Trust Quality and Performance Report October 2013 Agenda item 11.

Trust Quality and Performance Report

October 2013

Agenda item 11

Contents

Slide numbers

Executive Summary 2 - 4

Clinical Quality Priorities inc Ward Dashboard 5 - 19

Local Priorities 20 - 26

CQUIN 27 - 29

Monitor Compliance 30

Contract Priorities 31 - 33

1

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 September was 98.08%, exceeding the 95% target for the fourth consecutive month and placing the Trust in the top decile nationally. Quarterly performance at 96.36% was the top performance in the Region.

2. There were three cases of C.Diff in August against a threshold of two, the target for both the month and the quarter has not been achieved. This is covered on page 12 of this report.

3. Performance on outpatient and inpatient discharge summaries continued below target. Working with the CCG, a number of new steps are being introduced through October. Further detail is on page 3.

4. Performance on MRSA screening of emergency admissions was 93% against the 100% target. This is covered on page 12 of this report.

5. Stroke targets were achieved with the exception of admission of patients in atrial fibrillation presenting with stroke and where clinically indicated will receive anti-coagulation. Four of the six patients missed this target, one patient refused and three patients, although clinically indicated were not clinically appropriate to receive anti-coagulation. See page 3.

2

3

Performance Indicator Threshold September Lead Exec

Discharge Summaries - Outpatients 95% sent to GP’s within 3 days 85.74& Dermot O’Riordan


Discharge Summaries - Inpatients 95% sent to GP’s within 1 day 78.97% Dermot O’Riordan

Performance Indicator Threshold September Lead ExecProportion of patients in Atrial Fibrillation, presenting with stroke and where clinically indicated will receive anti-coagulation 60.00% 33.00% Jon Green

Executive Summary

Clinical staff and the project team have been exploring options. In agreement with the CCG a number of non-critical areas have been removed as part of the performance framework while data collection has been extended beyond just EPRO. TEG have agreed a number of initiatives to address the key issues, including performance discussion at consultant appraisal, targeting the underperforming specialities in directorates, where the Ops Groups have agreed a new process. Looking at automating the process further by sending letters sooner

In order to support Discharge Summaries and Letters the project team have been working with clinicians to explore a range of options in order to resolve the current performance. In agreement with the CCG a number of non-critical areas have been removed as part of the performance framework while data collection has been extended beyond just EPRO. In addition TEG have agreed a number of initiatives to address the key issues, including performance discussion at consultant appraisal, targeting the underperforming specialities in directorates including a new process agreed by the Ops Group. In addition looking at automating the process further by sending letters sooner

Target includes within dominator patients that refuse or are clinically inappropriate for anti-coagulation drugs. Four of the six patients during the month fell into this category (one patient refused and three patients were clinically inappropriate). The other two patients were appropriately treated. Year to date performance remains above 60.00%.

4


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

93.03% Nichole Day

Executive Summary



Sickness absence rate <3.5% 3.91% Jan Bloomfield

All staff to have an appraisal

Both 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

85.85% Jan Bloomfield


Clostridium (C.) difficile – meeting the C. difficile objective 2 3 Nichole Day

There were three cases of C.Diff in September . The target for both the month and the quarter has not been achieved. An external view has been commissioned by the Trust and the formal report has been received. This is covered on page 12 of this report.

Appraisals are monitored through the Trust’s Electronic Staff Record system (ESR), when a completed Personal Development Plan (PDP) is submitted to the HR Department (this can be done electronically or by using a paper based system). Reporting then takes place on a monthly basis, through the directorate performance management process. Managers can also request individual reports on their own staff from HR at any time.

The Trust Board receive appraisal take up information monthly. The target is 90% and as at end September the Trust compliance figure is at 85.85%.

Performance on MRSA screening of emergency admissions was 93% against the 100% target. This is covered on page 12 of this report.

Group Indicator Target Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU G5 F9 F10 G1 G3 G4 F7 G8 MTU F8 G9 F1 F11 F14HII compl iance 1a: Centra l venous catheter insertion

100% <85 85-99 100 NA NA NA NA 100 NA NA NA NA NA NA NA NA NA NA NA NA 100 NA NA NA NA NA

HII compl iance 1b: Centra l venous catheter ongoing care

100% <85 85-99 100 100 NA 100 NA 100 NA NA NA NA NA NA NA NA 100 NA NA NA NA NA NA NA NA NA

HII compl iance 2a: Periphera l cannula insertion

100% <85 85-99 100 NA NA NA NA 100 100 NA NA 100 NA NA NA NA NA NA NA NA 100 100 NA 100 NA NA

HII compl iance 2b: Periphera l cannula ongoing

100% <85 85-99 100 100 100 100 100 100 NA NA NA NA 100 100 100 100 88 100 NA 100 NA NA NA 100 NA 100

HII compl iance 4a: Preventing surgica l s i te infection preoperative

100% <85 85-99 100 NA NA NA NA NA NA 100 100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

HII compl iance 4b: Preventing surgica l s i te infection perioperative

100% <85 85-99 100 NA NA NA NA NA NA 100 100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

HII compl iance 5: Ventilator associated pneumonia

100% <85 85-99 100 NA NA NA NA 100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

HII compl iance 6a: Urinary catheter insertion

100% <85 85-99 100 NA NA NA NA NA 100 NA NA 100 NA NA NA NA NA NA NA NA NA ND NA NA NA NA

HII compl iance 6b: Urinary catheter on-going care

100% <85 85-99 100 100 100 100 100 NA NA NA NA NA 100 100 100 100 NA 100 NA 100 NA NA 100 NA NA NA

HII compl iance 7: Clostridium Diffi ci le- prevention of spread

100% <80 80-99 100 NA NA NA NA NA NA NA NA NA NA NA 100 NA NA NA NA NA NA NA NA NA NA NA

Seps is 6 pathway: antibiotic compl iance 100% <80 80-99 100 NA NA NA NA NA NA NA NA 74 NA NA NA NA NA NA NA NA NA NA NA NA NA NATota l no of MRSA bacteraemias : Hospita l 0/yr > 0 No Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Tota l no of MRSA bacteraemias : Community acquired

No Target No Target No Target No Target ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND

MRSA (admiss ion to discharge) 90% <80 80-89 90-100 96 100 100 91 NA NA NA NA NA 100 83 87 85 90 95 87 92 NA 96 85 NA 100 80MRSA decolonisation (treatment and post screening)

90% <80 80-89 90-100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND

MRSA Elective screening 100% <80 80-99 100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDMRSA Emergency screening 100% <80 80-99 100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDStool speciment col lection No Target No Target No Target No Target ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDHand hygiene compl iance 95% <85 85-94 95-100 100 100 100 100 100 NA 100 100 100 100 100 100 100 100 100 100 100 100 ND 100 100 86 100Standard principle compl iance 95% <80 80-99 90-100 86 97 92 98 NA NA NA NA NA 100 100 94 86 94 98 96 97 NA 92 97 100 86 92Tota l no of MSSA bacteraemias : Hospi ta l No Target No Target No Target No Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Tota l no of C. diff infections: Hospita l 19/yr >0 No Target 0 0 0 1 0 0 0 0 0 NA 0 0 0 0 0 0 1 1 NA 0 0 0 0 0Tota l no of C.diff infections: Community acquired

No Target No Target No Target No Target ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND

Antibiotic Audit 98% <85 85-97 98-100 98 NA 100 100 NA NA NA NA NA 80 100 100 98 97 97 100 95 NA 100 98 NA NA 100Tota l no of E Col i No Target No Target No Target No Target ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDIsolation data 95% <85 85-94 95-100 NA NA NA NA NA NA NA NA NA ND ND ND ND ND ND ND ND ND ND ND ND ND NDEnvironment/Isolation 90% <80 80-89 90-100 86 94 89 96 NA NA NA NA NA 95 94 89 89 89 95 93 90 NA 90 91 84 95 92VIP score documentation 90% <80 80-89 90-100 100 92 84 100 NA NA NA NA NA 100 NA 100 77 100 94 90 47 NA 85 81 100 100 100MEWS documentation and esca lation compl iance

100% <80 80-99 100 100 100 85 100 NA NA NA NA ND 100 97 70 100 100 100 100 100 ND 50 100 NA NA 100

No of patient fa l l s 0% >0 No Target 0 2 0 5 2 NA NA NA NA 0 0 6 5 3 1 3 8 6 0 4 4 NA 0 0Fal l s per 1,000 bed days 5.6% >5.8 5.6-5.8 <5.6 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NANo of patient fa l l s resulting in harm 0% >0 No Target 0 0 0 2 1 NA NA NA NA 0 0 2 0 2 1 1 2 2 0 3 0 NA 0 0No. of serious injuries or deaths resulting from fa l l s

0% >0 No Target 0 0 0 0 0 NA NA NA NA 0 0 0 0 0 0 0 0 0 0 0 0 NA 0 0

No of patients with ward acquired Grade 2 pressure ulcers

0% >0 No Target 0 1 0 0 0 NA NA NA NA NA 0 0 0 1 0 0 0 0 NA 0 1 NA 0 0

No of patients with avoidable ward acquired Grade 2 pressure ulcers

0% >0 No Target 0 ND 0 0 0 NA NA NA NA NA 0 0 0 ND 0 0 0 0 NA 0 0 NA 0 0

No of patients with ward acquired Grade 3 or 4 pressure ulcers

0% >0 No Target 0 1 0 0 0 NA NA NA NA NA 0 0 0 0 0 0 0 0 NA 0 1 NA 0 0

No of patients with avoidable ward acquired Grade 3 or 4 pressure ulcers

0% >0 No Target 0 ND 0 0 0 NA NA NA NA NA 0 0 0 0 0 0 0 0 NA 0 ND NA 0 0

Nutrition: Assessment and monitoring 95% <85 85-94 95-100 100 100 100 100 100 NA NA NA NA 100 100 100 90 100 100 100 100 NA ND 100 NA NA 100

Ward Analysis Quality Report - September 2013

Patient Safety

Surgery Medicine Women & Chi ldren

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Group Indicator Target Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU G5 F9 F10 G1 G3 G4 F7 G8 MTU F8 G9 F1 F11 F14

Hydration: Patients wi th appropriate fl uid ba lance management

No Target No Target No Target No Target 90 60 80 70 NA NA NA NA ND ND 60 70 60 40 100 40 90 ND ND 90 NA NA 100

No of SIRIs and potentia l SIRIs 0% >0 No Target 0 1 0 0 0 2 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0No of drug errors : resulti ng in harm 0% >0 No Target 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0No. of CD errors (patient safety) 0% >0 No Target 0 1 0 0 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0 2 0 0 0 0Cardiac arres ts : No. outs ide CCS No Target No Target No Target No Target 0 0 0 0 NA 0 0 0 0 1 1 2 1 0 0 0 0 0 0 0 0 0 0Cardiac arres ts outs ide CCS: No. of RCAs No Target No Target No Target No Target 0 0 0 0 NA 0 0 0 0 1 1 2 1 0 0 0 0 0 0 0 0 0 0

Pain Management: Quarterly interna l report 80% <70 70-79 80-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

VTE: Completed ri sk assessment (monthly Uni fy audi t)

> 98% < 98 No Target > 98 100 100 100 100 94.44 ND ND ND ND 100 100 100 100 ND 100 100 95.38 ND 88.89 97.37 ND 99.35 90.35

VTE: Prophylaxis compl iance 100% <95 95-99 100 100 100 100 100 ND NA NA NA NA 100 100 100 96 100 100 100 100 NA 100 100 NA 100 100Safety Thermometer: % of pati ents experiencing harm-free care

95% <95 95-99 100 84 100 100 100 75 NA NA NA NA 71.43 83.87 93.94 80.95 81.82 75.86 82.76 96.67 NA 100 100 NA 100 100

Pati ent Sati sfaction: In-pati ent overa l l resul t

85% <75 75-84 85-100 84 93 95 93 NA NA NA NA NA 96 87 85 89 91 94 85 NA NA 91 87 NA NA 98

How l ikely i s i t that you would recommend the service to friends and fami ly?


In your opinion, how clean was the hospi ta l room or ward that you are in?


Did you feel you were treated with respect and digni ty by s taff?


Were Staff caring and compass ionate in thei r approach?


Were you ever bothered by noise at night from other pati ents?


Did you fi nd someone on the hospi ta l s taff to ta lk to about your worries and fears?


Were you involved as much as you wanted to be in decis ions about your conditi on and treatment?


Were you given enough privacy when discuss ing your care?


Did you get enough help from s taff to eat your mea ls

85% <75 75-84 85-100 88 ND 100 100 NA NA NA NA NA 100 93 100 ND 83 100 100 NA NA ND 93 NA NA 100

Were you given enough privacy when being examined or treated?


Timely ca l l bel l response 85% <75 75-84 85-100 49 67 83 78 NA NA NA NA NA 86 54 48 45 78 71 41 NA NA 61 65 NA NA 90Number of surverys completed No Target No Target No Target No Target 34 52 37 34 NA NA NA NA NA 8 24 10 16 11 28 21 NA NA 26 36 NA NA 15Same sex accommodati on 0% >2 100% 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NA NA NASame sex accommodati on: tota l pati ents 0% >2 100% 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NA NA NACompla ints 0% >2 1-2 0 0 0 0 0 0 0 0 2 6 0 0 0 0 0 1 0 1 0 2 1 0 0 1Environment and Cleanl iness 90% <80 80-89 90-100 96 93 89 89 91 86 93 88 89 98 88 89 83 87 87 ND 91 93 97 88 92 93 95Environmenta l Audi t 90% <80 80-89 90-100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDPati ent Sati sfaction: short-s tay overa l l resul t

85% <75 75-84 85-100 NA 100 NA NA NA NA NA 100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

How l ikely i s i t that you would recommend the service to friends and fami ly?


Were you given enough privacy when being examined and treated?


Were s taff profess iona l , approachable and friendly?


Were you told who to contact i f you were worried after leaving hospi ta l?


Overa l l how would you rate the care you received in the department?


Number of surverys completed No Target No Target No Target No Target NA 70 NA NA NA NA NA 38 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Patient Safety


Patient Experience: short-stay

Surgery Medicine

Patient Experience: in-patient

Women & Chi ldren

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Group Indicator Target Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU G5 F9 F10 G1 G3 G4 F7 G8 MTU F8 G9 F1 F11 F14Pati ent Sati sfaction: A&E overa l l resul t 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA 90 NA NA NA NA NA NA NA NA NA NA NA NA NA NAHow l ikely i s i t that you would recommend the service to friends and fami ly?

75% <70 70-74 75-100 NA NA NA NA NA NA NA NA 59 NA NA NA NA NA NA NA NA NA NA NA NA NA NA



Were you given enough privacy when discuss ing your condition at recepti on?


Did Doctors and Nurses l i s ten to what you had to say?


Did a member of s taff tel l you what danger s igns to watch for when going home?


Did s taff tel l you who to contact i f you were worried about your condition after leaving A&E?


Number of surverys completed No Target No Target No Target No Target NA NA NA NA NA NA NA NA 419 NA NA NA NA NA NA NA NA NA NA NA NA NA NAPati ent Sati sfaction: A&E Chi ldren questi ons overa l l resul t


How l ikely are you to recommend our A&E department to friends and fami ly i f they needed s imi lar care or treatment?


Did the Doctor or Nurse l i s ten to what you had to say?


Were s taff friendly and kind to you and your fami ly?


Did we help wi th your pa in? 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA 83 NA NA NA NA NA NA NA NA NA NA NA NA NA NADid s taff expla in the care you need at home?

85% <75 75-84 85-100 NA NA NA NA NA NA NA NA 100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Number of surverys completed No Target No Target No Target No Target NA NA NA NA NA NA NA NA 7 NA NA NA NA NA NA NA NA NA NA NA NA NA NAPati ent Sati sfaction: Materni ty overa l l resul t

85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 93 NA

How l ikely i s i t that you would recommend the post-nata l ward to friends and fami ly i f they needed s imi lar care or treatment?


How l ikely are you to recommend our bi rthing uni t/labour sui te to friends and fami ly i f they needed s imi lar care or treatment?


How l ikely are you to recommend our antenata l department to friends and fami ly?


How l ikely are you to recommend our post-nata l care to friends and fami ly?




Did you fi nd someone on the hospi ta l s taff to ta lk to about your worries and fears?


Were you involved as much as you wanted to be in decis ions about your care and treatment?


Were you given enough privacy when being examined or treated?


Did you hold your baby in skin to skin contact after the bi rth (baby naked apart from the nappy and a hat, lying on your chest)?


Were you given adequate help and support to feed your baby whi l s t in hospi ta l?


Patient Experience: Maternity

Patient Experience:

A&E

Patient Experience:

A&E (Children

questions)

Ward Analysis Quality Report - September 2013 Surgery Medicine Women & Chi ldren

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Group Indicator Target Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU G5 F9 F10 G1 G3 G4 F7 G8 MTU F8 G9 F1 F11 F14How many minutes after you used the ca l l button did i t usual ly take before you got the help you needed?


Has a member of s taff told you about medication s ide effects to watch for when you go home?


Have hospita l s taff told you who to contact i f you are worried about your condition after you leave hospita l?


In your opinion, how clean was the hospita l room or ward that you were in?


Number of surverys completed No Target No Target No Target No Target NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 96 NAPatient Satisfaction: Chi ldren's Services Overa l l Result

85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 100 NA NA

How l ikely are you to recommend our ward to friends & fami ly i f they needed s imi lar care or treatment?


Did you understand the information given to you regarding your treatment and care?


Were you as involved as you wanted to be in decis ions about your care and treatment?


Did the Doctor or Nurses expla in what they were doing in a way that you could understand?


Were you offered age/need appropriate activities?

85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA ND NA NA

Was your experience in other hospita l departments (i .e. X-ray department, out-patient department, theatre) satisfactory?


Was your experience during procedures/investigations (i .e.blood tests , X-rays) managed sens itively?


If you were in pa in, did the Doctor or Nurse do everything they could to help with the pain?


Were s taff kind and caring towards you? 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 100 NA NAIs the environment chi ld - friendly? 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA ND NA NAOveral l , how would you rate your experience in the Paediatric Unit?

85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA ND NA NA

Number of surverys completed No Target No Target No Target No Target NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 5 NA NA

Patient Satisfaction: F1 Parent overa l l resul t 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 99 NA NA

How l ikely are you to recommend our ward to friends & fami ly i f they needed s imi lar care or treatment?


Did you understand the information given to you regarding your chi ld's treatment and care?


Were you and your chi ld as involved as you wanted to be in decis ions about care and treatment?


Did the Doctor or Nurses expla in what they were doing in a way that your chi ld could understand?


Were there appropriate play activities for your chi ld (such as toys , games and books)?


Was your chi ld's experience in other hospi ta l departments (i .e. X-ray department, out-patient department, theatre) satisfactory?


Surgery Medicine Women & Chi ldren

Patient Experience: Maternity

F1 Parent

Children's Services Patient

Satisfaction: Young

Children


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Group Indicator Target Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU G5 F9 F10 G1 G3 G4 F7 G8 MTU F8 G9 F1 F11 F14Was your chi ld's experience during procedures/investigations (i .e.blood tests , X-rays ) managed sens itively?


If your chi ld was in pa in, did the doctor or nurse do everything they could to help with the pa in?


Were s taff kind and caring towards your chi ld


Is the environment chi ld-friendly? 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 100 NA NAOvera l l , how would you rate your experience in the Chi ldren's Uni t?


Number of surverys completed No Target No Target No Target No Target NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 52 NA NAPatient Satisfaction: Stroke overa l l resul t 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 94 NA NA NA NA NA NAHow l ikely i s i t that you would recommend the service to friends and fami ly?

75% <70 70-74 75-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 100 NA NA NA NA NA NA

Have you been told you have had a s troke, which lead to your admiss ion to hospita l?


Have you been involved in planning your recovery / rehabi l i tation?


Whi le you were in the Stroke Department how much information about your condition or treatment was given to you?


Have you received the help you require whi le eating?


Do you feel cared for? 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 100 NA NA NA NA NA NAWere you given enough privacy when being examined or treated or when your care was discussed with you?


Number of surverys completed No Target No Target No Target No Target NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 16 NA NA NA NA NA NASickness 3.5% >6 3.5-6 <3.5 4.8 4.3 2.6 6.6 8.3 6.3 4 9.4 4.9 4.7 3.8 9.1 5.6 3.8 2.6 2.4 5 NA 3.5 1.1 2.1 5 10.1Sickness (Short term) No Target No Target No Target No Target 3.2 3.7 2.6 6.2 4 3.8 2.5 2 3.4 1.6 3.8 6.9 1.1 3.8 1.2 2.4 2.5 NA 3.4 1.1 1 3.7 2Sickness (Long term) No Target No Target No Target No Target 1.7 0.5 0 0.4 4.3 2.5 1.4 7.5 1.5 3.1 0 2.2 4.5 0 1.4 0 2.6 NA 0.2 0 1.1 1.3 8Vacancies (WTE) No Target No Target No Target No Target -4.1 -0.1 -1.1 -4.9 -5.2 -14.2 -1.5 1.4 -4.6 -1.8 -6.5 -1 0.9 -0.5 4.1 -3.7 -5 NA 13.7 0 -0.1 -15.2 -0.7Turnover (Annual ) 10% >10% No Target 0%-10% 6.8 ND 5.41 4.08 7.55 2.2 3.45 6.67 6.33 6.25 2.27 ND 2.56 10.26 6.67 5.17 9.26 NA 3.03 4.44 5.13 ND 6.67

Ward Analysis Quality Report - September 2013 Surgery Medicine Women & Chi ldren

Patient Experience:

Stroke

Staffing

F1 Parent

9

Clinical Quality Priorities: Summary

• The increase in C. difficile infections reported at the end of August continued in September and this continues to be a challenge for the Trust. An external review, commissioned by the Trust, was carried out on 7th October 2013 and the formal report has been received and has been circulated to the Board. The updated C. difficile action plan will be presented to the Clinical Safety & Effectiveness Committee in November and to the Board at the end of November.

• The Friends and Family score for inpatients returned to 87 after a slight fall last month.

• The Friends and Family score was commenced at four points of maternity care in September and the results are reported. The score for the post natal ward is lower than at other points of care but this is in line with scores in previous months (the post natal ward has carried out the Friends and Family test within the inpatient maternity questionnaire previously).

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Quality Priority: Ward Performance Issues

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

• Ward F3 continues to have a number of vacancies due to turnover. Six beds have been closed on the ward to ensure that patient safety and quality are maintained.

• Uplifts in nurse establishments have been agreed for wards F9 and G3.

• The newly opened F7/8 scored poorly in some of the quality audits such as hydration and MEWS in September. The ward is not up to a full complement of permanent staff yet and a large number of temporary staff have been utilised to fill the gaps. This has meant that there was less awareness of the documentation requirements for these areas of care, but it is being addressed by the acting unit manager.

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.

Quality Priority: Infection Control

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MRSA BacteraemiaThere were no hospital associated MRSA bacteraemia during September

C. difficileThere were three hospital acquired C. difficile infections this month and a period of increased incidence has been declared on ward G4 following 2 infections within 28 days. The ward has been deep cleaned.

An independent review has been carried out and the team visited the Trust on 7 th October 2013. Informal feedback at the end of the day identified some areas of action for the Trust which are being addressed. The formal report has now been received and the key areas of focus are included in the Chief Executives report.

Hand HygieneHand hygiene compliance was 100%.

MRSA screeningElective: 91.3% Non Elective: 93%Compliance in both elective and non-elective MRSA screening has increased this month but further improvements are needed if we are to achieve 100% compliance as required by the Commissioners. Discussions have taken place with the Oncology Day Unit to further investigate the issues to ensure improved compliance in this group of patients. In addition, plans to incorporate screening with the electronic risk assessment should also ensure that targeted action can be taken to address both elective and non-elective screening.

Quality Priority: Falls

Falls performance

This month we have changed the definition of falls which now includes patients who faint or collapse due to medical reasons. This brings us inline with other Trusts in the region; for this reason we anticipated a rise in the total number of falls per month. There were 49 falls across the Trust during September, 3 of which were faints and collapse; 15 of these falls resulted in harm but none resulted in serious harm. The rate per 1,000 occupied bed days is 5.31 (August 4.53).

ThemesOur preliminary work on falls in toilets has shown that in July, 15 falls or 17% of the total falls occurred in the WC, August had 5 or 10% of the total number and September 6 falls, which was 11.7% of the total number of falls.Detailed intelligence is being collected in October to reveal what the patient was actually doing at the time of the fall.The Estates Department are carrying out further assessment of the requirements for the provision of side rails in all toilets.No other themes have been identified to date..

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Quality Priority: Pressure Ulcers

14

The performance target is to have no avoidable Grade 2, 3 or 4 pressure ulcers 2013-14

Grade 2 pressure ulcersThere were three grade 2 pressure ulcers this month.The Trust has recently purchased 30 new pressure relieving mattresses to replace some of our aging equipment and to increase the overall number of specialist mattresses available to patients

Grade 3 and 4 pressure ulcersThere were two hospital associated grade 3 pressure ulcers this month. One was a patient who was admitted with a grade 2 sacral ulcer which unfortunately deteriorated on F3 ward. This patient was receiving end of life care and despite taking all preventative measures, including specialist mattress and regular turning, the ulcer unfortunately deteriorated. The second grade three occurred on ward G9. This patient was 28 years of age and independent and suffered from type one diabetes with peripheral neuropathy and mental heath issues. They had previously sustained lower limb injuries and required to wear an orthopaedic boot, under the boot was a recently heeled ulcer and the new skin was very delicate. The patient refused to allow staff to check their pressure areas and the ulcer broke down again during their hospital stay.

Safety thermometer results

Current performance for harm-free care is 91.03%. National September performance is 93.1%.

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 97.55%. National September performance is 97.2%.

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

Harm Free 92.44 92.15 92.71 93.77 95.66 93.02 93.36 93.68 91.47 93.20 92.60 93.22 92.68 91.03

Pressure Ulcers – All 3.78 3.80 4.02 3.38 1.79 5.17 3.55 3.51 4.50 4.28 5.36 3.52 2.98 5.16

Pressure Ulcers - New 0.58 0.25 1.51 0.26 1.02 0.52 0.71 0.94 0.95 1.01 0.00 1.08 0.00 1.09

Falls with Harm 0.00 0.76 0.75 0.26 0.51 0.78 0.71 0.23 1.66 0.00 0.26 0.81 0.27 0.00

Catheters & UTIs 2.03 2.78 2.01 2.08 1.79 1.03 1.66 2.58 0.95 1.76 1.53 2.17 2.98 3.60

Catheters & New UTIs 0.29 0.25 0.25 0.00 0.26 0.26 0.47 0.23 0.24 0.00 0.51 0.54 1.08 0.82

New VTEs 2.03 1.01 0.50 0.78 0.26 0.26 0.71 0.47 1.42 0.76 0.26 0.54 1.36 0.54

All Harms 7.56 7.85 7.29 6.23 4.34 6.98 6.64 6.32 8.53 6.80 7.40 6.78 7.32 8.97

New Harms 2.91 2.28 3.02 1.04 2.04 1.81 2.61 1.87 4.27 1.76 1.02 2.98 2.71 2.45

Sample 344 395 398 385 392 387 422 427 422 397 392 369 369 368

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

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Patient Safety

High Impact Medication Errors

During Quarter 2 July 2013 to 30 September 2013 there were 149 medication related incidents reported on the Datix system. Of these, 11 (7.4%) were classified as HIME’s. The Drugs and Therapeutics Committee continues to monitor all medication errors and ensure that organisation learning is disseminated. A Safety Bulletin from the Drugs and Therapeutics Committee has been developed to raise awareness of the issues and provide a monthly notification of current themes.

Deteriorating patient

The on going focus on early identification and escalation of patients who trigger on the MEWS score is ensuring that compliance is over 90%. There was a low score of 50% on F7/8; this is referred to in the ward performance summary of this report and is being addressed by the acting unit manager.

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Quality Priority: Patient Experience – Achievement of 85% satisfaction

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‘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 91%, in line with previous months. A workshop was held for the wards to discuss the findings of the Call Bell project and agree an action plan. This is reported separately.

Overall satisfaction scores for the OPD, A&E, short stay and Maternity services were maintained at a high level. The graphs below give some of the detail for the maternity survey. This shows a variation in the recommender score but this is not reflected in the scores for other questions.

Quality Priority: Patient Experience – recommend the service

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‘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 87 for inpatients during September, a return to a high score following a slight reduction in August.

The score for A&E was 59. It would appear that the score of 72 for A&E in April was a higher than normal score as subsequent scores have been between 54 and 64. This month there were six comments from patients in response to reasons for not scoring “extremely likely”. Four of these related to waiting times and two gave reasons unrelated to the perception of care: “don’t live in the area” and “if A&E needed then would come regardless of recommendations”.

Maternity services have been using the Friends and Family question within their survey for patients on the post-natal ward (F11) for over a year. However, the question has become a requirement nationally through CQUIN from this month. There is a requirement to ask the question four times; at the 36 week antenatal appointment, following birth in the delivery suite or birthing unit, post-natally on discharge from the post natal ward and lastly at the time of discharge in the community. The question is asked on its own except on the post natal ward. The scores for this month are shown below:

It is too early to say whether these variations are significant. The score on the post-natal ward has shown some variability from month to month previously.

Antenatal Birth Post natal ward Community

77 91 66 90

CQC Action Plan

Following the recent CQC inspection, an action plan was presented to the Board last month to address the issues in relation to variability of staff knowledge and application of the mental capacity act and documentation of verbal consent. The intention is to provide an update in this report each month as to progress against the plan.

Update

The education and training activities identified in the action plan are progressing well. There have been a number of in-house sessions and several staff have attended a UEA study day on MCA and DOLS. The university have planned several repeat sessions and a total of 25 nursing staff have, or have booked to attend the study days. This includes a range of staff from matron to newly qualified nurses. Monthly staff education sessions are being held in conjunction with the County MCA and DOLS Coordinator.

A session to discuss mental capacity assessment, DNACPR documentation and verbal consent was held at the Medical Directorate Governance/Audit afternoon in September and was well received. This will be repeated at the next Surgical Directorate Audit session.

Briefing documents and a flowchart have been distributed to wards and departments in September and October as per the timescale in the action plan.

The question has been added to the CQC assurance self assessment audits and the September results will be available next month.

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Local Priorities - Governance Dashboard

Indicator Performance target R A G Sep13 Commentary

Timely completion of incident investigations and actions

Outstanding RCAs (non SIRI) more than 45 days after incident reported

>1 1 0 0

RCA Actions beyond deadline for completion >=5 1-4 0 3 Discussed at Operational Steering Group

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

>150 50-150 <50 306 See exception report for details

Timely reporting of SIRIs

SIRIs reported > 2 working days identified as red

>1 1 0 0 7 / 7 within deadline. Three were identified as red after the incident date: one through a review of amber investigations, one through audit and one through inquest

SIRI final reports due in month submitted beyond timeframe

>1 1 0 0 11 / 11 within deadline

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

>10 6-10 0-5 18 See exception report for details

Duty of Candour Compliance with Duty of Candour requirements

<75% 75 – 94% >=95% 100% Duty of Candour achieved for all 18 applicable cases in September. This is the first time this indicator has been reported. Board approval of the KPI RAG rating is requested.

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% 96%

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Local Priorities - Governance Dashboard (cont.)

Indicator Performance target R A G Sep13 Commentary

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% 94% 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 Five interventional procedures and Six Clinical Guidelines are outstanding baselines assessment and require targeted follow up. IPG (Interventional procedure guideline) baseline

assessments beyond agreed deadline timeframe

>9 4 - 9 0 - 3 5

CG (Clinical guideline) baseline assessments beyond agreed deadline timeframe

>9 4 - 9 0 - 3 6

Complaints Response within 25 days or negotiated timescale with the complainant

<75% 75 – 89% >=90% 86% 5/35 responses due in September were sent out late

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

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 1

Compliments Compliments received centrally No RAG rating 52

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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. This was rebased in March to take into account the new dataset from the Apr12 - Sept 12 NRLS report showed a fall in the peer group median but upper and lower quartiles remained similar to previous reports.

There were 432 incidents reported in September including 361 patient safety incidents (PSIs). The reporting rate rose in September to just above the upper quartile for the peer group.. The number of harm incidents in September was below the peer group average level.

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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) has been rebased to 0.9% from the NPSA Apr ’12 – Sept ‘12 report and sits above the Trust’s average. The WSH data is plotted as a line which shows the rolling average over a 12 month period. The number of confirmed serious PSIs are plotted as a column on the secondary axis.

The unconfirmed incident in June 2012 was identified through TARN audit and the October 2012 incident via a complaint - both reported retrospectively in September 2013. In July there were six ‘Red’ patient safety incidents: Incorrect implant (1) pressure ulcer (1), deteriorating patient(1) and three awaiting confirmation through RCA: Fall (2) and Inquest (1)

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Local Priorities: Complaints

There was a slight reduction in the number of complaints received in September 2013 although numbers remain high compared with 2012.

Complaint response within agreed timescale with the complainant: 86% of responses due in September This represents 5 of the 32 complaint responses going out late.

Of the 29 complaints received in September, the breakdown by Primary Directorate is as follows: Medical (15), Surgical (5), Clinical Support (0), Facilities (1), and Women & Child Health (8). The high number of complaints received in Woman & Child Health has been brought to the attention of the General Manager of this directorate.

Trust-wide the top 5 most common problem areas are as follows:

All Aspects of Clinical Treatment 20

Communication / Information to Patients (written and oral) 12

Attitude of Staff 8

Admissions, Discharge and Transfer Arrangements 4

Aids and Appliances, Equipment, Premises (including access) 3

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Local Priorities: PALS (Patient Advice & Liaison Service)

In August 2013 there were 89 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.

A breakdown of contacts by Directorate from Sep’12 to Sep‘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.

Information/Advice request 36 All aspects of clinical treatment 24 Appointments, delay, cancellation (outpatients) 8

Communication/information to patients (written/oral) 6 Patients property and expenses 5

The numbers across the different areas of concern remain constant and there are no particular themes that the PALS Manager has identified this month. Two areas featuring again are Patients Property/Expenses which continues to be a misunderstanding about the role of PALS in this respect and a number of queries related to orthopaedic surgery.Orthopaedic surgery has been identified as increasing for the month however there is no identified trend or theme. This area will be kept under review. It is evident that the PALS Manager, in addition to assisting with genuine concerns from patients and relatives, frequently signposts enquirers to other services. She is also actively involved in dealing with specific in-patients and their families concerns during the total admission period.

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Local Priorities – Workforce Performance

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Performance Indicator ThresholdDirect

Financial Penalty

12 Month

YTDComments Lead Exec

Workforce

Sickness absence rate <3.5% NO 3.91% Jan Bloomfield

Turnover <10% NO 7.76% Jan Bloomfield

Reviews Grievance/Banding reviews NO 10No New Cases - 1 on-going Tribunal and 1 Outstanding Agenda for Change Banding Appeal

Jan Bloomfield

Recruitment Timescales Average number of weeks to recruit = 7 NO 5.7 Jan Bloomfield

CRB Disclosures existing staff To complete 95% of required CRB checks NO 98.51% Jan Bloomfield

All Staff to have an appraisal

Both 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 85.85% Jan Bloomfield

Mandatory Training compliance (reported Quarterly)

Jan Bloomfield

CQUIN – October 2013

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Monitor Compliance Framework

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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% 98.08% 98.53% 1.0 Jon Green

Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted 95% 99.87% 99.96% 1.0 Jon Green

Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway 92% 100.00% 99.97% 1.0 Jon Green

A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge 95% 98.11% 96.36% 1.0 Jon Green

All cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer 85% 87.00% 89.03%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% 97.02% 97.64%

0.5Jon Green

Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer not initially suspected) 93% 98.67% 98.59% Jon Green

Outcomes:

Clostridium (C.) difficile - meeting the C.difficile objective - MONTH 2 3

1.0

Nichole Day

Clostridium (C.) difficile - meeting the C.difficile objective - QUARTER Q1 = 3, Q2 = 4, Q3 = 6, Q4 = 6

8 Nichole Day

Clostridium (C.) difficile - meeting the C.difficile objective - ANNUALLY 19 16 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

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Performance Indicator ThresholdIn Month

Performance

YTD Comments Lead Exec

A&E

A&E - Threshold for admission via A&E

i) if the monthly ratio is above the corresponding 2011/12 monthly ratio for two month in a six month periodii) if year end is greater than 27%

23.90% 24.92% 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

StrokeStroke -Proportion of Patients admitted to an acute stroke unit within 4 hours of hospital arrival 90% 92.00% 84.83% Jon Green

Proportion of patients in Atrial Fibrillation, presenting with stroke and where clinically indicated will receive anti-co-agulation.

60% 33.00% 65.83% Jon Green

Stroke - % of Stroke patients with access to brain scan within 24 hours 100% 100.00% 98.33% Jon Green

Stroke - Proportion of Stroke Patients and carers with a joint health and social care plan on discharge 85% 100.00% 90.67% 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% 92.33% Jon Green

>80% treated on a stroke unit >90% of their stay 80% 88.00% 87.83% 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% 75.00% 76.33% 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% 76.00% 74.83% Jon Green

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

% Jon Green


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Discharge Summaries

Discharge Summaries - Outpatients 95% sent to GP's within 3 days 85.74% 84.62% Dermot O'Riordan

Discharge Summaries - A&E 95% of A&E Discharge Summaries to be sent to GPs within one working day 97.67% 97.50% Dermot

O'Riordan

Discharge Summaries - Inpatients 95% sent to GP's within 1 day 78.97% 82.92% Dermot O'Riordan

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 1.66% 1.15% Jon Green

Patients offered date within 28 days of cancelled operation 100% 100.00%

100.00% Jon Green

Maternity

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.

97.45% 95.94%

Nichole DayMaintain maternity 1:30 ratio 1:30 1:30 1:29 Nichole Day

Pledge 1.4: 1:1 care in established labour 1:1 100.00%100.00

% Nichole DayBreastfeeding initiation rates. 80% 76.68% 78.93% 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% 21.31% 18.84% Nichole Day


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Other contract / National targetsMixed Sex Accomodation breaches 0 Breaches 0 2 Jon Green

Consultant to consultant referral Commisioner to audit if concern about levels of consultant referrals 6.57% 5.92% 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% 87.29% 87.58% Jon Green

MRSA - emergency screeningAll emergency patients admissions are to be screened for MRSA within 24 hours of admission

93.03% 92.02% Nichole Day

Rapid access - chest pain clinic 100% of patients should have a maximum wait of two weeks 100.00% 74.72% Jon Green

New to Follow up Thresholds set at each speciality - overall Trust Threshold is 1.9 1.78 1.86 Jon Green

Trust Quality and Performance Report October 2013 Agenda item 11.

Documents

performance discussion

performance framework

performance reportoctober

current performance

date performance

quarterly performance

target values

dominator patients