Integrated Performance Report - Churchill Hospital€¦ · HGH Bed requirement to achieve 92% occupancy from July – March 2020 ; staffing is major factor to ensure all beds are

Integrated Performance Report Trust Board

Wednesday 13th November 2019

Sam Foster Chief Nursing Officer

Meghana Pandit Chief Medical Officer

Sara Randall Chief Operating Officer

Urgent Care 4 hour performance in September 19 was 8424 a minor improvement from month 5 but not achieving the 90 trajectory

In September 2019 month 6 the Trust achieved performance of 8424 compared to the trajectory agreed in the annual plan of 90

The HGH experienced a decrease in performance in September 2019 achieving 8511 The JR performance improved marginally to 8389 (figure 1)

The agreed trajectory (figure 2) shows an improvement to 90 from July 2019 with a drop in the challenging winter months of January and February but recovery to the 90 in March 2020

Figure 1 Emergency lsquo4 Hourrsquo Performance Sept 18-Sept 19 Figure 2 Emergency lsquo4 Hourrsquo Performance Trajectory 201920

Urgent Care Demand continues to increase a significant 124 increase on last year with bed occupancy levels at c100

Occupancy levels reaching c100 across

our 4 sites Adult occupancy at JR and HGH often over 100 resulting EAU areas become wards

and Emergency Departments become

Demand continues to increase across our sites impacting breach levels along with occupancy at c100 (figure 3)

ED attendances continue to increase (figure 4)

In month 6 ED attendances were 75 higher than the same period last year

Occupancy levels increased again in September averaging at c100 across all our sites often only beds available at night being Paediatric and Gynae

Attendance growth along with occupancy levels at c100 creating severe congestion in our Emergency departments particularly in the evening where the vast majority of our breaches are occurring

Figure 3 OUH General amp Acute Bed Occupancy Sept 2018 ndash Sept 2019

Figure 4 Emergency Department attendances Sept 18 ndash Sept 19 Type 1 Emergency Department Type 2 Other Emergency setting (eg Ophthalmology) Type 3 GP Streaming

Urgent Care Horton General Hospital(HGH)

Attendances Another month with a significant 113 higher than same period last year Peak in demand hits at 7pm Highest breach numbers are those patients that arrive at 6pm-7pm (figure 5) Admitted breaches have increased demonstrating a direct link to the occupancy constraints Occupancy levels often at 100 in the evening resulting in patients that would usually go to EAU for further investigation assessment remaining in ED and eventually going home in the morning increasing the number of recorded non-admitted breaches

Capacity throughout September bed occupancy levels for adults was c100

bull 12 beds were temporarily closed due to safe staffing levels 5 re-opened on EAU and 8 on trauma with 4 beds on Laburnum Ward flexed at times of pressure

bull Increase in demand for beds through ED attendances added to the pressure on occupancy

Figure 5 Sept 19 lsquo4 hourrsquo breaches by arrival time (HGH)

Figure 6 Breaches in Sept 19 by Admitted and Non-admitted pathways (HGH) Figure 7 Emergency Department Pathway Breaches Sept 18- Sept 19 (HGH)

lsquoAdult Majorsrsquo admitted and non admitted key breach reason

Urgent Care John Radcliffe Hospital (JR) Attendances 4 higher than the same period last year Peak of the breaches start from those that arrive at 7pm with another peak from those arriving at 10pm (figure 9) Admitted breaches continue throughout the day but hit a spike at 1am with adult occupancy levels consistently at 100 Non admitted breaches less prominent overnight demonstrating the pressure on occupancy and admitted breaches (figure 10) Admitted breaches are higher than non-admitted breaches every hour

Capacity adult occupancy levels throughout September remained at 100 with the site severely congested 24 hours a day

bull Staffing levels are very stretched across our wards consistently 16 beds temporarily closed for safe staffing

bull The patients that are ready for discharge on our wards are increasing The majority of the delays are due to the OUH HART (reablement service) which is having an impact on the acute hospital beds and community hospital beds both needed for our patients Improvements are being seen with the HART service and in addition the lsquoDischarge to Assessrsquo pilots commenced in July

Figure 9 Sept 19 lsquo4 hourrsquo breaches by arrival time (JR)

Adult and Childrenrsquos Majors admitted and non-admitted key breach reasons

Figure 10 Breaches in Sept 19 by Admitted and Non-admitted pathways (JR) Figure 11 Emergency Department Pathway Breaches August 18- August 19 (JR)

Urgent Care Extended Length of Stay (21+ days) improved from the previous month but is higher than same period last year

Patients with an extended LOS over 21 days (figure 13) Overall the number of patients with an extended LOS over 21 days has increased in month 6 to an average of 152 from 147 in the previous month of which approximately 60 were classified as not medically fit The HGH and Churchill saw increases in month with JR showing small improvement Actions to date bull The 1200hrs huddles are more action focussed following the addition of the ward discharge coordinators Deputy Divisional Nurse from MRC

and psychological medicine staff from the Home study All actions are agreed with the ward team CHC and adult social care to reduce the patients LOS

bull The Deputy Divisional nurses are working with Corporate Operations Team each week to review all those over 21 days bull We are also working on the peer review process to check if more can be done for the patients categorised as not medically fit Our main

delays on the JR site relate to the following

1 HART service average of 45 patients per day are waiting for the HART service Concerns about the increasing numbers of lsquo4 times a dayrsquo packages with associated long lengths of stay There are also patients waiting in Community hospitals (30) for the HART service

2 There is an average of 40 patients waiting for rehabilitation in a community hospital

3 Placement average of 10 patients waiting a mixture of private funders CHC funding and adult social care

Figure 13 Extended length of stay (21+ days) Sept 18 ndash Sept 19 by Hospital Site

HGH Bed Gap Analysis Month July Aug Sept Oct Nov Dec Jan Feb Mar Bed Gap versus Core Stock of Beds 6 6 2 6 -3 -13 -11 -19 12 Bed Gap versus Actual Beds Open (July) -11 -11 -10 -10 -20 -30 -28 -36 -5

Adult General amp Acute Beds Adult Critical Care Paediatric General amp Acute BedsEAU 36 CCU 4 Childresn Ward 14

Juniper 30

Laburnum 28 Total Adult CC 4 Paediatric GampA Beds 14

F ward Trauma HGH 28

Total GampA Beds 122 Adult Beds Closed EAU 5Temporarily Laburnum 4

Trauma 8Adult Beds Open 105

Horton Bed Sitrep July 2019

HGH Bed requirement to achieve 92 occupancy from July ndash March 2020 staffing is major factor to ensure all beds are open

Adult General amp Acute Beds Available is 122

Actual adult beds open in September was 122 the 4 beds on Laburnum are consistently open The additional 10 funded beds on Trauma F ward remain temporarily closed due to staffing

Adult Bed Requirement monthly to achieve 92 occupancy fluctuates over the year with the peak in February

Core stock of beds meet requirement during July-October 2019 and again in March 2019 but core stock is not enough during December 2019 ndash February 2020 Peak gap hits in February 2020

Each day we are short approximately 10 beds on the HGH site

JR Bed Gap AnalysisMonth July Aug Sept Oct Nov Dec Jan Feb MarBed Gap versus Core Stock of Beds -68 -50 -18 -16 -48 -40 -62 -64 -85Bed Gap versus Actual Beds Open -77 -59 -27 -25 -57 -49 -71 -73 -94

Adult General amp Acute Beds Adult Critical Care Paediatric General amp Acute Beds Paediatric Critical Care Ward 5A 22 Adult ICU 16 Bellhouse Drayson Ward 18 Neonates 50

Stroke 18 CCU 21 CDU 5 ITU 9

Ward 6C Short Stay 18 Neuro ICU 13 Kamrans Ward 9 HDU 8

7E Respiratory 21 Melanies Ward 12

Cardiology (inc RAU) 41 Total Adult CC 50 Robins Ward 14 Total Paed CC 67

Ward CMUA 18 Toms Ward 18

Ward CMU B 17

Ward CMUC 21 Paediatric GampA Beds 76

Ward CMUD 20

CTW 25

EAU 31

John Warin Ward inc CF 16

Sub Total MRC 268

Gynae 20

SEU D Side 12

SEU E Side 18

SEU F Side 20

Sub Total SUWO N 89

Vascular 6A 24

Ward 7F 20

Adams 20

Neurosciences Ward Green 12

Neurosciences Ward RedHC 22

Neurosciences Ward Blue 23

Neurosciences Ward Purple 18

SSIP 30 Adult Beds Closed Neurosciences 5Temporarily 5F 4

Sub Total NO TTS 169

TOTAL Adult GampA Beds 526 Adult Beds Open 517

John Radcliffe Bed Sitrep July 2019

JR Bed requirement to achieve 92 occupancy from July ndash March 2020 major factors for the bed gap are demand and discharge delays

Actual adult beds open in September was 517 14 beds temporarily closed due to safe staffing levels

Adult Bed Requirement monthly to achieve 92 occupancy fluctuates over the year with the peak in March 2020

Core stock of beds do not meet the 92 bed occupancy requirement in any month Peak gap hits in March 2020 Additional short stay beds have been procured to support gap in February amp March

Due to safe staffing levels we currently have 14 beds temporarily closed at JR increasing the gap to achieve 92 bed occupancy

HGH current plans show that we achieve the desired 92 in only one month from now until March 2020 More work required with system partners to improve on this

HGH Bed Gap Analysis Month July Aug Sept Oct Nov Dec Jan Feb MarBed Gap versus Actual Beds Open (July) -11 -11 -15 -11 -20 -30 -28 -36 -5

1 Flex Open Laburnum Beds 4 4 4 4 4 4 4 4 42 Staffing EAU Beds 0 0 5 5 5 5 5 5 53 Discharge to Assess Model 0 1 2 4 4 4 4 4 44 Extended length of stay reduction (21+ days) 2 2 3 3 4 4 5 5 6

Revise Bed Gap after mitigations -5 -4 -1 5 -3 -13 -10 -18 14

Bed Occupancy prediction () 960 950 930 880 945 1040 1005 1075 805

The beds on Laburnum ward are flexed to support days of need so far they have been open for the majority of September and will need to continue to support predicted bed gaps EAU 5 beds were opened in September 2019

The North Oxfordshire project will focus on assessing more patients in their own environment keeping them in their own home earlier discharge of North Oxfordshire patients from the HGH with a home first team MDT providing care from them in their own home

Discharge to assess model started in July Estimations of bed equivalent reductions have been made these will be reviewed as the programme expands

Extended length of stay (21+ days) reduction targets as agreed against national 16 reduction

JR current plans show that we do not the desired 92 in any month from now until March 2020 More work required with system partners to improve on this

JR Bed Gap Analysis Month July Aug Sept Oct Nov Dec Jan Feb MarBed Gap versus Actual Beds Open -77 -59 -27 -25 -57 -49 -71 -73 -94

1 Discharge to Assess Model 0 0 0 2 2 4 4 4 42 Surgical Delays ( Theatre dependant) 0 0 5 5 7 7 10 10 103 Transport 0 0 0 1 1 2 2 2 24 Mental health 1 1 1 1 1 15 Short Term Hub Beds (125 beds) TBC TBC TBC TBC TBC TBC TBC TBC TBC6 Increase medical assesment 4 4 4 47 Elective to Emergency bed change (Neuro) 10 10 108 Extended length of stay reduction (21+ days) 4 5 7 9 10 11 12 13 15

Revise Bed Gap after mitigations -73 -54 -15 -7 -36 -20 -28 -29 -48

Discharge to assess model started in July at JR Estimations of bed equivalent reductions have been made these will be reviewed as the programme expands

To support the SEU model OUH is currently reviewing the bed opportunity that additional emergency theatre space could provide estimations made above This will need to be balanced with other operational targets requiring theatres eg cancer waits especially as we have lost theatre time already in 201920 due to the JR2 refresh project

Improvements in transport will assist with discharges lost in early evening by having a single oversight of all transport with one group coordinating

Additional 20 Short Stay HUB beds will be procured in January 2020

Create additional ambulatory capacity within JR2 stack

Neurosurgery to reduce electives to support medical emergency demand Need to quantify impact of JR2 refresh to ensure that 52 weeks are not affected

HART Improvement Plan ndash September 2019 HART Improvement Plan Update 1) Performance increased in September to 246 new pick ups 2) Staffing levels are not where we would like them to be we currently have 13412 WTE support workers and 27 assessors In order

to hit our contract numbers our target is to get to 150 support workers and 30 assessors 3) 10 Assessors started in September After training we expect there to be a positive impact on the waiting list and reviews in October 4) Contingency levels are at 718 not the 600 target this is improved since August and we anticipate to see further improvement in

October 6) Discharge to Assess improvement project was initiated in July 19 within the North and City areas and within September have met the

agreed trajectory The Service will be looking to expand D2A into the West amp South in November in line with further recruitment of Therapists

7) The Prioritisation Protocol has been rewritten and submitted to the HART Assurance Board for System COOrsquos to sign off (0210) and start trial implementation using improvement methodology PDSA cycles

8) A new scheduling tool CM2000 Max Care Scheduling is currently being tested by the Service and due to be implemented by end of October

9) Combined OH amp OUH KPI Monthly Dashboard has been created and agreed across all system partners

Discharge to Assess ndash Improvement project update bull Over 214 service users through D2A in 13 weeks - 16 PDSA improvement cycles to

test the change bull 10 new Assessors have started bull Recruitment dates for support workers x 3 in SeptemberOctober bull Assurance plan and KPI dashboard created and reported on monthly bull CM2000 scheduling tool currently being tested ready for implementation

Urgent Care Programme Discharge to Assess improvement project (started July 2019)

Plan Do Study Act (PDSA) cycles

P1 - Implement discharge to assess

P2 - Improve in hospital acute pathways amp same day emergency care processes

P3 ndash Improve urgent care out of hours

P4 - Improve OPEL amp escalation response

P5 Enabler - Daily reporting data quality and external reporting

P6 - Timely management of patients who present with mental health issues

P7 - Reduction in the number of patients with an extended LOS over 21 days

Urgent Care Diagnostics have informed the Actions The Integrated Improvement programme for 201920 is focusing on 7 areas to improve on Urgent amp Emergency performance reporting monthly to Trust Management Executive Trust Board Sub committees Each project will have baseline data with clear measureable outcomes

Elective Care Total Waiting List Size and Long Waiting Patients

Waiting List Size Trajectory 201920 As agreed in our annual planning submission we have committed to an increase in our waiting list size of 2928 during 201920 This reflects the contractual position with Oxfordshire The trajectory is heavily weighted during April ndash August 2019 to reflect the closure of theatres whilst we complete the refresh of the JR2 theatres following the enforcement notice from the CQC in 2018 Month 6 Performance The submitted total waiting list size for September (52558) represents an increase in waiting list size (6 patients) when compared to August the Trust has achieved ahead of its submitted trajectory in September 2019 52 week wait positon month 6 September submission saw 6 patients waiting over 52 weeks for first definitive treatment exceeding the trajectory volume of zero Of the 6 submitted breaches 2 have now been treated in October 2 have TCI datesplan to treat scheduled in late October 1 patient is scheduled for November (Patient choice of date) Clinical harm reviews In line with the Trusts agreed protocol harm reviews have been requested for the 6 patients the deadline for completion is the 31st October 2019 Actions Central team are attending weekly meetings with the most challenged services to support management and monitoring of the long waiting patients

Total list size Actual Total list size Plan 52 week Plan 52 week Actual

Number of patients Plan for treatment

Maxillo Facial Surgery 1 Clock stopped 02102019

Plastic Surgery 1 Clock stopped 04102019

Spinal Surgery Service 1 TCI scheduled 15102019

Urology 1 OSM chasing surgeon for decision

Vascular Surgery 2

1 pt TCI scheduled 15102019 and 1pt scheduled for TCI 11112019 (pt choice)

Grand Total 6

Elective Care Diagnostic Waits (DM01)

bull Trajectory 201920 The agreed Trust Trajectory was set to achieve the 1 standard at the end of September 2019 with MRI providing the most significant challenge September Trust level position was 204 and therefore trajectory has not been met

bull Month 6 Performance At the end of September 2019 204 of patients waiting for diagnostic test were waiting more than 6 weeks therefore Trust level trajectory of 10 was not met for the month The main areas of under performance were seen in Audiology 1456 against a trajectory of 06 Cystoscopy at 455 against a trajectory of 20 MRI had the largest number of breaches at 163 (473) and also did not meet trajectory of 31 Workforce remains a challenge within Audiology and Echocardiography

bull Actions Continued plans to improve the MRI position are detailed in the ldquoRadiology Resourcesrdquo paper and include improved referral protocols (from Healthshare) The mobile scanner became operational in September accounting for the slight reduction in breaches seen in September position October is planned to see further reduction of MRI breaches as capacity through the mobile scanner has been increased in October when compared to September Neurophysiology ran 16 additional sessions in September resulting in a recovery of their position Echo ran additional Saturday lists in September creating an additional 52 slots Echo continue to try to minimise impact of staff vacancy by recruiting high cost agency using research registrar that can perform echo asking consultants to conduct their own linked echo however are forecasting the position will remain unstable as relying on staffing to do additional adhoc sessions which is currently unpredictable in volume

Patients waiting gt6weeks for diagnostic procedure against plan

Number of patients waiting over 6 weeks at submitted position for monthly diagnostic return

000050100150200250300

Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Actual Performance Plan Performance National standard

Specialty Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul -19 Aug-19 Sep-19 Trend rol l ing 12 month period

Magnetic Resonance Imaging 130 143 157 123 269 149 226 206 206 182 173 181 163Computed Tomography 5 12 9 5 4 5 2 6 6 5 8 8 9Non-obstetric ul trasound 0 0 0 0 0 0 0 3 4 3 0 0 0Barium Enema 0 0 0 0 0 0 0 0 0 0 0 0 0DEXA Scan 0 0 0 0 0 0 0 0 0 0 0 0 0Audiology - Audiology Assessments 20 19 3 8 21 9 5 12 28 30 12 25 60Cardiology - echocardiography 0 0 2 0 4 10 3 1 0 8 4 23 5Cardiology - electrophys iology 0 0 0 0 0 0 0 0 0 0 1 2 0Neurophys iology - periphera l neurophys iology 2 0 0 0 5 0 0 1 25 22 5 36 4Respiratory phys iology - s leep s tudies 0 0 1 0 15 35 37 28 13 4 1 9 5Urodynamics - pressures amp flows 6 6 17 2 0 1 0 1 0 0 0 2 6Colonoscopy 29 9 4 3 3 2 3 1 11 8 6 6 10Flexi s igmoidoscopy 6 6 1 0 0 0 2 3 5 3 6 3 10Cystoscopy 12 13 7 15 17 13 6 28 34 21 12 12 13Gastroscopy 23 8 3 8 5 8 7 10 10 3 7 17 9

Elective Care Elective on the day cancellations and 28 day readmission

Month 6 Performance There were 42 reportable (hospital non clinical) elective cancellations on the day throughout the month of September this represents an increase in cancellations due to these reasons when compared to previous months The specialties contributing to the 42 are listed on the table to the left the top 4 cancellation reasons were bull 9 patients due to list overranran out of theatre time bull 9 patients due to emergency case taking priority bull 5 patients due to anaesthetist unwellno anaesthetist bull 5 due to no bed (including ITU bed) The remaining were made up of equipment failure equipment unavailable Surgeon sickness There continues to be patients cancelled on the day due to medical notes being ldquomissingrdquo and not available 2 patients were not able to be offered a date of readmission within 28 days of cancellation and therefore breached the 28 day standard 1 patient was unable to be dated within the target date due to all available capacity within the 28 day timeframe being booked with clinically urgent cases The second patient was scheduled within 28 days but subsequently cancelled by hospital to accommodate emergency patient Action A theatre improvement programme is up and running and includes a workstream on pre-operative assessment ndash aims to reduce the volume of patients cancelled on the day for clinical reasons furthermore the data available to analyse reasons and target improvements is limited ndash the rollout of Surginet aims to improve this

28 Day reportable cancellationsreadmission breaches by Month Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19

Total Hospital Non clinical cancellations in period 51 75 69 46 58 67 49 21 45 47 35 24 42

28 day Readmission breaches in period 3 1 2 1 5 1 4 8 4 3 1 3 2

Other - reasons for elective on the day cancellation by Month Clinical reason 48 51 60 27 39 29 34 51 37 33 42 26 29

Patient declined treatment on the day 5 10 7 6 8 4 6 5 6 6 8 6 6

Not cancelled on the day of admission - admin error 29 55 66 55 75 30 62 28 52 47 57 49 42 Grand Total 82 116 133 88 122 63 102 84 95 86 107 81 77

Specialty Cancellations 28 day

Readmission Breaches

Thoracic Surgery 2 0 Clinical Immunology 1 0 Respiratory Physiology 2 0 Neurosurgery 4 1 Maxillo Facial Surgery 3 0 Ophthalmology 2 0 Paediatric ENT 1 0 Paediatric Plastic Surgery 1 0 Plastic Surgery 1 0 Orthopaedics 13 1 Endoscopy (General Surgery) 1 0 Gynaecology 6 0 Hepatobiliary and Pancreatic Surgery 1 0 Urology 4 0 Trust Total 42 2

Cancer Waiting Time Standards Month 5 Performance August 2019 In Month 5 we achieved 4 out of the 8 CWT Standards bull The 2ww performance during August improved to 955 against a

standard of 93 bull The 31 day standard for first definitive treatment performance declined

in August and is below the standard at 936

62 Day from a Screening Service All breaches relate to the breast screening service Pathway analysis completed and presented to the breast service The Trust Cancer Lead is meeting with the MDT chair to discuss the opportunities from recall to completion of diagnostics and first OPA The current average wait time from recall to screening is around 12 -14 days and it has been proposed as to whether this can be reduced to around 7 days The actions resulting from the discussion with the MDT chair will be acted upon with the service

62 Day from GP referral bull Our 62 day CWT Standard continues to fail with a slightly improved

position on last month to 709 against the CWT standard It also failed the Trust trajectory which was 823 for this month

bull The diagnostic delays were primarily due to high demand and reduced capacity in CT MRI and PET this also impacted on breast screening services

bull The Trust has also seen an increase in the complexity of patients being treated on specific cancer pathways eg lung Upper GI head amp neck

bull Specific actions on the development of Infoflex are underway and improvements on patient tracking and COSD are visible however there is still work to do

Specific Actions bull Infoflex Development to support COSD E-MDT and patient tracking bull Integrated Improvement programme projects including new

Trustwide twice weekly visual clinical pathway PTL bull Infoflex tumour site tracking process - ldquopatient next steprdquo focus

improving pathway visibility bull Validation plan for next quarter to reduce PTL by circa 1000 patients bull There has been an improvement on the waiting times and capacity

for CT and MRI which has in turn supported the 62-day pathway within the diagnostic services

Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19At least 93 of patients referred from a GP with suspected cancer will be seen within 2 weeks of referral 9757 9794 9811 9703 9681 9745 969 964 963 961 928 948 955

At least 93 of patients referred from a GP with breast symptoms but not suspected cancer will be seen within 2 weeks of referral 9621 9638 9873 9586 9429 8779 947 938 973 96 935 958 973

At least 96 of patients will receive first definitive treatment within 31 days of a decision to treat 9467 9004 9340 9605 8935 9083 923 917 957 965 937 96 936

At least 94 of patients will receive subsequent treatment with surgery within 31 days of decision to treat 9101 9400 9216 9688 9512 9524 100 962 963 951 982 955 85

At least 98 of patients will receive subsequent treatment with anti-cancer drug regimen within 31 days of decision to treat 100 100 100 100 100 100 100 992 100 100 100 100 100

At least 94 of patients will receive subsequent radiotherapy within 31 days of a decision to treat 9831 9541 9176 9565 9433 9630 975 100 995 995 995 992 995

At least 85 of patients will receive their first treatment within 62 days of referral from a GP 6806 7100 7123 7635 7082 6544 639 754 74 696 697 692 709

At least 90 of patients will receive their first treatment within 62 days following referral from a screening service 9615 8000 5833 8889 9474 5714 565 688 741 755 595 44 667

StandardOUH

Nursing and Midwifery Staffing NHSI Model Hospital Data (July 2019)

Care hours per patient day (CHPPD) is a nationally used principal measure of staff deployment within inpatient areas only

High or low CHPPD is not a measure of whether a clinical area is staffed correctly or not

It is used within OUH alongside quality and safety outcome measures as represented on the safe staffing dashboard

of 52 QC201939 Integrated Performance Report

Nursing and Midwifery Staffing Safe Staffing Dashboard ndash Nursing amp Midwifery (Inpatients)

Census

565 493 46 320 35 81 796 81 1644 1428 8683 1215 1174 9658 1371 1165 8497 693 784 11313 10000 2 0 3 5 2354 1716 346 602412 639 64 192 14 83 875 78 1643 1343 8177 611 312 5106 1702 1278 7509 345 265 7667 8556 1 0 1 0 1321 2328 287 320507 374 45 232 30 61 729 75 1818 1378 7582 1081 863 7987 993 894 9003 661 672 10166 9889 2 0 1 3 2658 1543 013 38370 1660 124 331 28 199 - 153 407 382 9377 - - - 583 488 8366 231 198 8571 NA 0 0 0 0 2535 1182 074 766

360 646 58 192 19 84 786 77 1455 1142 7849 361 351 9723 991 951 9591 330 342 10364 9667 0 0 0 1 2185 1106 606 000270 575 59 188 14 76 1037 73 1189 892 7502 675 383 5667 1047 704 6724 0 0 - 7556 0 0 0 0 2458 3189 510 000540 436 45 266 27 70 732 71 1780 1562 8774 864 876 10145 856 859 10035 568 558 9833 10000 1 0 1 2 -540 627 430 103270 767 62 256 05 102 1036 67 1200 938 7817 345 104 3000 1035 748 7222 345 23 667 10000 0 0 0 0 -603 1391 330 310308 575 67 096 19 67 1065 86 1277 1102 8626 338 365 10784 1035 967 9338 0 219 - 7444 1 0 0 0 -4483 650 262 829842 1287 142 219 33 151 - 175 8635 6036 6991 3468 1774 5115 8283 5950 7184 1380 1012 7333 NA 8 1 0 0 1064 1834 408 289467 386 41 397 37 78 881 78 1234 1040 8430 1283 943 7354 1036 887 8561 886 783 8842 10000 1 0 1 2 3011 1922 683 411548 458 50 256 44 71 993 94 2071 1474 7115 1051 1149 10937 1382 1290 9334 690 1266 18341 10000 0 0 0 4 1716 000 511 000360 493 48 605 42 110 828 91 1322 1061 8026 994 809 8140 693 683 9848 858 709 8263 10000 1 0 1 1 2552 1627 776 879485 627 73 426 67 105 1359 140 1899 1817 9571 1494 1653 11062 1731 1720 9936 1381 1599 11583 10000 3 0 1 4 1277 795 450 484295 2300 226 329 13 263 - 239 6151 4568 7427 690 219 3174 3793 2104 5547 690 173 2500 NA 2 0 1 1 -049 1714 316 473235 595 79 082 07 68 95 86 1412 1059 7502 661 160 2421 1035 799 7722 0 0 - 9889 2 0 0 0 2604 1266 000 1395750 598 51 266 28 86 89 79 2496 1921 7697 1329 1244 9360 2149 1900 8842 661 825 12477 10000 3 0 3 2 2843 1907 238 204387 633 76 192 14 83 1025 90 2290 1556 6796 690 391 5667 1380 1380 10000 335 162 4843 10000 2 1 0 1 -388 1677 209 329720 505 38 302 24 81 775 61 1854 1563 8431 1235 1058 8563 1218 1155 9483 661 652 9856 10000 3 0 3 7 3035 1475 258 000565 492 48 292 29 78 753 78 1668 1579 9466 1054 957 9084 1383 1153 8340 692 698 10094 10000 1 0 0 2 2925 000 137 115645 430 37 252 27 68 721 64 2046 1407 6876 1066 1026 9625 990 981 9909 660 704 10667 9778 2 0 1 5 2123 000 1346 000647 413 39 242 25 66 676 64 1880 1732 9215 1074 926 8624 912 806 8835 660 682 10333 9778 0 0 0 0 2388 2288 514 638390 2669 239 000 20 267 - 260 5106 4717 9237 719 530 7377 4995 4615 9238 346 265 7670 NA 2 0 0 2 2290 843 291 365

1230 495 44 185 15 68 763 59 3514 2872 8173 1372 1177 8575 2760 2553 9250 690 666 9652 10000 3 0 2 6 923 1775 112 176743 506 42 230 16 74 666 58 2129 1583 7432 900 760 8449 1703 1565 9189 530 427 8057 10000 0 0 1 2 2796 2231 520 500540 447 42 319 38 77 859 79 1542 1204 7807 1376 1163 8452 1059 1049 9906 679 865 12742 9889 1 0 1 9 969 1659 033 326505 474 36 338 43 81 1031 79 1384 940 6791 1036 1228 11857 865 878 10153 691 955 13831 9333 0 0 2 3 1661 665 727 000660 424 35 363 31 79 1012 67 1526 1266 8298 1377 1229 8930 1037 1072 10338 691 843 12200 10000 1 0 2 6 2094 852 163 000589 403 36 345 34 75 806 70 1547 1109 7167 1384 1201 8673 1039 1028 9889 691 794 11499 10000 0 0 1 7 2752 1707 467 383396 1895 225 000 21 190 - 246 6546 4535 6928 690 495 7167 5682 4362 7678 345 334 9667 NA 3 0 1 0 2609 1903 110 457

- 575 - 407 - 98 - - 1012 851 8409 822 548 6661 576 542 9418 404 346 8575 NA 0 0 0 6 1860 1312 232 283- 1091 - 436 - 153 - - 744 763 10262 393 268 6828 472 469 9936 104 104 10048 NA 0 0 0 0 2578 1738 500 000- 728 - 217 - 95 - - 933 857 9190 366 324 8865 840 744 8857 196 173 8824 2111 5 2 1 13 2150 1638 647 177- 899 - 271 - 117 - - 2038 1800 8831 712 355 4986 1196 1128 9427 300 224 7462 NA 5 0 0 5 1700 1967 332 362

480 611 48 381 34 99 877 82 1629 1214 7452 1470 899 6115 1381 1085 7859 1034 724 7006 10000 1 0 2 3 1124 2779 376 366900 385 34 403 28 79 767 61 2263 1723 7613 2956 1610 5447 1381 1323 9583 690 876 12696 10000 0 0 4 8 -656 1568 582 229840 412 32 288 31 70 755 63 2241 1547 6903 1378 1712 12420 1164 1166 10017 863 889 10301 10000 0 0 0 11 -185 998 524 459512 406 45 673 69 108 1021 113 1719 1410 8201 4391 2616 5958 950 880 9265 630 895 14209 10000 0 0 0 0 395 1410 267 212540 447 40 319 38 77 938 78 1532 1201 7837 1043 1154 11070 1036 956 9227 679 910 13412 10000 0 0 2 3 2234 2918 425 390540 831 51 192 30 102 87 81 1883 1602 8512 679 1023 15064 1703 1130 6632 346 605 17486 10000 0 0 1 5 -3191 486 1149 505660 470 37 261 26 73 788 64 1890 1269 6716 1018 998 9806 1391 1186 8526 689 740 10740 7333 1 0 1 5 3145 4385 167 000623 621 52 397 28 102 905 79 2482 1663 6701 1505 1043 6934 1726 1553 9000 1035 679 6556 10000 1 0 2 4 1993 948 692 229

469 472 64 235 26 71 801 90 2413 2020 8373 755 552 7307 1023 993 9705 691 656 9500 10000 1 1 0 2 -498 1728 583 208600 518 54 290 20 81 685 74 1907 1819 9540 1391 867 6234 1380 1427 10337 346 346 10000 10000 0 0 2 7 036 1362 132 432632 524 49 444 27 97 62 77 2377 1714 7209 1869 1141 6106 1980 1386 7000 660 594 9000 10000 3 0 0 3 2900 2672 404 000540 578 58 322 30 90 797 88 1957 1813 9263 1131 942 8329 1319 1320 10008 660 671 10167 9667 1 0 3 1 2306 2676 305 000480 620 63 301 31 92 832 94 1768 1648 9321 1121 1027 9161 1381 1358 9835 345 483 14000 9556 2 0 1 1 381 435 122 000450 537 56 307 34 84 843 91 1511 1505 9964 1051 987 9396 1037 1026 9894 345 563 16304 9667 0 0 0 0 631 2720 100 369360 577 52 192 18 77 697 70 1258 965 7675 361 323 8946 990 905 9136 330 312 9455 10000 0 0 0 2 2191 1550 107 000540 510 50 476 26 99 701 77 1604 1419 8847 1912 984 5148 1312 1303 9928 331 431 13021 9444 1 0 2 1 2226 1867 323 000587 462 46 239 21 70 711 67 1632 1441 8828 1097 893 8140 1321 1265 9575 330 328 9924 10000 7 0 2 0 2687 2101 258 420476 542 58 307 36 85 896 94 1896 1749 9224 805 895 11108 1037 993 9571 689 841 12209 10000 2 0 13 6 2175 1737 102 000450 768 73 329 27 110 1026 100 2342 1756 7499 1216 918 7549 1980 1540 7778 331 298 9003 10000 0 0 0 0 1933 2211 533 453480 657 60 220 23 88 825 83 1937 1591 8214 732 687 9385 1322 1281 9686 330 421 12760 10000 1 0 0 2 1590 496 261 355492 426 43 327 25 75 774 68 1609 1169 7268 1172 880 7514 993 939 9456 652 367 5629 10000 1 0 0 6 2014 000 383 00075 1629 250 766 146 240 - 396 1004 1064 10593 688 611 8880 841 815 9697 619 484 7817 NA 0 0 0 0

330 1911 238 1243 50 315 - 289 4232 4493 10616 1228 1055 8595 3461 3374 9749 805 603 7491 NA 0 0 0 1990 281 27 213 15 49 - 41 1388 1777 12802 1109 969 8738 1001 853 8521 681 493 7239 NA 3 0 0 0387 310 46 184 22 49 - 68 1343 1126 8384 484 485 10010 621 650 10463 380 381 10026 NA 0 0 0 0

91 1176 163 781 96 196 - 259 969 880 9080 631 562 8904 601 604 10058 304 312 10255 NA 1 0 0 0 412 000 548 483653 2702 205 461 24 316 - 228 8256 6658 8064 1541 848 5501 8037 6715 8355 1285 698 5430 NA 1 0 0 0 2877 2754 469 659

-2693 1034 463 248

Maternity Sensitive Indicators

Delay in induction (PROM or

booked IOL)

Pressure Ulcers

Proportion of women

readmitted postnatally

Proportion of mothers

who initiated

breastfeeding

NOTTSSCaN

Renal WardSEU D Side

John Warin Ward

Cardiology Ward

Robins WardSpecialist Surgery IP Ward

Adams Trauma

Complex Medicine Unit A

Neurosurgery RedHC WardPaediatric Critical Care

Average fi l l rate ()

Registered nursesmidwives Care Staff

Average fi l l rate

Total monthly planned

staff hours

Total monthly

actual staff hours

Actual Overa l l

Day NightRegistered nursesmidwives Care Staff

Melanies Ward

Head and Neck Blenheim WardHH Childrens Ward

Cumulative count over the month of patients

at 2359 each day

HH F WardKamrans Ward

Bellhouse Drayson WardBIU

Neurology - Purple Ward

HDURecovery (NOC)

Actual Regis tered nurses and midwives

September 2019

Budgeted Care Staff

Required Overa l l

Budgeted Overa l l

Census Compliance

Actual Care s taff

Total monthly

actual staff hours

Average fi l l rate

Total monthly planned staff

Average fi l l rate

staff hours

Ward Name

Monthly Hours

Budgeted Registered nurses and midwives

Care Hours Per Patient Day

Total monthly actual staff

Maternity ()

Nurse Sensitive Indicators HR

Sickness ()

Medication Administrati

on Error or Concerns

Pressure Ulcers

Category 23amp4

Vacancies ()

Turnover ()

Extravasation Incidents Falls

Medication errors (

administration delay or

omission)

HH ICU JR ICU

Laburnham

JR Emergency Department

Complex Medicine Unit C

Toms WardWard 6A - JR

Ward 7F Trauma

MW Level 6

MW The Spires

Upper GI WardUrology Inpatients

SEU E SideSEU F Side

Sobell House - Inpatients

Ward 5F - JR

MW Delivery Suite

Ward 5A - JR Ward 7E Osler Chest Ward

MW Level 5

Renal Transplant Ward

Complex Medicine Unit D

Gynaecology Ward - JR

Total monthly

actual staff hours

Neurosurgery Blue Ward

12 0 08

Oncology Ward

Complex Medicine Unit B

Ward E (NOC) Ward F (NOC)

WW Neuro ICU

Neurosurgery GreenIU Ward

HH EAUHH Emergency Department

Emergency Assessment Unit (EAU)

OCE Rehabilitation Nursing (NOC)Short Stay Ward (SSW)

Cardiothoracic Ward (CTW)

Juniper Ward

Haematology Ward Jane Ashley Colorectal Centre

Stroke Unit

Neonatal Unit

July 2019 is now the most recent NHSI Model Hospital data available An update is expected in the next 2-3 months

Increased activity seen in AICU at the John Radcliffe and Churchill Hospitals meant that the CHPPD is lower This was mitigated by the deployment of all staff away from non-clinical duties The directorate has indicated that this deployment is likely to have impacted on timings of appraisals and mandatory training in September Laburnum ward capacity was increased in September Staffing mitigation has been reliant on the flexible pool Review of safety indicators demonstrates an increase number of falls reported however no harm was sustained to patients However close monitoring continues with in line with the capacity increase An increase in falls has been seen within Haematology ward and and an increase in reported HAPUs in Sobell House Review of these has demonstrated that there were no lapses in care or serious harm Close ongoing monitoring of this continues by the Divisional Nurse

September has seen a further improvement in band 5 turnover position Midwifery vacancy is at 18wte or 62 International nurse recruitment continues to progress with 227 nurses landed and of that number 172 at the time of reporting are now on the Nursing and Midwifery Council Register

Nursing and Midwifery Staffing workforce report September 2019

Nursing and Midwifery Staffing Band 5 RNs in post budget leavers and starters and turnover trajectory in September 2019

Non-inpatienttheatre or critical care areas RN vacancy rates Staff in Post and Budget by Month

Nursing and Midwifery Staffing RN and Midwifery turnover by Band September 2019

FTE Leavers FTE Annual Turnover Rate Aug-19 Jul-19 Jun-19 May-19 Apr-19 Mar-19 Feb-19 Jan-19 Dec-18 Nov-18 Oct-18 Sep-18 Aug-18 Jul-18 Jun-18 May-18 Apr-18 Mar-18

All Nursing Turnover 2951 419 142 144 152 145 144 146 151 143 141 140 136 140 144 151 145 151 154 153 155

Band 5 Nursing Turnover 1349 278 206 210 226 216 213 214 219 197 196 199 192 196 202 218 207 211 215 216 215

Band 7+ Nursing Turnover 587 39 67 67 70 65 71 72 75 75 72 67 69 70 73 75 75 81 72 77 83

Registered Nursing Turnover

All Midwifery Turnover 273 32 116 123 136 152 145 147 145 131 140 150 148 153 160 165 169 146 150 159 154

Band 5 Midwifery Turnover 36 3 73 120 108 68 46 44 43 43 63 63 62 59 51 35 126 110 138 167 167

Band 7+ Midwifery Turnover 60 4 62 80 105 132 134 117 130 101 100 115 156 161 164 147 105 73 83 83 70

Registered Midwifery Turnover

Vacancy at band 5 in wte Vacancy at band 67 in wte

Vacancy at band 5 in numbers of posts Vacancy at band 67 in numbers of posts

Nursing and Midwifery Staffing Nurse Vacancy overview by division September 2019

Nursing and Midwifery Staffing Divisional distribution of internationally recruited nurses

Harm from Pressure Ulceration Incidence of Hospital Acquired Pressure Ulceration (HAPU) category 2-4 reported on Datix ndash April 2016 to September 2019

000010020030040050060070080

Cat 2-4

Median

Cat 3 and 4

Median

All HAPU Category 2-4 are validated by the Tissue Viability Service All HAPU Category 3 and 4 follow the Trust process for Moderate Harms In September 2019 a total of 12 x Category 3 HAPU and 1 x Category 4 were reported The incident involving a child with a Category 4 pressure ulcer (Device Related) is being investigated as a Serious Incident along with one Category 3 incident Local investigations have been conducted for 8 of the incidents and 3 incidents investigated at Divisional level

Incidence of Category 3 and 4 HAPU as a subset of the above

Harm from Pressure Ulceration Number of Incidents Reported

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Cat 1 46 29 37 46 40 27 Cat 2 63 49 50 54 43 45 Cat 3 5 13 2 6 6 12 Cat 4 0 0 0 0 0 1 Total 114 91 89 106 89 85 Cat 2-4 68 62 52 60 49 58 Cat 3-4 5 13 2 6 6 13

September saw a reduction in the reporting of Category One pressure damage but an increase in Category 3 Specific causation is currently unclear A Deep Dive exercise has been recommended to be led by the Deputy Divisional Nurses to explore themes and report back to the Harm Free Assurance Forum

Early reporting of superficial pressure damage is linked to earlier risk mitigation and implementation of prevention measures leading to less severe outcomes

MRCApr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19

Cat 1 12 9 12 11 12 17Cat 2 24 17 18 21 20 17Cat 3 3 7 2 2 3 6Cat 4 0 0 0 0 0 0Total 39 33 32 34 35 40Cat 2-4 27 24 20 23 23 23Cat 3-4 3 7 2 2 3 6

NOTSSCaNApr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19

SUWONApr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19

CSSApr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19

Actions

Themes from the Category 3 and above pressure damage investigations across all Divisions are reviewed and discussed at the Trust-wide Harm Free Assurance Forum (HFAF) Emerging themes from an increase in September of category 3 HAPU will be considered in relation to a Deep Dive exercise led by the Deputy Divisional Nurses

Serious Investigation Action Plans related to Pressure Damage will be shared and closed at HFAF

A revised Framework to support the investigation of HAPU Category 3 and above pressure damage will be piloted from 4th November 2019

The Trust are working with an NHSi Collaborative programme focused on reducing pressure ulcer occurrence using Quality Improvement methodology These projects are initially being piloted in two clinical areas with a view to rapid spread of successful interventions

Harm from Falls Incidence of Inpatient Falls Reported on Datix Falls Assessments and Falls Prevention implementations

Inpatient Falls reported on Datix Over the last few months falls incidents reported on Datix are increasing and the moderate harm level incident have also showed an increase This maybe due to number of complex patients who require more intense supervision and staffing levels do not always allow for this independent patients mobilising post procedures and feeling faint Unwitnessed falls and falls from bed continue to be the two highest reported categories Staff will be reminded about provisions of low beds completion of Bedrails Assessment Tool and ldquoLowb4ugordquo campaign Education will be given to staff about asking more questions about the fall to discover what actually prompted to the patient to get up or no use a call bell etc

The data collection for the Falls CQUIN continues and quarter two showed 17 compliance This is an increase of 2 from the previous quarter but remains under the minimum threshold for CQUIN compliance which is 25 Band 6 Falls Data Collector hoping to start on the 111119 and they will work with Falls Prevention Practice Educator until 31st March 2020 Plans for improvement include bull Use new Harm Free meetings to share information regarding CQUIN

compliance with Senior colleagues to disseminate across their divisions and for them to devise improvement plans

bull CMU wards are just in the beginning of a project to improve compliance with Lying and Standing blood pressure measurements This has engagement of the Matron Ward Sisters Consultant and PDNs It will start on two wards initially and then progress once embedded

To develop a strategic falls plan for the trust for the future Falls Prevention Practice Educator and Head of Therapies for AMR are working on this

Falls Prevention Practice Educator to share monthly data about falls with attendees at Harm Free Assurance Forum

Use strategic plans and Quality Improvement Methodology to increase the CQUIN compliance rate Falls Prevention Practice Educator has resources available for Head of Nursing and Clinical Governance Leads to move forward with this

The National Audit of Inpatients Falls continues and data is inputted about fractured neck of femurs which have occurred during hospital admission

The trust need to consider the expansion of provisions of Low beds floor protection mats and the current levels of availability on all four sites

Encourage staff to debrief on falls incidents to reduce repeat fallers

A trajectory of improvement bi Division will be monitored at Executive performance reviews

Dates to be secured and circulated for 2020 Falls Prevention Practical Skills Workshops 75 people attended the workshops in 2019 and 13 new Falls Prevention Champions recruited

Falls Prevention Practice Educator to liaise with Head of Nursing and Clinical Governance Leads and Matrons to develop a focused and agreed plan for interaction engagement and development of Falls Prevention Champions across the trust

Harm from Falls Strategic plans going forward

Friends and Family Test Response Rates

Oct-18 Jan-19 Apr-19 Jul-19

ED Response Rate

OUH OUH 12mo mean Nat Avg

IP DC Response Rate

Maternity Response Rate (LampB only)

Childrens Response Rate

OUH OUH 12mo mean

Above charts show FFT response rates for each category over the 12 months concluding in September 2019

Childrens response has increased slightly in the last month and is currently above the 12month mean

Maternity response has continued to recover significantly from Julyrsquos low point at 46 and has reached an annual high of 388 in September continuing the upward trajectory

Patient experience team building ward focused direct activity plans focused on increasing response rates

Update from NHS England received on 1 September 2019 agreed changes to FFT and full guidance has now been issued for implementation by 1 April 2020

Action

Maternity and Childrens services will be included in SMS Texting as part of the new FFT contract from 1st April 2020 It is anticipated that introduction of this survey method would smooth monthly variations in Maternity response rates

Friends and Family Test Recommend

939 930

Oct-18 Dec-18 Feb-19 Apr-19 Jun-19 Aug-19

Outpatients Recommend

OUH OUH 12mo meanNat Avg OUH upper control (+3SD)

Maternity Recommend

IP DC Recommend

ED Recommend

Childrens Recommend

OUH OUH 12mo mean

The 5 Charts above compare the Trustrsquos recommend rates with the national average for the four main FFT categories over the 12 months concluding September 2019 Please note that national-level data is not yet available for September at time of writing

Recommend rates are holding steady in IPDC and ED with slight month-on-month increase in Maternity

There are no exceptions to report this month

Staff attitude

Implem

entation of Care

Patient Mood Feeling

Clinical Treatment

Waiting Tim

Admission

unication

Appointment

Cancellations

Environment

Positive Comments ( Total)

4912 (850)

2524 (823)

1082 (728)

1087 (750) 715 (612) 864 (759) 653 (706) 461

(529) 446 (707) 230 (618)

Negative Comments ( Total)

320 (55) 186 (61) 163

(110) 152 (105) 215 (184) 112 (98)

110 (119)

200 (230)

76 (120)

66 (177)

Total (N) of comments for

theme 5778 3067 1486 1450 1169 1138 925 871 631 372

Friends and Family Test Trust wide Themes September 2019

The table shows the top 10 most commonly raised FFT themes from across the Trust September 2019 Please note that counts of neutral comments are not displayed here but have still been included in total comments line

The top 10 themes (by quantity) comprise 16887 comments a decrease of -570 vs Augustrsquos 17457

The top three positive (by proportion) comments for August remain staff attitude implementation of care and Admission

The top three negative (by proportion) comments among these themes relate to appointment cancellations waiting times and PLACE

Friends and Family Test Divisional Focus

Chart X Recommend Rate by Division Chart X Not Recommend Rate by Division Chart X Response Rates by Division

930935940945950955960965970975980

CSS MRC NOTSSCaN SUWON

FFT recommend by division September 2019

FFT not recommend by division September 2019

205 213

FFT response rates by division September 2019

The 3 charts show FFT response recommendation and non-recommendation rates across all divisions for September 2019 (sourcing from inpatient day case FFT data)

Response Rates Vary from 134 (NOTSSCaN) ndash 228 (SUWON) Response rates in NOTSSCaN increased in September by 09pp compared to August The other divisions had slight variations in responses in the same month (SUWON = -31pp MRC = +03pp CSS = -03pp) NOTSSCaNrsquos response rates c continue to be restrained by Childrens directorate Adult-only response rate is 199

Recommend Rates These range between 949 (MRC) ndash 977 (CSS) Recommend rates changes MRC (-01pp) SUWON (+16pp) and NOTSSCaN (+20pp)CSS (-01pp)

Not Recommend Rates These rates range between 12 (CSS) and 24 (SUWON)

Care and com

passion of staff

InformationCom

munication

Play areaactivities W

ard facilities

Miscellaneous

Timeliness

Noise at N

Excellence

Cleanliness

Positive Comments 77 11 9 8 2 0 0 0 2 1

Negative Comments 0 9 7 6 6 4 2 2 0 0

Total (N) of comments for theme

77 20 16 14 8 4 2 2 2 1

Friends and Family Test Childrenrsquos Themes September 2019

The Table shows Septembers comment themes raised from Childrens and parents feedback There were 76 (46) respondents from Inpatient and Day case areas The data capture was inconsistent last month and not all data was included A meeting with the FFT supplier is schedule for 24 October 2019 to resolve this

The Childrens Patient Experience team are feeding back the comments raised to clinical and supportive teams with suggested plans for improvement for areas such as hot drinks allowed in safety cups for parents on wards soft closing bins and quiet shoes to reduce noise at night as well as improved communication with children and their families Positive comments including named staff are also presented back to the wards

Comments and challenges are presented at Childrens directorate Quality Committee and to the Division reported through governance reporting

The thematic data is collected analysed then assessed to enable service improvement plans and recommendations to the clinical teams

987 of respondents would recommend the ward they were on

Childrenrsquos Patient Experience - September 2019

Yippee Team Use of Virtual Reality Headsets Yippee (Young People Executive) Activity

Gave feedback on virtual reality headsets for use with painful procedures for a dissertation research project for a childrenrsquos student nurse She had seen the need when she was part of the play team

There are a number of projects that are ongoing These include

Planning for Takeover Day

Reviewing of Promises survey ( FFT)

Being part of the climate change event in October jointly run with Voice of Oxfordshire Youth and Oxfordshire County Council

Ongoing plans and actions

Working in partnership with OUH volunteer team particularly looking at how we can use 16-18 year olds within the hospital as well as increasing the amount of feedback

National Children and Young Peoples Survey to be published Nov 2019

Transition

There are ongoing plans to have a coordinated approach to transition across children and adult services A bid to Roald Dahl charitable funds for a transitional nurse has been submitted

Trust Performance August 2019

MRC NOTSCaN SUWON CSS Corporate

Complaints received in September 2019 95 16 38 29 7 5

Acknowledgement

Closure Q1

92 96 89 93 94 93

PALS and Complaints Performance

Complaints received Complaints concluded within 25 working days15 day extension

Q2 1819Q3 1819 Q4 1819 Q1 1920

Complaints concluded within 25 working days number ofcomplaintsconcluded within25 working days

concluded within25 working days

KPI = 95

10152025303540 Complaints over the previous eight months

Corporate

NOTSSC

The number of complaints received decreased by 17 overall this month

99 of complaints were acknowledged within the 3 day KPI and overall 92 of complaints were closed within the 25 working day (plus 15 day extension) timescale (Q1) This is an increase in performance The figures above show the of complaints closed by each Division within the KPI

PALS and Complaints Complaints dashboard

PALS and Complaints Divisional comments on complaints performance CSS The focus on turnaround times in CSS continues to have a positive impact There has been a large increase in the number of complaints received this month there does not seem to be a theme in these

MRC The number of complaints received in September decreased to 16 with the majority of complaints closed within 25 working days The Division continues to strive to improve the quality of response complaints and has arranged for training session with the Complaints team to take place for those who regularly are involved in writing complaints responses There is also ongoing work to ensure any actions detailed in a complaint response are recorded evidenced and shared at Clinical Governance meetings

NOTSSCaN The Division recognise the challenge to investigate and close current complaints in a timely manner This is in part due to the current issues affecting access to theatre which is having an effect on the workload of the administration teams However the Division are taking all necessary steps to improve the current position on complaints as the team appreciate the importance of complaints in improving the experience of patients

SuWOn The Division are embedding advanced communication skills with the clinical teams Meanwhile the Division continue to monitor both themes and volume of complaints closely so that learning can be applied across services to improve patient experience

Corporate Car parking continues to be an ongoing theme for Corporate complaints predominantly about access to the JR and Churchill sites Communications facilities and values and behaviours of staff are also concerns emerging from the complaints The closure rate of complaints has improved considerably increasing from 80 in Q4 (201819) to 9375 in Quarter 1

Clinical treatment

Appointments

unication

Values amp Behaviours

(staff)

Patient Care

Facilities

Access to Treatment amp

PrivacyDignityWellbe

Trust adm

inpoliciesprocedures (including patient record m

anagement)

Prescribing

June 21 9 18 7 9 7 6 0 0 1 0 July 34 7 16 12 6 2 7 1 1 1 2

August 34 14 19 5 8 5 4 1 1 4 2 September 35 13 14 7 5 1 3 0 0 1 2

PALS and Complaints Themes and Actions

Thematic breakdown for the top 5 reasons for complaint across the Trust

Clinical Treatment Complex complaints pertaining to issues including dispute over diagnosis birth injury inadequate pain management mismanagement of labour surgical site infection and retained needleswabinstrument

Appointments Regarding appointment letters not sent cancellations delayed referrals and errors

Communication Mix of complaints including communication failure with patient delay in giving informationresults inadequate record keeping and conflicting information

Values amp Behaviours Pertaining to the care needs not adequately met inadequate support provided alleged physical assault and failure to provide adequate care

Patient Care Issues include acquired pressure ulcer care needs not adequately met and call bell ndash failure to respond

Action

Each complaint is triangulated to establish if an incident has been raised and if the legal team are involved The thematic triangulation across Complaints Patient Safety Safeguarding and Legal Teams to establish joint themes for Trust wide learning

A new complaints dashboard has been developed (Appendix x) showing the current Trust performance at a glance at both Divisional and Directorate level Appendix x also shows the comments from the Divisions on their current performance and their plans for improvement

Delivering Same Sex Accommodation (DSSA)

Month Trust Performance

MRC NOTSSCaN SUWON CSS

Dec 2018 55 0 13 0 42

Jan 2019 57 0 14 0 43

Feb 2019 83 1 29 0 53

Mar 2019 41 0 9 0 32

Apr 2019 39 0 7 0 32

May 2019 53 0 13 0 40

June 2019 46 0 10 0 36

July 2019 58 0 5 0 53

Aug 2019 58 0 9 0 49

Sept 2019 56 0 6 0 50

The unjustified breaches for September were 56 The overall Trust number has reduced slightly

The risk is patient flow and capacity within critical care This is a similar experience across the South East and has been previously reported to Trust Board and Quality Committee

Progress on the Trust plan to become compliant with the new NHS I guidelines The new national guidance becomes mandatory across the on 1st January 2020

bull New policy drafted and out for consultation across the Trust bull Telephone meeting scheduled with the NHS EampI Regional Chief Nurse for South East on 31st October 2019 to

benchmark the approach for reporting process for unjustified breaches and justified mixing bull The patient experience reporting tool has been developed and will be reviewed by the Chief Nursing Officer and the

Divisional Nurses in the first instance bull Presentation for use at ward and department meetings New completion date - 1st December 2019 bull Development of an audit tool for use in all clinical areas New completion date - 1st December 2019

Children Safeguarding Report

Chart 1 Activity Chart 2ED Safeguarding Liaison Chart 3 Training

Activity Chart 1 shows the children safeguarding team consultation activity Activity during September dropped by 27 (n=211) with the trend increasing overall during the year Maternity activity remains complex due to mothers with learning difficulties complex mental health drugalcohol issues and domestic abuse A review of the data is being undertaken to report to the OSCB as this impacts on partner agencies Delays in discharging teenagers with mental health or social issues continues to be an issue A senior multi-agency management meeting to review processes is planned and an audit of data has been undertaken to demonstrate the extent of the delays This issue is being monitored and will be reported to the OSCB as part of the ongoing review There is recognition of the complexity of these cases the limitation of agency resource to consider alternatives to managing these cases

ED Safeguarding Liaison Chart 2 shows referrals from ED over the year There were 571liaison referrals to share with primary care and children social care in June a decrease of 93 There was a slight increase in adults (n=55) referred with dependant children who present with safeguarding concerns eg self-harm or domestic abuse There was an increase in domestic abuse related attendances in adults with dependant children resulting in referrals to children social care to ensure assessments are undertaken to safeguard children Gang related and child exploitation related attendances are being closely monitored as part of a multi-agency child exploitation review

Training Compliance Chart 3 shows levels of safeguarding children training compliance is below the national and local KPI of 90 Level 1 is 84 Level 2 is 83 and Level 3 is 82 A review of children safeguarding mapping to ensure staff are aligned to the correct level of training has been finalised to implement Bespoke training has been delivered for ED and childrens services to focus on priority areas to improve compliance

Child Protection-Information Sharing (CP-IS) integrated within EPR in has been further delayed and reduced to priority level 5 The interim process to request staff to access CP-IS information directly from the spine has been implemented and when used has had a positive impact on safeguarding specific children

Q3 Q4 Q1 Q2

Children Safeguarding Training

Level 1

Level 2

Level 3

900 ED Safeguarding Liaison

Adults

Babies

Safe-guarding

Adult Safeguarding Report

Chart 2 Consultations Chart 1 Activity

Section 42 (Sc 42) Enquiries Chart 4 shows the 25 Sc 42 enquiries with outcome over the previous 2 years The reason for Sc 42 has changed over the year to neglect discharge and physical assault MRC have the most Sc 42 enquiries because of the vulnerability of patients supported by the Division The governance and Ward to Board line of sight on Sc42 investigations DOLS applications and safeguarding review of clinical incidents at the Trustrsquos weekly SIRI forum was reported to Quality Committee on 9th October 2019

Chart 4 Section 42 Enquiries Chart 3 Training

Activity Chart 1 shows the teamrsquos responsive activity across consultations and the review of DATIX incidents and Emergency Department (ED) EPR referrals Chart 2 shows the breadth of consultations across the Trust The activity to support the recognition and reporting of safeguarding concerns was reported to Quality Committee on 9th October 2019

Training Compliance The Oxfordshire modern slavery partnership have commended the Trusts inclusion of the Modern Slavery module in the adult Safeguarding level 2 training To date 7770 (82 of required staff) have completed this training The Trustrsquos compliance with Safeguarding Adults and Prevent Training remains below the national and local KPIs shown in Chart 4 Action bull The Chief Medical Officerrsquos business office have a plan in place to support the increase in training compliance across the Medical and

Dental staff group bull Level 3 training will include the national Mental Capacity Act training the mental capacity assessment competencies developed by the

Trust and an online training surrounding the Care Act (2014) and Deprivation of Liberty Safeguards (DOLS) This training will be rolled out for 3300 staff who are Band 7 and above or equivalent on 26th November 2019 In total the training will consist of 13 modules and will take five hours to complete starting with the mental capacity training It will be released onto ELMS accounts on a monthly basis over 7 months to reduce the impact on clinical staff

bull The ACT Awareness eLearning (httpswwwgovukgovernmentnewsact-awareness-elearning) will be rolled out to all staff This is different to the Prevent training and will enable staff to better understand and mitigate against current terrorist concerns This will be uploaded onto the Trustrsquos ELMS system on 26th November 2019

Key Quality Metrics Table

ID Descriptor Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19

PS01 Safety Thermometer ( patients receiving care free of any newly acquired harm) 9785 9845 9780 9795 9732 9807 9807 9833 9811 9771 9733 9793

PS02 Safety Thermometer ( patients receiving care free of any harm - irrespective of acquisition)

9440 9511 9438 9409 9287 9158 9204 9298 9232 9239 9081 9369

PS03 VTE Risk Assessment( admitted patients receiving risk assessment) 9798 9783 9778 9777 9772 9788 9737 NA 9850 9838 9850 9826

PS05 Number of cases of Clostridium Diffici le gt 72 hours (cumulative year to date) 33 38 40 44 48 51 4 12 17 22 32 42

PS06 Number of cases of MRSA bacteraemia gt 48 hours (cumulative year to date) 2 2 2 2 2 2 0 0 1 1 2 2

PS08 patients receiving stage 2 medicines reconcil iation within 24h of admission 6961 6958 6657 6927 6677 6433 6615 6546 6957 7505 7147 6713

PS09 patients receiving allergy reconcil iation within 24h of admission 100 100 100 100 100 100 100 100 100 100 100 100

PS10 of incidents associated with moderate harm or greater 086 085 075 083 092 130 128 178 147 200 143 NA

PS13 Cleaning Score - of inpatient areas with initial score gt 92 5067 4203 2553 2969 4250 5717 6667 4756 4091 3239 4068 3385

PS14 Radiology direct access 7 day turnaround times - Plain Film CT MRI amp Ultrasound 8952 8812 8581 8517 8765 8385 7446 7486 7962 7681 7662 NA

PS16 CAS alerts breaching deadlines at end of month andor closed during month beyond deadline

0 0 0 0 0 0 0 0 0 0 0 0

PS17 Number of hospital acquired thromboses identified and judged avoidable 3 0 0 0 1 0 1 1 3 0 0 0

CE02 Crude Mortality 187 206 199 248 210 183 204 195 197 161 181 175

CE03 Dementia - patients aged gt 75 admitted as an emergency who are screened 8163 8253 7887 7853 7503 7898 7517 7563 7790 8015 7398 NA

CE06 ED - patients seen assessed and discharged admitted within 4h of arrival 8959 8650 8739 8603 8139 8586 8473 8663 8578 8683 8409 8424

PE01 Friends amp Family test likely to recommend - ED 8998 8888 8871 9007 8601 8757 8725 8715 8636 8654 8652 8751

PE02 Friends amp Family test not l ikely to recommend - ED 648 722 688 682 862 677 848 796 941 877 817 691

PE03 Friends amp Family test likely to recommend - Mat 9773 9570 9799 9641 9707 9603 9600 9735 9612 9500 9673 9750

PE04 Friends amp Family test not l ikely to recommend - Mat 000 143 050 135 000 144 182 088 129 450 082 8900

PE05 Friends amp Family test likely to recommend - IP 9551 9599 9506 9644 9589 9585 9619 9658 9606 9633 9507 9603

PE06 Friends amp Family test not l ikely to recommend - IP 220 166 280 164 183 219 193 203 212 187 217 209

PE07 Friends amp Family test likely to recommend - OP 9410 9443 9502 9491 9437 9438 9448 9436 9430 9470 9440 9392

PE08 Friends amp Family test not l ikely to recommend - OP 291 289 278 255 313 321 326 330 310 273 322 321

PE15 patients EAU length of stay lt 12h 5405 5418 5583 5051 5008 5202 4545 4641 4846 5391 5449 5341

PE16 Complaints upheld or partially upheld [Quarterly in arrears] NA NA 6487 NA NA 6932 NA NA 5504 NA NA NA

Key Quality Metrics exception reports

Red exceptions

CE03 Dementia - patients aged gt 75 admitted as an emergency who are screened - Elderly patients admitted on a non-elective basis should be screened for dementia using a screening question and or a simple cognitive test Target 90

MRC- Dementia screening compliance decreased in performance in August 749 from 802 reported in July AMR now has an interim dementia specialist nurse who is working with ward areas and discharge planners to ensure they are checking the task lists and highlighting those who have an outstanding risk assessment to improve performance NOTSSCaN ndash Continues to increase in the month of August with 812 compliance Julyrsquos compliance was reported at 806 The results are feed back to the Directorates via the monthly governance and assurance meetings

SuWOn ndash Performance was recorded at 654 in August which is lower than the 794 compliance in July This will be discussed at the Divisional Governance Meeting and Directorates have considered their performance - the Surgery Directorate completed a service analysis and OampH reviewing the white board rounds

Red exceptions

Amber exceptions

Infection prevention and control - Sepsis

bull 82 sepsis admissions received antibiotics within 1h in Q2 (highest yet target gt90)

bull Updates this month include ndash Patient Group Direction (PGD) for sepsis approved by OXMID Infection Group ndash Sepsis update at ED Clinical Governance Meeting ndash including feedback of positive momentum ndash Decision after stakeholder consultation to extend sepsis dialog box alerts to nurses amp

pharmacists (in addition to existing face up alerts visible to all clinical staff) ndash in progress

Data from audit minor adjustments to ORBIT data after case notes review

Infection Prevention and Control

bull C diff SPC chart reflects changes in apportion of cases for 201920 Rates in line with agreed annual trajectory

bull Gram negative blood stream infections (GNBSI) NHSI Target to reduce health care associated GNBSI by 50 by 202324

bull MSSA 4 cases -in September ndash 3 were line related infections bull MRSA 1 case of pre 48hr Although this was blood culture taken

whilst the patient was in a community hospital there is learning for the OUH

bull Estates amp Environmental Concerns (1) West Wing theatres alleged foreign substance on ventilation grille microbiological sampling undertaken and all clear at present (2) Cancer amp Haematology Centre Due to ongoing incidence of legionella in the water system point of use filters fitted to all outlets Unfortunately there has now been a single case of legionella infection in a patient who has died which is being investigated as a SIRI A Legionella Incident Management team has been set up and is meeting weekly Legionella is commonly found in water including in the home and the environment but it is probable that this was a hospital acquired infection

WHO audits - Documentation

Division Area Exceptions (if applicable) Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19

Pain Management NA 1000 1000 1000 1000 1000 10000 33

Radiology

There was one non-compliance at the JR Radiology Department (angioplasty performed on 30th September 2019) The WHO checks were performed and all sections completed bar the signature on the sign out The modality lead has spoken with the Radiographer Superintendent and the nurse and has been given assurance that the procedure was performed safely There are notes on the sign out section of the form to suggest all were committed in the sign out of the WHO however it is missing a signature for that section Investigation concluded that the lack of signature did not result in poor quality of care

1000 1000 994 984 984 9932 145146

Breast Imaging Centre NA 951 1000 1000 1000 1000 10000 3535

Cardiothoracic Ward NA 967 1000 1000 1000 1000 10000 1010

Cardiac AngiographyThe area of non-compliance within Cardiac Angiography suite is due to no sign-out signature from scrub nurse and no signature from scrub nurse for Cardiology This has been followed up with the manager of the area who has spoken to the staff involved

996 1000 996 1000 1000 9887 175177

Respiratory Intervention

NA 1000 1000 1000 1000 1000 10000 1010

West Wing Theatres One sign out with name and signature of practitioner not completed 982 933 957 944 967 9655 2829

JR Theatres1 sign in anaesthetist signature missing handed over to band 7 scrub nurse in charge who spoken to the team and one missing patient details (procedure) date and sign out date Matron in charge came to check and spoken to the team

750 900 925 800 967 8000 810

Childrens

There were two non-compliant Gastroenterology forms (same consultant) sign out not completed on either and check boxes unticked on one The Deputy Divisional Medical Director and Directorate Governance Lead will meet with the lead clinician to discuss with a view to improving compliance

949 960 1000 1000 982 9412 3234

NOC Theatres One failed sign in as no boxes had been ticked 1000 1000 1000 1000 1000 9655 2829

Maternity NA 963 850 875 1000 875 10000 2626

Gynae JR amp HGH NA 960 849 875 1000 1000 10000 5050

Endoscopy JR amp HGH NA - - - 1000 1000 10000 1212

CH amp HGH Theatres NA 973 1000 972 1000 983 10000 6060

971 957 968 979 9829857 622631OUH

CSS 9946

MRC 9898

NOTSSCaN 9412

SuWOn 10000

WHO audits - Observation

Radiology No Audits performed - 1000 808 1000 - -

Breast Imaging Centre No Audits performed - 1000 - 1000 - -

Cardiac Theatres NA - 1000 1000 1000 900 10000 88

Cardiac Angiography NA 1000 1000 1000 1000 1000 10000 1717

West Wing Theatres NA 1000 1000 1000 1000 1000 10000 1010

JR Theatres NA 1000 1000 1000 1000 1000 10000 1010

Childrens NA 1000 1000 1000 1000 1000 10000 66

NOC Theatres NA 1000 917 1000 1000 1000 10000 1616

Gynae JR amp HGH10 observational audits were carried out On two occasions 1 member of staff was on lunchbreak for question lsquoTime Out all team members presentrsquo (Theatre 2 ndash Gynae l ist And Theatre 1 - Gynae l ist)

807 - - 933 - 8000 810

970 996 983 994 9929900 199201OUH

CSS 10000

MRC 10000

NOTSSCaN 10000

SuWOn 9845

Discharge Summary Results Endorsed amp Outpatient Letters

eIDD sent

before discharge or within 24 hours

eIDD sent gt24 hours or not sent

eIDD sent

CSS 16 6 22 727 8 2 10 800 9 8 17 529MRC 3435 308 3743 918 3485 383 3868 901 3219 443 3662 879NOTSSCaN 2060 586 2646 779 1846 558 2404 768 1861 589 2450 760SuWOn 2007 192 2199 913 1861 201 2062 903 1735 208 1943 893NULLUnknown 0 0 0 - 0 - 0 -Grand Total 7518 1092 8610 873 7200 1144 8344 863 6824 1248 8072 845

Target 900 Target 900 Target 900

Endorsed within 1 week

Not endorsed within 1 week

CSS 837 584 1421 589 439 287 726 605 682 382 1064 641MRC 179648 27884 207532 866 159898 28066 187964 851 157307 24635 181942 865NOTSSCaN 92148 52682 144830 636 78941 51371 130312 606 71394 48744 120138 594SuWOn 196449 59329 255778 768 166115 67699 233814 710 177551 44057 221608 801NULLUnknown 3724 2055 5779 644 3907 2007 5914 661 3709 1809 5518 672Grand Total 472806 142534 615340 768 409300 149430 558730 733 410643 119627 530270 774

Target TBC Target TBC Target TBC

Sent within 7

Sent gt7 days

Total sent

within 7 days

Sent within 7

Sent gt7 days

Total sent

within 7 days

Sent within 7

Sent gt7 days

Total sent

within 7 days

Sep-19

Aug-19

Discharge Summary

Jul-19

Results Endorsed

Jul-19

Outpatient Letters

Jul-19 Aug-19

Aug-19

Local Safety Standards in Invasive Procedures (LocSSIPs)

October 8th Safety Summit Never Events and WHO Surgical Safety Checklist This event included NHSIE presenting the National Strategy to improve Patient Safety as well as local learning from themes of Never Events and Serious Incidents situation update on LocSSIPs and the development of the revised generic WHO surgical safety checklist The event was well attended and the organisers have received positive feedback Current LocSSIP status bull 13 have been completed

Tracheostomy and laryngectomy management Central venous catheter insertion (CVCI) Stop before you block Paracentesis in adult patients with cirrhosis Gynaecology amp Colposcopy outpatient accountable items Arthroscopy Safety standards in theatre for radiographers Peri-operative specimens Chest drain insertion and invasive pleural procedures Lumbar Puncture Outpatient Ophthalmic Laser Procedures (lsquoStop before you zaprsquo) Medical Peritoneal Dialysis (PD) Catheter Insertion Breast biopsy wire marker insertion

bull 18 are in draft bull 31 are proposed Key policies progress bull Prosthesis verification policy ndash approved at Octoberrsquos Clinical Policy Group and now published on the

intranet

Clinical Risk Never Events

No new Never Events were identified in September Four Never Events have been called so far in 201920

Clinical Risk Serious Incidents Requiring Investigation (SIRI)

13 SIRIs were declared by the Trust in September 2019 4 SIRI investigation reports were submitted for closure (approval) to the Oxfordshire Clinical Commissioning Group in the same period SIRIs declared and completed in the last 24 months

Clinical Risk Harm reviews from extended waits

The Trust has an established process for assessing clinical and psycho-social harm for patients waiting for over 52 weeks for an operation this is in addition to the program of harm reviews for patients undergoing care for cancer whose pathways exceed 104 days

Confirmed Harm reviews by month and level of harm Pie chart representation of the services where patients have waited in excess of 52 week waits

Of the 676 harm reviews requested since the process started 675 harm reviews have been completed (rounded up to 100) The majority of reviews identified no harm or minor harm The Gynaecology Directorate represents circa 71 of all 52 week harm reviews though they only account for 13 of breaches to date in 1920 21 reviews for breaches that occurred May 2018 to August 2019 inclusive have been confirmed as covering Moderate or Major harm following discussion at the Harm Review Group and where relevant the Trust SIRI Forum Of these 2 have been called as SIRIs 18 are being investigated at a Divisional level and one at a Local level

Weekly Safety Messages

Since 5 February 2019 a weekly safety message has been issued from the central Clinical Governance team emailed to all staff accounts and available on the intranet

Incidents reported in the last 24 months and Patient Safety Response (PSR)

1853 patient incidents were reported to Datix in September 2019 the mean number over the past 24 months is 1894

In September 72 incidents were discussed 12 of which were downgraded following discussion at PSR meetings In 3 cases a delegation from the meetingrsquos attendees visited the area to source further information and to ensure that staff were supported and patients informed under Duty of Candour

Mortality indicators

There have been no mortality outliers reported for the OUH from the Care Quality Commission or the Dr Foster Unit at Imperial College The Summary Hospital-level Mortality Indicator (SHMI) for the data period June 2018 to May 2019 is 092 This is banded lsquoas expectedrsquo

SHMI is normally expressed as a standardised ratio with a baseline of 1 this has been multiplied by 100 to express as a relative risk with a baseline of 100 to enable comparison to the HSMR

The HSMR is 86 for June 2018 to May 2019 The HSMR value has decreased from 87 and remains rated as lsquolower than expectedrsquo

Slide Number 1

Slide Number 3

Urgent Care John Radcliffe Hospital (JR)

Slide Number 6

Slide Number 7

Slide Number 8

HART Improvement Plan ndash September 2019

Slide Number 12

Cancer Waiting Time Standards

Slide Number 17

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Slide Number 59

MRC- Dementia screening compliance decreased in performance in August 749 from 802 reported in July AMR now has an interim dementia specialist nurse who is working with ward areas and discharge planners to ensure they are checking the task lists and highlighting those who have an outstanding risk assessment to improve performance

NOTSSCaN ndash Continues to increase in the month of August with 812 compliance Julyrsquos compliance was reported at 806 The results are feed back to the Directorates via the monthly governance and assurance meetings

SuWOn ndash Performance was recorded at 654 in August which is lower than the 794 compliance in July This will be discussed at the Divisional Governance Meeting and Directorates have considered their performance - the Surgery Directorate completed a service analysis and OampH reviewing the white board rounds