nhs hounslow ccg governing body cover sheet · clinical lead dr. prashant gupta manager lead sue...

PAPER 11

of 2

NHS HOUNSLOW CCG GOVERNING BODY Cover Sheet

Date: 23rd July 2013

Report title Hounslow CCG Performance and Quality Report M2

Author Commissioning Support Unit

Clinical Lead Dr. Prashant Gupta

Manager Lead Sue Jeffers Managing Director

Audit Trail: Finance and Performance Committee

Presented by Sue Jeffers Organisation HCCG

Executive Summary and Purpose of report

This is the first iteration of the CCG report. It is divided into sections that cover the range of reporting requirements. Section 2 is the executive summary. In Section 4 the CCG outcomes has a range of indicators that have annual reporting cycles, where the data is either not available or is 2011 data.

The Quality Premium on Section 5 includes the CCG Local Priorities that were agreed with our Health and Wellbeing Board and are in our Plan on a Page.

A new section on the CCG progress against Shaping a Healthier Future indicators is available at Section 7

Significant issues for Hounslow are:

not meeting the 62 days to treatment for cancer patients

LAS handover

The number of health visitors

Friends and Family test response rate in A&E and IP

Recommended Actions / Next steps

Recommended actions are listed in Section 13

It is recommended that Finance and Performance Committee over sees progress against the actions outlined in Section 13 and reports back to the Governing body in next month’s performance report

The Governing Body is asked to:

1. NOTE the report

2. Discuss the report and agree any particular actions for F&P to oversee or take forward.

Links to CCG strategy and objectives

Fits directly with CCG Operating Plan and Plan on a Page

PAPER 11

of 2

Key Issues and Risks Limited data from Ashford St Peters

Indicate implications for:

Please outline implications for the CCG within the four categories below. Considering all four categories, if there are no implications, please state why.

Patient and public engagement

Performance Report discussed in public at the Governing Body

FinancialFinancial penalties associated with non‐delivery of certain performance indicators; the Quality Premium carries a financial incentive for delivery, worked example in Appendix 1

Quality and Performance Core to this report

Information Governance Management Technology

(IGMT)N/A

Equality impact analysis

N/A

Legal Issues Implications for the CCG delivery of the NHS Constitution and the NHS Mandate;

Hounslow CCG Performance & Quality Report – May 2013

Month 2FINAL

PAPER 11 (b)

1

Section 1: Executive summary

high quality support to commissioners to improve health and wellbeing

▪ CCG Operating Framework ‐ The CCG is currently meeting constitutional performance measures with the exception of – Health Care Acquired Infection (HCAI): 14 cases C.Diff cases against a year to date tolerance of 10 cases. – 18 week RTT: 2 patients waiting over 52 weeks were reported by King’s College and Royal Free Hampstead hospitals.– Cancer: Hounslow CCG is not meeting the 62 day to treatment standard achieving 77.8% (6 breaches) across ICHT, WMUH and the Royal

Marsden.

▪ Quality Premium – With the exception of HCAI, the related indicators are reported quarterly and annually. The CCG is within the zero tolerance for MRSA cases . To date 14 CDiff cases have been reported against reported against a year to date tolerance of 10 cases but the CCG is still within its annual tolerance of 48 cases.

▪ Areas where provider performance (trust‐wide across all CCGs) is below standard:– 18 weeks RTT: At ICHT, standards are not being met across 3 specialities and 7 patients waited over 52 weeks. – HCAI: 4 MRSA and 18 CDiff cases at ICHT year to date. 6 CDiff cases at WMUH year to date. – LAS arrival to handover waits greater than 30mins / 60 mins: 36 / 1 patient breaches reported at ICHT and 72 / 0 patient breaches

reported at WMUH in Month 2– Friends & Family Test (FFT) : Low response rate at WMUH with 1% of A&E attendances completing FFT survey.– Cancer: ICHT did not meet the 31 days to treatment standard achieving 95.1% in Month 2 against a requirement of 96% or the 62 days

referral to urgent treatment standard achieving 74.5% against a requirement of 85%. In addition WMUH did not did not meet the 62 day screening and consultant upgrade standards achieving 50% and 0% respectively.

– No. of Health Visitors at HRCH: The Trust has 37.2 wte Health Visitors in post against the 52.8 wte target

▪ The CCG, supported by CSU, is taking the following actions to address these performance concerns:– Contract penalties will be applied to all Trusts breaching national standards, for example £5000 for each 18 week 52 week wait, 1000k for a

60 minute handover breach, and £200 for a 30 minute handover breach. – Root cause analyses, exception reports and action plans are required where providers have breached quality standards which are discussed

at relevant contractual meetings. Where required the CSU performance and quality teams undertakes critical analysis of exception reports, demand and capacity assessments, and action plans submitted by providers.

– The CSU also monitors action plans on a weekly / month basis and A&E pressures on a daily basis. Where necessary the CSU meet with providers to agree additional actions required.

2high quality support to commissioners to improve health and wellbeing

Key messages

Section 2: NHS CCG Operating Framework

Performance MeasureReporting Period

Reporting Frequency

ThresholdNHS HOUNSLOW CCG

West Middlesex University Hospital NHS Trust

Imperial College Healthcare NHS Trust

Ashford & St Peters

Hospital Trust

In mth/qtr YTD In mth/qtr YTD Variance In mth/qtr YTD VarianceIn

mth/qtrYTD

18 weeks RTT ‐ admitted performance within 18 weeks

Monthly M2

90%

93.1% 93.3% 96.7% 96.2% 0 92.9% 92.1% 0 91.6% >90%

18 weeks RTT ‐ admitted performance within 18 weeks: specialties that failed to achieve the threshold

Monthly M2

ENT 89.5%Oral Surgery 83.3%

Neurosurgery 78.6%

T&O 60.2%Other Specialties 89.9%

18 weeks RTT ‐ non‐admitted performance within 18 weeks

Monthly M2

95%

97.9% 97.5% 98.3% 98.0% 0 97.1% 96.9% 0 98.6% >95%

18 weeks RTT ‐ non‐admitted performance within 18 weeks: specialties that failed to achieve the threshold

Monthly M2

General Surgery 92.1% General Surgery 80.6%Urology 87.5%

T&O 94.9%

18 weeks RTT ‐ incomplete pathways within 18 weeks

Monthly M2 92%

96.1% 95.7% 95.5% 95.3% 0 96.4% 95.7% 0 97.7% >92%

18 weeks RTT ‐ incomplete pathways within 18 weeks: specialties that failed to achieve the threshold

T&O 91.2% Oral Surgery 90.7% Urology 90.2%T&O 90.7%

Number of 52 week RTT pathways ‐admitted

Monthly M2 0

0 0 0 1 ‐1

Number of 52 week RTT pathways ‐ non‐admitted

0 0 0 3 0

Number of 52 week RTT pathways ‐incomplete

2 0 0 3 2

Percentage of patients waiting 6 weeks or more for a diagnostic test

Monthly M2 1% 0.3% 0.2% 0.00% 0.01% 0 0.08% 0.15% 0 0% 0%

▪ Hounslow CCG is meeting RTT performance standards overall but not the 52 week wait or specialty standards. The 2 patients waiting over 52 weeks were reported by King’s College and Royal Free Hampstead hospitals. Hounslow’s specialty performance has been impacted by ICHT reducing it’s backlog within General Surgery, and T&O. For admitted performance there were small numbers of patients treated in Oral Surgery and Neurosurgery. In addition, ENT was impacted by 6 breaches at WHUH.

▪ ICHT, is not meeting 18 week RTT speciality standards (3 challenged specialties) and also the 52 week standard (7 patients). Recovery trajectories are in place for the 3 challenged specialities not achieving RTT standards at ICHT.


Section 2: NHS CCG Operating Framework (contd.)


Reporting Frequency




Ashford & St Peters

Hospital Trust

In mth/qtr YTDIn

mth/qtrYTD Variance In mth/qtr YTD Variance

In mth/qtr

YTD

Total time spent in A & E < 4 hours (all types) Monthly M2 95% 97.73% 96.67% 0 97.07% 96.14% 0 92.7% <95%Patients who have waited over 12 hours in A&E from decision to admit to admission

Monthly M2 0 0 0 0 0 0 0 0 0

Number of LAS arrival to handover > 30mins Monthly M2 0 72 158 ‐14 36 85 ‐13 58 165Number of LAS arrival to handover > 60mins Monthly M2 0 0 4 ‐4 1 1 0 5 15Percentage of patients seen within two weeks of an urgent GP referral for suspected cancer

Monthly M2 93% 94.5% 93.6% 93.9% 92.9% 0 97.9% 98.2% 0 98.3% >93%

Percentage of patients seen within two weeks of an urgent referral for breast symptoms where cancer is not initially suspected

Monthly M2 93% 98.8% 94.5% 97.1% 95.4% 0 98.0% 97.6% 0 98.0% >93%

Percentage of patients receiving first definitive treatment within one month of a cancer diagnosis

Monthly M2 96% 100.0% 97.4% 100.0% 100.0% 0 95.1% 95.7% 0 100% 100%

Percentage of patients receiving subsequent treatment for cancer within 31‐days where that treatment is Surgery

Monthly M2 94% 100.0% 100.0% 100.0% 100.0% 0 95.7% 94.9% 0 100% 100%

Percentage of patients receiving subsequent treatment for cancer within 31‐days where that treatment is an Anti‐Cancer Drug Regime

Monthly 98% 100.0% 100.0% 100.0% 100.0% 0 100.0% 100.0% 0 100% 100%

Percentage of patients receiving subsequent treatment for cancer within 31‐days where that treatment is a Radiotherapy Treatment Course

Monthly M2 94% 95.2% 98.1%No

Patients Treated

No Patients Treated

97.8% 97.9% 0No

Patients

No Patients

Percentage of patients receiving first definitive treatment for cancer within 62‐days of an urgent GP referral for suspected cancer

Monthly M2 85% 77.8% 75.5% 85.0% 81.6% 0 74.5% 74.7% 0 87.5% >85%

Percentage of patients receiving first definitive treatment for cancer within 62‐days of referral from a Cancer Screening Service

Monthly M2 90% 100.0% 75.0% 50.0% 66.7% ‐1 97.4% 89.7% 0 100% 100%

Percentage of patients receiving first definitive treatment for cancer within 62‐days of a consultant decision to upgrade their priority status

Monthly M2 85%No patients treated

100.0% 0.0% 50.0% ‐1 93.5% 95.9% 0 100% 100%

Key messages

▪ LAS arrival to handover waits greater than 30mins / 60 mins: 36 / 1 patients at ICHT and 72 / 0 patients at WMUH in Month 2 30 minute and 60 minute ambulance handover breaches have reduced across ICHT and WMUH in Month 2 compared to Month 1.

▪ Cancer: Hounslow CCG is not meeting the 62 day to treatment standard achieving 77.8% (6 breaches) across ICHT, WMUH and the Royal Marsden. Root cause analyses are being provided by all providers not meeting cancer standards that will be reviewed by the CSU cancer commissioning team.




Reporting Frequency




Ashford & St Peters

Hospital Trust

In mth/qtr YTD In mth/qtr YTD VarianceIn

mth/qtrYTD Variance

In mth/qtr

YTD

MSA breachesMonthly

M2 0 0 0 0 0 0 0 0 0 0 1

MSA breach rate M2 0.00 0.00 0.00 0.00 0 0.00 0.00 0Not

availableNot

available

Cancelled ops ‐ breaches of 28 days readmission guarantee as % of cancelled ops*

Monthly 5% 0.0% 0.0% 0 28.9% 26.1% 0 0.0% 0.0%

Number of last minute cancelled operations by the hospital for non‐clinical reasons*

Monthly M2 6 11 1 76 138 14Not

availableNot

available

Number of urgent operations that are cancelled by the trust for non‐clinical reasons, which have already been previously cancelled once for non‐clinical reasons

Monthly M2 0 0 0 0 0 0 0 0 0

Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)*

M2 Monthly Reduction 39.7 77.7 110 209 11 241 468 14Not

availableNot

available

Unplanned hospitalisation for asthma, hypertension, diabetes and epilepsy in under 19s*

M2 Monthly Reduction 24.3 37.2 21 30 12 16 24 8Not

availableNot

available

Emergency admissions for acute conditions that should not usually require hospital admission*

M2 Monthly Reduction 148 318 ‐22 310 592 28Not

availableNot

available

Key messages

▪ Cancelled operation – ICHT did not meet cancelled operations standard in Month 2 and the Trust will clarify remedial action at the July CQG meeting.




Reporting Frequency




Ashford & St Peters

Hospital Trust

In mth/qtr YTDIn

mth/qtrYTD Variance In mth/qtr YTD Variance

In mth/qtr

YTD

Patient reported outcomes measures for elective procedures ‐ hip replacement

Apr‐12 to Dec‐12

(provisional)

Monthly Increase 0.396 ** 0.388YTD =

2010/11 final

** 0.393YTD =

2010/11 final

Patient reported outcomes measures for elective procedures ‐ knee replacement


2010/11 final

** 0.240YTD =

2010/11 final

Patient reported outcomes measures for elective procedures ‐ groin hernia


2010/11 final

0.058 **YTD =

2010/11 final

Patient reported outcomes measures for elective procedures ‐ varicose veins

Monthly Increasedata supressed due to

small numbersN/A

No data

0.100 0.075YTD =

2010/11 final

Patient Experience: Overall score across 5 domains (inpatient survey)

2012 Annual4‐5 passes out of 5 themes

71.8 ‐0.7 74.4 1.6

MRSA MonthlyMonthly Target 0 0 0 0 0 0

M2 0 0 0 0 0 0 4 4 4 0 0

C.DiffM2

ProvisionalMonthly

Monthly Target 4 10 1 2 5 11

Annual Target 48 12 65Actual 5 14 0 6 0 6 18 6 0 1

Dementia Diagnosis rate not availableThe proportion of patients on Care Programme Approach (CPA) are followed up within 7 days Q4 12/13 Quarterly

95% 99.00% 98.50%

Proportion of people with depression receiving psychological therapies Q4 12/13 Quarterly

1.3% (Q4)5.0% (YTD)

2.50% 9.00%

Proportion of people with depression receiving psychological therapies who are moving to recovery Q4 12/13 Quarterly

30.7% (Q4)30.2% (YTD)

38.50% 35.70%

Key messages

• Infection control: Hounslow CCG did not meet the C.Diff standard in Month 2 or the year to date with 14 cases reported against a tolerance of 10 cases. Acute provider apportioned cases were reported by WMUH (3), ICHT (2), and University College Hospitals (1) . WMUH and ICHT have provided RCA’s and an action plan in relation to infection control cases to Month 2.

6

Section 3: CCG Outcomes Framework


This section is a performance dashboard that gives the CCG an overview of its position in relation to the indicators listed in the CCG Outcomes Framework. All indicators have an improvement threshold. HCAI is reported monthly and related comments have been provided in Section 4 of this report.

Key messages

Domain Description Period Baseline TargetPrevious

Performance

Current

PerformanceRAG assessment

Reporting

Frequency

Date next

available

Potential years of life lost (PYLL) from causes considered

amendable to healthcare ‐ MALE2011 reduction

2111.69

(2010)

2336.71

(2011)Annual Sep‐13

Potential years of life lost (PYLL) from causes considered

amendable to healthcare ‐ FEMALE2011 reduction

1718.55

(2010)

1855.21


Under 75 mortality rate from cardiovascular disease2011 reduction not available

60.73


Under 75 mortality from respiratory disease2011 reduction not available

28.02


Under 75 mortality rate from liver disease2011 reduction not available

16.45


Emergency admissions for alcohol‐related liver disease2011/12 reduction

31.51

(10/11)

35.57

(11/12)Annual TBC

Under 75 mortality rate from cancer2011 reduction not available

118.35


Antenatal assessments <13 weeksQ4 2012/13 increase

947

(Q3 12/13)

916

(Q4 12/13)Quarterly Oct‐13

Maternal smoking at deliveryQ4 2012/13 reduction

4.2%

(Q3 12/13)

3.5%

(Q4 12/13)Quarterly Aug‐13

Breast feeding prevalence at 6‐8 weeksQ4 2012/13 increase

67.1%

(Q3 12/13)

65.9%

(Q4 12/13)Quarterly Oct‐13

People suffering from a long term condition feeling

supported2012/13 increase

75.6%

(Apr‐Jun)

75.4%

(July‐Mar)Six monthly not known

Unplanned hospitalisation for chronic ambulatory care

sensitive (ACS) conditions (adults)2011/12 reduction

833.28

(10/11)

905.35

(11/12)Annual TBC

Unplanned hospitalisation for asthma, diabetes and

epilepsy (under 19s)2011/12 reduction

275.33

(10/11)

252.06

(11/12)Annual TBC

Estimated diagnosis rate for people with dementia no data no data no data no data no data no data no data

Preventing people

from dying prematurely

Enhancing the quality

of life of

people with long

term

conditions

7

Section 3: CCG Outcomes Framework (contd.)


Domain Description Period Baseline TargetPrevious

Performance

Current

PerformanceRAG assessment

Reporting

Frequency

Date next

available

Emergency admissions for acute conditions that should not

usually require hospital admission2011/12 reduction

1017.04

(10/11)

1049.47

(11/12)Annual TBC

Emergency readmissions within 30 days of discharge from

hospital2010/11 reduction not available

12.72

(10/11)Annual TBC

Increased health gain as assessed by patients for elective

procedures ‐ hip replacement2011/12 increase

0.374

(10/11)

0.396

(11/12)Annual TBC


procedures ‐ knee replacement2011/12 increase

0.264

(10/11)

0.339

(11/12)Annual TBC


procedures ‐ groin hernia2011/12 increase

0.105

(10/11)

0.102

(11/12)Annual TBC


procedures ‐ varicose veins. 2011/12 increasedata supressed

due to small

numbers

data supressed

due to small

numbers

Annual TBC

Emergency admissions for children with lower respiratory

tract infections (LRTIs)2011/12 reduction

188.9

(10/11)

215.03

(11/12)Annual TBC

Patient experience of GP out of hours services2012/13 improvement

55.5%

(Apr‐Jun)

56.6%

(Jul‐Mar)Six monthly not known

Patient experience of hospital care (CCG weighted

average)2011 improvement not available

72

(2011)Annual TBC

Patient experience of outpatient services2011 improvement not available

76

(2011)Annual Autumn 13

Improvement in hospitals’ responsiveness to personal

needs2011 improvement not available

62

(2011)Annual TBC

Patient experience of accident and emergency (A&E)

services.2011 improvement not available

77

(2011)Annual TBC

Patient safety incidents reportedApr‐12 to Sep‐12 0 not available

9

(Apr‐Sep)Six monthly Sep‐13

Incidence of healthcare associated infection (HCAI): MRSAApr‐May 13 0

14

(12/13)

0

(Apr‐May)Monthly Aug‐13

Incidence of healthcare associated infection (HCAI):

Clostridium difficile (C.difficile)Apr‐May 13 10

62

(12/13)

14

(Apr‐May)Monthly Aug‐13

Helping people to recove

r from

ill h

ealth or following injury

Preve

nting people from dying

prematurely

Treating for

people in

a safe

environment an

d

protecting them

from avo

idab

le

harm

8

Section 4: Quality premium


National indicators

Local indicators

Actual TargetPotential Loss of income £k

Maximum value £k Frequency

TBD

TBD

Monthly

TBD Annual

TBD Annual

TBD Monthly

Key messages

Early warning for indicators on a problem trajectory

TBD

Gateway indicators

▪ Cat A red 1 ambulance calls

▪ 18 weeks RTT (incomplate pathway)

▪ A&E waits (CCG mapped from HES provider data)

▪ Cancer waits – 62 days (urgent GP referral)

92% N/A N/A

85%

75%

N/A N/A

N/A N/A

N/A N/A

97.2% (M2 ytd) 95%95.7% (M2 ytd

75.5% (M2 ytd)69.2% (M1)

Please see Appendix 1 for Quality Premium calculation guidance

▪ With the exception of HCAI, the related indicators are reported quarterly and annually. The CCG is within the zero tolerance for MRSA cases . To date 14 CDiff cases have been reported against reported against a year to date tolerance of 10 cases but the CCG is still within its annual tolerance of 48 cases.

Annual

tbc

tbc

▪ Preventing healthcare associated infections 0 (MRSA)14 (C.Difficile)

0 (MRSA)10 (C.Difficile)

▪ Reducing potential years of lives lost through amenable mortality

2,156 (male)1,533 (female)

Available on Summer 2013

▪ Reducing avoidable emergency admissions Not available

▪ Patient experience of acute inpatient care and A&E using the Friends and Family Test Not available

Data not available

Data not available

162,462

324,924

162,462

162,462

tbc▪ Alcohol – increase in iHear Activity tbc

▪ Unplanned hospital admissions for ambulatory care sensitive conditions

905.4 1016

▪ GP Practice patient experience% rating ‘fairly good’ or ‘very good’ 84%78.4%

0162,4 62

162,462

162,462

TBD : to be determined

9

Section 5: NHSE Assurance – provider quality of care


Key messages

Domain 1: Are local people getting good quality care?

▪ Data is for Quarter 1 YTD▪ West Mid FFT action plans refers to the 2013/14 CQUIN regarding response rates of a minimum 15%. This is monitored quarterly.▪ Chelsea and Westminster and Imperial are outliers on SHMI: they are lower than expected on the SHMI.▪ All providers that have reported single sex accommodation breaches and or MRSA cases have action plans in place

▪ Trusts have either 45 or 60 days to close SI’s. It is unlikely that trusts will be in a position of having no open SI’s.

Indicator Outcome

Providers (where CCG commissioning constitutes more than %5 of the providers income):

West Middlesex University Hospital HRCH WLMHT Imperial

Has local provider been subject to local enforcement action by the CQC? No No No No

Has local provider been flagged as a 'quality compliance risk' by Monitor and/or are requirements in place around breaches of provider licence conditions?

N/A N/A N/A N/A

Has local provider been subject to enforcement action by the NHS TDA based on 'quality' risk?

No No No No

Does feedback from the Friends and Family test (or any other patient feedback) indicate any causes for concern?

Yes ‐ Action plan in place N/A N/A No

Has the provider been identified as a 'negative outlier' on SHMI or HSMR? No No No No

Do provider level indicators from the National Quality Dashboard show that MRSA cases are above zero?

NoNo cases reported on HPA website

No cases reported on HPA website Yes ‐ Action plan in place

Do provider level indicators from the National Quality Dashboard show that the provider has reported more C difficile cases than trajectory?

Yes ‐ Action plan in placeNo cases reported on HPA website

No cases reported on HPA website

Yes ‐ Action plan in place

Do provider level indicators from the National Quality Dashboard show that MSA breaches are above zero?

Yes ‐ Action plan in place N/A N/A Yes ‐ Action plan in place

Does provider currently have any unclosed Serious Untoward Incidents (SUIs)? Yes ‐ Action plan in place Yes ‐ Action plan in place Yes ‐ Action plan in place Yes ‐ Action plan in place

Has the provider experienced any 'Never Events' during the last quarter? Yes ‐ Action plan in place No No Yes ‐ Action plan in place

10

Section 5: NHSE Assurance – provider quality of care (contd.)


Key messages

Domain 2: Are patient rights under the NHS Constitution being promoted?

▪ One MRSA case reported against the CCG is a non acute setting acquired infection. Awaiting CCG approval for CSU to access and investigation HPA database.

▪ One patient waited over 52 weeks at CW for plastic surgery. A treatment plan is in place.

▪ One MRSA case reported against the CCG is a non acute setting acquired infection. Awaiting CCG approval for CSU to access and investigation HPA database.

▪ One patient waited over 52 weeks at CW for plastic surgery. A treatment plan is in place.

11

Section 6: Shaping a Healthier Future tracker information: UCC/WiC and A&E attendances, non‐elective admissions and community events

Key message

▪ The Shaping a Healthier Future programme requires Out of Hospital strategies to reduce unnecessary attendances and non‐elective admissions. They do this by (i) providing improved care in the community to prevent emergency attendances; (ii) diverting minor A&E attendances away from A&E departments to Urgent Care/walk‐in centres and primary care. The graphs show trends in Hounslow for UCC/WiC and A&E attendances, non‐elective admissions and care in the community events (Rapid Response).

▪ For Hounslow, whilst UCC attendances are increasing and A&E attendances are decreasing the number of non‐elective admissions remains relatively constant

.Data and narrative provided by the Shaping a Healthier Future (SaHF) team).


12

Section 7: Acute provider performance – exceptions and early warnings ‐WMUH


Remedial and improvement actions are detailed in section 14

Key messages

▪ Actions detailed in section 14

In month YTDRed/amber rated indicators Threshold

▪ Number of 52 week RTT pathways ‐ admitted

▪ Number of 52 week RTT pathways – non‐ admitted

▪ Number of 52 week RTT pathways ‐ incomplete

Trends

▪ Number of LAS arrival to handover greater than 30mins


▪ No. MRSA cases

▪ No. of C.Diff cases

91.19%▪ A&E 4hr wait – type 1

0 (0)▪ Maternal Mortality (rate per 100,00)

6/6▪ National Reporting and Learning System Uploading (no. of months incidents reported in last 6 months)

9 21▪ No. of Serious Incidents (occurred)

94.59%

▪ No. of Serious Incidents (reported) 15 27

▪ Choose & Book (slot availablity) 14.4%14.6%▪ CMS compliance (KPI 1)(80% within 2hrs) 41.1%43.4%

▪ Delayed transfers of care 2.63%3.57%

▪ Mortality Rate As expected

▪ Patient survey results ‐ Inpatient 71.8

▪ No. of LAS arrival to handover > 30mins


72 158

0 4

0

0

95%

2%

2%

80%

13%▪ Friends & family test: response rate (inpatient)

▪ Friends & family test: response rate (A&E)

14%

▪ No. of MRSA cases 0


0

0 6

1%1%

15%

0

2

15%

▪ Never Events 1 1 0

13

Section 7: Acute provider performance – exceptions and early warnings – WMUH (contd.)



Key messages



50.0%0.0% 85%

50.0% 90%66.7%

Trends

▪ First definitive treatment for cancer within 62 days of NHS cancer screening referral

▪ First definitive treatment for cancer within 62 days of consultant upgrade

▪ First definitive treatment for cancer within 62 days of GP referral


92.9%93.9% 93%▪ Patients seen within 2 weeks of

urgent GP referral for suspected cancer

▪ First definitive treatment for cancer within 62 days of consultant upgrade

81.6%85.0% 85%▪ First definitive treatment for cancer

within 62 days of GP referral

▪ Patients seen within 2 weeks of urgent GP referral for suspected cancer

14

Section 8: Acute provider performance – exceptions and early warnings ‐ ICHT


Key messages



92.17%▪ A&E 4hr wait – type 1

▪ % of patient complaints responded to within agreed time frame

22.67 (2)▪ Maternal Mortality (rate per 100,000)

5/6▪ National Reporting and Learning System Uploading (no. of months incidents reported in last 6 months)

0 0▪ No. of never events (reported)

9 19▪ No. of Serious Incidents (occurred)

94.16% 95%

0

▪ No. of Serious Incidents (reported) 19 26

▪ Choose & Book (slot availablity) 11.9%13.9% 2%

▪ CMS compliance (KPI 1)(80% within 2hrs) 54.0%53.8% 80%

25 daysNot available

Not available

▪ No. 52 week waiters – all RTT pathways 7 013 ▪ Number of 52 week RTT pathways ‐ admitted

▪ Number of 52 week RTT pathways – non‐ admitted

▪ Number of 52 week RTT pathways ‐ incomplete

Trends



36 85

1 1

▪ No. of MRSA cases 4


4

6 18

0

0

0

11



▪ No. MRSA cases


▪ Mortality Rate Below expected


15

Section 8: Acute provider performance – exceptions and early warnings – ICHT (contd.)


Key messages



95.7%95.1% 95%

74.5% 85%74.7%

Trends


▪ First definitive treatment for cancer within 31 days of cancer diagnosis


▪ First definitive treatment for cancer within 31 days of cancer diagnosis89.7%97.4% 90%




16

Section 9: Community provider performance – exceptions and early warnings


Key messages

▪ The key underperforming indicators are No. of Health Visitors, HPV vaccinations and No. of 4 week smoking quitters▪ 5 out of 8 indicators are Green▪ Issue with recruitment of has been a key driver of under performance for No. of Health Visitors. Bank and agency use continues and will be reduced as appointments commence. Student Health Visitors will start from September

▪ Current HPV performance is shown to be below trajectory . HPV final performance to be confirmed in September 2013 as programme is run on academic year

▪ End of year activity has now been finalised for no. of 4 week smoking quitters. Hounslow achieved 1908 quitters against target of 1956. For 2013‐14 targeted actions will be aimed at high risk groups and schools.


HRCH

In month(M12) YTDRed/amber rated indicators

Threshold%

37.2 N/A*▪ No. of Health Visitors 52.8

193

88.3%**▪ HPV vaccinations (12‐13yrs) 90%

▪ No. of 4 week smoking quitters 1908 1956

*YTD performance for No. of Health Visitors is Not Applicable as performance is measured as a monthly snap shot**Data is for second of three doses of HPV Vaccine for the academic year 2012‐13

17

Section 10: Mental Health provider performance – exceptions and early warnings


Across Hounslow CCG, West London Mental Health Trust has successfully achieved a green rating against key performance indicators andlocal targets across Q3 & Q4 2012/13.

The provider has sustained performance against the following :

• Early Intervention in Psychosis• Crisis Resolution Home Treatment• Care Programme Approach ( CPA) – 7 day follow up• IAPT

Key messages


Section 11: Serious Incident Categories

Key messages

National Pressure ulcer prevalence (PST) = 5.53%, Imperial 3.56%, West Mid 7.73%, HRCH 4.38%,Imperial have an average of 6.5 incidents per 100 admissions and report higher than average numbers of near misses/no harm incidents.WMUH Never Event was SI category ‘Surgical Error’ – all actions taken, WMUH have 60 days to report back on RCA

ImperialSerious Incident Categories

▪ Ambulance Delay

▪ C.Diff & Health Care Acquired Infections

▪ Communicable Disease and Infection Tissue

▪ Maternity Services Maternal Unplanned Admission to ITU

▪ Maternity Services – Unexpected admission to NICU (neonatal intensive care unit)

▪ Maternity Services – Unexpected neonatal death

▪ Pressure Ulcer Grade 3

▪ Pressure Ulcer Grade 4▪ Slips/Trips/Falls

▪ Sub‐optimal care of the deteriorating patient

▪ Surgical Error

▪ Unexpected Death (general)

▪ TOTAL

HRCHWMUH Total

0

10

20

May Jul Sep Nov Jan Mar May

% PU All ICHT

PU All

Pressure Ulcer Prevalence

1

1

4

0

3

2

3

1

1

1

1

1

19

0

0

0

0

0

0

1

0

0

0

0

0

1

0

3

4

1

5

2

7

2

2

1

2

1

35

0

2

0

1

2

0

3

1

1

0

1

0

15

▪ Ambulance (general) 0 0 33

▪ Attempted Suicide by Inpatient (in receipt) 0 0 11

0

10

20


% PU All WMUH

PU All

0

10

20


% PU All HRCH

PU All

19

Section 12: 111 Pilot Services

Source: Unify sitrep data WE 07/07/13

mCLWHHillingdon

47.868.4/10

Key messages

▪ Recovery plans are in place with both providers and will begin to address the longer waits in CWLH ▪ The CSU are monitoring providers work force plans to address the level of clinical call backs across NWL.


BEHHBrent, Ealing Harrow

& HounslowCall Standards I

94.7% 94.5%96.4%▪ % of calls answered in 60 seconds 96.9%

52%54.5%▪ Recommended to attend Primary and community care

65.6% 64.9%

4%1.1%▪ Recommended to attend other service 1.3% 4.2%

7.7%▪ Recommended to attend A&E 7.5%

8.8%11%▪ Led to Ambulance dispatches 14.2% 8.9%

39.5%▪ % of clinical call backs within 10 mins 57.5% 59.6%

17.2%▪ % of calls requiring Clinical advice offered call back

18.5% 11.4%

87.9%88.3%▪ % of calls triaged 109.6% * 100%

1.7%▪ % of calls abandoned after 30 seconds 0.7% 0.5%

CLWHCentral London, West London &

Hammersmith & Fulham

Hillingdon

111 Dispositions / % of Triaged Calls which:

England

10%

7%

14% 16.8% 14.4% 16.1%

49.4%

11.7%

* The % of calls triaged is taken from the clinical system and the % of calls answered is from the telephony system. There is a variation due to some of the Hillingdon patients coming through on a different telephony line.

▪ Did not recommended to attend other service

1.1%


Section 13: 111 Governance

Key messages

▪ Interface between 111 and out of hours is being addressed by Harmoni and due for update at end of July▪ Performance notice has been issued. Update in M3

Month 2 111 (Hounslow, Ealing, Harrow and Brent)

Total number of calls this month 7187

Serious Incidents

SIs opened this month 0SIs this calendar year 0

Of the total for

this calendar year

Closed and actual 0Closed and NOT SI 0

Still open 0

Number of complaints

0

Number remaining open0

Number of incidents

0

Number remaining open

0Number of Professional Feedback Forms 20; 2 in May, 8 in April and 10 in

MarchNumber with outstanding actions:

Not known

Feedback themes: The Interface between 111, GP and OOH services.

Current state of play eg: Service running within tolerance Service Running ‐ Abandonment rates and Calls answered in 60 seconds running above national and local requirements. Call backs remain a challenge with 5‐10 per week exceeding 45 minutes although a number of these did receive first attempt call backs within this time.

21

Section 14: Action Log


… …

Key lines of enquiry

Issue Provider Root Cause Action Closed Risk

Actions for CSU

Not meeting specialty or 52 week standards

ICHT Poor waiting list management ‐ ‐ Plan in place for the patient waiting over 52 weeks.‐ Financial penalties applied for failing at specialty level and for patients waiting over 52 weeks.

Yes

Yes

Not applicable

‐28 breaches (2 week rule)‐62 day urgent GP referral 77.8%

WMUHT ‐Patient choice‐Urology outpatient capacity, diagnostic delay and inter‐site transfer delays

‐A detailed review of the root cause analysis to identify additional actions required.

Yes Not applicable

75% 62 day from GP referral

3 breaches (62 day screening)

ICHT ‐6 breaches due to complex diagnostic pathway and co‐morbidity‐5 inter Trust delays‐4 administrative errors‐1 elective cancellation

‐A detailed review of the root cause analysis to identify additional actions required.

Yes

Not applicable

ICHT A&E local standard not met

ICHT Poor A&E processes ‐Whole system plan to form the basis for pressure surge assurance process for 13/14. No

Agreed action completion date July 2013

WMUH A&E local standard not met

WMUH The Trust has identified that A&E waits are largely due to poor inpatient processes. These require improvement to enable the reduction in length of stay and timely discharges on the day of discharge.

‐Whole system plan to form the basis for pressure surge assurance process for 13/14.‐IST action plan to improve ward processes to be implemented

No

No


22

Section 14: Action log (contd.)


… …



Actions for CSU

ASPH A&E local standard not met

ASPH ‐Surgical and frail elderly patient pathway not optimised‐Lack of medical staffing‐Management of bed stock and restricted intermediate care beds

Monthly monitoring of ECIST action plan

No


WMUH & ICHT reported 72 & 49 30 minute LAS handover breaches.

ICHT Poor A&E processes Ensure that actions related to handover times in whole system plans are reviewed as part of winter assurance process.

WMUH pilot site for implementing new joint hospital handover process.

No

No


Pilot due to start in July 2013

Annual C.Difficile tolerance is 65 cases with 12 cases reported in M1.

ICHT Detailed root cause analysis is being undertaken and will be submitted by the 14th June 2013. Discussion on further actions required to mitigate risk will be agreed at June CQG meeting.

Any additional actions will be identified at the CQG.

Yes

Not applicable


WMUH Final Trust HCAI action plan for 2013/14 will be reviewed at the June CQG.

Any additional actions will be identified at the CQG.

Yes Not applicable

HPV vaccination (12‐13yrs) HRCH Currently performance is shown to be below trajectory but year end has not been reached

HPV final position to be confirmed in September 2013 as programme is run on academic year

No

Not applicable

23

Section 14: Action log (contd.)


… …



Actions for CSU

No. of Health Visitors HRCH Issues with recruitment of Health Visitors

Interviews to be held in July. Bank and agency staff use continues and will be reduced as appointments commence

NoNot applicable

Smoking quitters HRCH Issue with initial funding to meet target

End of year activity has now been finalised. Hounslow achieved 1908 quitters against target of 1956.

Yes

Not applicable

Maternal Mortality Ratio ICHT RCA's ICHT have had 2 maternal deaths in 2012/13 (2 in 8819). Al RCA’s received and action plans agreed.

Yes

Not applicable

NRLS Uploads ICHT Trust not submitting data Trust to continue to upload onto the NRLS. Next Quarterly report due September.

No

Poor data submission may lead to missed opportunities to prevent further similar events occurring at a national level.

National Inpatient Survey West Middlesex University Hospital NHS Trust

TBD Trust made aware of results .Action plan to be requested at next CQG.

No

Not applicable

Issue CCG Root Cause Action Closed Risk

Actions for CCG

CSU does not have access to HCAI database at a CCG level

CCG Unknown CCG need to approve CSU access to HCAI database

No CSU unable to review individual infections leading to lack of detail within reports.


ICHT Poor waiting list management ‐ CCG to approve plan. No Could lead to the inability to apply contract management mechanisms if ICHT not meeting milestones.


WMUH Final Trust HCAI action plan for 2013/14 will be reviewed at the June CQG.

CWHH has commissioned an external review of the Trust’s action plan.

No Not applicable

24

Section 15: Recommendations and next steps


… …


Issue Provider Root Cause Action Accountable Officer

Date

Actions for CSU

Not meeting 62 days to treatment ICHTWMUH

Currently under review ‐A detailed review of the root cause analysis to identify additional actions required.

July 2013


ICHT Poor waiting list management

‐Monitor against current plan‐Review of plans and actions in place for 52 week waiters

July 2013

LAS Hospital handover KPIs ICHT & WMUH Poor A&E processes ‐Monitoring of progress against The recovery and improvement plan.

On‐going

HPV vaccination (12‐13yrs) HRCH Currently performance is shown to be below trajectory but year end has not been reached

HPV final position to be confirmed in September 2013 as programme is run on academic year

September 2013

No. of Health Visitors HRCH Issues with recruitment of Health Visitors

Recruitment drive to continue. Bank and agency use continues and will be reduced as appointments commence

On‐going

Smoking quitters HRCH Issue with initial funding to meet target

For 13‐14 targeted actions will be aimed at high risk groups and schools.

2013‐14

25

Section 15: Recommendations and next steps (contd.)


… …


Issue Provider Root Cause Action AccountableOfficer

Date

Actions for CSU

No complaints data submitted

ICHT Trust not submitting dataCSU to discuss at next CQG. CSU quality team Month 3

Friends and Family test response rate in A&E and IP.

WMUH Systems and process top capture FFT score

CQUIN target in place in relation to FFT. Response rates to be greater than 15% in Q1.

CSU quality team Month 3

No complaints data submitted

WMUH Trust not submitting complaints data

CSU to discuss at next CQG. CSU quality team Month 3

26

Appendix 1 :Quality Premium Calculation Guidance


nhs hounslow ccg governing body cover sheet · clinical lead dr. prashant gupta manager lead sue...

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