Trust Quality and Performance Report
23 May 2014
(April Performance Pack)
Contents
Slide numbers
Executive Summary
2-5
Clinical Quality Priorities (inc Ward Dashboard)
6 - 17 & 31 - 36
Local Priorities
18 - 27
Monitor Compliance
28
Contract Priorities
29 - 30
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.
The 4 hour performance target for April was 94.96%, failing the target by one patient. This is the
first time the Trust has failed the target since May 2013. Full details are on page 3.
2.
There were zero cases of C.Diff in April against the threshold of two. This is covered within the
quality report.
3.
The Trust failed one Stroke target in April; patient being discharged with health and social care plan.
See page 3.
4.
Performance on outpatient and inpatient discharge summaries remains below target. See page 4.
5.
Performance on MRSA screening of emergency admissions was 96.22% against the 100% target.
This is covered on page 3 & 7 of this report.
6.
The Trust missed the breastfeeding initiation rate with performance of 76.3% against an 80% target
See page 4.
2
Executive Summary
Performance Indicator
A&E: Maximum waiting time of four hours from arrival to
admission/transfer/discharge
Threshhold
95.00%
April
94.96%
Lead Executive
Jon Green
The Trust failed the 4 hour target for the first time since May 2013 with performance of 94.96% (1 patient breach below target). The main factor in the
monthly performance was Norovirus affecting F8/F7 during the first week of April,. This resulted in the ward being closed and all medical admissions
managed via F7.
Performance Indicator
Stroke - Proportion of Stroke Patients and carers with a joint
health and social care plan on discharge
Threshhold
100%
April
73.00%
Lead Executive
Jon Green
The Trust missed this quality standard by 3 patients in April. One patient was discharged for End of Life Care only and the other two patients were
considered, by clinicians, to be inappropriate for a joint plan on discharge. We are in discussion with the CCG on how these types of patient are classed for
this target.
Performance Indicator
MRSA - emergency screening
Threshhold
All emergency patients admissions ae to be
screened for MRSA within 24 hours of admission
April
96.22%
Lead Executive
Nichole Day
Within emergency MRSA screening, the acute medical admission wards primarily F7 (19 missed) and to a lesser degree F8 (5 missed) & CDU (13 missed)
record the greatest non-compliance - 37 missed opportunities out of the overall total of 53. For elective MRSA screening the main area of non-compliance
continues to be Oncology Day unit although the compliance was greater than previous months with 12 fails out of the overall total of 28.
Whilst Oncology day unit (ODU) have improved in April following on-going meetings with the service, this is unlikely to be sustained in May as the laboratory
have received large numbers of unlabelled swabs this month from ODU. We have not yet had a response following flagging this to them, IPT will urgently
pursue this
3
Performance Indicator
Breastfeeding initiation rates
Threshhold
April
Lead Executive
80.00%
76.26%
Nichole Day
The breastfeeding initiation rate for April is very similar to that of last April and has improved by almost 2% from the March figure. All women are encouraged to
attend a breastfeeding workshop to give them information on breastfeeding and encourage them to give breastfeeding a go. All women are offered skin to skin
contact with their baby regardless of their intended method of feeding as some mothers will change their mind following this and give the baby at least one
breastfeed. Almost all staff in maternity and paediatrics have been trained in breastfeeding and are aware of the benefits to both maternal and child health, and
encourage women to breastfeed where possible.
Performance Indicator
Discharge Summaries - Inpatients
Threshhold
April
Lead Executive
95% sent to GP’s within 1 day
89.39%
Dermot O’Riordan
Performance is steadily improving although the target has been missed this month. Performance against this indicator is monitored at monthly Divisional
Performance Management meetings and responsibility for addressing poor performance will lie with each Directorate. This will assist in embedding change and
enabling continuous improvement. In addition, arrangements are being put in place for the Medical Director to receive performance figures at an individual
consultant level and he will then be writing to those with below target performance for both letters and in-patient summaries to improve performance further.
This issue is also being discussed at the monthly Executive Performance Meeting.
Performance Indicator
Discharge Summaries - Outpatients
Threshhold
April
Lead Executive
95% sent to GP’s within 3 days
91.69%
Dermot O’Riordan
Performance is steadily improving although the target has been missed this month. Performance against this indicator is monitored at monthly Divisional
Performance Management meetings and responsibility for addressing poor performance will lie with each Directorate. This will assist in embedding change and
enabling continuous improvement.
In addition, the Medical Director will be seeking to resolve whether the three day timescale for Outpatient letters can be extended and also whether these
letters can be sent “dictated but not approved” with CCG clinicians at the next WSH WSCCG Clinical Liaison Forum in May.
Discharge summary and clinic letter performance is part of the new Appraisal system that is in the process of being implemented and consultants will be
expected to present their figures at these meetings.
4
Performance Indicator
Sickness absence rate
Threshhold
<3.5%
April
3.67%
Lead Executive
Jan Bloomfield
Highest percentage continues to be Estates and Facilities directorate at 4.90%. This directorate continues to have a number of staff on long term sick which
adversely affects the figures. The lowest directorate is Corporate Services at 2.15%.
Performance Indicator
All Staff to have an appraisal
Threshhold
90%
April
89.49%
Lead Executive
Jan Bloomfield
Down by 0.13% on last month. Highest percentage is Estates and Facilities at 94.37%, lowest is Clinical Support directorate at 84.81%. A number of training
sessions/ meetings have taken place in the last month to remind appraisers about the appraisal process and policy, especially the need to send their
completed Personal Development plans through to HR for recording. We are in the process of developing a more robust system for managers to check on
their individual staff members’ appraisal date etc. (similar to mandatory training).
Performance Indicator
Turnover
Threshhold
<10%
April
11.37%
Lead Executive
Jan Bloomfield
This increase in turnover is due to the TUPE transfer of the pathology staff to the Pathology Partnership on 1 st May 2014.
5
Clinical Quality Priorities: Summary
• Norovirus affected F8 this month resulting in the closure of 2 bays for a total of 8 days.
• 45 patients fell during April; a decrease of 12 compared to March. 1 fall resulted in a
fractured neck of femur.
• There were no cases of Clostridium Difficile in April against a yearly trajectory of 25.
6
Quality Priority: Infection Control
MRSA Bacteraemia
There were no cases of hospital attributable MRSA bacteraemia in April.
MSSA Bacteraemia
There were 2 cases of hospital attributable MSSA bacteraemia in April.
C. Difficile
There were no cases of Clostridium difficile in April.
A case from December 2013 which went to appeal was upheld.
Norovirus
A patient was admitted to F8 from home on 1 April with vomiting. Norovirus was confirmed. A further 3 patients developed
symptoms of Norovirus which resulted in the closure of 2 bays for a total of 8 days and the ward being closed to transfers
throughout this period.
MRSA Screening
Elective 97.8% compared to 96.2% in March
Emergency 96.2% compared to 96.2% in March
7
Quality Priority: Ward Performance Issues
•
Acute Medical Unit (AMU) – comprising of F7 & F8.
There are a number of red and amber scores for AMU this month. These are mainly for
documentation and patient experience. Actions to improve documentation and lower scoring
aspects of the patient experience are being formulated into an action plan in conjunction with the
ward manager, general manager and matron.
•
Ward G4
Improvements on scores for patient safety are seen this month. This is shown in documentation,
especially MEWS & Nutrition assessment. A higher patient satisfaction score of 93 has been
achieved compared to 78 in March. The Friends & Family test (recommender question) score
was 73 compared to 33 for March.
8
Quality Priority: Falls
Falls Performance
There were 45 falls this month, 1 of which resulted in serious harm, the patient sustained a fractured hip on ward F7.
31 falls resulted in No Harm and the remaining 13 were recorded as Negligible or Minor Harm.
The rate per 1,000 occupied bed days is 4.16 (March 4.8)
WSNHSFT falls with harm April: 0.54%, National falls with harm April: 0.7% (Safety Thermometer).
Themes
There were 4 falls in the toilet this month, this is 8.8% of all falls compared to 8.7% last month. A trial has commenced on G3 to
use patient movement sensors in bathrooms and commodes for at risk patients.
There were 12 falls on G5, (10 last month) 9 falls were during the night, the staffing review is looking at staffing during the day
and at night.
9
Quality Priority: Falls
Investigation into WSH falls over the last two years has been carried out by a statistical analyst commissioned by the CCG.
The following SPC chart shows a statistical improvement in the number of falls since March/April 2013. Further in-depth
analysis to be carried out and reported later in the year.
10
Quality Priority: Pressure Ulcers
.
The performance target is to have no avoidable Hospital Acquired Pressure Ulcers (HAPU) Grade 2, 3 or 4 during 2013-14.
Grade 2 Pressure Ulcers
There were three grade 2 HAPU this month all three of which we believe to have been unavoidable, the CCG have yet to
confirm this.
Out of the six reported HAPU for March four have been confirmed by the CCG as Unavoidable
Grade 3 pressure Ulcers
No grade 3 HAPU this month, last grade 3 HAPU was in January. We have had no grade 4 HAPU since February 2010.
11
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 0.82% therefore, our new harm free care is 99. 18%. The National new harm for April is 2.5% or
(97.5%) and national harm free is 93.6%.
The data for April shows we had 0.54% of falls with harm and the national performance for April 2014 was 0.7%.
The data also shows we had no new pressure ulcers recorded in April 2014 against the national performance of 1%.
It should be noted that the Safety Thermometer is a spot audit and data is collected on a specific day each month.
Mar 13
Apr 13
May 13
Jun 13
Jul 13
Aug 13
Sep 13
Oct 13
Nov 13
Dec 13
Jan 14
Feb 14
Mar 14
Apr 14
Harm Free
93.68
91.47
93.20
92.60
93.22
92.68
91.03
92.46
90.28
93.00
93.86
94.09
93.85
94.02
Pressure Ulcers – All
3.51
4.50
4.28
5.36
3.52
2.98
5.16
4.06
4.72
3.25
3.07
4.63
5.08
4.35
Pressure Ulcers - New
0.94
0.95
1.01
0.00
1.08
0.00
1.09
0.00
0.83
0.25
0.00
0.00
0.27
0.00
Falls with Harm
0.23
1.66
0.00
0.26
0.81
0.27
0.00
0.00
1.11
0.50
0.51
0.00
0.00
0.54
Catheters & UTIs
2.58
0.95
1.76
1.53
2.17
2.98
3.60
3.48
3.33
3.00
2.30
1.03
1.07
0.82
Catheters & New UTIs
0.23
0.24
0.00
0.51
0.54
1.08
0.82
0.00
0.83
1.00
0.26
0.26
0.27
0.00
New VTEs
0.47
1.42
0.76
0.26
0.54
1.36
0.54
0.58
0.83
0.50
0.51
0.26
0.00
0.27
All Harms
6.32
8.53
6.80
7.40
6.78
7.32
8.97
7.54
9.72
7.00
6.14
5.91
6.15
5.98
New Harms
1.87
4.27
1.76
1.02
2.98
2.71
2.45
0.58
3.61
2.25
1.28
0.51
0.53
0.82
Sample
427
422
397
392
369
369
368
345
360
400
391
389
374
368
Surveys
18
18
18
18
17
17
17
17
17
17
17
18
18
18
12
Safety Thermometer Rolling Programme
Falls With Harm April 2014
WSH
Rolling 12
months
National
Average
WSH
Monthly
Data
WSH
Rolling 12
months
4
National
Average
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
0
Nov-13
2
Oct-13
WSH
Monthly
Data
New Harm April 2014
6
Sep-13
Apr-…
0
Jul-13
Aug-…
Sep-…
Oct-…
Nov-…
Dec-…
Jan-14
Feb-…
Mar…
Apr-…
0.5
WSH
Rolling 12
months
National
Average
Jul-13
1
May…
Jun-…
Percentages
New VTE April 2014
1.5
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
WSH
Monthly Data
Aug-13
0
Jun-13
National
Average
0.5
May-…
1
2
1.5
1
0.5
0
Apr-13
WSH Rolling
12 months
Percentages
1.5
Percentages
Percentages
New Pressure Ulcers April 2014
WSH
Monthly
Data
Percentages
Catheters and New UTIs April 2014
1.5
1
0.5
0
WSH Rolling
12 months
National
Average
WSH
Monthly
Data
13
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.
Being treated with dignity & respect and Staff being compassionate in their approach are the
highest scoring questions (both 99%).
Getting enough help from staff at mealtimes scored lower this month with 4 wards with scores of less
than 85%. Matrons will be conducting mealtime observations to monitor this and determine reasons for
this response. 6 volunteers have completed training in April to assist with feeding patients and can be
deployed once competency has been achieved.
Noise at night from other patients and timeliness of call bell response are the lowest scoring questions
and remain the areas of focus.
14
Call Bell Response Times
Call bell response times are now captured electronically on 7 wards. A planned upgrade to install this
technology across the Trust was not successful and a further attempt is planned for the end of May.
Response time for April are shown below.
F5
F12
F3
F6
G3
F4
F7
5 wards increased the percentage of call bells answered within 0-2 minutes compared to March data. 1 further ward
maintained a score of 68% answered in 0-2 minutes. This will be a focus of Matrons rounds this month to obtain verbal
feedback from patients or their perception of response timeliness.
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.
Overall satisfaction scores for the OPD, A&E, and short stay were maintained at a high level with short stay achieving
100% from 313 responses.
Department
Score
A&E
87 %
OPD
94 %
Short stay
100 %
The lowest scoring question in the A&E survey was “Were you given enough privacy when discussing your condition at
reception?” at 79%. Signs are in place in the reception area of the department offering patients a private space when
discussing their condition.
The lowest scoring question in the OPD survey was “Were you informed of any delays in being seen?” at 75%.
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 Friends and Family test score of 89 for inpatients during April, maintaining the high scores of previous
months.
AMU scored 67 for the Friends and Family test. This reflects the overall low scoring for patient experience indicators. A ward
action plan to address this has been formulated.
The recommender score for A&E was 54 maintaining a similar score to previous months. The response rate to the Friends
and Family test in A&E has improved with a total of 995 responses in April.
Maternity recommender scores are high for all stages of the pathway as indicated below:
Antenatal care
Birthing Unit
Only
Labour Suite
Post natal ward
Post natal
community care
84
96
85
77
88
17
Local Priorities: Exception report
Incidents (Amber / Green) with investigation overdue (over 12 days)
The next NRLS cut off for incidents between Oct13 to Apr14 is the 31st May. All patient safety incidents will need to have been
investigated and finally approved prior to the cut off date to allow upload to the NRLS. There are (as at 12/05/14) 222 green and amber
incidents overdue an investigation and an additional 55 which have been investigated but are still awaiting final approval.
The General Managers and Clinical directors have received details of the individuals who have overdue incident investigations that predate the NRLS cut off and these are being actively followed up. In addition the Operational Steering group on the 12/05/14 received the
details of individual with high numbers of overdue investigations.
Late by Directorate
Red (RAG)
14th April
9th May
change
Clinical Support
>15
5
10

Estates and Facilities
>10
4
8

Medical
>70
118
116
-
Surgical
>40
42
36

Women & Children’s Health
>15
53
43

Other
No target
9
9
-
TOTAL
>150
231
222
-
18
Local Priorities: Exception report
RCA actions overdue
Governance provide the General Managers with a regular report on the first working day of the month listing all overdue and upcoming
RCA actions. Progress with closing these actions is monitored through the Directorate performance meetings.
There are currently 17 overdue actions including 3 which have completion dates before April 2014.
Actions overdue
Directorate
Detail of pre-April overdue actions
Total
Pre-April
Medicine
6
0
Surgery
0
0
Women & Children
6
3
Clinical Support
0
0
Other
5
0
Use of saturation monitoring (due 31/12/13)
Review of CTG guideline (due 31/01/14)
Antenatal appointment blood pressure monitoring (due 28/02/14)
Complaint second letters
There were eight second letters received in April which related to requirement for further information and/or lack of agreement with
the content of the initial response. Increased numbers of complaints will result in increased numbers of second letters. A total of 35
second letters were received in 2013-14 against 356 first responses therefore 90% of complaints were resolved at first response.
There was a 22% increase in the total number of complaints received compared to the previous year.
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
Apr14
Commentary
>3
1-3
0
0
RCA Actions beyond deadline for completion
>=10
5-9
0-4
17
See exception report for details.
Incidents (Amber / Green) with investigation
overdue (over 12 days)
>150
50 - 150
<50
222
See exception report for details.
SIRIs reported > 2 working days from
identification as red
>1
1
0
0
4/4 incidents were submitted to STEIS within two
working days of identification as red. 3/4 were
submitted to STEIS within four working days of the
incident.
One case was initially reported as an Amber
incident and upgraded to Red following investigation
and discussion of the case. This was submitted to
STEIS 57 working days after the incident.
SIRI final reports due in month submitted
beyond 45 working days
>1
1
0
0
5/5 were submitted within 45 working days
SIRI final reports due in month submitted
beyond local target (40 working days,
30days for pressure ulcers)
>1
1
0
0
5/5 were submitted within 40 working days
6
All six cases were submitted to the CCG within the
local 40 days deadline and no feedback has been
received to date. An update on status has been
requested from the CCG to allow closure.
Number of SIRI reports open on STEIS more
than 45 days after initial notification
>10
6 - 10
0-5
20
Local Priorities - Governance Dashboard (cont.)
Indicator
Performance target
Duty of
Candour
Compliance with Duty of Candour
requirements
Risk
assessment
Active risk assessments in date
<75%
Outstanding actions in date for Red / Amber
entries on Datix risk register
Clinical Audit
Trust participation in relevant ongoing National
audits
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.
98.0
Ward Check 1
100
Ward Check 2
R
A
>3
Apr14
0
0
75 – 94%
>=95%
100%
<75%
75 – 94%
>=95%
99%
<75%
75 – 89%
>=90%
97%
<90%
1-3
G
90% - 98%
>98%
Commentary
Non compliance is reported to individuals
(daily) and Clinical Directors (weekly). This
analysis is based on 4053 checks during
the month.
99.5
Sign In – Complete
98.5
Sign Out – Surgeon
98.3
Time Out - Scrub
97.1
21
Local Priorities - Governance Dashboard (cont.)
Indicator
Performance target
NICE
TA (Technology appraisal) business case beyond
agreed deadline timeframe
Complaints
Response within 25 working days or negotiated
timescale with the complainant
R
A
>9
G
4-9
Apr14
0-3
2
93%
<75%
75 –
89%
>=90%
Number of second letters received
>=5
1-4
0
8
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
4
Commentary
See exception report for details.
22
Patient Safety 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)
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
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
0
May-12
Number of incidents reported
500
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 Apr13 – Sept13 NRLS report was issued in April and the benchmark in the graph above was updated. This shows an increase in
reporting across the peer group.
There were 358 incidents reported in April including 286 patient safety incidents (PSIs). The Trust reporting rate fell in April to the lowest
level since August 2012 to below the lower quartile threshold for the peer group. We are currently reviewing areas which have seen a
significant reduction in reporting (AMU and A&E) and areas with consistent low levels of reporting (F14 and Theatres).
The number of harm incidents in April remained below the peer group average which has also been updated for the Apr13 – Sept13 NRLS
report release.
23
8
1.2%
7
6
2
1.0%
5
0.8%
1
1
2
0.6%
2
0.2%
3
2
1
4
3
1
6
5
0.4%
4
2
1
3
4
2
3
2
2
1
2
2
4
3
2
1
2
3
1
2
2
1
2
2
2
1
1
Pending final grade
Avoidable Hospital acquired pressure ulcer
Confirmed severe harm/death (excl. PU)
(1ary axis) Benchmark NRLS Serious harm (%)
(1ary axis) WSH confirmed serious harm - 12 month rolling average WSH%
Benchmark NRLS Serious harm (number)
Feb-14
Jan-14
Dec-13
Nov-13
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
0
Apr-12
0.0%
2ary axis (number of confirmed PSIs)
1.4%
Mar-12
1ary axis (serious harm PSIs as a % of total PSIs)
Patient Safety Incidents (Severe harm or death)
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 Apr13 – Sept13 report sits below the Trust’s average. The WSH percentage
data is plotted as a line which shows the rolling average over a twelve month period.
The number of serious PSIs (confirmed and unconfirmed) are plotted as a column on the secondary axis with avoidable hospital acquired pressure
ulcers indentified separately. The benchmark line applies the peer group percentage serious harm to the peer group median total PSIs to give a
comparison with the Trust’s monthly figures. In February there were two confirmed patient safety incidents: one delay in diagnosis and one
intrauterine death.
24
Local Priorities: Complaints
Of the 27 complaints received in April,
the breakdown by Primary Directorate
is as follows: Medical (7), Surgical (7),
Clinical Support (4), Facilities (2), and
Women & Child Health (7).
There were 8 second letters received in
April which related to requirement for
further information and/or disagreement
with the content of the initial response.
Increased numbers of complaints will
result in increased numbers of second
letters. A total of 29 second letters were
received in 2013-14 against 359 first
responses therefore 92% of complaints
were resolved at first response. There
was a 22% increase in the total number
of complaints received compared to the
previous year.
Trust-wide the top 5 most common
problem areas are as follows:
45
40
Number of complaints
Complaint response within agreed
timescale with the complainant: 93% in
April. This is due to increased
workload.
35
30
25
20
15
10
5
0
Complaints 2013/14
Apr
33
Complaints 2014/15
27
Second letters 2013/2014
0
Second letters 2014/2015
8
May
31
Jun
29
Jul
38
Aug
32
Sep
29
Oct
26
Nov
40
Dec
15
Jan
21
Feb
24
Mar
41
1
3
3
1
0
2
1
3
5
6
4
All Aspects of Clinical Treatment
18
Attitude of Staff
11
Communication / Information to Patients (written and oral)
6
Admissions, Discharge and Transfer Arrangements
3
Aids and Appliances, Equipment, Premises (including access)
3
25
Local Priorities: PALS (Patient Advice & Liaison Service)
Clinical support
Other / Not categorised
120
102
50
90
90
72
40
102
95
94
89
77
71
100
88
80
69
63
27
Information/Advice request
29
Appointments, delay, cancellation
19
Admission/discharge and transfer arrangements
2
Apr-14
Jan-14
All aspects of clinical treatment
Mar-14
0
Feb-14
0
Dec-13
20
Nov-13
10
Oct-13
40
Sep-13
20
Aug-13
60
Jul-13
30
Apr-13
Trust-wide the most common five reasons for
contacts are shown below.
Surgical
Facilities
60
Jun-13
A breakdown of contacts by Directorate from
April 13 to April 2014 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.
Medical
Women and Child Health
Total
May-13
In April 2014 there were 95 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.
Communication
8
The numbers per Ward/Department remain small and consistent when spread across all areas of care provided, although the PALS Manager
continues to receive complaints about cancellations for pain treatment. April has seen a reduction in the number of concerns around
Admission/discharge and transfer arrangements.
It is evident that the PALS Manager, in addition to assisting with genuine concerns from patients and relatives, often signposts enquirers from the
community to other Trusts & external organisations to resolve their concerns.
26
Local Priorities – Workforce Performance
Performance Indicator
Threshold
Direct
Financial
Penalty
YTD
Comments
Lead Exec
Workforce
Sickness absence rate
<3.5%
NO
3.67%
Turnover
<10%
NO
11.37%
Reviews
Grievance/Banding reviews
NO
4
Recruitment Timescales
Average number of weeks to recruit = 7
NO
5.1
DBS Checks
To complete 95% of required DBS checks
NO
98.40%
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
89.49%
All cases completed/resolved
Jan
Bloomfield
Jan
Bloomfield
Jan
Bloomfield
Jan
Bloomfield
Jan
Bloomfield
Jan
Bloomfield
27
Monitor Compliance Framework
Note: 18 week performance data provisional information prior to final sign off
Monitor Compliance Framework
Performance Indicator
Access:
Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted
Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted
Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete
pathway
A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge
All cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer
All cancers: 62-day wait for first treatment (5) from: NHS Cancer Screening Service referral
All cancers: 31-day wait for second or subsequent treatment, comprising: Surgery
All cancers: 31-day wait for second or subsequent treatment, comprising: anti-cancer drug treatments
All cancers: 31-day wait for second or subsequent treatment, comprising: radiotherapy - Not applicable to
WSFT
All cancers: 31-day wait from diagnosis to first treatment
Cancer: two week wait from referral to date first seen (8), comprising:
all urgent referrals (cancer suspected)
Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer
not initially suspected)
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
Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - MONTH
Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - QUARTER
Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - ANNUALLY
Certification against compliance with requirements regarding access to healthcare for people with a learning
disability
Threshold
Month
QTD
Weighting Lead Exec
90%
95%
91.77%
98.58%
1.0
1.0
Jon Green
Jon Green
92%
98.33%
1.0
Jon Green
95%
94.96%
94.96%
1.0
Jon Green
85%
92.00%
92.00%
90%
94%
98%
100.00% 100.00%
100.00% 100.00%
100.00% 100.00%
96%
99.00%
99.00%
93%
98.40%
98.40%
1.0
1.0
0.5
Jon Green
Jon Green
Jon Green
Jon Green
Jon Green
Jon Green
0.5
93%
98.00%
2
Q1 = 6, Q2 =
6, Q3 = 5, Q4
=8
25
0
0
0
0
N/A
-
98.00%
Jon Green
Nichole Day
0
1.0
0
0
0
0
1.0
-
0.5
Nichole Day
Nichole Day
Nichole Day
Nichole Day
Nichole Day
Nichole Day
28
Contract Priorities Dashboard
Contract Priorities with financial penalty
In Month
Performance
YTD
25.33%
25.33%
Jon Green
BOTH MET
-
Jon Green
96.00%
96.00%
Jon Green
67.00%
67.00%
Jon Green
100.00%
100.00%
Jon Green
73.00%
73.00%
Jon Green
100.00%
100.00%
Jon Green
100.00%
100.00%
Jon Green
82.00%
82.00%
Jon Green
78.00%
78.00%
Jon Green
% of Patients eligible for Thrombolysis, Thrombolysed within 4.5 hours 100% of all eligible patients
100.00%
100.00%
Jon Green
Discharge Summaries
Discharge Summaries - Outpatients
91.69%
91.69%
Dermot O'Riordan
96.69%
96.69%
Dermot O'Riordan
89.39%
89.39%
Dermot O'Riordan
Performance Indicator
Threshold
Comments
Lead Exec
A&E
A&E - Threshold for admission via A&E
A&E - Service User Impact Indicators
i) if the monthly ratio is above the corresponding
2012/13 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 Service
User Impact Indicators:
1. Unplanned Reattendances within 7 days below
5% (Reattendances for the same condition)
2. Left department without being seen below 5%
Stroke
Stroke -Proportion of Patients admitted to an acute stroke unit within
90%
4 hours of hospital arrival
Proportion of patients in Atrial Fibrillation, presenting with stroke and
60%
where clinically indicated will receive anti-co-agulation.
Stroke - % of Stroke patients with access to brain scan within 24 hours 100%
Stroke - Proportion of Stroke Patients and carers with a joint health
85%
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 slot within usual working
100% of stroke patients eligible for a brain scan
hours or less than 60 minutes out of hours as defined from time to
scanned within one hour
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 of 1st contact but not 60%
admitted
Stroke - 65% of patients with low risk TIA have access to MRI or carotid
65%
scan within 7 days (seen, investigated and treated)
Discharge Summaries - A&E
Discharge Summaries - Inpatients
95% sent to GP's within 3 days
95% of A&E Discharge Summaries to be sent to
GPs within one working day
95% sent to GP's within 1 day
29
Contract Priorities Dashboard
Choose & Book
Provider failure to ensure that “sufficient appointment slots”
are made available on the Choose and Book system
A maximum of 3% slots unavailable (£50 per
appointment over 5%. Threshold applied over
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 non-clinical
i) 1% of all elective procedures
reasons either before or after Patient admission
Patients offered date within 28 days of cancelled operation
100%
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.
3.00%
-
100.00%
-
The Threshold applied to fines is 5%
Jon Green
Jon Green
0.63%
Jon Green
Jon Green
100.00%
96.28%
Nichole Day
This was delivered by senior
midwives in management role s
delivering direct patient care and is
not sustainable in the medium term
Maintain maternity 1:30 ratio
1:30
Pledge 1.4: 1:1 care in established labour
Breastfeeding initiation rates.
Reduction in the proportion of births that are undertaken as
caesarean sections. Suffolk CCG Only
Other contract / National targets
Mixed Sex Accomodation breaches
1:1
80%
1:30
99.00%
76.26%
22.70%
19.63%
19.63%
0
0
Jon Green
5.31%
-
Jon Green
-
-
Jon Green
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 admitted patients Maintain or improve the mix as specified = 89.84%
for such procedures, unless clinical reasons can be
demonstrated for increase in admissions.
MRSA - emergency screening
100% Screened within 24 hours
100% of patients should have a maximum wait of
Rapid access - chest pain clinic
two weeks
Thresholds set at each speciality - overall Trust
New to Follow up
Threshold is 1.9
Patients receiving primary diagnostic test within 6 weeks of
99%
referral for diagnostic test
96.22%
Nichole Day
Nichole Day
Nichole Day
Nichole Day
Nichole Day
100.00%
100.00
%
Jon Green
2.05
2.05
Jon Green
100.00%
100.00
%
Jon Green
30
Clinical Quality Priorities: Ward Dashboard
A3 Printout of Ward Analysis
Quality Report From Trust
Dashboard
31-36