Trust Quality and Performance Report

Trust Quality and Performance Report

20 December 2013(November Performance Pack)

Contents

1

Slide numbers

Executive Summary  2 - 4

Clinical Quality Priorities inc Ward Dashboard 5 - 18

Local Priorities 19 - 26

Monitor Compliance 27

Contract Priorities 28 - 29

Executive Summary

This commentary provides an overview of key issues during the month and highlights where performance fell short of the target values as well as areas of improvement and noticeable good performance.

1. A&E Performance for November was 96.06%, exceeding the 95% target for the sixth consecutive month and continues at a rate well above both the regional and national averages.

2. There were zero cases of C.Diff in November against the threshold of two. This is covered on page 12 of this report.

3. All Stroke targets were achieved for the second consecutive month.

4. Performance on outpatient and inpatient discharge summaries remains below target. In addition to previous actions, further PMO support to this target has been introduced. Further details on page 3.

5. Performance on MRSA screening of emergency admissions was 96% against the 100% target. This is covered on page 12 of this report.

NOTE – due to the early board reports the Trust is unable to confirm final 18 week performance for November. A verbal update will be given at the board.

2

3

Performance Indicator Threshold November Lead ExecDischarge Summaries - Outpatients 95% sent to GP’s within 3 days 82.81% Dermot O’Riordan

Performance Indicator Threshold November Lead ExecDischarge Summaries - Inpatients 95% sent to GP’s within 1 day 81.94% Dermot O’Riordan

Executive Summary

Additional work is now being taken forward with new performance information to look at individual department and consultants - led by Medical Director.

Has now increased to its highest level with support at ward level and further performance information being provided via whiteboards .

Performance Indicator Threshold November Lead Exec

Discharge Summaries - A&E 95% of A&E Discharge Summaries to be sent to GPs within one working day 93.76% Dermot O’Riordan

The A&E letters are down because of a technical fault with the letter template that stopped the sending on 20th Nov – these letters were subsequently re-sent manually.

4

Performance Indicator Threshold November Lead Exec

MRSA – Emergency ScreeningAll emergency patients admissions are to be screened for MRSA within 24 hours of admission

95.97% Nichole Day

Executive Summary

Performance Indicator Threshold November Lead Exec

Sickness absence rate <3.5% 3.90% Jan Bloomfield

Performance on MRSA screening of emergency admissions was 95.97% against the 100% target. This is covered on page 12 of this report.

All staff to have an appraisalBoth general and consultant staff each have a target of 90% to have had an appraisal within the previous 12 months. Appraisal is a rolling programme

86.91% Jan Bloomfield

Trust compliance has increased very slightly this month. The highest area being the Medical Directorate (90.20%) and the lowest being the Surgical Directorate (82.83%). Senior medical staff appraisal is at 82%. The following initiatives are in place; A new electronic appraisal/ revalidation system for doctors has been purchased and will be implemented in January 2014. The Strengthening Appraisal & Revalidation Database (SARD) will go live from 1st January 2014. Monthly reports are produced for general managers listing those staff that are due to expire, and training is available to all new and existing appraisers through the skills+ programme.

Performance Indicator Threshold November Lead Exec

The Trusts cumulative sickness absence rate is currently 3.90% (over 12 month period). The highest % being in Estates and Facilities (4.97%) and the lowest in Corporate Services (2.39%). A number of initiatives are currently in place to further address this issue; The Trust’s solicitors are undertaking a review of our policy/process to see if further changes can be introduced. The Well Managed Ward Manager Programme will address managing sickness absence, and a specific KPI added. Medical staff absence has been investigated as part of the regional quality benchmark, for the Quality & Risk Committee. Monthly reports are provided to all General Managers and cascaded to all managers, regular training for managers is offered through the skills+ programme and HR & Occupational Health continue to review all long term sickness absence.

A3 Printout of Ward Analysis Quality Report From Trust

Dashboard

Clinical Quality Priorities: Ward Dashboard

5-9

Clinical Quality Priorities: Summary

• There has been an increase in grade 3 pressure ulcers this month.

• There were no C. difficile infections during November.

• Analysis of the Trust’s incident reporting shows a reduction in reporting for November ’13. This is in the context of a national increase in reporting for our peer  (source National Reporting & Learning System (NRLS)). This indicator will be kept under review and the reporting rate for December ’13 will be reviewed in greater detail if the trend continues.

10

Quality Priority: Ward Performance Issues

• No ward had more than 3 red scores in patient satisfaction.

• Ward F9 continues to experience vacancy issues and this is being managed through regular meetings between the Head of Nursing and the management team for the ward. Compliance with the hydration audits increased to 90% this month from 30% last month, MEWS escalation audits achieved 100% and there were no pressure ulcers or falls during November.

• Ward F3 decreased its bed capacity due to staffing issues but on occasions this was increased during November due to Trust wide bed capacity issues. The recommender score for this ward was lower than average for the Trust and there were amber scores for the questions in the patient experience survey relating to opportunity to talk about worries and fears, involvement in decision making and help with meals. Although the ward is meeting its core staffing levels for the reduced bed capacity, when bed numbers were increased this caused additional pressure. Approval to recruit to the numbers required for the six additional beds has been put forward.

11

Quality Priority: Infection Control

MRSA BacteraemiaThere were no hospital associated MRSA bacteraemia’s during November.

C. difficileThere were no hospital acquired C.difficile infections during November.

High Impact interventionsAll High Impact Intervention audit results were 100% except for peripheral cannula on-going care which scored 93% overall. Failures in compliance in relation to this indicator were related to documentation of VIP scores. This has been highlighted with the wards concerned and the Matron is undertaking additional spot checks.

MRSA screeningElective: 87.60% Non Elective: 92.84%

.

12

Quality Priority: Falls

Falls performance

There were 50 falls this month 15 of which resulted in negligible or minor harm, none incurred serious harm. Two were due to collapse for medical reasons and would not have been counted in our old definition.

The rate per 1,000 occupied bed days is 5 (October 5) which is below National average of 5.6 (NPSA 2010)

ThemesWe continue to monitor the number of falls in toilets: this month 8% of our falls occurred in the toilet, the same number as in October

Detailed intelligence continues to be collected to reveal what the patient was actually doing at the time of the fall.

Only one patient slipped from their chair this month. Down from 6 last month. This patient did not have an alternating air cushion in place.Several patient fell while attending to their own hygiene needs after using the toilet, hand rails may have prevented these falls, and work is

about to start to fit safety rails in all patient toilets.

It should be noted that since publishing last month’s data one more fall has been recorded and we are now reporting 52 falls for October. The quality report and Datix records have been amended.

13

Quality Priority: Pressure Ulcers

The performance target is to have no avoidable Hospital Acquired Pressure Ulcers (HAPU) Grade 2, 3 or 4 pressure ulcers 2013-14.

Grade 2 Pressure Ulcers

There was one grade 2 HAPU this month which we believe was unavoidable. All four grade 2 HAPU from last month have been deemed UNAVOIDABLE by the CCG.

Grade 3 pressure Ulcers

There were five grade 3 HAPU in November, at least two of these are thought to be UNAVOIDABLE but we are still awaiting CCG confirmation.

Three may have been avoidable as risk assessments and other documentation could have been improved,. Two of the pressure ulcers were on the ears of palliative patients receiving oxygen therapy. It has been highlighted to ward staff to check patients ears when checking other

pressure points. We have also obtained pressure relieving gel tape to protect wars ate risk

We are looking into ways of improving and streamlining our service to provide pressure relieving mattresses to the wards.

We plan to steam clean electric beds, fit them with an electric alternating mattresses and deliver the whole package to the ward requesting the mattress. This will provide improved systems to ensure mattresses are fitted correctly, safely and ready for use.

14

Safety thermometer results

The National ‘harm free’ care composite measure is defined as the proportion of patients without a pressure ulcer (ANY origin, category II-IV), harm from a fall in the last 72 hours, a urinary tract infection (in patients with a urethral urinary catheter) or new VTE treatment.

The data can be manipulated to just look at “new harm” (harm that occurred within our care) and with this parameter, our Trust score is 96.39%. National November performance is 97.4%.

It should be noted that the Safety Thermometer is a spot audit and data is collected on a specific day each month. The number of falls were higher than normal, in November, on the day of the audit however the Trust total for the month remain constant.

Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13

Harm Free 92.71 93.77 95.66 93.02 93.36 93.68 91.47 93.20 92.60 93.22 92.68 91.03 92.46 90.28

Pressure Ulcers – All 4.02 3.38 1.79 5.17 3.55 3.51 4.50 4.28 5.36 3.52 2.98 5.16 4.06 4.72

Pressure Ulcers - New 1.51 0.26 1.02 0.52 0.71 0.94 0.95 1.01 0.00 1.08 0.00 1.09 0.00 0.83

Falls with Harm 0.75 0.26 0.51 0.78 0.71 0.23 1.66 0.00 0.26 0.81 0.27 0.00 0.00 1.11

Catheters & UTIs 2.01 2.08 1.79 1.03 1.66 2.58 0.95 1.76 1.53 2.17 2.98 3.60 3.48 3.33

Catheters & New UTIs 0.25 0.00 0.26 0.26 0.47 0.23 0.24 0.00 0.51 0.54 1.08 0.82 0.00 0.83

New VTEs 0.50 0.78 0.26 0.26 0.71 0.47 1.42 0.76 0.26 0.54 1.36 0.54 0.58 0.83

All Harms 7.29 6.23 4.34 6.98 6.64 6.32 8.53 6.80 7.40 6.78 7.32 8.97 7.54 9.72

New Harms 3.02 1.04 2.04 1.81 2.61 1.87 4.27 1.76 1.02 2.98 2.71 2.45 0.58 3.61

Sample 398 385 392 387 422 427 422 397 392 369 369 368 345 360

Surveys 17 17 17 17 18 18 18 18 18 17 17 17 17 17

15

Quality Priority: Patient Experience – Achievement of 85% satisfaction

‘Achieve at least 85% satisfaction in internal patient satisfaction surveys’ is a Quality Priority for the Trust.

The overall score for the inpatient survey was 90%, in line with previous months. Overall satisfaction scores for the OPD, A&E, short stay and maternity services were maintained at a high level with each scoring over 90% overall.

Call Bell ProjectA meeting was held on 29th November with the ward managers to review the action plan. • The ward managers are disseminating the results of the project at their team meetings. Unfortunately there have been

problems with the CD provided by the Patients Association and therefore it has not been possible to use the video clips with the ward staff to date. However, a hand out for staff has been produced.

• The ward managers are ensuring that there is meticulous attention to intentional rounding in order to reduce the need for the call bells to be pressed.

• The use of tables in bays for documentation tasks by staff is being encouraged where these are available.• Clocks are available in the bay areas of most wards.• A project to consider alternative methods of organising care to enable call bells to be answered more quickly is being

focused on the early adopter wards where ‘supervisory status’ is being piloted. • As an example the response times for F5 and F6 are shown in the graph below.

16

Quality Priority: Patient Experience – recommend the service

‘Patients would recommend the service to their family and friends’ is a Quality Priority for the Trust.

The Trust achieved a net promoter score of 84 for inpatients during November, maintaining the high scores of previous months.

Two wards had noticeably lower scores, these were wards F3 and G4. There was only one comment regarding G4 and this indicated that the patient felt that they should not be mixed with dementia patients. In relation to F3 there were 5 comments as follows:• Two indicated that they felt that there was not enough staff on duty to meet the needs of the patients• One said that they were kept waiting too long to go to the toilet• 2 said the ward was chaotic and noisy

The score for A&E was 61. There were five comments from patients relating to the score, these were as follows:• Doctors good, nurses less so• After care ‘virtually non existent’• Long wait and not kept informed• Slow service, not very helpful• Stupid question.

Maternity services introduced the Friends and Family test at 4 points of the care pathway last month and the scores this month are good. These are provided in the table below.

Antenatal Birth Post natal ward Post natal care

79 93 95 95

17

CQC Action Plan

Update

The only outstanding actions within the CQC Action Plan are as follows:

• A presentation and discussion at the Surgical Clinical Governance Audit session on Consent, MCA and DNACPR in January

• MCA and DoLS updates provided in conjunction with the County MCA/DoLS Facilitator will continue into 2014 to maximise attendance

• MCA and DOLS awareness information to be included in the Greensheet scheduled for week of 16th December.

• Dedicated webpages on the staff intranet in January

• Displays in ‘Time Out Staff Restaurant re: MCA / DoLS / IMCA / Consent planned to follow Greensheet publication

It is anticipated that all actions will be complete by the end of January 2013.

18

Local Priorities: Exception report

Late by Directorate  Red (RAG) Oct Nov change

Clinical Support >15 6 9 -

Estates and Facilities >10 9 12

Medical >70 152 85

Surgical >40 65 32

Women & Children’s Health >15 19 31

Other No target 10 4

TOTAL  >150 261 173

Incidents (Amber / Green) with investigation overdue (over 12 days)The Trust met the deadline for submission of all PSIs in Apr-September NRLS of the 30 th November. This has resulted in a reduction in the total overdue for investigation and final approval. Ops group identified a need to consider a robust method for ensuring timeliness of future investigation and sign off to ensure the levels do not start to creep up again now the submission deadline has passed.

RCA actions overdue n = 8Six actions became overdue in November and are being actively followed up to ensure completion. Two others due in October relate

to policies currently being drafted.

19

Local Priorities - Governance Dashboard

Indicator Performance target R A G Nov13 Commentary

Timely completion of incident investigations and actions

Red non-SIRI investigation not complete more than 45 days after incident reported

>3 1 - 3 0 0

RCA Actions beyond deadline for completion >=5 1 – 4 0 8 Reduction from 9 reported in Nov ‘13. See Exception report

Incidents (Amber / Green) with investigation overdue (over 12 days)

>150 50 - 150 <50 173 Reduction from 261 reported in Nov ‘13. See Exception report

Timely reporting of SIRIs

SIRIs reported > 2 working days from identification as red

>1 1 0 0 All six incidents were submitted to STEIS within two days of identification as red. Four were regraded as Red following review by Tissue viability.

SIRI final reports due in month submitted beyond timeframe

>1 1 0 0 5/6 were submitted within deadline. One has a ‘stop the clock’ agreed by the CCG and has now been sent.

Number of SIRI reports open on STEIS more than 45 days after initial notification

>10 6 - 10 0-5 2 Four incidents have an CCG agreed “stop the clock” and are therefore excluded from this indicator.

Duty of Candour Compliance with Duty of Candour requirements

<75% 75 – 94% >=95% 90% One (from a total of ten cases) cases is being actively followed up with the staff caring for the patient as the notes do not document a conversation that may have taken place at the time.

Risk assessment

Active risk assessments in date <75% 75 – 94% >=95% 100%

Outstanding actions in date for Red / Amber entries on Datix risk register

<75% 75 – 94% >=95% 98%

20

Local Priorities - Governance Dashboard (cont.)

Indicator Performance target R A G Nov13 Commentary

Risk assessment

Active risk assessments in date <75% 75 – 94% >=95% 100%

Outstanding actions in date for Red / Amber entries on Datix risk register

<75% 75 – 94% >=95% 98%

Clinical Audit

Trust participation in relevant ongoing National audits (reported by Quarter)

<75% 75 – 89% >=90% 100%

Safer surgery

Completion of WHO checks during surgery. This is a composite indicator of the checks at ward, sign-in, time-out and sign-out.

<90% 90% - 98% >98% 97% Non compliance reported to individuals (daily) and Clinical Directors (weekly)

NICE TA (Technology appraisal) business case beyond agreed deadline timeframe

>9 4 - 9 0 - 3 1 These outstanding seven Interventional procedures and eight Clinical guidelines are outstanding baseline assessments and require targeted follow up.

IPG (Interventional procedure guideline) baseline assessments beyond agreed deadline timeframe

>9 4 - 9 0 - 3 7

CG (Clinical guideline) baseline assessments beyond agreed deadline timeframe

>9 4 - 9 0 - 3 8

Complaints Response within 25 working days or negotiated timescale with the complainant

<75% 75 – 89% >=90% 96%

Number of second letters received >=5 1-4 0 1

Health Service Referrals accepted by Ombudsman >=2 1 0 0

Red complaints actions beyond deadline for completion >=5 1-4 0 0

Number of PALS contacts becoming formal complaints >=10 6 - 9 <=5 2

21

Patient Safety Incidents reported

The rate of PSIs is a nationally mandated item for inclusion in the Quality Accounts. The NRLS target lines shows how many patient safety incidents WSH would have to report to fall into the median / upper and lower quartiles for small acute trusts reporting per 100 admissions. The Oct12 – Mar13 NRLS report was issued but then withdrawn for technical reasons therefore the Apr ’12 – Sept ’12 rate is still shown as the benchmark in the graph above.

There were 385 incidents reported in November including 316 patient safety incidents (PSIs). The reporting rate fell to its lowest rate since September 2012 but still remains above the benchmark median. The number of harm incidents in November was below the peer group average (Apr ’12 – Sept ’12 benchmark).

May

-12

Jun-

12

Jul-1

2

Aug-

12

Sep-

12

0

50

100

150

200

250

300

350

400

WSH (harm PSIs) NRLS benchmark (harm PSIs) WSH (all PSIs) NRLS Lower quartile (all PSIs)NRLS Median (all PSIs) NRLS Upper quartile (all PSIs)

Nu

mb

er o

f in

cid

ents

rep

ort

ed

22

Patient Safety Incidents (Severe harm or death)

The percentage of PSIs resulting in severe harm or death is a nationally mandated item for inclusion in the Quality Accounts. The peer group average (serious PSIs as a percentage of total PSIs) from the NPSA Apr ’12 – Sept ‘12 report and sits below the Trust’s average (updated benchmark not yet available from NRLS for Oct ‘12 – Mar ‘ 13). The WSH data is plotted as a line which shows the rolling average over a 12 month period. The number of serious PSIs (confirmed and unconfirmed) are plotted as a column on the secondary axis with avoidable hospital acquired pressure ulcers (HAPU) indentified separately.

In September there were six ‘Red’ patient safety incidents: cardiac arrest (1), AKI (1), pressure ulcer (1), deteriorating patient (1), delayed admission to CCS (1), and one awaiting confirmation through RCA Cardiac arrest (1).

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Feb-

12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep-

12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb-

13

Mar

-13

Apr

-13

May

-13

Jun-

13

Jul-1

3

Aug

-13

Sep-

13

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

0

1

2

3

4

5

6

7

8

12

1 12 2

3

5

3

12 2

3

12 2 2

4 4

7

5

23

4

2

2

2

1

1

1

1

1

1

Confirmed severe harm/death (excl. PU) Hospital acquired pressure ulcersPending final grade (1ary axis) Benchmark NRLS Serious harm average(1ary axis) WSH confirmed serious harm - 12 month rolling average WSH%

1ary

axi

s (s

erio

us

har

m P

SIs

as

a %

of

tota

l P

SIs

)

2ary

axi

s (nu

mbe

r of c

onfir

med

PSI

s)

23

Local Priorities: Complaints

There was a large increase in complaints received in November 2013 compared to November 2012.

Complaint response within agreed timescale with the complainant: 96% of responded to in November. This represents 1 of the 23 complaint responses going out late.

Of the 40 complaints received in November, the breakdown by Primary Directorate is as follows: Medical (19), Surgical (14), Clinical Support (4), Facilities (1), and Women & Child Health (2).

Trust-wide the top 6 most common problem areas are as follows:

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

Complaints 2013/14 33 31 29 38 32 29 26 40 NaN NaN NaN NaN

Complaints 2012/13 19 22 26 18 34 18 28 22 20 24 25 27

Second letters 2013/2014 0 1 3 3 1 0 2 1 NaN NaN NaN NaN

2.5

12.5

22.5

32.5

42.5

Num

ber

of c

ompl

aint

s

All Aspects of Clinical Treatment 21

Communication / Information to Patients (written and oral) 20

Admissions, Discharge and Transfer Arrangements 11

Attitude of Staff 6

Appointments, Delay / Cancellation (outpatient) 3

Hotel Services (including food) 3

24

Local Priorities: PALS (Patient Advice & Liaison Service)

In November 2013 there were 71 recorded PALS contacts. This number denotes initial contacts and not the number of actual communications between the patient/visitor which can, in some particular cases, be multiple. Although the overall number of initial contacts is much less for November, the length of time dealing with families has been prolonged.

A breakdown of contacts by Directorate from Nov’12 to Nov‘13 is given in the chart and a synopsis of enquiries received for the same period is given below. Total for each month is shown as a line on a second axis.

Trust-wide the most common five reasons for contacts are shown below. No

v-12

Dec-

12

Jan-

13

Feb-

13

Mar

-13

Apr-1

3

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct-1

3

Nov-

13

0

10

20

30

40

50

60

0

20

40

60

80

100

120103

81

92100

88 90

7277

90

102

89

102

71

Medical Surgical Clinical support Women and Child Health

Facilities Other / Not categorised Total

Information/Advice request 21 All aspects of clinical treatment 16 Appointments, delay, cancellation (outpatients) 9

Other 5 Communication 5

The numbers are quite small and consistent when spread across the different areas although the PALS Manager has noticed a definite trend in the patient’s dissatisfaction with cancelled clinics (particularly surgical). The other main areas where concerns were raised in November 2013 are Ward G9 (5); Emergency Department (4); and Ward G5 (4)

It is evident that the PALS Manager, in addition to assisting with genuine concerns from patients and relatives, frequently signposts enquirers to other services including the formal complaints process. She is also actively involved in dealing with specific in-patients and their families’ concerns during the total admission period. This last month has been particularly busy with patient families raising queries with the PALS Manager.

25

Local Priorities – Workforce Performance

26

Performance Indicator Threshold Direct Financial Penalty

12 Month YTD Comments Lead Exec

WorkforceSickness absence rate <3.5% NO 3.90% Jan BloomfieldTurnover <10% NO 7.64% Jan Bloomfield

Reviews Grievance/Banding reviews NO 9 1 Tribunal withdrawn and 1 Ongoing Agenda for Change Banding Appeal Jan Bloomfield

Recruitment Timescales Average number of weeks to recruit = 7 NO 5.5 Jan BloomfieldCRB Disclosures existing staff To complete 95% of required CRB checks NO 98.00% Jan Bloomfield

All Staff to have an appraisalBoth general and consultant staff each have a target of 90% to have had an apprasial within the previous 12 months. Appraisal is a rolling programme

NO 86.91% 

Jan Bloomfield

Monitor Compliance Framework

27

Monitor Compliance Framework Performance Indicator Threshold Month QTD Weighting Lead ExecAccess: Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted 90% TBC 98.61% 1.0 Jon Green

Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted 95% TBC 99.72% 1.0 Jon Green

Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway 92% TBC 100.00% 1.0 Jon Green

A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge 95% 96.06% 96.95% 1.0 Jon Green

All cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer 85% 85.00% 87.00%1.0

Jon Green

All cancers: 62-day wait for first treatment (5) from: NHS Cancer Screening Service referral 90% 100.00% 100.00% Jon Green

All cancers: 31-day wait for second or subsequent treatment, comprising: Surgery 94% 100.00% 100.00%1.0

Jon Green

All cancers: 31-day wait for second or subsequent treatment, comprising: anti-cancer drug treatments 98% 100.00% 100.00% Jon Green

All cancers: 31-day wait for second or subsequent treatment, comprising: radiotherapy - Not applicable to WSFT

All cancers: 31-day wait from diagnosis to first treatment 96% 100.00% 100.00% 0.5 Jon Green

Cancer: two week wait from referral to date first seen (8), comprising:all urgent referrals (cancer suspected) 93% 97.90% 98.90%

0.5Jon Green

Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer not initially suspected) 93% 98.10% 97.10% Jon Green

Outcomes:

Clostridium (C.) difficile - meeting the C.difficile objective - MONTH 2 0

1.0

Nichole Day

Clostridium (C.) difficile - meeting the C.difficile objective - QUARTER Q1 = 4, Q2 = 5, Q3 = 5, Q4 = 5

2 Nichole Day

Clostridium (C.) difficile - meeting the C.difficile objective - ANNUALLY 19 18 Nichole Day

Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - MONTH 0 0 1.0

Nichole Day

Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - QUARTER 0 0 Nichole Day

Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - ANNUALLY 0 1 Nichole Day

Certification against compliance with requirements regarding access to healthcare for people with a learning disability N/A - - 0.5 Nichole Day

Contract Priorities Dashboard

28

Contract Priorities with financial penalty          

Performance Indicator ThresholdIn Month

PerformanceYTD Comments Lead Exec

A&E

A&E - Threshold for admission via A&Ei) if the monthly ratio is above the corresponding 2011/12 monthly ratio for two month in a six month periodii) if year end is greater than 27%

27.07% 24.82% Jon Green

A&E - Timeliness Indicators

To satisfy at least one of the following Timeliness Indicators:1. Time to initial assessment (95th percentile) below 15 minutes2. Time to treatment in department (median) below 60 minutes ONE MET - Jon Green

Stroke

Stroke -Proportion of Patients admitted to an acute stroke unit within 4 hours of hospital arrival 90% 92.00% 86.50% Jon Green

Proportion of patients in Atrial Fibrillation, presenting with stroke and where clinically indicated will receive anti-co-agulation. 60% 60.00% 67.25% Jon Green

Stroke - % of Stroke patients with access to brain scan within 24 hours 100% 100.00% 98.75% Jon Green

Stroke - Proportion of Stroke Patients and carers with a joint health and social care plan on discharge 85% 92.00% 91.25% Jon Green

Stroke - Patients (as per NICE guidance) with suspected stroke to have access to an urgent brain scan in the next slot within usual working hours or less than 60 minutes out of hours as defined from time to time by the ASHN

100% of stroke patients eligible for a brain scan scanned within one hour 100.00% 94.25% Jon Green

>80% treated on a stroke unit >90% of their stay 80% 88.00% 89.00% Jon Green

>60% of people who have a TIA and are high risk (ABCD 2 score 4 or more) are scanned and treated within 24 hours of 1st contact but not admitted

60% 64.00% 76.75% Jon Green

Stroke - 65% of patients with low risk TIA have access to MRI or carotid scan within 7 days (seen, investigated and treated) 65% 83.00% 74.63% Jon Green

% of Patients eligible for Thrombolysis, Thrombolysed within 4.5 hours 100% of all eligible patients 100.00% 100.00% Jon Green

Discharge Summaries

Discharge Summaries - Outpatients 95% sent to GP's within 3 days 82.81% 84.02% Dermot O'Riordan

Discharge Summaries - A&E 95% of A&E Discharge Summaries to be sent to GPs within one working day 93.76% 97.04% Dermot O'Riordan

Discharge Summaries - Inpatients 95% sent to GP's within 1 day 82.94% 82.26% Dermot O'Riordan

Contract Priorities Dashboard

29

Choose & Book          

Provider failure to ensure that “sufficient appointment slots” are made available on the Choose and Book system

A maximum of 3% slots unavailable (£50 per appointment over 5%. Threshold applied over monthly figures) 3.00% - The Threshold applied to fines is 5% Jon Green

All 2 Week Wait services delivered by the Provider shall be available via Choose & Book (subject to any exclusions approved by NHS East of England)

100% 100.00% - Jon Green

Cancelled OperationsProvider cancellation of Elective Care operation for non-clinical reasons either before or after Patient admission i) 1% of all elective procedures 0.77% 1.15%

Jon GreenPatients offered date within 28 days of cancelled operation 100% 100.00% 100.00% Jon GreenMaternity

Access to Maternity services (VSB06)90% of women who have seen a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks and choices by 12 completed weeks of pregnancy.

97.61% 96.36%

Nichole DayMaintain maternity 1:30 ratio 1:30 1:30 1:29 Nichole DayPledge 1.4: 1:1 care in established labour 1:1 100.00% 100.00% Nichole DayBreastfeeding initiation rates. 80% 84.11% 80.35% Nichole DayReduction in the proportion of births that are undertaken as caesarean sections. Suffolk PCT Only

1% reduction in proportion compared to 2011/12 baseline - 22.70% 20.09% 18.67%

Nichole DayOther contract / National targetsMixed Sex Accomodation breaches 0 Breaches 0 4 Jon Green

Consultant to consultant referral Commisioner to audit if concern about levels of consultant referrals TBC 6.19% Jon Green

Current ratios of OP procedure to day case for agreed list of procedures to be maintained or improved, i.e. the Commissioner will not fund a higher level of admitted patients for such procedures, unless clinical reasons can be demonstrated for increase in admissions.

Maintain or improve the mix as specified = 90.17% TBC 87.55% Jon Green

MRSA - emergency screening All emergency patients admissions are to be screened for MRSA within 24 hours of admission 95.97% 92.42% Nichole Day

Rapid access - chest pain clinic 100% of patients should have a maximum wait of two weeks 93.18% 80.19% Jon Green

New to Follow up Thresholds set at each speciality - overall Trust Threshold is 1.9 TBC 1.84 Jon Green

Patients receiving primary diagnostic test within 6 weeks of referral for diagnostic test 99% 99.00% 97.65% Jon Green