Emergency Medicine
75%
♠
4
5
1
4 & 20
0
0
100%
0
0
100%
0
0
100%
13
99%
0%
1%
#REF!
98%
2%
0%
0
0
#REF!
99%
0%
% shifts 'at risk
staffing'
#REF!
0
% shifts 'minimum
staffing'
0
100%
% shifts 'agreed
staffing'
100%
64%
4
SIRIs Not Incl
Pressure Ulcers
HGH ED **
11
4&9
Single Sex Breaches
88%
4
Compliance with
Nutritional Assessments
87%
100%
Overall percentage
of indications &
durations recorded
National Cleaning
Overall Score
85%
100%
Number of
Prescriptions
ANTT Injectables
100%
JR EAU *
Ward
Hand Hygiene
JR ED **
Directorate
Ambulatory, Chest, ID
Emergency Medicine, Therapies & Ambulatory (7)
Division
Antimicrobial
Hospital acquired
Pressure Ulcers Grade
3/4 / Skin Integrity
8
8
Compliance with Track
and Trigger / EWS
8
Total No of medication
errors that did harm
8
Total No of Falls that
caused Harm
EMTA Quality Scorecard Board
November Data
CQC Outcomes
1%
HGH EAU *
100%
100%
94%
11
82%
0
0
100%
0
100%
3
#REF!
85%
15%
0%
7A *
100%
100%
93%
10
80%
0
0
100%
1
80%
0
#REF!
70%
30%
0%
7B *
100%
100%
93%
10
50%
0
0
100%
100%
0
52%
44%
4%
7C *
100%
100%
Not audited
14
50%
0
0
100%
0
94%
0
#REF!
77%
20%
3%
7D *
100%
100%
90%
10
90%
1
0
100%
0
100%
0
#REF!
84%
17%
0%
Short stay / 7f
95%
100%
Not audited
14
86%
0
0
100%
0
100%
0
#REF!
65%
34%
1%
5C
97%
100%
93%
n/a
n/a
0
0
100%
0
100%
0
#REF!
100%
0%
0%
5A *
100%
100%
91%
7
57%
0
0
0
#REF!
75%
36%
0%
PAU *
100%
100%
na
10
90%
1
0
0
1
94%
6%
0%
Oak *
100%
100%
NA
11
73%
0
0
0
0
100%
0%
%
Laburnam *
100%
100%
NA
14
71%
0
0
92%
100%
0
0
81%
19%
0%
Juniper *
100%
100%
85%
10
80%
0
0
95%
100%
0
0
64%
36%
0%
100%
95%
0
Level 4 *
85%
100%
N/A
10
90%
0
0
100%
1
80%
0
#REF!
90%
10%
0%
ASU *
100%
100%
93%
8
63%
1
0
100%
0
90%
0
#REF!
85%
15%
0%
John Warin **
96%
100%
N/A
32
97%
0
90%
0
100%
Geoffrey Harris *
100%
100%
N/A
15
100%
0
0
100%
0
100%
Treatment Centre
100%
0%
N/A
0
0
#REF!
Dermatology
100%
#REF!
91%
0
0
#REF!
0
0
0
0
73%
27%
0%
0
0
26%
70%
4%
0
0
0
Immunology
100%
10100%0%
N/A
0
0
#REF!
OCDEM Endocrine
100%
0%
N/A
0
0
#REF!
OCDEM Diabetes
100%
#REF!
N/A
0
0
#REF!
0
Sleep Physiology
N/A
#REF!
N/A
0
0
#REF!
0
100%
#REF!
91%
0
0
#REF!
0
N/A
#REF!
N/A
0
0
#REF!
0
GUM
Genetics
0
Fall that caused harm
7D ‐ One fall which resulted in a fractured NOF, the patient has made a good recovery post surgery. Action to focus on falls care plans and assessments in December.
Low cleaning scores
Juniper ward ‐ Cleaning score below target for second month. Discussion with Head of facilities and estates. Walk around re audit and review of cleaning hours / procedures particularly at weekends. JR‐ED
scores very low, challenging audit results and awaiting re audit
Antimicrobial
Twice weekly meetings take place involving, pharmacy, infection control, microbiology across EMT to address this.
Hospital acquired pressure ulcers
There were two hospital acquired pressure ulcers, both of these being grade three. The one from the patient on Geratology was admitted with a grade 2 and deteriorated to a grade 3. All risk assessment had
been carried out and all preventative measures had been taken. The Division are looking to appoint a part time band 6 TVN. Single sex breaches
There were three locally reportable episodes of breaches during November. These occurred on EAU at the Horton. Two of the three patients needed cardiac monitoring and close observations and therefore were clinically justified. The third breach occurred at night and avoided waking all patients to re‐order bays.
SIRI
C Difficile in part 1A of death certificate SIRI held on 13.12.12
Key
National Cleaning Specification (%)
Antimicrobial Prescribing
Poor
V. High Risk
**
>95
90‐95
<90
Green
Fair
High Risk
*
>92
87‐92
<87
Amber
70 ‐ 79%
Good
Significant Risk
>85
80‐85
<80
Red
69% and below
>92
87‐92
<87
Amber
70 ‐ 79%
>85
80‐85
<80
Red
69% and below
Fair
High Risk
Good
Significant Risk
*
80% or more
8
8
8
% shifts 'at risk
staffing'
0
0
N/A
n=10
100%
0
0
89%
0
100%
0
0
97%
3%
0%
90%
0
0
93%
n=9
80%
0
0
81%
0
92%
0
0
87%
13%
0%
Childrens Ambulatory Care
93%
100%
0
0
91%
0
0
N/A
0
N/A
0
0
97%
3%
0%
HGH Childrens W *
Bel / Dray *
Kamrans **
Melanies *
NNU**
SCBU**
PHDU**
PICU**
95%
100%
0
0
0
0
95%
0
92%
0
0
95%
5%
0%
90%
100%
0
0
N/A
n=6
50%
0
0
100%
0
90%
0
0
79%
20%
1%
90%
91%
0
0
96%
n‐8
70%
0
0
100%
0
90%
0
0
85%
15%
0%
100%
95%
0
0
93%
n‐11
100%
0
0
87%
0
90%
0
0
94%
6%
0%
100%
100%
0
0
n=29
100%
0
0
n/a
0
0
0
98%
2%
0%
0
0
0
0
n/a
0
n/a
0
98%
2%
0%
0
0
n/a
0
0
0
100%
0%
0%
0
0
n/a
0
0
0
100%
0%
0%
100%
C-Diff post 72 hrs
90%
95%
Catheter on going
care
100%
Catheter Insertion
Toms *
Robins *
Ward
ANTT Injectables
% shifts 'minimum
staffing'
13
% shifts 'agreed
staffing'
4 & 20
SIRIs Not Incl
Pressure Ulcers
1
Single Sex Breaches
5
Compliance with
Nutritional
Assessments
4
Pressure Ulcers Grade
2/3/4 / Skin Integrity
4
Overall percentage
of indications &
durations recorded
4&9
Number of
Prescriptions
4
National Cleaning
Overall Score
Antimicrobial
Compliance with Track
and Trigger / EWS
8
Saving Lives Catheter
Care
Total No of medication
errors that did harm
8
8
MRSA / MSSA post 48
hrs
8
Hand Hygiene
Directorate
Paediatrics
Paediatric
Critical Care
Children's
Division
CQC Outcomes
Total No of Accidents
that did harm
November Data C & W Quality Scorecard Board
92%
100%
0
0
95%
94%
100%
0
0
93%
n=9
100%
ANTIMICROBIAL PRESCRIBING Bellhouse Drayson: ‐ Arrangements have been made for the IC nurses to undertake a regular slot in the SHO induction on AMP. Weekly audits will be taking place Key
National Cleaning Specification (%)
Antimicrobial Prescribing
Poor
V. High Risk
**
>95
90‐95
<90
Green
Fair
High Risk
*
>92
87‐92
<87
Amber
70 ‐ 79%
Good
Significant Risk
>85
80‐85
<80
Red
69% and below
80% or more
4
5
1
4 & 20
13
% shifts 'at risk staffing'
4
100%
0%
0%
0
100%
0%
0%
Gynae Scrub
90%
0%
0%
0
0%
0
0
100%
0%
0%
Gynae A & R
0%
0%
0%
0
0%
0
0
100%
0%
0%
100%
95%
0%
0
0
100%
0%
100%
0
0
Maternity Theatres
95%
0
0
Spires Midwifery Led
0%
0
0
% shifts 'minimum
staffing'
0
0
% shifts 'agreed
staffing'
0
100%
Overall percentage
of indications &
durations recorded
90%
0
Number of
Prescriptions
0
0%
National Cleaning
Overall Score
100%
0%
ANTT
Injectables
0%
100%
Hand Hygiene
90%
HGH Gynae*
Directorate
Pressure Ulcers Grade
2/3/4 / Skin Integrity
4&9
Compliance with Track
and Trigger / EWS
4
JR Gynae*
Ward
Delivery Suite / Obs
Maternity
Gynae and Maternity
Gynae
Division
Antimicrobial
SIRIs Not Incl
Pressure Ulcers
8
8
Single Sex Breaches
8
Compliance with
Nutritional
Assessments
8
Total No of medication
errors that did harm
CQC Outcomes
Gynae and Maternity Quality Scorecard Board
Total No of Falls That
did harm
November Data
0%
0
0
99%
0%
1%
Level 5
100%
93%
0%
0%
0
0
0%
0
0
96%
0%
4%
Level 6
100%
93%
100%
100%
0
0
0%
0
0
97%
0%
3%
0%
0
0
0%
0
0
95%
0%
5%
0
0
0%
0
0
100%
0%
100%
0
0
0%
0
0
100%
0%
100%
Level 7
0%
HGH Delivery Suite
95%
HGH P
Postt N
Natal
t lW
Ward
d
85%
0%
50%
50%
There were only 2 prescription charts on the Horton Post Natal Ward and 1 was fully complete. See action plan
Gynae Ward: there was one medication error where a patient was given 60mgs Codeine Phosphate while a morphine PCA was in situ. No harm came to the patient who was informed of the incident. The nurse was spoken with, was very distressed and written a reflective piece on the incident. She has gained definite learning from the incident.
National Cleaning Specification (%)
Key
Antimicrobial Prescribing
80% or more
Poor
V. High Risk
**
>95
90‐95
<90
Green
Fair
High Risk
*
>92
87‐92
<87
Amber
70 ‐ 79%
Good
Significant Risk
>85
80‐85
<80
Red
69% and below
Medication errors
causing harm
Compliance with Track
and Trigger / EWS
Pressure Ulcers Grade
2/3/4 / Skin Integrity
Single Sex Breaches
SIRIs Not Incl
Pressure Ulcers
% shifts 'agreed
staffing'
% shifts 'minimum
staffing'
% shifts 'at risk
staffing'
100%
Theatres**
100%
100%
Compliance with
Nutritional
Assessments
Falls causing harm
100%
13
Overall percentage
of indications &
durations recorded
Hand Hygiene
5D*
4 & 20
100%
0
0
0
18%
82%
0%
100%
0
100%
0
0
96%
2%
2%
96%
75%
75%
0
0
0
100%
0
0
56%
41%
3%
93%
70%
70%
0
0
100%
0
100%
0
0
71%
20%
9%
86%
86%
0
0
100%
0
90%
0
0
94%
4%
2%
100%
100%
0
0
100%
0
90%
0
0
33%
67%
0%
0
0
N/A
0
N/A
0
0
100%
0%
0%
100%
100%
1
0
100%
100%
5
0
CTCC / CCU**
94%
4
0
94%
100%
4
1
83%
100%
CTW *
4&9
100%
82%
100%
6A *
4
100%
Antimicrobial
CAS **
Ward
8
8
National Cleaning
Overall Score
8
ANTT Injectables
8
Cardiology *
Directorate
Medicin
PP Surg & Vasc
e
Cardiac, Vascular
and Thoracic (3)
Division
CQC Outcomes
C, V & T Quality Scorecard Board
Number of
Prescriptions
November Data
94%
National Cleaning Specification (%)
Key
Antimicrobial Prescribing
Poor
V. High Risk
**
>95
90‐95
<90
Green
Fair
High Risk
*
>92
87‐92
<87
Amber
80% or more
70 ‐ 79%
Good
Significant Risk
>85
80‐85
<80
Red
69% and below
The Key
Insufficient Data
Issue
Antimicrobial prescribing audit results on Ward D was <80%;
Nutritional Assessment 95%
1 SIRI: Post-72 hours C difficile case noted in part A of death
4 falls with a minor impact, 2 of these falls related to the same
92% Track and Trigger Score
1 fall with moderate impact- patient insisted on using comode
Full Compliance
Target met but not fully
compliant
Target not met
Not applicable
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
97%
92%
100%
96%
98%
100%
Action
Raised with teams involved via clinical
Weekly audit until 100% achieved for 2
Root cause analysis and case review
Review of all cases and report on
Weekly audits unitl 100% achieved for
Falls assessment and care plan were
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100%
100%
95%
100%
100%
100%
100%
100%
0
0
0
0
0
0
0
0
Lead
Review Date
Clinical
31-Dec-12
Louise Flaxman,
31-Dec-12
Bridget Atkins,
31-Dec-12
Lucy Wood,
31-Dec-12
Lucy Wood,
31-Dec-12
Sue Sadler,
31-Jan-13
4&
20
13
% shifts 'at risk staffing'
0
0
0
0
0
0
0
0
0
0
1
SIRI's (Not Pressure Ulcers)
0
0
2
3
2
2
3
3
0
1
5
Single Sex Breaches
0
0
0
0
0
0
0
0
0
0
Acquired Pressure Ulcers grade 4
0
0
0
0
0
1
0
0
0
0
Track and Trigger
0
0
0
4
0
0
0
0
0
0
Acquired Pressure Ulcers grade 3
100%
0
0
1
9
3
4
0
0
0
7
4
Acquired Pressure Ulcers grade 2
12
Major/Extreme Impact
100%
60%
N/A
80%
Moderate Impact
15
5
0
5
Minor Impact
Medication
Near miss/ No harm
Falls
Major/Extreme Impact
Antimicrobial
Overall percentage of
indications & durations
recorded
4 &9
Number of presciptions
4
Moderate Impact
97%
100%
100%
95%
98%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
4
8
Minor Impact
100%
100%
99%
100%
100%
100%
95%
98%
100%
98%
8
Near miss/No harm
Day Surgery
Ward A
Ward B
Ward D
Ward E
Ward F
Recovery
Theatres
Outpatients/POAC
Outpatients/POAC
OCE Ward
8
National Cleaning Scores
Hand Hygiene
Ward
Action Plan
Ward/Department
Ward D /Ward F
BIU
BIU
Ward D
Ward D
Ward F
♠
8
ANTT Injectables
Directorate
Orthopaedics
R
MARS
Division
CQC Outcomes
Nutritional Assessments
MARS Division Quality Metrics November 2012
0
0
1
0
0
0
0
0
0
0
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
Status
Completed
In progress
In progress
Completed
In progress
Planned
8
4
4&9
Antimicrobia
l
94%
100%
0
0
0
100%
0
0
94%
4%
2%
100%
84%
75%
0
0
100%
0
100%
0
0
76%
10%
13%
% shifts 'at risk
staffing'
% shifts 'agreed
staffing'
100%
90%
% shifts 'minimum
staffing'
SIRIs Not Incl
Pressure Ulcers
95%
Neurosciences IP *
Ward
Number of
Single Sex Breaches
13
Compliance with
Nutritional
Assessments
4 & 20
Pressure Ulcers Grade
2/3/4/ Skin Integrity
1
Total No of medication
errors that did harm
5
Total No of Falls thatr
did harm
4
Overall percentage
of indications &
durations recorded
4
National Cleaning
Overall Score
8
ANTT Injectables
8
Hand Hygiene
Combined
8
NICU **
Directorate
Trauma
Specialist Surgery
Neuro, Trauma, Specialist
Surgery (3)
Neuro
Division
CQC Outcomes
Compliance with Track
and Trigger / EWS
NTSS Quality Scorecard Board
November Data
Neurosciences OPD
100%
0
0%
0%
0%
2A *
100%
100%
90%
0
0
90%
2
90%
0
0
78%
20%
2%
3A *
95%
100%
100%
0
0
95%
0
90%
0
0
76%
18%
4%
Trauma OPD
100%
0
100%
0%
0%
F Ward *
100%
100%
80%
2
0
98%
3
90%
0
0
79%
21%
0%
SSIP *
100%
100%
91%
0
1
100%
0
90%
0
0
94%
6%
0%
0
61%
38%
1%
0
95%
5%
0%
Lichfield *
90%
SSOPD
100%
87%
OPD Eye
100%
0
70%
30%
0%
OMFS OPD
100%
0
95%
5%
0%
Cleaning remains closely monitored, all identified shortfalls are now being reported through the helpdesk. . Pressure ulcers 2A ‐ all steps taken to prevent cat 2 ulcer formation. F ward ‐ 3 ulcers identified on admission. Pressure ulcers 2A all steps taken to prevent cat 2 ulcer formation. F ward 3 ulcers identified on admission. Medication error ‐ Medical and nursing team to be made aware of insulin types and those to be continued when a patient is placed on sliding scale.
Sister to ensure all nurses have undertaken insulin e‐learning & liaise with Consultant teams to raise awareness & for this to be discussed at Speciality governance meetings in December
F ward fall ‐ matron assessed incident unavoidable falls, skin abrasion as result of fall. Key
National Cleaning Specification (%)
Antimicrobial Prescribing
Poor
V. High Risk
**
>95
90‐95
<90
Green
Fair
High Risk
*
>92
87‐92
<87
Amber
80% or more
70 ‐ 79%
Good
Significant Risk
>85
80‐85
<80
Red
69% and below
% shifts 'agreed
staffing'
% shifts 'minimum
staffing'
% shifts 'at risk
staffing'
Compliance with
Nutritional
Assessments
13
SIRIs Not Incl
Pressure Ulcers
4 & 20
Single Sex Breaches
1
Total No of medication
errors that did harm
5
Total No of Falls that
did harm
4
Overall percentage
of indications &
durations recorded
4
Number of
Prescriptions
4&9
National Cleaning
Overall Score
4
Pressure Ulcers Grade
2/ 3/4 / Skin Integrity
8
8
ANTT
Injectables
8
Hand Hygiene
8
AICU **
89%
100%
0%
100%
0%
0
0
3
6
0
100%
0%
0%
CICU **
91%
100%
95%
100%
0%
0
0
2
0
0
100%
0%
0%
HGH CICU **
92%
93%
0%
40%
0%
0
0
0
12
0
100%
0%
0%
HGH DCU *
100%
90%
0
0
0
0
0
100%
0%
0%
Th West Wing **
72%
0%
0
0
0
0
0
100%
0%
0%
Directorate
Anaes / CC / Th
Critical Care, Theatres,
Diagnostics & Pharmacy
(6)
Division
CQC Outcomes
Compliance with Track
and Trigger / EWS
CCTDP Quality Scorecard Board
November Data
Ward
0%
Antimicrobial
Th JR **
69%
83%
89%
0
0
0
1
0
100%
0%
0%
Th HGH **
91%
93%
95%
0
0
0
0
0
100%
0%
0%
All pressure ulcers on critical care grade 2 and all acquired prior to admission
l
k f
l
l
h h
h
No cleaning audits undertaken for CCU @HH and AICU. Densie Pawley emailed to enquire why this is the case
Unusual result for antimicrobial correct prescription in CCU as it is usually more compliant. Pharmicist contacted by deputy matron to discuss results and formulate action plan
Hand hygiene continues to be challenging within theatres. Dr John Stevens will be sending a letter to all anaesthetic consultants, details of which will be cascaded to their teams, detailing what is acceptable hand hygiene practice. Sisters within theatres are working with infection control to set up hand hygiene information station with use of UV light box to present the importance to staff. Matron for CCTA to undertake audits with sisters in theatres this month and challenge persistant offenders.
Key
National Cleaning Specification (%)
Antimicrobial Prescribing
Poor
V. High Risk
**
>95
90‐95
<90
Green
Fair
High Risk
*
>92
87‐92
<87
Amber
70 ‐ 79%
Good
Significant Risk
>85
80‐85
<80
Red
69% and below
80% or more
In Patient Wards
73%
2
0
100%
0
94%
94%
1
0
98%
% shifts 'at risk
staffing'
73%
na
Overall percentage
of indications &
durations recorded
91%
100%
Number of
Prescriptions
99%
90%
Hand Hygiene
100%
13
% shifts 'minimum
staffing'
4 & 20
Pressure Ulcers Grade
2/3/4/ Skin Integrity
1
Compliance with Track
and Trigger / EWS
5
Total No of medication
errors that did harm
4
National Cleaning
Overall Score
4
Oncology Ward **
Division
Clinical Areas
4&9
Haematology **
Ward
Surgery
u
& Oncology (6)
4
ANTT Injectables
Antimicrobial
% shifts 'agreed
staffing'
8
8
SIRIs Not Incl
Pressure Ulcers
8
Single Sex Breaches
8
Compliance with
Nutritional
Assessments
CQC Outcomes
Total No of Falls that
did harm
S & O Quality Scorecard Board
November Data
90%
0
0
86%
14%
0%
100%
0
0
77%
23%
0%
Sobell *
100%
96%
92%
100%
100%
1
0
na
0
90%
0
0
75%
25%
0%
SEU D & Triage*
96%
100%
NA
100%
100%
0
0
100%
1
100%
0
1
80%
20%
0%
SEU E
100%
100%
NA
100%
100%
0
0
100%
0
100%
0
0
80%
20%
0%
SEU F *
96%
100%
NA
100%
100%
0
0
100%
0
100%
0
0
80%
20%
0%
5F *
100%
92%
NA
100%
100%
0
0
100%
0
100%
0
0
75%
23%
2%
HGH E Ward *
97%
98%
92%
83%
83%
0
0
99%
0
100%
0
0
90%
10%
0%
3%
UGI *
95%
98%
NA
100%
100%
0
0
100%
0
80%
0
0
85%
12%
Colorectal *
100%
100%
NA
100%
100%
0
0
100%
0
70%
0
0
78%
21%
0%
Jane Ashley *
100%
100%
96%
100%
100%
0
0
90%
0
100%
n/a
0
98%
2%
0%
Urology *
90%
100%
92%
90%
90%
0
0
90%
0
60%
0
0
92%
8%
0%
Transplant **
95%
94%
89%
85%
80%
0
0
96%
0
55%
0
0
86%
14%
0%
Renal Ward **
89%
100%
97%
85%
85%
0
0
90%
0
100%
0
0
53%
45%
2%
Oxford Man Unit*
94%
100%
94%
100%
0
0
0
0
90%
10%
0%
Oxford Tarver Dialysis*
96%
100%
96%
100%
0
0
0
100%
0%
0%
Stoke Mandeville *
100%
100%
100%
100%
0
0
0
0
100%
0%
0%
Milton Keynes *
100%
90%
100%
90%
0
0
0
0
67%
33%
0%
Swindon *
100%
100%
100%
100%
0
0
0
0
100%
0%
0%
Wycombe *
100%
90%
100%
90%
0
0
0
0
86%
14%
0%
Th Churchill **
91%
92%
0
0
0
0
85%
10%
5%
95%
5%
0%
Th TDA / DCU *
90%
0
0
0
0
Oncology Treatment
89%
100%
84%
0
0
N/A
0
Brody Centre HGH
98%
100%
95%
0
0
N/A
0
Triage
100%
100%
92%
0
0
0
0
Research
95%
98%
92%
0
0
0
0
JR Endoscopy **
97%
100%
90%
1
0
0
0
100%
0%
0%
HGH Endoscopy **
89%
100%
0
0
0
0
70%
24%
6%
Actions
1. Nutritional Assessments: Matrons continue to work closely with ward sisters and nursing teams by auditing results regularly and feeding back results and actions via team meetings. Focus in December will
be on regular audits on colorectal, transplant and urology wards to ensure results improve.
2. Anti-microbial results: Results have improved further this month in all clinical areas except oncology where the clinical team will focus their efforts to communicate the importance of documenting the
indication and duration of prescription for all antimicrobials on the drug chart to ensure that these results improve this month.
3. One grade 3 pressure ulcer on SEU this month: new care plan to be implemented for patients from other specialist wards to ensure nursing staff have confidence in moving these patients.
Key
Antimicrobial Prescribing
National Cleaning Specification (%)
80% or more
Poor
V. High Risk
**
>95
90‐95
<90
Green
Fair
High Risk
*
>92
87‐92
<87
Amber
70 ‐ 79%
Good
Significant Risk
>85
80‐85
<80
Red
69% and below