trust quality and performance report
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Trust Quality and Performance Report. 29 November 2013 (October Performance Pack). Contents. 1. Executive Summary. - PowerPoint PPT PresentationTRANSCRIPT
Trust Quality and Performance Report
29 November 2013(October Performance Pack)
Contents
Slide numbers
Executive Summary 2 - 4
Clinical Quality Priorities inc Ward Dashboard 5 - 18
Local Priorities 19 - 26
CQUIN 27 - 30
Monitor Compliance 31
Contract Priorities 32 - 34
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 October was 97.08%, exceeding the 95% target for the fifth consecutive month and placing the Trust in the top quartile nationally and remains the best performance in the Region.
2. There were two cases of C.Diff in October against the threshold of two. This is covered on page 12 of this report.
3. Performance on outpatient and inpatient discharge summaries remains below target. A number of new steps have been introduced through the month. Further detail is on page 3.
4. Performance on MRSA screening of emergency admissions was 95% against the 100% target, and 92% for elective admissions. This is covered on page 12 of this report.
5. All Stroke targets were achieved for the month.
6. The Trust had 2 single sex breaches during October. All 2 occurred within a short timescale. See page 3.
2
3
Performance Indicator Threshold October Lead ExecDischarge Summaries - Outpatients 95% sent to GP’s within 3 days 81.63% Dermot O’Riordan
Performance Indicator Threshold October Lead ExecDischarge Summaries - Inpatients 95% sent to GP’s within 1 day 77.57% Dermot O’Riordan
Performance Indicator Threshold October Lead ExecMixed Sex Accommodation Breaches 0 3 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 .
All 3 breaches were associated with ITU step-down and occurred over a 48 hour period. High levels of level 3 occupancy and limited ward beds meant these patients could be neither safely partioned or stepped-down to wards.
4
Performance Indicator Threshold October Lead Exec
MRSA – Emergency ScreeningAll emergency patients admissions are to be screened for MRSA within 24 hours of admission
95.09% Nichole Day
Executive Summary
Performance Indicator Threshold October Lead Exec
Sickness absence rate <3.5% 3.89% Jan Bloomfield
Performance on MRSA screening of emergency admissions was 95.09% 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
85.47% Jan Bloomfield
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 October the Trust compliance figure is at 85.47%.
Performance Indicator Threshold October Lead Exec
A3 Printout of Ward Analysis Quality Report From Trust
Dashboard
Clinical Quality Priorities: Ward Dashboard
5-9
Clinical Quality Priorities: Summary
• The Friends and Family score was commenced at four points of maternity care in September. Scores for all of these are good and lie between 82 and 90.
• There were two same sex accommodation breaches this month involving a total of five patients. Both were in critical care where patients who had recovered enough for transfer to the ward were delayed in moving to general wards due to capacity issues within the Trust. Discussions have been held with the Bed Managers and Critical Care to identify ways to prioritise patient movement from Critical care onto the main wards.
• Falls with harm are lower this month and there were no falls with serious harm.
10
Quality Priority: Ward Performance Issues
• No ward had more than 3 red scores in patient satisfaction.
• The newly opened F7/8 scored poorly in some of the quality audits in September. Although the ward is still not up to a full complement of permanent staff, the quality indicators have improved with an increase in MEWS compliance from 50% in September to100% this month.
• Quality indicators for ward F9 continue to give some concern: there was a grade 3 pressure ulcer during October; concerns regarding infection prevention issues and compliance with the hydration audits was only 30%. However other indicators are improving. An increase in staffing has been agreed for the ward and four new nursing assistants have been appointed, along with two new Portuguese nurses. Interviews for 2 more nursing assistants are planned. When these are in post, this should have a considerable impact.
11
Quality Priority: Infection Control
12
MRSA BacteraemiaThere were no hospital associated MRSA bacteraemia during October.
C. difficileThere were two hospital acquired C. difficile infections this month both of which occurred on Ward G4. Both patients were female patients identified 3 days apart. These formed part of a period of increased incidence and was investigated accordingly. Ribotyping demonstrated they were different types. The first case was not thought to be clinically significant and is being appealed. The second case was clinically significant but a mild infection; the patient had had antibiotics (appropriately), but the case was not deemed suitable for appeal. The RCA documentation has been slightly modified to streamline the process and clarify grounds for appeal. The C. difficile action plan has been updated to incorporate recommendations from the external review and has been discussed at TEG and CSEC and will be reported to the Board separately.
Hand HygieneHand hygiene compliance was 100%. There was one failure in compliance on ward G5, in respect of a student nurse. This was addressed with the nurse at the time of the audit.
MRSA screeningElective: 92% Non Elective: 95%Compliance in elective screening has improved slightly and non-elective screening has increased by 3% this month but further improvements are needed if we are to achieve 100% compliance as required by the Commissioners. This will impact on the closure of the Remedial Action Plan.
Quality Priority: Falls
Falls performance
Despite changing the definition of falls last month to include patients who faint or collapse due to medical reasons, the total number of falls in October was 50, none of which were faints or collapse. Twelve of these falls resulted in harm but none resulted in serious harm. The rate per 1,000 occupied bed days is 5 (September 5.31) giving an overall downward trend.
ThemesWe continue to monitor the number of falls in toilets: this month 8% of our falls occurred in the toilet, down from 11.7 in September.Detailed intelligence continues to be collected to reveal what the patient was actually doing at the time of the fall.A detailed survey of all inpatient toilets was completed this week, to highlight where extra hand rail support is required. The results will be analysed and reported to the Board next month.Several patients slipped from their chair this month (6), four of these patients had an alternating air cushion in place which makes the chair significantly higher, this may have contributed to their fall and for that reason, all patients using chairs fitted with an air cushion will now be risk assessed by occupational therapy, physiotherapy or a registered nurse to ensure safety. ..
13
Quality Priority: Pressure Ulcers
The performance target is to have no avoidable Grade 2, 3 or 4 pressure ulcers 2013-14.
Grade 2 pressure ulcers
There were four HAPU grade 2 this month, all of which the Trust believes to be unavoidable, due to compliance and or morbidity.
Grade 3 and 4 pressure ulcers
There was one HAPU grade 3, which may have been avoidable as risk assessments and other documentation had not been fully and accurately completed.
Our 29 new mattresses are in place and relevant training is underway on all wards.
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 99.42%. National October performance is 97.3%.
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 Oct 13
Harm Free 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 92.46
Pressure Ulcers – All 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 4.06
Pressure Ulcers - New 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 0.00
Falls with Harm 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 0.00
Catheters & UTIs 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 3.48
Catheters & New UTIs 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 0.00
New VTEs 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 0.58
All Harms 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 7.54
New Harms 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 0.58
Sample 395 398 385 392 387 422 427 422 397 392 369 369 368 345
Surveys 17 17 17 17 17 18 18 18 18 18 17 17 17 17
Current performance for harm-free care is 92.46%. National October performance is 93.4%.
15
Quality Priority: Patient Experience – Achievement of 85% satisfaction
16
‘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. Overall satisfaction scores for the OPD, A&E, short stay and maternity services were maintained at a high level.
There was a significant increase in the number of surveys completed by both patients and parents in paediatrics this month and good scores were achieved for all questions.
The number of responses to the surveys have increased since the appointment (part time) of a Patient Feedback Coordinator and her continued input to all areas. Unfortunately the focus on maintaining the numbers of responses has reduced her ability to carry out more in-depth pieces of work and introducing new sources of feedback. However, the post holder played a vital role in the call bell project. An update on the implementation of the call bell action plan will be provided next month. It is hoped that the data on the call bell response times and the number of calls for the six wards with the wireless call bell system will be provided within this report from next month.
Quality Priority: Patient Experience – recommend the service
17
‘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 October, maintaining the high scores of previous months.
The score for A&E was 59, this score has been fairly stable over recent months. Analysis of the very few comments on the reasons for not giving a promoter response has not led to any conclusions as to themes/issues other than waiting times.
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
87 95 82 90
CQC Action Plan
Update
The education and training activities identified in the action plan continue to progress well, except on F7/8 where there have been significant challenges in ensuring all new staff achieve the competencies and training required for all elements of their role .
All wards now have an MCA and DOLS resource folder on the ward and folders have been prepared for all departments. This ensures that all staff have easy access to guidance and documentation in hard copy.
Additional questions were added to the internal CQC assurance audits and incorporated into the peer review audits last month. These demonstrate, whilst consent is sought for treatments and procedures, documentation on capacity and completion of DNACPR documentation to indicate involvement of patients, families and capacity assessment is not consistent. Full implementation of the action plan will address this issue.
The process for CQC assurance audits will be changed from Quarter 4. The audits will focus on half of the outcomes in more depth rather than carrying out assessments against all of the outcomes. However, Outcomes 4 and 11 will be included in all the audits.
18
Local Priorities: Exception Reporting
KPI-3 SIRIs open more than 45 days after submission on STEISThis measures all SIRIs that remain open on STEIS beyond the final report submission deadline. This includes three sub-sets:
SIRI final report overdue submission (n = 0) SIRI final reports for which WSFT response to CCG queries is pending (n = 7) SIRI final reports submitted for which feedback / closure by the CCG is pending (n = 4)
RAG rating* RED (n >10) Amber (n = 6 - 10) Green (0 - 5)As @ 15/11/13 n = 10 (Amber)RAG rating based on local benchmark data for 22 Trusts provided by CCG
The number of open reports has fallen considerably from 24 in September to18 in October to 10 in November. One of the 10 SIRIs has had a “stop the clock” pending the findings of an external review of CTG tracing.
Incidents (Amber / Green) with investigation overdue (over 12 days)The next deadline for NRLS submission is the 30th November. The Operational Steering Group have agreed a pathway to complete sign off of the Apr-September incidents within the timeframe which has resulted in a reduction in the total overdue for investigation and final approval. Ops group also identified a need to consider a robust method for ensuring timeliness of future investigation and sign off.
Late by Directorate Red (RAG) Oct Nov change
Clinical Support >15 22 6
Estates and Facilities >10 17 9
Medical >70 149 152
Surgical >40 79 65
Women & Children’s Health >15 31 19
Other No target 8 10
TOTAL >150 306 261
RCA actions overdueSeven of the actions are from Maternity RCAs and have only
just become overdue in November. These will be actively followed up to ensure completion. Two relate to others policies currently being drafted.
19
Local Priorities - Governance Dashboard
Indicator Performance target R A G Oct13 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 9 Seven of the actions are from Maternity RCAs and have only just become overdue. These will be actively followed up to ensure completion. Two relate to others policies currently being drafted.
Incidents (Amber / Green) with investigation overdue (over 12 days)
>150 50 - 150 <50 261 See exception report for details
Timely reporting of SIRIs
SIRIs reported > 2 working days from identification as red
>1 1 0 0 All incidents were submitted to STEIS within the 2 day timeframe. Two incidents were reported late on Datix and three were re-graded as Red following initial review.
SIRI final reports due in month submitted beyond timeframe
>1 1 0 0 8/ 8 within deadline
Number of SIRI reports open on STEIS more than 45 days after initial notification
>10 6 - 10 0-5 10 Reduced from 18 in October. One SIRI included in this figure had a “stop the clock” pending the findings of an external review of CTG tracing.
Duty of Candour Compliance with Duty of Candour requirements
<75% 75 – 94% >=95% 88% 88% = 14/16. The two non compliant cases relate to pressure ulcers identified on critically ill patients who subsequently died for whom a conversation with the family about the pressure ulcer was not considered appropriate at the time.
Risk assessment
Active risk assessments in date <75% 75 – 94% >=95% 99%
Outstanding actions in date for Red / Amber entries on Datix risk register
<75% 75 – 94% >=95% 99%
20
Local Priorities - Governance Dashboard (cont.)
Indicator Performance target R A G Oct13 Commentary
Risk assessment
Active risk assessments in date <75% 75 – 94% >=95% 99%
Outstanding actions in date for Red / Amber entries on Datix risk register
<75% 75 – 94% >=95% 99%
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% 95% 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 2 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% 88% This represents 4 of the 32 responses that were sent out in October. We continue to manage a high number of complaints and must ensure the responses address all issues, this can sometimes results in a slight delay with a few of the responses.
Number of second letters received >=5 1-4 0 2 Two second letters were received. One complainant is adamant that she wants the PHSO to review her complaint but has been told by them she must first write back to us in the first instance. One remains dissatisfied with her care despite the explanation given.
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
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 it has not been updated on the graph above..
There were 447 incidents reported in October including 358 patient safety incidents (PSIs). The reporting rate has remained relatively static over the last six months. The number of harm incidents in October was below the peer group average (updated benchmark not yet available from NRLS).
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 Oct ’12 – Mar ‘12 report and sits above 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 confirmed serious PSIs are plotted as a column on the secondary axis.
The unconfirmed incident in October 2012 was identified via a complaint and reported retrospectively in September 2013. In August there were four ‘Red’ patient safety incidents: Pressure ulcer (1), Retained tampon (1), DNACPR (1), and one awaiting confirmation through RCA: Fall (1)
Sep-
11
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
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.6%
0
1
2
3
4
5
6
7
8
5
12
1 12 2
5
7
3
12 2
3
12 2
45
4
76
3 3
1
1
1
Confirmed severe harm/death Pending final grade
(1ary axis) Benchmark NRLS Serious harm average (1.2%) (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 slight reduction in the number of complaints received in October 2013 compared to other months this year and compared to October 2012.
Complaint response within agreed timescale with the complainant: 88% of responded to in October. This represents 4 of the 32 complaint responses going out late.
Of the 26 complaints received in October, the breakdown by Primary Directorate is as follows: Medical (12), Surgical (11), Clinical Support (2), Facilities (0), and Women & Child Health (1). There was a higher than average number of complaints about the Orthopaedic Department and this has been highlighted to the Clinical Lead.
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 NaN NaN NaN NaN NaN
Complaints 2012/13 19 22 26 18 34 18 28 22 20 24 25 27
Pain complaints 2013/2014
1 1 0 0 1 1 1 NaN NaN NaN NaN NaN
2.5
12.5
22.5
32.5
Num
ber o
f com
plai
nts
All Aspects of Clinical Treatment 28Admissions, Discharge and Transfer Arrangements 13Communication / Information to Patients (written and oral) 11Attitude of Staff 5Aids and Appliances, Equipment, Premises (including access) 3Patients Privacy and Dignity 3
24
Local Priorities: PALS (Patient Advice & Liaison Service)
In October 2013 there were 102 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 April’12 to October ‘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
Oct-1
2
Nov-
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
0
10
20
30
40
50
60
0
20
40
60
80
100
120
88
103
81
92100
88 90
7277
90
102
89
102
Medical Surgical Clinical support Women and Child Health
Facilities Other / Not categorised Total
Information/Advice request 34 All aspects of clinical treatment 22 Appointments, delay, cancellation (outpatients) 12
Attitude of staff 5 Other 7
The numbers across the different areas of concern remain constant and there are no particular themes that the PALS Manager has identified this month. The number of comments about staff attitude has risen slightly again, which the PALS Manager has personally noticed a problem in the out-patients area. However, the main area where concerns are raised about care and waiting times is A/E (8) with other issues following such as care of the elderly (6); orthopaedic surgery (5); ophthalmology (6); emergency assessment, cardiology and general medicine (5).
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.
25
Local Priorities – Workforce Performance
26
Performance Indicator ThresholdDirect
Financial Penalty
12 Month
YTDComments Lead Exec
Workforce
Sickness absence rate <3.5% NO 3.89%
Jan Bloomfield
Turnover <10% NO 7.71%
Jan Bloomfield
Reviews Grievance/Banding reviews NO 91 New Case, 1 on-going Tribunal, 1 Outstanding Agenda for Change Banding Appeal and 1 Grievance
Jan Bloomfield
Recruitment Timescales Average number of weeks to recruit = 7 NO 5.5
Jan Bloomfield
CRB 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 85.47%
Jan Bloomfield
CQUIN – November 2013
27
NOVEMBER 2013 – CQUIN Report By PMO: This provides an update on CQUIN progress supported by the Trusts Programme Management Office (PMO) working with Target Owners.Q2 Report – CCG acceptance/ final feedback due 25 November. 3i – Unify data used for Q2 accepted. Use EPRO new data for Unify Q3 onwards shows 100% met.Q2 remaining issues:7 – Psychiatric Liaison. Launch November/ final recruitment on-going (external influence) – % income deferred to Q3 tbc 25/11. Team on site w/e 15/11.8 – Pain Pathway – (external influence) more complex than when set up so work on-going into Q3 in conjunction with CCG. % income deferred tbc 25/11.14 – GP Assessment area - finalise delivery Q3 onwards. 11 - 7 day - Diagnostic Test higher trajectory set at CCG request – part not met Q2. CCG to advise outcome 25/11. Review of what is possible electronically for other 7 day evidence for Q4 (versus manual audit evidence for Q2, Q3). Q3 - Dispute re: 2i – CCG to agree not set % for falls in toilets. Dispute re: 3iii – dementia carers – CCG agree not set target.2014-5 targets setting – involve relevant staff, ensure data collection available or allowances made, ensure responsibilities allocated – collaborative working.If felt appropriate – own Trust ideas were to be submitted 14 November 2013 / however, Trust work with CCG on integrated way forward.PMO support colour coding:
A. No PMO support except Quarterly reports if required
B. Minimal support C. Significant/on-going
Code Target Q2
PredictedQ3 Q4
A. Friends and Family Test x 3 (National Target). 1i – F&F Phased expansion to Maternity & Endoscopy. Met
N/A Nov £ re: Maternity
G: 3
B - C. 1ii – F&F Increased response rate. (National Target). *Q4 must be higher than Q1 but aware there is ‘room for improvement’ available to meet. Q1: 20.10%. Q2 21.03%. Q3 so far: October 20.81%. New Target Owner.
N/A though on track
N/A though on track
G: 6+ 20.10%
B. 1iii – F&F Improved performance on Staff Test. (National Target). Review previous response / performance rates – Trust recommend score: 2012 = 3.87. National average: 3.57. *Will be unknown until published 2014.
N/A N/A G : 9* tbc 2014
CQUIN – November 2013
28
C. 2i - NHS Safety Thermometer – Improvement – Safety Cross: Pressure Ulcers & Falls (National Target). Q2 met - Updated Harm Free Action Plan (Q2 feedback: further information on Work-stream 10 sent 11/11). Falls Lessons Learned accepted. Trajectory was to be set for FALLS – however, CCG agreed theme/areas for action & be measured against implement/ evaluation. Area identified as falls in toilets. Q2 feedback dispute – not agreed to prove % reduction in future. Hand rail work timings advised to CCG (showing completion within this financial year). CCG advise 25/11.
G
G: 9 CCG to accept no set target re: Falls in toilets
G: 3
C.
Dementia x 3 (National target) 3i – Dementia – Find, Assess, Investigate, Refer. Similar to 2012-3 targets (x3). Q2 –submitted Unify data – target met (in alignment with CCG accessible data source). Q3 (OCT) so far shows 100% - so met.
G G: 3
G: 3
A. 3ii – Dementia Clinical Leadership. Training programme plans & documents provided. All in progress towards next report due Q4 – training delivered, new plan for 2014-5.
N/A N/A G: 3
B.
3iii – Dementia – Supporting Carers – Q2 part met. CCG requested evidence of Carer forms given out by 11/11 – explanation given. CCG to accept – to be advised 25/11. Q3: CCG request minimum survey sample size of 15 per month from Nov – disputed on 11/11 Q2 feedback as target was to report figures not meet target. TBC action from 25/11 feedback. Q1 and Q2 used Norfolk & Suffolk Dementia Alliance (NSDA)/ UEA – pilot pre-printed question and review of results – 5 Trusts participated (including WSHFT). Following review & unsatisfactory level of results – decision made at Dementia Strategy Group & Family Carers Group to change survey method to in-house (so no need for carer to post). Captures all carers (so will help for 9i). Launched 14 Oct.
As at 11/11 G: 9 CCG to accept extra info
G: 6 CCG to accept dispute re: target or meet with CCG
G: 3
Not under PMO
VTE x 2 (national target). 4i – VTE – Risk Assessment – 98% patients to have RA. Q2 met: 99.84% Q1 met: 99.51%. Plus meet RCA target 4ii. Q2 met: July 99.60%. Aug 99.92%, Sept 100%. Q3: OCT 99.72%.
Q1 & 2 met
B. 4ii – VTE RCA – Q2 met. Was ‘Locally agreed target of ‘in depth’ 10 per quarter’. CCG agreed regarding revision as data showed lower number required once reviewed. Q2-4 – report actual number with evidence – mentioned on Q1 & 2 report. Q2: RCA’s received for 4 cases and individual action plans noted. CCG require for Q3 an aggregate action plan with demonstrated progress/completion against each action within the plan.
G G: 3 G: 3
A. 5i – End of Life Education – Q2 met. Q2 – show 25% of staff trained & shared practice (e.g. Hospice) evidence. Full report given to CCG, achieved 38% - breakdown of staff trained advised.
G G: 3 G: 3
A. 6i – Nursing e-forms – Q2-4 – measure/agree baseline & improvement/ pilot, training. No report due until Q4. Project remains on schedule and all key milestones at Q2 met.
Progress to meet Q4 met. No report due
Ensure progress to meet Q4. No report due
G: 3
CQUIN – November 2013
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B. 7i – Psychiatric liaison – Q2 – working with external partners = part met – supplied updated information 11/11 & ongoing into Q3. Q2 was: Commission service, agree reporting system re 7 data elements to be collected (to report on Q3). Go live – current staff – aim due on site w/e 15/11. Green Sheet will announce (original aim was 1st Oct). Recruitment was delayed by NSFT finances agreement with CCG. Consultant for ‘Elderly’ recruitment in progress – CCG email advises locum cover in meantime. SLA developed between WSH and NSFT to support the arrangements between the trusts – aim to be signed w/e 15/11 (latest version sent to CCG 11/11).
A: 15 external reliance on NSFT. CCG to advise if part £ 25/11
G: Tbc 9 ensure on track / data due/ rely NSFT
G: Tbc 9/ ensure on track/ data / rely NSFT
A.
8i – Pain Pathway – Q2 CCG lead put forward this Trust met requirements as far as possible however work is on-going due to complexities and is liaising with Target Owner/ other staff involved including CCG. CCG response: Q1 and Q2 funded at 50% - opportunity for full payment in Q3 if milestones met. Q2: formal agreement exit plan – in progress CCG. CCG Lead left in Nov. New (not on site) CCG Lead.
A –15 £ moved to Q3 – CCG to advise if part £ 25/11
G: 9 Q1 & Q2 50%
G Tbc: 9
C. 9i – Carer Involvement – Q2 met. Implementation and agree data collection, spot-check audit. Full report given on launch of Carer support scheme, plus audit on 2 wards re: carers identified, reason for admission, support needs. Change of Target Owner.
G
G: 3 G: 3
A. 10i – Breast Feeding – Q1/Q2 targets met. Confirmed with Target Lead plans are in place for training of staff/ data required/ Co-ordinator employed (secondment), staff for home visiting. Put forward that this Trust does not collect data of mothers feeding 6-8 weeks, though new co-ordinator will work with community.
G G: 3 G: 3
C. 11i – 7 day working – (similar to 2012-3 target but now requires evidence). Q2 part met*. Ownership – Q2 – PMO managed a), b), e) evidence re: Consultant seen patient within 24 hours/ daily on F8 – manual audit CCG agreement reached for 2.5-3% (180 submitted as evidence). Met. Target owner liaised d) Outreach – audit and as 100% achieved, put forward to continue – CCG set 98% minimum. Met. Imaging Services Manager - progressed re: c) & f) patient exceptions & new trajectories for *diagnostic tests – original trajectory rejected by CCG, new trajectory set following meeting with CCG 12/9. Q2 response to CCG sent 11/11 re: part shortfall % trajectory not fully met – CCG advise £ 25/11/ Contingency Q4 while upgrade due. COO updated. Joint target owner – progressing future electronic data collection to use for a), b), e) – though not yet available for all 4 elements required Q3/ tbc Q4. Funds for large manual audit agreed at PMO Steering Group 28 October. Medical Director requested to highlight to doctors to record date and time on paperwork – now sent. Paper forms to be amended to highlight ‘time’ next print run. Though PMO/ 2 target owners input is required from clinical/ management where required.
A: 12 Diagnostic test % CCG to advise part £ 25/11 Plus re: Q4 upgrade
G: 9 data electronically not all avail for a), b) and e)/ MANUAL AUDIT = 5 weeks work in hand Note: Overall G: 3
G: 9 data electronically - tbc not avail for all of a), b) and e)/ G: 3 - if efforts made on audits/ Outreach *A: 12 CCG to advise re diagnostic test trajectory during upgrade
CQUIN – November 2013
30
A. 12i – Stroke SSNAP improvement – Q2 was not fully met – further information from previous system sent 11/11 together with action plan. Q2 should now be met. Dedicated Stroke System went live 1 October. Clinical engagement in place and benefits programme prepared. SSNAP information as to which targets will be reported on is due. CCG are keen to understand how the system will support national drivers. CCG in liaison with Target Owner.
CCG to accept update & plan =G As at 11/11 R: 16
G: 3 If all well with Q2 response
G: 3
B. 13i – PAU Paediatrician – Extended from 2012-3. Q2 met – full report submitted including required audits. Note Dr Lakshman stepped down as clinical lead after Sept.
G G: 3 G: 3
C. 14i – a) GP Assessment Area – Q3 prove closed 85% of the time by midnight (Q4 90%) liaise new Owner. b) Reduction in Emergency Admission for acute conditions that should not usually require hospital admission. MB confirmed target details with CCG 11/11. Information Team progressing data to be collected. CCG to confirm funds moved into Q3 & Q4 25/11.
N/A but CCG to confirm moving £ to Q3 & 4 on 25/11
G tbc: 6
G tbc: 3
A. 15i – Telecare scheme – Q2 was not fully met. Formal notification to change of original target sent 11/11 plus confirmation of figures aim per Quarter. Q2 should now be met. CCG to agree met 25/11. Following demonstration to Trust exec and Clinicians, agreement has now been made to support Rheumatology. Approved via TEG for VR to continue. Further work underway with GP’s and Community although delays are potentially encountered for Q3 as CCG introduce new technology and consider space in GP’s (Rheumatology will required GP clinic area)
CCG to accept update =G As at 11/11 R: 16
A: 12 CCG to provide technical and structural support at GP’s may impact WSH
G: 3
Monitor Compliance Framework
31
Monitor Compliance Framework Performance Indicator Threshold Month QTD Weighting Lead Exec
Access:
Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted 90% 98.61% 98.61% 1.0 Jon Green
Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted 95% 99.72% 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% 100.00% 100.00% 1.0 Jon Green
A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge 95% 97.79% 97.79% 1.0 Jon Green
All cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer 85% 87.00% 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% 98.90% 98.90%
0.5
Jon Green
Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer not initially suspected) 93% 97.10% 97.10% Jon Green
Outcomes:
Clostridium (C.) difficile - meeting the C.difficile objective - MONTH 2 2
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
32
Performance Indicator ThresholdIn Month
Performance
YTD 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%
25.20% 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
StrokeStroke -Proportion of Patients admitted to an acute stroke unit within 4 hours of hospital arrival 90% 91.00% 85.71% Jon Green
Proportion of patients in Atrial Fibrillation, presenting with stroke and where clinically indicated will receive anti-co-agulation.
60% 83.00% 68.29% Jon Green
Stroke - % of Stroke patients with access to brain scan within 24 hours 100% 100.00% 98.57% Jon Green
Stroke - Proportion of Stroke Patients and carers with a joint health and social care plan on discharge 85% 94.00% 91.14% 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% 93.43% Jon Green
>80% treated on a stroke unit >90% of their stay 80% 97.00% 89.14% 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% 92.00% 78.57% 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% 65.00% 73.43% Jon Green
% of Patients eligible for Thrombolysis, Thrombolysed within 4.5 hours 100% of all eligible patients 100.00% 100.00
% Jon Green
Contract Priorities Dashboard
33
Discharge Summaries
Discharge Summaries - Outpatients 95% sent to GP's within 3 days 81.63% 84.19% Dermot O'Riordan
Discharge Summaries - A&E 95% of A&E Discharge Summaries to be sent to GPs within one working day 97.54% 97.50% Dermot
O'Riordan
Discharge Summaries - Inpatients 95% sent to GP's within 1 day 77.57% 82.16% 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 0.57% 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.
96.23% 96.20%
Nichole DayMaintain maternity 1:30 ratio 1:30 1:30 1:29 Nichole Day
Pledge 1.4: 1:1 care in established labour 1:1100.00%
100.00% Nichole Day
Breastfeeding initiation rates. 80% 81.73% 79.81% 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% 16.26% 18.47%
Nichole Day
Contract Priorities Dashboard
34
Other contract / National targetsMixed Sex Accomodation breaches 0 Breaches 2 4 Jon Green
Consultant to consultant referral Commisioner to audit if concern about levels of consultant referrals 7.13% 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% 87.33% 87.55% Jon Green
MRSA - emergency screening All emergency patients admissions are to be screened for MRSA within 24 hours of admission 95.09% 92.42% Nichole Day
Rapid access - chest pain clinic 100% of patients should have a maximum wait of two weeks 100.00% 78.33% Jon Green
New to Follow up Thresholds set at each speciality - overall Trust Threshold is 1.9 1.89 1.84 Jon Green
Patients receiving primary diagnostic test within 6 weeks of referral for diagnostic test 99% 99.49% 97.77% Jon Green