1

Outcome: 1. Staying Healthy Latest Performance

Page Lead Director

1.1 Measure: Immunisation Data To Be Developed

75% uptake of influenza vaccination among - Over 65s To Be Developed 4Director of Public Health

75% uptake of influenza vaccination among - Under 65s in at risk groups To Be Developed 4Director of Public Health

50% uptake of influenza vaccine among Clinical Staff 50.2% 4Director of Public Health

95% Vaccination of all children to age 4 with all scheduled vaccines To Be Developed 5Director of Public Health

Outcome: 2. Safe Care Latest Performance

Page Lead Director

2.1 Measure: Hospital Acquired InfectionsTo Be Developed 6

Director of Therapies, Health Science, Quality & Safety

2.2 Measure: Compliance with Hand Hygiene (WHO 5 Moments)To Be Developed 7

Director of Therapies, Health Science, Quality & Safety

2.3 Measure: Number of Patients with Acquired Pressure Damage who are Powys Residents

To Be Developed 8Director of Therapies, Health Science, Quality & Safety

2.4 Measure: Pressure Damage Incidents Originating Outside Powys.To Be Developed 9

Director of Therapies, Health Science, Quality & Safety

2.5 Measure: Medical Device IncidentsTo Be Developed 10

Director of Therapies, Health Science, Quality & Safety

2.6 Measure: Falls DataTo Be Developed 11

Director of Therapies, Health Science, Quality & Safety

2.7 Measure: Falls DataTo Be Developed 12

Director of Therapies, Health Science, Quality & Safety

2.8 Measure: Risk Management PerformanceTo Be Developed 13

Director of Therapies, Health Science, Quality & Safety

Quality Key Performance Indicators: March 2015

2

Outcome 2: Safe Care Latest Performance

Page Lead Director

2.9 Measure: Risk Management PerformanceTo Be Developed 14

Director of Therapies, Health Science, Quality & Safety

2.10 Measure: Medicine IncidentsTo Be Developed 15 Medical Director

2.11 Measure: Wye Valley InformationTo Be Developed 16

Director of Planning?

2.12 Measure: Shrewsbury & Telford Hospitals NHS TrustTo Be Developed 17

Director of Planning

Outcome 3: Effective Care Latest Performance

Page Lead Director

3.1 Measure: Emergency Readmissions for Chronic ConditionsTo Be Developed 18

Medical Director

3.2 Measure: Powys Inpatient Crude Mortality RatesTo Be Developed 19

Medical Director

3.3 Measure: Powys residents who died whilst receiving in-patient care.To Be Developed 20

Medical Director

Outcome 4: Dignified Care Latest Performance

Page Lead Director

4.1 Measure: Patient Experience SurveyTo Be Developed 21

Director of Therapies and Health Science

4.2 Measure: Redress Data and ThemesTo Be Developed 22

Director of Therapies and Health Science

4.3 Measure: Complaints DataTo Be Developed 23

Director of Therapies and Health Science

3

Outcome 5: Timely Care Latest Performance

Page Lead Director

5.1 Measure: Waiting Times Target To Be Developed24

Director of Planning

5.2 Measure: Waiting Times Target in A & E: To Be Developed25

Medical Director

5.3 Measure: Diagnostic & Therapy Services Waiting Times To Be Developed26

Director of Therapies & Health Sciences

5.4 Measure: Mental Health Waiting Times To Be Developed27

Nurse Director

5.5 Measure: Cancer Referral to Treatment Targets (Welsh Providers)

To Be Developed28

Director of Planning

5.6 Measure: Cancer Referral to Treatment Targets (English Providers).

To Be Developed29

Director of Planning

5.7 Measure: Opening Hours of GP Surgeries To Be Developed31

Medical Director

5.8 Measure: Ambulance Response Times, Category A To Be Developed32

Medical Director

5.9 Measure: Patient Transport Data To Be Developed33

Medical Director

Outcome 6. Individual Care Latest Performance

PageLead Director

6.1 Measure: Improvement in Delayed Transfers of Care (DTOC) Delivery (Rate per 10,000 Population.)

To Be Developed34

Nurse Director

4

Outcome 7. Our Staff and Resources Latest Performance

Page Lead Director

7.1 Measure: Staff IncidentsTo Be Developed 35

Director of Therapies & Health Sciences

7.2 Measure: Staff Incidents, To Be Developed 36

Director of Therapies & Health Sciences

7.3 Measure: % of Staff Appraisals completed within last 12 months. Target of 85% for staff excluding Medical staff.

To Be Developed 37Director of Workforce and OD

7.4 Measure: IQT Bronze & Silver LevelTo Be Developed 38

Director of Workforce and OD

7.5 Measure: Statutory and Mandatory Training ComplianceTo Be Developed 39

Director of Workforce and OD

1. Staying Healthy

Key Messages/Themes:

GP practices are continuing to vaccinate vulnerable patients against flu. Powys’ uptake for patients aged over 65 years and those aged under

65 at clinical risk is below that of Wales average, but similar to uptake in 2013-14. GP Practices have received feedback of their uptake rates.

Uptake for all pregnant women is above Wales’ average, although rates for pregnant women at risk (49.1%) is below Wales’ position (61.9%).

Focused work is being undertaken by the midwifery team to follow up all pregnant women on an individual basis, to ensure that this is

addressed. Staff uptake rates are higher than Wales’ average. Staff with direct patient contact are exceeding the target at (50.4%).

A review of the 2014/15 flu season is being planned, in order to strengthen the planning for 2015/16.

.

1.1 Measure: Immunisation Data

Data Currently Available: Jan 2015Data Source: IPR Jan 2015; PHW - National Weekly Summary of Flu Immunisation 24/12/2014

Measure: 75% uptake of influenza vaccination among Over 65’s, Under 65’s in at risk groups & pregnant women. 50% among health care workers

5

Categorised % Uptake of Influenza Immunisation- Target 75%

1. Staying Healthy

Key Messages/Themes:

To meet the Tier 1 target in Q3 2014, we would have needed 20 additional children to be up to date with all three scheduled vaccinations by the

age of 4 years. The target may not be met even if the 95% target was met for each of the three individual component vaccinations that make up

the overall target.

There is a focus in the Powys Vaccination Plan on actions to increase uptake in pre-school children, including:

- a focus on improved intelligence on local uptake levels, increased local ownership of the Tier 1 target and increased collaborative working

between primary care professionals such as GPs and Health Visitors.

-Ensuring that best practice is being followed, by undertaking an audit of the Child Health Immunisation Process Standards.

1.1 Measure: Immunisation Data

Data Currently Available: Quarter 3 2014-2015Data Source : Public Health Wales COVER 112 published December 2014.Measure: Childhood Immunisation uptake for resident children getting the 4 in 1 pre – school booster, the

Hib/ MenC booster and second MMR dose by four years of age.Measure: 95% uptake of scheduled immunisations for children under 4 years

6

2. Safe Care

Key Messages/ThemesNursing and domestic cleaning schedules are now being used organisation wide, with the support of the Infection Prevention & Control Nurse (IPCN) and Facilities Manager (FM). IPCN joins the FM in Environmental Cleanliness Audits and reports are fed back to high level management with any concerns. This really has raised to profile of cleaning within the organisation and is at the forefront of everyone’s minds. Ward management are now involved on the audits along with senior nurses and locality management. There is now stronger communication with estates, on the back of these audits, meaning that problems are solved in a more efficient and timely manner. The engagement of the whole organisation in all matters IPC is now apparent. The healthboard held a successful IPC study day in February for the whole of the organisation (clinical and ancillary staff) with guest speakers from WG, PHW and ABUHB, subjects-environmental cleanliness, MRSA/C diff awareness, safe sharps, CAUTI, Datix reporting, hand hygiene. The aim was to heighten awareness, enthuse and promote collaborative working between staff groups. There have been no incidences of MRSA/MSSA reported to date during 2014- 2015.

2.1 Measure: Healthcare Associated Infections

Data Currently Available: Feb 2015Data Source : IFOR This data does not show infection cases which initially occur outside Powys healthcare. Due to submissions and validation figures

may change retrospectively. Future reports will always show the latest standpoint at the date the report was run.

7

Healthcare Associated Infections (Norovirus/D & V Outbreak)

Hospital EpisodesTotal Number of Persons Affected

Number of Days Ward Closed to New

Admissions

1st Quarter 2014-2015 0 0 0

2nd Quarter 2014-2015

1 4 7

3rd Quarter 2014-2015

2 4 0

2. Safe Care

Key Messages/Themes: Completeness and Gaps in DataThis is for 2 reasons: (i) Training needs- in that staff were undertaking the audits but unable to upload results to Fundamentals of Care. These results have now been backfilled retrospectively. (ii) Key people that undertake the audits were on annual/sick leave. These issues are being addressed by the study day noted below and by validation audits by the Infection Prevention & Control Nurse (IPCN.)ValidityFrom the information in the table above it would seem that PTHB has a very high mean compliance rate. However, when the IPCN has carried out standard precaution audits and hand hygiene checks on the wards, the picture is quite different. The IPCN audits compliance rates were found to be significantly lower. There are several reasons as to why this could be the case. Firstly, staff carrying out audit are not familiar with the “5 Moments” and are not conducting audits accurately. Secondly, as staff carry out audits on their own wards the question of bias may be an issue. In order to address both of these areas a PtHB wide Study day has been organised. The study will include training around the “5 moments” together with how to audit, how to report and why this is so important. Also, it is important that staff do not audit their own wards, along with the IPCN carrying out periodic checks around scoring. These actions will ensure that completeness and bias are addressed. It is important that compliance is accurately reported in order to ensure our patients are looked after in safe environments where hand hygiene is seen as a priority and these audits are taken seriously. Therefore, it is expected that there will be a drop in the compliance figures initially from Jan 15 whilst the above is addressed.

2.2 Measure: Compliance with Hand Hygiene (WHO 5 Moments)

Data Currently Available: Feb 2015Data Source: Powys Teaching Health Board.

8

Month Llewellyn

Ward

Epynt Ward Y Bannau Graham

Davies

Claerwen

Ward

Twymyn

Ward

Brynheulog

Ward

Maldwyn

Ward

Adelina Patti

Ward

Powys tHB

Monthly

Average

Apr-14 90.00% 92.31% 100.00% 100.00% 100.00% 90.00% 100.00% 90.00% 90.48% 94.1%

May-14 100.00% 95.65% 100.00% 100.00% 100.00% no data 100.00% 100.00% n/a 99.4%

Jun-14 100.00% 100.00% 85.71% 100.00% 100.00% 100.00% 100.00% 100.00% 94.12% 96.5%

Jul-14 100.00% 95.45% 100.00% 100.00% 95.45% 90.00% 100.00% 100.00% 90.48% 96.9%

Aug-14 100.00% 100.00% 100.00% 100.00% 100.00% no data 100.00% 80.00% 90.48% 96.5%

Sep-14 100.00% 73.81% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 90.00% 93.4%

Oct-14 100.00% 77.42% 78.57% 100.00% 95.00% 100.00% 100.00% 85.00% 85.71% 90.2%

Nov-14 100.00% 43.48% 100.00% 100.00% 95.83% 100.00% 100.00% 90.00% 85.71% 90.7%

Dec-14 100.00% 83.33% 96.00% 100.00% 96.55% 96.00% 100.00% 85.00% 85.00% 93.9%

Jan-15 90.00% 33.33% 59.26% 100.00% 97.37% 100.00% 100.00% 95.00% 85.00% 87.4%

Feb-15 85.00% 75.00% 91.67% 100.00% 56.00% 91.67% 100.00% 95.00% no data 85.0%

Source: Powys Teaching Health Board Qualtiy and Saftey

Individual Ward Compliance with Hand Hygiene (WHO 5 moments)

2. Safe Care

Key Messages/Themes:The data demonstrates pressure damage only that has either developed under our service provision or the service provision we commission through external Trusts and

Health Boards. It does not currently include pressure damage reported in Residential Home / Nursing Homes. The data also does not include incidents of pressure

damage we are asked to manage in the community that arose beyond the sphere of our care.

It is notable that the level of pressure damage within our community hospitals ranges between 2 and 9 reports per month and within this data the number of patients

reporting pressure damage grade 3 and above has proportionally reduced. Our community teams who are reporting pressure damage under their care ranges from 3 to

11 reports per month. There has been a reduction in pressure damage reported as originating within the DGH compared to 2013/14 however the proportion of grade 3

and above pressure damage within these has not seen a reduction.

2.3 Measure: Number of Patients with Acquired Pressure Damage who are Powys Residents

Data Currently Available: Feb 2015Data Source: Datix Risk Management System Powys tHB

9

2. Safe Care

Key Messages/Themes:In total there were 23 incidences of grade 3 pressure damage and 9 Incidences of Grade 4 pressure damage originating outside the Health Board premises between the 1st April 2014 and 30th Jan 2015. 19 of these were patients admitted from their own homes. Some of this activity will be monitored through the organisations contract/ commissioning meetings as we go forward with this work.Links are also being made with Tissue Viability Nurses from the various DGH’s to inform them if a pressure damage report has been received in to Powys via their DGH.

2.4 Measure: Pressure Damage Incidents Originating Outside Powys.

Data From: April 2014- Jan 2015Data Source: IFOR/Datix Risk Management System Powys tHB

10

0

1

2

3

Grade 3 Pressure Damage Originating Outside Powys : Apr 14- Jan 15(Trend line for Origin Patient Home Included)

Royal Shrewsbury Hospital

Cartreff Residential Home

Hereford County Hosp

Morriston

Nevill Hall

Patient's Home

Robert Jones and Agnes HuntOrthopaedics

Royal Gwent

Linear (Patient's Home) 0

1

2

Grade 4 Pressure Damage Originating Outside Powys : Apr 14- Jan 15

Patient's Home

Morriston

Royal ShrewsburyHospital

2. Safe Care

2.5 Measure: Medical Device Incidents

Data Currently Available: Apr 2012- Dec 2014Data Source: Datix Risk Management System Powys tHB

11

Key Messages/Themes:The data search displayed in the graph above has been run over the period First Financial Quarter 2012- 13 Third Financial Quarter 2014-15 to identify trends in medical devices reported incidents. Caution should be used due to the relatively low numbers of incidents involved. However, running the data set over a longer time does show a recent increase in both NRS issues and device failure.

0

2

4

6

8

10

12

14

16

18

12/13 Q1 12/13 Q2 12/13 Q3 12/13 Q4 13/14 Q1 13/14 Q2 13/14 Q3 13/14 Q4 14/15 Q1 14/15 Q2 14/15 Q3

Medical Devices Incidents by Adverse Event - Apr 2012- Dec 2014

Lack/unavailability of device

Wrong device/equipment used

HSDU Issue

Injury caused by medical device

Failure of a device or equipment

NRS Issue

Medical device/equipment - other

User error

2. Safe Care

Key Messages/Themes:The overall trend with inpatient falls is that they have reduced in volume over 2014/15 based on levels reported in 12/13 and 13/14 however

this is a picture of mixed improvement by inpatient sites with some sites demonstrating significant improvement in the number of falls

where other have not made much improvement. Within the number of falls the number of falls resulting in physical harm has also reduced

and this has been demonstrated across all sites, showing a greater improvement in harm caused by falls. It is not possible to mitigate

against all falls as the reason for falls are multi factorial, however in introducing falls measures through multi factorial interventions it is

possible to reduce the level of harm caused by falls and this data supports improvement in this respect.

2.6 Measure: Falls Data

Data Source: IFOR- Datix Risk Management System Powys tHBData: March 2015

12

Severity

of Fall

Brecon War

Memorial

Community

Hospital

Bro Ddyfi

Community

Hospital

(Machynllet

h Hospital)

Bronllys

Community

Hospital

Knighton

Community

Hospital

Knighton

Cottage

View

Llandrindo

d Wells

Community

Hospital

Llanidloes

Community

Hospital

MCI -

Newtown

Hospital

Welshpool

Hospital

Ystradgynla

is

Community

Hospital

No Injury42 5 27 9 2 18 11 20 28 5

Very Low6 4 3 6 5 12 12 15 13 2

Low26 12 13 10 4 15 2 8 18 6

Moderate3 5 6 8 0 10 8 3 12 4

Severe1 0 0 0 0 0 1 0 0 0

Death0 0 0 0 0 0 0 0 1 0

Total 2014-

2015 78 26 49 33 11 55 34 46 72 17

Number of Falls by Severity by Hospital by Financial Year - Source: Datix

2. Safe Care

Key Messages/Themes:The overall trend with inpatient falls is that they have reduced in volume over 2014/15 based on levels reported in 12/13 and 13/14 however

this is a picture of mixed improvement by inpatient sites with some sites demonstrating significant improvement in the number of falls

where other have not made much improvement. Within the number of falls the number of falls resulting in physical harm has also reduced

and this has been demonstrated across all sites, showing a greater improvement in harm caused by falls. It is not possible to mitigate

against all falls as the reason for falls are multi factorial, however in introducing falls measures through multi factorial interventions it is

possible to reduce the level of harm caused by falls and this data supports improvement in this respect.

2.7 Measure: Falls Data

Data Source: IFOR- Datix Risk Management System Powys tHBData: March 2015

13

0

20

40

60

80

100

120

2012-2013 2013-2014 2014-2015

Nu

mb

er

of

Pat

ien

t Fa

lls

Patient Falls by Site and Year Brecon War MemorialCommunity HospitalBro Ddyfi Community Hospital(Machynlleth Hospital)Bronllys Community Hospital

Builth Hospital

Knighton Community Hospital

Knighton Cottage View

Llandrindod Wells CommunityHospitalLlanidloes Community Hospital

MCI - Newtown Hospital

Park Street Clinic

Welshpool Hospital

Ystradgynlais CommunityHospital

2. Safe Care

Key Messages/Themes: The data search displayed in the graph above has been run over the period First Financial Quarter 2012- 13 Third Financial Quarter 2014-15.

2.9 Measure: Incidents Involving Patients

Data Source: Incidents Involving Patients Datix Risk Management System Powys tHB Data From: Apr 2012-Dec 2014 by Financial Quarter

14

0

100

200

300

400

500

600

12/13 Q112/13 Q212/13 Q312/13 Q413/14 Q113/14 Q213/14 Q313/14 Q414/15 Q114/15 Q214/15 Q3

Total Number of Incidents Involving Patients: Apr 2012-Dec 2014 by Financial Quarter

IncidentsInvolvingPatients

Linear (IncidentsInvolvingPatients)

Key Messages/Themes:This section is in its infancy and as commissioning arrangements strengthen it is hoped that more detailed information will be made available to Powys teaching Health Board. These figures apply to Powys residents treated/admitted to SATH.

2.8 Measure: Shrewsbury & Telford Hospitals NHS TrustData Source: SATH NHS Trust has provided the information belowData Sourced: 3rd Quarter 2014-2015

2. Safe Care

15

Third Quarter

2014-2015 Grade 1

Subcategory

FallsDelayed

OPD

Reported

SATH Serious

Incidents

Involving

Powys

Patients

2 1 1

Third Quarter

2014-2015Oct Nov Dec Total

Reported

SATH MRSA

Cases Involving

Powys Patients

2 2 2 6

Third Quarter

2014-2015Oct Nov Dec Total

Reported

SATH C.diff

Cases Involving

Powys Patients2 1 0 3

Key Messages/Themes

With the Chronic condition readmissions there is always a delay of at least 3 months as the data is reliant on coded episodes.

3.1 Measure: Emergency Readmissions for Chronic Conditions

Data Source: NWIS DatasetData Sourced: March 2015

3. Effective Care

16

Powys Residents Emergency Readmissions for Basket of 8 Chronic Conditions

(12 Month Rolling minus 3 months to allow for coding delays)

Key Messages/ThemesAs clearly can be seen from the graph the most significant factor in our crude mortality rate is the falling number of admissions to Powys wards. Staff shortages and refurbishment programs has meant that the tHB is caring for 10% fewer patients than 12 months previously. During this time however priority has been given to the admission of patients who require end of life palliative care. As can be seen by the lower yellow line total monthly deaths have remained essentially constant but the lower denominator has resulted in an increased mortality rate.Future trend: Crude mortality will continue to rise as the lower bed numbers work through the system.

3.2 Measure: Powys Inpatient Crude Mortality Rates

Data Source: IFORData Sourced Feb 2015

3. Effective Care

17

18

3.3 Measure: Powys residents who died whilst receiving in-patient care.Data Source: PTHB Information TeamData Sourced: Quarters 1-3: 2014-2015

Key Messages/Themes: Top 7

Between 1 April and Dec 2014 a total of 676 Powys residents died whilst receiving in-patient care. The majority of these deaths occurred in seven NHS Trust/Health Board locations:

Shrewsbury & Telford Hosp. Trust 191 deathsPowys tHB Community Hospitals 145 deathsWye Valley NHS Trust 141 deathsAneurin Bevan Univ. Health Board 85 deathsAbertawe Bro Morgannwg UHB 48 deathsHywel Dda Univ. Health Board 27 deathsCardiff & Vale UHB 7 deaths

* The figures on theses slides are totals and do not currently reflect the % rates i.e. the numbers of Powys inpatients admitted to each hospital

3. Effective Care

0

5

10

15

20

25

30

35

Dea

ths

Inpatient Mortality- Quarters 1-3: 2014-2015

Wye ValleyNHS Trust

Hywel DdaLocal HealthBoard

Cardiff & ValeUniversityLocal HealthBoard

Inpatient Mortality Quarters 1-3:2014-2015- Other Locations

Cwm Taf Local Health Board 5

Gloucestershire Hospitals NHS Foundation Trust 2

Heart Of England NHS Foundation Trust 1

NULL 1

Oxford Radcliffe Hospitals NHS Trust 1

Robert Jones & Agnes Hunt Orthopaedic & District Trust 1

Royal Free Hampstead NHS Trust 1

South Staffordshire & Shropshire Healthcare NHS Trust 1

The Royal Wolverhampton Hospitals NHS Trust 1

University Hospital Birmingham NHS Foundation Trust 3

University Hospital Of North Staffordshire NHS Trust 6

University Hospital Of South Manchester NHS Foundation Trust 1

Worcestershire Acute Hospitals NHS Trust 4

York Hospitals NHS Foundation Trust 1

Key Messages/Themes:

It was agreed the questionnaire would be given to all new referrals to the CMATS clinics held in Ystradgynlais during 1st July 2014 and 30th November 2014. The questionnaire was given to the patient at the end of their initial appointment and they were asked to return the completed questionnaire to the physiotherapy department. A total of 11 questionnaires were received.

The overall feedback was positive and all of the patients felt that people were always polite to them and that they were always listened to.

10 of the patients felt they were always given all the information they needed; 1 patient did not answer the question

All of the patients felt they were given enough privacy when they attended the clinic and that they always got assistance if they required it

In response to the question which asked them to rate their overall experience. 9 rated their experience as 10, being excellent and the remainder (2) rated their experience as 9.

The following comments were received in response to a question which asked patients to comment on anything particularly good about their experience:

• Speed and efficiency of service• Physio was pleasant• Good service• Fast referral and quick appointment• Very good service• Being made to understand how to prevent my injury from returning• Explanation of problem was quality (comforting)

There were no comments received on how to improve their experience.

4.1 Measure: Patient Experience SurveyData Source: CMATS = Clinical Musculoskeletal Assessment and Treatment ServiceData Sourced: Jan 2015

4. Dignified Care

19

Key Messages/Themes

Small numbers of moderate harm and above incidents are occurring

4.2 Measure: Redress Data and ThemesData Source: Datix Risk Management SystemData: Third Quarter 2014-2015

4. Dignified Care

20

Number of ‘Investigations’ that Identified an ErrorThird Quarter

2014-2015

Number of Moderate Harm, patient related incidents that under review 3

Number of Moderate Harm Incidents/Complaints that have been presented to the Redress Panel. 0

Number of those presented to Redress Panel identified as having a Breach of Duty which caused harm to the

patient. 0

Number of those presented to Redress Panel identified as having a Duty of Care but No Breach of Duty; 0

Number of those presented to Redress Panel which identified a Duty of Care and a Breach of Duty but the panel

concluded that this Breach did not cause the harm to the patient.0

Number of those presented to Redress Panel identified as having a Duty of Care where the Breach of Duty &/or

Causation is still to be determined or Further information required before the panel can reach a conclusion. 0

Number of incidents identified areas where lessons needed to be learnt and actions put in place. 0

4. Dignified Care

21

Category (Formal complaints) Qtr 1

1/4/14 to 30/6/14

(n)

Qtr 1

(%)

Qtr 2

1/7/14 to 30/9/14

(n)

Qtr 2

(%)

Qtr 3

1/10/14 to 31/12/14

(n)

Qtr 3

(%)

Cum

(n)

Cum

(%)

Total formal complaints received including commissioned services 39 n/a 47 n/a 46 n/a 132 n/a

Total formal complaints received excluding commissioned services ** 23 n/a 42 n/a 36 n/a 101 n/a

Complaints responded to in 30 working days (Powys led complaints) 3 13% 15 36% 10 28% 28 28%

Complaints responded to outside of 30 working days but within 6

months (Powys led complaints)

13 57% 6 14% 3 8% 22 22%

Complaints responded to beyond 6 months but less than 12 months 0 0 8 19% 0 0 8 8%

Complaints withdrawn/ Not pursued/ POVA 0 2 5% 1 3% 3 3%

On-going complaints marked as open within qualifying dates (Powys

led complaints)

7 30% 11 26% 22 61% 40 39%

Ongoing complaints marked as open (Powys led complaints) 28

(end of qtr 1)

n/a 39

(end of qtr 2)

n/a 45

(end of qtr 3)

n/a 45 n/a

Number presented to redress panel (Powys led complaints) 1 n/a 0 n/a 0 n/a 1 n/a

Key Messages/Themes: The Patient Experience/ Concerns team continue to work closely with the Localities to improve the quality and

timeliness of investigations so that the Health Board can improve on its response times. A Master class on investigating concerns is being organised for June 2015 and the target audience will include senior staff responsible for conducting

and approving investigation reports/ action plans/ draft responses

4.3 Measure: Complaints Data

Data Source: Datix Risk Management SystemData Sourced: Third Quarter 2014-2015

Key Messages/Themes:Weekly Waiting List meetings have been re-established to monitor and address RTT and follow up issues. The group is working to reduce all provider waits to 26 weeks by March 2015. The group covers all localities, therapy and health sciences and Women &Children’s Services. As well as looking at provider services, the reported position of commissioned services is also considered and appropriate action will be taken to reduce the waits, either through discussion with the provider or through securing alternative providers.

5.1 Measure: Waiting Times Target

95% of patients waiting less then 26 weeks for treatment with a maximum wait of 36 weeks (all Powys residents)

Data Source: NWIS; IPR March 2015Data Sourced: Jan 2015

5. Timely Care

22

*Aggregate RTT Performance for Powys Patients (Jan 2015)

Providers Under 26 Weeks 26 to 35 Weeks 36 to 51 Weeks 52 Weeks and

Over

Total

Welsh 92.0% 7573 5.1% 424 2.4% 197 0.5% 40 8234

English 92.4% 3437 4.9% 183 2.1% 78 0.6% 23 3721

Powys patient waiting "All Providers" 92.1% 11010 5.1% 607 2.3% 275 0.5% 63 11955

5. Timely Care

Key Messages/Themes

A&E - Powys as a provider are meeting the targets. The performance levels for the percentage of Powys patients being seen within 4 hours

vary considerably. Some of this variation is due to small numbers attending which can skew the percentages disproportionately as can the

influence of Powys MIUs on the case mix in neighbouring A&Es

5.2 Measure: Waiting Times Target in A & E: 95% of patients spend less than 4 hours in A&E from arrival until admission, transfer or discharge plus eradication of over 12 hour waits.

Data Source: Accident & Emergency: NWISData Sourced: Feb 2015

23

Number of patients

attending

% seen within 4

hrs

Number of patients

waiting over 4 hrs

Number of patients

waiting over 12 hrs

Number of patients

attending

% seen within 4

hrs

Number of patients

waiting over 4 hrs

% seen within 12

hrs

Number of patients

waiting over 12 hrs

211 86.73% 28 4 1812 91.11% 161 99.12% 16

7 100.00% 0 0 2594 82.65% 450 98.30% 44

144 58.33% 60 11 5751 65.54% 1982 92.40% 437

258 80.23% 51 17 3119 88.49% 359 96.70% 103

23 91.30% 2 0 3966 88.50% 456 98.87% 45

1 100.00% 0 0 3543 73.81% 928 93.08% 245

1 100.00% 0 0 5628 85.91% 793 96.57% 193

1 100.00% 0 0 4443 87.60% 551 98.29% 76

11 90.91% 1 0 9145 84.78% 1392 99.18% 75

2 100.00% 0 0 2711 76.69% 632 96.42% 97

19 78.95% 4 2 4629 71.61% 1314 94.88% 237

1 100.00% 0 0 3914 69.21% 1205 90.19% 384

0 0 3492 78.55% 749 93.24% 236

679 78.50% 146 34 54747 79.96% 10972 96.00% 2188

Number of patients

attending

% seen within 4

hrs

Number of patients

waiting over 4 hrs

Number of patients

waiting over 12 hrs

Number of patients

attending

% seen within 4

hrs

Number of patients

waiting over 4 hrs

% seen within 12

hrs

Number of patients

waiting over 12 hrs

364 99.73% 1 0 391 99.74% 1 100.00% 0

353 99.72% 1 0 367 99.73% 1 100.00% 0

255 100.00% 0 0 284 100.00% 0 100.00% 0

67 100.00% 0 0 108 100.00% 0 100.00% 0

1039 99.81% 2 0 1150 99.83% 2 100.00% 0

Number of patients

attending

% seen within 4

hrs

Number of patients

waiting over 4 hrs

Number of patients

waiting over 12 hrs

Number of patients

attending

% seen within 4

hrs

Number of patients

waiting over 4 hrs

% seen within 12

hrs

Number of patients

waiting over 12 hrs

1788 91.72% 148 34 67938 83.40% 11275 96.76% 2202

*The Total Major & Minor Sites in Wales figure will be consistently higher as we do not display non Powys minor site numbers and performance in

the above breakdown tables.

Powys Patients All Patients

% seen within 12

hrs

*Total Major & Minor Sites in Wales 98.10%

Victoria Memorial Hospital 100.00%

Ystradgynlais Community Hospital 100.00%

Total 100.00%

All Patients

Powys MIU Hospital Site's % seen within 12

hrs

Breconshire War Memorial Hospital 100.00%

Llandrindod Wells Hospital 100.00%

Ysbyty Gwynedd

Total 94.99%

Powys Patients

Withybush General Hospital 100.00%

Wrexham Maelor Hospital 89.47%

Ysbyty Glan Clwyd 100.00%

Royal Gwent Hospital 100.00%

The Royal Glamorgan Hospital 100.00%

University Hospital Of Wales 100.00%

Nevill Hall Hospital 93.41%

Prince Charles Hospital 100.00%

Princess Of Wales Hospital 100.00%

Bronglais General Hospital 98.10%

Glangwili General Hospital 100.00%

Morriston Hospital 92.36%

Unscheduled Care - Accident & Emergency Performance Emergency Department Dataset (EDDS) - 2015-02

Powys Patients All Patients

Non Powys Major Sites % seen within 12

hrs

Key Messages/Themes

• An option appraisal has been completed and a business case will be submitted to the executive team within the month for consideration in order to develop the service across Powys. While this is a longer term solution, it should help to address the waiting list in a sustainable way. In the short term, the teams are working to reduce the waiting lists and these continue to be monitored via the waiting list meetings.

• For non-obstetric ultrasound – this has been monitored closely through the waiting list meetings, with an action plan agreed with the Head of Service. Additional sessions have been agreed across Powys and it has been reported that the waits should hopefully return to below 8 weeks by the end of March.

5.3 Measure: Diagnostic & Therapy Services Waiting Times

Data Source: Myrddin & AuditData Sourced: Feb 2015

5. Timely Care

24

Diagnostic waits should be no more than 8 weeks

Therapy waits should be no more than 14 weeks

Key Messages/Theme:

Recovery Plan: i) £500,000 on-line CBT initiative being implemented; ii) improve information/awareness /appropriate sign-posting to £1.2m third sector services; iii) re-enforce Mental Health Measure Implementation Plan – including training; iv) ensure WTEs reported correctly; v) address particular issues with particular providers – BCUHB exceptionally low level of assessments (being re-checked/ sick leave?) – ABUHB low level of interventions on time; V) learn from CAMHS where intervention initiated following assessment vi) further roll-out access to psychological therapies when further funding available. - Analysis work performed has shown higher levels of referrals in Powys than in the rest of Wales. This may be due to the inclusion of Counselling in Powys Part 1 information. We will be reviewing Part 1 information by the end of this financial year.

5.4 Measure: Mental Health Waiting TimesData Source: Delivery Division, WG (Powys tHB), Data Sourced: Jan 2015

5. Timely Care

25

80% of assessments within 28 days following receipt of referral & 90% of therapeutic interventions following an assessment started/undertaken within 56 days by LPMHSS

Key Messages/Themes:Performance of Welsh providers should be viewed with caution as low numbers adversely affect statistics. Powys monitors the cancer pathways and raises any concerns in relation to delays in treatment with Welsh Providers directly case by case at the time the information is made available.Service or Capacity shortfalls that are identified through bullet point 1 are managed through the performance meetings.

5.5 Measure: Cancer Referral to Treatment Targets (Welsh Providers)

Data Source: South Wales Cancer Network, (12 month rolling) Data Sourced: February 2015

5. Timely Care

Total patients treated within 31 days 12 16 13 18 15 12 16 20 12 24 16 11

Number of patients breaching 0 0 0 1 0 1 1 0 1 1 3 1

Total patients treated within 62 days 4 2 5 11 7 4 7 8 7 11 5 3

Number of patients breaching 0 0 0 3 0 0 0 0 1 1 0 0

Key Messages/Themes:

Notes/Actions:

• Welsh Government has agreed that monitoring of English targets for Welsh Patients treated in England is an appropriate proxy for performance against

Welsh Government set targets, as it is not possible to directly convert data to Welsh Performance target as the inclusion criteria differ.

• Cancer performance is monitored through monthly contract meetings with providers and reasons for delays are being investigated.

• Powys monitors the cancer pathways and raises any concerns in relation to delays in treatment with English Providers directly case by case at the time

the information is made available.

• Service or Capacity shortfalls that are identified through bullet point 1 are managed through the performance meetings.

5.Timely Care

27

5.6 Measure: Cancer Referral to Treatment Targets (English Providers).Data Source: Open Exeter System, Data Sourced: Jan 2015

Key Messages/Themes

All GP surgeries in Powys are currently meeting the Tier 1 measure

5.7 Measure: Opening Hours of GP Surgeries

Data Source: Each GP Practice was contacted by the Primary Care department to confirm opening hours.Data Sourced: June 2014- Data updated annually

5. Timely Care

28

5.8 Measure: Ambulance Response Times, Category A

Data Source: WAST Performance: Stats Wales, Data Sourced: January 2015

5.Timely Care

29

Key Messages/Themes: The tHB has an Unscheduled Care Plan and Winter Plan that include immediate and strategic actions to manage

and modernise the unscheduled care pathway to assist in Ambulance Performance. The tHB participates in the new Emergency Ambulance

Service Commissioner arrangements.

:

Key Messages/Themes

Unfortunately due to staff shortages WAST were unable to deliver these statistics for this KPI. This will be followed through and additional detail added with time.

5.9 Measure: Patient Transport Data

Data Source: WAST Performance: Stats Wales, Data Sourced:

5.Timely Care

30

Under Construction

Key Messages/Themes:Non Mental Health - Our expectation over the issues around access to home care were that they would have been resolved by the autumn this year and September time however the transfer to the new contracting arrangements which caused the significant rise in DToC over the last 2 years seems to have not made the recovery we had expected and there has only been slow progress with small pockets of success. To resolve this issue PtHB has been holding 3 conference calls per week with our LA colleagues to ensure that patients are being prioritised and even with this level of scrutiny the ability of the home care providers in having the capacity to meet the needs of our patients has been severely tested. We remain hopeful that as capacity comes on line the DToC numbers will decrease, it has and is taking much longer than expected.

Mental Health - DtOC from all providers are now being reported. Discussion in LTA meetings and weekly telephone conference where necessary. Issue of the policy being applied to Powys residents by external providers

6. Individual Care

31

6.1 Measure: Improvement in Delayed Transfers of Care (DTOC) Delivery (Rate per 10,000 Population.)

Data Source: DTOC Stats Wales

Data Sourced: Jan 2015

Key Messages/Themes:A Datix search was undertaken to identify staff incidents between April 2012- Dec 2014. The data was manipulated in an excel spreadsheet to identify incidents in key areas of (i) Manual Handling/ Musculoskeletal Incidents (ii) Sharps & Infection Control Incidents (iii) Road Traffic Accidents in Course of Delivering Care (iv) Slips, Trips & Falls Incidents (v) Security Incidents (vi) Environment/ Infrastructure Incidents (vii) Equipment Related Incidents (viii) Waste Management Incidents. All categories except violence and aggression show a quarterly total of less than 8. Over the period the overall trend analysis for violence and aggression shows a gradual decrease in the number of incidents reported. However, over the first 3 quarters of 2014-2015 the trend has been upwards. Closer analysis reveals that this has been due to an increase in the category of physical abuse, assault or violence during the 3rd Quarter of 2014-2015. These incidents involved inpatients and were due to their clinical condition. One difficult to manage patient generated six individual incidents of physical abuse, assault or violence during this quarter.

7.1 Measure: Staff Incidents- Violence & Aggression

Data Source: Datix Risk Management SystemData Sourced: April 2012- Dec 2014

7. Our Staff and Resources

32

0

5

10

15

20

25

30

35

40

45

12/13 Q1 12/13 Q2 12/13 Q3 12/13 Q4 13/14 Q1 13/14 Q2 13/14 Q3 13/14 Q4 14/15 Q1 14/15 Q2 14/15 Q3

Total Violence & Aggression Incidents Involving Staff : April 2012- Dec 2014 by Financial Year & Quarter

Total Violence &Aggression Incidents

Linear (Total Violence& Aggression Incidents)

7. Our Staff and Resources

33

Key Messages/Themes:Due to the Tier 1 Delivery Framework, from April 2014 the way Powys reports its PADR performance has changed. The requirement is for

PADR’s to be split into staff excluding medical and medical staff undertaking PADR. Due to this the we have started a new graph with the

current target.

Staff Excluding Medical - Monthly reports issued to every Appraiser as well as performance reports to Executive Management Team and to

Localities and Directorates. Following July report, Workforce and OD Business Partners are reviewing each appraiser who isn't on target and

agreeing an action plan for improvement, with a prioritised focus on those with lowest compliance.

Medical Staff - Monthly reports issued to every Appraiser as well as performance reports to Executive Management Team and to Localities

and Directorates. System of reporting appraisal activity into ESR is being put into place to update performance at the end of September. Not all

Appraisals are recorded in a timely way on ESR and we have picked up some omissions when comparing with other data e.g. GP Appraisal

system. We are confident that this figure is actually higher due to non-recording of appraisals within ESR.

7.2 Measure: % of Staff Appraisals completed within last 12 months. Target of 85% for staff excluding Medical staff.Data Source: Electronic Staff Record, Data Sourced: Feb 2015

Key Messages/Themes: Successful Silver level project have included:

•To reduce the number of inappropriate interruptions to patient services team in Llandrindod Hospital by 90% in 6 months•The adaption of the National Early Warning Score methodology for use in a Community Hospital setting•To make 100% of patients discharged from the Powys Stroke/ Neuro-rehab service aware of further relevant services that are available to them. •Reducing falls in the ward bathroom/toilet area to zero for patients who take up the option of support in bathing and toileting•Prudent Insulin Ordering: Reducing medication waste in residential homes.There are also 10 Silver Projects that are planned to be submitted Easter 2015

7.3 Measure: IQT Bronze & Silver Level

Data Source: Electronic Staff Record Data Sourced: February 2015

7. Our Staff and Resources

34

Directorates/LocalitiesImproving Quality

Together –Bronze Level %

Corporate 13.33%

Directorate of Finance 51.52%

Directorate of Medical Services 58.93%

Directorate of Nursing Services 35.90%

Directorate of Planning 84.00%

Directorate of Primary & Community Care 11.43%

Directorate of Therapies 42.86%

Directorate of Workforce & OD 81.08%

Mid Locality Management 51.95%

North Locality Management 22.88%

South Locality Management 42.86%

Women & Children Directorate 47.66%

Grand Total 41.16%

Directorates/ LocalitiesImproving Quality

Together -Silver Level

Corporate (PMU Unit) 1

Directorate of Nursing Services 1

Directorate of Therapies 1

Directorate of Workforce & OD 4

Medical Directorate 1

Mid Locality 1

North Locality 1

South Locality 2

Grand Total 12

Key Messages/ Themes: There have been problems experienced across the NHS in Wales regarding the interface between Moodle (the e-learning platform) and the Electronic Staff record (ESR). E-Learning reporting is currently uploaded from Moodle through to ESR and the link has not be functioning fully. As a consequence, the table above may show an under reporting of compliance.

7.4 Measure: Statutory and Mandatory Training Compliance

Data Source: Electronic Staff Record- M&S Training Report Feb 2015 Data Sourced: February 2015

7. Our Staff and Resources

35

Directorates/LocalitiesInformation

Security Guidelines

Fire Safety Induction

Treat Me Fairly

Health & Safety

Violence and Aggression

Infection Prevention & Control

Safeguarding Adults

Safeguarding Children

Manual Handling

Improving Quality

Together -Bronze Level

Resuscitation Average %

Corporate 13.33% 13.33% 0.00% 20.00% 6.67% 13.33% 6.67% 13.33% 6.67% 13.33% 0.00% 8.89%

Directorate of Finance 21.21% 27.27% 24.24% 27.27% 27.27% 27.27% 0.00% 12.12% 24.24% 51.52% 15.15% 21.46%

Directorate of Medical Services 16.07% 48.21% 33.93% 50.00% 55.36% 50.00% 1.79% 58.93% 51.79% 58.93% 1.79% 35.57%

Directorate of Nursing Services 41.03% 58.97% 38.46% 43.59% 30.77% 38.46% 10.26% 35.90% 43.59% 35.90% 12.82% 32.48%

Directorate of Planning 80.00% 64.00% 48.00% 76.00% 68.00% 76.00% 0.00% 44.00% 64.00% 84.00% 12.00% 51.33%Directorate of Primary & Community Care 17.14% 22.86% 14.29% 14.29% 11.43% 11.43% 0.00% 14.29% 42.86% 11.43% 8.57% 14.05%

Directorate of Therapies 28.57% 23.81% 9.52% 14.29% 4.76% 9.52% 19.05% 28.57% 28.57% 42.86% 0.00% 17.46%

Directorate of Workforce & OD 67.57% 67.57% 62.16% 64.86% 51.35% 56.76% 0.00% 51.35% 51.35% 81.08% 29.73% 48.65%

Mid Locality Management 44.92% 80.47% 49.22% 64.45% 54.69% 64.45% 11.72% 48.05% 66.02% 51.95% 22.27% 46.52%

North Locality Management 22.37% 45.24% 24.42% 46.27% 40.62% 44.22% 11.05% 40.10% 62.72% 22.88% 15.68% 31.30%

South Locality Management 30.99% 64.41% 28.57% 48.91% 39.23% 48.18% 10.41% 23.00% 56.90% 42.86% 10.65% 33.68%

Women & Children Directorate 45.79% 58.41% 44.39% 60.75% 58.41% 54.67% 6.07% 81.31% 58.41% 47.66% 22.43% 44.86%

Grand Total 33.86% 57.93% 33.79% 51.21% 44.29% 49.12% 9.07% 41.88% 57.66% 41.16% 15.53% 36.29%