Trust Quality and Performance Report

31 January 2014(December Performance Pack)

Contents

1

Slide numbers

Executive Summary  2 - 4

Clinical Quality Priorities inc Ward Dashboard 5 - 13

Local Priorities 14 - 21

Monitor Compliance 22

Contract Priorities 23 - 28

Executive Summary

This commentary provides an overview of key issues during the month and highlights where performance fell short of the target values as well as areas of improvement and noticeable good performance.

1.A&E Performance for December was 96.78%, quarterly performance was 96.9%; the highest in the Region and second quarter in a row that the Trust has achieved the target. Year to date performance is now also above 95%.

2.There were three cases of C.Diff in December against the threshold of two. This is covered within the quality report. The Trust met the Q3 ceiling with five cases in the quarter (ceiling of five). The YTD position is 21 cases against a year end ceiling of 19.

3.The Trust failed one Stroke performance measure in December. See page 4.

4.Performance on outpatient and inpatient discharge summaries remains below target. In addition to previous actions, further PMO support to this target has been introduced. Further details on page 3.

5.Performance on MRSA screening of emergency admissions was 97% against the 100% target. This is covered on page 12 of this report.

6.The Trust failed the 28 day re-booking target with one patient not offered a new date for surgery within 28 days of being cancelled on the day. See page 4.

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3

Executive Summary

Performance Indicator Threshhold December Lead Executive

Discharge Summaries - Outpatients 95% sent to GP’s within 3 days 87.07% Dermot O’Riordan

The Medical Director has sent a reminder to medical staff on the importance of sending outpatient letters on time via the Medical Staff Bulletin in January. The Medical Director is continually monitoring the performance of individual consultants against this target.

Performance Indicator Threshhold December Lead Executive

Discharge Summaries - Inpatients 95% sent to GP’s within 1 day 78.35% Dermot O’Riordan

PMO initiated in early January, a daily floor-walking or telephoning exercise to all wards to investiagate what the root cause of why the summaries are outstanding, work to find solutions for delays with operational colleageus and to raise awareness of the importance of this indicator. To this end a ‘discharge summaries’ article has been published in the Green Sheet with the aim of improving Trust performance. IT related issues regarding Cardiology have been resolved. Issues still to be resolved: Evidence shows that not all doctors are prioritising discharge summaries; discharge summaries are not completed for patients whose operation is cancelled on day of surgery or for those last on the surgery list; EPRO is expecting a discharge summary for patients transferred to another hospital or ward. However, we anticipate improvement in performance next month with the steps taken so far.

Performance Indicator Threshhold December Lead Executive

Sickness absence rate <3.5% 3.86% Jan Bloomfield

The highest percentage continues to be Estates and Facilities Directorate at 4.80% (down by 0.17 from November), the lowest Corporate Services at 2.24 (again down by 0.15). “Back to work” meetings are undertaken by managers after any absence, Stage 1 meetings are undertaken when an employee has a Bradford factor of 100+, and occupational health involved as required. As an example, Estates and Facilities also currently have a number of long term sickness absences as a result of major gynaecological conditions, cancers and mental health issues (not work related), all of these staff are being supported, however their absence has been certificated by their medical practitioner, so there is limited action possible. The actions reported last month continue to be pursued. (The method of reporting sickness absence has also been reviewed and “as at” reporting will be piloted from April 2014 – there is a risk that the administration of sickness forms at ward and department level, for those not on Healthroster, may result in some sickness absence returns not being captured).

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Performance Indicator Threshhold December Lead ExecutiveAll staff to have an appraisal Both general and consultant staff each have a target of 90% to have had an

appraisal within the previous 12 months. Apppraisal is a rolling programme87.19% Jan Bloomfield

Appraisal compliance has increased marginally, with the Medical Directorate continuing to be the highest area (90.32). The lowest is again the Surgical Directorate (83.68). The SARD system for medical staff has gone live, and although early days, is being reported as a user friendly system. Managers continue to be reminded each month as to compliance levels and who has expired.

Performance Indicator Threshhold December Lead ExecutiveMRSA – emergency screening All emergency patients admissions are to be screened for MRSA within 24

hours of admission 96.91% Nichole Day

Performance on MRSA screening of emergency admissions was 97.00% against the 100% target. This is covered on page 12 of this report.Performance Indicator Threshhold December Lead ExecutiveClostidium (C.) difficile – meeting the C.Difficile objective - MONTH

2 3 Nichole Day

There were three hospital acquired C.difficile infections during December. This is covered on page 12 of this report.Performance Indicator Threshhold December Lead ExecutivePatients offered date within 28 days of cancelled operation

100% 93.93% Jon Green

There were two patients cancelled. Patient 1 cancelled twice due to no beds and lack of theatre time. Will be re-booked for the earliest available slot. Patient 2 was cancelled due to no theatre staff and is now waiting for both equipment and surgeon to be available at the same time before can be re-booked.

Performance Indicator Threshhold December Lead ExecutiveStroke - % of Stroke patients with access to brain scan within 24 hours

100% 97% Jon Green

The Trust failed one of the eight stroke targets this month. A single patient was not offered a brain scan within 24hrs of arrival. Whilst This patient was a complex case on this occasion the stroke protocols were not followed.

Clinical Quality Priorities: Summary

• Falls and pressure ulcers reduced in December, giving our lowest totals in a month for this year.

• MRSA screening continues to improve and reached over 95% for emergency screening. However, the target from the CCG is for 100% compliance.

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Quality Priority: Ward Performance Issues

• Ward F9 continues be monitored closely and monthly meetings held between the Head of Nursing, Matron, Ward Manager and Service Manager. Overall the quality indicators have improved over the last two months with 100% compliance this month in nutrition and MEWS audits and 80% compliance with hydration. There was one fall that did not result in harm but no pressure ulcers were recorded for the ward in December. However, vacancies remain a challenge as the ward is losing staff to the newly opening F12 ward and although sickness is being robustly managed, it remains at 14%.

• Ward F3 has seen increases in bed capacity at intervals during December in response to pressures on bed capacity within the Trust. This was done with the agreement that temporary staff would be utilised to manage this, however, there has been an impact on the consistency of care. This is reflected in a number of quality indicators triggering red or amber during the month. The recommender score for the ward remains lower than most other wards. However, the comments from patients in response to the patient experience survey were generally very positive with a number of comments from patients about the nurses’ sensitive management of patients with challenging behaviour. The two negative comments related to the perception that the ward was understaffed.

• Ward G4 continues to have a relatively low recommender score, with a score this month of 53. The high number of patients with confusion and dementia on this ward, impacts on the experience of other patients and the view is frequently expressed by patients that they should be cared for separately. In addition, there is no bedside entertainment system on the ward and this has an impact on their experience. However, given the particularly dependent patient groups cared for on this ward, the number of falls are low and the quality indicators are generally good. There have been no avoidable ward acquired pressure ulcers since May 2013. An action plan for G4 is being presented to the Board separately.

• Ward G5 has a number of amber and red indicators this month. Actions are being taken by the Ward Manager and Matron to improve compliance with MRSA screening and Matron’s patient ward rounds will focus on call bell response times to identify whether there are any issues specific to G5 that are influencing response times. However, the noise at night score improved in December and the amber scores for the survey are not felt to signify an on-going problem, but more a result of normal variations.

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Quality Priority: Infection Control

MRSA BacteraemiaThere were no hospital associated MRSA bacteraemia’s during December.

C. difficileThere were three hospital acquired C.difficile infections during December. These are awaiting RCA and occurred in three different wards (F3, F6 and G1). Initial examination suggests that there may be grounds for appeal in two of these cases. We have appealed eight cases of which four have been rejected. All four remaining cases are pending results of the appeal.F12 is due to open on 30 January 2014 providing an eight bedded isolation facility.

High Impact interventionsAll High Impact Intervention audit results were 100%.

MRSA screeningEmergency screening reached almost 97% in December has been over 95% for the last three months. Further improvements should be seen following the implementation of daily reports for the Matrons and Ward Managers. Elective screening compliance was 93.5% for December. In relation to elective screening:•Coding and categorisation continue to be addressed to ensure that procedures that do not require screening are not included in the figures. •Day case procedures where the interval between pre-assessment and surgery is outside the screening window continues to cause some problems. •A small number of oncology day case patients who attend on an on-going basis are still not being screened as frequently as necessary. For example two patients who attended six times in December without a screen account for12 failures in screening.

VIP Score auditsThe VIP score audits carried out by the Infection Prevention Team have identified variations in compliance with daily recording of VIP score between different wards. Those wards such as F5, F9 and F10 have implemented spot checks by the Matron and peer reviews by other members of the ward team.

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Quality Priority: Falls

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Falls PerformanceThere were 40 falls this month, 27of which resulted in negligible or minor harm, one incurred serious harm. One was due to a collapse for medical reasons and would not have been counted in our old definition.The rate per 1,000 occupied bed days is 3.41 (November 4.86) giving an overall downward trend.In November we reported 50 falls. However on investigation, one was incorrectly categorised, therefore 49 falls for November.

ThemesWe continue to monitor the number of falls occurring in toilets: there were 5 this month, 12.8% of our total number, which was up from 3 falls (or 6%) in November.

Detailed intelligence continues to be collected to reveal what the patient was actually doing at the time of the fall.Work is about to start to fit hand rails in all toilets this was delayed due to materials availability.

We have investigated falls by day of week, fall numbers have not been higher at weekends.

Quality Priority: Pressure Ulcers

The performance target is to have no avoidable Hospital Acquired Pressure Ulcers (HAPU) Grade 2, 3 or 4 pressure ulcers 2013-14.

Grade 2 Pressure Ulcers

There was one grade 2 HAPU this month which the CCG have confirmed was unavoidable.

This PU occurred on the bridge of the nose of a Critical Care patient. The patient required continuous ventilator support via a tight face mask. The damage occurred due to the frailty of the patients skin, which despite protection, could not be avoided.

Grade 3 pressure Ulcers

There were no grade 3 HAPU

The improvement in the data may be attributed to the increase in availability of pressure relieving equipment , and increased education from the Tissue Viability Team. Ward managers have received a Masterclass in Preserving Skin Integrity this month.

Matrons continue to check patient equipment needs and risk assessments on daily rounds.

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Safety thermometer results

The National ‘harm free’ care composite measure is defined as the proportion of patients without a pressure ulcer (ANY origin, category II-IV), harm from a fall in the last 72 hours, a urinary tract infection (in patients with a urethral urinary catheter) or new VTE treatment.

The data can be manipulated to just look at “new harm” (harm that occurred within our care) and with this parameter, our Trust score is 97.75%. National December performance is 97.5%.

The data for December shows we had 0.50% of falls with harm and the national performance for December was 0.8%.The data also shows we had 0.25% of new pressure ulcers recorded in December against the national performance of 1.0%

It should be noted that the Safety Thermometer is a spot audit and data is collected on a specific day each month.

Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13

Harm Free 93.77 95.66 93.02 93.36 93.68 91.47 93.20 92.60 93.22 92.68 91.03 92.46 90.28 93.00

Pressure Ulcers – All 3.38 1.79 5.17 3.55 3.51 4.50 4.28 5.36 3.52 2.98 5.16 4.06 4.72 3.25

Pressure Ulcers - New 0.26 1.02 0.52 0.71 0.94 0.95 1.01 0.00 1.08 0.00 1.09 0.00 0.83 0.25

Falls with Harm 0.26 0.51 0.78 0.71 0.23 1.66 0.00 0.26 0.81 0.27 0.00 0.00 1.11 0.50

Catheters & UTIs 2.08 1.79 1.03 1.66 2.58 0.95 1.76 1.53 2.17 2.98 3.60 3.48 3.33 3.00

Catheters & New UTIs 0.00 0.26 0.26 0.47 0.23 0.24 0.00 0.51 0.54 1.08 0.82 0.00 0.83 1.00

New VTEs 0.78 0.26 0.26 0.71 0.47 1.42 0.76 0.26 0.54 1.36 0.54 0.58 0.83 0.50

All Harms 6.23 4.34 6.98 6.64 6.32 8.53 6.80 7.40 6.78 7.32 8.97 7.54 9.72 7.00

New Harms 1.04 2.04 1.81 2.61 1.87 4.27 1.76 1.02 2.98 2.71 2.45 0.58 3.61 2.25

Sample 385 392 387 422 427 422 397 392 369 369 368 345 360 400

Surveys 17 17 17 18 18 18 18 18 17 17 17 17 17 17

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Quality Priority: Nutrition and Hydration

NutritionCompliance with nutritional screening and assessment is being maintained consistently this year at levels over 95%.

HydrationThe action taken to improve fluid management is starting to have an impact. Some wards improved more quickly and the actions they had taken to improve were discussed at length at the Matron’s performance meeting at the beginning of December and cascaded to the poorer performing wards. This month no ward scored lower than 70% in the audits and the overall compliance increased to over 85%.

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Quality Priority: Patient Experience – Achievement of 85% satisfaction

‘Achieve at least 85% satisfaction in internal patient satisfaction surveys’ is a Quality Priority for the Trust.

The overall score for the inpatient survey was 89, in line with previous months. Overall satisfaction scores for the OPD, A&E, and short stay were maintained at a high level with each scoring at least 90% overall.

Call Bell Project•A review meeting was held with the surgical ward managers in January. There has been a particular focus on prompt response to patients using the toilet. Clocks have been purchased for all of the wards and will be installed during February 2014. •A project plan for the rollout of the upgraded call bell system, allowing monitoring of actual response times, is being developed and will be presented to the next meeting of the Board.• The ward managers are ensuring that there is meticulous attention to intentional rounding in order to reduce the need for the call bells to be pressed.

Score No of responses

A&E 90 238

OPD 95 109

Short stay 97 191

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Quality Priority: Patient Experience – recommend the service

‘Patients would recommend the service to their family and friends’ is a Quality Priority for the Trust.

Inpatient

The Trust achieved a net promoter score of 82 for inpatients during December, maintaining the high scores of previous months. Currently those wards with lower recommender scores tend to have a greater percentage of patients who score “likely” and are therefore classified as passive rather than a higher percentage of patients who are detractors.

The two wards that had low scores last month were wards F3 and G4. These have had similar scores this month. As with last month there were few comments, but comments received for G4 indicated that patients without dementia feel that they should not be on a ward with predominantly dementia patients and for F3 there were several comments regarding perceived low staffing levels.

A&EThe recommender score for A&E has remained fairly static over the last few months with the scores being between 58 and 61. The score for December 2013 was 59.

MaternityMaternity recommender scores are good at all stages of the pathway as indicated below:

 

Antenatal care Birth Post natal ward Post natal community care

85 97.5 94 96

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Local Priorities: Exception report

Late by Directorate  Red (RAG) 9th Dec 23rd Jan change

Clinical Support >15 9 7 -

Estates and Facilities >10 12 11 -

Medical >70 85 70

Surgical >40 32 44

Women & Children’s Health >15 31 29 -

Other No target 4 12

TOTAL  >150 173 173

Incidents (Amber / Green) with investigation overdue (over 12 days)The Trust met the deadline for submission of all PSIs in Apr-September NRLS of the 30 th November. This has resulted in a reduction in

the total overdue for investigation and final approval. Medicine in particular have demonstrated a noticeable improvement.

Duty of Candour (DoC) non-compliance

Case one: A patient on critical care sustained a grade 2 pressure ulcer following essential treatment to assist his breathing . The patient was in a poor state of health and prior to admission resided in a residential home with 24 hour care in place  as the result of a long term debilitating illness. It was judged inappropriate to discuss with the family as the patient was dying and the PU was unavoidable and did not impact on the outcome

Case two: A patient with C. difficile. Whilst the clinical management was discussed and documented, DoC was not undertaken - the impact of the infection on the patient was not clinically significant. The case was review at the Operational Steering Group and actions agreed to strengthen medical staff awareness of the requirement of DoC with regard to cases of C difficile.

The RAG rating for the KPIs has been adjusted to use actual numbers rather than percentages. This is considered more meaningful given the relatively small number of incidents involved.

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Local Priorities - Governance Dashboard

Indicator Performance target R A G Dec13 Commentary

Timely completion of incident investigations and actions

Red non-SIRI investigation not complete more than 45 days after incident reported

>3 1 - 3 0 0

RCA Actions beyond deadline for completion >=10 5 - 9 0 - 4 9 A number of actions are in progress but not yet complete

Incidents (Amber / Green) with investigation overdue (over 12 days)

>150 50 - 150 <50 173 See exception report for details.

Timely reporting of SIRIs

SIRIs reported > 2 working days from identification as red

>1 1 0 0 2/2 incidents were submitted to STEIS within two days of identification as red. One was re-graded as red following review by Tissue viability.

SIRI final reports due in month submitted beyond 45 working days

>1 1 0 0 7/7 were submitted within 45 working days.

SIRI final reports due in month submitted beyond local target (40 working days, 30days for pressure ulcers)

>1 1 0 1 1/7 was sent on day 42 as it was a complex case requiring clarification post RCA to ensure report was complete.

Number of SIRI reports open on STEIS more than 45 days after initial notification

>10 6 - 10 0-5 1 Two incidents have an CCG agreed “stop the clock” and are therefore excluded from this indicator.

Duty of Candour

Compliance with Duty of Candour requirements

>3 1 - 3 0 2 Two (from a total of seven cases) cases were not undertaken – See exception report for details.

Risk assessment

Active risk assessments in date <75% 75 – 94% >=95% 95%

Outstanding actions in date for Red / Amber entries on Datix risk register

<75% 75 – 94% >=95% 97%

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Local Priorities - Governance Dashboard (cont.)

Indicator Performance target R A G Dec13 Commentary

Clinical Audit

Trust participation in relevant ongoing National audits (reported by Quarter)

<75% 75 – 89% >=90% 100%

Safer surgery

Completion of WHO checks during surgery. This is a composite indicator of the checks at ward, sign-in, time-out and sign-out.

<90% 90% - 98%

>98% 97% There has been a 2% improvement over the quarter. Non compliance is reported to individuals (daily) and Clinical Directors (weekly). This analysis is based on 3724 checks during the month.

NICE TA (Technology appraisal) business case beyond agreed deadline timeframe

>9 4 - 9 0 - 3 1 The seven Interventional Procedures and eight Clinical guidelines are outstanding baseline assessments and require targeted follow up. This will be addressed through the directorate governance steering groups.

IPG (Interventional procedure guideline) baseline assessments beyond agreed deadline timeframe

>9 4 - 9 0 - 3 7

CG (Clinical guideline) baseline assessments beyond agreed deadline timeframe

>9 4 - 9 0 - 3 8

Complaints Response within 25 working days or negotiated timescale with the complainant

<75% 75 – 89% >=90% 100%

Number of second letters received >=5 1-4 0 3 This is in the context of the highest ever number of complaints received by the Trust in November 2013.  Two second letters were complex clinical complaints and further assurance was requested on the care plan and outcome. One relates to a different recollection of events between the patient and staff.

Health Service Referrals accepted by Ombudsman >=2 1 0 0

Red complaints actions beyond deadline for completion >=5 1-4 0 0

Number of PALS contacts becoming formal complaints >=10 6 - 9 <=5 2

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Patient Safety Incidents reported

The rate of PSIs is a nationally mandated item for inclusion in the Quality Accounts. The NRLS target lines shows how many patient safety incidents WSH would have to report to fall into the median / upper and lower quartiles for small acute trusts reporting per 100 admissions. The Oct12 – Mar13 NRLS report was issued in December and the benchmark in the graph above has been backdated to September. This shows a increase in reporting across the peer group and the Trust reporting rate has now fall in the last two months and sits approximately on the median for the peer group.

There were 385 incidents reported in December including 318 patient safety incidents (PSIs). The reporting rate in November and December is at its lowest since September 2012. Analysis of the data shows a reduction in reporting of “equipment availability”, This has been addressed by the purchase of additional pressure relieving equipment in October 2013). There is also a drop in the number of falls reported. Other perceived drops in reporting by area need to be reviewed in more detail and followed up locally. The reporting culture within the Trust remains positive as measured in the annual staff survey.

The number of harm incidents in December was below the peer group average (also backdated to September for the latest NRLS benchmark)

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Patient Safety Incidents (Severe harm or death)

The percentage of PSIs resulting in severe harm or death is a nationally mandated item for inclusion in the Quality Accounts. The peer group average (serious PSIs as a percentage of total PSIs) from the NPSA Oct ’12 – Mar ‘13 report and sits below the Trust’s average (NRLS benchmark updated from September ‘13). The WSH data is plotted as a line which shows the rolling average over a six month period. This has been changed from the previous reported 12 month period as six months matches the NRLS reporting period.

The number of serious PSIs (confirmed and unconfirmed) are plotted as a column on the secondary axis with avoidable hospital acquired pressure ulcers (HAPU) indentified separately. In October there were three ‘Red’ patient safety incidents: a deteriorating patient, one inquest awaiting confirmation through RCA and one pressure ulcer judged as unavoidable awaiting confirmation from the CCG before downgrade.

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Local Priorities: Complaints

After the large number of complaints received in November (40), December saw a significant reduction (15).

Complaint response within agreed timescale with the complainant: 100% of responded to in December.

Of the 15 complaints received in December, the breakdown by Primary Directorate is as follows: Medical (9), Surgical (3), Clinical Support (2), Facilities (1), and Women & Child Health (0).

Trust-wide the top 3* most common problem areas are as follows:

Attitude of Staff 6

All Aspects of Clinical Treatment 4

Appointments, Delay / Cancellation (outpatient) 2

*all other problem areas had a count of one

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Local Priorities: PALS (Patient Advice & Liaison Service)

In December 2013 there were 63 recorded PALS contacts. This number denotes initial contacts and not the number of actual communications between the patient/visitor which can, in some particular cases, be multiple. Although the overall number of initial contacts is much less for November, the length of time dealing with families has been prolonged.

A breakdown of contacts by Directorate from April’12 to December‘13 is given in the chart and a synopsis of enquiries received for the same period is given below. Total for each month is shown as a line on a second axis.

Trust-wide the most common five reasons for contacts are shown below

Information/Advice request 26 All aspects of clinical treatment 17 Appointments, delay, cancellation (outpatients) 7

Other 2 Communication 3

It is evident that the PALS Manager, in addition to assisting with genuine concerns from patients and relatives, frequently signposts enquirers to other services including the formal complaints process. She is also actively involved in dealing with specific in-patients and their families’ concerns during the total admission period. This last month has been particularly busy with patient families raising queries with the PALS Manager.

No trends within specific departments/wards identified this month.

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Local Priorities – Workforce Performance

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Performance Indicator ThresholdDirect

Financial Penalty

YTD Comments Lead Exec

Workforce

Sickness absence rate <3.5% NO 3.86% Jan Bloomfield

Turnover <10% NO 7.52% Jan Bloomfield

Reviews Grievance/Banding reviews NO 9 All cases now completed/resolvedJan Bloomfield

Recruitment Timescales Average number of weeks to recruit = 7 NO 5.3 Jan Bloomfield

DBS Checks To complete 95% of required DBS checks NO 98.70% Jan Bloomfield

All Staff to have an appraisal

Both general and consultant staff each have a target of 90% to have had an apprasial within the previous 12 months. Appraisal is a rolling programme

NO 87.19%

Jan Bloomfield

Monitor Compliance Framework

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Monitor Compliance Framework Performance Indicator Threshold Month QTD Weighting Lead ExecAccess: Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted 90% 97.79% 98.61% 1.0 Jon GreenMaximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted 95% 97.20% 98.96% 1.0 Jon Green

Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway 92% 100.00% 99.98% 1.0 Jon Green

A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge 95% 96.78% 96.89% 1.0 Jon GreenAll cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer 85% 90.00% 88.07%

1.0Jon Green

All cancers: 62-day wait for first treatment (5) from: NHS Cancer Screening Service referral 90% 100.00% 98.33% Jon GreenAll cancers: 31-day wait for second or subsequent treatment, comprising: Surgery 94% 100.00% 100.00%

1.0Jon Green

All cancers: 31-day wait for second or subsequent treatment, comprising: anti-cancer drug treatments 98% 100.00% 100.00% Jon GreenAll cancers: 31-day wait for second or subsequent treatment, comprising: radiotherapy - Not applicable to WSFT All cancers: 31-day wait from diagnosis to first treatment 96% 100.00% 100.00% 0.5 Jon GreenCancer: two week wait from referral to date first seen (8), comprising:all urgent referrals (cancer suspected) 93% 98.84% 98.55%

0.5Jon Green

Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer not initially suspected) 93% 95.40% 96.87% Jon Green

Outcomes: Clostridium (C.) difficile - meeting the C.difficile objective - MONTH 2 3

1.0

Nichole Day

Clostridium (C.) difficile - meeting the C.difficile objective - QUARTER Q1 = 4, Q2 = 5, Q3 = 5, Q4 = 5

5 Nichole Day

Clostridium (C.) difficile - meeting the C.difficile objective - ANNUALLY 19 21 Nichole DayMethicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - MONTH 0 0

1.0Nichole Day

Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - QUARTER 0 0 Nichole DayMethicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - ANNUALLY 0 1 Nichole DayCertification against compliance with requirements regarding access to healthcare for people with a learning disability N/A - - 0.5 Nichole Day

Contract Priorities Dashboard

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Contract Priorities with financial penalty

Performance Indicator Threshold In Month Performance YTD Comments Lead Exec

A&E

A&E - Threshold for admission via A&E

i) if the monthly ratio is above the corresponding 2011/12 monthly ratio for two month in a six month periodii) if year end is greater than 27%

28.08% 24.82% Jon Green

A&E - Timeliness Indicators

To satisfy at least one of the following Timeliness Indicators:1. Time to initial assessment (95th percentile) below 15 minutes2. Time to treatment in department (median) below 60 minutes

ONE MET - Jon Green

StrokeStroke -Proportion of Patients admitted to an acute stroke unit within 4 hours of hospital arrival 90% 91.00% 87.00% Jon Green

Proportion of patients in Atrial Fibrillation, presenting with stroke and where clinically indicated will receive anti-co-agulation. 60% 89.00% 69.67% Jon Green

Stroke - % of Stroke patients with access to brain scan within 24 hours 100% 97.00% 98.56% 1 Patient waited over 24 hours Jon Green

Stroke - Proportion of Stroke Patients and carers with a joint health and social care plan on discharge 85% 100.00% 92.22% Jon Green

Stroke - Patients (as per NICE guidance) with suspected stroke to have access to an urgent brain scan in the next slot within usual working hours or less than 60 minutes out of hours as defined from time to time by the ASHN

100% of stroke patients eligible for a brain scan scanned within one hour 100.00% 94.89% Jon Green

>80% treated on a stroke unit >90% of their stay 80% 94.00% 89.56% Jon Green>60% of people who have a TIA and are high risk (ABCD 2 score 4 or more) are scanned and treated within 24 hours of 1st contact but not admitted

60% 89.00% 78.11% Jon Green

Stroke - 65% of patients with low risk TIA have access to MRI or carotid scan within 7 days (seen, investigated and treated) 65% 65.00% 73.56% Jon Green

% of Patients eligible for Thrombolysis, Thrombolysed within 4.5 hours 100% of all eligible patients 100.00% 100.00% Jon Green

Discharge SummariesDischarge Summaries - Outpatients 95% sent to GP's within 3 days 87.07% 84.36% Dermot O'Riordan

Discharge Summaries - A&E 95% of A&E Discharge Summaries to be sent to GPs within one working day 97.28% 97.06% Dermot O'Riordan

Discharge Summaries - Inpatients 95% sent to GP's within 1 day 78.35% 81.82% Dermot O'Riordan

Contract Priorities Dashboard

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Choose & Book          

Provider failure to ensure that “sufficient appointment slots” are made available on the Choose and Book system

A maximum of 3% slots unavailable (£50 per appointment over 5%. Threshold applied over monthly figures)

3.00% - The Threshold applied to fines is 5% Jon Green

All 2 Week Wait services delivered by the Provider shall be available via Choose & Book (subject to any exclusions approved by NHS East of England)

100% 100.00% - Jon Green

Cancelled OperationsProvider cancellation of Elective Care operation for non-clinical reasons either before or after Patient admission i) 1% of all elective procedures 1.48% 1.15% Jon GreenPatients offered date within 28 days of cancelled operation 100% 93.93% 97.64% Jon GreenMaternity

Access to Maternity services (VSB06)

90% of women who have seen a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks and choices by 12 completed weeks of pregnancy.

97.28% 96.36%

Nichole DayMaintain maternity 1:30 ratio 1:30 1:30 1:29 Nichole Day

Pledge 1.4: 1:1 care in established labour 1:1 100.00%100.00

% Nichole DayBreastfeeding initiation rates. 80% 79.90% 80.35% Nichole DayReduction in the proportion of births that are undertaken as caesarean sections. Suffolk PCT Only

1% reduction in proportion compared to 2011/12 baseline - 22.70% 79.90% 25.47% Nichole Day

Other contract / National targetsMixed Sex Accomodation breaches 0 Breaches 0 4 Jon Green

Consultant to consultant referral Commisioner to audit if concern about levels of consultant referrals 7.20% - Jon Green

Current ratios of OP procedure to day case for agreed list of procedures to be maintained or improved, i.e. the Commissioner will not fund a higher level of admitted patients for such procedures, unless clinical reasons can be demonstrated for increase in admissions.

Maintain or improve the mix as specified = 90.17% 87.95% 87.55% Jon Green

MRSA - emergency screening All emergency patients admissions are to be screened for MRSA within 24 hours of admission 96.91% 92.42% Nichole Day

Rapid access - chest pain clinic 100% of patients should have a maximum wait of two weeks 100.00% 82.39% Jon Green

New to Follow up Thresholds set at each speciality - overall Trust Threshold is 1.9 1.83 - Jon Green

Patients receiving primary diagnostic test within 6 weeks of referral for diagnostic test 99% 99.47% 97.85% Jon Green

A3 Printout of Ward Analysis Quality Report From Trust

Dashboard

Clinical Quality Priorities: Ward Dashboard

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