item 8 trust quality and performance report june...

Trust Quality and Performance Report

June 2012

Contents

Slide numbers

Clinical Quality Priorities inc Ward Dashboard 4 - 17

CQUIN 18 – 21

Local Priorities 22 – 28

Monitor Compliance 29 – 30

Contract Priorities 31 – 35

2

Introduction

This Corporate Trust Dashboard provides narrative for performance in

five key areas: Clinical Quality Priorities, CQUIN Performance, Local

Priorities, Monitor Compliance and Contract Priorities.

3

Clinical Quality Priorities

Summary

The quality report this month incorporates new performance metrics for 2012-13.

The new net promoter score was introduced this month within the patient experience surveys. This

uses a nationally set question, response set and scoring system explained in last months report.

Initial scores appear positive; benchmarked scores will be available in the future to compare our

performance with other Trusts.

Pressure ulcer performance has decreased this month and this will be addressed at the pressure

ulcer prevention group and an action plan developed to improve performance. Pressure ulcers are

presented differently on the dashboard as there are now subsections of Grade 2 and 3/4

prevalence to determine if they were avoidable or unavoidable.

4

Indicator Target

Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU/F2 EAU G5 Rehab F9 F10 G1 G3 G4 F7 G8 MTU F1 F11 F12

HII compliance 1a: Central venous catheter

insertion100% <85 85-99 100 100 100 100 100

HII compliance 1b: Central venous catheter

ongoing care100% <85 85-99 100 100 NIL 100 NIL 100 NIL NIL 100 NIL 100 100 NIL 100 100 NIL 100

HII compliance 2a: Peripheral cannula insertion 100% <85 85-99 100 100 100 100 100 100 100 100

HII compliance 2b: Peripheral cannula ongoing 100% <85 85-99 100 100 100 100 100 100 100 100 90 100 100 80 80 100 100 100 100 97

HII compliance 4a: Preventing surgical site

infection preoperative100% <85 85-99 100 100 100 100

HII compliance 4b: Preventing surgical site

infection perioperative100% <85 85-99 100 100 100 100

HII compliance 5: Ventilator associated

pneumonia100% <85 85-99 100 100 100

HII compliance 6a: Urinary catheter insertion 100% <85 85-99 100 100 100 100 100

HII compliance 6b: Urinary catheter on-going

care100% <85 85-99 100 100 100 100 100 100 100 100 100 100 100 90 100 100 100 99

No of patient falls 0 variable by ward 1 0 7 4 0 0 0 0 0 0 2 0 1 3 6 1 5 5 1 0 0 0 0 36

No of patient falls resulting in harm 0 > 0 0 0 0 3 1 0 0 0 0 0 0 0 0 0 0 1 0 0 2 1 0 0 0 0 8

No. of serious injuries or deaths resulting from

falls>0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

No of patients with ward acquired Grade 2

pressure ulcers0 > 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 3

No of patients with avoidable ward acquired

Grade 2 pressure ulcers0 > 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1

No of patients with ward acquired Grade 3 or 4

pressure ulcers0 > 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 2

No of patients with avoidable ward acquired

Grade 3 or 4 pressure ulcers0 > 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Nutrition: Assessment and monitoring 95% <85 85-94 95-100 100 100 100 100 100 100 100 100 100 100 100 100 90 90 100 100 99

Hydration: Patients having a risk assessment for

hydration100 100 100 100 100 100 10 100 100 100 100 100 100 100 100

Total no of MRSA bacteraemias: Hospital 2/yr > 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Total no of MSSA bacteraemias: Hospital > 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Total no of C. diff infections: Hospital 29/yr > 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 4

Hand hygiene compliance 95% <85 85-94 95-100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

No of SIRIs and potential SIRIs 0 >0 0 0 0 0 0 0 1 0 0 0 0 0 2 0 0 0 1 0 0 2 0 0 0 0 7

Antibiotic Audit: Prescribing 90% <80 80-89 90-100 0

Cardiac arrests: No. outside CCS 0 0 0 1 0 0 0 1 0 0 1 1 0 1 0 0 0 0 0 0 0 5

VTE: Completed risk assessment (monthly

Unify audit)> 98% < 98 > 98 99.0 100.0 99.6 100.0 100.0 100.0 94.4 100.0 98.4 100.0 100.0 100.0 100.0 100.0 94.4 100 100 98

Medical DirectorateSurgical DirectoratePerformance Rating

W&C Directorate

Pa

tie

nt

Sa

fety

TRUST

TOTAL

5

Indicator Target



W&C DirectorateTRUST

TOTAL

Patient Satisfaction: In-patient overall result 88 95 91 91 94 91 83 90 96 93 93 88 82 100 92

In your opinion, how clean was the hospital

room or ward that you are in?100 99 96 95 100 89 94 100 100 100 96 99 96 100 97

Were you ever bothered by noise at night from

other patients?64 90 76 77 88 71 79 81 82 80 80 61 32 100 76

Were you ever bothered by noise at night from

hospital staff?79 89 86 87 88 83 94 100 100 80 94 83 92 100 90

Were staff professional, approachable and

friendly?96 100 100 97 100 96 97 100 100 100 100 100 96 100 99

Did you find someone on the hospital staff to

talk to about your worries and fears? 93 95 98 91 93 88 82 82 96 88 90 88 75 100 90

Were you involved as much as you wanted to

be in decisions about your condition and

treatment?

95 97 91 95 88 96 86 80 100 100 95 87 92 100 93

Were you given enough privacy when

discussing your care?96 98 96 96 98 99 95 98 100 100 98 93 99 100 98

Were you given enough privacy when being

examined or treated?98 100 97 97 100 100 97 100 100 100 100 100 96 100 99

Did nurses talk in front of you as if you were not

there?95 98 95 99 98 98 93 100 100 100 99 100 99 100 98

Did doctors talk in front of youas if you were

not there?95 93 91 97 87 99 82 100 100 100 95 100 83 100 94

Before hand did a member of staff answer your

questions regarding your care/procedure? 100 99 96 98 100 100 100 99

Did the anaesthetist or a member of staff

explain to you how you would be put to sleep in

a way you could understand? 100 100 100 100 100 100 100 100

Timely call bell response 61 73 65 70 85 75 43 40 72 67 70 64 36 100 66

How likely is it that you would recommend the

service to friends and family? 57 92 81 77 92 95 58 100 100 100 96 83 82 100 84

Same sex accommodation 0 >2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Same sex accommodation: total patients 0 >2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Complaints 0 >2 1-2 0 0 0 0 1 0 0 0 0 2 0 0 0 2 0 0 0 0 1 1 0 0 0 0 22

Environment and Cleanliness 90% <80 80-89 90-100 85 90 92 93 95 84 83 94 89 93 90 90 79 88 92 86 82 87 95 91 92 96 85 90

Environmental audit 90% <80 80-89 90-100 0

85% <75 75-84 85-100

Pa

tie

nt E

xp

erie

nce

: in

-pa

tie

nt

6

Indicator Target




TOTAL

Patient Satisfaction: short-stay overall result99 99


examined and treated?100 100


friendly?100 100

Were you told who to contact if you were

worried after leaving hospital?98 99

Overall how would you rate the care you

received in the department? 100 98


service to friends and family?

95 98

85-100

Pa

tie

nt

Ex

pe

rie

nce

: sh

ort-

sta

y

<75 75-84

Patient Satisfaction: A&E overall result 92 92

How long did you wait to first speak to a doctor

or nurse?89 89


friendly?100 100

Did staff explain about your treatment and care

in a way you could understand?92 92

Were you able to talk to a member of staff

about your worries and fears?100 100


examined and treated?100 100

Do you think the hospital staff did everything

they could to help control your pain? 100 100

Did a member of staff tell you what danger

signs to watch for when going home?

84 84

Overall how would you rate the care you

received in the emergency department?79 79


service to friends and family?.84 84

If you're under 3 were you offered a teddy?100 100

If you are over 3 were you given a busy bag?0

Did the nurse or doctor involve you when

asking questions?100 100

Were the staff friendly and kind to you? 100 100

Did we help with your pain? 100 100

Were you given information about what care

you needed at home?100 100

85-100

75-84 85-100<75

Pa

tie

nt E

xp

erie

nce

: A

&E

85%

Pa

tie

nt E

xp

erie

nce

: A

&E

(C

hil

dre

n q

ue

stio

ns)

<75 75-8485%

7

Indicator Target




TOTAL

Patient Satisfaction: Maternity overall result92 92

In your opinion, how clean was the hospital

room or ward that you were in?97 97


friendly?97 97

Did you find someone on the hospital staff to

talk to about your worries and fears?

96 96

Were you involved as much as you wanted to

be in decisions about your care and treatment?

95 95


examined or treated?100 100

Did you hold your baby in skin to skin contact

after the birth (baby naked apart from the

nappy and a hat, lying on your chest)?

84 84

Were you given adequate help and support to

feed your baby whilst in hospital?

95 95

How many minutes after you used the call

button did it usually take before you got the

help you needed?

83 83

Has a member of staff told you about

medication side effects to watch for when you

go home?

91 91

Have hospital staff told you who to contact if

you are worried about your condition after you

leave hospital?

91 91



84 84

Pa

tie

nt

Ex

pe

rie

nce

: M

ate

rnit

y

<75 75-84 85-10085%

Were you as involved as you wanted to be in

decisions about your care and treatment?

100 100

Did you understand the information given to

you regarding your treatment and care?

100 100

Did you find someone to talk to about any

worries and fears you may have?90 90

Were you offered age/need appropriate

activities?90 90

Did you like the food choices you were offered?100 100

Was your experience in other hospital

departments (i.e. X-ray department, out-

patient department, theatre) satisfactory?

100 100

Was your experience during

procedures/investigations (i.e.blood tests, X-

rays) managed sensitively?

100 100

Were staff professional and approachable?100 100

Is the environment young person-friendly?100 100

Overall, how would you rate your experience in

the Paediatric Unit?90 90

Ch

ild

ren

's S

erv

ice

s P

ati

en

t S

ati

sfa

ctio

n:

Yo

un

g C

hil

dre

n

<75 75-84 85-100

8

Indicator Target




TOTAL

Were you and your child as involved as you

wanted to be in decisions about care and

treatment?

96 96

Did you understand the information given to

you regarding your child's treatment and care?

100 100

Did you find someone to talk to about any

worries and fears you may have?96 96

Were you offered age/need appropriate play

activities for your child?75 75

Did you find the food choices suitable for your

child's needs?100 100

Was your child's experience in other hospital

departments (i.e. X-ray department, out-

patient department, theatre) satisfactory?

94 94

Was your child's experience during

procedures/investigations (i.e.blood tests, X-

rays) managed sensitively?

100 100

Were staff professional and approachable?98 98

Is the environment young person-friendly?100 100

Overall, how would you rate your experience in

the Children's Unit?90 90

75-84 85-100

F1

Pa

ren

t

<75

Patient Satisfaction: Stroke overall result93 93

Have you been told you have had a stroke,

which lead to your admission to hospital?

100 100

Have you been involved in planning your

recovery / rehabilitation?94 94

Have you been given a Personal Stroke Care

Plan (show example if necessary)? 82 82

Have you been helped with your eating and

drinking requirement (if not eating food

requirements)?

89 89

Do you feel cared for? 97 97


examined or treated or when your care was

discussed with you?

100 100



88 88

Pa

tie

nt

Ex

pe

rie

nce

: S

tro

ke

<75 75-84 85-10085%

Sickness 4% >6 3.5-6 <3.5 12 5 1 7 5 6 3 10 1 9 8 18 5 4 4 2 4 5 1 2 4 6

Vacancies -2 -2 -2 -3 1 -2 0 -4 -1 -3 -3 -5 0 -1 4 -5 -1 -5 3 -15 0 -2

Turnover (Annual) 10% >10% 0%-10% 13 9 3 7 6 2 3 3 14 5 12 6 7 10 2 6 11 5 10 7

Turnover (Monthly) 10% >10% 0%-10% 3 0 0 2 2 0 0 0 5 0 0 0 3 0 0 0 0 0 0 0 0 1

Sta

ffin

g

9

Quality Priority: Ward Performance Issues

Patient surveys – (This section identifies wards that have three red ratings for patient satisfaction or a significant change from last month)

Most ward areas have seen a general improvement in patient experience scores however G3 call bell response time has decreased to 70%. From the callaid reporting system, we know that the average response time was 107 seconds. G3 is a high performing ward and this call bell response time does not demonstrate poor performance or represent a trend. The net promoter question has improved from 67% to 96%.

F3 has seen a decrease in their score from the net promoter question which requires investigation and action. The matron has been asked to investigate this to determine the reasons for the decrease. F3 has seen improved scores in all other aspects of their quality performance therefore there is no evidence to support major concerns in this area but we do need to understand the reasons behind decreased recommender score.

Ward Issues

Theatres have a low score for environment and cleanliness. This related to non-patient areas (changing rooms) following the end of the afternoon lists. Cleaning services will now be provided in theatres overnight to ensure that changing rooms are cleaned by the morning.

Staffing Issues

During data collection period 22nd April- 19th May, healthroster identified 32 WTE nursing workforce vacancies (Bands 2-7) across the medical and surgical directorates. We are implementing a new recruitment strategy for student nurses qualifying in September to ensure that we offer as many as possible employment to plan for our future vacancy requirements. Students will go through a group interview process and we will offer part-time posts if the demand for jobs is larger than our Band 5 vacancies. This will ensure we recruit all the students for our future recruitment needs as their hours can be increased to full-time as vacancies become available.

External mock CQC assessments

The first external inspection using the CQC assurance framework was held on 15th June. The majority of clinical areas were assessed for compliance against all the CQC essential standards of quality and safety. The assessors were from NHS Suffolk, LINKs, governors, and neighboring acute and community Trusts. The feedback is currently being collated and will be reported to the appropriate forums.

10

Quality Priority: Infection Control

There were no cases of MRSA bacteraemia or MSSA bacteraemia during May. There were 4 cases of clinically significant hospital acquired C. difficile

during May (giving a total of 6 during 2012-13 against a profile of 5). There was an increased incidence on Ward G8 that coincided with an outbreak of

norovirus. Increased cleaning had been carried out due to the norovirus and no deficiencies in cleaning were identified. RCAs were carried out

individually and a SIRI has been reported. G8 was decanted to another area to allow complete fogging of the ward to take place.

High Impact Interventions

In respect of compliance with the High Impact Interventions (HII), all interventions scored 100% except peripheral cannula ongoing care (97%) and

urinary catheter ongoing care (99%). Both these scores were an improvement on last month‟s performance.

Isolation audit data

Of the 33 side rooms in the Trust, 17 were used for IC purposes. There were 4 high risk patients who should have been isolated and were not due to

bed capacity and the need to main single sex accomodation. The F9c cohort was in operation and had 4 patients in it on the day of audit.

0 0 0

1

2

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

MRSA Total no ofMRSAbacteraemias:Hospital

MRSACumulativeCeiling:HospitalAcquired

MRSACumulativeActual:HospitalAcquired

Number

11

Quality Priority: Falls

0

10

20

30

40

50


Falls No of patient falls

No of patient fallsresulting in harm

No. of serious injuriesor deaths resultingfrom falls

Number

The contract target for falls during 2012-13 is to reduce serious harm/ death from falls and to complete a risk assessment for 95% of patients who attend A&E

as a result of a fall.

Falls resulting in serious harm.

The ceiling for Q1 is 2 incidences of serious harm or death resulting from a fall. The NPSA criteria for serious harm resulting from a fall is, “where permanent

harm, such as brain damage or disability was likely to result from the fall”. This includes patients who have fractured their neck of femur as up to 90% of older

patients who fracture their neck of femur fail to recover their previous level of mobility or independence.

During May we had no falls resulting in serious harm.

A&E risk assessment

The pathway for risk assessing and reporting via discharge summaries is currently being developed and a report detailing the implementation plan will be

available to NHS Suffolk by the end of Q1.

Falls performance

There were 36 falls across the Trust during May a reduction

as compared to April. 8 falls resulted in minor harm e.g. small skin

laceration.

Two wards had a higher than usual number of falls during May: G1 and

F5. However, G5 and F4 had no falls at all this month.

F5 had 7 falls of which 3 resulted in minor harm. 3 of the falls occurred in patients who were independent and could not have been foreseen e.g. fell out of bed

when stretching to pick up glass of water from locker, knocked over urine bottle and fell when trying to sort it out, and another fell within a few minutes of

arriving on the ward during the handover of the patient. The remaining falls occurred in patients who required assistance but mobilised without asking for help

despite having been advised to ask.

G1 had 6 falls (of which 3 occurred in one patient). G1 is composed of single rooms and the falls occurred mainly at night. The patient who had 3 falls was

moved near to the nurses station for ease of observation following the first fall. A wander guard was requested following the second fall but was unavailable due

to usage elsewhere. A more sophisticated system similar to the wander guard is being considered for G1. This would trigger an alarm on a bleeper system that

could be carried by the nurse. This would enable staff to monitor such patients more easily when they are occupied with other duties.

12

Quality Priority: Pressure Ulcers

The performance target is to have no avoidable Grade 3/4 pressure ulcers 2012-13 with

a penalty of £5,000 for each incident. 2 patients developed Grade 3 hospital acquired

pressure ulcers during May on G5. The RCAs have not yet been held to determine if

these pressure ulcers were avoidable. One RCA is scheduled for 28th June and the other

16th July. The performance target re: Grade 2 pressure ulcers is a ceiling of 11

for Quarter 1 with a penalty of £500 for each incidence above the ceiling. 3 patients

developed Grade 2 hospital acquired pressure ulcers this month, 1 of which was

avoidable taking the total to 4 YTD. This occurred on G5 and was considered avoidable

as not all documentation was complete.

Regional best practice

The Midlands and East SHA Pressure Ulcer Programme Board have developed a pressure ulcer prevention and treatment pathway based on best practice

recommended by the Expert Working Group (“Stop pressure now” campaign). All Trusts are currently working to implement the best practice within their

organisations. As the intensive support team also recommended greater collaboration across the health systems in Suffolk to prevent pressure ulcer

development, NHS Suffolk chair a county-wide group and a county-wide action plan is being developed.

Specific actions for West Suffolk:

• Our policies and pathways already support best practice, therefore the focus on changing practice is not required but we need to provide assurance that

the policies and pathways are implemented. The SHA pathway has an audit plan that we will implement to provide that assurance.

• The RCA process needs updating to include a new generic RCA form - all Grade 2 RCAs will now be sent to NHS Suffolk for confirmation that the

pressure ulcer is avoidable/unavoidable.

• Generic training packages on the pathway implementation and components are being developed by the Expert Working Group which will be used as

soon as they are available.

• An engagement and behavioural change programme is being developed regionally to support the organisational change programmes required to embed

the “Stop pressure now” campaign. 4 champions will attend this programme from West Suffolk Hospital.

• As part of the pressure ulcer prevention project plan for 2012-13, the tissue viability team restructure will allocate one member of the team as pressure

ulcer prevention lead and Trust priorities re: pressure ulcer reduction will inform their role objectives and daily work schedules.

• G5 is receiving intensive support from the tissue viability team to improve performance in pressure ulcer prevention and there has been a significant

reduction in incidence during June. Discussions with other acute Trusts have highlighted that it is not uncommon for rehabilitation areas to have higher

incidences of pressure ulcers compared to acute clinical areas as rehabilitation patients have often had lengthy inpatient stays and periods of ill-health

prior to their transfer to rehabilitation areas. However reducing pressure ulcers on G5 remains a priority for the tissue viability team.

0

2

4

6

8

10


Pressure ulcers No of patientswith wardacquired Grade2 pressureulcers

No of patientswith wardacquired Grade3 or 4 pressureulcers

Number

13

Quality Priority: Patient Experience – Achievement of 85% satisfaction

‘Achieve at least 85% satisfaction in internal patient satisfaction surveys’ is a Quality Priority for the Trust

The overall results for the inpatient survey rose to 92% this month and this reflects an increase in the scores for most questions. Scores of over

95% were achieved in most of the questions, with noise at night from other patients (76%) and timely call bell response (66%) being the only

scores below 90%.

The number of responses for each ward were reasonable except for F12 (4 responses) and G1 (5 responses). This is being addressed with the

ward managers concerned.

In the outpatient survey, the overall result was 88% with provision of information about delays being the only low scoring question. Issues

related to this have been discussed at the Patient Experience Committee and a piece of work is being carried out by the OPD and Health Records

Manager to address these.

The A&E survey indicated good levels of satisfaction with an overall score of 92%. However, the number of returns was unacceptably low and an

increased target to compensate for the low returns in May has been set for June. Daily monitoring of responses has been introduced.

14

Quality Priority: Patient Experience – Recommend the service

Score Category Number of responses

0-6 Detractors 12

7-8 Passive 48

9-10 Promoters 378

‘Patients would recommend the service to their family and friends’ is a Quality Priority for the Trust

The Trust sampled 438 inpatients (15%) and achieved a net promoter score of 83.5 overall during May. This was split as follows:

Scores for April and May place the Trust in the top quartile performance in the Region.

An additional question has been added for those scoring below 9,to identify the reasons behind the score. The results for April and May were reviewed to provide some initial analysis of the reasons behind the score. Only 25 patients (out of a possible 116) completed this question and 5 of the comments indicated a reluctance to give a perfect score despite a lack of complaint (i.e. “nobody is perfect” (4pts) ) and 1 mentioned parking charges. Of the comments related to care, 5 patients felt that more staff were needed, 2 mentioned call bell response times, 2 noise at night, 2 food and 2 communication

15

Hospital Mortality Rates (Relative Risk), SHMI and Crude Mortality Rates

Report as at:

Dr Foster re-aligned their benchmark position in October 2011.

National Rate from last

reporting period

May 10 -

April 11

June 10 -

May 11

July 10 -

June 11

Aug 10 -

July 11

Sept 10 -

Aug 11

Oct 10 -

Sept 11

Nov 10 -

Oct 11

Dec 10 -

Nov 11

Jan 11 -

Dec 11

Feb 11 -

Jan 12

Mar-11 -

Feb 12

Apr-11 -

Mar 12

Rolling 12 Month HSMR-All Admissions 100 85 83.9 84.6 84.9 83.8 83.2 83.6 82.1 82.6 78.5 78.3 82.9

SMR Stroke (Acute Cerebrovascular Disease) 86.2 82 79.3 76.8 76.5 72.6 71 66.8 66.1 65.5 67.6 69.6 77.3

SMR - Heart Attack (AMI) 90 75 74.4 73.5 69.7 66.7 71.5 68.3 62.7 47.5 38 41.5 61.4

SMR - FNOF 81.6 71.6 77.1 81.6 88.7 87.7 82.1 82.8 81.7 82.5 79.2 68.3 69.5

Mortality from Low Risk Conditions 0.84 - 0.55 0.6 0.51 0.51 0.52 0.57 0.58 0.65 0.65 0.6 0.61

SHMI (Quarterly Indicator) 100 - - 91.47 - - 90.94 - -

Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-1277 62 54 68 61 79 71 75 78 82 98 73

11/06/2012

Crude Mortality

74

76

78

80

82

84

86

May 1

0 -

April

11

June 10 -

May 1

1

July

10 -

June

11

Aug

10 -

July

11

Sept

10 -

Aug

11

Oct 10 -

Sept

11

Nov 1

0 -

Oct

11

Dec 1

0 -

Nov

11

Jan 1

1 -

Dec

11

Feb 1

1 -

Jan

12

Mar-11 -

Feb

12

Apr-11 -

Mar

12

Rolling 12 Month HSMR-All Admissions

0

20

40

60

80

100

120

Jun

-11

Jul-

11

Au

g-1

1

Se

p-1

1

Oct-

11

No

v-1

1

De

c-1

1

Jan

-12

Fe

b-1

2

Ma

r-1

2

Ap

r-1

2

Ma

y-1

2

Crude Mortality for WSH

Quality Priority: Mortality

16

0

10

20

30

40

50

60

70

80

90

Ma

y 1

0 -

Ap

ril 1

1

Ju

ne

10 -

May 1

1

July

10 -

Ju

ne

11

Au

g 1

0 -

Ju

ly

11

Se

pt 1

0 -

Aug

11

Oct 10 -

Sept

11

No

v 1

0 -

Oc

t 1

1

De

c 1

0 -

No

v

11

Ja

n 1

1 -

De

c

11

Fe

b 1

1 -

Ja

n

12

Mar-

11 -

Feb

12

Ap

r-1

1 -

Ma

r 1

2

SMR Stroke (Acute Cerebrovascular Disease)

0

10

20

30

40

50

60

70

80

May 1

0 -

Apri

l 11

June 1

0 -

May

11

July

10 -

June

11

Aug

10 -

July

11

Sept

10 -

Aug

11

Oct 10 -

Sept

11

Nov 1

0 -

Oct

11

Dec 1

0 -

Nov

11

Jan 1

1 -

Dec

11

Feb 1

1 -

Jan

12

Mar-

11 -

Feb

12

Apr-

11 -

Mar

12

SMR - Heart Attack (AMI)

0

10

20

30

40

50

60

70

80

90

100

Ma

y 1

0 -

Ap

ril 1

1

Ju

ne

10 -

May 1

1

July

10 -

June 1

1

Au

g 1

0 -

Ju

ly

11

Sept 10 -

Aug

11

Oct 1

0 -

Se

pt

11

No

v 1

0 -

Oc

t 1

1

De

c 1

0 -

No

v

11

Jan 1

1 -

Dec

11

Fe

b 1

1 -

Ja

n

12

Ma

r-11 -

Fe

b

12

Ap

r-1

1 -

Ma

r 1

2

SMR - FNOF

17

Most CQUIN targets are progressing to plan. Some still require final agreement with the PCT; 7 day working and hand off to the community. A

meeting is scheduled with the PCT on 26th June to agree and finalise the plans.

Exceptions

• Patient Survey - Net promoter Question - A&E, outpatients and daycases

In order to achieve the quarterly target the volunteers have been assisting in A&E and in day surgery unit to encourage patients to answer the net

promoter question. There is a daily report on the number of outstanding surveys. A verbal update on the likely quarter position will be provided at

the board.

CQUIN

Summary & Exceptions report

Area MTD

(at at 24 June)

QTD (at at 24

June)

Target for Q1

Total outstanding

for Q

OPD 161 794 600 0

A&E 179 226 300 74

DSU 45 103 120 17

18

Performance Indicator Threshold DescriptorIn Month

Performance QTD RAG Comments Lead Exec

VTE Screening

98%

Number of all adult inpateint admissions

reported as having had a VTE risk assessment

on admission to hospital using the national

tool 98.26% 97.10% Dermot O'Riordan

VTE Prophylaxis100%

Number of high risk patients receiving

appropriate prophylaxis - - Quarterly monitored Dermot O'Riordan

Patient Survey - National

ConsolidatedAchieve composite score of 70 (February 2011 = 68.38)

Composite score from 5 'responiveness to

personal needs of patients' questions

Report expected April 2013

2011 National Patient Survey action

plan in place Nichole Day

Patient Survey - Local focus

Achieve score of 49 or greater (February 2012 = 46.7)

Improvement on the question(s) which have

the poorest score in 2011 National Patient

Experience Survey - Question 64. Medication

side effects advice - results from Feb 12 = 46.7

Report expected April 2013

2011 National Patient Survey action

plan in place Nichole Day

Patient Survey - Net Promoter

Question - Inpatients

Q1 = Survey with question and establish baseline

Q2 = Survey with question and plan for % improvement (% to

be agreed once baseline established)

Q3 = Add the 'Why' question

Q4 = implement action plan to improve

10% of inpatients (over 18, excluding daycases,

A&E and outpatients) asked the question to

establish the Net Promoter Score 83.56

Baseline score = 81.47

The Trust score is within the upper

quartile - no need for improvement Nichole Day

Patient Survey - Net Promoter

Question - A&E, outpatients and

daycases

Q1 = Survey with question and establish baseline

Q2 = Survey with question and plan for % improvement (% to

be agreed once baseline established)

Q3 = Add the 'Why' question

Q4 = implement action plan to improve

number of outpatients

(A&E = 100 per month, Outpatients = 200 per

month, daycases = 40 per month) asked the

question to establish the Net Promoter Score

Survey totals - QTD (as at 20 June12)

OPD = 768 (Target = 600)

A&E = 120 (Target = 300)

DSU = 96 (Target = 120)

Action plan is in place to achieve Q

target for each of the 3 areas Nichole Day

Dementia - Screening

90% achievement for 3 consecutive months within 2012/13

% of all patients aged over 75 who were

admitted includes emergency admissions, non

elective admissions (excluding day cases) as

inpatients should be screened following

admission to hospital (within 48 hours) using

the recommended tool in the local dementia

pathway (CT scans excluded)

Changes to EPRO to achieve target

and collect data have been made.

Reporting available from Q2 Nichole Day

Dementia - Risk Assessment

90% achievement for 3 consecutive months within 2012/13

% of all patients aged over 75 who have been

screened as at risk of dementia, who have had

a dementia risk assessment within 48 hours of

admission to hospital, using the locally agreed

dementia pathway risk assessment tool




Dementia - Referall for specialist

Diagnosis90% achievement for 3 consecutive months within 2012/13

% of all patients aged over 75 who have been

identified as at risk of having dementia, who

are referred for specialist diagnosis




Safety Themometer

Q1 = Implement data collection tools

Q2 = full set of data covering 4 elements submitted on time



Monthly surveying of all appropriate patients

on 4 outcomes, pressure ulcers, urinary tract

infection in patients with catheters and VTE

Data collection tools in place

Report from Q2 Nichole Day

Assessment of risk of falls in pt aged

65 or over that attend A&E

Q1 = Implement data collection tools

Q2 = 50% achievement in last month of quarter

Q3 = 90%

Q4 = 95%

Total number of people aged over 65

attending A&E who have been assessed using

the Stage 2 risk assessment tool and discharge

summary to GP

Data collection tools in place

Report from Sept 12 (3rd month of

Q2) Nichole Day

Every Contact Counts - Breast-

feeding UNICEF training

Q1 & Q2 = >18 staff trained

Q3 = >30 staff trained

Q4 = > 70 staff trained

Number of staff trained in UNICEF

breastfeeding management 3 day course - 25 Training plan in place Gwen Nuttall

CQUIN

19

Every Contact Counts - Breast-

feeding 'Give it a go' materials

Q1 = 75%

Q2 = 75%

Q3 = 75%

Q4 = 75%

Number of mothers given breastfeeding 'Give

it a go' social marketing campaign material

All booking appointments given the

Breast-feeding materials from 8th

May. Data collection in place for

reporting Q1 performance Gwen Nuttall

Number of electronic patient referrals to NHSS

smoking cessation services (excludes

maternity)

Q1 - 125

Q2 - 175

Q3 - 0

Q4 - 280 17 188 Q1 target achieved Gwen Nuttall

1,000 (positive) PATs completed by March 2012

leading to 200 referrals which includes brief

advice session for each patient.

Q1 - 0

Q2 - 0

Q3 - 500

Q4 - 500 n/a Report from Q3 Gwen Nuttall

67% of staff to be trained to deliver brief

intervention

Q1 - 50%

Q2 - 50%

Q3 - target complete

Q4 - target complete - 35 WTE

72 WTE in A&E requiring training.

48.09 Nursing and 24 Medical.

Q1 - 35 WTE trained (mainly nursing)

Q2 - 37 WTE staff remaining - these

are mainly medical staff Gwen Nuttall

Q1 implementation of data collection tool

Q2 50%

Q3 70%

Q4 90%

Number of expectant mothers who have CO

validated and recorded smoking status in

records at first midwife appt

Database set up to collect

information and will be collated

monthly from Q2 Gwen Nuttall


Q2 70%

Q3 90%

Q4 100%

Number of pregnant smokers given brief

interventions at first booking





Q2 70%

Q3 90%

Q4 100%

Number of pregnant smokers who are offered

a referral to smoking cessation services




Discharge Summaries - All

medications listed on discharge

Q1 = Provider to work with CCGs to agree a plan and formats

for additional information

Q2 = Implement plan

Q3 = Survey to guage impact

Q4 = Develop action plan for improvement

Improvement in information provided to GPs

on the Dischagre Summaries

Meeting scheduled to take place

22nd June to discuss requirements of

Discharge Summary Dermot O'Riordan

Discharge Summaries - Social care

discharge package information100% of stroke patients eligible for a brain scan scanned

within one hour

minimum requirement is for social care

package to be included on discharge summary




Discharge Summaries - Process for

agreeing additional fields and

outpatient consultation clinical

feedback Detail to be developed in Q1

minimum requirement is for follow up

arrangments and reason to be included on

discharge summary




Discharge Summaries - Cancer end

of treatment - using Information

Prescriptions system

Q1 – establish plan and package to offer to patients at the

end of a period of acute treatment for cancer and pilot

(breast, colorectal and prostate)

Q2 – 25%

Q3 – 50%

Q4 – 80%

Patients at the end of a period of acute

treatment for cancer are offered an end of

treatment assessment and care

plan/treatment summary

Currently writing the necessary

patient package information for

breast & colorectal and devising a

standard template for the prostate

patients. Dermot O'Riordan

Every Contact Counts - Smoking -

pregnant women

Every Contact Counts - Smoking &

Alcohol Screening Q1 = electronic pathway established and 125 smoking

referrals of which 75% recording giving consent. Training of

doctors and ENP staff 50% of target trained.

Q2 = 175 smoking referalls of which 75% record giving

consent. Training of doctors and ENP staff - remaining 50%

target trained.

Q3 = 500 PATs completed

Q4 = 280 smoking referrals of which 75% record giving

consent. a further 500 PATs completed with 200 referrals to

SATS.



20

Planned Care - Training in

recognising deteriorating pt

i) Q1 Enrolment and commencement of Section 7 module by

minimum of 20% of Registered nurses and HCA's in each

ward, department

Month 2 & 3 implementation plan commenced

i) Q2 10 % ward /department/bank staff to have completed

Section 7 Assessment and Observation module.

i) Q3 15 % ward /department /bank staff to have completed

Section 7 Assessment and Observation module.

i) Q4 25% ward /departmentstaff to have completed Section 7

Assessment and Observation module

i) Number of staff members completing

section 7 (Assessment and Observation) of e-

learning workbook

I.T interface issues now resolved.

Q1 target being achieved Nichole Day

Digital by default

Q1 = Identify specialties and within those the patient mix

Q2 = Pilot in 4 different areas (condition specific rather than

specialty)

Q3 = Review with NHSS for potential for roll out with review

and consideration for extension which will include patient

feedback

Q4 = Further improvements and refining

Number of alternative non face to face

consultations made

Specialties currently being identified

in conjunction with NHSS Gwen Nuttall

Integrated care - EAU consultant to

7pm30% avoided admission

EAU consultants advice and guidance service

to support clinical management in the

community Plan being achieved Gwen Nuttall

Integrated care - PAU Paediatrician

Q1 = establish service from 2nd April - collect data from

month 2

Q2 = target to be agreed at end of Q1



Paediatric consultant advice and guidance

service to support clinical management in the

community System in place Gwen Nuttall

Integrated care - Emergency Surgical

Referral triage - consultant

Service in place as reported by GPs and monthly monitoring

of data to indicate reduction in acute surgical admissions, and

quarterly feedback of learning to GP's

Surgical consultant advice and guidance

service to support clinical management in the

community

System now in place and data being

collected Dermot O'Riordan

Integrated care - 7 day working

Q1 = Agree plan

Q2 = TBC

Q3 = TBC

Q4 = TBC

Pt review on admission and access to

diagnostics and Consultant review within 24

hours

Plan still being worked up - Meeting

scheduled with PCT 26th June Gwen Nuttall

Integrated care - hand off to the

community

Q1 = Agree plan

Q2 = TBC

Q3 = TBC

Q4 = TBC

Reduction in the number of heart failure and

COPD readmissions within 7 days of discharge

through referring for targetted support for

patients with poorly managed conditions and

telephone courtesy follow up one day after

discharge

Plan still being worked up - Meeting

scheduled with PCT 26th June Gwen Nuttall



21

• Overall performance is good or improving. The NICE TA business case remains at amber but progress has been achieved in

clearing the backlog. There is a monthly review meeting in place to ensure that action is being taken against all NICE

assessments.

• There was an increase in the number of PAL contacts that became formal complaints in May. Details of the issues are contained

within the complaints report which will be discussed in the private session of the Board because they contain patient identifiable

information.

• Datix has been successfully rolled out across the Trust and this will enable feedback to areas of „perceived‟ low reporting.

Local Priorities


22

Local Priorities - Governance Dashboard

Indicator Performance target R A G May12 Commentary

National

safety alerts

Number of NPSA alerts beyond national

implementation deadline

>=5 1-4 0 1 One NPSA alert remains overdue and on the Risk register:

SPN/2008/014Right Patient Right Blood. A plan to achieve

compliance in 2012 is being developed and will be presented at TEG

in July.

Timely

completion of

Red incident

investigations

and action

RCAs (non SIRI) completed more than 45 days after

incident reported

>=1 0 0

Actions beyond deadline for completion >=5 1-4 0 0

Timely

reporting of

SIRIs to NHS

Suffolk

SIRIs 2 day report beyond timeframe >=1 0 0 The 6 SIRIs reported in May all had the relevant reports submitted

within the required timescale. SIRIs 7 day report beyond timeframe >=1 0 0

SIRIs 45 day reports beyond timeframe >=1 0 0 The 3 SIRIs 45-day reports due in May were all submitted within the

agreed timescales.

Risk

assessments

Active risk assessments in date <75% 75 –

94%

>=95% 96%

Outstanding actions in date <75% 75 –

94%

>=95% 98%

NICE TA (Technology appraisal) business case beyond

agreed deadline timeframe

>9 4 - 9 0 - 3 6 The number of technology appraisal business cases continue to

reduce , the process includes new Technology Appraisal Guidance

reaching the deadline for business cases submission each month so

the 6 currently outstanding break down into four historically

outstanding and two newly outstanding for business cases.

IPG (Interventional procedure guideline) baseline

assessments beyond agreed deadline timeframe

>9 4 - 9 0 - 3 9

CG (Clinical guideline) baseline assessments beyond

agreed deadline timeframe

>9 4 - 9 0 - 3 9

Clinical Audit Trust participation in relevant ongoing National audits

(reported by Quarter)

<75% 75 –

89%

>=90% - 96% at end of Q4

Complaints

Response within 25 days or negotiated timescale with

the complainant

<75% 75 –

89%

>=90% 100%

Number of second letters received >=5 1-4 0 2

Health Service Referrals accepted by Ombudsmen >=2 1 0 0

Red complaints actions beyond deadline for

completion

>=5 1-4 0 0

Number of PALS contacts that became formal

complaints

>=10 6 - 9 <=5 4

23

0

50

100

150

200

250

300

350

400

Jun-1

1

Jul-1

1

Aug-1

1

Sep-1

1

Oct-

11

No

v-1

1

De

c-1

1

Jan-1

2

Feb

-12

Ma

r-1

2

Apr-

12

Ma

y-1

2

Nu

mb

er

of

incid

en

ts r

ep

ort

ed

Patient Safety Incidents reported to Trust

WSH (harm PSIs) NRLS benchmark (harm PSIs) WSH (all PSIs)

NRLS Lower quartile (all PSIs) NRLS Median (all PSIs) NRLS Upper quartile (all PSIs)

There were 291 incidents reported in May including 225 patient safety incidents (PSIs).

The NRLS target lines shows how many incidents WSH would have to report to fall into the median / upper and lower quartiles for small acute trusts

reporting per 100 admissions (from Apr-Sept11 NRLS report). The rate of PSIs is a nationally mandated item for inclusion in the 2012/13 Quality

Accounts.

The number of PSIs reported in May 2012 still falls below the lower quartile benchmark but it has shown an increase from April. The number of harm

incidents has risen compared to April but is still lower than in previous months.

Now that Datix reporting has been rolled out successfully in all clinical areas there will be targeted feedback to areas of perceived „low reporting‟. 24

5

2

1

2

5

1

2

1 1

2

1

1

2

0

1

2

3

4

5

6

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

Ma

y-1

1

Ju

n-1

1

Ju

l-1

1

Au

g-1

1

Se

p-1

1

Oct-

11

No

v-1

1

De

c-1

1

Ja

n-1

2

Fe

b-1

2

Ma

r-12

Ap

r-1

2

2ary

axis

(n

um

ber

of

co

nfi

rmed

PS

Is)

1ary

axis

(seri

ou

s h

arm

PS

Is a

s a

% o

f to

tal

PS

Is)

Serious Patient Safety Incidents reported to NRLS

pending final grade(2ary axis) WSH serious harm PSIs(1ary axis) Benchmark NRLS Serious harm average (1.2%)(1ary axis) WSH serious harm - 12 month rolling average WSH%

May: Falls # (2), Delayed diagnosis (2), Deteriorating patient (1)

September : Falls # (2), Delayed diagnosis (2), C. difficile outbreak (1)

The percentage of PSIs resulting in severe harm or death is a nationally mandated item for inclusion in the 2012/13 Quality Accounts.

The graph above plots the peer group average of 1.2% (serious PSIs as a percentage of total PSIs) from the NPSA April - September 2011 report.

The WSH data is plotted as a line which shows the rolling average over a 12 month period. There is a downward trend evident since May 2011.

The number of serious PSIs confirmed grade are plotted as a column on the secondary axis. There was a peak in September 2011 but no trend was

identified from the data.

25

Complaint response within agreed timescale with

the complainant: 100% of responses due in May

were responded to within the agreed timescale

(target 90).

Of the 22 complaints received in May, the

breakdown by Primary Directorate is as

follows: Medical (11), Surgical (5), Clinical

Support (2), Women & Child Health (4) and

Facilities (0).

Trust-wide the most common problem areas are

as follows:

- All Aspects of Clinical Treatment 9

- Communication 9

- Attitude of Staff 5

- Admission, Discharge & Transfer 5

This breakdown reflects an expected distribution across the categories. (Please note that more than one category can be allocated to each complaint so

the total number of problem areas does not correlate with the total number of complaints) .

The data in the graph above demonstrates that there has been a decrease in the number of complaints received in May 2012/13 compared to May

2011/12.

Themes from Red complaints

All actions identified from Red complaints are currently within deadline for completion


Complaints 2012/13 19 22

Complaints 2011/12 22 26 27 19 27 24 24 22 15 32 23 22

0

5

10

15

20

25

30

35

Nu

mb

er

of co

mp

lain

ts

Local Priorities - Complaints

26

In May 2012 there were 80 recorded PALS

contacts. This number denotes initial contacts

and not the number of actual communications

between the patient/visitor and PALS.

A breakdown of contacts by Directorate from

June11 to May12 is given in the chart and a

synopsis of enquiries received for the same period

is given below. Total for each month is shown as

a line on a second axis.

Trust-wide the most common five reasons for

contacts are as follows:

General enquiries, concerns about aspects of clinical treatment and attitude of staff remain the most prominent reasons for contacting PALS this month.

However, there are no trends identified for specific groups of staff, speciality or discipline.

The PALS Manager continues to deal with requests for information which can vary from clarification of hospital procedure to specific details about

treatment given; future care plans; outcome or length of time waiting for results of tests and discrepancies about diagnosis and/or discharge

arrangements.

A number of queries also relate to appointment dates and length of time waiting for these; the length of time waiting in clinics; and general enquiries about

services not directly managed by West Suffolk Hospital.

The PALS Manager frequently helps to improve communication between the Trust and patients‟ family members both in this country and abroad.

Any issues which are not able to be dealt with by PALS are directed, if appropriate, to the formal complaints process.

The very nature of the PALS service requires responses to queries, concerns or complaints to be dealt with expediently. A Target of 80% for responding

fully (completing the enquiry) within 48 hours has been set or within a timeframe agreed with the enquirer. This target is currently being monitored and

there is now evidence that the Manager consistently meets this target.

88

97

76

59

83 88

84

100

81

63

96

80

0

20

40

60

80

100

120

0

5

10

15

20

25

30

35

40

45

50

Jun-1

1

Jul-11

Aug-1

1

Sep-1

1

Oct-

11

Nov-1

1

Dec-1

1

Jan-1

2

Feb-1

2

Mar-

12

Apr-

12

May-1

2

Medical Surgical Clinical support

Women and Child Health Facilities Not categorised

Total

Information (advice) 27 Attitude of staff 10 Communication Information to patients 6

All aspects of clinical treatment 15 Other organisations, etc 7

Local Priorities - PALS (Patient Advice & Liaison Service)

27

Local Priorities – Workforce Performance

• Recruitment Timescales – the Suffolk Redeployment Clearing House requires the Trust to place

all appropriate vacancies with them for a period of 1 week prior to opening up the vacancy to

outside competition. This has had the effect of adding 1 week to our usual recruitment timescales

and therefore the target has been amended to include the additional week.

Performance Indicator Threshold Direct Financial

Penalty In Month

Performance Comments Lead Exec

Workforce

Sickness absence rate <4.39% (National Average) NO 3.81% Jan Bloomfield Turnover <14.2% (National Average) NO 7.36% Jan Bloomfield

Reviews Grievance/Banding reviews NO 3 One Grievance and Two Employment Tribunals Jan Bloomfield

Recruitment Timescales Average number of weeks to recruit = 7

NO 6.5

This will continue to include any additional weeks for the Suffolk Redeployment Clearing House Jan Bloomfield

CRB Disclosures existing staff To complete 95% of required CRB checks

NO 99.00% Jan Bloomfield

All Staff to have an appraisal 90% of staff have had an appraisal within the previous 12 months

NO

90.84% Jan Bloomfield

Mandatory Training compliance (reported Quarterly) Jan Bloomfield

Consultant appraisals 100% by end of October NO 99.00% Jan Bloomfield

28

All performance (other than C.Diff) was achieved for May.

Exception

C.Diff

Four cases of C. difficile occurred during May and as a result, the total number of cases is above trajectory for the year (cumulative total 6, against a

trajectory of 5). The cases occurred on one ward and no further cases have been reported since the end of the month (as of 22 June 2012) on that

ward.

Monitor Compliance


29

Monitor Compliance FrameworkPerformance Indicator Threshold Month QTD Weighting Lead Exec

Clostridium (C.) difficile - meeting the C.difficile objective - MONTH 2 4 6 1.0 Nichole Day

Clostridium (C.) difficile - meeting the C.difficile objective - QUARTER

Q1 = 7

Q2 = 7

Q3 = 7

Q4 = 6 6 6 Nichole Day

Clostridium (C.) difficile - meeting the C.difficile objective - ANNUALLY 27 6 6 Nichole Day

Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - MONTH 0 0 1.0 Nichole Day

Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - QUARTER 0 0 Nichole Day

Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - ANNUALLY 1 0 0 Nichole Day

All cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer 85% 89.00% 89.45% 1.0 Gwen Nuttall

All cancers: 62-day wait for first treatment (5) from: NHS Cancer Screening Service referral 90% 100.00% 96.50% Gwen Nuttall

All cancers: 31-day wait for second or subsequent treatment, comprising:

Surgery 94% 100.00% 100.00% 1.0 Gwen Nuttall

All cancers: 31-day wait for second or subsequent treatment, comprising: anti-cancer drug treatments 98% 100.00% 100.00% Gwen Nuttall

All cancers: 31-day wait for second or subsequent treatment, comprising: radiotherapy - Not applicable to

WSFT

Cancer: two week wait from referral to date first seen (8), comprising:

all urgent referrals (cancer suspected) 93% 94.25% 94.26% 0.5 Gwen Nuttall

Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer

not initially suspected) 93% 96.81% 98.41% Gwen Nuttall

All cancers: 31-day wait from diagnosis to first treatment 96% 100.00% 100% 0.5 Gwen Nuttall

Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted 90% 100.00% 100% 1.0 Gwen Nuttall

Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted 95% 100.00% 100% 1.0 Gwen Nuttall

Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway 92% 99.98% 100% 1.0 Gwen Nuttall

A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge 95% 96.19% 94.55% 1.0 Gwen Nuttall

Certification against compliance with requirements regarding access to healthcare for people with a learning

disability N/A 0 0 0.5 Nichole Day

30

Contract Priorities

Summary & Exceptions report There are two significant areas of poor performance in May:- A&E and Stroke.

Stroke

• As reported at the last Board meeting, stroke performance was severely affected by an outbreak of noro virus on ward G8 (dedicated stroke ward).

The ward was closed to all admissions during the outbreak. The ward was closed for 9 days, during which time stroke patients were admitted to the

emergency assessment unit.

• There are still delays with referrals to the hospital from GP‟s. Information is fed back to the PCT with regard to specific GP delay.

• There has been a change in emphasis in reporting from recording referral to onset of TIA. This is being discussed in the network as there are some

concerns as to the performance measurement of a target which is totally patient dependent.

• Early indications are that performance in June has improved across the board.

A&E

• Performance against A&E measures during May was mixed. There was achievement of the 95% target and demonstrable (but below standard)

improvement in ambulance handover and ambulance button submit.

• Some performance issues are linked with space and capacity in the department. There is a Board paper proposing development of increased

assessment space for consideration in the meeting.

• That said, the continued focus needs to be on improving flow within the Organisation to ensure patients can be admitted directly to EAU or other areas

when appropriate.

• Equally there has to be engagement with GP‟s and other stakeholders as overall attendances to A&E continue to rise, with many seeing the highest

monthly attendances recorded.

31

A&E Attendances and Emergency Admissions

A&E Attendances

April May June July August September October November December January February March YTD Total

Year %

Variance

2010/11 4270 4666 4391 4742 4389 4297 4337 4069 4140 4202 3748 4697 51948

2011/12 4679 4907 4770 4721 4620 4490 4840 4455 4389 4650 4376 4726 55623 6.61%

2012/13 4713 5166 9879

Emergency Admissions (excluding maternity)

April May June July August September October November December January February March YTD Total

Year %

Variance

2010/11 1839 1899 1894 1815 1753 1766 1753 1820 1985 1927 1663 1881 21995

2011/12 1747 1765 1785 1806 1752 1716 1863 1799 1866 1854 1756 1908 21617 -1.75%

2012/13 1733 1923 3656

0

1000

2000

3000

4000

5000

6000

April May June July August September October November December January February March

2010/11 2011/12 2012/13

1500

1600

1700

1800

1900

2000

2100

April May June July August September October November December January February March

2010/11 2011/12 2012/13 32

Contract Priorities with financial penalty

Performance Indicator ThresholdIn Month

PerformanceYTD Comments Lead Exec

A&E - Time to initial assessment (95th percentile) Emergency Ambulance

Arrivals a 95th percentile time to assessment above 15 minutes 02:05 - Gwen Nuttall

A&E - Time to initial assessment (% below 25 mins) 98% 96.80% - Gwen Nuttall

A&E Time to treatment in department (median) - CDM a median time to treatment above 60 minutes 00:49 - Gwen Nuttall

A&E - Single longest total time spent by patients in the A&E department,

for admitted and non admitted patients Should not exceed 6 hours 10:11 -

Delay with Mental Health

Referral Gwen Nuttall

A&E - Time to treatment: Time from arrival to start of definitive

treatment from a decision making clinician: Single Longest Wait

No patient must wait longer than the single longest patient in

2010/11 (04:42) 05:50 - Gwen Nuttall

A&E - Time to initial assessment - Single Longest Wait No pt must wait longer than 25 minutes 02:15 - Gwen Nuttall

A&E - Ambulance Handover

Q1 = 80%

Q2 = 80%

Q3 = 85%

Q4 = 90%

note: % total is average over quarter 68.00% 71.00%

Performance Improving, but

below target. Gwen Nuttall

A&E - Ambulance Handover - Button Submit 80% 79.00% 78.50%

Performance Improving, but

below target. Gwen Nuttall

Discharge Summaries - Outpatients 95% sent to GP's within 3 days 86.11% 86.57% Dermot O'Riordan

Discharge Summaries - A&E

95% of A&E Discharge Summaries to be sent to GPs within one

working day 98.00% 98.37% Dermot O'Riordan

Discharge Summaries - Inpatients 95% sent to GP's within 1 day 80.31% 84.15% Dermot O'Riordan

Stroke -Proportion of Patients admitted to an acute stroke unit within 4

hours of hospital arrival 90% 48.90% 61.45%

17 Patients admitted to other

wards, 16 due to Norovirus, 1

Delayed Diagnosis Gwen Nuttall

Proportion of patients in Atrial Fibrillation, presenting with stroke and

where clinically indicated will receive anti-co-agulation. ASI Target - 60% 75.00% 77.50% 1 Patient Refused Gwen Nuttall

Stroke - % of Stroke patients with access to brain scan within 24 hours 100% 97.00% 96.00%

1 Patient Failure, Referred to

ENT and then Stroke Team Gwen Nuttall

Stroke - Proportion of Stroke Patients and carers with a joint health and

social care plan on discharge Opportunity to have a care plan is offered to 100% 80.00% 83.50% Poor Documentation Gwen Nuttall

Stroke - Patients (as per NICE guidance) with suspected stroke to have

access to an urgent brain scan in the next slot within usual working hours

or less than 60 minutes out of hours as defined from time to time by the

ASHN

100% of stroke patients eligible for a brain scan scanned within

one hour 80.00% 85.00% Delay in A&E Assessment Gwen Nuttall

>80% treated on a stroke unit >90% of their stay 81% 55.00% 70.00%

All Patients admitted to other

wards due to Norovirus Gwen Nuttall

>60% of people who have a TIA and are high risk (ABCD 2 score 4 or

more) are scanned and treated within 24 hours of 1st contact but not

admitted 60% 83.00% 71.50% Gwen Nuttall

Stroke - 65% of patients with low risk TIA have access to MRI or carotid

scan within 7 days (seen, investigated and treated) from onset 65% 44.00% 54.00%

All Patients breached on

referral due to recorded onset

time. Gwen Nuttall

% of Patients eligible for Thrombolysis, Thrombolysed within 4.5 hours 100% of all eligible patients 100.00% 100.00% Gwen Nuttall

A&E

Discharge Summaries

Stroke

33

Falls - reduction of serious injury and harm from falls

50% reduction in incidence of serious injury and death from falls

by December 2012

Q1 = 2

Q2 = 2

Q3 = 2

Q4 = 1 0 1 Nichole Day

New to Follow up Thresholds set at each speciality - overall Trust Threshold is 1.9 1.96 1.98

Specialties above target:

Urology, Gynaecology and

Cardiology. All being reviewed. Gwen Nuttall

Pressure Ulcers - reduction of grade 3 and 4 avoidable

Q1 = 25%

Q2 = 50%

Q3 = 75%

Q4 = 100%

note: reductions to be made on March 2012 baseline

Total avoidable for 2011/12 = 0 therefore the target remains at 0

avoidable grade 3 and 4 pressure ulcers 0 0 Nichole Day

Pressure Ulcers - reduction of grade 2 avoidable Maintain or improve the mix as specified = 90.17% 1 4 Nichole Day

Other

Contract Priorities - Other

Performance Indicator ThresholdDirect Financial

Penalty

In Month

PerformanceYTD Comments Lead Exec

A&E - Threshold for admission via A&E

i) if the monthly ratio is above the corresponding 2011/12 monthly ratio for

two month in a six month period

ii) if year end is greater than 27% YES 23.72% 24.27% Gwen Nuttall

A&E - Service experience 85% of overall patient experience to be maintained NO 92.00% 93.50% Gwen Nuttall

A&E - Indicators

To satisfy at least one of the following patient impact indicators

1. achieve a rate below 5% of unplanned re-attendance rate

2. achieve a rate at or below 5% of patients left department without being

seen

and at least one of the timeliness indicators

1. no deterioration on Q1 2011/12 outturn for % of A&E attendances for

cellulitus and DVT that ended in admission

2. number of admissions for cellulitus and DVT per head of weighted

population

3. % of pts representing at type 1 and 2 A&E sites in certain high risk

categories who are reviewed by an emergency medicine consultant before

being discharged NO

ACHIEVED AT

LEAST 2

ACHIEVED AT

LEAST 2 Gwen NuttallChoose & Book

Provider failure to ensure that “sufficient appointment slots” are made available on the

Choose and Book system

A maximum of 3% slots unavailable (£50 per appointment over 5%. Threshold

applied over monthly figures)YES

4.00% - Gwen Nuttall

All patients referred for an outpatient appointment should be able to choose a named

consultant-led team and the consultant should be available in the clinic.more than 95% NO

95.80% - As agreed with the PCT Gwen Nuttall

All 2 Week Wait services delivered by the Provider shall be available via Choose & Book

(subject to any exclusions approved by NHS East of England)100% YES

100.00% - Gwen Nuttall

All outpatient services shall be available via a CMS process available via Choose & Book at

the request of the commissioner100% within the agreed timescales set out in the flow diagram NO

- -

Pilot specialties available, roll out

to be agreed with NHSS Gwen Nuttall

All Outpatient diagnostic testing services delivered by the Provider shall be available via

Choose & Book.50% by 1 June 2011 & >75% by 1 September 2011 and thereafter NO

- - Data not available from the EofE Gwen Nuttall

Provider shall minimise the number of ‘Do Not Use’ or ‘Test’ services on their Directory of

Services< 5 by 1 June 2011 and thereafter NO

0 0 Gwen Nuttall

All services delivered by the provider (excluding Outpatient diagnostic testing services and

those sevices appearing in the "excluded services" lis approved by NHS EoE) shall be available

and directly bookable via Choose & Book

>95% NO

99.00% 99.00% Gwen Nuttall

A&E

34

Provider cancellation of Elective Care operation for non-clinical reasons either before or after

Patient admissioni) 1% of all elective procedures NO


Patients offered date within 28 days of cancelled operation 100% 100.00% 100.00% Gwen Nuttall

Access to Maternity services (VSB06):-

90% of women who have seen a midwife or a maternity healthcare

professional, for health and social care assessment of needs, risks and

choices by 12 completed weeks of pregnancy.

NO

93.57% 94.32% Nichole Day

Maintain maternity 1:30 ratio 100% NO 96.67% 98.34% Nichole Day

Pledge 1.4: 1:1 care in established labour 100% of stroke patients eligible for a brain scan scanned within one hour NO 100.00% 100.00% Nichole Day

Breastfeeding initiation rates. 80% NO 78.13% 80.23% Nichole Day

Reduction in the proportion of births that are undertaken as caesarean sections. 1% reduction in proportion compared to 2011/12 baseline - 23.20% YES 14.29% 19.03% Nichole Day

Appropriate prescribing of antibiotics 95% NO - - Available Quarterly Gwen Nuttall

Breast Cancer operation Length of Stay <=24 hours 80% NO 97.30% 97.49% Gwen Nuttall

Delayed Transfers of Care to be maintained at a minimal level 6 DTOC's per week NO 35 35

Increase due to target action on

discharge planning Gwen Nuttall

Mixed Sex Accomodation breaches 0 Breaches YES 0 0 Gwen Nuttall

Consultant to consultant referral Defined at specialty level YES 8.52% 7.91% Target to be confirmed Gwen Nuttall

Current ratios of OP procedure to day case for agreed list of procedures to be maintained or

improved, i.e. the Commissioner will not fund a higher level of admitted patients for such

procedures, unless clinical reasons can be demonstrated for increase in admissions.

Maintain or improve the mix as specified = 90.17% YES


Direct Access Diagnostics

Direct access diagnostic findings to be dispatched to referrers within 3

working days of test being undertaken NO 100.00% 100.00% Gwen Nuttall

All ELECTIVE excess bed days per elective spell to not exceed 0.086 excess

bed days per spell 0.02 - Gwen Nuttall

All NON ELECTIVE excess bed days not to exceed 0.678 excess bed days per

spell YES 0.39 - Gwen Nuttall

MRSA - emergency screening

All emergency patients admissions are to be screend for MRSA within 24

hours of admission NO 100.00% 100.00% Gwen Nuttall

Unplanned attendance

No deterioration on 2011/12 out-turn

1. for chonic ambulatory care sensitive conditions

2. for asthma, diabetes and epilepsy in under 19's

3. for acute conditions that should not usuall require hospital admission NO - -

Data is currently being reconciled

with NHSS Gwen Nuttall

Rapid access - chest pain clinic 100% of patients should have a maximum wait of two weeks NO 100.00% 100.00% Gwen Nuttall

Readmissions - Post Elective TBC YES 39 79 Target to be confirmed Dermot O'Riordan

Readmissions - Post Non Elective TBC YES 184 364 Target to be confirmed Dermot O'Riordan

Liverpool Care Pathway (LCP) 75% of patients entering the last days of life to be care for on an LCP NO 100.00% 100.00% Nichole Day

Cancelled Operations

Maternity

Other contract / National targets

Excess bed days

35

item 8 trust quality and performance report june...

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