clinical operations and key quality indicators performance ... · 26.11.2013 · clinical...

Clinical Operations & Key Quality Indicators Performance Report – October 2013 Northern Devon Healthcare NHS Trust Trust Board 26 November 2013 Incorporating community services in Exeter, Mid and East Devon

Performance Team of 58

Report to Trust Board Date Tuesday 26 November 2013 Agenda Number 2.3

Agenda Item Clinical Operations and Key Quality Indicators Performance Report –

October 2013

Sponsor Kate Lyons, Director of Operations

Carolyn Mills, Director of Nursing

Maureen Bignell, Director of Personnel and Development

Prepared by Performance Team

Presented by Kate Lyons, Director of Operations

EXECUTIVE SUMMARY

1 Purpose and Key Issues The purpose of this paper is to present a summary of Trust achievement against Key Performance and Workforce Indicators and to brief the Trust Board on operational performance and workforce issues from the Clinical Directorates. Key issues include:

C.difficile now at 8 cases to date this year against a yearly limit of 10. Appropriate antibiotics were given in all cases and Significant Event Audits have been completed (6) or are in progress (2). Of the 6 Significant Event Audits completed, 2 cases were acquired at North Devon District Hospital, 4 others were acquired in the community prior to admission. (Page 7 and 10)

Cancer 62 day referral from screening service – 50% of patients (1/2) were treated within 62 days. Patient choice applies for the patient who did not meet the standard. (Page 7)

Breast symptomatic 2 week waits – standard not achieved for third consecutive month. Surgical and diagnostic capacity is under review to ensure the Trust is able to meet future demand. (Page 7)

One MRSA recorded for Acute in September against a yearly limit of 0. A Significant Event Audit is in progress. (Page 10)

Dr Foster data has been updated and rebased as from September 2013. (Page 11)

There were no Mixed Sex Accommodation sleeping breaches in October as the acute bed capacity was able to match the gender mix of admitted patients. (Page 13)

Stroke 90% Acute – Nine breaches in October. An early view of November data shows high levels of activity for the month (25 stroke admissions in 2 weeks compared to a monthly average of 27). The changes made to the service in sending referrals directly to the unit, and installing the South Western Ambulance NHS Foundation Trust alert system on the Acute Stroke Unit will support shortening the patient’s pathway on admission. Four additional stroke beds will also come on line at the end of November, and a further meeting is planned with the stroke team to review other improvements which can be made to the stroke pathway. (Page 15)



Ambulance Handovers – 30 minute position improved in October with A&E reconfiguration, and continual monitoring and validation of handover data. (Page 16)

A&E 4 Hour Standard – not achieved in October for Type 1 attendances by 9 breaches. The combined A&E performance for all types continues strongly and has been listed at the 6th best in the country between July and September 2013. (Page 17)

1 patient waited longer than 52 weeks for treatment in October. The delay was due to miscommunication regarding diagnostic tests. A Significant Event Audit is in progress, and the patient was successfully treated in early November. (Page 18)

Friends and Family Test performance for North Devon District Hospital Acute Inpatients for October 2013 is a Friends and Family Test score of +80 (against a Trust target of +60). Community Hospitals score is +72 and Maternity is +78. (Pages 37-41)

Overall training compliance has reached a record high with all categories showing some improvement this month. (Page 57)

Appraisal rates remain at a comparative high of 71.7%, but further improvement is needed in order to achieve the 80% financial year-end target. (Page 56)

The annual sickness absence rate shows little change and remains well above target at 4.06%. Long-term sickness accounts for two-thirds of all days lost. (Page 52)

2 Supporting Information

The report is attached.

3 Controls and Assurance

The Clinical Operations Performance and Workforce Report is presented to the Executive Team prior to Trust Board. The Workforce Monitoring section of the report is also presented to the Strategic Workforce Development Committee. The items within this report are the subject of scrutiny through internal performance management and governance systems. Many indicators are also subject to external monitoring by the Department of Health, Southern Strategic Health Authority, or commissioning Clinical Commissioning Groups.

4 Legal Implications The legal implications have been considered and none have been identified.

5 Equality and Diversity Implications

The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. No adverse or positive impacts have been identified from this report.

6 Patient, Public and Staff Involvement The Trust ensures that patients, the public and staff are involved in the decision-making process when appropriate.



7 Cost Implications There are no direct cost implications from this report, although adverse performance may give rise to contractual penalties.

8 Potential Risk to the Organisation

This report aims to reduce the risk of non-achievement against NHS national and locally agreed key performance standards, and workforce standards, by clearly showing the current performance position and highlighting any areas of specific concern. Non-compliance with key standards is likely to result in additional external scrutiny, eg from Commissioners or via Care Quality Commission challenge or inspections. Significant or prolonged non-compliance with key standards may give rise to adverse publicity.

9 Committee Prompts

Does the Board require any additional information or assurance?

10 Recommendations

The Trust Board is asked to RECEIVE this report.

11 References Not applicable.

12 Strategic Objectives

The Trust’s Strategic Objectives were reviewed by the Board in February 2012.

X Highest quality Flexible and multiskilled workforce

Sustainable services X Efficient and effective

Integrated health and social care Local provider of choice

13 Principal Risks

The Trust’s Principal Risks have been identified through the Trust’s risk management processes. They are updated as they are identified by the Risk Management Committee.

X Financial planning & management

Clinical records management

Strategic & business planning X Leadership & management

Workforce numbers Unsafe behaviour

Workforce skills X External demands

Procedural management Partnership arrangements

Equipment & facilities arrangements

Communication



Clinical Operations and Workforce

Trust Board Briefing Paper

Month 7 October 2013

Prepared: 19 November 2013 Updated: 20 November 2013



CONTENTS PAGE CONTENTS PAGE

Performance: Workforce:

Monitor Governance Risk Assessment Indicators

Third Parties Assessment

Summary Dashboards

7

9

Summary 48

Patient Safety 10 Workforce Analysis 49

Quality of Services 13 Percentage of Budgeted WTE Used 49

Patient Experience 18 Percentage of Pay Budget Used 50

Maternity 19 Workforce Reduction Plan 51

Operational Effectiveness 20 Sickness Absence 52

Contracted Activity Summary 21 Sickness Benchmarking 53

Standardised Mortality Ratio Trend 23 Staff Turnover 55

Maternity Indicator Trends 25 Appraisal Completion 56

CQUINs

Patient Complaints, Comments and Satisfaction Scores

26

30

Statutory and Mandatory Training Completion

57

Patient Experience Report

Research and Development

TDA Quality Dashboard

Performance Glossary

33

42

43

47

Workforce Glossary 59

Key to Performance Traffic Lights

Traffic Light Key Performance

Red

Worse than plan

Amber

Almost on plan

Green

As plan or better

Key to Direction of Travel

Key

Variation between actual performance and planned performance indicates an improvement since last month

Variation between actual performance and planned performance has remained constant since last month

Variation between actual performance and planned performance indicates a deterioration since last month


6

Trust Board – Monitor Governance Risk Assessment (shadow monitoring 2013/14)

Last Full Year Last 4 Quarters Current Quarter

Key Indicators QuarterTarget

Weighting Data Qual-ity

2012/13 Q3

2012/13 Q4

2012/13 Q1

2013/14 Q2

2013/14 October 2013 November 2013 December 2013 FOT

FOT Value

Score Commentary

Status Status Status Status Status Status Value Status Value Status Value

Safety

C.Difficile: NDDH (Annual threshold 10)

3 1.0 8 8 0

Annual Limit = 10. See below.

Quality

Cancer 31 day subsequent treatment surgery

94% 1.0 100% >94 0

Cancer 31 day subsequent treatment drug

98% 1.0 100% >98 0

Cancer 62 day referral from urgent GP

85% 1.0 87.5% >85 0

October shared breach data not yet available.

Cancer 62 day referral from screening

90% 0.5 50% >90 0.5 See below.

Cancer 62 day cons upgrade

90% 0.5 100% >90 0

Cancer 31 day Diagnosis to Treatment

96% 0.5 100% >96 0

Cancer 2 week waits from referral to date seen All cancers

93% 0.5 94.7% >93 0

Cancer 2 week waits from referral to date seen Breast symptomatic

93% 0.5 85.7% >93 0.5 See below.


7


Key Indicators QuarterTarget

Weighting Data Qual-ity

2012/13 Q3

2012/13 Q4

2012/13 Q1

2013/14 Q2

2013/14 October 2013 November 2013 December 2013 FOT

FOT Value

Score Commentary


Quality

A&E, MIU & WIC Combined Max Wait 4 hours

95% 1 98.7% >95 0

National performance reporting is at provider combined level

Patient Experience

RTT Admitted % <18wks TOTAL

90% 1 95.1% >94 0

Fail in one month = Quarterly Fail. Each indicator scores 1.0 but max impact is capped at 2.0. (Latest month may be early view data)

RTT Non-Admitted % <18wks TOTAL

95% 1 99.6% >98 0

RTT Incomplete % <18wks TOTAL

92% 1 98.5% >95 0

Access for people with learning disability – 6 criteria

Yes all 0.5 0

Effectiveness

Data Completeness Referral to Treatment

50% 1.0 NA

80 80 0 Refers to data completeness levels for community services (CIDS). Each indicator scores 1.0 but max impact capped at 1.0. Failure of same measure for 3 quarters = Red-rating.

Data Completeness Referral Information

50% 1.0 NA

90 80 0

Data Completeness Treatment Activity Info

50% 1.0 NA

90 80 0

KPI Risk Score 1.0

C difficile – 2 further cases recorded in October for the Acute setting. All cases of C difficile are investigated as SIRIs and a root cause analysis is completed.

Cancer 62 day referral from screening - Only 2 patients this month for this category (both bowel screening patients). One patient breached (took 86 days) because they chose to delay their diagnostic endoscopy and the clock cannot be paused in the diagnostic phase even for patient choice. Cancer 2 week waits from referral to date seen Breast symptomatic - 14 patients in total in this category. 12 seen within 2 weeks and 2 delayed due to lack of breast clinic capacity. One was seen at 17 days and one was seen at 18 days. All referrals are clinically triaged to identify those who are a clinical priority. Neither of these 2 were found to have cancer or needed any further treatment for their breast symptoms. We are reviewing both diagnostic and surgical capacity to ensure we are able to meet future demand.


8

Monitoring Risk Scoring System

Green score of less than 1.0

Amber-Green score between 1.0 – 2.0

Amber-Red score between 2.5 and 4.0

Red score of more than 4.0

Monitor uses a number of triggers to establish whether a Trust should be considered for escalation. These include:

A red Compliance Risk Rating (i.e. with a score greater than 4.0)

A Financial Risk Rating of 1 or 2

Reports raising significant concerns about clinical quality, patient safety or service performance or investigations by the care Quality Commission or other similar body.

Third Parties Assessment

Care Quality Commission

Moretonhampstead Hospital October 2012 (Moderate Concern) 1

NDDH Planned Inspection February 2013 - Report Received - Fully Compliant 0

Tiverton and District Community Hospital Inspection May 2013 (Moderate Concern) 1

NHS Litigation Authority

CNST October 13 Level 2 Ongoing 0

NHSLA March 12 Level 1 Ongoing

3. Mandatory Services – Declared risk of, or actual, failure to deliver mandatory services

No Items 0

4. Other Certification Failures – If not covered above. Failure to either (i)provide or (ii) subsequently comply with annual or quarterly board statements

No items 0

5. Other Factors – Failure to comply with material obligations in areas not directly monitored by Monitor, includes exception or third party reports, represents a material risk to compliance

No Items 0

Total 2

Monitor Overall Compliance Score 3.0


9

Patient Safety


Healthcare Acquired Infections

Quarter Target

KPI Source

Data Quality

2012/13 Q3

2012/13 Q4

2012/13 Q1

2013/14 Q2

2013/14 October 2013 November 2013 December 2013

FOT

FOT Value

Travel Commentary


MRSA Bacteraemia over 2 Days : NDDH

0 DH

0

1

See page 1 for commentary,.

MRSA Bacteraemia over 2 Days : Eastern Comm

0 Local

0 0

MRSA Bacteraemia over 2 Days: Northern Comm

0 Local

0 0

MRSA Screening Elective Adms: Trust Total

95.0% Local

97.2% >95

MRSA Screening Emergency Adms: Total

95.0% Local

96% >95

MSSA Bacteraemia over 2 Days: NDDH

3 Local

2 2

Remains below threshold of 5 year to date.

MSSA Bacteraemia over 2 days: Eastern Comm

0 Local

0 1

MSSA Bacteraemia over 2 Days: Northern Comm

0 Local

0 0

E. Coli Bacteraemia over 3 days: NDDH

4 Local

1 7


E.Coli Bacteraemia over 3 days: Eastern Comm

1 Local

0 1

E.Coli Bacteraemia over 3 days: Northern Community

1 Local

0 1

C.Difficile over 3 days: NDDH

10 DH

2 <9

Above trajectory, yearly threshold is 10. See above for commentary.

C.Difficile over 3 days: Total Eastern Comm

13 Local

1 <4


C.Difficile over 3 days: Total Northern Comm

4 Local

1 <2


Hand Hygiene Compliance - Trust Total

95% Local

97% >95


10


Hospital Mortality Ratios

Quarter Target

KPI Source

Data Quality

2012/13 Q3

2012/13 Q4

2012/13 Q1

2013/14 Q2

2013/14 October 2013 November 2013

December 2013 FOT

FOT Value

Travel Commentary

Status Status Status Status Status Value Status Value Status Value

SMR Trust Overall (rolling 12 months)

<100 Local

98.3

100

Latest Data = Sep 12 – Aug 13

SMR Acute Only (rolling 12 months)

<100 Local

91.6

<100


SMR North Community Hospitals (rolling 12 months)

<100 Local

88.8

100


SMR East Community Hospitals (rolling 12 months)

<100 Local

103.4

>100

Latest Data = Sep 12 – Aug 13. See below.

Last 4 quarters Current Period

4 1 2 3 RYQ4 RYQ1 RYQ2

Summary Hospital Mortality Indicator - Trust Overall

<100 NHS IC

96.59 93.46 91.6 <100

Latest Data = Apr 12-Mar 13

SHMI Elective

<100 EMQO

137.72 151.9 150.6

See below.

SHMI Non-Elective

<100 EMQO

95.79 92.4 90.6

SHMI Stroke (66)

<100 EMQO

68.09 69.9 66.2

SHMI COPD (75)

<100 EMQO

152.49 131.4 125.8

See below.

SHMI MI (57)

<100 EMQO

82.11 79.4 70.7

SHMI #NOF (120)

<100 EMQO

54.54 57.4 52.2

SHMI Pneumonia (73)

<100 EMQO

75.97 75.5 78.2

SHMI Renal (99)

<100 EMQO

73.08 79.6 80.3

SHMI CHF (65)

<100 EMQO

128.1 125.9 116.4

See below.

SHMI Diabetes (35)

<100 EMQO

73.7 71.2


11

SMR East Community Hospitals (rolling 12 months) - Spot checks have been carried out at the four hospitals with the highest SMR; no areas of concern were identified. Work continues on the application of palliative care codes and rollout of the “obs no probs” campaign. Quality standards have been introduced for GPs working in community hospitals, and work continues to introduce these same standards for Devon Doctors. SHMI Elective - Small number previously recorded as mortality within 30 days of discharge. All cases are reviewed individually and data is corrected where required. SHMI COPD - Investigation by Medical Director and report to CQC Dec 2012. All cases are reviewed individually and data is corrected where required. SHMI CHF - All cases are reviewed individually and data is corrected where required.


12


Further Patient Safety Indicators

Target KPI Source

Data Quality

2012/13 Q3

2012/13 Q4

2012/13 Q1

2013/14 Q2


December 2013 FOT

FOT Value

Travel Commentary


Never Events 0 DH

0

1

Compliance with WHO checklist

100% TBC

Local 96 96 96 96 96

94.2%

96

Medication Errors per 1000 Bed Days

7.17 EMQO 2010/11 10.11 Q3-Q4 15.61

Apr-Sep 12 = 13.70

National mean = 7.17

NHSLA claims per 10,000 bed days

<4 TBC

Local 4.0 5.0 4.8 4.2 5.5

1.4

3.4

Includes all claims

CNST claims per 10,000 bed days

1.91 Nat av

EMQO/Local

2011/12 1.44

3.6 2.1 2.9 4.4

0

2.5

Indicator definition is under review by MEQO

New SIRIs <9 TBC

Local 36

2

<9

Medicines Reconciliation (Acute)

95% Local 75%

<90

See below.

Medicines Reconciliation (East Community)

95% Local

<95

Medicines Reconciliation (North Community)

95% Local

<95

VTE Prophylaxis - Number of adult patients receiving appropriate prophylaxis (Acute)

90% Local

85%

100

See below

Unplanned Ward Transfers >1 transfer

30 TBC

Local 48 30 30 72

17

>30

Periods of increased pressure on EM admissions

Breach of EMSA General Wards

0 DH 0

36

Cancelled Operations rebooked <28 days

100% DH 100%

100

Early view

Delayed Transfer of Care (Acute monthly average)

<3.5% DH 1.8%

2.3

Delayed Transfer of Care (Northern CHs average)

<8% DH

8.7%

<8

Threshold increased to 8%

Delayed Transfer of Care (Eastern CHs average)

<8% DH

8.7%

<8

Threshold increased to 8%


13


Safe Care Environment

Target KPI Source

Data Quality

2012/13 Q3

2012/13 Q4

2012/13 Q1

2013/14 Q2


December 2013 FOT

FOT Value

Travel Commentary


Bed Occupancy % - Acute G&A Specialities

86% Local

88 90 90 85 76 70 93.2

Bed Occupancy % - Eastern Community Hospitals

86% Local

90 91 91 88 85 85 93.3

Bed Occupancy % - Northern Community Hospitals

86% Local

93 85 89 83 75 81 90.5

Medicines Reconciliation (Acute) - Work with junior doctors continues in order to increase the percentage of patients who have a medicines reconciliation on admission. This work is being undertaken in conjunction with improvement work to ensure medicines are reconciled on discharge, with any changes made during admission clearly documented on the discharge summary. VTE Prophylaxis - Number of adult patients receiving appropriate prophylaxis (Acute) - This is a very small sample size (20 patients per month) carried out in two to three wards. Any non-compliance is raised at the time of the audit and fed back to nursing and medical teams. However, the Trust’s CQUIN performance (which includes measurement of VTE risk assessment of all eligible patients on discharge) routinely measures 95% or above. Delayed Transfers of Care (Eastern and Northern Community) – For Eastern the main reasons for delay in October are care package and patient or family choice. For Northern the main reasons for delay in October are housing and patient or family choice.


14

Quality of Services


Stroke Indicators Target KPI Source

Data Quality

2012/13 Q3

2012/13 Q4

2012/13 Q1

2013/14 Q2


December 2013 FOT

FOT Valu

e

Travel

Commentary


Stroke Direct Admission to Acute Stroke Unit

90% Local

52%

63.0

Stroke >90% stay on Unit North Acute

80% Local

64%

65.0

9 breaches in October of which 5 were Stroke Team unaware, 1 Short LoS

Stroke >90% stay on Unit N. Acute – Excl 1 day LOS

80% Local

68%

78.8

Subset report with <1 Day LOS breaches assumed compliant

Stroke >90% stay on Unit North Super spell

80% Local

64%

<80

Stroke >90% stay on Unit North Super spell Excluding Patient/Clinician Choice

80% Local

NA

68%

<80

Excludes stay on non-stroke unit due to patient choice or specific clinical decision

Stroke Urgent Scan <1Hr 90% Local

100%

78

Stroke Routine Scan <24Hr

90% Local

94%

92

15/16

Stroke >90% stay on Unit East Community Hospital

80% TDA

68%

80

October data is early view.

Stroke >90% stay on Unit East Community Excluding Patient/Clinician Choice

80% Local

NA

68%

80

Excludes stay on non-stroke unit due to patient choice or specific clinical decision . October data is early view.

Two key issues have been identified in September and October which are affecting consistent delivery of both the direct admission and 90% stay on a stroke unit targets:

1) Stroke patients not being referred to the stroke team – referrals for all stroke patients, including patients with TIA who symptoms have not resolved within 3 hours, are now being made to the Acute Stroke Unit (ASU) and not to individual clinicians to support these patients being pulled in a more timely way to the ASU. Pre-alert for all stroke patients being brought in by SWAST was implemented within the ASU in this month.

2) Short length of stay patients – The methodology for calculating performance against the 90% stay target has been amended following the implementation of the stroke SSNAP dataset. This nationally agreed database collects stroke pathway data for all stroke patients and for the 90% stay calculation removes 4 hours per patient in recognition of the time spent in ED. The revised methodology will be agreed with the NEW Devon CCG and used for future local reporting arrangements.

Eastern 90% stay – Performance is currently being validated by the Stroke Nurse Consultant.


15


Endoscopy Target KPI Source

Data Quality

2012/13 Q3

2012/13 Q4

2012/13 Q1

2013/14 Q2

2013/14 October 2013 Novembre 2013

December 2013 FOT

FOT Value

Travel Commentary


Endoscopy patients urgent waiting < 2 weeks

95% Local 92.9% 90.8

5 x waiting >2wks at October End

Endoscopy patients routine waiting < 6 weeks

95% Local 100% 97.2

0 waiting >6wks at October End


Emergency Readmissions

Target KPI Source

Data Quality

2012/13 Q3

2012/13 Q4

2012/13 Q1

2013/14 Q2


December 2013 FOT

FOT Value

Travel Commentary


28 Day Emergency Readmissions

<100 Local 92.3

<100

Latest Data = June 12 – May 13

Following Previous Elective Admission

<100 Local 84.3

<100


Following Previous Emergency Admission

<100 Local 94.9

<100



Ambulance Handovers

Target

KPI Source

Data Quality

2012/13 Q3

2012/13 Q4

2012/13 Q1

2013/14 Q2


December 2013 FOT

FOT Value

Travel Commentary


Ambulance Handovers % > 15 mins

0% Contract

27%

35

Standard generally not being achieved, SW average 42%

Ambulance Handovers % > 30 mins

0% Contract 2.5%

5

Validated Ambulance Handovers (number) > 30 mins

0% Contract 206 149 9

<530

Financial penalties apply. See below.

Validated Ambulance Handovers > 1 hour

0 Contract

21 5

1

22

Financial penalties apply. See below.

Validated Ambulance Handovers > 2 hours

0 Contract

0

0

Ambulance Handovers – Average handover time for October 2013 was 13 minutes 19 seconds compared to the SWAST area average time of 15 minutes 4 seconds. We have completed work to reconfigure A&E to enhance capacity. Further additional staffing comes on line during November to aid handover process. Continual monitoring and validation of handovers introduced in September and ongoing.


16


A&E Indicators

Type 1 - NDDH Target

KPI Source

Data Quality

2012/13 Q3

2012/13 Q4

2012/13 Q1

2013/14 Q2


December 2013 FOT

FOT Value

Travel Commentary


A&E Type 1 maximum waiting time of 4 hours

95% Local

94.7% <95

See below.

A&E, MIU & WIC Attendances and 4 Hour Breaches

95% Monitor

98.7%

>95

% Admitted from A&E TBC Local

32.1% 36.7% 36.7% 33.3% 31.6% 34.5% 37

National Experimental Indicators

A&E waiting time- Unplanned re-attendance at A&E within 7 days

5% DH

5% 5.7

National = 7.1% (NHS IC Data Nov 2012)

A&E waiting time - Total time spent in dept 95th percentile (admitted)

4 DH

5.1 5.11

National = 7:18

A&E waiting time - Number of patients spending over 6 hours in A&E (admitted)

0 DH

29 196

No benchmarking available

A&E waiting time - Total time spent in dept 95th percentile (non-admitted)

4 DH

3.52 <4

National = 3:56

A&E waiting time - Number of patients spending over 6 hours in A&E department - 95th percentile (non-admitted)

0 DH

11 70

No benchmarking available

A&E waiting time- Patients left department without being seen rate

5% DH

1.7% <5

National = 2.6%

A&E waiting time - Time to initial assessment 95th percentile (ambulance arrivals only)

0.15 DH

0.12 15

National = 39 Min

A&E waiting time - Time to treatment (median)

0.6 DH

0.47 <60

National = 53 Min

A&E Type 1 maximum waiting time of 4 hours - Performance was adversely impacted upon by a small number of challenging days, especially towards the end of the month. With 9 fewer breaches the 95% standard would have been achieved. Breaches for reasons of transport have significantly increased in October, as have psychiatric assessment breaches. Emergency admissions from A&E have also increased month on month. Enhanced majors capacity is now on line. Work is being undertaken with the CCG through the Urgent Care Forum to look at time of patient arrival to assist with capacity pressures. The impact of the new patient transport contract is being assessed.


17

Patient Experience

Last Full

Year Last 4 Quarters Current Quarter

RTT and Elective Waiting Times

Target KPI Source Data

Quality

2012/13 Q3

2012/13 Q4

2012/13 Q1

2013/14 Q2


December 2013 FOT

FOT Value

Travel Commentary


RTT Admitted Median <11.10 DH

7.9

<11

RTT Admitted 95th Percentile

<23.00 DH

18

<23

RTT Non-admitted Median

<6.60 DH

3.3

<6.6

RTT Non-admitted 95th Percentile

<18.30 DH

11.3

<18

RTT Admitted Pathways - Specialties that failed 18 week target

0 DH

0

3

RTT Non-Admitted Pathways - Specialties that failed 18 week target

0 DH

0

0

RTT >52wk Waiters - Admitted pathway

0 DH

NA

1

2

See below.

RTT >52wk Waiters - Non-Admitted pathway

0 DH

NA

0

1

Outpatients GP Referred Waiting >11 weeks

2 Local

0

3

Outpatient Waiting List 2049 Local

NA 2945 2790 2126 2106

2244

NA

Elective Patients Waiting >20 Weeks

2 Local

0

1

Elective Waiting List 1106 Local

NA 1677 1579 1289 1371

1434

NA

AHP RTT Waiting Time Non-Admitted <18 Weeks

95% Contract

NA NA 96.8 97.1% 97.1%

September is latest data.

Diagnostics Waiting >6 weeks (<1%)

>99% DH

99.8%

99.4

RTT >52wk Waiters - Admitted pathway - 1 patient waited more than 52 weeks for an ENT operation. Miscommunication regarding diagnostic tests has been identified as the main reason for delay. The patient was successfully treated in early November. An SEA is in progress and from this an action plan will be developed to address the risk of recurrence.


18


Further Key Indicators

Target KPI Source

Data Quality

2012/13 Q3

2012/13 Q4

2012/13 Q1

2013/14 Q2


December 2013 FOT

FOT Value

Travel Commentary


Percentage of last minute cancelled operations

0.80% Local

0.56%

0.80

Early view

G U Medicine appointments offered in 48 hours Trust Total

100% TDA

100%

100


Maternity Indicators

Target KPI Source

Data Qual-ity

2012/13 Q3

2012/13 Q4

2012/13 Q1

2013/14 Q2


December 2013 FOT

FOT Value

Travel Commentary


Women Seen <13 weeks of Pregnancy (Local PCTs)

90% Local

86.4% 86.4 88.3 88.3 83.4

85%

90

% Eligible Referred to Smoking Cessation

>90% Local

>90

Deliveries N/A Local

1602 399 362 365 403

136

360

Caesarean % Overall 24.5%

Nat. Av. EMQO

27% 28.4 29.7 29.3 22.8

31%

27

Caesarean % Elective 10.45% Nat. Av.

EMQO

12.8% 12.4 13.6 14.2 10.9

12%

13

Patient Choice applies

Caesarean % Emergency

14.29% Nat. Av.

EMQO

14.2% 16.0 16.2 13.0 11.9

21%

14

Breastfeeding Initiation within 48 Hours

>71% Local

76.1% 77.1 72.4 77.2 78.2

76%

73

Smoking at Delivery

<20% Local

13.1% 12.6 13.3 10 9.9

9%

14

% of All Babies Admitted to Neonatal Care

<15.4 TBC

Local

13.8% 15.6 14.2 11.8 13.8

>15

% All Babies Readmitted within 28 Days of Delivery

7%. Local

10.95% 10 14.8 12.5 10.4

5.2

<10


19

Operational Effectiveness


Q Target

KPI Source

Data Qual-ity

2012/13 Q1

2012/13 Q2

2012/13 Q3

2012/13 Q4

2012/13 July 2013 August 2013

September 2013 FOT

FOT Value

Travel Commentary


Admitted Patient Care % Valid Data (Average)

95.5% Nat. Av.

EMQO

98.4 98.2 98.4 94.7 92.7%

(SUS National DQ Dashboard) EMQO latest is Apr 13

Outpatient % Valid Data

95.2% Nat. Av.

EMQO

93.3 93.6 93.6 93.5 94.1%

(SUS National DQ Dashboard)

A&E % Valid Data

96.4% Nat. Av.

EMQO

94.9 95.5 95.7 97.7 96.3%

(SUS National DQ Dashboard)

APC % Records First Submitted with Valid HRG

97.8% Nat. Av.

EMQO

76.0 98.7 97.2 98.4 98.4% (Mar 13)

Q3 2012/13

Q4 2012/13

Q1 2013/14

Q2 2013/14

October 2013 November

2013 December

2013

Status Status Status Status Status Value Status Value Status Value

CDC Coded within 5 days of Discharge

95% Contract

55 59 70 84

88

>90

Data as at Month End

CDC Coding Backlog

<500 Local

765 500

Data as at Month End

OP First To Follow Up Ratio

2.5 tbc

Local

2.5 2.4 2.4 2.6

2.3

2.5

Dr Foster PPM4 – Sept 13 latest National Median 3.0

OP FST DNA Rate

<5.9 tbc

Local

5.93% 5.5 5.9 5.4

4.8%

6.2

Dr Foster PPM4 – Sept 13 latest

OP FUP DNA Rate

<8.0 tbc

Local

8.1% 8.0 8.0 8.0

7.5%

8.3

Dr Foster PPM4 – Sept 13 latest

CDC Coded within 5 days of Discharge – A steady improvement in coding rate within 5 days is apparent with an upward trajectory from April 2013 onwards.


20

Contracted Activity Delivered

Acute Contract Activity (Plan = Contracted Volumes)

Month Data

Quality

Current Month Year to Date

Commentary Target Value

Value vs Target

Value vs Target (%)

Status Target Value Value vs Target

Value vs Target (%)

Status

GP Referrals October

2864 2786 -78 97.3%

18690 18568 -122 99.3%

Excludes Obs/Mid

Other Referrals October

1516 1575 59 103.9%

9689 10182 493 105.1%

Excludes Obs/Mid

Total Referrals October

4380 4361 -19 99.6%

28379 28750 371 101.3%

Outpatient First Attendances TOTAL October

4160 4341 181 104.4%

27131 28751 1620 106%

Outpatient Waiting List TOTAL October

2049 2244 195 109.5%

Outpatient Follow-up Attendances TOTAL October

8036 8755 719 109.9%

52406 56788 4382 108.4%

Outpatient Follow Up Overdue Backlog October

N/A 2565 N/A N/A

Previously 2949.

Elective Daycase Spells TOTAL October

1702 1910 208 112.2%

11103 11706 603 105.4%

Elective Inpatient Spells TOTAL October

324 224 -100 69.1%

2111 1652 -459 78.3%

Elective (Inpatient & Daycase) Spells TOTAL

October 2026 2134 108 105.3%

13214 13358 144 101.1%

DC Rate Overall October

83.9% 89.5%

84% 87.6%

Elective Waiting List TOTAL October

1106 1434 328 129.7%

Non-elective (Gen & Acute) October

1413 1258 -155 89%

9754 9400 -354 96.4%

Non-elective (All inc Mat.)

October 1571 1650 79 105%

10845 12011 1166 110.8%

Number of A&E Attendances - NDDH only October

3333 3021 -312 90.6%

25538 24275 -1263 96.2%

Total Referrals – Monthly referrals reduced in October compared to the previous month. Cumulatively year to date total referrals are slightly above plan due to over-performance in Other referrals. Outpatient Follow-Up Overdue Backlog – List is gradually reducing although some specialties still have large numbers of patients awaiting follow-up. Elective Waiting List – Both Day Case and Inpatient lists have increased in size in October following the upward movement of referrals in September.


21

North Community Hospital Contract Activity (Plan = Last Year Actual)

Month Data

Quality



Value vs Target

Value vs Target (%)


Value vs Target (%)

Status

Elective DC Activity October

39 36 -3 92.3% 252 295 43 117.1%

Elective IP Activity October 3 5 2 166.7% 20 12 -8 60% Current Plan is for minimal Elective IP activity at CHs

Elective Total Activity October

42 41 -1 97.6% 272 307 35 112.9%

Non-elective (Gen & Acute) October 110 93 -17 84.5% 756 695 -61 91.9%

MIU Attendances October

1210 1039 -71 85.9%

8354 8609 255 103.1%

East Community Hospital Contract Activity (Plan = Last Year Actual)

Month Data

Quality



Value vs Target

Value vs Target (%)


Value vs Target (%)

Status

Total Outpatient Clinic Attendances October

1,028 1,057 29 103.8%

7,148 7,155 7 100.1%

Under-reporting likely due to delays in outcoming.

Total Contacts - day treatments total eastern

October

73 83 10 113.70%

418 523 105 125.12%

East Elective Daycase Procedures activity October

38 84 46 218.65%

267 351 84 131.42%

Non-elective transfers (Gen Medical) October

178 173 -5 96.99%

1,231 1,064 -167 86.41%

Non-elective Direct (Gen Medical) October

86 66 -20 76.47%

596 491 -105 82.41%

Non-elective Others (Gen Medical) October

23 18 -5 78.13%

159 198 39 124.5%

(Validation in progress)

Non-Elective Total (Including Stroke) October

288 257 -31 89.32%

1986 1643 -343 82.72%

Occupied Bed Days October

6,245 5,097 -1,148 81.61%

43,114 39,855 -3,259 92.44%

MIU Attendances Total - Eastern locality October

4,089 3,612 -477 88.34%

32,312 29,371 -2,941 90.9%

WIC Wonford total attendances October

2,247 2,319 72 103.2%

17,077 16,358 -719 95.79%

Sidwell Street Attendances Total - Eastern locality

October

1,911 2,002 91 104.76%

13,254 13,053 -201 98.48%

Total WIC Attendances - Eastern locality October

4,158 4,321 163 103.92%

30,331 29,411 -920 96.97%


22

HSMR Data Refresh 1 November (Data Sep 12-Aug 13) (Source Data: Dr Foster RTM Version 8)

Trust Overall – All Diagnoses RR = 98.3 (Last month 99.2) Data has been rebased by Dr Foster.

NDDH Overall –All Diagnoses RR = 91.6 (Last month 91.5)


23

Northern Community Hospitals - All RR = 88.8 (Last month 87.1)

Eastern Community Hospitals- All RR = 103.4 (Last month 106.6)


24

Maternity Key Indicator – Trends


25

CQUIN Summary ACUTE CONTRACT Last Update Current Target Current Value Short Term Trend Arrow Traffic Light Icon Spark Chart

Friends and Family test - Phased expansion (Acute) Implement Friends and Family Test in Maternity Services: Q2 – establish baseline Q3 – collect and analyse data Q4 – evidence improvement in results

Friends and Family test - Phased expansion (Acute) Q4 – evidence improved results from Q3 to Q4

Friends and Family test - Improved response rate (Acute) October 2013 20% 36.3%

Friends and Family test - Improved Performance on the Staff Friends and Family Test (Acute)

2012/13 result is 3.55 <3.55 Yearly survey

NHS Safety Thermometer - Pressure Ulcer improvement (Acute)

October 2013 4.75 4.57

NHS Safety Thermometer - Pressure Ulcer, old (Acute) October 2013 6.57

Dementia Screening (Acute) September 2013 90.0% 100.0%

Dementia Risk Assessment (Acute) September 2013 90.0% 76.1%

Dementia Referral for Specialist Diagnosis (Acute) September 2013 90.0% 100.0%

Dementia - Clinical Leadership (Acute) Confirm named lead clinician for dementia (completed)

Dementia - Clinical Leadership (Training) (Acute) September 2013 85.0% 79.7%

Dementia - Supporting Carers of People with Dementia Q1 – design audit process covering supporting carers of people with dementia (completed) Q2 – implement quarterly audit

VTE Risk Assessment (Acute) September 2013 95% 95.06%

VTE Root Cause Analyses (Acute) September 2013 100% 100%

High Risk Medication - Omissions (Acute) October 2013 5% 0.07%

Clarity of Discharge Information for changes of Drug Therapy

June 2013 95% 76.47%

Fracture Clinic - Osteoporosis, low risk (Acute) Process and data flows agreed with operational lead Q1 – produce scoping report on staff training and identification of clinical lead (completed) Q2 – train staff and implement data collection Q3-4 – report data Payment is 50% for each of Q3 and Q4

Fracture Clinic - Osteoporosis, medium risk (Acute)

Fracture Clinic - Osteoporosis, high risk (Acute)

Fracture Clinic - Osteoporosis, total (Acute)

TIA Access Q1 – option appraisal of NICE compliant service models and produce scoping report (completed) Q2 – agree recommendations, implement change and test KPIs Q3-4 – measure and report improvement

Dementia Clinical Leadership Training (Acute) – performance against the year end target is 79.7% and is on track to achieve the year end 85% rate. Reminder to all clinical areas to ensure their support workers have received training will be sent by the end of November 2013.


26

EASTERN COMMUNITY CONTRACT Last Update Current Target Current Value Short Term Trend

Arrow Traffic Light Icon Spark Chart

Friends and Family test - Phased expansion (Community) Implement Friends and Family Test in Community Hospitals (inpatients): Q2 – establish baseline (completed) Q3 – collect and analyse data Q4 – evidence improvement in results

Friends and Family test - Phased expansion (Community) Q4 – evidence improved results from Q3 to Q4

Friends and Family test - Improved response rate (Community)

Q1 – establish baseline Q4 – demonstrate improved response rate from Q1, with performance in top 50%

Friends and Family test - Improved Performance on the Staff Friends and Family Test (Community)


NHS Safety Thermometer - Pressure Ulcer improvement (Community)

October 2013 8.5% 5.4%

NHS Safety Thermometer - Pressure Ulcer, old (Community)

October 2013 36.3%

Dementia Screening (Community) September 2013 90% 100%

Dementia Risk Assessment (Community) September 2013 90% 100%

Dementia Referral for Specialist Diagnosis (Community) September 2013 90% 100%

Dementia - Clinical Leadership (Community) Confirm named lead clinician for dementia (completed)

Dementia - Clinical Leadership (Training) (Community) September 2013 85.0% 86.5%


VTE Risk Assessment (Community) September 2013 95.0% 97.2%

VTE Root Cause Analyses (Community) September 2013 100% 100%

Community Hospitals Discharge Summary (Community) (GP within 72 hours)

September 2013 95% 56%

Community Hospitals Clinical Quality September 2013 95.0% 81.1%

Fracture Clinic - Osteoporosis, low risk (Community) Process and data flows agreed with operational lead. Applies to Exmouth and Tiverton only Q1 – produce scoping report on staff training and identification of clinical lead (completed) Q2 – train staff and implement data collection (completed) Q3-4 – report data Payment is 50% for each of Q3 and Q4

Fracture Clinic - Osteoporosis, medium risk (Community)

Fracture Clinic - Osteoporosis, high risk (Community)

Fracture Clinic - Osteoporosis, total (Community)

Commentary:

NORTHERN COMMUNITY CONTRACT Last Update Current Target Current Value Short Term Trend Traffic Light Icon Spark Chart

Dementia FAIR – Early view of October data shows achievement of all 3 elements. CQUIN Discharge Summary within 72 hours (Eastern) - This is an improving position. This is discussed every 2 weeks at divisional meeting and also deputy matron meetings. Support is also provided to managers. This continues and reliant on GPs who provide medical cover engaging with the process ie final sign off by the GP within 72 hours. CQUIN Community Hospitals clinical quality (Eastern) – This is a steadily improving position on the minimum data set.


27

Arrow

Friends and Family test - Phased expansion (Community) Implement Friends and Family Test in Community Hospitals (inpatients): Q2 – establish baseline (completed) Q3 – collect and analyse data Q4 – evidence improvement in results

Friends and Family test - Phased expansion (Community) Q4 – evidence improved results from Q3 to Q4

Friends and Family test - Improved response rate (Community)

Q1 – establish baseline Q4 – demonstrate improved response rate from Q1, with performance in top 50%

Friends and Family test - Improved Performance on the Staff Friends and Family Test (Community)


NHS Safety Thermometer - Pressure Ulcer improvement (Community)

October 2013 8.5% 5.4%

NHS Safety Thermometer - Pressure Ulcer, old (Community)

October 2013 36.3%

Dementia Screening (Community) September 2013 90.0% 100.0%

Dementia Risk Assessment (Community) September 2013 90.0% 66.7%

Dementia Referral for Specialist Diagnosis (Community) September 2013 90.0% 100.0%

Dementia - Clinical Leadership (Community) Confirm named lead clinician for dementia (completed)

Dementia - Clinical Leadership (Training) (Community) September 2013 85.0% 92.7%


VTE Risk Assessment (Community) September 2013 95.0% 100.0%

VTE Root Cause Analyses (Community) September 2013 100% 100%

Community Hospitals Discharge Summary (Community) (GP within 72 hours)

September 2013 95.0% 63.5%

Community Hospitals Clinical Quality September 2013 95.0% 92.1%

CQUIN Discharge Summary within 72 hours (Northern) The deterioration this quarter will be investigated further by DGM. CQUIN Community Hospitals clinical quality (Northern) – This remains steady at quarter 2.


28

Specialist Commissioning CQUINs

No. Description Last Update Current Target Current Value Short Term Trend

Traffic Light Icon

NIC 1 Improved Access to breast milk in preterm infants September 2013 locally agreed sliding scale based on babies rather than % (see SCG CQUINs dashboard for detail)

60%

NIC 3 Timely and simple discharge September 2013 60% No eligible patients

HIV Registration and communication with GPs about the care of HIV patients – Proportion of patients diagnosed with HIV registered with and disclosed to their GP. Sample is all patients diagnosed with HIV

September 2013 70% 87%

HIV Registration and communication with GPs about the care of HIV patients – Annual (at least) communication with GPs about the care of HIV patients who are registered with and disclosed to a GP. Sample is patients registered with a GP and disclosed.

September 2013 100% 98.1%

Dash-board

To implement the routine use of specialised services clinical dashboards September 2013 tbc 100%

.

NIC 1 - The total number of babies included was 5, and of these 3 met the CQUIN criteria. The breastfeeding support is unchanged and the change in numbers is therefore due to parental choice. 1 mother declined to breast feed despite repeated attempts to encourage and the other wanted to bottle feed but did express milk so the baby received some expressed breast milk. NIC 3 - There were no eligible babies for this CQUIN schedule. In Q1 the achievement was 20% based on 1 baby in 5 achieving the standard. As there are no eligible babies this quarter then the numerator and denominator remain the same. Based on a percentage view (assuming that we are awarded 100% when there are no eligible babies) then the Q2 position would be 60% (20% + 100%) / 2 = 60% However, if the calculation is based on the numerator and denominator values then the percentage achievement will remain at 20%.


29

0

5

10

15

20

25

30

35

21

16

1921

24

31

23

2 2

10

6

4

8

0

Number of Complaints and Concerns received 1 April 2013 - 31 October 2013

Complaints toreceive a formalresponse

Complaints toreceive aresponse byServiceManager

0

5

10

15

20

25

30

35

40

45

50

Complaints response time performance by month for complaints closed 1 April - 31 October 2013

40 dayso/due

20-40 dayso/due

10-20 dayso/due

Withintimescale

No of days to respond

Patient Complaints, Comments and Satisfaction Scores – 1 April 2013 – 31 October 2013

Where a complaint has not been responded to within the initial 35 working days (or alternative agreed timescale), an extension is agreed. Complaint response performance is being monitored via the Customer Relations Complaint Action Plan and through existing reports for the Learning from Patient Experience Group (LPEG) and Directorate reports.

Where possible, all complaints are verbally acknowledged at the outset and the way forward is agreed with the complainant

Complaints

received

No

acknowledged

within 3 w/days

%

acknowledged

within 3 w/days

April 23 19 83%

May 18 17 94%

June 29 26 90%

July 28 27 96%

August 29 28 97%

September 39 31 79%

October 23 14 61%

November 0 n/a n/a

December 0 n/a n/a

January 0 n/a n/a

February 0 n/a n/a

March 0 n/a n/a

Total 189 162 86%

A total of 189 complaints/concerns were received in the period 1 April 2013 – 31 October 2013.


30

26

56

10

21

13 16

11

2 3

31

0

10

20

30

40

50

60

Complaints and Concerns received by Directorate 1 April - 31 October 2013

Clinical Care and Treatment

45%

Attitude of Staff13%

Access to Clinical Services

6%

Communication17%

Discharge arrangements

5%

Top 5 Subject themes for complaints/concerns received 1 April - 31 October 2013

The Directorates mainly involved in the Top 5 subjects above were:

Clinical Care and Treatment – Multiple Specialities (38), Attitude of Staff - Surgical Specialities (16), Access to Clinical Services - Surgical Specialities (6) Communication - Surgical Specialities (14), Discharge Arrangements – Multiple Specialities (5)

Of the 31 complaints that were logged as multiple directorates, 20 involved Surgery, 15 involved Emergency Services, 13 involved Medicine, 10 involved Clinical Support Services, 5 involved Health & Social Care, and 5 involved Community Hospitals.


31

Poor medical care13%

Communication to patients, parents

or carers13%

Poor nursing/ midwifery care

11%

Lack of empathy/caring

7%

Unexpected outcome

7%

Top 5 Sub-subject themes for complaints/concerns received 1 April - 31 October 2013

Ombudsman activity Number of local resolution meetings held by month

Month held Number of meetings

Apr 8

May 3

Jun 6

Jul 9

Aug 4

Sept 7

October 6

November n/a

December n/a

January n/a

February n/a

March n/a

Total 11

Complaints referred by Outcome Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

Request received from Ombudsman 1 1 0 0 1 1 1 0 0 0 0 0 turned for local resolution (further response or meeting)

0 0 0 0 0 0 0 0 0 0 0 0

Case closed with no further action 2 0 1 2 0 0 0 0 0 0 0 0

Issue upheld and recommendations made 0 0 0 0 0 0 0 0 0 0 0 0

All complainants are offered the opportunity of meeting with staff at the outset as part of our acknowledgement, and the take-up of meetings at the beginning of the complaint process is being monitored by the Customer Relations department. At the time of this report there are 10 meetings waiting to take place.

The Directorates mainly involved in the Top 5 subjects above were: Lack of Empathy - Surgical Specialities (8), Poor Medical Care –Surgical Specialities (14) Poor Nursing/Midwifery care – Surgical Specialities (8) Communication – Surgical Specialities (10) Unexpected outcome - Multiple Specialities (8)


32

Patient Experience Report April – October 2013


33


of 58

Months

PI Short Name Target April 2013 May 2013 June 2013 July 2013 August 2013 September 2013 October 2013

Value Status Short Trend







Patient Experience - Composite Indicator - Total (Acute)

73 83.3

88.9

89.8

89.6

90

88

88.5

Patient Experience - Were you as involved as much as you wanted to be?

73 84.5

87.6

87.8

91.1

92.2

86.6

88.9

Patient Experience - Did you find someone to talk to about worries and fear?

73 86.8

91.2

89.1

93.2

87.6

89.9

92.2

Patient Experience - Were you given enough privacy?

73 91.1

89.7

93.8

97

96.1

93.9

95.8

Patient Experience - Were you told about medication side effects to watch for?

73 62.1

79

79.6

71.8

75

72.3

72.5

Patient Experience - Were you told who to contact if you were worried?

73 92

97.1

98.6

95.2

99

97.2

92.9

Patient Experience - Composite Indicator - Total (East Community)

73 81.6

86.1

85.4

85.8

81.9

84.7

78


73 77.1

87.3

89.3

88.2

88.9

85.4

73.6


73 90

82.7

94

92.7

82.4

83.3

92.6


73 96.3

100

100

97.3

98.6

97.9

91.4


73 53.7

66.7

55.6

61.2

46.9

61.4

65.7


73 90.9

93.9

88

89.4

92.6

95.2

66.7


of 58

Months

PI Short Name Target April 2013 May 2013 June 2013 July 2013 August 2013 September 2013 October 2013








Patient Experience - Composite Indicator - Total (North Community)

73 86.7

84.8

84.5

92.7

93.4

85.2

94


73 84.1

87.5

85.7

91.7

91.7

89.3

89.5


73 80

83.3

78.6

95.8

92.1

88.5

94.7


73 93.2

96.9

89.3

95.8

100

96.7

94.7


73 76.3

56.3

77.3

80

83.3

60.7

90.9


73 100

100

91.7

100

100

90.9

100


of 58

National ‘Friends and Family Test’ - Oct-13

The individual ward scores for Oct-13 for the National ‘Friends and Family Test’ are positive, reflecting the positive results also obtained to this question from our real-time patient experience tracker. The ‘Friends and Family Test’ score can range between -100 and +100. The Friends and Family Test performance for NDDH Acute Inpatients for October 2013 is a Friends and Family Test score of +80 (against a Trust target of +60). Based on 885 discharges during the month of October 2013, approximately 25% of Acute Inpatients were asked for their feedback. This is against a target of 20%. There is a Trust-wide response rate of 36.3%.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Alexand raWard

CarolineTh orpe Ward

Acute StrokeUnit

Lundy /Robo rough

Ward

Victoria Ward MedicalAssessment

Unit

Glossop WardKing Ge orge VWard

Fo rtescu eWard

Cape ner WardStaples Wa rd A&E

How likely are you to recommend our ward / A&E department to friends and family if they needed similar care or treatment?

Extremely likely Likely Neither likely nor unlikely Unlikely Extremely unlikely Don't know

Ward / Department Extremely likely Likely Neither likely nor unlikely Unlikely Extremely unlikely Don't know Total FFT Score Response Rate

Alexandra Ward 0 0 0 0 0 0 0 No data No data

Caroline Thorpe Ward 0 0 0 0 0 0 0 No data No data

Acute Stroke Unit 10 0 0 0 0 0 10 100 32.3

Lundy / Roborough Ward 21 1 0 0 0 0 22 95 19.1

Victoria Ward 15 1 0 0 0 0 16 94 14.7

Medical Assessment Unit 36 8 0 0 0 0 44 82 45.4

Glossop Ward 20 5 1 0 0 0 26 73 23.2

King George V Ward 16 4 1 0 0 0 21 71 11.5

Fortescue Ward 15 2 0 1 1 0 19 68 13.3

Capener Ward 6 3 0 0 0 0 9 67 8.4

Staples Ward 3 2 0 0 0 0 5 60 7.2

A&E 364 156 36 50 103 8 717 25 48.8

Total 506 182 38 51 104 8 889 36 36.3

Percentage 57 20 4 6 12 1 100


of 58

National ‘Friends and Family Test’ Scores The score is calculated as the proportion of respondents who would be extremely likely to

recommend (response category: ‘Extremely likely’) minus the proportion of respondents who would not recommend (response categories: ‘Neither likely nor unlikely’, ‘Unlikely’ and ‘Extremely unlikely’). The ‘Don’t know’ responses are excluded but as the ‘Likely’ responses are included in the denominator for both parts of the calculation they have the capacity to affect the overall score significantly. The ‘Friends and Family Test’ score ranges between -100 and +100. The Trust’s target score is +60.

87

86

100

80

67

82

100

70

67

90

44

69

100

90

64

50

100

100

86

91

100

56

40

91

100

50

74

67

40

100

65

67

86

88

91

85

90

77

80

100

60

67

82

81

75

55

92

100

100

100

58

100

100

82

80

89

100

67

0

100

50

94

60

95

71

73

68

67

100

25

0 10 20 30 40 50 60 70 80 90 100

Victoria Ward

Staples Ward

Lundy / Roborough Ward

King George V Ward

Glossop Ward

Fortescue Ward

Caroline Thorpe Ward

Capener Ward

Alexandra Ward

Acute Stroke Unit

A&E / MAU

Oct-13 Sep-13 Aug-13 Jul-13 Jun-13 May-13 Apr-13


of 58

National ‘Friends and Family Test’ - Oct-13 - Community Hospitals

With effect from Oct-13, the Trust became an early adopter of the National Friends and Family Test across the community hospitals.

The ‘Friends and Family Test’ score can range between -100 and +100. The overall ‘Friends and Family Test’ score across the community hospitals for the first month was +72. This exceeded the Trust’s target score of +60. The overall ‘Friends and Family Test’ response rate across the community hospitals was 21.9% against a target of 20%.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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Oct-13How likely are you to recommend our community hospital to friends and family if they needed similar care or treatment?

Extremely likely Likely Neither likely nor unlikely Unlikely Extremely unlikely Don't know


of 58

Community Hospital

Extremely likely

Likely

Neither likely nor unlikely

Unlikely

Extremely unlikely

Don't know

Total

FFT Score

Response

Rate %

1 Budleigh Salterton 0 0 0 0 0 0 0 No data No data

2 Exmouth - Geoffrey Willoughby 0 0 0 0 0 0 0 No data No data

3 Holsworthy 0 0 0 0 0 0 0 No data No data

4 Moretonhampstead 0 0 0 0 0 0 0 No data No data

5 Tiverton - Blackdown 0 0 0 0 0 0 0 No data No data

6 Tiverton - Twyford 0 0 0 0 0 0 0 No data No data

7 Torrington 0 0 0 0 0 0 0 No data No data

8 Axminster - Morton 1 0 0 0 0 0 1 100 5.9

9 Crediton - Kirton 3 0 0 0 0 0 3 100 60.0

10 Crediton - Stroke Unit 2 0 0 0 0 0 2 100 33.3

11 Exmouth - Doris Heard 4 0 0 0 0 0 4 100 22.2

12 Sidmouth 2 0 0 0 0 0 2 100 9.1

13 Ilfracombe - Tyrell 9 1 0 0 0 0 10 90 66.7

14 Seaton 5 1 0 0 0 0 6 83 37.5

15 South Molton 7 0 0 0 1 0 8 75 100.0

16 Ottery St Mary 2 1 0 0 0 0 3 67 20.0

17 Bideford - Willow 7 2 0 1 0 0 10 60 40.0

18 Exeter - Budlake 3 2 0 0 0 0 5 60 20.0

19 Okehampton 5 4 0 0 0 0 9 56 34.6

20 Honiton 2 0 0 1 0 0 3 33 12.5

21 Bideford - Elizabeth 1 0 1 0 0 0 2 0 15.4

Total 53 11 1 2 1 0 68 72 21.9

Percentage 78 16 1 3 1 0 100


of 58

National ‘Friends and Family Test’ - Oct-13 - Maternity Services

The ‘Friends and Family Test’ was launched in Maternity Services with effect from 1 October.

The ‘Friends and Family Test’ score ranges between -100 and +100. The Trust’s target score is +60. The overall ‘Friends and Family Test’ score achieved across the service was +78, exceeding the Trust’s target score of +60. The overall ‘Friends and Family Test’ response rate across the service was 3.5%. The response rate achieved for Oct-13 was lower than anticipated but is expected to increase during Nov-13.

Maternity Service

Extremely likely

Likely Neither

likely nor unlikely

Unlikely Extremely

unlikely Don't know

Total FFT Score

Response Rate %

1 Antenatal Service 0 1 0 0 0 0 1 0 0.7

2 Labour Ward - NDDH / Homebirth Service 9 3 0 0 0 0 12 75 8.8

3 Bassett Ward, NDDH 5 0 0 0 0 0 5 100 4.9

4 Postnatal Community Service 0 0 0 0 0 0 0 No data No data

Total 14 4 0 0 0 0 18 78 3.5

Percentage 78 22 0 0 0 0 100


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Research and Development Summary

Open studies Total number of studies open to recruitment 118 Percentage of total observational studies 65% Percentage of total interventional studies 35% Number of studies in which areas Clinical Support Services 39 Emergency Services, Logistics and Resilience 3 Surgical Specialities 7 Medical Specialties 43 Health and Social 0 Specialist Services 7 Other - Student studies 19

Recruitment

Trust data captured (Report 4 NIHR database captured studies and non)

Report 4 (national database for recruitment*** national delay in the upload of data )

2012/2013 recruitment total 1205 717

2012/2013 years recruitment total Observation studies 1019 2012/2013 years recruitment total Interventional studies 186 2013-2014 recruitment (Data as of 31st October 2013) 251 179

Trust data captured minus non report 4 studies 221 Percentage of 500 recruit target hit 49% 35%

Percentage of recruit total observational studies 61% Percentage of recruit total interventional studies 39% Total number Observation studies 151 Total Number Interventional studies 98

Commercial activity Total Number of Commercial studies open 8 Percentage of studies open that are commercial 7% Number of commercial studies in which areas Clinical Support Services 5 Medical Specialties 3


42

Quality Dashboard 1 England


43

2 South of England


44

3 Devon, Cornwall and Isles of Scilly


45

4 Northern Devon Healthcare Trust


46

Performance Glossary of Terms

A&E Accident and Emergency Department ASU Acute Stroke Unit C.DIFF Clostridium Difficile CONS Consultant CQC Care Quality Commission CQUIN Commissioning for Quality & Innovation CUM Cumulative CWT Cancer Waiting Times DC Day Case DGH District General Hospital DIR Direction EM Emergency FST First (New Outpatient Attendance) FUP Follow Up (Outpatient Attendance) G&A General and Acute specialties only (excludes Obstetrics & Midwifery) GU Genito Urinary Medicine HSMR Hospital Standardised Mortality Ratio (56 Nationally defined Diagnoses) IP In Patient IT Information Technology KPI Key Performance Indicator LFY Last Financial Year LOS Length of Stay MAT Maternity MAU Medical Assessment Unit MRSA Methicillin Resistant Staphylococcus Aureus MSSA Methicillin-Sensitive Staphylococcus Aureus NDHT Northern Devon Healthcare NHS Trust NICE National Institute for Clinical Excellence #NOF Fractured Neck of Femur OP Out Patient Q1 Quarter 1 (IE April – June) Q of S Quality of Service RD&E Royal Devon & Exeter NHS Foundation Trust RTM Real Time Monitoring (Benchmarking System) RTT Referral To Treatment (Time) SHMI Summary Hospital Mortality Indicator SMR Standardised Mortality Ratio (All Diagnoses) SWAST South West Ambulance Services Foundation Trust TBC To Be Confirmed TYPE 1 A&E department located at main hospital VTE Venous-thromboembolism WL Waiting List YTD Year To Date


47

WORKFORCE REPORT

SECTION 1 KEY PERFORMANCE INDICATORS - SUMMARY

1 Performance Indicators

Latest Month 12-Month Rolling Period

Indicator Mth Plan Actual Ind Dir Plan Actual Ind Dir Directorate Lead

Sickness Absence Sep 3.0% 3.91% 3.0% 4.06% Maureen Bignell

Turnover Oct 0.83% 0.72% 10% 11.1% Maureen Bignell

Appraisal Oct - - - - - - - - - - - - - 80% 71.7% Maureen Bignell

Training Oct - - - - - - - - - - - - - 82% 82.7% Maureen Bignell


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SECTION 2 Workforce Analysis

2.1 Percentage of Budgeted WTE Used

92.9% 92.8% 93.1% 92.5% 93.0% 93.5% 93.1% 92.9% 93.0% 93.5%92.5% 92.9%

94.3%

2.2% 2.2% 2.0% 2.4%2.3%

2.6%2.2% 2.3% 2.3%

2.3%2.7%

2.6%

2.7%1.8% 1.7% 1.6% 1.8% 1.7%1.8%

2.2% 2.9% 2.8% 2.4%2.3% 1.9%

1.4%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13

% of Budgeted WTE's UsedAgency WTE % NHSP & Locum WTE % Contract WTE %

Notes –

To provide the % figure used in period, the WTE equivalent hours worked by category are divided by the total budgeted WTE hours available. Issues to Highlight

The percentage of budgeted WTE hours worked by contracted staff has increased to 94.3% which is the highest figure recorded in more than a year.

The combined NHSP and Locum staff figure shows little recent change and currently stands at 2.7% for the month.

The Agency percentage figure shows another relatively large reduction. The current 1.4% rate is half of the May and June figures and the lowest seen in the last 12 months.


49

2.2 Percentage of Pay Budget Use

91.8%90.5%

91.8% 92.4% 92.5%94.3%

90.8%89.4%

92.0% 91.4% 91.4% 91.6% 91.8%

2.6%

2.6%

2.9% 2.2%2.8%

2.7%

2.7%

3.3%

3.0%

2.5% 2.8% 2.5% 2.5%

6.2%

6.1%4.3% 4.8%

5.2%

4.4%

6.1%6.7%

5.9%7.2% 6.4% 5.9%

4.7%

75%

80%

85%

90%

95%

100%


% of Budgeted £'s UsedAgency £'s % NHSP & Locum £'s % Contracted £'s %

Notes –

The monthly pay cost by category, which includes any overtime premiums, is divided by the total budgeted figure within the month to provide the % of the pay budget used.

Issues to Highlight

The current month’s agency figure has reduced for the 3rd successive month to 4.7% and is now clearly below the 12-month average of 5.6%.

The NHSP and Locum Staff usage remains at 2.5% which continues to match the lowest level seen in the last year.

The contracted workforce clearly delivers the best overall value. The current figure of 91.8% is now fractionally above the 12-month average of 91.7%.


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SECTION 3 Workforce Reduction Plan

3.1 Workforce Reduction Plan

3,100

3,200

3,300

3,400

3,500

3,600

3,700

3,800

3,900

Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13

WT

E's

Workforce Reduction Plan Curr Budgeted Posts Contracted Staff In Post

2013/14 Target Incl. Investment Substantive Staff In Post

Notes –

The end of year target is determined by deducting the planned number of WTE’s from the existing budgeted posts as at 31st March 2013. Any new posts (‘investment’) are added to this figure in order to provide a fair reflection. Issues to Highlight

The current target is for the budgeted workforce to reduce by 41.5 WTE from the March 2013 position, in line with the LTFM plan. The current position is only just short of this target.


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SECTION 4 SICKNESS ABSENCE

4.1 Sickness Absence (General)

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13

Sickness Absence Current Mth Sickness 12-Mth Sickness Target

Short Term (1-7 days) Med Term (8-20 days) Long Term (21+ days)

Notes –

All figures shown are based a full year of absence data up to the period end date shown.

Issues to Highlight

The Annual sickness rate figure has shown very little change this year and currently stands at 4.06%.

Absence due to Long Term (21+ Days) sickness remains high at 2.73% and currently accounts for 2/3rds of all days lost in the last year.

The latest monthly sickness figure for September of 3.91% is above last month’s revised 3.63%, but is fractionally lower than the 3.94% seen for the corresponding period in 2012.


52

4.2 Sickness Benchmarking

Data is sourced from the NHS Information Centre website using the ‘I-View’ tool. Updates are generally available around 3 months after the quarterly period end date, with this section of the workforce report being updated accordingly.

4.2 (a) National Acute

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

Oct - Dec 2012 Jan - Mar 2013 Apr - Jun 2013 Jul - Sep 2013

Sickness Benchmarking - National Acute Trusts

(1) Acute Large (2) Acute Medium (3) Acute Small (4) Acute All (5) N.D.H.T.

Note –

N.D.H.T. is categorized as a Small Acute Trust within the benchmarking tool. Issues to Highlight

Following the high NDHT figures seen at the end of 2012, sickness rates generally compare well against the national figures during the first 3 quarters of 2013.


53

4.2 (b) Local Acute & Other Combined Trusts

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

Oct - Dec 2012 Jan - Mar 2013 Apr - Jun 2013 Jul - Sep 2013

Sickness Benchmarking - Local Acute Trusts & Other Combined Trusts

(1) Plymouth Hospitals (2) Royal Cornwall (3) Royal Devon & Exeter

(4) South Devon (5) Taunton & Somerset (6) Weston

(7) County Durham & Darlington (8) Great Western Hosp (9) N.D.H.T.

Note –

Large Acute Trusts: Plymouth Hospitals; Royal Cornwall; Royal Devon & Exeter. Medium Acute Trusts: South Devon; Taunton & Somerset. Small Acute Trusts: Weston. Combined Trusts: County Durham & Darlington; Great Western Hospital. Issues to Highlight

With the exception of the final quarter of 2012, N.D.H.T. sickness figures tend to be within the mid-range of the benchmarking group.


54

SECTION 5 STAFF TURNOVER

5.1 Staff Turnover

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

0

4

8

12

16

20

24

28

32

36

40

44

48


Starters & Leavers (Substantive Staff Only)

Starters WTE (Subst. Only) Leavers WTE (Subst. Only) Annual Subst. Turnover ( % )

Notes –

Within this graph all locums and staff on fixed-term contracts (including the rotational junior doctors) are excluded from the starter, leaver and turnover figures.

Employees transferring to other NHS employers as a result of organisational change are also excluded.

The turnover figure is calculated as follows –

Total substantive staff leavers (WTE) in last 12 months, Divided by -

Average number of substantive staff (WTE) in post, Multiplied by 100.

Issues to Highlight

Annual substantive staff turnover shows little change at 11.1% this month.


55

SECTION 6 APPRAISAL COMPLETION

5.1 Annual Appraisal Completion Analysis

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

0

50

100

150

200

250

300

350

400

450

500

Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13

Appraisals ReportedAppraisals by Month (number) Current Appraisal ( % ) Annual Target ( % )

Notes –

The Trust appraisal target was increased from 64% to 80% at the beginning of the 2012/13 financial year.

Issues to Highlight

Appraisal rates remain at a comparative high of 71.7%, but further improvement is needed in order to achieve the 80% financial year-end target.


56

SECTION 7 Statutory and Mandatory Training Completion

Target

%

Current

%

Prev

%

Dir of

Travel

Conflict Resolution 80% 69.6% 65.7% ▲

Customer Care 80% 81.5% 78.4% ▲

Information Governance 95% 72.0% 68.1% ▲

Resuscitation 80% 69.0% 66.7% ▲

Awareness 80% 97.0% 96.8%

Dementia 80% 88.3% 87.2% ▲

Deprivation of Liberty 80% 68.9% 66.8% ▲

Mental Capacity Act 80% 71.6% 69.5% ▲

Group 1 * (see below ) 90% 96.3% 95.3% ▲

Group 2 * (see below ) 90% 65.2% 60.8% ▲

Group 3 * (see below ) 90% 76.3% 68.7% ▲

Equality & Diversity 80% 93.1% 91.4% ▲

Fire 80% 75.7% 73.5% ▲

Health & Safety 80% 91.1% 88.2% ▲

Infection Control 80% 79.8% 78.5% ▲

Moving & Handling 80% 79.1% 78.0% ▲

Slips, Trips & Falls 80% 94.9% 93.2% ▲

Average Compliance Figure 82% 82.7% 80.0% ▲

Target AchievedTarget Achieved

Below Target> 75% of Target Figure

< 75% of Target< 75% of Target Figure

▲

▼

% Increase > 0.5%

% Change +/- 0.5%

% Decrease > 0.5%

Mandatory

Safeguarding

Adults

Safeguarding

Children

Statutory

Key

Notes – The data provided is a rolling percentage of compliance, in line with the frequency of renewal. Safeguarding Children

Group 1 * = Awareness level training for all employees (three yearly update) Group 2 * = Practitioner level training for all patient facing staff (three yearly update) Group 3 * = Higher level training for staff with frequent access to children such as those

employed on the Paediatric Wards, MIU, A&E, SCBU, etc.


57

Issues to Highlight

Overall compliance continues to improve. The general target has been exceeded for the 1st time with all mandatory training categories showing stable or increasing figures.

Following 4 months of decline, Information Governance training shows a relatively large increase to 72%.

The higher level Safeguarding Children figures remain below target, but compliance has improved noticeably in both categories, with record high numbers being seen.

Fire training compliance has increased by 3% following the additional sessions provided in October. Further sessions are planned in November and December ahead of the revised delivery model which is due to start in January.

Overall there continues to be a noticeable number of DNA’s and a reduction in booking numbers across a small number of directorates, some of which is reflected in reduced compliance across clinical areas known to be experiencing high activity. This trend has been offset by increases in compliance across the majority of directorates.


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SECTION 8 WORKFORCE GLOSSARY OF TERMS

Curr Current Dir Direction DNA Did Not Attend EoY End of Year ESR Employee Staff Record FTCs Fixed-Term Contracts Hrs Hours IG Information Governance Ind Indicator LTFM Long Term Financial Management MCA Mental Capacity Act Mth Month Mthly Monthly NDHT Northern Devon Healthcare NHS Trust NHS Profs NHS Professionals OT Overtime STAR Staff Training Access & Resource SWDC Strategic Workforce Development Committee TCS Transforming Community Services WTE Whole-Time Equivalent (number of staff) YTD Year to Date

clinical operations and key quality indicators performance ... · 26.11.2013 · clinical...

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