1 integrated quality and performance report m3– june 2011 presented by: bernie bluhm (chief...

1

Integrated Quality and Performance ReportM3– June 2011

Presented by: Bernie Bluhm (Chief Operating Officer) and Jo Thomas ( Chief Nurse)Author: Char Fletcher (Senior Performance Manager)

Trust Board – 21 July 2011Agenda item: 4.1

2 2

Performance Report M3 - June

Summary: The report updates the Board on the key national, contractual KPIs across the Trust for the Month 3 of 2011-12 (June). The Q1 forecast for the trust remains ‘underperforming’ There remain some Issues with validating the 18 week position. The data was not available at the time of this report. No exception report has been provided for Appraisal and Statutory and Mandatory compliance as data the data is currently being mapped to each division New workforce exception reports are under development. They will utilize SPC charts to identify when a KPI is outside of control limits. Data quality indicators are under development

Action: The Trust Board is asked to Note and accept this report

Notes:

Legal: What are the legal considerations & implications linked to this item? Please name relevant Act

Not applicable.

Regulation: What aspect of regulation applies and what are the outcome implications? This applies to any regulatory body – key regulators include: Care Quality Commission, MHRA, NPSA & Audit Commission)

Department of Health.

Trust objective: Please list number and statement. this paper relates to.

Deliver safe, high quality co-ordinated care;Develop an effective organisation

Trust Board

Agenda Item:4.1

3

Contents

1. Integrated Quality and Performance Dashboard

Page 4 Operating framework metrics Page 5 Outcomes framework metrics Page 6 internal metrics

2. Exception Reports

3. Glossary of Terms

Indicators used for external assessment

Direction of Travel vs. Plan

Target YTD Actual

▲=above plan►=on

plan▼=below plan Jan Feb March Apr-11 May-11 Jun-11 Q1 2011/12 Q2 2010/11 Q3 2010/11 Q4 2010/11

<15 77

▲116 111 77

<60 53 ▼ 78 68 53

240 1029 ▲ 997 970 1029

240 294 ▲ 442 353 294

95% 79.7% ▼ 82.4% 82.0% 81.9% 75.6% 79.9% 82.6% 95.0% 93.0% 90.7%

0 2 ▲ 0 0 3 0 0 2 0 11 3

<5% 4.7% ▼ 4.0% 5.0% 5.0%

<5% 2.6% ▼ 3.4% 2.6% 1.9%

N/A 11832 4379 3833 4469 2683 3829 5320TBD 3.1% 2.9% 3.4% 2.9% 2.8% 3.0% 3.4%0.33 1 ► 0 1 0 0 0 1 1 1 1 1

4.2 7 ► 5 5 8 3 2 2 7 14 19 18

N/A 12 5 2 5

N/A 3 Not avail 3 3

<=23 29.0 32.0 32.0 Not avail Not avail Not avail 25 32

<=18.3 17.0 20.0 20.0 Not avail Not avail Not avail 16.7 20

<=28 25.0 26.0 26.0 Not avail Not avail Not avail 23 26

N/A 6.0 4.0 4.0 Not avail Not avail 0

11.1 13.0 14.0 14.0 Not avail Not avail 0 12 13

7.2 7.0 7.0 7.0 Not avail Not avail Not avail 8 7

90% 81.0 74.9 74.9 #DIV/0! #DIV/0! #DIV/0! 90%

95% 95.4 92.1 92.1 #DIV/0! #DIV/0! #DIV/0! 97%

93% 95.0% ▲ 93.9% 96.9% 95.2% 96.2% 94.1% 94.8% 95.0% 91.1% 91.7% 92.4%

93.0% 94.7% ▲ 93.8% 93.8% 93.9% 93.4% 98.5% 93.1% 94.7%

94.0% 94.4% ▲ 88.9% 92.0% 100.0% 94.4%

98.0% 100.0% ▲ 100.0% 100.0% 100.0% 100.0%

96.0% 99.2% ▲ 98.7% 98.7% 100.0% 99.2%

85% 86.35% ▲ 89.5% 89.6% 84.5% 86.7% 82.9% 88.4% 86.35% 88.4% 88.7% 88.2%

90% 100.0% ▲ 0.0% 100.0% 75.0% 100.0% 100.0% 100.0%

0 10 ▼ 6 0 10 10 26 9

80% 65.7%▼

56.0% 48.0% 54.0% 59.5% 69.7% 69.0%

85% 65.5% ▼ 59.0% 70.0% 73.3% 59.1% 76.7% 64.3%

N/A 1258 260 382 616

N/A -2,807 -£66 £246 £215 £320 -3507 380

Data Quality

*E . C oli

MS S A (trust and community acquired)

C DiffU

nder

Con

stru

ctio

n

% of patients in A&E under 4 hours

Operating Framework

R T T - non- admitted 95% in 18 wks

R T T - incomplete -median

Mixed S ex Accommodation

Res

ourc

esMonthly Trend

new metric for 2011/12




31 day second or subsequent treatment (surgery)

31 day second or subsequent treatment (drug)

31 day diagnos is to T reatment

Financial Position (£,000)

62 days urgent referral to treatment of all cancers

Delivery of Savings Plan

P atients that have spent more than 90% of their s tay in hospital on a s troke unitF ractured Neck of F emur <36

Median wait times -non-admitted

Median wait times - admitted


62 wait firs t treatment from C onsultant screening

18 weeks R T T - non-admitted including audiology (DAA)- 95th percentile @

R T T - incomplete - 95th percentile

2 week G P referral to 1st outpatient

2 week G P referral to 1st outpatient - breast symptoms

R T T - admitted 90% in 18 weeks

E mergency R eadmiss ions within 30 days of discharge

Performance

18 weeks R T T admitted - 95th P ercentile @



number of of patients in A&E over 12 hours (trolley waits )

T otal time in A&E non-admitted(95th percentlie)

A&E Attaendances

Qua

lity

Quarterly Trend

A&E time to initial assessment(95th percentile)

T ime to T reatment (median)

MR S A (trust acquired)

T otal time in A&E admitted (95th percentlie)

A&E Unplanned R e-attendance rate (within 7 days )

L eft without being seen (L WBS ) R ate

Indicators used for external assessment Direction of

Travel vs. Plan

Target YTD Actual


plan▼=below plan Jan Feb March Apr-11 May-11 Jun-11 Q1 2011/12 Q2 2010/11 Q3 2010/11 Q4 2010/11

N/A 642 260 382 0

N/A -3,187 -£66 £246 £215 £320 -3507 0

N/A

100 98.2

▼

108 84.6 74.5 93.4 Data

reported in

arrears

Data reported

in arrears

100% 99% ▼ 100.0% 100.0% 100.0% 100.0% 98.2% 100.0% 100.0% 100.0% 100.0% 100.0%

95% N/A 67.0% 100.0% 100.0% N/A N/A Data reported

in arrears

60% N/A 67.0% 100.0% 33.0% N/A N/A Data reported

in arrears

60% 80.0%▲

77.8% 40.0% 75.0% 90.0% 80.0% 73.3%

80% N/A

▼92.0% 77.0% 94.0% 73.0% 64.0% 71%

80% N/A▼

78.0% 72.0% 78.0% 78.0% 65.0% 78%

80% N/A▼

83.0% 80.0% 89.0% 76.0% 70.0% 74%

TBD 56 15 12 21 16 23 17

73 95 ▼ 32 42 20 18 48 29

0 0 ► 3 1 4 0 0 0

*We are not yet aware of any algorithm for attributing these(E.Coli) cases. So in the short term we have adopted the normal BSI algorithm using pre and post 48 hours of admission. These figures may change

**There were no PPCI's performed in month

Quarterly Trend

Indicators used for external assessment

Performance

Notes:

Stroke/TIA treated within 24 hours

Number of falls reported as clinical incidents

Newly acquired Pressure Ulcers (grade 2 and above)

Number of medication errors resulting in an adverse event

% of patients surveyed who would choose to be treated at SASH in Future% of patients surveyed that staff treated them with kindness and respect

Non-Elective FFCE's

HSMR

Delivery of Savings Plan

Outcomes framework

Patie

nt

Expe

rienc

e

**PPCI 150 min call to ballon time

Financial Position (£,000)

Und

er c

onst

ruct

ion

2 wks rapid access chest pain

PPCI 120 min call to ballon time

Safe

ty

% of patients surveyed who felt their dignity was maintained the whole time they were a patient

Res

ourc

esEf

fect

iven

ess

Monthly Trend

Data Quality

Und

er

Con

stru

ctio

n

Indicators used for Internal assessment

Direction of Travel vs. Plan

Target YTD Actual


plan▼=below plan Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Q1 2011/12 Q2 2010/11 Q3 2011/12 Q4 2011/12

Q4 201

90% 60.6%

▼

40.2% 38.5% 41.0% 43.6% 51.8% 60.6%

<=100 99.2 110.4 85.5 74.9 93.3 Data reported in arrears

Data reported in arrears

0 3

▼

1 0 2 1 1 1

50% 43%

▼44.0% 27.0% 29.0% 43.2% 32.1% 57.9%

2.2% 2.4% 2.1% 1.9% 2.3% 2.3%2.9% 3.4% 2.9% 2.8% 3.0% 3.4%

100% N/A N/A 0% 100.0%0 1 ► 0 0 0 0 0 1

80-90% 89%►

65.5% 78.3% 89.8% 90.0% 89.6% 86.4%

23% 30.2% ▼ 28.8 29.7 32.7 31.9% 30.5% 28.3%

90% 88.3%▼

85.9% 89.5% 93.8% 91.1% 84.5% 89.6%

90% 80.1%▼

81.0% 79.0% 83.7 77.9% 80.4% 82.0%

99% 98.4% ▼ 99.1% 99.2% 99.6% 97.6% 98.2% 99.3%

100% 102%

►

Data Reported

Quarterly

Data Reported

Quarterly

Data Reported

Quarterly

100% 118%

▲

Data Reported

Quarterly

Data Reported

Quarterly

Data Reported

Quarterly

<=5% 10.3% ▼ 0.0% 8.3% 8.3% 11.1% 0.0% 14.3%

<=0.80 1.6%▼

2.3% 2.2% 2.1% 2.5% 0.8% 1.6% 1.6%

TBD 80.4% 81.2% 79.4%

TBD 6 4.1 6.0 6.3TBD 4.4 3.6 4.3 3.03.5% 1.95% ► 1.72% 2.65% 2.10% 1.81% 2.13% 1.91% 1.95%

N/A 1175 1294 1386 1063 1101 1053

<=10% 10.8% 9.8% 9.8% 9.8% 10.0% 10.1%N/A 3167 3136 3137 3136.3 3156 3165 3167

2766 2848 2799 2825 2829 2,845 2848 2848<=3.0% 3.8% ▲ 4.2% 4.4% 4.4% 3.8% 3.6% 4.0%

<=210 221.1 ▲ 246 232 240 231.4 208.8 223.2

<=40 53.1 ▲ 63 60 59 51.7 33.9 53.1

***24% 22%

▼

5.0% 13.0% 22%

***24% 12%▼

4.0% 12%

* data as of 12/07/2011** exception reports provided on a quarterly basis

****Target is cumulative

Data Quality

Monthly Trend Quarterly TrendPerformance

new metric for 2011/12Unplanned Readmissions within 30 days

Total WTE Agency Staff (excluding extra capacity nursing)new construction

118.0%

102.0%

**C-section rate

Delayed T rans fers of C are

% of women seen by a midwife or healthcare professional at 12 wks 6dys

VTE Risk Assessments

Clin

ical Q

uality

Number of falls resulting in a fracture/head injury

% of Stroke patients Scanned within 1 hour of hospital arrival

Unplanned Readmissions within 14 days

HSMR Non-elective

Safe, High Quality Coordinated Care

Number of Never events reported% Complaints responded to within agreed timeline with complainant/ 25 working days

Mate

rnit

y

Breastfeeding initiation

MRSA screening compliance (elective)

% of SUI's due to be closed in month that were closed

Hand Hygiene compliance

MRSA screening compliance (nonelective)

Total Establishment

Infe

cti

on

Co

ntr

ol

E xcess follow ups

Average L O S non-E lective

Pro

du

cti

vit

y a

nd

eff

ecti

ven

ess

cancelled operations as a percentage of elective admiss ions

Average L O S E lective

Daycase R ate

**% of cancelled operations not treated within 28 days

% of staff who have completed stat and mandatory training

Total in post

Sickness absence rate

Wo

rkfo

rce

Total WTE Bank Staff (excluding extra capacity nursing)

Vacancy Rate

% of staff who have been appraisednew construction

7

Contents




8

2. Charts for Performance Exception Areas

Weekly Type1&3 A&E Attendances seen in less then 4 hours

80%

85%

90%

95%

100%

105%

05/0

4/20

0926

/04/

2009

17/0

5/20

0907

/06/

2009

28/0

6/20

0919

/07/

2009

09/0

8/20

0930

/08/

2009

20/0

9/20

0911

/10/

2009

01/1

1/20

0922

/11/

2009

13/1

2/20

0903

/01/

2010

24/0

1/20

1014

/02/

2010

07/0

3/20

1028

/03/

2010

18/0

4/20

1009

/05/

2010

30/0

5/20

1020

/06/

2010

11/0

7/20

1001

/08/

2010

22/0

8/20

1012

/09/

2010

03/1

0/20

1024

/10/

2010

14/1

1/20

1005

/12/

2010

26/1

2/20

1016

/01/

2011

06/0

2/20

1127

/02/

2011

20/0

3/20

1110

/04/

2011

01/0

5/20

1122

/05/

2011

12/0

6/20

11

C-Sections

15%

20%

25%

30%

35%

40%

Apr-

08

May-0

8Jun-0

8Jul-08

Aug-0

8S

ep-0

8O

ct-

08

Nov-0

8D

ec-0

8Jan-0

9F

eb-0

9M

ar-

09

Apr-

09

May-0

9Jun-0

9Jul-09

Aug-0

9S

ep-0

9O

ct-

09

Nov-0

9D

ec-0

9Jan-1

0F

eb-1

0M

ar-

10

Apr-

10

May-1

0Jun-1

0Jul-10

Aug-1

0S

ep-1

0O

ct-

10

Nov-1

0D

ec-1

0Jan-1

1F

eb-1

1M

ar-

11

Apr-

11

May-1

1Jun-1

1

C-Section rates Target Trend linear

Stroke - 90% or more of time spend time on stroke unit

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Apr

-09

May

-09

Jun-

09Ju

l-09

Aug

-09

Sep

-09

Oct

-09

Nov

-09

Dec

-09

Jan-

10F

eb-1

0M

ar-1

0A

pr-1

0M

ay-1

0Ju

n-10

Jul-1

0A

ug-1

0S

ep-1

0O

ct-1

0N

ov-1

0D

ec-1

0Ja

n-11

Feb

-11

Mar

-11

Apr

-11

May

-11

Jun-

11

Stroke - 90% or more of time spend time on stroke unitTargetTrend linear

Cancelled Operations not treated within 28 days vs.Target

0%

5%

10%

15%

20%

25%

30%

Apr

-09

May

-09

Jun-

09Ju

l-09

Aug

-09

Sep

-09

Oct

-09

Nov

-09

Dec

-09

Jan-

10F

eb-1

0M

ar-1

0A

pr-1

0M

ay-1

0Ju

n-10

Jul-1

0A

ug-1

0S

ep-1

0O

ct-1

0N

ov-1

0D

ec-1

0Ja

n-11

Feb

-11

Mar

-11

Apr

-11

May

-11

Jun-

11

% Cancelled Operations not treated within 28 daysTargetTrend line

Divis ion/C linic al S ervic e: Medical Divis ion E mergency Department.K ey P erformanc e Indic ator: 95% of patients seen and treated in under 4 hours in E D K P I R ef No: X X X

C urrent Months P erf. Y TD P erf. Trend from previous month E xpec ted date to meet s tandard

80% 80% ٧

Num. Named L eadNew Ac tion

Ong oing Ac tion

E xpec ted C ompletion date Outc ome

1 C arlos x

2 P aula T ooms x continuous3 Ben Mearns x implemented4 P aula T ooms x ongoing5 P aula T ooms x5

Named R es pons ible L ead

P aula T ooms

Other K P I's Affec ted

R is ks

Ac tion

Ac tions for next monthOng oing ac tions from E D works tream c over Arrivals , Majors ,Obs ervation Unit, C ons ultant J ob P lanning , rec ruitment, revis ing of rotas and c ontinued review of metric 's .

S upport from the C orporate S ervic es

Internal refurbishment of department to facilitate improved streaming and working space, increase assessment and treatment capacity.P aula T ooms

Imformation and IT support with data collection and validation process , also C erner support following intergration of UT C with E D.

P erformance E xception R eport

S tandard

95%

Des c riptionR ef No.

Ac tions to improve performanc e

What is Driving the R eported Under P erformanc eAcheivement of the targets is s trongly linked to the capacity and flow of patients through the trust. F ailure to allocate beds to DT A's causes a backlog of patients to build up in E D which then impedes the flow and capacity of the department to see and treat patients efficently. Added to this is the change in measures being recorded in E D which has required s ignificant training with staff, followed by review to establish where data recording has been in accurate and corrections need to be made. A need to implement all actions within the E D transformation first 4 hours workstream is required to maximise internal performance.

Medical directorate implementation of Urgent C are L eads to provide access for consultant advice from G P 'sIntergration of UT C with E D, review of patient activity and selection to support E D flow.

E D quality indicators are now broken down into several area's , one's linked to time are all potientially affected due to delays being cascaded once we have accumulated them.

C ontinued lack of capacity with T rust

E D first 4 hours workstreamInternal review of weekly metrics to identify changes in performance that are incons istent with expectation and provide action plans or rationale for change, then implement action plan if required.

1st August implement new junior and middle grade rotas . C ommence new workflow streaming for patients through the department, with triage, arrivals , treatment process .complete review of UT C activity and demand, matching to staffing need, medical, E NP and NP 's .

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr-

11

May-1

1

Jun-1

1

Jul-11

Aug-1

1

Sep-1

1

Oct-

11

Nov-1

1

Dec-1

1

Jan-1

2

Feb-1

2

Mar-

12

Month

Pe

rce

nta

ge

co

mp

lia

nc

e

Divis ion/C linic al S ervic e: S urgical/ 18 weeks (Admitted P athway)K ey P erformanc e Indic ator: 90% of all Admitted pathway patients treated within 18 weeks K P I R ef No: X X X


O ct-11


Ong oing Ac tion


1 B ernie B luhm X 01/07/2011

2 Hamish Wallis X 25/06/2011agreements in place (298

pts R x Y T D)

3 C linton K rynie X01/07/2011 18/07/2011 validation still continuing

4 Hamish Wallis X 31/07/2011

5 C linton K rynie X01/07/2011 01/08/2011

delaied due to delay in validation


S tandard

90%

review and implement T rust Access policy

O utsourcing - put in place agreements to outsource 1000 patients in Q1 & 2.



Ac tions for next month


18 week dashboard to be implemetned and updated on weekly bas is - enabling trust to report performance

Informatics - Accurate and timely reporting of 18 weeks

Hamish Wallis

What is Driving the R eported Under P erformanc eHistorical backlog of patients caused by: R eferral demand in excess to commiss ioned activity, T heatre efficiency, B ed P ressures - on the day/day before cancellation due to non-availability of beds ( 28 in May), L ate decis ion making with regards to DT A from the Non Admitted P athway, Annual L eave Management – his torically this has been poorly managed.T he T rust is now in a pos ition where the total waiting lis t for the Admitted P athway is double the des ired s ize (including 1300 patients over 18 weeks). In order to bring the waiting lis t down to the des ired level and clear the backlog agreement has been reached with the P C T ’s and S HA for the trust to underperform on 18 weeks in Quarter 1 and 2

Validate all patients on the waiting lis t and ensure T rust is reporting accurate information

Ac tion

Median Waiting timesNon Admitted P athway performance

bed pressures - demand for beds from the emergency flow results in elective patients being cancelled

Agree plan (in plac e) and monitoring with P C T 's and S HA for clearance of backlog (us ing IS T modelling) - weekly/monthly monitoring forum to be established


C ontinue to inc reas e outs ourc ing c apac ity, by bring on line three more providers (B rig hton, E ps om, G atwic k P ark), plus inc reas in c apapc ity with c urrent providers

reduce income for elective activity due to cancellation of internal activity due to capacity - lack of ability to make up lost capacity (other than by outsourcing)

C omplete validation of Admitted pathway

Income and E xpenditure forecasted budget/plan for outsourcing


R is ks

C ancelled ops(non clincal reason) not treated within 28 days

R esolve issues regarding cashing up of clinics and inputting of outcome forms to ensure accurate information is being input in timely manner (identify any training issues needed)

Dashboards: finalise and implement to ensure accurate weekly reporting

0%

20%

40%

60%

80%

100%

120%

Ap

r-1

1

Ma

y-1

1

Ju

n-1

1

Ju

l-1

1

Au

g-1

1

Se

p-1

1

Oct-

11

No

v-1

1

De

c-1

1

Ja

n-1

2

Fe

b-1

2

Ma

r-1

2

Month

Pe

rce

nta

ge

co

mp

lia

nc

e

Date by which compliance is required

Divis ion/C linic al S ervic e: MedicineK ey P erformanc e Indic ator: mixed sex accommodation K P I R ef No: X X X


9 ▼


Ong oing Ac tion


1Angela

S tevenson x DailyMixed sex breaches

minimised

2 L isa C heek x Dailymixed sex breaches

minimised

3Angela

S tevenson x Dailymixed sex breaches

minimised


L isa C heek


R is ks

Ac tion

Ac tions for next monthAs above.

S upport from the C orporate S ervic esNone


S tandard

0



What is Driving the R eported Under P erformanc eT he T rust continued to be very busy through J une 2011 with several escalation areas open and operationally was very challenging. T he 10 breaches which occurred in the medical divis ion were in the discharge lounge and A&E observation ward. 8 breaches occured in the observation ward and 2 breaches in the discharge lounge which is used as an escalation area over night. All measures were taken to prevent any mixed sex breaches and verbal information was given to the patients ..

P atients are moved at the earliest opportunity if a breach has occurred

None

s ite meeting attended by operation staff and clinical s taff and all oportunities explored to prevent any mixed sex accomodation.

All potentials to mix a bay are escalated through a matron to ensure all alternatives are cons idered first.

Divis ion/C linic al S ervic e: Medical Divis ion, S trokeK ey P erformanc e Indic ator: S troke 90% or more time spent on S troke Unit K P I R ef No:

C urrent Months P erf. Y TD Avg P erf. Trend from previous month E xpec ted date to meet s tandard69% 65% ▲ Apr-12


O ng oing Ac tion


1 Natasha Hare

X2 Natasha Hare

X 30-S ep-113 Natasha Hare

X 31-May-11 C omplete4 F iona White

(NHS West S x)

X 30-S ep-11 O ngoing5 Natasha Hare

X5 R obyn Davies

(NHS S urrey) X 30-S ep-117 B ernie B luhm

X

E ast S urrey E arly S upported D ischarge pilot (s tart date tbc but likely to s tart in J uly).

R ing-fence beds on Abinger ward to be used for S troke patients only and monitor impact on a weekly bas is

Achievement of best practice tariff

% of patients admitted directly to AS U within 4 hours of hospital arrival

Winter / E mergency B ed P ressures

D&V outbreaks and subsequent ward closures

P roposal to combine s troke beds into one ward to be discussed at divis ional level.

What is Driving the R eported Under P erformanc eAchievement of the 90% indicator is s trongly linked to the emergency patient flow pathway and associated actions relating to bed management and effective and timely discharge. T he non-performing pathways were again linked to continued pressures on bed capacity, which are not showing s igns of improvement. We continue to see steady improvement month on month helped by the ring fencing of beds although this alone has not made a s ignificant impact.

T IA pathway and booking process has been reviewed and communicated to G P s to improve communication and reduce time.

West S ussex E arly S upported D ischarge pilot underway (too early for results and under threat due to funding cuts ).

O utlying patients are reviewed daily and repatriated as soon as clinically appropriate.

L ocum consultant on C apel ward appointed until a substantive appointment is made. J ob description for the substantive post is awaiting C ollege approval.


S tandard80%



Named R es pons ible L eadNatasha Hare


R is ks

Ac tion

Ac tions for next monthP ublis h L oS K P I information at ward level s o that all s taff c an eas ily s ee c urrent performanc e.


Introduction of Medihome / virtual ward / early discharge in J uly 2011

S upport ring fenced beds

90% stay on stroke unit

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90%

Ap

r-1

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Winter Pressures

Stroke Beds ring fenced

Improved Flow i.e. impact of Medihome / virtual ward

Early Supported Discharge

Divis ion/C linic al S ervic e: S urgical Divis ion/ #NOFK ey P erformanc e Indic ator: 85% of #NOF operated on within 36 hours K P I R ef No: X X X


66% 66% Aug-11

Num. Named L ead New Ac tionOng oing Ac tion


1 S ally P aterson 01/07/2011complete - needs to

be audited

2 G T selentakis X 01/08/20113 Hamish Wallis X 30/07/2011 part complete4 G T selentakis X 30/08/2011 on-going

E nsure that patients admitted with F racture neck of femur are admitted to Newdigate ward, not outlying wards

Iliaca F emoral B lock (% of patients who received) - 50%day 1 P ost op P hys iotherapy - 80%DVT P rophylas is - 87%

Other Non #NOF trauma patients being admitted that are clinical urgent (activity is increas ing)


S tandard

85%

Number of #NOF patietns transferred to Newdigate Ward within 4 hours - 4




Hamish Wallis

What is Driving the R eported Under P erformanc eIn J une there was a higher than normal level of patients (5) that required medical s tabilisation before they could be operated on. 4 patients breached the target due to insufficent operating time and were therefore rescheduled to the next day.

T ransfer T rauma lis t from white Board to E lectronic system within C erner - resulting in better management of lis ts and accessablity of lis tImplementation of action plan following the Moran R eview

Ac tion


R is ks


E nsure order of lis t is agreed and set the night before with #NOF patient first on lis tS unday T rauma lis t to run for 6 hours starting at 10.30am - Medical teams have agreed, this needs to go into new specialty Doctor contract, T heatre nurs ing rota now this cover sess ion

E nsure the availability of the F ast-track bed

Agree S unday morning lis t in job plan of specialty doctorE stablish effective escalation system for patients who are fit for surgery but unlikely to be operated on with 36hrs

Audit the order of the lis t, ensuring that it is agreed the previous day and the first patient doesn't change

S upport from the C orporate S ervic esR efocus on the F ascia Iliaca B lock performance

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-11

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14 14

FnoF – Exception graphs

S AS H T rauma (#NOF and Other) by Month

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NO N #NO F #NO F

Complaince for DVT, Day 1 post op physio & Iliaca Block for #NOF patients per month

0.00%

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120.00%

January February March April May June July August September October November December January February March April May June

Month

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DVT Prophylaxis % received physio on day 1 post op % pts receiving Iliaca Block

S AS H T rauma - #NOF c omplianc e

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% R x in 36 hrs % R x in 48 hrs T arget


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NO N #NO F #NO F


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% R x in 36 hrs % R x in 48 hrs T arget


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NON #NOF #NOF


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Divis ion/C linic al S ervic e: C linical S upport S ervicesK ey P erformanc e Indic ator: K P I R ef No: X X X


0 1 ▼ J uly


Ong oing Ac tion


1 C hristine P owell X C ompleted No action required


J ackie B rown


R is ks

Ac tion

Ac tions for next monthNone

S upport from the C orporate S ervic esNone R equired


S tandard

0



What is Driving the R eported Under P erformanc eO n the 20/06/11 - P atient was walking with a nurse in the outpatient department waiting area at Horsham O P D and caught her foot on corner of one of the fixed waiting room chair legs and fell. T he patient was both elderly and frail hence walking with the nurse in the waiting room area. A doctor in the O P D saw the incident and attended the patient with the nurs ing s taff whils t they were waiting for an ambulance to arrive. It was thought from initial examnination that the patients sustained a fracture neck of femur. T he patient was admitted to Newdigate Ward at E S H and found to have fractured her left neck of femur following x-ray. T he incident was reports to the Head of O P &HR S and patient's next of kin. An incident report was completed. T he Head of O P &HR S reported the matter to her AD of C S S . R oot cause analys is showed this incident was an accident.

None

Incident was investigated

Divis ion/C linic al S ervic e: Medical Divis ion, WAC H K ey P erformanc e Indic ator: VT E assessment within 24hours 90% K P I R ef No: X X X

C urrent Months P erf. Y TD P erf. Trend from previous month E xpec ted date to meet s tandard83% Medical, 35% WAC H, 44% S urgical 53.4% T rustwide ▲ J ul-11 Medical, S ept-11 WAC H,


Ong oing Ac tion


1(Med) J eff T hompson x end J uly

2(Med) P aula T ooms x end J uly3(Med) J eff T hompson x end J uly4(wach) Dr. Nadim x5 (wach) Dr. Nadim x

6(S urg) Hamish Wallace x 01/07/2011done but being

repeated

7(S urg) Hamish Wallace x 01/07/2011 completed

8(S urg) Hamish Wallace x 01/07/2011

agreed to be included (?not been

done)9(S urg) Hamish Wallace x on going

VT E Assessment will be recorded on cerner by the B rockham ward s taff

T raining and communication to Medical and Nurs ing s taff on completing the E lectronic vers ionR eview of what is being included and what should be excluded from the lis t of patients elig ible for VT E Assessment – there are a large portion of patients being included that should not be (i.e. O phthalmology, E ndoscopy).

R eview of how and when data is be input (E .g. Urology completing 100% at P re assessment but data not being picked up)

C QUIN: T here is National best practice guidance which is linked to C QUIN funding to further encourage focus on this area of patient safety.

C ontinued data collection issues .

R emove E ndoscopy and Angiography day case activity from medical admiss ion data. Needs further refining in sense of only zero L O S patients to be excluded.R eview of 10 patient episodes coded to E D observation and Discharge lounge to assess pathway of patients and establish whether they fulfil the criteris for inclus ion in the data

Non-elig ible patients appearing on the lis t, which is dis torting the results - due to no distinction in coding between G A and L ocal'sMedical S taff - time constraints

(S urg) P re assessment VT E assessments to be included as agreed at Management B oard - this has not been done and so needs to be reviewed and completed(S urg) C ontinue monitoring within S AU of all elig ible patients being admitted on the emergency pathway.

What is Driving the R eported Under P erformanc eAll medically expected or internally referred patients are unable to be admitted unless there VT E assessment is completed as it is a mandatory field. C ontinued concern about the integrety of the data collection and presentation.

R eview of internal referrals to medicine, i.e surgical or ME T calls to see if reason for failure to assess as already admitted.VT E Assessment will be undertaken during the admiss ions process .


S tandard

90%




B en Mearns (Medical), Debbie P ullen(WAC H) Hamish Wallace (S urgical)


R is ks

Ac tion

Ac tions for next month(Med) Work with information to refine data collection and presentation

(S urg) R eview process for elective patients on day of admiss ion to ensure VT E Assessment is on system

Weekly monitoring of compliance by speciality/location

(S urg) communication: continue to raise profile of VT E assessments (electronically) at all S pecialty meeting and training days .

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Target

Medical Forecast

WACH Forecaast

Surgical Forecast

Divis ion/C linic al S ervic e: W&C HK ey P erformanc e Indic ator: C aesarean sections K P I R ef No: X X X

C urrent Months P erf. Y TD P erf. Trend from previous monthE xpec ted date to meet s tandard

29% 30% ▼ 31.3.12


Ong oing Ac tion


1 S harmila S ivarajan Y es No Aug-11E xamine data and act on

information

2 Denise Newman Y es No1.8.11 & constant

C hange of mindset of women and midwives re risk


S ue C hapman


R is ks

Ac tion

Ac tions for next monthMonitor outc omes and build on s uc c es s es



S tandard

23%



What is Driving the R eported Under P erformanc eL ow tolerance to changing plan to C aesarean S ection

None

Despite many previous actions we have seen little improvement in the rate

10 week prospective audit underwayNew B irthing Unit T eam L eader in post - change admiss ion pathway and admit as low risk by default and only transfer to main delivery suite if confirmed high risk. Dedicated midwifery team.

Divis ion/C linic al S ervic e: W&C HK ey P erformanc e Indic ator: Women booked by 12wks & 6 days K P I R ef No: X X X


89.6% 88.3% ▲


Ong oing Ac tion


1Maureen

R oyds-J onesNone in

month Y es O ngoing


S ue C hapman


R is ks

Ac tion

Ac tions for next monthE nc ourag ement of women to book early



S tandard

90%



What is Driving the R eported Under P erformanc eS ome months women do not access care in a timely manner

None

F luctuation as dependent upon women notifying their pregnancy and booking appoitments

E nsure adeqaute capacity of appointments

Divis ion/C linic al S ervic e: W&C HK ey P erformanc e Indic ator: B reast feeding initiation rate K P I R ef No: X X X

C urrent Months P erf. Y TD P erf. Trend from previous monthE xpec ted date to meet s tandard

82% 80% ▲ 31.12.11


Ong oing Ac tion


1 J anice B lythman no yes Apr-12 Increased rates


S ue C hapman


R is ks

Ac tion

Ac tions for next monthC ontinue with educ ation of all relevant s pec ialties



S tandard

90%



What is Driving the R eported Under P erformanc eWomen's choice and incons is tent advice from various staff groups

None

Despite many previous actions we have seen little improvement in the rate & women's choice will always influence this

Undertaking 2 year B aby F riendly project

Divis ion/C linic al S ervic e: C ancelled O perations not treated within 28 days K ey P erformanc e Indic ator: % of cancelled operations not treated within 28 days K P I R ef No: X X X

Quarterly P erf. Y TD P erf. Trend from previous month E xpec ted date to meet s tandard

10% 10% Aug-11


Ong oing Ac tion


1 S ue C orby X on going

2 Hamish Wallis X on going

3 S ue C orby X on going

4

Ac tion


C ancelled operations as a percentage of elective admiss ions

B ed C apacity (Winter P ressures)

C ancellations are being reviewed on a weekly bas is to ensure compliance.

All patients cancelled for non clinical reasons to have a new T C I within 7 days of being cancelled – if not then to be escalated through weekly P T L meeting.


R is ks



S tandard

%

All patients cancelled on the day to be reviewed at weekly P T L meeting



Hamish Wallis

What is Driving the R eported Under P erformanc eIn quarter 1 there was 138 patients cancelled on the day (vast majority due to bed pressures) and 116 patients who had 28 day breach dates of which 12 were not treated within their breach date due to capacity issues . T his equates to 10.34% of cancelled operations not treated within 28 days in for Quarter 1.O f the 4 who breached their 28 days the original reason for the cancellation on the day was due to:9x = No B eds , 1x = P atient issue, 1x = surgeon s ick and no one available to do operation.

C ontinue with weekly monitoring of cancellations through the P T L meeting

S upport from the C orporate S ervic esE lective beds to be refenced

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21

Contents




22

3. Glossary Of terms

MRSA - Methicillin-resistant Staphylococcus aureus Cdiff - Clostridium difficile HSMR – Hospital Standardised Mortality Rates TIA - Transient Ischaemic Attack RIDDOR – Reporting of Injuries Dieses And Dangerous Occurrences ITU – Intensive Treatment Unit WTE – Whole Time Equivalent FFCE – First Finished Consultant episode AMI – Acute Myocardial Infraction RACP – Rapid Access Chest Pain CDS – Commissioning Data Set LOLER - Lifting Operations and Lifting Equipment Regulations 1998 SUI – Serious Untoward Incident ITU – Intensive Treatment Unit H&S – Health and Safety

1 integrated quality and performance report m3– june 2011 presented by: bernie bluhm (chief...

Documents

integrated quality

performance exception

exception reports3

performance dashboard2

data quality indicators

performance dashboardpage

care quality commission

fnof exception graphs