PAPER 13
Summary Sheet: Governing Body meeting in public
Date
Tuesday 11th November 2014
Title of Paper
Integrated Quality and Performance Report Month 5
Presenter & Organisation
Sue Jeffers
Author
David Thomas, Asst. Director
Responsible Director
Sue Jeffers, Managing Director
Clinical Lead
Nicola Burbidge, Chair
Confidential
Yes
No
(items are only confidential if it is in the public interest for them to be so)
The Governing body is asked to:
Note the Hounslow wide performance
CCG Operating Framework:
 RTT - Hounslow CCG did not meet 52 weeks wait and specialty standards in M5. •
 Cancer: Hounslow CCG did not meet the 62 day and 62 day consultant upgrade, standards in M5,
Quality Premium
 Hounslow CCG performance against potential funding of £1.5M is being monitored monthly.
Current assessment based on available information indicates a deduction from potential funding of
£370k due to failure of meeting LAS performance targets.
Areas where provider performance (trust-wide across all CCGs) is below standard:
 18 weeks RTT: ASPH and ICHT did not meet the admitted RTT standard overall in M5
 Cancer: WMUH and ASPH did not meet 31 day subsequent treatment (surgery), 62 day and 62 day
consultant upgrade standards in M5. ASPH did not meet the 2 week breast symptoms standard.
 HCAI: ICHT and ASPH exceeded their C. Diff Tolerance for M5
 Ambulance arrival to handover waits: 167, 113 and 38 patient breaches > 30 minutes reported at
WMUH, ICHT and ASPH respectively.
 Cancelled operations: ICHT did not meet the cancelled operation (28 day rebook) standard
reporting 5 breaches.
 CLA Initial Health Assessments (IHA) conducted within 20 operational days including late
notifications from Local Authority, HRCH achieved 50% and for LAC Review Health Assessments
(RHA) conducted within 6 calendar week HRCH achieved 64.7% against the 98% target.
 HRCH achieved 6.1% against 4.5% threshold for the ‘did not attend’ (DNA) rate for M5.
 WLMHT did not achieve M5 targets for IAPT Recovery rates reporting 47.3% (target of 50%).
 New Psychosis Cases: WLMHT reported 27.9% across Hounslow CCG against a target of 95%.
 CPA reviews: WLMHT failed to achieve M5 targets for both CPA Review indicators.
Page 1 of 2
Summary of purpose and scope of report
To update the Governing Body on the performance of their main NHS providers
Quality & Safety/ Patient Engagement/ Impact on patient services:
NA
Financial and resource implications
NA
Equality / Human Rights / Privacy impact analysis
NA
Risk
NA
Supporting documents
Governance and reporting (list committees, groups, or other bodies that have discussed the paper)
Committee name
Date discussed
Outcome
F&P
04/11/14
Approved for GB
Page 2 of 2
Hounslow CCG
Integrated Performance & Quality Report
August 2014 (Month 5)
Final
Table of Contents
Introduction
Section 1 – CCG Operational Performance
1.1 Operational Performance Overview
1.2 NHS Performance Standards – 18 Weeks RTT
1.3 NHS Performance Standards – Cancer Waits
1.4 NHS Performance Standards – Other Acute Measures
1.5 NHS Performance Standards – Out of Area Providers
1.6 NHS Performance Standards – Mental Health
1.7 NHS Performance Standards – Community Services
1.8 CCG Quality Premium
Section 2 – Quality & Safety Performance
2.1 Provider Quality & Safety Overview
2.2 Acute Provider Quality Performance
2.3 Community Provider Quality Performance
2.4 Mental Health Provider Quality Performance
Section 3 – Out of Hospital Services Performance
3.1 GP Out Of Hours (OOH) Services
3.2 NHS 111 Pilot Services
3.3 London Ambulance Service (LAS)
Appendix A – Shaping a Healthier Future (SaHF) – Systems Monitoring Dashboard
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Introduction
The Hounslow CCG Integrated Performance & Quality Report is aimed at providing a monthly update on the performance of the CCG based on the
latest performance information available, and reporting on actions being taken to address any performance issues with progress to date. The content
of the report are defined by the CCG’s priorities which are informed by nationally defined objectives for commissioners - the NHS Constitution,
Everyone Counts Guidance for 2014-15 (operating framework) and the NHS Mandated Outcomes Framework.
The report is split into 3 sections. Section 1 of the report provides an update on CCG and related providers’ operational performance against national
standards. This includes 18 weeks RTT, cancer waits , A&E waits and ambulance handover times. Detailed information on underachieving indicators
including trends and action log are also provided.
Provider Quality and Safety issues are covered in section 2 of the report. The key areas highlighted in this section are Maternity Indicators, Quality
Indicators, Patient Experience and Serious Incidents. These are presented in trend charts and tables with commentary and actions for areas of concern.
Section 3 provides an update on performance of out-of-hospital services namely Out of Hours (OOH) service, the NHS 111 Pilot Service including
service governance and London Ambulance Service (LAS).
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2
Section 1 – CCG Operational Performance
For Finance & Performance Committee
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3
1.1 Operational Performance Overview
CCG Operating Framework:
• RTT performance standards: Hounslow CCG did not meet 52 weeks wait and specialty standards in M5. The 52 week breach was reported by University College
London Hospitals (UCLH) within Neurosurgery and the Trust has confirmed that treatment plans are in place for October 2014. The CCG specialty performance
was largely impacted by performance at Imperial College Healthcare Trust (ICHT), Ashford and St. Peter’s Hospital (ASPH) and West Middlesex University
Hospitals (WMUH).
• Cancer: Hounslow CCG did not meet the 62 day and 62 day consultant upgrade, standards in M5, achieving 75% and 75% respectively. M5 performance was
driven by WMUH.
Quality Premium – Hounslow CCG performance against potential funding of £1.5M is being monitored monthly. Current assessment based on available information
indicates a deduction from potential funding of £370k due to failure of meeting LAS performance targets.
Areas where provider performance (trust-wide across all CCGs) is below standard:
• 18 weeks RTT: ASPH and ICHT did not meet the admitted RTT standard overall in M5 and are not meeting this standard for the year to date. In addition, ICHT
did not meet the incomplete pathway and reported 5 breaches against the 52 week standard.
• Cancer: WMUH and ASPH did not meet 31 day subsequent treatment (surgery), 62 day and 62 day consultant upgrade standards in M5. In addition , ASPH did
not meet the 2 week breast symptoms standard.
• HCAI: ICHT and ASPH exceeded their C. Diff Tolerance for M5 reporting 10 and 3 cases respectively.
• Ambulance arrival to handover waits: 167, 113 and 38 patient breaches > 30 minutes reported at WMUH, ICHT and ASPH respectively. ASPH also reported 4
patients waiting over 1 hour to hospital handover.
• Cancelled operations: ICHT did not meet the cancelled operation (28 day rebook) standard reporting 5 breaches.
• For CLA Initial Health Assessments (IHA) conducted within 20 operational days including late notifications from Local Authority, HRCH achieved 50% and for LAC
Review Health Assessments (RHA) conducted within 6 calendar week HRCH achieved 64.7% against the 98% target.
• HRCH achieved 6.1% against 4.5% threshold for the did not attend (DNA) rate for M5.
• WLMHT did not achieve M5 targets for IAPT Recovery rates reporting 47.3% against a target of 50%.
• New Psychosis Cases: WLMHT reported 27.9% across Hounslow CCG against a target of 95%.
• CPA reviews: WLMHT failed to achieve M5 targets for both CPA Review indicators.
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1.2 NHS Performance Standards – 18 Weeks RTT
18 Weeks RTT Performance Dashboard
Performance
Measure
Description
Reporting
Frequency
Reporting
Period
18 weeks RTT - Admitted Pathway
18 weeks RTT - Non-admitted Pathway
18 weeks RTT
Monthly
18 weeks RTT - Incomplete Pathway
Number of 52 week RTT Waiters - Incomplete Pathway
NHS HOUNSLOW CCG
Threshold
West Middlesex University Hospital
NHS Trust
Imperial College Healthcare NHS
Trust
Ashford & St. Peter's Hospitals NHS
Trust
In mth/qtr
YTD
In mth/qtr
YTD
In mth/qtr
YTD
In mth/qtr
YTD
90%
90.8%
91.4%
94.7%
95.0%
84.0%
87.4%
87.0%
84.4%
95%
96.7%
96.7%
97.4%
97.2%
95.0%
94.9%
95.2%
95.5%
92%
93.7%
94.2%
95.5%
96.0%
87.5%
90.3%
96.0%
95.4%
0
1
N/A
0
4
5
N/A
0
N/A
M5
• Hounslow CCG did not meet 52 weeks wait and specialty standards in M5. The 52 week breach was reported by UCLH within Neurosurgery for the
incomplete pathway and the Trust has confirmed that treatment plans are in place for October 2014. Summary of specialty performance includes:
• Admitted specialty performance in M5 was largely driven by ICHT within Cardiothoracic Surgery and Urology, ASPH within T&O, CW within Plastic
Surgery, WMUH within General Surgery and Moorfields Eye Hospital within Ophthalmology.
• Non-admitted specialty performance in M5 was largely driven by ICHT within Urology, WMUH within Plastic Surgery and both ASPH and EHT within
General Surgery and Neurology.
• Incomplete specialty performance in M5 was largely driven by ICHT within and T&O and Urology and WMUH within General Surgery and Plastic
Surgery. In M5, there have been increasing backlogs in ENT, General Surgery, Plastic Surgery, T&O and “Other”, largely driven by ICHT and WMUH.
There are currently 19 Hounslow CCG patients waiting over 40 weeks across WMUH (6), UCLH (6), ICHT (4), CW (2) and Moorfields Eye Hospital (1).
Providers have been asked to clarify treatment plans for these patients.
• ICHT did not meet the overall admitted RTT, incomplete RTT or specialty standards in M5. The Trust’s RTT backlog has continued to increase in M5,
however this has slowed in M6. An increasing 18 week backlog will impact on the Trust’s future performance overall and at a specialty level. ICHT
are reporting data quality issues following the implementation of a new patient administration system. A Contract query has been issued and
penalties are being applied at a specialty level and for each 52 week breach.
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1.2 NHS Performance Standards – 18 Weeks RTT (2)
Issue & Root Cause
Provider
RTT standards not met due to:
• Performance reporting issues
ICHT
following PAS implementation.
• Demand and capacity imbalance.
Actions
CCG
Lead
Original Revised
Status
Due Date Due Date
Progress Update
Trust to submit revised trajectory
following the allocation of additional
NHS England resilience monies.
EY
NHS England agreed trajectory for
the Trust to meet overall RTT
14/08/14 30/09/14 Closed
standards to be met by the end of
October 2015.
Monitoring against agreed trajectories
JP
31/10/14
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N/A
Open Trust meeting M5 trajectory
6
1.3 NHS Performance Standards – Cancer Waits
Cancer Waits Performance Dashboard
Performance
Measure
Cancer 2 Week
Waits
Description
Reporting
Frequency
Reporting
Period
Percentage of patients seen within two weeks of an
urgent GP referral for suspected cancer
Percentage of patients seen within two weeks of an
urgent referral for breast symptoms where cancer is not
initially suspected
Monthly
Cancer 31 Day
Waits
Cancer 62 Day
Waits
Percentage of patients receiving subsequent treatment
for cancer within 31-days where that treatment is an
Anti-Cancer Drug Regime
Percentage of patients receiving subsequent treatment
for cancer within 31-days where that treatment is a
Radiotherapy Treatment Course
Percentage of patients receiving first definitive
treatment for cancer within 62-days of an urgent GP
referral for suspected cancer
Percentage of patients receiving first definitive
treatment for cancer within 62-days of referral from an
NHS Cancer Screening Service
Percentage of patients receiving first definitive
treatment for cancer within 62-days of a consultant
decision to upgrade their priority status
Monthly
Monthly
West Middlesex University Hospital
NHS Trust
Imperial College Healthcare NHS
Trust
Ashford & St. Peter's Hospitals NHS
Trust
In mth/qtr
YTD
In mth/qtr
YTD
In mth/qtr
YTD
In mth/qtr
YTD
93%
95.8%
94.3%
94.4%
94.4%
96.2%
94.0%
93.4%
93.7%
93%
95.2%
94.0%
97.6%
98.5%
98.1%
89.4%
86.3%
91.8%
96%
100.0%
99.4%
100.0%
100.0%
97.7%
97.7%
97.1%
98.6%
94%
100.0%
97.4%
92.9%
95.2%
96.4%
96.8%
92.9%
98.6%
98%
100.0%
100.0%
100.0%
100.0%
100.0%
99.8%
100.0%
100.0%
94%
100.0%
98.2%
No patients
treated
100.0%
98.8%
98.1%
No patients
treated
No patients
treated
85%
75.0%
72.7%
82.0%
77.1%
87.1%
85.8%
80.5%
77.6%
90%
100.0%
79.1%
100.0%
75.0%
92.6%
91.1%
100.0%
91.7%
85%
75.0%
78.6%
75.0%
82.1%
91.1%
92.1%
0.0%
50.0%
M5
Percentage of patients receiving first definitive
treatment within one month of a cancer diagnosis
Percentage of patients receiving subsequent treatment
for cancer within 31-days where that treatment is
Surgery
NHS HOUNSLOW CCG
Threshold
M5
M5
Hounslow CCG did not meet the 62 day (75%) and 62 day consultant upgrade (75%) standards in M5.
• 62 day standard was not met as a result of 6 breaches due to late inter provider transfers from WMUH to ICHT (4), delay in workup (1) and
patient choice (1). 2 breaches were over 100 days.
• 62 day consultant upgrade standard was not met due to 1 late inter provider transfer from WMUH to ICHT. This breach was over 100 days.
WMUH did not meet 31 day subsequent treatment (surgery), 62 day and 62 day consultant upgrade (75%) standards in M5. Full breach reports have
been requested and the following provides a summary for M5:
• 31 day subsequent treatment (surgery) standard: 1 breach due to patient choice.
• 62 day standard: 4.5 breaches over 7 patient pathways due to delayed inter provider transfer from WMUH to ICHT (5), delay in workup (1) and
patient choice (1). 2 patients waited over 100 days.
• 62 day consultant upgrade standard: 1 shared breach due to a delayed inter provider transfer from WMUH to ICHT.
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1.2 NHS Performance Standards – Cancer Waits (2)
Action Log
Issue & Root Cause
Provider
Actions
31 day subsequent (surgery) and 62
day, 62 day consultant upgrade
WMUH
standards
Trust to submit breach exception
reports, to include assessment against
best practice timed pathways.
Cancer performance – 2 week rule
(breast). Q1 performance not met
due to capacity issues.
Monitoring progress against remedial
action plan
ICHT
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CCG Lead
SU
EY
Original
Due Date
21/10/14
31/10/14
Revised
Due Date
N/A
N/A
Status
Progress Update
Hounslow CCG has agreed
Remedial Action Plan with the
Trust. NWL CCG performance
Open
team is undertaking an
assessment of progress against
milestones.
Open
Improved performance in M5
although Q2 currently not
meeting standard based on M4
performance.
8
1.4 NHS Performance Standards – Other Acute Measures
Performance Dashboard – Diagnostics, Cancelled Ops, MSA, A&E, HCAI and Ambulance Handover
Performance
Measure
Description
Diagnostic Waits
Patients waiting more than 6 weeks for a diagnostic test
Cancelled
Operations
Urgent operations
cancelled for a
second time
Cancelled ops - breaches of 28 days readmission
guarantee
Number of urgent operations that are cancelled by the
trust for non-clinical reasons, which have already been
previously cancelled once for non-clinical reasons
EMSA
HCAI
Reporting
Frequency
Reporting
Period
NHS HOUNSLOW CCG
Threshold
A&E
Ambulance
Handover
Imperial College Healthcare NHS
Trust
Ashford & St. Peter's Hospitals NHS
Trust
In mth/qtr
YTD
In mth/qtr
YTD
In mth/qtr
YTD
In mth/qtr
YTD
0.4%
0.5%
0.04%
0.05%
1.22%
1.21%
0.98%
0.68%
Monthly
M5
1%
Monthly
M5
0
Data not available by CCG
0
0
5
28
Data not available
Monthly
M5
0
Data not available by CCG
0
0
0
0
0
Mixed Sex Accommodation (MSA) breaches
Monthly
M5
0
0
0
0
0
0
0
3
7
MRSA
Monthly
M5
0
0
2
0
0
0
3
0
0
Monthly Target*
4
27
1
5
5
C.Diff
Monthly
M5
Total time spent in A & E < 4 hours (all activity types)
Patients who have waited over 12 hours in A&E from
decision to admit to admission
Number of Ambulance arrival to handover greater than
30mins
Number of Ambulance arrival to handover greater than
60mins
55
Annual Target
Actual
Trolley Waits in
A&E
West Middlesex University Hospital
NHS Trust
2
14
12
25
0
Data not available
65
9
0
4
10
41
3
7
Monthly
M5
95%
Data not available by CCG
98.18%
96.97%
95.37%
95.89%
96.31%
95.22%
Monthly
M5
0
Data not available by CCG
0
0
0
0
0
0
Monthly
M5
0
Data not available by CCG
167
715
113
549
38
207
Monthly
M5
0
Data not available by CCG
0
2
0
0
4
50
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1.4 NHS Performance Standards – Other Acute Measures (2)
Action Log
Issue & Root Cause
• Diagnostics - Cerner
implementation within Neuro
Physiology led to booking
process issues
Provider
Actions
CCG Lead
Original Due Revised
Date
Due Date
Status
Performance team to review month 6
performance.
JP
06/11/14
N/A
Open
Infection control:
• 41 C.Diff against tolerance of 25 ICHT
for the year to date.
Review of antibiotic prescribing with
CWHHE CCG pharmacy lead.
EY
31/10/14
N/A
Open
Cancelled operations not rebooked
within 28 days in M5 – 5 cases
reported.
ICHT
Trust requested to provide an
assessment of the reason for each
breach.
EY
24/10/14
N/A
Open
167 breaches of the LAS >30mins
handover waits
WMUH
Contract penalties of £200 per 30
minute breach.
SU
29/08/14
16/09/14
Open
ICHT
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Progress Update
Trust reporting improved
performance for M6 and 1%
tolerance should be achieved
for M7.
Infection control meeting held
between the Trust and CWHHE
infection control lead with an
agreed review of antibiotic
prescribing.
Improvement on quarter 1
performance with the Trust
reporting improved escalation
and bed management
processes. Trust reported a
reduced number of cancelled
operations for non-clinical
reasons in M5.
CCG agreed not to issue
Contract Query Notice.
10
1.5 NHS Performance Standards – Other Out of Area Providers
Target
Period
UCLH
Guys & St Thomas
Royal Free
Royal Marsden
18 weeks RTT – Admitted Pathway
90%
M5
86.3%
85.3%
90.9%
97.2%
18 weeks RTT - Non-admitted Pathway
95%
M5
93.2%
95.2%
97.0%
97.8%
18 weeks RTT - Incomplete Pathway
92%
M5
87.9%
92.1%
92.1%
95.7%
Cancer 2 week wait from GP referral
93%
M5 (M4
UCLH&RFH)
94.4%
93.7%
95.5%
95.3%
Cancer 2 week wait for breast symptoms
93%
M5 (M4
UCLH&RFH)
96.9%
96.5%
93.9%
86.1%
Cancer 31 day to treatment
96%
M5 (M4
UCLH&RFH)
96.9%
96.9%
97.8%
100.0%
Cancer 31 day wait for surgery
94%
M5 (M4
UCLH&RFH)
100.0%
97.8%
98.1%
96.0%
Cancer 31 day wait for drug treatment
98%
M5 (M4
UCLH&RFH)
100.0%
100.0%
100.0%
100.0%
Cancer 31 day wait for radiotherapy treatment
94%
M5 (M4
UCLH&RFH)
100.0%
97.9%
100.0%
96.6%
Cancer 62 wait standard
85%
M5 (M4
UCLH&RFH)
71.3%
73.2%
90.3%
68.6%
Cancer 62 day wait from screening service
90%
M5 (M4
UCLH&RFH)
100.0%
60.0%
100.0%
100.0%
85%
No Threshold - UCLH&RFH
M5 (M4
UCLH&RFH)
90.0%
73.9%
95.8%
N/A
0
M5
1
1
1
0
Annual Tolerance
2014-15
71
37
38
16
YTD Actual
M5
44
28
26
12
Performance Measure
Cancer 62 wait from consultant upgrade
MRSA cases (YTD)
C. Diff cases (YTD)
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1.5 NHS Performance Standards - Out of Area Providers (2)
Action Log
Issue & Root Cause
Provider
Not meeting the admitted RTT
standard overall and is also not
meeting the specialty and 52
week standards. Performance
ASPH
due to an identified reporting
error of clock pauses and
demand and capacity imbalance
in specific specialties.
Cancer performance – 62 day
standards – Due to Urology
ASPH
pathway issues and patient
choice
Actions
Progress reviewed at contract and
service management meeting with
Hounslow CCG and CSU
contracting team.
The Trust is developing action plan
to share with lead CCG.
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CCG Lead
Original
Due Date
Revised
Due Date
SU
21/11/14
N/A
SU
17/10/14
N/A
Status
Progress Update
Joint investigation
completed and agreed action
plan in place with lead
commissioner. Trust report
Open
improved performance
although on-going pressures
within T&O.
Open
12
1.6 NHS Performance Standards – Mental Health IAPT
Quality Requirement
Description
Threshold
NHS HOUNSLOW CCG
In mth/qtr
IAPT
IAPT Access: 15% of people with common mental illness (CMI) receiving
psychological therapy
YTD
Annual target submitted to NHSE
13.2%
Annual target (local)
10.0%
Monthly target (local)
0.7%
3.3%
Actual
0.9%
4.7%
WLMHT has met the IAPT Access target for Month 5 2014-15 across Hounslow CCG and YTD achievement is on track .
WLMHT has submitted a Trust wide performance improvement plan to recover performance across the system which will help to support continued achievement
against this indicator. Actions include: Working with the CCG to review service capacity, data quality improvement, staff training and revised referral criteria.
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1.6 NHS Performance Standards – Mental Health IAPT (2)
Quality
Requirement
IAPT
Description
Threshold
Recovery rate IAPT: 50 % of people who complete treatment and are moving to recovery
Issue & Root Cause
Provider
Actions
CCG Lead
Original
Due Date
Revised
Due Date
NHS HOUNSLOW CCG
In mth/qtr
YTD
Local Target
50.00%
50.00%
Actual
47.3%
45.1%
Status
Progress Update
Data Quality check to be completed to
ensure amendments are ready ahead of
the data refresh submission date.
Recruitment to address staff capacity
on-going
IAPT: Recovery:
Underperformance is attributed to a
rise in complex cases due to increased
thresholds in secondary care.
WLMHT
WLMHT to conduct a review of how
data from the i-CBT course in entered as
improvements in waiting times appears
to be affecting recovery rates.
Service lead to work with Anchor
Counselling Service to improve
monitoring of counsellors recovery rate,
to ensure data is being captured within
Trust Recovery rate submission.
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MC
01/11/14
N/A
Recruitment of additional staff is
underway. With increased
capacity, there will be an
opportunity to offer additional
sessions and a ‘work to wellness’
Open scheme which will help improve
recovery rates.
CCG Contract & Performance
teams to continue to monitor
performance through CQG and FIG
meetings.
14
1.6 NHS Performance Standards – Mental Health
Quality Requirement
CPA Reviews
Issue & Root Cause
CPA Reviews:
% CPA reviews sent to GPs &
communication for updated physical
health conditions.
Data recording and quality
Description
NHS HOUNSLOW CCG
Threshold
In mth/qtr
YTD
% of CPA reviews/care plans sent to GPs within 2 weeks
95%
45.5%
57.4%
% all patients and those on CPA where communicated with patient’s GP
practice for updated physical health conditions
95%
56.2%
39.0%
Provider
Actions
CCG Lead
Procedure notes to be written &
shared with all staff to set out CPA
& Encounter Records process and
how to record accurately on RiO
Informatics reports to be shared
with teams that show all patients
that have received a CPA review but
MC
have not been sent to GP within
timescale and for all patients who
do not have a valid Encounter
Record.
Original
Due Date
Revised
Status
Due Date
Progress Update
Issues affecting
underperformance are likely to
be caused by the fact that this is
a new indicator and staff are not
yet experienced in reporting
against it.
30/09/14
31/10/14
Open
CCG Contract & Performance
teams to continue to monitor
performance through CQG and
FIG meetings.
WLMHT NHS.net accounts to be set up for
all staff to enable secure email
route to GPs.
Non-compliance in M3 to be
reviewed on a case by case basis to
identify reasons for each individual
breach.
MC
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30/09/14
N/A
Reasons for non compliance
include data capture errors on
RiO, CPA reviews sent outside of
timeframe & CPA Reviews not
sent. The procedure notes
Closed
currently in development will
outline process to mitigate
against future
underperformance.
15
1.6 NHS Performance Standards – Mental Health (2)
Quality Requirement
Smoking Status
Description
% of patients accepted to Trust caseload with smoking status recorded in
electronic records
Issue & Root Cause
Provider
Actions
CCG Lead
Procedure notes will be written and
shared with all staff explaining
exactly where the smoking status
of their patients should be
recorded on RiO.
% patients accepted with smoking status
recorded:
Smoking cessation questions are not
routinely incorporated within
Community Services
Regular informatics reports will be
pulled and shared with teams
showing all patients that do not
have their smoking status
WLMHT
recorded. This action will enable us
to correct under-performance.
The Informatics Team will produce
a report showing all patients
without their smoking status
recorded.
high quality support to commissioners to improve health and wellbeing
NHS HOUNSLOW CCG
Threshold
Original
Due Date
80%
Revised
Status
Due Date
In mth/qtr
YTD
19.1%
18.5%
Progress Update
Performance has declined on
Month 4, however,
improvement is anticipated as
procedures are implemented.
MC
31/08/14
31/10/14
Open
MC
31/08/14
30/09/14
Open
CCG Contract & Performance
teams to continue to monitor
performance through CQG and
FIG meetings.
This action has been completed.
Smoking cessation reports are
now routinely available.
16
1.6 NHS Performance Standards – Mental Health (3)
NHS HOUNSLOW CCG
In mth/qtr
YTD
Quality Requirement
Description
Threshold
Early Intervention Service
Meeting commitment to serve new psychosis cases by Early Intervention Teams (performance against
commissioner targets)
95%
27.9%
83.4%
CR/HT Team
% inpatients gate kept by CR/HT teams
95%
90.5%
93.3%
Issue & Root Cause
Provider
Actions
CCG Lead
Original
Due Date
Revised
Status
Due Date
Commitment to serve new psychosis cases:
Service leads to ensure staffing is
Underperformance is attributed to
WLMHT maintained to ensure all new
psychosis cases are met.
fluctuations in GP referrals for First Episode
Psychosis in month
MC
31/10/14
N/A
Open
Progress Update
WLMHT expected to see 4 new
psychosis cases in August,
however, only 1 was actually seen.
This is an annual target, which is
measured on a quarterly basis and
monitored monthly.
Performance is expected to
recover in Q3.
CCG Contract & Performance
teams to continue to monitor
performance through CQG and FIG
meetings.
Processes and procedures are
being revisited by AMHP
Managers to ensure future
adherence.
% Inpatients gate kept by CR/HT teams:
M5 performance relates to 2 admissions
relating to Hounslow CCG patients that
were not gate kept by CRHT.
Senior Nurse Managers to meet
WLMHT urgently with CRHT Managers to
understand the issues in month.
MC
31/10/14
N/A
M5 performance has been
discussed at internal meetings
with Unit Co-ordinators to ensure
Open
staff are aware that all patients
are gate kept by CRHT prior to
admission onto the wards.
CCG Contract & Performance
teams to continue to monitor
performance through CQG and FIG
meetings.
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17
1.6 NHS Performance Standards – Mental Health (4)
Quality Requirement
DToC
Description
Delayed transfers of care
Issue & Root Cause
Provider
NHS HOUNSLOW CCG
In mth/qtr
YTD
17.8%
14.7%
Threshold
<7.5%
Actions
Local Authority and CCG to work
together to develop a protocol for
dealing with delays caused by
accommodation.
Local Authority and CCG to work
together to review the protocol in
DToC:
each Borough when a patient does
WLMHT not have recourse to public
Underperformance has been attributed
funding.
to 9 patients with a Hounslow GP who
Discussions to be held with Local
are responsible for 233 bed nights lost in
Authority partners in Hounslow
month.
(Ealing and H&F) to to review the
Reasons for delays are:
LA internal processes for escalation
Awaiting completion of assessment
of blockages which cause DTOC.
Awaiting residential home placement or
availability
Awaiting nursing home
Local Services have successfully
placement/availability
submitted a business case for 3
Awaiting care package in own home
Recovery Houses as alternative
Housing - patients not covered by NHS
options to a delayed inpatient stay.
and Community Care Act Patient or
It is anticipated that the first
Family Choice
recovery house will open in late
2014.
CCG Lead
Original
Due Date
Revised
Status
Due Date
MC
30/09/14
31/10/14
MC
31/08/14
31/10/14
MC
31/08/14
31/10/14
Progress Update
Performance against this indicator
Open has been addressed at FIG. The
Trust have been requested to
provide a revised PIP to provide
clarity on next steps to recover
performance.
Open A meeting has been scheduled
between the Associate Director of
Local Services, the Head of
Inpatient and the Community
Service Managers on 16.10.14 to
review all the existing actions and
Open protocols put in place to date and
assess effectiveness.
Protocols to manage delays caused
by accommodation and funding
issues will be revisited following
this discussion.
MC
31/12/14
N/A
The regular ward interface
meetings with LA staff are not as
effective as anticipated due to lack
Open of representation from LA partners.
The meetings are currently under
review to determine their
suitability going forward.
A timeline for the Hounslow
Recovery House is under
development.
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18
1.6 NHS Performance Standards – Mental Health (5)
Quality Requirement
Description
Mental Health Tariff
Issue & Root Cause
Provider
NHS HOUNSLOW CCG
Threshold
In mth/qtr
YTD
% of patients receiving their initial clustering assessment
within DH guidelines – 2nd face to face/ 2nd bed night
93%
68.0%
79.4%
MH Tariff of eligible caseload with accurate cluster
98%
82.6%
85.7%
Actions
Clinical Director to link with each
clinical lead to ensure that they
have clustering on their agenda.
Clinical lead for MH Tariff to
provide update MH Tariff training
to clinical teams across Local
Services.
MH Tariff:
WLMHT
Low staff awareness about clustering
RiO integration of predictive
accurately and within agreed timeframes
algorithm for red rules to be
implemented to ensure accurate
clustering.
Data Quality Manager to send
regular reports relating to MH
targets to team managers to
ensure they are aware of
performance.
high quality support to commissioners to improve health and wellbeing
CCG Lead
Original
Due Date
Revised
Status
Due Date
Progress Update
MC
30/09/14
31/12/14
Staff training for clinical teams
across local services
Open commenced in August. Training
has also been provided to
recently recruited Junior
Doctors.
MC
30/09/14
31/12/14
Open
MC
31/10/14
N/A
MC
31/08/14
N/A
Meetings are underway
between WLMHT’s Clinical
Director and clinical leads to
discuss clustering.
CCG Contract & Performance
Open teams to continue to monitor
performance through CQG and
FIG meetings.
This action is complete.
Performance reports are now
Closed
routinely circulated from the
Data Improvement Manager.
19
1.6 NHS Performance Standards – Mental Health CAMHS
Quality Requirement
DNA
Description
Threshold
% DNA for 1st appointments
% DNA for follow up
Issue & Root Cause
Provider
<15%
Actions
CCG Lead
Overarching Trust actions to improve
performance against this quality
requirement include:
% DNA for follow up.:
Underperformance has been
attributed to increased DNA rates
over the summer holiday period,
patients repeatedly not attending an
data recording errors for some
WLMHT
cancelled patients.
Performance has also been distorted
by the inclusion of follow ups
relating to Tier 2 services. This
service frequently reports high rates
due to the complexity of the
patients they work with.
CAMHS DNAs:
Lack of clarity amongst clinical staff
regarding how to accurately record
DNA on RiO
<15%
Work to reduce patient anxiety by
ensuring patients know about the
service , why they have been referred
and what to expect. The service will
introduce service leaflets that will be
sent to patients prior to their first
appointment.
A common letter format will be
introduced across the service
including information on how to
cancel an appointment if necessary.
WLMHT
Operations Manager to develop a
training document to highlight
common coding mistakes and how to
accurately record DNA against a
number of common scenarios.
high quality support to commissioners to improve health and wellbeing
MC
Original
Due Date
31/08/14
Revised
Due Date
30/11/14
NHS HOUNSLOW CCG
In mth/qtr
YTD
15.9%
12.1%
21.9%
18.8%
Status
Progress Update
Open
Performance has been discussed
through FIG. A contract query is
in the process of being raised
against this indicator with
formal documentation expected
to be sent w/c 13.10.14.
A renewed action plan to
address under performance has
been requested and developed
and will be available for M6.
MC
MC
31/07/14
31/08/14
30/11/14
30/11/14
Open
Open
The Lead Nurse responsible for
running the service user
involvement group is on long
term leave. Work to reduce
patient anxiety and service
leaflets will be picked up once
the current vacancy has been
addressed.
The training document has been
delayed due to a staff vacancy
against the CAMHS Operational
Manager post.
Staffing constraints are being
addressed by the Provider and a
further update will be available
in November.
20
1.6 NHS Performance Standards – Mental Health CAMHS (2)
Quality Requirement
HoNOSCA
Description
Threshold
% HoNOSCA (Health of the Nation Outcome Scales Child and Adolescent) completion rate on acceptance
into the service
% of HoNOSCA completion rate on discharge from the service
Issue & Root Cause
Provider
CAMHS HoNOSCA :
Underperformance has been
attributed to data quality as staff
begin to use HONOSCA to record
completion rate on acceptance,
completion rate on discharge and
paired scores.
Actions
CCG Lead
Original
Due Date
Revised
Due Date
A quarterly meeting is being established to
review missing measures which will include
HoNOSCA auditing.
MC
31/10/14
30/11/14
WLMHT
In mth/qtr
YTD
80%
54.8%
62.5%
80%
7.7%
9.5%
Status
WLMHT’s CORC lead to regularly monitor and
audit staff compliance with HoNOSCA.
Open
NHS HOUNSLOW CCG
Progress Update
There has been a significant
improvement on M4, however,
performance has been
discussed through FIG and a
contract query is in the process
of being raised against this
indicator with formal
documentation expected to be
sent w/c 13.10.14.
The CORC Lead has taken
responsibility for regularly
monitoring and auditing staff
compliance with HoNOSCA.
CCG Contract & Performance
teams to continue to monitor
performance through CQG and
FIG meetings.
Underperformance has been
attributed to a level of ambiguity in
the Contracted Information Schedule
regarding performance measures, as
well as a continuing debate around
the compatibility between IAPT and
HoNOSCA.
Provider to cease using CGAS as the
performance measure and revert to
HoNOSCA going forwards.
high quality support to commissioners to improve health and wellbeing
MC
31/08/14
30/09/14
From 26 August staff have been
informed that HoNOSCA scores
must be recorded directly onto
Closed
RiO. The current practice of
recording HoNOSCA manually
has been stood down.
21
1.7 NHS Performance Standards – Community Services
Quality Requirement
CLA Assessment
Performance Measure
Target
NHS HOUNSLOW CCG
Month
YTD
CLA Initial Health Assessments (IHA) conducted within 20 operational days including late notification
98%
50.0%
90.0%
CLA Review Health Assessments (RHA) conducted within 6 calendar weeks
98%
64.7%
92.5%
Issue & Root Cause
Provider
CLA Initial Health Assessments (IHA)
conducted within 20 operational
days including late notification and HRCH
CLA Review Health Assessments
(RHA) conducted within 6 calendar
weeks:
Looked after children (Teenagers)
often DNA for appointments and a
number have been offered up to 6
appointments before the CLA Nurse
has been able to see them.
Meeting with Local Authority (LA) to
look at improving communication
between LA & HRCH ensuring
referrals are received within 24 hours
of a child being looked after.
Recruitment to CLA Designated
Nurse post.
recruited commenced
August 2014
Delay in practitioner being able to
undertake assessments due to 3
CLA posts vacant including CLA
medical officer and LAC Nurse
posts.
Local authority delays to notify
service as soon as a child becomes
looked after.
Actions
Recruitment to CLA Nurse post.
CCG Lead
PF
PF
PF
Original
Due Date
Revised
Due Date
Status
Progress Update
31/10/14
N/A
Open
Meeting delayed at LA request
until new medical advisor in post
29/08/14
N/A
CLA Designated Nurse recruited
Closed and commenced 29.08.14
15/09/14
N/A
CLA Nurse recruited and
Closed commenced 15.9.14
HRCH
Recruited to commence for
CLA medical advisor.
high quality support to commissioners to improve health and wellbeing
PF
22/10/14
N/A
Open
CCG Contract & Performance
teams to continue to monitor
performance through CQG
meetings.
22
1.7 NHS Performance Standards – Community Services (2)
Quality Requirement
DNA
Performance Measure
Target
4.5%
Pre-booked appointments DNA or UTA rate
Issue & Root Cause
Provider
DNA Rate:
Seasonal variation due to summer
holidays.
HRCH
Actions
Trust to replace the phone system in
the Therapy Block, West Middlesex
Hospital, so that communicating with
the department is more
straightforward.
high quality support to commissioners to improve health and wellbeing
CCG Lead
PF
Original
Due Date
13/11/14
Revised
Due Date
N/A
Status
Open
NHS HOUNSLOW CCG
Month
YTD
6.1%
5.7%
Progress Update
Patients are currently booked in
for a follow-up when they have
an appointment. The new phone
system will facilitate patients
booking appointments as
needed.
CCG Contract & Performance
teams to continue to monitor
performance through CQG
meetings.
23
1.8 CCG Quality Premium – 2014/15
CCG funding achievement will be based on year-end performance against the pre-qualifying criteria, national and local measures with adjustments for
constitutional gateway measures breaches. Please note IAPT performance is measured against CCG plans submitted to NHSE.
Financial
Gateway
Operate in a manner consistent with Managing Public Money in
2014/15
Quality Premium Measures
Reducing Potential Years of Life Lost (PYLL) through causes
considered amenable to healthcare and including addressing
locally agreed priorities for reducing premature mortality
Improving Access to Psychological Therapies (IAPT)
(Quarterly Performance - Q1)
National
measures
Reducing avoidable emergency admissions (Composite Measure)
Improving Patient
Experience:
(i) Supporting roll-out of Friends and
Family Test (FFT) by local providers
Not Incur Unplanned deficit in 2014/15, or require financial support to avoid
unplanned deficit
2014/15 Target
YTD/Qtrly Targets
YTD M5/Qtrly
Performance
Maximum
Available
1868
(per 100k population)
1868
(per 100k population)
Available in summer
2015
£222,276
Annual
13.2%
2.9%
2.8%
£222,276
Quarterly
1831
(admissions per 100k
pop.)
1831
(admissions per 100k
pop.)
Available in summer
2015
£370,460
Annual
Evidence of engagement
Evidence of engagement
tbc
£222,276
Annual
(ii) Improvement in 'Patient Experience of Improvement on 2013/14 Improvement on 2013/14
Hospital Care'
score of 70.7
score of 70.7
Improving the reporting of medication-related safety incidents
Hounslow CCG People with diabetes diagnosed less than a year who are referred
Local Measure to structured education
Not incur a qualified audit report in respect of 2014/15
Available in summer
2015
Local Providers Target
tbc
£222,276
Monthly
69.78%
70%
tbc
£222,276
tbc
£1,481,840
Total Maximum Funding Available
Gateway
measures
(Penalty)
Reporting
Frequency
Local Providers Target
Total
Constitutional Measures
Potential
Deductions
£0
£1,481,840
Potential
Adjustment to
Funding
Reporting
Frequency
94.2%
-
Monthly
97.4%
-
Monthly
Target
YTD Target
YTD M5 Performance
18 Week RTT (Incomplete Pathway)
92%
92%
A&E waits (CCG mapped from HES provider data)
95%
95%
Cancer waits - 14 days (Urgent GP referral for Suspected Cancer)
93%
93%
94.3%
Cat A red 1 ambulance calls (LAS performance)
75%
75%
74.7%
Potential Year End Achievement (after Gateway Measures Performance Adjustments)
high quality support to commissioners to improve health and wellbeing
Potential %
Adjustment to
Funding
25%
-
Monthly
-£370,460
Monthly
£1,111,380
24
Section 2 Quality & Safety Performance
For Quality, Risk & Safety Committee
high quality support to commissioners to improve health and wellbeing
25
2.1 Acute Providers Maternity Dashboard 1
% of first
booking
maternity apps
12 weeks + 6
days as %
of apps (exc.
late referrals)
Target
ICHT
Aug
YTD
Target
NWLHT
Aug
YTD
Target
EHT
Aug
YTD
Target
THH
Aug
YTD
Target
WMUH
Aug
YTD
Target
ChelWest
Aug
YTD
95%
94.3%
80.1%
95%
96.2%
96.6%
95%
100%
94.2%
>90%
97%
97.1%
95%
99.7%
98.8%
95%
95.8%
94.8%
90%
87.7%
56.6%
90%
92.7%
92.1%
90%
89.2%
91.7%
>83%
85.2%
84.7%
95%
90.2%
92.7%
90%
87.4%
91.9%
1.4%
0%
0.1%
0.8%
0.3%
0.2%
1%
1.1%
1.6%
2.1%
2.4%
2.6%
2.0%
1.9%
1.2%
10%
7.1%
7.4%
10%
1.9%
2.3%
<10%
1.2%
1.8%
5%
1.6%
1.9%
5%
2.9%
4.5%
5%
1.9%
1.7%
Breastfeeding
initiation rate
N/A
Home Births
10%
3.6%
1.7%
10%
3.8%
4.6%
10%
5%
5%
1.7%
1.6%
5%
2.5%
3.2%
5%
Not
reported
5%
Percentage of
women smoking
at the time of
delivery
Percentage of
women
experiencing
3rd degree tear
high quality support to commissioners to improve health and wellbeing
26
2.1 Acute Providers Maternity Dashboard 2
Percentage of
women that
have elective
caesarean
sections
Percentage of
women that
have nonelective
caesarean
sections
Target
ICHT
Aug
YTD
Target
NWLHT
Aug
YTD
Target
EHT
Aug
YTD
Target
THH
Aug
YTD
Target
WMUH
Aug
YTD
Target
13%
9.1%
9%
10%
11.6%
12.1%
12%
13.3%
10.7%
27%
22.3%
26.3%
12%
12%
10.7%
15%
Percentage of women that
have elective /non elective
caesarean sections combined
(THH only)
15%
16.2%
15%
17.1%
18%
15%
18.3%
19.9%
2.4%
N/R
2.4%
0.5%
0.9%
2.4%
0.4%
0.5%
2.4%
0.6%
N/R
90%
96.3%
N/R
100%
99.1%
N/A
95%
13.3%
ChelWest
Aug
YTD
10.2%
14.2%
80
12%
13.4%
14.3%
15%
10%
14%
0.8%
2.4%
2.6%
2%
2.4%
1.6%
1.8%
95.8%
95.6%
95%
83.3%
83.4%
98%
93.4%
N/A
Post Partum
Haemorrhage 2
litres and above
1:1 midwife care
in established
labour
No data
Midwife to birth
ratio -
ICHT Target: 1:30
SMH in month: 1:33
QCCH in month: 1:31
1:30
1:25
1:30
1:30
1:30
1:30
1:31
1:30
1:36
1:30
1:32
Consultant ward
coverage –
hours per week
ICHT Target: 60 hrs
SMH in month:
QCCH in month:
98
108
60
60
98
114
114
98
92
98
110
high quality support to commissioners to improve health and wellbeing
27
2.1 NHS Choices Experience Ratings (All Trusts)
Please note that these are the averages of unsolicited reviews provided by patients using
the NHS Choices website (www.nhs.uk).
Same-sex
accommodation
NHS Choices
User’s Overall Rating
Cleanliness
Staff co-operation
Dignity and Respect
Involvement in Decisions
Based on 135 ratings
124 ratings
129 ratings
127 ratings
124 ratings
84 ratings
Based on 82 ratings
82 ratings
83 ratings
83 ratings
81 ratings
65 ratings
Based on 75 ratings
67 ratings
69 ratings
70 ratings
66 ratings
47 ratings
St Mary’s
Hospital
(Imperial)
Based on 104 ratings
101 ratings
105 ratings
104 ratings
102 ratings
79 ratings
Chelsea and
Westminste
r Hospital
Based on 74 ratings
74 ratings
75 ratings
74 ratings
72 ratings
56 ratings
Based on 51 ratings
48 ratings
49 ratings
48 ratings
45 ratings
35 ratings
Indicator
Charing
Cross
Hospital
(Imperial)
Hammersmi
th Hospital
(Imperial)
Queen
Charlotte’s
Hospital
(Imperial)
Ealing
Hospital
NHS Choices
NHS Choices
NHS Choices
NHS Choices
NHS Choices
th
Data extracted from NHS Choices 24 September 2014
high quality support to commissioners to improve health and wellbeing
28
2.1 NHS Choices Experience Ratings (All Trusts)
Please note that these are the averages of unsolicited reviews provided by patients using
the NHS Choices website (www.nhs.uk).
Indicator
Central
Middlesex
Hospital
(NWLHT)
User’s Overall Rating
NHS Choices
Cleanliness
NHS Choices
Staff co-operation
NHS Choices
NHS Choices
Involvement in
Decisions
NHS Choices
Same-sex
accommodation
NHS Choices
Dignity and Respect
Based on 61 ratings
54 ratings
59 ratings
56 ratings
52 ratings
40 ratings
Northwick
Park Hospital
(NWLHT)
Based on 161 ratings
161 ratings
164 ratings
163 ratings
159 ratings
133 ratings
St Mark’s
Hospital
(NWLHT)
Based on 21 ratings
21 ratings
21 ratings
21 ratings
20 ratings
20 ratings
Based on 120 ratings
123 ratings
122 ratings
122 ratings
115 ratings
92 ratings
Based on 55 ratings
56 ratings
56 ratings
56 ratings
55 ratings
50 ratings
Based on 187 ratings
187 ratings
187 ratings
188 ratings
181 ratings
138 ratings
The
Hillingdon
Hospital
(THH)
Mount
Vernon
Hospital
(THH)
West
Middlesex
University
Hospital
th
Data extracted from NHS Choices 24 September 2014
high quality support to commissioners to improve health and wellbeing
29
2.2 Imperial College Hospital NHS Trust (ICHT): Safety Overview
CQC Intelligent Monitoring Report Overview
July-14
Priority banding for CQC Inspection
Recently inspected
NWLHT
WMUH
1
EHT
1
ICHT
5
RBH
3
Recently inspected
THH
6
Number of 'Risks'
10
11
12
3
1
5
1
Number of 'Elevated Risks'
5
5
2
1
2
1
0
Overall Risk Score
20
21
16
5
5
7
1
Number of Applicable Indicators
Proportional Score
Maximum Possible Risk Score
CW
93
92
90
93
53
91
96
10.75%
11.41%
8.89%
2.69%
4.72%
3.85%
0.52%
186
184
180
186
106
182
192
1 = highest priority and 6 the lowest. Full reports available at http://www.cqc.org.uk/download/a-to-z/hospital-imonitoring-july-2014 . Hospitals that have recently been inspected are not banded.
Identified Risks
Indicators identified as a 'Risk'
Indicators identified as an ‘Elevated Risk’
1.
2.
3.
1.
Never Event incidence
NHS Staff Survey KF10 – The proportion of staff receiving health and safety training in the last 12 months
Composition risk rating of ESR items relating to staff stability
Incidence of MRSA
high quality support to commissioners to improve health and wellbeing
30
2.2 ICHT: Safety
Indicator
Threshold
In Month
Expected = 100
77.7
% of Patients Experiencing Harm Free
Care
National average = 93.66%
97.08%
% of Patients who have been harmed in
a fall
National average = 0.71%
0.17%
Pressure Ulcer Prevalence (All)
National average = 4.57%
2.53%
Standardised Hospital Mortality
Indicator (SHMI)
Trend
Data Released: Jul/14
Coverage Period: Jan/13 – Dec/13
Patient Safety Thermometer
Patient Safety Thermometer – % of patients that
have been hurt in a fall in a 3 day period
Patient Safety Thermometer
high quality support to commissioners to improve health and wellbeing
31
2.2 ICHT: Serious Incidents Report
Indicator
Threshold
In Month
YTD
N/A
13
47
Percentage of SIs reported on to StEIS
within 48 hours of identification
100%
77%
67%
Percentage of Root Cause Analysis
(RCA) investigation reports submitted
within 45/60 working day deadline or
agreed extension date
100%
67%
(2/3)
62%
Issue
Actions
Contract Manager Lead
Original
Due Date
Revised
Due Date
Status
Trust reporting SIs late on to StEIS
Contract Manager to monitor issue
at CQG
EY
31/10/14
N/A
Open
Standing agenda item at CQG
Trust submitting RCAs late
Contract Manager to monitor issue
at CQG
EY
31/10/14
N/A
Open
Standing agenda item at CQG
Number of Serious Incidents (SIs)
Trend
(where date of identification was included)
high quality support to commissioners to improve health and wellbeing
Progress Update
32
2.2 ICHT: Maternity Indicators Exception Report 1
Indicator
Threshold
In Month
YTD
Breastfeeding initiation rate
90%
87.7%
56.6%
First booking maternity appointments
completed by 12 weeks + 6 days as a
percentage of total booking
appointments in month excluding late
referrals (women referred after 10
weeks + 6 days)
95%
94.3%
80.1%
Midwife to Birth Ratio
1:30
Issue
Actions
SMH: 1:33
QCH: 1:31
N/A
Contract Manager Lead
Information breach notice issued due to
Potential Cerner-related data quality
data quality issues.
issues with the below indicators:
There are on-going data quality issues
• Breast feeding initiation rate below
following the Trust implementation of
threshold
Cerner. A Remedial Action Plan has been
• First booking maternity
agreed and the Trust will provide by 10
appointments below threshold
October a definitive list of the indicators
• Midwife to Birth Ratio
affected by the issue.
high quality support to commissioners to improve health and wellbeing
EY
Trend
Original
Revised
Status
Due Date Due Date
30/09/14 31/10/14
Open
Progress Update
Previous meeting between
Chief Officers and an action
plan is has been agreed.
A business case has been
approved to reach 1:30 ratio
from April 15
33
2.2 ICHT: Maternity Indicators Exception Report 2
Indicator
Threshold
In Month
YTD
Home births
1.4%
0%
0.1%
Percentage of women that have nonelective caesarean section
15%
16.2%
13.3%
Issue
Actions
Contract Manager
Lead
Information breach notice issued due to
data quality issues.
Potential Cerner-related data quality There are ongoing data quality issues
issues with the below indicators:
following the Trust implementation of
• Home births
Cerner. A Remedial Action Plan has been
agreed and the Trust will provide by 10
October a definitive list of the indicators
affected by the issue.
high quality support to commissioners to improve health and wellbeing
EY
Trend
Original
Revised
Status
Due Date Due Date
30/09/14 31/10/14
Open
Progress Update
Previous meeting between
Chief Officers and an action
plan is has been agreed. Trust
has advised that issues will
take 2-3 months to resolve.
Once an IT solution is in place,
a number of midwives will be
released every month to focus
on home births
34
2.2 ICHT: Quality Indicators Exception Report
Indicator
Threshold
In Month
YTD
% of stroke patients eligible for
thrombolysis, to receive treatment
within 45 minutes of entry to A&E
90%
100%
88.9%
Issue
Actions
Contract Manager Lead
Original
Due Date
Revised
Due Date
Status
Trust performance has recovered
in M5.
Potential data quality issue, to be
clarified whether indicator is affected
EY
31/10/14
N/A
Closed
high quality support to commissioners to improve health and wellbeing
Trend
Progress Update
35
2.2 ICHT: Complaints
Indicator
Threshold
In Month
YTD
% of complaints acknowledged
within 3 days of receipt
100%
100%
N/A
% of complaints responded to
within the agreed target
100%
57%
N/A
Trend
Complaints data is one month in arrears
Issue
% of complaints acknowledged
within 3 days of receipt and
responded to within the agreed
target
Actions
Contract Manager Lead
Identify whether indicators have been
affected by data quality issue.
high quality support to commissioners to improve health and wellbeing
EY
Original
Due Date
30/03/14
Revised
Due Date
31/10/14
Status
Progress Update
Open
Data quality issues reported by
Trust regarding IT software,
Trust has advised issues will take
2-3 months to resolve
36
2.2 ICHT – Patient Experience
Complaints by Category, Severity and Specialty
Complaints by Category – one month in arrears
Aids/Appliances
Appointments
Attitude (Medical Staff)
Attitude (Nursing Staff)
Attitude (Other Staff)
Clinical Care Medical Staff
Clinical Care Nursing Staff
Clinical care other
Communication / Information to Patients
Consent to treatment
Discharge / Transfer
Other
Hotel Services
Patient’s property and expenses
Personal records
Privacy & Dignity
Patient Discrimination
Transport
Waiting Times
Apr
1
14
3
2
2
20
15
21
37
4
10
1
2
5
2
3
0
0
0
May
2
20
6
0
3
49
14
0
38
0
3
0
2
2
0
0
0
3
10
June
1
20
2
2
5
38
15
0
13
0
6
0
0
3
2
2
2
2
13
July
0
21
14
5
4
16
10
6
6
0
9
1
0
0
2
0
0
2
21
YTD
4
75
25
9
14
123
54
27
94
4
28
2
4
10
6
5
2
7
44
Complaints by Specialty
Inpatient Services
Outpatient Services
A&E
Other
Maternity
Apr
33
49
12
June
47
56
8
July
30
71
9
1 (ambulance)
0
May
42
52
8
0
1
3 (walk – in)
1
1 (walk – in)
6
YTD
152
228
37
5
8
Complaints by Severity
Low
Moderate
High
Apr
94
1
0
May
104
0
0
June
109
4
2
July
103
10
4
YTD
307
15
6
high quality support to commissioners to improve health and wellbeing
37
2.2 ICHT: A&E Friends and Family Test (FFT)
Indicator
Threshold
In Month
Nat Avg
A&E FFT: Score
N/A
50
57
A&E FFT: Response Rate
15%
16.9%
20%
Score
Response
Rate
Responses
Charing Cross Hospital
50
30.8%
417
Hammersmith Hospital
49
33.6%
295
St Mary’s Hospital
56
2.9%
63
Western Eye Hospital
50
16%
560
Imperial A&E FFT
high quality support to commissioners to improve health and wellbeing
Trend
38
2.2 ICHT: Inpatient Friends and Family Test (FFT)
Indicator
Threshold
In Month
Nat Avg
Inpatient FFT: Score
N/A
68
74
Inpatient FFT: Response Rate
15%
41%
36.9%
Score
Response
Rate
Responses
Charing Cross Hospital
59
52.53%
654
Hammersmith Hospital
79
35.86%
359
St Mary’s Hospital
73
31.45%
301
Imperial Inpatient FFT
high quality support to commissioners to improve health and wellbeing
Trend
39
2.2 ICHT: Maternity FFT
Indicator
Threshold
In Month Nat Avg
Maternity Q2 FFT: Score
N/A
65
77
Maternity Q2 FFT:
Response Rate
15%
25.9%
21.9%
Issue
Action
Response rate for Maternity FFT
below threshold
Contract Manager
Lead
Contract manager to monitor
performance at CQG
EY
Trend
Original due Revised due
date
date
30/09/14
Score
Response
Rate
Responses
Queen Charlotte’s Hospital
100
9%
34
St Mary’s Hospital
56
47.5%
140
Imperial Maternity FFT
high quality support to commissioners to improve health and wellbeing
N/A
Status
Progress
Closed
Response rate recovered
40
2.2 West Middlesex University Hospital (WMUH):
Safety Overview
CQC Intelligent Monitoring Report Overview
July-14
Priority banding for CQC Inspection
Recently inspected
NWLHT
WMUH
1
EHT
1
ICHT
5
RBH
3
Recently inspected
THH
6
Number of 'Risks'
10
11
12
3
1
5
1
Number of 'Elevated Risks'
5
5
2
1
2
1
0
Overall Risk Score
20
21
16
5
5
7
1
Number of Applicable Indicators
Proportional Score
Maximum Possible Risk Score
CW
93
92
90
93
53
91
96
10.75%
11.41%
8.89%
2.69%
4.72%
3.85%
0.52%
186
184
180
186
106
182
192
1 = highest priority and 6 the lowest. Full reports available at http://www.cqc.org.uk/download/a-to-z/hospital-imonitoring-july-2014 . Hospitals that have recently been inspected are not banded.
Identified Risks
Indicators identified as a 'Risk'
1.
Never Event incidence
2.
Incidence of Meticillin-resistant Staphylococcus aureus (MRSA)
3.
Maternity outlier alert: Puerperal sepsis and other puerperal infections
4.
Composite indicator: Emergency readmissions with an overnight stay following an emergency admission
5.
Proportion of patients who received all the secondary prevention medications for which they were eligible
6.
Inpatient Survey Q34 "Did you find someone on the hospital staff to talk to about your worries and fears?"
7.
Inpatient Survey Q23 "Did you get enough help from staff to eat your meals?“
8.
Inpatient Survey Q39 "Do you think the hospital staff did everything they could to help control your pain?“
9.
Inpatient Survey Q67 "Overall, did you feel you were treated with respect and dignity while you were in the hospital?“
10. Maternity Survey D6 "Thinking about your stay in hospital, how clean were the toilets and bathrooms you used?"
11. Composite risk rating of ESR items relating to ratio: Staff vs bed occupancy
1. Potential under-reporting of patient safety incidents
2.
Indicators identified as an ‘Elevated Risk’ 3.
Inpatient Survey Q35 "Do you feel you got enough emotional support from hospital staff during your stay?"
Inpatient Survey Q32 "Were you involved as much as you wanted to be in decisions about your care and treatment?"
4.
Inpatient Survey Q68 "Overall…" (I had a very poor/good experience)
5.
Inpatient Survey Q28 "Did you have confidence and trust in the nurses treating you?"
high quality support to commissioners to improve health and wellbeing
41
2.2 WMUH: Safety
Indicator
National Average
In Month
YTD
Expected = 100
96.7
N/A
% of Patients Experiencing Harm Free
Care
National average = 93.66%
94%
N/A
% of Patients who have been harmed in
a fall
National average = 0.71%
0.57%
N/A
Pressure Ulcer Prevalence (All)
National average = 4.57%
3.14%
N/A
Standardised Hospital Mortality
Indicator (SHMI)
Trend
Data Released: Jul/14
Coverage Period: Jan/14 – Dec/14
Patient Safety Thermometer
Patient Safety Thermometer – % of patients that
have been hurt in a fall in a 3 day period
Patient Safety Thermometer
high quality support to commissioners to improve health and wellbeing
42
2.2 WMUH: Serious Incidents Report
Indicator
Threshold
In Month
YTD
N/A
5
30
Percentage of SIs reported on to StEIS
within 48 hours of identification
100%
100%
94%
Percentage of Root Cause Analysis
(RCA) investigation reports submitted
within 45/60 working day deadline or
agreed extension date
100%
100%
( 5 / 5)
85%
Number of Serious Incidents (SIs)
Trend
(where date of identification is included)
high quality support to commissioners to improve health and wellbeing
43
2.2 WMUH: Maternity Indicators Exception Report 1
Indicator
Percentage of women that have
non-elective caesarean sections
Issue
Trust exceeding threshold of nonelective C-sections
Indicator
Breastfeeding initiation rate
Issue
Threshold
In Month
YTD
12%
13.4%
14.3%
Actions
Contract Manager Lead
Original
Due Date
Revised
Due Date
Status
Progress Update
SU
30/09/14
30/11/14
Open
Deep-dive maternity audit to be
requested at upcoming CQG.
In-depth review of maternity
indicators to be discussed at
upcoming CQG
Threshold
In Month
YTD
95%
90.2%
92.7%
Actions
Trend
Trend
Contract Manager Lead
Original
Due Date
Revised
Due Date
Status
Progress Update
SU
30/11/14
N/A
Open
Deep-dive maternity audit to be
requested at upcoming CQG.
In-depth review of maternity
Breast feeding initiation rate below
indicators to be discussed at
threshold in month
upcoming CQG
high quality support to commissioners to improve health and wellbeing
44
2.2 WMUH: Maternity Indicators Exception Report 2
Indicator
1:1 midwife care in established
labour
Issue
1:1 midwife care outside of
threshold in month
Indicator
Post Partum Haemorrhage percentage
Issue
Post Partum Haemorrhage
Threshold
In Month
YTD
95%
83.3%
83.4%
Actions
Contract Manager Lead
In-depth review of maternity
indicators to be discussed at
upcoming CQG
In Month
YTD
2.4%
2.6%
2%
In-depth review of maternity
indicators to be discussed at
upcoming CQG
Contract Manager Lead
SU
high quality support to commissioners to improve health and wellbeing
Original
Revised
Status
Due Date Due Date
30/09/14 30/11/14
SU
Threshold
Actions
Trend
Open
Progress Update
Deep-dive maternity audit to be
requested at upcoming CQG.
Trend
Original
Revised
Status
Due Date Due Date
30/09/14 30/11/14
Open
Progress Update
Deep-dive maternity audit to be
requested at upcoming CQG.
45
2.2 WMUH: Maternity Indicators Exception Report 3
Indicator
Threshold
In Month
Consultant Ward coverage
98hrs
92hrs
Midwife to birth ratio
1:30
1:36
Issue
Consultant Ward coverage outside of
threshold in month
Actions
Trend
Contract
Original
Revised
Manager Lead Due Date Due Date
In-depth review of maternity indicators
to be discussed at upcoming CQG
SU
30/06/14
31/10/14
Status
Open
Progress Update
Deep-dive maternity audit to be
requested at upcoming CQG.
Midwife to birth ratio
high quality support to commissioners to improve health and wellbeing
46
2.2 WMUH: Complaints
Indicator
Threshold
In Month
% of complaints acknowledged
within 3 days of receipt
100%
Not
Reported
No data
% of complaints responded to
within the agreed target
100%
Not
Reported
No data
Issue
Trust are not submitting
complaints KPI data
Actions
YTD
Trend
Contract Manager Lead
Original
Due Date
Revised
Due Date
Status
Progress Update
SU
31/03/14
30/11/14
Open
Previously raised with
Complaints manager at WMUH
and at the CQG + PCE.
Contract manager to issue
Information Breach
high quality support to commissioners to improve health and wellbeing
47
2.2 WMUH: A&E and Inpatient Friends & Family Test (FFT)
Indicator
Threshold
In Month
Nat Avg
A&E FFT: Score
N/A
73
57
A&E FFT: Response Rate
15%
24.7%
20%
Threshold
In Month
Nat Avg
Inpatient FFT: Score
N/A
56
74
Inpatient FFT: Response Rate
15%
42.2%
36.9%
Indicator
high quality support to commissioners to improve health and wellbeing
Trend
Trend
48
2.2 WMUH: Maternity FFT
Indicator
Threshold
In Month
Nat. Avg
Maternity Q2 FFT: Score
N/A
93
77
Maternity Q2 FFT:
Response Rate
15%
3.3%
21.9%
Root Cause
Trust response rate below 15%
threshold
Actions
Trend
CSU Lead
Original
Due Date
Revised
Due Date
Status
SU
30/09/14
30/11/14
Open
Contract Manager to raise at CQG
high quality support to commissioners to improve health and wellbeing
Progress Update
49
2.3 Hounslow and Richmond Community Healthcare NHS Trust
(HRCH) – Hounslow Community Services: Serious Incidents Report
Indicator
Threshold
In Month
YTD
N/A
5
22
Percentage of SIs reported on to StEIS
within 48 hours of identification
100%
60%
82%
Percentage of Root Cause Analysis
(RCA) investigation reports submitted
within 45/60 working day deadline or
agreed extension date
100%
80%
(4 / 5)
49%
Issue
Actions
Number of Serious Incidents (SIs)
Trend
(where date of identification is provided)
Drop in performance of reporting SIs
on to StEIS within deadline
Contract Manager Lead
Contract Manager to monitor
performance at CQG
Trust are submitting RCA reports late
high quality support to commissioners to improve health and wellbeing
Original
Due Date
Revised
Due Date
Status
30/09/14
30/12/14
Open
Standing agenda item at CQG
30/09/14
30/12/14
Open
Standing agenda item at CQG
Progress Update
SU
50
2.3 HRCH – Hounslow Community Services: Pressure Ulcers
Indicator
Threshold
In Month
YTD
Pressure Ulcer Grade 2
N/A
3
11
Pressure Ulcer Grade 3
N/A
1
4
Pressure Ulcer Grade 4
N/A
0
0
National average = 4.57%
7.66%
N/A
Pressure Ulcer Prevalence (All)
Patient Safety Thermometer
All HRCH Services
high quality support to commissioners to improve health and wellbeing
Trend
51
2.3 HRCH – Hounslow Community Services: Complaints &
Safeguarding Training
Indicator
Threshold
In Month
YTD
% of complaints acknowledged within 3 days
of receipt
100%
100%
100%
% of complaints responded to within the
agreed target
100%
50%
72.2%
Indicator
Threshold
In Month
YTD
Eligible staff who have received appropriate
Children’s safeguarding training (Levels 1,2 &
3): Community medical staff
100%
100%
Eligible staff who have received appropriate
Adult’s safeguarding training (Levels 1,2 &
3): District Nurses
100%
93%
Issue
Actions
Contract
Manager Lead
Complaints responded to within agreed target Review of complaints in month
conducted
below threshold
District Nursing Adult Safeguarding Training
Action Plan in place and is being
monitored
Safeguarding Training
Trajectory to be agreed with Trust
high quality support to commissioners to improve health and wellbeing
SU
Trend
Trend
Original
Revised
Status
Due Date Due Date
30/09/14
N/A
Closed
30/09/13
N/A
Open
31/08/14 31/10/14
Progress Update
1 complaint was 1 day overdue
due to administrative reasons
Staff members missed in
previous months have been
identified and contacted
Open
52
2.4 West London Mental Health NHS Trust (WLMHT) – All
Boroughs: Serious Incidents Report
Indicator
Number of Serious Incidents (SIs)
Percentage of SIs reported on to StEIS
within 48 hours of identification
(where date of identification is provided)
Percentage of Root Cause Analysis
investigation reports submitted within
45/60 working day deadline (or agreed
extension date)
Issue
Threshold
In Month
YTD
N/A
6
24
100%
0%
20%
100%
Non due in
month
100%
Actions
Trend
Contract Manager Lead
Original
Due Date
Revised
Due Date
Status
MC
31/10/14
N/A
Open
Trust reporting SIs on to StEIS outside Contract manager to monitor at
CQG
required deadline
high quality support to commissioners to improve health and wellbeing
Progress Update
Standing agenda item at CQG
53
2.4 WLMHT – Mental Health Services in All Boroughs: Incidents
by Severity
Indicator
Threshold
In Month
YTD
Number of incidents:
No harm
N/A
174
1002
Number of incidents:
Low harm
N/A
9
79
Number of incidents:
Moderate harm
N/A
8
34
Number of incidents:
violence and aggression
N/A
22
346
high quality support to commissioners to improve health and wellbeing
Trend
54
2.4 WLMHT – Mental Health Services in Hounslow CCG: Safety
Indicator
Pressure Ulcer Prevalence (All)
All WLMHT services
Under 18s admitted on to an Adult
Psychiatric ward, unless age
appropriate
Threshold
In Month
YTD
National average = 4.57%
0%
N/A
0
0
1
90%
Q1
82%
N/A
Actions
Contract
Manager
Lead
Trend
WLMHT Mental Health Services in
Hounslow CCG
Patient feeling safe on an inpatient
unit
WLMHT Mental Health Services in Hounslow
CCG
Issue
% of patient reporting feeling safe on
an inpatient unit is below threshold
Action plan in place, continue to monitor,
data reported quarterly.
high quality support to commissioners to improve health and wellbeing
MC
Original Due Revised
Date
Due Date
31/10/14
N/A
Status
Progress Update
Open
Actions in place include:
- Encourage patients to be open
about any issues
- Strengthening communication
amongst staff and with patients
55
Section 3– Out of Hospital Services Performance
high quality support to commissioners to improve health and wellbeing
56
3.1 GP Out of Hours (OOH) Service
Key messages
•
•
Volumes in the OOH services remained fairly stable in August, with just small changes in overall demand. Home and PCC visits were down in Hounslow and also
slightly down in the LCW service, though both increased in Ealing.
NQR performance was generally improved on July; the Ealing and Hounslow services saw increases in routine triage within 60 minutes, though both remained
slightly below target. Hounslow returned to above target levels on NQR 12e (Urgent visits within 2 hours), although performance on this metric did drop in Ealing.
This equated to 7 breaches in the month.
NWL GP OOHs Data- May 2014
Ealing CCG – Care UK
Hounslow CCG – Care UK
Volume
% of Total
Volume
% of Total
GP visit
269
21.35%
216
PCC/UCC
369
29.29%
GP/nurse advice
538
A&E / Admitted to
Hospital
Brent CCG –
Care UK
Volume
% of Total
20.53%
349
12.9%
399
37.93%
604
22.4%
42.70%
370
35.17%
1609
59.7%
47
3.73%
35
3.33%
n/a
n/a
999
11
0.87%
5
0.48%
38
1.4%
Community Nursing
3
0.24%
6
0.57%
n/a
n/a
Call Handler only
(Message only)
16
1.27%
11
1.05%
n/a
n/a
Other referral
7
0.56%
10
0.95%
n/a
n/a
1260
100.00%
1052
100.00%
2695
100.00%
2
0.16%
2
0.19%
95
3.5%
Final Dispositions/Outcome (Adastra)
Total
Walk In Pts.
high quality support to commissioners to improve health and wellbeing
Volume
Central/ West London & H&F –
LCW
57
3.1 GP Out of Hours (OOH) Service (2)
National Quality Requirements
Target
Ealing CCG
Hounslow CCG
Brent CCG
Central/ West
London & H&F CCG
9b
% calls triaged within 20 minutes (urgent)
100%
95.77%
98.79%
98.85%
9c
% calls triaged within 60 minutes (routine)
100%
94.30%
94.25%
98.58%
10b
% walk-ins triage complete within 20 minutes
100%
100.00%
100.00%
100.00%
10c
% walk-ins triage complete within 60 minutes
100%
100.00%
100.00%
98.89%
11
GP cons available at all times & places
100%
100.00%
100.00%
100.00%
12a
% emergencies consulted within 1 hour
100%
100.00%
100.00%
100.00%
12b
% urgents consulted within 2 hours
100%
100.00%
97.62%
100.00%
12c
% routines consulted within 6 hours
100%
100.00%
98.50%
99.20%
12d
% emergencies visited within 1 hour
100%
100.00%
100.00%
100.00%
12e
% urgents visited within 2 hours
100%
91.86%
98.51%
98.28%
12f
% routines visited within 6 hours
100%
98.16%
95.65%
99.66%
13
Patient communication - special needs met
100%
100.00%
100.00%
100.00%
high quality support to commissioners to improve health and wellbeing
58
3.2 NHS 111 Pilot Services
Key messages
▪
▪
▪
Performance improved across the board in August; Care UK’s services in ONWL and Hillingdon met call answering/abandonment targets every week in the
month, whilst the LCW INWL service met them in most weeks.
There were some specific issues which impacted on the INWL performance in August. In the w/e 3rd August, the service was affected by two failures, one of the
telephony system and one of the Adastra system used to run the NHS Pathways software. In the final week of the month, there was high staff sickness at the
weekend which reduced the overall average for the week on call answering.
Clinical performance also improved in all services, though call backs generally remained above the target level. However, towards the end of the month there
were significant improvements; Care UK are now using clinicians to answer calls much less frequently, which has increased their availability for transfers and call
backs. LCW are now reporting their call data in a different way as a result of implementing a new telephony system, and this is showing much lower rates of call
back.
03- August
10- August
24- August
17- August
Call standards
ONWL*
Hillingdon
INWL**
Eng.
ONWL
Hillingdon
INWL
Eng.
ONWL
Hillingdon
INWL
Eng.
ONWL
Hillingdon
INWL
Eng.
% Calls answered in 60
secs
95.5%
95.3%
94.6%
88.4%
94.9%
95.1%
97.3%
96.1%
98.4%
98.3%
96.6%
97.3%
99.2%
99.1%
96.9%
97.1%
% Calls abandoned in
30 secs
1.0%
0.8%
1.1%
0.8%
0.7%
1.0%
1.0%
0.8%
0.5%
0.5%
0.5%
0.5%
0.1%
0.0%
0.5%
0.5%
% Calls triaged
79.4%
67.3%
100.0%
85.5%
78.6%
66.4%
100.0%
85.8%
79.8%
68.0%
41.3%
84.9%
76.0%
69.0%
43.5%
84.6%
% Calls where a call
back was offered*
7.7%
6.3%
6.8%
9.0%
7.2%
4.9%
5.1%
8.7%
7.5%
6.0%
2.1%
8.1%
4.6%
3.8%
1.6%
7.4%
% Call backs within 10
minutes***
31.9%
36.6%
57.1%
50.8%
38.2%
42.0%
68.4%
49.2%
46.7%
49.0%
57.7%
53.1%
43.0%
32.4%
70.2%
53.5%
Dispositions
ONWL
Hillingdon
INWL
Eng.
ONWL
Hillingdon
INWL
Eng.
ONWL
Hillingdon
INWL
Eng.
ONWL
Hillingdon
INWL
Eng.
Led to ambulance
dispatches
10.5%
11.0%
12.9%
11.0%
10.3%
9.9%
11.9%
11.0%
9.7%
10.0%
14.8%
11.3%
9.5%
11.7%
12.9%
10.7%
Recommended to attend
A&E
9.9%
11.0%
8.8%
8.6%
8.5%
9.6%
9.7%
8.4%
9.5%
8.2%
6.8%
8.3%
8.7%
8.1%
6.5%
7.8%
Recommended to attend
primary/community care
62.3%
62.5%
57.4%
60.0%
64.0%
61.1%
54.7%
60.7%
63.7%
64.6%
54.0%
61.0%
65.0%
63.3%
58.5%
62.3%
Recommended to attend
other services
2.8%
2.1%
4.8%
3.9%
1.3%
2.7%
3.8%
3.5%
1.5%
2.1%
4.2%
3.5%
1.7%
2.4%
3.4%
3.8%
Did not recommend to
attend other service
14.6%
13.5%
16.0%
16.6%
15.9%
16.8%
19.9%
16.4%
15.6%
15.0%
20.1%
16.0%
15.1%
14.4%
18.8%
15.4%
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3.2 NHS 111 Pilot Services (2)
31- August
Call standards
ONWL*
Hillingdon
INWL**
Eng.
% Calls answered in 60
secs
99.2%
99.3%
92.5%
95.8%
% Calls abandoned in
30 secs
0.2%
0.1%
1.3%
0.7%
% Calls triaged
79.1%
70.1%
44.9%
84.9%
% Calls where a call
back was offered*
4.1%
3.3%
1.8%
7.6%
% Call backs within 10
minutes***
51.8%
52.1%
55.6%
51.5%
Dispositions
ONWL
Hillingdon
INWL
Eng.
Led to ambulance
dispatches
11.7%
11.4%
14.8%
10.9%
Recommended to attend
A&E
9.4%
8.9%
6.9%
7.7%
Recommended to attend
primary/community care
61.4%
64.0%
56.1%
62.4%
Recommended to attend
other services
2.0%
1.8%
5.4%
4.0%
Did not recommend to
attend other service
15.5%
14.0%
16.8%
15.0%
*ONWL = Brent, Ealing, Harrow, Hounslow
**INWL = Central London, West London, Hammersmith & Fulham
*** It is expected that call backs are an Exception
Source: Unify 2
INWL is an outlier for calls triaged due to a telephony issue which prevents accurate reporting of the triage rate. LCW have now migrated to a new
telephony system, and it is expected that once this is fully up and running the accuracy of this reporting should improve.
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3.2 NHS 111 Pilot Services (3)
Overview & Key messages
The below table shows monthly data and achievement against the contracted standards. Three months’ data is displayed in order to track trends.
▪ Call volumes increased in August compared with July, and were up by around 900 calls in ONWL and 500 calls in Hillingdon. It should be noted that the INWL
figures are significantly higher in August than July as a result of changes to how LCW report all of their call data. It has been confirmed that the higher figure
is correct and is now being reported through Sitreps and Unify submissions.
▪ Performance on call answering improved in both Care UK services in August to almost 98% of calls answered within 60 seconds, and remained stable in INWL.
▪ Clinical performance also improved in August, with a reduction in call backs offered across all services. Call backs within 10 minutes also improved in all
services; both providers are continuing to increase clinician staffing levels in preparation for winter.
June 2014
ONWL
August 2014
July 2014
Hillingdon
INWL
ONWL
Hillingdon
ONWL
INWL
Hillingdon
INWL
Call standards
No. calls
%
No. calls
%
No. calls
%
No. calls
%
No. calls
%
No. calls
%
No. calls
%
No. calls
%
No. calls
%
Number of calls
offered
6853
N/A
7885
N/A
6821
N/A
6652
N/A
7843
N/A
6975
N/A
7702
N/A
8306
N/A
16386
N/A
Number of calls
answered
6766
N/A
7804
N/A
6770
N/A
6562
N/A
7756
N/A
6925
N/A
7673
N/A
8275
N/A
15776
N/A
Calls answered in
60 secs
6342
93.7%
7348
94.2%
6378
94.2%
6046
92.1%
7189
92.7%
6648
96.0%
7504
97.8%
8094
97.8%
14576
95.8%
Calls abandoned
in 30 secs
87
1.3%
81
1.0%
50
0.7%
90
1.4%
89
1.1%
50
0.7%
29
0.4%
31
0.4%
121
0.7%
5369
79.4%
5788
74.2%
6770
100%
5213
79.4%
5679
73.2%
6925
100.0%
5995
78.1%
5981
72.3%
7283
46.2%
Calls where a call
back was offered*
468
8.7%
431
7.4%
575
8.5%
567
10.9%
509
9.0%
568
8.2%
445
7.4%
419
7.0%
324
4.4%
Call backs within
10 minutes**
233
49.8%
226
52.4%
314
54.6%
247
43.6%
210
41.3%
316
55.6%
201
45.2%
200
47.7%
223
68.8%
Calls triaged
* Figure expressed as percentage of calls answered
** Figure expressed as percentage of calls offered a call back
Source: Daily sitreps/Unify 2
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3.2 NHS 111 Pilot Services (4)
Key messages
The below table shows monthly data on the volume and proportion of calls which were routed to different disposition types. Three months’ data is displayed in
order to track trends.
▪ Ambulance dispatches increased slightly in ONWL and Hillingdon in August, although there are no particular trends of note at present. There was a slight
decrease in ambulance dispatches in INWL, although the service remains an outlier for London.
▪ A&E referrals continue to show no specific patterns across the three month period, although they did reduce in all services in August. Primary care referrals rose
in ONWL and remained stable in Hillingdon and INWL; LCW are currently looking at primary care referrals as part of their on-going work on ambulance dispatch
rates. They are expecting to see a decrease in ambulance dispatches and a rise in primary care referrals as new call handlers becoming more experienced and
confident in the use of NHS Pathways.
▪ Recommendations to attend other services decreased in ONWL but rose in Hillingdon and INWL, whilst in the two Care UK services there was a slight drop in
calls closed with no onward referral. In INWL this disposition type increased to over 18% of calls.
June 2014
ONWL
August 2014
July 2014
Hillingdon
INWL
ONWL
Hillingdon
ONWL
INWL
Hillingdon
INWL
No. calls
%
No. calls
%
No. calls
%
No. calls
%
No. calls
%
No. calls
%
No. calls
%
No. calls
%
No. calls
%
Led to ambulance
dispatches
566
10.0%
561
9.9%
990
14.2%
579
9.7%
571
10.1%
1005
14.2%
623
10.3%
610
10.7%
1012
13.9%
Recommended to
attend A&E
533
9.5%
571
10.0%
534
7.7%
568
10.4%
520
9.2%
584
8.2%
548
9.1%
501
8.8%
550
7.5%
Recommended to
attend primary/
community care
3532
62.6%
3553
62.4%
4188
60.3%
3290
60.7%
3575
63.7%
4018
56.9%
3849
63.8%
3621
63.6%
4123
56.5%
Recommended to
attend other service
163
2.9%
161
2.8%
274
3.9%
124
2.2%
106
1.8%
319
4.5%
109
1.8%
129
2.3%
270
3.7%
Did not recommend
to attend other
service
848
15.0%
847
14.9%
964
13.9%
859
15.8%
833
14.8%
1134
16.0%
905
15.0%
835
14.7%
1337
18.3%
Dispositions
Source: Unify 2
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3.2 NHS 111 Pilot Services (5)
The table below shows the disposition split across all London contracts for the most recent month available. It should be noted that this is July 2014 rather than
August due to the time lag between the end of the month and publication of the MDS by NHS England.
Area
July 2014
ONWL
Hillingdon
INWL
Croydon
Sutton &
Merton
Wandsworth
Kingston &
Richmond
North Central
South East
London
East London
& City
Outer North
East London
No.
calls
%
No.
calls
%
No.
calls
%
No.
calls
%
No.
calls
%
No.
calls
%
No.
calls
%
No.
calls
%
No.
calls
%
No.
calls
%
No.
calls
%
Led to ambulance
dispatches
579
10.6%
571
10.1%
1005
14.2%
391
10.5%
251
9.0%
413
8.7%
242
9.0%
2480
15.9%
1755
7.9%
652
10.1%
1686
11.0%
Recommended to
attend A&E
568
10.4%
520
9.2%
584
8.2%
334
9.1%
258
9.3%
487
10.2%
224
8.3%
1392
8.9%
1878
8.4%
693
10.7%
1318
8.6%
Recommended to
attend primary/
community care
3290
60.7%
3575
63.7%
4018
56.9%
2274
62.5%
1748
63.1%
3102
65.4%
1681
62.7%
9009
58.0%
11787
53.1%
3947
61.2%
8864
58.0%
Recommended to
attend other
service
124
2.2%
106
1.8%
319
4.5%
110
3.0%
85
3.0%
114
2.4%
52
1.9%
614
3.9%
1154
5.2%
257
3.9%
1197
7.8%
Did not
recommend to
attend other
service
859
15.8%
833
14.8%
1134
7.4%
526
14.4%
424
15.3%
626
13.2%
479
17.8%
2021
13.02%
5618
25.3%
891
13.8%
2210
14.4%
Dispositions
Source: NHS England Minimum Data Set
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3.2 NHS 111 Governance
Site and Provider
111 ONWL Service
111 Monthly Clinical Governance Report
August 2014
NWL CSU
Month
Prepared by
Potential Incidents and Serious Incidents
Total potential Serious Incidents this calendar year
2
Closed and actual
0
Closed and not SI
0
Still Open
Potential Serious Incidents this month
0
Date occurred
StEIS Log number and
Current Status
SI upheld
Pathways issues log number
21/06/2014
27/04/2014
Call Volume
7702
Type of event
(StEIS no.)
Complaint
Complaint (Case
no 33376)
Complaint
Complaint
PI9436
No of call reviews
Provider call audits:
346HA calls audited
73CA calls audited
2
RCA received
Under investigation
Under investigation
No of end to end reviews
3
Performance and Reviews
Complaints
4
Health professional forms
0
Details of Incidents, Near Misses & Complaints
Detailed description including themes identified
Patient suffered a chest injury and called the NHS 111 service. The Health Advisor that assessed his
symptoms told him an ambulance was not necessary.
The pain in his chest worsened so he called the service again and this time an ambulance was sent.
Patient is unhappy that this did not happen during the first call as he was already breathless.
Patient is unhappy about the poor quality of service he received.
The Health Advisor they spoke with was impatient, rude, unprofessional and not passionate. The
patient would like the Health Advisor to be re-trained and disciplined
Patient failed to receive a call-back from the OOH service
Investigation
Complete
Compliments
0
Learning and Improvements
made
Investigated and call was not N/A – Care UK did not take call
taken by Care UK
On-going
Investigated and call was not N/A – Care UK did not take call
taken by Care UK
Patient was unhappy that there was no record of a prior call that she had made to the service earlier in Investigated and call was not N/A – Care UK did not take call
the evening of Saturday 23rd August.
taken by Care UK
Current Governance Activity and State of Play
Description of current governance activity quality assurance mechanisms, current and future planning
Latest CG meeting and call reviews took place on 12th September
Performance notice remains open due to failure to achieve NQR8; significant performance improvements seen in recent weeks
CG group considering proposals from Care UK relating to management of clinical queue
th September
Next commissioner-led
performance
review meeting
took place
on 16and
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3.3 London Ambulance Service (LAS)
Key messages
The LAS failed to achieve both Red 1 (life threatening) and Red 2 targets during August. The LAS is under immense pressure across London and major concerns
about LAS performance response times have been raised, and LAS are currently not meeting their planned recovery trajectory. As a result there are a number of
actions being taken.
These include, daily monitoring and reporting, weekly tri-partite meetings led by Commissioners and involving LAS, TDA and NHSE, rota improvements, private
ambulances and taxi’s for low acuity patients and a worldwide recruitment push and creation of band 6 paramedic posts. The single largest short term action is
increasing the use of overtime, however preliminary reports suggest that the uptake rates are considerably lower than required.
Description
Reporting Frequency
Reporting Period
Threshold
In Month
YTD
Cat A Red 1 responses within 8 mins
Monthly
M5
75%
72.9%
74.7%
Cat A Red 2 responses within 8 mins
Monthly
M5
75%
69.1%
69.9%
Cat A 19 transportation within 19 mins
Monthly
M5
95%
95.8%
96.1%
CCG Cat A 8 mins Performance
Threshold
Reporting Period
In Month
Notes
Hounslow
75% within 8 minutes 45
seconds
M5
66.2%
This table shows the percentage of responses arriving on scene within 8 minutes and 45
seconds. The colour is shown Red where performance is below the agreed monthly threshold.
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Variance
Notes
Quality Premium payment based on achievement of Red
1 target which has been achieved.
65
Appendices
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WMUH - SaHF Systems Monitoring Dashboard for w/e 3rd Oct.
Key:
Care setting
LAS
UCC
A&E
Ward & ICU
# Indicator
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
LAS conveyance to A&E
% LAS arrival to handover < 30 mins
% LAS arrival to handover < 60 mins
LAS blue lights to A&E
LAS conveyance to UCC
LAS conveyance to UCC triaged to A&E
LAS conveyance to UCC refused
UCC SUIs
UCC incidents
UCC attendances
UCC 4 hour performance
% of UCC patient transferred to A&E on triage
% of patients using single point of access (where offered)
% of UCC patient transferred to A&E within 60 minutes
A&E SUIs
A&E Incidents
All A&E Type attendance
Type 1 A&E attendance
All type A&E - 4 hour performance
Type 1 - 4 hour performance
Treat & transfer
Transfer to ITU
12 hour trolley wait
Friends & Family test score
Unfilled A&E rotas
Emergency admissions
% of beds occupied by medically fit for discharge
DTOC (% of available bed days lost)
Bed balance
Bed occupancy
Level 2/3 occupancy
Non surgical LOS
18 week RTT - admitted
Critical Care transfers (clinical)
Critical Care transfers (capacity)
WMUH
Actual
416
91.6%
100.0%
29
21
2
0
0
1494
99.5%
13.0%
Description:
Performance or activity within average range
Performance or activity at limit of average range
Performance or activity outside average range
Data currently being collected
Not collected or not applicable
Coding for each indicator are based on the deviation from the mean of
available data for the individual sites from week ending 27 June to
week ending 5 Sept.
3.0%
0
2613
1119
95.3%
89.8%
11
3
39
644
1.5%
2.5%
-13
91.3%
5.80
94.5%
0
0
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ICHT - SaHF Systems Monitoring Dashboard for w/e 3rd Oct.
Key:
ICHT
Care setting
LAS
UCC
A&E
Ward & ICU
# Indicator
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
LAS conveyance to A&E
% LAS arrival to handover < 30 mins
% LAS arrival to handover < 60 mins
LAS blue lights to A&E
LAS conveyance to UCC
LAS conveyance to UCC triaged to A&E
LAS conveyance to UCC refused
UCC SUIs
UCC incidents
UCC attendances
UCC 4 hour performance
% of UCC patient transferred to A&E on triage
% of patients using single point of access (where offered)
% of UCC patient transferred to A&E within 60 minutes
A&E SUIs
A&E Incidents
All A&E Type attendance
Type 1 A&E attendance
All type A&E - 4 hour performance
Type 1 - 4 hour performance
Treat & transfer
Transfer to ITU
12 hour trolley wait
Friends & Family test score
Unfilled A&E rotas
Emergency admissions
% of beds occupied by medically fit for discharge
DTOC (% of available bed days lost)
Bed balance
Bed occupancy
Level 2/3 occupancy
Non surgical LOS
18 week RTT - admitted
Critical Care transfers (clinical)
Critical Care transfers (capacity)
SMH
Actual
531
91.3%
99.8%
68
8
0
HH
Actual
0
0
1078
97.2%
16.9%
0
1
603
100.0%
2.6%
TBC
100.0%
0
1
879
100.0%
13.4%
364
-11
98.1%
97.0%
0
N/A
N/A
12
92.8%
94.0%
0
95.0%
95.0%
81.7%
0
0
0
0
0
0
16.7%
0
0
2457
1379
90.4%
85.1%
0
1
0
384
8
0
CXH
Actual
302
97.7%
100.0%
6
6
0
Description:
Performance or activity within average range
Performance or activity at limit of average range
Performance or activity outside average range
Data currently being collected
Not collected or not applicable
Coding for each indicator are based on the deviation from the mean
of available data for the individual sites from week ending 27 June to
week ending 5 Sept.
100.0%
0
0
1567
688
93.9%
86.0%
0
1
0
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