Integrated Quality and Operational Compliance Report · Report (April data) Well Led. k7.11: Time to Hire (% staff hired in < 88 working days) The proportion of new hires which took

Enclosure C

Integrated Quality and OperationalCompliance Report

February 2020

16/03/20 |Draft Report V1

1 of 44

Contents

Domain Pages

Safe 03 to 13

Effective 14 to 19

Caring 20 to 24

Responsive 25 to 31

Well Led 32 to 34

Domain Scorecard Summary 35 to 38

Glossary 39 to 45

2 of 44

03 to 1314 to 19


Safe Is Care Safe? February 2020

Author: Sally Brittain, Director of Nursing & Quality Pressure Ulcers

VERBAL UPDATE TO BE PROVIDED Falls

VERBAL UPDATE TO BE PROVIDED Infection Control

VERBAL UPDATE TO BE PROVIDED

Serious Incidents Author: Melanie Whitfield | Head of Patient Safety, Governance and Risk Information in the report There was 1 Serious Incident reported in February 2020. 3 Serious Incidents were closed during the reporting period. 1 Serious Incident was de-escalated. Number of SIs where Duty of Candour could be completed: 3 As at 29th February 2020, there were 3 open/ongoing SI investigations. No new extensions have been requested. KHFT are 100% compliant with the Duty of Candour requirements.

3 of 44

Safe03 to 1314 to 19


Ward Day Staffing Rate - RN/MW Day Staffing Rate - HCA Night Staffing Rate - RN/MW Night Staffing Rate - HCACare Hours Per Patient Day

(CHPPD)

AAU 100.3% 100.0% 101.5% 110.3% 7.9 RN Registered Nurse

Alexandra Ward 102.8% 111.9% 103.5% 143.0% 6.7 MW Registered Midwife

Astor Ward 98.7% 118.5% 100.0% 139.7% 6.4 HCA Healthcare Assistant

Blyth Ward 100.0% 99.1% 100.0% 98.0% 5.9

Bronte Ward 103.2% 102.5% 98.5% 105.9% 7.8

Cambridge Ward 100.1% 101.2% 100.0% 99.9% 6.5

Canbury Ward 105.1% 96.6% 100.0% 100.0% 6.8

Critical Care Unit 97.4% 31.0% 96.2% #DIV/0! 32.8

Derwent Ward 98.7% 99.8% 100.0% 102.0% 7.6

Hamble Ward 101.3% 107.3% 106.7% 100.0% 6.3

Hardy Ward 100.4% 98.4% 100.0% 98.4% 8.0

Isabella 99.2% 98.4% 91.3% 75.0% 7.7

Keats Ward 99.1% 96.0% 101.1% 99.8% 6.7

Kennet Ward 98.0% 99.3% 98.9% 101.1% 7.0

Neonatal Unit 81.6% 106.9% 87.7% 58.6% 12.4

Paediatric Unit 98.0% 89.1% 99.9% 49.6% 10.9

Maternity 105.5% 70.7% 97.5% 71.9% 15.3

Trust Average 99.8% 95.1% 98.3% 96.9% 8.7

Key

February 2020

Author: Nichola Kane, Deputy Director of Nursing


Safer Staffing

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

140.0%

160.0%

AAU AlexandraWard

Astor Ward Blyth Ward Bronte Ward CambridgeWard

Canbury Ward Critical CareUnit

Derwent Ward Hamble Ward Hardy Ward Isabella Keats Ward Kennet Ward Neonatal Unit PaediatricUnit

Day Staffing Rate - RN/MW Day Staffing Rate - HCA Night Staffing Rate - RN/MW Night Staffing Rate - HCA

4 of 44

14 to 19


k1.03 | Number of patients with hospital acquired pressure

ulcers (Grade 2)

k.1.04 | Number of patients with hospital acquired pressure

ulcers (Grade 2) per 1000 beddays

32 to 34

Is Care Safe?Safe February 2020


ulcers (Grade 3&4)


ulcers (Grade 3&4) per 1000 beddays

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1.1

1.2

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard <=0.1

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard <=0.51

1 1 1 1 0 1 0 0 0 4 8 4 3

5 2 3 0

1

2

2 2 0

2

4

2

1

0

1

2

3

4

5

6

7

8

9

10

0

1

2

3

4

5

6

7

8

9

10

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Avoidable Un-avoidable Standard

Standard <=1

Standard <=1

2 1 1 3 5 5 5 2 4 2 3 4 7

1

6 2

3

0 1 0

6

3

2

6

1

3

0

1

2

3

4

5

6

7

8

9

10

0

1

2

3

4

5

6

7

8

9

10

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Avoidable Un-avoidable Standard

Standard <=3

5 of 44

14 to 19


k1.07 | Clostridium difficile infections (Hospital Apportioned)k1.08 | Clostridium difficile infections (Hospital Apportioned) due

to confirmed Lapse in Care


k1.05 | MRSA Bacteraemias (Hospital Assigned) k1.06 | MSSA Bacteraemias (Hospital Apportioned)

32 to 34

0 0 0

1

0 0 0 0

2

0

1 1

0 0

1

2

3

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Zero Standard

Zero

2

0

4

0

2

5

1

2

1

4 4 4

2

0

1

2

3

4

5

6

7

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard N/A

Standard 8 for year

0 0

2

0 0 0 0 0 0 0

2 2

0 0

1

2

3

4

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard 8 for year

1 1

0 0

1 1

0

1 1

0 0 0

1

0

1

2

3

4

5

6

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard <=1

6 of 44

14 to 19


k1.10 | Completed Patient Observations - Paediatric Inpatients

(NEWS)

32 to 34


k1.19 | Number of Escherichia (E. coli) bacteraemiak1.09 | Completed Patient Observations - Adult inpatients

(NEWS)

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard N/A

86%

88%

90%

92%

94%

96%

98%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=97%

1 0 0 2 0 1 3 2 2 2 1 0 0

9

0

7

14 18

18

10 13

12 10

9 10

0 0

2

4

6

8

10

12

14

16

18

20

22

24

26

28

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

E.Coli bacteraemia (Hospital Apportioned) E.Coli bacteraemia (Community Apportioned)

Standard N/A

Standard N/A

Standard N/A

Standard N/A

7 of 44

14 to 19


k1.16 | Medication Incidents k1.15 | Never Events


k1.12 | Number of Patient Safety Incident (PSI) Fallsk1.13 | Number of Patient Safety Incident Falls per 1000 G&A

beddays

32 to 34

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard <=5.3

0 0 0 0 0 0 0

1

0 0 0 0 0 0

1

2

3

4

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard Zero

2 0 2 2 2 1 1 2 3 5 0 2 0

71 68

59 61

77

53 56

84

57 61

40

49

0

0

10

20

30

40

50

60

70

80

90

0

2

4

6

8

10

12

14

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standards - - - Total PSI Falls <=58 ..... Moderate / Severe Harm <=6

0 1 1 1 0 0 1 0 0 0 0 0 0

45

56 59

62 60 63 64

67 66

55

47

61

0

0

10

20

30

40

50

60

70

80

90

0

2

4

6

8

10

12

14

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standards Total Medication Incidents: N/A

8 of 44

14 to 19



k1.18 | Number of Serious Untoward Incidents

1

0

4

0

2

7

3

1

3 3 3

2

1

0

2

4

6

8

10

12

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard N/A

9 of 44

14 to 19


32 to 34


k4.01 | Day - Registered Midwives / Nurses Fill Rate k4.02 | Day - Assistant Fill Rate

k4.03 | Night - Registered Midwives / Nurses Fill Rate k4.04 | Night - Assistant Fill Rate

80%

90%

100%

110%

120%

130%

140%

150%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard N/A

80%

85%

90%

95%

100%

105%

110%

115%

120%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard N/A

80%

85%

90%

95%

100%

105%

110%

115%

120%

125%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard N/A

80%

85%

90%

95%

100%

105%

110%

115%

120%

125%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard N/A

10 of 44

14 to 19


32 to 34


k4.05 | Overall Trust Fill Ratek4.06 | % of Registered Nurse and Midwife Expenditure on

Agency Staff

k4.07 | Care Hours per Patient Day (CHPPD)

0%

1%

2%

3%

4%

5%

6%

Fe

b-1

9

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun

-19

Jul-1

9

Aug

-19

Sep

-19

Oct-

19

Nov-1

9

Dec-1

9

Jan

-20

Fe

b-2

0

Standard N/A

92%

94%

96%

98%

100%

102%

104%

Fe

b-1

9

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun

-19

Jul-1

9

Aug

-19

Sep

-19

Oct-

19

Nov-1

9

Dec-1

9

Jan

-20

Fe

b-2

0

Standard N/A

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

Fe

b-1

9

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun

-19

Jul-1

9

Aug

-19

Sep

-19

Oct-

19

Nov-1

9

Dec-1

9

Jan

-20

Fe

b-2

0

Standard N/A

11 of 44

14 to 19


32 to 34

Is Care Safe? : MaternitySafe February 2020

k5.01 | Caesarean section ratek5.02 | % women with a primary postpartum haemorrhage of

1500ml or more

k5.03 | % women with a primary postpartum haemorrhage of

2000ml or morek5.04 | Significant Perineal Trauma

0%

1%

2%

3%

4%

5%

6%

7%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard <3.1%

20%

22%

24%

26%

28%

30%

32%

34%

36%

38%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard <=26%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard <=1.0%

0%

1%

2%

3%

4%

5%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard N/A

12 of 44

14 to 19


Effective Is Care Effective? February 2020

Joscelin Miles, Head of Clinical Audit and Effectiveness Junior Doctors at Kingston Hospital: Enthusiastic and committed to driving improvements that matter to patients via clinical audit activity Each year the Trust is required to participate in a large number of national audits and other priority projects. To successfully participate in these projects junior doctor support is vital. From data collection to driving the entire improvement process, we simply could not do this without their support. As well as helping us to meet our requirements both from NHS England and our commissioners, it also provides the junior doctors with the opportunity to contribute to large, reputable projects as well as ongoing improvement across the Trust. This year we have been overwhelmed with the level of enthusiasm with which the F1s and F2s have embraced the clinical audit process. Their support for their project (allocated as part of their educational requirements) has been unquestionable, and their desire to support further projects and QIPs has been very welcome. They have also stepped up on multiple occasions when clinical teams have needed additional support with clinical audit. In addition Drew Walker (F2), Sophie Scandrett (F2), Jenn Shallop (F2), Rachel Snow (F1) and Gurpreet Beghal (F1) took up the role of junior doctor representative on the Clinical Audit Group (CAG) and Clinical Effectiveness Committee (CEC) As valued members of both CAG and CEC, they have successfully provided a junior doctor perspective into the ongoing development of the governance structures and processes supporting clinical audit and effectiveness within the Trust; ensuring they drive improvements that matter to patients. This includes, but is not limited to, contributing to the discussion of: Clinical audits that have been assessed as indicating a high risk to the patient The appropriateness and sustainability of actions planned to improve patient care arising

from both clinical audits and best practice recommendations produced by confidential enquiries

New and updated Trust-wide clinical policies and guidelines In addition they have also supported the Clinical Audit Team review and update our junior doctor clinical audit training and will be supporting us further with the review and update of the clinical audit intranet pages as we strive to ensure that we continually meet the needs of the junior doctors.

13 of 44

14 to 19


32 to 34

Is Care Effective?Effective February 2020

k2.01 | SHMI k2.02 | Unadjusted Mortality Rate

k2.03 | Sepsis - % of eligible patients screened for sepsis -

Emergency Department

k2.04 | Sepsis - % of eligible patients who received antibiotics

within 1 hour of arrival - Emergency Department

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard N/A

75

77

79

81

83

85

87

89

91

93

95

97

99

101

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard <=95

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=90%

14 of 44

14 to 19



k2.13 | Sepsis - % of eligible patients screened for sepsis -

Inpatients

k2.14 | Sepsis - % of eligible patients who received antibiotics

within 1 hour - Inpatients

32 to 34

k2.05 | Prevention of Hospital Acquired VTE (% patients risk assessed)

k2.06 | Incidence of Hospital Acquired VTE (HAT)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=90%

1 3 7 5 2 2 1 0 0 2 1 2 0 80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

0

2

4

6

8

10

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standards - - - % Risk Assessed >= 95% .... Incidences of HAT <= 3

15 of 44

14 to 19


32 to 34


k2.07 | % of eligible patients screened for dementiak2.08 | % of patients with dementia who were appropriately

assessed

k2.09 | % Emergency Readmissions following an elective

admission - 30 days

k2.10 | % Emergency Readmissions following an emergency

admission - 30 days

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=90%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard N/A

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard N/A

16 of 44

14 to 19



k3.15 | Hand Hygiene

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=95%

17 of 44

03 to 1314 to 19


Effective Learning from Deaths February 2020

Reporting Month

This Month This Month

79 0

This Year (YTD) This Year (YTD)

676 214

Feb-20

64

708

0

586

Total Number of Deaths Total Deaths Reviewed

Last month

Last Year (same YTD)

Last month

Last Year (same YTD)

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

0

10

20

30

40

50

60

70

80

90

100

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

""Total No. of Deaths 2018/19" "Total No. of Deaths 2019/20" "Death Rate 2018/19" "Death Rate 2019/20"

18 of 44

x`

03 to 1314 to 19


Caring Patient Experience February 2020

Complaints Author: Clare Parker, Head of Legal Complaints and PALS

The trust received 41 complaints in February 2020 compared to 22 in February 2019.

Planned Care received the highest number of complaints accounting for 61% of the total

received followed by Unplanned Care 29% and Corporate Services 10%.

Within Planned Care the following areas received complaints in February 2020

Ophthalmology (5), Gynaecology (3), General Surgery (2), Paediatrics (2), Orthopaedics

(2), Urology (2), ENT & Audiology (1), Cancer Services (1), Anti-Coagulant Service (1),

Anaesthetics Department (1), Rheumatology (1), Canbury Ward (1), Jasmine Unit (1) and

Kingston Private Health (1).

Within Unplanned Care the following areas received complaints in February 2020

Accident & Emergency (4), Bronte Ward (2), Acute Assessment Unit (2), Radiology (2),

Hamble Ward (1) and Elderly Care (1).

Subjects

The most frequent subjects related to were Appointments (17%), Diagnosis (17%) and

Care and Treatment (17%)

Reopened Complaints

2 complaints were reopened in February 2020. The reasons for the complaints being

reopened were Further Questions (2).

Ombudsman Referrals

No complaints were referred to the Ombudsman in February 2020.

Friends and Family Test Author: Elizabeth Tsangarakiwilding, Patient Experience & Quality Improvement Lead (Job-share with : Jane Suppiah )


19 of 44

14 to 19


k3.03 | Number of Complaints referred to ombudsman

Patient ExperienceCaring February 2020

k3.01 | Number of Complaints received

k3.14 | % Complaints responded to within 25 working days

(or date as agreed with complainant)

k3.02 | Number of Complaints reopened

32 to 34

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

1

2

3

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard N/A

5 6

1

3

5

11 11

5

10

6 5

2

0

2

4

6

8

10

12

14

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard N/A

23 30 26 37 32 54 34 42 55 32 30 30 41 0

10

20

30

40

50

60

70

80

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standards No Standard: Num. of Complaints ..... % within 25 days >=80%

20 of 44

14 to 19



k3.20 | Complaints per 100 patient contacts

0.00

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

0.10

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard <=0.07

21 of 44

14 to 19



k3.05 | Friends and Family Score - Trustk3.06 | Friends and Family Score - Inpatients (excluding

daycases)

k3.07 | Friends and Family Score - Paediatric Inpatient k3.08 | Friends and Family Score - Outpatient

92

.6%

92

.2%

92

.5%

93

.1%

93

.2%

92

.8%

93

.9%

93

.1%

93

.3%

92

.9%

90

.9%

93

.1%

91

.5%

0%

20%

40%

60%

80%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

% Would Recommend % Would Not Recommend

Standard N/A

96

.8%

96

.0%

95

.8%

97

.2%

96

.0%

95

.1%

95

.7%

96

.2%

95

.3%

96

.0%

94

.8%

97

.7%

95

.3%

0%

20%

40%

60%

80%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Response Rate % Would Recommend % Would Not Recommend Standard

Standard >=96%

93

.4%

93

.1%

93

.6%

93

.8%

94

.0%

93

.3%

94

.7%

93

.1%

93

.8%

93

.7%

92

.1%

92

.9%

92

.0%

0%

20%

40%

60%

80%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20


Standard N/A

97

.6%

94

.4%

93

.3%

89

.3%

91

.7%

92

.5%

86

.7%

94

.2%

90

.6%

93

.6%

94

.9%

98

.9%

94

.7%

0%

20%

40%

60%

80%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Response Rate % Would Recommend % Would Not Recommend

Standard N/A

Standard N/A

22 of 44

14 to 19



k3.09 | Friends and Family Score - A&E k3.10 | Friends and Family Score - Maternity

32 to 34

k3.11 | Friends and Family Score - Daycases k3.13 | Number of Mixed Sex Accommodation Breaches

87

.0%

87

.6%

88

.1%

89

.1%

89

.9%

89

.3%

90

.7%

90

.1%

89

.7%

88

.2%

85

.2%

89

.2%

86

.0%

0%

20%

40%

60%

80%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20


Standard N/A

96

.7%

96

.2%

96

.5%

97

.1%

93

.9%

96

.7%

95

.1%

96

.0%

98

.3%

97

.4%

96

.7%

97

.1%

98

.0%

0%

20%

40%

60%

80%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20


Standard N/A

97

.3%

95

.5%

98

.1%

97

.3%

97

.5%

97

.1%

97

.8%

96

.7%

97

.6%

96

.1%

97

.3%

97

.1%

96

.7%

0%

20%

40%

60%

80%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20


Standard N/A

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

1

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard Zero

23 of 44

03 to 1314 to 1925 to 31

February 2020


Responsive Is Care Responsive?

Cancer Author: Nichola Kane, Deputy Director of Nursing

VERBAL UPDATE TO BE PROVIDED RTT & Diagnostics Author: Anna Jebb, Associate Director, Planned care RTT

VERBAL UPDATE TO BE PROVIDED Diagnostics


A&E Performance Author: Tracey Moore, Associate Director, Unplanned Care


24 of 44

14 to 19


Is Care Responsive?Responsive February 2020

K8.02 | A&E 4 hour waiting time (type 1) K8.01 | A&E 4 hour waiting time (all types)

K8.03 | Number of A&E 12 hour trolley waits K8.04 | LAS Ambulance Handovers - % within 15 minutes

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Fe

b-1

9

Ma

r-19

Ap

r-19

Ma

y-1

9

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct-

19

Nov-1

9

Dec-1

9

Ja

n-2

0

Fe

b-2

0

Standard >=95%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Fe

b-1

9

Ma

r-19

Ap

r-19

Ma

y-1

9

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct-

19

Nov-1

9

Dec-1

9

Ja

n-2

0

Fe

b-2

0

Standard N/A

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Fe

b-1

9

Ma

r-19

Ap

r-19

Ma

y-1

9

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct-

19

Nov-1

9

Dec-1

9

Ja

n-2

0

Fe

b-2

0

Standard N/A

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

1

2

3

Fe

b-1

9

Ma

r-19

Ap

r-19

Ma

y-1

9

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct-

19

Nov-1

9

Dec-1

9

Ja

n-2

0

Fe

b-2

0

Standard Zero

25 of 44

14 to 19


32 to 34


K8.05 | LAS Ambulance Handovers - 30 min waits K8.06 | LAS Ambulance Handovers - 60 min waits

K8.07/08 | Stranded Patients (>=7 days and >=21 days) K8.10 | Delayed transfers of care - Rate per occupied bed day

4

14 13 14

3 8

3 4 5 10

2

10 7

0

10

20

30

40

50

60

70

80

90

Fe

b-1

9

Ma

r-19

Ap

r-19

Ma

y-1

9

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct-

19

Nov-1

9

Dec-1

9

Ja

n-2

0

Fe

b-2

0

Standard Zero

1 1 0 0 0 0 0 0 0 0 0 0 0 0

10

20

30

40

50

60

70

80

Fe

b-1

9

Ma

r-19

Ap

r-19

Ma

y-1

9

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct-

19

Nov-1

9

Dec-1

9

Ja

n-2

0

Fe

b-2

0

Standard Zero

47 43

58 55 45

54 50 52 48 47 57 61 60

159 154 162 161 159

171

154 161 162

169 167

190 180

0

20

40

60

80

100

120

140

160

180

200

Fe

b-1

9

Ma

r-19

Ap

r-19

Ma

y-1

9

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct-

19

Nov-1

9

Dec-1

9

Ja

n-2

0

Fe

b-2

0

Super-Stranded Patient (>= 21 days) Stranded Patients (>= 7 days)

Standard N/A

Standard N/A

0%

1%

1%

2%

2%

3%

3%

4%

4%

5%

5%

Fe

b-1

9

Ma

r-19

Ap

r-19

Ma

y-1

9

Ju

n-1

9

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct-

19

Nov-1

9

Dec-1

9

Ja

n-2

0

Fe

b-2

0

Standard <=4%

26 of 44

14 to 19


32 to 34


K8.11 | Average length of stay - Emergency Admissions K8.12 | 18 weeks Referral to Treatment - Incomplete pathways

K8.13 | 18 weeks Referral to Treatment - number of

incomplete over 52 week waitersK8.14 | Diagnostic test - % waiting 6 weeks or less

90%

91%

91%

92%

92%

93%

93%

94%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=92%

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

5.5

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard <=5.23

85%

86%

87%

88%

89%

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=99%

0 0

1

3

0 0 0 0 0 0

1 1 1

0

2

4

6

8

10

12

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard Zero

27 of 44

14 to 19


32 to 34


K8.17 | Cancer - Patients receiving first definitive treatment

within one month (31 days) of a cancer diagnosisK8.18 | Cancer - 31 day second or subsequent treatment - drug

K8.19 | Cancer - 31 day second or subsequent treatment -

surgeryK8.20 | Cancer - Two month urgent referral to treatment wait

0%

20%

40%

60%

80%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=94%

70%

75%

80%

85%

90%

95%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=85%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=96%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=98%

28 of 44

14 to 19


27/06/18 16:30 |Final Report v1.3

32 to 34


K8.21 | Cancer - 62 day wait for first treatment following

referral from a NHS Cancer Screening Service

K8.22 | Cancer - 62 day wait for first treatment following

consultant upgrade

K8.24 | Number of cancelled operations

30%

40%

50%

60%

70%

80%

90%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=90%

70%

75%

80%

85%

90%

95%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=85%

7

2

8

5 5 5

4

5 5

7

6

0 #N/A 0

1

2

3

4

5

6

7

8

9

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard N/A

29 of 44

03 to 1314 to 19


Well-led Are we Well-Led? February 2020

Comparators (14 Trusts): St George's Healthcare, Epsom & St Helier, Croydon Health, Guy's and St Thomas', Imperial College Healthcare, Chelsea & Westminster, West Middlesex, Ashford & St Peter's, Frimley ,Royal Surrey, West Hertfordshire Hospitals, Dartford & Gravesham, Barking, Havering & Redbridge and Hillingdon Hospital.

Author: Carolyn Floyd, Workforce Information & Planning Manager 1. Vacancy (target 6%) Vacancy rates have decreased and remain below our target at 4.89%, green rated. The Admin & Estates staff group remains the group with the highest vacant WTE and continues to be the focus for recruitment campaigns. Some of the issues in this group are around the holding of vacancies to meet our CIP plans. The red rated vacancies overall are in the lower pay band of 2 and 3. The average vacancy rate for or comparators is 11.46% (Oct-19) which the Trust falls well below. 2. Turnover (target 13.5%) Turnover has decreased this month to 14.40%, an amber rating. The highest turnover is within the lower pay band of 2, 3 and 4. It is within the Admin & Estates group that the highest number of leavers are recorded, work on tackling vacancies will stabilise this staff group. The number of admin leavers have risen within the Corporate areas but have reduced in the clinical areas. All the Service Line in Cluster 2 are red rated, apart from Elderly Care and Cluster 4 is also red rated and will need some focus. The average turnover rate for our comparator's is 14.36% (Oct-19) which the Trust falls slightly below 3. Sickness (target 2.6%) This month sickness has reduced to 3.08%, a slight decrease since last month. In light of the current COVID-19 epidemic this may well increase next month. The highest percentage of sickness continues to falls within the lower pay bands 2. 3 and 4. Sickness is over 4.5% in the staff groups Maternity Support Workers and Qualified Scientific and Professional. Overall Sickness is red-rated in both Planned and Unplanned Care this month. The only non-red rated clusters remain as 6 and 1. The Corporate areas are the only green-rated area. The average sickness rate for our local comparator's is 3.44% (Oct-19) which the Trust is now above.

4. Mandatory Training (target 85%) This month the compliance rate has decreased slightly to 83.04%, an amber rating. This is because some re-alignment of frequencies of mandatory courses has taken place. It is the Medical & Dental staff that have reduced the most so the and the education centre are targeting this staff group to ensure we are capturing all their training accurately. It is Clusters 6 and 1 that record the lowest compliance still, although they are amber rated. A&E and Trauma & Orthopaedics are the only red-rated Services and will need focus. The average Mandatory Training compliance for our comparator's is 88.60% (Oct19) which the Trust is now below. 6. Appraisals (target 90%) This continues to be the only red-rated KPI at 73.92%. however, the steady improvement each month continues. Lowest compliance is in the Central Directorates and a focus here will significantly improve the overall rate. The lowest compliance is within Admin and Estates and for pay band it is Bands 3 and 4 recording the lowest percentages. A real focus on lowest performing areas will continue to help drive up compliance. The average Appraisal compliance for our comparator's is 78.31% (Oct-19) which the Trust is currently below 10. Stability (target 90%) Stability records an amber rating of 85.66% this month, a slight increase since last month. Band 2 and 5 record a red-rating, but this is not an unusual trend due to natural career progression. There are 10 Service Lines with a red-rating the lowest being; Diabetes, Outpatients & Record, Corporate Affairs and Gynaecology & Breast. Overall the Central Directorates are the less stable than the clinical areas. Overall the percentage of leavers with under a year's service has reduced this month to 26%, but still remains just over a quarter of our leavers. 11. Time to Hire (under 20 days) This month the figure remains static at 16 days, a green rated There are very few Services over the target but this have been identified and work on improving these will take place over the coming months.

30 of 44

14 to 19


32 to 34

k7.03 | Sickness rate k7.04 | Mandatory training

Are we Well-Led?Well-led February 2020

k7.01 | Vacancy rate k7.02 | Turnover rate

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard <=2.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard >=85%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard <=6%

12.5%

13.0%

13.5%

14.0%

14.5%

15.0%

Feb

-19

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun-1

9

Jul-1

9

Aug-1

9

Sep-1

9

Oct-

19

Nov-1

9

Dec-1

9

Jan-2

0

Feb

-20

Standard <=13.5%

31 of 44

14 to 19



k7.05 | Appraisals / PDRs completed K7.10 | Stability ( %Staff Retained > 1yr)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Fe

b-1

9

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun

-19

Jul-1

9

Aug

-19

Sep

-19

Oct-

19

Nov-1

9

Dec-1

9

Jan

-20

Fe

b-2

0

Standard >=90%

Actuals reset at start of financial year

70%

75%

80%

85%

90%

95%

100%

Fe

b-1

9

Ma

r-1

9

Apr-

19

Ma

y-1

9

Jun

-19

Jul-1

9

Aug

-19

Sep

-19

Oct-

19

Nov-1

9

Dec-1

9

Jan

-20

Fe

b-2

0

Standard >=90%

32 of 44

14 to 19



Corporate Performance - Key Highlights

Turnover Stability Vacancy Sickness Training Appraisal

Rank Target 13.50% 90.00% 6.00% 2.60% 85.00% 90.00%

1 Admin & Estates 18.80% 82.70% 10.59% 4.28% 84.82% 65.16%

2 Clinical Support 13.83% 94.55% 17.10% 3.66% 88.55% 85.28%

3 Maternity Support Workers 13.58% 92.57% 8.00% 10.27% 86.34% 89.83%

4 Medical & Dental 6.25% 91.15% 1.17% 0.59% 83.65%

5 Nursing Assistants 17.58% 77.71% 7.89% 3.73% 82.79% 79.07%

6 Qualified AHPs 16.61% 85.85% 6.57% 2.89% 84.14% 76.51%

7 Qualified Midwives 10.41% 89.26% -3.15% 4.58% 73.33% 78.06%

8 Qualified Nursing 12.31% 87.49% 1.97% 2.16% 84.10% 76.33%

9 Qualified ST&Ts 15.79% 80.11% 7.63% 4.61% 68.40% 71.97%

Feb-20

33 of 44


KPI Description

Typ

e

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

k1.01 Pressure ulcers - Hospital acquired (Grade 3 and 4) per month Number 3 4 1 1 3 2 2 0 6 12 4 4

k1.011 Pressure ulcers - Hospital acquired (Grade 3 and 4) - Avoidable Number 1 1 1 0 0 0 0 4 8 4 3

k1.012 Pressure ulcers - Hospital acquired (Grade 3 and 4) - Unavoidable Number 2 3 0 1 2 2 2 0 2 4 2 1

k1.02Patients with Hospital acquired pressure ulcers (Grade 3 and 4) per 1000

beddaysper month Rate 0.26 0.37 0.09 0.09 0.26 0.19 0.18 0.00 0.50 1.04 0.32 0.35

k1.03 Pressure ulcers - Hospital acquired (Grade 2) per month Number 7 3 6 5 6 5 8 7 4 9 5 10

k1.031 Pressure ulcers - Hospital acquired (Grade 2) - Avoidable Number 1 1 3 5 5 5 2 4 2 3 4 7

k1.032 Pressure ulcers - Hospital acquired (Grade 2) - Unavoidable Number 6 2 3 0 1 0 6 3 2 6 1 3

k1.04 Patients with Hospital acquired pressure ulcers (Grade 2) per 1000 beddays per month Rate 0.61 0.28 0.53 0.45 0.53 0.47 0.73 0.60 0.33 0.78 0.41 0.87

k1.05 MRSA Bacteraemias (Hospital Assigned) per month Number 0 0 1 0 0 0 0 2 0 1 1 0

k1.06 MSSA Bacteraemias (Hospital Apportioned) per month Number 1 0 0 1 1 0 1 1 0 0 0 1

k1.07 Clostridium difficile Infections (Hospital Apportioned) Number 0 4 0 2 5 1 2 1 4 4 4 2

k1.08Clostridium difficile Infections (Hospital Apportioned) due to Lapse in Care

(confirmed cases)per annum Number 0 2 0 0 0 0 0 0 0 2 2 0

k1.09 Completed Patient Observations - Adult inpatients (NEWS) per month % 97.7% 98.8% 98.1% 98.6% 97.0% 100.0% 99.3% 100.0% 100.0% 100.0%

k1.10a Completed Patient Observations - Paediatric Inpatients (PEWS) per month % 93.8% 99.0% 97.1% 100.0% 99.1% 97.4% 97.4%

k1.12 Patient Safety Incident (PSI) Falls per month Number 68 59 61 77 53 56 84 57 61 40 49 0

k1.13 Number of Patient Safety incident Falls per 1000 (G&A) bed days per month Rate 5.96 5.43 5.34 6.98 4.65 5.24 7.66 4.93 5.11 3.47 3.97 0.00

k1.14 Patient Falls with moderate or severe harm per month Number 0 2 2 2 1 1 2 3 5 0 2 0

k1.15 Never Events per month Number 0 0 0 0 0 0 1 0 0 0 0 0

k1.16 Medication Incidents Number 56 59 62 60 63 64 67 66 55 47 61 0

k1.17 % Medication Incidents where Moderate or Severe Harm occurred per month % 1.8% 1.7% 1.6% 0.0% 0.0% 1.6% 0.0% 0.0% 0.0% 0.0% 0.0%

k1.18 Serious Untoward Incidents Number 0 4 0 2 7 3 1 3 3 3 2 1

k1.19 Escherichia Coli bacteraemia (all) Number 20 7 16 17 19 13 15 14 12 10 10 13

k4.01 Safer Staffing - Day - Registered Midwives / Nurses fill rate % 97.9% 98.7% 97.7% 97.9% 99.1% 97.5% 97.8% 99.7% 100.3% 98.6% 100.2% 99.8%

k4.02 Safer Staffing - Day - Assistant Fill Rate % 96.1% 102.3% 98.8% 100.6% 102.6% 94.0% 95.0% 93.6% 94.9% 103.2% 96.6% 95.1%

-

-

=0

-

<=0.04

-

-

>=0.97

<=58

<=5.3

<=6

=0

<=1

<=8

>=0.97

<=0.1

<=3

<=0.51

Standard

(From Apr '18)

<=10

Domain Scorecard Summary Rolling 12-Month Scorecard

Safe

34 of 44


KPI Description

Typ

e

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

(From Apr '18)


k4.03 Safer Staffing - Night - Registered Midwives / Nurses fill rate % 96.9% 99.1% 97.4% 97.9% 99.5% 95.5% 98.4% 97.9% 97.5% 100.9% 98.4% 98.3%

k4.04 Safer Staffing - Night - Assistant Fill Rate % 95.6% 105.9% 107.0% 107.7% 116.2% 96.3% 96.0% 97.7% 99.8% 119.5% 102.8% 96.9%

k4.05 Safer Staffing - Overall trust fill rate % 97.0% 100.4% 99.0% 99.7% 102.0% 96.1% 97.2% 97.7% 98.4% 102.7% 99.4% 98.0%

k4.06 Safer Staffing - % of Registered Nurse and Midwife expenditure on agency staff % 3.6% 4.2% 4.2% 3.5% 3.2% 2.9% 3.2% 3.7% 3.1% 5.7% 3.89% 4.55%

k4.07 Safer Staffing - Care Hours per Patient Day Rate 8.20 8.18 8.35 8.59 8.13 8.55 8.33 8.74 8.51 8.39 8.50 8.71

k5.01 Maternity - Caesarean section rate per month % 33.6% 35.9% 32.6% 33.1% 31.2% 30.0% 30.3% 27.7% 32.7% 33.6% 28.8% 31.2%

k5.02Maternity - % of women with a primary postpartum haemorrhage of 1500ml or

moreper month % 4.8% 5.2% 4.4% 2.9% 4.5% 5.1% 4.4% 4.9% 3.6% 4.7% 5.4% 6.4%

k5.03Maternity - % of women with a primary postpartum haemorrhage of 2000ml or

moreper month % 1.3% 2.1% 1.9% 2.9% 2.0% 2.3% 1.3% 2.4% 2.5% 1.7% 2.1% 2.5%

k5.04 Maternity - Significant Perineal Trauma % 1.8% 1.6% 1.9% 1.2% 1.4% 2.0% 1.5% 4.1% 3.0% 2.5% 3.1% 2.5%

k2.01 Standardised healthcare mortality index (SHMI) - most recent score Index 81.939 77.778 77.778 77.778 77.778 77.816 77.816 77.551 77.551 76.589 76.589 75.415

k2.02 Unadjusted Mortality Rate % 0.8% 0.8% 1.1% 0.8% 0.7% 0.7% 0.7% 0.6% 0.9% 1.1% 0.8% 1.1%

k2.03 Sepsis - % of eligible patients screened for sepsis - ED per month % 93.8% 88.9% 84.6% 92.0% 95.0% 80.0% 95.0% 90.0% 100.0% 95.00% 85.00% 100.00%

k2.04Sepsis - % of eligible patients who received antibiotics within 1 hour of arrival -

EDper month % 88.5% 100.0% 66.7% 94.7% 100.0% 90.0% 92.3% 81.8% 88.9% 92.31% 90.00% 90.00%

k2.13 Sepsis - % of eligible patients screened for sepsis - Inpatients per month % 90.2% 84.2% 88.0% 82.1% 95.0% 95.0% 85.0% 85.0% 85.0% 95.00% 95.00% 95.00%

k2.14 Sepsis - % of eligible patients who received antibiotics within 1 hour - Inpatients per month % 77.8% 71.4% 71.4% 90.9% 75.0% 80.0% 60.0% 100.0% 100.0% 88.89% 85.71% 100.00%

k2.05 VTE Assessments (Trust) per month % 97.8% 98.2% 98.3% 97.9% 97.7% 98.0% 97.4% 98.0% 98.1% 97.4% 97.8% 97.3%

k2.06 Incidence of Hospital Acquired VTE (HAT) Number 3 7 5 2 2 1 0 0 2 1 2 0

k2.07 % of eligible patients screened for dementia per month % 74.3% 71.2% 71.3% 75.7% 75.3% 81.3% 79.6% 79.9% 84.3% 86.3% 84.9% 66.7%

k2.08 % of patients with dementia who were properly assessed per month % 86.0% 65.9% 85.4% 88.0% 79.4% 72.1% 89.7% 84.9% 91.7% 97.0% 92.5% 35.7%

k2.09 % emergency readmissions following elective admission - 30 days % 2.4% 2.5% 1.7% 2.6% 2.3% 3.4% 2.7% 2.4% 2.9% 3.2% 1.8% 2.8%

k2.10 % emergency readmissions following emergency admission - 30 days % 16.2% 16.4% 15.6% 16.2% 17.2% 17.5% 16.7% 16.4% 18.6% 17.7% 18.5% 17.3%

k3.15 Hand Hygiene (Infection Control - Core Elements Tool) per month % 98.2% 98.4% 98.6% 98.0% 98.2% 97.9% 98.5% 98.3% 98.8% 98.8% 98.6% 98.0%

Caring

>=90%

-

-

>=95%

>=90%

>=90%

>=95%

-

>=90%

-

<=95

-

>=90%

>=90%

-

-

<=0.26

<0.031

<=0.01

-

-

-

Effective

35 of 44


KPI Description

Typ

e


(From Apr '18)


k3.01 Number of complaints received this month Number 30 26 37 32 54 34 42 55 32 30 30 41

k3.02 Number of complaints reopened this month Number 6 1 3 5 11 11 5 10 15 6 5 2

k3.03 Number of complaints referred to ombudsman this month Number 0 0 0 0 0 0 0 0 0 0 0 0

k3.14 Complaints Response Rate % 74.1% 65.5% 50.0% 53.1% 41.5% 57.1% 41.5% 65.3% 69.6% 62.5% 45.5% 36.4%

k.3.05b FFT - Trust - % Would Recommend % 92.2% 92.5% 93.1% 93.2% 92.8% 93.9% 93.1% 93.3% 92.9% 90.9% 93.1% 91.5%

k3.06a FFT - InPatients - % Would Recommend per month % 96.0% 95.8% 97.2% 96.0% 95.1% 95.7% 96.2% 95.3% 96.0% 94.8% 97.7% 95.3%

k3.07 FFT - Paediatric InPatients - % Would Recommend % 94.4% 93.3% 89.3% 91.7% 92.5% 86.7% 94.2% 90.6% 93.6% 94.9% 98.9% 94.7%

k3.08a FFT - OutPatients - % Would Recommend % 93.1% 93.6% 93.8% 94.0% 93.3% 94.7% 93.1% 93.8% 93.7% 92.1% 92.9% 92.0%

k3.09a FFT - A&E - % Would Recommend % 87.6% 88.1% 89.1% 89.9% 89.3% 90.7% 90.1% 89.7% 88.2% 85.2% 89.2% 86.0%

k3.10c FFT - Maternity - % Would Recommend % 96.2% 96.5% 97.1% 93.9% 96.7% 95.1% 96.0% 98.3% 97.4% 96.7% 97.1% 98.0%

k3.11 FFT - Daycases - % Would Recommend % 95.5% 98.1% 97.3% 97.5% 97.1% 97.8% 96.7% 97.6% 96.1% 97.3% 97.1% 96.7%

k3.13 Number of Mixed Sex accommodation breaches Number 0 0 0 0 0 0 0 0 0 0 0 0

k3.2 Complaints per 100 patient contacts Rate 0.05 0.04 0.06 0.05 0.08 0.06 0.07 0.09 0.05 0.05 0.05 0.07

K8.01 A&E 4 hour waiting time (all types) per month % 88.0% 87.5% 89.1% 86.9% 86.5% 90.3% 86.2% 86.6% 84.4% 85.9% 84.1% 84.9%

K8.02 A&E 4 hour waiting time (type 1) 86.7% 86.1% 87.9% 85.5% 84.9% 89.2% 84.7% 85.1% 82.7% 84.8% 82.4% 83.3%

K8.03 A&E 12 hour trolley waits per month Number 0 0 0 0 0 0 0 0 0 0 0 0

K8.04 LAS Ambulance Handovers - within 15 minutes - % 37.2% 34.3% 31.7% 36.5% 37.1% 39.9% 36.6% 34.8% 31.2% 36.6% 31.8% 32.4%

K8.05 LAS Ambulance Handovers - 30 min handover waits per month Number 14 13 14 3 8 3 4 5 10 2 10 7

K8.06 LAS Ambulance Handovers - 60 min handover waits per month Number 1 0 0 0 0 0 0 0 0 0 0 0

K8.07 Stranded Patients (>= 7 days) Number 154 162 161 159 171 154 161 162 169 167 190 180

K8.08 Super-Stranded Patient (>= 21 days) Number 43 58 55 45 54 50 52 48 47 57 61 60

K8.09 Delayed transfers of care (bed days) - Number 411 361 364 433 375 482 346 426 343 316 340 281

K8.10 Delayed transfers of care (rate per occupied bed days) <=4% per month % 3.6% 3.3% 3.2% 3.9% 3.3% 4.5% 3.2% 3.7% 2.9% 2.7% 2.8% 2.4%

>=95%

0

=0

=0

-

<=0.07

>96%

-

-

-

-

=0

-

-

-

>=80%

-

Responsive

36 of 44


KPI Description

Typ

e


(From Apr '18)


K8.11 Average length of stay - Emergency Services (Emergency admissions only) <=5.23 per month Rate 4.08 3.97 4.48 3.95 4.11 4.04 4.03 3.64 3.70 3.52 3.90 4.22

K8.12 RTT - incomplete 92% in 18 weeks (NONC) >=92% per month % 93.0% 93.3% 92.7% 92.2% 92.2% 92.1% 92.1% 92.3% 92.2% 91.2% 92.0% 91.6%

K8.13 RTT - incomplete 52+ Week Waiters (NONC) =0 per month Number 0 1 3 0 0 0 0 0 0 1 1 1

K8.14 Diagnostic Test Waiting Times - Completed within 6 weeks (ALL) >=99% per month % 99.5% 98.6% 99.2% 97.8% 92.4% 92.7% 93.0% 91.9% 88.7% 86.3% 87.0% 93.3%

K8.17Percentage of patients receiving first definitive treatment within one month (31-

days) of a cancer diagnosis (measured from ‘date of decision to treat’)per month % 100.0% 100.0% 94.8% 98.5% 100.0% 98.4% 96.6% 100.0% 98.6% 100.0% 96.2%

K8.18 31 day second or subsequent treatment - drug per month % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

K8.19 31-Day Standard for Subsequent Cancer Treatments-Surgery per month % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 92.3% 100.0%

K8.20 All Cancer Two Month Urgent Referral to Treatment Wait per month % 97.7% 100.0% 100.0% 93.6% 96.9% 91.8% 95.2% 94.3% 92.7% 87.8% 95.3%

K8.2162-Day Wait for First Treatment Following Referral from an NHS Cancer

Screening Serviceper month % 100.0% 100.0% 50.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

K8.22 62-Day Wait for First Treatment Following Referral from Consultant Upgrade per month % 100.0% 100.0% 100.0% 100.0% 94.1% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

K8.24 Number of last minute cancelled operations - Number 2 8 5 5 5 4 5 5 7 6

K8.25 Number of patients not treated within 28 days of last minute cancellation per month Number 1 2 0 1 0 0 2 1 1 0

k7.01 Vacancy rate per month % 6.8% 8.9% 8.7% 8.8% 8.1% 8.2% 7.0% 6.1% 5.1% 5.6% 5.7% 4.9%

k7.02 Turnover rate per month % 14.6% 14.6% 14.6% 14.9% 14.4% 14.0% 13.7% 13.9% 14.0% 14.1% 14.3% 14.4%

k7.03 Sickness rate per month % 2.8% 2.8% 2.4% 2.8% 2.9% 2.7% 2.7% 3.2% 3.6% 3.6% 3.8% 3.1%

k7.04 Mandatory Training per month % 73.8% 77.5% 76.0% 76.3% 82.0% 86.4% 89.7% 90.1% 90.0% 89.5% 83.9% 83.0%

k7.05 Appraisals / PDRs completed year end % 89.6% 65.3% 68.2% 69.8% 68.9% 65.8% 70.7% 66.0% 68.7% 69.3% 72.1% 73.9%

K7.10 Stability (% Staff Retained >1yr) % 84.6% 84.6% 85.1% 84.7% 85.4% 86.9% 87.2% 85.6% 85.5% 87.3% 85.4% 85.7%

>=96%

>=98%

>=94%

Well-led

>90.%

<=6%

<=13.5%

<=2.6%

>=85%

>=90%

>=85%

>=90%

>=85%

=0

37 of 44

Report Glossary

DomainIndicator

referenceDescription Indicator Methodology Data source Notes

Safe k1.01Patients with hospital acquired pressure ulcers

(Grades 3 & 4)

Number of patients with a newly hospital acquired pressure ulcers (Grades 3 &

4)Ulysses

Safe k1.02Patients with hospital acquired pressure ulcers

(Grades 3 & 4) per 1000 bed days

Number of patients with a newly hospital acquired pressure ulcers (Grades 3 &

4) divided by number of General and Acute (G&A) occupied bed days

(n) Ulysses

(d) Internal bedstate

summary

20/02/20 |Draft Report V2k1.03Patients with hospital acquired pressure ulcers

(Grade 2)Number of patients with hospital acquired pressure ulcers (Grade 2) Ulysses

Safe k1.04Number of patients with hospital acquired pressure

ulcers (Grade 2) per 1000 bed days

Number of patients with a newly hospital acquired pressure ulcers (Grade 2)

divided by number of General and Acute occupied bed days

(n) Ulysses


summary

Safe k1.05 MRSA Bacteraemias (Hospital Assigned)

Number of hospital assigned MRSA bacteraemia.

This includes all cases that are assigned through a post infection review (PIR).

Any 'hospital apportioned' MRSA cases with an ongoing PIR investigation will

also be reported - this includes all MRSA cases that where the patients' first

positive test for MRSA was taken on their third day of admission or afterwards.

Infection Control team - as

reported to PHE

Safe k1.06 MSSA Bacteraemias (Hospital Apportioned)

Number of hospital apportioned cases of MSSA bacteraemia.

This includes all MSSA cases that where the patients' first positive test for

MSSA was taken on their third day of admission or afterwards.


reported to PHE

Safe k1.07Clostridium difficile Infections (Hospital

Apportioned)

Number of hospital acquired C diff bacteraemia.

Includes all CDiff cases that where the patients' first positive test for CDiff was

taken on their fourth day of admission or afterwards.


reported to PHE

Safe k1.08

Clostridium difficile Infections (Hospital

Apportioned) due to Lapse in Care (confirmed

cases)

Number of Clostridium Difficile Infections which are attributable to a lapse in

care.

Only applies to Cliff cases here the patients' first positive test for CDiff was

taken on their fourth day of admission or afterwards.


reported to PHE

Safe k1.09Completed Patient Observations (NEWS) - Adult

Inpatients

The percentage of patients who have received 2 or more completed sets of

NEWS observations within a 24 hour period - Inpatients Only (Excluding

Paeds)

Clinical Audit

Safe k1.10Completed Patient Observations (NEWS) -

Paediatric Inpatients

The percentage of patients who have received 2 or more completed sets of

NEWS observations within a 24 hour period - Paeds onlyClinical Audit

Safe k1.12 Number of Patient Safety Incident (PSI) Falls Number of falls reported Ulysses

Safe k1.13Number of Patient Safety Incident Falls per 1000

G&A bed days

Number of reported falls divided by number of General and Acute (G&A)

occupied bed days

(n) Ulysses


summary

Safe k1.14Number of Patient Safety Incident Falls where

moderate or severe harm occurredIncludes falls resulting in moderate harm to severe harm/death Ulysses

38 of 44

Report Glossary

DomainIndicator


Safe k1.15 Number of Never Events

"Never events" are very serious, largely preventable patient safety incidents

that should not occur if the relevant preventative measures have been put in

place.

Safe k1.16 Number of Medication Incidents

The number of incidents which actually caused harm or had the potential to

cause harm involving an error in administrating, prescribing, preparing,

dispensing or monitoring medication.

Ulysses

Safe k1.17% of Medication Incidents Where Moderate or

Severe Harm Occurred

The number of Medication Incidents Where Moderate or Severe Harm

Occurred divided by the total Number of Medication IncidentsUlysses

Safe k1.18 Number of Serious Untoward Incidents Total number of serious untoward incidents reported Ulysses

Effective k2.01Standardised healthcare mortality index (SHMI) -

most recent score

This ratio demonstrates the ratio between the actual number of deaths

following hospital care in relation to the number of patients who were expected

to die based on the patient's characteristics and comorbidities

HSCIC

Effective k2.02 Unadjusted Mortality RateThe number of deaths as a percentage of all discharges, including daycase

patientsCRS

Effective k2.03Sepsis - % of eligible patients screened for sepsis -

Emergency Dept.

The percentage of patients sampled who met the criteria of the local protocol

and were screened for sepsis.Clinical Audit

Effective k2.04Sepsis - % of eligible patients who received

antibiotics within 1 hour of arrival

The total number of patients sampled who received antibiotics within 1 hour of

arrival as a percentage of those who should have received antibiotics within 1

hour of arrival.

Clinical Audit

Effective k2.05 VTE Assessments (Trust)Percentage of patients risk-assessed for Venous-Thromboembolism within 24

hours of admissionCRS

Effective k2.06 Incidence of Hospital Acquired VTE (HAT) Number of recorded instances of VTE acquired while admitted Ulysses

Effective k2.07 % of eligible patients screened for dementiaOf the patients who were eligible to be screened for dementia (aged 75 and

with a length of stay of 72 hours or greater), how many were screenedClinical Audit

Effective k2.08% of patients with dementia who were properly

assessed

Of the patients who were identified using the dementia screening assessments,

how many were appropriately assessed.Clinical Audit

Effective k2.09% emergency readmissions following elective

admission - 30 days

Percentage of patients re-admitted within 30 days of a previous elective

admissionCRS

Effective k2.10% emergency readmissions following emergency

admission - 30 days

Percentage of patients re-admitted within 30 days of a previous emergency

admissionCRS

Effective k2.11 Hand Hygiene Compliance rate with the Infection Control Saving Lives Audit Infection Control

39 of 44

Report Glossary

DomainIndicator


Effective k2.12Open Incidents - % of managers reports

completed within 10 days

Percentage of Incidents Recorded on Ulysses that have been completed within

appropriate time frameUlysses

Patient

Experiencek3.01 Number of complaints received this month Number of complaints received this month Ulysses

Patient

Experiencek3.02 Number of complaints reopened this month Number of complaints reopened this month Ulysses

Patient

Experiencek3.03

Number of complaints referred to ombudsman this

monthNumber of complaints referred to ombudsman this month Ulysses

Patient

Experiencek3.14

% complaints responded to within agreed

timeframe

Percentage of complaints that have received a response within the agreed time

frame, based on the month in which the response was due.Ulysses

Patient

Experiencek3.20 Complaints per 100 patient contacts

The number of patient complaints divided by the number of 'patient contacts'

multiplied by 100. KPI defined to be the same as that at Frimley Hospital

A 'patient contact' is defined as one of: An inpatient discharge, a outpatient

appointment or DNA, or an A&E attendance, or a daycase attendance.

CRS and Ulysses Added For June 2018's Board Meeting

Patient

Experiencek3.05 Friends and Family Score - Trust

Number of patients who would recommend the Trust to friends and family, as a

percentage of all respondents.FFT

Patient

Experiencek3.06

Friends and Family Score - Inpatient (excluding

daycases)



Patient

Experiencek3.07 Friends and Family Score - Paediatric Inpatient



Patient

Experiencek3.08 Friends and Family Score - Outpatient



Patient

Experiencek3.09 Friends and Family Score - A&E



Patient

Experiencek3.10 Friends and Family Score - Maternity



Patient

Experiencek3.11 Friends and Family Score - Daycases



Patient

Experiencek3.12 Friends and Family Score - Dementia Carers

Number of carers of patients with dementia who would recommend the Trust to

friends and family, as a percentage of all respondents.FFT

40 of 44

Report Glossary

DomainIndicator


Patient

Experiencek3.13 Number of Mixed Sex accommodation breaches Number of Mixed Sex accommodation breaches CRS

Safer Staffing k4.01Safer Staffing - Day - Registered Midwives /

Nurses fill rate

Total hours worked by registered nurses and midwives as a percentage of the

planned hours - Day shiftHealthRoster

Safer Staffing k4.02 Safer Staffing - Day - Assistant Fill RateTotal hours worked by healthcare assistants as a percentage of the planned

hours - Day shiftHealthRoster

Safer Staffing k4.03Safer Staffing - Night - Registered Midwives /

Nurses fill rate

Total hours worked by registered nurses and midwives as a percentage of the

planned hours - Night shiftHealthRoster

Safer Staffing k4.04 Safer Staffing - Night - Assistant Fill RateTotal hours worked by healthcare assistants as a percentage of the planned

hours - Night shiftHealthRoster

Safer Staffing k4.05 Safer Staffing - Overall trust fill rate Total hours worked as a percentage of the planned hours - All shifts HealthRoster

Safer Staffing k4.06Safer Staffing - % of Registered Nurse and

Midwife expenditure on agency staff

Safer Staffing - % of Registered Nurse and Midwife expenditure on agency

staffHealthRoster

Safer Staffing k4.07 Safer Staffing - Care Hours per Patient DayTotal hours worked by staff proportionate to the number of occupied beds at

midnightHealthRoster/CRS

Maternity k5.01 Maternity - Caesarean section rate Percentage of caesarean sections relative to all births CRS/Maternity Forms

Maternity k5.02Maternity - % of women with a primary postpartum

haemorrhage of 1500ml or more

Maternity - % of women with a primary postpartum haemorrhage of 1500ml or

moreCRS/Maternity Forms

Maternity k5.03Maternity - % of women with a primary postpartum

haemorrhage of 2000ml or more

Maternity - % of women with a primary postpartum haemorrhage of 2000ml or

moreCRS/Maternity Forms

Maternity k5.04 Maternity - Significant Perineal Trauma Maternity - Significant Perineal Trauma CRS/Maternity Forms

Responsive K8.11Average length of stay (ALOS) - Emergency

Admissions

The mean length of stay for patients, calculated by dividing the total inpatient

days by the number of dischargesCRS

Responsive K8.12Referral to Treatment (RTT) within 18 weeks -

incomplete pathwaysRTT 18 weeks - incomplete pathway UNIFY2 / NHS England

Responsive K8.13RTT 18 weeks - incomplete pathway 52+ week

waitersRTT 18 weeks - incomplete pathway 52+ week waiters UNIFY2 / NHS England

41 of 44

Report Glossary

DomainIndicator


Responsive K8.14 Diagnostic test waiting times Diagnostic test waiting times UNIFY2 / NHS England

Responsive K8.02 A&E 4 hour waiting time (type 1)Percentage of patients who received treatment and were admitted or

discharged within 4 hours of arrival - Main A&E OnlyUNIFY2 / NHS England

Responsive K8.01 A&E 4 hour waiting time (all types)Percentage of patients who received treatment and were admitted or

discharged within 4 hours of arrival - Both Main A&E and Royal Eye UnitUNIFY2 / NHS England

Responsive K8.03 A&E 12 hour trolley waits A&E 12 hour trolley waits UNIFY2 / NHS England

Responsive K8.04London Ambulance Service (LAS) Handovers - %

within 15 minutes

Percentage of Ambulance handovers completed within 15 minutes of Arrival at

A&ELAS portal

Responsive K8.05 LAS Ambulance Handovers - 30 min waits LAS Ambulance Handovers - 30 min waits LAS portal

Responsive K8.06 LAS Ambulance Handovers - 60 min waits LAS Ambulance Handovers - 60 min waits LAS portal

Responsive K8.15 Cancer - Two week waitPercentage of patients seen by a specialist within two weeks of an urgent GP

referral for suspected cancerInfoflex

Responsive K8.16Cancer - Two week referral to 1st outpatient -

breast symptoms

Percentage of patients seen by a specialist within two weeks of an urgent GP

referral for suspected breast cancerInfoflex

Responsive K8.17

Cancer - Patients receiving first definitive

treatment within one month (31 days) of a cancer

diagnosis

Percentage of patients who began first definitive treatment within 31 days of

receiving a cancer diagnosisInfoflex

Responsive K8.18Cancer - 31 day second or subsequent treatment -

drug

Percentage of patients who began treatment within 31 days of diagnosis,

where the required treatment was an anti-cancer drug regimenInfoflex

Responsive K8.19Cancer - 31 day second or subsequent treatment -

surgery

Percentage of patients who began treatment within 31 days of diagnosis,

where the required treatment was surgeryInfoflex

Responsive K8.20Cancer - Two month urgent referral to treatment

waitPercentage of patients treated within two months of an urgent GP referral Infoflex

Responsive K8.21Cancer - 62 day wait for first treatment following

referral from an NHS Cancer Screening Service

Percentage of patients treated within two months of an urgent referral from an

NHS Cancer Screening ServiceInfoflex

Responsive K8.2262-Day Wait for First Treatment Following Referral

from Consultant Upgrade

Percentage of patients treated within two months of a consultant's decision to

upgrade their priorityInfoflex

42 of 44

Report Glossary

DomainIndicator


Responsive K8.99 Delayed transfers of care (number)Number of patients whose transfer is delayed at midnight on the last Thursday

of the month

Responsive K8.09 Delayed transfers of care (bed days) Number of General and Acute (G&A) occupied bed days

Responsive K8.10Delayed transfers of care (rate per occupied bed

days)Delayed transfers per 1,000 bed days CRS

Responsive K8.24 Number of last minute cancelled operations Number of operations cancelled within 24 hours of the planned operation

Responsive K8.25Number of patients not treated within 28 days of

last minute cancellationNumber of patients not treated within 28 days of last minute cancellation

Responsive K8.07 Stranded Patients (>= 7 days) Daily average number of patients in hospital for over 6 days. CRS

Responsive K8.07 Super-Stranded Patient (>= 21 days) Daily average number of patients in hospital for over 20 days. CRS

Well Led k7.01 Vacancy rate Vacancy rate Human Resources

Well Led k7.02 Turnover rate Turnover rate Human Resources

Well Led k7.03 Sickness rate Sickness rate Human Resources

Well Led k7.04 Mandatory Training Mandatory Training Human Resources

Well Led k7.05 Appraisals / PDRs completed Appraisals / PDRs completed Human Resources

Well Led k7.06 Flu Immunisation Percentage of staff who have received the flu vaccination Human Resources

Well Led k7.07 Staff FFT (Work) - ScorePercentage of staff who would recommend the Trust to friends and family as a

place to workNHS England

Well Led k7.08 Staff FFT (Care) - ScorePercentage of staff who would recommend the Trust to friends and family if

they needed care or treatmentNHS England

43 of 44

Report Glossary

DomainIndicator


Well Led k7.09 Staff Survey - Response RatePercentage of staff who completed the survey, of those who were asked to

complete itHuman Resources Annual Survey

Well Led k7.10 Stability (% Staff Retained >1yr) The proportion of permanent staff with a length of service of over1 year Human ResourcesNew KPI added in May 2018's Board

Report (April data)

Well Led k7.11 Time to Hire (% staff hired in < 88 working days)

The proportion of new hires which took 88 or less working days from the post

being advertised for recruitment and the new staff member starting their role

within the Trust

Human ResourcesNew KPI added in May 2018's Board

Report (April data)

44 of 44

Documents

Integrated Quality and Operational Compliance Report · Report (April data) Well Led. k7.11: Time to Hire (% staff hired in < 88 working days) The proportion of new hires which took