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1
Integrated Quality and Performance ReportM3– June 2011
Presented by: Bernie Bluhm (Chief Operating Officer) and Jo Thomas ( Chief Nurse)Author: Char Fletcher (Senior Performance Manager)
Trust Board – 21 July 2011Agenda item: 4.1
2 2
Performance Report M3 - June
Summary: The report updates the Board on the key national, contractual KPIs across the Trust for the Month 3 of 2011-12 (June). The Q1 forecast for the trust remains ‘underperforming’ There remain some Issues with validating the 18 week position. The data was not available at the time of this report. No exception report has been provided for Appraisal and Statutory and Mandatory compliance as data the data is currently being mapped to each division New workforce exception reports are under development. They will utilize SPC charts to identify when a KPI is outside of control limits. Data quality indicators are under development
Action: The Trust Board is asked to Note and accept this report
Notes:
Legal: What are the legal considerations & implications linked to this item? Please name relevant Act
Not applicable.
Regulation: What aspect of regulation applies and what are the outcome implications? This applies to any regulatory body – key regulators include: Care Quality Commission, MHRA, NPSA & Audit Commission)
Department of Health.
Trust objective: Please list number and statement. this paper relates to.
Deliver safe, high quality co-ordinated care;Develop an effective organisation
Trust Board
Agenda Item:4.1
3
Contents
1. Integrated Quality and Performance Dashboard
Page 4 Operating framework metrics Page 5 Outcomes framework metrics Page 6 internal metrics
2. Exception Reports
3. Glossary of Terms
Indicators used for external assessment
Direction of Travel vs. Plan
Target YTD Actual
▲=above plan►=on
plan▼=below plan Jan Feb March Apr-11 May-11 Jun-11 Q1 2011/12 Q2 2010/11 Q3 2010/11 Q4 2010/11
<15 77
▲116 111 77
<60 53 ▼ 78 68 53
240 1029 ▲ 997 970 1029
240 294 ▲ 442 353 294
95% 79.7% ▼ 82.4% 82.0% 81.9% 75.6% 79.9% 82.6% 95.0% 93.0% 90.7%
0 2 ▲ 0 0 3 0 0 2 0 11 3
<5% 4.7% ▼ 4.0% 5.0% 5.0%
<5% 2.6% ▼ 3.4% 2.6% 1.9%
N/A 11832 4379 3833 4469 2683 3829 5320TBD 3.1% 2.9% 3.4% 2.9% 2.8% 3.0% 3.4%0.33 1 ► 0 1 0 0 0 1 1 1 1 1
4.2 7 ► 5 5 8 3 2 2 7 14 19 18
N/A 12 5 2 5
N/A 3 Not avail 3 3
<=23 29.0 32.0 32.0 Not avail Not avail Not avail 25 32
<=18.3 17.0 20.0 20.0 Not avail Not avail Not avail 16.7 20
<=28 25.0 26.0 26.0 Not avail Not avail Not avail 23 26
N/A 6.0 4.0 4.0 Not avail Not avail 0
11.1 13.0 14.0 14.0 Not avail Not avail 0 12 13
7.2 7.0 7.0 7.0 Not avail Not avail Not avail 8 7
90% 81.0 74.9 74.9 #DIV/0! #DIV/0! #DIV/0! 90%
95% 95.4 92.1 92.1 #DIV/0! #DIV/0! #DIV/0! 97%
93% 95.0% ▲ 93.9% 96.9% 95.2% 96.2% 94.1% 94.8% 95.0% 91.1% 91.7% 92.4%
93.0% 94.7% ▲ 93.8% 93.8% 93.9% 93.4% 98.5% 93.1% 94.7%
94.0% 94.4% ▲ 88.9% 92.0% 100.0% 94.4%
98.0% 100.0% ▲ 100.0% 100.0% 100.0% 100.0%
96.0% 99.2% ▲ 98.7% 98.7% 100.0% 99.2%
85% 86.35% ▲ 89.5% 89.6% 84.5% 86.7% 82.9% 88.4% 86.35% 88.4% 88.7% 88.2%
90% 100.0% ▲ 0.0% 100.0% 75.0% 100.0% 100.0% 100.0%
0 10 ▼ 6 0 10 10 26 9
80% 65.7%▼
56.0% 48.0% 54.0% 59.5% 69.7% 69.0%
85% 65.5% ▼ 59.0% 70.0% 73.3% 59.1% 76.7% 64.3%
N/A 1258 260 382 616
N/A -2,807 -£66 £246 £215 £320 -3507 380
Data Quality
*E . C oli
MS S A (trust and community acquired)
C DiffU
nder
Con
stru
ctio
n
% of patients in A&E under 4 hours
Operating Framework
R T T - non- admitted 95% in 18 wks
R T T - incomplete -median
Mixed S ex Accommodation
Res
ourc
esMonthly Trend
new metric for 2011/12
new metric for 2011/12
new metric for 2011/12
new metric for 2011/12
31 day second or subsequent treatment (surgery)
31 day second or subsequent treatment (drug)
31 day diagnos is to T reatment
Financial Position (£,000)
62 days urgent referral to treatment of all cancers
Delivery of Savings Plan
P atients that have spent more than 90% of their s tay in hospital on a s troke unitF ractured Neck of F emur <36
Median wait times -non-admitted
Median wait times - admitted
new metric for 2011/12
62 wait firs t treatment from C onsultant screening
18 weeks R T T - non-admitted including audiology (DAA)- 95th percentile @
R T T - incomplete - 95th percentile
2 week G P referral to 1st outpatient
2 week G P referral to 1st outpatient - breast symptoms
R T T - admitted 90% in 18 weeks
E mergency R eadmiss ions within 30 days of discharge
Performance
18 weeks R T T admitted - 95th P ercentile @
new metric for 2011/12
new metric for 2011/13
number of of patients in A&E over 12 hours (trolley waits )
T otal time in A&E non-admitted(95th percentlie)
A&E Attaendances
Qua
lity
Quarterly Trend
A&E time to initial assessment(95th percentile)
T ime to T reatment (median)
MR S A (trust acquired)
T otal time in A&E admitted (95th percentlie)
A&E Unplanned R e-attendance rate (within 7 days )
L eft without being seen (L WBS ) R ate
Indicators used for external assessment Direction of
Travel vs. Plan
Target YTD Actual
▲=above plan►=on
plan▼=below plan Jan Feb March Apr-11 May-11 Jun-11 Q1 2011/12 Q2 2010/11 Q3 2010/11 Q4 2010/11
N/A 642 260 382 0
N/A -3,187 -£66 £246 £215 £320 -3507 0
N/A
100 98.2
▼
108 84.6 74.5 93.4 Data
reported in
arrears
Data reported
in arrears
100% 99% ▼ 100.0% 100.0% 100.0% 100.0% 98.2% 100.0% 100.0% 100.0% 100.0% 100.0%
95% N/A 67.0% 100.0% 100.0% N/A N/A Data reported
in arrears
60% N/A 67.0% 100.0% 33.0% N/A N/A Data reported
in arrears
60% 80.0%▲
77.8% 40.0% 75.0% 90.0% 80.0% 73.3%
80% N/A
▼92.0% 77.0% 94.0% 73.0% 64.0% 71%
80% N/A▼
78.0% 72.0% 78.0% 78.0% 65.0% 78%
80% N/A▼
83.0% 80.0% 89.0% 76.0% 70.0% 74%
TBD 56 15 12 21 16 23 17
73 95 ▼ 32 42 20 18 48 29
0 0 ► 3 1 4 0 0 0
*We are not yet aware of any algorithm for attributing these(E.Coli) cases. So in the short term we have adopted the normal BSI algorithm using pre and post 48 hours of admission. These figures may change
**There were no PPCI's performed in month
Quarterly Trend
Indicators used for external assessment
Performance
Notes:
Stroke/TIA treated within 24 hours
Number of falls reported as clinical incidents
Newly acquired Pressure Ulcers (grade 2 and above)
Number of medication errors resulting in an adverse event
% of patients surveyed who would choose to be treated at SASH in Future% of patients surveyed that staff treated them with kindness and respect
Non-Elective FFCE's
HSMR
Delivery of Savings Plan
Outcomes framework
Patie
nt
Expe
rienc
e
**PPCI 150 min call to ballon time
Financial Position (£,000)
Und
er c
onst
ruct
ion
2 wks rapid access chest pain
PPCI 120 min call to ballon time
Safe
ty
% of patients surveyed who felt their dignity was maintained the whole time they were a patient
Res
ourc
esEf
fect
iven
ess
Monthly Trend
Data Quality
Und
er
Con
stru
ctio
n
Indicators used for Internal assessment
Direction of Travel vs. Plan
Target YTD Actual
▲=above plan►=on
plan▼=below plan Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Q1 2011/12 Q2 2010/11 Q3 2011/12 Q4 2011/12
Q4 201
90% 60.6%
▼
40.2% 38.5% 41.0% 43.6% 51.8% 60.6%
<=100 99.2 110.4 85.5 74.9 93.3 Data reported in arrears
Data reported in arrears
0 3
▼
1 0 2 1 1 1
50% 43%
▼44.0% 27.0% 29.0% 43.2% 32.1% 57.9%
2.2% 2.4% 2.1% 1.9% 2.3% 2.3%2.9% 3.4% 2.9% 2.8% 3.0% 3.4%
100% N/A N/A 0% 100.0%0 1 ► 0 0 0 0 0 1
80-90% 89%►
65.5% 78.3% 89.8% 90.0% 89.6% 86.4%
23% 30.2% ▼ 28.8 29.7 32.7 31.9% 30.5% 28.3%
90% 88.3%▼
85.9% 89.5% 93.8% 91.1% 84.5% 89.6%
90% 80.1%▼
81.0% 79.0% 83.7 77.9% 80.4% 82.0%
99% 98.4% ▼ 99.1% 99.2% 99.6% 97.6% 98.2% 99.3%
100% 102%
►
Data Reported
Quarterly
Data Reported
Quarterly
Data Reported
Quarterly
100% 118%
▲
Data Reported
Quarterly
Data Reported
Quarterly
Data Reported
Quarterly
<=5% 10.3% ▼ 0.0% 8.3% 8.3% 11.1% 0.0% 14.3%
<=0.80 1.6%▼
2.3% 2.2% 2.1% 2.5% 0.8% 1.6% 1.6%
TBD 80.4% 81.2% 79.4%
TBD 6 4.1 6.0 6.3TBD 4.4 3.6 4.3 3.03.5% 1.95% ► 1.72% 2.65% 2.10% 1.81% 2.13% 1.91% 1.95%
N/A 1175 1294 1386 1063 1101 1053
<=10% 10.8% 9.8% 9.8% 9.8% 10.0% 10.1%N/A 3167 3136 3137 3136.3 3156 3165 3167
2766 2848 2799 2825 2829 2,845 2848 2848<=3.0% 3.8% ▲ 4.2% 4.4% 4.4% 3.8% 3.6% 4.0%
<=210 221.1 ▲ 246 232 240 231.4 208.8 223.2
<=40 53.1 ▲ 63 60 59 51.7 33.9 53.1
***24% 22%
▼
5.0% 13.0% 22%
***24% 12%▼
4.0% 12%
* data as of 12/07/2011** exception reports provided on a quarterly basis
****Target is cumulative
Data Quality
Monthly Trend Quarterly TrendPerformance
new metric for 2011/12Unplanned Readmissions within 30 days
Total WTE Agency Staff (excluding extra capacity nursing)new construction
118.0%
102.0%
**C-section rate
Delayed T rans fers of C are
% of women seen by a midwife or healthcare professional at 12 wks 6dys
VTE Risk Assessments
Clin
ical Q
uality
Number of falls resulting in a fracture/head injury
% of Stroke patients Scanned within 1 hour of hospital arrival
Unplanned Readmissions within 14 days
HSMR Non-elective
Safe, High Quality Coordinated Care
Number of Never events reported% Complaints responded to within agreed timeline with complainant/ 25 working days
Mate
rnit
y
Breastfeeding initiation
MRSA screening compliance (elective)
% of SUI's due to be closed in month that were closed
Hand Hygiene compliance
MRSA screening compliance (nonelective)
Total Establishment
Infe
cti
on
Co
ntr
ol
E xcess follow ups
Average L O S non-E lective
Pro
du
cti
vit
y a
nd
eff
ecti
ven
ess
cancelled operations as a percentage of elective admiss ions
Average L O S E lective
Daycase R ate
**% of cancelled operations not treated within 28 days
% of staff who have completed stat and mandatory training
Total in post
Sickness absence rate
Wo
rkfo
rce
Total WTE Bank Staff (excluding extra capacity nursing)
Vacancy Rate
% of staff who have been appraisednew construction
7
Contents
1. Integrated Quality and Performance Dashboard
2. Exception Reports
3. Glossary of Terms
8
2. Charts for Performance Exception Areas
Weekly Type1&3 A&E Attendances seen in less then 4 hours
80%
85%
90%
95%
100%
105%
05/0
4/20
0926
/04/
2009
17/0
5/20
0907
/06/
2009
28/0
6/20
0919
/07/
2009
09/0
8/20
0930
/08/
2009
20/0
9/20
0911
/10/
2009
01/1
1/20
0922
/11/
2009
13/1
2/20
0903
/01/
2010
24/0
1/20
1014
/02/
2010
07/0
3/20
1028
/03/
2010
18/0
4/20
1009
/05/
2010
30/0
5/20
1020
/06/
2010
11/0
7/20
1001
/08/
2010
22/0
8/20
1012
/09/
2010
03/1
0/20
1024
/10/
2010
14/1
1/20
1005
/12/
2010
26/1
2/20
1016
/01/
2011
06/0
2/20
1127
/02/
2011
20/0
3/20
1110
/04/
2011
01/0
5/20
1122
/05/
2011
12/0
6/20
11
C-Sections
15%
20%
25%
30%
35%
40%
Apr-
08
May-0
8Jun-0
8Jul-08
Aug-0
8S
ep-0
8O
ct-
08
Nov-0
8D
ec-0
8Jan-0
9F
eb-0
9M
ar-
09
Apr-
09
May-0
9Jun-0
9Jul-09
Aug-0
9S
ep-0
9O
ct-
09
Nov-0
9D
ec-0
9Jan-1
0F
eb-1
0M
ar-
10
Apr-
10
May-1
0Jun-1
0Jul-10
Aug-1
0S
ep-1
0O
ct-
10
Nov-1
0D
ec-1
0Jan-1
1F
eb-1
1M
ar-
11
Apr-
11
May-1
1Jun-1
1
C-Section rates Target Trend linear
Stroke - 90% or more of time spend time on stroke unit
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Apr
-09
May
-09
Jun-
09Ju
l-09
Aug
-09
Sep
-09
Oct
-09
Nov
-09
Dec
-09
Jan-
10F
eb-1
0M
ar-1
0A
pr-1
0M
ay-1
0Ju
n-10
Jul-1
0A
ug-1
0S
ep-1
0O
ct-1
0N
ov-1
0D
ec-1
0Ja
n-11
Feb
-11
Mar
-11
Apr
-11
May
-11
Jun-
11
Stroke - 90% or more of time spend time on stroke unitTargetTrend linear
Cancelled Operations not treated within 28 days vs.Target
0%
5%
10%
15%
20%
25%
30%
Apr
-09
May
-09
Jun-
09Ju
l-09
Aug
-09
Sep
-09
Oct
-09
Nov
-09
Dec
-09
Jan-
10F
eb-1
0M
ar-1
0A
pr-1
0M
ay-1
0Ju
n-10
Jul-1
0A
ug-1
0S
ep-1
0O
ct-1
0N
ov-1
0D
ec-1
0Ja
n-11
Feb
-11
Mar
-11
Apr
-11
May
-11
Jun-
11
% Cancelled Operations not treated within 28 daysTargetTrend line
Divis ion/C linic al S ervic e: Medical Divis ion E mergency Department.K ey P erformanc e Indic ator: 95% of patients seen and treated in under 4 hours in E D K P I R ef No: X X X
C urrent Months P erf. Y TD P erf. Trend from previous month E xpec ted date to meet s tandard
80% 80% ٧
Num. Named L eadNew Ac tion
Ong oing Ac tion
E xpec ted C ompletion date Outc ome
1 C arlos x
2 P aula T ooms x continuous3 Ben Mearns x implemented4 P aula T ooms x ongoing5 P aula T ooms x5
Named R es pons ible L ead
P aula T ooms
Other K P I's Affec ted
R is ks
Ac tion
Ac tions for next monthOng oing ac tions from E D works tream c over Arrivals , Majors ,Obs ervation Unit, C ons ultant J ob P lanning , rec ruitment, revis ing of rotas and c ontinued review of metric 's .
S upport from the C orporate S ervic es
Internal refurbishment of department to facilitate improved streaming and working space, increase assessment and treatment capacity.P aula T ooms
Imformation and IT support with data collection and validation process , also C erner support following intergration of UT C with E D.
P erformance E xception R eport
S tandard
95%
Des c riptionR ef No.
Ac tions to improve performanc e
What is Driving the R eported Under P erformanc eAcheivement of the targets is s trongly linked to the capacity and flow of patients through the trust. F ailure to allocate beds to DT A's causes a backlog of patients to build up in E D which then impedes the flow and capacity of the department to see and treat patients efficently. Added to this is the change in measures being recorded in E D which has required s ignificant training with staff, followed by review to establish where data recording has been in accurate and corrections need to be made. A need to implement all actions within the E D transformation first 4 hours workstream is required to maximise internal performance.
Medical directorate implementation of Urgent C are L eads to provide access for consultant advice from G P 'sIntergration of UT C with E D, review of patient activity and selection to support E D flow.
E D quality indicators are now broken down into several area's , one's linked to time are all potientially affected due to delays being cascaded once we have accumulated them.
C ontinued lack of capacity with T rust
E D first 4 hours workstreamInternal review of weekly metrics to identify changes in performance that are incons istent with expectation and provide action plans or rationale for change, then implement action plan if required.
1st August implement new junior and middle grade rotas . C ommence new workflow streaming for patients through the department, with triage, arrivals , treatment process .complete review of UT C activity and demand, matching to staffing need, medical, E NP and NP 's .
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr-
11
May-1
1
Jun-1
1
Jul-11
Aug-1
1
Sep-1
1
Oct-
11
Nov-1
1
Dec-1
1
Jan-1
2
Feb-1
2
Mar-
12
Month
Pe
rce
nta
ge
co
mp
lia
nc
e
Divis ion/C linic al S ervic e: S urgical/ 18 weeks (Admitted P athway)K ey P erformanc e Indic ator: 90% of all Admitted pathway patients treated within 18 weeks K P I R ef No: X X X
C urrent Months P erf. Y TD P erf. Trend from previous month E xpec ted date to meet s tandard
O ct-11
Num. Named L eadNew Ac tion
Ong oing Ac tion
E xpec ted C ompletion date Outc ome
1 B ernie B luhm X 01/07/2011
2 Hamish Wallis X 25/06/2011agreements in place (298
pts R x Y T D)
3 C linton K rynie X01/07/2011 18/07/2011 validation still continuing
4 Hamish Wallis X 31/07/2011
5 C linton K rynie X01/07/2011 01/08/2011
delaied due to delay in validation
P erformance E xception R eport
S tandard
90%
review and implement T rust Access policy
O utsourcing - put in place agreements to outsource 1000 patients in Q1 & 2.
Ac tions to improve performanc e
Named R es pons ible L ead
Ac tions for next month
S upport from the C orporate S ervic es
18 week dashboard to be implemetned and updated on weekly bas is - enabling trust to report performance
Informatics - Accurate and timely reporting of 18 weeks
Hamish Wallis
What is Driving the R eported Under P erformanc eHistorical backlog of patients caused by: R eferral demand in excess to commiss ioned activity, T heatre efficiency, B ed P ressures - on the day/day before cancellation due to non-availability of beds ( 28 in May), L ate decis ion making with regards to DT A from the Non Admitted P athway, Annual L eave Management – his torically this has been poorly managed.T he T rust is now in a pos ition where the total waiting lis t for the Admitted P athway is double the des ired s ize (including 1300 patients over 18 weeks). In order to bring the waiting lis t down to the des ired level and clear the backlog agreement has been reached with the P C T ’s and S HA for the trust to underperform on 18 weeks in Quarter 1 and 2
Validate all patients on the waiting lis t and ensure T rust is reporting accurate information
Ac tion
Median Waiting timesNon Admitted P athway performance
bed pressures - demand for beds from the emergency flow results in elective patients being cancelled
Agree plan (in plac e) and monitoring with P C T 's and S HA for clearance of backlog (us ing IS T modelling) - weekly/monthly monitoring forum to be established
Des c riptionR ef No.
C ontinue to inc reas e outs ourc ing c apac ity, by bring on line three more providers (B rig hton, E ps om, G atwic k P ark), plus inc reas in c apapc ity with c urrent providers
reduce income for elective activity due to cancellation of internal activity due to capacity - lack of ability to make up lost capacity (other than by outsourcing)
C omplete validation of Admitted pathway
Income and E xpenditure forecasted budget/plan for outsourcing
Other K P I's Affec ted
R is ks
C ancelled ops(non clincal reason) not treated within 28 days
R esolve issues regarding cashing up of clinics and inputting of outcome forms to ensure accurate information is being input in timely manner (identify any training issues needed)
Dashboards: finalise and implement to ensure accurate weekly reporting
0%
20%
40%
60%
80%
100%
120%
Ap
r-1
1
Ma
y-1
1
Ju
n-1
1
Ju
l-1
1
Au
g-1
1
Se
p-1
1
Oct-
11
No
v-1
1
De
c-1
1
Ja
n-1
2
Fe
b-1
2
Ma
r-1
2
Month
Pe
rce
nta
ge
co
mp
lia
nc
e
Date by which compliance is required
Divis ion/C linic al S ervic e: MedicineK ey P erformanc e Indic ator: mixed sex accommodation K P I R ef No: X X X
C urrent Months P erf. Y TD P erf. Trend from previous month E xpec ted date to meet s tandard
9 ▼
Num. Named L eadNew Ac tion
Ong oing Ac tion
E xpec ted C ompletion date Outc ome
1Angela
S tevenson x DailyMixed sex breaches
minimised
2 L isa C heek x Dailymixed sex breaches
minimised
3Angela
S tevenson x Dailymixed sex breaches
minimised
Named R es pons ible L ead
L isa C heek
Other K P I's Affec ted
R is ks
Ac tion
Ac tions for next monthAs above.
S upport from the C orporate S ervic esNone
P erformance E xception R eport
S tandard
0
Des c riptionR ef No.
Ac tions to improve performanc e
What is Driving the R eported Under P erformanc eT he T rust continued to be very busy through J une 2011 with several escalation areas open and operationally was very challenging. T he 10 breaches which occurred in the medical divis ion were in the discharge lounge and A&E observation ward. 8 breaches occured in the observation ward and 2 breaches in the discharge lounge which is used as an escalation area over night. All measures were taken to prevent any mixed sex breaches and verbal information was given to the patients ..
P atients are moved at the earliest opportunity if a breach has occurred
None
s ite meeting attended by operation staff and clinical s taff and all oportunities explored to prevent any mixed sex accomodation.
All potentials to mix a bay are escalated through a matron to ensure all alternatives are cons idered first.
Divis ion/C linic al S ervic e: Medical Divis ion, S trokeK ey P erformanc e Indic ator: S troke 90% or more time spent on S troke Unit K P I R ef No:
C urrent Months P erf. Y TD Avg P erf. Trend from previous month E xpec ted date to meet s tandard69% 65% ▲ Apr-12
Num. Named L eadNew Ac tion
O ng oing Ac tion
E xpec ted C ompletion date Outc ome
1 Natasha Hare
X2 Natasha Hare
X 30-S ep-113 Natasha Hare
X 31-May-11 C omplete4 F iona White
(NHS West S x)
X 30-S ep-11 O ngoing5 Natasha Hare
X5 R obyn Davies
(NHS S urrey) X 30-S ep-117 B ernie B luhm
X
E ast S urrey E arly S upported D ischarge pilot (s tart date tbc but likely to s tart in J uly).
R ing-fence beds on Abinger ward to be used for S troke patients only and monitor impact on a weekly bas is
Achievement of best practice tariff
% of patients admitted directly to AS U within 4 hours of hospital arrival
Winter / E mergency B ed P ressures
D&V outbreaks and subsequent ward closures
P roposal to combine s troke beds into one ward to be discussed at divis ional level.
What is Driving the R eported Under P erformanc eAchievement of the 90% indicator is s trongly linked to the emergency patient flow pathway and associated actions relating to bed management and effective and timely discharge. T he non-performing pathways were again linked to continued pressures on bed capacity, which are not showing s igns of improvement. We continue to see steady improvement month on month helped by the ring fencing of beds although this alone has not made a s ignificant impact.
T IA pathway and booking process has been reviewed and communicated to G P s to improve communication and reduce time.
West S ussex E arly S upported D ischarge pilot underway (too early for results and under threat due to funding cuts ).
O utlying patients are reviewed daily and repatriated as soon as clinically appropriate.
L ocum consultant on C apel ward appointed until a substantive appointment is made. J ob description for the substantive post is awaiting C ollege approval.
P erformance E xception R eport
S tandard80%
Des c riptionR ef No.
Ac tions to improve performanc e
Named R es pons ible L eadNatasha Hare
Other K P I's Affec ted
R is ks
Ac tion
Ac tions for next monthP ublis h L oS K P I information at ward level s o that all s taff c an eas ily s ee c urrent performanc e.
S upport from the C orporate S ervic es
Introduction of Medihome / virtual ward / early discharge in J uly 2011
S upport ring fenced beds
90% stay on stroke unit
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Ap
r-1
1
Ma
y-1
1
Ju
n-1
1
Ju
l-1
1
Au
g-1
1
Se
p-1
1
Oct-
11
No
v-1
1
De
c-1
1
Ja
n-1
2
Fe
b-1
2
Ma
r-1
2
Month
Pe
rc
en
tag
e c
om
pli
an
ce Target Forecast Actual
Winter Pressures
Stroke Beds ring fenced
Improved Flow i.e. impact of Medihome / virtual ward
Early Supported Discharge
Divis ion/C linic al S ervic e: S urgical Divis ion/ #NOFK ey P erformanc e Indic ator: 85% of #NOF operated on within 36 hours K P I R ef No: X X X
C urrent Months P erf. Y TD P erf. Trend from previous month E xpec ted date to meet s tandard
66% 66% Aug-11
Num. Named L ead New Ac tionOng oing Ac tion
E xpec ted C ompletion date Outc ome
1 S ally P aterson 01/07/2011complete - needs to
be audited
2 G T selentakis X 01/08/20113 Hamish Wallis X 30/07/2011 part complete4 G T selentakis X 30/08/2011 on-going
E nsure that patients admitted with F racture neck of femur are admitted to Newdigate ward, not outlying wards
Iliaca F emoral B lock (% of patients who received) - 50%day 1 P ost op P hys iotherapy - 80%DVT P rophylas is - 87%
Other Non #NOF trauma patients being admitted that are clinical urgent (activity is increas ing)
P erformance E xception R eport
S tandard
85%
Number of #NOF patietns transferred to Newdigate Ward within 4 hours - 4
Des c riptionR ef No.
Ac tions to improve performanc e
Named R es pons ible L ead
Hamish Wallis
What is Driving the R eported Under P erformanc eIn J une there was a higher than normal level of patients (5) that required medical s tabilisation before they could be operated on. 4 patients breached the target due to insufficent operating time and were therefore rescheduled to the next day.
T ransfer T rauma lis t from white Board to E lectronic system within C erner - resulting in better management of lis ts and accessablity of lis tImplementation of action plan following the Moran R eview
Ac tion
Other K P I's Affec ted
R is ks
Ac tions for next month
E nsure order of lis t is agreed and set the night before with #NOF patient first on lis tS unday T rauma lis t to run for 6 hours starting at 10.30am - Medical teams have agreed, this needs to go into new specialty Doctor contract, T heatre nurs ing rota now this cover sess ion
E nsure the availability of the F ast-track bed
Agree S unday morning lis t in job plan of specialty doctorE stablish effective escalation system for patients who are fit for surgery but unlikely to be operated on with 36hrs
Audit the order of the lis t, ensuring that it is agreed the previous day and the first patient doesn't change
S upport from the C orporate S ervic esR efocus on the F ascia Iliaca B lock performance
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Apr-
11
May-
11
Jun-1
1
Jul-11
Aug-1
1
Sep-1
1
Oct
-11
Nov-
11
Dec-
11
Jan-1
2
Feb-1
2
Mar-
12
Month
Perc
en
tag
e c
om
plian
ce
14 14
FnoF – Exception graphs
S AS H T rauma (#NOF and Other) by Month
0
20
40
60
80
100
120
140
160
180
200
NO N #NO F #NO F
Complaince for DVT, Day 1 post op physio & Iliaca Block for #NOF patients per month
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
January February March April May June July August September October November December January February March April May June
Month
Per
cen
tag
e
DVT Prophylaxis % received physio on day 1 post op % pts receiving Iliaca Block
S AS H T rauma - #NOF c omplianc e
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
% R x in 36 hrs % R x in 48 hrs T arget
S AS H T rauma (#NOF and Other) by Month
0
20
40
60
80
100
120
140
160
180
200
NO N #NO F #NO F
Complaince for DVT, Day 1 post op physio & Iliaca Block for #NOF patients per month
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
January February March April May June July August September October November December January February March April May June
Month
Per
cen
tag
e
DVT Prophylaxis % received physio on day 1 post op % pts receiving Iliaca Block
S AS H T rauma - #NOF c omplianc e
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
% R x in 36 hrs % R x in 48 hrs T arget
S AS H T rauma - #NOF c omplianc e
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
% R x in 36 hrs % R x in 48 hrs Target
S AS H T rauma (#NOF and Other) by Month
0
20
40
60
80
100
120
140
160
180
200
NON #NOF #NOF
Complaince for DVT, Day 1 post op physio & Iliaca Block for #NOF patients per month
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
January February March April May June July August September October November December January February March April May June
Month
Perc
enta
ge
DVT Prophylaxis % received physio on day 1 post op % pts receiving Iliaca Block
Divis ion/C linic al S ervic e: C linical S upport S ervicesK ey P erformanc e Indic ator: K P I R ef No: X X X
C urrent Months P erf. Y TD P erf. Trend from previous month E xpec ted date to meet s tandard
0 1 ▼ J uly
Num. Named L eadNew Ac tion
Ong oing Ac tion
E xpec ted C ompletion date Outc ome
1 C hristine P owell X C ompleted No action required
Named R es pons ible L ead
J ackie B rown
Other K P I's Affec ted
R is ks
Ac tion
Ac tions for next monthNone
S upport from the C orporate S ervic esNone R equired
P erformance E xception R eport
S tandard
0
Des c riptionR ef No.
Ac tions to improve performanc e
What is Driving the R eported Under P erformanc eO n the 20/06/11 - P atient was walking with a nurse in the outpatient department waiting area at Horsham O P D and caught her foot on corner of one of the fixed waiting room chair legs and fell. T he patient was both elderly and frail hence walking with the nurse in the waiting room area. A doctor in the O P D saw the incident and attended the patient with the nurs ing s taff whils t they were waiting for an ambulance to arrive. It was thought from initial examnination that the patients sustained a fracture neck of femur. T he patient was admitted to Newdigate Ward at E S H and found to have fractured her left neck of femur following x-ray. T he incident was reports to the Head of O P &HR S and patient's next of kin. An incident report was completed. T he Head of O P &HR S reported the matter to her AD of C S S . R oot cause analys is showed this incident was an accident.
None
Incident was investigated
Divis ion/C linic al S ervic e: Medical Divis ion, WAC H K ey P erformanc e Indic ator: VT E assessment within 24hours 90% K P I R ef No: X X X
C urrent Months P erf. Y TD P erf. Trend from previous month E xpec ted date to meet s tandard83% Medical, 35% WAC H, 44% S urgical 53.4% T rustwide ▲ J ul-11 Medical, S ept-11 WAC H,
Num. Named L eadNew Ac tion
Ong oing Ac tion
E xpec ted C ompletion date Outc ome
1(Med) J eff T hompson x end J uly
2(Med) P aula T ooms x end J uly3(Med) J eff T hompson x end J uly4(wach) Dr. Nadim x5 (wach) Dr. Nadim x
6(S urg) Hamish Wallace x 01/07/2011done but being
repeated
7(S urg) Hamish Wallace x 01/07/2011 completed
8(S urg) Hamish Wallace x 01/07/2011
agreed to be included (?not been
done)9(S urg) Hamish Wallace x on going
VT E Assessment will be recorded on cerner by the B rockham ward s taff
T raining and communication to Medical and Nurs ing s taff on completing the E lectronic vers ionR eview of what is being included and what should be excluded from the lis t of patients elig ible for VT E Assessment – there are a large portion of patients being included that should not be (i.e. O phthalmology, E ndoscopy).
R eview of how and when data is be input (E .g. Urology completing 100% at P re assessment but data not being picked up)
C QUIN: T here is National best practice guidance which is linked to C QUIN funding to further encourage focus on this area of patient safety.
C ontinued data collection issues .
R emove E ndoscopy and Angiography day case activity from medical admiss ion data. Needs further refining in sense of only zero L O S patients to be excluded.R eview of 10 patient episodes coded to E D observation and Discharge lounge to assess pathway of patients and establish whether they fulfil the criteris for inclus ion in the data
Non-elig ible patients appearing on the lis t, which is dis torting the results - due to no distinction in coding between G A and L ocal'sMedical S taff - time constraints
(S urg) P re assessment VT E assessments to be included as agreed at Management B oard - this has not been done and so needs to be reviewed and completed(S urg) C ontinue monitoring within S AU of all elig ible patients being admitted on the emergency pathway.
What is Driving the R eported Under P erformanc eAll medically expected or internally referred patients are unable to be admitted unless there VT E assessment is completed as it is a mandatory field. C ontinued concern about the integrety of the data collection and presentation.
R eview of internal referrals to medicine, i.e surgical or ME T calls to see if reason for failure to assess as already admitted.VT E Assessment will be undertaken during the admiss ions process .
P erformance E xception R eport
S tandard
90%
Des c riptionR ef No.
Ac tions to improve performanc e
Named R es pons ible L ead
B en Mearns (Medical), Debbie P ullen(WAC H) Hamish Wallace (S urgical)
Other K P I's Affec ted
R is ks
Ac tion
Ac tions for next month(Med) Work with information to refine data collection and presentation
(S urg) R eview process for elective patients on day of admiss ion to ensure VT E Assessment is on system
Weekly monitoring of compliance by speciality/location
(S urg) communication: continue to raise profile of VT E assessments (electronically) at all S pecialty meeting and training days .
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ap
r-11
May-1
1
Jun-1
1
Jul-1
1
Au
g-1
1
Se
p-1
1
Oct-
11
Nov-1
1
Dec-1
1
Jan-1
2
Fe
b-1
2
Mar-
12
Month
Perc
en
tag
e c
om
plian
ce
Target
Medical Forecast
WACH Forecaast
Surgical Forecast
Divis ion/C linic al S ervic e: W&C HK ey P erformanc e Indic ator: C aesarean sections K P I R ef No: X X X
C urrent Months P erf. Y TD P erf. Trend from previous monthE xpec ted date to meet s tandard
29% 30% ▼ 31.3.12
Num. Named L eadNew Ac tion
Ong oing Ac tion
E xpec ted C ompletion date Outc ome
1 S harmila S ivarajan Y es No Aug-11E xamine data and act on
information
2 Denise Newman Y es No1.8.11 & constant
C hange of mindset of women and midwives re risk
Named R es pons ible L ead
S ue C hapman
Other K P I's Affec ted
R is ks
Ac tion
Ac tions for next monthMonitor outc omes and build on s uc c es s es
S upport from the C orporate S ervic es
P erformance E xception R eport
S tandard
23%
Des c riptionR ef No.
Ac tions to improve performanc e
What is Driving the R eported Under P erformanc eL ow tolerance to changing plan to C aesarean S ection
None
Despite many previous actions we have seen little improvement in the rate
10 week prospective audit underwayNew B irthing Unit T eam L eader in post - change admiss ion pathway and admit as low risk by default and only transfer to main delivery suite if confirmed high risk. Dedicated midwifery team.
Divis ion/C linic al S ervic e: W&C HK ey P erformanc e Indic ator: Women booked by 12wks & 6 days K P I R ef No: X X X
C urrent Months P erf. Y TD P erf. Trend from previous month E xpec ted date to meet s tandard
89.6% 88.3% ▲
Num. Named L eadNew Ac tion
Ong oing Ac tion
E xpec ted C ompletion date Outc ome
1Maureen
R oyds-J onesNone in
month Y es O ngoing
Named R es pons ible L ead
S ue C hapman
Other K P I's Affec ted
R is ks
Ac tion
Ac tions for next monthE nc ourag ement of women to book early
S upport from the C orporate S ervic es
P erformance E xception R eport
S tandard
90%
Des c riptionR ef No.
Ac tions to improve performanc e
What is Driving the R eported Under P erformanc eS ome months women do not access care in a timely manner
None
F luctuation as dependent upon women notifying their pregnancy and booking appoitments
E nsure adeqaute capacity of appointments
Divis ion/C linic al S ervic e: W&C HK ey P erformanc e Indic ator: B reast feeding initiation rate K P I R ef No: X X X
C urrent Months P erf. Y TD P erf. Trend from previous monthE xpec ted date to meet s tandard
82% 80% ▲ 31.12.11
Num. Named L eadNew Ac tion
Ong oing Ac tion
E xpec ted C ompletion date Outc ome
1 J anice B lythman no yes Apr-12 Increased rates
Named R es pons ible L ead
S ue C hapman
Other K P I's Affec ted
R is ks
Ac tion
Ac tions for next monthC ontinue with educ ation of all relevant s pec ialties
S upport from the C orporate S ervic es
P erformance E xception R eport
S tandard
90%
Des c riptionR ef No.
Ac tions to improve performanc e
What is Driving the R eported Under P erformanc eWomen's choice and incons is tent advice from various staff groups
None
Despite many previous actions we have seen little improvement in the rate & women's choice will always influence this
Undertaking 2 year B aby F riendly project
Divis ion/C linic al S ervic e: C ancelled O perations not treated within 28 days K ey P erformanc e Indic ator: % of cancelled operations not treated within 28 days K P I R ef No: X X X
Quarterly P erf. Y TD P erf. Trend from previous month E xpec ted date to meet s tandard
10% 10% Aug-11
Num. Named L eadNew Ac tion
Ong oing Ac tion
E xpec ted C ompletion date Outc ome
1 S ue C orby X on going
2 Hamish Wallis X on going
3 S ue C orby X on going
4
Ac tion
Ac tions for next month
C ancelled operations as a percentage of elective admiss ions
B ed C apacity (Winter P ressures)
C ancellations are being reviewed on a weekly bas is to ensure compliance.
All patients cancelled for non clinical reasons to have a new T C I within 7 days of being cancelled – if not then to be escalated through weekly P T L meeting.
Other K P I's Affec ted
R is ks
Des c riptionR ef No.
P erformance E xception R eport
S tandard
%
All patients cancelled on the day to be reviewed at weekly P T L meeting
Ac tions to improve performanc e
Named R es pons ible L ead
Hamish Wallis
What is Driving the R eported Under P erformanc eIn quarter 1 there was 138 patients cancelled on the day (vast majority due to bed pressures) and 116 patients who had 28 day breach dates of which 12 were not treated within their breach date due to capacity issues . T his equates to 10.34% of cancelled operations not treated within 28 days in for Quarter 1.O f the 4 who breached their 28 days the original reason for the cancellation on the day was due to:9x = No B eds , 1x = P atient issue, 1x = surgeon s ick and no one available to do operation.
C ontinue with weekly monitoring of cancellations through the P T L meeting
S upport from the C orporate S ervic esE lective beds to be refenced
0%
20%
40%
60%
80%
100%
120%
Apr-
11
May-1
1
Jun-1
1
Jul-11
Aug-1
1
Sep-1
1
Oct-
11
Nov-1
1
Dec-1
1
Jan-1
2
Feb-1
2
Mar-
12
Month
Perc
en
tag
e c
om
plian
ce
21
Contents
1. Integrated Quality and Performance Dashboard
2. Exception Reports
3. Glossary of Terms
22
3. Glossary Of terms
MRSA - Methicillin-resistant Staphylococcus aureus Cdiff - Clostridium difficile HSMR – Hospital Standardised Mortality Rates TIA - Transient Ischaemic Attack RIDDOR – Reporting of Injuries Dieses And Dangerous Occurrences ITU – Intensive Treatment Unit WTE – Whole Time Equivalent FFCE – First Finished Consultant episode AMI – Acute Myocardial Infraction RACP – Rapid Access Chest Pain CDS – Commissioning Data Set LOLER - Lifting Operations and Lifting Equipment Regulations 1998 SUI – Serious Untoward Incident ITU – Intensive Treatment Unit H&S – Health and Safety