Integrated Report
Quality,Performance & Workforce toend September 2017
Contents
Sep-17 Sep-17 01/07/2017 01/08/2017 01/09/2017
Current MthTrend on
prev mth
Previous
MthJul-17 Aug-17 Sep-17 FYTD
1 23 2 1
441 Emergency Department Attendances 5257 5698 5725 5698 5257 33187
2508 Outpatient Attendances 22436 24944 24727 24944 22436 145304
15 Inpatient Admissions (Elective & Emergency) 3869 3884 4095 3884 3869 23718
278 Other (regular day patients, day cases etc) 2885 3163 3015 3163 2885 18730
Compliance Scorecard1
Quality & Risk2
Performance & Standards3
CQUINS4
Workforce5
Appendices6
7
8
Page 3
Page 4
Page 32
Page 49
Page 50
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
QTDJul Aug Sep Qtr 1 Qtr 2 Qtr 3 Qtr 4 *FYTD
Risk Assessment framework 2015/16 5 01/07/2017 01/08/2017 01/09/2017 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% 77.22% 77.81% 78.55% 75.39% 78.34% 77.22% 78.34%
18 Wks - Non Adm Target18 Wks - Non Adm Perf 95.00% 84.61% 88.31% 82.29% 83.19% 91.40% 84.61% 88.17%
18 Wks - Incomp Target18 Wks - Incomp Perf 92.00% 87.66% 88.04% 87.74% 87.20% 92.02% 87.66% 89.82%
A&E 4 Hr TargetA&E 4 Hour Performance 95.00% 89.04% 84.14% 89.80% 93.55% 88.64% 89.04% 88.84%
Cancer-62 Days RTT TargetCancer-62 Days RTT 85.00% 87.42% 86.49% 88.31% n/a 79.37% 87.42% 83.10%
Cancer-31 Days Sub Treat (Surg) TargetCancer - 31 Days Subsq Treatment - Surgery 94.00% 100.00% 100.00% 100.00% n/a 93.55% 100.00% 95.83%
Cancer-31 Days Sub Treat (Drug) TargetCancer - 31 Days Subsq - Drug Treatments 98.00% 99.14% 98.04% 100.00% n/a 100.00% 99.14% 99.64%
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% 98.35% 97.41% 99.21% n/a 98.39% 98.35% 98.38%
Cancer-2ww TargetCan
cer-Cancer-2 Wk Waits - All urgent Referrals (cancer suspected) 93.00% 96.17% 95.88% 96.45% n/a 97.44% 96.17% 96.90%
Cancer-2ww (Breast Symptomatic) TargetCan
cer-Cancer-2 Wk Waits - Symptomatic breast patients (cancer not initially suspected) 93.00% 99.37% 100.00% 98.72% n/a 97.13% 99.37% 98.01%
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 4 13 5 3 5 9 13 0 0 22
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 4 **
*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
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Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
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01/07/2017 01/08/2017 01/09/2017
Indicators Var to prev mth Target Jul Aug Sep *FYTDCritical Incidents 01/07/2017 01/08/2017 01/09/2017 2017/18 2016/17
Total Never Events (Target)Total Never Events 0 0 0 0 0Total Falls Resulting in Serious Harm (Target)Total Falls Resulting in Serious Harm 0 0 1 0 3Pressure Ulcers - Grade 3 (Target)Pressure Ulcers - Grade 3 0 2 1 3 10Pressure Ulcers - Grade 4 (Target)Pressure Ulcers - Grade 4 0 0 0 0 0Total Other SIs (Target)Total Other Sis 0 1 1 0 11Pressure Ulcers - Grade 2 (Target)Pressure Ulcers - Grade 2 0 3 4 2 15Safety Thermometer - (new harm only) TargetSafety Thermometer - (New Harm Free) 95.00% 96.50% 96.12% 97.22% 96.00%VTE Assess TargetVTE Assessment Completeness 97.24% 97.42% 97.28% NA 97.50%
Infection ControlMRSA (Target)MRSA 0 0 0 0 0CDIFF (Target)CDIFF 4 5 3 5 22
Indicators Var to prev mth Target Jul Aug Sep *FYTDPatient experienceFFT % Recommended (IP & DC) 94.75% 95.75% 95.35% 95.58%FFT % Recommended (AE) 95.39% 94.41% 93.97% 92.58%
FFT Resp Rate (IP & DC) TargetFFT Response Rate (IP & DC) 30.00% 32.63% 29.44% 30.03% 32.22%FFT Resp Rate (AE) TargetFFT Response Rate (AE) 20.00% 14.19% 13.58% 16.61% 17.54%MSA Breaches TargetNo. of Mixed Sex Accommodation breaches 0 6 8 4 29
Number of Patient moves (over 2) 48 30 34 252Positive experienceCompliments 150 180 152 925Complaints
Non-Clinical Complaints TargetNon-Clinical Complaints 1 6 7 16Clinical Complaints TargetClinical Complaints 31 32 27 176
Indicators Var to prev mth Target Jul Aug Sep *FYTDMortality
Crude Mortality (deaths per 1000 admissions) TargetDeaths per 1000 admsCrude Mortality (deaths per 1000 admissions) 19 11.1 14.3 14.4 13.5RAMI (Risk adjusted mortality) (National target)SHMI (Summary Hospital Level Mortality Indicator) Apr 16 - Mar 17 as expected 98.14
HSMR (Hospital Standardised Mortality Ratio) Jul 16 - Jun 17 as expected 101.50Outcome
Stroke - 90% of Stay on SU TargetStroke - 90% of Stay on a Stroke Unit 80.00% 75.41% 87.50% NA 82.54%TIA - HR TIA seen & treated <24hrs TargetTIA - High Risk,Non admitted TIA treated in 24 Hrs 60.00% 63.16% 66.67% NA 75.00%EL LOS TargetLength of stay - Elective 2.2 1.6 1.5 1.6 1.7EM LOS TargetLength of stay - Emergency 5.0 3.6 3.9 3.9 3.7Readm Rate (EL) TargetReadmission Rate - ElReadmission Rate - Elective 3.00% 4.34% 3.62% NA 4.34%Readm Rate (Em) TargetReadmission Rate - EmReadmission Rate - Emergency 10.00% 15.19% 15.75% NA 15.83%
Indicators Var to prev mth Target Jul Aug Sep Rolling 12 mthsWorkforce
Sickness Absence Rate (Target)Sickness Absence Rate 3.50% 5.17% 5.06% 4.80% 4.99%Staff Turnover Rate Complete Trust (Target)Staff Turnover Rate Complete Trust 10.00% 11.45% 11.16% 11.68% 11.26%Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) (Target)Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) 10.00% 7.74% 6.47% 8.80% 10.54%Staff Turnover Rate Registered Nursing & Midwifery (Target)Staff Turnover Rate Registered Nursing & Midwifery 10.00% 14.83% 14.70% 15.41% 14.22%Staff Turnover Rate Allied Health Professionals (Target)Staff Turnover Rate Allied Health Professionals 10.00% 19.56% 17.83% 15.48% 18.04%
*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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Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
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Methodology used to derive the HSMR is freely available. Latest Dr Foster Mortality Summary shows QEH is 101.5 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 Jul 16 - Jun 17 is 101.5 as expected
Weekday HSMR is 99.84 as expected
Weekend HSMR is 105.14 as expected
Latest Report shows QEH is 98.14 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 Apr 16 - Mar 17 is 98.14 as expected
SHMI for Q4 of 16/17 is 99.45 which is as expected
Reporting to the Board - The Medical Director will continue to monitor HSMR and SHMI data and provide exception reports to the Board as necessary, should these indicators demonstrate results which are other than ‘as expected’.
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)
Our HSMR is within expected at 101.5. Our SHMI is also within expected at 0.98. Both weekday and weekend HSMR are within the expected ranges.
Compliance Scorecard
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StandardsCQUINS Workforce Finance Appendices
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Crude rate within HSMR basket is 3.42% (based on Jul 16-Jun 17),East of England rate = 3.72%
Perinatal mortality - Death of the foetus or live born between 24 weeks gestational age to 7 days post natal
May's Crude Mortality Rate (3.39) is comparable to that of May of 2016 (3.40). However the rate dropped in
Jun's to 2.81 which is the lowest recorded rate since Oct 2011.
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 'Palliative Care Coding' rate of (1.43%) for 17/18, is low when compared to the National average (3.50%)
Key Points/Operational Actions
There were 97 deaths in the hospital in September 2017, this number is comparable to last year (93) and equates to 14.4 deaths per 1000 admissions which is higher than our previous rate in September 2016 at 12.8.
The most number of deaths occurred on our care of the elderly ward (21) and respiratory ward (10). The highest number of deaths were recorded against a final diagnosis of pneumonia (19) and sepsis (12).
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17
Observed 2 1 3 0 1 1 0 0 0 0 1 0
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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
Key Points/Operational Actions
Definitions
0Total Serious Incidents aaaa
0of which were "Never Events"
Serious Incidents (Rolling 12 months)
0123456789
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
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 0 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
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Ref Incident date SI/NE Inc: SI Reported Date Location Exact Division
Serious Incidents during Sep 2017
Number of Open Serious Incidents
Adverse Event Number of open Si's
Breach of confidentiality of staff records or information 1
Unintended injury in the course of an operation or clin task 1
Fall on level ground 1
Apgars <6 at 5 mins 1
Suspected fall 1
Lack of clinical or risk assessment 1
Neonatal seizures 1
Other medication incident 1
Failure to follow up 1
Unexpected re-admission or re-attendance 1
Grand Total 10
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
12 14 16 7 14 16
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
20 17 12 12 12 10
No. of open SI's as at date of provision of data for Board Report
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Learning from incidents closed
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
RefSTEIS
Number
SI Declared
Date
Location
Exact
Adverse
EventSI/NE Summary Root Causes Lessons Learned
60 Day
Submission
Compliance
WEB41417 2017/12819 17/05/2017 Windsor
Ward
Cardiac arrest Failure to instigate a cardiac arrest call in a timely
manner for a patient who had been considered
medically fit for discharge. Patient pronounced
dead 45 minutes later.
1. Junior skill mix and delay in commencing cardiac arrest
procedure.
2. No ceiling of treatment decision by senior medical staff. Lack of
experience in cardiac arrest situation made junior staff panic.
3. Misunderstanding information about hospital at night team
role.
1. Sister E has reviewed skill mix and will place
junior staff in-charge of the ward on days for
support and supervision before being rostered for
in-charge shifts on night duty.
2. Review of documentation and charts for when
patients are deemed medically fit for discharge with
an agreed trust standard of frequency of
observations.
3. Support for junior staff in areas of infrequent
cardiac arrest situations staff involved with incident
have now had further teaching from the resus team
in the simulation suite to improve their confidence.
Regular debriefing sessions following cardiac arrest
for all staff involved.
4. Better overview from senior medical staff on
DNR/CPR decision making with trusts standards that
on the frailty wards all patients should have this
documentation reviewed within a set timeframe by
a senior clinician.
Y
Produced by the Performance and Information Team 8 of 57
10 5
Analysis of "Other Incidents"
Key Points/Operational Actions
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 9 of 57
Falls by Degree of Harm inc rate per 1000 beddays
Key Points/Operational Actions
There are a total of 63 validated falls reported in September 2017 which is 4.97 per 1000 days rate. We have a slight increase from previous month (August 4.5/1000 bed days). This month’s report remains high and just under the Trusts benchmark standard of 5 falls per 1000 bed days, although this is still below the national average of 6 falls per 1000 bed days.
This month’s fall consequences: 0 catastrophic, 0 major, 2 moderates, 15 minor and 46 negligible.
Repeat Fallers this month:
6 Patients fell on more than one occasion:
1 patient (2x falls ) on Denver1 patient (2x falls) on Gayton1 patient (2x falls) on Windsor1 patient (2X falls) on Tilney (with in-patient falls in)1 patient (2x falls) on MAU and Terrington1 patient (2 falls) on Windsor and Tilney
On-going and Recommended Actions:
Falls prevention strategies training on the ward is on-going including management of falls to address practice issues in management of in-patient falls across the trust.
On-going review of Falls Prevention and Management Policy according to trust change of practice and National guidance, including Post Fall Protocol and Falls Prevention Care Plan.
Trial of post fall grab bag is underway. This bag will contain post fall protocol, Neurological Observation Chart, pen torch, post fall stickers/checklist, Duty of Candour Sticker, red socks and first aid kit.
On-going/extended trial of Ultra low bed from Medstrom continues on West Newton ward. The feedback we received from staff remains positive and we are hoping to move to this new product (Medstrom Ultralow) within this 2017.
We are still waiting to hear from LOF (League of Friends) regarding request of funds to purchase specialised equipment such as Scoop stretchers, Hover Jacks and Hover Mats. These will be situated between wards to become accessible to staff.
“Falls Prevention Awareness Week” initiated this week in the hospital and will continue the campaign annually. This campaign will be followed by a “Falls Summit” in February 2018.
The National Falls Audit findings are not yet available (expected December 2017). Attached is a local falls audit undertaken in May 2017 and falls audit presentation at the Clinical Audit Annual Symposium held on 12 October 2017.
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)
Compliance Scorecard
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StandardsCQUINS Workforce Finance Appendices
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Key Points/Operational Actions
The trust has maintained a level of 5 hospital acquired pressure ulcers this month, however 4 of the 5 were avoidable;2 x grade 2’s, Windsor and Oxborough. Both of which were avoidable.3 x grade 3’s, Gayton and Terrington were avoidable. Necton was unavoidable.Themes;Failure to evidence adequate repositioning.Failure to provide adequate equipment for level of risk.
Induction, mandatory, NA and adhoc training continues re: pressure ulcer prevention. Training for agency staff via the PDN’s is yet to commence. Spot checks on wards have seen a slow but steady improvement in documentation.
There is to be a collaboration between the TVN’s, Podiatry, Diabetes Specialist Nurses, the Consultant Nurse for Emergency Medicine and MAU consultant, to re-launch the CPR for feet campaign, raising awareness of checking feet for diabetic patients, as part of the full skin inspection on admission.
Hospital Acquired Pressure Ulcers inc rate per 1000 beddays ,and analysis of avoidable/unavoidable cases
Definitions
Total number Pressure Ulcers incidents per month / per 1000 beddays / proportion of avoidable and unavoidable Pressure Ulcer incidents each month
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 11 of 57
For Safety Thermometer the rate of New Harms (Developed by the QEH) for September 2017 was 2.78% a reduction from the previous month which was at 3.88% making the QEH 97.22% New Harm Free. Harm free care relates to the % of patients on the day of the study September who were Harm Free from Pressure Ulcers, Falls, VTE events and Catheter Associated Urinary Tract Infections.
The results for September show a continued maintenance of the previous performance of 95% or above.
Safety Thermometer (Hospital Acquired Harm)CQUIN
Safety Thermometer
Key Points/Operational Actions
Definitions
97.22%
Safety Thermometer (Target 95%) aaaa
94.9
4%
95.1
5% 96.3
1%
96.9
6%
97.8
2%
96.9
3%
96.5
5%
98.4
9%
91.2
5%
96.5
0%
96.1
2% 97.2
2%
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
Safety Thermometer Performance - New Harm Free
Safety Thermometer - (New Harm Free) Target
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 12 of 57
The Trust as a whole has been revalidated by King’s College, London, as a ‘Venous Thromboembolism (VTE) prevention’ exemplar site. The VTE Prevention Exemplar Centres Network remains central for the continued success of the National VTE Prevention Programme as there is collaboration to reduce avoidable harm and improve outcomes for patients. The VTE Exemplar process focuses on 4 areas central to VTE prevention policy:
• Risk assessment• Thromboprophylaxis• Root cause analysis• Patient information.
The Trust became a VTE Exemplar Site in 2011 and have maintained that status since, which contributes toward assurance of this process.
VTE:Proportion of admissions that have been VTE assessed within the reporting month (1 month in arrears)
VTE Assessment
Key Points/Operational Actions
Definitions
97.28%VTE Assessments Completed (Target 97.24%) aaaa
98.1
2%
97.9
1%
98.6
5%
97.5
7%
97.6
0%
97.4
3%
97.4
7%
97.5
1%
97.7
1%
97.4
1%
97.4
2%
97.2
8%
80%
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17
VTE Assessment Performance
VTE Assessment Completeness VTE Assess Target
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 13 of 57
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
Key Points/Operational Actions
MRSA screening across the Trust (both weekly and admission) continues to remain high at 97%; this continued improvement helps identify patients who require isolation and treatment protecting both the patient and others from invasive infection and BSI.
0MRSA
aaaa
0MRSA
aaaa
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
MRSA Weekly Screening Compliance Across Trust
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 14 of 57
Latest Month's Performance Financial YTD
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
Key Points/Operational Actions
To date 26 cases of Hospital Acquired infection (April 17-March 18) to date 16th October 2017, trajectory set by NHSi for the year is no more than 53 cases. In the previous year the trust reported 22 cases and this time last year 12 cases were recorded. Following review from CCG IP&C Lead we have had 6 of these cases deemed non trajectory as all measures were taken in line with national and local policies.
As numbers hare significantly higher than last year at this time and x2 Periods of increased incidence (PIIs) have been identified on Stanhoe and Windsor Wards the CCG IP&C and
Quality Leads have undertaken a visit looking at these two areas, a full report has been received and current actions taken around deep cleaning and improvements in IP&C
practices are in line with expectations. A visit from IP&C Lead NHSi (East and Midlands) Dr Debra Adams is planned on 16th October 2017.
5C Diff (All cases)
rrrr
22CDIFF (All cases) aaaa
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 15 of 57
Gram Negative BSI
Definitions
Key Points/Operational Actions
In response to Lord O’Neill’s challenge to strengthen Infection Prevention and Control (IPC), the Secretary of State for Health has launched an important ambition to reduce Gram-negative BSIs by 50% by 2021. It is this can only achieve this by working together across the NHS and by starting to take action now.
One of our first priorities must be addressing Escherichia coli BSIs, which represent 55% of all Gram-negative BSIs. Latest data from Public Health England show a large variation in infection rates across clinical commissioning groups (CCGs). E. coli BSIs have increased by a fifth in the last five years and the trend is worryingly continuing upwards. This is an important patient safety issue. Furthermore, preventing BSIs should have a major impact on reducing the need to prescribe antimicrobials, which is a key way of reducing the rise in antibiotic resistance”.
The IP&C team are currently working with CCG colleagues to identify causes of BSI both Community and Hospital Acquired. Although there are no official reduction targets set this year a quality premium for the CCG is set for a 10% reduction – April 2017 – March 2018.
Graphs opposite illustrate E coli and other Gram negative BSI :
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
0
5
10
15
20
25
E.coli Bacteraemia (Hospital & Community Apportioned Cases)
HAI CAI
0
1
2
3
4
5
6
7Klebsiella Bacteraemia (Hospital & Community Apportioned Cases)
HAI CAI
0
0.5
1
1.5
2
2.5
Psuedomonas Bacteraemia (Hospital & Community Apportioned Cases)
HAI CAI
Produced by the Performance and Information Team 16 of 57
IPC Dashboard
Definitions
Key Points/Operational Actions
In order to ensure IP&C practice is maintained at a high standard the IP&C team undertake auditing of Hand Hygiene and cleanliness of commodes. A new Hand Hygiene policy has been launched (Oct 17) to include all staff in clinical areas required to be bare below elbows, this not only protects patient by ensuring good hand hygiene practices but raises awareness of IP&C at a time where C difficile numbers are than expected and there has been likely transmission on 2 wards.
Compliance Scorecard
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StandardsCQUINS Workforce Finance Appendices
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Service line Clinical Indicators (by ward)
Definitions
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Indicator Description
Fluid Charts 97% 98% 95% 91% 91% 95% 96% 89% 90% 98% 96% 97% 91% 97% 94% 96%
MUST Assessment 100% 82% 75% 89% 67% 138% 100% 50% 100% 86% 80% 100% 100% 67%
Waterlow Assessment 50% 89% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 93%
Waterlow Re-Scored 89% 100% 82% 100% 50% 69% 57% 100% 67% 100% 100% 100% 82% 100%
Has A Body Map Been Completed 100% 95% 85% 85% 67% 67% 90% 90% 80% 95% 75% 90% 100% 95% 90% 85%
Moving And Handling Assessment
Completed95% 65% 100% 95% 85% 83% 84% 90% 70% 85% 50% 45% 70% 100% 75% 95%
Falls Assessment Done 100% 100% 100% 100% 100% 100% 100% 100% 100% 71% 100% 100% 100% 100%
Falls assessment rescored weekly 89% 100% 75% 57% 17% 77% 50% 93% 20% 100% 50% 82% 91% 100%
Is a Falls Care Plan Completed? 90% 95% 100% 85% 74% 17% 84% 55% 60% 85% 50% 50% 55% 95% 35% 85%
EWS for each set of OBS? 90% 100% 100% 95% 100% 100% 95% 90% 85% 100% 100% 95% 90% 85% 100% 100%
Care Rounds Completed 96% 82% 99% 96% 95% 96% 52% 94% 100% 89% 97% 98% 95% 100% 90%
Bedrail Assessment if "At Risk" (on
admission)0% 85% 44% 0% 0% 92% 50% 50% 50% 100% 50% 25%
Obs Frequency documented 95% 100% 5% 15% 35% 100% 20% 15% 15% 80% 17% 15% 25% 0% 85% 65%
Serious Incidents 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Drug Administration Errors 0 3 1 2 2 4 5 1 4 1 0 2 2 1 1 4
Falls Total 3 0 1 7 4 0 4 4 5 4 1 6 4 5 2 9
H/A Pressure Ulcers Grade 2 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0
H/A Pressure Ulcers Grade 3 0 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0
C.Diff > 2 Days 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 2
Harm Free Care 90% 82% 83% 100% 92% 100% 92% 91% 91% 88% 83% 93% 94% 96% 96% 78%
Complaints 0 2 1 0 1 0 2 2 1 2 0 0 0 0 0 0
Family And Friends Response Rate 56% 54% 38% 37% 27% 173% 27% 37% 39% 46% 27% 40% 38% 48% 60% 24%
Family And Friends Results 93% 94% 97% 91% 93% 100% 91% 74% 91% 90% 100% 98% 94% 84% 98% 97%
% Of Active Mentors 63% 75% 86% 88% 100% 80% 80% 50% N/A N/A 67% 38% 67% 80% 22% 50% 17%
Fill Rate Registered 96% 93% 91% 92% 86% 81% 94% 88% 94% 91% 92% 93% 93% 93% 92% 98%
Fill Rate Unregistered 107% 91% 96% 100% 89% 92% 107% 98% 97% 107% 98% 89% 104% 126% 80% 93%
CHPPD 5.6 5.9 10.6 5.9 5.8 27.8 9.8 5.7 5.1 6.3 7.8 5.2 5.6 8.1 7.0 5.7
Appraisals 71% 89% 95% 80% 76% 90% 96% 95% 75% 91% 96% 94% 97% 58% 87% 95%
Sickness 9% 12% 5% 2% 6% 4% 1% 8% 8% 10% 3% 4% 4% 7% 11% 5%
Vacancies 20% 13% 14% 16% 20% 8% 28% 21% 41% 8% 18% 19% 22% 19% 4% 15%
DenPati
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
The Nursing Indicators have now been fully revised and all patient safety indicators from audit of documentation are now RAG rated. The Chief Nurse and Deputy Chief nurse have met with the Matrons and ACNs to ensure that all Ward Managers fully understand the audit process. All Ward Managers are meeting monthly with the Chief Nurse to explain the specific actions they are taking to improve or maintain performance e.g improvement in the documentation of the frequency of observation.
To ensure validity of the EWS audit the responsibility of this has now been transferred to the Critical Care Outreach team and will be reported for month 7.
Key Points/Operational Actions
Produced by the Performance and Information Team 18 of 57
Maternity Clinical Performance & Governance Scorecard 2017-18
Please note that the Paediatric Dashboard currently shows data 2 months in arrears.Definitions
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Activity Activity in September has been lower than expected however this is because we had a significant amount due at the end of September that subsequently delivered in October.There were 8 homebirths due in September but only 4 delivered (which makes 1.5%) and the remaining would deliver in October.
ModeSeptember saw excellent numbers of deliveries on Waterlily which has had an impact on the reduction in our caesarean section rate. However the electives continue to be static in relation to other months and the reduction is seen in the emergencies. The induction is also slightly lower than August but is relatively static. The induction rate continues to be higher than our current benchmark, however following the introduction of the GROW programme this is in line with the national picture.
Activity: Antenatal and Postnatal CareThe number of bookings has increased this month and also the number of women being seen within 12+6 weeks has also improved.Readmissions cases are all being reviewed.Following extensive evaluation of breastfeeding data collection and BadgerNet it is clear that the issue prior was that the statics did not support the breaking down of areas e.g., WaterLily and Castleacre. On review we have now collated the stats into initiation, discharge home regardless of location within the unit and feeding on discharge to the health visitor. This has enabled us to have accurate statistics and therefore improved the position across the service. There is still work to be done and this is being taken forward by the breastfeeding midwife and senior midwifery manager.
GovernanceThe service has recently promoted the use of datix and re-launched the trigger lists, which has been received positively and this is reflected in the increase of incidents reported.No SI’s have been declared in September and the unit did not close.
M easurement R easo n Green A mber R ed D ata So urce
Apr
May
Jun
Jul
Aug
Sep
Women Delivered Total no. o f women giving birth at QEH Local M onitoring Birth Register 182 199 191 218 194 191Babies Born Total no. o f babies born at QEH Local M onitoring Birth Register 185 202 193 223 193 193Live Births Total no. o f live babies born at QEH Local M onitoring 185 201 193 223 193 193
% Home Births % of 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%BBAs Babies born before arrival o f a professional Local M onitoring 0 Between >=2 Birth Register 1 1 3 4 3 1
StillbirthsStillbirth: Babies born after 24 weeks gestation showing no signs of life. Stillbirth Rate = 4.6/1000 birhs.
QEH annual to tal should not exceed 15 stillbirthsYearly to tal that exceeds 15 0 Between >=2 Birth Register 0 1 0 0 0 0
Neonatal Death (No.) N eo natal D eath : No .o f babies that are born alive but die within 28 days of age. Yearly to tal that exceeds 7 0 Between >=2 NICU/DATIX 0 0 0 1 0 0Twins No. babies - twins Local M onitoring Birth Register 3 3 2 5 0 2
Triplets No. o f babies - triplets Local M onitoring Birth Register 0 0 0 0 0 0Transfers out No. o f transfers out o f QEH M aternity unit. Local monitoring Birth Register 0 0 1 2 0 0
% Women Delivered on M LBU Women who have given birth in Waterlily Local M onitoring >= 20% Between <15% Birth Register 17.6% 24.8% 23.5% 14.7% 20.7% 22.5%% Women delivered on CDS Women who have given birth on Delivery Suite Local M onitoring <75% Between >85% Birth Register 80.8% 65.2% 76.4% 81.2% 78.6% 75.9%
% Normal B irths Spontaneous vaginal births Benchmark Vs Nat Rate 2013/14 = 60.9% > 63% Between < 52% Birth Register 67.0% 69.6% 59.4% 63.2% 63.4% 65.8%% Instrumental Deliveries Combined rate: Forceps + Ventouse Benchmark Vs Nat Rate 2013/15 = 12.9% 5% - 12% Between <5% or >20% Birth Register 10.7% 7.7% 10.3% 6.8% 10.3% 9.8%% Vaginal Breech Births 1.0% 0.0% 1.0% 0.9% 1.0% 1.0%
% Elective LSCS Women having planned CS Local M onitoring <10% Between >12% Birth Register 8.2% 10.3% 10.9% 11.0% 11.3% 10.9%% Emergency LSCS Women having an emergency CS Local M onitoring < 15% Between >16% Birth Register 13.1% 12.4% 16.2% 19.0% 16.5% 12.6%
% Total CS Total CS performed: Elective +Emergency Benchmark Vs Nat Rate 2013/14 = 26.2 % <= 25% Between >= 28% Birth Register 21.3% 22.7% 28.9% 30.0% 27.8% 24.4%% Induction Rates Women who have their labour induced (denominator = to tal women minus ElSCS) <18% Between >24% Birth Register 25.7% 31.8% 29.2% 30.3% 29.1% 27.7%
% Bookings < 12 weeks 6 days Women who have their first booking appt by 12+6 KPI >= 90% Between <= 85% HoM 90.0% 90.0% 90.0% 89.0% 86.9% 92.0%No. o f women seen on DAU @ N C H Local monitoring DAU 91 130 20 130 90 115
Closure of DAU - hours @ N C H Local monitoring DAU 12 12 0 0 15 0% 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%
No. o f women seen on DAU @ QEH Local monitoring DAU 347 396 389 445 422 369Closure of DAU - hours @ Q EH Local monitoring DAU 24 24 0 0 0 0
% women in DAU seen within 4 hrs @ QEH Local monitoring >=95% Between <= 90% DAU 99.4% 99.7% 97.4% 99.3% 99.5% 97.8%% Breastfeeding Breastfeeding / Breast M ilk initiated, attempted or achieved KPI >=70% Between < 65% Badgernet 74.2% 69.2% 69.4% 70.0% 69.9% 73.6%% Breastfeeding Breastfeeding on discharge from hospital KPI >=70% Between < 65% Badgernet 68.2% 53.3% 60.0% 57.9% 34.2% 66.7%% Breastfeeding Women breastfeeding at transfer to Health Visitor Local monitoring Badgernet 49.3% 37.9% 43.6% 45.9% 46.1% 45.2%
% of women who stopped smoking at delivery Women who stopped smoking by the time of delivery Local monitoring Badgernet 18.0% 21.7% 5.3% 14.3% 15.6% 13.3%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
No of SUIs Local monitoring 0 >=1 Risk & DS 1 0 0 0 1 0Total number o f reported clinical incidents Local monitoring Datix 39 39 47 52 51 87
Total no. o f adverse staffing incidents reported Local monitoring Datix 1 2 1 42 8 6No. times CDS closed Local monitoring 0 1 >=2 DS 0 0 1 0 0 0
Total hours CDS closed Local monitoring DS 0 0 8 0 0 0Suspension of HBS Local monitoring 0 1 >=2 DS 0 0 0 0 0 0Suspension of HBS Local monitoring 0 1 >=2 DS 0 0 0 0 0 0
No Benchmark
No Benchmark
ACTIV
ITY
: A
/N &
P/N
Care
No Benchmark
No Benchmark
No Benchmark
No Benchmark
Operational Targets
GO
VERN
AN
CE
No Benchmark
ACTIV
ITY
: Bir
th S
tati
stic
sM
OD
ENo Target
No Target
No Target
No Benchmark
No Benchmark
Risk M anagement No Benchmark
No Benchmark
No Benchmark
No Benchmark
Day Assessment Unit
Produced by the Performance and Information Team 19 of 57
Maternity Clinical Performance & Governance Scorecard 2017-18 (continued)
Definitions Please note that the Maternity Dashboard currently shows data 2 months in arrears.
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Maternal & Perinatal StatisticsPPH rates have improved this month and the tear rate has also remained low.In September there was a huge improvement with only 1 avoidable readmission that has been reviewed. The 3 readmissions of women are currently still being reviewed to identify any lessons to be learnt.
WorkforceA huge amount of training in relation to the definition of 1:1 care in labour has now shown an improvement, which represents staff’s perception. Due to annual leave and sickness the on call midwife was called in on 6 occasions in the month.
Patient FeedbackAgain the service has received a high number of compliments.
There have been 4 complaints received that relate to:Theatres - concerns around readmissionCDS & Castleacre both relate to poor communication and staff attitude Appleton Unit – Patient raised concerns regarding loss of baby
Following the introduction of the electronic monitoring of FFT we now see the huge improvement in response rates. The team are still working on the denominator for the postnatal section, a meeting is planned for us to discuss how we can ensure that the data is accurate.However the number of women likely to recommend the service is over 98% across all areas.
M easurement R easo n Green A mber R ed D ata So urce
Apr
May
Jun
Jul
Aug
Sep
PPH >=1000 or<2000ml Local M onitoring < 9% Between >12% Birth Register / CDS 6.1% 6.9% 4.1% 2.9% 4.6% 1.6%PPH >=2000ml Local M onitoring <=1% Between >=2.5% Birth Register / CDS 0.0% 0.0% 1.5% 0.9% 1.5% 1.6%
% of women sustaining 3rd & 4th degree tears (no/total- Elective CS) Local M onitoring <=3% Between >=5% Birth Register / CDS 1.6% 1.1% 3.2% 1.8% 1.0% 1.6%No. o f women sustaining 3rd & 4th degree tears (no/to tal- Elective CS) 3a Local M onitoring <= 4 >= 5 Birth Register / CDS 1 1 2 2 1 1No. o f women sustaining 3rd & 4th degree tears (no/to tal- Elective CS) 3b Local M onitoring <= 2 >= 3 Birth Register / CDS 2 1 3 2 1 1No. o f women sustaining 3rd & 4th degree tears (no/to tal- Elective CS) 3c Local M onitoring 0 >= 1 Birth Register / CDS 0 0 0 0 0 1No. o f women sustaining 3rd & 4th degree tears (no/total- Elective CS) 4 Local M onitoring 0 >= 1 Birth Register / CDS 0 0 0 0 0 0
Blood transfusions > 4 units Local M onitoring Haemato logy 0 0 0 0 0 0Postpartum hysterectomies Local M onitoring 0 1 >1 Birth Register 0 0 0 0 0 0
ITU /HDU admissions Local M onitoring 0 1 >1 Birth Register 0 0 0 0 0 0M aternal Deaths Local M onitoring 0 >0 Birth Register 0 0 0 0 0 0
Avoidable Term Admissions to NICU from CDS Local M onitoring NICU / Datix 0 0 0 0 0 0Avoidable Term Admissions to NICU from Castlecare Local M onitoring NICU / Datix 1 0 0 0 0 0No. of babies with avoidable readmissions <28 days old Local M onitoring <= 2 3 - 5 >= 6 Datix 5 3 0 6 6 1No. of women with avo idable readmissions <28 days old Local M onitoring <= 2 3 - 5 >= 6 Datix 5 5 2 0 0 0
1:1 C are M LB U 1:1 care in labour achieved on M LBU Local monitoring >=95% 90-94 <= 89% M LBU 88.0% 96.0% 93.0% 95.0% 100.0% 100.0%1:1 C are C D S 1:1 care in labour achieved on CDS Local monitoring >=95% 90-94 <= 89% DS 97.0% 97.0% 93.0% 93.0% 87.0% 98.0%
On C all M idwife No. o f hrs On call midwife called to work in Unit Local monitoring DS 38 22 51 59 31 53On C all M idwife No. of occassions On call midwife called to work in Unit Local monitoring DS 4 5 5 9 4 6
Compliments Total M idwifery Compliments received in month Local monitoring PALS Team 1 16 4 33 33 8Complaints Total M idwifery Complaints received in month Local monitoring PALS Team 0 2 3 2 4 4
Response Rate Antenatal Patient Experience Team >= 15% < 15% Patient Experience Team
Likely to recommend Antenatal Patient Experience Team >= 95% <95% Patient Experience Team 97.30% 96.43% 97.37% 98.49% 98.35% 98.35%Response Rate Birth / Labour Patient Experience Team >= 15% < 15% Patient Experience Team 16.76% 18.08% 13.56% 16.76% 17.20% 22.63%
Likely to recommend Birth / Labour Patient Experience Team >= 95% <95% Patient Experience Team 96.67% 100.00% 100.00% 96.67% 93.75% 100.00%Response Rate Postnatal Castleacre Ward Patient Experience Team >= 15% < 15% Patient Experience Team 47.55% 55.90% 60.78% 59.12% 54.04% 60.17%
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%Response Rate Community Postnatal Patient Experience Team >= 15% < 15% Patient Experience Team
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%
PA
TIE
NT F
EED
BA
CK
No Benchmark
No Benchmark
No Benchmark
Local monitoring of poor
outcomes and factors that may
have an impact on women's
future health. Includes data for
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
Produced by the Performance and Information Team 20 of 57
Paediatric Clinical Performance & Governance Scorecard 2017-18
Definitions Please note that the Paediatric Dashboard currently shows data 2 months in arrears.
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Activity PAU attendances returned to predicted figures. There continues to be an increase in times that middle grade staffing levels were not met due to vacancies on the rota. Only 8 children were not seen by a senior clinician within 4 hours, due to middle grade vacancies and covering the assessment area and the ward. 95.5% of all children in September were assessed by nursing staff within 15 minutes of arrival.
WorkforceThere were 8 episodes when escalation beds were opened to accommodate elective surgical & medical admissions, due to the opening of the beds staffing levels were not met each time. One night shift covered by 1 registered paediatric nurse, 1 x supernumerary paediatric nurse and 2 very experienced adult nurses which unfortunately does meet RCN guidelines.
Governance No SI’s declared in September, only one delayed discharge as Tier 4 bed was required
Patient Feedback No complaints received in September and 8 compliments. Response rate for FFT was an increase to 28% and 98.37% would recommend our service. FFT collection will be electronic in the near future.
Descriptor Measurement Green Red Data Source Apr
May
Jun
Jul
Aug
Sep
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
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
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%)
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%)
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%)
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%)
HDU Days No. of HDU days in month Internal <= 15 >= 30 Rudham Stats 10 8.5 4 6 3.5 14
HDU Patients No. of HDU patients in month Internal <= 3 >= 4 Rudham Stats 9 7 2 1 4 7
Ward Attenders No. of children post discharge reviewAverage No. of Patients from
2016 = 61<= 61 >= 62 Rudham Stats 78 64 76 96 74 91
Medical & Surgical OutliersPatients aged 16 years and over that are not under
a PaediatricianInternal 0 >= 1 Rudham Stats 2 1 0 0 2 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
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
Transfers out with an escort No. of transfers out requiring a nurse escort Internal <= 1 >= 2 Rudham Stats 2 1 4 0 0 1
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
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
No. of SUI reported to CCG Serious Incident and report prcoess actioned Internal 0 >= 1 Risk Dept 1 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
No. of patients medically fit who have delayed
discharge.Internal 0 >= 1 Bed stats 0 2 1 1 1 1
No. of days medically fit patients who delayed
discharge.Internal 0 >= 1 Bed stats 0 6 14 5 6 10
Other Clinical Incidents All other on ward incidentsAll incidents to exclude
staffing incidents 0 >= 1 Datix 4 13 7 8 7 17
Patient Feedback Compliments Total Rudham Compliments
received in monthPALS Team 8 5 6 11 8 14
Patient Feedback ComplaintsTotal Rudham complaints
received in monthPALS Team 2 1 0 1 0 0
Patient Feedback Response Rate Rudham Ward >= 15% < 15%Patient
Experience Team29.9% 25.6% 20.10% 25.60% 17.50% 28.00%
Patient Feedback Likely to recommend Rudham Ward >= 95% < 94%Patient
Experience Team98.5% 97.5% 96.51% 94.87% 98.55% 98.37%
Act
ivit
y
Local monitoring
Local monitoring
Wo
rkfo
rce
Delayed Discharges
Cli
nic
al In
dic
ato
rsFri
en
ds
& F
am
ily
Produced by the Performance and Information Team 21 of 57
NICU Clinical Performance & Governance Scorecard 2017-18
Definitions Please note that the NICU Dashboard currently shows data 2 months in arrears.
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Activity NICU accepted 3 in utero transfers, but CDS were unable to accept due to workload.
Descriptor Measurement Green RedData
Source Apr
May
Jun
Jul
Aug
Sep
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
2016/2017 to gain average
30 23 39 29 29 30
Admissions to NICU from MLBUNo. of infants admittedfrom MLBU 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
2016/2017 to gain average
0 0 1 0 0 2
Admissions to NICU from Post natal WardNo. of infants admittedfrom PNW 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
2016/2017 to gain average
8 4 7 8 6 7
Admissions to NICU from HomeNo. of infants admittedfrom home 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
2016/2017 to gain average
6 4 2 9 7 8
Admissions to NICU from other unitNo. of infants admittedfrom other units 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
2016/2017 to gain average
3 4 2 1 8 0
Admissions to NICU from Rudham WardNo. of infants admittedfrom Rudham Ward 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
2016/2017 to gain average
0 0 0 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
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
ITU days Available number from funded cot = 30 30 <= 31 > 90 12 25 20 19 7 2
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
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
HDU days Available number from funded cot = 60 Average for 2016 = 52 <= 60 >= 61 32 75 49 37 91 26
Number of HDU babies No of HDU babies on unit in month Average for 2016 =9 <= 9 >= 10 10 11 12 8 12 6
SC days Available number from funded cot = 270 Average for 2016 =299 < 270 > 300 305 248 322 290 334 297
Number of SC babies No of SC babies on unit in month Average for 2016=48 <=48 >=49 49 54 53 52 60 47
No. of babies over 44 weeks of age No. of babies aged over 44 weeks 0 0 >=1 0 0 0 0 1 1
No. of occasions in month Over 80% cot occupancy 0 >1 7 7 18 5 13 0
No. of occasions in month Over 100% cot occupancy 0 >1 0 0 0 2 2 0
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
Number of babies receiving care from the
NCTNo. of babies having care in the community Internal Internal Internal 24 29 30 28 21 23
Number of NCT visits No. of visits carried out by NCT each month Internal Internal Internal 71 93 87 63 70 53
Ward attenders No. of babies attending on ward NICU Internal Internal Internal 8 13 6 6 11 8
In uter transfers accepted NICU Internal Internal Internal 1 2 3 0 0 3
In uter transfers refused NICU Internal Internal Internal 1 1 0 0 2 0
Transfers out >1 if due to capacity issues Internal 0 >= 1 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
No of hours NICU on divert internal Internal 0 >= 1 0 56.5 0 0 84 0
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
NIC
U / B
ad
gern
et
NIC
U
Cot occupancy
Unit escalation (in hours)
Act
ivit
y
Produced by the Performance and Information Team 22 of 57
NICU Clinical Performance & Governance Scorecard 2017-18 cont'd
Definitions Please note that the NICU Dashboard currently shows data 2 months in arrears.
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Mortality In September there was one baby with a Pneumothorax (treated conservatively). 2 Infants had positive Blood Cultures x1 staphylococcus epidermis? Contaminant x1 Enterococcus faecalis triggering two of these metrics.
Governance There were10 reported clinical incidents
Clinical Activity 4/8 infants met the criteria for receiving breast milk at discharge, 4 were discharged bottle feeding due to maternal choice.
Patient FeedbackIn September there was 1 complaint, 4 compliments and a 95% recommendation rate from FFT. The FFT response rate was 131% and work is in progress to start recording this electronically and hopefully giving us a continually consistent response rate.
Descriptor Measurement Green Red Data Source Apr
May
Jun
Jul
Aug
Sep
HypoglycaemiaInternal Guideance and standards not
followed 1 >= 3 NICU 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
Accidental extubation NEVER EVENT 0 >= 1 DATIX 0 0 0 0 0 0
Infection (Positive culture
and CSF) (NNAP)Laboratory results 1 >= 3 NICU Badgernet 0 0 1 0 0 2
Pnuemothorax Incidents each month 1 >= 3 DATIX / Badgernet 0 0 0 0 1 1
No of SUIs Incidents each month 0 >= 1 DATIX / Risk dept 0 0 0 0 0 0
Total No of reported
incidentsIncidents each month Internal Internal 16 17 14 11 17 10
Staffing Incidents Staffing level Incidents each month 0 >= 1 0 2 1 0 3 0
NNAP standard NNAP >= 58% <58% NICU Badgernet 100% 33% 100% 0% 0% 50%
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
ROP Screening prior to discharge NNAP standard NNAP 100% <100% 100% 100% 100% 100% 100% 100%
Parents seen within 24hrs of
admissionNNAP standard NNAP >= 88% <88% 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
Patient Experience FFT / NICU 100% 100% 100% 100% 100% 95.2%
Patient Experience PALS / Audit 16 8 5 4 13 4
Patient Experience FFT / NICU 29.1% 12.8% 10.7% 13.5% 100% 131%
Patient Experience PALS / Audit 0 0 0 0 0 1
* 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
Go
vern
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 -
Produced by the Performance and Information Team 23 of 57
The response rate exceeded the target of 30% (30.03% - this equates to 2 cards above the target) and the likelihood to recommend score for the month remains above the 95% target for the month and year to date.
The benchmark figures for the region place the Trust 10/13 based on August’s figures (the same as July). The reasons that patients cited as to why they were not able to recommend the care they had received were wide ranging but can be grouped into these areas - staff attitude (both our staff and agency), food, noise at night, lack of care, cleanliness, communication between staff and patients / relatives and call bell response.
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)
Key Points/Operational Actions
Definitions
95.35%
% Recommend the service
1.22%% Do not recommend the service
30.03%
Response Rate (Target 30%) aaaa
Friends and Family Test - Inpatient & Daycase (Response Rates)
Ward / Area Performance - Inpatient & Day Cases Benchmarking - Inpatient & Day Cases0.6
6%
0.7
1%
1.2
4%
0.9
2%
0.6
8%
1.0
2%
1.0
1%
0.4
8%
1.0
3%
1.2
1%
0.8
9%
1.2
2%
95.4
0%
95.6
4%
95.7
7%
96.1
9%
96.1
6%
95.6
1%
96.0
0%
96.1
2%
95.4
7%
94.7
5%
95.7
5%
95.3
5%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Monthly % Recommend / Not Recommend - Inpatients & Day Cases
FFT % Not Recommended (IP & DC) FFT % Recommended (IP & DC)
34.6
4%
31.3
4%
32.7
0%
29.1
4%
32.2
7%
34.3
5%
32.7
5%
33.5
9%
34.5
8%
32.6
3%
29.4
4%
30.0
3%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Monthly Response Rates for Inpatients & Day Cases
FFT Response Rate (IP & DC)
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
RQW 99.02% 0.00% 42.96%
RGR 98.40% 0.44% 25.22%
RGM 97.46% 0.28% 44.04%
RGN 97.42% 0.47% 30.82%
RDE 97.38% 0.67% 40.88%
RM1 97.11% 1.37% 14.39%
RGQ 96.97% 0.85% 36.94%
RGP 96.89% 0.84% 24.70%
RGT 96.82% 1.09% 8.85%
RCX 95.75% 0.89% 29.44%
RDD 95.25% 1.36% 37.76%
RAJ 92.96% 3.97% 29.46%
RQ8 91.16% 5.01% 21.52%MID ESSEX HOSPITAL SERVICES NHS TRUST
SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST
BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
THE QUEEN ELIZABETH HOSPITAL, KING'S LYNN, NHS FOUNDATION TRUST
CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
JAMES PAGET UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
Org Code Organisation Name (Ranked by % Recommended)
IPSWICH HOSPITAL NHS TRUST
NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST
NORTH WEST ANGLIA NHS FOUNDATION TRUST
PAPWORTH HOSPITAL NHS FOUNDATION TRUST
%
Recommended
% Response
Rate
% Not
Recommended
WEST SUFFOLK NHS FOUNDATION TRUST
THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST
Produced by the Performance and Information Team 24 of 57
The Emergency Department has again dipped just below the target of 95% (93.97%) and a slight increase in the percentage not recommending the service to 2.14%.
The response rate is still concerning, although it has risen this month to 16.61%, which is 4.5% below the target. New ways to collect FFT have not yet been introduced.
Overall the service benchmarks at 5/12 based on August’s figures for likelihood to recommend (this is down from 1st in July). There were only 11 patients unlikely to recommend the care they received and the reasons included waiting times, staff attitude, lack of entertainment for teenagers, care of mental health patients and being given nothing but pain relief and sent home.
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
93.97%
% Recommend the service
2.14%% Do not recommend the service
24.4
0%
23.0
5%
21.8
8%
23.2
8%
26.7
1%
20.2
4%
21.7
0%
19.0
2%
20.6
6%
14.1
9%
13.5
8%
16.6
1%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Friends and Family Test - Monthly Response Rates for AE
FFT Response Rate (AE) FFT Resp Rate (AE) Target
16.61%
Response Rate(Target 20%)
rrrr
Key Points/Operational Actions
Friends and Family Test - A & E (Response Rates)
Benchmarking - A & E
3.6
3%
1.8
1%
2.5
4%
1.7
6%
6.2
0%
5.1
8%
4.3
2%
5.0
1%
2.4
7%
0.8
8%
1.2
9%
2.1
4%
91.9
7%
93.9
6%
92.0
8%
94.0
9%
90.7
0%
90.9
7%
89.9
7%
89.2
0%
94.1
3%
95.3
9%
94.4
1%
93.9
7%
0%
20%
40%
60%
80%
100%
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Friends and Family Test - Monthly % Recommend / Not Recommend for A&E
FFT % Not Recommended (AE) FFT % Recommended (AE)
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Org Code%
Recommended
% Not
Recommended
% Response
Rate
RQW 96.45% 2.22% 26.43%
RGN 95.52% 0.56% 5.97%
RGT 94.83% 2.31% 21.93%
RGR 94.72% 1.89% 26.78%
RCX 94.41% 1.29% 13.58%
RGP 91.94% 2.38% 12.72%
RM1 91.11% 6.11% 2.39%
RQ8 87.73% 7.40% 20.23%
RAJ 87.44% 6.67% 16.91%
RDE 87.26% 7.37% 23.42%
RDD 84.13% 7.48% 21.79%
RGQ 77.18% 12.03% 14.26%
Organisation Name (Ranked by % Recommended)
NORTH WEST ANGLIA NHS FOUNDATION TRUST
THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST
NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
JAMES PAGET UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
THE QUEEN ELIZABETH HOSPITAL, KING'S LYNN, NHS FOUNDATION TRUST
WEST SUFFOLK NHS FOUNDATION TRUST
CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
MID ESSEX HOSPITAL SERVICES NHS TRUST
IPSWICH HOSPITAL NHS TRUST
BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST
SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST
Produced by the Performance and Information Team 25 of 57
Friends and Family Test - Maternity Services (Recommended/Not Recommended)
Definitions
Key Points/Operational Actions
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 an increase in response rate (birth) to 22.63% (15% target) and had 100% level of recommendation for birth.
All areas achieved the 95% likelihood to recommend target.
The service benchmarked at 11h out of 12 based on the labour rating in August across the region for likelihood to recommend (down from 9th in July). This is affected by the low number of responses generally for maternity. There were only 890 cards collected across the region in the birth category, only 3 hospitals collected over 100 cards in a month, only 4 hospitals achieved over a 30% response rate. This results in a very fluid likelihood to recommend value.
1.2
0%
0.4
1%
0.4
1%
98.4
9%
98.3
5%
98.3
5%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jul Aug Sep
FFT - % Recommend/ Not Recommend (Antenatal)
FFT % Recommended Mat Q1 (Antenatal)FFT % Not Recommended Mat Q1 (Antenatal)
3.3
3%
3.1
3%
96.6
7%
93.7
5%
100.0
0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jul Aug Sep
FFT - % Recommend/ Not Recommend (Labour)
FFT % Recommended Mat Q2 (Labour)FFT % Not Recommended Mat Q2 (Labour)
97.2
0%
97.8
7%
98.5
9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jul Aug Sep
FFT - % Recommend/ Not Recommend (Postnatal Ward)
FFT % Recommended Mat Q3 (Postnatal)FFT % Not Recommended Mat Q3 (Postnatal)
3.2
3%
100.0
0%
96.7
7%
100.0
0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jul Aug Sep
FFT - % Recommend/ Not Recommend (Community PostNatal)
FFT % Recommended Mat Q4 (Comm Postnatal)FFT % Not Recommended Mat Q4 (Comm Postnatal)
Response Rate - Labour
16.7
6%
17.2
0%
22.6
3%
0%
5%
10%
15%
20%
25%
30%
Jul Aug Sep
FFT - Response Rate (Labour)
FFT Response Rate Mat Q2 (Labour)FFT Resp Rate (Labour) Target
Benchmarking - Maternity Services
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 26 of 57
Definitions
Key Points/Operational Actions
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)
0.7
3%
0.9
3%
0.2
4%
0.9
4%
0.4
7%
0.9
8%
1.0
3%
0.2
9%
1.1
8%
1.0
2%
0.9
3%
0.7
6%
95.9
9%
96.7
3%
96.7
9%
97.4
1%
97.5
5%
96.6
7%
96.4
1%
97.0
3%
96.2
9%
95.5
0%
97.1
1%
96.7
2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
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 96.72% and the Trust benchmarked at 1/13 regionally in August in relation to likelihood to recommend (a rise from 6th the previous month). There were 10 patients unlikely to recommend and their concerns were across many services but revolved around waiting times across numerous clinics, staff attitude and 2 patients being asked to attend pre-assessment twice for the same operation. The partial booking system in some clinics, notably ENT, is still causing delays and concerns for patients – this topic is due to be discussed at the PandA meeting.
Across the hospital the main areas for concern remain:• Staff Attitude• Waiting times, especially in Outpatients
Benchmarking - Outpatient Services
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Org Code % Recommended% Not
Recommended
RCX 97.11% 0.93%
RGQ 96.85% 1.07%
RGR 96.50% 0.93%
RDE 96.18% 0.36%
RGN 95.75% 0.88%
RM1 95.63% 1.70%
RGP 95.39% 0.96%
RGM 95.35% 2.33%
RQW 95.01% 3.17%
RAJ 93.07% 2.47%
RGT 92.86% 2.21%
RDD 91.79% 2.94%
RQ8 89.34% 5.23%
Organisation Name (Ranked by % Recommended)
NORTH WEST ANGLIA NHS FOUNDATION TRUST
COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST
WEST SUFFOLK NHS FOUNDATION TRUST
IPSWICH HOSPITAL NHS TRUST
THE QUEEN ELIZABETH HOSPITAL, KING'S LYNN, NHS FOUNDATION TRUST
NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
PAPWORTH HOSPITAL NHS FOUNDATION TRUST
JAMES PAGET UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST
MID ESSEX HOSPITAL SERVICES NHS TRUST
BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST
Produced by the Performance and Information Team 27 of 57
Latest Month's Performance Financial YTD
The Trust experienced two mixed sex accommodation incidents during the last month affecting four patients in total. Both of these incidents took place on the Critical Care Unit and involved patients identified as fit to transfer to a lower dependency bed but unable to do so within the allotted timeframe due to capacity issues affecting the availability of vacant ward beds. This is an improvement on the previous month but remains an issue for the Trust due to the constant pressure on bed availability.
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
Key Points/Operational Actions
Definitions
2Incidents of Mixed Sex Accommodation rrrr
4No. of Patientsaffected rrrr
14Incidents of Mixed Sex Accommodation rrrr
29No. of Patients affected rrrr
Mixed Sex Accommodation Breaches
2
8
0
8
4
21
0
43
4
2
0
2
4
6
8
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
No. of Mixed Sex Accommodation Incidents
No. of Mixed sex Accommodation Incidents
4
18
0
18
9
42
0
9
68
4
0
4
8
12
16
20
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
No. of Mixed Sex Accommodation breaches
No. of Mixed Sex Accommodation Breaches
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 28 of 57
Analysis of Current Month and YTD
Number of Complaints received into the Trust (Clinical and Non-Clinical)
Complaints
Key Points/Operational Actions
Definitions
27Current Month
7Current Month
176YTDrrrr rrrr
rrrr
Non Clinical Complaints
16YTD
rrrr
Number of complaints received
During the month of September the Trust received 34 complaints. This is four fewer than last month and one more than in September 2016, in which the Trust received 33 complaints.
Complaints received by Specialty/Key Issues Table
During September 2017, the Emergency Department had 4 complaints, General Surgery and General Medicine each had 3. The complaints regarding these areas involved the following issues:
• Staff attitude• Poor communication with patient/relatives • Acquired pressure ulcer• Care needs not met
Lessons Learned
• To ensure that doctors who undertake lumbar puncture procedures are adequately trained and supported• Reiterating the importance of line managers regularly reviewing staff performance and communication skills• When new equipment is introduced ensuring that there is a robust process for removing the old equipment, audits have been undertaken to
ensure compliance
Other Information
• At present, one complaint received in June 2017 has been re-opened.• 9 local resolution meetings were held.• One complaint was referred to the Parliamentary and Health Service Ombudsman.• 115 Travel Expense claims were processed.• Three complaint satisfaction questionnaires were returned. One complainant was happy with the outcome, stating that they were satisfied with
the response and praised the staff for the treatment they have received; whilst the other two complainants stated they were not fully satisfied by the responses received.
• An interim PALS and Complaints Manager was appointed to cover the scheduled absence of the post-holder and has commenced duties.
Four PALS surveys were completed and although some were incomplete, 100% advised that that they were extremely happy with the service they had received. Further comments were made stating ‘fast reply giving information needed.’
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 29 of 57
Actions Taken & Lessons Learned
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 30 of 57
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 fell again this month to 51%, as nineteen breaches occurred. At present a number of complaint investigations have not yet been completed but these continue to be chased and escalated, some complaints have since been completed and closed. Med 1 and Women and Children’s Services each had 5 breaches. Patient Services had 3 breaches and Cancer Diagnostics, Surgery 2 and Med 2 each had 2.
Divisional leads have been contacted in terms of the overdue complaint responses for management plans to improve compliance.
152 compliments were received this month, which shows a decrease from 178 compliments received last month and a decrease in comparison to September 2016, in which the Trust received 171 compliments.
PALS contacts have had 368 contacts this month, compared to a figure of 414 in the previous month. This is also a decrease in comparison to September 2016, in which 398 contacts were recorded. The top subjects for this month are noted below:
General Information 61
Complaints Procedure 23
Enquiry 23
Directions within the Trust 14
Travel Expenses 14
Waiting List In-Patients 13
Department Details 12
Cancellation 11
Parking Fine 11
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 31 of 57
01/07/2017 01/08/2017 01/09/2017 2016/17
Indicators Var to prev mth Target Jul Aug Sep FYTD
National standards 01/07/2017 01/08/2017 01/09/2017 2017/18
18 Wks - Adm (adjusted) Target18 Wks - Adm Perf (adjusted) 90.00% 77.81% 78.55% 75.39% 78.34%
18 Wks - Non Adm Target18 Wks - Non Adm Perf 95.00% 88.31% 82.29% 83.19% 88.17%
18 Wks - Incomp Target18 Wks - Incomp Perf 92.00% 88.04% 87.74% 87.20% 89.82%
Cancer-2ww TargetCancer-2ww 93.00% 95.88% 96.45% NA 96.90%
Cancer-2ww (Breast Symptomatic) TargetCancer-2ww (Breast Symptomatic) 93.00% 100.00% 98.72% NA 98.01%
31 Day Diag to Treat Target31 Day Diag to Treat 96.00% 97.41% 99.21% NA 98.38%
Cancer-62 Days RTT TargetCancer-62 Days RTT 85.00% 86.49% 88.31% NA 83.10%
Cancer-31 Days Sub Treat (Surg) TargetCancer - 31 Days Subsq Treatment - Surgery 94.00% 100.00% 100.00% NA 95.83%
Cancer-31 Days Sub Treat (Drug) TargetCancer - 31 Days Subsq - Drug Treatments 98.00% 98.04% 100.00% NA 99.64%
Cancer Screening (62 Day) TargetCancer Screening (62 Day) 90.00% 100.00% 96.97% NA 99.13%
A&E 4 Hr TargetA&E 4 Hour Performance 95.00% 84.14% 89.80% 93.55% 88.84%
Amb turmaround TargetAmbulance turmaround 100.00% 25.54% 20.78% 24.09% 24.70%
Stroke - 90% of Stay on SU TargetStroke - 90% of Stay on a Stroke Unit 80.00% 75.41% 87.50% NA 82.54%
TIA - HR TIA seen & treated <24hrs TargetTIA - High Risk,Non admitted TIA treated in 24 Hrs 60.00% 63.16% 66.67% NA 75.00%
Cancelled Ops - as a % of Elective Admissions TargetCancelled Ops - as a % of Elective Admissions 0.80% 0.56% 0.55% 0.43% 0.67%
Diagnostic Over 6 Week Waiters - % of Total WL TargetDiagnostic Over 6 Week Waiters - % of Total WL 1.00% 0.73% 0.13% 0.35% 0.36%
Indicators Var to prev mth Target Jul Aug Sep FYTD
Local standards
Day Case Rate TargetDay Case Rate 82.00% 85.76% 85.87% NA 86.29%
DNA Rate TargetDNA Rate 5.00% 6.36% 6.48% 6.44% 6.40%
New to FUP Ratio TargetNew to FUP Ratio 2.3 2.6 2.8 2.6 2.7
Readm Rate (EL) TargetReadmission Rate - ElReadmission Rate - Elective 3.00% 4.34% 3.62% NA 4.34%
Readm Rate (Em) TargetReadmission Rate - EmReadmission Rate - Emergency 10.00% 15.19% 15.75% NA 15.83%
EL LOS TargetLength of stay - Elective 2.2 1.6 1.5 1.6 1.7
EM LOS TargetLength of stay - Emergency 5.0 3.6 3.9 3.9 3.7
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
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 32 of 57
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
Key Points/Operational Actions
Definitions
84
.31
%
81
.30
%
81
.29
%
80
.03
%
76
.23
%
78
.26
%
79
.65
%
82
.90
%
75
.80
%
77
.81
%
78
.55
%
75
.39
%
83.16%80.31% 80.76%
78.53%75.89%
77.84% 79.23%82.59%
75.50%77.22% 78.46%
74.98%
60%
65%
70%
75%
80%
85%
90%
95%
100%
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
18 Wks Admitted Performance
18 Wks - Adm Perf (adjusted) 18 Wks - Adm (adjusted) Target 18 Wks - Adm Perf (unadjusted)
94
.01
%
91
.94
%
90
.49
%
90
.30
%
90
.94
%
90
.43
%
91
.96
%
92
.94
%
89
.32
%
88
.31
%
82
.29
%
83
.19
%
80%
85%
90%
95%
100%
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
18 Wk Non- Admitted Performance
18 Wks - Non Adm Perf 18 Wks - Non Adm Target
92
.97
%
93
.33
%
92
.97
%
92
.64
%
92
.77
%
92
.38
%
92
.01
%
92
.03
%
92
.03
%
88
.04
%
87
.74
%
87
.20
%
80%
85%
90%
95%
100%
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
18 Wk Incompletes Performance
18 Wks - Incomp Perf 18 Wks - Incomp Target
74.98%Admitted "Unadjusted) (Target 90%) rrrr
75.39%Admitted "Adjusted"(Target 90%) rrrr
83.19%Non-Adm (Target 95%) rrrr
87.20%Incompletes (Target 92%) rrrr
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 33 of 57
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
Key Points/Operational Actions
Definitions
90%
92%
94%
96%
98%
100%
Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
2WW Performance
Cancer-2ww 2 WW Target
96.45%2ww (Target 93%)
aaaa
99.21%
31 Day (Target 96%)
aaaa
88.31%62 Day (Target 85%)
aaaa
90%
92%
94%
96%
98%
100%
Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
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%
Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
62 Day Ref To Treat Performance
Cancer-62 Days RTT 62 Day Target
100.00%31 Day Subs Treat - Surg (Target 94%) aaaa
100.00%31 Day Subs Treat - Drug (Target 98%) aaaa
98.72%2ww Breast Symptomatic (Target 93%) aaaa
96.97%62 Day Screening (Target 90%) aaaa
Site Level Breach Analysis - Latest Month
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 34 of 57
Cancer Waiting Times cont'd
Key Points/Operational Actions
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Sustainability Sustainability Sustainability Sustainability
Cancer Site(Target - 85%
Compliance)
Estimated
remainder to
achieve
Estimated
remainder to
achieve ForecastSnapshot
position Trajectory Flag
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 0.00 0.00 0.00
Treated Within 62 Days 0.00 0.00 0.00 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% 0.0% 0.0% 0.0%
Estimated breaches allowed 0.0 0.0 0.0 0.0
Total Treated 7.00 5.50 10.00 8.00 2.00 7.00 6.00 1.00 6.00
Treated Within 62 Days 7.00 5.50 10.00 7.00 2.00 7.00 6.00 1.00 6.00
% Within 62 Days 100.0% 100.0% 100.0% 87.5% 100.0% 100.0% Alert 100.0% 100.0% 100.0%
Estimated breaches allowed 0.0 0.0 -1.0 0.0
Total Treated 7.00 4.00 5.00 5.00 2.00 4.00 4.50 1.00 4.50
Treated Within 62 Days 6.00 4.00 4.50 4.00 1.00 2.50 3.00 1.00 3.00
% Within 62 Days 85.7% 100.0% 90.0% Alert 80.0% 50.0% 62.5% 66.7% 100.0% 66.7%
Estimated breaches allowed -1.5 -0.5 0.5 0.0
Total Treated 1.50 1.50 3.00 1.00 0.00 1.00 2.00 0.00 2.00
Treated Within 62 Days 0.00 0.00 2.50 0.00 0.00 0.00 1.00 0.00 1.00
% Within 62 Days 0.0% 0.0% 83.3% Alert 0.0% 0.0% 0.0% 50.0% 0.0% 50.0%
Estimated breaches allowed 1.0 -1.0 0.0 0.0
Total Treated 1.00 1.00 4.50 4.00 1.00 2.00 2.00 0.50 2.00
Treated Within 62 Days 0.00 0.00 3.50 2.00 0.50 1.00 Alert 2.00 0.00 2.00
% Within 62 Days 0.0% 0.0% 77.8% Alert 50.0% 50.0% 50.0% 100.0% 0.0% 100.0%
Estimated breaches allowed -3.0 0.0 -1.0 0.0
Total Treated 6.00 5.00 11.00 8.00 1.00 8.00 8.00 0.00 8.00
Treated Within 62 Days 4.00 3.00 10.50 5.00 1.00 6.00 6.00 0.00 6.00
% Within 62 Days 66.7% 60.0% 95.5% Alert 62.5% 100.0% 75.0% Alert 75.0% 0.0% 75.0%
Estimated breaches allowed -3.0 -1.5 -1.0 0.0
Total Treated 1.00 1.00 3.50 5.00 0.00 5.00 6.00 0.00 6.00
Treated Within 62 Days 1.00 1.00 3.00 3.00 0.00 4.00 5.00 0.00 5.00
% Within 62 Days 100.0% 100.0% 85.7% 60.0% 0.0% 80.0% Alert 83.3% 0.0% 83.3%
Estimated breaches allowed -2.5 0.5 -1.0 0.0
Total Treated 0.00 0.00 0.50 1.00 0.00 1.00 1.00 0.00 1.00
Treated Within 62 Days 0.00 0.00 0.00 0.50 0.00 1.00 1.00 0.00 1.00
% Within 62 Days 0.0% 0.0% 0.0% 50.0% 0.0% 100.0% Alert 100.0% 0.0% 100.0%
Estimated breaches allowed 0.0 0.5 -0.5 0.0
Total Treated 15.00 10.50 11.00 18.00 1.00 18.00 16.00 0.00 16.00
Treated Within 62 Days 14.50 10.00 10.00 17.50 1.00 17.50 15.00 0.00 15.00
% Within 62 Days 96.7% 95.2% 90.9% 97.2% 100.0% 97.2% 93.8% 0.0% 93.8%
Estimated breaches allowed 0.0 0.5 0.0 0.0
Total Treated 4.50 4.00 5.50 4.50 0.50 4.50 4.00 0.50 4.00
Treated Within 62 Days 3.50 3.50 3.00 4.00 0.50 3.00 3.00 0.50 3.00
% Within 62 Days 77.8% 87.5% 54.5% 88.9% 100.0% 66.7% 75.0% 100.0% 75.0%
Estimated breaches allowed -2.5 1.5 1.0 0.0
Total Treated 20.00 18.50 21.00 21.00 4.00 22.00 20.00 2.00 20.00
Treated Within 62 Days 18.50 18.00 16.50 21.00 4.00 20.00 17.00 2.00 17.00
% Within 62 Days 92.5% 97.3% 78.6% 100.0% 100.0% 90.9% 85.0% 100.0% 85.0%
Estimated breaches allowed -0.5 3.0 2.0 0.0
Total Treated 0.00 0.00 3.00 3.00 0.00 3.00 2.00 0.00 2.00
Treated Within 62 Days 0.00 0.00 3.00 3.00 0.00 3.00 2.00 0.00 2.00
% Within 62 Days 0.0% 0.0% 100.0% 100.0% 0.0% 100.0% 100.0% 0.0% 100.0%
Estimated breaches allowed 0.0 0.0 0.0 0.0
Total Treated 63.00 51.00 78.00 78.50 11.50 69.00 71.50 5.00 71.50
Treated Within 62 Days 54.50 45.00 66.50 67.00 10.00 59.00 61.00 4.50 61.00
% Within 62 Days 86.51% 88.24% 85.26% 85.35% 86.96% 85.5% Alert 85.31% 90.00% 85.3%
Estimated breaches allowed -12.0 3.0 -1.5 0.0
Nov-17November
Trajectory
Trust Total
Lung
Sarcoma
Skin
Upper
Gastrointestinal
Urological
Other
Lower
Gastrointestinal
Breast
Gynaecological
Haematological
Head & Neck
Oct-17October
Trajectory
Brain/Central Nervous
System
Sep-17September
Trajectory
Produced by the Performance and Information Team 35 of 57
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%
QEH JPH CUH IP WS P&S N&N
2WW Wait Perf for Qtr 1 across East of England
SEEN WITHIN 14 DAYS National Target
70%
75%
80%
85%
90%
95%
100%
WS PAP JPH P&S QEH N&N CUH IP
31 Day Perf for Qtr 1 across East of England
TREATED WITHIN 31 DAYS National Target
45%
55%
65%
75%
85%
95%
JPH WS P&S PAP QEH CUH IP N&N HHC
62 Day RTT Perf for Qtr 1 across East of England
TREATED WITHIN 62 DAYS National Target
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 36 of 57
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
93.55%AE Performance - Prev Mth (Target 95%) rrrr
88.84%AE Performance - YTD (Target95%) rrrr
Previous Month's KPI's
Benchmarking across NHS England Midlands & East (East)
Key Points/Operational Actions
Activity & Performance levels of the last 3 months
AE performance (Last 12 month)
89.4
0%
90.4
9%
93.0
1%
86.3
1%
90.4
9%
90.6
8%
91.3
1%
91.0
2%
83.6
4%
84.1
4%
89.8
0%
93.5
5%
75%
80%
85%
90%
95%
100%
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug SepA&E 4 Hour Performance A&E 4 Hr Target
In month 4 hour performance for September was 93.55% compared to 89.90% in August
• Trajectory was exceeded for September (trajectory was at 91.05%) • Attendances were 5,257 for September (down from 5698 in August)• Average attendances for September were 175 down slightly to those in August• Attendances across the month are down 1% compared to 2016• The biggest percentage of breeches again related to no flow/limited bed capacity• The closure of Obs bay to support RATing has impacted on number of patients admitted particularly overnight when no transport is available for discharge • Estates, Pathway and recruitment work on Primary Care Streaming continues
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 37 of 57
Latest Month's Performance Financial YTD
Potential fines per case in
£66,000.00
£388,000.00
£179,400.00
£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
Key Points/Operational Actions
Definitions
24.09%
% of handovers within 15 minutes
24.70%
% 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.
• % ambulances with clinical handover <15 mins =24.09% (August 20.78%)• % ambulances with clinical handover <30 mins = 90.3% (August 88.1%)• % ambulances with clinical handover <60 mins = 98.0% (August 96.5%)• Concerns still existing over ‘batching’ of vehicles which leads to a high number of vehicle attendances within a short episode of time• Fit to Sit is being encouraged with patients arriving by ambulance. Wheelchair issue currently being reviewed• New arrival/handover front screen is being introduced 18th October. This will need close monitoring as individual CAD specific PIN numbers are now required to complete the handover process• Training on AEC pathways as part of Majors2Majors initiative is being arranged with EEAST staff
0
200
400
600
800
1000
1200
1400
1600
1800
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
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+
2422
6034
897
388
66
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%
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Nu
mb
er
of
Pa
tie
nts
Handovers within 0-15 mins & 15-30 mins - rolling 12 Months
0 - 15 Minutes 15-30 Min
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 38 of 57
Improvement in overall SSNAP score from C to B reflects newly agreed Stroke Referral Pathway from A&E, resulting in the right patients on the right ward more of the time, and subsequent improvement in metrics.
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
Key Points/Operational Actions
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
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
90.00%
85.00%
80.00%
75.00%
<75.00%
87.50%
Monthly Performance %
E
D
Aug-17
A
B
CSSNAP Level
YTD Performance %
B C
YTD SSNAP Level
80.43%
YTD 2017/2018SSNAP Target Levels
Produced by the Performance and Information Team 39 of 57
3 out of 4 TIA targets achieved consistently, including both High Risk targets. The 4th target (Low Risk TIA treated within 7 days of onset), is the least under QEH control, and is dependent on the patient presenting and reporting to the GP, and then referred to QEH by the GP.
There is increased demand this year for TIA outpatient services (~+25%), and an additional clinic room will be required in the medium term to manage this. The challenge will be to locate this room in the vicinity of West Raynham, to enable the consultants to cover both services concurrently as they currently do.
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
Key Points/Operational Actions
Definitions
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 40 of 57
The Trust has achieved the Diagnostic 6 week target in September and is inside the 1% threshold.
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)
Key Points/Operational Actions
Definitions
0.35%(Target 1%)
aaaa
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 41 of 57
SAFER Dashboard
Key Points/Operational Actions
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 42 of 57
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
2.6 2.62.8 2.8 2.7 2.8 2.8 2.8 2.7 2.6
2.82.6
0.0
1.0
2.0
3.0
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
New to Follow Up ratio against local target
New to FUP Ratio target
2.6
Trust Level New to Review Rate
(Target 2.3) rrrr
Key Points/Operational Actions
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 43 of 57
Top 10 Specialties with most "Appointment Slot Issues" over last 4 weeks
Within the Trust the majority of specialties have a polling range to 6 weeks, this is to prevent patients being cancelled when clinical staff book leave. Currently we have a high ASI rate and relatively low cancelled clinic rate.
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
Key Points/Operational Actions
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
28/09 05/10 12/10 19/10
DER 588 617 649 630
CAR 499 505 517 509
NEU 473 456 462 440
URO 384 383 391 393
ORT 431 397 387 384
RES 205 205 209 215
PAE 179 182 194 195
ENT 229 242 234 181
END 147 128 137 139
RHE 115 113 120 109
PC 76 82 91 96
UGI 61 59 63 69
OPH 64 55 58 63
NEP 47 49 45 43
GER 29 32 31 33
2WW 11 2 21 21
GYN 19 15 10 4
VAS 1 1 3 2
SUR 8 3 3 1
ASI's Last 4 Weeks
Produced by the Performance and Information Team 44 of 57
Latest Month's Performance
DNA :Ratio between the total number of new and follow up appointment DNAs against the total number of Attendances and DNAs (Did not attend)The DNA chart above now excludes Physiotherapy, Radiology, or G.U.M specialties.
DNA rate
Definitions
6.61%5.92%
6.58% 6.50% 6.31% 6.05% 6.02% 6.35% 6.72% 6.36% 6.48% 6.44%
0.0%
2.0%
4.0%
6.0%
8.0%
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
DNA (Did not attend appointments) rate against local target
DNA Rate DNA Rate Target
6.44%DNA rate (Target 5.0) rrrr
Key Points/Operational Actions
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 45 of 57
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
1.7 1.7 1.82.2
1.81.5
1.8 1.72.2
1.6 1.5 1.6
0.0%
2.0%
4.0%
6.0%
0.0
0.5
1.0
1.5
2.0
2.5
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
Trust Level - Average LOS - Elective
Length of stay - Elective target Readmission Rate - El
1.6
Average LOS
Elective Admission (Target 2.2) aaaa
3.62%
Re-adm following Elective
Admission (Target 3%) rrrr
Definitions
4.4
4%
3.9
4%
4.2
0%
4.3
1%
4.3
2%
5.1
9%
4.1
7%
4.4
0%
4.8
4%
4.5
0%
4.3
4%
3.6
2%
0%
1%
2%
3%
4%
5%
6%
Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17
Trust Level - Elective Re-admission Rate Performance Against Target
Readmission Rate - El Readm Rate (EL) Target
Key Points/Operational Actions
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 46 of 57
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 3.7 3.8 3.7 3.7 3.6 3.6 3.4 3.5 3.6 3.9 3.9
0.0%
5.0%
10.0%
15.0%
20.0%
0.0
2.0
4.0
6.0
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
Trust Level - Average LOS - Emergency
Length of stay - Emergency target Readmission Rate - Em
3.9
Average LOS Emergency Admission (Target 5.0) aaaa
15.75%
Re-adm following Emergency Admission (Target 10%) rrrr
Definitions
13
.30
%
14
.05
%
13
.35
%
15
.40
%
15
.98
%
15
.53
%
15
.78
%
17
.08
%
15
.73
%
15
.51
%
15
.19
%
15
.75
%
0%
5%
10%
15%
20%
Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17
Trust Level - Emergency Re-admission Rate Performance Against Target
Readmission Rate - Em Readm Rate (Em) Target
Key Points/Operational Actions
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 47 of 57
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
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 48 of 57
CQUINs
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
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 £21,712.50 £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 £138,959.20 £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 £86,849.50 £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 £86,849.50 £86,849.50 £86,849.50
8 Supporting Proative
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 £138,959.20 £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 £13,525.00 £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 £11,089.75 £11,089.75 £11,089.75
3 Breast Screening STILL WITH NHSE TO SET CQUIN FOR Q3 & Q4 TBC TBC TBC TBC
4 Armed Forces Embedding the Armed Forces Covenant to
support improved health outcomes for the
Armed Forces Community
AC
HIE
VED
10
0%
£6,301.50 £6,301.50 £12,603.00
CQUIN Description
H&W
SEPSIS
N/A
N/A
AC
HIE
VED
10
0%
ACUTE CONTRACT
Update only no Financial
value
N/A
NHSE SPECIALIST CONTRACT
Produced by the Performance and Information Team 49 of 57
Indicators Var to prev mth Target Jul Aug SepRolling
12 mths
Staff Sickness & Turnover 01/07/2017 01/08/2017 01/09/2017
Sickness Absence Rate (Target)Sickness Absence Rate 3.50% 5.17% 5.06% 4.80% 4.99%
Staff Turnover Rate Complete Trust (Target)Staff Turnover Rate Complete Trust 10.00% 11.45% 11.16% 11.68% 11.26%
Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) (Target)Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) 10.00% 7.74% 6.47% 8.80% 10.54%
Staff Turnover Rate Registered Nursing & Midwifery (Target)Staff Turnover Rate Registered Nursing & Midwifery 10.00% 14.83% 14.70% 15.41% 14.22%
Staff Turnover Rate Allied Health Professionals (Target)Staff Turnover Rate Allied Health Professionals 10.00% 19.56% 17.83% 15.48% 18.04%
Appraisals
Appraisal Completeness excluding bank staff (Target)Appraisal Completeness excluding bank staff 90.00% 85.31% 82.90% 82.26% 84.52%
Vacancies
Medical & Dental Vacancies (as % of Medical Posts) (Target)Medical & Dental Vacancies (as % of Medical Posts) 5.00% 20.15% 21.95% 21.25% 19.37%
Registered Nurses & Midwives Vacancies (as % of Nurse Posts) (Target)Registered Nurses & Midwives Vacancies (as % of Nurse Posts) 6.00% 14.45% 13.88% 14.39% 12.07%
Allied Health Professional Vacancies (as % of AHP Posts) (Target)Allied Health Professional Vacancies (as % of AHP Posts) 6.00% 11.26% 11.68% 5.24% 10.26%
Contracted staff in Post (WTE) 2760 2757 2765 2769
Temporary Staff in Post (WTE) 314 358 345 308
Mandatory Training
Conflict Resolution Training (Target)Conflict Resolution Training 95.00% 83.42% 82.65% 82.76% 83.14%
Equality and Diversity Training (Target)Equality and Diversity Training 95.00% 67.32% 70.66% 73.73% 77.68%
Fire Training (Target)Fire Training 95.00% 75.49% 70.83% 73.52% 78.46%
Health & Safety Training (Target)Health & Safety Training 95.00% 92.19% 89.91% 89.89% 91.51%
Infection Control Training (Target)Infection Control Training 95.00% 78.61% 74.93% 75.92% 80.29%
Information Governance Training (Target)Information Governance Training 95.00% 88.78% 86.78% 86.00% 89.20%
Manual Handling Training (Target)Manual Handling Training 95.00% 82.94% 82.36% 81.85% 84.25%
Resuscitation Training (Target)Resuscitation Training 95.00% 82.97% 81.22% 78.46% 82.40%
Risk Management Training (Target)Risk Management Training (Level 2 only) 90.00% 98.03% 70.13% 72.33% 93.87%
Safeguarding Adults Training (Target)Safeguarding Adults Training 95.00% 94.23% 92.01% 90.24% 94.30%
Safeguarding Children Training (Target)Safeguarding Children Training 95.00% 92.61% 90.26% 89.86% 91.67%
Slips, Trips & Falls Training (Target)Slips, Trips & Falls Training 90.00% 94.25% 90.80% 89.34% 93.79%
VTE Training (Target)VTE Training 90.00% 77.24% 76.11% 74.18% 81.39%
Mandatory Training Overall (10 core subjects) (Target)Mandatory Training Overall (10 core subjects) 95.00% 83.86% 82.16% 82.22% 85.29%
The percentage figure shown for Risk Management Training currently represents Level 2 only (Level 2 - Heads of Departments)
Wo
rkfo
rce
Workforce Scorecard
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 50 of 57
Safer Staffing Return
Key Points/Operational Actions
The fill rates of actual shifts against planned including temporary staff are:
• For Registered Nurses/ Midwives Day - 87.1% Night - 96.7%• For Care staff Day - 93.6% Night - 105.8%
Whilst the overall fill rate for RN days was 87.1%, there were 13 areas out of 20 that has fill RN rates under 90% during this period. This is a reduction from the previous month where 10 out of 20 clinical areas reported at under 90%.There has also been a slight reduction of fill rates on day and nights from the previous month.
There was one area with a RN fill rate under 80% this was critical care at 77.5% this is due to vacancies within the unit, however each patient was risk assessed and no patient breached the 1:1 / 1:2 standard.
Senior nurses review the staffing 3 times a day, identifying areas of need and relocating staff depending on the activity and patient acuity using professional judgment to ensure patient safety. However continued use of the escalation areas can be seen to impacting on the ability of the Trust to secure fill rates above 90% in all areas and the high RN vacancy rate contributes to high % of temporary staff : permanent staff ratios in many areas.
In addition to this the senior nurses now receive data each week form the staffing and safety tool that reviews red flag events and this is used to review clinical incidents in relation to staffing levels. This data is in its pilot stage and will be included in future Board Reports once the data collection is assured.
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Specialty 1 Specialty 2
West Newton 430 - GERIATRIC MEDICINE 88.6% 115.1% 99.5% 142.1% 829 2.9 5.3 8.1
Necton 340 - RESPIRATORY MEDICINE 81.8% 97.5% 99.9% 98.9% 938 3.1 2.7 5.7
Windsor 430 - GERIATRIC MEDICINE 96.4% 84.0% 100.0% 109.9% 957 2.8 2.8 5.7
Stanhoe 301 - GASTROENTEROLOGY 350 - INFECTIOUS DISEASES 85.4% 97.9% 99.2% 122.6% 960 3.1 3.2 6.3
Tilney 320 - CARDIOLOGY 88.3% 83.1% 100.1% 99.9% 774 3.1 2.1 5.2
West Raynham 300 - GENERAL MEDICINE 87.1% 73.6% 99.8% 89.8% 778 4.1 2.8 7.0
Denver 100 - GENERAL SURGERY 93.3% 96.6% 100.3% 130.4% 860 2.8 2.7 5.6
Marham 100 - GENERAL SURGERY 82.1% 87.0% 91.9% 92.6% 679 3.5 2.3 5.8
Elm 100 - GENERAL SURGERY 88.2% 90.4% 101.8% 91.7% 543 3.1 2.8 5.9
Gayton 110 - TRAUMA & ORTHOPAEDICS 100 - GENERAL SURGERY 88.3% 92.7% 99.1% 111.9% 920 2.8 3.2 5.9
Shouldham 315 - PALLIATIVE MEDICINE 823 - HAEMATOLOGY 86.9% 107.4% 99.6% 93.3% 347 4.8 3.0 7.8
Critical Care 192 - CRITICAL CARE MEDICINE 77.5% 91.8% 85.4% 243 26.1 1.7 27.8
Central Delivery suite 501 - OBSTETRICS 95.4% 89.0% 96.9% 86.4% 153 27.2 8.3 35.4
Surgical Assessment Unit 100 - GENERAL SURGERY 93.2% 92.9% 88.6% 99.9% 260 7.9 2.8 10.6
Medical Assessment Unit 300 - GENERAL MEDICINE 84.3% 103.5% 109.1% 111.7% 512 6.8 2.9 9.8
Terrington 300 - GENERAL MEDICINE 93.8% 113.4% 92.2% 96.0% 925 3.3 2.3 5.6
Castleacre 501 - OBSTETRICS 97.5% 94.6% 99.0% 95.3% 332 5.3 4.1 9.4
NICU 420 - PAEDIATRICS 80.3% 94.7% 98.1% 103.3% 207 11.5 5.3 16.8
Rudham 420 - PAEDIATRICS 80.1% 66.4% 101.1% 110.0% 256 11.5 3.8 15.3
ED Obs Ward 180 - ACCIDENT & EMERGENCY 111.2% 93.9% 13 54.7 0.0 54.7
Oxborough 300 - GENERAL MEDICINE 90.8% 97.4% 99.1% 96.1% 945 2.5 2.6 5.1
Sep-17
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
Day
Ward name
Main 2 Specialties on each ward
Average
fill rate -
registered
nurses/mid
wives (%)
Average
fill rate -
care staff
(%)
Overall
Produced by the Performance and Information Team 51 of 57
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
Key Points/Operational Actions
Definitions
VacanciesThe number of registered nursing vacancies has increased to 14.39% from 13.88% in August 2017. Medical & Dental vacancies have decreased from 21.95% to 21.25% as have AHP vacancies from11.68% to 5.24%
TurnoverTurnover has increased for the month of September. A new set of guidelines for leaving employment has been developed which makes it mandatory for all managers to meet with staff when they tender their resignation. The purpose is to look to see if any measures can be put into place to prevent the member of staff leaving the organisation, to fully understand the reason the employee has chosen to tender their resignation and to thank them for their work and dedication to the trust.
It is following this meeting that the manager then acknowledges the resignation and completes the necessary paperwork.
This new process is being piloted for two months across the medicine division and results will be reported early November. Following the completion of this trial the process will be rolled out across the Trust.
Exit interviews are offered to all members of staff who hand in their resignation but numbers being completed have fallen. As part of the new process managers will pass an exit interview to their member of staff during their meeting and advise them of the different options to complete the form.
Work continues to monitor areas with high turnover rates across the whole Trust and further analysis work is being undertaken. It is to be noted that although some areas appear as having a high turnover rate this is due to them being relatively smaller teams.
In addition the Trust is developing a recruitment and retention strategy and creating a sub committee to focus on recruitment and retention. Alongside this the Trust will be looking at reward and recognition and developing new initiatives to ensure staff feel valued at work.
780
800
820
840
860All Registered Nursing Staff in Post : Rolling year
All registered Nursing Staff in post: Rolling yearLinear (All registered Nursing Staff in post: Rolling year)
320
340
360
380
400Elective/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
410
420
430
440All 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)
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 52 of 57
Latest Month's Performance
Overdue by 18-24 months
11 Permanent, 2 Bank staff
• Scientific & Technical x 1• Additional Clinical Services x 3• Admin & Clerical x 1• Estates & Ancillary x 2• Healthcare Scientists x 2
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
Key Points/Operational Actions
Definitions
82.26%Appraisal Compliance Exc Bank Staff (Target 90%) rrrr
82.6
7%
85.5
4%
85.6
5%
86.4
5%
86.8
5%
83.7
8%
83.8
7%
84.4
6%
84.2
3%
85.3
1%
82.9
0%
82.2
6%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
Appraisal Compliance Rates (exc Bank Staff)
Actual (excluding bank staff) Target (excluding bank staff) Prev Year
Excluding bank staff, the appraisal completion compliance has decreased to 82.26% (81.10% including bank staff) in September 2017. The number of seriously overdue appraisals has increased again
Overdue by 24 months +
1 Permanent staff
• Additional Clinical Services x 1
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
81.1
9%
84.0
3%
84.5
8%
85.4
1%
86.2
4%
83.3
1%
83.2
3%
83.4
7%
83.3
9%
83.5
6%
81.1
8%
81.1
0%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
Appraisal Compliance Rates (inc Bank Staff)
Actual (including bank staff) Target (including bank staff)
Monthly Appraisal Reports continue to be issued to ED’s and senior management teams showing compliance rates and highlight all staff currently outstanding and those with appraisals due within the next two months. HRBP’s follow up with each of their areas to monitor against these reports and follow the escalation process where appraisals remain outstanding in accordance with the Appraisal policy. Appraisal questionnaires completed and returned to HR following individual appraisals show 98% of staff completing the feedback rate the quality of their appraisal in terms of value and usefulness to them as very much or quite a lot with 2 % rating not very or not at all.Positive feedback on the revised Appraisal record received during appraisal training and drop in sessions to support the new paperwork.
Draft recommendations to strengthen control frameworks following recent internal Audit of Appraisals is to be worked through with HRBP’s and Training & Development Manager to review practical implementation of suggestions in particular:• Introduce regular sample checking of completed appraisals• Review current process of directorate meetings to ensure consistency and ownership of actions• Introduce appraisee training for all staff
Produced by the Performance and Information Team 53 of 57
The monthly sickness rate for September 2017 is 4.80% which is a decrease of 0.26% from last month’s adjusted figure (5.06%). The highest staff groups are:
• Scientific & Technical (6.44%)• Additional Clinical Services (6.72%)• Estates and Ancillary (7.57%)
All other staff groups were below 5%.
Sickness continues to be higher than Trust target of 4% but a number of measures / actions are being put into place to help reduce the sickness rate.
1) New sickness reporting processA new manager call back system has been put into place whereby the expectation is the individuals line manager calls the absent employee back.
A request has been made to the HRBP team for additional training to be arranged to help managers in making these calls and adding in a level of challenge and control. This is in the process of being arranged.
Since the new process has been rolled out the reliance on E-roster has increased, in respect of recording return to work dates, running trigger reports, individual sickness reports and trend reports. In order to assist with this and to help managers in how to utilise e-roster to its full capacity additional training is being arranged.
2) Completion of return to work interviews continue to be monitored.
3) New policyA new managing attendance policy is being developed which is based on managers knowing their staff and is not the traditional approach to managing absence. A pilot of the new process will be run across surgery division starting in November 2017. In addition an implementation plan will be developed for the new process, to include communications to staff and managers, policy briefing sessions, management training days and an intranet site dedicated to absence. This will be run in conjunction with the RCN.
4) Monthly Management meetings / performance meetings Monthly meetings continue to take place between ward managers and Assistant HRBPs to discuss workforce KPIs.
5) Top areasWork continues in reviewing the top 10 areas for absence on a monthly basis. A new template report is being developed for the top 10 areas in relation to absence, vacancies and bank and agency spend which will be presented at performance meetings
6) Long term sickness cases and hearings
Further work is being undertaken in managing long term sickness which accounts for a significant proportion of overall sickness.A number of staff have also been redeployed to alternative areas of work.
7) TrainingAs highlighted above there has been a request for additional training to be provided to support managers to managing absence.
In addition the Training and Development team are looking at rolling out mindfulness and mental health first aid training for staff as stress , anxiety and depression remains one of the top reasons for sickness
8) Early intervention support, Staff health and well being , Sub committee A. Additional support has been offered by the Royal College of Nursing to help to develop initiatives to support the health and well being of staff.
A further sub committee will be created to also look at these areas.
Percentage sickness absence for the month. Based on FTE days absent divided by FTE days available.
Sickness Absence & Turnover
Key Points/Operational Actions
Definitions
4.80%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
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 54 of 57
The percentage figure shown for Risk Management Training currently represents Level 2 only (Level 2 - Heads of Departments)
Mandatory Training
Key Points/Operational Actions
Definitions
82.22%Mandatory Training (Trust) rrrr
Compliance rate for the 10 core subjects has increased very slightly to 82.22% from 82.16% in August 2017.
Currently scheduling the Clinical and Medical mandatory training days 1 & 2 for 2018 and the Induction programmes. The revised clinical Day 2 programme moved to scenario based training delivery for 2017 and although proving popular with staff places are limited to 25 to assist the facilitation. An additional clinical day 2 will need to be scheduled each month for 2018 to provide sufficient places and to be agreed with facilitators. To assist essential maintenance works on the training room windows/roof we are being asked to free up a working week before the financial year end. Unless these works are carried out over the Christmas break there will be an impact on the mandatory training delivery programme. Currently liaising with Estates on this. Revising Appendix 6 of Induction policy to provide a clear checklist of mandatory requirements for local induction so that it supports managers in starting new members of staff prior to Trust Induction. This will be incorporated into the recruitment process.
The Core Mandatory training covers the statutory and mandatory subjects: Manual Handling, Conflict Resolution, Equality & Diversity, Fire Safety, Health and Safety,Infection Control & Prevention, Resuscitation, Safeguarding Adults and Safeguarding Children and Prevent
Other Mandatory training: Consent, dementia Awareness, Diabetes, Health Record keeping, Learning Difficulties, Medicines management, Mental Capacity, Risk Management, Slips, Trips & Falls, Tissue Viability, Venous Thromboembolism, Transfusion, Breakaway, mentor updatesWe are seeking clarity on which subjects beyond statutory mandatory are actually required for the Workforce score card reporting to Board.
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Sep-17Mthly
Target
Rolling
12 Mths
Conflict Resolution Training 82.76% 95.00% 83.14%
Equality and Diversity Training 73.73% 95.00% 77.68%
Fire Training 73.52% 95.00% 78.46%
Health & Safety Training 89.89% 95.00% 91.51%
Infection Control Training 75.92% 95.00% 80.29%
Information Governance Training 86.00% 95.00% 89.20%
Manual Handling Training 81.85% 95.00% 84.25%
Resuscitation Training 78.46% 95.00% 82.40%
Risk Management Training (level 2 only) 72.33% 90.00% 93.87%
Safeguarding Adults Training 90.24% 95.00% 94.30%
Safeguarding Children Training 89.86% 95.00% 91.67%
Slips, Trips & Falls Training 89.34% 90.00% 93.79%
VTE Training 74.18% 90.00% 81.39%
Mandatory Training Overall (10 core subjects) 82.22% 95.00% 85.29%
Produced by the Performance and Information Team 55 of 57
Finance report to follow seperately
Finance
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 56 of 57
None
Appendices
Compliance Scorecard
Quality & RiskPerf &
StandardsCQUINS Workforce Finance Appendices
Produced by the Performance and Information Team 57 of 57