Board Report template - qehkl Report 2017 10.pdf · Crude Mortality (deaths per 1000 admissions) TargetDeaths per 1000 admsCrude Mortality (deaths per 1000 admissions) 19 11.1 14.3

Integrated Report

Quality,Performance & Workforce toend September 2017

Contents

Sep-17 Sep-17 01/07/2017 01/08/2017 01/09/2017

Current MthTrend on

prev mth

Previous

MthJul-17 Aug-17 Sep-17 FYTD

1 23 2 1

441 Emergency Department Attendances 5257 5698 5725 5698 5257 33187

2508 Outpatient Attendances 22436 24944 24727 24944 22436 145304

15 Inpatient Admissions (Elective & Emergency) 3869 3884 4095 3884 3869 23718

278 Other (regular day patients, day cases etc) 2885 3163 3015 3163 2885 18730

Compliance Scorecard1

Quality & Risk2

Performance & Standards3

CQUINS4

Workforce5

Appendices6

7

8

Page 3

Page 4

Page 32

Page 49

Page 50

Page 57

Context for the Integrated Report

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

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

Indicators TargetCurrent

QTDJul Aug Sep Qtr 1 Qtr 2 Qtr 3 Qtr 4 *FYTD

Risk Assessment framework 2015/16 5 01/07/2017 01/08/2017 01/09/2017 Qtr 1 2017/18 Qtr 2 2017/18 Qtr 3 2017/18 Qtr 4 2017/18 2017/18

18 Wks - Adm (adjusted) Target18 Wks - Adm Perf (adjusted) 90.00% 77.22% 77.81% 78.55% 75.39% 78.34% 77.22% 78.34%

18 Wks - Non Adm Target18 Wks - Non Adm Perf 95.00% 84.61% 88.31% 82.29% 83.19% 91.40% 84.61% 88.17%

18 Wks - Incomp Target18 Wks - Incomp Perf 92.00% 87.66% 88.04% 87.74% 87.20% 92.02% 87.66% 89.82%

A&E 4 Hr TargetA&E 4 Hour Performance 95.00% 89.04% 84.14% 89.80% 93.55% 88.64% 89.04% 88.84%

Cancer-62 Days RTT TargetCancer-62 Days RTT 85.00% 87.42% 86.49% 88.31% n/a 79.37% 87.42% 83.10%

Cancer-31 Days Sub Treat (Surg) TargetCancer - 31 Days Subsq Treatment - Surgery 94.00% 100.00% 100.00% 100.00% n/a 93.55% 100.00% 95.83%

Cancer-31 Days Sub Treat (Drug) TargetCancer - 31 Days Subsq - Drug Treatments 98.00% 99.14% 98.04% 100.00% n/a 100.00% 99.14% 99.64%

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

31 Day Diag to Treat Target31 Day Diag to Treat 96.00% 98.35% 97.41% 99.21% n/a 98.39% 98.35% 98.38%

Cancer-2ww TargetCan

cer-Cancer-2 Wk Waits - All urgent Referrals (cancer suspected) 93.00% 96.17% 95.88% 96.45% n/a 97.44% 96.17% 96.90%

Cancer-2ww (Breast Symptomatic) TargetCan

cer-Cancer-2 Wk Waits - Symptomatic breast patients (cancer not initially suspected) 93.00% 99.37% 100.00% 98.72% n/a 97.13% 99.37% 98.01%

Care Programme Approach (CPA) patients

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

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

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

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

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

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

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

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

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

Clostridium Difficile

CDIFF (Target)CDIFFClostridium (C.) Difficile - meeting the C. difficile objective 4 13 5 3 5 9 13 0 0 22

Mental Health

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

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

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

Certification against compliance with requirement regarding access to health care for

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

Monitor Compliance Framework Total ScoreScore 5 4 **

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

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

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

Acc

ess

Trust Risk Assessment frameworkO

utc

om

es

Compliance Scorecard

Quality & RiskPerf &

StandardsCQUINS Workforce Finance Appendices

Produced by the Performance and Information Team 3 of 57

01/07/2017 01/08/2017 01/09/2017

Indicators Var to prev mth Target Jul Aug Sep *FYTDCritical Incidents 01/07/2017 01/08/2017 01/09/2017 2017/18 2016/17

Total Never Events (Target)Total Never Events 0 0 0 0 0Total Falls Resulting in Serious Harm (Target)Total Falls Resulting in Serious Harm 0 0 1 0 3Pressure Ulcers - Grade 3 (Target)Pressure Ulcers - Grade 3 0 2 1 3 10Pressure Ulcers - Grade 4 (Target)Pressure Ulcers - Grade 4 0 0 0 0 0Total Other SIs (Target)Total Other Sis 0 1 1 0 11Pressure Ulcers - Grade 2 (Target)Pressure Ulcers - Grade 2 0 3 4 2 15Safety Thermometer - (new harm only) TargetSafety Thermometer - (New Harm Free) 95.00% 96.50% 96.12% 97.22% 96.00%VTE Assess TargetVTE Assessment Completeness 97.24% 97.42% 97.28% NA 97.50%

Infection ControlMRSA (Target)MRSA 0 0 0 0 0CDIFF (Target)CDIFF 4 5 3 5 22

Indicators Var to prev mth Target Jul Aug Sep *FYTDPatient experienceFFT % Recommended (IP & DC) 94.75% 95.75% 95.35% 95.58%FFT % Recommended (AE) 95.39% 94.41% 93.97% 92.58%

FFT Resp Rate (IP & DC) TargetFFT Response Rate (IP & DC) 30.00% 32.63% 29.44% 30.03% 32.22%FFT Resp Rate (AE) TargetFFT Response Rate (AE) 20.00% 14.19% 13.58% 16.61% 17.54%MSA Breaches TargetNo. of Mixed Sex Accommodation breaches 0 6 8 4 29

Number of Patient moves (over 2) 48 30 34 252Positive experienceCompliments 150 180 152 925Complaints

Non-Clinical Complaints TargetNon-Clinical Complaints 1 6 7 16Clinical Complaints TargetClinical Complaints 31 32 27 176

Indicators Var to prev mth Target Jul Aug Sep *FYTDMortality

Crude Mortality (deaths per 1000 admissions) TargetDeaths per 1000 admsCrude Mortality (deaths per 1000 admissions) 19 11.1 14.3 14.4 13.5RAMI (Risk adjusted mortality) (National target)SHMI (Summary Hospital Level Mortality Indicator) Apr 16 - Mar 17 as expected 98.14

HSMR (Hospital Standardised Mortality Ratio) Jul 16 - Jun 17 as expected 101.50Outcome

Stroke - 90% of Stay on SU TargetStroke - 90% of Stay on a Stroke Unit 80.00% 75.41% 87.50% NA 82.54%TIA - HR TIA seen & treated <24hrs TargetTIA - High Risk,Non admitted TIA treated in 24 Hrs 60.00% 63.16% 66.67% NA 75.00%EL LOS TargetLength of stay - Elective 2.2 1.6 1.5 1.6 1.7EM LOS TargetLength of stay - Emergency 5.0 3.6 3.9 3.9 3.7Readm Rate (EL) TargetReadmission Rate - ElReadmission Rate - Elective 3.00% 4.34% 3.62% NA 4.34%Readm Rate (Em) TargetReadmission Rate - EmReadmission Rate - Emergency 10.00% 15.19% 15.75% NA 15.83%

Indicators Var to prev mth Target Jul Aug Sep Rolling 12 mthsWorkforce

Sickness Absence Rate (Target)Sickness Absence Rate 3.50% 5.17% 5.06% 4.80% 4.99%Staff Turnover Rate Complete Trust (Target)Staff Turnover Rate Complete Trust 10.00% 11.45% 11.16% 11.68% 11.26%Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) (Target)Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) 10.00% 7.74% 6.47% 8.80% 10.54%Staff Turnover Rate Registered Nursing & Midwifery (Target)Staff Turnover Rate Registered Nursing & Midwifery 10.00% 14.83% 14.70% 15.41% 14.22%Staff Turnover Rate Allied Health Professionals (Target)Staff Turnover Rate Allied Health Professionals 10.00% 19.56% 17.83% 15.48% 18.04%

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

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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 101.5 as expected

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

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

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

· Does not include deaths after discharge

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

HSMR for the 12 month period Jul 16 - Jun 17 is 101.5 as expected

Weekday HSMR is 99.84 as expected

Weekend HSMR is 105.14 as expected

Latest Report shows QEH is 98.14 as expected

· Available to public on the NHS Choices website

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

· Includes deaths within 30 days of discharge.

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

SHMI for the 12 month data period of Apr 16 - Mar 17 is 98.14 as expected

SHMI for Q4 of 16/17 is 99.45 which is as expected

Reporting to the Board - The Medical Director will continue to monitor HSMR and SHMI data and provide exception reports to the Board as necessary, should these indicators demonstrate results which are other than ‘as expected’.

Mortality- HSMR (Hospital Standardised Mortality Ratio)

SHMI - (Quarterly Trend)

HSMR - (Monthly Trend) Key Points/Operational Actions

Definitions

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

HSMR: 99.8% control limits are applicable.

Key Points/Operational Actions

Mortality- SHMI (Summary Hospital Mortality Indicator)

Our HSMR is within expected at 101.5. Our SHMI is also within expected at 0.98. Both weekday and weekend HSMR are within the expected ranges.





Crude rate within HSMR basket is 3.42% (based on Jul 16-Jun 17),East of England rate = 3.72%

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

May's Crude Mortality Rate (3.39) is comparable to that of May of 2016 (3.40). However the rate dropped in

Jun's to 2.81 which is the lowest recorded rate since Oct 2011.

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

Mortality - Crude Mortality Rate (per 1000 admissions)

Definitions

Mortality - HSMR Basket Crude Rate (Yearly Comparison)

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

Palliative Care Coding Rate

The Trust's 'Palliative Care Coding' rate of (1.43%) for 17/18, is low when compared to the National average (3.50%)


There were 97 deaths in the hospital in September 2017, this number is comparable to last year (93) and equates to 14.4 deaths per 1000 admissions which is higher than our previous rate in September 2016 at 12.8.

The most number of deaths occurred on our care of the elderly ward (21) and respiratory ward (10). The highest number of deaths were recorded against a final diagnosis of pneumonia (19) and sepsis (12).




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

Observed 2 1 3 0 1 1 0 0 0 0 1 0


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

0Total Serious Incidents aaaa

0of which were "Never Events"

Serious Incidents (Rolling 12 months)

0123456789

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

Total Serious Incidents: rolling year (with trendline)

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

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

Category of most recently Reported (SI's)

Compliance with SI Report submission dates




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

Serious Incidents during Sep 2017

Number of Open Serious Incidents

Adverse Event Number of open Si's

Breach of confidentiality of staff records or information 1

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

Fall on level ground 1

Apgars <6 at 5 mins 1

Suspected fall 1

Lack of clinical or risk assessment 1

Neonatal seizures 1

Other medication incident 1

Failure to follow up 1

Unexpected re-admission or re-attendance 1

Grand Total 10

Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

12 14 16 7 14 16

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17

20 17 12 12 12 10

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


Learning from incidents closed




RefSTEIS

Number

SI Declared

Date

Location

Exact

Adverse

EventSI/NE Summary Root Causes Lessons Learned

60 Day

Submission

Compliance

WEB41417 2017/12819 17/05/2017 Windsor

Ward

Cardiac arrest Failure to instigate a cardiac arrest call in a timely

manner for a patient who had been considered

medically fit for discharge. Patient pronounced

dead 45 minutes later.

1. Junior skill mix and delay in commencing cardiac arrest

procedure.

2. No ceiling of treatment decision by senior medical staff. Lack of

experience in cardiac arrest situation made junior staff panic.

3. Misunderstanding information about hospital at night team

role.

1. Sister E has reviewed skill mix and will place

junior staff in-charge of the ward on days for

support and supervision before being rostered for

in-charge shifts on night duty.

2. Review of documentation and charts for when

patients are deemed medically fit for discharge with

an agreed trust standard of frequency of

observations.

3. Support for junior staff in areas of infrequent

cardiac arrest situations staff involved with incident

have now had further teaching from the resus team

in the simulation suite to improve their confidence.

Regular debriefing sessions following cardiac arrest

for all staff involved.

4. Better overview from senior medical staff on

DNR/CPR decision making with trusts standards that

on the frailty wards all patients should have this

documentation reviewed within a set timeframe by

a senior clinician.

Y


10 5

Analysis of "Other Incidents"






Falls by Degree of Harm inc rate per 1000 beddays


There are a total of 63 validated falls reported in September 2017 which is 4.97 per 1000 days rate. We have a slight increase from previous month (August 4.5/1000 bed days). This month’s report remains high and just under the Trusts benchmark standard of 5 falls per 1000 bed days, although this is still below the national average of 6 falls per 1000 bed days.

This month’s fall consequences: 0 catastrophic, 0 major, 2 moderates, 15 minor and 46 negligible.

Repeat Fallers this month:

6 Patients fell on more than one occasion:

1 patient (2x falls ) on Denver1 patient (2x falls) on Gayton1 patient (2x falls) on Windsor1 patient (2X falls) on Tilney (with in-patient falls in)1 patient (2x falls) on MAU and Terrington1 patient (2 falls) on Windsor and Tilney

On-going and Recommended Actions:

Falls prevention strategies training on the ward is on-going including management of falls to address practice issues in management of in-patient falls across the trust.

On-going review of Falls Prevention and Management Policy according to trust change of practice and National guidance, including Post Fall Protocol and Falls Prevention Care Plan.

Trial of post fall grab bag is underway. This bag will contain post fall protocol, Neurological Observation Chart, pen torch, post fall stickers/checklist, Duty of Candour Sticker, red socks and first aid kit.

On-going/extended trial of Ultra low bed from Medstrom continues on West Newton ward. The feedback we received from staff remains positive and we are hoping to move to this new product (Medstrom Ultralow) within this 2017.

We are still waiting to hear from LOF (League of Friends) regarding request of funds to purchase specialised equipment such as Scoop stretchers, Hover Jacks and Hover Mats. These will be situated between wards to become accessible to staff.

“Falls Prevention Awareness Week” initiated this week in the hospital and will continue the campaign annually. This campaign will be followed by a “Falls Summit” in February 2018.

The National Falls Audit findings are not yet available (expected December 2017). Attached is a local falls audit undertaken in May 2017 and falls audit presentation at the Clinical Audit Annual Symposium held on 12 October 2017.

Definitions

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






The trust has maintained a level of 5 hospital acquired pressure ulcers this month, however 4 of the 5 were avoidable;2 x grade 2’s, Windsor and Oxborough. Both of which were avoidable.3 x grade 3’s, Gayton and Terrington were avoidable. Necton was unavoidable.Themes;Failure to evidence adequate repositioning.Failure to provide adequate equipment for level of risk.

Induction, mandatory, NA and adhoc training continues re: pressure ulcer prevention. Training for agency staff via the PDN’s is yet to commence. Spot checks on wards have seen a slow but steady improvement in documentation.

There is to be a collaboration between the TVN’s, Podiatry, Diabetes Specialist Nurses, the Consultant Nurse for Emergency Medicine and MAU consultant, to re-launch the CPR for feet campaign, raising awareness of checking feet for diabetic patients, as part of the full skin inspection on admission.

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

Definitions

Total number Pressure Ulcers incidents per month / per 1000 beddays / proportion of avoidable and unavoidable Pressure Ulcer incidents each month





For Safety Thermometer the rate of New Harms (Developed by the QEH) for September 2017 was 2.78% a reduction from the previous month which was at 3.88% making the QEH 97.22% New Harm Free. Harm free care relates to the % of patients on the day of the study September who were Harm Free from Pressure Ulcers, Falls, VTE events and Catheter Associated Urinary Tract Infections.

The results for September show a continued maintenance of the previous performance of 95% or above.

Safety Thermometer (Hospital Acquired Harm)CQUIN

Safety Thermometer


Definitions

97.22%

Safety Thermometer (Target 95%) aaaa

94.9

4%

95.1

5% 96.3

1%

96.9

6%

97.8

2%

96.9

3%

96.5

5%

98.4

9%

91.2

5%

96.5

0%

96.1

2% 97.2

2%


Safety Thermometer Performance - New Harm Free

Safety Thermometer - (New Harm Free) Target





The Trust as a whole has been revalidated by King’s College, London, as a ‘Venous Thromboembolism (VTE) prevention’ exemplar site. The VTE Prevention Exemplar Centres Network remains central for the continued success of the National VTE Prevention Programme as there is collaboration to reduce avoidable harm and improve outcomes for patients. The VTE Exemplar process focuses on 4 areas central to VTE prevention policy:

• Risk assessment• Thromboprophylaxis• Root cause analysis• Patient information.

The Trust became a VTE Exemplar Site in 2011 and have maintained that status since, which contributes toward assurance of this process.

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

VTE Assessment


Definitions

97.28%VTE Assessments Completed (Target 97.24%) aaaa

98.1

2%

97.9

1%

98.6

5%

97.5

7%

97.6

0%

97.4

3%

97.4

7%

97.5

1%

97.7

1%

97.4

1%

97.4

2%

97.2

8%

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

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

VTE Assessment Performance

VTE Assessment Completeness VTE Assess Target





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


MRSA screening across the Trust (both weekly and admission) continues to remain high at 97%; this continued improvement helps identify patients who require isolation and treatment protecting both the patient and others from invasive infection and BSI.

0MRSA

aaaa

0MRSA

aaaa

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

MRSA Weekly Screening Compliance Across Trust






Benchmarked figures will always be 1 month in arrears

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

Clostridium Difficile

C Diff Incidents

Definitions

C Diff Incidents VS Prev Years C Diff Benchmarking


To date 26 cases of Hospital Acquired infection (April 17-March 18) to date 16th October 2017, trajectory set by NHSi for the year is no more than 53 cases. In the previous year the trust reported 22 cases and this time last year 12 cases were recorded. Following review from CCG IP&C Lead we have had 6 of these cases deemed non trajectory as all measures were taken in line with national and local policies.

As numbers hare significantly higher than last year at this time and x2 Periods of increased incidence (PIIs) have been identified on Stanhoe and Windsor Wards the CCG IP&C and

Quality Leads have undertaken a visit looking at these two areas, a full report has been received and current actions taken around deep cleaning and improvements in IP&C

practices are in line with expectations. A visit from IP&C Lead NHSi (East and Midlands) Dr Debra Adams is planned on 16th October 2017.

5C Diff (All cases)

rrrr

22CDIFF (All cases) aaaa





Gram Negative BSI

Definitions


In response to Lord O’Neill’s challenge to strengthen Infection Prevention and Control (IPC), the Secretary of State for Health has launched an important ambition to reduce Gram-negative BSIs by 50% by 2021. It is this can only achieve this by working together across the NHS and by starting to take action now.

One of our first priorities must be addressing Escherichia coli BSIs, which represent 55% of all Gram-negative BSIs. Latest data from Public Health England show a large variation in infection rates across clinical commissioning groups (CCGs). E. coli BSIs have increased by a fifth in the last five years and the trend is worryingly continuing upwards. This is an important patient safety issue. Furthermore, preventing BSIs should have a major impact on reducing the need to prescribe antimicrobials, which is a key way of reducing the rise in antibiotic resistance”.

The IP&C team are currently working with CCG colleagues to identify causes of BSI both Community and Hospital Acquired. Although there are no official reduction targets set this year a quality premium for the CCG is set for a 10% reduction – April 2017 – March 2018.

Graphs opposite illustrate E coli and other Gram negative BSI :




0

5

10

15

20

25

E.coli Bacteraemia (Hospital & Community Apportioned Cases)

HAI CAI

0

1

2

3

4

5

6

7Klebsiella Bacteraemia (Hospital & Community Apportioned Cases)

HAI CAI

0

0.5

1

1.5

2

2.5

Psuedomonas Bacteraemia (Hospital & Community Apportioned Cases)

HAI CAI


IPC Dashboard

Definitions


In order to ensure IP&C practice is maintained at a high standard the IP&C team undertake auditing of Hand Hygiene and cleanliness of commodes. A new Hand Hygiene policy has been launched (Oct 17) to include all staff in clinical areas required to be bare below elbows, this not only protects patient by ensuring good hand hygiene practices but raises awareness of IP&C at a time where C difficile numbers are than expected and there has been likely transmission on 2 wards.





Service line Clinical Indicators (by ward)

Definitions




Indicator Description

Fluid Charts 97% 98% 95% 91% 91% 95% 96% 89% 90% 98% 96% 97% 91% 97% 94% 96%

MUST Assessment 100% 82% 75% 89% 67% 138% 100% 50% 100% 86% 80% 100% 100% 67%

Waterlow Assessment 50% 89% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 93%

Waterlow Re-Scored 89% 100% 82% 100% 50% 69% 57% 100% 67% 100% 100% 100% 82% 100%

Has A Body Map Been Completed 100% 95% 85% 85% 67% 67% 90% 90% 80% 95% 75% 90% 100% 95% 90% 85%

Moving And Handling Assessment

Completed95% 65% 100% 95% 85% 83% 84% 90% 70% 85% 50% 45% 70% 100% 75% 95%

Falls Assessment Done 100% 100% 100% 100% 100% 100% 100% 100% 100% 71% 100% 100% 100% 100%

Falls assessment rescored weekly 89% 100% 75% 57% 17% 77% 50% 93% 20% 100% 50% 82% 91% 100%

Is a Falls Care Plan Completed? 90% 95% 100% 85% 74% 17% 84% 55% 60% 85% 50% 50% 55% 95% 35% 85%

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

Care Rounds Completed 96% 82% 99% 96% 95% 96% 52% 94% 100% 89% 97% 98% 95% 100% 90%

Bedrail Assessment if "At Risk" (on

admission)0% 85% 44% 0% 0% 92% 50% 50% 50% 100% 50% 25%

Obs Frequency documented 95% 100% 5% 15% 35% 100% 20% 15% 15% 80% 17% 15% 25% 0% 85% 65%

Serious Incidents 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Drug Administration Errors 0 3 1 2 2 4 5 1 4 1 0 2 2 1 1 4

Falls Total 3 0 1 7 4 0 4 4 5 4 1 6 4 5 2 9

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

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

C.Diff > 2 Days 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 2

Harm Free Care 90% 82% 83% 100% 92% 100% 92% 91% 91% 88% 83% 93% 94% 96% 96% 78%

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

Family And Friends Response Rate 56% 54% 38% 37% 27% 173% 27% 37% 39% 46% 27% 40% 38% 48% 60% 24%

Family And Friends Results 93% 94% 97% 91% 93% 100% 91% 74% 91% 90% 100% 98% 94% 84% 98% 97%

% Of Active Mentors 63% 75% 86% 88% 100% 80% 80% 50% N/A N/A 67% 38% 67% 80% 22% 50% 17%

Fill Rate Registered 96% 93% 91% 92% 86% 81% 94% 88% 94% 91% 92% 93% 93% 93% 92% 98%

Fill Rate Unregistered 107% 91% 96% 100% 89% 92% 107% 98% 97% 107% 98% 89% 104% 126% 80% 93%

CHPPD 5.6 5.9 10.6 5.9 5.8 27.8 9.8 5.7 5.1 6.3 7.8 5.2 5.6 8.1 7.0 5.7

Appraisals 71% 89% 95% 80% 76% 90% 96% 95% 75% 91% 96% 94% 97% 58% 87% 95%

Sickness 9% 12% 5% 2% 6% 4% 1% 8% 8% 10% 3% 4% 4% 7% 11% 5%

Vacancies 20% 13% 14% 16% 20% 8% 28% 21% 41% 8% 18% 19% 22% 19% 4% 15%

DenPati

ent

Safe

tyPati

ent

Experi

ence

Eff

ect

iveness

Sta

ff

Experi

ence

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

The Nursing Indicators have now been fully revised and all patient safety indicators from audit of documentation are now RAG rated. The Chief Nurse and Deputy Chief nurse have met with the Matrons and ACNs to ensure that all Ward Managers fully understand the audit process. All Ward Managers are meeting monthly with the Chief Nurse to explain the specific actions they are taking to improve or maintain performance e.g improvement in the documentation of the frequency of observation.

To ensure validity of the EWS audit the responsibility of this has now been transferred to the Critical Care Outreach team and will be reported for month 7.



Maternity Clinical Performance & Governance Scorecard 2017-18

Please note that the Paediatric Dashboard currently shows data 2 months in arrears.Definitions




Activity Activity in September has been lower than expected however this is because we had a significant amount due at the end of September that subsequently delivered in October.There were 8 homebirths due in September but only 4 delivered (which makes 1.5%) and the remaining would deliver in October.

ModeSeptember saw excellent numbers of deliveries on Waterlily which has had an impact on the reduction in our caesarean section rate. However the electives continue to be static in relation to other months and the reduction is seen in the emergencies. The induction is also slightly lower than August but is relatively static. The induction rate continues to be higher than our current benchmark, however following the introduction of the GROW programme this is in line with the national picture.

Activity: Antenatal and Postnatal CareThe number of bookings has increased this month and also the number of women being seen within 12+6 weeks has also improved.Readmissions cases are all being reviewed.Following extensive evaluation of breastfeeding data collection and BadgerNet it is clear that the issue prior was that the statics did not support the breaking down of areas e.g., WaterLily and Castleacre. On review we have now collated the stats into initiation, discharge home regardless of location within the unit and feeding on discharge to the health visitor. This has enabled us to have accurate statistics and therefore improved the position across the service. There is still work to be done and this is being taken forward by the breastfeeding midwife and senior midwifery manager.

GovernanceThe service has recently promoted the use of datix and re-launched the trigger lists, which has been received positively and this is reflected in the increase of incidents reported.No SI’s have been declared in September and the unit did not close.

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

Apr

May

Jun

Jul

Aug

Sep

Women Delivered Total no. o f women giving birth at QEH Local M onitoring Birth Register 182 199 191 218 194 191Babies Born Total no. o f babies born at QEH Local M onitoring Birth Register 185 202 193 223 193 193Live Births Total no. o f live babies born at QEH Local M onitoring 185 201 193 223 193 193

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

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

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

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

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

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

% Normal B irths Spontaneous vaginal births Benchmark Vs Nat Rate 2013/14 = 60.9% > 63% Between < 52% Birth Register 67.0% 69.6% 59.4% 63.2% 63.4% 65.8%% Instrumental Deliveries Combined rate: Forceps + Ventouse Benchmark Vs Nat Rate 2013/15 = 12.9% 5% - 12% Between <5% or >20% Birth Register 10.7% 7.7% 10.3% 6.8% 10.3% 9.8%% Vaginal Breech Births 1.0% 0.0% 1.0% 0.9% 1.0% 1.0%

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

% Total CS Total CS performed: Elective +Emergency Benchmark Vs Nat Rate 2013/14 = 26.2 % <= 25% Between >= 28% Birth Register 21.3% 22.7% 28.9% 30.0% 27.8% 24.4%% Induction Rates Women who have their labour induced (denominator = to tal women minus ElSCS) <18% Between >24% Birth Register 25.7% 31.8% 29.2% 30.3% 29.1% 27.7%

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

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

No. o f women seen on DAU @ QEH Local monitoring DAU 347 396 389 445 422 369Closure of DAU - hours @ Q EH Local monitoring DAU 24 24 0 0 0 0

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

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

No of SUIs Local monitoring 0 >=1 Risk & DS 1 0 0 0 1 0Total number o f reported clinical incidents Local monitoring Datix 39 39 47 52 51 87

Total no. o f adverse staffing incidents reported Local monitoring Datix 1 2 1 42 8 6No. times CDS closed Local monitoring 0 1 >=2 DS 0 0 1 0 0 0

Total hours CDS closed Local monitoring DS 0 0 8 0 0 0Suspension of HBS Local monitoring 0 1 >=2 DS 0 0 0 0 0 0Suspension of HBS Local monitoring 0 1 >=2 DS 0 0 0 0 0 0

No Benchmark

No Benchmark

ACTIV

ITY

: A

/N &

P/N

Care

No Benchmark

No Benchmark

No Benchmark

No Benchmark

Operational Targets

GO

VERN

AN

CE

No Benchmark

ACTIV

ITY

: Bir

th S

tati

stic

sM

OD

ENo Target

No Target

No Target

No Benchmark

No Benchmark

Risk M anagement No Benchmark

No Benchmark

No Benchmark

No Benchmark

Day Assessment Unit


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

Definitions Please note that the Maternity Dashboard currently shows data 2 months in arrears.




Maternal & Perinatal StatisticsPPH rates have improved this month and the tear rate has also remained low.In September there was a huge improvement with only 1 avoidable readmission that has been reviewed. The 3 readmissions of women are currently still being reviewed to identify any lessons to be learnt.

WorkforceA huge amount of training in relation to the definition of 1:1 care in labour has now shown an improvement, which represents staff’s perception. Due to annual leave and sickness the on call midwife was called in on 6 occasions in the month.

Patient FeedbackAgain the service has received a high number of compliments.

There have been 4 complaints received that relate to:Theatres - concerns around readmissionCDS & Castleacre both relate to poor communication and staff attitude Appleton Unit – Patient raised concerns regarding loss of baby

Following the introduction of the electronic monitoring of FFT we now see the huge improvement in response rates. The team are still working on the denominator for the postnatal section, a meeting is planned for us to discuss how we can ensure that the data is accurate.However the number of women likely to recommend the service is over 98% across all areas.

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

Apr

May

Jun

Jul

Aug

Sep

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

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

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

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

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

1:1 C are M LB U 1:1 care in labour achieved on M LBU Local monitoring >=95% 90-94 <= 89% M LBU 88.0% 96.0% 93.0% 95.0% 100.0% 100.0%1:1 C are C D S 1:1 care in labour achieved on CDS Local monitoring >=95% 90-94 <= 89% DS 97.0% 97.0% 93.0% 93.0% 87.0% 98.0%

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

Compliments Total M idwifery Compliments received in month Local monitoring PALS Team 1 16 4 33 33 8Complaints Total M idwifery Complaints received in month Local monitoring PALS Team 0 2 3 2 4 4

Response Rate Antenatal Patient Experience Team >= 15% < 15% Patient Experience Team

Likely to recommend Antenatal Patient Experience Team >= 95% <95% Patient Experience Team 97.30% 96.43% 97.37% 98.49% 98.35% 98.35%Response Rate Birth / Labour Patient Experience Team >= 15% < 15% Patient Experience Team 16.76% 18.08% 13.56% 16.76% 17.20% 22.63%

Likely to recommend Birth / Labour Patient Experience Team >= 95% <95% Patient Experience Team 96.67% 100.00% 100.00% 96.67% 93.75% 100.00%Response Rate Postnatal Castleacre Ward Patient Experience Team >= 15% < 15% Patient Experience Team 47.55% 55.90% 60.78% 59.12% 54.04% 60.17%

Likely to recommend Postnatal Castleacre Ward Patient Experience Team >= 95% <95% Patient Experience Team 92.65% 98.89% 94.62% 97.20% 97.87% 98.59%Response Rate Community Postnatal Patient Experience Team >= 15% < 15% Patient Experience Team

Likely to recommend Community Postnatal Patient Experience Team >= 95% <95% Patient Experience Team 100.00% 100.00% 100.00% 100.00% 96.77% 100.00%

PA

TIE

NT F

EED

BA

CK

No Benchmark

No Benchmark

No Benchmark

Local monitoring of poor

outcomes and factors that may

have an impact on women's

future health. Includes data for

the M aternity Safety

Thermometer: Post partum

Haemorrhage & 3rd and 4th

Degree perineal tears.

Work

forc

e

No Benchmark

NICU Admissions Castle acre

Mate

rnal &

Peri

nata

l Sta

tist

ics

No Benchmark


Paediatric Clinical Performance & Governance Scorecard 2017-18

Definitions Please note that the Paediatric Dashboard currently shows data 2 months in arrears.




Activity PAU attendances returned to predicted figures. There continues to be an increase in times that middle grade staffing levels were not met due to vacancies on the rota. Only 8 children were not seen by a senior clinician within 4 hours, due to middle grade vacancies and covering the assessment area and the ward. 95.5% of all children in September were assessed by nursing staff within 15 minutes of arrival.

WorkforceThere were 8 episodes when escalation beds were opened to accommodate elective surgical & medical admissions, due to the opening of the beds staffing levels were not met each time. One night shift covered by 1 registered paediatric nurse, 1 x supernumerary paediatric nurse and 2 very experienced adult nurses which unfortunately does meet RCN guidelines.

Governance No SI’s declared in September, only one delayed discharge as Tier 4 bed was required

Patient Feedback No complaints received in September and 8 compliments. Response rate for FFT was an increase to 28% and 98.37% would recommend our service. FFT collection will be electronic in the near future.

Descriptor Measurement Green Red Data Source Apr

May

Jun

Jul

Aug

Sep

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

No of times PAU staffing standards not

met

Middle grade medical staff not allocated / available

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

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

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

9

(5.7%)

13

(6.7%)

4

(2.5%)

6

(4.0%)

0

(0.0%)

7

(4.5%)

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

(2.0%)

0

(0.0%)

10

(6.5%)

7

(5.7%)

8

(5.2%)

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

PAU over 6 hrs. < 0 >1 PAU Data

6

(3.8%)

12

(6.2%)

9

(5.7%)

2

(1.3%)

6

(4.9%)

7

(4.5%)

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

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

49

(31.2%)

46

(23.7%)

49

(30.8%)

59

(38.3%)

31

(25.4%)

48

(31.2%)

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

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

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

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

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

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

Medical InvestigationsNo. of children attending for diagnostic

investigations. Stay on ward was greater than 4 hrs.

Average No. of Patients from

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

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

Stay on ward was greater than 4hrs

Average No. of Patients from

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

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

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

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

No. of times recommended staffing level

not met

When no of RSCN / RN child does not adhere to

RCN recommendation

Meeting the children to

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

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

Number of babies under 28 days of age

admitted to rudham

No of admissions that may have been avoided had

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

No. of patients medically fit who have delayed

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

No. of days medically fit patients who delayed

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

Other Clinical Incidents All other on ward incidentsAll incidents to exclude

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

Patient Feedback Compliments Total Rudham Compliments

received in monthPALS Team 8 5 6 11 8 14

Patient Feedback ComplaintsTotal Rudham complaints

received in monthPALS Team 2 1 0 1 0 0

Patient Feedback Response Rate Rudham Ward >= 15% < 15%Patient

Experience Team29.9% 25.6% 20.10% 25.60% 17.50% 28.00%

Patient Feedback Likely to recommend Rudham Ward >= 95% < 94%Patient

Experience Team98.5% 97.5% 96.51% 94.87% 98.55% 98.37%

Act

ivit

y

Local monitoring

Local monitoring

Wo

rkfo

rce

Delayed Discharges

Cli

nic

al In

dic

ato

rsFri

en

ds

& F

am

ily


NICU Clinical Performance & Governance Scorecard 2017-18

Definitions Please note that the NICU Dashboard currently shows data 2 months in arrears.




Activity NICU accepted 3 in utero transfers, but CDS were unable to accept due to workload.

Descriptor Measurement Green RedData

Source Apr

May

Jun

Jul

Aug

Sep

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

Average for 2016 (no breakdown

collected for full year) Available from

March 2018

No Parameter available until March

2018 as data not available

2016/2017 to gain average

No Parameter available until

March 2018 as data not available


30 23 39 29 29 30

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

required



March 2018







0 0 1 0 0 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

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

required



March 2018







6 4 2 9 7 8

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

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

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

25.4%

35

17.4%

51

26.4%

47 /

21%

50 /

25.8%37

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

16.7%

19

9.4%

34

17.6%

31 /

13.9%

32 /

16.5%31

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

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

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

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

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

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

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

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

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

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

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

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

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

Number of babies receiving care from the

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

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

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

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

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

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

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

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

Number of times BAPM staffing levels not

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

NICU /

Badgernet0 14 13 5 13 0

NIC

U / B

ad

gern

et

NIC

U

Cot occupancy

Unit escalation (in hours)

Act

ivit

y


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

Definitions Please note that the NICU Dashboard currently shows data 2 months in arrears.




Mortality In September there was one baby with a Pneumothorax (treated conservatively). 2 Infants had positive Blood Cultures x1 staphylococcus epidermis? Contaminant x1 Enterococcus faecalis triggering two of these metrics.

Governance There were10 reported clinical incidents

Clinical Activity 4/8 infants met the criteria for receiving breast milk at discharge, 4 were discharged bottle feeding due to maternal choice.

Patient FeedbackIn September there was 1 complaint, 4 compliments and a 95% recommendation rate from FFT. The FFT response rate was 131% and work is in progress to start recording this electronically and hopefully giving us a continually consistent response rate.

Descriptor Measurement Green Red Data Source Apr

May

Jun

Jul

Aug

Sep

HypoglycaemiaInternal Guideance and standards not

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

Pre -Term Hypothermia less

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

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

Infection (Positive culture

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

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

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

Total No of reported

incidentsIncidents each month Internal Internal 16 17 14 11 17 10

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

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

Internal Internal Internal Internal Internal4 out

of 4

1 out

of 3

2 out of

2

0 out

of 1

0 out

of 1

4 out

of 8

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

Parents seen within 24hrs of

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

Delayed Discharge No of babies delayed

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

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

Patient Experience PALS / Audit 16 8 5 4 13 4

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

Patient Experience PALS / Audit 0 0 0 0 0 1

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

Recommend

Compliments

Go

vern

an

ce

Risk Management

Response RateFFT

Complaints

DATIX

Clin

ical A

ctiv

ity Less than 33 weeks babies receiving

breast milk on discharge (32+6

DAYS)

NICU Badgernet

Mo

rtality

Unexpected Neonatal morbidity -


The response rate exceeded the target of 30% (30.03% - this equates to 2 cards above the target) and the likelihood to recommend score for the month remains above the 95% target for the month and year to date.

The benchmark figures for the region place the Trust 10/13 based on August’s figures (the same as July). The reasons that patients cited as to why they were not able to recommend the care they had received were wide ranging but can be grouped into these areas - staff attitude (both our staff and agency), food, noise at night, lack of care, cleanliness, communication between staff and patients / relatives and call bell response.

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

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

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

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


Definitions

95.35%

% Recommend the service

1.22%% Do not recommend the service

30.03%

Response Rate (Target 30%) aaaa

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

Ward / Area Performance - Inpatient & Day Cases Benchmarking - Inpatient & Day Cases0.6

6%

0.7

1%

1.2

4%

0.9

2%

0.6

8%

1.0

2%

1.0

1%

0.4

8%

1.0

3%

1.2

1%

0.8

9%

1.2

2%

95.4

0%

95.6

4%

95.7

7%

96.1

9%

96.1

6%

95.6

1%

96.0

0%

96.1

2%

95.4

7%

94.7

5%

95.7

5%

95.3

5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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

Monthly % Recommend / Not Recommend - Inpatients & Day Cases

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

34.6

4%

31.3

4%

32.7

0%

29.1

4%

32.2

7%

34.3

5%

32.7

5%

33.5

9%

34.5

8%

32.6

3%

29.4

4%

30.0

3%

0%

5%

10%

15%

20%

25%

30%

35%

40%


Monthly Response Rates for Inpatients & Day Cases

FFT Response Rate (IP & DC)




RQW 99.02% 0.00% 42.96%

RGR 98.40% 0.44% 25.22%

RGM 97.46% 0.28% 44.04%

RGN 97.42% 0.47% 30.82%

RDE 97.38% 0.67% 40.88%

RM1 97.11% 1.37% 14.39%

RGQ 96.97% 0.85% 36.94%

RGP 96.89% 0.84% 24.70%

RGT 96.82% 1.09% 8.85%

RCX 95.75% 0.89% 29.44%

RDD 95.25% 1.36% 37.76%

RAJ 92.96% 3.97% 29.46%

RQ8 91.16% 5.01% 21.52%MID ESSEX HOSPITAL SERVICES NHS TRUST

SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

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

CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

JAMES PAGET UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

Org Code Organisation Name (Ranked by % Recommended)

IPSWICH HOSPITAL NHS TRUST

NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST

NORTH WEST ANGLIA NHS FOUNDATION TRUST

PAPWORTH HOSPITAL NHS FOUNDATION TRUST

%

Recommended

% Response

Rate

% Not

Recommended

WEST SUFFOLK NHS FOUNDATION TRUST

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST


The Emergency Department has again dipped just below the target of 95% (93.97%) and a slight increase in the percentage not recommending the service to 2.14%.

The response rate is still concerning, although it has risen this month to 16.61%, which is 4.5% below the target. New ways to collect FFT have not yet been introduced.

Overall the service benchmarks at 5/12 based on August’s figures for likelihood to recommend (this is down from 1st in July). There were only 11 patients unlikely to recommend the care they received and the reasons included waiting times, staff attitude, lack of entertainment for teenagers, care of mental health patients and being given nothing but pain relief and sent home.

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

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

Definitions

93.97%

% Recommend the service

2.14%% Do not recommend the service

24.4

0%

23.0

5%

21.8

8%

23.2

8%

26.7

1%

20.2

4%

21.7

0%

19.0

2%

20.6

6%

14.1

9%

13.5

8%

16.6

1%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%


Friends and Family Test - Monthly Response Rates for AE

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

16.61%

Response Rate(Target 20%)

rrrr


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

Benchmarking - A & E

3.6

3%

1.8

1%

2.5

4%

1.7

6%

6.2

0%

5.1

8%

4.3

2%

5.0

1%

2.4

7%

0.8

8%

1.2

9%

2.1

4%

91.9

7%

93.9

6%

92.0

8%

94.0

9%

90.7

0%

90.9

7%

89.9

7%

89.2

0%

94.1

3%

95.3

9%

94.4

1%

93.9

7%

0%

20%

40%

60%

80%

100%


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 96.45% 2.22% 26.43%

RGN 95.52% 0.56% 5.97%

RGT 94.83% 2.31% 21.93%

RGR 94.72% 1.89% 26.78%

RCX 94.41% 1.29% 13.58%

RGP 91.94% 2.38% 12.72%

RM1 91.11% 6.11% 2.39%

RQ8 87.73% 7.40% 20.23%

RAJ 87.44% 6.67% 16.91%

RDE 87.26% 7.37% 23.42%

RDD 84.13% 7.48% 21.79%

RGQ 77.18% 12.03% 14.26%

Organisation Name (Ranked by % Recommended)








MID ESSEX HOSPITAL SERVICES NHS TRUST






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 an increase in response rate (birth) to 22.63% (15% target) and had 100% level of recommendation for birth.

All areas achieved the 95% likelihood to recommend target.

The service benchmarked at 11h out of 12 based on the labour rating in August across the region for likelihood to recommend (down from 9th in July). This is affected by the low number of responses generally for maternity. There were only 890 cards collected across the region in the birth category, only 3 hospitals collected over 100 cards in a month, only 4 hospitals achieved over a 30% response rate. This results in a very fluid likelihood to recommend value.

1.2

0%

0.4

1%

0.4

1%

98.4

9%

98.3

5%

98.3

5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul Aug Sep

FFT - % Recommend/ Not Recommend (Antenatal)

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

3.3

3%

3.1

3%

96.6

7%

93.7

5%

100.0

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul Aug Sep

FFT - % Recommend/ Not Recommend (Labour)

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

97.2

0%

97.8

7%

98.5

9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul Aug Sep

FFT - % Recommend/ Not Recommend (Postnatal Ward)

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

3.2

3%

100.0

0%

96.7

7%

100.0

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul Aug Sep

FFT - % Recommend/ Not Recommend (Community PostNatal)

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

Response Rate - Labour

16.7

6%

17.2

0%

22.6

3%

0%

5%

10%

15%

20%

25%

30%

Jul Aug Sep

FFT - Response Rate (Labour)

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

Benchmarking - Maternity Services





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)

0.7

3%

0.9

3%

0.2

4%

0.9

4%

0.4

7%

0.9

8%

1.0

3%

0.2

9%

1.1

8%

1.0

2%

0.9

3%

0.7

6%

95.9

9%

96.7

3%

96.7

9%

97.4

1%

97.5

5%

96.6

7%

96.4

1%

97.0

3%

96.2

9%

95.5

0%

97.1

1%

96.7

2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


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

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

The level of recommendation within Outpatient services remains high at 96.72% and the Trust benchmarked at 1/13 regionally in August in relation to likelihood to recommend (a rise from 6th the previous month). There were 10 patients unlikely to recommend and their concerns were across many services but revolved around waiting times across numerous clinics, staff attitude and 2 patients being asked to attend pre-assessment twice for the same operation. The partial booking system in some clinics, notably ENT, is still causing delays and concerns for patients – this topic is due to be discussed at the PandA meeting.

Across the hospital the main areas for concern remain:• Staff Attitude• Waiting times, especially in Outpatients

Benchmarking - Outpatient Services




Org Code % Recommended% Not

Recommended

RCX 97.11% 0.93%

RGQ 96.85% 1.07%

RGR 96.50% 0.93%

RDE 96.18% 0.36%

RGN 95.75% 0.88%

RM1 95.63% 1.70%

RGP 95.39% 0.96%

RGM 95.35% 2.33%

RQW 95.01% 3.17%

RAJ 93.07% 2.47%

RGT 92.86% 2.21%

RDD 91.79% 2.94%

RQ8 89.34% 5.23%

Organisation Name (Ranked by % Recommended)







PAPWORTH HOSPITAL NHS FOUNDATION TRUST



MID ESSEX HOSPITAL SERVICES NHS TRUST






The Trust experienced two mixed sex accommodation incidents during the last month affecting four patients in total. Both of these incidents took place on the Critical Care Unit and involved patients identified as fit to transfer to a lower dependency bed but unable to do so within the allotted timeframe due to capacity issues affecting the availability of vacant ward beds. This is an improvement on the previous month but remains an issue for the Trust due to the constant pressure on bed availability.

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

Patient Experience - Mixed Sex Accommodation

Mixed Sex Accommodation Incidents


Definitions

2Incidents of Mixed Sex Accommodation rrrr

4No. of Patientsaffected rrrr

14Incidents of Mixed Sex Accommodation rrrr

29No. of Patients affected rrrr

Mixed Sex Accommodation Breaches

2

8

0

8

4

21

0

43

4

2

0

2

4

6

8


No. of Mixed Sex Accommodation Incidents

No. of Mixed sex Accommodation Incidents

4

18

0

18

9

42

0

9

68

4

0

4

8

12

16

20


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

27Current Month

7Current Month

176YTDrrrr rrrr

rrrr

Non Clinical Complaints

16YTD

rrrr

Number of complaints received

During the month of September the Trust received 34 complaints. This is four fewer than last month and one more than in September 2016, in which the Trust received 33 complaints.

Complaints received by Specialty/Key Issues Table

During September 2017, the Emergency Department had 4 complaints, General Surgery and General Medicine each had 3. The complaints regarding these areas involved the following issues:

• Staff attitude• Poor communication with patient/relatives • Acquired pressure ulcer• Care needs not met

Lessons Learned

• To ensure that doctors who undertake lumbar puncture procedures are adequately trained and supported• Reiterating the importance of line managers regularly reviewing staff performance and communication skills• When new equipment is introduced ensuring that there is a robust process for removing the old equipment, audits have been undertaken to

ensure compliance

Other Information

• At present, one complaint received in June 2017 has been re-opened.• 9 local resolution meetings were held.• One complaint was referred to the Parliamentary and Health Service Ombudsman.• 115 Travel Expense claims were processed.• Three complaint satisfaction questionnaires were returned. One complainant was happy with the outcome, stating that they were satisfied with

the response and praised the staff for the treatment they have received; whilst the other two complainants stated they were not fully satisfied by the responses received.

• An interim PALS and Complaints Manager was appointed to cover the scheduled absence of the post-holder and has commenced duties.

Four PALS surveys were completed and although some were incomplete, 100% advised that that they were extremely happy with the service they had received. Further comments were made stating ‘fast reply giving information needed.’





Actions Taken & Lessons Learned





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

Definitions

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

PALS Contacts (including Compliments)

Compliments

The Trust is required to investigate and share the response with the complainant within 30 working days. The compliance fell again this month to 51%, as nineteen breaches occurred. At present a number of complaint investigations have not yet been completed but these continue to be chased and escalated, some complaints have since been completed and closed. Med 1 and Women and Children’s Services each had 5 breaches. Patient Services had 3 breaches and Cancer Diagnostics, Surgery 2 and Med 2 each had 2.

Divisional leads have been contacted in terms of the overdue complaint responses for management plans to improve compliance.

152 compliments were received this month, which shows a decrease from 178 compliments received last month and a decrease in comparison to September 2016, in which the Trust received 171 compliments.

PALS contacts have had 368 contacts this month, compared to a figure of 414 in the previous month. This is also a decrease in comparison to September 2016, in which 398 contacts were recorded. The top subjects for this month are noted below:

General Information 61

Complaints Procedure 23

Enquiry 23

Directions within the Trust 14

Travel Expenses 14

Waiting List In-Patients 13

Department Details 12

Cancellation 11

Parking Fine 11





01/07/2017 01/08/2017 01/09/2017 2016/17

Indicators Var to prev mth Target Jul Aug Sep FYTD

National standards 01/07/2017 01/08/2017 01/09/2017 2017/18

18 Wks - Adm (adjusted) Target18 Wks - Adm Perf (adjusted) 90.00% 77.81% 78.55% 75.39% 78.34%

18 Wks - Non Adm Target18 Wks - Non Adm Perf 95.00% 88.31% 82.29% 83.19% 88.17%

18 Wks - Incomp Target18 Wks - Incomp Perf 92.00% 88.04% 87.74% 87.20% 89.82%

Cancer-2ww TargetCancer-2ww 93.00% 95.88% 96.45% NA 96.90%

Cancer-2ww (Breast Symptomatic) TargetCancer-2ww (Breast Symptomatic) 93.00% 100.00% 98.72% NA 98.01%

31 Day Diag to Treat Target31 Day Diag to Treat 96.00% 97.41% 99.21% NA 98.38%

Cancer-62 Days RTT TargetCancer-62 Days RTT 85.00% 86.49% 88.31% NA 83.10%

Cancer-31 Days Sub Treat (Surg) TargetCancer - 31 Days Subsq Treatment - Surgery 94.00% 100.00% 100.00% NA 95.83%

Cancer-31 Days Sub Treat (Drug) TargetCancer - 31 Days Subsq - Drug Treatments 98.00% 98.04% 100.00% NA 99.64%

Cancer Screening (62 Day) TargetCancer Screening (62 Day) 90.00% 100.00% 96.97% NA 99.13%

A&E 4 Hr TargetA&E 4 Hour Performance 95.00% 84.14% 89.80% 93.55% 88.84%

Amb turmaround TargetAmbulance turmaround 100.00% 25.54% 20.78% 24.09% 24.70%

Stroke - 90% of Stay on SU TargetStroke - 90% of Stay on a Stroke Unit 80.00% 75.41% 87.50% NA 82.54%

TIA - HR TIA seen & treated <24hrs TargetTIA - High Risk,Non admitted TIA treated in 24 Hrs 60.00% 63.16% 66.67% NA 75.00%

Cancelled Ops - as a % of Elective Admissions TargetCancelled Ops - as a % of Elective Admissions 0.80% 0.56% 0.55% 0.43% 0.67%

Diagnostic Over 6 Week Waiters - % of Total WL TargetDiagnostic Over 6 Week Waiters - % of Total WL 1.00% 0.73% 0.13% 0.35% 0.36%

Indicators Var to prev mth Target Jul Aug Sep FYTD

Local standards

Day Case Rate TargetDay Case Rate 82.00% 85.76% 85.87% NA 86.29%

DNA Rate TargetDNA Rate 5.00% 6.36% 6.48% 6.44% 6.40%

New to FUP Ratio TargetNew to FUP Ratio 2.3 2.6 2.8 2.6 2.7

Readm Rate (EL) TargetReadmission Rate - ElReadmission Rate - Elective 3.00% 4.34% 3.62% NA 4.34%

Readm Rate (Em) TargetReadmission Rate - EmReadmission Rate - Emergency 10.00% 15.19% 15.75% NA 15.83%

EL LOS TargetLength of stay - Elective 2.2 1.6 1.5 1.6 1.7

EM LOS TargetLength of stay - Emergency 5.0 3.6 3.9 3.9 3.7

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

De

lay

fre

e

Performance & Standards Scorecard

Op

era

tio

na

l E

ffic

ien

cy





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

84

.31

%

81

.30

%

81

.29

%

80

.03

%

76

.23

%

78

.26

%

79

.65

%

82

.90

%

75

.80

%

77

.81

%

78

.55

%

75

.39

%

83.16%80.31% 80.76%

78.53%75.89%

77.84% 79.23%82.59%

75.50%77.22% 78.46%

74.98%

60%

65%

70%

75%

80%

85%

90%

95%

100%


18 Wks Admitted Performance

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

94

.01

%

91

.94

%

90

.49

%

90

.30

%

90

.94

%

90

.43

%

91

.96

%

92

.94

%

89

.32

%

88

.31

%

82

.29

%

83

.19

%

80%

85%

90%

95%

100%


18 Wk Non- Admitted Performance

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

92

.97

%

93

.33

%

92

.97

%

92

.64

%

92

.77

%

92

.38

%

92

.01

%

92

.03

%

92

.03

%

88

.04

%

87

.74

%

87

.20

%

80%

85%

90%

95%

100%


18 Wk Incompletes Performance

18 Wks - Incomp Perf 18 Wks - Incomp Target

74.98%Admitted "Unadjusted) (Target 90%) rrrr

75.39%Admitted "Adjusted"(Target 90%) rrrr

83.19%Non-Adm (Target 95%) rrrr

87.20%Incompletes (Target 92%) rrrr





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%

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

2WW Performance

Cancer-2ww 2 WW Target

96.45%2ww (Target 93%)

aaaa

99.21%

31 Day (Target 96%)

aaaa

88.31%62 Day (Target 85%)

aaaa

90%

92%

94%

96%

98%

100%


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

98.72%2ww Breast Symptomatic (Target 93%) aaaa

96.97%62 Day Screening (Target 90%) aaaa

Site Level Breach Analysis - Latest Month





Cancer Waiting Times cont'd





Sustainability Sustainability Sustainability Sustainability

Cancer Site(Target - 85%

Compliance)

Estimated

remainder to

achieve

Estimated

remainder to

achieve ForecastSnapshot

position Trajectory Flag

Estimated

remainder to



Estimated

remainder to



Total Treated 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Treated Within 62 Days 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

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

Estimated breaches allowed 0.0 0.0 0.0 0.0

Total Treated 7.00 5.50 10.00 8.00 2.00 7.00 6.00 1.00 6.00


% Within 62 Days 100.0% 100.0% 100.0% 87.5% 100.0% 100.0% Alert 100.0% 100.0% 100.0%

Estimated breaches allowed 0.0 0.0 -1.0 0.0

Total Treated 7.00 4.00 5.00 5.00 2.00 4.00 4.50 1.00 4.50


% Within 62 Days 85.7% 100.0% 90.0% Alert 80.0% 50.0% 62.5% 66.7% 100.0% 66.7%

Estimated breaches allowed -1.5 -0.5 0.5 0.0

Total Treated 1.50 1.50 3.00 1.00 0.00 1.00 2.00 0.00 2.00



Estimated breaches allowed 1.0 -1.0 0.0 0.0

Total Treated 1.00 1.00 4.50 4.00 1.00 2.00 2.00 0.50 2.00

Treated Within 62 Days 0.00 0.00 3.50 2.00 0.50 1.00 Alert 2.00 0.00 2.00


Estimated breaches allowed -3.0 0.0 -1.0 0.0

Total Treated 6.00 5.00 11.00 8.00 1.00 8.00 8.00 0.00 8.00


% Within 62 Days 66.7% 60.0% 95.5% Alert 62.5% 100.0% 75.0% Alert 75.0% 0.0% 75.0%

Estimated breaches allowed -3.0 -1.5 -1.0 0.0

Total Treated 1.00 1.00 3.50 5.00 0.00 5.00 6.00 0.00 6.00




Total Treated 0.00 0.00 0.50 1.00 0.00 1.00 1.00 0.00 1.00



Estimated breaches allowed 0.0 0.5 -0.5 0.0

Total Treated 15.00 10.50 11.00 18.00 1.00 18.00 16.00 0.00 16.00


% Within 62 Days 96.7% 95.2% 90.9% 97.2% 100.0% 97.2% 93.8% 0.0% 93.8%


Total Treated 4.50 4.00 5.50 4.50 0.50 4.50 4.00 0.50 4.00


% Within 62 Days 77.8% 87.5% 54.5% 88.9% 100.0% 66.7% 75.0% 100.0% 75.0%

Estimated breaches allowed -2.5 1.5 1.0 0.0

Total Treated 20.00 18.50 21.00 21.00 4.00 22.00 20.00 2.00 20.00


% Within 62 Days 92.5% 97.3% 78.6% 100.0% 100.0% 90.9% 85.0% 100.0% 85.0%

Estimated breaches allowed -0.5 3.0 2.0 0.0

Total Treated 0.00 0.00 3.00 3.00 0.00 3.00 2.00 0.00 2.00


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


Total Treated 63.00 51.00 78.00 78.50 11.50 69.00 71.50 5.00 71.50




Nov-17November

Trajectory

Trust Total

Lung

Sarcoma

Skin

Upper

Gastrointestinal

Urological

Other

Lower

Gastrointestinal

Breast

Gynaecological

Haematological

Head & Neck

Oct-17October

Trajectory

Brain/Central Nervous

System

Sep-17September

Trajectory


Benchmarking data will only be updated once every quarter.

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

Definitions

Cancer Waiting Times (Benchmarking)

70%

75%

80%

85%

90%

95%

100%

QEH JPH CUH IP WS P&S N&N

2WW Wait Perf for Qtr 1 across East of England

SEEN WITHIN 14 DAYS National Target

70%

75%

80%

85%

90%

95%

100%

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

31 Day Perf for Qtr 1 across East of England

TREATED WITHIN 31 DAYS National Target

45%

55%

65%

75%

85%

95%

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

62 Day RTT Perf for Qtr 1 across East of England

TREATED WITHIN 62 DAYS National Target





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

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

Accident and Emergency

Definitions

93.55%AE Performance - Prev Mth (Target 95%) rrrr

88.84%AE Performance - YTD (Target95%) rrrr

Previous Month's KPI's

Benchmarking across NHS England Midlands & East (East)


Activity & Performance levels of the last 3 months

AE performance (Last 12 month)

89.4

0%

90.4

9%

93.0

1%

86.3

1%

90.4

9%

90.6

8%

91.3

1%

91.0

2%

83.6

4%

84.1

4%

89.8

0%

93.5

5%

75%

80%

85%

90%

95%

100%

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

In month 4 hour performance for September was 93.55% compared to 89.90% in August

• Trajectory was exceeded for September (trajectory was at 91.05%) • Attendances were 5,257 for September (down from 5698 in August)• Average attendances for September were 175 down slightly to those in August• Attendances across the month are down 1% compared to 2016• The biggest percentage of breeches again related to no flow/limited bed capacity• The closure of Obs bay to support RATing has impacted on number of patients admitted particularly overnight when no transport is available for discharge • Estates, Pathway and recruitment work on Primary Care Streaming continues






Potential fines per case in

£66,000.00

£388,000.00

£179,400.00

£0.00

£0.000 - 15 Min

2017/18 YTD value of breaches

30 - 60 Min

15 - 30 Min

Over 2 Hr

1 - 2 Hr

Ambulance Handovers


Definitions

24.09%

% of handovers within 15 minutes

24.70%

% of handovers within 15 minutes rrrrrrrr

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

• % ambulances with clinical handover <15 mins =24.09% (August 20.78%)• % ambulances with clinical handover <30 mins = 90.3% (August 88.1%)• % ambulances with clinical handover <60 mins = 98.0% (August 96.5%)• Concerns still existing over ‘batching’ of vehicles which leads to a high number of vehicle attendances within a short episode of time• Fit to Sit is being encouraged with patients arriving by ambulance. Wheelchair issue currently being reviewed• New arrival/handover front screen is being introduced 18th October. This will need close monitoring as individual CAD specific PIN numbers are now required to complete the handover process• Training on AEC pathways as part of Majors2Majors initiative is being arranged with EEAST staff

0

200

400

600

800

1000

1200

1400

1600

1800


Nu

mb

er

of

Pa

tie

nts

Monthly Ambulance Handover Times

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

2422

6034

897

388

66

2017/18 YTD Ambulance Handover times

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

0%

10%

20%

30%

40%

50%

60%

70%

80%


Nu

mb

er

of

Pa

tie

nts

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

0 - 15 Minutes 15-30 Min





Improvement in overall SSNAP score from C to B reflects newly agreed Stroke Referral Pathway from A&E, resulting in the right patients on the right ward more of the time, and subsequent improvement in metrics.

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

Stroke Performance


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%

87.50%

Monthly Performance %

E

D

Aug-17

A

B

CSSNAP Level

YTD Performance %

B C

YTD SSNAP Level

80.43%

YTD 2017/2018SSNAP Target Levels


3 out of 4 TIA targets achieved consistently, including both High Risk targets. The 4th target (Low Risk TIA treated within 7 days of onset), is the least under QEH control, and is dependent on the patient presenting and reporting to the GP, and then referred to QEH by the GP.

There is increased demand this year for TIA outpatient services (~+25%), and an additional clinic room will be required in the medium term to manage this. The challenge will be to locate this room in the vicinity of West Raynham, to enable the consultants to cover both services concurrently as they currently do.

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

Transient Ischaemic Attack (TIA) Performance


Definitions





The Trust has achieved the Diagnostic 6 week target in September and is inside the 1% threshold.

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

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


Definitions

0.35%(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

2.6 2.62.8 2.8 2.7 2.8 2.8 2.8 2.7 2.6

2.82.6

0.0

1.0

2.0

3.0


New to Follow Up ratio against local target

New to FUP Ratio target

2.6

Trust Level New to Review Rate

(Target 2.3) rrrr






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

Within the Trust the majority of specialties have a polling range to 6 weeks, this is to prevent patients being cancelled when clinical staff book leave. Currently we have a high ASI rate and relatively low cancelled clinic rate.

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

ASI's (Appointment Slot Issues)

Definitions





28/09 05/10 12/10 19/10

DER 588 617 649 630

CAR 499 505 517 509

NEU 473 456 462 440

URO 384 383 391 393

ORT 431 397 387 384

RES 205 205 209 215

PAE 179 182 194 195

ENT 229 242 234 181

END 147 128 137 139

RHE 115 113 120 109

PC 76 82 91 96

UGI 61 59 63 69

OPH 64 55 58 63

NEP 47 49 45 43

GER 29 32 31 33

2WW 11 2 21 21

GYN 19 15 10 4

VAS 1 1 3 2

SUR 8 3 3 1

ASI's Last 4 Weeks



DNA :Ratio between the total number of new and follow up appointment DNAs against the total number of Attendances and DNAs (Did not attend)The DNA chart above now excludes Physiotherapy, Radiology, or G.U.M specialties.

DNA rate

Definitions

6.61%5.92%

6.58% 6.50% 6.31% 6.05% 6.02% 6.35% 6.72% 6.36% 6.48% 6.44%

0.0%

2.0%

4.0%

6.0%

8.0%


DNA (Did not attend appointments) rate against local target

DNA Rate DNA Rate Target

6.44%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

1.7 1.7 1.82.2

1.81.5

1.8 1.72.2

1.6 1.5 1.6

0.0%

2.0%

4.0%

6.0%

0.0

0.5

1.0

1.5

2.0

2.5


Trust Level - Average LOS - Elective

Length of stay - Elective target Readmission Rate - El

1.6

Average LOS

Elective Admission (Target 2.2) aaaa

3.62%

Re-adm following Elective

Admission (Target 3%) rrrr

Definitions

4.4

4%

3.9

4%

4.2

0%

4.3

1%

4.3

2%

5.1

9%

4.1

7%

4.4

0%

4.8

4%

4.5

0%

4.3

4%

3.6

2%

0%

1%

2%

3%

4%

5%

6%


Trust Level - Elective Re-admission Rate Performance Against Target

Readmission Rate - El Readm Rate (EL) Target






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

Re-admissions is currently reported 1 month in arrears

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

Emergency Admissions - Average Length of Stay & Re-admissions

3.6 3.7 3.8 3.7 3.7 3.6 3.6 3.4 3.5 3.6 3.9 3.9

0.0%

5.0%

10.0%

15.0%

20.0%

0.0

2.0

4.0

6.0


Trust Level - Average LOS - Emergency

Length of stay - Emergency target Readmission Rate - Em

3.9

Average LOS Emergency Admission (Target 5.0) aaaa

15.75%

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

Definitions

13

.30

%

14

.05

%

13

.35

%

15

.40

%

15

.98

%

15

.53

%

15

.78

%

17

.08

%

15

.73

%

15

.51

%

15

.19

%

15

.75

%

0%

5%

10%

15%

20%


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 £21,712.50 £21,712.50 £21,712.50

2c Empiric Review of antibiotic prescriptions

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

2d Reduction in Antibiotic Consumption per 1,000

admissions£86,850.00

4 Improving services for

people presenting

with Mental Health

needs in A&E

Frequent Attenders (more than 10 occurrences

in 16/17) - identify cohort of patients who

would benefit from mental health &

psychology interventions AC

HIE

VED

10

0%

£34,739.80 £138,959.20 £34,739.80 £138,959.20

6 Offering Advice &

Guidance

Improvement of A&E for Rhuematology &

Neurology / Implement Quality standard /

propose additional services in Q4 to take

forward next year AC

HIE

VED

10

0%

£86,849.50 £86,849.50 £86,849.50 £86,849.50

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

such services and make ALL of their First O/P

Appointments slots available on NHS e-referral

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

trajectory

2. a trajectory to reduce Appointment Slot

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

Q4A

CH

IEV

ED

10

0%

£86,849.50 £86,849.50 £86,849.50 £86,849.50

8 Supporting Proative

and Safe Discharge

2.5% point increase discharge to usual place of

residence: across Q3 and Q4 2017/18 OR an

increase to 47.5% across Q3 and 4 2017/18

AC

HIE

VED

10

0%

£52,109.70 £138,959.20 £17,369.90 £138,959.20

1 Medicines

Optimisation

The CQUIN aims to support the procedural and

cultural changes required fully to optimise use

of medicines commissioned by specialised

services. AC

HIE

VED

10

0%

£31,560.00 £13,525.00 £22,542.00 £40,577.00

2 Dental Dashboard Provider is required to submit a fully populated

Dental Quality Dashboard as per the embedded

format (see actual CQUIN) in respect of the

dental specialties they provide AC

HIE

VED

10

0%

£11,089.75 £11,089.75 £11,089.75 £11,089.75

3 Breast Screening STILL WITH NHSE TO SET CQUIN FOR Q3 & Q4 TBC TBC TBC TBC

4 Armed Forces Embedding the Armed Forces Covenant to

support improved health outcomes for the

Armed Forces Community

AC

HIE

VED

10

0%

£6,301.50 £6,301.50 £12,603.00

CQUIN Description

H&W

SEPSIS

N/A

N/A

AC

HIE

VED

10

0%

ACUTE CONTRACT

Update only no Financial

value

N/A

NHSE SPECIALIST CONTRACT


Indicators Var to prev mth Target Jul Aug SepRolling

12 mths

Staff Sickness & Turnover 01/07/2017 01/08/2017 01/09/2017

Sickness Absence Rate (Target)Sickness Absence Rate 3.50% 5.17% 5.06% 4.80% 4.99%

Staff Turnover Rate Complete Trust (Target)Staff Turnover Rate Complete Trust 10.00% 11.45% 11.16% 11.68% 11.26%

Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) (Target)Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) 10.00% 7.74% 6.47% 8.80% 10.54%

Staff Turnover Rate Registered Nursing & Midwifery (Target)Staff Turnover Rate Registered Nursing & Midwifery 10.00% 14.83% 14.70% 15.41% 14.22%

Staff Turnover Rate Allied Health Professionals (Target)Staff Turnover Rate Allied Health Professionals 10.00% 19.56% 17.83% 15.48% 18.04%

Appraisals

Appraisal Completeness excluding bank staff (Target)Appraisal Completeness excluding bank staff 90.00% 85.31% 82.90% 82.26% 84.52%

Vacancies

Medical & Dental Vacancies (as % of Medical Posts) (Target)Medical & Dental Vacancies (as % of Medical Posts) 5.00% 20.15% 21.95% 21.25% 19.37%

Registered Nurses & Midwives Vacancies (as % of Nurse Posts) (Target)Registered Nurses & Midwives Vacancies (as % of Nurse Posts) 6.00% 14.45% 13.88% 14.39% 12.07%

Allied Health Professional Vacancies (as % of AHP Posts) (Target)Allied Health Professional Vacancies (as % of AHP Posts) 6.00% 11.26% 11.68% 5.24% 10.26%

Contracted staff in Post (WTE) 2760 2757 2765 2769

Temporary Staff in Post (WTE) 314 358 345 308

Mandatory Training

Conflict Resolution Training (Target)Conflict Resolution Training 95.00% 83.42% 82.65% 82.76% 83.14%

Equality and Diversity Training (Target)Equality and Diversity Training 95.00% 67.32% 70.66% 73.73% 77.68%

Fire Training (Target)Fire Training 95.00% 75.49% 70.83% 73.52% 78.46%

Health & Safety Training (Target)Health & Safety Training 95.00% 92.19% 89.91% 89.89% 91.51%

Infection Control Training (Target)Infection Control Training 95.00% 78.61% 74.93% 75.92% 80.29%

Information Governance Training (Target)Information Governance Training 95.00% 88.78% 86.78% 86.00% 89.20%

Manual Handling Training (Target)Manual Handling Training 95.00% 82.94% 82.36% 81.85% 84.25%

Resuscitation Training (Target)Resuscitation Training 95.00% 82.97% 81.22% 78.46% 82.40%

Risk Management Training (Target)Risk Management Training (Level 2 only) 90.00% 98.03% 70.13% 72.33% 93.87%

Safeguarding Adults Training (Target)Safeguarding Adults Training 95.00% 94.23% 92.01% 90.24% 94.30%

Safeguarding Children Training (Target)Safeguarding Children Training 95.00% 92.61% 90.26% 89.86% 91.67%

Slips, Trips & Falls Training (Target)Slips, Trips & Falls Training 90.00% 94.25% 90.80% 89.34% 93.79%

VTE Training (Target)VTE Training 90.00% 77.24% 76.11% 74.18% 81.39%

Mandatory Training Overall (10 core subjects) (Target)Mandatory Training Overall (10 core subjects) 95.00% 83.86% 82.16% 82.22% 85.29%

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

Wo

rkfo

rce

Workforce Scorecard





Safer Staffing Return


The fill rates of actual shifts against planned including temporary staff are:

• For Registered Nurses/ Midwives Day - 87.1% Night - 96.7%• For Care staff Day - 93.6% Night - 105.8%

Whilst the overall fill rate for RN days was 87.1%, there were 13 areas out of 20 that has fill RN rates under 90% during this period. This is a reduction from the previous month where 10 out of 20 clinical areas reported at under 90%.There has also been a slight reduction of fill rates on day and nights from the previous month.

There was one area with a RN fill rate under 80% this was critical care at 77.5% this is due to vacancies within the unit, however each patient was risk assessed and no patient breached the 1:1 / 1:2 standard.

Senior nurses review the staffing 3 times a day, identifying areas of need and relocating staff depending on the activity and patient acuity using professional judgment to ensure patient safety. However continued use of the escalation areas can be seen to impacting on the ability of the Trust to secure fill rates above 90% in all areas and the high RN vacancy rate contributes to high % of temporary staff : permanent staff ratios in many areas.

In addition to this the senior nurses now receive data each week form the staffing and safety tool that reviews red flag events and this is used to review clinical incidents in relation to staffing levels. This data is in its pilot stage and will be included in future Board Reports once the data collection is assured.




Specialty 1 Specialty 2

West Newton 430 - GERIATRIC MEDICINE 88.6% 115.1% 99.5% 142.1% 829 2.9 5.3 8.1

Necton 340 - RESPIRATORY MEDICINE 81.8% 97.5% 99.9% 98.9% 938 3.1 2.7 5.7

Windsor 430 - GERIATRIC MEDICINE 96.4% 84.0% 100.0% 109.9% 957 2.8 2.8 5.7

Stanhoe 301 - GASTROENTEROLOGY 350 - INFECTIOUS DISEASES 85.4% 97.9% 99.2% 122.6% 960 3.1 3.2 6.3

Tilney 320 - CARDIOLOGY 88.3% 83.1% 100.1% 99.9% 774 3.1 2.1 5.2

West Raynham 300 - GENERAL MEDICINE 87.1% 73.6% 99.8% 89.8% 778 4.1 2.8 7.0

Denver 100 - GENERAL SURGERY 93.3% 96.6% 100.3% 130.4% 860 2.8 2.7 5.6

Marham 100 - GENERAL SURGERY 82.1% 87.0% 91.9% 92.6% 679 3.5 2.3 5.8

Elm 100 - GENERAL SURGERY 88.2% 90.4% 101.8% 91.7% 543 3.1 2.8 5.9

Gayton 110 - TRAUMA & ORTHOPAEDICS 100 - GENERAL SURGERY 88.3% 92.7% 99.1% 111.9% 920 2.8 3.2 5.9

Shouldham 315 - PALLIATIVE MEDICINE 823 - HAEMATOLOGY 86.9% 107.4% 99.6% 93.3% 347 4.8 3.0 7.8

Critical Care 192 - CRITICAL CARE MEDICINE 77.5% 91.8% 85.4% 243 26.1 1.7 27.8

Central Delivery suite 501 - OBSTETRICS 95.4% 89.0% 96.9% 86.4% 153 27.2 8.3 35.4

Surgical Assessment Unit 100 - GENERAL SURGERY 93.2% 92.9% 88.6% 99.9% 260 7.9 2.8 10.6

Medical Assessment Unit 300 - GENERAL MEDICINE 84.3% 103.5% 109.1% 111.7% 512 6.8 2.9 9.8

Terrington 300 - GENERAL MEDICINE 93.8% 113.4% 92.2% 96.0% 925 3.3 2.3 5.6

Castleacre 501 - OBSTETRICS 97.5% 94.6% 99.0% 95.3% 332 5.3 4.1 9.4

NICU 420 - PAEDIATRICS 80.3% 94.7% 98.1% 103.3% 207 11.5 5.3 16.8

Rudham 420 - PAEDIATRICS 80.1% 66.4% 101.1% 110.0% 256 11.5 3.8 15.3

ED Obs Ward 180 - ACCIDENT & EMERGENCY 111.2% 93.9% 13 54.7 0.0 54.7

Oxborough 300 - GENERAL MEDICINE 90.8% 97.4% 99.1% 96.1% 945 2.5 2.6 5.1

Sep-17

Average

fill rate -

registered

nurses/mid

wives (%)

Night Care Hours Per Patient Day (CHPPD)

Average

fill rate -

care staff

(%)

Cumulative

count over

the month

of patients

at 23:59

each day

Registered

midwives/

nurses

Care Staff

Day

Ward name

Main 2 Specialties on each ward

Average

fill rate -

registered

nurses/mid

wives (%)

Average

fill rate -

care staff

(%)

Overall


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

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

Nursing staff


Definitions

VacanciesThe number of registered nursing vacancies has increased to 14.39% from 13.88% in August 2017. Medical & Dental vacancies have decreased from 21.95% to 21.25% as have AHP vacancies from11.68% to 5.24%

TurnoverTurnover has increased for the month of September. A new set of guidelines for leaving employment has been developed which makes it mandatory for all managers to meet with staff when they tender their resignation. The purpose is to look to see if any measures can be put into place to prevent the member of staff leaving the organisation, to fully understand the reason the employee has chosen to tender their resignation and to thank them for their work and dedication to the trust.

It is following this meeting that the manager then acknowledges the resignation and completes the necessary paperwork.

This new process is being piloted for two months across the medicine division and results will be reported early November. Following the completion of this trial the process will be rolled out across the Trust.

Exit interviews are offered to all members of staff who hand in their resignation but numbers being completed have fallen. As part of the new process managers will pass an exit interview to their member of staff during their meeting and advise them of the different options to complete the form.

Work continues to monitor areas with high turnover rates across the whole Trust and further analysis work is being undertaken. It is to be noted that although some areas appear as having a high turnover rate this is due to them being relatively smaller teams.

In addition the Trust is developing a recruitment and retention strategy and creating a sub committee to focus on recruitment and retention. Alongside this the Trust will be looking at reward and recognition and developing new initiatives to ensure staff feel valued at work.

780

800

820

840

860All Registered Nursing Staff in Post : Rolling year

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

320

340

360

380

400Elective/Emergency based Registered Nursing Staff in Post: Rolling year

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

400

410

420

430

440All Unregistered Nursing Staff in Post : Rolling year

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

100

150

200

250

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

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






Overdue by 18-24 months

11 Permanent, 2 Bank staff

• Scientific & Technical x 1• Additional Clinical Services x 3• Admin & Clerical x 1• Estates & Ancillary x 2• Healthcare Scientists x 2

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

Appraisal


Definitions

82.26%Appraisal Compliance Exc Bank Staff (Target 90%) rrrr

82.6

7%

85.5

4%

85.6

5%

86.4

5%

86.8

5%

83.7

8%

83.8

7%

84.4

6%

84.2

3%

85.3

1%

82.9

0%

82.2

6%

60.0%

70.0%

80.0%

90.0%

100.0%


Appraisal Compliance Rates (exc Bank Staff)

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

Excluding bank staff, the appraisal completion compliance has decreased to 82.26% (81.10% including bank staff) in September 2017. The number of seriously overdue appraisals has increased again

Overdue by 24 months +

1 Permanent staff

• Additional Clinical Services x 1




81.1

9%

84.0

3%

84.5

8%

85.4

1%

86.2

4%

83.3

1%

83.2

3%

83.4

7%

83.3

9%

83.5

6%

81.1

8%

81.1

0%

60.0%

70.0%

80.0%

90.0%

100.0%


Appraisal Compliance Rates (inc Bank Staff)

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

Monthly Appraisal Reports continue to be issued to ED’s and senior management teams showing compliance rates and highlight all staff currently outstanding and those with appraisals due within the next two months. HRBP’s follow up with each of their areas to monitor against these reports and follow the escalation process where appraisals remain outstanding in accordance with the Appraisal policy. Appraisal questionnaires completed and returned to HR following individual appraisals show 98% of staff completing the feedback rate the quality of their appraisal in terms of value and usefulness to them as very much or quite a lot with 2 % rating not very or not at all.Positive feedback on the revised Appraisal record received during appraisal training and drop in sessions to support the new paperwork.

Draft recommendations to strengthen control frameworks following recent internal Audit of Appraisals is to be worked through with HRBP’s and Training & Development Manager to review practical implementation of suggestions in particular:• Introduce regular sample checking of completed appraisals• Review current process of directorate meetings to ensure consistency and ownership of actions• Introduce appraisee training for all staff


The monthly sickness rate for September 2017 is 4.80% which is a decrease of 0.26% from last month’s adjusted figure (5.06%). The highest staff groups are:

• Scientific & Technical (6.44%)• Additional Clinical Services (6.72%)• Estates and Ancillary (7.57%)

All other staff groups were below 5%.

Sickness continues to be higher than Trust target of 4% but a number of measures / actions are being put into place to help reduce the sickness rate.

1) New sickness reporting processA new manager call back system has been put into place whereby the expectation is the individuals line manager calls the absent employee back.

A request has been made to the HRBP team for additional training to be arranged to help managers in making these calls and adding in a level of challenge and control. This is in the process of being arranged.

Since the new process has been rolled out the reliance on E-roster has increased, in respect of recording return to work dates, running trigger reports, individual sickness reports and trend reports. In order to assist with this and to help managers in how to utilise e-roster to its full capacity additional training is being arranged.

2) Completion of return to work interviews continue to be monitored.

3) New policyA new managing attendance policy is being developed which is based on managers knowing their staff and is not the traditional approach to managing absence. A pilot of the new process will be run across surgery division starting in November 2017. In addition an implementation plan will be developed for the new process, to include communications to staff and managers, policy briefing sessions, management training days and an intranet site dedicated to absence. This will be run in conjunction with the RCN.

4) Monthly Management meetings / performance meetings Monthly meetings continue to take place between ward managers and Assistant HRBPs to discuss workforce KPIs.

5) Top areasWork continues in reviewing the top 10 areas for absence on a monthly basis. A new template report is being developed for the top 10 areas in relation to absence, vacancies and bank and agency spend which will be presented at performance meetings

6) Long term sickness cases and hearings

Further work is being undertaken in managing long term sickness which accounts for a significant proportion of overall sickness.A number of staff have also been redeployed to alternative areas of work.

7) TrainingAs highlighted above there has been a request for additional training to be provided to support managers to managing absence.

In addition the Training and Development team are looking at rolling out mindfulness and mental health first aid training for staff as stress , anxiety and depression remains one of the top reasons for sickness

8) Early intervention support, Staff health and well being , Sub committee A. Additional support has been offered by the Royal College of Nursing to help to develop initiatives to support the health and well being of staff.

A further sub committee will be created to also look at these areas.

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

Sickness Absence & Turnover


Definitions

4.80%Sickness Absence Rate

rrrr

0.0%

2.0%

4.0%

6.0%

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

QEH

SmallacuteNHS

TargetQEH





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

Mandatory Training


Definitions

82.22%Mandatory Training (Trust) rrrr

Compliance rate for the 10 core subjects has increased very slightly to 82.22% from 82.16% in August 2017.

Currently scheduling the Clinical and Medical mandatory training days 1 & 2 for 2018 and the Induction programmes. The revised clinical Day 2 programme moved to scenario based training delivery for 2017 and although proving popular with staff places are limited to 25 to assist the facilitation. An additional clinical day 2 will need to be scheduled each month for 2018 to provide sufficient places and to be agreed with facilitators. To assist essential maintenance works on the training room windows/roof we are being asked to free up a working week before the financial year end. Unless these works are carried out over the Christmas break there will be an impact on the mandatory training delivery programme. Currently liaising with Estates on this. Revising Appendix 6 of Induction policy to provide a clear checklist of mandatory requirements for local induction so that it supports managers in starting new members of staff prior to Trust Induction. This will be incorporated into the recruitment process.

The Core Mandatory training covers the statutory and mandatory subjects: Manual Handling, Conflict Resolution, Equality & Diversity, Fire Safety, Health and Safety,Infection Control & Prevention, Resuscitation, Safeguarding Adults and Safeguarding Children and Prevent

Other Mandatory training: Consent, dementia Awareness, Diabetes, Health Record keeping, Learning Difficulties, Medicines management, Mental Capacity, Risk Management, Slips, Trips & Falls, Tissue Viability, Venous Thromboembolism, Transfusion, Breakaway, mentor updatesWe are seeking clarity on which subjects beyond statutory mandatory are actually required for the Workforce score card reporting to Board.




Sep-17Mthly

Target

Rolling

12 Mths

Conflict Resolution Training 82.76% 95.00% 83.14%

Equality and Diversity Training 73.73% 95.00% 77.68%

Fire Training 73.52% 95.00% 78.46%

Health & Safety Training 89.89% 95.00% 91.51%

Infection Control Training 75.92% 95.00% 80.29%

Information Governance Training 86.00% 95.00% 89.20%

Manual Handling Training 81.85% 95.00% 84.25%

Resuscitation Training 78.46% 95.00% 82.40%

Risk Management Training (level 2 only) 72.33% 90.00% 93.87%

Safeguarding Adults Training 90.24% 95.00% 94.30%

Safeguarding Children Training 89.86% 95.00% 91.67%

Slips, Trips & Falls Training 89.34% 90.00% 93.79%

VTE Training 74.18% 90.00% 81.39%

Mandatory Training Overall (10 core subjects) 82.22% 95.00% 85.29%


Finance report to follow seperately

Finance





None

Appendices





Board Report template - qehkl Report 2017 10.pdf · Crude Mortality (deaths per 1000 admissions) TargetDeaths per 1000 admsCrude Mortality (deaths per 1000 admissions) 19 11.1 14.3

Documents