Trust Quality and Performance Report

28 March 2014(February Performance Pack)

Contents

1

Slide numbers

Executive Summary  2 - 4

Clinical Quality Priorities (inc Ward Dashboard) 5 - 14 & 27 - 32

Local Priorities 15 - 23

Monitor Compliance 24

Contract Priorities 25 - 26

Executive Summary

This commentary provides an overview of key issues during the month and highlights where performance fell short of the target values as well as areas of improvement and noticeable good performance.

1. A&E Performance for January was 96.3%, the ninth month in a row that the Trust has achieved the target. Year to date performance remains above 95% and the Trust is on target to achieve this for the year.

2. There were zero cases of C.Diff in February against the threshold of two. This is covered within the quality report. The YTD position is 21 cases against a year end ceiling of 19.

3. The Trust achieved all Stroke targets for February.

4. Performance on outpatient and inpatient discharge summaries remains below target, although this has improved since January. See page 3.

5. Performance on MRSA screening of emergency admissions was 96.87% against the 100% target. This is covered on pages 3 & 6 of this report.

6. The Trust achieved all access targets including the six-week diagnostic test target for February.

2

3

Executive Summary

Performance Indicator Threshhold February Lead ExecutiveDischarge Summaries - Outpatients 95% sent to GP's within 3 days 92.37% Dermot O'Riordan Significant improvement has been made since December, although further effort is needed to reach the 95% target.In addition to the interventions by the PMO the following steps have been taken to improve performance further: The Medical Director has instructed the secretaries that they and their consultants have three working days to dictate, type, correct, authorise and send the Outpatient 

letters. If a letter is not approved by then they will be sent out clearly marked “dictated but not approved”. Discharge summary and clinic letter performance is part of the new Appraisal system that is in the process of being implemented and consultants will be expected to 

present their figures. 

Performance Indicator Threshhold February Lead ExecutiveDischarge Summaries - Inpatients 95% sent to GP's within 1 day 91.91% Dermot O'Riordan Since  the PMO team have been chasing up ward clerks and ward managers on outstanding discharge summaries we have noticed a change in behlaviour leading to performacne against this indicator  improving significantly.  Having resolved some of the operational issues the following  changes will be implemented to embed  behaviour and improve our performance in order  to meet the 95% target: Information Team will assume sole responsibility for data management and reporting of discharge summaries.  Compliance against this indicator will monitored at monthly Divisional Performance Management meetings and responsibility for addressing poor performance will lie 

with each Directorate. The Medical Director will be receiving performance figures at an individual consultant level and will be writing to those with below target performance for both letters 

and in-patient summaries to improve performance further. 

Performance Indicator Threshhold February Lead ExecutiveMRSA - emergency screening All emergency patients admissions are to be

screened for MRSA within 24 hours of admission96.87% Nichole Day

 MRSA screening shows some improvement following data scrutiny with the assistance of the information team, in that the Elective MRSA screening for February was 97%, Emergency MRSA screening was 96.87%All areas with deficits are given patient level information specific to their area in order to assist in improving compliance. Feedback is given to the information team in order to ensure the correct patient categories are captured. 

4

Performance Indicator Threshhold February Lead ExecutiveSickness absence rate <3.5% 3.79% Jan Bloomfield The highest percentage continues to be Estates and Facilities Directorate at 4.88% (up by 0.12 from January), the lowest Corporate Services at 2.28 (up by 0.08). The Trust will be consulting with the Trade Union representatives at the end of this month with regard to; reducing the number of stages (from 4 or 2) that we go through when dealing with short term frequent absence, reducing the timescales for these stages down to six months from one year, and counting the 8 weeks redeployment time as part of contractual notice, thereby reducing the notice period required.  

Performance Indicator Threshhold February Lead ExecutiveAll Staff to have an appraisal Both general and consultant staff each have a

target of 90% to have had an apprasial within the previous 12 months. Appraisal is a rolling programme

88.31% Jan Bloomfield

 Appraisal compliance has improved, with the Medical Directorate continuing to be the highest area (89.99). The lowest is again the Surgical Directorate (86.20). the Trust will be reviewing this KPI as part of the Staff Survey action. 

Clinical Quality Priorities: Summary

• An outbreak of Norovirus affecting 33 patients and 5 staff in February resulted in the closure of 2 wards for a total of 17 days. A further ward had 1 bay closed for 6 days.

• 50 patients fell during February; an increase of 12 compared to January. No patients sustained serious harm.

• There were no hospital associated C. difficile infections in February.

5

Quality Priority: Infection Control

MRSA BacteraemiaThere were no hospital associated MRSA bacteraemias during February

MSSA Bacteraemia 1 hospital attributable MSSA bacteraemia was reported in February on G5. An investigation has been completed and the root cause of this bacteraemia was paratitis.

C. difficileThere were no hospital acquired C.difficile infections during February.

The Trust was notified on the 7th March by the CCG that the area team had turned down one of the CDT cases sent for appeal against trajectory. The main aspect on which the appeal was not upheld was that the cleaning score for the ward was 92% and the area team assessor’s criteria is set at 95%.

Norovirus In February there were 2 wards affected by Norovirus G3 & G5 which resulted in ward closure. The index case is thought to be a patient admitted from a Nursing Home to G3 who developed symptoms following admission. Prior to the result being available a contact transferred to G5 and is this is the likely index case for G5.G8 had a single bay affected and closed to admissions. Due to the fact that Bay A could be segregated from the rest of the ward by closing doors it was possible to contain the outbreak.This outbreak has been declared a SIRI due to impact on service delivery.  MRSA ScreeningThe number of both elective and emergency patients screened for MRSA has increased this month.Elective 97% from in 95% January Emergency 96.8% from 95.9% in January

6

Quality Priority: Ward Performance Issues

• Ward F9 continues be monitored closely and monthly meetings held between the Head of Nursing, Matron, Ward Manager and Service Manager. There is an improving trend in quality generally, however, there was an increase in the number of inpatient falls (6) with 1 resulting in minor harm. A two week audit has commenced to monitor hydration documentation to address February’s low score. The on going work to reduce noise at night has shown signs of improvement this month resulting in a score of 46% compared with 26% last month. Sickness is being robustly managed and has reduced to 4.3% compared to 9.2% in January.

• Ward G4 reported low scores on MEWS and hydration documentation. Weekly audits will commence in March to monitor compliance with MEWS scoring & documentation of IV fluid completion time. Patient experience has improved with a score of 90% for satisfaction and a with recommender score of 81%.

• Ward G5 was reported last month as having a number of red and amber indicators. An action plan was developed to address the identified issues. Work to reduce falls has decreased the number to 2 this month compared to 8 in January. Patient experience indicators scored low in many areas and work is in progress to improve this. There are 6.5 WTE vacancies which are being advertised for recruitment. This may have had an affect on patient satisfaction.

• Ward F4 had a low score of 15% for noise at night although this is not reflected in verbal feedback from patients on Matron’s rounds. All patients admitted to F4 will be given ear plugs on admission and the Site Clinical Practitioners have been asked to visit the ward at night to assess noise levels. A pain re- audit this month showed a 90% compliance in documentation, an increase on January’s performance.

7

Quality Priority: Falls

8

Falls PerformanceThere were 50 falls this month, 12 of which resulted in negligible or minor harm, one incurred moderate harm there were no falls with serious harm.

The rate per 1,000 occupied bed days is 4.61 (January 3.1). The National average is 5.6% (NPSA 2010)

Safety ThermometerWSNHSFT falls with harm Feb: 0%, National falls with harm Feb: 0.8% (Safety Thermometer 2014).

ThemesWe continue to monitor the number of falls occurring in toilets: there were 5 this month, 10% of our total number, which was down by 1 fall in January. Detailed intelligence continues to be collected to reveal what the patient was actually doing at the time of the fall. Most patients were attempting to stand from the toilet seat, none had pressed the call bell. A three month trial is due to commence in April using patient alert systems in toilets and on commodes in ward G3. Work is almost completed to fit hand rails in all toilets.

Quality Priority: Pressure Ulcers

The performance target is to have no avoidable Hospital Acquired Pressure Ulcers (HAPU) Grade 2, 3 or 4 during 2013-14.

Grade 2 Pressure Ulcers

There were six grade 2 HAPU this month four of which we believe to have been unavoidable, the CCG have yet to confirm this.

Grade 3 pressure Ulcers

No grade 3 HAPU

We have had no grade 4 HAPU during 2013/14

We currently have several initiatives in progress to help prevent pressure damage:

Stop the Clock Stop the Pressure Project launched on F9 this month. Stop clocks are being used to monitor the time an immobile patient stays sitting in a chair, a change of position is required at least every two hours.

All wards have a Tissue Viability link nurse, a study event was held this month to share in-depth information and teaching on wound care and pressure ulcer prevention.

.

9

Safety Thermometer results

10

The National ‘harm free’ care composite measure is defined as the proportion of patients without a pressure ulcer (ANY origin, category II-IV), harm from a fall in the last 72 hours, a urinary tract infection (in patients with a urethral urinary catheter) or new VTE treatment.

The data can be manipulated to just look at “new harm” (harm that occurred within our care) and with this parameter, our Trust score is 0.51% therefore, our new harm free care is 99. 49%. The National new harm for February is 2.8% and national harm free is 93.3%.

The data for February shows we had 0% of falls with harm and the national performance for February 2014 was 0.8%.The data also shows we had 0% of new pressure ulcers recorded in February 2014 against the national performance of 1.1%

It should be noted that the Safety Thermometer is a spot audit and data is collected on a specific day each month.

Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14

Harm Free 93.02 93.36 93.68 91.47 93.20 92.60 93.22 92.68 91.03 92.46 90.28 93.00 93.86 94.09

Pressure Ulcers – All 5.17 3.55 3.51 4.50 4.28 5.36 3.52 2.98 5.16 4.06 4.72 3.25 3.07 4.63

Pressure Ulcers  - New 0.52 0.71 0.94 0.95 1.01 0.00 1.08 0.00 1.09 0.00 0.83 0.25 0.00 0.00

Falls with Harm 0.78 0.71 0.23 1.66 0.00 0.26 0.81 0.27 0.00 0.00 1.11 0.50 0.51 0.00

Catheters & UTIs 1.03 1.66 2.58 0.95 1.76 1.53 2.17 2.98 3.60 3.48 3.33 3.00 2.30 1.03

Catheters & New UTIs 0.26 0.47 0.23 0.24 0.00 0.51 0.54 1.08 0.82 0.00 0.83 1.00 0.26 0.26

New VTEs 0.26 0.71 0.47 1.42 0.76 0.26 0.54 1.36 0.54 0.58 0.83 0.50 0.51 0.26

All Harms 6.98 6.64 6.32 8.53 6.80 7.40 6.78 7.32 8.97 7.54 9.72 7.00 6.14 5.91

New Harms 1.81 2.61 1.87 4.27 1.76 1.02 2.98 2.71 2.45 0.58 3.61 2.25 1.28 0.51

Sample 387 422 427 422 397 392 369 369 368 345 360 400 391 389

Surveys 17 18 18 18 18 18 17 17 17 17 17 17 17 18

Safety Thermometer Rolling Programme

CQUIN Target started April 2012.  

Feb-1

3

Mar-13

Apr-13

May-13

Jun-13Jul-13

Aug-13

Sep-1

3

Oct-13

Nov-13

Dec-13Jan-14

Feb-1

4012345

New Harm February 14WSH Rolling 12 months

National Average

WSH Monthly Data

Perc

enta

ges

Feb-1

3

Mar-13

Apr-13

May-13

Jun-13Jul-13

Aug-13

Sep-1

3

Oct-13

Nov-13

Dec-13Jan-14

Feb-1

40

0.5

1

1.5

New Pressure Ulcers February 2014

WSH Rolling 12 months

National Average

WSH Monthly Data

Axis Title

Feb-1

3

Mar-13

Apr-13

May-13

Jun-13Jul-13

Aug-13

Sep-1

3

Oct-13

Nov-13

Dec-13Jan-14

Feb-1

40

0.5

1

1.5

Catheters and New UTIs February 2014 WSH Rolling 

12 months

National Average

WSH Monthly Data

Perc

enta

ges

Feb-1

3

Apr-13

Jun-13

Aug-13

Oct-13

Dec-13

Feb-1

40

0.4

0.8

1.2

1.6

Falls with Harm February 14

WSH Rolling 12 monthsNational AverageWSH Monthly Data

pers

enta

gesFeb-1

3

Apr-13

Jun-13

Aug-13

Oct-13

Dec-13

Feb-1

40

0.20.40.60.81

1.21.41.6

New VTE February 2014

WSH Rolling 12 monthsNational AverageWSH Monthly Data

Perc

enta

ges

11

Quality Priority: Patient Experience – Achievement of 85% satisfaction

12

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

The overall score for the inpatient survey was 90%, in line with previous months.

Privacy during examinations is the highest scoring question. Noise at night from other patients and timeliness of call bell response are the lowest scoring questions and remain the areas of focus.

Call bell response times recorded electronically (across 5 wards) indicates that 76% of patients call bells are answered in the target time of 2 minutes..

Analysis of patient satisfaction questionnaire responses reveals that 20% of patients stated that call bell answered immediately and 50% stated call bell was answered within 1-2 minutes. From this data source 70% of patients call bells

were answered between 0-2 minutes. There is a small discrepancy between actual response time and perception.

Actions to improve call bell response times such as increasing visibility of nurses in bays, installing wall clocks and reducing the need for use of call bells have been implemented as part of the Patient Association call bell project. 1

outstanding action is the reorganisation of care activities to enable prompt answering of call bells. This will be piloted on 1 ward in March to understand benefits.

G3 F5 F6

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.

Overall satisfaction scores for the OPD, A&E, and short stay were maintained at a high level.

Work is planned during March to review the questions which comprise the internal satisfaction surveys to ensure we gain maximum benefit from the questions we ask.

Work is in progress in A&E to meet the proposed 2014/15 CQUIN increased response rate for FFT. This includes exploring other ways of conducting surveys.

Department ScoreA&E 94OPD 95Short stay 97

13

Quality Priority: Patient Experience – recommend the service

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

The Trust achieved a Friends and Family test score of 88 for inpatients during February, maintaining the high scores of previous months.

G5 scored 50% for the Friend and Family test. This reflects the overall low scoring for patient experience indicators. The Ward Manager has been tasked to improve patient perception of care which centred on waits for care associated with staffing levels.

The recommender score for A&E has improved with a score of 72 for February compared to 64 in January and is the highest score this financial year.

Maternity recommender scores at all stages of the pathway are indicated below:

The post natal ward scored 70 which is a slight decrease from the January score of 75. No trends could be identified from comment analysis. 

Antenatal care Birthing Unit Only

Labour Suite Post natal ward Post natal community care

84 94 86 70 90

14

Local Priorities: Exception Report

Late by Directorate  Red (RAG) 12th Feb 12th March change

Clinical Support >15 6 8 -

Estates and Facilities >10 10 6

Medical >70 101 103 -

Surgical >40 49 44

Women & Children’s Health >15 22 12

Other No target 8 6 -

TOTAL  >150 196 179

Incidents (Amber / Green) with investigation overdue (over 12 days)This has improved over the last month. A message has been included in the Medical bulletin highlighting staff’s responsibilities to ensure timely completion of incident investigations and an escalation process agreed whereby all green and amber outstanding incidents will be monitored against time frames and escalated; initially to the Clinical Director (when one month overdue) and subsequently to the Medical Director (when two months overdue).

RCA actions overdue

A number of RCA actions became due in February / March that have not been confirmed as closed. It has been agreed that from April 2014 Governance will provide the General Managers with a regular report on the first working day of the month listing all overdue and upcoming RCA actions. Progress with closing these actions will then be monitored through the Directorate performance meetings.

Complaint second lettersThere were six second letter received in the month. All are requests for further clarification on the information provided. Two of these complaints have had RCA investigations and a local resolution meeting in addition to the detailed investigation undertaken by the Complaints Manager. Review of the initial complaint letters does not show any theme/trend in the nature of the complaint. These six second letters relate to responses from December, January and February (a total of 69 first response letters).

15

Local Priorities - Governance Dashboard

Indicator Performance target R A G Feb14 Commentary

Timely completion of incident investigations and actions

Red non-SIRI investigation not complete more than 45 days after incident reported

>3 1 - 3 0 0

RCA Actions beyond deadline for completion >=10 5 - 9 0 - 4 19 See exception report for details.

Incidents (Amber / Green) with investigation overdue (over 12 days)

>150 50 - 150 <50 179 See exception report for details.

Timely reporting of SIRIs

SIRIs reported > 2 working days from identification as red

>1 1 0 0 7/7 incidents were submitted to STEIS within two working days of identification as red. One was identified through an inquest notification following a death in the community (21 working days after the incident). One was initially reported as an amber however was upgraded to red once it was identified that surgery would be required following a fall with moderate harm (5 working days after the incident)

SIRI final reports due in month submitted beyond 45 working days

>1 1 0 0 1/1 were submitted within 45 working days.

SIRI final reports due in month submitted beyond local target (40 working days, 30days for pressure ulcers)

>1 1 0 0 1/1 were sent on or before Day 40

Number of SIRI reports open on STEIS more than 45 days after initial notification

>10 6 - 10 0-5 0 Two incidents have an CCG agreed “stop the clock” and are therefore excluded from this indicator.

16

Local Priorities - Governance Dashboard (cont.)

Indicator Performance target R A G Feb14 Commentary

Duty of Candour

Compliance with Duty of Candour requirements >3 1 - 3 0 2 2 (from a total of 14 cases) cases have not yet been undertaken. Duty of candour not conducted yet in line with CCG policy. These cases are being led by the Medical Director and Chief Nurse.

Risk assessment

Active risk assessments in date <75% 75 – 94% >=95% 99%

Outstanding actions in date for Red / Amber entries on Datix risk register

<75% 75 – 94% >=95% 96%

Clinical Audit Trust participation in relevant ongoing National audits

<75% 75 – 89% >=90% 100%

Safer surgery

Completion of WHO checks during surgery. This is a composite indicator of the checks at ward, sign-in, time-out and sign-out.

<90% 90% - 98% >98%

97.6 Non compliance is reported to individuals (daily) and Clinical Directors (weekly). This analysis is based on 4039 checks during the month.

Ward Check 1 99.7

Ward Check 2 99.1

Sign In – Complete 100

Sign Out – Surgeon 96.7

Time Out - Scrub 94.8

17

Local Priorities - Governance Dashboard (cont.)

Indicator Performance target R A G Feb14 Commentary

NICE TA (Technology appraisal) business case beyond agreed deadline timeframe

>9 4 - 9 0 - 3 1 The May Board (April data) will reflect the 2014/15 CCG contract relating to this data item. The Trust will be using the alerts module of the Datix system to allocate and monitor compliance with NICE guidance including Quality standards from April 2014

Complaints Response within 25 working days or negotiated timescale with the complainant

<75% 75 – 89% >=90% 91%

Number of second letters received >=5 1-4 0 6 See exception report for details.

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

Red complaints actions beyond deadline for completion

>=5 1-4 0 0

Number of PALS contacts becoming formal complaints >=10 6 - 9 <=5 4

18

Patient Safety Incidents Reported

The rate of PSIs is a nationally mandated item for inclusion in the Quality Accounts. The NRLS target lines shows how many patient safety incidents WSH would have to report to fall into the median / upper and lower quartiles for small acute trusts reporting per 100 admissions. The Oct12 – Mar13 NRLS report was issued in December and the benchmark in the graph above was updated. This shows a increase in reporting across the peer group. The Trust reporting rate in February is just below the median for the peer group.

There were 395 incidents reported in February including 319 patient safety incidents (PSIs). The reporting rate in February has fallen to a similar level as November and December although it is acknowledged that it is a shorter month which will have an impact on reporting numbers.

The number of harm incidents in February remained below the peer group average.

May-12

Jun-12

Jul-1

2

Aug-12

Sep-12

0

50

100

150

200

250

300

350

400

WSH (harm PSIs) NRLS benchmark (harm PSIs) WSH (all PSIs) NRLS Lower quartile (all PSIs)NRLS Median (all PSIs) NRLS Upper quartile (all PSIs)

Nu

mb

er o

f in

cid

ents

rep

ort

ed

19

Patient Safety Incidents (Severe harm or death)

The percentage of PSIs resulting in severe harm or death is a nationally mandated item for inclusion in the Quality Accounts. The peer group average (serious PSIs as a percentage of total PSIs) from the NPSA Oct ’12 – Mar ‘13 report and sits below the Trust’s average. The WSH percentage data is plotted as a line which shows the rolling average over a twelve month period.

The number of serious PSIs (confirmed and unconfirmed) are plotted as a column on the secondary axis with avoidable hospital acquired pressure ulcers indentified separately. The benchmark line applies the peer group percentage serious harm to the peer group median total PSIs to give a comparison with the Trust’s monthly figures. In December there were two patient safety incidents: one fall with fractured neck of femur and one delay in communication of an abnormal test result.

Jan-12

Feb-12

Mar-12

Apr

-12

May

-12

Jun-12

Jul-1

2

Aug

-12

Sep-12

Oct-12

Nov

-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr

-13

May

-13

Jun-13

Jul-1

3

Aug

-13

Sep-13

Oct-13

Nov

-13

Dec-13

0

1

2

3

4

5

6

7

8

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

12 2

3

5

3

12 2

3

12 2 2

4 4

76

34 4

1 12

2

2

2

1

1

1

1 1

2

Confirmed severe harm/death (excl. PU) Avoidable Hospital acquired pressure ulcerPending final grade Benchmark NRLS Serious harm (number)(1ary axis) Benchmark NRLS Serious harm (%) (1ary axis) WSH confirmed serious harm - 12 month rolling average   WSH%

2ary

axi

s (nu

mbe

r of c

onfir

med

PSI

s)

1ary

axi

s (s

erio

us

har

m P

SIs

as

a %

of

tota

l P

SIs

)

20

Local Priorities: Complaints

There was an increase in the number of complaints received compared with the previous month but this number is still considerably less than other months throughout the financial year. Of these 24 complaints the majority were received with a very short timeframe of the episode of care.

Complaint response within agreed timescale with the complainant: 91% in February.

Of the 24 complaints received in February, the breakdown by Primary Directorate is as follows: Medical (9), Surgical (10), Clinical Support (1), Facilities (1), and Women & Child Health (3).

Trust-wide the top 5 most common problem areas are as follows:

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

Complaints 2013/14 33 31 29 38 32 29 26 40 15 21 24 NaN

Complaints 2012/13 19 22 26 18 34 18 28 22 20 24 25 27

Second letters 2013/2014 0 1 3 3 1 0 2 1 3 5 6 NaN

2.57.5

12.517.522.527.532.537.542.5

Num

ber

of c

ompl

aint

s

All Aspects of Clinical Treatment 15Communication / Information to Patients (written and oral) 11Attitude of Staff 6Admissions, Discharge and Transfer Arrangements 4Appointments, Delay / Cancellation (outpatient) 3

21

Local Priorities: PALS (Patient Advice & Liaison Service)

In February 2014 there were 78 recorded PALS contacts. This number denotes initial contacts and not the number of actual communications between the patient/visitor which can, in some particular cases, be multiple.

A breakdown of contacts by Directorate from April 13 to March 2014 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 shown below.

Feb-13

Mar-13

Apr-1

3

May-13

Jun-13

Jul-1

3

Aug-13

Sep-13

Oct-1

3

Nov-13

Dec-13

Jan-14

Feb-14

0

10

20

30

40

50

60

0

20

40

60

80

100

120

100

88 90

7277

90

102

89

102

7163

94

69

Medical Surgical Clinical support Women and Child Health

Facilities Other / Not categorised Total

All aspects of clinical treatment 24 Information/Advice request 11 Communication 4

Appointments, delay, cancellation 8 Admission/discharge and transfer arrangements 8 Attitude of staff 4

The numbers of contacts have reduced slightly in February which reflects the shorter reporting period. The numbers per Ward/Department remain small and consistent when spread across all areas of care provided, although the PALS Manager continues to receive complaints about cancellations. A number of enquiries relate to out-patients but they are not necessarily complaints – more clarification about appointment times.

It is evident that the PALS Manager, in addition to assisting with genuine concerns from patients and relatives, frequently signposts enquirers to other services including the formal complaints process. She is also actively involved in dealing with specific in-patients and their families’ concerns during the total admission period. This last month has been particularly busy with patient families raising queries with the PALS Manager.

22

Local Priorities – Workforce Performance

23

Performance Indicator ThresholdDirect

Financial Penalty

YTD Comments Lead Exec

Workforce

Sickness absence rate <3.5% NO 3.79% 

Jan Bloomfield

Turnover <10% NO 7.95% 

Jan Bloomfield

Reviews Grievance/Banding reviews NO 8All cases now complete/resolved 

Jan Bloomfield

Recruitment Timescales Average number of weeks to recruit = 7 NO 6 

Jan Bloomfield

DBS Checks To complete 95% of required DBS checks NO 98.74% 

Jan Bloomfield

All Staff to have an appraisalBoth general and consultant staff each have a target of 90% to have had an appraisal within the previous 12 months. Appraisal is a rolling programme

NO 88.31%

 

Jan Bloomfield

Monitor Compliance Framework

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Monitor Compliance Framework Performance Indicator Threshold Month QTD Weighting Lead ExecAccess: Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted 90% 0.00% 95.18% 1.0 Jon GreenMaximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted 95% 0.00% 98.96% 1.0 Jon GreenMaximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway 92% 0.00% 98.89% 1.0 Jon GreenA&E: maximum waiting time of four hours from arrival to admission/transfer/discharge 95% 96.30% 95.70% 1.0 Jon GreenAll cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer 85% 87.00% 89.00%

1.0Jon Green

All cancers: 62-day wait for first treatment (5) from: NHS Cancer Screening Service referral 90% 100.00% 100.00% Jon GreenAll cancers: 31-day wait for second or subsequent treatment, comprising: Surgery 94% 100.00% 100.00%

1.0Jon Green

All cancers: 31-day wait for second or subsequent treatment, comprising: anti-cancer drug treatments 98% 98.00% 99.00% Jon GreenAll cancers: 31-day wait for second or subsequent treatment, comprising: radiotherapy - Not applicable to WSFT      All cancers: 31-day wait from diagnosis to first treatment 96% 100.00% 100.00% 0.5 Jon Green

Cancer: two week wait from referral to date first seen (8), comprising:all urgent referrals (cancer suspected) 93% 99.20% 98.65%

0.5Jon Green

Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer not initially suspected) 93% 99.20% 99.60% Jon Green

Outcomes:

Clostridium (C.) difficile - meeting the C.difficile objective - MONTH 2 0

1.0

Nichole Day

Clostridium (C.) difficile - meeting the C.difficile objective - QUARTER Q1 = 4, Q2 = 5, Q3 = 5, Q4 = 5

0 Nichole Day

Clostridium (C.) difficile - meeting the C.difficile objective - ANNUALLY 19 21 Nichole DayMethicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - MONTH 0 0

1.0Nichole Day

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

Certification against compliance with requirements regarding access to healthcare for people with a learning disability N/A - - 0.5 Nichole Day

Contract Priorities Dashboard

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Contract Priorities with financial penalty          

Performance Indicator ThresholdIn Month

Performance YTD Comments Lead Exec

A&E

A&E - Threshold for admission via A&Ei) if the monthly ratio is above the corresponding 2011/12 monthly ratio for two month in a six month periodii) if year end is greater than 27%

27.50% 25.76%   Jon Green

A&E - Timeliness Indicators

To satisfy at least one of the following Timeliness Indicators:1. Time to initial assessment (95th percentile) below 15 minutes2. Time to treatment in department (median) below 60 minutes

ONE MET -   Jon Green

StrokeStroke -Proportion of Patients admitted to an acute stroke unit within 4 hours of hospital arrival 90% 100.00% 88.64%   Jon Green

Proportion of patients in Atrial Fibrillation, presenting with stroke and where clinically indicated will receive anti-co-agulation. 60% 75.00% 68.36%   Jon Green

Stroke - % of Stroke patients with access to brain scan within 24 hours 100% 100.00% 98.82%   Jon Green

Stroke - Proportion of Stroke Patients and carers with a joint health and social care plan on discharge 85% 100.00% 91.82%   Jon Green

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 100.00% 95.82%   Jon Green

>80% treated on a stroke unit >90% of their stay 80% 89.00% 89.64%   Jon Green>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% 100.00% 78.27%   Jon Green

Stroke - 65% of patients with low risk TIA have access to MRI or carotid scan within 7 days (seen, investigated and treated) 65% 65.00% 72.18%   Jon Green

% of Patients eligible for Thrombolysis, Thrombolysed within 4.5 hours 100% of all eligible patients 100.00% 100.00%   Jon Green

Discharge SummariesDischarge Summaries - Outpatients 95% sent to GP's within 3 days 92.37% 85.62%   Dermot O'Riordan

Discharge Summaries - A&E 95% of A&E Discharge Summaries to be sent to GPs within one working day 97.45% 97.11%   Dermot O'Riordan

Discharge Summaries - Inpatients 95% sent to GP's within 1 day 91.91% 84.20%   Dermot O'Riordan

Contract Priorities Dashboard

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Choose & 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)

3.00% - The Threshold appliedto fines is 5% Jon Green

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% 100.00% -   Jon Green

Cancelled OperationsProvider cancellation of Elective Care operation for non-clinical reasons either before or after Patient admission i) 1% of all elective procedures 0.99% 1.10%

  Jon GreenPatients offered date within 28 days of cancelled operation 100% 100.00% 97.64%   Jon GreenMaternity

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.

93.82% 96.36%

  Nichole DayMaintain maternity 1:30 ratio 1:30 1:30 1:29   Nichole Day

Pledge 1.4: 1:1 care in established labour 1:1100.00%

100.00%   Nichole Day

Breastfeeding initiation rates. 80% 84.92% 80.35%   Nichole DayReduction in the proportion of births that are undertaken as caesarean sections.  Suffolk PCT Only

1% reduction in proportion compared to 2011/12 baseline - 22.70% 19.50% 19.00%

  Nichole DayOther contract / National targetsMixed Sex Accomodation breaches 0 Breaches 0 4   Jon Green

Consultant to consultant referral Commisioner to audit if concern about levels of consultant referrals 7.40% -   Jon Green

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% 88.02% 87.64%   Jon Green

MRSA - emergency screening All emergency patients admissions are to be screened for MRSA within 24 hours of admission 96.87% 92.42%   Nichole Day

Rapid access - chest pain clinic 100% of patients should have a maximum wait of two weeks 100.00% 85.59%   Jon Green

New to Follow up Thresholds set at each speciality - overall Trust Threshold is 1.9 1.86 -   Jon Green

Patients receiving primary diagnostic test within 6 weeks of referral for diagnostic test 99% 100.00% 98.07%   Jon Green

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