INTEGRATED PERFORMANCE REPORT
Enclosure 3
for period ending
31st
October 2010
Trust Board – 3 December 2010 - Quality
EXECUTIVE
RESPONSIBLE
Adam Cairns
Chief Executive
AUTHOR (if different
from above)
Paul Hodson
Head of Contracts & Performance
Pete Gordon
Head of Continuous Improvement
William Wraith
Head of Human Resources
Tony Brown
Assistant Director Financial Performance
CORPORATE
OBJECTIVE
Enhancing Patient Experience, Safety and Effectiveness,
Achieving NHS Foundation Trust Status
BUSINESS PLAN
OBJECTIVE NO(S)
6.1 - Establish a new Quality Framework for the Trust.
6.1.1 - Develop an integrated performance management framework
that includes a balanced set of quality metrics across the domains of
safety, effectiveness and patient experience.
EXECUTIVE
SUMMARY
This paper reports current performance against a number
of KPIs for the period up to the end of October 2010. As
detailed in previous papers this reports only includes
slides for those KPIs identified as suitable for monthly
reporting. The summary sheet will continue to show a
RAG for all KPIs with quarterly KPIs showing their RAG
status at the end of the last full quarter.
KEY FACTS
• 18 Weeks, Stroke National & Local, MRSA and C.
Difficile, Cancer 14 and 31 day and Rapid Access
Chest Pain targets achieved in month.
• Thrombolysis, Outpatient Utilisation, Cancelled
Operations, A&E, Workforce Numbers and Cancer 62
day all under achieved in month.
RECOMMENDATIONS
1
The Board is asked to NOTE:
• performance against a range of Key Performance
Indicators covering Quality, Delivery and Foundations.
Appendix 1
Integrated Performance Report: Quality (CO1)
Executive
Lead
Monthly
Performance
Direction of
Travel
Year to Date
Forecast
Commentary
Frequency
Improve responsiveness to personal needs of patients (CO1.3 / CO1.7)
(CQUIN)
DSD
GREEN
=
GREEN
GREEN
Target 2010/11 89% overall patient satisfaction
5 indicators identified form 2009/10 results
M
Breaches in single sex accommodation compliance (CO1.5)
DSD
GREEN
=
GREEN
GREEN
Number of breaches caused by each occurrence will be equal to the total
number of patients effected
i.e. 1 female with 5 males is 6 breaches
M
To maintain a minimum level of non medical cancellations in
accordance with national criteria
DSD
RED
=
GREEN
GREEN
47 cancelled in month
M
Readmit all non medical cancellations within 28 days in accordance
with national criteria
DSD
GREEN
=
GREEN
GREEN
No 28 day breaches in month
M
Cleanliness
To maintain cleanliness score of 92% across the Trust
DSD
GREEN
=
GREEN
GREEN
Both sites were Green at the time of October monitoring
M
Choose & Book
Maintain a monthly slot availability rate of at least 90% for
appointments made via the Choose & Book System
DSD
RED
=
RED
RED
The October report is based on 3 weeks data available due to C&B
systems upgrade
M
Complaints
National response times are that all complaints are completed in their
entirety within six months, unless exceptional circumstances
DCA
GREEN
=
GREEN
GREEN
Of the 184 cases opened in the first quarter these have all been
responded to within the 6 months statutory deadline
Q
End of Life (CQUIN)
% of admitted patients at end of life following the Liverpool End of Life
Pathway (CO1.3)
DSD
GREEN
=
GREEN
GREEN
New CQUIN Target for 2010/11
Q2 – baseline 27%
Q4 to improve compliance by 20% target 32%
M
Rate of patient safety incidents reports (CO1.6)
MD
GREEN
=
GREEN
GREEN
Incident reporting rate of 8.4%
M
Serious Incidents Requiring Investigation (CO1.6)
MD
GREEN

GREEN
GREEN
Less than 8 SIRIs per month
M
No more than 6 post 48-hour MRSA bacteraemias
MD
GREEN
=
GREEN
GREEN
Total of 2 MRSA cases YTD
M
No more than 166 post 72-hour C. Difficile infections
MD
GREEN
=
GREEN
GREEN
Total of 40 C. Difficile cases YTD
M
Delayed and missed doses of medicines for hospital inpatients
MD
GREEN
=
GREEN
GREEN
Target (2010/11)
Patient Satisfaction
Patient Experience
Cancelled Operations
Incidents
Safety
Healthcare Associated
Infections (HCAIs)
Medicines Management
(CQUIN)
Baseline audit undertaken in May, second audit is now completed
Improvement Target agreed with PCTs
M
• Q1 Baseline – 142 Falls per month
• Q2 4%, reduction
• Q3 7%, reduction
• Q4 10% reduction
Effectiveness
Patient Falls (CQUIN)
No. of inpatients having a fall whilst an inpatient (CO1.3)
DSD
RED
=
AMBER
AMBER
Hospital Standardised
Mortality Ratio (HSMR)
HSMR for the most recent complete 12 months based on the HSMR
basket of 56 diagnosis groups
MD
RED

AMBER
AMBER
Month: 105.6 (95% CI: (88.38 – 125.3)
Last quarter: 110.2 (99.4-121.9)
Last 12 months: 112.7 (107.3 – 118.4)
M
Stroke - National Target
% of Patients spending 90% of time on Stroke Unit
MD
GREEN
=
GREEN
GREEN
Sustainable improvement continues
M
Stroke – Compound
Indicator
Compound based on Swallow Screens, TIAs and % of Time on Stroke
Unit
MD
GREEN
=
GREEN
GREEN
Quarter three to date, all three targets achieved
M
2
M
Appendix 1
Integrated Performance Report: Quality (CO1)
Target (2010/11)
Executive
Lead
Monthly
Performance
Direction
of Travel
Year to
Date
Forecast
Commentary
Frequency
Stroke (CQUIN)
Admissions to Stroke Unit within 4 hours of Arrival at Hospital
MD
GREEN
=
GREEN
GREEN
New CQUIN Target for 2010/11 value worth £200K
M
Early Access to
Maternity
Achieve contract milestones for early access to maternity services
(90% by Q4 and 86% full year) (CO1.1)
DSD
AMBER

AMBER
GREEN
October 2010
T&WPCT = 75%
SCPCT = 86%
M
Q
Effectiveness
Nutrition
% Completion of Nutrition Screening Tool ( C01.7)
DSD
GREEN
=
GREEN
GREEN
Baseline Audit 58%
Q2 65%
Q3 75%
Q4 90%
Readmission Rates
Relative Risk of Emergency Readmission within 28 days of
discharge
MD
GREEN
=
GREEN
GREEN
The relative risk of Emergency Readmission remains significantly
lower (better) than the average for England
M
Venous
Thromboembolism
(CQUIN)
% of adult inpatients who have had a VTE risk assessment on
admission (CO1.3)
MD
No update provided at the time of issue
M
Think Glucose (CQUIN)
Compliance with Think Glucose guidance (CO1.3)
MD
GREEN
=
GREEN
GREEN
Action plan compliant with milestone achievement
M
Tissue Viability (CQUIN)
Reduction in the number of Grade 3 and 4 Pressure Ulcers – to
be confirmed with PCT (CO1.3)
DSD
RED

AMBER
AMBER
3
New CQUIN 2010/11
Target to reduce by Q4 number of
grade 3/4 ulcers by 10%
M
Integrated Performance Report: Delivery (CO2, CO3 & CO4)
Target (2010/11)
Executive
Lead
Monthly
Performance
Direction of
Year to Date
Travel
Appendix 1
Forecast
Commentary
Frequency
Working in partnership as the
provider of choice
Appraisals
SaTH target of 80%
DCA
GREEN
=
GREEN
GREEN
Trust performance at 86% appraisal completion
M
Staff Satisfaction
A continual improvement in staff satisfaction, as assessed by the Annual
Staff Survey (CO3.3)
DCA
GREEN
=
GREEN
GREEN
2009 survey shows continued improvement over previous years
Q
Smoking (CQUIN)
90% of smokers/users of tobacco attending new patient appointments at
selected outpatient clinics receive brief intervention (CO4.3)
MD
No update provided at the time of issue
M
% of patients receiving cognitive assessment on admission
MD
Baseline to be obtained from the National Audit of Dementia.
Findings due Oct. – Dec. 2010 (Q2)
Q
An informed and effective workforce for people with dementia
MD
Preliminary Review of Educational requirements around Dementia
to increase knowledge & understanding amongst all Trust Staff
(Q2)
Q
MD
9a) PCT and Trust agreement on delivery with concerns raised
about responsibility lines after April 2011. Project Group meeting
and awaiting clarification of SLA for both sites
9b) PCT and Trust agreed target. SLA to be agreed for roll out.
Development in line with action plan
M
Dementia
Staying Healthy (Alcohol)
(CQUIN)
9a) 90% of people attending A&E with alcohol related condition & are not
admitted who receive a brief intervention to reduce alcohol consumption
9b) ?% of people who are admitted to hospital with alcohol related
condition receive brief interventions to reduce alcohol consumption
GREEN
4
=
AMBER
RED
Integrated Performance Report: Foundations (CO5 & CO6)
Target (2010/11)
Appendix 1
Executive
Lead
Monthly
Performance
Direction of
Travel
Year to Date
Forecast
Commentary
Frequency
DCA
GREEN
=
GREEN
GREEN
Trust now registered without conditions (Q2)
Q
FD
GREEN
=
GREEN
GREEN
Coding levels remain the same as previous month
M
Achieving NHS Foundation Trust status
Care Quality Commission
Registration
Maintain Trust Registration with the Care Quality Commission
Coding
To increase the numbers of FCEs with coded comorbidities
A&E 4 Hours
95% of patients to be admitted, discharged or transferred within 4 hrs.
of registering at A&E
DSD
RED
=
GREEN
GREEN
Local Health Economy underachieved target for October
M
1a - Admitted Clock Stops above 90%
DSD
GREEN
=
GREEN
GREEN
Trust achieved the 90% target during October
M
1b - Non-Admitted Clock Stops above 95%
DSD
GREEN
=
GREEN
GREEN
Trust achieved the 95% target during October
M
14 Days from urgent GP referral to first outpatient appointment for all
urgent suspected cancer referrals
DSD
GREEN

AMBER
GREEN
14 day target achieved in month
M
31 Days from diagnosis to treatment for all cancers
DSD
GREEN

GREEN
GREEN
31 day target achieved in month
M
62 Day from urgent referral to treatment of all cancers
DSD
RED

GREEN
GREEN
62 day target underachieved in month
M
Thrombolysis
68% of patients admitted with ST Elevation MI should receive
Thrombolysis within 60 minutes of call for help
DSD
RED
=
RED
GREEN
Only 2 eligible patient in the year to date. CQC guidance states that for
this indicator a ‘low numbers' rule will be applied which will withdraw Trusts
treating a low number of eligible cases from the assessment
M
Rapid Access Chest Pain
A maximum of two-week wait for rapid access chest pain clinic (CO6.6)
DSD
GREEN
=
GREEN
GREEN
Well established service with consistent high performance
M
18 Weeks
Cancer
5
Patient Satisfaction
Monthly
Status
Executive
Lead
Target (2010/11)
Improve responsiveness to personal
needs of patients (CO1.3 / CO1.7)
(CQUIN)
DSD
GREEN
Direction
of Travel
=
Year to
Date
GREEN
Forecast
Commentary
GREEN
Target 2010/11 89% overall patient
satisfaction
5 indicators identified form 2009/10
results
GREEN
Number of breaches caused by each
occurrence will be equal to the total
number of patients effected
i.e. 1 female with 5 males is 6 breaches
Patient Satisfaction
Breaches
in
Single
Sex
Accommodation (CSA) compliance
(CO1.5)
DSD
GREEN
=
GREEN
1000
800
• Capital funding approved to improve washing and toilet facilities.
600
• In October a total of 21 breaches on four occasions: 1 episode in Ward 4 Stroke
bay and 3 in MAU RSH. All were in response to high demand for beds and for
overriding clinical reasons. All breaches were corrected before the following shift.
400
200
0
• Patient Experience Tracker audits being rolled out across the organisation.
Apr-10 May-10 Jun-10
Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11
Breaches by month
287
195
165
157
45
5
21
Breaches YTD
287
482
647
804
849
854
875
Actions:
• To develop an overarching strategy for collection of patient experience information including patient stories.
• A Dignity in Care Conference is being organised in SECC for May 12th 2011 to celebrate Nurses Day .
6
28 Day Cancelled Operations
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Forecast
Commentary
To maintain a minimum level of non
medical cancellations in accordance
with national criteria
DSD
RED
=
GREEN
GREEN
47 cancelled in month
Readmit all non medical cancellations
within 28 days in accordance with
national criteria
DSD
GREEN
=
GREEN
GREEN
No 28 day breaches in month
Target (2010/11)
28 Day Cancelled Operations
Cancelled Operations 2010/11 - by Site
%
50
• 47 operations cancelled in October for non medical reasons.
0
Apr-10 M ay-10 Jun-10
Jul-10
Aug-10 Sep-10
Oct-10 Nov-10 Dec-10
PRH
15
6
17
20
15
25
15
RSH
0
8
15
26
12
28
32
33
33
35
36
30
34
35
Anticipated Threshold
Jan-11
Feb-11 M ar-11
• 202 operations cancelled for non medical reasons in the year-to-date.
33
31
31
34
40
• The national target applies only to those cancellations that happened on or after
the day of admission and only for non-medical reasons.
Cancelled Operations 2010/11 by Reason
60
50
• Current guidance indicates that the CQC threshold for achievement will be no more
than 0.8% of relevant elective activity. We are currently below this figure for the
year-to-date but the in month performance is above the anticipated threshold.
40
30
20
10
0
Apr-09
No Beds
May-09
No Anaesthetist
Jun-09
No Time
Jul-09
Aug-09
Theatre Closed
Sep-09
No Equipment
Oct -09
Nov-09
Dec-09
Cancelled by Surgeon
Jan-10
No Surgeon
Feb-10
Mar-10
Trauma
Other
Actions:
• During October the main causes of patient cancellations were 1) no bed (23 patients) and 2) theatre list overruns (10 patients). The list overruns in the main are due to
beds being identified too late during the theatre list. In October there have been a significant number of outliers within the surgical specialities bedbase.
• There is a further process mapping session for the Surgical Admission Suite in December, to address some of the patient flow challenges.
7
Cleanliness
Target (20010/11)
To maintain cleanliness score of 92%
across the Trust
Cleanliness
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Forecast
Commentary
DSD
GREEN
=
GREEN
GREEN
Both sites were Green at the time of
October monitoring
• Target score of 92% is based on the Patient Environment Action Team (PEAT)
score to achieve “excellent”.
• Monthly cleanliness scores collected from Domestic Services Department Quality
Monitoring Programme.
SATH Cleanliness Score for 2010 - 2011
RSH
100
Percentage
80
• April and May figures only collated as combined scores.
PRH
60
• Overall score of 95.82% was achieved for the Trust in October 2010.
SATH Score
40
20
Green
(=>92%)
• Cleanliness Score for RSH much improved this month.
0
Mar-11
Feb-11
Jan-11
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Amber
(<92% and
>87%)
• The main issue at PRH this month was the public toilets but all issues found are
being addressed.
Monthly
• Based on April to October figures the year-end forecast is 94.49% (this will be
submitted as part of the PEAT Assessment process).
Actions:
• Manual system of recording of monitoring used at present. Electronic System to be implemented by January 2011.
8
Choose and Book
Target (2010/11)
Choose and Book
Maintain a monthly slot availability rate
of at least 90% for appointments
made via the Choose & Book System
Monthly
Status
Executive
Lead
DSD
RED
Direction
of Travel
=
Year to
Date
RED
Forecast
Commentary
RED
The October report is based on 3
weeks data available due to C&B
systems upgrade
• The planned upgrade to the national C&B system took place 23/24th October. We
await the new report format being compiled by the national C&B team.
Slot availability rate for appointments made via the Choose &
Book System
• Appointment Slot Issues (ASIs) are now directly available to the SDU on a C&B
worklist, allowing more proactive management of the capacity available to provide
the appointments needed. ‘Superuser’ training has been provided on how to
access and manage the ASI worklist.
%
100.00%
• An average of 95 patients per week were unable to book their appointment via
C&B up to October 24th. Of these, 75% were in the following specialties:-
80.00%
60.00%
Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11
-
Actual 86.00% 84.00% 80.00% 85.00% 87.40% 82.95%
Profile 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%
Actions:
• Review and action ASIs within the SDUs.
9
Ophthalmology – av. 27 per week (increase of 10 per week from September)
Children & Adolescent – av. 14 per week (increase of 5 per week from September)
T&O – av. 11 per week
ENT av. 11 per week
Dermatology av. 9 per week.
End of Life
End of Life (CQUIN)
Monthly
Status
Executive
Lead
Target (2010/11)
% of admitted patients at end of life
following the Liverpool End of Life
Pathway (CO1.3)
DSD
Percentage of patients with anticipated death managed on
LCP at End of Life
100
80
EOL deceased patients
60
LCP
GREEN
Direction
of Travel
=
Year to
Date
GREEN
Forecast
Commentary
GREEN
New CQUIN Target for 2010/11
Q2 – baseline 27%
Q4 to improve compliance by 20%
target 32%
• Q1 electronic data collection system established. Monthly reports generated from
contracts, performance and Vitalpac data.
• Q2 base line position of 27% compliance. Baseline position reached by comparing
deceased patients coded for palliative care against patients recorded on Vitalpac
as on Liverpool Care Pathway (LCP).
%
40
Target %
20
• Baseline identified using month six data as thought to be the most reliable due to
improvements in coding for palliative care.
0
Q2
Q4
Actions:
• Q3 monitor against baseline. Monthly meeting with clinical coding and palliative care CNS to support data validation.
• To take forward recommendations for the development and improvements to Bereavement Services.
10
Incidents
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Year End
Forecast
Commentary
Rate of patient safety incidents reports
(CO1.6)
MD
GREEN
=
GREEN
GREEN
Incident reporting rate of 8.4%
Serious Incidents Requiring
Investigation (CO1.6)
MD
GREEN

GREEN
GREEN
Less than 8 SIRIs per month
Target (2010/11)
Incidents
Incident rate per number of admissions (08/09 HES data)
8.5
8
7.5
%
7
6.5
6
5.5
5
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Month
Number of SUIs and Patient RIDDOR reports (excluding pressure ulcers and
MRSA bacteramia)
12
10
Total
8
RIDDOR
6
• The Trust reports Patient Safety Incidents & Near Misses to the National Reporting &
Learning System (NRLS). The rate is based on the number of incidents each month as a
percentage of the monthly admissions (based on 2008/09 HES data).
• The Care Quality Commission (CQC) receive weekly reports from the NRLS & are
regularly provided with further information about incidents. Managers are reminded to
ensure that compiled information on investigations & actions is included on the reports
before final submission.
• The number of Serious Incidents Requiring Investigation (SIRI) includes Serious Untoward
Incidents (SUIs) & Patient Incidents which have been reported under RIDDOR (Reporting
of Injuries, Diseases & Dangerous Occurrences Regulations). MRSA bacteraemias and
grade 3/4 pressure sores are excluded as these are reported separately.
SUI
4
2
0
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Month
Actions:
• Incident Review Group meets monthly to discuss incidents & trends. Further Root Cause Analysis training for Managers is being planned to improve the consistency of
investigation.
11
Healthcare Associated Infections (HCAIs)
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Forecast
No more than 6 post 48-hour MRSA
bacteraemias
MD
GREEN
=
GREEN
GREEN
Total of 2 MRSA cases YTD
No more than 166 post 72-hour C.
Difficile infections
MD
GREEN
=
GREEN
GREEN
Total of 40 C. Difficile cases YTD
Target (2010/11)
Healthcare Associated
Infections (HCAIs)
MRSA Cases v Profile 2010/11
Cases
10
0
Apr10
M ayAugJun-10 Jul-10
10
10
Sep10
Oct10
M RSA Cases YTD
0
0
0
0
0
0
2
M RSA Cases by M onth
0
0
0
0
0
0
2
National Target Profile YTD
1
1
2
2
3
3
4
Nov10
Dec10
4
5
Jan-11 Feb-11
5
6
M ar11
6
SaTH C-Diff Cases in Patients over the age of 2 2010/11
Cases
150
100
50
0
Apr10
M ayAugJun-10 Jul-10
10
10
Sep10
Oct10
Nov10
Dec10
40
40
40
40
40
112
126
140
153
166
C-Diff Cases YTD
7
17
22
26
31
34
40
C-Diff Cases by M onth
7
10
5
4
5
3
6
National Target Profile YTD
14
28
42
56
70
84
98
Jan-11 Feb-11
M ar11
Commentary
MRSA
• There were 2 post 48 hour cases of MRSA bacteraemia in October.
• Both cases were in ITU at RSH. RCA has been carried out. In one the likely
source was a chest infection and in the other a wound infection. We are typing the
MRSA strains to see if they are the same.
• Two cases to end of October 2010 vs. target of not more than 6 post 48 cases
2010/11.
• There was one pre 48 hour MRSA bacteraemia in October. This was investigated
by the PCT and found to be from a pressure sore.
• Ongoing work – maximising admission screening, re-screening wards where
acquisition occurs, reducing line sepsis, screening new staff.
• C. Difficile
• To end October 2010 - 40 SaTH responsible cases (post 72 hrs.).
• In October 6 SaTH cases, 5 in RSH and 1 in PRH, were diagnosed more than 72
hrs. post admission and therefore count vs. SaTH target.
• One ward has had more than five cases within 30 days. RCA suggested antibiotic
use and cross infection were issues.
Actions:
• C difficile cluster: An intensive deep clean and review of practice has being carried out. Antibiotic audits are continuing.
12
Medicines Management
Medicines Management
(CQUIN)
Monthly
Status
Executive
Lead
Target (2010/11)
Delayed and missed doses
medicines for hospital inpatients
of
MD
GREEN
Direction
of Travel
=
Year to
Date
GREEN
Forecast
Commentary
GREEN
Baseline audit undertaken in May,
second audit is now completed
Improvement Target agreed with PCTs
Baseline Audit Results May 2010
Patients records reviewed
364
Number of times where medicines were
prescribed
4383
Prescription omitted for a clinical or patient
specific reason i.e. patient refused
643
14.67%
Prescription omitted due to a record of non
available
80
1.83%
Prescription where medicines regarded as
critical
38
0.89%
Prescription where more than 1 dose
omitted
22
0.50%
• To agree list of Critical Medicines for baseline audit- achieved.
• To undertake baseline audit in May 2010 - achieved. 3 day audit of Admission
areas, 364 patient records/charts included, second audit completed, final audit
planned for January 2011.
• Report to PCTs in July 2010- achieved, November 2010 in progress & March 2011.
• Baseline Audit accepted & 20% improvement target provisionally agreed, based on
improvement over the next two audits.
• Stock lists and out of hours arrangements amended in line with audit results &
training & support advice provided to nursing staff to locate & obtain critical
medicines.
Actions:
• Second Audit now completed, results expected to be available at the end of November.
• Report to be forwarded to PCT when audit results are available.
• Action plan to be further developed dependent on audit results.
13
Patient Falls
No. of inpatients having a fall whilst an
inpatient (CO1.3)
Patient Falls (CQUIN)
Monthly
Status
Executive
Lead
Target (2010/11)
DSD
RED
Direction
of Travel
=
Year to
Date
AMBER
Forecast
Commentary
AMBER
• Q1 Baseline – 142 Falls per month
• Q2 4%, reduction
• Q3 7%, reduction
• Q4 10% reduction
• Patient “comfort Rounds” have been introduced for ‘At Risk’ patients.
12 month run chart for showing falls in SaTH
• Gold squares to be placed above all patient’s bed who have been assessed and
deemed at risk of having a fall.
• “Tip Tree Box” to be trialled on Care of the Elderly Ward. This is a tool kit for use in
hospital wards as therapeutic intervention with patients suffering from dementia.
Contains everyday familiar items and a table where patients can sit safely and not
be confined to their bedside.
150
100
50
• Weighted alarms to be trialled on Ward 4 for a 4–6 week period starting 12th
November 2010.
0
Apr
May
Jun
SaTH 09-10
Jul
Aug
SaTH 10-11
Sep
Oct
Nov
10-11 Trajectory
Dec
Jan
Feb
Mar
• Patient Safety First week – falls workshop to be included.
• Executive Nurse Root Cause Analysis Review Meetings to be held every 2 weeks.
Actions:
• Falls information on Internet and Intranet.
• To undertake further in depth analysis on falls data and categories.
• Ward Managers and Matrons to be alerted to falls on daily basis so more proactive and immediate review can take place.
14
Hospital Standardised Mortality Ratio (HSMR)
Target (2010/11)
Hospital Standardised
Mortality Ratio (HSMR)
Period
HSMR
Sept 09 –
Aug 10
RED
(worse)
Jul 09-Sep
09
RED
(worse)
Oct 09-Dec
09
RED
(worse)
Jan 10Mar 10
RED
(worse)
Apr 10-Jun
10
AMBER
HSMR for the most recent complete
12 months based on the HSMR
basket of 56 diagnosis groups
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Forecast
Commentary
MD
RED

AMBER
AMBER
Month: 105.6 (95% CI: (88.38 – 125.3)
Last quarter: 110.2 (99.4-121.9)
Last 12 months: 112.7 (107.3 – 118.4)
• HSMR is calculated from hospital activity using the Dr Foster Real Time Monitoring
(RTM) Analysis Tool, using the most recent available data (currently three months
in arrears). It compares the mortality rates in our hospitals with the average
expected across England, adjusted to reflect factors such as age and case mix.
• Dr Foster has rebased the HSMR which has resulted in a change in the Trust’s
reported HSMR which has been applied retrospectively for the last year.
• The annual HSMR for the year Sept 2009 to August 2010 is worse than the
national average for England (based on a 95% confidence interval).
• The HSMR for the latest month is 112.7 and for the last quarter is 110.2. For the
months April – August, April, ,June, July and August were close to the England
averages.
• Trust-level Mortality data has been triangulated using other quality analysis tools,
such as CHKS. This has not replicated the alert from the Dr Foster system.
Number of deaths per month (HSMR basket)
180
160
140
80
60
40
20
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Mar-10
Feb-10
Jan-10
Dec-09
Nov-09
0
Oct-09
TWO
100
Sep-09
Negative
Triggers
(comparable but
one trigger)
Number
120
Actions:
• Senior nurses will be trained in the use of the Global Trigger Tool in December.
• A coding workshop was held on 15th October. A number of Clinicians have been identified as ‘Coding Champions’. A further workshop will be held in November.
• The Trust is working with the University of Birmingham to understand the data more fully; develop an alternative system for monitoring deaths, and to set up a research
project.
15
Stroke
Target (2010/11)
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Year End
Forecast
Commentary
Stroke National Target
% of Patients spending 90% of time on Stroke Unit
MD
GREEN
=
GREEN
GREEN
Sustainable improvement continues
Stroke – Compound Indicator
Based on targets agreed with local Commissioners
MD
GREEN
=
GREEN
GREEN
Quarter three to date, all three targets
achieved.

90% of Time on Acute Stroke Unit
Sw allow Screen Within 24 Hrs
90.0%
90.0%
60.0%
60.0%
30.0%
30.0%
Qtr 1
Qtr 2
Qtr 3
Qtr 4
SaTH
76.9%
81.0%
82.8%
Target
66.5%
71.0%
75.5%
80.0%
•
•
Qtr 1
Qtr 2
Qtr 3
SaTH
78.9%
87.1%
84.5%
Target
64.8%
66.5%
68.3%
Qtr 1
Qtr 2
Qtr 3
SaTH
23.1%
80.6%
88.9%
Target
47.3%
51.5%
55.8%
•
70.0%
•
•
TIA - Scanned & Treated Within 24 Hrs
(Rothw ell Score 4+)
100.0%
80.0%
60.0%
40.0%
20.0%
Qtr 4
Qtr 4
60.0%
Current Performance Proportion of People who spent at least 90% of their time on a Stroke
Unit: Quarter 3 Target 75.5.0%, PRH 95.5%, RSH 75.0%.
The overall SaTH performance continues to exceed this target. Improvement noted at
RSH, however work is required as performance is still fractionally short of target.
Current Performance for swallow screening on both sites:
Quarter 3 Target 68.3%, PRH 90.9%, RSH 80.6%.
Current Performance for TIA on both sites:
Quarter 3 Target 55.8%, PRH 100%, RSH 75.0%.
Marked improvement continues against this target.
Trust delegates will be hosting an exhibit at the UK Stroke Conference in Glasgow in
December sharing our best practice on TIA pathway redesign.
• West Midlands Quality Review Service visited both sites in September.
– Formal feedback has been received. An action plan has been completed.
– Meetings with PCT representatives and Chief Executive to formalise Economy Wide
response to deliver improved performance in highlighted areas.
Actions:
•
•
•
•
•
Data Analyst interviews to take place on Friday November 5th.
Thrombolysis Service to commence seven days a week 08:00 – 20:00 at both PRH and RSH from December 6th (Phase One).
Hyper acute Stroke patients (including Thrombolysis) to be provided at one site only (PRH) during hours 20:00 – 08:00 from January 5th (Phase Two – Interim phase).
Option appraisal to be carried out during March 2011 (re. Phase Two).
Implement a twenty-four/seven service to include Thrombolysis at a single site (Phase Three).
16
Stroke - CQUIN
Target (2010/11)
Admissions to Stroke Unit within 4
hours of Arrival at Hospital
Stroke
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Year End
Forecast
Commentary
Medical
Director
GREEN
=
GREEN
GREEN
New CQUIN Target for 2010/11 value
worth £200K
Admission to Stroke Unit w ithin 4 hours of
Arrival
60.0%
40.0%
20.0%
0.0%
• Current performance for admitted to Stroke Unit within four hours of Arrival:
Quarter 3 Target 33%, PRH 60.9%, RSH 53.9%.
Qtr 1
Qtr 2
Qtr 3
SaTH
54.5%
54.8%
56.5%
Target
23.0%
29.0%
33.0%
Qtr 4
• New CQUIN Target from April 2010 to demonstrate Admission to Stroke Unit within
4 hours of Arrival at Hospital – value worth £200k.
38.0%
Actions:
17
Early Access to Maternity
Achieve contract milestones for early
access to maternity services (90% by
Q4 and 86% full year) (CO1.1)
Early Access to Maternity
Monthly
Status
Executive
Lead
Target (2010/11)
DSD
Quarter 1 Data: Validated
Quarter 2 Data: Validated
Quarter 3 Data: Unvalidated
AMBER
Direction
of Travel

Year to
Date
AMBER
Forecast
Commentary
GREEN
October 2010
T&WPCT = 75%
SCPCT = 86%
• Action plan being developed for both PCT areas.
• Meeting with TWPCT and GP Maternity Lead held in November 2010 – offered
support to encourage the use of the electronic Notification of Pregnancy (NOP)
with TWPCT GP surgeries.
Early Access Target
95.00%
90.00%
SATH
85.00%
Target
80.00%
75.00%
Qtr 1
Qtr 2
Qtr 3
SATH
81.50%
87%
84%
Target
80%
85%
88.90%
Qtr 4
90%
• Permanent booking co-ordinator posts recruited, commencement dates TBC.
• Regular SCPCT Service Review Meetings (as per existing TWPCT Review
Meetings) are still to be confirmed.
• Flexible working required to meet peaks in referrals.
• Work to convert the playroom to a booking room at Wrekin nearly completed.
Actions:
• Review of database to identify specific GP practices referring pregnant women late to Maternity Services.
• Review of database to identify midwives undertaking booking assessment outside of target (following appropriate referral into the system).
• Recruitment to midwifery vacancies within PRH to be tightly managed.
18
Nutrition
% Completion of Nutrition Screening
Tool ( CO1.7)
Nutrition
Monthly
Status
Executive
Lead
Target 2010/11
DSD
GREEN
Direction
of Travel
=
Year to
Date
GREEN
Forecast
Commentary
GREEN
Baseline Audit 58%
Q2 65%
Q3 75%
Q4 90%
• A baseline audit conducted in April 2010 showed 58% of Nutritional Screening
Assessments were completed within 6 hours of patient admission.
100%
90%
80%
• Targets for 2010/11 have been agreed as:
70%
Q2 65% compliance
Q3 75% compliance
Q4 90% compliance.
%
60%
50%
40%
30%
• New Dietician appointed with specific role to monitor Nutritional Compliance and
Out comes.
20%
10%
0%
% compliance
Target
Q1
Q2
58%
91%
65%
Q3
Q4
• Nutritional Steering Group established.
75%
90%
• Protected Meal Times being trialled in wards 7, 15 and 16 at PRH.
19
Readmission Rates
Relative
Risk
of
Emergency
Readmission within 28 days of
discharge
Readmission Rate
GREEN
6.0%
GREEN
(better)
300
200
100
Apr-10
Mar-10
Feb-10
0
Jan-10
ONE
400
Dec-09
Specialty Alerts
500
Nov-09
Full data not
available
600
May-09
Apr 10-June 10
700
Oct-09
Jan 10-Mar 10
GREEN
(comparable)
=
Year to
Date
GREEN
Forecast
Commentary
GREEN
The relative risk of Emergency
Readmission remains significantly
lower (better) than the average for
England
• The relative risk of Emergency Readmission was lower (better) than the average
for England (based on a 95% confidence interval) for the most recent available full
data year (June 2009 to May 2010) and was significantly lower than (2 quarters) or
comparable with (2 quarters) the average for England in the four quarters of the
most recent available data year.
Readmissions
Sep-09
Oct 09-Dec 09
GREEN
(better)
Jul-09
GREEN
(better)
Aug-09
Jul 09-Sep 09
Direction
of Travel
• Relative risk of emergency readmission within 28 days of discharge is calculated
from hospital activity using the Dr Foster Real Time Monitoring Analysis Tool, using
the most recent available data (currently five months in arrears, to ensure that
readmissions have been mapped to previous spells). It compares the Emergency
Readmission in our hospitals with the average expected across England, adjusted
to reflect factors such as age and case mix.
Jun-09
Jun 09 to May
10
MD
Risk Rating
Number
Period
Monthly
Status
Executive
Lead
Target (2010/11)
Actions:
20
Venous Thromboembolism
Target (2010/11)
Venous Thromboembolism
(CQUIN)
% of adult inpatients who have had a
VTE risk assessment on admission
(CO1.3)
Monthly
Status
Executive
Lead
MD
Direction
of Travel
Year to
Date
Forecast
Commentary
No update provided at the time of issue
Actions:
21
Think Glucose
Target (2010/11)
Think Glucose (CQUIN)
Milestones
Compliance with
guidance (CO1.3)
Think
Glucose
Completion Date
Compliance
Baseline audit
Q1
Green
Robust process for
patient identification
Safe use of Insulin
implemented
Q2
Green
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Forecast
Commentary
MD
GREEN
=
GREEN
GREEN
Action plan compliant with milestone
achievement
• Think Glucose is a practical and easy to use tool which improves the care,
outcomes and experience of people with diabetes who are admitted to hospital with
non-diabetes related problems.
• Ongoing training in progress to Ward Champions.
• Ward Hypoglycaemic boxes ordered & stocked.
Review of patient
identification
Visibility and education
roll out Re-audit against
toolkit
Q3
CQUIN compliance
Q4
• Ward Resource Toolkit box disseminated to all wards and departments.
Actions:
• Continuation of delivery of action plan.
• Plan to roll out pre filled insulin syringes during January.
• Develop audit tool to measure compliance.
22
Tissue Viability
Reduction in the number of Grade 3
and 4 Pressure Ulcers – to be
confirmed with PCT (CO1.3)
Tissue Viability (CQUIN)
Monthly
Status
Executive
Lead
Target (2010/11)
DSD
RED
Direction
of Travel

Year to
Date
AMBER
Forecast
AMBER
Commentary
New CQUIN 2010/11
Target to reduce by Q4 number of
grade 3/4 ulcers by 10%
• Increase in the total number of ulcers may be attributable to greater compliance
with reporting due to on ongoing increased awareness in the use of the new E
Trace system with ‘Skin Sunday’.
Pressure Ulcers Developed in Trust by Grade
• Monthly status red as 5 SUI in October so above 3 per month target .
60
50
Grade 4
40
Grade 3
30
Grade 2
20
Grade 1
10
h
Ma
rc
Se
pt
em
be
r
Oc
tob
er
No
ve
mb
er
De
ce
mb
er
Ja
nu
ar
y
Fe
br
ua
ry
Au
gu
st
Ju
ly
Ju
ne
Ma
y
0
•
•
•
•
• Case review meetings of RCA’s commenced by Executive Nurse & Head of Nursing to
learn lessons from RCA.
• Delivery of detailed education programme continues, this has been rolled out to Ward 28,
Ward 16, Ward. 24, 8/9 and MAU in progress. Roll out plan for the rest of Trust
constructed.
• Root Cause Analysis Training given to Matrons and Lead Nurses.
• Trust wide prevalence audit completed .
• Trust Surveillance Nurse will assist TV Nurse 8 hrs. per week to ensure ward staff can
access early advice/intervention for grade 3 and 4 pressure ulcers.
Actions:
• RCA training arranged in November for Ward Managers .
•
•
Key Themes From RCA’s
Inadequate documentation of patients nursing care in care plan.
Wound assessment documentation not completed accurately.
Delay in reporting pressure ulcer & referring to TVN.
Continue with education roll out.
To review Trust wide Prevalence audit results.
23
Appraisals
Target (2010/11)
Appraisals
SaTH target of 80%
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Forecast
Commentary
DCA
GREEN
=
GREEN
GREEN
Trust performance at 86% appraisal
completion
• As at month ending 31st October 2010, 86% of staff excluding Bank Staff have had
a KSF appraisal within the last 15 months.
• Departments continue to improve completion performance, although this must be
sustained over the winter months when operational pressures normally impact.
• Appraisal Quality Audits are currently being trialled to improve the effectiveness of
individual appraisals.
Completed Appraisals (excluding Bank Staff)
100.0
80.0
% Appraisals Completed
• The lowest 5 performing areas for September with over 15 staff were as shown.
All have action plans in place to achieve 80%.
60.0
40.0
20.0
0.0
Area
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
% Appraisals Completed 2009-10
69
71
71
73
74
77
77
78
76
74
76
84
% Appraisals Completed 2010-11
84
81
83
84
85
84
86
% Target Appraisals Completed
80
80
80
80
80
80
80
80
80
80
80
80
Staff
Completed
%
Div.
Portering Department (RSH)
37
10
27
Cor
p.
Ward 11 - Trauma & Orthopaedics
23
12
52
1
Ward 23 - Haematology
17
9
53
2
Ward 10 - Trauma & Orthopaedics
27
15
56
1
Ward 9 - General Medicine
23
14
61
1
Actions:
• Departments falling below 60% are performance managed by the relevant Executive Director.
24
Smoking
Target (2010/11)
Smoking (CQUIN)
90% of smokers/users of tobacco
attending new patient appointments at
selected outpatient clinics receive brief
intervention (CO4.3)
Monthly
Status
Executive
Lead
MD
Direction
of Travel
Year to
Date
Forecast
Commentary
No update provided at the time of issue
Actions:
25
Staying Healthy (Alcohol) - CQUIN
Staying Healthy (Alcohol)
9a) 90% of people attending A&E with alcohol
related condition and are not admitted who
receive a brief intervention to reduce alcohol
consumption
9b) 75% of people who are admitted to hospital
with alcohol related condition receive brief
interventions to reduce alcohol consumption
Pts presented A&E:
RSH = 50
Pts seen by alcohol
specialist:
2
(4%)
Monthly
Status
Executive
Lead
Target (2010/11)
Pts presented at PRH
= 65
Pts sent information
packs:
50
(100%)
MD
GREEN
Direction
of Travel
=
Year to
Date
AMBER
Forecast
Commentary
RED
9a) PCT and Trust agreement on delivery
with concerns raised about responsibility
lines after April 2011. Project Group
meeting and awaiting clarification of SLA
for both sites
9b) PCT and Trust agreed target. SLA to
be agreed for roll out. Development in line
with action plan
Part 9a:
• Data Assessment shows 100% patients attending A&E at RSH had a delivered intervention
for September.
• Monthly Project Group verbalised concerns around meeting this target if intervention is
decreed as being anything more than a sticker and ‘pack sent’ approach. Skill mix review
in these areas needs to link into delivery of IBA (Identification and Brief Advice). Alcohol
Nurse Specialists through MHL Services started and are based at PRH Ward 9. There is
no facility for engaging across both sites due to commissioning streams. Achieved CQUIN
in this group for this month.
Part 9b:
• Reviewed Alcohol Screening Tool and agreed trial to start December, first working day.
SDU is taking cost for this. Tool will be trialled on 27G, Ward 9 and MAU’s for 3 months to
assess function in practice. Project Group to work with SAU’s to access this client group.
• Awaiting agreement of information leaflets so that there is a consistent approach for both
sites. This has been assigned to project leads and will be ready by December. In January
2011 PRH will have access to information leaflets and packs to send out to fully meet
CQUIN.
Actions:
• 9a: There are significant concerns around the delivery of IBA after April 2011 at RSH due to resourcing Alcohol specialist post. CQUIN uplift payments are required to assist in service
provision and agreement of this needs to allow for 3 months to ensure continuity and training.
• 9b: Delay in agreement for SLA across providers/commissioners. The need for this is agreed and will be written by PCT’s in discussion with acute Trust. This is not totally in the control of
the CQUIN group.
26
Care Quality Commission Registration
Target (2010/11)
Care Quality Commission
Registration
Maintain Trust Registration with the Care
Quality Commission
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Forecast
Commentary
DCA
GREEN
=
GREEN
GREEN
Trust now registered without conditions
(Q2)
The new registration system for health and adult social care will make sure that people
can expect services to meet essential standards of quality and safety that respect their
dignity and protect their rights. The new system is focused on outcomes rather than
systems and processes, and places the views and experiences of people who use
services at its centre
There are 28 outcomes, each reflecting a specific regulation. Of these 28 regulations
and outcomes, there are 16 that relate most directly to the quality and safety of care
and which apply to all types of provider. The other 12 regulations may apply
differently to different types of provider.
There are 28 outcomes grouped into six key areas:
● Involvement and Information
● Personalised Care, Treatment and Support
● Safeguarding and Safety
● Suitability of Staffing
● Quality and Management
● Suitability of Management.
• The Trust declared compliant with all relevant outcomes across the six key areas in
the January Initial Registrations process.
• SaTH has set up templates for lead managers to collate evidence of compliance.
• The CQC are introducing a new quality & risk profiling tool that SaTH will
incorporate in to the assessment process however publication of the second quality
and risk profile has been delayed from April until at least September.
• The Trust remains registered without any conditions.
• The CQC have completed their responsive review.
• The DoH and CQC have agreed to halt further action on the periodic review of the
NHS – there will be no ratings published for Quality and Use of Resources.
Actions:
• Lead Managers have been asked to submit evidence of continuing compliance against the Essential Standards of Quality and Safety for Quarter 2.
• Internal Audit will be auditing the evidence of compliance in November.
27
Coding
Target (2010/11)
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Forecast
Commentary
FD
GREEN
=
GREEN
GREEN
Coding levels remain the same as
previous month
To increase the numbers of FCEs with
coded co-morbidities
Coding
FCEs with Coded Co-morbidities
72%
71%
• The Target is to ensure that co-morbidities are captured by clinicians for each
Finished Consultant Episode (FCE), where applicable.
70%
69%
• Work is currently underway by MedeAnalytics to analyse national coding statistics
and provide a national benchmark by which SaTH clinical coding can be
compared.
68%
67%
66%
65%
64%
10/11 Actual
Apr
May
Jun
Jul
Aug
Sept
66%
65%
69%
71%
72%
72%
Oct
Nov
Dec
Jan
Feb
Mar
• New guidance for 2010/11 has been issued by Connecting for Health which
clarifies the recording of co-morbidities and is responsible for the increased depth
of coding.
Data report one month in arrears
Actions:
• The Clinical Coding Manager continues to audit the recording of co-morbidities on a monthly basis making use of the Coding analytics software.
28
A&E 4 Hour Waits
Target (2010/11)
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Forecast
Commentary
DSD
RED
=
GREEN
GREEN
Local Health Economy underachieved
target for October
95% of patients to be admitted,
discharged or transferred within 4 hrs.
of registering at A&E
A&E 4 Hour Waits
• The Trust achieved 92.80% unmapped during October.
• The Local Health Economy achieved 96.69% mapped during October.
Total Time in A&E - Less than 4 Hours
100%
• For the year-to-date the Trust has achieved 97.04% unmapped.
%
98%
• For the year to date the Local Health Economy has achieved 98.48% mapped.
96%
• Recently revised NHS Operating Framework has amended target to 95% for
2010/11, however the internal target of 98% remains and is shown in the graph.
94%
92%
M apped Total
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
M ar-10
Apr-10
M ay-10
Jun-10
Jul-10
97.20% 95.90% 95.73% 97.50% 99.08% 98.77% 99.01% 99.00% 99.08% 98.71%
2.73%
2.89%
1.84%
0.76%
1.08%
0.35%
0.27%
0.26%
0.92%
Aug-10
Sep-10
Oct-10
97.55% 95.98% 96.69%
PCT Element
1.48%
0.52%
0.56%
3.89%
SaTH Element
95.72%
National Target
95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%
Stretch Target
98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00%
93.17% 92.84% 95.66% 98.32% 97.69% 98.66% 98.73% 98.82% 97.79% 97.03% 95.42% 92.80%
• Performance in the month has been assessed against the internal stretch target of
98%. The Trust continues to achieve the National 95% target.
• Performance notice received from Shropshire County PCT for October’s
performance.
Actions:
• Daily Conference Calls continue.
• Health and Social Care Winter Planning commenced.
• Urgent Care Network Review and relaunch.
29
18 Weeks
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Forecast
Commentary
1a - Admitted Clock Stops above 90%
DSD
GREEN
=
GREEN
GREEN
Trust achieved the 90% target during
October
1b - Non-Admitted Clock Stops above
95%
DSD
GREEN
=
GREEN
GREEN
Trust achieved the 95% target during
October
Target (2010/11)
18 Weeks
18 Weeks Part 1a - Admitted Clock Stops
%
100.00%
80.00%
60.00%
Apr 10
M ay 10
Jun 10
Jul 10
Aug 10
Sep 10
Oct 10
Actual
90.50%
91.83%
91.57%
91.41%
90.52%
90.71%
90.22%
Profile
90.00%
90.00%
90.00%
90.00%
90.00%
90.00%
90.00%
Nov 10
Dec 10
Jan 11
Feb 11
M ar 11
90.00%
90.00%
90.00%
90.00%
90.00%
Nov 10
Dec 10
Jan 11
Feb 11
M ar 11
95.00%
95.00%
95.00%
95.00%
95.00%
18 Weeks Part 1b - Non Admitted Clock Stops
%
100.00%
80.00%
60.00%
Apr 10
M ay 10
Jun 10
Jul 10
Aug 10
Sep 10
Oct 10
Actual
96.40%
97.12%
97.03%
96.30%
95.25%
96.23%
97.02%
Profile
95.00%
95.00%
95.00%
95.00%
95.00%
95.00%
95.00%
• The Trust Achieved the overall target of 90% and 95%.
• PCT performance for September was:1a
1b
Shropshire County PCT 90.14% 97.02%
Telford & Wrekin PCT
90.12% 97.02%
• Achieved the 95% target for Audiology in October with 96% of non admitted
Audiology patients completing their pathways within 18 weeks with 92% data
completeness which is within the anticipated 90 – 110% threshold.
• Specialty level performance for admitted patients (part 1a) was below 90% in ENT
(78.69%) Ophthalmology (84.87%) Oral Surgery ( 78.57%) T&O (87.02%).
• Specialty level performance for non admitted patients (part 1b) was below 95% in
Oral Surgery ( 93.63%) .
• The DOH and SHA have confirmed the following thresholds will apply when
reviewing performance against median waits for each pathway type, >11.1weeks
Admitted, >6.6 weeks Non Admitted and >7.2 weeks Incomplete
• At the end of September SaTH was below the Admitted and Non Admitted
thresholds with 7.53 and 6.58 respectively. For Incomplete pathways SaTH
exceeded the threshold with 8.84 weeks
Actions:
30
14 Day Cancer
Target (2010/11)
Cancer – 14 Day
14 Days from urgent GP referral to
first outpatient appointment for all
urgent suspected cancer referrals
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Forecast
Commentary
DSD
GREEN

AMBER
GREEN
14 day target achieved in month
• 14 day target achieved in October (95.23%), against a year end cumulative target
of 93%. There were 43 breaches out of a total of 903 referrals.
14 Day Target
• Performance excluding choice was 95.68%.
%
100.00%
80.00%
60.00%
Actual
Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11
84.61% 87.94% 88.40% 87.62% 85.62% 89.52% 95.23%
Exc Choice 100.00%100.00%100.00% 98.09% 97.72% 100.00% 95.68%
Profile
93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00%
At the time of writing this report the actual performance for the months of April, May, June.
July, August and September are validated but the actual performance for the month of October
is still being validated before submission of data to the national Cancer Waiting Times
Database
• 39 patients chose to wait longer than 14 days for their first appointment. Details of
the Specialties are as follows:
Breast 5, Colorectal 6, Gynae. 5, Haematology 1, Head & Neck 6
Paediatrics 1, Skin 7, Upper GI 3, Urology 5
• 3 patients waited longer than 14 days due to medical reasons:
Breast Symptomatic 1, Colorectal 1, Gynae. 1,
• 1 patient waited longer than 14 days due to other reasons:
UGI 1
• 14 day target YTD 89% against a year end cumulative target of 93%.
Actions:
• The 14 day target has improved significantly and has been sustained over the past few weeks. This is due to the additional capacity which is now available within the Breast Service to
ensure patients are offered the choice of two dates. We are continuing to work closely with the PCTs and auditing the patients that choose not to accept an appointment within 14 days and
looking into each case individually. In order to establish why patients are choosing to wait longer than 14 days, we are telephoning patients to establish the reason why.
• Demand and capacity for all specialities has been audited over the last 12 months and processes are being put in place to increase capacity where appropriate because from 1st December
2010 all two week wait appointments will be on Choose and Book.
31
31 Day Cancer
Target (2010/11)
Cancer – 31 Day
31 Days from diagnosis to treatment
for all cancers
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Forecast
Commentary
DSD
GREEN

GREEN
GREEN
31 day target achieved in month
31 Day Target
%
100.00%
80.00%
60.00%
Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11
Actual 97.30% 97.76% 97.95% 96.45% 98.80% 93.66% 97.00%
• 31 day target overall achieved (excluding Radiotherapy) in October (97%), against
a year end cumulative target of 96%.
• 31 day target first definitive treatment achieved in October (98.00%), against a year
end cumulative target of 96%.
• 31 day target subsequent treatment (Surgery) underachieved in October (92%),
against a year end cumulative target of 94%.
• 31 day target subsequent treatment (Anti Cancer Drugs) underachieved in October
( 97%) against a year end cumulative target of 98%.
• 31 day target subsequent treatment (Radiotherapy) underachieved in October
(90%), against a year end cumulative target of 94%.
Profile 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00%
At the time of writing this report the actual performance for the months of April, May, June,
July, August and September are validated but the actual performance for the month of
October is still being validated before submission of data to the national Cancer Waiting
Times Database
• There were 19 breaches in October out of 316 referrals of which were due to
patient choice - 10, medical reasons - 2 and others - 7.
• Current YTD position is 97% against a year end cumulative target of 96%.
Actions:
• Although not consistently, we have previously met this target and have gone over and above it. Our aim is to meet this target consistently by the end of December 2010.
We have both capacity & staffing issues within Radiotherapy Department which have been acknowledged. The number of Oncologists employed has increased and
therefore the demand for access to the radiotherapy machines has increased and plans have been agreed to increase radiography and physics staffing to increase linac
capacity in line with NRAG recommendations.
32
62 Day Cancer
Target (2010/11)
62 Day from urgent referral to
treatment of all cancers
Cancer – 62 Day
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Forecast
Commentary
DSD
RED

GREEN
GREEN
62 day target underachieved in month
• 62 day target overall underachieved in October (74%), against a year end
cumulative target of 85%.
• 62 day first definitive cancer target underachieved in October (69.44%), against a
year end cumulative target of 85%.
• 62 day screening to first definitive treatment underachieved in October (80%),
against a year end cumulative target of 90%.
• 62 day consultant upgrade achieved in October (93.54%) – target to be
confirmed.
62 Day Target
%
100.00%
80.00%
60.00%
Apr 10 May 10 Jun 10
Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10
Jan 11 Feb 11 Mar 11
Actual 89.32% 85.52% 87.79% 88.60% 95.00% 89.00% 74.00%
• There were 28 breaches in October out of 123 referrals of which 14 were patient
choice, 2 complex pathways, 1 DNA, 4 were due to medical suspensions and 7
others.
Profile 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%
At the time of writing this report the actual performance for the months of April, May June, July,
August and September are validated but the actual performance for the month of October is
still being validated before submission of data to the national Cancer Waiting Times Database
• Current YTD position is 87% against a year end cumulative target of 85%.
Actions:
• In order to improve and maintain the delivery of the 62 day target, the pathway for Upper GI patients will be re-designed to improve the current delays. This work is being
coordinated by the Service Improvement Nurse within Cancer Services. Changes made within the Administration Team will ensure that all patients are tracked correctly to
ensure there are no delays.
• Work is starting in December with the Department of Health Intensive Support Team to identify areas for improvement.
33
Thrombolysis
68% of patients admitted with ST
Elevation
MI
should
receive
Thrombolysis within 60 minutes of call
for help
Thrombolysis
Monthly
Status
Executive
Lead
Target (2010/11)
DSD
RED
Direction
of Travel
=
Year to
Date
RED
Forecast
Commentary
GREEN
Only 2 eligible patient in the year to
date. CQC guidance states that for this
indicator a ‘low numbers' rule will be
applied which will withdraw Trusts
treating a low number of eligible cases
from the assessment
Thrombolysis Profile 2010/11
75.00%
%
70.00%
65.00%
60.00%
Apr 10
M ay 10
Jun 10
Jul 10
Aug 10
Sep 10
Oct 10
Actual YTD
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
Nov 10
Dec 10
Jan 11
Feb 11
M ar 11
Profile
68.00% 68.00% 68.00% 68.00% 68.00% 68.00% 68.00% 68.00% 68.00% 68.00% 68.00% 68.00%
Thrombolysis Performance YTD
PRH
RSH
SaTH
Call to Needle Eligible Admissions
0
2
2
Call to Needle < 60 minutes
NA
0
0
Performance Achieved YTD
NA
0%
0%
• Year-to-date performance of 0%.
• This is a combined target for the Trust and the Ambulance Services.
• Rurality issues within Shropshire County and Powys impact on the Call to Door
time. Both West Midlands and Welsh Ambulance Services are able to deliver prehospital thrombolysis in accordance with strict eligibility criteria.
• The introduction of direct access Primary Angioplasty at UHNS and
Wolverhampton Hospitals has led to a reduction in the number of SaTH Myocardial
Infarction admissions.
• Patient 1 - (Powys) had call to door time of 132 minutes no evidence of pre hospital
thrombolysis assessment.
• Patient 2 - (Oswestry) had call to door time 42 minutes no evidence of pre hospital
thrombolysis assessment.
Actions:
• Internal systems and processes for the delivery of thrombolysis in A&E and the management of acute chest pain admissions ongoing.
• Chest Pain direct admission to CCU project initiated, awaiting outcome report.
34
Rapid Access Chest Pain
Target (2010/11)
Executive
Lead
Monthly
Status
Direction
of Travel
Year to
Date
Forecast
Commentary
DSD
GREEN
=
GREEN
GREEN
Well established service with consistent
high performance
A maximum of two-week wait for rapid
access chest pain clinic (CO6.6)
Rapid Access Chest Pain
Rapid Access Chest Pain Clinic
75.00%
70.00%
%
• 5 Rapid Access clinics running each week across SaTH.
65.00%
60.00%
• Capacity appropriately matched to demand.
Apr 10
May 10
Jun 10
Jul 10
Aug 10
Sep 10
Oct 10
Nov 10
Dec 10
Jan 11
Feb 11
Mar 11
Actual YTD 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
Profile
100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
Actions:
35