Trust Quality and Performance Report

25 April 2014(March Performance Pack)

Contents

1

Slide numbers

Executive Summary  2 - 5

Clinical Quality Priorities (inc Ward Dashboard) 6 - 17 & 31 - 36

Local Priorities 18 - 27

Monitor Compliance 28

Contract Priorities 29 - 30

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 March was 95.5%, the tenth month in a row that the Trust has achieved the target. The Trust has also achieved Q4 (95.6%) and the A&E 95% target for the year (95.3%).

2. There were two cases of C.Diff in March against the threshold of two. This is covered within the quality report. The YTD position is 23 cases against a year end ceiling of 19.

3. The Trust failed two Stroke targets in March, access to brain scan in 24 hours and low risk TIA access in scan within 7 days. See page 3.

4. Performance on outpatient and inpatient discharge summaries remains below target, although this has improved since February. See page 3.

5. Performance on MRSA screening of emergency admissions was 96.17% against the 100% target. This is covered on page 3 & 7 of this report.

6. The Trust achieved all access targets including the six-week diagnostic test target for February.

7. The Trust failed the patients treated within 28 days of cancelled operation target. See page 3.

2

3

Executive Summary

Performance Indicator Threshhold March Lead ExecutiveStroke - % of Stroke patients with access to brain scan within 24 hours

100% 93.00% Jon Green

Both patients’ conditions had deteriorated and the medical teams did not refer to CT scan until after the 24 hours period had elapsed. Performance Indicator Threshhold March Lead ExecutiveStroke - 65% of patients with low risk TIA have access to MRI or carotid scan within 7 days (seen, investigated and treated)

65% 59.00% Jon Green

Breaches were due to patients not seeking medical advice in a timely fashion and therefore outside the control of the stroke team Performance Indicator Threshhold March Lead ExecutivePatients offered date within 28 days of cancelled operation 100% 85.71% Jon Green The March performance was 85.71% against a target of 100%. Of the 28 cancelled operations there were 4 patients who did not receive their surgery within 28 days – 3 Oral and 1 Orthopaedic Surgery. On all 4 occasions this was due to a problem with equipment availability. Performance Indicator Threshhold March Lead ExecutiveMRSA - emergency screening All emergency patients admissions ae to be screened

for MRSA within 24 hours of admission96.17% Nichole Day

The March data for emergency screening is 96.17% whilst this is 1% lower than last month it represents a total of 49 screens not meeting the criteria of day of admission or the next 24 hours. (1195 screened out of a total of 1244) Performance Indicator Threshhold March Lead ExecutiveBreastfeeding initiation rates 80.00% 72.96% Nichole Day Although the breastfeeding initiation rate for March was 74.3%, overall for quarter 4 the rate was 81%. There appears to be no explanation for a higher amount of women choosing to bottle-feed during March although we continue to strive to support women with choice. 100% of maternity and paediatric staff have been trained in the UNICEF breastfeeding initiative and with the introduction of the Families and Babies (FAB) peer supporters on the ward and in the community more women are continuing to breastfeed for longer. The total initiation rate of the year April 13 – March 14 is 80.3% which is above target.

4

Performance Indicator Threshhold March Lead ExecutiveDischarge Summaries - Inpatients 95% sent to GP’s within 1 day 91.82% Dermot O’Riordan Performance is steadily improving although the target has been missed this month. A recommendation has been made to the PMO Steering Group proposing that performance against this indicator is monitored at monthly Divisional Performance Management meetings and responsibility for addressing poor performance will lie with each Directorate. This will assist in embedding change and enabling continuous improvement. In addition, arrangements are being put in place for the Medical Director to receive performance figures at an individual consultant level and he will then be writing to those with below target performance for both letters and in-patient summaries to improve performance further.

Performance Indicator Threshhold March Lead ExecutiveDischarge Summaries - Outpatients 95% sent to GP’s within 3 days 92.90% Dermot O’Riordan Performance is steadily improving although the target has been missed this month. A recommendation has been made to the PMO Steering Group to agree that performance against this indicator is monitored at monthly Divisional Performance Management meetings and responsibility for addressing poor performance will lie with each Directorate. This will assist in embedding change and enabling continuous improvement. In addition, the Medical Director will be seeking to resolve whether the three day timescale for Outpatient letters can be extended and also whether these letters can be sent “dictated but not approved” with CCG clinicians at the next WSH WSCCG Clinical Liaison Forum in May. Discharge summary and clinic letter performance is part of the new Appraisal system that is in the process of being implemented and consultants will be expected to present their figures at these meetings.

Performance Indicator Threshhold March Lead ExecutiveSickness absence rate <3.5% 3.74% Jan Bloomfield The highest percentage continues to be the Estates and Facilities Directorate at 4.90% (up by 0.02% from February), the directorate has a number of long term sickness issues which effect the figures. These are being monitored on a regular basis.The lowest is Corporate Services at 2.20% (down by 0.08%).

Performance Indicator Threshhold March Lead ExecutiveAll Staff to have an appraisal 90% 89.62% Jan Bloomfield See page 5

Appraisal monitoring – 89.62% (1.31%)The Trust Board has set a target of 90% of staff having had an appraisal meeting in any year, and this is reported to and monitored each month by the Board of Directors, General Managers and individual managers.

Compliance within the Trust is currently reported at 89.62% for March 2014 (this is measured by returned personal development plans (PDP’s) to the HR Directorate, and is recorded on ESR) against a figure of 40.71% in December 2011. This figure differs from that reported by the staff survey.

Those with up to date PDP’s are as follows;Surgery - 90.27% Medicine - 90.85% Clinical support - 86.88% Women and Children - 89.33% Corporate - 87.24%Estates and Facilities - 92.12%

The latest staff survey response (2013) which surveyed approximately 450 staff (the Trust headcount is currently around 2,955), suggests that we are in the bottom 20% of acute trusts for staff being appraised in the last 12 months, with our score being 75%, against a national average of 84%. This represents a 4% decrease on the 2012 survey. We are also slightly below average for staff feeling that their appraisal meetings are well structured. (3.62 against an acute average score of 3.64)Monitoring is undertaken at various levels within the organisation;Monthly board reportingMonthly reporting at directorate level, as part of performance management meetings.In depth reporting each month by individual budget code.

 

Encouraging appraisal take up Appraisal completion forms part of the management role and responsibility for all staff with people management in their job description. Managers attend training in the undertaking of appraisal, during which they learn about the skills, process and paperwork etc. Appraisal is identified as a mandatory requirement for all staff.Failure to meet this requirement could be met as follows;Managers who fail will be met informally in the first instance to be tasked with improving their performance in this area.Disciplinary rules then allow the Trust to take action under “failure to undertake a reasonable management instruction”. Incremental progression could be withheld for those managers who have not reached the top of their Pay band (currently 45% of those in Bands 7 and above, 192 managers out of 428 in total). However national Terms & Conditions do not allow for increments to be withdrawn for those managers who have reached the top of their scale (currently 55% of those on band 7 and above).In order to withhold increments a systematic approach would need to be introduced, (to avoid a legal challenge from a contractual basis) A business case was produced to introduce this, but was not approved due to current financial constraints.

5

Clinical Quality Priorities: Summary

• 57 patients fell during March; an increase of 7 compared to February. 1 fall resulted in a neck of femur fracture.

• There were 2 hospital associated C. difficile infections in March against a trajectory of 19 for the year.

6

Quality Priority: Infection Control

MRSA Bacteraemia

There were no cases of hospital attributable MRSA bacteraemia in March.

MSSA Bacteraemia

There were 2 cases of hospital attributable MSSA bacteraemia in March.

C. Difficile

2 cases of C. Difficile were confirmed in March. 1 on G3 and 1 on G8.There were 23 cases of C. Difficile during 2013/14; 10 less than during 2012/13.

MRSA ScreeningElective 96.2% compared to 97% in February Emergency 96.2% compared to 96.8% in February

Trust Antibiotic Audit For Quarter 4 the Trust overall achieved 95% compliance against a target of 98%. A detailed breakdown of results have been distributed to all clinical areas & teams for action.

Sepsis 6 auditA low score this month (55%) has prompted a review of the data collection tool to ensure that it meets audit outcome requirements.

7

Quality Priority: Infection Control

Quarter 4 Infection Prevention Audit Results show an overall compliance of 91% against a target of 90%.Action plans are in place on F9 & G9 to increase compliance with VIP (Visual Infusion Phlebitis) score and a re-audit is planned for April.A cannula care newsletter has been developed by the Infection Prevention team for ward areas to remind them of the importance of cannula care and VIP score documentation.

8

Quality Priority: Ward Performance Issues

• Ward G4 has reported a number of red and amber indicators this month. A focus on documentation in March has improved the score for MEWS & escalation. Nutrition assessment and monitoring has scored lower than February. Work continues to improve documentation in all areas. A lower score for patient satisfaction overall (78 compared to 90 in January & February) was reported with a score of 33 for the Friends & Family test (recommender question). Identified areas for focus from the surveys are noise at night, help with meals and being able to discuss worries or fears with staff.

• Ward F8 have had a challenging month with beds used for escalation for most of the month. Monitoring of staffing levels has shown that 77.4% of shifts over the month were staffed with less than planned numbers. Reduced staffing per shift is reflected in the poorer performance against patient safety & quality indicators this month. Plans are in place to improve performance at ward level with increased monitoring & support from the Nursing Directorate.

9

Quality Priority: Falls

10

Falls PerformanceThere were 57 falls this month, 1 of which resulted in serious harm, this patient was normally independent around his side room and to the bathroom, on this occasion he fell and sustained a fractured hip.

45 falls resulted in no harm and the remaining 12 were recorded as negligible or minor harm.

The rate per 1,000 occupied bed days is 4.8 (Feb 4.61).

WSNHSFT falls with harm March: 0%, National falls with harm March: 0.7% (Safety Thermometer).

ThemesThere were 5 falls in the toilet this month, this is 8.77% of all falls down from 10% last month. Work to install safety rails in toilets is now complete.F7/F8 had 11 falls this month, 9 of which occurred at night none of which occured in the toilet.

Quality Priority: Pressure Ulcers

.

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

Grade 2 Pressure Ulcers

There were six grade 2 HAPU again this month, four of which we believe to have been unavoidable, the CCG have yet to confirm this. The CCG have now confirmed 3 of last months HAPU to be unavoidable.

Grade 3 pressure Ulcers

No grade 3 HAPU, last grade 3 HAPU was in January

We have had no grade 4 HAPU during 2013/14.

11

Safety Thermometer results

12

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.

New harm (harm that occurred within our care) is 0.53% therefore, our new harm free care is 99. 47%. The National new harm for March is 2.6% and national harm free is 93.6%.

The data for March shows we had 0% of falls with harm and the national performance for March 2014 was 0.7%.The data also shows we had 0.27% of new pressure ulcers recorded in March 2014 against the national performance of 1%.

It should be noted that the Safety Thermometer is a spot audit and data is collected on a specific day each month.

Feb 13 Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14

Harm Free 93.36 93.68 91.47 93.20 92.60 93.22 92.68 91.03 92.46 90.28 93.00 93.86 94.09 93.85

Pressure Ulcers – All 3.55 3.51 4.50 4.28 5.36 3.52 2.98 5.16 4.06 4.72 3.25 3.07 4.63 5.08

Pressure Ulcers - New 0.71 0.94 0.95 1.01 0.00 1.08 0.00 1.09 0.00 0.83 0.25 0.00 0.00 0.27

Falls with Harm 0.71 0.23 1.66 0.00 0.26 0.81 0.27 0.00 0.00 1.11 0.50 0.51 0.00 0.00

Catheters & UTIs 1.66 2.58 0.95 1.76 1.53 2.17 2.98 3.60 3.48 3.33 3.00 2.30 1.03 1.07

Catheters & New UTIs 0.47 0.23 0.24 0.00 0.51 0.54 1.08 0.82 0.00 0.83 1.00 0.26 0.26 0.27

New VTEs 0.71 0.47 1.42 0.76 0.26 0.54 1.36 0.54 0.58 0.83 0.50 0.51 0.26 0.00

All Harms 6.64 6.32 8.53 6.80 7.40 6.78 7.32 8.97 7.54 9.72 7.00 6.14 5.91 6.15

New Harms 2.61 1.87 4.27 1.76 1.02 2.98 2.71 2.45 0.58 3.61 2.25 1.28 0.51 0.53

Sample 422 427 422 397 392 369 369 368 345 360 400 391 389 374

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

Safety Thermometer Rolling Programme

CQUIN Target started April 2012.  

Mar-13

Apr-13

May-13

Jun-13Jul-1

3

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

012345

New Harm March 2014

WSH Rolling 12 monthsNational AverageWSH Monthly Data

Perc

enta

ges

Mar-13

Apr-13

May-13

Jun-13Jul-1

3

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13Jan

-14

Feb-14

Mar-14

0

0.5

1

1.5Catheters and New UTIs March

2014 WSH Rolling 12 months

National Average

WSH Monthly Data

Perc

enta

ges

Mar-13

Apr-13

May-13

Jun-13Jul-1

3

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

0

0.5

1

1.5

New VTE March 2014 WSH Rolling 12 months

National Average

WSH Monthly Data

Perc

enta

ges

Mar-13

Apr-13

May-13

Jun-13Jul-1

3

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

0

0.5

1

1.5New Pressure Ulcers March 2014

WSH Rolling 12 months

National Average

WSH Monthly Data

Perc

enta

ges

13

Mar-13

Apr-13

May-13

Jun-13Jul-1

3

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

00.5

11.5

2

Falls With Harm March 2014WSH Rolling 12 months

National Average

WSH Monthly Data

Perc

enta

ges

Quality Priority: Patient Experience – Achievement of 85% satisfaction

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

The overall score for the inpatient survey was 90%, in line with previous months.

Privacy during examinations is the highest scoring question. Noise at night from other patients and timeliness of call bell response are the lowest scoring questions and remain the areas of focus.

Call bell response times are able to be recorded electronically (across 5 wards). Plans are in place to roll out this method of data capture across all wards.

Due to a technical problem this data is not available this month but will be included on next months report.

Analysis of patient satisfaction questionnaire responses on “timeliness of call bell responses” reveals that 24% of patients stated that their call bell was answered immediately and 42% stated their call bell was answered within 1-2 minutes. 66% of call bells were answered within 2 minutes. 11% of call bells were answered between 3-5 minutes.

14

Quality Priority: Patient Experience – Achievement of 85% satisfaction

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

Overall satisfaction scores for the OPD, A&E, and short stay were maintained at a high level.

The lowest scoring question in the A&E survey was “Were you given enough privacy when discussing your condition at reception” at 84%.

2013 National In-Patient SurveyThe results of the National In-patient Survey were publicised in April which highlight many positive aspects of the patient experience.• Overall: 80% rated care 7+ out of 10.• Overall: treated with respect and dignity 81%.• Doctors: always had confidence and trust 81%.• Hospital: room or ward was very/fairly clean 97%.• Hospital: toilets and bathrooms were very/fairly clean 96%.• Care: always enough privacy when being examined or treated 90%.WSFT scored worst than other Trusts in questions about discharge planning and information, being bothered by noise at night, knowing how to complain and not being asked about quality of care. Further analysis will be conducted and a summary of results and an action plan will be presented to Patient Experience Committee in June.

Department Score

A&E 89

OPD 95

Short stay 99

15

Quality Priority: Patient Experience – recommend the service

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

The Trust achieved a Friends and Family test score of 89 for inpatients during March, maintaining the high scores of previous months.

G4 scored 33 for the Friends and Family test. This reflects the overall low scoring for patient experience indicators. The Ward Manager has been tasked to improve scores for next month.

The recommender score for A&E has declined to 56 for March. 92% of patients’ surveyed were either Extremely Likely or Likely to recommend the service.

Maternity recommender scores are high for all stages of the pathway as indicated below:

 This shows an improvement for the postnatal ward from a score of 70 for February to 86 in March.

Antenatal care Birthing Unit Only

Labour Suite Post natal ward Post natal community care

94 89 86 86 94

16

Local Priorities: Exception report

Late by Directorate  Red (RAG) 12th March 14th April change

Clinical Support >15 8 5

Estates and Facilities >10 6 4 -

Medical >70 103 118

Surgical >40 44 42 -

Women & Children’s Health >15 12 53

Other No target 6 9 -

TOTAL  >150 179 231

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

The next NRLS cut off for incidents from OCT13 to APR14 is the 31st May. All patient safety incidents will need to have been investigated and finally approved prior to the cut off date to allow upload to the NRLS. There are (as at 14/04/14) 231 green and amber incidents overdue an investigation and an additional 51 which have been investigated but are still awaiting final approval.

The General Managers have received details of the non-medical individuals who have overdue incident investigations and the Medical Director has circulated the medical staff overdue incidents for follow up. In addition the Operational Steering group on the 14/04/14 received the details of individual and locations with high numbers of overdue investigations and a list of all the overdue amber incidents with identified handlers.

17

Local Priorities: Exception report

RCA actions overdue

Governance provide the General Managers with a regular report on the first working day of the month listing all overdue and upcoming RCA actions. Progress with closing these actions will then be monitored through the Directorate performance meetings.

There are currently 20 overdue actions including 7 which have completion dates before March 2014.

DirectorateActions overdue

Detail of overdue actionsTotal pre-March

Medicine 6 1 Completion of audit and feedback of learning to local areas

Surgery 0 0 None overdue

Women & Children 8 5Clinical guideline development, feedback of learning to local areas and one relating to regional Paediatric cardiology services

Clinical Support 1 0 Review of current processes and availability of walking aids out of hours

Other 6 1 Communication and feedback to staff and families

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

There were six complaints sent out late this month due to volume of work.

Complaints - Number of second letters received

There were five second letters received in March which related to requirement for further information and/or disagreement with the content of the initial response. Increased numbers of complaints will result in increased numbers of second letters. However, in the year the Trust has resolved 92% of complaints at first response.

18

Local Priorities - Governance Dashboard

Indicator Performance target R A G Mar14 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 1 One case took longer than the 45 day target to ensure appropriate clinical involvement from multiple specialties involved in the incident.

RCA Actions beyond deadline for completion >=10 5 - 9 0 - 4 20 See exception report for details.

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

>150 50 - 150 <50 232 See exception report for details.

Timely reporting of SIRIs

SIRIs reported > 2 working days from identification as red

>1 1 0 0 4/4 incidents were submitted to STEIS within two working days of identification as red. Two incidents were reported within two working days of the incident. The other two both occurred on Saturday and were reported by staff on the next working day. These were both submitted to STEIS within three working days of the incident.

SIRI final reports due in month submitted beyond 45 working days

>1 1 0 0 3/4 were submitted within 45 working days and one had an agreed stop the cloak to allow external organisation input to the final report.

SIRI final reports due in month submitted beyond local target (40 working days, 30days for pressure ulcers)

>1 1 0 0 3/4 were submitted within 45 working days and one had an agreed stop the cloak to allow external organisation input to the final report.

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

>10 6 - 10 0-5 4 This excludes three cases for which a ‘stop the clock has been agreed. All four cases were submitted to the CCG within the local 40 days deadline target and no feedback has been received to date. An update on status has been requested from the CCG to allow closure.

19

Local Priorities - Governance Dashboard (cont.)

Indicator Performance target R A G Mar14 Commentary

Duty of Candour

Compliance with Duty of Candour requirements >3 1 - 3 0 3 3 cases (from a total of 19) have not yet been undertaken.

Risk assessment

Active risk assessments in date <75% 75 – 94% >=95% 96.5%

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

<75% 75 – 94% >=95% 100%

Clinical Audit Trust participation in relevant ongoing National audits

<75% 75 – 89% >=90% 100%

Safer surgery

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

<90% 90% - 98% >98%

97.8% Non compliance is reported to individuals (daily) and Clinical Directors (weekly). This analysis is based on 4445 checks during the month.

Ward Check 1 100%

Ward Check 2 99.2%

Sign In – Complete 100%

Sign Out – Surgeon 96.2%

Time Out - Scrub 95.4%

20

Local Priorities - Governance Dashboard (cont.)

Indicator Performance target R A G Mar14 Commentary

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

>9 4 - 9 0 - 3 2 The May Board (April data) will reflect the 2014/15 CCG contract relating to this data item. The Trust will be using the alerts module of the Datix system to allocate and monitor compliance with NICE guidance and Quality standards excluding TAs including from April 2014.

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

<75% 75 – 89% >=90% 74% See exception report for details.

Number of second letters received >=5 1-4 0 5 See exception report for details.

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 in December and the benchmark in the graph above was updated. This shows a increase in reporting across the peer group. The Trust reporting rate has risen in March following the dip in the shorter month of February and is now just below the upper quartile threshold for the peer group.

There were 474 incidents reported in March including 389 patient safety incidents (PSIs). The Trust reporting rate has risen in March following the dip in the shorter month of February and is now just below the upper quartile threshold for the peer group.

The number of harm incidents in March remained below the peer group average.

May

-12

Jun-

12

Jul-1

2

Aug-

12

Sep-

12

0

50

100

150

200

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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)

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ents

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ort

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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) from the NPSA Oct ’12 – Mar ‘13 report and sits below the Trust’s average. The WSH percentage data is plotted as a line which shows the rolling average over a twelve month period.

The number of serious PSIs (confirmed and unconfirmed) are plotted as a column on the secondary axis with avoidable hospital acquired pressure ulcers indentified separately. The benchmark line applies the peer group percentage serious harm to the peer group median total PSIs to give a comparison with the Trust’s monthly figures. In January there were three confirmed patient safety incidents: one pressure ulcer one fall and one delay in diagnosis and two awaiting confirmation through RCA: one delay in patient management and one inquest.

Feb-

12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep-

12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb-

13

Mar

-13

Apr

-13

May

-13

Jun-

13

Jul-1

3

Aug

-13

Sep-

13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

0

1

2

3

4

5

6

7

8

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

2 23

5

3

12 2

3

12 2 2

4 4

76

34 4

1 12

3

2

2

2

1

1

1

1 1

2

2

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

2ary

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)

23

Local Priorities: Complaints

There was a significant increase in the number of complaints received compared with the previous three months but this high number is consistent with the other months of the year, although this is the single highest number received on any given month of this financial year.

Complaint response within agreed timescale with the complainant: 74% in March. This is due to increased workload.

Of the 41 complaints received in February, the breakdown by Primary Directorate is as follows: Medical (21), Surgical (7), Clinical Support (9), Facilities (1), and Women & Child Health (3).

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

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

Complaints 2013/14 33 31 29 38 32 29 26 40 15 21 24 41

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

Second letters 2013/2014 0 1 3 3 1 0 2 1 3 5 6 4

2.57.5

12.517.522.527.532.537.542.5

Num

ber

of c

ompl

aint

s

All Aspects of Clinical Treatment 22

Appointments, Delay / Cancellation (outpatient) 8

Admissions, Discharge and Transfer Arrangements 6

Communication / Information to Patients (written and oral) 6

Attitude of Staff 5

24

Local Priorities: PALS (Patient Advice & Liaison Service)

In March 2014 there were 88 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 13 to March 2014 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.

Mar

-13

Apr-1

3

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct-1

3

Nov-

13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

0

10

20

30

40

50

60

0

20

40

60

80

100

120

88 90

7277

90

102

89

102

7163

94

69

88

Medical Surgical Clinical support Women and Child Health

Facilities Other / Not categorised Total

All aspects of clinical treatment 26 Information/Advice request 19 Communication 6

Appointments, delay, cancellation 8 Admission/discharge and transfer arrangements 8

The numbers per Ward/Department remain small and consistent when spread across all areas of care provided, although the PALS Manager continues to receive complaints about cancellations for pain treatment.

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

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Local Priorities – Workforce Performance

26

Performance Indicator ThresholdDirect

Financial Penalty

YTD Comments Lead Exec

Workforce

Sickness absence rate <3.5% NO 3.74%

Jan Bloomfield

Turnover <10% NO 8.68%

Jan Bloomfield

Reviews Grievance/Banding reviews NO 7All cases completed/resolved

Jan Bloomfield

Recruitment Timescales Average number of weeks to recruit = 7 NO 5.1

Jan Bloomfield

DBS Checks To complete 95% of required DBS checks NO 98.50%

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 89.62%

 

Jan Bloomfield

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% 93.65% 1.0 Jon GreenMaximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted 95% 97.27% 1.0 Jon Green

Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway 92% 98.76% 1.0 Jon Green

A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge 95% 95.50% 95.63% 1.0 Jon GreenAll cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer 85% 92.00% 89.73%

1.0Jon Green

All cancers: 62-day wait for first treatment (5) from: NHS Cancer Screening Service referral 90% 100.00% 97.23% Jon GreenAll cancers: 31-day wait for second or subsequent treatment, comprising: Surgery 94% 100.00% 100.00%

1.0Jon Green

All cancers: 31-day wait for second or subsequent treatment, comprising: anti-cancer drug treatments 98% 100.00% 100.00% Jon GreenAll 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 GreenCancer: two week wait from referral to date first seen (8), comprising:all urgent referrals (cancer suspected) 93% 97.90% 98.40%

0.5Jon Green

Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer not initially suspected) 93% 98.20% 99.13% 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 23 Nichole DayMethicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - MONTH 0 0

1.0Nichole Day

Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - QUARTER 0 0 Nichole DayMethicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - ANNUALLY 0 1 Nichole DayCertification 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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Contract Priorities with financial penalty          

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%

24.82% 25.76% 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% 93.00% 89.00% Jon Green

Proportion of patients in Atrial Fibrillation, presenting with stroke and where clinically indicated will receive anti-co-agulation. 60% 60.00% 67.67% Jon Green

Stroke - % of Stroke patients with access to brain scan within 24 hours 100% 93.00% 98.33% Jon Green

Stroke - Proportion of Stroke Patients and carers with a joint health and social care plan on discharge 85% 93.00% 91.92% 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% 96.17% Jon Green

>80% treated on a stroke unit >90% of their stay 80% 97.00% 90.25% 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% 50.00% 75.92% 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% 59.00% 71.08% Jon Green

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

% Jon Green

Discharge SummariesDischarge Summaries - Outpatients 95% sent to GP's within 3 days 92.90% 86.23% Dermot O'Riordan

Discharge Summaries - A&E 95% of A&E Discharge Summaries to be sent to GPs within one working day 96.41% 97.05% Dermot O'Riordan

Discharge Summaries - Inpatients 95% sent to GP's within 1 day 91.82% 84.83% Dermot O'Riordan

Contract Priorities Dashboard

29

Choose & Book          

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

A maximum of 3% slots unavailable (£50 per appointment over 5%. Threshold applied over monthly figures)

3.00% - The Threshold applied to fines is 5% Jon Green

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

100% 100.00% - Jon Green

Cancelled OperationsProvider cancellation of Elective Care operation for non-clinical reasons either before or after Patient admission i) 1% of all elective procedures 1.07% 1.10%

Jon GreenPatients offered date within 28 days of cancelled operation 100% 85.71% 98.19% Jon GreenMaternity

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

97.24% 96.36%

Nichole DayMaintain maternity 1:30 ratio 1:30 1:30 1:29 Nichole DayPledge 1.4: 1:1 care in established labour 1:1 100.00% 100.00% Nichole DayBreastfeeding initiation rates. 80% 72.96% 80.35% Nichole DayReduction in the proportion of births that are undertaken as caesarean sections. Suffolk PCT Only

1% reduction in proportion compared to 2011/12 baseline - 22.70% 16.32% 18.77%

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

Consultant to consultant referral Commisioner to audit if concern about levels of consultant referrals 8.10% - 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% 89.19% 87.77% Jon Green

MRSA - emergency screening All emergency patients admissions are to be screened for MRSA within 24 hours of admission 96.17% 92.42% Nichole Day

Rapid access - chest pain clinic 100% of patients should have a maximum wait of two weeks 0.00% 85.59% Jon Green

New to Follow up Thresholds set at each speciality - overall Trust Threshold is 1.9 2.05 - Jon Green

Patients receiving primary diagnostic test within 6 weeks of referral for diagnostic test 99% 100.00% 98.07% Jon Green