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Trust Quality and Performance Report 29 November 2013 (October Performance Pack)

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Contents Slide numbers Executive Summary 2 - 4 Clinical Quality Priorities inc Ward Dashboard5 - 18 Local Priorities19 - 26 CQUIN27 - 30 Monitor Compliance31 Contract Priorities32 - 34 1

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Executive Summary This commentary provides an overview of key issues during the month and highlights where performance fell short of the target values as well as areas of improvement and noticeable good performance. 1.A&E Performance for October was 97.08%, exceeding the 95% target for the fifth consecutive month and placing the Trust in the top quartile nationally and remains the best performance in the Region. 2.There were two cases of C.Diff in October against the threshold of two. This is covered on page 12 of this report. 3.Performance on outpatient and inpatient discharge summaries remains below target. A number of new steps have been introduced through the month. Further detail is on page 3. 4.Performance on MRSA screening of emergency admissions was 95% against the 100% target, and 92% for elective admissions. This is covered on page 12 of this report. 5.All Stroke targets were achieved for the month. 6.The Trust had 2 single sex breaches during October. All 2 occurred within a short timescale. See page 3. 2

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3 Performance IndicatorThresholdOctoberLead Exec Discharge Summaries - Outpatients95% sent to GPs within 3 days81.63%Dermot ORiordan Performance IndicatorThresholdOctoberLead Exec Discharge Summaries - Inpatients95% sent to GPs within 1 day77.57%Dermot ORiordan Performance IndicatorThresholdOctoberLead Exec Mixed Sex Accommodation Breaches03Jon Green Executive Summary Clinical staff and the project team have been exploring options. In agreement with the CCG a number of non-critical areas have been removed as part of the performance framework while data collection has been extended beyond just EPRO. TEG have agreed a number of initiatives to address the key issues, including performance discussion at consultant appraisal, targeting the underperforming specialities in directorates, where the Ops Groups have agreed a new process. Looking at automating the process further by sending letters sooner In order to support Discharge Summaries and Letters the project team have been working with clinicians to explore a range of options in order to resolve the current performance. In agreement with the CCG a number of non-critical areas have been removed as part of the performance framework while data collection has been extended beyond just EPRO. In addition TEG have agreed a number of initiatives to address the key issues, including performance discussion at consultant appraisal, targeting the underperforming specialities in directorates including a new process agreed by the Ops Group. In addition looking at automating the process further by sending letters sooner. All 3 breaches were associated with ITU step-down and occurred over a 48 hour period. High levels of level 3 occupancy and limited ward beds meant these patients could be neither safely partioned or stepped-down to wards.

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4 Performance IndicatorThresholdOctoberLead Exec MRSA Emergency Screening All emergency patients admissions are to be screened for MRSA within 24 hours of admission 95.09%Nichole Day Executive Summary Performance IndicatorThresholdOctoberLead Exec Sickness absence rate

Local Priorities: Exception Reporting KPI-3SIRIs open more than 45 days after submission on STEIS This measures all SIRIs that remain open on STEIS beyond the final report submission deadline. This includes three sub-sets: SIRI final report overdue submission (n = 0) SIRI final reports for which WSFT response to CCG queries is pending (n = 7) SIRI final reports submitted for which feedback / closure by the CCG is pending (n = 4) RAG rating*RED (n >10)Amber (n = 6 - 10)Green (0 - 5) As @ 15/11/13n = 10 (Amber) RAG rating based on local benchmark data for 22 Trusts provided by CCG The number of open reports has fallen considerably from 24 in September to18 in October to 10 in November. One of the 10 SIRIs has had a stop the clock pending the findings of an external review of CTG tracing. Incidents (Amber / Green) with investigation overdue (over 12 days) The next deadline for NRLS submission is the 30 th November. The Operational Steering Group have agreed a pathway to complete sign off of the Apr-September incidents within the timeframe which has resulted in a reduction in the total overdue for investigation and final approval. Ops group also identified a need to consider a robust method for ensuring timeliness of future investigation and sign off. Late by Directorate Red (RAG) OctNovchange Clinical Support>15 226 Estates and Facilities>10 179 Medical>70 149152 Surgical>407965 Women & Childrens Health>15 3119 OtherNo target 810 TOTAL >150 306261 RCA actions overdue Seven of the actions are from Maternity RCAs and have only just become overdue in November. These will be actively followed up to ensure completion. Two relate to others policies currently being drafted. 19

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Local Priorities - Governance Dashboard IndicatorPerformance targetRAGOct13Commentary Timely completion of incident investigations and actions Red non-SIRI investigation not complete more than 45 days after incident reported >31 - 300 RCA Actions beyond deadline for completion>=51 409Seven of the actions are from Maternity RCAs and have only just become overdue. These will be actively followed up to ensure completion. Two relate to others policies currently being drafted. Incidents (Amber / Green) with investigation overdue (over 12 days) >15050 - 150 2 working days from identification as red >1100All incidents were submitted to STEIS within the 2 day timeframe. Two incidents were reported late on Datix and three were re-graded as Red following initial review. SIRI final reports due in month submitted beyond timeframe >11008/ 8 within deadline Number of SIRI reports open on STEIS more than 45 days after initial notification >106 - 100-510Reduced from 18 in October. One SIRI included in this figure had a stop the clock pending the findings of an external review of CTG tracing. Duty of CandourCompliance with Duty of Candour requirements =95%88%88% = 14/16. The two non compliant cases relate to pressure ulcers identified on critically ill patients who subsequently died for whom a conversation with the family about the pressure ulcer was not considered appropriate at the time. Risk assessment Active risk assessments in date=95%99% Outstanding actions in date for Red / Amber entries on Datix risk register =95%99% 20

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Local Priorities - Governance Dashboard (cont.) IndicatorPerformance targetRAGOct13Commentary Risk assessment Active risk assessments in date =95% 99% Outstanding actions in date for Red / Amber entries on Datix risk register =95% 99% Clinical Audit Trust participation in relevant ongoing National audits (reported by Quarter) =90% 100% Safer surgery Completion of WHO checks during surgery. This is a composite indicator of the checks at ward, sign-in, time-out and sign-out. 98% 95%Non compliance reported to individuals (daily) and Clinical Directors (weekly) NICE TA (Technology appraisal) business case beyond agreed deadline timeframe >94 - 90 - 3 2 These outstanding five interventional procedures and six Clinical Guidelines are outstanding baselines assessment and require targeted follow up. IPG (Interventional procedure guideline) baseline assessments beyond agreed deadline timeframe >94 - 90 - 3 5 CG (Clinical guideline) baseline assessments beyond agreed deadline timeframe >94 - 90 - 3 6 Complaints Response within 25 days or negotiated timescale with the complainant =90% 88% This represents 4 of the 32 responses that were sent out in October. We continue to manage a high number of complaints and must ensure the responses address all issues, this can sometimes results in a slight delay with a few of the responses. Number of second letters received>=51-40 2 Two second letters were received. One complainant is adamant that she wants the PHSO to review her complaint but has been told by them she must first write back to us in the first instance. One remains dissatisfied with her care despite the explanation given. Health Service Referrals accepted by Ombudsman >=210 0 Red complaints actions beyond deadline for completion>=51-40 0 Number of PALS contacts becoming formal complaints>=106 - 9

Contract Priorities Dashboard 32 Performance IndicatorThreshold In Month Performan ce YTDCommentsLead Exec A&E A&E - Threshold for admission via A&E i) if the monthly ratio is above the corresponding 2011/12 monthly ratio for two month in a six month period ii) if year end is greater than 27% 25.20%24.82% Jon Green A&E - Timeliness Indicators To satisfy at least one of the following Timeliness Indicators: 1. Time to initial assessment (95th percentile) below 15 minutes 2. Time to treatment in department (median) below 60 minutes ONE MET- Jon Green Stroke Stroke -Proportion of Patients admitted to an acute stroke unit within 4 hours of hospital arrival 90%91.00%85.71% Jon Green Proportion of patients in Atrial Fibrillation, presenting with stroke and where clinically indicated will receive anti-co-agulation. 60%83.00%68.29% Jon Green Stroke - % of Stroke patients with access to brain scan within 24 hours 100%100.00%98.57% Jon Green Stroke - Proportion of Stroke Patients and carers with a joint health and social care plan on discharge 85%94.00%91.14% Jon Green Stroke - Patients (as per NICE guidance) with suspected stroke to have access to an urgent brain scan in the next slot within usual working hours or less than 60 minutes out of hours as defined from time to time by the ASHN 100% of stroke patients eligible for a brain scan scanned within one hour 100.00%93.43% Jon Green >80% treated on a stroke unit >90% of their stay80%97.00%89.14% Jon Green >60% of people who have a TIA and are high risk (ABCD 2 score 4 or more) are scanned and treated within 24 hours of 1st contact but not admitted 60%92.00%78.57% Jon Green Stroke - 65% of patients with low risk TIA have access to MRI or carotid scan within 7 days (seen, investigated and treated) 65%65.00%73.43% Jon Green % of Patients eligible for Thrombolysis, Thrombolysed within 4.5 hours 100% of all eligible patients100.00% Jon Green

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Contract Priorities Dashboard 33 Discharge Summaries Discharge Summaries - Outpatients95% sent to GP's within 3 days81.63%84.19% Dermot O'Riordan Discharge Summaries - A&E 95% of A&E Discharge Summaries to be sent to GPs within one working day 97.54%97.50% Dermot O'Riordan Discharge Summaries - Inpatients95% sent to GP's within 1 day77.57%82.16% Dermot O'Riordan Choose & Book Provider failure to ensure that sufficient appointment slots are made available on the Choose and Book system A maximum of 3% slots unavailable (50 per appointment over 5%. Threshold applied over monthly figures) 3.00%- The Threshold applied to fines is 5% Jon Green All 2 Week Wait services delivered by the Provider shall be available via Choose & Book (subject to any exclusions approved by NHS East of England) 100%100.00%- Jon Green Cancelled Operations Provider cancellation of Elective Care operation for non- clinical reasons either before or after Patient admission i) 1% of all elective procedures0.57%1.15% Jon Green Patients offered date within 28 days of cancelled operation 100% 100.00% Jon Green Maternity Access to Maternity services (VSB06):- 90% of women who have seen a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks and choices by 12 completed weeks of pregnancy. 96.23%96.20% Nichole Day Maintain maternity 1:30 ratio1:30 1:29 Nichole Day Pledge 1.4: 1:1 care in established labour1:1 100.00% Nichole Day Breastfeeding initiation rates.80% 81.73%79.81% Nichole Day Reduction in the proportion of births that are undertaken as caesarean sections. Suffolk PCT Only 1% reduction in proportion compared to 2011/12 baseline - 22.70% 16.26%18.47% Nichole Day

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Contract Priorities Dashboard 34 Other contract / National targets Mixed Sex Accomodation breaches0 Breaches24 Jon Green Consultant to consultant referral Commisioner to audit if concern about levels of consultant referrals 7.13%6.19% Jon Green Current ratios of OP procedure to day case for agreed list of procedures to be maintained or improved, i.e. the Commissioner will not fund a higher level of admitted patients for such procedures, unless clinical reasons can be demonstrated for increase in admissions. Maintain or improve the mix as specified = 90.17% 87.33%87.55% Jon Green MRSA - emergency screening All emergency patients admissions are to be screened for MRSA within 24 hours of admission 95.09%92.42% Nichole Day Rapid access - chest pain clinic 100% of patients should have a maximum wait of two weeks 100.00%78.33% Jon Green New to Follow up Thresholds set at each speciality - overall Trust Threshold is 1.9 1.891.84 Jon Green Patients receiving primary diagnostic test within 6 weeks of referral for diagnostic test 99%99.49%97.77% Jon Green