Board Report template - qehkl Report 2017 12.pdf · 2018-01-04 · Context for the Integrated...

Integrated Report

Quality &Performance toend November 2017

Contents

Nov-17 Nov-17 01/09/2017 01/10/2017 01/11/2017

Current MthTrend on

prev mth

Previous

MthSep-17 Oct-17 Nov-17 FYTD

1 23 2 1

355 Emergency Department Attendances 5083 5438 5257 5438 5083 43708

152 Outpatient Attendances 24336 24488 22351 24488 24336 187494

-102 Inpatient Admissions (Elective & Emergency) 4072 3970 3856 3970 4072 31742

44 Other (regular day patients, day cases etc) 3327 3371 3058 3371 3327 25608

Compliance Scorecard1

Quality & Risk2

Performance & Standards3

CQUINS4

Finance5

Appendices6

7

8

Page 3

Page 4

Page 32

Page 49

Page 50

Page 51

Context for the Integrated Report

Produced by the Performance and Information Team, ext 3735 2 of 51

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

Indicators TargetCurrent

QTDSep Oct Nov Qtr 1 Qtr 2 Qtr 3 Qtr 4 *FYTD

Risk Assessment framework 2015/16 6 01/09/2017 01/10/2017 01/11/2017 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% 72.97% 75.39% 72.97% 77.47% 77.22% 72.97% 77.47%

18 Wks - Non Adm Target18 Wks - Non Adm Perf 95.00% 85.28% 83.19% 85.28% 0.00% 91.40% 84.61% 85.28% 87.80%

18 Wks - Incomp Target18 Wks - Incomp Perf 92.00% 86.47% 87.20% 86.49% 86.45% 92.02% 87.66% 86.47% 88.97%

A&E 4 Hr TargetA&E 4 Hour Performance 95.00% 90.48% 93.57% 93.82% 86.90% 88.64% 89.05% 90.48% 89.24%

Cancer-62 Days RTT TargetCancer-62 Days RTT 85.00% 88.42% 87.04% 88.42% n/a 79.37% 87.44% 88.42% 84.27%

Cancer-31 Days Sub Treat (Surg) TargetCancer - 31 Days Subsq Treatment - Surgery 94.00% 100.00% 96.55% 100.00% n/a 93.55% 98.33% 100.00% 96.30%

Cancer-31 Days Sub Treat (Drug) TargetCancer - 31 Days Subsq - Drug Treatments 98.00% 100.00% 100.00% 100.00% n/a 100.00% 99.47% 100.00% 99.75%

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% 100.00% 98.91% 100.00% n/a 98.39% 98.52% 100.00% 98.69%

Cancer-2ww TargetCan

cer-Cancer-2 Wk Waits - All urgent Referrals (cancer suspected) 93.00% 95.93% 96.14% 95.93% n/a 97.44% 96.21% 95.93% 96.68%

Cancer-2ww (Breast Symptomatic) TargetCan

cer-Cancer-2 Wk Waits - Symptomatic breast patients (cancer not initially suspected) 93.00% 98.78% 98.44% 98.78% n/a 97.13% 99.10% 98.78% 98.18%

Care Programme Approach (CPA) patients

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

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

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

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

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

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

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

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

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

Clostridium Difficile

CDIFF (Target)CDIFFClostridium (C.) Difficile - meeting the C. difficile objective 5 11 5 7 4 9 13 11 0 33

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 5 **

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

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

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

Acc

ess

Trust Risk Assessment frameworkO

utc

om

es

Compliance Scorecard

Quality & RiskPerf &

StandardsCQUINS Workforce Finance Appendices

Awaiting sign off

Produced by the Performance and Information Team 3 of 51

01/09/2017 01/10/2017 01/11/2017

Indicators Var to prev mth Target Sep Oct Nov *FYTDCritical Incidents 01/09/2017 01/10/2017 01/11/2017 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 0 1 4Pressure Ulcers - Grade 3 (Target)Pressure Ulcers - Grade 3 0 3 3 2 15Pressure Ulcers - Grade 4 (Target)Pressure Ulcers - Grade 4 0 0 0 0 0Total Other SIs (Target)Total Other Sis 0 0 4 3 18Pressure Ulcers - Grade 2 (Target)Pressure Ulcers - Grade 2 0 2 5 5 25Safety Thermometer - (new harm only) TargetSafety Thermometer - (New Harm Free) 95.00% 97.22% 97.83% 97.47% 96.39%VTE Assess TargetVTE Assessment Completeness 97.24% 97.65% 97.51% NA 97.50%

Infection ControlMRSA (Target)MRSA 0 0 0 0 0CDIFF (Target)CDIFF 5 5 7 4 33

Indicators Var to prev mth Target Sep Oct Nov *FYTDPatient experienceFFT % Recommended (IP & DC) 95.35% 96.04% 94.85% 95.55%FFT % Recommended (AE) 93.97% 95.44% 93.61% 93.07%

FFT Resp Rate (IP & DC) TargetFFT Response Rate (IP & DC) 30.00% 30.03% 31.60% 29.72% 31.81%FFT Resp Rate (AE) TargetFFT Response Rate (AE) 20.00% 16.61% 16.73% 23.45% 18.12%MSA Breaches TargetNo. of Mixed Sex Accommodation breaches 0 4 4 8 41

Number of Patient moves (over 2) 34 35 46 333Positive experienceCompliments 152 168 172 1265Complaints

Non-Clinical Complaints TargetNon-Clinical Complaints 7 6 2 24Clinical Complaints TargetClinical Complaints 27 15 25 216

Indicators Var to prev mth Target Sep Oct Nov *FYTDMortality

Crude Mortality (deaths per 1000 admissions) TargetDeaths per 1000 admsCrude Mortality (deaths per 1000 admissions) 19 14.0 11.0 12.4 13.0RAMI (Risk adjusted mortality) (National target)SHMI (Summary Hospital Level Mortality Indicator) Apr 16 - Mar 17 as expected 98.14

HSMR (Hospital Standardised Mortality Ratio) Sep 16 - Aug 17 as expected 101.06Outcome

Stroke - 90% of Stay on SU TargetStroke - 90% of Stay on a Stroke Unit 80.00% 92.98% 85.71% NA 82.89%TIA - HR TIA seen & treated <24hrs TargetTIA - High Risk,Non admitted TIA treated in 24 Hrs 60.00% 60.00% 70.83% NA 73.02%EL LOS TargetLength of stay - Elective 2.2 1.6 1.6 1.6 1.7EM LOS TargetLength of stay - Emergency 5.0 4.3 4.0 3.8 4.0Readm Rate (EL) TargetReadmission Rate - ElReadmission Rate - Elective 3.00% 2.76% 3.93% NA 3.68%Readm Rate (Em) TargetReadmission Rate - EmReadmission Rate - Emergency 10.00% 15.90% 16.50% NA 17.33%

Indicators Var to prev mth Target Sep Oct Nov Rolling 12 mthsWorkforce

Sickness Absence Rate (Target)Sickness Absence Rate 3.50% 4.78% 5.44% 0.00% 4.99%Staff Turnover Rate Complete Trust (Target)Staff Turnover Rate Complete Trust 10.00% 11.68% 11.66% 0.00% 11.31%Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) (Target)Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) 10.00% 8.80% 8.75% 0.00% 10.21%Staff Turnover Rate Registered Nursing & Midwifery (Target)Staff Turnover Rate Registered Nursing & Midwifery 10.00% 15.41% 14.82% 0.00% 14.19%Staff Turnover Rate Allied Health Professionals (Target)Staff Turnover Rate Allied Health Professionals 10.00% 15.48% 15.38% 0.00% 17.96%

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

Safe

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Quality & Risk Scorecard

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Methodology used to derive the HSMR is freely available. Latest Dr Foster Mortality Summary shows QEH is 101.06 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 Sep 16 - Aug 17 is 101.06 as expected

Weekday HSMR is 99.01 as expected

Weekend HSMR is 105.65 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 mortality surveillance group continues to closely monitor both higher than expected areas of mortality and trends that suggest where future outliers may be. This informs audit and the work of that group. This report will show from January 2018,

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

Mortality- HSMR (Hospital Standardised Mortality Ratio)

SHMI - (Quarterly Trend)

HSMR - (Monthly Trend) Key Points/Operational Actions

Definitions

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

HSMR: 99.8% control limits are applicable.

Key Points/Operational Actions

Mortality- SHMI (Summary Hospital Mortality Indicator)





Crude rate within HSMR basket is 3.46% (based on Sep 16-Aug 17),East of England rate = 3.68%

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

The Crude Mortality increased slightly in Aug to 3.32, from 2.98 (Jul). A similar increase at this time of year

was also seen in 2015, but not 2016.

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 (1.56%) for 17/18, is low when compared to the National average (3.61%)





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

Observed 3 0 1 1 0 0 0 0 1 0 0 0


10 5

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

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

Serious Incidents


Definitions

4Total Serious Incidents rrrr

0of which were "Never Events"

Serious Incidents (Rolling 12 months)

0123456789

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

01

0

3

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

Category of most recently Reported (SI's)

Compliance with SI Report submission dates




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

WEB45547 06/11/2017 SI 13/11/2017 Central Delivery Suite Women & Children Division

WEB45611 08/11/2017 SI 27/11/2017 Medical Assessment Unit Medical Division

WEB45661 09/11/2017 SI 17/11/2017 Accident & Emergency Medical Division

WEB45980 24/11/2017 SI 28/11/2017 Necton Ward Medical Division

Serious Incidents during Nov 2017

Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17

16 7 14 16 20 17

Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17

12 12 12 10 9 11

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

Number of Open Serious Incidents

Adverse Event Number of open Si's

Unplanned admission / transfer to specialist care unit 2

Delay / difficulty in obtaining clinical assistance 1

Healthcare associated cross infection 1

Unintended injury in the course of an operation or clin task 1

Neonatal seizures 1

Other medication incident 1

Fetal abnormality detected at birth 1

Fall from a height, bed or chair 1

Apgars <6 at 5 mins 1

Stillbirth 1

Grand Total 11


Learning from incidents closed




RefSTEIS

Number

SI Declared

Date

Location

Exact

Adverse

EventSI/NE Summary Root Causes Lessons Learned

60 Day

Submission

Compliance

WEB42092 2017/14762 09/06/2017 Elm SAU Unexpected

re-admission

or re-

attendance

92 year old patient readmitted to A&E in septic

shock 21 hours following discharge from Surgical

Assessment Unit. Failure to act on all presenting

symptoms and abnormal blood results on first

admission. Patient died in resus.

1. On discharge from SAU on the evening on

the 30.05.17 the patient did not physically

show signs of deterioration. On the available

recorded information, they were not vomiting

and was tolerating fluids and had responded

to an enema well.

2. The blood results on the day of discharge

were also satisfactory. There was no indication

that the patient needed to remain in hospital.

No concerns were raised through

communication between nursing staff and

daughter.

3. The patient was readmitted as an

emergency on the 31.05.17 and sadly passed

away due to bowel obstruction.

1. There is evidence of acceptance of the working diagnosis of

urinary retention which they clearly had but it is difficult to

demonstrate clinical inquiry of other general health issues.

2. There was possibly as assumption made in this case regarding his

normal operative status without full review of activities of daily

living. However, whilst this may have indicated patient was not at

baseline, this alone was unlikely to change the plan of care.

Y

WEB43619 2017/20595 17/08/2017 West Newton

Ward

Fall on level

ground

9.8.17 - Patient had mobilised to the toilet and was

heard calling out. Found sitting in the toilet floor.

12.8.17 patient discovered to have fractured left

next of femur went to theatre 14.8.17.

1. Patient had developmental delay and short

term memory. He has no formal diagnosis of

LD. His medical condition may have

contributed to his behavioural symptoms.

2. Patient was positive with Romberg's test

undertaken by medical staff on admission.

3. Patient mainly speaks Italian and little

English. Brother was the source of information

and his translator. Staff are aware that family

should not be used to translate.

4. It has been noted that he has been

confused, sometimes pleasant, sometimes

agitated and unsettled at bedtime. He usually

likes to wander, ask for food and frequently

go to the toilet.

5. There is no evidence or record of 'This is me,

my hospital passport' has been completed.

According to staff, the brother was asked to

assist with this but did not want to

contribute.

6. This vision was checked on admission, hazy

on both eyes and visual fields slightly

reduced. Ophthalmic review on 19th July 2017

showed he had bilateral cataracts and ARMD

(Age Related Macular Degeneration). There

was no evidence or documentation.

1. Phase 3 Duty of Candour to be completed - sharing the

investigation with the patient and family.

2. Post fall assessments to be re-educated to the ward staff

3. Address this issue with the Information Governance (IG) team.

Highlight the missing documentation to the ward to ensure fracture

documentation is filed in the notes and improve the system of work

in storing nursing documentation through the patients stay.

4. Share final investigation with Radiology staff to make them

aware that although hip x-ray was not requested on day of fall, it

was viable on the CT results / image for Chest, Abdomen and Pelvis

but not clinically identified in the final results on Patient Centre.

5. Improve standardisation of practice post fall. Fall prevention and

management policy which is awaiting ratification includes the

involvement of rehabilitation for all patients post fall. This will be

shared with Rehabilitation Services and the ward staff.

6. Medical and nursing staff to be more cautious and consider

additional support in management patient with difficulties (i.e.

using a translator). Patients with communication barriers is also

included in the Falls Prevention and Management Policy which is

awaiting ratification.

Y


10 5

Analysis of "Other Incidents"






Falls by Degree of Harm inc rate per 1000 beddays


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)






I am pleased to report there has been a reduction on the previous month’s figures, 6 in total for November. Unfortunately, so far 3 have been deemed avoidable, 2 unavoidable and a final decision to be made on one due to the pending investigation.

Avoidables;Oxborough – 2 x grade 2West Raynham – 1 x grade 2These were due to failure to provide appropriate equipment and lack of evidence to support two hourly repositioning.

Unavoidables;Theatres – 1 x grade 3 – The staff used all of the prevention they had available to them to prevent the skin damage, however this has now prompted a search for new equipment. TVN’s have been to theatres to provide some education regarding this incident.Stanhoe – 1 x grade 2, ASKINS bundle was implemented appropriately and in a timely manner.

Decision pending due to incomplete RCA;Stanhoe – 1 x grade 3Initial findings show that the ASKINS bundle was implemented in a timely manner.

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





The rate of New Harms ( Developed by the QEH) for November 2017 was 2.53%, an increase from 2.17% in October making the QEH 97.47%, New Harm Fee. Harm Free Care relates to the % of patients on the day of the study November who were harm free from Pressure Ulcers, Falls, VTE events and Catheter associated urinary tract infections.

Safety Thermometer (Hospital Acquired Harm)CQUIN

Safety Thermometer


Definitions

97.47%

Safety Thermometer (Target 95%) aaaa

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%

97.8

3%

97.4

7%


Safety Thermometer Performance - New Harm Free

Safety Thermometer - (New Harm Free) Target





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

VTE Assessment


Definitions

97.51%VTE Assessments Completed (Target 97.24%) aaaa

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%

97.6

5%

97.5

1%

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

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

VTE Assessment Performance

VTE Assessment Completeness VTE Assess Target





Latest Month's Performance Financial YTD

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

MRSA

Definitions


0MRSA

aaaa

0MRSA

aaaa

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

MRSA Weekly Screening Compliance Across Trust




MRSA Screening - November update to above chart not available at time of printing.



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


4C Diff (All cases)

aaaa

33CDIFF (All cases) aaaa





Gram Negative BSI

Definitions


November update not available at time of printing.




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

3

3.5

Psuedomonas Bacteraemia (Hospital & Community Apportioned Cases)

HAI CAI


IPC Dashboard

Definitions





Nov Data not

available at time of printing


Service line Clinical Indicators (by ward)

Definitions





Indicator Description

Fluid Charts

MUST Assessment 95% 65%

Waterlow Assessment 100% 100% 70% 100% 100% 95% 100% 100% 100% 100% 100% 80% 100% 100% 100%

Waterlow Re-Scored 60% 100% 80% 73% 88% 100% 60% 100% 81% 100% 86%

Has A Body Map Been Completed 85% 47% 55% 45% 30% 89% 30% 50% 60% 25% 67% 30% 65% 50% 95% 100%

Moving And Handling Assessment

Completed95% 80% 95% 85% 70% 100% 80% 75% 100% 50% 50% 90% 85% 85% 90% 90%

Falls Assessment Done 100% 100% 100% 93% 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Falls assessment rescored weekly 40% 38% 50% 82% 81% 100% 40% 100% 94% 100% 86%

Is a Falls Care Plan Completed? 80% 80% 95% 90% 55% 50% 60% 80% 90% 75% 33% 75% 60% 85% 100% 90%

EWS for each set of OBS? 95% 100% 95% 95% 100% 100% 90% 100% 95% 100% 100% 95% 85% 85% 100% 100%

Care Rounds Completed

Bedrail Assessment if "At Risk" (on

admission)50% 40% 88% 100% 71% 50% 80% 75% 50% 100% 100% 0% 86% 86%

Obs Frequency documented 100% 80% 35% 80% 90% 100% 45% 60% 100% 85% 75% 85% 10% 30% 95%

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

Drug Administration Errors 2 7 0 3 4 7 7 4 1 6 0 0 1 3 6 6

All Drug Errors (inc Admin) 3 7 2 9 8 8 12 4 2 6 2 0 1 6 7 9

Falls Total 2 4 0 5 2 0 4 5 0 10 3 9 6 4 5 8

H/A Pressure Ulcers Grade 2 0 0 0 0 0 0 0 0 3 1 0 0 0 0 1 0

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

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

Harm Free Care 97% 95% 100% 96% 96% 73% 92% 91% 93% 94% 92% 93% 100% 82% 92% 78%

Complaints 1 2 0 2 0 1 2 2 1 1 0 1 4 1 0 0

Family And Friends Response Rate 43% 29% 35% 6% 34% 380% 16% 37% 41% 17% 25% 36% 42% 53% 49% 26%

Family And Friends

(% Recommended)91% 91% 94% 80% 95% 95% 94% 90% 91% 90% 100% 97% 94% 88% 100% 94%

% Of Active Mentors 63% 86% 86% 88% 100% 79% 100% 50% N/A N/A 78% 71% 100% 50% 33% 60% 50%

Fill Rate Registered 95% 97% 92% 94% 92% 88% 101% 87% 99% 97% 92% 95% 94% 100% 96% 89%

Fill Rate Unregistered 118% 96% 112% 98% 91% 99% 101% 100% 97% 97% 98% 105% 100% 132% 93% 91%

CHPPD 6.1 5.8 10.4 6.9 5.5 26.2 7.5 5.7 5.2 6.4 7.7 5.5 5.2 9.1 7.4 6.2

Appraisals 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Sickness 11% 11% 3% 4% 10% 4% 4% 6% 2% 9% 5% 5% 6% 11% 3% 6%

Vacancies 20% 23% 24% 41% 27% 8% 22% 34% 50% 14% 15% 14% 38% 20% 20% 22%

Den

Pati

ent

Safe

tyPati

ent

Experi

ence

Eff

ect

iveness

Sta

ff

Experi

ence

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

Appraisal data not available at time of production

Audit Data not available at time of production

Audit Data not available at time of production


Maternity Clinical Performance & Governance Scorecard 2017-18

Definitions




Activity In October there were 198 women delivered and 203 live births; 6 sets of twins and one still birth. The home birth rate was 3% and 20% of the women had births on MLBU. There were no BBA’s.

ModeIn October the induction rate was high at 35% which was also reflected in our slightly higher emergency Caesarean section of 18%. However the elective caesarean section rate was low at 6.5% giving our overall caesarean section rate of 24%.

Activity: Antenatal and Postnatal CarePerformance within this category is in line with targets except for breastfeeding. October figures are still lower than expected and the infant feeding coordinator is investigating this.

GovernanceWe had three SI’s declared in October. • Lady with DVT and subsequent PE transferred to ITU and then transferred out to NNUH. Very unstable and had an intrauterine death of baby, delivered by caesarean section, maternal major PPH. Still an inpatient

at NNUH.• Intrapartum Stillbirth at term on WaterLily. Clinical picture of a sudden placental abruption, maternal PPH, mother physically recovered.• Admission to DAU for reduced fetal movements, poor CTG and delivered by emergency grade 1 caesarean Baby delivered in poor condition and transferred out to Luton and Dunstable for Cooling. Baby returning

to NICU in Kings Lynn.

M easurement R easo n Green A mber R ed D ata So urce

Apr

May

Jun

Jul

Aug

Sep

Oct

Women Delivered Total no. of women giving birth at QEH Local M onito ring Birth Register 182 199 191 218 194 191 198Babies Bo rn Total no. o f babies bo rn at QEH Local M onito ring Birth Register 185 202 193 223 193 193 204Live B irths Total no. o f live babies bo rn at QEH Local M onito ring 185 201 193 223 193 193 203

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

StillbirthsStillbirth: Babies born after 24 weeks gestation showing no signs of life. Stillbirth Rate = 4.6/1000 birhs.

QEH annual total should not exceed 15 stillbirthsYearly total that exceeds 15 0 Between >=2 Birth Register 0 1 0 0 0 0 1

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

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

% Women Delivered on M LBU Women who have given birth in Waterlily Local M onito ring >= 20% Between <15% Birth Register 17.6% 24.8% 23.5% 14.7% 20.7% 22.5% 20.2%% Women delivered on CDS Women who have given birth on Delivery Suite Local M onito ring <75% Between >85% Birth Register 80.8% 65.2% 76.4% 81.2% 78.6% 75.9% 76.3%

% 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% 65.2%% Instrumental Deliveries Combined rate: Fo rceps + 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% 8.6%% Vaginal Breech Births 1.0% 0.0% 1.0% 0.9% 1.0% 1.0% 1.4%

% Elective LSCS Women having planned CS Local M onito ring <10% Between >12% Birth Register 8.2% 10.3% 10.9% 11.0% 11.3% 10.9% 6.5%% Emergency LSCS Women having an emergency CS Local M onito ring < 15% Between >16% Birth Register 13.1% 12.4% 16.2% 19.0% 16.5% 12.6% 18.2%

% Total CS To tal 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% 24.7%% Induction Rates Women who have their labour induced (denominator = total women minus ElSCS) <18% Between >24% Birth Register 25.7% 31.8% 29.2% 30.3% 29.1% 27.7% 35.9%

% Bookings < 12 weeks 6 days Women who have their first booking appt by 12+6 KP I >= 90% Between <= 85% HoM 90.0% 90.0% 90.0% 89.0% 86.9% 92.0% 88.2%No. of women seen on DAU @ N C H Local monitoring DAU 91 130 20 130 90 115 122

Closure o f DAU - hours @ N C H Local monito ring DAU 12 12 0 0 15 0 0% women in DAU seen within 4 hrs @ N C H Local monito ring >=95% Between <= 90% DAU 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100%

No. of women seen on DAU @ QEH Local monito ring DAU 347 396 389 445 422 369 359Closure of DAU - hours @ QEH Local monito ring DAU 24 24 0 0 0 0 0.00

% women in DAU seen within 4 hrs @ QEH Local monito ring >=95% Between <= 90% DAU 99.4% 99.7% 97.4% 99.3% 99.5% 97.8% 99.7%% Breastfeeding Breastfeeding / Breast M ilk initiated, attempted o r achieved KP I >=70% Between < 65% Badgernet 74.2% 69.2% 69.4% 70.0% 69.9% 73.6% 74.1%% Breastfeeding Breastfeeding on discharge from hospital KP I >=70% Between < 65% Badgernet 68.2% 53.3% 60.0% 57.9% 34.2% 66.7% 61.5%% Breastfeeding Women breastfeeding at transfer to Health Visitor Local monito ring Badgernet 49.3% 37.9% 43.6% 45.9% 46.1% 45.2% 34.0%

% of women who stopped smoking at delivery Women who stopped smoking by the time o f delivery Local monito ring Badgernet 18.0% 21.7% 5.3% 14.3% 15.6% 13.3% 39.5%Readmission onto Castleacre Ward <28 days Number o f avoidable maternal readmission up to 28 days post birth Local monito ring <= 4 Between >= 7 Castleacre 5 5 2 0 4 3 0

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

No. times CDS closed Local monito ring 0 1 >=2 DS 0 0 1 0 0 0 0Total hours CDS closed Local monito ring DS 0 0 8 0 0 0 0

Suspension of HBS Local monito ring 0 1 >=2 DS 0 0 0 0 0 0 0Suspension of HBS Local monito ring 0 1 >=2 DS 0 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

E

No Target

No Target

No Target

No Benchmark

No Benchmark

Risk M anagementNo Benchmark

No Benchmark

No Benchmark

Day Assessment Unit


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

Definitions




Maternal & Perinatal StatisticsIn October there were 0 babies re-admitted.There was one stillbirth which was unexpected at term and is one of the SI’s.There were 10 times during the month the on call midwife was called to support the unit totally 75 hours this is under review.

All other statistics are within expected limit.

WorkforceIn October 1-1 care in labour has increased to 94% and MLBU 100%.

Patient Feedback42 compliments were received in October. 2 complaints received.FFT response rates for labour and birth has remained inconsistent but hopefully now all areas using electronic reporting this will improve. From the responses received over 96% of women would recommend the services.Plans are in place for future to use other staff as well as midwives.

M easurement R easo n Green A mber R ed D ata So urce

Apr

May

Jun

Jul

Aug

Sep

Oct

PPH >=1000 or<2000ml Local M onitoring < 9% Between >12% B irth Register / CDS 6.1% 6.9% 4.1% 2.9% 4.6% 1.6% 1.5%PPH >=2000ml Local M onitoring <=1% Between >=2.5% Birth Register / CDS 0.0% 0.0% 1.5% 0.9% 1.5% 1.6% 2.0%

% of women sustaining 3rd & 4th degree tears (no/to tal- Elective CS) Local M onitoring <=3% Between >=5% B irth Register / CDS 1.6% 1.1% 3.2% 1.8% 1.0% 1.6% 1.5%No. of women sustaining 3rd & 4th degree tears (no/to tal- Elective CS) 3a Local M onitoring <= 4 >= 5 B irth Register / CDS 1 1 2 2 1 1 2No. of women sustaining 3rd & 4th degree tears (no/to tal- Elective CS) 3b Local M onitoring <= 2 >= 3 B irth Register / CDS 2 1 3 2 1 1 1No. of women sustaining 3rd & 4th degree tears (no/to tal- Elective CS) 3c Local M onitoring 0 >= 1 B irth Register / CDS 0 0 0 0 0 1 0No. o f women sustaining 3rd & 4th degree tears (no /to tal- Elective CS) 4 Local M onitoring 0 >= 1 B irth Register / CDS 0 0 0 0 0 0 0

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

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

Avoidable Term Admissions to NICU from CDS Local M onitoring NICU / Datix 0 0 0 0 0 0 0Avoidable Term Admissions to NICU from Castlecare Local M onitoring NICU / Datix 1 0 0 0 0 0 0No. of babies with avoidable readmissions <28 days o ld Local M onitoring <= 2 3 - 5 >= 6 Datix 5 3 0 6 6 1 0No. of women with avoidable readmissions <28 days o ld Local M onitoring <= 2 3 - 5 >= 6 Datix 5 5 2 0 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% 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% 94.0%

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

Compliments Total M idwifery Compliments received in month Local monitoring PALS Team 1 16 4 33 33 8 42Complaints Total M idwifery Complaints received in month Local monitoring PALS Team 0 2 3 2 4 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% 94.41%Response Rate B irth / Labour Patient Experience Team >= 15% < 15% Patient Experience Team 16.76% 18.08% 13.56% 16.76% 17.20% 22.63% 14.14%

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% 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% 39.73%

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


Paediatric Clinical Performance & Governance Scorecard 2017-18

Definitions




Activity PAU attendances returned to predicted figures. There appears to be an increase in medical breeches however unrecorded data of time seen caused the increase, these have all been escalated to consultants and this is being addressed. 98.3% of all children in October were assessed by nursing staff within 15 minutes of arrival. PAU are trialling a triage area to ensure rapid assessment on arrival.

WorkforceThere were 2 episodes when escalation beds were opened to accommodate elective surgical & medical admissions, due to the opening of the beds 1 episode where staffing levels were not met. 5 newly registered staff nurses have completed their supernumerary period.

Governance No SI’s declared in October, no delayed discharges.

Patient Feedback No complaints received in October and 8 compliments. Response rate for FFT was 21.7% and 98.04% would recommend our service. Excellent patient feedback for multiple areas.

Descriptor Measurement Green Red Data Source Apr

May

Jun

Jul

Aug

Sep

Oct

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

No of times PAU staffing standards not

met

Middle grade medical staff not allocated / available

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

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

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

9

(5.7%)

13

(6.7%)

4

(2.5%)

6

(4.0%)

0

(0.0%)

7

(4.5%)

3

(1.6%)

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

(2.0%)

0

(0.0%)

10

(6.5%)

7

(5.7%)

8

(5.2%)

15

(8.4%)

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

PAU over 6 hrs. < 0 >1 PAU Data

6

(3.8%)

12

(6.2%)

9

(5.7%)

2

(1.3%)

6

(4.9%)

7

(4.5%)

5

(2.7%)

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

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

49

(31.2%)

46

(23.7%)

49

(30.8%)

59

(38.3%)

31

(25.4%)

48

(31.2%)

46

(25.7%)

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

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

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

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

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

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

Medical InvestigationsNo. of children attending for diagnostic

investigations. Stay on ward was greater than 4 hrs.

Average No. of Patients from

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

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

Stay on ward was greater than 4hrs

Average No. of Patients from

2016 = 48<= 48 >= 49 Rudham Stats 25 19 39 31 33 38 32

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

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

inpatients0 >= 1 Rudham Stats 2 1 6 5 1 8 2

No. of times recommended staffing level

not met

When no of RSCN / RN child does not adhere to

RCN recommendation

Meeting the children to

childrens nurse ratio0 >= 1 DATIX 1 0 7 1 2 9 1

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

Number of babies under 28 days of age

admitted to rudham

No of admissions that may have been avoided had

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

No. of patients medically fit who have delayed

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

No. of days medically fit patients who delayed

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

Other Clinical Incidents All other on ward incidentsAll incidents to exclude

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

Act

ivit

yW

ork

forc

e

Delayed Discharges

Cli

nic

al

Ind

icato

rs


NICU Clinical Performance & Governance Scorecard 2017-18

Definitions




Activity NICU accepted 5 in utero transfers, but CDS were unable to accept due to workload. Intensive care level days were high at 35 days, with one day having 3 intensive care patients. There were no avoidable admissions over 37 weeks gestation. All Maternity PNRA were reviewed by the Infant Feeding Co-ordinator & were appropriate. There were two infants admitted from RAF Lakenheath. NICU closed to the Neonatal network for 120 hours due to acuity & nursing staff skill mix.

Descriptor Measurement Green RedData

Source Apr

May

Jun

Jul

Aug

Sep

Oct

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

Average for 2016 (no breakdown

collected for full year) Available from

March 2018

No Parameter available until March

2018 as data not available

2016/2017 to gain average

No Parameter available until

March 2018 as data not available


30 23 39 29 29 20 21

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

required



March 2018







0 0 1 0 0 2 2

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

required



March 2018







8 4 7 8 6 7 5

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

required



March 2018







6 4 2 9 7 8 1

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

required



March 2018







3 4 2 1 8 0 2

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

care required



March 2018







0 0 0 0 0 0 0

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

25.4%

35

17.4%

51

26.4%

47 /

21%

50 /

25.8%

37 /

19.2%

31 /

15.2%

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

16.7%

19

9.4%

34

17.6%

31 /

13.9%

32 /

16.5%

31 /

16.1%

21 /

10.3%

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

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

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

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

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

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

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

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

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

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

No. of occasions in month Over 100% cot occupancy 0 >1 0 0 0 2 2 0 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 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 24

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

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

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

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

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

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

No of hours NICU on divert internal Internal 0 >= 1 0 56.5 0 0 84 0 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 9

NIC

U / B

ad

gern

et

NIC

U

Cot occupancy

Unit escalation (in hours)

Act

ivit

y


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

Definitions




Mortality There was one 36 week infant who had a pneumothorax which was treated conservatively & one 24 week infant who required a chest drain. There were three 24 week infants delivered, who were then transferred to Level 3 units. Two 24 week and one 29 week infants had sub optimal admission temperatures, despite additional warming measures being taken at delivery.

Governance There were14 reported clinical incidents.

Clinical Activity 50% of infants met the criteria for receiving breast milk at discharge, 1 was discharged bottle feeding due to maternal choice. All parents were seen by a senior staff member within 24 hours of admission.

Patient FeedbackIn October there were no complaints and 10 compliments. The FFT response rate was 100%, with 100% recommendation. 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

Oct

HypoglycaemiaInternal Guideance and standards not

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

Pre -Term Hypothermia less

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

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

Infection (Positive culture

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

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

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

Total No of reported

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

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

NNAP standard NNAP >= 58% <58% NICU Badgernet 100% 33% 100% 0% 0% 50% 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

1 out

of 2

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

Parents seen within 24hrs of

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

Delayed Discharge No of babies delayed

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

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

Patient Experience PALS / Audit 16 8 5 4 13 4 1000%

Patient Experience FFT / NICU 29.1% 12.8% 10.7% 13.5% 100% 131% 100%

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

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

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 -

Recommend

Compliments

Go

vern

an

ce

Risk Management

Response RateFFT

Complaints


The response rate did not reach the target of 30% (29.72% - the target was missed by 18 responses (1863 collected)) and the likelihood to recommend score for the month also missed the 95% target for the month (94.85%) although year to date still exceeds 95% likelihood to recommend and the 30% response rate.

The benchmark figures for the region place the Trust 10/13 based on October’s figures (a rise from 11th last month). The reasons that patients cited as to why they were not able to recommend the care they had received can be grouped into these areas - Noise at night (mainly Necton, Elm), call bell answering (Denver), staffing levels (Oxborough, Elm), staff attitude (Rudham), waiting (AEC, Elm), cleanliness (Elm), communication (Emergency Obs and Treatment Ward), medical care (Terrington) and food (West Newton).

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

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

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

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


Definitions

94.85%

% Recommend the service

0.86%% Do not recommend the service

29.72%

Response Rate (Target 30%) rrrr

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

Ward / Area Performance - Inpatient & Day Cases Benchmarking - Inpatient & Day Cases1.2

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%

0.9

4%

0.8

6%

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%

96.0

4%

94.8

5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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

Monthly % Recommend / Not Recommend - Inpatients & Day Cases

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

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%

31.6

0%

29.7

2%

0%

5%

10%

15%

20%

25%

30%

35%

40%


Monthly Response Rates for Inpatients & Day Cases

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




RGR 98.53% 0.33% 21.93%

RQW 98.49% 0.00% 34.96%

RDE 98.43% 0.49% 38.26%

RGM 98.26% 0.78% 58.31%

RGQ 96.86% 0.27% 34.68%

RGP 96.62% 1.21% 19.39%

RDD 96.40% 1.04% 37.85%

RM1 96.31% 1.25% 11.70%

RGT 96.06% 1.55% 10.08%

RCX 96.04% 0.94% 31.60%

RGN 95.31% 0.63% 25.51%

RAJ 92.96% 3.73% 26.76%

RQ8 91.90% 4.38% 23.28%

JAMES PAGET UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

IPSWICH HOSPITAL NHS TRUST

PAPWORTH HOSPITAL NHS FOUNDATION TRUST

COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST

%

Recommended

% Response

Rate

% Not

Recommended

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST

WEST SUFFOLK NHS FOUNDATION TRUST

BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

MID ESSEX HOSPITAL SERVICES NHS TRUST

SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

NORTH WEST ANGLIA NHS FOUNDATION TRUST

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

CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

Org Code Organisation Name (Ranked by % Recommended)


The Emergency Department has missed the target of 95% (93.61%) and there is a slight increase in the percentage not recommending the service (1.60%). This is well below the national average for unlikely to recommend.

The response rate has risen and achieved the 20% required (23.45%), the electronic collection method is gaining momentum and new team members are supporting it. Overall the service benchmarks at 2/12 based on October’s figures for likelihood to recommend (this is up from 4th in September).

There were 11 patients unlikely to recommend the care they have received (from a total of 689 responses) and the reasons included mainly staff attitude, staffing levels, waiting time (36% of patients unlikely to recommend stated this reason) and the waiting room environment.

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

93.61%

% Recommend the service

1.60%% Do not recommend the service

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%

16.7

3% 23.4

5%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%


Friends and Family Test - Monthly Response Rates for AE

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

23.45%

Response Rate(Target 20%)

aaaa


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

Benchmarking - A & E

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%

1.2

8%

1.6

0%

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%

95.4

4%

93.6

1%

0%

20%

40%

60%

80%

100%


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

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




Org Code%

Recommended

% Not

Recommended

% Response

Rate

RQW 97.45% 2.55% 8.94%

RCX 95.44% 1.28% 16.73%

RGN 95.25% 2.01% 5.86%

RGR 94.91% 0.52% 28.53%

RM1 94.34% 3.14% 2.08%

RGT 93.94% 2.67% 19.12%

RGP 93.82% 2.84% 11.03%

RQ8 91.21% 4.13% 20.27%

RDE 87.35% 6.24% 23.86%

RAJ 83.11% 10.55% 15.57%

RDD 82.39% 10.04% 22.88%

RGQ 78.86% 10.08% 11.95%

MID ESSEX HOSPITAL SERVICES NHS TRUST





Organisation Name (Ranked by % Recommended)









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

Definitions


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

The Maternity service showed a decrease again in response rate (birth) to 12.36% (15% target) and had 90.91% level of recommendation for birth. All areas (except birth) achieved the 95% likelihood to recommend target.

The service benchmarked at 1st out of 12 based on the labour rating in October across the region for likelihood to recommend (the same as in September). There were only 920 cards collected across the region in the birth category, only 5 hospitals collected responses from more than 25% of their eligible patients.

The response rate of 14.14% for September puts us at 8th out of 12 in relation to response rate. No patients were unlikely to recommend their birth experience at the QEH although two patients provided neutral responses; one as she had a procedure without being informed or giving consent and the other patient was unable to have a home birth. As this feedback is anonymous it is not possible to delve deeper into the reasons for these comments.

0.4

1%

0.9

6%

2.7

6%

98.3

5%

98.4

1%

96.6

9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sep Oct Nov

FFT - % Recommend/ Not Recommend (Antenatal)

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

100.0

0%

100.0

0%

90.9

1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sep Oct Nov

FFT - % Recommend/ Not Recommend (Labour)

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

1.7

2%

98.5

9%

96.5

5%

100.0

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sep Oct Nov

FFT - % Recommend/ Not Recommend (Postnatal Ward)

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

100.0

0%

100.0

0%

100.0

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sep Oct Nov

FFT - % Recommend/ Not Recommend (Community PostNatal)

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

Response Rate - Labour

22.6

3%

14.1

4%

12.3

6%

0%

5%

10%

15%

20%

25%

30%

Sep Oct Nov

FFT - Response Rate (Labour)

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

Benchmarking - Maternity Services





Definitions


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

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

0.2

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%

1.1

6%

0.8

2%

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%

96.1

0%

96.5

3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


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

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

The level of recommendation within Outpatient services remains high at 96.53% and the Trust benchmarked at 5/13 regionally in October in relation to likelihood to recommend (a drop from 3rd the previous month). There were 8 patients unlikely to recommend and their concerns were across many services but revolved around waiting times across numerous clinics, being kept informed of delays and the waiting room environment.

Across the hospital the main areas for concern remain:• Staff Attitude / Communication• Waiting time / environment• Staffing levels

Benchmarking - Outpatient Services




Org Code % Recommended% Not

Recommended

RGM 97.44% 1.71%

RDE 97.04% 0.33%

RGQ 96.82% 0.93%

RGP 96.20% 0.95%

RCX 96.10% 1.16%

RGR 95.85% 0.86%

RGN 95.76% 0.90%

RM1 95.40% 2.30%

RAJ 92.58% 2.88%

RQW 92.39% 4.60%

RGT 92.34% 2.15%

RDD 92.20% 2.77%

RQ8 88.99% 5.78%MID ESSEX HOSPITAL SERVICES NHS TRUST




Organisation Name (Ranked by % Recommended)





PAPWORTH HOSPITAL NHS FOUNDATION TRUST







For the month of November there were 4 incidents of ESMA breaches, all in the critical care unit, involving 8 patients, all relate to increased capacity within the Trust with has prevented movement from critical care to beds within ward areas. All potential EMSA breaches are reviewed daily and discussed at the bed meetings with a view to assessing when the patient can be moved to a ward bed as soon as can be facilitated.

An action plan has been developed by the CCG to support the Trust’s aim to try and reduce the EMSA breaches in critical care.

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

Patient Experience - Mixed Sex Accommodation

Mixed Sex Accommodation Incidents


Definitions

4Incidents of Mixed Sex Accommodation rrrr

8No. of Patientsaffected rrrr

20Incidents of Mixed Sex Accommodation rrrr

41No. of Patients affected rrrr

Mixed Sex Accommodation Breaches

0

8

4

21

0

43

4

2 2

4

0

2

4

6

8


No. of Mixed Sex Accommodation Incidents

No. of Mixed sex Accommodation Incidents

0

18

9

42

0

9

68

4 4

8

0

4

8

12

16

20


No. of Mixed Sex Accommodation breaches

No. of Mixed Sex Accommodation Breaches





Analysis of Current Month and YTD

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

Complaints


Definitions

25Current Month

2Current Month

216YTDrrrr rrrr

rrrr

Non Clinical Complaints

24YTD

rrrr

Number of complaints receivedDuring the month of November, the Trust received 27 complaints. This is 6 more than last month and 11 fewer than in November 2016, in which the Trust received 38 complaints.

Complaints received by Specialty/Key Issues Table

During November 2017, Trauma & Orthopaedics had 5 complaints; Terrington Short Stay had 4 complaints and General Surgery had 3 complaints. The complaints regarding these areas involved the following issues:

• Staff attitude• Poor communication with patient/relatives • Clinical treatment • Discharge arrangements• Delay/Failure to diagnosis

Lessons Learned

• Improve communication with patients at pre-assessment to ensure all relevant information is provided and queries answered in full prior to procedure.

• To ensure comprehensive and accurate record keeping of patients’ up to date contact details. • Ensure when ordering medication to take home that the prescription chart is available to administer analgesia when required on the

day of discharge.• Training/awareness regarding the effects that miscarriages can have on the patient. • To improve staff knowledge of the processes for parents to view and spend time with their baby following a miscarriage.

Other Information

• Three complaints have been re-opened in November and are under investigation.• 3 local resolution meetings were held in November 2017.• No complaints were referred to the Parliamentary and Health Service Ombudsman.• 85 Travel Expense claims were processed in November 2017.• No complaint satisfaction questionnaires were returned. • 7 PALS surveys were completed and although 2 were incomplete, 100% of respondents found the PAL’s service that they received to be

extremely helpful. Further comments were made stating ‘They took my email seriously and got my problems sorted within 24 hours; I really cannot thank these people enough.’





Actions Taken & Lessons Learned




Actions taken & lessons learned following conciliation meetings held in NovKey Issues Lessons Identified Action

Patient has had an incomplete recovery post-knee replacement

surgery. Complications post-operatively have caused pain and

are preventing the patient from being able to complete daily tasks.

Other issues that the patient raised include: Poor advice in pre-

assessment, failing to keep comprehensive and accurate records

of up to date contact details, cancellation of procedures in Day Surgery and lack of analgesia on day of discharge due to

prescription chart being in Pharmacy all day.

Improve communication with patients at pre-assessment to ensure

all relevant information is provided and queries answered in full

prior to procedure.

Importance of ensuring that comprehensive and accurate records are kept of a patient's up to date contact details.

Ensure that arrangements are put in place to continue administering a patient's required medication whilst also

successfully obtaining medication to go home.

Discuss the procedural failures within Pre-Assessment and Day

Surgery with the Matron to prevent similar problems in the

future. Clinical Lead and Surgeon involved to reflect regarding clinical

concerns following surgery. Reminder to all wards to ensure continued administration of

critical medicines on day of discharge.

Family concerned about care and management of relative

during final illness, citing poor communication, lack of

fundamental care, attitude of staff and failure to liaise with previous clinical team in another hospital for advice and

information.

Importance of delivering good, attentive, fundamental care to the

patient.

Importance of good communication both within the clinical and nursing teams and with the patient and family.

Action plan in progress regarding improving quality of nursing

care on ward. A regime of daily visits and audits of practice is

underway and there is commitment to delivering measurable improvements in the standards of care.

Staff attitude addressed with staff concerned.

Letter sent from Clinical Lead to consultant in previous trust to determine whether there are any lessons to be learnt in terms

of patient management, currently awaiting a reply.

Patient and her husband were dealt with in an insensitive and

poorly informed manner by staff following a miscarriage.

Lack of training/awareness regarding the effect that a miscarriage

can have on a patient. Inadequate knowledge of the processes for parents to view and

spend time with their baby following a miscarriage.

Matron met with the patient and her husband and has

undertaken to speak to all of the staff involved to raise awareness of the effect that their conduct and poor attitude

had on them both (the patient has consented to the use of the

recording of the meeting to reinforce this message).

Matron will also provide them with information in relation to the processes for parents to view and spend time with their

baby. Matron arranged for the patient to meet with the

Bereavement Midwife.


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

Definitions

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

PALS Contacts (including Compliments)

Compliments

The Trust is required to investigate and share the response with the complainant within 30 working days. The compliance rate has increased from last month to 48%, but 9 breaches still occurred:

• Surgery 2 had 5 breaches out of 8 complaint responses that were due• Medicine 2 had 2 breaches out of 4 complaint responses that were due• Medicine 1 had 1 breach in November out of 2 complaint responses that were due• Risk & Governance had one breach

Currently 8 complaint investigations/responses are overdue and have not yet been completed, these continue to be chased and escalated. Some overdue complaint responses have now been received from the Divisions and following Executive review and Chief Executive sign off they will be completed and closed. Divisional leads have been contacted in terms of the overdue complaint responses for management plans to improve compliance.

172 compliments were received this month, which shows an increase from 168 compliments received last month and an increase in comparison to November 2016, in which the Trust received 163 compliments.

The PALS service has had 391 contacts this month, compared to a figure of 397 in the previous month. This is a decrease in comparison to November 2016, in which 432 contacts were recorded. The top subjects for this month are noted below:

General Information 65

Travel Expenses 22

Enquiry 16

Directions within the Trust 14

Sign Post to another Organisation 14

Complaints Procedure 12

Concern 12

Staff Attitude 12

Clinical Care 11

Discharge Arrangements 11

Lack of Information 11





01/09/2017 01/10/2017 01/11/2017 2016/17

Indicators Var to prev mth Target Sep Oct Nov FYTD

National standards 01/09/2017 01/10/2017 01/11/2017 2017/18

18 Wks - Adm (adjusted) Target18 Wks - Adm Perf (adjusted) 90.00% 75.39% 72.97% 77.47%

18 Wks - Non Adm Target18 Wks - Non Adm Perf 95.00% 83.19% 85.28% 0.00% 87.80%

18 Wks - Incomp Target18 Wks - Incomp Perf 92.00% 87.20% 86.49% 86.45% 88.97%

Cancer-2ww TargetCancer-2ww 93.00% 96.14% 95.93% NA 96.68%

Cancer-2ww (Breast Symptomatic) TargetCancer-2ww (Breast Symptomatic) 93.00% 98.44% 98.78% NA 98.18%

31 Day Diag to Treat Target31 Day Diag to Treat 96.00% 98.91% 100.00% NA 98.69%

Cancer-62 Days RTT TargetCancer-62 Days RTT 85.00% 87.04% 88.42% NA 84.27%

Cancer-31 Days Sub Treat (Surg) TargetCancer - 31 Days Subsq Treatment - Surgery 94.00% 96.55% 100.00% NA 96.30%

Cancer-31 Days Sub Treat (Drug) TargetCancer - 31 Days Subsq - Drug Treatments 98.00% 100.00% 100.00% NA 99.75%

Cancer Screening (62 Day) TargetCancer Screening (62 Day) 90.00% 100.00% 100.00% NA 99.26%

A&E 4 Hr TargetA&E 4 Hour Performance 95.00% 93.57% 93.82% 86.90% 89.24%

Amb turnaround TargetAmbulance turnaround 100.00% 24.09% 24.03% 23.39% 24.45%

Stroke - 90% of Stay on SU TargetStroke - 90% of Stay on a Stroke Unit 80.00% 92.98% 85.71% NA 82.89%

TIA - HR TIA seen & treated <24hrs TargetTIA - High Risk,Non admitted TIA treated in 24 Hrs 60.00% 60.00% 70.83% NA 73.02%

Cancelled Ops - as a % of Elective Admissions TargetCancelled Ops - as a % of Elective Admissions 0.80% 0.43% 0.79% 0.69% 0.68%

Diagnostic Over 6 Week Waiters - % of Total WL TargetDiagnostic Over 6 Week Waiters - % of Total WL 1.00% 0.35% 0.18% 0.27% 0.32%

Indicators Var to prev mth Target Sep Oct Nov FYTD

Local standards

Day Case Rate TargetDay Case Rate 82.00% 85.04% 84.80% NA 85.88%

DNA Rate TargetDNA Rate 5.00% 6.48% 6.42% 6.49% 6.53%

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

Readm Rate (EL) TargetReadmission Rate - ElReadmission Rate - Elective 3.00% 2.76% 3.93% NA 3.68%

Readm Rate (Em) TargetReadmission Rate - EmReadmission Rate - Emergency 10.00% 15.90% 16.50% NA 17.33%

EL LOS TargetLength of stay - Elective 2.2 1.6 1.6 1.6 1.7

EM LOS TargetLength of stay - Emergency 5.0 4.3 4.0 3.8 4.0

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




Awaiting sign off


Admitted, Admitted (Adjusted) & Non-Admitted performance unavailable at time of going to print.

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

18 Weeks Referral To Treatment


Definitions

81

.29

%

80

.03

%

76

.23

%

78

.26

%

79

.65

%

82

.90

%

75

.80

%

77

.81

%

78

.55

%

75

.39

%

72

.97

%

0.0

0%

80.76%78.53%

75.89%77.84% 79.23%

82.59%

75.50%77.22% 78.46%

74.98%72.21%

60%

65%

70%

75%

80%

85%

90%

95%

100%


18 Wks Admitted Performance

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

90

.49

%

90

.30

%

90

.94

%

90

.43

%

91

.96

%

92

.94

%

89

.32

%

88

.31

%

82

.29

%

83

.19

%

85

.28

%

0.0

0%80%

85%

90%

95%

100%


18 Wk Non- Admitted Performance

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

92

.97

%

92

.64

%

92

.77

%

92

.38

%

92

.01

%

92

.03

%

92

.03

%

88

.04

%

87

.74

%

87

.20

%

86

.49

%

86

.45

%

80%

85%

90%

95%

100%


18 Wk Incompletes Performance

18 Wks - Incomp Perf 18 Wks - Incomp Target

86.45%Incompletes (Target 92%) rrrr




Awaiting

sign offAwaiting

sign off


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

Cancer Waiting Times


Definitions

90%

92%

94%

96%

98%

100%

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

2WW Performance

Cancer-2ww 2 WW Target

95.93%2ww (Target 93%)

aaaa

100.00%

31 Day (Target 96%)

aaaa

88.42%62 Day (Target 85%)

aaaa

90%

92%

94%

96%

98%

100%


31 Day Diag To Treat Performance

31 Day Diag to Treat 31 Day Target

60%

64%

68%

72%

76%

80%

84%

88%

92%

96%

100%


62 Day Ref To Treat Performance

Cancer-62 Days RTT 62 Day Target

100.00%31 Day Subs Treat - Surg (Target 94%) aaaa

100.00%31 Day Subs Treat - Drug (Target 98%) aaaa

98.78%2ww Breast Symptomatic (Target 93%) aaaa

100.00%62 Day Screening (Target 90%) aaaa

Site Level Breach Analysis - Latest Month





Cancer Waiting Times (Forecasting)





Sustainability Sustainability

Cancer Site(Target - 85%

Compliance)

Estimated

remainder to

achieve Forecast Snapshot position Trajectory Flag

Estimated

remainder to

achieve ForecastSnapshot

position Trajectory Flag ForecastSnapshot

position Trajectory ForecastSnapshot

position Trajectory

Total Treated 0.00 0.00 0.00 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 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% 0.0% 0.0% 0.0%

Estimated breaches allowed 0.0 0.0

Total Treated 11.00 11.00 6.00 8.00 1.00 4.00 11.00 0.00 11.00 11.00 0.00 11.00


% Within 62 Days 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% 100.0% 100.0% 0.0% 100.0%


Total Treated 7.50 4.00 4.50 6.00 0.00 5.00 6.00 0.00 6.00 7.00 0.00 7.00


% Within 62 Days 40.0% 50.0% 66.7% Alert 50.0% 0.0% 80.0% Alert 58.3% 0.0% 58.3% 64.3% 0.0% 64.3%

Estimated breaches allowed -3.0 -2.0

Total Treated 0.00 0.00 2.00 3.00 0.00 1.00 1.00 0.00 1.00 3.00 0.00 3.00


% Within 62 Days 0.0% 0.0% 50.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 33.3% 0.0% 33.3%

Estimated breaches allowed 1.0 -2.0

Total Treated 0.50 0.50 2.00 2.50 0.50 2.00 2.00 0.00 2.00 3.50 0.00 3.50


% Within 62 Days 100.0% 100.0% 100.0% 0.0% 0.0% 50.0% Alert 50.0% 0.0% 50.0% 71.4% 0.0% 71.4%


Total Treated 5.00 5.00 8.00 8.50 1.00 6.00 6.00 0.00 6.00 7.00 0.00 7.00




Total Treated 4.00 4.00 6.00 3.50 0.00 2.00 3.00 0.00 3.00 3.00 0.00 3.00




Total Treated 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.50 0.00 0.50


% Within 62 Days 0.0% 0.0% 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%


Total Treated 21.00 13.00 16.00 Alert 15.00 0.00 9.00 Alert 15.00 0.00 15.00 18.00 0.00 18.00

Treated Within 62 Days 20.00 12.00 15.00Alert

14.00 0.00 9.00Alert

15.00 0.00 15.00 18.00 0.00 18.00



Total Treated 3.50 3.00 4.00 3.00 0.00 3.00 3.50 0.00 3.50 3.50 0.00 3.50


% Within 62 Days 28.6% 33.3% 75.0% Alert 100.0% 0.0% 16.7% 85.7% 0.0% 85.7% 71.4% 0.0% 71.4%

Estimated breaches allowed -1.5 2.5

Total Treated 13.50 11.50 20.00 13.50 0.00 15.00 16.00 0.00 16.00 18.00 0.00 18.00




Total Treated 0.00 0.00 2.00 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% 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%


Total Treated 66.00 52.00 71.50 63.00 2.50 47.00 63.50 0.00 63.50 74.50 0.00 74.50


% Within 62 Days 81.82% 82.69% 85.3%Alert 71.43% 80.00% 85.1%

Alert 85.04% 0.00% 85.0% 85.23% 0.00% 85.2%


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

Breast

November

Trajectory

Gynaecological

Haematological

Head & Neck

Brain/Central Nervous

System

Trust Total

Lung

Sarcoma

Skin

Upper

Gastrointestinal

Urological

Other

Lower

Gastrointestinal

Dec-17Nov-17December

TrajectoryFeb-18 TrajectoryJan-18

Trajectory


Benchmarking data will only be updated once every quarter.

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

Definitions

Cancer Waiting Times (Benchmarking)




70%

75%

80%

85%

90%

95%

100%

JPH QEH P&S CUH IP WS N&N

2WW Wait Perf for Qtr 2 across East of England

SEEN WITHIN 14 DAYS National Target

70%

75%

80%

85%

90%

95%

100%

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

31 Day Perf for Qtr 2 across East of England

TREATED WITHIN 31 DAYS National Target

45%

55%

65%

75%

85%

95%

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

62 Day RTT Perf for Qtr 2 across East of England

TREATED WITHIN 62 DAYS National Target


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

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

Accident and Emergency

Definitions

86.90%AE Performance - Prev Mth (Target 95%) rrrr

89.24%AE Performance - YTD (Target95%) rrrr

Previous Month's KPI's

Benchmarking across NHS England Midlands & East (East)


Activity & Performance levels of the last 3 months

AE performance (Last 12 month)

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

7%

93.8

2%

86.9

0%

75%

80%

85%

90%

95%

100%

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

• There has been a significant deterioration in Trust 4 hour performance in month • Limited onward flow remains the biggest contributor to breaches• Bedded patients in the Department in the morning has also led to capacity issues within the Department which has caused delays for patients to be seen and treated• Average attendances continue to rise month on month in comparison to last year• ECIP continue to support process and pathway redesign within the Department






Potential fines per case in

£77,000.00

£505,000.00

£228,200.00

£0.00

£0.000 - 15 Min

2017/18 YTD value of breaches

30 - 60 Min

15 - 30 Min

Over 2 Hr

1 - 2 Hr

Ambulance Handovers


Definitions

23.39%

% of handovers within 15 minutes

24.45%

% 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.

• Ambulance handover has remained steady however improvement work has commenced• Focus has been on the handovers that are currently taking between 15 and 30 minutes• Working with ECIP the Department has looked to streamline the clinical handover process• Initial work focussed on reducing the amount of documentation that needs to be completed between ED staff and ambulance staff before clinical handover is complete• The Department footprint has also been reviewed and changes made to space utilisation to provide further ambulance handover bays and a designated fit2sit area• Although some progress has been made the full benefits of the project have yet to be fully realised.• Handover times remain compromised by reduced flow through the organisation• Issues have also arisen when a large volume of patients are waiting within the department prior to clinical handover being taken. This has compromised the safety of the department and the privacy and

dignity for all patients.

0

200

400

600

800

1000

1200

1400

1600

1800


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+

3199

8164

1141

505

77

2017/18 YTD Ambulance Handover times

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

0%

10%

20%

30%

40%

50%

60%

70%

80%


Nu

mb

er

of

Pa

tie

nts

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

0 - 15 Minutes 15-30 Min





Time to and time on unit under pressure due to system pressures affecting whole Trust – both scoring a B in October.

Scanning performance improved and now both measures are scoring A’s.

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

Stroke Performance


Definitions

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




90.00%

85.00%

80.00%

75.00%

<75.00%

85.71%

Monthly Performance %

E

D

Oct-17

A

B

CSSNAP Level

YTD Performance %

B C

YTD SSNAP Level

82.89%

YTD 2017/2018SSNAP Target Levels


All 4 scores improved

“Low risk, treated within 7 days of onset” – didn’t achieve target in October, but significantly improved on September.

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

Transient Ischaemic Attack (TIA) Performance


Definitions





The Trust has achieved the Diagnostic 6 week target in November 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)


Definitions

0.27%(Target 1%)

aaaa





SAFER Dashboard






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

2.8 2.8 2.7 2.8 2.6 2.6 2.5 2.4 2.7 2.5 2.5 2.3

0.0

2.0

4.0


New to Follow Up ratio against local target

New to FUP Ratio target

2.3

Trust Level New to Review Rate

(Target 2.3) rrrr






Top 10 Specialties with most "Appointment Slot Issues" over last 4 weeks

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





16/11 23/11 30/11 07/12

DER 651 684 586 626

CAR 529 535 543 552

URO 388 409 417 387

ORT 363 372 353 379

NEU 366 341 324 378

ENT 176 214 225 214

RES 239 236 240 211

PAE 169 161 173 178

OPH 105 136 157 156

RHE 129 132 136 141

END 123 130 138 139

PC 126 134 133 137

UGI 64 59 60 70

NEP 46 46 52 54

GYN 5 4 15 31

GER 18 19 19 20

2WW 16 16 10 9

SUR 0 0 2 2

VAS 0 0 1 1

DM 0 0 0 1

ASI's Last 4 Weeks


Latest Month's Performance

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

DNA rate

Definitions

6.58% 6.50% 6.31% 6.05% 6.20% 6.51% 6.85% 6.58% 6.65% 6.48% 6.42% 6.49%

0.0%

2.0%

4.0%

6.0%

8.0%


DNA (Did not attend appointments) rate against local target

DNA Rate DNA Rate Target

6.49%DNA rate (Target 5.0) rrrr






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

Re-admissions is currently reported 1 month in arrears

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

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

Elective Inpatient - Average Length of Stay & Re-admissions

1.82.2

1.81.5

1.8 1.72.1

1.5 1.4 1.6 1.6 1.6

0.0%

2.0%

4.0%

6.0%

0.0

0.5

1.0

1.5

2.0

2.5


Trust Level - Average LOS - Elective

Length of stay - Elective target Readmission Rate - El

1.6

Average LOS

Elective Admission (Target 2.2) aaaa

3.93%

Re-adm following Elective

Admission (Target 3%) rrrr

Definitions

4.2

0%

4.3

1%

4.3

2%

5.1

9%

4.1

7%

3.5

4%

4.1

7%

4.1

5%

3.8

8%

3.2

4%

2.7

6%

3.9

3%

0%

1%

2%

3%

4%

5%

6%


Trust Level - Elective Re-admission Rate Performance Against Target

Readmission Rate - El Readm Rate (EL) Target






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

Re-admissions is currently reported 1 month in arrears

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

Emergency Admissions - Average Length of Stay & Re-admissions

3.8 3.7 3.7 3.6 3.9 3.7 3.9 4.0 4.3 4.3 4.0 3.8

0.0%

5.0%

10.0%

15.0%

20.0%

0.0

2.0

4.0

6.0


Trust Level - Average LOS - Emergency

Length of stay - Emergency target Readmission Rate - Em

3.8

Average LOS Emergency Admission (Target 5.0) aaaa

16.50%

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

Definitions

13

.35

%

15

.40

%

15

.98

%

15

.53

%

15

.78

%

18

.71

%

17

.57

%

17

.52

%

17

.31

%

17

.81

%

15

.90

%

16

.50

%

0%

5%

10%

15%

20%


Trust Level - Emergency Re-admission Rate Performance Against Target

Readmission Rate - Em Readm Rate (Em) Target






Elective Re-admissions Rates by Specialty

Definitions

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

Emergency Re-admissions Rates by Specialty





CQUINs




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

1a Heallthy Foods - more healthy options /

reduced sugar content etc

£115,892.00

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

questions relating to H&W

£115,753.00

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

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

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

2c Empiric Review of antibiotic prescriptions

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

2d Reduction in Antibiotic Consumption per 1,000

admissions£86,850.00

4 Improving services for

people presenting

with Mental Health

needs in A&E

Frequent Attenders (more than 10 occurrences

in 16/17) - identify cohort of patients who

would benefit from mental health &

psychology interventions AC

HIE

VED

10

0%

£34,739.80

AC

HIE

VED

10

0%

£138,959.20 £34,739.80 £138,959.20

6 Offering Advice &

Guidance

Improvement of A&E for Rhuematology &

Neurology / Implement Quality standard /

propose additional services in Q4 to take

forward next year AC

HIE

VED

10

0%

£86,849.50

AC

HIE

VED

10

0%

£86,849.50 £86,849.50 £86,849.50

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

such services and make ALL of their First O/P

Appointments slots available on NHS e-referral

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

trajectory

2. a trajectory to reduce Appointment Slot

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

Q4A

CH

IEV

ED

10

0%

£86,849.50

AC

HIE

VED

10

0%

£86,849.50 £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

AC

HIE

VED

10

0%

£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 TBC £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

AC

HIE

VED

10

0%

£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 TBC £6,301.50 £12,603.00

Update only no Financial

value

N/A

NHSE SPECIALIST CONTRACT

CQUIN Description

H&W

SEPSIS

N/A

N/A

AC

HIE

VED

10

0%

ACUTE CONTRACT

PA

RTIA

LLY

AC

HIE

VED

83

.25

%


Finance report to follow seperately

Finance





None

Appendices





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