integrated quality and operational compliance report · through the patient safety and risk...
TRANSCRIPT
Enclosure C
Integrated Quality and OperationalCompliance Report
June 2019
24/07/19 |Draft Report V2
1 of 45
Contents
Domain Pages
Safe 03 to 13
Effective 14 to 19
Caring 20 to 24
Responsive 25 to 31
Well Led 32 to 34
Domain Scorecard Summary 35 to 38
Glossary 39 to 45
2 of 45
03 to 1314 to 19
Safe Is Care Safe? June 2019
Pressure Ulcers Author: Berenice Constable, Head of Nursing, Unplanned Care Division Falls: There was an increase in the number of Falls reported in June (77), The highest number reported since December 2018. There were 3 Falls with Harm in June ( Blyth, Bronte and ED), resulting in fractured Neck of Femur- SI investigations are underway. The 72hr RCA process post fall is continuing and being embedded in the wards. A thematic review is being undertaken by the Falls Group led by one of the Matrons, and the results will be shared through the Patient Safety and Risk Management Committee. A further 3 Day Patient Safety event is planned for September with a day being allocated to Falls Prevention. Pressure Ulcers: • The number of patients reported with trust acquired pressure ulcers in June was 6. 5
category 2 pressure ulcers and 1 category 3 pressure ulcer. • Following investigation and presentation to PUMP, 5 were found to have resulted due to a
lapse in care and 1 had no lapse in care. Action plans have been developed to ensure that the risk of potential damage has been minimised for those presented. Completion of actions is being monitored by PUMP.
There was no device related pressure ulcers reported in June.
Serious Incidents Author: Melanie Whitfield, Head of Patient Safety, Governance and Risk • There were 2 Serious Incidents reported in June 2019. • 3 Serious Incidents were closed during the reporting period. • As at 30th June 2019, there were 6 open/ongoing SI investigations.
Infection Control Author: Fran Brooke-Pearce, CNS Infection Prevention & Control Infection Control June 2019
•There were no Trust-apportioned MRSA bacteraemia cases. •There was one Trust-apportioned MSSA bacteraemia case in AAU. •There were two Trust-apportioned Clostridium difficile toxin positive cases - one HOHA (hospital onset healthcare associated) in Alex ward and one COHA (community onset healthcare associated) in AAU. •There were no Trust-apportioned E.coli bacteraemias. •There were two cases of confirmed Norovirus this month in AAU. •There were no cases of confirmed flu this month.
3 of 45
Safe03 to 1314 to 19
24/07/19 |Draft Report V2
Ward Day Staffing Rate - RN/MW Day Staffing Rate - HCA Night Staffing Rate - RN/MW Night Staffing Rate - HCACare Hours Per Patient Day
(CHPPD)
AAU 95.6% 103.9% 95.9% 105.4% 8.4 RN Registered Nurse
Alexandra Ward 119.7% 85.0% 123.3% 193.3% 6.0 MW Registered Midwife
Astor Ward 106.3% 89.1% 102.2% 92.9% 5.9 HCA Healthcare Assistant
Blyth Ward 27.4% 23.8% 33.3% 36.7% 8.6
Bronte Ward 93.4% 152.4% 98.9% 98.3% 5.3
Cambridge Ward 109.8% 113.8% 92.0% 115.3% 27.9
Canbury Ward 140.4% 108.5% 105.3% 126.7% 11.9
Critical Care Unit 91.4% 93.4% 26.9
Derwent Ward 115.7% 111.0% 110.2% 195.5% 6.8
Hamble Ward 129.3% 129.9% 145.2% 126.7% 7.3
Hardy Ward 112.6% 136.5% 106.7% 186.7% 6.3
Isabella 87.2% 144.7% 74.4% 1439.1% 6.7
Keats Ward 112.1% 105.0% 108.8% 98.3% 6.7
Kennet Ward 97.0% 134.2% 100.1% 168.9% 6.5
Neonatal Unit 93.7% 80.0% 104.0% 48.3% 12.2
Paediatric Unit 98.7% 97.5% 100.8% 44.6% 11.9
Maternity 93.9% 72.3% 97.5% 71.7% 14.9
Trust Average 97.9% 100.6% 97.9% 107.7% 8.6
Key
June 2019
Author: Nichola Kane, Deputy Director of Nursing
Safe staffing levels continue to be monitored via the bi-weekly Safer Staffing Meeting. Where the data indicates over 100% compliance for HCA’s this is related to 1:1 and enhanced supervision required
for specific patients. The wards with over 100% RN compliance relates to escalated beds being opened and high patient acuity (Bronte). When staffing levels go above the planned establishment this is
agreed by the Head of Nursing for the Division
Safer Staffing
0.0%
200.0%
400.0%
600.0%
800.0%
1000.0%
1200.0%
1400.0%
1600.0%
AAU AlexandraWard
Astor Ward Blyth Ward Bronte Ward CambridgeWard
Canbury Ward Critical CareUnit
DerwentWard
Hamble Ward Hardy Ward Isabella Keats Ward Kennet Ward Neonatal Unit PaediatricUnit
Day Staffing Rate - RN/MW Day Staffing Rate - HCA Night Staffing Rate - RN/MW Night Staffing Rate - HCA
4 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
32 to 34
Is Care Safe?Safe June 2019
k1.01 | Number of patients with hospital acquired pressure
ulcers (Grade 3&4)
k1.02 | Number of patients with hospital acquired pressure
ulcers (Grade 3&4) per 1000 beddays
k1.03 | Number of patients with hospital acquired pressure
ulcers (Grade 2)
k.1.04 | Number of patients with hospital acquired pressure
ulcers (Grade 2) per 1000 beddays
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard <=0.1
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard <=0.51
2 0 1 0 2 1 0 2 1 1 1 1 0
2
0
1
0
1
2
1
2
5 2 3 0
1 0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Avoidable Un-avoidable Standard
Standard <=1
Standard <=1
6 4 1 0 0 1 1 5 2 1 1 3 5
0
3
2
0 1
1 3
5
1
6 2
3
0
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Avoidable Un-avoidable Standard
Standard <=3
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14 to 19
27/06/18 16:30 |Final Report v1.3
Is Care Safe?Safe June 2019
k1.05 | MRSA Bacteraemias (Hospital Assigned) k1.06 | MSSA Bacteraemias (Hospital Apportioned)
32 to 34
k1.07 | Clostridium difficile infections (Hospital Apportioned)k1.08 | Clostridium difficile infections (Hospital Apportioned) due
to confirmed Lapse in Care
0 0 0 0 0 0 0 0 0 0 0
1
0 0
1
2
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Zero Standard
Zero
4
3
1
2
1 1 1
0
2
0
4
0
2
0
1
2
3
4
5
6
7
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
Standard 8 for year
1 1
0 0 0 0 0 0 0 0 0 0 0 0
1
2
3
4
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard 8 for year
2 2 2
0
1 1 1
0
1 1
0 0
1
0
1
2
3
4
5
6
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard <=1
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14 to 19
27/06/18 16:30 |Final Report v1.3
32 to 34
Is Care Safe?Safe June 2019
k1.19 | Number of Escherichia (E. coli) bacteraemiak1.09 | Completed Patient Observations - Adult inpatients
(NEWS)
k1.10 | Completed Patient Observations - Paediatric Inpatients
(NEWS)
88%
90%
92%
94%
96%
98%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
86%
88%
90%
92%
94%
96%
98%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=97%
4 1 1 0 4 1 2 1 1 0 0 2 0
14
9 11
0
0
0 0
0
9
0
7
14 18
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
E.Coli bacteraemia (Hospital Apportioned) E.Coli bacteraemia (Community Apportioned)
Standard N/A
Standard N/A
Standard N/A
Standard N/A
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14 to 19
27/06/18 16:30 |Final Report v1.3
Is Care Safe?Safe June 2019
k1.12 | Number of Patient Safety Incident (PSI) Fallsk1.13 | Number of Patient Safety Incident Falls per 1000 G&A
beddays
32 to 34
k1.16 | Medication Incidents k1.15 | Never Events
3.0
4.0
5.0
6.0
7.0
8.0
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard <=5.3
0 0 0 0 0 0 0 0 0 0 0 0 0 0
1
2
3
4
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard Zero
0 1 3 1 0 1 4 1 2 0 2 2 2
53 52
68 66
58
83 86
72 71 68
59 61
77
0
10
20
30
40
50
60
70
80
90
0
2
4
6
8
10
12
14
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standards - - - Total PSI Falls <=58 ..... Moderate / Severe Harm <=6
2 0 0 0 0 0 1 0 0 1 1 1 0
59
68
75
33
43
72
45
57
45
56 59
62 60
0
10
20
30
40
50
60
70
80
90
0
2
4
6
8
10
12
14
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standards Total Medication Incidents: N/A .... Moderate / Severe Harm <=2
8 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
Is Care Safe?Safe June 2019
k1.18 | Number of Serious Untoward Incidents
2
6
2 2
3
2 2
0
1
0
4
0
2
0
2
4
6
8
10
12
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
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14 to 19
27/06/18 16:30 |Final Report v1.3
k4.03 | Night - Registered Midwives / Nurses Fill Rate k4.04 | Night - Assistant Fill Rate
32 to 34
Is Care Safe?Safe June 2019
k4.01 | Day - Registered Midwives / Nurses Fill Rate k4.02 | Day - Assistant Fill Rate
80%
90%
100%
110%
120%
130%
140%
150%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
80%
85%
90%
95%
100%
105%
110%
115%
120%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
80%
85%
90%
95%
100%
105%
110%
115%
120%
125%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
80%
85%
90%
95%
100%
105%
110%
115%
120%
125%
130%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
10 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3k4.07 | Care Hours per Patient Day (CHPPD)
32 to 34
Is Care Safe?Safe June 2019
k4.05 | Overall Trust Fill Ratek4.06 | % of Registered Nurse and Midwife Expenditure on
Agency Staff
0%
1%
1%
2%
2%
3%
3%
4%
4%
5%
5%
Jun
-18
Jul-1
8
Aug
-18
Sep
-18
Oct-
18
Nov-1
8
Dec-1
8
Jan
-19
Fe
b-1
9
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun
-19
Standard N/A
90%
92%
94%
96%
98%
100%
102%
104%
106%
Jun
-18
Jul-1
8
Aug
-18
Sep
-18
Oct-
18
Nov-1
8
Dec-1
8
Jan
-19
Fe
b-1
9
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun
-19
Standard N/A
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
Jun
-18
Jul-1
8
Aug
-18
Sep
-18
Oct-
18
Nov-1
8
Dec-1
8
Jan
-19
Fe
b-1
9
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun
-19
Standard N/A
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14 to 19
27/06/18 16:30 |Final Report v1.3
k5.03 | % women with a primary postpartum haemorrhage of
2000ml or morek5.04 | Significant Perineal Trauma
32 to 34
Is Care Safe? : MaternitySafe June 2019
k5.01 | Caesarean section ratek5.02 | % women with a primary postpartum haemorrhage of
1500ml or more
0%
1%
2%
3%
4%
5%
6%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard <3.1%
20%
22%
24%
26%
28%
30%
32%
34%
36%
38%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard <=26%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard <=1.0%
0%
1%
2%
3%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
12 of 45
14 to 19
Effective Is Care Effective? June 2019
Joscelin Miles, Head of Clinical Audit and Effectiveness Seven Day Services - Kingston Hospital continues to exceed the national target for patients reviewed within 14 hours of admission In 2013, ten clinical standards for seven day services in hospitals were developed through the Seven Day Services Forum, chaired by Sir Bruce Keogh and involving a range of clinicians and patients. In order to prepare for seven day services, bi-annual national audits commenced in Mar-16. The audits focused on four of the key clinical standards on the basis of their potential to positively affect patient outcome: • Standard 2 - Time to first consultant review. • Standard 5 - Access to diagnostic tests. • Standard 6 - Access to consultant-directed interventions. • Standard 8 - Ongoing review by consultant twice daily if high dependency patients, daily for others. In Jan-19 NHS England (NHSE) replaced the national audit with the requirement that each NHS Trust Board must receive 6-monthly assurance on progress in achieving the four priority 7 day service (7DS) clinical standards via a self-assessment survey, populated with information obtained from local audit. The assessment is also used for national reporting to NHSE. Latest performance (May-19): • 98% of patients were reviewed by a Consultant within 14 hours of admission. KHFT performance
continues to exceed the NHS England target of 90%, which was first achieved by the Trust in Sep-17.
• 100% of patients who required twice daily consultant reviews received them and 95% of patients who required a daily consultant review received it (NHS England Target 90%).
• 88% of patients (and where appropriate families / carers) were involved in discussions about the initial review within 48 hours of admission and 97% of patients were informed of review outcomes/changes to their care plan during their admission.
• KHFT patients have access to all 6 consultant directed diagnostics (CT, Echocardiograph, Microbiology, MRI, Ultrasound and Upper GI Endoscopy).
Areas targeted for improvement/ assurance - Patients reviewed by a Consultant within 14 hours of admission (Apr-18 compared to May-19): • General Surgery: Performance improved from 72% to 100%. • Trauma and Orthopaedic Surgery: Performance improved from 75% to 100%. • Urology: Performance improved from 50% to 83%. • AAU, Cardiology, Elderly Care, ICU, Obstetrics and Gynaecology, Paediatrics and Respiratory:
Excellent performance was sustained; minor improvement from 96% to 98%. What makes this happen: Ongoing education and reminders of the expected standards, both of clinical care (initial and ongoing consultant review, communication with patient and/or relatives) and documentation of that care have been instrumental in achieving these improvements.
Jane Wilson, Medical Director The performance KPI's for Effective have remained in control in June 2019. Mortality remains low with SHMI in lower than expected range and unadjusted mortality stable. The trust has appointed a medical examiner officer, who will commence in September 2019 and 5 medical examiners are commencing training. The process of SJR continues and specific attention is being given to departments whose performance with M&M reviews is low. In June 2019 the Trust met 3 of the 4 sepsis targets, with over 90% of patients being screened for sepsis when required and patients receiving antibiotics within 1 hour throughout the Trust. Continued efforts are being made to achieve the target for screening in-patients. In April and May 2019 there was an increase in the number of Hospital Acquired Thromboses. Root cause analysis is undertaken for all these events and local actions taken where appropriate. In view of the higher incidence the Serious Incident Group has requested a themed report is received to determine whether any Trust wide interventions are required. It is reassuring the number of incidents in June has returned to previous range.
13 of 45
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27/06/18 16:30 |Final Report v1.3
k2.03 | Sepsis - % of eligible patients screened for sepsis -
Emergency Department
k2.04 | Sepsis - % of eligible patients who received antibiotics
within 1 hour of arrival - Emergency Department
32 to 34
Is Care Effective?Effective June 2019
k2.01 | SHMI k2.02 | Unadjusted Mortality Rate
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
80
82
84
86
88
90
92
94
96
98
100
102
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard <=95
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=90%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=90%
14 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
k2.05 | Prevention of Hospital Acquired VTE (% patients risk assessed)
k2.06 | Incidence of Hospital Acquired VTE (HAT)
Is Care Effective?Effective June 2019
k2.13 | Sepsis - % of eligible patients screened for sepsis -
Inpatients
k2.14 | Sepsis - % of eligible patients who received antibiotics
within 1 hour - Inpatients
32 to 34
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=90%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=90%
6 4 2 0 2 1 2 1 3 7 5 2 80%
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
0
2
4
6
8
10
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standards - - - % Risk Assessed >= 95% .... Incidences of HAT <= 3
15 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
k2.09 | % Emergency Readmissions following an elective
admission - 30 days
k2.10 | % Emergency Readmissions following an emergency
admission - 30 days
32 to 34
Is Care Effective?Effective June 2019
k2.07 | % of eligible patients screened for dementiak2.08 | % of patients with dementia who were appropriately
assessed
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=90%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=90%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
16 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
Is Care Effective?Effective June 2019
k3.15 | Hand Hygiene
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=95%
17 of 45
03 to 1314 to 19
27/06/18 16:30 |Final Report v1.3
Effective Learning from Deaths June 2019
Reporting Month
This Month This Month
63 24
This Year (YTD) This Year (YTD)
178 95
Jun-19
60
196
29
175
Total Number of Deaths Total Deaths Reviewed
Last month
Last Year (same YTD)
Last month
Last Year (same YTD)
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
0
10
20
30
40
50
60
70
80
90
100
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
""Total No. of Deaths 2018/19" "Total No. of Deaths 2019/20" "Death Rate 2018/19" "Death Rate 2019/20"
18 of 45
03 to 1314 to 19
27/06/18 16:30 |Final Report v1.3
Caring Patient Experience June 2019
Complaints Author: Clare Parker, Head of Legal Complaints and PALS The trust received 32 complaints in June 2019 compared to 26 in June 2018. Within Urgent & Emergency Care and ITU, the following areas received complaints in June 2019 Accident and Emergency (9), Acute Assessment Unit (1) and Intensive Care Unit (1) Within Surgery, Anaesthetic & Endoscopy, the following areas received complaints in June 2019 Cambridge Ward (2) , Day Surgery Unit (1), Gastroenterology Department (2), General Surgery Department (1) and Orthopaedics Department (2) Subjects The most frequent subjects related to were Care & Treatment (28%), Test/Investigations (16%), Appointments (13%) and Diagnosis (13%). Reopened Complaints 5 complaints were reopened in June 2019. The reasons for the complaints being reopened were Further Questions (3), Facts Challenged (1) and Issued Not Responded to Adequately (1). Ombudsman Referrals No complaints were referred to the Ombudsman in June 2019.
Friends and Family Test Author: Elizabeth Tsangarakiwilding, Patient Experience & Quality Improvement Lead (Job-share with : Jane Suppiah ) The Trust received 7495 responses from the Friends & Family Test feedback in June and 5404 comments. The Positive Recommend rating (93.3%) continues to increase, indicating that the patient experience is improving month on month and at its highest since June last year. The top three positive themes relate to ‘staff attitude’ (3609 comments), ‘implementation of care’ (1561) and ‘environment’ (1130). The most popular words used in these comments are ‘friendly’, ‘staff’ and ‘treatment’. Negative comments received in June relate to ‘staff attitude’ (163), ‘environment' (118) and ‘waiting time’ (110) all of which have decreased from May. The response rates in paediatrics has seen an impressive increase from 16% to 33% with more patients reporting a positive experience and this is reflected in the increased satisfaction score. The positive recommendation rate has increased in outpatients for the 5th consecutive month and it has also increased for ED and daycases. Inpatients has seen a slight drop in satisfaction from 97.2% to 96.0% but moreso in Maternity, which has seen a drop of 3.2%. No overriding themes have been identified but this will be a focus for quality improvement over the next month.
19 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
Patient ExperienceCaring June 2019
k3.01 | Number of Complaints received
k3.14 | % Complaints responded to within 25 working days
(or date as agreed with complainant)
k3.02 | Number of Complaints reopened
32 to 34
k3.03 | Number of Complaints referred to ombudsman
0
2
0 0 0
1
0 0 0 0 0 0 0 0
1
2
3
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
3
1
6
1
6 5
4 5 5
6
1
3
5
0
2
4
6
8
10
12
14
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
26 35 26 33 37 28 17 25 23 30 26 37 32 0
10
20
30
40
50
60
70
80
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standards No Standard: Num. of Complaints ..... % within 25 days >=80%
20 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
Patient ExperienceCaring June 2019
k3.20 | Complaints per 100 patient contacts
0.00
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard <=0.07
21 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
k3.07 | Friends and Family Score - Paediatric Inpatient k3.08 | Friends and Family Score - Outpatient
Patient ExperienceCaring June 2019
k3.05 | Friends and Family Score - Trustk3.06 | Friends and Family Score - Inpatients (excluding
daycases)
90
.7%
90
.5%
91
.5%
91
.6%
91
.9%
92
.5%
93
.0%
93
.1%
92
.6%
92
.2%
92
.5%
93
.1%
93
.2%
0%
20%
40%
60%
80%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
% Would Recommend % Would Not Recommend
Standard N/A
94
.9%
93
.5%
96
.3%
97
.0%
95
.4%
96
.0%
95
.5%
97
.1%
96
.8%
96
.0%
95
.8%
97
.2%
96
.0%
0%
20%
40%
60%
80%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Response Rate % Would Recommend % Would Not Recommend Standard
Standard >=96%
92
.1%
91
.9%
91
.4%
92
.7%
92
.4%
93
.0%
94
.0%
93
.7%
93
.4%
93
.1%
93
.6%
93
.8%
94
.0%
0%
20%
40%
60%
80%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
% Would Recommend % Would Not Recommend
Standard N/A
82
.9%
90
.9%
98
.3%
89
.6%
98
.4%
94
.7%
87
.0%
95
.5%
97
.6%
94
.4%
93
.3%
89
.3%
91
.7%
0%
20%
40%
60%
80%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Response Rate % Would Recommend % Would Not Recommend
Standard N/A
Standard N/A
22 of 45
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27/06/18 16:30 |Final Report v1.3
k3.11 | Friends and Family Score - Daycases k3.13 | Number of Mixed Sex Accommodation Breaches
Patient ExperienceCaring June 2019
k3.09 | Friends and Family Score - A&E k3.10 | Friends and Family Score - Maternity
32 to 34
85
.6%
86
.2%
89
.3%
86
.3%
88
.9%
89
.3%
89
.4%
89
.2%
87
.0%
87
.6%
88
.1%
89
.1%
89
.9%
0%
20%
40%
60%
80%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Response Rate % Would Recommend % Would Not Recommend
Standard N/A
95
.2%
82
.1%
93
.8%
96
.4%
98
.9%
86
.8%
97
.5%
90
.2%
96
.7%
96
.2%
96
.5%
97
.1%
93
.9%
0%
20%
40%
60%
80%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
% Would Recommend % Would Not Recommend
Standard N/A
96
.4%
97
.0%
97
.6%
97
.2%
98
.2%
98
.1%
98
.9%
96
.5%
97
.3%
95
.5%
98
.1%
97
.3%
97
.5%
0%
20%
40%
60%
80%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Response Rate % Would Recommend % Would Not Recommend
Standard N/A
0 0 0 0 0 0 0 0 0 0 0 0 0 0
1
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard Zero
23 of 45
03 to 1314 to 1925 to 31
Responsive Is Care Responsive? June 2019
Cancer Author: Paul Nicholas, Cancer Performance & Information Manager The Trust achieved all cancer targets in May, apart from 62-day screening, which was due to one patient, a 3-Trust pathway, with a change of treatment plan (full breach reallocated to KHFT due to new allocation rules) We had a strong 62 day (GP) performance 97.6%, and no 100 day breaches. Two-week wait referral numbers were high, with although compliant had higher numbers of breaches – due to impact on diagnostics on straight to test pathways. Shadow monitoring for day 28 commenced in April ahead of going live from the 1st of April 2020. Sustaining cancer performance remains challenging, especially with the new breach allocation process, continual increase in 2ww referrals and competing demands on diagnostic services: June 62-day performance will be lower than recent months, due to increased number of breaches – due to late referrals to treating Trusts caused by diagnostic delays Referral To Treatment (RTT) and Diagnostic Performance Author: Jenny Farley, Associate Director, Planned Care The trust 18 week RTT performance was 92.21%, for June 2019, which remains above the 92 percent target. There were no 52 week waiters in June 2019. The diagnostic performance has dropped to 97.79%, below the target of 99 percent. This is as a result of deliberate action taken by the trust, as cancer targets have been prioritised over routine. The Chief Operating Officer is leading work to address this issue. Solutions, including additional mobile capacity and additional staffing are being sought. However, non-urgent demand in MRI, CT and Non-Obstetric Ultrasound will remain problematic and will unlikely be resolved in the coming month.
A&E Performance Author: Tracey Moore, Associate Director, Unplanned Care The emergency standard performance in June was 87.04%, with 11,356 attendances in the month. This represented an increase of 9% as compared to June 2018 against a national increase of 0.7%. Admissions reduced by -1.6% when compared to June 2018 – against a national increase of 3% The Trust maintained its excellent performance on ambulance handovers over 60 minutes – O in the month. The number of 30 minute handover breaches was also very low at 3. The stranded metric was 156 and the super-stranded was 39 as of 28th 2019. The DTOC position was 3.93%. Whilst ED performance has reduced, as compared with the same period in 2018, the Trust has managed to maintain its performance in relation to stranded and super stranded metrics and dtoc despite the significant increase in activity. Escalation beds on Kennet Ward and Keats ward in medicine continued to be used during June. However all efforts were made, through the management of ‘silver command’ to close the Kennet beds in order to support the building programme on Kennet ward and these beds closed on 5th July. Escalated beds on Cambridge Ward in orthopaedics have remained open and flexible use has been made of beds in the private patient unit in order to support the elective programme. The unprecedented increase in ED emergencies is such that the triggers we set for black escalation is last year’ winter plan, are now considered to be business as usual. We are exploring with partners alternative ways of managing this increased demand in order and will have an agreed plan for implementation from October over the next few weeks. This plan will be shared with colleagues internally and externally to ensure that our response is proportionate and provides safe and effective care to our patients.
24 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
k6.03 | 18 weeks Referral to Treatment - number of incomplete
over 52 week waitersk6.04 | Diagnostic test - % waiting 6 weeks or less
32 to 34
Is Care Responsive?Responsive June 2019
k6.01 | Average length of stay - Emergency Admissions k6.02 | 18 weeks Referral to Treatment - Incomplete pathways
90%
91%
91%
92%
92%
93%
93%
94%
94%
95%
95%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=92%
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard <=5.23
97%
98%
99%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=99% 11 11
7
3
0 0 0 0 0 0
1
3
0 0
2
4
6
8
10
12
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard Zero
25 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
k6.07 | Number of A&E 12 hour trolley waits k6.08 | LAS Ambulance Handovers - % within 15 minutes
32 to 34
Is Care Responsive?Responsive June 2019
k6.05 | A&E 4 hour waiting time (type 1) k6.06 | A&E 4 hour waiting time (all types)
80%
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
Ju
n-1
8
Ju
l-1
8
Au
g-1
8
Se
p-1
8
Oct-
18
Nov-1
8
Dec-1
8
Ja
n-1
9
Fe
b-1
9
Ma
r-19
Ap
r-19
Ma
y-1
9
Ju
n-1
9
Standard >=95%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ju
n-1
8
Ju
l-1
8
Au
g-1
8
Se
p-1
8
Oct-
18
Nov-1
8
Dec-1
8
Ja
n-1
9
Fe
b-1
9
Ma
r-19
Ap
r-19
Ma
y-1
9
Ju
n-1
9
Standard N/A
80%
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
Ju
n-1
8
Ju
l-1
8
Au
g-1
8
Se
p-1
8
Oct-
18
Nov-1
8
Dec-1
8
Ja
n-1
9
Fe
b-1
9
Ma
r-19
Ap
r-19
Ma
y-1
9
Ju
n-1
9
Standard N/A
0 0 0 0 0 0 0 0 0 0 0 0 0 0
1
2
3
Ju
n-1
8
Ju
l-1
8
Au
g-1
8
Se
p-1
8
Oct-
18
Nov-1
8
Dec-1
8
Ja
n-1
9
Fe
b-1
9
Ma
r-19
Ap
r-19
Ma
y-1
9
Ju
n-1
9
Standard Zero
26 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
k6.11 | Cancer - Two week waitk6.12 | Cancer - Two week referral to 1st outpatient - breast
symptoms
32 to 34
Is Care Responsive?Responsive June 2019
k6.09 | LAS Ambulance Handovers - 30 min waits k6.10 | LAS Ambulance Handovers - 60 min waits
88%
90%
92%
94%
96%
98%
100%
Ju
n-1
8
Ju
l-1
8
Au
g-1
8
Se
p-1
8
Oct-
18
Nov-1
8
Dec-1
8
Ja
n-1
9
Fe
b-1
9
Ma
r-19
Ap
r-19
Ma
y-1
9
Ju
n-1
9
Standard >=93%
80%
85%
90%
95%
100%
Ju
n-1
8
Ju
l-1
8
Au
g-1
8
Se
p-1
8
Oct-
18
Nov-1
8
Dec-1
8
Ja
n-1
9
Fe
b-1
9
Ma
r-19
Ap
r-19
Ma
y-1
9
Ju
n-1
9
Standard >=93%
0 3
10 4
11
19
7 14
4
14 13 14
3
0
10
20
30
40
50
60
70
80
90
Ju
n-1
8
Ju
l-1
8
Au
g-1
8
Se
p-1
8
Oct-
18
Nov-1
8
Dec-1
8
Ja
n-1
9
Fe
b-1
9
Ma
r-19
Ap
r-19
Ma
y-1
9
Ju
n-1
9
Standard Zero
0 0 0 0 0 0 0 2 1 1 0 0 0 0
10
20
30
40
50
60
70
80
Ju
n-1
8
Ju
l-1
8
Au
g-1
8
Se
p-1
8
Oct-
18
Nov-1
8
Dec-1
8
Ja
n-1
9
Fe
b-1
9
Ma
r-19
Ap
r-19
Ma
y-1
9
Ju
n-1
9
Standard Zero
27 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
k6.15 | Cancer - 31 day second or subsequent treatment -
surgeryk6.16 | Cancer - Two month urgent referral to treatment wait
32 to 34
Is Care Responsive?Responsive June 2019
k6.13 | Cancer - Patients receiving first definitive treatment
within one month (31 days) of a cancer diagnosisk6.14 | Cancer - 31 day second or subsequent treatment - drug
0%
20%
40%
60%
80%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=94%
70%
75%
80%
85%
90%
95%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=85%
92%
93%
94%
95%
96%
97%
98%
99%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=96%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=98%
28 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
k6.20 | Number of delayed transfers of care - bed days k6.21 | Delayed transfers of care - Rate per occupied bed day
32 to 34
Is Care Responsive?Responsive June 2019
k6.17 | Cancer - 62 day wait for first treatment following
referral from a NHS Cancer Screening Service
k6.18 | Cancer - 62 day wait for first treatment following
consultant upgrade
30%
40%
50%
60%
70%
80%
90%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=90%
70%
75%
80%
85%
90%
95%
100%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=85%
44
7
43
3
42
7
44
7
30
3
36
1
26
1
32
9
32
0 41
1
36
1
36
4
43
3
0
200
400
600
800
1,000
1,200
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
0%
1%
1%
2%
2%
3%
3%
4%
4%
5%
5%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard <=4%
29 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
32 to 34
Is Care Responsive?Responsive June 2019
k6.22 | Number of cancelled operationsk6.23 | Number of patients not treated within 28 days of last
minute cancellation
k6.30 | Stranded Patients (>=7 days and >=21 days)
7
2
7
4
6
5 5
2
7
2
8
5 5
0
1
2
3
4
5
6
7
8
9
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard N/A
0 0 0 0 0 0
3
0
1 1
2
0
1
0
1
2
3
4
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard Zero
53 48 48
54 49 48
39 43 47 43
58 55 45
149 146 150 154 145
156
134
153 159 154
162 161 159
0
20
40
60
80
100
120
140
160
180
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Super-Stranded Patient (>= 21 days) Stranded Patients (>= 7 days)
Standard N/A
Standard N/A
30 of 45
03 to 1314 to 19
Well-led Are we Well-Led? June 2019
Comparators (14 Trusts): St George's Healthcare, Epsom & St Helier, Croydon Health, Guy's and St Thomas', Imperial College Healthcare, Chelsea & Westminster, West Middlesex, Ashford & St Peter's, Frimley ,Royal Surrey, West Hertfordshire Hospitals, Dartford & Gravesham, Barking, Havering & Redbridge and Hillingdon Hospital.
Author: Carolyn Floyd, Workforce Information & Planning Manager 1. Vacancy (target 6%) Vacancy rates have increased very slighly this month to 8.77%, red rated . This is largely due to a higher number of leavers in the month compare to starters. The highest WTE vacant is within Cluster 4, specifically the Oral & ENT and Ophthalmology Service Lines. Other Service Lines with higher WTE vacant are Anaesthetics, Theatres & DSU and Elderly Care. In terms of staff groups the highest vacancies fall within the two largest groups Qualified Nursing and Admin & Estates. An overseas programme for Qualified Nurse recruitment continues as well as cohort recruitment. For the Admin staff group work on strengthening the Talent Pool and introducing a cohort programme will be undertaken over the next few months to tackle filling the gaps for high turnover areas. The average vacancy rate for or comparators is 11.02% (Mar-19) which the Trust fall well below. 2. Turnover (target 13.5%) Turnover is amber rated at 14.85% a slight increase since last month. This is due to the hiher volume of leavers in June. Highest turnover is within the lower pay band, especially in the Admin and Estates group. It is within the Admin & Estates group that the highest number of leavers are recorded, work on tackling vacancies will stabilise this staff group. Two of the Clusters have red rated turnover; Cluster 4 and 2 and these areas will be targeted to understand why staff are leaving these particular areas. For Cluster 2 the focus needs to be on the Respiratory and Therapies Service Lines and for Cluster 4 Ophthalmology. The average turnover rate for our comparator's is 14.10% (Mar-19) which the Trust are still sitting above.. 3. Sickness (target 2.6%) This month sickness is amber rated at 2.75%. The highest percentage of sickness falls within the lower pay bands 2 and 3, this is due to a higher number of staff recording long term sickness in these groups. Staff Groups that are red rate all include lower paid employees are Unqualified Nursing staff. Red Rated sickness rates recorded in Cacer, Outpatients & Recrods, Ophthalmology and Surgery and Urology Service Lines. The average sickness rate for our local comparator's is 3.47% (Mar-19) which the Trust fall
4. Mandatory Training (target 85%) This month the compliance rate has increade very slightly to 76.31%, an amber rating target. The Trust have been running familiarisation sessions on Managers Self Service and Employee Self Service to sign-post staff to how to view and undertake their on-line training through ESR. these sessions will continue for the next few months as staff have been asked to really focus ion ensuring their compliance is up to date. Compliance is low in the lower pay band 2 and 3 particularly in the unqualified Nursing staff groups .Cluster 3 is the only Cluster with a green rating, Clusters 1, 2 and 6 are all red rated. Particularly low Service Lines being Neurology, Cancer and Surgery & Urology. The average Mandatory Training compliance for our comparator's is 86.87% (Mar-19) and the Trust records the lowest percentage of all the Trusts. 6. Appraisals (target 90%) The Trust have now changed the Appraisal compliance to run over a rolling year. Currently we are rated at 69.82%. Lowest compliance is in Strategy, Plastics and Dermatology and Histopathology Service Lines. For staff groups lowest compliance is within Admin and Esttes and Qualified Allied Health Profesions and for pay band Bit is Bands 2 and 7 are recording the lowest percertnages. 10. Stability (target 90%) This month records shows amber rating of 84.68%, a very slight decrease. Band 5 and Band 2 record a red rate, but this is not an unusual trend due to natural career progression. Cluster 2 is the only red rated area and Service Lines with low stability are Outpatients & Records, Human Resources, Diabetes and Neurology. 11. Time to Hire (under 20 days) The Time to Hire is now measured on working days from Advert end date to unconditional offer over a rolling year. This month the figure remains green rated at 15 days. There are very few Services over the target but this have been identified and work on improving these will take place over the coming months.
31 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
32 to 34
k7.03 | Sickness rate k7.04 | Mandatory training
Are we Well-Led?Well-led June 2019
k7.01 | Vacancy rate k7.02 | Turnover rate
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard <=2.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard >=85%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard <=6%
12.5%
13.0%
13.5%
14.0%
14.5%
15.0%
15.5%
16.0%
Jun-1
8
Jul-1
8
Aug-1
8
Sep-1
8
Oct-
18
Nov-1
8
Dec-1
8
Jan-1
9
Feb
-19
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun-1
9
Standard <=13.5%
32 of 45
14 to 19
27/06/18 16:30 |Final Report v1.3
Are we Well-Led?Well-led June 2019
k7.05 | Appraisals / PDRs completed K7.10 | Stability ( %Staff Retained > 1yr)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun
-18
Jul-1
8
Aug
-18
Sep
-18
Oct-
18
Nov-1
8
Dec-1
8
Jan
-19
Fe
b-1
9
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun
-19
Standard >=90%
Actuals reset at start of financial year
70%
75%
80%
85%
90%
95%
100%
Jun
-18
Jul-1
8
Aug
-18
Sep
-18
Oct-
18
Nov-1
8
Dec-1
8
Jan
-19
Fe
b-1
9
Ma
r-1
9
Apr-
19
Ma
y-1
9
Jun
-19
Standard >=90%
33 of 45
14 to 19
Are we Well-Led?Well-led June 2019
Corporate Performance - Key Highlights
34 of 45
27/06/18 16:30 |Final Report v1.3KPI Description
Typ
e
Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19YTD
(2018/19)
2017/18
(Full Year)
k1.01 Pressure ulcers - Hospital acquired (Grade 3 and 4) per month Number 0 2 0 2 2 1 4 6 3 4 1 1 31 36
k1.011 Pressure ulcers - Hospital acquired (Grade 3 and 4) - Avoidable Number 0 1 0 2 0 2 1 1 1 1 0 0 0
k1.012 Pressure ulcers - Hospital acquired (Grade 3 and 4) - Unavoidable Number 0 1 0 1 2 1 2 5 2 3 0 1 49 44
k1.02Patients with Hospital acquired pressure ulcers (Grade 3 and 4) per 1000
beddaysper month Rate 0.00 0.19 0.00 0.18 0.18 0.09 0.35 0.60 0.26 0.37 0.09 0.09 0.24 0.26
k1.03 Pressure ulcers - Hospital acquired (Grade 2) per month Number 8 3 0 2 3 4 10 3 7 3 6 5 49 44
k1.031 Pressure ulcers - Hospital acquired (Grade 2) - Avoidable Number 4 1 0 0 1 1 5 2 1 1 3 5 13 13
k1.032 Pressure ulcers - Hospital acquired (Grade 2) - Unavoidable Number 3 2 0 1 1 3 5 1 6 2 3 0 21 18
k1.04 Patients with Hospital acquired pressure ulcers (Grade 2) per 1000 beddays per month Rate 0.76 0.28 0.00 0.18 0.27 0.37 0.88 0.30 0.61 0.28 0.53 0.45 0.37 0.32
k1.05 MRSA Bacteraemias (Hospital Assigned) per month Number 0 0 0 0 0 0 0 0 0 0 1 0 1 4
k1.06 MSSA Bacteraemias (Hospital Apportioned) per month Number 2 2 0 1 1 1 0 1 1 0 0 1 13 13
k1.07 Clostridium difficile Infections (Hospital Apportioned) Number 3 1 2 1 1 1 0 2 0 4 0 2 21 18
k1.08Clostridium difficile Infections (Hospital Apportioned) due to Lapse in Care
(confirmed cases)per annum Number 1 0 0 0 0 0 0 0 0 0 0 0 3 4
k1.09 Completed Patient Observations - Adult inpatients (NEWS) per month % 98.3% 99.1% 99.5% 99.7% 97.8% 97.6% 99.4% 98.2% 97.7% 98.8% 98.1% 98.6% 98.2% 97.3%
k1.10a Completed Patient Observations - Paediatric Inpatients (NEWS) per month % 92.5% 97.8% 100.0% 100.0% 100.0% 100.0% 94.7% 96.0% 93.8% 99.0% 97.1% 100.0% 97.9% 98.6%
k1.12 Patient Safety Incident (PSI) Falls per month Number 52 68 66 58 83 86 72 71 68 59 61 77 779 688
k1.13 Number of Patient Safety incident Falls per 1000 (G&A) bed days per month Rate 4.95 6.33 6.22 5.27 7.60 8.02 6.30 7.05 5.96 5.43 5.34 6.98 6.49 5.00
k1.14 Patient Falls with moderate or severe harm per month Number 1 3 1 0 1 4 1 2 0 2 2 2 13 11
k1.15 Never Events per month Number 0 0 0 0 0 0 0 0 0 0 0 0 1 0
k1.16 Medication Incidents Number 68 75 33 43 72 45 57 45 56 59 62 60 672 677
k1.17 % Medication Incidents where Moderate or Severe Harm occurred per month % 0.0% 0.0% 0.0% 0.0% 0.0% 2.2% 0.0% 0.0% 1.8% 1.7% 1.6% 0.0% 0.6% 0.0%
k1.18 Serious Untoward Incidents Number 6 2 2 3 2 2 0 1 0 4 0 2 26 31
k1.19 Escherichia Coli bacteraemia (all) Number 10 12 14 20 8 2 11 10 20 7 16 17 150 148
k4.01 Safer Staffing - Day - Registered Midwives / Nurses fill rate % 99.1% 94.1% 97.2% 97.0% 102.0% 100.9% 97.7% 100.6% 97.9% 98.7% 97.7% 97.9% 98.6% 94.3%
k4.02 Safer Staffing - Day - Assistant Fill Rate % 112.7% 101.2% 106.7% 92.3% 105.2% 101.5% 91.5% 92.8% 96.1% 102.3% 98.8% 100.6% 102.7% 112.5%
k4.03 Safer Staffing - Night - Registered Midwives / Nurses fill rate % 97.4% 91.3% 95.9% 96.9% 99.4% 100.0% 97.4% 99.2% 96.9% 99.1% 97.4% 97.9% 97.9% 99.1%
k4.04 Safer Staffing - Night - Assistant Fill Rate % 124.3% 100.9% 107.0% 95.2% 109.9% 104.9% 95.4% 98.5% 95.6% 105.9% 107.0% 107.7% 106.4% 119.2%
k4.05 Safer Staffing - Overall trust fill rate % 103.6% 95.8% 99.8% 95.8% 102.9% 101.3% 96.1% 98.4% 97.0% 100.4% 99.0% 99.7% 100.2% 102.3%
k4.06 Safer Staffing - % of Registered Nurse and Midwife expenditure on agency staff % 4.6% 4.2% 2.2% 2.9% 3.6% 3.1% 3.8% 3.6% 3.6% 4.2% 4.17% 3.49% 3.8% 4.8%
Standard
(From Apr '18)
<=10
Domain Scorecard Summary Rolling 12-Month Scorecard
Safe
=0
<=1
<=8
>=0.97
<=0.1
<=3
<=0.51
=0
-
<=0.04
-
-
>=0.97
<=58
<=5.3
<=6
-
-
-
-
-
-
35 of 45
27/06/18 16:30 |Final Report v1.3KPI Description
Typ
e
Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19YTD
(2018/19)
2017/18
(Full Year)
Standard
(From Apr '18)
Domain Scorecard Summary Rolling 12-Month Scorecard
k4.07 Safer Staffing - Care Hours per Patient Day Rate 8.10 8.31 8.06 7.99 8.60 8.46 8.23 8.11 8.20 8.18 8.35 8.59 8.25 8.05
k5.01 Maternity - Caesarean section rate per month % 28.6% 29.4% 31.0% 27.6% 35.9% 35.5% 30.1% 27.9% 33.6% 35.9% 32.6% 33.1% 31.3% 28.6%
k5.02Maternity - % of women with a primary postpartum haemorrhage of 1500ml or
moreper month % 4.4% 4.4% 4.3% 5.1% 3.2% 4.1% 5.2% 5.0% 4.8% 5.2% 4.4% 2.9% 4.4% 3.4%
k5.03Maternity - % of women with a primary postpartum haemorrhage of 2000ml or
moreper month % 1.5% 1.3% 1.9% 2.9% 1.2% 1.5% 2.0% 1.9% 1.3% 2.1% 1.9% 2.9% 1.8% 1.3%
k5.04 Maternity - Significant Perineal Trauma % 2.6% 1.3% 1.0% 2.7% 1.7% 2.1% 1.7% 1.4% 1.8% 1.6% 1.9% 1.2% 1.9% 2.1%
k2.01 Standardised healthcare mortality index (SHMI) - most recent score Index 85.782 85.782 83.266 83.266 83.266 82.247 81.939 81.939 81.939 77.778 77.778 77.778
k2.02 Unadjusted Mortality Rate % 0.8% 0.7% 1.0% 0.8% 0.6% 0.9% 1.0% 1.2% 0.8% 0.8% 1.1% 0.8% 0.9% 1.0%
k2.03 Sepsis - % of eligible patients screened for sepsis - ED per month % 88.0% 72.0% 91.4% 76.0% 78.0% 92.0% 92.3% 92.0% 93.8% 88.89% 84.62% 92.0% 86.2% 80.2%
k2.04Sepsis - % of eligible patients who received antibiotics within 1 hour of arrival -
EDper month % 75.0% 65.9% 75.0% 68.6% 73.2% 77.4% 84.4% 90.5% 88.5% 100.00% 66.67% 94.7% 77.1% 70.1%
k2.13 Sepsis - % of eligible patients screened for sepsis - Inpatients per month % 61.4% 80.4% 80.0% 76.0% 76.0% 84.0% 85.7% 84.0% 90.2% 84.21% 88.00% 82.14% 75.7% 69.0%
k2.14 Sepsis - % of eligible patients who received antibiotics within 1 hour - Inpatients per month % 81.1% 81.4% 92.3% 85.4% 88.9% 81.8% 57.1% 70.0% 77.8% 71.43% 71.43% 90.9% 82.2% 62.1%
k2.05 VTE Assessments (Trust) per month % 97.7% 98.1% 98.3% 98.1% 98.2% 97.8% 98.1% 98.1% 97.8% 98.2% 98.3% 97.9% 98.0% 97.9%
k2.06 Incidence of Hospital Acquired VTE (HAT) Number 4 2 0 2 0 1 2 1 3 7 5 2 27 30
k2.07 % of eligible patients screened for dementia per month % 72.9% 77.0% 77.2% 79.9% 80.2% 79.4% 76.0% 71.9% 74.3% 71.2% 71.3% 75.7% 76.5% 70.5%
k2.08 % of patients with dementia who were properly assessed per month % 91.8% 91.3% 90.0% 79.2% 50.9% 61.2% 70.2% 74.6% 86.0% 65.9% 85.4% 88.0% 81.3% 91.2%
k2.09 % emergency readmissions following elective admission - 30 days % 3.1% 2.2% 2.0% 2.8% 2.5% 3.0% 2.3% 1.7% 2.4% 2.5% 1.7% 2.6% 2.5% 2.5%
k2.10 % emergency readmissions following emergency admission - 30 days % 14.8% 15.8% 15.8% 15.2% 13.6% 15.6% 14.9% 15.5% 16.2% 16.4% 15.6% 16.2% 15.7% 15.8%
k3.15 Hand Hygiene (Infection Control - Core Elements Tool) per month % 98.6% 98.3% 98.9% 98.2% 97.2% 98.3% 99.3% 99.0% 98.2% 98.4% 98.6% 98.0% 98.4% 96.9%
Caring
k3.01 Number of complaints received this month Number 35 26 33 37 28 17 25 23 30 26 37 32 344 338
k3.02 Number of complaints reopened this month Number 1 6 1 6 5 4 5 5 6 1 3 5 50 50
k3.03 Number of complaints referred to ombudsman this month Number 2 0 0 0 1 0 0 0 0 0 0 0 3 2
k3.14 Complaints Response Rate % 67.9% 76.9% 75.8% 50.0% 50.0% 50.0% 78.9% 72.2% 74.1% 65.5% 50.0% 53.1% 61.2% 71.3%
k.3.05b FFT - Trust - % Would Recommend % 90.5% 91.5% 91.6% 91.9% 92.5% 93.0% 93.1% 92.6% 92.2% 92.5% 93.1% 93.2% 91.7% 91.6%
k3.06a FFT - InPatients - % Would Recommend per month % 93.5% 96.3% 97.0% 95.4% 96.0% 95.5% 97.1% 96.8% 96.0% 95.8% 97.2% 96.0% 95.5% 95.4%
k3.07 FFT - Paediatric InPatients - % Would Recommend % 90.9% 98.3% 89.6% 98.4% 94.7% 87.0% 95.5% 97.6% 94.4% 93.3% 89.3% 91.7% 91.3% 93.2%
k3.08a FFT - OutPatients - % Would Recommend % 91.9% 91.4% 92.7% 92.4% 93.0% 94.0% 93.7% 93.4% 93.1% 93.6% 93.8% 94.0% 92.6% 93.2%
Effective
-
<=0.26
<0.031
<=0.01
>=90%
>=90%
>=95%
-
>=90%
-
<=95
-
>=90%
>=90%
-
-
-
>=80%
-
>=90%
-
-
>=95%
>96%
-
-
36 of 45
27/06/18 16:30 |Final Report v1.3KPI Description
Typ
e
Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19YTD
(2018/19)
2017/18
(Full Year)
Standard
(From Apr '18)
Domain Scorecard Summary Rolling 12-Month Scorecard
k3.09a FFT - A&E - % Would Recommend % 86.2% 89.3% 86.3% 88.9% 89.3% 89.4% 89.2% 87.0% 87.6% 88.1% 89.1% 89.9% 87.5% 86.1%
k3.10c FFT - Maternity - % Would Recommend % 82.1% 93.8% 96.4% 98.9% 86.8% 97.5% 90.2% 96.7% 96.2% 96.5% 97.1% 93.9% 95.0% 96.6%
k3.11 FFT - Daycases - % Would Recommend % 97.0% 97.6% 97.2% 98.2% 98.1% 98.9% 96.5% 97.3% 95.5% 98.1% 97.3% 97.5% 96.9% 97.0%
k3.13 Number of Mixed Sex accommodation breaches Number 0 0 0 0 0 0 0 0 0 0 0 0 0 0
k3.2 Complaints per 100 patient contacts Rate 0.06 0.05 0.06 0.06 0.05 0.03 0.04 0.04 0.05 0.04 0.06 0.05 0.00 0.00
k6.01 Average length of stay - Emergency Services (Emergency admissions only) per month Rate 4.04 4.17 4.11 4.34 4.50 3.93 3.96 4.12 4.08 3.97 4.48 3.95 4.18 4.77
k6.02 RTT - incomplete 92% in 18 weeks (NONC) per month % 93.9% 93.6% 93.2% 93.3% 94.4% 93.8% 92.9% 93.0% 93.0% 93.3% 92.7% 92.2% 93.6% 94.3%
k6.03 RTT - incomplete 52+ Week Waiters (NONC) per month Number 11 7 3 0 0 0 0 0 0 1 3 0 42 11
k6.04 Diagnostic Test Waiting Times - Completed within 6 weeks (ALL) per month % 99.6% 99.7% 99.8% 99.5% 99.4% 99.9% 98.4% 99.3% 99.5% 98.6% 99.2% 97.8% 99.5% 99.4%
k6.05 A&E 4 hour waiting time (type 1) - % 89.3% 89.0% 87.1% 90.9% 86.1% 87.1% 85.3% 85.2% 86.7% 86.1% 87.9% 85.5% 88.0% 87.9%
k6.06 A&E 4 hour waiting time (all types) per month % 90.4% 90.2% 88.4% 91.9% 87.6% 88.3% 86.8% 86.7% 88.0% 87.5% 89.1% 86.9% 89.2% 89.2%
k6.07 A&E 12 hour trolley waits per month Number 0 0 0 0 0 0 0 0 0 0 0 0 0 1
k6.08 LAS Ambulance Handovers - within 15 minutes - % 42.9% 38.1% 47.3% 44.2% 41.3% 40.7% 36.5% 36.8% 37.2% 34.3% 31.7% 36.5% 39.7% 46.1%
k6.09 LAS Ambulance Handovers - 30 min handover waits per month Number 3 10 4 11 19 7 14 4 14 13 14 3 93 288
k6.10 LAS Ambulance Handovers - 60 min handover waits per month Number 0 0 0 0 0 0 2 1 1 0 0 0 4 29
k6.11 All Cancer Two Week Wait per month % 99.0% 99.2% 99.3% 99.0% 99.3% 99.2% 98.7% 99.0% 98.7% 98.5% 96.7% 99.0% 98.5%
k6.12 2 week GP referral to 1st outpatient - breast symptoms per month % 100.0% 100.0% 100.0% 99.3% 99.4% 100.0% 98.5% 100.0% 98.5% 98.7% 100.0% 99.3% 97.9%
k6.13Percentage of patients receiving first definitive treatment within one month (31-
days) of a cancer diagnosis (measured from ‘date of decision to treat’)per month % 100.0% 99.0% 100.0% 100.0% 99.1% 100.0% 98.9% 97.8% 100.0% 100.0% 94.8% 99.4% 99.3%
k6.14 31 day second or subsequent treatment - drug per month % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
k6.15 31-Day Standard for Subsequent Cancer Treatments-Surgery per month % 100.0% 94.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.3% 98.9%
k6.16 All Cancer Two Month Urgent Referral to Treatment Wait per month % 97.2% 94.9% 96.8% 96.1% 97.0% 97.5% 91.7% 92.0% 97.7% 100.0% 100.0% 96.0% 92.7%
k6.1762-Day Wait for First Treatment Following Referral from an NHS Cancer
Screening Serviceper month % 66.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 50.0% 98.5% 95.2%
k6.18 62-Day Wait for First Treatment Following Referral from Consultant Upgrade per month % 100.0% 100.0% 100.0% 88.2% 100.0% 94.7% 95.7% 96.3% 100.0% 100.0% 100.0% 96.9% 92.8%
k6.20 Delayed transfers of care (bed days) - Number 433 427 447 303 361 261 329 320 411 361 364 433 4567 6661
k6.21 Delayed transfers of care (rate per occupied bed days) per month % 4.1% 4.0% 4.2% 2.8% 3.3% 2.4% 2.9% 3.2% 3.6% 3.3% 3.2% 3.9% 3.5% 4.8%
k6.22 Number of last minute cancelled operations - Number 2 7 4 6 5 5 2 7 2 8 5 5 70 130
k6.23 Number of patients not treated within 28 days of last minute cancellation per month Number 0 0 0 0 0 3 0 1 1 2 0 1 5 0
>=85%
>=90%
>=85%
<=4%
=0
Responsive
-
<=0.07
<=5.23
>=92%
=0
-
-
=0
>=93%
>=93%
>=96%
>=98%
>=94%
>=99%
>=95%
=0
=0
=0
37 of 45
27/06/18 16:30 |Final Report v1.3KPI Description
Typ
e
Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19YTD
(2018/19)
2017/18
(Full Year)
Standard
(From Apr '18)
Domain Scorecard Summary Rolling 12-Month Scorecard
k6.30 Stranded Patients (>= 7 days) Number 146 150 154 145 156 134 153 159 154 162 161 159 0 0
k6.31 Super-Stranded Patient (>= 21 days) Number 48 48 54 49 48 39 43 47 43 58 55 45 0 0
k7.01 Vacancy rate per month % 9.0% 8.7% 8.0% 6.8% 6.2% 7.3% 6.3% 6.8% 6.8% 8.9% 8.7% 8.8%
k7.02 Turnover rate per month % 14.4% 15.2% 14.6% 14.3% 14.3% 14.3% 14.3% 14.4% 14.6% 14.6% 14.6% 14.9%
k7.03 Sickness rate per month % 2.6% 2.5% 2.7% 2.5% 2.9% 2.3% 3.2% 3.2% 2.8% 2.8% 2.4% 2.8%
k7.04 Mandatory Training per month % 70.0% 68.6% 70.6% 70.9% 70.9% 71.1% 73.0% 75.6% 73.8% 77.5% 76.0% 76.3%
k7.05 Appraisals / PDRs completed year end % 43.1% 56.6% 65.9% 71.9% 75.3% 78.8% 83.3% 85.7% 89.6% 65.3% 68.2% 69.8%
K7.10 Stability (% Staff Retained >1yr) % 82.1% 85.6% 84.7% 84.5% 85.0% 85.4% 85.1% 84.8% 84.6% 84.6% 85.1% 84.7%>90.%
<=6%
<=13.5%
<=2.6%
>=85%
>=90%
Well-led
38 of 45
Report Glossary
DomainIndicator
referenceDescription Indicator Methodology Data source Notes
Safe k1.01Patients with hospital acquired pressure ulcers
(Grades 3 & 4)
Number of patients with a newly hospital acquired pressure ulcers (Grades 3 &
4)Ulysses
Safe k1.02Patients with hospital acquired pressure ulcers
(Grades 3 & 4) per 1000 bed days
Number of patients with a newly hospital acquired pressure ulcers (Grades 3 &
4) divided by number of General and Acute (G&A) occupied bed days
(n) Ulysses
(d) Internal bedstate
summary
27/06/18 16:30 |Final Report v1.3k1.03Patients with hospital acquired pressure ulcers
(Grade 2)Number of patients with hospital acquired pressure ulcers (Grade 2) Ulysses
Safe k1.04Number of patients with hospital acquired pressure
ulcers (Grade 2) per 1000 bed days
Number of patients with a newly hospital acquired pressure ulcers (Grade 2)
divided by number of General and Acute occupied bed days
(n) Ulysses
(d) Internal bedstate
summary
Safe k1.05 MRSA Bacteraemias (Hospital Assigned)
Number of hospital assigned MRSA bacteraemia.
This includes all cases that are assigned through a post infection review (PIR).
Any 'hospital apportioned' MRSA cases with an ongoing PIR investigation will
also be reported - this includes all MRSA cases that where the patients' first
positive test for MRSA was taken on their third day of admission or afterwards.
Infection Control team - as
reported to PHE
Safe k1.06 MSSA Bacteraemias (Hospital Apportioned)
Number of hospital apportioned cases of MSSA bacteraemia.
This includes all MSSA cases that where the patients' first positive test for
MSSA was taken on their third day of admission or afterwards.
Infection Control team - as
reported to PHE
Safe k1.07Clostridium difficile Infections (Hospital
Apportioned)
Number of hospital acquired C diff bacteraemia.
Includes all CDiff cases that where the patients' first positive test for CDiff was
taken on their fourth day of admission or afterwards.
Infection Control team - as
reported to PHE
Safe k1.08
Clostridium difficile Infections (Hospital
Apportioned) due to Lapse in Care (confirmed
cases)
Number of Clostridium Difficile Infections which are attributable to a lapse in
care.
Only applies to Cliff cases here the patients' first positive test for CDiff was
taken on their fourth day of admission or afterwards.
Infection Control team - as
reported to PHE
Safe k1.09Completed Patient Observations (NEWS) - Adult
Inpatients
The percentage of patients who have received 2 or more completed sets of
NEWS observations within a 24 hour period - Inpatients Only (Excluding
Paeds)
Clinical Audit
Safe k1.10Completed Patient Observations (NEWS) -
Paediatric Inpatients
The percentage of patients who have received 2 or more completed sets of
NEWS observations within a 24 hour period - Paeds onlyClinical Audit
Safe k1.12 Number of Patient Safety Incident (PSI) Falls Number of falls reported Ulysses
Safe k1.13Number of Patient Safety Incident Falls per 1000
G&A bed days
Number of reported falls divided by number of General and Acute (G&A)
occupied bed days
(n) Ulysses
(d) Internal bedstate
summary
Safe k1.14Number of Patient Safety Incident Falls where
moderate or severe harm occurredIncludes falls resulting in moderate harm to severe harm/death Ulysses
39 of 45
Report Glossary
DomainIndicator
referenceDescription Indicator Methodology Data source Notes
Safe k1.15 Number of Never Events
"Never events" are very serious, largely preventable patient safety incidents
that should not occur if the relevant preventative measures have been put in
place.
Safe k1.16 Number of Medication Incidents
The number of incidents which actually caused harm or had the potential to
cause harm involving an error in administrating, prescribing, preparing,
dispensing or monitoring medication.
Ulysses
Safe k1.17% of Medication Incidents Where Moderate or
Severe Harm Occurred
The number of Medication Incidents Where Moderate or Severe Harm
Occurred divided by the total Number of Medication IncidentsUlysses
Safe k1.18 Number of Serious Untoward Incidents Total number of serious untoward incidents reported Ulysses
Effective k2.01Standardised healthcare mortality index (SHMI) -
most recent score
This ratio demonstrates the ratio between the actual number of deaths
following hospital care in relation to the number of patients who were expected
to die based on the patient's characteristics and comorbidities
HSCIC
Effective k2.02 Unadjusted Mortality RateThe number of deaths as a percentage of all discharges, including daycase
patientsCRS
Effective k2.03Sepsis - % of eligible patients screened for sepsis -
Emergency Dept.
The percentage of patients sampled who met the criteria of the local protocol
and were screened for sepsis.Clinical Audit
Effective k2.04Sepsis - % of eligible patients who received
antibiotics within 1 hour of arrival
The total number of patients sampled who received antibiotics within 1 hour of
arrival as a percentage of those who should have received antibiotics within 1
hour of arrival.
Clinical Audit
Effective k2.05 VTE Assessments (Trust)Percentage of patients risk-assessed for Venous-Thromboembolism within 24
hours of admissionCRS
Effective k2.06 Incidence of Hospital Acquired VTE (HAT) Number of recorded instances of VTE acquired while admitted Ulysses
Effective k2.07 % of eligible patients screened for dementiaOf the patients who were eligible to be screened for dementia (aged 75 and
with a length of stay of 72 hours or greater), how many were screenedClinical Audit
Effective k2.08% of patients with dementia who were properly
assessed
Of the patients who were identified using the dementia screening assessments,
how many were appropriately assessed.Clinical Audit
Effective k2.09% emergency readmissions following elective
admission - 30 days
Percentage of patients re-admitted within 30 days of a previous elective
admissionCRS
Effective k2.10% emergency readmissions following emergency
admission - 30 days
Percentage of patients re-admitted within 30 days of a previous emergency
admissionCRS
Effective k2.11 Hand Hygiene Compliance rate with the Infection Control Saving Lives Audit Infection Control
40 of 45
Report Glossary
DomainIndicator
referenceDescription Indicator Methodology Data source Notes
Effective k2.12Open Incidents - % of managers reports
completed within 10 days
Percentage of Incidents Recorded on Ulysses that have been completed within
appropriate time frameUlysses
Patient
Experiencek3.01 Number of complaints received this month Number of complaints received this month Ulysses
Patient
Experiencek3.02 Number of complaints reopened this month Number of complaints reopened this month Ulysses
Patient
Experiencek3.03
Number of complaints referred to ombudsman this
monthNumber of complaints referred to ombudsman this month Ulysses
Patient
Experiencek3.14
% complaints responded to within agreed
timeframe
Percentage of complaints that have received a response within the agreed time
frame, based on the month in which the response was due.Ulysses
Patient
Experiencek3.20 Complaints per 100 patient contacts
The number of patient complaints divided by the number of 'patient contacts'
multiplied by 100. KPI defined to be the same as that at Frimley Hospital
A 'patient contact' is defined as one of: An inpatient discharge, a outpatient
appointment or DNA, or an A&E attendance, or a daycase attendance.
CRS and Ulysses Added For June 2018's Board Meeting
Patient
Experiencek3.05 Friends and Family Score - Trust
Number of patients who would recommend the Trust to friends and family, as a
percentage of all respondents.FFT
Patient
Experiencek3.06
Friends and Family Score - Inpatient (excluding
daycases)
Number of patients who would recommend the Trust to friends and family, as a
percentage of all respondents.FFT
Patient
Experiencek3.07 Friends and Family Score - Paediatric Inpatient
Number of patients who would recommend the Trust to friends and family, as a
percentage of all respondents.FFT
Patient
Experiencek3.08 Friends and Family Score - Outpatient
Number of patients who would recommend the Trust to friends and family, as a
percentage of all respondents.FFT
Patient
Experiencek3.09 Friends and Family Score - A&E
Number of patients who would recommend the Trust to friends and family, as a
percentage of all respondents.FFT
Patient
Experiencek3.10 Friends and Family Score - Maternity
Number of patients who would recommend the Trust to friends and family, as a
percentage of all respondents.FFT
Patient
Experiencek3.11 Friends and Family Score - Daycases
Number of patients who would recommend the Trust to friends and family, as a
percentage of all respondents.FFT
Patient
Experiencek3.12 Friends and Family Score - Dementia Carers
Number of carers of patients with dementia who would recommend the Trust to
friends and family, as a percentage of all respondents.FFT
41 of 45
Report Glossary
DomainIndicator
referenceDescription Indicator Methodology Data source Notes
Patient
Experiencek3.13 Number of Mixed Sex accommodation breaches Number of Mixed Sex accommodation breaches CRS
Safer Staffing k4.01Safer Staffing - Day - Registered Midwives /
Nurses fill rate
Total hours worked by registered nurses and midwives as a percentage of the
planned hours - Day shiftHealthRoster
Safer Staffing k4.02 Safer Staffing - Day - Assistant Fill RateTotal hours worked by healthcare assistants as a percentage of the planned
hours - Day shiftHealthRoster
Safer Staffing k4.03Safer Staffing - Night - Registered Midwives /
Nurses fill rate
Total hours worked by registered nurses and midwives as a percentage of the
planned hours - Night shiftHealthRoster
Safer Staffing k4.04 Safer Staffing - Night - Assistant Fill RateTotal hours worked by healthcare assistants as a percentage of the planned
hours - Night shiftHealthRoster
Safer Staffing k4.05 Safer Staffing - Overall trust fill rate Total hours worked as a percentage of the planned hours - All shifts HealthRoster
Safer Staffing k4.06Safer Staffing - % of Registered Nurse and
Midwife expenditure on agency staff
Safer Staffing - % of Registered Nurse and Midwife expenditure on agency
staffHealthRoster
Safer Staffing k4.07 Safer Staffing - Care Hours per Patient DayTotal hours worked by staff proportionate to the number of occupied beds at
midnightHealthRoster/CRS
Maternity k5.01 Maternity - Caesarean section rate Percentage of caesarean sections relative to all births CRS/Maternity Forms
Maternity k5.02Maternity - % of women with a primary postpartum
haemorrhage of 1500ml or more
Maternity - % of women with a primary postpartum haemorrhage of 1500ml or
moreCRS/Maternity Forms
Maternity k5.03Maternity - % of women with a primary postpartum
haemorrhage of 2000ml or more
Maternity - % of women with a primary postpartum haemorrhage of 2000ml or
moreCRS/Maternity Forms
Maternity k5.04 Maternity - Significant Perineal Trauma Maternity - Significant Perineal Trauma CRS/Maternity Forms
Responsive k6.01Average length of stay (ALOS) - Emergency
Admissions
The mean length of stay for patients, calculated by dividing the total inpatient
days by the number of dischargesCRS
Responsive k6.02Referral to Treatment (RTT) within 18 weeks -
incomplete pathwaysRTT 18 weeks - incomplete pathway UNIFY2 / NHS England
Responsive k6.03RTT 18 weeks - incomplete pathway 52+ week
waitersRTT 18 weeks - incomplete pathway 52+ week waiters UNIFY2 / NHS England
42 of 45
Report Glossary
DomainIndicator
referenceDescription Indicator Methodology Data source Notes
Responsive k6.04 Diagnostic test waiting times Diagnostic test waiting times UNIFY2 / NHS England
Responsive k6.05 A&E 4 hour waiting time (type 1)Percentage of patients who received treatment and were admitted or
discharged within 4 hours of arrival - Main A&E OnlyUNIFY2 / NHS England
Responsive k6.06 A&E 4 hour waiting time (all types)Percentage of patients who received treatment and were admitted or
discharged within 4 hours of arrival - Both Main A&E and Royal Eye UnitUNIFY2 / NHS England
Responsive k6.07 A&E 12 hour trolley waits A&E 12 hour trolley waits UNIFY2 / NHS England
Responsive k6.08London Ambulance Service (LAS) Handovers - %
within 15 minutes
Percentage of Ambulance handovers completed within 15 minutes of Arrival at
A&ELAS portal
Responsive k6.09 LAS Ambulance Handovers - 30 min waits LAS Ambulance Handovers - 30 min waits LAS portal
Responsive k6.10 LAS Ambulance Handovers - 60 min waits LAS Ambulance Handovers - 60 min waits LAS portal
Responsive k6.11 Cancer - Two week waitPercentage of patients seen by a specialist within two weeks of an urgent GP
referral for suspected cancerInfoflex
Responsive k6.12Cancer - Two week referral to 1st outpatient -
breast symptoms
Percentage of patients seen by a specialist within two weeks of an urgent GP
referral for suspected breast cancerInfoflex
Responsive k6.13
Cancer - Patients receiving first definitive
treatment within one month (31 days) of a cancer
diagnosis
Percentage of patients who began first definitive treatment within 31 days of
receiving a cancer diagnosisInfoflex
Responsive k6.14Cancer - 31 day second or subsequent treatment -
drug
Percentage of patients who began treatment within 31 days of diagnosis,
where the required treatment was an anti-cancer drug regimenInfoflex
Responsive k6.15Cancer - 31 day second or subsequent treatment -
surgery
Percentage of patients who began treatment within 31 days of diagnosis,
where the required treatment was surgeryInfoflex
Responsive k6.16Cancer - Two month urgent referral to treatment
waitPercentage of patients treated within two months of an urgent GP referral Infoflex
Responsive k6.17Cancer - 62 day wait for first treatment following
referral from an NHS Cancer Screening Service
Percentage of patients treated within two months of an urgent referral from an
NHS Cancer Screening ServiceInfoflex
Responsive k6.1862-Day Wait for First Treatment Following Referral
from Consultant Upgrade
Percentage of patients treated within two months of a consultant's decision to
upgrade their priorityInfoflex
43 of 45
Report Glossary
DomainIndicator
referenceDescription Indicator Methodology Data source Notes
Responsive k6.19 Delayed transfers of care (number)Number of patients whose transfer is delayed at midnight on the last Thursday
of the month
Responsive k6.20 Delayed transfers of care (bed days) Number of General and Acute (G&A) occupied bed days
Responsive k6.21Delayed transfers of care (rate per occupied bed
days)Delayed transfers per 1,000 bed days CRS
Responsive k6.22 Number of last minute cancelled operations Number of operations cancelled within 24 hours of the planned operation
Responsive k6.23Number of patients not treated within 28 days of
last minute cancellationNumber of patients not treated within 28 days of last minute cancellation
Responsive k6.30 Stranded Patients (>= 7 days) Daily average number of patients in hospital for over 6 days. CRS
Responsive k6.30 Super-Stranded Patient (>= 21 days) Daily average number of patients in hospital for over 20 days. CRS
Well Led k7.01 Vacancy rate Vacancy rate Human Resources
Well Led k7.02 Turnover rate Turnover rate Human Resources
Well Led k7.03 Sickness rate Sickness rate Human Resources
Well Led k7.04 Mandatory Training Mandatory Training Human Resources
Well Led k7.05 Appraisals / PDRs completed Appraisals / PDRs completed Human Resources
Well Led k7.06 Flu Immunisation Percentage of staff who have received the flu vaccination Human Resources
Well Led k7.07 Staff FFT (Work) - ScorePercentage of staff who would recommend the Trust to friends and family as a
place to workNHS England
Well Led k7.08 Staff FFT (Care) - ScorePercentage of staff who would recommend the Trust to friends and family if
they needed care or treatmentNHS England
44 of 45
Report Glossary
DomainIndicator
referenceDescription Indicator Methodology Data source Notes
Well Led k7.09 Staff Survey - Response RatePercentage of staff who completed the survey, of those who were asked to
complete itHuman Resources Annual Survey
Well Led k7.10 Stability (% Staff Retained >1yr) The proportion of permanent staff with a length of service of over1 year Human ResourcesNew KPI added in May 2018's Board
Report (April data)
Well Led k7.11 Time to Hire (% staff hired in < 88 working days)
The proportion of new hires which took 88 or less working days from the post
being advertised for recruitment and the new staff member starting their role
within the Trust
Human ResourcesNew KPI added in May 2018's Board
Report (April data)
45 of 45