cog (07/19) item€¦ · subject integrated performance report ... plan 11,721 11,493 11,934 11,116...

CoG (07/19) Item

DATE 4th July 2019

REPORT FOR

Council of Governors

REPORT FROM

Jug Johal

CONTACT OFFICER

Alex Bell, Head of Information Services

SUBJECT

Integrated Performance Report

BACKGROUND DOCUMENT (IF ANY)

Appendix A – Integrated Performance Report

EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN THAT THE COG NEED TO BE MADE AWARE OF)

CoG is asked to note revised performance report with updated Single Oversight Framework section (currently just operational performance) using SPC output. This will be updated further with quality measures for the following board. As per content of the report, the board is asked to note delivery to date:

RTT – Seen continued reduction in waiting list, however growth in overdue follow ups. 52 weeks continue to be managed, however still finding patients with long waits.

Cancer – Continued to deliver 2WW, however pressure regarding 62 day Cancer metrics. Tertiary capacity continues to be challenging.

Diagnostic – Continued pressures within diagnostics specifically across MRI and CT.

A&E – Whilst we have failed to meet performance trajectory, this is against continued growth in demand with no increase in admissions which demonstrates good A&E management providing the right outcomes for patients. Falls – A reduction in falls per thousand bed days. Workforce – a slight increase in the vacancy rate across registered nursing staff, alongside increases in PADR and mandatory training rates. Further narrative on qualitative data will be included for the following board.

COUNCIL ACTION REQUIRED

Note Performance to date

FandP

Integrated Performance Report - Appendix A

Key Performance Indicator Current

Target

Group by May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19

current

Activity vs Plan Actual 6,447 6,157 6,152 5,882 5,642 6,478 6,476 5,203 6,211 5,835 6,481 5,759 6,425

Plan 5,622 5,902Comments:

Actual 6,158 6,045 6,143 6,056 5,698 6,469 6,192 5,173 6,258 5,473 5,785 5,646 6,196


Actual 12,742 12,418 12,439 12,276 11,954 13,430 12,900 10,498 12,678 11,398 12,275 11,405 12,621

Plan 11,721 11,493 11,934 11,116 11,213 11,441 10,801 10,952 11,105 10,252 11,791 10,241 10,752Comments:

Actual 10,628 10,269 10,950 9,597 10,041 11,558 11,114 9,309 10,969 9,997 10,736 10,109 10,791

Plan 3,610 3,572 3,671 3,573 3,743 4,057 3,800 4,073 4,287 3,680 4,207 10,323 10,838 Comments:

Actual 21,062 20,693 21,599 19,198 20,125 23,395 22,539 17,871 22,709 20,783 21,990 21,117 21,770

Plan 21,062 22,168 22,302 22,430 22,417 24,191 23,884 19,814 23,610 22,446 23,318 20,198 21,207 Comments:

Actual 31,690 30,962 32,549 28,795 30,166 34,953 33,653 27,180 33,678 30,780 32,726 31,226 32,561

Plan 24,672 25,740 25,973 26,003 26,160 28,248 27,684 23,887 27,897 26,126 27,525 30,521 32,045Comments:

Actual 5,799 5,671 5,991 5,495 5,461 6,588 6,453 5,216 6,519 6,238 6,555 5,486 5,721


Actual 4,849 4,607 4,918 4,432 4,230 4,700 4,730 3,820 4,639 4,119 4,550 4,371 4,674

Plan 4,787 5,089 4,988 4,856 4,745 5,127 5,047 4,166 4,702 4,638 4,884 4,231 4,444Comments:

Actual 625 611 589 629 635 694 679 558 551 538 651 548 581

Plan 659 664 614 596 648 694 678 506 453 487 475 512 538Comments:

Actual 5,474 5,218 5,507 5,061 4,865 5,394 5,409 4,378 5,190 4,657 5,201 4,919 5,255

Plan 5,446 5,753 5,602 5,452 5,393 5,821 5,725 4,672 5,155 5,125 5,359 4,743 4,982 Comments:

Actual 1,072 993 1,057 1,077 1,019 1,083 1,117 1,002 1,047 973 1,011 1,032 1,130


Actual 3,298 3,168 3,374 3,254 3,144 3,401 3,408 3,354 3,426 3,161 3,317 3,180 3,344


Actual 4,369 4,161 4,431 4,331 4,163 4,484 4,525 4,356 4,473 4,134 4,328 4,212 4,474

Plan 3,610 3,572 3,671 3,573 3,743 4,057 3,800 4,073 4,287 3,680 4,207 4,439 4,430

Non-Elective Admissions - 0 LoS

Non-Elective Admissions - +1 LoS

Total Non-Elective Admissions

Elective Admissions - Ordinary

Total Elective Admissions

Total Consultant Led Outpatient

Attendances

Total Outpatient Appointments with

Procedures

Elective Admissions - Day Case

Total Referrals (General and Acute)

Consultant Led First Outpatient

Attendances

Consultant Led Follow-Up Outpatient

Attendances

Other Referrals (General and Acute)

Activity vs Plan

GP Referrals (General and Acute)

Information Services 1 of 15 Activity

FandP


Target


current

Activity vs Plan

Comments:

Actual 758 750 754 748 740 745 726 727 718 692 716 699 696

Plan 714 710Comments:

Actual 12,323 12,237 12,838 11,971 11,597 12,087 11,847 12,023 12,436 11,226 12,823 12,549 13,039

Plan 11,721 11,493 11,934 11,116 11,213 11,441 10,801 10,952 11,105 10,252 11,791 12,583 13,547Comments:

Actual 12,323 12,237 12,838 11,971 11,597 12,087 11,847 12,023 12,436 11,226 12,823 12,549 13,039

Plan 11,721 11,493 11,934 11,116 11,213 11,441 10,801 10,952 11,105 10,252 11,791 12,583 13,547Comments:

Total A&E Attendances excluding

Planned Follow Ups

Total Non-Elective Admissions

Average Number of G&A Beds open per

day

Type 1 A&E Attendances excluding

Planned Follow Ups

Information Services 2 of 15 Activity

FandP


Target


current

Accident and Emergency> 95% Actual 88.3% 88.1% 84.0% 87.0% 89.2% 86.4% 86.8% 85.1% 80.5% 77.6% 82.2% 80.0% 81.4% 81.1%

Plan 86.7% 85.8% 84.7% 90.6% 90.0% 89.0% 89.2% 88.7% 87.1% 84.2% 83.5% 85.2% 86.6% 86.8%Comments:

Actual 953 976 941 849 785 949 977 1,103 1,153 986 1,099 1,037 998


Actual 503 571 576 476 381 463 504 606 683 544 463 453 380 106

Plan 614 696 654Comments:

Actual 81 88 134 80 59 90 69 160 216 188 80 171 72 35

Plan 131 137 130 Comments:

Diagnostic Test Waiting Times Actual 12,711 11,213 11,768 12,442 13,249 11,966 11,627

Plan 11,809 11,783 Comments:

Actual 13,862 12,874 13,373 13,451 14,787 13,914 13,411


< 1% Actual 17.1% 14.5% 13.4% 13.9% 11.0% 7.7% 8.3% 12.9% 12.0% 7.5% 10.4% 14.0% 13.3%

Plan 9.0% 8.8%Comments:

Count of Ambulance handover delays 15-

30 mins

Performance vs Trajectory

Accident and Emergency - Performance

%

Count of Ambulance handover delays 30-

60 mins

Count of Ambulance handover delays

60+ mins

Number Waiting < 6 Weeks

Total Number Waiting

DM01 Performance %

Information Services 3 of 15 Performance

FandP


Target


current


Referral to Treatment Actual 21,125 21,306 20,841 20,518 20,316 20,596 20,764 20,361 19,995 20,363 20,495 20,614 20,808


Actual 1,464 1,439 1,399 1,527 1,511 1,142 1,014 1,021 809 782 612 472 431

Plan

Comments:

Actual 30,107 30,153 29,366 29,393 29,302 28,938 28,551 28,015 27,043 27,020 29,906 26,838 26,635

Plan 30,107 30,222 30,520 30,207 30,187 30,297 30,109 29,789 29,899 30,025 30,118 26,226 26,071Comments:

> 92% Actual 70.2% 70.7% 71.0% 69.8% 69.3% 71.2% 72.7% 72.7% 73.9% 75.4% 76.1% 76.7% 78.1%

Plan 70.2% 70.1% 70.9% 72.0% 72.8% 73.5% 73.9% 74.2% 73.0% 72.8% 72.6% 76.0% 76.5%Comments:

Actual 322 312 294 299 300 234 169 144 96 110 29 6 10 7

Plan 322 315 309 290 255 220 187 140 85 43 0 0 0Comments:

Actual 1,976 1,835 2,016 2,099 1,958 1,970 2,059 1,585 2,070 1,751 1,847 1,762 1,793

Plan 1,821 1,920 1,878 1,730 1,834 2,055 2,005 1,460 1,359 1,456 1,700 1,757 1,845Comments:

Actual 7,295 7,214 7,803 6,874 7,154 8,594 8,594 6,911 8,661 7,463 8,217 7,531 8,109

Plan 6,861 6,720 6,122 6,213 6,672 6,919 7,007 5,371 7,091 6,491 6,447 7,068 7,422Comments:

Actual 10,321 9,825 9,839 9,367 9,338 10,798 10,621 8,372 10,115 9,326 10,170 9,446 10,225

Plan 10,119 10,109 9,539 9,561 9,570 10,199 9,964 7,561 9,247 8,646 9,410 8,807 9,247Comments:

Actual 32,134 31,433 31,410 32,499 32,541 32,224 31,116 32,858 33,143 32,106 32,015 33,225 33,673

Plan

Comments:

Number of incomplete RTT pathways <=

18 weeks

Number of incomplete RTT pathways >

40 Weeks

Number of incomplete RTT pathways

Total

Referral to Treatment Incompletes -

Performance %

Number of Incomplete RTT pathways >

52 weeks

Number of completed admitted RTT

pathways

Number of completed non-admitted

RTT pathways

Number of New RTT pathways

Number of Overdue Outpatient Review

Appointments


FandP


Target


current


Cancer> 93% Actual 96.0% 96.4% 96.2% 96.3% 98.6% 97.8% 96.3% 97.7% 97.8% 96.9% 96.1% 96.6% 97.5%


> 93% Actual 88.8% 89.7% 85.4% 86.2% 96.7% 96.4% 97.5% 89.4% 97.0% 92.6% 92.4% 92.1% 95.7%


> 96% Actual 99.3% 97.9% 98.0% 100.0% 97.2% 98.2% 100.0% 100.0% 97.8% 100.0% 97.0% 98.6% 92.7%


> 94% Actual 95.2% 100.0% 94.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%


> 98% Actual 100.0% 97.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.7% 100.0%


> 94% Actual N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Plan N/A N/AComments:

> 85% Actual 69.1% 73.0% 75.0% 73.1% 74.7% 72.2% 75.0% 79.2% 71.1% 73.2% 80.0% 76.5% 64.3%

Plan 68.2% 72.4% 73.3% 73.3% 73.6% 76.7% 79.3% 79.3% 80.0% 80.3% 81.1% 73.3% 75.7%Comments:

> 90% Actual 77.8% 77.8% 87.5% 90.9% 100.0% 100.0% 92.3% 100.0% 81.8% 100.0% 100.0% 80.0% 57.0%


Actual 83.3% 85.7% 100.0% 80.0% 100.0% 57.1% 100.0% 42.9% 80.0% 72.7% 83.3% 80.0% 71.4%


Other Actual 77.8% 77.8% 90.2% 90.0% 88.9% 86.8% 89.8% 87.7% 89.7% 92.5% 89.0% 85.2%

Plan

Comments:

Actual 28 6 2 7

Plan

Comments:

Cancer Waiting Times - 31 Day Surgery

Cancer Waiting Times - 31 Day Drugs

Cancer Waiting Times - 2 Week Wait

Cancer Waiting Times - 2 Week Wait

(Breast Symptoms)

Cancelled Patients not offered another

date within 28 days

Cancer Waiting Times - 62 Day Upgrade

Dementia assessment and referral:

appropriately assess

Cancer Waiting Tmes - 31 Day

Radiotherapy

Cancer Waiting Times - 62 Day GP

Referral

Cancer Waiting Times - 62 Day

Screening

Cancer Waiting Times - 31 Day First

Treatment


FandP


Target


current

Unplanned Care< 5 Actual 4.55 4.39 4.41 4.31 4.22 4.35 4.01 4.39 4.31 4.60 4.54 4.30 4.20

Plan

Comments:

< 4.1 Actual 4.82 4.71 4.69 4.58 4.51 4.64 4.35 4.66 4.57 4.85 4.86 4.64 4.40

Plan

Comments:

< 2.4 Actual 2.68 2.20 2.32 2.44 2.31 2.48 1.80 2.33 2.23 2.63 2.40 2.60 2.80

Plan

Comments:

Actual 90.2% 88.7% 90.7% 86.6% 88.0% 87.9% 87.0% 91.0% 96.0% 95.0% 94.0% 96.3%

Plan

Comments:

Actual 82.8% 80.5% 83.2% 79.0% 82.5% 83.3% 83.0% 86.0% 91.0% 89.0% 91.4% 84.1%

Plan

Comments:

Actual 346 340 321 335 304 282 268 286 312 282 292 298 289

Plan

Comments:

< 78 Actual 108 103 87 90 88 62 74 75 90 82 81 78 82

Plan

Comments:

< 8.3% Actual 6.6% 6.4% 7.1% 6.9% 7.2% 7.0% 7.1% 7.7% 7.2% 6.9% 7.1% 6.6% 5.6%

Plan

Comments:

Overall Non-Elective Length of Stay

Efficiency and Flow

Overall Average Length of Stay

Overall Elective Length of Stay

Bed Occupancy Midday

Bed Occupancy Midnight

Number of Stranded Patients (9am

Position at Month End) - 7+ Days

Number of Super Stranded Patients

(9am Position at Month End) - 21+ Days

30 day emergency readmissions rate

Information Services 6 of 15 Efficiency and Flow

FandP


Target


current

Efficiency and Flow

Planned CareActual 86.5% 87.2% 91.0% 91.3% 90.6% 91.8% 92.5% 90.3% 91.0% 92.0% 93.3% 92.5% 93.6%

Plan

Comments:

< 8% Actual 7.9% 8.0% 7.7% 7.9% 8.1% 7.7% 7.8% 8.4% 7.8% 7.0% 6.9% 7.3% 8.0%

Plan

Comments:

< 2 Actual 2.0 2.0 2.0 2.0 2.0 2.0 2.0 1.9 2.1 2.1 2.1 2.0 2.0

Plan

Comments:

Actual 74.7% 77.3% 75.5% 74.5% 76.6% 73.3% 75.4% 71.8% 72.9% 74.0% 75.6% 76.8%

Plan

Comments:

> 85.2% Actual 88.6% 88.3% 89.3% 87.6% 86.9% 87.1% 87.4% 87.3% 89.4% 88.4% 87.5% 88.9% 88.9%

Plan

Comments:

% of Elective Care Delivered via Day

Case

Outpatient New to Review Ratio

Outpatient Utilisation Rate

Elective Theatre Utilisation Rate

Outpatient Did Not Attend Rate

Information Services 7 of 15 Efficiency and Flow

FandP



Target


current

Performance

0 Trust 0 0 0 0 0 0 0 0 0 0 0 1 0

Trajectory

Comments:

0 Trust 0 0 0 0 0 0 0 0 0 0 0 0 0

Trajectory

Comments:

Trust 144 151 144 102 130 132 136 124 117 138 101

Trajectory

Comments:

80 Trust 101 113 97 68 88 91 99 74 79 92 61

Trajectory

Comments:

40 Trust 38 36 45 31 40 41 36 48 37 44 36

Trajectory

Comments:

0 Trust 5 1 2 2 2 0 0 2 0 0 1

Trajectory

Comments:

0 Trust 1 0 0 1 0 1 0 0 1 0 1 2 3

Trajectory

Comments:

0 Trust 6.7 7.4 7.2 5.0 6.4 6.4 6.3 6.3 5.6 6.7 4.8

Trajectory

Comments:

30 Trust 44 28 36 22 17 32 19 22 47 40 35 34 37

Trajectory

Comments:

6 Trust 10 1 11 4 5 1 3 3 10 15 9 6 19

Trajectory

Comments:

0 Trust 0 0 0 0 0 1 0 0 0 0 0 0 0

Trajectory

Comments:

# Trust 2.50 1.40 2.20 1.30 1.10 1.70 1.10 1.20 2.60 2.80 2.10 1.90 2.70

Trajectory

Comments:

Patient Falls - No Harm

Safer

MRSA (hospital acquired)

Full ward closure due to outbreak

Patients Falls - All

Patient Falls - Minor Harm

Patient Falls - Moderate Harm

Patient Falls - Major or Catastrophic

Harm

Patient Falls (all) per thousand bed days

Pressure Ulcers (Grade 2 only)

Pressure Ulcers Grade 3

Pressure Ulcers Grade 4

Pressure Ulcers (2+) per thousand bed

days (acute - non-validated)

Information Services 8 of 15 Safer

FandP


Target


current

Safer

Trust 9 5 13 15 8 20 29 8 14 9 10 6 13

Trajectory

Comments:

95.0% Trust 92.7% 92.8% 92.8% 91.9% 92.5% 93.6% 94.3% 92.6% 93.3% 92.6% 93.7% 94.2% 94.2%

Trajectory

Comments:

0 Trust 12 20 26 21 11 10 3 11 5 3 2 5 5

Trajectory

Comments:

0 Trust 0 0 0 2 0 1 0 0 0 0 0 0 0

Trajectory

Comments:

Trust 1 0 0 0 0 1 1 0 0 0 0

Trajectory

Comments:

Trust 2.0 1.0 2.0 3.0 5.0 1.0 1.0 2.0 0.0 1.0 1.0

Trajectory

Comments:

36 Trust 6.0 3.0

Trajectory

Comments:

Trust 64 43 50 56 42 54 42 39 40 40 38 18 33

Trajectory

Comments:

100 Trust 113

Trajectory

Comments:

# 0 Trust 119 117

Trajectory

Comments:

100 Trust 117 115 112 111 113

Trajectory

Comments:

95.0% Trust 90.2% 90.4% 90.8% 89.2% 92.2% 91.6% 94.1% 90.6% 89.7% 91.0% 92.4% 92.4% 89.8%

Trajectory

Comments:

95.0% Trust 93.1% 92.0% 92.8% 92.0% 94.7% 92.3% 91.8% 92.9% 94.5% 91.7% 94.6% 93.6% 93.5%

Trajectory

Comments:

TBD Trust 11 4 7 6 5 7 2 10 4 6 3 6 5

Trajectory

Comments:

TBD Trust 265 194 263 202 178 274 345 315 384 298 247 299 190

Trajectory

Comments:

VTE %

Serious Incidents - Raised in Month

Medical Outliers

Catheter Associated UTI

Number of Never Events

C.Diff plan: Actual versus Plan

C.Diff: Overall infection rate

Complaints Received in Month

SHMI - Rolling 12 Month Offical Release

Trust Attributed C. Diff

SHMI - Rolling 12 Month

HSMR - Rolling 12 Month

Safety Thermometer - Acute

Safety Thermometer - Community

Gram Negative blood stream infections

Information Services 9 of 15 Safer

FandP



Target


current

Performance Trust 96.0% 96.0% 94.0% 93.0% 92.0% 95.0% 92.3% 91.9% 95.4% 95.0% 97.0% 95.0% 91.0%

Trajectory

Comments:

0 Trust 78 65 66 76 59 4 0 19 4 36 0 0 0

Trajectory

Comments:

Trust 84.0% 85.0% 85.0% 85.0% 85.0% 87.0% 87.0% 85.0% 89.0% 85.0% 89.0% 89.0% 90.0%

Trajectory

Comments:

Trust 88.0% 89.0% 88.0% 88.0% 88.0% 84.0% 83.0% 87.0% 84.0% 87.0% 84.0% 85.0% 86.0%

Trajectory

Comments:

95.0% Trust 80.5% 76.2% 75.1% 79.3% 78.1% 80.5% 74.1% 78.8% 75.9% 73.0% 75.2% 74.7% 73.3%

Trajectory

Comments:

Trust 7.3% 7.5% 7.1% 9.4% 6.5% 6.8% 6.1% 5.1% 4.6% 5.2% 5.7% 8.0% 6.2%

Trajectory

Comments:

95.0% Trust 96.6% 96.0% 87.4% 90.6% 86.4% 80.8% 81.9% 66.7% 84.8% 100.0% 93.1% 88.5% 92.9%

Trajectory

Comments:

Trust 1.1% 0.3% 0.2% 0.2% 0.2% 0.2% 0.1% 0.1% 0.2% 0.4% 0.3% 0.6%

Trajectory

Comments:

95.0% Trust 97.8% 97.2% 97.4% 97.9% 97.1% 97.6% 98.2% 97.6% 97.5% 99.3% 99.0% 97.3% 96.8%

Trajectory

Comments:

Trust 23.0% 23.2% 20.0% 24.0% 17.7% 19.0% 19.6% 15.0% 13.6% 16.8% 18.1% 16.5% 12.5%

Trajectory

Comments:

95.0% Trust 98.7% 100.0% 100.0% 100.0% 98.3% 100.0% 96.3% 100.0% 100.0% 100.0% 100.0% 97.3% 98.8%

Trajectory

Comments:

Trust 20.2% 20.7% 8.6% 23.2% 16.6% 22.4% 16.3% 20.6% 16.4% 18.9% 21.4% 23.1% 26.1%

Trajectory

Comments:

FFT - Recommendation Rate - Inpatients

Caring

Hand Hygiene Audit - Nursing

Mixed Sex Accomodation Breaches

Safeguarding Level 1 Training (trust)

Safeguarding Level 2 Training (trust)

FFT - Recommendation Rate - A&E

FFT - Response Rate - A&E

FFT - Recommendation Rate -

Outpatients

FFT - Response Rate - Outpatients

FFT - Response Rate - Inpatients

FFT - Recommendation Rate - Maternity

FFT - Response Rate - Maternity

Information Services 10 of 15 Caring

FandP


Target


current

Caring

95.0% Trust 100.0% 100.0% 100.0% 99.4% 100.0% 98.9% 99.2% 100.0% 98.2% 98.2% 99.2% 99.4%

Trajectory

Comments:

Trust 1.3% 1.5% 1.4% 1.3% 1.6% 1.4% 2.0% 1.3% 1.3% 1.4% 3.9% 2.8%

Trajectory

Comments:

FFT - Recommendation Rate -

Community

FFT - Response Rate - Community

Information Services 11 of 15 Caring

FandP



Target


current

Patient ExperienceTrust 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Trajectory

Trust 2 6 3 0 1 3 2 0 3 0

Trajectory

Comments:

Trust 100% 100% 100% 100% 100% 100% N/A 100% 100% N/A

Trajectory

Comments:

Trust 59.0% 54.4% 57.8% 52.0% 46.5% 57.0% 63.2% 64.4% 53.3% 50.0%

Trajectory

Comments:

Trust 100.0% 100.0% 100.0% 100.0% 100.0% 35.0% 31.0% 44% 30% 3%

Trajectory

Comments:

Clinical EffectivenessTrust 90.2% 89.2% 90.9% 93.3% 93.6% 94.6% 93.6% 90.1% 90.1% 81.1%

Trajectory

Comments:

Trust 90.0% 91.1% 90.0% 89.6% 89.9% 88.3% 88.7% 89.5% 89.5% 86.9% 86.9% 87.4%

Trajectory

Comments:

Trust 98.6% 100.0% 100.0% 99.2% 100.0% 100.0% 100.0% 100.0% 100.0% 98.0% 96.2% 98.5%

Trajectory

Comments:

Trust 100.0% 100.0% 100.0% 88.7% 100.0% 100.0% 100.0% 100.0% 100.0% 82.0% 80% 83.2%

Trajectory

Comments:

Trust 97.3% 89.0% 87.0% 76.5% 81.0% 75.0% 75.0% 75.0% 83.0% 62.0% 67% 83.2%

Trajectory

Comments:

Governance

Complaints acknowledged within 3

working daysComments:

Complaints investigated within

timescale agreed with complainant

Adherence to NICE guidance (exc.

Quality Standards)

Complaints action plans drafted

Complaints action plans implemented

PALs concerns responded to within 5

working days

Following approval at governance, Quality

Accounts and National Clinical Audit and

Patient Outcome Programme (NCAPOP)

national audits are on target to have action

plans completed

Documents in compliance within

document control system

Quality Accounts and National Clinical Audit

and Patient Outcome Programme (NCAPOP)

national audits are on target for completion

within timescales

Quality Accounts and National Clinical Audit

and Patient Outcome Programme (NCAPOP)

national audits are on target to have an

action plan developed and agreed at

Governance

Information Services 12 of 15 Governance

FandP


Target


current

Governance

Patient SafetyTrust 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 88.0% 88.0% 88.0%

Trajectory

Comments:

Trust 27.5% 32.1% 46.6% 22.4% 56.3% 43.0% 0.0% 0.0% 17.0% 55.0% 26.0%

Trajectory

Comments:

Trust 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 33.0%

Trajectory

Comments:

Trust 100.0% 100.0% 66.7% 100.0% 100.0% 60.0% 62.5% 37.0% 56.0% 100.0% 100.0%

Trajectory

Comments:

Trust 100.0% 100.0% 92.3% 93.3% 100.0% 93.0% 100.0% 100.0% 80.0% 77.0% 75.0%

Trajectory

Comments:

Trust 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Trajectory

Comments:

Patient Safety Alerts to be actioned by

the specified deadlines

CCG incidents responded to within 20

working days

SIs reported to commissioners within 48

hours of SI being confirmed

SI responded to within the re-

negotiated timescale

Duty of candour met in line with Trust

policy (SIs)

SI responded to within the required 12

week timescale

Information Services 13 of 15 Governance

FandP



Target


current

Performance 80.0% Trust 97.6% 95.0% 95.0% 92.5% 94.8% 97.9% 99.0% 95.8% 97.2% 96.5% 97.6% 97.6% 96.8%

Trajectory

Comments:

80.0% Trust 103.1% 98.3% 96.8% 98.0% 86.4% 103.6% 97.6% 97.3% 97.8% 99.0% 100.6% 100.9% 100.3%

Trajectory

Comments:

7.3 Trust 7.5 7.0 7.2 7.6 7.9 8.0 7.9 7.6 7.6 7.3 7.6 7.5 7.6

Trajectory

Comments:

Trust 28.5 25.4 39.7 43.5 34.5 29.6 45.5 34.3 29.4 30.5 33.5 33.5 33.8

Trajectory

Comments:

0.8% Trust 0.9% 1.2% 0.6% 0.5% 0.8% 0.9% 0.9% 0.7% 0.6% 0.6% 0.7% 0.7% 0.7%

Trajectory

Comments:

Trust 9.8% 9.7% 9.2% 9.2% 8.0% 7.4% 6.5% 6.9% 6.5% 6.2% 6.2% 7.0% 7.0%

Trajectory

Comments:

< 15.0% Trust 21.9% 21.9% 21.1% 18.7% 16.1% 14.3% 16.9% 15.9% 14.8% 14.0% 14.5% 15.9% 15.5%

Trajectory

Comments:

< 6.0% Trust 10.4% 10.6% 11.2% 12.1% 11.9% 11.2% 7.4% 8.4% 8.6% 8.4% 8.6% 9.8% 10.0%

Trajectory

Comments:

< 2.0% Trust 2.9% 2.9% 3.8% 3.9% 2.5% 1.8% 1.5% 2.3% 2.0%

Trajectory

Comments:

Trust £2,114 £1,965 £2,265 £2,388 £2,148 £2,245 £1,896 £1,928 £1,817 £1,577 £1,085 £1,525

Trajectory

Comments:

< 4.1% Trust 4.0% 4.5% 4.5% 4.2% 4.2% 4.3% 4.1% 4.0% 4.7% 4.8% 4.4% 4.3%

Trajectory

Comments:

Trust 9.1% 8.4% 7.9% 7.4% 8.3% 8.8% 8.9% 8.4% 8.7% 8.7% 8.8% 8.7% 8.6%

Trajectory

Comments:

Proportion of temporary staff

Nursing staff vacancy - Unregistered

Total Agency expenditure (£000)

Sickness levels

Medical staff vacancy

Nursing staff vacancy - Registered

Care Hours per Patient per Day

(CHPPD)

Staff Turnover FTE

% Turnover rate

People

Safer Staffing fill rate - Registered Staff

Safer Staffing fill rate - Carer Staff

% Vacancy factor

Information Services 14 of 15 People

FandP


Target


current

People

> 85.0% Trust 87.0% 83.0% 81.0% 83.0% 81.0% 78.0% 76.0% 77.0% 79.0% 80.0% 80.0% 81.0% 82.0%

Trajectory

Comments:

> 95.0% Trust 75.0% 72.0% 68.0% 67.0% 76.0% 66.0% 69.0% 67.0% 72.0% 75.0% 74.0% 75.0% 76.0%

Trajectory

Comments:

Trust 26.3% 28.4% 28.2% 34.3% 38.7% 46.9% 50.6% 54.1% 54.6% 53.4% 49.2%

Trajectory

Comments:

% Trust wide mandatory training

compliance

PADR rate

Distance from providers gap

(cumulative)

Information Services 15 of 15 People

IPR- Jun-19

NLaG Mortality Focus

Mortality Statistics:Crude Mortality: Non- Moving Annual Totals: (Site-Split)

Comments:

National Mortality Indicators:

NHS Digital SHMI Mortality: 114 HED SHMI Mortality: 110 HSMR Mortality: 109

Comments:

Comments: Comments:

Latest HSMR puts the trust at 109 (Jan-19: HED- DPOW: 118/ SGH: 105)

with statistics presenting a decline since Feb-18 at both sites with DPOW

consistently incurring a higher rate than SGH.

The most recent SHMI (NHS Digital) published in Jun-19 (Period: Feb18 –

Jan19) places the trust at 114 ranking as ‘Higher than Expected’.

Mortality Focus

Latest NLaG Crude Mortality displays the trust's crude rate at both sites performing within statistically-defined control limits; with DPOW performing in adherence with peer average but SGH incurring more deaths than peer benchmarkers.

The latest winter peak displays smaller number of deaths compared to previous winter peak periods in the past 2 years. NLaG (both sites) still remains higher than National Average benchmark.

Latest NLAG SHMI (HED) places trust at 110 (Dec-19) ranking as 'As Expected'.

NLAG had of SHMI score of 99 for 'In hospital' deaths and 137 for 'Out of Hospital'

deaths higher than the national rate average (Only 6 other trust higher values than

NLAG for out of hospital deaths). NLAG is an outlier based on post-30 discharge

deaths mostly driven by difference in denominator (Expected value lower for

DPOW than SGH) despite similar number of comorbidities per spell at both sites)

Information Services 1 of 3 Mortality

IPR- Jun-19

Learning From Deaths:

Mortality Themes & Actions: Since April 18 to Date:

1. EOL/ DNAR Themes

EOL Strategy Group:

M&M Meetings:

2. Medical Models/ Oxygen Care Themes:

M&M Meetings:

3. Fluid/ Electrolyte Management Themes:

Improved Fluid Balance Surveillance Tool:

NMAF/ Nursing Forum Collaboration:

4. Community/ Primary Care Themes:

Bi-Monthly Community Collaborative Alliance:

Refreshed bedside documentation which includes fluid balance documentation to improve ownership and

accountability along with supporting escalation where necessary

Business case for increased staffing resource at SGH to support placement of NG tubes when needed to

ensure equitable services

Sharing of Fluid & Electrolyte themes with the Trust's Nursing/NMAF Group to address highlighted issues

with fluid management.

NLaG Learning From Deaths Dashboard displays the total deaths in scope, reviewed and RCP Avoidability score summary. This also includes a summary of Learning Diasabilty in scope.

Individual and thematic learning points highlighted in specialty Mortality & Morbidity meetings driving

improvement projects as necessary to ensure learning lessons are achieved. Themes are also taken to

Quality and Safety Committee.

Cases highlighted Fluid issues in care relating to the following: Inadequate Fluid Management/ Monitoring-

Intake/ Outake, Maintenance/ Improvement of I/O Chart, No adequate/ timely fluids administered, SALT

Review delay, etc.

Cases highlighted EOL issues in care relating to the following: Earlier initiation EOL pathway, Poor/

incorrect/ incomplete documentation, Anticipatory medication not discussed/ in EOL plan, EOL not

considered in certain deteriorating cases, Issues relating to EOL decision making, etc.

Cases highlighted DNAR issues in care relating to the following: Earlier initiation of DNAR, No completion

of DNAR documentation, earlier discussion with family/ PAO holders, incomplete document completion of

DNAR, etc.

Sharing of EOL related themes with the Trust's EOL Strategy Group and the Multi-agency EOL Strategy

Group.

Individual and thematic learning points highlighted in specialty Mortality & Morbidity meetings driving

improvement projects as necessary to ensure learning lessons are achieved. Themes are also taken to

Quality and Safety Committee.

Cases highlighted Medical Model compliance issues in care relating to the following bundles: Sepsis 6

Pathway, Decompensated cirrhosis, Liver Disease.

Cases highlighted Oxygen Care issues in care relating to the following: Poor/Inadequate oxygen

prescription & administration, inadequate monitoring and documentation, Inappropriate high 02

administration, etc.

Cases highlighted care issues stemming from Community/ primary care presenting gaps within services

and an opportunity for improvement. Thsi related to the following: Better Advance Care Plan in Community

required, Anticoagulation Monitoring in AF Patients, DNAR, Fast track discharge To Community/ Hospice

Care, etc.

Closer collaborative case note review processes with GP and community partners to understand further

detail regarding patients deemed to have had an inappropriate hospital admission to support the need for

further action in response.

Northern Lincolnshire and Goole NHS Foundation Trust: Learning from Deaths Dashboard - June 2019-20

* Total deaths being reviewed via RCP methodology includes deaths confirmed as an SI post SJR review also.

Start date Q1 Q1

This Month 0 0.0% This Month 0 0.0% This Month 0 - 0.0% This Month 0 0.0% This Month 2 100.0% This Month 0 0.0%

This Quarter 0 0.0% This Quarter 0 0.0% This Quarter 0 - 0.0% This Quarter 1 2.0% This Quarter 3 6.1% This Quarter 45 91.8%-

This Year 0 0.0% This Year 0 0.0% This Year 0 - 0.0% This Year 1 2.0% This Year 3 6.1% This Year 45 91.8%

2019-20 Q1

PLEASE NOTE: THERE IS ALWAYS A DELAY IN LEDER REVIEWS AS PROCESS IS TIME-CONSUMING

This Month:

(Jun-19)

This Month:

(Jun-19)

This Month:

(Jun-19)

20 0 0

This Quarter:

(Q1. 1920)This Quarter:

(Q1. 1920)

This Quarter:

(Q1. 1920)

0 0 0

This Year:

(Q1. 1920)

This Year:

(Q1. 1920)

This Year:

(Q1. 1920)

0 0 0

72

290

1023

Previous Month: (May-19)

139

Previous Quarter: (Q4. 1819)

553

Previous Year: (FY. 1819)

1765

199

13

Previous Month:

(May-19)

Previous Quarter:

(Q4. 1819)

Previous Year:

(FY. 1819)

2019-20

Total Number of Deaths in Scope

(Includes A&E deaths)

This Month: (Jun-19)

77

This Quarter: (Q1. 1920)

378

Total Learning Disability Deaths and total reviewed under the LeDeR methodology: End dateQ12016-17Start date

0

This Year:

(Q1. 1920)

0

This Month:

(Jun-19)

NQB Deaths: Non- NQB Deaths:

Score 6Definitely Avoidable Strong evidence of Avoidability Probably Avoidable (>50:50) Probably Avoidable (<50:50) Slight evidence of Avoidability Definitely not Avoidable

NQB Deaths:

This Quarter:

(Q1. 1920)

13

This Year:

(Q1. 1920)

This Month:

(Jun-19)

0 4

26

100

Total Deaths considered to have been Potentially Avoidable- (RCP<=3)

This Month: (Jun-19) Previous Month: (May-19)

0 0

This Quarter: (Q1. 1920) Previous Quarter: (Q4. 1819)

End date:

This Year:

(Q1. 1920)

199

Time Series: 2016-17

44 351

8 18 44 112

This Year:

(Q1. 1920)

Previous Year:

(FY. 1819)

This Year:

(Q1. 1920)

Previous Year:

(FY. 1819)

8 86

5 5 0

2 2 0

Previous Year:

(FY. 1819)

Previous Year:

(FY. 1819)

Previous Year:

(FY. 1819)

Summary of total number of deaths and total number of cases reviewed under the Structured Judgement Review Methodology

This Year: (From Q1. 1920)

378

0 4 0 16

This Quarter:

(Q1. 1920)

Previous Quarter:

(Q4. 1819)

This Quarter:

(Q1. 1920)

Previous Quarter:

(Q4. 1819)

Total Mortality SJR Reviewed: *

This Month:

(Jun-19)

Previous Month:

(May-19)

This Month:

(Jun-19)

Previous Month:

(May-19)

Previous Year:

(FY. 1819)

Non- NQB Deaths:

Total Mortality SJR Distributed:

This Month:

(Jun-19)

Previous Month:

(May-19)

24

This Quarter:

(Q1. 1920)

Previous Quarter:

(Q4. 1819)

This Year: (From Q1. 1920) Previous Year: (FY. 1819)

0 2

0 4

Total Death under SI framework:Confirmed SI Prior-SJR:

Previous Month:

(May-19)

Avoidable deaths data: This is an assessment of whether the death was felt to be avoidable or not, using a Likert-type 6 factor scale. This is the initial reviewer’s assessment from the retrospective assessment of the medical record. Any case

reviews completed that identify that further understanding is needed is reviewed a second time by another clinician. This process links into the Trust’s Serious Incident Framework if necessary. It should be stressed that this data is not a reliable

measure of deaths that were avoidable, rather it is designed as an indicator to support local review and learning processes with the aim of helping improve quality of care.

Score 1

Total Deaths Reviewed by RCP Methodology Score:Score 2 Score 3 Score 4 Score 5

Previous Month:

(May-19)

Confirmed SI Post-SJRThis Month:

(Jun-19)

Considered for SI Post-SJRThis Month:

(Jun-19)

Previous Month:

(May-19)

0

This Year:

(Q1. 1920)

0

0

0

This Year:

(Q1. 1920)

0

This Quarter:

(Q1. 1920)

Previous Quarter:

(Q4. 1819)

Previous Year:

(FY. 1819)

0

This Quarter:

(Q1. 1920)

0

3

14

0

Previous Quarter:

(Q4. 1819)

0

Previous Year:

(FY. 1819)

0

0 0 0

Previous Quarter:

(Q4. 1819)

Previous Quarter:

(Q4. 1819)

Previous

Quarter:

(Q4. 1819)

Total Number of LD

Deaths in scope

Total Deaths 'In Progress'

through LeDeR Methodology

(or equivalent).

Total Deaths

considered potentially

Avoidable

Previous Month:

(May-19)

0

Previous Quarter:

(Q4. 1819)

2

Previous Year:

(FY. 1819)

9

Previous Month:

(May-19)

Previous

Month:

(May-19)

0

This Quarter:

(Q1. 1920)

0

100

200

300

400

500

600

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

2016-17 2017-18 2018-19 2019-20

Tota

l Dea

ths

Mortality over time, total deaths reviewed and deaths considered to have been potentially

avoidable(Note: Changes in recording or review practice may make comparison over time invalid)

Total deaths Deaths reviewed

0

1

2

3

4

5

6

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

2016-17 2017-18 2018-19 2019-20

Tota

l Dea

ths:

LD Mortality over time, total deaths reviewed and deaths considered to have been potentially

avoidable(Note: Changes in recording or review practice may make comparison over time invalid)

Series1 Series2 Series3


IPR- Jun-19

Learning From Deaths:

Perinatal Mortality (PMRT) Themes & Consequent Actions:1. Late Bookings:Guidelines for women who book late for pregnancy care from our definition should be booked for serial scans.

Green Top Guideline number 57 (Reduced Fetal Movement) considers issues with an access to care as a factor for

an increased risk of stillbirth. The group was in agreement that late booking constitutes poor access to care; therefore

guidelines are to be updated to reflect this.

NLaG Learning From Deaths Dashboard displays the total deaths in scope & reviewed using the Perinatal Mortality Review Tool.

Total Deaths: Since Dec-18 to current

Previous Month: (May-19)This Month: (Jun-19)

00Previous Quarter: (Q4.

1819)This Quarter: (Q1. 1920)

30

Previous Year: (FY. 1819)

30

This Year: (From Q1. 1920)

1 6

This Month: (Jun-19) Previous Month: (May-19)

This Quarter: (Q1. 1920)Previous Quarter: (Q4.

1819)

This Year: (From Q1. 1920) Previous Year: (FY. 1819)

0 1

Total Deaths Reviewed: Since Dec-18 to current

1 6
