Agenda Item No. 3.2
Manchester Health and Care Commissioning Board Meeting Performance and Quality Improvement One Report
Agenda Item: 3.2 Date: 28 March 2018
Report Title: Performance and Quality Improvement (PQI) Report
Michelle Buls – Performance and Quality Improvement Prepared by: Contracts Manager
Michelle Irvine – Director of Performance and Quality Presented by: Improvement
This report summarises the quality and performance highlights, to be brought to the attention of the committee. The report covers all national, regional and local key performance indicators as set out in the annual planning guidance and those embedded as contractual requirements for Manchester Summary of Report: Health and Care Commissioning’s (MHCC) main providers – Manchester University Foundation Trust (MFT) and Pennine Acute Hospitals Trust (PAHT).
In addition, section 3 contains a “focus on” section
To improve the health and wellbeing of people in Manchester To strengthen the social determinants of health and promote healthy lifestyles Strategic Objective: To ensure services are safe, equitable and of a high standard with less variation To enable people and communities to be active partners in their health and wellbeing To achieve a sustainable system
Board Assurance Framework Risks identified in this report are included in the organisational Risk: risk register. Outcome of Impact Assessments completed (e.g. N/A Quality IA or
Agenda Item No. 3.2
Equality IA):
Outline public engagement – clinical, stakeholder and N/A public/patient: MHCC is asked to support the actions being undertaken to Recommendation: improve the quality and performance for the population of Manchester.
Agenda Item No. 3.2
1.0 Introduction
1.1 This report summarises the quality and performance highlights, to be brought to the attention of MHCC. The report covers all national, regional and local key performance indicators as set out in the annual planning guidance and those embedded as contractual requirements for MHCC main providers – Manchester University Foundation Trust (MFT) and Pennine Acute Hospitals Trust (PAHT).
1.2 The following scorecards are attached:
Appendix A MHCC 5 year forward view Appendix B MFT Contract key performance indicators Appendix C MFT (formerly Central Manchester University NHS Foundation Trust (CMFT)) contract key performance indicators (KPIs) Appendix D MFT (formerly University Hospital of South Manchester (UHSM)) contract key performance indicators Appendix E Pennine Acute Hospital Trust (PAHT) contract key performance indicators Appendix F PAHT Community KPI
1.3 KPI scorecard exceptions will be reported monthly and quarterly with additional specific ‘focus on’ areas
1.4 This month’s focus areas are contained in section 3 of this report as below:
3.1 Adult social care 3.2 Contract planning update 3.3 PAHT community services 3.4 Greater Manchester Mental Health (GMMH) Care quality commission (CQC) report 3.5 PAHT quality update 3.6 PAHT CQC published report 3.7 Small provider update 3.8 Small provider commissioning for quality and innovation (CQUIN) achievement 3.9 Walkrounds 3.10 Never events
1.5 The data contained in this report is the latest published data. However, the narrative has been updated to the most recent local information.
Agenda Item No. 3.2
2. Exception reports
This section of the report sets out those areas that are currently underperforming across MHCC’s main providers by themed family groups and the actions being undertaken to address them.
2.1 Urgent care
Urgent care
Manchester Health & Care Commissioning
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value February Percentage of patients who spent 4 hours or less in 95.0% 88.5% 95.0% 85.0% 2018 A&E result
North West Ambulance Service NHS Trust
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value February NWAS Response time for Category 1 calls - Mean 07:00 09:52 07:00 08:51 2018 (mm:ss) result February NWAS Response time for Category 2 calls - Mean 18:00 31:48 18:00 31:59 2018 (mm:ss) result February NWAS Response time for Category 2 calls - 90th 40:00 72:31 40:00 72:05 2018 percentile (mm:ss) result February NWAS Response time for Category 3 calls - 90th 120:00 144:07 120:00 180:02 2018 percentile (mm:ss) result February NWAS Response time for Category 4 calls - 90th 180:00 174:22 180:00 190:54 2018 percentile (mm:ss) result
Manchester University NHS Foundation Trust
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value February Percentage of patients who spent 4 hours or less in 90.1% 90.0% 86.5% 2018 A&E (STF) result February Ambulance Handover Delays over 30 Minutes 0 3866 0 489 2018
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result February Ambulance Handover Delays over 1 Hour 0 845 0 98 2018 result February Ambulance Handover Delays over 2 Hours 0 126 0 12 2018 result January Delayed transfers of care - DTOCs as a % of total 3.3% 3.3% 4.9% 2018 beds result January % of patients who spend at least 90% of inpatient 80.0% 59.9% 80.0% 53.6% 2018 stay on a stroke unit result
Manchester University NHS Foundation Trust (formerly CMFT)
Annual 2017/18 Performan Period Indicator Target ce in Period Target 2017/18 Value Period February Percentage of patients who spent 4 hours or less in 91.27% 90.00% 88.23% 2018 A&E (STF) result February Ambulance Handover Delays over 30 Minutes 0 1657 0 179 2018 result February Ambulance Handover Delays over 1 Hour 0 469 0 64 2018 result February Ambulance Handover Delays over 2 Hours 0 95 0 10 2018 result January Percentage of patients who spend at least 90% of 80.0% 60.8% 80.0% 54.5% 2018 their inpatient stay on a stroke unit result
Manchester University NHS Foundation Trust (formerly UHSM)
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value February Percentage of patients who spent 4 hours or less in 86.5% 90.0% 80.7% 2018 A&E (STF) result February Ambulance Handover Delays over 30 Minutes 0 2209 0 310 2018 result February Ambulance Handover Delays over 1 Hour 0 376 0 34 2018 result
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February Ambulance Handover Delays over 2 Hours 0 31 0 2 2018 result January Delayed transfers of care - DTOCs as a % of total 3.3% 3.3% 8.5% 2018 beds result January Percentage of patients who spend at least 90% of 80.0% 59.3% 80.0% 52.9% 2018 their inpatient stay on a stroke unit result
Pennine Acute Hospitals NHS Trust
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value February Percentage of patients who spent 4 hours or less in 83.8% 91.1% 81.7% 2018 A&E (STF) result February Trolley Waits in A&E (NMGH) 0 69 0 2 2018 result February Ambulance Handover Delays over 30 Minutes 0 7421 0 755 2018 result February Ambulance Handover Delays over 1 Hour 0 2282 0 228 2018 result February Ambulance Handover Delays over 2 Hours 0 453 0 48 2018 result January Delayed transfers of care - DTOCs as a % of total 3.3% 3.3% 3.3% 2018 beds result January Delayed transfers of care - DTOC as a % of total 3.3% 7.5% 3.3% 5.0% 2018 beds (NMGH) result Novemb % of high risk TIA cases investigated and treated 60.0% 59.5% 60.0% 50.0% er 2017 within 24 hours result
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value Latest result for Compliance with overall SSNAP score - Level B 2017/18 (Levels A to E represented by a score of 5 to 1 4 2 4 2 as of respectively) UHSM Novemb er 2017
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Agenda Item No. 3.2
2.1.1 Urgent care
Definitions
Percentage of A and E attendances where the patient spent 4 hours or less in A and E from arrival to transfer, admission or discharge Number of ambulance handovers taking more than 30 minutes Number of ambulance handovers over an hour DTOCs (delayed transfers of care)as a percentage of total beds
Issues
Accident and Emergency 4 hour performance continues to be challenging across all of Manchester’s acute Trusts.
MFT and PAHT are reporting performance below the 95% constitutional standard, and below the sustainability and transformation fund (STF) trajectories set for quarter 4, 2017/18.
Continued pressure in our urgent care system has contributed to ambulance crews being delayed for over 30 minutes.
Multiple ambulances can attend a site within a short period which impacts on the system ability to deal with the surge of patients due to limited cubicles and the flow of patients with the hospital.
The number of delayed transfer of care patients remains higher than the 3.3% targets set by the Greater Manchester (GM) Partnership. This can impact the trusts’ ability to respond to surges in demand, and maintain hospital flow.
Trusts continue to report patients presenting with more complex conditions and with higher acuity, increased variation in attendance and admission levels.
Agenda Item No. 3.2
Key actions taken/planned
Surge and escalation framework established with system partners to respond to pressures with actions and co-ordinated approach led by the performance and quality improvement (PQI), resilience and improvement team Weekly tactical conference calls and reporting continued through February 2018 Manchester winter schemes to support resilience are now all live with monitoring in place to measure impact Plans for Easter weekends are underway within the urgent care system with the following assurance:
1. Service planning outlining the availability of services and variation on standard operations by staffing and opening hours 2. Completion of a national assurance template 3. Incorporation and implementation of new ways of working following lessons learned from Christmas and New Year 4. LOS meetings in place for March and ‘home for Easter’ campaigns to focus on discharges 5. System escalation calls in place starting 23 March to aid in communication and planning for Easter
Trust executive team attending bed meetings and present on site on weekends in order to support patient flow MFT’s Manchester Royal Infirmary (MRI) site is to hold a perfect week from 14 March to 21 March, with the aim of testing new ways of working that will impact on improving patient flow and performance. Focussed work through the North West Ambulance Service (NWAS) task and finish group has seen a reduction of 1 hour and 2 hour handover breaches at all sites There is live monitoring by each trust site, with a zero tolerance approach to holding ambulance crews longer than required Trusts will complete a root cause analysis on each lengthy handover breach and share this with the PQI manager, with trends shared with A and E operational delivery groups (ODGs) Manchester and Trafford transfer of care action plans and improvement trajectories are in place and being monitored PQI manager onsite support for escalation and delayed transfers of care (DTOC) related issues at PAHT and MFT (formerly UHSM) every week with an ability to respond to surge and escalation Trafford and Manchester have established independent DTOC control rooms that monitor the daily issues with DTOC and forensically review each patient Increased use in the discharge to assess model implemented in Trafford and Manchester with the ability to step-up / step-down patients
MHCC is committed to delivery of the above and plans and progress will be managed by the locality operational delivery groups and Manchester and Trafford urgent and emergency care transformation and delivery board.
The PQI team continue to lead work with NWAS and trusts across Manchester. The aim is to improve ambulance handover times and reduce handover breaches by sharing best practice.
Agenda Item No. 3.2
Risks
Flu numbers have reduced across all three hospital sites, there are still a number of cases within hospital sites. Hospitals are following their internal flu plans but there is recognition that this has an impact on delivery of the 4 hour performance targets Compromised patient flow within hospitals due to restricted bed capacity and unable to free up the beds needed for admissions Staffing shortages remain a concern. Trusts are managing to fill rotas via recurrent establishment or agency but frequently reporting shortfall due to sickness The impact of slower handovers will prevent the crews from responding to other emergency calls Delays to patient handover can delay patient treatment Risks remain associated with the delivery of DTOC target. This is highly dependent on the home care providers ability to meet demand within commissioned budgets
Timescales for delivery
A and E 4 Hour: All Hospital Trusts have agreed sustainability and transformation fund (STF) trajectories for 2017/18 and will not deliver the quarter 4 trajectory Ambulance Handovers: Stepped improvement is expected over winter, with delivery of national targets for handovers expected by March 2018 DTOC: Stepped improvement in DTOC over winter, with delivery expected to meet the 3.3% target before March 2018
2.1.2 Stroke
GM has operated a centralised model of stroke care since the beginning of 2015. Under this model, patients with newly onset symptoms of stroke would usually receive the first part of their care at one of three hyper acute stroke units (HASU), and then step down into their local district stroke centre (DSC) sites at either, MFT, Wythenshawe site, MRI site, Trafford general hospital site, or into the community.
Stroke performance is measured over a 4 month period. This update covers August 2017 to November 2017. This information was released in February 2018.
The performance and quality of stroke services are measured nationally by the Sentinel Stroke National Audit Programme (SSNAP). This assigns providers a performance level based on a range of 10 care domains of A to E (A being highest and E being lowest).
Domains for SSNAP Key Indicators scoring are:
Domain 1: Scanning Domain 2: Stroke unit Domain 3: Thrombolysis Domain 4: Specialist assessments Domain 5: Occupational therapy Domain 6: Physiotherapy Domain 7: Speech and language therapy Domain 8: Multidisciplinary team working Domain 9: Standards by discharge
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Domain 10: Discharge processes.
Further details on domains can be found at https://www.Strokeaudit.org/
All 10 domains apply to routinely admitting teams. These are the hospitals where a patient is usually taken for treatment immediately after their stroke like a Hyper Acute Stroke Unit (HASU). For the non-routinely admitting acute teams only 6 of the 10 domains are applicable (2, 5, 6, 7, 9, and 10). The non-routinely admitting acute teams (e.g. DSC) are expected to have fewer than 50% directly admitted patients and do not offer thrombolysis for example. MHCC performance
The following section will provide reassurance that good stroke care is offered across GM and the performance remains stable for Manchester residents.
In the period of August 2017 to November 2017 SSNAP reported 224 Manchester residents as having a stroke. The numbers of strokes slightly increased from the previous period (202), but inline with expected numbers. The percentage of CCG patients who have a stroke that are treated at a HASU has remained high at 77% (172 patients). With the remaining patients being seen at a DSC.
August-November 2017 Manchester CCG (224 patients)
Salford Royal Hospital (109 patients - SSNAP level A)
Stepping Hill Hospital (35 patients - SSNAP level A)
Fairfield General Hospital (28 patients - SSNAP level A)
Wythenshawe Hospital (22 patients - SSNAP level D)
Manchester Royal Infirmary (20 patients - SSNAP level B) Other (10 Patients)
The weighted average stroke care for residents of Manchester is ‘A’ rated care. This is due to the HASU performance. This is in line with expectations of the centralised model.
SSNAP patient centred total score by CCG 2016 2017 Aug Jan-Mar Apr-Jul Aug-Nov Dec 16-Mar Apr-Jul -Nov 2016 2016 2016 2017 2017 2017 North Manchester A A A A CCG Central Manchester B A A A CCG South Manchester B B A A CCG Manchester CCG A A *Source: Greater Manchester Integrated Stroke Service Update – Feb 2018
Agenda Item No. 3.2
Monitoring of performance of trusts The performance of DSCs within our CCG footprint is monitored by the PQI team alongside the GM Stroke operational delivery network (ODN). MFT, Trafford General site remained ‘A’ status and MRI a ‘B’ status. During this period MFT, Wythenshawe site did have some issues, resulting in a drop to ‘D’ status.
SSNAP level Team Centred Aug-Nov Dec 16- Apr- Aug- 2016 Mar 17 Jul 2017 Nov 2017 District MRI B B B B Stroke Trafford General A B A A Centres Wythenshawe B B C D *Source: Greater Manchester Integrated Stroke Service Update – Feb 2018
The drop in performance at MFT (formerly UHSM) was attributed to higher number of direct admissions to the stroke ward in the period. Over 50% of patients recorded were directly admitted, this results in the applicability of all 10 domains which impacted performance. Being a DSC they do not offer scanning or thrombolysis, this resulted in a zero scoring for these domains, impacting the overall score.
The high number of direct admissions to MFT, Wythenshawe site would indicate that patient flows through the model are not optimal. This matter is subject to further investigation to establish the causes behind the higher volumes of direct admissions to the unit, and whether any remedial action is required by MFT and via the GM stroke ODN. This was identified in January 2018 and a look back to ensure no patient harm is currently taking place and has been recorded on the MFT and CCG risk registers. Changes to the monitoring of admissions and escalation for delays at HASU will be updated to ensure the centralised model is effective.
It should be highlighted that at all centres, particularly those which deliver tertiary services will have a potential cohort of patients who have a stroke in conjunction with other comorbidities, and whose care is therefore most appropriately delivered at their host site rather than at a hyper acute stroke centre.
Performance at MFT, Wythenshawe site has improved since the reporting period due to a reduction of directly admitted patients returning to previous levels.
All stoke units SSNAP reports are available to the general public via https://www.Strokeaudit.org/
Summary
The quality and performance improvement committee are asked to note the report, and that CCG level data gives reassurance that the stroke services available to Manchester residents is good. The local stroke units at MFT will be monitored and requested to record the live numbers of directly admitted patients to ensure appropriate pathways are followed and patients receive the appropriate care.
Agenda Item No. 3.2
2.2 Elective care
Manchester Health & Care Commissioning
Annual 2017/18 Target Period Performance Indicator Period 2017/1 Value Target in Period 8 Q3 Cancer 62 day waits following urgent GP referral 85.0% 80.0% 85.0% 81.5% 2017/18 result January Diagnostic Waiting Times % waiting > 6 weeks 1.0% 2.2% 1.0% 2.0% 2018 result January RTT: Incomplete pathways % within 18 weeks 92.0% 90.0% 92.0% 90.0% 2018 result January Number of patients waiting >52 weeks on 0 22 0 4 2018 incomplete pathways result
Manchester University NHS Foundation Trust
Annual 2017/1 Period Performance in Indicator Target 8 Period Target Period 2017/18 Value Novembe Cancer 62 day waits following urgent GP referral 85.0% 84.5% 85.0% 84.9% r 2017 January Diagnostic Waiting Times % waiting > 6 weeks 1.0% 2.9% 1.0% 3.3% 2018 result January RTT: Incomplete pathways % within 18 weeks 92.0% 90.0% 92.0% 90.0% 2018 (NHS Constitution) result January Percentage of cancelled elective operations that are 0.8% 1.2% 0.8% 1.0% 2018 cancelled at the last minute for non-clinical reasons result January Cancelled elective operations - breaches of 28 day 0 123 0 12 2018 standard result
Manchester University NHS Foundation Trust (formerly CMFT)
Annual 2017/1 Period Performance Indicator Target 8 Period Target in Period 2017/18 Value November Cancer 62 day waits following urgent GP referral 77.41 85.00% 64.86% 2017 (STF) % result
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Cancer 62 day waits following referral from NHS November 90.0% 52.2% 90.0% 66.7% screening service 2017 January Diagnostic Waiting Times % waiting > 6 weeks 1.0% 3.5% 1.0% 5.0% 2018 (NHS Constitution) result January RTT: Incomplete pathways % within 18 weeks 92.0% 90.5% 92.0% 90.5% 2018 result January Percentage of cancelled elective operations that are 0.8% 1.2% 0.8% 0.9% 2018 cancelled at the last minute for non-clinical reasons result January Cancelled elective operations - breaches of 28 day 0 99 0 11 2018 standard result
Manchester University NHS Foundation Trust (formerly UHSM)
Annual 2017/1 Period Performance Indicator Target 8 Period Target in Period 2017/18 Value Cumulativ e result for Q4 Number of patients waiting >52 weeks on 0 149 0 25 2017/18 incomplete pathways as of January 2018 January Percentage of patients waiting more than 36 weeks 1.00% 1.09% 1.00% 1.09% 2018 on incomplete pathways result January Percentage of cancelled elective operations that are 0.8% 1.4% 0.8% 1.4% 2018 cancelled at the last minute for non-clinical reasons result January Cancelled elective operations - breaches of 28 day 0 24 0 1 2018 standard result January RTT: Incomplete pathways % within 18 weeks 89.1% 90.6% 89.1% 2018 (STF) result
Pennine Acute Hospitals NHS Trust
Annual 2017/1 Period Performance Indicator Target 8 Period Target in Period 2017/18 Value Q3 Cancer two week waits (urgent referrals) 93.0% 88.5% 93.0% 91.5% 2017/18 result Cancer 31 day waits for subsequent treatment 94.0% 97.0% 94.0% 92.9% Q3
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(Surgery) 2017/18 result Q3 Cancer 31 day waits for subsequent treatment 98.0% 98.8% 98.0% 97.2% 2017/18 (Drugs) result Q3 Cancer 62 day waits following urgent GP referral 85.0% 74.5% 85.0% 76.6% 2017/18 result Q3 Cancer 62 day waits following referral from NHS 90.0% 79.6% 90.0% 50.0% 2017/18 screening service result January RTT: Incomplete pathways % within 18 weeks 92.0% 87.3% 92.0% 87.3% 2018 (NHS Constitution) result January Number of patients waiting >52 weeks on 0 4 0 1 2018 incomplete pathways result December Cancelled elective operations - breaches of 28 day 0 86 0 15 2017 standard result
2.2.1 Elective
Definitions
The % of patients waiting 6 weeks or more for a diagnostic test as at the end of the reporting period The % of incomplete referral to treatment (RTT) pathways (patients waiting to start treatment) of 18 weeks or more at the end of the reporting period. Number of patients waiting more than 52 weeks or more at the end of the reporting period. When a patient’s operation is cancelled by the hospital on the day of admission or later, for non-clinical reasons, the hospital will have to offer another binding date to treat patient within a maximum of 28 days. % of cancelled elective operations that are cancelled at the last minute for non-clinical reasons.
Issues
Manchester University foundation trust (MFT) performance against the diagnostic test standard remains static at 2.5%. MFT (formerly UHSM) continues to achieve target (0.4%) with the MFT (formerly CMFT – 3.6%) experiencing capacity issues in adult and children endoscopy services. Pennine Acute hospital trust (PAHT) fell below target in December at 1.5% following 2 months of achievement.
MFT is failing to achieve the RTT national standard. MFT (formerly CMFT) is below target (90%) although there have been improvements in children’s services. MFT (formerly UHSM) revised its improvement trajectory but fell below this in December, reporting 88.8% against 89.8%.
PAHT continues to underachieve against the RTT standard and MHCC has received recovery plan and trajectories for a number of key specialities, and awaits an overall PAHT recovery trajectory. The focus continues to be on monitoring and supporting the digestive diseases (general surgery, colorectal and gastroenterology) improvement plan.
MFT (formerly UHSM) does not have the capacity to undertake deep inferior epigastric perforator (DIEP) procedures within the RTT standards and has 25 patients waiting over 52 weeks. The specific issues are as follows;
Manchester Health and Care Commissioning agreed a local tariff with the Trust in late 2017.
The Trust has since undertaken extensive demand and capacity modelling to better understand the infra-structure requirements moving forward to ensure women are seen and treated in this service within national waiting time standards.
A business case is in the final stages of development that outlines the expansion requirements to meet current and likely future demands.
All women who have waited in excess of 52 weeks are being clinical validated and choice discussions are taking place.
Trusts have operational processes in place to minimise the number of cancelled operations. The table below shows the number of cancelled operations and or un-utilised slots as a result of winter pressures at MFT.
Cancellations and or un-utilised W/C W/C W/C W/C W/C W/C W/C Total slots as a result of 01/01 08/01 15/01 22/01 29/01 05/02 12/02 winter pressures Total Inpatients 116 130 116 106 70 67 21 626 Total Outpatients 55 0 0 0 0 0 0 55
The majority of lost activity has been experienced in the Surgery Division within Manchester Royal Infirmary (MRI). MFT report that patients were cancelled in advance where possible and as such wouldn’t be a reportable cancellation or subject to the 28 day standard, although it is likely that they may have an increase in January against this standard as it will have proved difficult to schedule in any reportable cancellations that occurred in December. In addition, of the 626 cancellations, 156 were un-utilised slots, whereby no patients were scheduled given they were actively cancelling.
Key actions taken / planned
The endoscopy suite on the Manchester Royal Infirmary (MRI) site has reopened and will increase capacity.
Additional staff means paediatric magnetic resonance imaging (MR) capacity can be opened up.
PAHT continue to outsource diagnostic tests and undertake weekend lists.
MFT is working on an RTT sustainability plan for the organisation with specific focus on the fragile services.
PAHT continues to outsource elective activity and initiating discussions with neighbouring NHS trusts with regards to support for general surgery. A new weekly performance report to stakeholders to support progress against trajectory is in place.
The MRI have confirmed that as of week beginning 19th February they are aiming to recommence the elective programme, however this will be closely monitored in line with emergency pressures. In addition, the MRI will be undertaking a perfect week from the 14 – 22 March to support flow.
Risks
PAHT continues to rely on outsourced activity to deliver the 1% diagnostic standard. The most significant risk for both MFT and PAHT remains endoscopy capacity; MFT (formerly CMFT) is also experiencing capacity issues in paediatric MR.
Over the winter period, trusts have prioritised patient on an inpatient ward awaiting diagnostic tests over patient waiting for routine access. In addition, the elective programme was reduced. Although the trust will work to recover this, RTT performance may be affected.
PAHT is reporting the majority of patients are choosing to stay at PAHT even when offered shorter waits at an alternative provider. There is restricted capacity to undertake DIEP procedures.
Timescales for delivery
MFT is still expecting to deliver the diagnostic target across all sites at the end of quarter 4 with the February provisional position at 1.99%, down from 2.5% in December.
Current focus for RTT at MFT is the clearing of long wait patients. Pennine continue to focus and report RTT performance on a weekly basis to the CCG, with focus on long wait patients and increased capacity.
A proposed recovery action plan for DIEP will be available within the next 4 weeks that will outline the arrangements to see and treat existing patients and provide assurances on future service provision.
The impact of elective cancellations will be assessed to understand the contribution towards under performance against the RTT standards as noted above.
2.2.3 Cancer
The complex nature of cancer pathways in GM means that for many tumour types, patients receive their treatment, chemotherapy/radiotherapy/specialist surgery, at a different provider from the one to which they were originally referred. For ‘treating’ trusts this means that their performance against the 62 day standard relies on receiving timely referrals from the providers carrying out the initial diagnostic and staging investigations.
MHCC
Quarter 3 2017/18 performance
Manchester CCG Numerator Denominator Percentage Target Cancer two week waits (urgent referrals) 4,288 4,528 94.70% 93.00% Cancer two week waits for breast symptoms 571 594 96.13% 93.00% Cancer 31 day waits for first definitive treatment (All cancers) 426 430 99.07% 96.00% Cancer 31 day waits for subsequent treatment (Surgery) 100 100 100.00% 94.00% Cancer 31 day waits for subsequent treatment (Drugs) 98 98 100.00% 98.00% Cancer 31 day waits for subsequent treatment (Radiotherapy) 145 145 100.00% 94.00% Cancer 62 day waits following urgent GP referral 176 216 81.48% 85.00% Cancer 62 day waits following referral from NHS screening service 23 25 92.00% 90.00% Cancer 62 day waits following consultant decision to upgrade 70 78 89.74% 85.00%
MHCC performed well against 8, of the 9 cancer targets. The 62 day wait following urgent GP referral performance fell short of the expected 85% target at 81.48% in quarter 3.
Performance showed that 176 of the 216 patients were seen within 62 days following urgent GP referral. The 40 patient breaches have been reviewed and the trends suggest these are
mainly late referrals/communication and referral protocol (CARP) delays or clinically complex cancers.
While Manchester patients can be seen at various trusts across Manchester each of them have high level patient tracking lists that are reviewed and managed. Trusts focus on improving performance of all specialities.
The main specialities which had breaches were lower and upper gastrointestinal and urology, recovery plans continue to be implemented by all failing directorates at each trust. MFT (formerly CMFT and UHSM) and PAHT all have improvement trajectories in place, with an improvement in cancer 62 day waits following urgent GP referral expected in quarter 1 2018/19.
Monitoring performance of trusts
The performance of Trusts within Manchester is monitored by the PQI team. Focus remains on the delivery of 62 day standards.
MFT
The MRI and Trafford sites have a focus on performance improvement overseen by a site cancer board. The work within failing specialities continues to ensure improved performance. The creation of MFT presents opportunities to share best practice and sustain improvement.
The MFT, Wythenshawe site consistently achieves all cancer waiting times standards and has robust tracking arrangements and a proactive approach to the management of cancer pathways.
Christie
The reported performance from the Christie was above the standard.
Pennine
The 62 day performance is being progressed and monitored through 5 working groups. The oversight of the Pennine performance is from the North East sector tactical group, PQI are an active part of this group. The group targets improvement of specific tumours, specialities and did not attend (DNA) rates.
Quality process
MFT (formerly UHSM)
A pathway timeline is completed for all breaches of the 62-day standard (GP referred and consultant upgrades). The PQI team (clinical quality manager and PQI manager) meet with MFT to discuss patients who breach 62 days with the directorates on a quarterly basis. The outcomes of the investigations inform the trust’s cancer improvement plan.
MFT (formerly CMFT)
A root cause analysis (RCA) is completed for each breach of the 62-day standard for MFT, Central and Trafford, which identifies a primary breach reason and assesses whether the
breach was avoidable or unavoidable. RCAs completed by the divisional management teams are reviewed by the Trust corporate cancer management team and a summary shared with commissioners. This is a lengthy process meaning that the summary is not shared with commissioners until at least the end of the quarter after the quarter in which the breaches occurred.
Pennine
A breach reason report is shared once a month with commissioners for 62 day GP referrals and upgrades. This breaks down each breach per specialty and breach reason. An RCA summary for each patient is given.
In line with national requirements, a clinical review for harm is carried out for all pathways in excess of 104 days by all trusts and outcome shared.
Summary
The cancer standards that are presented are currently performing well. All trusts are engaging with MHCC and have improvement trajectories for underperforming specialities. Investigations are completed and lessons learnt are shared to improve performance. While staffing issues within certain specialties remain a national issue and risk, new ways of working collaboratively are being explored.
Changes to the GM access policy took place in February 2018, whereby patient choice exemptions will no longer be permitted and consequently will be included in performance figures. A small deterioration in cancer performance is expected across GM.
3.0 Focus Area Updates
3.1 Adult social care (ASC) update
The tables below show the current Care Quality Commission (CQC) inspection rating for the care homes and home care across Manchester that has had completed inspections by the CQC in the last 18 months.
Care homes (67 inspected up to end of February 2018) OUTSTANDING Fairleigh House % Mary & Joseph CQC inspection Number of care House rating homes
GOOD
2 3% See list in locality table Outstanding below
36 54% Good REQUIRES IMPROVEMENT See list in locality table Requires 25 37% below improvement
4 6% Inadequate INADEQUATE Beechill Nursing Home
Total 67 Seymour Care Home 100% Viewpark Residential Care Home Abbotsford
Home care (14 inspected up to end of February 2018) GOOD Sevacare Number of Casa CQC inspection rating home care HG Care % providers Care 24 REQUIRES IMPROVEMENT 4 28% Good MRL
The Care Company
9 64% Medacs Requires improvement Premier
Human Support Inadequate 1 8% Age Concern North
We Care
Trafford Housing Total 14 100% iCare Solutions
INADEQUATE
Enterprise
CQC ratings of care homes by locality
North (N1 and N2) Central (C1 and C2) South (S1 and S2)
City Centre, Ardwick, Gorton Old Moat and Withington Blackley North and Gorton South
Allendale Residential Home Beyer Lodge Nursing Home Brocklehurt Nursing Home Blackley Premier Care Gorton Parks Eachstep Blackley The Dell Downing House Polefield Nursing Home St Euphrasia’s Care Home Charlestown, Crumpsall and Hulme, Moss Side, Whalley Chorlton Park, Didsbury Harpurhey Range, and Burnage
Chataway Nursing Home Abbotsford Nursing Home Ashley House Residential Chestnut House Alness Lodge Ltd Home Holmeleigh Dom Polski Residential Care Chorlton Place Nursing Israel Sieff Court Fairleigh House Home Oakbank Care Home Mariana House Clyde Court Nursing Wellfield House Home Holmefield Care Laurel Court Rowsley House Russley House Yorklea Nursing Home Moston, Cheetham, Miles Rusholme, Longsight and Northenden, Sharston Platting and Newton Heath Levenshulme and Woodhouse Park
Acacia Lodge Grange Avenue Mainwaring Terrace Averill House Oakland House Nursing Home Marion Lauder House Beechill Nursing Home Park Crescent NWCS (Manchester) 62 Brookdale View Richmond Care Bradgate Cl Doves Nest Nursing Home St James House Ringway Mews Lightbowne Hall St Joseph’s Manchester St Bonaventures Lindenwood Residential Care Victoria Nursing Home The Peele Moston Grange Nursing Home The White House Nextstep Yew Tree Manor Norlands Nursing Home NW Community Serv (McrLtd) NWCS (M/cr Ltd) 11 Bacup St NWCS (M/cr) 20 Swallow St Silverdene Residential Home The Royal Elms Care Home Viewpark Care Home Wellington Lodge Ancoats, Clayton and Bradford Chorlton and Fallowfield Brooklands and Baguley
Brownlow House Alexandra Lodge Care Centre EAM Lodge CIC Mary & Joseph House Maybank House Seymour Care Home
The update below shows the progress of the CQC inspections and outcomes during January and February 2018.
Care Homes
The information below will give a brief overview for each of the homes rated as ‘inadequate’. Please note that Abbotsford nursing home now falls into this category from its previous rating of ‘requires improvement’. There is a service improvement plan in place and the home is engaging well in the process both with the CQC and MHCC.
In terms of improvements to CQC ratings, The Dell has improved from ‘inadequate’ to ‘requires improvement’ during re-inspection in January 2018 which was unannounced, which is positive news.
Inadequate care homes
Beechill Nursing Home
Locality: Cheetham Number of Beds: 31
Safe Effective Caring Responsive Well led
• MHCC (PQI) suspended service 18 August 2017, following site visit and serious concerns identified • CQC visited 29 and 30 August 2017 and reported that the home required improvement, report never published • Immediate service improvement plan (SIP) developed with provider including multi- disciplinary team (MDT), specifically infection control and medication management. • August 2017 referral to immigration unit for support of recruitment checks. • CQC re-inspected in September 2017 following PQI reporting to them a number of serious concerns. These included the lack of leadership, poor environment, lack of equipment, poor recruitment practices, lack of reporting, concerns around care planning and medication management • On 16 October 2017 the CQC issued the provider with a notice of proposal (NOP) to de-register the registered manager and another NOP to de-register the location • Weekly site visits from PQI for service improvement plan (SIP) development • Regular site visits from infection control and medication management • CQC revisited 23 October 2017 and removed the embargo on new placements; however MHCC’s suspension remains in place to date • The PQI team continue to visit and monitor the SIP on a fortnightly basis with the home. A lot of improvements have been identified and completed, whilst the home continues to work to a full completion of their SIP Viewpark Residential Care Home
Locality: Moston Number of Beds: 27
Safe Effective Caring Responsive Well led
CQC originally visited in November 2016 and found the home to be ‘inadequate’ in safe, responsive and well led standards. CQC issued a NOP to deregister the manager and site on 15 February 2017, provider made representations in March 2017 PQI developed SIP with provider and MDT CQC issued notice of decision (NOD) to deregister the manager and site 18 September 2017 Service suspended 10 October 2017 Local authority colleagues met with families on 3 October 2017 to inform them of the current CQC position and what this meant to residents Ongoing weekly site visits for SIP updates CQC re-inspection week commencing 2 January 2018, currently awaiting outcomes It is of the opinion of the PQI team that they do not have confidence in the actions and improvements made by the provider since having been first inspected and despite weekly visits, support, and signposting from PQI, the provider has failed to make the desired long term improvements required to avoid a possible tribunal for the NOD to deregister.
Abbotsford Nursing Home
Locality: Whalley Range Number of Beds: 44
Safe Effective Caring Responsive Well led
CQC inspected on 7, 14 and 19 December 2017 and has received an inadequate rating which is now in the public domain MHCC responded immediately in providing clinical oversight Daily district nurse visits Weekly GPO ward rounds Weekly MHCC quality visits Provider has been full engaged in turning this service round. SIP in place and progressing positively Provider has until 5 March 2018 to submit representations against the issued NOP for deregistration of the home and provider
MHCC is confident in the provider’s response to the inspection and the work they are putting in place to ensure compliance.
The Seymour Care Home Locality: Clayton Number of Beds: 26
Safe Effective Caring Responsive Well led
CQC inspected The Seymour Care Home on 30 and 31 October 2017. This was a re- inspection from the last one in Sept 2016 Prompted in part following information of serious concerns received from two whistle- blowers, alleging physical, psychological and emotional abuse to seven people living at the home Initial investigations confirmed the whistle-blower concerns
Staff members where immediately dismissed Care home was suspended SIP created and home fully engaged with weekly visits Significant progress made, and assurances gained, Site visits reduced to monthly monitoring SIP progress
Requiring improvement
There are currently 25 care homes across Manchester that have been rated as ‘require improvement’
The PQI team are in the process of reviewing the 25 care homes that ‘require improvement’ to identify themes and trends with a view to establishing a reporting schedule that will offer MHCC assurance of the actions/improvements being taken to improve the ratings. Updates will be shared with the PQI committee once available.
To offer assurance at this time, all the homes have a self-generated action plan in place from the monitoring visits that the PQI team have carried out. Visits to the homes are prioritised in terms of risk and the RAG rating given, is captured on the PQI team risk log. All of these homes are being monitored on a regular basis by the team.
Recent inspection resulting in revised CQC rating
The Dell
Locality: Gorton Number of Beds: 40
July 2017 – Inadequate
Safe Effective Caring Responsive Well led
January 2018 – Requires improvement
Safe Effective Caring Responsive Well led
CQC originally inspected The Dell on 17th and 19th July 2017 and The outcome was an ‘inadequate’ rating. At the time of the inspection in July the management team were new to the service Information requested to demonstrate residents was safe was not available at the time PQI completed a site visit along with health and local authority, safety lead in September 2017 SIP created with the new home manager Reassurance on the health and safety reports gained and immediate actions completed Provider fully engaged in the improvement plan All actions completed and reassurance gained Re-inspection took place on 15 and 16 January 2018 which was unannounced and the outcome was ‘requires improvement’ Monitoring visits have now reduced to 6-8 weekly
Additional care and quality concerns
Yew Tree Manor CQC rating – Requires improvement
Locality: Northenden Number of Beds: 43
Lack of understanding of clinical needs of patients Accepting referrals for residents that present complex mental health and physical health needs, whilst not necessarily having the skill’s to provide appropriate care for them Poor clinical leadership Poor / inadequate documentation
CQC engagement and next steps
The ASC PQI team have recently engaged with north regional CQC team as part of the PQI diagnostic, scoping and development process of integration.
The CQC team have endorsed our approach and establishment of the new framework and welcomed our strategy in moving away from the present reactive arrangements to a more proactive effective relationship where we can work together to support homes to improve their delivery of care in support of good or outstanding CQC ratings.
Following the inaugural meeting held on 22 February 2018, chaired by the MHCC improvement lead, the following actions were agreed:
Greater transparency and shared information processes MHCC access to the CQC portal where data can be accessed to support our locality measure and review CQC reflection of our escalation MDT proposals CQC reflection of our proposed quality risk stratification tool (QRST) ahead of implementation and rollout 2018/19 PQI team and CQC to establish a present baseline and timeline of our locality to clearly describe the status of our high risk, inadequate and requires improvement providers. To be shared with the executive committee upon completion CQC membership to our new monthly improvement group as a sub group of the residential nursing and homecare oversight group The above group will be two part, first part small group dedicated to core business and issues with the second part opened up to MDT membership for focused discussion on present provider issues. CQC represented both parts CQC will provide advice and guidance to providers if required following a recent Homecare
During February 2018, Enterprise Homecare received a CQC outcome of ‘inadequate’. The service is currently suspended from accepting new referrals and MHCC commissioning is considering next steps whilst supporting the service provision at Enterprise Homecare. Homecare providers that ‘require improvement’ receive a site visit from a contracts officer in the ASC PQI team. The aim of the visit it to develop a detailed action plan with the provider identifying the areas for improvement, allocating identified responsible individuals to each task and assigning a timeframe for achievement or review. This is monitored on a fortnightly
basis by completing further site visits, reviewing the actions and gaining evidence and assurance of progress and achievement.
3.2 Contract planning update
The PQI team has reviewed the current quality and performance elements of contract schedules to ensure they are fit for 2018/19.
The overriding principle has been to ensure provider contracts contain standardised quality and performance standards that are based on best practice.
Allocated leads for each sector are progressing negotiations and an update is provided below:
Community and local care organisation (LCO)
A working group was established to develop quality and performance indicators and standards which can be used across all the community health providers. A small number of performance indicators have been developed as a first draft. These are in line with the local care organisation (LCO) strategic priorities.
Small providers
All contractual quality and performance schedules have been reviewed to ensure consistency across similar services e.g. endoscopy services.
The majority of negotiations have been completed with a handful of more in depth meeting taking place with the remaining providers.
No risks have been identified.
Mental health small providers
All contractual quality and performance schedules have been reviewed. There is further work with commissioners required to align the contents prior to negotiation.
No current risks identified.
All work will be completed by March 2018.
GMMH
Due to the intensive contracting process last year, there are minimal changes for 2018/19. The PQI team has been working closely with commissioning colleagues at Manchester and Trafford to align the performance and quality elements of the two contracts. It has been agreed that in 2018/19, Manchester and Trafford commissioners will formally combine their contracts meetings with the Trust, these are currently held separately.
Key performance indicators (KPIs) have been agreed together with a list of information requirements and developmental KPIs which will be phased in during 2018/19 and will go into the Service Development Improvement Plan (SDIP).
All the schedules have been agreed. The data quality improvement plan is being included in the business intelligence negotiations.
Acute providers
MHCC has produced a list of KPIs, the majority of which have been agreed to be included in the appropriate contract schedule.
Negotiations are ongoing with no identified risks.
3.3 Community Services at PAHT - Quality
Quality areas update
MHCC PQI team confirm that quality standards have been met for quarter 3 of 2017/8.
There are monthly governance meetings taking place where the PAHT community services are represented and contributing to monthly service provision and areas of concerns. MHCC attend these meetings where possible and receive full papers/minutes and there is a good overview of quality within the services.
Discussion points at these meetings include:
patient safety serious incidents lessons learned from serious incidents infection control health and safety mandatory training complaints and compliments clinical outcomes/effectiveness
The meeting also offers community provision to discuss good practice, innovation and quality and performance monitoring.
Meetings are very well attended by service leads and each meeting does showcase a community service being provided to residents in the area, the nature of the service and what is offered and successes/achievements.
Safety
There had been no reported breaches of duty of candour in quarter 3 of 2017/18.
There were no serious incidents reported in quarter 3 for PAHT community services.
The PQI quality team noted that each division of the PAHT community service reviews its staffing levels regularly. Any identified issues or risks are raised at Senior Leadership Team (SLT) level and escalated to the PAHT executive directorate team if required.
The risk register for community services is discussed at the PAHT governance meeting.
All teams completed service risk registers and identified areas for escalation to the directorate register. There are robust systems and processes in place for monitoring and updating risks, services are challenged when actions are not completed in a timely manner and there is a high level of accountability.
There are three KPIs in relation to mandatory training that are underperforming presently, there has been lot of difficulty in extracting the community training data from the overall PAHT trust data which is impacting on reporting and data quality. Although compliance has dropped all targets are above the 85% mark and work to improve compliance continues.
Patient experience
Complaints
PAHT community services continue to meet all key performance indicators in relation to complaints; they have done this consistently throughout 2017/18. Performance indicator data shows that there is full compliance in:
responding to complaints within agreed timescales upon receipt of the complaint acknowledging complaints in 3 working days of the day following complaint received, and the number of complainants satisfied with the conclusion of the complaint
Compliments
PAHT also routinely collect and report compliments. Podiatry, district nursing and the palliative care team recorded high levels of compliments in quarter 3 for the care and support offered to patients in the community.
One staff member has been invited to attend Buckingham Palace on 14 March 2018 in recognition of their work in front line nursing - in the presence of His Royal Highness, The Prince of Wales.
PAHT routinely review and act on feedback from the friends and family test. Themes identified in quarter 3 include;
appointments being put back and long waiting lists for services telephone access to podiatry services
To address these issues, PAHT has developed further information for patients on access and waiting times to help manage patients’ expectations of services and also did some real time testing of the phone line into podiatry to identify issues and try and improve access to this service.
Clinical effectiveness
When new guidance is brought out nationally or locally PAHT review this and issue guidance to the relevant staff to ensure that it is implemented in the right way.
Examples of this include:
guidance on the use of social media responsibly (ref: Nursing and Midwifery Council) eat well drink well and keep the skin well (from NHS Improvement, January 2018) to help prevent pressure ulcers and promote wound healing competency framework for pressure area management for trainee assistant practitioners/health care support workers, and North Manchester community urgent diabetes assessment clinic referral pathway
Good practice
The intermediate care facility has had input from the dementia specialist nurse to ensure the unit becomes more dementia friendly. There are dementia champions across the PAHT community services.
Staff have been provided with prompt cards on the area of deprivation of liberties and mental capacity assessments when supporting and caring for patients in the community.
PAHT peer review
It was decided that in quarter 3, the MHCC PQI, quality team would use PAHT’s peer review, a quality monitoring tool which assesses each service around all elements of quality. There are 9 sections of the peer review all with a set of questions that relate to the elements of quality;
1. Governance basics 2. Patient and customer experience 3. Safety and risk management 4. Education and training/Continuing Professional Development 5. Clinical effectiveness and best practice 6. Audits (including clinical audits) 7. Information governance 8. Safeguarding 9. End of life
A more detailed update on this piece of work will be provided in the next update on PAHT community service.
End of Life (EOL)
Palliative and EOL care performance data is assessed and monitored for compliance with the following targets:
75% of patients on the community palliative team caseload dying in their preferred place 90% of response times by priority for patients referred to community palliative care team - Priority 1, within 2 hours 90% of response times by priority for patients referred to community palliative care team - Priority 2, within 24 hours 90% of response times by priority for patients referred to community palliative care team - Priority 1, within 5 days 95% of patients on the palliative care teams caseload who have been screened for anxiety and depression
80% of patients on the palliative care teams caseload who died with an agreed plan and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) where appropriate
All EOL KPIs have been met for the year to date.
In addition, PAHT community services were awarded a CQC rating of ‘good’ in the provision of EOL care (based on the CQC report of August 2016).
Commissioning for Quality and Innovations
Quarter 3 CQUIN
CQUINs have been recommended for full payment in the following areas:
CQUIN reference Description 1a Improvement of health and wellbeing of NHS staff Improving the uptake of flu vaccinations for frontline clinical staff. Reporting on this CQUIN was not required for this quarter but will be reported on in 1c quarter 4 8b Supporting proactive and safe discharge (Community) 9a Preventing ill health by risky behaviours - alcohol and tobacco: tobacco screening 9b Preventing ill health by risky behaviours - alcohol and tobacco: alcohol screening 9c Preventing ill health by risky behaviours - alcohol and tobacco: tobacco referral and 9e Preventing ill health by risky behaviours - alcohol and tobacco: alcohol brief advice or referral Preventing ill health by risky behaviours - alcohol & 9d tobacco: alcohol screening Preventing ill health by risky behaviours - alcohol & 9e tobacco: alcohol brief advice or referral 10 Improving the assessment of wounds 11 Personalised care and support planning
In Year 2, the provider is required to demonstrate a year on year improvement in all indicators.
Quality and performance sub-committee community services forward plan
The quality forward plan for our community provider allows them to showcase their service provision and look at certain aspects of quality such as:
CQUINs leadership and safer staffing experience and engagement effectiveness and clinical audits
Equality, diversity and human rights (EDHR)
At each meeting, the services will continue to discuss standing agenda items such as KPIs; duty of candour exceptions reports; serious incidents and items requiring escalation to contracts meetings. The forward plan will commence from April 2018.
3.4 Mental health update and GMMH CQC inspection report
CQC Inspection
The Care Quality Commission (CQC) inspected GMMH NHS Foundation Trust (GMMH) from the 18 September to 7 December 2017 and published their findings in February 2018.
GMMH was formed on 1 January 2017, following Greater Manchester West NHS Foundation Trust’s (GMW) acquisition of Manchester Mental Health Social Care Trust (MMHSCT). GMW were previously rated good by CQC, this rating has been maintained after the acquisition of MMHSCT. Within the overall ‘good’ rating, GMMH also received an outstanding rating for services being ‘well led’. The inspection team were struck by how well the leadership team had brought the Manchester services into the trust and improved them. The link to the full report can be accessed at http://www.cqc.org.uk/sites/default/files/new_reports/AAAG9950.pdf
Performance
Improving Access to Psychological Therapies (IAPTS)
Manchester has historically under-performed against the IAPT national standards. However, following acquisition of mental health services by GMMH, an IAPT transformation programme has been put into action.
As at the end of November, the IAPT standards continue to under-perform. Since April to November 2017, 8910 people have received treatment, which equates to 10% of all adults with a common mental health disorder. This is below the target of 11.2% by the end of November. The annual access rate target is 17% by March 2018.
Currently 61% of people had their first treatment within six weeks of referral (target of 75%) and 92% of people received treatment within 18 weeks (95%). A total of 37% of people recovered following treatment, which is below the 50% standard. It is anticipated that all the IAPT standards will meet the national requirements by the end of quarter 1 of 2018/19.
First episode of psychosis
As at the end December 2017, 64% of people experiencing a first episode of psychosis were treated with a NICE approved care package within two weeks of referral, above the national standard of 50%.
Out of area mental health placements (OAPs)
The use of inappropriate OAPs continues across GM. In Manchester OAPs has increased from 55 in December 2017 to 74 in January 2018. More recent data received from the Trust (as at 4 March 2018) shows an improved position with 52 OAPs, of which 34 were placed outside of GM. The average LOS of those currently placed outside of GM is 23 days.
A GM trajectory on reducing the number of OAPs is expected to be agreed by the end of March 2018. A GM wide action plan is also being developed, led by GMMH. In the meantime, GMMH continues to do all it can to repatriate patients quickly. This includes weekly action focused patient flow meeting to enable robust monitoring of admissions, discharges, delayed transfers and OAP. All service users with a length of stay over 50 days are monitored assertively. A strategic lead for patient flow has been appointment.
Also the transformational work-streams currently underway at GMMH, particularly around improvement to the acute and urgent care pathway will result in further provision of realistic alternatives to admission across the city.
Children and Young People (CYP) access to mental health services
There is a new national access indicator designed to measure increases in access to mental health services for CYP. The indicator measures the total number of CYP aged 0-18, receiving treatment by NHS funded community mental health services. The aim is to increase the numbers of CYP accessing mental health services year on year.
The number of CYP with a diagnosable mental health condition is estimated to be 12,364. The target for 2017-18 is to ensure that at least 30% of these CYP receive treatment. As at the end of September 2017, 2025 CYP received treatment, according to the national mental health dataset. This equates to 16.4% of the estimated total number of CYP with a diagnosable mental health problem. Based on current trajectories, Manchester is on course to deliver against the target 30% by April 2018.
The CYP access indicator is new and ongoing issues continue in relation to data quality and technical difficulties in providers being able to submit CYP patient data to the national data set.
A and E 4 hour standard for patients presenting with mental health conditions
In January, 89.4% of patients attending A and E due to a mental health conditions were either admitted or discharged within four hours, compared to 88.4% the previous month. In South Manchester, the 4 hour target was achieved in month.
GMMH have recently secured GM funding to increase capacity of the Mental Health Liaison Team and establish a CORE 24 complaint service. Manchester Royal Infirmary is in phase one of the funding (Sept 2018), Wythenshawe hospital the second (2019) and North Manchester General Hospital the third phase (2020).
3.5 Small Provider update
In the previous report the PQI team provided an overview of small providers which were a cause of concern to the team due to quality and/or performance issues.
Those providers are as follows:
Age UK – day care and counselling services Alliance Medical – Magnetic Resonance Imaging (MRI) Concordia - dermatology
Optegra- eye surgery Spire- surgical provider
The following gives an update on the issues and risks per provider.
Age UK, CQC Not registered
The meeting at the end of January between Age UK and MHCC leads to discuss commissioning and quality concerns was successful. A second meeting was held to complete the MHCC quality risk profile tool which was successful; a service review will be carried out in due course.
Alliance Medical, CQC registered but not yet inspected
Quality and KPI concerns had been raised in January with a deadline to respond by mid- February. These actions have not yet completed and the provider has been given the opportunity to do so by the end of February. Should the actions not be complete or are inadequate the PQI team will escalate accordingly.
Concordia, CQC rated Good
As reported in February, Concordia continue to adhere to monitoring requirements and key audits, due at the end of March 2018 will give a view on whether improvements have been made. The risk on MHCC quality and performance committee register will remain at 12 until the audits have been received.
Optegra, CQC rated requires improvement
Representatives from MHCC medicines management, PQI and a clinical expert in ophthalmology will be visit the service on 7th March 2018, to review the service and improvements to date following the CQC rating. An update will be available in the next report.
Spire, CQC rated requires improvement
Spire has fulfilled all CQC and MHCC walkround actions required and therefore it was recommended and agreed at the February MHCC PQI committee that the risk be closed.
3.6 PAHT CQC published report
England’s Chief Inspector of Hospitals has rated the services provided by PAHT as ‘requires improvement’ following inspection by the CQC. Overall, the trust has improved, moving from Inadequate to ‘requires improvement’. A team of inspectors visited North Manchester General Hospital, The Royal Oldham Hospital and Fairfield General Hospital, between 17 October and 16 November 2017. The inspections were unannounced.
At North Manchester General Hospital CQC inspected urgent and emergency care, medical services, maternity and children and young people because these services were rated as inadequate at the last inspection. Inspectors also looked at surgical
services which were rated as requires improvement. Overall, this hospital is now rated as ‘requires improvement’.
Overall rating for NMGH Requires Improvement Are the services safe? Requires improvement Are services effective? Requires improvement Are services caring? Good Are services responsive? Requires improvement Are services well-led? Good
North Manchester General Hospital is now rated requires improvement with services rated as follows:
Maternity and gynaecology Good Medical care Requires improvement Urgent and emergency care services Good Surgery Requires improvement Intensive/critical care Good Services for children and young people Requires Improvement End of life care Good Outpatients Good
Maternity outlier alert PAHT
Definition
CQC uses the term ‘outlier’ to describe a service that lies outside the expected range of performance. One example of where they use this is their mortality outlier programme. Their process involves analysing data that suggests concerning trends in the death rate for specific conditions or operations.
The trends are calculated using a statistical technique known as statistical process control (SPC). This measures where there has been an increase in death rate which is greater than could be explained confidently by random variation over time. These measures may be indicative of problems in the quality of so they are of interest to CQC as a regulator, and the reasons for the outlier need to be understood. A concerning trend is not, of itself, evidence of poor quality. Alerts can be caused by at least one of three reasons:
The trust is treating more complicated cases than the norm, which cannot be adequately reflected completely in the recording of individual diagnoses Problems with data quality and coding meaning that the patients who died were incorrectly assigned to a specific diagnosis Poor quality of care
When issued with an alert providers have a responsibility to respond. If CQC is not satisfied with the response they may take immediate action to address concerns. Historically CQC were closing alerts on receipt of a robust response from the provider, this has now changed and they are now keeping alerts open and the local CQC inspection team is reviewing the implementation of any improvements prior to closing the alert.
Issue
PAHT has received a maternity outlier alert. This is due to the fact that analysis of maternity indicators undertaken by the CQC has indicated significantly high rates of emergency caesarean sections at PAHT.
PAHT response
PAHT have responded to the alert. They have undertaken a data analysis and case note review out to understand the cause for the outlier alert for high rates of emergency caesarean sections.
The reviews demonstrated there was a coding discrepancy with some elective caesarean section cases being coded as emergency sections although this was an incidental finding and did reduce the emergency section but obviously did not reduce our overall section rate and increased our elective section rate.
However, there were other issues identified by the case note review which could reduce their emergency section rate, including increased consideration being given to foetal blood sampling during the early stages of labour.
A number of initiatives have been agreed and are being introduced to reduce the emergency caesarean section rate.
CQC have acknowledged the response and action plan and will keep this alert open until the action plan is implemented. They will visit the Trust prior to the closure of this alert to monitor this. CQC mortality outlier alert for ‘septicaemia (except in labour)’ (emergency admissions) at Salford Royal NHS Foundation Trust (SRFT)
Issue
SRFT has received a mortality outlier alert for sepsis. The alert has arisen as a result of an association between raised mortality and this group of patients and that the primary diagnosis of sepsis does not necessarily reflect the cause of death for these patients. CQC feels it is important to explore whether there are common factors among this group of patients which may explain the apparent raised mortality. Therefore, they have requested that SRFT provides information to explain their understanding of the underlying issues that relate to this alert.
The response from SRFT is due with the CQC by the 23 March 2018, a further update in relation to this will be provided in due course.
3.7 CQUIN position quarter 3
CMFT, UHSM and GMMH have met all of the CQUIN requirements for quarter 3. There are three outstanding queries with PAHT in relation to antibiotic review, offering advice and guidance and e-referrals. These should be resolved by the end of the month. In relation to small providers there are a number of outstanding queries that are still being processed. Creative Support and Survivors Manchester have met the CQUIN requirements for quarter 3.
3.8 Primary Care CQC published inspection report
The table below shows the current CQC inspection rating for all GP practices across Manchester as at 28 February 2018:
Figure 1: Summary of Manchester GP practices CQC ratings
OUTSTANDING CQC Inspection Rating Number of GP practices % Urban Village Medical Practice 4.3% 3 The Docs Outstanding Five Oaks
79 91.4% Good REQUIRES IMPROVEMENT
4 2.8% Artane Medical Requires Improvement Practice The Neville
3 Family Medical Inadequate 1.5% Centre Wilmslow Road
Medical Centre Total 89 100% Cornerstone Family Practice INADEQUATE Droylsden Road Family Practice Brookdale Surgery Merseybank Surgery
Figure 1 above equates to:
4.3% of Manchester’s registered population supported by a CQC ‘outstanding’ practice (27,288 people) 91.4% of Manchester’s registered population supported by a CQC ‘good’ practice (584,353 people) 2.8% of Manchester’s registered population supported by a practice that is CQC ‘requiring improvement’ (18,195 people) 1.5% of Manchester’s registered population supported by a practice rated as CQC ‘inadequate’ (9,333 people)
MHCC - CQC ratings by neighbourhood – updated 09 February 2018 North Central South Ancoats, Clayton and Ardwick and Longsight Didsbury Burnage and Bradford Chorlton Five Oaks Family Practice Drs Ngan & Chan Kingsway Medical Practice Urban Village MP Ailsa Craig Medical Practice Barlow Medical Centre Lime Square MC Surrey Lodge Group Practice Merseybank Surgery (Concerns) David Medical Centre Drs Hanif and Bannuru Dickenson Road Medical Didsbury Medical Centre Cornerstone Family Practice Centre Burnage Healthcare Practice Dr Cunningham & Partners Florence House Medical Drs Chiu, Koh & Gan Practice Parkside Medical Centre Eastlands Medical Practice Longsight Medical Practice New Islington Medical Centre New Bank Health Centre Mazhari & Partner Crumpsall and Cheetham Chorlton, Whalley Range Withington and Fallowfield and Fallowfield Artane Medical Centre Ashville Surgery Borchardt Medical Centre The Neville Family Practice The Range Medical Centre Ladybarn Group Practice Collegiate Medical Centre Princess Road Surgery Mauldeth Medical Centre Cheetham Hill Medical Centre Chorlton Family Practice Bodey Medical Centre The Wilbraham Surgery Fallowfield Medical Centre Wellfield Medical Centre The Alexandra Practice Al-Shifa Medical Centre Aleeshan Medical Centre Corkland Road M P Queens Medical Centre Park View Medical Centre Jolly Medical Centre Higher Blackley, Harpurhey Gorton and Levenshulme Wythenshawe and Charlestown Valentine Medical Centre Levenshulme Medical Centre R K Medical Practice Beacon Medical Centre Peel Hall Medical Practice Conran Medical Practice West Point Medical Centre Maples Medical Centre The Avenue Medical Centre Gorton Medical Centre Bowland Medical Practice Singh Practice Mount Road Surgery Benchill Medical Practice Fernclough Surgery West Gorton Medical Centre Cornishway Group Practice Willowbank Surgery Tregenna Group Practice Dam Head Medical Centre Ashcroft Surgery Charlestown Surgery Hawthorn Medical Centre Miles Platting, Newton Hulme, Moss Side and Wythenshawe and Northenden Heath, City Centre and Rusholme Moston Brookdale Surgery The Robert Darbishire Practice Northenden Group Practice Droylesden Rd Family Practice The Park Medical Centre Manchester Medical Brooklands Medical Practice St Georges Medical Centre Wilmslow Road MC Northern Moor Medical Practice Whitley Road Medical Centre The Arch Medical Practice The Whitswood Practice Woodlands Medical Practice Hazeldene Medical Centre Cornbrook Medical Practice Newton Heath Health Centre The Docs Victoria Mill Medical Practice
Simpson Medical Practice City Health Centre
Since the previous report, the following CQC ratings have changed in Manchester GP practices:
Wilmslow road medical centre’s inspection report has been published; their CQC rating has changed from inadequate to requires improvement Cornerstone family practice has been re-inspected and their CQC rating has changed from a previous rating of good in 2015 to requires improvement Sections 3.0 and 4.0 below provide a brief overview for each of the practices rated as ‘inadequate’ or ‘requires improvement’ Inadequate
Droylesden Road Family Practice (DRFP)
Neighbourhood: Miles Platting, Newton Heath, City Centre & Moston List size: 4427
Safe Effective Caring Responsive Well led
On the 1 February 2017, GTD Healthcare Ltd took over the contract for DRFP and significant progress has been made by the new providers with regards to access and quality.
MHCC is awaiting a date for DRFP to be re-inspected by the CQC.
Brookdale Surgery
Neighbourhood: Miles Platting, Newton Heath, City Centre & Moston List size: 2513
Safe Effective Caring Responsive Well led
As part of their on-going enforcement action, the CQC undertook a re-inspection of Brookdale surgery on 2 November 2017, and has given the provider a rating of inadequate across all domains again. The report is available at: http://www.cqc.org.uk/sites/default/files/new_reports/AAAG8940.pdf
MHCC will continue to work with partner organisations to determine appropriate next steps in respect to the practice. A meeting took place on 14 February 2018 between MHCC representatives and the GP contractor; members of the Manchester local medical committee (LMC) were also present. Follow up correspondence with the practice has been sent, outlining the current position, intended next steps in regarding their contractual options. The practice response is awaited and expected by Monday 5 March 2018, regarding their decision on how they wish to proceed in relation to their contract.
Merseybank Surgery
Neighbourhood: Didsbury, Burnage & Chorlton List size: 2671
Safe Effective Caring Responsive Well led
Following three consecutive unsatisfactory inspections, the CQC made the decision to cancel the registration of Merseybank Surgery. From July 2017 the contract was varied onto a neighbouring practice’s contract by mutual agreement in anticipation of a formal practice merger. Preparatory work is taking place at both practices in advance of the full merger of practice lists. The completion of all technical work is currently estimated for March 2018. In the lead up to full merger MHCC has worked closely with the practices to help facilitate the transformation and support resilience during this period.
Requires improvement
Wilmslow Road Medical Centre (WRMC)
Neighbourhood: Hulme, Moss Side and Rusholme List size: 4823
At the practice’s initial CQC inspection which took place on 25 April 2017, the practice received an overall rating of ‘Inadequate’ each domain was rated as follows:-
Report published June 2017
Safe Effective Caring Responsive Well led
MHCC commissioners and clinical leads engaged with the practice to help support improvements and a second CQC inspection took place at Wilmslow Road medical centre on 13 December 2017. The resulting report was published on 14 February 2018.
The practice is no longer in special measures, however, the domains of caring and responsive are now rated as ‘requires improvement’ and therefore the practice’s overall rating has moved from ‘inadequate’ to ‘requires improvement’.
Report published – February 2018
Safe Effective Caring Responsive Well led
MHCC will continue to work with WRMC to secure contractual compliance and quality improvements. A practice visit will take place in March 2018 to progress.
Artane Medical Centre
Neighbourhood: Crumpsall & Cheetham List size: 2616
Safe Effective Caring Responsive Well led
Group members have received previous briefing in relation to the ongoing significant quality concerns at Artane medical centre. The quality concerns were subject to CQC enforcement action and MHCC contractual action which resulted in a contract termination notice to be served to the practice on 11 December 2017. The registered patients at Artane medical centre are now receiving their care at a neighbouring practice, The Jolly medical centre.
Following the contract termination, regular coordination meetings have been established at MHCC with representation from medicines optimisation, safeguarding, information governance, IT and data quality, performance and quality, commissioning and communications and engagement to identify and mitigate risk, manage transitional issues and provide regular reporting to the MHCC executive team and board. GMHSCP also has representation at this group.
A full confidential report can be found in: Appendix 1.
The Neville Family Medical Centre
Neighbourhood: Crumpsall & Cheetham List size: 3848
Safe Effective Caring Responsive Well led
MHCC and GMHSCP continue to work together to seek assurance around contractual compliance and quality improvements are in progress at The Neville family medical centre. further update to PQI members will be submitted in due course. a practice visit will be arranged to review the issues raised in the contractual compliance plan. This is likely to take place in April 2018.
Cornerstone Family Practice
Neighbourhood: Ancoats, Clayton and Bradford List size: 6,477
Previous inspection rating at July 2015:
Report published – July 2015
Safe Effective Caring Responsive Well led
Cornerstone family practice was re-inspected on 14 November 2017 and the resulting report published on 11 January 2018 has determined the practice overall rating as ‘requires improvement’.
Report published – January 2018
Safe Effective Caring Responsive Well led
The full report is available at: http://www.cqc.org.uk/sites/default/files/new_reports/AAAG8901.pdf
The summary below outlines the legal requirements that were not being met by the practice. The provider must send CQC a report that says what action they are going to take to meet these requirements. Regulated activity Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment The registered persons had not done all that was reasonably practicable to mitigate risks to the health and safety of service users receiving care and treatment. In particular:
The practice had no safeguarding training in place for staff and we were unsure of all the clinician’s safeguarding status. There was no learning outcomes demonstrated or follow up actions recorded for significant event process. Non clinical staff had not been trained for chaperoning duties.
The branch site had no fire safety processes in place. There was no assessment of the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated. In particular:
The branch site had no infection control process and no Legionella risk assessment in place. Staff were following individual processes and no annual audit had been carried out at either sites.
This was in breach of regulation 12 of the health and social care act 2008 (regulated activities) regulations 2014.
The registered person had systems or processes in place that operating ineffectively in that they failed to enable the registered person to evaluate and improve their practice in respect of the processing of the information obtained throughout the governance process. In particular:
patients had no face to face contact with practice staff between the hours of 12noon and 4pm daily there was no process or record of DBS checks or risk assessments in staff HR folder. there was no training taking place for staff there were no staff appraisals taking place NICE alerts and MHRA alerts were not being monitored. there had been no carers identified
This was in breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
diagnostic and screening procedures maternity and midwifery services surgical procedures treatment of disease, disorder or injury
MHCC is in the process of arranging a meeting with the practice to discuss the concerns and in particular the concern around the practice’s opening hours.
Next Steps
The implementation of the primary care quality assurance and Improvement Framework has now been agreed and implementation will begin from March 2018. The framework will help to identify practices in need of quality support at an early stage and ensure MHCC move towards a more proactive approach to quality improvement. The framework describes the offer of a targeted programme of support, including a programme of practice visits, prioritised by the primary care improvement group.
Alongside this, MHCC is working with the CQC to improve communications and work towards establishing the new inspection structure.
3.9 Quality walkrounds
The purpose of the quality walk round programme is to provide assurance to the MHCC quality and performance committee and board that clinical services are delivering safe and high standards of care to the public. This is currently undertaken by a small team of professionals form MHCC and Trafford CCG, including a GP; nurse; safeguarding nurse and a patient representative (resources are pooled).
A number of sources of intelligence are utilised to determine which clinical areas are inspected, such as serious incidents; complaints, CQC findings and the provider itself. The quality walk rounds do not just focus on areas that are under performing, but those that have made demonstrable improvements and outstanding clinical areas.
The walk rounds provide a ‘snapshot’ of the service on that day. The team ask some specific questions which relate to the general safety and quality culture, such as medical and nursing staffing; harm free care data; process for disseminating learning and escalating safeguarding concerns.
Historically, MHCC and Trafford CCG aim to undertake walk rounds in the following clinical areas per quarter:
Acute Community Mental Health Small providers, where there are significant concerns Proposal
The PQI team have reflected on the walk round process and ways this could add more value to commissioners and providers as a whole. We are proposing a shift from looking at clinical areas/services in isolation to a patient journey/clinical pathway approach. This would mean that a clinical pathway would be reviewed from point of entry (primary care) right through to exit (community and adult social care). We would also look to visit all services that we have commissioned around that pathway including adult social care, primary care, voluntary sectors and our NHS providers. This would provide the committee and board assurances of care provision through the full continuum of services that we commission from a health and social care perspective.
To aid these walkrounds we would source the relevant NICE guidance/ quality standard and use this as almost an audit template against which to review the clinical pathway. We would also link in with commissioning colleagues in relation to service specifications that were relevant, this could also assist with service reviews.
Operationally, this would work by creating a ‘walk round week’ whereby the walk round team would prioritise some time, during one week only, to undertake a visit to services. For example the primary care lead would schedule in their own diary visits to four GP surgeries across Trafford; North; Central and South Manchester. This would create the least disruption to their work schedule over the course of a quarter. Similarly the team suggests that acute
clinical areas, such as a surgical ward and theatre or independent provider (dependent on the clinical pathway being reviewed) are visited on the same day (for the duration of the day) with all the personnel required as stated above. Depending on the clinical pathways being reviewed visits to the care home sector would also be undertaken.
Working to this model we would undertake one physical health clinical pathway and one mental health clinical pathway each quarter.
We would determine the clinical pathway walkrounds with the commissioning leads and in line with the priorities of this organisation. We hope this would add more value into the walk round process for us as a commissioning organisation and for the wider system.
We would continue to undertake ad-hoc visits to providers and clinical areas on the back of serious incidents, never events or adverse CQC or media reports.
3.10 Never Events
There has been a new never event reported at MFT, on the 12 of March 2018. This brings the total for MFT up to 5 for the year now.
This occurred at St Marys and was a retained foreign object.
A neonate had urinary catheter inserted ( for neonates a guide wire is used to site these) at 19:20 at 21:00 on checking baby it was found that the guide wire had not been removed. Baby had catheter replaced - no evidence of harm from retained guide wire.
This was a Salford CCG patient, they have been informed. We are awaiting the 72 hour report from the provider
4.0 Recommendations
MHCC is asked to support the actions being undertaken to improve the quality and performance for the population of Manchester.
Appendix 1 -Manchester Health and Care Commissioning Performance Scorecard 2017/18
Urgent Care
2016/17 2017/18 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Indicator Target Value Value 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 90.8% 91.6% 90.5% 91.6% 90.6% 89.7% 89.5% 87.7% 82.6% 84.4% 85.0% Percentage of patients who spent 4 hours or less in A&E 88.6% 88.5% 95.0% 21,293 22,826 21,250 22,809 20,690 21,406 24,112 22,802 21,404 21,634 19,557 23,444 24,919 23,489 24,889 22,841 23,853 26,955 25,995 25,925 25,632 23,011 Elective
2016/17 2017/18 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Indicator Target Value Value 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 1.7% 2.4% 2.7% 2.0% 4.1% 2.5% 1.6% 1.7% 1.7% 2.0% Diagnostic Waiting Times % waiting > 6 weeks 2.8% 2.2% 1.0% 146 234 276 195 409 260 178 187 202 237 8,786 9,794 10,121 9,900 9,891 10,310 11,202 10,897 11,707 12,133 72.3% 72.0% 69.7% 72.5% 72.9% 79.0% 75.5% 79.7% 83.3% Utilisation of the NHS e-Referral Service to enable choice at first 6,530 7,439 7,579 7,562 7,794 7,718 8,139 9,124 7,303 81.7% 75.1% 88.6% routine elective referral 8,770.7 9,033 10,332 10,874 10,435 10,697 9,774 10,773 11,454 2 91.3% 91.4% 91.5% 91.1% 90.4% 90.9% 91.1% 91.3% 90.3% 90.0% RTT: Incomplete pathways % within 18 weeks 91.8% 90.0% 92.0% 32,272 32,906 33,701 34,240 34,264 33,965 33,594 34,143 33,416 32,563 35,341 36,006 36,847 37,579 37,909 37,347 36,861 37,398 37,004 36,178
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016/17 2017/18 Indicator Target 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Number of patients waiting >52 weeks on incomplete pathways 85 22 0 5 4 2 0 0 2 2 1 2 4
2016/17 2017/18 Indicator Q1 2017/18 Q2 2017/18 Q3 2017/18 Q4 2017/18 Value Value 83.8% 87.9% Percentage of children waiting less than 18 weeks for a wheelchair 90.5% 86.1% 62 80 74 91
2016/17 2017/18 Freque Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Indicator Target Value Value ncy 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 85.9% 74.1% 76.1% 76.0% 83.6% 81.9% 78.0% 78.3% 89.2% 75.6% M 55 63 51 57 56 77 71 47 58 59 64 85 67 75 67 94 91 60 65 78 Cancer 62 day waits following urgent GP referral 83.9% 80.0% 85.0% 78.7% 81.3% 81.5% Q 174 191 176 221 235 216 92.2% 94.0% 93.1% 92.7% 90.8% 91.9% 94.5% 95.8% 93.8% 93.3% M 1,127 1,372 1,439 1,319 1,384 1,302 1,482 1,508 1,297 1,458 1,223 1,460 1,546 1,423 1,525 1,417 1,569 1,574 1,383 1,563 Cancer two week waits (urgent referrals) 94.5% 92.8% 93.0% 93.8% 91.8% 94.7% Q 3,980 4,001 4,288 4,241 4,360 4,528 90.7% 92.4% 94.5% 94.8% 94.7% 97.5% 96.4% 94.0% 98.4% 92.7% M 196 194 208 200 216 199 187 202 181 179 216 210 220 211 228 204 194 215 184 193 Cancer two week waits for breast symptoms 90.7% 94.9% 93.0% 94.2% 95.6% 96.1% Q 604 615 571 641 643 594 100.0% 100.0% 97.2% 99.3% 98.6% 98.4% 100.0% 97.3% 100.0% 97.6% M 131 165 140 134 142 186 157 145 124 165 131 165 144 135 144 189 157 149 124 169 Cancer 31 day waits for first definitive treatment (All cancers) 98.5% 98.9% 96.0% 99.1% 98.7% 99.1% Q 444 467 426 448 473 430 Cancer 31 day waits for subsequent treatment (Surgery) 97.8% 98.8% 94.0% M 92.6% 100.0% 100.0% 100.0% 100.0% 96.6% 100.0% 100.0% 100.0% 100.0% 2016/17 2017/18 Freque Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Indicator Target Value Value ncy 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 25 31 24 26 27 28 28 36 32 27 27 31 24 26 27 29 28 36 32 27 98.8% 98.8% 100.0% Q 82 84 100 83 85 100 100.0% 100.0% 97.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% M 24 36 37 32 42 32 35 40 23 36 24 36 38 32 42 32 35 40 23 36 Cancer 31 day waits for subsequent treatment (Drugs) 99.5% 99.5% 98.0% 99.0% 100.0% 100.0% Q 98 108 98 99 108 98 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% M 31 47 43 54 57 40 50 52 43 52 31 47 43 54 57 40 50 52 43 52 Cancer 31 day waits for subsequent treatment (Radiotherapy) 100.0% 100.0% 94.0% 100.0% 100.0% 100.0% Q 121 152 145 121 152 145 100.0% 81.8% 88.9% 100.0% 100.0% 83.3% 100.0% 92.3% 83.3% 100.0% M 11 9 8 5 8 5 6 12 5 7 11 11 9 5 8 6 6 13 6 7 Cancer 62 day waits following referral from NHS screening service 92.9% 93.9% 90.0% 93.3% 94.7% 92.0% Q 28 18 23 30 19 25 83.3% 95.5% 83.3% 93.8% 96.2% 91.3% 91.7% 90.6% 87.0% 84.2% M 15 21 20 15 25 21 22 29 20 32 18 22 24 16 26 23 24 32 23 38 Cancer 62 day waits following consultant decision to upgrade 87.1% 90.8% 85.0% 87.5% 93.9% 89.7% Q 56 62 70 64 66 78
Safety
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016/17 2017/18 Annual Indicator Target 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Value Value Clostridium Difficile Infections (CDiff) - All Cases 146 120 127 11 13 8 9 15 16 11 15 9 13 Incidence of MRSA - Total Attributed 13 9 0 1 2 3 0 0 1 1 0 0 1 Incidence of MRSA - CCG Assigned 9 2 0 0 0 0 0 0 0 1 0 0 1
Mental Health & Learning Disabilities
2016/17 2017/18 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Indicator Target Value Value 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 75.4% 75.9% 76.3% 75.9% 76.5% 76.4% 75.7% 76.5% 76.6% 76.1% Dementia diagnosis rate (aged 65+) 83.2% 76.1% 67% 2,765 2,790 2,806 2,795 2,815 2,815 2,788 2,807 2,812 2,784 3,667.4 3,675.8 3,675.9 3,684.9 3,681 3,682.3 3,682.3 3,670.8 3,672.7 3,659.8 88% 64% 76% 53% 57% 55% 73% 56% 56% 64% First episode of psychosis or ARMS (at risk mental state) treated 83% 64% 50% 14 14 16 10 12 16 19 9 9 7 with a NICE approved care package within two weeks of referral 16 22 21 19 21 29 26 16 16 11
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016/17 2017/18 Indicator Target 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Value Value Value Value Value Value Value Value Value Value Value Value Value Value IAPT Achieving better access 13.89% 10.08% 11.20% 1.10% 1.33% 0.89% 1.52% 1.26% 1.24% 1.30% 1.44% IAPT Roll-out - number receiving therapy 12280 8910 975 1175 785 1345 1110 1100 1145 1275 IAPT Roll-out - Prevalence 88398 88398 88398 88398 88398 88398 88398 88398 88398 88398 88398 88398 88398 88398
2016/17 2017/18 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Indicator Value Value 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 29.8% 42.5% 32.4% 42.6% 38.5% 33.7% 36.3% 39.8% IAPT Recovery rate 36.6% 37.1% 125 240 165 200 200 165 165 195 420 565 510 470 520 490 455 490 59.1% 59.3% 56.6% 69.7% 62.4% 58.8% 62.1% 61.2% IAPT Waiting times (6 weeks) 56.0% 61.1% 260 350 300 345 340 300 295 315 440 590 530 495 545 510 475 515 90.9% 90.7% 89.6% 94.9% 93.6% 92.2% 93.7% 91.3% IAPT Waiting times (18 weeks) 85.0% 92.1% 400 535 475 470 510 470 445 470 440 590 530 495 545 510 475 515
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016/17 2017/18 Indicator Target 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Number of patients with a learning disability and/or autism in inpatient care in the Transforming Care Partnership per million GP 54.85 51.86 47.11 54.02 51.86 51.86 51.86 54.02 54.02 51.86 51.86 51.86 51.86 registered adult population Number of people from the TCP with a learning disability and/or autism in inpatient care for mental and/or behavioural needs - 55 45 50 50 50 50 50 50 45 45 45 45 Commissioned by CCG Number of people from the TCP with a learning disability and/or autism in inpatient care for mental and/or behavioural needs - 70 75 75 70 70 70 75 75 75 75 75 75 Commissioned by NHS England
2016/17 2017/18 Q1 2017/18 Q2 2017/18 Q3 2017/18 Q4 2017/18 Indicator Target Value Value Value Value Value Value Improve access rate to CYPMH 24.22% 29.84% 12.58% 10.72% 6.55% Number of individual children and young people aged 0-18 receiving 2995 3690 948 1555 1325 810 treatment Number of children and young people with a new referral receiving at least two contacts (including indirect contacts) within a six week 1390 395 420 395 period
2017/18 Indicator Q1 2017/18 Q2 2017/18 Q3 2017/18 Q4 2017/18 Value
Percentage of children & young people with eating disorders (routine 86.7% 90.2% 97.4% 91.7% cases) that wait 4 weeks or less (rolling 6 mths) 26 37 37 30 41 38 100.0% 75.0% 66.7% Percentage of children & young people with eating disorders (urgent 75.0% 2 6 4 cases) that wait 1 week or less (rolling 6 mths) 2 8 6
Primary Care
2016/17 2017/18 Q1 2017/18 Q2 2017/18 Q3 2017/18 Q4 2017/18 Indicator Target Value Value Value Value Value Value Personal health budgets per 100,000 population 24.6 13.1 49.8 11.8 12.8 13.1
2016/17 2017/18 Indicator H1 2017/18 H2 2017/18 Value Value 82.0% Extended access (evening and weekends) at GP services 80.0% 82.0% 73 89
Appendix 2 - Manchester University NHS Foundation Trust Scorecard 2017-18
The second line of STF indicators shows the target trajectory.
Urgent Care
2016/17 2017/18 Q1 Q2 Q3 Q4 Indicator Current Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Value Value 2017/18 2017/18 2017/18 2017/18 93.3% 92.2% 87.4% 86.0% 90.9% 89.8% 88.4% 84.1% 85.5% 86.5%
Percentage of patients who spent 4 hours or less in A&E 90.2% 92.5% 90.8% 90.0% 92.5% 90.8% 90.8% 90.8% 90.0% 90.0% 90.4% 90.1% 90.0% (STF) 95,105 92,463 91,065 55,261 30,508 32,081 30,332 28,652 28,852 26,409 101,942 100,234 104,140 64,278 33,563 35,744 34,314 34,082 33,758 30,520
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 94.2% 94.3% 94.7% 93.9% 95.0% 94.6% 94.7% 94.8% 93.7% 94.2% Ambulance: Compliance with recording patient handover 92.2% 94.3% 90.0% 90.0% 13,252 13,832 14,293 8,498 4,588 4,823 4,689 4,781 4,546 3,952 14,066 14,672 15,098 9,047 4,828 5,101 4,953 5,044 4,851 4,196
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Trolley Waits in A&E 17 0 0 0 0 0 0 0 0 0 0 0 0 0 Ambulance Handover Delays over 30 Minutes 4506 3866 0 0 507 689 1563 1107 273 347 407 809 618 489 Ambulance Handover Delays over 1 Hour 1363 845 0 0 71 88 410 276 37 59 89 262 178 98 Ambulance Handover Delays over 2 Hours 232 126 0 0 7 1 69 49 0 10 12 47 37 12 Urgent operations cancelled for a second time 0 0 0 0 0 0 0 0 0 0 0 0 0
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 Delayed transfers of care - DTOCs as a % of total beds 3.3% 3.3% 4.9% 5.7% 5.4% 4.3% 4.9% 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 88.1 101.9 95.6 76.5 87.8 1,780 1,780 1,780 1,780 1,779 72.6% 68.9% 85.1% 81.6% 65.2% 84.6% 77.3% 94.7% 81.6% % of high risk TIA cases investigated and treated within 56.4% 76.3% 60.0% 60.0% 45 51 57 31 15 22 17 18 31 24 hours 62 74 67 38 23 26 22 19 38 58.5% 59.6% 63.6% 53.6% 59.5% 66.7% 62.1% 61.3% 53.6% % of patients who spend at least 90% of inpatient stay on 59.9% 80.0% 80.0% 72 68 63 15 25 26 18 19 15 a stroke unit 123 114 99 28 42 39 29 31 28
Elective
2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 94.2% 93.6% 95.1% 94.0% 96.2% 94.9% 94.2% 94.7% Cancer two week waits (urgent referrals) 95.0% 93.9% 93.0% 93.0% 5,530 5,693 5,842 1,820 2,024 2,089 1,726 1,848 5,873 6,085 6,142 1,936 2,103 2,202 1,833 1,952 92.8% 95.5% 95.5% 96.2% 95.1% 94.0% 97.7% 95.7% Cancer two week waits for breast symptoms 93.8% 94.1% 93.0% 93.0% 953 972 941 304 294 342 304 313 1,027 1,018 985 316 309 364 311 327 98.7% 97.9% 97.8% 98.2% 97.9% 98.8% 98.1% Cancer 31 day waits for first definitive treatment (All 98.2% 98.3% 96.0% 96.0% 943 957 967 317 319 328 317 316 cancers) 955 978 985 324 325 335 321 322 97.4% 98.6% 99.2% 99.0% 97.3% 98.7% 100.0% 95.9% Cancer 31 day waits for subsequent treatment (Surgery) 97.8% 98.0% 94.0% 94.0% 223 276 237 97 73 76 66 70 229 280 239 98 75 77 66 73 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Cancer 31 day waits for subsequent treatment (Drugs) 100.0% 100.0% 98.0% 98.0% 63 71 94 31 37 29 28 28 63 71 94 31 37 29 28 28 2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 N/A N/A N/A N/A N/A N/A N/A N/A Cancer 31 day waits for subsequent treatment N/A N/A 94.0% 94.0% 0 0 0 0 0 0 0 0 (Radiotherapy) 0 0 0 0 0 0 0 0 84.0% 84.9% 83.3% 91.5% 77.4% Cancer 62 day waits following urgent GP referral 86.5% 84.5% 85.0% 85.0% 310 313 104.5 113 91 369 368.5 125.5 123.5 117.5 94.6% 98.8% 93.9% 97.4% 89.7% 91.2% 100.0% 98.5% Cancer 62 day waits following referral from NHS 95.0% 96.5% 90.0% 90.0% 105 85.5 92.5 19 26 31 33 33 screening service 111 86.5 98.5 19.5 29 34 33 33.5 89.0% 89.3% 90.6% 88.0% 95.2% 87.7% 92.1% 86.3% Cancer 62 day waits following consultant decision to 90.4% 89.2% 85.0% 85.0% 154.5 163 174 58.5 60 50 58 69.5 upgrade 173.5 182.5 192 66.5 63 57 63 80.5 2.8% 3.4% 2.3% 3.3% 3.5% 2.2% 2.2% 2.5% 3.3% Diagnostic Waiting Times % waiting > 6 weeks 3.1% 2.9% 1.0% 1.0% 1,371 1,666 1,134 517 545 367 374 393 517 49,754 48,620 49,471 15,856 15,685 16,770 16,780 15,921 15,856 75.7% 75.8% 76.6% 75.7% 76.6% 77.2% 76.2% 76.3% 75.7% RTT: Admitted pathways % within 18 weeks 74.3% 76.0% 8,628 9,603 9,879 3,325 3,175 3,495 3,564 2,820 3,325 11,394 12,663 12,900 4,390 4,144 4,525 4,677 3,698 4,390 90.2% 89.5% 89.9% 90.3% 88.7% 89.7% 89.0% 91.2% 90.3% RTT: Non-Admitted pathways % within 18 weeks 89.0% 89.9% 52,873 53,869 54,447 19,038 17,972 19,280 19,541 15,626 19,038 58,600 60,161 60,591 21,083 20,260 21,492 21,958 17,141 21,083 90.5% 90.5% 90.0% 90.0% 90.5% 90.6% 90.7% 90.0% 90.0% RTT: Incomplete pathways % within 18 weeks (NHS 90.9% 90.0% 92.0% 92.0% 66,051 65,706 63,808 62,593 65,706 65,330 64,924 63,808 62,593 Constitution) 73,017 72,627 70,912 69,583 72,627 72,143 71,546 70,912 69,583 0.7% 0.7% 0.8% 0.9% 0.7% 0.8% 0.7% 0.8% 0.9% Percentage of patients waiting more than 36 weeks on 1.0% 0.8% 1.0% 1.0% 1,529 1,639 1,670 601 516 555 522 593 601 incomplete pathways 213,897 219,698 214,601 69,583 72,627 72,143 71,546 70,912 69,583
Percentage of cancelled elective operations that are 1.2% 0.9% 1.7% 1.0% 0.8% 1.5% 1.6% 1.9% 1.0% 1.3% 1.2% 0.8% 0.8% cancelled at the last minute for non-clinical reasons 467 371 685 147 109 221 238 226 147 2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 38,502 40,747 41,231 14,028 13,393 14,399 14,899 11,933 14,028
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Number of patients waiting >52 weeks on incomplete 257 167 0 0 45 34 64 24 13 16 23 25 24 pathways Cancelled elective operations - breaches of 28 day 72 123 0 0 47 25 39 12 7 11 10 18 12 standard
Quality - Safety
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Overall number of MRSA bacteraemia - Trust Attributable 9 5 0 0 4 0 0 1 0 0 0 0 1 Overall number of MRSA bacteraemia - Non-attributable 10 4 0 0 2 1 0 1 0 0 0 0 1 CDiff infections caused by lapse in care (NHS Patients) 27 26 105 87 12 6 6 2 2 3 2 1 2 CDiff infections - Overall number of cases (NHS Patients) 118 110 31 37 26 16 12 7 12 7 16
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 95.9% 97.7% 97.4% 98.1% 97.2% 97.2% 97.0% 97.9% 98.1% Percentage of patients receiving harm free care 96.2% 97.1% 95.0% 95.0% 6,492 6,537 6,654 2,295 2,148 2,170 2,216 2,268 2,295 6,770 6,694 6,833 2,339 2,211 2,233 2,284 2,316 2,339 0.37% 0.64% 0.34% 0.17% 0.86% 0.31% 0.39% 0.30% 0.17% Percentage of adult VTE Incidences that occurred whilst 0.47% 0.42% 0.25% 0.25% 25 43 23 4 19 7 9 7 4 receiving care from the provider 6,770 6,694 6,833 2,344 2,211 2,233 2,284 2,316 2,344 Percentage of pressure ulcer incidences that occurred 0.55% 0.34% 1.00% 1.00% 0.53% 0.21% 0.26% 0.34% 0.14% 0.31% 0.26% 0.22% 0.34% 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 whilst receiving care from the provider 36 14 18 8 3 7 6 5 8 6,770 6,694 6,833 2,344 2,211 2,233 2,284 2,316 2,344 0.31% 0.49% 0.70% 0.21% 0.59% 0.76% 1.05% 0.30% 0.21% Percentage of falls incidences that occurred whilst 0.18% 0.47% 1.00% 1.00% 21 33 48 5 13 17 24 7 5 receiving care from the provider 6,770 6,694 6,833 2,344 2,211 2,233 2,284 2,316 2,344 0.22% 0.15% 0.28% 0.13% 0.27% 0.27% 0.44% 0.13% 0.13% Percentage of catheter acquired UTIs incidences that 0.19% 0.21% 0.25% 0.25% 15 10 19 3 6 6 10 3 3 occurred whilst receiving care from the provider 6,770 6,694 6,833 2,344 2,211 2,233 2,284 2,316 2,344 4.2% 4.5% 4.9% 4.9% NHS staff sickness absence rate 4.7% 4.4% 65,540 48,797 27,066 27,066 1,573,086 1,077,687 548,537 548,537 88.8% 85.9% 83.2% 85.2% 83.3% 83.7% 82.6% Safe Staffing - Day Nurse Staff Fill Rate % 88.8% 85.8% 479,910 476,454 564,719 162,263 185,984 189,884 188,851 540,414 554,570 678,614 190,458 223,161 226,810 228,643 97.1% 95.3% 100.3% 94.4% 103.2% 99.6% 98.3% Safe Staffing - Day Care Staff Fill Rate % 97.7% 97.8% 237,338 240,762 317,594 82,599 103,819 106,517 107,258 244,369 252,578 316,639 87,491 100,602 106,919 109,118 91.4% 88.9% 88.7% 88.1% 89.5% 88.8% 87.7% Safe Staffing - Day Staff (Overall) Fill Rate % 91.6% 89.5% 717,248 717,215 882,312 244,862 289,803 296,400 296,109 784,783 807,147 995,252 277,949 323,762 333,729 337,761 89.9% 88.1% 91.1% 89.7% 91.1% 90.6% 91.5% Safe Staffing - Night Nurse Staff Fill Rate % 92.9% 89.7% 392,966 396,335 425,279 118,417 141,005 140,827 143,447 436,925 450,057 466,969 132,085 154,860 155,401 156,708 101.0% 100.9% 122.3% 104.3% 121.5% 122.9% 122.4% Safe Staffing - Night Care Staff Fill Rate % 109.6% 107.9% 179,824 188,037 215,092 55,498 70,075 71,790 73,227 178,038 186,305 175,889 53,221 57,671 58,401 59,817 93.1% 91.8% 99.6% 93.9% 99.3% 99.4% 100.1% Safe Staffing - Night Staff (Overall) Fill Rate % 97.6% 94.9% 572,790 584,370 640,370 173,914 211,080 212,617 216,673 614,963 636,361 642,857 185,306 212,531 213,802 216,524 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 54.5% 61.9% 29.1% 50.7% 54.5% 61.9% Healthcare Worker Flu vaccination uptake (October to 46.1% 61.9% 75.0% 75.0% 8,526 9,676 4,548 7,921 8,526 9,676 February surveys) 15,632 15,632 15,632 15,632 15,632 15,632
Quality - Experience
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Mixed Sex Accommodation (MSA) Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 45.6% 53.6% 51.1% 22.6% 51.4% 53.7% 60.0% 40.0% 22.6% Percentage of complaints responded to within timescale 47.8% 47.1% 90.0% 90.0% 178 209 232 35 72 88 84 60 35 390 390 454 155 140 164 140 150 155 97.1% 99.5% 90.6% 98.7% 100.0% 93.3% 90.9% 86.4% 98.7% Percentage of complaints acknowledged in 3 working 96.5% 95.9% 90.0% 90.0% 339 425 405 148 127 154 149 102 148 days of day following receipt of complaint 349 427 447 150 127 165 164 118 150 5.7% 5.6% 5.9% 6.8% 5.3% 6.3% 5.4% 6.1% 6.8% FFT - A&E % not recommend 7.1% 5.8% 601 615 733 237 216 281 243 209 237 10,607 11,048 12,417 3,496 4,053 4,474 4,529 3,414 3,496 89.3% 90.0% 88.4% 89.7% 90.7% 85.0% 91.1% 89.3% 89.7% FFT - A&E % recommend 87.3% 89.3% 9,474 9,946 10,978 3,136 3,677 3,805 4,126 3,047 3,136 10,607 11,048 12,417 3,496 4,053 4,474 4,529 3,414 3,496 14.1% 15.2% 18.0% 16.2% 17.1% 18.0% 19.0% 16.7% 16.2% FFT - A&E response rate 9.4% 15.7% 10,607 11,048 12,417 3,496 4,053 4,474 4,529 3,414 3,496 75,406 72,803 69,130 21,515 23,704 24,817 23,822 20,491 21,515 FFT - Inpatient % not recommend 1.1% 1.2% 1.0% 1.3% 1.4% 1.1% 1.3% 1.3% 1.5% 1.6% 1.1% 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 167 228 227 54 74 71 83 73 54 17,009 17,164 15,828 5,057 5,492 5,615 5,598 4,615 5,057 96.7% 96.5% 96.6% 96.8% 96.4% 96.5% 97.0% 96.1% 96.8% FFT - Inpatient % recommend 95.8% 96.6% 16,447 16,565 15,282 4,897 5,295 5,420 5,428 4,434 4,897 17,009 17,164 15,828 5,057 5,492 5,615 5,598 4,615 5,057 0.0% 2.2% 0.9% 0.5% 1.7% 1.5% 0.0% 0.5% FFT - Maternity % not recommend 0.4% 1.0% 0 5 3 1 2 3 0 1 120 231 320 191 116 199 121 191 100.0% 97.4% 97.2% 98.4% 97.4% 97.5% 96.7% 98.4% FFT - Maternity % recommend 97.6% 97.9% 120 225 311 188 113 194 117 188 120 231 320 191 116 199 121 191 4.8% 6.8% 14.2% 16.9% 10.2% 17.3% 11.0% 16.9% FFT - Maternity response rate 7.3% 8.9% 158 231 320 191 116 199 121 191 3,315 3,406 2,247 1,133 1,136 1,150 1,097 1,133
Appendix 3 - Manchester University NHS Foundation Trust (formerly CMFT) - Performance & Quality Scorecard 2017-18
The second line of STF indicators shows the target trajectory.
Urgent Care
2016/17 2017/18 Q1 Q2 Q3 Q4 Indicator Current Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Value Value 2017/18 2017/18 2017/18 2017/18 93.57% 93.30% 89.13% 87.96% 92.26% 90.30% 89.33% 87.71% 87.72% 88.23%
Percentage of patients who spent 4 hours or less in A&E 90.25% 92.98% 91.07% 90.00% 92.98% 91.07% 91.07% 91.07% 90.00% 90.00% 91.99% 91.27% 90.00% (STF) 71,969 70,043 69,893 42,891 23,374 24,331 23,105 22,457 22,306 20,585 76,915 75,071 78,413 48,762 25,336 26,945 25,865 25,603 25,430 23,332
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 95.7% 95.9% 96.2% 96.1% 96.3% 95.5% 97.0% 96.1% 95.9% 96.3% Ambulance: Compliance with recording patient handover 93.2% 96.0% 90.0% 90.0% 7,093 7,364 7,507 4,437 2,432 2,562 2,453 2,492 2,344 2,093 7,415 7,675 7,806 4,616 2,526 2,682 2,530 2,594 2,443 2,173
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Trolley Waits in A&E 0 0 0 0 0 0 0 0 0 0 0 0 0 Ambulance Handover Delays over 30 Minutes 3392 1657 0 0 308 270 641 438 66 176 173 292 259 179 Ambulance Handover Delays over 1 Hour 1169 469 0 0 55 40 208 166 6 37 59 112 102 64 Ambulance Handover Delays over 2 Hours 212 95 0 0 6 1 53 35 0 8 11 34 25 10 Urgent operations cancelled for a second time 0 0 0 0 0 0 0 0 0 0 0 0 0
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 2.8% 3.2% 3.9% 2.7% 2.6% Delayed transfers of care - DTOCs as a % of total beds 3.3% 3.3% 29.7 34.2 41.4 28.6 28.3 1,062 1,062 1,062 1,062 1,075 57.1% 63.6% 80.0% 75.0% 33.3% 100.0% 66.7% N/A 75.0% Percentage of high risk TIA cases investigated and 47.9% 66.7% 60.0% 60.0% 4 7 4 3 2 2 2 0 3 treated within 24 hours 7 11 5 4 6 2 3 0 4 55.4% 63.8% 69.0% 54.5% 52.9% 76.9% 75.0% 50.0% 54.5% Percentage of patients who spend at least 90% of their 60.8% 80.0% 80.0% 31 30 20 6 9 10 6 4 6 inpatient stay on a stroke unit 56 47 29 11 17 13 8 8 11
April - July August - November December - March
2016/17 2017/18 Current Jul 2017 November 2017 March 2018 Indicator Value Value target Value Value Value Compliance with overall SSNAP score - Level B (Levels A to E represented by a score of 5 to 1 respectively) - 4 4 4 4 4 CMFT MRI Compliance with overall SSNAP score - Level B (Levels A to E represented by a score of 5 to 1 respectively) - 4 5 4 5 5 CMFT TGH
Elective
2016/17 2017/18 Q1 Q2 Q3 Q4 Indicator Current Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Value Value 2017/18 2017/18 2017/18 2017/18 79.56% 79.51% 77.60% 76.70% 82.03% 64.86% 79.00% 82.17% 85.00% 85.27% 83.72% 85.00% 85.00% 85.00% 84.88% 84.88% Cancer 62 day waits following urgent GP referral (STF) 82.72% 77.41% 85.00% 109 114.5 123 39.5 52.5 36 34 137 144 158.5 51.5 64 55.5 40
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 93.2% 91.5% 93.9% 92.3% 96.6% 93.0% 91.9% Cancer two week waits (urgent referrals) 94.1% 92.3% 93.0% 93.0% 2,483 2,580 2,658 853 924 955 776 2,664 2,820 2,830 924 957 1,027 844 N/A N/A N/A N/A N/A N/A N/A Cancer two week waits for breast symptoms N/A N/A 93.0% 93.0% 0 0 0 0 0 0 0 0 0 0 0 0 0 0 97.2% 93.9% 97.1% 93.4% 95.9% 96.0% 95.6% Cancer 31 day waits for first definitive treatment (All 96.5% 95.6% 96.0% 96.0% 277 262 236 85 117 96 87 cancers) 285 279 243 91 122 100 91 94.1% 97.1% 98.6% 97.1% 97.1% 95.5% 100.0% Cancer 31 day waits for subsequent treatment (Surgery) 95.2% 95.8% 94.0% 94.0% 80 102 72 34 33 21 16 85 105 73 35 34 22 16 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Cancer 31 day waits for subsequent treatment (Drugs) 100.0% 100.0% 98.0% 98.0% 11 20 14 7 8 4 5 11 20 14 7 8 4 5 N/A N/A N/A N/A N/A N/A N/A Cancer 31 day waits for subsequent treatment N/A N/A 94.0% 94.0% 0 0 0 0 0 0 0 (Radiotherapy) 0 0 0 0 0 0 0
Cancer 62 day waits following referral from NHS 47.1% 66.7% 33.3% 75.0% 0.0% 100.0% 62.0% 52.2% 90.0% 90.0% screening service 4 2 0.5 1.5 0 1 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 8.5 3 1.5 2 2 1 88.1% 88.6% 82.5% Cancer 62 day waits following consultant decision to 90.7% 88.3% 85.0% 85.0% 44.5 46.5 16.5 upgrade 50.5 52.5 20 3.6% 3.1% 3.4% 5.0% 3.3% 3.2% 3.3% 3.6% 5.0% Diagnostic Waiting Times % waiting > 6 weeks (NHS 4.3% 3.5% 1.0% 1.0% 1,158 983 1,078 497 326 344 363 371 497 Constitution) 32,414 31,398 31,885 10,029 9,964 10,761 10,902 10,222 10,029 84.0% 85.6% 86.9% 87.4% 87.4% 87.3% 86.9% 86.3% 87.4% RTT: Admitted pathways % within 18 weeks 81.9% 85.7% 90.0% 6,185 7,411 7,210 2,411 2,430 2,572 2,613 2,025 2,411 7,363 8,662 8,300 2,758 2,780 2,946 3,008 2,346 2,758 91.6% 90.9% 90.3% 90.8% 90.5% 90.3% 89.5% 91.4% 90.8% RTT: Non-Admitted pathways % within 18 weeks 91.9% 90.9% 95.0% 34,671 35,225 35,571 12,264 11,724 12,577 12,869 10,125 12,264 37,831 38,755 39,385 13,504 12,955 13,923 14,385 11,077 13,504 92.2% 92.0% 90.6% 90.5% 92.0% 91.7% 91.6% 90.6% 90.5% RTT: Incomplete pathways % within 18 weeks 92.7% 90.5% 92.0% 92.0% 43,574 43,220 42,308 41,232 43,220 43,236 43,018 42,308 41,232 47,278 46,964 46,677 45,570 46,964 47,170 46,982 46,677 45,570 0.5% 0.5% 0.6% 0.7% 0.5% 0.6% 0.6% 0.6% 0.7% Percentage of patients waiting more than 36 weeks on 0.4% 0.7% 1.0% 1.0% 245 251 301 336 251 297 261 301 336 incomplete pathways 47,278 46,964 46,677 45,570 46,964 47,170 46,982 46,677 45,570 1.1% 0.9% 1.6% 0.9% 0.9% 1.4% 1.7% 1.7% 0.9% Percentage of cancelled elective operations that are 1.2% 1.2% 0.8% 0.8% 281 246 427 78 78 130 166 131 78 cancelled at the last minute for non-clinical reasons 25,431 26,709 26,434 8,989 8,755 9,301 9,562 7,571 8,989
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Number of patients waiting >52 weeks on incomplete 1 21 0 0 17 4 0 0 0 0 0 0 0 pathways Cancelled elective operations - breaches of 28 day 54 99 0 0 30 24 34 11 7 11 6 17 11 Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value standard
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 75.1% 77.7% 77.0% 73.2% 77.8% 77.3% 74.6% 79.4% 73.2% Percentage of women who have seen a midwife or a maternity healthcare professional by 12 weeks and 6 73.4% 76.2% 90.0% 90.0% 1,972 1,952 2,000 680 634 723 668 609 680 days of pregnancy 2,627 2,512 2,597 929 815 935 895 767 929 95.6% 96.7% 96.9% 96.5% 96.7% 97.5% 97.0% 96.9% 96.5% Percentage of women (who present) who have seen a midwife or a maternity healthcare professional by 12 93.9% 96.3% 90.0% 90.0% 689 606 587 634 606 699 644 587 634 weeks and 6 days of pregnancy 721 627 606 657 627 717 664 606 657 68.2% 81.3% 78.8% Percentage of patients achieving recommended length of 78.6% 77.0% 80.0% 15 26 26 stay (LOS) for gynaecological procedures (≤5 days)* 22 32 33 50.0% 55.6% 100.0% Percentage of patients achieving recommended length of 41.4% 62.6% 60.0% 19 15 18 stay (LOS) for colorectal procedures (≤7 days)* 38 27 18 83.3% 100.0% 50.0% Percentage of patients achieving recommended length of 89.7% 86.7% 80.0% 80.0% 5 7 1 stay (LOS) for urological procedures (≤5 days) 6 7 2 92.3% 83.3% 84.6% Percentage of applicable MDT meetings that are quorate 66.0% 86.8% 95.0% 95.0% 12 10 11 13 12 13 100.0% 100.0% 100.0% Colorectal surgeon (1) - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 13 12 13 13 12 13 100.0% 91.7% 92.3% Colorectal surgeon (2) - % of MDT meetings attended 92.5% 94.7% 66.6% 66.6% 13 11 12 13 12 13 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 92.3% 83.3% 69.2% Clinical oncologist - % of MDT meetings attended 77.4% 81.6% 66.6% 66.6% 12 10 9 13 12 13 76.9% 66.7% 69.2% Oncologist - % of MDT meetings attended 92.5% 71.1% 66.6% 66.6% 10 8 9 13 12 13 100.0% 100.0% 100.0% Imaging specialist - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 13 12 13 13 12 13 100.0% 100.0% 100.0% Histopathologist - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 13 12 13 13 12 13 0.0% 0.0% 0.0% Colonoscopist - % of MDT meetings attended 7.3% 0.0% 66.6% 66.6% 0 0 0 13 12 13 100.0% 100.0% 100.0% Colorectal nurse specialist - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 13 12 13 13 12 13 100.0% 100.0% 100.0% MDT coordinatory/secretary - % of MDT meetings 100.0% 100.0% 66.6% 66.6% 13 12 13 attended 13 12 13 30.5% 33.8% 37.0% Compliance with key elements of the cancer pathway - 32.6% 33.8% 58.5% 815 956 1,048 1st appointment within 7 days 2,672 2,828 2,831 28.6% 39.8% 40.2% Compliance with key elements of the cancer pathway - 43.4% 36.4% 95.0% 44 70 66 Confirmed diagnosis within 28 days 154 176 164
Compliance with key elements of the cancer pathway - 72.0% 76.5% 67.7% 70.4% 72.1% 76.0% MDT to take place within 35 days 237 289 243 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 329 378 359 65.9% 65.2% 52.0% Compliance with key elements of the cancer pathway - 63.3% 60.7% 85.0% 60 88 65 Decision to treat within 42 days 91 135 125 79.2% 96.3% 86.8% 92.9% 100.0% 85.0% 90.5% 83.3% 92.9% Percentage of patients diagnosed with a macular 86.7% 86.9% 97.0% 97.0% 20.333 17.333 15.333 13 21 17 19 10 13 condition who receive first injection within 14 days 25.667 18 17.667 14 21 20 21 12 14 67.3% 68.6% 78.3% 71.9% 68.9% 80.1% 73.9% 81.3% 71.9% Follow-up injection within 7 days of the planned date for 76.3% 71.3% 90.0% 90.0% 3,111 3,220 3,453 1,246 1,067 1,164 1,153 1,136 1,246 patients who have active disease (treatment to plan) 4,623 4,695 4,411 1,732 1,548 1,454 1,560 1,397 1,732 76.2% 79.3% 80.3% 78.3% 84.1% 86.9% 75.5% 75.8% 78.3% % of patients referred to EMAC with suspect macular 78.3% 95.0% 95.0% 157 115 118 36 37 53 40 25 36 condition and clinically assessed within 3 days 206 145 147 46 44 61 53 33 46
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Endophthalmitis rate by eye 1 0 0 0 1 0 0 1 0 0 0 0
Child & Family Health
2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 53.3% 48.0% 64.5% 30.8% 64.5% % of children and young people who receive an initial 52.4% 90.0% 90.0% 40 49 20 8 20 assessments within 20 working days of entry into care 75 102 31 26 31
% of children and young people looked after for 12 86.5% 90.3% 86.4% 87.7% 90.0% 90.0% months or more with an up to date health assessment 768 807 755 2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 888 894 874 90.1% 91.6% 88.2% % of children and young people looked after for 12 90.0% 92.0% 92.0% 800 812 772 months or more with an up to date immunisations 888 886 875 90.6% 100.0% 94.9% % of children aged under 5 and looked after for 12 95.3% 90.0% 90.0% 48 59 56 months or more with up to date development review 53 59 59
Quality - Safety
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Overall number of MRSA bacteraemia - Trust attributable 6 1 0 0 0 0 0 1 0 0 0 0 1 Overall number of MRSA bacteraemia - Non-attributable 7 3 0 0 2 1 0 0 0 0 0 0 0 CDiff infections caused by lapse in care (NHS Patients) 12 12 66 55 4 5 3 0 2 2 1 0 0 CDiff infections - Overall number of cases (NHS Patients) 74 71 18 24 17 12 8 5 7 5 12 Occurrence of a Never Event 2 0 0 2
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 98.5% 98.5% 98.8% 98.3% 98.5% 98.7% 98.1% 98.8% 98.3% Compliance with the hand hygiene audit 97.7% 98.3% 95.0% 95.0% 856 875 882 872 875 888 873 882 872 869 888 893 887 888 900 890 893 887 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Duty of Candour - Percentage of serious incidents where section on Duty of Candour is included in every Root 100.0% 100.0% 100.0% 100.0% 18 16 17 2 3 5 6 6 2 Cause Analysis Investigation Report and on STEIS 18 16 17 2 3 5 6 6 2
Duty of Candour - Percentage of incidents (level 3 and 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% above excluding SIs) reported in month where the 37 48 56 16 9 25 15 16 16 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 patient/family were notified of suspected or actual 37 48 56 16 9 25 15 16 16 incident 97.5% 97.6% 97.7% 98.1% 97.2% 97.3% 97.5% 98.4% 98.1% Percentage of patients receiving harm free care 98.3% 97.7% 95.0% 95.0% 4,143 4,170 4,105 1,422 1,385 1,294 1,423 1,388 1,422 4,248 4,272 4,200 1,449 1,425 1,330 1,460 1,410 1,449 0.35% 0.87% 0.38% 0.28% 0.98% 0.30% 0.48% 0.35% 0.28% Percentage of adult VTE Incidences that occurred whilst 0.56% 0.51% 0.25% 0.25% 15 37 16 4 14 4 7 5 4 receiving care from the provider 4,248 4,272 4,200 1,449 1,425 1,330 1,460 1,410 1,449 95.3% 95.7% 95.0% 95.9% 95.1% 95.0% 95.0% Percentage of all adult patients who have had a VTE risk 95.3% 95.3% 95.0% 95.0% 30,884 32,159 31,845 10,777 11,137 11,058 9,650 assessment using an approved assessment tool 32,392 33,621 33,506 11,233 11,711 11,638 10,157 0.38% 0.26% 0.26% 0.28% 0.14% 0.38% 0.21% 0.21% 0.28% Percentage of pressure ulcer incidences that occurred 0.26% 0.30% 1.00% 1.00% 16 11 11 4 2 5 3 3 4 whilst receiving care from the provider 4,248 4,272 4,200 1,449 1,425 1,330 1,460 1,410 1,449 0.38% 0.49% 0.83% 0.21% 0.70% 0.90% 1.44% 0.14% 0.21% Percentage of falls incidences that occurred whilst 0.11% 0.53% 1.00% 1.00% 16 21 35 3 10 12 21 2 3 receiving care from the provider 4,248 4,272 4,200 1,449 1,425 1,330 1,460 1,410 1,449 0.09% 0.12% 0.26% 0.14% 0.21% 0.08% 0.55% 0.14% 0.14% Percentage of catheter acquired UTIs incidences that 0.21% 0.16% 0.25% 0.25% 4 5 11 2 3 1 8 2 2 occurred whilst receiving care from the provider 4,248 4,272 4,200 1,449 1,425 1,330 1,460 1,410 1,449
Healthcare Worker Flu vaccination uptake (October to 47.6% February surveys)
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Percentage of patients with medicines reconciliation 87.7% 86.6% 85.0% 85.0% 88.7% 72.7% 85.0% 86.6% 72.7% 84.5% 79.6% 85.0% 86.6% within 24 hours Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Percentage of medication omissions that occurred whilst 85.2% 176.4% 12.0% 12.0% 43.7% 53.1% 62.4% 17.2% 17.0% 22.4% 23.6% 16.4% 17.2% receiving care from the provider (excluding valid reasons) Percentage of patients with allergy status documented in 96.2% 97.9% 95.0% 95.0% 98.7% 95.5% 96.6% 97.9% 95.5% 98.3% 98.0% 96.6% 97.9% medication chart
2016/17 2017/18 Current Q1 Q2 Q3 Q4 Indicator Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Value Value Target 2017/18 2017/18 2017/18 2017/18 4.20% 4.49% NHS staff sickness absence rate 4.92% 4.32% 44,213 32,389 1,053,916 721,020 88.9% 86.4% 85.8% Safe Staffing - Day Nurse Staff Fill Rate % 88.0% 87.7% 284,564 280,751 98,948 319,957 324,946 115,385 92.2% 93.0% 92.1% Safe Staffing - Day Care Staff Fill Rate % 91.6% 92.6% 129,125 131,842 47,272 140,048 141,755 51,351 89.9% 88.4% 87.7% Safe Staffing - Day Staff (Overall) Fill Rate % 89.2% 89.2% 413,689 412,593 146,220 460,005 466,700 166,736 90.4% 88.4% 91.1% Safe Staffing - Night Nurse Staff Fill Rate % 92.3% 89.4% 255,279 257,314 73,361 282,431 291,063 80,526 94.9% 95.5% 101.4% Safe Staffing - Night Care Staff Fill Rate % 101.9% 95.2% 110,129 115,525 32,012 116,028 120,962 31,577 91.7% 90.5% 94.0% Safe Staffing - Night Staff (Overall) Fill Rate % 95.0% 91.1% 365,408 372,838 105,373 398,459 412,024 112,103
Quality - Experience
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Mixed Sex Accommodation (MSA) Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 27.2% 33.7% 41.1% 35.4% 27.5% 39.0% 45.5% 39.2% 35.4% Percentage of complaints responded to within timescale 23.8% 34.5% 90.0% 90.0% 76 89 130 34 25 46 46 38 34 279 264 316 96 91 118 101 97 96 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Percentage of complaints acknowledged in 3 working 99.7% 100.0% 90.0% 90.0% 247 299 311 99 90 113 116 82 99 days of day following receipt of complaint 247 299 311 99 90 113 116 82 99 5.6% 5.0% 4.8% FFT - A&E % not recommend 7.0% 5.3% 417 402 148 7,503 8,051 3,078 89.4% 90.8% 91.7% FFT - A&E % recommend 87.2% 90.1% 6,705 7,309 2,822 7,503 8,051 3,078 12.9% 14.4% 17.0% FFT - A&E response rate 7.4% 13.7% 7,503 8,051 3,078 57,998 55,791 18,149 1.4% 1.8% 2.1% FFT - Inpatient % not recommend 1.8% 1.6% 115 169 62 8,509 9,149 2,974 95.9% 95.8% 95.1% FFT - Inpatient % recommend 94.4% 95.8% 8,156 8,762 2,827 8,509 9,149 2,974 FFT - Inpatient response rate 16.8% 32.0% 31.6% 32.3% 31.6% 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 8,509 9,149 2,974 26,911 28,298 9,419 0.0% 3.4% 2.7% FFT - Maternity % not recommend 0.7% 2.7% 0 5 2 38 149 73 97.4% 96.6% 97.3% FFT - Maternity % recommend 96.4% 96.8% 37 144 71 38 149 73 1.7% 6.4% 9.6% FFT - Maternity response rate 5.9% 4.1% 38 149 73 2,275 2,316 763
Quality - Effectiveness
2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18
Summary Hospital-level Mortality Indicator (SHMI) - 1.115 Deaths associated with hospitalisation
Information and Data Quality
2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 99.3% 99.2% 99.4% 99.3% 99.4% 99.4% 99.3% Completion of a valid NHS Number field in mental health and acute commissioning data sets submitted via SUS - 99.2% 99.3% 99.0% 99.0% 70,919 74,851 74,073 24,996 24,721 25,660 23,692 Inpatient 71,431 75,419 74,552 25,162 24,875 25,819 23,858
Completion of a valid NHS Number field in mental health 99.31% 99.36% 99.62% 99.42% 99.59% 99.60% 99.68% 99.15% 99.43% 99.00% 99.00% and acute commissioning data sets submitted via SUS - 324,414 325,885 329,016 108,763 117,200 121,565 90,251 2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 Outpatient 326,669 327,996 330,275 109,402 117,678 122,057 90,540 91.8% 95.4% 95.3% 95.4% 95.3% 95.3% 95.3% Completion of a valid NHS Number field in A&E 90.0% 93.2% 95.0% 95.0% 20,152 21,257 20,942 21,257 22,584 21,722 20,942 commissioning data sets submitted via SUS 21,956 22,293 21,986 22,293 23,700 22,788 21,986
Appendix 4 - Manchester University NHS Foundation Trust (formerly UHSM) - Performance & Quality Scorecard 2017-18
The second line of STF indicators shows the target trajectory.
Urgent Care
2016/17 2017/18 Q1 Q2 Q3 Q4 Indicator Current Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Value Value 2017/18 2017/18 2017/18 2017/18 92.4% 89.1% 82.3% 79.6% 86.7% 88.1% 85.6% 73.0% 78.6% 80.7%
Percentage of patients who spent 4 hours or less in A&E 90.0% 90.8% 90.0% 90.0% 90.8% 90.0% 90.0% 90.0% 90.0% 90.0% 85.6% 86.5% 90.0% (STF) 23,136 22,420 21,198 12,366 7,134 7,750 7,265 6,183 6,546 5,820 25,027 25,163 25,755 15,538 8,227 8,799 8,488 8,468 8,328 7,210
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 92.6% 92.4% 93.1% 91.6% 93.7% 93.5% 92.3% 93.4% 91.4% 91.9% Ambulance: Compliance with recording patient handover 91.0% 92.5% 90.0% 90.0% 6,159 6,468 6,786 4,061 2,156 2,261 2,236 2,289 2,202 1,859 6,651 6,997 7,292 4,431 2,302 2,419 2,423 2,450 2,408 2,023
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Trolley Waits in A&E 17 0 0 0 0 0 0 0 0 0 0 0 0 Ambulance Handover Delays over 30 Minutes 1114 2209 0 0 199 419 922 669 207 171 234 517 359 310 Ambulance Handover Delays over 1 Hour 194 376 0 0 16 48 202 110 31 22 30 150 76 34 Ambulance Handover Delays over 2 Hours 20 31 0 0 1 0 16 14 0 2 1 13 12 2 Urgent operations cancelled for a second time 0 0 0 0 0 0 0 0 0 0 0 0 0
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 Delayed transfers of care - DTOCs as a % of total beds 3.3% 3.3% 8.1% 9.4% 7.5% 6.7% 8.5% 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 58.4 67.7 54.2 47.9 59.5 718 718 718 718 704 74.5% 69.8% 85.5% 82.4% 76.5% 83.3% 78.9% 94.7% 82.4% Percentage of high risk TIA cases investigated and 57.5% 77.6% 60.0% 60.0% 41 44 53 28 13 20 15 18 28 treated within 24 hours 55 63 62 34 17 24 19 19 34 61.2% 56.7% 61.4% 52.9% 64.0% 61.5% 57.1% 65.2% 52.9% Percentage of patients who spend at least 90% of their 56.5% 59.3% 80.0% 80.0% 41 38 43 9 16 16 12 15 9 inpatient stay on a stroke unit 67 67 70 17 25 26 21 23 17
April - July August - November December - March
2016/17 2017/18 Current Jul 2017 November 2017 March 2018 Indicator Value Value target Value Value Value Compliance with overall SSNAP score - Level B (Levels A to E represented by a score of 5 to 1 respectively) 4 2 4 3 2 UHSM
Elective
2016/17 2017/18 Q1 Q2 Q3 Q4 Indicator Current Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Value Value 2017/18 2017/18 2017/18 2017/18 87.3% 87.6% 88.8% 89.1% 87.6% 88.6% 89.2% 88.8% 89.1% 87.3% 90.8% 89.8% 90.6% 90.8% 88.6% 89.2% 89.8% 90.6% 91.4% RTT: Incomplete pathways % within 18 weeks (STF) 87.4% 89.1% 90.6% 22,477 22,486 22,036 21,912 22,486 22,570 22,460 22,036 21,912 25,739 25,663 24,820 24,604 25,663 25,488 25,168 24,820 24,604
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 Cancer two week waits (urgent referrals) 95.7% 95.1% 93.0% 93.0% 95.0% 95.3% 95.6% 96.0% 96.5% 96.1% 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 3,047 3,113 967 1,096 1,134 956 3,209 3,265 1,012 1,142 1,175 995 92.8% 95.5% 96.2% 95.1% 94.5% 97.8% Cancer two week waits for breast symptoms 93.8% 94.1% 93.0% 93.0% 953 972 304 294 342 305 1,027 1,018 316 309 362 312 99.4% 99.4% 99.6% 99.5% 98.7% 100.0% Cancer 31 day waits for first definitive treatment (All 99.1% 99.4% 96.0% 96.0% 666 695 232 201 232 229 cancers) 670 699 233 202 235 229 99.3% 99.4% 100.0% 100.0% 100.0% 100.0% Cancer 31 day waits for subsequent treatment (Surgery) 99.0% 99.4% 94.0% 94.0% 143 174 63 41 54 50 144 175 63 41 54 50 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Cancer 31 day waits for subsequent treatment (Drugs) 100.0% 100.0% 98.0% 98.0% 52 51 24 28 26 23 52 51 24 28 26 23 N/A N/A N/A N/A N/A N/A Cancer 31 day waits for subsequent treatment N/A N/A 94.0% 0 0 0 0 0 0 (Radiotherapy) 0 0 0 0 0 0 86.6% 88.4% 86.5% 91.0% 87.6% 90.5% Cancer 62 day waits following urgent GP referral 89.1% 87.5% 85.0% 85.0% 201 199 64 60.5 53 67 232 225 74 66.5 60.5 74 98.5% 100.0% 100.0% 92.9% 100.0% 100.0% Cancer 62 day waits following referral from NHS 98.0% 99.2% 90.0% 90.0% 101 83.5 18.5 26 31.5 32 screening service 102.5 83.5 18.5 28 31.5 32 89.4% 89.6% 90.3% 95.2% 96.4% 97.8% Cancer 62 day waits following consultant decision to 90.3% 89.5% 85.0% 85.0% 110 116.5 42 40 40 45.5 upgrade 123 130 46.5 42 41.5 46.5 1.2% 4.0% 0.3% 0.4% 3.8% 0.4% 0.2% 0.4% 0.4% Diagnostic Waiting Times % waiting > 6 weeks 0.5% 1.7% 1.0% 1.0% 213 683 59 23 219 23 12 24 23 17,340 17,222 17,651 5,870 5,721 6,009 5,913 5,729 5,870 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 60.6% 54.8% 58.4% 56.3% 54.6% 58.9% 57.2% 59.2% 56.3% RTT: Admitted pathways % within 18 weeks 64.2% 57.8% 90.0% 2,443 2,192 2,724 929 745 946 968 810 929 4,031 4,001 4,667 1,649 1,364 1,607 1,691 1,369 1,649 87.6% 87.1% 89.1% 89.4% 85.5% 88.7% 88.1% 90.8% 89.4% RTT: Non-Admitted pathways % within 18 weeks 83.3% 88.1% 18,202 18,644 19,347 6,927 6,248 6,912 6,786 5,649 6,927 20,769 21,406 21,723 7,747 7,305 7,795 7,705 6,223 7,747 1.30% 1.03% 1.18% 1.09% 1.03% 1.03% 1.06% 1.18% 1.09% Percentage of patients waiting more than 36 weeks on 0.91% 1.09% 1.00% 1.00% 334 265 294 267 265 263 266 294 267 incomplete pathways 25,739 25,663 24,820 24,604 25,663 25,488 25,168 24,820 24,604 88.7% 89.5% 92.2% Percentage of children waiting less than 18 weeks for a 90.3% 90.9% 126 111 154 wheelchair 142 124 167 1.4% 0.9% 1.7% 1.4% 0.7% 1.8% 1.3% 2.2% 1.4% Percentage of cancelled elective operations that are 1.6% 1.4% 0.8% 0.8% 186 125 258 69 31 91 72 95 69 cancelled at the last minute for non-clinical reasons 13,071 14,038 14,797 5,039 4,638 5,098 5,337 4,362 5,039
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Number of patients waiting >52 weeks on incomplete 256 149 0 0 28 30 66 25 13 17 24 25 25 pathways Cancelled elective operations - breaches of 28 day 18 24 0 0 17 1 5 1 0 0 4 1 1 standard
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 96.5% 94.5% 95.0% 93.9% 92.1% 95.8% 93.9% 95.3% 93.9% Percentage of women who have seen a midwife or a maternity health professional by 12 weeks and six days 99.1% 95.2% 90.0% 90.0% 1,061 966 930 322 291 339 325 266 322 of pregnancy 1,099 1,022 979 343 316 354 346 279 343 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 100.0% 100.0% 100.0% Percentage of patients achieving recommended length of 100.0% 80.0% 80.0% 3 3 2 stay (LOS) for gynaecological procedures 3 3 2 92.9% 40.0% 35.7% Percentage of patients achieving recommended length of 47.0% 60.6% 70.0% 13 2 5 stay (LOS) for colorectal procedures 14 5 14 N/A N/A 0.0% Percentage of patients achieving recommended Length 100.0% 0.0% 80.0% 80.0% 0 0 0 of stay (LOS) for urological procedures 0 0 1 88.2% 91.2% 85.1% Percentage of patients achieving recommended length of 99.1% 88.2% 70.0% 165 156 143 stay (LOS) for breast procedures* 187 171 168 100.0% 100.0% 92.3% Percentage of applicable MDT meetings that are quorate 90.4% 97.3% 95.0% 95.0% 11 13 12 11 13 13 100.0% 100.0% 100.0% Colorectal surgeon (1) - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 11 13 13 11 13 13 100.0% 100.0% 100.0% Colorectal surgeon (2) - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 11 13 13 11 13 13 100.0% 100.0% 92.3% Clinical oncologist - % of MDT meetings attended 94.2% 97.3% 66.6% 66.6% 11 13 12 11 13 13 100.0% 100.0% 92.3% Oncologist - % of MDT meetings attended 94.2% 97.3% 66.6% 66.6% 11 13 12 11 13 13 100.0% 100.0% 100.0% Imaging specialist - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 11 13 13 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 11 13 13 100.0% 100.0% 100.0% Histopathologist - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 11 13 13 11 13 13 100.0% 100.0% 100.0% Colonoscopist - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 11 13 13 11 13 13 100.0% 100.0% 100.0% Colorectal nurse specialist - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 11 13 13 11 13 13 100.0% 100.0% 100.0% MDT coordinatory/secretary - % of MDT meetings 100.0% 100.0% 66.6% 66.6% 11 13 13 attended 11 13 13 19.7% 23.3% 27.2% Compliance with key elements of the cancer pathway - 24.8% 23.5% 55.0% 620 764 929 1st appointment within 7 days 3,143 3,282 3,420 62.4% 71.8% 66.0% Compliance with key elements of the cancer pathway - 66.2% 66.7% 69.0% 148 163 140 Confirmed diagnosis within 28 days 237 227 212 47.6% 45.8% 47.3% Compliance with key elements of the cancer pathway - 53.7% 46.9% 69.0% 79 66 53 MDT to take place within 35 days 166 144 112 92.1% 77.8% 83.2% Compliance with key elements of the cancer pathway - 74.7% 83.5% 80.0% 93 112 104 Decision to treat within 42 days 101 144 125
Quality - Safety
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Overall number of MRSA bacteraemia - Trust attributable 3 4 0 0 4 0 0 0 0 0 0 0 0 Overall number of MRSA bacteraemia - Non-attributable 3 0 0 0 0 0 0 0 0 0 0 0 0 CDiff infections caused by lapse in care (NHS Patients) 15 14 39 32 8 1 3 2 0 1 1 1 2 CDiff infections - Overall number of cases (NHS Patients) 44 39 13 13 9 4 4 2 5 2 4
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 47.1% 77.2% 70.2% 71.9% 77.2% 75.4% 80.7% 70.2% 71.9% Compliance with the hand hygiene audit 95.4% 72.2% 95.0% 95.0% 24 44 40 41 44 43 46 40 41 51 57 57 57 57 57 57 57 57 93.1% 97.7% 96.8% 98.1% 97.1% 97.0% 96.2% 97.1% 98.1% Percentage of patients receiving harm free care 92.5% 96.1% 95.0% 95.0% 2,349 2,367 2,549 873 763 876 793 880 873 2,522 2,422 2,633 890 786 903 824 906 890 0.40% 0.25% 0.27% 0.00% 0.64% 0.33% 0.24% 0.22% 0.00% Percentage of adult VTE Incidences that occurred whilst 0.30% 0.27% 0.25% 0.25% 10 6 7 0 5 3 2 2 0 receiving care from the provider 2,522 2,422 2,633 895 786 903 824 906 895 95.8% 95.2% 95.4% 95.7% 95.0% 95.1% 95.4% 95.8% 95.7% Percentage of all adult patients who have had a VTE risk 95.2% 95.5% 95.0% 95.0% 22,142 23,145 23,981 8,350 7,672 8,151 8,331 7,499 8,350 assessment using an approved assessment tool 23,107 24,324 25,127 8,721 8,073 8,568 8,733 7,826 8,721 0.79% 0.12% 0.27% 0.45% 0.13% 0.22% 0.36% 0.22% 0.45% Percentage of pressure ulcer incidences that occurred 1.09% 0.40% 1.00% 1.00% 20 3 7 4 1 2 3 2 4 whilst receiving care from the provider 2,522 2,422 2,633 895 786 903 824 906 895 0.24% 0.38% 0.55% 0.22% 0.38% 0.55% 0.36% 0.55% 0.22% Percentage of falls incidences resulting in harm that 0.32% 0.38% 1.00% 1.00% 2 3 5 2 3 5 3 5 2 occurred whilst receiving care from the provider 827 786 906 895 786 903 824 906 895 0.44% 0.21% 0.30% 0.11% 0.38% 0.55% 0.24% 0.11% 0.11% Percentage of catheter acquired UTIs incidences that 0.17% 0.30% 0.25% 0.25% 11 5 8 1 3 5 2 1 1 occurred whilst receiving care from the provider 2,522 2,422 2,633 895 786 903 824 906 895 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 57.5% 74.4% 79.1% 80.7% Healthcare Worker Flu vaccination uptake (October to 66.1% 80.7% 3,088 4,000 4,252 4,337 February surveys) 5,375 5,375 5,375 5,375
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Percentage of patients with medicines reconciliation 81.4% 94.0% 85.0% 85.0% 82.1% 87.7% 84.0% 94.0% 87.7% 79.1% 83.0% 84.0% 94.0% within 24 hours Percentage of medication omissions that occurred whilst 71.9% 12.0% 12.0% 12.0% 11.8% 7.9% 10.0% 12.0% 7.9% 11.0% 18.0% 10.0% 12.0% receiving care from the provider (excluding valid reasons) Percentage of patients with allergy status documented in 98.8% 99.0% 95.0% 95.0% 97.2% 99.6% 94.0% 99.0% 99.6% 96.7% 98.0% 94.0% 99.0% medication chart
2016/17 2017/18 Current Q1 Q2 Q3 Q4 Indicator Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Value Value Target 2017/18 2017/18 2017/18 2017/18 4.11% 4.60% NHS staff sickness absence rate 4.10% 4.31% 21,327 16,408 519,170 356,667 88.6% 85.2% 84.3% Safe Staffing - Day Nurse Staff Fill Rate % 90.1% 86.9% 195,346 195,703 63,315 220,457 229,624 75,073 103.7% 98.3% 97.8% Safe Staffing - Day Care Staff Fill Rate % 108.5% 100.9% 108,213 108,920 35,327 104,321 110,823 36,140 93.5% 89.5% 88.7% Safe Staffing - Day Staff (Overall) Fill Rate % 96.0% 91.4% 303,559 304,622 98,642 324,778 340,447 111,213 Safe Staffing - Night Nurse Staff Fill Rate % 93.8% 88.3% 89.1% 87.4% 87.4% 2016/17 2017/18 Current Q1 Q2 Q3 Q4 Indicator Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Value Value Target 2017/18 2017/18 2017/18 2017/18 137,687 139,021 45,056 154,494 158,994 51,559 112.4% 111.0% 108.5% Safe Staffing - Night Care Staff Fill Rate % 122.2% 111.7% 69,695 72,512 23,486 62,010 65,343 21,644 95.8% 94.3% 93.6% Safe Staffing - Night Staff (Overall) Fill Rate % 101.7% 95.0% 207,382 211,532 68,541 216,504 224,337 73,203
Quality - Experience
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Mixed Sex Accommodation (MSA) Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 91.9% 95.2% 73.9% 1.7% 95.9% 91.3% 97.4% 41.5% 1.7% Percentage of complaints responded to within timescale 96.0% 74.9% 90.0% 90.0% 102 120 102 1 47 42 38 22 1 111 126 138 59 49 46 39 53 59 90.2% 98.4% 69.1% 96.1% 100.0% 78.8% 68.8% 55.6% 96.1% Percentage of complaints acknowledged in 3 working 89.6% 86.6% 90.0% 90.0% 92 126 94 49 37 41 33 20 49 days of day following receipt of complaint 102 128 136 51 37 52 48 36 51 5.9% 7.1% 7.0% FFT - A&E % not recommend 7.4% 6.5% 184 213 68 3,104 2,997 975 89.2% 88.0% 87.7% FFT - A&E % recommend 87.4% 88.6% 2,769 2,637 855 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 3,104 2,997 975 17.8% 17.6% 17.6% FFT - A&E response rate 17.4% 17.7% 3,104 2,997 975 17,408 17,012 5,555 0.6% 0.7% 0.5% FFT - Inpatient % not recommend 0.7% 0.7% 52 59 12 8,500 8,015 2,518 97.5% 97.4% 98.0% FFT - Inpatient % recommend 96.6% 97.5% 8,291 7,803 2,468 8,500 8,015 2,518 41.1% 37.2% 34.8% FFT - Inpatient response rate 41.0% 39.1% 8,500 8,015 2,518 20,675 21,567 7,234 0.0% 0.0% 0.0% FFT - Maternity % not recommend 0.0% 0.0% 0 0 0 83 82 43 100.0% 98.8% 97.7% FFT - Maternity % recommend 99.1% 99.4% 83 81 42 83 82 43 11.5% 7.5% 11.5% FFT - Maternity response rate 10.4% 9.5% 120 82 43 1,040 1,090 373
Quality - Effectiveness
2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 Summary Hospital-level Mortality Indicator (SHMI) - 0.955 2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 Deaths associated with hospitalisation
Information and Data Quality
2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 99.8% 99.8% 99.8% 99.8% 99.8% 99.8% 99.8% 99.8% 99.8% Completion of a valid NHS Number field in mental health 99.8% 99.8% 99.0% 99.0% 67,713 66,384 53,156 64,044 66,384 64,404 60,917 53,156 64,044 and acute commissioning data sets submitted via SUS 67,832 66,515 53,267 64,156 66,515 64,514 61,028 53,267 64,156 98.6% 98.1% 98.2% 98.7% 97.6% 97.3% 98.8% 98.6% 98.7% Completion of a valid NHS Number field in A&E 98.5% 98.3% 95.0% 95.0% 24,982 24,775 25,373 8,225 8,066 8,595 8,387 8,391 8,225 commissioning data sets submitted via SUS 25,335 25,262 25,829 8,331 8,261 8,837 8,485 8,507 8,331
Appendix 5 - Pennine Acute Hospitals NHS Trust Scorecard 2017-18
Second line of STF indicators shows target trajectory.
Urgent Care
2016/17 2017/18 Q1 Q2 Q3 Q4 Indicator Current Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Value Value 2017/18 2017/18 2017/18 2017/18 83.7% 84.8% 84.2% 81.8% 85.0% 88.5% 85.8% 78.3% 82.0% 81.7%
Percentage of patients who spent 4 hours or less in A&E 86.4% 88.9% 89.5% 90.2% 89.4% 91.1% 82.1% 83.8% 91.1% (STF) 68,130 69,391 84,056 50,216 22,749 29,839 28,284 25,933 26,772 23,444 81,436 81,801 99,799 61,372 26,749 33,702 32,967 33,130 32,667 28,705 83.7% 84.2% 84.2% 83.8% 84.2% 85.0% 85.1% 84.2% 84.0% 83.8%
Percentage of patients who spent 4 hours or less in A&E 82.1% 83.8% (STF) - Cumulative performance 68,130 137,521 221,577 271,793 137,521 167,360 195,644 221,577 248,349 271,793 81,436 163,237 263,036 324,408 163,237 196,939 229,906 263,036 295,703 324,408
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 94.0% 92.6% 92.4% 93.2% 92.3% 91.7% 93.2% 92.4% 93.5% 92.9% Ambulance: Compliance with recording patient handover 92.8% 93.0% 90.0% 90.0% 16,595 17,592 18,626 11,361 5,698 6,027 6,249 6,350 6,078 5,283 17,646 19,002 20,154 12,192 6,173 6,573 6,705 6,876 6,504 5,688
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Trolley Waits in A&E 786 109 0 0 50 31 22 6 6 5 5 12 2 4 Trolley Waits in A&E (NMGH) 571 69 0 0 46 8 13 2 2 3 2 8 0 2 Ambulance Handover Delays over 30 Minutes 7584 7421 0 0 1515 1758 2530 1618 657 637 804 1089 863 755 Ambulance Handover Delays over 1 Hour 2770 2282 0 0 465 528 783 506 181 170 226 387 278 228 Ambulance Handover Delays over 2 Hours 675 453 0 0 90 94 160 109 33 28 32 100 61 48 Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Urgent operations cancelled for a second time 0 0 0 0 0 0 0 0 0 0 0 0 0
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 3.9% 3.8% 3.2% 3.5% 3.3% Delayed transfers of care - DTOCs as a % of total beds 3.3% 3.3% 42.7 42.3 35.4 38.8 35.2 1,101 1,101 1,101 1,101 1,064 5.1% 9.7% 8.5% 5.0% 10.1% 10.0% 9.6% 5.8% 5.0% Delayed transfers of care - DTOC as a % of total beds 7.5% 3.3% 3.3% 62 117.4 100.5 19.3 39.7 39.5 38 23 19.3 (NMGH) 1,218 1,206 1,182 384 394 394 394 394 384 60.9% 53.1% 66.1% 48.1% 77.8% 50.0% % of high risk TIA cases investigated and treated within 76.9% 59.5% 60.0% 60.0% 98 77 72 26 49 23 24 hours 161 145 109 54 63 46
April - July August - November December - March
2017/18 Current Jul 2017 November 2017 March 2018 Indicator Value target Value Value Value Compliance with overall SSNAP score - Level B (Levels A 10 4 5 5 to E represented by a score of 5 to 1 respectively)
Elective
2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 92.1% 84.9% 91.5% 86.8% 84.1% 97.8% 93.6% 91.1% Cancer two week waits (urgent referrals) 94.2% 88.5% 93.0% 93.0% 5,272 4,955 5,646 1,591 1,894 1,988 1,761 1,977 2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 5,725 5,836 6,168 1,834 2,251 2,033 1,881 2,171 99.7% 98.7% 99.5% 99.4% 100.0% 99.5% 98.9% 92.9% Cancer two week waits for breast symptoms 85.8% 99.2% 93.0% 93.0% 645 587 593 179 225 188 180 157 647 595 596 180 225 189 182 169 99.2% 98.5% 98.6% 98.7% 99.4% 96.3% 100.0% 97.3% Cancer 31 day waits for first definitive treatment (All 99.1% 98.8% 96.0% 96.0% 472 473 492 156 180 155 144 179 cancers) 476 480 499 158 181 161 144 184 95.5% 98.2% 92.9% 100.0% 94.7% 87.0% 100.0% 87.0% Cancer 31 day waits for subsequent treatment (Surgery) 98.5% 97.0% 94.0% 94.0% 42 54 52 15 18 20 13 20 44 55 56 15 19 23 13 23 97.8% 100.0% 97.2% 100.0% 100.0% 100.0% 92.9% 100.0% Cancer 31 day waits for subsequent treatment (Drugs) 100.0% 98.8% 98.0% 98.0% 45 34 35 16 14 8 13 16 46 34 36 16 14 8 14 16 N/A N/A N/A N/A N/A N/A N/A N/A Cancer 31 day waits for subsequent treatment N/A N/A 94.0% 94.0% 0 0 0 0 0 0 0 0 (Radiotherapy) 0 0 0 0 0 0 0 0 72.5% 76.6% 74.5% 79.0% 80.7% Cancer 62 day waits following urgent GP referral 79.3% 74.5% 85.0% 85.0% 250 260.5 76 109 98 345 340 102 138 121.5 86.7% 70.8% 50.0% 60.0% 33.3% 75.0% 54.5% 53.8% Cancer 62 day waits following referral from NHS 60.6% 79.6% 90.0% 90.0% 13 8.5 7 1.5 2 1.5 3 3.5 screening service 15 12 14 2.5 6 2 5.5 6.5 83.6% 94.4% 89.7% 95.8% 86.3% 94.9% 87.5% 78.6% Cancer 62 day waits following consultant decision to 84.5% 89.2% 85.0% 85.0% 48.5 59 74 23 22 28 24.5 22 upgrade 58 62.5 82.5 24 25.5 29.5 28 28 1.4% 2.2% 1.1% 0.9% 1.7% 0.8% 1.0% 1.5% 0.9% Diagnostic Waiting Times % waiting > 6 weeks (NHS 3.5% 1.5% 1.0% 1.0% 441 635 324 87 151 80 95 149 87 Constitution) 30,712 29,107 29,861 9,507 9,102 10,024 9,861 9,976 9,507 RTT: Admitted pathways % within 18 weeks 80.9% 73.9% 77.3% 74.0% 71.6% 69.1% 71.5% 72.0% 71.8% 71.0% 69.1% 2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 5,923 5,210 5,290 1,581 1,710 2,027 1,795 1,468 1,581 7,659 7,043 7,384 2,287 2,392 2,817 2,500 2,067 2,287 96.8% 96.1% 94.4% 93.5% 96.0% 95.6% 93.5% 93.9% 93.5% RTT: Non-Admitted pathways % within 18 weeks 95.7% 95.5% 40,713 42,006 42,634 14,414 14,158 15,217 15,027 12,390 14,414 42,061 43,707 45,178 15,408 14,750 15,914 16,074 13,190 15,408 92.2% 90.4% 88.0% 87.3% 90.4% 90.4% 90.3% 88.0% 87.3% RTT: Incomplete pathways % within 18 weeks (NHS 92.2% 87.3% 92.0% 92.0% 29,650 33,054 33,666 32,424 33,054 34,311 34,065 33,666 32,424 Constitution) 32,155 36,574 38,240 37,155 36,574 37,964 37,740 38,240 37,155 0.6% 0.5% 0.7% 0.9% 0.5% 0.5% 0.6% 0.7% 0.9% Percentage of patients waiting more than 36 weeks on 0.6% 0.9% 2.6% 2.6% 185 190 285 317 190 187 214 285 317 incomplete pathways 32,155 36,574 38,240 37,155 36,574 37,964 37,740 38,240 37,155
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Number of patients waiting >52 weeks on incomplete 0 4 0 0 1 1 1 1 1 0 0 1 1 pathways Cancelled elective operations - breaches of 28 day 58 86 0 0 27 35 24 3 3 6 15 standard Cancelled outpatient appointments (hospital fault) <5 22.2% 14.8% 3.0% 3.0% 4.6% 5.8% 4.4% 1.7% 1.5% 1.6% 1.3% working days Percentage of women who have seen a midwife or a maternity health professional by 12 weeks and six days 82.5% 90.0% 90.0% 81.5% 81.2% 84.7% of pregnancy Percentage of women who have seen a midwife or a maternity health professional by 12 weeks and six days 93.8% 95.4% 90.0% 90.0% 94.3% 94.8% 97.2% of pregnancy (referred 10wks 3 days)
Quality - Safety
Annual Current Q1 Q2 Q3 Q4 Indicator 2016/17 2017/18 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Overall number of MRSA bacteraemia - Avoidable 1 2 0 0 0 2 0 0 2 0 0 0 0 Overall number of MRSA bacteraemia - Unavoidable 9 4 0 0 1 2 1 0 1 1 0 0 0 CDiff infections caused by lapse in care (NHS Patients) 23 19 55 41 6 7 6 1 0 1 5 CDiff infections - Overall number of cases (NHS Patients) 59 38 14 12 10 2 2 2 2 6 2 Occurrence of a Never Event 8 4 0 0 0 1 3 0 1 1 1 Harm Free Care - Venous Thromboembolism (VTE) 99.0% 95.0% 95.0% 99.7% 99.8% 99.7% 99.6% Harm free care - Pressure ulcers 99.2% 95.0% 95.0% 99.6% 99.5% 99.0% 99.2% Harm Free Care - Falls 99.6% 99.9% 95.0% 95.0% 99.8% 99.9% 99.8% 99.9% Harm Free Care - Catheter Induced Urinary Tract 99.4% 99.8% 95.0% 95.0% 99.9% 99.9% 99.9% 99.8% Problems Harm Free Care - VTE - risk assessment 96.1% 94.1% 95.0% 95.0% 94.5% 95.4% 95.2% 94.1% Harm Free Care - VTE - root cause analysis 100.0% 100.0% 100.0% Medicines reconciled <72 hours 89.7% 86.5% 95.0% 95.0% 86.7% 87.4% 86.5% Medicines reconciled <24 hours 195.4% 45.6% 50.0% 50.0% 45.8% 47.3% 45.6% % of inpatients (>18yrs) identified as a 'High Risk', (score of 3 or above) following a nutritional assessment, which 65.2% 90.0% 90.0% 63.2% 58.5% are referred to a dietician Dementia - basic level awareness training 98.0% 90.0% 90.0% 90.0% 90.0% Midwife to birth ratio
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 3.98% 4.16% 4.29% 4.04% 4.29% NHS staff sickness absence rate 4.24% 4.10% 40,709 43,489 15,432 13,909 15,432 1,022,647 1,045,131 359,602 344,339 359,602 92.8% 89.0% 89.2% 87.9% 88.8% 90.1% 88.6% Safe Staffing - Day Nurse Staff Fill Rate % 92.7% 90.3% 336,248 328,471 337,711 107,108 112,568 111,435 113,708 362,364 369,248 378,788 121,830 126,758 123,675 128,355 100.6% 97.5% 96.9% 96.5% 96.2% 98.3% 96.4% Safe Staffing - Day Care Staff Fill Rate % 99.6% 98.3% 240,166 243,526 242,431 79,478 81,518 79,763 81,150 238,628 249,750 250,073 82,350 84,743 81,120 84,210 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 95.9% 92.4% 92.3% 91.4% 91.8% 93.4% 91.7% Safe Staffing - Day Staff (Overall) Fill Rate % 95.4% 93.5% 576,413 571,996 580,141 186,585 194,085 191,198 194,858 600,991 618,998 628,860 204,180 211,500 204,795 212,565 94.0% 92.5% 93.1% 91.4% 91.7% 94.7% 92.8% Safe Staffing - Night Nurse Staff Fill Rate % 95.0% 93.2% 208,489 206,399 213,844 66,497 70,385 71,173 72,286 221,877 223,116 229,799 72,776 76,750 75,139 77,910 119.4% 116.7% 114.3% 114.7% 114.5% 114.0% 114.3% Safe Staffing - Night Care Staff Fill Rate % 113.7% 116.7% 140,890 145,930 149,590 47,712 49,898 48,781 50,911 118,010 125,066 130,914 41,601 43,576 42,806 44,532 102.8% 101.2% 100.8% 99.9% 100.0% 101.7% 100.6% Safe Staffing - Night Staff (Overall) Fill Rate % 101.2% 101.6% 349,378 352,329 363,434 114,209 120,283 119,954 123,197 339,886 348,181 360,712 114,377 120,326 117,944 122,442 76.7% 78.7% 55.3% 69.3% 76.7% 78.7% Healthcare Worker Flu vaccination uptake (October to 53.6% 78.7% 75.0% 75.0% 5,263 5,402 3,977 4,797 5,263 5,402 February surveys) 6,860 6,860 7,188 6,924 6,860 6,860
Quality - Experience
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Mixed Sex Accommodation (MSA) Breaches 284 138 0 0 25 43 49 21 14 20 14 15 21 Percentage of complaints acknowledged in 3 working 99.0% 90.0% 90.0% 90.0% 96.0% 99.0% 90.0% 99.0% 97.0% 99.0% 90.0% days of day following receipt of complaint Complaints - responded to within timescale agreed at the 44.0% 61.0% 80.0% 41.0% 55.0% 61.0% 55.0% 53.0% 61.0% outset of complaint Complaints - satisfied on conclusion of complaint 3.0% 4.0% 30.0% 30.0% 7.0% 6.0% 4.0% Complaints - Number of Complaints still open > 100 days 0 0 0 0 0 0 0 0 0 0
Indicator 2016/17 2017/18 Current Q1 Q2 Q3 Q4 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Value Value Target 2017/18 2017/18 2017/18 2017/18 9.1% 9.2% 9.9% 9.6% 9.8% 9.2% 9.8% 10.9% 9.6% FFT - A&E % not recommend 10.5% 9.4% 851 995 1,122 324 353 338 423 361 324 9,333 10,855 11,298 3,363 3,618 3,672 4,318 3,308 3,363 83.7% 83.6% 83.5% 83.6% 82.1% 84.5% 83.9% 81.9% 83.6% FFT - A&E % recommend 81.5% 83.6% 7,814 9,077 9,433 2,811 2,972 3,103 3,621 2,709 2,811 9,333 10,855 11,298 3,363 3,618 3,672 4,318 3,308 3,363 13.8% 16.0% 17.1% 15.8% 16.5% 16.5% 19.8% 15.1% 15.8% FFT - A&E response rate 16.4% 15.6% 9,333 10,855 11,298 3,363 3,618 3,672 4,318 3,308 3,363 67,746 67,932 66,139 21,241 21,960 22,321 21,853 21,965 21,241 4.0% 4.1% 4.3% 3.6% 3.4% 4.2% 3.9% 5.3% 3.6% FFT - Inpatient % not recommend 3.3% 4.0% 546 444 426 116 96 161 150 115 116 13,817 10,946 9,917 3,230 2,842 3,862 3,876 2,179 3,230 90.4% 89.9% 90.3% 91.3% 91.8% 90.8% 90.2% 89.6% 91.3% FFT - Inpatient % recommend 88.2% 90.3% 12,489 9,841 8,957 2,948 2,609 3,507 3,498 1,952 2,948 13,817 10,946 9,917 3,230 2,842 3,862 3,876 2,179 3,230 22.2% 25.3% 28.1% 26.2% 28.0% 30.9% 31.9% 20.4% 26.2% FFT - Inpatient response rate 28.4% 24.7% 13,817 10,946 9,917 3,230 2,842 3,862 3,876 2,179 3,230 62,232 43,311 35,322 12,323 10,167 12,482 12,164 10,676 12,323 2.3% 2.8% 3.8% 4.5% 1.0% 0.7% 9.6% 4.5% FFT - Maternity % not recommend 1.7% 3.0% 8 10 8 5 1 1 7 5 341 362 209 110 100 136 73 110 94.7% 85.4% 94.3% 94.5% 64.0% 97.1% 89.0% 94.5% FFT - Maternity % recommend 81.2% 91.3% 323 309 197 104 64 132 65 104 341 362 209 110 100 136 73 110 15.6% 15.5% 13.3% 14.5% 12.9% 17.3% 9.2% 14.5% FFT - Maternity response rate 26.3% 14.9% 341 362 209 110 100 136 73 110 2,189 2,337 1,576 757 776 786 790 757
Quality - Effectiveness
2016/17 2017/18 Q1 Q2 Q3 Q4 Indicator Target Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Value Value 2017/18 2017/18 2017/18 2017/18 1.035 Summary Hospital-level Mortality Indicator (SHMI) - 1.074 1.035 3,820 Deaths associated with hospitalisation 3,690
Information and Data Quality
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Completion of a valid NHS Number field in mental health 99.7% 99.6% 99.0% 99.0% 99.8% 99.7% 99.7% 99.6% and acute commissioning data sets submitted via SUS Completion of a valid NHS Number field in A&E 99.0% 97.9% 95.0% 95.0% 98.6% 98.4% 98.0% 97.9% commissioning data sets submitted via SUS Outpatient letters < 10 working days of first attendance 95.4% 96.7% 95.0% 95.0% 96.7% 97.2% 97.0% 96.7% Discharge summaries <24 hours of all A&E attendances 94.7% 95.0% 95.0% 95.0% 94.9% 95.0% 95.0% 95.0% & IP discharges
Appendix 6 - Pennine Acute Hospitals NHS Trust (Community Services) Scorecard 2017-18
Overarching
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value % of clinical staff who have received 'health promotion' training 100.0% 100.0% 90.0% 90.0% 100.0% 100.0% in the last 12 months % of eligible staff who have completed mandatory training in 99.0% 92.3% 95.0% 95.0% 98.1% 92.3% adult protection in the last 12 months % of patient handling staff, where it is applicable to their post, who have completed mandatory safeguarding vulnerable 97.0% 90.7% 95.0% 95.0% 92.0% 90.7% Children Level 2 within the last 3 year % of clinical staff who have completed mandatory training in 89.0% 87.5% 95.0% 95.0% 84.5% 87.5% Infection Prevention in the last 12 months % of non-clinical staff who have completed mandatory training 100.0% 97.8% 90.0% 90.0% 98.0% 97.8% in infection prevention in the last 3 years % of staff who have direct patient contact who have received 98.4% 93.1% 75.0% 75.0% 97.1% 93.1% basic level awareness training for dementia % of complaints responded to within timescale agreed at the 100.0% 100.0% 90.0% 90.0% 100.0% 100.0% 100.0% N/A N/A N/A N/A 100.0% N/A N/A outset upon receipt of the complaint with complainant % of complainants satisfied on conclusion of complaint 100.0% 100.0% 90.0% 90.0% 100.0% 100.0% 100.0% N/A N/A N/A N/A 100.0% N/A N/A % of complaints acknowledged in 3 working days of day 100.0% 100.0% 90.0% 90.0% 100.0% 100.0% 100.0% N/A N/A N/A N/A 100.0% N/A N/A following receipt of complaint Number of MRSA cases in community 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Number of case studies/patient stories presented to the CCG's 12 10 12 1 3 3 3 1 1 1 1 1 1 1 Quality and Performance Committee
Acute Respiratory Assessment Service (ARAS)
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value
% of patients with an agreed care plan 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value
% of care plans shared with NWAS 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% Number of patients taken home on early supported discharge 28 27 21 (Information only)
Number of patients stepped up with support (Information only) 293 118 85 90 % of patients on caseload where an admission was avoided 30 96.0% 98.2% 80.0% 80.0% 93.8% 89.3% 98.2% days post start of exacerbation (from point of referral to ARAS)
Average length of stay on an acute caseload (days) 9 7 10 10 9 5 7
Bladder & Bowel Service
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Percentage of patients who receive a 12 month product review 75.8% 90.0% 90.0% 78.8% 81.0% 62.7% 90.7% 88.7% 79.6% 47.3% 91.7% 45.0% 90.7% Percentage of appointments at community service clinics who 19.3% 22.2% 15.0% 15.0% 22.3% 17.7% 26.9% 24.9% 21.0% 17.7% 20.0% 24.2% 38.3% 24.9% 'Did Not Attend' (DNA) Percentage of clinic appointments booked where the patient has 100.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% been offered a choice of appointment time Percentage of adults who have a personalised care plan within days of assessment, detailing treatment and/or goals to be 100.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% achieved
Cardiac Rehabilitation
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value % of high priority coded patients completing rehabilitation who are readmitted 12 months after discharge (Information Only) % of patients assessed within 10 days of referral 100.0% 95.5% 95.5% 93.3% 100.0% 97.1% 100.0% 97.1% 100.0% 96.7% 100.0% 97.1% 100.0% % of patients with a care plan in place within 7 days of 98.5% 100.0% 90.0% 90.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% assessment/acceptance % of 1st attendance at course within 3 weeks of referral for MI 100.0% 95.0% 95.0% 100.0% 100.0% N/A 100.0% 100.0% 100.0% 100.0% N/A 100.0% and/or percutaneous intervention patients Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value % of 1st attendance at course within 6 weeks of referral for 100.0% 95.0% 95.0% 100.0% N/A N/A 100.0% 100.0% N/A N/A N/A 100.0% heart failure patients Minimise the number of DNA 10.0% 10.0% 10.0% 12.0% 9.3% 8.9% 8.8% 7.0% 9.7% 8.5% 8.7% 9.9% 8.8% % of patients who started CR who were signposted to peer support 3rd sector support and self-management programmes N/A 95.0% 95.0% 100.0% N/A N/A N/A N/A N/A N/A N/A N/A N/A in order to educate and empower patients to enhance their ability to self-care % of patient plans to GP within 3 days of discharge 100.0% 90.0% 90.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Percentage of patients at stage 2-3 completing assessments 1 67.9% 59.0% 72.7% 69.1% 81.0% 38.7% 100.0% 83.3% 46.9% 84.0% 81.0% pre CR (Information Only) % of total patients at stages 4-5 who started CR for CABG, MI, 54.0% 65.0% 48.3% 61.7% 48.3% 65.0% 50.0% 60.0% 50.0% 45.0% 50.0% 65.0% PCC, PCCI against CCG plan (Information Only) % of patients at stage 4-5 who started CR for other cardiac 62.5% 83.3% 66.7% 29.2% 87.5% 37.5% 87.5% 50.0% 12.5% 25.0% 87.5% events against CCG plan (Information Only) % of patients at stage 4-5 who started CR for ICD or unstable 8.0% 85.0% 13.3% 0.0% 13.3% 0.0% 0.0% 0.0% 20.0% 20.0% 0.0% 0.0% angina (Information Only) Number of patients at stage 6 completing CR for CABG, MI, 72 21 27 18 6 9 12 9 4 5 6 PCC, PCCI (Information Only) Number of patients at stage 6 completing CR for ICD, unstable 30 8 14 8 0 3 4 6 2 0 0 angina (Information Only) Number of patients at stage 6 completing CR for other cardiac 8 3 1 0 4 0 0 0 0 0 4 event (Information Only) Number of patients at stage 6 completing CR for HF 3 1 1 1 0 0 0 0 0 1 0
Community Assessment Support Service (CASS)
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Number of placements to residential and nursing care - TOTAL 149 60 16 26 18 8 8 7 3 8 Number of placements to residential and nursing care - from 92 28 6 10 12 3 3 4 1 7 locality Number of placements to residential and nursing care - from 57 32 10 16 6 5 5 3 2 1 hospital Percentage of patients where CASS avoided an A&E admission 81.9% 97.2% 50.0% 50.0% 93.9% 96.1% 98.8% 100.0% 100.0% 99.0% 96.7% 100.0% 99.4% 100.0% Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Percentage of patients where CASS avoided a non-elective 65.2% 72.7% 50.0% 50.0% 78.7% 71.8% 68.5% 67.9% 74.8% 71.1% 69.5% 71.3% 64.0% 67.9% admission Percentage of CASS patients who were readmitted to hospital 7.7% 6.2% 10.0% 10.0% 3.2% 4.6% 7.2% 16.3% 2.9% 6.8% 5.3% 7.0% 9.0% 16.3% Average bed based intermediate care length of stay (bed days) 22 24 26 24 22 25 25 23 24 22 19 25 Percentage of completed assessments using the frailty tool 95.7% 98.7% 95.0% 95.0% 97.8% 98.6% 99.4% 98.3% 100.0% 98.4% 98.8% 100.0% 99.6% 98.3% Validated tool scores show increase in independence 85.8% 88.1% 65.0% 65.0% 89.8% 90.7% 87.4% 78.8% 94.3% 85.1% 84.2% 88.6% 90.0% 78.8% Percentage of patients aged 65+ who are screened for 96.6% 98.9% 95.0% 95.0% 97.7% 98.6% 100.0% 98.3% 100.0% 99.2% 100.0% 100.0% 100.0% 98.3% dementia Destination on discharge - more patients remain at home at 30 85.4% 87.0% 75.0% 75.0% 83.1% 87.7% 91.5% 83.8% 94.8% 86.0% 89.1% 87.2% 98.3% 83.8% days following discharge from CASS Destination on discharge - more patients remain at home at 91 86.2% 87.4% 75.0% 75.0% 82.8% 90.0% 88.6% 88.5% 93.5% 89.0% 87.0% 81.8% 96.9% 88.5% days following discharge from CASS Percentage of referrals acknowledged within 30 minutes 99.0% 100.0% 90.0% 90.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Percentage of CASS referrals (initial) responded to within 1 99.0% 98.7% 90.0% 90.0% 98.8% 100.0% 100.0% 93.8% 100.0% 100.0% 100.0% 100.0% 100.0% 93.8% hour Percentage of CASS referrals (urgent) responded to within 2 96.8% 98.4% 90.0% 90.0% 96.1% 99.2% 99.6% 96.3% 100.0% 96.2% 100.0% 98.4% 100.0% 96.3% hours Percentage of CASS referrals (non urgent) responded to within 98.5% 100.0% 90.0% 90.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 24 hours Patients' overall experience of the service 99.8% 99.5% 95.0% 95.0% 100.0% 98.0% 100.0% 100.0% 95.6% 100.0% 100.0% 100.0% 100.0% 100.0% Patients who have an agreed, shared care plan following CASS 97.9% 98.3% 95.0% 95.0% 97.9% 98.2% 99.6% 96.3% 100.0% 98.8% 99.4% 99.4% 100.0% 96.3% assessment
Community IV
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value
A minimum number of Step Up referrals 280 36 36 39 114 127 % of patients deemed as admission avoidance (50% of patients 90.8% 96.4% 95.0% 95.0% 96.8% 95.8% 95.5% 100.0% 95.7% 92.3% 84.6% 100.0% 100.0% 100.0% to have referral source of Community) All patients/carers, referrers, staff are given a satisfaction questionnaire. An audit of the responses to be undertaken and 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% finding shared. Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Record any re-referrals to secondary care admissions within 30 30.3% 95.0% 95.0% 95.1% .0% 1.9% days post intervention % of patients accepted onto service, who then go onto 1.9% 5.0% 5.0% 4.9% 5.6% 1.9% admission/readmission % of patients accepted referrals from other acute Trusts for NMCCG registered Patients requiring IV therapy as per 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% acceptance criteria. (North Manchester patients accepted from other Trusts identified as Step up patients.)
Discharge letters completed within 3 business days 100.0% 95.0% 95.0% 100.0% 100.0% 100.0%
Crumpsall Vale
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value
Average LOS for Step Down medically fit patients (days) 24.0 27.0 27.0 24.0 24.0
Average LOS for Step Up medically stable patients (days) 24.0 21.0 21.0 24.0 24.0
% of patients achieving their expected date of discharge (EDD) 58.3% 70.0% 70.0% 58.3% 58.3% % of patients showing an increased independence in their 58.3% 65.0% 65.0% 58.3% 58.3% validated tool score between start and end of stay
% of patients who are screened for dementia 100.0% 95.0% 95.0% 100.0% 100.0% % of patients who are living in their own home at 30 days after 84.2% 75.0% 75.0% 84.2% 84.2% being discharged from the service % of patients who are living in their own home at 91 days after 75.0% being discharged from CASS % of patients who are on the palliative care pathway 4.2% 4.2% 4.2% (Information only)
Diabetes Service
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Access - % of patients referred are seen within 2 weeks 82.1% 91.5% 80.0% 80.0% 94.9% 97.3% 90.7% 0.0% 100.0% 96.0% 92.3% 91.3% 88.5% 0.0% Access - % of patients referred are seen within 4 weeks 97.5% 98.3% 95.0% 95.0% 100.0% 100.0% 97.3% 71.4% 100.0% 100.0% 96.2% 100.0% 96.2% 71.4% DNA - % of appointments that DNA 20.7% 22.1% 15.0% 15.0% 22.0% 19.1% 24.5% 27.3% 17.1% 26.0% 32.8% 19.4% 20.3% 27.3% Percentage of clinics cancelled by provider 0.6% 8.3% 3.0% 3.0% 0.0% 0.6% 5.7% 68.0% 0.0% 1.8% 0.9% 7.2% 9.4% 68.0% Percentage of patients with a care plan 95.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Number of sessions per month 31 26 26 26 9 9 7 1 3 3 3 3 1 1 Percentage of patients with waiting time for course within 8 100.0% 100.0% 90.0% 90.0% 100.0% 100.0% weeks Percentage of DESMOND patients that DNA 25.7% 22.0% 10.0% 10.0% 21.9% 11.1% 28.6% 50.0% 10.0% 4.5% 4.2% 41.7% 61.5% 50.0%
DNs and Treatment Room
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Percentage of adults who have personalised care plan detailing 100.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% treatment and/or goals to be achieved Percentage of patients on a caseload with a pressure ulcer of grade 2 or higher as measured against a recognised tool 1.1% 1.0% 5.0% 5.0% 1.5% 1.1% 1.3% 1.0% 1.3% 1.1% 1.2% 1.4% 1.3% 1.0% approved by the commissioner e.g. Waterlow Number of clinics available per month (4 week period) 104 101 100 100 100 101 101 101 101 101 101 101 101 101
Intermediate Care (J5 Pilot)
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Percentage of referrals that are step-up 6.7% 38.0% 40.0% 33.3% 42.3% 23.1% 33.3% 46.2% 38.5% Average LOS for Step Down medically fit patients 24.5 23.0 30.0 30.0 24.0 26.0 23.0 26.0 26.0 22.0 23.0 Average LOS for Step Up medically stable patients 13.1 21.0 15.0 15.0 27.0 9.0 21.0 14.0 9.0 10.0 21.0 % of patients achieving their expected date of discharge (EDD) 76.9% 80.0% 80.0% 54.5% 66.7% 76.9% 69.2% 66.7% 90.9% 76.9%
Leg Circulation
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value % of adults who have a personalised care plan detailing 100.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% treatment and/or goals to be achieved % of new people assessed for peripheral arterial disease (PAD) 12.8% 25.0% 25.0% 7.6% 3.8% 2.6% 12.8% 7.0% 3.8% 8.3% 3.3% 2.6% 12.8% who are then referred on to Secondary Care Vascular Services % of new people referred to LCS who wait less than 28 days for a new appointment offer for a peripheral arterial disease (PAD) 97.4% 60.0% 60.0% 98.0% 91.1% 94.9% 97.4% 72.7% 91.1% 100.0% 100.0% 94.9% 97.4% assessment from receipt of referal
Navigation Service
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Percentage of patients seen by the Navigator Team in A&E who 67.9% 71.4% 60.0% 60.0% 77.1% 68.3% 70.4% are not admitted
Non-AQP Audiology
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Percentage of patients whose first contact to offer an 100.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% assessment appointment is within 3 days of receipt of referral Percentage of patients whose actual appointment/assessment 100.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% is within 6 weeks of first contact Percentage of patients with an agreed care plan, including self- 100.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% management/education
Percentage of patients assessed using a validated tool 100.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% Percentage of discharge letters issued to patients GP within 3 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% working days of discharge
North Manchester Integrated Care Team
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Minimum of 52 patients per months collectively per 17 16 18 14 15 18 18 15 15 20 10 18 neighbourhood team PAHT have representation at 98% of multi-disciplinary meetings 100.0% 100.0% 98.0% 98.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Percentage of discharge letters that are completed by the 99.7% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% keyworker back to the referrer within 3 business days All patients referred to the service to have care plan completed 97.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% that included self care goals Percentage of patients receiving (1) PAM tool; (2) info booklet and contact details; and (3) consent form on their first visit 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% (Information Only) Percentage of patients at 12 weeks receiving evaluation by their key worker and ongoing interventions agreed by MDT Team 100.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% Leader Average length of stay on active caseload 67.6 65.5 84.0 84.0 55.3 59.3 79.3 73.0 64.0 72.0 84.0 95.0 59.0 73.0
% of PAM tools completed 81.0% 83.1% 78.2%
Palliative and End of Life Care
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value % of patients on the community palliative team caseload dying 83.9% 83.1% 75.0% 75.0% 78.7% 90.3% 80.6% in their preferred place % of response times by priority for patients referred to community palliative care team-PRIORITY 1, WITHIN 2 100.0% 100.0% 90.0% 90.0% 100.0% 100.0% 100.0% N/A 100.0% 100.0% N/A 100.0% N/A N/A HOURS % of response times by priority for patients referred to community palliative care team-PRIORITY 2, WITHIN 24 100.0% 100.0% 90.0% 90.0% 100.0% 100.0% 100.0% N/A 100.0% 100.0% 100.0% 100.0% 100.0% N/A HOURS % of response times by priority for patients referred to 100.0% 100.0% 90.0% 90.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% community palliative care team - PRIORITY 1, WITHIN 5 DAYS % of patients on the palliative care teams caseload who have 100.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% N/A 100.0% N/A N/A 100.0% 100.0% N/A been screened for anxiety and depression % of patients on the palliative care teams caseload who died 83.5% 90.4% 80.0% 80.0% 87.9% 96.6% 87.3% with an agreed plan and DNACPR where appropriate
Physiotherapy - Community
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value % of patients assessed using a validated assessment tool 99.8% 99.4% 95.0% 95.0% 100.0% 98.4% 100.0% 100.0% 93.9% 100.0% 100.0% 100.0% 100.0% 100.0% appropriate to the scope of practice % of patients achieving optimum health as measured using a 86.8% 91.9% 85.0% 85.0% 92.9% 94.4% 87.8% 90.0% 94.4% 91.7% 88.9% 95.0% 72.7% 90.0% validated assessment tool % of adults who have a personalised care plan detailing 100.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% treatments and/or goals to be achieved
Physiotherapy - Direct Access
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Percentage of patients seen within 6 weeks (Direct Access) 79.3% 88.2% 90.0% 90.0% 80.6% 82.0% 95.8% 100.0% 79.2% 88.6% 93.7% 95.1% 100.0% 100.0% Longest wait in days for patients seen within the period 46 33 40 40 38 40 24 21 45 35 30 21 21 21 New to follow-up ratio 00: 03: 00: 03: 03: 03: 03: 03: 03: 03: 03: 03:
Physiotherapy - MSK
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Percentage of patients seen within 6 weeks (MSK) 92.2% 62.7% 90.0% 90.0% 100.0% 78.0% 8.1% 67.7% 100.0% 52.4% 2.0% 2.3% 20.9% 67.7%
Podiatry
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Percentage of patients with diabetes presenting with a new foot 36.7% 94.7% 90.0% 90.0% 96.9% 94.9% 98.8% 81.8% 100.0% 100.0% 100.0% 100.0% 96.6% 81.8% emergency who are triaged within 1 working day
Pulmonary Rehabilitation
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value
% of patients completing the course of pulmonary rehab 74.7% 67.8% 80.0% 76.5% 50.0% Percentage of patients where time from receipt of referral to first contact with patient to offer an assessment appointment is 98.3% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% within 10 days Percentage of patients where time between first contact and 100.0% 98.5% 95.0% 95.0% 100.0% 96.2% 100.0% actual assessment is within 4 weeks Percentage of patients where time taken from assessment to 99.1% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% start date of the course is within 2 weeks The number of places available and the number of course run 220 165 220 55 55 55 55 each year Number of patients on domiciliary rehab programme 149 39 49 45 16 13 18 15 16 14 16 (information only)
Stroke
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Percentage of patients referred are seen within 72 hours for an 96.1% 99.2% 95.0% 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% assessment Provide equitable access to specialist stroke care in the 28 27 25 25 30 31 22 25 40 33 28 21 18 25 community for all stroke patients All stroke patients will be assessed by CSRT for their 100.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% rehabilitation needs before hospital discharge Appropriate patients to be discharged through the ESD pathway 70.1% 70.2% 40.0% 40.0% 62.5% 73.2% 80.6% 66.7% 75.0% 78.9% 70.0% 71.4% 100.0% 66.7% ESD patients will be contacted within 72 hours of leaving hospital and be offered therapy at the same intensity as in 100.0% 98.1% 95.0% 95.0% 97.1% 100.0% 100.0% hospital by CSRT % of caseload who are readmitted with a stroke-related 9.1% 2.2% 8.0% 8.0% 1.6% 4.8% .0% condition within 28 days of discharge Reduce patient dependency levels as measured by recognised 97.7% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% clinical tool care All discharged stroke patients who are appropriate, will receive 100.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% 100.0% N/A 100.0% N/A 100.0% N/A 100.0% at least 5 sessions per week for up to 6 weeks post discharge All discharged stroke patients will have a record of 100.0% 100.0% 95.0% 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value comprehensive assessment impairments and activity limitations using standardised measurement tools Patients should be given a set of jointly agreed short and long term goals within 2 weeks of admission to the community 95.8% 100.0% 95.0% 95.0% 94.4% 100.0% 100.0% rehabilitation service All medically suitable stroke patients will be offered a 6 month 96.9% 100.0% 80.0% 80.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% review within an appropriate community setting close to home
Tissue Viability and Leg Ulcer
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Indicator Target 2017/18 2017/18 2017/18 2017/18 Target Value Value 2017/18 Value Value Value Value Value Value Value Value Value Value Shortest time in working days to first available appointment for 0 2 6 6 5 0 0 15 0 0 0 0 0 15 each community scheduled service Longest time in working days to first available appointment for 10 25 28 28 23 16 29 44 22 15 20 42 26 44 each community scheduled service % of venous wounds that have healed at 24 weeks from the 84.5% 83.0% 70.0% 70.0% 78.0% 81.4% 87.2% 90.0% 80.0% 82.4% 84.6% 89.5% 86.7% 90.0% start of treatment Percentage of clinics that are utilised 81.7% 67.1% 60.0% 60.0% 82.7% 57.7% 51.0% 42.7% 76.0% 57.7% 64.4% 49.0% 51.0% 42.7% Number of Cancelled Clinics 0 1 0 0 0 0 0 1 0 0 0 0 0 1