Transcript INTEGRATED PERFORMANCE REPORT for period ending 31st …
INTEGRATED PERFORMANCE REPORT
Enclosure 3
for period ending 31
st
October 2010 Trust Board – 3 December 2010 - Quality KEY FACTS EXECUTIVE RESPONSIBLE AUTHOR (if different from above) CORPORATE OBJECTIVE BUSINESS PLAN OBJECTIVE NO(S)
Adam Cairns
Chief Executive
Paul Hodson
Head of Contracts & Performance
Pete Gordon
Head of Continuous Improvement
William Wraith
Head of Human Resources
Tony Brown
Assistant Director Financial Performance
Enhancing Patient Experience, Safety and Effectiveness, Achieving NHS Foundation Trust Status 6.1 - Establish a new Quality Framework for the Trust.
6.1.1 - Develop an integrated performance management framework that includes a balanced set of quality metrics across the domains of safety, effectiveness and patient experience.
• 18 Weeks, Stroke National & Local, MRSA and C.
Difficile, Cancer 14 and 31 day and Rapid Access Chest Pain targets achieved in month.
• Thrombolysis, Outpatient Utilisation, Cancelled Operations, A&E, Workforce Numbers and Cancer 62 day all under achieved in month.
EXECUTIVE SUMMARY
This paper reports current performance against a number of KPIs for the period up to the end of October 2010. As detailed in previous papers this reports only includes slides for those KPIs identified as suitable for monthly reporting. The summary sheet will continue to show a RAG for all KPIs with quarterly KPIs showing their RAG status at the end of the last full quarter.
RECOMMENDATIONS
The Board is asked to NOTE: • performance against a range of Key Performance Indicators covering Quality, Delivery and Foundations.
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Integrated Performance Report: Quality (CO1)
Appendix 1
Patient Satisfaction Cancelled Operations Cleanliness Choose & Book Complaints End of Life (CQUIN) Incidents Healthcare Associated Infections (HCAIs) Medicines Management (CQUIN)
Improve responsiveness to personal needs of patients (CO1.3 / CO1.7) (CQUIN) Breaches in single sex accommodation compliance (CO1.5) To maintain a minimum level of non medical cancellations in accordance with national criteria Readmit all non medical cancellations within 28 days in accordance with national criteria To maintain cleanliness score of 92% across the Trust Maintain a monthly slot availability rate of at least 90% for appointments made via the Choose & Book System National response times are that all complaints are completed in their entirety within six months, unless exceptional circumstances % of admitted patients at end of life following the Liverpool End of Life Pathway (CO1.3) Rate of patient safety incidents reports (CO1.6) Serious Incidents Requiring Investigation (CO1.6) No more than 6 post 48-hour MRSA bacteraemias No more than 166 post 72-hour C. Difficile infections Delayed and missed doses of medicines for hospital inpatients
Patient Falls (CQUIN) Hospital Standardised Mortality Ratio (HSMR) Stroke - National Target Stroke – Compound Indicator Target (2010/11)
No. of inpatients having a fall whilst an inpatient (CO1.3) HSMR for the most recent complete 12 months based on the HSMR basket of 56 diagnosis groups % of Patients spending 90% of time on Stroke Unit Compound based on Swallow Screens, TIAs and % of Time on Stroke Unit
Executive Lead Monthly Performance Direction of Travel Year to Date Forecast
DSD DSD DSD
GREEN GREEN RED = = = GREEN GREEN GREEN Commentary GREEN GREEN GREEN
Target 2010/11 89% overall patient satisfaction 5 indicators identified form 2009/10 results Number of breaches caused by each occurrence will be equal to the total number of patients effected i.e. 1 female with 5 males is 6 breaches 47 cancelled in month
Frequency
M M M DSD DSD DSD DCA DSD MD MD MD MD MD DSD MD MD MD
GREEN GREEN RED GREEN GREEN GREEN GREEN GREEN GREEN GREEN RED RED GREEN GREEN = = = = = = = =
= = = =
GREEN GREEN RED GREEN GREEN GREEN GREEN GREEN GREEN GREEN AMBER AMBER GREEN GREEN GREEN GREEN RED GREEN GREEN GREEN GREEN GREEN GREEN GREEN AMBER AMBER GREEN GREEN
No 28 day breaches in month Both sites were Green at the time of October monitoring The October report is based on 3 weeks data available due to C&B systems upgrade Of the 184 cases opened in the first quarter these have all been responded to within the 6 months statutory deadline New CQUIN Target for 2010/11 Q2 – baseline 27% Q4 to improve compliance by 20% target 32% Incident reporting rate of 8.4% Less than 8 SIRIs per month Total of 2 MRSA cases YTD Total of 40 C. Difficile cases YTD Baseline audit undertaken in May, second audit is now completed Improvement Target agreed with PCTs • Q1 Baseline – 142 Falls per month • Q2 4%, reduction • Q3 7%, reduction • Q4 10% reduction Month: 105.6 (95% CI: (88.38 – 125.3) Last quarter: 110.2 (99.4-121.9) Last 12 months: 112.7 (107.3 – 118.4) Sustainable improvement continues Quarter three to date, all three targets achieved M M M Q M M M M M M M M M M
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Integrated Performance Report: Quality (CO1)
Stroke (CQUIN) Early Access to Maternity Nutrition Target (2010/11)
Admissions to Stroke Unit within 4 hours of Arrival at Hospital Achieve contract milestones for early access to maternity services (90% by Q4 and 86% full year) (CO1.1) % Completion of Nutrition Screening Tool ( C01.7)
Readmission Rates Venous Thromboembolism (CQUIN) Think Glucose (CQUIN) Tissue Viability (CQUIN)
Relative Risk of Emergency Readmission within 28 days of discharge % of adult inpatients who have had a VTE risk assessment on admission (CO1.3) Compliance with Think Glucose guidance (CO1.3) Reduction in the number of Grade 3 and 4 Pressure Ulcers – to be confirmed with PCT (CO1.3)
Executive Lead
MD DSD DSD MD MD MD DSD
Monthly Performance GREEN AMBER GREEN GREEN GREEN RED Direction of Travel =
= = =
Year to Date GREEN AMBER Forecast GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN AMBER AMBER
Appendix 1
Commentary
New CQUIN Target for 2010/11 value worth £200K October 2010 T&WPCT = 75% SCPCT = 86% Baseline Audit 58% Q2 65% Q3 75% Q4 90% The relative risk of Emergency Readmission remains significantly lower (better) than the average for England No update provided at the time of issue
Frequency
M M Q M Action plan compliant with milestone achievement New CQUIN 2010/11 Target to reduce by Q4 number of grade 3/4 ulcers by 10% M M M
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Integrated Performance Report: Delivery (CO2, CO3 & CO4)
Appendix 1
Appraisals Target (2010/11)
SaTH target of 80%
Executive Lead Monthly Performance Direction of Travel Year to Date Forecast
DCA
GREEN = GREEN GREEN Commentary
Trust performance at 86% appraisal completion
Frequency
M
Staff Satisfaction
A continual improvement in staff satisfaction, as assessed by the Annual Staff Survey (CO3.3) DCA
Smoking (CQUIN)
90% of smokers/users of tobacco attending new patient appointments at selected outpatient clinics receive brief intervention (CO4.3) % of patients receiving cognitive assessment on admission
Dementia
An informed and effective workforce for people with dementia
Staying Healthy (Alcohol) (CQUIN)
9a) 90% of people attending A&E with alcohol related condition & are not admitted who receive a brief intervention to reduce alcohol consumption 9b) ?% of people who are admitted to hospital with alcohol related condition receive brief interventions to reduce alcohol consumption MD MD MD MD
GREEN GREEN = = GREEN GREEN
2009 survey shows continued improvement over previous years
AMBER
Q
RED
No update provided at the time of issue Baseline to be obtained from the National Audit of Dementia. Findings due Oct. – Dec. 2010 (Q2) Preliminary Review of Educational requirements around Dementia to increase knowledge & understanding amongst all Trust Staff (Q2) 9a) PCT and Trust agreement on delivery with concerns raised about responsibility lines after April 2011. Project Group meeting and awaiting clarification of SLA for both sites 9b) PCT and Trust agreed target. SLA to be agreed for roll out. Development in line with action plan M Q Q M
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Integrated Performance Report: Foundations (CO5 & CO6)
Target (2010/11) Care Quality Commission Registration
Maintain Trust Registration with the Care Quality Commission
Executive Lead Monthly Performance Direction of Travel Year to Date Forecast
DCA
GREEN = GREEN GREEN Commentary
Trust now registered without conditions (Q2)
Appendix 1
Frequency
Q
Coding
To increase the numbers of FCEs with coded comorbidities FD
GREEN = GREEN GREEN
M Coding levels remain the same as previous month
A&E 4 Hours
95% of patients to be admitted, discharged or transferred within 4 hrs.
of registering at A&E
18 Weeks
1a - Admitted Clock Stops above 90% 1b - Non-Admitted Clock Stops above 95% 14 Days from urgent GP referral to first outpatient appointment for all urgent suspected cancer referrals 31 Days from diagnosis to treatment for all cancers
Cancer
62 Day from urgent referral to treatment of all cancers
Thrombolysis Rapid Access Chest Pain
68% of patients admitted with ST Elevation MI should receive Thrombolysis within 60 minutes of call for help A maximum of two-week wait for rapid access chest pain clinic (CO6.6) DSD DSD DSD DSD DSD DSD DSD DSD
RED GREEN GREEN GREEN GREEN RED RED GREEN = = = = =
GREEN GREEN GREEN AMBER GREEN GREEN RED GREEN GREEN
Local Health Economy underachieved target for October
GREEN GREEN GREEN
Trust achieved the 90% target during October Trust achieved the 95% target during October 14 day target achieved in month
GREEN
31 day target achieved in month
GREEN GREEN GREEN
62 day target underachieved in month Only 2 eligible patient in the year to date. CQC guidance states that for this indicator a ‘low numbers' rule will be applied which will withdraw Trusts treating a low number of eligible cases from the assessment Well established service with consistent high performance M M M M M M M M
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Patient Satisfaction
Target (2010/11)
Patient Satisfaction
Executive Lead Monthly Status Direction of Travel Year to Date
Improve responsiveness to personal needs of patients (CO1.3 / CO1.7) (CQUIN) Breaches Accommodation (CSA) compliance (CO1.5) in Single Sex DSD DSD
GREEN GREEN
= =
Forecast Commentary
GREEN GREEN GREEN
Target 2010/11 89% overall patient satisfaction 5 indicators identified form 2009/10 results
GREEN
Number of breaches caused by each occurrence will be equal to the total number of patients effected i.e. 1 female with 5 males is 6 breaches 1000 800 600 • Capital funding approved to improve washing and toilet facilities.
400 • In October a total of 21 breaches on four occasions: 1 episode in Ward 4 Stroke bay and 3 in MAU RSH. All were in response to high demand for beds and for overriding clinical reasons. All breaches were corrected before the following shift.
200 0 Breaches by month Breaches YTD Apr-10 May-10 Jun-10 287 287 195 482 165 647 Jul-10 157 804 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 45 849 5 854 21 875 Jan-11 Feb-11 Mar-11 • Patient Experience Tracker audits being rolled out across the organisation.
Actions:
• To develop an overarching strategy for collection of patient experience information including patient stories.
• A Dignity in Care Conference is being organised in SECC for May 12th 2011 to celebrate Nurses Day .
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Target (2010/11)
28 Day Cancelled Operations
Executive Lead Monthly Status Direction of Travel Year to Date Forecast
28 Day Cancelled Operations
To maintain a minimum level of non medical cancellations in accordance with national criteria Readmit all non medical cancellations within 28 days in accordance with national criteria
Cancelled Operations 2010/11 - by Site
DSD DSD
RED GREEN
= =
GREEN GREEN GREEN GREEN
Commentary
47 cancelled in month No 28 day breaches in month 50 0 PRH RSH Anticipated Threshold Apr-10 M ay-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 M ar-11 15 0 33 6 8 33 17 15 35 20 26 36 15 12 30 25 28 34 15 32 35 33 31 31 34 40
Cancelled Operations 2010/11 by Reason
60 50 40 30 20 10 0 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct -09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 No Beds No Anaesthetist No Time Theatre Closed No Equipment Cancelled by Surgeon No Surgeon Trauma Other • 47 operations cancelled in October for non medical reasons.
• 202 operations cancelled for non medical reasons in the year-to-date.
• The national target applies only to those cancellations that happened on or after the day of admission and only for non-medical reasons.
• Current guidance indicates that the CQC threshold for achievement will be no more than 0.8% of relevant elective activity. We are currently below this figure for the year-to-date but the in month performance is above the anticipated threshold.
Actions:
• During October the main causes of patient cancellations were 1) no bed (23 patients) and 2) theatre list overruns (10 patients). The list overruns in the main are due to beds being identified too late during the theatre list. In October there have been a significant number of outliers within the surgical specialities bedbase.
• There is a further process mapping session for the Surgical Admission Suite in December, to address some of the patient flow challenges.
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Cleanliness
100 80 60 40 20 0
Cleanliness
Target (20010/11)
To maintain cleanliness score of 92% across the Trust
SATH Cleanliness Score for 2010 - 2011 Executive Lead
DSD
Monthly Status Direction of Travel Year to Date Forecast Commentary
GREEN
=
GREEN GREEN
Both sites were Green at the time of October monitoring • Target score of 92% is based on the Patient Environment Action Team (PEAT) score to achieve “excellent”.
• Monthly cleanliness scores collected from Domestic Services Department Quality Monitoring Programme.
RSH PRH • April and May figures only collated as combined scores.
Monthly
SATH Score • Overall score of 95.82% was achieved for the Trust in October 2010.
Green (=>92%) Amber (<92% and >87%) • Cleanliness Score for RSH much improved this month.
• The main issue at PRH this month was the public toilets but all issues found are being addressed.
• Based on April to October figures the year-end forecast is 94.49% (this will be submitted as part of the PEAT Assessment process).
Actions:
• Manual system of recording of monitoring used at present. Electronic System to be implemented by January 2011.
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Choose and Book
Target (2010/11)
Choose and Book
Executive Lead Monthly Status Direction of Travel Year to Date Forecast
Maintain a monthly slot availability rate of at least 90% for appointments made via the Choose & Book System DSD
RED
=
RED RED
Commentary
The October report is based on 3 weeks data available due to C&B systems upgrade • The planned upgrade to the national C&B system took place 23/24 th await the new report format being compiled by the national C&B team.
October. We
Slot availability rate for appointments made via the Choose & Book System
• Appointment Slot Issues (ASIs) are now directly available to the SDU on a C&B worklist, allowing more proactive management of the capacity available to provide the appointments needed. ‘Superuser’ training has been provided on how to access and manage the ASI worklist.
100.00% 80.00% 60.00%
Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Actual 86.00% 84.00% 80.00% 85.00% 87.40% 82.95% Profile 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% • An average of 95 patients per week were unable to book their appointment via C&B up to October 24th. Of these, 75% were in the following specialties: - Ophthalmology – av. 27 per week (increase of 10 per week from September) - Children & Adolescent – av. 14 per week (increase of 5 per week from September) - T&O – av. 11 per week - ENT av. 11 per week - Dermatology av. 9 per week.
Actions:
• Review and action ASIs within the SDUs.
End of Life (CQUIN)
Target (2010/11)
End of Life
Executive Lead Monthly Status Direction of Travel Year to Date Forecast
% of admitted patients at end of life following the Liverpool End of Life Pathway (CO1.3) DSD
GREEN
=
Commentary
GREEN GREEN
New CQUIN Target for 2010/11 Q2 – baseline 27% Q4 to improve compliance by 20% target 32% 100 80 60 40 20 0
Percentage of patients with anticipated death managed on LCP at End of Life
• Q1 electronic data collection system established. Monthly reports generated from contracts, performance and Vitalpac data.
EOL deceased patients LCP % Target % • Q2 base line position of 27% compliance. Baseline position reached by comparing deceased patients coded for palliative care against patients recorded on Vitalpac as on Liverpool Care Pathway (LCP).
• Baseline identified using month six data as thought to be the most reliable due to improvements in coding for palliative care.
Q2 Q4
Actions:
• Q3 monitor against baseline. Monthly meeting with clinical coding and palliative care CNS to support data validation. • To take forward recommendations for the development and improvements to Bereavement Services.
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Incidents
Target (2010/11) Executive Lead Monthly Status Direction of Travel Year to Date Year End Forecast Commentary
Incidents
Rate of patient safety incidents reports (CO1.6) Serious Incidents Requiring Investigation (CO1.6) MD MD
GREEN GREEN
=
GREEN GREEN GREEN GREEN
Incident reporting rate of 8.4% Less than 8 SIRIs per month
Incident rate per number of admissions (08/09 HES data)
12 10 8 6 4 2 0 8.5
8 7.5
7 6.5
6 5.5
5 Apr May Jun Jul Aug Sept Oct
Month
Nov Dec Jan Feb
Number of SUIs and Patient RIDDOR reports (excluding pressure ulcers and MRSA bacteramia)
Mar RIDDOR SUI • The Trust reports Patient Safety Incidents & Near Misses to the National Reporting & Learning System (NRLS). The rate is based on the number of incidents each month as a percentage of the monthly admissions (based on 2008/09 HES data).
• The Care Quality Commission (CQC) receive weekly reports from the NRLS & are regularly provided with further information about incidents. Managers are reminded to ensure that compiled information on investigations & actions is included on the reports before final submission.
• The number of Serious Incidents Requiring Investigation (SIRI) includes Serious Untoward Incidents (SUIs) & Patient Incidents which have been reported under RIDDOR (Reporting of Injuries, Diseases & Dangerous Occurrences Regulations). MRSA bacteraemias and grade 3/4 pressure sores are excluded as these are reported separately.
Apr May Jun Jul Aug Sept Oct
Month
Nov Dec Jan Feb Mar
Actions:
• Incident Review Group meets monthly to discuss incidents & trends. Further Root Cause Analysis training for Managers is being planned to improve the consistency of investigation.
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Healthcare Associated Infections (HCAIs)
Target (2010/11) Executive Lead Monthly Status Direction of Travel Year to Date Forecast Commentary
Healthcare Associated Infections (HCAIs)
10 No more than 6 post 48-hour MRSA bacteraemias No more than 166 post 72-hour C.
Difficile infections
MRSA Cases v Profile 2010/11
MD MD 0 M RSA Cases YTD M RSA Cases by M onth National Target Profile YTD Apr 10 0 0 1 M ay 10 Jun-10 Jul-10 Aug 10 0 0 1 0 0 2 0 0 2 0 0 3 Sep 10 0 0 3 Oct 10 2 2 4 Nov 10 4 Dec 10 Jan-11 Feb-11 M ar 11 5 5 6 6
SaTH C-Diff Cases in Patients over the age of 2 2010/11
150 100 50 0 C-Diff Cases YTD C-Diff Cases by M onth National Target Profile YTD Apr 10 7 7 14 M ay 10 Jun-10 Jul-10 Aug 10 17 10 28 22 5 42 26 4 56 31 5 70 Sep 10 34 3 84 Oct 10 40 6 98 Nov 10 40 112 Dec 10 40 Jan-11 Feb-11 M ar 11 40 40 40 126 140 153 166
GREEN GREEN
2010/11.
• C. Difficile = =
GREEN GREEN MRSA
• There were 2 post 48 hour cases of MRSA bacteraemia in October.
• Both cases were in ITU at RSH. RCA has been carried out. In one the likely source was a chest infection and in the other a wound infection. We are typing the MRSA strains to see if they are the same.
• Two cases to end of October 2010 vs. target of not more than 6 post 48 cases • There was one pre 48 hour MRSA bacteraemia in October. This was investigated by the PCT and found to be from a pressure sore.
• Ongoing work – maximising admission screening, re-screening wards where acquisition occurs, reducing line sepsis, screening new staff.
• To end October 2010 - 40 SaTH responsible cases (post 72 hrs.).
• In October 6 SaTH cases, 5 in RSH and 1 in PRH, were diagnosed more than 72 hrs. post admission and therefore count vs. SaTH target.
• One ward has had more than five cases within 30 days. RCA suggested antibiotic use and cross infection were issues.
Actions:
• C difficile cluster: An intensive deep clean and review of practice has being carried out. Antibiotic audits are continuing.
GREEN GREEN
Total of 2 MRSA cases YTD Total of 40 C. Difficile cases YTD
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Medicines Management (CQUIN)
Target (2010/11)
Medicines Management
Executive Lead Monthly Status Direction of Travel Year to Date Forecast
Delayed and missed doses of medicines for hospital inpatients MD
GREEN
=
Commentary
GREEN GREEN
Baseline audit undertaken in May, second audit is now completed Improvement Target agreed with PCTs
Baseline Audit Results May 2010
Patients records reviewed 364 Number of times where medicines were prescribed Prescription omitted for a clinical or patient specific reason i.e. patient refused Prescription omitted due to a record of non available Prescription where medicines regarded as critical Prescription where more than 1 dose omitted 4383 643 80 38 22 14.67% 1.83% 0.89% 0.50% • To agree list of Critical Medicines for baseline audit- achieved.
• To undertake baseline audit in May 2010 - achieved. 3 day audit of Admission areas, 364 patient records/charts included, second audit completed, final audit planned for January 2011.
• Report to PCTs in July 2010- achieved, November 2010 in progress & March 2011.
• Baseline Audit accepted & 20% improvement target provisionally agreed, based on improvement over the next two audits.
• Stock lists and out of hours arrangements amended in line with audit results & training & support advice provided to nursing staff to locate & obtain critical medicines.
Actions:
• Second Audit now completed, results expected to be available at the end of November. • Report to be forwarded to PCT when audit results are available.
• Action plan to be further developed dependent on audit results.
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Patient Falls Patient Falls (CQUIN)
Target (2010/11)
No. of inpatients having a fall whilst an inpatient (CO1.3)
Executive Lead Monthly Status
DSD
Direction of Travel Year to Date Forecast Commentary
RED
=
AMBER AMBER
• Q1 Baseline – 142 Falls per month • Q2 4%, reduction • Q3 7%, reduction • Q4 10% reduction • Patient “comfort Rounds” have been introduced for ‘At Risk’ patients.
12 month run chart for showing falls in SaTH • Gold squares to be placed above all patient’s bed who have been assessed and deemed at risk of having a fall.
150 100 • “Tip Tree Box” to be trialled on Care of the Elderly Ward. This is a tool kit for use in hospital wards as therapeutic intervention with patients suffering from dementia.
Contains everyday familiar items and a table where patients can sit safely and not be confined to their bedside.
50 0 Apr May Jun SaTH 09-10 • Weighted alarms to be trialled on Ward 4 for a 4–6 week period starting 12 th November 2010.
Jul Aug SaTH 10-11 Sep Oct Nov 10-11 Trajectory Dec Jan Feb Mar • Patient Safety First week – falls workshop to be included.
• Executive Nurse Root Cause Analysis Review Meetings to be held every 2 weeks.
Actions:
• Falls information on Internet and Intranet.
• To undertake further in depth analysis on falls data and categories. • Ward Managers and Matrons to be alerted to falls on daily basis so more proactive and immediate review can take place.
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Hospital Standardised Mortality Ratio (HSMR) Hospital Standardised Mortality Ratio (HSMR) Period Sept 09 – Aug 10
09 Jul 09-Sep 09 Oct 09-Dec Jan 10 Mar 10 10 Apr 10-Jun Negative Triggers
HSMR RED (worse) RED (worse) RED (worse) RED (worse) AMBER
(comparable but one trigger)
TWO
Target (2010/11)
HSMR for the most recent complete 12 months based on the HSMR basket of 56 diagnosis groups
Executive Lead Monthly Status Direction of Travel Year to Date Forecast
MD
RED
Commentary
AMBER AMBER
Month: 105.6 (95% CI: (88.38 – 125.3) Last quarter: 110.2
(99.4-121.9) Last 12 months: 112.7 (107.3 – 118.4) 180 160 140 120 100 80 60 40 20 0
Number of deaths per month (HSMR basket)
• HSMR is calculated from hospital activity using the Dr Foster Real Time Monitoring (RTM) Analysis Tool, using the most recent available data (currently three months in arrears). It compares the mortality rates in our hospitals with the average expected across England, adjusted to reflect factors such as age and case mix.
• Dr Foster has rebased the HSMR which has resulted in a change in the Trust’s reported HSMR which has been applied retrospectively for the last year.
• The annual HSMR for the year Sept 2009 to August 2010 is worse than the national average for England (based on a 95% confidence interval).
• The HSMR for the latest month is 112.7 and for the last quarter is 110.2. For the months April – August, April, ,June, July and August were close to the England averages.
• Trust-level Mortality data has been triangulated using other quality analysis tools, such as CHKS. This has not replicated the alert from the Dr Foster system.
Actions:
• Senior nurses will be trained in the use of the Global Trigger Tool in December.
• A coding workshop was held on 15th October. A number of Clinicians have been identified as ‘Coding Champions’. A further workshop will be held in November.
• The Trust is working with the University of Birmingham to understand the data more fully; develop an alternative system for monitoring deaths, and to set up a research project.
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Stroke National Target Stroke – Compound Indicator Target (2010/11)
% of Patients spending 90% of time on Stroke Unit Based on targets agreed with local Commissioners 90% of Time on Acute Stroke Unit 90.0% 60.0% 30.0% SaTH Target Qtr 1 76.9% 66.5% Qtr 2 81.0% 71.0% Qtr 3 82.8% 75.5% Qtr 4 80.0% Sw allow Screen Within 24 Hrs
Stroke
Executive Lead Monthly Status
MD
GREEN
MD 90.0% 60.0% 30.0% SaTH Target Qtr 1 78.9% 64.8% Qtr 2 87.1% 66.5% Qtr 3 84.5% 68.3% Qtr 4 70.0% TIA - Scanned & Treated Within 24 Hrs (Rothw ell Score 4+)
Direction of Travel Year to Date Year End Forecast Commentary
=
GREEN GREEN
Sustainable improvement continues
GREEN
=
GREEN GREEN
Quarter three to date, all three targets achieved.
Current Performance Proportion of People who spent at least 90% of their time on a Stroke Unit: Quarter 3 Target 75.5.0%, PRH 95.5%, RSH 75.0%.
• The overall SaTH performance continues to exceed this target. Improvement noted at
RSH, however work is required as performance is still fractionally short of target.
• Current Performance for swallow screening on both sites: Quarter 3 Target 68.3%, PRH 90.9%, RSH 80.6%.
• Current Performance for TIA on both sites: Quarter 3 Target 55.8%, PRH 100%, RSH 75.0%.
• Marked improvement continues against this target. • Trust delegates will be hosting an exhibit at the UK Stroke Conference in Glasgow in
December sharing our best practice on TIA pathway redesign.
100.0% 80.0% 60.0% 40.0% 20.0% SaTH Target Qtr 1 23.1% 47.3% Qtr 2 80.6% 51.5% Qtr 3 88.9% 55.8% Qtr 4 60.0% • West Midlands Quality Review Service visited both sites in September .
– Formal feedback has been received. An action plan has been completed.
– Meetings with PCT representatives and Chief Executive to formalise Economy Wide response to deliver improved performance in highlighted areas.
Actions:
• Data Analyst interviews to take place on Friday November 5th.
• Thrombolysis Service to commence seven days a week 08:00 – 20:00 at both PRH and RSH from December 6th (Phase One).
• Hyper acute Stroke patients (including Thrombolysis) to be provided at one site only (PRH) during hours 20:00 – 08:00 from January 5th (Phase Two – Interim phase). • Option appraisal to be carried out during March 2011 (re. Phase Two).
• Implement a twenty-four/seven service to include Thrombolysis at a single site (Phase Three).
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Stroke
Target (2010/11)
Stroke - CQUIN
Executive Lead Monthly Status Direction of Travel Year to Date Year End Forecast
Admissions to Stroke Unit within 4 hours of Arrival at Hospital Medical Director
GREEN
=
Commentary
GREEN GREEN
New CQUIN Target for 2010/11 value worth £200K Admission to Stroke Unit w ithin 4 hours of Arrival 60.0% 40.0% 20.0% 0.0% SaTH Target Qtr 1 54.5% 23.0% Qtr 2 54.8% 29.0% Qtr 3 56.5% 33.0% Qtr 4 38.0% • Current performance for admitted to Stroke Unit within four hours of Arrival: Quarter 3 Target 33%, PRH 60.9%, RSH 53.9%.
• New CQUIN Target from April 2010 to demonstrate Admission to Stroke Unit within 4 hours of Arrival at Hospital – value worth £200k.
Actions:
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Early Access to Maternity
Target (2010/11)
Early Access to Maternity
Executive Lead Monthly Status Direction of Travel Year to Date Forecast
Achieve contract milestones for early access to maternity services (90% by Q4 and 86% full year) (CO1.1) DSD
AMBER
AMBER GREEN
Quarter 1 Data: Validated Quarter 2 Data: Validated Quarter 3 Data: Unvalidated
Early Access Target
95.00% 90.00% 85.00% 80.00% 75.00% SATH Target Qtr 1 81.50% 80% Qtr 2 Qtr 3 87% 85% 84% 88.90% Qtr 4 90% SATH Target
Commentary
October 2010 T&WPCT = 75% SCPCT = 86% • Action plan being developed for both PCT areas.
• Meeting with TWPCT and GP Maternity Lead held in November 2010 – offered support to encourage the use of the electronic Notification of Pregnancy (NOP) with TWPCT GP surgeries.
• Permanent booking co-ordinator posts recruited, commencement dates TBC.
• Regular SCPCT Service Review Meetings (as per existing TWPCT Review Meetings) are still to be confirmed.
• Flexible working required to meet peaks in referrals.
• Work to convert the playroom to a booking room at Wrekin nearly completed.
Actions:
• Review of database to identify specific GP practices referring pregnant women late to Maternity Services. • Review of database to identify midwives undertaking booking assessment outside of target (following appropriate referral into the system). • Recruitment to midwifery vacancies within PRH to be tightly managed.
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Nutrition
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % compliance Target Q1 58%
Target 2010/11
% Completion of Nutrition Screening Tool ( CO1.7)
Nutrition
Executive Lead Monthly Status Direction of Travel
DSD
Year to Date Forecast Commentary
GREEN
=
GREEN GREEN
Baseline Audit 58% Q2 65% Q3 75% Q4 90% • A baseline audit conducted in April 2010 showed 58% of Nutritional Screening Assessments were completed within 6 hours of patient admission.
Q2 91% 65% Q3 75% Q4 90% • Targets for 2010/11 have been agreed as: Q2 65% compliance Q3 75% compliance Q4 90% compliance.
• New Dietician appointed with specific role to monitor Nutritional Compliance and Out comes.
• Nutritional Steering Group established.
• Protected Meal Times being trialled in wards 7, 15 and 16 at PRH.
19
Readmission Rate
Target (2010/11)
Readmission Rates
Executive Lead Monthly Status Direction of Travel Year to Date Forecast
Relative Readmission within 28 days of discharge Risk of Emergency MD
GREEN
=
GREEN GREEN
Commentary
The relative risk of Emergency Readmission remains significantly lower (better) than the average for England
10 Period Jun 09 to May
Jul 09-Sep 09 Oct 09-Dec 09 Jan 10-Mar 10 Apr 10-June 10 Specialty Alerts
Risk Rating 6.0% GREEN (better) GREEN (better) GREEN (better) GREEN (comparable) Full data not available ONE
700 600 500 400 300 200 100 0
Readmissions
• Relative risk of emergency readmission within 28 days of discharge is calculated from hospital activity using the Dr Foster Real Time Monitoring Analysis Tool, using the most recent available data (currently five months in arrears, to ensure that readmissions have been mapped to previous spells). It compares the Emergency Readmission in our hospitals with the average expected across England, adjusted to reflect factors such as age and case mix.
• The relative risk of Emergency Readmission was lower (better) than the average for England (based on a 95% confidence interval) for the most recent available full data year (June 2009 to May 2010) and was significantly lower than (2 quarters) or comparable with (2 quarters) the average for England in the four quarters of the most recent available data year.
Actions:
20
Venous Thromboembolism (CQUIN)
Target (2010/11)
Venous Thromboembolism
Executive Lead Monthly Status Direction of Travel Year to Date Forecast
% of adult inpatients who have had a VTE risk assessment on admission (CO1.3) MD
Commentary
No update provided at the time of issue
Actions:
21
Think Glucose (CQUIN)
Target (2010/11)
Think Glucose
Executive Lead Monthly Status Direction of Travel Year to Date Forecast
Compliance with Think Glucose guidance (CO1.3) MD
GREEN
=
Commentary
GREEN GREEN
Action plan compliant with milestone achievement
Compliance Green Milestones
Baseline audit Robust process for patient identification Safe use of Insulin implemented Review of patient identification Visibility and education roll out Re-audit against toolkit CQUIN compliance
Completion Date
Q1 Q2 Q3 Q4
Green
• Think Glucose is a practical and easy to use tool which improves the care, outcomes and experience of people with diabetes who are admitted to hospital with non-diabetes related problems.
• Ongoing training in progress to Ward Champions.
• Ward Hypoglycaemic boxes ordered & stocked.
• Ward Resource Toolkit box disseminated to all wards and departments.
Actions:
• Continuation of delivery of action plan.
• Plan to roll out pre filled insulin syringes during January.
• Develop audit tool to measure compliance.
22
Tissue Viability (CQUIN)
30 20 10 0 60 50 40
M ay Ju ne
Target (2010/11)
Tissue Viability
Reduction in the number of Grade 3 and 4 Pressure Ulcers – to be confirmed with PCT (CO1.3)
Pressure Ulcers Developed in Trust by Grade
Ju ly A ug us t S ep te m be r O ct ob e r N ov em be r D ec em be r Ja nu ar y F eb ru ar y M ar ch
Executive Lead
DSD Grade 4 Grade 3 Grade 2 Grade 1
Monthly Status Direction of Travel Year to Date Forecast Commentary
RED
AMBER AMBER
New CQUIN 2010/11 Target to reduce by Q4 number of grade 3/4 ulcers by 10% • Increase in the total number of ulcers may be attributable to greater compliance with reporting due to on ongoing increased awareness in the use of the new E Trace system with ‘Skin Sunday’.
• Monthly status red as 5 SUI in October so above 3 per month target .
• Key Themes From RCA’s • Inadequate documentation of patients nursing care in care plan.
• Wound assessment documentation not completed accurately.
• Delay in reporting pressure ulcer & referring to TVN.
• Case review meetings of RCA’s commenced by Executive Nurse & Head of Nursing to learn lessons from RCA.
• Delivery of detailed education programme continues, this has been rolled out to Ward 28, Ward 16, Ward. 24, 8/9 and MAU in progress. Roll out plan for the rest of Trust constructed.
• Root Cause Analysis Training given to Matrons and Lead Nurses.
• Trust wide prevalence audit completed .
• Trust Surveillance Nurse will assist TV Nurse 8 hrs. per week to ensure ward staff can access early advice/intervention for grade 3 and 4 pressure ulcers.
• • •
Actions:
RCA training arranged in November for Ward Managers .
Continue with education roll out.
To review Trust wide Prevalence audit results.
23
Target (2010/11)
Appraisals
Executive Lead Monthly Status Direction of Travel Year to Date Forecast Commentary
Appraisals
SaTH target of 80% DCA
GREEN
=
GREEN GREEN
Trust performance at 86% appraisal completion
Completed Appraisals (excluding Bank Staff)
100.0
80.0
% Appraisals Completed
60.0
40.0
20.0
0.0
% Appraisals Completed 2009-10 % Appraisals Completed 2010-11 % Target Appraisals Completed Apr 69 84 80 May 71 81 80 Jun 71 83 80 Jul 73 84 80 Aug 74 85 80 Sep 77 84 80 Oct 77 86 80 Nov 78 Dec 76 80 80 Jan 74 80 Feb 76 Mar 84 80 80 • As at month ending 31 st October 2010, 86% of staff excluding Bank Staff have had a KSF appraisal within the last 15 months.
• Departments continue to improve completion performance, although this must be sustained over the winter months when operational pressures normally impact.
• Appraisal Quality Audits are currently being trialled to improve the effectiveness of individual appraisals.
• The lowest 5 performing areas for September with over 15 staff were as shown.
All have action plans in place to achieve 80%.
Area Staff Completed %
Portering Department (RSH) Ward 11 - Trauma & Orthopaedics Ward 23 - Haematology Ward 10 - Trauma & Orthopaedics Ward 9 - General Medicine 37 23 17 27 23 10 12 9 15 14 27 52 53 56 61
Div.
Cor p.
1 2 1 1
Actions:
• Departments falling below 60% are performance managed by the relevant Executive Director.
24
Smoking (CQUIN)
Target (2010/11)
90% of smokers/users of tobacco attending new patient appointments at selected outpatient clinics receive brief intervention (CO4.3)
Smoking
Executive Lead Monthly Status Direction of Travel Year to Date Forecast
MD
Commentary
No update provided at the time of issue
Actions:
25
Staying Healthy (Alcohol) - CQUIN
Target (2010/11) Executive Lead Monthly Status Direction of Travel Year to Date Forecast Commentary
Staying Healthy (Alcohol)
9a) 90% of people attending A&E with alcohol related condition and are not admitted who receive a brief intervention to reduce alcohol consumption 9b) 75% of people who are admitted to hospital with alcohol related condition receive brief interventions to reduce alcohol consumption MD
GREEN
=
AMBER RED
9a) PCT and Trust agreement on delivery with concerns raised about responsibility lines after April 2011. Project Group meeting and awaiting clarification of SLA for both sites 9b) PCT and Trust agreed target. SLA to be agreed for roll out. Development in line with action plan
Pts presented A&E
:
RSH = 50 Pts seen by alcohol specialist: 2 (4%) Pts presented at PRH = 65 Pts sent information packs: 50 (100%) Part 9a:
• Data Assessment shows 100% patients attending A&E at RSH had a delivered intervention for September.
• Monthly Project Group verbalised concerns around meeting this target if intervention is decreed as being anything more than a sticker and ‘pack sent’ approach. Skill mix review in these areas needs to link into delivery of IBA (Identification and Brief Advice). Alcohol Nurse Specialists through MHL Services started and are based at PRH Ward 9. There is no facility for engaging across both sites due to commissioning streams. Achieved CQUIN in this group for this month.
Part 9b:
• Reviewed Alcohol Screening Tool and agreed trial to start December, first working day.
SDU is taking cost for this. Tool will be trialled on 27G, Ward 9 and MAU’s for 3 months to assess function in practice. Project Group to work with SAU’s to access this client group.
• Awaiting agreement of information leaflets so that there is a consistent approach for both sites. This has been assigned to project leads and will be ready by December. In January 2011 PRH will have access to information leaflets and packs to send out to fully meet CQUIN.
Actions:
• 9a: There are significant concerns around the delivery of IBA after April 2011 at RSH due to resourcing Alcohol specialist post. CQUIN uplift payments are required to assist in service provision and agreement of this needs to allow for 3 months to ensure continuity and training.
• 9b: Delay in agreement for SLA across providers/commissioners. The need for this is agreed and will be written by PCT’s in discussion with acute Trust. This is not totally in the control of the CQUIN group.
26
Care Quality Commission Registration
Target (2010/11) Executive Lead Monthly Status Direction of Travel Year to Date Forecast Commentary Care Quality Commission Registration
Maintain Trust Registration with the Care Quality Commission DCA
GREEN
=
GREEN GREEN
Trust now registered without conditions (Q2) The new registration system for health and adult social care will make sure that people can expect services to meet essential standards of quality and safety that respect their dignity and protect their rights. The new system is focused on outcomes rather than systems and processes, and places the views and experiences of people who use services at its centre There are 28 outcomes, each reflecting a specific regulation. Of these 28 regulations and outcomes, there are 16 that relate most directly to the quality and safety of care and which apply to all types of provider. The other 12 regulations may apply differently to different types of provider.
• The Trust declared compliant with all relevant outcomes across the six key areas in the January Initial Registrations process.
• SaTH has set up templates for lead managers to collate evidence of compliance.
• The CQC are introducing a new quality & risk profiling tool that SaTH will incorporate in to the assessment process however publication of the second quality and risk profile has been delayed from April until at least September.
• The Trust remains registered without any conditions.
• The CQC have completed their responsive review.
There are 28 outcomes grouped into six key areas:
● Involvement and Information ● ● ● Personalised Care, Treatment and Support Safeguarding and Safety Suitability of Staffing ● ● Quality and Management Suitability of Management.
• The DoH and CQC have agreed to halt further action on the periodic review of the NHS – there will be no ratings published for Quality and Use of Resources.
Actions:
• Lead Managers have been asked to submit evidence of continuing compliance against the Essential Standards of Quality and Safety for Quarter 2.
• Internal Audit will be auditing the evidence of compliance in November.
27
Coding
Target (2010/11)
Coding
Executive Lead Monthly Status Direction of Travel Year to Date Forecast Commentary
To increase the numbers of FCEs with coded co-morbidities FD
GREEN
=
GREEN GREEN
Coding levels remain the same as previous month
FCEs with Coded Co-morbidities 72% 71% 70% 69% 68% 67% 66% 65% 64% 10/11 Actual Apr 66% May 65% Jun 69% Jul 71% Aug 72% Sept 72% Oct Nov Dec Jan Feb Mar
• The Target is to ensure that co-morbidities are captured by clinicians for each Finished Consultant Episode (FCE), where applicable.
• Work is currently underway by MedeAnalytics to analyse national coding statistics and provide a national benchmark by which SaTH clinical coding can be compared.
• New guidance for 2010/11 has been issued by Connecting for Health which clarifies the recording of co-morbidities and is responsible for the increased depth of coding.
Data report one month in arrears
Actions:
• The Clinical Coding Manager continues to audit the recording of co-morbidities on a monthly basis making use of the Coding analytics software.
28
A&E 4 Hour Waits
Target (2010/11)
A&E 4 Hour Waits
Executive Lead Monthly Status Direction of Travel Year to Date
95% of patients to be admitted, discharged or transferred within 4 hrs.
of registering at A&E DSD
RED
=
Forecast Commentary
GREEN GREEN
Local Health Economy underachieved target for October
Total Tim e in A&E - Less than 4 Hours
100% 98% 96% 94% 92% M apped Total PCT Element SaTH Element National Target Stretch Target Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 M ar-10 Apr-10 M ay-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 97.20% 95.90% 95.73% 97.50% 99.08% 98.77% 1.48% 2.73% 2.89% 1.84% 0.76% 1.08% 99.01% 99.00% 99.08% 0.35% 0.27% 0.26% 98.71% 0.92% 97.55% 95.98% 96.69% 0.52% 0.56% 3.89% 95.72% 93.17% 92.84% 95.66% 98.32% 97.69% 98.66% 98.73% 98.82% 97.79% 97.03% 95.42% 92.80% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% • The Trust achieved 92.80% unmapped during October.
• The Local Health Economy achieved 96.69% mapped during October.
• For the year-to-date the Trust has achieved 97.04% unmapped.
• For the year to date the Local Health Economy has achieved 98.48% mapped.
• Recently revised NHS Operating Framework has amended target to 95% for 2010/11, however the internal target of 98% remains and is shown in the graph.
• Performance in the month has been assessed against the internal stretch target of 98%. The Trust continues to achieve the National 95% target.
• Performance notice received from Shropshire County PCT for October’s performance.
Actions:
• Daily Conference Calls continue.
• Health and Social Care Winter Planning commenced.
• Urgent Care Network Review and relaunch.
29
18 Weeks 18 Weeks
100.00% 80.00% 100.00% 80.00%
Target (2010/11)
1a - Admitted Clock Stops above 90% 1b - Non-Admitted Clock Stops above 95%
18 Weeks Part 1a - Admitted Clock Stops 18 Weeks Part 1b - Non Admitted Clock Stops Executive Lead
DSD DSD 60.00% Actual Profile Apr 10 90.50% 90.00% M ay 10 91.83% 90.00% Jun 10 91.57% 90.00% Jul 10 91.41% 90.00% Aug 10 90.52% 90.00% Sep 10 90.71% 90.00% Oct 10 90.22% 90.00% Nov 10 90.00% Dec 10 90.00% Jan 11 90.00% Feb 11 M ar 11 90.00% 90.00% 60.00% Actual Profile Apr 10 96.40% 95.00% M ay 10 97.12% 95.00% Jun 10 97.03% 95.00% Jul 10 96.30% 95.00% Aug 10 95.25% 95.00% Sep 10 96.23% 95.00% Oct 10 97.02% 95.00% Nov 10 95.00% Dec 10 95.00% Jan 11 Feb 11 M ar 11 95.00% 95.00% 95.00%
Monthly Status Direction of Travel Year to Date Forecast Commentary
GREEN
=
GREEN GREEN
Trust achieved the 90% target during October
GREEN
=
GREEN GREEN
Trust achieved the 95% target during October • The Trust Achieved the overall target of 90% and 95%.
• PCT performance for September was:-
Shropshire County PCT Telford & Wrekin PCT 1a 1b
90.14% 97.02% 90.12% 97.02% • Achieved the 95% target for Audiology in October with 96% of non admitted Audiology patients completing their pathways within 18 weeks with 92% data completeness which is within the anticipated 90 – 110% threshold.
• Specialty level performance for admitted patients (part 1a) was below 90% in ENT (78.69%) Ophthalmology (84.87%) Oral Surgery ( 78.57%) T&O (87.02%).
• Specialty level performance for non admitted patients (part 1b) was below 95% in Oral Surgery ( 93.63%) .
• The DOH and SHA have confirmed the following thresholds will apply when reviewing performance against median waits for each pathway type, >11.1weeks
Admitted, >6.6 weeks Non Admitted and >7.2 weeks Incomplete • At the end of September SaTH was below the Admitted and Non Admitted thresholds with 7.53 and 6.58 respectively. For Incomplete pathways SaTH exceeded the threshold with 8.84 weeks
Actions:
30
Cancer – 14 Day
Target (2010/11)
14 Day Cancer
Executive Lead Monthly Status Direction of Travel
14 Days from urgent GP referral to first outpatient appointment for all urgent suspected cancer referrals DSD
GREEN
Year to Date Forecast
AMBER GREEN
Commentary
14 day target achieved in month
14 Day Target
• 14 day target achieved in October (95.23%), against a year end cumulative target of 93%. There were 43 breaches out of a total of 903 referrals.
100.00% 80.00% 60.00%
Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Actual 84.61% 87.94% 88.40% 87.62% 85.62% 89.52% 95.23% Exc Choice 100.00%100.00%100.00% 98.09% 97.72% 100.00% 95.68% Profile 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% At the time of writing this report the actual performance for the months of April, May, June. July, August and September are validated but the actual performance for the month of October is still being validated before submission of data to the national Cancer Waiting Times Database • Performance excluding choice was 95.68%.
• 39 patients chose to wait longer than 14 days for their first appointment. Details of the Specialties are as follows: Breast 5, Colorectal 6, Gynae. 5, Haematology 1, Head & Neck 6 Paediatrics 1, Skin 7, Upper GI 3, Urology 5 • 3 patients waited longer than 14 days due to medical reasons: Breast Symptomatic 1, Colorectal 1, Gynae. 1, • 1 patient waited longer than 14 days due to other reasons: UGI 1 • 14 day target YTD 89% against a year end cumulative target of 93%.
Actions:
• The 14 day target has improved significantly and has been sustained over the past few weeks. This is due to the additional capacity which is now available within the Breast Service to ensure patients are offered the choice of two dates. We are continuing to work closely with the PCTs and auditing the patients that choose not to accept an appointment within 14 days and looking into each case individually. In order to establish why patients are choosing to wait longer than 14 days, we are telephoning patients to establish the reason why.
• Demand and capacity for all specialities has been audited over the last 12 months and processes are being put in place to increase capacity where appropriate because from 1st December 2010 all two week wait appointments will be on Choose and Book.
31
Cancer – 31 Day
Target (2010/11)
31 Day Cancer
Executive Lead Monthly Status Direction of Travel
31 Days from diagnosis to treatment for all cancers DSD
GREEN
Year to Date Forecast
GREEN GREEN
Commentary
31 day target achieved in month
31 Day Target
100.00% 80.00% 60.00%
Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 • 31 day target overall achieved (excluding Radiotherapy) in October (97%), against a year end cumulative target of 96%.
• 31 day target first definitive treatment achieved in October (98.00%), against a year end cumulative target of 96%.
• 31 day target subsequent treatment (Surgery) underachieved in October (92%), against a year end cumulative target of 94%.
• 31 day target subsequent treatment (Anti Cancer Drugs) underachieved in October ( 97%) against a year end cumulative target of 98%.
• 31 day target subsequent treatment (Radiotherapy) underachieved in October (90%), against a year end cumulative target of 94%.
Actual 97.30% 97.76% 97.95% 96.45% 98.80% 93.66% 97.00% Profile 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% At the time of writing this report the actual performance for the months of April, May, June, July, August and September are validated but the actual performance for the month of October is still being validated before submission of data to the national Cancer Waiting Times Database • There were 19 breaches in October out of 316 referrals of which were due to patient choice - 10, medical reasons - 2 and others - 7.
• Current YTD position is 97% against a year end cumulative target of 96%.
Actions:
• Although not consistently, we have previously met this target and have gone over and above it. Our aim is to meet this target consistently by the end of December 2010.
We have both capacity & staffing issues within Radiotherapy Department which have been acknowledged. The number of Oncologists employed has increased and therefore the demand for access to the radiotherapy machines has increased and plans have been agreed to increase radiography and physics staffing to increase linac capacity in line with NRAG recommendations.
32
Cancer – 62 Day
Target (2010/11)
62 Day Cancer
Executive Lead Monthly Status Direction of Travel Year to Date Forecast
62 Day from urgent referral to treatment of all cancers DSD
RED
Commentary
GREEN GREEN
62 day target underachieved in month
100.00% 80.00%
62 Day Target
• 62 day target overall underachieved in October (74%), against a year end cumulative target of 85%.
• 62 day first definitive cancer target underachieved in October (69.44%), against a year end cumulative target of 85%.
• 62 day screening to first definitive treatment underachieved in October (80%), against a year end cumulative target of 90%.
• 62 day consultant upgrade achieved in October (93.54%) – target to be confirmed.
60.00%
Apr 10 M ay 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 M ar 11 Actual 89.32% 85.52% 87.79% 88.60% 95.00% 89.00% 74.00% Profile 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% • There were 28 breaches in October out of 123 referrals of which 14 were patient choice, 2 complex pathways, 1 DNA, 4 were due to medical suspensions and 7 others.
At the time of writing this report the actual performance for the months of April, May June, July, August and September are validated but the actual performance for the month of October is still being validated before submission of data to the national Cancer Waiting Times Database • Current YTD position is 87% against a year end cumulative target of 85%.
Actions:
• In order to improve and maintain the delivery of the 62 day target, the pathway for Upper GI patients will be re-designed to improve the current delays. This work is being coordinated by the Service Improvement Nurse within Cancer Services. Changes made within the Administration Team will ensure that all patients are tracked correctly to ensure there are no delays.
• Work is starting in December with the Department of Health Intensive Support Team to identify areas for improvement.
33
Target (2010/11)
Thrombolysis
Executive Lead Monthly Status Direction of Travel Year to Date Forecast Commentary
Thrombolysis
68% of patients admitted with ST Elevation MI should receive Thrombolysis within 60 minutes of call for help DSD
RED
=
RED GREEN
Only 2 eligible patient in the year to date. CQC guidance states that for this indicator a ‘low numbers' rule will be applied which will withdraw Trusts treating a low number of eligible cases from the assessment
Thrombolysis Profile 2010/11
75.00% 70.00% 65.00% 60.00% Actual YTD Profile Apr 10 M ay 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 M ar 11 0.00% 68.00% 0.00% 68.00% 0.00% 68.00% 0.00% 68.00% 0.00% 68.00% 0.00% 68.00% 0.00% 68.00% 68.00% 68.00% 68.00% 68.00% 68.00%
Thrombolysis Performance YTD
Call to Needle Eligible Admissions Call to Needle < 60 minutes
Performance Achieved YTD PRH
0 NA
NA RSH
2 0
0% SaTH
2 0
0%
• Year-to-date performance of 0%.
• This is a combined target for the Trust and the Ambulance Services.
• Rurality issues within Shropshire County and Powys impact on the Call to Door time. Both West Midlands and Welsh Ambulance Services are able to deliver pre hospital thrombolysis in accordance with strict eligibility criteria.
• The introduction of direct access Primary Angioplasty at UHNS and Wolverhampton Hospitals has led to a reduction in the number of SaTH Myocardial Infarction admissions.
• Patient 1 - (Powys) had call to door time of 132 minutes no evidence of pre hospital thrombolysis assessment.
• Patient 2 - (Oswestry) had call to door time 42 minutes no evidence of pre hospital thrombolysis assessment.
Actions:
• Internal systems and processes for the delivery of thrombolysis in A&E and the management of acute chest pain admissions ongoing. • Chest Pain direct admission to CCU project initiated, awaiting outcome report.
34
Rapid Access Chest Pain
Target (2010/11)
Rapid Access Chest Pain
Executive Lead Monthly Status Direction of Travel Year to Date Forecast Commentary
A maximum of two-week wait for rapid access chest pain clinic (CO6.6) DSD
GREEN
=
GREEN GREEN
Well established service with consistent high performance
Actions: Rapid Access Chest Pain Clinic
75.00% 70.00% 65.00% 60.00%
Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Actual YTD 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% Profile 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% • 5 Rapid Access clinics running each week across SaTH.
• Capacity appropriately matched to demand.