Transcript Trust Quality and Performance Report 28 June 2013

Trust Quality and Performance Report
June 2013
1
Contents
Slide numbers
Executive Summary
3-6
Clinical Quality Priorities inc Ward Dashboard
6 - 27
Local Priorities
23 - 30
CQUIN
31 - 39
Monitor Compliance
Contract Priorities
40
41-42
2
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.
The pattern of increased A&E activity continued in May with 2.71% more
attendances (4.32% YTD) compared with the same period in 2012/13. It
is also notable that elective activity increased by 9.15% whilst nonelective admissions reduced by 4.3% on the previous year.
3
Performance Indicator
Clostridium (C.) difficile - meeting the C. difficile objective - MONTH
Threshold
2
May
1
Lead Exec
Nichole Day
May
Lead Exec
1
Nichole Day
May
Lead Exec
93.49%
Andy Graham
Whilst there was 1 case of C Diff in the month against a threshold of 2, the Trust had 6 cases
at the end of May against a quarter target of 3
Performance Indicator
Threshold
MRSA
0
There was also 1 MRSA bacteraemia. This is covered on page 10 of the quality report.
Performance Indicator
A&E: maximum waiting time of four hours from arrival to
admission/transfer/discharge
Threshold
95%
A&E performance was 93.49% against the 95% target. At the time of writing the Trust is on track to achieve 95% for
June in line with the objectives agreed with Monitor and WSCCG. It is anticipated that the ECIST programme will
continue to impact incrementally on this indicator.
4
6 of the 9 stroke targets have been achieved. The three that were not achieved are as follows
Performance Indicator
Threshold
Stroke - Patients (as per NICE guidance) with suspected stroke to have
100% of stroke patients
access to an urgent brain scan in the next slot within usual working hours or
eligible for a brain scan
less than 60 minutes out of hours as defined from time to time by the
scanned within one hour
ASHN
May
Lead Exec
79.00%
Andy Graham
May
Lead Exec
Performance Indicator
Threshold
Stroke -Proportion of Patients admitted to an acute stroke unit within 4
hours of hospital arrival
90%
78.00%
Andy Graham
Performance Indicator
Stroke - % of Stroke patients with access to brain scan within 24 hours
Threshold
100%
May
98.00%
Lead Exec
Andy Graham
5
The following measures are being implemented to positively impact on stroke performance
• 24 hour specialised stroke team anticipated to be in place by end of September.
• Improvements in emergency care. Anticipated completion of ECIST programme by end of September.
• Rapid assessment of patients arriving by emergency ambulance and ‘FAST’ assessment of all patients attending
A&E is being developed.
• Intensive performance management to be in place from July 2013.
Performance Indicator
Threshold
Cancer: two week wait from referral to date first seen (8), comprising:
all urgent referrals (cancer suspected)
93%
May
Lead Exec
92.36%
Andy Graham
The Trust achieved 92.36% against the 93% target. The patients not seen within 2 weeks were all patient not available
for some or all of the 2 week period and some patients were not aware of the urgency of this appointment. This has
been discussed with WSCCG and action is in place including a revised referral form advising GP’s to inform the patient
of the urgency of the appointment and indicating date the patient was not available. At the time of writing the Trust is on
track to achieve this measure for June and for the quarter.
6
Clinical Quality Priorities
7
8
9
10
Clinical Quality Priorities: Summary
•
New questions added to the internal patient survey scored very highly by patients including
patients’ satisfaction with the provision of compassionate care.
•
Response rates for the Friends and Family test have been maintained.
•
There was only 1 case of C. difficile this month, however, there was one MRSA bacteraemia.
•
Actions taken in relation to staffing challenges reported last month:
– Utilisation and scrutinisation of electronic rostering data within the Directorate Performance
meetings
– Control mechanism for signing additional duties put into place
– An external review of ward staffing
– Further recruitment plan including the introduction of a staff pool
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Quality Priority: Ward Performance Issues
•
•
•
•
•
Although on G4 there has been a decrease in performance in some of the KPIs this month, the
ward does not give us cause for concern. A number of unrelated events have coincided to flag
some indicators. However, the two complaints received in May relate to the attitude of one member
of staff
and this is being addressed by the ward manager with the nurse concerned.
.
A number of different issues have been identified in relation to F9 over the last two months. As a
result an action plan has been agreed by the Matron with the Ward Manager. This covers falls,
pressure ulcers, cleanliness, High Impact Interventions and drug errors. For example, actions
being taken relating to falls are given in the falls section of this report. In relation to environmental/
cleanliness issues, identified areas of suboptimal practice have been addressed and subsequent
audits have shown improved performance. The Matron is also carrying out formal quality
assurance rounds on a weekly basis to focus on all areas of the action plan.
F6 appears to flag on the dashboard but the drug errors identified are not major errors (and
practice issues have been highlighted to staff). The recommender question score is not reflective of
the scores for other questions or the comments on the surveys. It is therefore felt that scores for
next month will revert to normal.
Ward F3 had an unusually high number of falls, two pressure ulcers and a decrease in some of the
other KPIs in May. There are currently 4 WTE vacancies, and there was an increase in sickness
levels in May, which coincided with an increase in patient dependency. Two long term agency
nurses have been secured to boost staffing levels until recruitment has taken place.
Feedback in respect of G9 is provided in the patient experience section of this report.
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Quality Priority: Infection Control
MRSA Bacteraemia
There was one hospital associated MRSA bacteraemia during May on Ward F10. The RCA identified deficiencies
in the screening processes and an action plan has been agreed.
C. Difficile
The Trust has had one C. difficile case during May 2013. This originated in the critical care unit but the specimen
was sent from F9; this does not result in a period of increased incidence for F9. The RCA is awaited at the time of
writing this report. This brings the total number of cases to six to date in 2013/14.
Hand Hygiene
Hand hygiene and dress code overall audit results were 100% this month against a target of 95%.
High Impact Interventions
All results for these audits were above 90%. Failures in compliance relate to: documentation of care and one
failure to record VIP scores on the ward and in theatre, and a failure to wear gloves when undertaking
cannulation. Some practitioners still find it easier to site a cannula without gloves when a patient has veins that
are difficult to palpate.
MRSA screening
These are being reported for the first time this month and are split into elective admissions and emergency
admissions. The compliance for emergency admissions is 90% and the compliance for elective admissions is
79.6% for May 2013. The deficit in elective screening has been investigated and it appears that this is related to
the Oncology Day Unit and has been escalated to the service manager for investigation. A number of temporary
staff have been working in the unit recently and therefore screening procedures are being highlighted with them.
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Quality Priority: Falls
Falls performance
There were 63 falls across the Trust during May;16 of these falls resulted in harm but not serious harm. The rate per 1,000
occupied bed days is 6.0, which is approximately the same as for the last four months (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).
• Ward F3 had 12 falls, an unusually high number for the ward; 2 patients fell twice despite increased frequency of
observations (every 15 minutes and a Wanderguard being used). The majority of the falls occurred when the ward were
at least one nurse below core level on the shift. This ward is highlighted in the ward summary section of this report
• G9 had 10 falls, 3 of which occurred in patients who were independent and one occurred whilst the patient was walking
with a frame and accompanied by a member of staff (patient’s legs suddenly gave way and nurse could not prevent the
fall); 3 falls occurred in patients with confusion/dementia and at high risk of falls and staffing levels on occasions did not
enable the level of supervision required.
• G5 had 7 falls in May, most of which occurred at night. One of the falls occurred in a patient who had been assessed by
the OT as safe to mobilise independently. The Matron has asked the Ward Manager to look at the distribution of staff
across the 24hrs and increase the number of staff on duty at night. Other actions include placing a table in the ward
corridor at night to increase staff observation of patients and a focus on falls at each handover with discussion of fall
free days.
• Falls on Ward F9 reduced compared to last month but remain higher than normal. An action plan has been put into
place and this includes actions to reduce falls, including identifying a Band 6 Sister as the falls champion, improving risk
assessment, identifying all patients at high risk of falls at Board Rounds and ensuring compliance with intentional
rounding. Further analysis is provided in the ward performance section of this report.
In addition to the Trust falls action plan, wards with high numbers of falls have been asked to identify individual actions
pertinent to their area.
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Quality Priority: Pressure Ulcers
The performance target is to have no avoidable Grade 2, 3 or 4 pressure ulcers 2013-14
Grade 2 pressure ulcers
There were 10 grade 2 pressure ulcers this month; two were considered to be avoidable:
• A pressure ulcer developed in a patient on critical care on the patient’s toe. It was classified as avoidable as there
was insufficient evidence that the TED stockings had been removed and the skin in this area checked each day.
• A patient developed a pressure ulcer on the back of his ankle. The patient was tall and his ankle rested on the edge
of the mattress.
The unavoidable pressure ulcers mostly occurred in patients who refused pressure relieving equipment, despite being
advised that it was necessary, or all care had been put into place; but patients were extremely poorly.
Grade 3 and 4 pressure ulcers
There were no hospital associated grade 3 or 4 pressure ulcers this month.
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Quality Priority: Nutrition and Hydration
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.
Over 2012/13 there has been considerable improvement in the scores for these audits, however, there is
still variability between wards and month-on-month. A drop in compliance was seen in May due to very low
compliance (below 25%) on three wards. Further examination identified that the failures in compliance
were mainly related to failure to total intake and output daily and failure to transfer the totals to the
observation chart. There were a few instances where fluid targets had not been set by the medical staff.
Fluid targets were met in approximately 70% of patients on the wards where documentation was poor.
Ward Managers have been asked to check all fluid charts daily on the three wards where compliance was
below 25% and the Matrons are also carrying out further checks. Initial indications are that the results for
May should have improved.
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Safety thermometer results
Current performance for harm-free
care is 93.2%. National May
performance is 92.4%.
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 98.24%. National May
performance is 96.8%
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Quality Priority: Patient Experience – Achievement of 85% satisfaction
‘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% indicating a high level of satisfaction with most of the
areas covered in the survey. The internal survey questions were reviewed in the context of the feedback from
the Trust membership, the national survey results and the Trust priorities and some changes made which took
effect from 1 May 2013.
The three new questions added this month all scored 99%. These are:
• Were staff caring and compassionate in their approach?
• Were you treated with dignity and respect?
• Did you get enough help with your meals?
Overall satisfaction for the other internal surveys (OPD, short stay, A&E, Maternity, Children and stroke) have
remained stable.
Patient story
A patient story was discussed in May relating to an adverse experience on Ward G9 (Winter escalation ward).
The following actions have been agreed following this story:
• Aim to close the ward at the earliest opportunity
• Review of processes to escalate and discuss complaints.
• Enhance performance management of patient experience issues and manage action plans.
• Matrons undertaking ward rounds at visiting time to seek feedback on current inpatient stay.
• Deputy Chief Nurse and Chief Nurse to accompany Matrons on ward rounds.
• Progress hot line for staff to report issues of concern relating to patient care. Any issues logged will be
addressed by the Duty Manager and any further escalation agreed.
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Quality Priority: Patient Experience – recommend the service
‘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 85 for inpatients during May with a 36% response rate.
The score for A&E was 71 with a 15% response rate.
Comments from the inpatient surveys in relation to the score given included:
• 4 comments related to perception that there were not enough staff/busyness of ward eg staff lovely but
they can’t be everywhere at once …some patients need their constant care
• 2 comments regarding delays in the discharge process
• Long wait for scan then long wait for results
• Numerous ward moves
There were only 5 comments regarding the score for A&E; 4 related to long waiting times and the other
said not from this area.
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
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New Quality Priorities
Deteriorating Patient
Early identification of any deterioration in a patient’s condition is vital to ensure optimal outcomes for
the patient and can impact on mortality rates. The Trust has implemented an early warning score
(MEWS) which is calculated with every set of vital sign observations to aid identification of
deterioration and ensure objective assessment and escalation of a patient’s condition where
necessary. Recent RCAs carried out on patients who have had a cardiac arrest outside the critical
care unit, have suggested that delays in escalation or response to escalation have occurred in a small
number of cases. Therefore a decision has been made to increase the monitoring of the use of the
MEWS and resulting escalation through a monthly audit by ward managers. The audits commenced in
May on some wards and will be carried out on all wards in June. The results of the audits will be
reported monthly on the Ward Dashboard from July 2013.
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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Quality Priority: Mortality
Hospital Mortality Rates (Relative Risk), Summary Hospital Mortality Indicator (SHMI) and Crude Mortality Rates
04/06/2013
Report as at:
Dr Foster re-aligned their benchmark position in October 2011.
N at io nal R at e
f r o m last
r ep o r t ing p er io d
100
86.2
90
81.6
0.68
Rolling 12 Month HSMR-All Admissions
SMR Stroke (Acute Cerebrovascular Disease)
SMR - Heart Attack (AMI)
SMR - FNOF
Mortality from Low Risk Conditions
Jan 11 - Feb 11 - Mar-11 - Apr-11 Dec 11 Jan 12 Feb 12 Mar 12
81.7
73.6
80.5
77.4
87
86
83.5
86
83.5
85.9
82.4
88.2
82.6
93.9
80.4
87.7
81.1
89.9
81.4
86.8
81.1
85.0
80.6
87.6
61.4
46
49.1
49.7
51.4
51.4
45.7
53.4
59.4
70.3
75.8
80.9
74.9
69.5
0.61
67.5
0.56
69.7
0.56
78.3
0.52
75.2
0.57
76.5
0.52
75.8
0.41
66
0.51
66.2
0.41
55.3
0.41
62.6
0.41
72.7
0.47
71.2
0.47
Jun-12
Jul-12
100
73
78.5
67.6
78.3
69.6
82.9
77.3
47.5
38
41.5
82.5
0.65
79.2
0.65
68.3
0.6
82.6
65.5
Feb-12 Mar-12 Apr-12 May-12
Crude Mortality
82
78
75
71
May-11 - June-11 - July-11 - Aug-11 - Sep-11 - Oct-11 - Nov-11 - Dec-11 - Jan 12 - Feb 12 - Mar 12 - Apr 12 April 12 May 12 June 12 July 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13
Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13
72
54
76
80
65
80
92
89
90
85
Crude Mortality for WSH
Rolling 12 Month HSMR-All Admissions
120
88
86
100
84
80
82
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
Apr 12 - Mar 13
Mar 12 - Feb 13
Feb 12 - Jan 13
Jan 12 - Dec 12
Dec-11 - Nov 12
Nov-11 - Oct 12
Oct-11 - Sep 12
Sep-11 - Aug 12
Aug-11 - July 12
July-11 - June 12
June-11 -May 12
May-11 -April 12
Apr-11 - Mar 12
Mar-11 - Feb 12
Jan 11 - Dec 11
Feb 11 - Jan 12
0
72
May-12
20
74
Apr-12
40
76
Mar-12
78
Feb-12
60
80
21
0
10
Apr 12 - Mar 13
Mar 12 - Feb 13
10
10
0
0
Sep-11 - Aug 12
Aug-11 - July 12
July-11 - June
12
June-11 -May
12
May-11 -April 12
Apr-11 - Mar 12
Mar-11 - Feb 12
Feb 11 - Jan 12
Jan 11 - Dec 11
Apr 12 - Mar 13
Mar 12 - Feb 13
Feb 12 - Jan 13
Jan 12 - Dec 12
Dec-11 - Nov 12
20
Nov-11 - Oct 12
30
Oct-11 - Sep 12
40
Sep-11 - Aug 12
50
Aug-11 - July 12
50
July-11 - June 12
SMR Stroke (Acute Cerebrovascular Disease)
June-11 -May 12
60
60
May-11 -April 12
70
70
Apr-11 - Mar 12
80
80
Mar-11 - Feb 12
90
Feb 11 - Jan 12
100
Jan 11 - Dec 11
Apr 12 - Mar 13
Mar 12 - Feb 13
Feb 12 - Jan 13
20
Feb 12 - Jan 13
30
Jan 12 - Dec 12
40
Jan 12 - Dec 12
50
Dec-11 - Nov 12
60
Dec-11 - Nov 12
70
Nov-11 - Oct 12
80
Nov-11 - Oct 12
SMR - FNOF
Oct-11 - Sep 12
90
Oct-11 - Sep 12
Sep-11 - Aug 12
Aug-11 - July 12
July-11 - June
12
June-11 -May
12
May-11 -April 12
Apr-11 - Mar 12
Mar-11 - Feb 12
Feb 11 - Jan 12
Jan 11 - Dec 11
Quality Priority: Mortality cont
90
SMR - Heart Attack (AMI)
40
30
20
22
Local Priorities: Summary and exception report (Red indicators)
RCA Actions beyond deadline for completion
The Datix system now has an automated process for follow up of overdue actions on a fortnightly basis.
Incidents (Amber / Green) with investigation overdue (over 12 days)
~ 100 incidents were closed off centrally to achieve the 31st May external deadline for NRLS submission. This has meant that the total
number overdue has dropped, however it has not addressed the underlying reason why some areas are not closing incidents off in a timely
manner. It has been agreed that any ‘problem areas’ would be escalated directly to the relevant GM to follow up and that areas with low
numbers of staff undertaking incidents would be encouraged to increase the pool of staff able to undertake this role.
Late by Directorate
Red (RAG)
14th May
10th June
change
Clinical Support
>15
18
9

Estates and Facilities
>10
25
20

Medical
>70
132
107
Surgical
>40
44
58


Women & Children’s Health
>15
41
34

Other
No target
6
6

TOTAL
>150
266
234

SIRI notification beyond timeframe.
There were three SIRIs which were notified to the CCG beyond the two working day timeframe. One incident involving the administration of
insulin was delayed while confirming the outcome to the patient (5763).
SIRI final reports beyond timeframe
Three SIRIs were sent to the commissioners outside of the 45 working day timeframe. A remedial action plan has been submitted to the
CCG with a trajectory to address the outstanding SIRI reports.
23
Local Priorities - Governance Dashboard
Indicator
Performance target
Timely completion
of incident
investigations and
actions
Outstanding RCAs (non SIRI) which are
more than 45 days after incident reported
R
A
>1
RCA Actions beyond deadline for completion
>=5
Incidents (Amber / Green) with investigation
overdue (over 12 days)
>150
G
May13
1
0
0
1-4
0
10
<50
234
50-150
Commentary
Timely reporting of
SIRIs
SIRI notification beyond timeframe
>=1
0
3
2/5 met new target timescales
SIRI final reports beyond timeframe
>=1
0
3
2/5 met new target timescales
Risk assessment
Active risk assessments in date
<75%
75 – 94%
>=95%
96%
Outstanding actions in date for Red / Amber
entries on Datix risk register
<75%
75 – 94%
>=95%
98%
Trust participation in relevant ongoing
National audits (reported by Quarter)
<75%
75 – 89%
>=90%
Clinical Audit
100% at end of last quarter
24
Local Priorities - Governance Dashboard (cont.)
Indicator
Performance target
NICE
TA (Technology appraisal) business case beyond
agreed deadline timeframe
>9
4-9
0-3
2
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
Compliments
Response within 25 days or negotiated timescale
with the complainant
R
A
<75%
75 – 89%
G
May13
>=90%
100%
Number of second letters received
>=5
1-4
0
1
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
3
Compliments received centrally
No RAG rating
Commentary
47
25
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 459 incidents reported in May including 390 patient safety incidents (PSIs). The reporting rate fell in May but remained above
the upper quartile for peer group. The number of harm incidents in May remained at the peer group average level.
26
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.
In April there were six ‘Red’ patient safety incidents: Deteriorating patient (1), Pressure ulcer (2), Fall (2) and Ophthalmology (1) all awaiting
confirmation of grade through RCA.
27
Local Priorities: Complaints
The Trust continued to receive a high
number of complaints in May
compared to 2012/13.
Complaint response within agreed
timescale with the complainant: 100%
of responses due in May were
responded to within the agreed
timescale (target 90%).
Of the 31 complaints received in May,
the breakdown by Primary Directorate
is as follows: Medical (16), Surgical
(9), Clinical Support (1), Facilities (0),
Other (0) and Women & Child Health
(5).
Trust-wide the most common problem
areas are as follows:
Admissions, Discharge and Transfer Arrangements
5
All Aspects of Clinical Treatment
14
Appointments, Delay / Cancellation (inpatient)
1
Appointments, Delay / Cancellation (outpatient)
3
Attitude of Staff
9
Communication / Information to Patients (written and oral)
6
Other
3
Patients Privacy and Dignity
1
Patients Property and Expenses
1
Personal Records (including medical and / or complaints)
1
28
Local Priorities: PALS (Patient Advice & Liaison Service)
In May 2013 there were 72 recorded PALS
contacts. This number denotes initial contacts
and not the number of actual communications
between the patient/visitor and PALS which is
recorded as 85 for this month.
A breakdown of contacts by Directorate from
Jun’12 to May‘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.
The number of contacts has reduced which is
possibly due to two bank holiday periods
during the month.
Trust-wide the most common five reasons for
contacts are shown below.
Information/Advice request
22
All aspects of clinical treatment
Other (including other organisations)
12
9
Attitude of staff
Communication/information to patients (written/oral)
10
8
The most common reasons for contacts have only changed slightly since the last report. Although the number of concerns relating to staff
attitude had reduced last month this has risen again. There is no individual person, ward or department identified and the contact with PALS
frequently relates to inadequate communication and relatives perception of urgency.
There are no particular themes that the PALS Manager has identified this month. The contacts with PALS during May have covered all services
with an even distribution across most wards and departments, with the exception of the Emergency Assessment Unit (7) and Accident and
Emergency Department (8). These continue to relate to queries about relatives that may have been admitted and delays in diagnosis and/or
being transferred to wards.
29
Local Priorities – Workforce Performance
Workforce
Sickness absence rate
Turnover
<4.39% (National Average)
<14.2% (National Average)
NO
NO
4.03%
7.02%
Reviews
Grievance/Banding reviews
NO
1
Jan Bloomfield
Jan Bloomfield
One Employment Tribunal and One Grievance
Recruitment Timescales
CRB Disclosures existing staff
All Staff to have an appraisal
Average number of weeks to recruit = 7
To complete 95% of required CRB checks
90% of staff have had an appraisal within the previous 12 months
NO
NO
NO
Jan Bloomfield
6.5
98.50%
87.20%
Jan Bloomfield
Jan Bloomfield
Jan Bloomfield
Mandatory Training compliance (reported Quarterly)
Jan Bloomfield
30
CQUIN: Summary & Exceptions report
Good progress is being made in implementing CQUIN
schemes and evidence of Q1 performance will be presented
to West Suffolk CCG in early July.
One target is rated ‘red’ and this relates to closing EAU beds
at night. The target was negotiated before the Trust had
agreed the Emergency Care Plan (ECP) with WSCCG. The
model agreed through ECP supersedes the CQUIN target
agreed and the Trust has proposed to the CCG that the
assessment is based on opening the surgical assessment
unit (SAU) and improvement to the pathway for patients with
a fractured neck of femur.
31
A4 printout
of CQUIN
Monitor Compliance Framework
Monitor Compliance Framework
Performance Indicator
Access:
Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted
Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted
Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway
A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge
All cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer
All cancers: 62-day wait for first treatment (5) from: NHS Cancer Screening Service referral
All cancers: 31-day wait for second or subsequent treatment, comprising: Surgery
All cancers: 31-day wait for second or subsequent treatment, comprising: anti-cancer drug treatments
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
Cancer: two week wait from referral to date first seen (8), comprising:
all urgent referrals (cancer suspected)
Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer not
initially suspected)
Outcomes:
Clostridium (C.) difficile - meeting the C.difficile objective - MONTH
Clostridium (C.) difficile - meeting the C.difficile objective - QUARTER
Clostridium (C.) difficile - meeting the C.difficile objective - ANNUALLY
Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - MONTH
Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - QUARTER
Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - ANNUALLY
Certification against compliance with requirements regarding access to healthcare for people with a learning disability
Threshold
Month
QTD
Weighting
Lead Exec
90%
95%
92%
95%
85%
90%
94%
98%
99.57%
100.00%
100.00%
93.49%
87.00%
100.00%
100.00%
100.00%
99.41%
100.00%
99.77%
91.05%
91.10%
95.45%
100.00%
100.00%
1.0
1.0
1.0
1.0
1.0
Andy Graham
Andy Graham
Andy Graham
Andy Graham
Andy Graham
Andy Graham
Andy Graham
Andy Graham
96%
98.00%
99.00%
0.5
Andy Graham
93%
92.36%
94.28%
0.5
Andy Graham
93%
100.00%
100.00%
2
Q1 = 3, Q2 = 4,
Q3 = 6, Q4 = 6
19
0
0
0
1
N/A
-
1.0
Andy Graham
Nichole Day
6
1.0
6
1
1
1
1.0
-
0.5
Nichole Day
Nichole Day
Nichole Day
Nichole Day
Nichole Day
Nichole Day
40
Contract Priorities Dashboard
A4 printout