Board Report template - CM (final version) › Documents › Board Report template - CM (final version).pdfContents Current Mth Trend on Previous Mth Outpatient Attendances Jun-18

Integrated Report

Quality,Performance & Workforce toend June 2018

Chief Operating Officer Jonathan Wade

Chief Nurse Emma Hardwick

Medical Director Nick Lyons

Director Of Human Resources Karen Charman

Contents

Current Mth Trend on Previous Mth

Outpatient Attendances

Jun-18 Jun-18 01/04/2016 01/05/2016 01/06/2016

21859

We are delighted to add new elements to our IPR as we work towards creating a better report.

This will be an iterative process and pages will be subject to change over the coming months as we improve our reporting and reporting tools.

Context for the Integrated Report - Hospital activity

Inpatient Admissions

(Elective & Emergency) 3977 4044

35713124Other (regular day patients,

day cases etc)

Emergency Department

Attendances 5707 5963

20250

Executive Summary1

Quality Account2

Quality & Risk3

Performance & Standards4

CQUIN5

Workforce6

Appendices7

8

Page 3

Page 5

Page 6

Page 23

Page 35

Page 36

Page 42

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EXECUTIVE SUMMARY

The Trust strategy for 2018/19 is based upon delivering high quality, patient focused and integrated healthcare for our community

whilst improving patient flow through the hospital in order that we can deliver our activity plan and our £10m Cost Improvement Programme for the year.

The QEH is ranked 16th (out of 18 within the region) for the Trust Safety Thermometer in June with a score of 95.10% (in relation to New Harm Free only)

which is below the national average of 97.3%. More detail can be found on page 7.

The reported Hospital Standardised Mortality Ratio (HSMR) for the latest available data (April 2017 to Mar 2018) is 103, which is ' as expected' . The crude

mortality rate within the HSMR basket puts the QEH slightly above the region for the April 17 to Mar 18 period. Details can be found on page 8.

There were no Never Events reported in June.

4 Serious Incidents were reported this month.

There were no cases of MRSA bacteraemia in June. The latest MRSA bacteraemia rate comparative data (May 17 to Mar 18) puts the Trust 13th out of 17 in

our region.

There were 0 inpatients confirmed with C. difficile infection June. The latest C. difficile rate comparative data (12 months to May 2018) puts the Trust 4th

highest out 17 Trusts within our region.

The Friends & Family Test (FFT) Recommend scores are being monitored in line with NHS England guidance. The Trust achieved the "95% recommended"

target in all areas with the exception of AE (90.87%). The "Response Rate" target was met in all relevant areas, again with the exception of AE.

Performance against the Four Hour standard improved to 91.92% in June.

Type 1 attendances in June were 190 per day on average, which reflects growth of 1.03% compared to 2017 and 4.5 down on May. Year to date growth in

attendances is 3.48%. The conversion rate for June was 26%, which was the lowest rate in 2018/19.

In June 2018 we saw 1823 conveyances by ambulance to QEH, an increase of 8.56% from June 2017 and lower than May 2018 activity of 63 conveyances per

day. 42.60% of our handovers were clear within 15mins, 30 minute handover delays were 7.9%, and 60 minute handover delays were 1.97%, this compares to

May 2018 when our 15 minute performance was 40.78%.

Bed days lost to Delayed Transfer of Care (DToC) increased in June to 612 compared to 577 in May. This represents 5% of occupied bed days, a worse position

than May 2018.

In May 2018 all Cancer standards were achieved except the 62 day standard which was 84.28%.

Page Authors: Nick Lyons, Emma Hardwick, Jonathan Wade, Roy Jackson, Karen Charman

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Executive Summary continued

The number of patients over 18 weeks has increased by 13 in the last month. The overall waiting list size rose by 166. Of the 18 nationally reported specialties

3 sustained the 92% standard in June. The poorest performing specialty was Urology, with the best performing being Dermatology. The most recovered

specialty was Rheumatology

Overall the Trust’s Turnover rate was 12.34% and Sickness rates is 4.70% in June.

The staff in post has remained steady over the last 12 months with an average staff in post of 2780 FTE despite staff turnover.

The vacancy rate for Registered Nurses decreased by 0.3% from previous month to 15.23%. The Trust continues to work with partners to recruit

internationally. The vacancy rate for HCAs has increased by 1.73% from the previous month to 11.12%., however there are over 50 successful candidates in

the conditional offer stage so we expect the position to improve.

There has been a decrease in temporary nursing requests in June 2018 compared to the previous month. There has been less demand due to escalation areas

not being opened and a greater emphasis on compliance with completing rosters in advance.

The overall Trust position on Mandatory Training compliance remains below the Trust’s KPI of 95% at 85.52%. Compliance rates for Safeguarding Children is

92.15%.

The Trust has a CIP target for the year of £10m recurrent savings.the Trust continues to strive towards identifying new transformtaional opportunities to

address any gaps.

Page Authors: Nick Lyons, Emma Hardwick, Jonathan Wade, Roy Jackson, Karen Charman

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Priority

Introduction of NEWS 2

Improvements in Infection Control

Cleaning standards

Matrons charter

Quality improvement programme around nutrition and hydration

Improvements in Medicines Management – Anti-coagulation

Quality improvement programme around nutrition and hydration

Improve understanding of the Mental Capacity Act 2005 amongst staff

and how it is used within healthcare practice.

Quality improvements within End of Life care

Improving communication with patients who have a sensory impairment

such as deafness or visually impairment

Development of an Older People’s Strategy encompassing dementia and

delirium care and frailty management.

Quality improvements within maternity care – exact goals to be

confirmed

I would recommend my organisation as a place to work [FFT]

When errors, near misses or incidents are reported, my organisation takes

action to ensure that

they do not happen again

I would feel confident that the organisation would address concerns

about unsafe clinical practice 18/19

Well led

Page Authors: Various: Owner Emma Hardwick

This section is new and we will populate in August 2018

Indicators

Quality Account

Patient safety indicators are monitored within the new quality improvement plan. There is

a launch day planned for November for NEWS2

We continue with our deep cleaning programme and liaise with NHSI for support

The matrons charter, nutrition and hydration and improvements in medicines

management are all in review and we will align metrics to measure and monitor in the

coming month.

The Trust has developed a more robust Quality Improvement plan with oversight from the

CEO and Board. There are agreed timeframes regarding training and embedding MCA. We

are trialling an EOL dashboard. Our practice development nurses continue to train our

staff in awareness of patients with sensory impairment and visual impairment

The Trust has been an active participant in cohort 8 of the Acute Frailty network. We have

regular conference calls with the network to update on our plans and share bets practice

with peers.

There is a maternity improvement plan which we rea supported with from NHSI.

Patient Safety

Patient Experience

Clinical effectiveness

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10 5

Data provided from DATIX and is a snapshot of data recorded on DATIX at the time which is normally around the 10th calendar day of the month after the reporting period.

Serious Incidents

Definitions

Serious Incidents Update

There were 4 Serious Incidents reported to the CCG in June 2018.

There were 4 Serious incidents occurred in June and 1 Never Event.4 SI’s including 2 Obstetrics incidents, 1 Paediatric fall, 1 Patient Transfer incident1 NE for Long line insertion

We have seen a steady increase in the number of Serious incidents being reported during the past 3 months.

There have been 2 incidents which breached the 60 day target. These are both owing to investigation skills capacity and complexity of investigation. Additional skills have been sourced to support the production of SI investigations.

Planned actions for the forthcoming monthQuality of Serious incident investigation reports is monitored by the Risk and Governance team and the WNCCG for quality monitoring. Co-jointly this process results in high quality reports submitted to NHS improvement.

There has been noted via the CQRM meeting there are variations with the quality of serious incident reports produced at QEH submitted to the WNCCG.

In response the trust is arranging additional training sessions for investigators, this includes a one day refresher event on 19th September and a 2-day training program for new investigators on 20th and 21st September.

The embedding of actions and learning from SI’s still requires active management and this is a devolved function to the relevant divisions and CBU’s. Actions are logged on the datix system. To increase effectiveness the Risk and governance team are working on automated notification and monitoring of actions from serious incidents.

To increase visibility of Lessons learned the Risk and Governance team are working on a 1 page template to convey learning to staff from serious incident reports.

0

1

2

3

4

5

6

Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18

Total Serious Incidents - Rolling 12 Months

Total Never Events Total Falls Resulting in Serious Harm Total PU's as SI's Total Other Sis

Executive

SummaryQuality & Risk

Perf & Standards

CQUINS Workforce Finance Appendices

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The QEH is ranked 16th (out of 18 regional Trusts) for the Trust Safety Thermometer in June with a score of 95.10% (in relation to New Harm Free only).

This is below the national average of 97.3%.

Data Source: Data extracted from the National Safety Thermometer Tool after submission by the Trust's Clinical Audit normally around the 10th calendar day of the month after the reporting period.

Safety Thermometer

Definitions

Executive

SummaryQuality & Risk Perf & Standards CQUINS Workforce Finance Appendices

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Methodology used to derive the HSMR is freely available. Latest Dr Foster Mortality Summary shows QEH is 103 as expected

· Included in the new intelligence monitoring system used by the CQC and available to the public through the CQC website

· Widely reported (including as part of the Dr Foster Good Hospital Guide and in the press)

· Risk of death based on diagnosis at first episode of care

· Does not include deaths after discharge

· Can be adversely affected by low use of palliative care codes (QEH is historically a low user of these codes)

HSMR for the 12 month period Apr 17 - Mar 18 is 103 as expected

Weekday HSMR is 101.1 as expected

Weekend HSMR is 108.7 as expected

June Update

Latest Report shows QEH is 98 as expected

· Available to public on the NHS Choices website

· Risk of death based on diagnosis at first episode of care

· Includes deaths within 30 days of discharge.

· Rolling 12 month average, but only published 6 months in arrears

SHMI for the 12 month data period of Jan 17 - Dec 17 is 98 as expected

SHMI for Q2 of 17/18 is 88.93 which is as expected

Reporting to the Board - The mortality surveillance group continues to closely monitor both higher than expected areas of mortality and trends that suggest where future outliers may be. This informs audit and the work of that group. This report will show from January 2018,

in addition to the present metrics, the incidence of avoidable deaths as they are identified

Mortality- HSMR (Hospital Standardised Mortality Ratio)

SHMI - (Quarterly Trend)

HSMR - (Monthly Trend) Key Points/Operational Actions

DefinitionsWhat does ‘as expected’ mean? SHMI: 95% control limits from a random effects model applying a 10% trim for over-dispersion are used to give a Trust a banding of ‘as expected’, ‘higher than expected’ or ‘lower than expected’.

HSMR: 99.8% control limits are applicable.

Key Points/Operational Actions

Mortality- SHMI (Summary Hospital Mortality Indicator)

There were 90 deaths in the hospital in June 2018, this number is slightly higher than last year (88) and equates to 12.7 deaths per 1000 admissions which is higher than our previous rate in June 2017 at 11.8.

The most number of deaths occurred on our care of the elderly (11) Respiratory (10) and Oncology (10) wards.

The highest number of deaths were recorded against a final diagnosis of pneumonia and sepsis.

Our HSMR is within expected at 103.0. Our SHMI is also within expected at 0.98. Both weekday and weekend HSMR are within the expected ranges.

Executive


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Crude rate within HSMR basket is 3.58% (based on Apr 17-Mar 18),East of England rate = 3.57%

Perinatal mortality - Death of the foetus or live born between 24 weeks gestational age to 7 days post natal

The Crude Mortality rate dropped to 3.01 in Mar, from 4.25 (Feb) in line with the trend of the previous

years.

Mortality Rate for the Trust per 1000 Admissions, Calculation = Total Deaths/Total spells *1000.Perinatal mortality - Death of the foetus or live born between 24 weeks gestational age to 7 days post natal. Data taken from Dr Foster normally around 10th calendar each month.

Mortality - Crude Mortality Rate (per 1000 admissions)

Definitions

Mortality - HSMR Basket Crude Rate (Yearly Comparison)

Perinatal Mortality - QEH Relative Risk (Monthly) & Observed No'sPerinatal Mortality - QEH Benchmarked Vs East of England

Palliative Care Coding Rate

The Trust's Non-Elective 'Palliative Care Coding' rate of (1.76%) for 17/18, is low when compared to the National average (4.10%)

Key Points/Operational Actions

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Observed 0 1 0 0 0 0 2 1 0 0 4 0

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Data Source: The dashboard above is populated based on Mortality data extracted from PAS and after discussions at the routine Trust's Mortality Review meetings.

Mortality - Learning from Deaths Dashboard

Definitions

Executive


Perf & Standards


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The incidence of Hospital Acquired Pressure Ulcers (HAPU) per 1000 beddays was 0.57

Definitions

Data provided from DATIX and is a snapshot of data recorded on DATIX at the time which is normally around the 10th calendar day of the month after the reporting period.Total number Falls/PU incidents per month (across all levels of Harm) . Number of Falls/PU incidents per 1000 beddays, per month (across all levels of Harm) .

During the month of June 2018, 7 Hospital Acquired Pressure Ulcers were reported. 3 x Category 3, and 4 x Category 2. Three of the Pressure Ulcers were verified as being avoidable.

The unavoidable Pressure Ulcers, meaning all assessments were accurate and appropriate and all prevention was in place in a timely manner are as follows;1 x category 3 on Necton (coccyx)1 x category 2 on Stanhoe (sacrum)1 x category 2 on Shouldham (heel)1 x category 2 on Windsor (sacrum)

The wards with avoidable Pressure Ulcers and areas for improvement which the Trust is working with are as follows;1 x category 3, Terrington (right ear) – failure to monitor skin regularly for pressure damage, or to implement pressure relief under a medical device.1 x category 3, West Newton/MAU (sacrum) - Failure to provide appropriate pressure relieving equipment. Failure to complete nutritional assessment in a timely manner. Failure to reposition 2 hourly.1 x category 2, Gayton (chin from collar) - Documentation fails to evidence that the collar was removed daily for skin inspection.(this was also part of the instruction from the Consultant/Reg review)

All category 3’s have had a full Route Cause Analysis (RCA) with action plans to improve practice. All category 2’s have had an ASKINS checklist completed, with any areas for improvement highlighted to the ward manager and matron.

The incidence of falls per 1000 beddays in June was 4.1: Validated 51 for June Trust decrease on May 5.68. The National rate 6.63

Following further validation of the falls data the fall graded as moderate on the June data has now been downgraded to minor. We have reviewed and improved our falls which have been ratified during June and reflect changes in both operational and NICE/national standards and guidance. Weekly falls data is provided to clinical teams with the Falls team working closely with them to develop action plans to improve knowledge and skill set in falls prevention and management. Through discussions at the falls steering group and Nursing and Midwifery board there was general agreement to remove crash mats placed next to hi/lo profiling beds. There was agreement that they are a fall / trip hazard for staff and patients (with some Trusts nationally reporting such injuries), they present a significant IP&C challenge in maintaining their cleanliness and are often an obstacle to safe moving and handling practices. Revised guidance for the use of hi/lo beds to be developed.

This month’s data returns us to a previously seen downward trajectory in reported non injury falls across the Trust, although in June as in May the Trust has had 2 falls with significant injuries, 1 being major and 1 being moderate. During this month all other falls were recorded as (0) catastrophic (18) minor (31) negligible.

We have begun developing a business case to secure the required funding to implement the new ‘retrieval from the from the floor’ protocol within the recently revised falls policy. Following a successful trial of the new ‘stealth’ sensor falls mats we are keen to look at how these could be introduce within our current falls prevention strategy. Falls training programme for registered and unregistered staff continues with additional sessions also being planned regarding recognition of ‘enhanced care needs’ in July. Review of ‘falls sticker’ - Following attendance at National Falls Summit and observation of different post fall strategies adopted by other Trusts at the time of a patient fall. This has supported and enhanced the

Falls & Pressure Ulcers

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QEH trend analysis

MRSA bacteraemia ceiling for 2018/19 is 0 avoidable Trust acquired cases.

There has been 2 cases of avoidable Trust acquired MRSA bacteraemia in 2018/19.

C. Difficile ceiling for 2018/19 is no more than 53 Trust acquired cases.

There were 4 cases of Trust acquired C. Difficile in 2018/19.

There have been 0 cases of MRSA bacteraemia in Jun-18

The latest MRSA bacteraemia rate comparative data May-17 to Mar-18 puts the Trust 13th out of 18 in our region.

All cases are discussed at HICC and RCA meetings and key themes identified. Actions include addition of IPC as standing

agenda item on CBU and Divisional meeting agendas. Antibiotic prescribing work with health economy and cleaning.

Compliance with MRSA decolonisation was 43% in June however this included 9/14 patients that were discharged prior to

end of treatment completion.

Data Source: Data provided by the Infection Prevention and Control Team normally around the 10th calendar day of the month after the reporting period.CDIFF - The objective aims to deliver a continuing reduction in Clostridium difficile infections. Organisations with higher baseline rates will be required to deliver larger reductions.MRSA - The objective aims to deliver a continuing reduction in MRSA bacteraemia by requiring acute trusts and PCOs to improve to the level of top performers.

MRSA & Clostridium Difficile

Definitions

Key Points / Operational actions

No further cases of MRSA in June. Possible transmission of MRSA colonisation on Stanhoe Ward, x3 cases. Further screening negative results. CVC tip positive to MRSA on Terrington ward, patient unwell and treated for line related infection. Blood cultures negative to MRSA. Incident reported and moderate - investigation underway.

Change in performance in the last month

No change. 0 cases of MRSA.

Planned actions for the forthcoming month

• Moderate incident investigation re CVC tip line.• Continue to monitor weekly screening for compliance.• ANTT training continues led by PDN team.• Further training planned with use of extension/multi lumen lines to improve ANTT standards with IV

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C. Difficile Infection

The latest C. Difficile rate comparative data (12 months to May-18) put the Trust 4th out of 18 in our region

There have been 0 cases of Trust acquired C.Difficile infection in Jun

To date 4 cases have been reviewed with the CCG following completion of the RCA, with 2 cases being successfully

appealed and 1 case pending.

CDIFF - The objective aims to deliver a continuing reduction in Clostridium difficile infections. Organisations with higher baseline rates will be required to deliver larger reductions.Data Source: Data provided by the Infection Prevention and Control Team normally around the 10th calendar day of the month after the reporting period.

Clostridium Difficile

Definitions


Deep clean programme commenced with admission areas MAU and Terrington.


Improved performance on May with 0 cases of HAI toxin identified. HCA PCR C diff identified on Oxborough Ward with evidence of transmission and non compliance with isolation of patients. This has been addressed and on going work with the ward continues.


Continue with deep clean programme, once admission areas are completed areas identified with C diff transmission in outbreak will be next to have repairs, deep clean and HPV.

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Latest Month's Performance Financial YTD

Number of Incidents of Mixed Sex Accommodation (MSA) - The number of times Mixed Sex Accommodation occurred within the specified time period.Number of Breaches of Mixed Sex Accommodation (MSA) - The total number of patients affected by Mixed Sex Accommodation occurrences within the specified time period.

Patient Experience - Mixed Sex Accommodation

Definitions

1Incidents of Mixed Sex Accommodation rrrr

2No. of Patientsaffected rrrr

7Incidents of Mixed Sex Accommodation rrrr

14No. of Patients affected rrrr

34

2 2

4

0 0

45

3 3

1

0

2

4

6

8

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

No. of Mixed Sex Accommodation Incidents

No. of Mixed sex Accommodation Incidents

68

4 4

8

0 0

9

12

6 6

2

0

4

8

12

16

20


No. of Mixed Sex Accommodation breaches

No. of Mixed Sex Accommodation Breaches


Change in performance in the last monthThere has been some improvement this month with only one breach of the mixed sex accommodation guidelines affecting two individuals. This was again due to a patient on the Critical Care Unit experiencing a delay in accessing a step down bed on a general ward.

Planned actions for the forthcoming monthWe will continue to focus on and manage EMSA breaches in a timely fashion, monitoring and daily agreement of eraly moves will eb catively managed in the operations centre via the Duty Director.

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Data Source: Patient Safety (Light Blue section) provided by Clinical Audit, Incidents data from DATIX , C Diff/MRSA data from Infection Prevention & Control Team , Compliments & Complaints provided by the Complaints Dept, FFT provided by Meridian. Fill Rates obtained from the Trust's monthly Safer Staffing Return & Staff Experience data provided by HR. Data normally received around the 10th calendar day of the month after reporting period.

Service line Clinical Indicators (by ward)

Definitions

Jun-18 Indicator Description

Fluid Charts 98% 91% 59% 67% 87% 98% N/A N/A 100% 80% 72% 93% 70% 95% 71% 79% 60% 83%

MUST Assessment 100% 100% 90% 93% N/A N/A 100% 100% 100% 83% 0% 100% 94%

Waterlow Assessment 100% 100% 100% 29% 100% N/A N/A 100% 100% 100% 100% 100% 100% 100%

Waterlow Re-Scored 100% 100% 100% 100% N/A N/A 92% 88% 95% 100% 83% 63% 88% 93%

Has A Body Map Been Completed 45% 13% 40% 50% 31% 100% N/A N/A 70% 85% 80% 83% 50% 70% 35% 60% 70%

Moving And Handling Assessment Completed 90% 100% 100% 100% 75% 100% N/A N/A 90% 100% 85% 100% 79% 90% 90% 85% 100%

Falls Assessment Done 100% 100% 90% 100% 83% N/A N/A 100% 100% 100% 100% 100% 100% 89%

Falls assessment rescored weekly 100% 100% 100% 100% N/A N/A 100% 88% 95% 100% 83% 75% 94% 80%

Is a Falls Care Plan Completed? 85% 100% 95% 100% 38% 67% N/A N/A 90% 100% 100% 100% 63% 70% 90% 90% 100%

EWS for each set of OBS? 100% 100% 100% 100% 100% 100% N/A N/A 100% 100% 100% 92% 100% 100% 85% 100% 100%

Care Rounds Completed 94% 85% 85% 66% 100% 100% N/A N/A 96% 83% 100% 98% 88% 100% 97% 85% 92% 67%

Bedrail Assessment if "At Risk" (on admission) 100% 100% 80% 79% 67% N/A N/A 50% 100% 86% 87% 70% 100% 74%

Obs Frequency documented 100% 100% 70% 100% 81% 17% N/A N/A 85% 100% 100% 67% 95% 90% 85% 100% 100%

Total Incidents (SI's, Falls, PU's & Drug Errors only) 5 3 2 4 0 2 0 1 2 N/A 7 6 7 11 4 3 10 4 4 10

Serious Incidents 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0

Drug Administration Errors 0 1 2 2 0 2 0 1 1 4 3 2 2 0 1 3 1 1 4

All Drug Errors (inc Admin) 1 3 2 4 0 3 0 1 2 7 5 6 3 1 2 4 3 1 7

Falls Total 5 1 0 1 0 0 0 0 0 2 2 5 8 3 2 6 2 3 5

H/A Pressure Ulcers Grade 2 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1



C.Diff > 2 Days 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Harm Free Care 100% 27% 90% 90% 100% 100% N/A N/A N/A N/A N/A 100% 91% 81% 94% 92% 96% 94% 81% 100% 88%

MRSA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

C4C Audit % 92% 89% 89% 90% 96% N/A N/A N/A N/A 97% N/A 91% 98% ### 95% 98% 97% 97% 93% N/A N/A N/A N/A ###### ##

Hand Hygiene % 96% 81% 100% 87% 97% N/A N/A N/A N/A 82% N/A 84% 87% 89% 96% 100% 92% 88% N/A N/A N/A N/A 94%

MSSA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

E.Coli 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1

ESBL 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Psuedomonas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Klebsiella 0 0 0 0 0 0 0 0 0 N/A 0 1 0 0 0 0 0 1 1 0

Complaints 1 2 0 0 0 0 0 0 2 0 2 1 0 0 2 1 0 0 0

Compliments 4 1 2 10 8 14 0 1 4 0 10 7 8 0 3 3 5 7 5

Family And Friends Response Rate 38% 35% 19% 39% 28% 245% 0% 37% 17% 35% 27% 62% 53% 67% 41% 35% 67% 51% 48%

Family And Friends (% Recommended) 97% 89% 98% 94% 96% 100% 0% 93% 91% 91% 92% 94% 91% 97% 94% 92% 97% 94% 96%

% Of Active Mentors 25% 40% 67% 89% 100% 58% N/A N/A N/A N/A 56% 100% 50% N/A N/A 33% 100% 67% 0% 38% 63% 33%

Fill Rate Registered 95% 96% 89% 95% 94% 84% 0% N/A N/A 103% 94% 93% 103% 96% 91% 96% 95% 97% 96% 97%

Fill Rate Unregistered 119% 115% 101% 100% 94% 71% 0% N/A N/A 100% 119% 97% 87% 100% 100% 101% 92% 133% 94% 101%

CHPPD 6.0 6.6 12.3 6.0 6.0 29.0 0.0 N/A N/A 12.5 8.4 5.8 6.2 6.4 8.0 5.5 6.2 8.6 7.5 5.8

Appraisals 85% 69% 100% 84% 82% 88% 0% 55% 65% 94% 80% 63% 98% 100% 88% 97% 65% 98% 88%

Sickness 9% 7% 3% 4% 4% 11% 0% 2% 8% 2% 10% 8% 8% 4% 1% 7% 5% 9% 8%

Vacancies 28% 26% 19% 17% 19% 11% 0% -1% 22% 26% 40% 28% 38% 2% 26% 50% 35% 22% 27%

Mandatory Training 83% 76% 96% 92% 88% 86% 0% 70% 83% 86% 86% 89% 91% 91% 80% 83% 91% 91% 85%

"Total Incidents (SI's, Falls, PU's & Drug Errors only)" figure includes Serious Incidents, Falls, Pressure Ulcers and Drug "Administration Errors" only, not all Drug Errors.

Den Lev Esc

Patient

Experi

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Eff

ect

iveness

Sta

ff

Experi

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Elm SAU Gayt Mar C Care

Pati

ent

Safe

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WindAEC A&E MAU Nec Oxb Stan Sho Til TSS West New West Ray

Data Not Applicable

Data N/A

Data N/A

Data N/A

Monthly Quality performance review meetings continue chaired by the Chief Nurse or Deputy Chief Nurse the ward/department managers attend with their matron and ACN, each ward/department review their data and performance measures and actions planned or already in place.

We can report there has been an improvement in the completion in the fluid charts, MUST and waterlow assessment, observation frequency, bed rail assessments, moving and handling assessments with a reduction of indicators in red, with several improved to amber and green. It is expected that with this continued approach a month on month improvement will be made.


• Monthly Quality performance review meetings in place chaired by the Chief Nurse the ward/dept managers attend with their matron and ACN, each ward/dept reviewing their data and performance measures and actions planned or already in place.

• Individualised QIP are in place per ward/dept with 1:1 meetings in place to monitor/review processes established by ward managers and matrons.• Meetings and action plan in place to support cohesion and improved communications between the audit department and clinical staff.• Mandatory ACN support meetings in place with Chief Nure..• Revised process in place with matron review of audit data from their ward/dept prior to submission to allow oversight and if required actions to be activated in a timely manner.• Training complete for all the areas that will be using perfect ward. The specialty areas such as Theatres, paediatrics, out patients etc have adapted the audit templates to support data collection from their areas and are now beginning to commence

pilot audits.

Change in performance in the last month• ACNs reporting an improvement in communication and escalation on any concerns from the audit department.• The data collection detail behind the % for each clinical indicator has supported the ward managers and matrons in the analysis and informed specific action planning.

Planned actions for the forthcoming month• Develop a Standard Operational Procedural document in preparation for perfect ward implementation Trustwide.

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The % of patients "Recommending / Not Recommending the Service" shown above will not always equal a combined total of 100% as it does not include those who are undecided. Data Source: Meridian normally around the 10th calendar day of the month after the

reporting period.The Friends & Family Test Scores & Response Rates shown above includes Inpatients & Daycase activity.

* Response rates of greater than 100% can occur when responses relating to discharges in one month are received by organisations too late for that month’s submission and are submitted as part of the return in the following month or Patients/Carers/Family members may also choose to submit responses at multiple points during a period of care/treatment resulting in multiple submissions to the same month.

Friends and Family Test

Definitions

Key Points / Operational actionsA&E – response rate is improving and June had the highest response rate since Nov 2017. Likelihood to recommend whilst missing the target of 95%, has increased slightly to over 90% (the highest since Feb 2017)Inpatient – response rate continues to improve above the 30% target and likelihood to recommend remains above the 95% target as it has done since Dec 2017.Maternity – only birth response rate is reported on – the target is 15% this has been rising steadily all financial year and is nearly twice the target. Likelihood to recommend is 100% in 3of the 4 areas and is above 95% in antenatal.Outpatient – there is no response rate target – the likelihood to recommend score is above the 95% target and has been for the last rolling 12 months.

Change in performance in the last monthA&E are showing an improvement in achieving the target. All other areas have met their target this month.A&E are focusing on promoting the collection of FFT feedback with the support of Patient Experience as well as undertaking a fortnightly walkabout involving the Matron, Patient Experience Lead and a Governor to improve aspects of the patient experience to hopefully benefit future patients.

Planned actions for the forthcoming monthRolling 12 month review of response rate targets highlighting the individual wards/areas not achieving target to be communicated to Matrons / Ward Managers and ACNs to prompt suggestions or sharing of best practice.

2017/07 2017/08 2017/09 2017/10 2017/11 2017/12 2018/01 2018/02 2018/03 2018/04 2018/05 2018/06Difference

(Prev Mth)

% Recommend (Target 95%) 95.39% 94.41% 93.97% 95.44% 93.61% 92.51% 96.90% 93.71% 89.73% 88.20% 90.00% 90.87% 0.87%

% Not Recommend 0.88% 1.29% 2.14% 1.28% 1.60% 3.04% 1.03% 2.40% 4.69% 3.83% 2.50% 2.48%

Response Rate 14.19% 13.58% 16.61% 16.73% 23.45% 15.18% 16.03% 13.02% 13.84% 10.35% 11.52% 17.67% 6.15%

Response Rate Target 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00%

% Recommend (Target 95%) 94.75% 95.75% 95.35% 96.04% 94.85% 94.46% 96.43% 96.09% 95.07% 95.38% 96.18% 95.87% -0.31%

% Not Recommend 1.21% 0.89% 1.22% 0.94% 0.86% 1.42% 0.33% 0.62% 1.26% 0.92% 1.17% 0.84%

Response Rate 32.63% 29.44% 30.03% 31.60% 29.72% 27.05% 24.81% 26.76% 30.56% 31.72% 31.14% 33.96% 2.82%



% Not Recommend 1.20% 0.41% 0.41% 0.96% 2.76% 4.76% 1.03% 0.00% 0.00% 0.00% 0.00% 1.15%


% Not Recommend 3.33% 3.13% 0.00% 0.00% 0.00% 0.00% 0.00% 4.35% 0.00% 7.89% 0.00% 0.00%

Response Rate 16.76% 17.20% 22.63% 14.14% 12.36% 14.72% 9.52% 13.77% 11.66% 20.32% 26.74% 29.51% 2.76%



% Not Recommend 0.00% 0.00% 0.00% 1.72% 0.00% 0.00% 0.00% 0.00% 0.00% 2.27% 0.00% 0.00%


% Not Recommend 0.00% 3.23% 0.00% 0.00% 0.00% 2.33% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%


% Not Recommend 1.02% 0.93% 0.76% 1.16% 0.82% 0.82% 0.41% 1.13% 0.66% 1.07% 0.51% 0.93%

A&E

FFT Summary Scorecard

Outpatient

Inpatient / Day Case

Maternity Antenatal

Maternity Birth

Maternity PostNatal Ward

Maternity Comm PostNatal

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Analysis of Current Month and YTD

June 2018

General Information 37

Department Details 20

Sign Post to another NHS Trust 18

Enquiry 17

Discharge Arrangements 15

Access to Health Records 14

Cancellation 13

Complimentary Car Parking following cancellation 13

Complaints Procedure 13

Parking Fine 13

Poor Communication 13

Travel Expenses 11

Sign Post to another Organisation 11

General enquires 10

Staff Attitude 10

Data Sourced from Complaints Dept normally around the 10th calendar day of the month after the reporting period.

Complaints

Definitions

Complaints Received During the month of June 2018, the Trust received 31 formal complaints. This is the same number as last month and three fewer than in June 2017 when the Trust received 34 complaints.

Response RatesThe Trust is required to investigate and share the response with the complainant within 30 working days. The compliance rate has increased from last month to 63% with 14 breaches occurring. Division 1 has had 9 breaches out of 17 responses that were due to be sent in June 2018Division 2 have had 4 breaches out of 18 responses that were due to be sent in June 2018.Patient Services has had 1 breach out of 2 responses that were due.Currently there are 14 complaint investigations/responses that are overdue and have not yet been completed, these continue tobe chased and escalated. Some overdue complaint responses have now been received from the Divisions and following Executive review and Chief Executive sign-off they will be completed and closed. An action plan has been developed with a trajectory to improve compliance of the 30 working day response time across the Trust to achieve 90% by August 2018.

Complaints received by Specialty / Key Issues TableDuring June 2018, Outpatients had 3 complaints, Tilney, A&E, Castleacre and Elm Ward each had 2 complaints. The complaints regarding these areas included the following issues: Delay or failure to diagnoseCommunication with relatives/carersDischarge Arrangements (including lack of /or poor planning)Lost property Staff Attitude

Lessons LearnedTo ensure that patients and their relatives have receive appropriate advice at the time of discharge and information for ongoing support in the community if it is required.To ensure that patients with dementia are provided with appropriate care to meet their needs. When a patient does not have capacity to discuss their own care, family members should be involved in admission and discharge planning. To ensure that communication with patients and their relatives is open and honest and relatives should have access to speak to the clinical team during admission. Staff attitude should reflect a safe, caring environment on the ward for patients and their relatives.To ensure that patients and relatives are kept updated hourly by staff if they is a delay in being able to off load from an ambulance to the Emergency Department due to capacity problems. To ensure a robust process of ensuring patients have received appropriate treatment on the ambulance if required.To ensure that a patient’s treatment needs are met during admission and that this information is handed over when the patient is transferred to another ward. Clinical staff must ensure appropriate discussions have been held with the patient and/or family regarding DNAR decisions.To ensure that patients and their relatives are given clear and accurate information during admission at each stage of care. To ensure that they are communicated with in an appropriate and compassionate manner by all staff. To inform patients of the options that may be available to them for their treatment to address their individual needs. To ensure waiting room environments are comfortable and suitable for the client group.

Other InformationNo complaints have been re-opened in June 2018. 8 local resolution meetings were held in June 2018 (2 were follow up meetings).No complaints were referred to the Parliamentary and Health Service Ombudsman (PHSO). 51 Travel Expense claims were processed in May 2018.1 PALS survey was completed in June 2018. The respondent noted the service received as poor, commenting, ‘at the hospital they agree, but nothing changes.’

PALS Contacts (excluding compliments)The PALS service has had 406 contacts this month, compared to a figure of 394 in the previous month. This is a decrease in comparison to June 2017, in which 457 contacts were recorded. The top subjects for this month are noted opposite.Compliments158 compliments were received this month, which is a decrease from 216 compliments received last month and an increase in comparison to June 2017, in which the Trust received 172 compliments.

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Maternity Clinical Performance & Governance Scorecard 2018-19

ActivityIn May 174 women delivered of which 177 babies born, 176 live births. 3 Set of Twins1 medical termination for multiple fetal abnormalities at 27 weeks

ModeHomebirth 0.57%, 17.82% delivered on MLBU- further promote unit.1 BBA- 36+1 non English speaking did not call delivery suite. Call made to CDS 0300 from A&E asking for midwife assistance as patient is on route delivering in car. Midwife attended A&E on arrival and already delivered baby. Baby in good condition, placenta delivered at hospital.In May the induction rate was at 31.61% Total C-Section rate was 29.89.%, with the 24.7% rate of emergencies and an elective rate of 5.17%

Activity: Antenatal and Postnatal Care88.39% booked less than 12+6 weeks – we saw a few women who transferred across from other hospitals. Some were undecided if going to deliver with us. Booking Clerk is to monitor over 10 weeks. B/F initiation 71.59%, on discharge from hospital 59.04%, transfer to health visitor 35.62%- community support worker &- infant feeding healthcare assistant interviews occurred and appointed.

Governance0 SI’sCDS remained open within the month and the Home Birth Service continued as normal

Data provided by the Women & Children Division and is normally a month in arrears.

Definitions

Descriptor Measurement Reason Green Amber Red Data Source Apr May

Women Delivered Total no. of women giving birth at QEH Local monitoring Birth Register 191 174

Babies Born Total no. of babies born at QEH Local monitoring Birth Register 195 177

Live Births Total no. of live babies born at QEH Local monitoring Birth Register 194 176

% Home Births % of women giving birth at home Local monitoring >=2% Between <1% Birth Register 1.05% 0.57%

BBAs Babies born before the arrival of a professional Local monitoring 0 Between >=2 Birth Register 3 1

Stillbirths

Stillbirth: Babies born after 24 weeks gestation showing no signs of life. Stillbirth Rate = 4.6/1000 births.

QEH annual total should not exceed 15 stillbirths.Yearly total that exceeds 15 0 Between >=2 Birth Register 1 1

Neonatal Death (No.) Neonatal death: No. of Babies that are born alive but die within 28 days of age. Yearly total that exceeds 7 0 Between >=2 NICU / Datix 0 0

Twins No. babies - twins Local monitoring Birth Register 4 3

Triplets No. of babies - triplets Local monitoring Birth Register 0 0

Transfers out No. of transfers out of QEH Maternity unit. local monitoring Birth Register 0 0

% Women Delivered on MLBU Women who have given birth in Waterlily Local monitoring >=20% Between <15% Birth Register 17.28% 17.82%

% Women delivered on CDS Women who have given birth on Delivery Suite Local monitoring <75% Between >85% Birth Register 79.58% 80.46%

% Normal Births Spontaneous vaginal birthsBenchmark against national rate 2013/14 =

60.9 %>63% Between <52% Birth Register 62.83% 62.64%

% Instrumental Deliveries Combined rate: Forceps + VentouseBenchmark against national rate 2013/14 =

12.9 %5% - 12% 12.1-19.9% <5% or >20% Birth Register 5.76% 9.20%

% Vaginal Breech Births 0.00% 0.57%

% Elective LSCS Women having planned CS Local monitoring <10% Between >12% Birth Register 11.52% 5.17%

% Emergency LSCS Women having an emergency CS Local monitoring <15% Between >16% Birth Register 20.42% 24.71%

% Total CS Total CS performed: Elective +Emergency Benchmark against national rate 2013/14 =

26.2 %<=25% Between >=28% Birth Register 31.94% 29.89%

% Induction rates Women who have their labour induced (denominator = total women minus ElSCS) <18% Between >24% Birth Register 28.27% 31.61%

% Bookings < 12 weeks 6 days Women who have their first booking appt by 12+6 KPI >=90% Between <=85% HoM 85.92% 88.39%

No. of women seen on DAU @ NCH Local monitoring DAU 120 105

Closure of DAU -hours @ NCH Local monitoring DAU 0 8

% women in DAU seen within 4 hrs @ NCH Local monitoring >=95% Between <=90% DAU 100.00% 100.00%

No. of women seen on DAU @ QEHKL Local monitoring DAU 568 462

Closure of DAU -hours @ QEHKL Local monitoring DAU 0 24

% women in DAU seen within 4 hrs @ QEHKL Local monitoring >=95% Between <=90% DAU 99.12% 99.13%

% Breastfeeding Breastfeeding/ breast milk initiated, attempted or achieved KPI >=70% Between <65% BadgerNet 71.65% 71.59%

% Breastfeeding % breast feeding on discharge from hospital KPI >=70% Between <65% BadgerNet 50.00% 59.04%

% Breastfeeding %women breast feeding at transfer to Health Visitor Local monitoring BadgerNet 42.55% 35.62%

% of women who stopped smoking at delivery Women who stopped smoking by the time of delivery Local monitoring BadgerNet 13.56% 20.34%

Readmisions onto Castleacre Ward <28 days Number of avoidable maternal readmission up to 28 days post birth Local monitoring <=4 Between >=7 Castleacre 0 0

No of SUIs Local monitoring 0 >=1 Risk & DS 1 0

Total number of reported clinical incidents Local monitoring Datix 68 68

TOTAL number of adverse staffing incidents reported Local monitoring Datix 6 2

No. times CDS closed Local monitoring 0 1 >=2 DS 0 0

Total hours CDS closed Local monitoring DS 0 0

Suspension of HBS hrs Local monitoring 0 1 >=2 DS 0 0

Suspension of HBS Occassions Local monitoring 0 1 >=2 DS 0 0

AC

TIV

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nte

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tal a

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Post

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are

GO

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No Benchmark

No Benchmark

No Benchmark

Day Assement Unit

No Benchmark

No Benchmark

Risk Management

No Benchmark

Operational Targets

AC

TIV

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MO

DE

No Target

No Target

No Target

No Benchmark

No Benchmark

No Benchmark

No Benchmark

No Benchmark

No Benchmark

No Benchmark

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Maternity Clinical Performance & Governance Scorecard 2018-19 (continued)

Maternal & Perinatal Statistics

In April there were 0 unavoidable re-admissions PPH >2000ml was lower at 0.56%. PPH 100-2000 - 7.22% - both green3 women sustaining 3rd degree tears (1.75%)

Workforce

1:1 care on MLBU 100%. 1:1 care on CDS is 93.13%- this will need investigation as previously this was not recorded in the electronic record but had been achievedOn call midwife called in 5 Times – total of 46 hours

Patient Feedback

FFT response rate has improved this month


Definitions

Descriptor Measurement Reason Green Amber Red Data Source Apr May

PPH >1000 or<2000ml Local monitoring <9% Between >12% Birth Register / CDS 7.04% 7.22%

PPH >2000ml Local monitoring <=1% Between >=2.5 Birth Register / CDS 1.01% 0.56%

% of women sustaining 3rd & 4th degree tears (no/total minus Elective CS) Local monitoring <=3% Between >=5% Birth Register / CDS 2.51% 1.75%

No. of women sustaining 3rd & 4th degree tears (no/total minus Elective

CS) - 3aLocal monitoring <=4 >=5 Birth Register / CDS 4 1

No. of women sustaining 3rd & 4th degree tears (no/total minus Elective

CS) - 3bLocal monitoring <=2 >=3 Birth Register / CDS 1 2

No. of women sustaining 3rd & 4th degree tears (no/total minus Elective CS)

- 3cLocal monitoring 0 >=1 Birth Register / CDS 0 0

No. of women sustaining 3rd & 4th degree tears (no/total- Elective CS) - 4 Local monitoring 0 >=1 Birth Register / CDS 0 0

Blood transfusions > 4 units Local monitoring Haematology 0 0

Postpartum hysterectomies Local monitoring 0 1 >1 Birth Register 0 0

ITU /HDU admissions Local monitoring 0 1 >1 Birth Register 0 0

Maternal Deaths Local monitoring 0 >0 Birth Register 0 0

Avoidable Term Admissions to NICU from CDS Local monitoring NICU / Datix 0 0

Avoidable Term Admissions to NICU from Castleacre Local monitoring NICU / Datix 0 0

No. of babies with avoidable readmission within < 28 days old Local monitoring <=2 3-5 >=6 Datix 0 0

1:1 Care MLBU 1:1 care in labour achieved on MLBU Local monitoring >=95% 90-94 <=89% MLBU 100.00% 100.00%

1:1 Care CDS 1:1 care in labour achieved on CDS Local monitoring >=95% 90-94 <=89% DS 87.60% 93.13%

On Call Midwife No. of hrs On call midwife called to work in Unit Local monitoring DS 58 46

On Call Midwife No. of occassions On call midwife called to work in Unit Local monitoring DS 7 5

Compliments Total midwifery Compliments received in month Local monitoring PALS Team 9 53

Complaints Total Midwifery complaints received in month Local monitoring PALS Team 1 0

Response Rate Antenatal Patient Experience Team >=15% <15% Patient Experience Team 37.26% 39.32%

Likely to recommend Antenatal Patient Experience Team >=95% Between <94% Patient Experience Team 96.20% 100.00%

Response Rate Birth / Labour Patient Experience Team >=15% <15% Patient Experience Team 20.32% 26.74%

Likely to recommend Birth / Labour Patient Experience Team >=95% Between <94% Patient Experience Team 92.11% 95.65%

Response Rate Postnatal Castleacre Ward Patient Experience Team >=15% <15% Patient Experience Team 28.57% 38.06%

Likely to recommend Postnatal Castleacre Ward Patient Experience Team >=95% Between <94% Patient Experience Team 95.45% 98.04%

Response Rate Community Postnatal Patient Experience Team >=15% <15% Patient Experience Team

Likely to recommend Community Postnatal Patient Experience Team >=95% Between <94% Patient Experience Team 98.11% 98.00%

MA

TER

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TISTI

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No Benchmark WO

RK

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PA

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BA

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No Benchmark

NICU Admissions Castleacre

No Benchmark

No Benchmark

Local monitoring of poor outcomes and factors that may

have an impact on women's future health. Includes data

for the Maternity Safety Thermometer: Post partum

Haemorrhage & 3rd and 4th Degree perineal tears.

No Benchmark

Ma

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Paediatric Clinical Performance & Governance Scorecard 2018-19

Activity

PAU

High volume of patients exceeding 12 patients x 6 days ( 1st,2nd,3rd,10th,21st,25th)Registrar cross covering ward and PAU x 6 shifts (8th, 9th, 10th, 11th, 18th, 21st,) PLUS additional shifts covered by locum shifts for 17 sessions 9x Afternoon, 1-22;00, 8X Morning sessions 9-13:00)No SHO, cross covering x 1 day (31st). No full ward clerk cover x 1 (25th). N/A off sick not replaced x 2 (29th, 30th). S/N off sick, not replaced (25th)..SHO and reg to resus (30th)RUDHAM

High combined ward attenders = 118, Low elective surgical admissions, CAMHS patients = 7

Workforce

3 clinical incidents involving staffing - Emergency transfer overnight, High dependency patient, Staff sicknessRecommended staffing levels not met are now identified when the following staffing levels are not met - Day shift – 5 registered staff, Nigh shift – 4 registered staffMonth of May 12 day Shifts & 29 night shifts ( the night shift levels are new uplift and would not have been staffed in the past, it will require recruitment to vacancies)

Governance

No SI’s declared in MayClinical incidents - Unavoidable under 28 days = 5, Clinical incidents/ direct care = 4, IG = 1, Medication errors = 4 Lessons learnt from clinical incidentsTo remain vigilant with the completion of prescription charts.Care of cannulas unfortunately is a recurring issue so a Peripheral cannula record chart has been devised .Good practice was seen when restraining a patient all documentation was completed .

Patient Feedback

Friends and family recommend rate has increased from last month to 93.18% response rate 9.1%.


Definitions

DESCRIPTOR MEASURMENT Green Red Data Source Apr May

No. of PAU attendances Direct referrals from GP's, A&E and other agenciesEast of England

5 beds<130 >=131 PAU 180 183

No of times PAU staffing standards not metMiddle grade medical staff not allocated / available to PAU during opening

hours

East of England

5 beds0 >=1 PAU 15 6

No. of nursing assessment breaches Length of time to be seen by nursing staff (within 15 mins) Not seen within 15 mins 0 >=1 PAU Data 4 / 2.2% 8 / 4.4%

No. of medical assessment breaches Seen by senior clinician Within 4 hrs 0 >=1 PAU Data19 /

10.6%

25 /

13.7%

No. of 6 hour breaches Length of stay on PAU Any children with a stay on PAU over 6 hrs. 0 >=1 PAU Data 12 / 6.7% 10 / 5.5%

No. of admissions from PAU % of the total attendances to PAU who are admitted to Rudham Internal <=40% >=70% PAU52 /

28.9%

64 /

35.0%

HDU days No. of HDU days in month Internal <=15 >= 30 Rudham Stats 7.0 23.0

HDU patients No. of HDU patients in month Internal <=3 >= 4 Rudham Stats 5 13

Ward Attenders Ward Attenders No. of children post discharge review Average number of patients from 2016 = 61 <=61 >=62 Rudham Stats 108 52

Medical and Surgical outliers Patients aged 16 years and over that are not under a Paediatrician Internal 0 >=1 Rudham Stats 0 3

Medical InvestigationsNo. of children attending for diagnostic investigations. Stay on ward was

greater than 4 hrs. Average number of patients from 2016 = 48 <=48 >=49 Rudham Stats 15 17

Elective surgical admissionsNo. of children attending ward for elective surgery. Stay on ward was greater

than 4hrsAverage number of patients from 2016 = 48 <=48 >=49 Rudham Stats 21 7

Tier 4 transfers No. of children awaiting transfer to a tier 4 bed InternalLocal

monitoring

Local

monitoringRudham Stats 0 0

Days Wait No. of days waited by children InternalLocal

monitoring

Local

monitoringRudham Stats 0 0

Transfers out with an escort No. of transfers out requiring a nurse escort Internal <=1 >=2 Rudham Stats 1 3

No. of 7hr periods escalation beds open 5 escalation beds on Rudham ward Rudham has more than 18 inpatients 0 >=1 Rudham Stats 0 0

No. of 7hr periods recommended staffing level

not metWhen no of RSCN / RN child does not adhere to RCN recommendation Meeting the children to childrens nurse ratio 0 >=1 DATIX 20 41

No. of SUI reported to CCG Serious Incident and report process actioned Internal 0 >=1 Risk dept 0 0

No. of babies under 28 days of age admitted to

Rudham

No. of admissions that may have been avoided had appropriate prior

intervention been in place.Internal 0 >=1 Datix 0 0

No. of patients medically fit who have delayed discharge. Internal 0 >=1 Bed stats 0 0

No. of days medically fit patients who delayed discharge. Internal 0 >=1 Bed stats 0 0

Other Clinical Incidents All other on ward incidents All incidents to exclude staffing incidents 0 >=1 Datix 17 19

Patient Feedback Compliments Total Rudham Compliments received in monthLocal

monitoring

Local

monitoringPALS Team 6 13

Patient Feedback Complaints Total Rudham complaints received in monthLocal

monitoring

Local

monitoringPALS Team 0 1

Patient Feedback Response Rate Rudham Ward >=15% <15%

Patient

Experience

Team

22.53% 7.80%

Patient Feedback Likely to recommend Rudham Ward >=95% <94%

Patient

Experience

Team

82.46% 95.65%

FRIE

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Delayed discharges

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NICU Clinical Performance & Governance Scorecard 2018-19

ActivityThere were 8 days with more than 2 HDU babies; 6 days with 3 HDU babies and 2 days with 4 HDU babies. A total of 56 HDU days and 1 day with 2 Intensive care babies. There were 38 normal care days on NICU. 22 babies were admitted to NICU of which 16 were 37 weeks or more. (1? seizures, 2 Foster care, 1 respiratory, 2 with hypoglycaemia, 2 bilious vomiting, 2 IUGR, 5 suspected sepsis and 1 HIE).


Definitions

Descriptor Measurement Green Red Data Source Apr May

Admissions to NICU from CDSNo. of infants admitted from CDS admitted due to level of care

requiredAverage for 2017/2018 <=23 >23 17 15

Admissions to NICU from MLBUNo. of infants admitted from MLBU admitted due to level of care

requiredAverage for 2017/2018 0 >=1 2 1

Admissions to NICU from Post natal WardNo. of infants admitted from PNW admitted due to level of care

requiredAverage for 2017/2018 <5 >=5 7 5

Admissions to NICU from HomeNo. of infants admitted from home admitted due to level of care

requiredInternal Internal Internal 1 0

Admissions to NICU from other unitNo. of infants admitted from other units admitted due to level of care

requiredInternal Internal Internal 1 1

Admissions to NICU from Rudham WardNo. of infants admitted from Rudham Ward admitted due to level of

care requiredAverage for 2017/2018 0 >=1 1 0

Total NICU Admissions No. / Percentage of live births admitted to NICU 10% of births<11% of birth

rate>15% of birth rate

29 /

14.8%

22 /

12.4%

NICU TC Admissions No. / Percentage of live births on unit in month 10% of births <10% >15%26 /

13.3%

24 /

13.6%

ITU days Available number from funded cot = 30 30 <=31 >90 17 9

No of occasions >1 ITU infants on unit No of times above funded ITU cots = 1 0 0 >=1 1 0

48 hrs ventilatedNo of babies ventilated for more that 48 hrs that have not been

discussed with Tert centre0 0 >=1 0 0

HDU days Available number from funded cot = 60 Average for 2016 = 52 <=60 >=61 85 56

No of occasions>2 HDU infants on unit No of times above funded HDU cots = 2 0 0 >=2 18 8

SC days Available number from funded cot = 270 Average for 2016 =299 <270 >300 222 217

Normal care days Number of babies on NICU receiving normal care 0 0 >=1 69 38

No. of babies over 44 weeks of age No. of babies aged over 44 weeks 0 0 >=1 2 0

No. of occasions in month Over 80% cot occupancy 0 >1 14 0

No. of occasions in month Over 100% cot occupancy 0 >1 1 0

Number of avoidable admissions > 37 weeks No. of admissions that may have been avoided had appropriate prior

intervention been in place.0 0 >=1 DATIX 0 0

Number of babies receiving care from the NCT No. of babies having care in the community Internal Internal Internal 23 24

Number of NCT visits No. of visits carried out by NCT each month Internal Internal Internal 64 76

Ward attenders No. of babies attending on ward NICU Internal Internal Internal 16 6

In uter transfers accepted NICU Internal Internal Internal 0 0

In uter transfers refused NICU Internal Internal Internal 1 3

Transfers out >1 if due to capacity issues Internal 0 >=1 1 0

No of hours NICU on divert to network Internal 0 >=1 72 0

No of hours NICU on divert internal Internal 0 >=1 36 0

Number of times BAPM staffing levels not met per

monthNo of times in month Staffing levels don’t meet BAPM standards BAPM 0-5 times 10 times and above

NICU /

Badgernet21 0

NIC

U / B

adgern

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Cot occupancy

Unit escalation (in hours)

NIC

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NICU Clinical Performance & Governance Scorecard 2018-19 cont'd

Mortality 38 week infant admitted with hypoglycaemia- protocol not followed- CDS Lead midwife to investigate.24 week infant – Temperature less than 36.5 & pneumothorax- Lead ANNP investigating.

Governance There were 27 clinical incidents reported.

Clinical Activity93.8% (15/16) of parents were seen by a senior staff member within 24 hours of admission, 1 baby went to foster care & parents did not wish to receive any information.0% (0 of 1) of babies born at less than 32+6 weeks were discharged receiving breast milk, this was due to maternal choice.

Patient FeedbackThere were no complaints and 6 compliments. The FFT response rate was 325%% with 100% recommendation.


Definitions

Descriptor Measurement Green Red Data Source Apr May

HypoglycaemiaInternal Guidance and standards not

followed 1 >=3 NICU 0 1

Pre -Term Hypothermia less than 32 weeks (NNAP) NNAP standard not achieved 0 >=1 NICU / BadgerNet 0 1

Accidental extubation NEVER EVENT 0 >=1 DATIX 0 1

Infection (Positive culture and CSF) (NNAP) Laboratory results 1 >=3 NICU / BadgerNet 0 0

Pneumothorax Incidents each month 1 >=3 DATIX / Badgernet 0 1

No of SUIs Incidents each month 0 >=1 DATIX / Risk dept 0 0

Total No of reported incidents Incidents each month Internal Internal 34 27

Staffing Incidents Staffing level Incidents each month 0 >=1 3 0

NNAP standard NNAP >=58% <58% NICU / Badgernet 50.0% 0.0%

Internal Internal Internal Internal Internal 1 out of 2 0 out of 1

ROP Screening prior to discharge NNAP standard NNAP 100% <100% 100.0% 100.0%

Parents seen within 24hrs of admission NNAP standard NNAP >=88% <88% 96.4% 93.8%

Delayed Discharge No of babies delayed discharged Local / National /Internal 0 >=1 NICU 1 0

NICU Likely to recommend

(Inpatient)Percentage of patients who recommend the service Internal >=95% <94%

Patient Experience

Team85.7% 100.0%

NICU FFT response rate

(Inpatient)Percentage of eligible patients who responded National >=30% <30%

Patient Experience

Team466.7% 325.0%

Patient Experience PALS / Audit 1 6

Patient Experience PALS / Audit 0 0PA

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Unexpected Neonatal morbidity

GO

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Less than 33 weeks babies receiving breast milk on

discharge (32+6 DAYS)

DATIX

NICU / Badgernet

Risk management

Compliments

Complaints

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18 Weeks RTT Incomplete Performance Trajectory

Page Owner: Jonathan Wade

The Trusts current RTT performance improved in June to 82%.

The no. of patients over 18 weeks increased by 13 to 2664.

Neurology saw the biggest increase over the month (49), with ENT decreasing by the same number.

The overall waiting list size rose by 165 with the total waiting list size now at 14797.

We reported 0 over 52 week breaches.

3 of the 17 nationally reportable specialties sustained the 92% standard in month of June.

The number of patients waiting over 40 weeks decreased from 177 in May to 171 in June. With 37 patients the highest volume (%) now in Gynaecology .

RTT Forecast and RecoveryThe CCGs are following the NHSE planning guidance issued for 2018/19 which states “the RTT waiting list, measured as the number of patients on an incomplete pathway, will be no higher in March 2019 than in March 2018”. NHS England, our specialist commissioners who remain on Payment by Results, currently want to see the specialties that they directly commission recover

Actions

Each specialty has developed a recovery trajectory.

There is weekly oversight at our RTT performance meetings

There is a weekly check and challenge meeting via our Executives on activity delivered to what has been planned..

We are developing an outpatients dashboard which will allow specialities and managers have greater oversight and visibility on unused slots within clinics.

RTT Waiting Times – Admitted (90% Target <18 Wks.) RTT Waiting Times – Non-Admitted (95% Target <18 Wks). RTT Waiting Times - Incompletes (92%).

18 Weeks Referral To Treatment

Definitions

88.04% 87.74% 87.20% 86.49% 86.45%

81.32% 82.05% 82.76%81.05% 80.17%

81.88% 82.00%

70%

75%

80%

85%

90%

95%

100%


18 Wks - Incomp Perf 18 Wks - Incomp Target LCL UCL

RTT Backlog and still waiting volumes

DOH GroupTotal

Incomplete

> 18

Weeks

%

Incomplete

Total

Incomplete

> 18

Weeks

%

Incomplete

Backlog

Variance

>18Wk

Variance

General Surgery 859 141 83.59% 900 143 84.11% 41 2

Urology 1282 498 61.15% 1185 459 61.27% -97 -39

Trauma & Orthopaedics 1691 396 76.58% 1715 379 77.90% 24 -17

Ear, Nose & Throat (ENT) 1486 282 81.02% 1397 233 83.32% -89 -49

Ophthalmology 1631 112 93.13% 1657 135 91.85% 26 23

Oral Surgery 287 21 92.68% 474 21 95.57% 187 0

Plastic Surgery 63 5 92.06% 76 8 89.47% 13 3

Cardiothoracic Surgery 7 1 85.71% 3 1 66.67% -4 0

General Medicine 264 6 97.73% 235 18 92.34% -29 12

Gastroenterology 552 37 93.30% 579 60 89.64% 27 23

Cardiology 904 134 85.18% 881 107 87.85% -23 -27

Dermatology 1027 21 97.96% 994 34 96.58% -33 13

Neurology 729 236 67.63% 754 285 62.20% 25 49

Rheumatology 382 91 76.18% 386 75 80.57% 4 -16

Geriatric Medicine 117 29 75.21% 116 39 66.38% -1 10

Gynaecology 835 174 79.16% 898 178 80.18% 63 4

other 2515 467 81.43% 2547 489 80.80% 32 22

Total 14631 2651 81.88% 14797 2664 82.00% 166 13

May-18 Jun-18

2018-19 Y1 M01 Y1 M02 Y1 M03 Y1 M04 Y1 M05 Y1 M06 Y1 M07 Y1 M08 Y1 M09 Y1 M10 Y1 M11 Y1 M12

2501 2340 2099 1958 1845 1697 1566 1414 1304 1195 1033 939

12929 12895 12762 12642 12581 12522 12580 12574 12524 12488 12523 12486

80.66% 81.85% 83.55% 84.51% 85.34% 86.45% 87.55% 88.75% 89.59% 90.43% 91.75% 92.48%

80.2% 81.9%

Referral to treatment

Incompletes - >18 weeks


Incompletes - Total patients


Incompletes - Trajectory %

Actual performance

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Cancer Wait Times (62 Day Performance) Trajectory

Percentage of cancer patients first seen within 2 weeks in the reporting month (1 month in arrears). Percentage of above Cancer Pathway completed within 31 Days in the reporting month (1 month in arrears)Percentage of above Cancer Pathway completed within 62 Days in the reporting month (1 month in arrears).Data Source: Performance data based on activity information extracted from PAS, Open Exeter and Somerset Systems, and provided as part of the Trust's routine monthly Cancer Wait Times submission.

Cancer Waiting Times

Definitions

Site Level Breach Analysis - Latest Month

Key Points / Operational actionsAll cancer standards achieved with the exception of 62D 2WW which missed achievement of standard by 1 breach in May. High number of Urology breaches result of significant step change increase in 2WW referrals (+43%) and subsequent confirmed patients requiring complex surgery at tertiary centre. This increase is reflected in other centres in Norfolk.

Change in performance in the last month62D 2WW has improved significantly from April, and was 1 patient from achieving the required standard.

Planned actions for the forthcoming monthWorking with relevant specialties to address required capacity.Ongoing pathway redesign in Lung and Prostate.Prostate triage has potential to save 1-2 weeks off the pathway.


04/2018 05/2018 06/2018 07/2018 08/2018 09/2018 10/2018 11/2018 12/2018 01/2019 02/2019 03/2019

18.5 16.5 11.5 10.5 10.5 9 9 10 8 8 8.5 9

62.5 75 64 71 74 65 64 67.5 57 54 58.5 64.5

70.40% 78.00% 82.03% 85.21% 85.81% 86.15% 85.94% 85.19% 85.96% 85.19% 85.47% 86.05%

72.8%Actual performance

Cancer 62 days - >62 days

Cancer 62 days - Total seen

Cancer 62 days - Trajectory%

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Cancer Waiting Times - 62 Day Breaches at 63-69 Days & 104+ Day Breaches

Key Points / Operational actionsComplex Prostate pathway with diagnostics and long waits at tertiary centre for treatment leading to excessive total waits.

Change in performance in the last month104D breaches decreased by 1 overall.

Common themes from the Clinical teams:• No harm to patient, but ? psychological harm• Delay in diagnostics and reporting• Delay in histology reporting• Multiple sites (ie referred to H&N then Haem)• Complex pathways – needing many investigations/discussions• Patient choice

Planned actions for the forthcoming monthWorking with relevant specialties to address required capacity.

Ongoing pathway redesign in Lung and Prostate.

Prostate triage has potential to save 1-2 weeks off the pathway.

Work continues to reduce delays;• Lung & Prostate pathway re-design• Haematology consultants have provided additional capacity to manage demand• Tertiary centre to put on additional lung lists due to high demand• Enhanced escalation process and weekly senior management review of performance

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A & E Performance Trajectory

Page Owner: Jonathan Wade

Percentage of total A&E Attendances for the reporting month that are admit.ted or discharged within the 4 hour target. The latest benchmarking data is based on the monthly performance (2 months in arrears).Data Source: Performance data based on activity information extracted from EDIS system, and provided as part of the Trust's routine monthly AE submission.

Definitions

AE performance (Last 12 months)


• The Trust performance against target has continued to improve in month.• Attendance rates remain high – there has been a change in attendance patterns with

Monday, Tuesday and Wednesday now seeing peaks in activity (regularly 200+). • ED clinical and operational staff are working in conjunction with the CCG to review findings

of the recent front door audit. • Essential estates work (floor repairs) remain outstanding.


• The Patient Navigator post in ED continues and will be reviewed shortly – early indications are that the role has had a positive impact.

• Communication supported by the use of radios between the Site Team, ED and the assessment areas continues to have a positive impact.

• Conversion rates remain high (above peer average) – it is anticipated that the Assessment zone project in MAU will have a positive impact on this data.


• The creation of an Assessment Zone within MAU to facilitate GP admission direct to MAU and an early ‘pull’ of referred patient from ED is currently being piloted. Early indications are positive both for patient experience and performance.

• The nurse staffing skill mix is being assessed and reviewed by the new ED Matron.• ED matron in conjunction with the Ops team have created an action plan to support

improvement within ED.


04/2018 05/2018 06/2018 07/2018 08/2018 09/2018 10/2018 11/2018 12/2018 01/2019 02/2019 03/2019

927 893 868 779 665 532 520 472 450 402 307 288

5545 5765 5766 5603 5854 5362 5366 5185 5790 5760 4921 5946

83.28% 84.51% 84.95% 86.10% 88.64% 90.08% 90.31% 90.90% 92.23% 93.02% 93.76% 95.16%

81.3% 82.6% 91.9%

Accident and Emergency - >4 hour

wait

Accident and Emergency - Total

Patients

Accident and Emergency - Trajectory

%

Actual performance

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Page Owner: Andrew Evans, Raj Shekhar

Ambulance Handovers

Definitions

The percentage of the total Ambulance handovers within the reporting month where the handover was less than 15 minutes in duration.

0

500

1000

1500

2000

2500


Nu

mb

er

of

Pati

en

tsMonthly Ambulance Handover Times

0 - 15 Minutes 15 - 30 Minutes 30 - 1 Hour 1 - 2 Hours 2 Hr+


• Performance remains on an upward trajectory with the majority of handovers occurring in under 30 minutes.• An increasing number of handovers now take place in under 15 minutes.• Escalation has continued to improve and is supported by the instantaneous communication achieved by utilising the radio system.• The inability to cohort (due to lack of staff) has not had a detrimental effect on handover times.• Patients continue to arrive with paper documentation rather than EPR – this continues to have a negative effect on handover times.


• Continued improvement in handover under 30 minutes.• Patient Navigator role continues to support flow into and out of the Department.


• Review of the cohort role is being undertaken in tandem with the new ED Matron • Review of the Patient Navigator role to be undertaken

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Key Performance Issues

Cancelled operations on or after the day increased in June to 1.34% of all elective admissions, with 17 breaches of the 28 day rebook standard.

Our performance at 1.14% cancelled for the year. We have seen 42 more patients cancelled on the day when compared to the same period in 2017/18.

Across the year, "Staff Shortgaes"was the highest reason for cancellations on the day, resulting in 25% of all cancellations.

The 3 specialties with the highest no. of cancellations in this current financial YTD is as follows;

Ophthalmology (36)Urology (28)General Surgery (15)

Cancelled Operations:The no. of patients cancelled at the "last minute" for "non clinicial" reasons. A "breach" of the 28 day standard occurs if that patient does not have their operation within 28 days of the cancellation. Data Source: Performance data based on activity information extracted from PAS, & provided as part of the Trust's monthly Quarterly Cancelled Operations Return (QMCO) submission.

Cancelled Operation's

Definitions


No. of Operations cancelled at the "last minute" 18 20 15 31 28 41 38 70 66 33 46 51

Canc Ops - Not Re-adm within 28 days 2 0 2 0 3 3 8 6 26 9 12 17

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Key Points / Operational actionsEcho breaches due to outsourcing provider failing to complete any of the tests sent to them, including cancelling a list on the final day of the month. Additional capacity was put on to absorb the gap in capacity vs demand, but this was not able to absorb the outsourcing cancellations.

Change in performance in the last monthDeterioration as detailed above.

Planned actions for the forthcoming monthEcho will no longer outsource to the private provider who has proved to be increasingly unreliable. Team have planned to put on additional sessions to meet and adjusted scheduling of inpatients vs outpatients to provide additional capacity.

June performance:Outsourcing provider failed to perform any of the scheduled Echos sent, cancelling sessions with little notice, including on the last day of the monthJuly onwards:Not using outsource provider going forwardDemand vs CapacityAdditional sessionsReworked clinic sessions and job plans to maximise efficiency

Denominator :The no. of patients waiting for a diagnostic test at the end of the reporting period. Numerator: The no of patients waiting 6 weeks or more for a diagnostic test at the end of the reporting period. Data Source: Performance data based on activity information extracted from PAS, & provided as part of the Trust's monthly Diagnostics Wait Times (DM01) submission.

Diagnostic Waiting Times (% of Pat's Waiting >6 Wks)

Definitions

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Data Source: Four Eyes Insight

Theatres - Four Eyes Inisght

Definitions

By the end of the on-site Four Eyes visit the utilisation opportunity had reduced to 5 % from 13%.Cardiology outliers on the average case per session. Planned vs actual hours of surgery – results are really good and this is also shown in the Model Hospital benchmarking data.

Key Points / Operational actionsReview of Cardiology list utilisation options to change frequency. Continued work with Urology to maximise utilisation, however current case mix needs to be considered.

Change in performance in the last monthFirst month of reporting.


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Discharge Letters


There has been a reduction in ‘incomplete letters’ when reporting on last month. Focused support is on-going in relation to a daily chase and the response of staff has improved. Incomplete letters currently total 107 of which 88 relate to July.

Planned actions for the forthcoming monthWe continue to work with clinicians in ensuring timely sending of letters. We have sought assurance form Divsions at our monthly Progress Reveiw meetings that they will focus on this important matter.

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Stroke

Sentinel Stroke National Audit Programme (SSNAP) is the single source of data for stroke in England and Wales. It provides the data for all other statutory data collections in England including the NICE Quality Standard and Accelerating Stroke Improvement (ASI) metrics and is the chosen method for collection of stroke measures in the NHS Outcomes Framework and the CCG Outcomes Indicator Set. SSNAP metrics are aligned with those in the Cardiovascular Disease Outcomes Strategy. SSNAP data are being used as risk indicators for Care Quality Commission’s Intelligent Monitoring and for the Stroke Care in England NHS Marker.

Primary Key Indicators:Percentage of Stroke patients that spend 90% of their hospital stay on the stroke unit (latest available data). Percentage of Stroke patients directly admitted to a stroke unit within 4 hours of clock start (latest available data)Percentage of Stroke patients scanned within 1 hour of clock start (latest available data). Percentage of Stroke patients scanned within 12 hours of clock start (latest available data)

TIA1) % of High Risk TIA's that are not admitted, seen and treated within 24 hours (latest available data). 2) % of High Risk TIA's that are seen and treated within 24 hours (latest available data).

3) % of Low Risk TIA's that are seen and treated within 7 days of 1st contact with a healthcare professional (latest available data). 4) % of Low Risk TIA's that are seen and treated within 7 days of onset of symptoms (latest available data)

Definitions

StrokeKey Points / Operational actions

• 14 hrs consultant review has been maintained at 80% or more .• Challenging diagnosis and overall patient flow pressure impacting, but steady improvement since low

score of .• Door to scan performance under pressure .• National clinical lead for Stroke positive feedback about QEH stroke services and performance

following recent face to face meeting.

Risks we are carrying at the moment.• Stroke Specialist Thrombo nurse [SSTN]still included in the numbers at night .• ESD for West Norfolk patient as CCG is not agreeing for ESD pathway (almost all stroke services in

England have ESD except us).

Change in performance in the last month• Challenging diagnosis and overall patient flow pressure impacting, but steady improvement since low

score of February

Planned actions for the forthcoming month• Continued focus on the pathways. Continue to monitor SSTN in numbers

TIAKey Points / Operational actions• Service continues to respond in timely manner to highest risk patients

Change in performance in the last month• Performance down for all measures on previous month, but still achieving required standard with

exception of 4th measure which is reliant on patient presenting

Planned actions for the forthcoming monthReview of patients TIA low risk and treated within 7 days from onset

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Narrative - no narrative currently provided, this is a new section and will be covered in the exception reports of the relevant Director .

From August 2018 the TRust will add actions and narrative.

DNA Rate: Total No. of New & Follow Up appointments where the outcome was "DNA" (Did Not Attend), as a proportion of the Total No. of "Attended" and DNA'd appointmentsThe DNA figures above exclude Ward Attender activity, and is based on "Clinic" Specialty, rather than "Referral" Specialty. DNA Data Source: Performance data based on activity information extracted from PAS normally collected around the 10th calendar day of the month after the reporting period.ASI - Appointment Slot Issues. ASI's occur in e-Referral (Choose & Book) because of an insufficient no. of slots available within a 'polling range' for a specialty. Data Source: E Referral Booking System

Outpatients

Definitions

6.57% 6.65%6.48% 6.39% 6.36%

6.91%

6.55%6.39%

6.60% 6.56%

7.02%

7.54%

4.0%

4.5%

5.0%

5.5%

6.0%

6.5%

7.0%

7.5%

8.0%


DNA rate against local target

DNA Rate Target DNA Rate LCL UCL

Executive


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Narrative - no narrative currently provided, this is a new section and will be covered in the exception reports of the relevant Director .

Average LOS - The average spell length of stay for Elective & Emergency Admissions discharged within the reporting month.Re-admissions - The % of patients readmitted within 30 days of an Elective & Emergency admission during the current financial year. Data Source: Performance data based on activity information extracted from PAS normally collected around the 10th calendar day of the month after the reporting period.

Average Length of Stay & Re-admissions

1.51.4

1.6 1.6 1.6 1.5

1.0 1.0

1.4 1.4 1.41.5

0%

1%

2%

3%

4%

5%

6%

0.0

0.5

1.0

1.5

2.0

2.5


Elective Average LOS & Readm Rate - (Trust Level)

Length of stay - Elective target Readmission Rate - El

Definitions

4.0 4.3 4.34.0 3.8

4.1 4.2 4.4 4.4 4.5 4.34.0

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

0.0

1.0

2.0

3.0

4.0

5.0

6.0


Emergency Average LOS & Readm Rate - (Trust Level)

Length of stay - Emergency target Readmission Rate - Em

Executive


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Data Source: Karen Wilson - Commissioning & Contracting Team.

CQUIN Update June

Work continues across all CQUINs.

The main areas of concern for 2018/19 are as follows;

• Health and Wellbeing – Staff Survey : £116K• Health and Wellbeing – Healthy Food : £116K• Advice & Guidance : £363K• Risky Behaviours : £363K

Risks have been highlighted to the CQUIN ownersspecifically in relation to achievement of the ‘Preventing ill health by risky behaviours – alcohol and tobacco’ CQUIN within quarter 1.

This has a total value of £91k for the quarter.

Specific documentation has been produced and disseminated within the clinical areas.

The risk relates to the training requirements which we are required to evidence.

Plans are in place, but documented evidence is required to support delivery of the key parameters and this requires stronger engagement from clinical / operational leads.

The Trust will enact steps to ensure this risk is reduced.

CQUINs

CQUIN No. Q1 STATUS Q1 VALUE Q2 STATUS Q2 VALUE Q3 STATUS Q3 VALUE Q4 STATUS Q4 VALUE

1a Heallthy Foods - more healthy options /

reduced sugar content etc

£116,181.00

1b Staff Survey - 5% improvement on 2 out of the 3

questions relating to H&W

£116,181.00

1c Flu uptake (front line clinical staff) 75% £116,181.00

2a Sepsis -timely Identification £23,599.00 £23,599.00 £23,599.00 £23,599.00

2b Sepsis - timely treatment £23,599.00 £23,599.00 £23,599.00 £23,599.00

2c Empiric Review of antibiotic prescriptions

(72hrs)£23,599.00 £23,599.00 £23,599.00 £23,599.00

2d Reduction in Antibiotic Consumption per 1,000

admissions£94,397.00

4 Improving services

for people presenting

with Mental Health

needs in A&E

Frequent Attenders - Maintain improvement

made in 17/18 and identify new cohort of

patients from 1718 and reduce by 20%.

Improvement coding for ECDS

£72,613.00 £290,454.00

6 Offering Advice &

Guidance

Trust to achieve 80% of A&G requests within 2

working days for on a group of specialties which

receive 75% of GP referrals by Q4.

Trajectory:-

Q1 – 50%

Q2 – 60%

Q3 – 70%

Q4 – 80%

£54,460.00 £54,460.00 £54,460.00 £199,687.00

9a Tobacco Screening £18,153.00 £18,153.00 £18,153.00 £18,153.00

9b Tobacco brief advice £18,153.00 £18,153.00 £18,153.00 £18,153.00

9c Tobacco referral and medication offer £18,153.00 £18,153.00 £18,153.00 £18,153.00

9d Alcohol Screening £18,153.00 £18,153.00 £18,153.00 £18,153.00

9e Alcohol brief advice or referral £18,153.00 £18,153.00 £18,153.00 £18,153.00

8 STP Sustainability and Transformation Plans £1,815,336.00

1 Medicines

Optimisation

The CQUIN aims to support the procedural and

cultural changes required fully to optimise use

of medicines commissioned by specialised

services.

2 Dental Dashboard Provider is required to submit a fully populated

Dental Quality Dashboard as per the embedded

format (see actual CQUIN) in respect of the

dental specialties they provide

£11,199.41 £11,199.41 £11,199.41 £11,199.41

3 Breast Screening Breast Cancer Screening Interval Cancer

Network for Norfolk and Waveney£6,615.19 £6,615.19

4 Armed Forces Embedding the Armed Forces Covenant to

support improved health outcomes for the

Armed Forces Community

£5,876.00 £13,710.90

Q1 CQUIN TO BE SUBMITTED TO COMMISSIONERS BY 26TH JULY

N/A

NHSE SPECIALIST CONTRACT

N/A N/A

N/A

Risky Behaviours -

Alcohol and Tobacco

N/A

N/A

CQUIN Description

ACUTE CONTRACT

H&W

N/A

SEPSIS

N/A

N/A

Overall CQUIN worth £108,940.00 - Quarterly split to be confirmed

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35 of 44

The Safer Staffing figures above represent those submitted as part of the Trust's mandatory monthly Safer Staffing return to the Department of Health.

Safer Staffing Return

Definitions

Specialty 1 Specialty 2

West Newton 430 - GERIATRIC MEDICINE 96.0% 126.0% 98.1% 143.4% 829 3.0 5.6 8.6

Necton 340 - RESPIRATORY MEDICINE 88.2% 96.7% 104.5% 98.3% 963 3.2 2.6 5.8

Windsor 430 - GERIATRIC MEDICINE 94.7% 97.6% 100.0% 105.9% 965 2.8 3.0 5.8

Stanhoe 301 - GASTROENTEROLOGY 350 - INFECTIOUS DISEASES 95.4% 97.4% 97.9% 104.4% 951 3.3 3.1 6.4

Tilney 320 - CARDIOLOGY 90.7% 101.3% 104.5% 101.5% 787 3.1 2.3 5.5

West Raynham 300 - GENERAL MEDICINE 93.6% 93.2% 99.7% 96.3% 799 4.2 3.3 7.5

Denver 100 - GENERAL SURGERY 93.0% 109.5% 98.5% 139.6% 844 2.9 3.1 6.0

Marham 100 - GENERAL SURGERY 91.3% 93.8% 97.6% 94.9% 713 3.6 2.3 6.0

Elm 100 - GENERAL SURGERY 91.2% 117.1% 102.7% 112.7% 559 3.1 3.4 6.6

Gayton 110 - TRAUMA & ORTHOPAEDICS 100 - GENERAL SURGERY 91.9% 96.5% 100.0% 106.5% 928 2.8 3.1 6.0

Shouldham 315 - PALLIATIVE MEDICINE 823 - HAEMATOLOGY 86.6% 113.1% 97.5% 92.3% 338 4.9 3.1 8.0

Critical Care 192 - CRITICAL CARE MEDICINE 81.8% 71.4% 86.2% 233 27.6 1.4 29.0

Central Delivery suite 501 - OBSTETRICS 89.2% 94.2% 89.6% 100.0% 150 25.8 9.3 35.1

Surgical Assessment Unit 100 - GENERAL SURGERY 94.2% 96.8% 84.3% 106.1% 225 8.9 3.4 12.3

Medical Assessment Unit 300 - GENERAL MEDICINE 81.4% 127.0% 112.4% 108.6% 610 5.7 2.7 8.4

Terrington 300 - GENERAL MEDICINE 99.8% 91.1% 89.6% 93.0% 988 3.2 3.0 6.2

Castleacre 501 - OBSTETRICS 96.3% 92.1% 101.7% 96.7% 370 4.8 3.7 8.5

NICU 420 - PAEDIATRICS 89.9% 88.2% 98.7% 95.9% 250 10.2 5.5 15.7

Rudham 420 - PAEDIATRICS 92.2% 85.9% 100.0% 100.0% 273 11.7 4.1 15.8

ED Obs Ward 180 - ACCIDENT & EMERGENCY 103.3% 99.5% 56 6.8 5.7 12.5

Oxborough 300 - GENERAL MEDICINE 100.5% 84.1% 106.7% 92.5% 976 2.9 3.3 6.2

Jun-18

Average

fill rate -

registered

nurses/mid

wives (%)

Night Care Hours Per Patient Day (CHPPD)

Average

fill rate -

care staff

(%)

Cumulative

count over

the month

of patients

at 23:59

each day

Registered

midwives/

nurses

Care Staff

Day

Ward name

Main 2 Specialties on each ward

Average

fill rate -

registered

nurses/mid

wives (%)

Average

fill rate -

care staff

(%)

Overall

Key Points / Operational actions5 areas had a RN/ RM fill rate of <90% - these were : Necton, CCC, MAU, CDS and Shouldham, an increase from the previous month where only 2 areas had a fill rate of <90% 9 (CDS and CCC).

Change in performance in the last monthThe overall fill rate for RN/ RM was 93.5%, compared to a fill rate of 96.6% for May.

For the month of June, the average staffing fill rate for RN/ NM was 91.2% for Day and 96.9% for nights.

Planned actions for the forthcoming monthThere has been a reduction in the fill rate on the last few weeks of June due to a reduced agency fill rate, particularly in relation to night duties. We are in discussion with ID Medical, our master vendor, to review how the fill rate can be improved.

Executive Summary Quality & Risk Perf & Standards CQUINS Workforce Finance Appendices

36 of 44

Workforce - Current Staffing Profile

Current Staffing profile & Bank AgencyThe data below displays the current staffing profile of the Trust and key bank and agency data

COMMENTARY

The Trust currently employs 3203 substantive headcount, working a

substantive whole time equivalent of 2765.69

The funded establishment for 2018/19 was increased slightly again in

June to 3166.63 FTE from 3162.94 reported in May 2018

June 2018 FTE Split: Under established by 16.62 FTE

• Substantive: 2765.69

• Bank: 235.32

• Agency: 149.00

• Establishment: 3166.63

Substantive FTE and headcount both decreased in June.

Bank fill rates decreased slightly by 3.39 FTE, however weekly pay

timetables will impact on this figure depending on the number of

weeks within each month. Agency use decreased by 19.04 FTE

Trust vacancy rate has increased to 12.41% from 12.06% in the

previous month.

Staff Turnover decreased to 12.34%, a decrease of 0.11% on the

previous month.

2600.00

2700.00

2800.00

2900.00

3000.00

3100.00

3200.00

3300.00


FTE split by month

Substantive FTE Bank FTE Agency FTE Funded FTE

2640.00

2660.00

2680.00

2700.00

2720.00

2740.00

2760.00

2780.00

2800.00

2820.00


FTE

Monthly Staff in Post FTE

Contracted staff in Post (WTE) Previous Contracted staff in Post (WTE)

Data Source: Workforce Information Team

Definitions

Executive Summary Quality & RiskPerf &

StandardsCQUINS Workforce Finance Appendices

37 of 44

Workforce KPI's - Trust Level

KPI

Change

over the

year

Change

since

last

month

Vacancy 1.04% 0.35%

Sickness -0.47% 0.34%

Stability -0.69% -0.25%

Turnover 0.89% -0.11%

Appraisal (ex Bank) -3.39% 1.17%

Appraisal (inc Bank) -3.90% 1.47%

0.00%

5.00%

10.00%

15.00%

Staff Turnover Rate

Previous Staff Turnover Rate

Staff Turnover Rate

Staff Turnover Rate Target

11.37% 12.41%

0.00%2.00%4.00%6.00%8.00%

10.00%12.00%14.00%

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

De

c-17

Jan

-18

Feb

-18

Ma

r-18

Ap

r-1

8

Ma

y-1

8

Jun

-18

Trust Vacancy Rate

5.17%4.70%

3.50%

0.00%

2.00%

4.00%

6.00%

8.00%

Sickness Rate

91.05% 90.36%

89.00%

90.00%

91.00%

92.00%

93.00%

Stability

85.31%

81.92%

83.56%

79.66%75.00%

80.00%

85.00%

90.00%

95.00%

Appraisal Rate

Actual (excluding bank st aff) Actual (including bank staff)

Prev Year

Apr-18

11%

May-18

11%

Jun-18

11%Balance

67%

Agency Spend Tracker 18/19

0

200

400

600

800

1000

1200

1400

1600

1800

£0

00

Monthly Spend on Agency Staff YTD

Previous All Agency All Agency NHSI Ceiling

0

100

200

300

400

500

600

700

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Q2

16/17

Q4

16/17

Q1

17/18

Q2

17/18

Q4

17/18

Q1

18/19

Total

Responses

Recommen

d %

Friends & Family Test

Place for Treatment %

Place to Work %

Total Responses

Workforce - KPI's


Definitions



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Narrative - no narrative currently provided, this is a new section and will be covered in the exception reports of the relevant Director . From August 2018 the TRust will add actions and

narrative.

Workforce - KPI's by Ward


Definitions



39 of 44

Narrative - no narrative currently provided, this is a new section and will be covered in the exception reports of the relevant Director . From August 2018 the TRust will add actions and

narrative.

Workforce - FTE Split (Medical Workforce)


Definitions



40 of 44

Narrative - no narrative currently provided, this is a new section and will be covered in the exception reports of the relevant Director . From August 2018 the TRust will add actions and narrative.

Workforce - FTE SPlit (Allied Health Professionals)


Definitions



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Quality and Risk Scorecard

Performance & Standards Scorecard

Appendices



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01/04/2018 01/05/2018 01/06/2018

Indicators Var to prev mth Target Apr May Jun *FYTDCritical Incidents 01/04/2018 01/05/2018 01/06/2018 2018/19 2017/18

Total Never Events (Target)Total Never Events 0 0 0 0 0Total Falls Resulting in Serious Harm (Target)Total Falls Resulting in Serious Harm 0 0 1 1 2Pressure Ulcers - Grade 3 (Target)Pressure Ulcers - Grade 3 0 5 3 3 11Pressure Ulcers - Grade 4 (Target)Pressure Ulcers - Grade 4 0 0 0 0 0Total Other SIs (Target)Total Other Sis 0 2 2 3 7Pressure Ulcers - Grade 2 (Target)Pressure Ulcers - Grade 2 0 4 4 4 12Safety Thermometer - (new harm only) TargetSafety Thermometer - (New Harm Free) 95.00% 92.15% 98.00% 95.10% 94.90%VTE Assess TargetVTE Assessment Completeness 97.24% 97.66% 97.26% NA 97.45%

Infection ControlMRSA (Target)MRSA 0 2 0 0 2CDIFF (Target)CDIFF 4 3 1 0 4

Indicators Var to prev mth Target Apr May Jun *FYTDPatient experienceFFT % Recommended (IP & DC) 95.38% 96.18% 95.87% 95.82%FFT % Recommended (AE) 88.20% 90.00% 90.87% 89.96%

FFT Resp Rate (IP & DC) TargetFFT Response Rate (IP & DC) 30.00% 31.72% 31.14% 33.96% 32.26%FFT Resp Rate (AE) TargetFFT Response Rate (AE) 20.00% 10.35% 11.52% 17.67% 13.25%MSA Breaches TargetNo. of Mixed Sex Accommodation breaches 0 6 6 2 14

Number of Patient moves (over 2) 48 41 37 126Positive experienceCompliments 128 216 158 502Complaints

Non-Clinical Complaints TargetNon-Clinical Complaints 4 7 8 19Clinical Complaints TargetClinical Complaints 26 24 23 73

Indicators Var to prev mth Target Apr May Jun *FYTDMortality

Crude Mortality (deaths per 1000 admissions) TargetDeaths per 1000 admsCrude Mortality (deaths per 1000 admissions) 19 14.0 12.2 12.7 13.0RAMI (Risk adjusted mortality) (National target)SHMI (Summary Hospital Level Mortality Indicator) Jan 17 - Dec 17 as expected 0.00

HSMR (Hospital Standardised Mortality Ratio) Apr 17 - Mar 18 as expected 0.00Outcome

Stroke - 90% of Stay on SU TargetStroke - 90% of Stay on a Stroke Unit 80.00% 81.48% 83.64% NA 82.93%TIA - HR TIA seen & treated <24hrs TargetTIA - High Risk,Non admitted TIA treated in 24 Hrs 60.00% 90.91% 75.76% NA 79.55%EL LOS TargetLength of stay - Elective 2.2 1.4 1.4 1.5 1.4EM LOS TargetLength of stay - Emergency 5.0 4.5 4.3 4.0 4.2Readm Rate (EL) TargetReadmission Rate - ElReadmission Rate - Elective 3.00% 4.09% 3.50% NA 3.77%Readm Rate (Em) TargetReadmission Rate - EmReadmission Rate - Emergency 10.00% 18.12% 18.36% NA 18.24%

Indicators Var to prev mth Target Apr May Jun Rolling 12 mthsWorkforce

Sickness Absence Rate (Target)Sickness Absence Rate 3.50% 4.57% 4.36% 4.70% 5.25%Staff Turnover Rate Complete Trust (Target)Staff Turnover Rate Complete Trust 10.00% 12.69% 12.45% 12.34% 11.94%Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) (Target)Staff Turnover Rate Medical & Dental (excluding Jnr Doctors) 10.00% 14.61% 14.65% 15.08% 10.86%Staff Turnover Rate Registered Nursing & Midwifery (Target)Staff Turnover Rate Registered Nursing & Midwifery 10.00% 14.38% 14.58% 14.00% 14.26%Staff Turnover Rate Allied Health Professionals (Target)Staff Turnover Rate Allied Health Professionals 10.00% 14.42% 13.75% 13.79% 15.71%

*FYTD denotes Financial Year to Date (HSMR & SHMI will be at snapshot date specified) Stroke, TIA, VTE, Re-adm is 1 month in arrears.

Safe

care

Quality & Risk Scorecard

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01/04/2018 01/05/2018 01/06/2018 2017/18

Indicators Var to prev mth Target Apr May Jun FYTD

National standards 01/04/2018 01/05/2018 01/06/2018 2018/19

18 Wks - Adm (adjusted) Target18 Wks - Adm Perf (adjusted) 90.00% 77.70% 78.40% 72.73% 76.15%

18 Wks - Non Adm Target18 Wks - Non Adm Perf 95.00% 74.10% 79.65% 77.73% 77.29%

18 Wks - Incomp Target18 Wks - Incomp Perf 92.00% 80.17% 81.88% 82.00% 81.37%

Cancer-2ww TargetCancer-2ww 93.00% 96.68% 96.83% NA 96.76%

Cancer-2ww (Breast Symptomatic) TargetCancer-2ww (Breast Symptomatic) 93.00% 97.62% 97.33% NA 97.48%

31 Day Diag to Treat Target31 Day Diag to Treat 96.00% 99.02% 98.25% NA 98.61%

Cancer-62 Days RTT TargetCancer-62 Days RTT 85.00% 72.80% 84.28% NA 79.23%

Cancer-31 Days Sub Treat (Surg) TargetCancer - 31 Days Subsq Treatment - Surgery 94.00% 100.00% 100.00% NA 100.00%

Cancer-31 Days Sub Treat (Drug) TargetCancer - 31 Days Subsq - Drug Treatments 98.00% 100.00% 100.00% NA 100.00%

Cancer Screening (62 Day) TargetCancer Screening (62 Day) 90.00% 100.00% 100.00% NA 100.00%

A&E 4 Hr TargetA&E 4 Hour Performance 95.00% 81.30% 82.63% 91.92% 85.32%

Amb turnaround TargetAmbulance turnaround 100.00% 40.43% 40.78% 42.62% 41.27%

Stroke - 90% of Stay on SU TargetStroke - 90% of Stay on a Stroke Unit 80.00% 81.48% 83.64% NA 82.93%

TIA - HR TIA seen & treated <24hrs TargetTIA - High Risk,Non admitted TIA treated in 24 Hrs 60.00% 90.91% 75.76% NA 79.55%

Cancelled Ops - as a % of Elective Admissions TargetCancelled Ops - as a % of Elective Admissions 0.80% 0.92% 1.15% 1.34% 1.14%

Diagnostic Over 6 Week Waiters - % of Total WL TargetDiagnostic Over 6 Week Waiters - % of Total WL 1.00% 7.03% 0.48% 1.35% 3.05%

Indicators Var to prev mth Target Apr May Jun FYTD

Local standards

Day Case Rate TargetDay Case Rate 82.00% 90.66% 87.73% NA 89.11%

DNA Rate TargetDNA Rate 5.00% 6.56% 7.02% 7.54% 7.03%

New to FUP Ratio TargetNew to FUP Ratio 2.3 2.4 2.3 2.1 2.3

Readm Rate (EL) TargetReadmission Rate - ElReadmission Rate - Elective 3.00% 4.09% 3.50% NA 3.77%

Readm Rate (Em) TargetReadmission Rate - EmReadmission Rate - Emergency 10.00% 18.12% 18.36% NA 18.24%

EL LOS TargetLength of stay - Elective 2.2 1.4 1.4 1.5 1.4

EM LOS TargetLength of stay - Emergency 5.0 4.5 4.3 4.0 4.2

Cancer, Stroke, TIA, Day Case & Re-admissions Rates are all normally shown 1 month in arrears.

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Performance & Standards Scorecard

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