Hammersmith & Fulham CCG Performance & Quality Report ... · Number of 52 week RTT pathways - non-admitted 0 0 5 0 5 1 10 0 0 Number of 52 week RTT pathways - incomplete pathways

Hammersmith & Fulham CCG Performance & Quality Report –August 2013

Month 5

1

CCG Operating Framework

CCG Outcomes framework

Provider issues

Quality premium

Section 1: Table of contents

high quality support to commissioners to improve health and wellbeing

Section 3

Section 4

Section 9

Section 7

Section 6 NHSE Assurance – provider quality

Section 5

Recommendations and next steps Sections 11

Executive Summary & Key Messages Section 2

111 Pilot Services

Sections 10 Action log

Shaping a Healthier Future

Section 8

2

Section 2: Executive Summary


▪ CCG Operating Framework - The CCG is currently meeting constitutional performance measures with the exception of – RTT performance standards at specialty level and 52 week standards. The CCG performance was largely impacted by Imperial College Hospitals Trust

(ICHT) and Chelsea & Westminster hospital (CW). – Cancer: H&F CCG did not meet the 62 day to treatment standard in M5 or the year to date, with performance in M5 driven by ICHT. – Health Care Acquired Infection (HCAI) H&F CCG reported 17 C.Diff cases against a tolerance of 13 cases with no hospital acquired cases in M5.

Performance year to date driven by ICHT with all 11 hospital acquired cases for H&F CCG. No patient tested positive for MRSA bacteraemia in M5 with 4 cases reported year to date.

• Quality Premium – H&F CCG is not meeting the cancer 62 days to treatment standard a gateway metric to receiving quality premium funding. In addition, the CCG is not meeting HCAI and MMR immunisation standards and the MRSA tolerance has been exceeded for 2013/14. Under current DH guidance the HCAI Quality Premium is awarded only where both HCAI tolerances are met. Information on other metrics is not currently available as these are annual or quarterly measures.

▪ Areas where provider performance (trust-wide across all CCGs) is below standard:

– CW, ICHT and RBH are meeting RTT standards overall but not at a speciality level. ICHT also reported 3 breaches of the 52 week standard and has confirmed that all 3 were treated in M5 and there are no patients waiting over 52 weeks at month end.

– Cancer: ICHT did not meet the 62 days to treatment standard following urgent referral in M5 achieving 65.6%. RBH did not meet the 62 day consultant upgrade standard with 1 breach due to a complex pathway. ICHT is not meeting the 31 days to treatment standard year to date achieving 95.2% against a 96% standard.

– HCAI: 1 MRSA was reported in M5 by CW and ICHT. CW, ICHT and RBH will not meet the “zero tolerance” MRSA requirement for 2013/14 reporting 2, 5, and 2 cases respectively. ICHT met C.Diff tolerance in M5 but not year to date and RBH has exceeded its C.Diff tolerance year to date but is within the Monitor de-minimis tolerance.

– LAS arrival to handover waits greater than 30mins : 4 and 26 patient breaches reported at CW and ICHT respectively in M5. – ICHT reported that 5.4% of operations cancelled on the day for non clinical reasons were not rebooked within 28 days in M5. – WLMHT did not meet the 11% target for DNA Follow Up and 8.1% target for Readmission Within 30 days with 12.3% and 9.6% respectively – CLCH achieved 96.0% at M5 against 98.0% target for LAC Initial Health Assessments conducted within 20 operational days – Actions being taken or in place by individual providers are outlined in Section 11 of this report.

3

Section 2: Executive Summary (contd)


The CCG, supported by CSU, is taking the following actions to address these performance concerns:

– Contract penalties will be applied to all Trusts breaching national standards, for example £5000 for each 18 week 52 week wait, £1000 for a 60 minute handover breach, and £200 for a 30 minute handover breach.

– Root cause analyses, exception reports and action plans are required where providers have breached quality standards which are discussed at relevant contractual meetings. Where required the CSU performance and quality teams undertakes critical analysis of exception reports, demand and capacity assessments, and action plans submitted by providers.

– The CSU also monitors action plans on a weekly / month basis and A&E pressures on a daily basis. Where necessary the CSU meet with providers to agree additional actions required.

– Recovery actions for individual providers are detailed in Section 11

4

Section 2: Key Messages


Key Messages Further Detail

NHS CCG Operating Framework

The CCG currently assessed ‘green’ for 18 indicators, and ‘red’ on 2 indicators. A further 19 indicators are not assessed as data is either not yet available or the indicator is in development.

Please see section 3

Outcomes Framework

The CCG currently assessed as improving for 11 indicators with a fall in performance for 9 indicators. A further 10 indicators are not assessed as data is either not yet available or the indicator is in development.


Quality Premium

1 national domain measure is assessed as not met 3 national domain measures are currently not assessed. The CGG is not meeting 1 local measure and is not assessed on 2 local measures


NHSE Assurance

The CCG currently assessed ‘green’ for 20 indicators, and ‘red’ on 5 indicators. A further 26 indicators are not assessed as data is either not yet available or the indicator is in development.


5 high quality support to commissioners to improve health and wellbeing

Section 3: NHS CCG Operating Framework

Key messages • H&F CCG is meeting RTT performance standards overall but not specialty or 52 week standards. The admitted patient that waited longer than 52 week wait was reported by ICHT and has been

treated in M5. The Trust has confirmed that no further patients are waiting over 52 weeks at month end. H&F CCG specialty performance has been impacted by ICHT reducing its’ backlog within General Surgery, T&O and Urology. Plastic Surgery and General Medicine did not meet non admitted RTT standards due to a small number of breaches at CW.

• CW, ICHT and RBH are meeting RTT standards overall but not at a speciality level. Action plans are in place to improve the management of 18 week RTT at both ICHT and CW. CW has reviewed waiting list management processes after reporting a number of surgical specialties did not meet RTT standards in M5 and has reported an improved position in M6. ICHT has reported that it is on plan to meet T&O admitted standard by the end of October 2013 but not the non-admitted General Surgery standard by the end of September 2013. An update to the Trust planned trajectory has been requested.

• ICHT reported 5.4% of operations cancelled on the day for non-clinical reasons were not rebooked within 28 days in M5. ICHT has provided an action plan and is on trajectory to meet standard in Q2.

Please see Appendix 2 for further report definitions guidance

In

mth/qtrYTD Variance

In

mth/qtrYTD Variance

In

mth/qtrYTD Variance

In

mth/qtrYTD Variance

18 weeks RTT - admitted performance within 18 weeks 91.6% 90.7% 91.0% 90.7% 93.6% 92.8% 94.7% 93.1%

18 weeks RTT - admitted performance within 18 weeks:

specialties that failed to achieve the threshold

18 weeks RTT - non-admitted performance within 18 weeks 97.1% 97.2% 98.0% 97.6% 96.8% 97.0% 97.1% 97.9%

18 weeks RTT - non-admitted performance within 18 weeks:


18 weeks RTT - incomplete pathways performance within 18

weeks95.1% 95.5% 92.3% 93.1% 95.6% 96.0% 94.8% 95.1%

18 weeks RTT - incomplete pathways within 18 weeks:


Number of 52 week RTT pathways - admitted 0 1 9 0 1 2 6 0 0

Number of 52 week RTT pathways - non-admitted 0 0 5 0 5 1 10 0 0

Number of 52 week RTT pathways - incomplete pathways 0 0 2 0 2 0 4 0 3

Diagnostic Waits Patients waiting more than 6 weeks for a diagnostic test Monthly M5 1% 0.5% 0.2% 0.00% 0.03% 0.29% 0.16% 0.00% 0.00%

Cancelled OperationsCancelled ops - breaches of 28 days readmission guarantee

as % of cancelled opsMonthly M5 5% 0.0% 0.0% 5.4% 14.3% 0.0% 0.0%

Urgent operations

cancelled for a second

time

Number of urgent operations that are cancelled by the trust

for non-clinical reasons, which have already been previously

cancelled once for non-clinical reasons

Monthly M5 0 0 0 0 0 0 0

Data not available by CCG


92% General Surgery 91.5%

Urology 90.6%

T&O 89.8%

Cardiothoracic Surg 85.0%

Cardiology 94.9%

Other Specialties 90.7%

Gastroenterology 92.9%

Rheumatology 93.0%

General Surgery 88.6%

Urology 91.9%

T&O 89.1%

Plastic Surgery 87.0%

95% General Surgery 91.6%

Urology 86.8%


General Medicine 92.3%

General Surgery 85.6%

Urology 82.8%18 weeks RTT

performance within 18

weeks

Monthly M5

90%General Surgery 88.1%

Urology 85.1%

T&O 84.7%

Other Specialties 88.9%Urology 84.9%

T&O 87.5%

Ophthalmology 88.5%


T&O 71.4%

Royal Brompton and

Harefield NHS Foundation

TrustPerformance Measure DescriptionReporting

Frequency

Reporting

PeriodThreshold

NHS Hammersmith &

Fulham CCG

Chelsea and Westminister

Hospital NHS Foundation

Trust

Imperial College Healthcare

NHS Trust


Section 3: NHS CCG Operating Framework (contd.)

• Cancer: H&F CCG did not meet the 62 day to treatment standard in M5 or the year to date. All three 62 days to treatment breaches were reported by ICHT, 1 patient choice, 1 due to poor administrative processes and 1 is being investigated. RCA’s are being provided by all providers not meeting cancer standards and these will be reviewed by the CSU cancer commissioning team.

• ICHT did not meet the 62 days to treatment standard in M5 or the year to date achieving 72.7%, a total of 24 breaches (4 shared). Although full RCA’s are awaited initial findings indicate a number of breaches were due to poor administrative processes and capacity issues particularly in Urology. A new consultant Urologist and CNS have started in October and improvement is expected from M7. The CSU contracting team is meeting with the Trusts cancer lead to review progress against ICHT’s revised cancer plan and agree an improvement trajectory. RBH did not meet the 62 day consultant upgrade standard with 1 breach due to a complex pathway.

• LAS arrival to handover waits greater than 30mins : 4 and 26 patient breaches reported at CW and ICHT respectively in M5 an improving position on M4. Recovery and improvement plans are in place.

Key messages


In

mth/qtrYTD Variance

In

mth/qtrYTD Variance

In

mth/qtrYTD Variance

In

mth/qtrYTD Variance

A&E Total time spent in A & E < 4 hours (all activity types) Monthly M5 95% 98.3% 98.6% 96.5% 96.4% N/A N/A

Trolley Waits in

A&E

Patients who have waited over 12 hours in A&E from

decision to admit to admissionMonthly M5 0 0 0 0 0 N/A N/A

Number of LAS arrival to handover > 30mins Monthly M5 0 4 23 26 168 N/A N/A

Number of LAS arrival to handover > 60mins Monthly M5 0 0 0 0 1 N/A N/A

Percentage of patients seen within two weeks of an

urgent GP referral for suspected cancerM5 93% 98.9% 97.7% 98.4% 96.1% 98.6% 98.3% 100.0% 100.0%

Percentage of patients seen within two weeks of an

urgent referral for breast symptoms where cancer is

not initially suspected

M5 93% 98.8% 98.4%

No

Patients

Treated

No

Patients

Treated

98.0% 97.6%

No

Patients

Treated

No

Patients

Treated

Percentage of patients receiving first definitive

treatment within one month of a cancer diagnosisM5 96% 100.0% 96.4% 100.0% 98.2% 97.7% 95.2% 100.0% 98.8%

Percentage of patients receiving subsequent

treatment for cancer within 31-days where that

treatment is Surgery

M5 94% 100.0% 96.1%

No

Patients

Treated

100.0% 96.0% 95.8% 100.0% 100.0%



treatment is an Anti-Cancer Drug Regime

M5 98% 100.0% 100.0%

No

Patients

Treated

100.0% 100.0% 99.6%

No

Patients

Treated

No

Patients

Treated



treatment is a Radiotherapy Treatment Course

M5 94% 100.0% 100.0%

No

Patients

Treated

No

Patients

Treated

100.0% 97.9%

No

Patients

Treated

No

Patients

Treated


treatment for cancer within 62-days of an urgent GP

referral for suspected cancer

M5 85% 75.0% 75.3% 100.0% 91.2% 65.6% 72.7% 90.9% 72.2%


treatment for cancer within 62-days of referral from

an NHS Cancer Screening Service

M5 90% 100.0% 100.0%

No

Patients

Treated

No

Patients

Treated

91.2% 93.1% N/A N/A


treatment for cancer within 62-days of a consultant

decision to upgrade their priority status

M5 85% 100.0% 94.4% 100.0% 100.0% 92.3% 92.0% 50.0% 90.0%

Chelsea and Westminister

Hospital NHS Foundation Trust


NHS Trust

Royal Brompton and Harefield

NHS Foundation TrustPerformance

MeasureDescription

Reporting

FrequencyReporting Period Threshold

NHS Hammersmith & Fulham

CCG

Cancer 62 Day

WaitsMonthly



Ambulance

Handover



Cancer 2 Week

WaitsMonthly

Cancer 31 Day

WaitsMonthly


Section 3: NHS CCG Operating Framework (contd.)

Key messages

• Infection control: H&F CCG met the C.Diff standard in M5 with 1 case but not for the year to date with 17 cases (11 apportioned to acute providers) reported against a tolerance of 13 cases. The CDiff case in M5 was assessed as not hospital acquired. All 11 acute provider apportioned cases were reported by ICHT. H&F CCG met the “zero tolerance” MRSA standard in M5, but not year to date with 4 cases, of which 2 were assessed as hospital acquired with CW and ICHT both reporting 1 case. An additional case is expected to be allocated to ICHT in M 4 following post infection review.

• CW, ICHT and RBH are not meeting the “zero tolerance” MRSA bacteraemia standard, reporting 2, 5 and 2 cases year to date respectively, with 1 case reported by both CW and ICHT in M5. A post infection review has been undertaken for the ICHT case and this has been assessed as not hospital acquired therefore the HPA has been asked to reallocate. ICHT and RBH reported 3 and 1 C.Diff cases in M5 respectively with both Trusts in excess of their year to date tolerance. ICHT has now been within tolerance for the second consecutive month and is currently reporting a similar position for M6 . RBH has reported 5 C.Diff cases year to date, which is in line with its Monitor de-minimis tolerance.


In

mth/qtrYTD Variance

In

mth/qtrYTD Variance

In

mth/qtrYTD Variance

In

mth/qtrYTD Variance

MSA breaches 0 0 1 0 0 0 0 0 0

MSA breach rate 0.00 0.00 0.05 0.00 0.00 0.00 0.00 0.00 0.00

Unplanned hospitalisation for chronic

ambulatory care sensitive conditions

(adults)*

566.2 58 341 196 1,099 4 29

Unplanned hospitalisation for asthma,

hypertension, diabetes and epilepsy in

under 19s*

246.8 6 58 11 64 0 0

Emergency Admissions

Emergency admissions for acute

conditions that should not usually require

hospital admission*

Monthly M5 Reduction 860.0 92 528 324 1,529 N/A N/A

Patient reported outcomes measures for

elective procedures - hip replacementN/A N/A


elective procedures - knee replacementN/A N/A


elective procedures - groin hernia0.058 N/A N/A


elective procedures - varicose veins0.100 N/A N/A

Net promoter score of recommendations

to friends and family by people receiving

Inpatient NHS Treatment

Monthly M5 Improvement 64 69 87



A&E NHS Treatment

Monthly M5 Improvement 77 53 N/A N/A



Inpatient/A&E NHS Treatment

Monthly M5 Improvement 67 60 87

Patient ExperiencePatient Experience: Overall score across 5

domains (inpatient survey)Annual 2012

4-5 passes out

of 5 themes74.4 74.4 83.6

MRSA Monthly M5 0 0 4 1 2 1 5 0 2

Monthly Target 3 13 1 6 5 26 0 2

Annual Target 39 13 65 7

Actual 1 17 0 1 3 32 1 5

Data suppressed due to

small numbers


small numbers


small numbers


small numbers


small numbers


small numbers

C.Diff Monthly M5

Friends & Family Test





HCAI


small numbers


small numbers


small numbers


small numbers

EMSA Monthly M5

Unplanned

hospitalisationMonthly

M5 Rolling 12

monthsReduction

PROMs AnnualProvisional

Apr-Dec 2012Increase

Performance Measure DescriptionReporting

Frequency

Reporting

PeriodThreshold

NHS Hammersmith &

Fulham CCG


NHS Trust

Chelsea and Westminster

Hospital NHS Foundation

Trust

Royal Brompton and

Harefield NHS Foundation

Trust


Section 3: NHS CCG Operating Framework (Dementia and IAPT)

Key messages

IAPT - Remedial and improvement actions are detailed in section 11. IAPT Figures below are reported locally to M5 13/14 because national reporting has been ceased in 13/14.


In mth/qtr YTD

Local Target 0.80% 3.92%

Actual 1.12% 5.24%

Local Target 46.3% 46.3%

Actual 46.4% 46.3%

Target 95.0% 95.0%

Actual 95.1% 95.1%

People with

dementia

Diagnosis rate for people with dementia, expressed as

a percentage of the estimated prevalence

Annual N/A Improvement

Quarterly

Mental Health-

CPA 7 day

follow up

The proportion of patients on Care Programme

Approach (CPA) discharged from in patient care who

are followed up within 7 days

Q1

Performance

MeasureDescription

Reporting

Frequency

Reporting

PeriodThreshold

Mental Health -

IAPT

Proportion of people with depression and/or anxiety

disorders referred for and receiving psychological

therapies

Quarterly M5

Proportion of people with depression and/or anxiety

disorders receiving psychological therapies who are

moving to recovery

Quarterly M5

Data not available

West London

Mental Health Trust

9

Section 3: Out of Area (M5 performance)


Performance Measure Ashford & St Peters UCLH Guy’s & St Thomas’ Royal Free

In month YTD In month YTD In month YTD In month YTD

18 weeks – admitted 92.3% (M5) Data not available 90.3% (M4) 91.2% (M4) 93.0% (M5) Data not available 92.6% (M4) 91.8% (M4)

18 weeks - non-admitted 97.8% (M5) Data not available 96.2% (M4) 96.9% (M4) 96.6% (M5) Data not available 96.5% (M4) 97.3% (M4)

18 weeks - incomplete 98.3% (M5) Data not available 92.1% (M4) 92.1% (M4) 93.5% (M5) Data not available 92.1% (M4) 92.1% (M4)

6 week diagnostic test waiters 0.0% (M5) Data not available 0.5% (M4) 0.9% (M4) 5.1% (M5) Data not available 0.7% (M4) 0.6% (M4)

A&E 4hr waits – all types 97.7% (M5) Data not available 96.3% (M5) 95.6% (M5) 95.4% (M5) 95.7% (M5) 96.5% (M5) 95.7% (M5)

Trolley waits in A&E 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5)

LAS handovers >30mins 13 (M5) 244 (M5) 7 (M5) 51 (M5) 8 (M5) 139 (M5) 4 (M5) 51 (M5)

LAS handovers >60mins 3 (M5) 18 (M5) 0 (M5) 0 (M5) 0 (M5) 11 (M5) 0 (M5) 1 (M5)

Cancer 2 week wait 96.6% (M5) Data not available 94.2% (M4) 93.8% (M4) 94.1% (M5) Data not available 97.7% (M4) 97.7% (M4)

Cancer 2 week wait – breast 93.2% (M5) Data not available 83.4% (M4) 88.4% (M4) 96.8% (M5) Data not available 96.5% (M4) 96.6% (M4)

Cancer 31 day standard 100% (M5) Data not available 97.4% (M4) 97.3% (M4) 96.9% (M5) Data not available 100% (M4) 99.0% (M4)

Cancer 31 day treatment – surgery 100% (M5) Data not available 89.2% (M4) 95.3% (M4) 98.7% (M5) Data not available 100% (M4) 98.9% (M4)

Cancer 31 day treatment – drugs 100% (M5) Data not available 100% (M4) 100% (M4) 99.3% (M5) Data not available 100% (M4) 100% (M4)

Cancer 31 day treatment – radiotherapy No patients

treated Data not available 100% (M4) 100% (M4) 94.0% (M5) Data not available 100% (M4) 100% (M4)

Cancer 62 day standard 91.0% (M5) Data not available 76.5% (M4) 82.6% (M4) 80.0% (M5) Data not available 87.2% (M4) 89.5% (M4)

Cancer 62 day treatment – screening 100% (M5) Data not available 83.3% (M4) 93.3% (M4) 71.4% (M5) Data not available 100% (M4) 100% (M4)

Cancer 62 day consultant upgrade 100% (M5) Data not available 78.6% (M4) 73.3% (M4) 89.8% (M5) Data not available 77.8% (M4) 78.9% (M4)

Mixed sex accommodation breaches 0 (M5) 1 (M5) 1 (M5) 9 (M5) 0 (M5) 9 (M5) 0 (M5) 0 (M5)

Mixed sex accommodation breach rate 0.0 (M5) Data not available 0.1 (M5) Data not available 0.0 (M5) Data not available 0.0 (M5) 0.0 (M5)

Cancelled operations – 28 day standard 0.0% (M5) 0.0% (M5) 19.2% (Q1) 1.0% (Q1) 0.0% (Q1)

Urgent operations cancelled for a second time 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5)


Please note: the dashboard shows the position for local Out of Area (OOA) Trusts. Only measure where data is available from validated published data sources are included. The M5 dashboard will include all mandated and constitutional standards and year to date position. Where out of area providers have impacted on CCG performance , commentary is included in Section 3.

Key messages

10

Section 3: Out of Area (M5 performance) (contd.)


Performance Measure Ashford & St Peters UCLH Guy’s & St Thomas’ Royal Free

PROMS – hip replacement 0.406 0.393 0.407 0.384 PROMS – knee replacement 0.297 0.242 0.249 0.261 PROMS – groin hernia 0.093 0.067 0.084 0.051

PROMS – varicose veins Data not available due to

low numbers 0.078 0.079 0.078

Friends & family test score – A&E 50 (M5) 45 (M5) 52 (M5) 39 (M5) Friends & family test score – Inpatient 74 (M5) 70 (M5) 79 (M5) 45 (M5) Friends & family test score – Combined 59 (M5) 58 (M5) 71 (M5) 41 (M5) Patient experience of hospital care 73.7 78.1 78.9 73.6 MRSA cases 0 (M5 YTD) 3 (M5 YTD) 3 (M5 YTD) 0 (M5 YTD)

C.Diff cases 2 (M5 YTD)

Annual target = 13 33 (M5 YTD)

YTD target = 15 12 (M5 YTD)

Annual target = 47 13 (M5 YTD)

YTD target = 12

Please note: the dashboard shows the position for local Out of Area (OOA) Trusts. Only measure where data is available from validated published data sources are included. The M5 dashboard will include all mandated and constitutional standards and year to date position. Where out of area providers have impacted on CCG performance, commentary is included in section 3.

Key messages


11

Section 4: CCG Outcomes Framework


This section is a performance dashboard that gives the CCG an overview of its position in relation to the indicators listed in the CCG Outcomes Framework. All indicators have an improvement threshold. HCAI is reported monthly and related comments have been provided in Section 14 of this report.

Key messages


Domain Description Period Baseline TargetPrevious

Performance

Current

Performance

Performance

assessment

Reporting

Frequency

Date next

available

Potential years of life lost (PYLL) from causes considered

amendable to healthcare - MALE2012 reduction

2552.0

(2011)

2058.8

(2012)Annual TBC


amendable to healthcare - FEMALE2012 reduction

1748.8

(2011)

1968.1

(2012)Annual TBC


amendable to healthcare - ALL PERSONS2012 reduction

2132.9

(2011)

1998.2

(2012)Annual TBC

Under 75 mortality rate from cardiovascular disease2012 reduction

80.7

(2011)

61.6

(2012)Annual TBC

Under 75 mortality from respiratory disease2012 reduction

24.8

(2011)

29.8

(2012)Annual TBC

Under 75 mortality rate from liver disease2012 reduction

24.5

(2011)

21.7

(2012)Annual TBC

Emergency admissions for alcohol-related liver disease2011/12 reduction

33.89

(10/11)

29.7

(11/12)Annual TBC

Under 75 mortality rate from cancer2012 reduction

119

(2011)

107.6

(2012)Annual TBC

Antenatal assessments <13 weeksQ4 2012/13 increase

536

(Q3 12/13)

542

(Q4 12/13)Quarterly TBC

Maternal smoking at deliveryQ4 2012/13 reduction

4.0%

(Q3 12/13)

3.3%

(Q4 12/13)Quarterly Nov-13

Breast feeding prevalence at 6-8 weeksQ4 2012/13 increase

77.4%

(Q3 12/13)

74.1%

(Q4 12/13)Quarterly TBC

People suffering from a long term condition feeling

supported2012/13 increase

80.7%

(Apr-Jun)

74.9%

(Jul-Mar)Six monthly not known

Unplanned hospitalisation for chronic ambulatory care

sensitive (ACS) conditions (adults)2011/12 reduction

914.7

(10/11)

982

(11/12)Annual TBC

Unplanned hospitalisation for asthma, diabetes and

epilepsy (under 19s)2011/12 reduction

269.97

(10/11)

267.7

(11/12)Annual TBC

Estimated diagnosis rate for people with dementia no data no data no data no data no data no data no data

Prev

enti

ng p

eopl

e

from

dyi

ng p

rem

atur

ely

Enha

ncin

g th

e qu

alit

y

of li

fe o

f

peop

le w

ith

long

term

con

diti

ons

12

Section 4: CCG Outcomes Framework (contd.)

high quality support to commissioners to improve health and wellbeing Please see Appendix 2 for further report definitions guidance

Domain Description Period Baseline TargetPrevious

Performance

Current

Performance

Performance

assessment

Reporting

Frequency

Date next

available

Emergency admissions for acute conditions that should not

usually require hospital admission2011/12 reduction

1334.38

(10/11)

1265.7

(11/12)Annual TBC

Emergency readmissions within 30 days of discharge from

hospital2010/11 reduction not available

13.3

(10/11)Annual TBC

Increased health gain as assessed by patients for elective

procedures - hip replacement2011/12 increase

0.456

(10/11)

0.452

(11/12)Annual TBC


procedures - knee replacement 2011/12 increasedata supressed

due to small

numbers

0.305

(11/12)Annual TBC


procedures - groin hernia 2011/12 increasedata supressed

due to small

numbers

0.046

(11/12)Annual TBC


procedures - varicose veins. 2011/12 increasedata supressed

due to small

numbers

data supressed

due to small

numbers

Annual TBC

Emergency admissions for children with lower respiratory

tract infections (LRTIs)2011/12 reduction

335.47

(10/11)

255.8

(11/12)Annual TBC

Patient experience of GP out of hours services2012/13 improvement

65.7%

(Apr-Jun)

60.1%

(Jul-Mar)Six monthly not known

Patient experience of hospital care (CCG weighted

average)2011 improvement not available

75

(2011)Annual TBC

Patient experience of outpatient services2011 improvement not available

78

(2011)Annual Autumn 13

Improvement in hospitals’ responsiveness to personal

needs2011 improvement not available

66

(2011)Annual TBC

Patient experience of accident and emergency (A&E)

services.2011 improvement not available

78

(2011)Annual TBC

Patient safety incidents reportedApr-12 to Oct-12 0 not available

4

(Apr-Sep)Six monthly Oct-13

Incidence of healthcare associated infection (HCAI): MRSAApr-Aug 13 1

4

(2012/13)

4

(Apr-Aug)Monthly Nov-13

Incidence of healthcare associated infection (HCAI):

Clostridium difficile (C.difficile)Apr-Aug 13 13

36

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Section 5: Quality premium

▪ H&F CCG reported a total of 17 C.Diff YTD cases which is 4 cases above its year to date tolerance of tolerance of 13 cases. All hospital acquired cases (11 out of 17) were reported by ICHT. H&F CCG is above the zero tolerance for MRSA bacteremia with 4 cases reported YTD (1 case reported by ICHT, 1 by CW and 2 cases which was assessed as not hospital acquired). Both providers have undertaken Root Cause Analysis with action Plans in place. Under current DH guidance the HCAI Quality Premium is awarded only where the number of cases are at or below both C.Diff and MRSA tolerances.

Key messages

Actual Target Max.

Value (£) Potential loss of income (£) Frequency

Gateway measures

18 week RTT (incomplete pathway) 95.5% (M5 YTD) 92% N/A N/A Monthly A&E waits (CCG mapped from HES provider data)

97.7% (M5 YTD) 95% N/A N/A Monthly

Cancer waits - 62 days (urgent GP referral)

75.3% (M5 YTD) 85% N/A N/A Monthly

Cat A red 1 ambulance calls (LAS performance) 77.7% (M5 YTD) 75% N/A N/A Monthly

Domain measures

Reducing potential years of lives lost through amenable mortality

1,998 (2012) Available later in

2013 111,417 Annual

Reducing avoidable emergency admissions (composite measure)

Not yet available Not yet available 222,834 Annual

Patient experience of acute inpatient care and A&E using the Friends and Family Test

Not yet available Not yet available 111,417 Annual

Preventing healthcare associated infections

4 MRSA (M5 YTD) 17 C.Difficile (M5 YTD)

0 MRSA (M5 YTD) 13 C.Difficile (M5 YTD)

111,417 111,417 Monthly

Local measures

Year 2 first dose Immunisation MMR 81.3% (Q4 12/13) 84.90% 111,417 111,417 Quarterly

Care Planning: X-PERT Programme for Diabetes

Not yet available 18% 111,417 TBD

Physical health checks for people with severe and enduring mental illness

Not yet available 86% 111,417 TBD

TBD

TBD

TBD

TBD

TBD

Please see Appendix 1 for Quality Premium calculation guidance Please see Appendix 2 for further report definitions guidance

14

Section 6: NHSE Assurance – provider quality of care


▪ No provider has been subject to a local enforcement action by the Care Quality Commission and no provider has been flagged as a quality compliance risk by Monitor

▪ Chelsea and Westminster Friends & Family Test improvement action plans in place; CQUIN target is for a minimum of 15% response rate. ▪ Similarly all providers that have reported single sex accommodation breaches and or MRSA cases have action plans in place.

Key messages

Domain 1: Are local people getting good quality care? Providers Provider 1 Provider 2 Provider 3 Provider 4

Provider Name CENTRAL LONDON

COMMUNITY HEALTHCARE NHS TRUST

WEST LONDON MENTAL HEALTH NHS TRUST

IMPERIAL COLLEGE HEALTHCARE NHS TRUST

CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION

TRUST

Please identify the percentage of provider income for CCG: 14 18 47 21

Is this CCG the lead or associate commissioner? Associate Associate Lead Associate

Has local provider been subject to local enforcement action by the CQC? No No No No

Has local provider been flagged as a 'quality compliance risk' by Monitor and/or are requirements in place around breaches of provider licence conditions?

No No No No

Has local provider been subject to enforcement action by the NHS TDA based on 'quality' risk?

No No No No

Does feedback from the Friends and Family test (or any other patient feedback) indicate any causes for concern?

No No No No

Has the provider been identified as a 'negative outlier' on SMHI or HSMR? No No No No

Do provider level indicators from the National Quality Dashboard show that MRSA cases are above zero?

No No Yes – Action plan in place Yes – Action plan in place

Do provider level indicators from the National Quality Dashboard show that the provider has reported more C difficile cases than trajectory?

No No Yes – Action plan in place No

Do provider level indicators from the National Quality Dashboard show that MSA breaches are above zero?

No No No No

Does provider currently have any unclosed Serious Untoward Incidents (SUIs)?

Yes – Action plan in place Yes – Action plan in place Yes – Action plan in place Yes – Action plan in place

Has the provider experienced any 'Never Events' during the last quarter? No No Yes – Action plan in place No

Is provider meeting the 15% response rates on FFT ? (Domain 3) Further development required Further development required Yes – No action plan in place Yes – No action plan in place

15

Section 6: NHSE Assurance – provider quality of care (contd.)


▪ RTT performance 52 week standard with 1 breach reported by ICHT. The patient was treated in M5. ▪ H&F CCG did not meet the 62 day to treatment standard in M5 or the year to date, with performance in M5 driven by ICHT. ▪ H&F CCG met Health Care Acquired Infection in M5 but not year to date. ▪ National CPA Target is reported quarterly . The Trust was not meeting the target for Q1 , however local Trust reporting indicates that the M5 target has been met

Key messages

Domain 2: Are patient rights under the NHS Constitution being promoted?

16

Section 7: Shaping a Healthier Future tracker information: UCC and A&E attendances, non-elective admissions and community events


Key message

▪ The Shaping a Healthier Future programme requires Out of Hospital strategies to reduce unnecessary attendances and non-elective admissions. They do this by (i) providing improved care in the community to prevent emergency attendances; (ii) diverting minor A&E attendances away from A&E departments to Urgent Care Centres and primary care. The graphs show trends in Hammersmith & Fulham for UCC and A&E attendances and non-elective admissions.

▪ For Hammersmith & Fulham UCC & A&E attendances are increasing and non-elective admissions are decreasing. Investigations are planned into the completeness and quality of Rapid Response data hence its absence from this month’s report.

Note: Activity being verified and subject to change

Note: Rapid response data subject to review

17

Section 8: Acute provider operational performance – exceptions and early warnings – ICHT


Key messages

Remedial and improvement actions are detailed in section 10 & 11

Red/amber indicators In month YTD Threshold Trend

No. 52 week waiters – admitted pathways 2

6

0

No. 52 week waiters – non-admitted pathways 1 10 0

No. 52 week waiters – incomplete pathways 0 4 0

LAS arrival to handover > 30mins

26 (Hammersmith

Hosp. 6) (Charing Cross 7)

(St Mary’s 13)*

168 (Hammersmith

Hosp. 33) (Charing Cross

31) (St Mary’s 104)*

0

LAS arrival to handover > 60mins 0

1 (Hammersmith

Hosp. 1) 0

Cancelled operations – breaches of 28 days readmission standard

5.4% 14.3% 5.0%

Please see Appendix 2 for further report Definitions guidance

• Note: site specific data subject to futher validation

18

Section 8: Acute provider operational performance – exceptions and early warnings – ICHT (contd.)


Key messages


First definitive treatment for cancer within 31 days of diagnosis

97.7% 95.2% 96%

First definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer

65.6% 72.7% 85%

No. of MRSA cases 1 5

0

No. of C.Diff Cases 3 32

5 (M5) 26 (YTD)

A&E 4hr wait – type 1 92.6% 92.7%

95%



19

Section 8: Acute provider operational performance – exceptions and early warnings – ICHT (contd.)


Key messages


CMS Compliance (KPI 1): updating of ED status page outside of the hours 01:00-06:00

54.6% 53.0% 80% within 2

hours

CMS Provider Compliance KPI 2: Updating of Bed Status page between the hours of 06:00-22:00 within 4 hours

75.6% 79.6% 80% within 2

hours

Choose & Book: slot availability 18.8% 16.8% 2%

Breastfeeding initiation rate 89.4% 88.2% 90%

Newborn blood spot screening tests 76.7% 79.9% 100%

Midwife to birth ratio 1:33 (SMH)

1:31 (QCCH)

Not applicable

1:30 Not Applicable

Home births 1.35% 0.8% 1.35%

NRLS System Uploads in the past 6 months Not applicable 5/6 months uploaded

(Apr-Sep12) 6/6 months Not Applicable



20

Section 8: Acute provider operational performance – exceptions and early warnings – CW


Key messages


No. 52 week waiters – admitted pathways 0 1 0

No. 52 week waiters – non-admitted pathways 0 5 0


LAS arrival to handover > 30mins 4 23 0

No. of MRSA cases 1 2 0

Home births 0.5% 1.2% 2.0%

Percentage of elective c-sections 12.3% 15.5% 15%

Percentage of non-elective c-sections 15.4% 18.2% 12%



21

Section 8: Acute provider operational performance – exceptions and early warnings – CW (contd.)


Key messages


Midwife to birth ratio 1:36 Not

Applicable 1:30 Not Applicable

CMS Compliance (KPI 1): updating of ED status page outside of the hours 01:00-06:00

60.5% 64.9% 80% within 2

hours


Delayed transfers of care 2.5% 1.5% 2%

Stroke TIA - % of people referred with a suspected TIA, who are at high risk of stroke, who are assessed and treated within 24 hours

66.7% 80.8% 75%



22

Section 8: Acute provider operational performance – exceptions and early warnings – RBH


Key messages



First definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer

90.9% 72.2% 85%

First definitive treatment for cancer within 62 days of a consultant decision to upgrade

50.0% 90.0% 85%

Urgent operations cancelled for the second time 0 2 0

No. of MRSA cases 0 2 0

No. of C.Diff Cases 1 5 0 (M5)

2 (YTD)




23

Section 9: Acute provider quality performance – exceptions and early warnings – ICHT


• The Maternal Mortality Ratio (MMR): the number of maternal deaths per 100,000 live births over a 12 month period. The actual number of maternal deaths is specified in brackets after the Maternal Mortality Ratio. It is a pathway measure across a number of providers.

• Serious Incidents Reported: YTD SI data does not take into account de-escalations. • Average Delay (in days) of Reporting Serious Incidents from date identified: 12% (8) of reported Serious Incidents did not have the date of identification available and are

not included in the indicator

Key messages


Maternal Mortality Rate (per 100,000) < 42 days 0 (0) 13.98 Not Applicable

Maternal Mortality Rate (per 100,000) > 42 days 22.67 (2) 13.98 Not Applicable

Standardised Hospital Mortality Indicator (SHMI) Jan 12 - Dec 12

76.49 100

Serious Incidents Reported 11 65

Never Events 0 1 0

Average Delay (in days) of Serious Incidents Reporting from date identified

3 5 2 New metric

Number of Serious Incident RCA Reports Overdue 2 14 0 New metric

Pressure Ulcer Prevalence (All) 3.18% 3.25% National avg

5.07%

▪ Actions detailed in section 12

Please see Appendix 2 for further report definition guidance

24

Section 9: Acute provider quality performance – exceptions and early warnings – ICHT


• Patient-Led Assessments of the Care Environment (PLACE) are new and replace the Patient Environment Action Team (PEAT) programme. This new process and assessment is a collaboration between hospital staff and patient assessors, focusing on the four key areas:

(1) Cleanliness – including hand hygiene (2) Buildings and facilities – condition, appearance and maintenance of the building, fixtures and fittings (3) Privacy and Dignity (4) Food and hydration

• The RAG rating for the PLACE indicators is based upon the national averages

Key messages


Patient-Led Assessments of the Care Environment (PLACE) Q1 2013/14

Cleanliness 99.03% National avg

95.74% New metric

Food and Hydration 80.91% National avg

88.75% New metric

Privacy, Dignity and Wellbeing 88.61% National avg

88.87% New metric

Condition, Appearance and Maintenance 89.22% National avg

84.98% New metric

Friends and Family Test (FFT)

FFT Response Rate – A&E 16.3% 17.9% 15%

FFT Score – A&E 53 50.4

FFT Response Rate - Inpatient 31.6% 26.0% 15%

FFT Score - Inpatient 69 69.8



25

Section 9: Provider Serious Incidents and Complaints Categories – ICHT (contd.)


Remedial and improvement actions are detailed in section 14

Key messages

Complaints category data is not in contract specification Complaints indicators are one month behind

Complaints Indicators Target Jul-13 YTD

% of complaints acknowledged within 3 days of receipt

100% 100% 100%

% of complaints responded to within the agreed target

100% 95% 95.5%

Serious Incidents Categories Aug-13

C.Diff & Health Care Acquired Infections 1

Delayed diagnosis 1

Maternity Services - Maternal unplanned admission to ITU 1

Maternity Services - Unexpected admission to NICU (neonatal intensive care unit)

1

Pressure ulcer Grade 3 3

Radiology/Scanning incident 1

Screening Issues 1

Unexpected Death (general) 1

Unexpected Death of Outpatient (not in receipt) 1

TOTAL 11

Complaints Categories Apr-13 May-13 Jun-13 Jul-13 Aug-13 YTD

Admission, transfer and discharge arrangements

6 9 3 5 5 28

Delay or cancellation of an inpatient appointment

2 1 4 3 10

Delay or cancellation of outpatient 7 8 9 12 5 41

Attitude of staff 4 7 3 11 2 27

All aspects of clinical care 41 44 28 41 39 193

Communication to patients or relatives 5 5 4 7 6 27

Patient’s property or expenses 1 2 1 2 6

Policy or commercial decisions of the Trust

1 2 3

Hotel services 1 1

Transport 3 2 1 4 10

Pt. Status / Discrimination 1 1 1 3

Personal Records 1 1

Privacy & Dignity 1 1 3 5

Aids & Appliances 1 1

TOTAL 67 80 58 82 69 356



26

Section 8: Acute provider quality performance – exceptions and early warnings – CW


The Maternal Mortality Ratio (MMR) is the number of maternal deaths per 100,000 live births over a 12 month period. The actual number of maternal deaths is specified in brackets after the Maternal Mortality Ratio. It is a pathway measure across a number of providers. YTD SI data does not take into account de-escalations. 8% (3) of reported SIs do not have date identified available and are not included in the ‘average delay in days of serious incident reporting’ indicator– we are currently chasing up the missing information

Key messages


Maternal Mortality Rate (per 100,000) < 42 days 20.08 (1) 13.98 Not Applicable

Maternal Mortality Rate (per 100,000) > 42 days 0 (0) 13.98 Not Applicable


78.1 100


Never Events 0 1 0


10 19 2 New metric



5.07%



27

Section 9: Acute provider quality performance – exceptions and early warnings – CW


• The Maternal Mortality Ratio (MMR) is the number of maternal deaths per 100,000 live births over a 12 month period. The actual number of maternal deaths is specified in brackets after the Maternal Mortality Ratio. It is a pathway measure across a number of providers.

• Serious incidents Reported: YTD SI data does not take into account de-escalations. • Average Delay (in days) of Serious incidents Reporting from date identified: 8% (3) of reported SIs do not have date identified available and are not

included in the ‘average delay in days of serious incident reporting’ indicator – we are currently chasing up the missing information

Key messages


Maternal Mortality Rate (per 100,000) < 42 days 20.08 (1) 13.98 Not Applicable

Maternal Mortality Rate (per 100,000) > 42 days 0 (0) 13.98 Not Applicable


78.1 100


Never Events 0 1 0


10 19 2 New metric



5.07%




Section 9: Provider Serious Incidents and Complaints Categories – CW (contd.)


Central Alerting System overdue NPSA alerts 3 3



95.74% New metric


88.75% New metric


88.87% New metric


84.98% New metric


FFT Response Rate – A&E 11.9% 11.8% 15%

FFT Score – A&E 77 72.4

FFT Response Rate – Inpatient 33.8% 36% 15%

FFT Score – Inpatient 64 64.6



• Patient-Led Assessments of the Care Environment (PLACE) are new and replace the Patient Environment Action Team (PEAT) programme. This new process and assessment is a collaboration between hospital staff and patient assessors, focusing on the four key areas:


• Overdue NPSA alerts involve ‘Safer spinal (intrathecal), epidural and regional devices (Part A and B)’ and ‘Minimising risk of mismatching spinal, epidural and regional devices with incompatible connectors’ – alerts overdue because no suitable replacements are available. Alerts are being monitored by the trust through the risk register and the Governance and Quality Committee – as per advice from the Association of Anaesthetists of Great Britain and Ireland (AAGBI).


Section 9: Provider Serious Incidents and Complaints Categories – CW (contd.)

Complaints categories data is not in contract specification. Complaints indicators are one month behind.



100% 100% 100%


100% 85.7% 82.9%


Allegation Against HC Professional 2

Communicable Disease and Infection Issue 2


Safeguarding Vulnerable Adult 1

TOTAL 8

Complaints Categories Jul-13 Aug-13


1 2

Failure to follow agreed procedure 2

Attitude of staff 8 3

All aspects of clinical care 19 12

Communication to patients or relatives 5

Information/Communication 2

Delay/Cancellation 1

Other 1 5

TOTAL 36 25



30

Section 9: Acute provider quality performance – exceptions and early warnings – RBH


• Serious Incidents Reported: YTD SI data does not take into account de-escalations. • Average Delay (in days) of Serious Incident Reporting: 33% (3) of reported Serious Incidents did not have the date of identification available

and are not included in the indicator

Key messages



Never Events 0 1 0


3 13 2 New metric


Pressure Ulcer (All) 1.92% 1.84% National avg

5.07%

NRLS System Uploads in the past 6 months 6/6 Not Applicable



31

Section 9: Acute provider quality performance – exceptions and early warnings – RBH


Key messages


Central Alerting System overdue NPSA alerts 3 3

NRLS uploading 5/6 6/6



95.74% New metric


88.75% New metric


88.87% New metric


84.98% New metric


FFT Response Rate – A&E n/a n/a Not Applicable

FFT Score – A&E n/a n/a Not Applicable

FFT Response Rate - Inpatient 20.4% 23.0%

FFT Score - Inpatient 87 85.6



• Patient-Led Assessments of the Care Environment (PLACE) are new and replaces the Patient Environment Action Team (PEAT) programme. This new process and assessment is a collaboration between hospital staff and patient assessors, focusing on the four key areas:


• The RAG rating for the PLACE indicators is based upon the national averages. • Overdue NPSA alerts involve ‘Safer spinal (intrathecal), epidural and regional devices (Part A and B)’ and ‘Minimising risk of mismatching spinal, epidural and regional devices

with incompatible connectors’ – alerts overdue because no suitable replacements are available. Alerts are being monitored by the trust through the risk register and the Governance and Quality Committee – as per advice from the Association of Anaesthetists of Great Britain and Ireland (AAGBI).

32

Section 9: Provider Serious Incidents and Complaints Categories – RBH (contd.)


Key messages

Complaints categories data is not in contract specification; NWL CSU will be obtaining complaints categories data from NHS England. Complaints indicators are one month behind



100% 100% 100%


100% 100% 100%

Complaints Categories Apr-13 May-13 Jun-13 Total


2 1 1 4

Delay or cancellation of an inpatient appointment

1 0 1 2

Delay or cancellation of outpatient 3 0 1 4

Attitude of staff 3 5 4 12

All aspects of clinical care 12 15 10 37

Communication to patients or relatives 2 3 1 6

Patient’s property or expenses 2 0 0 2

Hotel services 0 1 2 3

Other 2 2 1 5

TOTAL 27 27 21 75


C.Diff & Health Care Acquired Infections 1


TOTAL 2



33

Section 9: Community provider performance – exceptions and early warnings – Central London Community Healthcare (H&F)


• Serious Incidents Reported: YTD SI data does not take into account de-escalations. • Average Delay (in days) of Serious Incidents Reporting from date identified: 20% (2) of reported Serious Incidents did not have the date of identification available and are

not included in the indicator • Patient-Led Assessments of the Care Environment (PLACE) are new and replaces the Patient Environment Action Team (PEAT) programme. This new process and assessment

is a collaboration between hospital staff and patient assessors, focusing on the four key areas: (1) Cleanliness – including hand hygiene (2) Buildings and facilities – condition, appearance and maintenance of the building, fixtures and fittings (3) Privacy and

Dignity (4) Food and hydration • The RAG rating for the PLACE assessment is based upon the national averages

Key messages




1 10 2 New metric



5.07%



95.74% New metric


88.75% New metric


88.87% New metric


84.98% New metric



34

Section 9: Provider Serious Incidents and Complaints Categories – Central London Community Healthcare (H&F)


Complaints categories data is not in contract specification. The category of the complaints received in month was requested from the provider but was not received in time to be included in this report.

Key messages



TOTAL 1



35

Section 8: Mental provider performance – exceptions and early warnings – WLMHT (H&F CCG Performance)


10 &11

Key messages

Remedial and improvement actions are detailed in section 10 &11


% of CPA follow up 7 days after discharge 89.2% (Q1)

Not available

95% Not Available

% of DNA for follow up 11.6% Not available

11.0%

(by end Q4)

Not Available

% of Patients readmitted within 30 days of discharge 13.2% Not available 8.1%

(by end Q4)

Not Available

% of complaints resolved within timescale 33.3% Not available 100% Not Available


36

Section 9: Mental Health provider performance – exceptions and early warnings - West London Mental Health Trust (H&F)


• Serious Incidents Reporting: YTD SI data does not take into account de-escalations. • Average Delay (in days) of Serious Incidents Reporting: 14% (1) of reported Serious Incidents did not have the date of identification available and are not included in the indicator • Patient-Led Assessments of the Care Environment (PLACE) are new and replace the Patient Environment Action Team (PEAT) programme. This new process and assessment is a collaboration

between hospital staff and patient assessors, focusing on the four key areas: (1) Cleanliness – including hand hygiene (2) Buildings and facilities – condition, appearance and maintenance of the building, fixtures and fittings (3) Privacy and Dignity (4) Food and

hydration. • The RAG rating for the PLACE indicators is based upon the national averages.

Key messages




8 9 2 New metric



5.07%



95.74% New metric


88.75% New metric


88.87% New metric


84.98% New metric



37

Section 9: Provider Serious Incidents and Complaints Categories West London Mental Health Trust (H&F)


Complaints categories data is not in contract specification. Complaints data relate to H&F only.

Key messages

Complaints Categories Jul-13

All aspects of clinical care 1

Other 1

TOTAL 2


Attempted Suicide by Outpatient (in receipt) 1

TOTAL 1



38

Section 9: 111 Pilot Services

Key messages

▪ Recovery plans are in place with both providers and will begin to address the longer waits in CWLH ▪ The CSU are monitoring providers work force plans to address the level of clinical call backs across NWL.


Source: Unify 2, a query has been raised about the calculations used for the disposition data with NHSE

*BEHH = Brent, Ealing, Harrow, Hounslow

** CLWH = Central London, West London, Hammersmith & Fulham

*** It is expected that call backs are an Exception

Call Standards *BEHH Hillingdon **CLWH Eng *BEHH Hillingdon **CLWH Eng *BEHH Hillingdon **CLWH Eng *BEHH Hillingdon **CLWH Eng

Percentage of calls answered in 60

seconds97.7% 98.3% 96.2% 97.7% 98.4% 98.9% 95.4% 98.2% 98.8% 98.9% 97.1% 98.3% 97.7% 98.6% 95.7% 97.5%

Percentage of calls abandoned after 30

seconds1.6% 1.4% 0.5% 0.6% 0.2% 0.1% 0.6% 0.5% 0.1% 0.2% 0.6% 0.4% 0.3% 0.3% 0.4% 0.6%

Percentage of calls triaged 92.6% 117.6% 100.0% 78.1% 81.6% 92.6% 100.0% 86.1% 80.7% 82.2% 100.0% 86.0% 74.4% 84.5% 100.0% 85.7%

% of calls requiring clinical advice offered

call back ***14.5% 16.4% 9.3% 8.3% 7.1% 8.0% 9.2% 8.0% 5.4% 4.8% 8.4% 6.9% 2.2% 4.2% 6.2% 7.0%

Percentage of clinical call backs within 10

minutes57.6% 57.7% 73.0% 45.2% 66.3% 62.0% 69.4% 44.0% 72.6% 61.0% 68.3% 45.4% 69.0% 58.9% 65.5% 61.3%

Dispositions BEHH Hillingdon **CLWH Eng BEHH Hillingdon **CLWH Eng BEHH Hillingdon **CLWH Eng BEHH Hillingdon **CLWH Eng

Led to ambulance dispatches 11.2% 14.3% 10.5% 8.4% 10.8% 13.4% 9.1% 9.3% 11.3% 10.2% 10.5% 9.3% 10.1% 11.9% 10.5% 8.6%

Recommended to attend A&E 8.5% 9.9% 7.8% 9.2% 6.0% 7.6% 7.8% 6.9% 7.8% 6.6.% 8.5% 6.8% 7.2% 7.4% 8.4% 6.4%

Recommended to attend primary and

community care56.8% 72.1% 74.5% 45.4% 49.1% 56.5% 72.8% 53.9% 47.7% 52.6% 59.3% 53.5% 45.9% 50.6% 63.4% 54.8%

Recommended to attend other service 2.3% 3.0% 4.3% 3.6% 2.2% 1.4% 6.3% 4.0% 2.5% 1.6% 6.8% 3.9% 1.5% 1.9% 4.8% 4.1%

Did not recommend to attend other

service13.6% 18.1% 2.9% 11.4% 13.5% 13.8% 3.9% 12.4% 11.4% 11.1% 15.0% 12.4% 9.8% 12.6% 12.9% 11.8%

04-Aug 11-Aug 18-Aug 25-Aug


Section 9: 111 Governance

Key messages

NHS 111 Live Site

Report to Pan London Clinical Leads Group 111

Name of service INWL 111 Service

Report for the month of August 2013

Audit Update No. of local/internal CG audits carried

out

Nil

Audit Update No. of End to End Call Reviews (include

review of full NHS Pathway)

2nd August 4 call reviews undertaken

Governance Activity Attendance at Pan London 111 CGG.

Call review meeting with LAS in relation to Serious Incident

SI RCA panel meeting and investigation process, LAS call reviews undertaken in relation to

case, independent call reviews organised of LAS calls.

Safeguarding audit in progress

Total number of calls this month 6558

Serious Incidents

SIs opened this month 0

SIs this calendar year 1

Of the total for this

calendar year

Closed and actual 0

Closed and NOT SI 0

Still open 1

40

Section 10: Action Log: provider performance


… …

Key lines of enquiry

Issue Provider Root Cause Action Closed Risk

None Actions for CSU

Not meeting specialty or 52 week standards

RBHT Poor waiting list management Critical review of action plan and reasons for the 52 week wait

No (Due to be reviewed at Oct. CQG)

Lack of assurance on mitigating actions in place NHSE contacted and requested to review as lead commissioner.

RBH did not meet M3 C.Diff tolerance

RBH Poor infection control processes Review tolerance for 13/14 with DH No

Not applicable

Not meeting 31day to treatment, and 62 days to treatment cancer standards.

ICHT RBH

Currently under review -A detailed review of the root cause analysis of M4 breaches to identify additional actions required. -Update of ICHT cancer action plan at CQG

Yes

Not meeting 18 week RTT specialty standards

ICHT Poor waiting list management -Review updated action plan and trajectories Yes

LAS handover breaches ICHT & CW A&E processes -Daily monitoring of A&E pressures and provider actions in place -Submission of winter assurance and demand and capacity plans to NHS England

Yes

Last minute cancelled operations ICHT Poor escalation processes Monitor progress against action plan Yes

ICHT did not meet YTD C.Diff tolerance and MRSA tolerance

ICHT Poor infection control processes Update to action plan to be reviewed at CQG. No Lack of assurance on mitigating actions in place to reduce

Choose and Book Compliance ICHT Outpatient capacity and administrative processes

Review of ICHT action plan (due for submission at the end of September)

No Not applicable

41

Section 10: Action log: provider performance (contd.)


… …


Issue Provider Root Cause Action Owner Closed Risk

Actions for CSU

CPA 7 day follow up

WLMHT National CPA Target is reported quarterly . The Trust were not meeting the target for Q1 , however local Trust reporting indicates that the M5 target has been met

WLMHT

Yes

Not applicable

Percentage of DNA for follow up

WLMHT High number of patients on holiday during August

E-referral has been rolled out to some GP practices across the boroughs which has helped to reduce the DNA rate. E-referral s currently being rolled out to all GP practices.

WLMHT

No

Patients may continue to DNA appointments due to reasons out of the control of the service

Percentage Readmissions within 30 days

WLMHT

Patients that were discharged had relapse and returned to inpatient unit within 30 days.

For patients with a readmission within 30 days, a review by the whole clinical team will take place to ascertain reasons and lessons learnt

WLMHT No

Patients may continue to be discharged appropriately but there is a risk that the reasons for relapse and consequent readmission may be out of control of the service

Percentage of complaints resolved within timescale

WLMHT Staffing Recruitment drive completed and month on month improvement although below target. CSU to monitor.

WLMHT

No

Not applicable

42

Section 10: Action log: provider performance (contd.)


… …


Issue CCG Root Cause Action Closed Risk

Actions for CCG

CSU does not have access to HCAI database at a CCG level

CCG Unknown CCG need to approve CSU access to HCAI database

No CSU unable to review individual infections leading to lack of detail within reports.

Not meeting specialty or 52 week standards

ICHT Poor waiting list management - CCG to approve plan. Yes

Referrals responded to during the day, twilight or night service periods within 4 hours

CLCH Finalised KPI definitions were circulated at Care Quality Group on 15.09.13. The provider is still putting procedures in place to collect the data appropriately.

Provider to commence data collection by M6 reporting . CSU to ensure this issue is addressed at Data Quality and Reporting Improvement Group with CLCH to be will be held on 14.10.13

No

Risk that data collection may not commence in time of M6 reporting Referrals responded to during the

day, twilight or night service periods within 24 hours

LAC Initial Health Assessments CLCH The new changes introduced in the spring of 2013 have meant that a cohort of children under 18 are now classed as Looked after Children (LAC). The acute paediatrician has arranged a visit to Feltham Young Offenders Prison to undertake the assessments there. 12 outstanding referrals have caused the dip in performance.

The Associate Director for Safeguarding in CWHH will clarify the reporting position with regards to referrals from Feltham Young Offender Prison at CQG on 30th October 2013 . The 12 outstanding cases are being reviewed by the Designated Nurse for LAC and the an update will be provided by the Associate Director for Safeguarding in CWHH at CQG on 30th October 2013

No

Impact on performance may be affected by inclusion of new cohort of children

43

Section 10: Action log: provider quality


… …


Issue Provider Root Cause Action Owner Closed Risk

Actions for CSU

The trust has now submitted data on complaints. 99% are responded to within the agreed time frame.

ICHT Trust not responding within agreed time frames

Discussed at CQG. CSU to monitor performance.

ICHT

Yes

44

Section 11: Recommendations and next steps


… …


Issue Provider Root Cause Action Accountable Officer

Date

Actions for CSU

Not meeting 31day to treatment, and 62 days to treatment cancer standards.

ICHT RBH

• Poor administrative processes and capacity issues at ICHT

• RBH reported complex pathway

• A detailed review of the root cause analysis of M5 breaches to identify additional actions required.

• Review of progress against cancer action plan and agree trajectory with ICHT. Contract penalty to be applied

CSU performance team CSU Contract team

October 2013 October 2013


ICHT • Poor waiting list management

• Review updated action plan, reasons for 52 week breaches and trajectories

• Contract penalty to be applied

CSU performance team CSU Contract team

October 2013


CW • Poor waiting list management

• Monitor plan CSU performance team

October 2013

LAS handover breaches ICHT & CW • A&E processes • Daily monitoring of A&E pressures and provider actions in place

CSU performance team October 2013

Last minute cancelled operations ICHT • Poor escalation processes • Monitor progress against action plan

CSU performance team October 2013

1 MRSA bacteraemia CW • Unknown • Review post infection review • Contract penalty to be applied

CSU quality team CSU Contract team

October 2013

1 MRSA bacteraemia ICHT • Complex case • Review post infection review • Contract penalty to be applied

CSU quality team CSU Contract team

Completed

45



… …



Date

Actions for CSU

Delay in reporting SI's Chelsea and Westminister, ICHT, RBH, WLMHT

Trust not reporting onto StEIS within the NPSA timeline.

NWL CSU have written to trusts to highlight these delays. Delay in reporting has been reducing, when looking across all trusts, from 22 days in M1 to 12 days in M5. Suggest monthly monitoring at individual trusts level until NPSA target achieved.

Chelsea and Westminister, ICHT, RBH, WLMHT

Closed

Delay in reporting SI's ChelWest Trust not reporting onto StEIS within the NPSA timeline.

NWL CSU have previously written to trusts to highlight these delays. Chelwest has seen a reduction in delays, from 16 days average delay in M1 to 6 days average delay in M5, however, it is still significantly above the NPSA guidance of 2 days

ChelWest On-going

Delay in reporting SI's ICHT Trust not reporting onto StEIS within the NPSA timeline.

NWL CSU have previously written to trusts to highlight these delays. ICHT has seen a slight decrease in delays, from 6 days average delay in M1 to 3 days average delay in M5, which is slightly above the NPSA guidance of 2 days.

ICHT On-going

Delay in reporting SI's RBH Trust not reporting onto StEIS within the NPSA timeline.

NWL CSU have previously written to trusts to highlight these delays. RBH has seen a slight decrease in delays, from 8 days average delay in M1 to 3 days average delay in M5, which is slightly above the NPSA guidance of 2 days.

RBH On-going

Delay in reporting SI's WLMHT Trust not reporting onto StEIS within the NPSA timeline.

THH has seen a slight decreased in delays, from 11 days average delay in M1 to 7 days average delay in M5, which is significantly above the NPSA guidance of 2 days. Please note that the data is not borough specific

WLMHT October

SI reports overdue Chelsea and Westminister, ICHT, WLMHT, CLCH

Trust not completing reports within the NPSA timeline.

NWL CSU have written to each trust to highlight all cases still open and request resolution. There has been an improvement when looking across all trusts. In M3 30% of reports were received on time, whereas in M5 57% of reports were received on time

Chelsea and Westminister, ICHT, WLMHT

October

SI reporting RBH Trust delay in completing all SI actions

There has been a decrease in numbers of SI reports overdue. The main issue is one RCA; the CSU is following this up before hand over to NHS England.

NWL CSU October

46



… …



Date

Actions for CSU

FFT Inpatient score ChelWest A decrease in M5 compared with M4

Slight drop in Inpatient score in M5 compared to M4, which was a decrease compared to M3. However the response rate has increased whilst the score has decreased.

n/a Not applicable

FFT A&E Response Rate ChelWest A decrease in M5 compared with M4

Drop in A&E response rate in M5 compared to M4, which was a decrease compared to M3.

n/a Not applicable

FFT Inpatient score ICHT A decrease in M5 compared with M4

Slight drop in Inpatient score in M5 compared to M4, which was a decrease compared to M3. However the response rate has increased whilst the score has decreased.

n/a Not applicable

% of complaints responded to within time frame

ICHT Trust not responding within time scale

Nil. Has been discussed at CQG and Improving trajectory

Not applicable


ChelWest Trust not responding within time scale

Nil. Has been discussed at CQG and Improving trajectory

Not applicable

New-born blood spot screening tests

ICHT Difficulty with Data collection New metric that requires liaison with community teams to capture accurate data. To raise at next CQG

ICHT October

Home births ICHT Low numbers of home births being reported by the trust

To discuss at CQG ICHT October

Never Event - 2013/21061 - Surgical Error

Chelsea and Westminster

TBD - RCA due 8th October 2013

Review of RCA once received and monitoring of action plans

Chelsea and Westminster November

NRLS uploading RBH Upload missed in M3 Discuss at CQG and monthly monitoring

NWL CSU October

47



…


Date

Actions for CSU

Percentage of DNA for follow up

WLMHT High number of patients on holiday during August

Persistent offenders (patients that have DNA’d more than once) will be identified, contacted and reviewed SMS text reminders have been trialled across the borough, whereby patients are called 7 days before their appointment. This is planned to be rolled out to the whole service as standard practice.

WLMHT WLMHT

October 2013 October 2013

Percentage Readmissions within 30 days

WLMHT Patients that were discharged had relapse and returned to inpatient unit within 30 days.

Discharged patients to receive regular weekly contact for four weeks after discharge. CSU Contracting & Performance Teams to continue to monitor progress against action plan

WLMHT NWL CSU Contracting & Performance Team

November 2013 October 2013


48

Appendix 1:Quality Premium Calculation Guidance


49

Appendix 2: Report Guidance & Definitions


▪ Slide 5 – A&E 4hr waits. Please note that the formal measure for this indicator is reported at provider level only. Performance at CCG level is not yet available.

▪ Slide 7 – HCAI data is reported at CCG level, provider Trust data is provided at Trust-wide level (i.e not at CCG level) ▪ Slides 5-8, 18-34, 36-37 – Where provider Trust data is provided this figure is at Trust level (i.e not at CCG level) ▪ Slides 5-7, 27,30 – Variance arrows indicate change from previous period ▪ Slide 13 – (Quality Premium). N/A = “not applicable”, TBD = “ to be determined” ▪ Slide 13 – (Quality Premium). CCG performance data for A&E 4hrs waits is calculated using provider HES data mapped by the DH to commissioner level ▪ Slides 9-10 – CCG Outcomes Framework. Where the current RAG status is greyed out this indicates data for the previous period is not yet available ▪ Slide 9-10 – CCG Outcomes Framework. Indicators have been excluded from the dashboard where data is currently not yet available (data sources are shown

in the table below) ▪ Slide 22 – maternity mortality indicator definition is taken from the Organisation Health Intelligence Reports produced by NHS London in 12/13, as below:

NHS London has developed the following RAG rating: GREEN is below the London maternal death rate (deaths/100,000 deliveries) and no two deaths occurring within 31 days of each other. AMBER is equal to or more than London Maternal Death Rate but less than twice the London Maternal Death Rate. RED is if there have been two death within 31 days of each other and/or greater than twice the London Maternal Death Rate. (Trusts that have <4000 deliveries/year will show as red even though they may have only one maternal death in the reporting period due to the way that the maternal death rate is calculated).

In 13/14 the same definition is used however this also broken down by the number of deaths with 42 days of birth and those after. Domain Description Data Source Domain Description Data Source Domain Description Data Source

Potential years of life lost (PYLL) from causes

considered amendable to healthcare - MALE

Health and Social Care

Information Centre Portal

People suffering from a long term condition feeling

supported

GP Patient Survey Patient experience of GP out of hours services GP Patient Survey

Potential years of life lost (PYLL) from causes

considered amendable to healthcare - FEMALE



Unplanned hospitalisation for chronic ambulatory

care sensitive (ACS) conditions (adults)



Patient experience of hospital care (CCG

weighted average)

CQC Inpatient Survey

Under 75 mortality rate from cardiovascular disease Health and Social Care


Unplanned hospitalisation for asthma, diabetes and

epilepsy (under 19s)



Patient experience of outpatient services CQC Outpatient Survey

Under 75 mortality from respiratory disease Health and Social Care


Estimated diagnosis rate for people with dementia QOF & Health and Social

Care Information Centre

Portal

Improvement in hospitals’ responsiveness to

personal needs

CQC Inpatient Survey

Under 75 mortality rate from liver disease Health and Social Care


Emergency admissions for acute conditions that

should not usually require hospital admission



Patient experience of accident and emergency

(A&E) services.

CQC A&E Survey

Emergency admissions for alcohol-related liver

disease



Emergency readmissions within 30 days of discharge

from hospital



Patient safety incidents reported National Reporting and

Learning System – NRLS

Under 75 mortality rate from cancer Health and Social Care


Increased health gain as assessed by patients for

elective procedures - hip replacement



Incidence of healthcare associated infection

(HCAI): MRSA

Health Protection Agency -

HCAI Data Capture System

Antenatal assessments <13 weeks Unify2 (IPMR return) Increased health gain as assessed by patients for

elective procedures - knee replacement



Incidence of healthcare associated infection

(HCAI): Clostridium difficile (C.difficile)

Health Protection Agency -

HCAI Data Capture System

Maternal smoking at delivery OMNIBUS Increased health gain as assessed by patients for

elective procedures - groin hernia



Breast feeding prevalence at 6-8 weeks Unify2 (IPMR return) Increased health gain as assessed by patients for

elective procedures - varicose veins.



Emergency admissions for children with lower

respiratory tract infections (LRTIs)



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Q1 Balanced score-care report

28/10/2013

Summary of the balanced score-cared for CWHH in Q1

Central West H&F Hounslow

Domain 1 AMBER-GREEN AMBER-GREEN AMBER-GREEN AMBER-GREEN

- A number of

indicators re

quality

- A number of

indicators re quality

- A number of indicators

re quality

- A number of indicators

re quality

Domain 2 AMBER-RED AMBER-RED RED RED - Maximum two

month (62 day)

wait from urgent

GP referral to

first definitive

treatment for

cancer

- Maximum two month

(62 day) wait from

urgent GP referral to

first definitive

treatment for cancer

- Maximum two month

(62 day) wait from


first definitive treatment

for cancer

- Mental illness

specialities on CPA

followed up within 7

days of discharge

- Maximum two month (62

day) wait from urgent GP

referral to first definitive


- Maximum 62 day wait

from referral from an

NHS screening service

to first definitive

treatment for all cancers

Domain 3 AMBER-RED AMBER-RED RED AMBER-RED - Incidence of

healthcare

associated

infection

(MRSA)

- Are providers

meeting the

15% response

rates on FFT

- Incidence of

healthcare

associated infection

(MRSA)

- Are providers

meeting the 15%

response rates on

FFT

- Incidence of healthcare


(MRSA)


associated infection (c-

diff)

- Are providers meeting

the 15% response

rates on FFT



(MRSA)

- Are providers meeting

the 15% response rates

on FFT

Domain 4 AMBER-RED AMBER-RED GREEN AMBER-GREEN

- Surplus YTD - Surplus YTD

Domain 5 Fully authorised Fully authorised Fully authorised Fully authorised

Domain 1: Are local people getting good quality care?

This domain includes:

8 performance indicators for our main providers (WLMHT, Imperial, Chel West, CLCH)

1. Has local provider been subject to local enforcement action by the CQC?

2. Has local provider been flagged as a 'quality compliance risk' by Monitor and/or are requirements in place around breaches of provider licence

conditions?

3. Has local provider been subject to enforcement action by the NHS TDA based on 'quality' risk?

4. Does feedback from the Friends and Family test (or any other patient feedback) indicate any causes for concern?

5. Has the provider been identified as a 'negative outlier' on SMHI or HSMR?

6. Do provider level indicators from the National Quality Dashboard show that MRSA cases are above zero?

7. Do provider level indicators from the National Quality Dashboard show that the provider has reported more C difficile cases than trajectory?

8. Do provider level indicators from the National Quality Dashboard show that MSA breaches are above zero?

6 clinical governance indicators:

Are there…

Concerns about quality issues being discussed regularly by the CCG governing body?

Concerns about the arrangements in place to proactively identify early warnings of a failing service?

Concerns around the arrangements in place to deal with and learn from serious untoward incidents and never events?

Concerns around being an active participant in its Quality Surveillance Group?

If there was an emergency event in the last quarter, has the CCG self assessed and identified any areas of concern on the arrangements in place for

dealing with such an event?

Has the CCG self assessed and identified any risk to progress against its Winterbourne View action plan?

Domain 1 Status AMBER-GREEN

Domain 2: Are patients rights under the NHS constitution being

promoted?


• Referral to treatment times for non-urgent treatments

• Diagnostic test waiting times

• A&E waits

Indicator Operationa

l Standard

Perfor

mance Action plan

Maximum on month

(31day) wait from

diagnosis to first

definitive treatment

for all cancers

96% 94.21

%

Q1 performance against the 62 day and 31 days waits is driven by capacity constraints in Urology and Lower GI

as specialities. The Trust has undertaken a redesign of both pathways with the following actions:

Across LGI the Trust has implemented direct access for the 1st OPD clinic into the endoscopy service. This has reduced the DNA rate from 42% to 2%

Across Urology an additional Nurse Practitioner is in post and Consultant cover is being increased by 1wte from October 2013

The Trust has moved from Consultant led follow up clinic to Nurse led clinics where clinically appropriate to maximise OPD capacity.

A ‘one stop’ Urology diagnostic clinic will be in place from October 2013 to facilitate timely assessment and treatment and improve patient experience

The Trust expects to start recovering the position from October when all these actions have been fully

implemented

Maximum two month

(62 day) wait from


first definitive


85% 70.83

%

Care Programme

Approach (CPA): The

proportion of people

under mental illness

specialties on Care

Programme Approach

(CPA) who are

followed up within 7

days of discharge

from psychiatric in

patient care

95% 89.25

%

There 6 breaches in May 2013. A local investigation is being carried out to understand this issue.

In addition:

• Internal processes will be improved by the compilation of a 'Daily Notification' form by Ward Admin

highlighting all discharges from the wards. This form will then be sent to the CMHTs on a daily basis.

• The updating of patient's contact details will be prioritised prior to them being discharged from the ward.

This will give the community teams a better chance of completing the 7 day follow up.

• H&F Inpatient managers will work with their community colleagues to implement the Hounslow system

whereby the CMHTs have a NHS.net 'Duty' email address that is checked regularly though out the day by the

Duty Clinician. The 'Duty' NHS.net email address will be a safe and consistent place for Ward staff to send all

discharge notifications.

• Manual validations are to be phased out

• Any homeless patients ready for discharge will be accompanied to the Homeless Person's Unit (HPU)

• Category A ambulance calls

• Mixed sex accommodation breaches

• Mental Health Care Programme Approach

Domain Status RED This is the result of the issues below:

• Cancer patients – 2 week waits

• Cancer waits – 31 days

• Cancer waits – 62 days

Domain 3: Are health outcomes improving for local people


• Treating and caring for people in a safe environment and protecting them from avoidable harm

• Friends and family response rate

• IAPT

• Delivery of operating plan local priorities (Year 2 first dose MMR, X-PERT Programme for diabetes, Physical health checks for people with severe

and enduring mental illness)

Action plan:

• ICHT continue to provide post infection review of C.Diff cases to CQG with analysis of patients fed through into CQG

• ICHT have developed a new management reporting algorithm and control mechanisms are in place which are being integrated with an external mandated review

process.

• C-Diff – forensic examination of the C-Diff patients has taken place. The patients who acquired C-Diff were largely on antibiotics. Antibiotic exposure was therefore

being examined.

• Have introduced the isolation of patients with infectious diarrhoea within 2 hours,. Continue to work closely with bed management teams and regularly reviewing

plans. ICH is working with other teaching hospitals and working on best practice

• MRSA – all cases were complex and centred around tertiary in-patients with long LoS. After investigating, the source of the risk was deemed to be around devices,

therefore extra care was being taken around devices and a letter had been sent to all doctors and ward managers identifying the extra review processes to be put

in place.

Indicator Baseline

position Performance Analysis

Incidence of healthcare associated

infections: MRSA 0 1

11 cases reported by ICHT and 4 cases occurred in a non acute setting

Both ICHT and CW have provided post infection reviews and action plans which are monitored via CQG

Incidence of healthcare associated

infections: C difficile 10 15

Friends & Family rates 0 All providers are above 15% in the combined score using

NHSE guidance, so RAG rating should be green

Domain Status RED This is the result of the issues below:

Domain 4: Are CCGs delivering services within their financial plans?


• Underlying recurrent surplus

• Activity trends – year to date

• Activity trends – full year forecast

• Financial management

Domain 4 Status AMBER-GREEN

Appendix – RAG criteria

Documents

Hammersmith & Fulham CCG Performance & Quality Report ... · Number of 52 week RTT pathways - non-admitted 0 0 5 0 5 1 10 0 0 Number of 52 week RTT pathways - incomplete pathways