Integrated Quality and Performance Report

Integrated Quality and Performance Report

M03 2018-19 Report (June)

Governing Body

M03_BWCCG_IQPR_Final Page 1 of 18

Contents

1 Executive summary 3

2 Patient safety 4

3 Patient experience 5

4 Clinical effectiveness 6

5 Independent Providers 7-8

6 Maternity 9

7 SCAS 10-11

8 Quality assurance visits 12

Performance

9 Urgent care 13-14

10 Long term conditions 14

11Children's, Maternity, Mental

Health and Voluntary15-16

12 Planned Care 17-19

13 HCAI 19

14 Quality premium 20-21

Month 03 Report

This is the month 03 (June 2018) report

as this is the latest month for which

nationally verified and provider data is

available.

Some services can be tracked more

frequently and where more recent

performance is known it may be

included or commented on in the

report.

There may also be incidences where

data is not available, and therefore the

most recent is presented within the

report.

Please note, this is a public report.

Quality


1. Executive Summary - June 2018

l

l

l

l A&E Performance

l DToC Performance

l NHS 111 - Percentage of abandoned calls

l Ambulance response times

l Total A&E Attendaces excluding plannned follow ups

l Type 1 A&E Attendances excluding planned follow up

l Number of Completed Admitted RTT Pathways (E.M.18)

l Number of Completed Non-Admitted RTT Pathways (E.M.19)

l Number of New RTT Pathways (Clockstarts) (E.M.20)

l Total Other Referrals (G&A)

l Consultant led first outpatient attendances (G&A) (E.M.8)

l Consultant led follow up outpatient attendances (G&A)

l Total elective admissions - Ordinary

l RTT incomplete pathways waiting 18 weeks or less

l MRSA

l Cdiff

l Mixed sex accommodation

l Care bundles (SCAS)

l Safeguarding training

l The percentage of 111 calls answered within 60 seconds

l Total Non - Elective Admissions - 0 LOS

l Total Non - Elective Admissions - +1 LOS

l Total GP Referrals (G&A)

l Total elective admissions - Day Cases

l Cancer waiting times -31 day (Subs-surgery)

l Cancer waiting times -62 days (Screening)

l RTT - Incompletes and 52+ weeks waits

l Diagnostic waits

l E-Referral Coverage (Utilisation)

Above or maintaining performance

Areas of challenging performance

C-diff (providers)

Pressure ulcers

VTE assessment


2. Quality Dashboard: Patient SafetyT

hem

e

Indicator Measure

Data

freq

uen

cy

Targ

et

Peri

od

RB

FT

HH

FT

GW

H

BH

FT

Jun-18 0 0 0 0

Q1 1 0 1 0

17/18 2 1 0 0

YTD 1 0 1 0

Jun-18 7 6 2 5

Q1 21 16 12 17

17/18 66 46 27 75

YTD 21 16 12 17

Jun-18 1 1 1 0

Q1 2 3 8 0

17/18 5 3 6 2

YTD 2 3 8 0

Jun-18 0 1 0 0

Q1 2 7 0 3

17/18 16 19 1 7

YTD 2 7 0 3

Jun-18 2 1 2 0

Q1 6 2 8 0

17/18 23 24 25 0

YTD 6 2 8 0

Jun-18 0 0 0 0

Q1 0 0 0 1

17/18 2 0 0 0

YTD 0 0 0 1

RBFT - There have been 2 Trust apportioned cases of Clostridium difficile (C.diff) reported in June 2018. The total number of cases reported to date for 18/19

stands at 6, against an upper limit of 26 for the full year.

HHFT - 1 cases in month HHFT had fallen within trajectory for 2017/18.

BHFT - Nil cases reported for June

GWH - 2 cases of Clostridium difficile was attributed to Acute Services at GWH June 2018. There is still a common trend in relation to Coamoxiclav

that is being addressed by alerts from Microbiology and Pharmacy, to try to find an alternative treatment plan for at risk groups.

MRSA Number of MRSA Bacteraemia Monthly 0

Nil reported for all providers for June 2018

Number of Clostridium Difficile MonthlyAs per

provider

Falls (as SI's) Number reported Monthly N/A

RBFT - No falls reported in June.

BHFT - No falls reported in June. Falls: In Q1, there were 3 SIs reported for a patient fall resulting in serious harm accounting for 18% of SIs reported. 2 of the falls

resulted in fractures (Highclere Ward and Windsor Ward). 1 was a fall that resulted in a subdural haematoma (Windsor Ward).

HHFT - One fall reported in June. GWH - No falls

reported.

None reported for all providers for June 2018.

Number of serious incidents Number of reported serious incidents Monthly N/A

RBFT - Trust reported 7 SIs in June (2 Diagnostic incident including delay (including failure to act on test results), one HCAI/Infection control incident, one

Maternity/Obstetric incident meeting SI criteria: baby only (this include foetus. neonate and infant), one Maternity/Obstetric incident meeting SI criteria: mother and

baby (this include foetus. neonate and infant), one Pressure ulcer and one Treatment delay SI).

BHFT - 5 Mental Health SIs reported in June (One Abuse/alleged abuse of adult patient by staff SI and 4 Apparent/actual/suspected self-inflicted harm SIs). 1 was a

West Patient , this was an unexpected death.

HHFT- Trust reported 6 SIs in June (One Maternity/Obstetric incident meeting SI criteria: baby only (this include foetus. neonate and infant), one

Maternity/Obstetric incident meeting SI criteria: mother only, one pressure ulcer, one Slips/trips/falls, one Surgical/invasive procedure incident and one Treatment

delay SI).

GWH - Trust reported 2 SIs in June (One Diagnostic incident including delay meeting SI criteria (including failure to act on test results) and one Pressure ulcer).

Reportable Pressure ulcers G3 & G4 Number reported

Pati

en

t S

afe

ty

Number of never events Number of never events = zero Monthly 0

Monthly N/A

RBFT- Trust reported one PU SI in June.

BHFT - Trust reported no category 3 or 4 PU as SI in June and there were no learning events with lapse in care identified .

HHFT - One pressure ulcers reported in month.

GWH - 1 grade 3/4 pressure ulcers reported in month.

C.diff


3. Quality Dashboard: Patient ExperienceT

hem

e

Indicator Measure

Data

freq

uen

cy

Targ

et

Peri

od

RB

FT

HH

FT

GW

H

BH

FT

Jun-18 15 4 0 0

17/18 1565 109 148 0

YTD 309 7 0 0

Jun-18 13 45 78 23

17/18 228 552 1240 204

YTD 62 148 53

May-18 96% 100%

YTD 89.0% 67.0%

Public/Patient Engagement

CCGs have a number of routes for gaining Public and Patient Engagement information which include reports by partner organisations, such as

Patient Participation Groups and Healthwatch, in support of the Patient Engagement Strategy which are presented to the Governing Body.

Additionally within the Clinical Quality forums there are patient stories presented by the provider and a discussion relating to this regarding

assurance actions taken where required.

RBFT -Analysis of the PALS has shown a top theme of Administration (91 received), which equates to 51% of all PALS concerns received

in June. Of the complaints closed in June; 1 was well founded, 5 partially founded and 2 were not founded. We are awaiting outcomes for

14 complaints; these are being actively chased up. 2 were rated as Orange (Moderate), 5 as Yellow (Low), 15 as Green (V Low).

BHFT - Complaints - • 100% of complaints responded to within timescale

• Top four services for complaints received were CMHT, CAMHS, Community Inpatient Wards and Mental Health Inpatients

• There has been a decrease in complaints for CRHTT

• There were no complaints for mental health wards for older people, Highclere ward and Henry Tudor Ward

HHFT - 45 complaints reported in month. Main themes included discharge arrangements, communication and information. Clinical themes

were around care and treatment, patient care, care needs not adequately met and delay or difficulty in obtaining clinical assistance.

GWH - 178 concerns and complaints were received during June 2018 a decrease on last month. Top service areas which received the

majority of concerns, complaints for June 2018 Emergency Department 12 (6%), Booking Centre 10 (5%), Ophthalmology 8 (5%), Urology

8 (4%). Top themes highlighted from Concerns and Complaints for June 2018: Communication 25 (14%), Waiting time 24 (13%),

Behaviour/Attitude of staff 18 (10%), Clinical Care 17 (9%).

Clinical concerns

Percentage of concerns

responded to within 30 working

days

Monthly

(month in

arrears)

>90%

RBH- achieved 96%

BHFT - Achieved 100% noting both are reported one month in arrears, of which 10 were closed between April and June. There was an

increase in clinical concerns closed during June 2018 (6 – 100% compliant with timescale). Care and treatment was the main subject for

50% (3) of the clinical concerns, the remaining 50% being financial issues/policy, management and administration and waiting times for

appointments. There are no themes to the clinical concerns closed by service which were: Crisis Resolution & Home Treatment Team

(CRHTT) District Nursing, Finance Service, Health HUB, Physiotherapy Musculoskeletal Podiatry

RBFT - The Trust has recorded a total of 15: 11 for Acute Medical Unit (AMU) and 4 for Emergency Department Observation (ED Obs).

HHFT - The Trust had 4 mixed sex breaches in month due to delays for critical care patients being placed on an „appropriate‟ ward due to

bed availability.

GWH - Nil breaches were reported during June, which is the third consecutive month of recording zero.

Complaints Number of complaints received

Monthly

(month in

arrears)

N/A

Pati

en

t E

xp

eri

en

ce

Mixed sex accommodation

(MSA) breachesNumber of breaches = 0 Monthly 0


4. Quality Dashboard: Clinical Effectiveness

Th

em

e

Indicator Measure

Data

freq

uen

cy

Targ

et

Peri

od

RB

FT

HH

FT

GW

H

BH

FT

VTE assessment Achieved for at least 95% of patients Quarterly 95% Q1 96.7% 97.1% 99.8%

Fractured neck of femur % in theatre within 36 hours Monthly 85% June 86.2%

Staff turnover Staff turnover rate (%) QuarterlyProvider

targetJune 15.0% 13.7% 16.7%

Sickness absenceSickness absence rate against provider

target (%)Quarterly

Provider

targetQ1 3.3% 3.77% 4.4% 3.76%.

RBFT-The Neck of Femur (NOF) performance has improved for a second month. Further work is on going to address the issues contributing to variable

performance against this standard.

RBFT -Turnover remains consistent at 15%. The retention steering group are focusing on key areas they feel are key to retaining staff with the Trust. These

include working with partners to address affordable housing, increase availability of accommodation for staff at Sovereign Housing, developing innovative new

roles and assessing the option of more flexible working.

GWH - Turnover remains stable at slightly above the 13% internal target set by GWH. A survey has been undertaken amongst the 15-29 age group in

relation to recruitment and retention. A task and finish group has been created to support apprentices and younger workers, and will develop an induction

programme to support younger workers.

BHFT - The Trust-wide turnover rate at the end of Q1 has increased slightly to 16.69%, A „stay survey‟ has been circulated to all community nursing staff in

East and West adult services, the feedback from which will inform the retention plans which are currently in draft form. The deadline for responding to the

survey was extended following a positive response and initial analysis has identified some themes for improvement including: options for more flexible working

including long days, technology to support mobile working, and team communications. The retention plans will be completed by the end of July, with the

Children‟s Services plan finalised in August. Plans are also being developed to identify opportunities to retain those staff who are approaching retirement age

RBFT- The rolling year rate for sickness absence for June has fallen slightly this month, this is to be expected as we go into the summer months, but is

encouraging to see. Nevertheless, the rate is slightly higher than at the same point last year.

HHFT - Sickness Absence has increased this month to 3.77% compared April‟s end of month position of 3.36%. However this is a provisional figure and is

expected to increase. April‟s increased by just over half a percentage point on review to 4.04%.

GWH - Remains at 4.4%, with actions being implemented in order to support staff and clinical leaders to manage periods of sickness.

BHFT - The Trust for May was 3.58% this was similar to the reported position of 3.5% in April. There was a slight increase in the short term sickness rate in

May to 0.86% (from 0.83% in April). Further analysis shows that this increase is due to very slight increases in the short term sickness rates across several

reason categories with no significant trends identified. There has been a further decrease in absences due to cold/cough/flu, There has been a further slight

increase in the long term sickness rate in May to 2.07%. This is attributable to a further increase in the long term rate due to anxiety/stress/depression to

0.73% (from 0.67% in April), and also an increase in the long term rate due to injury/fracture, which was 0.24% in May (against an average over the previous

six months of 0.14%).

Clin

ical E

ffecti

ven

ess

RBFT - Above target for VTE assessment. One hospital acquired Venous thromboembolism (VTE) was reported in June. Consistent achievement for this

quality measure.

HHFT - above target for VTE assessment.


4A. Quality Dashboard: Clinical Effectiveness

Th

em

e

Indicator Measure

Data

fre

qu

en

cy

Targ

et

Peri

od

RB

FT

HH

FT

GW

H

BH

FT

Vacancies Vacancy rates (%) QuarterlyProvider

targetQ1 8.5% 7.7% 10.7% 9%

Agency spend % of total staff cost Agency staff (%) QuarterlyProvider

targetQ1 4.3% 4%

Appraisals Staff with annual appraisal (%) QuarterlyProvider

targetQ1 87.2% 67% 78.3% 85.9%

Level 2

85%Q1 91.6% 71.0% 89.5% 91.0%

All staff should have training in

safeguarding of Adults (to include

introductory DoLS & MCA)

Safeguarding adults level 1 Quarterly 95.0% Q1 92.0% 82.0%No

Data93.0%

RBFT - Level 1 child safeguarding training compliance for non-clinical staff remains just below compliance. There will continue to be a focus on circulating compliance

figures and exception reports to Care Groups and Corporate Directors.

HHFT - Compliance target is set to 80%, the safeguarding children and adults team are planning to explore joint safeguarding training for level 1 and level 2 training in 2018.

GWH - Quarter 4 displays a continued improvement in all levels of safeguarding training. The Named Nurse will continue to meet with all Divisional Directors of Nursing

to discuss this to ensure that all staff have been correctly allocated the right level of training required.

BHFT - Safeguarding level 1 training is at 91%, staff and their managers have all be contacted asking them to either complete eLearning or face to face training and three

bespoke sessions for catering and domestic staff have been organised at venues across the Trust.

RBFT - Compliant with safeguarding adults training. also to note that there has been a significant improvement in conflict resolution training compliance in A&E, 88.9%, for

June in comparison to the average for the last six month around 60-70%.

HHFT - Compliance target is set to 80%

GWH - There remains to be Nil Data relating to this indicator. However, the Trust report 92.24% compliance with MCA training, DoLS and consent training against a

Trust 80% compliance threshold.

BHFT - Training has reached compliance for this area.

RBFT - Appraisal rates have slipped over 1.5% points to 87.2%. Planned Care improved further to 91.7% but this was offset by weaker figures in all other areas. Estates and

Facilities dropped below 90% for the first time in 6 months.

HHFT - Appraisal rates at Trust level reduced to 67% a series of planned actions have been identified to target staff groups.

GWH - Appraisal rates have fallen slightly to below the internal GWH target of 80%. As a result of the Staff Survey results, The Trust has identified that the quality of

appraisals has deteriorated. A new appraisal form has been piloted and launched, this is intended to provide a more meaningful appraisal; alongside appraisal training being

included in the new managers training programme.

BHFT - At the end of Quarter 1, compliance with the appraisal process is 85.9%. Appraisals were completed April to June 2018 so the final data entry is now taking place.

We expect to reach the target of 95% in the early part of July.

Head count measured for compliance excludes staff on long term absence and those staff employed for less than six months. Medical staff are also excluded from appraisal

reporting due to their validation process which includes appraisal and is audited separately. It should be noted that this data is now reported under the new organisational

structure and as such is not directly comparable to previous reports. at the end of June expected compliance of 95% within the appraisals window ( April-June) was not

achieved compliance was 90% with weekly reports being circulated to Managers to ensure that the target of 95% is reached during July

Safeguarding training - ChildrenAppropriate level of training according to

contact with childrenQuarterly

Level 1

95%Q1 93.6% 71.0% 93.4%

Clin

ical E

ffecti

ven

ess

RBFT- The substantive workforce has risen by 13 WTE in this financial year. Vacancies are higher though, as less of the Trust QIPP target has been allocated to pay this

year, meaning that there is a small increase in the posts that are open to recruit to. The vacancy rate has increased to 8.2%. There is still a challenge with recruitment. We

are continuing with our recruitment initiatives across all staff groups, however band 5 nurse recruitment remains competitive across the region. The Trust held its monthly

nursing open day on Saturday 14 July with 16 student nurses attending. We are thinking of creative ways we can attract staff for other staff groups which are hard to recruit

nationally and devising a recruitment strategy for these departments.

GWH - Currently the Trust is showing vacancies of 10.65%, equivalent to 472 WTE of which the areas of the largest vacancies is within Nursing (Band 5 registered) and

Admin & Clerical. Bank, Locum and Agency staff equivalent to 405 WTE were utilised to backfill these vacant posts where required. Our priority areas for recruitment are

nursing roles in Elderly Care, Acute Medicine and Emergency Care. The Trust continues to hold regular recruitment events for nursing and healthcare roles, which have

been held monthly since April 2018. There have been around 30 new recruits to both substantive and bank roles from these events. Recruitment open days are held once a

quarter, with the latest one in June seeing 20 attendees, and five job offers are now being progressed. The next event is planned for 22 September.

HHFT - Agency FTE remained stable at 72 FTE, whilst Bank decreased by 43 FTE to 377 FTE.The Trust‟s total appraisal rate reduced to 66%. This is on a par with May

2017‟s rate.

BHFT - Trust vacancy rate for Q1 on average is 9.3%, Staff vacancy rate including use of Agency Staff for Q1 – on average is 1.8%. This is based on Staff worked. The Trust

gross vacancy rate in June was 9.1% with the Locality experiencing the highest rates being Mental Health Inpatient services with a vacancy rate of 24%.A working group has

been established to identify opportunities to capitalise on the national “We are the NHS” recruitment campaign, with plans including a local advertising campaign and a

personalised letter to nursing leavers in the last two years, with a view to encouraging them to consider re-employment with the Trust. A recruitment plan for the next 12

months is currently being developed which will quantify the nursing recruitment required across all areas of nursing, including mental health, community and learning

disabilities. The plan will also incorporate the use of social media to attract and recruit, and opportunities to grow our pipeline of candidates, along with ways to ensure that

our future workforce is more diverse.

RBFT -We have seen a reduction in agency spend of 0.9% this month. All non-medical staff groups have seen a reduction in their agency spend and this is due to a reduction

in the demand. 50% of shifts released are filled by the bank. Due to tight controls in place, senior managers will make the decision which of the remaining shifts need to be

released to agencies and which can be covered internally. We have also converted some agency staff into substantive staff, which is a continuous aim of the Trust.

GWH- Staff vacancy cover (Nursing - £1,134k YTD; Medical - £498k YTD) covering vacancies in LAMU & ED (nursing and medical) and Cancer Services (medical) Close

support activity (£118k YTD). This was predominantly in Unscheduled Care on Neptune, Jupiter and Woodpecker Wards and Paediatric Assessment Unit (PAU)

Supernumerary costs for international nurses. These are in line with the current trajectory and have reduced significantly in June. The expected supernumerary period for

international nurses is 12 weeks. Costs associated with extreme escalation £80k YTD and remain mainly within LAMU and ED. Total WTE used in June was 126 WTE

compared with 131 WTE in May.

HHFT - Agency expenditure increased in month to £773k. The Trust is currently £0.4m above the NHSI Agency Cap, and targeted reductions in Medical agency continue

to under deliver.

91.0%


5. Independent Providers(NVC02) (NV323) (NT344)

Th

em

e

Indicator MeasureData

frequencyTarget Period

Ram

say

Cir

cle

Sp

ire

Su

e R

yd

er

Jun-18 0 0 0 0 √

Q1 0 0 0 0

17/18 0 0 2 0

YTD 0 0 0 0

Jun-18 0 0 0 0 √

Q1 0 0 0 0

17/18 0 0 0 0

YTD 0 0 0 0

Jun-18 0 0 0 0

Q1 0 0 0 0

17/18 0 0 0 0

YTD 0 0 0 0

Jun-18 0 0 0 0

Q1 0 0 0 0

17/18 0 0 0 0

YTD 0 0 0 0

Jun-18 0 0 0 0

17/18 0 0 0 0

YTD 0 0 0 0

Jun-18 0 0 0 0

17/18 0 0 0 0

YTD 0 0 0 0

Jun-18 0 0 0 0 √

YTD 0 0 0 0

No mixed sexed breaches were reported. Pati

en

t

Mixed sex accommodation

(MSA) breachesNumber of breaches = 0 Monthly 0%

MRSA Number of MRSA Bacteraemia Monthly 0

Number reported Monthly N/A

None reported.

Clostridium Difficile Number of Clostridium Difficile Monthly 0

Nil SIs reported by any Independent Providers.

Number of never events Number of never events = zero Monthly N/A

None reported.

Falls (as SI's) Number reported

Pati

en

t S

afe

ty

Number of serious incidentsNumber of reported serious

incidentsMonthly N/A

Monthly N/A

There have been no falls reported by any Providers for June 2018.

Reportable Pressure ulcers G3 &

G4


5A. Independent Providers

(NVC02) (NV323) (NT344)

Th

em

e


frequencyTarget Period

Ram

say

Cir

cle

Sp

ire

Su

e R

yd

er

Vacancies Vacancy rates (%) Quarterly Provider target Q1 9.4% 8.6% 4.7% No data

Sickness AbsenceSickness absence rate against

provider target (%)Quarterly Provider target Q1 5.2% 2.2% 3.3% 2.5%

Appraisals Staff with annual appraisal (%) Quarterly Provider target Q1 95.2% 100.0% 100.0% 100.0%

Transfers to acute trust Unplanned transfer to an Acute Quarterly N/A Q1 0 0 0

95.0% Jun-18 99% 91% 74.1% 97%

Safeguarding training Adults (to

include introductory DoLS &

MCA)

Safeguarding adults Monthly 95.0% Jun-18 99% 91% 74.6% 96%

Circle - Circle moved to a new reporting system recently, at the point of submission validated data was not provided. This is currently being reviewed by department

leads.

Spire - Data has been reviewed and current data provided, actions have been put in place for ward managers to address non-compliance with staff.

VTE risk assessment remains on target.

Safeguarding training - ChildrenAppropriate level of training

according to contact with childrenMonthly

95% Q1 100% 100% 95.4% 100%

Clin

ical E

ffe

cti

ve

ne

ss

Ramsay - Current vacancies are out to advert, interview dates scheduled with offers in progress.

Circle - Recruitment campaign on-going which has yielded positive results within hard to recruit areas of the hospital. Review of current salaries to ensure Circle

Reading is competitive with local NHS providers.

Sue Ryder - Inpatient Unit recruited 5 new registered nurses to be in post by end of September leaving ward manager post vacant - interview date confirmed.

Community Teams - fully established across Wokingham, Newbury and Reading with new starters to join shortly.

VTE assessmentAchieved for at least 95% of

patientsQuarterly


6. Maternity - RBFT Maternity Dashboard Summary

ThemeIndicator Goal Red flag

17/18

OutturnApr-18 May-18 Jun-18

% of deliveries on MLU 20% <15% 17% 20% 16% 14%

Transfer rate Primips <40% >45% 42% 37% 20(40%) 43%

Transfer rate multips <13% >15% 13% 15% 10(22%) 20%

Total transfer rate in labour <25% >32% 28% 27% 31% 35%

% of deliveries 4% <2% 2% 3.30% 1.00% 2%

Transfer rate Primips <45% >46% 70% 25% 66% (2) 50% (1)

Transfer rate multips <12% >13% 25% 13% 0% 33% (2)

Total transfer rate in labour 25% >32% 38% 16% 40% (2) 37% (3)

Intention for vaginal birth after caesarean section (VBAC) 55% <50% 56% 47% 44% 54%

Vaginal birth after caesarean section (VBAC) 65% <60% 64% 53% 59% 67%

Total % of instrumental deliveries 20% >25% 15.47% 15.80% 13.00% 16.92%

Total number of primary caesarean sections <17% >20% 13.04% No Data No Data No Data

Elective rate <12% >14% 14% 14.25% 13.01% 12.88%

Emergency rate 14% >16% 13% 16.06% 14.16% 14.39%

Total caesarean rate 26% 30% 27% 30.31% 27.17% 27.27%

Midwife: birth ratio 01:30 >01:30 01:32 01:31 01:31 01:30

Weekly hours of dedicated senior obstetric cover on delivery suite 168 <90 117 154 154 154

ITU admissions in obstetrics 1 per month >1 per month 2 1 1 2

Postpartum hysterectomies 0 >1 per month 0 1 0 0

Massive PPH >2L 4 per month >6 per month 7 1.5% (6) 1.4% (6) 1.8% (7)

Shoulder dystocia <4 >10 7 1.2% (5) 1.8% (8) 0.8% (3)

Number of cases of Meconium aspiration 0 >5 1 2 1 4

Number of term babies admitted to SCBU/NNICU unexpected <6% >6% 4.3% 2.80% 4.50% 2.50%

Perineal suturing commenced within 1 hour of delivery (excluding 3rd and 4th degree tears) 90% 80% 86.3% No Data No Data No Data

Education and training - midwifery attendance at maternity specific mandatory training days 80% <75% 91.2% 85.83% 86.28% 79.04%

Education and training - medical attendance at maternity specific mandatory training days 80% <75% 81.3% 70.90% 82% 82%

Number of serious incidents 0 >1 1 67.40% 75% 77%

Number of complaints 0 >5 2 1 0 2

Number of occasions MLU service suspended for 4 hours or more <3 4 8 0 3 2

Number of occasions home birth service suspended 0 >1 0 2 7 7

Number of women affected 0 1 0 0 1 1

Number of times unit implemented diversion policy 0 >1 3 0 0 1

Number of times unit attempted to divert but unable as no other unit can accept 0 >1 1 1 2 1

Number of women diverted 0 1 3 0 1 2

Education and training

Governance

Suspension of services

The data table details areas of concern and further monitoring by exception with inclusion of increase or decrease in performance.

Number of Births in June 403 and deliveries 396.

The maternity unit has implemented the diversion policy twice in June, diverted once and attempted on the other occasion. No women were diverted.

Rushey midwifery led unit (MLU) has achieved 14% of all births in June, which is under the target of 20%, this is attributed to closures in June when there were 7 occasions due to midwifery staffing across the unit but also there was an increase

in the transfer rate of 35%. Ward manager is to review all transfers for multiparous women to consider themes and identify if there can be any learning.

MLU

Home Births

Method of delivery

Support in labour

Maternal morbidity

Neonatal morbidity


7. SCAS

Th

em

eIndicator Measure

Data

fre

qu

en

cy

Targ

et

Peri

od

999 F

ron

tlin

e

999 E

OC

TV

IU

C

(111)

PT

S

Staff turnover Staff turnover rate (%) MonthlyProvider

targetQ1 15.0% 26.0% 14.9% 19.0%

Sickness absenceSickness absence rate against provider

target (%)Monthly

Provider

targetQ1 4.7% 4.7%

No

Data5.5%

Vacancies Vacancy rates (%) MonthlyProvider

targetQ1 24% 18% 13% 7%

Appraisals Staff with annual appraisal (%) MonthlyProvider

targetQ1 93.0% 92.0% 74.3% 94.0%

Complaint ResponsesThe provider will ensure that

complaints are resolved in line with Monthly 95% Jun-18 100.0% No Data

HCPF / Clinical Concerns

Responses

The provider will ensure that

complaints are resolved in line with Monthly 95% Jun-18 No Data

Level 1

95%Q1 97.0% 99.0%

Level 2

85%Q1 86.0% 97.0%

All staff should have training

in safeguarding of Adults (to

include introductory DoLS &

MCA)

Safeguarding adults level 1 Quarterly 90.0% Q1 97.0% 99.0%98.0%

At the end of Q4, SCAS have maintained their high performance with Safeguarding Adult training

Safeguarding training -

Children

Appropriate level of training according

to contact with childrenQuarterly

98.0%

98.0%

SCAS have maintained their high performance with Safeguarding Children training

As a result of the NHS Staff Survey, 21% of respondents considered that their appraisal had definitely helped them to improve how they did their

jobs, therefore continued focus is highlighting the importance of staff members being clear about the objectives of the appraisal and what it was

intended to achieve. additionally, the recent introduction of the Values Based Appraisal process has been implemented post staff survey had been

carried out before the introduction of the new appraisal process therefore the Trust is hopeful that this would lead to an improvement in terms of

supporting staff to better deliver their jobs.

67.0%

90.0%

999 - Complaints response had decreased significantly due to the Trust concentrating on closure of historic complaints, it was discussed that the

Trust only received 3 in month.

PTS - Data is not available for PTS as the method of measurement is being reviewed by SCAS.

Clin

ical E

ffecti

ven

ess

SCAS Recruitment across 999, EOC, 111 and PTS have all been on plan, with retention starting the year on plan also. The only exception to this is

EOC, where attrition was higher than plan; this is due to several internal movements/promotions.

999 - Turnover is below plan for the 999 service, there are certain areas in Thames Valley which have higher areas of turnover, this includes

Buckinghamshire and East Berkshire.

111 - SCAS are focusing on how they can improve development of staff in the 111 service to allow them to progress into other roles such as call

auditors, and the possibility of rotational posts.

PTS - Overall staff numbers are improving as detailed below in the vacancies section. A policy has been put into place to limit the number of

Ambulance Care Assistants each quarter who can leave the role into an Emergency Care Assistant role within 999.

Full workforce presentation was provided to the August CQRM detailing the workforce attrition, recruitment initiatives, social media presence etc.

999 - Sickness in the 999 service has seen a small decrease in the frontline.

PTS - has been effected by the expansion into Surrey and Sussex in the last financial year.

It has been noted that SCAS have not benchmarked favourably when looking at other Ambulance Trusts as the above variety of services needed to

be taken into account when benchmarking sickness absence levels. Both EOC and 111 have commenced the financial year with sickness levels

above the plan for 2018/19.

SCAS reported an increase in stress related absence and highlighted the focus that the Trust now had on mental health and wellbeing. Supporting

staff to return to work quicker following a period of sickness absence was key to addressing the challenges, and

that additional resources were being invested into this.

999 - Recruitment is proceeding with both local recruitment days and overseas recruitment. Recruitment into EOC is challenging due to local

employment conditions, there is low unemployment in the Oxford/Bicester area. SCAS are reviewing the skill mix of clinicians in the EOC to

incorporate band 5 nurses, and are looking to expand the utilisation of Conduit from TVIUC to incorporate Emergency Call Taker and Clinical

Support Desk roles.

111 - SCAS have recruited band 5 nurses to the general clinician role within TVIUC, this is a change from previously recruiting band 6 nurses. The

supervision of the band 5 nurses is being designed to provide support around independent working. The use of Home Working is being

implemented within IUC and clinicians are being recruited on home working contracts.

PTS - Across Thames Valley recruitment continues, with 15 WTE vacancies across Thames Valley. Adverts are placed on NHS Jobs on a rolling

basis.


7. SCAS

Th

em

e


frequencyTarget Period SCAS

Jun-18 0

Q1 2

17/18 16

YTD 2

Jun-18 0

Q1 0

17/18 1

YTD 0

7A. SCAS 999Asthma care bundle Monthly 95% Jun-18 82.6%

Febrile convulsions in children Monthly 95% Jun-18 91.7%

Single limb fractures Monthly 75% Jun-18 58.3%

STEMI Monthly 85% Jun-18 61.0%

Falls Risk Assessment Tool

(FRAT) CompletedMonthly 95% Jun-18 51.3%

Referral to appropriate service Monthly 95% Jun-18 51.3%

Conveyance of patients detained

under a Section 136

Conveyance within 30 minutes of

callMonthly 90% Jun-18 70.0%

There remains a discrepancy in referral criteria in Oxfordshire and Berkshire East, this is being followed up between SCAS, Falls Services and the

relevant Commissioners. A workshop is to be held in order to reach an agreement with the criteria for usage.

Clin

ical

Eff

ecti

ven

ess

This action plan has now been closed following three months of consecutive performance. Discussions has also been held regarding the presentation of

data for both 30min and 60 min as agreed.

Pati

en

t S

afe

ty

Improving patient outcomes by

compliance with evidence based

care bundles

STEMI 150 - There are still low numbers of patients recorded in the MINAP database SCAS are working with Commissioners to

ensure that Acute Trusts upload the data. The STEMI 150 measure is changing nationally and will be amended in due course to reflect this.

Asthma Care bundle- The low compliance is due to peak flow recording or the recording of a valid exception. This will be communicated to the staff

by the Clinical Governance Leads via the Level 2 Operational meetings

Falls Risk Assessments and

Referrals to Appropriate

Services

Falls (as SI's) Number reported Monthly N/A

Nil SIs reported in June.

Pati

en

t S

afe

ty

Number of serious incidentsNumber of reported serious

incidentsMonthly N/A


8. Quality Dashboard - Quality Assurance Visits

Trust Area Date Recommendations Trust response

RBFT Radiology 6th June 2018

1) To ensure all call bells are in good

working order within the CT waiting area

2) Continued progression toward imaging

accreditation

3) Continued engagement with ICS pathway

developments

4) MRI demand management and capacity

modelling and support from CCG re primary

care referrals

1) The call bell in question was in the MRI/CT bed wait-area. The bell had a broken handset which had

been reported to the Estates and Facilities Management Department to be repaired. Since the CCG visit,

the repair has been completed and all call bells within the department are fully functional

2) The Department registered for the Imaging Services Accreditation Scheme (ISAS) on-line accreditation

tool in December 2017 and held an on-site ISAS workshop in April 2018. Since June there has been a site

visit to a fully accredited organisation and a Radiology Quality Committee has been convened, which

includes Consultant Radiologist representation.

The Department recognises the requirement under accreditation for a Quality Manager and intends to

recruit to the current vacancy over the next few months, pending the necessary approvals.

3) As discussed during the visit, the Radiology Clinical Services Manager is both work-stream lead for the

Procedures & Diagnostics work-stream of the Trust Outpatient Modernisation Programme, and a

member of the Integrated Care System (ICS) Outpatient Transformation Steering group. This provides a

mechanism for on-going Radiology engagement in all relevant ICS pathway and service developments.

4) MRI demand and capacity modelling has been previously carried out both internally and by external

review. This data has been used to inform the Radiology strategy regarding MRI capacity needs.

Recent data has also highlighted a significant rise in direct access referrals for MRI Spine and MRI Knee. A

meeting was held on 25th July 2018 with Karen Grannum, Interim Planning & Transformation Lead, Berks

West CCG, to discuss reviewing guidelines and standardising referral processes. The aim is to reduce the

number of inappropriate referrals and address variations in clinical practice.

RBFT Delivery Suite 14th June 2018

1) To consider a seconded opportunity for

an IT lead midwife

2) To progress discussions for

transformational fund monies to establish

one IT system interface

3) Consider the reconfiguration/relocation of

the Induction of Labour room to the

consultants room within the delivery suite

4) Continue with the recruitment and

retention strategies

1) This post has been advertised.

2) A Project Manager has been appointed by the Information Management and Technology Department

to map the Information Technology requirements for maternity. This project has is in its early stages and

once complete, the Maternity Service will review its recommendations and if appropriate, consider a bid

for transformational fund monies at that time.

3) This idea is aspirational however is not currently a priority as funding has been agreed within the

service to develop a Higher Monitoring Unit for the Deliver Suite, a large building project commencing in

Autumn 2018. Pro-tem, an IT solution is being explored.

4) This is continuing as work-in-progress; the Trust currently has a waiting list for midwives to join the

maternity service.

CCG Quality Assurance Visits undertaken in July: NIL

CQC Visits:

BHFT- The trust is currently participating in its well led and focused CQC inspection process, report unavailable until Q2/3.

SCAS- The Trust has participated in a robust inspection of services and full report of findings due in October 2018


9. Urgent Care Performance

Indicator Target OrgM01

Apr

M02

May

M03

Jun

YTD

RBFT 93.3% 96.1% 96.5% 95.3%

GWH 90.9% 94.1% 91.7% 91.5%

HHFT 89.5% 85.8% 85.6% 86.9%

RBFT 4.5% 3.5% 3.5%

BHFT 12.7% 9.8% 12.3%

BW CCG 313 261 329 903

Thames Valley 1,411 1,440 1,470 4,321

BW CCG 00:06:31 00:06:58 00:06:28 00:06:38

Thames Valley 00:06:41 00:06:46 00:06:46 00:06:51

BW CCG 00:11:22 00:13:07 00:11:05 00:11:50

Thames Valley 00:12:21 00:12:24 00:12:53 00:12:04

BW CCG 2,303 2,451 2,300 7,054

Thames Valley 11,415 11,863 11,573 34,851

BW CCG 00:13:48 00:13:57 00:14:27 00:14:04

Thames Valley 00:13:57 00:14:29 00:14:14 00:16:06

BW CCG 00:28:00 00:28:07 00:29:48 00:28:36

Thames Valley 00:26:47 00:28:37 00:27:38 00:32:51

BW CCG 1,476 1,493 1,539 4,508

Thames Valley 7,389 7,784 7,926 23,099

BW CCG 00:46:17 00:52:18 00:51:51 00:50:11

Thames Valley 00:45:46 00:47:40 00:46:02 00:49:10

BW CCG 01:43:00 02:07:06 01:56:17 01:54:49

Thames Valley 01:42:47 01:50:39 01:46:58 01:55:27

BW CCG 133 145 139 417

Thames Valley 726 779 709 2,214

BW CCG 01:11:28 01:08:02 01:16:56 01:12:06

Thames Valley 01:10:28 01:10:30 01:05:59 01:15:52

BW CCG 02:42:41 02:37:30 02:40:28 02:41:48

Thames Valley 02:42:05 02:37:57 02:32:0703:00:32

Delayed Transfers of Care

DToC performance at RBH continues to be very strong. Days lost to DToCs in June were the lowest since records began

in April 2013. The focus is now moving to stranded patients (patients remaining in an acute bed for more than 7 days for

any reason) and a national target has been set to reduce the number of days lost to stranded patients by 24% by end of

2018-19. The new weekly DASS DToC meetings are proving beneficial in both addressing individual DToCs and identifying

themes and solutions. The BW10 DG continues to have oversight of the action plan to address the 8 High Impact Change

model and Sarah Mitchell, from the LGA, continues to support the system. Mental Health delays continue to be of concern

and a meeting is scheduled for 5th Sept to discuss.

<3.5%

DT

0C

SC

AS

- 9

99

SCAS have met the vast majority of new ARP targets for quarter 1. This is a significant achievement for SCAS. This is

against a backdrop of reduced activity and SCAS are predicting that performance in quarter 2 wil be more challenged. New

quarterly national Ambulance Integration Programme meetings have been establlished and there are clear national

priorities emerging around the clinical triage of Category 3 and 4 calls to ensure ambulances are only despatched if

clinically appropriate. Locally this is being driven through the Non Conveyance CQUIN.

Cat 4 - Number of incidents

Cat 4 (Mean) - Category 4 calls mean time

taken for a response to arrive

Cat 4 (90th Percentile) - Category 4 calls -

90th percentile taken for a response to arrive

-

No target

<=03:00:00



Cat 3 - Number of incidents





No target

<=02:00:00

Cat 2 - Number of incidents -

Cat 1 - Number of incidents -







<= 00:07:00

<=00:15:00

<=00:18:00

<=00:40:00

-

Year to date performance is strong and the 95% target is being achieved. RBHT have been working with NHS

Improvement on an ED Recovery Programme and are confident that this has supported an improvement in performance.

The new operating model is in operation and will run upto March 2019. However, the model is being kept under continual

review.

Percentage of patients admitted transferred

or discharged within 4 hours of their arrival

at an A&E department

>=95%

A&

E


12. Urgent Care Performance

Target OrgM01

Apr

M02

May

M03

Jun

YTD

BW CCG 3.2% 1.2% 1.8% 2.1%

Thames Valley 3.2% 1.3% 1.7% 2.1%

BW CCG 79.1% 86.5% 85.7% 83.8%

Thames Valley 79.7% 86.5% 86.0% 84.1%

BW CCG 9.7% 10.7% 10.4% 10.2%

Thames Valley 9.2% 9.5% 10.0% 9.5%

BW CCG 5.4% 5.9% 5.8% 5.7%

Thames Valley 5.4% 5.3% 5.6% 5.4%

BW CCG 4.3% 4.8% 4.6% 4.6%

Thames Valley 3.9% 4.2% 4.4% 4.2%

BW CCG 8.4% 8.7% 8.6% 8.5%

Thames Valley 7.7% 7.2% 7.9% 7.8%

BW CCG 0.8% 0.9% 1.1% 0.9%

Thames Valley 1.7% 2.6% 2.2% 2.0%

Referral to Emergency Disposition - Eligble calls (Type 1 and Type

2) that are transferred to an enhanced ED desk>80% Thames Valley 37.8% 36.1% 41.6% 40.2%

BW CCG 21.5% 19.0% 13.5% 18.0%

Thames Valley 21.0% 18.9% 13.9% 17.9%

BW CCG 97.8% 99.0% 96.9% 98.0%

Thames Valley 99.3% 99.1% 98.2% 99.0%

BW CCG 28.7% 28.3% 23.4% 26.7%

Thames Valley 29.7% 28.0% 23.8% 27.1%

Referral to Emergency Disposition - Percentage of patients advised

to attend Emergency Department (ED) from NHS 111 (Cat 1 &

Cat 2)

Referral to Emergency Disposition - Percentage of patients advised

to attend Emergency Department (ED) from NHS 111 (Cat 3 &

Cat 4)

<5%

Transfer to 999 - % 111 calls to Ambulance Dispatch

Warm Transfers - calls transferred while patient on the call >85%

Transfer to 999 - % 111 calls to Ambulance Dispatch (Cat 3 & Cat

4)<10%

<5%

<10%

Transfer to 999 - % 111 calls to Ambulance Dispatch (Cat 1 & Cat

2)<10%

The percentage of abandoned 111 calls (callers hang up before

they get through)<5%

The percentage of 111 calls answered within 60 seconds >=95%

Indicator

TV

- I

UC

There is continued focus on call answering performance which has fallen short of target since the contract began. The key constraint is

workforce and SCAS continue to look creatively at ways to retain and recruit staff including rotational posts across PTS, 999 and IUC. The

introduction of the new Service Advisor role, Band 2, should also support recuitment and provide opportunities for career progression.

Warm Transfer waiting time (60 secs) 99%

Warm Transfer time taken for call back (LQ15) 10 mins (P1 and

P2)>85%


9. Urgent Care & Emergency QP Indicators

M01

Apr

M02

May

M03

Jun

YTD

Actual 14,664 15,419 15,143 45,226

Plan 15,193 16,607 15,689 47,489

Actual 8,828 9,326 9,317 27,471

Plan 9,288 10,151 9,591 29,030

Actual 1,158 1,253 1,232 3,643

Plan 1,064 1,273 1,140 3,477

Actual 2,492 2,626 2,533 7,651

Plan 2,392 2,620 2,638 7,650

10. Planned Care

M01

Apr

M02

May

M03

Jun

YTD

Actual 1,847 1,975 1,945 5,767

Plan 2,071 2,522 2,499 7,092

Actual 5,998 6,808 6,460 19,266

Plan 6,344 6,494 6,794 19,632

Actual 11,561 11,947 12,114 35,622

Plan 11,762 12,047 12,490 36,299

Actual 9,785 11,022 10,907 31,714

Plan 9,414 9,959 10,650 30,023

Actual 6,890 4,819 4,640 16,349

Plan 6,939 7,643 7,820 22,402

Actual 15,453 16,637 16,087 48,177

Plan 15,699 17,457 17,924 51,080

Actual 27,429 28,400 27,491 83,320

Plan 26,452 28,374 28,633 83,459

Actual 3,301 3,659 3,696 10,656

Plan 3,246 3,568 3,702 10,516

Actual 610 711 681 2002

Plan 726 731 772 2229

Total elective admissions - Day Cases

(E.M.10a)

Total elective admissions - Ordinary

(E.M.10b)

For planned care activity, GP referrals and daycases are higher than plan. This is primarily due to the changes made

to the reporting warehouse at RBFT. Overall referrals and elective activity is below plan YTD.

Number of New RTT Pathways (Clockstarts)

(E.M.20)

Total GP Referrals (G&A)

(E.M.7a)

Total Other Referrals (G&A)

(E.M.7b)

Consultant led first outpatient attendances (G&A)

(E.M.8)

Consultant led follow up outpatient attendances

(G&A) (E.M.9)

A&E attendances are under plan for BWCCG. There is a 5% increase in 0 LOS non elective admissions YTD, This is

in part due to the work being done at RBFT to improve patient flow through the hospital. This however does

impact the achievement of 2018-19 QP indicators around emergency care. This accounts for 70% of the QP

allocations.

Type 1 A&E Attendances excluding planned

follow ups (E.M.12a)

Total A&E Attendaces excluding plannned

follow ups (E.M.12)

Total Non - Elective Admissions - 0 LOS

(E.M.11a)

Total Non - Elective Admissions - +1 LOS

E.M.11b)

Number of Completed Admitted RTT Pathways

(E.M.18)

Number of Completed Non-Admitted RTT

Pathways (E.M.19)

Qual

ity

Pre

miu

m Indic

ato

rs

Par

t B

Par

t A

Indicator

Indicator


10. Planned Care Performance - Cancer

2 week wait 2-week waits

(breast

symptoms)

31-day wait (first

definitive

treatment)

31-day wait (subs -

surgery)

31-day wait (subs -

anti-cancer drug

regimen)

31-day wait (subs -

radiotherapy)

62-day wait (GP

referral)

62-day wait NHS

screening

62-day wait

(Upgrade)

93.0% 93.0% 96.0% 94.0% 98.0% 94.0% 85.0% 90.0% No Target

BW CCG 94.3% 93.8% 98.1% 93.2% 99.4% 94.4% 85.0% 93.1% 66.7%

Seen 4187 485 630 68 158 204 317 27 10

Breaches 252 32 12 5 1 12 56 2 5

RBFT 94.7% 94.4% 97.9% 94.9% 99.2% 97.5% 86.4% 57.0% 64.1%

Seen 4400 503 1232 112 362 616 636 50 16

Breaches 247 30 28 6 4 24 102 9 8

GWH 95.1% 89.9% 99.6% 100.0% 100.0% No data 87.0% 97.7% 69.4%

Seen 3405 232 858 64 214 0 429 117 7

Breaches 176 26 4 0 0 0 62 4 5

BW CCG 92.5% 94.0% 98.6% 88.9% 100.0% 94.5% 86.0% 100.0% 100.0%

Seen 1364 171 207 24 50 69 104 12 3

Breaches 111 11 3 3 0 4 17 0 0

RBFT 95.6% 92.4% 97.9% 89.5% 99.0% 98.7% 85.7% 56.6% 75.0%

Seen 1597 134 444 34 134 202 58 0 4

Breaches 73 11 10 4 2 4 40 3 2

GWH 94.9% 98.6% 100.0% 100.0% 100.0% No Data 93.6% 100.0% 0.0%

Seen 1311 34 302 18 72 0 52 10 2

Breaches 56 3 0 0 0 0 22 2 3

BW CCG 95.4% 91.3% 97.9% 92.0% 100.0% 95.9% 85.9% 91.7% 71.4%

Seen 1527 136 233 23 53 70 122 11 5

Breaches 74 13 5 2 0 3 20 1 2

RBFT 95.6% 92.4% 97.8% 89.5% 98.5% 98.1% 85.5% 82.4% 75.0%

Seen 1597 134 222 17 67 101 117.5 7 3

Breaches 73 11 5 2 1 2 20 1.5 1

GWH 95.9% 91.9% 100.0% 100.0% 100.0% No data 87.0% 95.0% 70.0%

Seen 1311 34 151 9 36 0 73.5 19 3.5

Breaches 56 3 0 0 0 0 11 1 1.5

BW CCG has not achieved the 31 day subs surgery standard ( June and Q1) and 2ww standard (June) . RBFT has achieved all cancer standards for Q1 with the exception of 62day from screening standard.

Q1

Indicator ->

Target (>=)

M03

(JUN)

M02

(May)


10. Planned Care Performance

Indicator Org Target M01

Apr

M02

May

M03

Jun

YTD

BW CCG 92.3% 92.2% 93.0% 92.5%

RBFT 92.5% 92.2% 93.1% 92.6%

GWH 87.1% 87.2% 86.8% 87.0%

BW CCG 2 3 4

RBFT 0 0 0 0

GWH 14 17 19 19

BW CCG 1.4% 3.2% 3.4% 2.7%

RBFT 1.7% 2.5% 3.2% 2.4%

GWH 15.4% 25.1% 21.0% 20.7%

E-Referrals Utilisation BW CCG 80% 62.2% 55.7% 56.2% 57.9%

11. HCAI

Indicator Org Target M01

Apr

M02

May

M03

Jun

YTD

Number of cases of Methicillin-resistant

Staphylococcus aureus bacteraemia BW CCG0 0 0 0 0

Indicator M01

Apr

M02

May

M03

Jun

YTD

2 9 6 17

7 12 10 29

BWCCG is under its YTD and monthly limits for c-diff infections.

Target

BW CCG Monthly Limits

BW CCG ActualNumber of cases of Clostridium Difficile Infection

There have been no reported cases of MRSA bacteraemias for BWCCG for 2018-19.

Incomplete RTT pathways (yet to start

treatment) waiting 18 weeks or less from referral

to hospital treatment

Both RBFT and Berkshire West CCG have achieved the incomplete standard for June.

RTT wait over 52 weeks for incomplete

pathways

E-Referrals Utilisation has dropped in the last couple of months as compared to April. The performance is likely to improve

with paper switch off of referrals at RBFT.

RBFT had no patients waiting more than 52 weeks for first treatment at the end of June. There were 4 patients waiting over

52 weeks at the end of June for Berkshire West at OUH, GWH and BIH Ramsey.

Diagnostic tests - the percentage of service users

waiting 6 weeks or more from referral for a

diagnostic test

Diagnostic performance has deteriorated at RBFT in recent months. This is primarily in electocardiography due to staffing

issues and also in MRI due to the new MPMRI pathway.

>=92%

0

<=1%


Documents

Integrated Quality and Performance Report