Trust Quality and Performance Report July 2013. Contents Slide numbers Executive Summary 2 - 4 Clinical Quality Priorities inc Ward Dashboard5 - 22 Local

Trust Quality and Performance Report

July 2013

Contents

Slide numbers

Executive Summary 2 - 4

Clinical Quality Priorities inc Ward Dashboard 5 - 22

Local Priorities 23 - 30

CQUIN 31 - 33

Monitor Compliance 34

Contract Priorities 35 - 36

1

Executive Summary

This commentary provides an overview of key issues during the month and highlights where performance fell short of the target values as well as areas of improvement and noticeable good performance.

A&E performance for June was above the 95% target (95.42%) for the first month since December 2012, although the quarterly position remains off-track at 92.57%. The Trust also achieved all Stroke targets for June, the first month we have done so in 2013/14.The Trust achieved all access targets.

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Performance Indicator Threshold June Lead Exec

Breastfeeding initiation rates. 80% 79.25% Nichole Day

Discharge Summaries - Outpatients 95% sent to GP's within 3 days 84.23% Dermot O'Riordan



Discharge Summaries - Inpatients 95% sent to GP's within 1 day 83.50% Dermot O'Riordan

3

The breastfeeding initiation rate is improving but is just under target. Action already taken to improve includes the provision of written information and Breast Feeding workshops offered in localities antenatally and staff training. In addition, an Infant feeding coordinator was appointed on 1st July to visit the post natal ward, paediatrics and the neonatal unit to support breast feeding and there is a tender out to provide home visiting support to ladies after discharge. We have received Stage 1 accreditation with UNICEF for the Breast Feeding Initiative and we are working towards Stage 2 which involves additional training for all staff in Midwifery.


All Staff to have an appraisal90% of staff have had an appraisal within the previous 12 months

86.50% Jan Bloomfield


MRSA - emergency screening

All emergency patients admissions are to be screend for MRSA within 24 hours of admission

89.94% Nichole Day

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Attending an appraisal meeting (at least annually) is mandatory for all staff. The Trust provides comprehensive training for appraisers as part of its skills+ programme, and has developed a policy document which explains the process and paperwork. Paperwork is available electronically on the intranet. Doctors have a separate national process which is closely linked to revalidation. Appraisals are monitored through the Trusts’ Electronic staff record system (ESR), when a completed personal development plan (PDP) is submitted to the HR department. (This can be done electronically or by using a paper based system). Reporting then takes place on a monthly basis, through the directorate performance management process. Managers can also request individual reports on their own staff from HR at any time.The Trust Board receive appraisal take up information monthly. The target is 90%, and as at end June the Trust compliance figure is at 86.50%.

The percentage compliance has increased but does not meet the target. Analysis of non compliant data suggests that the majority of these patients are admitted through F8, with SAU and F6 and some medical wards having some non compliance. Additional IPT checks on EAU are being put into place and the Information Team are checking to ensure that patients who do not meet the criteria for screening are not included.

Group Indicator Target Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU G5 F9 F10 G1 G3 G4 F7 G8 MTU G9 F8 F1 F11 F14HII compl iance 1a : Centra l venous catheter insertion

100% <85 85-99 100 NA NA NA NA 100 NA NA NA NA NA NA NA NA NA NA NA NA NA 100 NA NA NA NA NA

HII compl iance 1b: Centra l venous catheter ongoing care

100% <85 85-99 100 100 NA 100 NA 100 NA NA NA NA ND ND ND 100 100 ND 0 75 NA NA ND NA NA NA NA

HII compl iance 2a : Periphera l cannula insertion

100% <85 85-99 100 NA NA NA NA 100 80 NA NA NA NA NA NA NA NA NA NA NA NA 80 NA 100 100 NA NA

HII compl iance 2b: Periphera l cannula ongoing 100% <85 85-99 100 100 100 100 100 100 NA NA NA NA 100 100 100 100 100 90 100 90 100 NA 100 NA 63 NA ND

HII compl iance 4a : Preventing surgica l s i te infection preoperative

100% <85 85-99 100 NA NA NA NA NA NA 100 100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

HII compl iance 4b: Preventing surgica l s i te infection perioperative

100% <85 85-99 100 NA NA NA NA NA NA 100 100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

HII compl iance 5: Ventilator associated pneumonia

100% <85 85-99 100 NA NA NA NA 100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

HII compl iance 6a : Urinary catheter insertion 100% <85 85-99 100 NA NA NA NA NA ND NA NA NA NA NA NA NA 100 NA NA NA NA NA NA ND NA NA NAHII compl iance 6b: Urinary catheter on-going care

100% <85 85-99 100 100 100 100 100 NA NA NA NA NA 100 100 100 100 100 100 100 100 90 NA 100 NA NA NA 100

HII compl iance 7: Clos tridium Diffi ci le- prevention of spread

100% <80 80-99 100 NA NA NA NA NA NA NA NA NA NA NA 100 NA NA NA NA NA NA NA NA NA NA NA NA

Seps is 6 pathway: antibiotic compl iance 100% <80 80-99 100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDTota l no of MRSA bacteraemias : Hospi ta l 0/yr > 0 No Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Tota l no of MRSA bacteraemias : Community acquired

No Target No Target No Target No Target ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND

MRSA (admiss ion to discharge) 90% <80 80-89 90-100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDMRSA decolonisation (treatment and post screening)

90% <80 80-89 90-100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND

MRSA Elective screening 100% <80 80-99 100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDMRSA Emergency screening 100% <80 80-99 100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDStool speciment col lection No Target No Target No Target No Target ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDHand hygiene compl iance 95% <85 85-94 95-100 100 100 100 100 100 NA 100 100 100 100 100 100 100 100 100 100 100 100 100 100 90 100 ND 100Standard principle compl iance 95% <80 80-99 90-100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDTota l no of MSSA bacteraemias : Hospi ta l No Target No Target No Target No Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0Tota l no of C. diff infections : Hospi ta l 19/yr >0 No Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0Tota l no of C.diff infections : Community acquired

No Target No Target No Target No Target ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND

Antibiotic Audit 98% <85 85-97 98-100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDTota l no of E Col i No Target No Target No Target No Target ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDIsolation data 95% <85 85-94 95-100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDEnvironment/Isolation 90% <80 80-89 90-100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDVIP score documentation 90% <80 80-89 90-100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND NDMEWS documentation and esca lation compl iance

100% <80 80-99 100 ND ND 100 100 NA NA NA NA NA 86 100 ND 92 100 ND 84 91 97 NA NA 89 NA NA NA

No of patient fa l l s 0% >0 No Target 0 4 0 1 1 0 NA NA 0 0 2 8 5 2 3 1 10 8 7 0 6 2 NA NA NAFal l s per 1,000 bed days 560% >5.8 5.6-5.8 <5.6 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NANo of patient fa l l s resulting in harm 0% >0 No Target 0 1 0 1 1 0 NA NA ND 0 0 1 1 1 0 1 3 3 1 0 2 0 NA NA NA

Patient Safety

Ward Analysis Quality Report - June 2013 Surgery Medicine Women & Chi ldren

Group Indicator Target Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU G5 F9 F10 G1 G3 G4 F7 G8 MTU G9 F8 F1 F11 F14No. of serious injuries or deaths resulting from fa l l s

0% >0 No Target 0 1 0 0 0 0 NA NA 0 0 0 1 0 0 0 0 1 0 0 0 0 0 NA NA NA

No of patients with ward acquired Grade 2 pressure ulcers

0% >0 No Target 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 NA NA NA

No of patients with avoidable ward acquired Grade 2 pressure ulcers

0% >0 No Target 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 NA NA NA

No of patients with ward acquired Grade 3 or 4 pressure ulcers

0% >0 No Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 NA NA NA

No of patients with avoidable ward acquired Grade 3 or 4 pressure ulcers

0% >0 No Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ND 0 0 0 0 NA NA NA

Nutrition: Assessment and monitoring 95% <85 85-94 95-100 100 100 100 100 100 NA NA NA NA 100 100 100 90 70 100 100 90 100 NA 90 100 NA NA 0Hydration: Patients with appropriate fluid balance management

No Target No Target No Target No Target 40 100 88 70 NA NA NA NA NA 100 100 100 100 89 90 70 80 100 NA 30 0 NA NA 30

No of SIRIs and potential SIRIs 0% >0 No Target 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 1 0 0 0 1 0 1 0No of drug errors : resulting in harm 0% >0 No Target 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0No. of CD errors (patient safety) 0% >0 No Target 0 0 1 0 1 0 0 0 0 0 0 1 1 1 0 0 0 1 0 0 1 1 0 0 0Cardiac arrests : No. outs ide CCS No Target No Target No Target No Target 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0Cardiac arrests outs ide CCS: No. of RCAs No Target No Target No Target No Target 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0Pain Management: Quarterly internal report 80% <70 70-79 80-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NAVTE: Completed ri sk assessment (monthly Uni fy audit)

> 98% < 98 No Target > 98 99.3 98.8 99.6 100 92.9 NA NA 100 NA 100 93.5 95.45 98.04 100 99.12 98.61 100 94.12 NA 100 100 NA 95.48 98.15

VTE: Prophylaxis compl iance 100% <95 95-99 100 100 ND 100 ND 100 NA NA NA NA 100 100 100 100 100 100 100 100 100 NA NA 100 NA 100 100Safety Thermometer: % of patients experiencing harm-free care

95% <95 95-99 100 100 100 100 100 100 NA NA NA NA 100 96.77 90.62 88 81.82 100 75 85.29 96 NA 77.78 94.94 NA 100 83.33

Patient Satisfaction: In-patient overal l result 85% <75 75-84 85-100 86 93 92 96 NA NA NA NA NA 94 81 88 92 97 90 88 91 NA 96 NA 85 NA NA 95How l ikely i s i t that you would recommend the service to friends and fami ly?

75% <70 70-74 75-100 57 95 93 90 NA NA NA NA NA 100 70 90 100 100 93 80 81 NA 100 NA 86 NA NA 50

In your opinion, how clean was the hospita l room or ward that you are in?


Did you feel you were treated with respect and dignity by s taff?


Were Staff caring and compass ionate in their approach?


Were you ever bothered by noise at night from other patients?


Did you find someone on the hospita l s taff to ta lk to about your worries and fears?


Were you involved as much as you wanted to be in decis ions about your condition and treatment?


Were you given enough privacy when discuss ing your care?


Did you get enough help from staff to eat your meals

85% <75 75-84 85-100 87 100 92 100 NA NA NA NA NA 100 100 100 100 100 100 100 100 NA 100 NA 75 NA NA NA

Were you given enough privacy when being examined or treated?


Timely ca l l bel l response 85% <75 75-84 85-100 54 74 73 76 NA NA NA NA NA 89 30 62 61 72 77 62 61 NA 83 NA 89 NA NA 94Number of surverys completed No Target No Target No Target No Target 61 87 27 39 NA NA NA NA NA 9 23 31 31 15 42 15 26 NA 17 NA 7 NA NA 6Same sex accommodation 0% >2 100% 0 - - - - - - - - - - - - - - - - - - - - - - - -Same sex accommodation: tota l patients 0% >2 100% 0 0 0 0 0 0 NA NA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NA NA NAComplaints 0% >2 1-2 0 0 0 1 0 0 0 0 0 4 0 1 1 1 0 0 1 0 1 0 0 3 1 0 1Environment and Cleanl iness 90% <80 80-89 90-100 90 95 92 89 96 90 93 89 88 93 93 92 93 90 86 92 87 93 93 ND 87 94 94 93Environmental Audit 90% <80 80-89 90-100 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND

Surgery Medicine Women & Chi ldrenWard Analysis Quality Report - June 2013

Patient Experience: in-patient

Patient Safety

Group Indicator Target Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU G5 F9 F10 G1 G3 G4 F7 G8 MTU G9 F8 F1 F11 F14Patient Satisfaction: short-s tay overa l l resul t 85% <75 75-84 85-100 NA NA NA NA NA NA NA 100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NAHow l ikely i s i t that you would recommend the service to friends and fami ly?

75% <70 70-74 75-100 NA NA NA NA NA NA NA 97 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Were you given enough privacy when being examined and treated?


Were staff profess ional , approachable and friendly?


Were you told who to contact i f you were worried after leaving hospita l?


Overal l how would you rate the care you received in the department?


Number of surverys completed No Target No Target No Target No Target NA NA NA NA NA NA NA 67 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NAPatient Satisfaction: A&E overal l result 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA 89 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NAHow l ikely i s i t that you would recommend the service to friends and fami ly?.

75% <70 70-74 75-100 NA NA NA NA NA NA NA NA 54 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Were staff profess ional , approachable and friendly?


Were you given enough privacy when discuss ing your condition at reception?


Did Doctors and Nurses l i s ten to what you had to say?


Did a member of s taff tel l you what danger s igns to watch for when going home?


Did staff tel l you who to contact i f you were worried about your condition after leaving A&E?


Number of surverys completed No Target No Target No Target No Target NA NA NA NA NA NA NA NA 341 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NAPatient Satisfaction: A&E Chi ldren questions overal l resul t


How l ikely are you to recommend our A&E department to friends and fami ly i f they needed s imi lar care or treatment?


Did the Doctor or Nurse l i s ten to what you had to say?


Were staff friendly and kind to you and your fami ly?


Did we help with your pain? 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA 80 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NADid staff expla in the care you need at home? 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA ND NA NA NA NA NA NA NA NA NA NA NA NA NA NA NANumber of surverys completed No Target No Target No Target No Target NA NA NA NA NA NA NA NA 7 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Ward Analysis Quality Report - June 2013

Patient Experience:

A&E

Patient Experience:

A&E (Children questions)

Patient Experience: short-stay

Surgery Medicine Women & Chi ldren

Group Indicator Target Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU G5 F9 F10 G1 G3 G4 F7 G8 MTU G9 F8 F1 F11 F14Patient Satisfaction: Maternity overa l l resul t 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 93 NAIn your opinion, how clean was the hospita l room or ward that you were in?

85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 94 NA

Were s taff profess ional , approachable and friendly?


Did you find someone on the hospita l s taff to ta lk to about your worries and fears?


Were you involved as much as you wanted to be in decis ions about your care and treatment?


Were you given enough privacy when being examined or treated?


Did you hold your baby in skin to skin contact after the bi rth (baby naked apart from the nappy and a hat, lying on your chest)?


Were you given adequate help and support to feed your baby whi ls t in hospi ta l?


How many minutes after you used the ca l l button did i t usua l ly take before you got the help you needed?


Has a member of s taff told you about medication s ide effects to watch for when you go home?


Have hospita l s taff told you who to contact i f you are worried about your condition after you leave hospita l?


How l ikely i s i t that you would recommend the service to friends and fami ly?


Number of surverys completed No Target No Target No Target No Target NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 97 NAPatient Satisfaction: Chi ldren's Services Overa l l Result

85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 98 NA NA

How l ikely are you to recommend our ward to friends & fami ly i f they needed s imi lar care or treatment?


Did you understand the information given to you regarding your treatment and care?


Were you as involved as you wanted to be in decis ions about your care and treatment?


Did the Doctor or Nurses expla in what they were doing in a way that you could understand?


Were you offered age/need appropriate activities?

85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA ND NA NA

Was your experience in other hospita l departments (i .e. X-ray department, out-patient department, theatre) satisfactory?


Was your experience during procedures/investigations (i .e.blood tests , X-rays ) managed sens itively?


If you were in pa in, did the Doctor or Nurse do everything they could to help with the pain?


Were s taff kind and caring towards you? 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 100 NA NAIs the environment chi ld - friendly? 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA ND NA NAOveral l , how would you rate your experience in the Paediatric Uni t?

85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA ND NA NA

Number of surverys completed No Target No Target No Target No Target NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 6 NA NA

Patient Experience: Maternity

Children's Services Patient

Satisfaction: Young Children

Ward Analysis Quality Report - June 2013 Surgery Medicine Women & Chi ldren

Group Indicator Target Red Amber Green F3 F4 F5 F6 CCS Theatres Recovery DSU A&E CCU G5 F9 F10 G1 G3 G4 F7 G8 MTU G9 F8 F1 F11 F14Patient Satisfaction: F1 Parent overal l result 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 94 NA NAHow l ikely are you to recommend our ward to friends & fami ly i f they needed s imi lar care or treatment?


Did you understand the information given to you regarding your chi ld's treatment and care?


Were you and your chi ld as involved as you wanted to be in decis ions about care and treatment?


Did the Doctor or Nurses expla in what they were doing in a way that your chi ld could understand?


Were there appropriate play activities for your chi ld (such as toys , games and books)?


Was your chi ld's experience in other hospita l departments (i .e. X-ray department, out-patient department, theatre) satisfactory?


Was your chi ld's experience during procedures/investigations (i .e.blood tests , X-rays) managed sens itively?


If your chi ld was in pa in, did the doctor or nurse do everything they could to help with the pain?


Were staff kind and caring towards your chi ld 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 96 NA NAIs the environment chi ld-friendly? 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 100 NA NAOveral l , how would you rate your experience in the Chi ldren's Unit?


Number of surverys completed No Target No Target No Target No Target NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 13 NA NAPatient Satisfaction: Stroke overal l result 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 93 NA NA NA NA NA NAHow l ikely i s i t that you would recommend the service to friends and fami ly?

75% <70 70-74 75-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 100 NA NA NA NA NA NA

Have you been told you have had a s troke, which lead to your admiss ion to hospita l?


Have you been involved in planning your recovery / rehabi l i tation?


Whi le you were in the Stroke Department how much information about your condition or treatment was given to you?


Have you received the help you require whi le eating?


Do you feel cared for? 85% <75 75-84 85-100 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 94 NA NA NA NA NA NAWere you given enough privacy when being examined or treated or when your care was discussed with you?


Number of surverys completed No Target No Target No Target No Target NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 8 NA NA NA NA NA NASickness 3.5% >6 3.5-6 <3.5 5.1 2.4 1.7 5.7 3.7 7.5 3.5 8.5 7.4 4.2 7.5 4.5 5.9 4.6 2.6 6.7 8.8 3.6 NA 0 5 2.6 5.4 8.7Sickness (Short term) No Target No Target No Target No Target 5.1 1.6 0.9 2.1 3 4.6 2 3.5 2.5 1.3 3.2 2.9 3.1 1.4 1 3.5 3.2 3 NA 0 5 1.7 2.1 6Sickness (Long term) No Target No Target No Target No Target 0 0.8 0.8 3.6 0.7 2.9 1.5 5 4.9 2.9 4.3 1.5 2.8 3.2 1.6 3.2 5.6 0.6 NA 0 0 0.8 3.3 2.7Vacancies No Target No Target No Target No Target -4.1 1.3 1.7 -1.8 -4.7 0.3 -0.1 -3.6 -7.4 -1.8 -5 -1.7 2 -4.9 3.2 -0.8 -2.3 -2.4 NA 0 -3.8 -1.6 -6.1 -0.9Turnover (Annual ) 10% >10% No Target 0%-10% 4.6 0 7.9 0 7.3 3.5 0 4.4 3.6 12.5 4.2 0 2.4 5.3 9.52 3.4 4.3 9.3 NA ND 5.4 2.7 0 14.3

Staffing

Ward Analysis Quality Report - June 2013

Patient Experience: Stroke

F1 Parent

Surgery Medicine Women & Chi ldren

Clinical Quality Priorities: Summary

• Inpatient survey results remain good particularly in the new questions included in the surveys. There are fluctuations in the Friends and family score for individual areas and these seem to reflect changes in the balance between the number of patients scoring ‘very likely’ and ‘likely’ rather than a change in the number of detractors.

• The number of hospital acquired pressure ulcers reduced this month.

• Improvement was seen in the scores for the hydration audits with an overall score of 74% as compared to 59% in May

• The audit to check compliance with the identification and escalation of deteriorating patients has been completed for the first time across the Trust this month with a compliance of 94%

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Quality Priority: Ward Performance Issues

• Last month issues in relation to ward F9 were reported and it was reported that an action plan had been agreed by the Matron with the Ward Manager, covering falls, pressure ulcers, cleanliness, High Impact Interventions and drug errors. Daily checks of the environment have been carried out during June and an improvement has been reported, with a score of 92%. Falls have reduced, following a focus on this at handover and identification of patients at high risk on the ward white boards. Spot checks of VIP scores three times daily have been carried out and 2 nursing assistants with a Band 6 nurse have been tasked with improving response rates to the internal survey and generally improving patient experience.

• The number of falls on Ward F3 reduced following an unusually high number of falls last month. Vacancies and maternity leave continue to impact on staffing levels on the ward. Unfortunately there has been a delay in securing the two long term agency nurses reported last month, due to issues with the staff concerned, however, a replacement has been found for one nurse and another part time agency nurse has been identiifed both of whom start at the end of July. A post has also been offered to a student nurse who will qualify in September.

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.

Quality Priority: Infection Control

12

MRSA BacteraemiaThere were no hospital associated MRSA bacteraemia during June

C. DifficileThe Trust has had two C. difficile cases during June 2013.

Hand HygieneHand hygiene and dress code overall audit results were 100% this month against a target of 95%.

High Impact InterventionsAll results for these audits were above 90%. Failures in compliance relate to failure to record VIP scores for patients in relation to peripheral catheter care. Central line care audits show a low compliance on G4 due to only one patient being applicable for the audit and a missing care plan for the patient, and only 4 patients met the criteria for audit on ward F7. However, a letter has been sent out to all registered nurses on these wards identifying the issues and additional spot checks are being carried out this month.

MRSA screeningFigures for June were not available at the time of this report being completed

Quality Priority: Falls

Falls performance

There were 60 falls across the Trust during June;16 of these falls resulted in harm and 3 resulted in serious harm. The rate per 1,000 occupied bed days is 5.71 which has reduced compared to the last few months (6.0 per thousand bed days in May, 6.1 per thousand bed days in April, 6.00 per 1,000 bed days in March, 6.39 per 1,000 bed days in February and 6.1 per 1,000 bed days in January). The 3 serious harms were as follows:• A patient on ward F3 suffered a fractured femur. The patient was admitted following a fall at home and was therefore identified as at high risk. He had become bilaterally hard of hearing and in addition to verbal instructions not to get up on his own, this was also written down for him. However, he did not ask for assistance and was found on the floor. • A patient on ward G4 suffered a fractured femur following an unwitnessed fall. She needed assistance to mobilise but on this occasion decided to try to go to the toilet on her own.•A patient on ward G5 suffered a head injury after falling backwards. He has dementia and had a wanderguard in situ. A nursing assistant had been in the bay 5mins prior to the fall and the patient was asleep.RCAs are planned for each of these to identify any lessons to be learnt.

In relation to other falls:•G4 had 10 falls. One patient fell 3 times. This was a patient who had previously been independent, but was admitted due to right sided weakness and did not recognise her limitations. She was placed in a high visibility bay following the first fall. The majority of the remaining falls occurred in patients who had been advised to call for assistance prior to mobilising but tried to mobilise independently.•G5 had 8 falls in June. Two of these occurred in patients who were receiving assistance at the time of the fall, but in one case the patient was aggressive and refusing direct help and in the other, the nurse was in the toilet, wiping the seat at the patient’s request. Fewer falls occurred at night this month and this may be due in part to the placing of a table at the end of the ward at night where a nurse could be based when not attending directly to patients needs.•Wards G8 and F7 also had an unusually high number of falls in June. The only theme arising from falls in June is that a high proportion have occurred in patients who require some assistance to mobilise and have been told to call for assistance but failed to do so, either because they felt they could manage on their own or had dementia. In addition several fell when they had been checked a short while before the fall. The falls group meeting in July will consider any additional actions to further reduce falls. Action taken to identify patients at high risk of falls on the ward white boards as well as at handover is felt to have helped on ward F9.

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Quality Priority: Pressure Ulcers

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The performance target is to have no avoidable Grade 2, 3 or 4 pressure ulcers 2013-14

Grade 2 pressure ulcersThere were 2 grade 2 pressure ulcers this month, both were considered avoidable due to a lack of pressure relieving chair cushion in one and an insufficiently high level of pressure relieving mattress in the other. The Safety Thermometer action plan for the ward has been reviewed to ensure this issue is addressed.

Grade 3 and 4 pressure ulcersThere was one hospital associated grade 3 pressure ulcer this month. This occurred on ward F7 and was considered avoidable as heel protectors could have been used and had not been.

Two of the pressure ulcers this month occurred on patient’s heels and occurred in patients who were fairly independent. Staff have been reminded of the necessity to visually check all high risk patient’s pressure areas and not rely on patient feedback.

Quality Priority: Patient Safety

Hydration

Hydration audits were introduced in 2012/13 and examine whether patients who are identified as at risk of dehydration have fluid targets set, whether those targets are met and whether documentation is completed accurately to monitor the patient’s intake and output. As with the high impact intervention audits, 10 patients are surveyed each month and compliance is only considered to have been achieved for each patient if all elements of the audit are achieved.

In May it was reported that there was very low compliance (below 25%) on three wards and great variability between wards in compliance with this audit. Ward Managers were asked to check all fluid charts daily on the three wards where compliance was below 25% and the Matrons also carried out further spot checks. Following this action, this month, the compliance with the target improved considerably.

Fluid targets are normally set at 1500mls for patients with the option for medical staff to adjust the target for patients where this is not appropriate. In patients where the fluid target has not been met it is felt that this is frequently because the target has not been adjusted to take account of the individual patient rather than the patient not being offered fluids.

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New Quality Priorities: Patient Safety

Deteriorating Patient

A monthly audit of 10 patients per ward has been initiated to examine whether a full set of observations has been carried out on all patients, the MEWS score calculated correctly from this, that escalation has occurred as indicated by the score and whether the patient has been seen within 30 minutes of escalation. This is the first month that the audit has been completed on all wards. The areas of initial non compliance are mainly related to not totalling the score in some patients who would not have triggered escalation and delays in response to escalation of between 30 mins and 60mins.

Sepsis Six

Sepsis six is a set of actions to be taken when a patient presents with potential sepsis. Evidence shows that timely identification and treatment can have a significant impact on the patients chances of survival. The Patient Safety Implementation Group have identified that this is an area that would benefit from a focused improvement programme. One of the key targets is the provision of antibiotics within one hour of arrival in the A&E department and this aspect of sepsis six will be reported within the Trust dashboard. The details of data collection are currently being developed and it is expected that reporting to the Board will be able to start at the beginning of the second quarter of 2013/14 .

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Safety Thermometer Results

Current performance for harm-free care is 92.6%. National June performance is 92.8%.

The National ‘harm free’ care composite measure is defined as the proportion of patients without a pressure ulcer (ANY origin, category II-IV), harm from a fall in the last 72 hours, a urinary tract infection (in patients with a urethral urinary catheter) or new VTE treatment.

The data can be manipulated to just look at “new harm” (harm that occurred within our care) and with this new parameter, our Trust score is 98.98%. National June performance is 97%.

Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13

Harm Free 92.11 91.19 92.44 92.15 92.71 93.77 95.66 93.02 93.36 93.68 91.47 93.20 92.60

Pressure Ulcers – All 4.79 5.11 3.78 3.80 4.02 3.38 1.79 5.17 3.55 3.51 4.50 4.28 5.36

Pressure Ulcers - New 0.28 0.57 0.58 0.25 1.51 0.26 1.02 0.52 0.71 0.94 0.95 1.01 0.00

Falls with Harm 0.00 0.00 0.00 0.76 0.75 0.26 0.51 0.78 0.71 0.23 1.66 0.00 0.26

Catheters & UTIs 1.97 2.56 2.03 2.78 2.01 2.08 1.79 1.03 1.66 2.58 0.95 1.76 1.53

Catheters & New UTIs 0.00 0.28 0.29 0.25 0.25 0.00 0.26 0.26 0.47 0.23 0.24 0.00 0.51

New VTEs 1.41 1.70 2.03 1.01 0.50 0.78 0.26 0.26 0.71 0.47 1.42 0.76 0.26

All Harms 7.89 8.81 7.56 7.85 7.29 6.23 4.34 6.98 6.64 6.32 8.53 6.80 7.40

New Harms 1.69 2.56 2.91 2.28 3.02 1.04 2.04 1.81 2.61 1.87 4.27 1.76 1.02

Sample 355 352 344 395 398 385 392 387 422 427 422 397 392

Surveys 17 17 17 17 17 17 17 17 18 18 18 18 18

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Quality Priority: Patient Experience – Achievement of 85% satisfaction

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‘Achieve at least 85% satisfaction in internal patient satisfaction surveys’ is a Quality Priority for the Trust.

The overall score for the inpatient survey was 91% and satisfaction with call bell response times improved slightly. The report from the Patients Association call bell project is expected at the end of July.

Overall satisfaction for the other internal surveys (OPD, short stay, A&E, Maternity, Children and stroke) have remained stable. Key issues arising from these surveys are as follows:

• There was an improvement in the percentage of out patients who identified that they had been informed of any delays in being seen.

• In maternity there was a fall in the perception of cleanliness of the postnatal ward. This is being investigated.

• All scores for the survey for ward F1 (paediatrics) were above 90% but the number of questionnaires completed was very low.

Quality Priority: Patient Experience – recommend the service

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‘Patients would recommend the service to their family and friends’ is a Quality Priority for the Trust

The Trust achieved a net promoter score of 86 for inpatients during June.

The score for A&E was 54%, a drop from 71 in May.

There were no comments to explain the fall in score for A&E and further analysis showed that it was due to a larger number of patients scoring likely rather than an increase in detractors (those scoring ‘neither likely or unlikely, unlikely or very unlikely). Informally, our Patient Feedback Coordinator reports that waiting times is the main issue for patients who are less positive about the service.

Ward F3 had a score of 57 this month. There were only seven comments related to this• 2 stated that they would not want anyone to be in hospital, • one stated ‘past experience’• One noise at night• One that distressed patients should be nursed in a side room• One that patients wait too long to be seen• One that hospitals are not pleasant places but no improvement needed.

Score (previous scores)

Promoter Extremely likely (9 or 10)

Passive Likely (7 or 8)

Detractor Neither /nor (5 or 6)

Unlikely (3 or 4)

Very unlikely (1 or 2)

TOTAL

Quality Priority: Patient Experience

Improving support to family carersA group has been set up to develop and implement an action plan to improve support to family carers.

This will report to the Patient Experience Committee. The main actions that have been implemented are as follows:

• An environmental audit of access to areas within the Trust from the perspective of a carer has been carried out

• The group have developed information leaflets for both staff and family carers, both of which are being finalised currently.

• The initial nursing assessment documentation has been adjusted to allow identification of a patient’s main carer

• Plans are in place to launch a family carers initiative in October. This will include guidance to staff, the provision of a Family Carers badge to identify family carers who wish to be involved in the care of the patient whilst in hospital. It will enable increased visiting, provision of information on a regular basis to the carer and information about additional sources of support.

In parallel with this, Suffolk County Council have tendered for the provision of a Carer Support role based at the WSFT. This has been awarded to the Papworth Trust and an initial meeting has been held to discuss implementation of the role within the Trust.

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Quality Priorities: Car parking

The Trust identified a review of car parking charges and an increase in the number of disabled parking bays as a priority for this year

The Trust entered into a new contractual arrangement with effect from 1st July 2013. OCS (Legion Parking) is now managing the car parks on behalf of the Trust

Discussions have already taken place with OCS regarding a revised pricing structure and method of retrieving income from staff, patients and visitors. These discussions have taken account of the many comments that have been received from users of the site over the last seven years.

The discussions have acknowledged that it is essential to undertake a comprehensive financial analysis of anticipated income whilst balancing the needs of patients/visitors who require concessionary parking. This is in addition to ensuring any charging system for staff is equitable as well as simple to administer.

It is anticipated that the Trust’s income will increase automatically with 24/7 cover but the information available to date cannot be conclusive as to the total income forecast if changes are introduced to the existing tariffs.

Only limited adjustments have been made to the current charging arrangements with effect from 1st July 2013. OCS and the Trust will review closely the income streams over a period of six months, taking account of the many comments received from users of the site.

Review of income over a six months period to facilitate introduction of new tariff structure, to take account of users’ views. This will include closer scrutinisation of concessionary parking, the feasibility of a one hour tariff and charging disabled drivers.

This review will also take advice from Trust Governors, who have valuable knowledge from close contact with users of the site, and are willing to be involved in discussions on car parking issues.

• •

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Quality Priorities: Effectiveness

Reduce 5 High Impact Medication Errors by 50%High Impact medication errors identified by the Drugs and Therapeutics Committee to focus on this year are as follows:• Maladministration of Insulin. Maladministration in this instance refers to when a health professional:

uses any abbreviation for the words ‘unit’ or ‘units’ when prescribing insulin in writing, issues an unclear or misinterpreted written or verbal instruction to a colleague fails to use a specific insulin administration device e.g.an insulin syringe or insulin pen to draw up or administer insulin fails to give insulin when correctly prescribed

• Unsafe management of warfarin including unsatisfactory initiation or anticoagulation with an INR>5 • Prescription of any penicillin containing antibiotic to patients who are penicillin allergic. e.g. piperacillin/tazobactam (Tazocin) or co-

amoxiclav (Augmentin). • Prescription of trimethoprim to patients on methotrexate • Failure to check drug level of gentamicin at 12 hours after first dose administered for a course of treatment and/or incorrect timing of

second or subsequent doses.• Prescription of any medicine to which the patient has a recorded serious sensitivity, or a true allergy• Prescribing of duplicate medication for example:

Two NSAID’s (Ibuprofen and diclofenac prescribed for the same patient or a single agent prescribed regularly and PRN both at maximum doses),

Duplicate prescribing of a product by both brand name and generic name (e.g. Epilim and sodium valproate), Two paracetamol containing preparations both at maximum doses (e.g. Paractamol 1g QDS regularly plus co-codamol 8/500 two

tablets QDS PRN)

Information about these areas of focus have been sent to all wards and medical staff. Datix has been set up to enable identification of these errors and the Drugs and Therapeutics Committee are reviewing all incidents on a monthly basis to identify learning and actions. The data for this indicator takes some time to analyse and therefore reporting of incidents will be a month behind other indicators. May 2013 incidents are now available and will provide the baseline for the year with 8 High Impact errors. 5 of the errors occurred with insulin prescriptions, one with duplicate medication (paracetomol with co-codamol) and two administrations of medications in patients with an allergy.

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Local Priorities: Summary and exception report (Red indicators)

Incidents (Amber / Green) with investigation overdue (over 12 days)

This indicator remains red.

Late by Directorate Red (RAG) 10th June 12th July change

Clinical Support >15 9 11 Estates and Facilities >10 20 17 Medical >70 107 104 Surgical >40 58 79

Women & Children’s Health >15 34 22 Other No target 6 6

TOTAL >150 234 236

SIRI notification / final reports beyond timeframe.

There were two SIRIs reported in June which were notified to the CCG beyond the two working day timeframe and five SIRI final reports due in June which were sent to the CCG outside of the 45 working day timeframe. A remedial action plan has been agreed with the CCG which sets out a trajectory for submitting all final reports within timeframes from June onwards. Currently the trajectory is being exceeded and it is expected to further improve in July. Since the agreement of the remedial action plan all initial notifications to STEIS have met the 2 working day target timeframe.

May-13 Jun-13 Jul-13 Aug-13 Sep-13

SLA Standard 0 0 0 0 0

RAP Trajectory NA 10 7 2 0

Actual Performance 17 7

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Local Priorities - Governance Dashboard

Indicator Performance target R A G Jun13 Commentary

Timely completion of incident investigations and actions

Outstanding RCAs (non SIRI) which are more than 45 days after incident reported

>1 1 0 0

RCA Actions beyond deadline for completion >=5 1-4 0 3 Meetings in place with relevant managers

Incidents (Amber / Green) with investigation overdue (over 12 days)

>150 50-150 <50 236

Timely reporting of SIRIs

SIRI notification beyond timeframe in month >1 1 0 2 4/6 met new target timescales

SIRI final reports beyond timeframe in month >1 1 0 5 2/7 met new target timescales

Risk assessment Active risk assessments in date <75% 75 – 94% >=95% 97%

Outstanding actions in date for Red / Amber entries on Datix risk register

<75% 75 – 94% >=95% 96%

Clinical Audit Trust participation in relevant ongoing National audits (reported by Quarter)

<75% 75 – 89% >=90% 100%

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Local Priorities - Governance Dashboard (cont.)

Indicator Performance target R A G Jun13 Commentary

NICE TA (Technology appraisal) business case beyond agreed deadline timeframe

>9 4 - 9 0 - 3 1

These outstanding Five interventional procedures and Six Clinical Guidelines are outstanding baselines assessment and require targeted follow up.

IPG (Interventional procedure guideline) baseline assessments beyond agreed deadline timeframe

>9 4 - 9 0 - 3 5

CG (Clinical guideline) baseline assessments beyond agreed deadline timeframe

>9 4 - 9 0 - 3 6

Complaints Response within 25 days or negotiated timescale with the complainant

<75% 75 – 89% >=90% 92%

Number of second letters received >=5 1-4 0 3 Two of these complainants have been offered local resolution meetings to try and address their on going concerns.

Health Service Referrals accepted by Ombudsman >=2 1 0 0

Red complaints actions beyond deadline for completion

>=5 1-4 0 0

Number of PALS contacts becoming formal complaints

>=10 6 - 9 <=5 1

Compliments Compliments received centrally No RAG rating 62

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Patient Safety Incidents reported

The rate of PSIs is a nationally mandated item for inclusion in the 2012/13 Quality Accounts. The NRLS target lines shows how many patient safety incidents WSH would have to report to fall into the median / upper and lower quartiles for small acute trusts reporting per 100 admissions. This was rebased in March to take into account the new dataset from the Apr12 - Sept 12 NRLS report showed a fall in the peer group median but upper and lower quartiles remained similar to previous reports.

There were 446 incidents reported in June including 349 patient safety incidents (PSIs). The reporting rate in June fell below the upper quartile but above the median for peer group. The number of harm incidents in June fell to below the peer group average level.

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Patient Safety Incidents (Severe harm or death)

The percentage of PSIs resulting in severe harm or death is a nationally mandated item for inclusion in the Quality Accounts. The peer group average (serious PSIs as a percentage of total PSIs) has been rebased to 0.9% from the NPSA Apr ’12 – Sept ‘12 report and sits above the Trust’s average. The WSH data is plotted as a line which shows the rolling average over a 12 month period. The number of confirmed serious PSIs are plotted as a column on the secondary axis.

Three historic incidents were identified through: TARN audit (Aug-11), Complaints (Mar-13) and CQUIN VTE review (Apr-13). These were reported retrospectively in July and therefore remain unconfirmed on the graph above.

In May there were seven ‘Red’ patient safety incidents: Unexpected stroke, Inquest, Insulin medication, MRSA bacteraemia, Delay in diagnosis, Penicillin allergy, and Deteriorating patient all awaiting confirmation through RCA.

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Local Priorities: Complaints

The Trust continued to receive a high number of complaints in June compared to 2012/13 although the difference is less than in the preceding months.

Complaint response within agreed timescale with the complainant: 92% of responses due in June were responded to within the agreed timescale (target 90%).

Of the 29 complaints received in June, the breakdown by Primary Directorate is as follows: Medical (17), Surgical (6), Clinical Support (4), Facilities (0), Other (0) and Women & Child Health (2).

Trust-wide the most common problem areas are as follows: Admissions, Discharge and Transfer Arrangements 8All Aspects of Clinical Treatment 7Appointments, Delay / Cancellation (outpatient) 5Attitude of Staff 7Communication / Information to Patients (written and oral) 17

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Local Priorities: PALS (Patient Advice & Liaison Service)

In June 2013 there were 77recorded PALS contacts. This number denotes initial contacts and not the number of actual communications between the patient/visitor which can, in some particular cases, be multiple.

A breakdown of contacts by Directorate from April’12 to June‘13 is given in the chart and a synopsis of enquiries received for the same period is given below. Total for each month is shown as a line on a second axis.

Trust-wide the most common five reasons for contacts are shown below.

Information/Advice request 24 All aspects of clinical treatment 13 Communication/information to patients (written/oral)

12

Other (including other organisations) 9 Appointments/delays 5

The most common reasons for contacts have changed slightly since the last report and it is pleasing to note that the number relating to staff attitude has reduced and is not featured in the top five. However, the PALS Manager frequently has to personally deal with the agitation and aggression of the people who contact her.

There are no particular themes that the PALS Manager has identified this month and the contacts with PALS during June have covered all services with an even distribution across most wards and departments,

It is evident that the PALS Manager, in addition to assisting with genuine concerns from patients and relatives, frequently signposts enquirers to other services.

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Local Priorities – Workforce Performance

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Performance Indicator ThresholdDirect

Financial Penalty

12 Month YTD Comments Lead Exec

WorkforceSickness absence rate <4.39% (National Average) NO 3.99% Jan BloomfieldTurnover <14.2% (National Average) NO 7.14% Jan Bloomfield

Reviews Grievance/Banding reviews NO 1One Employment Tribunal and One Grievance Jan Bloomfield

Recruitment Timescales Average number of weeks to recruit = 7 NO 6.7

Jan BloomfieldCRB Disclosures existing staff To complete 95% of required CRB checks NO 99.00% Jan Bloomfield

All Staff to have an appraisal 90% of staff have had an appraisal within the previous 12 months NO 86.50%

Jan Bloomfield

Mandatory Training compliance (reported Quarterly)

Jan Bloomfield

CQUIN: Summary & Exceptions report

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Good progress has been made with the CQUIN targets for Q1 with all schemes being reported to the CCG as being met in early July.

The one previously reported ‘red’ scheme, that relates to the closing of EAU beds at night, has been altered as a CQUIN; we await the full details of this. Progress on Q2 targets is in line with expectations as this stage of the quarter.

A3 printout of CQUIN

32-33

Monitor Compliance Framework

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Monitor Compliance Framework Performance Indicator Threshold Month QTD Weighting Lead ExecAccess: Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted 90% 96.13% 98.31% 1.0 Andy GrahamMaximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted 95% 100.00% 100.00% 1.0 Andy Graham

Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway 92% 100.00% 99.85% 1.0 Andy Graham

A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge 95% 95.42% 92.57% 1.0 Andy GrahamAll cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer 85% 91.00% 91.47%

1.0Andy Graham

All cancers: 62-day wait for first treatment (5) from: NHS Cancer Screening Service referral 90% 100.00% 96.97% Andy GrahamAll cancers: 31-day wait for second or subsequent treatment, comprising: Surgery 94% 100.00% 100.00%

1.0Andy Graham

All cancers: 31-day wait for second or subsequent treatment, comprising: anti-cancer drug treatments 98% 100.00% 100.00% Andy Graham

All cancers: 31-day wait for second or subsequent treatment, comprising: radiotherapy - Not applicable to WSFT

All cancers: 31-day wait from diagnosis to first treatment 96% 100.00% 99.67% 0.5 Andy Graham

Cancer: two week wait from referral to date first seen (8), comprising:all urgent referrals (cancer suspected) 93% 94.70% 94.40%

0.5Andy Graham

Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer not initially suspected) 93% 94.50% 98.17% Andy Graham

Outcomes: Clostridium (C.) difficile - meeting the C.difficile objective - MONTH 2 2

1.0

Nichole Day

Clostridium (C.) difficile - meeting the C.difficile objective - QUARTER Q1 = 3, Q2 = 4, Q3 = 6, Q4 = 6

8 Nichole Day

Clostridium (C.) difficile - meeting the C.difficile objective - ANNUALLY 19 8 Nichole DayMethicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - MONTH 0 0

1.0

Nichole DayMethicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - QUARTER 0 1 Nichole Day

Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - ANNUALLY 0 1 Nichole Day

Certification against compliance with requirements regarding access to healthcare for people with a learning disability N/A - - 0.5 Nichole Day

Contract Priorities Dashboard

Contract Priorities with financial penalty

Performance Indicator Threshold In Month

PerformanceYTD Comments Lead Exec

A&E

A&E - Threshold for admission via A&Ei) if the monthly ratio is above the corresponding 2011/12 monthly ratio for two month in a six month periodii) if year end is greater than 27%

YES 24.59% 25.43% Andy Graham

A&E - Timeliness Indicators

To satisfy at least one of the following Timeliness Indicators:1. Time to initial assessment (95th percentile) below 15 minutes2. Time to treatment in department (median) below 60 minutes No ONE MET - Andy Graham

Stroke

Stroke -Proportion of Patients admitted to an acute stroke unit within 4 hours of hospital arrival

90% YES 92.00% 81.67% Andy Graham

Proportion of patients in Atrial Fibrillation, presenting with stroke and where clinically indicated will receive anti-co-agulation.

60% YES 100.00% 82.33% Andy Graham

Stroke - % of Stroke patients with access to brain scan within 24 hours 100% YES 100.00% 96.67% Andy Graham

Stroke - Proportion of Stroke Patients and carers with a joint health and social care plan on discharge

85% YES 91.00% 81.33% Andy Graham

Stroke - Patients (as per NICE guidance) with suspected stroke to have access to an urgent brain scan in the next slot within usual working hours or less than 60 minutes out of hours as defined from time to time by the ASHN

100% of stroke patients eligible for a brain scan scanned within one hour


>80% treated on a stroke unit >90% of their stay 80% YES 95.00% 87.67% Andy Graham

>60% of people who have a TIA and are high risk (ABCD 2 score 4 or more) are scanned and treated within 24 hours of 1st contact but not admitted

60% YES 85.00% 72.33% Andy Graham

Stroke - 65% of patients with low risk TIA have access to MRI or carotid scan within 7 days (seen, investigated and treated)

65% YES 78.00% 71.00% Andy Graham

% of Patients eligible for Thrombolysis, Thrombolysed within 4.5 hours100% of all eligible patients YES 100.00% 100.00% Andy Graham

Discharge Summaries

Discharge Summaries - Outpatients 95% sent to GP's within 3 days YES 84.23% 83.74% Dermot O'Riordan

Discharge Summaries - A&E95% of A&E Discharge Summaries to be sent to GPs within one working day

YES 97.97% 97.15% Dermot O'Riordan

Discharge Summaries - Inpatients 95% sent to GP's within 1 day YES 83.50% 85.24% Dermot O'Riordan

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Contract Priorities Dashboard Cont.

Choose & Book

Provider failure to ensure that “sufficient appointment slots” are made available on the Choose and Book system

A maximum of 3% slots unavailable (£50 per appointment over 5%. Threshold applied over monthly figures)

YES 3.00% -The Threshold applied to fines is 5%

Andy Graham

All 2 Week Wait services delivered by the Provider shall be available via Choose & Book (subject to any exclusions approved by NHS East of England)

100% YES 100.00% - Andy Graham

Cancelled Operations

Provider cancellation of Elective Care operation for non-clinical reasons either before or after Patient admission

i) 1% of all elective procedures NO 1.54% 1.05% Andy Graham

Patients offered date within 28 days of cancelled operation 100% NO 100.00% 100.00% Andy GrahamMaternity

Access to Maternity services (VSB06):-

90% of women who have seen a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks and choices by 12 completed weeks of pregnancy.

NO 93.57% 95.80%

Nichole DayMaintain maternity 1:30 ratio 1:30 NO 01:29 01:29 Nichole DayPledge 1.4: 1:1 care in established labour 1:1 NO 100.00% 100.00% Nichole DayBreastfeeding initiation rates. 80% NO 79.25% 78.93% Nichole DayReduction in the proportion of births that are undertaken as caesarean sections. Suffolk PCT Only

1% reduction in proportion compared to 2011/12 baseline - 22.70%

YES 19.08% 19.62% Nichole Day

Other contract / National targets

Mixed Sex Accomodation breaches 0 Breaches YES 0 1 Andy Graham

Consultant to consultant referralCommisioner to audit if concern about levels of consultant referrals


Current ratios of OP procedure to day case for agreed list of procedures to be maintained or improved, i.e. the Commissioner will not fund a higher level of admitted patients for such procedures, unless clinical reasons can be demonstrated for increase in admissions.

Maintain or improve the mix as specified = 90.17% YES 88.06% 87.88% Andy Graham

MRSA - emergency screeningAll emergency patients admissions are to be screend for MRSA within 24 hours of admission

NO 89.94% 89.82% Nichole Day

Rapid access - chest pain clinic100% of patients should have a maximum wait of two weeks

NO 100.00% 100.00% Andy Graham

New to Follow upThresholds set at each speciality - overall Trust Threshold is 1.9

YES 1.89 1.95 Andy Graham

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Documents

Trust Quality and Performance Report July 2013. Contents Slide numbers Executive Summary 2 - 4 Clinical Quality Priorities inc Ward Dashboard5 - 22 Local