1 board report – performance september 2009 produced by business intelligence (performance)

1

Board Report – Performance

September 2009

Produced by Business Intelligence (Performance)

2

Apr-

09

May-0

9

Jun-0

9

Jul-09

Aug-0

9

Sep-0

9

Oct-

09

Nov-0

9

Dec-0

9

Jan-1

0

Feb-1

0

Mar-

10

acquired pre admission 2 3 0 0

acquired post admission 2 0 2 1

YTD MRSA Infections 4 7 9 10

Cumulative Trajectory 2 4 6 8 10 13 15 17 19 21 22 22Western 4 3 1 1QVH 0 0 1 0BSUH 4 3 3 2SASH 2 3 0 1

0

1

2

3

4

5

6

7

8

9

10

April

May

June

July

August

Septe

mber

Octo

ber

Novem

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Decem

ber

January

Febru

ary

Marc

h 0

5

10

15

20

25

30

35

40

45

MRSA 2008/9 MRSA 2009/10 Cumulative trajectory

YTD Actual MRSA Infections 2008/9 YTD Actual MRSA Infections 2009/10

West Sussex PCT Cleanliness and HCAI - MRSA infections

The was only one case of MRSA recorded in July for Western Hospitals Trust. Cases have fallen month on month to a total of 10 for July against a DH target of 8,compared to 18 cases this time last year.

Numbers for August show 2 cases of MRSA. Trust and Community attributable show a fifty percent split. Work continues with West Sussex Trusts through the HCAI Task Force.

Brighton Trust shows 12 cases against a target of 10. 7 Hospital acquired, however the PCT is only measured against the Host Trust so BSUH and SASH are for information only.

Lead: Mona Walker – Interim Director of Quality

Cleanliness and HCAI

3

There were 32 cases for July against a DH trajectory of 50 and a stretch target of 45. This demonstrates the lowest number of cases in a month since the start of the year. From a year to date point of view we have 163 cases against a DH target of 210 and a stretch target of 179. This is an improvement on last year when we were 22 cases above DH target.

Community cases have also decreased and for the first time this year is showing green against stretch trajectory of 2 cases.

SASH is the only provider who are above stretch trajectory-by one case, however this does not affect the PCT target as we are only measured against the Host trust.

Lead: Mona Walker – Interim Director of Quality

Cleanliness and HCAI

Ap

r-0

9

Ma

y-0

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Ju

n-0

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Ju

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Au

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Se

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Oct-

09

No

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Ja

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Ma

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Community cumulative actual 15 33 57 70

Community Cumulative stretch target 12 25 39 54 71 89 106 125 143 161 183 206

Community Cumulative DH target 23 41 58 77 96 117 140 170 199 232 262 292

0

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20

30

40

50

60

70

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90

100

April May June July August September October November December January February March0

50

100

150

200

250

300

350

Community 2008/9 Community 2009/10 YTD DH Community trajectory YTD Actual C.diff 2008/9 YTD Community 2009/10

West Sussex PCT Cleanliness and HCAI - Commissioner Clostridium difficile infections (Community)

4

Emergency Care

The cumulative position has dropped below the 75% target for the first time this. The 75% target has not been met for 3 consecutive monthsand for the first time this month, SECAmb as a whole has dropped below the target.

In order to have achieved the 75% target:-Chichester – require to achieve 50 additional responses <8mins for July and 142 cumulativelyHorsham – require to achieve 47 additional responses <8mins for July and 173 cumulativelyMid Sussex – require to achieve 43 additional responses <8mins for July and 109 cumulatively

West Sussex – require to achieve 43 additional responses <8mins for July and 16 cumulatively

The number of Wards in the lower performing categories (<25% and 25-50%) has increased by 50% since last month (from 24 to 36) – the decrease is replicated within the 50-75% category. From the month 10 board update last year, an update was given that listed a number of schemes which would improve the ambulance response times for Category A within 8 minutes. Having monitored the response times since then a significant improvement has not been made at Ward level. A short report on the key action points will be agreed with SECAmb and an update will be provided next month. Ward level analysis can be found in Appendix 1.

District July 2009 + / - since last month June 2009

Adur 75.80% +1.06% 74.74%

Arun 77.64% -1.48% 79.12%

Chichester 61.26% +1.70% 59.56%

Crawley 84.81% -0.31% 85.12%

Horsham 59.47% +2.87% 56.60%

Mid Sussex 61.27% -11.48% 72.75%

Worthing 86.05% +3.05% 83.00%

West Sussex PCT 73.14% -0.82% 73.96%

Category A with 8 minutes response time by District for July – target 75%

5

Emergency Care

Both cumulatively and monthly, the 95% target has not been achieved. Underachievement has occurred for 4 consecutive months.

District July 2009 + / - Target

Adur 97.56% +2.56%

Arun 94.80% -0.20%

Chichester 84.98% -10.02%

Crawley 91.75% -3.25%

Horsham 83.59% -11.41%

Mid Sussex 82.19% -12.81%

Worthing 95.18% +0.18%

West Sussex PCT 90.24% -4.79%

Category B with 19 minutes response time by District for July – target 95%

6

Apr-

09

May-0

9

Jun-0

9

Jul-09

Aug-0

9

Sep-0

9

Oct-

09

Nov-0

9

Dec-0

9

Jan-1

0

Feb-1

0

Mar-

10

Patients waiting > 6 weeks for 15 key diagnostic tests (monthly data) 12 16 5 15Patients Waiting 6+ Weeks for all other diagnostic tests on Quarterly Census 0 0 0 0

Total 12 16 5 15Target 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

0

10

20

30

40

50

60

70

Apr-

08

May-0

8

Jun-0

8

Jul-08

Aug-0

8

Sep-0

8

Oct-

08

Nov-0

8

Dec-0

8

Jan-0

9

Feb-0

9

Mar-

09

Apr-

09

May-0

9

Jun-0

9

Jul-09

Aug-0

9

Sep-0

9

Oct-

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Nov-0

9

Dec-0

9

Jan-1

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Feb-1

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Mar-

10

No

. p

ati

en

ts >

/< 6

weeks

Non-obstetric ultrasound Audiology - Audiology Assessments Cardiology - echocardiography Colonoscopy Cystoscopy Other Quarterly data

West Sussex PCT 18 weeks - diagnostic tests

There were 15 breaches of the 6 week diagnostic wait in July. These consisted of the following:

Portsmouth Hospital – 1 patient was an ECG delay and this was due to capacity, St Georges Hospital Colonoscopy – 1 patient breached as Consultant was on annual leave and no locum was arranged for cover

Great Ormond Street (1 patient) and UCL (2 patients) MRI breaches due to capacity- to be rectified by end of the month

UCL – (1 patient) sleep studies awaiting confirmation from patient

Park Surgery – 8 patients waiting 6-7 weeks was a capacity issue and will be raised via contracting. 1 patient waiting 11-12 weeks is patient choice. These issues are still being raised with the practice through a variation to the contract.

Lead: Bianca Kokkolas, Head of Performance and Programme Management

Waiting times

7

Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09Patients waiting >26 weeks for IP appointment 4 5 4 3 9 8 12 9 6 3 6 5

Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10Patients waiting >26 weeks for IP appointment 0 1 1 1

6.) Maximum wait of 26 weeks for an inpatient appointment.

SASH – T&O patient

Patient cancelled on original date. Ward did not pass on information and patient was booked and discharged on IT system and therefore was removed from waiting list.

This is the third month in a row where SASH have breached due to administrative errors. This has been raised with their host commissioner, Surrey PCT and awaiting response.

Waiting times

Lead: Bianca Kokkolas Head of Performance and Programme Management

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Apr

-09

May

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Jun-

09

Jul-0

9

Aug

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Sep

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Oct

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Nov

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Dec

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Jan-

10

Feb

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Mar

-10

No. 15 - 24 year old persons screened or tested for Chlamydia 572 433 1,701 501target

1,467 1,467 1,467 1,750

Annualised Screening or testing 6,864 6,030 10,824 9,621The population aged 15 - 24 years 87,400 87,400 87,400 87,400

0

500

1000

1500

2000

2500

Apr

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May

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Jun-

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Jul-0

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Sep

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Total number Screened target

West Sussex PCT

Sexual Health - Screening for Chlamydia - number of paitients screened

Agreement has now been reached as to the funding of the programme, and the contract variation with Western Sussex Hospitals Trust has been prepared.

A formal letter has been drafted and will be sent to the Trust for them to sign off. The trajectory for achievement of this target has not yet been agreed but there will be a meeting at the end of Sept to agree this.

The IT system for the collection of data has been ordered and the Trust await delivery.

Lead: Paul Woodcock Public Health Programme Manager

Sexual Health – Chlamydia screening

Apr

-09

May

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Jul-0

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Aug

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Nov

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A nnualised Ac tual % population aged 15 - 24 sc reened or tes ted for chlam ydia 7.9% 6.9% 12.4% 11.0%Target % population aged 15 - 24 sc reened or tes ted for chlam ydia 25.0% 25.0% 25.0% 25.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

Apr

-08

May

-08

Jun-

08

Jul-0

8

Aug

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Sep

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Oct

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Nov

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Dec

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Jan-

09

Feb

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Mar

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Apr

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May

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Jun-

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Jul-0

9

Aug

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Sep

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Oct

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Nov

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Dec

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Jan-

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Feb

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Mar

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No

. P

atie

nts

scr

een

ed

Actual % population aged 15 - 24 sc reened or tes ted for chlam ydiaTarget % population aged 15 - 24 sc reened or tes ted for chlam ydia

W est Sussex PC T

Sexual Health - Screening for C hlamydia - % patients screened

9

Childhood Immunisation

90%

91%

92%

93%

94%

95%

96%

97%

Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10

Aged 1 immunized for DTaP/IPV/Hib target

West Sussex PCT

Health Improvement - Immunisation rates 2008-10Aged 1 immunized for DTaP/IPV/Hib

85%

86%

87%

88%

89%

90%

91%

92%

93%

94%

95%

96%

97%


Aged 2 immunised for PCV target

West Sussex PCT

Health Improvement - Immunisation rates 2008-10Aged 2 immunised for PCV

90%

91%

92%

93%

94%

95%

96%

97%


Aged 2 immunised for Hib/MenC target

West Sussex PCT

Health Improvement - Immunisation rates 2008-10Aged 2 immunised for Hib/MenC

85%

86%

87%

88%

89%

90%

91%

92%

93%

94%

95%

96%

97%


Aged 2 immunised for MMR target

West Sussex PCT

Health Improvement - Immunisation rates 2008-10Aged 2 immunised for MMR

10

Childhood Immunisation

80%

81%

82%

83%

84%

85%

86%

87%

88%

89%

90%

91%

92%

93%

94%

95%

96%

97%


Aged 5 immunised for DTaP/IPV target

Health Improvemet - Immunisation rates 2008-10Aged 5 immunised for DTaP/IPV

West Sussex PCT

80%

81%

82%

83%

84%

85%

86%

87%

88%

89%

90%

91%

92%

93%

94%

95%

96%

97%


Aged 5 immunised for MMR target

Health Improvemet - Immunisation rates 2008-10Aged 5 immunised for MMR

West Sussex PCT

DTaP/IPV/Hib age 1 is almost on target. Hib/MenC age 2 uptake is within 2.1% of the target and MMR age 2 is within 1.4% of the target. Although there has been a marked increase in uptake during the last quarter, considerable improvement is required for DTaP/IPV age 5 which is 6.4% below target.

An immunisation action plan has been developed using NICE guidance. The immunisation coordinator is consulting with practice managers, GP locality groups and the head of children’s services. A data reconciliation project is also in progress to improve the accuracy of records.

Lead: Nick Kendall

11

0

500

1000

1500

Apr-09 May-09 Jun-09 Jul-09

0%

20%

40%

60%

80%

100%

Total referrals seen during the period Number of Breaches

% meeting 2w w target Target

Cancer - Two week GP referral to first OP appointmentWest Sussex PCT

0

20

40

60

80

100

120


0%

20%

40%

60%

80%

100%

Total Treated Number of Breaches % meeting target Target

31 days from ECAD/DTT to second/subsequent Drug treatment

West Sussex PCT

Cancer Waiting Times

The change to the counting methodology we knew would have an impact and we are continuing to see this effect. Acute trusts report a specific problem in patients refusing the offered appointment within the 2 weeks. This then has a knock on effect throughout the pathway. The PCT has taken remedial action in writing to all GPs in West Sussex and explaining the constraints on trusts surrounding 2ww referrals and the need to ensure that patients understand they are on an urgent pathway. Via local cancer action groups we are also taking a local perspective and for Worthing have instigated some audits around referrals, which our GP lead will be looking at with the trust to identify any trends or particular problem areas.

Lead: Alison Hempstead

0

5

10

15

20

25

30

35


0%

20%

40%

60%

80%

100%


62 days from decision to treat to first treatment through screening

West Sussex PCT

0

5

10

15

20

25


0%

20%

40%

60%

80%

100%


62 days from decision to treat to first treatment from Consultant Upgrade

West Sussex PCT

Draft Target - still to be f inalised

12

Appendix 1 Focused Wards: Cat A (8 min) Calls

Wards with <60% Cat A (8 min) Response Rates in 08/09 - Arising 09/10

Number of Responses >8 min

Apr May Jun JulArun District Arundel 171 83 79 29 4 4 11 10Arun District Barnham 244 100 94 35 10 6 8 11Arun District Pagham and Rose Green 271 145 102 53 10 13 12 18Arun District Yapton 175 88 79 42 11 12 7 12

Chichester District East Wittering 215 106 67 36 8 7 13 8Chichester District Petworth 186 143 73 63 15 16 17 15Chichester District Southbourne 185 156 77 54 8 13 15 18Chichester District West Wittering 142 68 53 26 2 4 9 11Horsham District Billingshurst and Shipley 271 175 80 61 10 22 14 15Horsham District Bramber, Upper Beeding 139 88 32 20 4 8 3 5Horsham District Chanctonbury 150 80 67 35 8 8 13 6Horsham District Chantry 297 166 124 67 10 22 15 20Horsham District Itchingfield, Slinfold 160 91 61 43 7 11 19 6Horsham District Southwater 176 101 73 46 7 13 10 16Horsham District Steyning 184 96 55 24 2 11 7 4

Mid Sussex District Ardingly and Balcombe 175 106 69 34 6 4 9 15Mid Sussex District Crawley Down and Turner 147 111 32 26 7 10 5 4Mid Sussex District Hurstpierpoint and Down 190 100 77 41 9 12 10 10

District

YTD Total Cat A Resps. >8 min

09/10WardTotal Calls

08/09

YTD Total Cat A Resps.

09/10

Total Late Cat A Resps.

08/09

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Appendix 1 (continued)

1 board report – performance september 2009 produced by business intelligence (performance)

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