Enclosure 3

1

EXECUTIVE RESPONSIBLE

Adam Cairns Chief Executive

AUTHOR (if different from above)

Paul HodsonHead of Contracts & Performance

Pete GordonHead of Continuous Improvement

William WraithHead of Human Resources

Tony BrownAssistant Director Financial Performance

CORPORATE OBJECTIVE

Enhancing Patient Experience, Safety and Effectiveness,Achieving NHS Foundation Trust Status

BUSINESS PLAN OBJECTIVE NO(S)

6.1 - Establish a new Quality Framework for the Trust.6.1.1 - Develop an integrated performance management framework that includes a balanced set of quality metrics across the domains of safety, effectiveness and patient experience.

EXECUTIVE SUMMARY

This paper reports current performance against a number of KPIs for the period up to the end of October 2010. As detailed in previous papers this reports only includes slides for those KPIs identified as suitable for monthly reporting. The summary sheet will continue to show a RAG for all KPIs with quarterly KPIs showing their RAG status at the end of the last full quarter.

KEY FACTS • 18 Weeks, Stroke National & Local, MRSA and C. Difficile, Cancer 14 and 31 day and Rapid Access Chest Pain targets achieved in month.

• Thrombolysis, Outpatient Utilisation, Cancelled Operations, A&E, Workforce Numbers and Cancer 62 day all under achieved in month.

RECOMMENDATIONS The Board is asked to NOTE:• performance against a range of Key Performance

Indicators covering Quality, Delivery and Foundations.

INTEGRATED PERFORMANCE REPORT for period ending 31st October 2010 Trust Board – 3 December 2010 - Quality

Enclosure 3

2

Integrated Performance Report: Quality (CO1)Target (2010/11) Executive

LeadMonthly

PerformanceDirection of

TravelYear to Date Forecast Commentary Frequency

Patient Experience

Patient Satisfaction

Improve responsiveness to personal needs of patients (CO1.3 / CO1.7) (CQUIN) DSD GREEN = GREEN GREEN

Target 2010/11 89% overall patient satisfaction 5 indicators identified form 2009/10 results M

Breaches in single sex accommodation compliance (CO1.5) DSD GREEN = GREEN GREENNumber of breaches caused by each occurrence will be equal to the total

number of patients effectedi.e. 1 female with 5 males is 6 breaches

M

Cancelled Operations

To maintain a minimum level of non medical cancellations in accordance with national criteria DSD RED = GREEN GREEN 47 cancelled in month M

Readmit all non medical cancellations within 28 days in accordance with national criteria DSD GREEN = GREEN GREEN No 28 day breaches in month M

Cleanliness To maintain cleanliness score of 92% across the Trust DSD GREEN = GREEN GREEN Both sites were Green at the time of October monitoring M

Choose & BookMaintain a monthly slot availability rate of at least 90% for appointments made via the Choose & Book System DSD RED = RED RED

The October report is based on 3 weeks data available due to C&B systems upgrade M

ComplaintsNational response times are that all complaints are completed in their entirety within six months, unless exceptional circumstances DCA GREEN = GREEN GREEN

Of the 184 cases opened in the first quarter these have all been responded to within the 6 months statutory deadline Q

End of Life (CQUIN)% of admitted patients at end of life following the Liverpool End of Life Pathway (CO1.3) DSD GREEN = GREEN GREEN

New CQUIN Target for 2010/11Q2 – baseline 27%

Q4 to improve compliance by 20% target 32% M

Safety

IncidentsRate of patient safety incidents reports (CO1.6) MD GREEN = GREEN GREEN Incident reporting rate of 8.4% M

Serious Incidents Requiring Investigation (CO1.6) MD GREEN GREEN GREEN Less than 8 SIRIs per month M

Healthcare Associated Infections (HCAIs)

No more than 6 post 48-hour MRSA bacteraemias MD GREEN = GREEN GREEN Total of 2 MRSA cases YTD M

No more than 166 post 72-hour C. Difficile infections MD GREEN = GREEN GREEN Total of 40 C. Difficile cases YTD M

Medicines Management (CQUIN)

Delayed and missed doses of medicines for hospital inpatients MD GREEN = GREEN GREENBaseline audit undertaken in May, second audit is now completed

Improvement Target agreed with PCTs M

Patient Falls (CQUIN) No. of inpatients having a fall whilst an inpatient (CO1.3) DSD RED = AMBER AMBER

• Q1 Baseline – 142 Falls per month• Q2 4%, reduction • Q3 7%, reduction • Q4 10% reduction

M

Effectiveness

Hospital Standardised Mortality Ratio (HSMR)

HSMR for the most recent complete 12 months based on the HSMR basket of 56 diagnosis groups MD RED AMBER AMBER

Month: 105.6 (95% CI: (88.38 – 125.3)Last quarter: 110.2 (99.4-121.9)

Last 12 months: 112.7 (107.3 – 118.4)M

Stroke - National Target % of Patients spending 90% of time on Stroke Unit MD GREEN = GREEN GREEN Sustainable improvement continues M

Stroke – Compound Indicator

Compound based on Swallow Screens, TIAs and % of Time on Stroke Unit MD GREEN = GREEN GREEN Quarter three to date, all three targets achieved M

Appendix 1

3

Integrated Performance Report: Quality (CO1) Appendix 1

Target (2010/11) Executive Lead

Monthly Performance

Direction of Travel

Year to Date

Forecast Commentary Frequency

Effectiveness

Stroke (CQUIN) Admissions to Stroke Unit within 4 hours of Arrival at Hospital MD GREEN = GREEN GREEN New CQUIN Target for 2010/11 value worth £200K M

Early Access to Maternity

Achieve contract milestones for early access to maternity services (90% by Q4 and 86% full year) (CO1.1) DSD AMBER AMBER GREEN

October 2010T&WPCT = 75%SCPCT = 86%

M

Nutrition % Completion of Nutrition Screening Tool ( C01.7) DSD GREEN = GREEN GREEN

Baseline Audit 58% Q2 65%Q3 75%Q4 90%

Q

Readmission RatesRelative Risk of Emergency Readmission within 28 days of discharge MD GREEN = GREEN GREEN

The relative risk of Emergency Readmission remains significantly lower (better) than the average for England M

Venous Thromboembolism (CQUIN)

% of adult inpatients who have had a VTE risk assessment on admission (CO1.3) MD No update provided at the time of issue M

Think Glucose (CQUIN) Compliance with Think Glucose guidance (CO1.3) MD GREEN = GREEN GREEN Action plan compliant with milestone achievement M

Tissue Viability (CQUIN)Reduction in the number of Grade 3 and 4 Pressure Ulcers – to be confirmed with PCT (CO1.3) DSD RED AMBER AMBER

New CQUIN 2010/11Target to reduce by Q4 number of

grade 3/4 ulcers by 10%M

4

Integrated Performance Report: Delivery (CO2, CO3 & CO4)Target (2010/11)

Executive Lead

Monthly Performance

Direction of Travel

Year to Date Forecast Commentary Frequency

Appraisals SaTH target of 80% DCA GREEN = GREEN GREEN Trust performance at 86% appraisal completion M

Staff SatisfactionA continual improvement in staff satisfaction, as assessed by the Annual Staff Survey (CO3.3) DCA GREEN = GREEN GREEN 2009 survey shows continued improvement over previous years Q

Working in partnership as the

provider of choice

Smoking (CQUIN)90% of smokers/users of tobacco attending new patient appointments at selected outpatient clinics receive brief intervention (CO4.3) MD No update provided at the time of issue M

Dementia

% of patients receiving cognitive assessment on admission MD Baseline to be obtained from the National Audit of Dementia. Findings due Oct. – Dec. 2010 (Q2) Q

An informed and effective workforce for people with dementia MD Preliminary Review of Educational requirements around Dementia to increase knowledge & understanding amongst all Trust Staff (Q2) Q

Staying Healthy (Alcohol) (CQUIN)

9a) 90% of people attending A&E with alcohol related condition & are not admitted who receive a brief intervention to reduce alcohol consumption9b) ?% of people who are admitted to hospital with alcohol related condition receive brief interventions to reduce alcohol consumption

MD GREEN = AMBER RED

9a) PCT and Trust agreement on delivery with concerns raised about responsibility lines after April 2011. Project Group meeting and

awaiting clarification of SLA for both sites9b) PCT and Trust agreed target. SLA to be agreed for roll out.

Development in line with action plan

M

Appendix 1

5

Integrated Performance Report: Foundations (CO5 & CO6)Target (2010/11) Executive

LeadMonthly

PerformanceDirection of

TravelYear to Date Forecast Commentary Frequency

Care Quality Commission Registration

Maintain Trust Registration with the Care Quality Commission DCA GREEN = GREEN GREEN Trust now registered without conditions (Q2) Q

Coding To increase the numbers of FCEs with coded comorbidities FD GREEN = GREEN GREEN Coding levels remain the same as previous month M

Achieving N

HS Foundation Trust status

A&E 4 Hours95% of patients to be admitted, discharged or transferred within 4 hrs. of registering at A&E DSD RED = GREEN GREEN Local Health Economy underachieved target for October M

18 Weeks1a - Admitted Clock Stops above 90% DSD GREEN = GREEN GREEN Trust achieved the 90% target during October M

1b - Non-Admitted Clock Stops above 95% DSD GREEN = GREEN GREEN Trust achieved the 95% target during October M

Cancer

14 Days from urgent GP referral to first outpatient appointment for all urgent suspected cancer referrals DSD GREEN AMBER GREEN 14 day target achieved in month M

31 Days from diagnosis to treatment for all cancers DSD GREEN GREEN GREEN 31 day target achieved in month M

62 Day from urgent referral to treatment of all cancers DSD RED GREEN GREEN 62 day target underachieved in month M

Thrombolysis68% of patients admitted with ST Elevation MI should receive Thrombolysis within 60 minutes of call for help DSD RED = RED GREEN

Only 2 eligible patient in the year to date. CQC guidance states that for this indicator a ‘low numbers' rule will be applied which will withdraw Trusts

treating a low number of eligible cases from the assessmentM

Rapid Access Chest Pain A maximum of two-week wait for rapid access chest pain clinic (CO6.6) DSD GREEN = GREEN GREEN Well established service with consistent high performance M

Appendix 1

6


Target (2010/11)Executive

LeadMonthly

StatusDirection of Travel

Year to Date

Forecast Commentary


Improve responsiveness to personal needs of patients (CO1.3 / CO1.7) (CQUIN)

DSD GREEN = GREEN GREEN

Target 2010/11 89% overall patient satisfaction

5 indicators identified form 2009/10 results

Breaches in Single Sex Accommodation (CSA) compliance (CO1.5)


Number of breaches caused by each occurrence will be equal to the total

number of patients effectedi.e. 1 female with 5 males is 6

breaches

• Capital funding approved to improve washing and toilet facilities.

• In October a total of 21 breaches on four occasions: 1 episode in Ward 4 Stroke bay and 3 in MAU RSH. All were in response to high demand for beds and for overriding clinical reasons. All breaches were corrected before the following shift.

• Patient Experience Tracker audits being rolled out across the organisation.

Actions:• To develop an overarching strategy for collection of patient experience information including patient stories.• A Dignity in Care Conference is being organised in SECC for May 12th 2011 to celebrate Nurses Day .

0

200

400

600

800

1000

Breaches by month 287 195 165 157 45 5 21

Breaches YTD 287 482 647 804 849 854 875

Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11

7

28 Day Cancelled OperationsTarget (2010/11)

Executive Lead

Monthly


Year to Date

Forecast Commentary

28 Day Cancelled Operations

To maintain a minimum level of non medical cancellations in accordance with national criteria

DSD RED = GREEN GREEN 47 cancelled in month

Readmit all non medical cancellations within 28 days in accordance with national criteria

DSD GREEN = GREEN GREEN No 28 day breaches in month

• 47 operations cancelled in October for non medical reasons.

• 202 operations cancelled for non medical reasons in the year-to-date.

• The national target applies only to those cancellations that happened on or after the day of admission and only for non-medical reasons.

• Current guidance indicates that the CQC threshold for achievement will be no more than 0.8% of relevant elective activity. We are currently below this figure for the year-to-date but the in month performance is above the anticipated threshold.

Actions:• During October the main causes of patient cancellations were 1) no bed (23 patients) and 2) theatre list overruns (10 patients). The list overruns in the main are due to

beds being identified too late during the theatre list. In October there have been a significant number of outliers within the surgical specialities bedbase.• There is a further process mapping session for the Surgical Admission Suite in December, to address some of the patient flow challenges.

Cancelled Operations 2010/11 - by Site

0

50

%

PRH 15 6 17 20 15 25 15

RSH 0 8 15 26 12 28 32

Anticipated Threshold 33 33 35 36 30 34 35 33 31 31 34 40

Apr-10 May-10 J un-10 J ul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 J an-11 Feb-11 Mar-11

Cancelled Operations 2010/11 by Reason

0

10

20

30

40

50

60

Apr-09 May-09 J un-09 J ul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 J an-10 Feb-10 Mar-10

No Beds No Anaesthetist No Time Theatre Closed No Equipment Cancelled by Surgeon No Surgeon Trauma Other

8

Cleanliness


LeadMonthly


Year to Date

Forecast Commentary

CleanlinessTo maintain cleanliness score of 92% across the Trust DSD GREEN = GREEN GREEN

Both sites were Green at the time of October monitoring

• Target score of 92% is based on the Patient Environment Action Team (PEAT) score to achieve “excellent”.

• Monthly cleanliness scores collected from Domestic Services Department Quality Monitoring Programme.

• April and May figures only collated as combined scores.

• Overall score of 95.82% was achieved for the Trust in October 2010.

• Cleanliness Score for RSH much improved this month.

• The main issue at PRH this month was the public toilets but all issues found are being addressed.

• Based on April to October figures the year-end forecast is 94.49% (this will be submitted as part of the PEAT Assessment process).

Actions:• Manual system of recording of monitoring used at present. Electronic System to be implemented by January 2011.

SATH Cleanliness Score for 2010 - 2011

0

20

40

60

80

100

Apr-1

0

May-1

0

Jun-1

0

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov-1

0

Dec-1

0

Jan-1

1

Feb-1

1

Mar-1

1

Monthly

Pe

rce

nta

ge

RSH

PRH

SATH Score

Green(=>92%)

Amber(<92% and>87%)

99

Choose and Book


LeadMonthly


Year to Date

Forecast Commentary

Choose and Book Maintain a monthly slot availability rate of at least 90% for appointments made via the Choose & Book System

DSD RED = RED REDThe October report is based on 3 weeks data available due to C&B

systems upgrade

• The planned upgrade to the national C&B system took place 23/24 th October. We await the new report format being compiled by the national C&B team.

• Appointment Slot Issues (ASIs) are now directly available to the SDU on a C&B worklist, allowing more proactive management of the capacity available to provide the appointments needed. ‘Superuser’ training has been provided on how to access and manage the ASI worklist.

• An average of 95 patients per week were unable to book their appointment via C&B up to October 24th. Of these, 75% were in the following specialties:-

- Ophthalmology – av. 27 per week (increase of 10 per week from September) - Children & Adolescent – av. 14 per week (increase of 5 per week from September) - T&O – av. 11 per week - ENT av. 11 per week - Dermatology av. 9 per week.

Actions: • Review and action ASIs within the SDUs.

Slot availability rate for appointments made via the Choose & Book System

60.00%

80.00%

100.00%

%

Actual 86.00% 84.00% 80.00% 85.00% 87.40% 82.95%

Profile 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%

Apr 10 May 10 J un 10 J ul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 J an 11 Feb 11 Mar 11

10


LeadMonthly


Year to Date

Forecast Commentary

End of Life (CQUIN)% of admitted patients at end of life following the Liverpool End of Life Pathway (CO1.3)


New CQUIN Target for 2010/11Q2 – baseline 27%

Q4 to improve compliance by 20% target 32%

• Q1 electronic data collection system established. Monthly reports generated from contracts, performance and Vitalpac data.

• Q2 base line position of 27% compliance. Baseline position reached by comparing deceased patients coded for palliative care against patients recorded on Vitalpac as on Liverpool Care Pathway (LCP).

• Baseline identified using month six data as thought to be the most reliable due to improvements in coding for palliative care.

End of Life

Actions:• Q3 monitor against baseline. Monthly meeting with clinical coding and palliative care CNS to support data validation. • To take forward recommendations for the development and improvements to Bereavement Services.

Percentage of patients with anticipated death managed on LCP at End of Life

0

20

40

60

80

100

Q2 Q4

EOL deceased patients

LCP

%

Target %

11

Incidents


LeadMonthly


Year to Date

Year End Forecast

Commentary

Incidents

Rate of patient safety incidents reports (CO1.6) MD GREEN = GREEN GREEN Incident reporting rate of 8.4%

Serious Incidents Requiring Investigation (CO1.6) MD GREEN GREEN GREEN Less than 8 SIRIs per month

• The Trust reports Patient Safety Incidents & Near Misses to the National Reporting & Learning System (NRLS). The rate is based on the number of incidents each month as a percentage of the monthly admissions (based on 2008/09 HES data).

• The Care Quality Commission (CQC) receive weekly reports from the NRLS & are regularly provided with further information about incidents. Managers are reminded to ensure that compiled information on investigations & actions is included on the reports before final submission.

• The number of Serious Incidents Requiring Investigation (SIRI) includes Serious Untoward Incidents (SUIs) & Patient Incidents which have been reported under RIDDOR (Reporting of Injuries, Diseases & Dangerous Occurrences Regulations). MRSA bacteraemias and grade 3/4 pressure sores are excluded as these are reported separately.

Actions: • Incident Review Group meets monthly to discuss incidents & trends. Further Root Cause Analysis training for Managers is being planned to improve the consistency of investigation.

Incident rate per number of admissions (08/09 HES data)

5

5.5

6

6.5

7

7.5

8

8.5

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

Month

%

Number of SUIs and Patient RIDDOR reports (excluding pressure ulcers and MRSA bacteramia)

0

2

4

6

8

10

12


Month

To

tal

RIDDOR

SUI

12


LeadMonthly


Year to Date

Forecast Commentary


No more than 6 post 48-hour MRSA bacteraemias MD GREEN = GREEN GREEN Total of 2 MRSA cases YTD

No more than 166 post 72-hour C. Difficile infections MD GREEN = GREEN GREEN Total of 40 C. Difficile cases YTD

MRSA• There were 2 post 48 hour cases of MRSA bacteraemia in October. • Both cases were in ITU at RSH. RCA has been carried out. In one the likely

source was a chest infection and in the other a wound infection. We are typing the MRSA strains to see if they are the same.

• Two cases to end of October 2010 vs. target of not more than 6 post 48 cases 2010/11.

• There was one pre 48 hour MRSA bacteraemia in October. This was investigated by the PCT and found to be from a pressure sore.

• Ongoing work – maximising admission screening, re-screening wards where acquisition occurs, reducing line sepsis, screening new staff.

• C. Difficile• To end October 2010 - 40 SaTH responsible cases (post 72 hrs.).• In October 6 SaTH cases, 5 in RSH and 1 in PRH, were diagnosed more than 72

hrs. post admission and therefore count vs. SaTH target.• One ward has had more than five cases within 30 days. RCA suggested antibiotic

use and cross infection were issues.


Actions:

• C difficile cluster: An intensive deep clean and review of practice has being carried out. Antibiotic audits are continuing.

MRSA Cases v Profile 2010/11

0

10

Cas

es

MRSA Cases YTD 0 0 0 0 0 0 2

MRSA Cases by Month 0 0 0 0 0 0 2

National Target Profile YTD 1 1 2 2 3 3 4 4 5 5 6 6

Apr-10

May-10

J un-10 J ul-10Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

J an-11 Feb-11Mar-

11

SaTH C-Diff Cases in Patients over the age of 2 2010/11

0

50

100

150

Cas

es

C-Diff Cases YTD 7 17 22 26 31 34 40 40 40 40 40 40

C-Diff Cases by Month 7 10 5 4 5 3 6

National Target Profile YTD 14 28 42 56 70 84 98 112 126 140 153 166

Apr-10

May-10

J un-10 J ul-10Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

J an-11 Feb-11Mar-

11

13

Medicines Management


LeadMonthly


Year to Date

Forecast Commentary

Medicines Management (CQUIN)

Delayed and missed doses of medicines for hospital inpatients MD GREEN = GREEN GREEN

Baseline audit undertaken in May, second audit is now completed

Improvement Target agreed with PCTs

Baseline Audit Results May 2010

• To agree list of Critical Medicines for baseline audit- achieved.• To undertake baseline audit in May 2010 - achieved. 3 day audit of Admission

areas, 364 patient records/charts included, second audit completed, final audit planned for January 2011.

• Report to PCTs in July 2010- achieved, November 2010 in progress & March 2011.

• Baseline Audit accepted & 20% improvement target provisionally agreed, based on improvement over the next two audits.

• Stock lists and out of hours arrangements amended in line with audit results & training & support advice provided to nursing staff to locate & obtain critical medicines.

Actions: • Second Audit now completed, results expected to be available at the end of November. • Report to be forwarded to PCT when audit results are available.• Action plan to be further developed dependent on audit results.

Patients records reviewed 364

Number of times where medicines were prescribed

4383

Prescription omitted for a clinical or patient specific reason i.e. patient refused

643 14.67%

Prescription omitted due to a record of non available

80 1.83%

Prescription where medicines regarded as critical

38 0.89%

Prescription where more than 1 dose omitted

22 0.50%

14

Patient Falls


LeadMonthly


Year to Date

Forecast Commentary

Patient Falls (CQUIN)No. of inpatients having a fall whilst an inpatient (CO1.3) DSD RED = AMBER AMBER

• Q1 Baseline – 142 Falls per month• Q2 4%, reduction

• Q3 7%, reduction • Q4 10% reduction

• Patient “comfort Rounds” have been introduced for ‘At Risk’ patients.

• Gold squares to be placed above all patient’s bed who have been assessed and deemed at risk of having a fall.

• “Tip Tree Box” to be trialled on Care of the Elderly Ward. This is a tool kit for use in hospital wards as therapeutic intervention with patients suffering from dementia. Contains everyday familiar items and a table where patients can sit safely and not be confined to their bedside.

• Weighted alarms to be trialled on Ward 4 for a 4–6 week period starting 12 th November 2010.

• Patient Safety First week – falls workshop to be included.

• Executive Nurse Root Cause Analysis Review Meetings to be held every 2 weeks.

Actions:• Falls information on Internet and Intranet.• To undertake further in depth analysis on falls data and categories. • Ward Managers and Matrons to be alerted to falls on daily basis so more proactive and immediate review can take place.

12 month run chart for showing falls in SaTH

0

50

100

150

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

SaTH 09-10 SaTH 10-11 10-11 Trajectory

15


Actions:• Senior nurses will be trained in the use of the Global Trigger Tool in December. • A coding workshop was held on 15th October. A number of Clinicians have been identified as ‘Coding Champions’. A further workshop will be held in November.• The Trust is working with the University of Birmingham to understand the data more fully; develop an alternative system for monitoring deaths, and to set up a research project.

Period HSMR

Sept 09 – Aug 10

RED(worse)

Jul 09-Sep 09

RED(worse)

Oct 09-Dec 09

RED(worse)

Jan 10-Mar 10

RED(worse)

Apr 10-Jun 10

AMBER(comparable but

one trigger)

Negative Triggers

TWO

Number of deaths per month (HSMR basket)

0

20

40

60

80

100

120

140

160

180

Se

p-0

9

Oct-

09

No

v-0

9

De

c-0

9

Ja

n-1

0

Fe

b-1

0

Ma

r-1

0

Ap

r-1

0

Ma

y-1

0

Ju

n-1

0

Ju

l-1

0

Au

g-1

0

Nu

mb

er


LeadMonthly


Year to Date

Forecast Commentary


HSMR for the most recent complete 12 months based on the HSMR basket of 56 diagnosis groups

MD RED AMBER AMBERMonth: 105.6 (95% CI: (88.38 – 125.3)

Last quarter: 110.2 (99.4-121.9)Last 12 months: 112.7 (107.3 – 118.4)

• HSMR is calculated from hospital activity using the Dr Foster Real Time Monitoring (RTM) Analysis Tool, using the most recent available data (currently three months in arrears). It compares the mortality rates in our hospitals with the average expected across England, adjusted to reflect factors such as age and case mix.

• Dr Foster has rebased the HSMR which has resulted in a change in the Trust’s reported HSMR which has been applied retrospectively for the last year.

• The annual HSMR for the year Sept 2009 to August 2010 is worse than the national average for England (based on a 95% confidence interval).

• The HSMR for the latest month is 112.7 and for the last quarter is 110.2. For the months April – August, April, ,June, July and August were close to the England averages.

• Trust-level Mortality data has been triangulated using other quality analysis tools, such as CHKS. This has not replicated the alert from the Dr Foster system.

16


LeadMonthly


Year to Date

Year End Forecast

Commentary

Stroke National Target % of Patients spending 90% of time on Stroke Unit MD GREEN = GREEN GREEN Sustainable improvement continues

Stroke – Compound Indicator Based on targets agreed with local Commissioners MD GREEN = GREEN GREENQuarter three to date, all three targets

achieved.

Current Performance Proportion of People who spent at least 90% of their time on a Stroke Unit: Quarter 3 Target 75.5.0%, PRH 95.5%, RSH 75.0%.

• The overall SaTH performance continues to exceed this target. Improvement noted at RSH, however work is required as performance is still fractionally short of target.

• Current Performance for swallow screening on both sites: Quarter 3 Target 68.3%, PRH 90.9%, RSH 80.6%.• Current Performance for TIA on both sites: Quarter 3 Target 55.8%, PRH 100%, RSH 75.0%.• Marked improvement continues against this target.• Trust delegates will be hosting an exhibit at the UK Stroke Conference in Glasgow in

December sharing our best practice on TIA pathway redesign.

• West Midlands Quality Review Service visited both sites in September .

– Formal feedback has been received. An action plan has been completed.– Meetings with PCT representatives and Chief Executive to formalise Economy

Wide response to deliver improved performance in highlighted areas.

Stroke

Actions:• Data Analyst interviews to take place on Friday November 5th.• Thrombolysis Service to commence seven days a week 08:00 – 20:00 at both PRH and RSH from December 6th (Phase One).• Hyper acute Stroke patients (including Thrombolysis) to be provided at one site only (PRH) during hours 20:00 – 08:00 from January 5th (Phase Two – Interim phase). • Option appraisal to be carried out during March 2011 (re. Phase Two).• Implement a twenty-four/seven service to include Thrombolysis at a single site (Phase Three).

90% of Time on Acute Stroke Unit

30.0%

60.0%

90.0%

SaTH 76.9% 81.0% 82.8%

Target 66.5% 71.0% 75.5% 80.0%

Qtr 1 Qtr 2 Qtr 3 Qtr 4

Swallow Screen Within 24 Hrs

30.0%

60.0%

90.0%

SaTH 78.9% 87.1% 84.5%

Target 64.8% 66.5% 68.3% 70.0%


TIA - Scanned & Treated Within 24 Hrs (Rothwell Score 4+)

20.0%40.0%60.0%80.0%

100.0%

SaTH 23.1% 80.6% 88.9%

Target 47.3% 51.5% 55.8% 60.0%


17

Stroke - CQUIN


LeadMonthly


Year to Date

Year End Forecast

Commentary

StrokeAdmissions to Stroke Unit within 4 hours of Arrival at Hospital

Medical Director GREEN = GREEN GREEN

New CQUIN Target for 2010/11 value worth £200K

• Current performance for admitted to Stroke Unit within four hours of Arrival: Quarter 3 Target 33%, PRH 60.9%, RSH 53.9%.

• New CQUIN Target from April 2010 to demonstrate Admission to Stroke Unit within 4 hours of Arrival at Hospital – value worth £200k.

Actions:

Admission to Stroke Unit within 4 hours of Arrival

0.0%20.0%40.0%60.0%

SaTH 54.5% 54.8% 56.5%

Target 23.0% 29.0% 33.0% 38.0%


18


LeadMonthly


Year to Date

Forecast Commentary

Early Access to MaternityAchieve contract milestones for early access to maternity services (90% by Q4 and 86% full year) (CO1.1)

DSD AMBER AMBER GREENOctober 2010

T&WPCT = 75%SCPCT = 86%

Quarter 1 Data: ValidatedQuarter 2 Data: ValidatedQuarter 3 Data: Unvalidated

• Action plan being developed for both PCT areas.

• Meeting with TWPCT and GP Maternity Lead held in November 2010 – offered support to encourage the use of the electronic Notification of Pregnancy (NOP) with TWPCT GP surgeries.

• Permanent booking co-ordinator posts recruited, commencement dates TBC.

• Regular SCPCT Service Review Meetings (as per existing TWPCT Review Meetings) are still to be confirmed.

• Flexible working required to meet peaks in referrals.

• Work to convert the playroom to a booking room at Wrekin nearly completed.

Early Access to Maternity

Actions:• Review of database to identify specific GP practices referring pregnant women late to Maternity Services. • Review of database to identify midwives undertaking booking assessment outside of target (following appropriate referral into the system). • Recruitment to midwifery vacancies within PRH to be tightly managed.

Early Access Target

75.00%

80.00%

85.00%

90.00%

95.00%

SATH

Target

SATH 81.50% 87% 84%

Target 80% 85% 88.90% 90%


19

Nutrition

Target 2010/11Executive

LeadMonthly


Year to Date

Forecast Commentary

Nutrition% Completion of Nutrition Screening Tool ( CO1.7) DSD GREEN = GREEN GREEN

Baseline Audit 58% Q2 65%Q3 75%Q4 90%

• A baseline audit conducted in April 2010 showed 58% of Nutritional Screening Assessments were completed within 6 hours of patient admission.

• Targets for 2010/11 have been agreed as:

Q2 65% compliance Q3 75% compliance Q4 90% compliance.

• New Dietician appointed with specific role to monitor Nutritional Compliance and Out comes.

• Nutritional Steering Group established.

• Protected Meal Times being trialled in wards 7, 15 and 16 at PRH.

Actions: • Further expansion of Protected Meal Times implementation to commence from September 2010.• Nutritional Steering Group members to visit Trust in the Region who have successfully implemented Protected Meal Times.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

%

% compliance 58% 91%

Target 65% 75% 90%

Q1 Q2 Q3 Q4

20


LeadMonthly


Year to Date

Forecast Commentary

Readmission RateRelative Risk of Emergency Readmission within 28 days of discharge

MD GREEN = GREEN GREEN

The relative risk of Emergency Readmission remains significantly lower (better) than the average for

England

• Relative risk of emergency readmission within 28 days of discharge is calculated from hospital activity using the Dr Foster Real Time Monitoring Analysis Tool, using the most recent available data (currently five months in arrears, to ensure that readmissions have been mapped to previous spells). It compares the Emergency Readmission in our hospitals with the average expected across England, adjusted to reflect factors such as age and case mix.

• The relative risk of Emergency Readmission was lower (better) than the average for England (based on a 95% confidence interval) for the most recent available full data year (June 2009 to May 2010) and was significantly lower than (2 quarters) or comparable with (2 quarters) the average for England in the four quarters of the most recent available data year.

Readmission Rates

Actions:

Period Risk Rating

Jun 09 to May 10

6.0%

GREEN (better)

Jul 09-Sep 09 GREEN (better)

Oct 09-Dec 09 GREEN (better)

Jan 10-Mar 10 GREEN (comparable)

Apr 10-June 10 Full data not available

Specialty Alerts ONE

Readmissions

0

100

200

300

400

500

600

700

May

-09

Jun-

09

Jul-0

9

Aug

-09

Sep

-09

Oct

-09

Nov

-09

Dec

-09

Jan-

10

Feb-

10

Mar

-10

Apr

-10

Nu

mb

er

21


LeadMonthly


Year to Date

Forecast Commentary

Venous Thromboembolism (CQUIN)

% of adult inpatients who have had a VTE risk assessment on admission (CO1.3)

MD No update provided at the time of issue

Venous Thromboembolism

Actions:

22


LeadMonthly


Year to Date

Forecast Commentary

Think Glucose (CQUIN)Compliance with Think Glucose guidance (CO1.3) MD GREEN = GREEN GREEN

Action plan compliant with milestone achievement

• Think Glucose is a practical and easy to use tool which improves the care, outcomes and experience of people with diabetes who are admitted to hospital with non-diabetes related problems.

• Ongoing training in progress to Ward Champions.

• Ward Hypoglycaemic boxes ordered & stocked.

• Ward Resource Toolkit box disseminated to all wards and departments.

Think Glucose

Actions: • Continuation of delivery of action plan.• Plan to roll out pre filled insulin syringes during January.• Develop audit tool to measure compliance.

Milestones Completion Date Compliance

Baseline audit Q1 Green

Robust process for patient identificationSafe use of Insulin implemented

Q2 Green

Review of patient identificationVisibility and education roll out Re-audit against toolkit

Q3

CQUIN compliance Q4

23

Tissue Viability


LeadMonthly


Year to Date

Forecast Commentary

Tissue Viability (CQUIN)Reduction in the number of Grade 3 and 4 Pressure Ulcers – to be confirmed with PCT (CO1.3)

DSD RED AMBER AMBER New CQUIN 2010/11

Target to reduce by Q4 number of grade 3/4 ulcers by 10%

• Increase in the total number of ulcers may be attributable to greater compliance with reporting due to on ongoing increased awareness in the use of the new E Trace system with ‘Skin Sunday’.

• Monthly status red as 5 SUI in October so above 3 per month target .

• Key Themes From RCA’s• Inadequate documentation of patients nursing care in care plan.• Wound assessment documentation not completed accurately.• Delay in reporting pressure ulcer & referring to TVN.

• Case review meetings of RCA’s commenced by Executive Nurse & Head of Nursing to learn lessons from RCA.

• Delivery of detailed education programme continues, this has been rolled out to Ward 28, Ward 16, Ward. 24, 8/9 and MAU in progress. Roll out plan for the rest of Trust constructed.

• Root Cause Analysis Training given to Matrons and Lead Nurses. • Trust wide prevalence audit completed . • Trust Surveillance Nurse will assist TV Nurse 8 hrs. per week to ensure ward staff can

access early advice/intervention for grade 3 and 4 pressure ulcers.

Actions:• RCA training arranged in November for Ward Managers .• Continue with education roll out.• To review Trust wide Prevalence audit results.

Pressure Ulcers Developed in Trust by Grade

0

10

20

30

40

50

60

Grade 4

Grade 3

Grade 2

Grade 1

24


LeadMonthly


Year to Date

Forecast Commentary

Appraisals SaTH target of 80% DCA GREEN = GREEN GREENTrust performance at 86% appraisal

completion

• As at month ending 31st October 2010, 86% of staff excluding Bank Staff have had a KSF appraisal within the last 15 months.

• Departments continue to improve completion performance, although this must be sustained over the winter months when operational pressures normally impact.

• Appraisal Quality Audits are currently being trialled to improve the effectiveness of individual appraisals.

• The lowest 5 performing areas for September with over 15 staff were as shown. All have action plans in place to achieve 80%.

Appraisals

Actions:

• Departments falling below 60% are performance managed by the relevant Executive Director.

Completed Appraisals (excluding Bank Staff)

0.0

20.0

40.0

60.0

80.0

100.0

% Appraisals Completed

% Appraisals Completed 2009-10 69 71 71 73 74 77 77 78 76 74 76 84

% Appraisals Completed 2010-11 84 81 83 84 85 84 86

% Target Appraisals Completed 80 80 80 80 80 80 80 80 80 80 80 80

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

Area Staff Completed % Div.

Portering Department (RSH) 37 10 27 Corp.

Ward 11 - Trauma & Orthopaedics 23 12 52 1

Ward 23 - Haematology 17 9 53 2

Ward 10 - Trauma & Orthopaedics 27 15 56 1

Ward 9 - General Medicine 23 14 61 1

25

Smoking


LeadMonthly


Year to Date

Forecast Commentary

Smoking (CQUIN)

90% of smokers/users of tobacco attending new patient appointments at selected outpatient clinics receive brief intervention (CO4.3)

MD No update provided at the time of issue

Actions:

26

Staying Healthy (Alcohol) - CQUIN


LeadMonthly


Year to Date

Forecast Commentary

Staying Healthy (Alcohol)

9a) 90% of people attending A&E with alcohol related condition and are not admitted who receive a brief intervention to reduce alcohol consumption9b) 75% of people who are admitted to hospital with alcohol related condition receive brief interventions to reduce alcohol consumption

MD GREEN = AMBER RED

9a) PCT and Trust agreement on delivery with concerns raised about responsibility

lines after April 2011. Project Group meeting and awaiting clarification of SLA

for both sites9b) PCT and Trust agreed target. SLA to

be agreed for roll out. Development in line with action plan

Part 9a:• Data Assessment shows 100% patients attending A&E at RSH had a delivered

intervention for September.• Monthly Project Group verbalised concerns around meeting this target if intervention is

decreed as being anything more than a sticker and ‘pack sent’ approach. Skill mix review in these areas needs to link into delivery of IBA (Identification and Brief Advice). Alcohol Nurse Specialists through MHL Services started and are based at PRH Ward 9. There is no facility for engaging across both sites due to commissioning streams. Achieved CQUIN in this group for this month.

Part 9b:• Reviewed Alcohol Screening Tool and agreed trial to start December, first working day.

SDU is taking cost for this. Tool will be trialled on 27G, Ward 9 and MAU’s for 3 months to assess function in practice. Project Group to work with SAU’s to access this client group.

• Awaiting agreement of information leaflets so that there is a consistent approach for both sites. This has been assigned to project leads and will be ready by December. In January 2011 PRH will have access to information leaflets and packs to send out to fully meet CQUIN.

Actions:• 9a: There are significant concerns around the delivery of IBA after April 2011 at RSH due to resourcing Alcohol specialist post. CQUIN uplift payments are required to assist in service provision and agreement of this needs to allow for 3 months to ensure continuity and training.• 9b: Delay in agreement for SLA across providers/commissioners. The need for this is agreed and will be written by PCT’s in discussion with acute Trust. This is not totally in the control of

the CQUIN group.

Pts presented A&E:

RSH = 50

Pts seen by alcohol specialist:

2(4%)

Pts sent information packs:

50(100%)

Pts presented at PRH= 65

27

Care Quality Commission RegistrationTarget (2010/11)

Executive Lead

Monthly


Year to Date

Forecast Commentary

Care Quality Commission Registration

Maintain Trust Registration with the Care Quality Commission DCA GREEN = GREEN GREEN

Trust now registered without conditions (Q2)

The new registration system for health and adult social care will make sure that people can expect services to meet essential standards of quality and safety that respect their dignity and protect their rights. The new system is focused on outcomes rather than systems and processes, and places the views and experiences of people who use services at its centre

There are 28 outcomes, each reflecting a specific regulation. Of these 28 regulations and outcomes, there are 16 that relate most directly to the quality and safety of care and which apply to all types of provider. The other 12 regulations may apply differently to different types of provider.

There are 28 outcomes grouped into six key areas:

● Involvement and Information● Personalised Care, Treatment and Support● Safeguarding and Safety● Suitability of Staffing● Quality and Management● Suitability of Management.

• The Trust declared compliant with all relevant outcomes across the six key areas in the January Initial Registrations process.

• SaTH has set up templates for lead managers to collate evidence of compliance.• The CQC are introducing a new quality & risk profiling tool that SaTH will

incorporate in to the assessment process however publication of the second quality and risk profile has been delayed from April until at least September.

• The Trust remains registered without any conditions.• The CQC have completed their responsive review.

• The DoH and CQC have agreed to halt further action on the periodic review of the NHS – there will be no ratings published for Quality and Use of Resources.

Actions:• Lead Managers have been asked to submit evidence of continuing compliance against the Essential Standards of Quality and Safety for Quarter 2.• Internal Audit will be auditing the evidence of compliance in November.

28

Coding


LeadMonthly


Year to Date

Forecast Commentary

CodingTo increase the numbers of FCEs with coded co-morbidities FD GREEN = GREEN GREEN

Coding levels remain the same as previous month

Data report one month in arrears

• The Target is to ensure that co-morbidities are captured by clinicians for each Finished Consultant Episode (FCE), where applicable.

• Work is currently underway by MedeAnalytics to analyse national coding statistics and provide a national benchmark by which SaTH clinical coding can be compared.

• New guidance for 2010/11 has been issued by Connecting for Health which clarifies the recording of co-morbidities and is responsible for the increased depth of coding.

Actions:

• The Clinical Coding Manager continues to audit the recording of co-morbidities on a monthly basis making use of the Coding analytics software.

FCEs with Coded Co-morbidities

64%

65%

66%

67%

68%

69%

70%

71%

72%

10/11 Actual 66% 65% 69% 71% 72% 72%


29

A&E 4 Hour Waits


LeadMonthly


Year to Date

Forecast Commentary

A&E 4 Hour Waits95% of patients to be admitted, discharged or transferred within 4 hrs. of registering at A&E

DSD RED = GREEN GREENLocal Health Economy underachieved

target for October

• The Trust achieved 92.80% unmapped during October.

• The Local Health Economy achieved 96.69% mapped during October.

• For the year-to-date the Trust has achieved 97.04% unmapped.

• For the year to date the Local Health Economy has achieved 98.48% mapped.

• Recently revised NHS Operating Framework has amended target to 95% for 2010/11, however the internal target of 98% remains and is shown in the graph.

• Performance in the month has been assessed against the internal stretch target of 98%. The Trust continues to achieve the National 95% target.

• Performance notice received from Shropshire County PCT for October’s performance.

Actions: • Daily Conference Calls continue.• Health and Social Care Winter Planning commenced.• Urgent Care Network Review and relaunch.

Total Time in A&E - Less than 4 Hours

92%

94%

96%

98%

100%

%

Mapped Total 97.20% 95.90% 95.73% 97.50% 99.08% 98.77% 99.01% 99.00% 99.08% 98.71% 97.55% 95.98% 96.69%

PCT Element 1.48% 2.73% 2.89% 1.84% 0.76% 1.08% 0.35% 0.27% 0.26% 0.92% 0.52% 0.56% 3.89%

SaTH Element 95.72% 93.17% 92.84% 95.66% 98.32% 97.69% 98.66% 98.73% 98.82% 97.79% 97.03% 95.42% 92.80%

National Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%

Stretch Target 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00%

Oct-09 Nov-09 Dec-09 J an-10 Feb-10 Mar-10 Apr-10 May-10 J un-10 J ul-10 Aug-10 Sep-10 Oct-10

30

18 Weeks


LeadMonthly


Year to Date

Forecast Commentary

18 Weeks

1a - Admitted Clock Stops above 90% DSD GREEN = GREEN GREENTrust achieved the 90% target during

October

1b - Non-Admitted Clock Stops above 95% DSD GREEN = GREEN GREEN

Trust achieved the 95% target during October

• The Trust Achieved the overall target of 90% and 95%.• PCT performance for September was:- 1a 1b

Shropshire County PCT 90.14% 97.02%Telford & Wrekin PCT 90.12% 97.02%

• Achieved the 95% target for Audiology in October with 96% of non admitted Audiology patients completing their pathways within 18 weeks with 92% data completeness which is within the anticipated 90 – 110% threshold.

• Specialty level performance for admitted patients (part 1a) was below 90% in ENT (78.69%) Ophthalmology (84.87%) Oral Surgery ( 78.57%) T&O (87.02%).

• Specialty level performance for non admitted patients (part 1b) was below 95% in Oral Surgery ( 93.63%) .

• The DOH and SHA have confirmed the following thresholds will apply when reviewing performance against median waits for each pathway type, >11.1weeks Admitted, >6.6 weeks Non Admitted and >7.2 weeks Incomplete

• At the end of September SaTH was below the Admitted and Non Admitted thresholds with 7.53 and 6.58 respectively. For Incomplete pathways SaTH exceeded the threshold with 8.84 weeks

Actions:

18 Weeks Part 1a - Admitted Clock Stops

60.00%

80.00%

100.00%

%

Actual 90.50% 91.83% 91.57% 91.41% 90.52% 90.71% 90.22%

Profile 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%


18 Weeks Part 1b - Non Admitted Clock Stops

60.00%

80.00%

100.00%

%

Actual 96.40% 97.12% 97.03% 96.30% 95.25% 96.23% 97.02%

Profile 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%


31


LeadMonthly


Year to Date

Forecast Commentary

Cancer – 14 Day14 Days from urgent GP referral to first outpatient appointment for all urgent suspected cancer referrals

DSD GREEN AMBER GREEN 14 day target achieved in month

At the time of writing this report the actual performance for the months of April, May, June. July, August and September are validated but the actual performance for the month of

October is still being validated before submission of data to the national Cancer Waiting Times Database

• 14 day target achieved in October (95.23%), against a year end cumulative target of 93%. There were 43 breaches out of a total of 903 referrals.

• Performance excluding choice was 95.68%.

• 39 patients chose to wait longer than 14 days for their first appointment. Details of the Specialties are as follows:

Breast 5, Colorectal 6, Gynae. 5, Haematology 1, Head & Neck 6Paediatrics 1, Skin 7, Upper GI 3, Urology 5

• 3 patients waited longer than 14 days due to medical reasons: Breast Symptomatic 1, Colorectal 1, Gynae. 1,• 1 patient waited longer than 14 days due to other reasons: UGI 1• 14 day target YTD 89% against a year end cumulative target of 93%.

14 Day Cancer

Actions:• The 14 day target has improved significantly and has been sustained over the past few weeks. This is due to the additional capacity which is now available within the Breast Service to ensure patients are offered the choice of two dates. We are continuing to work closely with the PCTs and auditing the patients that choose not to accept an appointment within 14 days and looking into each case individually. In order to establish why patients are choosing to wait longer than 14 days, we are telephoning patients to establish the reason why. • Demand and capacity for all specialities has been audited over the last 12 months and processes are being put in place to increase capacity where appropriate because from 1st

December 2010 all two week wait appointments will be on Choose and Book.

14 Day Target

60.00%

80.00%

100.00%

%

Actual 84.61% 87.94% 88.40% 87.62% 85.62% 89.52% 95.23%

Exc Choice 100.00%100.00%100.00% 98.09% 97.72% 100.00% 95.68%

Profile 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00%


32

31 Day Cancer


LeadMonthly


Year to Date

Forecast Commentary

Cancer – 31 Day31 Days from diagnosis to treatment for all cancers DSD GREEN GREEN GREEN 31 day target achieved in month

At the time of writing this report the actual performance for the months of April, May, June, July, August and September are validated but the actual performance for the month of

October is still being validated before submission of data to the national Cancer Waiting Times Database

• 31 day target overall achieved (excluding Radiotherapy) in October (97%), against a year end cumulative target of 96%.

• 31 day target first definitive treatment achieved in October (98.00%), against a year end cumulative target of 96%.

• 31 day target subsequent treatment (Surgery) underachieved in October (92%), against a year end cumulative target of 94%.

• 31 day target subsequent treatment (Anti Cancer Drugs) underachieved in October ( 97%) against a year end cumulative target of 98%.

• 31 day target subsequent treatment (Radiotherapy) underachieved in October (90%), against a year end cumulative target of 94%.

• There were 19 breaches in October out of 316 referrals of which were due to patient choice - 10, medical reasons - 2 and others - 7.

• Current YTD position is 97% against a year end cumulative target of 96%.

Actions:

• Although not consistently, we have previously met this target and have gone over and above it. Our aim is to meet this target consistently by the end of December 2010. We have both capacity & staffing issues within Radiotherapy Department which have been acknowledged. The number of Oncologists employed has increased and therefore the demand for access to the radiotherapy machines has increased and plans have been agreed to increase radiography and physics staffing to increase linac capacity in line with NRAG recommendations.

31 Day Target

60.00%

80.00%

100.00%

%

Actual 97.30% 97.76% 97.95% 96.45% 98.80% 93.66% 97.00%

Profile 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00%


33

62 Day Cancer

Target (2010/11) Executive

LeadMonthly


Year to Date

Forecast Commentary

Cancer – 62 Day62 Day from urgent referral to treatment of all cancers DSD RED GREEN GREEN 62 day target underachieved in month

At the time of writing this report the actual performance for the months of April, May June, July, August and September are validated but the actual performance for the month of October is still being validated before submission of data to the national Cancer Waiting Times Database

• 62 day target overall underachieved in October (74%), against a year end cumulative target of 85%.

• 62 day first definitive cancer target underachieved in October (69.44%), against a year end cumulative target of 85%.

• 62 day screening to first definitive treatment underachieved in October (80%), against a year end cumulative target of 90%.

• 62 day consultant upgrade achieved in October (93.54%) – target to be confirmed.

• There were 28 breaches in October out of 123 referrals of which 14 were patient choice, 2 complex pathways, 1 DNA, 4 were due to medical suspensions and 7 others.

• Current YTD position is 87% against a year end cumulative target of 85%.

Actions:• In order to improve and maintain the delivery of the 62 day target, the pathway for Upper GI patients will be re-designed to improve the current delays. This work is being

coordinated by the Service Improvement Nurse within Cancer Services. Changes made within the Administration Team will ensure that all patients are tracked correctly to ensure there are no delays.

• Work is starting in December with the Department of Health Intensive Support Team to identify areas for improvement.

62 Day Target

60.00%

80.00%

100.00%

%

Actual 89.32% 85.52% 87.79% 88.60% 95.00% 89.00% 74.00%

Profile 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%


34

Thrombolysis


LeadMonthly


Year to Date

Forecast Commentary

Thrombolysis

68% of patients admitted with ST Elevation MI should receive Thrombolysis within 60 minutes of call for help

DSD RED = RED GREEN

Only 2 eligible patient in the year to date. CQC guidance states that for

this indicator a ‘low numbers' rule will be applied which will withdraw Trusts

treating a low number of eligible cases from the assessment

• Year-to-date performance of 0%.• This is a combined target for the Trust and the Ambulance Services.• Rurality issues within Shropshire County and Powys impact on the Call to Door

time. Both West Midlands and Welsh Ambulance Services are able to deliver pre-hospital thrombolysis in accordance with strict eligibility criteria.

• The introduction of direct access Primary Angioplasty at UHNS and Wolverhampton Hospitals has led to a reduction in the number of SaTH Myocardial Infarction admissions.

• Patient 1 - (Powys) had call to door time of 132 minutes no evidence of pre hospital thrombolysis assessment.

• Patient 2 - (Oswestry) had call to door time 42 minutes no evidence of pre hospital thrombolysis assessment.

Thrombolysis Profile 2010/11

60.00%

65.00%

70.00%

75.00%

%

Actual YTD 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Profile 68.00% 68.00% 68.00% 68.00% 68.00% 68.00% 68.00% 68.00% 68.00% 68.00% 68.00% 68.00%


Actions: • Internal systems and processes for the delivery of thrombolysis in A&E and the management of acute chest pain admissions ongoing. • Chest Pain direct admission to CCU project initiated, awaiting outcome report.

Thrombolysis Performance YTD PRH RSH SaTH

Call to Needle Eligible Admissions 0 2 2

Call to Needle < 60 minutes NA 0 0

Performance Achieved YTD NA 0% 0%

35

Rapid Access Chest Pain


LeadMonthly


Year to Date

Forecast Commentary

Rapid Access Chest PainA maximum of two-week wait for rapid access chest pain clinic (CO6.6) DSD GREEN = GREEN GREEN

Well established service with consistent high performance

• 5 Rapid Access clinics running each week across SaTH.

• Capacity appropriately matched to demand.

Actions:

Rapid Access Chest Pain Clinic

60.00%

65.00%

70.00%

75.00%

%

Actual YTD 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Profile 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%


Documents

Enclosure 3