Executive Summary This commentary provides an overview of key
issues during the month and highlights where performance fell short
of the target values as well as areas of improvement and noticeable
good performance. 1.A&E Performance for October was 97.08%,
exceeding the 95% target for the fifth consecutive month and
placing the Trust in the top quartile nationally and remains the
best performance in the Region. 2.There were two cases of C.Diff in
October against the threshold of two. This is covered on page 12 of
this report. 3.Performance on outpatient and inpatient discharge
summaries remains below target. A number of new steps have been
introduced through the month. Further detail is on page 3.
4.Performance on MRSA screening of emergency admissions was 95%
against the 100% target, and 92% for elective admissions. This is
covered on page 12 of this report. 5.All Stroke targets were
achieved for the month. 6.The Trust had 2 single sex breaches
during October. All 2 occurred within a short timescale. See page
3. 2
Slide 4
3 Performance IndicatorThresholdOctoberLead Exec Discharge
Summaries - Outpatients95% sent to GPs within 3 days81.63%Dermot
ORiordan Performance IndicatorThresholdOctoberLead Exec Discharge
Summaries - Inpatients95% sent to GPs within 1 day77.57%Dermot
ORiordan Performance IndicatorThresholdOctoberLead Exec Mixed Sex
Accommodation Breaches03Jon Green Executive Summary Clinical staff
and the project team have been exploring options. In agreement with
the CCG a number of non-critical areas have been removed as part of
the performance framework while data collection has been extended
beyond just EPRO. TEG have agreed a number of initiatives to
address the key issues, including performance discussion at
consultant appraisal, targeting the underperforming specialities in
directorates, where the Ops Groups have agreed a new process.
Looking at automating the process further by sending letters sooner
In order to support Discharge Summaries and Letters the project
team have been working with clinicians to explore a range of
options in order to resolve the current performance. In agreement
with the CCG a number of non-critical areas have been removed as
part of the performance framework while data collection has been
extended beyond just EPRO. In addition TEG have agreed a number of
initiatives to address the key issues, including performance
discussion at consultant appraisal, targeting the underperforming
specialities in directorates including a new process agreed by the
Ops Group. In addition looking at automating the process further by
sending letters sooner. All 3 breaches were associated with ITU
step-down and occurred over a 48 hour period. High levels of level
3 occupancy and limited ward beds meant these patients could be
neither safely partioned or stepped-down to wards.
Slide 5
4 Performance IndicatorThresholdOctoberLead Exec MRSA Emergency
Screening All emergency patients admissions are to be screened for
MRSA within 24 hours of admission 95.09%Nichole Day Executive
Summary Performance IndicatorThresholdOctoberLead Exec Sickness
absence rate
Local Priorities: Exception Reporting KPI-3SIRIs open more than
45 days after submission on STEIS This measures all SIRIs that
remain open on STEIS beyond the final report submission deadline.
This includes three sub-sets: SIRI final report overdue submission
(n = 0) SIRI final reports for which WSFT response to CCG queries
is pending (n = 7) SIRI final reports submitted for which feedback
/ closure by the CCG is pending (n = 4) RAG rating*RED (n
>10)Amber (n = 6 - 10)Green (0 - 5) As @ 15/11/13n = 10 (Amber)
RAG rating based on local benchmark data for 22 Trusts provided by
CCG The number of open reports has fallen considerably from 24 in
September to18 in October to 10 in November. One of the 10 SIRIs
has had a stop the clock pending the findings of an external review
of CTG tracing. Incidents (Amber / Green) with investigation
overdue (over 12 days) The next deadline for NRLS submission is the
30 th November. The Operational Steering Group have agreed a
pathway to complete sign off of the Apr-September incidents within
the timeframe which has resulted in a reduction in the total
overdue for investigation and final approval. Ops group also
identified a need to consider a robust method for ensuring
timeliness of future investigation and sign off. Late by
Directorate Red (RAG) OctNovchange Clinical Support>15 226
Estates and Facilities>10 179 Medical>70 149152
Surgical>407965 Women & Childrens Health>15 3119 OtherNo
target 810 TOTAL >150 306261 RCA actions overdue Seven of the
actions are from Maternity RCAs and have only just become overdue
in November. These will be actively followed up to ensure
completion. Two relate to others policies currently being drafted.
19
Slide 17
Local Priorities - Governance Dashboard IndicatorPerformance
targetRAGOct13Commentary Timely completion of incident
investigations and actions Red non-SIRI investigation not complete
more than 45 days after incident reported >31 - 300 RCA Actions
beyond deadline for completion>=51 409Seven of the actions are
from Maternity RCAs and have only just become overdue. These will
be actively followed up to ensure completion. Two relate to others
policies currently being drafted. Incidents (Amber / Green) with
investigation overdue (over 12 days) >15050 - 150 2 working days
from identification as red >1100All incidents were submitted to
STEIS within the 2 day timeframe. Two incidents were reported late
on Datix and three were re-graded as Red following initial review.
SIRI final reports due in month submitted beyond timeframe
>11008/ 8 within deadline Number of SIRI reports open on STEIS
more than 45 days after initial notification >106 -
100-510Reduced from 18 in October. One SIRI included in this figure
had a stop the clock pending the findings of an external review of
CTG tracing. Duty of CandourCompliance with Duty of Candour
requirements =95%88%88% = 14/16. The two non compliant cases relate
to pressure ulcers identified on critically ill patients who
subsequently died for whom a conversation with the family about the
pressure ulcer was not considered appropriate at the time. Risk
assessment Active risk assessments in date=95%99% Outstanding
actions in date for Red / Amber entries on Datix risk register
=95%99% 20
Slide 18
Local Priorities - Governance Dashboard (cont.)
IndicatorPerformance targetRAGOct13Commentary Risk assessment
Active risk assessments in date =95% 99% Outstanding actions in
date for Red / Amber entries on Datix risk register =95% 99%
Clinical Audit Trust participation in relevant ongoing National
audits (reported by Quarter) =90% 100% Safer surgery Completion of
WHO checks during surgery. This is a composite indicator of the
checks at ward, sign-in, time-out and sign-out. 98% 95%Non
compliance reported to individuals (daily) and Clinical Directors
(weekly) NICE TA (Technology appraisal) business case beyond agreed
deadline timeframe >94 - 90 - 3 2 These outstanding five
interventional procedures and six Clinical Guidelines are
outstanding baselines assessment and require targeted follow up.
IPG (Interventional procedure guideline) baseline assessments
beyond agreed deadline timeframe >94 - 90 - 3 5 CG (Clinical
guideline) baseline assessments beyond agreed deadline timeframe
>94 - 90 - 3 6 Complaints Response within 25 days or negotiated
timescale with the complainant =90% 88% This represents 4 of the 32
responses that were sent out in October. We continue to manage a
high number of complaints and must ensure the responses address all
issues, this can sometimes results in a slight delay with a few of
the responses. Number of second letters received>=51-40 2 Two
second letters were received. One complainant is adamant that she
wants the PHSO to review her complaint but has been told by them
she must first write back to us in the first instance. One remains
dissatisfied with her care despite the explanation given. Health
Service Referrals accepted by Ombudsman >=210 0 Red complaints
actions beyond deadline for completion>=51-40 0 Number of PALS
contacts becoming formal complaints>=106 - 9
Contract Priorities Dashboard 32 Performance IndicatorThreshold
In Month Performan ce YTDCommentsLead Exec A&E A&E -
Threshold for admission via A&E i) if the monthly ratio is
above the corresponding 2011/12 monthly ratio for two month in a
six month period ii) if year end is greater than 27% 25.20%24.82%
Jon Green A&E - Timeliness Indicators To satisfy at least one
of the following Timeliness Indicators: 1. Time to initial
assessment (95th percentile) below 15 minutes 2. Time to treatment
in department (median) below 60 minutes ONE MET- Jon Green Stroke
Stroke -Proportion of Patients admitted to an acute stroke unit
within 4 hours of hospital arrival 90%91.00%85.71% Jon Green
Proportion of patients in Atrial Fibrillation, presenting with
stroke and where clinically indicated will receive
anti-co-agulation. 60%83.00%68.29% Jon Green Stroke - % of Stroke
patients with access to brain scan within 24 hours
100%100.00%98.57% Jon Green Stroke - Proportion of Stroke Patients
and carers with a joint health and social care plan on discharge
85%94.00%91.14% Jon Green Stroke - Patients (as per NICE guidance)
with suspected stroke to have access to an urgent brain scan in the
next slot within usual working hours or less than 60 minutes out of
hours as defined from time to time by the ASHN 100% of stroke
patients eligible for a brain scan scanned within one hour
100.00%93.43% Jon Green >80% treated on a stroke unit >90% of
their stay80%97.00%89.14% Jon Green >60% of people who have a
TIA and are high risk (ABCD 2 score 4 or more) are scanned and
treated within 24 hours of 1st contact but not admitted
60%92.00%78.57% Jon Green Stroke - 65% of patients with low risk
TIA have access to MRI or carotid scan within 7 days (seen,
investigated and treated) 65%65.00%73.43% Jon Green % of Patients
eligible for Thrombolysis, Thrombolysed within 4.5 hours 100% of
all eligible patients100.00% Jon Green
Slide 30
Contract Priorities Dashboard 33 Discharge Summaries Discharge
Summaries - Outpatients95% sent to GP's within 3 days81.63%84.19%
Dermot O'Riordan Discharge Summaries - A&E 95% of A&E
Discharge Summaries to be sent to GPs within one working day
97.54%97.50% Dermot O'Riordan Discharge Summaries - Inpatients95%
sent to GP's within 1 day77.57%82.16% Dermot O'Riordan Choose &
Book Provider failure to ensure that sufficient appointment slots
are made available on the Choose and Book system A maximum of 3%
slots unavailable (50 per appointment over 5%. Threshold applied
over monthly figures) 3.00%- The Threshold applied to fines is 5%
Jon Green All 2 Week Wait services delivered by the Provider shall
be available via Choose & Book (subject to any exclusions
approved by NHS East of England) 100%100.00%- Jon Green Cancelled
Operations Provider cancellation of Elective Care operation for
non- clinical reasons either before or after Patient admission i)
1% of all elective procedures0.57%1.15% Jon Green Patients offered
date within 28 days of cancelled operation 100% 100.00% Jon Green
Maternity Access to Maternity services (VSB06):- 90% of women who
have seen a midwife or a maternity healthcare professional, for
health and social care assessment of needs, risks and choices by 12
completed weeks of pregnancy. 96.23%96.20% Nichole Day Maintain
maternity 1:30 ratio1:30 1:29 Nichole Day Pledge 1.4: 1:1 care in
established labour1:1 100.00% Nichole Day Breastfeeding initiation
rates.80% 81.73%79.81% Nichole Day Reduction in the proportion of
births that are undertaken as caesarean sections. Suffolk PCT Only
1% reduction in proportion compared to 2011/12 baseline - 22.70%
16.26%18.47% Nichole Day
Slide 31
Contract Priorities Dashboard 34 Other contract / National
targets Mixed Sex Accomodation breaches0 Breaches24 Jon Green
Consultant to consultant referral Commisioner to audit if concern
about levels of consultant referrals 7.13%6.19% Jon Green Current
ratios of OP procedure to day case for agreed list of procedures to
be maintained or improved, i.e. the Commissioner will not fund a
higher level of admitted patients for such procedures, unless
clinical reasons can be demonstrated for increase in admissions.
Maintain or improve the mix as specified = 90.17% 87.33%87.55% Jon
Green MRSA - emergency screening All emergency patients admissions
are to be screened for MRSA within 24 hours of admission
95.09%92.42% Nichole Day Rapid access - chest pain clinic 100% of
patients should have a maximum wait of two weeks 100.00%78.33% Jon
Green New to Follow up Thresholds set at each speciality - overall
Trust Threshold is 1.9 1.891.84 Jon Green Patients receiving
primary diagnostic test within 6 weeks of referral for diagnostic
test 99%99.49%97.77% Jon Green