Board Report template - qehkl

Integrated Report

Quality,Performance & Workforce toend February 2018

Contents

Feb-18 Feb-18 01/12/2017 01/01/2018 01/02/2018

Current MthTrend on

prev mth

Previous

MthDec-17 Jan-18 Feb-18 FYTD

1 23 2 1

554 Emergency Department Attendances 4774 5328 5655 5328 4774 59465

3532 Outpatient Attendances 20242 23774 19413 23774 20242 251636

467 Inpatient Admissions (Elective & Emergency) 3648 4115 4003 4115 3648 43501

510 Other (regular day patients, day cases etc) 2852 3362 2894 3362 2852 34966

Compliance Scorecard1

Quality & Risk2

Performance & Standards3

CQUINS4

Workforce5

Finance6

Appendices7

8

Page 3

Page 4

Page 33

Page 49

Page 50

Page 56

Page 57

Context for the Integrated Report

Produced by the Performance and Information Team, ext 3735 2 of 57

0 Qtr 1 2016/17Qtr 2 2016/17Qtr 3 2016/17Qtr 4 2016/172016/17

Indicators TargetCurrent

QTDDec Jan Feb Qtr 1 Qtr 2 Qtr 3 Qtr 4 *FYTD

Risk Assessment framework 2015/16 7 01/12/2017 01/01/2018 01/02/2018 Qtr 1 2017/18 Qtr 2 2017/18 Qtr 3 2017/18 Qtr 4 2017/18 2017/18

18 Wks - Adm (adjusted) Target18 Wks - Adm Perf (adjusted) 90.00% 74.85% 81.72% 73.66% 76.14% 77.05% 77.22% 75.91% 74.85% 77.05%

18 Wks - Non Adm Target18 Wks - Non Adm Perf 95.00% 84.17% 82.84% 81.90% 86.89% 91.40% 84.61% 83.79% 84.17% 86.28%

18 Wks - Incomp Target18 Wks - Incomp Perf 92.00% 82.41% 81.32% 82.05% 82.76% 92.02% 87.66% 84.75% 82.41% 87.09%

A&E 4 Hr TargetA&E 4 Hour Performance 95.00% 75.46% 80.97% 81.10% 69.17% 88.64% 89.05% 87.15% 75.46% 86.11%

Cancer-62 Days RTT TargetCancer-62 Days RTT 85.00% 80.00% 83.97% 80.00% n/a 79.37% 87.44% 85.06% 80.00% 83.83%

Cancer-31 Days Sub Treat (Surg) TargetCancer - 31 Days Subsq Treatment - Surgery 94.00% 94.74% 100.00% 94.74% n/a 93.55% 98.33% 100.00% 94.74% 96.70%

Cancer-31 Days Sub Treat (Drug) TargetCancer - 31 Days Subsq - Drug Treatments 98.00% 96.77% 98.18% 96.77% n/a 100.00% 99.47% 99.35% 96.77% 99.29%

Cancer - 31 Days Subsq - Radiotherapy 94.00% n/a n/a n/a n/a n/a n/a n/a n/a n/a

31 Day Diag to Treat Target31 Day Diag to Treat 96.00% 96.67% 99.04% 96.67% n/a 98.39% 98.52% 99.38% 96.67% 98.58%

Cancer-2ww TargetCan

cer-Cancer-2 Wk Waits - All urgent Referrals (cancer suspected) 93.00% 97.36% 96.27% 97.36% n/a 97.44% 96.21% 95.97% 97.36% 96.60%

Cancer-2ww (Breast Symptomatic) TargetCan

cer-Cancer-2 Wk Waits - Symptomatic breast patients (cancer not initially suspected) 93.00% 91.94% 97.14% 91.94% n/a 97.13% 99.10% 98.63% 91.94% 97.73%

Care Programme Approach (CPA) patients

Follow up contact within 7 days of discharge 95% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Having formal review within 12 months 95% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Admissions to inpatients services had access to crisis resolution / home treat teams 95% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Meeting commitment to serve new psychosis cases by early intervention teams 95% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Ambulance FTs-Category A call – emergency response within 8 minutes

Category A call – emergency response within 8 minutes - Red 1 calls 75% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Category A call – emergency response within 8 minutes - Red 2 calls 75% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Ambulance FTs-Category A call – emergency response within 19 minutes

Category A call – ambulance vehicle arrives within 19 minutes 95% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Clostridium Difficile

CDIFF (Target)CDIFFClostridium (C.) Difficile - meeting the C. difficile objective 5 8 1 3 5 9 13 12 8 42

Mental Health

Minimising Mental Health delayed transfer of care <7.5% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Mental Health data completeness: identifiers 97% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Mental Health data completeness: outcomes for patients on CPA 50% n/a n/a n/a n/a n/a n/a n/a n/a n/a

Certification against compliance with requirement regarding access to health care for

people with a learning disabililtyN/A n/a n/a n/a n/a n/a n/a n/a n/a n/a

Monitor Compliance Framework Total ScoreScore 5 7 **

*FYTD denotes Financial Year to Date (Please note - Cancer Wait Times figures are always 1 month in arrears)

** Not appropriate with absence of key data items for Cancer

The FYTD position for Cancer is based on the QTR 1 & July performance combined

Acc

ess

Trust Risk Assessment frameworkO

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es

Compliance Scorecard

Quality & RiskPerf &

StandardsCQUINS Workforce Finance Appendices

Produced by the Performance and Information Team 3 of 57

01/12/2017 01/01/2018 01/02/2018

Indicators Var to prev mth Target Dec Jan Feb *FYTDCritical Incidents 01/12/2017 01/01/2018 01/02/2018 2017/18 2016/17

Total Never Events (Target)Total Never Events 0 0 2 0 2Total Falls Resulting in Serious Harm (Target)Total Falls Resulting in Serious Harm 0 1 1 2 8Pressure Ulcers - Grade 3 (Target)Pressure Ulcers - Grade 3 0 1 1 2 19Pressure Ulcers - Grade 4 (Target)Pressure Ulcers - Grade 4 0 0 0 0 0Total Other SIs (Target)Total Other Sis 0 1 1 0 19Pressure Ulcers - Grade 2 (Target)Pressure Ulcers - Grade 2 0 2 5 5 37Safety Thermometer - (new harm only) TargetSafety Thermometer - (New Harm Free) 95.00% 90.54% 96.87% 90.51% 95.38%VTE Assess TargetVTE Assessment Completeness 97.24% 97.45% 95.65% NA 97.32%

Infection ControlMRSA (Target)MRSA 0 0 0 0 0CDIFF (Target)CDIFF 5 1 3 5 42

Indicators Var to prev mth Target Dec Jan Feb *FYTDPatient experienceFFT % Recommended (IP & DC) 94.46% 96.43% 96.09% 95.57%FFT % Recommended (AE) 92.51% 96.90% 93.71% 93.38%

FFT Resp Rate (IP & DC) TargetFFT Response Rate (IP & DC) 30.00% 27.05% 24.81% 26.76% 30.31%FFT Resp Rate (AE) TargetFFT Response Rate (AE) 20.00% 15.18% 16.03% 13.02% 17.27%MSA Breaches TargetNo. of Mixed Sex Accommodation breaches 0 0 0 9 50

Number of Patient moves (over 2) 49 41 60 483Positive experienceCompliments 163 173 105 1706Complaints

Non-Clinical Complaints TargetNon-Clinical Complaints 6 5 7 42Clinical Complaints TargetClinical Complaints 20 29 19 284

Indicators Var to prev mth Target Dec Jan Feb *FYTDMortality

Crude Mortality (deaths per 1000 admissions) TargetDeaths per 1000 admsCrude Mortality (deaths per 1000 admissions) 19 18.7 18.9 16.6 14.4RAMI (Risk adjusted mortality) (National target)SHMI (Summary Hospital Level Mortality Indicator) Jul 16 - Jun 17 as expected 98.06

HSMR (Hospital Standardised Mortality Ratio) Dec 16 - Nov 17 as expected 101.70Outcome

Stroke - 90% of Stay on SU TargetStroke - 90% of Stay on a Stroke Unit 80.00% 91.89% 83.33% NA 85.15%TIA - HR TIA seen & treated <24hrs TargetTIA - High Risk,Non admitted TIA treated in 24 Hrs 60.00% 70.00% 60.53% NA 69.34%EL LOS TargetLength of stay - Elective 2.2 1.5 1.0 1.0 1.5EM LOS TargetLength of stay - Emergency 5.0 4.1 4.2 4.5 4.1Readm Rate (EL) TargetReadmission Rate - ElReadmission Rate - Elective 3.00% 3.41% 3.30% NA 3.57%Readm Rate (Em) TargetReadmission Rate - EmReadmission Rate - Emergency 10.00% 17.27% 17.21% NA 17.38%

Indicators Var to prev mth Target Dec Jan Feb Rolling 12 mthsWorkforce

Sickness Absence Rate (Target)Sickness Absence Rate 3.50% 5.73% 6.55% 6.33% 5.12%Staff Turnover Rate Complete Trust (Target)Staff Turnover Rate Complete Trust 10.00% 11.76% 11.86% 12.25% 11.55%Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) (Target)Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) 10.00% 10.37% 10.89% 11.83% 9.35%Staff Turnover Rate Registered Nursing & Midwifery (Target)Staff Turnover Rate Registered Nursing & Midwifery 10.00% 13.27% 13.33% 13.87% 14.14%Staff Turnover Rate Allied Health Professionals (Target)Staff Turnover Rate Allied Health Professionals 10.00% 16.20% 15.67% 15.82% 17.76%

*FYTD denotes Financial Year to Date (HSMR & SHMI will be at snapshot date specified) Stroke, TIA, VTE, Re-adm is 1 month in arrears.

Safe

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Quality & Risk Scorecard

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Methodology used to derive the HSMR is freely available. Latest Dr Foster Mortality Summary shows QEH is 101.7 as expected

· Included in the new intelligence monitoring system used by the CQC and available to the public through the CQC website

· Widely reported (including as part of the Dr Foster Good Hospital Guide and in the press)

· Risk of death based on diagnosis at first episode of care

· Does not include deaths after discharge

· Can be adversely affected by low use of palliative care codes (QEH is historically a low user of these codes)

HSMR for the 12 month period Dec 16 - Nov 17 is 101.7 as expected

Weekday HSMR is 100.1 as expected

Weekend HSMR is 105.2 as expected

Latest Report shows QEH is 98.06 as expected

· Available to public on the NHS Choices website

· Risk of death based on diagnosis at first episode of care

· Includes deaths within 30 days of discharge.

· Rolling 12 month average, but only published 6 months in arrears

SHMI for the 12 month data period of Jul 16 - Jun 17 is 98.06 as expected

SHMI for Q1 of 17/18 is 92.62 which is as expected

Reporting to the Board - The mortality surveillance group continues to closely monitor both higher than expected areas of mortality and trends that suggest where future outliers may be. This informs audit and the work of that group. This report will show from January 2018,

in addition to the present metrics, the incidence of avoidable deaths as they are identified

Mortality- HSMR (Hospital Standardised Mortality Ratio)

SHMI - (Quarterly Trend)

HSMR - (Monthly Trend) Key Points/Operational Actions

Definitions

What does ‘as expected’ mean? SHMI: 95% control limits from a random effects model applying a 10% trim for over-dispersion are used to give a Trust a banding of ‘as expected’, ‘higher than expected’ or ‘lower than expected’.

HSMR: 99.8% control limits are applicable.

Key Points/Operational Actions

Mortality- SHMI (Summary Hospital Mortality Indicator)

The HSMR and the SHMI remains within the expected range.

The mortality surveillance group monitor trends closely and there are no early indicators of concern in specific clinical areas.

The increase in the crude death rate during the winter months has been carefully analysed and early analysis does not suggest this will lead to a rise in the SHMI or the HSMR due to the co-morbidities and the diagnoses of the elderly and ill patients admitted at that time.





Crude rate within HSMR basket is 3.5% (based on Dec 16-Nov 17),East of England rate = 3.6%

Perinatal mortality - Death of the foetus or live born between 24 weeks gestational age to 7 days post natal

The Crude Mortality rose to 3.23 in Nov, from 3.05 (Oct). This is similar to the rise seen during the equivalent

period last year.

Mortality Rate for the Trust per 1000 Admissions, Calculation = Total Deaths/Total spells *1000.Perinatal mortality - Death of the foetus or live born between 24 weeks gestational age to 7 days post natal

Mortality - Crude Mortality Rate (per 1000 admissions)

Definitions

Mortality - HSMR Basket Crude Rate (Yearly Comparison)

Perinatal Mortality - QEH Relative Risk (Monthly) & Observed No'sPerinatal Mortality - QEH Benchmarked Vs East of England

Palliative Care Coding Rate

The Trust's Non-Elective 'Palliative Care Coding' rate of (1.85%) for 17/18, is low when compared to the National average (4.05%)





Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17

Observed 1 0 0 1 0 1 0 0 0 0 2 0


December reviews are low as we distribute deaths near to month end and are awaiting completed reviews to be returned. Approximately 50% of deaths each month have been reviewed. We are working to combine the SI process and Learning from Deaths process. Learning Disability Deaths are being submitted through the LD portal. Two of our staff have been trained in reviewing LD deaths.

Mortality - Learning from Deaths Dashboard

Definitions






10 5

Details of the Serious Incidents are shown below (shown in order of the "Incident Date").

Data provided from DATIX and is a snapshot of data recorded on DATIX at the time.Incidents are assigned to a Service Group based on the Main Specialty of the consultant assigned to the patient in question.

Serious Incidents


Definitions

2Total Serious Incidents rrrr

0of which were "Never Events"

Learning from SI’s has led to discussions with Badger Net Supplier to improve fields that are ‘essential’ and improve standard of record keeping.

The OWL (generated from moderate incidents) has an icon on the front page of the intranet following suggestions from staff about accessibility.

Training into falls prevention has also been increased and targeted on wards where a higher incidence occurs.

There has also been an improvement in communication with the CCG and the use of tracked changes on draft reports has ensured specific questions are answered and delays to sign off minimised. All SI’s since December have been submitted within the 60 day standard.

Serious Incidents (Rolling 12 months)

0

1

2

3

4

5

6

Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

Total Serious Incidents: rolling year (with trendline)

Total Never Events Total Falls Resulting in Serious Harm Total PU's as SI's Total Other Sis

0

2

0 0Never Events Falls reported as SI's PU's reported as SI's Other SI's

Category of most recently Reported (SI's)

Compliance with SI Report submission dates




Ref Incident date SI/NE Inc: SI Reported Date Location Exact Division

WEB47911 07/02/2018 SI 12/02/2018 Leverington Escalation Medical Division

WEB48027 12/02/2018 SI 16/02/2018 Elm SAU Surgical Division

Serious Incidents during Feb 2018

Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17

16 20 17 12 12 12

Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

10 9 11 13 13 15

No. of open SI's as at date of provision of data for Board Report

Number of Open Serious Incidents

Adverse Event Number of open Si's

Fall on level ground 2

Never Event - Wrong site surgery 2

Fall from a height, bed or chair 2

Delay / difficulty in obtaining clinical assistance 1

Suspected fall 1

Breach of patient confidentiality 1

Treatment / procedure - failed 1

Other medication incident 1

Never Event - Retained foreign object post-operation 1

Healthcare associated cross infection 1

Unplanned admission / transfer to specialist care unit 1

Delay or failure to monitor 1

Grand Total 15


Learning from incidents closed




RefSTEIS

Number

SI Declared

Date

Location

ExactSI/NE Summary Root Causes Lessons Learned

60 Day

Submission

Compliance

WEB43648 2017/20114 11/08/2017 Central

Delivery Suite

Baby delivered following induction of labour

requiring resuscitation respiratory effort poor. Baby

transferred to Norfolk and Norwich for cooling.

1. Patient did not have continuity of obstetric

care throughout the antenatal period which

led to a robust management plan not being

initiated

2. Staff did not acknowledge uterine hyper

stimulation whilst reviewing the CTG

monitoring

3. Obstetric review was not sought prior to

further prostaglandins being administered

following the period of hyper stimulation

4. Lack of fetal monitoring or midwifery

review following the onset of regular uterine

activity

1. Women that are on High Risk pathway need to have thorough

reviews and a robust management plan in place throughout their

pregnancy, labour and birth and into the postnatal period to

prevent potential issues being missed

2. There are a number of record keeping issues that although they

may not have had a direct impact on the outcome but are not an

assurance of good practice

3. It is important for women to have observations performed in line

with current guidelines, throughout the antenatal and intrapartum

period

4. It is important for the Specialist Midwife for Safeguarding to

follow up women that have been referred to them for support

5. Women must commence continuous CTG monitoring upon the

onset of regular contractions to ensure both maternal and fetal well-

being

N

WEB45004 2017/25790 19/10/2017 Castle Acre

Ward

Unexpected admission to Critical Care

Centre/transfer to Specialist Unit (Maternal DVT &

PE)

1. Delay in referring patient for obstetric

review in a timely manner

2. Lack of robust handover of case from

specialty to specialty

3. Failure to recognise and escalate a seriously

ill patient

4. Lack of knowledge of MEOWS

5. Out of date and lack of availability of

comprehensive guidelines

1. Review of previous observations is essential including those taken

in A&E. this was not done in the case of this patient. Staff need to

be educated regarding the importance of keeping an eye on the

whole picture including observation trends

2. Escalation when observations are abnormal must follow actions

stated on the MEOWS chart. Education of staff in this area is

essential

3. It is difficult to track changes in patients' observations when

entered onto BadgerNet. The use of a paper MEOWS chart should

be considered in sick patients so that review of observations trends

can be done easily

4. There is a lack of ability to recognise severity of illness in obstetric

patients and training is probably required

5. some guidelines do not seem to be followed and may need

revising or communicating to other teams more effectively

6. There is poor awareness of D-Dimers not being useful in pregnant

patients. Teams need to be educated

Y



10 5

Analysis of "Other Incidents"






Falls by Degree of Harm inc rate per 1000 beddays


There are 80 validated falls reported in February 2018 which is 6.14 per 1000 beddays rate. We have experience an increased number of falls reported this month compared to previous month (January 3.69/1000 beddays). This month’s report is high and above the national average rate of 6 per 1000 bed days.

This month’s fall consequences are as follows: (1) Catastrophic, (1) Major, (1) Moderate, (27) Minor and (50) Negligible.

• Catastrophic (Leverington Escalation), where the patient sustained brain injury.• Major (Elm SAU), where the patient sustained fractured Neck of Femur.• Moderate (Windsor), where the patient’s on going haemorrhagic contusions has progressed after the fall.

There were 7 patients fell on more than one occasion:

• 1 patient had 3x falls on West Raynham• 1 patients had 3x falls (2 on Gayton and 1 on Marham)• 1 patient had 2x falls on Marham ward• 1 patient had 3x falls (2 on Terrington SS and 1 on MAU)• 1 patient had 2x falls on Shouldham• 1 patient had 2x falls on Terrington SS• 1 patient had 3x falls on Oxborough ward

Clinical areas with increased number of falls this month:(7) Terrington SS, Stanhoe, Windsor, (6) Gayton, (5) Oxborough, West Raynham, A & E, Marham, Denver, (4) Leverington Escalation and Elm

On-going and Recommended Actions:The falls co-ordinator has reviewed those patients who fell on a number of occasions and is providing supportive measure to these areas. Falls prevention strategies training on the ward remains on-going particularly on clinical areas with outstanding action plan and falls resulting to harm. Training includes, risk assessment standard practice and address poor practice in management of in-patient falls across the trust.

Additional equipment is funded through charitable funds. 1 scoop stretcher and 15 units of falls monitor for Terrington SS.We continue to explore on resources and funding for additional specialised equipment such as scoop stretchers, hover jack and mat in order to improve the Trust’s safe system of work in executing safe retrieval of patient after a fall.

Training video in moving and handling and use of appropriate equipment (Safe system of work) in retrieving patients from the floor who maybe or is injured after a fall is underway.

Definitions

Total number Falls incidents per month (across all levels of Harm) Number of Falls incidents per 1000 beddays, per month (across all levels of Harm)






February saw 7 pressure ulcers within the trust.

1 on Tilney and Oxborough.2 on Leverington Escalation 1 on Terrington/Elm who shared responsibility of a single pressure ulcer development.

1 was also reported to have developed on CCU, however this was validated by TVN as not being pressure damage and was therefore discounted.1 was an SDTI (Suspected Deep Tissue Injury) on West Raynham. Policy for SDTI is to “watch and wait” and review the skin damage in 7 days for further development. However in this case the patient was transferred to Swaffham Cottage Hospital prior to review and was lost to follow up.

Of the 5 validated pressure ulcers 1 was unavoidable (Tilney ward) and 4 were avoidable.

It has been recognised that some wards do require additional training/support with regards to pressure ulcer prevention. However, at present, the Tissue Viability Team have been unable to provide this due to the exceptional work load and the complex nature of the patient/wounds we are treating at present.

Hospital Acquired Pressure Ulcers inc rate per 1000 beddays ,and analysis of avoidable/unavoidable cases

Definitions

Total No. of Pressure Ulcers incidents per month / per 1000 beddays / proportion of avoidable/unavoidable PU incidents per month. Note - Figures for previous months can sometimes change if they are retrospectively re-classified on DATIX





For Safety Thermometer the rate of New Harms ( Developed by the QEH) for February 2018 was 9.49% making the QEH 90.51% New Harm Free.

Harm Free Care relates to the % of patients on the day of the study January who were harm free from Pressure Ulcers, Falls, VTE events and Catheter Associated Urinary Tract Infections. A review of the results indicate that the increase in new harms were due to an increase in the number of new VTE, Pressure Ulcers - 7, Falls with harm - 4 and new Catheter and new Urinary Tract Infections – 6.

The data collection is undertaken on a predetermined day each month and the dates for the rest of the year will be sent to all matrons and senior nurses to ensure that there is

Safety Thermometer (Hospital Acquired Harm)CQUIN

Safety Thermometer


Definitions

90.51%

Safety Thermometer (Target 95%) rrrr

96.9

3%

96.5

5%

98.4

9%

91.2

5%

96.5

0%

96.1

2% 97.2

2%

97.8

3%

97.6

6%

90.5

4%

96.8

7%

90.5

1%


Safety Thermometer Performance - New Harm Free

Safety Thermometer - (New Harm Free) Target





THE VTE assessments show a concerning decrease. Whilst this has also been seen in other Trusts a renewed emphasis on the importance of this assessment was communicated in February 2018 to medical staff and it is expected that this will be reversed in the March 2018 information.

There have been no adverse thrombotic episodes related in patients where the VTA assessment was not performed.

VTE:Proportion of admissions that have been VTE assessed within the reporting month (1 month in arrears)

VTE Assessment


Definitions

95.65%VTE Assessments Completed (Target 97.24%) rrrr

97.4

3%

97.4

7%

97.5

1%

97.7

1%

97.4

1%

97.4

2%

97.2

8%

97.6

5%

97.5

1%

97.7

3%

97.4

5%

95.6

5%

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18

VTE Assessment Performance

VTE Assessment Completeness VTE Assess Target





Latest Month's Performance Financial YTD

MRSA - The objective aims to deliver a continuing reduction in MRSA bacteraemia by requiring acute trusts and PCOs to improve to the level of top performers.

MRSA

Definitions


0 case of MRSA BSI apportioned to the Trust this year.

MRSA screening across the trust (both weekly and admission) continues to remain high.

In addition to weekly screening all inpatients (with exception of admission areas) are offered Octenisan body wash for the duration of their stay. Compliance with this is

0MRSA

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0MRSA

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50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

MRSA Weekly Screening Compliance Across Trust






Benchmarked figures will always be 1 month in arrears

CDIFF - The objective aims to deliver a continuing reduction in Clostridium difficile infections. Organisations with higher baseline rates will be required to deliver larger reductions.

Clostridium Difficile

C Diff Incidents

Definitions

C Diff Incidents VS Prev Years C Diff Benchmarking


To date (09/03/2018) 46 cases of Hospital acquired infection (April 2017 – March 2018), the trajectory for this year is 53 cases. Following a CCG review 8 cases have been deemed non trajectory – all measures were taken in line with national and local polices.

During Feb we had 5 cases of HAI C difficile, 2 of these cases were attributed to W Raynham triggering a (Period of Increased Incidence) PII on W Raynham Ward, supportive measures have been implemented and some cleaning undertaken, with plans for a bay decant to facilitate a deep clean and HPV some areas. Ribotyping on both the cases were the same (002) suggesting transmission.

A recent HAI case on W Newton alerted the IPC Team to a cluster of cases on Elm Ward, the patient had previously been on Elm when the last C difficile toxin was identified. Further investigation has uncovered a further 3 cases associated with Elm around that time. Supportive measures have been implemented and some cleaning undertaken, with plans for a decant to facilitate a deep clean and HPV some areas.

With the current rise in numbers of cases across the Trust, measures have been implemented to reduce any further cases. Awareness has been raised with all clinical staff and advice given re assessment and isolation of suspected cases, extra cleaning has been requested on the wards with cases, and 24 hour cleaning availability in A&E and admission areas. For cleaning of clinical equipment sporicidal wipes have been advised.

5C Diff (All cases)

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Gram Negative BSI

Definitions


The IP&C Team are working with CCG and other Acute Trust at reducing numbers of BSI, a quality premium of a 10% reduction has been set for CCG for this year. Data collection of themes and numbers .

Influenza:Total cases 262 (as of end of Feb 2018 ) laboratory confirmed since 30.12.17 these include A&E and AEC patients.

X2 main types: Flu A – H2N3 & Flu B some additional cases of Flu A H1N1Cohort areas set up on Stanhoe and Oxborough dedicated to flu A or Flu B also on Oxborough X2 bays for patients awaiting respiratory virus results, this was initially set up on Terrington ward as high numbers of patients on ward were awaiting test results.

SRs used as able for those patients requiring isolation on particular wards. Oversight was requested from medical Drs, assess patients symptoms and allow patient flow through these dedicated areas. Patients in contact with positive patients are and continue to be assessed for prophylaxis treatment and respiratory precautions advised for patients with active symptoms, this included advice for staff re vaccination.

Some internal spread identified on several wards with Windsor, Stanhoe, Leverington and Terrington identified with high numbers of cases. W Raynham and Necton Wards have had restrictions in place, as evidence of transmission throughout the ward(s) affecting high numbers of patients. Outbreak meetings with PHE and CCG have taken place and a daily update to NHSi has been sent.




0

5

10

15

20

25

E.coli Bacteraemia (Hospital & Community Apportioned Cases)

HAI CAI

0

1

2

3

4Klebsiella Bacteraemia (Hospital & Community Apportioned Cases)

HAI CAI

0

1

2

3

Psuedomonas Bacteraemia (Hospital & Community Apportioned Cases)

HAI CAI


IPC Dashboard

Definitions


IP&C audits include Hand Hygiene standards, cleaning of commodes/bed pans and other audits of practice. All data is fed back to clinical areas.





Service line Clinical Indicators (by ward)

Definitions




Currently the indicator data is collected centrally and with the new perfect ward this will be undertaken at point of care in the clinical areas

Fluid chart completion from the majority of surgical wards has not been scored although data was sent to Cinical Audit as they have indicated they have not been in receipt of these - process to ensure data is collected, sent received and analysed by Clinical Audit to be undertaken.

• Leverington – work to remind all staff on rescoring waterlow, completion of body map, falls assessment, scoring of EWS and observation frequency and moving and handling assessments will be done by the ward manager• Necton – areas for improvement are : on completion of fluid charts, waterlow, moving and handling charts, body maps, fall assessments and care rounds, which the ward manager will discuss with the team• West Newton – areas for improvement include; fluid charts, MUST assessment, waterlow assessment, body map completion, bed rails assessment and observation frequency• Terrington – areas for improvement include fluid chart completion , body map completion, manual handling assessment, fall care plan and obs frequency documented. Due to the short stay nature of the patients in this area patients are not usually on

the ward for a week so the rescore of waterlow is not applicable in this area • Elm- areas for improvement include waterlow assessment, body map completion and moving and handling and falls assessment

All areas review their indicators each month and share the results with the team, during the month of February we have seen increased acuity and dependency and capacity which has impact on workload in each area.


Indicator DescriptionFluid Charts 61% 36% 53% 39% 70% 81% 80% 70% 67% 62% 64%

MUST Assessment 90% 50% 56% 33%

Waterlow Assessment 100% 100% 90% 100% 100% 100% 50% 100% 100% 100% 89% 100% 67% 93%

Waterlow Re-Scored 75% 70% 100% 63% 22% 50% 94% 87% 83% 90% 0% 85% 88% 92%

Has A Body Map Been Completed 35% 47% 25% 45% 25% 15% 37% 16% 75% 40% 45% 40% 55% 40% 50% 85%

Moving And Handling Assessment

Completed83% 40% 95% 89% 95% 39% 94% 55% 95% 95% 90% 74% 74% 95% 90% 100%

Falls Assessment Done 100% 95% 100% 75% 100% 100% 50% 100% 50% 100% 89% 100% 83% 100%

Falls assessment rescored weekly 50% 60% 69% 75% 11% 13% 53% 93% 83% 80% 0% 85% 47% 92%

Is a Falls Care Plan Completed? 94% 33% 100% 89% 80% 33% 72% 45% 85% 89% 55% 68% 63% 80% 80% 100%

EWS for each set of OBS? 95% 100% 100% 100% 95% 95% 100% 100% 100% 95% 100% 100% 100% 100% 95% 100%

Care Rounds Completed 96% 70% 71% 96% 95% 79% 96% 93% 77% 75% 89% 76%

Bedrail Assessment if "At Risk" (on

admission)100% 75% 0% 67% 0% 100% 50% 17% 89%

Obs Frequency documented 95% 93% 75% 65% 70% 58% 53% 50% 100% 85% 82% 70% 60% 15% 90% 80%

Serious Incidents 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0

Drug Administration Errors 3 1 1 1 0 3 2 7 1 0 3 1 2 1 0 1 1

All Drug Errors (inc Admin) 4 2 2 2 0 4 3 9 3 0 3 2 3 3 0 2 3

Falls Total 5 4 1 6 5 0 4 3 3 5 7 3 2 7 2 5 7

H/A Pressure Ulcers Grade 2 0 0 0 0 0 1 1 0 0 1 0 0 1 0 0 1 0

H/A Pressure Ulcers Grade 3 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0

C.Diff > 2 Days 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 2 0

Harm Free Care 100% 80% 100% 75% 100% 86% 88% N/A 71% 91% 100% 52% 83% 78% 88% 93% 96% 94%

Complaints 1 0 0 0 1 0 1 0 0 0 1 0 0 0 2 0 1

Family And Friends Response Rate 38% 15% 29% 23% 17% 256% 4% 30% 26% 52% 25% 10% 36% 20% 19% 52% 25%

Family And Friends

(% Recommended)98% 100% 91% 92% 97% 100% 100% 92% 92% 91% 95% 100% 93% 86% 100% 100% 100%

% Of Active Mentors 63% 67% 86% 88% 100% 69% N/A N/A 100% 50% N/A N/A 67% 71% 100% 0% 22% 57% 57%

Fill Rate Registered 94% 94% 85% 93% 86% 89% 0% 95% 88% 98% 94% 84% 91% 84% 89% 89% 93%

Fill Rate Unregistered 110% 90% 101% 92% 85% 64% 0% 108% 98% 97% 94% 100% 98% 105% 129% 88% 91%

CHPPD 5.6 5.4 9.9 5.6 4.9 22.5 0.0 7.7 6.0 5.2 6.0 7.4 5.4 5.0 8.2 6.9 5.4

Appraisals 61% 83% 100% 85% 70% 93% N/A N/A 89% 90% 90% 94% 95% 82% 82% 55% 93% 88%

Sickness 6% 7% 9% 9% 5% 5% N/A N/A 6% 9% 8% 9% 7% 9% 4% 9% 6% 6%

Vacancies 24% 26% 19% 33% 23% 6% N/A N/A 19% 31% 44% 20% 22% 14% 42% 22% 18% 24%

Den Lev Esc

Pati

ent

Safe

tyPati

ent

Experi

ence

Eff

ect

iveness

Sta

ff

Experi

ence

Elm SAU Gayt Mar C Care WindMAU Nec Oxb Stan Sho Til TSS West New West Ray

Data notavailable

Data NotAvailable


Maternity Clinical Performance & Governance Scorecard 2017-18




ActivityIn February there were 178 women delivered and 180 babies, 176 live births; 2 sets of twins and 4 still births. 4 stillbirths were:1. Antepartum stillbirth (IUD) at 28+1 smoker, G9 P8, previous 3 SGA babies, having serial scans. 27+2 doppler traces abnormal referred to NNUH fetal medicine. No fetal heart at NNUH appointment.2. Antepartum stillbirth (IUD) at 40+5, no known risk factors. Admitted with no fetal movements IUD, later found to need very large dose of Anti-D (15000iunits) so suspected large feto-maternal bleed.3. Medical Termination at 29 weeks for fetal abnormalities. Fetocide.4. Hydrops and fetal demise on USS at 30+5There have been no neonatal deaths and no transfers out.

Homebirth rate still high at 2.8%, MLBU deliveries 17.4, promoting Waterlily as much as possible.

2 BBAs for waterlily • Phone call at 1914 contracting and TCI, 2025 main reception phoned to say woman had delivered in car at main entrance, midwives attended and woman brought to unit.• 0254- Phone call contracting 2-3:10 lasting 30 seconds, no Srom, para 2 , advised to have some paracetamol and stay at home. 0330 phoned back, contractions increased, SROM, TCI. Woman feels like she will be able to make it in. 0337 Partner

phoned to say can see head, guided through delivery, paramedics on route. Admitted to CDS as high risk.1 BBA for delivery suite • 1428 phone call with partner, SROM clear, contracting lasting 45seconds coming every few minutes. To come in, could not get any other details due to partner on phone, patient heard in background sounds very uncomfortable. Currently 36+6.

Delivered before ambulance arrived, transferred in.

ModeIn February the induction rate was at 30.34% Total C-Section rate was 33.7%, with the 25% rate of emergencies.

Activity: Antenatal and Postnatal CareB/F rate initiation 73.4%, discharge home from hospital 60%, on transfer to H/V 48.4%- data collection issue on Badgernet as indicates a high proportion of method of feeding not completed, to become mandatory, working alongside IF lead to improve rates with support in community and reviewing guidelines.

GovernanceNo SI’s declared for February. CDS remained open within the month and the Home Birth Service continued as normal.

M easurement R easo n Green A mber R ed D ata So urce Apr May Jun Jul Aug Sep Oct Nov Dec Jan FebWomen Delivered To tal no . of women giving birth at QEH Local M onitoring Birth Register 182 199 191 218 194 191 198 178 163 173 178

Babies Born Total no. of babies bo rn at QEH Local M onitoring Birth Register 185 202 193 223 193 193 204 178 168 173 180Live Births Total no. o f live babies bo rn at QEH Local M onitoring 185 201 193 223 193 193 203 178 168 173 176

% Home Births % o f women giving birth at home Local M onitoring >= 2% Between <1% Birth Register 3.0% 2.0% 2.5% 4.1% 1.5% 1.6% 3.0% 3.4% 4.9% 2.9% 2.8%BBAs Babies born before arrival o f a professional Local M onitoring 0 Between >=2 Birth Register 1 1 3 4 3 1 0 2 0 4 3

StillbirthsStillbirth: Babies born after 24 weeks gestation showing no signs of life. Stillbirth

Rate = 4.6/1000 birhs. QEH annual total should not exceed 15 stillbirthsYearly total that exceeds 15 0 Between >=2 Birth Register 0 1 0 0 0 0 1 0 0 0 4

Neonatal Death (No .) N eo natal D ea th : No .o f babies that are born alive but die within 28 days of age. Yearly total that exceeds 7 0 Between >=2 NICU/DATIX 0 0 0 1 0 0 0 0 0 0 0Twins No. babies - twins Local M onitoring Birth Register 3 3 2 5 0 2 6 0 5 0 2

Triplets No. of babies - triplets Local M onitoring Birth Register 0 0 0 0 0 0 0 0 0 0 0Transfers out No . of transfers out o f QEH M aternity unit. Local monitoring Birth Register 0 0 1 2 0 0 1 0 0 0 0

% Women Delivered on M LBU Women who have given birth in Waterlily Local M onitoring >= 20% Between <15% Birth Register 15.4% 20.6% 19.9% 14.7% 20.6% 22.5% 20.2% 18.5% 24.5% 11.6% 17.4%% Women delivered on CDS Women who have given birth on Delivery Suite Local M onitoring <75% Between >85% Birth Register 82.4% 73.9% 75.4% 81.2% 76.8% 75.9% 76.3% 78.1% 75.5% 83.2% 71.9%

% Normal B irths Spontaneous vaginal births Benchmark Vs Nat Rate 2013/14 = 60.9% > 63% Between < 52% Birth Register 67.0% 66.8% 60.7% 64.7% 60.8% 66.5% 67.7% 64.0% 69.9% 57.8% 68.5%% Instrumental Deliveries Combined rate: Forceps + Ventouse Benchmark Vs Nat Rate 2013/15 = 12.9% 5% - 12% Between <5% or >20% Birth Register 11.5% 8.0% 10.5% 6.9% 10.3% 10.0% 8.6% 11.2% 8.6% 9.8% 7.3%% Vaginal Breech B irths 1.1% 0.0% 0.5% 0.9% 0.0% 0.0% 1.0% 0.0% 0.0% 0.0% 1.1%

% Elective LSCS Women having planned CS Local M onitoring <10% Between >12% Birth Register 8.2% 10.1% 11.0% 11.0% 11.3% 11.0% 6.6% 8.4% 16.6% 10.4% 8.4%% Emergency LSCS Women having an emergency CS Local M onitoring < 15% Between >16% Birth Register 13.1% 12.1% 17.3% 19.3% 16.5% 12.6% 18.2% 16.3% 12.9% 21.4% 25.3%

% Total CS To tal CS performed: Elective +Emergency Benchmark Vs Nat Rate 2013/14 = 26.2 % <= 25% Between >= 28% Birth Register 21.4% 22.1% 28.3% 30.3% 27.8% 23.6% 24.8% 24.7% 29.5% 31.8% 33.7%% Induction Rates Women who have their labour induced (denominator = total women minus ElSCS) <18% Between >24% Birth Register 33.5% 25.1% 21.5% 30.3% 28.9% 27.8% 35.4% 33.7% 19.0% 27.8% 30.3%

% Bookings < 12 weeks 6 days Women who have their first booking appt by 12+6 KPI >= 90% Between <= 85% HoM 90.0% 91.0% 87.8% 89.3% 90.1% 92.4% 88.2% 93.0% 88.6% 90.4% 87.3%No. of women seen on DAU @ N C H Local monitoring DAU 91 130 20 130 90 115 120 150 79 130 114

Closure of DAU - hours @ N C H Local monitoring DAU 12 12 0 0 15 0 0 0 24 24 6% women in DAU seen within 4 hrs @ N C H Local monitoring >=95% Between <= 90% DAU 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100% 100% 100% 100% 100%

No. of women seen on DAU @ QEH Local monitoring DAU 347 396 389 445 422 369 359 434 378 559 432Closure of DAU - hours @ QEH Local monitoring DAU 24 24 0 0 0 0 0 24 18 0 36

% women in DAU seen within 4 hrs @ QEH Local monitoring >=95% Between <= 90% DAU 99.4% 99.7% 97.4% 99.3% 99.5% 91.2% 99.7% 98.6% 99.5% 99.5% 99.8%% Breastfeeding Breastfeeding / Breast M ilk initiated, attempted o r achieved KPI >=70% Between < 65% Badgernet 74.6% 67.2% 69.4% 70.0% 67.9% 73.6% 72.4% 73.6% 67.9% 64.2% 73.4%% Breastfeeding Breastfeeding on discharge from hospital KPI >=70% Between < 65% Badgernet 68.2% 53.3% 60.0% 57.9% 34.2% 66.7% 50.0% 85.0% 55.1% 40.5% 60.0%% Breastfeeding Women breastfeeding at transfer to Health Visitor Local monitoring Badgernet 49.3% 37.9% 43.6% 45.9% 46.1% 45.2% 42.0% 40.9% 38.9% 30.3% 48.4%

% of women who stopped smoking at delivery Women who stopped smoking by the time o f delivery Local monitoring Badgernet 22.9% 27.8% 27.8% 16.7% 18.5% 16.7% 65.4% 65.2% 45.0% 35.5% 24.4%Readmission onto Castleacre Ward <28 days Number of avo idable maternal readmission up to 28 days post birth Local monitoring <= 4 Between >= 7 Castleacre 5 5 2 0 4 3 0 0 0 0 0

No of SUIs Local monitoring 0 >=1 Risk & DS 1 0 0 0 1 0 3 1 0 0 0Total no. o f adverse staffing incidents reported Local monitoring Datix 1 2 1 42 8 6 1 1 3 3 2

No. times CDS closed Local monitoring 0 1 >=2 DS 0 0 1 0 0 0 0 0 1 0 0Total hours CDS closed Local monitoring DS 0 0 8 0 0 0 0 0 17 0 0

Suspension of HBS Local monitoring 0 1 >=2 DS 0 0 0 0 0 0 0 0 0 0 0Suspension of HBS Local monitoring 0 1 >=2 DS 0 0 0 0 0 0 0 0 0 0 0

Operational Targets

GO

VERN

AN

CE

No Benchmark

ACTIV

ITY

: Bir

th S

tati

stic

sM

OD

E

No Target

No Target

No Target

No Benchmark

No Benchmark

Risk M anagementNo Benchmark

No Benchmark

No Benchmark

Day Assessment Unit

No Benchmark

No Benchmark

ACTIV

ITY

: A/N

& P

/N C

are

No Benchmark

No Benchmark

No Benchmark

No Benchmark


Maternity Clinical Performance & Governance Scorecard 2017-18 (continued)




Maternal & Perinatal StatisticsIn February there were 0 babies re-admitted PPH >2000ml is 1.14%. 4 women sustaining 3rd degree tears.

WorkforceIn February 1-1 care in labour is at 100% in Waterlily and up to 96% for CDS, the non -compliant cases have all been reviewed and non- completion of badgernet field has been highlighted and midwives informed. All cases had been given 1:1 care.The on call midwife was called in 6 times totally 48 hours

Patient FeedbackCompliment recording remains low in February and staff are encouraged to scan cards to send to PALS to record events . We have seen an increase for our Antenatal with a 98.7% likely to recommend the service. Birth / Labour likely to recommend is down at 86.96%. We have seen an increase in percentage in response rate for Postnatal Castleacre Ward to 39.5% and also likely to recommend is up to 100%

M easurement R easo n Green A mber R ed D ata So urce Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

PPH >=1000 or<2000ml Local M onitoring < 9% Between >12% Birth Register / CDS 1.1% 2.5% 4.2% 2.3% 4.6% 2.6% 1.5% 0.6% 3.7% 1.2% 1.7%PPH >=2000ml Local M onitoring <=1% Between >=2.5% Birth Register / CDS 1.1% 0.0% 1.6% 0.9% 1.6% 0.5% 2.0% 1.7% 1.2% 1.7% 1.1%

% of women sustaining 3rd & 4th degree tears (no/total-

Elective CS)Local M onitoring <=3% Between >=5% Birth Register / CDS 2.2% 1.0% 2.6% 1.8% 1.0% 1.6% 1.5% 2.3% 0.6% 1.2% 2.3%

No. o f women sustaining 3rd & 4th degree tears (no /to tal-

Elective CS) 3aLocal M onitoring <= 4 >= 5 Birth Register / CDS 1 1 2 2 1 1 2 4 1 1 2


Elective CS) 3bLocal M onitoring <= 2 >= 3 Birth Register / CDS 2 1 3 2 1 1 1 0 0 0 1


Elective CS) 3cLocal M onitoring 0 >= 1 Birth Register / CDS 0 0 0 0 0 1 0 0 0 1 1


Elective CS) 4Local M onitoring 0 >= 1 Birth Register / CDS 0 0 0 0 0 0 0 0 0 0 0

Blood transfusions > 4 units Local M onitoring Haemato logy 0 0 0 0 0 0 0 0 0 0 0Postpartum hysterectomies Local M onitoring 0 1 >1 Birth Register 0 0 0 0 0 0 0 0 0 0 0

ITU /HDU admissions Local M onitoring 0 1 >1 Birth Register 0 0 0 0 0 0 1 0 0 0 0M aternal Deaths Local M onitoring 0 >0 Birth Register 0 0 0 0 0 0 0 0 0 0 0

Avoidable Term Admissions to NICU from CDS Local M onitoring NICU / Datix 0 0 0 0 0 0 0 0 0 0 0Avo idable Term Admissions to NICU from Castlecare Local M onitoring NICU / Datix 1 0 0 0 0 0 0 0 0 0 0No. of babies with avo idable readmissions <28 days o ld Local M onitoring <= 2 3 - 5 >= 6 Datix 5 3 0 6 6 1 0 0 0 0 0

1:1 C are M LB U 1:1 care in labour achieved on M LBU Local monito ring >=95% 90-94 <= 89% M LBU 87.5% 95.7% 91.1% 94.9% 100.0% 100.0% 100.0% 94.6% 100.0% 100.0% 100.0%1:1 C are C D S 1:1 care in labour achieved on CDS Local monito ring >=95% 90-94 <= 89% DS 96.7% 96.9% 92.7% 93.0% 87.1% 97.6% 93.5% 89.4% 95.8% 94.4% 96.5%

On C all M idwife No. of hrs On call midwife called to work in Unit Local monitoring DS 38 22 51 59 31 53 75 44 0 40 48On C all M idwife No. of occassions On call midwife called to work in Unit Local monitoring DS 4 5 5 9 4 6 10 6 0 5 6

Compliments Total M idwifery Compliments received in month Local monito ring PALS Team 1 16 4 33 33 8 42 57 8 4 7Complaints Total M idwifery Complaints received in month Local monito ring PALS Team 0 2 3 2 4 4 4 1 4 1 7

Likely to recommend Antenatal Patient Experience Team >= 95% <95% Patient Experience Team 97.30% 96.43% 97.37% 98.49% 98.35% 98.35% 98.41% 96.69% 92.86% 96.91% 98.70%Response Rate B irth / Labour Patient Experience Team >= 15% < 15% Patient Experience Team 16.76% 18.08% 13.56% 16.76% 17.20% 22.63% 14.14% 12.36% 14.72% 9.52% 13.77%

Likely to recommend B irth / Labour Patient Experience Team >= 95% <95% Patient Experience Team 96.67% 100.00% 100.00% 96.67% 93.75% 100.00% 100.00% 90.91% 100.00% 100.00% 86.96%Response Rate Postnatal Castleacre Ward Patient Experience Team >= 15% < 15% Patient Experience Team 47.55% 55.90% 60.78% 59.12% 54.02% 60.17% 39.73% 45.04% 29.08% 26.67% 39.58%

Likely to recommend Postnatal Castleacre Ward Patient Experience Team >= 95% <95% Patient Experience Team 92.65% 98.89% 94.62% 97.20% 97.87% 98.59% 96.55% 100.00% 100.00% 97.22% 100.00%Likely to recommend Community Postnatal Patient Experience Team >= 95% <95% Patient Experience Team 100.00% 100.00% 100.00% 100.00% 96.77% 100.00% 100.00% 100.00% 97.67% 100.00% 100.00%

PA

TIE

NT F

EED

BA

CK

No Benchmark

No Benchmark

No Benchmark

Local monito ring of

poor outcomes and

facto rs that may have

an impact on women's

future health. Includes

data fo r the M aternity

Safety Thermometer:

Post partum

Haemorrhage & 3rd

and 4th Degree

perineal tears.

Work

forc

e

No Benchmark

NICU Admissions

Castle acre

Mate

rnal &

Peri

nata

l Sta

tist

ics

No Benchmark


Paediatric Clinical Performance & Governance Scorecard 2017-18




Activity • PAU 174 PATIENTS + 21 PPAU• Rudham x 9 episodes over the month the ward was at High risk due to patient acuity & staffing

WorkforcePAU• High volume of patients exceeding 12 patients x 2 days ( 19th & 26th,)• Registrar cross covering ward and PAU x 4 shifts (8th,13th,14th,15th )• No full ward clerk cover x 1 (13th,t)• Closed at 20.00 due to staffing x 1 (22nd)• No N/A cover x 11 (1st,2nd,8th,9th,12th,13th,15th,16th,22nd,23rd & 28th)

Clinical incidents• Adverse Staffing on Rudham = 8• Due to patient requiring 1:1 inadequate staffing• High acuity levels• Inadequate staff due to sickness• Acuity & number of patients• Night shift staffing X 3• Staff sickness

GovernanceNo SI’s declared in FebruaryClinical incidentsUnavoidable under 28 days = 4Clinical incidents/ direct care = 6

Patient Feedback

Descriptor Measurement Green Red Data Source Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

No. of PAU attendances Direct referrals from GP's A&E and other agencies East of England 5 beds < 130 >= 131 PAU 157 194 159 154 122 154 179 258 197 215 174

No of times PAU staffing standards not

met

Middle grade medical staff not allocated / available

to PAU during opening hoursEast of England 5 beds 0 >= 1 PAU 6 5 6 13 13 10 4 5 4 10 4

No of nursing assessment breachesLength of time to be seen by nursing staff (within

15 mins)Within 15 mins < 0 >= 1 PAU Data

9

(5.7%)

13

(6.7%)

4

(2.5%)

6

(4.0%)

0

(0.0%)

7

(4.5%)

3

(1.6%)

31

(12%)

12

(6%)

3

(1.4%)

8

(4.6%)

No of medical assessment breaches Seen by senior clinician Within 4 hrs < 0 >= 1 PAU Data NA4

(2.0%)

0

(0.0%)

10

(6.5%)

7

(5.7%)

8

(5.2%)

15

(8.4%)

12

(4.6%)

15

(6.52%)

22

(10.2%)

9

(5.1%)

No. of 6 hour breaches Length of stay on PAUAny children with a stay on

PAU over 6 hrs. < 0 >1 PAU Data

6

(3.8%)

12

(6.2%)

9

(5.7%)

2

(1.3%)

6

(4.9%)

7

(4.5%)

5

(2.7%)

21

(8.2%)

12

(6%)

15

(6.97%)

22

(12.6%)

No. of admissions from PAU% of the total attendances to PAU who are

admitted to RudhamInternal <= 40% >= 70% PAU

49

(31.2%)

46

(23.7%)

49

(30.8%)

59

(38.3%)

31

(25.4%)

48

(31.2%)

46

(25.7%)

77

(29.8%)

55

(27.9%)

69

(32%)

52

(29.8%)

HDU Days No. of HDU days in month Internal <= 15 >= 30 Rudham Stats 10 8.5 4 6 3.5 14 5 30 17 9.5 18.5

HDU Patients No. of HDU patients in month Internal <= 3 >= 4 Rudham Stats 9 7 2 1 4 7 6 18 9 6 6

Ward Attenders No. of children post discharge reviewAverage No. of Patients from

2016 = 61<= 61 >= 62 Rudham Stats 78 64 76 96 74 91 93 80 88 91 75

Medical & Surgical OutliersPatients aged 16 years and over that are not under

a PaediatricianInternal 0 >= 1 Rudham Stats 2 1 0 0 2 0 0 0 0 0 0

Medical InvestigationsNo. of children attending for diagnostic

investigations. Stay on ward was greater than 4 hrs.

Average No. of Patients from

2016 = 48<= 48 >= 49 Rudham Stats 20 25 22 24 18 27 27 26 19 29 22

Elective surgical admissionsNo. of children attending ward for elective surgery.

Stay on ward was greater than 4hrs

Average No. of Patients from

2016 = 48<= 48 >= 49 Rudham Stats 25 19 39 31 33 38 32 43 34 28 22

Transfers out with an escort No. of transfers out requiring a nurse escort Internal <= 1 >= 2 Rudham Stats 2 1 4 0 0 1 0 0 0 2 2

No. of 7 hr periods escalation beds open 5 escalation beds on Rudham wardRudham has more than 18

inpatients0 >= 1 Rudham Stats 2 1 6 5 1 8 2 7 20 3 9

No. of times recommended staffing level

not met

When no of RSCN / RN child does not adhere to

RCN recommendation

Meeting the children to

childrens nurse ratio0 >= 1 DATIX 1 0 7 1 2 9 1 0 12 11 5

No. of SUI reported to CCG Serious Incident and report prcoess actioned Internal 0 >= 1 Risk Dept 1 0 0 0 0 0 0 0 0 0 0

Number of babies under 28 days of age

admitted to rudham

No of admissions that may have been avoided had

appropriate prior intervention been in place.Internal 0 >= 1 Datix 2 0 0 0 0 0 0 0 0 0 0

No. of patients medically fit who have delayed

discharge.Internal 0 >= 1 Bed stats 0 2 1 1 1 1 0 1 1 1 0

No. of days medically fit patients who delayed

discharge.Internal 0 >= 1 Bed stats 0 6 14 5 6 10 0 17 16 16 0

Other Clinical Incidents All other on ward incidentsAll incidents to exclude

staffing incidents 0 >= 1 Datix 4 13 7 8 7 17 13 18 12 13 10

Act

ivit

yW

ork

forc

e

Delayed Discharges

Clinic

al In

dic

ato

rs


NICU Clinical Performance & Governance Scorecard 2017-18

Definitions




Activity 2 Babies were appropriately repatriated to our unit. Acuity was high during the month seeing 6 days with 4 HDU babies and 8 days with 3 HDU babies with a total of 75 HDU care days. There were 4 shifts that nurse staffing did not meet BAPM standards, the escalation policy was initiated & the unit closed to admissions during this time, staffing levels have improved now that TC is staffed 24 /7. NICU closed to both the Neonatal network & CDS for 61.5 hours due to acuity. 2 babies were more than 44 weeks, both were extremely premature, remained on NICU as both on high flow, planned transfer to Paediatrics post-surgery. 1 PNRA from home under midwifery care admitted with weight loss 15.4%requiring feeding support.

Descriptor Measurement Green Red Data Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

Admissions to NICU from CDS No. of infants admittedfrom CDS admitted due to level of care required

Average for 2016 (no breakdown

collected for full year) Available from

March 2018

No Parameter available until March

2018 as data not available

2016/2017 to gain average

No Parameter available until

March 2018 as data not available


30 23 39 29 29 20 21 10 24 20 7

Admissions to NICU from MLBUNo. of infants admittedfrom MLBU admitted due to level of care

required



March 2018







0 0 1 0 0 2 2 0 1 0 0

Admissions to NICU from Post natal WardNo. of infants admittedfrom PNW admitted due to level of care

required



March 2018







8 4 7 8 6 7 5 4 14 2 5

Admissions to NICU from HomeNo. of infants admittedfrom home admitted due to level of care

required



March 2018







6 4 2 9 7 8 1 2 3 2 4

Admissions to NICU from other unitNo. of infants admittedfrom other units admitted due to level of care

required



March 2018







3 4 2 1 8 0 2 4 3 3 2

Admissions to NICU from Rudham WardNo. of infants admittedfrom Rudham Ward admitted due to level of

care required



March 2018







0 0 0 0 0 0 0 1 0 0 0

Total NICU Admissions No. / Percentage of live births admitted to NICU 10% of births <11% birth rate >15% of birth rate47

25.4%

35

17.4%

51

26.4%

47 /

21%

50 /

25.8%

37 /

19.2%

31 /

15.2%

21 /

11.79%

30 /

17.85%

27 /

15.69%

18 /

10.65%

NICU TC Admissions No. / Percentage of live births on unit in month 10% of births <10% >15%31

16.7%

19

9.4%

34

17.6%

31 /

13.9%

32 /

16.5%

31 /

16.1%

21 /

10.3%

22 /

12.35%

15 /

8.92%

26 /

15.11%

22 /

13.01%

ITU days Available number from funded cot = 30 30 <= 31 > 90 12 25 20 19 7 2 34 17 47 14 5

No of occassions >1 ITU infants on unit No of times above funded ITU cots = 1 0 0 >= 1 2 6 5 1 0 0 8 5 11 0 0

48 hrs ventilatedNo of babies ventilated for more that 48 hrs that have not been

discussed with Tert centre0 0 >1 0 0 0 0 0 0 0 0 0 0 0

HDU days Available number from funded cot = 60 Average for 2016 = 52 <= 60 >= 61 32 75 49 37 91 26 35 47 35 75 75

Number of HDU babies No of HDU babies on unit in month Average for 2016 =9 <= 9 >= 10 10 11 12 8 12 6 8 8 12 15 6

SC days Available number from funded cot = 270 Average for 2016 =299 < 270 > 300 305 248 322 290 334 297 300 265 344 346 237

Number of SC babies No of SC babies on unit in month Average for 2016=48 <=48 >=49 49 54 53 52 60 47 54 45 53 59 52

No. of babies over 44 weeks of age No. of babies aged over 44 weeks 0 0 >=1 0 0 0 0 1 1 0 1 0 1 2

No. of occasions in month Over 80% cot occupancy 0 >1 7 7 18 5 13 0 5 6 8 9 1

No. of occasions in month Over 100% cot occupancy 0 >1 0 0 0 2 2 0 0 1 3 3 1

Number of avoidable admissions > 37 weeks No. of admissions that may have been avoided had appropriate prior

intervention been in place.0 0 >=1 DATIX 5 3 0 6 6 0 0 4 1 0 1

Number of babies receiving care from the

NCTNo. of babies having care in the community Internal Internal Internal 24 29 30 28 21 23 24 22 31 26 18

Number of NCT visits No. of visits carried out by NCT each month Internal Internal Internal 71 93 87 63 70 53 57 62 69 83 62

Ward attenders No. of babies attending on ward NICU Internal Internal Internal 8 13 6 6 11 8 17 16 15 12 13

In uter transfers accepted NICU Internal Internal Internal 1 2 3 0 0 3 5 0 0 0 0

In uter transfers refused NICU Internal Internal Internal 1 1 0 0 2 0 0 2 1 3 0

Transfers out >1 if due to capacity issues Internal 0 >= 1 0 0 0 0 0 0 0 0 0 0 0

No of hours NICU on divert to network Internal 0 >= 1 0 68.5 26 24 171.5 0 120 156 368 228 61.5

No of hours NICU on divert internal Internal 0 >= 1 0 56.5 0 0 84 0 0 158 177 69 62

Number of times BAPM staffing levels not

met per monthNo of times in month Staffing levels don’t meet BAPM standards BAPM 0-5 times 10 times & above

NICU /

Badgernet0 14 13 5 13 0 9 5 18 17 4

NIC

U / B

adg

ern

et

NIC

U

Cot occupancy

Unit escalation (in hours)

Act

ivit

y


NICU Clinical Performance & Governance Scorecard 2017-18 cont'd

Definitions




Mortality There were 3 babies 37 + weeks admitted with temperatures less 36.5C ( 2 form theatre, 1 from CDS).

Governance There were 17 clinical incidents & 5 staffing incidents reported.

Clinical Activity All parents were seen by a senior staff member within 24 hours of admission. All babies received ROP on time. All babies less than 32+6 were discharged home receiving breast milk.

Patient FeedbackThere were no complaints and 8 compliments. The FFT response rate was175% with 100%recommendation.

Descriptor Measurement Green Red Data Source Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

HypoglycaemiaInternal Guideance and standards not

followed 1 >= 3 NICU 0 0 0 0 0 0 0 0 0 0 0

Pre -Term Hypothermia less

than 32 weeks (NNAP)NNAP standard not achieved 0 >= 1 NICU badgernet 0 0 1 0 0 0 3 0

1 out

of 20 0

Accidental extubation NEVER EVENT 0 >= 1 DATIX 0 0 0 0 0 0 0 0 0 0 0

Infection (Positive culture

and CSF) (NNAP)Laboratory results 1 >= 3 NICU Badgernet 0 0 1 0 0 2 0 0 0 1 0

Pnuemothorax Incidents each month 1 >= 3 DATIX / Badgernet 0 0 0 0 1 1 2 0 1 0 0

No of SUIs Incidents each month 0 >= 1 DATIX / Risk dept 0 0 0 0 0 0 0 0 0 0 0

Total No of reported

incidentsIncidents each month Internal Internal 16 17 14 11 17 10 19 22 16 17 15

Staffing Incidents Staffing level Incidents each month 0 >= 1 0 2 1 0 3 0 1 1 5 5 3

NNAP standard NNAP >= 58% <58% NICU Badgernet 100% 33% 100% 0% 0% 50% 50%Not

Eliagable0% 0% 100%

Internal Internal Internal Internal Internal4 out

of 4

1 out

of 3

2 out of

2

0 out

of 1

0 out

of 1

4 out

of 8

1 out

of 2

0 out of

0

0 out

of 4

0 out

of 0

2 out

of 2

ROP Screening prior to discharge NNAP standard NNAP 100% <100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Parents seen within 24hrs of

admissionNNAP standard NNAP >= 88% <88% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Delayed Discharge No of babies delayed

discharged Local / National /Internal 0 >= 1 NICU 0 0 0 0 0 0 0 0 0 2 0

Patient Experience FFT / NICU 100% 100% 100% 100% 100% 95.2% 100% 100% 100% 90.9% 100%

Patient Experience PALS / Audit 16 8 5 4 13 4 10 6 6 6 8

Patient Experience FFT / NICU 29.1% 12.8% 10.7% 13.5% 100% 131% 100% 200% 425% 183% 175% *

Patient Experience PALS / Audit 0 0 0 0 0 1 0 0 0 1 0

* Response Rates for NICU before Aug 2017 included responses from "Ward Attenders". These are now excluded as they have their own Outpatient FFT card.

Recommend

Compliments

Govern

an

ce

Risk Management

Response RateFFT

Complaints

DATIX

Clin

ical A

ctiv

ity Less than 33 weeks babies receiving

breast milk on discharge (32+6

DAYS)

NICU Badgernet

Mo

rtality

Unexpected Neonatal morbidity -


The response rate did not reach the target of 30% and has not since October 2017 (26.76% - the target was missed by 177 responses (1459 collected)) this is a slight improvement on January figures, the year to date rate is still above the target.

The likelihood to recommend score for the month achieved the 95% target (96.09%).

The benchmark figures for the region place the Trust 7/13 based on January’s figures (an improvement of 4 places from last month) and the best placing for this financial year. In February there were 9 inpatient and day case patients unlikely to recommend the care that they had received – 2 provided positive comments. The other comments related to delays in results being received, medication delays, staff attitude, lack of diagnosis and overwork/pressure on staff.

The % of patients "Recommending / Not Recommending the Service" shown above will not always equal a combined total of 100% as it does not include those who are undecided.

The Friends & Family Test Scores & Response Rates shown above includes Inpatients & Daycase activity. The benchmarking data is extracted from the Department of Health's Unify Reporting Tool ,and is shown at least a month in arrears.

* Response rates of greater than 100% can occur when responses relating to discharges in one month are received by organisations too late for that month’s submission and are submitted as part of the return in the following month or Patients/Carers/Familymembers may also choose to submit responses at multiple points during a period of care/treatment resulting in multiple submissions to the same month.

Friends and Family Test - Inpatients and Daycase (Recommended/Not Recommmended)


Definitions

96.09%

% Recommend the service

0.62%% Do not recommend the service

26.76%

Response Rate (Target 30%) rrrr

Friends and Family Test - Inpatient & Daycase (Response Rates)

Ward / Area Performance - Inpatient & Day Cases Benchmarking - Inpatient & Day Cases1.0

2%

1.0

1%

0.4

8%

1.0

3%

1.2

1%

0.8

9%

1.2

2%

0.9

4%

0.8

6%

1.4

2%

0.3

3%

0.6

2%

95.6

1%

96.0

0%

96.1

2%

95.4

7%

94.7

5%

95.7

5%

95.3

5%

96.0

4%

94.8

5%

94.4

6%

96.4

3%

96.0

9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

Monthly % Recommend / Not Recommend - Inpatients & Day Cases

FFT % Not Recommended (IP & DC) FFT % Recommended (IP & DC)

34.3

5%

32.7

5%

33.5

9%

34.5

8%

32.6

3%

29.4

4%

30.0

3%

31.6

0%

29.7

2%

27.0

5%

24.8

1%

26.7

6%

0%

5%

10%

15%

20%

25%

30%

35%

40%


Monthly Response Rates for Inpatients & Day Cases

FFT Response Rate (IP & DC) FFT Resp Rate (IP & DC) Target




RDE 98.82% 0.22% 37.87%

RQW 98.20% 0.82% 36.16%

RGR 98.01% 0.36% 19.48%

RGM 97.46% 0.56% 42.40%

RGQ 97.44% 0.32% 34.70%

RM1 96.93% 1.05% 10.88%

RCX 96.43% 0.33% 24.81%

RGP 95.95% 1.35% 16.00%

RGN 95.51% 1.18% 29.42%

RDD 95.26% 1.37% 39.48%

RGT 93.88% 1.89% 8.31%

RQ8 93.11% 3.03% 22.21%

RAJ 91.17% 4.63% 25.97%

NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

IPSWICH HOSPITAL NHS TRUST

PAPWORTH HOSPITAL NHS FOUNDATION TRUST

WEST SUFFOLK NHS FOUNDATION TRUST

%

Recommended

% Response

Rate

% Not

Recommended

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST

COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST

THE QUEEN ELIZABETH HOSPITAL, KING'S LYNN, NHS FOUNDATION TRUST

SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

MID ESSEX HOSPITAL SERVICES NHS TRUST

CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

NORTH WEST ANGLIA NHS FOUNDATION TRUST

JAMES PAGET UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

Org Code Organisation Name (Ranked by % Recommended)


The Emergency Department has missed the likelihood to recommend target of 95% (93.71%) and there is a corresponding increase in the percentage not recommending the service (2.40% up from 1.03%).

The response rate has fallen again and missed the 20% required (13.02%) for the third month in a row.

Overall the service benchmarks at 2/12 based on January’s figures for likelihood to recommend (this is up from 5th in December). There were 8 patients unlikely to recommend the care they have received (from a total of 334 responses) and the reasons included mainly waiting (this represented 62.5% of all negative responses up from 60% of negative responses in January) other comments were about staff attitude, receiving conflicting advice and lack of staff / overwork as well as 2 positive comments.

The % of patients "Recommending/Not Recommending the Service" shown above will not always equal a combined total of 100% as it does not include those who are undecided.

Friends and Family Test - A & E (Recommended/Not Recommended)

Definitions

93.71%

% Recommend the service

2.40%% Do not recommend the service

20.2

4%

21.7

0%

19.0

2%

20.6

6%

14.1

9%

13.5

8%

16.6

1%

16.7

3% 23.4

5%

15.1

8%

16.0

3%

13.0

2%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%


Friends and Family Test - Monthly Response Rates for AE

FFT Response Rate (AE) FFT Resp Rate (AE) Target

13.02%

Response Rate(Target 20%)

rrrr


Friends and Family Test - A & E (Response Rates)

Benchmarking - A & E

5.1

8%

4.3

2%

5.0

1%

2.4

7%

0.8

8%

1.2

9%

2.1

4%

1.2

8%

1.6

0%

3.0

4%

1.0

3%

2.4

0%

90.9

7%

89.9

7%

89.2

0%

94.1

3%

95.3

9%

94.4

1%

93.9

7%

95.4

4%

93.6

1%

92.5

1%

96.9

0%

93.7

1%

0%

20%

40%

60%

80%

100%


Friends and Family Test - Monthly % Recommend / Not Recommend for A&E

FFT % Not Recommended (AE) FFT % Recommended (AE)




Org Code%

Recommended

% Not

Recommended

% Response

Rate

RM1 98.70% 1.30% 2.29%

RCX 96.90% 1.03% 16.03%

RGR 95.79% 1.40% 15.73%

RGT 93.95% 2.15% 20.90%

RGP 92.14% 2.86% 5.85%

RGN 91.71% 4.66% 2.16%

RDE 89.77% 5.65% 26.42%

RQW 89.68% 7.80% 34.37%

RDD 89.35% 5.81% 31.72%

RQ8 88.58% 6.46% 18.84%

RGQ 84.14% 8.25% 6.97%

RAJ 83.36% 11.34% 15.38%




MID ESSEX HOSPITAL SERVICES NHS TRUST


Organisation Name (Ranked by % Recommended)









Friends and Family Test - Maternity Services (Recommended/Not Recommended)

Definitions


The % of patients "Recommending / Not Recommending the Service" shown above will not always equal a combined total of 100% as it does not include those who are undecided.Maternity benchmarking is ranked by Question 2 (Labour). Benchmarking data is extracted from the Department of Health's Unify Reporting Tool, and is currently shown a month in arrears.

The Maternity service showed a slight increase in response rate (birth) to 13.77% (15% target) and the lowest likelihood to recommend score for this financial year (86.96%) for birth.

Only 23 responses were collected over the month. All other areas of the maternity pathway achieved the 95% likelihood to recommend target. There was only one patient unlikely to recommend the care they had received across the maternity pathway and this related to staff attitude during birth and lack of acknowledgement of the patient’s birth plan.

Regional maternity information (birth) shows that based on January likelihood to recommend results QEHKL – was joint first.

4.7

6%

1.0

3%

92.8

6%

96.9

1%

98.7

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Dec Jan Feb

FFT - % Recommend/ Not Recommend (Antenatal)

FFT % Recommended Mat Q1 (Antenatal)FFT % Not Recommended Mat Q1 (Antenatal)

4.3

5%

100.0

0%

100.0

0%

86.9

6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Dec Jan Feb

FFT - % Recommend/ Not Recommend (Labour)

FFT % Recommended Mat Q2 (Labour)FFT % Not Recommended Mat Q2 (Labour)

100.0

0%

97.2

2%

100.0

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Dec Jan Feb

FFT - % Recommend/ Not Recommend (Postnatal Ward)

FFT % Recommended Mat Q3 (Postnatal)FFT % Not Recommended Mat Q3 (Postnatal)

2.3

3%

97.6

7%

100.0

0%

100.0

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Dec Jan Feb

FFT - % Recommend/ Not Recommend (Community PostNatal)

FFT % Recommended Mat Q4 (Comm Postnatal)FFT % Not Recommended Mat Q4 (Comm Postnatal)

Response Rate - Labour

14.7

2%

9.5

2% 13.7

7%

0%

5%

10%

15%

20%

25%

30%

Dec Jan Feb

FFT - Response Rate (Labour)

FFT Response Rate Mat Q2 (Labour)FFT Resp Rate (Labour) Target

Benchmarking - Maternity Services





Definitions


The % of patients "Recommending/Not Recommending the Service" shown above will not always equal a combined total of 100% as it does not include those who are undecided.The benchmarking data is extracted from the Department of Health's Unify Reporting Tool, and is currently shown a month in arrears.

Friends and Family Test - Outpatient Services (Recommended/Not Recommmended)

0.9

8%

1.0

3%

0.2

9%

1.1

8%

1.0

2%

0.9

3%

0.7

6%

1.1

6%

0.8

2%

0.8

2%

0.4

1%

1.1

3%

96.6

7%

96.4

1%

97.0

3%

96.2

9%

95.5

0%

97.1

1%

96.7

2%

96.1

0%

96.5

3%

96.3

6%

97.6

9%

96.9

3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Friends and Family Test - Monthly % Recommend / Not Recommend for Outpatients

FFT % Not Recommended (Outpatients) FFT % Recommended (Outpatients)

The level of recommendation within Outpatient services remains high at 96.93% and the Trust benchmarked at 2/13 regionally in January in relation to likelihood to recommend (an increase from 5rd the previous month). There were 14 patients unlikely to recommend and their concerns were across many services but focused on waiting time, the new booking system being used in Arthur Levin Pre-Assessment and the car park

Across the hospital the main areas for concern are (these three areas are regularly mentioned together on many responses received from patients):• Staff Attitude • Waiting time • Overworked and general lack of staff

Benchmarking - Outpatient Services




Org Code % Recommended% Not

Recommended

RDE 98.98% 0.51%

RCX 97.69% 0.41%

RGM 97.55% 1.23%

RGQ 97.23% 0.57%

RM1 96.75% 1.11%

RGP 96.60% 1.02%

RGN 96.02% 0.81%

RGR 95.06% 0.59%

RGT 94.05% 1.62%

RQW 93.97% 3.14%

RAJ 93.94% 2.00%

RDD 92.24% 2.60%

RQ8 90.65% 4.74%MID ESSEX HOSPITAL SERVICES NHS TRUST




Organisation Name (Ranked by % Recommended)



PAPWORTH HOSPITAL NHS FOUNDATION TRUST









Disappointingly after two months without any breaches there have been four breaches this month affecting nine patients in total. All the breaches took place on the Critical Care Unit and reflect the extreme pressure on bed capacity within the Trust that has prevented prompt transfer of patients to ward beds when fit for discharge from the Critical Care Unit. Prevention of MSA breaches remains a daily priority when allocating vacant beds.

Number of Incidents of Mixed Sex Accommodation (MSA) - The number of times Mixed Sex Accommodation occurred within the specified time period.Number of Breaches of Mixed Sex Accommodation (MSA) - The total number of patients affected by Mixed Sex Accommodation occurrences within the specified time period.

Patient Experience - Mixed Sex Accommodation

Mixed Sex Accommodation Incidents


Definitions

4Incidents of Mixed Sex Accommodation rrrr

9No. of Patientsaffected rrrr

24Incidents of Mixed Sex Accommodation rrrr

50No. of Patients affected rrrr

Mixed Sex Accommodation Breaches

21

0

43

4

2 2

4

0 0

4

0

2

4

6

8


No. of Mixed Sex Accommodation Incidents

No. of Mixed sex Accommodation Incidents

42

0

9

68

4 4

8

0 0

9

0

4

8

12

16

20


No. of Mixed Sex Accommodation breaches

No. of Mixed Sex Accommodation Breaches





Analysis of Current Month and YTD

Number of Complaints received into the Trust (Clinical and Non-Clinical)

Complaints


Definitions

19Current Month

7Current Month

284YTDrrrr rrrr

rrrr

Non Clinical Complaints

42YTD

rrrr

Number of complaints received

During the month of February 2018, the Trust received 26 formal complaints. This is eight fewer than last month and six fewer than February 2017 when the Trust received 32 complaints.

Complaints received by Specialty/Key Issues Table

During February 2018, the Emergency Department received 4 complaints, Care of the Elderly received 3 complaints and Gynaecology received 3 complaints. The complaints regarding these areas involved the following issues:

• Poor communication with patient/relatives • Delay or failure to diagnose • Discharge arrangements

Lessons Learned

• To ensure internal processes are followed in Phlebotomy to avoid samples failing to be booked into the system. • To ensure good communication between the treating clinician and family so that misunderstandings do not occur and to listen to

patients and their families and deal with any concerns at the time.

Other Information

• 2 complaints have been re-opened in February 2018. • 3 local resolution meetings were held in February 2018.• 1 complaint was referred to the Parliamentary and Health Service Ombudsman (PHSO). The PHSO are considering the referral of a second case

and the Trust is awaiting the decision as to whether they will investigate. • 75 Travel Expense claims were processed in February 2018.• No PALS surveys were completed in February 2018.





Actions Taken & Lessons Learned





Response Rate - No. of complaints closed within 30 daysCompliments - No. of compliments received into the Trust PALS Contacts - No. of compliments received into the Trust

Definitions

Complaints Cont'd - Response Rates Key Points/Operational Actions

PALS Contacts (including Compliments)

Compliments

The Trust is required to investigate and share the response with the complainant within 30 working days. The compliance rate hasremained the same as last month at 63%, and 10 breaches occurred:

• Surgery 1 had 1 breach out of 2 complaint responses that were due.

• Surgery 2 had 2 breaches out of 3 responses that were due.• Medicine 1 had 2 breaches out of 4 complaint responses that were due.• Medicine 2 had 3 breaches out of 9 complaint responses that were due.• Cancer, Diagnostic & Therapies had 2 breaches out of 5 complaint responses that were due.

Currently there are 19 complaint investigations/responses that are overdue and have not yet been completed, these continue to bechased and escalated. Some overdue complaint responses have now been received from the Divisions and following Executive review and Chief Executive sign-off they will be completed and closed. The Associate Director of Patient Experience and Complaints Manager

are now attending the senior nurse Top Team meetings on a bi-weekly basis with the Chief Nurse and ACN team to review progress and escalate complaints as required. Revised Complaints policy has been ratified and agreed at TEC in February 2018.

105 compliments were received this month, which is a decrease from 173 compliments received last month and in comparison to February 2017, in which the Trust received 130 compliments.

The PALS service has had 401 contacts this month, compared to a figure of 436 in the previous month. This is a decrease in comparison to February 2017, in which 486 contacts were recorded. The top subjects for this month are noted below:




General Information 62

Travel Expenses 26

Discharge Arrangements 20

Clinical Care 17

In-patient Enquiry 17

Complaints Procedure 15

General enquires 14

Test Results 13

Enquiry 12

Staff Attitude 12

Concern 11

Department Details 11

Poor Communication 11


01/12/2017 01/01/2018 01/02/2018 2016/17

Indicators Var to prev mth Target Dec Jan Feb FYTD

National standards 01/12/2017 01/01/2018 01/02/2018 2017/18

18 Wks - Adm (adjusted) Target18 Wks - Adm Perf (adjusted) 90.00% 81.72% 73.66% 76.14% 77.05%

18 Wks - Non Adm Target18 Wks - Non Adm Perf 95.00% 82.84% 81.90% 86.89% 86.28%

18 Wks - Incomp Target18 Wks - Incomp Perf 92.00% 81.32% 82.05% 82.76% 87.09%

Cancer-2ww TargetCancer-2ww 93.00% 96.27% 97.36% NA 96.60%

Cancer-2ww (Breast Symptomatic) TargetCancer-2ww (Breast Symptomatic) 93.00% 97.14% 91.94% NA 97.73%

31 Day Diag to Treat Target31 Day Diag to Treat 96.00% 99.04% 96.67% NA 98.58%

Cancer-62 Days RTT TargetCancer-62 Days RTT 85.00% 83.97% 80.00% NA 83.83%

Cancer-31 Days Sub Treat (Surg) TargetCancer - 31 Days Subsq Treatment - Surgery 94.00% 100.00% 94.74% NA 96.70%

Cancer-31 Days Sub Treat (Drug) TargetCancer - 31 Days Subsq - Drug Treatments 98.00% 98.18% 96.77% NA 99.29%

Cancer Screening (62 Day) TargetCancer Screening (62 Day) 90.00% 100.00% 90.91% NA 98.84%

A&E 4 Hr TargetA&E 4 Hour Performance 95.00% 80.97% 81.10% 69.17% 86.11%

Amb turnaround TargetAmbulance turnaround 100.00% 23.77% 16.03% 9.76% 22.04%

Stroke - 90% of Stay on SU TargetStroke - 90% of Stay on a Stroke Unit 80.00% 91.89% 83.33% NA 85.15%

TIA - HR TIA seen & treated <24hrs TargetTIA - High Risk,Non admitted TIA treated in 24 Hrs 60.00% 70.00% 60.53% NA 69.34%

Cancelled Ops - as a % of Elective Admissions TargetCancelled Ops - as a % of Elective Admissions 0.80% 1.22% 1.02% 2.11% 0.88%

Diagnostic Over 6 Week Waiters - % of Total WL TargetDiagnostic Over 6 Week Waiters - % of Total WL 1.00% 1.69% 2.81% 5.72% 1.19%

Indicators Var to prev mth Target Dec Jan Feb FYTD

Local standards

Day Case Rate TargetDay Case Rate 82.00% 83.49% 87.58% NA 85.82%

DNA Rate TargetDNA Rate 5.00% 6.91% 6.61% 6.56% 6.55%

New to FUP Ratio TargetNew to FUP Ratio 2.3 2.4 2.4 2.4 2.5

Readm Rate (EL) TargetReadmission Rate - ElReadmission Rate - Elective 3.00% 3.41% 3.30% NA 3.57%

Readm Rate (Em) TargetReadmission Rate - EmReadmission Rate - Emergency 10.00% 17.27% 17.21% NA 17.38%

EL LOS TargetLength of stay - Elective 2.2 1.5 1.0 1.0 1.5

EM LOS TargetLength of stay - Emergency 5.0 4.1 4.2 4.5 4.1

Cancer, Stroke, TIA, Day Case & Re-admissions Rates are all normally shown 1 month in arrears.

De

lay

fre

e

Performance & Standards Scorecard

Op

era

tio

na

l E

ffic

ien

cy





RTT Waiting Times – Admitted (90% Target <18 Wks.) RTT Waiting Times – Non-Admitted (95% Target <18 Wks). RTT Waiting Times - Incompletes (92%).

18 Weeks Referral To Treatment


Definitions

78

.26

%

79

.65

%

82

.90

%

75

.80

%

77

.81

%

78

.55

%

75

.39

%

72

.97

%

74

.75

%

81

.72

%

73.6

6%

76

.14

%

77.84% 79.23%82.59%

75.50%77.22% 78.46%

74.98%72.21%

74.39%

81.42%

72.92%75.78%

60%

65%

70%

75%

80%

85%

90%

95%

100%


18 Wks Admitted Performance

18 Wks - Adm Perf (adjusted) 18 Wks - Adm (adjusted) Target 18 Wks - Adm Perf (unadjusted)

90

.43

%

91

.96

%

92

.94

%

89

.32

%

88

.31

%

82

.29

%

83

.19

%

85

.28

%

83

.34

%

82

.84

%

81

.90

%

86

.89

%

80%

85%

90%

95%

100%


18 Wk Non- Admitted Performance

18 Wks - Non Adm Perf 18 Wks - Non Adm Target

92

.38

%

92

.01

%

92

.03

%

92

.03

%

88

.04

%

87

.74

%

87

.20

%

86

.49

%

86

.45

%

81

.32

%

82

.05

%

82

.76

%

80%

85%

90%

95%

100%


18 Wk Incompletes Performance

18 Wks - Incomp Perf 18 Wks - Incomp Target

82.76%Incompletes (Target 92%) rrrr





• Five of Eight Cancer Targets achieved in January except 31 Day Subs Chemotherapy, 2WW Breast Symptomatic and 62 Day GP Referral to Treatment.• Minor drops in performance for 31 Day Subs Chemotherapy and 2WW Breast Symptomatic largely represent patient choice over the Christmas period and are not expected to be repeated in February and

beyond.• Performance had been forecast to significantly drop in February as a result of 62 day backlog clearance however due to a greater than planned number of breach patients being rolled into March this

performance dip is forecast to occur one month later with February performance forecast to be 81.67%. This forecast performance dip is necessary to clear remaining backlog and ensure full and sustainable recovery in April.

• Work continues on the Urology (Prostate) and Lung Transformation projects run by Macmillan West Norfolk and Norfolk & Waveney STP, with revenue and capital funding for the latter now confirmed.

Percentage of cancer patients first seen within 2 weeks in the reporting month (1 month in arrears)Percentage of above Cancer Pathway completed within 31 Days in the reporting month (1 month in arrears)

Cancer Waiting Times


Definitions

90%

92%

94%

96%

98%

100%

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan

2WW Performance

Cancer-2ww 2 WW Target

97.36%2ww (Target 93%)

aaaa

96.67%

31 Day (Target 96%)

aaaa

80.00%62 Day (Target 85%)

rrrr

90%

92%

94%

96%

98%

100%


31 Day Diag To Treat Performance

31 Day Diag to Treat 31 Day Target

60%

64%

68%

72%

76%

80%

84%

88%

92%

96%

100%


62 Day Ref To Treat Performance

Cancer-62 Days RTT 62 Day Target

94.74%31 Day Subs Treat - Surg (Target 94%) aaaa

96.77%31 Day Subs Treat - Drug (Target 98%) rrrr

91.94%2ww Breast Symptomatic (Target 93%) rrrr

90.91%62 Day Screening (Target 90%) aaaa

Site Level Breach Analysis - Latest Month





Cancer Waiting Times (Forecasting)





Sustainability Sustainability

Cancer Site(Target - 85%

Compliance)Estimated remainder

to achieve ForecastSnapshot

position Trajectory Flag

Estimated remainder

to achieve ForecastSnapshot

position Trajectory Flag

Total Treated 0.00 0.00 0.00 0.00 0.00 0.00

Treated Within 62 Days 0.00 0.00 0.00 0.00 0.00 0.00

% Within 62 Days 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Estimated breaches allowed 0.0 0.0

Total Treated 8.00 7.00 11.00 8.00 2.00 10.00


% Within 62 Days 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%


Total Treated 4.00 1.00 7.00 6.50 0.00 6.50


% Within 62 Days 25.0% 100.0% 64.3% Alert 84.6% 0.0% 84.6%

Estimated breaches allowed -0.5 0.0

Total Treated 4.50 4.50 3.00 2.00 0.00 2.50


% Within 62 Days 88.9% 88.9% 33.3% 0.0% 0.0% 40.0% Alert

Estimated breaches allowed 1.5 -0.5

Total Treated 1.50 1.00 3.50 1.50 0.00 3.00


% Within 62 Days 66.7% 50.0% 71.4% Alert 33.3% 0.0% 66.7% Alert


Total Treated 4.00 1.00 7.00 6.50 0.00 7.00


% Within 62 Days 75.0% 100.0% 71.4% 76.9% 0.0% 71.4%


Total Treated 2.50 2.50 3.00 3.00 0.00 3.00


% Within 62 Days 40.0% 40.0% 66.7% Alert 66.7% 0.0% 66.7%

Estimated breaches allowed -0.5 0.0

Total Treated 0.00 0.00 0.50 0.00 0.00 0.50


% Within 62 Days 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%


Total Treated 13.00 9.00 18.00 10.00 1.00 17.00



Estimated breaches allowed -1.0 -3.0

Total Treated 1.00 1.00 3.50 1.50 0.50 3.00


% Within 62 Days 100.0% 100.0% 71.4% 66.7% 0.0% 66.7%


Total Treated 22.00 19.00 18.00 11.50 1.00 15.00




Total Treated 0.00 0.00 0.00 0.00 0.00 0.00


% Within 62 Days 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%


Total Treated 60.50 46.00 74.50 50.50 4.50 67.50


% Within 62 Days 77.69% 80.43% 85.2%Alert 70.30% 66.67% 85.2%

Alert


Mar-18 Trajectory

Breast

Gynaecological

Haematological

Head & Neck

Brain/Central Nervous

System

Trust Total

Lung

Sarcoma

Skin

Upper

Gastrointestinal

Urological

Other

Lower

Gastrointestinal

62 Day Referral to Treatment Cancer Pathway (Exc. screening and upgrades) 3.1

Feb-18 Trajectory


Benchmarking data will only be updated once every quarter.

Cancer Waiting Times - 62 Day Breaches at 63-69 Days

Definitions

Cancer Waiting Times (Benchmarking)




70%

75%

80%

85%

90%

95%

100%

JPH N&N QEH IP P&S CUH WS

2WW Wait Perf for Qtr 3 across East of England

SEEN WITHIN 14 DAYS National Target

70%

75%

80%

85%

90%

95%

100%

JPH WS QEH N&N PAP CUH P&S IP

31 Day Perf for Qtr 3 across East of England

TREATED WITHIN 31 DAYS National Target

45%

55%

65%

75%

85%

95%

PAP JPH WS IP QEH P&S N&N CUH

62 Day RTT Perf for Qtr 3 across East of England

TREATED WITHIN 62 DAYS National Target


The chart above shows the variance in AE activity & performance levels, when compared to the previous month

Percentage of total A&E Attendances for the reporting month that are admitted or discharged within the 4 hour target.The latest benchmarking data is based on the monthly performance (2 months in arrears)

Accident and Emergency

Definitions

69.17%AE Performance - Prev Mth (Target 95%) rrrr

86.11%AE Performance - YTD (Target95%) rrrr

Previous Month's KPI's

Benchmarking across NHS England Midlands & East (East)


Activity & Performance levels of the last 3 months

AE performance (Last 12 month)

90.6

8%

91.3

1%

91.0

2%

83.6

4%

84.1

4%

89.8

0%

93.5

7%

93.8

2%

86.9

0%

80.9

7%

81.1

0%

69.1

7%

0%

20%

40%

60%

80%

100%

Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan FebA&E 4 Hour Performance A&E 4 Hr Target

• Performance against the four target has continued to deteriorate with the top 3 breach causes being E1 bed capacity, A221/2 delays to initial assessment due to no capacity within the Department and A3 decision to admit/discharge (admission avoidance)

• Breaches related to psychiatric service availability remain a concern both for delay in initial assessment (particularly overnight and especially for CAMMS patients) and for bed availability. This is having an effect on the well-being of both the patients and the staff within the department.

• Ambulance handover delays and the number of patients queing/cohorted within the corridor capacity of the department has caused clinical concerns related to the overcrowding within a busy environment

• A number of initiatives have now been launched to stream line processes and improve performance .These remain at an early stage but initial findings are that each of the initiatives are having a positive impact on performance. This includes;

• RAB on MAU . The Rapid Assessment Bays create extra capacity and a focussed approach for the assessment and treatment of both GP and ED referred patients. When the RAB system has been in operation there has been a noticeable improvement in patient flow. This initiative needs to be maintained as the benefits out way the potential negatives. The Acute Physicians are driving this initiative which has been led by Sister Morris on MAU

• Patient Flow Navigator. This is a newly developed post which aims to give additional administrative support to the ED co-ordinator and act as a ‘breach buster’.• EDDS – focus on the EDDs through the point prevalence process is giving focus to discharge which creates further capacity






Potential fines per case in

£230,000.00

£958,000.00

£392,400.00

£0.00

£0.000 - 15 Min

2017/18 YTD value of breaches

30 - 60 Min

15 - 30 Min

Over 2 Hr

1 - 2 Hr

Ambulance Handovers


Definitions

9.76%

% of handovers within 15 minutes

22.04%

% of handovers within 15 minutes rrrrrrrr

The percentage of the total Ambulance handovers within the reporting month where the handover was less than 15 minutes in duration.

• Handover times have been compromised by poor flow in the Trust and a subsequent lack of capacity within the Department• A new handover SOP has been created which improves escalation so early sight of potential delays can be actioned• The SOP includes utilisation of additional cohort area although this is subject to staff availability• Load levelling has been in operation – this is discretionary and led by EEAST• Work continues to steam line the handover process which will improve performance for handovers that currently take between 15 and 30 minutes (this is our largest cohort of patient

delays)

0

500

1000

1500

2000

2500


Nu

mb

er

of

Pa

tie

nts

Monthly Ambulance Handover Times

0 - 15 Minutes 15 - 30 Minutes 30 - 1 Hour 1 - 2 Hours 2 Hr+

4085

11300

1962

958

230

2017/18 YTD Ambulance Handover times

0 - 15 Minutes 15 - 30 Minutes 30 - 1 Hour 1 - 2 Hours 2 Hours +

0%

10%

20%

30%

40%

50%

60%

70%

80%


Nu

mb

er

of

Pa

tie

nts

Handovers within 0-15 mins & 15-30 mins - rolling 12 Months

0 - 15 Minutes 15-30 Min





What’s working well Stroke Recent National SSNAP score – we have achieved ‘A’ (highest quartile). Door to Scan time has remained consistently good14 hrs consultant review has been maintained at 80% or more Challenging diagnosis and overall patient flow pressure did impact on overall improvement Appointment of new Band 7 Stroke Ward manager

Risks we are carrying at the momentStroke Specialist Thrombo nurse are not available 24/7 in a consistent way – it has impacted adversely on the performance of stroke services - it has been raised on many occasions as a significant riskESD for West Norfolk patient as CCG is not agreeing for ESD pathway (almost all stroke services in England have ESD except us)Stroke AF service – Successful in getting successful bid for AHSN funded Mobile ECG devices for AF detectionWeekend 14 hrs review- discussions with the team to extend review over the weekend – to have extended hours on the weekend

Sentinel Stroke National Audit Programme (SSNAP) is the single source of data for stroke in England and Wales. It provides the data for all other statutory data collections in England including the NICE Quality Standard and Accelerating Stroke Improvement (ASI) metrics and is the chosen method for collection of stroke measures in the NHS Outcomes Framework and the CCG Outcomes Indicator Set. SSNAP metrics are aligned with those in the Cardiovascular Disease Outcomes Strategy. SSNAP data are being used as risk indicators for Care Quality Commission’s Intelligent Monitoring and for the Stroke Care in England NHS Marker.Key Indicators:Percentage of Stroke patients that spend 90% of their hospital stay on the stroke unit (latest available data)Percentage of Stroke patients directly admitted to a stroke unit within 4 hours of clock start (latest available data)Percentage of Stroke patients scanned within 1 hour of clock start (latest available data)Percentage of Stroke patients scanned within 12 hours of clock start (latest available data)

Stroke Performance


Definitions

Key Indicator : Direct to Stroke Unit within 4 hours Key Indicator : Patient scanned within 1 hour of clock start Key Indicator : Patient scanned within 12 hours of clock start




90.00%

85.00%

80.00%

75.00%

<75.00%

83.33%

Monthly Performance %

E

D

Jan-18

A

B

CSSNAP Level

YTD Performance %

C B

YTD SSNAP Level

85.15%

YTD 2017/2018SSNAP Target Levels


The current RCP SSNAP still requires us to categorise TIA patients as High and Low risk where we have been achieving the target consistently for more than 6 months especially for high risk group who are at risk of impending stroke. 67% of High risk patients (risk of having stroke) are being reviewed by Stroke TIA team within 24 hours of their symptom onset (target being 60%). 76% of suspected Low risk patients are being seen within 7 days of patients making first medical contact in the primary care ; however only 41% when their first symptoms appeared ( it improves at the time of Stroke FAST national public education/awareness adverts) Weekend TIA services to be re-discussed – to be completed by Apr 2018

Percentage of High Risk TIA's that are not admitted, seen and treated within 24 hours (latest available data) Percentage of High Risk TIA's that are seen and treated within 24 hours (latest available data) Percentage of Low Risk TIA's that are seen and treated within 7 days of 1st contact with a healthcare professional (latest available data) Percentage of Low Risk TIA's that are seen and treated within 7 days of onset of symptoms (latest available data)

Transient Ischaemic Attack (TIA) Performance


Definitions





The Trust failed the 6 week diagnostic target in February.

A significant majority of the breaches are within DEXA. The main reasons for the breaches are capacity issues, machine down time, and no dedicated admin support.

A plan is being put into place to secure dedicated admin support for the service.

Across other diagnostic tests performance has improved from January

Denominator :The number of patients waiting for a diagnostic test at the end of the reporting periodNumerator: The number of patients waiting 6 weeks or more for a diagnostic test at the end of the reporting period

Diagnostic Waiting Times (% of Pat's Waiting >6 Wks)


Definitions

5.72%(Target 1%)

rrrr





Latest Month's Performance

New to review: Ratio of total follow-up attendances against the total number of new patient attendances for the reporting month

New to Follow up Ratio

Definitions

2.82.6 2.6 2.5 2.4

2.7 2.5 2.5 2.4 2.4 2.4 2.4

0.0

1.0

2.0

3.0


New to Follow Up ratio against local target

New to FUP Ratio target

2.4

Trust Level New to Review Rate

(Target 2.3) rrrr






For the specialties of Neurology, Pain, Paediatric ENT and Cardiology we are booking out to 10 weeks rather than the normal 6 weeks.Updates to e-Referral (Choose and Book) means that as from 19th March we are now able to view ASI’s without having to book the patient an appointment first of all. This should give us the benefit of reviewing referrals to ensure they are appropriately referred into the correct specialty.

ASI are appointment slot issues. ASI's occur in e-Referral (Choose & Book) because we have an insufficient number of clinic slots available within a 'polling range' for a specialty.

ASI's (Appointment Slot Issues)

Definitions





22/02 01/03 08/03 15/03

ORT 416 436 418 441

URO 390 404 414 426

CAR 308 303 308 330

ENT 269 291 297 308

DER 302 250 262 295

NEU 337 285 289 287

OPH 155 175 201 224

RES 184 188 190 185

RHE 138 138 145 159

PAE 133 146 157 157

END 106 107 113 112

PC 81 88 102 106

NEP 69 74 81 78

GYN 11 21 43 51

UGI 12 36 34 36

2WW 13 9 13 18

GER 13 14 17 16

SUR 0 0 1 1

DM 0 0 0 1

ORS 0 0 0 0

BSU 0 0 0 0

ASI's Last 4 Weeks



DNA Rate: Total No. of New & Follow Up appointments where the outcome was "DNA" (Did Not Attend), as a proportion of the Total No. of "Attended" and DNA'd appointmentsThe DNA figures above exclude Ward Attender activity, and is based on "Clinic" Specialty, rather than "Referral" Specialty.

DNA rate

Definitions

6.05% 6.20% 6.50% 6.84% 6.56% 6.65% 6.48% 6.39% 6.36%6.91% 6.61% 6.56%

0.0%

2.0%

4.0%

6.0%

8.0%


DNA (Did not attend appointments) rate against local target

DNA Rate DNA Rate Target

6.56%DNA rate (Target 5.0) rrrr






Latest Month's Performance Previous Month's Re-admission Rate

Re-admissions is currently reported 1 month in arrears

Elective Average LOS - The average spell length of stay for Elective Admissions discharged within the reporting month.

Elective Re-admissions - The % of patients readmitted within 30 days of an Elective admission during the current financial year.

Elective Inpatient - Average Length of Stay & Re-admissions

1.51.8 1.7

2.11.5 1.4 1.6 1.6 1.6 1.5

1.0 1.0

0.0%

2.0%

4.0%

6.0%

0.0

0.5

1.0

1.5

2.0

2.5


Trust Level - Average LOS - Elective

Length of stay - Elective target Readmission Rate - El

1.0

Average LOS

Elective Admission (Target 2.2) aaaa

3.30%

Re-adm following Elective

Admission (Target 3%) rrrr

Definitions

5.1

9%

4.1

7%

3.5

4%

4.1

8%

4.1

2%

3.8

8%

3.2

6%

2.6

4%

3.9

3%

3.3

4%

3.4

1%

3.3

0%

0%

1%

2%

3%

4%

5%

6%


Trust Level - Elective Re-admission Rate Performance Against Target

Readmission Rate - El Readm Rate (EL) Target






Latest Month's Performance Previous Month's Re-admission Rate

Re-admissions is currently reported 1 month in arrears

Emergency Average LOS - The average spell length of stay for Emergency Admissions discharged within the reporting month. Emergency Re-admissions - The % of patients readmitted within 30 days of an Emergency admission during the current financial year. This is currently reporting 1 month in arrears.

Emergency Admissions - Average Length of Stay & Re-admissions

3.6 3.9 3.7 3.9 4.0 4.3 4.3 4.0 3.8 4.1 4.2 4.5

0.0%

5.0%

10.0%

15.0%

20.0%

0.0

2.0

4.0

6.0


Trust Level - Average LOS - Emergency

Length of stay - Emergency target Readmission Rate - Em

4.5

Average LOS Emergency Admission (Target 5.0) aaaa

17.21%

Re-adm following Emergency Admission (Target 10%) rrrr

Definitions

15

.53

%

15

.78

%

18

.68

%

17

.57

%

17

.57

%

17

.31

%

17

.81

%

15

.90

%

16

.76

%

17

.77

%

17

.27

%

17

.21

%

0%

5%

10%

15%

20%


Trust Level - Emergency Re-admission Rate Performance Against Target

Readmission Rate - Em Readm Rate (Em) Target






Elective Re-admissions Rates by Specialty

Definitions

Elective Re-admissions - The % of patients per specialty readmitted within 30 days of an Elective admission during the current financial year. Based on the specialty at discharge.Emergency Re-admissions - The % of patients per specialty readmitted within 30 days of an Emergency admission during the current financial year. Based on the specialty at discharge.

Emergency Re-admissions Rates by Specialty





CQUINs




CQUIN No. Q1 STATUS Q1 VALUE Q2 STATUS Q2 VALUE Q3 STATUS Q3 VALUE Q4 STATUS Q4 VALUE

1a Heallthy Foods - more healthy options /

reduced sugar content etc

£115,892.00

1b Staff Survey - 5% improvement on 2 out of the 3

questions relating to H&W

£115,753.00

1c Flu uptake (front line clinical staff) £115,753.00

2a Sepsis -timely Identification £21,712.50 £21,712.50 £21,712.50 £21,712.50

2b Sepsis - timely treatment £21,712.50 £10,856.25 £21,712.50 £21,712.50

2c Empiric Review of antibiotic prescriptions

(72hrs)£21,712.50 £21,712.50 £21,712.50 £21,712.50

2d Reduction in Antibiotic Consumption per 1,000

admissions£86,850.00

4 Improving services for

people presenting

with Mental Health

needs in A&E

Frequent Attenders (more than 10 occurrences

in 16/17) - identify cohort of patients who

would benefit from mental health &

psychology interventions AC

HIE

VED

10

0%

£34,739.80

AC

HIE

VED

10

0%

£138,959.20

TRUST

CHALLENGING

DECISION - TO BE

DISCUSSED AT

NEXT CQRG -

12TH APRIL

£34,739.80 £138,959.20

6 Offering Advice &

Guidance

Improvement of A&E for Rhuematology &

Neurology / Implement Quality standard /

propose additional services in Q4 to take

forward next year AC

HIE

VED

10

0%

£86,849.50

AC

HIE

VED

10

0%

£86,849.50

AC

HIE

VED

10

0%

£86,849.50 £86,849.50

7 NHS e-Referral 1. NHS e-Referrals (All providers to publish ALL

such services and make ALL of their First O/P

Appointments slots available on NHS e-referral

services (e-RS) by 31st March 2018 following the

trajectory

2. a trajectory to reduce Appointment Slot

Issues to a level of 4%, or less, over Q2, Q3 and

Q4A

CH

IEV

ED

10

0%

£86,849.50

AC

HIE

VED

10

0%

£86,849.50

TRUST

CHALLENGING

DECISION - TO BE

DISCUSSED AT

NEXT CQRG -

12TH APRIL

£86,849.50 £86,849.50

8 Supporting Proactive

and Safe Discharge

2.5% point increase discharge to usual place of

residence: across Q3 and Q4 2017/18 OR an

increase to 47.5% across Q3 and 4 2017/18

AC

HIE

VED

10

0%

£52,109.70

AC

HIE

VED

10

0%

£138,959.20 NO

AC

HIE

VEM

E

NT

£17,369.90 £138,959.20

1 Medicines

Optimisation

The CQUIN aims to support the procedural and

cultural changes required fully to optimise use

of medicines commissioned by specialised

services. AC

HIE

VED

10

0%

£31,560.00

AC

HIE

VED

10

0%

£13,525.00

AC

HIE

VED

10

0%

£22,542.00 £40,577.00

2 Dental Dashboard Provider is required to submit a fully populated

Dental Quality Dashboard as per the embedded

format (see actual CQUIN) in respect of the

dental specialties they provide AC

HIE

VED

10

0%

£11,089.75

AC

HIE

VED

10

0%

£11,089.75Awaiting

confirmation£11,089.75 £11,089.75

3 Breast Screening Breast Cancer Screening Interval Cancer

Network for Norfolk and Waveney

AC

HIE

VED

10

0%

£3,201.00

AC

HIE

VED

10

0%

£3,201.00Awaiting

confirmation£3,201.00 £3,201.00

4 Armed Forces Embedding the Armed Forces Covenant to

support improved health outcomes for the

Armed Forces Community

AC

HIE

VED

10

0%

£6,301.50Awaiting

confirmation£6,301.50 £12,603.00

Update only no Financial

value

NHSE SPECIALIST CONTRACT

CQUIN Description

H&W

SEPSIS

N/A

N/A

AC

HIE

VED

10

0%

ACUTE CONTRACT

PA

RTIA

LLY

AC

HIE

VED

83

.25

%

AC

HIE

VED

10

0%


Indicators Var to prev mth Target Dec Jan FebRolling

12 mths

Staff Sickness & Turnover 01/12/2017 01/01/2018 01/02/2018

Sickness Absence Rate (Target)Sickness Absence Rate 3.50% 5.73% 6.55% 6.33% 5.12%

Staff Turnover Rate Complete Trust (Target)Staff Turnover Rate Complete Trust 10.00% 11.76% 11.86% 12.25% 11.55%

Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) (Target)Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) 10.00% 10.37% 10.89% 11.83% 9.35%

Staff Turnover Rate Registered Nursing & Midwifery (Target)Staff Turnover Rate Registered Nursing & Midwifery 10.00% 13.27% 13.33% 13.87% 14.14%

Staff Turnover Rate Allied Health Professionals (Target)Staff Turnover Rate Allied Health Professionals 10.00% 16.20% 15.67% 15.82% 17.76%

Appraisals

Appraisal Completeness excluding bank staff (Target)Appraisal Completeness excluding bank staff 90.00% 83.90% 85.31% 83.96% 84.06%

Vacancies

Medical & Dental Vacancies (as % of Medical Posts) (Target)Medical & Dental Vacancies (as % of Medical Posts) 5.00% 21.13% 20.93% 20.10% 20.67%

Registered Nurses & Midwives Vacancies (as % of Nurse Posts) (Target)Registered Nurses & Midwives Vacancies (as % of Nurse Posts) 6.00% 12.84% 11.67% 11.90% 12.87%

Allied Health Professional Vacancies (as % of AHP Posts) (Target)Allied Health Professional Vacancies (as % of AHP Posts) 6.00% 7.98% 7.38% 8.02% 9.35%

Contracted staff in Post (WTE) 2790 2802 2807 2777

Temporary Staff in Post (WTE) 206 187 207 283

Mandatory Training

Conflict Resolution Training (Target)Conflict Resolution Training 95.00% 83.42% 84.46% 84.74% 83.60%

Equality and Diversity Training (Target)Equality and Diversity Training 95.00% 78.85% 79.99% 80.65% 71.98%

Fire Training (Target)Fire Training 95.00% 75.44% 76.00% 75.72% 74.32%

Health & Safety Training (Target)Health & Safety Training 95.00% 89.05% 88.63% 91.44% 90.77%

Infection Control Training (Target)Infection Control Training 95.00% 78.79% 80.36% 80.91% 78.32%

Information Governance Training (Target)Information Governance Training 95.00% 83.24% 84.70% 84.80% 87.15%

Manual Handling Training (Target)Manual Handling Training 95.00% 81.85% 83.16% 82.62% 82.95%

Basic Life Support Training (Target)Basic Life Support Training 95.00% 79.83% 78.95% 80.42% 80.74%

Risk Management Training (Target)Risk Management Training (Level 2 only) 90.00% 94.77% 94.48% 94.49% 88.55%

Safeguarding Adults Training (Target)Safeguarding Adults Training 95.00% 92.83% 93.36% 93.07% 93.08%

Safeguarding Children Training (Target)Safeguarding Children Training 95.00% 91.22% 90.38% 90.19% 91.08%

Slips, Trips & Falls Training (Target)Slips, Trips & Falls Training 90.00% 86.41% 88.28% 90.83% 91.00%

VTE Training (Target)VTE Training 90.00% 71.99% 71.68% 72.41% 75.75%

Mandatory Training Overall (10 core subjects) (Target)Mandatory Training Overall (10 core subjects) 95.00% 83.45% 84.18% 84.46% 83.40%

The percentage figure shown for Risk Management Training currently represents Level 2 only (Level 2 - Heads of Departments)

Wo

rkfo

rce

Workforce Scorecard





Safer Staffing Return





Specialty 1 Specialty 2

West Newton 430 - GERIATRIC MEDICINE 84.4% 118.7% 96.4% 145.4% 767 2.8 5.5 8.2

Necton 340 - RESPIRATORY MEDICINE 80.6% 100.2% 105.3% 95.2% 847 3.2 2.7 6.0

Windsor 430 - GERIATRIC MEDICINE 86.5% 88.2% 104.7% 96.7% 911 2.6 2.7 5.4

Stanhoe 301 - GASTROENTEROLOGY 350 - INFECTIOUS DISEASES 85.7% 93.1% 104.5% 96.8% 899 3.2 2.9 6.0

Tilney 320 - CARDIOLOGY 88.1% 94.9% 96.4% 102.5% 716 3.0 2.3 5.4

West Raynham 300 - GENERAL MEDICINE 88.0% 84.8% 91.2% 93.1% 752 3.9 3.0 6.9

Denver 100 - GENERAL SURGERY 91.8% 98.9% 97.7% 135.5% 796 2.8 2.8 5.6

Marham 100 - GENERAL SURGERY 82.4% 80.8% 91.8% 92.6% 734 3.0 1.9 4.9

Elm 100 - GENERAL SURGERY 88.2% 92.9% 103.6% 86.3% 557 2.9 2.5 5.4

Gayton 110 - TRAUMA & ORTHOPAEDICS 100 - GENERAL SURGERY 88.4% 89.4% 101.2% 97.0% 870 2.8 2.9 5.6

Shouldham 315 - PALLIATIVE MEDICINE 823 - HAEMATOLOGY 73.3% 131.2% 100.6% 83.5% 328 4.3 3.0 7.4

Critical Care 192 - CRITICAL CARE MEDICINE 86.5% 64.2% 91.3% 305 21.6 0.9 22.5

Central Delivery suite 501 - OBSTETRICS 90.0% 96.4% 92.7% 88.5% 130 28.3 9.6 37.9

Surgical Assessment Unit 100 - GENERAL SURGERY 83.5% 98.7% 86.9% 103.1% 251 7.1 2.8 9.9

Medical Assessment Unit 300 - GENERAL MEDICINE 83.4% 88.4% 113.0% 134.6% 612 5.4 2.3 7.7

Terrington 300 - GENERAL MEDICINE 80.8% 111.4% 88.4% 99.8% 908 2.8 2.2 5.0

Castleacre 501 - OBSTETRICS 98.2% 96.7% 100.1% 97.9% 340 4.9 3.8 8.7

NICU 420 - PAEDIATRICS 91.3% 43.7% 101.5% 188.9% 207 11.7 4.7 16.4

Rudham 420 - PAEDIATRICS 87.3% 81.9% 102.5% 107.1% 341 8.6 3.0 11.6

ED Obs Ward 180 - ACCIDENT & EMERGENCY 87.1% 90.0% 82 6.9 0.0 6.9

Oxborough 300 - GENERAL MEDICINE 93.5% 97.5% 103.6% 97.5% 888 2.6 2.6 5.2

Overall

Day

Ward name

Main 2 Specialties on each ward

Average

fill rate -

registered

nurses/mid

wives (%)

Average

fill rate -

care staff

(%)

Feb-18

Average

fill rate -

registered

nurses/mid

wives (%)

Night Care Hours Per Patient Day (CHPPD)

Average

fill rate -

care staff

(%)

Cumulative

count over

the month

of patients

at 23:59

each day

Registered

midwives/

nurses

Care Staff


Number of leavers (HC) divided by average staff in post over previous 12 months. Permanent staff only.

Supernumerary staff are included within the Nursing & Midwifery vacancy rates calculation, providing the staff are NMC registered at the time.

Nursing staff


Definitions

VacanciesThe number of registered nursing vacancies increased to 11.90% from 11.67% in January 2018, as have AHP vacancies to 8.02% from 7.38%. Medical & Dental vacancies decreased to 20.10% from 20.93%.

TurnoverThe turnover rate for the Trust has increased for the third month to 12.25% from 11.86% in January 2018.

780

800

820

840All Registered Nursing Staff in Post : Rolling year

All registered Nursing Staff in post: Rolling yearLinear (All registered Nursing Staff in post: Rolling year)

330

340

350

360

370

380Elective/Emergency based Registered Nursing Staff in Post: Rolling year

Elective/Emergency based Registered Nursing Staff in post: Rolling YearLinear (Elective/Emergency based Registered Nursing Staff in post: Rolling Year)

400

420

440

460All Unregistered Nursing Staff in Post : Rolling year

All Unregistered Nursing Staff in Post : Rolling yearLinear (All Unregistered Nursing Staff in Post : Rolling year)

100

150

200

250

300 Elective/Emergency based on Unregistered Nursing Staff in Post: Rolling year

Elective/Emergency based on Unregistered Nursing Staff in Post: Rolling yearLinear (Elective/Emergency based on Unregistered Nursing Staff in Post: Rolling year)






Overdue by 18-24 months

16 Permanent, 1 Fixed Term Contract, 8 Bank staff

• Scientific & Technical x 3• Additional Clinical Services x 7• Admin & Clerical x 5• Allied Health Professionals x 2• Nursing & Midwifery x 8

Percentage of staff ( Headcount ) including bank who have had an appraisal within previous 12 months.Percentage of staff ( Headcount ) excluding bank who have had an appraisal within previous 12 months.

Appraisal


Definitions

83.96%Appraisal Compliance Exc Bank Staff (Target 90%) rrrr

83.7

8%

83.8

7%

84.4

6%

84.2

3%

85.3

1%

82.9

0%

82.2

6%

83.0

7%

85.3

1%

83.9

0%

85.3

1%

83.9

6%

60.0%

70.0%

80.0%

90.0%

100.0%


Appraisal Compliance Rates (exc Bank Staff)

Actual (excluding bank staff) Target (excluding bank staff) Prev Year

Excluding bank staff, the non-medical appraisal completion compliance has decreased to 82.49% (83.96% including bank staff) in February 2018. The number of seriously overdue appraisals continues to increase, with twenty five staff now in the 18 to 24 month category

Overdue by 24 months +




83.3

1%

83.2

3%

83.4

7%

83.3

9%

83.5

6%

81.1

8%

81.1

0%

81.9

1%

84.4

1%

83.1

3%

84.1

7%

82.4

9%

60.0%

70.0%

80.0%

90.0%

100.0%


Appraisal Compliance Rates (inc Bank Staff)

Actual (including bank staff) Target (including bank staff)


The monthly sickness rate for February 2018 is 6.33% which is a decrease of 0.22% from last month’s adjusted figure (6.55%).

The highest staff groups are:

• Scientific & Technical (10.10%)• Estates and Ancillary (8.46%)• Additional Clinical Services (8.34%)• Nursing & Midwifery (6.36%)• Admin & Clerical (5.76%)

All other staff groups were below 5%.

Percentage sickness absence for the month. Based on FTE days absent divided by FTE days available.

Sickness Absence & Turnover


Definitions

6.33%Sickness Absence Rate

rrrr

0.0%

2.0%

4.0%

6.0%

8.0%QEH sickness absence compared with complete NHS ("Complete NHS" data is currently 3 months in arrears)

QEH

SmallacuteNHS

TargetQEH





The percentage figure shown for Risk Management Training currently represents Level 2 only (Level 2 - Heads of Departments)

Mandatory Training


Definitions

84.46%Mandatory Training (Trust) rrrr

Compliance rate for the 10 core subjects has increased slightly to 84.46% from 84.18% in January 2018.




Feb-18Mthly

Target

Rolling

12 Mths

Conflict Resolution Training 84.74% 95.00% 83.60%

Equality and Diversity Training 80.65% 95.00% 71.98%

Fire Training 75.72% 95.00% 74.32%

Health & Safety Training 91.44% 95.00% 90.77%

Infection Control Training 80.91% 95.00% 78.32%

Information Governance Training 84.80% 95.00% 87.15%

Manual Handling Training 82.62% 95.00% 82.95%

Basic Life Support Training 80.42% 95.00% 80.74%

Risk Management Training (level 2 only) 94.49% 90.00% 88.55%

Safeguarding Adults Training 93.07% 95.00% 93.08%

Safeguarding Children Training 90.19% 95.00% 91.08%

Slips, Trips & Falls Training 90.83% 90.00% 91.00%

VTE Training 72.41% 90.00% 75.75%

Mandatory Training Overall (10 core subjects) 84.46% 95.00% 83.40%


Finance report to follow seperately

Finance





None

Appendices





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