Trust Quality and Performance Report
June 2012
Contents
Slide numbers
Clinical Quality Priorities inc Ward Dashboard 4 - 17
CQUIN 18 – 21
Local Priorities 22 – 28
Monitor Compliance 29 – 30
Contract Priorities 31 – 35
2
Introduction
This Corporate Trust Dashboard provides narrative for performance in
five key areas: Clinical Quality Priorities, CQUIN Performance, Local
Priorities, Monitor Compliance and Contract Priorities.
3
Clinical Quality Priorities
Summary
The quality report this month incorporates new performance metrics for 2012-13.
The new net promoter score was introduced this month within the patient experience surveys. This
uses a nationally set question, response set and scoring system explained in last months report.
Initial scores appear positive; benchmarked scores will be available in the future to compare our
performance with other Trusts.
Pressure ulcer performance has decreased this month and this will be addressed at the pressure
ulcer prevention group and an action plan developed to improve performance. Pressure ulcers are
presented differently on the dashboard as there are now subsections of Grade 2 and 3/4
prevalence to determine if they were avoidable or unavoidable.
4
Indicator Target
Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU/F2 EAU G5 Rehab F9 F10 G1 G3 G4 F7 G8 MTU F1 F11 F12
HII compliance 1a: Central venous catheter
insertion100% <85 85-99 100 100 100 100 100
HII compliance 1b: Central venous catheter
ongoing care100% <85 85-99 100 100 NIL 100 NIL 100 NIL NIL 100 NIL 100 100 NIL 100 100 NIL 100
HII compliance 2a: Peripheral cannula insertion 100% <85 85-99 100 100 100 100 100 100 100 100
HII compliance 2b: Peripheral cannula ongoing 100% <85 85-99 100 100 100 100 100 100 100 100 90 100 100 80 80 100 100 100 100 97
HII compliance 4a: Preventing surgical site
infection preoperative100% <85 85-99 100 100 100 100
HII compliance 4b: Preventing surgical site
infection perioperative100% <85 85-99 100 100 100 100
HII compliance 5: Ventilator associated
pneumonia100% <85 85-99 100 100 100
HII compliance 6a: Urinary catheter insertion 100% <85 85-99 100 100 100 100 100
HII compliance 6b: Urinary catheter on-going
care100% <85 85-99 100 100 100 100 100 100 100 100 100 100 100 90 100 100 100 99
No of patient falls 0 variable by ward 1 0 7 4 0 0 0 0 0 0 2 0 1 3 6 1 5 5 1 0 0 0 0 36
No of patient falls resulting in harm 0 > 0 0 0 0 3 1 0 0 0 0 0 0 0 0 0 0 1 0 0 2 1 0 0 0 0 8
No. of serious injuries or deaths resulting from
falls>0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No of patients with ward acquired Grade 2
pressure ulcers0 > 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 3
No of patients with avoidable ward acquired
Grade 2 pressure ulcers0 > 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1
No of patients with ward acquired Grade 3 or 4
pressure ulcers0 > 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 2
No of patients with avoidable ward acquired
Grade 3 or 4 pressure ulcers0 > 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Nutrition: Assessment and monitoring 95% <85 85-94 95-100 100 100 100 100 100 100 100 100 100 100 100 100 90 90 100 100 99
Hydration: Patients having a risk assessment for
hydration100 100 100 100 100 100 10 100 100 100 100 100 100 100 100
Total no of MRSA bacteraemias: Hospital 2/yr > 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Total no of MSSA bacteraemias: Hospital > 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Total no of C. diff infections: Hospital 29/yr > 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 4
Hand hygiene compliance 95% <85 85-94 95-100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
No of SIRIs and potential SIRIs 0 >0 0 0 0 0 0 0 1 0 0 0 0 0 2 0 0 0 1 0 0 2 0 0 0 0 7
Antibiotic Audit: Prescribing 90% <80 80-89 90-100 0
Cardiac arrests: No. outside CCS 0 0 0 1 0 0 0 1 0 0 1 1 0 1 0 0 0 0 0 0 0 5
VTE: Completed risk assessment (monthly
Unify audit)> 98% < 98 > 98 99.0 100.0 99.6 100.0 100.0 100.0 94.4 100.0 98.4 100.0 100.0 100.0 100.0 100.0 94.4 100 100 98
Medical DirectorateSurgical DirectoratePerformance Rating
W&C Directorate
Pa
tie
nt
Sa
fety
TRUST
TOTAL
5
Indicator Target
Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU/F2 EAU G5 Rehab F9 F10 G1 G3 G4 F7 G8 MTU F1 F11 F12
Medical DirectorateSurgical DirectoratePerformance Rating
W&C DirectorateTRUST
TOTAL
Patient Satisfaction: In-patient overall result 88 95 91 91 94 91 83 90 96 93 93 88 82 100 92
In your opinion, how clean was the hospital
room or ward that you are in?100 99 96 95 100 89 94 100 100 100 96 99 96 100 97
Were you ever bothered by noise at night from
other patients?64 90 76 77 88 71 79 81 82 80 80 61 32 100 76
Were you ever bothered by noise at night from
hospital staff?79 89 86 87 88 83 94 100 100 80 94 83 92 100 90
Were staff professional, approachable and
friendly?96 100 100 97 100 96 97 100 100 100 100 100 96 100 99
Did you find someone on the hospital staff to
talk to about your worries and fears? 93 95 98 91 93 88 82 82 96 88 90 88 75 100 90
Were you involved as much as you wanted to
be in decisions about your condition and
treatment?
95 97 91 95 88 96 86 80 100 100 95 87 92 100 93
Were you given enough privacy when
discussing your care?96 98 96 96 98 99 95 98 100 100 98 93 99 100 98
Were you given enough privacy when being
examined or treated?98 100 97 97 100 100 97 100 100 100 100 100 96 100 99
Did nurses talk in front of you as if you were not
there?95 98 95 99 98 98 93 100 100 100 99 100 99 100 98
Did doctors talk in front of youas if you were
not there?95 93 91 97 87 99 82 100 100 100 95 100 83 100 94
Before hand did a member of staff answer your
questions regarding your care/procedure? 100 99 96 98 100 100 100 99
Did the anaesthetist or a member of staff
explain to you how you would be put to sleep in
a way you could understand? 100 100 100 100 100 100 100 100
Timely call bell response 61 73 65 70 85 75 43 40 72 67 70 64 36 100 66
How likely is it that you would recommend the
service to friends and family? 57 92 81 77 92 95 58 100 100 100 96 83 82 100 84
Same sex accommodation 0 >2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Same sex accommodation: total patients 0 >2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Complaints 0 >2 1-2 0 0 0 0 1 0 0 0 0 2 0 0 0 2 0 0 0 0 1 1 0 0 0 0 22
Environment and Cleanliness 90% <80 80-89 90-100 85 90 92 93 95 84 83 94 89 93 90 90 79 88 92 86 82 87 95 91 92 96 85 90
Environmental audit 90% <80 80-89 90-100 0
85% <75 75-84 85-100
Pa
tie
nt E
xp
erie
nce
: in
-pa
tie
nt
6
Indicator Target
Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU/F2 EAU G5 Rehab F9 F10 G1 G3 G4 F7 G8 MTU F1 F11 F12
Medical DirectorateSurgical DirectoratePerformance Rating
W&C DirectorateTRUST
TOTAL
Patient Satisfaction: short-stay overall result99 99
Were you given enough privacy when being
examined and treated?100 100
Were staff professional, approachable and
friendly?100 100
Were you told who to contact if you were
worried after leaving hospital?98 99
Overall how would you rate the care you
received in the department? 100 98
How likely is it that you would recommend the
service to friends and family?
95 98
85-100
Pa
tie
nt
Ex
pe
rie
nce
: sh
ort-
sta
y
<75 75-84
Patient Satisfaction: A&E overall result 92 92
How long did you wait to first speak to a doctor
or nurse?89 89
Were staff professional, approachable and
friendly?100 100
Did staff explain about your treatment and care
in a way you could understand?92 92
Were you able to talk to a member of staff
about your worries and fears?100 100
Were you given enough privacy when being
examined and treated?100 100
Do you think the hospital staff did everything
they could to help control your pain? 100 100
Did a member of staff tell you what danger
signs to watch for when going home?
84 84
Overall how would you rate the care you
received in the emergency department?79 79
How likely is it that you would recommend the
service to friends and family?.84 84
If you're under 3 were you offered a teddy?100 100
If you are over 3 were you given a busy bag?0
Did the nurse or doctor involve you when
asking questions?100 100
Were the staff friendly and kind to you? 100 100
Did we help with your pain? 100 100
Were you given information about what care
you needed at home?100 100
85-100
75-84 85-100<75
Pa
tie
nt E
xp
erie
nce
: A
&E
85%
Pa
tie
nt E
xp
erie
nce
: A
&E
(C
hil
dre
n q
ue
stio
ns)
<75 75-8485%
7
Indicator Target
Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU/F2 EAU G5 Rehab F9 F10 G1 G3 G4 F7 G8 MTU F1 F11 F12
Medical DirectorateSurgical DirectoratePerformance Rating
W&C DirectorateTRUST
TOTAL
Patient Satisfaction: Maternity overall result92 92
In your opinion, how clean was the hospital
room or ward that you were in?97 97
Were staff professional, approachable and
friendly?97 97
Did you find someone on the hospital staff to
talk to about your worries and fears?
96 96
Were you involved as much as you wanted to
be in decisions about your care and treatment?
95 95
Were you given enough privacy when being
examined or treated?100 100
Did you hold your baby in skin to skin contact
after the birth (baby naked apart from the
nappy and a hat, lying on your chest)?
84 84
Were you given adequate help and support to
feed your baby whilst in hospital?
95 95
How many minutes after you used the call
button did it usually take before you got the
help you needed?
83 83
Has a member of staff told you about
medication side effects to watch for when you
go home?
91 91
Have hospital staff told you who to contact if
you are worried about your condition after you
leave hospital?
91 91
How likely is it that you would recommend the
service to friends and family?
84 84
Pa
tie
nt
Ex
pe
rie
nce
: M
ate
rnit
y
<75 75-84 85-10085%
Were you as involved as you wanted to be in
decisions about your care and treatment?
100 100
Did you understand the information given to
you regarding your treatment and care?
100 100
Did you find someone to talk to about any
worries and fears you may have?90 90
Were you offered age/need appropriate
activities?90 90
Did you like the food choices you were offered?100 100
Was your experience in other hospital
departments (i.e. X-ray department, out-
patient department, theatre) satisfactory?
100 100
Was your experience during
procedures/investigations (i.e.blood tests, X-
rays) managed sensitively?
100 100
Were staff professional and approachable?100 100
Is the environment young person-friendly?100 100
Overall, how would you rate your experience in
the Paediatric Unit?90 90
Ch
ild
ren
's S
erv
ice
s P
ati
en
t S
ati
sfa
ctio
n:
Yo
un
g C
hil
dre
n
<75 75-84 85-100
8
Indicator Target
Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU/F2 EAU G5 Rehab F9 F10 G1 G3 G4 F7 G8 MTU F1 F11 F12
Medical DirectorateSurgical DirectoratePerformance Rating
W&C DirectorateTRUST
TOTAL
Were you and your child as involved as you
wanted to be in decisions about care and
treatment?
96 96
Did you understand the information given to
you regarding your child's treatment and care?
100 100
Did you find someone to talk to about any
worries and fears you may have?96 96
Were you offered age/need appropriate play
activities for your child?75 75
Did you find the food choices suitable for your
child's needs?100 100
Was your child's experience in other hospital
departments (i.e. X-ray department, out-
patient department, theatre) satisfactory?
94 94
Was your child's experience during
procedures/investigations (i.e.blood tests, X-
rays) managed sensitively?
100 100
Were staff professional and approachable?98 98
Is the environment young person-friendly?100 100
Overall, how would you rate your experience in
the Children's Unit?90 90
75-84 85-100
F1
Pa
ren
t
<75
Patient Satisfaction: Stroke overall result93 93
Have you been told you have had a stroke,
which lead to your admission to hospital?
100 100
Have you been involved in planning your
recovery / rehabilitation?94 94
Have you been given a Personal Stroke Care
Plan (show example if necessary)? 82 82
Have you been helped with your eating and
drinking requirement (if not eating food
requirements)?
89 89
Do you feel cared for? 97 97
Were you given enough privacy when being
examined or treated or when your care was
discussed with you?
100 100
How likely is it that you would recommend the
service to friends and family?
88 88
Pa
tie
nt
Ex
pe
rie
nce
: S
tro
ke
<75 75-84 85-10085%
Sickness 4% >6 3.5-6 <3.5 12 5 1 7 5 6 3 10 1 9 8 18 5 4 4 2 4 5 1 2 4 6
Vacancies -2 -2 -2 -3 1 -2 0 -4 -1 -3 -3 -5 0 -1 4 -5 -1 -5 3 -15 0 -2
Turnover (Annual) 10% >10% 0%-10% 13 9 3 7 6 2 3 3 14 5 12 6 7 10 2 6 11 5 10 7
Turnover (Monthly) 10% >10% 0%-10% 3 0 0 2 2 0 0 0 5 0 0 0 3 0 0 0 0 0 0 0 0 1
Sta
ffin
g
9
Quality Priority: Ward Performance Issues
Patient surveys – (This section identifies wards that have three red ratings for patient satisfaction or a significant change from last month)
Most ward areas have seen a general improvement in patient experience scores however G3 call bell response time has decreased to 70%. From the callaid reporting system, we know that the average response time was 107 seconds. G3 is a high performing ward and this call bell response time does not demonstrate poor performance or represent a trend. The net promoter question has improved from 67% to 96%.
F3 has seen a decrease in their score from the net promoter question which requires investigation and action. The matron has been asked to investigate this to determine the reasons for the decrease. F3 has seen improved scores in all other aspects of their quality performance therefore there is no evidence to support major concerns in this area but we do need to understand the reasons behind decreased recommender score.
Ward Issues
Theatres have a low score for environment and cleanliness. This related to non-patient areas (changing rooms) following the end of the afternoon lists. Cleaning services will now be provided in theatres overnight to ensure that changing rooms are cleaned by the morning.
Staffing Issues
During data collection period 22nd April- 19th May, healthroster identified 32 WTE nursing workforce vacancies (Bands 2-7) across the medical and surgical directorates. We are implementing a new recruitment strategy for student nurses qualifying in September to ensure that we offer as many as possible employment to plan for our future vacancy requirements. Students will go through a group interview process and we will offer part-time posts if the demand for jobs is larger than our Band 5 vacancies. This will ensure we recruit all the students for our future recruitment needs as their hours can be increased to full-time as vacancies become available.
External mock CQC assessments
The first external inspection using the CQC assurance framework was held on 15th June. The majority of clinical areas were assessed for compliance against all the CQC essential standards of quality and safety. The assessors were from NHS Suffolk, LINKs, governors, and neighboring acute and community Trusts. The feedback is currently being collated and will be reported to the appropriate forums.
10
Quality Priority: Infection Control
There were no cases of MRSA bacteraemia or MSSA bacteraemia during May. There were 4 cases of clinically significant hospital acquired C. difficile
during May (giving a total of 6 during 2012-13 against a profile of 5). There was an increased incidence on Ward G8 that coincided with an outbreak of
norovirus. Increased cleaning had been carried out due to the norovirus and no deficiencies in cleaning were identified. RCAs were carried out
individually and a SIRI has been reported. G8 was decanted to another area to allow complete fogging of the ward to take place.
High Impact Interventions
In respect of compliance with the High Impact Interventions (HII), all interventions scored 100% except peripheral cannula ongoing care (97%) and
urinary catheter ongoing care (99%). Both these scores were an improvement on last month‟s performance.
Isolation audit data
Of the 33 side rooms in the Trust, 17 were used for IC purposes. There were 4 high risk patients who should have been isolated and were not due to
bed capacity and the need to main single sex accomodation. The F9c cohort was in operation and had 4 patients in it on the day of audit.
0 0 0
1
2
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
MRSA Total no ofMRSAbacteraemias:Hospital
MRSACumulativeCeiling:HospitalAcquired
MRSACumulativeActual:HospitalAcquired
Number
11
Quality Priority: Falls
0
10
20
30
40
50
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Falls No of patient falls
No of patient fallsresulting in harm
No. of serious injuriesor deaths resultingfrom falls
Number
The contract target for falls during 2012-13 is to reduce serious harm/ death from falls and to complete a risk assessment for 95% of patients who attend A&E
as a result of a fall.
Falls resulting in serious harm.
The ceiling for Q1 is 2 incidences of serious harm or death resulting from a fall. The NPSA criteria for serious harm resulting from a fall is, “where permanent
harm, such as brain damage or disability was likely to result from the fall”. This includes patients who have fractured their neck of femur as up to 90% of older
patients who fracture their neck of femur fail to recover their previous level of mobility or independence.
During May we had no falls resulting in serious harm.
A&E risk assessment
The pathway for risk assessing and reporting via discharge summaries is currently being developed and a report detailing the implementation plan will be
available to NHS Suffolk by the end of Q1.
Falls performance
There were 36 falls across the Trust during May a reduction
as compared to April. 8 falls resulted in minor harm e.g. small skin
laceration.
Two wards had a higher than usual number of falls during May: G1 and
F5. However, G5 and F4 had no falls at all this month.
F5 had 7 falls of which 3 resulted in minor harm. 3 of the falls occurred in patients who were independent and could not have been foreseen e.g. fell out of bed
when stretching to pick up glass of water from locker, knocked over urine bottle and fell when trying to sort it out, and another fell within a few minutes of
arriving on the ward during the handover of the patient. The remaining falls occurred in patients who required assistance but mobilised without asking for help
despite having been advised to ask.
G1 had 6 falls (of which 3 occurred in one patient). G1 is composed of single rooms and the falls occurred mainly at night. The patient who had 3 falls was
moved near to the nurses station for ease of observation following the first fall. A wander guard was requested following the second fall but was unavailable due
to usage elsewhere. A more sophisticated system similar to the wander guard is being considered for G1. This would trigger an alarm on a bleeper system that
could be carried by the nurse. This would enable staff to monitor such patients more easily when they are occupied with other duties.
12
Quality Priority: Pressure Ulcers
The performance target is to have no avoidable Grade 3/4 pressure ulcers 2012-13 with
a penalty of £5,000 for each incident. 2 patients developed Grade 3 hospital acquired
pressure ulcers during May on G5. The RCAs have not yet been held to determine if
these pressure ulcers were avoidable. One RCA is scheduled for 28th June and the other
16th July. The performance target re: Grade 2 pressure ulcers is a ceiling of 11
for Quarter 1 with a penalty of £500 for each incidence above the ceiling. 3 patients
developed Grade 2 hospital acquired pressure ulcers this month, 1 of which was
avoidable taking the total to 4 YTD. This occurred on G5 and was considered avoidable
as not all documentation was complete.
Regional best practice
The Midlands and East SHA Pressure Ulcer Programme Board have developed a pressure ulcer prevention and treatment pathway based on best practice
recommended by the Expert Working Group (“Stop pressure now” campaign). All Trusts are currently working to implement the best practice within their
organisations. As the intensive support team also recommended greater collaboration across the health systems in Suffolk to prevent pressure ulcer
development, NHS Suffolk chair a county-wide group and a county-wide action plan is being developed.
Specific actions for West Suffolk:
• Our policies and pathways already support best practice, therefore the focus on changing practice is not required but we need to provide assurance that
the policies and pathways are implemented. The SHA pathway has an audit plan that we will implement to provide that assurance.
• The RCA process needs updating to include a new generic RCA form - all Grade 2 RCAs will now be sent to NHS Suffolk for confirmation that the
pressure ulcer is avoidable/unavoidable.
• Generic training packages on the pathway implementation and components are being developed by the Expert Working Group which will be used as
soon as they are available.
• An engagement and behavioural change programme is being developed regionally to support the organisational change programmes required to embed
the “Stop pressure now” campaign. 4 champions will attend this programme from West Suffolk Hospital.
• As part of the pressure ulcer prevention project plan for 2012-13, the tissue viability team restructure will allocate one member of the team as pressure
ulcer prevention lead and Trust priorities re: pressure ulcer reduction will inform their role objectives and daily work schedules.
• G5 is receiving intensive support from the tissue viability team to improve performance in pressure ulcer prevention and there has been a significant
reduction in incidence during June. Discussions with other acute Trusts have highlighted that it is not uncommon for rehabilitation areas to have higher
incidences of pressure ulcers compared to acute clinical areas as rehabilitation patients have often had lengthy inpatient stays and periods of ill-health
prior to their transfer to rehabilitation areas. However reducing pressure ulcers on G5 remains a priority for the tissue viability team.
0
2
4
6
8
10
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Pressure ulcers No of patientswith wardacquired Grade2 pressureulcers
No of patientswith wardacquired Grade3 or 4 pressureulcers
Number
13
Quality Priority: Patient Experience – Achievement of 85% satisfaction
‘Achieve at least 85% satisfaction in internal patient satisfaction surveys’ is a Quality Priority for the Trust
The overall results for the inpatient survey rose to 92% this month and this reflects an increase in the scores for most questions. Scores of over
95% were achieved in most of the questions, with noise at night from other patients (76%) and timely call bell response (66%) being the only
scores below 90%.
The number of responses for each ward were reasonable except for F12 (4 responses) and G1 (5 responses). This is being addressed with the
ward managers concerned.
In the outpatient survey, the overall result was 88% with provision of information about delays being the only low scoring question. Issues
related to this have been discussed at the Patient Experience Committee and a piece of work is being carried out by the OPD and Health Records
Manager to address these.
The A&E survey indicated good levels of satisfaction with an overall score of 92%. However, the number of returns was unacceptably low and an
increased target to compensate for the low returns in May has been set for June. Daily monitoring of responses has been introduced.
14
Quality Priority: Patient Experience – Recommend the service
Score Category Number of responses
0-6 Detractors 12
7-8 Passive 48
9-10 Promoters 378
‘Patients would recommend the service to their family and friends’ is a Quality Priority for the Trust
The Trust sampled 438 inpatients (15%) and achieved a net promoter score of 83.5 overall during May. This was split as follows:
Scores for April and May place the Trust in the top quartile performance in the Region.
An additional question has been added for those scoring below 9,to identify the reasons behind the score. The results for April and May were reviewed to provide some initial analysis of the reasons behind the score. Only 25 patients (out of a possible 116) completed this question and 5 of the comments indicated a reluctance to give a perfect score despite a lack of complaint (i.e. “nobody is perfect” (4pts) ) and 1 mentioned parking charges. Of the comments related to care, 5 patients felt that more staff were needed, 2 mentioned call bell response times, 2 noise at night, 2 food and 2 communication
15
Hospital Mortality Rates (Relative Risk), SHMI and Crude Mortality Rates
Report as at:
Dr Foster re-aligned their benchmark position in October 2011.
National Rate from last
reporting period
May 10 -
April 11
June 10 -
May 11
July 10 -
June 11
Aug 10 -
July 11
Sept 10 -
Aug 11
Oct 10 -
Sept 11
Nov 10 -
Oct 11
Dec 10 -
Nov 11
Jan 11 -
Dec 11
Feb 11 -
Jan 12
Mar-11 -
Feb 12
Apr-11 -
Mar 12
Rolling 12 Month HSMR-All Admissions 100 85 83.9 84.6 84.9 83.8 83.2 83.6 82.1 82.6 78.5 78.3 82.9
SMR Stroke (Acute Cerebrovascular Disease) 86.2 82 79.3 76.8 76.5 72.6 71 66.8 66.1 65.5 67.6 69.6 77.3
SMR - Heart Attack (AMI) 90 75 74.4 73.5 69.7 66.7 71.5 68.3 62.7 47.5 38 41.5 61.4
SMR - FNOF 81.6 71.6 77.1 81.6 88.7 87.7 82.1 82.8 81.7 82.5 79.2 68.3 69.5
Mortality from Low Risk Conditions 0.84 - 0.55 0.6 0.51 0.51 0.52 0.57 0.58 0.65 0.65 0.6 0.61
SHMI (Quarterly Indicator) 100 - - 91.47 - - 90.94 - -
Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-1277 62 54 68 61 79 71 75 78 82 98 73
11/06/2012
Crude Mortality
74
76
78
80
82
84
86
May 1
0 -
April
11
June 10 -
May 1
1
July
10 -
June
11
Aug
10 -
July
11
Sept
10 -
Aug
11
Oct 10 -
Sept
11
Nov 1
0 -
Oct
11
Dec 1
0 -
Nov
11
Jan 1
1 -
Dec
11
Feb 1
1 -
Jan
12
Mar-11 -
Feb
12
Apr-11 -
Mar
12
Rolling 12 Month HSMR-All Admissions
0
20
40
60
80
100
120
Jun
-11
Jul-
11
Au
g-1
1
Se
p-1
1
Oct-
11
No
v-1
1
De
c-1
1
Jan
-12
Fe
b-1
2
Ma
r-1
2
Ap
r-1
2
Ma
y-1
2
Crude Mortality for WSH
Quality Priority: Mortality
16
0
10
20
30
40
50
60
70
80
90
Ma
y 1
0 -
Ap
ril 1
1
Ju
ne
10 -
May 1
1
July
10 -
Ju
ne
11
Au
g 1
0 -
Ju
ly
11
Se
pt 1
0 -
Aug
11
Oct 10 -
Sept
11
No
v 1
0 -
Oc
t 1
1
De
c 1
0 -
No
v
11
Ja
n 1
1 -
De
c
11
Fe
b 1
1 -
Ja
n
12
Mar-
11 -
Feb
12
Ap
r-1
1 -
Ma
r 1
2
SMR Stroke (Acute Cerebrovascular Disease)
0
10
20
30
40
50
60
70
80
May 1
0 -
Apri
l 11
June 1
0 -
May
11
July
10 -
June
11
Aug
10 -
July
11
Sept
10 -
Aug
11
Oct 10 -
Sept
11
Nov 1
0 -
Oct
11
Dec 1
0 -
Nov
11
Jan 1
1 -
Dec
11
Feb 1
1 -
Jan
12
Mar-
11 -
Feb
12
Apr-
11 -
Mar
12
SMR - Heart Attack (AMI)
0
10
20
30
40
50
60
70
80
90
100
Ma
y 1
0 -
Ap
ril 1
1
Ju
ne
10 -
May 1
1
July
10 -
June 1
1
Au
g 1
0 -
Ju
ly
11
Sept 10 -
Aug
11
Oct 1
0 -
Se
pt
11
No
v 1
0 -
Oc
t 1
1
De
c 1
0 -
No
v
11
Jan 1
1 -
Dec
11
Fe
b 1
1 -
Ja
n
12
Ma
r-11 -
Fe
b
12
Ap
r-1
1 -
Ma
r 1
2
SMR - FNOF
17
Most CQUIN targets are progressing to plan. Some still require final agreement with the PCT; 7 day working and hand off to the community. A
meeting is scheduled with the PCT on 26th June to agree and finalise the plans.
Exceptions
• Patient Survey - Net promoter Question - A&E, outpatients and daycases
In order to achieve the quarterly target the volunteers have been assisting in A&E and in day surgery unit to encourage patients to answer the net
promoter question. There is a daily report on the number of outstanding surveys. A verbal update on the likely quarter position will be provided at
the board.
CQUIN
Summary & Exceptions report
Area MTD
(at at 24 June)
QTD (at at 24
June)
Target for Q1
Total outstanding
for Q
OPD 161 794 600 0
A&E 179 226 300 74
DSU 45 103 120 17
18
Performance Indicator Threshold DescriptorIn Month
Performance QTD RAG Comments Lead Exec
VTE Screening
98%
Number of all adult inpateint admissions
reported as having had a VTE risk assessment
on admission to hospital using the national
tool 98.26% 97.10% Dermot O'Riordan
VTE Prophylaxis100%
Number of high risk patients receiving
appropriate prophylaxis - - Quarterly monitored Dermot O'Riordan
Patient Survey - National
ConsolidatedAchieve composite score of 70 (February 2011 = 68.38)
Composite score from 5 'responiveness to
personal needs of patients' questions
Report expected April 2013
2011 National Patient Survey action
plan in place Nichole Day
Patient Survey - Local focus
Achieve score of 49 or greater (February 2012 = 46.7)
Improvement on the question(s) which have
the poorest score in 2011 National Patient
Experience Survey - Question 64. Medication
side effects advice - results from Feb 12 = 46.7
Report expected April 2013
2011 National Patient Survey action
plan in place Nichole Day
Patient Survey - Net Promoter
Question - Inpatients
Q1 = Survey with question and establish baseline
Q2 = Survey with question and plan for % improvement (% to
be agreed once baseline established)
Q3 = Add the 'Why' question
Q4 = implement action plan to improve
10% of inpatients (over 18, excluding daycases,
A&E and outpatients) asked the question to
establish the Net Promoter Score 83.56
Baseline score = 81.47
The Trust score is within the upper
quartile - no need for improvement Nichole Day
Patient Survey - Net Promoter
Question - A&E, outpatients and
daycases
Q1 = Survey with question and establish baseline
Q2 = Survey with question and plan for % improvement (% to
be agreed once baseline established)
Q3 = Add the 'Why' question
Q4 = implement action plan to improve
number of outpatients
(A&E = 100 per month, Outpatients = 200 per
month, daycases = 40 per month) asked the
question to establish the Net Promoter Score
Survey totals - QTD (as at 20 June12)
OPD = 768 (Target = 600)
A&E = 120 (Target = 300)
DSU = 96 (Target = 120)
Action plan is in place to achieve Q
target for each of the 3 areas Nichole Day
Dementia - Screening
90% achievement for 3 consecutive months within 2012/13
% of all patients aged over 75 who were
admitted includes emergency admissions, non
elective admissions (excluding day cases) as
inpatients should be screened following
admission to hospital (within 48 hours) using
the recommended tool in the local dementia
pathway (CT scans excluded)
Changes to EPRO to achieve target
and collect data have been made.
Reporting available from Q2 Nichole Day
Dementia - Risk Assessment
90% achievement for 3 consecutive months within 2012/13
% of all patients aged over 75 who have been
screened as at risk of dementia, who have had
a dementia risk assessment within 48 hours of
admission to hospital, using the locally agreed
dementia pathway risk assessment tool
Changes to EPRO to achieve target
and collect data have been made.
Reporting available from Q2 Nichole Day
Dementia - Referall for specialist
Diagnosis90% achievement for 3 consecutive months within 2012/13
% of all patients aged over 75 who have been
identified as at risk of having dementia, who
are referred for specialist diagnosis
Changes to EPRO to achieve target
and collect data have been made.
Reporting available from Q2 Nichole Day
Safety Themometer
Q1 = Implement data collection tools
Q2 = full set of data covering 4 elements submitted on time
Q3 = full set of data covering 4 elements submitted on time
Q4 = full set of data covering 4 elements submitted on time
Monthly surveying of all appropriate patients
on 4 outcomes, pressure ulcers, urinary tract
infection in patients with catheters and VTE
Data collection tools in place
Report from Q2 Nichole Day
Assessment of risk of falls in pt aged
65 or over that attend A&E
Q1 = Implement data collection tools
Q2 = 50% achievement in last month of quarter
Q3 = 90%
Q4 = 95%
Total number of people aged over 65
attending A&E who have been assessed using
the Stage 2 risk assessment tool and discharge
summary to GP
Data collection tools in place
Report from Sept 12 (3rd month of
Q2) Nichole Day
Every Contact Counts - Breast-
feeding UNICEF training
Q1 & Q2 = >18 staff trained
Q3 = >30 staff trained
Q4 = > 70 staff trained
Number of staff trained in UNICEF
breastfeeding management 3 day course - 25 Training plan in place Gwen Nuttall
CQUIN
19
Every Contact Counts - Breast-
feeding 'Give it a go' materials
Q1 = 75%
Q2 = 75%
Q3 = 75%
Q4 = 75%
Number of mothers given breastfeeding 'Give
it a go' social marketing campaign material
All booking appointments given the
Breast-feeding materials from 8th
May. Data collection in place for
reporting Q1 performance Gwen Nuttall
Number of electronic patient referrals to NHSS
smoking cessation services (excludes
maternity)
Q1 - 125
Q2 - 175
Q3 - 0
Q4 - 280 17 188 Q1 target achieved Gwen Nuttall
1,000 (positive) PATs completed by March 2012
leading to 200 referrals which includes brief
advice session for each patient.
Q1 - 0
Q2 - 0
Q3 - 500
Q4 - 500 n/a Report from Q3 Gwen Nuttall
67% of staff to be trained to deliver brief
intervention
Q1 - 50%
Q2 - 50%
Q3 - target complete
Q4 - target complete - 35 WTE
72 WTE in A&E requiring training.
48.09 Nursing and 24 Medical.
Q1 - 35 WTE trained (mainly nursing)
Q2 - 37 WTE staff remaining - these
are mainly medical staff Gwen Nuttall
Q1 implementation of data collection tool
Q2 50%
Q3 70%
Q4 90%
Number of expectant mothers who have CO
validated and recorded smoking status in
records at first midwife appt
Database set up to collect
information and will be collated
monthly from Q2 Gwen Nuttall
Q1 implementation of data collection tool
Q2 70%
Q3 90%
Q4 100%
Number of pregnant smokers given brief
interventions at first booking
Database set up to collect
information and will be collated
monthly from Q2 Gwen Nuttall
Q1 implementation of data collection tool
Q2 70%
Q3 90%
Q4 100%
Number of pregnant smokers who are offered
a referral to smoking cessation services
Database set up to collect
information and will be collated
monthly from Q2 Gwen Nuttall
Discharge Summaries - All
medications listed on discharge
Q1 = Provider to work with CCGs to agree a plan and formats
for additional information
Q2 = Implement plan
Q3 = Survey to guage impact
Q4 = Develop action plan for improvement
Improvement in information provided to GPs
on the Dischagre Summaries
Meeting scheduled to take place
22nd June to discuss requirements of
Discharge Summary Dermot O'Riordan
Discharge Summaries - Social care
discharge package information100% of stroke patients eligible for a brain scan scanned
within one hour
minimum requirement is for social care
package to be included on discharge summary
Meeting scheduled to take place
22nd June to discuss requirements of
Discharge Summary Dermot O'Riordan
Discharge Summaries - Process for
agreeing additional fields and
outpatient consultation clinical
feedback Detail to be developed in Q1
minimum requirement is for follow up
arrangments and reason to be included on
discharge summary
Meeting scheduled to take place
22nd June to discuss requirements of
Discharge Summary Dermot O'Riordan
Discharge Summaries - Cancer end
of treatment - using Information
Prescriptions system
Q1 – establish plan and package to offer to patients at the
end of a period of acute treatment for cancer and pilot
(breast, colorectal and prostate)
Q2 – 25%
Q3 – 50%
Q4 – 80%
Patients at the end of a period of acute
treatment for cancer are offered an end of
treatment assessment and care
plan/treatment summary
Currently writing the necessary
patient package information for
breast & colorectal and devising a
standard template for the prostate
patients. Dermot O'Riordan
Every Contact Counts - Smoking -
pregnant women
Every Contact Counts - Smoking &
Alcohol Screening Q1 = electronic pathway established and 125 smoking
referrals of which 75% recording giving consent. Training of
doctors and ENP staff 50% of target trained.
Q2 = 175 smoking referalls of which 75% record giving
consent. Training of doctors and ENP staff - remaining 50%
target trained.
Q3 = 500 PATs completed
Q4 = 280 smoking referrals of which 75% record giving
consent. a further 500 PATs completed with 200 referrals to
SATS.
Performance Indicator Threshold DescriptorIn Month
Performance QTD RAG Comments Lead Exec
20
Planned Care - Training in
recognising deteriorating pt
i) Q1 Enrolment and commencement of Section 7 module by
minimum of 20% of Registered nurses and HCA's in each
ward, department
Month 2 & 3 implementation plan commenced
i) Q2 10 % ward /department/bank staff to have completed
Section 7 Assessment and Observation module.
i) Q3 15 % ward /department /bank staff to have completed
Section 7 Assessment and Observation module.
i) Q4 25% ward /departmentstaff to have completed Section 7
Assessment and Observation module
i) Number of staff members completing
section 7 (Assessment and Observation) of e-
learning workbook
I.T interface issues now resolved.
Q1 target being achieved Nichole Day
Digital by default
Q1 = Identify specialties and within those the patient mix
Q2 = Pilot in 4 different areas (condition specific rather than
specialty)
Q3 = Review with NHSS for potential for roll out with review
and consideration for extension which will include patient
feedback
Q4 = Further improvements and refining
Number of alternative non face to face
consultations made
Specialties currently being identified
in conjunction with NHSS Gwen Nuttall
Integrated care - EAU consultant to
7pm30% avoided admission
EAU consultants advice and guidance service
to support clinical management in the
community Plan being achieved Gwen Nuttall
Integrated care - PAU Paediatrician
Q1 = establish service from 2nd April - collect data from
month 2
Q2 = target to be agreed at end of Q1
Q3 = target to be agreed at end of Q1
Q4 = target to be agreed at end of Q1
Paediatric consultant advice and guidance
service to support clinical management in the
community System in place Gwen Nuttall
Integrated care - Emergency Surgical
Referral triage - consultant
Service in place as reported by GPs and monthly monitoring
of data to indicate reduction in acute surgical admissions, and
quarterly feedback of learning to GP's
Surgical consultant advice and guidance
service to support clinical management in the
community
System now in place and data being
collected Dermot O'Riordan
Integrated care - 7 day working
Q1 = Agree plan
Q2 = TBC
Q3 = TBC
Q4 = TBC
Pt review on admission and access to
diagnostics and Consultant review within 24
hours
Plan still being worked up - Meeting
scheduled with PCT 26th June Gwen Nuttall
Integrated care - hand off to the
community
Q1 = Agree plan
Q2 = TBC
Q3 = TBC
Q4 = TBC
Reduction in the number of heart failure and
COPD readmissions within 7 days of discharge
through referring for targetted support for
patients with poorly managed conditions and
telephone courtesy follow up one day after
discharge
Plan still being worked up - Meeting
scheduled with PCT 26th June Gwen Nuttall
Performance Indicator Threshold DescriptorIn Month
Performance QTD RAG Comments Lead Exec
21
• Overall performance is good or improving. The NICE TA business case remains at amber but progress has been achieved in
clearing the backlog. There is a monthly review meeting in place to ensure that action is being taken against all NICE
assessments.
• There was an increase in the number of PAL contacts that became formal complaints in May. Details of the issues are contained
within the complaints report which will be discussed in the private session of the Board because they contain patient identifiable
information.
• Datix has been successfully rolled out across the Trust and this will enable feedback to areas of „perceived‟ low reporting.
Local Priorities
Summary & Exceptions report
22
Local Priorities - Governance Dashboard
Indicator Performance target R A G May12 Commentary
National
safety alerts
Number of NPSA alerts beyond national
implementation deadline
>=5 1-4 0 1 One NPSA alert remains overdue and on the Risk register:
SPN/2008/014Right Patient Right Blood. A plan to achieve
compliance in 2012 is being developed and will be presented at TEG
in July.
Timely
completion of
Red incident
investigations
and action
RCAs (non SIRI) completed more than 45 days after
incident reported
>=1 0 0
Actions beyond deadline for completion >=5 1-4 0 0
Timely
reporting of
SIRIs to NHS
Suffolk
SIRIs 2 day report beyond timeframe >=1 0 0 The 6 SIRIs reported in May all had the relevant reports submitted
within the required timescale. SIRIs 7 day report beyond timeframe >=1 0 0
SIRIs 45 day reports beyond timeframe >=1 0 0 The 3 SIRIs 45-day reports due in May were all submitted within the
agreed timescales.
Risk
assessments
Active risk assessments in date <75% 75 –
94%
>=95% 96%
Outstanding actions in date <75% 75 –
94%
>=95% 98%
NICE TA (Technology appraisal) business case beyond
agreed deadline timeframe
>9 4 - 9 0 - 3 6 The number of technology appraisal business cases continue to
reduce , the process includes new Technology Appraisal Guidance
reaching the deadline for business cases submission each month so
the 6 currently outstanding break down into four historically
outstanding and two newly outstanding for business cases.
IPG (Interventional procedure guideline) baseline
assessments beyond agreed deadline timeframe
>9 4 - 9 0 - 3 9
CG (Clinical guideline) baseline assessments beyond
agreed deadline timeframe
>9 4 - 9 0 - 3 9
Clinical Audit Trust participation in relevant ongoing National audits
(reported by Quarter)
<75% 75 –
89%
>=90% - 96% at end of Q4
Complaints
Response within 25 days or negotiated timescale with
the complainant
<75% 75 –
89%
>=90% 100%
Number of second letters received >=5 1-4 0 2
Health Service Referrals accepted by Ombudsmen >=2 1 0 0
Red complaints actions beyond deadline for
completion
>=5 1-4 0 0
Number of PALS contacts that became formal
complaints
>=10 6 - 9 <=5 4
23
0
50
100
150
200
250
300
350
400
Jun-1
1
Jul-1
1
Aug-1
1
Sep-1
1
Oct-
11
No
v-1
1
De
c-1
1
Jan-1
2
Feb
-12
Ma
r-1
2
Apr-
12
Ma
y-1
2
Nu
mb
er
of
incid
en
ts r
ep
ort
ed
Patient Safety Incidents reported to Trust
WSH (harm PSIs) NRLS benchmark (harm PSIs) WSH (all PSIs)
NRLS Lower quartile (all PSIs) NRLS Median (all PSIs) NRLS Upper quartile (all PSIs)
There were 291 incidents reported in May including 225 patient safety incidents (PSIs).
The NRLS target lines shows how many incidents WSH would have to report to fall into the median / upper and lower quartiles for small acute trusts
reporting per 100 admissions (from Apr-Sept11 NRLS report). The rate of PSIs is a nationally mandated item for inclusion in the 2012/13 Quality
Accounts.
The number of PSIs reported in May 2012 still falls below the lower quartile benchmark but it has shown an increase from April. The number of harm
incidents has risen compared to April but is still lower than in previous months.
Now that Datix reporting has been rolled out successfully in all clinical areas there will be targeted feedback to areas of perceived „low reporting‟. 24
5
2
1
2
5
1
2
1 1
2
1
1
2
0
1
2
3
4
5
6
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.6%
1.8%
2.0%
Ma
y-1
1
Ju
n-1
1
Ju
l-1
1
Au
g-1
1
Se
p-1
1
Oct-
11
No
v-1
1
De
c-1
1
Ja
n-1
2
Fe
b-1
2
Ma
r-12
Ap
r-1
2
2ary
axis
(n
um
ber
of
co
nfi
rmed
PS
Is)
1ary
axis
(seri
ou
s h
arm
PS
Is a
s a
% o
f to
tal
PS
Is)
Serious Patient Safety Incidents reported to NRLS
pending final grade(2ary axis) WSH serious harm PSIs(1ary axis) Benchmark NRLS Serious harm average (1.2%)(1ary axis) WSH serious harm - 12 month rolling average WSH%
May: Falls # (2), Delayed diagnosis (2), Deteriorating patient (1)
September : Falls # (2), Delayed diagnosis (2), C. difficile outbreak (1)
The percentage of PSIs resulting in severe harm or death is a nationally mandated item for inclusion in the 2012/13 Quality Accounts.
The graph above plots the peer group average of 1.2% (serious PSIs as a percentage of total PSIs) from the NPSA April - September 2011 report.
The WSH data is plotted as a line which shows the rolling average over a 12 month period. There is a downward trend evident since May 2011.
The number of serious PSIs confirmed grade are plotted as a column on the secondary axis. There was a peak in September 2011 but no trend was
identified from the data.
25
Complaint response within agreed timescale with
the complainant: 100% of responses due in May
were responded to within the agreed timescale
(target 90).
Of the 22 complaints received in May, the
breakdown by Primary Directorate is as
follows: Medical (11), Surgical (5), Clinical
Support (2), Women & Child Health (4) and
Facilities (0).
Trust-wide the most common problem areas are
as follows:
- All Aspects of Clinical Treatment 9
- Communication 9
- Attitude of Staff 5
- Admission, Discharge & Transfer 5
This breakdown reflects an expected distribution across the categories. (Please note that more than one category can be allocated to each complaint so
the total number of problem areas does not correlate with the total number of complaints) .
The data in the graph above demonstrates that there has been a decrease in the number of complaints received in May 2012/13 compared to May
2011/12.
Themes from Red complaints
All actions identified from Red complaints are currently within deadline for completion
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Complaints 2012/13 19 22
Complaints 2011/12 22 26 27 19 27 24 24 22 15 32 23 22
0
5
10
15
20
25
30
35
Nu
mb
er
of co
mp
lain
ts
Local Priorities - Complaints
26
In May 2012 there were 80 recorded PALS
contacts. This number denotes initial contacts
and not the number of actual communications
between the patient/visitor and PALS.
A breakdown of contacts by Directorate from
June11 to May12 is given in the chart and a
synopsis of enquiries received for the same period
is given below. Total for each month is shown as
a line on a second axis.
Trust-wide the most common five reasons for
contacts are as follows:
General enquiries, concerns about aspects of clinical treatment and attitude of staff remain the most prominent reasons for contacting PALS this month.
However, there are no trends identified for specific groups of staff, speciality or discipline.
The PALS Manager continues to deal with requests for information which can vary from clarification of hospital procedure to specific details about
treatment given; future care plans; outcome or length of time waiting for results of tests and discrepancies about diagnosis and/or discharge
arrangements.
A number of queries also relate to appointment dates and length of time waiting for these; the length of time waiting in clinics; and general enquiries about
services not directly managed by West Suffolk Hospital.
The PALS Manager frequently helps to improve communication between the Trust and patients‟ family members both in this country and abroad.
Any issues which are not able to be dealt with by PALS are directed, if appropriate, to the formal complaints process.
The very nature of the PALS service requires responses to queries, concerns or complaints to be dealt with expediently. A Target of 80% for responding
fully (completing the enquiry) within 48 hours has been set or within a timeframe agreed with the enquirer. This target is currently being monitored and
there is now evidence that the Manager consistently meets this target.
88
97
76
59
83 88
84
100
81
63
96
80
0
20
40
60
80
100
120
0
5
10
15
20
25
30
35
40
45
50
Jun-1
1
Jul-11
Aug-1
1
Sep-1
1
Oct-
11
Nov-1
1
Dec-1
1
Jan-1
2
Feb-1
2
Mar-
12
Apr-
12
May-1
2
Medical Surgical Clinical support
Women and Child Health Facilities Not categorised
Total
Information (advice) 27 Attitude of staff 10 Communication Information to patients 6
All aspects of clinical treatment 15 Other organisations, etc 7
Local Priorities - PALS (Patient Advice & Liaison Service)
27
Local Priorities – Workforce Performance
• Recruitment Timescales – the Suffolk Redeployment Clearing House requires the Trust to place
all appropriate vacancies with them for a period of 1 week prior to opening up the vacancy to
outside competition. This has had the effect of adding 1 week to our usual recruitment timescales
and therefore the target has been amended to include the additional week.
Performance Indicator Threshold Direct Financial
Penalty In Month
Performance Comments Lead Exec
Workforce
Sickness absence rate <4.39% (National Average) NO 3.81% Jan Bloomfield Turnover <14.2% (National Average) NO 7.36% Jan Bloomfield
Reviews Grievance/Banding reviews NO 3 One Grievance and Two Employment Tribunals Jan Bloomfield
Recruitment Timescales Average number of weeks to recruit = 7
NO 6.5
This will continue to include any additional weeks for the Suffolk Redeployment Clearing House Jan Bloomfield
CRB Disclosures existing staff To complete 95% of required CRB checks
NO 99.00% Jan Bloomfield
All Staff to have an appraisal 90% of staff have had an appraisal within the previous 12 months
NO
90.84% Jan Bloomfield
Mandatory Training compliance (reported Quarterly) Jan Bloomfield
Consultant appraisals 100% by end of October NO 99.00% Jan Bloomfield
28
All performance (other than C.Diff) was achieved for May.
Exception
C.Diff
Four cases of C. difficile occurred during May and as a result, the total number of cases is above trajectory for the year (cumulative total 6, against a
trajectory of 5). The cases occurred on one ward and no further cases have been reported since the end of the month (as of 22 June 2012) on that
ward.
Monitor Compliance
Summary & Exceptions report
29
Monitor Compliance FrameworkPerformance Indicator Threshold Month QTD Weighting Lead Exec
Clostridium (C.) difficile - meeting the C.difficile objective - MONTH 2 4 6 1.0 Nichole Day
Clostridium (C.) difficile - meeting the C.difficile objective - QUARTER
Q1 = 7
Q2 = 7
Q3 = 7
Q4 = 6 6 6 Nichole Day
Clostridium (C.) difficile - meeting the C.difficile objective - ANNUALLY 27 6 6 Nichole Day
Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - MONTH 0 0 1.0 Nichole Day
Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - QUARTER 0 0 Nichole Day
Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - ANNUALLY 1 0 0 Nichole Day
All cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer 85% 89.00% 89.45% 1.0 Gwen Nuttall
All cancers: 62-day wait for first treatment (5) from: NHS Cancer Screening Service referral 90% 100.00% 96.50% Gwen Nuttall
All cancers: 31-day wait for second or subsequent treatment, comprising:
Surgery 94% 100.00% 100.00% 1.0 Gwen Nuttall
All cancers: 31-day wait for second or subsequent treatment, comprising: anti-cancer drug treatments 98% 100.00% 100.00% Gwen Nuttall
All cancers: 31-day wait for second or subsequent treatment, comprising: radiotherapy - Not applicable to
WSFT
Cancer: two week wait from referral to date first seen (8), comprising:
all urgent referrals (cancer suspected) 93% 94.25% 94.26% 0.5 Gwen Nuttall
Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer
not initially suspected) 93% 96.81% 98.41% Gwen Nuttall
All cancers: 31-day wait from diagnosis to first treatment 96% 100.00% 100% 0.5 Gwen Nuttall
Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted 90% 100.00% 100% 1.0 Gwen Nuttall
Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted 95% 100.00% 100% 1.0 Gwen Nuttall
Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway 92% 99.98% 100% 1.0 Gwen Nuttall
A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge 95% 96.19% 94.55% 1.0 Gwen Nuttall
Certification against compliance with requirements regarding access to healthcare for people with a learning
disability N/A 0 0 0.5 Nichole Day
30
Contract Priorities
Summary & Exceptions report There are two significant areas of poor performance in May:- A&E and Stroke.
Stroke
• As reported at the last Board meeting, stroke performance was severely affected by an outbreak of noro virus on ward G8 (dedicated stroke ward).
The ward was closed to all admissions during the outbreak. The ward was closed for 9 days, during which time stroke patients were admitted to the
emergency assessment unit.
• There are still delays with referrals to the hospital from GP‟s. Information is fed back to the PCT with regard to specific GP delay.
• There has been a change in emphasis in reporting from recording referral to onset of TIA. This is being discussed in the network as there are some
concerns as to the performance measurement of a target which is totally patient dependent.
• Early indications are that performance in June has improved across the board.
A&E
• Performance against A&E measures during May was mixed. There was achievement of the 95% target and demonstrable (but below standard)
improvement in ambulance handover and ambulance button submit.
• Some performance issues are linked with space and capacity in the department. There is a Board paper proposing development of increased
assessment space for consideration in the meeting.
• That said, the continued focus needs to be on improving flow within the Organisation to ensure patients can be admitted directly to EAU or other areas
when appropriate.
• Equally there has to be engagement with GP‟s and other stakeholders as overall attendances to A&E continue to rise, with many seeing the highest
monthly attendances recorded.
31
A&E Attendances and Emergency Admissions
A&E Attendances
April May June July August September October November December January February March YTD Total
Year %
Variance
2010/11 4270 4666 4391 4742 4389 4297 4337 4069 4140 4202 3748 4697 51948
2011/12 4679 4907 4770 4721 4620 4490 4840 4455 4389 4650 4376 4726 55623 6.61%
2012/13 4713 5166 9879
Emergency Admissions (excluding maternity)
April May June July August September October November December January February March YTD Total
Year %
Variance
2010/11 1839 1899 1894 1815 1753 1766 1753 1820 1985 1927 1663 1881 21995
2011/12 1747 1765 1785 1806 1752 1716 1863 1799 1866 1854 1756 1908 21617 -1.75%
2012/13 1733 1923 3656
0
1000
2000
3000
4000
5000
6000
April May June July August September October November December January February March
2010/11 2011/12 2012/13
1500
1600
1700
1800
1900
2000
2100
April May June July August September October November December January February March
2010/11 2011/12 2012/13 32
Contract Priorities with financial penalty
Performance Indicator ThresholdIn Month
PerformanceYTD Comments Lead Exec
A&E - Time to initial assessment (95th percentile) Emergency Ambulance
Arrivals a 95th percentile time to assessment above 15 minutes 02:05 - Gwen Nuttall
A&E - Time to initial assessment (% below 25 mins) 98% 96.80% - Gwen Nuttall
A&E Time to treatment in department (median) - CDM a median time to treatment above 60 minutes 00:49 - Gwen Nuttall
A&E - Single longest total time spent by patients in the A&E department,
for admitted and non admitted patients Should not exceed 6 hours 10:11 -
Delay with Mental Health
Referral Gwen Nuttall
A&E - Time to treatment: Time from arrival to start of definitive
treatment from a decision making clinician: Single Longest Wait
No patient must wait longer than the single longest patient in
2010/11 (04:42) 05:50 - Gwen Nuttall
A&E - Time to initial assessment - Single Longest Wait No pt must wait longer than 25 minutes 02:15 - Gwen Nuttall
A&E - Ambulance Handover
Q1 = 80%
Q2 = 80%
Q3 = 85%
Q4 = 90%
note: % total is average over quarter 68.00% 71.00%
Performance Improving, but
below target. Gwen Nuttall
A&E - Ambulance Handover - Button Submit 80% 79.00% 78.50%
Performance Improving, but
below target. Gwen Nuttall
Discharge Summaries - Outpatients 95% sent to GP's within 3 days 86.11% 86.57% Dermot O'Riordan
Discharge Summaries - A&E
95% of A&E Discharge Summaries to be sent to GPs within one
working day 98.00% 98.37% Dermot O'Riordan
Discharge Summaries - Inpatients 95% sent to GP's within 1 day 80.31% 84.15% Dermot O'Riordan
Stroke -Proportion of Patients admitted to an acute stroke unit within 4
hours of hospital arrival 90% 48.90% 61.45%
17 Patients admitted to other
wards, 16 due to Norovirus, 1
Delayed Diagnosis Gwen Nuttall
Proportion of patients in Atrial Fibrillation, presenting with stroke and
where clinically indicated will receive anti-co-agulation. ASI Target - 60% 75.00% 77.50% 1 Patient Refused Gwen Nuttall
Stroke - % of Stroke patients with access to brain scan within 24 hours 100% 97.00% 96.00%
1 Patient Failure, Referred to
ENT and then Stroke Team Gwen Nuttall
Stroke - Proportion of Stroke Patients and carers with a joint health and
social care plan on discharge Opportunity to have a care plan is offered to 100% 80.00% 83.50% Poor Documentation Gwen Nuttall
Stroke - Patients (as per NICE guidance) with suspected stroke to have
access to an urgent brain scan in the next slot within usual working hours
or less than 60 minutes out of hours as defined from time to time by the
ASHN
100% of stroke patients eligible for a brain scan scanned within
one hour 80.00% 85.00% Delay in A&E Assessment Gwen Nuttall
>80% treated on a stroke unit >90% of their stay 81% 55.00% 70.00%
All Patients admitted to other
wards due to Norovirus Gwen Nuttall
>60% of people who have a TIA and are high risk (ABCD 2 score 4 or
more) are scanned and treated within 24 hours of 1st contact but not
admitted 60% 83.00% 71.50% Gwen Nuttall
Stroke - 65% of patients with low risk TIA have access to MRI or carotid
scan within 7 days (seen, investigated and treated) from onset 65% 44.00% 54.00%
All Patients breached on
referral due to recorded onset
time. Gwen Nuttall
% of Patients eligible for Thrombolysis, Thrombolysed within 4.5 hours 100% of all eligible patients 100.00% 100.00% Gwen Nuttall
A&E
Discharge Summaries
Stroke
33
Falls - reduction of serious injury and harm from falls
50% reduction in incidence of serious injury and death from falls
by December 2012
Q1 = 2
Q2 = 2
Q3 = 2
Q4 = 1 0 1 Nichole Day
New to Follow up Thresholds set at each speciality - overall Trust Threshold is 1.9 1.96 1.98
Specialties above target:
Urology, Gynaecology and
Cardiology. All being reviewed. Gwen Nuttall
Pressure Ulcers - reduction of grade 3 and 4 avoidable
Q1 = 25%
Q2 = 50%
Q3 = 75%
Q4 = 100%
note: reductions to be made on March 2012 baseline
Total avoidable for 2011/12 = 0 therefore the target remains at 0
avoidable grade 3 and 4 pressure ulcers 0 0 Nichole Day
Pressure Ulcers - reduction of grade 2 avoidable Maintain or improve the mix as specified = 90.17% 1 4 Nichole Day
Other
Contract Priorities - Other
Performance Indicator ThresholdDirect Financial
Penalty
In Month
PerformanceYTD Comments Lead Exec
A&E - Threshold for admission via A&E
i) if the monthly ratio is above the corresponding 2011/12 monthly ratio for
two month in a six month period
ii) if year end is greater than 27% YES 23.72% 24.27% Gwen Nuttall
A&E - Service experience 85% of overall patient experience to be maintained NO 92.00% 93.50% Gwen Nuttall
A&E - Indicators
To satisfy at least one of the following patient impact indicators
1. achieve a rate below 5% of unplanned re-attendance rate
2. achieve a rate at or below 5% of patients left department without being
seen
and at least one of the timeliness indicators
1. no deterioration on Q1 2011/12 outturn for % of A&E attendances for
cellulitus and DVT that ended in admission
2. number of admissions for cellulitus and DVT per head of weighted
population
3. % of pts representing at type 1 and 2 A&E sites in certain high risk
categories who are reviewed by an emergency medicine consultant before
being discharged NO
ACHIEVED AT
LEAST 2
ACHIEVED AT
LEAST 2 Gwen NuttallChoose & Book
Provider failure to ensure that “sufficient appointment slots” are made available on the
Choose and Book system
A maximum of 3% slots unavailable (£50 per appointment over 5%. Threshold
applied over monthly figures)YES
4.00% - Gwen Nuttall
All patients referred for an outpatient appointment should be able to choose a named
consultant-led team and the consultant should be available in the clinic.more than 95% NO
95.80% - As agreed with the PCT Gwen Nuttall
All 2 Week Wait services delivered by the Provider shall be available via Choose & Book
(subject to any exclusions approved by NHS East of England)100% YES
100.00% - Gwen Nuttall
All outpatient services shall be available via a CMS process available via Choose & Book at
the request of the commissioner100% within the agreed timescales set out in the flow diagram NO
- -
Pilot specialties available, roll out
to be agreed with NHSS Gwen Nuttall
All Outpatient diagnostic testing services delivered by the Provider shall be available via
Choose & Book.50% by 1 June 2011 & >75% by 1 September 2011 and thereafter NO
- - Data not available from the EofE Gwen Nuttall
Provider shall minimise the number of ‘Do Not Use’ or ‘Test’ services on their Directory of
Services< 5 by 1 June 2011 and thereafter NO
0 0 Gwen Nuttall
All services delivered by the provider (excluding Outpatient diagnostic testing services and
those sevices appearing in the "excluded services" lis approved by NHS EoE) shall be available
and directly bookable via Choose & Book
>95% NO
99.00% 99.00% Gwen Nuttall
A&E
34
Provider cancellation of Elective Care operation for non-clinical reasons either before or after
Patient admissioni) 1% of all elective procedures NO
0.44% 0.47% Gwen Nuttall
Patients offered date within 28 days of cancelled operation 100% 100.00% 100.00% Gwen Nuttall
Access to Maternity services (VSB06):-
90% of women who have seen a midwife or a maternity healthcare
professional, for health and social care assessment of needs, risks and
choices by 12 completed weeks of pregnancy.
NO
93.57% 94.32% Nichole Day
Maintain maternity 1:30 ratio 100% NO 96.67% 98.34% Nichole Day
Pledge 1.4: 1:1 care in established labour 100% of stroke patients eligible for a brain scan scanned within one hour NO 100.00% 100.00% Nichole Day
Breastfeeding initiation rates. 80% NO 78.13% 80.23% Nichole Day
Reduction in the proportion of births that are undertaken as caesarean sections. 1% reduction in proportion compared to 2011/12 baseline - 23.20% YES 14.29% 19.03% Nichole Day
Appropriate prescribing of antibiotics 95% NO - - Available Quarterly Gwen Nuttall
Breast Cancer operation Length of Stay <=24 hours 80% NO 97.30% 97.49% Gwen Nuttall
Delayed Transfers of Care to be maintained at a minimal level 6 DTOC's per week NO 35 35
Increase due to target action on
discharge planning Gwen Nuttall
Mixed Sex Accomodation breaches 0 Breaches YES 0 0 Gwen Nuttall
Consultant to consultant referral Defined at specialty level YES 8.52% 7.91% Target to be confirmed Gwen Nuttall
Current ratios of OP procedure to day case for agreed list of procedures to be maintained or
improved, i.e. the Commissioner will not fund a higher level of admitted patients for such
procedures, unless clinical reasons can be demonstrated for increase in admissions.
Maintain or improve the mix as specified = 90.17% YES
86.47% 86.24% Gwen Nuttall
Direct Access Diagnostics
Direct access diagnostic findings to be dispatched to referrers within 3
working days of test being undertaken NO 100.00% 100.00% Gwen Nuttall
All ELECTIVE excess bed days per elective spell to not exceed 0.086 excess
bed days per spell 0.02 - Gwen Nuttall
All NON ELECTIVE excess bed days not to exceed 0.678 excess bed days per
spell YES 0.39 - Gwen Nuttall
MRSA - emergency screening
All emergency patients admissions are to be screend for MRSA within 24
hours of admission NO 100.00% 100.00% Gwen Nuttall
Unplanned attendance
No deterioration on 2011/12 out-turn
1. for chonic ambulatory care sensitive conditions
2. for asthma, diabetes and epilepsy in under 19's
3. for acute conditions that should not usuall require hospital admission NO - -
Data is currently being reconciled
with NHSS Gwen Nuttall
Rapid access - chest pain clinic 100% of patients should have a maximum wait of two weeks NO 100.00% 100.00% Gwen Nuttall
Readmissions - Post Elective TBC YES 39 79 Target to be confirmed Dermot O'Riordan
Readmissions - Post Non Elective TBC YES 184 364 Target to be confirmed Dermot O'Riordan
Liverpool Care Pathway (LCP) 75% of patients entering the last days of life to be care for on an LCP NO 100.00% 100.00% Nichole Day
Cancelled Operations
Maternity
Other contract / National targets
Excess bed days
35