Agenda Item 12.5

1

Integrated Healthcheck and Staffing Paper

Trust Board

28 March 2019 Presented for: Governance

Presented by: Dawn Marshall, Interim Chief Nurse

Author: Georgina Duncan, Lead Nurse Professional Practice Katie Robinson, Head of Nursing, Workforce and Education

Previous Committees: NONE

Key points

1. A LTHT Nursing, Midwifery and AHP Workforce Group (NMAWG) has been established to lead, support and develop resources/activities related to the workforce.

For Information

2. An escalation and response process has been implemented to support wards that have recorded 100% Amber or 50% Red for the preceding week on the LTHT Nurse Staffing Status Report (NSSR).

For information

3. In February 2019 the registered nursing, midwifery and Operating Department Practitioner (ODP) staff vacancies within the financial ledger are showing at 11% against the current establishment. Unregistered vacancies are showing as 6%

For Information

4. Recruitment activity continues to have successful outcomes with 407 external registered Band 5 staff starting in post since April 2018

For Information

5. Six wards were in first stage ward healthcheck escalation in January 2019

For Information

6. Data for January 2019 shows no direct correlation between shortfalls in nurse staffing and healthcheck metrics or new harms

For Information

7. 11 certificates were recently awarded as part of the ward healthcheck

metrics celebration programme

For Information

Trust Goals

The best for patient safety, quality and experience ✓

The best place to work ✓

A centre for excellence for research, education and innovation

Seamless integrated care across organisational boundaries

Financial sustainability ✓

Agenda Item 12.5

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1. Summary

The Integrated Healthcheck and Staffing Paper, provides a review of nursing, midwifery and perioperative

staffing and Ward Healthcheck data for the period January and February 2019.

This paper reports on a number of staffing metrics and presents performance across a number of domains

and considers this in the context of staffing, recruitment and ward/department performance within

Healthcheck domains.

2. Background

Safe levels of nurse, midwifery and theatre staffing are essential for the delivery of quality patient care.

Actual nurse establishments are calculated using a range of data with staffing updates submitted nationally

each month incorporating both substantive LTHT staff and additional temporary staff (bank and agency).

The ward/department Healthcheck provides a systematic overview of performance across a range of key

areas that influence or reflect the standards of care, patient outcomes and experience of care delivered in

LTHT. The data can be viewed at organisational, CSU and ward level, providing both a local and strategic

picture.

3.0 Nursing and Midwifery Staffing

Following the development of the LTHT Resource Management Group (RMG), the LTHT Nursing, Midwifery

and AHP Workforce Group (NMAWG) has been established to develop, implement, deliver and evaluate

workforce initiatives that are requested as specific work streams from the chief nurse via the Heads of

Nursing group and the RMG against the Trust workforce plan. Whilst the NMAWG will focus on the

immediate workforce priorities for 2019/20, it will also support Heads of Nursing, Midwifery and Allied Health

Professions to determine the longer term workforce plan taking into account national guidance, both at a

Trust level and as part of the wider Leeds health economy.

The formation of the NMAWG will ensure there is a multi-professional platform to discuss and develop

workforce initiatives, resources and guidance in relation to:

➢ Nursing, Midwifery & AHP staffing levels - including establishment setting using evidence based research/tools and workforce planning guidance

➢ Effective deployment of Nursing, Midwifery & AHP staff in LTHT ➢ New models of care including integrated clinical care pathways can be discussed, developed

and overseen from a workforce perspective ➢ Embedding of acuity and dependency tools in LTHT ➢ Integration of new roles- including Nursing, Midwifery & AHP Apprenticeship routes ➢ Use of temporary workforce ➢ Recruitment and Retention of Nursing, Midwifery & AHP workforce

3.1 Establishment reviews

CSUs have undertaken reviews of all clinical areas, in conjunction with Finance and Corporate Nursing, and

are proposing establishments for the financial year 2019/20. A series of challenge meetings were held in

January 2019 to further refine each CSU’s position. These have been submitted for approval through the

Finance and Performance Committee prior to sign off by the Trust Board. Once finalised the individual

ward/department roster templates will be updated with the agreed staffing plan for 2019/20.

CSU funding for apprenticeship routes into nursing has been agreed. In order to accurately track our

investment for nursing apprenticeships in 2019/20 this funding will be held centrally and released to CSU’s

as each apprentice commences employment.

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3.2 LTHT Operational Processes to support staffing

Reports from the Nurse Staffing Status Report (NSSR) continue to be reviewed at the Trust weekly quality

meeting chaired by the Chief Nurse or Chief Medical Officer. The purpose of the report is to highlight any

clinical area that reports its status as Amber for 100%, Red for 50% or greater of the shifts in one week or

any area that has rated itself Black at any time.

Figure 1: LTHT Nurse Staffing Status Report

The corporate workforce team have been supporting wards in escalation to offer advice and guidance. Action plans are being developed to support CSU’s which have wards in escalation; this focused support has been well received in clinical areas.

Following the implementation of the escalation pathway and embedding of the NSSR system, stage three will include the addition of weekend submissions planned to commence on the 23rd March 2019.

Work is underway to implement a real time acuity and dependency tool to further improve responsiveness to fluctuations in patient care and deployment of staff. A business case has been prepared alongside HR colleagues that will be presented to the Executive Directors by the Director of Human Resources. If approved the project plan is due to commence in April 2019, following 8 weeks of contract discussions and project set up the phase 1 proof of concept is anticipated to be completed by 30th November 2019.

3.3 Care Hours per Patient Day (CHPPD)

Alongside clinical quality and safety outcome measures, CHPPD can be used to identify unwarranted

variation and support delivery of high quality, efficient patient care. CHPPD is reported to NHSi monthly and

through the Model Hospital reporting suite. From this, Trusts are able to compare themselves against the

national average and peers (Figure 2). The Model Hospital is currently reporting CHPPD data up to

December 2018.

LTHT is indicated by the black bar, sitting in the middle of our peer Trusts (grey bars) in the third quartile.

CHPPD is an average measure of all the inpatient areas and the LTHT figure is influenced by:

• LTHT being a tertiary centre

• A significant number of critical care beds including neonates

• Enhanced care provision

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Figure 2 - LTHT Average CHPPD compared to national average and recommended peer group

(Source: NHSi Model Hospital, data December 2018)

Further figures in Appendix 1 include the Trust level CHPPD reporting January 2018 - February 2019 by

registered, unregistered and overall and the range of CHPPD by CSU for January and February 2019 .

3.4 Nursing and Midwifery Staffing Return (Hard Truths)

The Trust reports nurse staffing numbers including registered, unregistered, substantive and temporary to

NHS England via a monthly Nurse Staffing Return (Hard Truths) for 87 inpatient areas. The figures in

Appendix 2 show the number of areas where actual staffing hours available fell below 80% of the current

plan of staffing hours on the roster. The number of clinical areas that reported staffing levels lower than the

current 80% threshold were sixteen (18.4%) in January and eighteen (20.7%) in February 2019, this is a

decrease from the previous paper which was twenty and twenty one wards respectively for November and

December 2018.

Data also portrays actual staffing levels of greater than 130% against planned levels for unregistered staff

in many areas. These higher than planned levels are due to the deployment of unregistered staff to deliver:

• enhanced care provided by clinical support workers for patients identified at risk

• to mitigate risk for registered nursing shortfalls where appropriate

With the implementation of the NSSR we have operational oversight of staffing levels across the Trust.

Hard Truths data provides a retrospective view of actual staffing fill against planned.

3.5 Temporary staffing

Temporary staffing, bank and agency workers continue to be used across the Trust to support safe staffing

provision. Consistently the overall Bank hours are greater than Agency with an increasing differential (Figure

3).

The overall RN agency spend from the 2018/19 finance ledger is 1.6% year to date compared to the final

17/18 position of 2.53%.

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Figure 3 Total Bank and Agency hours (Registered and Unregistered)

We do not expect to see significant reduction in overall temporary staffing use due to a purposeful drive to

move LTHT staff towards working Bank in order to qualify for incentive schemes, and to support back fill

requirements for apprentice nurses and trainee nursing associates whilst undertaking education or

supernumerary placements.

3.6 Recruitment

LTHT continues to recruit band 5 registered midwives, nurses and operating department practitioners with

407 external registered band 5 staff starting in post since April 2018.

The first cohort of Nursing Associates have qualified and registered with the Nursing Midwifery Council

(NMC) in January 2019. 18 Nursing Associates have been deployed into band 4 roles in LTHT, adding a

new level of registered practitioners. A further 41 apprentice Nursing Associates were successfully recruited

and commenced in post December 2018 and an additional 28 trainees will commence in April 2019.

The RMG have defined the reporting of vacancies as being sourced from the financial ledger, using “in

month” data expressed in whole time equivalents (WTE). In February 2019 the combined vacancies for

registered and unregistered staff is showing at 10% (630.92 WTE) against the current establishment.

Registered nursing, midwifery and ODP staff vacancies are showing at 11% (513.15 WTE) and unregistered

vacancies are showing at 6% (117.77 WTE) based on the in-month figure in the February financial ledger.

The above WTE data is an increase from that reported in the previous paper, this may be compounded by

the difference from previously reporting the average month position to the newly agreed actual in month

position from the ledger.

Data published in the NHSI Quarterly performance (Q1 2018/19) for the NHS provider sector, shows an

aggregate national vacancy rate for Registered Nurses at 11.8%.

Agenda Item 12.5

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3.7 Clinical Service Units (CSU) Specific Staffing Issues

The overall Trust registered nurse, midwife and ODP vacancy has remained static at 11% in February 2019,

those CSUs that have a vacancy greater than 15% are:

• Emergency and Speciality Medicine - 22%

• Neurosciences - 22%

• Trauma and Related Services (TRS) - 20%

• Adult Critical Care - 18%

Not all wards within these CSUs are affected and some wards previously challenged are showing improved

staffing over the last six months. Some CSUs have vacancy hot spots, for example Oncology CSU have

an overall registered nurse vacancy of 13% however J93 has a registered nurse vacancy of 23%.

Alongside the remit of the newly formed RMG the Head of Nursing for Workforce and Education has

identified a need to further support CSU’s with recruitment difficulties at either a CSU level or a specific ward

or skillset. An example of this is the newly developed Care of the Critically ill adult scheme which is a 18

months rotation programme offered as a new post within LTHT.

3.8 Retention

Turnover of registered nurses, midwives and ODPs is 10.2%, (255 Band 5 leavers since April 2018) and for unregistered staff 9.4% (144 unregistered staff leavers since April 2018). There is a slight increase in the turnover of registered staff of 0.1% and a 2.1% decrease of unregistered staff since the last report.

The RMG is focusing on retention of registered staff as a priority, CSU level workforce data is being analysed for themes and trends alongside professional leads reviewing the profession specific data in order to gain insight to determine specific retention activities. This activity will be reported back to RMG in May 2019.

National 12 month turnover comparison data (NHSI November 2018) for registered nurses and midwives in acute teaching trusts shows LTHT as the green bar below:

The RMG are prioritising workforce retention and will work with CSUs to understand their “hot spots” to enable a focus to develop strategies and action plans. Actions that are currently being employed to support retention Trustwide include:

Agenda Item 12.5

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• The generic Introduction to Professional Practice which is part of the induction process for registered and unregistered nursing is being refreshed to include practical scenario sessions

• A LTHT clinical leadership offer is being scoped to provide a development pathway for existing registered staff.

• A developmental pathway for recruits or existing staff to widen participation to nurse associate and in turn registered nurse training is soon to be launched.

3.9 Maternity Staffing

The current midwife: birth ratio for LTHT remains 1:26 based on February’s births, as per previous months.

The Birthrate Plus workforce acuity tool that monitors staff vs acuity is established in the delivery suites with

daily, weekly and monthly monitoring within the CSU. This data is available and reported into the Women’s

CSU governance meeting with the clear breakdown of Birthrate Plus calculations.

The Delivery Suite coordinators remain supernumerary as evidenced via the health roster enabling the

coordinators to have oversight of all birth activity on the delivery suites. Additionally 1 to 1 care has been

maintained at 100% across both delivery suites.

Work is on-going within LTHT to refine the Birthrate Plus acuity tool on the antenatal and postnatal wards

due to the potential subjectivity with entering prospective data and clarity around inclusion of registered and

non registered staff in the calculations. There is currently a level of professional judgement required to

interpret the reports for these areas.

4. Ward Healthcheck

There is a professional requirement to measure standards of record keeping for the core activities that we

undertake for our patients. This includes measuring how we assess patient needs and deliver care to meet

these needs in order to improve the quality and consistency of care.

At LTHT the ward/department Healthcheck is the way we assess against a suite of standards. It is

undertaken in all adult and paediatric in-patient areas including Theatres, PACU, Emergency Departments,

Outpatients and wards staffed by the Independent provider Villa Care. It provides assurance on the quality

and safety of care provided.

An escalation process comprising of seven KPI’s is in place for all in-patient ward areas, excluding Villa

Care wards. This information is discussed in monthly governance meetings chaired by the Director of

Nursing Operations/Deputy Chief Nurse.

There are 91 in-patient wards included in the ward/department Healthcheck. The number of wards in

escalation varies month on month (see Figure 4). In January 2019 there were six wards that triggered first

stage escalation (L06, L52, J07, J09, J12, and J27). Where required, these wards will be offered informal

support for any identified areas for improvement from the Clinical Support Team. All wards will have local

action plans in place to ensure improvement in the healthcheck is achieved.

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Figure 4

5.1 Clinical Standards - Healthmetrics

The Healthmetrics monthly audit programme focuses on processes at ward/department level for identifying

and managing risk of harm rather than outcome (incidence of harm). A RAG rating is awarded based on

percentage compliance with assessment, clear interventions, evaluation and documentation.

The individual standard scores are collated to give an overall score;

• 79.9% or below is Red

• 80-89.9% is Amber

• 90% and above is Green.

The Figure in Appendix 3, illustrates a breakdown of Healthmetrics score by standard group. February 2019

has shown an improvement in medicine management domain and pressure ulcer assessment. Notation on

eMeds and PPM+ is providing clear assurance around these domains.

Two CSU’s have received support throughout January 2019, these are:

• Cardio Respiratory CSU

• Chapel Allerton CSU

Both are showing positive improvements in overall metric scores for February 2019.

Appendix 4 highlights the overall score by Trust and CSU level. All CSU’s have worked hard to improve and

maintain their Healthmetric scores. It is the first time in 6 months that all CSUs have an average overall

score > 90%.

A review of the wards with lower than 80% in the reported actual staffing (Appendix 2) has been undertaken.

Harm free care (new harms), falls and Pressure Ulcer (PU) incidents have all been triangulated with metrics

scores.

For example:

Ward J07 - Older Adult ward (ESM CSU)

0

2

4

6

8

Sep-18 Oct-18 Nov-18 Dec-18 Jan-19

Sep-18 Oct-18 Nov-18 Dec-18 Jan-19

No. of Areas 0 4 3 3 6

Number of Clinical Areas in Escalation 2018/2019

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• Health check metrics score 78.4%

• Average registered nurse (daytime) fill rate 63%

• No reportable increase in harms relating to falls and pressure ulcers

Healthcheck overall scores are RAG rated. Figure 5 shows LTHT performance for the last three months.

Teams continue to work hard to meet the agreed Healthcheck standards. There were three wards in red in

February 2019 (J07, J09, and J11). All wards have been reviewed and the teams offered support as

required.

Figure 5

Sustained performance in health check metrics is now recognised through the celebration programme. 11

wards and departments have been awarded either Bronze or Silver certificates of excellence for consecutive

months of green metrics. All teams were delighted to receive this accolade, and presentation photographs

were shared on social media platforms.

There has been significant work on the LTHT ward accreditation programme. Whilst still in development this

will be the next step for recognising and learning from wards that have sustained high levels of standards

and practice.

5.2 Summary of Actions being taken

• A LTHT Nursing, Midwifery and AHP Workforce Group (NMAWG) has been established to lead,

support and develop resources/activities related to this workforce in LTHT.

• The NSSR escalation process has been established with an immediate response from the Director

of Nursing (Operations)/ Deputy Chief Nurse for wards reporting potential unmitigated safety

concerns.

• A programme of support has been established for wards that trigger sustained nurse staffing

challenges. The response is led by the Nursing, Midwifery and AHP Workforce and Education team

to offer support and develop local action plans.

• A project has been initiated to introduce a Trust wide live system to capture acuity and dependency

of patients; this will be initially trialled in the Cardio-Respiratory CSU. This will strengthen the current

NSSR process and support the deployment of resources and inform future workforce plans

• 91 wards and departments continue to be monitored for standards of care delivered, outcomes of

harm and patient experience.

Dec 2018 Jan 2019 Feb 2019

Red 2% 1% 1%

Amber 9% 9% 9%

Green 89% 90% 90%

80%82%84%86%88%90%92%94%96%98%

100%

Pe

rce

nta

ge

RAG rated metrics scores Dec 18 - Feb 19

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• There is no direct correlation of below 80% staffing levels and outcomes relating to patient harm.

• There was an increase in wards in escalation for January 2019 compared to previous months ( 3

wards in Nov & Dec, 6 wards in Jan)

• Wards in sustained improvement associated with the ward metrics and now recognised through a

celebration programme.

• Nursing E-Documentation continues to be developed and is being received positively providing

clear assurances around the domains where it has been fully implemented.

7. Recommendations

The Trust Board is asked to:

• Receive this report and note the Nurse Staffing and Healthcheck data for January and February 2019.

• Note developments relating to workforce and the ward Healthcheck.

Georgina Duncan Lead Nurse Professional Practice Katie Robinson Head of Nursing, Workforce and Education 20th March 2019

Agenda Item 12.5

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Appendix 1

Care Hours per Patient Day (CHPPD)

CHPPD is calculated using actual registered and unregistered staffing alongside ward activity (bed

occupancy at midnight). This generates the number of hours of care available for patients per day. David

Beevers Day Unit, J43, L14, L28 and W1 have been excluded as they do not always have beds open at

12 midnight consistently over 7 days

CHPPD - Trust level data by registered, unregistered and overall

Variation in CHPPD is caused by a number of factors including:

• Acuity and dependency

• Enhanced care support is not captured on planned staffing templates

• Units that reduce base bed at night

• Bed occupancy (activity) data is based on PAS information of which is not always consistently

updated

• Recent recruitment activity

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CHPPD – CSU range January and February 2019

CSU January 2019 February 2019

Comments Mean CHPPD

Range Mean CHPPD Range

Abdominal Medicine & Surgery

6.1 ↓ 5.3 - 7.1 6.1→ 4.9-7.1

Adult Critical Care 26.4↑ 19.8 - 31.5 25.8↓ 20.8-33.4 Includes ICU and HDU

Cardio-Respiratory 7.6↓ 5.1 - 11.0 9.0↑ 5.0-10.8 Includes CCU

CAH 9.0↑ 7.8-9.7 9.0↑ 7.1-11.6

Children’s 12.6↓ 8.1 - 28.3 13.1↑ 6.4-30.1 Includes ICU and HDU

Emergency and Specialist Medicine

6.4→ 5.1 - 8.1 8.1↑ 5.3-8.1

Head & Neck 6.8↑ 6.8 6.6↓ 6.6

Institute of Neurosciences 7.9↑ 6.4-9.0 7.4↓ 5.7-9.0

Oncology 7.1↑ 5.4-11.4 7.3↑ 5.2-13.8

Trauma & Related Services 9.4↑ 6.719.5 9.1↓ 6.9-15.9 Includes HDU

Women’s 22.4↑ 8.3-40.1 23.7↑ 8.6-43.3 Includes Delivery Suites

(HDU – High Dependency Unit, ICU – Intensive Care Unit, CCU – Coronary Care Unit, PHDU - Paediatric

High Dependency Unit, PICU – Paediatric Intensive Care Unit)

Arrows indicate the movement in CHPPD since the previous report. In general the data is relatively stable

month on month. At CSU-level the data is skewed by the inclusion of HDU and ICU areas, with high

patient care requirements. No correlation has been identified between CHPPD and Healthcheck

information.

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Appendix 2

Nurse Staffing Return (Hard Truths)

The Trust reports staffing numbers to NHS England via a monthly Nurse Staffing Return (Hard Truths) for

87 inpatient areas. This report details the monthly staffing hours within a clinical area against their planned.

CHPPD data is recorded within the same report (Appendix 2)

Summary of the number of wards triggering < 80% staffing against planned

Data source: LTHT Workforce Intelligence

Day Registered Day Care staff Night Registered Night Care staff Total wards % of wards Dec-17 1 1 5 1 8 9.0% Jan-18 4 5 6 1 14 16.1% Feb-18 2 2 6 0 10 11.5% Mar-18 3 1 11 2 17 19.5% Apr-18 1 0 7 1 9 10.3%

May-18 0 0 7 0 7 8.0% Jun-18 2 3 5 2 11 12.6% Jul-18 2 2 12 0 14 15.9%

Aug-18 4 3 12 1 17 19.3% Sep-18 4 0 12 0 14 15.9% Oct-18 8 3 12 1 19 21.6% Nov-18 10 4 8 2 20 22.7% Dec-18 12 4 10 2 21 24.1% Jan-19 8 2 9 10 16 18.4% Feb-19 9 5 7 2 18 20.7%

The number of wards triggering <80% Staffing Fill Rates

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The table below represents the integrated Nurse Staffing Return inclusive of CHPPD for the individual

areas and the overall score on Healthcheck for February 2019. The data includes, Falls Pressure Ulcer

and Harm Free Care data as collected through Safety Thermometer.

Metrics

Registered Unregistered Overall

A M & S J42 Urology 92.0% 122.2% 107.3% 107.5% 2.5 2.9 5.5 98.8% 2 92.9%

A M & S J43 Short Stay Surgery 100.7% 116.2% 98.2% 117.9% 96.3% 0 1 100.0%

A M & S J44 General Surgery 79.9% 107.3% 72.6% 135.9% 2.4 3.0 5.4 96.7% 1 1 96.4%

A M & S J45 General Surgery 82.3% 119.1% 75.0% 125.1% 2.6 3.4 6.0 99.6% 0 2 92.0%

A M & S J46 Colorectal Surgery 89.5% 91.7% 97.6% 106.7% 2.4 3.4 5.9 98.5% 3 100.0%

A M & S J47 Colorectal Surgery 82.5% 94.8% 105.1% 113.8% 2.9 4.5 7.4 97.8% 0 100.0%

A M & S J49 Renal Medicine Male 98.0% 104.4% 100.3% 132.1% 3.1 3.3 6.4 96.6% 3 2 100.0%

A M & S J50 Renal Medicine Female 92.7% 98.1% 100.5% 157.1% 3.2 3.9 7.1 92.2% 0 100.0%

A M & S J82 UGI & HPB Surgery 80.4% 76.8% 71.4% 112.8% 2.4 2.5 4.9 98.9% 2 2 96.6%

A M & S J91 Gastro 76.7% 88.5% 100.0% 103.6% 2.4 3.0 5.4 98.9% 2 100.0%

A M & S J92 Gastro 92.1% 100.5% 97.4% 97.4% 2.4 3.9 6.4 96.5% 1 95.8%

A M & S J83 Leeds Liver Unit 79.9% 129.0% 83.8% 89.0% 2.7 4.1 6.8 98.5% 0 0 100.0%

Adult Critical Care J54 Intensive Care Ward 115.1% 96.7% 127.1% 98.8% 19.9 2.0 21.9 96.1% 1 2 100.0%

Adult Critical Care J81 HDU 94.1% 83.9% 100.5% 94.6% 15.4 5.4 20.8 96.2% 100.0%

Adult Critical Care L03 ITU 114.5% 108.0% 119.1% 127.1% 26.9 6.5 33.4 98.6% 100.0%

Adult Critical Care L04 Cardiac ITU 111.5% 115.1% 115.4% 103.7% 25.4 2.6 28.0 98.7% 1 100.0%

Adult Critical Care L06 Neuro ICU 109.5% 113.3% 115.9% 107.0% 21.5 3.4 24.9 98.7% 1 3 63.6%

Cardio-Respiratory J10 Respiratory Medicine 85.7% 112.8% 82.1% 94.0% 4.5 5.5 9.9 84.0% 1 90.9%

Cardio-Respiratory J12 Respiratory Medicine 90.1% 114.4% 86.2% 126.8% 2.4 4.1 6.5 86.6% 3 0 96.3%

Cardio-Respiratory J06 Adult Cystic Fibrosis 100.0% 128.9% 100.2% 98.6% 5.2 3.4 8.6 98.4% 100.0%

Cardio-Respiratory J09 Respiratory Medicine 85.0% 104.8% 88.1% 158.9% 2.0 4.0 6.0 78.3% 2 2 94.1%

Cardio-Respiratory L14 Cardiology Day Case 110.0% 111.9% 110.3% 175.0% N/A

Cardio-Respiratory L16 Cardiac Surgery 101.4% 81.6% 104.8% 140.0% 3.2 1.8 5.0 93.5% 1 100.0%

Cardio-Respiratory L18 Cardiology 99.2% 115.5% 117.0% 109.1% 2.3 3.7 6.1 97.4% 3 100.0%

Cardio-Respiratory L19 Cardiology 89.9% 86.1% 95.5% 120.6% 2.8 3.9 6.6 93.8% 4 0 100.0%

Cardio-Respiratory L20 CCU 92.5% 165.0% 96.2% - 8.8 2.0 10.8 94.9% 2 1 100.0%

Chapel Allerton C02 Dermatology/Rheumatology 90.0% 160.3% 100.0% 207.1% 3.4 3.7 7.1 90.4% 2 100.0%

Chapel Allerton C01 Neuro Rehabilitation 100.6% 118.3% 98.3% 103.6% 3.2 5.1 8.3 95.2% 3 0 96.0%

Chapel Allerton C03 Orthopaedic Centre 122.5% 116.9% 102.2% 159.8% 6.8 4.8 11.6 92.1% 4 100.0%

Chapel Allerton Ward 01 - WGH 110.8% 91.0% - - N/A Exempt

ChildrensL30 Childrens Respiratory/Cystic

Fibrosis76.0% 116.0% 70.9% 96.0% 10.6 7.0 17.6

95.3% Exempt

Childrens L31 Childrens Oncology 88.7% 66.8% 100.6% 75.0% 11.2 1.5 12.7 93.0% Exempt

Childrens L40 Childrens General Medicine 94.7% 71.0% 104.0% 96.7% 5.3 1.2 6.4 88.7% 0 Exempt

Childrens L41 Childrens Surgery 96.2% 119.4% 116.1% 107.1% 5.4 2.3 7.6 98.9% 1 Exempt

Childrens L42 Paediatric Surgery 94.9% 106.7% 99.9% 117.9% 6.0 1.5 7.5 98.1% Exempt

Childrens L47 PICU 92.9% 111.6% 96.9% - 28.6 1.5 30.1 98.0% 3 Exempt

Childrens L48 Childrens HDU 90.0% 82.1% 97.6% 71.4% 11.7 3.1 14.8 93.3% Exempt

Childrens L51 Childrens Cardiac Surgery 92.7% 105.8% 109.2% - 7.8 1.0 8.8 95.3% 0 Exempt

Childrens L52 Childrens Neurosciences 86.3% 115.2% 113.5% 121.1% 5.8 2.6 8.4 96.4% 1 Exempt

Childrens Transitional Care - SJH 97.6% 100.0% 108.3% 94.6% 8.2 4.8 13.0 100.0% Exempt

Childrens L09 Childrens Medicine 102.0% 75.0% 97.9% 91.0% 12.7 3.3 16.0 91.5% Exempt

Childrens J01 Neonatal Unit 92.4% 100.0% 96.3% 100.0% 9.3 1.2 10.6 99.4% Exempt

Childrens L43 Neonatal Unit 97.3% 103.7% 97.9% 100.0% 20.0 1.3 21.3 97.7% Exempt

Childrens L50 Childrens Liver & Renal 90.4% 104.0% 99.2% 85.2% 6.4 2.7 9.1 97.2% 0 Exempt

February 2019

CSU

CHPPD

Ward name

Average fill

rate -

registered

nurses/mid

wives (%)

Average fill

rate - care

staff (%)

Average fill

rate -

registered

nurses/midw

ives (%)

Day Night

Average fill

rate - care

staff (%)

Patient Safety

Healthch

eck

Scores

Falls

Pressure

Ulcers

New

Harm

Free

Care

Agenda Item 12.5

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Metrics

Registered Unregistered Overall

E & S M J14 Older Peoples Services 86.9% 95.7% 100.7% 107.1% 2.3 5.8 8.1 95.5% 4 1 100.0%

E & S M J15 Older Peoples Services 77.0% 100.9% 100.0% 106.7% 1.9 4.9 6.8 94.2% 7 3 100.0%

E & S M J17 Older Peoples Services 74.0% 107.5% 100.0% 104.7% 2.1 4.5 6.6 96.9% 6 2 92.6%

E & S M J19 Acute Medicine 87.0% 105.0% 105.4% 108.3% 2.0 3.3 5.4 94.4% 7 1 96.4%

E & S M J20 Infection & Travel Medicine 103.0% 71.0% 97.8% 113.6% 2.9 2.9 5.9 81.1% 2 84.2%

E & S M J21 Acute Medicine 84.0% 82.9% 99.7% 106.6% 1.9 3.5 5.3 98.1% 2 100.0%

E & S M J26 Medical Admissions Unit 79.4% 93.7% 80.6% 163.0% 2.7 4.4 7.1 98.6% 5 100.0%

E & S M J27 General Admissions 88.5% 94.9% 93.7% 160.0% 3.3 4.7 7.9 83.3% 5 1 100.0%

E & S MJ28 Elderly Short Stay And

Assessment79.4% 84.5% 75.0% 114.4% 2.4 5.0 7.3

96.3% 8 0 100.0%

E & S M J29 Elderly Admissions 78.5% 95.7% 65.5% 113.9% 2.2 5.0 7.2 82.5% 5 96.7%

E & S M J07 Older Peoples Services 63.0% 92.4% 101.8% 118.9% 1.7 3.6 5.3 78.4% 2 2 100.0%

E & S M J08 Older Peoples Services 68.0% 87.1% 100.0% 116.9% 1.7 3.7 5.4 86.3% 6 3 96.8%

Head & Neck L23 ENT/Spines 101.5% 114.2% 103.6% 111.6% 3.2 3.4 6.6 99.5% 0 0 100.0%

Neuro sciences L12 Stroke Rehab 82.0% 100.9% 100.0% 110.5% 2.6 3.1 5.7 93.8% 1 100.0%

Neuro sciences L21 Acute Stroke Unit 81.0% 96.1% 80.7% 117.1% 3.7 5.0 8.6 97.6% 6 1 96.8%

Neuro sciences L24 Neuro/Spines 87.6% 87.6% 98.3% 170.5% 2.9 4.4 7.3 94.3% 2 2 96.7%

Neuro sciences L25 Neuro/Spines 80.7% 126.4% 92.4% 157.9% 3.3 5.7 9.0 94.1% 2 2 96.9%

Neuro sciences L17 Neurology 85.6% 157.4% 96.3% 196.5% 2.7 4.5 7.2 95.9% 7 0 100.0%

Neuro sciences L28 Surgical Day Unit 105.6% 266.0% 96.4% 90.4% 93.5% 0 100.0%

Oncology J84 Thoracic Surgery 83.8% 112.9% 103.2% 118.8% 4.2 2.9 7.1 90.7% 1 2 96.4%

Oncology J88 Haematology 95.2% 133.9% 100.0% 118.6% 3.3 3.0 6.3 92.1% 1 100.0%

Oncology J89 Haematology BMTU 82.6% 126.6% 96.3% 123.2% 4.6 2.7 7.3 98.8% 4 1 100.0%

Oncology J93 Oncology 107.1% 111.9% 100.0% 114.2% 2.5 2.7 5.2 89.7% 1 0 100.0%

Oncology J94 Young Adults Unit 85.5% 132.1% 92.2% - 5.6 2.1 7.7 96.6% 100.0%

Oncology J96 Oncology Assessment 86.9% 95.2% 91.8% 119.6% 3.9 3.3 7.2 94.6% 4 100.0%

Oncology J97 Oncology 128.4% 90.5% 100.0% 129.5% 3.0 2.7 5.7 99.4% 2 0 100.0%

Oncology J98 Gynaecology 81.2% 110.7% 98.2% 104.8% 2.3 3.0 5.3 88.0% 3 0 100.0%

Oncology J23 Breast Surgery 81.4% 107.2% 81.3% 128.6% 6.1 7.7 13.8 94.4% 1 0 100.0%

Theatres David Beevers Day Unit - SJH 86.0% 112.0% 100.0% 100.0% N/A 2 N/A

T & R S L10 Major Trauma Ward 84.6% 139.8% 101.8% 149.4% 3.3 8.3 11.7 97.1% 0 3 100.0%

T & R S L15 Vascular 108.3% 108.4% 116.0% 108.9% 2.6 5.0 7.6 96.7% 5 4 92.0%

T & R S L35 Orthopaedic Trauma/Vascular 92.8% 80.0% 100.0% 99.3% 2.5 4.2 6.8 94.0% 0 100.0%

T & R S L37 Female Trauma Orthopaedics 90.1% 87.0% 98.0% 176.7% 2.2 5.7 7.9 90.6% 1 3 96.3%

T & R S L22 Plastics 102.9% 101.3% 98.2% 106.0% 2.6 4.2 6.9 85.4% 5 1 100.0%

T & R S L34 Orthopaedic Trauma 83.2% 86.2% 100.0% 96.4% 2.4 4.5 6.9 95.5% 3 1 100.0%

T & R S L08 Orthoplastic HDU 91.8% 86.3% 111.7% 101.0% 10.7 5.2 15.9 97.5% 1 100.0%

Womens J05 Obstetrics 83.9% 113.9% 78.6% 83.9% 5.8 4.1 9.9 95.9% 100.0%

Womens L36 Maternity 88.7% 84.4% 89.0% 92.6% 5.1 3.5 8.6 98.1% 100.0%

Womens L44 Maternity 99.3% 104.0% 86.5% 96.4% 11.2 4.0 15.3 94.2% 100.0%

Womens J03 Delivery Suite 83.3% 87.8% 94.8% 92.9% 35.1 8.2 43.3 97.2% 100.0%

Womens J04 Ante Natal 86.7% 101.4% 98.1% 89.3% 16.1 7.0 23.1 100.0% 100.0%

Womens L45 Delivery Suite 95.3% 87.0% 98.1% 96.2% 35.7 6.5 42.3 96.6% 100.0%

Womens J24 Gynaecology 107.8% 98.0% 96.4% 96.4% N/A 1 Exempt

February 2019

CSU

CHPPD

Ward name

Average fill

rate -

registered

nurses/mid

wives (%)

Average fill

rate - care

staff (%)

Average fill

rate -

registered

nurses/midw

ives (%)

Day Night

Average fill

rate - care

staff (%)

Patient Safety

Healthch

eck

Scores

Falls

Pressure

Ulcers

New

Harm

Free

Care

Agenda Item 12.5

16

Appendix 3 - Overall Healthmetrics Score Question Group January and February 2019

Question Group

Abdominal

Medicine and

Surgery

Adult Critical

Care

Cardio-

Respiratory

Centre for

Neurosciences

Chapel

Allerton

Hospital Childrens

Emergency

and Specialty

Medicine Head & Neck

Institute of

Oncology

Trauma and

Related

Services Womens

Medicines Management 95.3% 97.9% 82.9% 86.5% 80.0% 95.7% 91.0% 100.0% 89.4% 90.8% 91.5%

Patient Observations 95.9% 98.6% 84.7% 96.9% 89.8% 95.9% 98.3% 100.0% 94.9% 99.1% 98.9%

Falls Assessment 98.1% 94.0% 93.5% 93.1% 95.2% 98.9% 93.7% 100.0% 95.5% 96.8% 100.0%

Infection Prevention 96.5% 91.1% 88.9% 93.5% 95.7% 97.6% 92.6% 100.0% 89.7% 88.1% 94.3%

Pressure Area Care 98.9% 91.7% 90.8% 85.2% 83.3% 84.8% 87.7% 100.0% 90.8% 89.8% 87.9%

Continence 97.3% 100.0% 96.7% 92.5% 91.7% 98.9% 91.1% 100.0% 92.9% 100.0% 96.2%

Nutrition 98.8% 94.5% 87.0% 93.5% 87.9% 96.3% 89.1% 100.0% 84.6% 91.5% 100.0%

Hydration 99.2% 100.0% 85.4% 92.7% 96.4% 99.1% 84.8% 91.7% 89.0% 96.9% 100.0%

Pain Management 99.2% 100.0% 97.7% 99.1% 100.0% 99.0% 97.6% 100.0% 94.8% 97.6% 88.8%

Patient Dignity 100.0% 98.0% 95.5% 98.6% 97.2% 99.1% 97.3% 100.0% 99.5% 98.8% 99.2%

Discharge 96.7% 100.0% 73.8% 89.0% 91.4% 91.3% 97.1% 94.4% 89.2% 90.0% 100.0%

Documentation 98.8% 94.4% 92.8% 92.0% 68.0% 92.2% 92.3% 100.0% 92.3% 85.9% 99.3%

Emergency Equipment 95.2% 100.0% 93.3% 95.5% 75.0% 92.7% 95.7% 100.0% 91.4% 91.7% 90.0%

Patient Identification 97.8% 100.0% 100.0% 100.0% 100.0% 93.1% 99.0% 100.0% 100.0% 100.0% 100.0%

Magnetic Symbols 83.3% 80.0% 57.1% 83.3% 33.3% 100.0% 85.7% 100.0% 88.9% 80.0% -

Total 98.0% 96.4% 90.5% 93.6% 88.8% 95.6% 93.4% 99.0% 92.5% 93.9% 96.3%

Jan-19

Question Group

Abdominal

Medicine and

Surgery

Adult Critical

Care

Cardio-

Respiratory

Centre for

Neurosciences

Chapel

Allerton

Hospital Childrens

Emergency

and Specialty

Medicine Head & Neck

Institute of

Oncology

Trauma and

Related

Services Womens

Medicines Management 94.2% 94.3% 83.9% 92.3% 70.0% 94.2% 90.8% 100.0% 86.8% 96.0% 94.3%

Patient Observations 95.9% 98.6% 89.1% 96.9% 91.5% 97.4% 92.4% 94.4% 90.6% 96.2% 100.0%

Falls Assessment 98.2% 98.8% 93.5% 99.1% 98.0% 98.4% 91.2% 100.0% 97.2% 96.9% 100.0%

Infection Prevention 94.7% 96.5% 96.1% 95.3% 100.0% 96.9% 87.3% 100.0% 88.4% 94.9% 95.1%

Pressure Area Care 95.2% 98.3% 84.7% 90.7% 87.0% 87.4% 86.9% 100.0% 96.2% 90.9% 92.1%

Continence 99.0% 98.8% 95.1% 92.2% 96.2% 96.9% 88.4% 100.0% 95.2% 97.3% 91.7%

Nutrition 98.7% 99.1% 89.5% 99.2% 93.9% 95.3% 81.6% 100.0% 91.0% 90.6% 100.0%

Hydration 97.4% 98.8% 82.9% 88.0% 100.0% 97.4% 75.3% 100.0% 89.3% 97.1% 100.0%

Pain Management 99.6% 99.1% 96.9% 98.2% 100.0% 98.9% 97.1% 100.0% 98.8% 97.6% 92.9%

Patient Dignity 98.7% 100.0% 98.4% 99.3% 97.0% 98.2% 98.5% 100.0% 99.1% 98.3% 98.4%

Discharge 98.4% 100.0% 82.2% 83.6% 100.0% 89.1% 95.8% 100.0% 90.5% 88.0% 100.0%

Documentation 97.2% 92.8% 86.5% 90.7% 78.7% 96.2% 94.3% 100.0% 94.2% 82.9% 98.7%

Emergency Equipment 95.8% 100.0% 80.0% 90.0% 100.0% 94.4% 89.8% 100.0% 94.1% 100.0% 100.0%

Patient Identification 100.0% 100.0% 100.0% 100.0% 100.0% 96.2% 99.0% 100.0% 98.4% 100.0% 100.0%

Magnetic Symbols 80.0% 75.0% 85.7% 100.0% 100.0% 100.0% 100.0% 100.0% 87.5% 100.0% 0.0%

Total 97.4% 97.7% 90.4% 94.9% 92.7% 95.9% 91.0% 99.5% 93.8% 94.0% 97.0%

Feb-19

Agenda Item 12.5

17

Appendix 4: Accumulated Metrics Score by Trust and CSU December 2018 - February 2019

LTHT A M SAdult

Critical CareCardio-

RespiratoryNeuroscien

cesChapel

AllertonChildrens

Head &Neck

OncologyEmergency& SpecialtyMedicine

Trauma & RS

Womens

Dec-18 93.9 96.3 97.7 86.1 94.5 92.1 94.8 93.1 99.6 94.3 92.4 96

Jan-19 94.4 98 96.4 90.5 93.6 88.8 95.6 99 92.5 93.4 93.9 96.3

Feb-19 94.3 97.4 97.7 90.4 94.9 92.7 95.9 99.5 93.8 91 94 97

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Metric Standards - Overall Percentage by CSU

H

ealthch

eck G

oal