integrated healthcheck and staffing update trust board ...€¦ · documentation used by villa care...

Agenda Item 12.6

1

Integrated Healthcheck and Staffing Update

Trust Board

January 2018

Presented for: Governance

Presented by: Professor Suzanne Hinchliffe CBE, Chief Nurse/Deputy Chief Executive

Author Lorna Johnson, Head of Nursing, Professional Practice Safety Standards Heather McClelland, Head of Nursing Workforce and Education

Key points

1. Healthcheck outcomes for October and November 2017 alongside nurse staffing information shows no direct correlation between shortfalls in nurse staffing and a deterioration in reported metrics scores

For Information

2. Nine wards were in escalation in October and November compared to 8 in August and September although all were in first stage

For Information

3. Of the five wards in first stage escalation on the Healthcheck metrics, staff sickness is a trigger for two of the five areas.

For Information

4. Heather and Bilberry Wards at Wharfedale and J30 have modified monthly metrics to reflect different practices and documentation used by Villa Care

For Information

5. Twenty one (23.9%) and eight (9%) areas reported staffing levels lower than 80% in October and November

For Information

6. CHPPD data is consistent with previous months For Information

Trust Goals

The best for patient safety, quality and experience

The best place to work

A centre for excellence for research, education and innovation

Seamless integrated care across organisational boundaries

Financial sustainability

Agenda Item 12.6

2

Summary

This paper provides a review of Healthcheck and staffing data drawn from a number of sources for the

period October and November 2017. It presents performance across a number of domains and considers

this in the context of staffing, recruitment and ward/department performance within Healthcheck domains.

1. Background

Safe levels of nurse, midwifery and perioperative staffing are essential for the delivery of high quality

nursing care. Within Leeds Teaching Hospitals Trust (LTHT), nurse establishments are calculated using a

range of data as recommended in national guidance (NQB, 2016), including acuity/dependency, nurse:

patient ratios, and professional judgement. Staffing information is reported nationally, weekly and monthly

it incorporates both substantive LTHT staff and additional temporary staff (bank and agency).

The Ward Healthcheck has been rolled out incrementally since December 2013. It provides a systematic

overview of performance across a range of key areas that influence or reflect the standards of care,

patient outcomes and experience of care delivered in LTHT. The data can be viewed at organisational,

CSU and ward level, providing both a local and strategic picture. Data for all areas is displayed in ward

areas on standardised Patient Safety Boards and is visible to staff, patients and visitors.

2. Nursing and Midwifery Staffing

Since May 2016 LTHT has submitted workforce data to NHS Improvement (NHSI) for nursing and

midwifery areas on;

Nurse Staffing Return (Hard Truths) - planned vs. actual registered and unregistered nurse staffing

levels (section 3.1 and Appendix 1) - monthly

Care Hours Per Patient Day (CHPPD) submitted monthly alongside Hard Truths (section 3.2 and

Appendix 2) - monthly

Temporary workforce - Bank and Agency fill rates and pay rate breaches - weekly.

3.1 Nurse Staffing Return (Hard Truths) - (see Appendix 1)

Reported levels for nurse staffing are based on the staffing levels achieved throughout the month against

what was planned for that area. Data is extracted from e-roster for the included clinical areas and is

validated by corporate and clinical teams. Figure 1 depicts the number of areas where actual staffing

hours available fell below 80% of staffing hours planned on the roster, this is the threshold established by

NHSI. Twenty one (23.9%) and eight (9%) clinical areas reported staffing levels lower than the 80%

threshold in October and November respectively.

The data also portrays actual staffing levels of greater than 130% against planned levels for unregistered

staff in many areas. These higher than planned levels are due to the deployment of unregistered staff to

deliver:

enhanced care provided by clinical support workers for patients identified at risk

to mitigate risk for registered nursing shortfalls

The quality of reported data is dependent on:

The shift templates being up-to-date against budgeted establishments - this determines the plan.

Ward mangers updating the roster to reflect the day to day staffing- this is the actual.

The review of roster templates and the activation of the registration of the newly qualified starters have

contributed to the reduction in reporting of wards with less than 80% of the planned staffing.

Agenda Item 12.6

3

To mitigate the risk to patients, nurse staffing is reviewed daily at the Operational meeting, and actions

agreed, including:

proactively sending shifts to be filled by bank and agency workers

CSU staff being moved between clinical areas to meet gaps and maintain patient safety

increasing the number of CSWs on duty

deploying non-ward based clinical staff, e.g. Matron or Clinical Educators, to these areas to

provide care

3.2 Care Hours per Patient Day (CHPPD) (See Appendix 2)

CHPPD calculations are based on the actual hours of registered and unregistered staff available against

the ward activity, i.e. bed occupancy at midnight. Table 1 presents ward level CHPPD, split by registered

and unregistered staff and the combined total. Appendix 2 (Table 2) provides the CHPPD data for

November 2017, showing both the mean and range of data for each CSU. Data is consistent with previous

months. No national guidance on best practice CHPPD levels is currently available.

3.3 Clinical Service Units (CSU) Specific Staffing Issues

CSUs that continue to have registered nurse staffing pressures include:

Abdominal Medicine and Surgery

Cardio-Respiratory

Emergency and Specialist Medicine

Institute of Neurosciences

Trauma and Related services

Not all wards within these CSUs are affected and some wards previously challenged are showing

improved staffing over the last six months, due to newly qualified staff taking up post, improved temporary

worker fill rates and workforce innovations. Many of the areas are hard to recruit to nationally (complex

medicine and orthopaedics), have high levels of acuity and dependency, or are areas that require highly

specialist skills.

Actions taken to mitigate vacancy gaps include:

Clear escalation processes.

Use of temporary staffing

Use of incentives to increase uptake of temporary staffing shifts

Implementing specialist training and preceptorship packages to attract staff and engage staff early

in their development

Proactive recruitment, including presence at local and national events

Working with CSUs to develop incentives for recruitment and to review skill mix.

4. Ward Healthcheck

The ward Healthcheck is now undertaken in all adult and paediatric in-patient areas including Theatres,

PACU and Emergency Departments. In recent months Bilberry and Heather Units at Wharfdale have been

audited monthly as part of the Healthcheck. These wards are staffed by the Independent provider Villa

Care. In November J30 (which is now also staffed by Villa Care) was audited. The questions and

assessment for these wards have been modified to allow for different practices and documentation used

by the Villa Care Team, however the expectation relating to outcomes remains the same as the wards

managed by LTHT staff.

Agenda Item 12.6

4

The ward Healthcheck for in-patient areas has an escalation process comprising of six KPI’s; Core

Metrics, Friends and Family Test (response rates), Patient Experience, Staff Sickness, Safety

Thermometer and Health Care Associated Infections (HCAI). The progressive escalation process (stage 1

- 4) is associated with these domains, with a focus of resolution at CSU level. Some wards progress

beyond initial stages of escalation and they will have formal review meetings with the Corporate

Operations Team. The final stage of the escalation process is an Executive Director led review.

Assurance visits, which encompass the key lines of enquiry used by the CQC, can be undertaken at any

point and can be triggered by CSUs and/or Corporate Teams. These visits are undertaken by the

Corporate Nursing Team, who provide independent review and support with recommended areas for

improvement or change. Visit feedback is within five working days (but usually sooner) with a visit

summary also presented at the weekly Quality Meeting chaired by the Chief Medical Officer or Chief

Nurse.

There are 91 in-patient wards included in the healthcare Healthcheck. The number of wards in escalation

varies month on month (see Chart 1). The last two months has seen nine wards in escalation. Five wards

are triggering 1st Stage escalation in November 2017 (L52, L03, J82, J20, J07). Staff sickness is a trigger

for two of the five wards in escalation (threshold for sickness escalation is sickness more than 4%).

Chart 1

4.1 Clinical standards - Metrics

Heathcheck monthly audit programme focusses on processes at ward/department level for identifying and

managing risk of harm rather than outcome (incidence of harm). There are 11 standards assessed against

agreed criteria. A RAG rating is awarded based on percentage compliance with robust assessment,

consistent implementation of interventions, evaluation and documentation.

The individual standards scores are collated to give an overall score;

79.9% or below is Red

80-89.9% is Amber

90% and above is Green.

Appendix 3 (Table 5) illustrates a breakdown of metrics score by question group. October and November

2017 have shown some improvement particularly around positive identification of patients and

resuscitation checks. A focus on processes for discharge and standards for documentation continue to be

themes for improvement.

Appendix 4 (Table 6) highlights the overall score by Trust and CSU level. Chapel Allerton have worked

hard engaging teams to improve performance across most of the standards in October and November.

0

5

10

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17

No

of

clin

ical

are

as


Total 7 1 0 3 5 4 4 5

Number of Clinical Areas in Escalation April 2017 to November 2017

Agenda Item 12.6

5

Head and Neck (L23) saw a drop in scores in November but have seen subsequent improvement in

December. Data analysis suggested the ward needed to focus on assessment and documentation and the

Clinical Support Team have been undertaking documentation master classes with the nursing team.

Review of the CSU’s with lower than 80% in the reported CHPPD (Appendix 1 Table 1) do not show a

clear correlation between shortfalls in nurse staffing with a deterioration in reported metrics scores. The

monthly Healthcheck scores over a four month period for these wards (Chart 2) show small percentage

change which is normal statistical variation. Staffing and sickness may be a contributing factor to this.

Indeed the majority of wards have maintained or improved their Healthcheck scores.

Ward Sept-17 Oct-17 Nov-17

J82 84.3 98.3 96.5

J83 92.8 95.3 96.9

L20 97.4 89.7 84.5

J17 89.3 89.1 97.3

J19* 96.9 94.6 94.6

J21 91.0 96.5 98.0

J27 94.4 86.0 94.5

L22* 93.0 96.9 96.9

Chart 2

(* wards on bi-monthly Healthcheck audits)

Chart 3 shows for the eighth consecutive month no wards have scored less than 70% in compliance with

the agreed standards of the Healthcheck. There have been significant operational pressures during

October and November. This, together with a routine change in auditors in October, has been reflected in

a number of red metric scores. The Clinical Support Team is working with these areas to improve overall

scores by focusing on key standards.

Agenda Item 12.6

6

Chart 3

Summary of actions being taken:

Workforce metrics are under review to enhance ward to board visibility of key workforce indicators.

Monthly combined Staffing and Healthcheck data to be discussed by Professional Practice &

Safety Standards and Workforce & Education teams, any trends/risks identified and escalated.

Share Staffing & Healthcheck information with CSU’s to discuss at local governance meetings.

Proactive work with wards with low amber scores in the Healthcheck to help them recognise and

achieve improvement.

Professional Practice and Clinical Standards team working closely with Villa Care team at

Wharfedale to create adapted metrics which are now displayed on the dashboard. Villa Care are

now established on J30 and the metrics standards have been applied to this area as well.

QI work in Falls, Deteriorating Patient, Pressure Ulcer Reduction, Sepsis, Parkinson’s Disease,

Infection Prevention and Enhanced Care continues.

Celebration programme has been agreed to recognise those wards that are consistently

performing well in the Healthcheck audit. The programme commences in February 2018 in line

with changes in the metrics questions and is a pre-cursor to an accreditation scheme.

Areas achieving six consecutive months Green on the Healthcheck were awarded a Green

certificate ahead of the celebration programme due to commence in February 2018.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



Red 1% 2% 0% 0% 0% 0% 7% 5%

Amber 24% 18% 13% 22% 26% 13% 18% 14%

Green 75% 80% 87% 78% 74% 87% 75% 82%

RAG rated Healthcheck Scores

Agenda Item 12.6

7

3. Publication Under Freedom of Information Act

• This paper has been made available under the Freedom of Information Act 2000

4. Recommendations Trust Board is asked to:

Receive this report and note the Hard Truths and Healthcheck data for October and November 2017.

Note developments relating to workforce and the ward Healthcheck.

Lorna Johnson Head of Nursing, Professional Practice Safety Standards Heather McClelland Head of Nursing Workforce and Education 28th December 2017

Agenda Item 12.6

8

Appendix 1

Nurse Staffing Return (Hard Truths)

The Trust reports staffing numbers to NHS England via a monthly Nurse Staffing Return (Hard Truths) for

88 inpatient areas. This report details the monthly staffing hours within a clinical area against their

planned. CHPPD data is recorded within the same report (Appendix 2)

Figure 1 depicts the percentage of areas where actual staffing hours available fell below 80% of staffing

hours planned on the roster, this is the threshold established by NHS Improvement.

Figure 1 - Wards triggering < 80% staffing against planned

Data source: LTHT Workforce Intelligence

Table 1 represents the Nurse Staffing Return inclusive of CHPPD for the individual areas and the overall

score on Healthcheck for September 2017. The data has been RAG rated, red data indicates less than

80% of planned staffing. Amber rated data is that where staffing is reported as over 130% of the planned.

Agenda Item 12.6

9

Table 1– Ward Level Combined Staffing and Healthcheck Information

CSU Ward name

Average fill rate -

registered

nurses/midwives

(%)

Average fill rate -

care staff (%)

Average fill rate -

registered

nurses/midwives

(%)

Average fill rate -

care staff (%)

Cumulative count

over the month of

patients at 23:59

each day

Registered

midwives/ nursesCare Staff Overall

Ward

healthcheck

J42 Urology 91.6% 110.7% 107.8% 109.6% 791 2.5 2.8 5.3 93.7%

J43 Short Stay Surgery 99.7% 116.7% 125.5% 85.6% 607 2.9 2.8 5.7 100.0%

J44 General Surgery 86.6% 116.4% 86.9% 100.0% 826 2.3 2.9 5.2 97.2%

J45 General Surgery 99.9% 118.3% 87.7% 111.5% 757 2.5 3.2 5.7 98.7%

J46 Colorectal Surgery 82.6% 96.1% 100.6% 97.0% 763 2.4 3.4 5.8 96.1%

J47 Colorectal Surgery 81.4% 103.1% 102.6% 103.9% 712 2.8 2.9 5.7 91.7%

J49 Renal Medicine Male 99.9% 99.0% 100.0% 115.0% 645 2.7 2.8 5.5 94.5%

J50 Renal Medicine Female 94.7% 126.2% 100.0% 120.6% 628 2.7 3.1 5.7 95.5%

J82 UGI & HPB Surgery 80.2% 112.7% 76.7% 120.2% 903 2.4 2.6 5.0 96.5%

J83 Leeds Liver Unit 81.4% 119.7% 72.8% 105.0% 819 2.6 2.8 5.4 96.9%

J91 Gastro 85.8% 81.6% 100.0% 106.7% 777 2.2 2.4 4.7 98.0%

J92 Gastro 88.8% 124.4% 100.7% 110.0% 745 2.4 2.2 4.5 96.8%

J54 Intensive Care Ward 101.3% 101.5% 100.6% 104.7% 511 24.0 2.4 26.4 97.8%

J81 HDU 98.2% 82.2% 100.7% 80.8% 288 15.0 5.0 19.9 92.4%

L3 ITU 118.7% 103.4% 108.0% 98.4% 241 26.1 5.7 31.8 98.2%

L4 Cardiac ITU 109.1% 80.8% 101.8% 104.3% 358 22.9 1.8 24.7 100.0%

L6 Neuro ICU 105.8% 124.0% 100.2% 102.6% 357 22.3 3.4 25.7 95.2%

C2 118.1% 86.0% 98.3% 98.8% 521 3.4 2.7 6.1 99.4%

C3 Orthopaedic Centre 106.1% 95.8% 106.4% 106.5% 644 7.0 3.2 10.2 94.3%

Ward 1 - WGH 114.2% 85.4% 100.0% - 33

J6 Adult Cystic Fibrosis 105.5% 147.9% 98.8% 112.0% 350 6.3 3.0 9.3 90.4%

J9 Respiratory Medicine 85.2% 138.3% 92.0% 178.0% 887 2.2 4.3 6.5 96.1%



L14 Cardiology Day Case 118.0% 121.0% 97.7% 100.0% 228 5.3 2.3 7.6

L16 Cardiac Surgery 99.6% 101.7% 97.9% 153.0% 820 3.2 2.0 5.2 97.2%

L18 Cardiology 115.8% 131.5% 101.3% 231.8% 806 2.1 4.0 6.1 91.9%

L19 Cardiology 90.0% 120.6% 99.3% 113.1% 724 3.1 3.4 6.5 92.9%

L20 CCU 92.5% 109.0% 78.3% 100.0% 232 8.2 3.3 11.5 84.5%

J1 Neonatal Unit 100.0% 100.0% 97.8% 100.0% 360 10.6 1.2 11.8 95.4%

Transitional Care - SJH 100.0% 100.0% 99.1% 100.0% 99.2%

L9 Childrens Medicine 98.4% 91.3% 97.8% 96.8% 381 10.8 3.0 13.7 97.1%

L30 Childrens Respiratory 90.1% 100.0% 83.9% 127.5% 291 7.3 3.4 10.6 96.3%

L31 Childrens Oncology 93.0% 86.0% 98.2% 96.7% 574 9.1 1.5 10.6 86.8%

L40 Childrens General Medicine 111.6% 83.3% 115.0% 100.0% 463 5.0 1.3 6.3 95.8%

L41 Childrens Surgery 82.1% 95.1% 98.5% 100.3% 304 5.3 2.6 7.9 96.2%

L42 Paediatric Surgery 88.3% 110.8% 84.3% 103.5% 391 6.2 2.1 8.3 91.5%

L43 Neonatal Unit 86.1% 100.0% 88.0% 93.2% 698 15.5 1.3 16.8 97.2%

L47 PICU 94.8% 82.1% 98.0% 100.0% 343 26.6 1.4 28.0 96.7%

L48 Childrens HDU 91.8% 98.9% 93.5% 90.0% 129 13.3 5.1 18.4 94.0%

L50 Childrens Gastro 91.1% 115.9% 82.6% 103.3% 285 6.4 3.2 9.6 87.9%

L51 Childrens Cardiac Surgery 93.0% 87.3% 80.8% 100.0% 325 8.4 1.1 9.5 93.8%

L52 Childrens Neurosciences 97.7% 94.5% 98.5% 94.1% 282 6.2 3.4 9.6 88.9%

Day Night Care Hours Per Patient Day (CHPPD)Safer staffing return November 2017

Cardiorespiratory

Childrens

A M & S

Adult Critical Care

C A H

Agenda Item 12.6

10

CSU Ward name

Average fill rate -

registered

nurses/midwives

(%)

Average fill rate -

care staff (%)

Average fill rate -

registered

nurses/midwives

(%)

Average fill rate -

care staff (%)

Cumulative count

over the month of

patients at 23:59

each day

Registered

midwives/ nursesCare Staff Overall

Ward

healthcheck

J7 Older Peoples Services 100.3% 97.8% 103.4% 98.3% 932 1.8 3.4 5.2 69.4%


J11 Medical Discharge 100.0% 99.4% 100.0% 145.0% 703 1.8 4.6 6.4 96.9%




J19 Acute Medicine 74.0% 136.6% 100.6% 121.6% 871 2.0 3.6 5.6 94.6%

J20 Infection & Travel Medicine 101.4% 98.3% 98.5% 122.2% 525 3.0 2.1 5.1 83.5%

J21 Acute Medicine 67.5% 155.8% 98.3% 145.8% 882 1.8 3.6 5.4 98.0%

J26 Medical Admissions Unit 81.8% 113.9% 91.1% 119.9% 722 2.9 3.4 6.2 98.9%

J27 General Admissions 78.0% 101.2% 76.7% 124.6% 740 3.0 4.3 7.2 94.5%

J28 Elderly Short Stay 88.4% 97.8% 97.8% 117.5% 858 2.5 3.8 6.3 78.8%

J29 Elderly Admissions 90.3% 107.6% 95.1% 153.7% 838 2.5 3.8 6.3 93.7%

Head & Neck L23 ENT/Spines 95.5% 112.5% 100.0% 128.2% 624 3.1 2.6 5.7 66.3%

C1 Neuro Rehabilitation 106.2% 87.6% 99.9% 100.0% 656 3.2 5.6 8.8 94.3%

L12 Stroke Rehab 96.0% 127.3% 94.6% 100.0% 782 2.6 3.4 6.0 96.0%

L17 Neurology 98.8% 104.1% 102.4% 110.1% 672 2.7 2.6 5.3 94.0%

L21 Acute Stroke Unit 85.4% 94.4% 102.4% 97.4% 926 3.6 4.8 8.4 91.3%

L24 Neuro/Spines 92.1% 89.8% 112.9% 95.9% 940 3.0 3.9 6.9 98.4%

L25 Neuro/Spines 92.5% 88.8% 96.9% 98.1% 858 3.2 4.8 8.0 86.2%

L28 Surgical Day Unit 106.8% 128.5% 85.1% 100.0% 69

J23 Breast Surgery 103.4% 113.3% 98.0% 100.0% 428 5.1 3.3 8.4 84.5%

J84 Thoracic Surgery 90.9% 120.5% 91.8% 143.2% 946 3.6 2.3 5.9 82.6%

J88 Haematology 83.3% 124.8% 96.7% 98.3% 577 3.0 2.6 5.6 91.2%

J89 Haematology BMTU 89.1% 94.9% 84.5% 129.5% 605 4.2 2.2 6.4 98.2%

J93 Oncology 88.9% 107.5% 96.7% 107.1% 736 2.6 2.7 5.2 95.5%

J94 Young Adults Unit 88.4% 89.0% 100.4% 100.0% 263 6.4 1.3 7.7 92.0%

J96 Oncology Assessment 91.7% 100.0% 92.5% 115.0% 624 3.6 2.7 6.3 95.4%

J97 Oncology 91.1% 99.7% 100.0% 120.0% 724 2.9 2.4 5.3 96.8%

J98 Gynaecology 116.4% 111.4% 129.2% 111.6% 757 2.6 2.3 4.9 83.0%

L8 Orthoplastic HDU 109.1% 114.8% 98.0% 98.0% 174 11.1 4.8 15.9 94.8%

L10 Major Trauma Ward 100.5% 114.6% 101.4% 100.0% 527 3.9 4.5 8.4 97.7%

L15 Vascular 98.0% 107.6% 99.5% 89.1% 761 2.5 3.4 6.0 97.1%

L22 Plastics 87.0% 75.0% 94.8% 99.0% 662 2.5 3.5 6.0 96.9%

L34 Orthopaedic Trauma 92.0% 103.8% 102.0% 94.7% 664 2.4 4.5 7.0 91.8%

L35 Orthopaedic Trauma/Vascular 87.1% 103.6% 101.0% 107.1% 795 2.5 3.7 6.2 100.0%

L37 Female Trauma Orthopaedics 94.6% 111.6% 98.4% 111.1% 782 2.3 4.2 6.5 99.1%

Theatres David Beevers Day Unit - SJH 83.0% 103.0% 100.0% 100.0% 232

J3 Delivery Suite 99.4% 90.8% 97.5% 91.7% 212 32.3 7.0 39.4 95.1%

J4 Ante Natal 110.9% 90.0% 109.4% 100.0% 224 14.5 4.2 18.7 99.1%

J5 Obstetrics 120.2% 105.0% 103.7% 102.2% 498 5.2 3.1 8.3 94.4%

L36 Maternity 101.2% 82.7% 95.5% 96.4% 494 4.8 3.1 7.9 96.9%

L44 Maternity 103.9% 118.8% 109.2% 104.9% 326 11.2 4.7 15.9 97.1%

L45 Delivery Suite 104.5% 87.9% 100.4% 106.7% 227 30.0 6.8 36.8 97.0%

Day Night Care Hours Per Patient Day (CHPPD)

Womens

Safer staffing return November 2017

T R S

Oncology

E & S M

Neurosciences

Agenda Item 12.6

11

Appendix 2

Care Hours per Patient Day (CHPPD)

CHPPD is calculated using data collected for the Nurse Staffing Return. It is based on actual registered

and unregistered staffing alongside ward activity (bed occupancy at midnight). This generates the number

of hours of care available for patients per day. David Beevers Day Unit, L28 and W1 have been excluded

as they do not have beds open consistently at 12 midnight consistently over 7 days

The data in Table 1 above and 2 below does show variation which is caused by a number of factors

including:

Acuity and dependency

Enhanced care support is not captured on planned staffing templates

Units that reduce base bed at night

Bed occupancy (activity) data is based on PAS information of which is not always consistently

updated

Table 2 CHPPD – November 2017

CSU Mean CHPPD Range Comments

Abdominal Medicine & Surgery 5.4 ↓ 4.5-5.8

Emergency and Specialist Medicine 6.0 ↑ 5.1-7.2

Adult Critical Care 25.7↓ 19.9-31.8 Includes HDU and ICU

CAH 8.1 ↓ 6.1-10.2

Cardio-Respiratory 7.7 ↑ 5.2-11.5 Inc. CCU and RCU

Children’s 12.4 ↓ 6.3-28.0 Inc. PICU and Neonates

Head & Neck 5.7 ↓ 5.7

Institute of Neurosciences 7.2 ↓ 5.3-8.8

Oncology 6.2 → 4.9-8.4

Trauma & Related Services 8 ↑ 6.0-15.9 Inc. HDU

Women’s 21.2 ↑ 7.9-39.4 Inc. Delivery Suites

(HDU – High Dependency Unit, ICU – Intensive Care Unit, , CCU – Coronary Care Unit, PICU – Paediatric

Intensive Care Unit)

Arrows indicate the movement in CHPPD since the previous report. In general the data is relatively stable

month on month. At CSU-level the data is skewed by the inclusion of HDU and ICU areas, with high

patient care requirements. The workforce team are currently reviewing the metrics available in the

workforce dashboard; CHPPD will be reported as part of this in the future. In the interim, the data has

been correlated with ward metric data to identify any trends (Table 1). No correlation has been identified

between CHPPD and Healthcheck information.

Agenda Item 12.6

12

Appendix 3 - Overall Healthmetrics Score October and November 2017 by Question Group

Table 5

Question Group

Abdominal

Medicine

and

Surgery

Adult

Critical

Care

Cardio-

Respiratory

Centre for

Neurosciences

Chapel

Allerton

Hospital Childrens

Emergency

and

Specialty

Medicine

Head &

Neck

Institute of

Oncology

Trauma

and

Related

Services Womens Theatres ED OPD

Medicines Management/ Administration 92.2% 94.7% 90.2% 88.9% 97.3% 91.9% 89.3% 80.0% 90.4% 92.2% 91.4% 94.9% 91.2% 98.6%

Patient Observations 96.0% 96.3% 87.7% 95.0% 96.9% 93.2% 88.5% 75.0% 93.7% 94.4% 98.9% 95.0% 100.0%

Falls Assessment 95.2% 98.6% 91.3% 94.1% 89.5% 95.3% 84.9% 100.0% 91.7% 97.0% 100.0% N/A 100.0%

Infection Prevention 94.3% 94.2% 94.4% 95.7% 100.0% 95.9% 73.0% 85.7% 80.0% 96.8% 90.0% 92.8% 98.0% 98.9%

Pressure Area Care 94.0% 100.0% 96.0% 97.8% 96.8% 91.8% 84.0% 75.0% 87.1% 91.6% 90.9% 95.6% 92.3%

Continence 99.1% 100.0% 96.8% 98.3% 87.5% 98.8% 85.7% 100.0% 92.1% 95.6% 100.0%

Nutrition & Hydration Assessment 98.4% 96.6% 93.9% 95.3% 100.0% 92.3% 81.4% 100.0% 90.5% 95.3% 100.0%

Pain Management 97.3% 99.1% 98.0% 94.9% 100.0% 96.9% 92.6% 100.0% 94.8% 98.8% 100.0% 100.0%

Patient Dignity 98.0% 97.5% 98.2% 97.4% 100.0% 96.8% 92.7% 100.0% 98.3% 98.6% 96.3% 93.7% 88.9% 98.6%

Discharge 95.5% 100.0% 76.9% 93.9% 100.0% 75.8% 89.2% 100.0% 78.5% 91.3% 100.0% N/A 100.0% N/A

Documentation 94.5% 87.0% 82.4% 88.3% 100.0% 88.5% 79.9% 0.0% 82.2% 84.7% 95.0% 93.3% N/A 94.2%

Resuscitation Equipment 92.3% 100.0% 100.0% 100.0% 100.0% 93.8% 93.8% 100.0% 88.9% 100.0% 100.0% 78.9% 100.0% 94.7%

Patient Identification 95.8% 100.0% 93.3% 100.0% 100.0% 83.3% 87.1% 100.0% 94.4% 100.0% 100.0%

Magnetic Symbols 91.7% 100.0% 37.5% 83.3% 50.0% 63.6% 73.3% 0.0% 88.9% 71.4% 100.0%

Controlled Medicines 93.4% 81.3%

Transfer From Theatre 99.1%

Theatre Safety 87.7%

Medicine Prescribing 94.3%

Outpatient Prescription 89.1%

Environment 94.2%

Question Group

Abdominal

Medicine

and

Surgery

Adult

Critical

Care

Cardio-

Respiratory

Centre for

Neurosciences

Chapel

Allerton

Hospital Childrens

Emergency

and

Specialty

Medicine

Head &

Neck

Institute of

Oncology

Trauma

and

Related

Services Womens Theatres ED OPD

Medicines Management/ Administration 96.4% 94.5% 88.5% 87.0% 96.8% 94.3% 91.7% 75.0% 91.3% 95.4% 95.4% 94.6% 92.7% 97.0%

Patient Observations 96.3% 97.5% 88.8% 99.2% 100.0% 93.3% 90.3% 89.5% 91.2% 99.3% 98.9% 95.3% 100.0%

Falls Assessment 92.7% 98.6% 96.5% 95.4% 97.1% 97.3% 92.4% 53.3% 96.0% 100.0% 100.0% N/A 85.7%

Infection Prevention 94.9% 96.2% 90.4% 97.4% 100.0% 94.8% 82.0% 57.1% 88.4% 96.6% 89.7% 93.2% 96.2% 98.5%

Pressure Area Care 91.8% 100.0% 94.5% 87.2% 82.1% 88.2% 81.9% 50.0% 95.1% 96.9% 86.7% 98.6% 92.9%

Continence 97.2% 100.0% 98.3% 100.0% 100.0% 99.1% 87.7% 35.7% 96.1% 96.9% 100.0%

Nutrition & Hydration Assessment 92.9% 96.6% 92.9% 95.2% 96.2% 95.0% 89.5% 59.1% 95.8% 93.2% 100.0%

Pain Management 91.7% 99.0% 96.5% 99.2% 100.0% 98.7% 98.8% 64.0% 97.7% 98.8% 100.0% 100.0%

Patient Dignity 98.0% 97.4% 96.5% 97.5% 97.5% 97.7% 95.6% 100.0% 95.9% 98.6% 97.2% 91.1% 72.7% 99.3%

Discharge 92.9% 100.0% 81.6% 87.1% 100.0% 84.9% 89.8% 86.7% 74.1% 94.3% 100.0% N/A 100.0% N/A

Documentation 93.4% 87.0% 83.5% 81.7% 97.5% 93.3% 81.3% 40.0% 87.0% 93.0% 95.0% 95.2% N/A 97.8%

Resuscitation Equipment 100.0% 100.0% 100.0% 100.0% 100.0% 89.5% 93.8% 100.0% 90.0% 100.0% 100.0% 86.8% 100.0% 94.4%

Patient Identification 96.0% 100.0% 87.5% 100.0% 100.0% 91.4% 96.9% 100.0% 89.5% 100.0% 100.0%

Magnetic Symbols 100.0% 100.0% 50.0% 100.0% 50.0% 66.7% 92.3% 100.0% 70.0% 85.7% 100.0%

Controlled Medicines 95.2% 87.5%

Transfer From Theatre 98.3%

Theatre Safety 90.4%

Medicine Prescribing 80.4%

Outpatient Prescription 84.1%

Environment 90.8%

Only Applicable to Out-Patients

N/A

Only Applicable to Theatres

Oct-17

N/A

N/A

Incorporated into Medicines Management Standard

N/A

N/A

N/A

N/A

N/A

Only Applicable to Out-Patients

Nov-17

N/A

N/AN/A

N/A

N/A N/A

N/AIncorporated into Medicines Management Standard

Only Applicable to Theatres N/A

Agenda Item 12.6

13

Appendix 4: Accumulated Metrics Score by Trust and CSU July 2017 - November 2017

Table 6

H

ealthch

eck G

oal

integrated healthcheck and staffing update trust board ...€¦ · documentation used by villa care...

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