

Has A Body Map Been Completed 65% 20% 30% 20% 5% 100% 50% 10% 55% 5% 33% 30% 30% 50% 30% 45%

Moving And Handling Assessment

Completed90% 80% 80% 95% 60% 100% 88% 70% 85% 89% 67% 55% 85% 85% 95% 90%

Falls Assessment Done 100% 100% 100% 93% 100% 94% 100% 100% 100% 100% 90% 100% 100% 100% 67%

Falls assessment rescored weekly 86% 60% 50% 80% 73% 73% 57% 67% 69% 76% 100%

Is a Falls Care Plan Completed? 75% 87% 100% 100% 30% 67% 94% 75% 80% 89% 42% 50% 85% 65% 80% 80%

EWS for each set of OBS? 90% 93% 90% 95% 100% 100% 88% 95% 100% 100% 100% 100% 100% 100% 95% 100%

Care Rounds Completed 96% 90% 96% 84% 90% -0 99% 99% 100% 83% 92% 75%

Bedrail Assessment if "At Risk" (on

admission)50% 100% 55% 100% 100% 64% 67% 0% 100% 0% 50% 0% 71% 50%

Obs Frequency documented 90% 93% 40% 80% 20% 100% 59% 60% 95% 80% 58% 70% 55% 45% 85% 80%

Serious Incidents 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0

Drug Administration Errors 0 3 0 0 1 2 10 1 0 1 0 0 2 0 1 2

All Drug Errors (inc Admin) 0 4 0 0 2 3 16 2 0 4 0 0 5 0 1 5

Falls Total 4 0 0 3 2 0 9 5 8 4 6 1 7 5 4 12

H/A Pressure Ulcers Grade 2 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0

H/A Pressure Ulcers Grade 3 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0

C.Diff > 2 Days 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0

Harm Free Care 86% 100% 90% 100% 94% 92% 64% 91% 88% 88% 83% 93% 29% 93% 100% 94%

Complaints 0 0 1 1 0 0 1 1 1 1 0 0 1 0 1 0

Family And Friends Response Rate 33% 27% 33% 33% 22% 178% 9% 21% 48% 36% 10% 32% 40% 51% 45% 5%

Family And Friends

(% Recommended)92% 90% 93% 91% 93% 94% 71% 91% 89% 94% 67% 97% 93% 92% 82% 100%

% Of Active Mentors 63% 86% 86% 88% 100% 79% 100% 50% N/A N/A 67% 71% 100% 50% 22% 60% 60%

Fill Rate Registered 95% 89% 79% 89% 76% 85% 92% 83% 94% 95% 91% 91% 90% 88% 91% 94%

Fill Rate Unregistered 107% 95% 113% 96% 80% 85% 110% 100% 101% 109% 91% 94% 100% 122% 87% 101%

CHPPD 5.9 5.6 12.1 6.4 6.5 27.3 7.7 5.6 5.1 6.5 7.4 5.1 5.1 9.1 7.0 5.7

Appraisals 77% 71% 100% 85% 82% 91% 91% 98% 79% 94% 96% 84% 85% 67% 88% 95%

Sickness 13% 9% 5% 4% 7% 6% 7% 10% 4% 10% 5% 5% 9% 9% 9% 6%

Vacancies 24% 23% 29% 41% 27% 10% 22% 31% 54% 18% 15% 14% 38% 19% 20% 18%

Den

Pati

ent

Safe

tyPati

ent

Experi

ence

Eff

ect

iveness

Sta

ff

Experi

ence

Elm SAU Gayt Mar C Care WindMAU Nec Oxb Stan Sho Til TSS West New West Ray


Maternity Clinical Performance & Governance Scorecard 2017-18

Definitions




Activity 168 babies born in December. 4.91% homebirth rate. 24.54% of women delivered on MLBU.

ModeThe Elective c/s rate is high - work is being done around reasons for c/s and the gestation as to which c/s are being booked, Elective c/s should take place at 39 weeks. IOL is lower in December, an audit is being carried out at present to ensure IOLs are being undertaken for an appropriate, evidence based reason.

Activity: Antenatal and Postnatal CareWomen booked less than 12+6 weeks is less than 90% this month. This is due to when a woman presents to the GP/ midwife to inform them that they are pregnant.

Midwives encouraged to educate women on having first feed as a breastfeed. Work being undertaken to increase breastfeeding rate.

GovernanceCDS was closed on 1 occasion in December due to the high acuity on NICU deeming it unsafe if any other babies were to be admitted.

M easurement R easo n Green A mber R ed D ata So urce

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Women Delivered Total no. o f women giving birth at QEH Local M onitoring Birth Register 182 199 191 218 194 191 198 178 163Babies Born Total no. o f babies born at QEH Local M onitoring Birth Register 185 202 193 223 193 193 204 178 168Live Births Total no. o f live babies born at QEH Local M onitoring 185 201 193 223 193 193 203 178 168

% Home B irths % of women giving birth at home Local M onitoring >= 2% Between <1% Birth Register 3.0% 2.0% 2.5% 4.1% 1.5% 1.6% 3.0% 3.4% 4.9%BBAs Babies born before arrival of a professional Local M onitoring 0 Between >=2 Birth Register 1 1 3 4 3 1 0 2 0

StillbirthsStillbirth: Babies born after 24 weeks gestation showing no signs of life. Stillbirth

Rate = 4.6/1000 birhs. QEH annual to tal should not exceed 15 stillbirthsYearly to tal that exceeds 15 0 Between >=2 Birth Register 0 1 0 0 0 0 1 0 0

Neonatal Death (No.) N eo natal D eath : No .o f babies that are born alive but die within 28 days of age. Yearly to tal that exceeds 7 0 Between >=2 NICU/DATIX 0 0 0 1 0 0 0 0 0Twins No. babies - twins Local M onitoring Birth Register 3 3 2 5 0 2 6 0 5

Triplets No. o f babies - triplets Local M onitoring Birth Register 0 0 0 0 0 0 0 0 0Transfers out No. o f transfers out o f QEH M aternity unit. Local monitoring Birth Register 0 0 1 2 0 0 1 0 0

% Women Delivered on M LBU Women who have given birth in Waterlily Local M onitoring >= 20% Between <15% Birth Register 15.4% 20.6% 19.9% 14.7% 20.6% 22.5% 20.2% 18.5% 24.5%% Women delivered on CDS Women who have given birth on Delivery Suite Local M onitoring <75% Between >85% Birth Register 82.4% 73.9% 75.4% 81.2% 76.8% 75.9% 76.3% 78.1% 75.5%

% Normal Births Spontaneous vaginal births Benchmark Vs Nat Rate 2013/14 = 60.9% > 63% Between < 52% Birth Register 67.0% 66.8% 60.7% 64.7% 60.8% 66.5% 67.7% 64.0% 69.9%% Instrumental Deliveries Combined rate: Forceps + Ventouse Benchmark Vs Nat Rate 2013/15 = 12.9% 5% - 12% Between <5% or >20% Birth Register 11.5% 8.0% 10.5% 6.9% 10.3% 10.0% 8.6% 11.2% 8.6%% Vaginal Breech B irths 1.1% 0.0% 0.5% 0.9% 0.0% 0.0% 1.0% 0.0% 0.0%

% Elective LSCS Women having planned CS Local M onitoring <10% Between >12% Birth Register 8.2% 10.1% 11.0% 11.0% 11.3% 11.0% 6.6% 8.4% 16.6%% Emergency LSCS Women having an emergency CS Local M onitoring < 15% Between >16% Birth Register 13.1% 12.1% 17.3% 19.3% 16.5% 12.6% 18.2% 16.3% 12.9%

% Total CS Total CS performed: Elective +Emergency Benchmark Vs Nat Rate 2013/14 = 26.2 % <= 25% Between >= 28% Birth Register 21.4% 22.1% 28.3% 30.3% 27.8% 23.6% 24.8% 24.7% 29.5%% Induction Rates Women who have their labour induced (denominator = to tal women minus ElSCS) <18% Between >24% Birth Register 33.5% 25.1% 21.5% 30.3% 28.9% 27.8% 35.4% 33.7% 19.0%

% Bookings < 12 weeks 6 days Women who have their first booking appt by 12+6 KPI >= 90% Between <= 85% HoM 90.0% 91.0% 87.8% 89.3% 90.1% 92.4% 88.2% 93.0% 88.6%No. o f women seen on DAU @ N C H Local monitoring DAU 91 130 20 130 90 115 120 150 79

Closure o f DAU - hours @ N C H Local monitoring DAU 12 12 0 0 15 0 0 0 24% women in DAU seen within 4 hrs @ N C H Local monitoring >=95% Between <= 90% DAU 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100% 100% 100%

No. o f women seen on DAU @ QEH Local monitoring DAU 347 396 389 445 422 369 359 434 378Closure o f DAU - hours @ QEH Local monitoring DAU 24 24 0 0 0 0 0 24 18

% women in DAU seen within 4 hrs @ QEH Local monitoring >=95% Between <= 90% DAU 99.4% 99.7% 97.4% 99.3% 99.5% 91.2% 99.7% 98.6% 99.5%% Breastfeeding Breastfeeding / Breast M ilk initiated, attempted or achieved KPI >=70% Between < 65% Badgernet 74.6% 67.2% 69.4% 70.0% 67.9% 73.6% 72.4% 73.6% 67.9%% Breastfeeding Breastfeeding on discharge from hospital KPI >=70% Between < 65% Badgernet 68.2% 53.3% 60.0% 57.9% 34.2% 66.7% 50.0% 85.0% 55.1%% Breastfeeding Women breastfeeding at transfer to Health Visitor Local monitoring Badgernet 49.3% 37.9% 43.6% 45.9% 46.1% 45.2% 42.0% 40.9% 38.9%

% of women who stopped smoking at delivery Women who stopped smoking by the time of delivery Local monitoring Badgernet 22.9% 27.8% 27.8% 16.7% 18.5% 16.7% 65.4% 65.2% 45.0%Readmission onto Castleacre Ward <28 days Number o f avo idable maternal readmission up to 28 days post birth Local monitoring <= 4 Between >= 7 Castleacre 5 5 2 0 4 3 0 0 0

No of SUIs Local monitoring 0 >=1 Risk & DS 1 0 0 0 1 0 3 1 0Total no. o f adverse staffing incidents reported Local monitoring Datix 1 2 1 42 8 6 1 1 3

No. times CDS closed Local monitoring 0 1 >=2 DS 0 0 1 0 0 0 0 0 1Total hours CDS closed Local monitoring DS 0 0 8 0 0 0 0 0 17

Suspension of HBS Local monitoring 0 1 >=2 DS 0 0 0 0 0 0 0 0 0Suspension of HBS Local monitoring 0 1 >=2 DS 0 0 0 0 0 0 0 0 0

No Benchmark

No Benchmark

ACTIV

ITY

: A

/N &

P/N

Care

No Benchmark

No Benchmark

No Benchmark

No Benchmark

Operational Targets

GO

VERN

AN

CE

No Benchmark

ACTIV

ITY

: Bir

th S

tati

stic

sM

OD

ENo Target

No Target

No Target

No Benchmark

No Benchmark

Risk M anagementNo Benchmark

No Benchmark

No Benchmark

Day Assessment Unit


Maternity Clinical Performance & Governance Scorecard 2017-18 (continued)

Definitions




Maternal & Perinatal StatisticsPPH more than 2000mls 1.23%, may be due to the increase in elective c/s. Less than November which was 1.69%.

Workforce1:1 care on MLBU 100%, 1:1 care on CDS 95.83%.

Patient FeedbackFFT response - Antenatal recommend rate 92.86%, themes tend to be from antenatal clinic. Currently looking at better ways of working within that area. Response rate for labour/ birth 14.72%, increase from last month but still poor. Still awaiting access on patients phones to be able to complete FFT.

M easurement

R easo nGreen A mber R ed D ata So urce

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

PPH >=1000 o r<2000ml Local M onito ring < 9% Between >12% Birth Register / CDS 1.1% 2.5% 4.2% 2.3% 4.6% 2.6% 1.5% 0.6% 3.7%PPH >=2000ml Local M onito ring <=1% Between >=2.5% Birth Register / CDS 1.1% 0.0% 1.6% 0.9% 1.6% 0.5% 2.0% 1.7% 1.2%

% o f women sustaining 3rd & 4th degree tears (no /to tal-

Elective CS)Local M onito ring <=3% Between >=5% Birth Register / CDS 2.2% 1.0% 2.6% 1.8% 1.0% 1.6% 1.5% 2.3% 0.6%

No. o f women sustaining 3rd & 4th degree tears (no/to tal-

Elective CS) 3aLocal M onito ring <= 4 >= 5 Birth Register / CDS 1 1 2 2 1 1 2 4 1


Elective CS) 3bLocal M onito ring <= 2 >= 3 Birth Register / CDS 2 1 3 2 1 1 1 0 0


Elective CS) 3cLocal M onito ring 0 >= 1 Birth Register / CDS 0 0 0 0 0 1 0 0 0


Elective CS) 4Local M onito ring 0 >= 1 Birth Register / CDS 0 0 0 0 0 0 0 0 0

Blood transfusions > 4 units Local M onito ring Haematology 0 0 0 0 0 0 0 0 0Postpartum hysterectomies Local M onito ring 0 1 >1 Birth Register 0 0 0 0 0 0 0 0 0

ITU /HDU admissions Local M onito ring 0 1 >1 Birth Register 0 0 0 0 0 0 1 0 0M aternal Deaths Local M onito ring 0 >0 Birth Register 0 0 0 0 0 0 0 0 0

Avoidable Term Admissions to NICU from CDS Local M onito ring NICU / Datix 0 0 0 0 0 0 0 0 0Avoidable Term Admissions to NICU from Castlecare Local M onito ring NICU / Datix 1 0 0 0 0 0 0 0 0No. of babies with avoidable readmissions <28 days old Local M onito ring <= 2 3 - 5 >= 6 Datix 5 3 0 6 6 1 0 0 0

1:1 C are M LB U 1:1 care in labour achieved on M LBU Local monito ring >=95% 90-94 <= 89% M LBU 87.5% 95.7% 91.1% 94.9% 100.0% 100.0% 100.0% 94.6% 100.0%1:1 C are C D S 1:1 care in labour achieved on CDS Local monito ring >=95% 90-94 <= 89% DS 96.7% 96.9% 92.7% 93.0% 87.1% 97.6% 93.5% 89.4% 95.8%

On C all M idwife No. of hrs On call midwife called to work in Unit Local monito ring DS 38 22 51 59 31 53 75 44 0On C all M idwife No. of occassions On call midwife called to work in Unit Local monito ring DS 4 5 5 9 4 6 10 6 0

Compliments Total M idwifery Compliments received in month Local monito ring PALS Team 1 16 4 33 33 8 42 57 8Complaints To tal M idwifery Complaints received in month Local monito ring PALS Team 0 2 3 2 4 4 4 1 4

Response Rate Antenatal Patient Experience Team >= 15% < 15% Patient Experience Team

Likely to recommend Antenatal Patient Experience Team >= 95% <95% Patient Experience Team 97.30% 96.43% 97.37% 98.49% 98.35% 98.35% 98.41% 96.69% 92.86%Response Rate Birth / Labour Patient Experience Team >= 15% < 15% Patient Experience Team 16.76% 18.08% 13.56% 16.76% 17.20% 22.63% 14.14% 12.36% 14.72%

Likely to recommend Birth / Labour Patient Experience Team >= 95% <95% Patient Experience Team 96.67% 100.00% 100.00% 96.67% 93.75% 100.00% 100.00% 90.91% 100.00%Response Rate Postnatal Castleacre Ward Patient Experience Team >= 15% < 15% Patient Experience Team 47.55% 55.90% 60.78% 59.12% 54.02% 60.17% 39.73% 45.04% 29.08%

Likely to recommend Postnatal Castleacre Ward Patient Experience Team >= 95% <95% Patient Experience Team 92.65% 98.89% 94.62% 97.20% 97.87% 98.59% 96.55% 100.00% 100.00%Response Rate Community Postnatal Patient Experience Team >= 15% < 15% Patient Experience Team

Likely to recommend Community Postnatal Patient Experience Team >= 95% <95% Patient Experience Team 100.00% 100.00% 100.00% 100.00% 96.77% 100.00% 100.00% 100.00% 97.67%

PA

TIE

NT F

EED

BA

CK

No Benchmark

No Benchmark

No Benchmark

Local monito ring of

poor outcomes and

facto rs that may have

an impact on women's

future health. Includes

data fo r the M aternity

Safety Thermometer:

Post partum

Haemorrhage & 3rd

and 4th Degree

perineal tears.

Work

forc

e

No Benchmark

NICU Admissions

Castle acre

Mate

rnal &

Peri

nata

l Sta

tist

ics

No Benchmark


Paediatric Clinical Performance & Governance Scorecard 2017-18




Activity PAU attendances have increased due to the start of the winter season. Admission rates to Rudham however have remained at 27.9%.• PAU closed due to escalation on Rudham Ward on 2 occasions• Paediatric patients on divert on 2 occasions due to high work load / high acuity of patients

Workforce• There were 20 - 7 hour episodes when escalation beds were opened to accommodate acute, elective surgical & medical admissions.

• Registrar crossing covering ward and PAU on 4 occasions• No ward clerk cover on 6 episodes

Governance No SI’s declared in December.• Delayed discharges due patient awaiting a Tier 4 bed, eating disorder bed.

Patient Feedback Friends and family comments remain very good across all departments.

Descriptor Measurement Green Red Data Source Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

No. of PAU attendances Direct referrals from GP's A&E and other agencies East of England 5 beds < 130 >= 131 PAU 157 194 159 154 122 154 179 258 197

No of times PAU staffing standards not

met

Middle grade medical staff not allocated / available

to PAU during opening hoursEast of England 5 beds 0 >= 1 PAU 6 5 6 13 13 10 4 5 4

No of nursing assessment breachesLength of time to be seen by nursing staff (within

15 mins)Within 15 mins < 0 >= 1 PAU Data

9

(5.7%)

13

(6.7%)

4

(2.5%)

6

(4.0%)

0

(0.0%)

7

(4.5%)

3

(1.6%)

31

(12%)

12

(6%)

No of medical assessment breaches Seen by senior clinician Within 4 hrs < 0 >= 1 PAU Data NA4

(2.0%)

0

(0.0%)

10

(6.5%)

7

(5.7%)

8

(5.2%)

15

(8.4%)

12

(4.6%)

15

(6.52%)

No. of 6 hour breaches Length of stay on PAUAny children with a stay on

PAU over 6 hrs. < 0 >1 PAU Data

6

(3.8%)

12

(6.2%)

9

(5.7%)

2

(1.3%)

6

(4.9%)

7

(4.5%)

5

(2.7%)

21

(8.2%)

12

(6%)

No. of admissions from PAU% of the total attendances to PAU who are

admitted to RudhamInternal <= 40% >= 70% PAU

49

(31.2%)

46

(23.7%)

49

(30.8%)

59

(38.3%)

31

(25.4%)

48

(31.2%)

46

(25.7%)

77

(29.8%)

55

(27.9%)

HDU Days No. of HDU days in month Internal <= 15 >= 30 Rudham Stats 10 8.5 4 6 3.5 14 5 30 17

HDU Patients No. of HDU patients in month Internal <= 3 >= 4 Rudham Stats 9 7 2 1 4 7 6 18 9

Ward Attenders No. of children post discharge reviewAverage No. of Patients from

2016 = 61<= 61 >= 62 Rudham Stats 78 64 76 96 74 91 93 80 88

Medical & Surgical OutliersPatients aged 16 years and over that are not under

a PaediatricianInternal 0 >= 1 Rudham Stats 2 1 0 0 2 0 0 0 0

Medical InvestigationsNo. of children attending for diagnostic

investigations. Stay on ward was greater than 4 hrs.

Average No. of Patients from

2016 = 48<= 48 >= 49 Rudham Stats 20 25 22 24 18 27 27 26 19

Elective surgical admissionsNo. of children attending ward for elective surgery.

Stay on ward was greater than 4hrs

Average No. of Patients from

2016 = 48<= 48 >= 49 Rudham Stats 25 19 39 31 33 38 32 43 34

Transfers out with an escort No. of transfers out requiring a nurse escort Internal <= 1 >= 2 Rudham Stats 2 1 4 0 0 1 0 0 0

No. of 7 hr periods escalation beds open 5 escalation beds on Rudham wardRudham has more than 18

inpatients0 >= 1 Rudham Stats 2 1 6 5 1 8 2 7 20

No. of times recommended staffing level

not met

When no of RSCN / RN child does not adhere to

RCN recommendation

Meeting the children to

childrens nurse ratio0 >= 1 DATIX 1 0 7 1 2 9 1 0 12

No. of SUI reported to CCG Serious Incident and report prcoess actioned Internal 0 >= 1 Risk Dept 1 0 0 0 0 0 0 0 0

Number of babies under 28 days of age

admitted to rudham

No of admissions that may have been avoided had

appropriate prior intervention been in place.Internal 0 >= 1 Datix 2 0 0 0 0 0 0 0 0

No. of patients medically fit who have delayed

discharge.Internal 0 >= 1 Bed stats 0 2 1 1 1 1 0 1 1

No. of days medically fit patients who delayed

discharge.Internal 0 >= 1 Bed stats 0 6 14 5 6 10 0 17 16

Other Clinical Incidents All other on ward incidentsAll incidents to exclude

staffing incidents 0 >= 1 Datix 4 13 7 8 7 17 13 18 12

Act

ivit

yW

ork

forc

e

Delayed Discharges

Cli

nic

al In

dic

ato

rs


NICU Clinical Performance & Governance Scorecard 2017-18

Definitions




Activity NICU were unable to accept 1 in utero transfer requests due to workload. 3 Babies were appropriately repatriated to our unit. One day had 4 intensive care patients. There were 18 times that nurse staffing did not meet BAPM standards, the escalation policy was initiated & the unit closed to admissions during this time. There was 1 avoidable admission over 37 weeks gestation, the patient was admitted from community midwifery care with feeding & weight loss. NICU closed to the Neonatal network for 368 hours & CDS for 177 hours due to acuity & nursing staff skill mix & the need for a deep clean. No babies less than 32+6 weeks were discharge home on breast milk due to maternal choice.

Descriptor Measurement Green RedData

Source Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Admissions to NICU from CDS No. of infants admittedfrom CDS admitted due to level of care required

Average for 2016 (no breakdown

collected for full year) Available from

March 2018

No Parameter available until March

2018 as data not available

2016/2017 to gain average

No Parameter available until

March 2018 as data not available


30 23 39 29 29 20 21 10 24

Admissions to NICU from MLBUNo. of infants admittedfrom MLBU admitted due to level of care

required



March 2018







0 0 1 0 0 2 2 0 1

Admissions to NICU from Post natal WardNo. of infants admittedfrom PNW admitted due to level of care

required



March 2018







8 4 7 8 6 7 5 4 14

Admissions to NICU from HomeNo. of infants admittedfrom home admitted due to level of care

required



March 2018







6 4 2 9 7 8 1 2 3

Admissions to NICU from other unitNo. of infants admittedfrom other units admitted due to level of care

required



March 2018







3 4 2 1 8 0 2 4 3

Admissions to NICU from Rudham WardNo. of infants admittedfrom Rudham Ward admitted due to level of

care required



March 2018







0 0 0 0 0 0 0 1 0

Total NICU Admissions No. / Percentage of live births admitted to NICU 10% of births <11% birth rate >15% of birth rate47

25.4%

35

17.4%

51

26.4%

47 /

21%

50 /

25.8%

37 /

19.2%

31 /

15.2%

21 /

11.79%

30 /

17.85&

NICU TC Admissions No. / Percentage of live births on unit in month 10% of births <10% >15%31

16.7%

19

9.4%

34

17.6%

31 /

13.9%

32 /

16.5%

31 /

16.1%

21 /

10.3%

22 /

12.35%

15 /

8.92%

ITU days Available number from funded cot = 30 30 <= 31 > 90 12 25 20 19 7 2 34 17 47

No of occassions >1 ITU infants on unit No of times above funded ITU cots = 1 0 0 >= 1 2 6 5 1 0 0 8 5 11

48 hrs ventilatedNo of babies ventilated for more that 48 hrs that have not been

discussed with Tert centre0 0 >1 0 0 0 0 0 0 0 0 0

HDU days Available number from funded cot = 60 Average for 2016 = 52 <= 60 >= 61 32 75 49 37 91 26 35 47 35

Number of HDU babies No of HDU babies on unit in month Average for 2016 =9 <= 9 >= 10 10 11 12 8 12 6 8 8 12

SC days Available number from funded cot = 270 Average for 2016 =299 < 270 > 300 305 248 322 290 334 297 300 265 344

Number of SC babies No of SC babies on unit in month Average for 2016=48 <=48 >=49 49 54 53 52 60 47 54 45 53

No. of babies over 44 weeks of age No. of babies aged over 44 weeks 0 0 >=1 0 0 0 0 1 1 0 1 0

No. of occasions in month Over 80% cot occupancy 0 >1 7 7 18 5 13 0 5 6 8

No. of occasions in month Over 100% cot occupancy 0 >1 0 0 0 2 2 0 0 1 3

Number of avoidable admissions > 37 weeks No. of admissions that may have been avoided had appropriate prior

intervention been in place.0 0 >=1 DATIX 5 3 0 6 6 0 0 4 1

Number of babies receiving care from the

NCTNo. of babies having care in the community Internal Internal Internal 24 29 30 28 21 23 24 22 31

Number of NCT visits No. of visits carried out by NCT each month Internal Internal Internal 71 93 87 63 70 53 57 62 69

Ward attenders No. of babies attending on ward NICU Internal Internal Internal 8 13 6 6 11 8 17 16 15

In uter transfers accepted NICU Internal Internal Internal 1 2 3 0 0 3 5 0 0

In uter transfers refused NICU Internal Internal Internal 1 1 0 0 2 0 0 2 1

Transfers out >1 if due to capacity issues Internal 0 >= 1 0 0 0 0 0 0 0 0 0

No of hours NICU on divert to network Internal 0 >= 1 0 68.5 26 24 171.5 0 120 156 368

No of hours NICU on divert internal Internal 0 >= 1 0 56.5 0 0 84 0 0 158 177

Number of times BAPM staffing levels not

met per monthNo of times in month Staffing levels don’t meet BAPM standards BAPM 0-5 times 10 times & above

NICU /

Badgernet0 14 13 5 13 0 9 5 18

NIC

U / B

ad

gern

et

NIC

U

Cot occupancy

Unit escalation (in hours)

Act

ivit

y


NICU Clinical Performance & Governance Scorecard 2017-18 cont'd

Definitions




Mortality 1 baby less than 32 weeks gestation had an admission temperature of less than 36.5 despite appropriate warming measures being in place.

Governance There were 21 reported clinical incidents. No SUI’s were reported.

Clinical Activity All parents were seen by a senior staff member within 24 hours of admission.

Patient FeedbackIn November there were no complaints and 6 compliments. The FFT response rate was 425%, with 100% recommendation. Work is in progress to start recording this electronically and hopefully giving us a continually consistent response rate.

Descriptor Measurement Green Red Data Source Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

HypoglycaemiaInternal Guideance and standards not

followed 1 >= 3 NICU 0 0 0 0 0 0 0 0 0

Pre -Term Hypothermia less

than 32 weeks (NNAP)NNAP standard not achieved 0 >= 1 NICU badgernet 0 0 1 0 0 0 3 0

1 out

of 2

Accidental extubation NEVER EVENT 0 >= 1 DATIX 0 0 0 0 0 0 0 0 0

Infection (Positive culture

and CSF) (NNAP)Laboratory results 1 >= 3 NICU Badgernet 0 0 1 0 0 2 0 0 0

Pnuemothorax Incidents each month 1 >= 3 DATIX / Badgernet 0 0 0 0 1 1 2 0 1

No of SUIs Incidents each month 0 >= 1 DATIX / Risk dept 0 0 0 0 0 0 0 0 0

Total No of reported

incidentsIncidents each month Internal Internal 16 17 14 11 17 10 19 22 16

Staffing Incidents Staffing level Incidents each month 0 >= 1 0 2 1 0 3 0 1 1 5

NNAP standard NNAP >= 58% <58% NICU Badgernet 100% 33% 100% 0% 0% 50% 50%Not

Eliagable0%

Internal Internal Internal Internal Internal4 out

of 4

1 out

of 3

2 out of

2

0 out

of 1

0 out

of 1

4 out

of 8

1 out

of 2

0 out of

0

0 out

of 4

ROP Screening prior to discharge NNAP standard NNAP 100% <100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Parents seen within 24hrs of

admissionNNAP standard NNAP >= 88% <88% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Delayed Discharge No of babies delayed

discharged Local / National /Internal 0 >= 1 NICU 0 0 0 0 0 0 0 0 0

Patient Experience FFT / NICU 100% 100% 100% 100% 100% 95.2% 100% 100% 100%

Patient Experience PALS / Audit 16 8 5 4 13 4 10 6 6

Patient Experience FFT / NICU 29.1% 12.8% 10.7% 13.5% 100% 131% 100% 200% 425% *

Patient Experience PALS / Audit 0 0 0 0 0 1 0% 0 0

* Response Rates for NICU before Aug 2017 included responses from "Ward Attenders". These are now excluded as they have their own Outpatient FFT card.

DATIX

Clin

ical A

ctiv

ity Less than 33 weeks babies receiving

breast milk on discharge (32+6

DAYS)

NICU Badgernet

Mo

rtality

Unexpected Neonatal morbidity -

Recommend

Compliments

Go

vern

an

ce

Risk Management

Response RateFFT

Complaints


The response rate did not reach the target of 30% (27.05% - the target was missed by 169 responses (1551 collected)) and the likelihood to recommend score for the month also missed the 95% target for the month (94.46%) although year to date still exceeds both targets.

The benchmark figures for the region place the Trust 11/13 based on November’s figures (a drop from 10th last month). The reasons that patients cited as to why they were not able to recommend the care they had received can be grouped into these areas - Staff attitude (Rudham, MAU, Gayton), waiting times (AEC), staffing levels/ pressures (AEC, Denver and Gayton), delays (medication and scan results – SAU, personal care - Terrington), communication with patients (AEC, Rudham) and food (Gayton).

The % of patients "Recommending / Not Recommending the Service" shown above will not always equal a combined total of 100% as it does not include those who are undecided.

The Friends & Family Test Scores & Response Rates shown above includes Inpatients & Daycase activity. The benchmarking data is extracted from the Department of Health's Unify Reporting Tool ,and is shown at least a month in arrears.

* Response rates of greater than 100% can occur when responses relating to discharges in one month are received by organisations too late for that month’s submission and are submitted as part of the return in the following month or Patients/Carers/Familymembers may also choose to submit responses at multiple points during a period of care/treatment resulting in multiple submissions to the same month.

Friends and Family Test - Inpatients and Daycase (Recommended/Not Recommmended)


Definitions

94.46%

% Recommend the service

1.42%% Do not recommend the service

27.05%

Response Rate (Target 30%) rrrr

Friends and Family Test - Inpatient & Daycase (Response Rates)

Ward / Area Performance - Inpatient & Day Cases Benchmarking - Inpatient & Day Cases0.9

2%

0.6

8%

1.0

2%

1.0

1%

0.4

8%

1.0

3%

1.2

1%

0.8

9%

1.2

2%

0.9

4%

0.8

6%

1.4

2%

96.1

9%

96.1

6%

95.6

1%

96.0

0%

96.1

2%

95.4

7%

94.7

5%

95.7

5%

95.3

5%

96.0

4%

94.8

5%

94.4

6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Monthly % Recommend / Not Recommend - Inpatients & Day Cases

FFT % Not Recommended (IP & DC) FFT % Recommended (IP & DC)

29.1

4%

32.2

7%

34.3

5%

32.7

5%

33.5

9%

34.5

8%

32.6

3%

29.4

4%

30.0

3%

31.6

0%

29.7

2%

27.0

5%

0%

5%

10%

15%

20%

25%

30%

35%

40%


Monthly Response Rates for Inpatients & Day Cases

FFT Response Rate (IP & DC) FFT Resp Rate (IP & DC) Target




RM1 98.16% 1.00% 10.02%

RGM 97.51% 1.15% 63.35%

RDE 97.50% 0.65% 40.15%

RGQ 97.39% 0.83% 34.01%

RGP 97.24% 0.97% 23.04%

RGN 96.64% 0.80% 33.19%

RDD 96.58% 1.43% 39.11%

RGR 96.15% 0.96% 20.02%

RQW 95.60% 0.63% 39.61%

RGT 95.37% 1.70% 9.35%

RCX 94.85% 0.86% 29.72%

RQ8 92.81% 3.77% 22.10%

RAJ 92.55% 2.98% 27.48%SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

MID ESSEX HOSPITAL SERVICES NHS TRUST

THE QUEEN ELIZABETH HOSPITAL, KING'S LYNN, NHS FOUNDATION TRUST

CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST

WEST SUFFOLK NHS FOUNDATION TRUST

Org Code Organisation Name (Ranked by % Recommended)

BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

NORTH WEST ANGLIA NHS FOUNDATION TRUST

JAMES PAGET UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

IPSWICH HOSPITAL NHS TRUST

COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST

%

Recommended

% Response

Rate

% Not

Recommended

PAPWORTH HOSPITAL NHS FOUNDATION TRUST

NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST


The Emergency Department has missed the target of 95% (92.51%) and there is a sharp increase in the percentage not recommending the service (3.04% - up from 1.6% last month). This is still well below the national average for unlikely to recommend (7.23%).

The response rate has dropped and missed the 20% required (15.18%). The electronic collection method is gaining momentum and new team members are supporting it – 13% of all responses collected from A&E are now collected by electronic tablet. Overall the service benchmarks at 6/12 based on November’s figures for likelihood to recommend (this is down from 2nd in October).

There were 15 patients unlikely to recommend the care they have received (from a total of 494 responses) and the reasons included mainly waiting (this represented 80% of all negative responses up from 36% of negative responses in October) other comments relate to not living in the local area, junk food in the vending machines and lack of space in the waiting area.

The % of patients "Recommending/Not Recommending the Service" shown above will not always equal a combined total of 100% as it does not include those who are undecided.

Friends and Family Test - A & E (Recommended/Not Recommended)

Definitions

92.51%

% Recommend the service

3.04%% Do not recommend the service

23.2

8%

26.7

1%

20.2

4%

21.7

0%

19.0

2%

20.6

6%

14.1

9%

13.5

8%

16.6

1%

16.7

3% 23.4

5%

15.1

8%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%


Friends and Family Test - Monthly Response Rates for AE

FFT Response Rate (AE) FFT Resp Rate (AE) Target

15.18%

Response Rate(Target 20%)

rrrr


Friends and Family Test - A & E (Response Rates)

Benchmarking - A & E

1.7

6%

6.2

0%

5.1

8%

4.3

2%

5.0

1%

2.4

7%

0.8

8%

1.2

9%

2.1

4%

1.2

8%

1.6

0%

3.0

4%

94.0

9%

90.7

0%

90.9

7%

89.9

7%

89.2

0%

94.1

3%

95.3

9%

94.4

1%

93.9

7%

95.4

4%

93.6

1%

92.5

1%

0%

20%

40%

60%

80%

100%


Friends and Family Test - Monthly % Recommend / Not Recommend for A&E

FFT % Not Recommended (AE) FFT % Recommended (AE)




Org Code%

Recommended

% Not

Recommended

% Response

Rate

RQW 96.08% 3.61% 17.01%

RM1 95.24% 2.38% 2.33%

RGP 94.50% 1.20% 11.78%

RGR 94.37% 2.22% 27.94%

RGN 94.22% 2.38% 3.34%

RCX 93.61% 1.60% 23.45%

RGT 92.74% 2.86% 21.02%

RDE 89.06% 6.02% 25.95%

RQ8 88.44% 5.85% 18.16%

RAJ 86.62% 8.87% 14.59%

RDD 81.51% 9.32% 21.40%

RGQ 81.44% 8.37% 9.51%

Organisation Name (Ranked by % Recommended)











SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST



Friends and Family Test - Maternity Services (Recommended/Not Recommended)

Definitions


The % of patients "Recommending / Not Recommending the Service" shown above will not always equal a combined total of 100% as it does not include those who are undecided.Maternity benchmarking is ranked by Question 2 (Labour). Benchmarking data is extracted from the Department of Health's Unify Reporting Tool, and is currently shown a month in arrears.

The Maternity service showed an increase in response rate (birth) to 14.72% (15% target) and had 100% level of recommendation for birth. Had one additional response been collected the target of 15% would have been reached. All areas (except antenatal) achieved the 95% likelihood to recommend target. The reasons for not being able to recommend the antenatal care received occurred mainly in Brancaster Antenatal Clinic (3 responses) where one was concerned with the waiting time and the other two mentioned consultant attitude, lack of a consistent consultant and communication between the patient and the consultant. The other patient unlikely to recommend was cared for by the community midwifery team but provided no comment.

One patient was unlikely to recommend their community postnatal care due to the lack of a consistent consultant and the fact that the post-natal clinics all take place in the evening and the respondent felt it is not good to take a newborn baby out in the cold.

Regional maternity information has not changed since the last report to Board as NHS England have confirmed that November data is not ready for release due to technical difficulties.

0.9

6%

2.7

6%

4.7

6%

98.4

1%

96.6

9%

92.8

6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct Nov Dec

FFT - % Recommend/ Not Recommend (Antenatal)

FFT % Recommended Mat Q1 (Antenatal)FFT % Not Recommended Mat Q1 (Antenatal)

100.0

0%

90.9

1%

100.0

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct Nov Dec

FFT - % Recommend/ Not Recommend (Labour)

FFT % Recommended Mat Q2 (Labour)FFT % Not Recommended Mat Q2 (Labour)

1.7

2%

96.5

5%

100.0

0%

100.0

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct Nov Dec

FFT - % Recommend/ Not Recommend (Postnatal Ward)

FFT % Recommended Mat Q3 (Postnatal)FFT % Not Recommended Mat Q3 (Postnatal)

2.3

3%

100.0

0%

100.0

0%

97.6

7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct Nov Dec

FFT - % Recommend/ Not Recommend (Community PostNatal)

FFT % Recommended Mat Q4 (Comm Postnatal)FFT % Not Recommended Mat Q4 (Comm Postnatal)

Response Rate - Labour

14.1

4%

12.3

6%

14.7

2%

0%

5%

10%

15%

20%

25%

30%

Oct Nov Dec

FFT - Response Rate (Labour)

FFT Response Rate Mat Q2 (Labour)FFT Resp Rate (Labour) Target

Benchmarking - Maternity Services





Definitions


The % of patients "Recommending/Not Recommending the Service" shown above will not always equal a combined total of 100% as it does not include those who are undecided.The benchmarking data is extracted from the Department of Health's Unify Reporting Tool, and is currently shown a month in arrears.

Friends and Family Test - Outpatient Services (Recommended/Not Recommmended)

0.9

4%

0.4

7%

0.9

8%

1.0

3%

0.2

9%

1.1

8%

1.0

2%

0.9

3%

0.7

6%

1.1

6%

0.8

2%

0.8

2%

97.4

1%

97.5

5%

96.6

7%

96.4

1%

97.0

3%

96.2

9%

95.5

0%

97.1

1%

96.7

2%

96.1

0%

96.5

3%

96.3

6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Friends and Family Test - Monthly % Recommend / Not Recommend for Outpatients

FFT % Not Recommended (Outpatients) FFT % Recommended (Outpatients)

The level of recommendation within Outpatient services remains high at 96.36% and the Trust benchmarked at 3/13 regionally in November in relation to likelihood to recommend (an improvement from 5th the previous month). There were 7 patients unlikely to recommend and their concerns were across many services but revolved around waiting times across numerous clinics, the appointments system and cleanliness.

Across the hospital the main areas for concern remain (these three areas are regularly mentioned together on many responses received from patients):• Staff Attitude / Communication• Waiting time / environment• Staffing levels

Benchmarking - Outpatient Services




Org Code % Recommended% Not

Recommended

RGQ 97.39% 0.83%

RGM 96.64% 2.52%

RCX 96.53% 0.82%

RGR 96.42% 0.60%

RGP 96.37% 0.68%

RM1 96.16% 0.71%

RDE 96.09% 0.49%

RQW 95.66% 2.07%

RGN 94.22% 1.50%

RGT 93.63% 2.07%

RAJ 93.43% 2.48%

RDD 92.76% 3.23%

RQ8 89.62% 5.29%

Organisation Name (Ranked by % Recommended)




PAPWORTH HOSPITAL NHS FOUNDATION TRUST








SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST




It is pleasing to note that despite significant pressures on capacity this month there have been no breaches of the Mixed Sex Accommodation guidelines in the month of December. NHS England have informed trusts that compulsory reporting of breaches will continue during this period of heightened pressure within the NHS but the process of imposing fines will be suspended.

Number of Incidents of Mixed Sex Accommodation (MSA) - The number of times Mixed Sex Accommodation occurred within the specified time period.Number of Breaches of Mixed Sex Accommodation (MSA) - The total number of patients affected by Mixed Sex Accommodation occurrences within the specified time period.

Patient Experience - Mixed Sex Accommodation

Mixed Sex Accommodation Incidents


Definitions

0Incidents of Mixed Sex Accommodation aaaa

0No. of Patientsaffected aaaa

20Incidents of Mixed Sex Accommodation rrrr

41No. of Patients affected rrrr

Mixed Sex Accommodation Breaches

8

4

21

0

43

4

2 2

4

00

2

4

6

8


No. of Mixed Sex Accommodation Incidents

No. of Mixed sex Accommodation Incidents

18

9

42

0

9

68

4 4

8

00

4

8

12

16

20


No. of Mixed Sex Accommodation breaches

No. of Mixed Sex Accommodation Breaches





Analysis of Current Month and YTD

Number of Complaints received into the Trust (Clinical and Non-Clinical)

Complaints


Definitions

20Current Month

6Current Month

236YTDrrrr rrrr

rrrr

Non Clinical Complaints

30YTD

rrrr

Number of complaints received

During the month of December 2017, the Trust received 26 formal complaints. This is one fewer than last month and two fewer thanin December 2016 when the Trust received 28 complaints.

Complaints received by Specialty/Key Issues Table

During December 2017, Gynaecology had 3 complaints; Accident and Emergency, General Medical and General Surgery each had 2 complaints. The complaints regarding these areas involved the following issues:

• Staff attitude• Poor communication with patient/relatives • Clinical treatment • Delay/Failure to diagnosis and delay for appointments• Multiple ward moves

Lessons Learned

• To provide effective and appropriate communication to patients and their relatives to ensure they have a full understanding of their care and treatment plan.

• To ensure handover is concise and accurate to identify potential concerns that the receiving ward need to be aware of in relation to the patient's individual needs or concerns.

• To improve patient understanding of possible side effects from treatment and pain relief.

Other Information

• No complaints have been re-opened in December 2017. • 3 local resolution meetings were held in December 2017.• No complaints were referred to the Parliamentary and Health Service Ombudsman.• 52 Travel Expense claims were processed in December 2017.• 1 PALS survey was completed and the respondent found the PALS’ service to be extremely helpful.





Actions Taken & Lessons Learned





Response Rate - No. of complaints closed within 30 daysCompliments - No. of compliments received into the Trust PALS Contacts - No. of compliments received into the Trust

Definitions

Complaints Cont'd - Response Rates Key Points/Operational Actions

PALS Contacts (including Compliments)

Compliments

The Trust is required to investigate and share the response with the complainant within 30 working days. The compliance rate has increased from last month to 76%, but 6 breaches still occurred:

• Surgery 2 had 3 breaches out of 7 complaint responses that were due• Medicine 2 had 1 breach out of 6 complaint responses that were due• Medicine 1 had 1 breach in December out of 6 complaint responses that were due• Women & Children Services had 1 breach out of 4 complaint responses that were due

Currently there are 16 complaint investigations/responses that are overdue and have not yet been completed, these continue to be chased and escalated. Some overdue complaint responses have now been received from the Divisions and following Executive review and Chief Executive sign off they will be completed and closed.

163 compliments were received this month, which is a decrease from 172 compliments received last month and a decrease in comparison to December 2016, in which the Trust received 183 compliments.

The PALS service has had 326 contacts this month, compared to a figure of 391 in the previous month. This is a slight increase in comparison to December 2016, in which 321 contacts were recorded. The top subjects for this month are noted below:

General Information 51

Travel Expenses 17

Access to Health Records 14

Directions within the Trust 14

General Enquiries 13

Complaints Procedure 10

Discharge Arrangements 10

Loss of Personal Items 10

Sign Post to another NHS Trust 9

Department Details 8

Sign Post to another Organisation 8

Clinical Care 7

In-Patient Enquiry 7

Parking Fine 7

Poor Communication 7





01/10/2017 01/11/2017 01/12/2017 2016/17

Indicators Var to prev mth Target Oct Nov Dec FYTD

National standards 01/10/2017 01/11/2017 01/12/2017 2017/18

18 Wks - Adm (adjusted) Target18 Wks - Adm Perf (adjusted) 90.00% 72.97% 74.75% 81.72% 77.51%

18 Wks - Non Adm Target18 Wks - Non Adm Perf 95.00% 85.28% 83.34% 82.84% 86.73%

18 Wks - Incomp Target18 Wks - Incomp Perf 92.00% 86.49% 86.45% 81.32% 88.11%

Cancer-2ww TargetCancer-2ww 93.00% 95.93% 95.76% NA 96.55%

Cancer-2ww (Breast Symptomatic) TargetCancer-2ww (Breast Symptomatic) 93.00% 98.78% 100.00% NA 98.38%

31 Day Diag to Treat Target31 Day Diag to Treat 96.00% 100.00% 98.94% NA 98.71%

Cancer-62 Days RTT TargetCancer-62 Days RTT 85.00% 88.42% 83.33% NA 84.15%

Cancer-31 Days Sub Treat (Surg) TargetCancer - 31 Days Subsq Treatment - Surgery 94.00% 100.00% 100.00% NA 96.67%

Cancer-31 Days Sub Treat (Drug) TargetCancer - 31 Days Subsq - Drug Treatments 98.00% 100.00% 100.00% NA 99.77%

Cancer Screening (62 Day) TargetCancer Screening (62 Day) 90.00% 100.00% 100.00% NA 99.30%

A&E 4 Hr TargetA&E 4 Hour Performance 95.00% 93.82% 86.90% 80.98% 88.29%

Amb turnaround TargetAmbulance turnaround 100.00% 24.03% 23.39% 23.77% 24.37%

Stroke - 90% of Stay on SU TargetStroke - 90% of Stay on a Stroke Unit 80.00% 85.71% 98.18% NA 84.83%

TIA - HR TIA seen & treated <24hrs TargetTIA - High Risk,Non admitted TIA treated in 24 Hrs 60.00% 70.83% 64.29% NA 71.43%

Cancelled Ops - as a % of Elective Admissions TargetCancelled Ops - as a % of Elective Admissions 0.80% 0.79% 0.69% 1.25% 0.74%

Diagnostic Over 6 Week Waiters - % of Total WL TargetDiagnostic Over 6 Week Waiters - % of Total WL 1.00% 0.18% 0.27% 1.69% 0.48%

Indicators Var to prev mth Target Oct Nov Dec FYTD

Local standards

Day Case Rate TargetDay Case Rate 82.00% 84.55% 86.23% NA 85.90%

DNA Rate TargetDNA Rate 5.00% 6.40% 6.36% 6.95% 6.54%

New to FUP Ratio TargetNew to FUP Ratio 2.3 2.5 2.4 2.3 2.5

Readm Rate (EL) TargetReadmission Rate - ElReadmission Rate - Elective 3.00% 3.91% 3.33% NA 3.63%

Readm Rate (Em) TargetReadmission Rate - EmReadmission Rate - Emergency 10.00% 16.75% 17.52% NA 17.39%

EL LOS TargetLength of stay - Elective 2.2 1.6 1.6 1.5 1.6

EM LOS TargetLength of stay - Emergency 5.0 4.0 3.8 4.1 4.0

Cancer, Stroke, TIA, Day Case & Re-admissions Rates are all normally shown 1 month in arrears.

De

lay

fre

e

Performance & Standards Scorecard

Op

era

tio

na

l E

ffic

ien

cy





RTT Waiting Times – Admitted (90% Target <18 Wks.) RTT Waiting Times – Non-Admitted (95% Target <18 Wks). RTT Waiting Times - Incompletes (92%).

18 Weeks Referral To Treatment


Definitions

80

.03

%

76

.23

%

78

.26

%

79

.65

%

82

.90

%

75

.80

%

77

.81

%

78

.55

%

75

.39

%

72

.97

%

74

.75

%

81

.72

%

78.53%75.89%

77.84% 79.23%82.59%

75.50%77.22% 78.46%

74.98%72.21%

74.39%

81.42%

60%

65%

70%

75%

80%

85%

90%

95%

100%


18 Wks Admitted Performance

18 Wks - Adm Perf (adjusted) 18 Wks - Adm (adjusted) Target 18 Wks - Adm Perf (unadjusted)

90

.30

%

90

.94

%

90

.43

%

91

.96

%

92

.94

%

89

.32

%

88

.31

%

82

.29

%

83

.19

%

85

.28

%

83

.34

%

82

.84

%

80%

85%

90%

95%

100%


18 Wk Non- Admitted Performance

18 Wks - Non Adm Perf 18 Wks - Non Adm Target

92

.64

%

92

.77

%

92

.38

%

92

.01

%

92

.03

%

92

.03

%

88

.04

%

87

.74

%

87

.20

%

86

.49

%

86

.45

%

81

.32

%

80%

85%

90%

95%

100%


18 Wk Incompletes Performance

18 Wks - Incomp Perf 18 Wks - Incomp Target

81.32%Incompletes (Target 92%) rrrr





• Cancer 2WW Performance continues to meet the 93% standard and has remained stable throughout QTR3, with compliance being second highest in the region. Main reasons for breaches are lack of capacity, particularly in (Gynae, Lung, Urology) and patients choosing to wait longer than 14 days, for which no adjustment can be made. Aim for QTR4 is to maintain and improve 2WW performance which will improve 62 day pathways, main actions will be to undertake detailed capacity and demand analysis to ensure first appointments can be offered within 7 days of referral and to investigate internal and external methods of improving patient compliance with the pathway, e.g. reviewing information given to patients by GP’s when referring.

• Cancer 31 Day Performance (First and Subsequent Treatments) continues to be at or near 100% across all sites. Aim for ATR4 will be to maintain this position and continue to develop robust monitoring arrangements for patients on this pathway.

• Cancer 62 Day Performance has dipped in November at 83.5% against the 85% standard. There were 10 breaches in total, of which 4.5 contained largely avoidable delays (lack of OPA/diagnostic HDU capacity and process delays). 2 delays related to services provided by other hospitals (pathology and surgery). Significant focus has been applied to the 62 Day Cancer PTL with a view to reducing the number of patients waiting over 62 days from current figure of 32 to an ideal of 12, and by ensuring patients in the 43-62 day cohort have treatment dates within target. As backlog clearance occurs it is likely that December and January performance will be marginally below 85% with full recovery in February.

• Work continues on clinical pathways in Lung, Colorectal, Upper GI and Urology through both the QEH Macmillan Transformation Programme and the Norfolk & Waveney STP Cancer Programme. Adoption of best practice pathways

Percentage of cancer patients first seen within 2 weeks in the reporting month (1 month in arrears)Percentage of above Cancer Pathway completed within 31 Days in the reporting month (1 month in arrears)

Cancer Waiting Times


Definitions

90%

92%

94%

96%

98%

100%

Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov

2WW Performance

Cancer-2ww 2 WW Target

95.76%2ww (Target 93%)

aaaa

98.94%

31 Day (Target 96%)

aaaa

83.33%62 Day (Target 85%)

rrrr

90%

92%

94%

96%

98%

100%


31 Day Diag To Treat Performance

31 Day Diag to Treat 31 Day Target

60%

64%

68%

72%

76%

80%

84%

88%

92%

96%

100%


62 Day Ref To Treat Performance

Cancer-62 Days RTT 62 Day Target

100.00%31 Day Subs Treat - Surg (Target 94%) aaaa

100.00%31 Day Subs Treat - Drug (Target 98%) aaaa

100.00%2ww Breast Symptomatic (Target 93%) aaaa

100.00%62 Day Screening (Target 90%) aaaa

Site Level Breach Analysis - Latest Month





Cancer Waiting Times (Forecasting)





Sustainability Sustainability

Cancer Site(Target - 85%

Compliance)

Estimated

remainder to

achieve Forecast Snapshot position Trajectory Flag

Estimated

remainder to

achieve ForecastSnapshot

position Trajectory Flag ForecastSnapshot

position Trajectory ForecastSnapshot

position Trajectory

Total Treated 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Treated Within 62 Days 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

% Within 62 Days 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Estimated breaches allowed 0.0 0.0

Total Treated 11.00 11.00 6.00 7.00 7.00 4.00 8.00 2.00 11.00 11.00 0.00 11.00


% Within 62 Days 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% 100.0%


Total Treated 4.50 4.50 4.50 1.00 1.00 5.00 2.50 0.00 6.00 7.00 0.00 7.00


% Within 62 Days 55.6% 55.6% 66.7% Alert 0.0% 0.0% 80.0% Alert 60.0% 0.0% 58.3% 64.3% 0.0% 64.3%

Estimated breaches allowed -0.5 0.0

Total Treated 0.00 0.00 2.00 1.50 1.50 1.00 4.50 1.00 1.00 3.00 0.00 3.00


% Within 62 Days 0.0% 0.0% 50.0% 66.7% 66.7% 0.0% 22.2% 0.0% 0.0% 33.3% 0.0% 33.3%


Total Treated 0.50 0.50 2.00 2.50 1.50 2.00 1.50 0.00 2.00 3.50 0.00 3.50


% Within 62 Days 100.0% 100.0% 100.0% 40.0% 0.0% 50.0% Alert 0.0% 0.0% 50.0% 71.4% 0.0% 71.4%

Estimated breaches allowed 0.0 -0.5

Total Treated 5.00 5.00 8.00 6.50 6.50 6.00 5.50 0.00 6.00 7.00 0.00 7.00


% Within 62 Days 60.0% 60.0% 75.0% Alert 76.9% 76.9% 83.3% Alert 18.2% 0.0% 66.7% 71.4% 0.0% 71.4%


Total Treated 4.00 4.00 6.00 2.00 2.00 2.00 4.00 0.50 3.00 3.00 0.00 3.00


% Within 62 Days 50.0% 50.0% 83.3% Alert 100.0% 100.0% 75.0% 25.0% 100.0% 50.0% 66.7% 0.0% 66.7%


Total Treated 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.50 0.00 0.50


% Within 62 Days 0.0% 0.0% 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%


Total Treated 20.00 19.00 16.00 13.00 10.00 9.00 15.50 0.00 15.00 18.00 0.00 18.00

Treated Within 62 Days 19.00 18.00 15.00 Alert 12.00 9.00 9.00 15.00 0.00 15.00 18.00 0.00 18.00



Total Treated 4.00 4.00 4.00 6.00 6.00 3.00 3.00 1.00 3.50 3.50 0.00 3.50


% Within 62 Days 25.0% 25.0% 75.0% Alert 83.3% 83.3% 16.7% 100.0% 100.0% 85.7% 71.4% 0.0% 71.4%


Total Treated 12.50 12.50 20.00 26.00 26.00 15.00 18.00 3.00 16.00 18.00 0.00 18.00




Total Treated 0.00 0.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


% Within 62 Days 0.0% 0.0% 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%


Total Treated 60.50 60.50 71.50 65.50 61.50 47.00 62.50 7.50 63.50 74.50 0.00 74.50


% Within 62 Days 83.47% 83.47% 85.3%Alert 83.97% 82.93% 85.1%

Alert 72.80% 86.67% 85.0% 85.23% 0.00% 85.2%


Feb-18 TrajectoryJan-18

Trajectory

December

TrajectoryDec-17Nov-17

Trust Total

Lung

Sarcoma

Skin

Upper

Gastrointestinal

Urological

Other

Lower

Gastrointestinal

62 Day Referral to Treatment Cancer Pathway (Exc. screening and

upgrades) 3.1

Breast

November

Trajectory

Gynaecological

Haematological

Head & Neck

Brain/Central Nervous

System


Benchmarking data will only be updated once every quarter.

Cancer Waiting Times - 62 Day Breaches at 63-69 Days

Definitions

Cancer Waiting Times (Benchmarking)




70%

75%

80%

85%

90%

95%

100%

JPH QEH P&S CUH IP WS N&N

2WW Wait Perf for Qtr 2 across East of England

SEEN WITHIN 14 DAYS National Target

70%

75%

80%

85%

90%

95%

100%

WS PAP N&N JPH P&S QEH CUH IP

31 Day Perf for Qtr 2 across East of England

TREATED WITHIN 31 DAYS National Target

45%

55%

65%

75%

85%

95%

JPH PAP N&N QEH WS P&S CUH IP

62 Day RTT Perf for Qtr 2 across East of England

TREATED WITHIN 62 DAYS National Target


The chart above shows the variance in AE activity & performance levels, when compared to the previous month

Percentage of total A&E Attendances for the reporting month that are admitted or discharged within the 4 hour target.The latest benchmarking data is based on the monthly performance (2 months in arrears)

Accident and Emergency

Definitions

80.98%AE Performance - Prev Mth (Target 95%) rrrr

88.29%AE Performance - YTD (Target95%) rrrr

Previous Month's KPI's

Benchmarking across NHS England Midlands & East (East)


Activity & Performance levels of the last 3 months

AE performance (Last 12 month)

86.3

1%

90.4

9%

90.6

8%

91.3

1%

91.0

2%

83.6

4%

84.1

4%

89.8

0%

93.5

7%

93.8

2%

86.9

0%

80.9

8%

0%

20%

40%

60%

80%

100%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DecA&E 4 Hour Performance A&E 4 Hr Target

• Limited onward flow remains the biggest contributor to breaches• Bedded patients in the Department in the morning has also led to capacity issues within the Department which has caused delays for patients to be seen and treated• Average attendances continue to rise month on month in comparison to last year• Primary care streaming has commenced from the end of December supported by Winter project funding






Potential fines per case in

£90,000.00

£568,000.00

£256,600.00

£0.00

£0.000 - 15 Min

2017/18 YTD value of breaches

30 - 60 Min

15 - 30 Min

Over 2 Hr

1 - 2 Hr

Ambulance Handovers


Definitions

23.77%

% of handovers within 15 minutes

24.37%

% of handovers within 15 minutes rrrrrrrr

The percentage of the total Ambulance handovers within the reporting month where the handover was less than 15 minutes in duration.

• Although handover of patients under 15 minutes remains below anticipated levels it should be noted that 87% of handovers occur within 30 minutes of arrival• Work continues collaboratively with EEAST to stream line processes at the front door• It has not been possible to source additional resources even though these have been funded via winter monies• Handover remains compromised at times due to reduced flow through the organisation• PSIT team from EEAST have supported co-horting of patients during times of extreme pressure within the Department

0

200

400

600

800

1000

1200

1400

1600

1800


Nu

mb

er

of

Pa

tie

nts

Monthly Ambulance Handover Times

0 - 15 Minutes 15 - 30 Minutes 30 - 1 Hour 1 - 2 Hours 2 Hr+

3585

9184

1283

568

90

2017/18 YTD Ambulance Handover times

0 - 15 Minutes 15 - 30 Minutes 30 - 1 Hour 1 - 2 Hours 2 Hours +

0%

10%

20%

30%

40%

50%

60%

70%

80%


Nu

mb

er

of

Pa

tie

nts

Handovers within 0-15 mins & 15-30 mins - rolling 12 Months

0 - 15 Minutes 15-30 Min





Recently all the stroke indicators are improving including scan within 1 hour; 90% stay on the stroke unit and the direct admission to the stroke unit. Challenging diagnosis and overall patient flow pressure did impact on overall improvement and we are positive that the current improvement will be sustained. The one risk we are carrying at the moment is replacement of a senior nursing clinician(matron).

Sentinel Stroke National Audit Programme (SSNAP) is the single source of data for stroke in England and Wales. It provides the data for all other statutory data collections in England including the NICE Quality Standard and Accelerating Stroke Improvement (ASI) metrics and is the chosen method for collection of stroke measures in the NHS Outcomes Framework and the CCG Outcomes Indicator Set. SSNAP metrics are aligned with those in the Cardiovascular Disease Outcomes Strategy. SSNAP data are being used as risk indicators for Care Quality Commission’s Intelligent Monitoring and for the Stroke Care in England NHS Marker.Key Indicators:Percentage of Stroke patients that spend 90% of their hospital stay on the stroke unit (latest available data)Percentage of Stroke patients directly admitted to a stroke unit within 4 hours of clock start (latest available data)Percentage of Stroke patients scanned within 1 hour of clock start (latest available data)Percentage of Stroke patients scanned within 12 hours of clock start (latest available data)

Stroke Performance


Definitions

Key Indicator : Direct to Stroke Unit within 4 hours Key Indicator : Patient scanned within 1 hour of clock start Key Indicator : Patient scanned within 12 hours of clock start




90.00%

85.00%

80.00%

75.00%

<75.00%

YTD 2017/2018SSNAP Target Levels

98.18%

Monthly Performance %

E

D

Nov-17

A

B

CSSNAP Level

YTD Performance %

A C

YTD SSNAP Level

84.83%


The current RCP SSNAP still requires us to categorise TIA patients as High and Low risk where we have been achieving the target consistently for more than 6 months especially for high risk group who are at risk of impending stroke. However, a recent national guidelines suggests we see all the TIA within 24 hrs for which will need education and awareness to patients, primary and secondary care clinicians. There are no agreed criteria or incremental target linked to the new guidance as of yet.

Percentage of High Risk TIA's that are not admitted, seen and treated within 24 hours (latest available data) Percentage of High Risk TIA's that are seen and treated within 24 hours (latest available data) Percentage of Low Risk TIA's that are seen and treated within 7 days of 1st contact with a healthcare professional (latest available data) Percentage of Low Risk TIA's that are seen and treated within 7 days of onset of symptoms (latest available data)

Transient Ischaemic Attack (TIA) Performance


Definitions





The Trust was unable to achieve the 1% performance target for December 2017. Of the 56 breaches, 44 were in Radiology. These breaches were a result of capacity issues and staff shortages.

Denominator :The number of patients waiting for a diagnostic test at the end of the reporting periodNumerator: The number of patients waiting 6 weeks or more for a diagnostic test at the end of the reporting period

Diagnostic Waiting Times (% of Pat's Waiting >6 Wks)


Definitions

1.69%(Target 1%)

rrrr





Latest Month's Performance

New to review: Ratio of total follow-up attendances against the total number of new patient attendances for the reporting month

New to Follow up Ratio

Definitions

2.8 2.7 2.8 2.6 2.6 2.5 2.4 2.7 2.5 2.5 2.4 2.3

0.0

2.0

4.0


New to Follow Up ratio against local target

New to FUP Ratio target

2.3

Trust Level New to Review Rate

(Target 2.3) rrrr






Top 10 Specialties with most "Appointment Slot Issues" over last 4 weeks

ASI are appointment slot issues. ASI's occur in e-Referral (Choose & Book) because we have an insufficient number of clinic slots available within a 'polling range' for a specialty.

ASI's (Appointment Slot Issues)

Definitions





21/12 28/12 04/01 11/01

CAR 531 526 505 488

NEU 434 420 406 405

URO 417 413 394 398

ORT 395 387 370 363

DER 405 411 404 280

ENT 243 225 200 200

RES 201 193 191 194

RHE 142 137 133 140

END 130 136 128 130

PC 130 123 115 112

OPH 161 143 116 102

PAE 163 174 138 93

NEP 53 60 61 57

UGI 73 52 50 48

GER 19 21 20 23

2WW 2 0 0 6

GYN 17 16 10 3

SUR 1 1 1 1

ORS 0 0 0 0

BSU 0 0 0 0

VAS 1 0 0 0

ASI's Last 4 Weeks



DNA Rate: Total No. of New & Follow Up appointments where the outcome was "DNA" (Did Not Attend), as a proportion of the Total No. of "Attended" and DNA'd appointmentsThe DNA figures above exclude Ward Attender activity, and is based on "Clinic" Specialty, rather than "Referral" Specialty.

DNA rate

Definitions

6.50% 6.31% 6.05% 6.20% 6.50% 6.84% 6.57% 6.65% 6.47% 6.40% 6.36%6.95%

0.0%

2.0%

4.0%

6.0%

8.0%


DNA (Did not attend appointments) rate against local target

DNA Rate DNA Rate Target

6.95%DNA rate (Target 5.0) rrrr






Latest Month's Performance Previous Month's Re-admission Rate

Re-admissions is currently reported 1 month in arrears

Elective Average LOS - The average spell length of stay for Elective Admissions discharged within the reporting month.

Elective Re-admissions - The % of patients readmitted within 30 days of an Elective admission during the current financial year.

Elective Inpatient - Average Length of Stay & Re-admissions

2.21.8

1.51.8 1.7

2.11.5 1.4 1.6 1.6 1.6 1.5

0.0%

2.0%

4.0%

6.0%

0.0

0.5

1.0

1.5

2.0

2.5


Trust Level - Average LOS - Elective

Length of stay - Elective target Readmission Rate - El

1.5

Average LOS

Elective Admission (Target 2.2) aaaa

3.33%

Re-adm following Elective

Admission (Target 3%) rrrr

Definitions

4.3

1%

4.3

2%

5.1

9%

4.1

7%

3.5

4%

4.1

8%

4.1

5%

3.8

8%

3.2

4%

2.7

3%

3.9

1%

3.3

3%

0%

1%

2%

3%

4%

5%

6%


Trust Level - Elective Re-admission Rate Performance Against Target

Readmission Rate - El Readm Rate (EL) Target






Latest Month's Performance Previous Month's Re-admission Rate

Re-admissions is currently reported 1 month in arrears

Emergency Average LOS - The average spell length of stay for Emergency Admissions discharged within the reporting month. Emergency Re-admissions - The % of patients readmitted within 30 days of an Emergency admission during the current financial year. This is currently reporting 1 month in arrears.

Emergency Admissions - Average Length of Stay & Re-admissions

3.7 3.7 3.6 3.9 3.7 3.9 4.0 4.3 4.3 4.0 3.8 4.1

0.0%

5.0%

10.0%

15.0%

20.0%

0.0

2.0

4.0

6.0


Trust Level - Average LOS - Emergency

Length of stay - Emergency target Readmission Rate - Em

4.1

Average LOS Emergency Admission (Target 5.0) aaaa

17.52%

Re-adm following Emergency Admission (Target 10%) rrrr

Definitions

15

.40

%

15

.98

%

15

.53

%

15

.78

%

18

.68

%

17

.57

%

17

.57

%

17

.31

%

17

.81

%

15

.90

%

16

.75

%

17

.52

%

0%

5%

10%

15%

20%


Trust Level - Emergency Re-admission Rate Performance Against Target

Readmission Rate - Em Readm Rate (Em) Target






Elective Re-admissions Rates by Specialty

Definitions

Elective Re-admissions - The % of patients per specialty readmitted within 30 days of an Elective admission during the current financial year. Based on the specialty at discharge.Emergency Re-admissions - The % of patients per specialty readmitted within 30 days of an Emergency admission during the current financial year. Based on the specialty at discharge.

Emergency Re-admissions Rates by Specialty





CQUINs




CQUIN No. Q1 STATUS Q1 VALUE Q2 STATUS Q2 VALUE Q3 STATUS Q3 VALUE Q4 STATUS Q4 VALUE

1a Heallthy Foods - more healthy options /

reduced sugar content etc

£115,892.00

1b Staff Survey - 5% improvement on 2 out of the 3

questions relating to H&W

£115,753.00

1c Flu uptake (front line clinical staff) £115,753.00

2a Sepsis -timely Identification £21,712.50 £21,712.50 £21,712.50 £21,712.50

2b Sepsis - timely treatment £21,712.50 £10,856.25 £21,712.50 £21,712.50

2c Empiric Review of antibiotic prescriptions

(72hrs)£21,712.50 £21,712.50 £21,712.50 £21,712.50

2d Reduction in Antibiotic Consumption per 1,000

admissions£86,850.00

4 Improving services for

people presenting

with Mental Health

needs in A&E

Frequent Attenders (more than 10 occurrences

in 16/17) - identify cohort of patients who

would benefit from mental health &

psychology interventions AC

HIE

VED

10

0%

£34,739.80

AC

HIE

VED

10

0%

£138,959.20 £34,739.80 £138,959.20

6 Offering Advice &

Guidance

Improvement of A&E for Rhuematology &

Neurology / Implement Quality standard /

propose additional services in Q4 to take

forward next year AC

HIE

VED

10

0%

£86,849.50

AC

HIE

VED

10

0%

£86,849.50 £86,849.50 £86,849.50

7 NHS e-Referral 1. NHS e-Referrals (All providers to publish ALL

such services and make ALL of their First O/P

Appointments slots available on NHS e-referral

services (e-RS) by 31st March 2018 following the

trajectory

2. a trajectory to reduce Appointment Slot

Issues to a level of 4%, or less, over Q2, Q3 and

Q4A

CH

IEV

ED

10

0%

£86,849.50

AC

HIE

VED

10

0%

£86,849.50 £86,849.50 £86,849.50

8 Supporting Proative

and Safe Discharge

2.5% point increase discharge to usual place of

residence: across Q3 and Q4 2017/18 OR an

increase to 47.5% across Q3 and 4 2017/18

AC

HIE

VED

10

0%

£52,109.70

AC

HIE

VED

10

0%

£138,959.20 £17,369.90 £138,959.20

1 Medicines

Optimisation

The CQUIN aims to support the procedural and

cultural changes required fully to optimise use

of medicines commissioned by specialised

services. AC

HIE

VED

10

0%

£31,560.00

AC

HIE

VED

10

0%

£13,525.00 £22,542.00 £40,577.00

2 Dental Dashboard Provider is required to submit a fully populated

Dental Quality Dashboard as per the embedded

format (see actual CQUIN) in respect of the

dental specialties they provide AC

HIE

VED

10

0%

£11,089.75

AC

HIE

VED

10

0%

£11,089.75 £11,089.75 £11,089.75

3 Breast Screening Breast Cancer Screening Interval Cancer

Network for Norfolk and Waveney

AC

HIE

VED

10

0%

£3,201.00

AC

HIE

VED

10

0%

£3,201.00 £3,201.00 £3,201.00

4 Armed Forces Embedding the Armed Forces Covenant to

support improved health outcomes for the

Armed Forces Community

AC

HIE

VED

10

0%

£6,301.50 TBC £6,301.50 £12,603.00

Update only no Financial

value

NHSE SPECIALIST CONTRACT

CQUIN Description

H&W

SEPSIS

N/A

N/A

AC

HIE

VED

10

0%

ACUTE CONTRACT

PA

RTIA

LLY

AC

HIE

VED

83

.25

%


Indicators Var to prev mth Target Oct Nov DecRolling

12 mths

Staff Sickness & Turnover 01/10/2017 01/11/2017 01/12/2017

Sickness Absence Rate (Target)Sickness Absence Rate 3.50% 5.36% 5.26% 5.81% 4.98%

Staff Turnover Rate Complete Trust (Target)Staff Turnover Rate Complete Trust 10.00% 11.66% 11.64% 11.76% 11.39%

Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) (Target)Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) 10.00% 8.75% 8.72% 10.37% 9.54%

Staff Turnover Rate Registered Nursing & Midwifery (Target)Staff Turnover Rate Registered Nursing & Midwifery 10.00% 14.82% 14.37% 13.27% 14.06%

Staff Turnover Rate Allied Health Professionals (Target)Staff Turnover Rate Allied Health Professionals 10.00% 15.38% 16.77% 16.20% 18.17%

Appraisals

Appraisal Completeness excluding bank staff (Target)Appraisal Completeness excluding bank staff 90.00% 83.07% 85.31% 83.90% 84.39%

Vacancies

Medical & Dental Vacancies (as % of Medical Posts) (Target)Medical & Dental Vacancies (as % of Medical Posts) 5.00% 21.33% 20.97% 21.13% 20.21%

Registered Nurses & Midwives Vacancies (as % of Nurse Posts) (Target)Registered Nurses & Midwives Vacancies (as % of Nurse Posts) 6.00% 13.05% 12.40% 12.84% 12.66%

Allied Health Professional Vacancies (as % of AHP Posts) (Target)Allied Health Professional Vacancies (as % of AHP Posts) 6.00% 4.86% 7.85% 7.98% 9.85%

Contracted staff in Post (WTE) 2778 2790 2790 2772

Temporary Staff in Post (WTE) 337 209 206 298

Mandatory Training

Conflict Resolution Training (Target)Conflict Resolution Training 95.00% 84.20% 84.38% 83.42% 83.40%

Equality and Diversity Training (Target)Equality and Diversity Training 95.00% 75.41% 77.65% 78.85% 74.02%

Fire Training (Target)Fire Training 95.00% 72.02% 75.42% 75.44% 75.94%

Health & Safety Training (Target)Health & Safety Training 95.00% 89.58% 90.46% 89.05% 91.10%

Infection Control Training (Target)Infection Control Training 95.00% 75.32% 78.03% 78.79% 78.80%

Information Governance Training (Target)Information Governance Training 95.00% 84.46% 82.49% 83.24% 87.59%

Manual Handling Training (Target)Manual Handling Training 95.00% 82.26% 82.90% 81.85% 83.33%

Basic Life Support Training (Target)Basic Life Support Training 95.00% 77.08% 77.16% 79.83% 81.42%

Risk Management Training (Target)Risk Management Training (Level 2 only) 90.00% 72.40% 72.90% 94.77% 89.23%

Safeguarding Adults Training (Target)Safeguarding Adults Training 95.00% 91.78% 91.45% 92.83% 93.45%

Safeguarding Children Training (Target)Safeguarding Children Training 95.00% 90.05% 91.07% 91.22% 91.36%

Slips, Trips & Falls Training (Target)Slips, Trips & Falls Training 90.00% 86.81% 88.25% 86.41% 91.91%

VTE Training (Target)VTE Training 90.00% 72.17% 73.01% 71.99% 77.88%

Mandatory Training Overall (10 core subjects) (Target)Mandatory Training Overall (10 core subjects) 95.00% 82.04% 83.10% 83.45% 84.03%

The percentage figure shown for Risk Management Training currently represents Level 2 only (Level 2 - Heads of Departments)

Wo

rkfo

rce

Workforce Scorecard





Safer Staffing Return


Throughout the data monitoring period, wards with an overall rota fill of < 90%, or where the trained nursing rota was <90%, have been reviewed by the Associate Chief Nurses for each area.

The overall RN/RM fill rate for day shifts was 88.4%

Analysis of our night time planned versus actual RN/RM fill was 94%

All wards achieved an overall rate of >80% except Necton Ward (77.8%) & Marham (74.2%) in December.

Eleven wards did not achieve 90% - West Newton, Necton, Tilney, Shouldham, MAU, Ed Obs Ward, Marham, Elm, Gayton, Critical Care & SAU.




Specialty 1 Specialty 2

West Newton 430 - GERIATRIC MEDICINE 85.4% 110.1% 92.5% 141.1% 736 3.2 6.0 9.1

Necton 340 - RESPIRATORY MEDICINE 77.8% 102.4% 94.6% 96.4% 977 2.9 2.7 5.6

Windsor 430 - GERIATRIC MEDICINE 90.8% 94.9% 100.0% 112.2% 1005 2.7 3.0 5.7

Stanhoe 301 - GASTROENTEROLOGY 350 - INFECTIOUS DISEASES 91.8% 103.6% 98.4% 119.9% 999 3.2 3.3 6.5

Tilney 320 - CARDIOLOGY 88.3% 90.9% 94.6% 99.9% 821 2.9 2.2 5.1

West Raynham 300 - GENERAL MEDICINE 92.1% 88.4% 88.4% 84.4% 824 4.0 3.0 7.0

Denver 100 - GENERAL SURGERY 94.2% 100.5% 95.3% 120.5% 826 3.0 2.9 5.9

Marham 100 - GENERAL SURGERY 74.2% 76.6% 79.7% 84.8% 561 3.9 2.6 6.5

Elm 100 - GENERAL SURGERY 86.7% 96.6% 91.9% 92.8% 586 2.8 2.8 5.6

Gayton 110 - TRAUMA & ORTHOPAEDICS 100 - GENERAL SURGERY 85.7% 93.7% 94.7% 99.9% 845 3.0 3.4 6.4

Shouldham 315 - PALLIATIVE MEDICINE 823 - HAEMATOLOGY 85.2% 97.8% 100.9% 86.6% 364 4.7 2.7 7.4

Critical Care 192 - CRITICAL CARE MEDICINE 84.1% 85.0% 85.3% 265 25.8 1.5 27.3

Central Delivery suite 501 - OBSTETRICS 91.6% 91.9% 97.0% 82.1% 103 40.9 12.6 53.5

Surgical Assessment Unit 100 - GENERAL SURGERY 83.9% 119.7% 73.9% 106.2% 224 8.2 3.9 12.1

Medical Assessment Unit 300 - GENERAL MEDICINE 83.9% 110.9% 105.1% 108.7% 668 5.3 2.4 7.7

Terrington 300 - GENERAL MEDICINE 93.9% 108.5% 84.5% 92.1% 1006 3.0 2.1 5.1

Castleacre 501 - OBSTETRICS 97.0% 93.6% 98.4% 90.9% 337 5.4 4.1 9.5

NICU 420 - PAEDIATRICS 95.1% 87.4% 121.2% 91.8% 286 10.4 3.6 14.0

Rudham 420 - PAEDIATRICS 90.2% 61.6% 102.1% 101.5% 409 8.0 2.3 10.3

ED Obs Ward 180 - ACCIDENT & EMERGENCY 86.0% - 81.1% - 63 9.5 0.1 9.6

Oxborough 300 - GENERAL MEDICINE 92.3% 104.7% 97.1% 94.7% 1005 2.5 2.6 5.1

Overall

Day

Ward name

Main 2 Specialties on each ward

Average

fill rate -

registered

nurses/mid

wives (%)

Average

fill rate -

care staff

(%)

Dec-17

Average

fill rate -

registered

nurses/mid

wives (%)

Night Care Hours Per Patient Day (CHPPD)

Average

fill rate -

care staff

(%)

Cumulative

count over

the month

of patients

at 23:59

each day

Registered

midwives/

nurses

Care Staff


Number of leavers (HC) divided by average staff in post over previous 12 months. Permanent staff only.

Supernumerary staff are included within the Nursing & Midwifery vacancy rates calculation, providing the staff are NMC registered at the time.

Nursing staff


Definitions

Vacancies

The number of registered nursing vacancies increased to 12.84% from 12.4% in November 2017, as have Medical & Dental vacancies to 21.13% from 20.97% and AHP vacancies 7.98% from 7.85%.

Turnover

The turnover rate for the Trust has increased very slightly this month to 11.76% from 11.64% in November 2017.

780

800

820

840All Registered Nursing Staff in Post : Rolling year

All registered Nursing Staff in post: Rolling yearLinear (All registered Nursing Staff in post: Rolling year)

330

340

350

360

370

380Elective/Emergency based Registered Nursing Staff in Post: Rolling year

Elective/Emergency based Registered Nursing Staff in post: Rolling YearLinear (Elective/Emergency based Registered Nursing Staff in post: Rolling Year)

400

420

440

460All Unregistered Nursing Staff in Post : Rolling year

All Unregistered Nursing Staff in Post : Rolling yearLinear (All Unregistered Nursing Staff in Post : Rolling year)

100

150

200

250

300 Elective/Emergency based on Unregistered Nursing Staff in Post: Rolling year

Elective/Emergency based on Unregistered Nursing Staff in Post: Rolling yearLinear (Elective/Emergency based on Unregistered Nursing Staff in Post: Rolling year)






Overdue by 18-24 months14 Permanent, 1 Fixed Term Contract, 5 Bank staff

• Scientific & Technical x 2• Additional Clinical Services x 5• Admin & Clerical x 4• Allied Health Professionals x 3• Estates & Ancillary x 1• Healthcare Scientists x 1• Nursing & Midwifery x 4

Percentage of staff ( Headcount ) including bank who have had an appraisal within previous 12 months.Percentage of staff ( Headcount ) excluding bank who have had an appraisal within previous 12 months.

Appraisal


Definitions

83.90%Appraisal Compliance Exc Bank Staff (Target 90%) rrrr

86.4

5%

86.8

5%

83.7

8%

83.8

7%

84.4

6%

84.2

3%

85.3

1%

82.9

0%

82.2

6%

83.0

7%

85.3

1%

83.9

0%

60.0%

70.0%

80.0%

90.0%

100.0%


Appraisal Compliance Rates (exc Bank Staff)

Actual (excluding bank staff) Target (excluding bank staff) Prev Year

Excluding bank staff, the non-Medical appraisal completion compliance has decreased to 83.90% (83.13% including bank staff) in December 2017. The number of seriously overdue appraisals has increased again this month:

Overdue by 24 months +




85.4

1%

86.2

4%

83.3

1%

83.2

3%

83.4

7%

83.3

9%

83.5

6%

81.1

8%

81.1

0%

81.9

1%

84.4

1%

83.1

3%

60.0%

70.0%

80.0%

90.0%

100.0%


Appraisal Compliance Rates (inc Bank Staff)

Actual (including bank staff) Target (including bank staff)


The monthly sickness rate for December 2017 is 5.81% which is an increase of 0.55% from last month’s adjusted figure (5.26%).

The highest staff groups are:

• Estates and Ancillary (9.08%)• Additional Clinical Services (8.59%)• Scientific & Technical (7.27%)• Nursing & Midwifery (5.23%)

All other staff groups were below 5%.

Percentage sickness absence for the month. Based on FTE days absent divided by FTE days available.

Sickness Absence & Turnover


Definitions

5.81%Sickness Absence Rate

rrrr

0.0%

2.0%

4.0%

6.0%

8.0%QEH sickness absence compared with complete NHS ("Complete NHS" data is currently 3 months in arrears)

QEH

SmallacuteNHS

TargetQEH





The percentage figure shown for Risk Management Training currently represents Level 2 only (Level 2 - Heads of Departments)

Mandatory Training


Definitions

83.45%Mandatory Training (Trust) rrrr

Compliance rate for the 10 core subjects has increased slightly to 83.45% from 83.10% in November 2017.




Dec-17Mthly

Target

Rolling

12 Mths

Conflict Resolution Training 83.42% 95.00% 83.40%

Equality and Diversity Training 78.85% 95.00% 74.02%

Fire Training 75.44% 95.00% 75.94%

Health & Safety Training 89.05% 95.00% 91.10%

Infection Control Training 78.79% 95.00% 78.80%

Information Governance Training 83.24% 95.00% 87.59%

Manual Handling Training 81.85% 95.00% 83.33%

Basic Life Support Training 79.83% 95.00% 81.42%

Risk Management Training (level 2 only) 94.77% 90.00% 89.23%

Safeguarding Adults Training 92.83% 95.00% 93.45%

Safeguarding Children Training 91.22% 95.00% 91.36%

Slips, Trips & Falls Training 86.41% 90.00% 91.91%

VTE Training 71.99% 90.00% 77.88%

Mandatory Training Overall (10 core subjects) 83.45% 95.00% 84.03%


Finance report to follow seperately

Finance





None

Appendices





board report template report201801.pdf · 2018. 1. 26. · page55 page 56 context for the...

Documents