August 2019 - George Eliot Hospital · The A&E 4 hour continues to be a challenge, underperformance...

Integrated Performance Report

August 2019

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Contents Keys and Definitions......................................................................................................................................................................................................................... 3

Executive Summary .......................................................................................................................................................................................................................... 5

Director of Operations ..................................................................................................................................................................................................................... 6

Total time spent in A&E - % within 4 hours ........................................................................................................................................................................... 8

Ambulance Handover - handovers >60 minutes ................................................................................................................................................................ 10

Patients not treated within 28days of last minute cancellation ......................................................................................................................................... 13

Cancer Overall achievement- 62 day target* .................................................................................................................................................................... 14

Cancer pathway patients waiting over 104 days* .............................................................................................................................................................. 16

18wks RTT % Incomplete pathways <18 weeks ................................................................................................................................................................ 18

Stroke - The number (percentage) of people who are admitted to hospital following a stroke, who then spend 90% of their time on a Stroke

unit. ............................................................................................................................................................................................................................................ 22

Medical Director ............................................................................................................................................................................................................................ 24

Director of Nursing ......................................................................................................................................................................................................................... 25

Deteriorating patient – good response (sample audit of patients with MEWS of 3 and more) ................................................................................... 29

Falls (per 1000 bed days) ...................................................................................................................................................................................................... 34

Monthly prevalence of the harms reported on safety thermometer - Pressure Ulcers - Acute only ........................................................................... 36

Director of HR ................................................................................................................................................................................................................................ 39

Staff who have received PDP/Appraisal (rolling 12 month period) (%) .......................................................................................................................... 44

Director of Finance ......................................................................................................................................................................................................................... 46

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Keys and Definitions

Integrated Performance Dashboard – Explanatory note.

The purpose of this document is to assist with the navigation and interpretation of the Trust’s Integrated Performance Report. The report

displays Trust performance, indicator statuses, desired performance thresholds as well as who is accountable for the indicator. The report is

ordered by Executive Director areas of responsibility (i.e. Director of Operations; Medical Director; Director of Governance; Director of Nursing;

and Director of HR). Note that this explanatory note does not include a reference to the Finance section of the Integrated Performance

Dashboard report, as this element continues to use a format previously established by the Trust.

The indicators within each section of the Integrated Performance Report are mapped against the relevant CQC inspection domains (i.e. Safe;

Effective; Caring; Responsive and Well Led).

Report Summary Bar (Example section – Director of Operations)

The diagram below shows an example header from the Integrated Performance Dashboard report (example: Director of Operations

Responsiveness Indicator). The numerical bar directly underneath this diagram – included for illustrative purposes - represents each distinct

section of report

Section Title Description

1 Committee The abbreviated name of the Trust committee that has responsibility for reviewing performance against this indicator. Please refer to the abbreviations page in the Integrated Performance report for details of each committee listed.

2 Indicator This column details the name of the indicator and what it is measuring. In the example shown above, the indicators listed in this section will fall under the CQC domain of “Responsiveness”

3 Format (no.%) This column confirms whether the indicator is expressed as a number or as a percentage.

4 Source This column specifies whether the standard for the respective indicator has been set nationally, or set by the Trust as part of a local agreement.

5 Standard This column confirms the standard, against which Trust performance is measured, defined as a number or as a percentage. Note that if there is no defined national of local standard for an indicator, this section will be blank.

Committee RESPONSIVENESS: INDICATOR

Format

(no./%) Source Standard Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18

Last

Month

Mar 18

This

month

Apr 18

From last

month

From

April '17

1 2 3 4 5

Change Performance Score

6 7 8

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6 Months to date This section (of 13 columns) shows details of trust performance against the standard, by month. The end column of this section shows the most recent month’s data available for the reporting period covered by the board report. Each performance report will show data over a rolling 13 month period (i.e. the most recent month’s data followed by data for the previous 12 months). Note that the figure shown in each box is colour coded green or red, based on relative performance against its respective indicator. This is as follows: Indicates that Trust performance for that month met the required standard (defined in column 5) Indicates that Trust performance for that month did not meet the required standard (defined in column 5)

7 Change The two columns in this section provide a visual indicator showing how the most recent month’s performance compares against (i) the previous month; and (ii) from the position at the start of the previous 12 month period. The arrow symbols indicate the following: Represents comparative increase Represents no change Represents comparative decrease

8 Performance Score

The performance score section (containing three columns) has been developed by the Trust to give a locally defined relative assessment of the current month’s performance against the relevant standard for each indicator. The “score” is highlighted by an indicator in one of three categories. These are described below:

Performance is meeting and exceeding the required standard.

Performance is meeting the required standard, but is at or near to the desired threshold for this standard. The threshold for this indicator has been set locally by the Trust and, where applied, is indicator specific. Any indicator which falls into this category will be accompanied by an exception report in the narrative section which accompanies the performance dashboard.

Performance is below the required performance standard. Any indicator which falls into this category will

be accompanied by an exception report in the narrative section which accompanies the performance dashboard.

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Executive Summary

The A&E 4 hour continues to be a challenge, underperformance is flow constraints in the trust, late decisions being made either by ED or

specialties and waiting for blood results/or scan reports.

Performance against RTT standards continue to underperform and remains subject common variation and consistent in performance. The Trust

continues to achieve no 52 week waits.

Cumulative sickness absence (rolling 12 month period) remains the same as previous month 82% - in month sickness has slightly increased

from 3.89% to 4.02%.

The Trust continues to support on the completion of appraisals and all directorates have achieved the minimum target of 85% compliance for

statutory and mandatory training.

HSMR (56 Diagnosis Groups) for the period May18 – April19 is 115.9 (higher than expected). The Trust is anticipating HSMR will remain higher than expected for several months to come however HSMR has been reducing slowly for the last 7 months. However, SHMI has improved and now within the expected range nationally.

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Director of Operations

Operations Responsive Change Performance

Score

Cmte Indicator Format Source Stnd Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Apr 19 May 19 Jun 19 Jul 19 Aug 19 Latest Month

Latest Month Last Year

FPC Total time spent in A&E - % within 4 hours % National 95 % 90.27 % 87.94 % 86.31 % 83.60 % 78.24 % 77.95 % 77.06 % 80.28 % 84.15 % 80.88 % 79.02 % 76.83 % 85.47 % 82.94 %

FPC Ambulance Handover - handovers >60 minutes no. National 0 6 6 7 3 26 42 17 43 16 13 29 7 7 8

FPC 12 Hour Trolley Waits no. National 0 0 0 0 1 11 0 11 2 3 15 7 4 0 1

FPC Delayed Transfers of Care % National 4 % 2 % 1.95 % 1.62 % 2.59 % 2.60 % 2.27 % 1.64 % 4.02 % 2.13 % 2.58 % 3.71 % 3.73 % 3.47 % 1.63 %

FPC Urgent Operations Cancelled for 2nd Time no. National 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

FPC Patients not treated within 28days of last minute cancellation no National 0 4 0 0 0 0 0 3 0 0 4 0 0 1 4

FPC Cancer 14 Day Target - Suspected cancers* % National 93 % 97.95 % 97.25 % 96.31 % 97.46 % 96.98 % 97.26 % 92.80 % 93.66 % 96.94 % 96.04 % 97.83 % 94.59 %

FPC Cancer 14 day Target for Symptomatic Breast (Cancer not suspected) * % National 93 % 91.49 % 95 % 98.88 % 94.02 % 95.12 % 93.97 % 82.10 % 93.13 % 94.83 % 93.80 % 95.45 % 94.68 %

FPC Cancer 31 day subsequent treatment - Surgery* % National 94 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 %

FPC Cancer 31 day subsequent treatment - Anti Cancer Drug* % National 98 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 %

FPC Cancer 31 Day Target* % National 96 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 %

FPC Cancer Overall achievement- 62 day target* % National 85 % 72.46 % 78.85 % 66.67 % 72 % 76.67 % 82.22 % 67.35 % 87.50 % 73.02 % 84.06 % 74.67 % 80.28 %

FPC Cancer Overall achievement- 62 day National Screening Programme** % National 90 % 33.33 % 100 % 100 % 83.33 % 100 % 100 % 100 % 88.89 % 100 % 100 % 83.33 % 100 %

FPC Cancer pathway patients waiting over 104 days* no. National 0 10 15 11 5 5 8 10 12 11 9 5 10

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Operations Responsive (continued) Change Performance

Score



FPC 18wks RTT % Incomplete pathways <18 weeks % National 92 % 80.75 % 78.63 % 78.41 % 81.62 % 84.77 % 83.67 % 84.41 % 83.65 % 82.52 % 82.27 % 84.02 % 82.11 % 81.45 % 79.38 %

FPC 18wks RTT patients waiting >=52 weeks (at end of month) no. National 0 5 4 7 7 0 0 0 0 0 0 0 0 0 0

FPC 18wks RTT patients backlog >=18 weeks (at end of month) no. National 2,250 2,438 2,364 1,938 1,606 1,591 1,549 1,647 1,788 1,834 1,692 1,921 2,043 2,410

FPC 18wks RTT change in backlog no. National 0 190 188 -74 -426 -332 -15 -42 98 141 46 -142 229 122 489

FPC Diagnostics: Seen % within 6 weeks % National 99 % 99.92 % 98.72 % 96.80 % 99.54 % 100 % 99.88 % 100 % 99.39 % 99.96 % 99.44 % 98.10 % 99.60 % 99.16 % 99.02 %

Operations Effective Change Performance

Score



FPC A&E Unplanned Re Attendance Rate % National 5 % 2.34 % 2.27 % 2.56 % 2.24 % 2.39 % 2.30 % 1.82 % 1.89 % 1.81 % 1.94 % 2.10 % 2.21 % 2.37 % 2.47 %

FPC A&E Left department without being seen % National 5 % 1.85 % 1.55 % 1.55 % 1.66 % 1.70 % 1.74 % 1.53 % 1.64 % 1.15 % 1.45 % 1.60 % 1.86 % 1.70 % 1.68 %

FPC Stroke - The number (percentage) of people who are admitted to hospital following a stroke, who then spend 90% of their time on a Stroke unit.

% National 80 % 70 % 68.75 % 66.67 % 80.95 % 38.46 % 52.94 % 66.67 % 75 % 59.09 % 85 % 62.96 % 36.84 % 75 % 75 %

FPC Emergency readmissions within 30 days following an elective or emergency spell at the trust % National 8.77 % 8.96 % 8.11 % 7.60 % 6.66 % 8.02 % 7.16 % 6.93 % 6.74 % 6.81 % 7.24 % 7.47 % 7.86 % 8.53 %

Operations Caring Change Performance

Score



FPC Operations cancelled on the day % National 8 % 0.31 % 1.92 % 1.40 % 1.81 % 1.74 % 1.01 % 2.03 % 1.28 % 1.93 % 1.08 % 1.72 % 0.13 % 2.75 % 2.25 %

FPC Day Case Rates % Trust 85 % 92 % 91.38 % 90.98 % 90.73 % 91.67 % 93.75 % 93.75 % 85.56 % 88.03 % 90.91 % 94.51 % 92.13 % 95.15 % 92.11 %

FPC Length of Stay - Elective no. Trust 3 2 2 3 3 3 2 2 2 2 2 2 3 2

FPC Length of Stay - Emergency no. Trust 5 5 6 5 6 6 6 6 6 6 6 6 5 6

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Total time spent in A&E - % within 4 hours

Standard: 95 % Actual: 82.9 %

Accountability: Stephen Collman, Director of Operations Committee: FPC

What is driving the underperformance? Actions completed from last month to achieve recovery? Underperformance is flow constraints in the trust, late

decisions being made either by ED or specialties and waiting for blood results/or scan reports

Introduction of 9 by 10am process

MIST (Extend Minor Injuries See & Treat) has commenced

% Standard Actual Score

Jul 18 95.0 90.3

Aug 18 95.0 87.9

Sep 18 95.0 86.3

Oct 18 95.0 83.6

Nov 18 95.0 78.2

Dec 18 95.0 78.0

Jan 19 95.0 77.1

Feb 19 95.0 80.3

Mar 19 95.0 84.2

Apr 19 95.0 80.9

May 19 95.0 79.0

Jun 19 95.0 76.8

Jul 19 95.0 85.5

Aug 19 95.0 82.9

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Lead: What actions are being taken in the next month: Stephen Collman Action

Introduce direct GP referrals to SAU

Continue to work towards GPAU and frailty capacity being available 7 days a week

Trial separating the streaming and triage process

Review MIST opening times

Timescale October 2019

Commenced

October 2019

October 2019

Timeframe for recovery:

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Ambulance Handover - handovers >60 minutes

Standard: 0 Actual: 8


What is driving the underperformance? Actions completed from last month to achieve recovery? Capacity within the Emergency department

Lead: What actions are being taken in the next month: Action

Introduction of Rapid Assessment and Treatment (RAT) with a Doctor, band 5 and HCA using PDSA methodology



no. Standard Actual Score

Jul 18 0 6

Aug 18 0 6

Sep 18 0 7

Oct 18 0 3

Nov 18 0 26

Dec 18 0 42

Jan 19 0 17

Feb 19 0 43

Mar 19 0 16

Apr 19 0 13

May 19 0 29

Jun 19 0 7

Jul 19 0 7

Aug 19 0 8

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12 Hour Trolley Waits



What is driving the underperformance? Actions completed from last month to achieve recovery?

Lack of capacity in the hospital with all available capacity open Harm review was completed and no harm was recorded

All DTAs were reviewed following the breach

Introduction of 9 by 10am following ECIST visit

no. Standard Threshold Actual Score

Jul 18 0 0 0

Aug 18 0 0 0

Sep 18 0 0 0

Oct 18 0 0 1

Nov 18 0 0 11

Dec 18 0 0 0

Jan 19 0 0 11

Feb 19 0 0 2

Mar 19 0 0 3

Apr 19 0 0 15

May 19 0 0 7

Jun 19 0 0 4

Jul 19 0 0 0

Aug 19 0 0 1

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Lead: What actions are being taken in the next month:

Action

Daily management of demand

Continue to work towards GPAU and frailty capacity being available 7 days a week

Timescale

Commenced

Commenced


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Patients not treated within 28days of last minute cancellation



What is driving the underperformance? Actions completed from last month to achieve recovery? Emergency pressures resulting in elective procedures being

cancelled including emergency demand in Orthopaedics

Lead: What actions are being taken in the next month: Action

Robust process to be in place to ensure patients cancelled on the day are rebooked within 28 days



no Standard Threshold Actual Score

Jul 18 0 0 4

Aug 18 0 0 0

Sep 18 0 0 0

Oct 18 0 0 0

Nov 18 0 0 0

Dec 18 0 0 0

Jan 19 0 0 3

Feb 19 0 0 0

Mar 19 0 0 0

Apr 19 0 0 4

May 19 0 0 0

Jun 19 0 0 0

Jul 19 0 0 1

Aug 19 0 0 4

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Cancer Overall achievement- 62 day target*



What is driving the underperformance? Actions completed from last month to achieve recovery? Histopathology delays

Capacity issues (diagnostics)

Reliance on Tertiary provision

Oncology capacity (SLA with UHCW)

GEH in various specialty not following EAG/best practice pathways

Additional 2WW capacity been actioned for Breast and Gynaecology (on-going)

Weekly review meeting with Director of Operations for long waiters

Radiology task and finish group commenced to work through mitigations to improve radiology turnaround times for test and reporting

Histopathology delays escalated at HCP Cancer Board from all three trusts

% Standard Threshold Actual Score

Jul 18 85.0 90.0 72.5

Aug 18 85.0 90.0 78.9

Sep 18 85.0 90.0 66.7

Oct 18 85.0 90.0 72.0

Nov 18 85.0 90.0 76.7

Dec 18 85.0 90.0 82.2

Jan 19 85.0 90.0 67.4

Feb 19 85.0 90.0 87.5

Mar 19 85.0 90.0 73.0

Apr 19 85.0 90.0 84.1

May 19 85.0 90.0 74.7

Jun 19 85.0 90.0 80.3

Jul 19 85.0 90.0 78.3

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Tracker posts recruitment to be progressed once funding confirmation received

Gynaecology workshop in place to be held in September to look at mitigations to improve performance across the STP

On-going actions as above

Pathway reviews to start

Timescale September 19

September 19

September 19


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Cancer pathway patients waiting over 104 days*



What is driving the underperformance? Actions completed from last month to achieve recovery? Histopathology delays

Late referrals to Tertiary providers Additional 2WW capacity been actioned for Breast and

Gynaecology (on-going)


Gynaecology workshop in place to be held in September to look at



Jul 18 0 0 10

Aug 18 0 0 15

Sep 18 0 0 11

Oct 18 0 0 5

Nov 18 0 0 5

Dec 18 0 0 8

Jan 19 0 0 10

Feb 19 0 0 12

Mar 19 0 0 11

Apr 19 0 0 9

May 19 0 0 5

Jun 19 0 0 10

Jul 19 0 0 10

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mitigations to improve performance across the STP

Pathway reviews to start

September 19


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18wks RTT % Incomplete pathways <18 weeks

Standard: 92% Actual: 79.4 %


What is driving the underperformance? Actions completed from last month to achieve recovery? Emergency pressures resulting in elective procedures being

cancelled including emergency demand in Orthopaedics

Reduction in activity due to annual leave during this period

Consultant in Oral Surgery on long term sick

Capacity issues in key services

Ongoing management of long waiters at the weekly PTL meeting

Training on Access policy commenced

Sourced a Locum for Urology


Jul 18 92.0 80.8

Aug 18 92.0 78.6

Sep 18 92.0 78.4

Oct 18 92.0 81.6

Nov 18 92.0 84.8

Dec 18 92.0 83.7

Jan 19 92.0 84.4

Feb 19 92.0 83.7

Mar 19 92.0 82.5

Apr 19 92.0 82.3

May 19 92.0 84.0

Jun 19 92.0 82.1

Jul 19 92.0 81.5

Aug 19 92.0 79.4

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Urology Locum starting

External validation continues


Commenced


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18wks RTT change in backlog




Emergency pressures resulting in elective procedures being cancelled including emergency demand in Orthopaedics

Reduction in activity due annual leave during this period

Consultant in Oral Surgery on long term sick

Capacity issues in key services

Ongoing management of long waiters at the weekly PTL meeting

Training on Access policy commenced

no. Standard Actual Score

Jul 18 0 190

Aug 18 0 188

Sep 18 0 -74

Oct 18 0 -426

Nov 18 0 -332

Dec 18 0 -15

Jan 19 0 -42

Feb 19 0 98

Mar 19 0 141

Apr 19 0 46

May 19 0 -142

Jun 19 0 229

Jul 19 0 122

Aug 19 0 489

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Stephen Collman Action

Urology Locum starting

External validation continues

Timescale

October 2019 Commenced


Reduction in waiting list from March 2019 to be achieved in March 2020

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Stroke - The number (percentage) of people who are admitted to hospital following a stroke, who then spend 90% of their

time on a Stroke unit.

Standard: 80% Actual: 75.0 %


What is driving the underperformance? Actions completed from last month to achieve recovery? Capacity on the unit not being available


Jul 18 80.0 86.0 70.0

Aug 18 80.0 86.0 68.8

Sep 18 80.0 86.0 66.7

Oct 18 80.0 86.0 81.0

Nov 18 80.0 86.0 38.5

Dec 18 80.0 86.0 52.9

Jan 19 80.0 86.0 66.7

Feb 19 80.0 86.0 75.0

Mar 19 80.0 86.0 59.1

Apr 19 80.0 86.0 85.0

May 19 80.0 86.0 63.0

Jun 19 80.0 86.0 36.8

Jul 19 80.0 86.0 75.0

Aug 19 80.0 86.0 75.0

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Continue with direct admission to Felix when assessment bed available hour pathway

Timescale Commenced


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Medical Director

Format EFFECTIVE

Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Apr19 May19 Jun 19 Jul 19 Aug 19

Latest period 12 months

ago Standard

no HSMR Dr Foster 121.9 Jul17- Jun18

121.2 Aug 17- Jul 18

122.1 Sept 17- Aug 18

121.9 Oct17-Sept18

123.5 Nov17-Oct18

123.6 Dec17 – Nov 18

122.3 Jan18 – Dec18

120.9 Feb18 – Jan19

120.0 Mar18 –

Feb19 117.2

Apr18 – Mar19

115.9 May18- Apr19

Latest Data May18- Apr19

120.2 Jun17- May18

100 National Benchmark

% HSMR Crude Mortality as Percentage of Discharges

5.8 5.8 5.9 5.8 5.7 5.7 5.5 5.6 5.6 5.4 5.3 5.3 5.8 3.2

National Average

% Hospital Standardised Mortality Ratio – Weekend

132.0 Jul17- Jun18

135.3 Aug17- Jul18

130 Sept17- Aug18

134.7 Oct17-Sept17

134.1 Nov17-Oct18

133 Dec17 – Nov 18

133.2

Jan18 – Dec18

127.9 Feb18 – Jan19

126.6 Mar18 –

Feb19 128.1

Ap18 – Mar19

127.4 May18- Apr19

Latest Data May18- Apr19

129.0 Jun17- May18

100 National HSMR

no SHMI by publication date (End date of reported period shown in brackets)

112

Apr17– Mar 18

114

Jul7– Jun 18

114

Oct17– Sept18

118

Jan18– Dec18

115

Feb18– Jan19

112

Apr18– Mar19

100 National

Benchmark

*Please note the latest data at the time of wiring this report is May18-April19 HSMR is 115.9

Medicine - Change Performance

Score

Cmte Indicator Format Source Stnd Jul 18 Aug 18

Sep 18

Oct 18

Nov 18

Dec 18

Jan 19

Feb 19

Mar 19

Apr 19

May 19

Jun 19 Jul 19

Aug 19

Latest Month


QAC National Never Events no. National 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0

QAC WHO compliance with surgical checklist-completed % National 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 %

QAC S.I.R.I's no. National 0 6 5 3 5 3 2 5 7 2 2 7 0 1 2

QAC VTE Risk Assessment % National 95 % 94.49 %

91.40 %

93.30 %

93.30 %

92.60 %

92.50 %

90.71 %

92.30 %

88.60 %

91.94 %

90.84 %

93.78 %

94.20 %

91.40 %

QAC Number of Deaths in Hospital no. 62 58 50 57 53 61 83 75 52 69 58 68 61 63

QAC Number of Deaths in Emergency

Department no. 3 2 6 5 8 5 7 7 9 3 3 4 6 10

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Headlines

HSMR (56 Diagnosis Groups) for the period May18 – April19 is 115.9 (higher than expected). HSMR has been reducing slowly since February 2019 and it is anticipated that HSMR should come within the expected range within the next few months if this trend continues

Published SHMI for the latest period April 18 – March 19 is 112, Band 2 Within the expected range. SHMI is no longer an outlier

Diagnosis groups within the HSMR basket highlighted as outliers (with more than 10 deaths) include: UTI and Fluid and electrolyte disorders. SHMI outliers include: UTI

The Trust continues to participate in LeDeR reviews and attends Regional Meetings

The Trust attended the Coventry & Warwickshire Oversight Group

No Never Events were reported in August 2019

There were 2 SIRIs reported in August related to sub-optimal care of the deteriorating patient & Maternity/Obstetric Incident - Baby

VTE risk assessment has not achieved the target threshold of 95%. The VTE tasks and finish group continue to work on improvements with support from the transformation team. The new VTE electronic risk assessment tool has been developed and demonstrated to key clinicians. Implementation is expected later this year

What went well

SHMI has improved and now within the expected range nationally

A new pictorial dashboard/newsletter has been developed to improve learning from mortality reviews across the Trust. The first edition is due to signed off at the MDPG in September 2019

Medical Examiner had a meeting with the Coroner’s Office to discuss progress and gain feedback

Medical Examiners are in place and the referral of cases for review to M&M’s or for RCA is becoming more robust

SJR’s continue to be completed and themes shared across the Trusts. Examples of Poor and Excellent care are discussed at the MDPG and copies sent to parent teams and clinical directors for discussion at M&M

Good progress made against the Mortality Strategy and improvement plan. Reported at MDPG and QAC

Collaborative working with SWFT on the Child Death Review Process

The ‘Review of Harm’ group chaired by the Medical Director/ Associate Medical Director to review incidents continues to be successful and the team are reviewing incidents on a weekly basis

Compliance with WHO surgical checklist. WHO compliance is monitored and reported through the Operational Quality & Safety Committee. What was off plan

VTE risk assessment target has not been achieved. VTE steering group are cited on the decline and working through the action plan to try and address the gap. A new VTE pro-forma is in circulation. A VTE report on progress made is due to be presented in September’s QAC

HSMR for the reporting period continues to be a national outlier. It is anticipated that this may come within expected range if the HSMR continues to fall as it has done over the last 7 consecutive months

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Director of Nursing

Nursing - Caring Change Performance

Score



QAC Single Sex Accommodation no. National 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

QAC Dementia Screening - Emergency adm aged 75+* % National 90 % 81.54 % 87.50 % 77.25 % 80 % 95.05 % 97.32 % 98.10 % 97.86 % 97.27 % 97.20 % 97.30 % 100 % 100 %

QAC Deteriorating patient – good response (sample audit of patients with MEWS of 3 and more) % National 95 % 91 % 90.47 % 85 % 86 % 100 % 96 % 100 % 96 % 100 % 86 % 100 % 67 % 77 % 80 %

Nursing - Safe Change Performance

Score



QAC Clostridium Difficile - Hospital Acquired no. National <12 (Mar19) 0 4 0 0 1 1 1 1 3 3 4 0 0 1

QAC MRSA Screening Elective % National 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 100 % 99 % 100 % 99 % 100 % 100 %

QAC MRSA Bacteraemia - Post 48 hours apportioned to the trust no. National 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

QAC E.Coli Pre 48 hours no. National <104 (Mar 19) 12 23 12 11 11 9 13 12 6 12 10 14 18 16

QAC E.Coli Post 48 hours no. National <14 (Mar 19) 2 1 2 0 0 3 0 3 0 1 0 1 1 2

QAC Gram negative bacteraemia (pseudomonas,e-coli and klebsiella) pre 48hrs no. National 18 30 16 13 14 11 15 14 9 14 17 14 21 19

QAC Gram negative bacteraemia (pseudomonas,e-coli and klebsiella) post 48hrs no. National 3 1 2 0 0 4 1 3 0 1 0 1 1 2

QAC Gram negative bacteraemia (pseudomonas,e-coli and klebsiella) overall no. National 21 31 18 13 14 15 16 17 9 15 17 15 22 21

QAC Safety Thermometer - Acute only Overall % % National 98 % 96.60 % 96.01 % 94.64 % 95.41 % 95.85 % 96.18 % 94.24 % 96.07 % 96.47 % 97.32 % 95.92 % 96.98 % 97.08 % 96.23 %

QAC Safety Thermometer - Acute & Community Overall % % National 95 % 89.43 % 92.39 % 88.21 % 88.34 % 89.97 % 90.97 % 90.51 % 91.48 % 92.23 % 90.94 % 91.16 % 92.62 % 93.43 % 89.38 %

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Nursing - Safe (continued) Change Performance

Score



QAC Falls (per 1000 bed days) no. National 3.9 4.94 5.24 6.07 4.85 6.02 7.64 6.10 3.72 3.19 4.43 3.54 5.32 5.79 4.72

QAC Falls no. National 36 36 55 44 54 68 61 32 30 40 33 48 54 41

QAC Falls resulting in severe harm or injury no. National 0 0 3 0 2 1 1 4 0 0 1 4 0 1 0

QAC Pressure Ulcers - Number of avoidable pressure ulcers grade 2, 3 and 4 confirmed by SIG no. National 0 1 0 2 0 1 1 0 0 0 0 0 0 0 0

QAC Monthly prevalence of the harms reported on safety thermometer - Pressure Ulcers - Acute only % National 1.3 % 2.64 % 3.26 % 3.93 % 3.18 % 2.77 % 2.43 % 4.41 % 3.93 % 2.12 % 2.35 % 3.40 % 2.35 % 1.82 % 3.80 %

QAC Care Quality Indicator % Trust 91 % 89 % 90 % 88 % 88 % 90 % 89 % 89 % 89 % 91 % 91 % 92 % 89 % 91 % 92 %

QAC Cleaning Standards overall % Trust 95 % 95 % 95.50 % 91 % 96 % 93 % 89 % 95 % 95 % 95 % 97.50 % 98 % 98.80 % 98.10 % 98.73 %

QAC Maternity-C Sections - High Impact Actions for Nursing & Midwifery % Trust 27 % 29.05 % 24.30 % 27.91 % 25 % 26.77 % 25.91 % 26.04 % 28.24 % 31.55 % 28.48 % 26.55 % 28.57 % 27 % 41.31 %

QAC Number of hospital births no. National 159 218 217 164 199 194 194 173 170 172 179 191 200 216

QAC Maternity Still Births no. National 1 0 0 0 0 1 1 0 1 0 0 0 0 2

QAC Maternity Neonatal Deaths no. National 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Nursing - Well Led Change Performance

Score



QAC Friends & Family Test - Inpatient Response Rate* % National 20 % 19.60 % 19.30 % 20.60 % 39.80 % 40.10 % 34.10 % 30.10 % 27.90 % 30.70 % 30.20 % 29.10 % 32.50 % 29.70 % 34.40 %

QAC Friends & Family Test - Inpatient Recommenders Rate* % National 98 % 97 % 96 % 93 % 92 % 88 % 90 % 90 % 92 % 89 % 90 % 85 % 90 % 86 %

QAC Friends & Family Test - A&E Response Rate* % National 20 % 26 % 22.90 % 23.80 % 30.60 % 26.80 % 22.40 % 25.50 % 27 % 24.70 % 22.70 % 24 % 19.70 % 21.70 % 24.30 %

QAC Friends & Family Test - A&E Recommenders Rate* % National 86 % 86 % 86 % 87 % 84 % 86 % 87 % 88 % 88 % 87 % 85 % 85 % 86 % 86 %

QAC Friends & Family Test - Maternity Response Rate* % National 16 % 44.10 % 31 % 36.40 % 37.90 % 40.50 % 29.90 % 37.10 % 40.30 % 38.70 % 19.20 % 24.90 % 35.50 % 43 % 36.70 %

QAC Friends & Family Test - Maternity Recommenders Rate* % National 92 % 93 % 93 % 95 % 96 % 94 % 96 % 96 % 89 % 97 % 95 % 89 % 93 % 88 %

28 | P a g e

Nursing - Governance Change Performance

Score



QAC CQC Condition or Warning Notices no. National 0 by Q4 0 0 0 0 0 0 0 0 0 0 0 0 0 0

QAC Complaints responded to within 25 working days (month in arrears) % Contract 90 % 71 % 80 % 80 % 83 % 82 % 67 % 65 % 59 % 40 %

QAC Medication errors causing severe or moderate harm no. Trust 0 0 1 1 0 0 0 0 0 0 0 3 0 0 0

QAC CAS alerts outstanding (overdue) no. National 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

29 | P a g e

Deteriorating patient – good response (sample audit of patients with MEWS of 3 and more)


Accountability: Daljit Athwal, Director of Nursing Committee: QAC

What is driving the underperformance? Actions completed from last month to achieve recovery? Failure to recognize deteriorating patient

Escalation process not always adhered to

Patients not always having their observations repeated and a sepsis screen within an hour

Sepsis nurse reviewed how data is collected; now reviewing patients with a NEWS of >7 who were previously stable. Randomly selecting patients throughout the month rather than on one day

Trust has purchased 85 new observations machines


Jul 18 95.0 91.0

Aug 18 95.0 90.5

Sep 18 95.0 85.0

Oct 18 95.0 86.0

Nov 18 95.0 100.0

Dec 18 95.0 96.0

Jan 19 95.0 100.0

Feb 19 95.0 96.0

Mar 19 95.0 100.0

Apr 19 95.0 86.0

May 19 95.0 100.0

Jun 19 95.0 67.0

Jul 19 95.0 77.0

Aug 19 95.0 80.0

30 | P a g e

Lead: What actions are being taken in the next month: Barry O’Keefe Action

Relaunch SBAR to coincide with the distribution of observation screens

Launch campaign similar to the NEWS-2 programme


Timeframe for recovery: Quarter 4

31 | P a g e

Safety Thermometer - Acute only Overall %

Standard: 98 % Actual: 96.2%



Increase in pressure damage

Patient admitted with symptoms of PE technically not hospital harm but required to be reported as such on safety thermometer

Work undertaken as part of pressure ulcer and falls prevention

Link day held in September


Libby Holland Action

Revised trajectory to be agreed

Timescale

1st October 2019



Jul 18 98.0 98.5 96.6

Aug 18 98.0 98.5 96.0

Sep 18 98.0 98.5 94.6

Oct 18 98.0 98.5 95.4

Nov 18 98.0 98.5 95.9

Dec 18 98.0 98.5 96.2

Jan 19 98.0 98.5 94.2

Feb 19 98.0 98.5 96.1

Mar 19 98.0 98.5 96.5

Apr 19 98.0 98.5 97.3

May 19 98.0 98.5 95.9

Jun 19 98.0 98.5 97.0

Jul 19 98.0 98.5 97.1

Aug 19 98.0 98.5 96.2

32 | P a g e

Safety Thermometer - Acute & Community Overall %

Standard: 95 % Actual: 89.4%



Community pressure sores increased Work undertaken as part of pressure ulcer and falls prevention

Link day held with nursing home and community teams invited


Jul 18 95.0 96.0 89.4

Aug 18 95.0 96.0 92.4

Sep 18 95.0 96.0 88.2

Oct 18 95.0 96.0 88.3

Nov 18 95.0 96.0 90.0

Dec 18 95.0 96.0 91.0

Jan 19 95.0 96.0 90.5

Feb 19 95.0 96.0 91.5

Mar 19 95.0 96.0 92.2

Apr 19 95.0 96.0 90.9

May 19 95.0 96.0 91.2

Jun 19 95.0 96.0 92.6

Jul 19 95.0 96.0 93.4

Aug 19 95.0 96.0 89.4

33 | P a g e


Libby Holland Action

Revised trajectory to be agreed

Timescale

1st October 2019


Q3/4

34 | P a g e

Falls (per 1000 bed days)

Standard: 3.9 Actual: 4.7


What is driving the underperformance? Actions completed from last month to achieve recovery? Patient multifactorial risk assessment partially completed

resulting in reduced identification of patients at risk of falls.

Handover not identifying patients at risk.

Leaving patient whilst in the toilet or on the commode due to privacy and dignity.

Falls champion meeting held Falls coordinators visited colleagues at SWFT


Jul 18 3.9 3.5 4.9

Aug 18 3.9 3.5 5.2

Sep 18 3.9 3.5 6.1

Oct 18 3.9 3.5 4.9

Nov 18 3.9 3.5 6.0

Dec 18 3.9 3.5 7.6

Jan 19 3.9 3.5 6.1

Feb 19 3.9 3.5 3.7

Mar 19 3.9 3.5 3.2

Apr 19 3.9 3.5 4.4

May 19 3.9 3.5 3.5

Jun 19 3.9 3.5 5.3

Jul 19 3.9 3.5 5.8

Aug 19 3.9 3.5 4.7

35 | P a g e

Lead: What actions are being taken in the next month: Caroline Hughes Libby Holland Julie Brown

Action

Falls awareness week

Approval given for purchase of Hover jack

Timescale 23rd September

October 2019

Timeframe for recovery: Q3/4

36 | P a g e

Monthly prevalence of the harms reported on safety thermometer - Pressure Ulcers - Acute only

Standard: 1.30% Actual: 3.8%


What is driving the underperformance? Actions completed from last month to achieve recovery? Staff not using preventative measures when delivering oxygen

therapy Water low scoring has been amended for the new Trust

documentation to assist in ease of calculation.

Lead: What actions are being taken in the next month: Lorraine Thursby Action

Trial of O2 cannula with built in ear guards on CCU and Nason


Timeframe for recovery: Q3/4


Jul 18 1.3 1.1 2.6

Aug 18 1.3 1.1 3.3

Sep 18 1.3 1.1 3.9

Oct 18 1.3 1.1 3.2

Nov 18 1.3 1.1 2.8

Dec 18 1.3 1.1 2.4

Jan 19 1.3 1.1 4.4

Feb 19 1.3 1.1 3.9

Mar 19 1.3 1.1 2.1

Apr 19 1.3 1.1 2.4

May 19 1.3 1.1 3.4

Jun 19 1.3 1.1 2.4

Jul 19 1.3 1.1 1.8

Aug 19 1.3 1.1 3.8

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Maternity-C Sections - High Impact Actions for Nursing & Midwifery

Standard: 26.50 % Actual: 41.3 %



Noticeable increase in caesarean sections from March to date spilt into elective and emergency. Increase in induction rate has seen an increase in emergency caesarean rates. Induction rate has increased nationally due to ‘Saving Babies Lives’ and increased awareness around small for gestation age being detected.

Caesarean rates are reviewed monthly

Escalation of increased rates to CD


Jul 18 26.5 25.0 29.1

Aug 18 26.5 25.0 24.3

Sep 18 26.5 25.0 27.9

Oct 18 26.5 25.0 25.0

Nov 18 26.5 25.0 26.8

Dec 18 26.5 25.0 25.9

Jan 19 26.5 25.0 26.0

Feb 19 26.5 25.0 28.2

Mar 19 26.5 25.0 31.6

Apr 19 26.5 25.0 28.5

May 19 26.5 25.0 26.6

Jun 19 26.5 25.0 28.6

Jul 19 26.5 25.0 27.0

Aug 19 26.5 25.0 41.3

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Lydia Thomas

Donna Edgar

Action

Meeting arranged to complete audit/deep dive

Timescale

27th September 2019

Timeframe for recovery: Q4

39 | P a g e

Director of HR

Headlines

Turnover, statutory and mandatory training and Consultants have maintained performance within target. Vacancy and sickness rates show a

deteriorating position. Appraisal rates remain static and are below target.

What went well

Turnover continues on a downward trajectory. All directorates have achieved the minimum target of 85% compliance for statutory and

mandatory training.

What was off plan

Appraisal figures remain at 82% and four Directorates are below 85% with two directorates showing a reduction in their performance in month 5

taking them further below the Trust target.

HR - Change Performance

Score

Cmte Indicator Format Source Stnd Jul 18 Aug 18

Sep 18

Oct 18

Nov 18

Dec 18

Jan 19

Feb 19

Mar 19

Apr 19

May 19

Jun 19 Jul 19

Aug 19

Latest Month


WDC Turnover Rate (rolling year; excluding M&D staff group) % Trust <13.5% 12.60

% 14.26

% 13.64

% 14.03

% 13.69

% 14 % 14.10 %

13.68 %

12.76 %

13.02 %

13.05 %

12.87 %

11.50 %

11.29 %

WDC Vacancy rate % % Trust <=10% 11 % 10.90 % 10 % 11 % 9 % 9 % 10 % 10 % 10 % 10 % 11 % 11 % 10 % 11 %

WDC Sickness Absence Rate (%) In Month* % Trust <=4% 3.08 % 2.92 % 3.71 % 4.28 % 3.75 % 4.61 % 5.10 % 4.53 % 3.98 % 4.11 % 4.26 % 4.02 % 3.89 % 4.02 %

WDC Sickness Absence Rate (%) Cumulative (last 12 months)* % Trust <=4% 4.18 % 4.13 % 4.23 % 4.32 % 4.27 % 4.34 % 4.34 % 4.32 % 4.30 % 4.30 % 4.32 % 4.32 % 4.32 % 4.34 %

WDC Staff who have received

PDP/Appraisal (rolling 12 month period) (%)

% Trust EOY >85% 89 % 87 % 86 % 86 % 85 % 82 % 82 % 79 % 79 % 81 % 80 % 79 % 82 % 82 %

WDC Consultants who have received PDR (rolling 12 month period) (%) % Trust EOY

>85% 95 % 96 % 97 % 96 % 88 % 94 % 94 % 94 % 94 % 90 % 87 % 91 % 91 % 91 %

WDC Statutory Training Compliance (Rolling 12 months period)(%) % National EOY

>85% 93 % 91 % 91 % 91 % 91 % 90 % 90 % 90 % 89 % 90 % 91 % 91 % 91 % 91 %

WDC Statutory and Mandatory Training(CSTF) % National EOY

>85% 87 % 87 % 88 % 89 % 90 % 90 % 90 % 89 % 89 % 90 % 90 % 90 % 91 % 91 %

40 | P a g e

Vacancy rate %


Accountability: Sue Wakeman, Director of HR Committee: FPC

What is driving the underperformance? Actions completed from last month to achieve recovery? Urgent and Emergency Care Corporate

A number of departments have moved out of the Urgent and Emergency Care directorate.

One of these departments is over established and the figures will have distorted overall figures for this directorate previously.

This is why we now see a doubling of the vacancy figures for this area.

This figure is mainly affected by high vacancies for A&E Medical & Nursing staff.


Jul 18 10.0 11.0

Aug 18 10.0 10.9

Sep 18 10.0 10.0

Oct 18 10.0 11.0

Nov 18 10.0 9.0

Dec 18 10.0 9.0

Jan 19 10.0 10.0

Feb 19 10.0 10.0

Mar 19 10.0 10.0

Apr 19 10.0 10.0

May 19 10.0 11.0

Jun 19 10.0 11.0

Jul 19 10.0 10.0

Aug 19 10.0 11.0

41 | P a g e

Lead: What actions are being taken in the next month: Matron for A&E.

AMD for Medicine/CD for Urgent & Emergency Care.

Action

Management of Change process has commenced in two corporate functions that will lead to restructuring and recruitment campaigns that will reduce vacancies.

Recruitment event for nurses planned this month to fill vacancies.

Medical staff vacancies are currently

being addressed through: o UK and overseas doctors

taking part in a clinical rotation programme.

o Access to clinical attachments to improve overall experience e.g. shadowing of Urgent Care GPs.


.

September 2019

Ongoing

Timeframe for recovery: To be set through individual IQPM (Integrated Quality and Performance Meetings) at directorate level depending on their overall performance

against workforce KPIs

42 | P a g e

Sickness Absence Rate (%) In Month*



What is driving the underperformance? Actions completed from last month to achieve recovery? Four directorates contribute to high sickness levels for both KPIs as last month. They are:

Women and Children – both long term sickness is the key contributor

Technical – short term sickness is the key contributor

Urgent & Emergency Care – short term sickness is key contributor Corporate - both long term sicknesses is the key contributor

Urgent and Emergency Care have seen a 2.57% increase since last month in their in month sickness

Again, the operational re-structure has highlighted where reporting previously may not have given a true picture for some of the workforce KPIs at directorate level

In month sickness remains the main indicator attracting HR support as this contributes to success with other sickness KPIs

Workshops for first line supervisors taking place for hot spot areas.

HR follow up meetings with managers in hot spot areas to maintain momentum and support

Monthly sickness case management meeting between all HR staff to identify key themes, complex cases, and areas requiring their attention


Jul 18 4.0 3.1

Aug 18 4.0 2.9

Sep 18 4.0 3.7

Oct 18 4.0 4.3

Nov 18 4.0 3.8

Dec 18 4.0 4.6

Jan 19 4.0 5.1

Feb 19 4.0 4.5

Mar 19 4.0 4.0

Apr 19 4.0 4.1

May 19 4.0 4.3

Jun 19 4.0 4.0

Jul 19 4.0 3.9

Aug 19 4.0 4.0

43 | P a g e

Lead: What actions are being taken in the next month: Dedicated HR support and General Managers and Matrons for

each directorate

Action

Training across teams and

departments continues

Support meetings take place at

team and department level with

HR.

HR Business Partners to provide

support at directorate level with

senior management teams;

advising on how and where further

improvements can be made.

Timescale Ongoing

Ongoing

Ongoing



44 | P a g e

Staff who have received PDP/Appraisal (rolling 12 month period) (%)

Standard: 85% Actual: 82.0%


What is driving the underperformance? Actions completed from last month to achieve recovery? Older Adults and Medicine (now combined for reporting

purposes). Urgent and Emergency care Surgery Technical Corporate

Additional Appraisal training is being provided

Drop in sessions have been arranged to support appraisers

Appraisee workshops are ongoing

The OD function is providing more resources to appraisers and appraisees on appraisal preparation

More signposting of resources has been developed


Jul 18 85.0 89.0

Aug 18 85.0 87.0

Sep 18 85.0 86.0

Oct 18 85.0 86.0

Nov 18 85.0 85.0

Dec 18 85.0 82.0

Jan 19 85.0 82.0

Feb 19 85.0 79.0

Mar 19 85.0 79.0

Apr 19 85.0 81.0

May 19 85.0 80.0

Jun 19 85.0 79.0

Jul 19 85.0 82.0

Aug 19 85.0 82.0

45 | P a g e

Lead: What actions are being taken in the next month: Head of OD/HR Business Partners/ General and Divisional Managers Action

Upskilling and cascade opportunities to be considered at local/team levels to increase the levels of supervisors who can carry out appraisals on staff.

Inclusion of appraisals in advance rota planning.

Timescale September/October



46 | P a g e

Director of Finance

Financial Dashboard - August 2019NHSI Plan

September October November December January February March April May June July

2018 2018 2018 2018 2019 2019 2019 2019 2019 2019 2019

(1.860)

(7.207)

0.000

1.426

1.448

Statutory Duties

(14.276) (14.276) (14.276) (14.276) (14.276) (15.543) 0.000

16.283 16.283 16.283 16.283 15.006 15.006 14.876 8.515 8.515 6.319 6.319 6.319 16.283 14.876

8.443 8.443 6.340 6.340 5.773 5.172 5.172 9.556 9.556 7.360 7.360 7.360 8.443 5.172

*18/19 Forecast of £15.543m includes PSF finance performance income of £2.955m, but not recovery of the PSF A&E performance income of £1.267m.

The capital plan has been revised as per NHSI requirement for the STP to reduce capital spend to within capital allocation. This has resulted in a £2.196m reduced forecast for capital expenditure and the associated loan requirement.

Break Even

(2.195)

(4.669)

0.000

1.154

0.786

0.000 0.000

Q1 19/20

(3.171)

(3.171)

0.000

1.120

1.009

EFL

CRL

Trend

To plan

To plan

To plan

Q3 18/19

(14.276)

1.357

3.169

(14.276)

16.283

8.443

(13.671)

(5.279)

Q4 18/19

(1.820)

(15.492)

(15.543)

1.307

4.985

(15.543)

Standard

To plan

(1.694)

(10.086)

(14.276)

(0.409) (2.009)

(12.095)

(14.276)

(8.392)

(1.576)

(13.671)

(14.276)

To plan

Last Year

Aug 18

(1.907)

0.647 1.009

2.566

(15.492)

(15.543)

(2.175)

(5.345)

0.000

5.932

1.276

(2.474)

0.000

1.307

4.985

(15.543)

1.281

2.192

1.357

0.000

1.154

£'m Forecast I&E

Going Concern position

£'m Forecast Loan Requirement

£'m Forecast Capital

(1.562)

(14.276)

0.898

2.544

Format WELL LED

£’m Forecast*

£'m Capital Spend (Cumulative)

Origin

£’m Cash (Closing Balance)

£’m Cumulative Surplus / (Deficit)

£’m Surplus / (Deficit)

1.850

(14.276)

1.919

1.882 3.169

(15.578)

(15.543)

1.204

3.451

(2.474)

Q2 18/19

(3.467)

(8.392)

(14.276)

1.919

1.8821.219

1.498

(3.171)

0.000

This

Month

Aug 19

1.120

(14.276) 0.000

8.515

9.556

0.000

(2.479)

(18.057)

(15.543)

1.153

3.533

(14.276)

(7.983)

16.283

8.443

August 2019 - George Eliot Hospital · The A&E 4 hour continues to be a challenge, underperformance...

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