Draft Quality Account 2015/16.

Presentation to HSC 17 March 2016

Tracey McErlain-Burns, Chief Nurse

Quality ambitions 2014-16

SAFE - Mortality. Reduction in HSMR year on year

SAFE – Achieve 96% Harm Free Care (HFC) with zero

avoidable grade 2-4 pressure ulcers and zero

avoidable falls with harm

CARING & Achieve improvement in all Friends andCARING & Achieve improvement in all Friends and

RELIABLE - Family (FFT) responses

RELIABLE – Achieve all national waiting times targets i.e.

18 weeks, cancer and A&E

Quality improvements 2015/16• 100% of unpredicted deaths will be subject to review

• From a baseline of 120 we will reduce the number of

patients with a LOS >14/7

• Improved reporting of the deteriorating patient

• Reduce noise at night• Reduce noise at night

• Increase the number of colleagues trained in

dementia care & reduce complaints

• Improve complaints response times

• Meet stroke targets

So how have we done?Mortality

• Rolling 12 month HSMR:

– December 2014 = 99.28

– November 2015 = 108.06

(March 2015 – 112.48)(March 2015 – 112.48)

• SHMI July 2014 to June 2015:

– 111.64

Harm Free Care

Achieve minimum 96% Harm Free Care with the following percentage

reduction on the 2014/15 baseline:

No. Trending at

94.85%; a 0.5%

improvement on the

previous year.

Yes – 74% achieved.

• 70% reduction in avoidable pressure ulcers grade 2-4

• 50% reduction in avoidable falls with significant harm

Yes – 74% achieved.

Yes – 57% achieved.

Harm Free Care

FFT

Achieve and maintain a minimum 95% positive Friends and Family Test (FFT)

score – in-patients

Yes – 97% achieved

Achieve and maintain a minimum 86% positive Friends and Family Test (FFT)

score – A&E

Yes – 88% achieved

Achieve a 40% FFT response rate – in-patient areas. Yes – 41% achieved.

FFT

FFT

FFT

National targets – 4 hour access

4 hour access – national comparison

Period TRFT

Performance

TRFT Rank

(of 140)

England Avg

(Type 1)

No. of Trusts

>95% (Type 1)

April 93.3% 53 89.8% 31

May 97.3% 9 91.5% 45

June 97.1% 16 91.5% 53 Q1 95.7% 23 91.1% 44 Q1 95.7% 23 91.1% 44

July 93.7% 73 92.5% 55

August 88.6% 113 91.5% 44

September 93.9% 46 90.1% 34 Q2 92.1% 79 91.4% 43

October 92.5% 44 88.6% 21

November 93.7% 29 87.1% 14

December 85.5% 82 86.6% 14 Q3 90.5% 58 87.4% 12

Cancer

TRFT Cancer Performance Q1 to Q3 15/16

Target

Operational

Standard

Q1

2015/16

Q2

2015/16

Oct

2015/16

Nov

2015/16

Dec

2015/16

Q3

2015/16

National

(Q3)

2ww 93% 94.6% 94.8% 95.2% 95.4% 94.1% 94.9% 94.8%

31 Day First Definitive Treatment 96% 98.6% 98.8% 100.0% 97.0% 100.0% 99.1% 97.9%

62 Day from 2ww 85% 88.7% 85.1% 84.4% 88.9% 100.0% 91.2% 83.5%

Breast Symptoms 2ww 93% 97.3% 96.5% 100.0% 98.1% 97.3% 98.4% 93.4%

31 day Subsequent Treatment

Surgery 94% 100.0% 95.8% 100.0% 100.0% 100.0% 100.0% 96.2%

Drug 98% 100.0% 99.6% 100.0% 100.0% 100.0% 100.0% 99.6%

Palliative Care TBC 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%100.0%

62 Day Screening 90% 100.0% 95.7% 100.0% 100.0% 100.0% 100.0% 93.5%

18 weeks

TRFT 18 week RTT Performance Apr’15 to Oct’15

Q4

Apr May June Jul Aug Sep Oct Nov Dec Jan

Admitted

Clock Stops 1,802 1,601 1,509 1,730 1,353 1,617 1,662 1,380 1,065 1,176

Performance

Q1 Q2 Q3

Non-Admitted

Clock Stops 4,149 3,890 5,296 5,087 4,145 4,509 4,681 4,355 4,681 3,715

Incompletes

Total PTL 9,798 11,072 11,576 10,141 9,750 11,061 11,176 12,171 11,176 12,511

97.2%

91.3%

96.3%

96.0%96.1% 95.0%

Performance

(Target = 90%)

Performance

(Target = 95%)

Performance

(Target = 92%)

89.6%

96.2%

96.8% 97.3% 97.2% 96.4% 95.2% 96.3%

91.2% 91.0%

99.4% 99.0% 98.9% 99.0% 98.5% 98.3% 97.7% 96.0%

93.8% 95.6% 94.5% 95.1% 94.1% 92.5%

Long length of stay patients

No. of long stay patients (>14 days)

27.927.829.0

30.031.1

33.634.232.2

33.5

29.731.2

28.627.928.7

27.227.0

29.529.830.5

32.430.931.0

34.8

32.4

35.134.1

30.0

35.0

40.0

90

100

110

No. of Patients Max Pat Count Long Stay - ALOS (days)

88 83 93 93 83 80 83 92 79 84 78 81 81 70 76 92 89 81 84 75 83 94 88 100 88 88

0.0

5.0

10.0

15.0

20.0

25.0

50

60

70

80

90

17-A

ug

24-A

ug

31-A

ug

07-S

ep

14-S

ep

21-S

ep

28-S

ep

05-O

ct

12-O

ct

19-O

ct

26-O

ct

02-N

ov

09-N

ov

16-N

ov

23-N

ov

30-N

ov

07-D

ec

14-D

ec

21-D

ec

29-D

ec

04-Jan

11-Jan

18-Jan

25-Jan

01-Feb

08-Feb

AL

OS

No

. o

f P

ati

en

ts

Date

Medically fit and long length of stay

Medically fit for discharge patients and LOS

10

12

14

16

18

50

60

70

80

Ave

rage

LO

S

No

. o

f M

FF

D

0

2

4

6

8

10

0

10

20

30

40

02/11/2015

04/11/2015

06/11/2015

09/11/2015

11/11/2015

13/11/2015

17/11/2015

21/11/2015

23/11/2015

25/11/2015

27/11/2015

30/11/2015

02/12/2015

04/12/2015

08/12/2015

10/12/2015

12/12/2015

15/12/2015

17/12/2015

19/12/2015

22/12/2015

24/12/2015

29/12/2015

31/12/2015

05/01/2016

07/01/2016

09/01/2016

11/01/2016

14/01/2016

18/01/2016

20/01/2016

22/01/2016

26/01/2016

28/01/2016

Ave

rage

LO

S

No

. o

f M

FF

D

No. of MFFD Avg of No. of days MFFD

Other improvement priorities

100% unpredicted death reviews Yes

Reporting of the deteriorating patient yes

Noise at night ?

Dementia training yes

Complaints performance No

Stroke targets yes

61% of TRFT

colleagues have had

first level dementia

training

Improved proportion with AF anti

coagulated on discharge; proportion

admitted directly to stroke unit and

spending 90% of their time on the

stroke unit; proportion scanned within

an hour. Business case for allied health

professional ESD team supported.

Other items to be covered in the

Quality Account / Report

• Staff and patient survey results

• Listening into Action work

• Environmental improvements

• Community transformationCommunity transformation

• Progression from the CQC action plan to a Quality

Improvement Plan

• Serious incidents and Never Events

• Data Quality

• Workforce