Transcript Item 8 Trust Quality and Performance Report 28 July

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
Contract Priorities
34
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.
2
Performance Indicator
Threshold
Discharge Summaries - Outpatients
95% sent to GP's within 3 days
Performance Indicator
Threshold
Discharge Summaries - Inpatients
95% sent to GP's within 1 day
Performance Indicator
Threshold
Breastfeeding initiation rates.
80%
June
Lead Exec
84.23% Dermot O'Riordan
June
Lead Exec
83.50% Dermot O'Riordan
June
Lead Exec
79.25%
Nichole Day
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.
3
Performance Indicator
Threshold
MRSA - emergency screening
All emergency patients
admissions are to be screend for
MRSA within 24 hours of
admission
June
Lead Exec
89.94%
Nichole Day
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.
Performance Indicator
Threshold
June
Lead Exec
90% of staff have had an
appraisal within the previous 12
86.50%
Jan Bloomfield
months
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%.
All Staff to have an appraisal
4
Ward Analysis Quality Report - June 2013
Group
Patient
Safety
Surgery
Medi ci ne
Women & Chi l dren
Indicator
HII compl i a nce 1a : Centra l venous ca theter
i ns erti on
HII compl i a nce 1b: Centra l venous ca theter
ongoi ng ca re
HII compl i a nce 2a : Peri phera l ca nnul a
i ns erti on
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
F14
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
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
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 i a nce 2b: Peri phera l ca nnul a ongoi ng
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
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
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
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
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
NA
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
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
100%
0/yr
<80
>0
80-99
No Ta rget
100
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
ND
0
No Ta rget No Ta rget No Ta rget No Ta rget ND
HII compl i a nce 4a : Preventi ng s urgi ca l s i te
i nfecti on preopera ti ve
HII compl i a nce 4b: Preventi ng s urgi ca l s i te
i nfecti on peri opera ti ve
HII compl i a nce 5: Venti l a tor a s s oci a ted
pneumoni a
HII compl i a nce 6a : Uri na ry ca theter i ns erti on
HII compl i a nce 6b: Uri na ry ca theter on-goi ng
ca re
HII compl i a nce 7: Cl os tri di um Di ffi ci l epreventi on of s prea d
Seps i s 6 pa thwa y: a nti bi oti c compl i a nce
Tota l no of MRSA ba ctera emi a s : Hos pi ta l
Tota l no of MRSA ba ctera emi a s : Communi ty
a cqui red
MRSA (a dmi s s i on to di s cha rge)
MRSA decol oni s a ti on (trea tment a nd pos t
s creeni ng)
MRSA El ecti ve s creeni ng
MRSA Emergency s creeni ng
Stool s peci ment col l ecti on
Ha nd hygi ene compl i a nce
Sta nda rd pri nci pl e compl i a nce
Tota l no of MSSA ba ctera emi a s : Hos pi ta l
Tota l no of C. di ff i nfecti ons : Hos pi ta l
Tota l no of C.di ff i nfecti ons : Communi ty
a cqui red
Anti bi oti c Audi t
Tota l no of E Col i
Is ol a ti on da ta
Envi ronment/Is ol a ti on
VIP s core documenta ti on
MEWS documenta ti on a nd es ca l a ti on
compl i a nce
No of pa ti ent fa l l s
Fa l l s per 1,000 bed da ys
No of pa ti ent fa l l s res ul ti ng i n ha rm
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
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
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
ND ND ND ND
ND ND ND ND
ND ND ND ND
100 100 100 100
ND ND ND ND
0
0
0
0
0
0
0
0
ND
ND
ND
100
ND
0
0
ND
ND
ND
NA
ND
0
0
ND
ND
ND
100
ND
0
0
ND
ND
ND
100
ND
0
0
ND ND
ND ND
ND ND
100 100
ND ND
0
0
0
0
ND
ND
ND
100
ND
0
0
ND
ND
ND
100
ND
0
0
ND
ND
ND
100
ND
0
0
ND
ND
ND
100
ND
0
0
ND
ND
ND
100
ND
0
1
ND
ND
ND
100
ND
0
1
ND
ND
ND
100
ND
0
0
ND
ND
ND
100
ND
1
0
ND
ND
ND
100
ND
0
0
ND
ND
ND
100
ND
0
0
ND
ND
ND
90
ND
0
0
ND
ND
ND
100
ND
0
0
ND
ND
ND
ND
ND
0
0
ND
ND
ND
100
ND
0
0
100%
<80
80-99
100
100%
<80
80-99
100
No Ta rget No Ta rget No Ta rget No Ta rget
95%
<85
85-94
95-100
95%
<80
80-99
90-100
No Ta rget No Ta rget No Ta rget No Ta rget
19/yr
>0
No Ta rget
0
No Ta rget No Ta rget No Ta rget No Ta rget ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
98%
<85
85-97
98-100
No Ta rget No Ta rget No Ta rget No Ta rget
95%
<85
85-94
95-100
90%
<80
80-89
90-100
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
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
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
0%
560%
0%
>0
>5.8
>0
No Ta rget
5.6-5.8
No Ta rget
0
<5.6
0
4
NA
1
0
NA
0
1
NA
1
0
NA
0
NA
NA
NA
NA
NA
NA
0
NA
ND
0
NA
0
2
NA
0
8
NA
1
5
NA
1
2
NA
1
3
NA
0
1
NA
1
10
NA
3
8
NA
3
7
NA
1
0
NA
0
6
NA
2
2
NA
0
NA
NA
NA
NA
NA
NA
NA
NA
NA
1
NA
1
Ward Analysis Quality Report - June 2013
Group
Patient
Safety
Patient
Experience:
in-patient
Indicator
No. of s eri ous i njuri es or dea ths res ul ti ng from
fa l l s
No of pa ti ents wi th wa rd a cqui red Gra de 2
pres s ure ul cers
No of pa ti ents wi th a voi da bl e wa rd a cqui red
Gra de 2 pres s ure ul cers
No of pa ti ents wi th wa rd a cqui red Gra de 3 or 4
pres s ure ul cers
No of pa ti ents wi th a voi da bl e wa rd a cqui red
Gra de 3 or 4 pres s ure ul cers
Nutri ti on: As s es s ment a nd moni tori ng
Hydra ti on: Pa ti ents wi th a ppropri a te fl ui d
ba l a nce ma na gement
No of SIRIs a nd potenti a l SIRIs
No of drug errors : res ul ti ng i n ha rm
No. of CD errors (pa ti ent s a fety)
Ca rdi a c a rres ts : No. outs i de CCS
Ca rdi a c a rres ts outs i de CCS: No. of RCAs
Pa i n Ma na gement: Qua rterl y i nterna l report
VTE: Compl eted ri s k a s s es s ment (monthl y
Uni fy a udi t)
VTE: Prophyl a xi s compl i a nce
Sa fety Thermometer: % of pa ti ents
experi enci ng ha rm-free ca re
Pa ti ent Sa ti s fa cti on: In-pa ti ent overa l l res ul t
How l i kel y i s i t tha t you woul d recommend the
s ervi ce to fri ends a nd fa mi l y?
In your opi ni on, how cl ea n wa s the hos pi ta l
room or wa rd tha t you a re i n?
Di d you feel you were trea ted wi th res pect a nd
di gni ty by s ta ff?
Were Sta ff ca ri ng a nd compa s s i ona te i n thei r
a pproa ch?
Were you ever bothered by noi s e a t ni ght from
other pa ti ents ?
Di d you fi nd s omeone on the hos pi ta l s ta ff to
ta l k to a bout your worri es a nd fea rs ?
Were you i nvol ved a s much a s you wa nted to
be i n deci s i ons a bout your condi ti on a nd
trea tment?
Were you gi ven enough pri va cy when
di s cus s i ng your ca re?
Di d you get enough hel p from s ta ff to ea t your
mea l s
Were you gi ven enough pri va cy when bei ng
exa mi ned or trea ted?
Ti mel y ca l l bel l res pons e
Number of s urverys compl eted
Sa me s ex a ccommoda ti on
Sa me s ex a ccommoda ti on: tota l pa ti ents
Compl a i nts
Envi ronment a nd Cl ea nl i nes s
Envi ronmenta l Audi t
Surgery
Medi ci ne
Target
Red
Amber
Green
F3
F4
F5
F6
0%
>0
No Ta rget
0
1
0
0
0
0
NA
NA
0
0
0%
>0
No Ta rget
0
0
0
0
0
0
0
0
0
0%
>0
No Ta rget
0
0
0
0
0
0
0
0
0%
>0
No Ta rget
0
0
0
0
0
0
0
0
0%
>0
No Ta rget
0
0
0
0
0
95%
<85
85-94
95-100
Women & Chi l dren
G5
F9
F10
G1
G3
G4
F7
G8
MTU
G9
F8
F1
F11
F14
0
1
0
0
0
0
1
0
0
0
0
0
NA
NA
NA
0
0
0
0
2
0
0
0
0
0
0
0
0
NA
NA
NA
0
0
0
0
0
2
0
0
0
0
0
0
0
0
NA
NA
NA
0
0
0
0
0
0
0
0
0
1
0
0
0
0
NA
NA
NA
NA
0
0
0
0
0
0
0
0
0
0
0
0
ND
0
0
0
0
NA
NA
100 100 100 100
100
NA
NA
NA
NA
100
100
100
90
70
100
100
90
100
NA
90
100
NA
NA
0
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 Ta rget
0
0
No Ta rget
0
1
No Ta rget
0
0
No Ta rget No Ta rget 0
No Ta rget No Ta rget 0
70-79
80-100
NA
0
0
1
0
0
NA
0
0
0
0
0
NA
0
0
1
0
0
NA
0
0
0
0
0
NA
0
0
0
0
0
NA
0
0
0
0
0
NA
0
0
0
0
0
NA
0
0
0
0
0
NA
1
0
0
1
1
NA
1
1
1
0
0
NA
0
0
1
1
1
NA
0
0
1
0
0
NA
0
0
0
0
0
NA
0
0
0
0
0
NA
1
0
0
1
1
NA
1
0
1
0
0
NA
0
0
0
0
0
NA
0
0
0
0
0
NA
0
0
1
0
0
NA
1
0
1
0
0
NA
0
1
0
0
0
NA
1
0
0
0
0
NA
0
0
0
0
0
NA
98.15
No Ta rget No Ta rget No Ta rget No Ta rget
0%
>0
0%
>0
0%
>0
No Ta rget No Ta rget
No Ta rget No Ta rget
80%
<70
CCS Theatres Recovery DSU A&E CCU
> 98%
< 98
No Ta rget
> 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
100%
<95
95-99
100
100
100 ND
100
NA
NA
NA
NA
100
NA
100
95%
<95
95-99
100
100 100 100 100
100
NA
NA
NA
NA
100 96.77 90.62
85%
<75
75-84
85-100
86
93
92
96
NA
NA
NA
NA
NA
94
81
88
92
97
75%
<70
70-74
75-100
57
95
93
90
NA
NA
NA
NA
NA
100
70
90
100
100
85%
<75
75-84
85-100
96
100
98
99
NA
NA
NA
NA
NA
100
96
98
99
85%
<75
75-84
85-100
98
98
100 100
NA
NA
NA
NA
NA
100
96
100
85%
<75
75-84
85-100
98
98
100 100
NA
NA
NA
NA
NA
100
91
85%
<75
75-84
85-100
64
75
67
85
NA
NA
NA
NA
NA
56
85%
<75
75-84
85-100
78
97
95
97
NA
NA
NA
NA
NA
85%
<75
75-84
85-100
84
98
93
96
NA
NA
NA
NA
85%
<75
75-84
85-100
93
100
98
97
NA
NA
NA
85%
<75
75-84
85-100
87
100
92
100
NA
NA
NA
85%
<75
75-84
85-100
99
100 100 100
NA
NA
74
87
0
0
95
ND
NA
NA
0
0
96
ND
NA
NA
NA
0
90
ND
85%
<75
75-84
85-100
54
No Ta rget No Ta rget No Ta rget No Ta rget 61
0%
>2
100%
0
0%
>2
100%
0
0
0%
>2
1-2
0
0
90%
<80
80-89
90-100
90
90%
<80
80-89
90-100
ND
ND
73
27
0
1
92
ND
76
39
0
0
89
ND
100
100
100
100
100
100
100
NA
NA
100
100
81.82 100
75
85.29
96
NA 77.78 94.94 NA
100
83.33
90
88
91
NA
96
NA
85
NA
NA
95
93
80
81
NA
100
NA
86
NA
NA
50
100
97
100
96
NA
98
NA
95
NA
NA
100
98
100
100
100
98
NA
100
NA
100
NA
NA
100
98
100
100
99
97
96
NA
100
NA
93
NA
NA
100
35
55
74
100
69
73
65
NA
88
NA
43
NA
NA
67
100
92
90
90
100
95
85
92
NA
100
NA
88
NA
NA
100
NA
100
93
87
98
97
98
70
94
NA
97
NA
86
NA
NA
92
NA
NA
100
91
97
100
100
86
100
98
NA
94
NA
86
NA
NA
100
NA
NA
100
100
100
100
100
100
100
100
NA
100
NA
75
NA
NA
NA
NA
NA
NA
100
96
98
100
100
86
100
100
NA
94
NA
93
NA
NA
100
NA
NA
NA
0
93
ND
NA
NA
0
0
89
ND
NA
NA
0
4
88
ND
89
9
0
0
93
ND
30
23
0
1
93
ND
62
31
0
1
92
ND
61
31
0
1
93
ND
72
15
0
0
90
ND
77
42
0
0
86
ND
62
15
0
1
92
ND
61
26
0
0
87
ND
NA
NA
0
1
93
ND
83
17
0
0
93
ND
NA
NA
0
0
ND
ND
89
7
0
3
87
ND
NA
NA
NA
1
94
ND
NA
NA
NA
0
94
ND
94
6
NA
1
93
ND
88
100
Ward Analysis Quality Report - June 2013
Group
Patient
Experience:
short-stay
Patient
Experience:
A&E
Patient
Experience:
A&E
(Children
questions)
Indicator
Pa tient Sa tis fa ction: s hort-s tay overa l l res ul t
How l i kel y i s i t tha t you woul d recommend the
s ervi ce to fri ends a nd fa mi l y?
Were you gi ven enough pri va cy when bei ng
exa mi ned a nd trea ted?
Were s taff profes s i ona l , a pproa cha bl e a nd
fri endl y?
Were you tol d who to contact i f you were
worri ed a fter l ea vi ng hos pi tal ?
Overa l l how woul d you ra te the ca re you
recei ved i n the depa rtment?
Number of s urverys compl eted
Pa tient Sa tis fa ction: A&E overa l l res ul t
How l i kel y i s i t tha t you woul d recommend the
s ervi ce to fri ends a nd fa mi l y?.
Were s taff profes s i ona l , a pproa cha bl e a nd
fri endl y?
Were you gi ven enough pri va cy when
di s cus s i ng your condi tion a t reception?
Di d Doctors a nd Nurs es l i s ten to wha t you ha d
to s a y?
Di d a member of s taff tel l you wha t da nger
s i gns to wa tch for when goi ng home?
Di d s taff tel l you who to contact i f you were
worri ed a bout your condi tion a fter l ea vi ng
A&E?
Number of s urverys compl eted
Pa tient Sa tis fa ction: A&E Chi l dren ques tions
overa l l res ul t
How l i kel y a re you to recommend our A&E
depa rtment to fri ends a nd fa mi l y i f they
needed s i mi l a r ca re or trea tment?
Di d the Doctor or Nurs e l i s ten to wha t you ha d
to s a y?
Were s taff fri endl y a nd ki nd to you a nd your
fa mi l y?
Di d we hel p wi th your pa i n?
Di d s taff expl a i n the ca re you need a t home?
Number of s urverys compl eted
Surgery
Medi ci ne
Women & Chi l dren
Target
85%
Red
<75
Amber
75-84
Green
85-100
F3
NA
F4
NA
F5
NA
F6
NA
CCS Theatres Recovery DSU A&E CCU
NA
NA
NA
100 NA NA
G5
NA
F9
NA
F10
NA
G1
NA
G3
NA
G4
NA
F7
NA
G8
NA
MTU
NA
G9
NA
F8
NA
F1
NA
F11
NA
F14
NA
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
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
NA
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
NA
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
98
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
99
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
No Ta rget No Ta rget No Ta rget No Ta rget NA
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
67
NA
NA
89
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
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
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
NA
94
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
NA
81
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
NA
94
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
NA
88
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
NA
88
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
No Ta rget No Ta rget No Ta rget No Ta rget NA
NA
NA
NA
NA
NA
NA
NA
341
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
NA
84
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
75%
<70
70-74
75-100
NA
NA
NA
NA
NA
NA
NA
NA
14
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
NA
86
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
NA
83
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
85%
<75
75-84
85-100
NA
85%
<75
75-84
85-100
NA
No Ta rget No Ta rget No Ta rget No Ta rget NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
80
ND
7
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Ward Analysis Quality Report - June 2013
Group
Patient
Experience:
Maternity
Children's
Services
Patient
Satisfaction
: Young
Children
Indicator
Pa ti ent Sa ti s fa cti on: Ma terni ty overa l l res ul t
In your opi ni on, how cl ea n wa s the hos pi ta l
room or wa rd tha t you were i n?
Were s ta ff profes s i ona l , a pproa cha bl e a nd
fri endl y?
Di d you fi nd s omeone on the hos pi ta l s ta ff to
ta l k to a bout your worri es a nd fea rs ?
Were you i nvol ved a s much a s you wa nted to
be i n deci s i ons a bout your ca re a nd
trea tment?
Were you gi ven enough pri va cy when bei ng
exa mi ned or trea ted?
Di d you hol d your ba by i n s ki n to s ki n conta ct
a fter the bi rth (ba by na ked a pa rt from the
na ppy a nd a ha t, l yi ng on your ches t)?
Were you gi ven a dequa te hel p a nd s upport to
feed your ba by whi l s t i n hos pi ta l ?
How ma ny mi nutes a fter you us ed the ca l l
button di d i t us ua l l y ta ke before you got the
hel p you needed?
Ha s a member of s ta ff tol d you a bout
medi ca ti on s i de effects to wa tch for when you
go home?
Ha ve hos pi ta l s ta ff tol d you who to conta ct i f
you a re worri ed a bout your condi ti on a fter you
l ea ve hos pi ta l ?
How l i kel y i s i t tha t you woul d recommend the
s ervi ce to fri ends a nd fa mi l y?
Number of s urverys compl eted
Pa ti ent Sa ti s fa cti on: Chi l dren's Servi ces
Overa l l Res ul t
How l i kel y a re you to recommend our wa rd to
fri ends & fa mi l y i f they needed s i mi l a r ca re or
trea tment?
Di d you unders ta nd the i nforma ti on gi ven to
you rega rdi ng your trea tment a nd ca re?
Were you a s i nvol ved a s you wa nted to be i n
deci s i ons a bout your ca re a nd trea tment?
Di d the Doctor or Nurs es expl a i n wha t they
were doi ng i n a wa y tha t you coul d
unders ta nd?
Were you offered a ge/need a ppropri a te
a cti vi ti es ?
Wa s your experi ence i n other hos pi ta l
depa rtments (i .e. X-ra y depa rtment, outpa ti ent depa rtment, thea tre) s a ti s fa ctory?
Wa s your experi ence duri ng
procedures /i nves ti ga ti ons (i .e.bl ood tes ts , Xra ys ) ma na ged s ens i ti vel y?
If you were i n pa i n, di d the Doctor or Nurs e do
everythi ng they coul d to hel p wi th the pa i n?
Surgery
Medi ci ne
Women & Chi l dren
Target
85%
Red
<75
Amber
75-84
Green
85-100
F3
NA
F4
NA
F5
NA
F6
NA
CCS Theatres Recovery DSU A&E CCU
NA
NA
NA
NA
NA NA
G5
NA
F9
NA
F10
NA
G1
NA
G3
NA
G4
NA
F7
NA
G8
NA
MTU
NA
G9
NA
F8
NA
F1
NA
F11
93
F14
NA
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
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
96
NA
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
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
92
NA
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
98
NA
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
84
NA
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
98
NA
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
84
NA
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
90
NA
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
98
NA
75%
<70
70-74
75-100
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
65
NA
No Ta rget No Ta rget No Ta rget No Ta rget NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
97
NA
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
75%
<70
70-74
75-100
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
83
NA
NA
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
NA
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
NA
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
92
NA
NA
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
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
NA
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
NA
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
92
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
100
ND
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
ND
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
6
NA
NA
Were s ta ff ki nd a nd ca ri ng towa rds you?
85%
<75
75-84
85-100
Is the envi ronment chi l d - fri endl y?
85%
<75
75-84
85-100
Overa l l , how woul d you ra te your experi ence i n
85%
<75
75-84
85-100
the Pa edi a tri c Uni t?
Number of s urverys compl eted
No Ta rget No Ta rget No Ta rget No Ta rget
Ward Analysis Quality Report - June 2013
Group
Indicator
Pa ti ent Sa ti s fa cti on: F1 Pa rent overa l l res ul t
How l i kel y a re you to recommend our wa rd to
fri ends & fa mi l y i f they needed s i mi l a r ca re or
trea tment?
Di d you unders ta nd the i nforma ti on gi ven to
you rega rdi ng your chi l d's trea tment a nd ca re?
F1 Parent
Patient
Experience:
Stroke
Staffing
Were you a nd your chi l d a s i nvol ved a s you
wa nted to be i n deci s i ons a bout ca re a nd
trea tment?
Di d the Doctor or Nurs es expl a i n wha t they
were doi ng i n a wa y tha t your chi l d coul d
unders ta nd?
Were there a ppropri a te pl a y a cti vi ti es for your
chi l d (s uch a s toys , ga mes a nd books )?
Wa s your chi l d's experi ence i n other hos pi ta l
depa rtments (i .e. X-ra y depa rtment, outpa ti ent depa rtment, thea tre) s a ti s fa ctory?
Wa s your chi l d's experi ence duri ng
procedures /i nves ti ga ti ons (i .e.bl ood tes ts , Xra ys ) ma na ged s ens i ti vel y?
If your chi l d wa s i n pa i n, di d the doctor or
nurs e do everythi ng they coul d to hel p wi th the
pa i n?
Were s ta ff ki nd a nd ca ri ng towa rds your chi l d
Is the envi ronment chi l d-fri endl y?
Overa l l , how woul d you ra te your experi ence i n
the Chi l dren's Uni t?
Number of s urverys compl eted
Pa ti ent Sa ti s fa cti on: Stroke overa l l res ul t
How l i kel y i s i t tha t you woul d recommend the
s ervi ce to fri ends a nd fa mi l y?
Ha ve you been tol d you ha ve ha d a s troke,
whi ch l ea d to your a dmi s s i on to hos pi ta l ?
Ha ve you been i nvol ved i n pl a nni ng your
recovery / reha bi l i ta ti on?
Whi l e you were i n the Stroke Depa rtment how
much i nforma ti on a bout your condi ti on or
trea tment wa s gi ven to you?
Ha ve you recei ved the hel p you requi re whi l e
ea ti ng?
Do you feel ca red for?
Were you gi ven enough pri va cy when bei ng
exa mi ned or trea ted or when your ca re wa s
di s cus s ed wi th you?
Number of s urverys compl eted
Si cknes s
Si cknes s (Short term)
Si cknes s (Long term)
Va ca nci es
Turnover (Annua l )
Surgery
Medi ci ne
Women & Chi l dren
Target
85%
Red
<75
Amber
75-84
Green
85-100
F3
NA
F4
NA
F5
NA
F6
NA
CCS Theatres Recovery DSU A&E CCU
NA
NA
NA
NA
NA NA
G5
NA
F9
NA
F10
NA
G1
NA
G3
NA
G4
NA
F7
NA
G8
NA
MTU
NA
G9
NA
F8
NA
F1
94
F11
NA
F14
NA
75%
<70
70-74
75-100
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
85
NA
NA
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
NA
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
92
NA
NA
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
88
NA
NA
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
92
NA
NA
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
NA
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
85
NA
NA
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
95
NA
NA
85%
85%
<75
<75
75-84
75-84
85-100
85-100
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
96
100
NA
NA
NA
NA
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
92
NA
NA
No Ta rget No Ta rget No Ta rget No Ta rget NA
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
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
93
NA
NA
NA
NA
NA
NA
13
NA
NA
NA
NA
NA
100
NA
NA
NA
NA
NA
NA
75%
<70
70-74
75-100
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
88
NA
NA
NA
NA
NA
NA
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
100
NA
NA
NA
NA
NA
NA
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
88
NA
NA
NA
NA
NA
NA
85%
<75
75-84
85-100
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
100
NA
NA
NA
NA
NA
NA
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
NA
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
NA
No Ta rget
3.5%
No Ta rget
No Ta rget
No Ta rget
10%
No Ta rget
>6
No Ta rget
No Ta rget
No Ta rget
>10%
No Ta rget
3.5-6
No Ta rget
No Ta rget
No Ta rget
No Ta rget
No Ta rget
<3.5
No Ta rget
No Ta rget
No Ta rget
0%-10%
NA
5.1
5.1
0
-4.1
4.6
NA
2.4
1.6
0.8
1.3
0
NA NA NA
1.7 5.7 3.7
0.9 2.1
3
0.8 3.6 0.7
1.7 -1.8 -4.7
7.9 0
7.3
NA
7.5
4.6
2.9
0.3
3.5
NA
3.5
2
1.5
-0.1
0
NA
8.5
3.5
5
-3.6
4.4
NA
7.4
2.5
4.9
-7.4
3.6
NA
4.2
1.3
2.9
-1.8
12.5
NA
7.5
3.2
4.3
-5
4.2
NA
4.5
2.9
1.5
-1.7
0
NA
5.9
3.1
2.8
2
2.4
NA
4.6
1.4
3.2
-4.9
5.3
NA
2.6
1
1.6
3.2
9.52
NA
6.7
3.5
3.2
-0.8
3.4
NA
8.8
3.2
5.6
-2.3
4.3
8
3.6
3
0.6
-2.4
9.3
NA
NA
NA
NA
NA
NA
NA
0
0
0
0
ND
NA
5
5
0
-3.8
5.4
NA
2.6
1.7
0.8
-1.6
2.7
NA
5.4
2.1
3.3
-6.1
0
NA
8.7
6
2.7
-0.9
14.3
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%
10
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.
11
Quality Priority: Infection Control
MRSA Bacteraemia
There were no hospital associated MRSA bacteraemia during June
C. Difficile
The Trust has had two C. difficile cases during June 2013.
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 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 screening
Figures for June were not available at the time of this report being completed
12
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.
13
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 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 ulcers
There 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.
14
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.
15
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 .
16
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
17
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% 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.
18
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 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
19
Quality Priority: Patient Experience
Improving support to family carers
A 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.
20
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.
•
21
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 coamoxiclav (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.
22
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
0
0
0
0
0
RAP Trajectory
NA
10
7
2
0
Actual Performance
17
7
SLA Standard
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
G
Jun13
1
0
0
1-4
0
3
<50
236
Commentary
RCA Actions beyond deadline for completion
>=5
Incidents (Amber / Green) with investigation
overdue (over 12 days)
>150
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%
Trust participation in relevant ongoing
National audits (reported by Quarter)
<75%
75 – 89%
>=90%
100%
Clinical Audit
50-150
Meetings in place with relevant
managers
24
Local Priorities - Governance Dashboard (cont.)
Indicator
Performance target
NICE
TA (Technology appraisal) business case beyond
agreed deadline timeframe
>9
4-9
0-3
1
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
Jun13
>=90%
>=5
1-4
0
3
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
No RAG rating
These outstanding Five interventional
procedures and Six Clinical Guidelines are
outstanding baselines assessment and
require targeted follow up.
92%
Number of second letters received
Compliments received centrally
Commentary
Two of these complainants have been
offered local resolution meetings to try
and address their on going concerns.
62
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 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.
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.
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.
27
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 Discharge
follows: and Transfer Arrangements
Admissions,
All Aspects of Clinical Treatment
Appointments, Delay / Cancellation (outpatient)
Attitude of Staff
Communication / Information to Patients (written and oral)
8
7
5
7
17
28
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
Other (including other organisations)
13
9
Communication/information to patients (written/oral)
12
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.
29
Local Priorities – Workforce Performance
Direct
Financial
Penalty
12 Month
YTD
<4.39% (National Average)
<14.2% (National Average)
NO
NO
3.99%
7.14%
Grievance/Banding reviews
NO
1
Performance Indicator
Threshold
Workforce
Sickness absence rate
Turnover
Reviews
Comments
Lead Exec
Jan Bloomfield
Jan Bloomfield
One Employment Tribunal and One Grievance Jan Bloomfield
Recruitment Timescales
Average number of weeks to recruit = 7
NO
6.7
CRB Disclosures existing staff
To complete 95% of required CRB checks
90% of staff have had an appraisal within the previous 12
months
NO
99.00%
NO
86.50%
All Staff to have an appraisal
Mandatory Training compliance (reported
Quarterly)
Jan Bloomfield
Jan Bloomfield
Jan Bloomfield
Jan Bloomfield
30
CQUIN: Summary & Exceptions report
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.
31
A3 printout
of CQUIN
32-33
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
Threshold
Month
QTD
Weighting
Lead Exec
90%
95%
96.13%
100.00%
98.31%
100.00%
1.0
1.0
Andy Graham
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
All cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer
95%
95.42%
92.57%
1.0
Andy Graham
85%
91.00%
91.47%
90%
94%
98%
100.00%
100.00%
100.00%
96.97%
100.00%
100.00%
All cancers: 31-day wait from diagnosis to first treatment
96%
100.00%
99.67%
Cancer: two week wait from referral to date first seen (8), comprising:
all urgent referrals (cancer suspected)
93%
94.70%
94.40%
Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer not
initially suspected)
93%
94.50%
2
2
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
1.0
1.0
Andy Graham
Andy Graham
Andy Graham
Andy Graham
All cancers: 31-day wait for second or subsequent treatment, comprising: radiotherapy - Not applicable to WSFT
0.5
Andy Graham
Andy Graham
0.5
98.17%
Andy Graham
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
Q1 = 3, Q2 = 4,
Q3 = 6, Q4 = 6
19
0
0
Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - ANNUALLY
0
Certification against compliance with requirements regarding access to healthcare for people with a learning
disability
N/A
Nichole Day
8
1.0
8
0
1
1.0
1
-
-
Nichole Day
Nichole Day
Nichole Day
Nichole Day
Nichole Day
0.5
Nichole Day
34
Contract Priorities Dashboard
Contract Priorities with financial penalty
In Month
Performance
YTD
YES
24.59%
25.43%
Andy Graham
No
ONE MET
-
Andy Graham
Stroke -Proportion of Patients admitted to an acute stroke unit within 4
90%
hours of hospital arrival
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.
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
85%
social care plan on discharge
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
100% of stroke patients eligible for a brain scan scanned within
hours or less than 60 minutes out of hours as defined from time to time one hour
by the ASHN
YES
100.00%
88.67%
Andy Graham
>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
65%
scan within 7 days (seen, investigated and treated)
YES
78.00%
71.00%
Andy Graham
% of Patients eligible for Thrombolysis, Thrombolysed within 4.5 hours 100% of all eligible patients
YES
100.00%
100.00%
Andy Graham
Performance Indicator
Threshold
Comments
Lead Exec
A&E
A&E - Threshold for admission via A&E
i) if the monthly ratio is above the corresponding 2011/12
monthly ratio for two month in a six month period
ii) if year end is greater than 27%
To satisfy at least one of the following Timeliness Indicators:
1. Time to initial assessment (95th percentile) below 15 minutes
2. Time to treatment in department (median) below 60 minutes
A&E - Timeliness Indicators
Stroke
60%
Discharge Summaries
Discharge Summaries - Outpatients
95% sent to GP's within 3 days
YES
84.23%
83.74%
Dermot O'Riordan
Discharge Summaries - A&E
95% 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
35
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%
-
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%
-
NO
1.54%
1.05%
NO
100.00%
100.00%
NO
93.57%
95.80%
NO
NO
NO
01:29
100.00%
79.25%
01:29
100.00%
78.93%
YES
19.08%
19.62%
YES
0
1
Andy Graham
YES
5.61%
5.67%
Andy Graham
YES
88.06%
87.88%
Andy Graham
The Threshold applied to
fines is 5%
Andy Graham
Andy Graham
Cancelled Operations
Provider cancellation of Elective Care operation for non-clinical
i) 1% of all elective procedures
reasons either before or after Patient admission
Patients offered date within 28 days of cancelled operation
100%
Andy Graham
Andy Graham
Maternity
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.
Maintain maternity 1:30 ratio
Pledge 1.4: 1:1 care in established labour
Breastfeeding initiation rates.
Reduction in the proportion of births that are undertaken as
caesarean sections. Suffolk PCT Only
1:30
1:1
80%
1% reduction in proportion compared to 2011/12
baseline - 22.70%
Nichole
Nichole
Nichole
Nichole
Day
Day
Day
Day
Nichole Day
Other contract / National targets
Mixed Sex Accomodation breaches
Consultant to consultant referral
0 Breaches
Commisioner 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 Maintain or improve the mix as specified = 90.17%
for such procedures, unless clinical reasons can be
demonstrated for increase in admissions.
MRSA - emergency screening
All 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 clinic
100% of patients should have a maximum wait of two
weeks
NO
100.00%
100.00%
Andy Graham
New to Follow up
Thresholds set at each speciality - overall Trust
Threshold is 1.9
YES
1.89
1.95
Andy Graham
36