Trust Board – 21 July 2011
Agenda item: 4.1
Integrated Quality and
Performance Report
M3– June 2011
Presented by: Bernie Bluhm (Chief Operating Officer) and Jo Thomas ( Chief Nurse)
Author: Char Fletcher (Senior Performance Manager)
1
Performance Report M3 - June
Summary:






The report updates the Board on the key national, contractual KPIs across the Trust for the Month 3 of 2011-12 (June).
The Q1 forecast for the trust remains ‘underperforming’
There remain some Issues with validating the 18 week position. The data was not available at the time of this report.
No exception report has been provided for Appraisal and Statutory and Mandatory compliance as data the data is currently being mapped to each division
New workforce exception reports are under development. They will utilize SPC charts to identify when a KPI is outside of control limits.
Data quality indicators are under development
Trust Board
Agenda Item:4.1
Trust objective:
Please list number and
statement. this paper relates to.
Deliver safe, high quality co-ordinated care;
Develop an effective organisation
Action: The Trust Board is asked to Note and accept this report
Notes:
Legal: What are the legal
considerations & implications
linked to this item? Please name
relevant Act
Not applicable.
Regulation: What aspect of
regulation applies and what are
the outcome implications? This
applies to any regulatory body –
key regulators include: Care
Quality Commission, MHRA,
NPSA & Audit Commission)
Department of Health.
2
Contents
1. Integrated Quality and Performance Dashboard



Page 4 Operating framework metrics
Page 5 Outcomes framework metrics
Page 6 internal metrics
2. Exception Reports
3. Glossary of Terms
3

Indicators used
for external
assessment
Direction of
Travel vs. Plan
Performance
Data
Quality
▲=above
plan►=on
plan▼=below
plan
YTD Actual
Target
Monthly Trend
Jan
Feb
Quarterly Trend
Apr-11
March
May-11
Jun-11
Q1 2011/12
Q2 2010/11
Q3 2010/11
Q4 2010/11
Operating Framework
<15
A&E time to initial assessment(95th percentile)
T ime to T reatment (median)
<60
53
T otal time in A&E admitted (95th percentlie)
240
1029
T otal time in A&E non-admitted(95th percentlie)
240
294
% of patients in A&E under 4 hours
95%
79.7%
0
2
A&E Unplanned R e-attendance rate (within 7 days)
<5%
4.7%
L eft without being seen (L WB S ) R ate
A&E Attaendances
E mergency R eadmissions within 30 days of discharge
MR S A (trust acquired)
<5%
2.6%
N/A
TBD
0.33
11832
3.1%
1
C Diff
4.2
7
MS S A (trust and community acquired)
N/A
12
*E . C oli
N/A
3
number of of patients in A&E over 12 hours (trolley waits)
18 weeks R T T - non-admitted including audiology (DAA)@
95th percentile
R T T - incomplete - 95th percentile
Median wait times -non-admitted
Median wait times - admitted
Under Construction
Quality
18 weeks R T T admitted - 95th P ercentile @
▲
▼
▲
▲
▼
▲
▼
▼
new metric for 2011/12
116
111
77
new metric for 2011/12
78
68
53
new metric for 2011/12
997
970
1029
442
353
294
82.4%
82.0%
81.9%
75.6%
79.9%
82.6%
95.0%
93.0%
90.7%
0
0
3
0
0
2
0
11
3
new metric for 2011/12
4.0%
5.0%
5.0%
new metric for 2011/12
►
►
3.4%
2.6%
1.9%
4379
2.9%
0
3833
3.4%
1
4469
2.9%
0
2683
2.8%
0
3829
3.0%
0
5320
3.4%
1
1
1
1
1
5
5
8
3
2
2
7
14
19
18
new metric for 2011/12
5
2
5
new metric for 2011/13
Not avail
3
3
<=23
29.0
32.0
32.0
Not avail
Not avail
Not avail
25
32
<=18.3
17.0
20.0
20.0
Not avail
Not avail
Not avail
16.7
20
<=28
25.0
26.0
26.0
Not avail
Not avail
Not avail
23
26
12
13
8
7
91.1%
91.7%
92.4%
88.4%
88.7%
88.2%
N/A
6.0
4.0
4.0
Not avail
Not avail
0
11.1
13.0
14.0
14.0
Not avail
Not avail
0
7.2
7.0
7.0
7.0
Not avail
Not avail
Not avail
R T T - admitted 90% in 18 weeks
90%
81.0
74.9
74.9
#DIV/0!
#DIV/0!
#DIV/0!
R T T - non- admitted 95% in 18 wks
95%
95.4
92.1
92.1
#DIV/0!
#DIV/0!
#DIV/0!
2 week G P referral to 1st outpatient
93%
95.0%
96.9%
95.2%
96.2%
94.1%
94.8%
95.0%
2 week G P referral to 1st outpatient - breast symptoms
93.0%
94.7%
93.8%
93.8%
93.9%
93.4%
98.5%
93.1%
94.7%
31 day second or subsequent treatment (surgery)
94.0%
94.4%
31 day second or subsequent treatment (drug)
98.0%
100.0%
31 day diagnosis to T reatment
▲
▲
▲
▲
▲
▲
▲
▼
93.9%
6
0
10
10
26
9
▼
▼
56.0%
48.0%
54.0%
59.5%
69.7%
69.0%
59.0%
70.0%
73.3%
59.1%
76.7%
64.3%
260
382
616
£320
-3507
380
R T T - incomplete -median
96.0%
99.2%
62 days urgent referral to treatment of all cancers
85%
86.35%
62 wait first treatment from C onsultant screening
90%
100.0%
0
10
P atients that have spent more than 90% of their stay in
hospital on a stroke unit
F ractured Neck of F emur <36
80%
65.7%
85%
65.5%
Delivery of Savings Plan
N/A
1258
Financial Position (£,000)
N/A
-2,807
Mixed S ex Accommodation
Resources
77
90%
97%
88.9%
92.0%
100.0%
94.4%
100.0%
100.0%
100.0%
100.0%
98.7%
98.7%
100.0%
99.2%
89.5%
89.6%
84.5%
86.7%
82.9%
88.4%
86.35%
0.0%
100.0%
75.0%
100.0%
100.0%
100.0%
-£66
£246
£215
Indicators used for external assessment
Indicators used for
external assessment
Financial Position (£,000)
Non-Elective FFCE's
Under
Construction
Resources
Data
Quality
Delivery of Savings Plan
Direction of
Travel vs. Plan
Performance
▲=above
plan►=on
plan▼=below
plan
YTD Actual
Target
Monthly Trend
Jan
Feb
Quarterly Trend
Apr-11
March
May-11
Jun-11
Q1 2011/12
N/A
642
260
382
0
N/A
-3,187
£320
-3507
0
-£66
£246
£215
Q2 2010/11 Q3 2010/11 Q4 2010/11
N/A
Outcomes framework
100
98.2
Effectiveness
HSMR
100%
2 wks rapid access chest pain
99%
108
▼
▼
84.6
74.5
93.4
Data Data reported
reported in
arrears
100.0%
100.0%
100.0%
100.0%
100.0%
Data reported
95%
N/A
67.0%
100.0%
100.0%
N/A
N/A
60%
N/A
67.0%
100.0%
33.0%
N/A
N/A Data reported
60%
80.0%
77.8%
40.0%
75.0%
90.0%
80.0%
73.3%
80%
N/A
92.0%
77.0%
94.0%
73.0%
64.0%
71%
78.0%
72.0%
78.0%
78.0%
65.0%
78%
83.0%
80.0%
89.0%
76.0%
70.0%
74%
15
12
21
16
23
17
32
42
20
18
48
29
3
1
4
0
0
0
**PPCI 150 min call to ballon time
in arrears
PPCI 120 min call to ballon time
in arrears
Stroke/TIA treated within 24 hours
Number of falls reported as clinical incidents
Number of medication errors resulting in an adverse event
Notes:
*We are not yet aware of any algorithm for
attributing these(E.Coli) cases. So in the short term
we have adopted the normal BSI algorithm using
pre and post 48 hours of admission. These figures
may change
**There were no PPCI's performed in month
Under construction
Safety
Newly acquired Pressure Ulcers (grade 2 and above)
▲
▼
Patient
Experience
% of patients surveyed who would choose to be treated at
SASH in Future
% of patients surveyed that staff treated them with kindness
and respect
% of patients surveyed who felt their dignity was maintained
the whole time they were a patient
in arrears
98.2%
80%
N/A
80%
N/A
TBD
56
73
95
0
0
▼
▼
▼
►
100.0%
100.0%
100.0%
100.0%
Indicators used for
Internal assessment
Direction of
Travel vs. Plan
Performance
Data
Quality
YTD Actual
Target
▲=above
plan►=on
plan▼=below
plan
Monthly Trend
Jan-11
Feb-11
Mar-11
Apr-11
Quarterly Trend
May-11
Jun-11
Q1 2011/12
Safe, High Quality Coordinated Care
90%
60.6%
VTE Risk Assessments
Infection Control
Maternity
Clinical Quality
HSMR Non-elective
Unplanned Readmissions within 14 days
Unplanned Readmissions within 30 days
% of SUI's due to be closed in month that were closed
Number of Never events reported
% Complaints responded to within agreed timeline with
complainant/ 25 working days
**C-section rate
% of women seen by a midwife or healthcare professional
at 12 wks 6dys
Breastfeeding initiation
Hand Hygiene compliance
Productivity and
effectiveness
99.2
0
3
50%
43%
41.0%
43.6%
51.8%
60.6%
110.4
85.5
74.9
93.3
Data reported in
arrears
Data reported in
arrears
1
0
2
1
1
1
44.0%
27.0%
29.0%
43.2%
32.1%
57.9%
2.2%
2.4%
2.1%
2.9%
3.4%
2.9%
new metric for 2011/12
0
0
0
65.5%
78.3%
89.8%
1.9%
2.8%
N/A
0
90.0%
2.3%
3.0%
0%
0
89.6%
2.3%
3.4%
100.0%
1
86.4%
▼
100%
0
80-90%
N/A
1
89%
►
23%
30.2%
▼
28.8
29.7
32.7
31.9%
30.5%
28.3%
90%
88.3%
▼
85.9%
89.5%
93.8%
91.1%
84.5%
89.6%
90%
80.1%
81.0%
79.0%
83.7
77.9%
80.4%
82.0%
99.1%
99.2%
99%
98.4%
100%
102%
100%
118%
<=5%
10.3%
<=0.80
1.6%
►
▼
▼
99.6%
97.6%
98.2%
99.3%
102.0%
Data Reported
Data Reported
Data Reported
118.0%
Quarterly
Data Reported
Quarterly
Data Reported
Quarterly
Data Reported
►
MRSA screening compliance (elective)
cancelled operations as a percentage of elective
admis s ions
38.5%
▼
MRSA screening compliance (nonelective)
**% of cancelled operations not treated within 28 days
▲
▼
▼
Quarterly
Quarterly
Quarterly
0.0%
8.3%
8.3%
11.1%
0.0%
14.3%
2.3%
2.2%
2.1%
2.5%
0.8%
1.6%
80.4%
81.2%
79.4%
6.0
4.3
2.13%
6.3
3.0
1.91%
TBD
1.6%
D aycas e R ate
Average L O S non-E lective
Average L O S E lective
D elayed T rans fers of C are
E xces s follow ups
Vacancy Rate
Total Establishment
Total in post
Workforce
<=100
Number of falls resulting in a fracture/head injury
% of Stroke patients Scanned within 1 hour of hospital
arrival
40.2%
▼
Sickness absence rate
Total WTE Bank Staff (excluding extra capacity nursing)
Total WTE Agency Staff (excluding extra capacity nursing)
TBD
TBD
3.5%
6
4.4
1.95%
<=10%
N/A
2766
<=3.0%
3167
2848
3.8%
<=210
221.1
<=40
53.1
***24%
22%
***24%
12%
% of staff who have completed stat and mandatory
training
% of staff who have been appraised
* data as of 12/07/2011
** exception reports provided on a quarterly basis
****Target is cumulative
►
N/A
▲
▲
▲
1.72%
2.65%
2.10%
4.1
3.6
1.81%
1175
1294
1386
1063
1101
1053
10.8%
3136
2799
4.2%
9.8%
3137
2825
4.4%
9.8%
3136.3
2829
4.4%
9.8%
3156
2,845
3.8%
10.0%
3165
2848
3.6%
10.1%
3167
2848
4.0%
246
232
240
231.4
208.8
223.2
63
60
59
51.7
33.9
53.1
new construction
5.0%
13.0%
22%
4.0%
12%
▼
▼
new construction
1.95%
Q2 2010/11
Q3 2011/12
Q
4
2
0
Q4 2011/12 1
Contents
1. Integrated Quality and Performance Dashboard
2. Exception Reports
3. Glossary of Terms
7
85%
80%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Stroke - 90%or more of time spend time on stroke unit
Target
Trend linear
Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
05/04/2009
26/04/2009
17/05/2009
07/06/2009
28/06/2009
19/07/2009
09/08/2009
30/08/2009
20/09/2009
11/10/2009
01/11/2009
22/11/2009
13/12/2009
03/01/2010
24/01/2010
14/02/2010
07/03/2010
28/03/2010
18/04/2010
09/05/2010
30/05/2010
20/06/2010
11/07/2010
01/08/2010
22/08/2010
12/09/2010
03/10/2010
24/10/2010
14/11/2010
05/12/2010
26/12/2010
16/01/2011
06/02/2011
27/02/2011
20/03/2011
10/04/2011
01/05/2011
22/05/2011
12/06/2011
105%
40%
100%
35%
95%
30%
90%
25%
Stroke - 90% or more of time spend time on stroke unit
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
2. Charts for Performance Exception Areas
Weekly Type1&3 A&E Attendances seen in less then 4 hours
C-Sections
20%
15%
C-Sectio n rates
Target
Trend linear
Cancelled Operations not treated within 28 days vs.Target
30%
25%
20%
15%
10%
5%
0%
%Cancelled Operations not treated within 28 days
Target
Trend line
8
P erformance E xception R eport
D ivis ion/C linic al S ervic e:
K ey P erformanc e Indic ator:
S tandard
Medical D ivis ion E merg ency D epartment.
95% of patients s een and treated in under 4 hours in E D
C urrent Months P erf.
95%
Y T D P erf.
80%
K P I R ef No:
T rend from previous month
٧
80%
XXX
E x pec ted date to meet s tandard
Named R es pons ible L ead
P aula T ooms
What is D riving the R eported Under P erformanc e
A cheivement of the targ ets is s trong ly linked to the capacity and flow of patients throug h the trus t. F ailure to allocate beds to D T A 's caus es a backlog of patients to build up in E D which then impedes the flow and capacity
of the department to s ee and treat patients efficently. A dded to this is the chang e in meas ures being recorded in E D which has required s ig nificant training with s taff, followed by review to es tablis h where data recording
has been in accurate and corrections need to be made. A need to implement all actions within the E D trans formation firs t 4 hours works tream is required to maximis e internal performance.
A c tions to improve performanc e
Num.
1
2
3
4
5
5
Ac tion
New
A c tion
Named L ead
E D firs t 4 hours works tream
C arlos
Internal review of weekly metrics to identify chang es in performance that are incons is tent with expectation and provide action plans or
rationale for chang e, then implement action plan if required.
P aula T ooms
Medical directorate implementation of Urg ent C are L eads to provide acces s for cons ultant advice from G P 's
B en Mearns
Interg ration of UT C with E D , review of patient activity and s election to s upport E D flow.
P aula T ooms
Internal refurbis hment of department to facilitate improved s treaming and working s pace, increas e as s es s ment and treatment capacity.P aula
P aula
T ooms
T ooms
O ng oing
A c tion
E x pec ted
C ompletion
date
O utc ome
x
x
x
x
x
continuous
implemented
ong oing
A c tions for nex t month
O ng oing ac tions from E D works tream c over Arrivals , Majors ,O bs ervation Unit, C ons ultant J ob P lanning , rec ruitment, revis ing of rotas and c ontinued review of metric 's .
1s t A ug us t implement new junior and middle g rade rotas . C ommence new workflow s treaming for patients throug h the department, with triag e, arrivals , treatment proces s .
complete review of UT C activity and demand, matching to s taffing need, medical, E NP and NP 's .
S upport from the C orporate S ervic es
Imformation and IT s upport with data collection and validation proces s , als o C erner s upport following interg ration of UT C with E D .
R is ks
C ontinued lack of capacity with T rus t
O ther K P I's A ffec ted
R ef No.
D es c ription
E D quality indicators are now broken down into s everal area's , one's linked to time are all potientially affected due to delays being cas caded once we have accumulated them.
100%
80%
70%
60%
50%
40%
30%
20%
10%
Month
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
0%
Apr-11
Percentage compliance
90%
P erformance E xception R eport
D ivis ion/C linic al S ervic e:
K ey P erformanc e Indic ator:
S tandard
S urg ical/ 18 weeks (A dmitted P athway)
90% of all A dmitted pathway patients treated within 18 weeks
C urrent Months P erf.
Y T D P erf.
T rend from previous month
K P I R ef No:
XXX
E x pec ted date to meet s tandard
90%
Named R es pons ible L ead
O ct-11 H amis h W allis
What is D riving the R eported Under P erformanc e
H is torical backlog of patients caus ed by: R eferral demand in exces s to commis s ioned activity, T heatre efficiency, B ed P res s ures - on the day/day before cancellation due to non-availability of beds ( 28 in May), L ate decis ion making
with reg ards to D T A from the Non A dmitted P athway, A nnual L eave Manag ement – his torically this has been poorly manag ed.
T he T rus t is now in a pos ition where the total waiting lis t for the A dmitted P athway is double the des ired s iz e (including 1300 patients over 18 weeks ). In order to bring the waiting lis t down to the des ired level and clear the backlog
ag reement has been reached with the P C T ’s and S H A for the trus t to underperform on 18 weeks in Q uarter 1 and 2
A c tions to improve performanc e
Num.
A c tion
Named L ead
New
A c tion
O ng oing
A c tion
E x pec ted
C ompletion
date
1
A g ree plan (in plac e) and monitoring with P C T 's and S H A for clearance of backlog (us ing IS T modelling ) - weekly/monthly monitoring
forum to be es tablis hed
B ernie B luhm
X
01/07/2011
2
O uts ourcing - put in place ag reements to outs ource 1000 patients in Q 1 & 2.
H amis h W allis
X
3
4
V alidate all patients on the waiting lis t and ens ure T rus t is reporting accurate information
review and implement T rus t A cces s policy
C linton K rynie
H amis h W allis
X
X
5
18 week das hboard to be implemetned and updated on weekly bas is - enabling trus t to report performance
C linton K rynie
X
25/06/2011
01/07/2011
18/07/2011
31/07/2011
01/07/2011
01/08/2011
O utc ome
ag reements in place (298
pts R x Y T D )
validation s till continuing
delaied due to delay in
validation
A c tions for nex t month
C ontinue to inc reas e outs ourc ing c apac ity, by bring on line three more providers (B rig hton, E ps om, G atwic k P ark), plus inc reas in c apapc ity with c urrent providers
C omplete validation of A dmitted pathway
R es olve is s ues reg arding cas hing up of clinics and inputting of outcome forms to ens ure accurate information is being input in timely manner (identify any training is s ues needed)
Income and E xpenditure forecas ted budg et/plan for outs ourcing
D as hboards : finalis e and implement to ens ure accurate weekly reporting
S upport from the C orporate S ervic es
Informatics - A ccurate and timely reporting of 18 weeks
R is k s
bed pres s ures - demand for beds from the emerg ency flow res ults in elective patients being cancelled
reduce income for elective activity due to cancellation of internal activity due to capacity - lack of ability to make up los t capacity (other than by outs ourcing )
O ther K P I's A ffec ted
R ef No.
D es c ription
Non A dmitted P athway performance
Median W aiting times
C ancelled ops (non clincal reas on) not treated within 28 days
120%
80%
60%
D ate by which
compliance is
required
40%
20%
Month
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
0%
Apr-11
Percentage compliance
100%
P erformance E xception R eport
Divis ion/C linic al S ervic e:
K ey P erformanc e Indic ator:
S tandard
Medicine
mixed sex accommodation
C urrent Months P erf.
0
Y TD P erf.
K P I R ef No:
Trend from previous month
9
XXX
E xpec ted date to meet s tandard
▼
Named R es pons ible L ead
L isa C heek
What is Driving the R eported Under P erformanc e
T he T rust continued to be very busy through J une 2011 with several escalation areas open and operationally was very challenging. T he 10 breaches which occurred in the medical division were in the discharge lounge
and A&E observation ward. 8 breaches occured in the observation ward and 2 breaches in the discharge lounge which is used as an escalation area over night. All measures were taken to prevent any mixed sex
breaches and verbal information was given to the patients..
Ac tions to improve performanc e
E xpec ted
Num.
Ac tion
Named L ead
New
Ac tion
Ong oing C ompletion
Ac tion
date
Outc ome
1
site meeting attended by operation staff and clinical staff and all oportunities explored to prevent any mixed sex accomodation.
Angela
S tevenson
x
Daily
2
All potentials to mix a bay are escalated through a matron to ensure all alternatives are considered first.
L isa C heek
x
Daily
Mixed sex breaches
minimised
mixed sex breaches
minimised
3
P atients are moved at the earliest opportunity if a breach has occurred
Angela
S tevenson
x
Daily
mixed sex breaches
minimised
Ac tions for next month
As above.
S upport from the C orporate S ervic es
None
R is ks
Other K P I's Affec ted
R ef No.
Des c ription
None
P erforma nc e E xc eption R eport
D iv is io n /C lin ic al S erv ic e:
K ey P erfo rm an c e In d ic ato r:
S tan d ard
Medic a l D ivis ion, S troke
S troke 90% or more time s pent on S troke U nit
C u rren t Mo n th s P erf.
80%
Y T D A v g P erf.
69%
K P I R ef No :
T ren d fro m p rev io u s m o n th
E x p ec ted d ate to m eet s tan d ard
▲
65%
Nam ed R es p o n s ib le L ead
A pr-12 N a ta s ha H a re
Wh a t is D riv in g th e R ep o rted U n d er P erfo rm a n c e
A c hievement of the 90% indic a tor is s trong ly linked to the emerg enc y pa tient flow pa thwa y a nd a s s oc ia ted a c tions rela ting to bed ma na g ement a nd effec tive a nd timely dis c ha rg e. T he non-performing
pa thwa ys were a g a in linked to c ontinued pres s ures on bed c a pa c ity, whic h a re not s howing s ig ns of improvement. W e c ontinue to s ee s tea dy improvement month on month helped by the ring fenc ing of
beds a lthoug h this a lone ha s not ma de a s ig nific a nt impa c t.
A c tio n s to im p ro v e p erfo rm a n c e
Nu m .
A c tio n
Nam ed L ead
1
O utlying pa tients a re reviewed da ily a nd repa tria ted a s s oon a s c linic a lly a ppropria te.
N a ta s ha H a re
2
L oc um c ons ulta nt on C a pel wa rd a ppointed until a s ubs ta ntive a ppointment is ma de. J ob des c ription for the
s ubs ta ntive pos t is a wa iting C olleg e a pprova l.
N a ta s ha H a re
3
T IA pa thwa y a nd booking proc es s ha s been reviewed a nd c ommunic a ted to G P s to improve c ommunic a tion
a nd reduc e time.
N a ta s ha H a re
4
W es t S us s ex E a rly S upported D is c ha rg e pilot underwa y (too ea rly for res ults a nd under threa t due to funding
c uts ).
5
R ing -fenc e beds on A bing er wa rd to be us ed for S troke pa tients only a nd monitor impa c t on a weekly ba s is
F iona W hite
(N H S W es t
x) H a re
N a ta sSha
New
A c tio n
E x p ec ted
C o m p letio n
d ate
O n g o in g
A c tio n
O u tc o m e
X
X
30-S ep-11
X
X
31-Ma y-11
C omplete
30-S ep-11
O ng oing
X
5
E a s t S urrey E a rly S upported D is c ha rg e pilot (s ta rt da te tbc but likely to s ta rt in J uly).
7
Introduc tion of Medihome / virtua l wa rd / ea rly dis c ha rg e in J uly 2011
R obyn D a vies
(N H S S urrey)
X
30-S ep-11
B ernie B luhm
X
A c tio n s fo r n ex t m o n th
P u b lis h L o S K P I in fo rm a tio n a t wa rd lev el s o th a t a ll s ta ff c a n ea s ily s ee c u rren t p erfo rm a n c e.
P ropos a l to c ombine s troke beds into one wa rd to be dis c us s ed a t divis iona l level.
S u p p o rt fro m th e C o rp o rate S erv ic es
S upport ring fenc ed beds
R is k s
W inter / E merg enc y B ed P res s ures
D &V outbrea ks a nd s ubs equent wa rd c los ures
O th er K P I's A ffec ted
R ef No .
D es c rip tio n
% of pa tients a dmitted direc tly to A S U within 4 hours of hos pita l a rriva l
A c hievement of bes t pra c tic e ta riff
90% stay on stroke unit
Target
Forecast
Actual
90%
70%
60%
50%
Winter Pressures
Improved Flow i.e. impact
of Medihome / virtual ward
Stroke Beds
ring fenced
40%
30%
Early Supported Discharge
20%
10%
Month
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
0%
Apr-11
Percentage compliance
80%
P erformance E xception R eport
Divis ion/C linic al S ervic e:
K ey P erformanc e Indic ator:
S tandard
S urgical D ivis ion/ #NO F
85% of #NO F operated on within 36 hours
C urrent Months P erf.
85%
Y T D P erf.
66%
K P I R ef No:
T rend from previous month
XXX
E xpec ted date to meet s tandard
66%
Named R es pons ible L ead
Aug-11 Hamis h W allis
What is Driving the R eported Under P erformanc e
In J une there was a higher than normal level of patients (5) that required medical s tabilis ation before they could be operated on. 4 patients breached the target due to ins ufficent operating time and were therefore res cheduled to the next day.
Ac tions to improve performanc e
Num.
1
2
3
4
Ac tion
Named L ead
E ns ure order of lis t is agreed and s et the night before with #NO F patient firs t on lis t
S unday T rauma lis t to run for 6 hours s tarting at 10.30am - Medical teams have agreed, this needs to go into new s pecialty D octor contract, T heatre nurs ing rota now this
cover s es s ion
T rans fer T rauma lis t from white B oard to E lectronic s ys tem within C erner - res ulting in better management of lis ts and acces s ablity of lis t
Implementation of action plan following the Moran R eview
New Ac tion
O ng oing
Ac tion
S ally P aters on
G T s elentakis
Hamis h W allis
G T s elentakis
X
X
X
E xpec ted
C ompletion
date
O utc ome
01/07/2011
complete - needs to
be audited
01/08/2011
30/07/2011
30/08/2011
part complete
on-going
Ac tions for nex t month
Audit the order of the lis t, ens uring that it is agreed the previous day and the firs t patient does n't change
Agree S unday morning lis t in job plan of s pecialty doctor
E s tablis h effective es calation s ys tem for patients who are fit for s urgery but unlikely to be operated on with 36hrs
R efocus on the F as cia Iliaca B lock performance
S upport from the C orporate S ervic es
E ns ure that patients admitted with F racture neck of femur are admitted to Newdigate ward, not outlying wards
E ns ure the availability of the F as t-track bed
R is ks
O ther Non #NO F trauma patients being admitted that are clinical urgent (activity is increas ing)
O ther K P I's Affec ted
R ef No.
Des c ription
D VT P rophylas is - 87%
day 1 P os t op P hys iotherapy - 80%
Iliaca F emoral B lock (% of patients who received) - 50%
Number of #NO F patietns trans ferred to Newdigate W ard within 4 hours - 4
90%
70%
60%
50%
40%
30%
20%
10%
Month
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
0%
Apr-11
Percentage compliance
80%
FnoF – Exception graphs
Complaince for DVT, Day 1 post op physio & Iliaca Block for #NOF patients per month
S AS H Trauma (#NOF and Other) by Month
200
120.00%
180
100.00%
160
140
80.00%
Percentage
120
100
80
60
60.00%
40.00%
40
20
20.00%
NON #NOF
ne
Ju
Ma
y
ril
Ap
h
Ma
rc
a ry
br u
a ry
0.00%
January
February
March
April
May
June
July
August September October November December January February
March
April
May
June
Fe
r
be
De
Ja
cem
nu
r
be
er
to b
ve m
No
er
gu
mb
pte
Se
Au
Oc
st
ly
Ju
ne
Ju
Ap
Ma
y
ril
h
Ma
rc
Fe
Ja
nu
br u
a ry
a ry
0
Month
DVT Prophylaxis
#NOF
%received physio on day 1post op
%pts receiving Iliaca Block
S A S H T rau ma - #NO F c o mp lian c e
120.00%
100.00%
80.00%
60.00%
40.00%
20.00%
% R x in 36 hrs
% R x in 48 hrs
ne
Ju
M
ay
pr
il
A
M
ar
ch
y
ar
ru
eb
F
ce
e
D
Ja
m
nu
a
be
ry
r
r
be
m
N
o
ve
ct
o
O
te
m
S
ep
be
be
us
ug
A
r
r
t
ly
Ju
ne
Ju
M
ay
pr
il
A
M
ar
ch
ru
eb
F
Ja
nu
a
ar
ry
y
0.00%
Targ et
14
P erformance E xception R eport
Divis ion/C linic al S ervic e:
K ey P erformanc e Indic ator:
S tandard
C linical S upport S ervices
K P I R ef No:
C urrent Months P erf.
0
0
Y TD P erf.
Trend from previous month
1
▼
XXX
E xpec ted date to meet s tandard
J uly
Named R es pons ible L ead
J ackie B rown
What is Driving the R eported Under P erformanc e
O n the 20/06/11 - P atient was walking with a nurs e in the outpatient department waiting area at Hors ham O P D and caught her foot on corner of one of the fixed waiting room chair legs and fell. T he patient was both
elderly and frail hence walking with the nurs e in the waiting room area. A doctor in the O P D s aw the incident and attended the patient with the nurs ing s taff whils t they were waiting for an ambulance to arrive. It was
thought from initial examnination that the patients s us tained a fracture neck of femur. T he patient was admitted to Newdigate Ward at E S H and found to have fractured her left neck of femur following x-ray. T he
incident was reports to the Head of O P &HR S and patient's next of kin. An incident report was completed. T he Head of O P &HR S reported the matter to her AD of C S S . R oot caus e analys is s howed this incident was an
accident.
Ac tions to improve performanc e
Num.
1
Ac tion
Named L ead
Incident was inves tigated
C hris tine P owell
Ac tions for next month
None
S upport from the C orporate S ervic es
None R equired
R is ks
Other K P I's Affec ted
R ef No.
Des c ription
None
New
Ac tion
X
O ng oing
Ac tion
E xpec ted
C ompletion
date
C ompleted
O utc ome
No action required
P erforma nc e E xc eption R eport
D ivis ion/C linic al S ervic e:
K ey P erform anc e Indic ator:
S tandard
Medic a l D ivis ion, W A C H
V T E a s s es s ment within 24hours 90%
C urrent Months P erf.
Y T D P erf.
83% Medic a l, 35%
90% W A C H , 44% S urg ic a l
53.4% T rus twide
K P I R ef No:
T rend from previous m onth
▲
XXX
E x pec ted date to m eet s tandard
J ul-11 Medic a l, S ept-11 W A C H ,
Nam ed R es pons ible L ead
B en Mea rns (Medic a l), D ebbie P ullen(W A C H ) H a mis h W a lla c e (S urg ic a l)
Wh at is D rivin g th e R ep orted Un d er P erform an c e
A ll medic a lly expec ted or interna lly referred pa tients a re una ble to be a dmitted unles s there V T E a s s es s ment is c ompleted a s it is a ma nda tory field. C ontinued c onc ern a bout the integ rety of the da ta c ollec tion a nd
pres enta tion.
A c tion s to im p rove p erform an c e
Num .
A c tion
Nam ed L ead
R emove E ndos c opy a nd A ng iog ra phy da y c a s e a c tivity from medic a l a dmis s ion da ta . Needs further refining in s ens e of only z ero L O S
1(Med) pa tients to be exc luded.
R eview of 10 pa tient epis odes c oded to E D obs erva tion a nd D is c ha rg e loung e to a s s es s pa thwa y of pa tients a nd es ta blis h whether
2(Med) they fulfil the c riteris for inc lus ion in the da ta
3(Med) R eview of interna l referra ls to medic ine, i.e s urg ic a l or ME T c a lls to s ee if rea s on for fa ilure to a s s es s a s a lrea dy a dmitted.
4(wa c h) V T E A s s es s ment will be underta ken during the a dmis s ions proc es s .
5 (wa c h) V T E A s s es s ment will be rec orded on c erner by the B roc kha m wa rd s ta ff
6(S urg )
7(S urg )
New
A c tio n
T ra ining a nd c ommunic a tion to Medic a l a nd Nurs ing s ta ff on c ompleting the E lec tronic vers ion
R eview of wha t is being inc luded a nd wha t s hould be exc luded from the lis t of pa tients elig ible for V T E A s s es s ment – there a re a la rg e
portion of pa tients being inc luded tha t s hould not be (i.e. O phtha lmolog y, E ndos c opy).
O n g o in g
A c tio n
E x pec ted
C om pletion
date
J eff T homps on
x
end J uly
P a ula T ooms
J eff T homps on
D r. Na dim
D r. Na dim
x
x
end J uly
end J uly
H a mis h W a lla c e
x
01/07/2011
H a mis h W a lla c e
x
01/07/2011
x
x
R eview of how a nd when da ta is be input (E .g . U rolog y c ompleting 100% a t P re a s s es s ment but da ta not being pic ked up)
8(S urg )
9(S urg )
H a mis h W a lla c e
H a mis h W a lla c e
W eekly monitoring of c omplia nc e by s pec ia lity/loc a tion
O utc om e
x
x
01/07/2011
on g oing
done but being
repea ted
c ompleted
a g reed to be
inc luded (? not been
done)
A c tion s for n ex t m on th
(Med) W ork with informa tion to refine da ta c ollec tion a nd pres enta tion
(S urg ) P re a s s es s ment V T E a s s es s ments to be inc luded a s a g reed a t Ma na g ement B oa rd - this ha s not been done a nd s o needs to be reviewed a nd c ompleted
(S urg ) C ontinue monitoring within S A U of a ll elig ible pa tients being a dmitted on the emerg enc y pa thwa y.
(S urg ) R eview proc es s for elec tive pa tients on da y of a dmis s ion to ens ure V T E A s s es s ment is on s ys tem
(S urg ) c ommunic a tion: c ontinue to ra is e profile of V T E a s s es s ments (elec tronic a lly) a t a ll S pec ia lty meeting a nd tra ining da ys .
R is k s
C ontinued da ta c ollec tion is s ues .
Non-elig ible pa tients a ppea ring on the lis t, whic h is dis torting the res ults - due to no dis tinc tion in c oding between G A a nd L oc a l's
Medic a l S ta ff - time c ons tra ints
O th er K P I's A ffec ted
R ef No.
D es c ription
C Q U IN: T here is Na tiona l bes t pra c tic e g uida nc e whic h is linked to C Q U IN funding to further enc oura g e foc us on this a rea of pa tient s a fety.
Target
Medical Forecast
WACH Forecaast
Surgical Forecast
100%
80%
70%
60%
50%
40%
30%
20%
10%
Month
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
0%
Apr-11
Percentage compliance
90%
P erformance E xception R eport
Divis ion/C linic al S ervic e:
K ey P erformanc e Indic ator:
S tandard
W&C H
C aesarean sections
C urrent Months P erf.
23%
29%
K P I R ef No:
Y TD P erf.
XXX
Trend from previous monthE xpec ted date to meet s tandard
30%
▼
31.3.12
Named R es pons ible L ead
S ue C hapman
What is Driving the R eported Under P erformanc e
L ow tolerance to changing plan to C aesarean S ection
Ac tions to improve performanc e
E xpec ted
Num.
1
2
Named L ead
Ac tion
10 week prospective audit underway
New Birthing Unit T eam L eader in post - change admission pathway and admit as low risk by default and only transfer to main
delivery suite if confirmed high risk. Dedicated midwifery team.
Ac tions for next month
Monitor outc omes and build on s uc c es s es
S upport from the C orporate S ervic es
R is ks
Despite many previous actions we have seen little improvement in the rate
Other K P I's Affec ted
R ef No.
Des c ription
None
New
Ac tion
Ong oing C ompletion
Ac tion
date
S harmila S ivarajan
Y es
No
Denise Newman
Y es
No
Aug-11
1.8.11 &
constant
Outc ome
E xamine data and act on
information
C hange of mindset of women
and midwives re risk
P erformance E xception R eport
Divis ion/C linic al S ervic e:
K ey P erformanc e Indic ator:
S tandard
W&C H
Women booked by 12wks & 6 days
C urrent Months P erf.
90%
Y TD P erf.
89.6%
K P I R ef No:
XXX
Trend from previous month E xpec ted date to meet s tandard
▲
88.3%
Named R es pons ible L ead
S ue C hapman
What is Driving the R eported Under P erformanc e
S ome months women do not access care in a timely manner
Ac tions to improve performanc e
Num.
1
Ac tion
Named L ead
Maureen
R oyds-J ones
E nsure adeqaute capacity of appointments
Ac tions for next month
E nc ourag ement of women to book early
S upport from the C orporate S ervic es
R is ks
F luctuation as dependent upon women notifying their pregnancy and booking appoitments
Other K P I's Affec ted
R ef No.
Des c ription
None
New
Ac tion
None in
month
E xpec ted
Ong oing C ompletion
Ac tion
date
Y es
O ngoing
Outc ome
P erformance E xception R eport
Divis ion/C linic al S ervic e:
K ey Performanc e Indic ator:
S tandard
W&C H
Breast feeding initiation rate
C urrent Months Perf.
90%
Y TD Perf.
82%
K PI R ef No:
XXX
Trend from previous monthE xpec ted date to meet s tandard
80%
▲
31.12.11
Named R es pons ible L ead
S ue C hapman
What is Driving the R eported Under P erformanc e
Women's choice and inconsistent advice from various staff groups
Ac tions to improve performanc e
E xpec ted
Num.
1
Ac tion
Named L ead
Undertaking 2 year Baby F riendly project
J anice Blythman
Ac tions for next month
C ontinue with educ ation of all relevant s pec ialties
S upport from the C orporate S ervic es
R is ks
Despite many previous actions we have seen little improvement in the rate & women's choice will always influence this
Other K P I's Affec ted
R ef No.
Des c ription
None
New
Ac tion
no
Ong oing C ompletion
Ac tion
date
yes
Apr-12
Outc ome
Increased rates
P erforma nc e E xc eption R eport
D ivis ion/C linic al S ervic e:
K ey P erform anc e Indic ator:
S tandard
C a nc elled O pera tions not trea ted within 28 da ys
% of c a nc elled opera tions not trea ted within 28 da ys
Q uarterly P erf.
%
Y T D P erf.
10%
K P I R ef No:
T rend from previous m onth
XXX
E x pec ted date to m eet s tandard
10%
Nam ed R es pons ible L ead
A ug -11 H a mis h W a llis
What is D riving the R eported Under P erform anc e
In qua rter 1 there wa s 138 pa tients c a nc elled on the da y (va s t ma jority due to bed pres s ures ) a nd 116 pa tients who ha d 28 da y brea c h da tes of whic h 12 were not trea ted within their brea c h da te due to c a pa c ity is s ues . T his
equa tes to 10.34% of c a nc elled opera tions not trea ted within 28 da ys in for Q ua rter 1.
O f the 4 who brea c hed their 28 da ys the orig ina l rea s on for the c a nc ella tion on the da y wa s due to:
9x = No B eds , 1x = P a tient is s ue, 1x = s urg eon s ic k a nd no one a va ila ble to do opera tion.
A c tions to im prove perform anc e
Num .
A c tion
Nam ed L ead
1
C a nc ella tions a re being reviewed on a weekly ba s is to ens ure c omplia nc e.
2
A ll pa tients c a nc elled on the da y to be reviewed a t weekly P T L meeting
3
A ll pa tients c a nc elled for non c linic a l rea s ons to ha ve a new T C I within 7 da ys of being c a nc elled – if not then to be es c a la ted throug h
weekly P T L meeting .
New
A c tio n
O n g o in g
A c tio n
E x pec ted
C om pletion
date
S ue C orby
X
on g oing
H a mis h W a llis
X
on g oing
S ue C orby
X
on g oing
O utc om e
4
A c tions for nex t m onth
C ontinue with weekly monitoring of c a nc ella tions throug h the P T L meeting
S upport from the C orporate S ervic es
E lec tive beds to be refenc ed
R is k s
B ed C a pa c ity (W inter P res s ures )
O ther K P I's A ffec ted
R ef No.
D es c ription
C a nc elled opera tions a s a perc enta g e of elec tive a dmis s ions
120%
80%
60%
40%
20%
Month
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
0%
Apr-11
Percentage compliance
100%
Contents
1. Integrated Quality and Performance Dashboard
2. Exception Reports
3. Glossary of Terms
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3. Glossary Of terms
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MRSA - Methicillin-resistant Staphylococcus aureus
Cdiff - Clostridium difficile
HSMR – Hospital Standardised Mortality Rates
TIA - Transient Ischaemic Attack
RIDDOR – Reporting of Injuries Dieses And Dangerous Occurrences
ITU – Intensive Treatment Unit
WTE – Whole Time Equivalent
FFCE – First Finished Consultant episode
AMI – Acute Myocardial Infraction
RACP – Rapid Access Chest Pain
CDS – Commissioning Data Set
LOLER - Lifting Operations and Lifting Equipment Regulations 1998
SUI – Serious Untoward Incident
ITU – Intensive Treatment Unit
H&S – Health and Safety
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