Trust Quality and Performance Report
29 November 2013
(October Performance Pack)
Contents
Slide numbers
Executive Summary
2-4
Clinical Quality Priorities inc Ward Dashboard
5 - 18
Local Priorities
19 - 26
CQUIN
27 - 30
Monitor Compliance
Contract Priorities
31
32 - 34
1
Executive Summary
This commentary provides an overview of key issues during the month and highlights where performance
fell short of the target values as well as areas of improvement and noticeable good performance.
1.
A&E Performance for October was 97.08%, exceeding the 95% target for the fifth consecutive
month and placing the Trust in the top quartile nationally and remains the best performance in the
Region.
2.
There were two cases of C.Diff in October against the threshold of two. This is covered on page 12
of this report.
3.
Performance on outpatient and inpatient discharge summaries remains below target. A number of
new steps have been introduced through the month. Further detail is on page 3.
4.
Performance on MRSA screening of emergency admissions was 95% against the 100% target, and
92% for elective admissions. This is covered on page 12 of this report.
5.
All Stroke targets were achieved for the month.
6.
The Trust had 2 single sex breaches during October. All 2 occurred within a short timescale. See
page 3.
2
Executive Summary
Performance Indicator
Discharge Summaries - Outpatients
Threshold
95% sent to GP’s within 3 days
October
81.63%
Lead Exec
Dermot O’Riordan
Clinical staff and the project team have been exploring options. In agreement with the CCG a number of non-critical areas have been removed as part of
the performance framework while data collection has been extended beyond just EPRO. TEG have agreed a number of initiatives to address the key issues,
including performance discussion at consultant appraisal, targeting the underperforming specialities in directorates, where the Ops Groups have agreed a
new process. Looking at automating the process further by sending letters sooner
Performance Indicator
Discharge Summaries - Inpatients
Threshold
95% sent to GP’s within 1 day
October
77.57%
Lead Exec
Dermot O’Riordan
In order to support Discharge Summaries and Letters the project team have been working with clinicians to explore a range of options in order to resolve
the current performance. In agreement with the CCG a number of non-critical areas have been removed as part of the performance framework while data
collection has been extended beyond just EPRO. In addition TEG have agreed a number of initiatives to address the key issues, including performance
discussion at consultant appraisal, targeting the underperforming specialities in directorates including a new process agreed by the Ops Group. In addition
looking at automating the process further by sending letters sooner .
Performance Indicator
Mixed Sex Accommodation Breaches
Threshold
0
October
3
Lead Exec
Jon Green
All 3 breaches were associated with ITU step-down and occurred over a 48 hour period. High levels of level 3 occupancy and limited ward beds meant
these patients could be neither safely partioned or stepped-down to wards.
3
Executive Summary
Performance Indicator
Threshold
Sickness absence rate
<3.5%
Performance Indicator
Threshold
All staff to have an appraisal
Both general and consultant staff each have
a target of 90% to have had an appraisal
within the previous 12 months. Appraisal is
a rolling programme
October
Lead Exec
3.89%
Jan Bloomfield
October
Lead Exec
85.47%
Jan Bloomfield
Appraisals are monitored through the Trust’s Electronic Staff Record system (ESR), when a completed Personal Development Plan (PDP) is submitted to the
HR Department (this can be done electronically or by using a paper based system). Reporting then takes place on a monthly basis, through the directorate
performance management process. Managers can also request individual reports on their own staff from HR at any time.
The Trust Board receive appraisal take up information monthly. The target is 90% and as at end October the Trust compliance figure is at 85.47%.
Performance Indicator
MRSA – Emergency Screening
Threshold
All emergency patients admissions are to be
screened for MRSA within 24 hours of
admission
October
Lead Exec
95.09%
Nichole Day
Performance on MRSA screening of emergency admissions was 95.09% against the 100% target. This is covered on page 12 of this report.
4
Clinical Quality Priorities: Ward Dashboard
A3 Printout of Ward Analysis
Quality Report From Trust
Dashboard
5-9
Clinical Quality Priorities: Summary
•
The Friends and Family score was commenced at four points of maternity care in September.
Scores for all of these are good and lie between 82 and 90.
•
There were two same sex accommodation breaches this month involving a total of five patients.
Both were in critical care where patients who had recovered enough for transfer to the ward were
delayed in moving to general wards due to capacity issues within the Trust. Discussions have been
held with the Bed Managers and Critical Care to identify ways to prioritise patient movement from
Critical care onto the main wards.
•
Falls with harm are lower this month and there were no falls with serious harm.
10
Quality Priority: Ward Performance Issues
•
No ward had more than 3 red scores in patient satisfaction.
•
The newly opened F7/8 scored poorly in some of the quality audits in September. Although the
ward is still not up to a full complement of permanent staff, the quality indicators have improved
with an increase in MEWS compliance from 50% in September to100% this month.
•
Quality indicators for ward F9 continue to give some concern: there was a grade 3 pressure ulcer
during October; concerns regarding infection prevention issues and compliance with the hydration
audits was only 30%. However other indicators are improving. An increase in staffing has been
agreed for the ward and four new nursing assistants have been appointed, along with two new
Portuguese nurses. Interviews for 2 more nursing assistants are planned. When these are in post,
this should have a considerable impact.
11
Quality Priority: Infection Control
MRSA Bacteraemia
There were no hospital associated MRSA bacteraemia during October.
C. difficile
There were two hospital acquired C. difficile infections this month both of which occurred on Ward G4. Both patients were
female patients identified 3 days apart. These formed part of a period of increased incidence and was investigated
accordingly. Ribotyping demonstrated they were different types. The first case was not thought to be clinically significant and
is being appealed. The second case was clinically significant but a mild infection; the patient had had antibiotics
(appropriately), but the case was not deemed suitable for appeal. The RCA documentation has been slightly modified to
streamline the process and clarify grounds for appeal. The C. difficile action plan has been updated to incorporate
recommendations from the external review and has been discussed at TEG and CSEC and will be reported to the Board
separately.
Hand Hygiene
Hand hygiene compliance was 100%. There was one failure in compliance on ward G5, in respect of a student nurse. This
was addressed with the nurse at the time of the audit.
MRSA screening
Elective: 92%
Non Elective: 95%
Compliance in elective screening has improved slightly and non-elective screening has increased by 3% this month but
further improvements are needed if we are to achieve 100% compliance as required by the Commissioners. This will impact
on the closure of the Remedial Action Plan.
12
Quality Priority: Falls
Falls performance
Despite changing the definition of falls last month to include patients who faint or collapse due to medical reasons, the total number
of falls in October was 50, none of which were faints or collapse. Twelve of these falls resulted in harm but none resulted in serious
harm. The rate per 1,000 occupied bed days is 5 (September 5.31) giving an overall downward trend.
Themes
We continue to monitor the number of falls in toilets: this month 8% of our falls occurred in the toilet, down from 11.7 in September.
Detailed intelligence continues to be collected to reveal what the patient was actually doing at the time of the fall.
A detailed survey of all inpatient toilets was completed this week, to highlight where extra hand rail support is required. The results
will be analysed and reported to the Board next month.
Several patients slipped from their chair this month (6), four of these patients had an alternating air cushion in place which makes the
chair significantly higher, this may have contributed to their fall and for that reason, all patients using chairs fitted with an air cushion
will now be risk assessed by occupational therapy, physiotherapy or a registered nurse to ensure safety.
.
.
13
Quality Priority: Pressure Ulcers
The performance target is to have no avoidable Grade 2, 3 or 4 pressure ulcers 2013-14.
Grade 2 pressure ulcers
There were four HAPU grade 2 this month, all of which the Trust believes to be unavoidable, due to compliance and or morbidity.
Grade 3 and 4 pressure ulcers
There was one HAPU grade 3, which may have been avoidable as risk assessments and other documentation had not been fully and
accurately completed.
Our 29 new mattresses are in place and relevant training is underway on all wards.
14
Safety thermometer results
The National ‘harm free’ care composite measure is defined as the proportion of patients without a
pressure ulcer (ANY origin, category II-IV), harm from a fall in the last 72 hours, a urinary tract infection (in
patients with a urethral urinary catheter) or new VTE treatment.
The data can be manipulated to just look at “new harm” (harm that occurred within our care) and
with this parameter, our Trust score is 99.42%. National October performance is 97.3%.
Sep 12
Oct 12
Nov 12
Dec 12
Jan 13
Feb 13
Mar 13
Apr 13
May 13
Jun 13
Jul 13
Aug 13
Sep 13
Oct 13
Harm Free
92.15
92.71
93.77
95.66
93.02
93.36
93.68
91.47
93.20
92.60
93.22
92.68
91.03
92.46
Pressure Ulcers – All
3.80
4.02
3.38
1.79
5.17
3.55
3.51
4.50
4.28
5.36
3.52
2.98
5.16
4.06
Pressure Ulcers - New 0.25
1.51
0.26
1.02
0.52
0.71
0.94
0.95
1.01
0.00
1.08
0.00
1.09
0.00
Falls with Harm
0.76
0.75
0.26
0.51
0.78
0.71
0.23
1.66
0.00
0.26
0.81
0.27
0.00
0.00
Catheters & UTIs
2.78
2.01
2.08
1.79
1.03
1.66
2.58
0.95
1.76
1.53
2.17
2.98
3.60
3.48
Catheters & New UTIs
0.25
0.25
0.00
0.26
0.26
0.47
0.23
0.24
0.00
0.51
0.54
1.08
0.82
0.00
New VTEs
1.01
0.50
0.78
0.26
0.26
0.71
0.47
1.42
0.76
0.26
0.54
1.36
0.54
0.58
All Harms
7.85
7.29
6.23
4.34
6.98
6.64
6.32
8.53
6.80
7.40
6.78
7.32
8.97
7.54
New Harms
2.28
3.02
1.04
2.04
1.81
2.61
1.87
4.27
1.76
1.02
2.98
2.71
2.45
0.58
Sample
395
398
385
392
387
422
427
422
397
392
369
369
368
345
Surveys
17
17
17
17
17
18
18
18
18
18
17
17
17
17
Current performance for harm-free care is 92.46%. National October performance is 93.4%.
15
Quality Priority: Patient Experience – Achievement of 85% satisfaction
‘Achieve at least 85% satisfaction in internal patient satisfaction surveys’
is a Quality Priority for the Trust.
The overall score for the inpatient survey was 91%, in line with previous months.
Overall satisfaction scores for the OPD, A&E, short stay and maternity services were maintained at a
high level.
There was a significant increase in the number of surveys completed by both patients and parents in
paediatrics this month and good scores were achieved for all questions.
The number of responses to the surveys have increased since the appointment (part time) of a Patient
Feedback Coordinator and her continued input to all areas. Unfortunately the focus on maintaining the
numbers of responses has reduced her ability to carry out more in-depth pieces of work and introducing
new sources of feedback. However, the post holder played a vital role in the call bell project. An update
on the implementation of the call bell action plan will be provided next month. It is hoped that the data
on the call bell response times and the number of calls for the six wards with the wireless call bell
system will be provided within this report from next month.
16
Quality Priority: Patient Experience – recommend the service
‘Patients would recommend the service to their family and friends’
is a Quality Priority for the Trust.
The Trust achieved a net promoter score of 87 for inpatients during October, maintaining the high scores of previous
months.
The score for A&E was 59, this score has been fairly stable over recent months. Analysis of the very few comments on the
reasons for not giving a promoter response has not led to any conclusions as to themes/issues other than waiting times.
Maternity services introduced the Friends and Family test at 4 points of the care pathway last month and the scores this
month are good. These are provided in the table below.
Antenatal
Birth
Post natal ward
Post natal care
87
95
82
90
17
CQC Action Plan
Update
The education and training activities identified in the action plan continue to progress well, except on
F7/8 where there have been significant challenges in ensuring all new staff achieve the competencies
and training required for all elements of their role .
All wards now have an MCA and DOLS resource folder on the ward and folders have been prepared
for all departments. This ensures that all staff have easy access to guidance and documentation in
hard copy.
Additional questions were added to the internal CQC assurance audits and incorporated into the peer
review audits last month. These demonstrate, whilst consent is sought for treatments and procedures,
documentation on capacity and completion of DNACPR documentation to indicate involvement of
patients, families and capacity assessment is not consistent. Full implementation of the action plan will
address this issue.
The process for CQC assurance audits will be changed from Quarter 4. The audits will focus on half of
the outcomes in more depth rather than carrying out assessments against all of the outcomes.
However, Outcomes 4 and 11 will be included in all the audits.
18
Local Priorities: Exception Reporting
KPI-3 SIRIs open more than 45 days after submission on STEIS
This measures all SIRIs that remain open on STEIS beyond the final report submission deadline. This includes three sub-sets:
 SIRI final report overdue submission (n = 0)
 SIRI final reports for which WSFT response to CCG queries is pending (n = 7)
 SIRI final reports submitted for which feedback / closure by the CCG is pending (n = 4)
RAG rating*
As @ 15/11/13
RED (n >10)
n = 10 (Amber)
Amber (n = 6 - 10)
Green (0 - 5)
RAG rating based on local benchmark data for 22 Trusts provided by CCG
The number of open reports has fallen considerably from 24 in September to18 in October to 10 in November. One of the 10 SIRIs has had
a “stop the clock” pending the findings of an external review of CTG tracing.
Incidents (Amber / Green) with investigation overdue (over 12 days)
The next deadline for NRLS submission is the 30th November. The Operational Steering Group have agreed a pathway to complete sign off
of the Apr-September incidents within the timeframe which has resulted in a reduction in the total overdue for investigation and final
approval. Ops group also identified a need to consider a robust method for ensuring timeliness of future investigation and sign off.
RCA actions overdue
Seven of the actions are from Maternity RCAs and have only
just become overdue in November. These will be actively
followed up to ensure completion. Two relate to others policies
currently being drafted.
Late by Directorate
Red (RAG)
Oct
Nov
change
Clinical Support
>15
22
6

Estates and Facilities
>10
17
9

Medical
>70
149
152

Surgical
>40
79
65

Women & Children’s Health
>15
31
19

Other
No target
8
10
TOTAL
>150
306
261

19
Local Priorities - Governance Dashboard
Indicator
Performance target
Timely
completion of
incident
investigations
and actions
Red non-SIRI investigation not complete more
than 45 days after incident reported
Timely reporting
of SIRIs
R
A
G
Oct13
>3
1-3
0
0
RCA Actions beyond deadline for completion
>=5
1–4
0
9
Incidents (Amber / Green) with investigation
overdue (over 12 days)
>150
<50
261
50 - 150
Commentary
Seven of the actions are from Maternity
RCAs and have only just become overdue.
These will be actively followed up to ensure
completion. Two relate to others policies
currently being drafted.
See exception report for details
SIRIs reported > 2 working days from
identification as red
>1
1
0
0
All incidents were submitted to STEIS
within the 2 day timeframe. Two incidents
were reported late on Datix and three were
re-graded as Red following initial review.
SIRI final reports due in month submitted
beyond timeframe
>1
1
0
0
8/ 8 within deadline
Number of SIRI reports open on STEIS more
than 45 days after initial notification
>10
6 - 10
0-5
10
Reduced from 18 in October. One SIRI
included in this figure had a “stop the clock”
pending the findings of an external review
of CTG tracing.
88% = 14/16. The two non compliant cases
relate to pressure ulcers identified on
critically ill patients who subsequently died
for whom a conversation with the family
about the pressure ulcer was not
considered appropriate at the time.
Duty of Candour
Compliance with Duty of Candour
requirements
<75%
75 – 94%
>=95%
88%
Risk
assessment
Active risk assessments in date
<75%
75 – 94%
>=95%
99%
Outstanding actions in date for Red / Amber
entries on Datix risk register
<75%
75 – 94%
>=95%
99%
20
Local Priorities - Governance Dashboard (cont.)
Indicator
Performance target
Risk
assessment
Active risk assessments in date
<75%
75 – 94%
>=95%
99%
Outstanding actions in date for Red / Amber entries
on Datix risk register
<75%
75 – 94%
>=95%
99%
Clinical
Audit
Trust participation in relevant ongoing National audits
(reported by Quarter)
<75%
75 – 89%
>=90%
100%
Safer
surgery
Completion of WHO checks during surgery.
This is a composite indicator of the checks at ward,
sign-in, time-out and sign-out.
<90%
90% - 98%
>98%
95%
NICE
TA (Technology appraisal) business case beyond agreed
deadline timeframe
>9
4-9
0-3
2
IPG (Interventional procedure guideline) baseline
assessments beyond agreed deadline timeframe
>9
4-9
0-3
5
CG (Clinical guideline) baseline assessments beyond
agreed deadline timeframe
>9
4-9
0-3
6
>=90%
88%
Complaints
Response within 25 days or negotiated timescale with the
complainant
R
A
<75%
75 – 89%
G
Oct13
Number of second letters received
>=5
1-4
0
2
Health Service Referrals accepted by Ombudsman
>=2
1
0
0
Red complaints actions beyond deadline for completion
>=5
1-4
0
0
Number of PALS contacts becoming formal complaints
>=10
6-9
<=5
1
Commentary
Non compliance reported to individuals
(daily) and Clinical Directors (weekly)
These outstanding five interventional
procedures and six Clinical Guidelines are
outstanding baselines assessment and require
targeted follow up.
This represents 4 of the 32 responses that
were sent out in October. We continue to
manage a high number of complaints and must
ensure the responses address all issues, this
can sometimes results in a slight delay with a
few of the responses.
Two second letters were received. One
complainant is adamant that she wants the
PHSO to review her complaint but has been
told by them she must first write back to us in
the first instance. One remains dissatisfied
with her care despite the explanation given.
21
Patient Safety Incidents reported
Number of incidents reported
450
400
350
300
250
200
150
100
50
WSH (harm PSIs)
NRLS Lower quartile (all PSIs)
NRLS benchmark (harm PSIs)
NRLS Median (all PSIs)
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
0
WSH (all PSIs)
NRLS Upper quartile (all PSIs)
The rate of PSIs is a nationally mandated item for inclusion in the Quality Accounts. The NRLS target lines shows how many patient safety
incidents WSH would have to report to fall into the median / upper and lower quartiles for small acute trusts reporting per 100 admissions. The
Oct12 – Mar13 NRLS report was issued but then withdrawn for technical reasons therefore it has not been updated on the graph above..
There were 447 incidents reported in October including 358 patient safety incidents (PSIs). The reporting rate has remained relatively static
over the last six months. The number of harm incidents in October was below the peer group average (updated benchmark not yet available
from NRLS).
22
1.6%
8
1.4%
7
6
1.0%
5
0.8%
2ary axis (number of confirmed PSIs)
1
1.2%
4
7
1
7
0.6%
1
3
6
5
5
5
0.4%
4
3
0.2%
2
1
2
1
3
2
2
1
2
4
3
2
2
1
3
1
2
1
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
0
Oct-11
0.0%
Sep-11
1ary axis (serious harm PSIs as a % of total PSIs)
Patient Safety Incidents (Severe harm or death)
Pending final grade
Confirmed severe harm/death
(1ary axis) Benchmark NRLS Serious harm average (1.2%)
(1ary axis) WSH confirmed serious harm - 12 month rolling average WSH%
The percentage of PSIs resulting in severe harm or death is a nationally mandated item for inclusion in the Quality Accounts. The peer group
average (serious PSIs as a percentage of total PSIs) from the NPSA Oct ’12 – Mar ‘12 report and sits above the Trust’s average (updated
benchmark not yet available from NRLS for Oct ‘12 – Mar ‘ 13). The WSH data is plotted as a line which shows the rolling average over a 12 month
period. The number of confirmed serious PSIs are plotted as a column on the secondary axis.
The unconfirmed incident in October 2012 was identified via a complaint and reported retrospectively in September 2013. In August there were four
‘Red’ patient safety incidents: Pressure ulcer (1), Retained tampon (1), DNACPR (1), and one awaiting confirmation through RCA: Fall (1)
23
Local Priorities: Complaints
Complaint response within agreed
timescale with the complainant: 88% of
responded to in October. This represents
4 of the 32 complaint responses going out
late.
Of the 26 complaints received in October,
the breakdown by Primary Directorate is
as follows: Medical (12), Surgical (11),
Clinical Support (2), Facilities (0), and
Women & Child Health (1). There was a
higher than average number of complaints
about the Orthopaedic Department and
this has been highlighted to the Clinical
Lead.
40
35
Number of complaints
There was a slight reduction in the
number of complaints received in October
2013 compared to other months this year
and compared to October 2012.
30
25
20
15
10
5
0
Apr
33
May
31
Jun
29
Jul
38
Aug
32
Sep
29
Oct
26
Nov
Dec
Jan
Feb
Mar
Complaints 2013/14
Complaints 2012/13
19
22
26
18
34
18
28
22
20
24
25
27
Pain complaints 2013/2014
1
1
0
0
1
1
1
Trust-wide the top 6 most common
problem areas are as follows:
All Aspects of Clinical Treatment
Admissions, Discharge and Transfer Arrangements
Communication / Information to Patients (written and oral)
Attitude of Staff
Aids and Appliances, Equipment, Premises (including access)
Patients Privacy and Dignity
28
13
11
5
3
3
24
Local Priorities: PALS (Patient Advice & Liaison Service)
Medical
Women and Child Health
Total
60
50
Surgical
Facilities
Clinical support
Other / Not categorised
120
103
102
100
92
88
88
90
90
81
0
0
All aspects of clinical treatment
5
Other
7
Jul-13
12
Mar-13
Appointments, delay, cancellation (outpatients)
Jan-13
22
Oct-13
20
May-13
10
Apr-13
40
Feb-13
20
Dec-12
60
Sep-13
Attitude of staff
34
80
Aug-13
Information/Advice request
100
89
30
Oct-12
Trust-wide the most common five reasons for
contacts are shown below
72
40
Nov-12
A breakdown of contacts by Directorate from
April’12 to October ‘13 is given in the chart and
a synopsis of enquiries received for the same
period is given below. Total for each month is
shown as a line on a second axis.
102
77
Jun-13
In October 2013 there were 102 recorded
PALS contacts. This number denotes initial
contacts and not the number of actual
communications between the patient/visitor
which can, in some particular cases, be
multiple.
The numbers across the different areas of concern remain constant and there are no particular themes that the PALS Manager has identified this
month. The number of comments about staff attitude has risen slightly again, which the PALS Manager has personally noticed a problem in the
out-patients area. However, the main area where concerns are raised about care and waiting times is A/E (8) with other issues following such as
care of the elderly (6); orthopaedic surgery (5); ophthalmology (6); emergency assessment, cardiology and general medicine (5).
It is evident that the PALS Manager, in addition to assisting with genuine concerns from patients and relatives, frequently signposts enquirers to
other services. She is also actively involved in dealing with specific in-patients and their families concerns during the total admission period.
25
Local Priorities – Workforce Performance
Performance Indicator
Threshold
Direct
12
Financial Month
Penalty
YTD
Comments
Lead Exec
Workforce
Sickness absence rate
<3.5%
NO
3.89%
Turnover
<10%
NO
7.71%
Reviews
Grievance/Banding reviews
NO
Recruitment Timescales
Average number of weeks to recruit = 7
NO
CRB Disclosures existing staff
To complete 95% of required CRB checks
NO
All Staff to have an appraisal
Both general and consultant staff each have a
target of 90% to have had an apprasial within
the previous 12 months. Appraisal is a rolling
programme
NO
Jan
Bloomfield
Jan
Bloomfield
1 New Case, 1 on-going Tribunal, 1
9 Outstanding Agenda for Change
Jan
Banding Appeal and 1 Grievance
Bloomfield
Jan
5.5
Bloomfield
Jan
98.00%
Bloomfield
85.47%
Jan
Bloomfield
26
CQUIN – November 2013
NOVEMBER 2013 – CQUIN
Report By PMO: This provides an update on CQUIN progress supported by the Trusts Programme Management Office (PMO) working
with Target Owners.
Q2 Report – CCG acceptance/ final feedback due 25 November.
3i – Unify data used for Q2 accepted. Use EPRO new data for Unify Q3 onwards shows 100% met.
Q2 remaining issues:
7 – Psychiatric Liaison. Launch November/ final recruitment on-going (external influence) – % income deferred to Q3 tbc 25/11. Team on
site w/e 15/11.
8 – Pain Pathway – (external influence) more complex than when set up so work on-going into Q3 in conjunction with CCG. % income
deferred tbc 25/11.
14 – GP Assessment area - finalise delivery Q3 onwards.
11 - 7 day - Diagnostic Test higher trajectory set at CCG request – part not met Q2. CCG to advise outcome 25/11. Review of what is
possible electronically for other 7 day evidence for Q4 (versus manual audit evidence for Q2, Q3).
Q3 - Dispute re: 2i – CCG to agree not set % for falls in toilets. Dispute re: 3iii – dementia carers – CCG agree not set target.
2014-5 targets setting – involve relevant staff, ensure data collection available or allowances made, ensure responsibilities allocated –
collaborative working.
If felt appropriate – own Trust ideas were to be submitted 14 November 2013 / however, Trust work with CCG on integrated way forward.
PMO support colour coding:
A.
No PMO support except
Quarterly reports if required
Code
Target
A.
B - C.
B.
B. Minimal support
Friends and Family Test x 3 (National Target). 1i – F&F
Phased expansion to Maternity & Endoscopy. Met
1ii – F&F Increased response rate. (National Target). *Q4
must be higher than Q1 but aware there is ‘room for
improvement’ available to meet. Q1: 20.10%. Q2 21.03%.
Q3 so far: October 20.81%. New Target Owner.
1iii – F&F Improved performance on Staff Test. (National
Target). Review previous response / performance rates –
Trust recommend score: 2012 = 3.87. National average:
3.57. *Will be unknown until published 2014.
C. Significant/on-going
Predicted
Q2
N/A
N/A
though
on
track
N/A
Q3
Nov £ re:
Maternity
N/A
though on
track
Q4
G: 3
N/A
G:
9* tbc
2014
G: 6
+
20.10%
27
CQUIN – November 2013
C.
C.
A.
B.
2i - NHS Safety Thermometer – Improvement – Safety Cross: Pressure Ulcers & Falls
(National Target). Q2 met - Updated Harm Free Action Plan (Q2 feedback: further
information on Work-stream 10 sent 11/11). Falls Lessons Learned accepted. Trajectory
was to be set for FALLS – however, CCG agreed theme/areas for action & be measured
against implement/ evaluation. Area identified as falls in toilets. Q2 feedback dispute – not
agreed to prove % reduction in future. Hand rail work timings advised to CCG
(showing completion within this financial year). CCG advise 25/11.
Dementia x 3 (National target)
3i – Dementia – Find, Assess, Investigate, Refer. Similar to 2012-3 targets (x3). Q2 –
submitted Unify data – target met (in alignment with CCG accessible data source). Q3
(OCT) so far shows 100% - so met.
G
G
G: 3
G: 3
3ii – Dementia Clinical Leadership. Training programme plans & documents provided. All
in progress towards next report due Q4 – training delivered, new plan for 2014-5.
N/A
N/A
G: 3
3iii – Dementia – Supporting Carers – Q2 part met. CCG requested evidence of Carer
forms given out by 11/11 – explanation given. CCG to accept – to be advised 25/11.
Q3: CCG request minimum survey sample size of 15 per month from Nov – disputed
on 11/11 Q2 feedback as target was to report figures not meet target. TBC action from
25/11 feedback. Q1 and Q2 used Norfolk & Suffolk Dementia Alliance (NSDA)/ UEA – pilot
pre-printed question and review of results – 5 Trusts participated (including WSHFT).
Following review & unsatisfactory level of results – decision made at Dementia Strategy
Group & Family Carers Group to change survey method to in-house (so no need for
carer to post). Captures all carers (so will help for 9i). Launched 14 Oct.
As at 11/11
G: 9
G: 6
G: 3
Not
under
PMO
VTE x 2 (national target). 4i – VTE – Risk Assessment – 98% patients to have RA. Q2
met: 99.84% Q1 met: 99.51%. Plus meet RCA target 4ii. Q2 met: July 99.60%. Aug
99.92%, Sept 100%. Q3: OCT 99.72%.
B.
4ii – VTE RCA – Q2 met. Was ‘Locally agreed target of ‘in depth’ 10 per quarter’. CCG
agreed regarding revision as data showed lower number required once reviewed. Q2-4 –
report actual number with evidence – mentioned on Q1 & 2 report. Q2: RCA’s received
for 4 cases and individual action plans noted. CCG require for Q3 an aggregate action plan
with demonstrated progress/completion against each action within the plan.
5i – End of Life Education – Q2 met. Q2 – show 25% of staff trained & shared practice
(e.g. Hospice) evidence. Full report given to CCG, achieved 38% - breakdown of staff
trained advised.
6i – Nursing e-forms – Q2-4 – measure/agree baseline & improvement/ pilot, training.
No report due until Q4. Project remains on schedule and all key milestones at Q2 met.
A.
A.
G: 9
G: 3
CCG to accept
no set target
re: Falls in
toilets
CCG to
accept extra
info
CCG to accept
dispute re:
target or meet
with CCG
Q1 & 2 met
G
G: 3
G: 3
G
G: 3
G: 3
Progress to
meet Q4 met.
No report due
Ensure progress
to meet Q4.
No report due
G: 3
28
CQUIN – November 2013
B.
A.
C.
A.
C.
7i – Psychiatric liaison – Q2 – working with external partners = part met – supplied
updated information 11/11 & ongoing into Q3. Q2 was: Commission service, agree
reporting system re 7 data elements to be collected (to report on Q3). Go live – current
st
staff – aim due on site w/e 15/11. Green Sheet will announce (original aim was 1 Oct).
Recruitment was delayed by NSFT finances agreement with CCG. Consultant for ‘Elderly’
recruitment in progress – CCG email advises locum cover in meantime. SLA
developed between WSH and NSFT to support the arrangements between the trusts – aim
to be signed w/e 15/11 (latest version sent to CCG 11/11).
8i – Pain Pathway – Q2 CCG lead put forward this Trust met requirements as far as
possible however work is on-going due to complexities and is liaising with Target Owner/
other staff involved including CCG. CCG response: Q1 and Q2 funded at 50% opportunity for full payment in Q3 if milestones met. Q2: formal agreement exit plan – in
progress CCG.
CCG Lead left in Nov. New (not on site) CCG Lead.
9i – Carer Involvement – Q2 met. Implementation and agree data collection, spot-check
audit. Full report given on launch of Carer support scheme, plus audit on 2 wards re: carers
identified, reason for admission, support needs. Change of Target Owner.
10i – Breast Feeding – Q1/Q2 targets met. Confirmed with Target Lead plans are in place
for training of staff/ data required/ Co-ordinator employed (secondment), staff for home
visiting. Put forward that this Trust does not collect data of mothers feeding 6-8 weeks,
though new co-ordinator will work with community.
11i – 7 day working – (similar to 2012-3 target but now requires evidence). Q2 part met*.
Ownership – Q2 – PMO managed a), b), e) evidence re: Consultant seen patient within
24 hours/ daily on F8 – manual audit CCG agreement reached for 2.5-3% (180 submitted
as evidence). Met.
Target owner liaised d) Outreach – audit and as 100% achieved, put forward to continue –
CCG set 98% minimum. Met.
Imaging Services Manager - progressed re: c) & f) patient exceptions & new trajectories for
*diagnostic tests – original trajectory rejected by CCG, new trajectory set following
meeting with CCG 12/9. Q2 response to CCG sent 11/11 re: part shortfall % trajectory
not fully met – CCG advise £ 25/11/ Contingency Q4 while upgrade due. COO updated.
Joint target owner – progressing future electronic data collection to use for a), b), e) –
though not yet available for all 4 elements required Q3/ tbc Q4.
Funds for large manual audit agreed at PMO Steering Group 28 October. Medical
Director requested to highlight to doctors to record date and time on paperwork –
now sent. Paper forms to be amended to highlight ‘time’ next print run.
Though PMO/ 2 target owners input is required from clinical/ management where required.
A: 15
external
reliance on
NSFT.
CCG to
advise if part
£
25/11
A –15
£ moved to
Q3 –
G:
Tbc 9
ensure
on track
/ data
due/
rely
NSFT
G: 9
Q1 & Q2 50%
G:
Tbc 9/
ensure
on
track/
data
/
rely
NSFT
G
Tbc:
9
CCG to
advise if part
£ 25/11
G
G: 3
G: 3
G
G: 3
G: 3
A: 12
Diagnostic
test %
CCG to
advise part
£ 25/11
G: 9
data
electronically
not all avail
for
a), b)
and
e)/
G: 9
data
electronically - tbc not
avail
for all of
a), b)
and
e)/
MANUAL AUDIT
= 5 weeks work
in hand
G: 3 - if efforts
made on audits/
Plus re: Q4
upgrade
Outreach
Note:
Overall
G: 3
*A: 12
CCG to advise re
diagnostic test
trajectory during
upgrade
29
CQUIN – November 2013
A.
12i – Stroke SSNAP improvement – Q2 was not fully met – further information from
previous system sent 11/11 together with action plan. Q2 should now be met.
Dedicated Stroke System went live 1 October. Clinical engagement in place and benefits
programme prepared. SSNAP information as to which targets will be reported on is due.
CCG are keen to understand how the system will support national drivers.
CCG in liaison with Target Owner.
B.
13i – PAU Paediatrician – Extended from 2012-3. Q2 met – full report submitted including
required audits. Note Dr Lakshman stepped down as clinical lead after Sept.
C.
14i – a) GP Assessment Area – Q3 prove closed 85% of the time by midnight (Q4
90%) liaise new Owner. b) Reduction in Emergency Admission for acute conditions
that should not usually require hospital admission. MB confirmed target details with
CCG 11/11. Information Team progressing data to be collected. CCG to confirm funds
moved into Q3 & Q4 25/11.
A.
15i – Telecare scheme – Q2 was not fully met. Formal notification to change of original
target sent 11/11 plus confirmation of figures aim per Quarter. Q2 should now be met.
CCG to agree met 25/11. Following demonstration to Trust exec and Clinicians, agreement
has now been made to support Rheumatology. Approved via TEG for VR to continue.
Further work underway with GP’s and Community although delays are potentially
encountered for Q3 as CCG introduce new technology and consider space in GP’s
(Rheumatology will required GP clinic area)
CCG to
accept
update &
plan
=G
As at 11/11
R: 16
G
N/A but
CCG to
confirm
moving £ to
Q3 & 4 on
25/11
CCG to
accept
update
=G
As at 11/11
R: 16
G: 3
G: 3
If all well with
Q2 response
G: 3
G: 3
G tbc:
6
G tbc:
3
A: 12
CCG to provide
technical and
structural
support at GP’s
may impact
WSH
G: 3
30
Monitor Compliance Framework
Monitor Compliance Framework
Performance Indicator
Threshold
Month
QTD
Weighting
Lead Exec
Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted
90%
98.61%
98.61%
1.0
Jon Green
Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted
95%
99.72%
99.72%
1.0
Jon Green
Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway
92%
100.00%
100.00%
1.0
Jon Green
A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge
95%
97.79%
97.79%
1.0
Jon Green
85%
87.00%
87.00%
All cancers: 62-day wait for first treatment (5) from: NHS Cancer Screening Service referral
90%
100.00%
100.00%
All cancers: 31-day wait for second or subsequent treatment, comprising: Surgery
94%
100.00%
100.00%
All cancers: 31-day wait for second or subsequent treatment, comprising: anti-cancer drug treatments
98%
100.00%
100.00%
All cancers: 31-day wait from diagnosis to first treatment
96%
100.00%
100.00%
Cancer: two week wait from referral to date first seen (8), comprising:
all urgent referrals (cancer suspected)
93%
98.90%
98.90%
Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer not initially
suspected)
93%
97.10%
2
2
Access:
All cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer
1.0
Jon Green
Jon Green
1.0
Jon Green
Jon Green
All cancers: 31-day wait for second or subsequent treatment, comprising: radiotherapy - Not applicable to WSFT
0.5
Jon Green
Jon Green
0.5
97.10%
Jon Green
Outcomes:
Clostridium (C.) difficile - meeting the C.difficile objective - MONTH
Clostridium (C.) difficile - meeting the C.difficile objective - QUARTER
Clostridium (C.) difficile - meeting the C.difficile objective - ANNUALLY
Q1 = 4, Q2 = 5,
Q3 = 5, Q4 = 5
19
Nichole Day
2
18
0
Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - QUARTER
0
0
Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - ANNUALLY
0
1
N/A
-
Nichole Day
Nichole Day
0
Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - MONTH
Certification against compliance with requirements regarding access to healthcare for people with a learning disability
1.0
Nichole Day
-
1.0
Nichole Day
Nichole Day
0.5
Nichole Day
31
Contract Priorities Dashboard
Performance Indicator
Threshold
In Month
Performan YTD
ce
Comments
Lead Exec
A&E
A&E - Threshold for admission via A&E
A&E - Timeliness Indicators
i) if the monthly ratio is above the corresponding
2011/12 monthly ratio for two month in a six month
period
ii) if year end is greater than 27%
To satisfy at least one of the following Timeliness
Indicators:
1. Time to initial assessment (95th percentile) below
15 minutes
2. Time to treatment in department (median) below
60 minutes
Stroke
Stroke -Proportion of Patients admitted to an acute stroke
90%
unit within 4 hours of hospital arrival
Proportion of patients in Atrial Fibrillation, presenting
with stroke and where clinically indicated will receive
60%
anti-co-agulation.
Stroke - % of Stroke patients with access to brain scan
100%
within 24 hours
Stroke - Proportion of Stroke Patients and carers with a
85%
joint health and social care plan on discharge
Stroke - Patients (as per NICE guidance) with suspected
stroke to have access to an urgent brain scan in the next 100% of stroke patients eligible for a brain scan
slot within usual working hours or less than 60 minutes scanned within one hour
out of hours as defined from time to time by the ASHN
>80% treated on a stroke unit >90% of their stay
80%
>60% of people who have a TIA and are high risk (ABCD 2
score 4 or more) are scanned and treated within 24 hours 60%
of 1st contact but not admitted
Stroke - 65% of patients with low risk TIA have access to
MRI or carotid scan within 7 days (seen, investigated and 65%
treated)
% of Patients eligible for Thrombolysis, Thrombolysed
100% of all eligible patients
within 4.5 hours
25.20%
24.82%
Jon Green
ONE MET
-
Jon Green
91.00%
85.71%
Jon Green
83.00%
68.29%
Jon Green
100.00%
98.57%
Jon Green
94.00%
91.14%
Jon Green
100.00%
93.43%
Jon Green
97.00%
89.14%
Jon Green
92.00%
78.57%
Jon Green
65.00%
73.43%
Jon Green
100.00%
100.00
%
Jon Green
32
Contract Priorities Dashboard
Discharge Summaries
Discharge Summaries - Outpatients
95% sent to GP's within 3 days
81.63%
84.19%
Discharge Summaries - A&E
95% of A&E Discharge Summaries to be sent to GPs
within one working day
97.54%
97.50%
Discharge Summaries - Inpatients
95% sent to GP's within 1 day
77.57%
82.16%
3.00%
-
100.00%
-
0.57%
1.15%
100.00%
100.00
%
96.23%
96.20%
1:30
100.00%
81.73%
1:29
100.00
%
79.81%
16.26%
18.47%
Dermot
O'Riordan
Dermot
O'Riordan
Dermot
O'Riordan
Choose & Book
A maximum of 3% slots unavailable (£50 per
Provider failure to ensure that “sufficient appointment
appointment over 5%. Threshold applied over
slots” are made available on the Choose and Book system
monthly figures)
All 2 Week Wait services delivered by the Provider shall
be available via Choose & Book (subject to any exclusions 100%
approved by NHS East of England)
Cancelled Operations
Provider cancellation of Elective Care operation for noni) 1% of all elective procedures
clinical reasons either before or after Patient admission
Patients offered date within 28 days of cancelled
100%
operation
Maternity
90% of women who have seen a midwife or a
maternity healthcare professional, for health and
Access to Maternity services (VSB06):social care assessment of needs, risks and choices by
12 completed weeks of pregnancy.
Maintain maternity 1:30 ratio
1:30
Pledge 1.4: 1:1 care in established labour
1:1
Breastfeeding initiation rates.
80%
Reduction in the proportion of births that are undertaken 1% reduction in proportion compared to 2011/12
as caesarean sections. Suffolk PCT Only
baseline - 22.70%
The Threshold applied to
fines is 5%
Jon Green
Jon Green
Jon Green
Jon Green
Nichole Day
Nichole Day
Nichole Day
Nichole Day
Nichole Day
33
Contract Priorities Dashboard
Other contract / National targets
Mixed Sex Accomodation breaches
Consultant to consultant referral
0 Breaches
Commisioner to audit if concern about levels of
consultant referrals
Current ratios of OP procedure to day case for agreed
list of procedures to be maintained or improved, i.e.
the Commissioner will not fund a higher level of
Maintain or improve the mix as specified =
admitted patients for such procedures, unless clinical 90.17%
reasons can be demonstrated for increase in
admissions.
All emergency patients admissions are to be
MRSA - emergency screening
screened for MRSA within 24 hours of
admission
100% of patients should have a maximum wait
Rapid access - chest pain clinic
of two weeks
Thresholds set at each speciality - overall Trust
New to Follow up
Threshold is 1.9
Patients receiving primary diagnostic test within 6
99%
weeks of referral for diagnostic test
2
4
Jon Green
7.13%
6.19%
Jon Green
87.33%
87.55%
Jon Green
95.09%
92.42%
Nichole Day
100.00%
78.33%
Jon Green
1.89
1.84
Jon Green
99.49%
97.77%
Jon Green
34